- Email: [email protected]
ENTEROADHERENT ESCHERICHIA COLI ASSOCIATED WITH TRAVELLERS' DIARRHOEA
1048
showing simultaneous liver uptake of 99mT’c-cholesterol-labelled liposomes and 1251-labelled first antibody6 do not support the suggestion that the effect of LESA was the result of second antibody
PREVALENCE OF BACTERIAL ENTEROPATHOGENS IN STUDENTS mH
TRA VELLERS DIARRHOEA
into the circulation. reductions in circulating first antibody concentrations have been achieved with LESA (by comparison with untreated animals),6 and a plateau of the dose response curve had not been reached at this point. There are therefore good reasons to continue investigation of LESA.
released from
liposomes
Twenty-fold
R. H. J. BEGENT P. A. KEEP GREEN A. J. F. SEARLE K. D. BAGSHAWE Department of Medical Oncology, R. F. JEWKES Cross B. E. JONES Charing Hospital, London W6 8RF G. M. BARRATT B. E. RYMAN
*Multiple
agents from the
same
patient
are
listed
separately.
adherent, and only 2 were of the same serogroups we found (both 06). Non-EPEC EAEC raise the question of the relation were
ENTEROADHERENT ESCHERICHIA COLI ASSOCIATED WITH TRAVELLERS’ DIARRHOEA
between enteroadherence and E coli serotype. Our results suggest that EAEC strains may cause diarrhoea in adult travellers.
Supported by US Public Health Service training grant AI-07128 N01-AI-02662, NIAID, NIH, Bethesda, Maryland.
and
contract
SIR,-We have studied the aetiology of acute diarrhoea in 161 US travelling to Guadalajara, Mexico, as part of the summer study programes of the Universities of San Diego and Arizona. 29 stool specimens from students without acute diarrhoea were also studied. All specimens were examined for enterotoxigenic Escherichia coli (ETEC), Shigella, Salmonella, Campylobacter jejunz:
JOHN J. MATHEWSON
adults
and Aeromonas hydrophila. E coli were tested for mannose-resistant adherence in the HEp-2 tissue culture assay"* and adherent E coli were serogrouped. Acute and convalescent sera of patients from whom enteroadherent E coli (EAEC) were isolated as the sole agent were tested to see if the antibody titre to the somatic (0) antigen of the strain isolated from that patient had increased. 14 EAEC strains were isolated from the 161 ill patients (9%) (table). EAEC was the sole agent cultured from 9 patients (6%) and was isolated from 5 patients (3%) who also had another enteropathogen (4 Shigella and 1 C jejuni). No EAEC or other pathogens were isolated from the 29 well students. There was no difference in the clinical picture of patients with EAEC when compared with patients with other agents in their stools. 10 of the 14 EAEC strains belonged to known serogroups. 2 strains belonged to traditional EPEC serogroups (044 and 086) and the other typable strains belonged to 06, 015, 051, 099, 0130, and 0151. In tube agglutination tests with patients’ homologous strains, 3 of 4 paired sera showed 4-fold rises in antibody titre to the 0 antigen. The fourth patient had a 2-fold rise in titre. None of the patients’ convalescent sera neutralised adherence in the HEp-2 assay. None of the ETEC isolated in this study were adherent. Also, no EAEC -had colonisation factor antigens t or ii (when tested by mannoseresistant hemagglutination) or produced heat-stable or heat-labile enterotoxin. Our data suggest that EAEC strains can cause travellers’ diarrhoea in adults. EAEC was isolated from students with acute gastroenteritis but not from well students. Also, a serum antibody rise could be demonstrated in paired sera available for testing and 3 of 4 showed a 4-fold rise in titre. EAEC strains have been shown to cause diarrhoea, usually in infants,2-4 but most of these strains have belonged to EPEC serotypes. The only other report of EAEC not belonging to EPEC serotypes was by Cravioto et al,2 who found 5 of 17 strains of non-EPEC, non-ETEC from outbreaks of diarrhoea GM, Ryman BE, Begent RHJ, Keep PA, Searle F, Boden JA, Bagshawe KD Improved radioimmunodetection of tumours using liposomally entrapped antibody. Biochim Biophys Acta (in press). DuPont HL, Reves RR, Galindo E, Sullivan PS, Wood LV, Mendiola JG Treatment of travellers’ diarrhea with trimethoprim/sulfamethoxazole and trimethoprim alone N Engl J Med 1982; 307: 841-44. Cravioto A, Gross RJ, Scotland SM, Rowe R. An adhesive factor found in strains of Escherichia coli belonging to the traditional enteropathogenic serotypes Curr
6. Barratt
1
2.
Microbiol 1979; 3: 95-99. R, McAdams AJ, Gianella R, Partin JC A clinicopathologic study of enterocyteadherent Escherichia coli: a cause of protracted diarrhea in infants. Gastroenlerology 1982; 83: 441-54 4. Clausen CR, Christie DL. Chronic diarrhea caused by adherent enteropathogenic Escherichia coli J Pediatr 1982, 110: 358-61. 3. Rothbaum
Medical School, University of Texas Science Center at Houston, Houston, Texas 77025, USA
HERBERT L. DUPONT DONNA R. MORGAN SCOTT A. THORNTON CHARLES D. ERICSSON
THERAPEUTIC WINDOW FOR PLASMA HALOPERIDOL IN ACUTE SCHIZOPHRENIC PSYCHOSIS
SIR,-Several
investigations’have suggested
a therapeutic ng/ml for plasma haloperidol in the treatment of schizophrenic psychosis. Confirmation of such a window would be clinically important: it could be used to help establish therapeutic dosages for the individual patient more quickly and to help prevent relapses and side-effects. We report here a case of schizophrenia where the initial antipsychotic effect of haloperidol was lost and then regained when plasma levels went above and then were brought back into the suggested window. A 37-year-old single woman was admitted to the neuropsychiatric evaluation unit of Falkirk Hospital with paranoid delusions, auditory hallucinations, agitation, and bizarre behaviour. The paranoia had started 7 months before admission. She had been admitted to hospital elsewhere 1 month before admission, had responded well to neuroleptics, and then relapsed after discontinuing her medication. She met DSM III criteria for schizophrenia, paranoid type. She was treated with haloperidol 20-30 mg daily for the first3 days and improved. She was no longer hallucinating and was less paranoid and more relaxed. Benztropine 1 mg twice daily was prescribed for mild extrapyramidal side-effects. She was maintained on haloperidol 20 mg daily for the next 4 days and over this period her condition greatly worsened. Paranoid delusions returned with occasional auditory hallucinations. She was alert and oriented and her sensorium was unimpaired. There was no evidence of anticholinergic toxicity or significant extrapyramidal side-effects. The plasma haloperidol level2 on the morning of the seventh hospital day, 10 h after the previous bedtime dose, was 25-77 ng/ml. In view of the patient’s deterioration and the plasma level above the putative therapeutic window, the dosage was decreased to 10 mg daily and no "as necessary" medication was allowed. Within 4 days she was again much improved, without hallucinations or delusions, and participating in the full range of milieu therapies and activities. On the morning of day 16 her plasma haloperidol level was 10’0
window of 5-15
1 Magliozzi JR, Hollister LE, Arnold KV, Earle GM Relationship of serum haloperido levels to clinical response in schizophrenic patients. Am J Psychiatry 1981. 138: 365-67. 2. Extern I, Augusthy KA, Gold MS, Pottash haloperidol levels and clinical response in
Bull 1982; 18: 156-58.
ALC, Martin D, Potter WZ Plasma acute schizophrenia Psychopharma
showing simultaneous liver uptake of 99mT’c-cholesterol-labelled liposomes and 1251-labelled first antibody6 do not support the suggestion that the effect of LESA was the result of second antibody
PREVALENCE OF BACTERIAL ENTEROPATHOGENS IN STUDENTS mH
TRA VELLERS DIARRHOEA
into the circulation. reductions in circulating first antibody concentrations have been achieved with LESA (by comparison with untreated animals),6 and a plateau of the dose response curve had not been reached at this point. There are therefore good reasons to continue investigation of LESA.
released from
liposomes
Twenty-fold
R. H. J. BEGENT P. A. KEEP GREEN A. J. F. SEARLE K. D. BAGSHAWE Department of Medical Oncology, R. F. JEWKES Cross B. E. JONES Charing Hospital, London W6 8RF G. M. BARRATT B. E. RYMAN
*Multiple
agents from the
same
patient
are
listed
separately.
adherent, and only 2 were of the same serogroups we found (both 06). Non-EPEC EAEC raise the question of the relation were
ENTEROADHERENT ESCHERICHIA COLI ASSOCIATED WITH TRAVELLERS’ DIARRHOEA
between enteroadherence and E coli serotype. Our results suggest that EAEC strains may cause diarrhoea in adult travellers.
Supported by US Public Health Service training grant AI-07128 N01-AI-02662, NIAID, NIH, Bethesda, Maryland.
and
contract
SIR,-We have studied the aetiology of acute diarrhoea in 161 US travelling to Guadalajara, Mexico, as part of the summer study programes of the Universities of San Diego and Arizona. 29 stool specimens from students without acute diarrhoea were also studied. All specimens were examined for enterotoxigenic Escherichia coli (ETEC), Shigella, Salmonella, Campylobacter jejunz:
JOHN J. MATHEWSON
adults
and Aeromonas hydrophila. E coli were tested for mannose-resistant adherence in the HEp-2 tissue culture assay"* and adherent E coli were serogrouped. Acute and convalescent sera of patients from whom enteroadherent E coli (EAEC) were isolated as the sole agent were tested to see if the antibody titre to the somatic (0) antigen of the strain isolated from that patient had increased. 14 EAEC strains were isolated from the 161 ill patients (9%) (table). EAEC was the sole agent cultured from 9 patients (6%) and was isolated from 5 patients (3%) who also had another enteropathogen (4 Shigella and 1 C jejuni). No EAEC or other pathogens were isolated from the 29 well students. There was no difference in the clinical picture of patients with EAEC when compared with patients with other agents in their stools. 10 of the 14 EAEC strains belonged to known serogroups. 2 strains belonged to traditional EPEC serogroups (044 and 086) and the other typable strains belonged to 06, 015, 051, 099, 0130, and 0151. In tube agglutination tests with patients’ homologous strains, 3 of 4 paired sera showed 4-fold rises in antibody titre to the 0 antigen. The fourth patient had a 2-fold rise in titre. None of the patients’ convalescent sera neutralised adherence in the HEp-2 assay. None of the ETEC isolated in this study were adherent. Also, no EAEC -had colonisation factor antigens t or ii (when tested by mannoseresistant hemagglutination) or produced heat-stable or heat-labile enterotoxin. Our data suggest that EAEC strains can cause travellers’ diarrhoea in adults. EAEC was isolated from students with acute gastroenteritis but not from well students. Also, a serum antibody rise could be demonstrated in paired sera available for testing and 3 of 4 showed a 4-fold rise in titre. EAEC strains have been shown to cause diarrhoea, usually in infants,2-4 but most of these strains have belonged to EPEC serotypes. The only other report of EAEC not belonging to EPEC serotypes was by Cravioto et al,2 who found 5 of 17 strains of non-EPEC, non-ETEC from outbreaks of diarrhoea GM, Ryman BE, Begent RHJ, Keep PA, Searle F, Boden JA, Bagshawe KD Improved radioimmunodetection of tumours using liposomally entrapped antibody. Biochim Biophys Acta (in press). DuPont HL, Reves RR, Galindo E, Sullivan PS, Wood LV, Mendiola JG Treatment of travellers’ diarrhea with trimethoprim/sulfamethoxazole and trimethoprim alone N Engl J Med 1982; 307: 841-44. Cravioto A, Gross RJ, Scotland SM, Rowe R. An adhesive factor found in strains of Escherichia coli belonging to the traditional enteropathogenic serotypes Curr
6. Barratt
1
2.
Microbiol 1979; 3: 95-99. R, McAdams AJ, Gianella R, Partin JC A clinicopathologic study of enterocyteadherent Escherichia coli: a cause of protracted diarrhea in infants. Gastroenlerology 1982; 83: 441-54 4. Clausen CR, Christie DL. Chronic diarrhea caused by adherent enteropathogenic Escherichia coli J Pediatr 1982, 110: 358-61. 3. Rothbaum
Medical School, University of Texas Science Center at Houston, Houston, Texas 77025, USA
HERBERT L. DUPONT DONNA R. MORGAN SCOTT A. THORNTON CHARLES D. ERICSSON
THERAPEUTIC WINDOW FOR PLASMA HALOPERIDOL IN ACUTE SCHIZOPHRENIC PSYCHOSIS
SIR,-Several
investigations’have suggested
a therapeutic ng/ml for plasma haloperidol in the treatment of schizophrenic psychosis. Confirmation of such a window would be clinically important: it could be used to help establish therapeutic dosages for the individual patient more quickly and to help prevent relapses and side-effects. We report here a case of schizophrenia where the initial antipsychotic effect of haloperidol was lost and then regained when plasma levels went above and then were brought back into the suggested window. A 37-year-old single woman was admitted to the neuropsychiatric evaluation unit of Falkirk Hospital with paranoid delusions, auditory hallucinations, agitation, and bizarre behaviour. The paranoia had started 7 months before admission. She had been admitted to hospital elsewhere 1 month before admission, had responded well to neuroleptics, and then relapsed after discontinuing her medication. She met DSM III criteria for schizophrenia, paranoid type. She was treated with haloperidol 20-30 mg daily for the first3 days and improved. She was no longer hallucinating and was less paranoid and more relaxed. Benztropine 1 mg twice daily was prescribed for mild extrapyramidal side-effects. She was maintained on haloperidol 20 mg daily for the next 4 days and over this period her condition greatly worsened. Paranoid delusions returned with occasional auditory hallucinations. She was alert and oriented and her sensorium was unimpaired. There was no evidence of anticholinergic toxicity or significant extrapyramidal side-effects. The plasma haloperidol level2 on the morning of the seventh hospital day, 10 h after the previous bedtime dose, was 25-77 ng/ml. In view of the patient’s deterioration and the plasma level above the putative therapeutic window, the dosage was decreased to 10 mg daily and no "as necessary" medication was allowed. Within 4 days she was again much improved, without hallucinations or delusions, and participating in the full range of milieu therapies and activities. On the morning of day 16 her plasma haloperidol level was 10’0
window of 5-15
1 Magliozzi JR, Hollister LE, Arnold KV, Earle GM Relationship of serum haloperido levels to clinical response in schizophrenic patients. Am J Psychiatry 1981. 138: 365-67. 2. Extern I, Augusthy KA, Gold MS, Pottash haloperidol levels and clinical response in
Bull 1982; 18: 156-58.
ALC, Martin D, Potter WZ Plasma acute schizophrenia Psychopharma