187
regularly exposed to pesticides, among them phenoxyacetic acids, while washing her husband’s clothes, and 1 was potentially exposed phenoxyacetic acids during her work in deforestation. Department of Oncology, Drebro Medical Centre, S-701 85, Orebro, Sweden
LENNART HARDELL
1 Hardell L, Eriksson M, Lenner P, Lundgren E. Malignant lymphoma and exposure to chemicals, especially organic solvents, chlorophenols and phenoxy adds: a case-control study. Br J Cancer 1981; 43: 169-76. 2 Hardell L, Bengtsson NO. Epidemiological study of socioeconomic factors and clinical findings m Hodgkin’s disease, a reanalysis of previous data regarding chemical exposure. Br J Cancer 1983; 48: 217-25.
Destructive effect of prolonged autoclaving of blood specimens in Guthrie test SIR,- The Guthrie test is used in many countries to screen for phetyllcetonuria (PKU) in newborn infants.1 It is based on the inhibition of growth of Bacillus subtilis spores on minimal agar containing &bgr;-2-thienylalanine and the reversal of this inhibition by increased concentrations of phenylalanine in blood specimens applied to the agar on filter paper discs. The presence of antimicrobial agents in blood specimens can invalidate the results of the test and necessitate repeat testing,2-4which can lead to delay in the identification of new PKU cases.3 Clemens and colleagues4,5 reported that autoclaving of blood specimens for an extended period 20 min at 110°C as opposed to the recommended 3 min at 121 °C2,6) inactivated antimicrobial substances but did not affect phenylalanine levels, and they proposed that this simple modification could be used to overcome antibiotic interference. However, Guthrie and Susi6 had already warned that prolonged autoclaving would destroy phenylalanine. To resolve this contradiction, we examined the effect of the duration of autoclaving at 110°C and 12FC on the Guthrie test. The Guthrie test was done as described6 with PKU Test Agar and Bacto Subtilis Spore Suspension 2 (Difco). Blood standards
containing phenylalanine at 2, 4, 6, 8, 10, 12, or 20 mg/dl were prepared by adding L-phenylalanine (Sigma) to samples of human blood (type 0) from the Canadian Red Cross. Each of the standards was applied dropwise to multiple series of filter paper strips (903, Schleicher and Schuell) and allowed to air-dry. Each series of strips was autoclaved under 110&ogr;C for 3,10, or 20 min, or 121’C for 3,10, 20 min in a standard laboratory autoclave. After autoclaving, 6 mm diameter discs were punched from the strips and applied in duplicate to the surface of agar plates. One series was not autoclaved. After incubation for 18 h at 37°C, the zone of bacterial growth surrounding each disc was measured. Each experiment was done or
twice.
Autoclaving at either temperature reduced the growth zones of each of the standards and reductions increased as the duration of autoclaving was extended (table). In another experiment, blood specimens applied in duplicate to filter paper discs were obtained from 7 PKU patients. One of the discs from each patient was autoclaved at 110°C for 3 min and the other was autoclaved at the same temperature for 20 min before the Guthrie test. Growth zones for each of the specimens autoclaved for 20 min were considerably =matier than those autoclaved for only 3 min (3/20 min: 22/19, 25 22,29/25,19/16, 30/26, 18/15, and 27/25, respectively). Our results confirmed that autoclaving has a destructive effect on ’he phenylalanine concentration of dried blood samples as EFFECT OF DURATION OF AUTOCLAVING ON GUTHRIE TEST
by the Guthrie test. This effect was observed when autoclaving was under normal operating conditions at both 121°C and 110°C and it was increased by prolonging the autoclave period. Our findings indicate that the procedure to eliminate antibiotic interference4,5 could lead to underestimation of phenylalanine levels, and, perhaps, to false-negative results. By treating the phenylalanine standards under the same extended autoclaving conditions as the antibiotic-containing specimens from patients, it may be possible to measure the correct phenylalanine concentrations. However, this point was not addressed by Clemens measured
and co-workers and further studies are needed to determine if the limit of detection and therefore the sensitivity of the Guthrie test are affected by this modification to the procedure. We thank H. Lo, R.
Reyes, and M. Schuster for technical assistance.
PKU Laboratory, Clinical Bacteriology Section, Central Public Health Laboratory, Ontario Ministry of Health, Toronto, Ontario, Canada M5W 1 R5
MARTIN A. PRESTON ALEXANDER BORCZYK
Mabry CC. Phenylketonuria: contemporary screening and diagnosis. Ann Clin Lab Sci 1990; 20: 392-97 2. Fisch RO, Anthony BF, Bauer H, Bruhl HH. The effect of antibiotics on the results of the Guthrie test given to phenylketonuric patients. J Pediatr 1968; 73: 685-89. 3. Bracco G, Pagliardini S. Guthrie test recalls due to antibiotic inhibition. Lancet 1983; i: 1.
1331-32. 4. Clemens P, Voltmer C, Plettner C. Effect of antimicrobial agents on Guthrie test and its reversal by autoclaving. Lancet 1985; ii: 778-79. 5. Clemens PC, Plettner C. Phenylketonuria screening: avoiding a source of error by simplifying the procedure. Am J Clin Pathol 1989; 91: 747. 6. Guthrie R, Susi A. A simple phenylalanine method for detecting phenylketonuria in large populations of newborn infants. Pediatrics 1963; 32: 338-43.
Efficacy of perioperative nutritional support SIR,-Although preoperative nutritional support
may reduce
postoperative complications, especially in severely depleted patients,1-5 its use has not become common. Most studies however, have flaws (commonly, too few randomised patients) that are not overcome by meta-analysis. Two large trials gave opposing results. Mueller and co-workers’ trial6 found a benefit, whereas the Veterans Administration trial7 showed a negative result. Both trials have been criticised: the first for also including patients without signs of nutritional depletion, and the second for randomising only a small group of patients from the potentially large population that was subsequently treated in many different institutions. We have evaluated the results of a prospective randomised trial in a homogeneous group with histologically proven gastric or colorectal cancer. We studied the potential of at least 10 days’ preoperative nutrition, providing 150% basal energy expenditure non-protein energy, to reduce major postoperative complications or mortality in depleted patients. After stratification for percent weight loss (< or 15%), age (< or 65 years), and tumour localisation (gastric/colorectal), depleted patients were randomised to receive preoperative parenteral nutrition (TPN, n=51), preoperative enteral nutrition (TEN, n=50), or to undergo surgery without
delay (depleted patients, n = 50). Non-depleted patients (n = 49) randomised and also underwent surgery without delay. Complications were defined as minor (urinary tract, pulmonary tract, wound infection) or major (septic; intra-abdominal abscess, fistula, anastomotic leakage, wound dehiscence, sepsis). Mortality was evaluated separately. Depleted control patients had significantly more septic complications than patients in the non-depleted reference group (table). There was no significant difference, however, in septic complications between either of the nutritional support groups and the non-depleted controls. Stratification for weight loss allowed for subset analysis in the patients with more severe depletion. In these more severely depleted patients, the decrease of intra-abdominal abscesses in the TPN and TEN groups became significant. The differences between both intervention groups and the depleted group also became significant in the subset of patients with major blood loss during surgery. We conclude that preoperative nutritional support in patients with severe depletion results in a reduction of major complications to a degree that justifies its routine use in these patients. The benefit were not
188
lipopolysaccharide antibody, which is genus-specific, will also stain other chlamydial species, including C pneranarriae. Which antibody
SEPTIC COMPLICATION RATE
did Bavastrelli et al use? Answers to these questions are needed before one can reliably exclude C pneumoniae as an aetiological agent in these interesting cases of possible non-atopic, asthma-like illness in children. Arcand Park Clinic. Madison. Wisconsin 53704, USA
DAVID L. HAHN
Komaroff AL, William T, Branch J, Aronson MD, et al. Chlamydial pharyngitis. Ann Int Med 1989; 111: 537—38. 2. Hahn DL, Dodge R, Golubjatnikov R. Association of Chlamydia pneumoniae strain TWAR) infection with wheezing, asthmatic bronchitis and adult-onset asthma. JAMA 1991; 266: 225-30. 1.
-
r
i
i
i
i
"p < 0-05 TPN vs TEN vs depleted vs not depleted; tp < 0 05 TPN and TEN vs depleted, and ‡p < 0 05 depleted vs not depleted. (Chi-squared or Mantel-Haenszel tests )
of such treatment increases with the progression of depletion. We therefore advocate that patients with severe depletion receive nutritional support before undergoing surgical trauma. These observations may be extendable to other conditions in which trauma is purposefully administered (chemotherapy, radiotherapy, surgery for inflammatory bowel disease) to depleted patients.
W. J. H. J. MEIJERINK M. F. VON MEYENFELDT M. M. J. ROUFLART P. B. SOETERS
Department of Surgery, University Hospital Maastricht, 6202 AZ Maastricht, Netherlands
1. Brennan MF. Total parenteral nutrition in the cancer patient. N
Engl J Med 1981; 307:
375. 2 Klein S, Simes J, Blackburn GL Total parenteral nutrition and cancer clinical trials. Cancer 1986; 58: 1378-86 3. Detsky AS, Baker JP, O’Rourke K, Goel V. Perioperative parenteral nutrition: a meta-analysis. Ann Intern Med 1987; 107: 195-203 4. Buzby GP, Williford WO, Peterson OL, et al. A randomized clinical trial of total parenteral nutrition in malnourished surgical patients: the rationale and impact of previous clinical trials and pilot study on protocol design. Am J Clin Nutr 1988; 47: 357-65. 5. Meguid MM, Campos AC, Hammond WG. Nutritional support in surgical practice Am J Surg 1990; 159: 345-58 6 Mueller JM, Brenner U, Dienst C, Pichlmaier H. Preoperative parenteral feeding in patients with gastrointestinal carcinoma. Lancet 1982. i: 68-71. 7 The Veterans Affairs total parenteral nutrition cooperative study group. Perioperative total parenteral nutrition in surgical patients. N Engl J Med 1991; 325: 52532.
Chlamydia trachomatis and wheezing SIR,-Dr Bavastrelli and colleagues (May 9, p 1174) report wheezing simulating asthma in 7 children who had evidence of Chlamydia trachomatis infection diagnosed either by isolation on McCoy cell culture and/’or by direct fluorescent antibody testing of conjunctival or pharyngeal swabs. They report that asthmatic symptoms were eradicated in all 7 children after anti-chlamydial antibiotic therapy. Because this information is potentially very important, further details of these patients would be helpful. In particular, what clinical characteristics differentiated these children from "true" asthmatics? Bavastrelli et al report that these children did not respond to bronchodilator agents. Are they referring to inhaled adrenergic agents, theophylline preparations, steroids, or others? Were pulmonary function tests done? It is important to note that the cited high childhood rates (26.7% and 47. 2%) of C trachomatis seroprevalence are mostly due to crossreaciivity with C pneumoniae.1 Bavastrelli et al state "C pneunzorziae strain T W A R grows only on HeLa 229 cells and not on the McCoy cells we used for our isolation procedures". C pnetanomae does grow on McCoy cells, albeit not as readily as on HeLa 229 cells. McCoy cells have been used successfully to isolate .2 the organism in serologically confirmed C pnewnoniae infection The direct fluorescence antibody test for C trachomatis is speciesspecific only if the fluorescein-conjugated major outer membrane protein antibody is used. Use of the fluorescein-conjugated
*** This letter has been shown whose reply follows.-ED. L.
to
Dr Bavastrelli and
colleagues,
SIR,- The children we investigated had, besides the presenting expiratory wheezing, persistent dry cough, chest hyperexpansion, no fever, often conjunctivitis, and eosinophilia. The picture could hardly be differentiated from atopic asthma on clinical grounds alone, but in all children IgE was not raised and none showed specific responses to common allergens, on RAST or symptom of
on
skin
tests.
Some
were
treated with oral betamethasone sodium
phosphate, others with a mixture of beclomethasone dipropionate plus salbutamol by inhalation. With these treatments the wheezing persisted unmodified, but was eliminated by one or two courses of 2-week amacrolide. Pulmonary-function tests were not obtained. The direct fluorescence antibody test we used, in parallel with culture on McCoy cells, was Microtrak (Syva), which is based on monoclonal antibody raised against the fifteen serotypes of Chlamydia trachomatis that do not cross react with C pneumoniae. Moreover, C pneumoniae is more common in adults and is rare in childhood.’1 The conjunctival involvement in six of our seven patients, with ocular symptoms in four, favours a C trachomatis aetiology. Furthermore, C trachomatis was present in the urogenital tract or in the conjunctiva of the children’s parents, whereas TWAR does not appear to be a sexually transmitted disease or an important cause of
conjunctivitis.2 The
emerging from our data, perhaps worth is that C trachomatis infection should be suspected emphasising, and diagnosed not only in the child with wheezing but also in other members of his family. In fact, we have an additional duty to prevent reinfection by eradicating C trachomatis from the entire family. We agree that more data are needed to draw definitive conclusions, but we think that it was worth publishing out preliminary observation at a time when possible respiratory involvement by C trachomatis is emerging in bronchiolitis or pneumonia in children.3 message
Supported by grant 9103613 from CNR P. F. FATMA. MARIA BAVASTRELLI III Academic Department of Clinical Paediatrics, MARIO MIDULLA Università "La Sapienza" Roma, DANIELA ROSSI Istituto di Clinica Pediatrica, 00161 Rome. Italy MARCO SALZANO Grayston JT, Campbell LA, Kuo CC, et al. A new respiratory tract pathogen Chlamydia pneunomae strain TWAR. J Infect Du 1990; 161: 618-25. 2. Christopher DB, Grayston JT, Wang SP, et al. Chlamydia pneumoniae, strain TWAR. infection in patients with chronic obstructive pulmonary disease. Am Rev Respir Dis 1.
1991;
144: 1408-10.
G, Mahony JB, Videla C, et al. Chlamydial antibodies in children with lower respiratory disease. Pediatr Infect Dis J 1092; 11: 68-71.
3. Carballal
CORRECTIONS
...
Local anaesthetic creams and intradermal skin tests.-In this letter Dr F. E. R. Simons and her colleagues (May 30, p 1351), line 5 of paragraph3 should have read "... but the mean flare area decreased significantly..."
Efficacy of traditional Chinese herbal therapy in adult atop dermatitis.-In this article by Dr Sheehan and colleagues (July 4, p 13B the name of the fifth author should have read D. W. S. Harris.
regularly exposed to pesticides, among them phenoxyacetic acids, while washing her husband’s clothes, and 1 was potentially exposed phenoxyacetic acids during her work in deforestation. Department of Oncology, Drebro Medical Centre, S-701 85, Orebro, Sweden
LENNART HARDELL
1 Hardell L, Eriksson M, Lenner P, Lundgren E. Malignant lymphoma and exposure to chemicals, especially organic solvents, chlorophenols and phenoxy adds: a case-control study. Br J Cancer 1981; 43: 169-76. 2 Hardell L, Bengtsson NO. Epidemiological study of socioeconomic factors and clinical findings m Hodgkin’s disease, a reanalysis of previous data regarding chemical exposure. Br J Cancer 1983; 48: 217-25.
Destructive effect of prolonged autoclaving of blood specimens in Guthrie test SIR,- The Guthrie test is used in many countries to screen for phetyllcetonuria (PKU) in newborn infants.1 It is based on the inhibition of growth of Bacillus subtilis spores on minimal agar containing &bgr;-2-thienylalanine and the reversal of this inhibition by increased concentrations of phenylalanine in blood specimens applied to the agar on filter paper discs. The presence of antimicrobial agents in blood specimens can invalidate the results of the test and necessitate repeat testing,2-4which can lead to delay in the identification of new PKU cases.3 Clemens and colleagues4,5 reported that autoclaving of blood specimens for an extended period 20 min at 110°C as opposed to the recommended 3 min at 121 °C2,6) inactivated antimicrobial substances but did not affect phenylalanine levels, and they proposed that this simple modification could be used to overcome antibiotic interference. However, Guthrie and Susi6 had already warned that prolonged autoclaving would destroy phenylalanine. To resolve this contradiction, we examined the effect of the duration of autoclaving at 110°C and 12FC on the Guthrie test. The Guthrie test was done as described6 with PKU Test Agar and Bacto Subtilis Spore Suspension 2 (Difco). Blood standards
containing phenylalanine at 2, 4, 6, 8, 10, 12, or 20 mg/dl were prepared by adding L-phenylalanine (Sigma) to samples of human blood (type 0) from the Canadian Red Cross. Each of the standards was applied dropwise to multiple series of filter paper strips (903, Schleicher and Schuell) and allowed to air-dry. Each series of strips was autoclaved under 110&ogr;C for 3,10, or 20 min, or 121’C for 3,10, 20 min in a standard laboratory autoclave. After autoclaving, 6 mm diameter discs were punched from the strips and applied in duplicate to the surface of agar plates. One series was not autoclaved. After incubation for 18 h at 37°C, the zone of bacterial growth surrounding each disc was measured. Each experiment was done or
twice.
Autoclaving at either temperature reduced the growth zones of each of the standards and reductions increased as the duration of autoclaving was extended (table). In another experiment, blood specimens applied in duplicate to filter paper discs were obtained from 7 PKU patients. One of the discs from each patient was autoclaved at 110°C for 3 min and the other was autoclaved at the same temperature for 20 min before the Guthrie test. Growth zones for each of the specimens autoclaved for 20 min were considerably =matier than those autoclaved for only 3 min (3/20 min: 22/19, 25 22,29/25,19/16, 30/26, 18/15, and 27/25, respectively). Our results confirmed that autoclaving has a destructive effect on ’he phenylalanine concentration of dried blood samples as EFFECT OF DURATION OF AUTOCLAVING ON GUTHRIE TEST
by the Guthrie test. This effect was observed when autoclaving was under normal operating conditions at both 121°C and 110°C and it was increased by prolonging the autoclave period. Our findings indicate that the procedure to eliminate antibiotic interference4,5 could lead to underestimation of phenylalanine levels, and, perhaps, to false-negative results. By treating the phenylalanine standards under the same extended autoclaving conditions as the antibiotic-containing specimens from patients, it may be possible to measure the correct phenylalanine concentrations. However, this point was not addressed by Clemens measured
and co-workers and further studies are needed to determine if the limit of detection and therefore the sensitivity of the Guthrie test are affected by this modification to the procedure. We thank H. Lo, R.
Reyes, and M. Schuster for technical assistance.
PKU Laboratory, Clinical Bacteriology Section, Central Public Health Laboratory, Ontario Ministry of Health, Toronto, Ontario, Canada M5W 1 R5
MARTIN A. PRESTON ALEXANDER BORCZYK
Mabry CC. Phenylketonuria: contemporary screening and diagnosis. Ann Clin Lab Sci 1990; 20: 392-97 2. Fisch RO, Anthony BF, Bauer H, Bruhl HH. The effect of antibiotics on the results of the Guthrie test given to phenylketonuric patients. J Pediatr 1968; 73: 685-89. 3. Bracco G, Pagliardini S. Guthrie test recalls due to antibiotic inhibition. Lancet 1983; i: 1.
1331-32. 4. Clemens P, Voltmer C, Plettner C. Effect of antimicrobial agents on Guthrie test and its reversal by autoclaving. Lancet 1985; ii: 778-79. 5. Clemens PC, Plettner C. Phenylketonuria screening: avoiding a source of error by simplifying the procedure. Am J Clin Pathol 1989; 91: 747. 6. Guthrie R, Susi A. A simple phenylalanine method for detecting phenylketonuria in large populations of newborn infants. Pediatrics 1963; 32: 338-43.
Efficacy of perioperative nutritional support SIR,-Although preoperative nutritional support
may reduce
postoperative complications, especially in severely depleted patients,1-5 its use has not become common. Most studies however, have flaws (commonly, too few randomised patients) that are not overcome by meta-analysis. Two large trials gave opposing results. Mueller and co-workers’ trial6 found a benefit, whereas the Veterans Administration trial7 showed a negative result. Both trials have been criticised: the first for also including patients without signs of nutritional depletion, and the second for randomising only a small group of patients from the potentially large population that was subsequently treated in many different institutions. We have evaluated the results of a prospective randomised trial in a homogeneous group with histologically proven gastric or colorectal cancer. We studied the potential of at least 10 days’ preoperative nutrition, providing 150% basal energy expenditure non-protein energy, to reduce major postoperative complications or mortality in depleted patients. After stratification for percent weight loss (< or 15%), age (< or 65 years), and tumour localisation (gastric/colorectal), depleted patients were randomised to receive preoperative parenteral nutrition (TPN, n=51), preoperative enteral nutrition (TEN, n=50), or to undergo surgery without
delay (depleted patients, n = 50). Non-depleted patients (n = 49) randomised and also underwent surgery without delay. Complications were defined as minor (urinary tract, pulmonary tract, wound infection) or major (septic; intra-abdominal abscess, fistula, anastomotic leakage, wound dehiscence, sepsis). Mortality was evaluated separately. Depleted control patients had significantly more septic complications than patients in the non-depleted reference group (table). There was no significant difference, however, in septic complications between either of the nutritional support groups and the non-depleted controls. Stratification for weight loss allowed for subset analysis in the patients with more severe depletion. In these more severely depleted patients, the decrease of intra-abdominal abscesses in the TPN and TEN groups became significant. The differences between both intervention groups and the depleted group also became significant in the subset of patients with major blood loss during surgery. We conclude that preoperative nutritional support in patients with severe depletion results in a reduction of major complications to a degree that justifies its routine use in these patients. The benefit were not
188
lipopolysaccharide antibody, which is genus-specific, will also stain other chlamydial species, including C pneranarriae. Which antibody
SEPTIC COMPLICATION RATE
did Bavastrelli et al use? Answers to these questions are needed before one can reliably exclude C pneumoniae as an aetiological agent in these interesting cases of possible non-atopic, asthma-like illness in children. Arcand Park Clinic. Madison. Wisconsin 53704, USA
DAVID L. HAHN
Komaroff AL, William T, Branch J, Aronson MD, et al. Chlamydial pharyngitis. Ann Int Med 1989; 111: 537—38. 2. Hahn DL, Dodge R, Golubjatnikov R. Association of Chlamydia pneumoniae strain TWAR) infection with wheezing, asthmatic bronchitis and adult-onset asthma. JAMA 1991; 266: 225-30. 1.
-
r
i
i
i
i
"p < 0-05 TPN vs TEN vs depleted vs not depleted; tp < 0 05 TPN and TEN vs depleted, and ‡p < 0 05 depleted vs not depleted. (Chi-squared or Mantel-Haenszel tests )
of such treatment increases with the progression of depletion. We therefore advocate that patients with severe depletion receive nutritional support before undergoing surgical trauma. These observations may be extendable to other conditions in which trauma is purposefully administered (chemotherapy, radiotherapy, surgery for inflammatory bowel disease) to depleted patients.
W. J. H. J. MEIJERINK M. F. VON MEYENFELDT M. M. J. ROUFLART P. B. SOETERS
Department of Surgery, University Hospital Maastricht, 6202 AZ Maastricht, Netherlands
1. Brennan MF. Total parenteral nutrition in the cancer patient. N
Engl J Med 1981; 307:
375. 2 Klein S, Simes J, Blackburn GL Total parenteral nutrition and cancer clinical trials. Cancer 1986; 58: 1378-86 3. Detsky AS, Baker JP, O’Rourke K, Goel V. Perioperative parenteral nutrition: a meta-analysis. Ann Intern Med 1987; 107: 195-203 4. Buzby GP, Williford WO, Peterson OL, et al. A randomized clinical trial of total parenteral nutrition in malnourished surgical patients: the rationale and impact of previous clinical trials and pilot study on protocol design. Am J Clin Nutr 1988; 47: 357-65. 5. Meguid MM, Campos AC, Hammond WG. Nutritional support in surgical practice Am J Surg 1990; 159: 345-58 6 Mueller JM, Brenner U, Dienst C, Pichlmaier H. Preoperative parenteral feeding in patients with gastrointestinal carcinoma. Lancet 1982. i: 68-71. 7 The Veterans Affairs total parenteral nutrition cooperative study group. Perioperative total parenteral nutrition in surgical patients. N Engl J Med 1991; 325: 52532.
Chlamydia trachomatis and wheezing SIR,-Dr Bavastrelli and colleagues (May 9, p 1174) report wheezing simulating asthma in 7 children who had evidence of Chlamydia trachomatis infection diagnosed either by isolation on McCoy cell culture and/’or by direct fluorescent antibody testing of conjunctival or pharyngeal swabs. They report that asthmatic symptoms were eradicated in all 7 children after anti-chlamydial antibiotic therapy. Because this information is potentially very important, further details of these patients would be helpful. In particular, what clinical characteristics differentiated these children from "true" asthmatics? Bavastrelli et al report that these children did not respond to bronchodilator agents. Are they referring to inhaled adrenergic agents, theophylline preparations, steroids, or others? Were pulmonary function tests done? It is important to note that the cited high childhood rates (26.7% and 47. 2%) of C trachomatis seroprevalence are mostly due to crossreaciivity with C pneumoniae.1 Bavastrelli et al state "C pneunzorziae strain T W A R grows only on HeLa 229 cells and not on the McCoy cells we used for our isolation procedures". C pnetanomae does grow on McCoy cells, albeit not as readily as on HeLa 229 cells. McCoy cells have been used successfully to isolate .2 the organism in serologically confirmed C pnewnoniae infection The direct fluorescence antibody test for C trachomatis is speciesspecific only if the fluorescein-conjugated major outer membrane protein antibody is used. Use of the fluorescein-conjugated
*** This letter has been shown whose reply follows.-ED. L.
to
Dr Bavastrelli and
colleagues,
SIR,- The children we investigated had, besides the presenting expiratory wheezing, persistent dry cough, chest hyperexpansion, no fever, often conjunctivitis, and eosinophilia. The picture could hardly be differentiated from atopic asthma on clinical grounds alone, but in all children IgE was not raised and none showed specific responses to common allergens, on RAST or symptom of
on
skin
tests.
Some
were
treated with oral betamethasone sodium
phosphate, others with a mixture of beclomethasone dipropionate plus salbutamol by inhalation. With these treatments the wheezing persisted unmodified, but was eliminated by one or two courses of 2-week amacrolide. Pulmonary-function tests were not obtained. The direct fluorescence antibody test we used, in parallel with culture on McCoy cells, was Microtrak (Syva), which is based on monoclonal antibody raised against the fifteen serotypes of Chlamydia trachomatis that do not cross react with C pneumoniae. Moreover, C pneumoniae is more common in adults and is rare in childhood.’1 The conjunctival involvement in six of our seven patients, with ocular symptoms in four, favours a C trachomatis aetiology. Furthermore, C trachomatis was present in the urogenital tract or in the conjunctiva of the children’s parents, whereas TWAR does not appear to be a sexually transmitted disease or an important cause of
conjunctivitis.2 The
emerging from our data, perhaps worth is that C trachomatis infection should be suspected emphasising, and diagnosed not only in the child with wheezing but also in other members of his family. In fact, we have an additional duty to prevent reinfection by eradicating C trachomatis from the entire family. We agree that more data are needed to draw definitive conclusions, but we think that it was worth publishing out preliminary observation at a time when possible respiratory involvement by C trachomatis is emerging in bronchiolitis or pneumonia in children.3 message
Supported by grant 9103613 from CNR P. F. FATMA. MARIA BAVASTRELLI III Academic Department of Clinical Paediatrics, MARIO MIDULLA Università "La Sapienza" Roma, DANIELA ROSSI Istituto di Clinica Pediatrica, 00161 Rome. Italy MARCO SALZANO Grayston JT, Campbell LA, Kuo CC, et al. A new respiratory tract pathogen Chlamydia pneunomae strain TWAR. J Infect Du 1990; 161: 618-25. 2. Christopher DB, Grayston JT, Wang SP, et al. Chlamydia pneumoniae, strain TWAR. infection in patients with chronic obstructive pulmonary disease. Am Rev Respir Dis 1.
1991;
144: 1408-10.
G, Mahony JB, Videla C, et al. Chlamydial antibodies in children with lower respiratory disease. Pediatr Infect Dis J 1092; 11: 68-71.
3. Carballal
CORRECTIONS
...
Local anaesthetic creams and intradermal skin tests.-In this letter Dr F. E. R. Simons and her colleagues (May 30, p 1351), line 5 of paragraph3 should have read "... but the mean flare area decreased significantly..."
Efficacy of traditional Chinese herbal therapy in adult atop dermatitis.-In this article by Dr Sheehan and colleagues (July 4, p 13B the name of the fifth author should have read D. W. S. Harris.
