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Testing for syphilis
Bone Marrow Study To the Editor. Our research team is presently studying 20 patients in whom we are comparing bone marrow aspirates with venous samples in the typing and screening process. To date, we have two adults and one infant in whom the bone marrow aspirates were analyzed in the blood bank. The results of the typing and screening of these aspirates are identical to those of the sample obtained by normal venipuncture. The procedure consists of taking a 3-mL aspirate of bone marrow and placing this in the standard lavender-top tube containing EDTA (Becton-Dickinson). At this point, we have observed no major difficulties. We intend to re-
port at greater length on the completion of our study.
Paul Rega, MD Ken Krupp, MD Kris Brickman, MD Jan Alexander, M T (ASCP) SBB Michael Guinness, MD Emergency Medicine Residency St Vincent Medical Center and The Toledo Hospital Toledo, Ohio
Organophosphate Intoxication From Over-the-Counter Insecticides To the Editor: A 75-year-old man with underlying chronic obstructive pulmonary disease, renal insufficiency, and degenerative arthritis was admitted to the emergency department with a one-week history of nausea and diarrhea, increasing lethargy, and weakness. Physical examination showed signs of d e h y d r a t i o n , meiosis, bilateral p u l m o n a r y wheezes, and stupor. During the three weeks prior to admission, his wife was attempting to rid their apartment of ants and intermittently sprayed two cans of an over-thecounter preparation that contained 2(1)-methylethoxyphenol methylcarbamate (Baygon) and 2,2-dichlorodimethylvinylphosphate (DDVP), marketed as Black Flag Ant and Roach Killer ®. His multiple medical problems resulted in restricted activity and, unlike his wife who was able to leave the apartment, he remained in the apartment both during and after the spraying. O r g a n o p h o s p h a t e i n t o x i c a t i o n was confirmed by a plasma cholinesterase level of 0.31 units per hour (normal, 0.5 to 1.3 units per hour) on admission. The patient was treated with both 2-PAM and high doses of IV atropine, 20 mg in the first 24 hours and a total of 142 mg prior to discharge. The early clinical course was complicated by brief hypotension and respiratory failure. He was discharged 16 days later and died at home 25 days after admission. An autopsy revealed fibrinous pericarditis attrib-
uted to uremia, atherosclerotic cardiovascular disease, and focal terminal bronchopneumonia. Blood, liver, and fat samples showed no detectable levels of the pesticides, but the kidney had 1 ppm of DDVP. Although death was attributed to natural causes, this patient clearly had an initial episode of severe organophosphate poisoning from a readily available household pesticide, and a toxic exposure significantly contributed to the death of this elderly, medically compromised patient. In retrospect, the pesticide was used according to the label instructions. It was, however, used repeatedly in a closed area. The medical c o m m u n i t y may benefit from the knowledge that seemingly appropriate use of a readily available household spray in the residence of a chronically ill elderly person may result in toxic exposure and death. Improvement in the warning label and heightened awareness of this potential may prevent future occurrences.
Sheldon L Wagner, MD Department of Agricultural Chemistry Oregon State University James D Gallant, MD Good Samaritan Hospital Corvallis, Oregon
Testing for Syphilis To the Editor: Recent national survey data has noted an increasing prevalence of syphilisJ In order to determine if this trend was present in our patient population, the results of all RPR (rapid plasma reagin) tests performed on emergency department patients at the George Washington University Hospital between January 1, 1988, and May 31, 1988, were reviewed. Among the 240 tests performed, 31 patients (12.9%) had titers/> 1:8 (or titers ~ 1:2 with high clinical suspicion of recent infection), compared with seven posi18:7 July 1989
tive tests (6.9%) among the 101 tests performed during the same five-month period in 1987 (X-', = 2.0; P = .15). The most frequent physical findings were genital ulcers (14, 45%), rash (eight, 26%), and urethral discharge (five, 16%). Contrary to some textbook descriptions, many of the ulcers were quite painful and were often initially misdiagnosed as being caused by herpes simplex or H ducrei. Painful inguinal lymphadenitis was noted in many of the patients presenting with genital ulcers or a urethral dis-
Annals of Emergency Medicine
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CORRESPONDENCE
charge. Because our hospital laboratory performs the RPR assays on a batch basis, the emergency physician did not have access to a patient's RPR result during the initial patient encounter; consequently, only nine (29%) patients received antisyphilitic therapy during the first visit. The untreated patients were called back (or referred) for treatment. Despite the lack of standard criteria for assaying a patient's RPR, and a Xz P value of > .05 for the difference between the 1988 and 1987 rate of positive tests, several points can be made. Emergency physicians m u s t be very suspicious for syphilis in any patient with a perineal or genital ulcer regardless of the ulcer's characteristics. Emergency physicians should screen for latent syphilis in all patients presenting with a urethral discharge. Physi-
150/803
cians should be particularly suspicious if inguinal adenitis accompanies the s y m p t o m of discharge. We urge that hospital laboratories perform an RPR on receipt of the sample (25 to 35 minutes to perform) so that the emergency physician can make a treatment decision while the patient is still in the ED.
Hee Won Kim Robert Shesser, MD, MPH Mark Smith, MD Department of Emergency Medicine George Washington University Medical Center Washington, DC 1. Continuing increase in infectious syphilis 1988;37:35-38.
Annals of Emergency Medicine
United States. MMWR
18:7 July 1989
port at greater length on the completion of our study.
Paul Rega, MD Ken Krupp, MD Kris Brickman, MD Jan Alexander, M T (ASCP) SBB Michael Guinness, MD Emergency Medicine Residency St Vincent Medical Center and The Toledo Hospital Toledo, Ohio
Organophosphate Intoxication From Over-the-Counter Insecticides To the Editor: A 75-year-old man with underlying chronic obstructive pulmonary disease, renal insufficiency, and degenerative arthritis was admitted to the emergency department with a one-week history of nausea and diarrhea, increasing lethargy, and weakness. Physical examination showed signs of d e h y d r a t i o n , meiosis, bilateral p u l m o n a r y wheezes, and stupor. During the three weeks prior to admission, his wife was attempting to rid their apartment of ants and intermittently sprayed two cans of an over-thecounter preparation that contained 2(1)-methylethoxyphenol methylcarbamate (Baygon) and 2,2-dichlorodimethylvinylphosphate (DDVP), marketed as Black Flag Ant and Roach Killer ®. His multiple medical problems resulted in restricted activity and, unlike his wife who was able to leave the apartment, he remained in the apartment both during and after the spraying. O r g a n o p h o s p h a t e i n t o x i c a t i o n was confirmed by a plasma cholinesterase level of 0.31 units per hour (normal, 0.5 to 1.3 units per hour) on admission. The patient was treated with both 2-PAM and high doses of IV atropine, 20 mg in the first 24 hours and a total of 142 mg prior to discharge. The early clinical course was complicated by brief hypotension and respiratory failure. He was discharged 16 days later and died at home 25 days after admission. An autopsy revealed fibrinous pericarditis attrib-
uted to uremia, atherosclerotic cardiovascular disease, and focal terminal bronchopneumonia. Blood, liver, and fat samples showed no detectable levels of the pesticides, but the kidney had 1 ppm of DDVP. Although death was attributed to natural causes, this patient clearly had an initial episode of severe organophosphate poisoning from a readily available household pesticide, and a toxic exposure significantly contributed to the death of this elderly, medically compromised patient. In retrospect, the pesticide was used according to the label instructions. It was, however, used repeatedly in a closed area. The medical c o m m u n i t y may benefit from the knowledge that seemingly appropriate use of a readily available household spray in the residence of a chronically ill elderly person may result in toxic exposure and death. Improvement in the warning label and heightened awareness of this potential may prevent future occurrences.
Sheldon L Wagner, MD Department of Agricultural Chemistry Oregon State University James D Gallant, MD Good Samaritan Hospital Corvallis, Oregon
Testing for Syphilis To the Editor: Recent national survey data has noted an increasing prevalence of syphilisJ In order to determine if this trend was present in our patient population, the results of all RPR (rapid plasma reagin) tests performed on emergency department patients at the George Washington University Hospital between January 1, 1988, and May 31, 1988, were reviewed. Among the 240 tests performed, 31 patients (12.9%) had titers/> 1:8 (or titers ~ 1:2 with high clinical suspicion of recent infection), compared with seven posi18:7 July 1989
tive tests (6.9%) among the 101 tests performed during the same five-month period in 1987 (X-', = 2.0; P = .15). The most frequent physical findings were genital ulcers (14, 45%), rash (eight, 26%), and urethral discharge (five, 16%). Contrary to some textbook descriptions, many of the ulcers were quite painful and were often initially misdiagnosed as being caused by herpes simplex or H ducrei. Painful inguinal lymphadenitis was noted in many of the patients presenting with genital ulcers or a urethral dis-
Annals of Emergency Medicine
802/149
CORRESPONDENCE
charge. Because our hospital laboratory performs the RPR assays on a batch basis, the emergency physician did not have access to a patient's RPR result during the initial patient encounter; consequently, only nine (29%) patients received antisyphilitic therapy during the first visit. The untreated patients were called back (or referred) for treatment. Despite the lack of standard criteria for assaying a patient's RPR, and a Xz P value of > .05 for the difference between the 1988 and 1987 rate of positive tests, several points can be made. Emergency physicians m u s t be very suspicious for syphilis in any patient with a perineal or genital ulcer regardless of the ulcer's characteristics. Emergency physicians should screen for latent syphilis in all patients presenting with a urethral discharge. Physi-
150/803
cians should be particularly suspicious if inguinal adenitis accompanies the s y m p t o m of discharge. We urge that hospital laboratories perform an RPR on receipt of the sample (25 to 35 minutes to perform) so that the emergency physician can make a treatment decision while the patient is still in the ED.
Hee Won Kim Robert Shesser, MD, MPH Mark Smith, MD Department of Emergency Medicine George Washington University Medical Center Washington, DC 1. Continuing increase in infectious syphilis 1988;37:35-38.
Annals of Emergency Medicine
United States. MMWR
18:7 July 1989