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TACKLING TUMBU FLY LARVAE
37 GROWTH RETARDATION IN SICKLE-CELL DISEASE
SiR,-Any potential advance in the management of sickle-cell anaemia must be welcomed, and many readers will have been interested in that paper by Dr Heyman and colleagues (April 20, used in two children with sickle-cell p 903). Nasogastric feeding anaemia and "acceleration of growth" and fewer hospital admissions over 11-15 months were noted. However, fig 2 reveals that both children were still below the 5th percentile in both weight and height. I am surprised that the local ethical committee permitted experiments with nasogastric feeding and intestinal biopsy in these children. In deciding how this paper ought to influence patient management, several points should be noted. (1) Changes in the slope of the growth curve are the rule in growing children. (2) Absolute weight gains figures (eg, 4 - 2 kg) in growing children are meaningless, especially when children of different ages are involved. (3) If the three untreated children are to be viewed as controls, measurements on them should have been done at the same time intervals. (4) Extrapolation of height increases measured over weeks or months to "cm/year" is misleading. (5) One of the commonest causes of impaired somatic development in sickle-cell disease is relative folic acid deficiency.’ No information is provided on folic acid status: if it was to be marginal or low, simple folic acid supplementation would be likely to affect was
growth.’1
London W12 0HS 1.
chloroquine. The supplies of chloroquine came from widely different sources. Although half of the cases admitted to occasional use of marijuana or other psychoactive agents, and all might have been subjected to associated with such volunteer service, there is no convincing evidence that these are the explanation of the outbreak. stresses
We have been unable to determine the cause of this outbreak. Six of the eight cases were temporally related to the taking of therapeutic doses of chloroquine for apparent malaria, but a survey of the volunteers indicated that an even higher percentage (92%) had taken high-dose chloroquine for their most recent bout of malaria. Chloroquine can cause psychiatric symptoms,but has not been known to cause an outbreak such as the one reported here. We welcome comments from others with experience in this area.
L. LUZZATTO
Watson-Williams EJ. Folic acid, sickle cell anaemia and growth. In: Jonxis JHP, ed. Abnormal haemoglobins in Africa. Oxford: Blackwell Scientific Publications, 1965: 435.
PSYCHOTIC SYMPTOMS IN VOLUNTEERS SERVING OVERSEAS
SIR,-During the 15-month period from October, 1982, to December, 1983, four volunteers working in Nigeria with CUSO (a Canadian overseas volunteer service organisation) were repatriated to Canada with psychotic symptoms. This is grossly in excess of all other CUSO experience, in Nigeria or elsewhere. An extensive psychiatric investigation concluded that all four had had remarkably similar illnesses, clinically similar to a toxic psychosis. None had a history of psychiatric illness. All were in their midtwenties ; two were male and two female. The four were working in separate locations, and in most cases had not heard about the others’ problems. Three of the four had taken therapeutic doses of chloroquine (oral or injectable) for fever believed to be due to malaria during the 48 hours, and the fourth about 2 weeks, before the development of psychotic symptoms. The symptoms were not compatible with cerebral malaria. Two of the volunteers experienced recurrences several months after their return to Canada. A survey of sixty-nine other volunteers working in Nigeria
E. RAGAN R. WILSON
CUSO Health Services, Ottawa
Department of Epidemiology and Community Medicine, University of Ottawa,
F. LI R. SPASOFF
Ottawa, Ontario K I H 8M5
G. BIGELOW N. SPINNER
Department of Psychiatry, McMaster University, Hamilton 1. Good
(6) Hb apart, we are not told whether the group of five patients was homogeneous in respect of spleen size, HbF levels, or association with a-thalassaemia, for example. (7) Iron status was not assessed so iron supplements were not justified. (8) There is no information on the total calorie intake of the children who did not have nasogastric feeding. (9) Although it is stated that after nasogastric feeding the two patients had no hospital admissions, no attempt is made to control for the possible effects of increased physician surveillance, or to validate statistically this or any other aspect of the study. I do not expect a preliminary communication to report both on significant numbers of patients and on conclusive results, but this paper does neither. Contrary to the statement in the last paragraph, even the claimed benefit of nasogastric feeding in the two patients so treated is unproven. Publications on hundreds of patients from Africa and the West Indies, providing ample data on growth and on nutrition, are ignored. This paper ought not to influence anybody managing sickle-cell anaemia. Department of Haematology, Royal Postgraduate Medical School,
turned up four additional "cases", all less severe, of whom two had taken therapeutic doses ofchloroquine less than 48 hours before the onset of symptoms; the other two were on prophylactic
MI, Shader RI. Behavioural toxicity and equivocal suicide associated with
chloroquine and its derivatives. AmJ Psychiatry 1977;
134: 798-801.
TACKLING TUMBU FLY LARVAE
SIR,-Dr Chopra and colleagues (May 18, p 1165) are not entirely in their recommendation that tumbu larvae "must be removed intact by blocking the spiracles and taking them out with forceps or squeezing them out". A much gentler way is to apply a little sticking plaster over each lesion. The larva then disintegrates and its remnants are exuded without physical or psychological trauma in three or four days. When one is dealing with twenty such lesions in a child of two or three years old, the child, the doctor, the parents, and possibly even the tumbu fly prefer this form of treatment, which I have found invariably effective over thirty years of practice in Africa. correct
53
Montagu Avenue, Harare, Zimbabwe
P. R. OLIVER
TRANSFUSION-ASSOCIATED MALARIA
SIR,-As discussed by Linda Wells and Dr Ala (June 8, p 1317), transfusion-induced malaria is a serious complication which is readily treated if recognised. The ideal policy-of detecting and excluding parasitised donors-is often impossible in areas where malaria is endemic. I have lately worked in a rural hospital in Imo State, Nigeria, where nearly 100% of the population is parasitised by Plasmodium, mostly falciparum, and where 75% of six-year-old children have palpable spleens. Anaemia is also endemic in this area,
secondary to hookworm, malaria, malnutrition, sickle-cell disease, tropical splenomegaly. Lack of understanding of the benign nature of blood donation combined with widespread anaemia make and
most
residents reluctant
to
donate blood.
is, therefore, neither practical
Hence, blood is very
desirable to exclude a donor because of parasitaemia by Plasmodium except for donors with active infection. To prevent transfusion-induced malaria chloroquine prophylaxis was given routinely to all blood recipients (600 mg base initially, then 300 mg at 6, 24, and 48 h). Prophylaxis was also given to all postoperative patients since surgery often activates latent malaria. This regimen has been very successful, probably because there is little, if any, chloroquine resistance in this area of Africa. In areas with drug resistance it may be best to withhold routine prophylaxis and treat only patients in whom symptoms appear after transfusion. scarce.
It
Washington Street 1014, Brookline, Massachusetts 02146, USA
nor
44
BRIAN CAMAZINE
SiR,-Any potential advance in the management of sickle-cell anaemia must be welcomed, and many readers will have been interested in that paper by Dr Heyman and colleagues (April 20, used in two children with sickle-cell p 903). Nasogastric feeding anaemia and "acceleration of growth" and fewer hospital admissions over 11-15 months were noted. However, fig 2 reveals that both children were still below the 5th percentile in both weight and height. I am surprised that the local ethical committee permitted experiments with nasogastric feeding and intestinal biopsy in these children. In deciding how this paper ought to influence patient management, several points should be noted. (1) Changes in the slope of the growth curve are the rule in growing children. (2) Absolute weight gains figures (eg, 4 - 2 kg) in growing children are meaningless, especially when children of different ages are involved. (3) If the three untreated children are to be viewed as controls, measurements on them should have been done at the same time intervals. (4) Extrapolation of height increases measured over weeks or months to "cm/year" is misleading. (5) One of the commonest causes of impaired somatic development in sickle-cell disease is relative folic acid deficiency.’ No information is provided on folic acid status: if it was to be marginal or low, simple folic acid supplementation would be likely to affect was
growth.’1
London W12 0HS 1.
chloroquine. The supplies of chloroquine came from widely different sources. Although half of the cases admitted to occasional use of marijuana or other psychoactive agents, and all might have been subjected to associated with such volunteer service, there is no convincing evidence that these are the explanation of the outbreak. stresses
We have been unable to determine the cause of this outbreak. Six of the eight cases were temporally related to the taking of therapeutic doses of chloroquine for apparent malaria, but a survey of the volunteers indicated that an even higher percentage (92%) had taken high-dose chloroquine for their most recent bout of malaria. Chloroquine can cause psychiatric symptoms,but has not been known to cause an outbreak such as the one reported here. We welcome comments from others with experience in this area.
L. LUZZATTO
Watson-Williams EJ. Folic acid, sickle cell anaemia and growth. In: Jonxis JHP, ed. Abnormal haemoglobins in Africa. Oxford: Blackwell Scientific Publications, 1965: 435.
PSYCHOTIC SYMPTOMS IN VOLUNTEERS SERVING OVERSEAS
SIR,-During the 15-month period from October, 1982, to December, 1983, four volunteers working in Nigeria with CUSO (a Canadian overseas volunteer service organisation) were repatriated to Canada with psychotic symptoms. This is grossly in excess of all other CUSO experience, in Nigeria or elsewhere. An extensive psychiatric investigation concluded that all four had had remarkably similar illnesses, clinically similar to a toxic psychosis. None had a history of psychiatric illness. All were in their midtwenties ; two were male and two female. The four were working in separate locations, and in most cases had not heard about the others’ problems. Three of the four had taken therapeutic doses of chloroquine (oral or injectable) for fever believed to be due to malaria during the 48 hours, and the fourth about 2 weeks, before the development of psychotic symptoms. The symptoms were not compatible with cerebral malaria. Two of the volunteers experienced recurrences several months after their return to Canada. A survey of sixty-nine other volunteers working in Nigeria
E. RAGAN R. WILSON
CUSO Health Services, Ottawa
Department of Epidemiology and Community Medicine, University of Ottawa,
F. LI R. SPASOFF
Ottawa, Ontario K I H 8M5
G. BIGELOW N. SPINNER
Department of Psychiatry, McMaster University, Hamilton 1. Good
(6) Hb apart, we are not told whether the group of five patients was homogeneous in respect of spleen size, HbF levels, or association with a-thalassaemia, for example. (7) Iron status was not assessed so iron supplements were not justified. (8) There is no information on the total calorie intake of the children who did not have nasogastric feeding. (9) Although it is stated that after nasogastric feeding the two patients had no hospital admissions, no attempt is made to control for the possible effects of increased physician surveillance, or to validate statistically this or any other aspect of the study. I do not expect a preliminary communication to report both on significant numbers of patients and on conclusive results, but this paper does neither. Contrary to the statement in the last paragraph, even the claimed benefit of nasogastric feeding in the two patients so treated is unproven. Publications on hundreds of patients from Africa and the West Indies, providing ample data on growth and on nutrition, are ignored. This paper ought not to influence anybody managing sickle-cell anaemia. Department of Haematology, Royal Postgraduate Medical School,
turned up four additional "cases", all less severe, of whom two had taken therapeutic doses ofchloroquine less than 48 hours before the onset of symptoms; the other two were on prophylactic
MI, Shader RI. Behavioural toxicity and equivocal suicide associated with
chloroquine and its derivatives. AmJ Psychiatry 1977;
134: 798-801.
TACKLING TUMBU FLY LARVAE
SIR,-Dr Chopra and colleagues (May 18, p 1165) are not entirely in their recommendation that tumbu larvae "must be removed intact by blocking the spiracles and taking them out with forceps or squeezing them out". A much gentler way is to apply a little sticking plaster over each lesion. The larva then disintegrates and its remnants are exuded without physical or psychological trauma in three or four days. When one is dealing with twenty such lesions in a child of two or three years old, the child, the doctor, the parents, and possibly even the tumbu fly prefer this form of treatment, which I have found invariably effective over thirty years of practice in Africa. correct
53
Montagu Avenue, Harare, Zimbabwe
P. R. OLIVER
TRANSFUSION-ASSOCIATED MALARIA
SIR,-As discussed by Linda Wells and Dr Ala (June 8, p 1317), transfusion-induced malaria is a serious complication which is readily treated if recognised. The ideal policy-of detecting and excluding parasitised donors-is often impossible in areas where malaria is endemic. I have lately worked in a rural hospital in Imo State, Nigeria, where nearly 100% of the population is parasitised by Plasmodium, mostly falciparum, and where 75% of six-year-old children have palpable spleens. Anaemia is also endemic in this area,
secondary to hookworm, malaria, malnutrition, sickle-cell disease, tropical splenomegaly. Lack of understanding of the benign nature of blood donation combined with widespread anaemia make and
most
residents reluctant
to
donate blood.
is, therefore, neither practical
Hence, blood is very
desirable to exclude a donor because of parasitaemia by Plasmodium except for donors with active infection. To prevent transfusion-induced malaria chloroquine prophylaxis was given routinely to all blood recipients (600 mg base initially, then 300 mg at 6, 24, and 48 h). Prophylaxis was also given to all postoperative patients since surgery often activates latent malaria. This regimen has been very successful, probably because there is little, if any, chloroquine resistance in this area of Africa. In areas with drug resistance it may be best to withhold routine prophylaxis and treat only patients in whom symptoms appear after transfusion. scarce.
It
Washington Street 1014, Brookline, Massachusetts 02146, USA
nor
44
BRIAN CAMAZINE