Follow-up in Montelukast Treatment

plant EBV serology available who survived for ⬎ 1 month. Cumulative incidence proportions were compared using Fisher’s Exact Test, while risk ratios were compared using the MantelHaenszel test for homogeneity (Stata version 6.0; Stata Corporation; College Station, TX). Because of the wide confidence intervals for PTLD incidence in EBV seroconverters, one cannot conclude that the prevalence estimates are different across the two studies. In fact, the upper limits of the 95% confidence intervals are identical. More strikingly, the relative risks of PTLD by EBV serostatus are nearly identical when the two studies are compared. These results suggest that the low observed incidence of PTLD in the authors’ center is due entirely to the low prevalence of EBV seronegativity in their recipient population and cannot be attributed to any difference in patient management. Lianne G. Singer, MD James Theodore, MD, FCCP Heart-Lung and Lung Transplant Program Stanford University Stanford, CA Michael K. Gould, MD, MSc VA Palo Alto Health Care System Palo Alto, CA Correspondence to: Lianne G. Singer, MD, Heart-Lung and Lung Transplant Program, Stanford University Medical Center, 300 Pasteur Dr, Room H3143, Stanford, CA 94305-5236; e-mail: [email protected]

References 1 Levine SM, Angel L, Anzueto A, et al. A low incidence of posttransplant lymphoproliferative disorder in 109 lung transplant recipients. Chest 1999; 116:1273–1277 2 Aris RM, Maia DM, Neuringer IP, et al. Post-transplantation lymphoproliferative disorder in the Epstein-Barr virus-naive lung transplant recipient. Am J Respir Crit Care Med 1996; 154:1712–1717

now, at our center, we will continue using the currently successful, prolonged antiviral prophylactic regimen described in the article. Stephanie M. Levine, MD, FCCP Luis Angel, MD The University of Texas Health Science Center at San Antonio San Antonio, TX Correspondence to: Stephanie M. Levine, MD, FCCP, University of Texas Health Science Center at San Antonio, 22 Sheringham, San Antonio, TX 72818; e-mail: [email protected]

References 1 Aris RM, Maia DM, Neuringer IP, et al. Post-transplantation lymphoproliferative disorder in the Epstein-Barr virus-naı¨ve lung transplant recipient. Am J Respir Crit Care Med 1996; 154:1712–1717 2 Levine SM, Angel L, Anzueto A, et al. A low incidence of posttransplant lymphoproliferative disorder in 109 lung transplant recipients. Chest 1999; 116:1273–1277

Follow-up in Montelukast Treatment To the Editor: Regarding the very interesting article, “Churg-Strauss Syndrome in Patients Receiving Montelukast as Treatment for Asthma” (March 2000),1 the findings do point to this syndrome. I would like to know why a more involved workup was not performed in these and other referenced patients? I would suggest: (1) any atopic nature in all these patients could be involved; (2) workup for parasitic diseases; and (3) aspirin intolerance syndrome investigation. I look forward for the authors’ comments.

Gerald N. Cohen, MD, FCCP St. Francis Hospital Evanston, IL

To the Editor: The further statistical analysis of the posttransplant lymphoproliferative disorder (PTLD) data from our center is appreciated. We agree with the comments made by Dr. Singer and colleagues. Indeed, the low incidence of PTLD at our center may be due to the low prevalence of Epstein-Barr virus (EBV) seronegativity in our transplant group. As for our comparison between the PTLD incidences in EBV seroconverters in the study by Aris et al1 and our study (November 1999),2 I am sure that Dr. Singer and colleagues are aware that due to the small sample sizes in both studies, the power to detect differences between incidences is extremely low. In fact, a Fisher’s Exact Test with ␣ ⫽ 0.05 (two sided) will have only 7% power to detect the difference between a proportion of 20% and 42% when the sample sizes are 5 and 12, respectively. Therefore, our statement contrasting the two studies was intended to be purely observational. We would also like to comment that we have remained “fortunate” with our low overall incidence of PTLD. Recent analysis of our lung transplant patients (who have survived ⬎ 1 month following transplantation) reveals a total of six EBVseronegative converters with, to date, only the single case of PTLD as previously reported in this group (1 of 6; 16.7%). We also have an additional 19 seropositive transplant recipients without additional cases of PTLD other than the one previously reported (1 of 123; 0.8%). Thus, our overall PTLD incidence is 2 of 129 (1.6%), with a follow-up of ⬎ 4,800 patient-months. For 1228

Correspondence to: Gerald N. Cohen, MD, FCCP, Chief, Section of Allergy, Department of Medicine, St. Francis Hospital, 335 Ridge Ave, Evanston, IL 60202

Reference 1 Wechsler ME, Finn D, Gunawardena D, et al. Churg-Strauss syndrome in patients receiving montelukast as treatment for asthma. Chest 2000; 117:708 –713 To the Editor: Thank you for allowing us the opportunity to reply to the letter of Dr. Cohen in response to our article about the occurrence of Churg-Strauss syndrome in patients receiving montelukast. While Dr. Cohen agrees with our findings, he raises some interesting questions about further workup that could be undertaken in such patients. While such details were beyond the scope of our series, several of our patients did receive such an extensive workup. In fact, all of these patients had a history of atopy, although not all had skin tests to document such. We also agree that physicians should explore for other eosinophilic conditions in addition to the Churg-Strauss syndrome. Dr. Cohen raises the specter of the potential for parasitic disease and aspirin intolerance, but other vasculitides, as well as drug reactions, eosinophilic pneumonia, idiopathic eosinophilia, and malignancy, are Communications to the Editor