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Correspondence

THE NATIONAL MEDICAL JOURNAL OF INDIA YOL.2, NO.6

TB v. Crohn's disease

Sir-In the article on Crohn's disease andintestinal tuberculosis, I the role of asciticfluid examination and laparoscopy has notbeen discussed. In tuberculous patientswith ascites, peritoneal tap reveals a clearstraw-coloured exudate with a protein con-centration of more than 25 gIL and a lym-phocyte count exceeding 1000 cells/cmm.-and acid-fast bacilli can be cultured."Laparoscopic peritoneal biopsy may bediagnostic in many cases." At operation,gross caseation in the lymph nodes indicatestuberculosis.

The author recommends therapeuticchallenge as a diagnostic test. He observesthat systemic features such as fevera~or.exia and weight loss subside usuall;within 4 to 6 weeks while bowel symptomstake longer. Anti-tuberculous chemo-therapy for 4 to 6 weeks can alter thehistopathological picture so that differen-tiating tuberculosis from Crohn's diseasebecomes difficult. 4 Chemotherapy ofintestinal tuberculosis may cause obstruc-tive symptoms as healing leads to fibrousnarrowing.> In the report by Tandon andPrakash," 13 out of 39 patients who wereput on chemotherapy after biopsy had toundergo reoperation for obstructivesymptoms. An increased incidence of per-

. foration has also been reported in patientswith intestinal tuberculosis while on anti-tubercular treatment." In our experience,5 out of 13 patients with tubercular per-foration of the small intestine were onanti-tuberculous chemotherapy (un-published data).

The relationship between intestinaltuberculosis and Crohn's disease if anyhas not been touched upon in th~ article:A species of Mycobacteria, M. paratuber-culosis, has recently been isolated frompatients with Crohn's disease and Haddadet at.~ have gone to. the extent of sayingthat m future regional enteritis may belooked upon as a variant of abdominaltuberculosis.5 November 1989 V. K. Kapoor

Department of Surgical GastroenterologySGPGIMS, Lucknow

REFERENCES1 Anand BS. Distinguishing Crohn's disease

from intestinal tuberculosis. Natl Med 1India1989;2:170-5.

2 Udwadia TE. Peritoneoscopy in the diagnosisof abdominal tuberculosis. Indian 1 Surg1978;40:91-5.

3 Singh MM, Bhargava AN, Jain KP. Tuber-

culous peritonitis. An evaluation ofpathogenetic mechanisms, diagnosticprocedures .and therapeutic measures.N Engl 1Med 1969;281:1091-4.

4 Tandon HD, Prakash A. Pathology ofintes-tinal tuberculosis and its distinction fromCrohn's disease. Gut 1972;13:260-9.

5 Schofield PF. Abdominal tuberculosis. Gut1985;26:1275-8.

6 Tabrisky J, Lindstrom RR, Peters R,Lachman RS. Tuberculous enteritis. Reviewof a protean disease. Am 1 Gastroenterol1975;63:49-57.

7 Haddad FS, Ghossain A, Sawaya E, NelsonAR. Abdominal tuberculosis. Dis ColonRectum 1987;30:724-35.

The Widal Test

Sir-We did a prospective study to assessthe value of the Widal test in the diagnosisof typhoid fever in an endemic area. Wealso aimed to determine the factors whichmight influence the results of the test.Serum samples were collected from 500normal healthy individuals who had not had~AB vaccination or fever in the precedingSIX months, 250 bacteriologically provenpatients with typhoid fever and 200 patientswith other febrile illnesses. Isolation ofSalmonella typhi from different clinicalspecimens and the Widal test (tubeagglutination) was performed using thestandard procedures. I Agglutinable sus-pensions of Salmonella typhi, S. paratyphiA and S. paratyhpi B were obtained fromThe Central Research Institute, Kasauli.

Normal healthy individuals had titresbelow 1/80 and 11320 to '0' and 'H'agglutinins respectively. We thereforeconsidered titres of > 1180against the '0'antigen and> 11320against 'H' antigen tobe positive for evaluating the results of theWidal test. Positive Widal results werethus obtained in 86% (215/250) of patientswith typhoid and 5% of those with otherfebrile illnesses. or the 250 patients withbacteriologically proven typhoid fever51% were positive for '0' and 82% for 'H'agglutinins. In the Widal positive group,positive '0' titre alone was present in 3%,'H' alone in 41% and positive titres againstboth '0' and 'H' antigens were present in56%. The Widal test was positive in 5.6%of patients during the first week of their ill-ness, in 50.2% during the second weekand in 44.2% subsequently.

Several workers have expressed seriousdoubts about the reliability of the Widaltest in the serodiagnosis of typhoid fever. 2-5

Some of the factors which contribute tothe unreliability of the Widal test includeth~ use of poorly standardized antigens,pnor treatment with antibiotics, previousTAB vaccination, the prevalence ofthe anamneustic reactions and the lack ofdata on antibody titres in the normalpopulation."

Our study establishes that healthy NorthIndians have Widal titres to S. typhi '0' ofless than 1180and to 'H' of less than 11320.We conclude that in an endemic area theWidal test is of diagnostic value providedthe levels of agglutinin in normal individualsand patients with other febrile illnessesare known.3 September 1989 N. Jindal

S. AroraH. Prabhakar

Department of MicrobiologyMedical College, Amritsar

PunjabREFERENCESI Cruickshank R. Medical microbiology.

London:Churchill Livingstone, 1968:911.2 Schroeder SA. Interpretation of serological

tests for typhoid fever. lAMA 1968·206:839-40. '

3 Reynolds DW, Carpenter RL, Simon WHoDiagnostic specificity of Widai's reaction fortyphoid fever. lAMA 1970;214:2192-3.

4 Wicks ACB, Holmes GS, Davidson L.Endemic typhoid fever. A diagnostic pitfall.Q 1Med 1971;40:341-54.

5 Anonymous. Typhoid and its serology. BrMed 11978;1:389-90.

6 Pang T, Puthucheary SD. Significance andvalue .of the ":idal test in the diagnosis oftyphoid fever In an endemic area. 1 c/inPathoI1983;36:471-5.

Chloroquine-resistant plasmodiumvivax: The 'First' case report?

In 1986 a 29-year-old male patient (a resi-dent of Mathura district of Uttar PradeshIndia) gave a history of having hadrepeated attacks of malaria. His bloodexamination in our laboratory was positivefor malaria on twenty occasions over thefollowing 12 months-Plasmodium vivax

CORRESPONDENCE

on 19 examinations and P. falciparum inone. There was no evidence of mixedinfection. During the episodes of malariahe had chills, rigors and sweating withheadache and body pain. On examinationhis spleen was firm and enlarged to about3 cm below the costal margin. His weightfell from 95 kg in 1986 to 77 kg in 1987.

He was given several full courses of vari-ous antimalarials including chloroquine,quinine hydrochloride, primaquine, sulphapreparations together with antibioticssuch as ampicillin, gentamycin and tetra-cycline. After treatment he was onlytemporarily relieved-the symptomsrecurring after 2 or 3 weeks. There was noevidence of immune deficiency.

Rieckmann and colleagues have reportedin the Lancet' that 2 soldiers in Papua NewGuinea had chloroquine-resistant Plas-modium vivax. Recently, the AssistantDirector of the National Malaria Eradica-tion Programme in India is reported? tohave stated that no case of vivax resistanceto chloroquine has been recognized inIndia.

Is ours the first Indian case and shouldit not take precedence over the New Guineareport since we recognized the phenome-non in 1986?

20 November 1989 Haris M. KhanAbbas Ali Mahdi

H. KumarSohail Ahmed

Department of MicrobiologyJ. N. Medical College

Aligarh Muslim UniversityAligarh 202002. India

REFERENCESI Rieckmann KH, Davis DR. Hutton DC.

Plasmodium vivax resistance to chloroquine?Lancet 1989 ;2: 1183-4.

2 Malaria germ builds resistance to drugs. TheHindustan Times 1989. December II.

Resistant falciparum malariain South Gujarat

Sir-South Gujarat is not on the malarialmap of India, although the disease, espe-cially resistant faIciparum malaria, hasbeen a major public health hazard betweenthe months of July and October. Thestatistics of the Surat district alone for thelast four years show that total cases ofmalaria have increased from 32459 in 1984to 101692 in 1988 and those offaIciparummalaria from 8905 to 47 941 over the sameperiod. These figures probably do notreflect the magnitude of the problem

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because malaria is commonly self-treated.In South Gujarat, nearly half the patientsadmitted to hospital between July andOctober suffer from malaria.

South Gujarat comprises four districts-'Bharuch, Surat, Balsar and Dang. Thetotal population of the area according tothe 1981 census was about 45 lakhs. Theaverage rainfall is 1270 mm, which is farmore than that in the drought-prone areasof the state. The good rainfall has improvedagricultural prospects and increasedindustrial growth has led to the migrationof people to this region from other parts ofGujarat and even neighbouring states. Themigration of a non-immune population toa hyperendemic zone, the sudden increasein numbers and the industrial and agricul-tural growth seem to have contributed toan upsurge in the incidence of faIciparummalaria and its resistance to chloroquinetherapy. We therefore decided to deter-mine the incidence of resistant faIciparummalaria in this region.

1350 patients with malaria who had beenadmitted to one of the leading hospitals ofSouth Gujarat were studied retrospectively.For diagnosing resistant faIciparummalaria, we followed the World HealthOrganization guidelines (WHO standardfield test), i.e. after receiving 1500 mg ofchloroquine base (25 mg/kg) either orallyor parenterally over three days the thickperipheral smear was positive for theparasite for the next 7 days.' Most of thepatients had been given chloroquine athome by their family physicians. Afteradmission to hospital, quinine hydro-chloride was given to these patients eitherorally or parenterally. Clinical andlaboratory improvement was anotherindication that the patients had resitantfaIciparum malaria.

Out of the 1350 patients with malariathose with faIciparum were 453 (34 %) andthe vivax to faIciparum ratio was 2:1.Sixty-six (5%) patients were resistant totreatment with chloroquine.

Surprisingly, resistance of faIciparum hasonly been described in the North Easternstates of Assam, Meghalaya, Mizoram,Manipur and Tripura.l-' South Gujarat isnot mentioned on the malarial map ofIndia. Although we have found a lowincidence of resistant faIciparum malaria(5%) this may be the initial phase of agreater epidemic.

The indications for the future spelldisaster if we do not actively intervenenow. In the Surat district alone the annualparasite index has increased from 12.8 in1984 to 36.6 in 1988 and the Plasmodiumfalciparum infection rate has increasedfrom 27.4% to 47.1 % over the same period.In 1988, the incidence of P. falciparuminfection was greater than that of P. vivaxin Surat.

Factors which may have also contributedto the increasing incidence of malaria arepoor sanitation, ignorance of preventivemeasures, inadequate insecticidal andlarvicidal measures and the indiscriminateconstruction of new housing complexes.Inadequate treatment both by the patientsthemselves and by partially trained'doctors'. who give 1or 2 ml of chloroquineintramuscularly daily, may have also ledto the development of resistant strains ofP. falciparum.

We fear that a grave situation is likely tooccur in this region. We advise urgent inter-vention, not only by the government butalso by individual philanthropic agencies.ACKNOWLEDGEMENTWe thank Mr Kirit Bhai S. Arnin, DistrictMalaria Officer. Surat District for his help inproviding us with malarial statistics.

24 November 1989 Mahesh MehtaR. K. Desai

Manisha MehtaBarauni Refinery Township

Indian Oil CorporationBegusarai (Bihar)

REFERENCESI WHO Tech Rep Ser 1973;529:30--6.2 BulllCMR 1977;7:1.3 Gopinathan VP. Bhopte AG. J Indian Med

Assoc 1982;79:15()...{iO.

Passive smoking

Sir-The minister of state for healthrecently informed the Rajya Sabha thatthe government is considering a proposalto ban smoking in public places. There isno doubt that cigarette smoking besidesreducing the life-span is responsible forchronic bronchitis and lung carcinoma andthat it is a major risk factor for coronarydisease. What is not universally known oraccepted is that passive smoking is alsodetrimental to health.

Passive smoking is the breathing ofsmoke that contains air composed ofmainstream smoke exhaled by smokersand of side-stream smoke which leaves theburning end of the tobacco product duringpuff intermissions.' Cigarette smokecontains over 1000 substances; and someofthem such as tar, carbon monoxide andnicotine, are found in higher concentra-tions in the side-stream smoke than in themainstream. smoke. For example, theconcentration of Iiitrosamines (potentcarcinogens in animals) is 50 times greaterin side-stream smoke.?

Hirayama in his excellent study! hasshown that non-smoking wives of smokershave a higher risk of developing lung

306

cancer and that a dose-response relationis observed. The fact that there was asignificant relation (two tailed p=0.00097)between the amount that the husbandssmoked and the mortality of their non-smoking wives from lung cancer suggeststhat these findings were not the result ofchance. The risk of developing emphysemaand asthma seemed to be higher though itwas not statistically significant.

Smoking during pregnancy lowers meanbirth weight, raises the risk of perinatalmortality, congenital malformations andis a risk factor for spontaneous abortion.Passive exposure to parental cigarettesmoking is associated with an increase inmorbidity from respiratory illness in youngchildren." Passive smoking aggravatesangina pectoris, I and precipitates acuteattacks in asthmatics.

When his patients with ischaemic heartdisease were exposed to passive smokingin an unventilated room, Aronow' foundthat 30% of them developed prematureventricular beats after exercise. White andFroeb' evaluated the effects of long termpassive smoking in 2100 middle-aged sub-jects and concluded that chronic exposureto tobacco smoke in the work environmentis deleterious to non-smokers and markedlyreduces small airways function.

There is enough evidence to suggestthat passive smoking is detrimental tohealth and the contention that objection

Notices

THE NATIONAL MEDICAL JOURNAL OF INDIA VOL. 2, NO.6

to passive smoking may not be more thanaesthetic is not valid any longer. Smokingshould be forbidden in closed publicplaces, such as airplanes, auditoriums,cinema houses, restaurants and publictransport. The role of the physician doesnot end by merely advising the patient tostop smoking. 6lt is the responsibility of usphysicians to inform society of thedeleterious effects of passive smoking andadvocate new legislative action that willrestrict smoking in public places.15November 1989 A. Rama~i

G. N. KundajeManipal

REFERENCESI Aronow WS. Effects of passive smoking on

angina pectoris. N EnglJ Med 1978;299:21-4,2 Brunnemann KD. Adams JD. Ho DPS. et

al. The influence of tobacco smoke onindoor atmosphere. II. Volatile and tobaccospecific nitrosamines in main and side-stream smoke and their contribution toindoor pollution, In: Proceedings of the 4thJoint Conference on the Sensing of Environ-mental Pollutants, New Orleans. 1977.Washington:American Chemical Society,1978:876-80.

3 Hirayama T. Non-smoking wives of heavysmokers have a higher risk of lung cancer: Astudy from Japan, Br MedJ1981 ;282:183-5.

4 Tager IB, Weiss ST, Munoz A, Rosner B,Speizer FE. Longitudinal study of theeffects of maternal smoking on pulmonaryfunction in children. N Engl J Med1983;309:699-703,

5 White JR, Froeb HF. Small-airways dys-

function in nonsmokers chronically exposedto tobacco smoke. N Engl J Med1980;302:720-3.

6 Glynn TJ. Physicians and a smoke-freesociety. Arch Intern Med 1988;148:1013-16.

Amendment to IMC Act, 1956

Sir-The standards of the medical profes-sion in India are deteriorating and urgentaction is needed to arrest this trend. Themost important cause for this sorry state isthat the criteria for admission to under-graduate and postgraduate courses varywidely not only among different institu-tions but within the same institution aswell. The Medical Council of India isempowered to take effective action torectify this situation but cannot because ofeconomic, legal and social pressun;s. Weshould strengthen its powers through suit-able amendment of the 1956 Act of theIndian Medical Council so that it can workeffectively and efficiently. This will controlthe mushrooming growth of substandardmedical colleges with inadequate trainingfacilities.10 November 1989 R. S. Bhatia

Ludhiana

1. XVIII Annual Conference ofthe IACP (Indian Academy of .Clinical Psychologists), Madras, India 4-4i January 1990Information: Dr S. B. Virudhgirinathan

Organizing SecretaryInstitute of NeurologyGovernment General HospitalMadras 600003India

3. 3rd Annual Conference of the Indian Society forAtherosclerosis Research, Madras, India 9-11 January 1990Information: Dr (Mrs) M. Madhavan

Professor of PathologyDr A.L. Mudaliar P.G. Institute ofBasic Medical SciencesUniversity of Madras, TaramaniMadras 600113India

2. 43rd Annual Conference of Radiology and Imaging,Hyderabad, Indi!" 4-7 January 1990Information: Dr Anand Akbari

Shri X-ray clinic5-1-907, Putli BowliOpp. Osmania Medical CollegeHyderabad 5()()()()1India

4. Automated Percutaneous Disectomy Workshops,San Francisco, USA 13-14 January 1990Information: Radiology Postgraduate Education

University of CaliforniaSan FranciscoUSA