936
myself, and the patients had great difficulty in communicating with junior house officer. History taking and attending to acutely ill patients when language is a barrier can result in delays and misleading information which can be detrimental for patient care. I propose that all EC graduates should have linguistic assessment before registration in the country where they wish to work to identify those who may benefit from language courses, which could perhaps be financed by the EC. my
Department of Medicine and Therapeutics, University of Aberdeen, Foresterhill, Aberdeen AB9 2ZD, UK
A short list at the
IZHAR H. KHAN
Royal Free
SIR,-A note in your issue of March 14 on the case being brought by Dr Vivian Fonseca against the Royal Free Hospital School of Medicine alleges racial discrimination. As chairman of Council of the School of Medicine I inquired into the basis of Dr Fonseca’s case (I cannot reply in detail because the matter is sub judice) but there are several errors in your report. Despite the comments in your final paragraph, I believe that the School, in considering the applicants for appointment, applied formal procedures generally accepted in the University of London and other universities. We short-listed four applicants who gained the most votes in order of merit (all of whom, contrary to what you say, were accredited) and made our decision on selection for appointment to an academic post in accordance with academic criteria. Incidentally, the school denies vigorously any racial discrimination on its part. The candidate appointed is not of white British origin. Royal Free Hospital School of Medicine, University of London, London NW3 2PF, UK
L. H. L. COHEN
Treatment of early breast cancer SIR,-Some of your correspondents (Feb 15, p 423; March 14, p 675) seem reluctant to accept an important therapeutic role for ovarian suppression in young women with early breast cancer. Ovarian suppression is disparaged by being described as oldfashioned in comparison with modem chemotherapy. There is also a tendency to make the unreliable assumption that tamoxifen has the clinical effects as ovarian suppression in young women. We agree that there is little point in undertaking randomised trials merely to compare ovarian suppression with chemotherapy. Irrespective of trial outcome, will women have more to gain by receiving both treatments than either on its own? Future studies should aim to make chemotherapy and endocrine therapy effective partners, and trials are needed to test the added benefits of combined chemo-endocrine therapy. An important subsidiary aim of such studies should be to identify those women who would most benefit from combined modality treatment rather than endocrine therapy or chemotherapy alone. The UK National Adjuvant Breast Cancer (ABC) Trial has been launched to address these questions with the intended accrual of at least 5000 patients over the next three years. Individual participants or existing collaborative groups in the UK and overseas are invited to take part in this important initiative. same
Clinical Trials and Statistics Unit, Section of Epidemiology, Institute of Cancer Research, Sutton, Surrey SM2 5NG, UK
JUDITH M. BLISS JOHN R. YARNOLD
Hypernatraemia, acute diarrhoea, rehydration therapy to
and oral
SIR,-Dr Fayad and colleagues (Feb 15, p 389) were courageous report the unacceptably high frequency of hypematraemia that
occurred
early stages of the introduction of oral in rehydration therapy Egypt. Many of us who are interested in this treatment for acute diarrhoeal disease in infants and children knew of these early results and feared that they might not be published. The most important variable responsible for hypematraemia seems to be misuse of the oral rehydration solution (ORS), largely as a result of improper mixing to provide overconcentrated ORS, but
during
the
this is combined with restriction of other fluids-most importantly Once these difficulties were identifed and corrected, hyematraemia decreased to below that recorded when ORS was first formally introduced. The value of oral rehydration therapy is undisputed but, as this study shows, the solutions should be correctly prepared and, when the World Health Organisation ORS is used during the maintenance phase, additional free water should be given to avoid sodium overload. Are there other ways of reducing the risk of hypematraemia development during oral rehydration therapy? Fayad et al rightly comment on this, stating "there is a case, therefore, for reducing... the sodium content of ORS to 60-75 mmol/1, which is clinically as effective as 90 mmol/1 in the treatment of dehydration". We reviewed the many publications on sodium content of ORS and came to a similar conclusion.’ The stool sodium content in most cases of acute diarrhoea in infants and children is usually fairly low (30-40 mmol/1) and only exceeds 80-90 mmol/1 in cholera, which is not the major cause of acute diarrhoea in infants and children. There is a second advantage to reducing the sodium content of ORSnamely, that it allows a reduction in ORS osmolality. We have shown in various perfusion model systems in animals and man the potential benefit of hypotonic ORS,z-4 and a preliminary clinical study indicates that hypotonic glucose-electrolyte ORS can, like cereal-based ORS, reduce stool volume.S Indeed, the therapeutic benefit of complex substrate ORS may depend largely on the low initial osmolality (about 160 mOsm/kg). The European Society of Paediatric Gastroenterology and Nutrition has endorsed the findings of a European Working Group, which strongly supports the view that hypotonic ORS is the way forward for European children.6 There could be a case for extending these recommendations to other geographical locations. water.
Department of Gastroenterology, St Bartholomew’s Hospital, London EC1A 7BE, UK
M. J. G. FARTHING
EJ, Cunha-Ferreira R, Walker-Smith JA, Farthing MJG. Sodium content of oral rehydration solutions: a reappraisal. Gut 1989; 30: 1610-21. 2. Rolston DDK, Borodo MM, Kelly MJ, Dawson AM, Farthing MJG. Efficacy of oral rehydration solutions in a rat model of secretory diarrhoea. J Pediatr Gastroenterol Nutr 1987, 6: 624-30. 3. Da Cunha-Ferreira RMC, Elliott EJ, Watson AJM, Brennan E, Walker-Smith JA, Farthing MJG Dominant role for osmolality in the efficacy of glucose and glycine-containing oral rehydration solutions: studies in a rat model for secretory diarrhoea. Acta Paediatr 1992; 81: 46-50. 4. Hunt JB, Elliott EJ, Fairclough PD, Clark ML, Farthing MJG. Water and solute absorption from hypotomc glucose-electrolyte solutions in human jejunum. Gut 1 Elliott
1992, 33: 479-83. 5.
solutions
6.
Patrick MK. Companson of two oral rehydration children with gastroenteritis in Australia, Clin Therap 1990; 12
Cleghorn GJ, Shepherd RW, in
(suppl A):81-85. European Society of Paediatric Gastroenterology and Nutrition Working Group. Recommendation for composition of oral rehydration for the children of Europe J Pediatr Gastroenterol Nutr 1992; 14: 113-15.
PCR for confirmation of Brazilian fever
purpuric
SIR,-Brazilian purpuric fever (BPF), an infectious disease of children with a case-fatality rate of more than 60%," was first recognised in 1984. It is usually preceded by conjunctivitis and is caused by a specific clone of Haemophilus influenzae biogroup aegyptius known as the "BPF clone".4 Before 1989, the areas known to be affected by BPF were limited to the two adjacent Brazilian states of Sao Paulo and Parana and to Australia, where the illness is caused by a different cloned In 1989 BPF was identified in a third Brazilian state (Mato Grosso).6 Confirmation requires isolation of H influenzae biogroup aegyptius from a sterile site such as blood or cerebrospinal fluid (CSF) or specific clinical criteria in combination with negative laboratory results, such as antigen detection, to exclude other common bacterial diseases. No serological tests are yet available to help with the diagnosis. It is often difficult to confirm cases in Brazil because, in a few areas, blood samples are not routinely collected for culture and even when they are the culture is often negative. Any isolates obtained are often not characterised beyond the genus level or preserved for future characterisation. Antigen detection tests to exclude disease caused by Neisseria meningitidis, H influenzae type b, or Streptococcus pneumoniae are not widely available in Brazil.
937
Corporation, Bothell, Washington), which uses guanidinium salts to lyse the cells, to be the most appropriate. Nine blood culture specimens (five from patients who met the clinical definition of BPF, two from patients with H influenzae serotype b disease, and two from patients not infected with Haemophilus spp) were analysed by PCR. DNA was extracted from blood, and PCR reactions were set up using the two primer sets and appropriate controls. Amplification products were separated by agarose gel electrophoresis, stained with ethidium bromide, observed under ultraviolet light, and photographed. DNA extracts from the five patients who met the case definition of BPF (lanes 10-14) were positive with primer set 2 (amplicon size 273 bp) and negative with set 1 (expected amplicon size 343 bp). One of these blood samples (lane 10) was negative for the BPF clone by culture. As expected, the two specimens from patients with H influenzae b infection were positive with both sets. The two negative control specimens did not produce amplicons in either PCR. Southern blotting of the DNA from the gels with probes specific for the genes coding for Bex A protein and for P6 protein7 did not yield additional information about the clinical specimens, although it confirmed that the amplicon of about 360 bp seen with the BPF clone strain with primer set 1 (panel A, lane 4) was due to
non-specific amplification. Our results suggest that PCR may be useful for the rapid detection of the DNA of the BPF agent in clinical specimens. PCR may be especially useful for negative blood cultures from patients suspected of having BPF. The high sensitivity of PCR will be valuable when confirmation of disease is critical for a public health intervention or for epidemiological monitoring. DNA
amplified by PCR and analysed by electrophoresis.
agarose
gel
Panel A shows PCR products obtained after amplification with primers derived from the gene coding for Bex A protein, and panel B shows the products obtained with primers derived from the gene coding for P6 protein of H Influenzae. Lane 1=molecular size standard (Phi-X 174 DNA restricted with Haelll); lane 2= negative control (water), lane 3 PCRmix without DNA; lane 4= BPF clone strain of H influenzae biogroup aegyptius (F3031 ), lane 5=H mfluenzaetype b, lanes 6 and 7 blood culture specimens from patients not infected with H mfluenzae, lanes 8 and 9 = blood culture specimens from patients with H influenzae b; lanes 10-14= blood culture specimens from patients with BPFF =
=
Confirmation of suspected BPF is critical. Oral rifampicin seems be better than the routinely used topical chloramphenicol for eradication of the BPF clone among children with BPF clone conjunctivitis, and eradication of the BPF clone may prevent progression to BPF. The use of oral rifampicin, however, should be limited to situations where confirmed cases of BPF have been identified. Confirmation is also critical when a suspected case occurs outside regions known to be affected. Confirmation of even one case in a new region in Brazil or another part of the world might have major public health consequences and provide important epidemiological data for monitoring of this serious new infectious disease. We have evaluated a polymerase chain reaction (PCR) to detect H influenzae aegyptius DNA in a selected set of blood culture supemates to find out if such an assay was sensitive and specific enough to provide laboratory confirmation when blood cultures from suspected BPF cases are negative. Two primer sets developed by van Ketel et aF for the detection of H influenzae in CSF were used. Set I is derived from sequences coding for the capsulation-associated Bex A protein of encapsulated H influenzae and set 2 is derived from the sequence for the gene coding for outer-membrane lipoprotein P6 which would be present in capsulated and non-capsulated strains. Amplification of a target sequence with only the second set of primers would indicate H aegyptius, H haemolyticus, or unencapsulated H influenzae serotype b.7 Initial PCR experiments with human blood artificially inoculated with the BPF clone indicated the need to remove haem and other materials that interfere in the exponential amplification of the target sequences by Taq polymerase. We evaluated three extraction methods and found the IsoQuik DNA procedure (Microprobe
to
Bacteriology Division, Adolfo Lutz Institute, Sao Paulo, Brazil
MARIA LUCIA C. TONDELLA
Meningitis and Special Pathogens Branch, Division of Bacterial and Mycotic Diseases, GHASSAN M. MATAR BRADLEY A. PERKINS NCID, CDC, Atlanta Meningitis and Special Pathogens Branch, Division of Bacterial and Mycotic Diseases, National Center for Infectious Diseases, Centers for Disease Control, Atlanta, Georgia 30333, USA
BALA SWAMINATHAN
Purpunc Fever Study Group. Brazilian purpuric fever: epidemic purpura associated with antecedent purulent conjunctivitis. Lancet 1987; ii: 757-61. 2. Brazilian Purpuric Fever Study Group. Haemophilus aegyptius bacteraemia in Brazilian purpunc fever. Lancet 1987; ii: 761-63. 3 Harrison LH, da Silva GA, Pittman M, et al. Epidemiology and clinical spectrum of Brazilian purpunc fever J Clin Microbiol 1989; 27: 599-604 4. Brenner DJ, Mayer LW, Carlone GM, et al. Biochemical, genetic, and epidemiologic characterization of Haemophilus influenzae biogroup aegyptius (Haemophilus aegyptius) strains associated with Brazilian purpunc fever. J Clin Microbiol 1988; 26: 1524-34. 5 McIntyre PG, Wheaton G, Erlich J, et al. Brazilian purpuric fever in central Australia. Lancet 1987; ii 112 6. Centers for Disease Control Brazilian purpuric fever-Mato Grasso, Brazil. MMWR 1. Brazilian
7.
1990, 39: 903-05 Ketel RJ, de Wever B, van Alphen L. Detection of Haemophilus influenzae in cerebrospinal fluids by polymerase chain reaction DNA amplification. J Med Microbiol 1990, 33: 271-76
van
Vibrio cholerae non-O1 in sewage lagoons and seasonality in Peru cholera epidemic SIR,-Peru has been experiencing the largest epidemic of cholera this century.While El Tor cholera has not been seen before in South America, non-01 Vibrio cholerae has been present for some
seen
time. The figure shows the results obtained in 1986 for monthly water and plant samples taken from the waste treatment lagoons which serve southern Lima. Monthly cases of cholera in Lima in 1991 are also presented. Grab samples were taken from three lagoons arranged in series. The plant samples were Lemnagibba and Wolffia arrhiza growing in the ponds and vibrio counts were expressed per g wet weight of plant. Each point on the graph is the mean of the log concentration found in the three ponds. Water and plants were diluted in alkaline peptone broth, incubated for 24 h at 37°, and streaked on plates of thiosulphate/citrate/bile-salt. Identification of non-0I V cholerae was with an API system, followed by serological confirmation.
myself, and the patients had great difficulty in communicating with junior house officer. History taking and attending to acutely ill patients when language is a barrier can result in delays and misleading information which can be detrimental for patient care. I propose that all EC graduates should have linguistic assessment before registration in the country where they wish to work to identify those who may benefit from language courses, which could perhaps be financed by the EC. my
Department of Medicine and Therapeutics, University of Aberdeen, Foresterhill, Aberdeen AB9 2ZD, UK
A short list at the
IZHAR H. KHAN
Royal Free
SIR,-A note in your issue of March 14 on the case being brought by Dr Vivian Fonseca against the Royal Free Hospital School of Medicine alleges racial discrimination. As chairman of Council of the School of Medicine I inquired into the basis of Dr Fonseca’s case (I cannot reply in detail because the matter is sub judice) but there are several errors in your report. Despite the comments in your final paragraph, I believe that the School, in considering the applicants for appointment, applied formal procedures generally accepted in the University of London and other universities. We short-listed four applicants who gained the most votes in order of merit (all of whom, contrary to what you say, were accredited) and made our decision on selection for appointment to an academic post in accordance with academic criteria. Incidentally, the school denies vigorously any racial discrimination on its part. The candidate appointed is not of white British origin. Royal Free Hospital School of Medicine, University of London, London NW3 2PF, UK
L. H. L. COHEN
Treatment of early breast cancer SIR,-Some of your correspondents (Feb 15, p 423; March 14, p 675) seem reluctant to accept an important therapeutic role for ovarian suppression in young women with early breast cancer. Ovarian suppression is disparaged by being described as oldfashioned in comparison with modem chemotherapy. There is also a tendency to make the unreliable assumption that tamoxifen has the clinical effects as ovarian suppression in young women. We agree that there is little point in undertaking randomised trials merely to compare ovarian suppression with chemotherapy. Irrespective of trial outcome, will women have more to gain by receiving both treatments than either on its own? Future studies should aim to make chemotherapy and endocrine therapy effective partners, and trials are needed to test the added benefits of combined chemo-endocrine therapy. An important subsidiary aim of such studies should be to identify those women who would most benefit from combined modality treatment rather than endocrine therapy or chemotherapy alone. The UK National Adjuvant Breast Cancer (ABC) Trial has been launched to address these questions with the intended accrual of at least 5000 patients over the next three years. Individual participants or existing collaborative groups in the UK and overseas are invited to take part in this important initiative. same
Clinical Trials and Statistics Unit, Section of Epidemiology, Institute of Cancer Research, Sutton, Surrey SM2 5NG, UK
JUDITH M. BLISS JOHN R. YARNOLD
Hypernatraemia, acute diarrhoea, rehydration therapy to
and oral
SIR,-Dr Fayad and colleagues (Feb 15, p 389) were courageous report the unacceptably high frequency of hypematraemia that
occurred
early stages of the introduction of oral in rehydration therapy Egypt. Many of us who are interested in this treatment for acute diarrhoeal disease in infants and children knew of these early results and feared that they might not be published. The most important variable responsible for hypematraemia seems to be misuse of the oral rehydration solution (ORS), largely as a result of improper mixing to provide overconcentrated ORS, but
during
the
this is combined with restriction of other fluids-most importantly Once these difficulties were identifed and corrected, hyematraemia decreased to below that recorded when ORS was first formally introduced. The value of oral rehydration therapy is undisputed but, as this study shows, the solutions should be correctly prepared and, when the World Health Organisation ORS is used during the maintenance phase, additional free water should be given to avoid sodium overload. Are there other ways of reducing the risk of hypematraemia development during oral rehydration therapy? Fayad et al rightly comment on this, stating "there is a case, therefore, for reducing... the sodium content of ORS to 60-75 mmol/1, which is clinically as effective as 90 mmol/1 in the treatment of dehydration". We reviewed the many publications on sodium content of ORS and came to a similar conclusion.’ The stool sodium content in most cases of acute diarrhoea in infants and children is usually fairly low (30-40 mmol/1) and only exceeds 80-90 mmol/1 in cholera, which is not the major cause of acute diarrhoea in infants and children. There is a second advantage to reducing the sodium content of ORSnamely, that it allows a reduction in ORS osmolality. We have shown in various perfusion model systems in animals and man the potential benefit of hypotonic ORS,z-4 and a preliminary clinical study indicates that hypotonic glucose-electrolyte ORS can, like cereal-based ORS, reduce stool volume.S Indeed, the therapeutic benefit of complex substrate ORS may depend largely on the low initial osmolality (about 160 mOsm/kg). The European Society of Paediatric Gastroenterology and Nutrition has endorsed the findings of a European Working Group, which strongly supports the view that hypotonic ORS is the way forward for European children.6 There could be a case for extending these recommendations to other geographical locations. water.
Department of Gastroenterology, St Bartholomew’s Hospital, London EC1A 7BE, UK
M. J. G. FARTHING
EJ, Cunha-Ferreira R, Walker-Smith JA, Farthing MJG. Sodium content of oral rehydration solutions: a reappraisal. Gut 1989; 30: 1610-21. 2. Rolston DDK, Borodo MM, Kelly MJ, Dawson AM, Farthing MJG. Efficacy of oral rehydration solutions in a rat model of secretory diarrhoea. J Pediatr Gastroenterol Nutr 1987, 6: 624-30. 3. Da Cunha-Ferreira RMC, Elliott EJ, Watson AJM, Brennan E, Walker-Smith JA, Farthing MJG Dominant role for osmolality in the efficacy of glucose and glycine-containing oral rehydration solutions: studies in a rat model for secretory diarrhoea. Acta Paediatr 1992; 81: 46-50. 4. Hunt JB, Elliott EJ, Fairclough PD, Clark ML, Farthing MJG. Water and solute absorption from hypotomc glucose-electrolyte solutions in human jejunum. Gut 1 Elliott
1992, 33: 479-83. 5.
solutions
6.
Patrick MK. Companson of two oral rehydration children with gastroenteritis in Australia, Clin Therap 1990; 12
Cleghorn GJ, Shepherd RW, in
(suppl A):81-85. European Society of Paediatric Gastroenterology and Nutrition Working Group. Recommendation for composition of oral rehydration for the children of Europe J Pediatr Gastroenterol Nutr 1992; 14: 113-15.
PCR for confirmation of Brazilian fever
purpuric
SIR,-Brazilian purpuric fever (BPF), an infectious disease of children with a case-fatality rate of more than 60%," was first recognised in 1984. It is usually preceded by conjunctivitis and is caused by a specific clone of Haemophilus influenzae biogroup aegyptius known as the "BPF clone".4 Before 1989, the areas known to be affected by BPF were limited to the two adjacent Brazilian states of Sao Paulo and Parana and to Australia, where the illness is caused by a different cloned In 1989 BPF was identified in a third Brazilian state (Mato Grosso).6 Confirmation requires isolation of H influenzae biogroup aegyptius from a sterile site such as blood or cerebrospinal fluid (CSF) or specific clinical criteria in combination with negative laboratory results, such as antigen detection, to exclude other common bacterial diseases. No serological tests are yet available to help with the diagnosis. It is often difficult to confirm cases in Brazil because, in a few areas, blood samples are not routinely collected for culture and even when they are the culture is often negative. Any isolates obtained are often not characterised beyond the genus level or preserved for future characterisation. Antigen detection tests to exclude disease caused by Neisseria meningitidis, H influenzae type b, or Streptococcus pneumoniae are not widely available in Brazil.
937
Corporation, Bothell, Washington), which uses guanidinium salts to lyse the cells, to be the most appropriate. Nine blood culture specimens (five from patients who met the clinical definition of BPF, two from patients with H influenzae serotype b disease, and two from patients not infected with Haemophilus spp) were analysed by PCR. DNA was extracted from blood, and PCR reactions were set up using the two primer sets and appropriate controls. Amplification products were separated by agarose gel electrophoresis, stained with ethidium bromide, observed under ultraviolet light, and photographed. DNA extracts from the five patients who met the case definition of BPF (lanes 10-14) were positive with primer set 2 (amplicon size 273 bp) and negative with set 1 (expected amplicon size 343 bp). One of these blood samples (lane 10) was negative for the BPF clone by culture. As expected, the two specimens from patients with H influenzae b infection were positive with both sets. The two negative control specimens did not produce amplicons in either PCR. Southern blotting of the DNA from the gels with probes specific for the genes coding for Bex A protein and for P6 protein7 did not yield additional information about the clinical specimens, although it confirmed that the amplicon of about 360 bp seen with the BPF clone strain with primer set 1 (panel A, lane 4) was due to
non-specific amplification. Our results suggest that PCR may be useful for the rapid detection of the DNA of the BPF agent in clinical specimens. PCR may be especially useful for negative blood cultures from patients suspected of having BPF. The high sensitivity of PCR will be valuable when confirmation of disease is critical for a public health intervention or for epidemiological monitoring. DNA
amplified by PCR and analysed by electrophoresis.
agarose
gel
Panel A shows PCR products obtained after amplification with primers derived from the gene coding for Bex A protein, and panel B shows the products obtained with primers derived from the gene coding for P6 protein of H Influenzae. Lane 1=molecular size standard (Phi-X 174 DNA restricted with Haelll); lane 2= negative control (water), lane 3 PCRmix without DNA; lane 4= BPF clone strain of H influenzae biogroup aegyptius (F3031 ), lane 5=H mfluenzaetype b, lanes 6 and 7 blood culture specimens from patients not infected with H mfluenzae, lanes 8 and 9 = blood culture specimens from patients with H influenzae b; lanes 10-14= blood culture specimens from patients with BPFF =
=
Confirmation of suspected BPF is critical. Oral rifampicin seems be better than the routinely used topical chloramphenicol for eradication of the BPF clone among children with BPF clone conjunctivitis, and eradication of the BPF clone may prevent progression to BPF. The use of oral rifampicin, however, should be limited to situations where confirmed cases of BPF have been identified. Confirmation is also critical when a suspected case occurs outside regions known to be affected. Confirmation of even one case in a new region in Brazil or another part of the world might have major public health consequences and provide important epidemiological data for monitoring of this serious new infectious disease. We have evaluated a polymerase chain reaction (PCR) to detect H influenzae aegyptius DNA in a selected set of blood culture supemates to find out if such an assay was sensitive and specific enough to provide laboratory confirmation when blood cultures from suspected BPF cases are negative. Two primer sets developed by van Ketel et aF for the detection of H influenzae in CSF were used. Set I is derived from sequences coding for the capsulation-associated Bex A protein of encapsulated H influenzae and set 2 is derived from the sequence for the gene coding for outer-membrane lipoprotein P6 which would be present in capsulated and non-capsulated strains. Amplification of a target sequence with only the second set of primers would indicate H aegyptius, H haemolyticus, or unencapsulated H influenzae serotype b.7 Initial PCR experiments with human blood artificially inoculated with the BPF clone indicated the need to remove haem and other materials that interfere in the exponential amplification of the target sequences by Taq polymerase. We evaluated three extraction methods and found the IsoQuik DNA procedure (Microprobe
to
Bacteriology Division, Adolfo Lutz Institute, Sao Paulo, Brazil
MARIA LUCIA C. TONDELLA
Meningitis and Special Pathogens Branch, Division of Bacterial and Mycotic Diseases, GHASSAN M. MATAR BRADLEY A. PERKINS NCID, CDC, Atlanta Meningitis and Special Pathogens Branch, Division of Bacterial and Mycotic Diseases, National Center for Infectious Diseases, Centers for Disease Control, Atlanta, Georgia 30333, USA
BALA SWAMINATHAN
Purpunc Fever Study Group. Brazilian purpuric fever: epidemic purpura associated with antecedent purulent conjunctivitis. Lancet 1987; ii: 757-61. 2. Brazilian Purpuric Fever Study Group. Haemophilus aegyptius bacteraemia in Brazilian purpunc fever. Lancet 1987; ii: 761-63. 3 Harrison LH, da Silva GA, Pittman M, et al. Epidemiology and clinical spectrum of Brazilian purpunc fever J Clin Microbiol 1989; 27: 599-604 4. Brenner DJ, Mayer LW, Carlone GM, et al. Biochemical, genetic, and epidemiologic characterization of Haemophilus influenzae biogroup aegyptius (Haemophilus aegyptius) strains associated with Brazilian purpunc fever. J Clin Microbiol 1988; 26: 1524-34. 5 McIntyre PG, Wheaton G, Erlich J, et al. Brazilian purpuric fever in central Australia. Lancet 1987; ii 112 6. Centers for Disease Control Brazilian purpuric fever-Mato Grasso, Brazil. MMWR 1. Brazilian
7.
1990, 39: 903-05 Ketel RJ, de Wever B, van Alphen L. Detection of Haemophilus influenzae in cerebrospinal fluids by polymerase chain reaction DNA amplification. J Med Microbiol 1990, 33: 271-76
van
Vibrio cholerae non-O1 in sewage lagoons and seasonality in Peru cholera epidemic SIR,-Peru has been experiencing the largest epidemic of cholera this century.While El Tor cholera has not been seen before in South America, non-01 Vibrio cholerae has been present for some
seen
time. The figure shows the results obtained in 1986 for monthly water and plant samples taken from the waste treatment lagoons which serve southern Lima. Monthly cases of cholera in Lima in 1991 are also presented. Grab samples were taken from three lagoons arranged in series. The plant samples were Lemnagibba and Wolffia arrhiza growing in the ponds and vibrio counts were expressed per g wet weight of plant. Each point on the graph is the mean of the log concentration found in the three ponds. Water and plants were diluted in alkaline peptone broth, incubated for 24 h at 37°, and streaked on plates of thiosulphate/citrate/bile-salt. Identification of non-0I V cholerae was with an API system, followed by serological confirmation.
