Self-Inflicted Intramyocardial Injury

near-complete regression of pulmonary hypertension, although this hypothesis would need to be tested in a prospective trial. How long had nifedipine been discontinued in the authors' patient prior to repeat cardiac catheterization? How long has the patient's exercise tole rance remained dramatically improved since the discontinuation of vasodilators? James R. Gossage, MD, FCCP Department of Medicine Medical College of Georgia Augusta Reprint requests: James R. Gossage, MD, FCCP, Medical College of Georgia, Section of Pulmonary Diseases, BBR-5513, Augusta, GA 30912-3135

REFERENCES 1 Rossoff LJ, Genovese J, Coleman M, eta!. Prima1y pulmonary hypertension in a patient with CD8ff-cell large granulocyte leukemia: amelioration by cladribine therapy. Chest 1997; 112:551-553 2 Rich S, Dantzker D , Ayres SM , et al. Prima1y pulmonary hypertension: a national prospective study. Ann Inte rn Med 1987; 107:216-223 3 Kuo PC, Plotkin JS, Johnson LB, et a!. Distinctive clinical features of portopulmonary hypertension. Chest 1997; 112: 980-986 4 McLaughlin W , Genthner DE, Panella MM , et a!. Reduction in pulmonary vascular resistance with long-term epoprostenol (prostacyclin) therapy in prima1y pulmonary hypertension. N Eng! J M ed 1998; 338:273-277 5 Rich S, Brundage BH. High-dose calcium channel-blocking therapy for primary pulmonary hype rtension: evidence for long-term reduction in pulmonary arterial pressure and regression of right ventricular hypertrophy. Circulation 1987; 76: 135-141 6 Rich S, Kaufmann E, Levy PS. The effect of high doses of calcium-channel blockers on survival in primary pulmonary hypertension. N Eng! J M ed 1992; '327:76-81

Self-Inflicted lntramyocardial Injury To the Editor:

Jamila and Casey, in their report " S elf~Inflicte d Intramyocardial Injury With a Sewing Needle" (Februa1y, 1998) 1 mention that the re has been only one reported case of pneumothorax resulting from self-injury with a needle.2 That case of selfinduced pneumothorax was actually preceded by almost 50 years by th e ruse perpetrated by French physicians on their German captors in early World War II. The prevailing opinion through the 1930s was that pulmonary tuberculosis was the primary cause of pneumothorax. The French physicians surreptitiously induced "iatrogenic" pneumothorax with needles, causing pneumothorax which the Germans assumed to be caused by tuberculosis, and therefore repatriated the m back to their homeland. 3 Kenneth M. Frankel, MD, FCCP Department of Cardiothoracic Surgery Tufts Uni~;enity School of Medicine Springfield, MA

REFERENCES 1 Jamila FP, Casey LC. Self-inflicted intramyocardial injury with a sewing needle: a rare cause of pneumothorax. Chest 1998; 113:531- .534

2 Reinmuth N, Forster R, Scheid HH. From the neck to the lung: pneumothorax caused by a lost needle. Eur J Cardiothorac Surg 1995; 9:216-217 3 Lawrence GH. Problems of the pleural space. Philadelphia: WB Saunders Co., 1983:26

Misreading of the Tuberculin Skin Test To the Editor:

I read with great inte rest the recent article by Kendig and colleagues (May 1998), 1 as well as the accompanying editorial by Reichman (May 1998). 2 I certainly agree with their findings that there is a high level of inaccuracy in the interpretation of tuberculin skin tes ts. I was raised in East Africa, and in my early childhood received a Bacillus Calmette-Guerin (BCG) vaccination. As one would expect, my purified protein derivative (PPD) skin test has always been positive. When I went through my medical examination for entJy into the US, I had askin test that was interpreted by the examiner as being > 10 mm. Many years later another PPD was applied, and I interpreted the study as showing 19 mm of induration. The surrounding e1ythema produced a circle of 23 mm in diameter. My chest roentgenogram was normal. At the time I was an Assistant Professor of medicine in the department of pulmonary medicine a t a major university teaching hospital. I took the opportunity of asking 36 of my fellow academicians, fellows , internal medicine residents, clinic nurs es, and medical students to inte rpret my skin test. I was impressed by the diversity of opinion as to whether the test was even positive or negative. The distribution of results ranged between 0 mm of induration up to 22 mm (Figure 1). I did not get the impression that the study was unde rread, but rath er concluded that very few people could inte rpret the study correctly. My conclusion was that if it is indeed important to know the result of a patient's PPD, I would need to read the study myself. To rely on others carries the same risks inherent in relying on another individual's interpretation of any medical investigation, such as pulmonary function studies, chest roentgenograms, and sleep studies. We unfortunately have to rely too much on others to make imp01tant measurements for us. Temperatures, fluid intake and output, blood pressures, and even daily weights are excellent examples of measurements that we use constantly to make critical treahnent decisions, and in which the room for error is large. The recent article by Kendig and colleagues' serves a very useful reminder of th e adage that "... if a job is worth doing, it's worth doing oneself. " The tuberculin skin test is too important a test to leave to the whims of the uninitiated. I agree \vith Reichman 2 that to ignore the findings of this study, "... would be the height of irresponsibility." Graham C Scott, MD, FCCP Charleston Pulmonary Associates Charleston, South Carolina

REFERENCES 1 Kendig EL, Kirkpatrick BV, Ca1ter WH, et al. Underreading of the tuberculin skin test reaction. Chest 1998; 113:117.5-1177 2 Reichman LB. A scandalous incompetence . . continued. Ches t 1998; 113:11.53-1154 CHEST I 114 I 4 I OCTOBER, 1998

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