1387

UK in which that infection is rare. Since most of the combined kits are also as sensitive and specific in detecting anti-HIV-1 as most anti-HIV-1kits,2 they are now the HIV screening assays of choice,

provided that confirmatory testing for both antibodies is available. In countries where HIV-2 infection is

(and more anti-HIV-2 positive specimens are therefore available) further investigation of combined assay sensitivity for anti-HIV-2 is common

warranted. This work was funded Directorate.

by the Department

PHLS Virus Reference Laboratory, Central Public Health Laboratory, London NW9 5HT, UK

of Health Medical Devices

often

negative, as in two of the above three cases. The laboratory diagnosis of salmonellosis in such cases depends on the detection of specific antibodies in the serum. The increase in the diversity of salmonella serotypes associated with reactive arthritis renders the of sensitive serological screening tests2,7 of utmost importance.

use

Department of Medical Microbiology, Turku University, 20520 Turku, Finland, and Rheumatism Foundation Hospital, Heinola

OUTI MÄKI-IKOLA

Hargrett-Bean NT, Pavia AT, Tauxe RV. Salmonella isolates from humans in the United States, 1984-1986. MMWR 1988; 37 (SS-2): 25-31. 2. Isomaki O, Vuento R, Granfors K. Serological diagnosis of salmonella infections by enzyme immunoassay. Lancet 1989; i: 1411-14. 3. Granfors K, Jalkanen S, Lindberg AA, et al. Salmonella lipopolysaccharide in synovial cells from patients with reactive arthritis. Lancet 1990; 335: 685-88. 4. Inman RD, Johnston MEA, Hodge M, Falk J, Helewa A. Postdysenteric reactive arthritis: a clinical and immunogenetic study following an outbreak of 1.

PATRICIA O. ABIOLA JOHN V. PARRY PHILIP P. MORTIMER

1. Parry JV, McAlpine L, Avillez MF. Sensitivity of six commercial EIA kits that detect both anti-HIV 1 and anti-HIV 2. AIDS 1990; 4: 355-60. 2. Parry JV, Mortimer PP, MacDonald CA, Kennedy DA. An evaluation of twelve commercial anti-HIV kits (Department of Health publication STD/90/27). London: Supplies Technology Division, Department of Health, 1990.

salmonellosis. Arthritis Rheum 1988; 31: 1377-83. TJ, Leirisalo-Repo M. Clinical picture of reactive salmonella arthritis. J Rheumatol 1988; 15: 1668-71. 6. Mäki-Ikola O, Viljanen M, Tiitinen S, Toivanen P, Granfors K. Antibodies to arthritis-associated microbes in inflammatory joint diseases. Rheumatol Int (in

5. Hannu

press).

Reactive arthritis after unusual salmonella infections

7. Maki-Ikola O, Heesemann J, Lahesmaa-Rantala R, Toivanen A, Granfors K. Combined use of released proteins and lipopolysaccharide in enzyme-linked immunosorbent assay for serological screening of yersinia infections. J Infect Dis (in

press).

SIR,-As Dr Todd (Sept 29, p 788) and Dr Cooke (Sept 29, p 790) note, salmonella infections are increasing world-wide. This trend is due predominantly to Salmonella enteritidis and S typhimurium, although other serotypes contribute.’ The consequences may sometimes be more serious than a short episode of food poisoning since reactive arthritis may ensue. I report on three such patients admitted to the Rheumatism Foundation Hospital, Heinola, in whom reactive arthritis developed after infections with S saint paul, S montevideo, and Sagona, strains not previously associated with reactive arthritis. Case 1 (36, M). This man, who worked in the food industry, had a routine stool culture after a trip to Tunis. This was found to be positive for S saint paul. A week later, polyarthritis developed, affecting the left hip and several finger and toe joints. Latex and Waaler-Rose tests were negative; HLA-B27 antigen positive; erythrocyte sedimentation rate (ESR) 45 mm(h; Widal agglutination test negative; enzyme immunoassay (EIA) for salmonella IgM, IgG, and IgA antibodies2 highly positive. The disease resolved rapidly with anti-inflammatory analgesic therapy. Case 2 (50, M). He had diarrhoea after a trip to Romania. S montevideo was recovered on stool culture. A month after the onset of the enteric symptoms, migratory polyarthritis developed, affecting shoulders, wrists, hips, knees, ankles, and multiple finger joints. The Widal test was positive; latex and Waaler-Rose tests negative; HLA-B27 antigen negative; antinuclear antibodies negative; ESR 41 mm/h. Complete recovery was achieved with doxycycline and anti-inflammatory analgesic treatment at followup 8 months later. Case 3 (44, F). She had fever and diarrhoea during a holiday on a cruise liner in Europe. Stool cultures revealed S agona excretion for 2 months. After another 2 months arthritis of the knee developed. The Widal test was negative, but an EIA for IgG salmonella antibodies4 was positive. Latex, Waaler-Rose, and antinuclear antibody tests were negative; she was HLA B27 antigen negative; and her ESR was 15 mm/h. Synovial fluid culture and gram staining were negative. The synovitis was treated with local osmic acid. After 6 months she was almost symptom-free. These three patients had reactive arthritis after infections with salmonella serotypes not previously associated with that condition. Proof of an aetiological association between bacteria and arthritis has to come from a demonstration of their direct involvement in the disease, as has been shown for S enteritidis and S typhimurium.3 The clinical picture of these patients was similar to that described earlier for salmonella-triggered reactive arthritis, with variable time intervals between onset of infection and arthritis, clear gastrointestinal symptoms preceding arthritis, and good prognosis.3-6 However, as in case 1, patients with no enteric symptoms before the complication have also been reported.’’ When arthritic complications appear after salmonella infection stool cultures are

Occupational infection among anaesthetists SIR,-Your Nov 3 editorial (p 1103) cites a paper suggesting that the incidence of hepatitis B virus (HBV) markers in anaesthetists is greater than in the general population.1 This paper reported a study in the USA where prevalence of HBsAg in the general population is higher than in the UK. In 1987 we showed that HBV markers in anaesthetists in the Oxford region were no more common than in the general population.2 The annual incidence of acute HBV infection in surgeons in the UK has also been shown to be lower than in Denmark or the USA.1,3This is probably due to screening of high-risk patients and the low incidence of healthy carriers in the general population in the UK. Although we do not wish to underestimate the risk of HIV transmission, present data from the UK do not suggest that anaesthetists are at greater risk than the general population of acquiring either HBV or HIV infection. Nuffield Department of Anaesthetics, John Radcliffe Hospital, Oxford OX3 9DU, UK

M. E. SINCLAIR M. ASHBY

Berry AJ, Isaacson IJ, Kane MA, et al. A multicenter study of the epidemiology of hepatitis B in anesthesia residents. Anesth Analg 1985; 64: 672-76. 2. Sinclair ME, Ashby MW, Kurtz JB. The prevalence of serological markers for hepatitis B virus infection amongst anaesthetists in the Oxford region. Anaesthesia 1987; 42: 30-32. 3. Berry AJ, Isaacson IJ, Hunt D, Kane MA. The prevalence of hepatitis B viral markers in anaesthesia personnel. Anesthesiology 1984; 60: 6-9. 1.

When should

hairy cell leukaemia be treated?

SIR,-Your July 21 editorial (p 149) reviews treatments available for hairy cell leukaemia (HCL) but you do not discuss when to treat. The answer depends on the goal of treatment. With an incurable disease the least toxic and most cost-effective therapy that provides the best palliation is indicated. Despite the highly effective therapies you summarise, HCL not yet been shown to be a curable disease, as an international workshop held in Laguna Niguel, California, on October 18-21, 1989, showed. The goal of treatment in HCL remains palliative. Patients with symptomless and stable disease do not need therapy. The criteria for symptomless disease are no recurrent infections, no symptoms of anaemia or transfusion requirements, no symptoms caused by organomegaly, and no constitutional symptoms. Stable disease stable peripheral blood counts (haemoglobin, granulocytes, platelets) over the previous 3 months, alterations within the normal range being neglected. Therapy should be started only if

maans

Occupational infection among anaesthetists.

1387 UK in which that infection is rare. Since most of the combined kits are also as sensitive and specific in detecting anti-HIV-1 as most anti-HIV-...
183KB Sizes 0 Downloads 0 Views