HANTAVIRUS AND LEPTOSPIRA

460 blue has not been shown to be toxic to mucosal surfaces, both the other agents and the alcohol in which they are dissolved could harm the urothelium. Appropriate dilution of these solutions with water will prevent toxic chemical damage. We do not think that these agents should be withdrawn since we appreciate their value as skin markers in plastic surgery. Marker pens containing these chemicals are now available and if Bonney’s blue was dispensed only in this form or in small ampoules sufficient for use with a nib pen, the hazards that we describe could be prevented.

Department of Urology, Middlesex Hospital, London W1N 8AA

T. J. CHRISTMAS C. R. CHAPPLE E. J. G. MILROY R. T. TURNER WARWICK

Jones BM, Gault DT. Blue dyes in reconstructive surgery. Lancet 1988; i: 949-50. John RW. Necrosis of oral mucosa after local application of crystal violet. Br Med J 1968; i: 157-58. 3 Walsh C, Walsh A Haemorrhagic cystitis due to gentian violet. Br Med J 1986; 293:

1. 2

732.

LEGIONNAIRES’ DISEASE FOLLOWING IMMERSION IN A RIVER

SIR,—The water in air conditioning cooling units and shower heads has been incriminated in epidemics of legionnaires’ diseasel but immersion in river water has not been reported to result in infection with Legionella pneumophila. A 32-year-old HIV-antibody positive male attempted suicide by jumping into the River Thames from Waterloo Bridge. He was brought to St Thomas’ Hospital, where there were no abnormal physical findings and, after assessment by a psychiatrist, he was discharged. 11 days later he was admitted gravely ill. He was mute with a temperature of 403°C, tachycardia, severe tachypnoea, and signs of consolidation at the right lung base. There was hypoxia with mildly abnormal blood tests for liver function. Chest X-ray confirmed an extensive right basal pneumonia and he was treated with intravenous amoxycillin and flucloxacillin. Bronchoscopy was normal with no histological evidence of Pneumocystis carinii, and no pathogens were isolated from blood, sputum, or bronchial washings. He improved at first but then deteriorated, and chest X-rays revealed multiple peripheral lung shadows. Percutaneous lung aspiration yielded a moderate growth of L pneumophila, later identified as serogroup 10. Legionella serology was repeatedly negative. He was then treated with erythromycin with clinical improvement, and 6 months later he remains well. Legionnaires’ disease has seldom been reported in HIV-antibody positive patients. It has been suggested that it could result from aspiration of contaminated waterZ and one case may have followed

aspiration during gastric lavage.3 L pneumophila serogroup 10 is a rare cause of legionnaires’ disease, and aspiration of contaminated water probably caused this patient’s infection. Since 1978, 138 culture-positive cases of legionnaires’ disease have been recorded by the Communicable Disease Surveillance Centre; only 2 of the isolates have been identified as L pneumophila serogroup 10 (personal communication, Dr C. L. R. Bartlett). A survey of the river water near Waterloo Bridge, 1 month after the patient’s admission, revealed no evidence of Legionella spp. We thank Dr J. S. Colbourne of Thames Water for advice and for the river survey; Dr C. L. R. Bartlett at the Communicable Disease Surveillance Centre, Colindale, for help; and Dr T. Harrison, Legionella Reference Unit, Central Public Health Laboratory, Colindale, for identifying the serogroup.

water

J.M. FARRANT St Thomas’ Hospital, London SE1 7EH

A. E. C. DRURY R. P. H. THOMPSON

1 Finch R. Minimising the risk of Legionnaires’ disease. Br Med J 1988; 296: 1343-44. VL, Stout J, Zuravleff JJ, Brown A. Aspiration of contaminated water may be a mode of transmission for Legionella pneumophila. International Conference on Antimicrobial Agents and Chemotherapy, 1981; abstr 297. 3 Doumon E, Bure A, Desplaces N, Carette MR, Mayaud Ch. Legionnaires’ disease related to gastric lavage with tap water. Lancet 1982; i 797-98.

2. Yu

PHYSICAL THERAPY IN SPASTIC DIPLEGIA

SiR,—Your July 23 editorial is an odd mix of carefully referenced discussion of physical therapy with unsubstantiated and inaccurate statements about conductive education. You describe conductive education as "a new method of therapy". It is no more a therapy than is special education for the deaf or for the blind. Certainly it has been known of for many years and "some schools have tried to copy the methods": none, however, has analysed it as an educational system for enhancing children’s mental development and none has demonstrated that they have replicated either the substance or outcome of the work. "The patients are highly selected-eg, seizures are a reason for exclusion": the Peto Institute certainly selects its pupils carefully (as we are enjoined to do for schools for the physically handicapped in the UK) but children with seizures are not excluded. It is not claimed that "75% of children learn to walk" but that around that proportion of those who do complete a full-time course go on to operate independently in the school system. In view of the furore over conductive education it is right to ask searching questions about this system, its applicability, and its efficacy. The matter deserves more serious mention than your editorial grants. The long-term educational placement of British children (not "treatment") in the Budapest institute is likely to remain exceptional. The evaluation of conductive education and of the resources to be directed to it and comparisons of it with existing systems of provision will be made much closer to home. You mention the study by Palmer et all comparing Bobath’s neurodevelopmental therapy and "infant stimulation" for children with spastic diplegia. Even though this study was less than wholly conclusive, it does cast favourable light on the notion of providing such children with education (conductive or otherwise) rather than

therapy. Foundation for Conductive Education, University of Birmingham, Birmingham B15 2TT

ANDREW SUTTON

FB, Shapiro BK, Renee C, et al The effects of physical therapy on cerebral palsy N Engl J Med 1988; 318: 803-08.

1 Palmer

HANTAVIRUS AND LEPTOSPIRA

SIR,-We would like to support the observation of Dr Kudesia and colleagues (June 18, p 1397) of apparent dual infection with hantavirus and leptospira, and to present evidence for antibody to Hantaan-related virus in Ireland. Antibody was detected by a standard indirect immunofluorescence assay (IFA) on Vero E6 cells infected with a Rattus norwegicus derived hantavirus first isolated in China. Sera were screened at a dilution of 1 in 16 and all positive sera were titrated. IgG was detected with fluorescein isothiocyanate (FITC) conjugated sheep anti-human IgG. For IgM detection, sera were absorbed before use with ’Gullsorb’ (Gull Laboratories, Utah) to prevent non-specific reactions due to rheumatoid factor, and stained with FITC-conjugated goat anti-human IgM. Positive sera were screened on uninfected E6 cells to exclude non-specific reactions. Absorption of positive sera with acetone-fixed infected but not uninfected E6 cells removed this specific fluorescence. The results obtained are given in the table. Our finding that about 1 % of local farmers were hantavirus seropositive accords with results from studies done on mainland Britain (personal communication, Dr G. Lloyd, Centre for Applied Microbiology and Research, Porton Down). Only 1 seropositive farmer gave a history of foreign travel. The frequency in patients with chronic renal failure (9%) is higher than that reported for Belgium (0-7%1) or the UK as a whole (0-5% but resembles the frequency (10%) reported from Baltimore, USA.3 All of the patients in this group were on haemodialysis. The most striking result is in patients diagnosed serologically as having a current leptospira infection. 7 of the 10 patients were infected with Leptospira var icterohaemorrhagiae, 2 with Leptospzra var hardjo, and 1 with Leptospira var canicola. Our results indicate a common source exposure to hantavirus and leptospires. 31 farmers who screened negative for hantavirus were leptospira seropositive,

461 FLUORESCENT ANTIBODIES AGAINST HANTAAN-RELATED VIRUS INFECTIONS AMONG POPULATION GROUPS IN

NORTHERN IRELAND

supplemented with 10% CO2, but there was no growth after 48 h. Some of the deposit was also inoculated into an enrichment broth which also failed to yield bacteria on subculture. Examination of the CSF sample for antigens of Neisseria meningitidis, Streptococcus pmumomae, and Haemophilus influenzae by counter immunoelectrophoresis was also negative. Four drops of 10% saponin was added to the remainder of the centrifruged deposit for 5 min at room temperature before inoculation as before. A single colony of

electrophoresis was

N meningitidis was isolated after 24 h. The patient was given penicillin and chloramphenicol shortly after lumbar puncture and made a rapid and uneventful recovery. Chloramphenicol was discontinued immediately after the isolation of N meningitidis and rifampicin prophylaxis was offered to close *As reciprocal of highest dilution giving specific fluoresence. t3 sera contained hantavirus specific IgM alone.

making antigenic cross-reactivity unlikely. This group’s 24% seropositivity rate contrasts with the 4% found among patients for whom an aetiological agent for jaundice was not confirmed (which itself is higher than the 2% recorded for UK and Belgian blood donors2). The 3 laboratory personnel found to be hantavirus seropositive had all at some stage worked with rodents, although nonoccupational exposure could not be excluded. Our results give presumptive evidence for the presence of hantavirus in Ireland. Conclusive evidence will require identification of hantavirus strains in the local rodent population. In a preliminary survey we have found 2 of 27 mice trapped on the farms of two of the seropositive farmers to be reactive in our immunofluorescence assay. We will be attempting virus isolation from these and other rodents.

Belfast BT12 6BN

ELIZABETH A. DAVIES PAUL J. ROONEY PETER V. COYLE DAVID I. SIMPSON

Department of Biology, Queens University, Belfast

IAN W. MONTGOMERY

Royal Victoria Hospital, Belfast

CHARLES F. STANFORD

Regional Virus Laboratory, Department of Microbiology and Immunology, Royal Victoria Hospital,

G, Piot P, Desmyter J, et al. Seroepidemiology of Hantaan-related virus infections in Belgian populations. Lancet 1983; ii: 1493-94. 2 Lloyd G Hantavirus: cause for concern in the United Kingdom? PHLS Microbiol Dig 1. Van der Groen

1985, 2: 37-41. 3 Hantaviruses. 29th International

Colloquium Institute of Tropical Medicine, Antwerp. Dec 10-18, 1987; abstr.

LYSIS IN DETECTION OF INTRACELLULAR ORGANISMS

SiR,-Wel and others2 have shown that organisms can be recovered from samples of peritoneal dialysis effluent (PDE) which were sterile on coventional culture, after lysis of the white blood cells in the fluid. This technique could be applied to other body fluids in which intracellular organisms may be present, and the following case is an important example. A 24-year-old man presented with a 3 day history of fever, rigors, headache, and backache. There was no significant history and no recent medication. He looked pale and unwell and had a temperature of 38°C, but the rest of the examination was normal, including absence of neck stiffness, photophobia, Kernig’s sign, or rash. Haemoglobin was 14.6 g/dl with a white blood cell count of 88 x 109/1 (80% neutrophils). After overnight observation he was still unwell and a lumbar puncture was done to exclude bacterial

family contacts. Our ability to isolate the causative organism from a case of meningococcal meningitis, in which the numbers of organisms in the CSF must have been extremely low, reduced our patient’s exposure to a potentially toxic drug and justifiable prophylaxis could be offered to his close family contacts. In a wider context we were able to supply bacteriological proof of the cause of this case of meningitis, which would otherwise have remained an unconfirmed clinical diagnosis. The isolated organism is also available for epidemiological studies We thank Dr Lendrum for permission

to

report his

F. K. GOULD R. FREEMAN

Microbiology Department and Medical Unit 1 Freeman Hospital, Newcastle upon Tyne NE7 7DN 1.

case.

D. LAW T. MORIARTY

Law D, Freeman R, Tapson J. Diagnosis of peritonitis J Clin Pathol 1987; 40: 1267. IM, Casewell MW. The laboratory diagnosis of peritonitis during chronic ambulatory peritoneal dialysis. J Hosp Infect 1986; 7: 155-60.

2. Gould

MANAGEMENT OF BREAST CANCER IN THE ELDERLY

SiR,—The paper by Mr Gazet and colleagues (March 26, p 679) subsequent correspondence (May 7, p 1045; May 28, p 1218; Aug 6, p 345) leads us to review our results of treating breast cancer in frail elderly women by a combination of tamoxifen and low total dose, high dose per fraction ("flash") radiotherapy. Since 1984, 32 patients (mean age 83, range 66-93) have been thus treated. The stage distribution was: Tl-1 (3%), T2-21 (66%), T3-4 (12%), and T4-6 (19%). 23 (72%) were clinically node-negative (NO or Nla). and

Hormone receptor status was known in 25 cases and predicted hormone response well (table), as might be expected. 17 patients still had a palpable residual mass after tamoxifen and various "flash" radiotherapy prescriptions (usually fractions of 3-6 Gy four or five times at weekly intervals). However, only 2 patients have required surgery (mastectomy and axillary clearance) for local failure. 2 patients have distant metastases and both died. In total 2 patients have died of cancer and 5 of intercurrent disease, with a median follow-up of 16 months. Despite limited follow-up and heterogeneous treatment, we are encouraged to study this approach further in patients with hormone receptor titre levels that suggest probable hormone response, reserving mastectomy or lumpectomy and radiotherapy for patients with low or absent hormone receptor status. Toonkel et all and Dr RESPONSE TO TAMOXIFEN AND INCIDENCE OF LOCAL RECURRENCE AND METASTASES

meningitis. The blood cultures taken at admission were negative. The cerebrospinal fluid (CSF) contained white blood cells 4000/ul (98% neutrophils). This, together with a low CSF glucose and a raised CSF protein, suggested bacterial meningitis, but examination of several gram-stained films from the centrifuged deposit failed to show any extracellular or intracellular bacteria. The deposit was inoculated onto whole blood and heated blood agar plates which were incubated at 37°C aerobically and in an atmosphere

CR complete response, PR =partial response, SD =static rnsease, }’’E LR local recurrence, and DM = distant metastases. =

=not

evaluable,