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Macrolide-induced Churg-Strauss syndrome in a patient with atopy
THE LANCET
Number
Mean age
Mean parity
Literacy*
Score before game
Score after game
15
29
3·4
47%
1·73
2·13
0·19
Experimental 15 group
28
3·2
40%
1·43
5·27
<0·0001
Control group
p
*Mothers were classified as being literate if they were able to read the message “Mother, your breast milk is the only milk perfect for your child” written in Zulu. The Growth-monitoring Teaching Aid is available from TALC, PO Box 49, St Albans, Herts AL1 5TX. Price by sea mail £4.50 including postage and packing.
Trial of Growth-monitoring Teaching Aid
KwaZulu/Natal, South Africa. Mothers were divided into an experimental group who used the Growth-monitoring Teaching Aid for 2 to 4 hours and a control group who did not use it. Six questions were used to test each mother’s understanding of growth curves, scoring 0 to 6 for correct responses achieved before and after the intervention. Paired t tests showed that mothers exposed to the Growthmonitoring Teaching Aid significantly increased their understanding of a growth curve in a short time. There was no significant difference between mothers who played the game for 2 or 4 hours (table). Further research into the optimum duration for playing the game, the length of time that the new knowledge is retained, and whether this knowledge results in any behavioural changes is needed. 1 2
3
Grant JP. The State of the World’s Children 1987. UNICEF and Oxford University Press, 1986. Meegan M, Morley DC, Brown R. Child weighing by the unschooled: a report of a control-led study of growth monitoring over 12 months of Massai children using direct recording scales. Trans Roy Soc Trop Med Hygiene 1994; 88: 635–37. Morley DC. Mothers monitor growth. Tropical Doctor July 1993: 98–100.
refused by the patient. During steroid therapy his symptoms rapidly disappeared and blood chemistry returned to normal. 1 year later, an endonasal pansinus procedure was done because of impaired nasal ventilation. Histologically a marked eosinophilic infiltration of the mucosa without formation of granuloma or vasculitis was found. 2 weeks later roxithromycin was initiated because of purulent rhinitis. Therapy was discontinued after 5 days because of face swelling and diffuse myalgia. The facial oedema resolved within 2 days but progressive muscle weakness caused a second hospital admission. Arthralgia, an eosinophil count of 15·5⫻10–9/L (66%), and an extensive mononeuritis multiplex was noted. The skin was unaffected this time. IgE was 871 U/mL, whereas antinuclear antibodies, ds-DNA, rheumatoid factor, and antineutrophil cytoplasmic antibodies were negative. A bone-marrow biopsy specimen showed extensive eosinophilic infiltration but no granulomas. Non-fixed pulmonary infiltrates were documented radiologically. High-dose steroids were started and symptoms improved within days, although neurological deficits persist 1 year later. The triggering cause of Churg-Strauss syndrome is usually not known, but its occurrence was previously observed during hyposensitisation therapy in patients with atopy.2 The disease in our patient suggests that antigenic stimulation with macrolides stimulated the self-perpetuating vasculitic process which persisted despite withdrawal of the incriminating agent. 1 2
Churg J, Strauss L. Allergic granulomatosis, allergic angitis and periarteritis nodosa. Am J Pathol 1951; 27: 277–301. Lanham JG, Elkon KB, Pusey CD, Hughes GR. Systemic vasculitis with asthma and eosinophilia: a clinical approach to the ChurgStrauss syndrome. Medicine 1984; 63: 65–81.
Medizinische Klinik IV, HNO Klinik, and Sektion Nephrologie (K Andrassy), Universität Heidelberg, D-69115 Heidelberg, Germany
University of Leeds, Leeds LS2 9JT, UK (H Sohal); Centre for Epidemiological Research in Southern Africa, South African Medical Research Council, Hlabisa, South Africa; and University of London, London, UK
External hip protectors to prevent osteoporotic hip fractures Macrolide-induced Churg-Strauss syndrome in a patient with atopy C Hübner, A Dietz, W Stremmel, A Stiehl, K Andrassy
In 1951, Churg and Strauss described a rare clinical syndrome, characterised by asthma, fever, hypereosinophilia, and symptoms of systemic vasculitis.1 We describe a patient who developed Churg-Strauss syndrome according to the American College of Rheumatology criteria2 after exposure and rechallenge to macrolides. Our patient had a positive history of atopy, including paroxysmal asthma and seasonal rhinosinusitis since childhood. Repeated bacterial infections had been treated with penicillins and quinolones without side-effects. At the age of 49 years he was admitted to hospital with arthralgia, fever, and a purpuric exanthema 3 days after a 5-day treatment with azithromycin for an unproven respiratory infection. Reduced sensitivity was noted for the left peroneal nerve. C-reactive protein was increased to 12·8 mg/dL (normal <0·5), and IgE to 997 U/mL (normal <100). Eosinophilia was 4·75⫻10–9/L (38%). Chest radiograph, electrocardiogram, and abdominal ultrasound were normal. A pericardial effusion of 200 mL was detected by echocardiography, a sign not found in vasculitides except Churg-Strauss syndrome.2 Unfortunately a skin biopsy was
Vol 350 • August 23, 1997
A Ekman, H Mallmin, K Michaëlsson, S Ljunghall
Lauritzen and colleagues1 reported a study in a nursing home on prevention of hip fractures by an external hip protector. Such devices could constitute a simple but effective treatment in the frail elderly, and could be an alternative to or complement other treatments.2,3 No controlled studies of hip protection have confirmed Lauritzen’s findings. We tested a device similar to Lauritzen’s in residents recruited at four nursing homes in Uppsala, Sweden. During the study period, one of the homes was randomly selected, and all 302 residents were offered external hip protectors. The control nursing homes had 442 residents during the same period. All nursing homes recorded falls and use of hip protectors during an 11-month study period. The external hip protector (JOFA AB, Malung, Sweden) was placed over the greater trochanter, beneath underwear, without any special fixation. It is intended to divert direct impact away from the trochanter during a fall. In the control group 531 falls were registered during the study period compared with 294 in the group of residents offered hip-protectors, including 80 falls with the protector in place. 33 of these falls were verified as causing direct trauma to the trochanter. Average compliance with wearing the protector was 44%. Major reasons for not wearing protectors were being bedridden and skin irritation. 21 hip fractures were recorded during the study period, 17 hip
563
Number
Mean age
Mean parity
Literacy*
Score before game
Score after game
15
29
3·4
47%
1·73
2·13
0·19
Experimental 15 group
28
3·2
40%
1·43
5·27
<0·0001
Control group
p
*Mothers were classified as being literate if they were able to read the message “Mother, your breast milk is the only milk perfect for your child” written in Zulu. The Growth-monitoring Teaching Aid is available from TALC, PO Box 49, St Albans, Herts AL1 5TX. Price by sea mail £4.50 including postage and packing.
Trial of Growth-monitoring Teaching Aid
KwaZulu/Natal, South Africa. Mothers were divided into an experimental group who used the Growth-monitoring Teaching Aid for 2 to 4 hours and a control group who did not use it. Six questions were used to test each mother’s understanding of growth curves, scoring 0 to 6 for correct responses achieved before and after the intervention. Paired t tests showed that mothers exposed to the Growthmonitoring Teaching Aid significantly increased their understanding of a growth curve in a short time. There was no significant difference between mothers who played the game for 2 or 4 hours (table). Further research into the optimum duration for playing the game, the length of time that the new knowledge is retained, and whether this knowledge results in any behavioural changes is needed. 1 2
3
Grant JP. The State of the World’s Children 1987. UNICEF and Oxford University Press, 1986. Meegan M, Morley DC, Brown R. Child weighing by the unschooled: a report of a control-led study of growth monitoring over 12 months of Massai children using direct recording scales. Trans Roy Soc Trop Med Hygiene 1994; 88: 635–37. Morley DC. Mothers monitor growth. Tropical Doctor July 1993: 98–100.
refused by the patient. During steroid therapy his symptoms rapidly disappeared and blood chemistry returned to normal. 1 year later, an endonasal pansinus procedure was done because of impaired nasal ventilation. Histologically a marked eosinophilic infiltration of the mucosa without formation of granuloma or vasculitis was found. 2 weeks later roxithromycin was initiated because of purulent rhinitis. Therapy was discontinued after 5 days because of face swelling and diffuse myalgia. The facial oedema resolved within 2 days but progressive muscle weakness caused a second hospital admission. Arthralgia, an eosinophil count of 15·5⫻10–9/L (66%), and an extensive mononeuritis multiplex was noted. The skin was unaffected this time. IgE was 871 U/mL, whereas antinuclear antibodies, ds-DNA, rheumatoid factor, and antineutrophil cytoplasmic antibodies were negative. A bone-marrow biopsy specimen showed extensive eosinophilic infiltration but no granulomas. Non-fixed pulmonary infiltrates were documented radiologically. High-dose steroids were started and symptoms improved within days, although neurological deficits persist 1 year later. The triggering cause of Churg-Strauss syndrome is usually not known, but its occurrence was previously observed during hyposensitisation therapy in patients with atopy.2 The disease in our patient suggests that antigenic stimulation with macrolides stimulated the self-perpetuating vasculitic process which persisted despite withdrawal of the incriminating agent. 1 2
Churg J, Strauss L. Allergic granulomatosis, allergic angitis and periarteritis nodosa. Am J Pathol 1951; 27: 277–301. Lanham JG, Elkon KB, Pusey CD, Hughes GR. Systemic vasculitis with asthma and eosinophilia: a clinical approach to the ChurgStrauss syndrome. Medicine 1984; 63: 65–81.
Medizinische Klinik IV, HNO Klinik, and Sektion Nephrologie (K Andrassy), Universität Heidelberg, D-69115 Heidelberg, Germany
University of Leeds, Leeds LS2 9JT, UK (H Sohal); Centre for Epidemiological Research in Southern Africa, South African Medical Research Council, Hlabisa, South Africa; and University of London, London, UK
External hip protectors to prevent osteoporotic hip fractures Macrolide-induced Churg-Strauss syndrome in a patient with atopy C Hübner, A Dietz, W Stremmel, A Stiehl, K Andrassy
In 1951, Churg and Strauss described a rare clinical syndrome, characterised by asthma, fever, hypereosinophilia, and symptoms of systemic vasculitis.1 We describe a patient who developed Churg-Strauss syndrome according to the American College of Rheumatology criteria2 after exposure and rechallenge to macrolides. Our patient had a positive history of atopy, including paroxysmal asthma and seasonal rhinosinusitis since childhood. Repeated bacterial infections had been treated with penicillins and quinolones without side-effects. At the age of 49 years he was admitted to hospital with arthralgia, fever, and a purpuric exanthema 3 days after a 5-day treatment with azithromycin for an unproven respiratory infection. Reduced sensitivity was noted for the left peroneal nerve. C-reactive protein was increased to 12·8 mg/dL (normal <0·5), and IgE to 997 U/mL (normal <100). Eosinophilia was 4·75⫻10–9/L (38%). Chest radiograph, electrocardiogram, and abdominal ultrasound were normal. A pericardial effusion of 200 mL was detected by echocardiography, a sign not found in vasculitides except Churg-Strauss syndrome.2 Unfortunately a skin biopsy was
Vol 350 • August 23, 1997
A Ekman, H Mallmin, K Michaëlsson, S Ljunghall
Lauritzen and colleagues1 reported a study in a nursing home on prevention of hip fractures by an external hip protector. Such devices could constitute a simple but effective treatment in the frail elderly, and could be an alternative to or complement other treatments.2,3 No controlled studies of hip protection have confirmed Lauritzen’s findings. We tested a device similar to Lauritzen’s in residents recruited at four nursing homes in Uppsala, Sweden. During the study period, one of the homes was randomly selected, and all 302 residents were offered external hip protectors. The control nursing homes had 442 residents during the same period. All nursing homes recorded falls and use of hip protectors during an 11-month study period. The external hip protector (JOFA AB, Malung, Sweden) was placed over the greater trochanter, beneath underwear, without any special fixation. It is intended to divert direct impact away from the trochanter during a fall. In the control group 531 falls were registered during the study period compared with 294 in the group of residents offered hip-protectors, including 80 falls with the protector in place. 33 of these falls were verified as causing direct trauma to the trochanter. Average compliance with wearing the protector was 44%. Major reasons for not wearing protectors were being bedridden and skin irritation. 21 hip fractures were recorded during the study period, 17 hip
563