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Effects of swimming on diabetes insipidus treated with DDAVP
346
Editorial correspondence
The bactericidal defect we observed in the stressed neonates was detectable only when the PMNs were presented with a high bacteria to PMN ratio (2-6:1). No defect was detected when the mixture contained a ratio of one bacteria per PMN or less. Kaplan et aP used a 1 : 1 bacteria to PMN ratio in studies which showed that CGD P M N s killed Streptococcus faecalis, Streptococcus viridans, and Streptococcus pyogenes normally. Thus, an intact bactericidal mechanism including oxidative metabolism may be required to effectively kill a larger n u m b e r o f these organisms. Infants who develop group B disease usually have m a n y organisms in surface, respiratory, blood, a n d often CSF cultures. We suspect, therefore, that a high bacteria to P M N ratio would mimic the situation observed more closely. Ann O. Shigeoka, M.D. .losb Ignaeio Santos, M.D. Harry R. Hill, M.D. Department of Pediatrics The Univ~ersi(y of Utah Medical Center Salt Lake City, UT 84132
The Journal of Pediatrics February 1980
occasions associated wiih the episodic arthritis. Throat cultures grew group A beta hemolytic streptococcus each time that she had erythema nodosum. Exceptiffg the initial episode, all other episodes of arthritis were managed conservatively without the use of intravenous antibiotics. Oral penicillin was given lbr the treatment of the streptococcal infections associated with the episodes of erythema nodosum. COMMENT Episodic arthritis and erythema nodosum in patients with cystic fibrosis m a y be more c o m m o n than reported. D. Vaze, M.D., F.R.C.P.(C) Charles A. Janeway Child Health Centre St. John's, Neufoundland Canada A 1A 1R8 REFERENCE
1.
N e w m a n A J, and Ansell BM: Episodic arthritis in children with cystic fibrosis, J PEDIATR 94:594, 1979,
REFERENCES
1. Johnston RB Jr, and Baehner RL: Chronic granu[omatous disease: correlation between pathogenesis a n d clinical findings, Pediatrics 48:730, 1971, 2. Johnston RB Jr, and N e w m a n SL: Chronic granulomatous disease, Pediatr Clin North A m 24:365, 1977 3. Harvath L, and Anderson BR: Defective initiation of oxidative metabolism in polymorphonuclear leukocytes, N Engl J Med 300:1130, 1979. 4. Quie PG, White JG, Holmes B, et al: In vitro bactericidal capacity of h u m a n polymorphonuclear leukocytes: diminished activity in chronic granulomatous disease of childhood, J Clin Invest 46:668, 1967. 5. Kaplan EL, Laxdal T, and Quie PG: Studies of polymorphonuclear leukocytes from patients with chronic granulomatous disease of children: bactericidal capacity for streptococci, Pediatrics 41:591, 1968.
Episodic arthritis in cystic fibrosis To the Editor: The article by Newman et al' is of particular inlerest to us, We have encountered one patient with a similar problem. CASE REPORT
Patient C.D., a 14-year-old girl with cystic fibrosis, presented with a history of swelling of the left ankle associated with erythema and tenderness most marked over the anterior aspect of the joint. Roentgenograms failed to show any evidence of arthritis or periosteal swelling. She was treated with antibiotics administered intravenously for the possibility of osteomyelitis. The swelling subsided over one week. Since this episode she has had multiple admissions and outpatient visits for swelling involving different joints. On one occasion there was involvement of the sternoclavicular joint. She has had erythema n o d o s u m on a few
Repy To the Editor: We are gratified that Dr. Vaze has seen a case so very like our own. Awareness that this syndrome exists may spare youngsters unnecessary treatment. Unfortunately, D r Vaze was no more able than we to suggest the etiology of this phenomenon. Our patients had neither erythema n o d o s u m nor streptococcal infections, and we believe that there is no real evidence to relate them. Arthur J. Newman, M.D. Director Pediatric Rheumatology Rainbow Babies & Childrens Hospilal Barbara M. Ansell, M.D. C)imcal Research Centre Northwick Park Hospital Division of' Rheumatoloxv Cleveland, OH 44106
Effects of swimming on diabetes insipidus treated with DDA VP To the Editor: Water reaching the posterior nares during swimming and thus washing out DDAVP has been suggested by Riley and Rosenbloom' to occur in children with central diabetes insipidus being treated with that drug. Since nose plugs were rejected, a small dose of the drug in the afternoon was added. While swimming with handicapped as well as with normal children, we were often struck by the apparent increase of urine
Volume 96 Number 2
Editorial correspondence
produced during the time spent in water compared to that outside the water. Swallowing of water having occurred unnoticed was the usual explanation that seemed to fit the majority of such observations. Epstein's-' excellent review provides an alternative and entirely satisfying explanation: immersion of the h u m a n body. The diuretic response to immersion of the body was known and adequately explained as early as 1847 by Hartshorne. Water immersion is associated with natriuresis and a suppression of the renin atdosterone system as well as with changes in renal water handling. Natriuresis seems to be triggered by the afferents from suggested volume receptors centrally in the intrathoracic region. immersion is r e c o m m e n d e d as an investigative tool for assessing dynamically the control mechanisms of the renin-aldosterone system, ADH, and renal prostaglandins, as well as for therapeutic uses, the main advantage is its prompt reversibility: The volume stimulus is cut off by cessation of immersion (for references see Epstein).
Hubert Haber/ellner, M D Univ. Klinik .liar Kinderheilkunde A-6020 Innsbruck Austria REFERENCES
1. 2.
Riley WJ, and Rosenbloom AL: Washout of intranasal D D A V P with swimming, J PEmA'rR 94:1011, 1979. Epstein M: Renal effects of head-out water immersion in man: Implications for an understanding of volume homeostasis, Physiol Rev 58:529, 1978.
Repty To the Editor: The ADH-deficient patients who swam regularly and reported the decreased D D A V P effect were those who were physically active and not handicapped. Substantial water-swallowing was unlikely. According to Epstein/ the diuresis and natriuresis of immersion are dissociated phenomena. Diuresis occurs early (one to two hours) and is associated with A D H suppression; infusion of A D H abolishes the diuresis but has no effect on the natriuresis. Our patients would not be affected by a stimulus-suppressing endogenous ADH. They would, rather, correspond to the immersed study group receivSng vasopressin and not having diuresis. That some do have loss of exogenous vasopressin (DDAVP) effect with swimming due to washout thus remains likely.
William J. Riley, M.D. Fellow, Division of Endocrinology Department of Pediatrics Arlan L. Rosenbloom, M.D. Professor of Pediatrics University of Florida College of Medicine Box J-296 J. Itillis Miller Health Center Gainesville, FL 32610
347
REFERENCE 1.
Epstein M: Renal effects of head-out water immersion in man: Implications for a n understanding of volume homeostasis, Physiol Rev 58:529, 1978.
Staging of secondary sex characteristics To the Editor: Two aspects of the worthwhile report by Harlan et al' are unclear and another deserves comment. (1), The public hair staging criteria should be clarified. Since the highest grade of pubic hair was designated V in this study, are we to assume that the stage at which males progress beyond the female escutcheon stage was ignored? In the Tanner classification, Stage V describes the "female escutcheon" phase of pubic hair development. Normal males progress through this stage and beyond to Class VI. Does stage V include males who have passed beyond the actual T a n n e r stage or have the authors altered the classification so that Stage V represents the highest stage of masculinization of the pubic hair pattern? (2) The data do not seem to bear out the authors' conclusion that the " m e a n chronologic ages for each stage of pubic hair and ger~itaI development in the U.S. Health Examination Survey are comparable to the m e a n ages described by Marshall and Tanner. ''~ For example, consider pubic hair stage III (PH liD, the earliest phase of true sexual hair. Marshall and Tanner found that the average age for reaching PH Ill was 13.9 + 1.0 years. It would appear from the authors' data that 50% of boys reach PH 111 between the twelfth and thirteenth years, and.97% during the fifteenth years, suggesting that this stage is achieved at approximately 13.2 + 1.2 (SD) years. My extrapolations from the authors' data are based upon the assumption that stages are referenced to the nearest chronologic year. Thus, the average age for the onset of this important sign of the onset of puberty seems to be eight months earlier than was reported by T a n n e r in post-World War It British youths, though it does seem comparable to that reported in American boys in 19437 It would be valuable if the authors would present the mean +- SD at which each stage of pubic hair and genital development was achieved. It is unfortunate that Harlan and colleagues chose to use the Tanner genital staging system. The weakness of this system is that testicular growth, which is mainly a function of tubular development, and changes in the growth of penis and scrotum, which are greatly androgen-dependent phenomena, are linked together, making for a relatively subjective grade. Testicular growth can be assessed more objectively. For example, Winter and F a i m a n ' reported that about 50% of l 1-year-old Canadian boys had achieved a testicular long diameter greater than that of prepubertal boys, approximately 2.4 cm being the dividing line.
Robert L. Rosenfield, M.D. Wyler Children's Hospital 5825 Ma(yland Ave. Chicetgo, IL 60637
Editorial correspondence
The bactericidal defect we observed in the stressed neonates was detectable only when the PMNs were presented with a high bacteria to PMN ratio (2-6:1). No defect was detected when the mixture contained a ratio of one bacteria per PMN or less. Kaplan et aP used a 1 : 1 bacteria to PMN ratio in studies which showed that CGD P M N s killed Streptococcus faecalis, Streptococcus viridans, and Streptococcus pyogenes normally. Thus, an intact bactericidal mechanism including oxidative metabolism may be required to effectively kill a larger n u m b e r o f these organisms. Infants who develop group B disease usually have m a n y organisms in surface, respiratory, blood, a n d often CSF cultures. We suspect, therefore, that a high bacteria to P M N ratio would mimic the situation observed more closely. Ann O. Shigeoka, M.D. .losb Ignaeio Santos, M.D. Harry R. Hill, M.D. Department of Pediatrics The Univ~ersi(y of Utah Medical Center Salt Lake City, UT 84132
The Journal of Pediatrics February 1980
occasions associated wiih the episodic arthritis. Throat cultures grew group A beta hemolytic streptococcus each time that she had erythema nodosum. Exceptiffg the initial episode, all other episodes of arthritis were managed conservatively without the use of intravenous antibiotics. Oral penicillin was given lbr the treatment of the streptococcal infections associated with the episodes of erythema nodosum. COMMENT Episodic arthritis and erythema nodosum in patients with cystic fibrosis m a y be more c o m m o n than reported. D. Vaze, M.D., F.R.C.P.(C) Charles A. Janeway Child Health Centre St. John's, Neufoundland Canada A 1A 1R8 REFERENCE
1.
N e w m a n A J, and Ansell BM: Episodic arthritis in children with cystic fibrosis, J PEDIATR 94:594, 1979,
REFERENCES
1. Johnston RB Jr, and Baehner RL: Chronic granu[omatous disease: correlation between pathogenesis a n d clinical findings, Pediatrics 48:730, 1971, 2. Johnston RB Jr, and N e w m a n SL: Chronic granulomatous disease, Pediatr Clin North A m 24:365, 1977 3. Harvath L, and Anderson BR: Defective initiation of oxidative metabolism in polymorphonuclear leukocytes, N Engl J Med 300:1130, 1979. 4. Quie PG, White JG, Holmes B, et al: In vitro bactericidal capacity of h u m a n polymorphonuclear leukocytes: diminished activity in chronic granulomatous disease of childhood, J Clin Invest 46:668, 1967. 5. Kaplan EL, Laxdal T, and Quie PG: Studies of polymorphonuclear leukocytes from patients with chronic granulomatous disease of children: bactericidal capacity for streptococci, Pediatrics 41:591, 1968.
Episodic arthritis in cystic fibrosis To the Editor: The article by Newman et al' is of particular inlerest to us, We have encountered one patient with a similar problem. CASE REPORT
Patient C.D., a 14-year-old girl with cystic fibrosis, presented with a history of swelling of the left ankle associated with erythema and tenderness most marked over the anterior aspect of the joint. Roentgenograms failed to show any evidence of arthritis or periosteal swelling. She was treated with antibiotics administered intravenously for the possibility of osteomyelitis. The swelling subsided over one week. Since this episode she has had multiple admissions and outpatient visits for swelling involving different joints. On one occasion there was involvement of the sternoclavicular joint. She has had erythema n o d o s u m on a few
Repy To the Editor: We are gratified that Dr. Vaze has seen a case so very like our own. Awareness that this syndrome exists may spare youngsters unnecessary treatment. Unfortunately, D r Vaze was no more able than we to suggest the etiology of this phenomenon. Our patients had neither erythema n o d o s u m nor streptococcal infections, and we believe that there is no real evidence to relate them. Arthur J. Newman, M.D. Director Pediatric Rheumatology Rainbow Babies & Childrens Hospilal Barbara M. Ansell, M.D. C)imcal Research Centre Northwick Park Hospital Division of' Rheumatoloxv Cleveland, OH 44106
Effects of swimming on diabetes insipidus treated with DDA VP To the Editor: Water reaching the posterior nares during swimming and thus washing out DDAVP has been suggested by Riley and Rosenbloom' to occur in children with central diabetes insipidus being treated with that drug. Since nose plugs were rejected, a small dose of the drug in the afternoon was added. While swimming with handicapped as well as with normal children, we were often struck by the apparent increase of urine
Volume 96 Number 2
Editorial correspondence
produced during the time spent in water compared to that outside the water. Swallowing of water having occurred unnoticed was the usual explanation that seemed to fit the majority of such observations. Epstein's-' excellent review provides an alternative and entirely satisfying explanation: immersion of the h u m a n body. The diuretic response to immersion of the body was known and adequately explained as early as 1847 by Hartshorne. Water immersion is associated with natriuresis and a suppression of the renin atdosterone system as well as with changes in renal water handling. Natriuresis seems to be triggered by the afferents from suggested volume receptors centrally in the intrathoracic region. immersion is r e c o m m e n d e d as an investigative tool for assessing dynamically the control mechanisms of the renin-aldosterone system, ADH, and renal prostaglandins, as well as for therapeutic uses, the main advantage is its prompt reversibility: The volume stimulus is cut off by cessation of immersion (for references see Epstein).
Hubert Haber/ellner, M D Univ. Klinik .liar Kinderheilkunde A-6020 Innsbruck Austria REFERENCES
1. 2.
Riley WJ, and Rosenbloom AL: Washout of intranasal D D A V P with swimming, J PEmA'rR 94:1011, 1979. Epstein M: Renal effects of head-out water immersion in man: Implications for an understanding of volume homeostasis, Physiol Rev 58:529, 1978.
Repty To the Editor: The ADH-deficient patients who swam regularly and reported the decreased D D A V P effect were those who were physically active and not handicapped. Substantial water-swallowing was unlikely. According to Epstein/ the diuresis and natriuresis of immersion are dissociated phenomena. Diuresis occurs early (one to two hours) and is associated with A D H suppression; infusion of A D H abolishes the diuresis but has no effect on the natriuresis. Our patients would not be affected by a stimulus-suppressing endogenous ADH. They would, rather, correspond to the immersed study group receivSng vasopressin and not having diuresis. That some do have loss of exogenous vasopressin (DDAVP) effect with swimming due to washout thus remains likely.
William J. Riley, M.D. Fellow, Division of Endocrinology Department of Pediatrics Arlan L. Rosenbloom, M.D. Professor of Pediatrics University of Florida College of Medicine Box J-296 J. Itillis Miller Health Center Gainesville, FL 32610
347
REFERENCE 1.
Epstein M: Renal effects of head-out water immersion in man: Implications for a n understanding of volume homeostasis, Physiol Rev 58:529, 1978.
Staging of secondary sex characteristics To the Editor: Two aspects of the worthwhile report by Harlan et al' are unclear and another deserves comment. (1), The public hair staging criteria should be clarified. Since the highest grade of pubic hair was designated V in this study, are we to assume that the stage at which males progress beyond the female escutcheon stage was ignored? In the Tanner classification, Stage V describes the "female escutcheon" phase of pubic hair development. Normal males progress through this stage and beyond to Class VI. Does stage V include males who have passed beyond the actual T a n n e r stage or have the authors altered the classification so that Stage V represents the highest stage of masculinization of the pubic hair pattern? (2) The data do not seem to bear out the authors' conclusion that the " m e a n chronologic ages for each stage of pubic hair and ger~itaI development in the U.S. Health Examination Survey are comparable to the m e a n ages described by Marshall and Tanner. ''~ For example, consider pubic hair stage III (PH liD, the earliest phase of true sexual hair. Marshall and Tanner found that the average age for reaching PH Ill was 13.9 + 1.0 years. It would appear from the authors' data that 50% of boys reach PH 111 between the twelfth and thirteenth years, and.97% during the fifteenth years, suggesting that this stage is achieved at approximately 13.2 + 1.2 (SD) years. My extrapolations from the authors' data are based upon the assumption that stages are referenced to the nearest chronologic year. Thus, the average age for the onset of this important sign of the onset of puberty seems to be eight months earlier than was reported by T a n n e r in post-World War It British youths, though it does seem comparable to that reported in American boys in 19437 It would be valuable if the authors would present the mean +- SD at which each stage of pubic hair and genital development was achieved. It is unfortunate that Harlan and colleagues chose to use the Tanner genital staging system. The weakness of this system is that testicular growth, which is mainly a function of tubular development, and changes in the growth of penis and scrotum, which are greatly androgen-dependent phenomena, are linked together, making for a relatively subjective grade. Testicular growth can be assessed more objectively. For example, Winter and F a i m a n ' reported that about 50% of l 1-year-old Canadian boys had achieved a testicular long diameter greater than that of prepubertal boys, approximately 2.4 cm being the dividing line.
Robert L. Rosenfield, M.D. Wyler Children's Hospital 5825 Ma(yland Ave. Chicetgo, IL 60637