- Email: [email protected]
CHLOROQUINE-RESISTANT MALARIA IN MOZAMBIQUE
897
cortex.
Fig 1-Guineapig: cerebral and Numerous vacuoles, some indicated by arrowheads (haematoxylin
eosin, x 160).
CJD, and the times of death of other animals were consistent with CJD since control (non-infectious brain) does not cause significant mortality during this period. The buffy coat of patient 2 was inoculated into five hamsters and five guineapigs (30 1 and 50 1, respectively, of a 50% crude homogenate in saline). Three hamsters died,partly cannibalised and autolytic, 285, 306, and 379 days after inoculation, consistent with CJD transmission, but none had any obvious clinical signs of experimental CJD. However, two hamsters were killed at 323 and 360 days with clinical signs; one was frail and hunched for over 1 week and the other was weak and had had fluid retention and diarrhoea for about 3 weeks. Both brains were positive for CJD (fig 2). None of the five guineapigs acquired signs ofCJD, although they were observed for more than 1118 days. Control experiments were done in guineapigs inoculated with buffy coat from normal controls. These animals showed no clinical signs and lived for at least 1200 days. In both guineapigs and hamsters intracerebral inoculation of normal human and rodent brain, spleen, liver, cornea, and guineapig buffy coat never resulted in histologically characteristic CJD. In both patients CJD was diagnosed clinically and confirmed histologically. In some cases of scrapie or CJD the changes in the brain may be subtle, as in patient 2. Even microscopy may sometimes be insufficient for a positive diagnosis.l0 In such instances animal transmission can clarify the situation. The neuropathological diagnoses were confirmed by positive transmission from biopsy (case 1) and necropsy (case 2) samples into laboratory animals. Buffy coat samples were also positive (histologically verified) in transmission. We have thus
demonstrated viraemia in patients harbouring CJD, utilising the buffy coat of blood obtained at end stages of the disease. We do not know when (or at what periods) during the human disease viraemia appears. Buffy coat was obtained 4 days and 27 days before the deaths of patients 1 and 2, respectively. In experimental CJD in guineapigs viraemia was detected as early as 1 week after intracerebral inoculation and persisted throughout the course of the disease up to the end stages (28 weeks post inoculation). It is reasonable to consider that persistent viraemia in human beings with CJD may also occur. Extreme caution is therefore appropriate when blood is used for transfusion purposes; blood from any donor with dementia should be rejected, even if the cause of the condition has not been proven to be infectious. Some investigators consider that some dementias of unknown aetiology, including cases of Alzheimer’s disease, may have an infectious causesWhere brain biopsy is not medically justified, especially during early stages of the disease, transmission and biochemical experiments with buffy coat may be both useful and revealing; this procedure is also harmless. Some patients with dementias other than CJD may also harbour infectious agents in the blood at early stages of the disease, and these infectious agents may not be detectable at late or end stage periods.
Supported by the NIH grants AG 03106 and NS 12674 and Commonwealth Fund of America.
Section of Neuropathology, Yale University School of Medicine, New Haven, Connecticut 06510, USA
_...._._.......__...._.__..........._...v.._
Xumerous vacuoles of varying size
(haematoxylin and eosin; x 32).
in
the corpora
quadngemma
the
ELIAS E. MANUELIDIS JUNG H. KIM JAMES R. MERICANGAS LAURA MANUELIDIS
1.
Manuelidis EE, Gorgacz EJ, Manuelidis L. Viremia in experimental Creutzfeldt-Jakob disease. Science 1978; 200: 1069. 2. Kuroda Y, Gibbs CJ Jr, Amyx HL, Gajdusek DC. Creutzfeldt-Jakob disease in mice: Persistent viremia and preferential replication of virus in low-density lymphocytes. Infect Immun 1983; 41: 154. 3. Tateishi J, Sato Y, Koga M, Doi H, Ohta M. Experimental transmission of human subacute spongiform encephalopathy to small rodents I: Clinical and histological observations. Acta Neuropathol (Berl) 1980; 51: 127. 4. Diringer H. Sustained viremia in experimental hamster scrapie. Arch Virol 1984; 82: 105. 5. Clarke MC, 6. 7.
8. 9. 10.
Haig DA. Presence of the transmissible agent of scrapie in the serum of affected mice and rats. Vet Rec 1967; 80: 504. Dickinson AG, Meiule VMH, Fraser H. Genetical control ofthe concentration ofME7 scrapie agent in the brain of mice. J Comp Pathol 1969; 79: 15. Field EJ, Caspary EA, Joyce G. Scrapie agent in blood. Vet Rec 1968; 83: 109. Manuelidis EE, Manuelidis L, Pincus JH, Collins WF. Transmission from man to hamster, of Creutzfeldt-Jakob disease with clinical recovery. Lancet 1978; ii: 40. Manuelidis EE, Kim J, Angelo JN, Manuelidis L. Serial propagation of CreutzfeldtJakob disease in guinea pigs. Proc Natl Acad Sci USA 1976; 73: 223. Manuelidis EE. Presidential address: Creutzfeldt-Jakob disease. J Neuropathol Exp Neurol
1985, 44:
1.
CHLOROQUINE-RESISTANT MALARIA IN MOZAMBIQUE SIR,-Your June 29 editorial correctly includes Mozambique among African countries where chloroquine-resistant malaria has been detected. Since there has not yet been a description in an international journal of chloroquine resistance in Mozambique we would like to present some data and to indicate how we are tackling the problem. The first cases of chloroquine-resistant falciparum malaria in Mozambique were in 1983 in non-immune visitors who had been to neighbouring African countries. In the same year in-vivo resistance was also found in semi-immune Mozambicans in Maputo and All cases detected during 1983-84 have been summarised in a local journal.I In 1985 there has been a sharp increase in cases of chloroquineresistant malaria in Maputo. By the end of June, 79 cases had been verified by in-vivo tests at our institution, while nearly twice as many patients had received second-line treatment at other health centres because symptoms and parasites persisted beyond a week after adequate and supervised chloroquine therapy. In-vitro tests on randomly selected symptomless carriers have confirmed the seriousness of the situation. Isolates with a minimum inhibitory concentration of 1 - 6 mol/1 or more in the micro-scale in-vitro Plasmodiumfalciparum chloroquine susceptibility test were defined as resistant. During 1985 8/10 isolates successfully tested from Nampula were chloroquine resistant, and in Quelimine the figures
Nampula.
Fig 2-Hamster: midbrain.
by
898 were 8/14 and in Maputo 39/50. Local health authorities in Beira and Tete are reporting in-vitro resistant cases with increasing frequency. The very high frequency of resistant cases in Maputo may be ascribed to the low and variable immunity of the population in the capital, where malaria transmission is seasonal. Population movements and the presence of non-immune foreigners add to Maputo’s vulnerability, and it has been decided to initiate in 1985 a vector control programme, where systematic spraying of homes with DDT will complement drainage projects already in progress. It is hoped that this programme will help to reduce the need to prescribe second-line antimalarial drugs. We agree that amodiaquine is a useful alternative to chloroquine, but worry that its use as monotherapy may soon lead to widespread resistance. In the hope that combination therapy will delay the emergence of resistance, the Ministry of Health in Mozambique has decided to authorise amodiaquine combined with sulfadoxine and pyrimethamine, all in full therapeutic dosages, as second-line treatment. Every effort is being made to monitor the response to both drugs. The cure rate of proven chloroquine-resistant malaria with these combinations has been 93% in Maputo. What advice should be given to non-immune people going to Mozambique? The World Health Organisation recommends chloroquine or amodiaquine combined with proguanil or chlorproguanil in areas with a low degree of resistance,which Mozambique is still considered to be. Evidence on the efficacy of the biguanides here is scanty, but until this has been studied, their inclusion in a prophylactic regimen must be considered as safe an option as any other. In our experience the use of a therapeutic drug for prophylaxis leads to lax attitudes, and we would like to see both amodiaquine and pyrimethamine/sulfadoxine reserved for treating patients, including the country’s expatriate population.
National Institute of Health,
JOÃO SCHWALBACH
Ministry of Health, CP 264, Maputo, Mozambique
ALLAN SCHAPIRA GASSAN SULEIMANOV
1 Franco LTA, Schwalbach J, Fernandes A, Schapira A Exisiencia, em Moçamblque, de malária (P falciparum) resistente a cloroquina (1983-1984). Revista Méd 1984; 2: 83-84. 2. WHO Weekly Epidemiol Rec 1984, 30: 229-35.
Mocambique
EARLY DETECTION OF EXPERIMENTAL ALLERGIC ENCEPHALOMYELITIS BY MAGNETIC RESONANCE IMAGING
SIR,-Experimental allergic encephalomyelitis (EAE) is an animal model for multiple sclerosis. We report here a preliminary study of EAE in primates in which nuclear magnetic resonance imaging (NMRI) detected lesions before the onset of clinical signs. EAE was induced in a Macacafascicularis monkey by injection of monkey basic protein in Freund’s adjuvant intradermally in the hindfoot pad.2We used a Picker International ’NMR Cryogenic 2000’ system, operating at a field strength of0’15tt (corresponding to a proton resonance frequency of 6 4 MHz). The receiver coil was 15 cm in diameter. Both multislice spin-echo and inversionrecovery sequences were used, each providing eight contiguous 5 mm thick slices. Echo delays of 40 ms and 60 ms were used in the spin-echo sequepces. A T-time of 400 ms was used for the inversionrecovery sequence; in all sequences the repeat time was 2 s. These constants were chosen to allow direct comparison with human multiple sclerosis data. The monkey was observed daily for clinical signs and scanned T, AND T, VALUES FOR (WM), GREY MATTER (GM), AND LESION FROM SAME IMAGE-SLICE, FOR DAYS FOLLOWING SERIAL MEASUREMENTS OF
NORMAL-APPEARING WHITE-MATTER
INOCULATION
Spin-echo image of transverse section (5 mm thick) showing first lesion in left hemisphere (right side of image).
day 9. A definite lesion was observed in the left cerebral hemisphere 15-8days after inoculation (figure), when no major clinical signs3 were apparent. The development of this lesion and the detection of others was achieved by scanning every 10 h or so. Over 4 days the high-intensity area on the spin-echo image spread throughout the left hemisphere and down into the temporal lobe, The development of clinical symptoms, mainly on the right side of the body, reflected the spread of the lesion in the left hemisphere, Symptoms were first seen on day 16 - 8, starting with spasticity in the right arm and followed by progressive blindness in the right eye. Spin-lattice (TI) and spin-spin (T2) relaxation times were measured on the lesion from the day of appearance until death. A series of these measurements is shown in the table together with the values for grey and white matter which appeared normal in the same image. The computed T2 images did not discriminate between from
normal grey and white matter. The appearance of the first abnormal area was associated with changes that were more obvious in T2 than Tl. However, the change in T became more pronounced with time and the T] of normal appearing white-matter rose slightly before the abnormality was detectable on the print-out. If this early change in T is found to be characteristic it may be possible to use it to predict where a lesion will occur. Although this observation requires confirmation it is encouraging that NMRI in a second monkey has revealed the same sequence. Successful characterisation of the lesions for EAE in primates will provide the basis for extending these studies to multiple sclerosis. The differential between TI and T2 measurements may prove helpful in differentiating early from late lesions. Department
of Chemistry, British Columbia,
University of
Vancouver, Canada
W. A. STEWART
Department of Neuropathology, University of Washington Medical School, Seattle, Washington, USA
E. C. ALVORD S. HRUBY
Laboratory for Medicinal Chemistry, Cambridge University School of Clinical Medicine, Addenbrooke’s Hospital, Cambridge CB2 2QQ
L. D. HALL
Division
of Neurology, Department of Medicine, Health Sciences Centre Hospital, University of British Columbia 1. Raine CS 2 3
D. W. PATY
Biology of disease. Analysis of autoimmune demyelination, its impact upon multiple sclerosis J Lab Invest 1984, 50: 608-35. Alvord EC, Shaw C, Hruby S. Myelin basic protein: Treatment of experimental allergic encephalomyelitis in monkeys Ann Neurol 1979; 6: 469-73 Alvord EC, Shaw CM, Hruby S, et al. The onset of experimental allergic encephalomyelitis as defined by clinical, electro-physiological and immunochemical changes In Alvord EC, Kies MW, Suckling AJ, eds Experimental allergic encephalomyelitis, a useful model for multiple sclerosis (Progr Clin Biol Res 1983, 146) New York Alan R Liss, 1983. 461-66
cortex.
Fig 1-Guineapig: cerebral and Numerous vacuoles, some indicated by arrowheads (haematoxylin
eosin, x 160).
CJD, and the times of death of other animals were consistent with CJD since control (non-infectious brain) does not cause significant mortality during this period. The buffy coat of patient 2 was inoculated into five hamsters and five guineapigs (30 1 and 50 1, respectively, of a 50% crude homogenate in saline). Three hamsters died,partly cannibalised and autolytic, 285, 306, and 379 days after inoculation, consistent with CJD transmission, but none had any obvious clinical signs of experimental CJD. However, two hamsters were killed at 323 and 360 days with clinical signs; one was frail and hunched for over 1 week and the other was weak and had had fluid retention and diarrhoea for about 3 weeks. Both brains were positive for CJD (fig 2). None of the five guineapigs acquired signs ofCJD, although they were observed for more than 1118 days. Control experiments were done in guineapigs inoculated with buffy coat from normal controls. These animals showed no clinical signs and lived for at least 1200 days. In both guineapigs and hamsters intracerebral inoculation of normal human and rodent brain, spleen, liver, cornea, and guineapig buffy coat never resulted in histologically characteristic CJD. In both patients CJD was diagnosed clinically and confirmed histologically. In some cases of scrapie or CJD the changes in the brain may be subtle, as in patient 2. Even microscopy may sometimes be insufficient for a positive diagnosis.l0 In such instances animal transmission can clarify the situation. The neuropathological diagnoses were confirmed by positive transmission from biopsy (case 1) and necropsy (case 2) samples into laboratory animals. Buffy coat samples were also positive (histologically verified) in transmission. We have thus
demonstrated viraemia in patients harbouring CJD, utilising the buffy coat of blood obtained at end stages of the disease. We do not know when (or at what periods) during the human disease viraemia appears. Buffy coat was obtained 4 days and 27 days before the deaths of patients 1 and 2, respectively. In experimental CJD in guineapigs viraemia was detected as early as 1 week after intracerebral inoculation and persisted throughout the course of the disease up to the end stages (28 weeks post inoculation). It is reasonable to consider that persistent viraemia in human beings with CJD may also occur. Extreme caution is therefore appropriate when blood is used for transfusion purposes; blood from any donor with dementia should be rejected, even if the cause of the condition has not been proven to be infectious. Some investigators consider that some dementias of unknown aetiology, including cases of Alzheimer’s disease, may have an infectious causesWhere brain biopsy is not medically justified, especially during early stages of the disease, transmission and biochemical experiments with buffy coat may be both useful and revealing; this procedure is also harmless. Some patients with dementias other than CJD may also harbour infectious agents in the blood at early stages of the disease, and these infectious agents may not be detectable at late or end stage periods.
Supported by the NIH grants AG 03106 and NS 12674 and Commonwealth Fund of America.
Section of Neuropathology, Yale University School of Medicine, New Haven, Connecticut 06510, USA
_...._._.......__...._.__..........._...v.._
Xumerous vacuoles of varying size
(haematoxylin and eosin; x 32).
in
the corpora
quadngemma
the
ELIAS E. MANUELIDIS JUNG H. KIM JAMES R. MERICANGAS LAURA MANUELIDIS
1.
Manuelidis EE, Gorgacz EJ, Manuelidis L. Viremia in experimental Creutzfeldt-Jakob disease. Science 1978; 200: 1069. 2. Kuroda Y, Gibbs CJ Jr, Amyx HL, Gajdusek DC. Creutzfeldt-Jakob disease in mice: Persistent viremia and preferential replication of virus in low-density lymphocytes. Infect Immun 1983; 41: 154. 3. Tateishi J, Sato Y, Koga M, Doi H, Ohta M. Experimental transmission of human subacute spongiform encephalopathy to small rodents I: Clinical and histological observations. Acta Neuropathol (Berl) 1980; 51: 127. 4. Diringer H. Sustained viremia in experimental hamster scrapie. Arch Virol 1984; 82: 105. 5. Clarke MC, 6. 7.
8. 9. 10.
Haig DA. Presence of the transmissible agent of scrapie in the serum of affected mice and rats. Vet Rec 1967; 80: 504. Dickinson AG, Meiule VMH, Fraser H. Genetical control ofthe concentration ofME7 scrapie agent in the brain of mice. J Comp Pathol 1969; 79: 15. Field EJ, Caspary EA, Joyce G. Scrapie agent in blood. Vet Rec 1968; 83: 109. Manuelidis EE, Manuelidis L, Pincus JH, Collins WF. Transmission from man to hamster, of Creutzfeldt-Jakob disease with clinical recovery. Lancet 1978; ii: 40. Manuelidis EE, Kim J, Angelo JN, Manuelidis L. Serial propagation of CreutzfeldtJakob disease in guinea pigs. Proc Natl Acad Sci USA 1976; 73: 223. Manuelidis EE. Presidential address: Creutzfeldt-Jakob disease. J Neuropathol Exp Neurol
1985, 44:
1.
CHLOROQUINE-RESISTANT MALARIA IN MOZAMBIQUE SIR,-Your June 29 editorial correctly includes Mozambique among African countries where chloroquine-resistant malaria has been detected. Since there has not yet been a description in an international journal of chloroquine resistance in Mozambique we would like to present some data and to indicate how we are tackling the problem. The first cases of chloroquine-resistant falciparum malaria in Mozambique were in 1983 in non-immune visitors who had been to neighbouring African countries. In the same year in-vivo resistance was also found in semi-immune Mozambicans in Maputo and All cases detected during 1983-84 have been summarised in a local journal.I In 1985 there has been a sharp increase in cases of chloroquineresistant malaria in Maputo. By the end of June, 79 cases had been verified by in-vivo tests at our institution, while nearly twice as many patients had received second-line treatment at other health centres because symptoms and parasites persisted beyond a week after adequate and supervised chloroquine therapy. In-vitro tests on randomly selected symptomless carriers have confirmed the seriousness of the situation. Isolates with a minimum inhibitory concentration of 1 - 6 mol/1 or more in the micro-scale in-vitro Plasmodiumfalciparum chloroquine susceptibility test were defined as resistant. During 1985 8/10 isolates successfully tested from Nampula were chloroquine resistant, and in Quelimine the figures
Nampula.
Fig 2-Hamster: midbrain.
by
898 were 8/14 and in Maputo 39/50. Local health authorities in Beira and Tete are reporting in-vitro resistant cases with increasing frequency. The very high frequency of resistant cases in Maputo may be ascribed to the low and variable immunity of the population in the capital, where malaria transmission is seasonal. Population movements and the presence of non-immune foreigners add to Maputo’s vulnerability, and it has been decided to initiate in 1985 a vector control programme, where systematic spraying of homes with DDT will complement drainage projects already in progress. It is hoped that this programme will help to reduce the need to prescribe second-line antimalarial drugs. We agree that amodiaquine is a useful alternative to chloroquine, but worry that its use as monotherapy may soon lead to widespread resistance. In the hope that combination therapy will delay the emergence of resistance, the Ministry of Health in Mozambique has decided to authorise amodiaquine combined with sulfadoxine and pyrimethamine, all in full therapeutic dosages, as second-line treatment. Every effort is being made to monitor the response to both drugs. The cure rate of proven chloroquine-resistant malaria with these combinations has been 93% in Maputo. What advice should be given to non-immune people going to Mozambique? The World Health Organisation recommends chloroquine or amodiaquine combined with proguanil or chlorproguanil in areas with a low degree of resistance,which Mozambique is still considered to be. Evidence on the efficacy of the biguanides here is scanty, but until this has been studied, their inclusion in a prophylactic regimen must be considered as safe an option as any other. In our experience the use of a therapeutic drug for prophylaxis leads to lax attitudes, and we would like to see both amodiaquine and pyrimethamine/sulfadoxine reserved for treating patients, including the country’s expatriate population.
National Institute of Health,
JOÃO SCHWALBACH
Ministry of Health, CP 264, Maputo, Mozambique
ALLAN SCHAPIRA GASSAN SULEIMANOV
1 Franco LTA, Schwalbach J, Fernandes A, Schapira A Exisiencia, em Moçamblque, de malária (P falciparum) resistente a cloroquina (1983-1984). Revista Méd 1984; 2: 83-84. 2. WHO Weekly Epidemiol Rec 1984, 30: 229-35.
Mocambique
EARLY DETECTION OF EXPERIMENTAL ALLERGIC ENCEPHALOMYELITIS BY MAGNETIC RESONANCE IMAGING
SIR,-Experimental allergic encephalomyelitis (EAE) is an animal model for multiple sclerosis. We report here a preliminary study of EAE in primates in which nuclear magnetic resonance imaging (NMRI) detected lesions before the onset of clinical signs. EAE was induced in a Macacafascicularis monkey by injection of monkey basic protein in Freund’s adjuvant intradermally in the hindfoot pad.2We used a Picker International ’NMR Cryogenic 2000’ system, operating at a field strength of0’15tt (corresponding to a proton resonance frequency of 6 4 MHz). The receiver coil was 15 cm in diameter. Both multislice spin-echo and inversionrecovery sequences were used, each providing eight contiguous 5 mm thick slices. Echo delays of 40 ms and 60 ms were used in the spin-echo sequepces. A T-time of 400 ms was used for the inversionrecovery sequence; in all sequences the repeat time was 2 s. These constants were chosen to allow direct comparison with human multiple sclerosis data. The monkey was observed daily for clinical signs and scanned T, AND T, VALUES FOR (WM), GREY MATTER (GM), AND LESION FROM SAME IMAGE-SLICE, FOR DAYS FOLLOWING SERIAL MEASUREMENTS OF
NORMAL-APPEARING WHITE-MATTER
INOCULATION
Spin-echo image of transverse section (5 mm thick) showing first lesion in left hemisphere (right side of image).
day 9. A definite lesion was observed in the left cerebral hemisphere 15-8days after inoculation (figure), when no major clinical signs3 were apparent. The development of this lesion and the detection of others was achieved by scanning every 10 h or so. Over 4 days the high-intensity area on the spin-echo image spread throughout the left hemisphere and down into the temporal lobe, The development of clinical symptoms, mainly on the right side of the body, reflected the spread of the lesion in the left hemisphere, Symptoms were first seen on day 16 - 8, starting with spasticity in the right arm and followed by progressive blindness in the right eye. Spin-lattice (TI) and spin-spin (T2) relaxation times were measured on the lesion from the day of appearance until death. A series of these measurements is shown in the table together with the values for grey and white matter which appeared normal in the same image. The computed T2 images did not discriminate between from
normal grey and white matter. The appearance of the first abnormal area was associated with changes that were more obvious in T2 than Tl. However, the change in T became more pronounced with time and the T] of normal appearing white-matter rose slightly before the abnormality was detectable on the print-out. If this early change in T is found to be characteristic it may be possible to use it to predict where a lesion will occur. Although this observation requires confirmation it is encouraging that NMRI in a second monkey has revealed the same sequence. Successful characterisation of the lesions for EAE in primates will provide the basis for extending these studies to multiple sclerosis. The differential between TI and T2 measurements may prove helpful in differentiating early from late lesions. Department
of Chemistry, British Columbia,
University of
Vancouver, Canada
W. A. STEWART
Department of Neuropathology, University of Washington Medical School, Seattle, Washington, USA
E. C. ALVORD S. HRUBY
Laboratory for Medicinal Chemistry, Cambridge University School of Clinical Medicine, Addenbrooke’s Hospital, Cambridge CB2 2QQ
L. D. HALL
Division
of Neurology, Department of Medicine, Health Sciences Centre Hospital, University of British Columbia 1. Raine CS 2 3
D. W. PATY
Biology of disease. Analysis of autoimmune demyelination, its impact upon multiple sclerosis J Lab Invest 1984, 50: 608-35. Alvord EC, Shaw C, Hruby S. Myelin basic protein: Treatment of experimental allergic encephalomyelitis in monkeys Ann Neurol 1979; 6: 469-73 Alvord EC, Shaw CM, Hruby S, et al. The onset of experimental allergic encephalomyelitis as defined by clinical, electro-physiological and immunochemical changes In Alvord EC, Kies MW, Suckling AJ, eds Experimental allergic encephalomyelitis, a useful model for multiple sclerosis (Progr Clin Biol Res 1983, 146) New York Alan R Liss, 1983. 461-66