373 fact that beer contains calories and little sodium allows beer drinkers to subsist with little solid food which would normally supply sodium. Perhaps these factors alone are enough to explain why beer drinkers seem prone to hyponatraemia. If so, effective treatment should include restriction of the volume of beer and an adequate sodium intake, preferably through a satisfactory diet. RICHARD SWENSON Mercy Hospital, DAVID A. RATER Cedar Rapids, Iowa 52403, U.S.A.

CONCOMITANT MYELOBLASTIC AND LYMPHOCYTIC LEUKÆMIA

SIR,—Acute myeloid leukaemia (A.M.L.) is an unusual complication in patients with chronic lymphatic leukaemia (C.L.L.) treated with radiophosphorus or chlorambucil.Use of an allied drug, melphalan, has been implicated in the emergence of A.M.L. in the related B-cell neoplasm multiple myeloma.2 In view of such reports and general concern about the risk of malignancy after cytotoxic drugs and radiotherapy, a case of A.M.L. and C.L.L. in a patient who had never received such therapy may be of interest. A 62-year-old woman said to have had glandular fever in her teens had had for the previous 10 years recurrent herpes labialis treated with nystatin and cortisone creams. After 3 weeks of night sweats, fever, general malaise, a week’s history of severe occipital headache, transient diplopia, and an episode of delirium treated with ampicillin, cloxacillin, and co-trimoxazole, she was found on transfer to Aberdeen to have fever, generalised bruising, petechial haemorrhages, a right fundal haemorrhage, and haematuria. Small discrete cervical lymphadenopathy was noted but no hepatosplenomegaly was detected. Crepitations were heard throughout both lung fields and minimal left-sided upper-motor-neurone signs were demonstrable. Peripheral-blood examination revealed Hb 94 g/dl; white blood-cells 10.4x109/1; platelets l6.0x1012/1 with bloodsmear showing a virtual absence of granulocytes and monocytes and nearly 100% small lymphocytes and smear cells typical of C.L.L. Later the w.B.c. rose to 39x 109/1, and on wide scanning of the film occasional blast cells were seen; these were large with an open pattern to the nucleus which contained 1-4

1. Catovsky, D., Galton, D. A. G. Lancet, 1971, i, 478. 2. Rosner, F., Grunwald, H. Am. J. Med. 1974, 57, 927.

macronuclei. The cytoplasm was abundant and clear. Marrow aspirate revealed extensive replacement of normal elements by large blast cells showing evidence of primary granulation by Wright’s stain, heavy sudan-B positivity, and negative periodicacid/Schiff reactivity. In addition there was an infiltrate of small lymphocytes. Chest X-ray showed minor paratracheal lymph-gland enlargement. Other investigations included serum-protein of 51 g/1 with albumin 24 g/1 and no paraprotein demonstrable on serum electrophoresis. Immunoglobulin levels were estimated as IgG 8.6, IgM 1.5, and IgA 0-6 g/l. Profuse growth of Escherichia coli was detected on culturing the sputum, which cleared after treatment with cephalexin together with lysis of the fever and considerable clinical improvement. Unfortunately attempts to treat the underlying leukaemias with prednisolone, daunorubicin, cytarabine, and thioguanine were unsuccessful. Despite massive support with platelet and red-blood-cell concentrates the clinical course was complicated by recurrent haemorrhage and continuing anaemia. The patient died 6 weeks after diagnosis; necropsy was not allowed. A.M.L. and c.L.L. have infrequently been found to occur who have never received cytotoxic drugs together in patients 3 or radiotherapy. Increasing numbers of reports implicate cytotoxic drugs in the promotion of neoplasia, and their use may favour the emergence of A.M.L. in reticuloendothelial malignancy.’It would therefore seem relevant to determine the relative frequencies of malignant transformation in treated and untreated C.L.L., especially when it is remembered that cytotoxic therapy, although a useful adjunct in management of the patient with C.L.L., has had little impact upon survival.6 I thank Prof. D. A. G. Galton of the

Royal Postgraduate Medical my colleagues in the departments of medicine and pathology, University of Aberdeen, for their help and permission to prepare this report. School, London, for reviewing the marrow smears, and

Woodend Hospital, Aberdeen AB9 2YS.

Hospital,

Randwick, New South Australia.

Marrow

smear.

J. HAMILTON

RELEVANCE OF "SIGNIFICANT BACTERIURIA" TO ÆTIOLOGY AND DIAGNOSIS OF URINARY-TRACT INFECTION Younes7 SIR,-Dr questions the validity of results based on a single midstream-urine sample and suggests that an even lower rate of "significant bacteriuria" would be obtained in patients with lower-tract symptoms if repeat samples were examined. Nonetheless, as we stated,8 a count of 100 000 or more viable bacteria per ml in pure culture is generally accepted as indicative of infection in the presence of symptoms. Our results are comparable to similar studies in general practice, including those where suprapubic aspiration and catheter collection were used.9- 13 In practice it is not feasible to examine multiple confirmatory specimens, and this would, in any case, delay "diagnosis". Dr Younes would presumably agree that since uncomplicated urinary-tract infection and/or the urethral syndrome are of unknown setiology, reliance on culture of one or any number of midstream-urine samples for diagnosis and treatment is illogical. Prince of Wales

’Wright’s stain; reduced to5/8 of x 1250.)

P.

Wales,

J. W. TAPSALL P. C. TAYLOR S. M. BELL D. D. SMITH

3. Flandrin, G. et. al. Nouv. Revue fr. Hémat. 1970, 10, 771. 4. O’Neill, B. J. et al. Med. J. Aust. 1970, ii, 586. 5. Canellos, G. P. et al. Lancet, 1975, i, 947. 6. Hansen, M. M. Scand. J. Haemat. 1973, suppl. 18, 135. 7. Younes, R. Lancet, 1975, ii, 1217. 8. Tapsall, J. W., Taylor, P. C., Bell, S. M., Smith, D. D. ibid. p. 637. 9. Mond, N. C., Percival, A., Williams, J. D., Brumfitt, W. ibid. 1965, i, 514. 10. Brooks, D., Mauder, A. ibid. 1972, ii, 893. 11. Gallagher, D. J., Montgomerie, J. Z., North, J. D. K. Br. med. J. 1965, i, 622. 12. Dove, G. A., Bailey, A. J., Gower, P. E., Roberts, A. P., de Wardener, H. E. Lancet, 1972, ii, 1281. 13. Loudon, I. S. L., Greenhalgh, G. P. ibid. 1962, ii, 1246.

Letter: Relevance of "significant bacteriuria" to aetiology and diagnosis of urinary-tract infection.

373 fact that beer contains calories and little sodium allows beer drinkers to subsist with little solid food which would normally supply sodium. Perh...
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