1228
Significance of crystal clear urine
had AIDS (2
Kaposi sarcoma). None had signs of Wegener’s granulomatosis or other vasculitic diseases. Thirty-one sera from 24 patients showed a faint homogeneous cytoplasmic staining of neutrophils with immunofluorescence, probably representing nonspecific FC-receptor binding of IgG since all 15 patients with hypergammaglobulinaemia showed this staining pattern. Faint C-ANCA (titre 20) was seen in four sera from 3 patients. None showed P-ANCA. Nine sera from 5 patients were repeatedly borderline positive by ANCA-ELISA whereas 3 patients had positive MPO-ELISA values (table). There was no correlation between the presence of ANCA and stage of disease. In view of the increasing application of the new ANCA test systems for screening of systemic vasculitis doctors should be aware of "false-positive" reactions in HIV infection. Department of Internal Medicine, University of Heidelberg, 69 Heidelberg, West Germany
SIR,-Examination of urine specimens is one of the commonest investigations in diagnostic bacteriological laboratories and the cost is substantial. The cost of microscopy and culture, including the cost of labour, was £4-£5 per specimen at this hospital in 1989, and about 31 000 urine samples were examined so that the total cost was between 124 000 and 155 000. Attempts to reduce costs have included screening procedures for urinary culture, such as the blotting paper strip method, but since culture media contribute only a small proportion of the total costs the savings to be achieved in this way are limited. Substantial savings could be made if a system was used which obviated altogether the need to submit many specimens to examination and culture. With this in mind we have examined the
simple proposition that urine which is clear when it is passed is not J. KODERISCH K. ANDRASSY
Ear/Nose/Throat Department, Rigshospitalet, Copenhagen, Denmark
N. RASMUSSEN
Department of Dermatology, University of Heidelberg
M. HARTMANN W. TILGEN
1. Falk RJ, Jennette CH J. Anti-neutrophil cytoplasm autoantibodies with specificity for myeloperoxidase in patients with systemic vasculitis and idiopathic necrotizing and crescentic glomerulonephritis. N Engl J Med 1988; 318: 1651-57. 2. Andrassy K, Koderisch J, Rufer M, et al. Detection and clinical implication of antineutrophil cytoplasm antibodies in Wegener’s granulomatosis and rapidly progressive glomerulonephritis. Clin Nephrol 1989; 32: 159-67. 3. Kopelman RG, Zolla-Pazner S. Association of human immunodeficiency virus infection and autoimmune phenomena. Am J Med 1988; 218: 82-88. 4. Stimmler MM, Quismorio FP, McGehee WG, et al. Anticardiolipin antibodies in acquired immunodeficiency syndrome. Arch Intern Med 1989; 149: 1833-35: 5. Wiik A. Delineation of a standard procedure for indirect immunofluorescence detection of ANCA. APMIS 1989; 97 (suppl 6): 12-13. 6. Rasmussen N, Sjölin C, Isaksson B, et al. ELISA for detection of anti-neutrophil cytoplasm antibodies (ANCA). J Immunol Meth (in press).
infected. 376 samples were examined. They were taken from children attending the accident and emergency and paediatric nephrology outpatients departments at Guy’s Hospital. The patients were aged between 6 weeks and 17 years. 183 of the patients (49%) were male. 321 samples were mid-stream, 49 were bag samples, and 6 were taken by suprapubic bladder aspiration. Immediately after collection a sample, usually 5-10 ml, was placed in a sterile universal container, which was shaken and examined naked eye in a good light against a white background. If the specimen was not crystal clear two drops (0.1 ml) ofO.1 mol/1 acetic acid were added to dissolve any phosphates and the specimen was re-examined. If it was still not crystal clear it was recorded as being cloudy. All samples were then examined by direct microscopy in a Fuchs-Rosenthal counting chamber and leucocyte numbers were expressed as cells/µl. Another 5 ml urine was placed in a small container holding about 0’ 1 g sodium borate to retard bacterial growth and sent promptly to the laboratory. There the urine was subjected to direct and microscopic examination and cultured. A standard loop holding 1 gl was
Zidovudine for HIV infection without
symptoms SIR,-Your April 7 editorial on the US report on zidovudine in asymptomatic HIV infection1 points out limitations to the conclusions that can be drawn from the data. Like Friedland, in an editorial accompanying that report,2 you correctly point out that the long-term benefits of instituting therapy at a CD4 count below 500/ul and the most beneficial time to start therapy remain unknown. It may well be that a lower CD4 count, the rate of decline of CD4 cells alone or in combination with a specific level, or the onset of symptoms will prove to be better indicators of the time at which therapy should be begun in symptom-free persons. One statement in your editorial may lead to misunderstanding. You note that zidovudine in asymptomatic infection "represents prophylaxis rather than treatment". Even in symptomless people with HIV infection viral replication is present.3 Furthermore, most infected individuals will progress to disease, although this may take years.4 Finally, there is as yet no evidence that even in infected persons remaining well for years the risk of subsequent disease progression is reduced-nor are there data to suggest that antiretroviral therapy can indefinitely delay such progression. Therefore, effective antiviral therapy in asymptomatic HIV infection should no more be considered as prophylaxis rather than as treatment, than penicillin therapy is for latent syphilis. It would be very unwise for HIV-infected individuals, or their physicians, to consider themselves healthy simply because they feel well. Department of Medicine, Montefiore Medical Center, Bronx, New York 10467, USA
used for the culture and the medium used
was
CLED agar
(Oxoid). Direct sensitivity tests were done on DSTA agar (Difco) on specimens containing more than 40 leucocytes/µ1. After overnight incubation samples containing more than 100 000 colony-forming units (CFU)/ml were presumed to be infected; samples containing less than 10 000 CFU/ml were presumed to be contaminated; and between these two figures the results were regarded as inconclusive. 288 (76 %) of the urines were clear and 88 (24%) were cloudy. 286 clear specimens yielded no growth on culture or less than 10 000 CFU/ml. 2 of the clear specimens yielded growth in excess of 100 000 CFU/ml; 1 contained Streptococcusfaecalis and the other more than three types of Escherichia coli. The leucocyte count on both of the specimens was less than If III and repeat cultures showed less than 10 000 CFU/ml. Both specimens were probably falsepositive cultures. We conclude that, in this group of patients, if the urine is examined by the clinician shortly after it has been passed and is found to be crystal clear with or without acidification, it is not infected and culture is not necessary. Substantial savings could be made by the general application of this principle. K. RAWAL P. SENGUTTWAN M. MORRIS C. CHANTLER N. A. SIMMONS
Evelina Children’s Department and Department of Clinical Bacteriology and Virology,
UMDS,
Guy’s Hospital, London SE1 9RT, UK
Lack of cough reflex in
aspiration
pneumonia ROBERT S. KLEIN
Volberding PA, Lagakos SW, Koch MA, et al. Zidovudine is asymptomatic human immunodeficiency virus infection. N Engl J Med 1990; 322: 941-49. 2. Friedland GH. Early treatment for HIV. The time has come. N Engl J Med 1990; 322: 1.
1000-02. 3. Ho DD, Moudgil T, Alam M. Quantitation of human immunodeficiency virus type 1 in the blood of infected persons. N Engl J Med 1989; 321: 1621-25. 4. Lifson A, Hessol N, Rutherford GW, et al. The natural history of HIV infection in a cohort of homosexual and bisexual men: clinical manifestations, 1978-1989. Fifth International Conference on AIDS (June 6, 1989, Montreal); abstr TA032.
SIR,-An adequate protective reflex in the airway is important and depression or absence of this reflex has been suggested as leading to aspiration pneumonia.To see if aspiration pneumonia is associated with a decrease in cough reflex we studied this reflex response to citric acid and mechanical irritation in patients with aspiration pneumonia and in age-matched controls. The ten controls, mean age 78 (SE 3) years, had cerebral thrombosis or dementia due to cerebral arterial sclerosis. The five
Significance of crystal clear urine
had AIDS (2
Kaposi sarcoma). None had signs of Wegener’s granulomatosis or other vasculitic diseases. Thirty-one sera from 24 patients showed a faint homogeneous cytoplasmic staining of neutrophils with immunofluorescence, probably representing nonspecific FC-receptor binding of IgG since all 15 patients with hypergammaglobulinaemia showed this staining pattern. Faint C-ANCA (titre 20) was seen in four sera from 3 patients. None showed P-ANCA. Nine sera from 5 patients were repeatedly borderline positive by ANCA-ELISA whereas 3 patients had positive MPO-ELISA values (table). There was no correlation between the presence of ANCA and stage of disease. In view of the increasing application of the new ANCA test systems for screening of systemic vasculitis doctors should be aware of "false-positive" reactions in HIV infection. Department of Internal Medicine, University of Heidelberg, 69 Heidelberg, West Germany
SIR,-Examination of urine specimens is one of the commonest investigations in diagnostic bacteriological laboratories and the cost is substantial. The cost of microscopy and culture, including the cost of labour, was £4-£5 per specimen at this hospital in 1989, and about 31 000 urine samples were examined so that the total cost was between 124 000 and 155 000. Attempts to reduce costs have included screening procedures for urinary culture, such as the blotting paper strip method, but since culture media contribute only a small proportion of the total costs the savings to be achieved in this way are limited. Substantial savings could be made if a system was used which obviated altogether the need to submit many specimens to examination and culture. With this in mind we have examined the
simple proposition that urine which is clear when it is passed is not J. KODERISCH K. ANDRASSY
Ear/Nose/Throat Department, Rigshospitalet, Copenhagen, Denmark
N. RASMUSSEN
Department of Dermatology, University of Heidelberg
M. HARTMANN W. TILGEN
1. Falk RJ, Jennette CH J. Anti-neutrophil cytoplasm autoantibodies with specificity for myeloperoxidase in patients with systemic vasculitis and idiopathic necrotizing and crescentic glomerulonephritis. N Engl J Med 1988; 318: 1651-57. 2. Andrassy K, Koderisch J, Rufer M, et al. Detection and clinical implication of antineutrophil cytoplasm antibodies in Wegener’s granulomatosis and rapidly progressive glomerulonephritis. Clin Nephrol 1989; 32: 159-67. 3. Kopelman RG, Zolla-Pazner S. Association of human immunodeficiency virus infection and autoimmune phenomena. Am J Med 1988; 218: 82-88. 4. Stimmler MM, Quismorio FP, McGehee WG, et al. Anticardiolipin antibodies in acquired immunodeficiency syndrome. Arch Intern Med 1989; 149: 1833-35: 5. Wiik A. Delineation of a standard procedure for indirect immunofluorescence detection of ANCA. APMIS 1989; 97 (suppl 6): 12-13. 6. Rasmussen N, Sjölin C, Isaksson B, et al. ELISA for detection of anti-neutrophil cytoplasm antibodies (ANCA). J Immunol Meth (in press).
infected. 376 samples were examined. They were taken from children attending the accident and emergency and paediatric nephrology outpatients departments at Guy’s Hospital. The patients were aged between 6 weeks and 17 years. 183 of the patients (49%) were male. 321 samples were mid-stream, 49 were bag samples, and 6 were taken by suprapubic bladder aspiration. Immediately after collection a sample, usually 5-10 ml, was placed in a sterile universal container, which was shaken and examined naked eye in a good light against a white background. If the specimen was not crystal clear two drops (0.1 ml) ofO.1 mol/1 acetic acid were added to dissolve any phosphates and the specimen was re-examined. If it was still not crystal clear it was recorded as being cloudy. All samples were then examined by direct microscopy in a Fuchs-Rosenthal counting chamber and leucocyte numbers were expressed as cells/µl. Another 5 ml urine was placed in a small container holding about 0’ 1 g sodium borate to retard bacterial growth and sent promptly to the laboratory. There the urine was subjected to direct and microscopic examination and cultured. A standard loop holding 1 gl was
Zidovudine for HIV infection without
symptoms SIR,-Your April 7 editorial on the US report on zidovudine in asymptomatic HIV infection1 points out limitations to the conclusions that can be drawn from the data. Like Friedland, in an editorial accompanying that report,2 you correctly point out that the long-term benefits of instituting therapy at a CD4 count below 500/ul and the most beneficial time to start therapy remain unknown. It may well be that a lower CD4 count, the rate of decline of CD4 cells alone or in combination with a specific level, or the onset of symptoms will prove to be better indicators of the time at which therapy should be begun in symptom-free persons. One statement in your editorial may lead to misunderstanding. You note that zidovudine in asymptomatic infection "represents prophylaxis rather than treatment". Even in symptomless people with HIV infection viral replication is present.3 Furthermore, most infected individuals will progress to disease, although this may take years.4 Finally, there is as yet no evidence that even in infected persons remaining well for years the risk of subsequent disease progression is reduced-nor are there data to suggest that antiretroviral therapy can indefinitely delay such progression. Therefore, effective antiviral therapy in asymptomatic HIV infection should no more be considered as prophylaxis rather than as treatment, than penicillin therapy is for latent syphilis. It would be very unwise for HIV-infected individuals, or their physicians, to consider themselves healthy simply because they feel well. Department of Medicine, Montefiore Medical Center, Bronx, New York 10467, USA
used for the culture and the medium used
was
CLED agar
(Oxoid). Direct sensitivity tests were done on DSTA agar (Difco) on specimens containing more than 40 leucocytes/µ1. After overnight incubation samples containing more than 100 000 colony-forming units (CFU)/ml were presumed to be infected; samples containing less than 10 000 CFU/ml were presumed to be contaminated; and between these two figures the results were regarded as inconclusive. 288 (76 %) of the urines were clear and 88 (24%) were cloudy. 286 clear specimens yielded no growth on culture or less than 10 000 CFU/ml. 2 of the clear specimens yielded growth in excess of 100 000 CFU/ml; 1 contained Streptococcusfaecalis and the other more than three types of Escherichia coli. The leucocyte count on both of the specimens was less than If III and repeat cultures showed less than 10 000 CFU/ml. Both specimens were probably falsepositive cultures. We conclude that, in this group of patients, if the urine is examined by the clinician shortly after it has been passed and is found to be crystal clear with or without acidification, it is not infected and culture is not necessary. Substantial savings could be made by the general application of this principle. K. RAWAL P. SENGUTTWAN M. MORRIS C. CHANTLER N. A. SIMMONS
Evelina Children’s Department and Department of Clinical Bacteriology and Virology,
UMDS,
Guy’s Hospital, London SE1 9RT, UK
Lack of cough reflex in
aspiration
pneumonia ROBERT S. KLEIN
Volberding PA, Lagakos SW, Koch MA, et al. Zidovudine is asymptomatic human immunodeficiency virus infection. N Engl J Med 1990; 322: 941-49. 2. Friedland GH. Early treatment for HIV. The time has come. N Engl J Med 1990; 322: 1.
1000-02. 3. Ho DD, Moudgil T, Alam M. Quantitation of human immunodeficiency virus type 1 in the blood of infected persons. N Engl J Med 1989; 321: 1621-25. 4. Lifson A, Hessol N, Rutherford GW, et al. The natural history of HIV infection in a cohort of homosexual and bisexual men: clinical manifestations, 1978-1989. Fifth International Conference on AIDS (June 6, 1989, Montreal); abstr TA032.
SIR,-An adequate protective reflex in the airway is important and depression or absence of this reflex has been suggested as leading to aspiration pneumonia.To see if aspiration pneumonia is associated with a decrease in cough reflex we studied this reflex response to citric acid and mechanical irritation in patients with aspiration pneumonia and in age-matched controls. The ten controls, mean age 78 (SE 3) years, had cerebral thrombosis or dementia due to cerebral arterial sclerosis. The five
