ATHLETIC PSEUDONEPHRITIS

910 SALMONELLA MENINGITIS IN INFANTS

TRANSPLACENTAL AMINOPHYLLINE TOXICITY IN A NEONATE

SIR,—We would like to report a neonate who presented with symptoms of irritability, vomiting, and jitteriness, possibly related to maternal ingestion of aminophylline. A 36-week gestation 2.2 kg Black male infant was born to a 36-year-old gravida 7, para 5 mother by vaginal delivery. The mother had had symptoms of asthma on and off for the previous 3 years. During this pregnancy she had had a few episodes of wheezing for which she took aminophylline intermit-

tently. 1 day before delivery she came to the emergency room because of shortness of breath, wheezing, and abdominal pain and was given several drugs for her respiratory problem including aminophylline (500 mg by suppository and 100 mg by mouth), frusemide (furosemide), and nitroglycerine. Aminophylline (100 mg) was subsequently given every 4 h. The last dose was given 1 h before delivery. 12 h after admission, the mother was delivered of a healthy infant who had an Apgar score of 9 at 1 min and 10 at 5 min. Other than a slight tachycardia (170-180/min), the physical examination was unremarkable, and he was transferred to the nursery for routine

postnatal care. At 6 h of age the infant vomited and showed

slight jitteriBlood-glucose (’Dextrostix’ test) was more than 60 mg/dl. Similar symptoms were reported after the first and second feeding. He was transferred to the intensive-care unit (i.c.u.) ness.

for observation. While in the i.c.u., he was irritable and had another two episodes of gagging and vomiting, without signs of abdominal distention. The second episode was also associated with jitteriness and opisthotonos. Investigations, including a sepsis work-up, spinal tap, subdural tap, E.E.G., and urine aminoacids were all negative. The blood-sugar was 85 mg/dl, serum calcium 8.88 mg/dl, magnesium 2.1mg/dl, and serum-bilirubin 9 mg/dl. The hmmatocrit was 57% on admission and it remained stable. Without special treatment, the infant improved and tolerated oral feeding well from the 2nd day. He was discharged on the 5th day in very good condition. Neurological examination at 3 months of age was normal. The cord-serum aminophylline concentration was 9-2µg/ml and the serum-aminophylline at 52 h of age was 5.8µg/ml (measured by ultraviolet spectro-

photometry’). Although aminophylline toxicity

has been mentioned in infants who are treated for premature apnoea, transplacental aminophylline toxicity in the newborn has not been reported. The untoward effects of aminophylline therapy in the premature infant may include tachycardia, arrhythmia, irritability, and transient hyperglycæmia 2-4 In older children, administration of excessive aminophylline may cause neurological symptoms such as vomiting or seizures. The toxic theophylline level in neonates has not been well defined and may vary from infant to infants Our infant had a cord-serum level of 9.2 jjLg/ml, which Shannon et al. considered to be therapeutic. However, in view of the transience of the symptoms, the absence of perinatal hypoxia, and the normal blood chemistry, it would seem that aminophylline was responsible for the clinical findings. We suggest that infants born to asthmatic mothers who have been receiving high doses of aminophylline before delivery be observed for similar symptoms. Division of Neonatology, Cook County Children’s Hospital, Chicago, Illinois 60612, U.S.A.

T. F. YEH R. S. PILDES

Schack, J. A., Waxler, S. H. J. Pharmac. exp. Ther. 1949, 97, 283. Shannon, D. C., Gotay, F., Stem, I. M., Rogers, M. C., Todres, I. D., Moylan, F. M. B. Pediatrics, 1975, 55, 589. 3. Yurchak, A. M., Jusko, W. J. ibid. 1976, 57, 518. 4. Aranda, J. V., Dupont, C. J. Pediat. 1976, 89, 833. 5. Lucey, J. V. Pediatrics, 1975, 55, 584. 1. 2.

SIR,—Since the first reported case of Salmonella meningitis 1907, there have been a few reviews of this problem, notably one by Rabinowitz et al. Meningitis is not often associated in

with salmonellosis : Saphra and Winterzreported that among 7779 cases of salmonellosis, 77 (1%) had meningitis. In Dakar we have recorded Salmonella meningitis in 6% of patients with salmonellosis, and there were 50 such infections among 3658 patients with purulent meningitis. The frequency of Salmonella meningitis has been constant for ten years. 56% of patients were boys. No case has been observed in a baby, but Salmonella meningitis was common in infants-32 patients under 1 year, 9 aged 1-4,6 aged 5-9, and 2 aged 10 or more. The most common serotypes were typhimurium (14), enteritidis (9), and typhi (7): rarer Salmonella serotypes included antsalova, montevideo, ona, ordonez, and stanleyville. The clinical features are typical of any purulent meningius, and the isolation of Salmonella from cerebrospinal fluid permitted the diagnosis in 47 cases out of 50. Ampicillin or chloramphenicol were used in treatment either alone or combined with intrathecal injections of colistin or streptomycin. 62% of children died, and 9 of those who survived were left with permanent neurological deficiencies. Mortality was especially high in infants, in cases of delayed hospital admission (44% of patients with meningitis were admitted when they had had meningitis for a week or more), and where S. enteritidis was the infecting organism. The mortality-rate seems high but Beene et al. in their review calculated a death-rate of about 83% among patients treated with the broad-spectrum antibiotics (chloramphenicol,

tetracycline). and Infectious Diseases Department, Faculté de Médecine,

Microbiological Dakar, Senegal

F. DENIS S. BADIANE J. P. CHIRON A. SOW I. DIOP MAR

ATHLETIC PSEUDONEPHRITIS

SIR,—Prolonged muscular exercise may cause albuminuria, cylinduria, haematuria, 4and a reduction in glomerular filtration-rate.6 The condition has been termed "athletic pseu-

donephritis".45 Up to now, no-one has reported quantitatively on the reversibility of this supposedly benign condition. Fifteen healthy men (average age 196) volunteered to take part in a study before, during, and after an ice-hockey match lasting 60 min of stopped play on Feb. 9, 1977 at the Peoria Logan Ice Dome, Peoria, Illinois. Timed specimens of urine collected just before and after the match, and in recovery 24, 48, and 72 h. Control of diet, fluid intake, and activity was not practicable. The urine was tested for albumin, glucose, and ketone bodies and examined for casts, leucocytes, erythrocytes, epithelial cells, crystals, artifacts, and miscellaneous formed elements such as spermatozoa. The results were recorded as 0-100 (for chemical findings) and numbers of formed elements per low-power field. No specimen contained glucose. One specimen had a very small amount of ketone bodies, but the player had fasted 12 h before collecting it. All players after the game had diminished flow of urine and increased acidity; both flow and acidity reverted to normal within 48 h. The results for albumin and formed elements are presented semiquantitatively in the table. Four players had slight albuminuria before the match, while all fifteen had albuminuna were

at

Rabinowitz, S. G., MacLeod, N. R. Am J. Dis. Child. 1972, 123, 259 Saphra, I., Winter, J. W. New Eng. J. Med. 1957, 256, 1128. Beene, M. L., Hansen, A. E., Fulton, N. Am J. Dis. Child. 1951, 82, 567. 4. Gardner, K. D. J. Am. med. Ass. 1956, 161, 1613. 5. Kachadorian, W. A., Johnson, R. E., Buffington, R. E., Lawler, L., Serbin, J. J., Woodall, T. Med. Sci. Sports, 1970, 2, 142. 6. Kachadorian, W. A., Johnson, R. E. J. appl. Physiol. 1970, 28, 748. 1. 2. 3.

911 ALBUMIN AND FORMED ELEMENTS IN URINE OF ICE-HOCKEY

PLAYERS

(MEANS FOR FIFTEEN PLAYERS)

pre-match measurements at P≤0.05 by Student’s )..P.r.=low-power field. *Greater than

t test.

afterwards and formed elements as well. Albumin levels of 100 on the ’Multi-stix’ scale were found in two men who had no trace before the game or 48 h afterwards. These players were the lone defencemen in the team’s resounding 8-1 defeat, and they took a lot of body contact during the match. Of the formed elements, casts increased and returned to prematch levels in 48 h, leucocytes in 24 h. Epithelial cells increased about as much as leucocytes, but remained high until 72 h. These findings confirm the development of athletic pseudonephritis, but in a sport not reported before, ice-hockey; and they show that this condition is reversible within 24-48 h of prolonged hard exercise. Clinically, this response to exercise could be important in young people in whose urine albumin and formed elements have been found. Before diagnosing serious renal disease the clinician should consider the possibility of athletic pseudonephntis, keep the patient quiet for at least 48 h, and then examine the urine again. I thank the hockey players, the medical students and Knox undergraduates who assisted in the study, the biology department of Knox College for use of space, equipment, and supplies, and Dr Robert E.

Johnson for advice and encouragement. Knox-Rush Medical Program, Illinois 61401, U.S.A.

Galesburg,

DAVID

J. FLETCHER

GENTAMICIN RESISTANCE IN JAPAN

SIR,—Gentamicin resistance in bacteria is a growing problem.’ Shafi and Datta2 described four R plasmids carrying gentamicin resistance in Proteus mirabilis, and Port house et al.3 and Shanson et al. have reported on gentamicin-resistant Staphylococcus aureus. We have found 317 R plasmids carrying resistance to mercury, arsenate, and several antibiotics in Escherichia coli and Klebsiella pneumonice isolated at the Jikei

University Hospital.5 In 1974 and 1975 we isolated 39 gentamicin-resistant Pseudomonas æruginosa (7.1% of 553 isolates), but in 1976 the resistance-rate increased to 22.3% (79 out of 355). In 1974 and 1975 we found no gentamicin-resistant E. coli, K. pneumonice, Citrobacter, or Staph. aureus at our hospital, but in 1 Lancet, 1975, ii, 804. 2 Shafi, M. S., Datta, N. ibid. 1975, i, 1355. 3. Porthouse, A., Brown, D. F. J., Smith, R. G., Rogers, T. ibid. 4. Shanson, D. C., Kensit, J. G., Duke, R. ibid. 1976, ii, 1347.

1976,

i, 20.

5 Nakahara, H., Ishikawa, I. Sarai, Y., Kondo, I., Mistuhashi, S. Nature (in the press).

1976 24 strains (5% of 480 isolates) of E. coli, K. pneumoniæ and Citrobacter were gentamicin resistant, while only 1 Staph. aureus in 715 isolates was resistant. We examined the conjugal transferability of this resistance by using two recipients. One recipient, E. coli K12 ML1410-Nx, a nalidixic-acid-resistant mutant of E. coli K12, was used for the transfer of R plasmids in the first cycle. The other recipient, E. coli JE17-Rif, isolated in our laboratory, is a rifampicin-resistant mutant and used in the second cycle of transconjugation. Among 9 gentamicin-resistant E. coli, 6 R plasmids carrying gentamicin resistance were observed. Among 12 isolates of resistant K. pneumonice, 9 gentamicin-resistant R plasmids were isolated, moreover, in 3 resistant Citrobacter, 3 R plasmids with gentamicin resistance were observed. Transferable R plasmids carrying gentamicin resistance were present in most (66-7% of E. coli, 75% of K. pneumonia and 100% of Citrobacter) of the resistant isolates. In addition, among 79 gentamicin-resistant isolates, 24 R plasmids with gentamicin resistance were isolated in Ps. æruginosa.

Departments of Hygiene and Microbiology, Jikei University School of Medicine, Tokyo 105, Japan

HIDEOMI NAKAHARA TOMOAKI ISHIKAWA YASUNAGA SARAI ISAMU KONDO HIROYUKI KOZUKUE

PANCREATIC CANCER IN FATHER AND SON

SIR--The role of genetic or familial factors in pancreatic adenocarcinoma is uncertain. Three high-risk families have been reported,’-3 and some cases have been seen in kindreds with hereditary pancreatitis. and ataxia-telangiectasia.5 We have seen a 63-year-old White chemical worker with pancreatic cancer whose 36-year-old son had died from the same tumour one year earlier. Several years before his death the son had worked briefly with his father, who was in contact with vinyl chloride and other chemicals. Both were possibly exposed to mycotoxins as contaminants of pistachio nuts,6 which they consumed in large quantities after repeated purchases of lOlb (45 kg) lots from a wholesaler. Neither patient smoked cigarettes or had any condition, such as diabetes, that predisposes to pancreatic cancer.7 In previous families prone to pancreatic cancer only siblings have been involved. To our knowledge, this is the first report of the tumour in successive generations. This occurrence may be due to chance or possibly genetic transmission, but some features suggest an environmental influence. A common exposure to occupational chemicals is in keeping with preliminary findings that 8such workers may be at increased risk of pancreatic cancer.7 Aflatoxin ingestion has been linked to liver cancer in Africa,** but tumours of the pancreas have not been reported in humans or laboratory animals exposed to mycotoxins. Since interactions between environmental and heritable, factors may account for susceptibility to various neoplasms, evidence for both factors should be sought whenever a cancer-prone family is identified. Environmental Epidemiology and Medicine Branches, National Cancer Institute, Bethesda, Maryland 20014, U.S.A.

RONALD R. REIMER JOSEPH F. FRAUMENI, JR. ROBERT F. OZOLS RICHARD BENDER

1. MacDermott, R. P., Kramer P. Gastroenterology, 1973, 65, 137. 2. Friedman, J. M., Fialkow, P. J. Clin. Genet. 1976, 9, 463. 3. Rakhov, P. A. Questions Oncol. 1976, 22, 90 (Russian). 4. Appel, M. F. Archs Surg. 1974, 108, 63. 5. Swift, M., Sholman, L., Perry, M., Chase, C. Cancer Res. 1976, 36. 209. 6. Stoloff, L. Adv. Chem. 1976, 149, 23. 7. Fraumeni, J. F., Jr. Cancer Res. 1975, 35, 3437. 8. Li, F. P., Fraumeni, J. F., Jr., Mantel, N., Miller, R. W. J. natn. Cancer Inst. 1969, 43, 1159.