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CAMPYLOBACTER PYLORIDIS IS UNIQUE: GCLO-2 IS AN ORDINARY CAMPYLOBACTER
38 IMMUNOLOGICAL IDENTIFICATION OF CAMPYLOBACTER PYLORIDIS IN GASTRIC BIOPSY TISSUE
SIR,-Bacteria have been observed at the gastric epithelium in benign gastric and duodenal ulcerationl-3but identification has been complicated by the culture of endoscopic contaminants. Marshall4 has cultured a campylobacter-like organism (Campylobacterpyloridis) from gastric biopsy specimens. It has been inferred that the C pyloridis is not a contaminant, but specific identification of the bacterium in histological sections has been lacking. We have studied bacteria in gastric biopsy samples, using a rabbit anti-Cpyloridis serum (generously provided by Dr J. Dolby, Clinical Research Centre, Northwick Park Hospital, Harrow). The antiserum was raised by inoculating rabbits with Cpyloridis strain DU 21 which was heat killed at 62°C for 1 h. The inoculations were done twice weekly for four weeks with 0 -5ml C pyloridis (2 x 109 bacteria/ml) followed by two inoculations of 1 ml of heat-killed Cpyloridis during the fifth week. We first examined the specificity of this serum in labelling Cpyloridis in vitro. C pyloridis were pre-fixed with O. 1 % glutaraldehyde in 0-11 mol/1 phosphate buffer for 10 min at room temperature. The Cpyloridis were washed and incubated with 1:100 dilution of the rabbit antiserum and then placed on formvar/carbon coated grids and incubated with gold-labelled sheep anti-rabbit antisera (generously provided by Dr G. Rhodes, Imperial Cancer Research Fund, London). Both the flagella and surface of the C pyloridis were labelled (fig 1). There was no labelling with normal rabbit serum and no labelling of C jejuni. We next examined prepyloric biopsy tissue from six patients with prepyloric gastritis. Four also had benign duodenal ulceration. All the specimens had mucosa-related bacteria on histological sectioning, all had gram-negative bacteria on smears, and in five of the six patients campylobacter-like organisms were grown from their biopsy samples. Cryostat sections were air dried and fixed in absolute ethanol for 5 min at room temperature. The sections were incubated with a 1:100 dilution of the rabbit anti-Cpyloridis serum, washed, and then incubated with fluorescent labelled sheep anti-rabbit serum (generously provided by Dr D. Garrod, CRC Unit of Medical
AA-,
.
"’
2-Fluorescent photomicrograph with fluorescence related to luminal surface of gastric epithelial cells (x 160).
Fig
Oncology, Southampton General Hospital). The fluorescent labelling was related to the luminal surface of the gastric mucusproducing cells (fig 2) in all six patients and the labelling was often punctate. Control sections incubated in normal rabbit serum did not have this fluorescent labelling. These results provide direct evidence that at least some of the histologically observed mucosa related bacteria are antigenically identical to the campylobacter-like organism (C pyloridis) grown from gastric biopsy tissue. Department of Surgery, Southampton General Hospital, Southampton SO9 4XY and Experimental Pathology Laboratory, PHLS Centre for
Applied Microbiology and Research, Down, Salisbury
Porton
HOWARD W. STEER DIANE G. NEWELL
1. Steer HW. Ultrastructure of cell migration through the gastric epithelium and its relationship to bacteria. J Clin Path 1975; 28: 639-46. 2. Steer HW, Colin Jones DG. Mucosal changes in gastric ulceration and their response to carbenoxolone sodium. Gut 1975; 16: 590-97. 3. Warren JR. Unidentified curved bacilli on gastric epithelium in active chronic gastritis. Lancet 1983; i: 1273. 4. Marshall BJ. Unidentified curved bacilli on gastric epithelium in active chronic gastritis. Lancet 1983; i: 1273-75.
CAMPYLOBACTER PYLORIDIS IS UNIQUE: GCLO-2 IS AN ORDINARY CAMPYLOBACTER
SIR,-The campylobacter-like bacteria from the human stomach Lancet’ have now been officially named
first described in The
Campylobacter pyloridis.2Ultrastructural studies and studies of chemical composition indicate fundamental differences between Cpyloridis and other campylobacters.3C pyloridis has a smooth surface with multiple unipolar flagella of the sheathed type, each with a terminal bulb; it lacks the distinct pit-like depression at each pole from which the single flagellum of other campylobacters arises. Typically, campylobacters have a rugose cell wall, with unsheathed flagella without a terminal bulb.4 The major cellular fatty acids of Cpyloridis are tetradecanoic (14:0) and cis-9,10-methyleneoctadecanoic (19:OA), with a very small amount of hexadecanoic acid (16 :0).3 In other campylobacters the major fatty acids are hexadecanoic, octadecenoic (18:1), and hexadecenoic (16:1).5 We have just received three isolates of the gastric campylobacter-like organisms (GCLO-2) isolated by Kasper and Dickgiesser;the cellular fatty acid profile of this organism resembles that of C jejuni, to indicating that it is a true campylobacter and is unrelated Cpyloridis, confirming the observations of Steele et al.7 We report here that Cpyloridis lacks the methylated menaquinone-6 found in all other campylobacters8 and that it shows
Fig l-Electron micrograph with gold label body and flagella of C pyloridis (x6250).
attached
to
surface of
phosphatase activity in the phenolphthalein phosphate test in which other campylobacters and GCLO-2 are negative. We grew twelve isolates of Cpyloridis, including NCTC 11637% and NCTC 11638, Cjejuni, Cfetus, Claridis, and GCLO-2on brainheart infusion agar containing 10% horse serum, 0’25% yeast extract, and 0-01% phenolphthalein phosphate for 5 days in a
39 CLINICAL AND MICROBIOLOGICAL DETAILS
campylobacter gas mixture at 37°C. Staphylococcus aureus and S epidermidis were grown on the same medium in air at 30&ogr;C for five days. On the fifth day 0 - 1 ml ammonia solution (sp gr 0-880) was placed in the lid of each culture plate, and phosphatase-positive cultures of S aureus and Cpyloridis became bright pink, indicating release of free phenolphthalein. Cultures of S epidermidis, C jejuni, Cfetus, C laridis, and GCLO-2 did not show phosphatase activity. In tests for alkaline phosphatase activity C jejuni appears weakly positive and C fetus negative;9we have found C pyloridis to be strongly positive. Evidence for a new bacterial genus will have to await studies of cistron similarities. In view of the frequency with which C pyloridis is found there may well be an environmental or animal reservoir; and in a search for this, other spiral bacteria may be found which may prove to be more like Cpyloridis than classical campylobacters. We thank Dr R. J. Owen for
providing strains of GCLO-2. STEWART GOODWIN ELIZABETH BLINCOW JOHN ARMSTRONG ROSS MCCULLOCH
Departments of Microbiology and Electronmtcroscopy, Royal Perth Hospital, Perth, Western Australia 6001 Department of Microbiology, National Institute for Research
Shinfield, Reading
in
Dairying,
DAVID COLLINS
1. Warren
JR, Marshall B Unidentified curved bacilli on gastric epithelium in active chronic gastritis Lancet 1983; i: 1273-75. 2. Anon. Validation of the publication of new names and new combinations previously effectively published outside the IJSB: List no 17 Int J Syst Bacteriol 1985; 35: 223-25. 3. Goodwin CS, McCulloch RKM, Armstrong JA, Wee SH Unusual cellular fatty acids and distinctive ultrastructure in a new spiral bacterium (Campylobacter pyloridis) from the human gastric mucosa. J Med Microbiol 1985; 19: 257-67. 4. Pead PJ. Electron microscopy of Campylobacter Jejuni. J Med Microbiol 1979; 12: 383-85. 5. Curtis MA. Cellular fatty acid profiles of campylobacters Med Lab Sci 1983, 40: 333-48 6. Kasper G, Dickgiesser N. Isolation from gastric epithelium of campylobacter-like bacteria that are distinct from Campylobacter pyloridis. Lancet 1985; i. 111-12. 7. Steele TW, Lanser JA, Sangster N Nitrate-negative campylobacter-like organisms. Lancet 1985, i. 394. 8. Collins MD, Costas M, Owen RJ. Isoprenoid quinone composition of representatives of the genus Campylobacter. Arch Microbiol 1984; 137: 168-70. 9 Roop RM, Smibert RM, Johnson JL, Kreig NR. Differential characteristics ofcatalasepositive campylobacters correlated with DNA homology groups. Can J Microbiol 1984; 30: 939-51
RESISTANCE TO CIPROFLOXACIN
SIR,—Dr Crook and colleagues (June 1, p 1275) have reported the of clinically significant resistance to ciprofloxacin after long-term oral administration. We have observed the emergence of resistance in five patients given shorter courses. We have used ciprofloxacin in patients with pseudomonas or other serious gram-negative infections where there has been resistance or a poor response to other agents. The table shows the minimum inhibitory concentrations (MIC) of ciprofloxacin for isolates obtained before and during or after treatment. Serial specimens were obtained from all patients during therapy, and the increased MICs were confirmed at least twice. Ciprofloxacin was given for between 5 and 21 days. Patients 3 and 5 received 500 or 750 mg orally twice daily and patients 2 and 4 had 200 mg intravenously twice daily (patient 2 was changed to oral therapy after 12 days). Resistance emerged during therapy or in the colonising flora immediately after therapy (patient 1), and in three patients this was an important reason for stopping or altering the antibiotic regimen. The earliest resistance was noted after 5 days’
development
treatment
(patient 4).
Patient 1, a premature baby, had a good clinical response to ciprofloxacin after two episodes of bacteraemia with Enterobacter cloacae. Patient 2 had lobar pneumonia and septicaemia (Klebsiella pneumoniae); he responded well to ciprofloxacin at first but a large pulmonary empyema developed later which required surgical drainage. Patient 3 had chronic Pseudomonas aeruginosa bone graft infection which showed some clinical response at first but, not unexpectedly, eventually required further surgery. Patient 4 had renal and respiratory complications after an episode of pneumococcal pneumonia. He was in intensive care, on a ventilator, and had a secondary Ps aeruginosa chest infection which required
*For organisms, see text. tRange of MIC values from several
colomally distinguishable isolates.
therapy. This was altered as soon as ciprofloxacin resistnoted. Patient 5, who had recurrent respiratory infection by Ps aeruginosa, improved symptomatically and in lung function tests, but later deteriorated while on ciprofloxacin. These patients all had an underlying disease that might lead to failure of antibiotic treatment, and it would be unfair to assume that the potential emergence of resistance will always overshadow the therapeutic advantages of the newer quinolones. It will be interesting to note whether isolates from such patients will show reversion to sensitivity after ciprofloxacin therapy is withdrawn. antibiotic ance was
Departments of Microbiology, Southmead Hospital, Bristol BS10 5NB and Bristol Royal
Infirmary
S. T. CHAPMAN D. C. E. SPELLER D. S. REEVES
VANCOMYCIN DOSAGE RECOMMENDATIONS
SIR,-We wish to concur with Dr Holliman (June 15, p 1399) that too-rapid infusion or injection of vancomycin may be associated with the histamine-mediated reaction known as the "red man" or "red neck" syndrome. We have received approval from the Licensing Authority to modify our dosage recommendations in accordance with the United States package insert, but since this came too late for inclusion in the 1985-86 Data Sheet Compendium we are printing loose-leaf data sheets to coincide with that publication. There are two important changes: (1) When intermittent infusion is being used, vancomycin should be infused over a period of at least 60 min. (2) Dosage must be modified according to the degree of renal impairment: a nomogram, based on creatinine clearance, is included in the prescribing information. The new data sheet, together with a dose calculator, will be available upon request to the company. Eli Lilly and Co Ltd, Basingstoke, Hampshire RG21 2XA
B. J. MOORE
ACUTE DEAFNESS AND DESFERRIOXAMINE
SIR,—Long-term desferrioxamine treatment may cause ocular disorders in patients with or without normal renal function.1-3 We describe here acute hearing loss in a patient with chronic renal failure on the usual therapeutic doses of intravenous desferrioxamine. A 26-year-old woman who had been on haemodialysis three times a week for more than 8 years for chronic glomerulonephritis and who had had a bilateral nephrectomy 6 years earlier, acquired iron overload due to severe anaemia and frequent transfusion needs. Her serum iron was 33 - 2 µmol/1 and serum ferritin 980 pg/1. She did not have aluminium intoxication (serum aluminium 1’8 µmol/1, no aluminium stained surfaces on bone biopsy samples). Desferrioxamine 40 mg/kg was given at each dialysis and over 6 months her serum ferritin fell to 142 pg/1. At the beginning of the 7th month she complained of decreased hearing perception. An audiogram revealed high-frequency sensorineural hearing deficit with raised thresholds in the mid-high frequency range. Desferrioxamine was not suspected. Her hearing loss became much worse and a repeat audiogram revealed considerable aggravation of the deficit.
SIR,-Bacteria have been observed at the gastric epithelium in benign gastric and duodenal ulcerationl-3but identification has been complicated by the culture of endoscopic contaminants. Marshall4 has cultured a campylobacter-like organism (Campylobacterpyloridis) from gastric biopsy specimens. It has been inferred that the C pyloridis is not a contaminant, but specific identification of the bacterium in histological sections has been lacking. We have studied bacteria in gastric biopsy samples, using a rabbit anti-Cpyloridis serum (generously provided by Dr J. Dolby, Clinical Research Centre, Northwick Park Hospital, Harrow). The antiserum was raised by inoculating rabbits with Cpyloridis strain DU 21 which was heat killed at 62°C for 1 h. The inoculations were done twice weekly for four weeks with 0 -5ml C pyloridis (2 x 109 bacteria/ml) followed by two inoculations of 1 ml of heat-killed Cpyloridis during the fifth week. We first examined the specificity of this serum in labelling Cpyloridis in vitro. C pyloridis were pre-fixed with O. 1 % glutaraldehyde in 0-11 mol/1 phosphate buffer for 10 min at room temperature. The Cpyloridis were washed and incubated with 1:100 dilution of the rabbit antiserum and then placed on formvar/carbon coated grids and incubated with gold-labelled sheep anti-rabbit antisera (generously provided by Dr G. Rhodes, Imperial Cancer Research Fund, London). Both the flagella and surface of the C pyloridis were labelled (fig 1). There was no labelling with normal rabbit serum and no labelling of C jejuni. We next examined prepyloric biopsy tissue from six patients with prepyloric gastritis. Four also had benign duodenal ulceration. All the specimens had mucosa-related bacteria on histological sectioning, all had gram-negative bacteria on smears, and in five of the six patients campylobacter-like organisms were grown from their biopsy samples. Cryostat sections were air dried and fixed in absolute ethanol for 5 min at room temperature. The sections were incubated with a 1:100 dilution of the rabbit anti-Cpyloridis serum, washed, and then incubated with fluorescent labelled sheep anti-rabbit serum (generously provided by Dr D. Garrod, CRC Unit of Medical
AA-,
.
"’
2-Fluorescent photomicrograph with fluorescence related to luminal surface of gastric epithelial cells (x 160).
Fig
Oncology, Southampton General Hospital). The fluorescent labelling was related to the luminal surface of the gastric mucusproducing cells (fig 2) in all six patients and the labelling was often punctate. Control sections incubated in normal rabbit serum did not have this fluorescent labelling. These results provide direct evidence that at least some of the histologically observed mucosa related bacteria are antigenically identical to the campylobacter-like organism (C pyloridis) grown from gastric biopsy tissue. Department of Surgery, Southampton General Hospital, Southampton SO9 4XY and Experimental Pathology Laboratory, PHLS Centre for
Applied Microbiology and Research, Down, Salisbury
Porton
HOWARD W. STEER DIANE G. NEWELL
1. Steer HW. Ultrastructure of cell migration through the gastric epithelium and its relationship to bacteria. J Clin Path 1975; 28: 639-46. 2. Steer HW, Colin Jones DG. Mucosal changes in gastric ulceration and their response to carbenoxolone sodium. Gut 1975; 16: 590-97. 3. Warren JR. Unidentified curved bacilli on gastric epithelium in active chronic gastritis. Lancet 1983; i: 1273. 4. Marshall BJ. Unidentified curved bacilli on gastric epithelium in active chronic gastritis. Lancet 1983; i: 1273-75.
CAMPYLOBACTER PYLORIDIS IS UNIQUE: GCLO-2 IS AN ORDINARY CAMPYLOBACTER
SIR,-The campylobacter-like bacteria from the human stomach Lancet’ have now been officially named
first described in The
Campylobacter pyloridis.2Ultrastructural studies and studies of chemical composition indicate fundamental differences between Cpyloridis and other campylobacters.3C pyloridis has a smooth surface with multiple unipolar flagella of the sheathed type, each with a terminal bulb; it lacks the distinct pit-like depression at each pole from which the single flagellum of other campylobacters arises. Typically, campylobacters have a rugose cell wall, with unsheathed flagella without a terminal bulb.4 The major cellular fatty acids of Cpyloridis are tetradecanoic (14:0) and cis-9,10-methyleneoctadecanoic (19:OA), with a very small amount of hexadecanoic acid (16 :0).3 In other campylobacters the major fatty acids are hexadecanoic, octadecenoic (18:1), and hexadecenoic (16:1).5 We have just received three isolates of the gastric campylobacter-like organisms (GCLO-2) isolated by Kasper and Dickgiesser;the cellular fatty acid profile of this organism resembles that of C jejuni, to indicating that it is a true campylobacter and is unrelated Cpyloridis, confirming the observations of Steele et al.7 We report here that Cpyloridis lacks the methylated menaquinone-6 found in all other campylobacters8 and that it shows
Fig l-Electron micrograph with gold label body and flagella of C pyloridis (x6250).
attached
to
surface of
phosphatase activity in the phenolphthalein phosphate test in which other campylobacters and GCLO-2 are negative. We grew twelve isolates of Cpyloridis, including NCTC 11637% and NCTC 11638, Cjejuni, Cfetus, Claridis, and GCLO-2on brainheart infusion agar containing 10% horse serum, 0’25% yeast extract, and 0-01% phenolphthalein phosphate for 5 days in a
39 CLINICAL AND MICROBIOLOGICAL DETAILS
campylobacter gas mixture at 37°C. Staphylococcus aureus and S epidermidis were grown on the same medium in air at 30&ogr;C for five days. On the fifth day 0 - 1 ml ammonia solution (sp gr 0-880) was placed in the lid of each culture plate, and phosphatase-positive cultures of S aureus and Cpyloridis became bright pink, indicating release of free phenolphthalein. Cultures of S epidermidis, C jejuni, Cfetus, C laridis, and GCLO-2 did not show phosphatase activity. In tests for alkaline phosphatase activity C jejuni appears weakly positive and C fetus negative;9we have found C pyloridis to be strongly positive. Evidence for a new bacterial genus will have to await studies of cistron similarities. In view of the frequency with which C pyloridis is found there may well be an environmental or animal reservoir; and in a search for this, other spiral bacteria may be found which may prove to be more like Cpyloridis than classical campylobacters. We thank Dr R. J. Owen for
providing strains of GCLO-2. STEWART GOODWIN ELIZABETH BLINCOW JOHN ARMSTRONG ROSS MCCULLOCH
Departments of Microbiology and Electronmtcroscopy, Royal Perth Hospital, Perth, Western Australia 6001 Department of Microbiology, National Institute for Research
Shinfield, Reading
in
Dairying,
DAVID COLLINS
1. Warren
JR, Marshall B Unidentified curved bacilli on gastric epithelium in active chronic gastritis Lancet 1983; i: 1273-75. 2. Anon. Validation of the publication of new names and new combinations previously effectively published outside the IJSB: List no 17 Int J Syst Bacteriol 1985; 35: 223-25. 3. Goodwin CS, McCulloch RKM, Armstrong JA, Wee SH Unusual cellular fatty acids and distinctive ultrastructure in a new spiral bacterium (Campylobacter pyloridis) from the human gastric mucosa. J Med Microbiol 1985; 19: 257-67. 4. Pead PJ. Electron microscopy of Campylobacter Jejuni. J Med Microbiol 1979; 12: 383-85. 5. Curtis MA. Cellular fatty acid profiles of campylobacters Med Lab Sci 1983, 40: 333-48 6. Kasper G, Dickgiesser N. Isolation from gastric epithelium of campylobacter-like bacteria that are distinct from Campylobacter pyloridis. Lancet 1985; i. 111-12. 7. Steele TW, Lanser JA, Sangster N Nitrate-negative campylobacter-like organisms. Lancet 1985, i. 394. 8. Collins MD, Costas M, Owen RJ. Isoprenoid quinone composition of representatives of the genus Campylobacter. Arch Microbiol 1984; 137: 168-70. 9 Roop RM, Smibert RM, Johnson JL, Kreig NR. Differential characteristics ofcatalasepositive campylobacters correlated with DNA homology groups. Can J Microbiol 1984; 30: 939-51
RESISTANCE TO CIPROFLOXACIN
SIR,—Dr Crook and colleagues (June 1, p 1275) have reported the of clinically significant resistance to ciprofloxacin after long-term oral administration. We have observed the emergence of resistance in five patients given shorter courses. We have used ciprofloxacin in patients with pseudomonas or other serious gram-negative infections where there has been resistance or a poor response to other agents. The table shows the minimum inhibitory concentrations (MIC) of ciprofloxacin for isolates obtained before and during or after treatment. Serial specimens were obtained from all patients during therapy, and the increased MICs were confirmed at least twice. Ciprofloxacin was given for between 5 and 21 days. Patients 3 and 5 received 500 or 750 mg orally twice daily and patients 2 and 4 had 200 mg intravenously twice daily (patient 2 was changed to oral therapy after 12 days). Resistance emerged during therapy or in the colonising flora immediately after therapy (patient 1), and in three patients this was an important reason for stopping or altering the antibiotic regimen. The earliest resistance was noted after 5 days’
development
treatment
(patient 4).
Patient 1, a premature baby, had a good clinical response to ciprofloxacin after two episodes of bacteraemia with Enterobacter cloacae. Patient 2 had lobar pneumonia and septicaemia (Klebsiella pneumoniae); he responded well to ciprofloxacin at first but a large pulmonary empyema developed later which required surgical drainage. Patient 3 had chronic Pseudomonas aeruginosa bone graft infection which showed some clinical response at first but, not unexpectedly, eventually required further surgery. Patient 4 had renal and respiratory complications after an episode of pneumococcal pneumonia. He was in intensive care, on a ventilator, and had a secondary Ps aeruginosa chest infection which required
*For organisms, see text. tRange of MIC values from several
colomally distinguishable isolates.
therapy. This was altered as soon as ciprofloxacin resistnoted. Patient 5, who had recurrent respiratory infection by Ps aeruginosa, improved symptomatically and in lung function tests, but later deteriorated while on ciprofloxacin. These patients all had an underlying disease that might lead to failure of antibiotic treatment, and it would be unfair to assume that the potential emergence of resistance will always overshadow the therapeutic advantages of the newer quinolones. It will be interesting to note whether isolates from such patients will show reversion to sensitivity after ciprofloxacin therapy is withdrawn. antibiotic ance was
Departments of Microbiology, Southmead Hospital, Bristol BS10 5NB and Bristol Royal
Infirmary
S. T. CHAPMAN D. C. E. SPELLER D. S. REEVES
VANCOMYCIN DOSAGE RECOMMENDATIONS
SIR,-We wish to concur with Dr Holliman (June 15, p 1399) that too-rapid infusion or injection of vancomycin may be associated with the histamine-mediated reaction known as the "red man" or "red neck" syndrome. We have received approval from the Licensing Authority to modify our dosage recommendations in accordance with the United States package insert, but since this came too late for inclusion in the 1985-86 Data Sheet Compendium we are printing loose-leaf data sheets to coincide with that publication. There are two important changes: (1) When intermittent infusion is being used, vancomycin should be infused over a period of at least 60 min. (2) Dosage must be modified according to the degree of renal impairment: a nomogram, based on creatinine clearance, is included in the prescribing information. The new data sheet, together with a dose calculator, will be available upon request to the company. Eli Lilly and Co Ltd, Basingstoke, Hampshire RG21 2XA
B. J. MOORE
ACUTE DEAFNESS AND DESFERRIOXAMINE
SIR,—Long-term desferrioxamine treatment may cause ocular disorders in patients with or without normal renal function.1-3 We describe here acute hearing loss in a patient with chronic renal failure on the usual therapeutic doses of intravenous desferrioxamine. A 26-year-old woman who had been on haemodialysis three times a week for more than 8 years for chronic glomerulonephritis and who had had a bilateral nephrectomy 6 years earlier, acquired iron overload due to severe anaemia and frequent transfusion needs. Her serum iron was 33 - 2 µmol/1 and serum ferritin 980 pg/1. She did not have aluminium intoxication (serum aluminium 1’8 µmol/1, no aluminium stained surfaces on bone biopsy samples). Desferrioxamine 40 mg/kg was given at each dialysis and over 6 months her serum ferritin fell to 142 pg/1. At the beginning of the 7th month she complained of decreased hearing perception. An audiogram revealed high-frequency sensorineural hearing deficit with raised thresholds in the mid-high frequency range. Desferrioxamine was not suspected. Her hearing loss became much worse and a repeat audiogram revealed considerable aggravation of the deficit.