Mullish, BH

New England Journal of Medicine

English

Spiral - Imperial College Digital Repository

T h e  n e w  e ngl a nd  j o u r na l  o f  m e dic i n en engl j med 371;19 nejm.org november 6, 201418481. Greinacher A, Friesecke S, Abel P, et al. Treatment of severe neurological deficits with IgG depletion through immunoad-sorption in patients with Escherichia coli O104:H4-associated haemolytic uraemic syndrome: a prospective trial. Lancet 2011; 378:1166-73.2. Cornec-Le Gall E, Delmas Y, De Parscau L, et al. Adult-onset eculizumab-resistant hemolytic uremic syndrome associated with cobalamin C deficiency. Am J Kidney Dis 2014;63:119-23.DOI: 10.1056/NEJMc1410951Case 25-2014: A Man with Ulcerative Colitis and Bloody DiarrheaTo the Editor: The Case Record contributed by Hohmann et al. (Aug. 14 issue),1 regarding a man with ulcerative colitis in whom bloody diarrhea developed soon after fecal microbiota transplan-tation (FMT), highlights the difficulty in distin-guishing cytomegalovirus (CMV) as a direct cause of disease from its being an “innocent by-stander” in patients with CMV infection and ac-tive ulcerative colitis. However, the authors also reported an apparent case of diarrheal disease caused by Blastocystis hominis transmitted by means of FMT without describing the complex debate as to whether this organism is a true en-teropathogen. In developed countries, blastocystis is detect-able in more than 50% of healthy persons with the use of polymerase-chain-reaction–based as-says.2 No difference in the prevalence of blasto-cystis exists between hosts with gastrointestinal symptoms and those without such symptoms,3 and symptoms that are attributed to blastocystis infection may not improve even after the elimi-nation of the organism.4 The organism has been shown to be capable of both long-term coloniza-tion2 and spontaneous disappearance without intervention.4,5 Physicians offering FMT should carefully monitor FMT recipients for infectious complications but must be aware that presence is not the same as causation.Benjamin H. Mullish, M.B., B.Chir.Imperial College London London, United Kingdom b.mullish@imperial.ac.ukNo potential conflict of interest relevant to this letter was re-ported.1. Case Records of the Massachusetts General Hospital (Case 25-2014). N Engl J Med 2014;371:668-75.2. Scanlan PD, Stensvold CR, Rajilić-Stojanović M, et al. The microbial eukaryote Blastocystis is a prevalent and diverse mem-ber of the healthy human gut microbiota. FEMS Microbiol Ecol 2014 July 30 (Epub ahead of print).3. Udkow MP, Markell EK. Blastocystis hominis: prevalence in asymptomatic versus symptomatic hosts. J Infect Dis 1993;168: 242-4.4. Sun T, Katz S, Tanenbaum B, Schenone C. Questionable clinical significance of Blastocystis hominis infection. Am J Gastroenterol 1989;84:1543-7.5. Grossman I, Weiss LM, Simon D, Tanowitz HB, Wittner M. Blastocystis hominis in hospital employees. Am J Gastroenterol 1992;87:729-32.DOI: 10.1056/NEJMc1410949The Discussant Replies: We understand the controversy surrounding B. hominis (an anaerobic protozoan), and the case referenced in the dis-cussion, reported by a Canadian physician, high-lights it nicely. The patient had recurrent Clostrid-ium difficile infection, and the spousal donor, who had no gastrointestinal symptoms, had stool that tested positive for B. hominis (no other donor was readily available). The FMT cured the C. difficile infection, but intermittent loose stools lasting months subsequently developed, with positive tests for blastocystis. A course of nitazoxanide cured the symptoms. At a recent American Gastroenterological As-sociation conference on FMT, physicians noted that blastocystis was a common finding in do-nor stool specimens (e.g., in 6 of 38 specimens that were screened in an Australian study).1 The consensus of practitioners was that it would not be advisable to use such specimens for FMT. At-tendees did not mention other cases of trans-mission of infectious agents by FMT. Represen-tatives of the Food and Drug Administration highlighted the possibility of transmission of currently unknown infectious agents and the need for judicious use and careful follow-up of recipients of FMT.The New England Journal of Medicine Downloaded from nejm.org at IMPERIAL COLLEGE LONDON on September 25, 2015. For personal use only. No other uses without permission.  Copyright © 2014 Massachusetts Medical Society. All rights reserved. correspondencen engl j med 371;19 nejm.org november 6, 2014 1849Elizabeth L. Hohmann, M.D.Massachusetts General HospitalBoston, MAehohmann@partners.orgSince publication of her article, the author reports no further potential conflict of interest.1. Paramsothy S, Borody T, Lin E, et al. Obstacles to donor recruitment for fecal microbiota transplantation: experiences from the FOCUS Study. Presented at Therapeutic Innovations in Microbiome Research and Technology AGA Freston Conference, Chicago, August 13–14, 2014.DOI: 10.1056/NEJMc1410949 Catheterization of the Urethra in GirlsTo the Editor: As Manzano et al. noted in their Video in Clinical Medicine (July 10 issue),1 it is sometimes difficult for the examiner to identify the urethral meatus when attempting to perform catheterization of the urinary bladder in girls. In such instances, it may be helpful to draw the la-bial tissue upward by moving the nondominant hand anteriorly after spreading the labia majora with two fingers.2If the meatus remains hard to visualize, we suggest enlisting an assistant for the following maneuver, which we term “labial lift.” Both the examiner and the assistant should gently grasp one of the labia majora — the examiner on the side of her nondominant hand and the assistant opposite. Together, they lift the labia anteriorly, laterally, and caudad (Fig. 1). As shown in the figure, using the corner of a small piece of ster-ile gauze helps to maintain a comfortable hold on the labia, which may become slippery after sterile preparation. We have found that this technique seldom fails to allow the necessary visualization of the meatus.Mark A. Faasse, M.D., M.P.H.Max Maizels, M.D.Ann and Robert H. Lurie Children’s Hospital of ChicagoChicago, ILmfaasse@luriechildrens.orgNo potential conflict of interest relevant to this letter was re-ported.1. Manzano S, Vunda A, Schneider F, Vandertuin L, Lacroix LE. Videos in clinical medicine: catheterization of the urethra in girls. N Engl J Med 2014;371(2):e2.2. Cartwright PC, Wallis MC. Office procedures. In: Palmer JS, ed. Current clinical urology: pediatric urology. New York: Hu-mana Press, 2011:127-40.DOI: 10.1056/NEJMc1410733The authors reply: This is a very nice alterna-tive to the use of downward traction to the ceph-Figure 1. Labial Lift to Expose the Urethral Meatus in Girls.The examiner gently grasps the labium majus on the side of her nondominant hand, while the assistant does so on the opposite side. Together, the labia are lifted anteriorly, laterally, and caudad to allow visualization of the urethral meatus.Figure 1. Downward Traction of the Vaginal Mucosa.The examiner localizes the meatus by gently pulling the cephalad fold of the vaginal introitus downward.The New England Journal of Medicine Downloaded from nejm.org at IMPERIAL COLLEGE LONDON on September 25, 2015. For personal use only. No other uses without permission.  Copyright © 2014 Massachusetts Medical Society. All rights reserved. 

Case 25-2014: A man with ulcerative colitis and bloody diarrhea.

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Case 25-2014: A man with ulcerative colitis and bloody diarrhea.

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