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CYTOMEGALOVIRUS MONONUCLEOSIS
1153
level, and another had a normal level, which tended to decrease after the lyothyronine therapy. These results accord with the above-mentioned effects of the the untreated state in and hypothyroidism. However, serum-magnesium concentrations increased only slightly in patients with hyperthyroidism after clinical improvement following methimazole therapy. Further studies into the relation between the thyroid gland and magnesium metabolism
thyroid on magnesium metabolism in patients with both hyperthyroidism
seem
necessary. Department of Pædiatrics, Faculty of Medicine, University of Tokyo, Japan.
AKIO KOBAYASHI KEIKO TAKEUCHI.
CYTOLOGICAL EXAMINATION OF THE SPUTUM SIR,-The technique of cytological examination of the sputum, using cell concentrates after liquefaction by ultrasonic disintegration as described by Dr. Kuper and Dilys Shortridge (Nov. 11, p. 999) and Dr. Oppenheimer and his colleagues (p. 1001), can have no real value in the investigation of bronchial asthma. Asthmatics’ sputa have a characteristic appearance,1 which can only be fully demonstrated by paraffin sections of fixed sputum. Such sections display the typical features of these sputa in their entirety, showing the mucoproteinous matrix, eosinophils, shed epithelial fragments (the " Creola bodies " of Naylor 2), Kurschmann’s spirals, Charcot-Leyden crystals, and, most important of all, the formed laminated plugs. They will also demonstrate small but definite " asthmatic " foci in predominantly mucopurulent or otherwise
nondescript sputa. Dr. Oppenheimer and his colleagues state that they " have been mainly interested in the eosinophil leucocytes ", and use their technique to make leucocyte counts, expressing eosinophils as a percentage of total leucocytes. There is little to be gained and much to lose by undertaking such counts, whether on smears, cell concentrates, or in paraffin sections. (In fact, the paraffin-section technique was formerly used at this laboratory for the identification and counting of eosinophils.) There are two main reasons for this: (a) sputum showing definite asthmatic foci may be predominantly mucopurulent, in which case the eosinophils will form a negligible percentage of the total leucocyte count; (b) in many asthmatic plugs, often from patients with severe asthmatic attacks, the great majority of the eosinophils may be so degenerate as to be unrecognisable. Since cell concentrates merely demonstrate recognisable eosinophils, the technique is inferior to one giving smears which will show both eosinophils and shed epithelial fragments. Smears, in turn, are inferior to paraffin sections, since they fail to display the typical structure of formed asthmatic plugs and cannot demonstrate small asthmatic foci in predominantly mucopurulent sputa. The usefulness of the various techniques is shown
as
1. 2.
CYTOMEGALOVIRUS MONONUCLEOSIS SIR,-Cytomegalovirus has been found to cause a disease resembling infectious mononucleosis. We report here cytomegalovirus mononucleosis in a 2-year-old boy, a 5-month-old girl, and a 1-year-old boy. Clinical features were fever, enlargement of lymph-nodes, and hepatosplenomegaly, except DIFFERENTIAL COUNTS OF LEUCOCYTES AND WHITE AND RED BLOOD-CELL COUNTS
AT
EXAMINATIONS REVEALING
THE
HIGHEST
NUMBER
OF
LEUCOCYTES
in the third patient. Pharyngitis was found in only the first patient. Liver-function tests showed slight impairment in all patients. The blood-findings are shown in the accompanying table. Cytomegalovirus was isolated from urine of all patients, and from both urine and saliva of the second patient, in the course of their illnesses. All patients had negative Paul-Bunnell tests and high titres of cytomegalovirus complement-fixing antibody. We think that cytomegalovirus mononucleosis might be a clinical form of primary infection with cytomegalovirus. Department of Pædiatrics, Sapporo Medical College, S.1 W.16, Sapporo, Japan.
TOORU NAKAO SHUNZO CHIBA MASAMI OHSAKI HISAAKI HANAZONO.
follows:
possible but unnecessary, and could be with all techniques. Cell-concentration techniques could well have a useful role in the demonstration of malignant cells, and possibly for the identification of asbestos bodies, parasites, or cytomegalic or other inclusions, but they should certainly not be used for the investigation of bronchial asthma. Group Laboratory, St. David’s Hospital, N. G. SANERKIN. Cowbridge Road, Cardiff.
Eosinophil misleading
*#* This letter has been shown to Dr. Kuper, whose reply follows.-ED. L. SIR,-The brunt of Dr. Sanerkin’s point is unsuitability of homogenisation when looking for eosinophils. This may well be a valid point, but it is one that I would prefer to have answered by my clinical colleagues in the appropriate paper, who have returned to America. I think Dr. Sanerkin somewhat overemphasises his case in favour of sections. In my experience, ordinary smears fixed in Schaudinn’s fluid and stained with haematoxylin and eosin are perfectly satisfactory for the recognition of the eosinophils, epithelial fragments, and Kurschmann’s spirals. In any case, I have been interested primarily in methods of concentrating cellular elements in homogenised sputum-not in assessing whether aggregations of eosinophils and bronchial casts are present. The latter are easily recognised in smear and I normally report them as " aggregates of preparations eosinophils " and " Kurschmann’s spirals ". Brompton Hospital, S. W. A. KUPER. London S.W.3.
counts are
Sanerkin, N. G., Evans, D. M. D. J. Path. Bact. 1965, 89, 535. Naylor, B. Thorax, 1962, 17, 69.
M.C.Q. AND THE MEMBERSHIP SIR,-The depressing lesson to aspiring candidates for the M.R.C.P. who have already failed part I must be that they deserved to fail, that they would have failed part n anyway, and that they will fail part i when they try again. Perhaps they hold with Claude Bernard (a great sceptic in matters statistical) that " what is true in general is likely to be false in particular " for them. This view may be shared by statisticians who do not believe in extrapolating beyond the range of their data. The study group of the Royal College of Physicians of London (Nov. 11, p. 1034) might also consider a logical extension of their analysis-for, if the correlation in performance in parts i and II is so good, why bother to hold the second examination
at
all ?
G. H. HALL. 1.
Klemola, E., Kriainen, L. Br. med. J. 1965, ii, 1099. Kriainen, L., Klemola, E., Paloheimo, J. ibid. 1966, i, 1270. Kriainen, L., Paloheimo, J., Klemola, E., Makelä, T., Koivuniemi, A. Annls Med. exp. Biol. Fenn. 1966, 44, 297. Lamb, S. G., Stern, H. Lancet, 1966, ii, 1003.
level, and another had a normal level, which tended to decrease after the lyothyronine therapy. These results accord with the above-mentioned effects of the the untreated state in and hypothyroidism. However, serum-magnesium concentrations increased only slightly in patients with hyperthyroidism after clinical improvement following methimazole therapy. Further studies into the relation between the thyroid gland and magnesium metabolism
thyroid on magnesium metabolism in patients with both hyperthyroidism
seem
necessary. Department of Pædiatrics, Faculty of Medicine, University of Tokyo, Japan.
AKIO KOBAYASHI KEIKO TAKEUCHI.
CYTOLOGICAL EXAMINATION OF THE SPUTUM SIR,-The technique of cytological examination of the sputum, using cell concentrates after liquefaction by ultrasonic disintegration as described by Dr. Kuper and Dilys Shortridge (Nov. 11, p. 999) and Dr. Oppenheimer and his colleagues (p. 1001), can have no real value in the investigation of bronchial asthma. Asthmatics’ sputa have a characteristic appearance,1 which can only be fully demonstrated by paraffin sections of fixed sputum. Such sections display the typical features of these sputa in their entirety, showing the mucoproteinous matrix, eosinophils, shed epithelial fragments (the " Creola bodies " of Naylor 2), Kurschmann’s spirals, Charcot-Leyden crystals, and, most important of all, the formed laminated plugs. They will also demonstrate small but definite " asthmatic " foci in predominantly mucopurulent or otherwise
nondescript sputa. Dr. Oppenheimer and his colleagues state that they " have been mainly interested in the eosinophil leucocytes ", and use their technique to make leucocyte counts, expressing eosinophils as a percentage of total leucocytes. There is little to be gained and much to lose by undertaking such counts, whether on smears, cell concentrates, or in paraffin sections. (In fact, the paraffin-section technique was formerly used at this laboratory for the identification and counting of eosinophils.) There are two main reasons for this: (a) sputum showing definite asthmatic foci may be predominantly mucopurulent, in which case the eosinophils will form a negligible percentage of the total leucocyte count; (b) in many asthmatic plugs, often from patients with severe asthmatic attacks, the great majority of the eosinophils may be so degenerate as to be unrecognisable. Since cell concentrates merely demonstrate recognisable eosinophils, the technique is inferior to one giving smears which will show both eosinophils and shed epithelial fragments. Smears, in turn, are inferior to paraffin sections, since they fail to display the typical structure of formed asthmatic plugs and cannot demonstrate small asthmatic foci in predominantly mucopurulent sputa. The usefulness of the various techniques is shown
as
1. 2.
CYTOMEGALOVIRUS MONONUCLEOSIS SIR,-Cytomegalovirus has been found to cause a disease resembling infectious mononucleosis. We report here cytomegalovirus mononucleosis in a 2-year-old boy, a 5-month-old girl, and a 1-year-old boy. Clinical features were fever, enlargement of lymph-nodes, and hepatosplenomegaly, except DIFFERENTIAL COUNTS OF LEUCOCYTES AND WHITE AND RED BLOOD-CELL COUNTS
AT
EXAMINATIONS REVEALING
THE
HIGHEST
NUMBER
OF
LEUCOCYTES
in the third patient. Pharyngitis was found in only the first patient. Liver-function tests showed slight impairment in all patients. The blood-findings are shown in the accompanying table. Cytomegalovirus was isolated from urine of all patients, and from both urine and saliva of the second patient, in the course of their illnesses. All patients had negative Paul-Bunnell tests and high titres of cytomegalovirus complement-fixing antibody. We think that cytomegalovirus mononucleosis might be a clinical form of primary infection with cytomegalovirus. Department of Pædiatrics, Sapporo Medical College, S.1 W.16, Sapporo, Japan.
TOORU NAKAO SHUNZO CHIBA MASAMI OHSAKI HISAAKI HANAZONO.
follows:
possible but unnecessary, and could be with all techniques. Cell-concentration techniques could well have a useful role in the demonstration of malignant cells, and possibly for the identification of asbestos bodies, parasites, or cytomegalic or other inclusions, but they should certainly not be used for the investigation of bronchial asthma. Group Laboratory, St. David’s Hospital, N. G. SANERKIN. Cowbridge Road, Cardiff.
Eosinophil misleading
*#* This letter has been shown to Dr. Kuper, whose reply follows.-ED. L. SIR,-The brunt of Dr. Sanerkin’s point is unsuitability of homogenisation when looking for eosinophils. This may well be a valid point, but it is one that I would prefer to have answered by my clinical colleagues in the appropriate paper, who have returned to America. I think Dr. Sanerkin somewhat overemphasises his case in favour of sections. In my experience, ordinary smears fixed in Schaudinn’s fluid and stained with haematoxylin and eosin are perfectly satisfactory for the recognition of the eosinophils, epithelial fragments, and Kurschmann’s spirals. In any case, I have been interested primarily in methods of concentrating cellular elements in homogenised sputum-not in assessing whether aggregations of eosinophils and bronchial casts are present. The latter are easily recognised in smear and I normally report them as " aggregates of preparations eosinophils " and " Kurschmann’s spirals ". Brompton Hospital, S. W. A. KUPER. London S.W.3.
counts are
Sanerkin, N. G., Evans, D. M. D. J. Path. Bact. 1965, 89, 535. Naylor, B. Thorax, 1962, 17, 69.
M.C.Q. AND THE MEMBERSHIP SIR,-The depressing lesson to aspiring candidates for the M.R.C.P. who have already failed part I must be that they deserved to fail, that they would have failed part n anyway, and that they will fail part i when they try again. Perhaps they hold with Claude Bernard (a great sceptic in matters statistical) that " what is true in general is likely to be false in particular " for them. This view may be shared by statisticians who do not believe in extrapolating beyond the range of their data. The study group of the Royal College of Physicians of London (Nov. 11, p. 1034) might also consider a logical extension of their analysis-for, if the correlation in performance in parts i and II is so good, why bother to hold the second examination
at
all ?
G. H. HALL. 1.
Klemola, E., Kriainen, L. Br. med. J. 1965, ii, 1099. Kriainen, L., Klemola, E., Paloheimo, J. ibid. 1966, i, 1270. Kriainen, L., Paloheimo, J., Klemola, E., Makelä, T., Koivuniemi, A. Annls Med. exp. Biol. Fenn. 1966, 44, 297. Lamb, S. G., Stern, H. Lancet, 1966, ii, 1003.