LETTER FROM ABROAD

London.\p=m-\AThe Hague last week I attended the Third European Conference of Internal Medicine\p=m-\AEMIEin French, which gives a better idea of what it is about as MIE stands for "Medicine interne d'ensemble" (my italics). The organisation largely exists to promote preservation of general internists, against the challenge of organ specialists such as cardiologists and neurologists. In fact I was the only specialist there except for some experts in tropical disease\p=m-\neither they nor I being organ or system

specialists.

It was an interesting group consisting of mainly nationals who have been scrapping for centuries about who shall control the "cockpit of Europe" (Belgium) and the Rhine delta. Thus, of 162 who attended, only Netherlands, Britain, France, and Belgium achieved double figures. Nevertheless

there were visitors from four iron curtain countries in addition to such well-known bulwarks of Europe as the United States, Canada, Australia, and Algeria. Of the speakers, 70% used English, 22% French, and 8% German. The French, who once used to gabble at top speed in order to get as much said as possible before being gavelled by the chairman, are now ex¬ quisite to listen to. They are so deter¬ mined that French shall not go under as the international language that they enunciate each word like crystal and every chiselled epigram strikes home. The German speakers are not so much concerned, despite their pre¬ eminence 100 years ago. One spoke in German but handed an English man¬ uscript to the editor, saying "For God's sake don't print it in German, nobody reads that nowadays." I concluded that there would not be much point in trying to tie up the Eu¬

general physicians and the paediatricians. There was some com¬ mon ground, including an enjoyable day on "Tropical Disease in Europe." Good clinical stuff, and it showed me ropean

how out of date I was in the treat¬ ment of malaria, which I used to think I knew about after caring for several thousand patients between 1942 and 1944. But it also made an in¬ teresting comparison with an after¬ noon session that took place two weeks earlier, a meeting of the Trop¬ ical Child Health Group of the British

Paediatric Association in York, England. The subject was different, it was tropical paediatrics anywhere, not tropical disease in Europe. Each speaker had worked in the place he was talking about-usually Africa,

which has such a small population compared with Asia, but is generally much more popular with our physi¬ cians than other exotic continents. The speakers were, at a guess, 10 to 15 years younger than the internists at The Hague meeting, young en¬ thusiasts comparing their experience of neonatology, nutrition, growth, and the economics of getting medical care to rural tribes, as well as the in¬ evitable malaria and measles. India (including Pakistan and Bangladesh) provided the great in¬ centive for British interest in tropical medicine, and is the reason for strong schools of this subject developing in the ports of Liverpool and London, al¬ though some of the other lands that used to be coloured red on our maps (Sudan, Malaya) were influential too. With loss of influence, and more im¬ portantly loss of responsibility, atten¬ tion shifted to Africa. At this meet¬ ing there were 12 contributions, half of them from the little country of Uganda, which was never a colony, only a protectorate. And now there also, as the Preacher warned, the sil¬ ver cord is loosed, the pitcher broken at the fountain. He also said "One generation passeth away, and another generation cometh." How I wish I could see again the children's hospital in Saigon, in May 1975, and talk to my old Viet¬ namese colleagues. I suspect that the hospital, normally overcrowded, is nearly empty for that is what it was like during the Tet offensive of 1968— parents kept their children at home. As you know, we are in Britain committed to the idea that general practice is still possible and that it is an advantage to have a family physician rather than calling for a paediatrician when a child falls ill. Consequently, almost all senior pae¬ diatricians are consultants, rarely re¬ sponsible for primary care. It used to be common for a physi¬ cian to go into a practice as an assist¬ ant, and if after a year or two he liked the place and the people, he would settle in as a partner. There was no formal training, but now it is being organised. A five-year in-ser¬ vice training is planned, but for prac¬ tical reasons a three-year period is now common. This is only part of

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medical education, which is fashion¬ ably viewed as continuing from medi¬ cal school to retirement. A committee consisting of three paediatricians, three family physi¬ cians, and a psychiatrist (for bal¬ ance?) has been considering what sort of paediatrics should be taught to "doctors of first contact and contin¬ uing presence," and it makes a pret¬ ty tall order-human development, health and diseases (which are indi¬ vidually listed), human behaviour (es¬ pecially within the family), medicine and society (culture, class, epidemiol¬

ogy, paramedical workers, alcoholism, juvenile crime, etc), and practice or¬ ganisation, including the well-baby

clinic. The School Health Service will be optional, as it can also be provided by paediatricians, psychiatrists, and

psychologists. As

medical student he will learn less what he does now, so we can skip that. After graduating in medicine he should have as a min¬ imum a six-month resident paediat¬ ric post in a hospital, little enough time to learn about neonates, com¬ mon medical and surgical problems including orthopaedics, and psychia¬ try. After similar periods devoted to adult medicine, psychiatry, and gynaecology, he can continue train¬ ing in practice, learning on the job but also in "day-release courses." He is to be spared a compulsory examina¬ tion after all this but should use a self-administered questionnaire "as a simple means of detecting weak areas of knowledge and skill." There's also a movement to compel a

more or

paediatricians-in-training to spend six months in general practice, but that's another story. PHILIP R. EVANS, MD, FRCP The Hospital for Sick Children

Great Ormond Street London WC1, England

Disseminated in a Child In

Coccidioidomycosis

1964, Ziering and Rockas puba case report of disseminated

lished

coccidioidomycosis of a child.1 At the time of the publication, the 24-month\x=req-\ old child had severe disease involving the left knee, right wrist, and right elbow. Treatment with amphotericin B (Fungizone), 2.4 gm administered intravenously during a total hospitalization of 18

months, was ineffective.

No operation had been employed. Death was predicted, and the child

lost to follow-up. We can now report a longer-term follow-up on this child, in order to illustrate the fickle nature of coccidioidomycotic infection and the relative ineffectiveness of our treatment for this condition. The child's condition improved substantially without further treatment after he left Fresno, Calif, but he developed signs of active local and systemic disease in 1966 at the age of 5. He was admitted to a Galveston, Tex, hospital with obvious synovitis of the left knee and drainage from the right hand. His complement-fixation titer was positive at 1:64 dilutions. His con¬ dition improved after an additional adminis¬ 1.8 gm of amphotericin tered intravenously, and he was dis¬ charged home. Recurrent disease in the left knee led to rehospitalization, synovectomy, and intravenous administration of another 150 mg of amphotericin in yet another Texas hospital in March 1968. A month later the knee was ma¬ nipulated under general anesthesia to increase its range of motion. The pa¬ tient was again lost to follow-up. On reexamination in February 1973, he was asymptomatic. There was a foreshortened second metacarpal with a 40° flexion contracture of the metacarpophalangeal joint. The left knee had a full, painless range of motion with no effusion or synovial hypertrophy. Roentgenograms of the knee and hand showed no evidence of active disease. Complement-fixation titers were positive at 1:4 dilutions; creatinine level was 0.8 serum mg/100 ml. Comment. -Although human coccidioidomycosis is highly variable in all its manifestations, spontaneous cure of an established extrapulmonary focus is unreported. Nonethe¬ less, it is hard to convincingly relate this patient's apparent cure to any of the modalities employed in his treat¬ ment. The ineffectiveness of ampho¬ tericin therapy had already been demonstrated. Synovectomy has been proposed as a logical treatment, but can never remove more than a portion of the diseased tissue and infectious organisms. In a large series of pa¬ tients with coccidioidomycotic arthri¬ tis, synovectomy with or without ad¬ ministration of amphotericin failed to control disease activity in the ma¬ jority of cases.2 We do not know whether cure of this case of disseminated coccidioidomycosis after seven years was in was

any way related to treatment. We be¬ lieve that this case offers an excellent example of the unpredictability of hu¬ man coccidioidal infection. It may also offer support to a previously stated hypothesis that mycosis in children may be more benign than disseminated mycosis in adults.3 WILLIAM G. WINTER, JR, MD Orthopedic Service Veterans Administration Hospital Lexington, KY 40506 ROGER K. LARSON, MD Orthopedic and Medical Departments Valley Medical Center Fresno, Calif 1. Ziering WH, Rockas HR: Coccidioidomy-

cosis: Long-term treatment with amphotericin B of disseminated disease in a 3-month-old baby. Am J Dis Child 108:454-459, 1964. 2. Winter WG, Larson RK, Masten M, et al: Coccidioidal arthritis and its treatment\p=m-\1974.J Bone Joint Surg, to be published. 3. Dykes J, Segesman JK, Birsner JW: Coccidioidomycosis of bone in children. Am J Dis Child 85:34-42, 1953.

Unusual Gastrointestinal Manifestations of

Henoch-Sch\l=o"\nleinPurpura The gastrointestinal manifestations of Henoch-Sch\l=o"\nleinpurpura are diverse and, in the absence of the diagnostic rash, can easily be confused with other conditions. The case presented below illustrates the capacity of this entity to masquerade as acute appendicitis and as acute Crohn disease.

Report of a Case.\p=m-\A6-year-old boy had a four-day history of periumbilical pain and vomiting. He had had an upper-respiratory tract infection the week prior to development of symptoms, and a temperature of 38.3 C (101 F) orally on the day prior to presentation. He had no history of

diarrhea, hematochezia, trauma,

or uridid he have a past history of weight loss, unexplained fevers, or substantial abdominal pain. Physical examination disclosed an enervated boy with decreased moisture of his buccal mucosa, normal skin turgor, a soft but diffusely tender abdomen with voluntary guarding in all four quadrants, bilateral rebound tenderness greater on the right, and a diffusely tender rectum. A guaiac-negative stool was obtained. Laboratory examination showed a white blood cell count of 13,700/cu mm with 72% polymorphonuclear leukocytes and 3% band forms, and a hemoglobin level of 12.9 gm/100 ml. Roentgenograms of the abdo¬ men and chest were normal, as were re¬ sults of urinalysis, urine and throat cul¬ tures, and serum electrolyte levels. The child underwent laparotomy that evening and five segments of inflamed, thickened, and edematous bowel were

nary tract

symptoms,

nor

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found in the jejunum; the largest affected area was about 8 cm long, and another area 2 to 3 cm in length disclosed periserosal fat; six involved lymph nodes showed nonspecific adenitis on histological examination. To gross inspection, the ap¬ pendix, ileum, and ascending colon were uninvolved, and the postoperative diag¬ nosis was atypical acute regional enteritis. The patient had an uneventful postoper¬ ative course until one week later when he developed periumbilical pain and hemato¬ chezia. On proctoscopy, the rectal mucosa was studded with patchy, superficial ul¬ cérations with surrounding erythema and a central exúdate with normal intervening mucosal tissue; stool samples were nega¬ tive for bacterial pathogens, ova and para¬ sites, and amoebae. Rectal biopsy failed to show pathological changes. These symptoms resolved the following day and three days later the boy developed bilateral ankle swelling and petechiae over the anterior part of both tibiae and on the buttocks. All petechiae disappeared after four days and no hematuria or hyperten¬ sion developed on subsequent examina¬ tions. A series of roentgenograms of the upper-gastrointestinal tract and small bowel taken at the time of the skin erup¬ tion was completely normal.

Comment— This patient had ab¬ dominal pain, vomiting, and a leuko¬ cytosis, all of which can be found in acute appendicitis and in acute Crohn disease as well as in Henoch-Schön¬ lein purpura. However, the latter diagnosis could not be made in the ab¬ sence of the telltale rash. The review by Rodriguez-Erdmann and Levitan1 states that 14% of patients will show gastrointestinal features of anaphylactoid purpura before appearance of the rash. In this condition the bowel is edematous with submucosal and subserosal hemorrhages, while in acute Crohn disease the terminal part of the ileum is hyperemic and edema¬ tous.2 Furthermore, periserosal fat is usually seen in Crohn disease. Thus, one can see how at operation the bowel appearance could be mis¬ leading. Finally, although HenochSchönlein purpura has been reported to involve any part of the alimentary tract,3 rectal involvement is not com¬ mon and is more often seen with Crohn disease. A case similar to this in an adult was reported by Yentis.4 Philip Sunshine, MD, of Stanford University manuscript and aided in its prepa¬

reviewed the ration.

GORDON L. KLEIN, MD SAM STAFFORD III, MD Department of Pediatrics Naval Regional Medical Center Mountain Boulevard Oakland, CA 94627

Letter: Disseminated coccidioidomycosis in a child.

LETTER FROM ABROAD London.\p=m-\AThe Hague last week I attended the Third European Conference of Internal Medicine\p=m-\AEMIEin French, which gives a...
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