Screening for coeliac disease

Diphtheria In

Russia

world" for smoking betrays the friend and kills.1 And talking of the next world-a survey by a Japanese life-insurance company revealed that 27 5% of its 30 000 female employees smoked.2 According to the Japan Tobacco Corporation, the prevalence of smoking among women throughout the country in 1993 was 13-8%. The workers thus smoke twice as much as average. Are they really selling life insurance?

next

SIR-Rich (Jan 15, p 169) asserts that the current epidemic of diphtheria in Russia reflects poor immunisation uptake because of a lack of disposable needles and public concern about contracting blood-borne disease. Disposable syringes and needles are widely available and are used for immunisation. Until recently, I was a specialist in paediatric diphtheria at Tushinskaya Children’s Hospital, Moscow. Most children with diphtheria had not been immunised for medical reasons. Russian doctors are often reluctant to immunise children, including their own, because many medical conditions are considered contraindications. I know of a doctor who falsified her daughter’s immunisation card so that the girl could enter school. I understand that until recently British doctors also believed there were many contraindications. Last summer my British colleagues and I studied the immunisation rate of a group of Moscow children and our report will include the reasons for non-immunisation. Immunisation is compulsory in Russia for school entry but, because of the fear of side-effects of vaccine, children can easily escape protection. Better medical and public education will improve uptake in Russian children as it has in British children. As Rich’s figures show, it is the adult population which is most at risk. That is so not just in Russia but also in western countries

generally.

Hiroshi Kawane Department of Medicine, Kawasaki 1 2

Medical School, Kurashiki City 701-01, Japan

Kawane H. Smoking betrays the friend. Lancet 1993; 342: 1120. Anon. Lifestyles among female employees in a life insurance company.

Yomiuri Shimbun, Jan 13, 1994: 16.

Screening for coeliac disease SIR—Catassi and colleagues (Jan 22, p 200) report on the of subclinical coeliac disease in children. We agree with Challacombe (commentary, p 188) that delayed diagnosis is common in adults. We have diagnosed and treated 17 adults in whom we diagnosed coeliac disease. The patients were referred to the gastroenterology or medical outpatient clinics of our hospital. The diagnosis was made on the basis of two biopsies-at presentation and after a gluten-free diet-

diagnosis

and histological improvement. 6 men and 11 women (average age 43, range 18-69). 3 had a childhood history of coeliac disease (subsequently forgotten); symptoms in the others were diarrhoea (8), weight loss (5), and polymyositis (1). We found iron deficiency (mean serum iron 45 moljL) in all 9 patients tested, folate deficiency (average 2-52 nmol/L) in 9 out of 10, and vitamin B12 deficiency in 1. Coeliac disease may present unusually (eg, at age 69 or with symptoms that included polymyositis and severe

showing clinical, biochemical,

There were

VA Ivanov Queen Elizabeth Hospital for Children, London E2 8PS, UK

Compulsory treatment for Infectious disease SiR-Morton and Campbell (Feb 5, p 359) are correct in their section 37 of the UK’s Public Health (Control of 1984 contains no power for compulsory treatment Disease) Act of patients. However, many of the powers of this Act stem from the 1988 regulations, and this applies to tuberculosis. Section 37 only allows for removal to a suitable hospital; the person is free to walk out of the hospital immediately. Section 38 allows for detention but it can only be used if the person is already in hospital. A justice of the peace has to follow the vehicle being used to convey a person under section 37 so that a section 38 order can be served to prevent that person walking out. The view that treatment can be compulsory may thus arise from this compulsory detention. If the patient refuses treatment the section 38 order can be continued and when he or she complies the order can be lifted. The situation may arise in which patients can only leave hospital if they take adequate treatment-not technically compulsory treatment but the same thing. A combination of removal and essentially detention (sections 37 and 38) should be considered in the long overdue review of the law on communicable diseases, as should the ethical and legal problems arising from the public health threat of multi-drug resistant tuberculosis. comment that

proteinuria). We noted raised levels of anti-gliadin IgA in all 4 patients tested. The possibility of screening for coeliac disease by non-invasive serological testing in adults has been addressed previously.1.2 Of 25 patients with positive serum reticulin or gliadin antibody titres but normal small bowel on biopsy, 7 were found to develop villous atrophy during median followup of 5 years.3 Coeliac disease is underdiagnosed and a raised level of awareness could result in an increase in diagnosis-by noninvasive serological testing or by more duodenal biopsies during endoscopy for non-specific complaints. S D H Malnick, Y Lurie, D D Bass, D Geltner Department of Internal Medicine C and Division of Gastroenterology, Kaplan Hospital, Rehovot, Israel 1

2

Keith Neal

Watson EGP, McMillan SA, Dickey W, Biggart JD, Porter KG. Detection of undiagnosed coeliac disease with atypical features using antireticulin and antigliadin antibodies. Q J Med 1992; 84: 713-18. Carroccio A, Tacono G, Montalto G, et al. Immunologic and absorptive tests in celiac disease: can they replace intestinal biopsies? Scand J Gastroenterol 1993; 28: 673-76. Collin P, Helin M, Maki M, Hallstrom O, Karvonen A-L. Follow-up of patients positive in reticulin and gliadin antibody tests with normal small-bowel biopsy findings. Scand J Gastroenterol 1993; 28: 595-98.

Department of Public Health Medicine and Epidemiology, University Hospital, Queen’s Medical Centre, Nottingham NG7 2UH, UK

3

Cigarette smoking in the next world

SiR-Challacombe stresses the importance of reliable noninvasive screening tests for coeliac disease. I wish to report a clinical observation which may be a first step towards such a

mx-1 was asnamea to

see tne

pnotograpn presented by

Nussenzweig and Biggs (Feb 5, p 365). However, the message in English displayed on that cigarette vending machine must be for foreign visitors. There are no Japanese words there with the same meaning: the part in Japanese simply tells people how to use the machine and warns that underage smoking is prohibited by law. "... over there" says the message "Cigarettes are offered

to

express friendliness". Over there may

mean

"the

test.

A boy now aged 8 years presented at the age of 3 years with steatorrhoea, irritability, distension of the abdomen, and

growth failure. A jejunal biopsy showed mucosal atrophy. He was put on a gluten-free diet; all clinical manifestations cleared and reappeared on rechallenge with gluten. Ever since, he has been on a gluten-free diet and symptom-free. 675

presumably being absorbed. The mother intervened at this stage, and fears of systemic absorption of insecticide prevented further trials of this novel method. The remaining larvae were removed by gentle pressure applied from opposite sides of the lesions by the mother and swift action with tweezers. A 45-year-old African male nurse presented with severe anxiety and a live, motile larva of C anthropophaga in a piece of tissue paper. He had a 3-4 cm inflamed lesion on the penis and two on the scrotum, in one of these was a small, sharp-edged depression from which the larva had presumably emerged. On being informed that the cause was tumbu fly larva and the

Figure: Ungual atrophy In 8-year-old boy with coeliac disease Inadvertently exposed to chewable granules containing wheatgerm

Recently, apparently because of problems at school, he became overactive with tics. He was medicated, twice a day orally, with granules that contained very small amounts of phenylmalonylurea, cholesterol, citric acid, phosphate, calcium, and passiflora and a significant quantity of wheat germ. Because the granules were sweet he started to chew the granules, keeping them for a long time on his tongue, before swallowing. Within 2 weeks an atrophic lesion appeared on his tongue (figure); this cleared in 4 weeks when the medication stopped. Might the granules containing wheatgerm

treatment was pressure and tweezers, he declined further medical attention. When he was seen two weeks later the lesions had healed. Revolutionary methods for the removal of these, and similar, larvae appear from time to time.1,2 Most offer little advantage over the "old wives’ method" of gentle pressure and tweezer extraction. Sticking plaster has much to recommend it.3Bacon therapy1 takes too long and might be problematic in an Islamic country. Prevention is better than cure: all clothes or bedding dried in the open air should be ironed.4

Paul Nunn Tuberculosis

1 2

was

3

and chewed in close contact with the tongue mucosa, have caused, as in jejunal mucosa, accelerated degradation and atrophy of the cells? If so, this could be developed as a non-invasive screening test, and perhaps lingual biopsy might take the place of jejunal biopsy.

4

J M Ramos de Almeida Faculty of Medical Sciences, Campo Martires da Pátria 130, 1100 Lisbon, Portugal

Tangling with tumbu larvae SiR-There is more to myiasis than meets the eye (Bernhard’s commentary, Dec 4, p 1377). Three cases from the early 1980s illustrate the point. A 37-year-old expatriate physician working in West Africa presented with two inflamed and intensively painful 12 x 10 cm areas on the flank, on and just below the waist. Both discharged serous fluid from a central raw area. The patient had diagnosed "tumbu" fly, and injudicious attempts to dislodge them himself from this inaccessible site had resulted in the rupture of the larvae and a severe inflammatory response. An 8-month-old expatriate infant with nine lesions on the back, legs, and arms had been diagnosed by her father, a physician, as having chickenpox. Then the posterior spiracles of Cordylobia anthropophaga larvae were seen to move inside the "pustules" of two of the lesions. The father attempted to persuade the larvae to exit of their own accord by applying petroleum jelly. However, in West Africa petroleum jelly is often liquid and the attempt was unsuccessful. Pursuing larval asphyxiation, the father applied toothpaste, with equal lack of success. He then tried intoxication, pouring gin into a ring of plasticine around one lesion. The plasticine began to dissolve but the larvae were unaffected. At this point the infant became rather restless and the father may have lost his presence of mind for he cut a 1 cm hole in an A4 card and, placing this over the largest lesion, gave a less than one second burst of insecticide from an aerosol can held at about 30 cm. After about 15 seconds of violent movement the larva lay still. The lesion disappeared within about 4 days with no further intervention, the larva

676

Programe, World Health Organization, Geneva 27, Switzerland

Brewer TF, Wilson ME, Gonzalez E, Festenstein D. Bacon therapy and furuncular myiasis. JAMA 1993; 270: 2087-88. Loong PT, Lui H, Buck HW. Cutaneous myiasis: a simple and effective technique for extraction of Dermatobia hominis larvae. Int J Dermatol 1992; 31: 657-59. Oliver PR. Tackling tumbu fly larvae. Lancet 1985; ii: 37. Jopling WH. Ironing out the tumbu fly. Lancet 1982; i: 1254.

Intimal

injury In variant angina

SiR-Etsuda and colleagues (Nov 27, p 1322) report intimal at the site of induced or spontaneous coronary artery spasm in some patients with variant angina. Although few patients were investigated the study was well designed and revealed significant intimal damage at sites of spasm. However, their conclusion seems to me to be the wrong way round. Etsuda et al draw on animal models of atherosclerosis after deliberate intimal damage and conclude that "intimal injury is related to the pathogenesis of comary artery spasm". This may be reasonable in experiments where endothelial denudation is primary but why would coronary arteries in patients with

injury

variant angina be damaged in the first place, so as to predispose them to spasm? The lack of any relation between intimal damage and frequency of previous angina is irrelevant where spasm is being deliberately provoked (or occurring spontaneously) during the acute study period. It seems much more likely that the relation is the other way around-ie, that acute focal coronary artery spasm leads to a local increase in blood flow velocity and turbulence at the site, with corresponding alteration of wall shear stress and secondary intimal damage. This makes sense from the theoretical standpoint’ and is supported by evidence2.3 of vascular damage at the site of deliberate, experimental arterial constriction, and within a very short space of time.3

G W Boyd Department of Medicine, University of Tasmania, Hobart Tasmania 7000, Australia 1 2

3

Boyd GW. Atherosclerosis. In Boyd GW, ed. On stress, disease and evolution. Hobart: University of Tasmania, 1989: 51. Fry DL. Acute vascular endothelial changes associated with increased blood velocity gradients. Circ Res 1968; 22: 165-67. Gertz SD, Uretsky G, Wajnsberg RS, Navot N, Gotsman MS. Endothelial cell damage and thrombosis formation after partial construction: relevance

to

the role of coronary artery spasm in the

pathogenesis of myocardial infarction. Circulation 1981; 63: 476-86.