854
Letters to the Editor
that some of the individuals who have been reported as cases of MLNS have had leptospirosis." Dr. Humphry and his colleagues are to be congratulated for their astute diagnosis. Michael L. Wong, M.D. Sheldon Kaplan, M.D. Lisa M. Dunkle, M.D. Barbara W. Stechenberg, M.D. Ralph D. Feigin, M.D. St. Louis Children's Hospital 500 S. Kingshighway St. Louis, MO 63110
The Journal of Pediatrics November 1977
2.
3.
4.
5.
Prevention of rheumatic recurrence in the allergic, rheumatic fever patient To the Editor: Drs. Ginsburg and Eichenwald 1 appear to recommend erythromycin for streptococcal prophylaxis in penicillin-allergic rheumatic fever patients to prevent recurrences. They cite two small efficacy studies which lack comparative treatment groups. ~, ~ I think that they should have advocated sulfonamides, rather than erythromycin, as the preferred alternative to penicillin. Sulfadiazine has been rigorously tested in rheumatic fever patients and found to be as effective as oral penicillin in preventing streptococcal infections and rheumatic recurrences? Both oral regimens, however, are less effective than intramuscular benzathine penicillin because of poorer compliance. The American Heart Association recommendations on prevention of recurrent attacks of rheumatic fever reserve erythromycin for "the exceptional patient who may be sensitive to both penicillin and sulfonamides" and as a substitute for sulfonamides in penicillin-allergic women during late pregnancy? .~ Sulfonamides pass the placental barrier readily, compete with bilirubin for albumin-binding sites in the neonate, and may potentiate kernicterus. Although sulfonamides are effective for prophylaxis, they should not be used for treatment of streptococcal pharyngitis; they do not eradicate established streptococcal infection, and do not prevent rheumatic fever/ As noted by Drs. Ginsburg and Eichenwald, 1 erythromycin is appropriate treatment for penicillin-allergic patients with pharyngitis, since it eradicates streptococci and, by extrapolation, should prevent rheumatic fever. Stephen J. Lerman, M.D. Pediatric Infectious Disease Unit University of Nebraska Medical Center Omaha, NE 68105
REFERENCES
1. Ginsburg CM, and Eichenwald HF: Erythromycin: A review of its uses in pediatric practice, J PEDIATR 89:872, 1976.
6. 7.
Healey CE, and Simon AJ: The prophylactic use of erythromycin in convalescent rheumatic fever patients, in Antibiotics annual 1954-1955, New York, 1955, Medical Encyclopedia, Inc., p 242. Tidwell RA, and Lewis D: The use of erythromycin as a prophylactic agent, in Antibiotics annual 1956-1957, New York, 1957, Medical Encyclopedia Inc., p 168. Wood HF, Feinstein AR, Taranta A, et al: Rheumatic fever in children and adolescents. A long-term epidemiologic study of subsequent prophylaxis, streptococcal infections, and clinical sequelae. III. Comparative effectiveness of three prophylaxis regimens in preventing streptococcal infections and rheumatic recurrences. Ann Intern Med 60(Suppl 5):31, 1964. Committee on Rheumatic Fever and Bacterial Endocarditis of the American Heart Association: Prevention of rheumatic fever, Circulation 55:1, 1977. Ayoub EM: Use of sulfonamides for rheumatic fever prophylaxis during pregnancy, Circulation 46:49, 1972. Morris AJ, Chamovitz R, Catanzaro F J, and Rammelkamp CH: Prevention of rheumatic fever by treatment of previous streptococcic infections. Effect of sulfadiazine, JAMA 160:114, 1956.
Reply To the Editor: We thank Dr. Lerman for his comments. We are aware of the various recommendations for prevention of recurrent attacks o f rheumatic fever and agree that sulfonamides are suitable alternatives for the penicillin-allergic patient. It was not our intent to compare the efficacy of t h e various prophylactic regimens for rheumatic fever and as such we were not making specific recommendations in this regard. Charles M. Ginsburg, M.D. Heinz F. Eichenwald, M.D. Department of Pediatrics University of Texas Southwestern Medical School Dallas, Texas 75235
Oxandrolone therapy for children with Turner syndrome To the Editor: Moore and associates ~ have shown that the anabolic steroid, oxandrolone, significantly increases growth velocity in patients with Turner syndrome during the first year of therapy. This increase in growth velocity was not demonstrated in the subsequent years of treatment, andl indeed, there was deceleration in many cases. This group of workers went on to conclude that longterm oxandrolone treatment improved ultimate height. Their evidence for this deduction was more tenuous: it was based on
Letters to the Editor
that some of the individuals who have been reported as cases of MLNS have had leptospirosis." Dr. Humphry and his colleagues are to be congratulated for their astute diagnosis. Michael L. Wong, M.D. Sheldon Kaplan, M.D. Lisa M. Dunkle, M.D. Barbara W. Stechenberg, M.D. Ralph D. Feigin, M.D. St. Louis Children's Hospital 500 S. Kingshighway St. Louis, MO 63110
The Journal of Pediatrics November 1977
2.
3.
4.
5.
Prevention of rheumatic recurrence in the allergic, rheumatic fever patient To the Editor: Drs. Ginsburg and Eichenwald 1 appear to recommend erythromycin for streptococcal prophylaxis in penicillin-allergic rheumatic fever patients to prevent recurrences. They cite two small efficacy studies which lack comparative treatment groups. ~, ~ I think that they should have advocated sulfonamides, rather than erythromycin, as the preferred alternative to penicillin. Sulfadiazine has been rigorously tested in rheumatic fever patients and found to be as effective as oral penicillin in preventing streptococcal infections and rheumatic recurrences? Both oral regimens, however, are less effective than intramuscular benzathine penicillin because of poorer compliance. The American Heart Association recommendations on prevention of recurrent attacks of rheumatic fever reserve erythromycin for "the exceptional patient who may be sensitive to both penicillin and sulfonamides" and as a substitute for sulfonamides in penicillin-allergic women during late pregnancy? .~ Sulfonamides pass the placental barrier readily, compete with bilirubin for albumin-binding sites in the neonate, and may potentiate kernicterus. Although sulfonamides are effective for prophylaxis, they should not be used for treatment of streptococcal pharyngitis; they do not eradicate established streptococcal infection, and do not prevent rheumatic fever/ As noted by Drs. Ginsburg and Eichenwald, 1 erythromycin is appropriate treatment for penicillin-allergic patients with pharyngitis, since it eradicates streptococci and, by extrapolation, should prevent rheumatic fever. Stephen J. Lerman, M.D. Pediatric Infectious Disease Unit University of Nebraska Medical Center Omaha, NE 68105
REFERENCES
1. Ginsburg CM, and Eichenwald HF: Erythromycin: A review of its uses in pediatric practice, J PEDIATR 89:872, 1976.
6. 7.
Healey CE, and Simon AJ: The prophylactic use of erythromycin in convalescent rheumatic fever patients, in Antibiotics annual 1954-1955, New York, 1955, Medical Encyclopedia, Inc., p 242. Tidwell RA, and Lewis D: The use of erythromycin as a prophylactic agent, in Antibiotics annual 1956-1957, New York, 1957, Medical Encyclopedia Inc., p 168. Wood HF, Feinstein AR, Taranta A, et al: Rheumatic fever in children and adolescents. A long-term epidemiologic study of subsequent prophylaxis, streptococcal infections, and clinical sequelae. III. Comparative effectiveness of three prophylaxis regimens in preventing streptococcal infections and rheumatic recurrences. Ann Intern Med 60(Suppl 5):31, 1964. Committee on Rheumatic Fever and Bacterial Endocarditis of the American Heart Association: Prevention of rheumatic fever, Circulation 55:1, 1977. Ayoub EM: Use of sulfonamides for rheumatic fever prophylaxis during pregnancy, Circulation 46:49, 1972. Morris AJ, Chamovitz R, Catanzaro F J, and Rammelkamp CH: Prevention of rheumatic fever by treatment of previous streptococcic infections. Effect of sulfadiazine, JAMA 160:114, 1956.
Reply To the Editor: We thank Dr. Lerman for his comments. We are aware of the various recommendations for prevention of recurrent attacks o f rheumatic fever and agree that sulfonamides are suitable alternatives for the penicillin-allergic patient. It was not our intent to compare the efficacy of t h e various prophylactic regimens for rheumatic fever and as such we were not making specific recommendations in this regard. Charles M. Ginsburg, M.D. Heinz F. Eichenwald, M.D. Department of Pediatrics University of Texas Southwestern Medical School Dallas, Texas 75235
Oxandrolone therapy for children with Turner syndrome To the Editor: Moore and associates ~ have shown that the anabolic steroid, oxandrolone, significantly increases growth velocity in patients with Turner syndrome during the first year of therapy. This increase in growth velocity was not demonstrated in the subsequent years of treatment, andl indeed, there was deceleration in many cases. This group of workers went on to conclude that longterm oxandrolone treatment improved ultimate height. Their evidence for this deduction was more tenuous: it was based on
