THE MEDICAL JOURNAL OF AUSTRALIA
40
~39
,,38
CD
~ 151-159
~ 37f---f+-I-HI-++-*-+I-l-t#-I++f-+l-h'c+'t+'r--
E 4. Raine AE. Ledingham JG. Clinical experience with cap-
~36
351 2 3 4 5 6 7 8 9 10 11 12 13 14
Days
Figure: Patient temperature record. Captopril was last
taken on Day 6.
Results of her examination were otherwise
normal.
Laboratory investigations showed a haemo-
globin level of 145 gIL and a white cell count of
13.3 x 10 9/L with 10.2 x 10 9/L neutrophils. Her
erythrocyte sedimentation rate (ESR) was
95 mm in one hour. Liver function test (LFT)
results were as follows: serum albumin, 32 gIL
(normal range, 36-47); bilirubin, <20 urnol/L
(normal range, 3-20); alkaline phosphatase,
85 units/L (normal range, 35-120); y-glutamyl
transpeptidase, 66 units/L (normal range, 8-40);
and alanine aminotransferase, 49 units/L
(normal range, 8-40). Her urinalysis, chest x-
ray, serum creatinine level, blood sugar level
and quantitative electrophoretic pattern were all
normal. The results of repeated blood cultures
were negative. The results of an echocardio-
gram, abdominal ultrasound, thoraco-Iumbar
computed tomographic scan and whole body
gallium imaging scan were normal. Her bone
marrow, on examination, was normal.
The patient continued to have swinging
fevers but remained remarkably well while lab-
oratory investigations showed a persisting
leukocytosis, high ESR and abnormal LFT
results. The captopril was withdrawn on Day 6
and six days later her fever resolved (see
Figure). The laboratory test results returned to
normal over subsequent weeks.
Fever is a recognised side effect of captopril,
as part of a variable complex including fever,
rash, eosinophilia, hepatitis and interstitial
nephritis of which rash is a prominent feature.'-4
In one report fever was reported in tabulated
form as occurring in two of 33 patients but this
was part of a profile of adverse effects.· When
there is an associated skin eruption, there is
some indication that a therapeutic agent may be
responsible for a patient's symptoms. However,
if a patient presents, as mine did, after falls
(probably caused by postural hypotension pre-
cipitated by febrile vasodilatation) it is not
immediately obvious that a drug might be
responsible. Perhaps captopril should now be
considered as a cause of fever when investiga-
tions fail to define the cause.
Dan O'Donnell, FRACP, MRACOG
Consultant Physician
Fremantle Hospital. PO Box 480, Fremantle, WA 6160
Smith WR, Neill J, Cushman WC, Butkus DE. Captopril
- associated acute interstitial nephritis Am J Nephrol
1989; 9: 230-235
2. Chrysant SG, Dunn M, Marples 0, De Masters K. Severe
reversible azotemia from captopril therapy. Report of
Vol159 6/20 December 1993
three cases and review of the literature. Arch Intern Med
1983; 143 437-441
3 Luderer JR, Lookingbill DR Schneck OW,et at. Captopril
Induced skin eruptions. J Clin Pharmacal 1982; 22
topril in the treatment of severe drug-resistant hyper-
tension. Am J Cardiol1982; 49 1475-1479
Hepatitis B transmission and skin
infections
To the Editor: Burgess and colleagues found no
evidence of horizontal transmission of hepatitis
B virus (HBV) between high-risk and low-risk
groups of schoolchildren in Sydney.' This con-
trasts with the findings of Gardner et al.> which
suggest that there may be HBV transmission to
low-risk children in the Northern Territory. This
inconsistency may reflect differences in climate,
lifestyle, environment, health status or hygiene
between Sydney and the Northern Territory.
A potentially relevant difference is the high
prevalence of skin infections which can affect
17%-60% of children in remote Aboriginal com-
munities at anyone time (Guthridge SL and
Ashbridge DA, unpublished results).".• Such
infections are commonly initiated by scabies in
younger children although the 'prevalence of
streptococcal skin infections (Guthridge SL and
Ashbridge DA, unpublished results)"" peaks at a
later age than the prevalence of scabies. The
presence of hepatitis B surface antigen and e
antigen have previously been demonstrated in
the exudates of skin lesions of HBV carriers,"
with potential for cross infection either by direct
contact between sores or by contamination of
teaching materials, toys and other objects.
We suggest that the presumptive transmis-
sion of hepatitis B to Northern Territory children 2
may be partly due to the frequency of skin sores
in children of pre-school and school age; the
lack of evidence of transmission in Sydney
schools' may be due to the virtual absence of
skin sores in a more temperate climate with
more adequate hygiene facilities and practices.
The national hepatitis B vaccination policy
may need to be directed not just to high-risk chil-
dren but also to low-risk children living in high-
risk places like the Northern Territory.
Xinan Wan, MD, MPH
Postgraduate Student
John 0 Mathews, MB BS, MD, BSc, PhD,
FRACP, FRCPA
Professor and Director
Menzies School of Health Research
PO Box 41096, Casuarina. NT 0811
Steven Guthridge, MB BS, MTH, FAFPHM
Northern Territory Department of Health and
Community Services
PO Box 40596. Casuarina, NT 0811
1 Burgess MA. Mcintosh EDG, Allars HM, Kenrick GK
Hepatitis B in urban Australian schoolchildren. No evi-
dence of horizontal transmission between high-risk and
low-risk groups Med J Aust 1993; 159 315-319.
2. Gardner 10, Wan X, Simms PA, et a! Hepatitis B virus
markers in children and staff in Northern Territory
schools. Med J Aust 1992; 156 638-641
835
3 Van Buynder PG, Gaggin JA, Martin D. et al. Strepto-
coccal infection and renal disease markers in Australian
Aboriginal children. Med J Aust 1992; 156 537-540
4. Nimmo GR, Tinruswood RD, Nuttall N, et at. Group A
streptococcal infection in an Aboriginal community. Med
J Aust 1992; 157 521-522
5. Tibbs CJ. Hepatitis B, tropical ulcers, and immunisation
strategy in Kiribati. BMJ 1987. 294 537-540
In reply: We agree that the high prevalence of
skin infections in children in remote Aboriginal
communities may be partly responsible for the
spread of hepatitis B (HBV) infection. This route
of transmission was thought to be important
among children in Kiribati' (formerly the Gilbert
Islands) and in Vanuatu.>
The study in Northern Territory showed a
higher prevalence of hepatitis B surface antigen
in rural than in urban Aboriginal children." How-
ever, only six low-risk children from rural areas
were tested and none had been infected. Even
so, it seems prudent to vaccinate low-risk rural
children. The same study reported an increased
prevalence of hepatitis B markers in urban low-
risk children." It is difficult to interpret these
results because the sera were not tested for
antibody to hepatitis B core antigen (anti-HBc).
Testing for anti-HBc would have confirmed that
the children had been naturally infected rather
than vaccinated. As the age of the children
ranged from 9 up to 17 years, sexual transmis-
sion may also have played a role in some
instances.
Margaret A Burgess, MD, FRACP
Physician in Preventive Medicine, The Children's Hospital
Associate Professor of Paediatrics and Child Health
The University of Sydney
E David G Mcintosh, MB BS, MPH, FRACP
Fellow in Preventive Medicine
The Children's Hospital
PO Box 34, Camperdown, NSW 2050
Tibbs CJ. Hepatitis B. tropical ulcers, and immunisation
strategy in Kiribati. BMJ 1987; 294 537-540.
2. Maher CR Harris MS, Milne A, et al. Seroepidemiologyof
hepatitis B infection in children In Vanuatu. Med J Aust
1991, 154: 249-253.
3. Gardner 10. Wan X, Simms PA. et at. Hepatitis B virus
markers in children and staff in Northern Territory
schools. Med J Aust 1992; 156: 638-641
Animal experimentation and patients
To the Editor: The recent increase in violence
inflicted by animal liberationists, antivivisection-
ists and champions of animal rights upon sci-
entists who undertake animal research has
received considerable attention in the lay and
scientific press. It is undeniable that medical
knowledge and, therefore, patient treatment has
benefited from the dedicated work of experi-
mental scientists. The discovery and develop-
ment of vaccines, antibiotics and insulin, organ
transplantation procedures, cardiac surgery,
improvements in nutrition, and pain control are
but a few examples of advances that have
yielded great benefits.
The scientific community observes and main-
tains responsible protocols for the management
of animals for experimental purposes, and lay
836
people have had considerable input into deci-
sion making about animal experimentation.
Many members of the community are probably
unaware of the extent to which scientific know-
ledge accumulated from experimental studies on
animals is finally incorporated into protocols for
the treatment of patients. Therefore, the medical
profession has a responsibility in the controversy
generated by the antivivisectionist lobby to
inform the community, and particularly those
seeking medical treatment, of the crucial role of
animal experimentation in medical practice.
Since it is the sick who directly benefit from
medical treatment, it is this group that needs to
be informed. One simple way in which this could
be done is by drawing the attention of our
patients to the following statement:
''The drugs and procedures used in this hos-
pital (practice) for the treatment of injured and ill
patients have been developed as a direct result
of studies in experimental animals by dedicated
professional medical scientists."
This statement could be displayed in hospital
casualty departments and doctors' surgeries for
the information of patients. An informed com-
munity may then better appreciate the very cru-
cial contribution animal experimentation makes
to human welfare.
J S Chahl, MSc, PhD, MB BS
Lecturer in Anatomy
Faculty of Medicine
The University of Newcastle
University Drive, Callaghan, Newcastle, NSW 2308
Prevention of HIV and HBV
transmission In general practice
To the Editor: Christopher Cooper's article' is a
timely reminder of the risks to doctors and other
health care professionals who deal with poten-
tially contaminated sharp instruments and other
items.
Each day in the United States alone there are
2000 "sharps accidents". Each year, 12 000
health care workers develop hepatitis Band
between 200 and 300 die from hepatitis.s
Figures from Europe show similar staggering
rates of hepatitis in health professionals -
18000 are infected each year and 300 die."
In the US there are now over 100 cases of
HIV positivity in health care workers in which
transmission was proven to be from work-
related sharps accidents, with seroconversion
shown (Centers for Disease Control, Atlanta,
Georgia, personal communication). Many other
cases have been documented but not proven.
One area of great concern not covered in Dr
Cooper's article is that of the sharps used for
sensory testing. The risk here is not only from
sharps disposal but also from potential trans-
mission of infection when pins and other sharp
objects are re-used. There is a risk of transmis-
sion of viral and other infective particles even if
bleeding, which is commonly reported during
sensory testing particularly when performed with
hypodermic needles, does not occur. A study
from the Medical School, University of Sheffield
showed that re-use of pins in sensory testing is
still common practice." Anecdotal evidence and
THE MEDICAL JOURNAL OF AUSTRALIA Vol 159
observation suggest that this also remains
common practice in Australia and other coun-
tries.
The Australian Association of Neurologists
has recently released guidelines for the practice
of sensory testing. These state: "At the recent
Council Meeting the issue of sensory testing
was raised. Members are reminded that sharp
objects for testing pain should not be used on
more than one patient and that needles should
be disposed of safely at the site of use".
Guidelines for sharps used in sensory testing
should be added to all protocols concerned with
avoidance of sharps accidents. Instrument
design is moving towards a future in which
hospitals and clinics will be "sharps free".
Serge Bajada, MB BS, FRACP
Consultant Neurologist
221 High Street, Fremantle, WA 6160
Cooper C. Prevention of HIV and HBV transmission in
general practice. Med J Aust 1993; 159 339-342
2. Morgan DR, HIV and needlestick injuries [letter]. Lancet
1990; 335: 1280.
3. Hallauer J, Kane M, McCloy E. Proceedings of the Viral
Hepatitis Prevention Board International Congress;
1993 Mar 10-12; Vienna. London: The Board, 1993.
4. Cox J, Hodgson L Hepatitis B, AIDS and the neurolog-
ical pin [letter]. Med Educ 1988; 22: 83.
Nitrogen emphysema: a
complication of cryotherapy
To the Editor: The use of liquid nitrogen
cryotherapy for the treatment of a variety of
benign, premalignant and malignant skin lesions
has had increasing popularity in Australian
medical practice over recent years. The avail-
ability, efficacy and relative low cost of this tech-
nique has ensured widespread use. Although
complications are uncommon, they do occur and
we report two cases of an alarming incident
associated with cryotherapy.
Both cases involved the treatment of elderly
patients with actinic keratoses on the malar
region of the face. Both patients had fragile,
sun-damaged skin with marked wrinkling and
skin laxity. A standard Cry-ac flask and nozzle
were used by experienced practitioners, and the
liquid nitrogen was applied with the spray tech-
nique so that there was no direct contact
between the flask nozzle and the skin. When
spraying started, the cheek and lower eyelid of
both patients became dramatically swollen. The
swelling extended rapidly to the upper lid and
lateral canthus and, in one of the patients,
caused complete occlusion of the eye. The
swelling was not painful, but demonstrated typ-
ical gaseous crepitus to palpation. Gentle pres-
sure was applied and over a period of hours the
swelling dissipated without permanent damage.
Nitrogen gas insufflation has been reported
as a rare complication of cryotherapy.' In these
reports it has been associated with direct appli-
cation of the cryotherapy flask nozzle to the
skin" or other tissues," or with open wounds
such as biopsy sites. Neither situation applied to
our cases.
The rapidity of the development of the nitro-
gen emphysema was alarming to both the
6/20 December 1993
patient and the treating practitioner. We report
these cases to alert other practitioners to this
potential complication. We would use our exam-
ple to suggest that maximum care should be
taken when using liquid nitrogen cryotherapy on
fragile, sun-damaged skin, especially around the
malar and orbit regions.
David Cook, MB BS
Research Fellow
Katherine Georgouras, MB BS, DDM, FACD
Director
Dermatology Centre
Lidcombe Hospital
Joseph Street, Lidcombe, NSW 2141
Dawber RPR. Cryosurgery: complications and contra-
dictions Cfin Dermatof 1990; 8: 108-114.
2. Collins AG. Complication of cryotherapy [letter]. Med J
Aust 1992; 157: 843.
3. Schlinkert RT, Chapman TP Nitrogen embolus as a com-
plication of hepatic cryosurgery. Arch Surg 1990; 125:
1214.
Laparoscoplc cholecystectomy
To the Editor: I support the views expressed by
K B Orr' advising caution in discarding tradi-
tional surgical techniques to replace them with
new ones, particularly laparoscopic cholecys-
tectomy.
Recently, one of my patients underwent an
ultrasound scan which showed multiple gall-
stones and a 1 em thick gallbladder wall. She
had a history of numerous attacks of biliary colic
and an episode of jaundice due to calculus
obstruction of the common bile duct which was
demonstrated by endoscopy. A laparoscopic
cholecystectomy was performed with consider-
able difficulty. Bile peritonitis followed, which
required laparotomy, open drainage and six
weeks in an intensive care unit.
For all but the elite laparoscopist, it did not
require hindsight to predict the outcome in this
(not unusual) case. Perhaps the intensivists
could provide us with a survey of their experi-
ence so that indications for standard open
cholecystectomy can be defined in the best
interest of our patients.
D Angus, MB BS
1/28 Clyde Street, Kempsey, NSW 2440
Orr KB. Laparoscopic cholecystectomy [letter]. Med J
Aust 1993; 159: 432.
spontaneous rupture of a malarial
spleen
To the Editor: In areas where malaria is
endemic, spontaneous rupture of the spleen is
uncommon. However, because of increased
travel to endemic areas and resistance to anti-
malarial drugs, the disease is a major medical
problem which is becoming increasingly
important to surgeons everywhere. The case
described here concerns a spontaneous splenic
rupture, secondary to malaria in a patient who
presented with an acute abdomen.
A 42-year-old white man presented to hospi-
tal with sudden onset of upper abdominal pain,