2,300/cu mm; and on Oct 17, WBC of 8,600/cu mm and eosinophil count of 9007cu mm. Therapy with ethambutol, isoniazid, and streptomycin was continued throughout this period. A provocation test with rifampin was not thought to be justified. The patient's clinical condition improved consid erably, and there was an accompanying appearance of the chest x-ray film.
improvement
in the
DISCUSSION Although eosinophilia is described by Martindale1 as a side effect of therapy with rifampin, there have been no previous published case reports, and neither the British Committee on Safety of Medicines (data from Register of Adverse Reactions, Finsbury Square, Lon don) nor the manufacturers have received written re ports of this complication. According to the manufac turers, no causal relationship between therapy with rifampin and eosinophilia has previously been estab lished. In the present case a causal relationship seems probable in view of the appearance of eosinophilia on commencing therapy with rifampin and the regression of eosinophilia on stopping therapy with the drug. It seems unlikely that administration of streptomycin or isoniazid could have been responsible, as therapy with both drugs was continued uninterrupted and without change in dosage. Ian P. F. Mungall, M.D., Senior Registrar in Medicine and Vic F. Standing, B.Pharm., Ph.D. Pharmacist in Charge of Drug Information Killingbeck Hospital and St. James' Hospital Leeds, England, United Kingdom ACKNOWLEDGMENT: We wish to thank D. J. Charley, M.D., for permission to publish details of this case.
REFERENCE 1 Martindale W: The Extra Pharmacopoeia (27th ed). A Wade (ed), London, Pharmaceutical Press, 1977, p 1596
The Management Syndrome
of Sick Sinus
in Children
The Use of Exercise Tolerance Testing and Standardized Valsalva's Test To the Editor: We recently studied a child with sick sinus syndrome of unknown etiology in whom exercise testing and standardized Valsalva's tests were utilized as part of the determination a pacemaker.
of the suitability of implantation
of
CASEREPORT A 12-year-old girl had initially been seen at the age of 4 years with easy fatigability. An electrocardiogram had shown long sinus pauses with occasional junctional escape beats. When the patient was 6 years old, the sinus pauses were as long as 1.7 seconds, and a 3.0-second paroxysm of atrial flutter had been documented. At 8 years of age, she had a questionable syncopal episode. During the next four years the patient had experienced no episodes of faint ing or dizziness, although periods of sinus arrest up to 3.0 seconds, overall heart rates of 45 beats per minute, and junctional escape rhythm were documented (Fig 1). Cardiac catheterization in 1977 demonstrated no ab normality. Electrophysiologic studies revealed junctional rhythm with occasional conducted sinus beats. The P-A and His-ventricle (H-V) intervals were normal, but the atrio-His (A-H) interval was prolonged to 120 msec.1 Cessation of atrial pacing after two minutes at 152 beats per minute re sulted in an asystolic interval of 3,000 msec, followed by a junctional escape rhythm. Similar pacing after infusion of atropine resulted in a recovery time of 1,150 seconds and a junctional escape rhythm. Administration of a single bolus of atropine increased the heart rate to 80 beats per minute.
FIGURE 1. Electrocardiographic tracings (leads 1, 2, and 3) from 12-year-old girl with sick sinus syndrome. Long sinus pauses of up to 3.0 seconds with junctional escape, echo, and blocked atrial beats were noted. Overall heart rate was 45 beats per minute.
322 COMMUNICATIONS TOTHEEDITOR
CHEST,74: 3, SEPTEMBER, 1978
During multistage exercise testing on a treadmill (Bruce's protocol), the patient achieved a sinus rate of 110 beats per minute and an endurance time of ten minutes, closely approximating that seen in our laboratory for normal female subjects of similar age and physical activity. A standardized Valsalva's maneuver produced a mean heart rate of 60 beats per minute prior to forced expiration, a rate of 33 beats per minute at the onset of the and a heart rate of 58 beats per minute after the maneuver.2 While the heart rate during the
minimum maneuver, Valsalva's Valsalva's
maneuver decreased more than the predicted 8 beats per minute below the control rate, the patient remained asymp tomatic, with maximum R-R intervals no longer than those seen on routine tracings in long-term follow-up.
DISCUSSION We interpreted the results of these tests in our pa tient in the following manner. Exercise induced a re sponse and acceleration of the sinus node. Administra tion of atropine resulted in a response of the junctional tissue. The normal P-A time and H-V interval estab lished normal atrial tracts and conduction down the His bundle, suggesting that foci in the His bundle or junctional area may take over when the sinus node fails. A reliable and prompt junctional focus and the normal cardiovascular response to exercise may account for this patient's lack of symptoms. In light of these clinical findings and with due regard to the morbidity associated with implantation of pacemakers in chil dren,3'4 we have elected to withhold treatment by pace maker in this patient. We suggest that exercise and Valsalva's tests may be of value in determining the performance of the cardio vascular system and in predicting patients at risk and candidates for pacing. We realize that further studies with greater numbers of patients and long-term pro spective follow-up will be necessary before the absolute value of exercise testing and Valsalva's maneuvers in the assessment of the sick sinus syndrome in children is known. Arthur A. Klein, M.D.; Aaron R. Levin, M.D.; Jeffrey Kluger, M.D.; Kathryn H. Ehkrs, M.D.; and Mary Allen Engle, M.D., F.C.C.P. Departments of Pediatrics and Medicine New York Hospital-Cornell Medical Center, New York
Reprint requests: Dr. Levin, the New York Hospital, 525 East 38th St, Room F-468, New York 10021
REFERENCES 1 Levin AR, Haft JI, Engle MA, et al: Intracardiac conduc tion intervals in children with congenital heart disease. Circulation 55:286-294,1977 2 Elisberg E: Heart rate response to Valsalva. JAMA 186: 200-205,1963 3 Radford DJ, Julian DG: Sick sinus syndrome: Experience of a cardiac pacemaker clinic. Br Med J 3:504-507,1974 4 Marco JD, Codd JE, Earner HB, et al: Implantable pace makers in children. Arch Surg 110:880-883, 1975
CHEST,74: 3, SEPTEMBER, 1978
Method of Determining Aspiration in Patients with Tracheostoray To the Editor: The fiberoptic bronchoscope offers a simple method for the evaluation of both the larynx and the tracheobronchial tree of a patient with a tracheostomy. The tracheal stoma makes the bronchoscope uniquely help ful in the evaluation of laryngeal competence in pa tients with suspected aspiration. We have performed 154 procedures on 53 patients at the Texas Institute of Rehabilitation and Research, Houston. Of these, nine cases of aspiration were found.
METHOD The procedure is similar to routine bronchoscopic ex amination. Intravenous lines are in place for all initial evaluations and for subsequent examinations if clinically indicated. Cardiac monitors are attached to the patients with apnea. Additional emergency equipment is available for cardiac resuscitation, suction, oxygenation, and orotracheal intubation. An uncuffed tracheostomy tube one size below the tube already in place is present for insertion, should the tracheal stoma contract prematurely. First, 2 ml of a 4 percent solution of lidocaine is in jected topically through the tracheostomy tube and around the stoma externally. After analgesia is obtained, the tube is removed, and additional lidocaine solution is injected into the trachea in a cephalad direction. A 21-gauge needle is bent 90°to facilitate administration directly to the vocal cords. Any one of three fiberoptic bronchoscopes (Olympus BF5B2, 4B, or 3C2) may be used. The 3C2 and 4B models are most effective because of the length of the flexible tip and the degree of excursion. A dilution of green dye and water is placed in the pa tient's mouth while the vocal cords are being examined. The patient is instructed to swallow, and the cords are observed for aspiration of the dye. This indicator dye is very sensitive, and care should be taken to differentiate between leakage or staining of the cords and frank aspira tion of quantities of dye-stained fluid.
DISCUSSION This method is more reliable and less dangerous than the usual trial feeding, after which one frequently suctions the feeding from the trachea or lung. The major disadvantage of using a colored liquid as the "feeding" is that it is sometimes difficult to determine if the suctioned material is an inconsequential leakage through the vocal cords or a significant aspiration. Patients with aspiration were examined at intervals, and oral feedings were begun if laryngeal competence returned. No patients developed a recurrence of aspira tion pneumonitis if the laryngoscopic procedure did not demonstrate leakage through the vocal cords. Charles W. Ewing, M.D., F.C.C.P. Departments of Rehabilitation and Pediatrics Baylor College of Medicine, Houston
COMMUNICATIONS TOTHEEDITOR 323
improvement
in the
DISCUSSION Although eosinophilia is described by Martindale1 as a side effect of therapy with rifampin, there have been no previous published case reports, and neither the British Committee on Safety of Medicines (data from Register of Adverse Reactions, Finsbury Square, Lon don) nor the manufacturers have received written re ports of this complication. According to the manufac turers, no causal relationship between therapy with rifampin and eosinophilia has previously been estab lished. In the present case a causal relationship seems probable in view of the appearance of eosinophilia on commencing therapy with rifampin and the regression of eosinophilia on stopping therapy with the drug. It seems unlikely that administration of streptomycin or isoniazid could have been responsible, as therapy with both drugs was continued uninterrupted and without change in dosage. Ian P. F. Mungall, M.D., Senior Registrar in Medicine and Vic F. Standing, B.Pharm., Ph.D. Pharmacist in Charge of Drug Information Killingbeck Hospital and St. James' Hospital Leeds, England, United Kingdom ACKNOWLEDGMENT: We wish to thank D. J. Charley, M.D., for permission to publish details of this case.
REFERENCE 1 Martindale W: The Extra Pharmacopoeia (27th ed). A Wade (ed), London, Pharmaceutical Press, 1977, p 1596
The Management Syndrome
of Sick Sinus
in Children
The Use of Exercise Tolerance Testing and Standardized Valsalva's Test To the Editor: We recently studied a child with sick sinus syndrome of unknown etiology in whom exercise testing and standardized Valsalva's tests were utilized as part of the determination a pacemaker.
of the suitability of implantation
of
CASEREPORT A 12-year-old girl had initially been seen at the age of 4 years with easy fatigability. An electrocardiogram had shown long sinus pauses with occasional junctional escape beats. When the patient was 6 years old, the sinus pauses were as long as 1.7 seconds, and a 3.0-second paroxysm of atrial flutter had been documented. At 8 years of age, she had a questionable syncopal episode. During the next four years the patient had experienced no episodes of faint ing or dizziness, although periods of sinus arrest up to 3.0 seconds, overall heart rates of 45 beats per minute, and junctional escape rhythm were documented (Fig 1). Cardiac catheterization in 1977 demonstrated no ab normality. Electrophysiologic studies revealed junctional rhythm with occasional conducted sinus beats. The P-A and His-ventricle (H-V) intervals were normal, but the atrio-His (A-H) interval was prolonged to 120 msec.1 Cessation of atrial pacing after two minutes at 152 beats per minute re sulted in an asystolic interval of 3,000 msec, followed by a junctional escape rhythm. Similar pacing after infusion of atropine resulted in a recovery time of 1,150 seconds and a junctional escape rhythm. Administration of a single bolus of atropine increased the heart rate to 80 beats per minute.
FIGURE 1. Electrocardiographic tracings (leads 1, 2, and 3) from 12-year-old girl with sick sinus syndrome. Long sinus pauses of up to 3.0 seconds with junctional escape, echo, and blocked atrial beats were noted. Overall heart rate was 45 beats per minute.
322 COMMUNICATIONS TOTHEEDITOR
CHEST,74: 3, SEPTEMBER, 1978
During multistage exercise testing on a treadmill (Bruce's protocol), the patient achieved a sinus rate of 110 beats per minute and an endurance time of ten minutes, closely approximating that seen in our laboratory for normal female subjects of similar age and physical activity. A standardized Valsalva's maneuver produced a mean heart rate of 60 beats per minute prior to forced expiration, a rate of 33 beats per minute at the onset of the and a heart rate of 58 beats per minute after the maneuver.2 While the heart rate during the
minimum maneuver, Valsalva's Valsalva's
maneuver decreased more than the predicted 8 beats per minute below the control rate, the patient remained asymp tomatic, with maximum R-R intervals no longer than those seen on routine tracings in long-term follow-up.
DISCUSSION We interpreted the results of these tests in our pa tient in the following manner. Exercise induced a re sponse and acceleration of the sinus node. Administra tion of atropine resulted in a response of the junctional tissue. The normal P-A time and H-V interval estab lished normal atrial tracts and conduction down the His bundle, suggesting that foci in the His bundle or junctional area may take over when the sinus node fails. A reliable and prompt junctional focus and the normal cardiovascular response to exercise may account for this patient's lack of symptoms. In light of these clinical findings and with due regard to the morbidity associated with implantation of pacemakers in chil dren,3'4 we have elected to withhold treatment by pace maker in this patient. We suggest that exercise and Valsalva's tests may be of value in determining the performance of the cardio vascular system and in predicting patients at risk and candidates for pacing. We realize that further studies with greater numbers of patients and long-term pro spective follow-up will be necessary before the absolute value of exercise testing and Valsalva's maneuvers in the assessment of the sick sinus syndrome in children is known. Arthur A. Klein, M.D.; Aaron R. Levin, M.D.; Jeffrey Kluger, M.D.; Kathryn H. Ehkrs, M.D.; and Mary Allen Engle, M.D., F.C.C.P. Departments of Pediatrics and Medicine New York Hospital-Cornell Medical Center, New York
Reprint requests: Dr. Levin, the New York Hospital, 525 East 38th St, Room F-468, New York 10021
REFERENCES 1 Levin AR, Haft JI, Engle MA, et al: Intracardiac conduc tion intervals in children with congenital heart disease. Circulation 55:286-294,1977 2 Elisberg E: Heart rate response to Valsalva. JAMA 186: 200-205,1963 3 Radford DJ, Julian DG: Sick sinus syndrome: Experience of a cardiac pacemaker clinic. Br Med J 3:504-507,1974 4 Marco JD, Codd JE, Earner HB, et al: Implantable pace makers in children. Arch Surg 110:880-883, 1975
CHEST,74: 3, SEPTEMBER, 1978
Method of Determining Aspiration in Patients with Tracheostoray To the Editor: The fiberoptic bronchoscope offers a simple method for the evaluation of both the larynx and the tracheobronchial tree of a patient with a tracheostomy. The tracheal stoma makes the bronchoscope uniquely help ful in the evaluation of laryngeal competence in pa tients with suspected aspiration. We have performed 154 procedures on 53 patients at the Texas Institute of Rehabilitation and Research, Houston. Of these, nine cases of aspiration were found.
METHOD The procedure is similar to routine bronchoscopic ex amination. Intravenous lines are in place for all initial evaluations and for subsequent examinations if clinically indicated. Cardiac monitors are attached to the patients with apnea. Additional emergency equipment is available for cardiac resuscitation, suction, oxygenation, and orotracheal intubation. An uncuffed tracheostomy tube one size below the tube already in place is present for insertion, should the tracheal stoma contract prematurely. First, 2 ml of a 4 percent solution of lidocaine is in jected topically through the tracheostomy tube and around the stoma externally. After analgesia is obtained, the tube is removed, and additional lidocaine solution is injected into the trachea in a cephalad direction. A 21-gauge needle is bent 90°to facilitate administration directly to the vocal cords. Any one of three fiberoptic bronchoscopes (Olympus BF5B2, 4B, or 3C2) may be used. The 3C2 and 4B models are most effective because of the length of the flexible tip and the degree of excursion. A dilution of green dye and water is placed in the pa tient's mouth while the vocal cords are being examined. The patient is instructed to swallow, and the cords are observed for aspiration of the dye. This indicator dye is very sensitive, and care should be taken to differentiate between leakage or staining of the cords and frank aspira tion of quantities of dye-stained fluid.
DISCUSSION This method is more reliable and less dangerous than the usual trial feeding, after which one frequently suctions the feeding from the trachea or lung. The major disadvantage of using a colored liquid as the "feeding" is that it is sometimes difficult to determine if the suctioned material is an inconsequential leakage through the vocal cords or a significant aspiration. Patients with aspiration were examined at intervals, and oral feedings were begun if laryngeal competence returned. No patients developed a recurrence of aspira tion pneumonitis if the laryngoscopic procedure did not demonstrate leakage through the vocal cords. Charles W. Ewing, M.D., F.C.C.P. Departments of Rehabilitation and Pediatrics Baylor College of Medicine, Houston
COMMUNICATIONS TOTHEEDITOR 323
