VERRUGA PERUANA

Synonyms.—Peruvian warts; Carrion’s disease; Oroya fever; Fr., La Verruga;
Maladie de Carrion.

Definition.—A specific, inoculable affection, endemic in some
valleys of the Western Andes, in Peru, and characterized by a prodromal
febrile period and subsequent outbreak of peculiar, pin-head­ to pea-
sized or larger, reddish, rounded, granulomatous, wart-like elevations.¹

Symptoms.—The prodromic period, which may persist for weeks
or several months before the cutaneous outbreak, is characterized by
irregular fever of malarial or typhoid type, with rheumatic joint and
muscular symptoms and more or less profound anemia. Upon the
advent of the eruptive phenomena these symptoms abate or vanish,
or remissions may be noted. The eruption usually first show itself on
the face and limbs and begins as small reddish spots or incompletely
formed vesicles, which soon become pin-head­ to small pea-sized or larger,
conic, rounded, soft, or elastic elevations, which may be sessile or pedun-
culated. They are somewhat variable as to size, in moderate numbers
or abundant, and may be somewhat painful or tender to the touch.
They are often crowded together in small bunches. They are bright
red in color, later becoming dark red. The thinned epidermal covering
often cracks, and in some instances considerable hemorrhage may ensue,
and sometimes to a dangerous degree, the usual anemic condition of
the patient becoming thereby more pronounced. The lesions may
be small and remain small, and gradually dry up and disappear. When
crowded together, they seem almost confluent, irritated, and abraded,
crusting over, and discharging from time to time some sanious pus. While,
as a rule, the lesions are on the skin, they may be on the mucous mem­
branes, and even on the serous membranes, or there may be some sub­
cutaneous lesions, especially about the joints. These latter lesions feel
at first like small, movable bodies, and gradually disappear, or may in-

¹ An admirable and exhaustive paper by Matas on this disease to be found in Mor-
row’s System, vol. iii (Dermatology), p. 694; also in Sydenham Soc edit, of Hirsch’s
Handbook of Geographic and Historic Pathology, vol. ii, p. no; Escomel, Annales,
1902, p. 961; Elder, Jour. Trop. Med., 1906, p. 213; Jadassohn and Seifiert, Zeitschr.
f. Hyg. und Infectionskrankheiten, 1910, lxvi, p. 249 (case report; patient Swiss, moun­
tain guide—occurred after a visit to Peru; experimental transmission to apes; colored
illustrations of disease in the patient, and in an ape); Darling, Jour. Amer. Med.
Assoc, Dec, 23, 1911, p. 2071 (more especially as regards suspected organisms—with
references to findings of Barton, Galli-Valerio, Basset-Smith, Mayer, Laveran and
Carini, etc); Giltner, ibid., Dec 23, 1911, p. 2074 (with review); Barton, “De­
scription de elementos endo globulares hallados de fiebre verrucosa," Cron. Med.,
1909, xxvi, 7 (cited by Darling).

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crease in size, becoming as large as a nut or exceptionally as large as a
small orange, and break down. Crowded lesions, either of the surface or
the subcutaneous nodules, may undergo disintegration and result in the
formation of superficial fungoid ulcers. In some cases, as in a case
observed by me (a good replicate, but less extensive, of the case shown
in Sydenham’s atlas under the name of frambesia), the lesions are for
the most part small but numerous. In this case, as in others, such lesions
shrivel into black spots or specks on a level with the surface, which
exfoliate or drop off, leaving no trace. There is a tendency for the erup­
tion in some cases to come out in successive crops.

Etiology and Pathology.—The disease is peculiar to certain
valley districts of the Western Andes in Peru, the rare cases seen else-

Fig. 209.—Verruga peruana (case referred to in the text).

where, as the one seen by me in the Philadelphia Hospital referred to
above, having come from that country. It is inoculable, and the essen­
tial cause is considered (Yzquierdo)¹ to be a bacillus somewhat larger
than the tubercle bacillus. Barton and Darling and others have found
certain bacillus-like elements in the erythrocytes, Barton believing them
to be protozoa, and the specific agents of the disease; they appear in

¹ Yzquierdo, Archiv für path. Anat., etc, Berlin, 1885, vol. xciv, p. 411. Accord­
ing to Giltner (loc. cit.) natives of the infected districts are immune, and no authentic
case of infection by personal contact has been known to occur outside of infected dis­
tricts. Jadassohn (loc. cit.), however, produced the disease experimentally in an ape—
the inoculation material being obtained from a Swiss guide who had returned from a
visit to Peru.

VERRUGA PERUANA                                   861

the earlier febrile style, at first as slender rod-like forms with rounded
free ends and disappear about the time the eruption comes out. De­
bility from any cause is a predisposing factor. The connective-tissue
growths originating in the upper or lower part of the derma are vascular,
and some are cavernous.

A few observers (Manson, Scheube) consider the malady as yaws
modified by environmental conditions, but this view is not shared by
Hirsch, Plehn, Jeanselme, and others. Certainly both the objective
and constitutional characters, especially the latter, speak for its individu­
ality.

Fig. 210.—Verruga peruana (case referred to in the text).

The diagnosis in the early stages of the disease is difficult: it
may be made by exclusion, the fact being known that the patient has
resided in the affected district. As soon as the eruption comes out
the difficulty is solved, as it is peculiar and characteristic.

Prognosis and Treatment.—The disease is always to be con­
sidered grave; under favorable conditions the death-rate is about one
in six to eight; it is much higher when the disease is epidemic (Crocker).
The slow, sluggish cases, with scarcely any fever after the eruption
appears, are the most favorable. My case was under observation about
four weeks, and was gradually improving when he left the hospital.
The disease may last for weeks or months. Death may result before
the cutaneous eruption appears. Tonics, especially iron and quinin,
and stimulants, if necessary, are to be prescribed. It seems to be agreed

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that the eruptive tendency should be encouraged. Removing patient
from the affected region to the seashore is stated to be of great curative
value.

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