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Epidemiological significance of Strongyloides in sputum
688
CORRESPONDENCE
their folate requirements at pupation, so that at the immediately pre-pupal stage folate becomes a dietary necessity. I am, etc., n . VENTERS,
13 August, 1971
Sub-Department of Veterinary Parasitology, School of Tropical Medicine, Liverpool. REFERENCES
SANG, J. H. (1956). J. exp. Biol., 33, 45. SINGH, K. P. R. & BROWN, A. W. A. (1957). J. insect Physiol., 1, 199. VENTERS, D. (1971). Trans. R. Soc. trop. Med. Hyg., 65, 24. WILLIAMS, R. J. (1943). Vitams. Horm., 1, 229. EPIDEMIOLOGICAL SIGNIFICANCE OF S T R O N G Y L O I D B S
IN SPUTUM
SiR,--Recently we received a sample of sputum collected from a patient in Bristol (U.K.) on June 25th, 1971, with a request to identify some nematodes found in the specimen. I t had been delayed in the post and was not delivered to us until June 30th, 5 days after collection. On first examination we found rhabditiform bacteriophagous larvae of Strongyloides sp.; a few larvae, however, were filariform infective stages. T h e specimen was left on the bench and when examined again next day, almost all the larvae were found to have developed into filariform stages. SEABtmY et al. (1971) have similarly reported the culture of S. stercoralis in sputum. These observations raise the question of the possible spread of infection by promiscuous expectoration. Sputum, especially if associated with lung conditions accompanied by the copious production of mucus, provides a moist viscous medium for a rich bacterial culture with ideal foraging conditions for rhabditiform larvae and their subsequent growth to infective forms. Although this appears to be the first record of Strongyloides in sputum in the U.K., there are scattered reports of the parasite in human sputum, pleural exudate and lungs from other parts of the world (GAGE, 1911; FROES, 1930; YOSHINO, 1932; LAPTEV, 1945; CAMAIN et al., 1955; BROWN & PERNA, 1958; SEABURYet al., 1971). These infections appear to have been noticed only in patients with broncho-pneumonic symptoms. Premature development of Strongyloides in the lungs, which would be accompanied by the presence of larvae in sputum, is known to occur (MACKIE, 1948), but to provide evidence to support our suggestion that expectoration is of greater epidemiological importance in strongyloidiasis than usually realized, we need information on the incidence of larvae in the sputum of uncomplicated cases. There is no reason to suppose that the case in Bristol was an autochthonous infection. Although the patient had not been abroad since 1945, we assume this was a long-standing, low-grade infection. It has been suggested that chronic infections sometimes erupt "in patients who are weakened, ill or have some deficiency." (GALLIARD, 1967). I n the present case the patient suffered terminal carcinoma and died on the day we received the sputum. We thank Dr. Francis T. Page, Dr. D. S. Reevesand Mr. Martin Bywater of Southmead Hospital, Bristol, for bringing this case to our notice, and Mr. P. S. Gooch of the Commonwealth Institute of Helminthology for helping us to trace reports of Strongyloides in sputum. We are, etc., NEIL A. CROLL, R. KILLICK-KENDRICK, Department of Zoology and Applied Entomology, Imperial College, 17 August, 1971 London University. REFERENCES
BROWN, H. W. & PERNA, V. P. (1958). ft. Am. med. Ass., 168, 1648. CAMAIN, R., DESCI-IIENS,R. & SENECAL, J. (1955). Bull. Soc. Path. exot., 48, 51. FROES, S . P. (1930). Annls Parasit. hum. comp., 8, 171. GAGE, J. G. (1911). Arch. intern. Med., 7, 561. GALLIARD, H. (1967). Helm. Abs., 36, 247.
CORRESPONDENCE
689
LAPTEV, A. A. (1945). Klinich. Med., 23, 75. MACKIE, T. T. (1948). Dis. Chest, 14, 894. SEABURY, J. H . , ABADIE, S. & SAVOY, F. (1971). Am. J. trop. Med. Hyg., 20, 209. YOSHINO, K. (1932). Taiwan Igakkai Zasshi, 31, 99.
A CASE OF CONGENITAL MALARIA
SIR,--Mrs. B., a lady of 18 years, arrived in Bradford in November, 1967 from Karachi, West Pakistan. Between May, 1967 and August, 1968 she had a number of attacks of fever which she considered to be due to malaria. She was informed by her medical attendant that there was no malaria in England and she received neither diagnostic blood tests nor curative chemotherapy. O n 31st August, 1968 she gave birth to a male child (baby B.), birth weight--6 lbs. 13 ozs. On the day following the birth, Mrs. B. had a rigor. A blood film taken the following day showed the presence o f Plasmodium vivax and she received a course of chloroquine for this. (400 mg. chloroquine stat. and 200 mg. four-hourly: treatment was continued for 3 days.) Mrs. B. was discharged from hospital on completion of this treatment. Eight days after the birth of her child she was re-admitted after having suddenly collapsed. Repeat blood films taken at this time showed no parasites and it was considered that her illness was due to a pelvic infection which was successfully treated with tetracycline and ergometrine. To-date she has had no recurrence of malaria or a malaria-like fever. Baby B, born 31st August, 1968 progressed normally and examination soon after birth revealed no abnormality, apart from a small blind pilonidal sinus for which no early treatment was necessary. When the child was 7 weeks old, he was admitted to hospital with a history of 1 week's fever and vomiting. Examination revealed no abnormality: there was no sign of chest infection, no apparent dilatation of the stomach nor any enteritis. There is no note of the spleen being palpable at this time. A blood film showed the presence of Plasmodium vivax. T h e baby was treated with chloroquine at a dosage of 20 rag. b.d. for 5 days. Two days after treatment the spleen was noted as palpable but it could not be felt 2 weeks later. The child made an uneventful recovery. Anaemia was noted at the time of admission (5 "8 g./100 ml. blood) and at the end of the antimalarial treatment the level had risen to 7.8 g./100 ml. The child was treated with oral iron and the haemoglobin rose steadily to reach a level of 12.3 g./100 ml. by January, 1969, when the child was 5 months old. Blood films taken at the end of treatment and subsequently have shown no malaria parasites. The identification of the parasite was confirmed and there was no doubt that it was Plasmodium vivax : trophozoites only were seen. COVELL (1950) has made an extensive review of the literature on this subject. T h e number of infants affected found in areas of high malaria endemicity is very small. Although malaria infection in immigrants in England is not uncommon, expressed as a proportion of the population at risk, it is small. The amount of malaria seen among immigrants in Bradford is not great (BRUcE-CHWATT, 1969; DODGE, 1971) and has so far been confined to Plasmodium vivax infections. The possibility that a febrile, newly born infant, born in this country of immigrant parents, is suffering from congenital malaria is an extremely remote one and must be low on the list of possibilities of differential diagnosis: it is worth recording, however, that in this case the mother had a clear history of a number of febrile attacks, some of them in this country, consistent with a diagnosis of a malaria infection and familiar enough to her and to her husband that both she and he considered that she was suffering from malaria. Mrs. B. gave a positive result to the fluorescent antibody test but at low titre (positive 1/20). This low titre is probably due to the antigen used at that time, as other persons with confirmed recent malaria also gave low titres. I am, etc., ]'. S. DODGE, Department of Preventive and Social Medicine, University of Otago, 17 August, 1971 Dunedin, New Zealand. REFERENCES COVELL, G. (1950). Trop. Dis. Bull., 47, 1147.
CORRESPONDENCE
their folate requirements at pupation, so that at the immediately pre-pupal stage folate becomes a dietary necessity. I am, etc., n . VENTERS,
13 August, 1971
Sub-Department of Veterinary Parasitology, School of Tropical Medicine, Liverpool. REFERENCES
SANG, J. H. (1956). J. exp. Biol., 33, 45. SINGH, K. P. R. & BROWN, A. W. A. (1957). J. insect Physiol., 1, 199. VENTERS, D. (1971). Trans. R. Soc. trop. Med. Hyg., 65, 24. WILLIAMS, R. J. (1943). Vitams. Horm., 1, 229. EPIDEMIOLOGICAL SIGNIFICANCE OF S T R O N G Y L O I D B S
IN SPUTUM
SiR,--Recently we received a sample of sputum collected from a patient in Bristol (U.K.) on June 25th, 1971, with a request to identify some nematodes found in the specimen. I t had been delayed in the post and was not delivered to us until June 30th, 5 days after collection. On first examination we found rhabditiform bacteriophagous larvae of Strongyloides sp.; a few larvae, however, were filariform infective stages. T h e specimen was left on the bench and when examined again next day, almost all the larvae were found to have developed into filariform stages. SEABtmY et al. (1971) have similarly reported the culture of S. stercoralis in sputum. These observations raise the question of the possible spread of infection by promiscuous expectoration. Sputum, especially if associated with lung conditions accompanied by the copious production of mucus, provides a moist viscous medium for a rich bacterial culture with ideal foraging conditions for rhabditiform larvae and their subsequent growth to infective forms. Although this appears to be the first record of Strongyloides in sputum in the U.K., there are scattered reports of the parasite in human sputum, pleural exudate and lungs from other parts of the world (GAGE, 1911; FROES, 1930; YOSHINO, 1932; LAPTEV, 1945; CAMAIN et al., 1955; BROWN & PERNA, 1958; SEABURYet al., 1971). These infections appear to have been noticed only in patients with broncho-pneumonic symptoms. Premature development of Strongyloides in the lungs, which would be accompanied by the presence of larvae in sputum, is known to occur (MACKIE, 1948), but to provide evidence to support our suggestion that expectoration is of greater epidemiological importance in strongyloidiasis than usually realized, we need information on the incidence of larvae in the sputum of uncomplicated cases. There is no reason to suppose that the case in Bristol was an autochthonous infection. Although the patient had not been abroad since 1945, we assume this was a long-standing, low-grade infection. It has been suggested that chronic infections sometimes erupt "in patients who are weakened, ill or have some deficiency." (GALLIARD, 1967). I n the present case the patient suffered terminal carcinoma and died on the day we received the sputum. We thank Dr. Francis T. Page, Dr. D. S. Reevesand Mr. Martin Bywater of Southmead Hospital, Bristol, for bringing this case to our notice, and Mr. P. S. Gooch of the Commonwealth Institute of Helminthology for helping us to trace reports of Strongyloides in sputum. We are, etc., NEIL A. CROLL, R. KILLICK-KENDRICK, Department of Zoology and Applied Entomology, Imperial College, 17 August, 1971 London University. REFERENCES
BROWN, H. W. & PERNA, V. P. (1958). ft. Am. med. Ass., 168, 1648. CAMAIN, R., DESCI-IIENS,R. & SENECAL, J. (1955). Bull. Soc. Path. exot., 48, 51. FROES, S . P. (1930). Annls Parasit. hum. comp., 8, 171. GAGE, J. G. (1911). Arch. intern. Med., 7, 561. GALLIARD, H. (1967). Helm. Abs., 36, 247.
CORRESPONDENCE
689
LAPTEV, A. A. (1945). Klinich. Med., 23, 75. MACKIE, T. T. (1948). Dis. Chest, 14, 894. SEABURY, J. H . , ABADIE, S. & SAVOY, F. (1971). Am. J. trop. Med. Hyg., 20, 209. YOSHINO, K. (1932). Taiwan Igakkai Zasshi, 31, 99.
A CASE OF CONGENITAL MALARIA
SIR,--Mrs. B., a lady of 18 years, arrived in Bradford in November, 1967 from Karachi, West Pakistan. Between May, 1967 and August, 1968 she had a number of attacks of fever which she considered to be due to malaria. She was informed by her medical attendant that there was no malaria in England and she received neither diagnostic blood tests nor curative chemotherapy. O n 31st August, 1968 she gave birth to a male child (baby B.), birth weight--6 lbs. 13 ozs. On the day following the birth, Mrs. B. had a rigor. A blood film taken the following day showed the presence o f Plasmodium vivax and she received a course of chloroquine for this. (400 mg. chloroquine stat. and 200 mg. four-hourly: treatment was continued for 3 days.) Mrs. B. was discharged from hospital on completion of this treatment. Eight days after the birth of her child she was re-admitted after having suddenly collapsed. Repeat blood films taken at this time showed no parasites and it was considered that her illness was due to a pelvic infection which was successfully treated with tetracycline and ergometrine. To-date she has had no recurrence of malaria or a malaria-like fever. Baby B, born 31st August, 1968 progressed normally and examination soon after birth revealed no abnormality, apart from a small blind pilonidal sinus for which no early treatment was necessary. When the child was 7 weeks old, he was admitted to hospital with a history of 1 week's fever and vomiting. Examination revealed no abnormality: there was no sign of chest infection, no apparent dilatation of the stomach nor any enteritis. There is no note of the spleen being palpable at this time. A blood film showed the presence of Plasmodium vivax. T h e baby was treated with chloroquine at a dosage of 20 rag. b.d. for 5 days. Two days after treatment the spleen was noted as palpable but it could not be felt 2 weeks later. The child made an uneventful recovery. Anaemia was noted at the time of admission (5 "8 g./100 ml. blood) and at the end of the antimalarial treatment the level had risen to 7.8 g./100 ml. The child was treated with oral iron and the haemoglobin rose steadily to reach a level of 12.3 g./100 ml. by January, 1969, when the child was 5 months old. Blood films taken at the end of treatment and subsequently have shown no malaria parasites. The identification of the parasite was confirmed and there was no doubt that it was Plasmodium vivax : trophozoites only were seen. COVELL (1950) has made an extensive review of the literature on this subject. T h e number of infants affected found in areas of high malaria endemicity is very small. Although malaria infection in immigrants in England is not uncommon, expressed as a proportion of the population at risk, it is small. The amount of malaria seen among immigrants in Bradford is not great (BRUcE-CHWATT, 1969; DODGE, 1971) and has so far been confined to Plasmodium vivax infections. The possibility that a febrile, newly born infant, born in this country of immigrant parents, is suffering from congenital malaria is an extremely remote one and must be low on the list of possibilities of differential diagnosis: it is worth recording, however, that in this case the mother had a clear history of a number of febrile attacks, some of them in this country, consistent with a diagnosis of a malaria infection and familiar enough to her and to her husband that both she and he considered that she was suffering from malaria. Mrs. B. gave a positive result to the fluorescent antibody test but at low titre (positive 1/20). This low titre is probably due to the antigen used at that time, as other persons with confirmed recent malaria also gave low titres. I am, etc., ]'. S. DODGE, Department of Preventive and Social Medicine, University of Otago, 17 August, 1971 Dunedin, New Zealand. REFERENCES COVELL, G. (1950). Trop. Dis. Bull., 47, 1147.