692

Serological diagnosis of cutaneous L (V) braziliensis remains imperfect due to cross-reactivity with other protozoa and other leishmanial species.8 Nevertheless, IFAT, ELISA, and direct agglutination are widely used; the 2 seropositive cases will be carefully followed up. Leishmanin testing did not detect any subclinical infections. Reassuringly, serological tests did not suggest that any members were incubating espundia. Nevertheless, all members were advised to mention the risk of leishmaniasis, should a nasal sore develop. We thank Dr P.

Welsby (Edinburgh City Hospital) and Dr P. Stanley (East Birmingham Hospital) for assistance; Mr A. Moody (Hospital for Tropical Diseases) for help with parasite cultivation; Dr D. Evans (London School of Hygiene and Tropical Medicine) for isoenzyme analysis; and Ms L. Oke for photography and artwork. London School of Hygiene and Tropical Medicine, London WC1, UK

STEPHEN D.

MORRIS-JONES*

Hospital for Tropical Diseases, London *Present address: Gambia

Immunology Department,

ANTHONY D. BRYCESON MRC Laboratories, Fajara, Banjul, The

1. Llanos-Cuentas EA, Marsden PD, Lago EL, Barreto AC, Cuba CC, Johnson WD. Human mucocutaneous leishmaniasis in Tres Bracos, Bahia-Brazil: an area of Leishmania braziliensis braziliensis transmission II: cutaneous disease, presentation and evolution. Rev Soc Bras Med Trop 1984; 17: 169-77. 2. Marsden PD, Llanos-Cuentas EA, Lago EL, et al. Human mucocutaneous leishmaniasis in Tres Bracos, Bahia-Brazil: an area of Leishmania braziliensis braziliensis transmission III: mucosal disease, presentation and initial evolution. Rev Soc Bras Med Trop 1984; 17: 179-86. 3. Walton BC, Valverde Chinel L, Eguia y Eguia O. Onset of espundia after many years of occult infection with Leishmania braziliensis. Am J Trop Med Hyg 1973; 22: 696-98. 4. Marsden PD. Mucosal leishmaniasis ("espundia" Escomel, 1911). Trans R Soc Trop Med Hyg 1986; 80: 859-76. 5. Cuba CC, Netto EM, Marsden PD, Rosa AdeC, Llanos-Cuentas EA, Costa JL. Cultivation of Leishmania braziliensis braziliensis from skin ulcers in man under field conditions. Trans R Soc Trop Med Hyg 1986; 80: 456-57. 6. Shaw JJ, Lainson R. Leishmaniasis in Brazil: X. Some observations on intradermal reactions to different trypanosomatid antigens of patients suffering from cutaneous and mucocutaneous leishmaniasis. Trans R Soc Trop Med Hyg 1975; 69: 323-335. 7. Jones TC, Johnson WD, Barreto AC, et al. Epidemiology of Amencan cutaneous leishmaniasis due to Leishmania braziliensis braziliensis J Infect Dis 1987; 156: 73-83. 8. Chulay JD, Spencer HC, Mugambi M. Electrocardiographic changes during treatment of fleishmaniasis with pentavalent antimony (sodium stibogluconate). Am J Trop Med Hyg 1985; 34: 702-09.

High-dose intravenous immunoglobulin for multiple sclerosis efficacy of high-dose intravenous SIR,-Reports immunoglobulin (IVIG) in multiple sclerosis (MS) in the 1980s1-3 were largely unnoticed in much of the world. The following case-report shows that this may sometimes be an effective therapy. A 59-year-old woman who had presented with optic neuritis followed by spastic quadriparesis was diagnosed as having MS by magnetic resonance imaging appearances and biopsy evidence of demyelination and mononuclear cell perivascular inflammation. Symptoms improved with steroid therapy. 1 year later, bilateral arm and leg weakness reappeared over several weeks but course of intravenous methylprednisolone followed by dexamethasone produced no improvement. One month later she had hypoaesthesia to pain on the right with a high cervical sensory level. A course of corticotropin was administered, but she progressed to paraplegia with mild bilateral arm weakness. 1 month later she became fully quadriplegic. Cyclophosphamide and corticotropin were tried’ but the cyclophosphamide had to be discontinued because of leucopenia. During this treatment her vital capacity fell and mild tongue deviation developed. A gag reflex could no longer be elicited. On the tenth day of therapy her vital capacity was only 250 ml and her PACO, had risen to 50 mm Hg. She was intubated and placed on a respirator. Shortly thereafter no respiratory effort could be generated. An electromyogram showed no evidence of acute of

third day she appreciated deep pain applied to her arms and on the fourth day she regained rudimentary movements in her arms. By day 9 her vital capacity was 900 ml, but she tired easily. She was gradually weaned off the respirator by 4 weeks after initiation of therapy. At that time, strength had improved to II-IV/V in right arm and to I-II/V in the left arm (MRC scale). She was eating well without difficulty in swallowing. The tongue was midline. Four months after IVIG treatment strength was IV/V in nearly all muscle groups of the right arm and III-IV/V in most left arm muscles. The legs had not improved. Pinprick, light touch, and deep pressure sensation were appreciated above the right elbow and patchily distally. In the left arm light touch and pressure were felt at the shoulder and pinprick was felt in a patchy distribution elsewhere. Light touch and deep pressure were appreciated in the right leg and pinprick sensation was felt in the left leg. The timing of the onset of an impressive recovery and treatment with high-dose IVIG suggest that the treatment was effective. Successful treatment of autoimmune thrombocytopenic purpura with IVIG seems to be mediated by the Fc portion of the Ig molecule through blockade of reticuloendothelial Fc receptors.s Furthermore, the Fc portion delivers negative signals to B cells by binding to B cell Fc-receptors.6 Therefore, a rationale exists for this form of treatment in MS. IVIG has been used successfully in Guillain-Barre syndrome’ and in chronic inflammatory

demyelinating polyneuropathy.8 JAMES YAN JOHN R. RICHERT

Department of Neurology, Georgetown University Medical Center, Washington, DC 20007, USA

MICHAEL D. SIRDOFSKY

1. Rothfelder U, Neu I, Pelka R. Therapie der multiplen sklerose mit immunglobulin G Munch Med Wschr 1982; 124: 74-78. 2. Schuller E, Govaerts A. First results of immunotherapy with immunoglobulin Gin multiple sclerosis patients. Eur Neurol 1983; 22: 205-12. 3. Soukop W, Tschabitscher H. Gammaglobulintherapie bei multipler sklerose (MS) theoretische uberlegungen und erste klinische erfahrungen mit 7Simmunoglobulinen in der MS-therapie. Wein Med Wschr 1986; 136: 477-80. 4. Hauser SL, Dawson DM, Lehrich M, et al. Intensive immunosuppression in progressive multiple sclerosis: a randomized, three-arm study of high-dose intravenous cyclophosphamide, plasma exchange, and ACTH. N Engl J Med 1983, 308: 173-80. 5. Bussel JB, Hilgartner MW. The use and mechanism of action of intravenous immunoglobulin in the treatment of immune haematological disease. Br J Haematol 1984; 56: 1-7. 6. Hunziker W, Koch T, Whitney JA, Mellman I. Fc receptor phosphorylation during receptor-mediated control of B-cell activation. Nature 1990; 345: 628-32. 7. Kleyeg RP, van der Meche FG, Meulstee J. Treatment of Guillain-Barré syndrome with high dose gammaglobulin. Neurology 1988; 38: 1639-41. 8. van Doom PA, Brand A, Strengers PFW, Meulstee J, Vermeulen M. High-dose intravenous immunoglobulin treatment in chronic inflammatory demyelinating

polyneuropathy. Neurology 1990; 40:

209-12.

the

acquired demyelinating polyneuropathy. No further neurological change ensued over the subsequent month and IVIG 0-4 g/kg daily was administered for 5 days. On the

Controlled-release

prostaglandin E2 pessary

SIR,-The edited version of our letter (Sept 1, p 562) makes clear point that the ’Propess’ prostaglandin E2 pessary does have a predictable release rate of prostaglandin in vivo but in respect of the performance of the pessary in clinical practice it is misleading. In the prospective randomised trial comparing the controlled release pessary with a ’Witepsol’ pessary (Dynamit Nobel, UK) in 190 women with favourable induction features, 2 women in the witepsol group compared with none of the propess group delivered within 3 hours of pessary insertion. Furthermore, we recall no patient in

our

more

than 400 treated with the pessary in whom labour

was

completed within an hour. This is in contrast to previous experience reported in the correspondence columns of The Lancet. We hope we have now clarified the situation. Nuffield Department of Obstetrics and Gynaecology, University of Oxford, John Radcliffe Hospital, Oxford OX3 9DU, UK

A. V. G. TAYLOR I. Z. MACKENZIE

IZ, Annan B, Jackson C, Hurley P, Hey F, Newman M. A randomised trial comparing a non-biodegradable polymer PGE2 pessary with a glyceride PGE2 pessary for labour induction. XIIth World Congress of Gynecology and Obstetrics (Rio de Janeiro, October, 1988); abstr p 199.

1. MacKenzie

Controlled-release prostaglandin E2 pessary.

692 Serological diagnosis of cutaneous L (V) braziliensis remains imperfect due to cross-reactivity with other protozoa and other leishmanial species...
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