- Email: [email protected]
SHOULD INPATIENTS WITH PNEUMOCYSTIS CARINII BE ISOLATED?
46
Follicular growth was monitored by echoscopy (Searle ’Phosonic SM’) only. On the eighth day of treatment one follicle with a . diameter of 1 -8cm was seen in the left ovary. The right ovary contained two follicles 1’3and 1.4 4 cm in diameter. On day 9 the follicle in the left ovary had disappeared. On,the assumption that ovulation had occurred the pump was disconnected and hCG 10 000 IU was injected. This was done in view of the high cost of GnRH and because we wanted to be able to use the pump for another patient as soon as possible. Body temperature rose immediately. 7 days afterwards the left ovary was enlarged to 6 cm in diameter. The patient complained of slight bloatedness and constipation. 15 days after hCG injection a sensitive pregnancy test (’Neonosticon’; Organon) was positive. In the eighth week of pregnancy, echoscopy revealed three embryos in separate gestational sacs. From week 31, the patient was admitted to hospital as a precaution. In the 36th week elective caesarean section was done. Birthweights of the three healthy boys were 2290, 2460, and
1950 g. In the follicular phase of the induced cycle oestradiol rose from a basal value ofO-16 nmol/1 to 4-75 nmol/1 on day 8, representing clear hyperstimulation. During the fast rise of plasma oestradiol FSH remained high for the mid and late follicular phase. A clear mid-cycle LH peak was not detected. Midluteal progesterone was 228 nmol/1, more than twice the upper normal value. The results of the GnRH double stimulation test revealed a fourfold increase of LH (from 7 to 28 UtI) and a I -75 fold increase of FSH (from 6 to 10 U/1). This type of response is normal for the early follicular phase of the menstrual cycle. Apparently large pulses of GnRH can overcome the normal inhibition of hypophyseal FSH release by oestradiol. Therefore we recommend adjustment of the GnRH dose according to the classification of the LH/FSH response to GnRH-e.g., as proposed
by Leyendecker et al.3
D. BOGCHELMAN R. E. LAPPÖHN
Department of Obstetrics and Gynaecology, State University, Groningen, Netherlands
J. JANSSENS
SHOULD INPATIENTS WITH PNEUMOCYSTIS CARINII BE ISOLATED?
SIR,-Reports of Pneumocystis carÙ1Ù pneumonia in male homosexuals and drug addicts has widened the clinical spectrum of the disease4 P. carinii may exhibit atypical features in these
patients, resulting in delays in diagnosis and increasing the potential risk of nosocomial spread of the organism. There is clinical and experimental evidence for the communicability of P. carinii, probably by the respiratory route,5-8 yet- hospital infection control guidelines in the9 U.S.A. recommend no isolation precautions for P.
carinii patients.9
A 40-year-old male heroin addict was admitted to the medical intensive care unit with progressive pneumonia. Open lung biopsy revealed P. carinii; in vitro tests showed impaired cellular immunity. He promptly recovered with co-trimoxazole therapy. The patient spent 5 days in the open intensive care unit without isolation precautions. We did a serological survey of the unit’s staff and of a control group of other hospital workers who had no known exposure to the patients. Serum antibodies to human P. carinii, 3. Leyendecker G, Wildt L, Plotz EJ. Gynäkologe 1981; 14: 84-103.
Die
hypothalamische Ovanalinsuffizienz.
H, Michelis MA, Green JB, et al. An outbreak of community-squired Pneumocystis carinii pneumonia. Initial manifestation of cellular immune dysfunction. N Engl J Med 1981; 305: 1431-38.
4. Masur
Singer C, Armstrong D, Vosen PP, Schottenfeld D Pneumocystis carinii pneumonia. a cluster of eleven cases Ann Intern Med 1975; 82: 772-77. 6. Ruebush TK, Weinstein RA, Baehner RL, et al. An outbreak of pneumocystis pneumonia in children with acute lymphocytic leukemia. Am J Dis Child 1978; 132: 5.
143-48. 7.
8.
Hendley JO, Weller TH. Activation and transmission in rats of infection with Pneumocystis carinii Proc Soc Exp Biol Med 1971; 137: 1401-04. Walzer PD, Schnelle V, Armstrong D, Rosen PP Nude mouse. a new experimental model for
Pneumocystis carinii infection. Science 1977; 197: 177-79. techniques for use in hospitals, 2nd ed. Atlanta, Georgia CDC, 1975.
9. Centers for Disease Control. Isolation
SERUM ANTIBODIES TO P. CARINII I
*Reciprocal geometric mean±SD.
measured by an indirect fluorescent antibody technique,1O were found in all subjects and were mainly IgG (table). Antibody titres rose over time in the exposed group but did not reach statistical significance; however, antibody titres were significantly higher (p<0 025, one-tailed Student’s t-test) in the exposed group at two months than among the controls. Surveys in three countries have demonstrated that serum antibodies to P. carinii are mainl IgG and are present in most These studies emphasise the healthy people by early in P. carinii problems differentiating patients, contacts of these patients, and controls, by serological techniques currently available. While there are a variety of interpretations for our serological data, this survey raises the possibility that exposure of the intensive care unit staff to a patient with P. carinii pneumonia resulted in a booster effect of IgG antibody, implying probable aerosol transmission of P. carinii. We believe that until the epidemiology of P. carinii is better defined, it would be prudent to isolate these patients while they are in hospital. This could be accomplished by respiratory isolation or by physical separation from other immunosuppressed patients. We would be interested in the views of other readers.
childhood. -13
Queens Hospital Center Affiliation of Long Island Jewish-Hillside Medical Center, Jamaica, New York 11432, U.S.A University of Cincinnati Medical Center, Cincinnati, Ohio
JOSÉ A. GIRÓN STEVE MARTINEZ PETER D. WALZER
CRYSTALLINE DEPOSITS IN INFANT URINE DUE TO X-RAY CONTRAST MEDIUM
SIR,-A heavy crystalline deposit was noted in the urine of a 4-month-old boy presenting with severe failure to thrive. A 24 h urine sample had been collected, acidified, and stored at 4°C, and a thick crystalline deposit was noticed the following day, accounting for approximately one-fifteenth of the volume of urine passed. The aminoacid and organic acid chromatograms from this sample showed no abnormality, and the uric acid concentration was normal. Subsequent urine samples showed only slight deposits. The crystals, fine white needles about 1 mm long and roughly 0’ I mm square in cross-section, were soluble in strong alkali. The crystals were cleaned in 01mol/1 hydrochloric acid and dried, and a portion was analysed by mass spectrometry with a direct insertion probe. The electron impact mass spectrum of the compound suggested an iodinated compound. This was confirmed by accurate mass determination of the major ions due to 1+ and HI+ (m/z 126-905 and 127-912). The iodine content of the crystals was further confirmed by energy dispersive X-ray analysis. After a thorough examination of the clinical investigations which had been done, it came to light that the child had had an intravenous pyelogram with 10 ml of the X-ray contrast medium ’Urograph 10. Walzer PD, Rutledge MD. Humoral immunity in experimental Pneumocystis carinii infection. I. serum and bronchial lavage fluid antibody responses in rats. J Lab Clin Med 1981; 97: 820-33 11. Meuwissen JHE, Tauber I, Leewenbert ADEM, Beckers PJA, Sieben M. Parasitologic and serologic observations in infection with pneumocystis in humans. J Infect Dis 1977; 136: 43-49 12. Pifer LL, Hughes WT, Stagno S, Woods D. Pneumocystis carinii infection: evidence for high prevalence in normal and immunosuppressed children. Pediatrics 1978; 61: 35-41. 13. Shepherd VB, Jameson B, Knowles GK. Pneumocystis carinu pneumonitis a serological study J Clin Pathol 1979, 32: 773-77.
Follicular growth was monitored by echoscopy (Searle ’Phosonic SM’) only. On the eighth day of treatment one follicle with a . diameter of 1 -8cm was seen in the left ovary. The right ovary contained two follicles 1’3and 1.4 4 cm in diameter. On day 9 the follicle in the left ovary had disappeared. On,the assumption that ovulation had occurred the pump was disconnected and hCG 10 000 IU was injected. This was done in view of the high cost of GnRH and because we wanted to be able to use the pump for another patient as soon as possible. Body temperature rose immediately. 7 days afterwards the left ovary was enlarged to 6 cm in diameter. The patient complained of slight bloatedness and constipation. 15 days after hCG injection a sensitive pregnancy test (’Neonosticon’; Organon) was positive. In the eighth week of pregnancy, echoscopy revealed three embryos in separate gestational sacs. From week 31, the patient was admitted to hospital as a precaution. In the 36th week elective caesarean section was done. Birthweights of the three healthy boys were 2290, 2460, and
1950 g. In the follicular phase of the induced cycle oestradiol rose from a basal value ofO-16 nmol/1 to 4-75 nmol/1 on day 8, representing clear hyperstimulation. During the fast rise of plasma oestradiol FSH remained high for the mid and late follicular phase. A clear mid-cycle LH peak was not detected. Midluteal progesterone was 228 nmol/1, more than twice the upper normal value. The results of the GnRH double stimulation test revealed a fourfold increase of LH (from 7 to 28 UtI) and a I -75 fold increase of FSH (from 6 to 10 U/1). This type of response is normal for the early follicular phase of the menstrual cycle. Apparently large pulses of GnRH can overcome the normal inhibition of hypophyseal FSH release by oestradiol. Therefore we recommend adjustment of the GnRH dose according to the classification of the LH/FSH response to GnRH-e.g., as proposed
by Leyendecker et al.3
D. BOGCHELMAN R. E. LAPPÖHN
Department of Obstetrics and Gynaecology, State University, Groningen, Netherlands
J. JANSSENS
SHOULD INPATIENTS WITH PNEUMOCYSTIS CARINII BE ISOLATED?
SIR,-Reports of Pneumocystis carÙ1Ù pneumonia in male homosexuals and drug addicts has widened the clinical spectrum of the disease4 P. carinii may exhibit atypical features in these
patients, resulting in delays in diagnosis and increasing the potential risk of nosocomial spread of the organism. There is clinical and experimental evidence for the communicability of P. carinii, probably by the respiratory route,5-8 yet- hospital infection control guidelines in the9 U.S.A. recommend no isolation precautions for P.
carinii patients.9
A 40-year-old male heroin addict was admitted to the medical intensive care unit with progressive pneumonia. Open lung biopsy revealed P. carinii; in vitro tests showed impaired cellular immunity. He promptly recovered with co-trimoxazole therapy. The patient spent 5 days in the open intensive care unit without isolation precautions. We did a serological survey of the unit’s staff and of a control group of other hospital workers who had no known exposure to the patients. Serum antibodies to human P. carinii, 3. Leyendecker G, Wildt L, Plotz EJ. Gynäkologe 1981; 14: 84-103.
Die
hypothalamische Ovanalinsuffizienz.
H, Michelis MA, Green JB, et al. An outbreak of community-squired Pneumocystis carinii pneumonia. Initial manifestation of cellular immune dysfunction. N Engl J Med 1981; 305: 1431-38.
4. Masur
Singer C, Armstrong D, Vosen PP, Schottenfeld D Pneumocystis carinii pneumonia. a cluster of eleven cases Ann Intern Med 1975; 82: 772-77. 6. Ruebush TK, Weinstein RA, Baehner RL, et al. An outbreak of pneumocystis pneumonia in children with acute lymphocytic leukemia. Am J Dis Child 1978; 132: 5.
143-48. 7.
8.
Hendley JO, Weller TH. Activation and transmission in rats of infection with Pneumocystis carinii Proc Soc Exp Biol Med 1971; 137: 1401-04. Walzer PD, Schnelle V, Armstrong D, Rosen PP Nude mouse. a new experimental model for
Pneumocystis carinii infection. Science 1977; 197: 177-79. techniques for use in hospitals, 2nd ed. Atlanta, Georgia CDC, 1975.
9. Centers for Disease Control. Isolation
SERUM ANTIBODIES TO P. CARINII I
*Reciprocal geometric mean±SD.
measured by an indirect fluorescent antibody technique,1O were found in all subjects and were mainly IgG (table). Antibody titres rose over time in the exposed group but did not reach statistical significance; however, antibody titres were significantly higher (p<0 025, one-tailed Student’s t-test) in the exposed group at two months than among the controls. Surveys in three countries have demonstrated that serum antibodies to P. carinii are mainl IgG and are present in most These studies emphasise the healthy people by early in P. carinii problems differentiating patients, contacts of these patients, and controls, by serological techniques currently available. While there are a variety of interpretations for our serological data, this survey raises the possibility that exposure of the intensive care unit staff to a patient with P. carinii pneumonia resulted in a booster effect of IgG antibody, implying probable aerosol transmission of P. carinii. We believe that until the epidemiology of P. carinii is better defined, it would be prudent to isolate these patients while they are in hospital. This could be accomplished by respiratory isolation or by physical separation from other immunosuppressed patients. We would be interested in the views of other readers.
childhood. -13
Queens Hospital Center Affiliation of Long Island Jewish-Hillside Medical Center, Jamaica, New York 11432, U.S.A University of Cincinnati Medical Center, Cincinnati, Ohio
JOSÉ A. GIRÓN STEVE MARTINEZ PETER D. WALZER
CRYSTALLINE DEPOSITS IN INFANT URINE DUE TO X-RAY CONTRAST MEDIUM
SIR,-A heavy crystalline deposit was noted in the urine of a 4-month-old boy presenting with severe failure to thrive. A 24 h urine sample had been collected, acidified, and stored at 4°C, and a thick crystalline deposit was noticed the following day, accounting for approximately one-fifteenth of the volume of urine passed. The aminoacid and organic acid chromatograms from this sample showed no abnormality, and the uric acid concentration was normal. Subsequent urine samples showed only slight deposits. The crystals, fine white needles about 1 mm long and roughly 0’ I mm square in cross-section, were soluble in strong alkali. The crystals were cleaned in 01mol/1 hydrochloric acid and dried, and a portion was analysed by mass spectrometry with a direct insertion probe. The electron impact mass spectrum of the compound suggested an iodinated compound. This was confirmed by accurate mass determination of the major ions due to 1+ and HI+ (m/z 126-905 and 127-912). The iodine content of the crystals was further confirmed by energy dispersive X-ray analysis. After a thorough examination of the clinical investigations which had been done, it came to light that the child had had an intravenous pyelogram with 10 ml of the X-ray contrast medium ’Urograph 10. Walzer PD, Rutledge MD. Humoral immunity in experimental Pneumocystis carinii infection. I. serum and bronchial lavage fluid antibody responses in rats. J Lab Clin Med 1981; 97: 820-33 11. Meuwissen JHE, Tauber I, Leewenbert ADEM, Beckers PJA, Sieben M. Parasitologic and serologic observations in infection with pneumocystis in humans. J Infect Dis 1977; 136: 43-49 12. Pifer LL, Hughes WT, Stagno S, Woods D. Pneumocystis carinii infection: evidence for high prevalence in normal and immunosuppressed children. Pediatrics 1978; 61: 35-41. 13. Shepherd VB, Jameson B, Knowles GK. Pneumocystis carinu pneumonitis a serological study J Clin Pathol 1979, 32: 773-77.