- Email: [email protected]
RAISED MATERNAL SERUM ALPHA-FETOPROTEIN, OLIGOHYDRAMNIOS, AND THE FETUS
317
day prednisone may be similarly well tolerated in adults.3,4 The only adverse effect we have seen with any frequency is an occasional patient who has considerable appetite stimulation and excessive weight gain in association with the alternate-day prednisone usage. When recognised early, this adverse effect generally is readily reversible upon substitution of the inhaled steroid. I agree with Toogood that clinical usefulness is a function of both adverse effects and clinical efficacy. Both alternate-day prednisone and inhaled beclomethasone dipropionate offer means of using corticosteroids on a long term basis with an acceptable degree of safety for the control of chronic asthma. Both offer a degree of efficacy that may result in control of asthma when other measures have not been successful. Alternate-day prednisone is less expensive and simpler to administer, but sometimes causes excessive weight gain. Inhaled beclomethasone dipropionate is not a viable alternative for infants and toddlers with chronic asthma, causes oral moniliasis in some patients, and is not tolerated by an occasional patient who experiences cough from inhalation of the powder. The few side effects from both regimens are thus easily recognisable in medically supervised patients, are readily reversible, and are potentially manageable when necessary by using the alternative regimen. Some patients may be better controlled on one or the other, and some do not obtain optimal control with either. The physician should select the regimen which best suits the individual patient’s needs. Department of Pediatrics, University of Iowa Hospitals and Clinics, Iowa City, Iowa 52242, U.S.A.
MILES WEINBERGER
RAISED SERUM AFP LEVELS AND FETAL RENAL AGENESIS
SIR,-A variety of fetal abnormalities other than open neural tube defects may lead to a rise in maternal serum alphafetoprotein (AFP) in early pregnancy, including exomphalos, Finnish type congenital nephrosis, and intrauterine death.l The following two cases support the inclusion of congenital renal agenesis in this list. The first patient was a 23-year-old primagravida with Crohn’s disease (for which she was being treated with prednisone) and absence of left ovary, fallopian tube, and kidney. There was no family history of neural tube defect and nothing to suggest an error in her dates. The serum AFP at 15 weks was 95 mg/1. Amniocentesis was attempted at 16 and 17 weeks but no liquor was obtained. The serum AFP just before the second amniocentesis was 147 u.g/1..Both these serum AFP results were well above the 95th percentile. There was evidence of severe intrauterine growth retardation. Onset of labour at 34 weeks resulted in the breech delivery of a male with Potter facies, weighing only 1600 g. Little liquor was present. The placenta weighed 350 g. The infant died within an hour. Necropsy revealed hypoplastic atelectatic lungs and bilateral renal agenesis. The second patient was a 25-year-old woman whose brother had died from spina bifida and whose maternal aunt had a spina bifida child. Her first pregnancy had miscarried at 10 weeks. She was sure of her dates and when seen at 12 weeks for booking in her second pregnancy; the uterine size and dates were consistent. Serum AFP at 15 weeks was 65 g/1 (93rd percentile). Amniocentesis was attempted unsuccessfully under ultrasound control three times over the next 2 weeks. There 3. Ackerman
GL, Nolan CM. Adrenocortical responsiveness after alternate-day corticosteroid therapy. N Engl J Med 1978; 278: 405. 4 Collaborative study of the adult idiopathic nephrotic syndrome. A controlled study of short-term prednisone treatment in adults with membranous
nephropathy. N Engl J Med 1979; 301: 1301-06. 1. Editorial. Origin of maternal
serum
AFP. Lancet
1979; ii: 999.
ultrasound evidence of oligohydramnios but the fetal head and spine appeared normal. The uterine size remained consistently small for dates. Labour started spontaneously at 34 weeks with a breech presentation. At caaarean section a female weighing 1850 and having a Potter facies was delivered. A negligible amount of amniotic fluid was present. The placenta weighed 400 g and was heavily calcified. The infant died after 6 h. Necropsy showed bilateral hypoplastic atelectatic lungs, bilateral renal agenesis, a rudimentary bladder and absent uterus and tubes. Brockzspeculated that cases with renal agenesis would have low amniotic AFP levels because most of the AFP is assumed to reach the amniotic fluid via the fetal kidneys, and he suggested that this might afford a method of prenatal detection. However, the two cases of renal agenesis reported by Seller and Berry3 were associated with normal amniotic AFP levels. We do not know how AFP reaches the amniotic fluid when there are no functioning kidneys-perhaps secretions from the respiratory or gastrointestinal tracts play a part, and fetal skin contains large quantities of AFP.4 Sometimes there is little correlation between serum and liquor AFp5 levels; perhaps the raised serum AFP levels in our cases were due to intrauterine growth retardation or to renal agenesis putting some other strain on the fetoplacental unit. When the serum AFP level is raised in the presence of oligohydramnios, especially when the liquor AFP level is normal, it may be advisable to look for renal agenesis by scanning for fetal kidneys and bladder. If these organs cannot be found, frusemide should be administered to the mother to increase fetal urine production.6 If there is still no fetal bladder, this would strongly support a diagnosis of renal agenesis. was
Departments of Obstetrics and Gynæcology and Child Health, Welsh National School of Medicine, Heath Park, Cardiff CF4 4XN
R. P. BALFOUR K. M. LAURENCE
RAISED MATERNAL SERUM
ALPHA-FETOPROTEIN, OLIGOHYDRAMNIOS, AND THE FETUS
SIR,-Raised maternal serum alpha-fetoprotein (AFP) concentrations have been reported in other conditions besides open neural-tube defects; these include multiple pregnancy, fetal distress, threatened abortion and intrauterine death, and to this list we would now add severe oligohydramnios. Four patients presented for amniocentesis at 17-19 weeks’ gestation because of two raised maternal serum-AFP levels (A, B, and C) or because the woman had already had a child with a neural tube defect (D) (her serum AFP was also raised). In patients B, C, and D no liquor could be obtained, despite repeated attempts; in patient A a small volume of red fluid was eventually obtained at 21 weeks, which had a normal AFP level. Patient A had a caesarean section at 33 weeks because of antepartum haemorrhage. The female infant was small for dates, has an asymmetrical head, redundant skin folds over the neck, congenital dislocation of the hips, severe bilateral talipes, and a sacral dimple. She is alive and progressing. Her chromosome complement is 46,XX,t(5;12)qll;q24 mat. This balanced translocation is also carried by her normal mother, brother, and maternal aunt, and is thought to be incidental to her condition. 2. Brock DJH. Mechanisms by which amniotic fluid alpha-fetoprotein may be increased in fetal abnormalities. Lancet 1976; ii: 345-46. 3. Seller MJ, Berry AC. Amniotic fluid alpha-fetoprotein and fetal renal agenesis. Lancet 1978; i: 660. 4. Lawler SD, Nash SG. Alpha-fetoprotein in fetal skin and muscle. Br J Obstet Gynæcol 1977; 84: 51-54. 5. Second Report of the UK Collaborative Study on Alpha-fetoprotein in Relation to Neural Tube Defects. Amniotic fluid alpha-fetoprotein measurement in antenatal diagnosis of anencephaly and open spina bifida in early pregnancy. Lancet 1979; ii: 651-62. 6. Keirse MJN, Meerman RH. Antenatal Gynecol 1978, 52: 64-67.
diagnosis
of Potter
syndrome. Obstet
318 Patient D had spontaneous rupture of the membranes at 27 weeks, vaginal bleeding at 28 weeks, and delivered, at 29 weeks, a male who died immediately. He had an odd-shaped head, loose fold of skin over the occiput, limited hip adduction, severe bilateral talipes, and flexion deformities of the knee joints. No necropsy was done, but kidneys and bladder had been identified by ultrasound in utero. Patients B and C chose termination because of the apparently poor prognosis of early severe oligohydramnios. In B the male fetus at 22 weeks had severe bilateral talipes, legs in the position associated with extended breech presentation, adduction of the hips, and odd facies. The kidneys were normal. The female fetus of C at 18 weeks had no obvious internal or external abnormalities. The oligohydramnios was not due to renal agenesis and may have been due to leakage of liquor. The oligohydramnios associated with absent fetal kidneys is said not to develop until around the 35th week of pregnancy’ and certainly our two cases of this condition2 showed no evidence of oligohydramnios at the time of amniocentesis. Nevertheless, the abnormalities in the fetus are similar whatever the origin of the oligohydramnios-notably, odd facies and severe talipes-suggesting that they are imposed by the abnormal environment rather than being intrinsic to the fetus. These findings support the suggestion3 that the orthopaedic postural deformities and pulmonary abnormalities occasionally seen in babies who have undergone amniocentesis may be due to an insufficiency of amniotic fluid at critical stages of development. Our limited experience with raised maternal serum-AFP and oligohydramnios in the early second trimester suggests that if amniocentesis fails, a repeat is unlikely to be successful and is not necessary; the oligohydramnios is sufficient to explain the raised maternal serum-AFP. Indeed, even the first amniocentesis might be avoided if our findings are confirmed; sonography alone could assess the amount of liquor. However, if ultrasound scanning also reveals the presence of the fetal bladder and kidneys the parents should be told of the high risk of their child having severe lower limb deformities. We thank Mr J. S. Tomkinson, Mr E. D. Morris, Mr T. P. Shuttle-
worth, and Mr P. M. Fullman for permission
to
publish details of their
patients. Pædiatric Research Unit, Prince Philip Research Laboratories,
Guy’s Hospital, London SE1 9RT
MARY J. SELLER ANNE H. CHILD
NON-OPERATIVE MANAGEMENT OF COCCYGODYNIA
SiR,-Coccygodynia is a painful condition that frequently protracted course. It is usually caused by trauma to the anterior or posterior sacrococcygeal ligaments and may be
runs a
demonstrated on rectal examination when small movements of the coccyx cause great pain. Excision of the coccyx is the only permanently effective treatment though the introduction of local steroids into the joint space can afford relief for long periods. This is not easy because the joint is difficult to palpate externally. For this reason the following technique was used to facilitate the introduction of steroid into the sacrococcygeal
joint. 0-35 ml intra-articular triamcinolone (10 mg/ml) is drawn up into a 2 ml syringe and mixed with an equal amount of 2% plain lignocaine and attached to a 21 gauge needle. The patient is placed in the right lateral position near the edge of the 1. Saunders P, Rhodes P. The origin and circulation of the amniotic fluid. In: Fairweather DVI, Eskes TKAB, eds. Amniotic fluid: Research and clinical Application. Amsterdam: Exerpta Medica, 1973:1-18. 2. Seller MJ, Berry AC. Amniotic fluid alpha-fetoprotein and fetal renal agenesis. Lancet, 1978; i: 660. 3. Report to the M.R.C. by their Working Party on Amniocentesis. An assessment of the hazards of amniocentesis. Br J Obstet Gynœcol 1978; 85:
suppl 2.
couch. The physician’s gloved and lubricated left index finger is introduced into the rectum and advanced on the ventral surface of the coccyx until a transverse groove is felt. This groove, which is over the sacrococcygeal joint, is easily palpated because the rectum is closely apposed to the coccyx and sacrum at this point. The examining finger should be positioned so that the tip lies on the groove. The skin in the natal cleft is cleaned with a suitable antiseptic preparation and the hypodermic needle introduced at right angles to the skin in the midline over the tip of the left finger and advanced directly towards it. The needle should pass into the sacrococcygeal joint and 0.5 ml of the contents are injected. This technique has been used in five patients with immediate relief in all. One of these patients was pain free at 12 months. The other four were lost to follow up between 6 and 12 months, but were pain free when last seen. The technique is simple and little more time consuming than the original diagnostic rectal examination. It is suitable for use in general practice and may afford relief to patients who have had to sit on their complaint for too long. University Department of Dermatology, Royal Victoria Infirmary, Newcastle upon Tyne NE 1 4LP
P.
J. KERSEY
IMMUNOGLOBULIN BY INFUSION
SIR, Your editorial ends
on
immunoglobulin (Dec. 1,
p.
1168)
that "until intravenous preparations are more widely available it may be to the patient’s ultimate advantage to be generous with intramuscular IgG despite the added pain of injections". However, a weekly dose of 50 mg IgG/kg is a large and painful volume for an adult with agammaglobulintmia (approximately 20 ml per week for a person weighing 60 kg). In 1966 E. R. Stiehm and colleagues (Blood; 28: 918) reported the efficacy of plasma infusions in increasing serum immunoglobulin levels in patients with immunoglobulin deficiency. These findings have been corroborated by R. H. Buckley (Am J Dis Child 1972; 124: 376). Not only is the pain of large intramuscular volume circumvented but also IgA and IgM are provided, and specific antibody titres are higher. With careful donor selection hepatitis B is not a great hazard. We (and our patients) prefer regular plasma infusions as substitution therapy for immunoglobulin deficiency in larger children and adults.
by stating
Departments of Infectious Diseases, and Pædiatrics, University Hospital, Leiden, Netherlands
J.
W. M. VAN
L.
J. DOOREN
DER
MEER
BCG: BAD NEWS FROM INDIA
SIR,-The Indian experience is unhappy (Jan. 12, p. 73) but barriers against mycobacterial infection are far from complete, even in the U.K. Chronic infections are more complicated than the acute types, and the most complex are the mycobacterial diseases. Even in the U.K. the response to BCG inoculation varies considerably. 17 of 32 studenr nurses at this hospital were Mantoux negative in December, 1979. 25 nurses had received BCG at school during 1973-75. 12 of the Mantouxnegative cases did not respond to a second BCG injection, but 5 others showed brisk cutaneous reactions. Was the immunitv to tuberculosis short-lived in the latter girls? Was the lack of response in some of the others due to tuberculous anergy or occasionally to subclinical sarcoidosis?1 Are BCG inoculations in any way at all involved in the supposed increase in Crohn’s disease ? Many unanswered questions remain, including the viability of protoplasm mycobacteria. St Luke’s
Hospital, Guildford, Surrey GU1 3NT 1.
GERALD A. MACGREGOR
Caspary EA, Field EJ. Lymphocytic sensitisation 1971; ii: 143-45.
in sarcoidosis. Br
Med J
day prednisone may be similarly well tolerated in adults.3,4 The only adverse effect we have seen with any frequency is an occasional patient who has considerable appetite stimulation and excessive weight gain in association with the alternate-day prednisone usage. When recognised early, this adverse effect generally is readily reversible upon substitution of the inhaled steroid. I agree with Toogood that clinical usefulness is a function of both adverse effects and clinical efficacy. Both alternate-day prednisone and inhaled beclomethasone dipropionate offer means of using corticosteroids on a long term basis with an acceptable degree of safety for the control of chronic asthma. Both offer a degree of efficacy that may result in control of asthma when other measures have not been successful. Alternate-day prednisone is less expensive and simpler to administer, but sometimes causes excessive weight gain. Inhaled beclomethasone dipropionate is not a viable alternative for infants and toddlers with chronic asthma, causes oral moniliasis in some patients, and is not tolerated by an occasional patient who experiences cough from inhalation of the powder. The few side effects from both regimens are thus easily recognisable in medically supervised patients, are readily reversible, and are potentially manageable when necessary by using the alternative regimen. Some patients may be better controlled on one or the other, and some do not obtain optimal control with either. The physician should select the regimen which best suits the individual patient’s needs. Department of Pediatrics, University of Iowa Hospitals and Clinics, Iowa City, Iowa 52242, U.S.A.
MILES WEINBERGER
RAISED SERUM AFP LEVELS AND FETAL RENAL AGENESIS
SIR,-A variety of fetal abnormalities other than open neural tube defects may lead to a rise in maternal serum alphafetoprotein (AFP) in early pregnancy, including exomphalos, Finnish type congenital nephrosis, and intrauterine death.l The following two cases support the inclusion of congenital renal agenesis in this list. The first patient was a 23-year-old primagravida with Crohn’s disease (for which she was being treated with prednisone) and absence of left ovary, fallopian tube, and kidney. There was no family history of neural tube defect and nothing to suggest an error in her dates. The serum AFP at 15 weks was 95 mg/1. Amniocentesis was attempted at 16 and 17 weeks but no liquor was obtained. The serum AFP just before the second amniocentesis was 147 u.g/1..Both these serum AFP results were well above the 95th percentile. There was evidence of severe intrauterine growth retardation. Onset of labour at 34 weeks resulted in the breech delivery of a male with Potter facies, weighing only 1600 g. Little liquor was present. The placenta weighed 350 g. The infant died within an hour. Necropsy revealed hypoplastic atelectatic lungs and bilateral renal agenesis. The second patient was a 25-year-old woman whose brother had died from spina bifida and whose maternal aunt had a spina bifida child. Her first pregnancy had miscarried at 10 weeks. She was sure of her dates and when seen at 12 weeks for booking in her second pregnancy; the uterine size and dates were consistent. Serum AFP at 15 weeks was 65 g/1 (93rd percentile). Amniocentesis was attempted unsuccessfully under ultrasound control three times over the next 2 weeks. There 3. Ackerman
GL, Nolan CM. Adrenocortical responsiveness after alternate-day corticosteroid therapy. N Engl J Med 1978; 278: 405. 4 Collaborative study of the adult idiopathic nephrotic syndrome. A controlled study of short-term prednisone treatment in adults with membranous
nephropathy. N Engl J Med 1979; 301: 1301-06. 1. Editorial. Origin of maternal
serum
AFP. Lancet
1979; ii: 999.
ultrasound evidence of oligohydramnios but the fetal head and spine appeared normal. The uterine size remained consistently small for dates. Labour started spontaneously at 34 weeks with a breech presentation. At caaarean section a female weighing 1850 and having a Potter facies was delivered. A negligible amount of amniotic fluid was present. The placenta weighed 400 g and was heavily calcified. The infant died after 6 h. Necropsy showed bilateral hypoplastic atelectatic lungs, bilateral renal agenesis, a rudimentary bladder and absent uterus and tubes. Brockzspeculated that cases with renal agenesis would have low amniotic AFP levels because most of the AFP is assumed to reach the amniotic fluid via the fetal kidneys, and he suggested that this might afford a method of prenatal detection. However, the two cases of renal agenesis reported by Seller and Berry3 were associated with normal amniotic AFP levels. We do not know how AFP reaches the amniotic fluid when there are no functioning kidneys-perhaps secretions from the respiratory or gastrointestinal tracts play a part, and fetal skin contains large quantities of AFP.4 Sometimes there is little correlation between serum and liquor AFp5 levels; perhaps the raised serum AFP levels in our cases were due to intrauterine growth retardation or to renal agenesis putting some other strain on the fetoplacental unit. When the serum AFP level is raised in the presence of oligohydramnios, especially when the liquor AFP level is normal, it may be advisable to look for renal agenesis by scanning for fetal kidneys and bladder. If these organs cannot be found, frusemide should be administered to the mother to increase fetal urine production.6 If there is still no fetal bladder, this would strongly support a diagnosis of renal agenesis. was
Departments of Obstetrics and Gynæcology and Child Health, Welsh National School of Medicine, Heath Park, Cardiff CF4 4XN
R. P. BALFOUR K. M. LAURENCE
RAISED MATERNAL SERUM
ALPHA-FETOPROTEIN, OLIGOHYDRAMNIOS, AND THE FETUS
SIR,-Raised maternal serum alpha-fetoprotein (AFP) concentrations have been reported in other conditions besides open neural-tube defects; these include multiple pregnancy, fetal distress, threatened abortion and intrauterine death, and to this list we would now add severe oligohydramnios. Four patients presented for amniocentesis at 17-19 weeks’ gestation because of two raised maternal serum-AFP levels (A, B, and C) or because the woman had already had a child with a neural tube defect (D) (her serum AFP was also raised). In patients B, C, and D no liquor could be obtained, despite repeated attempts; in patient A a small volume of red fluid was eventually obtained at 21 weeks, which had a normal AFP level. Patient A had a caesarean section at 33 weeks because of antepartum haemorrhage. The female infant was small for dates, has an asymmetrical head, redundant skin folds over the neck, congenital dislocation of the hips, severe bilateral talipes, and a sacral dimple. She is alive and progressing. Her chromosome complement is 46,XX,t(5;12)qll;q24 mat. This balanced translocation is also carried by her normal mother, brother, and maternal aunt, and is thought to be incidental to her condition. 2. Brock DJH. Mechanisms by which amniotic fluid alpha-fetoprotein may be increased in fetal abnormalities. Lancet 1976; ii: 345-46. 3. Seller MJ, Berry AC. Amniotic fluid alpha-fetoprotein and fetal renal agenesis. Lancet 1978; i: 660. 4. Lawler SD, Nash SG. Alpha-fetoprotein in fetal skin and muscle. Br J Obstet Gynæcol 1977; 84: 51-54. 5. Second Report of the UK Collaborative Study on Alpha-fetoprotein in Relation to Neural Tube Defects. Amniotic fluid alpha-fetoprotein measurement in antenatal diagnosis of anencephaly and open spina bifida in early pregnancy. Lancet 1979; ii: 651-62. 6. Keirse MJN, Meerman RH. Antenatal Gynecol 1978, 52: 64-67.
diagnosis
of Potter
syndrome. Obstet
318 Patient D had spontaneous rupture of the membranes at 27 weeks, vaginal bleeding at 28 weeks, and delivered, at 29 weeks, a male who died immediately. He had an odd-shaped head, loose fold of skin over the occiput, limited hip adduction, severe bilateral talipes, and flexion deformities of the knee joints. No necropsy was done, but kidneys and bladder had been identified by ultrasound in utero. Patients B and C chose termination because of the apparently poor prognosis of early severe oligohydramnios. In B the male fetus at 22 weeks had severe bilateral talipes, legs in the position associated with extended breech presentation, adduction of the hips, and odd facies. The kidneys were normal. The female fetus of C at 18 weeks had no obvious internal or external abnormalities. The oligohydramnios was not due to renal agenesis and may have been due to leakage of liquor. The oligohydramnios associated with absent fetal kidneys is said not to develop until around the 35th week of pregnancy’ and certainly our two cases of this condition2 showed no evidence of oligohydramnios at the time of amniocentesis. Nevertheless, the abnormalities in the fetus are similar whatever the origin of the oligohydramnios-notably, odd facies and severe talipes-suggesting that they are imposed by the abnormal environment rather than being intrinsic to the fetus. These findings support the suggestion3 that the orthopaedic postural deformities and pulmonary abnormalities occasionally seen in babies who have undergone amniocentesis may be due to an insufficiency of amniotic fluid at critical stages of development. Our limited experience with raised maternal serum-AFP and oligohydramnios in the early second trimester suggests that if amniocentesis fails, a repeat is unlikely to be successful and is not necessary; the oligohydramnios is sufficient to explain the raised maternal serum-AFP. Indeed, even the first amniocentesis might be avoided if our findings are confirmed; sonography alone could assess the amount of liquor. However, if ultrasound scanning also reveals the presence of the fetal bladder and kidneys the parents should be told of the high risk of their child having severe lower limb deformities. We thank Mr J. S. Tomkinson, Mr E. D. Morris, Mr T. P. Shuttle-
worth, and Mr P. M. Fullman for permission
to
publish details of their
patients. Pædiatric Research Unit, Prince Philip Research Laboratories,
Guy’s Hospital, London SE1 9RT
MARY J. SELLER ANNE H. CHILD
NON-OPERATIVE MANAGEMENT OF COCCYGODYNIA
SiR,-Coccygodynia is a painful condition that frequently protracted course. It is usually caused by trauma to the anterior or posterior sacrococcygeal ligaments and may be
runs a
demonstrated on rectal examination when small movements of the coccyx cause great pain. Excision of the coccyx is the only permanently effective treatment though the introduction of local steroids into the joint space can afford relief for long periods. This is not easy because the joint is difficult to palpate externally. For this reason the following technique was used to facilitate the introduction of steroid into the sacrococcygeal
joint. 0-35 ml intra-articular triamcinolone (10 mg/ml) is drawn up into a 2 ml syringe and mixed with an equal amount of 2% plain lignocaine and attached to a 21 gauge needle. The patient is placed in the right lateral position near the edge of the 1. Saunders P, Rhodes P. The origin and circulation of the amniotic fluid. In: Fairweather DVI, Eskes TKAB, eds. Amniotic fluid: Research and clinical Application. Amsterdam: Exerpta Medica, 1973:1-18. 2. Seller MJ, Berry AC. Amniotic fluid alpha-fetoprotein and fetal renal agenesis. Lancet, 1978; i: 660. 3. Report to the M.R.C. by their Working Party on Amniocentesis. An assessment of the hazards of amniocentesis. Br J Obstet Gynœcol 1978; 85:
suppl 2.
couch. The physician’s gloved and lubricated left index finger is introduced into the rectum and advanced on the ventral surface of the coccyx until a transverse groove is felt. This groove, which is over the sacrococcygeal joint, is easily palpated because the rectum is closely apposed to the coccyx and sacrum at this point. The examining finger should be positioned so that the tip lies on the groove. The skin in the natal cleft is cleaned with a suitable antiseptic preparation and the hypodermic needle introduced at right angles to the skin in the midline over the tip of the left finger and advanced directly towards it. The needle should pass into the sacrococcygeal joint and 0.5 ml of the contents are injected. This technique has been used in five patients with immediate relief in all. One of these patients was pain free at 12 months. The other four were lost to follow up between 6 and 12 months, but were pain free when last seen. The technique is simple and little more time consuming than the original diagnostic rectal examination. It is suitable for use in general practice and may afford relief to patients who have had to sit on their complaint for too long. University Department of Dermatology, Royal Victoria Infirmary, Newcastle upon Tyne NE 1 4LP
P.
J. KERSEY
IMMUNOGLOBULIN BY INFUSION
SIR, Your editorial ends
on
immunoglobulin (Dec. 1,
p.
1168)
that "until intravenous preparations are more widely available it may be to the patient’s ultimate advantage to be generous with intramuscular IgG despite the added pain of injections". However, a weekly dose of 50 mg IgG/kg is a large and painful volume for an adult with agammaglobulintmia (approximately 20 ml per week for a person weighing 60 kg). In 1966 E. R. Stiehm and colleagues (Blood; 28: 918) reported the efficacy of plasma infusions in increasing serum immunoglobulin levels in patients with immunoglobulin deficiency. These findings have been corroborated by R. H. Buckley (Am J Dis Child 1972; 124: 376). Not only is the pain of large intramuscular volume circumvented but also IgA and IgM are provided, and specific antibody titres are higher. With careful donor selection hepatitis B is not a great hazard. We (and our patients) prefer regular plasma infusions as substitution therapy for immunoglobulin deficiency in larger children and adults.
by stating
Departments of Infectious Diseases, and Pædiatrics, University Hospital, Leiden, Netherlands
J.
W. M. VAN
L.
J. DOOREN
DER
MEER
BCG: BAD NEWS FROM INDIA
SIR,-The Indian experience is unhappy (Jan. 12, p. 73) but barriers against mycobacterial infection are far from complete, even in the U.K. Chronic infections are more complicated than the acute types, and the most complex are the mycobacterial diseases. Even in the U.K. the response to BCG inoculation varies considerably. 17 of 32 studenr nurses at this hospital were Mantoux negative in December, 1979. 25 nurses had received BCG at school during 1973-75. 12 of the Mantouxnegative cases did not respond to a second BCG injection, but 5 others showed brisk cutaneous reactions. Was the immunitv to tuberculosis short-lived in the latter girls? Was the lack of response in some of the others due to tuberculous anergy or occasionally to subclinical sarcoidosis?1 Are BCG inoculations in any way at all involved in the supposed increase in Crohn’s disease ? Many unanswered questions remain, including the viability of protoplasm mycobacteria. St Luke’s
Hospital, Guildford, Surrey GU1 3NT 1.
GERALD A. MACGREGOR
Caspary EA, Field EJ. Lymphocytic sensitisation 1971; ii: 143-45.
in sarcoidosis. Br
Med J