1169
lymphadenitis-a complication rate of 5 3%. This rate is in striking contrast to the 0.68% and 0’09%, with x lO5andO.5 x 10s viable units, respectively, reported previously for the Pasteur severe
vaccine.’ Department of Surgery I, and Institute for Hygiene, University Hospital Innsbruck, 6020 Innsbruck, Austria
PAUL HENGSTER MANFRED FILLE GESINE MENARDI
1 Mahmoud ME, Monhim A. Evaluation of BCG vaccination in Bab E1 Shaaria zone-Cairo. Dev Biol Stand 1986; 58: 249-56. 2. Tidjani O, Amedome A, Dam HG. The protective effect of BCG vaccination of the newborn against childhood tuberculosis in an African community. Tubercle 1986; 67: 269-81. 3. Bollaq U, Bollaq-Albrecht E. Tuberculin reaction and the extent of the vaccination scar following BCG vaccination in newborn infants. Schweiz Med Wochenschr 1988, 118: 1001-03. 4. Stephan U, Haupt H, Scheier R, Nada A, Grimrath U, Schmitt HG. BCG vaccination of the newborn infant with the 131 Copenhagen strain. Klin Padiatr 1986; 198: 295-98. 5 Young TK, Hershfield ES. A case-control study to evaluate the effectiveness of mass neonatal BCG vaccination among Canadian Indians. Am J Publ Health 1986; 76: 783-86. 6. Nyerqes G, Drinoczy M. Significance of the number of viable units in BCG vaccines. Dev Biol Stand 1986; 58: 331-36. 7 Caglayan S, Yeguin O, Kayran K, Timocin N, Kasirga E, Gun M. Is medical therapy effective for regional lymphadenitis following BCG vaccination? Am J Dis Child
1987; 141: 1213-14.
Human
pathogenicity of Ehrlichia canis
SIR,7-Ehrlichia canis is a rickettsia responsible for a canine disease well known to veterinary surgeons and characterised by pancytopenia. In the first human case, described in 1986,1 an acute febrile illness followed a tick bite; intraleucocytic inclusions morphologically related to E canis were seen on light microscopy, and there was a specific seroconversion. More than fifty cases have been reported in the United States since that first description, the diagnosis being based on clinical findings and on a fourfold rise in titre to E canis on immunofluorescence.2 The pathogen has not been isolated from human cases. E canis infection has not been described outside the US. To assess the transmission of E canis from dog to man we did two serosurveys in enzootic foci of canine ehrlichiosis in Tunisia (Bizerte area) and Senegal (Dakar area). Sera from military dogs and their trainers were collected in May, 1989, and May, 1990, respectively, and tested by indirect immunofluorescence.3 In Tunisia 43 of 60 dogs (72%) and in Senegal 27 of 66 dogs (41 %) were seropositive, titres ranging from 20 to 5120. All 113 human sera (Tunisia 71, Senegal 42) were seronegative despite the fact that the handlers had been in contact with dogs for 2-11 years. The dogs were heavily infested with Rhipicephalus sanguineus and the trainers gave histories of frequent tick bites. These results raise questions about E canis vectors and even the susceptibility of man to this pathogen. US researchers noted that the geographical distribution of human cases was the same as for the tick Amblyomma americanum. This tick could be a better vector for E canis. Another possibility is that man is not susceptible to E canis and that it is another rickettsia or ehrlichia, serologically related to E canis, that is involved in human cases. The reservoir seems to be wild canids and the vector A americanum. Laboratory of Clinical Biology, Laveran Military Hospital, Marseille
D. PARZY
Military Veterinary Service, 13998 Marseille Armées, France
B. DAVOUST
Parasitology Laboratory,
G. BISSUEL E. VIDOR
Rhône Merieux, Lyon
1 Maeda K, Markowitz N, Hawley RC, Ristic M, Cox D, McDade JE. Human infection with Ehrlichia cams, a leukocytic nckettsia. N Engl J Med 1987; 316: 853-56. 2 McDade JE. Ehrlichiosis: a disease of animals and humans. J Infect Dis 1990; 161: 609-17. 3 Ristic M, Huxsoll DL, Weisiger RM, Hildebrandt PK, Nyindo MBA. Serological diagnosis of tropical canine pancytopenia by indirect immunofluorescence. Infect Immun 1972, 6: 226-31. 4. Eng T, Harkess J, Fishbein D, et al. Epidemiologic, clinical and laboratory findings of human ehrlichiosis in the United States, 1988. JAMA 1990; 264: 2251-58.
Chlamydia trachomatis detection and non-invasive sampling methods SIR,—The notion of analysing centrifuged urine deposits for Chlamydia trachomatis is not new. Culture techniques yielded disappointing results1 but interest has been revived after the demonstration that analysis of early morning first-catch urine specimens with enzyme immunoassay tests (EIA) or direct immunofluorescence (DIF) is sensitive.2,3 Most chlamydia tests are done in departments of genitourinary medicine. To arrange routinely for the collection of first-catch early morning urine samples to screen for chlamydia is unfeasible in most clinic settings since this would mean an extra clinic visit, which might deter many patients. In Sheffield our policy is to screen all new male and female attenders for chlamydial infection to identify symptom-free chlamydial carriage, as well as for epidemiological reasons. Although we encourage all male patients to hold their urine for at least four hours before urethral tests this is not always possible since many patients are seen on a walk-in basis. We have evaluated the efficacy of the use of first-catch urine sampling in screening, in all male patients irrespective of the time urine was held, and compared this with urethral swabbing. Urethral swabs and a first-catch urine sample were assayed for C trachomatis by an amplified ELISA (NovaNordisk) and all positive results were confirmed by direct immunofluorescence with a monoclonal antibody against the major outer-membrane protein (Syva, Microtrack). Of 227 patients, 136 were symptom-free and 91 had symptoms. C trachomatis antigen was detected in 47 (21 %) of these patients; 20 were symptom-free and 27 had symptoms. In the symptom-free group 13 had features of urethritis and 5 were sexual contacts of known chlamydiapositive individuals. Urine and urethral swabs were both positive in 31 (66%), and either urine or urethral swabs were so in 13 (28%) and 3 (6%), respectively. Urine samples therefore detected 44 (94%) and urethral swabs only 34 (72%) of all positive patients. Urine sampling in female attenders is of little value. Our results (455 new attenders) suggest that urethral carriage of chlamydia is infrequent (1-3% of all new attenders) compared with a frequency of 12-3% at the cervix. In only 0-2% of new attenders was there urethral carriage in the absence of cervical carriage. The presence of a positive urine in this group probably represents a contaminated sample. Urethral swabs are uncomfortable and often inadequately taken (swabs at a depth of 2-4 cm into the urethra are recommended). They remain necessary to make a rapid (microscopic) diagnosis of gonococcal infection or non-specific urethritis. However, in view of the growing evidence that non-invasive techniques are best in the detection of urethral chlamydia infection in men the need for repeat routine swabbing of the urethra should be reassessed. Department of Genitourinary Medicine, Royal Hallamshire Hospital, Sheffield S10 2JS, UK
PHLS,
R. PATEL G. R. KINGHORN
G. KUDESIA R. VANHEGAN
Northern General Hospital, Sheffield
1. Smith TF, Weed LA. Comparison of urethral swabs, urine and urinary sediment for the isolation of Chlamydia. J Clin Microbiol 1975; 2: 134-35. 2. Chernesky M, Castriciano S, Sellors J, et al. Detection of Chlamydia trachomatis antigens in urine as an alternative to swabs and culture. J Infect Dis 1990; 161: 124-26. 3. Caul O, Paul ID, Milne JD, Crowley T. Non-invasive sampling method for detecting Chlamydia trachomatis. Lancet 1988; ii: 1246.
Salmeterol rash SIR,-We wish to report a previously undocumented adverse reaction to salmeterol. A 32-year-old woman with asthma required five hospital admissions over six months despite inhaled beclomethasone dipropionate (2000 jig/day), 5 mg prednisolone, nebulised bronchodilators, and oral theophyllines. She denied any history of urticaria or drug rash. Salmeterol 2 puffs twice daily (25 jig/puff) from a metered-dose inhaler was introduced with both a good
lymphadenitis-a complication rate of 5 3%. This rate is in striking contrast to the 0.68% and 0’09%, with x lO5andO.5 x 10s viable units, respectively, reported previously for the Pasteur severe
vaccine.’ Department of Surgery I, and Institute for Hygiene, University Hospital Innsbruck, 6020 Innsbruck, Austria
PAUL HENGSTER MANFRED FILLE GESINE MENARDI
1 Mahmoud ME, Monhim A. Evaluation of BCG vaccination in Bab E1 Shaaria zone-Cairo. Dev Biol Stand 1986; 58: 249-56. 2. Tidjani O, Amedome A, Dam HG. The protective effect of BCG vaccination of the newborn against childhood tuberculosis in an African community. Tubercle 1986; 67: 269-81. 3. Bollaq U, Bollaq-Albrecht E. Tuberculin reaction and the extent of the vaccination scar following BCG vaccination in newborn infants. Schweiz Med Wochenschr 1988, 118: 1001-03. 4. Stephan U, Haupt H, Scheier R, Nada A, Grimrath U, Schmitt HG. BCG vaccination of the newborn infant with the 131 Copenhagen strain. Klin Padiatr 1986; 198: 295-98. 5 Young TK, Hershfield ES. A case-control study to evaluate the effectiveness of mass neonatal BCG vaccination among Canadian Indians. Am J Publ Health 1986; 76: 783-86. 6. Nyerqes G, Drinoczy M. Significance of the number of viable units in BCG vaccines. Dev Biol Stand 1986; 58: 331-36. 7 Caglayan S, Yeguin O, Kayran K, Timocin N, Kasirga E, Gun M. Is medical therapy effective for regional lymphadenitis following BCG vaccination? Am J Dis Child
1987; 141: 1213-14.
Human
pathogenicity of Ehrlichia canis
SIR,7-Ehrlichia canis is a rickettsia responsible for a canine disease well known to veterinary surgeons and characterised by pancytopenia. In the first human case, described in 1986,1 an acute febrile illness followed a tick bite; intraleucocytic inclusions morphologically related to E canis were seen on light microscopy, and there was a specific seroconversion. More than fifty cases have been reported in the United States since that first description, the diagnosis being based on clinical findings and on a fourfold rise in titre to E canis on immunofluorescence.2 The pathogen has not been isolated from human cases. E canis infection has not been described outside the US. To assess the transmission of E canis from dog to man we did two serosurveys in enzootic foci of canine ehrlichiosis in Tunisia (Bizerte area) and Senegal (Dakar area). Sera from military dogs and their trainers were collected in May, 1989, and May, 1990, respectively, and tested by indirect immunofluorescence.3 In Tunisia 43 of 60 dogs (72%) and in Senegal 27 of 66 dogs (41 %) were seropositive, titres ranging from 20 to 5120. All 113 human sera (Tunisia 71, Senegal 42) were seronegative despite the fact that the handlers had been in contact with dogs for 2-11 years. The dogs were heavily infested with Rhipicephalus sanguineus and the trainers gave histories of frequent tick bites. These results raise questions about E canis vectors and even the susceptibility of man to this pathogen. US researchers noted that the geographical distribution of human cases was the same as for the tick Amblyomma americanum. This tick could be a better vector for E canis. Another possibility is that man is not susceptible to E canis and that it is another rickettsia or ehrlichia, serologically related to E canis, that is involved in human cases. The reservoir seems to be wild canids and the vector A americanum. Laboratory of Clinical Biology, Laveran Military Hospital, Marseille
D. PARZY
Military Veterinary Service, 13998 Marseille Armées, France
B. DAVOUST
Parasitology Laboratory,
G. BISSUEL E. VIDOR
Rhône Merieux, Lyon
1 Maeda K, Markowitz N, Hawley RC, Ristic M, Cox D, McDade JE. Human infection with Ehrlichia cams, a leukocytic nckettsia. N Engl J Med 1987; 316: 853-56. 2 McDade JE. Ehrlichiosis: a disease of animals and humans. J Infect Dis 1990; 161: 609-17. 3 Ristic M, Huxsoll DL, Weisiger RM, Hildebrandt PK, Nyindo MBA. Serological diagnosis of tropical canine pancytopenia by indirect immunofluorescence. Infect Immun 1972, 6: 226-31. 4. Eng T, Harkess J, Fishbein D, et al. Epidemiologic, clinical and laboratory findings of human ehrlichiosis in the United States, 1988. JAMA 1990; 264: 2251-58.
Chlamydia trachomatis detection and non-invasive sampling methods SIR,—The notion of analysing centrifuged urine deposits for Chlamydia trachomatis is not new. Culture techniques yielded disappointing results1 but interest has been revived after the demonstration that analysis of early morning first-catch urine specimens with enzyme immunoassay tests (EIA) or direct immunofluorescence (DIF) is sensitive.2,3 Most chlamydia tests are done in departments of genitourinary medicine. To arrange routinely for the collection of first-catch early morning urine samples to screen for chlamydia is unfeasible in most clinic settings since this would mean an extra clinic visit, which might deter many patients. In Sheffield our policy is to screen all new male and female attenders for chlamydial infection to identify symptom-free chlamydial carriage, as well as for epidemiological reasons. Although we encourage all male patients to hold their urine for at least four hours before urethral tests this is not always possible since many patients are seen on a walk-in basis. We have evaluated the efficacy of the use of first-catch urine sampling in screening, in all male patients irrespective of the time urine was held, and compared this with urethral swabbing. Urethral swabs and a first-catch urine sample were assayed for C trachomatis by an amplified ELISA (NovaNordisk) and all positive results were confirmed by direct immunofluorescence with a monoclonal antibody against the major outer-membrane protein (Syva, Microtrack). Of 227 patients, 136 were symptom-free and 91 had symptoms. C trachomatis antigen was detected in 47 (21 %) of these patients; 20 were symptom-free and 27 had symptoms. In the symptom-free group 13 had features of urethritis and 5 were sexual contacts of known chlamydiapositive individuals. Urine and urethral swabs were both positive in 31 (66%), and either urine or urethral swabs were so in 13 (28%) and 3 (6%), respectively. Urine samples therefore detected 44 (94%) and urethral swabs only 34 (72%) of all positive patients. Urine sampling in female attenders is of little value. Our results (455 new attenders) suggest that urethral carriage of chlamydia is infrequent (1-3% of all new attenders) compared with a frequency of 12-3% at the cervix. In only 0-2% of new attenders was there urethral carriage in the absence of cervical carriage. The presence of a positive urine in this group probably represents a contaminated sample. Urethral swabs are uncomfortable and often inadequately taken (swabs at a depth of 2-4 cm into the urethra are recommended). They remain necessary to make a rapid (microscopic) diagnosis of gonococcal infection or non-specific urethritis. However, in view of the growing evidence that non-invasive techniques are best in the detection of urethral chlamydia infection in men the need for repeat routine swabbing of the urethra should be reassessed. Department of Genitourinary Medicine, Royal Hallamshire Hospital, Sheffield S10 2JS, UK
PHLS,
R. PATEL G. R. KINGHORN
G. KUDESIA R. VANHEGAN
Northern General Hospital, Sheffield
1. Smith TF, Weed LA. Comparison of urethral swabs, urine and urinary sediment for the isolation of Chlamydia. J Clin Microbiol 1975; 2: 134-35. 2. Chernesky M, Castriciano S, Sellors J, et al. Detection of Chlamydia trachomatis antigens in urine as an alternative to swabs and culture. J Infect Dis 1990; 161: 124-26. 3. Caul O, Paul ID, Milne JD, Crowley T. Non-invasive sampling method for detecting Chlamydia trachomatis. Lancet 1988; ii: 1246.
Salmeterol rash SIR,-We wish to report a previously undocumented adverse reaction to salmeterol. A 32-year-old woman with asthma required five hospital admissions over six months despite inhaled beclomethasone dipropionate (2000 jig/day), 5 mg prednisolone, nebulised bronchodilators, and oral theophyllines. She denied any history of urticaria or drug rash. Salmeterol 2 puffs twice daily (25 jig/puff) from a metered-dose inhaler was introduced with both a good
