- Email: [email protected]
MYOTONIA REMISSION IN MUMPS ORCHITIS
468 the
point, that
the correct pronunciation was that with the i ". This confirmed the practice which we adopted at the time of our incorporation 39 years ago, on the advice of the late Sir Jack Drummond, who was himself responsible for the present spelling of the word. H. C. H. GRAVES Chairman and Managing Director,
on
long "
Vitamins Ltd.
KILLED-MEASLES-VIRUS VACCINE
delayed-type skin-test responses in killed-virus vaccinees on the intradermal inoculation of measles antigen.’ This delayed response does not occur in children who have received livevirus vaccine alone (or with y-globulin) or who have had the natural disease. We conclude that killed-measles-virus vaccine alters the host in an as-yet-undefined fashion. This can later result in an unusual response on administration of live virus or exposure to natural disease. For the present it is our conclusion that no healthy child should electively receive killed-measles-virus vaccine.
SIR,-Several of our British colleagues have suggested that we write to you concerning our recent untoward experiences with killed-measles-virus vaccine. In 1961-62 we engaged in a large field trial which used killedmeasles-virus vaccine in two immunising schedules.1One group received killed virus in three monthly doses (K.K.K.) and another received two monthly doses followed in one month by live-virus administration (K.K.L.). The killed-measles-virus vaccine used was an alum-precipitated, formaldehyde-inactivated, concentrated, monkey-kidney-tissue-culture-grown virus (Charles Pfizer and Co., supplied by Dr. Joel Warren). 90% of seronegative vaccinees developed serum antibody, and for six to twelve months it seemed that they were protected against the disease on natural exposure.12 We later learned that immunity waned in some K.K.K. vaccinees and that a modified or complete form of measles occurred on exposure.2 It is now five to six years since children in our series were immunised, and we are receiving increasing reports of natural disease in both the K.K.K. and K.K.L. vaccinees. In addition, 10 of these vaccinees, all of whom have required admission to hospital, have had a new disease which we have termed " atypical measles ". This is a strikingly febrile illness lasting four to seven days during which headache, myalgia, severe pneumonia, and a peculiar rash have been noted. In three instances the pneumonia has been associated with pleural effusion. The rash begins on the distal extremities, particularly the ankles and feet, and extends towards the trunk, which it eventually involves. In most instances the rash has been maculopapular with petechial and vesicular components. Peripheral oedema has regularly been noted. In 2 instances of the 10 observed in our unit a diagnosis of Rocky Mountain spotted fever was erroneously made. " Atypical measles " is not peculiar to Denver, for it has previously been reported by Rauh and Schmidt in Ohio and by Nader and colleagues in Wyoming.34 A similar disease has been noted by Norrby in two individuals in Sweden.6 In addition to the atypical measles observed in some vaccinees, we, as well as others, have observed an unusual and often severe local reaction at the site of subsequent livevirus immunisation in previous recipients of killed-measlesvirus vaccine.6 The local reaction consists of induration, erythema, and tenderness. It has been of variable duration and severity. We feel that it is probably a manifestation of altered immunological reactivity, possibly delayed hypersensitivity, in killed-measles-virus recipients. To our knowledge neither the atypical illness above described nor the local reactions have been observed in previous recipients of live-virus vaccine alone. The common denominator in all the children thus far reported is the administration of killed vaccine in the past. We have no evidence that either natural disease or live-virus immunisation produced altered reactivity. Lennon et al. have demonstrated 1. 2. 3. 4. 5.
Fulginiti, V. A., Leland, O. S., Kempe, C. H. Am. J. Dis. Child. 1963 105, 5. Fulginiti, V. A., Kempe, C. H. ibid. 1963, 106, 450. Rauh, W. W., Schmidt, R. ibid. 1965, 109, 232. Nader, P. Measles Surveillance Reports. Communicable Disease Center, Childhood Disease Surveillance Unit, Aug. 8, 1966. Norrby, E., Lagercrantz, R., Gard, S. Acta pœdiat., Stockh. 1966, 55, 457.
6.
Fulginiti, V. A., Arthur, J., Pearlman, D. S., Kempe, C. H. J. Pediat. 1966, 69, 891 (abstract). Scott, T. F., McNair, Bonanno, D. E. New Engl. J. Med. 1967, 277, 248. Buser, F. ibid. p. 250. Krugman, S., Giles, J. P., Friedman, H. in First International Conference on Vaccines against Viral and Rickettsial Diseases of Man. Scientific Publication no. 147, Pan American Health Organization/W.H.O., Washington, D.C., 1967.
Department of Pediatrics, University of Colorado, Medical Center, Denver, Colorado 80220.
VINCENT A. FULGINITI C. HENRY KEMPE.
MYOTONIA REMISSION IN MUMPS ORCHITIS SIR,-Krull et al. suggested that a substance in a patient’s blood during attacks of myotonia, which could elicit myotonia in rabbits, was the causative agent of the disease. A 40-year-old patient, who had had severe myotonia from an early age, was seen with mumps complicated by bilateral orchitis. Throughout his stay in hospital and for a fortnight thereafter he could perform eyelid, facial and both arm and leg movements entirely normally. After this interval myotonic symptoms appeared again. In order to determine whether the therapeutic administration of stilbaestrol had produced this transient beneficial effect, this drug was again administered in large doses, but without improvement. Next it was thought that during the patient’s illness pyrexia had produced the result described. Febrile attacks were elicited by pyrogenic substances and typhoidvaccine injections, but again to no avail. It was then suggested that testicular-cell destruction had liberated large amounts of hyaluronidose into the blood-stream. This substance was ad-
ministered, but only subjective improvement was noted. From this case-record it seems likely that some substance in the inflamed testes inhibited myotonic manifestations. I hope eventually to persuade the patient to consent to be again inoculated by mumps virus-innocuous to him by now-in order to test whether the virus, acting as a chemical substance, may have any effect on the course of his disease. In any case, I feel that the complete inhibition of myotonic manifestations in a patient with bilateral mumps orchitis should be further studied. Hospital for Infectious Diseases, L. KATSILAMBROS. Athens.
produced
FUNDI OF BATTERED BABIES SIR,-Lately increasing attention has been paid to the syndrome of the physically abused child (the " battered baby "), yet there seems to be only one published reference to9 any ocular condition directly connected with the syndrome.’ In the past few years our attention has been drawn to the ocular-fundus appearances in a number of infants, with subdural hasmatomas and other injuries, in whom with either hindsight or foresight this diagnosis has seemed likely. We have been impressed by the extreme degree and the persistence of the retinal haemorrhages, both preretinal and intraretinal, associated with striking engorgement of the retinal veins, in the physically abused child, and by the presence of gross papilloedema in some cases. Occasionally massive snowbank retinal exudates have also been present. We feel that the finding of ocular-fundus changes of the degree of severity which we have noted may well be helpful in the diagnosis of the physically abused child. It seems reasonable to suggest that such appearances may not be due simply to 7. Lennon, R.
G., Issacson, P., Rosales, T., Elsea, W. R., Karyon, D. T. Winkelstein, W., Jr. J. Am. med. Ass. 1967, 200, 275. 8. Krull, G. H., Leijnse, B., de Vlieger, M., Viëtor, W. P. J., ter Braak, J. W. G., Gerbrandy, J. Lancet, 1966, ii, 668. 9. Kiffney, G. T., Jr. Archs Ophthal., N.Y. 1964, 72, 231.
point, that
the correct pronunciation was that with the i ". This confirmed the practice which we adopted at the time of our incorporation 39 years ago, on the advice of the late Sir Jack Drummond, who was himself responsible for the present spelling of the word. H. C. H. GRAVES Chairman and Managing Director,
on
long "
Vitamins Ltd.
KILLED-MEASLES-VIRUS VACCINE
delayed-type skin-test responses in killed-virus vaccinees on the intradermal inoculation of measles antigen.’ This delayed response does not occur in children who have received livevirus vaccine alone (or with y-globulin) or who have had the natural disease. We conclude that killed-measles-virus vaccine alters the host in an as-yet-undefined fashion. This can later result in an unusual response on administration of live virus or exposure to natural disease. For the present it is our conclusion that no healthy child should electively receive killed-measles-virus vaccine.
SIR,-Several of our British colleagues have suggested that we write to you concerning our recent untoward experiences with killed-measles-virus vaccine. In 1961-62 we engaged in a large field trial which used killedmeasles-virus vaccine in two immunising schedules.1One group received killed virus in three monthly doses (K.K.K.) and another received two monthly doses followed in one month by live-virus administration (K.K.L.). The killed-measles-virus vaccine used was an alum-precipitated, formaldehyde-inactivated, concentrated, monkey-kidney-tissue-culture-grown virus (Charles Pfizer and Co., supplied by Dr. Joel Warren). 90% of seronegative vaccinees developed serum antibody, and for six to twelve months it seemed that they were protected against the disease on natural exposure.12 We later learned that immunity waned in some K.K.K. vaccinees and that a modified or complete form of measles occurred on exposure.2 It is now five to six years since children in our series were immunised, and we are receiving increasing reports of natural disease in both the K.K.K. and K.K.L. vaccinees. In addition, 10 of these vaccinees, all of whom have required admission to hospital, have had a new disease which we have termed " atypical measles ". This is a strikingly febrile illness lasting four to seven days during which headache, myalgia, severe pneumonia, and a peculiar rash have been noted. In three instances the pneumonia has been associated with pleural effusion. The rash begins on the distal extremities, particularly the ankles and feet, and extends towards the trunk, which it eventually involves. In most instances the rash has been maculopapular with petechial and vesicular components. Peripheral oedema has regularly been noted. In 2 instances of the 10 observed in our unit a diagnosis of Rocky Mountain spotted fever was erroneously made. " Atypical measles " is not peculiar to Denver, for it has previously been reported by Rauh and Schmidt in Ohio and by Nader and colleagues in Wyoming.34 A similar disease has been noted by Norrby in two individuals in Sweden.6 In addition to the atypical measles observed in some vaccinees, we, as well as others, have observed an unusual and often severe local reaction at the site of subsequent livevirus immunisation in previous recipients of killed-measlesvirus vaccine.6 The local reaction consists of induration, erythema, and tenderness. It has been of variable duration and severity. We feel that it is probably a manifestation of altered immunological reactivity, possibly delayed hypersensitivity, in killed-measles-virus recipients. To our knowledge neither the atypical illness above described nor the local reactions have been observed in previous recipients of live-virus vaccine alone. The common denominator in all the children thus far reported is the administration of killed vaccine in the past. We have no evidence that either natural disease or live-virus immunisation produced altered reactivity. Lennon et al. have demonstrated 1. 2. 3. 4. 5.
Fulginiti, V. A., Leland, O. S., Kempe, C. H. Am. J. Dis. Child. 1963 105, 5. Fulginiti, V. A., Kempe, C. H. ibid. 1963, 106, 450. Rauh, W. W., Schmidt, R. ibid. 1965, 109, 232. Nader, P. Measles Surveillance Reports. Communicable Disease Center, Childhood Disease Surveillance Unit, Aug. 8, 1966. Norrby, E., Lagercrantz, R., Gard, S. Acta pœdiat., Stockh. 1966, 55, 457.
6.
Fulginiti, V. A., Arthur, J., Pearlman, D. S., Kempe, C. H. J. Pediat. 1966, 69, 891 (abstract). Scott, T. F., McNair, Bonanno, D. E. New Engl. J. Med. 1967, 277, 248. Buser, F. ibid. p. 250. Krugman, S., Giles, J. P., Friedman, H. in First International Conference on Vaccines against Viral and Rickettsial Diseases of Man. Scientific Publication no. 147, Pan American Health Organization/W.H.O., Washington, D.C., 1967.
Department of Pediatrics, University of Colorado, Medical Center, Denver, Colorado 80220.
VINCENT A. FULGINITI C. HENRY KEMPE.
MYOTONIA REMISSION IN MUMPS ORCHITIS SIR,-Krull et al. suggested that a substance in a patient’s blood during attacks of myotonia, which could elicit myotonia in rabbits, was the causative agent of the disease. A 40-year-old patient, who had had severe myotonia from an early age, was seen with mumps complicated by bilateral orchitis. Throughout his stay in hospital and for a fortnight thereafter he could perform eyelid, facial and both arm and leg movements entirely normally. After this interval myotonic symptoms appeared again. In order to determine whether the therapeutic administration of stilbaestrol had produced this transient beneficial effect, this drug was again administered in large doses, but without improvement. Next it was thought that during the patient’s illness pyrexia had produced the result described. Febrile attacks were elicited by pyrogenic substances and typhoidvaccine injections, but again to no avail. It was then suggested that testicular-cell destruction had liberated large amounts of hyaluronidose into the blood-stream. This substance was ad-
ministered, but only subjective improvement was noted. From this case-record it seems likely that some substance in the inflamed testes inhibited myotonic manifestations. I hope eventually to persuade the patient to consent to be again inoculated by mumps virus-innocuous to him by now-in order to test whether the virus, acting as a chemical substance, may have any effect on the course of his disease. In any case, I feel that the complete inhibition of myotonic manifestations in a patient with bilateral mumps orchitis should be further studied. Hospital for Infectious Diseases, L. KATSILAMBROS. Athens.
produced
FUNDI OF BATTERED BABIES SIR,-Lately increasing attention has been paid to the syndrome of the physically abused child (the " battered baby "), yet there seems to be only one published reference to9 any ocular condition directly connected with the syndrome.’ In the past few years our attention has been drawn to the ocular-fundus appearances in a number of infants, with subdural hasmatomas and other injuries, in whom with either hindsight or foresight this diagnosis has seemed likely. We have been impressed by the extreme degree and the persistence of the retinal haemorrhages, both preretinal and intraretinal, associated with striking engorgement of the retinal veins, in the physically abused child, and by the presence of gross papilloedema in some cases. Occasionally massive snowbank retinal exudates have also been present. We feel that the finding of ocular-fundus changes of the degree of severity which we have noted may well be helpful in the diagnosis of the physically abused child. It seems reasonable to suggest that such appearances may not be due simply to 7. Lennon, R.
G., Issacson, P., Rosales, T., Elsea, W. R., Karyon, D. T. Winkelstein, W., Jr. J. Am. med. Ass. 1967, 200, 275. 8. Krull, G. H., Leijnse, B., de Vlieger, M., Viëtor, W. P. J., ter Braak, J. W. G., Gerbrandy, J. Lancet, 1966, ii, 668. 9. Kiffney, G. T., Jr. Archs Ophthal., N.Y. 1964, 72, 231.