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Stibogluconate for leishmaniasis
Ehrnst A, Peters CJ, Niklasson B, Svedmyr A, Holmgren B. Neurovirulent Toscana virus (a sandfly fever virus) in Swedish man after visit to Portugal. Lancet 1985; i: 1212-13. 6 Calisher CH, Weinberg AN, Muth DJ, Lazuick JS. Toscana virus infection in United States citizen returning from Italy. Lancet 1987; i: 165-66. 7 Eitrem R, Niklasson B, Weiland O. Sandfly fever among Swedish tourists. Scand J Infect Dis 1991; 23: 451-57. 8 Eitrem R, Vene S, Niklasson B. ELISA for detection of IgM and IgG antibodies to sandfly fever Sicilian virus. Res Virol 1991; 142: 387-94.
was 8-3 g/dL with a white of 11x109/L. Renal function had deteriorated (creatinine 747 umoI/L, compared with 324 ltmol/L a year before). Urine microscopy showed 20 white blood cells per 1tL and granular casts; culture was negative. Stool examination revealed a watery specimen with no leucocytes; no pathogens were isolated. Cefuroxime was started. Over 5 days he became increasingly drowsy and confused, and creatinine rose to 926 umoI/L. He was transferred to the Royal London Hospital, and daily haemodialysis was started. Profuse, watery green diarrhoea was noted and stool cultures were repeated. Neither Clostridium difficile nor its toxin were detected in several stools. Investigations for salmonella, shigella, campylobacter, and cryptosporidium and for faecal viruses and parasites were negative. A profuse growth of S aureus was seen on the MacConkey plate. Cefuroxime was stopped and oral vancomycin started. The staphylococcus proved resistant to methicillin and the patient was isolated. The organism was shown to produce enterotoxin A and was untypable. Diarrhoea resolved over the next 2 days and the patient became lucid. Dialysis could be stopped after 4 days and he was discharged 10 days after admission, having received 8 days of vancomycin. On review as an outpatient, diarrhoea had not recurred and serum creatinine had returned to baseline (346 umoI/L). The most severe form of post-antibiotic diarrhoea,
5
previous recordings. Haemoglobin cell
Stibogluconate for leishmaniasis SiR-Hepburn and colleagues (July 24, p 238) report that sodium stibogluconate is associated with acute hepato-biliary damage coupled with a fall in the functional metabolic capacity of the liver. We disagree with their view. We have investigated 6 patients with visceral leishmaniasis who received stibogluconate 20 mg/kg per day for 20 days by slow intravenous injection. There was no history of intake of alcohol or hepatotoxic drugs. Blood samples were obtained before and
count
pseudomembraneous colitis, is
Table: Serum albumin and ALT values in 6 patients with leishmaniasis at the end of treatment. Serum albumin and alanine aminotransferase (ALT) concentrations were measured. In patients with visceral leishmaniasis, the amount of serum albumin was low in comparison with serum globulin (reversed albumin globulin ratio) and ALT was higher. But after 20 days’ treatment with sodium stibogluconate, the amount of serum albumin returned towards normal and ALT fell to normal values (table). We therefore conclude that hepatic functional disturbances in visceral leishmaniasis are due to the disease process! and can be reversed by treatment with sodium
stibogluconate. M Misbahuddin, Nurul Absar
Kishowar Jahan, MA Jalil Chowdhury,
Department of Pharmacology and Medicine, Rajshahi Medical College, Rajshahi 6000, Bangladesh; and Department of Biochemistry, University of Rajshahi, Rajshahi 6205, Bangladesh 1
Aggarwal P, Wali J, Chopra P. Liver in kala-azar. Ind J Gastroenterol 1990; 9: 135-36.
Enterocolitis caused by methicillin-resistant
Staphylococcus aureus SiR-We report enterocolitis caused by a methicillin-resistant Staphylococcus aureus (MRSA). A 71-year-old man presented with retrosternal chest pain, anorexia, pruritus, and reduced urine output. He had longstanding Crohn’s disease, diagnosed after a right hemicolectomy, and was taking sulphasalazine. 11 years ago essential hypertension has been diagnosed and renal impairment noted. His hypertension has been well-controlled by atenolol and nifedipine. Angina and peripheral vascular disease have also been documented. A persistent irondeficiency anaemia was attributed to his Crohn’s disease. Examination revealed anaemia, mild ankle oedema, and a short ejection-systolic murmur. Admission investigations included an electrocardiogram that was unchanged compared with
804
now
attributed
to
overgrowth
of toxin-producing C difficile.1 In the early 1950s the stools of many patients with post-antibiotic enterocolitis yielded pure cultures of toxin-producing S aureus.2 A staphylococcal cause is seldom thought about nowadays when antibiotics precipitate severe diarrhoea. Several reports from Japan have associated the syndrome with MRSA.3-6 A nationwide survey of postoperative MRSA enterocolitis3 identified 87 cases; most followed administration of a cephalosporin and several infections were nosocomial. Staphylococcal enterocolitis should be considered in patients with antibiotic-related diarrhoea, especially when investigations for C difficile and its toxin are negative. Whilst vancomycin may be helpful, its use might not otherwise be considered when a clostridial cause has been excluded. Moreover the patient with MRSA in stool and with diarrhoea is likely to be an efficient disseminator of this troublesome
pathogen. We thank Dr R R Marples and the Staphylococcus Reference Unit, Central Public Health Laboratory, for typing the staphylococcus and for toxin
testing. Mark Taylor, Felicia Ajayi Department of Medical Microbiology, London Hospital
Medical
College,
London E1 2AD, UK
Michael Almond Department of Nephrology, Royal London Hospital, London E1 Willis AT, Smith GR. Gas gangrene and other clostridial infections of man and animals. In: Parker MT, Collier LH, eds. Topley and Wilson’s principles of bacteriology, virology and immunity, 8th ed. Bacterial diseases. Vol 3. London: Edward Arnold, 1990: 307-29. 2 Easmon CSF, Goodfellow M. Staphylococcus and Micrococcus. In: Parker MT, Collier LH, eds. Topley and Wilson’s principles of bacteriology, virology and immunity, 8th ed. Systematic bacteriology. Vol 2. London: Edward Arnold, 1990: 161-86. 3 Hori K, Yura J, Shinagawa N, et al. Postoperative enterocolitis and current status of MRSA enterocolitis: the result of a questionnaire survey in Japan. Kanshenshogaku Zasshi 1989; 63: 701-07. 4 Yoshida D, Fukunari H, Hojo I, et al. Enterocolitis due to methicillinresistant Staphyloccus aureus: report of two cases. Bull Tokyo Med Dent Univ 1992; 39: 31-34. 5 Masuda H, Yamada T, Nagamatsu H, et al. A case of staphylococcal enterocolitis caused by methicillin-resistant Staphylococcus aureus. Hinyokika Kiyo 1992; 38: 1425-28. 6 Inamatsu T, Ooshima H, Masuda Y, et al. Clinical spectrum of antibiotic associated enterocolitis due to methicillin-resistant Staphylococcus aureus. Nippon Rinsho 1992; 50: 1087-92. 1
was 8-3 g/dL with a white of 11x109/L. Renal function had deteriorated (creatinine 747 umoI/L, compared with 324 ltmol/L a year before). Urine microscopy showed 20 white blood cells per 1tL and granular casts; culture was negative. Stool examination revealed a watery specimen with no leucocytes; no pathogens were isolated. Cefuroxime was started. Over 5 days he became increasingly drowsy and confused, and creatinine rose to 926 umoI/L. He was transferred to the Royal London Hospital, and daily haemodialysis was started. Profuse, watery green diarrhoea was noted and stool cultures were repeated. Neither Clostridium difficile nor its toxin were detected in several stools. Investigations for salmonella, shigella, campylobacter, and cryptosporidium and for faecal viruses and parasites were negative. A profuse growth of S aureus was seen on the MacConkey plate. Cefuroxime was stopped and oral vancomycin started. The staphylococcus proved resistant to methicillin and the patient was isolated. The organism was shown to produce enterotoxin A and was untypable. Diarrhoea resolved over the next 2 days and the patient became lucid. Dialysis could be stopped after 4 days and he was discharged 10 days after admission, having received 8 days of vancomycin. On review as an outpatient, diarrhoea had not recurred and serum creatinine had returned to baseline (346 umoI/L). The most severe form of post-antibiotic diarrhoea,
5
previous recordings. Haemoglobin cell
Stibogluconate for leishmaniasis SiR-Hepburn and colleagues (July 24, p 238) report that sodium stibogluconate is associated with acute hepato-biliary damage coupled with a fall in the functional metabolic capacity of the liver. We disagree with their view. We have investigated 6 patients with visceral leishmaniasis who received stibogluconate 20 mg/kg per day for 20 days by slow intravenous injection. There was no history of intake of alcohol or hepatotoxic drugs. Blood samples were obtained before and
count
pseudomembraneous colitis, is
Table: Serum albumin and ALT values in 6 patients with leishmaniasis at the end of treatment. Serum albumin and alanine aminotransferase (ALT) concentrations were measured. In patients with visceral leishmaniasis, the amount of serum albumin was low in comparison with serum globulin (reversed albumin globulin ratio) and ALT was higher. But after 20 days’ treatment with sodium stibogluconate, the amount of serum albumin returned towards normal and ALT fell to normal values (table). We therefore conclude that hepatic functional disturbances in visceral leishmaniasis are due to the disease process! and can be reversed by treatment with sodium
stibogluconate. M Misbahuddin, Nurul Absar
Kishowar Jahan, MA Jalil Chowdhury,
Department of Pharmacology and Medicine, Rajshahi Medical College, Rajshahi 6000, Bangladesh; and Department of Biochemistry, University of Rajshahi, Rajshahi 6205, Bangladesh 1
Aggarwal P, Wali J, Chopra P. Liver in kala-azar. Ind J Gastroenterol 1990; 9: 135-36.
Enterocolitis caused by methicillin-resistant
Staphylococcus aureus SiR-We report enterocolitis caused by a methicillin-resistant Staphylococcus aureus (MRSA). A 71-year-old man presented with retrosternal chest pain, anorexia, pruritus, and reduced urine output. He had longstanding Crohn’s disease, diagnosed after a right hemicolectomy, and was taking sulphasalazine. 11 years ago essential hypertension has been diagnosed and renal impairment noted. His hypertension has been well-controlled by atenolol and nifedipine. Angina and peripheral vascular disease have also been documented. A persistent irondeficiency anaemia was attributed to his Crohn’s disease. Examination revealed anaemia, mild ankle oedema, and a short ejection-systolic murmur. Admission investigations included an electrocardiogram that was unchanged compared with
804
now
attributed
to
overgrowth
of toxin-producing C difficile.1 In the early 1950s the stools of many patients with post-antibiotic enterocolitis yielded pure cultures of toxin-producing S aureus.2 A staphylococcal cause is seldom thought about nowadays when antibiotics precipitate severe diarrhoea. Several reports from Japan have associated the syndrome with MRSA.3-6 A nationwide survey of postoperative MRSA enterocolitis3 identified 87 cases; most followed administration of a cephalosporin and several infections were nosocomial. Staphylococcal enterocolitis should be considered in patients with antibiotic-related diarrhoea, especially when investigations for C difficile and its toxin are negative. Whilst vancomycin may be helpful, its use might not otherwise be considered when a clostridial cause has been excluded. Moreover the patient with MRSA in stool and with diarrhoea is likely to be an efficient disseminator of this troublesome
pathogen. We thank Dr R R Marples and the Staphylococcus Reference Unit, Central Public Health Laboratory, for typing the staphylococcus and for toxin
testing. Mark Taylor, Felicia Ajayi Department of Medical Microbiology, London Hospital
Medical
College,
London E1 2AD, UK
Michael Almond Department of Nephrology, Royal London Hospital, London E1 Willis AT, Smith GR. Gas gangrene and other clostridial infections of man and animals. In: Parker MT, Collier LH, eds. Topley and Wilson’s principles of bacteriology, virology and immunity, 8th ed. Bacterial diseases. Vol 3. London: Edward Arnold, 1990: 307-29. 2 Easmon CSF, Goodfellow M. Staphylococcus and Micrococcus. In: Parker MT, Collier LH, eds. Topley and Wilson’s principles of bacteriology, virology and immunity, 8th ed. Systematic bacteriology. Vol 2. London: Edward Arnold, 1990: 161-86. 3 Hori K, Yura J, Shinagawa N, et al. Postoperative enterocolitis and current status of MRSA enterocolitis: the result of a questionnaire survey in Japan. Kanshenshogaku Zasshi 1989; 63: 701-07. 4 Yoshida D, Fukunari H, Hojo I, et al. Enterocolitis due to methicillinresistant Staphyloccus aureus: report of two cases. Bull Tokyo Med Dent Univ 1992; 39: 31-34. 5 Masuda H, Yamada T, Nagamatsu H, et al. A case of staphylococcal enterocolitis caused by methicillin-resistant Staphylococcus aureus. Hinyokika Kiyo 1992; 38: 1425-28. 6 Inamatsu T, Ooshima H, Masuda Y, et al. Clinical spectrum of antibiotic associated enterocolitis due to methicillin-resistant Staphylococcus aureus. Nippon Rinsho 1992; 50: 1087-92. 1