PNEUMOCYSTIS CARINII PNEUMONIA
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1229 Before any such conclusion can be seriously considered, the procedures for isolating the virus would have to be more closely standardised than they actually are. A finding of much interest at Marikissa was that neomycin plus streptomycin was more effective than streptomycin alone in preventing bacterial contamination in the developing chick embryos used for growing the virus. This excellent contribution by Dr. Collier and his team on the natural history of trachoma-an infection that leads to spontaneous cure much more often than to blindness- is a model of the sort of knowledge that still needs to be gained, if only to establish an adequate basis for assessing the value of immunisation and vaccines in the control of trachoma. MEDICAL EXAMINATION OF IMMIGRANTS A B.M.A. working party, under the chairmanship of Dr. C. Metcalfe Brown, recommends that all immigrants to this country, regardless of their origin, should be medically examined before setting out. The Government has maintained that medical examination of prospective immigrants in their own countries is impracticable 1; but several countries, including Australia, Canada, and the U.S.A., require examination in the country of origin, and the system appears to work well. The working party recommends that examinations should be done by medical officers seconded from Britain and through them by approved local doctors. The examination would include chest X-ray for immigrants over the age of 12 years, and examination of fasces for immigrants from countries where gastrointestinal infection is prevalent. Certain non- infectious diseases " which may impair an immigrant’s ability to support himself or his dependants " should also, the working party says, be grounds for exclusion. The report is both sensible and humane. Existing regulations (or lack of regulations) seek to avoid breaking up families by exempting relatives of immigrants already here. The working party believes that the right way to avoid this kind of tragedy is to admit immigrants in family groups rather than one at a time. This is an important principle for a further reason: that the immigrants in greatest danger of a breakdown of tuberculosis, or of contracting venereal disease, are men who live here while their wives and families stay at home. For those who have to follow later we commend the American arrangement whereby they may be admitted even in poor health if the relative already accepted as an immigrant guarantees that they will undergo proper treatment when they arrive. PNEUMOCYSTIS CARINII PNEUMONIA Pneumocystis carinii infection of the lung, or inter- stitial plasma-cell pneumonia, can appear in various forms which differ in age-incidence, epidemiology, and the presence or absence of associated disorders. The diffuse or focal pneumonia of the newborn arises in small insti- tutional epidemics in Europe. Sporadic cases of pneu- monia have been seen elsewhere affecting older infants and children. Rarely, the organism causes pneumonia in adults. And, finally, subclinical interstitial pneumonitis has been noted from time to time at all ages. Pneumocystis pneumonia first assumed clinical signi- 1. See Lancet, 1964, ii, 1300. ficance after the 1939-45 war when it caused epidemics in central Europe, almost exclusively attacking premature or debilitated infants in institutions. One of the latest large outbreaks has been described by Truckenbrodt et a1.l An epidemic in Nuremberg affected children who had been admitted to the Central Hospital. Of a total of 124 children in the hospital at the time, 40 were affected. The most obvious sign of illness was rapid breathing, which often reached 100-150 per minute, with cyanosis and restlessness, but fever was rare. Chest X-rays usually showed bilateral scattered consolidation. Of 18 children who were severely ill, 3 died. In 10 children, who were less seriously ill, the respiratory rate rarely went above 80 per minute. The rest had few symptoms, but X-ray changes were seen in all of them. No specific treatment is available. The disease is extremely infectious, and, since it may be present without apparent symptoms, transfer of infection is very hard to prevent. At Nuremberg an infected child was probably admitted and transferred the disease to others: not until some became seriously ill was the situation recognised. The disease is rarely identified in this country, and only 2 instances have been lately recorded.2 3 The agent responsible is a cyst, 7-10 f1. in diameter, which contains eight bodies surrounded by a mucoid, somewhat refrac- tile, capsule. The parasite is presumably a protozoon and seems to be of low virulence, and disease at any age seems to reflect lowered host resistance. Certainly, an association with deficiency or absence of y-globulin in children is well established. CEREBROVASCULAR ACCIDENTS IN 1957 4 and 1960 the outcome of treating patients in undergraduate teaching hospitals in Britain was compared favourably with the results in district hospitals, but the discussion that followed suggested that patient selection, and not better treatment, might have been responsible for differences observed. Now from the United States comes an interesting report by Wylie 6 of patients with cerebro- vascular accidents admitted to the University Hospital of Johns Hopkins in Baltimore during the eleven years 1952-62. The results were not compared with any other group: the objects of the study were " to describe the medical aspects and to suggest medical and socio- economic factors that might have produced the reported results ". Wylie does not mention any diagnostic criteria for distinguishing the main causes of strokes, and the 2106 patients (3 white to 2 non-white) were divided into 363 with subarachnoid hxmorrhage, 817 with cerebral hxmorrhage, 400 with cerebral thrombosis, and 526 with " other and ill-defined lesions " (which in fact are not defined at all). The overall mortality-rate was 37 %, but the annual rate dropped from 41 % in 1952 to 31 % in 1962. If the strangely large group of 526 patients with " other and ill-defined lesions " is omitted, 1580 patients are left with 23% diagnosed as subarachnoid haemorrhage, 52% as intracerebral hxmorrhage, and 25% as cerebral infarction, with mortality-rates of 47%, 52%, and 31%. Analysis of the results produced some striking points: 1. Truckenbrodt, von H., Hovels, O., Sulzbeck, H., Vivell, O. Med. Klin. 1965, 60, 1269. 2. Ludham, G. B., Beattie, C. P. Lancet, 1963, ii, 1136. 3. Rodgers, T. S., Haggie, M. H. K. ibid. 1964, i, 1042. 4. Lee, J. A. H., Morrison, S. L., Morris, J. N. Lancet, 1957, ii, 785. 5. Lee, J. A. H., Morrison, S. L., Morris, J. N. ibid. 1960, i, 170. 6. Wylie, C. M. Med. Care, 1965, 3, 133.
Transcript of PNEUMOCYSTIS CARINII PNEUMONIA
1229
Before any such conclusion can be seriously considered,the procedures for isolating the virus would have to bemore closely standardised than they actually are. A findingof much interest at Marikissa was that neomycin plusstreptomycin was more effective than streptomycin alonein preventing bacterial contamination in the developingchick embryos used for growing the virus.
This excellent contribution by Dr. Collier and his teamon the natural history of trachoma-an infection that leadsto spontaneous cure much more often than to blindness-is a model of the sort of knowledge that still needs to begained, if only to establish an adequate basis for assessingthe value of immunisation and vaccines in the control oftrachoma.
MEDICAL EXAMINATION OF IMMIGRANTS
A B.M.A. working party, under the chairmanship ofDr. C. Metcalfe Brown, recommends that all immigrantsto this country, regardless of their origin, should be
medically examined before setting out. The Governmenthas maintained that medical examination of prospectiveimmigrants in their own countries is impracticable 1; butseveral countries, including Australia, Canada, and theU.S.A., require examination in the country of origin, andthe system appears to work well. The working partyrecommends that examinations should be done by medicalofficers seconded from Britain and through them byapproved local doctors. The examination would includechest X-ray for immigrants over the age of 12 years, andexamination of fasces for immigrants from countries wheregastrointestinal infection is prevalent. Certain non-
infectious diseases " which may impair an immigrant’sability to support himself or his dependants " should also,the working party says, be grounds for exclusion.The report is both sensible and humane. Existing
regulations (or lack of regulations) seek to avoid breakingup families by exempting relatives of immigrants alreadyhere. The working party believes that the right way toavoid this kind of tragedy is to admit immigrants in familygroups rather than one at a time. This is an importantprinciple for a further reason: that the immigrants in
greatest danger of a breakdown of tuberculosis, or ofcontracting venereal disease, are men who live here whiletheir wives and families stay at home. For those who haveto follow later we commend the American arrangementwhereby they may be admitted even in poor health if therelative already accepted as an immigrant guaranteesthat they will undergo proper treatment when theyarrive.
PNEUMOCYSTIS CARINII PNEUMONIA
Pneumocystis carinii infection of the lung, or inter-stitial plasma-cell pneumonia, can appear in various formswhich differ in age-incidence, epidemiology, and the
presence or absence of associated disorders. The diffuseor focal pneumonia of the newborn arises in small insti-tutional epidemics in Europe. Sporadic cases of pneu-monia have been seen elsewhere affecting older infantsand children. Rarely, the organism causes pneumoniain adults. And, finally, subclinical interstitial pneumonitishas been noted from time to time at all ages.
Pneumocystis pneumonia first assumed clinical signi-1. See Lancet, 1964, ii, 1300.
ficance after the 1939-45 war when it caused epidemics incentral Europe, almost exclusively attacking prematureor debilitated infants in institutions. One of the latest
large outbreaks has been described by Truckenbrodtet a1.l An epidemic in Nuremberg affected children whohad been admitted to the Central Hospital. Of a total of124 children in the hospital at the time, 40 were affected.The most obvious sign of illness was rapid breathing,which often reached 100-150 per minute, with cyanosisand restlessness, but fever was rare. Chest X-rays usuallyshowed bilateral scattered consolidation. Of 18 childrenwho were severely ill, 3 died. In 10 children, who wereless seriously ill, the respiratory rate rarely went above80 per minute. The rest had few symptoms, but X-raychanges were seen in all of them.No specific treatment is available. The disease is
extremely infectious, and, since it may be present withoutapparent symptoms, transfer of infection is very hard to
prevent. At Nuremberg an infected child was probablyadmitted and transferred the disease to others: not untilsome became seriously ill was the situation recognised.The disease is rarely identified in this country, and
only 2 instances have been lately recorded.2 3 The agentresponsible is a cyst, 7-10 f1. in diameter, which containseight bodies surrounded by a mucoid, somewhat refrac-tile, capsule. The parasite is presumably a protozoon andseems to be of low virulence, and disease at any age seemsto reflect lowered host resistance. Certainly, an associationwith deficiency or absence of y-globulin in children iswell established.
CEREBROVASCULAR ACCIDENTS
IN 1957 4 and 1960 the outcome of treating patients inundergraduate teaching hospitals in Britain was comparedfavourably with the results in district hospitals, but thediscussion that followed suggested that patient selection,and not better treatment, might have been responsible fordifferences observed. Now from the United States comesan interesting report by Wylie 6 of patients with cerebro-vascular accidents admitted to the University Hospital ofJohns Hopkins in Baltimore during the eleven years1952-62. The results were not compared with anyother group: the objects of the study were " to describethe medical aspects and to suggest medical and socio-economic factors that might have produced the reportedresults ". Wylie does not mention any diagnosticcriteria for distinguishing the main causes of strokes, andthe 2106 patients (3 white to 2 non-white) were dividedinto 363 with subarachnoid hxmorrhage, 817 withcerebral hxmorrhage, 400 with cerebral thrombosis, and526 with " other and ill-defined lesions " (which in factare not defined at all). The overall mortality-rate was 37 %,but the annual rate dropped from 41 % in 1952 to 31 % in1962. If the strangely large group of 526 patients with" other and ill-defined lesions " is omitted, 1580 patientsare left with 23% diagnosed as subarachnoid haemorrhage,52% as intracerebral hxmorrhage, and 25% as cerebralinfarction, with mortality-rates of 47%, 52%, and 31%.
Analysis of the results produced some striking points:1. Truckenbrodt, von H., Hovels, O., Sulzbeck, H., Vivell, O. Med. Klin.
1965, 60, 1269.2. Ludham, G. B., Beattie, C. P. Lancet, 1963, ii, 1136.3. Rodgers, T. S., Haggie, M. H. K. ibid. 1964, i, 1042.4. Lee, J. A. H., Morrison, S. L., Morris, J. N. Lancet, 1957, ii, 785.5. Lee, J. A. H., Morrison, S. L., Morris, J. N. ibid. 1960, i, 170.6. Wylie, C. M. Med. Care, 1965, 3, 133.
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