191

recommends ribavirin for infants at high risk of severe or complicated RSV infection, infants admitted to hospital with RSV

lower-respiratory-tract disease who are severely ill, and infants who may be at increased risk of progressing to a more severe condition: Consider ribavirin therapy in infants and young children admitted to hospital with lower-respiratory-tract RSV infections, and with: Congenital heart disease

Bronchopulinonary dysplasia Other chronic lung conditions Certam premature infants

patients.

Immunodeficiency (severe combined, recent transplant, chemotherapy for malignancy) Pa02 < 65 mm Hg Increasing PACO,

We thank Dr McKendrick and other clinicians for providing specimens and our colleagues at the Public Health Laboratory, Sheffield, for technical assistance.

Less than 6 weeks of age

Multiple congenital anomalies or neurological or metabolic diseases Increased risk of disease progression from reports to American Infectious Diseases, 1991B

Adapted

ICN Pharmaceuticals, Costa Mesa, California 92626, USA

Academy of

Pediatrics Committee

CRAIG SHERMAN HUMBERTO FERNANDEZ

J Med 1991, 325: 24-29. et

al Ribavirin aerosol for acute bronchiolitis. Arch Dis Child

Public Health Laboratory, Northern General Hospital, Sheffield S5 7AU, UK

T. C. J. BOSWELL G. KUDESIA

on

1 Wilcox MH, Williams O, Camp SJ, Spencer RC, Barker I. Characteristics of successive epidemics of respiratory syncytial virus infection. Lancet 1991; 338: 943-44. 2. Smith D, et al. Aerosolized ribavirin m infants requiring mechanical ventilation for severe lower respiratory tract infection caused by respiratory syncytial virus. N Engl

3. Barry W,

These results indicate that a substantial proportion of patients with campylobacter gastroenteritis have antibodies that crossreact serologically with legionella by IFAT. This is important diagnostically since campylobacter infection may present as pyrexia of unknown origin, diarrhoea can be a prominent feature of legionnaires’ disease, and both infections may be acquired abroad. We therefore recommend caution in interpretation of positive legionella serological tests, especially in patients with a recent history of diarrhoea, and suggest culture of stool samples in all such

1986; 61:

593-97.

W, Kim H, et al. Aerosolized ribavirin m the treatment of patients with respiratory syncytial virus disease. Pediatr Infect Dis J 1987; 6: 159-63. 5. Sung R, et al Ribavarin treatment of severe respiratory syncytial viral infection in infants and young children: a local experience. J Hong Kong Med Assoc 1990, 42: 4. Rodriguez

80-82 6. Hall C, McBride J, et al. Aerosolized ribavirin treatment of infants with respiratory 1983; 308: 1443-47. syncytial viral infection. N Engl Med J 7. Lau Y, et al. Evaluation of ribavirin for treatment of respiratory syncytial virus. Sem Pediatr Infect Dis 1991; 2: 279-84. 8 Report of the Committee on Infectious Diseases, American Academy of Pediatrics,

22nd ed. 1991: 581-87.

Seropositivity for legionella in campylobacter infection SIR,-Despite the development of suitable culture media and other methods for direct detection of Legionella pneumophila, legionnaires’ disease is still diagnosed in most patients by serological testing. Crossreactions with other organisms that are seen when heat-killed antigens are used1,2 have generally not been found with a formatinised yolk-sac antigen (FYSA) of L pneumophila serogroup 1 in the indirect fluorescence antibody test (IFAT).3The specificity of IFAT is high, even for low titres of 16 or 32,4 and since 1978 there has been, as far as we are aware, only one reported case in which a diagnostic rise in titre of legionella antibodies by IFAT was due to a crossreaction with another organism.’ We have identified high legionella antibody titres in a 41-year-old man who presented with a 12-day history of diarrhoea, vomiting, fever, joint aches, and extreme fatigue. On admission this titre was 2048. However, the patient had no respiratory symptoms, chest radiography was unremarkable, and he had no epidemiological features suggesting legionellosis. Other initial investigations were negative but Campylobacter jejuni was subsequently isolated from three stool cultures. These findings prompted us to examine 50 serum samples (36 from 34 acutely ill and 14 from 11 convalescent patients) for legionella antibodies with IFAT in 45 inpatients with cultureproven campylobacter gastroenteritis. 1 sample (2-8%) from acutely ill patients and 10 (71 %) of 14 from convalescent patients were positive. The positive sample at the acute stage of illness had a titre of only 16 whereas 7 samples at the convalescent stage had titres between 128 and 2048. These antibodies could be absorbed by killed suspensions of campylobacter-a process that had no effect on serum legionella antibody from a patient with culture-proven legionnaires’ disease. 45 serum samples from 41 patients with salmonella gastroenteritis all had legionella antibody titres of less than 16 by IFAT.

1. Wilkinson HW, Farshy CE, Fikes BJ, Cruce DD, Yealy LP. Measure of immunoglobulin G-, M-, and A- specific titers against Legionella pneumophila and inhibition of titers against non-specific, gram-negative bacterial antigens in the indirect immunofluorescence test for legionellosis. J Clin Microbiol 1979; 10: 685-89. 2. Edelstein PH, McKinney RM, Meyer RD, Edelstein MAC, Krause CJ, Finegold SM. Immunologic diagnosis of legionnaires’ disease; cross-reactions with anaerobic and microaerophilic organisms and infections caused by them. J Infect Dis 1980; 141: 652-55. 3. Taylor AG, Harrison TG, Dighero MW, Bradstreet CMP. False positive reactions in the indirect fluorescent antibody test for legionnaires’ disease eliminated by use of formolised yolk-sac antigen. Ann Intern Med 1979; 90: 686-89. 4. Harrison TG, Taylor AG. The diagnosis of legionnaires’ disease by estimation of antibody levels. In. Harrison TG, Taylor AG, eds. A laboratory manual for legionella. Chichester. John Wiley, 1988. 113-35. 5. Gray JJ, Ward KN, Warren RE, Farrington M Serological cross-reaction between Legionella pneumophila and Citrobacter freundii in indirect immunofluorescence and rapid microagglutination tests. J Clin Microbiol 1991; 29: 200-01.

Omental

milky spots

SIR,-Dr Koten and Professor den Otter (Nov 9, p 1189) suggest that omental milky spots constitute a type of primary lymphoid organ, which processes gut-derived antigens and can cause disease in its own right. We think that this proposal is improbable. For some decades it has been suggested that gut-associated lymphoid tissue (GALT) has a role as a primary lymphoid organ. The basis for this largely relates to the existence of the bursa of Fabricius, by which the pattern of B-cell reactivity is thought to be regulated in birds. In mammals, Peyer’s patches, mesenteric lymph nodes, and the large number of lymphocytes within intestinal villi are thought to constitute a primary and secondary lymphoid organ, with the joint function of regulating potentially autodestructive responses to ubiquitous antigens while retaining the ability to react specifically with and inactivate antigens associated with lifethreatening pathogens. The proposal that omental milky spots are part of or even the main component of GALT with a predominantly primary function seems untenable. We prefer the notion of the omentum and its milky spots as the abdominal policeman rather than a misplaced thymus, and argue that their important association is not with the gut lumen but with the peritoneal cavity. Milky spots are reactive structures that increase in both size and number after appropriate stimulation. Situated in direct contact with the peritoneal cavity, glomus-like collections of vascular capillaries form a framework for milky spot macrophages and dendritic cells.1 Activation of these alarm cells can trigger a rapid exudation of neutrophils and macrophages in response to peritoneal infection.2 Although minute quantities of ingested particulate material find their way from the intestinal lumen to omental milky spots (and, importantly, to parathymic lymph nodes and thymic cortex), these amounts are considerably less than those entering GALT.3 The presence of milky spots might qualify the omentum to be a peripheral lymphoid organ.4 However, it should be remembered that in circumstances that include various autoimmune, infectious, and neoplastic conditions, lymphoreticular tissue can appear almost anywhere in the mesenchyme.5 In mice, repeated intraperitoneal injection of antigen leads to the appearance of IgM and IgG forming cells in omental milky spots, cells that almost certainly derive, via the circulation, from other remote lymphoid organs, including the

192

relation. The embryological association between the omentum and spleen is certainly curious, but to attribute a functional link between the two organs on the basis of a common venous drainage seems unconvincing and irrelevant. When considering the role of the omentum, a property that should not be forgotten is its angiogenic capacity. Omental capillaries provide a source of new blood vessels that may be important in repair and ischaemia within the abdominal cavity.’7 Whether this in turn owes anything to an activation of cells within milky spots is questionable. R. J. L. WILLIAMS Chase Farm Hospital, A. J. S. DAVIES Enfield EN2 8JL, UK

HEIGHTS AND HEIGHT DEFICITS IN TWO SURVEYS IN BRAZIL

spleen6-a systemic

RHJ, Fluitsma DM, Hoefsmit ECM. The cellular composition of omentum milky spots and the ultrastructure of milky spot macrophages and reticulum cells. J Reticuloendoth Soc 1980; 28: 585-99. 2. de Souza GEP, Ferreira SH Blockade of antimacrophage serum of the migration of PMN neutrophils into the inflamed pentoneal cavity. Agents Actions 1985; 17: 1. Beelen

97-103. 3. Matsuno K, Schaffner T, Gerber HA, Ruchti C, Hess MW, Cottier H. Uptake by enterocytes and subsequent translocation to internal organs, eg thymus, of Percoll microspheres administered per os to suckling mice. J Reticuloendoth Soc 1983; 33: 263-73. 4. Dux J, Rouse RV, Kyewski B. Composition of the lymphoid cell populations from omental milky spots during the immune response in C57BL/Ka mice. Eur J

Immunol 1986; 16: 1029-32. 5 Cottier H, Hees MW, Keller H-U Structural basis for lymphoid tissue functions: established and disputable sites of antigen-cell and cell to cell interactions in vivo. Monogr Allergy 1980; 60: 50-71. 6. Williams RJL, Brittle M. The influence of splenectomy on local immunity in the peritoneal cavity. Eur Surg Res 1989; 21 (suppl 2). 16. 7. Williams RJL. Angiogenesis and the greater omentum. In: Goldsmith HS, ed. The omentum. research and clinical applications. New York: Springer Verlag, 1990: 45-61.

for males and + 3-3 cm for females) could be approximated from the 1989 survey by subtracting the height deficits found in age groups 22 and 7 (7-8-4-5 =3-3 cm for males, 7-0-3-5=3-5 cm for females). Similar results were found using adjacent age groups (6 and 21 or 8 and 23). In other words, the single survey approach works, at least for Brazilian data. The lower values (0-8 cm for boys, 1. 1 cm for girls) obtained by subtracting height deficits in age groups 22 and 7 in the 1974 survey could indicate a recent acceleration in the trends, consistent with the patterns observed in other indicators, such as the infant mortality .*’ rates If our findings are confirmed in other studies, a very practical alternative for assessing trends in child growth would be immediately available. For example, household anthropometric surveys could include a sample of young adults, or parents’ height could be measured in surveillance systems of school-aged children. School of Public Health, University of Sao Paulo, Sao Paulo, Brazil

Delegacion

Trends in child

growth

from

a

single

cross-sectional survey SIR,-Growth in children is a good indicator of the health and wellbeing of a population and trends in child growth reflect the impact of social and economic changes and specific public health interventions. However, information on national trends is rarely available because few countries have two or more comparable anthropometric surveys.1 We propose a simpler alternative. The natural history of stunting in developing countries is quite well known: linear growth begins to fall off in the second 3 months of life and remains at about 80% of reference values until the second or third year; from then up to 5 years growth increments are not substantially different from those in developed countries.2 Four studies in developing countries have monitored growth from childhood, through adolescence, to adulthood,3-6 and all point to the same general fmding-namely, that total height gain from 5 years of age to adulthood is remarkably similar to reference values obtained in healthy and well-nourished populations. A relation has been postulated between the degree of stunting before puberty and the duration of the adolescent growth spurt-the more severe the stunting, the longer the growth spurts-and that would provide an efficient compensatory mechanism against further deterioration in growth after childhood. If this mechanism operates universally, a cohort of individuals, in any population, will tend to present similar height deficits at the end of childhood and as adults. Therefore, one cross-sectional survey on 5-year-old children and young adults (20-25 years) could provide useful information on trends in child

growth over a 15-20-year period. Two national surveys, done in 1974 and 1989 in Brazil’ and

entirely comparable with respect to sampling and data collection, provide a unique opportunity to test the "single survey" approach. Since mortality is very low among older children and young adults and the effect of migration in and out of the country is negligible, we will assume that adults of X years of age in 1989 represent the same cohort as children (X-15) years of age in 1974. The table shows median heights (and SE) for children aged 7 and adults aged 22 in the two surveys, and differences between median heights and the reference heights.8 The height deficits at adult ages were already present at age 7 (7-4 cm out of a total deficit of 7.8 cm for males, 6-8 out of 7-0 cm for females). On this basis, the 15-year trends between the two cross-sectional surveys (+2-9 cm

CARLOS A. MONTEIRO*

Provincial de Salud,

ALBERTO M. TORRES

Jaen, Andalucia, Spain *

Present address: Nutrition Unit, World Health Switzerland.

Organisation, CH-1211 Geneva 27,

ACC/SCN. Update report on the nutrition situation: recent trends in nutrition m 33 countries. Geneva: ACC/SCN, 1989. 2. Waterlow JC. Observations on the natural history of stunting. In: Waterlow J, ed Linear growth retardation in less developed countries. Nestlé Nutr Workshop Ser 1.

1988, no 14. 3.

Hauspie RC, Das SR, Preece MA, Tanner JM. A longitudinal study of the growth in height of boys and girls in West Bengal (India) aged six months to 20 years. Ann

Hum Biol 1980; 7: 429-41. WZ, McGregor IA. A birth-to-maturity longitudinal study of heights and weights in two West African (Gambian) villages, 1951-1975. Ann Hum Biol 1982, 9: 309-20. 5. Satyanarayana K, Radhaiah G, Murali Mohan B, et al. The adolescent growth spurt of height among rural Indian boys in relation to childhood nutritional background. a 18 year longitudinal study. Ann Hum Biol 1989; 16: 289-300. 6. Martorell R, Rivera J, Kaplowitz H. Consequences of stunting in early childhood for adult body size in rural Guatemala. Ann Nestlé 1990; 48: 85-92. 7. Monteiro CA, Benicio MHD’A, Gouveia NC. Growth and nutritional status of Brazilian children findings from the 1989 national health and nutritional survey (NUT/ANTREF/1/91). Geneva: WHO, 1991. 8. Dibley MJ, Goldsby JB, Staehling NW, et al Development of normalized curves for the international growth reference: historical and technical considerations. AmJ Clin Nutr 1987; 46: 749-62. 9. FIBGE/UNICEF. Perfil estatistico de criancas e maes no Brasil. Mortalidade infantil e saude na decada de 80. Rio de Janeiro: IBGE, 1989.

4. Billewicz

Pseudomembranous colitis

complicating

chemotherapy SIR,-A 43-year-old premenopausal woman with early-stage, node-positive breast cancer was treated with adjuvant CMF (oral cyclophosphamide 100 mg once daily for 14 days, fluorouracil 1 g intravenously on days 1 and 8, and methotrexate 50 mg intravenously on days 1 and 8). She tolerated the first three courses of chemotherapy well, her only complaint being increased bowel frequency (four times daily) for about 3 days after treatment. 3 days after her fourth course of chemotherapy diarrhoea developed (up to six times daily) which continued for 10 days, when she was admitted for further investigations. On admission she complained of anorexia, stabbing abdominal pains, and diarrhoea. She was mildly dehydrated and had diffuse abdominal tenderness but no evidence of peritonitis. Plain radiography of the abdomen showed slight distension of the small intestine with fluid, and sigmoidoscoPY revealed grade 1 colitis, but no pseudomembranes were seen. She