1048
and in 13% and 4% of the male and female blood
donors,
Our results indicate that the male orienteers were not more to C pneumoniae than healthy blood donors, but the difference usually seen in antibody prevalence between the sexes3 was almost eliminated at ages over 40 among orienteers. We have no explantion for the observed difference in prevalence of IgA antibodies between female orienteers and blood donors.
exposed
Departments of Clinical Microbiology and Infectious Diseases, Gavle Central Hospital, S-801 87 Gavle, Sweden; and Departments of Infectious Diseases and Clinical Immunology,
Huddinge University Hospital, Stockholm
Therefore, measurements of cardiac TnT in the medical management and monitoring of endurance athletes, especially during periods of extraordinary unremitting exercise or when athletes present with obscure symptoms. JOHANNES MAIR THOMAS WOHLFARTER ARNOLD KOLLER Departments of Medical Chemistry and Biochemistry, Internal Medicine, MARKUS MAYR and Sportsmedicine, ERIKA ARTNER-DWORZAK of Innsbruck, University BERND PUSCHENDORF A-6020 Innsbruck, Austria
one
marathon
may be
respectively.
HÅKAN GNARPE JUDY GNARPE BO SUNDELÖF ROLF GUSTAFSON ANN GARDULF
-
1. Editorial. Troponin T and myocardial damage. Lancet 1991; 338: 23-24 2. Apple FS, Rogers MA, Sherman WM, Costill DL, Hagermann C, Ivy JL. Profile of creatine
3. 1. Wesslén L, Påhlson C, Friman G, Fohlman J, Lindquist O, Johansson C. Myocarditis
caused by Chlamydia pneumoniae (TWAR) and sudden unexpected death in a Swedish elite orienteer. Lancet 1992; 340: 427. 2. Saikku P, Leinonen M, Tenkanen L, et al. Chronic Chlamydia pneumomae infection as a risk factor for coronary heart disease in the Helsinki Heart Study. Ann Intern Med 1992; 116: 273-78. 3. Grayston JT, Wang SP, Kuo CC, Campbell LA Current knowledge of chlamydia TWAR, an important cause of pneumonias and other acute respiratory diseaes. Eur J Clin Microbiol Infect Dis 1989; 8: 191-202
Serum cardiac troponin T after extraordinary endurance exercise SiR,—Dr Rowe’s hypothesis (Sept 19, p 712) on the pathophysiological mechanisms of myocardial injury in unremitting endurance exercise prompts us to report cardiac troponin T (TnT) concentrations in athletes before and after extraordinary endurance exercise. Rowe suggests that coronary vasospasm secondary to high catecholamine concentrations and other mechanisms causes focal necrosis, which leads to focal fibrosis of the myocardium. Cardiac TnT measurements are very sensitive and specific for the detection of myocardial darnage1 and may be the only non-invasive method to demonstrate minimal myocardial injury after endurance exercise. Creatine kinase isoenzyme MB is less suitable for this purpose because of its well established, substantial release from skeletal muscles of endurance-trained athletes after exercise.2 We investigated 20 male runners (aged 25-55 years, mean 42) who took part in the 1990 Berlinmarathon and 8 male participants (aged 25-48, mean 35) of the 1991 Otztal Radmarathon, which is a 230 km bicycle race in the Tyrol, including four mountain passes (total difference of altitude about 5000 m). Although all 28 athletes were amateur sportsmen, they can be regarded as elite endurancetrained athletes because they were able to finish their races in times equivalent to that standard. Blood samples were obtained 2 days before marathon, after finishing, and 2 days later in runners, and the day before the race, after finishing, and 1, 2, 3, 5, and 8 days thereafter in bicyclists. We measured cardiac TnT with an enzyme-immunometric one-step sandwich assay (Boehringer
Mannheim).3 All 28 athletes completed their races without evidence of myocardial ischaemia or extraordinary exhaustion during and after the competition. In all 28, cardiac TnT baseline concentrations were normal (mean [SD], runners 0 18 [0.14] µg/1; bicyclists 0.16 [0.06] jJ.g/1). These findings demonstrate that endurance training alone does not lead to an enhanced breakdown of myocardial muscle fibres. In runners and bicyclists, cardiac TnT did not increase significantly over baseline after competition. In all but one sample cardiac TnT concentrations were normal. The one abnormal result was in a 51-year-old apparently healthy marathon runner who had a TnT concentration of 10 µg/litre 2 days after competition. The mechanisms outlined by Rowe might cause focal myocardial necrosis during extraordinary endurance exercise even in the absence of coronary atherosclerosis and ventricular hypertrophy. However, in this 51-year-old man we cannot with certainty exclude silent myocardial ischaemia on the basis of coronary atherosclerosis. A single extraordinary endurance exercise does not usually lead to an increase in cardiac TnT serum concentrations. However, there is a potential cardiac risk, as indicated by the slight increase of TnT in
runner.
helpful
kinase
isoenzymes
m
skeletal muscles of marathon
runners.
Clin Chem
1984; 30: 413-16. Katus HA, Looser S, Hallermayer K, et al. Development and m vitro characterization of a new immunoassay of cardiac troponin T. Clin Chem 1992; 38: 386-93.
Lover’s
arm
SIR,-Deep-vein thrombosis of the arm is infrequent (reported are 1-2% of all deep-vein thrombosis1,2). Patients are usually classified into two distinct groups-those with spontaneouus and those with secondary thrombosis. We have seen a patient with an unusual secondary thrombosis. A 23-year-old woman woke up at 0400 h with a painful right arm. 5 h later she had a swollen, cyanotic, and painful arm and paraesthesia in her fingers. Ultrasonography confirmed our clinical suspicion of thrombosis of the right subclavian and brachial vein. She was given heparin and coumarin for eight months and took Mercilon rather than Marvelon as contraceptive agent (containing 20 pg and 30 jlg of ethinyloestradiol, respectively). We did not find other risk factors or laboratory abnormalities (protein C and S, antithrombin III, fibrinogen, activated partial thromboplastin time, prothrombin time, thrombin time, and clotting factor II) and the family history was negative. She was thrombosis free for 30 months, after which she presented with signs of thrombosis which had again occurred in the morning. This time the left arm was affected. The diagnosis was established by venography. All laboratory tests were normal and she had no risk factors. After a estimates
second conversation with a female member of staff we discovered that our patient’s habit was to lie with her arm under her partner’s head, which rested on her shoulder before falling asleep. After the first thrombotic episode she thought that compression on her right arm might be harmful and from that time on her partner slept on her left arm with his head in the same position as before. Although this sleeping habit cannot with certainty be attributed to be the cause of thrombosis, we believe that a triggering influence is highly probable. This seems analogous to the so called "paralysie des amoureux",3 in which the radial nerve is damaged by outside pressure on the upper arm instead of the vein. We feel that physicians should be aware of this possibility in young adults with axillary vein thrombosis. Departments of Clinical Epidemiology and Haematology, University Hospital Leiden, PO Box 9600, 2300 RC Leiden, Netherlands
T. KOSTER H. H. VAN BOVEN S. S. G. E. VAN BOOM E. BRIËT
1. Prescott SM, Tikoff G. Deep venous thrombosis of the upper extremity a reappraisal. Circulation 1979; 59: 350-55. 2. Horattas MC, Wright DJ, Fenton AH, et al. Changing concepts of deep venous thrombosis of the upper extremity: report of a series and review of the literature.
Surgery 1988; 104: 561-67. 3 Downie A. Peripheral nerve compression syndromes. In: Matthews WB, Glaser GH, eds. Recent advances m clinical neurology, no 3. Edinburgh: Churchill Livingstone, 1982. 47-66
CORRECTION Mortality and morbidity after high-titre measles vaccine in Mexico. -In this letter by Dr J. L. Diaz-Ortega and colleagues (Oct 10, p 924), reference 3 was wrongly included throughout and should be deleted. Reference 4 then becomes reference 3. In addition the plaque-forming units in the table were expressed as log10.
and in 13% and 4% of the male and female blood
donors,
Our results indicate that the male orienteers were not more to C pneumoniae than healthy blood donors, but the difference usually seen in antibody prevalence between the sexes3 was almost eliminated at ages over 40 among orienteers. We have no explantion for the observed difference in prevalence of IgA antibodies between female orienteers and blood donors.
exposed
Departments of Clinical Microbiology and Infectious Diseases, Gavle Central Hospital, S-801 87 Gavle, Sweden; and Departments of Infectious Diseases and Clinical Immunology,
Huddinge University Hospital, Stockholm
Therefore, measurements of cardiac TnT in the medical management and monitoring of endurance athletes, especially during periods of extraordinary unremitting exercise or when athletes present with obscure symptoms. JOHANNES MAIR THOMAS WOHLFARTER ARNOLD KOLLER Departments of Medical Chemistry and Biochemistry, Internal Medicine, MARKUS MAYR and Sportsmedicine, ERIKA ARTNER-DWORZAK of Innsbruck, University BERND PUSCHENDORF A-6020 Innsbruck, Austria
one
marathon
may be
respectively.
HÅKAN GNARPE JUDY GNARPE BO SUNDELÖF ROLF GUSTAFSON ANN GARDULF
-
1. Editorial. Troponin T and myocardial damage. Lancet 1991; 338: 23-24 2. Apple FS, Rogers MA, Sherman WM, Costill DL, Hagermann C, Ivy JL. Profile of creatine
3. 1. Wesslén L, Påhlson C, Friman G, Fohlman J, Lindquist O, Johansson C. Myocarditis
caused by Chlamydia pneumoniae (TWAR) and sudden unexpected death in a Swedish elite orienteer. Lancet 1992; 340: 427. 2. Saikku P, Leinonen M, Tenkanen L, et al. Chronic Chlamydia pneumomae infection as a risk factor for coronary heart disease in the Helsinki Heart Study. Ann Intern Med 1992; 116: 273-78. 3. Grayston JT, Wang SP, Kuo CC, Campbell LA Current knowledge of chlamydia TWAR, an important cause of pneumonias and other acute respiratory diseaes. Eur J Clin Microbiol Infect Dis 1989; 8: 191-202
Serum cardiac troponin T after extraordinary endurance exercise SiR,—Dr Rowe’s hypothesis (Sept 19, p 712) on the pathophysiological mechanisms of myocardial injury in unremitting endurance exercise prompts us to report cardiac troponin T (TnT) concentrations in athletes before and after extraordinary endurance exercise. Rowe suggests that coronary vasospasm secondary to high catecholamine concentrations and other mechanisms causes focal necrosis, which leads to focal fibrosis of the myocardium. Cardiac TnT measurements are very sensitive and specific for the detection of myocardial darnage1 and may be the only non-invasive method to demonstrate minimal myocardial injury after endurance exercise. Creatine kinase isoenzyme MB is less suitable for this purpose because of its well established, substantial release from skeletal muscles of endurance-trained athletes after exercise.2 We investigated 20 male runners (aged 25-55 years, mean 42) who took part in the 1990 Berlinmarathon and 8 male participants (aged 25-48, mean 35) of the 1991 Otztal Radmarathon, which is a 230 km bicycle race in the Tyrol, including four mountain passes (total difference of altitude about 5000 m). Although all 28 athletes were amateur sportsmen, they can be regarded as elite endurancetrained athletes because they were able to finish their races in times equivalent to that standard. Blood samples were obtained 2 days before marathon, after finishing, and 2 days later in runners, and the day before the race, after finishing, and 1, 2, 3, 5, and 8 days thereafter in bicyclists. We measured cardiac TnT with an enzyme-immunometric one-step sandwich assay (Boehringer
Mannheim).3 All 28 athletes completed their races without evidence of myocardial ischaemia or extraordinary exhaustion during and after the competition. In all 28, cardiac TnT baseline concentrations were normal (mean [SD], runners 0 18 [0.14] µg/1; bicyclists 0.16 [0.06] jJ.g/1). These findings demonstrate that endurance training alone does not lead to an enhanced breakdown of myocardial muscle fibres. In runners and bicyclists, cardiac TnT did not increase significantly over baseline after competition. In all but one sample cardiac TnT concentrations were normal. The one abnormal result was in a 51-year-old apparently healthy marathon runner who had a TnT concentration of 10 µg/litre 2 days after competition. The mechanisms outlined by Rowe might cause focal myocardial necrosis during extraordinary endurance exercise even in the absence of coronary atherosclerosis and ventricular hypertrophy. However, in this 51-year-old man we cannot with certainty exclude silent myocardial ischaemia on the basis of coronary atherosclerosis. A single extraordinary endurance exercise does not usually lead to an increase in cardiac TnT serum concentrations. However, there is a potential cardiac risk, as indicated by the slight increase of TnT in
runner.
helpful
kinase
isoenzymes
m
skeletal muscles of marathon
runners.
Clin Chem
1984; 30: 413-16. Katus HA, Looser S, Hallermayer K, et al. Development and m vitro characterization of a new immunoassay of cardiac troponin T. Clin Chem 1992; 38: 386-93.
Lover’s
arm
SIR,-Deep-vein thrombosis of the arm is infrequent (reported are 1-2% of all deep-vein thrombosis1,2). Patients are usually classified into two distinct groups-those with spontaneouus and those with secondary thrombosis. We have seen a patient with an unusual secondary thrombosis. A 23-year-old woman woke up at 0400 h with a painful right arm. 5 h later she had a swollen, cyanotic, and painful arm and paraesthesia in her fingers. Ultrasonography confirmed our clinical suspicion of thrombosis of the right subclavian and brachial vein. She was given heparin and coumarin for eight months and took Mercilon rather than Marvelon as contraceptive agent (containing 20 pg and 30 jlg of ethinyloestradiol, respectively). We did not find other risk factors or laboratory abnormalities (protein C and S, antithrombin III, fibrinogen, activated partial thromboplastin time, prothrombin time, thrombin time, and clotting factor II) and the family history was negative. She was thrombosis free for 30 months, after which she presented with signs of thrombosis which had again occurred in the morning. This time the left arm was affected. The diagnosis was established by venography. All laboratory tests were normal and she had no risk factors. After a estimates
second conversation with a female member of staff we discovered that our patient’s habit was to lie with her arm under her partner’s head, which rested on her shoulder before falling asleep. After the first thrombotic episode she thought that compression on her right arm might be harmful and from that time on her partner slept on her left arm with his head in the same position as before. Although this sleeping habit cannot with certainty be attributed to be the cause of thrombosis, we believe that a triggering influence is highly probable. This seems analogous to the so called "paralysie des amoureux",3 in which the radial nerve is damaged by outside pressure on the upper arm instead of the vein. We feel that physicians should be aware of this possibility in young adults with axillary vein thrombosis. Departments of Clinical Epidemiology and Haematology, University Hospital Leiden, PO Box 9600, 2300 RC Leiden, Netherlands
T. KOSTER H. H. VAN BOVEN S. S. G. E. VAN BOOM E. BRIËT
1. Prescott SM, Tikoff G. Deep venous thrombosis of the upper extremity a reappraisal. Circulation 1979; 59: 350-55. 2. Horattas MC, Wright DJ, Fenton AH, et al. Changing concepts of deep venous thrombosis of the upper extremity: report of a series and review of the literature.
Surgery 1988; 104: 561-67. 3 Downie A. Peripheral nerve compression syndromes. In: Matthews WB, Glaser GH, eds. Recent advances m clinical neurology, no 3. Edinburgh: Churchill Livingstone, 1982. 47-66
CORRECTION Mortality and morbidity after high-titre measles vaccine in Mexico. -In this letter by Dr J. L. Diaz-Ortega and colleagues (Oct 10, p 924), reference 3 was wrongly included throughout and should be deleted. Reference 4 then becomes reference 3. In addition the plaque-forming units in the table were expressed as log10.
