826
relevant (Aug 24, p 507). In reality, the daily dose may be four times this amount, and not uncommonly eight or more times greater (though this is beyond the recommended dose). My concern is that daily repeated doses of highly concentrated bromide applied directly to the airway epithelium may increase the amount of bromide available to eosinophils for the production of tissue-damaging brominating oxidants. Little is known about the chemistry of bromine in man, and the calculated influences of bromide concentrations in lung fluids, while arithmetically accurate, remain physiologically speculative. We need to find out by experiment if the bromide in fenoterol is available to activated eosinophils and whether repeated daily doses of it can increase the production of brominating oxidants. Department of Medicine, University of Sydney, Sydney, NSW 2006, Australia
W. F. GREEN
might have increased the likelihood of tuberculosis transmission in these patients who had both disseminated infection and extensive lung disease. Nurses are skin tested when appointed and annually thereafter. During 1990, only 3 (0-4%) of 774 nurses tested at our hospital had a positive PPD skin test, 2 of whom are included in this report. The risk of tuberculosis exposure to skin-test-negative staff in our hospital is probably unavoidable since most of our nurses test negative and exposure to infected patients or visitors might take place before the diagnosis of tuberculosis is even suspected. Our finding of PPD conversion in 4 workers, coincident with exposure to these 2 infants and with no other contact with tuberculosis, suggests that transmission by infants is possible. Any patient with known or suspected tuberculosis should be regarded as infectious and isolated, as suggested by the Centers for Disease spasms
Control.9 Division of Pediatric Infectious Diseases,
PPD skin test conversion in health-care workers after exposure to Mycobacterium tuberculosis infection in infants SiR,—The transmission of Mycobacterium tuberculosis from infants and children to their contacts is regarded as unlikely because the infant’s organism load is low, cavitary disease is usually absent, and they have a reduced ability to expectorate sputum.1-3 As such, respiratory isolation for infants with tuberculosis is generally not required.’ We report probable transmission of M tuberculosis to patient-care providers after exposure to infected infants. Patient 1-A 14-month-old boy was admitted for evaluation of failure to thrive, fever, and cervical lymphadenopathy. He was born very prematurely and had severe developmental delay. A chest radiograph revealed left upper lobe consolidation superimposed on chronic lung disease changes; no cavity was present. Acid-fast organisms were noted on direct stain of sputum and lymph node. M tuberculosis was recovered from cultures of urine, lymph node, sputum, and bone marrow. Contact tracing identified the child’s father as having active pulmonary tuberculosis. The father was present at the child’s admission and resumed visiting three weeks later while receiving antituberculous treatment. The child was transferred to a negative-pressure isolation room and the father was instructed to wear a mask at all times, as were staff when the father was present. Since the child needed frequent suctioning and chest physiotherapy, health-care workers with direct exposure to the patient were identified and offered PPD skin testing. 50 of 61 exposed personnel had skin testing 12 weeks after exposure, and 2 mm nurses and 1 medical student were PPD-positive (> 10 induration); all had negative tests within the previous 12 months. 1 nurse was exposed on the evening of admission, and the other had tended the patient for four 12 h work shifts before treatment was started. The medical student was exposed during 16 working days. Transmission from the father to the first nurse and the medical student cannot be ruled out. The second nurse was never exposed to the father. These 3 staff had had no other contact with tuberculosis. Patient 2-A 5-month-old infant was admitted for persistent left upper lobe pneumonia, fever, and weight loss. Acid-fast organisms were present on direct stain of a gastric aspirate. M tuberculosis was recovered in culture from gastric aspirate and cerebrospinal fluid. Both parents were PPD non-reactive and had normal chest radiographs. The infant had a prominent cough while in hospital but was not in respiratory isolation. Of 33 exposed health-care providers, 28 were tested within 8 weeks and again at 12 weeks after exposure. 1 nurse had a 10 mm induration PPD skin test 7 weeks after her first exposure. She had cared for this patient during five 12 h work shifts, two of which were before treatment. She had had a negative PPD skin test 3 months previously and no other contact with tuberculosis in the preceding 12 months. Nosocomial transmission of tuberculosis by infected adults is known, but there is little information about tuberculosis transmission in paediatric facilities. Our 2 infants were cared for in private rooms on a 24-bed general paediatric medical unit, and no other children had tuberculosis at this time. Frequent oropharyngeal suctioning, chest physiotherapy, and coughing
University of Louisville School of Medicine, Kosair Children’s Hospital, Louisville, Kentucky 40292, USA
GERARD RABALAIS GARRETT ADAMS BETH STOVER
1. Wallgren A. On contagiousness of childhood tuberculosis. Acta Paediatr Scand 1937, 22: 229-34. 2. Starke JR. Modern approaches to the diagnosis and treatment of tuberculosis in children. Pediatr Clin N Am 1988; 35: 441-64. 3. Smith MHD. Tuberculosis in children and adolescents. Clin Chest Med 1989, 10: 381-95. 4. Garner JS, Simmons BP. Guidelines for isolation precautions in hospitals. Infect Control 1983; 4 (suppl): 316-49. 5. CDC. Nosocomial transmission of multi-drug resistant tuberculosis to health care workers and HIV-infected patients in an urban hospital-Florida. MMWR 1990; 39: 718-22. 6. Catanzaro A. Nosocomial tuberculosis. Am Rev Respir Dis 1982; 125: 559-62. 7. Ehrenkranz NJ, Kicklighter JL. Tuberculosis outbreak in a general hospital; evidence of airborne spread of infection. Ann Intern Med 1972; 77: 377-82. 8. George RH, Bully PR, Gill ON, et al An outbreak of tuberculosis in a children’s hospital. J Hosp Infect 1986; 8: 129-42. 9. CDC. Guidelines for preventing the transmission of tuberculosis in health-care settings, with special focus on HIV-related issues. MMWR 1990; 39 (RR-17). 1-29.
Detecting splenomegaly by ultrasound SiR,—The spleen rate is a useful index of malaria endemicity. Palpation has long been used to measure spleen size and the proportion of individuals, especially children, with palpable splenomegaly is often estimated before control measures are introduced. However, palpation is subjective; it needs considerable experience and skill, and children are often frightened, showing resistance in the form of abdominal muscle stiffness. Ultrasonography (US) has been introduced in schistosomiasis and hydatid disease,1-3 and it has also been used to evaluate the spleen size of newborn babies in malarious and non-malarious regions of Papua New Guinea.4 Our study was in the Solomon Islands, where malaria is highly endemic. The aims were to try out a simple portable US machine and to compare parasite rates with measured spleen size. We examined 84 clinic patients with symptoms or signs of malaria such as fever and chills. Their ages ranged from 1 to 50 years and there were 44 males and 40 females. 34 were less than 15 years old. The US equipment weighed only 6 kg (Yokogawa type ULT-50) and had a ’Polaroid’ recording system. Subcostal, intracostal, and sagittal scans of the spleen were done with the patient lying on his or her left side. After adjustment to give optically the largest section area in the longitudinal and transverse planes, spleen length, depth, and/or breadth were measured, and volume was calculated by Dittrich’s formula.s Thick and thin blood films were examined immediately by a fluorescent dye staining combined with acridine-orange and interference filters6 using sunlight or a halogen beam. Other films were fixed and stained with Giemsa. Among patients less than 15 years old, only 3 were detected by palpation to have splenomegaly. 2 were positive for malaria parasites (fluorescent dye method). Among the remaining 31 patients, 12 were positive for malaria parasites. According to Dittrich, calculated spleen volume increases in relation to height during childhood. In 16 of the 34 children spleen volume exceeded the upper limit of normal for age. 12 of these some
827
Louse-borne
relapsing fever in Ethiopia
SIR,-Louse-borne relapsing fever (LBRF) is an acute febrile illness caused by the spirochaete Borrelia recurrentis, and it is transmitted to man by body lice.’ A huge epidemic during the 1939-45 war caused 50 000 deaths in North Africa and Europe.2 In northern Ethiopia 30 years of war came to an end in May, 1991. Relapsing fever is endemic in Ethiopia.3 We describe here an outbreak due to the return to their original recruitment areas of soldiers after the end of the fighting. Crowding, poverty, the cold season, and lack of hygiene resulted in an outbreak of LBRF in the Arssi region of southern Ethiopia. Between May and August, 1991, in the regional referral hospital of Asella, we recorded a significant increase to 104 cases out of 370 medical admissions; figures were 7/306, 4/377, and 0/375 for the same period in 1988, 1989, and 1990, respectively. 80% of cases were adults. Among the adults 50% were ex-soldiers and about 30% had a strong contact history with soldiers. All the cases included in this series were confirmed by blood smear and were admitted to hospital for treatment with low-dose penicillin.3 The in-hospital case fatality rate was 3-8%. Delousing and health education are being sustained in the Arssi region. This epidemic underlines the risk of relapsing fever beyond the immediate consequences of a war.
I>uay
y
n
Distribution of calculated
e
i
g
n
zc
m l
FILIPPO CHIABRERA
splenic volumes of children
according to height.
1.
. = P falciparum positive in blood. Oblique lines show (±2 SD) of normal spleen volume.
mean
children were positive for malaria parasites (figure), the other 4 having a history of recent malaria infection. Only 1 malaria-positive case with very low parasitaemia did not exhibit splenomegaly by US examination. In adults, spleen volume showed no correlation with malaria parasites in the bloodstream. In this study, most patients under 15 years old with malaria were detected by US examination; palpation was not helpful. Since US is simple, quick, and non-invasive, and since it can measure even a low to mild degree of spleen enlargement, it should be useful in assessing splenomegaly rates and in the monitoring of responses to, for
example, chemotherapy. Supported by a grant from the International Scientific Research Programme, Ministry of Education, Science and Culture, Japan. We thank the Ministry of Health and Medical Services, Solomon Islands for support, and Prof M. Sasa, Dr H. Suzuki, Dr P. F. Billingsley, and Ms M. Takagi for cooperation. Institute of Basic Medical Sciences, Tsukaba University
H. OHMAE
Department of Medical Zoology, Nagoya University School of Medicine
F. KAWAMOTO
Galloway RE, Levin J, Butler T, et al. Activation of protein mediators of inflanimation and evidence for entodoxemia in Borrelia recurrentis infection. Am J Med 1977; 63: 933-38.
2. Felsenfeld O. Borrelia
strains, vectors, human and animal borreliosis. St Louis: Warren H Green: 180. 3. Knaak RH, Wright LJ, Leithad CS, et al Penicillin vs tetracycline in the treatment of louse-born relapsing fever: a preliminary report. Ethiop Med J 1972; 10: 15-22.
Macular
degeneration of unknown origin
in
Tanzania SIR,-We report a form of macular degeneration accompanied by optic atrophy which seems to be new. During 1988, ophthalmologists at the Muhimbili Medical Centre, Tanzania, began to see Africans of both sexes, mainly aged 10-25 years, with sudden onset of painless bilateral loss of central vision. In 61 patients the visual loss occurred simultaneously in both eyes, at different times of the day, and was not associated with any particular activity. Vision was usually 6/36 or 6/60 at presentation. In 9 (15%) patients the vision spontaneously recovered to 6/6 within nine months. In most, however, it remained between 6/36 and finger counting at 1 m. Eyes were examined with a Haag-Streit 900 slit lamp and indirect ophthalmoscopy. In all patients, the pupils reacted briskly to light, the anterior segments were normal, and intraocular pressure was raised. Generalised thinning of the central retina and loss of the foveal reflex was seen. The pigment beneath the macula was dispersed and clumped; sometimes it formed a small ring (6 patients). 52 (85%) patients had pallor and atrophy of a 50°-60° temporal sector of each optic disc. The thinned retina corresponded to this sector, and was sharply demarcated within the main temporal vessel arcades. In 36 patients atrophy of some narrow nerve-fibre bundles was seen, radiating superotemporally or inferotemporally. The patients belonged to 35 different tribes and to all religious affiliations, and were well nourished. No Indians, Arabs, or Europeans presented. 18 (30%) were schoolchildren and 11 (18%) were housewives; the remainder were working men. There was no clustering related to places of residence or work, or within families. 4 of 37 patients and 4 of 37 controls tested were HIV positive. Headache was frequently noted at the onset of the visual problem; mouth sores or angular stomatitis (n 4), and hearing loss (n 4) were occasionally noted. Various drugs had been taken in the previous 2 years-mainly antimalarials and analgesics. There was no evidence of alcohol or drug abuse. The fundus appearance resembled the mild pigment stippling or mottling beneath the macula and loss of foveal reflexes
not
Department of Parasitology, National Institute of Health,
Tokyo 141, Japan
GIULIO BORGNOLO BELAYNEH HAILU
Asella Hospital, PO Box 15, Asella, Arssi Region, Ethiopia
A. ISHII
Ministry of
Health and Medical Service, Honiara, Solomon Islands
J. LEAFASIA
Medical Training and Resource Institute, Honiara
N. KERE
1. Houston S. Ultrasound: appropnate
technology for tropical field work. Trans R Soc Trop Med Hyg 1991; 85: 321-23. 2. Degremont A, Burki A, Burnier E, Schweizer W, Meudt B, Tanner M. Value of ultrasonography m investigating morbidity due to Schistosoma haematobium infection. Lancet 1985; i: 662-65. 3. Poltera AA, Renya O, Zea Flores G, Nowell De Arevalo AM, Beltranena F. Detection
of skin nodules in onchocerciasis by ultrasound scans. Lancet 1987; i: 505. 4. Corkill JA, Brabin BJ, Macgregor DF, Alpers MP, Milner RD. Newborn splenic volumes vary under different malaria endemic conditions. ArchDis Child 1889; 64: 541-45. 5. Dittrich M, Milde S, Dinkel E, Baumann W, Weizel D. Sonographic biometry of liver and spleen size in childhood. Paediatr Radiol 1983; 12: 206-11. 6. Kawamoto F. Rapid diagnosis of malaria by fluorescence microscopy with light microscope and interference filter. Lancet 1991; 337: 200-02.
=
=
relevant (Aug 24, p 507). In reality, the daily dose may be four times this amount, and not uncommonly eight or more times greater (though this is beyond the recommended dose). My concern is that daily repeated doses of highly concentrated bromide applied directly to the airway epithelium may increase the amount of bromide available to eosinophils for the production of tissue-damaging brominating oxidants. Little is known about the chemistry of bromine in man, and the calculated influences of bromide concentrations in lung fluids, while arithmetically accurate, remain physiologically speculative. We need to find out by experiment if the bromide in fenoterol is available to activated eosinophils and whether repeated daily doses of it can increase the production of brominating oxidants. Department of Medicine, University of Sydney, Sydney, NSW 2006, Australia
W. F. GREEN
might have increased the likelihood of tuberculosis transmission in these patients who had both disseminated infection and extensive lung disease. Nurses are skin tested when appointed and annually thereafter. During 1990, only 3 (0-4%) of 774 nurses tested at our hospital had a positive PPD skin test, 2 of whom are included in this report. The risk of tuberculosis exposure to skin-test-negative staff in our hospital is probably unavoidable since most of our nurses test negative and exposure to infected patients or visitors might take place before the diagnosis of tuberculosis is even suspected. Our finding of PPD conversion in 4 workers, coincident with exposure to these 2 infants and with no other contact with tuberculosis, suggests that transmission by infants is possible. Any patient with known or suspected tuberculosis should be regarded as infectious and isolated, as suggested by the Centers for Disease spasms
Control.9 Division of Pediatric Infectious Diseases,
PPD skin test conversion in health-care workers after exposure to Mycobacterium tuberculosis infection in infants SiR,—The transmission of Mycobacterium tuberculosis from infants and children to their contacts is regarded as unlikely because the infant’s organism load is low, cavitary disease is usually absent, and they have a reduced ability to expectorate sputum.1-3 As such, respiratory isolation for infants with tuberculosis is generally not required.’ We report probable transmission of M tuberculosis to patient-care providers after exposure to infected infants. Patient 1-A 14-month-old boy was admitted for evaluation of failure to thrive, fever, and cervical lymphadenopathy. He was born very prematurely and had severe developmental delay. A chest radiograph revealed left upper lobe consolidation superimposed on chronic lung disease changes; no cavity was present. Acid-fast organisms were noted on direct stain of sputum and lymph node. M tuberculosis was recovered from cultures of urine, lymph node, sputum, and bone marrow. Contact tracing identified the child’s father as having active pulmonary tuberculosis. The father was present at the child’s admission and resumed visiting three weeks later while receiving antituberculous treatment. The child was transferred to a negative-pressure isolation room and the father was instructed to wear a mask at all times, as were staff when the father was present. Since the child needed frequent suctioning and chest physiotherapy, health-care workers with direct exposure to the patient were identified and offered PPD skin testing. 50 of 61 exposed personnel had skin testing 12 weeks after exposure, and 2 mm nurses and 1 medical student were PPD-positive (> 10 induration); all had negative tests within the previous 12 months. 1 nurse was exposed on the evening of admission, and the other had tended the patient for four 12 h work shifts before treatment was started. The medical student was exposed during 16 working days. Transmission from the father to the first nurse and the medical student cannot be ruled out. The second nurse was never exposed to the father. These 3 staff had had no other contact with tuberculosis. Patient 2-A 5-month-old infant was admitted for persistent left upper lobe pneumonia, fever, and weight loss. Acid-fast organisms were present on direct stain of a gastric aspirate. M tuberculosis was recovered in culture from gastric aspirate and cerebrospinal fluid. Both parents were PPD non-reactive and had normal chest radiographs. The infant had a prominent cough while in hospital but was not in respiratory isolation. Of 33 exposed health-care providers, 28 were tested within 8 weeks and again at 12 weeks after exposure. 1 nurse had a 10 mm induration PPD skin test 7 weeks after her first exposure. She had cared for this patient during five 12 h work shifts, two of which were before treatment. She had had a negative PPD skin test 3 months previously and no other contact with tuberculosis in the preceding 12 months. Nosocomial transmission of tuberculosis by infected adults is known, but there is little information about tuberculosis transmission in paediatric facilities. Our 2 infants were cared for in private rooms on a 24-bed general paediatric medical unit, and no other children had tuberculosis at this time. Frequent oropharyngeal suctioning, chest physiotherapy, and coughing
University of Louisville School of Medicine, Kosair Children’s Hospital, Louisville, Kentucky 40292, USA
GERARD RABALAIS GARRETT ADAMS BETH STOVER
1. Wallgren A. On contagiousness of childhood tuberculosis. Acta Paediatr Scand 1937, 22: 229-34. 2. Starke JR. Modern approaches to the diagnosis and treatment of tuberculosis in children. Pediatr Clin N Am 1988; 35: 441-64. 3. Smith MHD. Tuberculosis in children and adolescents. Clin Chest Med 1989, 10: 381-95. 4. Garner JS, Simmons BP. Guidelines for isolation precautions in hospitals. Infect Control 1983; 4 (suppl): 316-49. 5. CDC. Nosocomial transmission of multi-drug resistant tuberculosis to health care workers and HIV-infected patients in an urban hospital-Florida. MMWR 1990; 39: 718-22. 6. Catanzaro A. Nosocomial tuberculosis. Am Rev Respir Dis 1982; 125: 559-62. 7. Ehrenkranz NJ, Kicklighter JL. Tuberculosis outbreak in a general hospital; evidence of airborne spread of infection. Ann Intern Med 1972; 77: 377-82. 8. George RH, Bully PR, Gill ON, et al An outbreak of tuberculosis in a children’s hospital. J Hosp Infect 1986; 8: 129-42. 9. CDC. Guidelines for preventing the transmission of tuberculosis in health-care settings, with special focus on HIV-related issues. MMWR 1990; 39 (RR-17). 1-29.
Detecting splenomegaly by ultrasound SiR,—The spleen rate is a useful index of malaria endemicity. Palpation has long been used to measure spleen size and the proportion of individuals, especially children, with palpable splenomegaly is often estimated before control measures are introduced. However, palpation is subjective; it needs considerable experience and skill, and children are often frightened, showing resistance in the form of abdominal muscle stiffness. Ultrasonography (US) has been introduced in schistosomiasis and hydatid disease,1-3 and it has also been used to evaluate the spleen size of newborn babies in malarious and non-malarious regions of Papua New Guinea.4 Our study was in the Solomon Islands, where malaria is highly endemic. The aims were to try out a simple portable US machine and to compare parasite rates with measured spleen size. We examined 84 clinic patients with symptoms or signs of malaria such as fever and chills. Their ages ranged from 1 to 50 years and there were 44 males and 40 females. 34 were less than 15 years old. The US equipment weighed only 6 kg (Yokogawa type ULT-50) and had a ’Polaroid’ recording system. Subcostal, intracostal, and sagittal scans of the spleen were done with the patient lying on his or her left side. After adjustment to give optically the largest section area in the longitudinal and transverse planes, spleen length, depth, and/or breadth were measured, and volume was calculated by Dittrich’s formula.s Thick and thin blood films were examined immediately by a fluorescent dye staining combined with acridine-orange and interference filters6 using sunlight or a halogen beam. Other films were fixed and stained with Giemsa. Among patients less than 15 years old, only 3 were detected by palpation to have splenomegaly. 2 were positive for malaria parasites (fluorescent dye method). Among the remaining 31 patients, 12 were positive for malaria parasites. According to Dittrich, calculated spleen volume increases in relation to height during childhood. In 16 of the 34 children spleen volume exceeded the upper limit of normal for age. 12 of these some
827
Louse-borne
relapsing fever in Ethiopia
SIR,-Louse-borne relapsing fever (LBRF) is an acute febrile illness caused by the spirochaete Borrelia recurrentis, and it is transmitted to man by body lice.’ A huge epidemic during the 1939-45 war caused 50 000 deaths in North Africa and Europe.2 In northern Ethiopia 30 years of war came to an end in May, 1991. Relapsing fever is endemic in Ethiopia.3 We describe here an outbreak due to the return to their original recruitment areas of soldiers after the end of the fighting. Crowding, poverty, the cold season, and lack of hygiene resulted in an outbreak of LBRF in the Arssi region of southern Ethiopia. Between May and August, 1991, in the regional referral hospital of Asella, we recorded a significant increase to 104 cases out of 370 medical admissions; figures were 7/306, 4/377, and 0/375 for the same period in 1988, 1989, and 1990, respectively. 80% of cases were adults. Among the adults 50% were ex-soldiers and about 30% had a strong contact history with soldiers. All the cases included in this series were confirmed by blood smear and were admitted to hospital for treatment with low-dose penicillin.3 The in-hospital case fatality rate was 3-8%. Delousing and health education are being sustained in the Arssi region. This epidemic underlines the risk of relapsing fever beyond the immediate consequences of a war.
I>uay
y
n
Distribution of calculated
e
i
g
n
zc
m l
FILIPPO CHIABRERA
splenic volumes of children
according to height.
1.
. = P falciparum positive in blood. Oblique lines show (±2 SD) of normal spleen volume.
mean
children were positive for malaria parasites (figure), the other 4 having a history of recent malaria infection. Only 1 malaria-positive case with very low parasitaemia did not exhibit splenomegaly by US examination. In adults, spleen volume showed no correlation with malaria parasites in the bloodstream. In this study, most patients under 15 years old with malaria were detected by US examination; palpation was not helpful. Since US is simple, quick, and non-invasive, and since it can measure even a low to mild degree of spleen enlargement, it should be useful in assessing splenomegaly rates and in the monitoring of responses to, for
example, chemotherapy. Supported by a grant from the International Scientific Research Programme, Ministry of Education, Science and Culture, Japan. We thank the Ministry of Health and Medical Services, Solomon Islands for support, and Prof M. Sasa, Dr H. Suzuki, Dr P. F. Billingsley, and Ms M. Takagi for cooperation. Institute of Basic Medical Sciences, Tsukaba University
H. OHMAE
Department of Medical Zoology, Nagoya University School of Medicine
F. KAWAMOTO
Galloway RE, Levin J, Butler T, et al. Activation of protein mediators of inflanimation and evidence for entodoxemia in Borrelia recurrentis infection. Am J Med 1977; 63: 933-38.
2. Felsenfeld O. Borrelia
strains, vectors, human and animal borreliosis. St Louis: Warren H Green: 180. 3. Knaak RH, Wright LJ, Leithad CS, et al Penicillin vs tetracycline in the treatment of louse-born relapsing fever: a preliminary report. Ethiop Med J 1972; 10: 15-22.
Macular
degeneration of unknown origin
in
Tanzania SIR,-We report a form of macular degeneration accompanied by optic atrophy which seems to be new. During 1988, ophthalmologists at the Muhimbili Medical Centre, Tanzania, began to see Africans of both sexes, mainly aged 10-25 years, with sudden onset of painless bilateral loss of central vision. In 61 patients the visual loss occurred simultaneously in both eyes, at different times of the day, and was not associated with any particular activity. Vision was usually 6/36 or 6/60 at presentation. In 9 (15%) patients the vision spontaneously recovered to 6/6 within nine months. In most, however, it remained between 6/36 and finger counting at 1 m. Eyes were examined with a Haag-Streit 900 slit lamp and indirect ophthalmoscopy. In all patients, the pupils reacted briskly to light, the anterior segments were normal, and intraocular pressure was raised. Generalised thinning of the central retina and loss of the foveal reflex was seen. The pigment beneath the macula was dispersed and clumped; sometimes it formed a small ring (6 patients). 52 (85%) patients had pallor and atrophy of a 50°-60° temporal sector of each optic disc. The thinned retina corresponded to this sector, and was sharply demarcated within the main temporal vessel arcades. In 36 patients atrophy of some narrow nerve-fibre bundles was seen, radiating superotemporally or inferotemporally. The patients belonged to 35 different tribes and to all religious affiliations, and were well nourished. No Indians, Arabs, or Europeans presented. 18 (30%) were schoolchildren and 11 (18%) were housewives; the remainder were working men. There was no clustering related to places of residence or work, or within families. 4 of 37 patients and 4 of 37 controls tested were HIV positive. Headache was frequently noted at the onset of the visual problem; mouth sores or angular stomatitis (n 4), and hearing loss (n 4) were occasionally noted. Various drugs had been taken in the previous 2 years-mainly antimalarials and analgesics. There was no evidence of alcohol or drug abuse. The fundus appearance resembled the mild pigment stippling or mottling beneath the macula and loss of foveal reflexes
not
Department of Parasitology, National Institute of Health,
Tokyo 141, Japan
GIULIO BORGNOLO BELAYNEH HAILU
Asella Hospital, PO Box 15, Asella, Arssi Region, Ethiopia
A. ISHII
Ministry of
Health and Medical Service, Honiara, Solomon Islands
J. LEAFASIA
Medical Training and Resource Institute, Honiara
N. KERE
1. Houston S. Ultrasound: appropnate
technology for tropical field work. Trans R Soc Trop Med Hyg 1991; 85: 321-23. 2. Degremont A, Burki A, Burnier E, Schweizer W, Meudt B, Tanner M. Value of ultrasonography m investigating morbidity due to Schistosoma haematobium infection. Lancet 1985; i: 662-65. 3. Poltera AA, Renya O, Zea Flores G, Nowell De Arevalo AM, Beltranena F. Detection
of skin nodules in onchocerciasis by ultrasound scans. Lancet 1987; i: 505. 4. Corkill JA, Brabin BJ, Macgregor DF, Alpers MP, Milner RD. Newborn splenic volumes vary under different malaria endemic conditions. ArchDis Child 1889; 64: 541-45. 5. Dittrich M, Milde S, Dinkel E, Baumann W, Weizel D. Sonographic biometry of liver and spleen size in childhood. Paediatr Radiol 1983; 12: 206-11. 6. Kawamoto F. Rapid diagnosis of malaria by fluorescence microscopy with light microscope and interference filter. Lancet 1991; 337: 200-02.
=
=
