Deaths and injuries caused by landmines

Enteritis, eosinophilia,

and Enterobius

vermicularis Sm—Although pinworm infection (enterobiasis or oxyuriasis) is regarded as the most common and the least pathogenic of all human helminth infections, it still can provide surprises, as was proved in Liu and colleagues’ (Aug 12, p 410) case of eosinophilic colitis. We report a similar case in Belgium. A 63-year-old farmer was admitted with a 4-day history of diarrhoea, palpitations, and weight loss in July, 1995. His only medical history was a myocardial infarction with residual angina. He had never been abroad. On physical examination he

rather nervous and slim man with mild dehydration, tachycardia, and otherwise normal vital signs. There was no evidence of visceral organ involvement, but his white cell count was 11.75 XI 09/L with 45% eosinophils. Endoscopy was not done. Direct examination of regular and concentrated stool samples on the day of admission showed multiple nematode larvae, 650 m to 1-0 mm in length. All the larvae examined had a tail tapering to a pointed end, and no genital primordium (figure). These larvae were identified at a reference laboratory for parasitology as rhabditiform larvae of Strongyloides stercoralis, despite their size (two to three times the normal length of rhabditiform strongyloides larvae) and other inconsistent morphological features. Furthermore, no cases of autochthonous stronglyloidiasis have recently been reported in Belgium. The patient received mebendazole (200 mg) for 1 day. His eosinophil count had fallen to 18% on the next day. Ivermectin treatment was given (200 ug/kg daily for 2 days) following the result from the reference laboratory. Serological testing for toxocariasis was negative. The patient recovered and has remained well until now, and a subsequent stool examination was negative. After Liu and colleagues’ publication, the possibility of invasion by female larvae of Enterobius vermicularis was considered on the basis of microscopic appearance. Ethanolpreserved stool samples were delivered to LXL, who undertook a molecular speciation to confirm this morphological diagnosis. Genomic DNA was extracted from single larvae and amplified with primers for the 28S rRNA and 5S spacer rRNA as described by Liu. An approximately 900 bp 5S spacer PCR product was obtained, which was

exactly the size predicted for enterobius-being smaller than the 5S spacer of ascarid nematodes and much larger than those of strongyloides or hookworms. Restriction endonuclease digest patterns of the rRNA products from this Belgian isolate were identical to that of E vermicularis. We believe that this is another case of inflammatory disease of the bowel caused by advanced stage larvae of E vermicularis. Unlike Liu’s earlier case, we observed a high eosinophilia in our patient, which could suggest a fierce invasion of the tissues. We also advocate detailed morphological descriptions in publications addressing parasitological diseases, especially when observations do not fit geographical or travel history.

was a

*I Surmont, L X Liu *Heilig Hartziekenhuis, B 8800 Roeselare, Belgium;

and Beth Israel Harvard Medical School, Boston, Massachusetts, USA

Deaths and

Hospital and

injuries caused by landmines

returned from Afghanistan, I would like to add support to Ascherio and colleagues’ view (Sept 16, p 721) that landmine case-mortality rates are largely underestimated. They are much higher than the 48% that they report for Mozambique and the 40% recorded by Andersson and colleagues’1 in Afghanistan, Bosnia, Cambodia, and Mozambique. It is noteworthy that 75% of all recorded landmine deaths in Ascherio’s series occurred in the prehospital period, which Coupland and Korver show to last most frequently between 6 and 24 h. It is impossible to say how many of those killed instantly by explosions are not taken to hospital and what proportion of these unrecorded deaths are children. Since a pressure of only 5 kg is required to trigger most antipersonnel mines, children are not spared by their lower body weight, and in my experience have a higher case-fatality rate than adults. The closer proximity of a child’s vital organs to the blast usually results in far more severe injury than in adults, which when combined with the child’s greater vulnerability to the stresses of trauma and a long journey to hospital more often leads to a fatal outcome. This added burden compounds the huge survival challenges that children already face in countries such as Afghanistan and Mozambique whose infant mortality rates are already among the highest in the world. It is essential that western governments increase their funding for demining and medical aid in the developing world. A vital part of this aid is mine awareness education, which must be targeted towards the most vulnerable population groups so that needless suffering and death are kept to a minimum.

SiR-Having lately

James G M McDiarmid Department of Anatomy, University College London, London WC1E 6BT, UK

1

2

Andersson N, Palha da Sousa C, Paredes S. Social cost of land mines in four countries: Afghanistan, Bosnia, Cambodia and Mozambique. BMJ 1995; 311: 718-21. Coupland R, Korver A. Injuries from antipersonnel mines: the experience of the International Committee of the Red Cross. BMJ

1991; 303: 1509-12.

SiR-The predicament of antipersonnel mines, like all those involving weapon use and manufacturing, is a moral one, not a political one. As long as there is money to be made, manufacturers will deny any responsibility for these weapons and frustrate political attempts to control them. Knowing the identity of the manufacturers of such items would allow those of us who wish to have one, an avenue of expressing our concern. Economic boycotts have been effective against

Figure: Advanced stage larvae of Enterobius vermicularis

such manufacturers in the past. Please ask those involved to identify the manufacturers. It is a curious fact that most weapons sold to terrorists, revolutionaries, and developing 1167

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countries originate in the major democracies-in particular the USA, which produces about half these weapons. One wonders about the intelligence, honesty, or mendacity (take your choice) of our politicians who bemoan the exporting of terrorism to our shores. Donald J Sherrard Renal Dialysis Unit, Department of Veterans Affairs, Medical Center, Seattle, WA 98108, USA

Unknown multiresistant gram-negative bacterium causing meningitis in HIV-positive patient in Africa

To our knowledge, RW isolate is the most resistant naturally occurring gram-negative species. Most antibiotics to which the organism is resistant are not available in Central Africa, and the refugees had only received chloramphenicol. This strain was recovered from an HIVinfected refugee of the civil war in Rwanda. Under such conditions, this probably only mildly virulent bacterium caused a life-threatening infection. Medical practitioners caring for HIV-infected people in Africa must be aware of this new infection for which only co-trimoxazole or ciprofloxacin may be effective. This work was made possible by Programme Hospitalier de Recherche Clinique, Assistance Publique a Marseille, 1993. We thank J Gouvemet for 16S rDNA analysis and phylogenetic tree construction.

SiR-In

M Drancourt, L Niel, *D Raoult

among Rwandan

*Unité des Rickettsies CNRS EP J0054, Faculté de Médecine, 13385 Marseille Cedex 05, France; Bioforce Militaire, Hôpital d’Instruction des Armées Robert Piqué, Bordeaux, France

August, 1994, an outbreak of typhus was suspected refugees in Goma, Zaire, after cases of meningoencephalitis associated with bilateral conjunctivitis with a high mortality rate were observed.’One of us (DR) asked to attend a mission in Goma to further assess these patients. On the basis of inconclusive physical examinations and inability to detect either specific antibodies in patients’ serum samples or rickettsial DNA in body lice, typhus was ruled out. Seven cerebrospinal fluid (CSF) samples were studied in Marseille. Three were sterile, and Neisseria meningitidis, Streptococcus pneumoniae, and Bacillus cereus were isolated from one sample each. A gram-positive bacillus, identified as a Corynebacterium, and a gram-negative bacillus (RW isolate) were observed microscopically in the last sample. Although the RW isolate grew on standard nonselective bacteriological media, tests with API and MicroScan systems did not lead to its identification. It was also resistant to almost all antibiotics tested including imipenem, and was susceptible only to co-trimoxazole ciprofloxacin, and colomycin. Determination of the 16S rDNA sequence of the bacillus after universal amplification2 and automated, direct sequencing showed it to be unique, but with a 98-3% similarity to Stenotrophomonas (Xanthomonas) maltophilia.3 Some similarity was also observed with P aeruginosa (833%), P cepacia (81 8%), and P testosteroni (815%) (figure). The CSF sample was tested for HIV antibodies and found positive. Using an indirect microimmunofluorescence technique and the agar-grown RW isolate as antigen, the CSF sample which yielded the RW isolate had titres of 10 for IgG, 8 for IgM, and 8 for IgA, which confirmed that this bacillus was responsible for the meningoencephalitis. was

I

1 2 3

Epidemic typhus risk in Rwandan refugee camps. Wkly Epidemiol Rec 1994; 34: 259. Weisburg WG, Barns SM, Pelletier DA, Lane DJ. 16S ribosomal DNA amplification for phylogenetic study. J Bacteriol 1991; 173: 697-703. Palleroni NJ, Bradbury JF. Stenotrophomonas, a new bacterial genus for Xanthomonas maltophilia (Hugh 1980) Swings et al. 1983. Int J Syst Bacteriol 1993; 43: 606-09.

Need for liver

transplantation

SiR-Modan and colleagues (Sept 9, p 660) estimate the annual need for liver transplantation as being between 10 and 15-5 per million population (pmp). They base this calculation on a retrospective analysis in Israel, of hospital admissions during 1987-88, to whom they applied a "current approach" for inclusion of candidates. These figures seem to be a clear underestimation of the true number of patients who might benefit from liver replacement, because of the many clinical situations that lead to end-stage liver failure. In 1994, in Spain (38-4 million inhabitants with 100% healthcare coverage) 829 patients with residence status were on the national waiting list for a liver transplant (21-5 pmp) of whom 614 were grafted during this period (16 pmp) and 60 died on waiting list.’ Only 19 of these transplants (3%) were done because of primary graft failure, and another 30 (4-9%) were late retransplantations. Since only four nonresident patients were included and no Spanish patients were sent abroad for grafting, these figures are a true estimation of the present state of this therapy in a country with a high cadaveric donor rate (25 donors pmp) and therefore high availability of cadaveric livers. Data for 1995 show a 15% increase after the first 8 months, and therefore 700 transplants (18-2 pmp) can be expected, with an ever increasing demand. For example, Murcia (1-0 million) has an active transplant programme with liver transplantation in 28-1pmp; in two other regions without a transplant programme only 6-6-7-5 pmp had liver

grafting. Transplantation is the

Figure: Unrooted phylogenetic tree based on comparison of 16S rDNA sequences, indicating the evolutionary relations between the Goma isolate (rw) and representative y-subgroup Proteobacteria The evolutionary distances separating two sequences was computed from the percent similarities; a neighbour-joining method was used to infer the phylogenetic tree most consistent with the calculated distances. Lines indicate relative evolutionary distances, and the

best treatment for end-stage organ failure. However, we are confronted with an increasing gap between supply of and demand for organs for transplantation. In Europe, 25% of patients on the waiting list for heart and liver transplants will not receive an organ and will die.2 The transplant community has therefore had to become more pragmatic when choosing patients to be grafted because to include patients with no real hope of getting an organ is pointless. The Spanish figures show that factors such as organ

horizontal bar indicates

availability,

vinciescens

1168

a

divergence of 0.079 Knuc.

awareness

by general practitioners

or

even