277 little is known about auditory function. We have investigated auditory function in complete and in partial trisomy 22. In the complete trisomy 22 (47,XY,+22),4 the left external auditory canal has a small cutaneous septum without atresia. In contrast, partial trisomy 22 (47,XY,+22q—[ql3]) shows no anomalies in the external auditory canal. The examination of auditory brainstem response resulted in -85dB for complete trisomy 22 but -70dB for partial trisomy 22 (see figure). The disturbance of the auditory function is more severe in complete trisomy 22 than in the partial trisomy. TAKASHI KATANO Pædiatric Department, HIDEKI YAMAOKA Hiroshima City Hospital, TAKASHI TAKIGUCHI Motomachi, Hiroshima, Japan Kadotani Medical Research Foundation,
Saijo, Higashihiroshima
TETSUJI KADOTANI
PITFALLS IN EARLY DETECTION OF ECTOPIC PREGNANCY
SIR,-The diagnosis of pregnancy by radioreceptor assay for human chorionic gonadotrophins (&bgr;-H.C.G.) was introduced in 1974.1 This sensitive, specific, and rapid assay permits detection of conception as early as 7 days post-ovulation. We have used the &bgr;-H.C.G. test routinely for the past 2 years to establish early normal and abnormal pregnancies. The test was positive in sixty-two women with suspected ectopic pregnancy, subsequently proved by laparoscopy and laparotomy. Three patients underwent a second laparoscopy before laparotomy, and only on the second intervention was a tubal mass seen. The following case illustrates the limitation of laparoscopy in detecting very early pregnancy. A 26-year-old woman was admitted because of pain in the right lower abdominal quadrant, missed period of 5 days, and a p-H.c.G. of 75 mi.u./ml. The uterus was normal and no adnexal mass was palpable. Examination under anaesthesia did not reveal any pathological findings; on curettage the endometrial tissue was not commensurate with pregnancy. At laparoscopy the uterus, tubes, and ovaries were congested but normal; there was no blood in the abdominal cavity. Early complete abortion was diagnosed, and the patient was sent home. 5 days later she was readmitted because of continuous vaginal bleeding and right lower abdominal pains. A 4x4 cm mass was palpated on the right side of the uterus. The pregnancy test demonstrated 200 mi.u. &bgr;-H.C.G./ml blood. At the second laparoscopy, 7 days after the first, a mass was clearly seen in the ampullary part of the right tube. The patient was immediately operated upon, and the clinical diagnosis of right tubal pregnancy was confirmed. The p-H.C.G. test could well detect very early pregnancy, even before macroscopic pathological changes in the tube can be distinguished. This supposition accords with the embryo studies of Patten2who found that at 18 days the conceptus is less than 10 mm long. It is imperative to determine tubal pregnancy as soon as possible to prevent rupture of the tubes, especially now that procedures such as microsurgery permit reconstruction and preservation of the tubes for future fertility. Very early ectopic pregnancy may not be detectable by laparoscopy. However, when the &bgr;-H.C.G. test is positive-and an intrauterine pregnancy has been ruled out-extrauterine pregnancy should be seriously considered. In such cases, laparoscopy is advocated. When nothing abnormal is seen, the -H.c.G. test should be repeated every week to either confirm or exclude ectopic pregnancy. H. YAFFE Department of Obstetrics and Gynæcology, D. NAVOT Hadassah University Hospital, Em Kerem, Jerusalem, Israel N. LAUFER 4.
Kadotam, T., Katano, T., Yamaoka, H., Murakami, M., Nakamoto, Y.,
Watanabe, V. Proc. Japan Acad. 1978, 54, B, 163. 5
Kadotani, T., Katano, T., Yamamoto, H., Murakami, M., Nakamoto, Y., Watanabe, Y. ibid, p. 217. 1. Rosal, T. P., Saxema, B. B., Landesman, R. Fertil. Steril. 1975, 26, 1105. 2. Patten, B. M. Human Embryology, p.145. New York, 1968.
SPRUE AND SUBCLINICAL MALABSORPTION IN THE TROPICS
SIR,-In their description of a high prevalence of morphoabnormalities of the small bowel among symptom-free persons in Southern Peru, Perea and colleagues wondered whether these changes might represent a subclinical form of tropical sprue. Their suggestion is based on my 1967 hypothesis2 that overt tropical sprue and subclinical malabsorption among residents of tropical areas where sprue is endemic represent different manifestations, in terms of clinical presentation and pathological severity, of the same disease process of which overt tropical sprue represents the clinically recognisable "tip of the iceberg". Perhaps there should be a statute of limitations for any such hypothesis; after a decade it should be reconsidered in light of the information available when it was first put forward, re-examined in terms of subsequently acquired facts, and then be reaffirmed, modified, or discarded. In 1967 information on subclinical malabsorption was confined to that from two tropical countries, South India and Haiti, both of which are endemic for sprue.34 In these areas adults showed a spectrum in the severity of symptoms, intestinal abnormalities, and nutritional deficiencies, varying from mild to moderate among relatively symptom-free persons to severe in overt sprue. It seemed reasonable at that time to conjecture that these abnormalities represent varied manifestations of the same disease process. This concept was supported by a failure to identify, by light or electron microscopy, any basic difference between the intestinal structural abnormalities in sprue and subclinical malabsorption,S and by the observation that treatment with folic acid and/or tetracycline improved the intestinal lesion in persons recognised to have sprue and in some with subclinical malabsorption.6 It now seems, however, that sprue and subclinical malabsorption represent different clinical entities in many instances. Subclinical intestinal abnormalities have now been described among residents of areas such as those described by Perea et al. where sprue does not occur and, in this circumstance, they clearly are unrelated to sprue. Such is undoubtedly also the case in many instances in areas where sprue is endemic, particularly in children among whom sprue is rare. The distinction remains less clear in some adults, however, due in large part to our inability to define precisely what constitutes tropical sprue. In 1971, Baker and I advocated that the rigid criteria for the diagnosis of sprue, such as megaloblastic anaemia, should be modified and that this disorder should be considered as a syndrome which is characterised by structural abnormalities and malabsorption of two distinct substances.7 This definition, which would encompass from 11 % of the population in Puerto Rico to 43% in Haiti,s requires further modification. Firstly, it fails to take into consideration the fact that in sprue symptoms (if present) and intestinal abnormalities get relentlessly worse until specific therapy is instituted, whereas the picture in subclinical malabsorption seems to vary only slightly over time, either improving or worsening.8 9 Secondly, although subclinical malabsorption may contribute to nutritional deficiencies where dietary intake is marginal or inadequate8 it is rarely severe enough to produce the multiple, severe nutritional deficiences characteristic of advanced sprue. Thirdly, the key role of folate or vitamin-B12 deficiency, which
logical
D., Fernan-Zegarra, L., Cruz, V. M., Ballon, R., Picoaga, J. L. Lancet, 1978, ii, 550. 2. Klipstein, F. A. Ann. intern. Med. 1967, 66, 622. 3. Baker, S. J. Indian J. med. Sci. 1957, 11, 687. 4. Klipstein, F. A., Samloff, I. M., Schenk, E. A. Ann. intern. Med. 1966, 64, 1. Perea, V.
575. 5. Brunser, O., Eidelman, S., Klipstein, F. A. Gastroenterology, 1970, 58, 655. 6. Klipstein, F. A., Samloff, I. M., Smarth, G., Schenk, E. A. Gut, 1969, 10, 315. 7. Klipstein, F. A., Baker, S. J. Gastroenterology, 1970, 58, 717. 8. Klipstein, F. A. in Gastroenterology, vol. ii (edited by H. L. Bockus); p. 285.
Philadelphia, 1976. 9. Lindenbaum, J., Jamiul Alam, A. K. M., Kent, T. H. Br. med. J. 1966, ii, 1616.
Saijo, Higashihiroshima
TETSUJI KADOTANI
PITFALLS IN EARLY DETECTION OF ECTOPIC PREGNANCY
SIR,-The diagnosis of pregnancy by radioreceptor assay for human chorionic gonadotrophins (&bgr;-H.C.G.) was introduced in 1974.1 This sensitive, specific, and rapid assay permits detection of conception as early as 7 days post-ovulation. We have used the &bgr;-H.C.G. test routinely for the past 2 years to establish early normal and abnormal pregnancies. The test was positive in sixty-two women with suspected ectopic pregnancy, subsequently proved by laparoscopy and laparotomy. Three patients underwent a second laparoscopy before laparotomy, and only on the second intervention was a tubal mass seen. The following case illustrates the limitation of laparoscopy in detecting very early pregnancy. A 26-year-old woman was admitted because of pain in the right lower abdominal quadrant, missed period of 5 days, and a p-H.c.G. of 75 mi.u./ml. The uterus was normal and no adnexal mass was palpable. Examination under anaesthesia did not reveal any pathological findings; on curettage the endometrial tissue was not commensurate with pregnancy. At laparoscopy the uterus, tubes, and ovaries were congested but normal; there was no blood in the abdominal cavity. Early complete abortion was diagnosed, and the patient was sent home. 5 days later she was readmitted because of continuous vaginal bleeding and right lower abdominal pains. A 4x4 cm mass was palpated on the right side of the uterus. The pregnancy test demonstrated 200 mi.u. &bgr;-H.C.G./ml blood. At the second laparoscopy, 7 days after the first, a mass was clearly seen in the ampullary part of the right tube. The patient was immediately operated upon, and the clinical diagnosis of right tubal pregnancy was confirmed. The p-H.C.G. test could well detect very early pregnancy, even before macroscopic pathological changes in the tube can be distinguished. This supposition accords with the embryo studies of Patten2who found that at 18 days the conceptus is less than 10 mm long. It is imperative to determine tubal pregnancy as soon as possible to prevent rupture of the tubes, especially now that procedures such as microsurgery permit reconstruction and preservation of the tubes for future fertility. Very early ectopic pregnancy may not be detectable by laparoscopy. However, when the &bgr;-H.C.G. test is positive-and an intrauterine pregnancy has been ruled out-extrauterine pregnancy should be seriously considered. In such cases, laparoscopy is advocated. When nothing abnormal is seen, the -H.c.G. test should be repeated every week to either confirm or exclude ectopic pregnancy. H. YAFFE Department of Obstetrics and Gynæcology, D. NAVOT Hadassah University Hospital, Em Kerem, Jerusalem, Israel N. LAUFER 4.
Kadotam, T., Katano, T., Yamaoka, H., Murakami, M., Nakamoto, Y.,
Watanabe, V. Proc. Japan Acad. 1978, 54, B, 163. 5
Kadotani, T., Katano, T., Yamamoto, H., Murakami, M., Nakamoto, Y., Watanabe, Y. ibid, p. 217. 1. Rosal, T. P., Saxema, B. B., Landesman, R. Fertil. Steril. 1975, 26, 1105. 2. Patten, B. M. Human Embryology, p.145. New York, 1968.
SPRUE AND SUBCLINICAL MALABSORPTION IN THE TROPICS
SIR,-In their description of a high prevalence of morphoabnormalities of the small bowel among symptom-free persons in Southern Peru, Perea and colleagues wondered whether these changes might represent a subclinical form of tropical sprue. Their suggestion is based on my 1967 hypothesis2 that overt tropical sprue and subclinical malabsorption among residents of tropical areas where sprue is endemic represent different manifestations, in terms of clinical presentation and pathological severity, of the same disease process of which overt tropical sprue represents the clinically recognisable "tip of the iceberg". Perhaps there should be a statute of limitations for any such hypothesis; after a decade it should be reconsidered in light of the information available when it was first put forward, re-examined in terms of subsequently acquired facts, and then be reaffirmed, modified, or discarded. In 1967 information on subclinical malabsorption was confined to that from two tropical countries, South India and Haiti, both of which are endemic for sprue.34 In these areas adults showed a spectrum in the severity of symptoms, intestinal abnormalities, and nutritional deficiencies, varying from mild to moderate among relatively symptom-free persons to severe in overt sprue. It seemed reasonable at that time to conjecture that these abnormalities represent varied manifestations of the same disease process. This concept was supported by a failure to identify, by light or electron microscopy, any basic difference between the intestinal structural abnormalities in sprue and subclinical malabsorption,S and by the observation that treatment with folic acid and/or tetracycline improved the intestinal lesion in persons recognised to have sprue and in some with subclinical malabsorption.6 It now seems, however, that sprue and subclinical malabsorption represent different clinical entities in many instances. Subclinical intestinal abnormalities have now been described among residents of areas such as those described by Perea et al. where sprue does not occur and, in this circumstance, they clearly are unrelated to sprue. Such is undoubtedly also the case in many instances in areas where sprue is endemic, particularly in children among whom sprue is rare. The distinction remains less clear in some adults, however, due in large part to our inability to define precisely what constitutes tropical sprue. In 1971, Baker and I advocated that the rigid criteria for the diagnosis of sprue, such as megaloblastic anaemia, should be modified and that this disorder should be considered as a syndrome which is characterised by structural abnormalities and malabsorption of two distinct substances.7 This definition, which would encompass from 11 % of the population in Puerto Rico to 43% in Haiti,s requires further modification. Firstly, it fails to take into consideration the fact that in sprue symptoms (if present) and intestinal abnormalities get relentlessly worse until specific therapy is instituted, whereas the picture in subclinical malabsorption seems to vary only slightly over time, either improving or worsening.8 9 Secondly, although subclinical malabsorption may contribute to nutritional deficiencies where dietary intake is marginal or inadequate8 it is rarely severe enough to produce the multiple, severe nutritional deficiences characteristic of advanced sprue. Thirdly, the key role of folate or vitamin-B12 deficiency, which
logical
D., Fernan-Zegarra, L., Cruz, V. M., Ballon, R., Picoaga, J. L. Lancet, 1978, ii, 550. 2. Klipstein, F. A. Ann. intern. Med. 1967, 66, 622. 3. Baker, S. J. Indian J. med. Sci. 1957, 11, 687. 4. Klipstein, F. A., Samloff, I. M., Schenk, E. A. Ann. intern. Med. 1966, 64, 1. Perea, V.
575. 5. Brunser, O., Eidelman, S., Klipstein, F. A. Gastroenterology, 1970, 58, 655. 6. Klipstein, F. A., Samloff, I. M., Smarth, G., Schenk, E. A. Gut, 1969, 10, 315. 7. Klipstein, F. A., Baker, S. J. Gastroenterology, 1970, 58, 717. 8. Klipstein, F. A. in Gastroenterology, vol. ii (edited by H. L. Bockus); p. 285.
Philadelphia, 1976. 9. Lindenbaum, J., Jamiul Alam, A. K. M., Kent, T. H. Br. med. J. 1966, ii, 1616.
