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LYME DISEASE IN PATIENTS PREVIOUSLY SUSPECTED OF ARBOVIRUS INFECTION
93 ATRIAL NATRIURETIC PEPTIDE CONCENTRATIONS IN BLOOD FROM RIGHT ATRIUM IN PATIENT WITH SEVERE RIGHT HEART FAILURE
Letters to the Editor
(ANP) 1,2
SIR,-Atrial natriuretic peptide(s) may play a major role in salt and water homoeostasis.3 Although ANP is released into the
LYME DISEASE IN PATIENTS PREVIOUSLY SUSPECTED OF ARBOVIRUS INFECTION
circulation by volume release is unclear.
SIR,-From sera from patients with neurological involvement and the Pasteur Institute’s arbovirus laboratory for arbovirus serology’ but found to be negative we selected some where the clinical manifestations suggested the possibility of Lyme disease. The patients became ill in Western Europe, mostly in France. 71 sera and 3 samples of cerebrospinal fluid (23 sera collected during 1970-73 and 48 sera and 3 spinal fluids collected during 1979-84) were examined by indirect immunofluorescence antibody test (IFAT) with Borrelia burgdorferi as antigen. The B burgdorferi strain (obtained from Dr L. B. Elliot, Texas 2 Department of Health) was cultivated in modified Kelly medium.2 A purified Borrelia suspension, inactivated with 0’ 2% formalin, in phosphate buffered saline was obtained by six centrifugations and then diluted so that about 1000 organisms could been seen in a microscope field under a x 40 objective lens. Acetone-fixed antigen, serum dilutions, and isothiocyanate-labelled anti-human Ig antibodies (Pasteur Diagnostic, code 74511) were successively placed (5 1 each) on the circles of microscope slides and examined under an Olympus B-microscope with vertical fluorescence illumination and under an Apo x 40 objective. 75% of sera (73% of patients) reacted with B burgdorferi antigen, and 38% of them had titres of 160 or more (see table). 1 of the 3 CSF samples tested was positive (titre 40, corresponding serum titre sent to
160). RESULTS OF IFAT TESTS FOR B BURGDORFERI INFECTIONS IN
71
SERA
Lack of information precludes detailed analysis of these results. In particular, it has not been possible to study properly the relation between the date of the infectious bite and the date when the sample was taken. Nor can we be precise about the season when or the place where the infection occurred. A tick bite was confirmed in 38 patients. Only 3 patients had arthritis, but such a symptom would not prompt a clinician to ask for investigation of arboviral disease. A cutaneous syndrome resembling erythema chronicum migrans was reported in 13 cases, a meningeal reaction (clinical and/or biological) in 32 cases, and polyradiculoneuritis (sometimes with facial paralysis) in 49 cases, but data on the timing of these events were usually imprecise. 18 sera (25%) remained negative, despite a suggestive clinical picture in some patients. These patients may not have had a B burgdorferi infection. Alternatively, the sample may have been taken too soon (the antibodies seem to appear late and titres to rise slowly). Furthermore the IFAT was done on European patients but with a Borrelia strain of American origin. Another possibility is that antibiotics were given before the samples were taken. The results in this small series suggest that Lyme disease is common in France and that all sera from patients with neurological manifestations after arthropod bites should be tested for antibodies to both arboviruses and B burgdorferi. Units
of Virological and Rickettsial Diagnosis Ecology, Institut Pasteur, and Viral
75015 Paris, France
loading
the
physiological
stimulus for this
In our radioimmunoassay human atrial peptide (hANP) is extracted from EDTA-plasma by ’Sep-Pak’ C-18 cartridges, eluted with 90% v/v methanol/0 - 5% v/v trifluoroacetic acid, lyophilised, and dissolved in buffer. We use a 24 h/24 h non-equilibrium radioimmunoassay with second antibody separation, similar to that of Tanaka et al.4The sensitivity of our procedure is around 2 pg hANP per tube with more than 95% recovery. hANP concentrations in peripheral venous blood from thirty-six healthy controls ranged from 10 to 70 ng/1,5 in good agreement with data reported by Schiffrin et al.6 To add to these data and to the recent reports of Japanese workers7,8 we report here measurements of plasma hANP concentrations in peripheral venous blood as well as in blood from right atrium in a patient with severe right heart failure. A 55-year-old woman was admitted with dyspnoea and cyanosis. She also had cardiac enlargement, distended neck veins, hepatomegaly, and massive peripheral oedema. She weighed 80 4 kg (height 174 cm). A chest X-ray revealed general cardiac dilatation and signs of discrete left heart failure. Atrial tachycardia (I80/min) with atrioventricular blocking of higher order, bigeminylike ventricular extrasystoles, occasional supraventricular beats with the characteristics ofa right fascicular block, abnormal left-axis deviation, and signs of right-ventricular hypertrophy were seen in the resting electrocardiogram. Severe dilatation of the right atrium and ventricle and pericardial effusion were found by
echocardiography. She responded to diuretics, digitalis, and oxygen within a few days, with loss of body weight, restoration of normal sinus rhythm, decreasing radiological signs of lung oedema, and improvement in dyspnoea and cyanosis. However, right ventricular and atrial hypertrophy persisted, as did an abnormal distribution pattern of blood in the lungs. At right heart catheterisation 5 days after admission the following pressures (mm Hg) were recorded at rest: right atrium 15, right ventricle 87/4, and pulmonary artery 88/23. 3 weeks after admission, when she felt well and had lost 25 kg in weight, these pressures had fallen sharply to 6, 50/0, and 53/29 mm Hg, respectively, but they were still above normal. These data, together with lung function studies (normal dynamic volumes, abnormal static volumes, disturbance of diffusion) suggested restrictive disease of the lung.
EWALD EDLINGER F. RODHAIN C. PEREZ Plasma concentrations ofhANP.
1. Rodhain F. Le diagnostic biologique des arboviroses. Méd Mal Infect 1983; 13: 212-21. 2. Stoenner HG, Larson C, Dodd T Antigenic variation of Borrelia hermsii J Exp Med
1982; 156: 1297-311
Blood from
(8);ap=mean
peripheral
vein
atrial pressure.
(0-0)
and from
right
cardiac atrium
Letters to the Editor
(ANP) 1,2
SIR,-Atrial natriuretic peptide(s) may play a major role in salt and water homoeostasis.3 Although ANP is released into the
LYME DISEASE IN PATIENTS PREVIOUSLY SUSPECTED OF ARBOVIRUS INFECTION
circulation by volume release is unclear.
SIR,-From sera from patients with neurological involvement and the Pasteur Institute’s arbovirus laboratory for arbovirus serology’ but found to be negative we selected some where the clinical manifestations suggested the possibility of Lyme disease. The patients became ill in Western Europe, mostly in France. 71 sera and 3 samples of cerebrospinal fluid (23 sera collected during 1970-73 and 48 sera and 3 spinal fluids collected during 1979-84) were examined by indirect immunofluorescence antibody test (IFAT) with Borrelia burgdorferi as antigen. The B burgdorferi strain (obtained from Dr L. B. Elliot, Texas 2 Department of Health) was cultivated in modified Kelly medium.2 A purified Borrelia suspension, inactivated with 0’ 2% formalin, in phosphate buffered saline was obtained by six centrifugations and then diluted so that about 1000 organisms could been seen in a microscope field under a x 40 objective lens. Acetone-fixed antigen, serum dilutions, and isothiocyanate-labelled anti-human Ig antibodies (Pasteur Diagnostic, code 74511) were successively placed (5 1 each) on the circles of microscope slides and examined under an Olympus B-microscope with vertical fluorescence illumination and under an Apo x 40 objective. 75% of sera (73% of patients) reacted with B burgdorferi antigen, and 38% of them had titres of 160 or more (see table). 1 of the 3 CSF samples tested was positive (titre 40, corresponding serum titre sent to
160). RESULTS OF IFAT TESTS FOR B BURGDORFERI INFECTIONS IN
71
SERA
Lack of information precludes detailed analysis of these results. In particular, it has not been possible to study properly the relation between the date of the infectious bite and the date when the sample was taken. Nor can we be precise about the season when or the place where the infection occurred. A tick bite was confirmed in 38 patients. Only 3 patients had arthritis, but such a symptom would not prompt a clinician to ask for investigation of arboviral disease. A cutaneous syndrome resembling erythema chronicum migrans was reported in 13 cases, a meningeal reaction (clinical and/or biological) in 32 cases, and polyradiculoneuritis (sometimes with facial paralysis) in 49 cases, but data on the timing of these events were usually imprecise. 18 sera (25%) remained negative, despite a suggestive clinical picture in some patients. These patients may not have had a B burgdorferi infection. Alternatively, the sample may have been taken too soon (the antibodies seem to appear late and titres to rise slowly). Furthermore the IFAT was done on European patients but with a Borrelia strain of American origin. Another possibility is that antibiotics were given before the samples were taken. The results in this small series suggest that Lyme disease is common in France and that all sera from patients with neurological manifestations after arthropod bites should be tested for antibodies to both arboviruses and B burgdorferi. Units
of Virological and Rickettsial Diagnosis Ecology, Institut Pasteur, and Viral
75015 Paris, France
loading
the
physiological
stimulus for this
In our radioimmunoassay human atrial peptide (hANP) is extracted from EDTA-plasma by ’Sep-Pak’ C-18 cartridges, eluted with 90% v/v methanol/0 - 5% v/v trifluoroacetic acid, lyophilised, and dissolved in buffer. We use a 24 h/24 h non-equilibrium radioimmunoassay with second antibody separation, similar to that of Tanaka et al.4The sensitivity of our procedure is around 2 pg hANP per tube with more than 95% recovery. hANP concentrations in peripheral venous blood from thirty-six healthy controls ranged from 10 to 70 ng/1,5 in good agreement with data reported by Schiffrin et al.6 To add to these data and to the recent reports of Japanese workers7,8 we report here measurements of plasma hANP concentrations in peripheral venous blood as well as in blood from right atrium in a patient with severe right heart failure. A 55-year-old woman was admitted with dyspnoea and cyanosis. She also had cardiac enlargement, distended neck veins, hepatomegaly, and massive peripheral oedema. She weighed 80 4 kg (height 174 cm). A chest X-ray revealed general cardiac dilatation and signs of discrete left heart failure. Atrial tachycardia (I80/min) with atrioventricular blocking of higher order, bigeminylike ventricular extrasystoles, occasional supraventricular beats with the characteristics ofa right fascicular block, abnormal left-axis deviation, and signs of right-ventricular hypertrophy were seen in the resting electrocardiogram. Severe dilatation of the right atrium and ventricle and pericardial effusion were found by
echocardiography. She responded to diuretics, digitalis, and oxygen within a few days, with loss of body weight, restoration of normal sinus rhythm, decreasing radiological signs of lung oedema, and improvement in dyspnoea and cyanosis. However, right ventricular and atrial hypertrophy persisted, as did an abnormal distribution pattern of blood in the lungs. At right heart catheterisation 5 days after admission the following pressures (mm Hg) were recorded at rest: right atrium 15, right ventricle 87/4, and pulmonary artery 88/23. 3 weeks after admission, when she felt well and had lost 25 kg in weight, these pressures had fallen sharply to 6, 50/0, and 53/29 mm Hg, respectively, but they were still above normal. These data, together with lung function studies (normal dynamic volumes, abnormal static volumes, disturbance of diffusion) suggested restrictive disease of the lung.
EWALD EDLINGER F. RODHAIN C. PEREZ Plasma concentrations ofhANP.
1. Rodhain F. Le diagnostic biologique des arboviroses. Méd Mal Infect 1983; 13: 212-21. 2. Stoenner HG, Larson C, Dodd T Antigenic variation of Borrelia hermsii J Exp Med
1982; 156: 1297-311
Blood from
(8);ap=mean
peripheral
vein
atrial pressure.
(0-0)
and from
right
cardiac atrium