Is "thucydides syndrome" back?

For centuries, historians and scientists have puzzled over the calamitous plague of Athens, which decimated the ancient city-state between 430 and 427 B.C. As vividly described by the historian Thucydides, himself a survivor of the illness, the plague attacked suddenly, causing "violent heats" in the head, inflammation of the eyes and throat, "reddish, livid" skin, extreme diarrhea and high fever. Historians agree that the epidemic, which killed the great statesman Pericles, contributed to the fall of Athens in the Peloponnesian War. But there is no agreement on its cause. Was it smallpox? Scarlet fever? Typhus? Measles?

A more exotic explanation was posed in the "New England Journal of Medicines in 1985 by Dr. Alexander Langmuir, formerly chief epidemiologist at the Centres for Disease Control in Atlanta. Thucydides' description, Langmuir theorized., fit the criteria for influenza complicated by toxic shock syndrome. And although this

peculiar combination of ailments had never been observed by modern physicians, Langmuir predicted that "Thucydides syndrome", as he called it, "may reappear", perhaps as part of some future epidemic of influenza.

The Delphian oracle could not have been more clairvoyant. In a recent issue of the "Journal of the American Medical Association", doctors at the Minnesota Department of Health, and the University of Virginia reported a total of ten cases of suspected Thucydides syndrome — flu complicated by TSS. Nine of the cases .occurred during a major influenza outbreak in Minnesota in the winter of 1985 —1986. One occurred in Roanoke, Va., and an eleventh case, in Oregon, has since been reported to the CDC. Like the Athenian scourge, the two-part illness was tethal: six of the patients died. Langmuir says the apparent fulfillment of his prophecy had him "blown over like a feather".

Though most U.S. cases of toxic shock occur in menstruating women, often in conjunction with the use of tampons, this was not true of the flu victims. Four of the eleven were males, and only two of the females were menstruating at the time they fell ill (both said they were not using tampons). The patients ranged in age from five to 56, but most of the deaths were among children. Says Dr. Kristine MacDonald of the Minnesota Department of Health: "There is some suggestion that younger people are more susceptible to TSS. As people get older, more of them have antibodies to protect them". Indeed most adults are immune to the syndrome.

TSS is caused by a toxin-producing strain of the common bacterium, Staphylococcus aureus, carried benignly in the respiratory and genital tracts of perhaps one out of three people. Under certain conditions — a wound, some infections, the presence of a tampon or contraceptive sponge — the bacteria multiply. If the toxin-producing strain is present, such proliferation can lead to TSS. The symptoms are dramatic and develop quickly: high fever, a sunburn-like rash, severe vomiting and diarrhea, culminating in shock, in which blood pressure plummets and circulation deteriorates. Doctors usually try to head off this life-threatening conditions by administering intravenous -fluids with electrolytes, and sometimes drugs to restore blood pressure.

MacDonald speculates that the influenza virus can injure the throat or lungs in a way that favors the growth of S. aureus. Though the complication appears to be rare, it is urgent that doctors be aware of it, says TSS Expert Bruce Dan, in an editorial that accompanied MacDonald's paper. Early recognition and treatment of the syndrome "is the most important factor in being able to prevent fatalities", says Dan. "It behooves all physicians to be on

the lookout for any influenza patient whose condition suddenly worsens".