George Orwell and Stevens-Johnson Syndrome
George Orwell (Eric Blair; 1903-1950) was one of the most influential of English writers in the 20th century. He wrote famous books such as 1984 (written in 1948): this masterpiece shows what totalitarian rule can be and even nowadays it displays how people can be manipulated to maintain society as it is.
He was a known case of tuberculosis.
Streptomycin is a treatment against tuberculosis and was put on the market in 1946. In England Orwell managed to get the drug while it was on trial in some hospitals in England (it was not available in the hospital in Scotland where Orwell was admitted):
- He was admitted in 1947 and the health care providers couldn’t get hold of his typewriter !
- He was given 1g of Streptomycin daily and appeared to be making some clinical response, but after a few weeks he developed a severe allergic reaction with dermatitis and stomatitis. He wrote an excellent description of this in his notebook, he could not receive any more of this drug
- In bold text, the cutaneous reactions that Orwell described in his notebook:
« At first, though the streptomycin seemed to produce an almost immediate improvement in my health, there were no secondary symptoms, except that a sort of discoloration appeared at the base of my fingers & toe nails. Then my face became noticeably redder & the skin had a tendency to flake off, & a sort of rash appeared all over my body, especially down my back. There was no itching associated with this. After about 3 weeks I got a severe sore throat, which did not go away & was not affected by sucking penicillin lozenges. It was very painful to swallow & I had to have a special diet for some weeks. There was now ulceration with blisters in my throat & in the insides of my cheeks, & the blood kept coming up into little blisters on my lips. At night these burst & bled considerably, so that in the morning my lips were always stuck together with blood & I had to bathe them before I could open my mouth. Meanwhile my nails had disintegrated at the roots & the disintegration grew, as it were, up the nail, new nails forming beneath meanwhile. My hair began to come out, & one or two patches of quite white hair appeared at the back (previously it was only speckled with grey) ».
« After 50 days the streptomycin, which had been injected at the rate of 1 gramme a day, was discontinued. The lips etc. healed almost immediately & the rash went away, though not quite so promptly. My hair stopped coming out & went back to its normal colour, though I think with more grey in it than before. The old nails ended by dropping out altogether, & some months after leaving hospital I had only ragged tips, which kept splitting, to the new nails. Some of the toenails did not drop out. Even now my nails are not normal. They are much more corrugated than before, & a great deal thinner, with a constant tendency to split if I do not keep them very short. At that time the Board of Trade would not give import permits for streptomycin, except to a few hospitals for experimental purposes. One had to get hold of it by some kind of wire-pulling. It cost £1 a gramme, plus 60% Purchase Tax ».
Desquamation affecting the cutaneous and mucosal surfaces fits with the description of Stevens Johnson Syndrome (SJS):
- Streptomycin has been described as an associated drug Sarkar SK, et al Stevens-Johnson syndrome caused by streptomycin., Tubercle. 1982 Jun;63(2):137-8.
- The syndrome was described in 1922 by 2 American Pediatricians: Dr Albert Mason Stevens and Dr Frank Chambliss Johnson
- Streptomycin has been described as potentially causing on the skin, angiedema, hives, pinpoint red spots, « skin rash », yellowness of the skin as well and sores and ulcers in the mouth. However is is not known in directly causing hair loss.
- However reversible hair fall and loss of nails (which can be permanent due to scarring) are features of Stevens Johnson-Syndrome (SJS)
- SJS is a milder form of toxic epidermal necrolysis (TEN). It is defined by less than 10% of Body surface area (BSA) involvement. Its overlap with TEN is defined by 11 to 30% BSA involvement.
We therefore conclude that George Orwell developed SJS following Streptomycin intake.
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Dr Christophe HSU – dermatologist. Geneva, Switzerland
Bibliography: Bastian H (2004). Down and almost out in Scotland: George Orwell, tuberculosis and getting streptomycin in 1948. JLL Bulletin: Commentaries on the history of treatment evaluation