521
for fluoxetine than for other antidepressant agents.’ Our suggest that the worsening of depressive symptoms that may occur in a minority of patients on fluoxetine can, in some cases, be reversed with titration to a therapeutic dose. Reports of suicidal beliefs in patients taking fluoxetine are of little value in addressing this issue, since none of the published case histories 2-4 included a documented attempt to taper fluoxetine dose. In some cases, the dose was increased when such symptoms were observed, and in all cases fluoxetine was eventually discontinued abruptly. A therapeutic window might account for worsening depressive symptoms in a few patients treated with fluoxetine. Our experience suggests that a cautious approach to dose titration might be warranted.
mucosa) and as specific as IgA AGA (none positive in 13 cases with normal mucosa). Thus in this form of coaliac disease in childhood, in which there is more IgG AGA than IgA AGA, EmA has advantages over AGA
Department of Psychiatry, Loyola University Stritch School of Medicine and Biological Psychiatry Section,
2nd Paediatric Clinic, Policlinico di Sant’ Orsola, University of Bologna,
Veterans Administration Edward Hines Jr Hospital, Hines, Illinois 60141, USA
Bologna, Italy
E. CACCIARI S. SALARDI S. TIBERI
Department of Medicine, University of Bologna
U. VOLTA N. MOLINARO F. B. BIANCHI
Department of Immunology, London Hospital Medical College, London, UK
G. F. BOTTAZZO
higher cases
Department of Psychiatry, University of Illinois College of Medicine, Chicago, Illinois
THOMAS
H. JOBE
Psychiatry, Rush-Presbyterian-St Luke’s
BENNETT G. BRAUN
1. Sommi
RW, Crismon ML, Bowden CL. Fluoxetine: a serotonin-specific, secondgeneration antidepressant. Pharmacotherapy 1987; 7: 1-15. 2. Teicher MH, Glod C, Cole JO. Emergence of intense suicidal preoccupation during fluoxetine treatment. Am J Psychiatry 1990; 147: 207-10. 3. Dasgupta K, Hoover CE. Additional cases of suicidal ideation associated with fluoxetine. Am J Psychiatry 1990; 147: 1570-71. 4. Masand P, Gupta S, Dewan M. Suicidal ideation related to fluoxetine treatment. N Engl J Med 1991; 324: 420. 5. Wernicke JF, Dunlop SR, Domseif BE, Zerbe RL. Fixed-dose fluoxetine therapy for depression. Psychopharm Bull 1987; 23: 164-68. 6. Damluji NF, Ferguson JM. Paradoxical worsening of depressive symptomatology caused by antidepressants. J Clin Psychopharmacol 1988; 8: 347-49. 7. Fava M, Rosenbaum JF. Suicidality and fluoxetine: is there a relationship? J Clin Psychiatry 1991; 52: 108-11.
Endomysial versus gliadin antibodies in diagnosis of coeliac disease in short children with no gastrointestinal symptoms SIR,-Anti-endomysial IgA antibodies (EmA) directed at reticulin-like structures in the smooth muscle of the gastrointestinal tract seem to correlate specifically with histopathological findings in coeliac disease. 1-3 We have been comparing EmA with anti-gliadin antibodies (AGA) in detecting coeliac disease in children with short stature and no gastrointestinal symptoms. In 1985 we looked at the diagnostic value of immunofluorescent AGA in this situation.4 Among 108 unselected short children, all tested for AGA and by jejunal biopsy, the IgG AGA test identified 8 of 9 cases of coeliac disease diagnosed histologically, but it was falsely positive in 6 of the 88 children with normal mucosa. The single missed case had a deficiency in serum IgA. Subsequently we used AGA to screen several hundred children with short stature for coeliac disease; only 41, those whose AGA were positive at a titre of 20 or more, had an intestinal biopsy. 28 of these 41 children had coeliac disease. After dietary management biopsy was repeated on 17 of these 28 and on the same day all children were tested for EmA by indirect immunofluorescence. Commercially available sections of monkey oesophagus were used and the antiserum consisted of human anti-IgA labelled with fluorescein isothiocyanate. In diagnosing coeliac disease in children with short stature but no gastrointestinal symptoms EmA was as sensitive as IgG AGA and more sensitive than IgA AGA, and more specific:
In monitoring coeliac disease in patients on a gluten-free diet EmA sensitive as IgG AGA (3 out of 4 cases with abnormal
was as
on
have coeliac disease.
CHRISTOPHER G. FICHTNER
Department of
Medical Center, Chicago, Illinois
diagnosis and monitoring. Had we done biopsies only on patients with IgA AGA we would have missed 6 cases of coeliac disease while doing biopsies on 2 patients with normal mucosa. Had we done a biopsy on every case with positive EmA we would have identified all cases but 1, and would not have done a biopsy on the 13 children with normal mucosa who were subjected to this procedure because of IgG AGA positivity. However, we cannot rule out the possibility that children who are positive for IgA AGA will not later for
1. Hallstrom O. Comparison of Ig-A-class reticulin and endomysium antibodies in coeliac disease and dermatitis herpetiformis. Gut 1989; 30: 1225-32. 2. Rossi TM, Kumar V, Lemer A, Heitlinger LA, Tucker N, Fisher J. Relationship of endomysial antibodies to jejunal mucosal pathology: specificity towards both symptomatic and asymptomatic celiacs. J Pediatr Gastroenterol Nutr 1988; 7: 858-63. 3 Calabuig M, Torregosa R, Polo P, et al. Serological markers and celiac disease: a new diagnostic approach? J Pediatr Gastroenterol Nutr 1990; 10: 435-42. 4 Cacciari E, Salardi S, Volta U, et al. Can antigliadin antibody detect symptomless coeliac disease in children with short stature? Lancet 1985; i: 1469-71.
Urinary saturation among phosphate-treated children with hypophosphataemic rickets SIR,-Hyperoxaluria has been suggested as a possible cause nephrocalcinosis in phosphate-treated children with hypophosphataemic rickets.1 We have studied the urinary saturation of several components of kidney stones in 7 children with hypophosphataemic rickets who had normal renal function (age range 4-16 years) and who were taking oral phosphate supplements (mean [SD] 2-39 [0.73] g/173 m2 per day), together with calcitriol (0-89 [0’42] )Jg daily). Except for the youngest patient, who had started treatment six months previously, the others had been on this regimen for an average of 7-8 years (range 4-12). No patient had renal calcifications on ultrasound. 24 h urine collections were studied for volume, pH, calcium, phosphate, sodium, potassium, magnesium, oxalate, urate, ammonium ions, sulphate, citrate, and creatinine. Free energy for crystallisation of calcium oxalate, brushite, and hydroxyapatite was calculated by computer program 2 All children excreted normal amounts of calcium (table); two subjects had slight hyperoxaluria. Urinary phosphate was of
URINE COMPOSITION AND SATURATION DATA
for fluoxetine than for other antidepressant agents.’ Our suggest that the worsening of depressive symptoms that may occur in a minority of patients on fluoxetine can, in some cases, be reversed with titration to a therapeutic dose. Reports of suicidal beliefs in patients taking fluoxetine are of little value in addressing this issue, since none of the published case histories 2-4 included a documented attempt to taper fluoxetine dose. In some cases, the dose was increased when such symptoms were observed, and in all cases fluoxetine was eventually discontinued abruptly. A therapeutic window might account for worsening depressive symptoms in a few patients treated with fluoxetine. Our experience suggests that a cautious approach to dose titration might be warranted.
mucosa) and as specific as IgA AGA (none positive in 13 cases with normal mucosa). Thus in this form of coaliac disease in childhood, in which there is more IgG AGA than IgA AGA, EmA has advantages over AGA
Department of Psychiatry, Loyola University Stritch School of Medicine and Biological Psychiatry Section,
2nd Paediatric Clinic, Policlinico di Sant’ Orsola, University of Bologna,
Veterans Administration Edward Hines Jr Hospital, Hines, Illinois 60141, USA
Bologna, Italy
E. CACCIARI S. SALARDI S. TIBERI
Department of Medicine, University of Bologna
U. VOLTA N. MOLINARO F. B. BIANCHI
Department of Immunology, London Hospital Medical College, London, UK
G. F. BOTTAZZO
higher cases
Department of Psychiatry, University of Illinois College of Medicine, Chicago, Illinois
THOMAS
H. JOBE
Psychiatry, Rush-Presbyterian-St Luke’s
BENNETT G. BRAUN
1. Sommi
RW, Crismon ML, Bowden CL. Fluoxetine: a serotonin-specific, secondgeneration antidepressant. Pharmacotherapy 1987; 7: 1-15. 2. Teicher MH, Glod C, Cole JO. Emergence of intense suicidal preoccupation during fluoxetine treatment. Am J Psychiatry 1990; 147: 207-10. 3. Dasgupta K, Hoover CE. Additional cases of suicidal ideation associated with fluoxetine. Am J Psychiatry 1990; 147: 1570-71. 4. Masand P, Gupta S, Dewan M. Suicidal ideation related to fluoxetine treatment. N Engl J Med 1991; 324: 420. 5. Wernicke JF, Dunlop SR, Domseif BE, Zerbe RL. Fixed-dose fluoxetine therapy for depression. Psychopharm Bull 1987; 23: 164-68. 6. Damluji NF, Ferguson JM. Paradoxical worsening of depressive symptomatology caused by antidepressants. J Clin Psychopharmacol 1988; 8: 347-49. 7. Fava M, Rosenbaum JF. Suicidality and fluoxetine: is there a relationship? J Clin Psychiatry 1991; 52: 108-11.
Endomysial versus gliadin antibodies in diagnosis of coeliac disease in short children with no gastrointestinal symptoms SIR,-Anti-endomysial IgA antibodies (EmA) directed at reticulin-like structures in the smooth muscle of the gastrointestinal tract seem to correlate specifically with histopathological findings in coeliac disease. 1-3 We have been comparing EmA with anti-gliadin antibodies (AGA) in detecting coeliac disease in children with short stature and no gastrointestinal symptoms. In 1985 we looked at the diagnostic value of immunofluorescent AGA in this situation.4 Among 108 unselected short children, all tested for AGA and by jejunal biopsy, the IgG AGA test identified 8 of 9 cases of coeliac disease diagnosed histologically, but it was falsely positive in 6 of the 88 children with normal mucosa. The single missed case had a deficiency in serum IgA. Subsequently we used AGA to screen several hundred children with short stature for coeliac disease; only 41, those whose AGA were positive at a titre of 20 or more, had an intestinal biopsy. 28 of these 41 children had coeliac disease. After dietary management biopsy was repeated on 17 of these 28 and on the same day all children were tested for EmA by indirect immunofluorescence. Commercially available sections of monkey oesophagus were used and the antiserum consisted of human anti-IgA labelled with fluorescein isothiocyanate. In diagnosing coeliac disease in children with short stature but no gastrointestinal symptoms EmA was as sensitive as IgG AGA and more sensitive than IgA AGA, and more specific:
In monitoring coeliac disease in patients on a gluten-free diet EmA sensitive as IgG AGA (3 out of 4 cases with abnormal
was as
on
have coeliac disease.
CHRISTOPHER G. FICHTNER
Department of
Medical Center, Chicago, Illinois
diagnosis and monitoring. Had we done biopsies only on patients with IgA AGA we would have missed 6 cases of coeliac disease while doing biopsies on 2 patients with normal mucosa. Had we done a biopsy on every case with positive EmA we would have identified all cases but 1, and would not have done a biopsy on the 13 children with normal mucosa who were subjected to this procedure because of IgG AGA positivity. However, we cannot rule out the possibility that children who are positive for IgA AGA will not later for
1. Hallstrom O. Comparison of Ig-A-class reticulin and endomysium antibodies in coeliac disease and dermatitis herpetiformis. Gut 1989; 30: 1225-32. 2. Rossi TM, Kumar V, Lemer A, Heitlinger LA, Tucker N, Fisher J. Relationship of endomysial antibodies to jejunal mucosal pathology: specificity towards both symptomatic and asymptomatic celiacs. J Pediatr Gastroenterol Nutr 1988; 7: 858-63. 3 Calabuig M, Torregosa R, Polo P, et al. Serological markers and celiac disease: a new diagnostic approach? J Pediatr Gastroenterol Nutr 1990; 10: 435-42. 4 Cacciari E, Salardi S, Volta U, et al. Can antigliadin antibody detect symptomless coeliac disease in children with short stature? Lancet 1985; i: 1469-71.
Urinary saturation among phosphate-treated children with hypophosphataemic rickets SIR,-Hyperoxaluria has been suggested as a possible cause nephrocalcinosis in phosphate-treated children with hypophosphataemic rickets.1 We have studied the urinary saturation of several components of kidney stones in 7 children with hypophosphataemic rickets who had normal renal function (age range 4-16 years) and who were taking oral phosphate supplements (mean [SD] 2-39 [0.73] g/173 m2 per day), together with calcitriol (0-89 [0’42] )Jg daily). Except for the youngest patient, who had started treatment six months previously, the others had been on this regimen for an average of 7-8 years (range 4-12). No patient had renal calcifications on ultrasound. 24 h urine collections were studied for volume, pH, calcium, phosphate, sodium, potassium, magnesium, oxalate, urate, ammonium ions, sulphate, citrate, and creatinine. Free energy for crystallisation of calcium oxalate, brushite, and hydroxyapatite was calculated by computer program 2 All children excreted normal amounts of calcium (table); two subjects had slight hyperoxaluria. Urinary phosphate was of
URINE COMPOSITION AND SATURATION DATA
