Document 6wyzn5pxkm2rX5Q4o22Y70Gw6

-S*iP papers. of acute or chronic infection. Broad The concepts of central control of ly speaking, two categories seem to diaphragm are well supported by the be involved: substantial bacteremia case reports of Dr Korczyn. However, from infections of lung, kidney, skin, we preferred the other more accepted and other foci of acute infection, and entity, viz, phrenic nerve palsy, to ex surgical or dental manipulations, such plain our findings. as abdominal surgery, genitourinary Balu H. Atmaeya, MO SftINIVAS PmASAD. MO Children's Seeshore House Atlantic City. NJ 1. Koresyn AD, Leibowitx U, Brudermsn I: Involve ment of the diaphragm in hemiplegia. Neurology 1937- procedures, and periodontal and exodontal surgery. We are taking this means to sug gest that all patients who have had total joint replacement, particularly 100, 1069. 2. Korczyn AD: Respiratory and cardiac abnormalities in brainstem ischaemia. J Neurol Neuroevrg Psychiatry those at high risk of infection (patients with rheumatoid arthritis, 3$: 187-190, 1975. on continual corticosteroid dosage or immunosuppressive medication, and Iron-Deficiency Pruritis with debilitating diseases including malignant neoplasms) be promptly To the Editor.-I read the article ''Pruritus: A Manifestation of Iron Deficiency" (2362319, 1976) and would like to draw attention to work on iron deficiency and generalized pruritus dating back to 1967. Then Sneddon and Garretts' described the relationship between itching and iron deficiency. Also, in 1972 Rook, Wilkinson, and Ebling2 described this condition, and in 1974 I published a paper1 describ ing the relationship of iron deficiency and vigorously treated with appropri ate antibiotics for any acute infec tious process of bacterial origin. We also suggest that they receive prophy lactic antibiotics before, during, and after any surgical or dental manipu lation that can produce a substantial bacteremia. Mark Q. Lazansky MO J. Pmluf nelson, ME) Mas s. Ettekhar, MO Col John Femm. mc. USA J. Drennan Loweu.. MD Edward Mhxer, MO NRW York to generalized pruritus in 87 patients. I would entirely agree with your authors but would disagree that this condition has not been described. Late Effects of Botulinum Intoxication C. F. H. VICKERS. MO. FRCP Liverpool Royal Infirmary Univarsity of Liverpool Liverpool, England To the Editor.~MX.eT reading the ar ticle by Barker et al (237:456,1977) re garding the outbreak of botulism and L Sneddon 16, Garretts M: The significance of low se rum iron levels in the causation of itching. Proe 12th Int Congress Dermatol, Munich 2:1061-3063, 1967. 2. Rook A. Wilkinson DS, Ebling FJG: Textbook ofD*r> matology. Oxford, England, Blackwell Scientific Publica tions, ed 2, 1972. 3. Vickers CFH: Nutrition and the skin: Iron defi ciency in dermatology. Proceedings of Tenth Symposium os Advanced Medicine. London, Royal College of Physi cians, 1974, 311-315. the subsequent management of the involved patients, we had occasion to examine their case 1 3)4 years after his intoxication. He was seen because of persistent fatigue, intermittent di plopia, and decreased sexual ability. Prior to the patient's botulism intoxi cation, he was physically and sexually active fer his age; subsequent to this, Infection and Total Joint Replacement although not incapacitating, these symptoms remain substantially dis tressing and have resulted in multiple To the Editor.-Total joint replace consultations with different special ment, particularly of the hip, is ists. rapidly becoming one of the more Barker et al reported good, immedi commonly performed orthopaedic sur ate response to the trivalent botu gical procedures. Deep infection, in lism antitoxin and further commented volving the prosthetic devices and that all cases of intoxication returned their anchoring acrylic cement, is the to normal after a few weeks. Al greatest threat to the success of these i though this is usually the case with operations. botulism intoxication, we believe it is We have observed, from our own quite easy to overlook, at times, the experience and the reports of others, subtle disturbances that may persist that a small but substantial propor but are not incapacitating. Chering- tion of the late postoperative infec ton' notes, for example, that recovery tions, that is, those becoming appar may be prolonged but nearly total in ent several months to several years all patients. Other authors- have after surgery', can be attributed to he noted pathological fatigability in matogenous seeding of the prosthetic long-term survivors of botulism in joint from distant primary sources toxication. Sexual dysfunction, al- We would like to emphasize that despite the fact that most patients subsequently do have a normal gen eral physical examination, important symptomatic complaints may persist, as noted in the aforementioned case and others. Joseph C. Maroon, md Presbyterian-University Hospital David Bissonctti Univarsity of Pittsburgh Pittsburgh 1. Cherington M: Botulism; Ten-year experience. Arch Neurol 30:432-437. 1974. 2. Rayn DW, Cherington M: Human type A botulism. JAMA 216*18-514, 1971. 3. Jeoser G, et al: Autonomic dysfunction in botulism B: A clinical report Nentol 25:160*153,1975. Laryngeal Coccidioidomycosis To the -Editor.--Platt (237:1234, 1977) is indeed correct that Coccidwides immitis is seldom recognized as a cause of pathogenic conditions of the upper respiratory tract. However, his asser tion that there are only two other published reports of coccidioidomyco sis of the upper respiratory tract, one of endolaryngeal and the other of epiglottic involvement, is erroneous. Oliver1 described a case of coccidioi domycosis in a 34-year-old man, in volving nose, left hand, left index fin ger, larynx, and epiglottis. Biopsy of cutaneous as well as laryngeal and epiglottic lesions was positive for C immitis. JataS. Ghosh, MS Ardmore, Pa 1. Oliver EA: Coccidioidomycosis with cutaneous in volvement. AMA Arch Dermatol Syphilol 70*37-338. 1954. _ Considerations on Etiologic Factors in Meat Wrappers' Asthma To the Editor.--A. recent letter (237:1826, 1977) reports interesting clinical and respiratory-function find ings in meat wrappers and a nonex- ^ posed control population. ^ Irritative respiratory symptoms and the meat wrappers' asthma syn- ^ drome have generally been thought to be etiologically related to decomposi- Op tion products of polyvinyl chloride (PVC), such as hydrochloric acid , and/or minute amounts of phosgene,~ and not, to PVC itself or to the mono mer vinyl chloride. The distinction is important to avoid confusion, especially since dif ferent mechanisms seem to be in volved. Ruth Uus. MD Mount Sinai School of Medicine of the City University of New York New York JAMA, July 11, 1977-Vol 238, No. 2 -------------- _ BFG219SS Letters 12S