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one to make this assertion with confidence. The act of attending aclinic every fortnight over many months might have led to animprovement, independent of the drug administered, and this effectmight be greatest after 3-4 months. Because this study did notcontain a group of subjects treated only with an inhaled placebo, inaddition to oral prednisolone, this possibility cannot be dismissed.

Department of Medicine,University of Auckland,Auckland 1, New Zealand PETER BLACK

1. Postma DS. Inhaled therapy in COPD: what are the benefits? Respir Med 1991; 85:447-49.

Author’s reply

SiR,—The making of the right diagnosis between asthma andchronic obstructive airways disease, is indeed, very relevant inclinical trials with anti-asthma drugs. We excluded all patients whosmoked as well as those over 65 years, since airway obstruction isless reversible in older patients than in younger patients.Unfortunately, the fact that we excluded smokers was not

mentioned in our article.With respect to fenoterol, patients were advised to contact a study

physician whenever the number of fenoterol puffs exceeded 10 perday. The decision whether or not to increase the oral steroid dosewas based on clinical judgment, symptoms, and peak expiratoryflow values and not only on the number of fenoterol puffs, eventhough excessive use of fenoterol would result in an increase of oralprednisolone. The peak expiratory flow values in both treatmentgroups remained very stable (between 290 and 320 L/min).We agree that the statement on the time needed to reach

minimum steroid requirement is not wholly conclusive. The studywas designed to examine the difference in oral steroid reduction andnot the time needed to reach the minimum. However, bothintention-to-treat analysis as well as protocol-correct analysis ofboth treatment groups showed that after 3-4 months no furtherreduction in mean oral steroid dose could be obtained. In other

settings this time may be different.We think that our study demonstrates the difficulties in detecting

differences in the effects of inhaled steroid doses on therapeuticresponse of asthma patients. Our findings also show, like some ofother studies, that in severe steroid-dependent asthma, inhaledsteroids cannot replace oral corticosteroids. One can only speculateabout the explanations for this: even though chronic inflammation isan important feature of asthma, we do not know whether theinflammatory cells are activated in the bronchi or if they havemigrated there after being activated elsewhere in the body. If thelatter is the case, topical therapy can only restrict the progression ofthe disease locally, whereas oral steroids or even more specificimmunosuppressive drugs would be needed to prevent the primarylymphocyte activation.Orion Farmos-pharmaceuticals,02101 Espoo, Finland

LASSE LEHTONEN,on behalf of the Study Group

Absence of hepatitis A after treatment withpasteurised factor VIII concentrates inchildren with haemophilia A and von

Willebrand disease

SIR,-Since Mannucci et all described 41 cases of hepatitis Avirus (HAV) infection in Italian patients with haemophilia, whowere treated exclusively with a high-purity factor VIII (FVIII)concentrate (Emoclot Octa VI, Octapharm), several other reportsappeared in The Lancet. Dr Gerritzen and colleagues (Nov 14, p1231) report 13 cases of HAV infection in German haemophilia Apatients treated with the same FVIII product; a further 17 cases ofHAV seroconversion were recorded by Professor Temperley (Dec12, p 1465) in Irish haemophiliacs, and these had also received afactor VIII concentrate prepared by Octapharm. Thismanufacturer uses a solvent/detergent method for virus inactivationfollowed by chromatographic purification. Dr Normann andcolleagues (Nov 14, p 1232) detected HAV RNA by antigencaptured polymerase chain reaction (PCR) in two of four testedbatches of commercial FVIII concentrate (Octavi, Octapharm).

One of these PCR-positive batches had been given to 4 patients withhaemophilia who developed acute HAV infection. ProfessorShouval and Professor Gerlich (Dec 12, p 1465), on behalf of theworking group on hepatitis A and clotting factors, suggested lookingfor HAV infections in recipients of FVIII products, irrespective ofmanufacturer, and Normann et al recommended the developmentof procedures other than the solvent/detergent method to inactivatevery stable infectious agents.

In our paediatric haemophilia centres in Frankfurt, Bremen, andMunich we investigated prospectively, and in some cases

retrospectively, HAV IgG (HAV AB enzyme immunoassay [EIA],Abbott) and HAV IgM (HAV AB-M EIA, Abbott) prevalences inpreviously untreated patients with haemophilia A (n = 58) and vonWillebrand disease (vWD) (n = 37), who were treated exclusivelywith pasteurised FVIII concentrates (Haemate HS, Beriate HS,Behringwerke Marburg). Virus inactivation was achieved bypasteurisation for 10 h at 60°C in aqueous solution.2 Over anobservation period of up to 12 years, with a total of 68 batches ofconcentrate, our patients with haemophilia A and vWD (aged 1-21years, median 8) showed no signs of HAV infection. 92 patientswere negative for both HAV IgG and HAV IgM. In 3 patientspositive for HAV IgG, 1 (5 months old when first investigated) withpassive maternal HAV IgG antibodies showed a decreasing IgGtitre and became negative. In the other 2 patients, from Pakistan andYugoslavia, HAV infection occurred before the initial substitutionwith FVIII I and had affected all members of both families. These 3

patients were also HAV IgM negative. As age-related controls, weinvestigated 61 children admitted for elective surgery and patientswith coagulation disorders requiring no substitution. 3 controlswere positive for HAV IgG, with no detectable HAV IgM.The prevalence of HAV IgG in patients treated with pasteurised

FVIII concentrates (3-16%) was similar to controls (4-92%) andmuch lower than that of corresponding Italian investigations.3 Nohepatitis A seroconversion occurred after treatment with

pasteurised factor VIII concentrates. Pasteurisation thereforeseems to be a secure method to prevent HAV infection. Accordingto the "rule of three" our data show the statistical risk oftransmission of HAV by pasteurised FVIII concentrates to bebetween 0 and 3%.

Centre of Paediatrics,Department of Haematology and-Oncology,Klinikum der Johann Wolfgang Goethe Universitat,D-6000 Frankfurt am Main, Germany

W. KREUZD. KLARMANN

Prof Hess-Kinderklinik, Bremen G. AUERSWALD

Centre of Pediatrics, Universitatskliniken Munchen K. AUBERGER

Max von Pettenkofer Institut, Munchen L. GÜRTLER

Department of Medical Virology,Klinikum der J W Goethe Universitat, Frankfurt

H. RABENAUW. D. DOERR

1. Mannucci PM for Medical-Scientific Committee, Fondazione dell’Emofilia.Outbreak of hepatitis A among Italian patients with haemophilia. Lancet 1992; 339:819.

2. Hewimburger N, Schwinn H, Gratz G et al. Faktor-VIII-Konzentrat, hochgereinigtund in Lösung erhitzt. Drug Res 1981; 31: 619-22.

3. Scaraggi FA, Perricci A, Petronelli M, et al. Prevalence of serum IgG antibodies tohepatitis A virus in Italian hemophiliacs. Lancet 1992; 339: 1486-87.

Pseudomeningitis: how clean arepre-cleaned slides?

SIR,-Pseudomeningitis may be defined as the false-positivefinding of microorganisms in the cerebrospinal fluid (CSF) ofpatients with symptoms suggesting meningitis. Over 5 weeks, weobserved spurious gram-stain results in 10 out of 42 CSF specimenssubmitted for culture. Smears of each of the specimens revealedgram-negative rods that could not be isolated from the

corresponding cultures. The first case occurred in a 42-year-oldman with an infected ventricular drain. The CSF leucocyte countwas 400/)jJL and CSF analysis included glucose of 1 mmol/L andprotein of 0 96 g/L. Correct diagnosis and appropriate treatmentwere delayed: the actual pathogen (Staphylococcus epidermidis)isolated from the enrichment broth was initially disregarded as acontaminant and correct antibiotic therapy was not started until

447

reisolation of S epidermidis from a second CSF specimen 7 dayslater. Being aware of the possibility of pseudomeningitis, weconsidered the presence of gram-negative rods in the other CSFspecimens as unreliable. No therapeutic decisions were made on thebasis of these results.Review of laboratory procedures pinpointed the lot of glass-slides

in use at that time as the source of the spurious gram-staining.Gram-stained slides of the implicated packs (Menzel-Gliizer,Germany) revealed organisms similar to those seen in the clinicalspecimens, in at least 1 of every 20 oil-immersion fields. When theslides were rinsed in alcohol and dried with a gauze, no organismcould be detected. Cultures of the surfaces of the slides yielded nogrowth. We concluded that the presence of non-viable bacteria onthe slides was responsible for the false-positive. The slides we usedhad been stored according to the manufacturer’s instructions.Concerned about this finding, we surveyed by telephone 58

laboratories in Belgium and the Netherlands. When staining CSFspecimens, 34 (59%) of our colleagues use "pre-cleaned" slides onthe (unproven) assumption that these slides are free of bacteria. 15(26%) "flame" the slides before use and only 5 (9%) rinse the slideswith alcohol and wipe them dry with a gauze. Surprisingly, 13(22%) mentioned false-positive results, which they attributed to theglass-slides. To our knowledge, glass-slides do not meet pre-defined quality standards. Manuals on quality assurance in medicalmicrobiology do not mention them.1-3 Guidelines from the

European Council for Clinical and Laboratory Standardizationshould include requirements for slides designed for diagnosticmicroscopy.

Department of Medical Microbiology,University Hospital Maastricht,6200 AZ Maastricht, Netherlands

J. A. JACOBSE. E. STOBBERINGH

1. European Committee for Clinical Laboratory Standards. Standards of qualityassurance part 2: internal quality control in microbiology. ECCLS document 2/4,1985.

2. Weissfeld AS, Cumitech A. Quality control and quality assurance practices in clinicalmicrobiology. Washington, DC: American Society for Microbiology, 1990.

3. Snell JS, Farrell ID, Roberts C, eds. Quality control: principles and practice in themicrobiology laboratory. London: Public Health Laboratory Service, 1991.

Zoster after shiatsu massage

SIR,-A 64-year-old woman was seen in the emergency room forsuspected myocardial infarction. Symptoms included chest painradiating from back to front and into the upper left arm. 3 daysearlier she had ended an overly vigorous shiatsu massage that causedpain in the left peri-cervical and suprascapular areas. 7 hours latersoreness persisted, followed by paresthesias in the left chest, back,and upper arm. The morning after the massage she had fingerstiffness and numbness along the ulnar edge of the left forearm.Investigation for infarction was negative, but radiating painssubsequently progressed and became excruciating. On the morningof the sixth day after the massage she awoke with a rash in the numbarea. Her doctor administered intramuscular methylprednisoloneacetate. Over the next several hours the rash spread to the upperarea, shoulder, and back. She was seen by us 7 days after themassage, at which time she had typical vesicular zoster along the lefteighth cervical dermatome, from the mid back to the heel of thepalm. She recounted an extremely severe case of varicella at age 11,requiring a week in hospital and a week of convalescence. Tzanckpreparations of two lesions were both positive. Mixed vesical fluidsand dermal scrapings inoculated directly onto WI-38 cells yieldedtypical cytopathic effect, with indirect fluorescent antibodyconfirmation of varicella zoster virus.

Though possibly coincidental, a causal link between shiatsumassage and zoster is supported by the patient’s claim of

massage-induced neck trauma, and by the temporal relationbetween trauma and onset of symptoms that progressed to zoster.Described by Charcot and Brown-Séquardl in 1859, "traumaticzoster" has long been controversial.2 Enactment of workmen’scompensation laws around the turn of the century promptedpublication of many case reports, but sceptics attributed them tochance.2 The condition is rarely diagnosed today; much of theevidence for its existence in anecdotal.3 Nevertheless, the apparent

clustering of onset of rash at around 3-4 days post-trauma and thepreponderance of right versus left involvement,4 especially incervical dermatomes,3 are otherwise difficult to explain. Wespeculate that in our patient zoster resulted from either directtrauma to the nerve or nerve root during the massage, or tosubsequent tissue inflammation causing swelling or immunologicalinjury to the nerve.

Preventive Medicine Service,Tripler Army Medical Center,Honolulu, Hawaii ALAN H. MUMM

Department of Tropical Medicineand Medical Microbiology,

School of Medicine,University of Hawaii,Honolulu, Hawaii 96816, US

DAVID M. MORENS

JOE L. ELMARWIND R. DIWAN

1. Charcot JM, Brown-Séquard E. Note sur quelques cas d’affection de la peaudédendant d’une influence du système nerveux. Suivie de remarques sur le moded’influence du système nerveux sur la nutrition III: Névralgie consécutive à unelesion traumatique et accompagnée d’une éruption de vésicules d’herpès.J Physiolog L’Homme Animaux 1859; 2: 108-13.

2. Thibierge G. Sur le zona traumatique. Gazette Hôpitaux Civils Militaires (LancetteFrancaise) 1923; 96: 1555-58.

3. Juel-Jensen BE. The natural history of shingles: events associated with reactivitation ofvaricella-zoster virus. J R Coll Gen Pract 1970; 20: 323-37.

4. Wilson JB. Thirty one years of herpes zoster in a rural practice. BMJ 1986; 293:1349-51.

PCR identification of Helicobacter pylori infaeces from gastritis patients

SiR,—The mode of transmission of Helicobacter pylori iscontroversial. Epidemiological data suggest an oral-oral or faecal-oral routed The organism has only recently been cultured from thefaeces of paediatric patients from The Gambia2 and has not yet beendemonstrated in the stools of adults in the UK. We used a validated

polymerase chain reaction (PCR)3 to detect H pylori DNA in thefaeces of patients with gastritis.

Faeces was collected from patients with dyspepsia. 75 L of a 1 / 1faeces/water mixture was ertracted.3 1 L of the resulting DNAsolution was used as the template for PCR which was single-stepwith primers specific for the 16S ribosomal RNA gene of H pylori.The sensitivity and specificity of the test was as before. H pyloriDNA was indicated by a 109 basepair amplified fragment.Water controls were used to detect contamination during DNA

extraction. All patients were classified as having H pylori gastritis ornormal stomachs by a gastric antral biopsy. Of 42 patientsexamined, 31 had helicobacter gastritis and 11 had normal gastricbiopsy specimens. Of the 31 patients with gastritis, 28 (90%) hadpositive stool samples. None of the 11 patients with normal gastricbiopsy samples had positive stool samples.Our results show that the DNA of H pylori can be detected with

high sensitivity and specificity of the faeces of patients withdyspepsia. The difficulty in culturing H pylori from faeces may bebecause many of the bacteria are in their coccoid form. This form ofthe organism has not yet been cultured. Our PCR test can detectDNA from the coccoid form.3The idea of a faecal PCR test for H pylori is attractive. A faecal

test would be non-invasive, potentially rapid (results could beobtained within 48 hours), and cheap. Potential uses would be inscreening for an open-access endoscopy unit or as an

epidemiological tool.

Centre for Digestive Diseases,General Infirmary at Leeds,Leeds LS1 3EX, UK,and Department of Microbiology,

Bradford Royal Infirmary

N. P. MAPSTONE D. A. F. LYNCHF. A. LEWIS A. T. R. AXOND. S. TOMPKINS M. F. DIXON

P. QUIRKE

1. Graham DY, Malaty HM, Evans DG, Evans DJ, Klein PD, Adam E. Epidemiologyof Helicobacter pylori in an asymptomatic population in the United States: effect ofage, race, and socioeconomic status. Gastroenterology 1991; 100: 1495-501.

2. Thomas J, Gibson G, Darboe M, Dale A, Weaver L. Isolation of Helicobacter pylorifrom human faeces. Lancet 1992; 340: 1194-95.

3. Ho A, Hoyle J, Lewis FA, et al. Direct polymerase chain reaction test for detection ofHelicobacter pylori in humans and animals. J Clin Microbiol 1991; 29: 2543-49.

4. Catrenich CE, Makin KM. Characterization of the morphologic conversion ofHelicobacter pylori from bacillary to coccoid forms. Scand J Gastroenterol 1991; 181(suppl): 58-64.