53

On the numbers available there was, in retrospect, a 90% chanceof detecting as significant at the 5% level a true difference betweencases and controls of 1’ 15 pmol/dl for zinc and 1.57 fmol/dl forcopper. The study was not large enough to detect substantiallysmaller differences with reasonable certainty.The RBP result for the non-pulmonary cancers was unexpected.

It is possible that even though the blood samples were taken, onaverage, 4 years before clinical evidence of cancer, RBP was beingproduced by fa,lo/ tumours.6,7 Our results did not show anydifferences for the lung cancer cases.Further work on vitamin A and factors involved in its transport is

required on larger .numbers of cancer patients in whom bloodsamples have been taken before the development of clinical signsand symptoms of cancer.

M.R.C Epidemiology and Medical Care Unit,Northwick Park Hospital,Harrow, Middlesex HA1 3UJ

Department of Foods and Nutrition,University of Alberta,Edmonton, Alberta, Canada

Unit for Metabolic Medicine,Department of Medicine,Guy’s Hospital, London

A. P. HAINES

S. G. THOMPSON

T. K. BASU

ROSEMARY HUNT

MICONAZOLE IN FUNGAL ENDOPHTHALMITIS

SIR,-The value of miconazole in the management of fungalendophthalmitis1,2 and its role in the treatment of systemic fungalinfections3 are uncertain. Our experience with miconazole in twocases of Candida albicans endophthalmitis in intravenous drugabusers, may help to clarify the therapeutic value of this drug.Endophthalmitis was diagnosed on clinical grounds and

confirmed by culture of candida from one or more of blood,vitreous, and skin nodules. In the first case the retinal lesions andthe vitreous changes became more extensive on the recommendeddose of intravenous miconazole (1200 mg daily), and resolution wasobtained only on doubling the dosage. In the second case, afterinitial dosage of 1200 mg daily, the dosage was doubled andcomplete resolution ensued. At the higher dosage distressing side-effects such as nausea and pruritus were encountered, but noresidual adverse effects were seen after treatment stopped.We have treated six other cases of endophthalmitis in intravenous

drug abusers with clinical features suggestive of fungal infection butnegative cultures. In every case progression of infection was haltedby the higher dosage of miconazole, and visual acuity improved intwo cases. All eight patients treated received oral 5-fluorocytosine150 mg/kg daily in addition to miconazole, and the duration of stherapy was from 7 to 28 days.We conclude that miconazole is effective in fungal

endophthalmitis and that before it is dismissed as a form oftreatment, further studies using dosages higher than those presentlyrecommended should be done.

Department of Medicineand Endocrinology Unit,

Sydney Hospital,Sydney, Australia

Department of ClinicalOphthalmology and Eye Health,

Sydney Eye Hospital

J. GALLOH. GRUNSTEINP. CLIFTON-BLIGH

F. A. BILLSON

K. H. TARR*

*Present address: Christchurch Hospital, New Zealand.

6. Sani BP, Condon SM, Brockman RW, Weiland LH, Schutt AJ Retinoic acid-bindingprotein in experimental and human colon tumours. Cancet 1980; 45: 1199

7 Ong DE, Chytil F Retinoic acid-binding protein occurrence in human tumours.Science 1975; 190: 60

1. Blumenkranz MS, Stevens DA. Therapy of endogenous fungal endophthalmitis. ArchOphthalmol 1980; 98: 1216-20.

2. Jones DB Therapy of postsurgical fungal endophthalmitis. Ophthalmology 1978; 85:357-73

3. Editorial. Treating fungal infections. Br Med J 1980; 280: 668-69.

GIARDIASIS BY INHALATION?

SIR,-A debilitating bout of giardial gastroenteritis in a physicianled to questions about the source of his infection. The usual modesof transmission were ruled out (foreign travel, contaminated rural ormunicipal water supply, or household contact with a known case).Rarer modes of transmission were also unlikely (contact with aninfected animal, contaminated food or laboratory exposure, orhomosexual transmisiion).1,2 Epidemiological investigationsuggests another possibility: exposure to two known cases of

giardiasis in the intimate confines of the orthopaedic cast-room.Review of the doctor’s records reveals a time sequence indicatingeither direct oral-faecal-hand transmission or inhalation and

swallowing of cyst-contaminated plaster dust.On March 9, 1981, a one-year old infant who attended a small

neighbourhood day care centre needed adjustment of her plastercast in the outpatient office. On April 16 the cast was removed. Onboth occasions, the cast was stained with dry and moist faeces. Thedoctor, a non-smoker, routinely washes his hands before and aftercast-changing, but he rarely wears a mask.In early May, the doctor experienced epigastric pain, bloating,

cramping, diarrhoea, anorexia, and weight loss. By July, he had lost15% of his body weight. When a stool examination revealed giardialcysts, he took a ten-day course of metronidazole. Symptomsdecreased dramatically; appetite and weight gain returned, with nosubsequent relapse.The index child was one of two preschool children under

treatment by the doctor. Interviews with the parents revealed thatboth children had been diagnosed and treated for giardiasis as hadvarious members of their households. Both children had been insmall day care centres for a considerable time while their mothersworked. Day-care-associated giardiasis appears to be endemic in thiscommunity and is being investigated by the health department. 3Can plaster cast dust transmit giardial cysts in the closed

atmosphere of the orthopaedic treatment room? This route isreminiscent of airborne infections during the 1940s when kitchen-blenders were widely used in laboratories.4 4

Department of Family Medicine,Medical University of South Carolina,Charleston, South Carolina, U.S.A.

Mount Pleasant, South Carolina

STANLEY H. SCHUMAN

ANDREW T. ARNOLD

J. ROGER ROWE

DETECTION OF DENGUE VIRUS BYIMMUNOFLUORESCENCE AFTER INTRACEREBRAL

INOCULATION OF MOSQUITOESSIR,-In this laboratory dengue viruses are isolated by

intrathoracic inoculation of mosquitoes with clinical materialobtained from patients with dengue haemorrhagic fever (DHF).5 5Viral antigen is sought by direct fluorescent antibody technique(DFAT) on day 14. 6We have now developed a system of intracerebral inoculation of

Toxorhynchites splendens mosquitoes with dengue-2 prototypevirus.7 The virus could be detected by DFAT as early as day 5.Concurrent intrathoracic inoculation of T. splendens with the sameprototype virus permits detection of viral antigen on day 10-14.This is the first time that an intracerebral inoculation technique has

1. Meyer EA. Giardiasis Am J Epidemiol 1980; 3: 1-122. Sealy DP, Schuman SH. Giardiasis: a common and underrecognized enteric pathogen

J of Family Pract 1981; 12: 47-543. Hankins CA, Lockerby CH. Giardiasis outbreak in a day care center. Alberta Canada

Dis Weekly Rep 1981; 7: 221-224. Benenson A, ed. Transmission of infectious agents. In: Control of communicable

disease of man, 12th ed. American Public Health Association, Washington, DC.1975; 386-88.

5. Rosen L, Gubler D The use of mosquito to detect and propagate dengue viruses Am JTrop Med Hyg 1974; 23: 1153-60.

6. Kuberski TT, Rosen L. A simple technique for the detection of dengue antigen inmosquitoes by immunofluorescence. Am J Trop Med Hyg 1977, 26: 533-37.

7. Thet-Win, Ohyama A. Detection of the dengue-2 prototype virus in Toxorhynchitesmosquitoes using intra-cerebral inoculation technique. Dengue Newsleter (SoutheastAsian & Western Pacific Regions WHO) 1981; 7: 51-52

54

been described for detection of dengue virus. The technique is asreliable and as specific as the standard intrathoracic method, but itprovides for earlier detection of dengue virus, within 5 days.

Earlier work (unpublished) had shown that mononuclear cells arealso a good source of dengue antigen, 8,9 so the cells inoculated weremononuclear cells (buffy coat) obtained by separation on ’Ficoll-paque’. JO 2-4 day old 7X splendens mosquitoes were used formosquito inoculation. The intracerebral inoculation was done

through the dorsal part of the head capsule, which lies between theneck and vertex (occiput). The amount of inoculum was 0 17 <1 permosquito. Infected mosquitoes were held at 32&deg;C, relative humidity80%, and fed on 10% sugar solution. Viral antigen was sought dailyby DFAT. On the 4th post-infection day, viral antigen in the form oftypical perinuclear fluorescence was detected.In a preliminary study of blood samples from 68 patients (63 non-

shock, 5 shock) with a diagnosis of DHF reached by the intracerebralinoculation method, dengue viral antigen was detected in the headsquash preparations (non-shock 13/63, shock 1/5) of the samples onthe 5th day. None of the samples negative for dengue viral antigenon the 5th day were positive when examined again on 6th, 7th, and8th days.Virus isolation based on an Aedes pseudoscutellaris (LSTM-AP-61)’

cell line had been shown to provide presumptive diagnosis ofdengue when cytopathic effect (CPE) was seen as early as 4-6 daysafter inoculation, i, lz but these cultures with CPE need to be testedand confirmed by complement fixation later. With our intracerebralinoculation method, dengue virus can be detected by DFAT fromthe 5th day after inoculation.Further tests are now being done to compare the sensitivity of

intracerebral inoculation with that of the intrathoracic method fromblood samples of DHFF.

Virology Research Division,Department of Medical Research,Rangoon, Burma THET-WIN

USE OF A BISACODYL SUPPOSITORY IN THEDIAGNOSIS OF AMOEBIASIS

SIR,-Examination of a stool sample is often an insensitivemethod of detecting Entamoeba histolytica. An improvement insensitivity was obtained by the following technique. 2 h beforeexamination a bisacodyl suppository was inserted in the rectumwith the aim of encouraging amoebae to move from the depths of theglands or base of the crypts to the surface. After defaecation,sigmoidoscopy was done and a sample of the exudate present in thehyperaemic rectal ampulla was collected and transferred to a

prewarmed (37&deg;C) test tube. The tube was maintained at 37&deg;C andits contents examined microscopically within 15 min of collection.The technique was used in 261 patients with a bowel disturbance

and the results were compared with those in the same patients forexamination ofa single fresh stool specimen by microscopy at 37&deg;C,by staining for ova andcysts, and by concentration for ova and cystsusing a flotation technique. The use of rectal exudate gave a twenty-fold increase in sensitivity . and this simple technique isrecommended for general use. Exudate examination picked up 65cases (24 - 9% of patients), the E. histolytica being haematophagousin 46. After stool examination only 3 cases (1 haematophagous) werediagnosed.Tehran Medical University,Tehran, Iran M. VAFAI

8 Boonpucknavig S, Bhamarapravati N, Nimmannitya S, Phalavadhtana A, Siripont J.Immunofluorescent staining of the surface of lymphocytes in suspension frompatients with dengue hemorrhagic fever. Am J Pathol 1976; 85: 37-47.

9. Suvatte V, Longsman M. Diagnostic value of buffy coat preparation in denguehemorrhagic fever Southeast Asian J Trop Med Pub Hlth 1979; 10: 7-12.

10. Boyum A. Separation of leukocytes from blood and bone marrow Scand J Clin LabInvest 1968; 21: 21.

11 Varma MGR, Pudney M, Leake CJ. Cell lines from larvae of Aedes (Stegomyia)malayensis Colless and Aedes (S) pseudoscutellaris (Theobald) and their infection withsome arboviruses. Trans Roy Soc Trop Med Hyg 1974, 68: 374-82.

12. Race MW, Wiliams MC, Agostini CFM. Dengue in the Caribbean: Virus isolation in amosquito (Aedes pseudoscutellaris) cell line Trans Roy Soc Trop Med Hyg 1979; 73:18-22.

ANAEROBIC CURVED RODS IN VAGINITIS

SIR,-We read with interest the letter by Eva Hjelm and hercolleagues (Dec. 12, p. 1353) describing anaerobic curved rods invaginitis since we have also been investigating exceedingly motilecurved organisms in patients with altered vaginal discharge. Theorganism we have been studying differs in two respects from theirdescription. Although it may appear gram negative when present invaginal discharge, it stains poorly unless dilute carbol fuchsin isused as the counterstain. In our experience 48 h cultures appeargram positive when stained in this way. Secondly, electronmicroscopy of vaginal discharges containing these organisms(figure) reveals curved rods 0-3x2-3 3 pm, with rounded ends andsubpolar flagella, ranging from 2-6 in number as described byCurtis. 1

Electronmicroscopy appearance of motile organism isolated frompatient with vaginitis.

After culture under anaerobic conditions on Oxoid DST agarsupplemented with 5% defibrinated horse blood, 1 % haemin, 0 2%vitamin K, and 0 - 5% yeast extract, minute colonies are visible after2 days of incubation at 37&deg;C. No growth occurs in 10% carbondioxide or under microaerophilic conditions. In view of the usualsensitivity of obligate anaerobes to metronidazole it is of interestthat under strictly anaerobic conditions the new strains we havetested all grow up to the edge of a disc containing 5 J..Ig of this agent.We agree with Hjelm and her co-workers on the need to

characterise this organism and establish its possible role in vaginitis.Department of Microbiology,Institute of Pathology,Newcastle General Hospital,Newcastle upon Tyne NE4 6BE

Department of Sexually Transmitted Diseases,Newcastle General Hospital

Department of Microbiology,Institute of Pathology,Newcastle General Hospital

M. S. SPROTT

R. S. PATTMAN

H. R. INGHAMG. R. SHORTH. K. NARANG

J. B. SELKON

1. Curtis AH A motile curved anaerobic bacillus in uterine discharges J Inf Dis 1913; 12:165-69.