- Email: [email protected]
Intravascular line infection with Exophiala dermatitidis
benign by the International Classification of Diseases for Oncology would not be registered by UK cancer registries, which may go some way towards explaining the deficit. However, since 1977, the UK Children’s Cancer Study Group has registered all cases of childhood cancer treated at specialist paediatric oncology centres (accounting for around 75% of all cases), including certain benign conditions. This has still
not
led
to
reports of this disease from outside the
Midlands.
Misdiagnosis must also be considered, since the diagnosis of mesothelioma is difficult. Most cases from the West Midlands Regional Children’s Tumour Research Group were reviewed by a panel of pathologists, and it is possible that the Midlands excess reflects the pathologists’ experience rather than the disease distribution. However, the Manchester Children’s Tumour Registry covers a population nearly as large as that of the West Midlands, also with central pathological review, but has not recorded any malignant mesotheliomas since records began in 1954.4 Four of the cases were aged between 10 and 15 years. The cluster might be an artifact of the age distribution of the disease, if its peak occurrence were in the teenage years, since cases aged 15 years and over do not normally appear in childhood registries. The West Midlands Regional Cancer Registry, however, has registered no mesothelioma cases in the 15-24 age band since 1978. The management of any rare disease is a clinical challenge, but the possibility that cases are not coming to light hampers the development of effective treatment protocols. We are concerned about the possible failure of registration and would welcome correspondence from practitioners who have encountered this disease in children or teenagers, to help us identify the reasons for the failure of registration, or alternatively, to confirm that this disease does in fact cluster in the Midlands. *J E Powell, M C G Stevens, C A Stiller Regional Children’s Tumour Research Group, Children’s Hospital, Ladywood Middleway, Birmingham B16 8ET, UK; and Childhood Cancer Research Group, University of Oxford
white cell count was 3.7×109/L (55% and the erythrocyte sedimentation rate was 50 mm/h. Blood specimens obtained through the central line grew a pigmented yeast from one of two bottles after 4 days’ incubation. Further blood cultures were done and the line was removed. The repeat blood cultures from the line also grew a yeast after 5 days, but peripheral blood cultures remained sterile. The organism was not isolated from the line tip, but cultures were incubated for only 48 h. The yeast was subsequently identified as E dermatitidis. She was given oral fluconazole for 4 days. A new feeding line was inserted after 3 days, and she made a good recovery without complications. Subsequent blood cultures were sterile. She remains well 2 years later. Fungal infections are a well-recognised complication of intravascular feeding lines,’-3 but we are not aware of previous reports of isolation of E dermatitidis in this setting. Bacterial line infections can sometimes be successfully treated with antibiotics,4 but fungal infections need line removal.’ Clinicians and microbiologists should consider fungi early in the differential diagnosis of all line infections for the best specimen collection and conditions for isolation to aid diagnosis. We agree with Kabel and colleagues that prolonged incubation of specimens is necessary if fungi are to be recovered.
peripheral neutrophils)
We thank
*A J H
3
Niggli FK, Gray TJ, Raafat F, Stevens MCG. Spectrum of peritoneal mesothelioma in childhood: clinical and histopathological features, including DNA cytometry. Pediatr Hematol Oncol 1994; 11: 399-408. Variend S, Gerrard M, Norris PD, Goepel JR. Intra-abdominal neuroectodermal tumour of childhood with divergent differentiation. Histopathology 1991; 18: 45-51. Fraire AE, Cooper S, Greenberg SD, et al. Mesothelioma of
4
childhood. Cancer 1988; 62: 838-47. Kelsey A. Mesothelioma in childhood. Pediatr Hematol Oncol 1994; 11:
2
461-62.
Intravascular line infection with
Exophiala
dermatitidis SIR-Kabel and colleagues (Oct 22, p 1167) describe a case of nosocomial infection with the pigmented mould Exophiala (formerly Wangiella) dermatitidis in a neutropenic patient. We have seen a similar case of intravascular line infection in a patient receiving long-term parenteral nutrition. A 53-year-old woman, having had a colectomy for polyposis coli, had desmoid disease and recurrent episodes of abdominal pain after food. Her condition resulted in her taking little by mouth and receiving long-term home parenteral nutrition. During her first 7 months she had two line infections with coliform bacilli, after which her line was changed, and she was started on six-weekly cycles of rotating antibiotics. She had no further episodes for 21 months, but on this presentation had been non-specifically unwell for 6 months. Previous blood cultures had remained sterile. Her
Simpson, J M D Nightingale
*Department of Medical Microbiology, St Bartholomew’s Hospital, London EC1A 7BE, UK; and Department of Gastroenterology, Leicester Royal Infirmary
1
2
3
*West Midlands
1
ProfE Lennard-Jones for his permission to report this case.
4
Lecciones JA, Lee JW, Navarro EE, et al. Vascular catheter-associated fungemia in patients with cancer: analysis of 155 episodes. Clin Infect Dis 1992; 14: 875-83. Curry CR, Quie PG. Fungal septicemia in patients receiving parenteral hyperalimentation. N Engl J Med 1971; 285: 1221-25. Nightingale JMD, Simpson AJ, Towler HMA, Lennard-Jones JE. Fungal feeding-line infections: beware the eyes and teeth. J R Soc Med
(in press). TSJ, Faroqui MH, Armstrong RF, Hanson GC. Guidelines for good practice in central venous catheterization. J Hosp Infect 1994; 28: Elliott
163-76.
Acute and recurrent airflow obstruction after exposure to artificial fog SIR-Environmental fog and smog can induce bronchospasm in asthmatics.’ Systems designed to develop indoor fog for theatre companies and simulated emergencies such as aircraft fires have used low-irritant polyfunctional (low-molecular weight, water-soluble) alcohols which are reported to be extremely safe.Though the manufacturers recognise the theoretical possibility of such systems triggering asthma, no cases have been reported. We report the case of a 15-year-old girl with a history of mild asthma who had an exacerbation after first exposure to artificial fog system, with recurrence of symptoms
an on
re-exposure.
participating in a high-school theatre rehearsal, a 15-year-old girl noticed increasing breathlessness and chest tightness with audible wheeze 10 min after exposure to artificial fog (Rosco Model 1500). She was immediately removed from the environment and her condition improved, but 20 min later she developed wheeze and breathlessness and was transferred to a hospital emergency room. In transit While
the ambulance service administered 5 mg of nebulised salbutamol with partial relief of her symptoms. On arrival at the emergency room she was tachypnoeic, had a resting arterial oxygen pressure of 99%, and measured forced 67
not
led
to
reports of this disease from outside the
Midlands.
Misdiagnosis must also be considered, since the diagnosis of mesothelioma is difficult. Most cases from the West Midlands Regional Children’s Tumour Research Group were reviewed by a panel of pathologists, and it is possible that the Midlands excess reflects the pathologists’ experience rather than the disease distribution. However, the Manchester Children’s Tumour Registry covers a population nearly as large as that of the West Midlands, also with central pathological review, but has not recorded any malignant mesotheliomas since records began in 1954.4 Four of the cases were aged between 10 and 15 years. The cluster might be an artifact of the age distribution of the disease, if its peak occurrence were in the teenage years, since cases aged 15 years and over do not normally appear in childhood registries. The West Midlands Regional Cancer Registry, however, has registered no mesothelioma cases in the 15-24 age band since 1978. The management of any rare disease is a clinical challenge, but the possibility that cases are not coming to light hampers the development of effective treatment protocols. We are concerned about the possible failure of registration and would welcome correspondence from practitioners who have encountered this disease in children or teenagers, to help us identify the reasons for the failure of registration, or alternatively, to confirm that this disease does in fact cluster in the Midlands. *J E Powell, M C G Stevens, C A Stiller Regional Children’s Tumour Research Group, Children’s Hospital, Ladywood Middleway, Birmingham B16 8ET, UK; and Childhood Cancer Research Group, University of Oxford
white cell count was 3.7×109/L (55% and the erythrocyte sedimentation rate was 50 mm/h. Blood specimens obtained through the central line grew a pigmented yeast from one of two bottles after 4 days’ incubation. Further blood cultures were done and the line was removed. The repeat blood cultures from the line also grew a yeast after 5 days, but peripheral blood cultures remained sterile. The organism was not isolated from the line tip, but cultures were incubated for only 48 h. The yeast was subsequently identified as E dermatitidis. She was given oral fluconazole for 4 days. A new feeding line was inserted after 3 days, and she made a good recovery without complications. Subsequent blood cultures were sterile. She remains well 2 years later. Fungal infections are a well-recognised complication of intravascular feeding lines,’-3 but we are not aware of previous reports of isolation of E dermatitidis in this setting. Bacterial line infections can sometimes be successfully treated with antibiotics,4 but fungal infections need line removal.’ Clinicians and microbiologists should consider fungi early in the differential diagnosis of all line infections for the best specimen collection and conditions for isolation to aid diagnosis. We agree with Kabel and colleagues that prolonged incubation of specimens is necessary if fungi are to be recovered.
peripheral neutrophils)
We thank
*A J H
3
Niggli FK, Gray TJ, Raafat F, Stevens MCG. Spectrum of peritoneal mesothelioma in childhood: clinical and histopathological features, including DNA cytometry. Pediatr Hematol Oncol 1994; 11: 399-408. Variend S, Gerrard M, Norris PD, Goepel JR. Intra-abdominal neuroectodermal tumour of childhood with divergent differentiation. Histopathology 1991; 18: 45-51. Fraire AE, Cooper S, Greenberg SD, et al. Mesothelioma of
4
childhood. Cancer 1988; 62: 838-47. Kelsey A. Mesothelioma in childhood. Pediatr Hematol Oncol 1994; 11:
2
461-62.
Intravascular line infection with
Exophiala
dermatitidis SIR-Kabel and colleagues (Oct 22, p 1167) describe a case of nosocomial infection with the pigmented mould Exophiala (formerly Wangiella) dermatitidis in a neutropenic patient. We have seen a similar case of intravascular line infection in a patient receiving long-term parenteral nutrition. A 53-year-old woman, having had a colectomy for polyposis coli, had desmoid disease and recurrent episodes of abdominal pain after food. Her condition resulted in her taking little by mouth and receiving long-term home parenteral nutrition. During her first 7 months she had two line infections with coliform bacilli, after which her line was changed, and she was started on six-weekly cycles of rotating antibiotics. She had no further episodes for 21 months, but on this presentation had been non-specifically unwell for 6 months. Previous blood cultures had remained sterile. Her
Simpson, J M D Nightingale
*Department of Medical Microbiology, St Bartholomew’s Hospital, London EC1A 7BE, UK; and Department of Gastroenterology, Leicester Royal Infirmary
1
2
3
*West Midlands
1
ProfE Lennard-Jones for his permission to report this case.
4
Lecciones JA, Lee JW, Navarro EE, et al. Vascular catheter-associated fungemia in patients with cancer: analysis of 155 episodes. Clin Infect Dis 1992; 14: 875-83. Curry CR, Quie PG. Fungal septicemia in patients receiving parenteral hyperalimentation. N Engl J Med 1971; 285: 1221-25. Nightingale JMD, Simpson AJ, Towler HMA, Lennard-Jones JE. Fungal feeding-line infections: beware the eyes and teeth. J R Soc Med
(in press). TSJ, Faroqui MH, Armstrong RF, Hanson GC. Guidelines for good practice in central venous catheterization. J Hosp Infect 1994; 28: Elliott
163-76.
Acute and recurrent airflow obstruction after exposure to artificial fog SIR-Environmental fog and smog can induce bronchospasm in asthmatics.’ Systems designed to develop indoor fog for theatre companies and simulated emergencies such as aircraft fires have used low-irritant polyfunctional (low-molecular weight, water-soluble) alcohols which are reported to be extremely safe.Though the manufacturers recognise the theoretical possibility of such systems triggering asthma, no cases have been reported. We report the case of a 15-year-old girl with a history of mild asthma who had an exacerbation after first exposure to artificial fog system, with recurrence of symptoms
an on
re-exposure.
participating in a high-school theatre rehearsal, a 15-year-old girl noticed increasing breathlessness and chest tightness with audible wheeze 10 min after exposure to artificial fog (Rosco Model 1500). She was immediately removed from the environment and her condition improved, but 20 min later she developed wheeze and breathlessness and was transferred to a hospital emergency room. In transit While
the ambulance service administered 5 mg of nebulised salbutamol with partial relief of her symptoms. On arrival at the emergency room she was tachypnoeic, had a resting arterial oxygen pressure of 99%, and measured forced 67