115
clinical relevance in HIV-positive patients with pneumonia when bacteria are found in sputum. Failure to suspect infection with C pseudodiphtheriticum may lead to treatment delay if macrolides are administered before culture. In addition, one of our isolates was resistant to co-trimoxazole given for PCP prophylaxis.
coryneform
We thank Dr Martine Kimedjian, Laboratoire des Identifications, Institut Pasteur, Paris, for identifying C pseudodiphtheriticum. Medical Resuscitation, Microbiology, and Internal Medicine Units,
Hôpital Louis Mourier, Colombes,
and 22 months of the first episode of pancytopenia. A third patient, the infant with CMV-B19 co-infection, died at 9 months. On the basis of our findings, B19 can be regarded as a cause of pancytopenia in children with HIV infection, independently of the haemophagocytic syndrome. Like other children with an impaired immune system HIV-infected children may not be able to produce neutralising antibodies, and thus develop persistently active B19
infection.4 On the other hand, as suggested for herpesviruses,s,6 a reciprocal activation between HIV and B19, and a possible role of B19 in the progression of HIV disease, cannot be ruled out.4
INSERM U 82, Faculty of Medicine Xavier Bichat, Université Paris VII,
YVES COHEN GILLES FORCE ISABELLE GROS
We thank Dr Pasquale Pisano, Dr Andreas Krzysztofiak, and Dr Elsa Bevivino for their collaboration. This work has been supported by funds from Ministry of Scientific Research (Ateneo projects) and National Council of
75018 Paris, and Internal Medicine and Microbiology Units, Hôpital Notre Dame du Perpétuel Secours, Lavallois-Perret, France
ANNE-MARIE CANZI LAURENCE LECLEACH DIDIER DREYFUSS
Research
GU, Stein DS. Pulmonary manifestations of acquired immunodeficiency syndrome, Clin Infect Dis 1992; 14: 98-113. 2. Emmons W, Reichwein B, Winslow DL. Rhodococcus equi infection m the patient with AIDS: literature review and report of an unusual case. Rev Infect Dis 1991; 13: 1. Meduri
91-96. 3. Rikitomi N, Nagatake T, Matsumoto K, Watanabe K, Mbaki N. Lower respiratory tract infections due to non-diphtheria corynebacteria m 8 patients with underlying lung diseases. Tohoku J Exp Med 1987; 153: 313-25. 4. Williams EA, Green JD, Salazar S, Berk SL. Pneumonia caused by Corynebacterium pseudodiphtheriticum. J Tenn Med Assoc 1991; 84: 223-24. 5. Morris A, Guild I. Endocarditis due to Corynebacterium pseudodiphtheriticum: five case reports, review, and antibiotic susceptibilities of nine strains. Rev Infect Dis
1991; 13: 887-92. 6. Rubler S, Harvey L, Avitabile A, Abenavoli T. Mitral valve obstruction in a case of bacterial endocarditis due to Corynebacterium hofmanii: echocardiographic diagnosis. NY State J Med 1982; 82: 1590-94. 7 Coyle MB, Lipsky BA. Coryneform bacteria in infectious diseases: clinical and laboratory aspects. Clin Microbiol Rev 1990; 3: 227-46. 8. Donaghy M, Cohen J. Pulmonary infection with Corynebacterium hofmanni complicating systemic lupus erythematosus. J Infect Dis 1983; 147: 962. 9. Andavolu RH, Jagadha V, Lue Y, McLean T. Lung abscess involving Corynebacterium pseudodiphtheriticum in a patient with AIDS-related complex. N Y State J 1986; 86: 594-96. 10. Brown AE. Other corynebacteria. In: Mandell GL, Douglas RG, Bennett JE, eds. Principles and practice of infectious diseases. 8th ed. 1990; 1581-86.
Parvovirus-B19-related pancytopenia in children with HIV infection SIR,-Dr Muir and colleagues (May 9, p 1139) report parvovirus-BI9-related pancytopenia and haemophagocytosis in patients with hereditary spherocytosis, suggesting that haemophagocytosis could account for the leucopenia and thrombocytopenia associated with parvovirus B19 infection. We have examined serum samples from four children with vertically-transmitted HIV infection and pancytopenia for IgM and IgG antibodies against parvovirus B19, by means of two enzyme immunoassays with synthetic peptide or recombinant protein and subsequent detection of serum B19-DNA with polymerase chain reaction.1-3 The patients (two boys, two girls) were, respectively, aged 1, 8, 14, and 26 months, and were in Centers for Disease Control disease stages P2ABD(two) and P2A (two). All were on zidovudine (600 mg daily). The 1-month-old infant also received ganciclovir (10 mg/kg daily for 2 weeks), since she had congenital cytomegalovirus (CMV) infection, as shown by culture and specific IgM at birth. The main clinical features were: hepatosplenomegaly with raised aminotransferase activities (3 patients), encephalopathy (3), interstitial pneumonitis (2), and cardiomyopathy (2). Pancytopenia was shown by a drop in mean values of haemoglobin (Hb), total while cell count (WCC), and platelets from 9-6 gdl, 54xx 109/1, and 198 x 109/1 to 5-6 g/dl, 3d x 109/1, and 68 x z1, respectively. Reticulocyte count ranged between 0-016% and 1% (mean 041%). Three patients also had fever and two had two
erythema. No haemophagocytosis could be
seen in either bonein bone marrow from another patient. At first the children showed strongly positive B19 IgM and IgG, which persisted for 8, 16, and 22 months in the three with recurrent pancytopenia. In addition, the 1-month-old infant showed B19 DNA. All children needed frequent blood transfusions for 2-4 months and one required repeated transfusions of platelets. However, two patients with persistent B 19 infection died within 5
marrow aspirate from two patients or
(CNR), project FATMA, no 9103613.
Paediatric Institute of "La Sapienza" University, 00137 Rome, Italy, Bambino Gesú Hospital, Rome; and Department of Virology, National Bacteriological Laboratory and Karolinska Institute, Stockholm, Sweden
GIOVANNI NIGRO GUIDO CASTELLI GATTINARA SILVIA MATTIA MAURIZIO CANIGLIA EVA FRIDELL
1. Fridell E, Cohen BJ, Wahren B. Evaluation of a synthetic peptide enzyme-linked immunosorbent assay for immunoglobulin M to human parvovirus B19. J Clin Microbiol 1991; 29: 1376-81. 2. Soderlund M, Brown KE, Meurman O, Hedman K. Prokaryotic expression of a VP1 polypeptide antigen for diagnosis by a human parvovirus B19 antibody enzyme immunoassay. J Clin Microbiol 1992; 30: 305-11. 3. Sahamans MMM, Holsappel S, van de Rijke FH, et al. Rapid detection of human parvovirus infection by dot-blot hybridization and the polymerase chain reaction. J Virol Methods 1989; 23: 19-28. 4. Nigro G, Luzi G, Fridell E, et al. Parvovirus infection in children with AIDS: high prevalence of B19-specific immunoglobulin M and G antibodies. AIDS 1992; 6: 679-84. 5. Rando RE, Pellett PE, Luciw PA, Bohan CA, Srinivasan A. Transactivation of human immunodeficiency virus by herpesviruses. Oncogene 1987; 1: 13-18. 6. Ho W-Z, Harouse JM, Rando RF, Gonczol E, Srinivasan A, Plotkin SA. Reciprocal enhancement of gene expression and viral replication between human cytomegalovirus and human immunodeficiency virus type 1. J Gen Virol 1990; 71: 97-103.
Erbium YAG laser for micromanipulation of oocytes and spermatozoa SIR,-Dr Tadir and colleagues (June 6, p 1424) express concern about potential thermal damage caused by our erbium-YAG laser (March 28, p 811) in the infrared range and potential mechanical damage. An erbium-YAG laser is usually guided by an optical mirror system like a "light scalpel" in non-contact mode. In usual applications (eg, in orthopaedic surgery), full energy is provided by this system. Guiding an erbium-YAG laser through a quartz-fibre means that most of its energy is being absorbed. Only a negligible amount of its original energy is released from the distal end of the fibre without any thermal effect and the cutting energy is limited to a thin layer (3 um). Therefore, the fibreoptic system of the erbium-YAG laser is ideally suited for micromanipulation of human oocytes and spermatozoa. Because of the high absorption coefficient in water and the low ablation threshold there is no mechanical damage due to shock waves or a cavitation effect. Previous investigations have shown that the erbium-YAG laser is better than the laser system proposed by Tadir et al-a 308 nm ultraviolet (UV) excimer laser-for avoidance of thermal tissue injury.’ Furthermore, there are indications of a certain risk of mutagenesis caused by excimer radiation in the UVA region in
therapeutic applications.2 Micromanipulation of spermatozoa (subzonal insemination) with our system is not based on the principle of an optical trap. Three to four spermatozoa are pushed by laser energy through a lasergenerated opening in the zona pellucida. Further clinical experience has shown that our laser-guided micromanipulation technique offers good results with the technique of assisted hatching.33 Recently, healthy twins have been delivered after transfer of laser-manipulated embryos. Assisted hatching, with the use of erbium-YAG laser, in patients with previously failed in-vitro fertilisation (IVF) attempts, has resulted in a pregnancy rate higher than that obtained with common IVF techniques: ten of fifteen patients became pregnant (seven singleton, three twin pregnancies;
clinical relevance in HIV-positive patients with pneumonia when bacteria are found in sputum. Failure to suspect infection with C pseudodiphtheriticum may lead to treatment delay if macrolides are administered before culture. In addition, one of our isolates was resistant to co-trimoxazole given for PCP prophylaxis.
coryneform
We thank Dr Martine Kimedjian, Laboratoire des Identifications, Institut Pasteur, Paris, for identifying C pseudodiphtheriticum. Medical Resuscitation, Microbiology, and Internal Medicine Units,
Hôpital Louis Mourier, Colombes,
and 22 months of the first episode of pancytopenia. A third patient, the infant with CMV-B19 co-infection, died at 9 months. On the basis of our findings, B19 can be regarded as a cause of pancytopenia in children with HIV infection, independently of the haemophagocytic syndrome. Like other children with an impaired immune system HIV-infected children may not be able to produce neutralising antibodies, and thus develop persistently active B19
infection.4 On the other hand, as suggested for herpesviruses,s,6 a reciprocal activation between HIV and B19, and a possible role of B19 in the progression of HIV disease, cannot be ruled out.4
INSERM U 82, Faculty of Medicine Xavier Bichat, Université Paris VII,
YVES COHEN GILLES FORCE ISABELLE GROS
We thank Dr Pasquale Pisano, Dr Andreas Krzysztofiak, and Dr Elsa Bevivino for their collaboration. This work has been supported by funds from Ministry of Scientific Research (Ateneo projects) and National Council of
75018 Paris, and Internal Medicine and Microbiology Units, Hôpital Notre Dame du Perpétuel Secours, Lavallois-Perret, France
ANNE-MARIE CANZI LAURENCE LECLEACH DIDIER DREYFUSS
Research
GU, Stein DS. Pulmonary manifestations of acquired immunodeficiency syndrome, Clin Infect Dis 1992; 14: 98-113. 2. Emmons W, Reichwein B, Winslow DL. Rhodococcus equi infection m the patient with AIDS: literature review and report of an unusual case. Rev Infect Dis 1991; 13: 1. Meduri
91-96. 3. Rikitomi N, Nagatake T, Matsumoto K, Watanabe K, Mbaki N. Lower respiratory tract infections due to non-diphtheria corynebacteria m 8 patients with underlying lung diseases. Tohoku J Exp Med 1987; 153: 313-25. 4. Williams EA, Green JD, Salazar S, Berk SL. Pneumonia caused by Corynebacterium pseudodiphtheriticum. J Tenn Med Assoc 1991; 84: 223-24. 5. Morris A, Guild I. Endocarditis due to Corynebacterium pseudodiphtheriticum: five case reports, review, and antibiotic susceptibilities of nine strains. Rev Infect Dis
1991; 13: 887-92. 6. Rubler S, Harvey L, Avitabile A, Abenavoli T. Mitral valve obstruction in a case of bacterial endocarditis due to Corynebacterium hofmanii: echocardiographic diagnosis. NY State J Med 1982; 82: 1590-94. 7 Coyle MB, Lipsky BA. Coryneform bacteria in infectious diseases: clinical and laboratory aspects. Clin Microbiol Rev 1990; 3: 227-46. 8. Donaghy M, Cohen J. Pulmonary infection with Corynebacterium hofmanni complicating systemic lupus erythematosus. J Infect Dis 1983; 147: 962. 9. Andavolu RH, Jagadha V, Lue Y, McLean T. Lung abscess involving Corynebacterium pseudodiphtheriticum in a patient with AIDS-related complex. N Y State J 1986; 86: 594-96. 10. Brown AE. Other corynebacteria. In: Mandell GL, Douglas RG, Bennett JE, eds. Principles and practice of infectious diseases. 8th ed. 1990; 1581-86.
Parvovirus-B19-related pancytopenia in children with HIV infection SIR,-Dr Muir and colleagues (May 9, p 1139) report parvovirus-BI9-related pancytopenia and haemophagocytosis in patients with hereditary spherocytosis, suggesting that haemophagocytosis could account for the leucopenia and thrombocytopenia associated with parvovirus B19 infection. We have examined serum samples from four children with vertically-transmitted HIV infection and pancytopenia for IgM and IgG antibodies against parvovirus B19, by means of two enzyme immunoassays with synthetic peptide or recombinant protein and subsequent detection of serum B19-DNA with polymerase chain reaction.1-3 The patients (two boys, two girls) were, respectively, aged 1, 8, 14, and 26 months, and were in Centers for Disease Control disease stages P2ABD(two) and P2A (two). All were on zidovudine (600 mg daily). The 1-month-old infant also received ganciclovir (10 mg/kg daily for 2 weeks), since she had congenital cytomegalovirus (CMV) infection, as shown by culture and specific IgM at birth. The main clinical features were: hepatosplenomegaly with raised aminotransferase activities (3 patients), encephalopathy (3), interstitial pneumonitis (2), and cardiomyopathy (2). Pancytopenia was shown by a drop in mean values of haemoglobin (Hb), total while cell count (WCC), and platelets from 9-6 gdl, 54xx 109/1, and 198 x 109/1 to 5-6 g/dl, 3d x 109/1, and 68 x z1, respectively. Reticulocyte count ranged between 0-016% and 1% (mean 041%). Three patients also had fever and two had two
erythema. No haemophagocytosis could be
seen in either bonein bone marrow from another patient. At first the children showed strongly positive B19 IgM and IgG, which persisted for 8, 16, and 22 months in the three with recurrent pancytopenia. In addition, the 1-month-old infant showed B19 DNA. All children needed frequent blood transfusions for 2-4 months and one required repeated transfusions of platelets. However, two patients with persistent B 19 infection died within 5
marrow aspirate from two patients or
(CNR), project FATMA, no 9103613.
Paediatric Institute of "La Sapienza" University, 00137 Rome, Italy, Bambino Gesú Hospital, Rome; and Department of Virology, National Bacteriological Laboratory and Karolinska Institute, Stockholm, Sweden
GIOVANNI NIGRO GUIDO CASTELLI GATTINARA SILVIA MATTIA MAURIZIO CANIGLIA EVA FRIDELL
1. Fridell E, Cohen BJ, Wahren B. Evaluation of a synthetic peptide enzyme-linked immunosorbent assay for immunoglobulin M to human parvovirus B19. J Clin Microbiol 1991; 29: 1376-81. 2. Soderlund M, Brown KE, Meurman O, Hedman K. Prokaryotic expression of a VP1 polypeptide antigen for diagnosis by a human parvovirus B19 antibody enzyme immunoassay. J Clin Microbiol 1992; 30: 305-11. 3. Sahamans MMM, Holsappel S, van de Rijke FH, et al. Rapid detection of human parvovirus infection by dot-blot hybridization and the polymerase chain reaction. J Virol Methods 1989; 23: 19-28. 4. Nigro G, Luzi G, Fridell E, et al. Parvovirus infection in children with AIDS: high prevalence of B19-specific immunoglobulin M and G antibodies. AIDS 1992; 6: 679-84. 5. Rando RE, Pellett PE, Luciw PA, Bohan CA, Srinivasan A. Transactivation of human immunodeficiency virus by herpesviruses. Oncogene 1987; 1: 13-18. 6. Ho W-Z, Harouse JM, Rando RF, Gonczol E, Srinivasan A, Plotkin SA. Reciprocal enhancement of gene expression and viral replication between human cytomegalovirus and human immunodeficiency virus type 1. J Gen Virol 1990; 71: 97-103.
Erbium YAG laser for micromanipulation of oocytes and spermatozoa SIR,-Dr Tadir and colleagues (June 6, p 1424) express concern about potential thermal damage caused by our erbium-YAG laser (March 28, p 811) in the infrared range and potential mechanical damage. An erbium-YAG laser is usually guided by an optical mirror system like a "light scalpel" in non-contact mode. In usual applications (eg, in orthopaedic surgery), full energy is provided by this system. Guiding an erbium-YAG laser through a quartz-fibre means that most of its energy is being absorbed. Only a negligible amount of its original energy is released from the distal end of the fibre without any thermal effect and the cutting energy is limited to a thin layer (3 um). Therefore, the fibreoptic system of the erbium-YAG laser is ideally suited for micromanipulation of human oocytes and spermatozoa. Because of the high absorption coefficient in water and the low ablation threshold there is no mechanical damage due to shock waves or a cavitation effect. Previous investigations have shown that the erbium-YAG laser is better than the laser system proposed by Tadir et al-a 308 nm ultraviolet (UV) excimer laser-for avoidance of thermal tissue injury.’ Furthermore, there are indications of a certain risk of mutagenesis caused by excimer radiation in the UVA region in
therapeutic applications.2 Micromanipulation of spermatozoa (subzonal insemination) with our system is not based on the principle of an optical trap. Three to four spermatozoa are pushed by laser energy through a lasergenerated opening in the zona pellucida. Further clinical experience has shown that our laser-guided micromanipulation technique offers good results with the technique of assisted hatching.33 Recently, healthy twins have been delivered after transfer of laser-manipulated embryos. Assisted hatching, with the use of erbium-YAG laser, in patients with previously failed in-vitro fertilisation (IVF) attempts, has resulted in a pregnancy rate higher than that obtained with common IVF techniques: ten of fifteen patients became pregnant (seven singleton, three twin pregnancies;
