LETTERS TO THE EDITOR
one (100 mg/kg/day in two divided doses) and
gentamicin (7.5 mg/kg/day in three divided doses), in
combination, for 14 days. The children were not given
oral feeds and kept on intravenous fluids as long as
they had vomiting or paralytic ileus. They became
afebrile and hepato-splenomegaly, and the gall bladder lump disappeared between the 7th and 10th day of
antibiotics therapy. No child required any surgical
intervention. The repeat ultrasound scan of abdomen
was normal in all the three cases at the end of therapy.
Acute acalculous cholecystitis usually occurs following major non-biliary surgery, burn, severe sepsis,
and parenteral nutrition. In our cases, it occurred
secondary to S. typhi infection and patients had
clinical findings similar to as reported in AAC. 4 ' 5
Biliary tract infection in typhoid fever is extremely
uncommon and clinical presentation is similar to that
of calculous cholecystitis.5
Due to difficulty in diagnosis, a high index of
suspicion is required, particularly in patients at risk
and ultrasound scan of abdomen is the investigation of
choice in such patients. The earlier recommended
treatment for AAC was surgical intervention like
cholecystectomy or tube cholecystostomy. 5 ' 6 Mortality in AAC is twice as high as in acute calculous
cholecystitis.7 However, our cases responded to only
antibiotics therapy. We feel that typhoid AAC in
children needs to be a distinct entity as it usually
responds to conservative therapy, unless there are
complications like perforation or gangrene of the gall
bladder. There is a definite upsurge of AAC associated
with multidrug-resistant typhoid fever. This emergence of a previously uncommon complication may be
attributed to increase in virulence of the organism.
Early recognition and vigorous antibiotics therapy are
required to improve the outcome.
O. P. MISHRA, B. K. DAS and J. PRAKASH
Department of Paediatrics,
Institute of Medical Sciences,
Banaras Hindu University,
Varanasi 221 005,
India
References
1. Koul PB, Murali MV, Sharma PP, Ghai OP, Ramachandran UG, Talwar V. Multidrug resistant Salmonella typhi
infection: Clinical profile and therapy. Ind Pediat 1991;
28:357-61.
2. Mishra S, Patwari AK, Anand VK. A clinical profile of
multidrug resistant typhoid fever. Ind Pediat 1991; 28:
3. Chandra R, Srinivasan S, Nalini P, Rao RS. Multidrug
resistant enteric fever. J Trop Med Hyg 1992; 95: 284-7.
4. Kabra SK, Talati A, Shah R, Desai KD, Modi RR. Acute
acalculous cholecystitis. Ind Pediat 1991; 28: 803-6.
5. Sherlock S, Dooley J. Gall Stones and inflammatory gall
bladder diseases. In: Diseases of Liver and Biliary System,
9th edn. Blackwell Scientific Publications, Oxford, 1993,
pp. 562-91.
Journal of Tropical Pediatrics
Vol.42
February 1996
6. Ternberg JL, Keating JP. Acute acalculous cholecystitis.
Complication of other illnesses of childhood. Arch Surg
1975; 110: 543-7.
7. Glenn F, Becker CG. Acute acalculous cholecystitis. Ann
Surg 1982; 195: 131.
Sir
Under-5 clinic attendance and immunization
compliance in Bwamanda, Zaire
A better understanding of the epidemiology of immunization delays in infants may help to optimize
immunization programmes. In Bwamanda, rural
Zaire, where immunizations depend on attendance at
monthly under-5 clinics, we analysed attendance and
immunization status in a random sample of 4238
children, aged 0-5 years. The global immunization
status was defined as either 'no vaccines', or 'up-toschedule', or 'delayed'. Low attendance (50 per cent)
was seen in both sexes, and in both the rainy and dry
season. Attendance was lower in children with mild
clinical malnutrition. The lowest attendance was seen
in the youngest children (0-3 months). This leads to a
high prevalence of immunization delays (73 per cent)
in the 3-6-month-olds, which contrasts with the high
global coverage rate (78 per cent) in all ages pooled.
This shows that high global coverage rates may mask
low compliance in specific age groups and, in our case,
the most vulnerable one. Further decline of infant
mortality by immunizations may strongly depend
upon a better coverage among the vulnerable 3-6month-olds. This goal is more likely to be achieved by
including home visits to the vaccine delivery strategy.
In previous analyses on the same cohort we found that
the age group of 3-6 months is definitely a high risk
group. Indeed, it has the highest morbidity1 and
mortality. 2 The high morbidity between 3 and 6
months contrasts with the low morbidity of the
youngest children, aged 0-3 months. The latter are
generally exclusively breastfed. In the period of 3—6
months, potentially contaminated, low-energy weaning foods are introduced, which may explain the
increased prevalence of diarrhoea.' With the diminishing passive immunity, the increased morbidity, and the
lower energy intake per kg body weight in the second
trimester of life, growth, which is excellent in the first
trimester, starts to falter between 3 and 6 months. 3 In
view of these results, we suggest that, in epidemiological studies of growth, nutrition, and health,
children of 0-3 and those of 3-6 months should not be
studied as one single group, as is often done. In
primary health care, special attention should be given
to prevention and treatment in the 3—6 months old.
Home visits to these children should help to avoid the
immunization delays, to do repeated clinical nutritional staging and to give personalized nutritional
advice.
This research was sponsored by the Nutricia
59
LETTERS TO THE EDITOR
Research Foundation and the Belgian Administration
for Development Co-operation.
JAN VAN dEN BROECK, MD, DTM&H
and ROGER EECKELS, MD, DTM&H
Department of Paediatrics,
University of Leuven,
Herestraat 49,
3000 Leuven, Belgium
References
1. Van den Broeck J, Eeckels R, Devlieger H. Child '
morbidity patterns in two tropical seasons and associated
mortality rates. Ira J Epidemiol 1993; 22: 1104-10.
2. Van den Broeck J, Eeckels R, Vuylsteke J. Influence of
nutritional status on child mortality in rural Zaire. Lancet
1993; 341: 1491-5.
3. Waterlow JC. Nutrition and growth In: Protein-Energy
Malnutrition Edward Arnold, London, 1992.
Sir,
Glucose Tolerance, C-peptide Response to Glucagon,
and Thyroid and Adrenal Fnctions in Relation to
Auto-antibodies in Vitiligo
Vitiligo is a relatively common disease that affects 1-2
per cent of the general population. It has clinical
association with many organ-specific auto-immune
diseases including Hashimoto's thyroiditis, Graves's
disease, adrenal insufficiency, and insulin-dependent
diabetes mellitus (IDDM) suggesting an auto-immune
etiology. 1 ' 2 Similarly, the increased prevalence of
auto-antibodies in patients with vitiligo and amelioration of the disease after prednisone therapy support
this hypothesis of auto-immune aggression. 3 ' 4 We
studied the prevalence of vitiligo in 500 patients with
non-insulin dependent diabetes mellitus (NIDDM),
and 60 children with IDDM and investigated the
thyroid and adrenal functions, glucose tolerance and
C-peptide response to i.v. glucagon in 15 children with
vitiligo and 20 age-matched normal children. The
prevalence of vitiligo was higher in patients with
IDDM (3 per cent) compared to those with NIDDM
(1 per cent), which confirms the anticipated clinical
association between IDDM and vitiligo. The hepatic
and renal functions as well as the haematological
parameters of two groups of children were within the
60
normal range and their serum was negative for
kidney/liver microsomal antibody, glomerular antibody, kidney basement-membrane antibody, and
gastric parietal-cell antibody. Insulin antibody was
detected in one child with vitiligo who had normal
glucose tolerance and C-peptide response to glucagon
(C-peptide = 5.9 and 4.6 ng/ml at 5 and 10 min after i.v
glucagon). Thyroid microsomal antibody was
detected in one child with vitiligo with normal serum
FT4 and TSH concentrations (FT4= 19.4 pmol/1 and
TSH = 2.5 mlU/ml). Impaired glucose tolerance was
noted in one child with vitiligo (glucose values were
5.6, 10.5, and 8.6 mmol/1 before, and at 1 and 2 hours
after the glucose load, respectively). This patient had
defective C-peptide release in response to glucagon
(peak C-peptide = 1.4 ng/ml), but did not have detectable insulin antibody in his serum. Thyroid function,
and basal and ACTH-provoked cortisol concentrations were normal in all the children. In conclusion,
vitiligo in children might be associated with glucose
intolerance and high levels of circulating thyroid
antimicrosomal and insulin antibodies. Therefore, it
might be useful to investigate the glucose tolerance and
thyroid function routinely in children with vitiligo.
ASHRAF T. SOLIMAN, M D ,
ABDUL RAOUF AL SUWEID, MD, HANI GAMIL, MD,
MOHAMED M. ABDEL KHADER, MD,
and MAURICE G. AFOUR, MD
Departments of Pediatrics and Endocrinology,
Royal Hospital,
and Departments of Dermatology and Medicine,
Nahda Hospital,
Muscat, Oman
References
1 Fitzpatrick TB, Eisen AZ, Wolff K, eds. Dermatology in
General Medicine, 3rd edn. Library of Congress and
Cataloging in Publishing Data, MacGraw Hill, USA,
1987.
2. Lerner AB, Nordlund JJ. Vitiligo—What is it 9 Is it
important? J Am Med Ass 1978; 239: 1183-7.
3 Brostoff J, Bor S, Feiwell M. Auto-antibodies in patients
with vitiligo. Lancet 1969; ii: 177-80.
4 Thomas PS. Prednisolone causing amelioration of both
vitiligo and chronic hepatitis. Br J Hosp Med 1987; 38.
464-8
Journal of Tropical Pediatrics
Vol.42
February 1996