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OCCULT BLOOD AND FAECAL LEUCOCYTE TESTS IN ACUTE INFECTIOUS DIARRHOEA IN CHILDREN
442
haemoglobinophilus (4), H aphrophilus (4), Hparaphrophilus (2), H ducreyi (2), and H parahaemolyticus (1). but
not
for H
Other bacteria often found in sputum did not react with 8BD9 in situ-namely, Pseudomonas aeruginosa (38), Streptococcus pneumoniae (28), Branhamella catarrhalis (24), Escherichia coli (22), Klebsiella pneumonia (9), Proteus mirabilis (8), Neisseria spp (7), coliform rods (6), and Klebsiella oxytoca (5). 7/36 Staphylococcus aureus strains did stain with 8BD9 because of non-specific binding of 8BD9, probably to protein A in the cell wall; preincubation with human serum obtained from healthy donors inhibited the staining. 839 sputum smears were stained and culture of washed sputum samples and 8BD9 staining were in accord in 824 (98 2%).169 were positive and 655 were negative in both tests. In 2 sputum smears 8BD9 stained bacteria were not found, while a few colonies of H influenzae
smears of the same In 182 8BD9 positive detected. 13 of the specimens specimens rod-like bacteria stained with the monoclonal antibody while H influenzae could not be cultured. 5 of these 13 discrepancies were caused by H haemolyticus (1) or H parainfluenzae (4) which reacted with 8BD9. In 7 sputa where H influenzae was not isolated, even after reculturing, the patients had been treated with antibiotics. In 1 of these 7 sputa P aeruginosa was found, and in 3 the primary culture was overgrown by P mirabilis. In 1 sputum B catarrhalis was found in abundance in culture,- and any H influenzae might well have been missed. We conclude that the immunological staining technique with monoclonal antibody 8BD9 is a fast and reliable diagnostic test for H influenzae in sputum, especially in patients with chronic bronchitis or cystic fibrosis where isolation of this bacterium may be difficult. K. GROENEVELD L. VAN ALPHEN Department of Medical Microbiology, N. J. GEELEN-VAN DEN BROEK were
cultured; in gram-stained
no bacteria were
Division of Bacteriology, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
Laboratory for Medical Microbiology, Academic Medical Centre, Amsterdam
P. P. EIJK H. C. ZANEN R.
J. VAN KETEL
May JR. In: Tavemer D, Trounce M, eds. The chemotherapy of chronic bronchitis and allied disorders. London. English Universities Press, 1972. 11-14. 2. Riley TV, Hoffman DC. Interference with Haemophilus influenzae growth by other microorganisms. FEMS Microbiol Lett 1986; 33: 55-58. 3. Poolman J, Zanen HC. Detection of antibody activity in human sera against meningococcal cell wall antigens using a gel-immuno-radio-assay (GIRA). FEMS Microbiol Lett 1980; 7: 293-96. 4. Murphy TF, Nelson MB, Dudas KC, Mylotte JM, Apicella MA. Identification of a specific epitope of Haemophilus influenzae on a 16,000-Dalton outer membrane protein. J Infect Dis 1985, 152: 1300-07. 5. Van Alphen L, Riemens T, Poolman J, Zanen HC. Characteristics of major outer membrane proteins of Haemophilus influenzae. J Bacteriol 1983; 155: 878-85. 6. Van Alphen L, Riemens T, Poolman J, Hopman C, Zanen HC. Homogeneity of cell envelope protein subtypes, lipopolysaccharide serotypes, and biorypes among Haemophilus influenzae type b from patients with meningitis in The Netherlands. J Infect Dis 1983; 148: 75-81. 1.
OCCULT BLOOD AND FAECAL LEUCOCYTE TESTS IN ACUTE INFECTIOUS DIARRHOEA IN CHILDREN
SiR,—To reduce the number of culture studies in children with diarrhoea a screening test for cases that are most probably bacterial in origin would be helpful. Faecal leucocytes are thought to be a reliable predictor of bacterial diarrhoea’ but in 1983 Vog2lin et aF suggested that a modified guaiac test (’Haemoccult’) on stool samples could replace the sometimes troublesome search for leucocytes. Haemoccult testing has been included in the initial diagnostic approach to acute diarrhoea in children outlined by Radetsky.3 We have studied 337 consecutive cases of acute diarrhoea presenting to this paediatric department in 1984-86. Stool samples were examined for Salmonella, Campylobacterjejuni, Yersinia enterocolitica, rotavirus, ova, and parasites. The physician on duty in the outpatient department looked for faecal leucocytes and occult blood (haemoccult). A smear of mucus or faeces was stained with methylene-blue for 5 min, and a finding of more than 5 leucocytes per x 1000 microscope field was regarded as positive. We identified 24 cases of Salmonella spp, 38 Cjejuni, 86 rotavirus, 3 Y enterocolitica, 3 Giardia lamblia, and 9 mixed infections acute
SEARCH FOR FAECAL LEUCOCYTES AND OCCULT BLOOD IN ACUTE DIARRHOEA IN CHILDHOOD
(bacteria and rotavirus); in 174 stool samples no intestinal pathogen found. Occult blood was found in most bacterial diarrhoeas (table) but also in about one-third of cases with rotavirus infection or with no pathogens. By contrast, leucocytes were positive in only about 10% of these two groups. We found faecal leucocytes less often that Vögtlin et al did2 and at a frequency similar to that recorded by Pickering et al.4 If we had chosen haemoccult as a screening test for further investigation by, for example, faecal culture, 84 children (27 with rotavirus and 57 without bacterial pathogens) would have been examined unnecessarily. Screening by faecal leucocytes would have yielded only 26 false positives. On the other hand the false negative rate would have been higher for faecal leucocytes (37 cases missed) than for haemoccult testing (14 cases). Vögtlin et al found good agreement between the two tests but they were studying adults, in whom rotavirus infection is unusual. Rotavirus is a major pathogen in infectious diarrhoea of childhood and it was in rotavirus infection that the two tests were most divergent in our series. In our experience the faecal leucocyte testis not a very sensitive screen for the acute diarrhoea of bacterial origin in childhood. Nor can it be replaced by occult blood testing, which is too non-specific for the purpose.
was
IV Paediatric
Department, University of Milan, Ospedale L. Sacco, 20157 Milan, Italy
SUSANNA PACCAGNINI ROSSANA CERIANI LUCIANA GALLI NICOLA PRINCIPI
MASSIMO FONTANA GIOVANNA ZUIN SANTINA QUARANTA
1. Harris JC, Dupont HL, Hornick RB. Fecal leucocytes in diarrhoeal illness. Ann Intern
Med 1972; 76: 697-703. Vogtlin J, Stalder H, Hürzeler L, et al. Modified guaiac test may replace search for faecal leucocytes in acute infectious diarrhoea. Lancet 1983; ii: 1204. 3. Radetsky M. Laboratory evaluation of acute diarrhea. Pediatr Infect Dis 1986; 5:
2.
230-38. 4.
Pickering LK, Du Pont HL, Olarte J, Conklin R, Ericsson C. Fecal leucocytes in enteric infections. Am J Clin Pathol 1977; 68: 562-65.
RHABDOMYOLYSIS IN DOXYLAMINE OVERDOSE
SIR,—Doxylamine-containing
preparations
are
available
without prescription in West Germany and many other countries, and doxylamine is involved in 2-3% of attempted suicides with drugs seen at the Berlin poison control centres. Rhabdomyolysis is one potentially serious complication of doxylamine overdose and has been noted in 7 of 442 cases of doxylamine overdose reported to our poison control centres in 1982-86. A rise in plasma creatine kinase from 980 to 63 400 U/1 (mean 18 800 U/1) and myoglobinuria was observed in six men and one woman aged 18-31 years (mean 23 years) who had swallowed between 500 and 3000 (mean 1480) mg of doxylamine. A single therapeutic dose is 25-50 mg. On admission, six patients were agitated and disoriented: one patient was somnolent. Haemodialysis was required in one patient with acute renal failure, and a transitory rise in plasma creatinine was observed in three patients. Transitory repolarisation disturbances on the ECG were noted in two patients. Rhabdomyolysis induced by drug overdose has also been reported for diphenhydramine,t,2 which is structurally related to doxylamine, but the mechanism is not clear. A direct toxic effect ofa drug on striated muscle has to be distinguished from muscle damage or necrosis due to secondary causes in acute poisoning via local compression of muscle in coma, muscle ischaemia in shock, or muscle necrosis after prolonged seizures or hypokalaemia.3 In none of the seven cases presented here was there an indication ofa secondary cause of rhabdomyolysis. It seems likely that doxylamuz had a direct toxic effect on striated muscle. We suggest that when
haemoglobinophilus (4), H aphrophilus (4), Hparaphrophilus (2), H ducreyi (2), and H parahaemolyticus (1). but
not
for H
Other bacteria often found in sputum did not react with 8BD9 in situ-namely, Pseudomonas aeruginosa (38), Streptococcus pneumoniae (28), Branhamella catarrhalis (24), Escherichia coli (22), Klebsiella pneumonia (9), Proteus mirabilis (8), Neisseria spp (7), coliform rods (6), and Klebsiella oxytoca (5). 7/36 Staphylococcus aureus strains did stain with 8BD9 because of non-specific binding of 8BD9, probably to protein A in the cell wall; preincubation with human serum obtained from healthy donors inhibited the staining. 839 sputum smears were stained and culture of washed sputum samples and 8BD9 staining were in accord in 824 (98 2%).169 were positive and 655 were negative in both tests. In 2 sputum smears 8BD9 stained bacteria were not found, while a few colonies of H influenzae
smears of the same In 182 8BD9 positive detected. 13 of the specimens specimens rod-like bacteria stained with the monoclonal antibody while H influenzae could not be cultured. 5 of these 13 discrepancies were caused by H haemolyticus (1) or H parainfluenzae (4) which reacted with 8BD9. In 7 sputa where H influenzae was not isolated, even after reculturing, the patients had been treated with antibiotics. In 1 of these 7 sputa P aeruginosa was found, and in 3 the primary culture was overgrown by P mirabilis. In 1 sputum B catarrhalis was found in abundance in culture,- and any H influenzae might well have been missed. We conclude that the immunological staining technique with monoclonal antibody 8BD9 is a fast and reliable diagnostic test for H influenzae in sputum, especially in patients with chronic bronchitis or cystic fibrosis where isolation of this bacterium may be difficult. K. GROENEVELD L. VAN ALPHEN Department of Medical Microbiology, N. J. GEELEN-VAN DEN BROEK were
cultured; in gram-stained
no bacteria were
Division of Bacteriology, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
Laboratory for Medical Microbiology, Academic Medical Centre, Amsterdam
P. P. EIJK H. C. ZANEN R.
J. VAN KETEL
May JR. In: Tavemer D, Trounce M, eds. The chemotherapy of chronic bronchitis and allied disorders. London. English Universities Press, 1972. 11-14. 2. Riley TV, Hoffman DC. Interference with Haemophilus influenzae growth by other microorganisms. FEMS Microbiol Lett 1986; 33: 55-58. 3. Poolman J, Zanen HC. Detection of antibody activity in human sera against meningococcal cell wall antigens using a gel-immuno-radio-assay (GIRA). FEMS Microbiol Lett 1980; 7: 293-96. 4. Murphy TF, Nelson MB, Dudas KC, Mylotte JM, Apicella MA. Identification of a specific epitope of Haemophilus influenzae on a 16,000-Dalton outer membrane protein. J Infect Dis 1985, 152: 1300-07. 5. Van Alphen L, Riemens T, Poolman J, Zanen HC. Characteristics of major outer membrane proteins of Haemophilus influenzae. J Bacteriol 1983; 155: 878-85. 6. Van Alphen L, Riemens T, Poolman J, Hopman C, Zanen HC. Homogeneity of cell envelope protein subtypes, lipopolysaccharide serotypes, and biorypes among Haemophilus influenzae type b from patients with meningitis in The Netherlands. J Infect Dis 1983; 148: 75-81. 1.
OCCULT BLOOD AND FAECAL LEUCOCYTE TESTS IN ACUTE INFECTIOUS DIARRHOEA IN CHILDREN
SiR,—To reduce the number of culture studies in children with diarrhoea a screening test for cases that are most probably bacterial in origin would be helpful. Faecal leucocytes are thought to be a reliable predictor of bacterial diarrhoea’ but in 1983 Vog2lin et aF suggested that a modified guaiac test (’Haemoccult’) on stool samples could replace the sometimes troublesome search for leucocytes. Haemoccult testing has been included in the initial diagnostic approach to acute diarrhoea in children outlined by Radetsky.3 We have studied 337 consecutive cases of acute diarrhoea presenting to this paediatric department in 1984-86. Stool samples were examined for Salmonella, Campylobacterjejuni, Yersinia enterocolitica, rotavirus, ova, and parasites. The physician on duty in the outpatient department looked for faecal leucocytes and occult blood (haemoccult). A smear of mucus or faeces was stained with methylene-blue for 5 min, and a finding of more than 5 leucocytes per x 1000 microscope field was regarded as positive. We identified 24 cases of Salmonella spp, 38 Cjejuni, 86 rotavirus, 3 Y enterocolitica, 3 Giardia lamblia, and 9 mixed infections acute
SEARCH FOR FAECAL LEUCOCYTES AND OCCULT BLOOD IN ACUTE DIARRHOEA IN CHILDHOOD
(bacteria and rotavirus); in 174 stool samples no intestinal pathogen found. Occult blood was found in most bacterial diarrhoeas (table) but also in about one-third of cases with rotavirus infection or with no pathogens. By contrast, leucocytes were positive in only about 10% of these two groups. We found faecal leucocytes less often that Vögtlin et al did2 and at a frequency similar to that recorded by Pickering et al.4 If we had chosen haemoccult as a screening test for further investigation by, for example, faecal culture, 84 children (27 with rotavirus and 57 without bacterial pathogens) would have been examined unnecessarily. Screening by faecal leucocytes would have yielded only 26 false positives. On the other hand the false negative rate would have been higher for faecal leucocytes (37 cases missed) than for haemoccult testing (14 cases). Vögtlin et al found good agreement between the two tests but they were studying adults, in whom rotavirus infection is unusual. Rotavirus is a major pathogen in infectious diarrhoea of childhood and it was in rotavirus infection that the two tests were most divergent in our series. In our experience the faecal leucocyte testis not a very sensitive screen for the acute diarrhoea of bacterial origin in childhood. Nor can it be replaced by occult blood testing, which is too non-specific for the purpose.
was
IV Paediatric
Department, University of Milan, Ospedale L. Sacco, 20157 Milan, Italy
SUSANNA PACCAGNINI ROSSANA CERIANI LUCIANA GALLI NICOLA PRINCIPI
MASSIMO FONTANA GIOVANNA ZUIN SANTINA QUARANTA
1. Harris JC, Dupont HL, Hornick RB. Fecal leucocytes in diarrhoeal illness. Ann Intern
Med 1972; 76: 697-703. Vogtlin J, Stalder H, Hürzeler L, et al. Modified guaiac test may replace search for faecal leucocytes in acute infectious diarrhoea. Lancet 1983; ii: 1204. 3. Radetsky M. Laboratory evaluation of acute diarrhea. Pediatr Infect Dis 1986; 5:
2.
230-38. 4.
Pickering LK, Du Pont HL, Olarte J, Conklin R, Ericsson C. Fecal leucocytes in enteric infections. Am J Clin Pathol 1977; 68: 562-65.
RHABDOMYOLYSIS IN DOXYLAMINE OVERDOSE
SIR,—Doxylamine-containing
preparations
are
available
without prescription in West Germany and many other countries, and doxylamine is involved in 2-3% of attempted suicides with drugs seen at the Berlin poison control centres. Rhabdomyolysis is one potentially serious complication of doxylamine overdose and has been noted in 7 of 442 cases of doxylamine overdose reported to our poison control centres in 1982-86. A rise in plasma creatine kinase from 980 to 63 400 U/1 (mean 18 800 U/1) and myoglobinuria was observed in six men and one woman aged 18-31 years (mean 23 years) who had swallowed between 500 and 3000 (mean 1480) mg of doxylamine. A single therapeutic dose is 25-50 mg. On admission, six patients were agitated and disoriented: one patient was somnolent. Haemodialysis was required in one patient with acute renal failure, and a transitory rise in plasma creatinine was observed in three patients. Transitory repolarisation disturbances on the ECG were noted in two patients. Rhabdomyolysis induced by drug overdose has also been reported for diphenhydramine,t,2 which is structurally related to doxylamine, but the mechanism is not clear. A direct toxic effect ofa drug on striated muscle has to be distinguished from muscle damage or necrosis due to secondary causes in acute poisoning via local compression of muscle in coma, muscle ischaemia in shock, or muscle necrosis after prolonged seizures or hypokalaemia.3 In none of the seven cases presented here was there an indication ofa secondary cause of rhabdomyolysis. It seems likely that doxylamuz had a direct toxic effect on striated muscle. We suggest that when