Volume 91 Number 5
Letters to the Editor
Robbins JB: Acquisition of "natural" and immunizationinduced immunity to Haemophilus type b diseases, in Schlessinger D, editor: Microbiology-1975, Washington, 1975, American Society for Microbiology.
Beta hemolytic group C streptococcal respiratory infection in infant and horse I was interested to read the papers by Benjamin and Perriello 1 and Stewardson-Krieger and Gotoff-' implicating group C hemolytic streptococci in the pathogenesis of infective illness in children. The organism is well recognized as a cause of a disease known as "Strangles" that occurs in young horses. We have recently treated an infant who suffered a series of apneic episodes caused by a tenacious mucopurulent nasopharyngeal exudate. A beta hemolytic group C streptococcus was grown from the throat swab. CASE REPORT Patient K. U., a 5-week-old male infant of Japanese parents, was admitted after a two-day history of being slow with feeds and breathing difficulty. He had a temperature of 37.4 ~ C, snuffles, and slight inspiratory retraction. He continued to deteriorate over the next 24 hours, becoming dusky in color with shallow respirations and intercostal retractions. Investigations included a throat swab that grew a group C hemolytic streptococcus and a serum sodium concentration of 119 mg/dl. He was initially treated with oral penicillin, but he continued to deteriorate and become apneic. He responded promptly to the aspiration of about 10 ml of extremely tenacious mucopurulent material from the nasopharynx. With the nasal passages cleared, the infant improved considerably becoming active, pink, and lusty. To prevent further episodes of apnea, regular aspiration was required as the material reaccumulated. His therapy was changed to intravenous penicillin and gentamicin and infusion of 0.45% sodium chloride solution. Over the next 24 hours the amount of aspirate diminished, the clinical condition rapidly improved, and serum electrolyte values returned to normal. DISCUSSION Strangles is an acute, contagious, serious disease of young horses characterized by inflammation of the upper respiratory mucous membranes, producing a serous mucopurulent nasal discharge which is expelled during coughing and snorting. The usual causative organism is a group C hemolytic streptococcus.:' The similarity between the equine disease and the clinical events in our case is striking, the tenacious mucopurulent material completely blocking the nasopharyngeal passage of the infant leading to apnea. The veterinary name appears therefore to be most apt! Stanley Rom, M.B., Ch.B. Paediatric Registrar Edgware General Hospital Edgware, Middlesex HA80AD
845
REFERENCES
1. Benjamin JT, and Perriello VA: Pharyngitis due to group C hemolytic streptococci in Children, J PEDIATR 89:254, 1976. 2. Stewardson Krieger P, and Gotoff SP: Neonatal meningitis due to group C beta hemolytic streptococcus, J PEDIATR 90:103, 1977. 3. Stableford AW, and Galloway IA: Infectious diseases o f animals. Disease due to bacteria Vol It, Butterworth Scientific Publication, 1959.
Inverse relationship of serum thyroxine and blood lead concentrations Lead intoxication, endemic in inner city areas such as the Bedford Stuyvesant section of Brooklyn, may be associated with cerebral dysfunction and impairment of other organ systems. Blood lead levels as low as 40/~g/dl may be responsible for these pathologic changes. There is evidence in experimental animals ~ and in adults 2 that lead intoxication interferes with uptake o f iodine by the thyroid gland. The effect of elevated lead levels on thyroid function in children, however, has not been investigated. We have recently correlated blood lead levels with serum thyroxine (T,) concentrations in a group of pediatric patients and have found a significant inverse correlation between their values. MATERIALS
AND METHODS
Sixty one patients, ages 1 to 6 years (median age 2V2 years), were the subjects of the study. Twenty-eight were male; 33, female. All were referred to the Special Lead Clinic from the General Pediatric Clinic or from local health facilities because of blood lead concentrations of 40 #g/dl or greater. On enrollment in the clinic, blood lead levels were redetermined by the method of Hessell. ~ Concurrently, T4 concentrations were measured by radioimmunoassay. 4 All children with lead levels above 60 #g/dl were admitted to the inpatient department for chelation therapy (in mid 1976, the level was lowered to 50/~g/dl). Follow-up determinations of T~ were not performed. Correlation of blood lead and T, concentrations were done by linear regression analysis. RESULTS In 18 children whose blood lead concentrations were between 40 and 60/Lg/dl, the median serum T, concentration value was 9.2 ~g/dl with a range of 6.5 to 15.0/~g/dl. In the 25 children with blood lead levels of 61 to 80/~g/dl, the median serum T4 value was 8.2/~g/dl, with a range o f 6.4 to 11.6 txg/dl; among the 18 children with blood lead levels of 81 to 100 /~g/dl, the median T4 value was 6.2/~g/dl, with a range of 5.2 to 9.4/~g/dl.
846
Letters to the Editor
The relationship of T4 to blood lead concentrations of the entire group of 61 children can be expressed by the linear equation y = --0.07x + 13.57 (r = -0.61; p < 0.001). DISCUSSION This report documents our observation that serum T4 values tend to decrease in relation to elevation of blood lead levels. None of the T~ values were less than the lower limit of normal. Although we did not study the mechanisms involved, it may be, as suggested by the studies of Sandstead I and Sandstead and associates, 2 that high blood lead levels inhibit enzymes responsible for trapping and concentration of iodinp by the thyroid gland, Since we did not perform follow-up thyroid function studies following chelation therapy, we do not know whether a decrease in blood lead levels was associated with an increase in T~ values. These preliminary findings warrant further studies relative to thyroid function in relation to blood lead concentrations. Ramesh Jhaveri, M.D. Lorenzo Lavorgna, M.D. Farida Khan, M.D. Rameshcandra Ubriani, M.D. Hugh E. Evans, M.D. Leonard Glass, M.D. Department of Pediatrics Jewish Hospital and Medical Center of Brooklyn Brooklyn, N Y 11238
The Journal of Pediatrics November 1977
REFERENCES 1.
2.
3.
4.
Sandstead HH: Effect of chronic lead intoxication on in Vivo 1-131 uptake by the rat thyroid, Proc Soc Exp Biol Med 124:18, 1967. Sandstead HH, Stant EG, Brill AB, Arias LI, and Terry RT: Lead intoxication and the thyroid, Arch Intern Med 123:632, 1969: Hessell DW: A simple and rapid quantitative determination of lead in blood, Atomic Absorption Newsletter 7:55, 1968. Nuclear Medical Laboratories: Tetra-Tab RIA T, Diagnostic kit, 1976.
Editorial correspondence
"Editorial correspondence" or letters to the Editor relative to articles published in the JOURNAL or to topics of current interest are subject to critical review and to current editorial policy in respect to publication in part or in full.
Confusion and clarification of current recommendations for measles vaccination
Dr. Saul Krugman in the January issue of TIlE JOURNAL1 outlined the following six situations which seem to call for vaccination or revaccination: "(1) those who never had measles and were never immunized with live attenuated measles-virus
See related articles, pp. 715 and 766. To the Editor: The recent return of measles in epidemic form has led to many academic questions about vaccine efficacy. The general pediatrician is being asked by parents, nurses, news media, and often even his own wife to list the criteria for revaccination.
vaccine; (2) those who received killed measles vaccine or followed shortly thereafter by live vaccine when it was available before 1968; (3) those who received live attenuated measles-virus vaccine, Edmonston B strain, with or without human immune
Letters to the Editor
Robbins JB: Acquisition of "natural" and immunizationinduced immunity to Haemophilus type b diseases, in Schlessinger D, editor: Microbiology-1975, Washington, 1975, American Society for Microbiology.
Beta hemolytic group C streptococcal respiratory infection in infant and horse I was interested to read the papers by Benjamin and Perriello 1 and Stewardson-Krieger and Gotoff-' implicating group C hemolytic streptococci in the pathogenesis of infective illness in children. The organism is well recognized as a cause of a disease known as "Strangles" that occurs in young horses. We have recently treated an infant who suffered a series of apneic episodes caused by a tenacious mucopurulent nasopharyngeal exudate. A beta hemolytic group C streptococcus was grown from the throat swab. CASE REPORT Patient K. U., a 5-week-old male infant of Japanese parents, was admitted after a two-day history of being slow with feeds and breathing difficulty. He had a temperature of 37.4 ~ C, snuffles, and slight inspiratory retraction. He continued to deteriorate over the next 24 hours, becoming dusky in color with shallow respirations and intercostal retractions. Investigations included a throat swab that grew a group C hemolytic streptococcus and a serum sodium concentration of 119 mg/dl. He was initially treated with oral penicillin, but he continued to deteriorate and become apneic. He responded promptly to the aspiration of about 10 ml of extremely tenacious mucopurulent material from the nasopharynx. With the nasal passages cleared, the infant improved considerably becoming active, pink, and lusty. To prevent further episodes of apnea, regular aspiration was required as the material reaccumulated. His therapy was changed to intravenous penicillin and gentamicin and infusion of 0.45% sodium chloride solution. Over the next 24 hours the amount of aspirate diminished, the clinical condition rapidly improved, and serum electrolyte values returned to normal. DISCUSSION Strangles is an acute, contagious, serious disease of young horses characterized by inflammation of the upper respiratory mucous membranes, producing a serous mucopurulent nasal discharge which is expelled during coughing and snorting. The usual causative organism is a group C hemolytic streptococcus.:' The similarity between the equine disease and the clinical events in our case is striking, the tenacious mucopurulent material completely blocking the nasopharyngeal passage of the infant leading to apnea. The veterinary name appears therefore to be most apt! Stanley Rom, M.B., Ch.B. Paediatric Registrar Edgware General Hospital Edgware, Middlesex HA80AD
845
REFERENCES
1. Benjamin JT, and Perriello VA: Pharyngitis due to group C hemolytic streptococci in Children, J PEDIATR 89:254, 1976. 2. Stewardson Krieger P, and Gotoff SP: Neonatal meningitis due to group C beta hemolytic streptococcus, J PEDIATR 90:103, 1977. 3. Stableford AW, and Galloway IA: Infectious diseases o f animals. Disease due to bacteria Vol It, Butterworth Scientific Publication, 1959.
Inverse relationship of serum thyroxine and blood lead concentrations Lead intoxication, endemic in inner city areas such as the Bedford Stuyvesant section of Brooklyn, may be associated with cerebral dysfunction and impairment of other organ systems. Blood lead levels as low as 40/~g/dl may be responsible for these pathologic changes. There is evidence in experimental animals ~ and in adults 2 that lead intoxication interferes with uptake o f iodine by the thyroid gland. The effect of elevated lead levels on thyroid function in children, however, has not been investigated. We have recently correlated blood lead levels with serum thyroxine (T,) concentrations in a group of pediatric patients and have found a significant inverse correlation between their values. MATERIALS
AND METHODS
Sixty one patients, ages 1 to 6 years (median age 2V2 years), were the subjects of the study. Twenty-eight were male; 33, female. All were referred to the Special Lead Clinic from the General Pediatric Clinic or from local health facilities because of blood lead concentrations of 40 #g/dl or greater. On enrollment in the clinic, blood lead levels were redetermined by the method of Hessell. ~ Concurrently, T4 concentrations were measured by radioimmunoassay. 4 All children with lead levels above 60 #g/dl were admitted to the inpatient department for chelation therapy (in mid 1976, the level was lowered to 50/~g/dl). Follow-up determinations of T~ were not performed. Correlation of blood lead and T, concentrations were done by linear regression analysis. RESULTS In 18 children whose blood lead concentrations were between 40 and 60/Lg/dl, the median serum T, concentration value was 9.2 ~g/dl with a range of 6.5 to 15.0/~g/dl. In the 25 children with blood lead levels of 61 to 80/~g/dl, the median serum T4 value was 8.2/~g/dl, with a range o f 6.4 to 11.6 txg/dl; among the 18 children with blood lead levels of 81 to 100 /~g/dl, the median T4 value was 6.2/~g/dl, with a range of 5.2 to 9.4/~g/dl.
846
Letters to the Editor
The relationship of T4 to blood lead concentrations of the entire group of 61 children can be expressed by the linear equation y = --0.07x + 13.57 (r = -0.61; p < 0.001). DISCUSSION This report documents our observation that serum T4 values tend to decrease in relation to elevation of blood lead levels. None of the T~ values were less than the lower limit of normal. Although we did not study the mechanisms involved, it may be, as suggested by the studies of Sandstead I and Sandstead and associates, 2 that high blood lead levels inhibit enzymes responsible for trapping and concentration of iodinp by the thyroid gland, Since we did not perform follow-up thyroid function studies following chelation therapy, we do not know whether a decrease in blood lead levels was associated with an increase in T~ values. These preliminary findings warrant further studies relative to thyroid function in relation to blood lead concentrations. Ramesh Jhaveri, M.D. Lorenzo Lavorgna, M.D. Farida Khan, M.D. Rameshcandra Ubriani, M.D. Hugh E. Evans, M.D. Leonard Glass, M.D. Department of Pediatrics Jewish Hospital and Medical Center of Brooklyn Brooklyn, N Y 11238
The Journal of Pediatrics November 1977
REFERENCES 1.
2.
3.
4.
Sandstead HH: Effect of chronic lead intoxication on in Vivo 1-131 uptake by the rat thyroid, Proc Soc Exp Biol Med 124:18, 1967. Sandstead HH, Stant EG, Brill AB, Arias LI, and Terry RT: Lead intoxication and the thyroid, Arch Intern Med 123:632, 1969: Hessell DW: A simple and rapid quantitative determination of lead in blood, Atomic Absorption Newsletter 7:55, 1968. Nuclear Medical Laboratories: Tetra-Tab RIA T, Diagnostic kit, 1976.
Editorial correspondence
"Editorial correspondence" or letters to the Editor relative to articles published in the JOURNAL or to topics of current interest are subject to critical review and to current editorial policy in respect to publication in part or in full.
Confusion and clarification of current recommendations for measles vaccination
Dr. Saul Krugman in the January issue of TIlE JOURNAL1 outlined the following six situations which seem to call for vaccination or revaccination: "(1) those who never had measles and were never immunized with live attenuated measles-virus
See related articles, pp. 715 and 766. To the Editor: The recent return of measles in epidemic form has led to many academic questions about vaccine efficacy. The general pediatrician is being asked by parents, nurses, news media, and often even his own wife to list the criteria for revaccination.
vaccine; (2) those who received killed measles vaccine or followed shortly thereafter by live vaccine when it was available before 1968; (3) those who received live attenuated measles-virus vaccine, Edmonston B strain, with or without human immune
