LEllERS TO THE EDITOR

The Reply: My editorial presented data compiled by several labora-

tories, including our own, on the occurrence of serum M components in patients with nonreticular forms of cancer. As stated, the frequency of occurrence of the phenomenon is currently unknown, primarily because these components occur in low concentrations and are not readily detected with standard electrophoretic procedures, e.g., electrophoresis on cellulose acetate membranes. Technics providing greater electrophoretic separation and resolution of cathodally- migrating serum proteins (such as electrophoresis on agarose gels [l] or membranes [2]) have revealed M components in serum specimens in which such components were not apparent by immunoelectrophoretic or other types of elec- trophoretic analyses. Whether the presence of an M com- ponent in the serum of a patient with cancer is a “chance” occurrence or represents a specific humoral response to the cancer remains to be determined. The purpose of my editorial was to present clinical and experimental data relevant to this important question. Furthermore, M components may not be necessarily associated with overt cancer. It is possible that such components may be part of a preneoplastic process. Thus, in addition to surveying age-matched control subjects, it would be essential to select for special study those people whose habits or occupations make them at risk in the de- velopment of certain forms of cancer.

ALAN SOLOMON, M.D. Research Professor University of Tennessee Center for the Health Sciences Knoxville, Tennessee 37920

References 1. Talerman A, Haije WG: The frequency of M-components in sera of pa- tients with solid malignant neoplasms. Br J Cancer 27: 275, 1973. 2. Solomon A: Recognition of chemotherapeutic-associated alterations of monoclonal and polyclonal immunoglobulins in multiple myeloma and lymphoma. Proceedings of the 10th International Congress of Chemotfwapy (in press).

TRANSTRACHEAL ASPIRATION IN MENINGOCOCCAL PNEUMONIA

To the Editor: The report by Koppes and associates entitled “Group Y

Meningococcal Disease in U.S. Air Force Recruits” (Am J Med 62: 661, 1977) presents an important new aspect of meningococcal disease, namely, frequent meningococcal pneumonia due to this serogroup. Elucidation of this syndrome was possible only by routine transtracheal aspiration before antibiotic therapy in all suspected bacterial pneumonias. This procedure presents risks to otherwise healthy young men which may not be justified for the purpose of documenting infection due to Neisseria, Hemophilus and Streptococcus most of which would respond to ampicillin, erythromycin or even tetracycline therapy. It would seem that the major jus- tification for documenting meningococcal pneumonia by transtracheal aspiration is the potential for preventing spread of the infection to close contacts in a recruit population. However, the authors did not mention the sulfonamide sen-

sitivity of their group Y isolates (most to date are sulfona- mide-sensitive) and seem not to have considered the use of prophylaxis, at least to room-mates, bunk-mates, etc. in order to limit what can be called an epidemic of meningococcal disease at Lackland Air Force Base.

JAMES J. RAHAL, Jr., M.D. Chief, Division of Infectious Disease Associate Professor of Medicine New York University Veterans Administration Hospital New York, New York 10010

To the Editor: The authors of “Group Y Meningococcal Disease in United

States Air Force Recruits” (Am J Med62: 661, 1977) have, knowingly or not, established a “pecking order” of patho- genicity based upon the results of transtracheal aspiration. The order runs as follows: (1) the disease is pneumococcal if pneumococci are recovered from the transtracheal aspirate with or without other potential pathogens; (2) the disease is meningococcal if meningococci are recovered alone or with microbes other than the pneumococcus; (3) the disease is due to H. influenzae if that microbe is recovered without pneumococci or meningococci; and (4) the illness is non- bacterial if the transtracheal aspirate is sterile or contains only normal nasopharyngeal flora. Such reasoning could have some merit but certainly does not if two major causes of pneumonia in military recruits are not included, namely, Mycoplasma pneumoniae and adenovirus. No attempt was made to recover these pathogens from the transtracheal aspirate specimens. Many of the 68 recruits with primary meningococcal pneumonia according to this “pecking order” suffered infection compatible with the syndrome of primary atypical pneumonia: nonconsolidating multilobular pneumonia with a short febrile illness, prolonged cough and fairly slow resolution of infiltrates. I recovered meningococci from 36 of 196 consecutive transtracheal aspirate specimens ob- tained from patients with chronic bronchitis without acute illness except an occasional exacerbation of their bronchitis. None had fever or pneumonia. My conclusion was that meningococci are capable of proliferating in bronchial se- cretions and will probably do so if they are present in the nasopharynx. Unfortunately, I did not study patients with acute bronchitis. Military recruits often have high nasopharyngeal carrier rates for meningococci. In the light of my findings in chronic bronchitis, I suspect that the majority of the 68 re- cruits had meningococcal colonization of acute bronchitic secretions induced by nonbacterial agents. Even those with positive blood cultures may have had a primary nonbacterial process, and the meningococcal infection could be consid- ered a superinfection. This concept has long been proposed to explain pneumococcal lobar pneumonia developing in normal young adults. If this concept is accepted, the high incidence of meningococcal pneumonia is an artifact of a faulty interpretation of the results of transtracheal aspiration and not a special feature of group Y meningococci. I certainly do not object to the treatment of patients with pneumococci, meningococci or even nontypable H. influenzae recovered from transtracheal aspiration; indeed, either interpretation justifies such treatment. On the other hand, the evaluation

1090 June 1978 The American Journal of Medlcine Volume 84