Toxoplasmosis is a common and widely distributed infection, especially in warm moist climates. This is shown by the high incidence of positive serological tests found in appropriate surveys. The purpose of this paper is to describe three cases of toxoplasma lymphadenopathy in order to draw attention to a condition which must be commoner in Malta than is generally supposed. Three young adults have been diagnosed as suffering from toxoplasma lymphadenopathy within the past year. The condition is not diagnosed as frequently as it ought to be. Though it is on the whole uncommon, it should become increasingly recognised in future, in this way helping to reduce the number of obscure cases of lymphadenopathy. It has been estimated that some 7% of cases of lymphadenopathy clinically diagnosed as glandular fever but giving a negative Paul-Bunnell test will be accounted for by toxoplasmosis.peer-reviewe

Attard, Raphael

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above, but he covers the grafts with a pressure dressing. No claim to priority is made for the technique we describe, particularly as our search of the literature has been incom-plete. However, it is presented as a well tried and tested method which seek to follow principles that have proved their worth in the treatment of burns. Acknowledgement We wish to thank Mr. W. D. C. Pad-field of the "3 M Company" for reprints of the literature. References CLARKSO:-l, P. (1963). Brit. ]. Surg 50, 457· 5 COPELAND, W.P. (1887). Med. Rec., May. FlSCHL, R.A. (1965). Brit. ]. Plast. Surg. 18, 435. GABARRO, P. (1943). Brit. med. ]. I, 723. GOLDE:-I, T. (1960). Amer. ]. Surg. 100, 789. HAAS, S.V. (1915). Amer. ]. Surg. 29, 61. HORTON, R.E. and DUFFW, G.M. (1965). Practi-tioner, 195, 654-LOWBURY, E.] .L., MILLER, R.W-.S., CASO:-l, ] .S. and ]ACKSO:-l, D.M. (1962). Lancet. 2, 958. MURRAY, P.].B. (1963). Brit. med. ]. 2, 1030. REESE, ].D. (1946). Plast. reconstr. Surg. I, 98. ROTHNIE, N.G. and TAYLOR, G.W. (1963). Brit. med. J. 2, 1027. SHEPHERD, M.P. (1966). Bd. ]. Surg. 53, 445· SKOOG, T. (1963). Acta Chir. Scand. 126. S:-IEVE, H. (1905). ]. Amer. med. Ass. 45, I. \\'ALLACE, A.B. (1951). Lancet. I, 501. ZEDERFELDT, B., BRU:-IIUS, U. and AHRE:I, C. (1967.) Bull. Soc. Inter. Chir. 27, 62. TOXOPLASMA LYMPHADENOPATHY R. ATTARD M.D., B.Sc. (MALTA), F.R.C.S. Surgeon, St. Luke's Hospital, Demonstrator in Surgery, Royal University of Malta. Toxoplasmosis is a common and wide-ly distributed infection, especially in warm moist climates. This is shown by the high incidence of positive serological tests found in appropriate surveys. Toxoplasma gondii was described and named by Nicolle and Manceaux who dis-covered it in a North African rodent Ctenodactylus gondi in 1908. It is an obli-gatory intracellular parasite probably be-longing to a species of protozoa and is 3-4 microns by 6-7 microns in size. The mode of spread is still uncertain. First reports of adult toxoplasmosis were pub-lished by Pinkerton and Weinman (1940) and by Pinkerton and Henderson (1941). The only published case from Malta so far is one of ocular toxoplasmosis in a girl of 11 (Damato and Agius Ferrante, 1966). The condition has also been diagnosed in a number of other children (Agius Fer-rante, 1968). The purpose of this paper is to des-cribe three cases of toxoplasma lympha-denopathy in order to draw attention to a condition which must be commoner in Malta than is generally supposed. Case I. G.Z. Case no. 1877/67. This 16 year old boy from Sliema was remitted to the surgical outpatient department of St. Luke's Hospital on 13 September 1967 for enlarged glands in the left side of the neck. The glands had first been noticed four months previously in the lower half of the left posterior triangle of the neck. They were small and beadlike at first but then slowly increased in size. At no time were they painful. He had no other symptoms whatever and there was no re-levant past history. On examination, he appeared to be a healthy boy.. There were moderately enlarged discrete rubbery non-tender glands in the left posterior triangle of the 6 neck presenting as a chain along the pos-terior border of the sternomastoid. An enlarged gland was found in the left sub-mandibular region. Tiny leadshot-sized glands were felt in the right axilla and groins. There was no other abnormality clinically. The investigations were as fol-lows: Hb 14.1 G.; WBC 8800/c.mm; poly-morphs 38%, eosinophils 2%, basophils 2%, lymphocytes 52%, monocytes 6%; Paul-Bunnel~ test negative; ESR 2 mm; Mantoux test negative; chest X-ray clear. On 24 September, excision biopsy of one of the larger cervical glands was car-ried out. The histological report (Prof. G. P. Xuereb) was as follows: "The size of the gland was 2.4 x 1.7 X 1.1 cms. The capsule is thickened and infiltrated by lymphocytes. The basic architecture is retained and the peripheral sinuses are distended. The lymphoid follicles are en-larged, their reaction centres show nuc-lear debris and mitoses. In addition, there are numerous clusters of epithelioid cells scattered in the medulla. There are no giant cells and necrosis is not a feature. The morphology is sufficiently characte-istic to justify provisional diagnosis of toxoplasmosis pending serological confir-mation." The toxoplasma dye test titre on se-rum collected on 13 October was 1/2048. On 25 October, the glands could no longer be felt. Even so, the toxoplasma dye test titre on serum collected on 7 December was still 1/1024. At this time, the patient's fundi were normal and an X-ray of the skull showed no calcifications. Case II. L.A. Case no. 2321/67. This 17 year old schoolgirl from Mqabba was remitted to the surgical outpatient depart-ment of St. Luke's Hospital on 8 November 1967 for cervical lymphadenopathy. She had noticed painful tender swellings in both submandibular regions fifteen days previously. There were no other symptoms and the patient felt quite well. The past history was irrelevant. On examination, she appeared quite healthy. The upper deep cervical groups of glands on both sides were enlarged, slightly tender, discrete and rubbery. There were also a gland in the left axilla and a small one in the right groin. No other abnormality could be found clinical-ly. The investigations were as follows: Hb 13.9 G.; WBC 9500/c.mm; polymorphs 30%, eosinophils 2%, basophils nil, lym-phocytes 66%, monocytes 2%. The report on the Paul-Bunnell test stated that the serum had some natural haemolysin which had made the test impossible to carry out - there were adequate controls and tech-nical errors could therefore be excluded. ESR 5 mm.; Mantoux test negative; chest X-ray clear. The patient was seen a second time on 22 November when, in view of the negative laboratory findings and the dia-gnosis of Case I the previous month, the possibility of toxoplasmosis was consi-dered. Clinically the position was un-changed but the patient refused admission to hospital for biopsy. On 13 December, the cervical glands were mostly unchanged though a new one had appeared in the right submandibular region. She also had glands in both axillae now and small lead-shot-sized ones in the groins. The patient still felt quite well. Further investigations showed the following results: Hb 15.8 G.; WBC 7400/c.mm; polymorphs 58%, eosinophils 2%, basophils nil, lymphocytes 33%, monocytes 7%; ESR 4 mm. The toxoplasma dye test titre on serum taken on 13 December was 1/2048. The patient was examined again on 24 January 1968 when the glands appeared to be much smaller everywhere. The pa-tient once more refused biopsy. The toxo-plasma dye test titre on serum taken on 24 January was 1/1024. At this time, the girl's fundi were normal and no intra-cranial calcifications were seen radiolo-gically. The girl was now started on a 10 day course of penicillin and sulphatriad. On 27 March, her mother came to say that her daughter was very well and had lost all her glands. The patient herself re-fused to attend again. Case Ill. D.A. Case no. 1672/67. This 18 year old lad from Msida was remitted to the surgical outpatient department of St. Luke's Hospital on 16 August 1967 for enlarged inguinal glands. Four months pre-viously he had noticed small swellings in both inguinal regions and one behind the left angle of the jaw. They were painless but slightly tender and enlarged slowly in size. He had no other symptoms what-ever and the past history was irrelevant. On examination, he looked quite healthy. There were moderately enlarged glands in the left groin which were dis-crete, mobile and rubbery. The ones in the right groin were quite small and the one behind the left angle of the mandible was moderately large. There were no other positive clinical findings. The inves-tigations were as follows: Rb 14.9 G.; WBC 10600/c.mm; polymorphs 68%, eosinophils 2%, basophils nil, lymphocytes 26%, monocytes 4%; Paul-Bunnell test negative on two occasions; ESR 3 mm; chest X-ray clear. When he was seen again on 30 August, the glands were distinctly smaller so that the patient only had to be kept under observation from time to time in the outpatient department. The glands continued to decrease in size and in November the one gland still palpable in the left groin was of the size of a pea while the one behind the left angle of the mandible was hardly palpable. When last seen on 24 January 1968, there was prac-tically no change clinically. The toxo-plasma dye test titre on serum taken the same day was 1/512. Discussion Though as already stated toxoplasma infection is widespread, clinical manifes-tations are not so common. The organs that may be affected include those of the reticulo-endothelial system (lymph-nodes, liver, spleen); the lungs; the heart; the musculoskeletal system; the eyes; the skin; the brain (Remington et al., 1960). The brain is affected most often in con-genital cases where radiological examina-tion of the skull may reveal calcifications which are taken as evidence of healed necrotic foci. It is also the site for the chronic form of the disease when the or-ganism is found in the cystic form. Broadly speaking, patients with the acute acquired disease fall into two main groups: 7 a) those with signs of severe gene-ralised infection with involvement of many organs and sometimes ending fatally (O'Reilly, 1954; Remington et al., 1960; Budzilovich, 1961); b) those with lymphadenopathy and mild or no constitutional symptoms and following a benign course. The latter is the commoner manifestation of the disease. Like the three cases described above, many patients with toxoplasma lympha-denopathy have no constitutional symp-toms. Others may complain of feeling off colour, of fatigue, depression, muscle pain, joint pains, with a slight, if any, pyrexia, and occasionally of abdominal pain - pro-bably from toxoplasma mesenteric adeni-tis, as in Desmonts' case (quoted by Be-verley and Beattie, 1958). The cervical glands are most often affected but the axillary and inguinal ones may be involved as well. In cases I and Il, the cervical glands were primarily affected while in case III the inguinal ones were. Clinically, however, there are no definitely diagnostic features. The patients are usually thought to be suffering from glandular fever but the Paul-Bunnell test is always negative as in the above cases. A relative lympho-cytosis was found in half the patients of a series of 30 cases of toxoplasma lympha-denopathy reported by Beverley and Beat-tie (1958). Two of the three cases in the present study showed a relative lympho-cytosis though case Il reverted to the nor-mal pattern in a later blood count. A few cases may show the atypical lymphocytes seen in glandular fever and others may be mildly anaemic. The parasites have rarely been seen in lymph glands but they have been demon-strated by inoculating crusned gland ma-terial intra peritoneally into mice and guinea-pigs which, unlike many other ani-mals, are not affected naturally by toxo-plasma (Cathie, 1954). The parasites have also been isolated from muscle, tonsil, blood and saliva on occasion. In view of these difficulties in demonstrating the toxoplasma, the diagnosis usually rests on the most commonly performed test: the toxoplasma dye test (Sabin and Feldman, 1948). Since the general population shows 8 a high incidence of positive results, low titres are not indicative of active infec-tion. Beverley and Beattie (1958) as well as Harrison (1966) take titres of 1/256 or higher as diagnostic of active infection. Remington et al. (1960) are even stricter and prefer to have titres at least over 1/1000. All the authors agree that the toxoplasma dye test titre falls slowly. Case I had a titre of 1/2048 five months after the glands first began to enlarge and was still 1/1024 two months later when the glands had subsided. Case Il had a titre of 1/2048 two months after the glands began to enlarge and six weeks later was still 1/1024 when the glands were appre-ciably smaller. Case III had a titre of 1/512 but this was nine months after the en-larged glands were first noticed and, by then, they had almost disappeared. So it is reasonable to suppose that the titre would have been even higher during the more acute phase of the disease. Another test, the complement fixa-tion test (Ludham, 1960) becomes positive in the later stages of the disease but the titre falls more quickly than with the toxo-plasma dye test. Harrison (1966) states that the histo-logy is fairly characteristic and suggestive enough to make a provisional diagnosis pending serological tests. The typical fea-tures are the large reactive follicles and small clusters of pale histiocytes or epi-thelioid cells. There are no giant cells and there is no evidence of necrosis or casea-tion. It was the histological report on Case I that started the present trail of discovery. Characteristically, the disease runs a prolonged but benign course with natural remissions. Case I lasted for five months and Case III lasted for about nine months and they both subsided without any treat-ment. Case Il lasted for some five months and though she was treated with penicillin and sulphatriad in the later stages her symptoms would probably have subsided in any case. The usual recommended treat-ment (Beverley and Beattie, 1958) is a combination of a triple sulphonamide IG. four times daily for three to four weeks and pyrimethamine 50mg. daily for two days and then 25mg. daily for three to four weeks. So far, patients in Malta found to be suffering from toxoplasmosis have either been children or young adults in their teens. This corresponds with Beverley and Beattie's (1958) series where 21 of 30 patients with toxoplasma lymphadeno-pathy were below the age of 20. Piringer-Kuchinka (1958) and Saxen (1962) how-ever both state the age-peak to be 25-35 years. Summary Three young adults have been dia-gnosed as suffering from toxoplasma lymphadenopathy within the past year. The condition is not diagnosed as fre-quently as it ought to be. Though it is on the whole uncommon, it should become increasingly recognised in future, in this way helping to reduce the number of ob-scure cases of lymphadenopathy. It has been estimated that some 7% of cases of lymphadenopathy clinicallly diagnosed as glandular fever but giving a negative Paul-Bunnell test will be accounted for by toxoplasmosis (Beverley and Beattie, 1958). Acknowledgements I wish to thank Dr. G. Fleck of the Public Health Laboratory, St. George's Hospital, Tooting Grove, London, S.W.17, for carrying out the toxoplasma dye test titres and Prof. G. P. Xuereb for the his-tology report. References AGrus FERRANTE, T.]. (1968). Personal communi-cation. BEVERLEY, ] .K.A. and BEATTIE, c.P., (1958). Lancet, 2, 379-384' BUDZlLOVICH, G.N. (1961). Amer. ]. Clin. Path. 35, 66. CATHIE, I.A.B (1954)' Lancet, 2, 115· DAMATO, F.]. and AGrus FERRA::\,TE, T.]. (1966). St. Luke's Hosp. Gaz., I, 29. HARRISO::\" C.V. (1966). Recent Advances in Patho-logy, 8th edition, p. 207 (J.A. Churchill). LUDHA~!, G.B. (1960). Proc. roy. Soc. Med. 53, ro8. NICOLLE, C. and MANcEAux, L. (1908). Compt. rend. Acad. d. se., I47, 763. O'REILLY, M.]. (1954)' M. J. Australia, 2, 968. PrXKERTo", H. and HExDE:tso", R.G. (1941). J.A.M.A. II6, 807. PI:\,KERTOX, H. and \YEI:\,l\lA:\,, D. (I940). Arch. Path., 30, 374· PIRINGER-KuCHINKA, A., MARTI:\', 1., and THALHA1\I-,[ER, O. (1958). Virchows Arch. path. Anat., 3P, 522 . 9 REMINGTO:\" J.S., JACOBS, L. and KAUFMA:\,, H.E. (1960). New Engl. J. Med., 262, 180 and 237. SABI:\' , A.B. and FELDMAN, H.A. (1948). Science. I08, 660. SAXEN, L. , SAXE", E. and TE:\,HUXEX, A. ( 1 962) . Acta Path. M:crobiol. Scand., 56, 284. DIABETES MELLlTUS AND PERIODONTAL DISEASE IN MALTA C. OLIVIERI-MUNROE F.D.S. Lecturer, Faculty of Dental Surgery Royal University of Malta In differing parts of the world dis-eases of the teeth and of their sEpporting structures assume roles of varying impor-tance according to prevalence and seve-rity. Although neither as yet can be total-ly prevented or cured the more advanced countries have shown that preventive measures, undertaken energetically, are effective in lowering the incidence of den-tal caries and of periodontal disease. In Malta public dental health and education are still in their infancy. A low incidence of dental caries as compared with some other countries is probably due to naturally occurring fluoride of almost optimal concentration in the water sup-plies. However it has also been shown that the oral soft tissues are attacked early and predispose to the periodontal pathology that is common in the 2.dult pODulation and that presents as the Island's major dental health problem (Olivieri-Munroe, 1968). This has been further confirmed by the fact that after 30 years of age, causes of tooth loss are predominantly periodon-tal (Camilleri, 1966). The aetiology of periodontal disease is complex but primarily extrinsic in na-ture. Neglect of oral hygiene, and forma-tion of supra- or sub-gingival calculus play a large part in its causation. However, the soft tissues of the mouth are in no way unique and are also influenced by systemic factors that can affect the body tissues in general. These include hormonal, dietary and other factors and many have been implicated in the causation of or predispo-sition to periodontal disease, or merely in altering the oral tissues response to local injurv. In this context, the possible role of diabetes mellitus is of great inter-est especially in these Islands where it has been shown that its incidence is high (Zammit Maempel. 1965). The effects of diabetes on the health of the oral cavity have been much debat-ed. Of the more recent investigations, Sandler and Stahl (1960) found a signifi-cantly higher prevalence of periodontal disease in natients with diabetes. Belting et al. (1964) noted that the severity of periodontal disease among diabetic patients was significantly greater than among non-diabetics and concluded that this was an-other manifestation of the peripheral vas-cular occlusive disorders associated with this condition. Stahl et al. (1962) found by gingival biopsy that peripheral vascu-lar changes were to be found, with in-creased thickening of arteriolar walls and decreased lumen size. These findings were confirmed and extended to pre-diabetes by McCullen et al. (1965). Animal experi-ments by Cohen et al. (1966) produced 

Toxoplasma lymphadenopathy

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Toxoplasma lymphadenopathy

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