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POLYCYTHAEMIA VERA CAN PRESENT WITH AQUAGENIC PRURITUS
1451
Letters
to
the Editor
SIX DEATHS FROM MEASLES
SIR,-SO far this year six children in England and Wales have died from measles. Five of these deaths were preventable since the child was old enough to have been vaccinated. Measles vaccine was introduced in the UK in 1968 and has reduced the average number of notifications per annum by four-fifths, and the regular biennial cycle has disappeared (figure). In 1987,42 065 cases of measles were notified-the lowest number since records began. An upsurge was expected in 1988, and in the first quarter of the year, notifications increased to more than double the number recorded in the first quarter of 1987.
It may be idiopathic but can accompany polycythaemia vera. Here describe a case in which aquagenic pruritus preceded the diagnosis of polycythaemia vera by 5 years. A 54-year-old woman was seen at this hospital in 1985, having presented to her general practitioner in 1980 with irritation of the skin after contact with water at any temperature. Her haemoglobin (16-4 g/dl) and packed cell volume (49 6%) in 1981 were thought to be normal. She described a prickling sensation, beginning as her skin started to dry; and she was also troubled by pruritus after a sudden change in temperature (eg, when she got in or out of bed or changed her clothing). Her symptoms lasted for about 45 min, affecting most of the body but sparing the face, hands, and scalp. For 18 months she had noticed that her eyes appeared redder than usual. On examination she had plethoric facies with "bloodshot" eyes and splenomegaly. There were no other abdominal masses, and examination of the cardiovascular, respiratory, and neurological systems was normal. Investigations revealed polycythaemia (Hb 21-3 g/dl, packed cell volume 64%, mean corpuscular volume 78 fl; mean corpuscular haemoglobin and white cell and platelet counts normal; erythrocyte sedimentation rate 0 mm/h. The red cell mass was 55 ml/kg (normal below 32) and the leucocyte alkaline phosphatase was increased at 343 (normal 35-100). A bone marrow (trephine) biopsy revealed increased cellularity and megakaryocytes with normal we
erythropoiesis and granulopoiesis, and absent iron stores, compatible with the diagnosis of polycythaemia vera. Abdominal ultrasound confirmed the splenomegaly but there were no renal masses.
Measles: quarterly notifications, England and Wales 1955-88.
Until measles vaccine completely replaces natural infection, outbreaks are inevitable, as susceptible populations build up. In a part-vaccinated population, the proportion of cases in older children and adults will eventually increase. This has been observed in the United States,’ and outbreaks in secondary schools suggest that a change in the age distribution is now taking place in the UK, although the absolute numbers in older age groups have continued to fall (PHLS Communicable Disease Surveillance Centre,
unpublished). Despite the well-established complications of measles/ the advice to vaccinate is still not being heeded. Failure to appreciate the severity of the disease, and professional uncertainty about contraindications have contributed to poor vaccine coverage. 3,4 There has been some improvement lately but current cover (71 % in 1986) is still well short of the required 90%.5Most children born in 1987 will not have been exposed to natural measles and are at risk of infection. It is essential that these children are protected as soon as possible after their first birthday. Older children not previously vaccinated should also receive measles vaccine, especially in areas where there has been little disease activity in recent years and therefore susceptible populations have accumulated. PHLS Communicable Disease Surveillance Centre, London NW9 5EQ
NORMAN T. BEGG
on college campuses-United States, 1985. MMWR 1985; 34: 445-49. 2. Miller CL. Severity of notified measles. Br Med J 1978; i. 1253. 3. Blair S, Shave N, McKay J. Measles matters, but do parents know? Br Med J 1985; 290: 623-24. 4. Pugh EJ, Hawker R. Measles immunisation. Professional knowledge and intention to vaccinate. Comm Med 1986; 8: 340-47. 5 Begg NT, Noah ND Immunisation targets in Europe and Britain. Br Med J 1985; 291: 1370-71.
The itching provoked by a sudden change in temperature was improved by aspirin 300 mg three times daily2 but the aquagenic pruritus was unaffected. The polycythaemia vera has been controlled by repeated venesection but this has not relieved her symptoms. It is difficult
to be certain whether the aquagenic pruritus preceded or accompanied the development of polycythaemia vera in this patient. We have since found that the haemoglobin in 1976 was 12.3 g/dl and packed cell volume 37-3%. The "high normal" haematological indices in 1981 may have represented the early changes of polycythaemia vera. There is only one case in which aquagenic pruritus definitely preceded polycythaemia vera (Dr ’T. S. Sonnex, personal communication). Aquagenic pruritus is not only associated with but also can be the presenting symptom of polycythaemia vera. Idiopathic aquagenic pruritus should be diagnosed only when polycythaemia vera has been excluded, and it seems wise for haematological indices in such patients to be monitored in case polycythaemia vera develops. An annual full blood count and leucocyte alkaline phosphatase measurement
should suffice.
St John’s Hospital for Diseases, of the Skin and Institute of Dermatology, London WC2H 7BJ 1 Steinman
C. B. ARCHER R. D. R. CAMP M. W. GREAVES
HK, Greaves MW. Aquagenic pruritus. J Am Acad Dermatol 1985; 13:
91-96. 2. Fjellner B, Hagermark O. Pruritus in polycythaemia vera: Treatment with aspirin and possibility of platelet involvement. Acta Derm Venereol ( Stockh) 1979; 59: 505-12.
1. Centers for Disease Control. Measles
POLYCYTHAEMIA VERA CAN PRESENT WITH AQUAGENIC PRURITUS
SIR,-Pruritus is
a common
complaint. Sometimes the itching
has a particular character and the possibility of a specific underlying cause
should
always be considered. Aquagenic pruritus is
widespread prickling-like skin discomfort evoked by water of any temperature,
contact with in the absence of observable skin lesions.i
PENICILLIN-RESISTANT PNEUMOCOCCI
SIR,-Your otherwise excellent editorial of May 21 fails to one issue raised by the increasing frequency of resistant pneumococci-namely, the further justification these findings provide for the use of pneumococcal vaccine. In the United States, pneumococcal vaccine has been strongly recommended for use among elderly and other high-risk persons since 1984. Canada has a similar immunisation policy. However, no European country currently recommends routine pneumococcal vaccination for these groups of patients. In the UK, the Joint address
Committee
on
Vaccination and Immunisation has
never
issued
a
pneumococcal vaccine. The first-generation 14-valent pneumococcal vaccine was licensed for use in the UK in 1978. Fewer than 10 000 doses were distributed during the period 1978 to 1984. When the time came to replace it with 23-valent statement on
Letters
to
the Editor
SIX DEATHS FROM MEASLES
SIR,-SO far this year six children in England and Wales have died from measles. Five of these deaths were preventable since the child was old enough to have been vaccinated. Measles vaccine was introduced in the UK in 1968 and has reduced the average number of notifications per annum by four-fifths, and the regular biennial cycle has disappeared (figure). In 1987,42 065 cases of measles were notified-the lowest number since records began. An upsurge was expected in 1988, and in the first quarter of the year, notifications increased to more than double the number recorded in the first quarter of 1987.
It may be idiopathic but can accompany polycythaemia vera. Here describe a case in which aquagenic pruritus preceded the diagnosis of polycythaemia vera by 5 years. A 54-year-old woman was seen at this hospital in 1985, having presented to her general practitioner in 1980 with irritation of the skin after contact with water at any temperature. Her haemoglobin (16-4 g/dl) and packed cell volume (49 6%) in 1981 were thought to be normal. She described a prickling sensation, beginning as her skin started to dry; and she was also troubled by pruritus after a sudden change in temperature (eg, when she got in or out of bed or changed her clothing). Her symptoms lasted for about 45 min, affecting most of the body but sparing the face, hands, and scalp. For 18 months she had noticed that her eyes appeared redder than usual. On examination she had plethoric facies with "bloodshot" eyes and splenomegaly. There were no other abdominal masses, and examination of the cardiovascular, respiratory, and neurological systems was normal. Investigations revealed polycythaemia (Hb 21-3 g/dl, packed cell volume 64%, mean corpuscular volume 78 fl; mean corpuscular haemoglobin and white cell and platelet counts normal; erythrocyte sedimentation rate 0 mm/h. The red cell mass was 55 ml/kg (normal below 32) and the leucocyte alkaline phosphatase was increased at 343 (normal 35-100). A bone marrow (trephine) biopsy revealed increased cellularity and megakaryocytes with normal we
erythropoiesis and granulopoiesis, and absent iron stores, compatible with the diagnosis of polycythaemia vera. Abdominal ultrasound confirmed the splenomegaly but there were no renal masses.
Measles: quarterly notifications, England and Wales 1955-88.
Until measles vaccine completely replaces natural infection, outbreaks are inevitable, as susceptible populations build up. In a part-vaccinated population, the proportion of cases in older children and adults will eventually increase. This has been observed in the United States,’ and outbreaks in secondary schools suggest that a change in the age distribution is now taking place in the UK, although the absolute numbers in older age groups have continued to fall (PHLS Communicable Disease Surveillance Centre,
unpublished). Despite the well-established complications of measles/ the advice to vaccinate is still not being heeded. Failure to appreciate the severity of the disease, and professional uncertainty about contraindications have contributed to poor vaccine coverage. 3,4 There has been some improvement lately but current cover (71 % in 1986) is still well short of the required 90%.5Most children born in 1987 will not have been exposed to natural measles and are at risk of infection. It is essential that these children are protected as soon as possible after their first birthday. Older children not previously vaccinated should also receive measles vaccine, especially in areas where there has been little disease activity in recent years and therefore susceptible populations have accumulated. PHLS Communicable Disease Surveillance Centre, London NW9 5EQ
NORMAN T. BEGG
on college campuses-United States, 1985. MMWR 1985; 34: 445-49. 2. Miller CL. Severity of notified measles. Br Med J 1978; i. 1253. 3. Blair S, Shave N, McKay J. Measles matters, but do parents know? Br Med J 1985; 290: 623-24. 4. Pugh EJ, Hawker R. Measles immunisation. Professional knowledge and intention to vaccinate. Comm Med 1986; 8: 340-47. 5 Begg NT, Noah ND Immunisation targets in Europe and Britain. Br Med J 1985; 291: 1370-71.
The itching provoked by a sudden change in temperature was improved by aspirin 300 mg three times daily2 but the aquagenic pruritus was unaffected. The polycythaemia vera has been controlled by repeated venesection but this has not relieved her symptoms. It is difficult
to be certain whether the aquagenic pruritus preceded or accompanied the development of polycythaemia vera in this patient. We have since found that the haemoglobin in 1976 was 12.3 g/dl and packed cell volume 37-3%. The "high normal" haematological indices in 1981 may have represented the early changes of polycythaemia vera. There is only one case in which aquagenic pruritus definitely preceded polycythaemia vera (Dr ’T. S. Sonnex, personal communication). Aquagenic pruritus is not only associated with but also can be the presenting symptom of polycythaemia vera. Idiopathic aquagenic pruritus should be diagnosed only when polycythaemia vera has been excluded, and it seems wise for haematological indices in such patients to be monitored in case polycythaemia vera develops. An annual full blood count and leucocyte alkaline phosphatase measurement
should suffice.
St John’s Hospital for Diseases, of the Skin and Institute of Dermatology, London WC2H 7BJ 1 Steinman
C. B. ARCHER R. D. R. CAMP M. W. GREAVES
HK, Greaves MW. Aquagenic pruritus. J Am Acad Dermatol 1985; 13:
91-96. 2. Fjellner B, Hagermark O. Pruritus in polycythaemia vera: Treatment with aspirin and possibility of platelet involvement. Acta Derm Venereol ( Stockh) 1979; 59: 505-12.
1. Centers for Disease Control. Measles
POLYCYTHAEMIA VERA CAN PRESENT WITH AQUAGENIC PRURITUS
SIR,-Pruritus is
a common
complaint. Sometimes the itching
has a particular character and the possibility of a specific underlying cause
should
always be considered. Aquagenic pruritus is
widespread prickling-like skin discomfort evoked by water of any temperature,
contact with in the absence of observable skin lesions.i
PENICILLIN-RESISTANT PNEUMOCOCCI
SIR,-Your otherwise excellent editorial of May 21 fails to one issue raised by the increasing frequency of resistant pneumococci-namely, the further justification these findings provide for the use of pneumococcal vaccine. In the United States, pneumococcal vaccine has been strongly recommended for use among elderly and other high-risk persons since 1984. Canada has a similar immunisation policy. However, no European country currently recommends routine pneumococcal vaccination for these groups of patients. In the UK, the Joint address
Committee
on
Vaccination and Immunisation has
never
issued
a
pneumococcal vaccine. The first-generation 14-valent pneumococcal vaccine was licensed for use in the UK in 1978. Fewer than 10 000 doses were distributed during the period 1978 to 1984. When the time came to replace it with 23-valent statement on