A Case of Cerebral Malaria on Board a Troopship
BMJ (Clinical Research Edition)
Since 1920 about one case of mammary haemangioma a year has been reported, in approximately equal numbers of cavernous and capillary types, and with evidence of malignancy in eight of these. Menville and Bloodgood (1933) describe eight examples, only one of which was malignant, in 3,000 consecutive breast neoplasms examined histologically. As probably all angiomata, but not all carcinomata, would be examined, this may well be too high a proportion. This is the only case treated at Charing Cross
... Hospital over a period in which about 1,000 breast tumours were seen. This suggests a general incidence of not more than 0.1 % of all mammary neoplasms, while the incidence of malignant haemangioma may possibly be as low as 0.03°,'-truly a rare condition. No recorded case, however, appears to have been associated with pregnancy, nor has the tumour reached such an enormous size as this one; and the malignant cases were generally of much lower grade. These three factors may possibly be interrelated, and, I think, make this case worth recording. The high degree of clinical malignancy, shown by the rapid recurrence and fatal outcome within nine months, was not predictable on histological grounds. Microscopically there was actually very little tumour tissue to be seen, which explains the earlier biopsy being quite negative even after re-examination in the light of subsequent findings. Menville and Bloodgood, in their review, point out that there is often enough clinical evidence for the diagnosis to be considered pre-operatively. Although this tumour was clinically atypical, the extremely rapid increase in size in April, due presumably to an interstitial haemorrhage, was suggestive. It has long been recognized that pregnancy may be associated with a particularly virulent form of carcinoma of the breast, but here we have an example of the mesoblastic tissues undergoing a malignant change under the influence of pregnancy. There was probably a pre-existing simple angioma which was stimulated into activity by hormonic influences similar to those which possibly produce carcinomata. It seems less probable that the process is a two-step one, the epithelial tissues, themselves stimulated by circulating hormone, causing a local stimulation of the surrounding mesoblastic tissues; for then one would expect mammary angioma to be much commoner than the above figures suggest. Report of Case A primipara aged 20 was admitted on April 17, 1945, with an enormous tumour of the left breast. The patient became pregnant in October, 1944, and three months later first noticed that the breast was becoming hard. Ten days before admission, for a reason not then apparent, the breast rapidly swelled and became tense, painful, and discoloured. She had a swinging temperature up to 103°F. (39.4°C.), and her pulse rate was 120 a minute. A diagnosis of probable suppuration was made, but attempted aspiration yielded only blood, which on culture was sterile. It then seemed likely that the condition was a lactation carcinoma or a sarcoma, and the patient was transferred to Charing Cross Hospital for radiotherapy. This was immediately started, but the tumour continued to increase in size as judged by circumferential measurement. At this stage the appearance of the tumour was of a very large rounded mass, 72 cm. in circumference, in the position of the left breast. The thin overlying skin had ulcerated, the ulcers being produced by the coalescence of the original aspiration punctures, each of which had been stretched to form a circular hole by the rapid increase in size of the tumour. They were thus serpiginous in outline, the edges being free from the underlying tissue, which appeared to be organizing blood-clot. The patient's general condition deteriorated steadily; her temperature remained high and her haemoglobin fell to only 4.8 g. % owing to several gross haemorrhages from and into the tumour. A biopsy was taken of the skin and underlying tissue and of material from the centre of the tumour, but no neoplastic cells were found, the sections showing suppurative reaction only. Local amputatio-n after transfusion was decided upon, being performed on May 7 (by Mr. Norman C. Lake) under trilene anaesthesia with no ill effect on the pregnancy. Her temperature immediately subsided, and her haemoglobin rose rapidly to 10.3 g. % on iron therapy. Two weeks after operation a minute plum-coloured recurrence appeared in the scar. This resolved with radiotherapy, but recurred again, ulcerated, and bled. Subsequently a diffuse mass was felt in the right breast; this also disappeared on treatment. She had a forceps delivery of a healthy female child at full term-July 12-Photomicrograph of the tumour and was given testosterone to dry up the right breast. She was discharged to the out-patient department, but attended twice only. A follow-up showed that she went rapidly downhill and died on Sept. 13 from pneumonia consequent upon direct invasion of the lung, as shown by the fact that she suffered greatly from pleural pain. Necropsy was not performed. At operation the tumour came away easily, but was found to infiltrate the pectoraiis major over a small area. It was not possible to decide whether it originated in the muscle or infiltrated this from the breast. It weighed 2,400 g., had a maximum circumference of 75 cm., and on incision appeared macroscopically to consist entirely' of semi-organized blood-clot. The report on its morbid histology (Dr. H. W. C. Vines) was: "The growth is essentially haemangiomatous in type and has given rise to extensive haemorrhage. The appearances are fairly representative of a capillary angioma, but in some areas the cells are more anaplastic and a small number show mitoses. These are more suggestive of an angioblastoma, and it should be regarded as such." I wish to thank Mr. Lake for his encouragement and permission to publish this case, and Dr. Vines for his pathological report and advice. The following case of cerebral malaria is thought worth recording because of the bizarre mode of onset. It should be explained that the ship left the United Kingdom with a large draft on board, and that on calling at a port in a highly malarious area a few personnel were embarked; these were berthed in scattered accommodation available through the ship. CASE RECORD When two days out fi om the malarious port a seaman aged 22 was brought into the troop hospital with the historyr that he had been found on the mess deck in a fit. The man was screaming and yelling, was throwing himself about, and had carpo-pedal spasms. He did not look ill; general physical examination was negative, his reflexes being normal but brisk. His pulse rate was 110; it was impossible to take his temperature. He appeared to be in a typical hysterical fit, and was treated as such, by slapping and cold water. He did not respond, and after about 20 minutes was given morphine 1/4 gr. (16 mg.) and scopolamine 1/150 gr. (0.43 mg.) and was restrained in a Neil-Robertson stretcher. In the meantime his messmates were again questioned, but nobody knew him. Eventually a man who had also embarked at this port stated that he thought the patient had been in hospital with malaria. Blood films were taken, and one of them showed a moderate number of M.T. rings.