Giostra, Emilio

Pascual, Manuel

Perrin, Luc

Schifferli, Jürg A.

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110 1990;162 (August) Correspondence 569washing and wearing gowns and gloves are important infection con-trol measures, whereas the aerosol dissemination of influenza virusnecessitates masks to prevent spread. A large prospective study usingviral cultures as well as serology is needed to assess more accuratelythe scope of this problem in older persons.Ann R. Falsey, Edward E. Walsh, and Robert F. BettsDepartments of Infectious Diseases, Medicine, and Pediatrics, InfectiousDisease Unit, University of Rochester School ofMedicine and Dentistry, New lVrkReferences1. Chanock RM, Parrot RH. Acute respiratory disease in infancy and child-hood: present understanding and prospects for prevention. Pediatrics1965;6:21-392. Johnson KM, Bloom HH, Mufson MA, Chanock RM. Natural reinfec-tion ofadults by respiratory syncytial virus: possible relation to mildupper respiratory diseases. N Engl J Med 1962;267:68-713. Finger R, Anderson JT, Dicker RC, Harrison B, Doan R, Downing A,Corey L. Epidemic infections caused by respiratory syncytial virusin institutionalized young adults. J Infect Dis 1987;155:1335-1339Hepatitis C Virus in Patients withCryoglobulinemia Type IICOLLEAGUES-The association between cryoglobulinemia and hep-atitis B virus (HBV) infection has been described [1]. Cryoglobulinshave been found in 6%-43 % ofpatients with chronic liver diseases,whether or not the liver disease was due to HBV [2]. Such cryoglobu-lins are most often of the mixed type without a monoclonal compo-nent [3]. This association is even stronger when the analysis isreversed: Two-thirds of patients with mixed essential cryoglobulin-emia have a liver disease or abnormalities in liver function tests [1,2]. Type IT cryoglobulinemia is characterized by the presence in thecryoprecipitate of a monoclonal immunoglobulin that binds t9 Fcportions of polyclonal IgG; most often this monoclonal componentis an IgMK. Ofthose with this type ofcryoglobulinemia, >50% havesome liver disease, including cryptogenic chronic hepatitis or HBV~hronic hepatitis [1, 2]. Although this high incidence has not beenfound everywhere [1], the association between chronic liver diseaseand cryoglobulins of type IT is unlikely to be fortuitous.Serologic markers for HBV and hepatitis C virus (HCV) antibod-ies [4] were measured in 10 patients with cryoglobulinemia type' IT(all: IgMK/polyclonal IgG). Six patients had positive markers forhepatitis B, and three had HCV antibodies detected by enzyme-linkedimmunosorbent assay (Ortho HCV ELISA; Ortho Pharmaceutical,Raritan, NJ; optical density at 490 om: 1.7, 1.02, and >2 for a cutoffof 0.45.Reprints and correspondence: Dr. J. A. Schitferli, Department of Medi-cine, Hopital Cantonal Universitaire, 24, rue Micheli-du-Crest, 1211 Geneva4, Switzerland.The Journal of Infectious Diseases 1990;162:569-570© 1990 by The University of Chicago. All rights reserved.0022-1899/90/6202-0048$01.004. Englund JA, Sullivan CJ, Jordan C, Dehner LP, Vercellotti GM, Bal-four HH. Respiratory syncytial virus infection in immunocompromisedadults. Ann Intern Med 1988;1:203-2085. Levenswon RM, Kanter OS. Fatal pneumonia in an adult due to respira-tory syncytial virus. Arch Intern Med 1987;147:791-7926. Garvie DG, Gray 1. Outbreak of respiratory syncytial virus infectionin the elderly. Br Med J 1980;281:1253-12547. Hart JC. An outbreak of respiratory syncytial virus infection in an oldpeople's home. J Infect 1984;8:259-2618. Sorvillo FJ, Huie SF, Strassburg MA, Butsumyo A, Shandra WX, Fan-nin SL. An outbreak of respiratory syncytial virus pneumonia in anursing home for the elderly. J Infect 1984;9:252-2569. Hendry MR, Bums JC, Walsh EE, Graham BS, Wright PF, HemmingVG, Rodriguez WI, Kim HW, Prince GA, McIntosh K, Chanock RM,Murphy BR. Strain-specific serum antibody responses in infants un-dergoing primary infection with respiratory syncytial virus. J InfectDis 1988;157:640-64710. Mathur U, Bentley OW, Hall CB. Concurrent respiratory syncytial vi-rus and influenza A infections in the institutionalized elderly and chron-ically ill. Ann Intern Med 1980;93:49-52Only 1 of3 patients with antibodies to HCV had hepatitis B mark-ers: a 33-year-old man with a history ofdrug addiction. He had an-tibodies to hepatitis B surface antigen (HBsAg) but was negative forHBsAg. He had moderately elevated transaminases, and liver bi-opsy showed chronic fibrosing hepatitis with a negative stain for hep-atitis B core antigen by immunofluorescence. The most likelydiagnosis was chronic HCV hepatitis [5].The second patient, a 44-year-old man, had membranoprolifera-tive glomerulonephritis, which was treated successfully with steroidsand cyclophosphamide, and persistently elevated transaminase lev-els of 4 years duration. He declined liver biopsy. The last patientwas 68 years old and, except for purpura, had no complaints. Liverfunction tests showed a slight increase in -y-glutamyltransferase (59units/I; normal, <42 units/I) and alkaline phosphatase (131 units/I;normal, <125 units/I); however, transaminases were normal.Although the number of patients is small, our observation sug-. gests an association between HCV and cryoglobulinemia type II.The emergence of a monoclonal rheumatoid factor has been linkedto chronic viral infection (Epstein-Barr virus [6], HBV [1]), whichmight participate in the activation process leading to the uncontrolledproliferation of a B cell clone. Hepatitis C virus may have a similareffect.Manuel Pascual, Luc Perrin, Emilio Giostra,and Jjjrg A. SchifferliDepartment of Medicine, Hopital Cantonal Universitaire,Geneva, SwitzerlandReferences1. Montagnino G. Reappraisal of the clinical expression of mixedcryoglobulinaemia. Springer Semin Immunopathol 1988;10:1-192. Zarski JP, Rougier 0, Aubert H, Renversez IC, Cordonnier 0, StroebnerP, Rachail M. Association cryoglobuline et maladie hepatique: fre-570 Correspondence JID 1990;162 (August)quence, nature et caracteres immuno-chimiques de la cryoglobulinemie.Gastroenterol Clin BioI 1984;8:845-8503. Garcia-Bragado F, Biosca M, Villar M, de la Figuera M, Rodrigo MJ,Vilardell M. Maladie hepatiques et cryoglobulinemie mixte. Gastroen-terol Clin BioI 1985;9:456-4574. Choo QL, Kuo G, Weiner AJ, Overby LR, Bradley DW, Houghton M.Isolation of a cDNA clone derived from blood-borne non-A, non-Bviral hepatitis genome. Science 1989;244:359-362Campylobacter jejuni versus Campylobacter coli inDeveloping Countries: How Accurate ArePrevalence &timates?COLLEAGUES - Campylobacter species are an important cause of in-fectious diarrhea, especially endemic diarrhea among children ofdeveloping countries and adults traveling to these areas. BecauseCampylobacter coli is generally thought to occur in <5 % of humanCampylobacter infections, most clinical laboratories do not attemptto distinguish between C. coli and Campylobacter jejuni [1]. Un-speciated Campylobacter isolates from diarrhea surveys are com-monly reported as "Campylobacter spp.,""C. jejuni/coli," or simply"Co jejuni." As a result, the frequency of C. coli infections and itsrelative importance as a diarrheal agent are unknown for many areasof the world.During 1984-1989, 513 diarrheic and 379 nondiarrheic stool spec-imens from adult US citizens living in or visiting Lima, Peru, weretested for presence of Campylobacter and other common bacterialenteropathogens. On the whole, Campylobacter organisms were aless important cause ofdiarrhea than anticipated, being isolated from6.1%of cases and 2.1%of controls, accounting for only 17%of allInformed consent was obtained from participants; the US Navy's guide-lines for use of human subjects were followed.The opinions and assertions contained herein are the private ones of theauthors and are not to be construed as official or reflecting the views of theUS or Peruvian Navy Departments.Financial support: US Naval Medical Research and Development Com-mand (6277OA 3M162770.A870.AR-522, 61l02A 3M161l02.BS13.AK-51l);Surgeon General's Office of the Peruvian Navy.Correspondence: LCDR G. Pazzaglia, MSC, USN, NAMRID, APO Mi-ami, FL 34031. Reprints: Editorial Assistant, NAMRID, APO Miami, FL34031.The Journal of Infectious Diseases 1990;162:570This article is in the public domain.0022-1899/90/6202-00495. Alter HJ, Purcell RH, Shih JW, Melpolder JC, Houghton M, Choo QL,Kuo G. Detection ofantibody to hepatitis C virus in prospectively fol-lowed transfusion recipients with acute and chronic non-A, non-B hep-atitis. N Engl J Med 1989;321:1494-15006. Fiorini GF, Sinico RA, Winearls C, Custode P, De Guili-Morghen C,Di\mico G. Persistent Epstein-Barr virus infection in patients with typeII essential mixed cryoglobulinaemia. Clin Immunol Immunopathol1988;47:262-269enteropathogens isolated from patients with diarrhea. Campylobac-ter isolates were speciated according to their ability to hydrolyzehippurate [1). The isolation frequency for C. jejuni was 2.5% fromstools ofdiarrheic individuals and 1.3%from control stools. C. coli,however, was less frequently isolated from cases (0.8 %) than fromcontrols (1.6%), suggesting C jejuni may be the only important causeof Campylobacter-associated diarrhea in adult travelers to Peru. Fur-thermore, because 36% of Campylobacter isolates were C. coli, thetrue frequency of C. jejuni-associated diarrhea could have been over-estimated by 144% if it had been assumed that most isolates wereC. jejuni.These limited results indicate American adults living in or travelingto Peru are at relatively low risk of developing Campylobacter-associated diarrhea. Not surprisingly, most of the risk is attributableto C. jejuni. However, the high proportion of C. coli isolates amongall Campylobacter species isolated suggests that infection or tran-sient colonization by this organism may be much more common inmany areas of the world than previously considered. For Peru andother countries where C. coli is prevalent, the unexpectedly highproportion of C. coli among all Campylobacter isolates could leadto inflated estimates of the relative importance of C. jejuni if eachspecies is not considered separately. To establish whether thisphenomenon occurs in other geographic regions, we encourage di-arrheal disease investigators to report Campylobacter isolates ac-cording to species.G. Pazzaglia, R. Batchelor, J. Escamilla,M. Bernal, and G. NunezDepartment of Bacteriology and Epidemiology, United States Naval.Medical Research Institute Detachment, Lima, Peru \~Reference1. Morris GK, Patton CM. Campylobacter. In: Lennette EH, ed. Manualof clinical microbiology. 4th ed. Washington, DC: American Societyfor Microbiology, 1985

Hepatitis C Virus in Patients with Cryoglobulinemia Type II

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