638 TREATMENT OF SALMONELLA TYPHIMURIUM SALMONELLOSIS
SIR,-Chloramphenicol and ampicillin are the drugs of choice irt the treatment of Salmonella typhimurium infection 12 but resistance to both drugs has been reported. 3-6 A 66-year-old patient was admitted to our department with severe diarrhoea, which had lasted for 12 days, complicated by acute renal failure. Despite optimal doses of ampicillin and later chloramphenicol, diarrhoea continued and renal failure progressed. Faecal and urine cultures grew S. typhimurium resistant to chloramphenicol, ampicillin, tetracycline, and carbenicillin, but sensitive to co-thmoxazole, streptomycin, cephalosporins, and nitrofurazone. The patient was treated with co-trimoxazole and responded well. Among 17 S. typhimurium strains isolated in our hospital during 1977 15 (88%) were resistant to both chloramphenicol and ampicillin. Of 305 S. typhimurium strains isolated in Northern Israel during the same year 160 (52%) were resistant to both drugs, and only 3 (1%) were resistant to co-trimoxazole. We believe that co-trimoxazole should be the antibiotic of choice for S. typhimurium infections in Israel. Because of the growing resistance of S. typhimurium to chloramphenicol and ampicillin in the world36 the possibility of treating S. typhimurium salmonellosis with co-trimoxazole deserves worldwide consideration. We thank the bacteriological laboratory, W. Hirsch Central Laboratory, Kupat Holim, Haifa; the bacteriological laboratory at the Rothschild Hospital in Haifa; and the public health laboratory, Haifa, for supplying us with their data.
Departments of Medicine and Microbiology, Rambam Medical Centre and Aba Khoushy School of Medicine,
Technion, Israel
RAFAEL ENAT SIMON POLLACK SHAI LIN DAVID MERZBACH DAVID BARZILAI
H.D.L. CHOLESTEROL IN DIABETES AND HEART DISEASE
SIR,-High-density-lipoprotein (H.D.L.) cholesterol estimaon 200 diabetics attending our clinic failed to demonstrate a significant correlation between H.D.L. cholesterol and total glycosylated haemoglobin A as proposed by Dr Calvert and colleagues (July 8, p. 66). Although a reciprocal relationship exists in a subpopulation (female insulin-dependent diabetics, aged 15-40 years) it is lost when the whole population is considered because other factors, particularly type of treatment, seem far more important than degree of control of hyperglycxmia in’influencing H.D.L. cholesterol levels indiations
betics. Like those of Calvert et al., our diabetics on insulin have higher H.D.L. cholesterol levels than patients matched for age and sex on diet and/or oral hypoglycaemics (see table). This difference is reduced by obesity and smoking, which are associated with lower H.D.L. cholesterol levels in our population. There is no difference between H.D.L. cholesterol levels in our patients treated by diet alone, and those on diet plus oral hypoglycæmics, suggesting the insulin augments H.D.L. rather than that oral hypoglycaemics have a special effect. We are now testing this hypothesis with a prospective study. I have also looked at the association between plasma-lipids, including H.D.L. cholesterol, and vascular disease. Although Gardner, P., Provine, H. T. Manual of Acute Bacterial Infections. p. 82. Boston, 1975. 2. Grossman, M., Jawetz E. in Current Medical Diagnosis and Treatment 1977 (edited by M. A. Krupp and M. U. Chatton); p. 815. Los Altos, 1977. 3. Mohadjer, S., Badalian, K., Mehrabian, S.J. trop. Med. Hyg. 1973, 76, 265. 4. Anderson, E. S. W.H.O. Weekly Epidem. Rec 1974, 8, 65. 5. McHuge G. L., Moellering, R. C., Hopkins, C. C., Swartz, M. N. Lancet, 1975, i, 235. 6. Grant, R. B., Bannatyne, R. M., Shapiey, A. J. J. infect. Dis. 1976, 134,
H.D.L. CHOLESTEROL IN DIABETES
(PATIENTS 50-70 YRS OLD)
AND IN HEART DISEASE
patients with cardiac disease have marginally higher total cholesterols and triglyceride and lower H.D.L. cholesterol (see table) the results are less impressive than those obtained by others with non-diabetics. Only by studying H.D.L. in more detail prospectively will we ascertain whether changes in H.D.L. cholesterol are of the same significance in the diabetic as in the non-diabetic. Diabetic Unit. Royal Perth Hospital, Perth, Western Australia
KIM STANTON
CIRCULATING IMMUNE COMPLEXES IN DENGUE HÆMORRHAGIC FEVER
SIR,—Dengue hæmorrhagic
tever
(D.H.F.)
is characterised
by increased vascular permeability, thrombocytopenia, and haemorrhagic diathesis.’ Immune complexes may play a role in the pathogenesis of D.H.F. as indicated by serum-complement changes,2 the presence of curculating immune complexes detectable by the Raji-cell technique,3 and by platelet-aggre-
gation.4 Plasma from 21 D.H.F. cases was collected on days 2-11 of the fever, stored at -20°C for up to 4 months, and tested for immune complexes by platelet aggregation. All the patients had primary or secondary dengue infection according to Winter5 (serology done at S.E.A.T.O. medical research laboratory in Bangkok). Platelet-aggregation tests were done with fresh platelets at pH 7.6and 6.5.6 A glutaraldehyde-preserved platelet suspension at pH 7.6was also used. An increased platelet-aggregation titre with fresh platelets was found in 10 cases comprising all four grades of disease. At pH 6.5 the titre was increased in 1 of 18 cases while preserved platelets revealed an increased titre in 1 of 11 cases. Most of the increases at pH 7.6 were small to moderate. The titres were 1:16 in 4 cases, 1:32 in 4 cases, 1:64 in 1 case, and 1:256 in 1 case. Normal controls had a titre of 1:2-1:4, and rarely reached 1:8. There was no association between the presence of
immune complexes, the grade of disease, or the haemagglutination inhibition titres. The platelet-aggregation test results suggested that dengue plasma contained immune complexes. Complexes are poorly reactive with fresh platelets at pH 6.56 and do not react with preserved platelets.4 The circulating complexes could increase vascular permeability by binding complement and induce platelet destruction, both of which fit the clinical’picture of D.H.F. Low levels of circulating complexes were found in 47.6% of D.H.F. cases in all grades of diseases. With the Raji-cell technique complexes were detected at all grades of disease in 62% of cases of D.H.F.3 The absence of an association between the presence of com-
1
354.
1. Russel, P. K. in Progress in Immunology, p. 831. London, 1971. 2. Bull. Wld Hlth Org. 1973, 48, 117. 3. Theofilopoulos, A. N., Wilson, C. B., Dixon, F J. J. clin Invest. 1976, 57, 169. 4. Myllaya, C. Scand. J. Hœmat. Suppl 1973, 19. 5. Winter, P. E., Yuill, T. M., Udomsakdi, S., Gould, D., Nontapanich, S., Russel, P. K. Am J. trop. Med. Hyg. 1968, 17, 590. 6. Hedford, E , Norberg, R. Clin. exp Immun. 1974, 16, 493.
SIR,-Chloramphenicol and ampicillin are the drugs of choice irt the treatment of Salmonella typhimurium infection 12 but resistance to both drugs has been reported. 3-6 A 66-year-old patient was admitted to our department with severe diarrhoea, which had lasted for 12 days, complicated by acute renal failure. Despite optimal doses of ampicillin and later chloramphenicol, diarrhoea continued and renal failure progressed. Faecal and urine cultures grew S. typhimurium resistant to chloramphenicol, ampicillin, tetracycline, and carbenicillin, but sensitive to co-thmoxazole, streptomycin, cephalosporins, and nitrofurazone. The patient was treated with co-trimoxazole and responded well. Among 17 S. typhimurium strains isolated in our hospital during 1977 15 (88%) were resistant to both chloramphenicol and ampicillin. Of 305 S. typhimurium strains isolated in Northern Israel during the same year 160 (52%) were resistant to both drugs, and only 3 (1%) were resistant to co-trimoxazole. We believe that co-trimoxazole should be the antibiotic of choice for S. typhimurium infections in Israel. Because of the growing resistance of S. typhimurium to chloramphenicol and ampicillin in the world36 the possibility of treating S. typhimurium salmonellosis with co-trimoxazole deserves worldwide consideration. We thank the bacteriological laboratory, W. Hirsch Central Laboratory, Kupat Holim, Haifa; the bacteriological laboratory at the Rothschild Hospital in Haifa; and the public health laboratory, Haifa, for supplying us with their data.
Departments of Medicine and Microbiology, Rambam Medical Centre and Aba Khoushy School of Medicine,
Technion, Israel
RAFAEL ENAT SIMON POLLACK SHAI LIN DAVID MERZBACH DAVID BARZILAI
H.D.L. CHOLESTEROL IN DIABETES AND HEART DISEASE
SIR,-High-density-lipoprotein (H.D.L.) cholesterol estimaon 200 diabetics attending our clinic failed to demonstrate a significant correlation between H.D.L. cholesterol and total glycosylated haemoglobin A as proposed by Dr Calvert and colleagues (July 8, p. 66). Although a reciprocal relationship exists in a subpopulation (female insulin-dependent diabetics, aged 15-40 years) it is lost when the whole population is considered because other factors, particularly type of treatment, seem far more important than degree of control of hyperglycxmia in’influencing H.D.L. cholesterol levels indiations
betics. Like those of Calvert et al., our diabetics on insulin have higher H.D.L. cholesterol levels than patients matched for age and sex on diet and/or oral hypoglycaemics (see table). This difference is reduced by obesity and smoking, which are associated with lower H.D.L. cholesterol levels in our population. There is no difference between H.D.L. cholesterol levels in our patients treated by diet alone, and those on diet plus oral hypoglycæmics, suggesting the insulin augments H.D.L. rather than that oral hypoglycaemics have a special effect. We are now testing this hypothesis with a prospective study. I have also looked at the association between plasma-lipids, including H.D.L. cholesterol, and vascular disease. Although Gardner, P., Provine, H. T. Manual of Acute Bacterial Infections. p. 82. Boston, 1975. 2. Grossman, M., Jawetz E. in Current Medical Diagnosis and Treatment 1977 (edited by M. A. Krupp and M. U. Chatton); p. 815. Los Altos, 1977. 3. Mohadjer, S., Badalian, K., Mehrabian, S.J. trop. Med. Hyg. 1973, 76, 265. 4. Anderson, E. S. W.H.O. Weekly Epidem. Rec 1974, 8, 65. 5. McHuge G. L., Moellering, R. C., Hopkins, C. C., Swartz, M. N. Lancet, 1975, i, 235. 6. Grant, R. B., Bannatyne, R. M., Shapiey, A. J. J. infect. Dis. 1976, 134,
H.D.L. CHOLESTEROL IN DIABETES
(PATIENTS 50-70 YRS OLD)
AND IN HEART DISEASE
patients with cardiac disease have marginally higher total cholesterols and triglyceride and lower H.D.L. cholesterol (see table) the results are less impressive than those obtained by others with non-diabetics. Only by studying H.D.L. in more detail prospectively will we ascertain whether changes in H.D.L. cholesterol are of the same significance in the diabetic as in the non-diabetic. Diabetic Unit. Royal Perth Hospital, Perth, Western Australia
KIM STANTON
CIRCULATING IMMUNE COMPLEXES IN DENGUE HÆMORRHAGIC FEVER
SIR,—Dengue hæmorrhagic
tever
(D.H.F.)
is characterised
by increased vascular permeability, thrombocytopenia, and haemorrhagic diathesis.’ Immune complexes may play a role in the pathogenesis of D.H.F. as indicated by serum-complement changes,2 the presence of curculating immune complexes detectable by the Raji-cell technique,3 and by platelet-aggre-
gation.4 Plasma from 21 D.H.F. cases was collected on days 2-11 of the fever, stored at -20°C for up to 4 months, and tested for immune complexes by platelet aggregation. All the patients had primary or secondary dengue infection according to Winter5 (serology done at S.E.A.T.O. medical research laboratory in Bangkok). Platelet-aggregation tests were done with fresh platelets at pH 7.6and 6.5.6 A glutaraldehyde-preserved platelet suspension at pH 7.6was also used. An increased platelet-aggregation titre with fresh platelets was found in 10 cases comprising all four grades of disease. At pH 6.5 the titre was increased in 1 of 18 cases while preserved platelets revealed an increased titre in 1 of 11 cases. Most of the increases at pH 7.6 were small to moderate. The titres were 1:16 in 4 cases, 1:32 in 4 cases, 1:64 in 1 case, and 1:256 in 1 case. Normal controls had a titre of 1:2-1:4, and rarely reached 1:8. There was no association between the presence of
immune complexes, the grade of disease, or the haemagglutination inhibition titres. The platelet-aggregation test results suggested that dengue plasma contained immune complexes. Complexes are poorly reactive with fresh platelets at pH 6.56 and do not react with preserved platelets.4 The circulating complexes could increase vascular permeability by binding complement and induce platelet destruction, both of which fit the clinical’picture of D.H.F. Low levels of circulating complexes were found in 47.6% of D.H.F. cases in all grades of diseases. With the Raji-cell technique complexes were detected at all grades of disease in 62% of cases of D.H.F.3 The absence of an association between the presence of com-
1
354.
1. Russel, P. K. in Progress in Immunology, p. 831. London, 1971. 2. Bull. Wld Hlth Org. 1973, 48, 117. 3. Theofilopoulos, A. N., Wilson, C. B., Dixon, F J. J. clin Invest. 1976, 57, 169. 4. Myllaya, C. Scand. J. Hœmat. Suppl 1973, 19. 5. Winter, P. E., Yuill, T. M., Udomsakdi, S., Gould, D., Nontapanich, S., Russel, P. K. Am J. trop. Med. Hyg. 1968, 17, 590. 6. Hedford, E , Norberg, R. Clin. exp Immun. 1974, 16, 493.
