Leprosy: a 'common' and curable cause of peripheral neuropathy with skin lesions

Leprosy (or Hansen's disease) is a curable chronic infectious disease caused by the acid-fast bacillus Mycobacterium leprae. While leprosy remains one of the most common causes of neuropathy worldwide, its rarity in the UK means that many doctors are unfamiliar with the typical clinical features. This is problematic because early recognition and treatment is vital in order to minimise disease-related complications such as nerve injury. We describe a 75-year-old man who presented with multiple mononeuropathy (mononeuritis multiplex, particularly affecting the ulnar nerves) and typical granulomatous skin lesions, in whom the diagnosis was made on the basis of skin biopsy. We highlight the clinical features, investigations and treatment of the patient, and provide information about the epidemiology and pathogenesis of leprosy.

Treatment of visceral leishmaniasis

The available treatment options for visceral leishmaniasis (VL) have problems relating to efficacy, adverse effects and cost, making treatment a complex issue. We review the evidence relating to the different methods of treatment in relation to - efficacy and toxicity of the drugs in different areas of the world; ability to monitor side effects, length of treatment; ability of patients to pay for and stay safe during treatment, ability of the healthcare services to give intramuscular, intravenous or oral therapy; the sex and child-bearing potential of the patient and the immune status of the patient. The high mortality of untreated/ poorly treated VL infection makes the decisions paramount, but a unified and coordinated response by each area is likely to be more effective and informative to future policies than an ad hoc response. For patients in resource-rich countries, liposomal amphotericin B appears to be the optimal treatment. In South Asia, miltefosine is being used; the combination of single dose liposomal amphotericin B and short course miltefosine looks encouraging but has the problem of potential reproductive toxicities in females. In Africa, the evidence to switch from SSG is not yet compelling. The need to monitor and plan for evolving drug failure, secondary to leishmania parasite resistance, is paramount. With a few drugs the options may be limited; however, we await key ongoing trials in both Africa and India to explore the effects of combination treatment. If safe and reliable combinations are revealed by the ongoing studies, it is far from clear as to whether this will avoid leishmania parasite resistance. The development of new drugs to add to the armamentarium is paramount. Lessons can be learnt from the management of diseases such as tuberculosis and malaria in terms of planning the switch to combination treatment. As important as establishing the best choice for specific antileishmanial agent is ensuring treatment centers, which can best manage the problems encountered during treatment, specifically malnutrition, bleeding, intercurrent infections, drug side effects and detecting and treating underlying immunosuppression.

New world cutaneous leishmaniasis in returned travellers: treatment failures using intravenous sodium stibogluconate

Treatment outcome was determined among a cohort of travellers who returned to the UK between February 2000 and February 2001 with New World cutaneous leishmaniasis caused by species of the Leishmania (Viannia) subgenus. Among 18 patients who completed treatment with 20 mg/kg/d of i.v. sodium stibogluconate (NaSb) for 20 d, early relapse of disease occurred in 2 patients with regional dissemination in 1 and mucocutaneous involvement in the other. Drug susceptibility testing in vitro of the clinical isolate from 1 of these patients confirmed tolerance to high concentrations of NaSb.

Borderline tuberculoid leprosy: an immune reconstitution phenomenon in a human immunodeficiency virus-infected person

Two months after starting highly active antiretroviral treatment (HAART), an individual with human immunodeficiency virus type 1 (HIV-1) infection and profound CD4+ T lymphocytopenia developed several erythematous plaques on his face, which were due to borderline tuberculoid leprosy with reversal reaction. The temporal association between the development of these lesions and changes in blood CD4+ lymphocyte count and plasma HIV-1 load observed during HAART strongly suggests that the presentation of leprosy resulted from immune reconstitution.

Update on leprosy

Leprosy, a result of infection by Mycobacterium leprae, is a leading cause of peripheral neuropathy. The World Health Organization aimed to eliminate leprosy as a public health problem by 2000, but this has not been attained. Patients with leprosy continue to present in the UK. The diagnosis of leprosy is frequently not considered, with resultant pathological and psychological problems for patients.

Immunohistochemical analysis of cellular infiltrate and gamma interferon, interleukin-12, and inducible nitric oxide synthase expression in leprosy type 1 (reversal) reactions before and during prednisolone treatment

The effects of prednisolone treatment on the cellularity and cytokine (gamma interferon, interleukin-12, and inducible nitric oxide synthase) profiles of leprosy skin type 1 (reversal) reactions were studied using immunohistochemistry. Skin biopsies were taken from 15 patients with leprosy type 1 (reversal) reactions at days 0, 7, 28, and 180 after the start of steroid treatment. Prednisolone treatment had little effect at day 7, but by day 28 significant decreases were found in cytokine levels. Some patients maintained cytokine production at days 28 and 180. These results illustrate the strong Th1 profile of type 1 reactional lesions, the slow response to steroid therapy, and continuing activity at 180 days.

The diagnosis of leprosy is delayed in the United Kingdom

Diagnostic delay in leprosy can have serious neurological consequences for the patient. We studied the presentation of leprosy patients, focusing on delays in diagnosis, in a retrospective case-note review of 28 patients referred to The Hospital for Tropical Diseases during 1995-1998. The median ages at onset of symptoms and at diagnosis were 25.1 years (range 9-77.7) and 30.1 years (range 9-78.3), respectively. The median time from symptom onset to diagnosis was 1.8 years (0.2-15.2). Prior to referral to a leprologist, patients had seen a dermatologist (20), neurologist (9), orthopaedic surgeon (5) and rheumatologist (2). Delay in diagnosis occurred in 82% of cases. Misdiagnoses as dermatological and neurological conditions were important causes of delay, and 68% of patients had nerve damage resulting in disability. Leprosy can be difficult to diagnose outside endemic areas. Increased awareness amongst general practitioners and hospital specialists would lead to more rapid diagnosis, thus minimizing damage and disability.

Steroids in leprosy type 1 (reversal) reactions: mechanisms of action and effectiveness

Steroids are widely used for the treatment of leprosy reactions. The effectiveness of steroid treatment is variable, with only 60% of patients regaining nerve function. Sequential skin biopsy specimens, obtained from 15 patients with type 1 (reversal) reactions, have been studied to document the cytokine profile and cellularity of the lesions. All of the patients were placed on a standard course of steroids after the first biopsy. Subsequent biopsies were performed seven, 28 and 180 days later. The specimens were stained for interferon-gamma (IFN gamma), interleukin-12 (IL-12) and inducible nitric oxide synthase (iNOS). After the first biopsy, all patients were placed on a standard reducing course of steroids beginning at 30 mg daily. By day 7, treatment with prednisolone showed little effect on the cellularity and cytokine profiles. However, by day 28, significant decreases of IFN-gamma, IL-12 and iNOS were found for most patients. Some patients maintained cytokine production at day 28 and even at day 180. These data illustrate the strong Th1 profile of type 1 reactional lesions, the relatively slow response to therapy, and the continuing activity after treatment with steroids for 180 days. The variation of individual responses emphasizes their importance. Additional prospective studies will be required to determine whether patients with high intra-lesional levels of cytokine are at risk of recurrent reactions. The need for studies both of different glucocorticoids and of other non-steroidal immunosuppressants for the treatment of reactions is discussed.

The pattern of leprosy-related neuropathy in the AMFES patients in Ethiopia: definitions, incidence, risk factors and outcome

The ALERT MDT Field Evaluation Study (AMFES) began in 1988 and followed patients prospectively for up to 10 years after release from treatment (RFT). This paper presents the findings from this cohort with regard to neuropathy and nerve damage. Five hundred and ninety-four new cases of leprosy are included in the study, 300 multibacillary (MB) and 294 paucibacillary (PB) cases. Fifty-five percent of patients had some degree of impairment at diagnosis and a further 73 (12%) developed new nerve function impairment (NFI) after starting multiple drug therapy (MDT). The overall incidence rate for neuropathy was 39 episodes per 100 PYAR in the first year after diagnosis, gradually declining to 12 episodes per 100 PYAR in the sixth year. In those patients without impairment at diagnosis, the incidence rate of neuropathy was 25 episodes per 100 PYAR for MB cases and 11 per 100 PYAR for PB cases in the first year; in 33% of MB cases whose first episode of neuropathy occurred after diagnosis, that first episode took place after the first year, or after the normal period of treatment with MDT. Seventy-three patients with neuropathy developing after diagnosis are reported more fully: 34 (47%) had only one nerve involved and of these 25 (73%) had a single, acute episode of neuropathy. Nine (27%) had further episodes. Thirty-nine (53%) had more than one nerve involved and of these 16 (41%) had a single, acute episode, while 23 (59%) had further episodes. The terms 'chronic' and 'recurrent' neuropathy are defined and used to describe the pattern of neuropathy in those with repeated attacks. In patients with no impairment at the start of the study, treatment with steroids resulted in full recovery in 88% of nerves with acute neuropathy but only 51% of those with chronic or recurrent neuropathy. The median time to full recovery from acute neuropathy was approximately 6 months, but in a few cases recovery occurred gradually over 2-3 years. Severe neuropathy was less likely to be followed by a complete recovery than mild or moderate neuropathy. Forty-two percent of nerves with acute neuropathy that were not treated with steroids also fully recovered. In the group of patients who were thought to have old, permanent impairments at diagnosis, full recovery of nerve function occurred in 87/374 (23%) of the nerves involved. The overall outcome is illustrated by examining the average EHF score for groups of patients. Patients with no new neuropathy after diagnosis show a gradual improvement in their EHF score, while those with any episodes of neuropathy after diagnosis show a gradual deterioration after completion of MDT. Possible explanations for these findings are discussed. Risk factors for neuropathy, for chronic and recurrent neuropathy, and for a poor outcome 5 years after release from treatment, are examined. Impairment at diagnosis was the main risk factor for a poor outcome, accompanied by the occurrence of chronic/recurrent neuropathy or a reversal reaction.

Immunohistochemical detection of PGL-1, LAM, 30 kD and 65 kD antigens in leprosy infected paraffin preserved skin and nerve sections

A panel of lipid, carbohydrate and protein antibodies were optimized for use in detecting M. leprae antigens in paraffin embedded material. Skin and nerve biopsies from 13 patients across the leprosy spectrum were studied. All antibodies detected antigen in tissues with a BI > 1. Phenolic-glycolipid was not detected in bacteriologically negative tissue but lipoarabinomanan (LAM) and protein antigens were detected. Staining with LAM was strongest and gave least background. The transfer of this immunohistochemical technique to paraffin embedded material will allow examination of tissue with better morphology and from clinics without access to tissue freezing facilities.

Leprosy in England and Wales

This paper reviews cases of leprosy notified in England and Wales to the Central Leprosy Register since its inception in 1951. Leprosy remains a rare condition in England and Wales, with fewer than ten cases notified on average in recent years. No definite case of indigenously acquired leprosy has been reported since the disease became notifiable. Although only a small number of patients present each year, leprosy remains a debilitating disease, and the unfamiliarity of clinicians with this condition can lead to delays in diagnosis and undernotification.

Kellersberger Memorial Lecture 1998: Nerve Damage in Leprosy: a problem for patients, doctors and scientists

There are interesting challenges in leprosy right now. The last fifteen years have seen the world-wide implementation of multidrug therapy with tangible benefits for patients and doctors. Paradoxically this success has revealed how much we still need to understand about leprosy nerve damage. For patients it is imperative that nerve damage is detected at an early stage when damage is still reversible. They need effective education to prevent the development of disability and to minimise the social and economic effects of nerve damage. For doctors and paramedical workers nerve damage needs effective treatment. We need to use current treatments effectively and also develop new treatments. This lecture looks critically at the pathology, detection and treatment of nerve damage, reviewing our present knowledge and looking to future developments.

Specificity and function of immunogenic peptides from the 35-kilodalton protein of Mycobacterium leprae

We identified a T-cell determinant of the 35-kDa antigen of Mycobacterium leprae which is discriminatory against cross-sensitization by its closely related homologue in Mycobacterium avium. From synthetic peptides covering the entire sequence, those with the highest affinity and permissive binding to purified HLA-DR molecules were evaluated for the stimulation of proliferation of peripheral blood mononuclear cells (PBMCs) from leprosy patients and healthy sensitized controls. Responses to the peptide pair 206-224, differing by four residues between M. leprae and M. avium, involved both species-specific and cross-reactive T cells. Lymph node cell proliferation in HLA-DRB1*01 transgenic mice was reciprocally species specific, but only the response to the M. leprae peptide in the context of DR1 was immunodominant. Of the cytokines in human PBMC cultures, gamma interferon production was negligible, while interleukin 10 (IL-10) responses in both patients and controls were more pronounced. IL-10 was most frequently induced by the shared 241-255 peptide, indicating that environmental cross-sensitization may skew the response toward a potentially pathogenic cytokine phenotype.

Pregnancy and leprosy: a comprehensive literature review

The interaction between pregnancy, leprosy and leprosy reactions was examined in a systematic literature review. Several retrospective case series and one retrospective cohort study but only one prospective cohort study were identified in the English literature. Type 1 (reversal) reactions were particularly likely to occur during the post partum. This temporal association was also present for both overt and silent neuritis. Type 2 (erythema nodosum leprosum) reactions occur throughout pregnancy and during lactation, and may be severe and recurrent. No prospective, controlled studies were found that documented the complications of pregnancy in women treated with multidrug therapy regimens. Our study highlights the need for such studies, with appropriate controls, on women throughout pregnancy and lactation so that risk factors for reaction and neuritis during pregnancy can be identified and quantified.

Immunocytochemical localization of inducible nitric oxide synthase and transforming growth factor-beta (TGF-beta) in leprosy lesions

Inducible nitric oxide synthase (iNOS) and TGF-beta were localized by immunocytochemistry in skin lesions from patients across the leprosy spectrum, and from patients undergoing reversal reaction. iNOS expression was highest at the tuberculoid pole of the spectrum, and increased during reversal reaction. TGF-beta was observed throughout the leprosy spectrum, but was highest at the lepromatous pole. Levels of TGF-beta decreased during reversal reaction. Reduced levels of TGF-beta may contribute to unregulated inflammatory responses during reactional episodes.

Harnessing the strengths of the leprosy programme to control tuberculosis

Tuberculosis remains a leading cause of death in Ethiopia but there is no effective national tuberculosis control programme. By contrast, the leprosy control programme has been very successful, with a 10-fold reduction in the number of leprosy cases requiring antibacterial treatment, though patients with nerve damage require continuing care. The paradox of rising numbers of tuberculosis cases and declining numbers of leprosy cases may be solved by joint leprosy-tuberculosis clinics. The strengths of leprosy fieldworkers in control management, case holding, and compliance can be harnessed in developing an effective tuberculosis control programme. Implementing a joint programme in Ethiopia may be beneficial not only for tuberculosis patients but also for leprosy patients, who are thus brought closer to general medical services.

Tumour necrosis factor-alpha (TNF-alpha) synthesis is associated with the skin and peripheral nerve pathology of leprosy reversal reactions

Leprosy may be complicated by episodes of increased cell-mediated immunity towards Mycobacterium leprae (reversal reactions) which result in severe local immunopathology in skin lesions and peripheral nerves. Using in situ hybridization and MoAb techniques we have demonstrated TNF-alpha mRNA and TNF-alpha protein in macrophages infiltrating leprosy skin and peripheral nerve. Levels of TNF-alpha mRNA are significantly increased in reactional skin and nerve, particularly in borderline tuberculoid patients. TNF-alpha mRNA and TNF-alpha protein levels are higher in reactional nerves then reactional skin. In both reactional skin and nerve TNF-alpha mRNA is more abundant than TNF-alpha protein; this may reflect the rapid turnover of TNF-alpha protein in an immunologically dynamic situation, such as is seen in reversal reaction. Our findings emphasize the importance of documenting both mRNA and protein production when assessing the role of cytokines in pathology. The leprosy reversal reaction may be regarded as a useful model of tissue immunopathology in which TNF-alpha is generated as part of the host response to infection, but also produces local tissue damage.

Recent advances in tropical medicine

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Nerve and skin damage in leprosy is associated with increased intralesional heat shock protein

Leprosy is frequently complicated by the development of reversal reactions in which peripheral nerve and skin lesions become inflamed and irreversible nerve damage may ensue. Increased expression of proteins belonging to the 70-kD heat shock family (hsp 70) occurs in cells of the central nervous system exposed to hyperthermia, physical damage or drug-induced trauma. In the present study we have used immunocytochemical staining to monitor hsp70 levels in peripheral nerves infected by Mycobacterium leprae. Hsp70 was detected in skin and nerve lesions from all leprosy patients, but was particularly prominent in lesions from patients undergoing reversal reactions. Hsp70 immunocytochemistry can thus be used as a marker of neural injury in the peripheral as well as in the central nervous system. The cellular dynamics of nerve damage in leprosy are currently poorly understood, and we postulate that the immunopathology of leprosy may be partly due to an autoimmune response to heat shock proteins.

Clinical features and outcome of reversal (type 1) reactions in Hyderabad, India

A retrospective survey of the notes on all patients attending Dhoolpet Leprosy Research Center, India, during 1985 was done to establish the frequency, timing, and clinical features of reversal (type 1) reactions; 494 case notes were examined and clinical evidence of a reversal reaction was found in 44 cases (10.9%). Reactions were most common in borderline patients, with 11.4% and 14.8% of borderline tuberculoid (BT) and borderline lepromatous (BL) patients developing reactions, respectively. Presentation in reaction was frequent with 47.5% of reactional patients having signs of a reversal reaction at the time of their first visit to the Dhoolpet clinic; 50% of skin reactions developing in patients on antileprosy treatment occur within the first month of treatment. Neurological reactions occur later and over a longer time course. Late reactions may occur up to 6 1/2 years after the start of treatment. Further reactional episodes occurred in 31.8% of the patients, and may be repeated. Steroid treatment produced improvement of both skin lesions and neuritis, but improvement in clinical signs and symptoms occurred in only 50% of the neuritic episodes.

Infections from animals to man

A conference on 'Infections from Animals to Man' was held at the Royal College of Physicians on 8 July 1992. The aim of the conference was to discuss the epidemiology and control of the zoonoses and the risks posed by zoonoses.

Skin problems in returning travelers

A new skin lesion in a returning traveler often poses a difficult diagnostic problem for the clinician whose knowledge of geographic medicine is limited. To reach a diagnosis the physician has to consider the location and style of travel, exposure to pathogens, length of stay, epidemiology, incubation period, and clinical presentation of dermatologic diseases in the countries visited. As with any dermatologic problem, the appearance of the presenting lesion should help to establish the differential diagnosis. This article is a guide to the diagnosis and investigation of skin lesions in returning travelers; it is not intended as a comprehensive review of tropical dermatology.

DLCO/Q and diffusion limitation at rest and on exercise in patients with interstitial fibrosis

Pulmonary diffusing capacity for carbon monoxide (DLCO) and pulmonary capillary blood flow (Qp) were measured on exercise in patients with a low DLCO with the aim of predicting, from the overall DL/Qp ratio, diffusion limitation for oxygen and relating it to the fall in arterial oxygen saturation actually observed. Five patients with cryptogenic fibrosing alveolitis (DLCO ranging from 20-54% predicted normal) exercised for 5 min at a work load equal to 60% of their maximum (45 to 90 watts). At 5 min (and previously at rest) they rebreathed rapidly for 15 sec from a 1.0 L bag containing helium (He), sulphur hexafluoride (SF6) and freon-22, 30% oxygen in argon and less than 1 ppm 11C-labelled carbon monoxide. Pulmonary capillary blood flow (Qp) and diffusing capacity (DLCO) were measured from flow-weighted breath-by-breath concentrations of freon-22 and 11CO, after correction for gas mixing delays (using He and SF6). Oxygen saturation (SaO2) (ear oximetry), MO2 and MCO2 and cardiac frequency were measured. PAO2 (ideal) was derived and mixed venous O2 saturation and content were calculated (Fick); PaO2 and PVO2 were derived from standard dissociation curves. For comparison, DLCO and Qp were measured in a similar fashion in five normal subjects exercising at 60 watts. Mean DLCO in patients with fibrosis was 9.62 (SD 2.88) ml.min-1, mm Hg-1 on exercise and mean Qp was 10.48 (SD 1.79) L.min-1 giving mean DLCO/Q ratios of 0.92 (SD 0.28). At 60 watts mean DLCO/Qp in normal subjects was 2.54 (SD 0.3), 2.76-times greater than in patients. SaO2% fell in patients by 3-15% on exercise. Predictions of alveolar-end capillary PO2 gradients from these overall DL/Q gradients showed that diffusion limitation accounted for 99% of the alveolar-arterial PO2 gradient on exercise in fibrosing alveolitis. Hughes (1991 Respir. Physiol. 83:167-178) [corrected] suggests that this simple approach overestimates the contribution of diffusion limitation by about 30%.

Revaccination with BCG: its effects on skin tests in Kuwaiti senior school children

Following a policy of BCG vaccination adopted in Kuwait more than 20 yrs ago, children receive their first vaccination just before starting school. Those who have a response of less than 10 mm induration to 2 tu of RT23 PPD, when they are 13 yrs old, are revaccinated. The effects of this revaccination on skin test positivity in a group of 18 yr old senior school children have been investigated. In a random study group 23% were found to have received BCG a second time. Revaccination resulted in a significant increase in positivity to tuberculin, and to the other 6 reagents tested, that was much more than would have been expected due to the passage of time alone in low responders. Scars of the second BCG vaccination were larger than those after the first vaccination, and showed a sex difference, with scars being significantly larger in boys than in girls. Boys also tended to show the largest responses to skin tests, with the notable exception of tuberculin to which girls showed the largest response. In most cases responses to skin tests were larger after revaccination than after a single vaccination. Based on this study, it is impossible to be sure that revaccination improved protective immunity, but the increase in tuberculin responsiveness, and recognition of environmental mycobacterial species may be indirect evidence supporting this conclusion.

Revaccination with BCG: its effects on skin tests in Kuwaiti senior school children

Following a policy of BCG vaccination adopted in Kuwait more than 20 yrs ago, children receive their first vaccination just before starting school. Those who have a response of less than 10 mm induration to 2 tu of RT23 PPD, when they are 13 yrs old, are revaccinated. The effects of this revaccination on skin test positivity in a group of 18 yr old senior school children have been investigated. In a random study group 23% were found to have received BCG a second time. Revaccination resulted in a significant increase in positivity to tuberculin, and to the other 6 reagents tested, that was much more than would have been expected due to the passage of time alone in low responders. Scars of the second BCG vaccination were larger than those after the first vaccination, and showed a sex difference, with scars being significantly larger in boys than in girls. Boys also tended to show the largest responses to skin tests, with the notable exception of tuberculin to which girls showed the largest response. In most cases responses to skin tests were larger after revaccination than after a single vaccination. Based on this study, it is impossible to be sure that revaccination improved protective immunity, but the increase in tuberculin responsiveness, and recognition of environmental mycobacterial species may be indirect evidence supporting this conclusion.

Parasite infections in AIDS

'Illnesses no one's got' was the epidemiological clue that led to the identification of AIDS as a new disease in 1981 when a rare infectious organism Pneumocystis carinii was seen in previously healthy homosexuals. Since then a wide range of parasite infections has been recognized in AIDS patients. However, these patients are not susceptible to just any passing parasite. The human immunodeficiency virus (HIV) produces a specific immune defect and only parasites that can exploit that defect will be able to flourish. In this review Diana Lockwood and Jonathan Weber explore the spectrum of parasite diseases recognized in AIDS and also consider those parasites that occur infrequently in AIDS. Analysis of parasitic infections that AIDS patients do not suffer from will yield valuable information about immune recognition and handling of these parasites.

A pilot study of three potential vaccines for leprosy in Bombay

Three vaccines, BCG Glaxo alone (vaccine A), BCG Glaxo plus 10(7) killed Mycobacterium vaccae (vaccine B), and BCG Glaxo plus 10(7) killed M. leprae (vaccine C), were given to groups of selected children. The effects of these vaccines on subsequent quadruple skin testing 1-3 years after vaccination were compared. All three vaccines equally and significantly (p less than 0.00001) increased positivity to tuberculin, but only vaccine B was found to significantly enhance development of skin-test positivity to leprosin A (p less than 0.002). The data support the evidence previously obtained in rural Iran that the combination of BCG with killed M. vaccae is likely to be a better vaccine for leprosy than is BCG alone.

Recognition of a category of responders to group II, slow-grower associated antigens amongst Kuwaiti senior school children, using a statistical model

A mathematical model previously developed to test the validity of categorisation of skin test responders has been applied to data obtained from 3 age groups of Kuwaiti school children. Two specially designed sets of 4 new tuberculins were tested on senior school children to determine whether extra categories of responders might exist amongst them. Strong statistical evidence has been obtained that a proportion of the children respond to group ii, slow-grower associated antigen, creating a fourth responder category, but no evidence was found for responses to group iii, fast-grower associated antigen. The significance of group ii antigens in immune protection from tuberculosis has never been considered specifically. It is of special interest to note that responders to these antigens have been readily found in Kuwait, a country where BCG is thought to be effective, whereas no such category could be found in India or Sri Lanka, where the efficacy of the vaccine is less certain.

A severe coagulopathy following volume replacement with hydroxyethyl starch in a Jehovah's Witness

Blood volume was maintained by an infusion of hydroxyethyl starch 2000 ml (Hespan: HES) during and for the first 28 hours after a major orthopaedic operation in a 13-year-old girl who was a Jehovah's Witness. This was responsible for a generalised clinical haemorrhagic state, an acquired coagulopathy associated with a shortened thrombin, prolonged prothrombin and activated partial thromboplastin times, and an acquired von Willebrand syndrome. The coagulation, after cessation of the infusion of HES, did not become normal until approximately 72 hours later.

Three types of response to mycobacterial antigens

Responses to pathogenic and environmental mycobacteria were assessed in 2680 children in India and Sri Lanka using quadruple skin-testing with new tuberculins. Statistical analysis of the results, by fitting a log-linear mixture model, confirmed the presence of three different categories of response: category 2 non-responders (about 55%) did not react to any component of the mycobacteria; category 3 responders (about 40%) were sensitive to the species-specific group iv antigens; and category 1 responders (about 5%) were sensitive to the group i antigens which are common to all mycobacteria. The proportions of the three response categories vary with age and with BCG status. BCG vaccination and increasing age act independently to decrease the proportion of category 2 non-responders and increase the proportion of category 3 individuals. BCG vaccination and increasing age interact to increase the proportion of category 1 responders.

Clinical experience of clerks and dressers: a three-year study of Birmingham medical students

A survey of the clinical experience of junior medical clerks and surgical dressers on their first clinical attachment in the Birmingham University Teaching Hospitals was organized by students over a three-year period. A typical clinical student had performed basic clinical procedures such as putting up a drip, doing an ECG, bladder catheterization and seen a wide range of other procedures. Most students felt involved in the work of the firm, had clerked routine admissions, and regularly attended the firm's emergency admission night. Consultants on most firms were felt to be concerned about student progress. Students attached to district general hospitals gained a wider range of clinical experience than those at established teaching hospitals. Student-run audit is a useful way of monitoring the clinical experience gained by medical students.

Student audit of clinical teaching: a three year study

An audit of teaching to junior clinical students in the University of Birmingham organised by students identified several surgical and medical firms on which they received little clinical teaching. Consultants spent an average of four and a half hours a week teaching junior students on the wards, arrived about 10 minutes late for that teaching, but missed less than 10% of teaching sessions. Junior students missed less than 10% of consultant teaching sessions and found them useful, though not always stimulating. Audit organised by students is an acceptable method of monitoring the informal teaching received by clinical students.

The preregistration year: Chaos by consensus

A questionnaire was sent to all preregistration housemen who had graduated from the University of Birmingham in July, 1975. The results showed much dissatisfaction with the workings of the houseyear--specifically, with the long, sleepless hours of work, the almost negligible educational role of the year, the lack of time for human contact with patients, and the tendious, repetitive nature of the work. It is proposed that a shift system, which wound seem to be acceptable to most housemen, would solve many of these problems, and result in a better deal for both doctors and patients.