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Mycetoma by Nocardia brasiliensis successfully treated with ethambutol
881 TRANSACTIONS OF THE ROYAL SOCIETY OF TROPICAL MEDICINE AND HYGIENE. Vol. 63. No. 6. 1969.
CORRESPONDENCE
To the Editor FRACTURE OF RIBS IN TROPICAL EOSINOPHILIA
SIR,--Rib fracture from muscular effort occurs as a result of the most varied circumstances but especially after a violent paroxysm of coughing (DERBES and HARAN, 1954). A woman student aged 22 was admitted to the General Hospital, Madras, with complaints of dyspnoea, cough and wheezing for a few days before admission. Auscultation of the chest revealed diminished air entry and a typical asthmatic wheeze. The white blood count was 10,400 per c.mm.; eosinophils 5,408; polymorphs 3,120; lymphocytes 1,664; and basophils 208. An X-ray film of the chest showed an increase in the normal lung markings and fine mottling. The 8th rib on the right side and the 10th rib on the left side showed recent fractures with callus formation about the site of the fractures. T h e r e w a s no displacement of the fractured ends. T h e patient remembered experiencing a sudden sharp pain in the side of the chest after a particularly violent cough about 10 days before; the pain had subsided within a f e w days. T h e following investigations were performed to exclude any predisposing systemic abnormalities. Urine: no evidence of Bence-Jones protein. Serum proteins: normal electrophoretic pattern. Serum calcium: 10.2 rag. per 100 ml. Blood sugar: 110 rag. per 100 ml. Serum uric acid: 5.2 rag. per 100 ml. Serum alkaline phosphatase: 10 K.A. units per 100 ml. She was treated with antibiotics, bronchodilators and a course of diethylcarbamazine, and made a complete recovery. Delay in recognition or treatment of tropical eosinophilia, superadded bacterial infection and aggravation of symptoms in the early stages of treatment with large doses of diethylcarbamazine or arsenic (VISWANATHAN, 1948; CHAUDHURI et al., 1954; ANNAMALAI, 1960) are factors w'fich m~y provoke violent cough resulti:~g in rib fracture. The fracture is an indication of the severity of the cough rather than the aetiology. W e are, etc., AL. ANNAMALAI S. S HREEKUMAR V. SHANTHAKUMAR
Dept. of Medicine, Madras Medical College and General Hospital, Madras. 24 August, 1969 REFERENCES
ANNAMALAI,AL. (1960). Indian Practitioner, 13, 79. CHAL'DHURI, R. N., AIKAT, B. K. & SANJIVI, K. S. (1954). DERBES, V. J. & HARAN, T. (1954). Surgery, 35, 294, VlSWANATHAN,R. (1948). Quart. ~. Med., 17, 257.
Indian J. rned. Res., 42, 635.
MYCETOMA BY N O C A R D I A B R A S I L I E N S I S SUCCESSFULLY TREATED WITH ETHAMBUTOL
SIR,--It is a generally accepted rule that drugs active against myeobacteria must be assayed against actinomycetic infections. A mycetoma had being extending during 20 years from the skin of the neck to the whole anterior part of the thorax above the mammary glands in a Venezuelan labourer from the Andean region. Previous treatment with sulphonamide drugs and tetracyclines had been of no avail. Plenty of minute, pale, polymorphous, clavate grains were to be found in the lesions. Nocardia brasiliensis was repeatedly isolated both through culture on lactritmel medium without antibiotics and through inoculation into the dorsal skin of white mice. T h e isolate, when inoculated peritoneaUy into white mice, could he recovered immediately from brain and lungs, later from lungs mid later on it produced death (as usual) through the development of monstrous abdominal mycetomata, in which the pathogen was present as innumerable minute, pale, non-clavate grains.
882
CORRESPONDENCE
The sole treatment of the patient was Myambutol (Lederle's brand of ethambutoi) administered in the dose of 25 rag. per kg. of body weight, daily, during 6 months. Lesions got better during the first week of treatment; later suppuration ceased, ulcerations healed, subcutaneous infiltration disappeared. The last grain was found 3 months after starting treatment. Ophthalmic examination was performed before, monthly during, and after ending the treatment with ethambutol: no disorder could be found. T h e general condition of the patient improved in the meantime, but the erythrocyte sedimentation rate did not sink correspondingly: it merely varied from 35 to 18 ram., presumably owing to a concomitant infectious periodonfitis. We think now that ethambutol: (1) as an active antimycobacterial drug has made good its promise, when applied to our case of nocardial infection, and (2) it deserves further trial in this field. DANTE BORELLI, M.D. Jos~ LEAL, M.D. Servicio de Dermatologia, Hospital Universitario, Caracas, Venezuela. 25 August, 1969
A CASE OF TOXOPLASMIC LYMPHADENITIS IN AN IRAQI PATIENT
SIR,--This is the first confirmed case of toxoplasmic lymphadenitis in Iraq. Y. Rahdi, 35 years old, Iraqi soldier, was admitted to Rashid Military Hospital ( R M H ) on 3.4.1969, complaining of fever and malaise for several weeks. On examination an enlarged lymph node could be felt in the right cervical re#on. No other lymph # a n d was enlarged; Spleen and liver were not palpable. T h e blood picture and ESR were normal except for leucopenia, which persisted on several occasions, ranging from 2,100-2,400 per c.mm. with relative lymphocytosis. Blood culture did not yield any growth. The Paul Bunnell test and agglutination tests were negative. Stool and urine examination did not show any significant findings. Repeated blood smears were negative for malaria parasites. X-ray of the chest was normal. The patient was treated symptomatically, but he had had treatment with chloramphenicol and butazolidine before admission to R.M.H., this might account for his leucopenia. T h e differential diagnosis was either enteric fever or malignant lymphoma. As blood culture and agglutination tests were negative the cervical lymph node was removed and sent for histopathological examination. Macroscopic examination showed an enlarged lymph node 2 x 1 cm. T h e cut surface was firm and greyish. Microscopic examination. Sections showed chronic lymphadenitis and periadenitis with infiltration of the th/ckened capsule by plasma cells and lymphocytes, the l y m p h follicles were enlarged with active germinal centres. T h e most striking finding was scattered clusters of histiocytes all over the gland, also invading the lymph follicles, giving a spotted appearance on low power examination T h e histiocytes are large cells of pale eosinophilic cytoplasm with vesicular nuclei. These cells are similar to epithelioid cells of tuberculosis but there was no evidence of Langhans giant cells or caseation. T h e clusters of cells are smaller and generally less sharply defined than the focal collection of similar cells seen in sarcoidosis (Figure). The histiocytes show phagocytosis and are seen engulfing much debris, probably due to cellular necrosis of the lymph follicles. T h e lymph sinuses contain a variety of cells--lymphocytes, plasma cells and phagocytes. No L D bodies or parasites could be seen. T h e microscopical findings are highly suggestive of toxoplasmic lymphadenitis, which was reported as such, to be confirmed by special serological tests. The toxoplasma dye test performed on 4.7.1969 was positive, titre 1 in 2,000, indicating active process of toxoplasmosis.
CORRESPONDENCE
To the Editor FRACTURE OF RIBS IN TROPICAL EOSINOPHILIA
SIR,--Rib fracture from muscular effort occurs as a result of the most varied circumstances but especially after a violent paroxysm of coughing (DERBES and HARAN, 1954). A woman student aged 22 was admitted to the General Hospital, Madras, with complaints of dyspnoea, cough and wheezing for a few days before admission. Auscultation of the chest revealed diminished air entry and a typical asthmatic wheeze. The white blood count was 10,400 per c.mm.; eosinophils 5,408; polymorphs 3,120; lymphocytes 1,664; and basophils 208. An X-ray film of the chest showed an increase in the normal lung markings and fine mottling. The 8th rib on the right side and the 10th rib on the left side showed recent fractures with callus formation about the site of the fractures. T h e r e w a s no displacement of the fractured ends. T h e patient remembered experiencing a sudden sharp pain in the side of the chest after a particularly violent cough about 10 days before; the pain had subsided within a f e w days. T h e following investigations were performed to exclude any predisposing systemic abnormalities. Urine: no evidence of Bence-Jones protein. Serum proteins: normal electrophoretic pattern. Serum calcium: 10.2 rag. per 100 ml. Blood sugar: 110 rag. per 100 ml. Serum uric acid: 5.2 rag. per 100 ml. Serum alkaline phosphatase: 10 K.A. units per 100 ml. She was treated with antibiotics, bronchodilators and a course of diethylcarbamazine, and made a complete recovery. Delay in recognition or treatment of tropical eosinophilia, superadded bacterial infection and aggravation of symptoms in the early stages of treatment with large doses of diethylcarbamazine or arsenic (VISWANATHAN, 1948; CHAUDHURI et al., 1954; ANNAMALAI, 1960) are factors w'fich m~y provoke violent cough resulti:~g in rib fracture. The fracture is an indication of the severity of the cough rather than the aetiology. W e are, etc., AL. ANNAMALAI S. S HREEKUMAR V. SHANTHAKUMAR
Dept. of Medicine, Madras Medical College and General Hospital, Madras. 24 August, 1969 REFERENCES
ANNAMALAI,AL. (1960). Indian Practitioner, 13, 79. CHAL'DHURI, R. N., AIKAT, B. K. & SANJIVI, K. S. (1954). DERBES, V. J. & HARAN, T. (1954). Surgery, 35, 294, VlSWANATHAN,R. (1948). Quart. ~. Med., 17, 257.
Indian J. rned. Res., 42, 635.
MYCETOMA BY N O C A R D I A B R A S I L I E N S I S SUCCESSFULLY TREATED WITH ETHAMBUTOL
SIR,--It is a generally accepted rule that drugs active against myeobacteria must be assayed against actinomycetic infections. A mycetoma had being extending during 20 years from the skin of the neck to the whole anterior part of the thorax above the mammary glands in a Venezuelan labourer from the Andean region. Previous treatment with sulphonamide drugs and tetracyclines had been of no avail. Plenty of minute, pale, polymorphous, clavate grains were to be found in the lesions. Nocardia brasiliensis was repeatedly isolated both through culture on lactritmel medium without antibiotics and through inoculation into the dorsal skin of white mice. T h e isolate, when inoculated peritoneaUy into white mice, could he recovered immediately from brain and lungs, later from lungs mid later on it produced death (as usual) through the development of monstrous abdominal mycetomata, in which the pathogen was present as innumerable minute, pale, non-clavate grains.
882
CORRESPONDENCE
The sole treatment of the patient was Myambutol (Lederle's brand of ethambutoi) administered in the dose of 25 rag. per kg. of body weight, daily, during 6 months. Lesions got better during the first week of treatment; later suppuration ceased, ulcerations healed, subcutaneous infiltration disappeared. The last grain was found 3 months after starting treatment. Ophthalmic examination was performed before, monthly during, and after ending the treatment with ethambutol: no disorder could be found. T h e general condition of the patient improved in the meantime, but the erythrocyte sedimentation rate did not sink correspondingly: it merely varied from 35 to 18 ram., presumably owing to a concomitant infectious periodonfitis. We think now that ethambutol: (1) as an active antimycobacterial drug has made good its promise, when applied to our case of nocardial infection, and (2) it deserves further trial in this field. DANTE BORELLI, M.D. Jos~ LEAL, M.D. Servicio de Dermatologia, Hospital Universitario, Caracas, Venezuela. 25 August, 1969
A CASE OF TOXOPLASMIC LYMPHADENITIS IN AN IRAQI PATIENT
SIR,--This is the first confirmed case of toxoplasmic lymphadenitis in Iraq. Y. Rahdi, 35 years old, Iraqi soldier, was admitted to Rashid Military Hospital ( R M H ) on 3.4.1969, complaining of fever and malaise for several weeks. On examination an enlarged lymph node could be felt in the right cervical re#on. No other lymph # a n d was enlarged; Spleen and liver were not palpable. T h e blood picture and ESR were normal except for leucopenia, which persisted on several occasions, ranging from 2,100-2,400 per c.mm. with relative lymphocytosis. Blood culture did not yield any growth. The Paul Bunnell test and agglutination tests were negative. Stool and urine examination did not show any significant findings. Repeated blood smears were negative for malaria parasites. X-ray of the chest was normal. The patient was treated symptomatically, but he had had treatment with chloramphenicol and butazolidine before admission to R.M.H., this might account for his leucopenia. T h e differential diagnosis was either enteric fever or malignant lymphoma. As blood culture and agglutination tests were negative the cervical lymph node was removed and sent for histopathological examination. Macroscopic examination showed an enlarged lymph node 2 x 1 cm. T h e cut surface was firm and greyish. Microscopic examination. Sections showed chronic lymphadenitis and periadenitis with infiltration of the th/ckened capsule by plasma cells and lymphocytes, the l y m p h follicles were enlarged with active germinal centres. T h e most striking finding was scattered clusters of histiocytes all over the gland, also invading the lymph follicles, giving a spotted appearance on low power examination T h e histiocytes are large cells of pale eosinophilic cytoplasm with vesicular nuclei. These cells are similar to epithelioid cells of tuberculosis but there was no evidence of Langhans giant cells or caseation. T h e clusters of cells are smaller and generally less sharply defined than the focal collection of similar cells seen in sarcoidosis (Figure). The histiocytes show phagocytosis and are seen engulfing much debris, probably due to cellular necrosis of the lymph follicles. T h e lymph sinuses contain a variety of cells--lymphocytes, plasma cells and phagocytes. No L D bodies or parasites could be seen. T h e microscopical findings are highly suggestive of toxoplasmic lymphadenitis, which was reported as such, to be confirmed by special serological tests. The toxoplasma dye test performed on 4.7.1969 was positive, titre 1 in 2,000, indicating active process of toxoplasmosis.