1051 CERVICAL INFECTION WITH HERPES SIMPLEX VIRUS
SIR,-During 1968-79 herpes simplex virus (HSV) was isolated from the cervix uteri of 79 patients attending the genitourinary medicine clinic of the Royal Infirmary of Edinburgh. The patients The isolates were typed and antiwere aged 15-61 (average HSV antibodies were sought. The clinical records were studied to determine whether the patient had external herpetic lesions of the genitalia, inguinal lymphadenopathy, or generalised cervicitis or discrete herpetic ulceration of the cervix, and any other pathogens involved were noted. 68 patients presented with lymphadenopathy and/or external herpetic lesions; 6 were examined as contacts of herpetic infection; and five were detected during examination for other sexually transmitted diseases. Few patients were thus symptom-free, in contrast to the 30-50% without external signs detected by others2,3 during routine cytological screening. The clinical and laboratory findings are given in the table. 12 (75%) of the 16 HSV-1infections and 36 (57%) of the 63 HSV-2 infections were primary herpes infections. This accords with the findings of Kaufman et a1.,4but others have recorded figures at only 25-35%.’ External lesions were reported in 92% of the primary infections and in 81% of the non-primary ones. Clinical signs of infection of the cervix were recorded in 70-75% of all patients, but further analysis showed that patients with primary HSV-2 infections had discrete herpetic lesions of the cervix much more commonly than diffuse cervicitis; for all other groups, the converse held. A greater incidence of cervicitis has previously been reported in patients with non-primary HSV-2 infections.2,3 Inguinal lymphadenopathy was apparent in 33% of the primary HSV-1 infections, in 37% of the recurrent HSV-2 infections, and in 67% of primary HSV-2 infections. Thus, it would appear that a primary genital infection with HSV-2 gives rise to a greater inflammatory response. An earlier study also associated lymphadenopathy with primary infections, but no distinction was made between HSV-1 and HSV-2.4Chang et al.reported lymphadenopathy in almost all primary and recurrent infections. Over half of the small proportion of the viruses typed were HSV-1, so it would appear that the inflammatory response to the New England strains of HSV-1was much greater than that found in our
Edinburgh cases. One or more other sexually transmitted pathogen was found in 19 of the patients (8 Trichomonas vaginalis, 8 Candida albicans, 5 1.
Peutherer JF, Smith Isabel W, Robertson DHH. Genital infection with herpes simplex virus type 1 (in press). 2. Josey WE, Nahmias AJ, Naib ZM, Utley PM, McKenzie WJ, Coleman MT. Genital herpes simplex infection in the female Am J Obstet Gynecol 1966; 66: 493-501. 3. Ng ABP, Reagan JW, Yen SSC. Herpes genitalis. Obstet Gynecol 1970; 36: 645-51. 4. Kaufman RH, Gardner HC, Rawls WE, Dixon RE, Young RL. Clinical features of herpes genitalis. Cancer Res 1973; 33: 1446-51. 5 Rawls WE, Gardner HL, Flanders RW, Lowry SP, Kaufman RH, Melnick JC. Genital herpes in two social groups. AmJ Obstet Gynecol 1971; 110: 682-89. 6. Josey WE, Nahmias AJ, Naib ZM. The epidemiology of type 2 (genital) herpes simplex 7
virus infection. Obstet Gynecol Surv 1972; 27: 295-302. Chang T-W, Fiumara NJ, Weinstein L. Genital herpes: Some clinical and laboratory
observations. JAMA 1974; 229: 544-45.
VIRUS TYPE, SEROLOGICAL STATUS, AND CLINICAL FEATURES IN PATIENTS WITH HERPETIC CERVICITIS
Neisseria gonorrhoeae) and 3 had genital warts. As these organisms were not in association with any one clinical feature, they were not thought to be the cause of the lymphadenopathy or cervicitis. In this series of patients with signs and symptoms of genital herpetic infection, it appears that HSV-2 gives rise to a greater inflammatory response and the development of discrete herpetic lesions of the cervix if the patient has no antibody to HSV. HSV-1 infections of the cervix are associated with a generally minor response whether antibody is present or not; the minor reaction with diffuse cervicitis and much less lymphadenopathy resembles that associated with HSV-2 in the presence of antibody. Department of Bacteriology, Medical School,
ISABEL W. SMITH
University of Edinburgh, Edinburgh EH8 9AG
J. F. PEUTHERER
Department of Genitourinary Medicine, Royal Infirmary of Edinburgh
JENNIFER M. HUNTER
PNEUMONIA, STROKE, AND LATERALITY SIR,-Professor Kaldor and Dr Berlin (April 11, p. 843) report that pneumonia is more likely on the affected side in stroke patients.
Many physiotherapists pay particular attention to the ipsilateral side when treating chest infections in hemiplegic patients. To determine whether pneumonia is indeed more common on the hemiplegic side, I have reviewed the necropsy reports for all stroke patients on whom a post-mortem was done in Nottingham over 12 months. 317 patients had pathological features of cerebrovascular disease and in 104 of these pneumonia was recorded as a complication. I then obtained the case-notes of these patients with pneumonia to identify those who had shown clinical features of hemiplegia. The admitting doctor had noted hemiplegia in 71 cases. In 2 of these, the pneumonia was found at necropsy to be distal to tumour, and these cases are excluded from further analysis. The hemiplegic patients with pneumonia consisted of 51 patients with recent strokes and 18 patients with long-standing ones. 35 of the patients had right-sided and 34 had left-sided hemiplegia. Only 11 of the 69 patients had unilateral consolidation at necropsy and in 6 of these the consolidation was on the hemiplegic side. The other 58 patients had bilateral pneumonia. In 11of these the pneumonia was more extensive on one side but in only 4 of these was it more pronounced on the hemiplegic side. Most hemiplegic patients dying with pneumonia have bilateral consolidation. In those with unilateral consolidation this is equally likely to affect the non-hemiplegic as the hemiplegic side. Why is this? The clinical observation that chest movements may be reduced on the hemiplegic side has been confirmed by recordings. During voluntary deep breathing, there is a reduction in movement of both upper and lower chest on the hemiplegic side; by contrast, there is no asymmetry of movement during involuntary deep breathing. However, when a hemiplegic patient breathes quietly the movement of the lower chest is symmetrical, but recordings show that upper chest movement decreases by a mean value of 10% on the affected side. The vast majority of the patients whom I studied had lower lobe consolidation: as the lower chest usually moves symmetrically in hemiplegic patients it is perhaps no surprise that pneumonia is usually bilateral. This is a retrospective study of a selected minority of stroke patients who died and had necropsies. Kaldor and Berlin’s study is also retrospective and determination of the side of pneumonia was presumably made on chest auscultation, which is notoriously difficult in the elderly. Prospective studies are needed. Whether physiotherapy or nursing techniques prevent or help to improve pneumonia in stroke has yet to be established. In the meantime it would seem sensible to direct efforts to both sides of the chest in hemintefnc oatients. Department of Health Care of the Elderly, Hospital, Nottingham Sherwood
’?7,rr,gry =no antibody to HSV at Ôrat time of infection.
1. Fluck DC. Chest movements
G. P. MULLEY Clin Sci 1966, 31: 383-88.