HERPES SIMPLEX ENCEPHALITIS

HERPES SIMPLEX ENCEPHALITIS

1426 if the required heat can be produced without shivering and thus displacing all the bedding. Brown fat is just the thing for this task, and this ...

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1426

if the required heat can be produced without shivering and thus displacing all the bedding. Brown fat is just the thing for this task, and this most central form of heating is turned on by noradrenaline; maybe circulating noradrenaline is what turns the waking hamster’s feet pale, since neurovascular conduction to his feet may still be cold-blocked. Without brown fat it may be hard to wake up properly, as the hamster does, and thus difficult to keep properly in touch with the changing state of national fuel supplies. On the whole it seems wise never to hibernate without consultant advice, and hospital admission is mandatory. For the more faint-hearted, winter sleep with modest temperature drop (to say 34 °C) may be more appropriate. This is the speciality of the bear, who can keep it up for say 4 months, neither eating nor drinking nor defxcating, and be readily rousable. More remarkable still, the female can give birth and lactate successfully during the sleep.s Naturally, with no water to spare, the milk is made ten times richer in fat than human milk, so that metabolic water is available so far as possible. This remarkable animal has much to teach us, though we might be rash to sit at its feet.

TENNIS ELBOW

TENNIS elbow is such a common chronic condition in such a superficial part of the body that it is surprising that doubt remains about the pathology and treatment. The condition is still ill-understood, and the experiences of some 1800 patients in two large American series 1,2 answer only some of the points often raised. Both groups agree, in most respects, on the natural history and on much of the treatment. Coonrad and Hooperwere able to follow up only 339 patients out of 1000 treated. 39 were operated on and 28 of these had tears of the tendon origin. This is not the pathological picture usually described,3 but all the patients treated surgically in the two series had received local steroids previously. Coonrad and Hooper believe this did not influence the situation at operation, but the concentrations they used have certainly produced local degenerative processes in tendons injected experimentally or therapeutically. 4,5 Both groups think local steroids reduce the symptoms while spontaneous cure is taking place, and both concur with the usual British view that fewer than 5% of the patients require operation. Neither paper makes any reference to the long-term fate of these patients, with their tendency to relapse after moderate stress and their increased risk of polyarthritis in later years. Whilst the saying " once a tennis elbow, always a tennis elbow " is not strictly true, there is a grain of truth in it: chronic cases tend not to come to doctors’ notice because patients learn to live with their comparatively minor symptoms. The basis of conservative treatment is that any pain is a further sprain and should be avoided, and that painless exercise does good, as with other soft1. 2. 3. 4. 5.

Coonrad, R. W., Hooper, W. R. J. Bone Jt Surg. 1973, 55, 1177. Boyd, H. B., McLeod, J. A. C. ibid. p. 1183. Goldie, I. Acta chir. scand. 1964, suppl. 339. Balasubramaniam, P., Prathap, K. J. Bone Jt Surg. 1972, 54B, 729. Cowan, M. A., Alexander, S. Br. med. J. 1961, i, 1658.

tissue and joint injuries. The best sort of operation is still in doubt-high success-rates are reported in both the large American series with very different operations. What is clear is that operations involving division or repair of the extensor origin are followed by very slow convalescence. HERPES SIMPLEX ENCEPHALITIS

encephalitic illness commonly arises after exanthem such as chickenpox or measles,l but where there is no such history infection with herpes simplex virus (H.s.v.) requires urgent consideration, now that new and possibly specific antiviral agents At an international symposium2 it are emerging. became clear that, with such a rare disease, no one unit is likely to solve all the problems on its own. ACUTE

an

Accordingly,

a

working-party

was

set up to

plan

a

multicentre therapeutic trial. H.s.v. may cause two types of neurological illness-a benign asepticmeningitis syndrome and an encephalitic illness which is often severe. The former is associated with H.s.v. type 2 (the virus of genital herpes) and the latter with 1 Most encephalitic patients are probably type 1.3 undergoing primary herpetic infection, but there are some who have antibodies and a history of recurrent cold sores when the illness begins. Such cases are undoubtedly due to activation of latent virus. Symptoms are varied and often bizarre.4 Unusual behaviour, change of personality, and aphasia are early signs which may lead to a patient’s admission to a mental hospital. On the other hand, persistent headache, fits, myoclonicjerks or other motor signs (which may be unilateral), disturbance of consciousness, and perhaps other evidence of increasing intracranial pressure suggest an expanding intracranial lesion requiring

urgent neurosurgical investigation. Again, dysphasia is likely to be prominent. Pathologically the temporal lobes are always involved, with one side much more affected than the other.6 There is spread of necrosis from the grey to the white matter, with gross destruction of the temporal lobes in most survivors.6 Investigation is urgent and requires the collaboration of many disciplines. It has a twofold aimexclusion of other causes of what is often a difficult clinical problem, plus definitive diagnosis of H.S.V. encephalitis. Non-specific but helpful diagnostic pointers are a sterile cerebrospinal fluid (c.s.F.) with a lymphocytic pleocytosis (recovery of H.s.v. type 1 from the lumbar c.s.F. is extremely rare), diffuse slow-wave activity associated with increased spike activity on electroencephalogram,’ and brain shift in over half the patients as shown by angiography, ventriculography, or scan.6 Acute necrotising or acute inclusion-body encephalitis is probably synonymous with H.s.v. encephalitis, but when potentially toxic agents are likely to be used in treatment a more specific diagnosis is essential. This demands identification of H.s.v. in biopsy material from the brain 1. 2. 3. 4. 5. 6. 7.

McKendrick, G. D. W. Lancet, 1968, i, 1248. Postgrad. med. J. 1973, 49, 572. Skoldenberg, B., Jeansson, S. Br. med. J. 1973, ii, 611. Liversedge, L. A. Postgrad. med. J. 1973, 49, 383. Oxbury, J. M., MacCallum, F. O. ibid. p. 387. Adams, H., Miller, D. ibid. p. 393. Illis, L. S., Taylor, F. M. Lancet, 1972, i, 718.

1427 or

the

ventricular

c.s.F.

by immunofluorescence,

culture. Late confirmation in survivors may come from a rise of antibodies to H.s.v. in the c.s.F. The mortality of H.s.v. encephalitis is high and the quality of survivors poor.s Some workers believe that reduction of intracranial pressure by medical (dexamethasone 8.9) or surgical means is an essential element in treatment. Rappel pleads for the addition of antiviral therapy when steroids are used, because of the theoretical dangers.10 Despite preliminary enthusiasm for idoxuridine there has been no convincing evidence that this drug is of any value in H.s.v. encephalitis. 8, 11 Cytosine arabinoside in vitro inhibits the growth of several D.N.A. viruses, including H.s.v., and this is the drug the working-partyproposes to use in the multicentre trial. Enthusiasts claim a striking therapeutic effect in herpesvirus infections in individual cases,12,13 but the only controlled trial in a herpes infection (disseminated zoster) did not show any benefit.14 Nevertheless, the outlook in H.s.v. is so encephalitis poor that a properly conducted double-blind trial of an agent known to be active in the laboratory is clearly justified if the drug treatment is combined with routine supportive measures, including reduction of intracranial pressure. For any treatment to be effective, really early diagnosis is probably essential, maybe even within the first 48 hours. This is a major difficulty because many patients at this stage do not have symptoms which merit the insult of a brain biopsy as an investigation procedure.

electronmicroscopy,

or

virus

THE AGED AILING AFRICAN our knowledge of the prevalence of uncovered by necropsies is based on young

MUCH of

disease

as

But in Monroe County, New York, Kunitz and Edland 15 have noted a disproportionately high necropsy-rate for young people of all races-partly a reflection, they believe, of the feeling that death in In less affluent the young is somehow unnatural. societies the disparity may be even greater. Thus, in Uganda, where in 1948 about 11% of the population were living for 45 years, only 21 persons over 60 years old came to necropsy in the years 1931-47.16 But now, with increasing numbers of people, there are greater numbers living to an advanced age. In 1959 Uganda had 248,000 aged 60 or more and in 1969, 564,000: Drury 17 has written of the diseases revealed at necropsy in 373 Ugandans aged 60 or over. (In 1960 Thomas et al.1111were able to find necropsy reports in 245 Ugandans over 40 years of age and 4 over 60, for comparison with age and sex matched U.S. Blacks.) The major diseases (not

people.

8. 9. 10. 11. 12.

13. 14.

15. 16. 17. 18.

Upton, A. R. M. Br. med. J. 1972, i, 226. Habel, A. H., Brown, J. K. Lancet, 1972, i, 695. Rappel, M. Br. med. J. 1972, ii, 655. Juel-Jensen, B. E. Br. J. Hosp. Med. 1973, 10, 402. Jeul-Jensen, B. E., MacCallum, F. O. Herpes Simplex, Varicella and Zoster: Clinical Manifestations and Treatment; p. 117. London, 1972. Longson, M., Beswick, T. S. L. Lancet, 1971, i, 749. Stevens, D. A., Jordan, G. W., Waddall, T. F., Merigan, T. C. New Engl. J. Med. 1973, 17, 873. Kunitz, S. J., Edland, J. F. J. forens. Sci. 1973, 18, 370. Davies, J. N. P. E. Afr. med. J. 1948, 25, 117. Drury, R. A. B. Trop. geog. Med. 1972, 24, 382. Thomas, W. A., Davies, J. N. P., O’Neal, R. M., et al. Am. J. Cardiol. 1960, 5, 41.

necessarily the

of

death) in Drury’s subjects categories and the infective subset into 3 categories-parasitic, tuberculous, The male/female ratio was 4/1. Each and other. subject aged 60 or over was randomly matched were

grouped

cause

into 8

with a control of the same sex and tribe but 30 years younger. Though over-60s are over-represented in hospital admissions, biopsies, and operations,19 there was little difference in the major causes of death between them and their juniors by 30 years." The important differences were a 65% increase in cancer (less obvious in women), an almost 50% reduction in traumatic deaths, and proportionately fewer deaths from tuberculosis. These findings emphasise three points. Firstly, in the elderly African the frequency of preventable and treatable infective diseases is high and very similar to that in younger Africans. Secondly, even in the aged African degenerative cardiovascular disease is of little importance-only 6 (1-6%) of the over-60 group died of arteriosclerosis and a total of 14 died of what could be termed degenerative diseases; thus ischsemic heart-disease, arteriosclerosis, and other cardiovascular conditions so common in elderly Whites remain uncommon in the elderly Ugandan, as elsewhere in African. 200 Finally, the increased proportion of cancer does not mean that the discrepancies found in the past can now be disregarded. They remain as great as ever. 19,21 The only cancer seen in the elderly and not present in their juniors was Liver cancer, lymphomas and prostatic cancer. leukasmia, and bladder cancer were the commonest, with oesophageal and prostatic cancers the runners-up.

There is no evidence of the " missing " lung and bowel cancers which have been so much discussed. Before long, if the lessons of this report are heeded, we may have a report of a large series of necropsies in Africans over 70, and surely there will be much to learn from it.

COMMUNITY PHYSICIANS

PERHAPS Sir Keith Joseph is right to maintain the of his reorganisation-keeping his head when all about him are losing theirs. But, as the pace quickens, difficulties come thick and fast. Most of them, in themselves, are minor; clearly the Staff Commission has been overburdened-one hears, for instance, of a doctor being shortlisted for a job he did not apply for. Now the telescoped timetable has produced another irritant: regional and area medicalofficer appointments are not to be announced till the second week of January, whereas the communityphysician applications have to be in by Jan. 7. Thus, the future community physician cannot choose who he will (or will not) work under. To slow down the programme, it is said, would be bad for morale; here there seems a case for speeding it up: the Staff Commission should announce the medical-officer appointments before Jan. 7. momentum

-

Davies, J. N. P., Knowelden, J., Wilson, B. A. J. natn. Cancer Inst. 1965, 35, 789. 20. Williams, A. O., Resch, J. A., Loewenson, R. B. E. Afr. med. J. 1971, 48, 152. 21. Templeton, A. C. (editor). Tumours in a Tropical Country. Berlin, 19.

1973.