hyperpressure.After removal of such obstruction resorption of the
air which has rushed into the peribronchovascular sheets becomes easier. Flexible proved effective in both unilateral and bilateral PIE (figure). Monitoring confirmed adequate oxygenation despite transient bradycardia during lavages, which stopped ventilation for a few seconds. In very severely distressed patients, however, even the brief suppression of mechanical ventilation required for endotracheal aspiration induces cyanosis and bradycardia. Endoscopy would then not be practicable, and lung puncture or artificial pneumothorax could be attempted. In other cases flexible bronchoscopy can be tried when PIE persists beyond 3 days or worsens despite conservative management. J. DE BLIC Infant Allergology and Pneumonology Service, P. SCHEINMANN Hôpital des Enfants Malades, 75730 Paris, France J. PAUPE
1. Frantz ID, Stark AR, Werthammer J. Improvement in pulmonary interstitial emphysema with high frequency ventilation. Pediatr Res 1981; 15: 719. 2. Brooks JG, Bustamante SA, Koops BL, et al Selective bronchial intubation for the treatment of severe localized pulmonary interstitial emphysema in newborn infants. J Pediatr 1977; 91: 648-52. 3. Swingle HM, Eggert LD, Bucciarelli RL. New approach to management of unilateral tension pulmonary interstitial emphysema in premature infants. Pediatrics 1984; 74: 354-57. 4. Dear PRF, Conway SP. Treatment of severe bilateral interstitial emphysema in a baby by artificial pneumothorax and pneumotomy Lancet 1984; i: 273 5. Milligan DWA, Issler H, Massam M, Reynolds EOR. Treatment of neonatal pulmonary interstitial emphysema by lung puncture Lancet 1984; i: 1010-11. 6. de Blic J, Valleur D. Une technique simple de fibroscopie bronchique chez le nouveauné et le prématuré. Nouv Presse Méd 1982; 11: 2018-19. 7. Wood RE, Sherman JM. Pediatric flexible bronchoscopy. Ann Otol 1980, 89: 414-16. 8. Macklin MT, Macklin C. Malignant interstitial emphysema of the lungs and mediastinum as an important occult complication in many respiratory diseases and other conditions: an interpretation of the clinical literature in the light of laboratory experiment. Medicine 1944; 23: 281-358.
SiR.—Dr Cruickshank and his colleagues (Oct 6,
p 804) describe of vaccine-associated paralytic poliomyelitis. We have similar cases in the Cologne area, two of which have been
two cases seen
To calculate the true number of complications after administration of oral polio vaccine (OPV) the number of vaccinations should be correlated with seroconversions (primary infections). In view of the changed epidemiological picture in developed countries after 25 years of OPV use, one can assume that a young person about to be vaccinated for the first time is seronegative. The- rate of vaccine-associated poliomyelitis may be increasing; in Cologne we see about 5 paralytic cases for every million doses of OPV. Since simultaneous intramuscular injections may increase the incidence of paralytic poliomyelitis,4,5 injections such as diphtheria-tetanus immunisation should not be given at the same time as OPV. Polio vaccination must be promoted but thought needs to be given to the possibility that a combined vaccination strategy with inactivated polio vaccine for the first polio vaccination in early infancy combined with diphtheria and tetanus might be a safer alternative in the developing world. Other lessons from such cases are that vaccination of all family members should be urged, and hygienic precautions must be observed. When vaccine-associated poliomyelitis is suspected intense and early efforts should be made to achieve a comprehensive
virological diagnosis. Institute of Virology, University of Cologne, D-5000 Cologne 41, West Germany
Case 1 : chest
Day Day Day Day
6: bilateral PIE before first flexible bronchoscopy. 6: resolution ofleft PIE just after first bronchoscopy. 10: persisting right PIE just before second bronchoscopy 11. normal.
TH. MERTENS HANS J. EGGERS
1. Mertens Th, Schürmann W, Kruppenbacher J, et al. Problems of live virus vaccineassociated poliomyelitis: a paralytic case with isolation of all three poliovirus types. Med Microbiol Immunol 1983; 172: 13-21. 2. Kruppenbacher J, Mertens Th, Adrian M, et al. Die Impfpoliomyelitis als Komplikation der Oralvakzination. Öffentl Gesundheitswesen 1983; 45: 528-31. 3. Mertens Th, Schurmann W, Kruppenbacher J, et al. Two cases of vaccine-induced poliomyelitis. Acta Paediatr Scand 1984; 73: 133-34. 4. Bodian D, Horstmann DM. Polioviruses. In: Horsfall FL, Tamm I, eds. Viral and rickettsial infections of man. Philadelphia: Lippincott, 1965: 430-73. 5. McCloskey BP The relation of prophylactic inoculations to the onset of poliomyelitis Lancet 1950; i: 659-63.
SIR,-As a sequel to Dr Cruickshank and colleagues’ letter on vaccine-associated paralytic poliomyelitis, I would like to report two similar cases with a possible new interpretation. These cases were seen in two small towns north of Lima, Peru. Both children had a paralytic poliomyelitis-like illness 12 days after receiving oral
poliovaccine. The first child had a febrile syndrome followed by asymmetric left arm and the right leg. In the second case, a had acute meningitis with high fever, muscular of both legs, and weakness of the arms, and intercostal muscles. The boy also had respiratory difficulties, confusion, and convulsions. He went into a coma and died 18 days later. There was no connection between the children or their families. They lived more than a hundred miles apart. These cases presented during an immunisation campaign in 1966. Both were the only cases in their towns. There were no facilities for laboratory studies on the identity of the virus. In a retrospective review of the clinical history of these children I was surprised to find that both had been splenectomised some years earlier-after a traffic accident in the first case and because of chronic haemolytic anaemia with splenomegaly in the second. The spleen plays an important role in the transmission of some infectious diseases. Malaria, bartonellosis, and babesiasis (piroplasmosis) appear spontaneously in men and other animals lacking spleens. 1-3 3 years later I saw two similar cases in the jungle of the Amazon river in Peru. Two adults died with acute toxic hepatitis with black vomit, after live yellowfever vaccination. In both cases the spleen had been removed some years before. In 1967I raised the possibility that administration of live vaccines to splenectomised people could be followed by transmission of the
paralysis of the 12-year-old boy pain, paralysis
diseases.4 Earlier this year I consulted Dr Albert Sabin about my cases of after the live vaccine. He did not accept that poliomyelitis had been transmitted via the vaccine; nor did he think that splenectomy had played a role. However, in the United States more than a hundred cases of polio-like infections after administration of Sabin vaccine have been reported and, as far as I know, no one has studied the spleen in these cases. Dr 0. D. Sordelli, ofthe department of immunology, Georgetown University Medical Center, agrees with me that the administration of different live virus vaccines in animals without a spleen should be studied. Perhaps such studies will throw light on the killed/live virus vaccine
possible poliovirus transmission
He remained in hospital for 4 months and recovered little function apart from return of bladder control after 3 weeks. The diagnosis of poliomyelitis was confirmed by the isolation from faeces of poliovirus type 3, later identified by the Van Wezel intratypic neutralisation test as a Sabin strain, and by a fourfold rise in a serum neutralising antibody to this virus. Serum antibodies to polioviruses types 1 and 2 were also detected, suggesting that he probably had been immunised previously. He thought he had been immunised in childhood, though this could not be confirmed from general practitioner or community health records. There was a record of immunisation against smallpox and he was known to have made four visits for immunisation in 1959. Careful questioning revealed no likely source of infection. He had not been abroad. Contact tracing was initiated immediately and twenty-five close contacts were identified. Six of them reported a variety of symptoms, none of which proved to have been due to poliovirus. 2 weeks before his illness, he had attended a wedding with seventyfive other guests and their children, most of whom lived locally. Two of these children had been immunised with live poliovaccine 9 days before the wedding, although there was no known direct contact with the patient. No other potential source of infection was identified. This case underlines the fact that permanent paralysis may result from vaccine-associated poliomyelitis and that the disease must still be considered in any patient with a lower-motor-neurone lesion even if the epidemiological history makes this diagnosis unlikely. The presence of circulating antibodies to all three types of poliovirus suggests that he had been immunised previously, and that previous childhood immunisation may not offer complete protection. This reinforces the recommendations of the Joint Committee on Vaccination and Immunisation that a booster dose of poliovaccine should be given to school leavers.The risk of vaccineassociated disease appears to be greater in the contacts of a vaccinated person than in the recipient, and close consideration must be given, therefore, to the need for immunisation of unprotected family contacts of a child receiving poliovaccine.2-4
Department of Medicine and Communicable Diseases, Lodge Moor Hospital, Sheffield S10 4LH
M. W. MCKENDRICK
Department of Therapeutics, University of Sheffield
L. E. RAMSAY
Departments of Pathology,
Department of Community Medicine, Derbyshire Health Authority
D. PECK A. PALMER
Public Health Laboratory, Northern General Hospital, Sheffield
San Marcos University, and "Two May Hospital", Lima, Peru
*Present address: 11 Island Avenue, Suite 905, Miami
Beach, Florida 33139, USA.
1. Garnham PCC. The role of the spleen in protozoal infections with special reference to splenectomy. Acta Trop 1970; 27: 1-13. 2 Schitzer B, Sodeman T, Mead ML. Pitting function of the spleen in malaria: Ultrastructural observation. Science 1972, 177: 175. 3 Dooley JR. Haemotropic bacteria in man. Lancet 1980; ii: 1237-39. 4. Urteaga-Ballon O Verruga Peruana ó enfermedad de carrion. Archos Peruanos Pat Clin
1. 2. 3. 4
Joint Committee on Vaccination and Immunisation against Infectious Disease. London: DHSS, 1984. WHO Consultative Group. The relation between acute persisting spinal paralysis and poliomyelitis vaccine: Results of a ten year enquiry. Bull WHO 1982, 60: 231-42. Grist NR. Safety of poliomyelitis vaccine. Br Med J 1983; 286: 917. Grist NR Poliomyelitis vaccine precautions. Br Med J 1983; 287: 1823-24.
1967; 21: 107-36.
of vaccineassociated paralytic poliomyelitis reported by Dr Cruickshank and colleagues. We have seen a case of vaccine-associated paralytic poliomyelitis in Sheffield in an adult with no history of recent immunisation. The patient, a previously healthy 25-year-old bachelor, was admitted to hospital in April, 1984, with a 2-day history of frontal headache and aching pains in the thighs, progressive weakness of his legs, and difficulty in passing urine. He was febrile and had urinary retention and asymmetrical lower-motor-neurone weakness in both legs (power grade zero left limb, grade 1-2 right limb). He also had trunk weakness but there was no sensory deficit. A myelogram, done to exclude a spinal cord lesion, was normal. The CSF showed 178 x 106 white blood cells/I (75% lymphocytes) and a protein of 1 - 2 g/1; no virus was isolated from tissue culture. In view of the possibility of poliomyelitis he was transferred to an isolation unit.
read of the
SiR,-Professor Hull and Dr Nicoll acknowledge the conflict of opinion even between Department of Health publications and the British National Formulary (Nov 24, p 1215). It is unfair to blame the manufacturers for printing in inserts as full a list of contraindications as they feel are worthy of being brought to the attention of the doctor clinically responsible for the use of a particular vial of vaccine. There is a way out. The DHSS should take over complete. responsibility for product control, buy the vaccine, and distribute it to NHS doctors with a covering letter giving DHSS recognised contraindications. Then there will be no legal risks to the manufacturers. Any claims for damages would be borne by the DHSS and/or the doctor-if the court were to find in favour of the claimant. And it would usher in the age of generic prescribing. 68 Ledbury Road.
J. K. ANAND