977
PREVIOUS ANTIBIOTIC TREATMENT AND DIAGNOSIS OF MENINGITIS S)R,—Dr Cargill (Oct. 4, p. 665) describes a case of pneumococcal meningitis with a lymphocyte pleocytosis in the cerebro-
spinal fluid, presumably caused by treatment with tetracycline. The difficulties in diagnosis raised by previous antibiotic treatment in bacterial meningitis are classical. A recent analysis found surprisingly few differences between pretreated and non-pretreated patients2,but this does not exclude difficulty in a particular case, as illustrated by our series. Of 92 patients with bacterial meningitis 30 (33%) had had antibiotic treatbefore admission. The age range was 1 month to 78 years. One had a story very similar to that of Dr Cargill’s patient. A 3-year-old boy was admitted because of meningitis, after an upper respiratory infection for one week. He had been treated with tetracycline for 2 days. He was stiff necked but the c.s.F. contained only 71 leucocytes/mm3, predominantly lymphocytes. He was observed without antibiotic treatment, because his general condition was good and serous meningitis was suspected. The next day he deteriorated, and the c.s.F. ment
showed rising pleocytosis (165/mm),but mainly lymphocytes. Hcemophilus influenzae was detected in the C.S.F., and ampicillin was started immediately, with rapid improvement. The subsequent course was uneventful. In contrast to the case described by Dr Cargill, our patient had normal c.s.F. sugar, which is not uncommon, even in purulent meningitis. But if c.s.F. sugar is low, that can be of great value. We were convinced that the lymphocyte reaction in our patient was due to tetracycline, but this cannot be proved. This case illustrates the value of clinical observation in lymphocytic meningitis, especially when there is a history of antibiotic treatment, and the importance of repeated lumbar puncture if the patient deteriorates. Perhaps countercurrent immunoelectro-osmophoresis’ may be of value in these rare cases of acute bacterial meningitis presenting with a lymphocytosis in the c.s.F., possibly after antibiotic treatment. ’
immunofluorescence at 18 with human rotavirus (x 500).
Intracytoplasmic
Virus
Laboratory, Birmingham Children’s Hospital, Birmingham B16 8ET, and Institute of Child Health, University of Birmingham.
D. R. PURDHAM P. A. PURDHAM N. EVANS A. S. MCNEISH
A MODIFIED NATIONAL DRIED MILK
Aarhus,
FRODE K. RØMER
ISOLATION OF HUMAN ROTAVIRUS USING HUMAN EMBRYONIC GUT MONOLAYERS
Sm,—Dr Banatvala and others (Oct. 25, p. 821) described the in-vitro detection of human rotavirus antigen by immunofluorescence, using pig-kidney cultures (IB-RS-2) and a centrifugational inoculation method. We have developed a technique using monolayer cultures of human embryonic gut (H.E.G.) in which rotavirus can be detected by immunofluorescence and by electron microscopy (E.M.). Primary monolayer cultures of trypsinised H.E.G. in medium 199 (Wellcome) were inoculated with 0.cm3 of infants’ faeces extracts in Eagle’s medium that were known by E.M. to contain human rotavirus. Further primary H.E.G. cells were layered onto the original cultures at 6-7 day intervals. A bovine antiserum to calf rotavirus (that had been shown to cross-react with human rotavirus3) was used for indirect immunofluorescence. Cytoplasmic antigen was easily detected at 18 days (see accompanying figure), and increased with further passages to day 30, when typical virus particles were detected by E.M. of ultrasonically disrupted cells. Negative controls were included
throughout. The standard nature of these methods suggests that this virus could be isolated by routine laboratories. The ability to 1
of H.E.G. cells infected
maintain rotavirus in a human cell line may be important for further study of this common pathogenic agent. We thank Dr Janice Bridger and Mr Gerald Woode for the gift of antiserum, Dr R. George for his encouragement, and Miss D. A. Ratcliffe and Mr P. J. Turner for technical assistance.
University Department of Medicine II, Aarhus Amtssygehus, Denmark.
days
Hoff, G. E., Høiby, N. Ugeskr, Lœg. 1975, 137, 1713. 2. Jarvis, C. W., Saxona, K. M. Clin. Pediat. 1972, 11. 201. 3 Flewett, T. H., Bryden, A. S., Davies, H., Woode, G. N., Bridger, J. C., Derrick, J. M. Lancet, 1974, ii, 61.
SIR,-It is now over a year since a working-party set up by the D.H.S.S. published the excellent report Present-day Practice in Infant Feeding.! From this report and from a subsequent letter2we were led to believe that a low-solute, modified or "humanised" National dried milk was imminent to replace the present N.D.M. which, as we all know, can cause serious problems.3 and may even be implicated in sudden unexpected death .4 May I ask why we are still waiting for this product ? Although a number of modified milks are available commercially, their rapidly increasing cost (now approximately three to four times that of N.D.M.) is putting them out of reach of more and more mothers. Understandably they are switching to N.D.M. or plain cow’s milk for their babies earlier and earlier after leaving the hospital nurseries. We all hope to see a return to breast-feeding, but it is only realistic to expect the need for a powdered milk substitute to continue indefinitely and, I understand that a "ready-to-use" milk no matter how desirable, would be extremely costly to introduce for general use. In my view subsidised, modified N.D.M. (powdered or "readyto-use") should be made available with some urgency. We know that mothers will continue to make mistakes in preparation however carefully they are instructed. We should at least ensure that even these mistakes (usually towards over concentration) will not cause harm to infants. If Dr Dunn and Dr Pollitz3 are right, and I agree with their estimates, then a large Practice in Infant Feeding. D.H.S.S. Report on Health and Social Subjects no. 9. H.M. Stationery Office, 1974. 2. Arneil, G. C., Creery, R. D. G., Lloyd, J. K., Oppé, T. E., Stroud, C. E., Wharton, B. A., Widdowson, P. M. Lancet, 1975, i, 450. 3. Dunn, P. M., Pollnitz, R. ibid. p.269. 4. Emery, J. L., Swift, P. G. F., Worthy, E. Archs Dis Childh. 1974, 49, 636. 1.
Present-day
PREVIOUS ANTIBIOTIC TREATMENT AND DIAGNOSIS OF MENINGITIS S)R,—Dr Cargill (Oct. 4, p. 665) describes a case of pneumococcal meningitis with a lymphocyte pleocytosis in the cerebro-
spinal fluid, presumably caused by treatment with tetracycline. The difficulties in diagnosis raised by previous antibiotic treatment in bacterial meningitis are classical. A recent analysis found surprisingly few differences between pretreated and non-pretreated patients2,but this does not exclude difficulty in a particular case, as illustrated by our series. Of 92 patients with bacterial meningitis 30 (33%) had had antibiotic treatbefore admission. The age range was 1 month to 78 years. One had a story very similar to that of Dr Cargill’s patient. A 3-year-old boy was admitted because of meningitis, after an upper respiratory infection for one week. He had been treated with tetracycline for 2 days. He was stiff necked but the c.s.F. contained only 71 leucocytes/mm3, predominantly lymphocytes. He was observed without antibiotic treatment, because his general condition was good and serous meningitis was suspected. The next day he deteriorated, and the c.s.F. ment
showed rising pleocytosis (165/mm),but mainly lymphocytes. Hcemophilus influenzae was detected in the C.S.F., and ampicillin was started immediately, with rapid improvement. The subsequent course was uneventful. In contrast to the case described by Dr Cargill, our patient had normal c.s.F. sugar, which is not uncommon, even in purulent meningitis. But if c.s.F. sugar is low, that can be of great value. We were convinced that the lymphocyte reaction in our patient was due to tetracycline, but this cannot be proved. This case illustrates the value of clinical observation in lymphocytic meningitis, especially when there is a history of antibiotic treatment, and the importance of repeated lumbar puncture if the patient deteriorates. Perhaps countercurrent immunoelectro-osmophoresis’ may be of value in these rare cases of acute bacterial meningitis presenting with a lymphocytosis in the c.s.F., possibly after antibiotic treatment. ’
immunofluorescence at 18 with human rotavirus (x 500).
Intracytoplasmic
Virus
Laboratory, Birmingham Children’s Hospital, Birmingham B16 8ET, and Institute of Child Health, University of Birmingham.
D. R. PURDHAM P. A. PURDHAM N. EVANS A. S. MCNEISH
A MODIFIED NATIONAL DRIED MILK
Aarhus,
FRODE K. RØMER
ISOLATION OF HUMAN ROTAVIRUS USING HUMAN EMBRYONIC GUT MONOLAYERS
Sm,—Dr Banatvala and others (Oct. 25, p. 821) described the in-vitro detection of human rotavirus antigen by immunofluorescence, using pig-kidney cultures (IB-RS-2) and a centrifugational inoculation method. We have developed a technique using monolayer cultures of human embryonic gut (H.E.G.) in which rotavirus can be detected by immunofluorescence and by electron microscopy (E.M.). Primary monolayer cultures of trypsinised H.E.G. in medium 199 (Wellcome) were inoculated with 0.cm3 of infants’ faeces extracts in Eagle’s medium that were known by E.M. to contain human rotavirus. Further primary H.E.G. cells were layered onto the original cultures at 6-7 day intervals. A bovine antiserum to calf rotavirus (that had been shown to cross-react with human rotavirus3) was used for indirect immunofluorescence. Cytoplasmic antigen was easily detected at 18 days (see accompanying figure), and increased with further passages to day 30, when typical virus particles were detected by E.M. of ultrasonically disrupted cells. Negative controls were included
throughout. The standard nature of these methods suggests that this virus could be isolated by routine laboratories. The ability to 1
of H.E.G. cells infected
maintain rotavirus in a human cell line may be important for further study of this common pathogenic agent. We thank Dr Janice Bridger and Mr Gerald Woode for the gift of antiserum, Dr R. George for his encouragement, and Miss D. A. Ratcliffe and Mr P. J. Turner for technical assistance.
University Department of Medicine II, Aarhus Amtssygehus, Denmark.
days
Hoff, G. E., Høiby, N. Ugeskr, Lœg. 1975, 137, 1713. 2. Jarvis, C. W., Saxona, K. M. Clin. Pediat. 1972, 11. 201. 3 Flewett, T. H., Bryden, A. S., Davies, H., Woode, G. N., Bridger, J. C., Derrick, J. M. Lancet, 1974, ii, 61.
SIR,-It is now over a year since a working-party set up by the D.H.S.S. published the excellent report Present-day Practice in Infant Feeding.! From this report and from a subsequent letter2we were led to believe that a low-solute, modified or "humanised" National dried milk was imminent to replace the present N.D.M. which, as we all know, can cause serious problems.3 and may even be implicated in sudden unexpected death .4 May I ask why we are still waiting for this product ? Although a number of modified milks are available commercially, their rapidly increasing cost (now approximately three to four times that of N.D.M.) is putting them out of reach of more and more mothers. Understandably they are switching to N.D.M. or plain cow’s milk for their babies earlier and earlier after leaving the hospital nurseries. We all hope to see a return to breast-feeding, but it is only realistic to expect the need for a powdered milk substitute to continue indefinitely and, I understand that a "ready-to-use" milk no matter how desirable, would be extremely costly to introduce for general use. In my view subsidised, modified N.D.M. (powdered or "readyto-use") should be made available with some urgency. We know that mothers will continue to make mistakes in preparation however carefully they are instructed. We should at least ensure that even these mistakes (usually towards over concentration) will not cause harm to infants. If Dr Dunn and Dr Pollitz3 are right, and I agree with their estimates, then a large Practice in Infant Feeding. D.H.S.S. Report on Health and Social Subjects no. 9. H.M. Stationery Office, 1974. 2. Arneil, G. C., Creery, R. D. G., Lloyd, J. K., Oppé, T. E., Stroud, C. E., Wharton, B. A., Widdowson, P. M. Lancet, 1975, i, 450. 3. Dunn, P. M., Pollnitz, R. ibid. p.269. 4. Emery, J. L., Swift, P. G. F., Worthy, E. Archs Dis Childh. 1974, 49, 636. 1.
Present-day
