452
CORRESPONDENCE
chronic lymphatic leucaemia and CORNILLE-BROGGER (1975) recently described the occurrence of primary IgM deficiency in a healthy Nigerian. This report prompted us to review the results of IgM determinations carried out in our laboratory over the past four years. During the aeriod November 1973-June 1976. 1.026 sera were submitted to the Immunology laboratory’ for IgM determination; most of these samples came from patients with splenomegaly who were suspected of having the tropical splenomegaly syndrome. 43 patients had an IgM of < 104 IU/ml-a value of less than two standard deviations below the geometric mean value (338 III/ml) of 97 healthy adult Nigerians. The diagnoses made in these 43 patients are shown in the table. It is unlikely that any of the patients had primary IgM deficiency. Half the patients had a malignancy-usually chronic lymphatic leucaemia or a lymphoma-showing that in this Dart of Nigeria. as in Eurooe (HOBBS. 1975). this group of cond%ons is the most important cause of secondary IgM deficiency. Thus in an African patient detection of a serum IgM level below the normal range of people living in that area should suggest a diagnosis of malignancy, even if the serum IgM is well within the normal range of people living in developed countries.
Table - Diagnoses in 43 patients with IgM deficiency Chronic lymphatic leucaemia Lymphoma Other malignancies (hepatoma 2, myeloma 1, acute leucaemia 1 and carcinoma of the ovary 1) Schistosomiasis Cirrhosis Miscellaneous Fully investigated but not diagnosis Imcompletely investigated Total
9 6 5 4 2 6 7 4
43 -
We are, etc., Y. M. FAKUNLE M. DAMISAH A. B. AJDUKIEWICZ H. C. WHITTLE B. M. GREENWOOD The Department of Medicine, Ahmadu Bell0 University, Zaria, Nigeria.
References Cornille-Brogger, R. (1975). A case of serum IgM deficiency in an area of high endemicity of malaria (Northern Nigeria). Transactions of the Royal Society if Tropical Medicine and Hygiene, 69, 515-5 16. Hobbs. J. R. (1975). InM deficiencv. In: 1mmunodeficiency in man and &imaZs, Bergsma, D., Good, R. A., Finstad, J. & Paul, N. W. (Editors). Sunderland, Massachusetts: Sinauer Ass. Inc., pp. 112-l 16. Sagoe, A-S. (1970). Tropical splenomegaly syndrome: long-term proguanil therapy correlated with spleen size, serum IgM and lymphocyte transformation. British Medical Journal, iii, 378-382. Accepted for publication
10th July 1977
Filariasis due to Wuchereria bancrofti in Haiti SIR-In Haiti the incidence of filariasis due to Wuchereria bancrofti, though recognized since the XVIIIth Century, has only been studied by WILSON (1928) who made a preliminary study in the principal cities. During the last ten years at the Hopital le Bon Samaritan in Limbe analyses carried out for blood-carried microfilariae by Knott’s method have regularly uncovered some cases of W. bancrofti and also of Masonella ozzardi. M. ozzardi affects the coastal regions of the island, where it seems to be transmitted by Culicoides furens (RIPERT, RACCURT & DOUYON, 1976), W. bancrofti is encountered much more in the urban milieu. Epidemiologic research has been continuing in the city of Limb6 since February 1977. Limb&, in the north of Haiti, is situated at 72” 24’ W and 19” 43’ N, some 10 km from the coast, in a fertile plain of 90 km2, surrounded by steep mountains, and influenced by the torrential character of the river which runs through it. Having a tropical humid climate, the region receives an average rainfall of 2,000 mm a year, which makes it quite fertile for agriculture. Approximately 60,000 people live in the valley of Limb& The city, which lies on the left side of the river, has about 15,000 inhabitants, and is crossed at its centre by a poorly cared-for canal where water stagnates all year long. A sample of the population chosen at random has been studied by a finger-prick blood sample of volume 20 mm3 drawn between 8.00 and 10.30 p.m. The first results which we are reporting were obtained from a sample of 1,135 persons. Microfilariae of W. bancrofti were recovered from 203, an incidence of 17.9 %, of which three cases also showed M. ozzardi. Three four-year-old children and 22% of those between 10 and 14 years showed the microfilariae. After puberty, males are more frequently parasitized than the females. The people who came from houses quite close to the canal were more frequently parasitized, and to a higher degree. The pathology most frequently encountered is a lymphadenitis of the inguinal nodes in almost all of the microfilaria carriers. Less frequently, engorged lymphatic vessels (lymphoceles) were noted, and also oedema of the lower extremities, and hydrocele. Elephantiasis and chyluria which are sometimes noted in this region have not yet been found in the course of this investigation. Mosquitoes were captured by aspiration in all of the houses where there were cases of microfilaraemia. Culex pipiens fatigans was the most abundant, but Aedes aegypti and A. taen~orhynchus were also recovered. Only C. pipiens fatigans harboured filarial larvae, the dimensions and morphology of which were characteristic of W. bancrqfti. Of 100 female specimens of C. pipens fatigans, previously treated with 70 % alcohol and stained bv the method of NELSON (1958). 20 were found to be infected with W. bancrofti,. six ‘having thoracic microfilariae, one having microfilariae and first-stage larvae in the thoracic muscles, nine having first-stage larvae (short and long sausage forms), three having second-stage larvae in the thoracic muscles, and one having four third-stage larvae in the head and proboscis. Filariasis due to W. bancroftiis therefore a real problem in the cities of the north of Haiti. The parasite is also known at the present time in Cap Haitien, Port Margot, Grande Riviere du Nord, Plaisance, and Gonaives. The vector is Culexpipiensfutigans and these first results from the town of Limb& prove that there is extensive trans-
CORRESPONDENCE mission of the parasite, affecting even the infants of a very early age. We are, etc., CHRISTIANRACCURT Service de Microbiologic, Fact&C de Medecine. Port-au-Prince, ‘ Haiti. WILLIAM HODGES Hopital le Bon Samaritan, Limb& Haiti. References Nelson, G. S. (1958). Staining of filarial larvae in insects before dissection. Bulletin of the World Health Organization, 19,204. Ripert, C., Raccurt, C. & Douyon, P. L. (1976). La filariose & Mansonella ozzardi en Haiti (Grandes Antilles). Premieres donnees epidemiologiques. Bordeaux Medecine. (In press.) Wilson, W. P. (1928). Contribution a l’ttude de la malaria et de la microfilaire. Bulletin de la Sock% de Medecine d’Haiti, 7, 51-63. Accepted for publication 15th July, 1977. Tissue reacting Ig in children parasitaemic with Trypanosoma cruzi SIR-Antibodies reacting against the plasma membrane of endothelial cells, vascular structures and striated muscle (EVI antibodies) have been found in people infected chronically or acutely with Trypanosoma cruzi (COSSIO et al.. 1974: SZARFMANet al.. 1977). The uresence of Ias reacting with Schwann cells of peripheral nerves has also been reported in patients chronically infected with T. cruzi (I(HouRY et al., 1979. We report here the presence of both types of tissuereacting antibodies in the first serum samples obtained six to 3.5days after the onset of symptoms in 38 children recently infected with T. cruzi. All had positive parasitaemia detected either by the STROUT(1966) method or by xenodiagnosis (SCHENONE et al., 1968) and 31 also had IgM anti-T. cvuzi antibodies, established by the indirect immunofluorescence test (IIF) (VATTCJONEet al., 1973) with titres which could be considered positive (> 1:16). Tissue-reacting antibodies were established by IIF test using as antigens cryostat sections of mouse heart, skeletal muscle and sciatic peripheral nerve. Titres > 1 :lO were considered reactive for EVI (COSSIOet al., 1974; KHOURY et al., 1976; SZARFMANet al., 1977) and >20 for peripheral nerve. The results are shown in Table I. ,
,
I
Table I - Tissue-reacting antibodies in recent human Chagas’s disease
IgM
No. of cases
antiT. cruzi antibodies
Tissue-reacting Igs EVI Peripheral Parasitaemia nerve
4 3
-
1 1
+ +
i -
+
1 +
9 20
+ +
+
+
+ +
+ -t
+
453
The appearance of the immunoglobulins reacting against the different host tissues early in the course of the infection suggests that they had originated in crossreacting antigens between T. cruzi and human tissues. Furthermore, the fact that EVI and peripheral nerve antibodies were usually associated, suggests a close relationship between them. This work was made nossible with funds nrovided bv grant No. 362 from- FINEP, Brazil, ‘CONICET, Argentina and WHO. We are, etc., A. SZARFMAN,* P. M. Cossto,t E. L. KHOURY,~ V. RITACO,~ R.M.ARANA~ and G.A. SCHMU%* *Institute of Microbiology, Federal University of Rio de Janeiro, Brazil. iCenter for Medical Education and Clinical Investigation, Buenos Aires, Argentina. References Cossio, P. M., Diez, C., Szarfman, A., Kreutzer, E., Candiolo, B. & Arana, R. M. (1974). Chagasic cardiopathy : demonstration of a serum gamma globulin factor which reacts with endocardium and vascular structures. Circulation, 49, 13-21. Khoury, E. L., Cossio, P. M., Ritacco, V., Diez, C., Laguens, R. P., Segal A., Szarfman, A. &Arana, R. M. (1976). Tincibn inmunofluorescente de nervio periferico asociada al anticuerpo. EVI (Abstract.) Medicina (Buenos Aires), 36, 539. Schenone, N., Alfaro, E. & Reyes, H. (1969). Rendimiento de1 xenodiagnostico en las formas aguda y congenita de la enfermedad de Chagas. Boletin Chileno de Parasitologia, 24,105-106. Strout, R. G. (1962). A method for concentrating hemoflagellates. Journal of Parasitology, 48, 100. Szarfman, A., Cossio, P. M., Schnuniis, G. A. & Arana, R. M. (1977). The EVI antibody in acute Chagas’ disease. Journal of Parasitology, 63, 149. Vattuone. N. H.. Szarfman. A. & Gonzalez Cavna. S. M. (1973).‘Antibddy response and immunoglobuhn levels in humans with acute or chronic Trypanosoma cruzi infections (Chagas’ disease). Journal of Tropical Medicine and Hygiene, 76, 4547. Accepted for publication 22nd June, 1977. Hyperparatbyroidism in the African Srr-Hyperparathyroidism was described over 40 years ago as a common and polymorphic condition (ALBRIGHT et al., 1934). The prevalence of the condition in patients attending a general medical clinic has been estimated as one case per 834 patients (BOONSTRA& JACKSON,1965). An even higher incidence of proven or presumed hyperparathyroidism (1.4%) of 1,630 patients was found among asymptomatic patients during routine medical examinations (PURNELLet al., 1971). However, primary hyperparathyroidism in the African south of the Sahara is extremely rare. Single cases have been reported from Johannesburg (TUCKER et al., 1975), Uganda (MEHTA et al., 1972) and we have collected three cases in a large
CORRESPONDENCE
chronic lymphatic leucaemia and CORNILLE-BROGGER (1975) recently described the occurrence of primary IgM deficiency in a healthy Nigerian. This report prompted us to review the results of IgM determinations carried out in our laboratory over the past four years. During the aeriod November 1973-June 1976. 1.026 sera were submitted to the Immunology laboratory’ for IgM determination; most of these samples came from patients with splenomegaly who were suspected of having the tropical splenomegaly syndrome. 43 patients had an IgM of < 104 IU/ml-a value of less than two standard deviations below the geometric mean value (338 III/ml) of 97 healthy adult Nigerians. The diagnoses made in these 43 patients are shown in the table. It is unlikely that any of the patients had primary IgM deficiency. Half the patients had a malignancy-usually chronic lymphatic leucaemia or a lymphoma-showing that in this Dart of Nigeria. as in Eurooe (HOBBS. 1975). this group of cond%ons is the most important cause of secondary IgM deficiency. Thus in an African patient detection of a serum IgM level below the normal range of people living in that area should suggest a diagnosis of malignancy, even if the serum IgM is well within the normal range of people living in developed countries.
Table - Diagnoses in 43 patients with IgM deficiency Chronic lymphatic leucaemia Lymphoma Other malignancies (hepatoma 2, myeloma 1, acute leucaemia 1 and carcinoma of the ovary 1) Schistosomiasis Cirrhosis Miscellaneous Fully investigated but not diagnosis Imcompletely investigated Total
9 6 5 4 2 6 7 4
43 -
We are, etc., Y. M. FAKUNLE M. DAMISAH A. B. AJDUKIEWICZ H. C. WHITTLE B. M. GREENWOOD The Department of Medicine, Ahmadu Bell0 University, Zaria, Nigeria.
References Cornille-Brogger, R. (1975). A case of serum IgM deficiency in an area of high endemicity of malaria (Northern Nigeria). Transactions of the Royal Society if Tropical Medicine and Hygiene, 69, 515-5 16. Hobbs. J. R. (1975). InM deficiencv. In: 1mmunodeficiency in man and &imaZs, Bergsma, D., Good, R. A., Finstad, J. & Paul, N. W. (Editors). Sunderland, Massachusetts: Sinauer Ass. Inc., pp. 112-l 16. Sagoe, A-S. (1970). Tropical splenomegaly syndrome: long-term proguanil therapy correlated with spleen size, serum IgM and lymphocyte transformation. British Medical Journal, iii, 378-382. Accepted for publication
10th July 1977
Filariasis due to Wuchereria bancrofti in Haiti SIR-In Haiti the incidence of filariasis due to Wuchereria bancrofti, though recognized since the XVIIIth Century, has only been studied by WILSON (1928) who made a preliminary study in the principal cities. During the last ten years at the Hopital le Bon Samaritan in Limbe analyses carried out for blood-carried microfilariae by Knott’s method have regularly uncovered some cases of W. bancrofti and also of Masonella ozzardi. M. ozzardi affects the coastal regions of the island, where it seems to be transmitted by Culicoides furens (RIPERT, RACCURT & DOUYON, 1976), W. bancrofti is encountered much more in the urban milieu. Epidemiologic research has been continuing in the city of Limb6 since February 1977. Limb&, in the north of Haiti, is situated at 72” 24’ W and 19” 43’ N, some 10 km from the coast, in a fertile plain of 90 km2, surrounded by steep mountains, and influenced by the torrential character of the river which runs through it. Having a tropical humid climate, the region receives an average rainfall of 2,000 mm a year, which makes it quite fertile for agriculture. Approximately 60,000 people live in the valley of Limb& The city, which lies on the left side of the river, has about 15,000 inhabitants, and is crossed at its centre by a poorly cared-for canal where water stagnates all year long. A sample of the population chosen at random has been studied by a finger-prick blood sample of volume 20 mm3 drawn between 8.00 and 10.30 p.m. The first results which we are reporting were obtained from a sample of 1,135 persons. Microfilariae of W. bancrofti were recovered from 203, an incidence of 17.9 %, of which three cases also showed M. ozzardi. Three four-year-old children and 22% of those between 10 and 14 years showed the microfilariae. After puberty, males are more frequently parasitized than the females. The people who came from houses quite close to the canal were more frequently parasitized, and to a higher degree. The pathology most frequently encountered is a lymphadenitis of the inguinal nodes in almost all of the microfilaria carriers. Less frequently, engorged lymphatic vessels (lymphoceles) were noted, and also oedema of the lower extremities, and hydrocele. Elephantiasis and chyluria which are sometimes noted in this region have not yet been found in the course of this investigation. Mosquitoes were captured by aspiration in all of the houses where there were cases of microfilaraemia. Culex pipiens fatigans was the most abundant, but Aedes aegypti and A. taen~orhynchus were also recovered. Only C. pipiens fatigans harboured filarial larvae, the dimensions and morphology of which were characteristic of W. bancrqfti. Of 100 female specimens of C. pipens fatigans, previously treated with 70 % alcohol and stained bv the method of NELSON (1958). 20 were found to be infected with W. bancrofti,. six ‘having thoracic microfilariae, one having microfilariae and first-stage larvae in the thoracic muscles, nine having first-stage larvae (short and long sausage forms), three having second-stage larvae in the thoracic muscles, and one having four third-stage larvae in the head and proboscis. Filariasis due to W. bancroftiis therefore a real problem in the cities of the north of Haiti. The parasite is also known at the present time in Cap Haitien, Port Margot, Grande Riviere du Nord, Plaisance, and Gonaives. The vector is Culexpipiensfutigans and these first results from the town of Limb& prove that there is extensive trans-
CORRESPONDENCE mission of the parasite, affecting even the infants of a very early age. We are, etc., CHRISTIANRACCURT Service de Microbiologic, Fact&C de Medecine. Port-au-Prince, ‘ Haiti. WILLIAM HODGES Hopital le Bon Samaritan, Limb& Haiti. References Nelson, G. S. (1958). Staining of filarial larvae in insects before dissection. Bulletin of the World Health Organization, 19,204. Ripert, C., Raccurt, C. & Douyon, P. L. (1976). La filariose & Mansonella ozzardi en Haiti (Grandes Antilles). Premieres donnees epidemiologiques. Bordeaux Medecine. (In press.) Wilson, W. P. (1928). Contribution a l’ttude de la malaria et de la microfilaire. Bulletin de la Sock% de Medecine d’Haiti, 7, 51-63. Accepted for publication 15th July, 1977. Tissue reacting Ig in children parasitaemic with Trypanosoma cruzi SIR-Antibodies reacting against the plasma membrane of endothelial cells, vascular structures and striated muscle (EVI antibodies) have been found in people infected chronically or acutely with Trypanosoma cruzi (COSSIO et al.. 1974: SZARFMANet al.. 1977). The uresence of Ias reacting with Schwann cells of peripheral nerves has also been reported in patients chronically infected with T. cruzi (I(HouRY et al., 1979. We report here the presence of both types of tissuereacting antibodies in the first serum samples obtained six to 3.5days after the onset of symptoms in 38 children recently infected with T. cruzi. All had positive parasitaemia detected either by the STROUT(1966) method or by xenodiagnosis (SCHENONE et al., 1968) and 31 also had IgM anti-T. cvuzi antibodies, established by the indirect immunofluorescence test (IIF) (VATTCJONEet al., 1973) with titres which could be considered positive (> 1:16). Tissue-reacting antibodies were established by IIF test using as antigens cryostat sections of mouse heart, skeletal muscle and sciatic peripheral nerve. Titres > 1 :lO were considered reactive for EVI (COSSIOet al., 1974; KHOURY et al., 1976; SZARFMANet al., 1977) and >20 for peripheral nerve. The results are shown in Table I. ,
,
I
Table I - Tissue-reacting antibodies in recent human Chagas’s disease
IgM
No. of cases
antiT. cruzi antibodies
Tissue-reacting Igs EVI Peripheral Parasitaemia nerve
4 3
-
1 1
+ +
i -
+
1 +
9 20
+ +
+
+
+ +
+ -t
+
453
The appearance of the immunoglobulins reacting against the different host tissues early in the course of the infection suggests that they had originated in crossreacting antigens between T. cruzi and human tissues. Furthermore, the fact that EVI and peripheral nerve antibodies were usually associated, suggests a close relationship between them. This work was made nossible with funds nrovided bv grant No. 362 from- FINEP, Brazil, ‘CONICET, Argentina and WHO. We are, etc., A. SZARFMAN,* P. M. Cossto,t E. L. KHOURY,~ V. RITACO,~ R.M.ARANA~ and G.A. SCHMU%* *Institute of Microbiology, Federal University of Rio de Janeiro, Brazil. iCenter for Medical Education and Clinical Investigation, Buenos Aires, Argentina. References Cossio, P. M., Diez, C., Szarfman, A., Kreutzer, E., Candiolo, B. & Arana, R. M. (1974). Chagasic cardiopathy : demonstration of a serum gamma globulin factor which reacts with endocardium and vascular structures. Circulation, 49, 13-21. Khoury, E. L., Cossio, P. M., Ritacco, V., Diez, C., Laguens, R. P., Segal A., Szarfman, A. &Arana, R. M. (1976). Tincibn inmunofluorescente de nervio periferico asociada al anticuerpo. EVI (Abstract.) Medicina (Buenos Aires), 36, 539. Schenone, N., Alfaro, E. & Reyes, H. (1969). Rendimiento de1 xenodiagnostico en las formas aguda y congenita de la enfermedad de Chagas. Boletin Chileno de Parasitologia, 24,105-106. Strout, R. G. (1962). A method for concentrating hemoflagellates. Journal of Parasitology, 48, 100. Szarfman, A., Cossio, P. M., Schnuniis, G. A. & Arana, R. M. (1977). The EVI antibody in acute Chagas’ disease. Journal of Parasitology, 63, 149. Vattuone. N. H.. Szarfman. A. & Gonzalez Cavna. S. M. (1973).‘Antibddy response and immunoglobuhn levels in humans with acute or chronic Trypanosoma cruzi infections (Chagas’ disease). Journal of Tropical Medicine and Hygiene, 76, 4547. Accepted for publication 22nd June, 1977. Hyperparatbyroidism in the African Srr-Hyperparathyroidism was described over 40 years ago as a common and polymorphic condition (ALBRIGHT et al., 1934). The prevalence of the condition in patients attending a general medical clinic has been estimated as one case per 834 patients (BOONSTRA& JACKSON,1965). An even higher incidence of proven or presumed hyperparathyroidism (1.4%) of 1,630 patients was found among asymptomatic patients during routine medical examinations (PURNELLet al., 1971). However, primary hyperparathyroidism in the African south of the Sahara is extremely rare. Single cases have been reported from Johannesburg (TUCKER et al., 1975), Uganda (MEHTA et al., 1972) and we have collected three cases in a large
