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REVIEW ARTICLE

The Language of Infectious Disease: A Light-Hearted Review

Ludwig A. Lettau
Lowcountry Infectious Diseases, Charleston, South Carolina

Contemporary terminology related to infectious disease (ID) is a patchwork collection that includes foreign words, slang, euphemisms, misnomers, acronyms, and a variety of other terms referring to people, places, foods, colors, and animals. The only constant of any language is change, and, from early concepts of contagion to modern day ID speak, the language of the eld has evolved in response to new developments in the identication, classication, epidemiology, diagnosis, and treatment of infectious agents and the associated diseases. This seriously light-hearted review of the ID language is in large part a personal perspective and commentary. Resources used include several dictionaries [13], the International Classication of Diseases, Ninth Revision (ICD-9), various other references as noted, and the authors experience and imagination. This review is written for the general ID community, but it may also be of interest to medical students, international medical graduates, ivy-covered professors in ivory towers, and aspiring authors of the hot zone type of infection-related ction. A Visit to the Graveyard Terms and expressions related to infection are conceived, go on to mature, and may eventually die of causes varying from disuse atrophy to political incorrectness. It seems appropriate to begin by paying due respect to a few deceased terms and expressions now found only in dictionaries, historical reviews, archival medical writings, and, surprisingly, the ICD-9. The latter includes many archaic termssuch as pseudoscarlatina, Chicago disease, Whitmores bacillus, uta, and Posada-Wernicke diseasethat have no meaning for most ID physicians in practice. Venereal disease (VD) has almost been eradicated! Unfortunately, this was accomplished mainly by a name change to sexually transmitted disease (STD), a substitution likely promoted by the Valentines Day ower and greeting card lobbies.
Received 5 January 2000; revised 1 May 2000; electronically published 4 October 2000. Reprints or correspondence: Dr. Ludwig A. Lettau, Lowcountry Infectious Diseases, 2093 Henry Tecklenburg Dr., Suite 308, Charleston, SC 29414 (llettau@awod.com).
Clinical Infectious Diseases 2000; 31:7348 2000 by the Infectious Diseases Society of America. All rights reserved. 1058-4838/2000/3103-0017$03.00

VD does still survive as part of the Venereal Disease Research Laboratory (VDRL) test. A number of deceased terms refer to other laboratory tests no longer in use, such as the quellung reaction and the Widal test. One notable acronym died in infancy: GRID was an acronym for gay-related immune deciency, an early term for AIDS in the 1980s. Death came quickly as a result of both political and epidemiological incorrectness. Lymphadenopathy-associated virushuman T cell lymphotropic virus type III (LAV-HTLV-III, or was it HTLV-III-LAV?) was the original name for HIV that was coined by the Centers for Disease Control and Prevention in an attempt to stay neutral with respect to conicting claims of the discovery of HIV by leading French and American researchers. A number of terms referring to upper respiratory tract infection have become obsolete. Inuenza used to be called grippe, but this term has been lost. Quinsy was a term for peritonsillar abscess, and angina referred to a sore throat due to any of a variety of causes. Angina has been usurped by the cardiologists and now only lives on in the ID eld as Ludwigs angina (one of my personal favorites) and as Vincents angina, although Vincents term is probably about to expire. Current Terms for Germs and Infectious Inrmities Because a specic etiology is never determined for most human infections that occur, some general terminology for microbes remains useful. The lay publics catchall term is germs, and health professionals use the terms pathogens, microbes, or, commonly, bugs. Like it or not, ID physicians are sometimes referred to as bug doctors or bug eas [4]. For a patient with the crud that is going around, the expression probably a virus is commonly cited for the presumed etiology. Unidentied perpetrators of infection. An unknown or incompletely characterized etiologic microbe is sometimes called an agent (e.g., the Delta agent) or is described as -like (e.g., Legionella-like and Norwalk viruslike). The disease itself may be called a syndrome (e.g., AIDS and chronic fatigue syndrome) or described with the -oid sufx (e.g., typhoid and erysipeloid) to denote similarity to a known entity. A disease of uncertain microbial etiology can also be named according to what the disease is not, by use of the prex non-. Examples include nonspecic urethritis, nontyphoid

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salmonellosis, and the current non-A, non-B, non-C, non-D, non-E, non-F, and non-G viral hepatitis. As the nomenclature of newly identied hepatotropic viruses marches through the alphabet, such terminology becomes more and more ponderous [5]. Certain infections can also be presumed by the clinical response to an antibioticthe so-called antibiotic deciency state. One example of this is doxycycline deciency, as evident in patients who have a clinical history, symptoms, signs, or laboratory test results suspicious for a rickettsial infection and then respond promptly to the drug. Sometimes persistent diarrhea turns out to be metronidazole deciency. Abbreviations of microbial names. Names of microorganisms are often long and unwieldy; thus, shortened forms are popular because they save time. They are often used for fungi (e.g., histo, blasto, and crypto) or bacteria (e.g., strep, staph, and actino). In other cases, such as in the shortening of Coccidioides immitis to cocci or Bacille CalmetteGue rin to BCG, uncertainty as to spelling and pronunciation would also favor use of a shortened form. Many shortened names for microbes simply consist of initials, such as HIV or MAC (Mycobacterium avium complex). Initials and acronyms are even more common when referring to drug-resistant bacteria, because adding wondercillin-resistant usually at least doubles the length of the name. The abbreviation MDR (multidrug resistant) is sometimes used as a prex, such as in MDR tuberculosis. IDs personied. It has been a common practice to honor leading researchers in the ID eld through the incorporation of their name into terminology. The honored persons name may be part of terminology of a genus, species, disease, syndrome, technique, laboratory test, set of criteria or postulates, clinical symptom or sign, or even a commercial product (Listerine). Sometimes multiple persons share hyphenated credit, although who gets top billing may be a matter of dispute; for example, Creutzfeldt-Jakob disease was at one time called Jakob-Creutzfeldt disease. Nonmedical persons are sometimes immortalized through nomenclature. A noted mycologist reportedly named a new Trichophyton species (T. gloriae) after his spouse (M. Rinaldi, personal communication). Celebrities are also sometimes honored. A few years ago a Chicago researcher named a new species Salmonella mjordan [6]. One would think that a species in a loftier-sounding genus such as Aeromonas or Helicobacter might have been more appropriate to honor Michael Jordan. The only connection between diarrhea and basketball that readily comes to mind is dribbling on the fast break. Because of the negative image of Salmonella, the salmon industry has been lobbying for years to get the name of the genus changed to something less offensive to their food product. However, perhaps because the genus is named for a pathologist,

Daniel Salmon, rather than the sh, the pleas of Big Salmon have fallen on deaf ears.

Shaking and Baking A shaking chill is a symptom frequently encountered in ID practice. A severe chill is called a rigor, sometimes vividly described as a bed-shaking chill. A patient of mine once exclaimed, I shook so hard my eyeglasses ew off. A more rigorous and quantitative classication of the magnitude of chills and shaking is provided by the rigor scale [7]. Several other cold-related terms are in use. Cold abscess refers to a collection of pus lacking the calor component, and therefore the expression qualies as an oxymoron. Cold sore would seem to be likewise, but cold in this case refers to induction of the lesion by rhinovirus infection. Finally, although procedural specialists in medicine get gold chains, we in the ID eld have only cold chains. Chills are typically followed by an elevation in the body temperature set point that we call a fever (most commonly dened by an oral temperature of 38.1C). However, it is well known to any experienced ID practitioner that an astounding proportion of our patients claim to have a much lower-thannormal baseline body temperature; thus, a temperature of 37.4C should be considered a signicant fever for them. Physicians commonly refer to a fever spike and the temperature curve, although the line connecting the measurements on the graphics page more often resembles the western skyline viewed from Denver. Adjectives describing fever patterns include continuous, remittent, intermittent, recurrent, and hectic, most of which mean little, particularly when ward nurses are plying febrile patients with acetaminophen at every 4-h opportunity. Fever and the heat of local inammation have generated many other terms and expressions that refer to elevated temperature. A fever itself is sometimes referred to as heat by surgeons, as in Any heat today? The formal term for fever is pyrexia, which is derived from the Greek stem word pyr, meaning re. Relatives often will describe the patient as burning up with a fever. Some names for infection refer directly to re, such as St. Anthonys re, which was a term for erysipelas. The ery agent of the Israelites is not a man from the Mossad but, rather, another name for lariasis [2]. There are dozens of IDs whose names include the word fever preceded by a descriptive symptom, sign, or epidemiological feature. Colorful disease names such as yellow fever, scarlet fever, and blackwater fever paint a vivid picture of a symptom or sign of the infection.

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A Broad Spectrum of Living Color Colors abound in the ID language and may refer to a symptom or sign or to some characteristic of a microorganism. Such terms span the visual spectrum, but red and its variations seem to be most common. We try to dismiss red herrings and to not miss red snappers. We see pinkeye, red throats, and red necks but not usually in the same patient. There is a Red Book, but it does not go into a red bag. There are both rose spots and roseola, but neither are caused by Roseomonas [8]. We see red diapers caused by Serratia, green nails caused by Pseudomonas, and purple urine bags caused by Klebsiella. There is black plague and white plague (tuberculosis), as well as black piedra and white piedra. A rapid dose of vancomycin may cause a red man, an overdose of rifampin may cause an orange person, and a high dose of chloramphenicol may cause a gray baby. Such antibiotic side effects serve to introduce the subject of antimicrobial use, an integral part of both the practice and the ID language. The Great Antimicrobial Wars Pathogenic microbes are the enemy, and military terms are commonly used to describe the battle against infection. For example, bacteria invade the lung by breaching host defenses in an attack of pneumonia. We boast of our armamentarium of big gun antibiotics with powerful bactericidal action. We long for an effective narrow-spectrum magic bullet to ght an infection, but too often we use broad-spectrum shotgun therapy that inicts major collateral damage on innocent bystander normal ora and peace-loving commensals. Such broad antibacterial coverage generally also includes the ora inhabiting the lower backside of the prescriber. The desired powerful action of an antimicrobial drug may be suggested by the trade name, which is always carefully chosen by the manufacturer. Word elements such as max, sup, dyna, and omni are incorporated to convey an aura of strength, superiority, or broad action [9]. Combining word elements are also used in drug names to designate a specic class of antimicrobial. Examples include vir for antivirals, ox for uoroquinolones, ceph for cephalosporins, and conazole for azole antifungal drugs. One exception is mycin, which is part of the name of drugs in at least 5 different classes of antibiotics (thus accounting for the consternation that results when a patient declares that he or she is allergic to all mycins). There appear to be rules of nomenclature that apply to certain classes of antimicrobials. For example, generic names of third-generation cephalosporins must consist of mind-boggling permutations of the letters c, f, t, z, and x. Another rule is that nucleoside-analogue antiretrovirals must have 3 names: an easy-to-forget generic name, a trade name, and an easy-to-remember designation of 3 letters and/or numbers (e.g., AZT or 3TC)and we wonder why medication adherence is a problem in the treatment of patients with HIV.

Other ID slang related to antimicrobial treatment includes bug juice or bug killer for antibiotics in general, amphoterrible for the unpleasant side effects of amphotericin B, and wondercillin or ceph-du-jour for the latest powerful broadspectrum antibiotic. Such medical slang and euphemisms are quite common in the ID language.

Slang and Euphemisms ID practice occasionally requires detailed description and discussion of sex, drug use, and disagreeable body secretions and excretions, as well as unpleasant medical conditions such as an STD, diarrhea, or ectoparasite infestation. It is not surprising, then, that slang and euphemisms spice up the ID language. Zesty liaisons and social diseases. Social disease is a euphemism for an STD, and most of the social diseases in turn have multiple other common names. Syphilis was called the great pox as it ravaged Europe in the years after Columbuss return from the New World. An international blame game was in full force at the time, because syphilis was also called the French disease by the English and Germans, the Spanish pox by the French, the Polish disease by the Russians, the Turkish disease by the Persians, and so on [3]. Lues is a more formal name for syphilis that is most often used when speaking about this infection at the bedside of the patient for whom the diagnosis is being considered. Bad blood as an old lay term for syphilis is just too ambiguous to be useful in the era of bloodborne viruses. Gonorrhea has been called a dose of the clap, just a dose, or just the clap. Ectoparasites. Lice and mites include most human ectoparasites, and they are often referred to generically as cooties or bugs. Pubic lice have classically been called crabs, although their microscopic appearance is rather more turtle-like. Colorful street names for pubic lice include crotch crickets, gentlemens companions, and neighbors to the south (head lice should logically then be called neighbors to the north). Body lice should really be called clothing lice, since they spend most of their time in the seams of clothing and only visit the skin to take a blood meal. Therefore, seam squirrels and pants rabbits are tting slang names. Scabies has been referred to as the 7-year itch, attesting to its capacity for chronic infestation. Scabies plagued Napoleon and his troops in epidemic proportions during the Russian campaign, perhaps explaining the mystery of why Napoleon has almost always been depicted with one hand inside his shirt (he was scratching himself). Diarrhea. Unpleasant gastrointestinal experiences have generated a variety of cute slang terms, such as technicolor yawn for vomiting. Diarrheal stools are generically called the runs or the trots. Giardiasis has at least 2 colorful synonyms: purple burps, which refers to the associated metallic gassy dyspepsia, and beaver fever, which stems from its possible

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acquisition as a result of drinking stream water contaminated by beavers. Analysis of the scatological euphemisms for travelers diarrhea reveals that almost all are made up of 2 parts [10]. First is the localizing word or expression that is usually a geographic reference to a specic city, region, or country. It can also refer to an ethnic group (Aztec 2-step) or a well-known deceased person associated with a certain region (Montezumas revenge). This person must have been wronged by others (travelers perhaps) while alive, and therefore his or her spirit is still extracting revenge to this day. Reference to a specic person also fullls the need to blame someone else for the intestinal misfortune rather than the travelers own promiscuous gormandizing. The second part of the typical euphemism for travelers diarrhea most often refers to some type of fast movement. Because the onset of travelers diarrhea may strike with an intense urge to purge to the point of impending fecal incontinence, the fast movement is usually locomotion in the direction of the nearest bathroom (back door sprint or Bangladash). The fast movement may also refer to the speed of peristalsis (coeliac ux). Other synonyms for travelers diarrhea may be completed with a reference to abdominal anatomy (Delhi belly), with a reference to the liquid nature of stools (Chile waters), or by simply adding the letter s to almost anything else, with the plurality used as an indicator of the multiple trips to the bathroom typically endured. To make the whole expression a little cuter and more memorable, it is helpful to use alliteration (Rome runs), rhyme (mummy tummy), or a play on words (Turkey trots). Many of these synonyms for travelers diarrhea might be considered by some to be politically incorrect. It is also likely in this be-sensitive-or-else era that many traditional names of IDs are now considered by some people to be offensive either to themselves or to some other group.

The AIDS era. Societal reaction to the AIDS epidemic in the 1980s was notable for the frequent insensitivity displayed toward patients and the disease in general. Early reference to AIDS as the Haitian disease is reminiscent of the international blame game that occurred with the great pox epidemic of the late 15th century in Europe. Undoubtedly, however, some people in other countries to this day refer to AIDS as the American disease. Other conditions. Words or phrases with both a negative connotation and any suggestion of a specic gender are verboten under the rules of political correctness [12]. Herpes becomes gender neutral with a change to his-n-herpes, as does cowpox with a change to bovinepox. With respect to the other poxes, because the words chicken and small both have negative connotations, changes to fowl-americanpox and size-challengedpox, respectively, would be appropriate.

Proposed Additions to the ID Vocabulary Aside from political correctnessdriven proposals for new terminology, there are a number of other words that are not in any ID dictionary but that, for various reasons, should be a part of our ofcial vocabulary. A good example of a word that should logically be in our lexicon is ergic, which would mean capable of responding to common skin-test antigens. Currently, the awkward double negative not anergic must be used to express the same concept. The -demic family of words describes the occurrence of disease in populations and includes epidemic (outbreak), endemic (background rate), and pandemic (widespread, possibly worldwide). One other family member is academic, which means very rare and usually only seen or spoken of in quaternary care institutions of higher learning. Several new -demic word-family members need to be introduced. The rst is circumdemic, which would refer to the going around nature of whatever u or other infectious condition happens to be circulating in a community at a given time. Another is emergidemic, which would describe an emerging infectious disease. Re- or neo- could be added as combining elements to distinguish reemergence of an old infectious disease versus emergence of a new one. For example, MDR tuberculosis was a neoemergidemic ID that was circumdemic in hospitals in New York City a few years ago. Another proposed addition to the family is pharmacodemic, which would describe the rate of prescription drug usage in a population over a given time. The standard and the newly proposed -demic word elements may also be combined as in the following example: quinolone use has been epipharmacodemic for several years in this country, and expandedspectrum quinolones are currently emergipharmacodemic. Epimedia should be a word to designate an outbreak of stories in the print or electronic media that are about either a small number of cases or merely the potential for occurrence

Politically Correct, Microbially Challenging Conditions The general concept of political correctness should come easily to us since ID specialists regularly do it with culture and sensitivity, although the political correctness crowd does seem to carry the process to extremes. Oriental sore makes Orientals sore. Infectious agents recognize neither race nor national boundaries; therefore, traditional infection names that include a nationality or race could be considered insensitive. Norwegian scabies was the name derived from Boecks original description of the entity in Norwegian persons with leprosy. A change in terminology to crusted scabies was proposed in 1976 but has never completely caught on [11]. One wonders whether Bolivians, Argentines, Venezuelans, or Koreans are actually bothered by the notoriety of having one of the hemorrhagic fevers named for their country, but no other names for these diseases have been proposed.

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of an infection or other health problem. Examples of recent epimedias, where the story-to-case ratio has been at least 100 (or more) to 1, have been mad cow disease, Ebola virus in the United States, and HIV antibodynegative AIDS. Urosepsis is a bona de word that has come into vogue in recent years and describes a septic state arising from a urinary tract infection. So why not expand -osepsis into a family of words to include arthrosepsis, pneumosepsis, enterosepsis, hepatobiliosepsis, and dermatosepsis? Neurosepsis would encompass all the possibilities of brain abscess, encephalitis, and meningitis in 1 word. In contrast to proposals for more-concise new words, there is also a need for increasing the complexity of some expressions. For example, an ID specialist tends to say bulls-eye or target lesion for the primary lesion of Lyme disease, whereas a dermatologist would always call it erythema chronicum migrans, which is much more impressive to patients and thirdparty payers. Dermatologists are acknowledged masters at creating elaborate latinized 3-part scientic names of skin lesions that sound diagnostic but are really only descriptive. In fact, whole books have been written on the subject of terminology in dermatology [13]. Accordingly, the itchy red bump skin problem seen in patients with AIDS should be called something like prurigo nodularis rubra, and the red man syndrome resulting from vancomycin-induced histamine release should be called hominis rubra glycopeptidogenica. Another time-honored but dull phrase that needs a complexity upgrade is fever of unknown origin. Although it does hint a bit of befuddlement, pyrexia perplexia sounds more impressive and more worthy of the extensive evaluation that is often required to make a diagnosis. Summary This eclectic review of various aspects of the ID language was never intended to be comprehensive. It was written to dem-

onstrate some evolutionary changes in our language, to point out a few of the quirks and idiosyncrasies, to highlight the colorful slang and euphemisms, to make suggestions for new terminology, and to have some fun in the process of doing so. Unbankable rewards of work in the ID eld include the thrill of the hunt for etiologic microbes, the power to prevent or cure otherwise lethal infection, and the excitement of meeting the challenges of emerging infectious agents and resistance to antimicrobial drugs. The richness of our language is the frosting on the ID cake. We should savor it also.

References 1. Stedmans medical dictionary. 26th ed. Baltimore: Williams and Wilkins, 1995. 2. Segen JC. Current med talk: a dictionary of medical terms, slang and jargon. Stamford, CT: Appleton and Lange, 1995. 3. Haubrich WS. Medical meanings: a glossary of word origins. Philadelphia: American College of Physicians, 1997. 4. Coombs RH, Chopra S, Schenk DR, Yutan E. Medical slang and its functions. Soc Sci Med 1993; 36:98798. 5. Lettau LA. Alphabet now complete: NIH discovers hepatitis Z virus. Ann Intern Med 1993; 119:167. 6. Johnson S, Shulman ST. Infectious diarrhea. In: Shulman ST, Phair JP, Peterson LR, Warren JR, eds. The biologic and clinical basis of infectious diseases. 5th ed. Philadelphia: WB Saunders, 1997:23562. 7. Lettau LA. The rigor scale. Infect Dis Clin Prac 1998; 7:399. 8. Rihs JD, Brenner DJ, Weaver RE, et al. Roseomonas, a new genus associated with bacteremia and other human infections. J Clin Microbiol 1993; 31: 327583. 9. Cortes E, Diaz J, Verghese A. Antibiotics: too many names. N Engl J Med 1993; 328:1047. 10. Lettau LA. On the run: emporiatric enteritis by every other name. StitchesThe Journal of Medical Humour 1997; 61:2731. 11. Spach DH, Fritsche TR. Scabies [letter]. N Engl J Med 1995; 332:6112. 12. Beard H, Cerf C. The ofcial politically correct dictionary and handbook. New York: Villard Books, 1994. 13. Carter RL. A dictionary of dermatologic terms. 4th ed. Baltimore: Williams and Wilkins, 1992.