- Email: [email protected]
Measles, Crohn's disease, and recurrent oral ulceration
THE LANCET
different dose-response curves, but confirming their more pronounced effects on reducing clot strength. It is regrettable that we did not have whole blood as well as crystalloid controls in our TEG experiments, which would allow better comparison between reports, but the technique allows only for paired samples, and after the clot weight studies we felt crystalloid controls more appropriate. In these clot-weight experiments (in which we propose weight reflects the extent of the fibrin mesh), undiluted controls were used, and dilution with crystalloid produced a proportionate loss in weight, which at each dilution was exaggerated when gelatincontaining fluids were used. Finally, what is the explanation for the well-documented observation that dilution with saline alters the rate of clot formation? This change is likely to be caused by a disproportionate loss of activity of anticoagulant factors occurring on dilution compared with procoagulant factors, and it is in this sense that we described saline as inert. Although Ruttmanns’ work confirms this effect, there may be some inaccuracy in their r times (measuring the initial phase of coagulation), since they define them in their methods as commencing with the start of TEG recording, and not from the time of venesection, which is the more appropriate method when fresh blood is used.5
sterile specimen jars by discarding the piece of tongue depressor from the faeces pots; the jars themselves appeared identical. The hospital had changed the supplier for tongue depressors some months before, and the new supply was manufactured in a different country. Samples of depressors from the transplant and intensive care units, and from several medical and surgical wards, were cultured. All grew Rhizopus, as did those from boxes from the hospital store. Samples of the previous supplier’s tongue depressors did not grow the organism. The use of heavily contaminated depressors was judged an infection risk in the hospital and they were replaced with a non-contaminated batch by the distributor. The practice of using specimen jars with wooden tongue depressors for stool specimens was discontinued and containers appropriate for stool collection were purchased by our laboratory. Reports from the UK have also identified tongue depressors as a source of Rhizopus contamination of predominantly stool specimens.2,3 It is assumed that we did not detect Rhizopus in such specimens because of bacterial overgrowth. The discovery of this problem in both Australia and the UK suggests that fungal contamination of tongue depressors may be widespread and is a potential source of outbreaks elsewhere.
*S N Mardel, F M Saunders, C M Edwards, D T Baddeley
*J J Harper, C Coulter, G R Lye, G R Nimmo
*129 Spital, Old Aberdeen, Aberdeen AB2 3HX, UK; Accident and Emergency Department, Royal Oldham Hospital; Department of Life Science, University of Nottingham; and Pharmacy Department Royal Conwall Hospitals NHS Trust, Treliske, Truro
Department of Microbiology, Princess Alex andra Hospital, Brisbane, Queensland 4012, Australia
1 1
2 3
4
5
Mardel SN, Saunders F, Ollerenshaw L, Edwards C, Baddeley DT. Reduced quality of in-vitro clot formation with gelatin-based substitutes. Lancet 1996; 347: 825. Ruttman TG, James MFM, Viljoen JF. Haemodilution induces a hypercoagulable state. Br J Anaesth 1996; 76: 412–14. Ng KFJ, Lo JWR. The development of hypercoagulability state, as measured by thromboelastography, associated with intraoperative surgical blood loss. Anaesth Intens Care 1996; 24: 20–25. Kim HW, Stubdal H, Greenburg AG. Coagulation dynamics after hemodilution with polyhemoglobin. Surg Gynecol Obstet 1992; 175: 219. De Nicola P. Thrombelastography. Illinois: Springfield, 1957.
Rhizopus and tongue depressors SIR—Mitchell and colleagues (Aug 17, p 441)1 report an outbreak of cutaneous mucormycosis in a neonatal intensive care unit, the source being wooden tongue depressors contaminated with Rhizopus microsporus. An outbreak of Rhizopus infection at our institution was attributed by the laboratory to cultures contaminated with a Rhizopus sp, and was also traced to contaminated wooden tongue depressors. Rhizopus is an uncommon pathogen but, from May to July, 1995, it was grown from 18 specimens including vascular catheter tips, sputum, and fluid aspirates. All isolates were morphologically identical but they were not identified to species level. The patients were from various wards, including the transplant unit; none had clinical or histological evidence of mucormycosis though one patient with cirrhosis was treated with amphotericin B for presumed fungal peritonitis. The laboratory failed to trace an airborne source of contaminated culture media. Because all contaminated specimens were collected in the same brand of sterile plastic screw-top jars, unused containers from several wards were cultured. 130 empty containers yielded no organism, but 22 jars containing a piece of tongue depressor intended for faecal samples all grew the same Rhizopus sp. It was common practice in the wards to replenish stocks of
1250
2 3
Mitchell SJ, Gray J, Morgan MD, et al. Nosocomial infection with Rhizopus microsporus in preterm infants: association with wooden tongue depressors. Lancet 1996; 348: 441–43. Department of Health. Commun Dis Rep Wkly 1996; 6: 145–48. Leeming JG, Moss HA, Elliott TSJ. Risk of tongue depressors to the immunocompromised. Lancet 1996; 348: 889.
Measles, Crohn’s disease, and recurrent oral ulceration SIR—Oral ulceration is a prominent feature in Crohn’s disease, and is used to define disease activity.1 Recurrent aphthous ulcerations and Crohn’s disease share features such as familial tendency, psychological factors, and response to corticosteroids and immunosuppresive drugs; both are considered to be of autoimmune nature.2 Studies have associated Crohn’s disease with measles, however the data were indirect and based on epidemiological studies.3,4 During an outbreak of measles in 1994, we observed an annual incidence of 3·4 per 1000 in Israel defence force soldiers, most of whom had been vaccinated in the past. 20%
Figure: Oral ulceration on lower lip of a patient with measles
Vol 348 • November 2, 1996
THE LANCET
presented during their illness with severe oral ulceration easily distinguishable from Koplik’s spots (figure). The oral mucosa has several functional similarities with small intestinal epithelium, including immunological functions. Oral ulcerations in measles other than Koplik’s spots have not been reported in the past to the best of our knowledge. Our observation may be a further hint of an association between measles and Crohn’s disease and raises again the possibility of a viral aetiology in another autoimmune disease—recurrent aphthous stomatitis.
available name applied to a taxon (article 23), unless the original author has clearly made a spelling error (articles 32–33). This is not the case for Ornithodoros. The use of Ornithodorus therefore does not accord with the nomenclatural rules. *Trevor N Petney, Matthias Maiwald Hygiene-Institut der Universität, Abteilung Parasitologie und Abteilung Hygiene und Medizinische Mikrobiologie, 69120 Heidelberg, Germany
1
Joseph Katz, Finndler Mordechai, Marmary Itchak, Ashkenazi Isaac, Joshua Shemer Medical Corps, IDF Militry Post 02149, Israel
2 3
1 2 3
4
Hanaver SB. Inflammatory bowel disease. N Engl J Med 1996; 334: 841–47. Glickman R. Inflammatory bowel disease in Harrison’s principle of internal, medicine, McGraw Hill 11th ed, 1987, p 1288. Thompson NP, Montgomery SM, Pounder RE, Wakefield AJ. Is measles vaccination a risk factor for inflammatory bowel disease. Lancet 1995; 345: 1071–74. Ekbom A, Wakefield AJ, Zack M, Adami HO. Perinatal measles infection and subsequent Crohn’s disease. Lancet 1994; 343: 508–10.
Tick nomenclature SIR—We were intrigued by the use of the generic name Ornithodorus by Anda and colleagues (July 20, p 162)1 as well as by Guy in his accompanying commentary.2 This tick genus still appears occasionally with the Latin -us termination. It is, however, much more commonly written with the Greek termination as Ornithodoros. The use of -us in The Lancet suggests that a brief discussion would be worthwhile to avoid future divergent spelling. This genus was first described by Koch3 in 1844 for the new species Ornithodoros coriaceus and for Ornithodoros savignyi which had previously been attributed to the genus Argas. According to Najera,4 the first use of the Latin ending was in 1845 by Agassiz. After this time both forms were regularly used. Nevertheless, the most important tick taxonomists of late last century and of this century (eg, Cooley, Kohls, Neumann, Nuttall, Warburton) continued to use the Greek ending.4 Najera4 reviewed the question of which ending is taxonomically correct and concluded that the -os termination should be used. He based his argument on both philological and nomenclatural grounds. Koch, in his original description,3 specified neither the origin nor the meaning of the Greek words he used to form Ornithodoros. ' means bird. Najera concluded that Koch had used the word in the sense of beak to describe an analogy between a bird’s beak and the mouthparts of the tick. However, according to Najera, beak is not the correct translation and the word is more likely to be derived from either , meaning leather bag or sack, or , , meaning splinter, spear, or lance. From the philological standpoint the use of is the most acceptable (W D Furley, Department of Classical Philology, University of Heidelberg, personal communication). Najera’s interpretation is confirmed by the latest edition of the International Code of Zoological Nomenclature.5 The original description by Koch correctly transliterates the two Greek root words into Latin ( ' transliterated to ornis and to doros) but retains the Greek ending. According to article 11 of the International Code of Zoological Nomenclature it is mandatory to transliterate words from languages that use a non-Latin alphabet, but latinisation of the endings is optional. Priority should be given to the oldest
Vol 348 • November 2, 1996
4 5
Anda P, Sánchez-Yebra W, del Mar Vitutia M, et al. A new Borrelia species isolated from patients with relapsing fever in Spain. Lancet 1996; 348: 162–65. Guy E. Epidemiological surveillance for detecting atypical Lyme disease. Lancet 1996; 348: 141–42. Koch CL. Systematische Übersicht über die Ordnung der Zecken. Arch Naturgesch 1844; 10: 217–39. Najera LE. Sobre nomenclature entomologica: Ornithodoros u Ornithodorus. Ana Med Publ Santa Fe 1951; 3: 185–90. International Trust for Zoological Nomenclature. International code of zoological nomenclature. 3rd edn. London: International Trust for Zoological Nomenclature, 1985.
The Sheffield table for primary prevention of coronary heart disease: corrected SIR—We regret that there was an important error in the Sheffield table (Aug 10, p 387),1 and a corrected version is presented on p 1252. The error in the original was in the table for men only, and arose because the column headings indicating different combinations of risk factors were accidentally transposed as the final table was prepared. Thus the numbers in the table are correct, but do not always correspond to the risk factor combinations shown above them. We are aware that some colleagues have used the table to evaluate individuals, and will want to know what the practical consequences may be. The inaccurate table still predicts, on average, a coronary heart disease (CHD) event rate of 3·0% per year. For eight of the twelve columns in the table for men the risk targeted was acceptably accurate, ranging from 2·8 to 3·2% CHD events per year. Two of the columns would target treatment at men with a lower CHD risk—1·9% and 2·3% per year, respectively. Statin treatment is readily justifiable at this level of risk2 and this inaccuracy should therefore cause no harm. However, in two columns men were signalled as not needing treatment when their risk of CHD was in fact substantially higher than 3·0% per year—at 3·8% and 4·2% per year. These men should be reassessed by the corrected Sheffield table reproduced overleaf. They can in fact be identified readily, because they are all men with hypertension and left ventricular hypertrophy (LVH) shown by electrocardiography. We therefore suggest that any man with hypertension plus LVH who was assessed by the Sheffield table and not treated should be reassessed with the corrected table. We apologise to colleagues for any inconvenience caused by our error. *L E Ramsay, I U Haq, P R Jackson, W W Yeo University Department of Medicine and Pharmacology, Section of Clinical Pharmacology and Therapeutics, Royal Hallamshire Hospital, Sheffield S10 2JF, UK
1
2
Ramsay LE, Haq IU, Jackson PR, Yeo WW, Pickin DM, Payne JN. Targeting lipid-lowering drug therapy for primary prevention of coronary heart disease: an updated Sheffield table. Lancet 1996; 348: 387–88. Shepherd J, Cobbe SM, Ford I, et al, for the West of Scotland Coronary Prevention Study Group. Prevention of coronary heart disease with pravastatin in men with hypercholesterolemia. N Engl J Med 1995; 333: 1301–07.
1251
different dose-response curves, but confirming their more pronounced effects on reducing clot strength. It is regrettable that we did not have whole blood as well as crystalloid controls in our TEG experiments, which would allow better comparison between reports, but the technique allows only for paired samples, and after the clot weight studies we felt crystalloid controls more appropriate. In these clot-weight experiments (in which we propose weight reflects the extent of the fibrin mesh), undiluted controls were used, and dilution with crystalloid produced a proportionate loss in weight, which at each dilution was exaggerated when gelatincontaining fluids were used. Finally, what is the explanation for the well-documented observation that dilution with saline alters the rate of clot formation? This change is likely to be caused by a disproportionate loss of activity of anticoagulant factors occurring on dilution compared with procoagulant factors, and it is in this sense that we described saline as inert. Although Ruttmanns’ work confirms this effect, there may be some inaccuracy in their r times (measuring the initial phase of coagulation), since they define them in their methods as commencing with the start of TEG recording, and not from the time of venesection, which is the more appropriate method when fresh blood is used.5
sterile specimen jars by discarding the piece of tongue depressor from the faeces pots; the jars themselves appeared identical. The hospital had changed the supplier for tongue depressors some months before, and the new supply was manufactured in a different country. Samples of depressors from the transplant and intensive care units, and from several medical and surgical wards, were cultured. All grew Rhizopus, as did those from boxes from the hospital store. Samples of the previous supplier’s tongue depressors did not grow the organism. The use of heavily contaminated depressors was judged an infection risk in the hospital and they were replaced with a non-contaminated batch by the distributor. The practice of using specimen jars with wooden tongue depressors for stool specimens was discontinued and containers appropriate for stool collection were purchased by our laboratory. Reports from the UK have also identified tongue depressors as a source of Rhizopus contamination of predominantly stool specimens.2,3 It is assumed that we did not detect Rhizopus in such specimens because of bacterial overgrowth. The discovery of this problem in both Australia and the UK suggests that fungal contamination of tongue depressors may be widespread and is a potential source of outbreaks elsewhere.
*S N Mardel, F M Saunders, C M Edwards, D T Baddeley
*J J Harper, C Coulter, G R Lye, G R Nimmo
*129 Spital, Old Aberdeen, Aberdeen AB2 3HX, UK; Accident and Emergency Department, Royal Oldham Hospital; Department of Life Science, University of Nottingham; and Pharmacy Department Royal Conwall Hospitals NHS Trust, Treliske, Truro
Department of Microbiology, Princess Alex andra Hospital, Brisbane, Queensland 4012, Australia
1 1
2 3
4
5
Mardel SN, Saunders F, Ollerenshaw L, Edwards C, Baddeley DT. Reduced quality of in-vitro clot formation with gelatin-based substitutes. Lancet 1996; 347: 825. Ruttman TG, James MFM, Viljoen JF. Haemodilution induces a hypercoagulable state. Br J Anaesth 1996; 76: 412–14. Ng KFJ, Lo JWR. The development of hypercoagulability state, as measured by thromboelastography, associated with intraoperative surgical blood loss. Anaesth Intens Care 1996; 24: 20–25. Kim HW, Stubdal H, Greenburg AG. Coagulation dynamics after hemodilution with polyhemoglobin. Surg Gynecol Obstet 1992; 175: 219. De Nicola P. Thrombelastography. Illinois: Springfield, 1957.
Rhizopus and tongue depressors SIR—Mitchell and colleagues (Aug 17, p 441)1 report an outbreak of cutaneous mucormycosis in a neonatal intensive care unit, the source being wooden tongue depressors contaminated with Rhizopus microsporus. An outbreak of Rhizopus infection at our institution was attributed by the laboratory to cultures contaminated with a Rhizopus sp, and was also traced to contaminated wooden tongue depressors. Rhizopus is an uncommon pathogen but, from May to July, 1995, it was grown from 18 specimens including vascular catheter tips, sputum, and fluid aspirates. All isolates were morphologically identical but they were not identified to species level. The patients were from various wards, including the transplant unit; none had clinical or histological evidence of mucormycosis though one patient with cirrhosis was treated with amphotericin B for presumed fungal peritonitis. The laboratory failed to trace an airborne source of contaminated culture media. Because all contaminated specimens were collected in the same brand of sterile plastic screw-top jars, unused containers from several wards were cultured. 130 empty containers yielded no organism, but 22 jars containing a piece of tongue depressor intended for faecal samples all grew the same Rhizopus sp. It was common practice in the wards to replenish stocks of
1250
2 3
Mitchell SJ, Gray J, Morgan MD, et al. Nosocomial infection with Rhizopus microsporus in preterm infants: association with wooden tongue depressors. Lancet 1996; 348: 441–43. Department of Health. Commun Dis Rep Wkly 1996; 6: 145–48. Leeming JG, Moss HA, Elliott TSJ. Risk of tongue depressors to the immunocompromised. Lancet 1996; 348: 889.
Measles, Crohn’s disease, and recurrent oral ulceration SIR—Oral ulceration is a prominent feature in Crohn’s disease, and is used to define disease activity.1 Recurrent aphthous ulcerations and Crohn’s disease share features such as familial tendency, psychological factors, and response to corticosteroids and immunosuppresive drugs; both are considered to be of autoimmune nature.2 Studies have associated Crohn’s disease with measles, however the data were indirect and based on epidemiological studies.3,4 During an outbreak of measles in 1994, we observed an annual incidence of 3·4 per 1000 in Israel defence force soldiers, most of whom had been vaccinated in the past. 20%
Figure: Oral ulceration on lower lip of a patient with measles
Vol 348 • November 2, 1996
THE LANCET
presented during their illness with severe oral ulceration easily distinguishable from Koplik’s spots (figure). The oral mucosa has several functional similarities with small intestinal epithelium, including immunological functions. Oral ulcerations in measles other than Koplik’s spots have not been reported in the past to the best of our knowledge. Our observation may be a further hint of an association between measles and Crohn’s disease and raises again the possibility of a viral aetiology in another autoimmune disease—recurrent aphthous stomatitis.
available name applied to a taxon (article 23), unless the original author has clearly made a spelling error (articles 32–33). This is not the case for Ornithodoros. The use of Ornithodorus therefore does not accord with the nomenclatural rules. *Trevor N Petney, Matthias Maiwald Hygiene-Institut der Universität, Abteilung Parasitologie und Abteilung Hygiene und Medizinische Mikrobiologie, 69120 Heidelberg, Germany
1
Joseph Katz, Finndler Mordechai, Marmary Itchak, Ashkenazi Isaac, Joshua Shemer Medical Corps, IDF Militry Post 02149, Israel
2 3
1 2 3
4
Hanaver SB. Inflammatory bowel disease. N Engl J Med 1996; 334: 841–47. Glickman R. Inflammatory bowel disease in Harrison’s principle of internal, medicine, McGraw Hill 11th ed, 1987, p 1288. Thompson NP, Montgomery SM, Pounder RE, Wakefield AJ. Is measles vaccination a risk factor for inflammatory bowel disease. Lancet 1995; 345: 1071–74. Ekbom A, Wakefield AJ, Zack M, Adami HO. Perinatal measles infection and subsequent Crohn’s disease. Lancet 1994; 343: 508–10.
Tick nomenclature SIR—We were intrigued by the use of the generic name Ornithodorus by Anda and colleagues (July 20, p 162)1 as well as by Guy in his accompanying commentary.2 This tick genus still appears occasionally with the Latin -us termination. It is, however, much more commonly written with the Greek termination as Ornithodoros. The use of -us in The Lancet suggests that a brief discussion would be worthwhile to avoid future divergent spelling. This genus was first described by Koch3 in 1844 for the new species Ornithodoros coriaceus and for Ornithodoros savignyi which had previously been attributed to the genus Argas. According to Najera,4 the first use of the Latin ending was in 1845 by Agassiz. After this time both forms were regularly used. Nevertheless, the most important tick taxonomists of late last century and of this century (eg, Cooley, Kohls, Neumann, Nuttall, Warburton) continued to use the Greek ending.4 Najera4 reviewed the question of which ending is taxonomically correct and concluded that the -os termination should be used. He based his argument on both philological and nomenclatural grounds. Koch, in his original description,3 specified neither the origin nor the meaning of the Greek words he used to form Ornithodoros. ' means bird. Najera concluded that Koch had used the word in the sense of beak to describe an analogy between a bird’s beak and the mouthparts of the tick. However, according to Najera, beak is not the correct translation and the word is more likely to be derived from either , meaning leather bag or sack, or , , meaning splinter, spear, or lance. From the philological standpoint the use of is the most acceptable (W D Furley, Department of Classical Philology, University of Heidelberg, personal communication). Najera’s interpretation is confirmed by the latest edition of the International Code of Zoological Nomenclature.5 The original description by Koch correctly transliterates the two Greek root words into Latin ( ' transliterated to ornis and to doros) but retains the Greek ending. According to article 11 of the International Code of Zoological Nomenclature it is mandatory to transliterate words from languages that use a non-Latin alphabet, but latinisation of the endings is optional. Priority should be given to the oldest
Vol 348 • November 2, 1996
4 5
Anda P, Sánchez-Yebra W, del Mar Vitutia M, et al. A new Borrelia species isolated from patients with relapsing fever in Spain. Lancet 1996; 348: 162–65. Guy E. Epidemiological surveillance for detecting atypical Lyme disease. Lancet 1996; 348: 141–42. Koch CL. Systematische Übersicht über die Ordnung der Zecken. Arch Naturgesch 1844; 10: 217–39. Najera LE. Sobre nomenclature entomologica: Ornithodoros u Ornithodorus. Ana Med Publ Santa Fe 1951; 3: 185–90. International Trust for Zoological Nomenclature. International code of zoological nomenclature. 3rd edn. London: International Trust for Zoological Nomenclature, 1985.
The Sheffield table for primary prevention of coronary heart disease: corrected SIR—We regret that there was an important error in the Sheffield table (Aug 10, p 387),1 and a corrected version is presented on p 1252. The error in the original was in the table for men only, and arose because the column headings indicating different combinations of risk factors were accidentally transposed as the final table was prepared. Thus the numbers in the table are correct, but do not always correspond to the risk factor combinations shown above them. We are aware that some colleagues have used the table to evaluate individuals, and will want to know what the practical consequences may be. The inaccurate table still predicts, on average, a coronary heart disease (CHD) event rate of 3·0% per year. For eight of the twelve columns in the table for men the risk targeted was acceptably accurate, ranging from 2·8 to 3·2% CHD events per year. Two of the columns would target treatment at men with a lower CHD risk—1·9% and 2·3% per year, respectively. Statin treatment is readily justifiable at this level of risk2 and this inaccuracy should therefore cause no harm. However, in two columns men were signalled as not needing treatment when their risk of CHD was in fact substantially higher than 3·0% per year—at 3·8% and 4·2% per year. These men should be reassessed by the corrected Sheffield table reproduced overleaf. They can in fact be identified readily, because they are all men with hypertension and left ventricular hypertrophy (LVH) shown by electrocardiography. We therefore suggest that any man with hypertension plus LVH who was assessed by the Sheffield table and not treated should be reassessed with the corrected table. We apologise to colleagues for any inconvenience caused by our error. *L E Ramsay, I U Haq, P R Jackson, W W Yeo University Department of Medicine and Pharmacology, Section of Clinical Pharmacology and Therapeutics, Royal Hallamshire Hospital, Sheffield S10 2JF, UK
1
2
Ramsay LE, Haq IU, Jackson PR, Yeo WW, Pickin DM, Payne JN. Targeting lipid-lowering drug therapy for primary prevention of coronary heart disease: an updated Sheffield table. Lancet 1996; 348: 387–88. Shepherd J, Cobbe SM, Ford I, et al, for the West of Scotland Coronary Prevention Study Group. Prevention of coronary heart disease with pravastatin in men with hypercholesterolemia. N Engl J Med 1995; 333: 1301–07.
1251