- Email: [email protected]
ENDEMIC MALARIA IN HONG KONG
1324 Effective
is available and complications can thus be A history of a tick bite or erythema migrans will add
treatment
prevented. diagnostic support.
Borrelia Laboratory, Department of Treponematoses, Statens Seruminstitut, DK-2300 Copenhagen S, Denmark
KLAUS HANSEN
of Internal Medicine B,
Department Rigshospitalet, Copenhagen, Denmark
JAN KYST MADSEN
1. Burgdorfer W, Barbour AG, Hayes SF, et al. Lyme disease: a tick-borne spirochetosis? Science 1982; 216: 1317-19. 2. Steere AC, Grodzicki RL, Kornblatt AN, et al. The spirochetal etiology of Lyme disease. N Engl J Med 1983; 308: 733-39. 3. Wulff CH, Hansen K, Strange P, Trojaborg W. Multiple mononeuritis and radiculitis with erythema, pain, elevated CSF protein and pleocytosis (Bannwarth’s syndrome). J Neurol Neurosurg Psychiatry 1983; 46: 485-90. 4. Steere AC, Batsford WP, Weinberg M, et al. Lyme carditis: Cardiac abnormalities of Lyme disease. Ann Intern Med 1980; 93: 8-16.
ENDEMIC MALARIA IN HONG KONG ,,1:-,:,1B’) I-Br I t.r1
SIR,-Although Hong Kong
t.rn I nt.l"11B I"1IUr1fU1J
was once
malarious, control
of
reduced endemic transmission to zero by 1969, and the colony is now widely regarded as malaria-free. Since 1983,
of borrelia
however, there have been 5 cases of vivax malaria in British soldiers serving in the New Territories, near the Kwangtung province of southern China. None of the soldiers had been outside Hong Kong in the preceding 12 months, and they were almost certainly infected locally. Over the same period of time, 39 cases of malaria (all vivax) were reported in Chinese civilians who had not recently travelled outside of Hong Kong. Almost all of these patients were infected in the rural areas of the New
measures
Serial
IgG/IgM antibodies against inyocarditis.
B
burgdorferi
in
a case
borrelia
treatable condition
we
report here
two
cases
myocarditis admitted to the departments of infectious diseases and cardiology,, Rigshospitalet, Copenhagen. Both fit the pattern of myocarditis reported in Lyme disease.’ A 32-year-old man was admitted on July 29, 1985, with
intermittent
severe
dyspnoea,
chest
pain,
severe
musculoskeletal pains, and fever (38-5°C) that had lasted for 4 days. The pulse was irregular 30-50/min. The ECG revealed a fluctuating 1to 3° atrioventricular block. The echocardiogram showed a pericardial effusion of 2 mm. Apart from an alanine aminotransferase of 105 IU (normal below 25) all laboratory tests, including the erythrocyte sedimentation rate, were normal. Because his history on admission raised a slight suspicion of leptospirosis he was put on penicillin G 16 million IU daily. Serological reactions for leptospirosis remained negative. 2 months later raised IgG antibody titres against B burgdorferi were found in blood samples from the acute and convalescent stages. Titres by enzyme linked immunosorbent assay were 100 and 80, respectively normal below 75, the 95% percentile in 240 control sera). The symptoms disappeared within 4 days of the start of treatment. ECGs revealed normal atrioventricular conduction after 3 and 7 weeks. Upon questioning the patient did recall a tick bite before he fell ill. A 32-year-old man was admitted with a similar history on Aug 14, 1985, complaining of severe muscle pain, intermittent dyspnoea, fever (38-39°C), and extreme fatigue for 14 days. About 4 weeks earlier he had noticed an annular, slowly expanding erythema on his right thigh. On admission his pulse was irregular, and an ECG demonstrated fluctuating l’ to 3° atrioventricular block with several 2 or 3 s episodes of ventricular asystole. The echocardiogram and all laboratory tests were normal. Because a viral infection was suspected no antibiotic treatment was given until, 2 months later, the similarity to the first case was recognised and prompted a search for borrelia antibodies. A high IgG and IgM antibody level was found in serial blood samples drawn in the acute and convalescent stage (figure). At this time the patient was given oral doxycycline 200 mg daily for 14 days. Upon his discharge on Aug 29 and 6 weeks later ECGs revealed 1 atrioventricular block. At follow-up 5 months later he had recovered completely and his ECG was normal. The higher antibody level and longer lasting cardiac signs in the second case may be related to the delay in treatment. These two cases demonstrate that in patients with signs of myocarditis it is worth testing for B burgdorferi infection.
Territories.
Hong Kong remains a very popular tourist centre. Increasingly, the tourist itinerary includes the rural areas of the New Territories, particularly those that overlook China. Visitors, tour operators, and doctors should realise that a small malaria threat exists in the New Territories, particularly in areas close to China. The British Army uses proguanil 200 mg daily for all soldiers exposed to malaria in Hong Kong. Visitors the New Territories should use personal antimosquito as liberal use of insect repellents containing diethyltoluamide and the wearing of long sleeves and trousers between dusk and dawn. For visitors at higher risk, particularly those remaining in the New Territories at night during the hot summer months, chemoprophylaxis with proguanil should be considered. The urban areas of Hong Kong Island and Kowloon seem to be malaria-free still.
to
measures, such
British Military Hospital, BFPO 1,
Hong Kong
A. HENDERSON
WHEN TO USE LEVODOPA IN PARKINSONISM SIR,-Dr Pincus (March 15, p 612) argues for the early use of levodopa in Parkinson’s disease. It is, however, not clear how soon levodopa should be started. Should it be on the day the
physician makes the diagnosis, or later? Pincus’ conclusions seem to be based solely on consideration of fluctuations in clinical response-ic, dyskinesias, wearing-off, and "on-off’ effects. No clinician would withhold levodopa from a patient who was not well controlled with less potent drugs such as anticholinergic agents or amantadine.1,2 However, it is important to recognise that the usefulness of levodopa lasts about five years, and once 2 treatment failure emerges, further management is very difficult. a a be Thus, 60-year-old patient may, by age 65, hopeless therapeutic failure. Would it not be better to get as much mileage out of other measures as possible and so delay the levodopa failure for several years? Pincus claims that it is the severity of the disease itself rather than levodopa that is responsible for clinical fluctuations.
is available and complications can thus be A history of a tick bite or erythema migrans will add
treatment
prevented. diagnostic support.
Borrelia Laboratory, Department of Treponematoses, Statens Seruminstitut, DK-2300 Copenhagen S, Denmark
KLAUS HANSEN
of Internal Medicine B,
Department Rigshospitalet, Copenhagen, Denmark
JAN KYST MADSEN
1. Burgdorfer W, Barbour AG, Hayes SF, et al. Lyme disease: a tick-borne spirochetosis? Science 1982; 216: 1317-19. 2. Steere AC, Grodzicki RL, Kornblatt AN, et al. The spirochetal etiology of Lyme disease. N Engl J Med 1983; 308: 733-39. 3. Wulff CH, Hansen K, Strange P, Trojaborg W. Multiple mononeuritis and radiculitis with erythema, pain, elevated CSF protein and pleocytosis (Bannwarth’s syndrome). J Neurol Neurosurg Psychiatry 1983; 46: 485-90. 4. Steere AC, Batsford WP, Weinberg M, et al. Lyme carditis: Cardiac abnormalities of Lyme disease. Ann Intern Med 1980; 93: 8-16.
ENDEMIC MALARIA IN HONG KONG ,,1:-,:,1B’) I-Br I t.r1
SIR,-Although Hong Kong
t.rn I nt.l"11B I"1IUr1fU1J
was once
malarious, control
of
reduced endemic transmission to zero by 1969, and the colony is now widely regarded as malaria-free. Since 1983,
of borrelia
however, there have been 5 cases of vivax malaria in British soldiers serving in the New Territories, near the Kwangtung province of southern China. None of the soldiers had been outside Hong Kong in the preceding 12 months, and they were almost certainly infected locally. Over the same period of time, 39 cases of malaria (all vivax) were reported in Chinese civilians who had not recently travelled outside of Hong Kong. Almost all of these patients were infected in the rural areas of the New
measures
Serial
IgG/IgM antibodies against inyocarditis.
B
burgdorferi
in
a case
borrelia
treatable condition
we
report here
two
cases
myocarditis admitted to the departments of infectious diseases and cardiology,, Rigshospitalet, Copenhagen. Both fit the pattern of myocarditis reported in Lyme disease.’ A 32-year-old man was admitted on July 29, 1985, with
intermittent
severe
dyspnoea,
chest
pain,
severe
musculoskeletal pains, and fever (38-5°C) that had lasted for 4 days. The pulse was irregular 30-50/min. The ECG revealed a fluctuating 1to 3° atrioventricular block. The echocardiogram showed a pericardial effusion of 2 mm. Apart from an alanine aminotransferase of 105 IU (normal below 25) all laboratory tests, including the erythrocyte sedimentation rate, were normal. Because his history on admission raised a slight suspicion of leptospirosis he was put on penicillin G 16 million IU daily. Serological reactions for leptospirosis remained negative. 2 months later raised IgG antibody titres against B burgdorferi were found in blood samples from the acute and convalescent stages. Titres by enzyme linked immunosorbent assay were 100 and 80, respectively normal below 75, the 95% percentile in 240 control sera). The symptoms disappeared within 4 days of the start of treatment. ECGs revealed normal atrioventricular conduction after 3 and 7 weeks. Upon questioning the patient did recall a tick bite before he fell ill. A 32-year-old man was admitted with a similar history on Aug 14, 1985, complaining of severe muscle pain, intermittent dyspnoea, fever (38-39°C), and extreme fatigue for 14 days. About 4 weeks earlier he had noticed an annular, slowly expanding erythema on his right thigh. On admission his pulse was irregular, and an ECG demonstrated fluctuating l’ to 3° atrioventricular block with several 2 or 3 s episodes of ventricular asystole. The echocardiogram and all laboratory tests were normal. Because a viral infection was suspected no antibiotic treatment was given until, 2 months later, the similarity to the first case was recognised and prompted a search for borrelia antibodies. A high IgG and IgM antibody level was found in serial blood samples drawn in the acute and convalescent stage (figure). At this time the patient was given oral doxycycline 200 mg daily for 14 days. Upon his discharge on Aug 29 and 6 weeks later ECGs revealed 1 atrioventricular block. At follow-up 5 months later he had recovered completely and his ECG was normal. The higher antibody level and longer lasting cardiac signs in the second case may be related to the delay in treatment. These two cases demonstrate that in patients with signs of myocarditis it is worth testing for B burgdorferi infection.
Territories.
Hong Kong remains a very popular tourist centre. Increasingly, the tourist itinerary includes the rural areas of the New Territories, particularly those that overlook China. Visitors, tour operators, and doctors should realise that a small malaria threat exists in the New Territories, particularly in areas close to China. The British Army uses proguanil 200 mg daily for all soldiers exposed to malaria in Hong Kong. Visitors the New Territories should use personal antimosquito as liberal use of insect repellents containing diethyltoluamide and the wearing of long sleeves and trousers between dusk and dawn. For visitors at higher risk, particularly those remaining in the New Territories at night during the hot summer months, chemoprophylaxis with proguanil should be considered. The urban areas of Hong Kong Island and Kowloon seem to be malaria-free still.
to
measures, such
British Military Hospital, BFPO 1,
Hong Kong
A. HENDERSON
WHEN TO USE LEVODOPA IN PARKINSONISM SIR,-Dr Pincus (March 15, p 612) argues for the early use of levodopa in Parkinson’s disease. It is, however, not clear how soon levodopa should be started. Should it be on the day the
physician makes the diagnosis, or later? Pincus’ conclusions seem to be based solely on consideration of fluctuations in clinical response-ic, dyskinesias, wearing-off, and "on-off’ effects. No clinician would withhold levodopa from a patient who was not well controlled with less potent drugs such as anticholinergic agents or amantadine.1,2 However, it is important to recognise that the usefulness of levodopa lasts about five years, and once 2 treatment failure emerges, further management is very difficult. a a be Thus, 60-year-old patient may, by age 65, hopeless therapeutic failure. Would it not be better to get as much mileage out of other measures as possible and so delay the levodopa failure for several years? Pincus claims that it is the severity of the disease itself rather than levodopa that is responsible for clinical fluctuations.