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Tropheryma whippelii in peripheral blood mononuclear cells and cells of pleural effusion
THE LANCET
We also warn patients without spleens to take particular care when handling domestic pets, to avoid bites and scratches. Such patients are especially susceptible to Capnocytophaga canimorsus
(DF2) septicaemia-in the 57 cases reported so far, 18 (32%) were patients without spleens usually infected after trivial bites or scratches.! None of these patients were on antimicrobial prophylaxis on admission, and 4 died despite treatment. Studies of normal canine oral flora revealed Staphylococcus aureus in 72% of animals, Pasteurella multocida in 66%2 and C canimorsus in 24%.3 Hence, to cover all these potential pathogens we suggest empirical of animal bites in patients without amoxycillin/clavulanic acid or erythromycin.
treatment
Public Health Laboratory, Heavitree, Exeter EX2 5AD, UK
spleens with
MARINA S. MORGAN JOHN G. CRUICKSHANK
1. Hicklin H, Verghese A, Alvarez S.
Dysgonic fermenter 2 septicaemia. Rev Infect Dis 1987, 9: 884-90. 2. Baillie WE, Stowe EC, Schmitt AM. Aerobic bacterial flora of oral and nasal fluids of canines with reference to bacteria associated with bites. J Clin Microbiol 1978; 7: 223-31. 3. Westwell AJ, Kerr 298: 116-17
K, Spencer MB, Hutchinson DM. DF-2 infection. BMJ 1989;
Tropheryma whippelii in peripheral blood mononuclear cells and cells of pleural effusion SIR,-Whipple’s disease is a systemic illness characterised by periodic-acid-Schiff (PAS) staining positive macrophages in the affected tissues. Although bacilli have been observed by electron microscopy’ and suspected to be the causative agent, identification and taxonomic categorisation have been achieved only recently with amplification and sequencing of bacterial 16S ribosomal RNA (rRNA) from infected tissues.2,3 We have applied this method to demonstrate that genomic material of Tropheryma whippelii is present in peripheral blood mononuclear cells and cells derived from pleural effusion in a patient with Whipple’s disease. A 58-year-old man with Whipple’s disease, as diagnosed by numerous PAS-positive macrophages in duodenal biopsy samples, had a pleural effusion as an extraintesdnal manifestation of the disease. DNA was prepared from duodenal mucosa, peripheral
701
blood mononuclear cells, plasma, and from cells and cell-free fluid from pleural effusion by standard techniques.’ Duodenal biopsy specimens from a patient with Helicobacter pylori associated peptic ulcer disease were used as control. 16S-rRNA sequences were amplified from 1 pg total DNA with either T whippelii specific primers or unspecific broad-range primers capable of amplifying any bacterial 16S-rRNA sequence.3 Ethidium bromide staining after agarose electrophoresis of the generated product showed a T whippelii specific 284 basepairs fragment in samples from duodenal mucosa, in peripheral blood mononuclear cells, and in pleural effusion cells. However, plasma and cell-free pleural effusion fluid were negative (figure). The specificity of the reaction was validated by the amplification of an 834 basepair fragment by broad-range primers for bacterial 16S-rRNA in both duodenal tissue of the control patient infected with H pylori and duodenal mucosa from the patient with Whipple’s disease. No amplification product was found in the duodenal sample of the control when T whippelii specific primers were used. The demonstration of genetic material of T whippelii in peripheral blood mononuclear cells and pleural effusion cells illustrates the systemic nature of the disease at the molecular level and opens the way for a non-invasive assay for Whipple’s disease. Universitatsklinik fur Innere Medizin IV, Währinger Gürtel 18-20, A-1090 Vienna, Austria
CHRISTIAN MÜLLER CHRISTOPH STAIN OTTO BURGHUBER
1. Chears WC Jr, Ashworth CT. Electron microscopic study of the intestinal mucosa in Whipple’s disease: demonstration of encapsulated bacilliform bodies in the lesion. Gastroenterology 1961; 41: 129-38. 2. Wilson KH, Blitchington R, Frothingham R, Wilson JAP. Phylogeny of the
Whipple’s-disease-associated bacterium. Lancet 1991; 338: 474-75. 3. Relman DA, Schmidt TM, MacDermott RP, Falkow S. Identification of the uncultured bacillus of Whipple’s disease. N Engl J Med 1992; 327: 293-301. 4. Sambrook J, Fritsch EF, Maniatis T. Molecular cloning. 2nd ed. Cold Spring Harbour: Cold Spring Harbour Laboratory Press, 1989.
ciprofloxacin in Campylobacter spp
Resistance to
SIR,-Dr McIntyre and Dr Lyons (Jan 16, p 188) state, "we have an increasing tendency towards empirical treatment of
noted
gastroenteritis with ciprofloxacin in the community, although ciprofloxacin has not been licensed for this indication". This statement is only partly correct. Ciprofloxacin is not licensed for travellers’ diarrhoea but is indicated for the treatment of infective diarrhoea, as can be seen in the data sheet which indicates ciprofloxacin in the treatment of enteric fever and infective diarrhoea. The data sheet also includes such organisms as Salmonella spp, Campylobacter coli, Cjejuni, and Escherichia coli as being fully sensitive to ciprofloxacin. Bayer plc. Bayer House, Newbury, Berkshire RG13 1JA, UK
Oral
B.
J. O’KEEFFE
immunoglobulin A supplement in
treatment of Clostridium difficile enteritis
PCR amplification product (284 basepairs) of 16S rRNA of T whippelii.
Amplification fragment of 834 basepairs is a product of non-specific broad-range primers for bacterial 16S-rRNA. Lanes 1 and 12=100 basepair ladder. T whippelii specific primers’ (pW3FE and pW2RB)lanes 2 and 9= water; patient: lane 3 = duodenum, 4 = pleural effusion cells, 5=peripheral blood mononuclear cells, 6=plasma, and 7=pleural effusion fluid; and control patient with H pylori infection: lane 8=duodenum Broad-range bacterial primers’ (p8FPL and p806R)-patient- lane 10=duodenum; control patient with H pylori infection. lane 11 = duodenum.
SIR,-Diarrhoea due to toxin-producing Clostridizan difficile is a well-known complication of antibiotic therapy.l Most cases of C difficile enteritis in children soon recover. In some cases, however, the clinical course can be protracted and difficult to manage with antimicrobial treatment. We tested orally administered immunoglobulin A as a treatment for this type of severe diarrhoea in a case resistant to other therapies. A 3½ year-old boy presented with a high temperature and diarrhoea on Dec 1, 1991. He had had two episodes of otitis media during the preceding 2 months, both of which had been treated with phenoxymethyl penicillin. The last course began on Nov 23,1991, even though he had a 3-day history of diarrhoea. A diet of boiled fish, meat, rice, and potatoes was used to cope with the diarrhoea. After some improvement, diarrhoea returned on Dec 10 now containing blood. Faecal analyses revealed C difficile toxin A but was negative for bacteria. The boy was treated with oral vancomycin for a week and improved. However, he relapsed with loose stools
We also warn patients without spleens to take particular care when handling domestic pets, to avoid bites and scratches. Such patients are especially susceptible to Capnocytophaga canimorsus
(DF2) septicaemia-in the 57 cases reported so far, 18 (32%) were patients without spleens usually infected after trivial bites or scratches.! None of these patients were on antimicrobial prophylaxis on admission, and 4 died despite treatment. Studies of normal canine oral flora revealed Staphylococcus aureus in 72% of animals, Pasteurella multocida in 66%2 and C canimorsus in 24%.3 Hence, to cover all these potential pathogens we suggest empirical of animal bites in patients without amoxycillin/clavulanic acid or erythromycin.
treatment
Public Health Laboratory, Heavitree, Exeter EX2 5AD, UK
spleens with
MARINA S. MORGAN JOHN G. CRUICKSHANK
1. Hicklin H, Verghese A, Alvarez S.
Dysgonic fermenter 2 septicaemia. Rev Infect Dis 1987, 9: 884-90. 2. Baillie WE, Stowe EC, Schmitt AM. Aerobic bacterial flora of oral and nasal fluids of canines with reference to bacteria associated with bites. J Clin Microbiol 1978; 7: 223-31. 3. Westwell AJ, Kerr 298: 116-17
K, Spencer MB, Hutchinson DM. DF-2 infection. BMJ 1989;
Tropheryma whippelii in peripheral blood mononuclear cells and cells of pleural effusion SIR,-Whipple’s disease is a systemic illness characterised by periodic-acid-Schiff (PAS) staining positive macrophages in the affected tissues. Although bacilli have been observed by electron microscopy’ and suspected to be the causative agent, identification and taxonomic categorisation have been achieved only recently with amplification and sequencing of bacterial 16S ribosomal RNA (rRNA) from infected tissues.2,3 We have applied this method to demonstrate that genomic material of Tropheryma whippelii is present in peripheral blood mononuclear cells and cells derived from pleural effusion in a patient with Whipple’s disease. A 58-year-old man with Whipple’s disease, as diagnosed by numerous PAS-positive macrophages in duodenal biopsy samples, had a pleural effusion as an extraintesdnal manifestation of the disease. DNA was prepared from duodenal mucosa, peripheral
701
blood mononuclear cells, plasma, and from cells and cell-free fluid from pleural effusion by standard techniques.’ Duodenal biopsy specimens from a patient with Helicobacter pylori associated peptic ulcer disease were used as control. 16S-rRNA sequences were amplified from 1 pg total DNA with either T whippelii specific primers or unspecific broad-range primers capable of amplifying any bacterial 16S-rRNA sequence.3 Ethidium bromide staining after agarose electrophoresis of the generated product showed a T whippelii specific 284 basepairs fragment in samples from duodenal mucosa, in peripheral blood mononuclear cells, and in pleural effusion cells. However, plasma and cell-free pleural effusion fluid were negative (figure). The specificity of the reaction was validated by the amplification of an 834 basepair fragment by broad-range primers for bacterial 16S-rRNA in both duodenal tissue of the control patient infected with H pylori and duodenal mucosa from the patient with Whipple’s disease. No amplification product was found in the duodenal sample of the control when T whippelii specific primers were used. The demonstration of genetic material of T whippelii in peripheral blood mononuclear cells and pleural effusion cells illustrates the systemic nature of the disease at the molecular level and opens the way for a non-invasive assay for Whipple’s disease. Universitatsklinik fur Innere Medizin IV, Währinger Gürtel 18-20, A-1090 Vienna, Austria
CHRISTIAN MÜLLER CHRISTOPH STAIN OTTO BURGHUBER
1. Chears WC Jr, Ashworth CT. Electron microscopic study of the intestinal mucosa in Whipple’s disease: demonstration of encapsulated bacilliform bodies in the lesion. Gastroenterology 1961; 41: 129-38. 2. Wilson KH, Blitchington R, Frothingham R, Wilson JAP. Phylogeny of the
Whipple’s-disease-associated bacterium. Lancet 1991; 338: 474-75. 3. Relman DA, Schmidt TM, MacDermott RP, Falkow S. Identification of the uncultured bacillus of Whipple’s disease. N Engl J Med 1992; 327: 293-301. 4. Sambrook J, Fritsch EF, Maniatis T. Molecular cloning. 2nd ed. Cold Spring Harbour: Cold Spring Harbour Laboratory Press, 1989.
ciprofloxacin in Campylobacter spp
Resistance to
SIR,-Dr McIntyre and Dr Lyons (Jan 16, p 188) state, "we have an increasing tendency towards empirical treatment of
noted
gastroenteritis with ciprofloxacin in the community, although ciprofloxacin has not been licensed for this indication". This statement is only partly correct. Ciprofloxacin is not licensed for travellers’ diarrhoea but is indicated for the treatment of infective diarrhoea, as can be seen in the data sheet which indicates ciprofloxacin in the treatment of enteric fever and infective diarrhoea. The data sheet also includes such organisms as Salmonella spp, Campylobacter coli, Cjejuni, and Escherichia coli as being fully sensitive to ciprofloxacin. Bayer plc. Bayer House, Newbury, Berkshire RG13 1JA, UK
Oral
B.
J. O’KEEFFE
immunoglobulin A supplement in
treatment of Clostridium difficile enteritis
PCR amplification product (284 basepairs) of 16S rRNA of T whippelii.
Amplification fragment of 834 basepairs is a product of non-specific broad-range primers for bacterial 16S-rRNA. Lanes 1 and 12=100 basepair ladder. T whippelii specific primers’ (pW3FE and pW2RB)lanes 2 and 9= water; patient: lane 3 = duodenum, 4 = pleural effusion cells, 5=peripheral blood mononuclear cells, 6=plasma, and 7=pleural effusion fluid; and control patient with H pylori infection: lane 8=duodenum Broad-range bacterial primers’ (p8FPL and p806R)-patient- lane 10=duodenum; control patient with H pylori infection. lane 11 = duodenum.
SIR,-Diarrhoea due to toxin-producing Clostridizan difficile is a well-known complication of antibiotic therapy.l Most cases of C difficile enteritis in children soon recover. In some cases, however, the clinical course can be protracted and difficult to manage with antimicrobial treatment. We tested orally administered immunoglobulin A as a treatment for this type of severe diarrhoea in a case resistant to other therapies. A 3½ year-old boy presented with a high temperature and diarrhoea on Dec 1, 1991. He had had two episodes of otitis media during the preceding 2 months, both of which had been treated with phenoxymethyl penicillin. The last course began on Nov 23,1991, even though he had a 3-day history of diarrhoea. A diet of boiled fish, meat, rice, and potatoes was used to cope with the diarrhoea. After some improvement, diarrhoea returned on Dec 10 now containing blood. Faecal analyses revealed C difficile toxin A but was negative for bacteria. The boy was treated with oral vancomycin for a week and improved. However, he relapsed with loose stools