584
isoniazid, thiacetazone, and streptomycin for eight weeks. Treatment with isoniazid and thiacetazone is continued for ten months. In our experience health workers can be taught how to recognise suspect skin lesions, such as itching and slight rashes. In these cases
change treatment immediately to ethambutol, thereby preventing the development of serious skin lesions. No doubt we may diagnose some false-positive cases of thiacetazone-induced reactions, especially when there is concomitant use of chloroquine. Since the introduction of this policy we have not seen any case of serious skin disease due to thiacetazone, though we have identified 18 cases of adverse reactions to this drug in two years. All these patients were HIV-1seropositive. Since patients in Zambia stay in hospital for eight weeks and adverse reactions usually appear within this time, as Nunn and colleagues show, there are few extra costs with respect to this policy in this country. we
Nyanje Hospital, Post Bag 1,
H. M. KOLE
Sinda, Zambia
Infection of aortic aneurysm with Coxiella burnetii SIR,-Coxiella burnetii, the agent of Q fever, can lead to chronic infections, including endocarditis.’ Aneurysm infections have been
reported
on
the basis of
serology
alone.2,3 We report
a case
aneurysm infection after acute Q fever in which C burnetii isolated from the aneurysm. A 65-year-old woman, alcoholic and a heavy smoker,
of
was
was
admitted to hospital in February, 1988, with fever and laboratory evidence for hepatitis. She lived in Grenoble, in the French Alps, an area endemic for Q fever. Acute Q fever was diagnosed by immunofluorescence serology (table) and she was treated with doxycycline 200 mg daily for 21 days. An asymptomatic 100 x 40 mm suprarenal aortic aneurysm was identified echographically. In March, 1988, she had a fever, a relapse seemed likely and she was treated again with doxycycline. Corticosteroids were added because of persistent fever in May, 1988, for 1 month. In November, 1988, a new febrile episode lead to the addition of rifampicin to doxycycline. In September, 1989, despite 38 months of treatment, the serological profile suggested chronic Q fever but treatment was stopped. In April, 1990, she relapsed and her aneurysm was resected. C burnetii was isolated from the aneurysm by the centrifugation shell vial assay.4 She was then treated with doxycycline. Chronic Q fever is serologically characterised by enhanced C burnetii phase I IgG and IgA antibodies.5 This case seems to be the first isolation of C burnetii from an aneurysm. Furthermore there are two main hypotheses on chronic Q fever: either it is strain specificity that determines the type infection (acute or chronic)6 or it is host specificity.’ In this case it seems that an asymptomatic aneurysm was colonised and then infected by C burnetii during acute Q fever despite doxycycline treatment, which is not bactericidal.8 This is a strong argument for the host-factor hypothesis, and if she had not had an aneurysm she might have escaped with acute Q fever only. Corticosteroids have been reported to permit relapses in anirnals9 and excacerbation of the disease in SEROLOGICAL RESULTS
endocarditis. 10 This case emphasises the need for a longer treatment and a long serological surveillance in patients with acute Q fever who have an underlying valve disorder or aneurysm. Infections Diseases Clinic, CHU Grenoble,
M. MICOUD J. C. BOULARD
J. P. BRION J. L. MAGNE
Richettsia Unit, CHU Timone
B. GRATACAP
Infection Diseases Clinic, CHU Grenoble
J. P. STAHL
General and Vascular Surgery Service, CHU Grenoble
I. FARAH
Richettsia Unit, CHU Timone, 13385 Marseille, France
D. RAOULT
1. Raoult
D, Piquet P, Gallais H, De Micco C, Drancourt M, Casanova P. Coxiella burnetii infection of vascular prosthesis. N Engl JMed 1986; 315: 1358. 2. Ellis ME, Smitt CC, Moffatt MAJ. Chronic or fatal Q fever infection: a review of 16 patients in North East Scotland (1967-1980) QJ Med 1983; 52: 54. 3. Ferguson RJ, Shaw TR, Kitchin AH, Matthews MB, Inglis JM, Peutherer JF. Subclinical chronic Q fever. QJ Med 1985; 57: 669-76. 4. Raoult D, Vestris G, Enea M. Isolation of 16 strains of Coxiella burnetii from patients by using a sensitive centrifugation cell culture system and establishment of strains in HEL cells. J Clin Microbiol 1990; 28: 2482-84. 5. Peacock M, Philip RN, Williams JC, Faulkner RS. Serological evaluation of Q fever in humans: enhanced phase I titres of immunoglobulins G and A are diagnostic for Q fever endocarditis. Infect Immunol 1983; 41: 108. 6. Hackstadt T. The role of lipopolysaccharides in the virulence of Coxiella burnetii. Ann NY Acad Sci 1990; 590: 27-32. 7. Raoult D. Hosts factors in the seventy of Q fever Ann NY Acad Sci 1990; 590: 33-38. 8. Raoult D, Drancourt M, Vestris G. Bactericidal effect of doxycycline associated with lysosomotropic agents on Coxiella burnetii in P388D1 cells. Antimicrob Agents Chemother 1990, 34: 1512-14. 9. Sidwell RW, Thorpe BD, Gebhardt LP. Studies of latent Q fever infections: II. effects of multiple cortisone injections. Am J Hyg 1964; 79: 320-27. 10 Lev BI, Shachar A, Segev S, Weiss P, Rubinstein E. Quiescent Q fever endocarditis exarcerbated by cardiac surgery and corticosteroid therapy. Arch Intern Med 1988, 148: 1531-32.
Gregory, Julian, and the public health reporting year SIR,- The UK Government’s consultative document The of the Nation gives statistics almost all of which, especially
Health
those for international comparisons, are on a calendar year basis up to 1989. The document mentions the annual reports produced by directors of public health. We will wish to quote comparative statistics, but as a consequence of the Komer working-party’s recommendations activity statistics are now collected on a fiscal year basis as from 1990. We may therefore in future end up with data similar to figs 20 and 21 in the consultation document where Great Britain statistics for January to December, 1988, are compared with England and Wales data from April, 1986, to March, 1987. This is stupid. The Department of Health should direct that health activity statistics other than financial ones should continue to be collected on a calendar year basis. The origin of the UK fiscal year beginning April 5 is not well known. In 1582 a more accurate calendar was introduced by Pope Gregory, and when Britain changed from the Julian to the Gregorian calendar in 1752 the difference was 11days. Before 1752 the Exchequer had used Lady Day (March 25, one of the "quarter days") as its financial year beginning. This was also the civil or legal beginning of the year, in line with the agricultural seasons. With its usual intransigence and blinkered outlook the Treasury saw no reason to sacrifice 11 days of revenue and ruled that the financial year 1752-53 would end on April 5 rather than March 24. When comparisons are made with neighbouring countries we must compare annual statistics that cover the same months and unless we use calendar years, we will be unable to continue to make many international comparisons. Many directors of public health contribute a section to their local authority annual report, which is on a calendar year basis. Directors of public health should quote all statistics on a calendar year basis and health activity matters nationally should continue to be quoted on that basis. Hull Health Authority, Hull HU2 8TD, UK
JAMES M. DUNLOP
isoniazid, thiacetazone, and streptomycin for eight weeks. Treatment with isoniazid and thiacetazone is continued for ten months. In our experience health workers can be taught how to recognise suspect skin lesions, such as itching and slight rashes. In these cases
change treatment immediately to ethambutol, thereby preventing the development of serious skin lesions. No doubt we may diagnose some false-positive cases of thiacetazone-induced reactions, especially when there is concomitant use of chloroquine. Since the introduction of this policy we have not seen any case of serious skin disease due to thiacetazone, though we have identified 18 cases of adverse reactions to this drug in two years. All these patients were HIV-1seropositive. Since patients in Zambia stay in hospital for eight weeks and adverse reactions usually appear within this time, as Nunn and colleagues show, there are few extra costs with respect to this policy in this country. we
Nyanje Hospital, Post Bag 1,
H. M. KOLE
Sinda, Zambia
Infection of aortic aneurysm with Coxiella burnetii SIR,-Coxiella burnetii, the agent of Q fever, can lead to chronic infections, including endocarditis.’ Aneurysm infections have been
reported
on
the basis of
serology
alone.2,3 We report
a case
aneurysm infection after acute Q fever in which C burnetii isolated from the aneurysm. A 65-year-old woman, alcoholic and a heavy smoker,
of
was
was
admitted to hospital in February, 1988, with fever and laboratory evidence for hepatitis. She lived in Grenoble, in the French Alps, an area endemic for Q fever. Acute Q fever was diagnosed by immunofluorescence serology (table) and she was treated with doxycycline 200 mg daily for 21 days. An asymptomatic 100 x 40 mm suprarenal aortic aneurysm was identified echographically. In March, 1988, she had a fever, a relapse seemed likely and she was treated again with doxycycline. Corticosteroids were added because of persistent fever in May, 1988, for 1 month. In November, 1988, a new febrile episode lead to the addition of rifampicin to doxycycline. In September, 1989, despite 38 months of treatment, the serological profile suggested chronic Q fever but treatment was stopped. In April, 1990, she relapsed and her aneurysm was resected. C burnetii was isolated from the aneurysm by the centrifugation shell vial assay.4 She was then treated with doxycycline. Chronic Q fever is serologically characterised by enhanced C burnetii phase I IgG and IgA antibodies.5 This case seems to be the first isolation of C burnetii from an aneurysm. Furthermore there are two main hypotheses on chronic Q fever: either it is strain specificity that determines the type infection (acute or chronic)6 or it is host specificity.’ In this case it seems that an asymptomatic aneurysm was colonised and then infected by C burnetii during acute Q fever despite doxycycline treatment, which is not bactericidal.8 This is a strong argument for the host-factor hypothesis, and if she had not had an aneurysm she might have escaped with acute Q fever only. Corticosteroids have been reported to permit relapses in anirnals9 and excacerbation of the disease in SEROLOGICAL RESULTS
endocarditis. 10 This case emphasises the need for a longer treatment and a long serological surveillance in patients with acute Q fever who have an underlying valve disorder or aneurysm. Infections Diseases Clinic, CHU Grenoble,
M. MICOUD J. C. BOULARD
J. P. BRION J. L. MAGNE
Richettsia Unit, CHU Timone
B. GRATACAP
Infection Diseases Clinic, CHU Grenoble
J. P. STAHL
General and Vascular Surgery Service, CHU Grenoble
I. FARAH
Richettsia Unit, CHU Timone, 13385 Marseille, France
D. RAOULT
1. Raoult
D, Piquet P, Gallais H, De Micco C, Drancourt M, Casanova P. Coxiella burnetii infection of vascular prosthesis. N Engl JMed 1986; 315: 1358. 2. Ellis ME, Smitt CC, Moffatt MAJ. Chronic or fatal Q fever infection: a review of 16 patients in North East Scotland (1967-1980) QJ Med 1983; 52: 54. 3. Ferguson RJ, Shaw TR, Kitchin AH, Matthews MB, Inglis JM, Peutherer JF. Subclinical chronic Q fever. QJ Med 1985; 57: 669-76. 4. Raoult D, Vestris G, Enea M. Isolation of 16 strains of Coxiella burnetii from patients by using a sensitive centrifugation cell culture system and establishment of strains in HEL cells. J Clin Microbiol 1990; 28: 2482-84. 5. Peacock M, Philip RN, Williams JC, Faulkner RS. Serological evaluation of Q fever in humans: enhanced phase I titres of immunoglobulins G and A are diagnostic for Q fever endocarditis. Infect Immunol 1983; 41: 108. 6. Hackstadt T. The role of lipopolysaccharides in the virulence of Coxiella burnetii. Ann NY Acad Sci 1990; 590: 27-32. 7. Raoult D. Hosts factors in the seventy of Q fever Ann NY Acad Sci 1990; 590: 33-38. 8. Raoult D, Drancourt M, Vestris G. Bactericidal effect of doxycycline associated with lysosomotropic agents on Coxiella burnetii in P388D1 cells. Antimicrob Agents Chemother 1990, 34: 1512-14. 9. Sidwell RW, Thorpe BD, Gebhardt LP. Studies of latent Q fever infections: II. effects of multiple cortisone injections. Am J Hyg 1964; 79: 320-27. 10 Lev BI, Shachar A, Segev S, Weiss P, Rubinstein E. Quiescent Q fever endocarditis exarcerbated by cardiac surgery and corticosteroid therapy. Arch Intern Med 1988, 148: 1531-32.
Gregory, Julian, and the public health reporting year SIR,- The UK Government’s consultative document The of the Nation gives statistics almost all of which, especially
Health
those for international comparisons, are on a calendar year basis up to 1989. The document mentions the annual reports produced by directors of public health. We will wish to quote comparative statistics, but as a consequence of the Komer working-party’s recommendations activity statistics are now collected on a fiscal year basis as from 1990. We may therefore in future end up with data similar to figs 20 and 21 in the consultation document where Great Britain statistics for January to December, 1988, are compared with England and Wales data from April, 1986, to March, 1987. This is stupid. The Department of Health should direct that health activity statistics other than financial ones should continue to be collected on a calendar year basis. The origin of the UK fiscal year beginning April 5 is not well known. In 1582 a more accurate calendar was introduced by Pope Gregory, and when Britain changed from the Julian to the Gregorian calendar in 1752 the difference was 11days. Before 1752 the Exchequer had used Lady Day (March 25, one of the "quarter days") as its financial year beginning. This was also the civil or legal beginning of the year, in line with the agricultural seasons. With its usual intransigence and blinkered outlook the Treasury saw no reason to sacrifice 11 days of revenue and ruled that the financial year 1752-53 would end on April 5 rather than March 24. When comparisons are made with neighbouring countries we must compare annual statistics that cover the same months and unless we use calendar years, we will be unable to continue to make many international comparisons. Many directors of public health contribute a section to their local authority annual report, which is on a calendar year basis. Directors of public health should quote all statistics on a calendar year basis and health activity matters nationally should continue to be quoted on that basis. Hull Health Authority, Hull HU2 8TD, UK
JAMES M. DUNLOP
