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Letters to the Editor

References 1 Simpson G. Audit of inpatient referrals. Intern Med J 2015; 45: 589. 2 Brown MG, Campbell D, Maydom BW. The undivided patient: a retrospective

cohort analysis of speciality referrals made from inpatient general medical units comparing regional to metropolitan practice. Intern Med J 2014; 44: 884–9. 3 Simpson FG, Wilson J, Peake MD, Cooke NJ. Audit of work-load of physicians with

Leprosy and Australia While syphilis has been hailed as ‘the great imitator’, leprosy can also qualify, as illustrated by Turner et al.1 in a summary of cases treated in a tertiary centre in Victoria. The authors make the point that little has been published about aspects of the disease in developed settings. Some readers may be interested in two accounts of leprosy2,3 as seen in New South Wales from the 1950s to the 1970s, revealing confusion in clinical assessments and differential diagnoses in these patients. In this country, leprosy in

References 1 Turner D, McGuinness SL, Leder K. Leprosy: diagnosis and management in a

its clinical manifestations is seen infrequently, and by many clinicians not at all, so that the diagnosis is often simply not considered. Received 9 February 2015; accepted 10 February 2015. doi:10.1111/imj.12745

C. R. Boughton Division of Infectious Diseases, Prince of Wales Hospital, University of New South Wales, Sydney, New South Wales, Australia

developed setting. Intern Med J 2015; 45: 109–12. 2 Boughton CR. Leprosy and Australia. Med J Aust 1972; 2: 837–42.

Not only monoclonal antibodies . . . The recent case report by Commons et al.1 suggests that monoclonal antibody therapy was the triggering factor for the development of melioidosis in a patient with psoriatic arthritis. As the physician caring for this patient at the time, I feel the authors have jumped to a conclusion regarding the possible connection with anti-tumour necrosis factor and anti-IL12/23 treatment in this case. While this patient’s spondylitis responded well to biologic therapy, he also suffered from severe, extensive plaque psoriasis that was largely unresponsive to treatment (aside from a short lived initial improvement after etanercept therapy). Given the fact that there is a considerable (>100) number of patients maintained on biologic therapy in

a special interest in respiratory medicine. Br J Dis Chest 1987; 81: 150–4.

3 Boughton CR. Leprosy in Sydney. Med J Aust 1977; 2: 351–3.

Darwin in the last 5–10 years and the fact that this is the first case of melioidosis observed in this group, I remain unconvinced that treatment was a triggering factor in this case. Working in the garden during the wet season with extensive psoriatic skin lesions and without the use of protective gear seems to have been the most likely route of inoculation. Therefore, in my opinion, it would have been more appropriate to add active psoriasis to the author’s list of risk factors for acquiring melioidosis in endemic areas. Received 15 January 2015; accepted 4 February 2015. doi:10.1111/imj.12742

J. C. Nossent School of Medicine and Pharmacology, The University of Western Australia, Perth, Western Australia, Australia

Reference 1 Commons RJ, Grivas R, Currie BJ. Melioidosis in a patient on monoclonal antibody therapy for psoriatic arthritis. Intern Med J 2014; 44: 1245–46.

© 2015 Royal Australasian College of Physicians

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