188
lipopolysaccharide antibody, which is genus-specific, will also stain other chlamydial species, including C pneranarriae. Which antibody
SEPTIC COMPLICATION RATE
did Bavastrelli et al use? Answers to these questions are needed before one can reliably exclude C pneumoniae as an aetiological agent in these interesting cases of possible non-atopic, asthma-like illness in children. Arcand Park Clinic. Madison. Wisconsin 53704, USA
DAVID L. HAHN
Komaroff AL, William T, Branch J, Aronson MD, et al. Chlamydial pharyngitis. Ann Int Med 1989; 111: 537—38. 2. Hahn DL, Dodge R, Golubjatnikov R. Association of Chlamydia pneumoniae strain TWAR) infection with wheezing, asthmatic bronchitis and adult-onset asthma. JAMA 1991; 266: 225-30. 1.
-
r
i
i
i
i
"p < 0-05 TPN vs TEN vs depleted vs not depleted; tp < 0 05 TPN and TEN vs depleted, and ‡p < 0 05 depleted vs not depleted. (Chi-squared or Mantel-Haenszel tests )
of such treatment increases with the progression of depletion. We therefore advocate that patients with severe depletion receive nutritional support before undergoing surgical trauma. These observations may be extendable to other conditions in which trauma is purposefully administered (chemotherapy, radiotherapy, surgery for inflammatory bowel disease) to depleted patients.
W. J. H. J. MEIJERINK M. F. VON MEYENFELDT M. M. J. ROUFLART P. B. SOETERS
Department of Surgery, University Hospital Maastricht, 6202 AZ Maastricht, Netherlands
1. Brennan MF. Total parenteral nutrition in the cancer patient. N
Engl J Med 1981; 307:
375. 2 Klein S, Simes J, Blackburn GL Total parenteral nutrition and cancer clinical trials. Cancer 1986; 58: 1378-86 3. Detsky AS, Baker JP, O’Rourke K, Goel V. Perioperative parenteral nutrition: a meta-analysis. Ann Intern Med 1987; 107: 195-203 4. Buzby GP, Williford WO, Peterson OL, et al. A randomized clinical trial of total parenteral nutrition in malnourished surgical patients: the rationale and impact of previous clinical trials and pilot study on protocol design. Am J Clin Nutr 1988; 47: 357-65. 5. Meguid MM, Campos AC, Hammond WG. Nutritional support in surgical practice Am J Surg 1990; 159: 345-58 6 Mueller JM, Brenner U, Dienst C, Pichlmaier H. Preoperative parenteral feeding in patients with gastrointestinal carcinoma. Lancet 1982. i: 68-71. 7 The Veterans Affairs total parenteral nutrition cooperative study group. Perioperative total parenteral nutrition in surgical patients. N Engl J Med 1991; 325: 52532.
Chlamydia trachomatis and wheezing SIR,-Dr Bavastrelli and colleagues (May 9, p 1174) report wheezing simulating asthma in 7 children who had evidence of Chlamydia trachomatis infection diagnosed either by isolation on McCoy cell culture and/’or by direct fluorescent antibody testing of conjunctival or pharyngeal swabs. They report that asthmatic symptoms were eradicated in all 7 children after anti-chlamydial antibiotic therapy. Because this information is potentially very important, further details of these patients would be helpful. In particular, what clinical characteristics differentiated these children from "true" asthmatics? Bavastrelli et al report that these children did not respond to bronchodilator agents. Are they referring to inhaled adrenergic agents, theophylline preparations, steroids, or others? Were pulmonary function tests done? It is important to note that the cited high childhood rates (26.7% and 47. 2%) of C trachomatis seroprevalence are mostly due to crossreaciivity with C pneumoniae.1 Bavastrelli et al state "C pneunzorziae strain T W A R grows only on HeLa 229 cells and not on the McCoy cells we used for our isolation procedures". C pnetanomae does grow on McCoy cells, albeit not as readily as on HeLa 229 cells. McCoy cells have been used successfully to isolate .2 the organism in serologically confirmed C pnewnoniae infection The direct fluorescence antibody test for C trachomatis is speciesspecific only if the fluorescein-conjugated major outer membrane protein antibody is used. Use of the fluorescein-conjugated
*** This letter has been shown whose reply follows.-ED. L.
to
Dr Bavastrelli and
colleagues,
SIR,- The children we investigated had, besides the presenting expiratory wheezing, persistent dry cough, chest hyperexpansion, no fever, often conjunctivitis, and eosinophilia. The picture could hardly be differentiated from atopic asthma on clinical grounds alone, but in all children IgE was not raised and none showed specific responses to common allergens, on RAST or symptom of
on
skin
tests.
Some
were
treated with oral betamethasone sodium
phosphate, others with a mixture of beclomethasone dipropionate plus salbutamol by inhalation. With these treatments the wheezing persisted unmodified, but was eliminated by one or two courses of 2-week amacrolide. Pulmonary-function tests were not obtained. The direct fluorescence antibody test we used, in parallel with culture on McCoy cells, was Microtrak (Syva), which is based on monoclonal antibody raised against the fifteen serotypes of Chlamydia trachomatis that do not cross react with C pneumoniae. Moreover, C pneumoniae is more common in adults and is rare in childhood.’1 The conjunctival involvement in six of our seven patients, with ocular symptoms in four, favours a C trachomatis aetiology. Furthermore, C trachomatis was present in the urogenital tract or in the conjunctiva of the children’s parents, whereas TWAR does not appear to be a sexually transmitted disease or an important cause of
conjunctivitis.2 The
emerging from our data, perhaps worth is that C trachomatis infection should be suspected emphasising, and diagnosed not only in the child with wheezing but also in other members of his family. In fact, we have an additional duty to prevent reinfection by eradicating C trachomatis from the entire family. We agree that more data are needed to draw definitive conclusions, but we think that it was worth publishing out preliminary observation at a time when possible respiratory involvement by C trachomatis is emerging in bronchiolitis or pneumonia in children.3 message
Supported by grant 9103613 from CNR P. F. FATMA. MARIA BAVASTRELLI III Academic Department of Clinical Paediatrics, MARIO MIDULLA Università "La Sapienza" Roma, DANIELA ROSSI Istituto di Clinica Pediatrica, 00161 Rome. Italy MARCO SALZANO Grayston JT, Campbell LA, Kuo CC, et al. A new respiratory tract pathogen Chlamydia pneunomae strain TWAR. J Infect Du 1990; 161: 618-25. 2. Christopher DB, Grayston JT, Wang SP, et al. Chlamydia pneumoniae, strain TWAR. infection in patients with chronic obstructive pulmonary disease. Am Rev Respir Dis 1.
1991;
144: 1408-10.
G, Mahony JB, Videla C, et al. Chlamydial antibodies in children with lower respiratory disease. Pediatr Infect Dis J 1092; 11: 68-71.
3. Carballal
CORRECTIONS
...
Local anaesthetic creams and intradermal skin tests.-In this letter Dr F. E. R. Simons and her colleagues (May 30, p 1351), line 5 of paragraph3 should have read "... but the mean flare area decreased significantly..."
Efficacy of traditional Chinese herbal therapy in adult atop dermatitis.-In this article by Dr Sheehan and colleagues (July 4, p 13B the name of the fifth author should have read D. W. S. Harris.
lipopolysaccharide antibody, which is genus-specific, will also stain other chlamydial species, including C pneranarriae. Which antibody
SEPTIC COMPLICATION RATE
did Bavastrelli et al use? Answers to these questions are needed before one can reliably exclude C pneumoniae as an aetiological agent in these interesting cases of possible non-atopic, asthma-like illness in children. Arcand Park Clinic. Madison. Wisconsin 53704, USA
DAVID L. HAHN
Komaroff AL, William T, Branch J, Aronson MD, et al. Chlamydial pharyngitis. Ann Int Med 1989; 111: 537—38. 2. Hahn DL, Dodge R, Golubjatnikov R. Association of Chlamydia pneumoniae strain TWAR) infection with wheezing, asthmatic bronchitis and adult-onset asthma. JAMA 1991; 266: 225-30. 1.
-
r
i
i
i
i
"p < 0-05 TPN vs TEN vs depleted vs not depleted; tp < 0 05 TPN and TEN vs depleted, and ‡p < 0 05 depleted vs not depleted. (Chi-squared or Mantel-Haenszel tests )
of such treatment increases with the progression of depletion. We therefore advocate that patients with severe depletion receive nutritional support before undergoing surgical trauma. These observations may be extendable to other conditions in which trauma is purposefully administered (chemotherapy, radiotherapy, surgery for inflammatory bowel disease) to depleted patients.
W. J. H. J. MEIJERINK M. F. VON MEYENFELDT M. M. J. ROUFLART P. B. SOETERS
Department of Surgery, University Hospital Maastricht, 6202 AZ Maastricht, Netherlands
1. Brennan MF. Total parenteral nutrition in the cancer patient. N
Engl J Med 1981; 307:
375. 2 Klein S, Simes J, Blackburn GL Total parenteral nutrition and cancer clinical trials. Cancer 1986; 58: 1378-86 3. Detsky AS, Baker JP, O’Rourke K, Goel V. Perioperative parenteral nutrition: a meta-analysis. Ann Intern Med 1987; 107: 195-203 4. Buzby GP, Williford WO, Peterson OL, et al. A randomized clinical trial of total parenteral nutrition in malnourished surgical patients: the rationale and impact of previous clinical trials and pilot study on protocol design. Am J Clin Nutr 1988; 47: 357-65. 5. Meguid MM, Campos AC, Hammond WG. Nutritional support in surgical practice Am J Surg 1990; 159: 345-58 6 Mueller JM, Brenner U, Dienst C, Pichlmaier H. Preoperative parenteral feeding in patients with gastrointestinal carcinoma. Lancet 1982. i: 68-71. 7 The Veterans Affairs total parenteral nutrition cooperative study group. Perioperative total parenteral nutrition in surgical patients. N Engl J Med 1991; 325: 52532.
Chlamydia trachomatis and wheezing SIR,-Dr Bavastrelli and colleagues (May 9, p 1174) report wheezing simulating asthma in 7 children who had evidence of Chlamydia trachomatis infection diagnosed either by isolation on McCoy cell culture and/’or by direct fluorescent antibody testing of conjunctival or pharyngeal swabs. They report that asthmatic symptoms were eradicated in all 7 children after anti-chlamydial antibiotic therapy. Because this information is potentially very important, further details of these patients would be helpful. In particular, what clinical characteristics differentiated these children from "true" asthmatics? Bavastrelli et al report that these children did not respond to bronchodilator agents. Are they referring to inhaled adrenergic agents, theophylline preparations, steroids, or others? Were pulmonary function tests done? It is important to note that the cited high childhood rates (26.7% and 47. 2%) of C trachomatis seroprevalence are mostly due to crossreaciivity with C pneumoniae.1 Bavastrelli et al state "C pneunzorziae strain T W A R grows only on HeLa 229 cells and not on the McCoy cells we used for our isolation procedures". C pnetanomae does grow on McCoy cells, albeit not as readily as on HeLa 229 cells. McCoy cells have been used successfully to isolate .2 the organism in serologically confirmed C pnewnoniae infection The direct fluorescence antibody test for C trachomatis is speciesspecific only if the fluorescein-conjugated major outer membrane protein antibody is used. Use of the fluorescein-conjugated
*** This letter has been shown whose reply follows.-ED. L.
to
Dr Bavastrelli and
colleagues,
SIR,- The children we investigated had, besides the presenting expiratory wheezing, persistent dry cough, chest hyperexpansion, no fever, often conjunctivitis, and eosinophilia. The picture could hardly be differentiated from atopic asthma on clinical grounds alone, but in all children IgE was not raised and none showed specific responses to common allergens, on RAST or symptom of
on
skin
tests.
Some
were
treated with oral betamethasone sodium
phosphate, others with a mixture of beclomethasone dipropionate plus salbutamol by inhalation. With these treatments the wheezing persisted unmodified, but was eliminated by one or two courses of 2-week amacrolide. Pulmonary-function tests were not obtained. The direct fluorescence antibody test we used, in parallel with culture on McCoy cells, was Microtrak (Syva), which is based on monoclonal antibody raised against the fifteen serotypes of Chlamydia trachomatis that do not cross react with C pneumoniae. Moreover, C pneumoniae is more common in adults and is rare in childhood.’1 The conjunctival involvement in six of our seven patients, with ocular symptoms in four, favours a C trachomatis aetiology. Furthermore, C trachomatis was present in the urogenital tract or in the conjunctiva of the children’s parents, whereas TWAR does not appear to be a sexually transmitted disease or an important cause of
conjunctivitis.2 The
emerging from our data, perhaps worth is that C trachomatis infection should be suspected emphasising, and diagnosed not only in the child with wheezing but also in other members of his family. In fact, we have an additional duty to prevent reinfection by eradicating C trachomatis from the entire family. We agree that more data are needed to draw definitive conclusions, but we think that it was worth publishing out preliminary observation at a time when possible respiratory involvement by C trachomatis is emerging in bronchiolitis or pneumonia in children.3 message
Supported by grant 9103613 from CNR P. F. FATMA. MARIA BAVASTRELLI III Academic Department of Clinical Paediatrics, MARIO MIDULLA Università "La Sapienza" Roma, DANIELA ROSSI Istituto di Clinica Pediatrica, 00161 Rome. Italy MARCO SALZANO Grayston JT, Campbell LA, Kuo CC, et al. A new respiratory tract pathogen Chlamydia pneunomae strain TWAR. J Infect Du 1990; 161: 618-25. 2. Christopher DB, Grayston JT, Wang SP, et al. Chlamydia pneumoniae, strain TWAR. infection in patients with chronic obstructive pulmonary disease. Am Rev Respir Dis 1.
1991;
144: 1408-10.
G, Mahony JB, Videla C, et al. Chlamydial antibodies in children with lower respiratory disease. Pediatr Infect Dis J 1092; 11: 68-71.
3. Carballal
CORRECTIONS
...
Local anaesthetic creams and intradermal skin tests.-In this letter Dr F. E. R. Simons and her colleagues (May 30, p 1351), line 5 of paragraph3 should have read "... but the mean flare area decreased significantly..."
Efficacy of traditional Chinese herbal therapy in adult atop dermatitis.-In this article by Dr Sheehan and colleagues (July 4, p 13B the name of the fifth author should have read D. W. S. Harris.
