316

rifabutin, ciprofloxadn, ethambutol, isoniazid, and pyrazinamide has failed and tubercle bacilli can still be cultured from his sputum. Frequent tests have confirmed compliance with treatment. A computerised tomographic scan of his thorax has shown pulmonary fibrosis, emphysema, and calcified lymph nodes but no evidence of occult malignancy. His alcohol intake has been low (at most 16 g [2 units] daily) and his liver function is normal. HIV testing and cell phenotyping were done with the patient’s informed consent. He was HIV seronegative and neither HIV-1nor HIV-2 have been cultured or identified from his lymphocytes. A positive tuberculin skin test confirmed antigen-specific CD4 T-cell reactivity. There was an absolute and relative reduction in CDS cells while other lymphocyte subpopulations were merely reduced (table). 2 months later his CD4 cell count proportionately had returned to normal but the significant reduction in CDS cells has persisted. A lymphopenia and a reduction in CD4 cells has been reported in association with tuberculosis.’ An increase in CDS cells with tuberculosis has also been reported, so it is unlikely that tubercle bacilli themselves could have caused the reduction in CDS cells 5 3 months’ treatment has been associated with a return to normal in the number of CD4 and CDS cells;6 there appears to be no toxic effect of rifampicin on CDS cells." Patients with alcoholic liver disease may show an increase in CD4 and CDS cells.8 This report suggests that antibiotics alone may not eradicate tubercle bacilli and that CDS T cells may have an important, and hitherto unrecognised, role in the successful treatment of human tuberculosis.

GRAHAM H. BOTHAMLEY FREDA FESTENSTEIN ADRIAN NEWLAND

London Chest Hospital, London E2 9JX, UK

1. Barnes PF, Bloch AB, Davidson PT, Snider DE. Tuberculosis in patients with human

immunodeficiency virus infection. N Engl J Med 1991; 324:

1644-50.

2. Kaufmann SHE. In vitro analysis of the cellular mechanisms involved in immunity to

tuberculosis. Rev Infect Dis 1989; 11 (suppl 2): S448-54. 3. Editorial. Homes for tuberculous homeless alcoholics. Br Med J 1978; ii: 1107-08. 4. Beck JS, Potts RC, Kardjito T, Grange JM. T4 lymphopenia in patients with active pulmonary tuberculosis. Clin Exp Immunol 1985; 60: 49-54. 5. Singhal M, Banavalikar JN, Charma S, Saha K. Peripheral blood T lymphocyte subpopulations in patients with tuberculosis and the effect of chemotherapy. Tubercle 1989; 70: 171-78. 6. Humber DP, Nsanzumuhire H, Aluoch JA, et al. Controlled double blind study on the effect of rifampicin on humoral and cellular immune response in patients with pulmonary tuberculosis and in tuberculosis control. Am Rev Respir Dis 1980; 122: 425-56. 7. Vidhidharam A, Matang-Kasombut P, Bovornkitti S. T cell subpopulations in tuberculosis and the effects of rifampicin. Asian Pacific J Allergy Immunol 1985; 3: 165-73. 8. Muller C, Wolf H, Gottlicher J, Eibl MM. Phenotypic analysis of lymphocytes involved in major histocompatibility complex unrestricted cellular cytotoxicity in patients with alcoholic cirrhosis. Int Arch Allergy Appl Immunol 1990; 91: 329-34.

Omeprazole and oesophageal stricture MR,—(Jmeprazoie

is

ettectlve in the treatment of retlux

but results of only one study have suggested that it may prevent the recurrence of peptic stricture.! We retrospectively reviewed outcome in 53 patients who attended the endoscopy unit with oesophageal stricture during 1 year. We compared the number of oesophageal dilatations needed during the subsequent year in patients treated with omeprazole or histamine receptor antagonists. The median number of oesophageal dilatations per patient before the study was started was 1 dilatation (range 1-16). Treatment was not randomised; patients received either cimetidine (800 mg), ranitidine (300 mg), omeprazole 20 mg or 40 mg), or histamine receptor antagonist (Hz) followed by

oesophagitis,

omeprazole. The number of oesophageal dilatations needed per year in the received an Hz antagonist did not differ from pretreatment values. In patients receiving only omeprazole the number of dilatations was significantly reduced compared with pretreatment. Patients in the remaining group (Hz antagonist followed by omeprazole) showed no significant reduction in the number of dilatations while on Hz antagonist, but in the subsequent treatment with omeprazole a significant reduction was seen with respect to pretreatment and Hz antagonist treatment values (table). The reduction in the number of dilatations per year after treatment was 14% in the Hz agonist group, 48% in omeprazole-treated

patients who

NUMBER OF OESOPHAGEAL DILATATIONS (MEDIAN IN RELATION TO THERAPY

[RANGE])

H2RA= H2 receptor antagonist OMEP=omeprazole. Mann Whitney U test, *p < 0 02, tp < 0.01, versus H2RA treatment.

patients, and 66% in those who received Hz antagonist followed by omeprazole. One other study has shown that after treatment with omeprazole only 13% of patients with reflux oesophagitis and peptic stricture required further dilatation.1 In the present study 5 patients treated with omeprazole needed further dilatation, but an increase in the dose of omeprazole resulted in improvement. There has been much debate about the safety of long-term omeprazole treatment.2 Reports of hyperplasia of enterochromaffin cells and gastric carcinoid tumours in the rat that are caused by hypergastrinaemia have led to concerns about long-term treatment.3 However, several workers have suggested that maintenance treatment in selected patients is now acceptable. Z,4 The prevention of recurrence of oesophageal stricture with long-term omeprazole therapy would save elderly patients from repeated oesophageal dilatation and from admission for the most severe

cases.

Gastroenterology Unit, Leicester General Hospital,

S. J. CARR

Leicester LE5 4PW, UK

A. C. WICKS

Ching CK, Shaheen MZ, Holmes GTK. Is omeprazole more effective in the treatment of resistant reflux oesophagitis and associated peptic stricture? Gastroenterology 1990; 98: A30. 2. Langman MJS. Omeprazole. Br MedJ 1991; 303: 481-82. 3. Editorial. Omeprazole and genotoxicity. Lancet 1990; 335: 386. 4. Omeprazole blocks gastric add secretion completely. Drug Ther Bull 1990; 28: 49-52 1.

New

glands for old

SIR,-Your Nov 30 editorial discussing Dr Serge Voronoffs transplantation of monkey testes into ageing men, invokes Arthur Conan Doyle who, through Sherlock Holmes in The Sign of the Four, wrote "Eliminate all other factors and that which remains must be the truth". You urge readers

to

"remember this advice before

rejecting what seems improbable". But Conan Doyle went beyond an open mind in The Adventure of the Creeping Man, written during the period when Voronoff was doing his transplantation, published in his book Rejuvenating by Grafting (1925). In this story, Professor Presbury, the 61-year-old "Camford" physiologist, in an effort to restore his virility so that he could marry the young daughter of a colleague in the chair of comparative anatomy, injects himself every nine days with a serum. This was obtained from an obscure scientist in Prague, and was prepared from the langur monkey ("the most human of climbing monkeys") rather than from an anthropoid (which "walks erect"). As a result of this mismatched therapy the professor was transformed periodically into a creeping monster who climbed the ivy-covered walls of his house in a vain effort to attack his own daughter. At this, Sherlock Holmes drew the line and stopped the importation of these "poisons" into Britain. Conan Doyle himself foresaw "a very real danger to humanity". The medical research councils you mention will insist on appropriate controls before they "fund further research on monkey glands". Mount Sinai School of Medicine, New York, NY 10129, USA

HENRY D.

JANOWITZ

CORRECTION Interaction of thyrotropin and thyroid-stimulating antibodies with recombinant extracellular region of human TSH receptor.-In this letta by Dr E. Harfst and colleagues (Jan 18, p 193), the figure on p 194 should have been labelled "A" (left) and "B" (right).

Omeprazole and oesophageal stricture.

316 rifabutin, ciprofloxadn, ethambutol, isoniazid, and pyrazinamide has failed and tubercle bacilli can still be cultured from his sputum. Frequent...
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