- Email: [email protected]
Runway malaria
1537
cell-mediated response to BCG given at birth was significantly greater in breast-fed infants than in those who were formula fed.2 evidence for a high efficacy of BCG comes from the negative experience among the generally well nourished Swedish population. As Fine and Rodrigues note, there was 6-fold increase in childhood tuberculosis following cessation of BCG vaccination of newborn babies in Sweden.3 There is, therefore, experimental and epidemiological evidence of an impact of nutritional levels on the efficacy of BCG vaccination. Rather than disregarding BCG immunisation, perhaps we should give as much attention to the more difficult issue of nutrition. Since HIV and tuberculosis are chronic infections and protection depends greatly on cellular immunological health, this consideration may also have implications for future trials of HIV vaccines. We should not forget that we are vaccinating people, and people need to be nourished.
Epidemiological
40°C). Thick-film examination showed 12% parasitaemia with Plasmodiumfalciparum. She deteriorated rapidly, fulfilling Warrell and colleagues’ criteria’ for the diagnosis of cerebral malaria. She was treated with intravenous quinine and an exchange transfusion of eight units of blood, but, as Dr Phillips-Howard and colleagues also note (Jan 13, p 119), she had several severe complications of malaria and its treatment-grand mal convulsions, thrombocytopenia, hyponatraemia, and hyperpyrexia (41°C)—as well as rhabdomyolysis (creatine kinase 3500 IU/1, before convulsions, normal range less than < 170 IU/1) with prolonged muscle pain which delayed convalescence. The patient had never been to an endemic malaria area. Her flight from Johannesburg to Europe had landed in Abidjan at night for about
one
hour. She did
leave her seat, but as did Conlon and that the aircraft doors remained open. insecticidal spraying within the cabin before not
colleagues’ patient, noted There
was
no
departure.
Department of Medicine, Cambridge Hospital, Harvard Medical School, Cambridge, MA 02139, USA
PAUL R. EPSTEIN
1. Chandra RK. Nutrition, immunity and infection: present knowledge and future directions. Lancet 1983; i: 688-91. 2. Pabst HF, Godel J, Grace M, Cho H, Spady DW. Effect of breast-feeding on immune response to BCG vaccination. Lancet 1989; i: 295-97. 3. Romanas V. Tuberculosis in Bacillus Calmette-Guerin immunized and unimmunized children in Sweden: a 10 year evaluation following the cessation of general bacillus Calmette-Guerin immunization of the newborn in 1975. Pediatr Infect Dis J 1987;
6: 272-80.
Pneumococcal vaccine SIR,-Dr Shann (April 14, p 898) analyses the US indications for the polyvalent pneumococcal polysaccharide vaccine. However, he omits several important aspects of these recommendations. First, he states that the effectiveness of the vaccine is controversial in "high-risk" groups, but he does not define what he means by such groups. The trials subsequently mentioned all concern elderly patients, but it is controversial to classify healthy people over 65 years as a group at increased risk for invasive pneumococcal infection. In this respect Shann fails to mention that elderly people with a concomitant disease-ie, chronic cardiovascular or chronic pulmonary disease-might be at risk for increased morbidity and mortality from pneumococcal infection. Furthermore, patients with diabetes mellitus are not at an increased risk of such infection. Second, Shann does not emphasise the most important indication for this vaccine-namely, splenectomy. Such patients are at increased risk for invasive pneumococcal infections and are susceptible to the so-called OPSI syndrome, with a high mortality rate. The vaccine is strongly recommended for this high-risk group, and there is no debate about its efficacy. The vaccine should be given to all patients who have undergone splenectomy, if possible before the procedure. The polyvalent polysaccharide pneumococcal vaccine should only be used in well-defined groups of patients at risk, who can be expected to respond immunologically to the vaccine. Department of Rheumatology, Medisch Centrum Leeuwarden, Leeuwarden, Netherlands
We conclude that our patient acquired severe falciparum malaria from one non-endemic area to another, via a mosquito bite while on the runway in Abidjan. Both our patient and the patient described by Colon et al had severe life threatening complications, no doubt attributable to their non-immune state and the lack of en route
G. A. W. BRUYN
Runway malaria
chemoprophylaxis. These two cases suggest that air travellers in transit through endemic malaria areas should be advised to take appropriate chemoprophylaxis no matter how slight their risk of exposure. Alternatively, airlines should take scrupulous precautions to keep to a minimum the risk of exposure of their passengers to the malaria parasite, by thorough insecticidal spraying and keeping cabin doors closed during short refuelling stops in at-risk areas. We thank Dr A. P. Hall for his Princess Elizabeth
help with the management of this case.
Hospital,
G. OSWALD E. P. LAWRENCE
Guernsey, Channel Islands, UK
1. Warrell DA. Cerebral malaria.
Q J Med 1989; 71:
369-71.
Relation between serum cholesterol and diabetic nephropathy SIR,-Despite satisfactory control of the risk factors (hypertension and metabolic variables) diabetic nephropathy usually progresses to end-stage renal failure. Besides being of prognostic importance for cardiovascular morbidity, raised serum cholesterol seems to be one mediator of renal injury in diabetic rats.2 There are no data on the long-term effect of serum lipids on kidney diseases in man. We have, however, investigated serum cholesterol and the rate of decline in glomerular filtration rate in diabetic nephropathy. In a continuing prospective randomised trial of two antihypertensive strategies (enalapril versus metoprolol), 31 patients with type 1 diabetes and nephropathy have been followed up for more than a year (mean eighteen months). Clinical data and the short-term effects on proteinuria have been reported.3 Kidney function was measured every six months by the plasma clearance of 51 Cr-EDT A. Serum cholesterol was measured every six months and the urinary albumin excretion and haemoglobin Al every two months. The mean cholesterol concentration at entry (7-4, SD 1 -9 mmol/1) was significantly correlated with the decline in glomerular filtration PATIENT DETAILS
SIR,-Dr Conlon and colleagues (Feb 24, p 472) report a non-immune patient who acquired malaria while in transit through Abidjan, Ivory Coast, without alighting from the aircraft. We report a similar case from the same geographical area which may have wide
implications. A 37-year-old British woman, who had lived in Capetown, South Africa, for 4 years, travelled to the UK in July, 1989. Fourteen days after arrival she had fever and malaise, for which she was treated at home with antibiotics. Three days later, the development of jaundice and rigors led to her admission for suspected hepatitis. She was deeply jaundiced, semiconscious, and pyrexial (temperature
*Means (SD) of measurements throughout observation penod tNo treated with enalapnl/metoprolol = 11 /6 (,,:;7 mmol/1) and 8/6 (> 7 mmol/1) t = p < 0 05, 9 p < 0 01, Wilcoxon’s rank sum test G FR glomerular filtration rate. =
cell-mediated response to BCG given at birth was significantly greater in breast-fed infants than in those who were formula fed.2 evidence for a high efficacy of BCG comes from the negative experience among the generally well nourished Swedish population. As Fine and Rodrigues note, there was 6-fold increase in childhood tuberculosis following cessation of BCG vaccination of newborn babies in Sweden.3 There is, therefore, experimental and epidemiological evidence of an impact of nutritional levels on the efficacy of BCG vaccination. Rather than disregarding BCG immunisation, perhaps we should give as much attention to the more difficult issue of nutrition. Since HIV and tuberculosis are chronic infections and protection depends greatly on cellular immunological health, this consideration may also have implications for future trials of HIV vaccines. We should not forget that we are vaccinating people, and people need to be nourished.
Epidemiological
40°C). Thick-film examination showed 12% parasitaemia with Plasmodiumfalciparum. She deteriorated rapidly, fulfilling Warrell and colleagues’ criteria’ for the diagnosis of cerebral malaria. She was treated with intravenous quinine and an exchange transfusion of eight units of blood, but, as Dr Phillips-Howard and colleagues also note (Jan 13, p 119), she had several severe complications of malaria and its treatment-grand mal convulsions, thrombocytopenia, hyponatraemia, and hyperpyrexia (41°C)—as well as rhabdomyolysis (creatine kinase 3500 IU/1, before convulsions, normal range less than < 170 IU/1) with prolonged muscle pain which delayed convalescence. The patient had never been to an endemic malaria area. Her flight from Johannesburg to Europe had landed in Abidjan at night for about
one
hour. She did
leave her seat, but as did Conlon and that the aircraft doors remained open. insecticidal spraying within the cabin before not
colleagues’ patient, noted There
was
no
departure.
Department of Medicine, Cambridge Hospital, Harvard Medical School, Cambridge, MA 02139, USA
PAUL R. EPSTEIN
1. Chandra RK. Nutrition, immunity and infection: present knowledge and future directions. Lancet 1983; i: 688-91. 2. Pabst HF, Godel J, Grace M, Cho H, Spady DW. Effect of breast-feeding on immune response to BCG vaccination. Lancet 1989; i: 295-97. 3. Romanas V. Tuberculosis in Bacillus Calmette-Guerin immunized and unimmunized children in Sweden: a 10 year evaluation following the cessation of general bacillus Calmette-Guerin immunization of the newborn in 1975. Pediatr Infect Dis J 1987;
6: 272-80.
Pneumococcal vaccine SIR,-Dr Shann (April 14, p 898) analyses the US indications for the polyvalent pneumococcal polysaccharide vaccine. However, he omits several important aspects of these recommendations. First, he states that the effectiveness of the vaccine is controversial in "high-risk" groups, but he does not define what he means by such groups. The trials subsequently mentioned all concern elderly patients, but it is controversial to classify healthy people over 65 years as a group at increased risk for invasive pneumococcal infection. In this respect Shann fails to mention that elderly people with a concomitant disease-ie, chronic cardiovascular or chronic pulmonary disease-might be at risk for increased morbidity and mortality from pneumococcal infection. Furthermore, patients with diabetes mellitus are not at an increased risk of such infection. Second, Shann does not emphasise the most important indication for this vaccine-namely, splenectomy. Such patients are at increased risk for invasive pneumococcal infections and are susceptible to the so-called OPSI syndrome, with a high mortality rate. The vaccine is strongly recommended for this high-risk group, and there is no debate about its efficacy. The vaccine should be given to all patients who have undergone splenectomy, if possible before the procedure. The polyvalent polysaccharide pneumococcal vaccine should only be used in well-defined groups of patients at risk, who can be expected to respond immunologically to the vaccine. Department of Rheumatology, Medisch Centrum Leeuwarden, Leeuwarden, Netherlands
We conclude that our patient acquired severe falciparum malaria from one non-endemic area to another, via a mosquito bite while on the runway in Abidjan. Both our patient and the patient described by Colon et al had severe life threatening complications, no doubt attributable to their non-immune state and the lack of en route
G. A. W. BRUYN
Runway malaria
chemoprophylaxis. These two cases suggest that air travellers in transit through endemic malaria areas should be advised to take appropriate chemoprophylaxis no matter how slight their risk of exposure. Alternatively, airlines should take scrupulous precautions to keep to a minimum the risk of exposure of their passengers to the malaria parasite, by thorough insecticidal spraying and keeping cabin doors closed during short refuelling stops in at-risk areas. We thank Dr A. P. Hall for his Princess Elizabeth
help with the management of this case.
Hospital,
G. OSWALD E. P. LAWRENCE
Guernsey, Channel Islands, UK
1. Warrell DA. Cerebral malaria.
Q J Med 1989; 71:
369-71.
Relation between serum cholesterol and diabetic nephropathy SIR,-Despite satisfactory control of the risk factors (hypertension and metabolic variables) diabetic nephropathy usually progresses to end-stage renal failure. Besides being of prognostic importance for cardiovascular morbidity, raised serum cholesterol seems to be one mediator of renal injury in diabetic rats.2 There are no data on the long-term effect of serum lipids on kidney diseases in man. We have, however, investigated serum cholesterol and the rate of decline in glomerular filtration rate in diabetic nephropathy. In a continuing prospective randomised trial of two antihypertensive strategies (enalapril versus metoprolol), 31 patients with type 1 diabetes and nephropathy have been followed up for more than a year (mean eighteen months). Clinical data and the short-term effects on proteinuria have been reported.3 Kidney function was measured every six months by the plasma clearance of 51 Cr-EDT A. Serum cholesterol was measured every six months and the urinary albumin excretion and haemoglobin Al every two months. The mean cholesterol concentration at entry (7-4, SD 1 -9 mmol/1) was significantly correlated with the decline in glomerular filtration PATIENT DETAILS
SIR,-Dr Conlon and colleagues (Feb 24, p 472) report a non-immune patient who acquired malaria while in transit through Abidjan, Ivory Coast, without alighting from the aircraft. We report a similar case from the same geographical area which may have wide
implications. A 37-year-old British woman, who had lived in Capetown, South Africa, for 4 years, travelled to the UK in July, 1989. Fourteen days after arrival she had fever and malaise, for which she was treated at home with antibiotics. Three days later, the development of jaundice and rigors led to her admission for suspected hepatitis. She was deeply jaundiced, semiconscious, and pyrexial (temperature
*Means (SD) of measurements throughout observation penod tNo treated with enalapnl/metoprolol = 11 /6 (,,:;7 mmol/1) and 8/6 (> 7 mmol/1) t = p < 0 05, 9 p < 0 01, Wilcoxon’s rank sum test G FR glomerular filtration rate. =