Letters to the Editor - February 1, 2000 - American Academy of Family Physicians

Letters to the Editor

Neurologic Complications of Epstein-Barr Virus Infection

TO THE EDITOR: It has been estimated that less than 1 percent of persons infected with Epstein-Barr virus (EBV) have central nervous system complications. These complications include encephalitis, Guillain-Barré syndrome, aseptic meningitis, facial palsy, transverse myelitis and Bell's palsy.^1-3 EBV encephalitis is generally self-limited without sequelae but may produce cerebellar ataxia.^4,5 I would like to present a report on a child with encephalitis and cerebellar ataxia from EBV infection.

A two-year-old girl presented with a generalized seizure with tonic-clonic movements of all extremities. She was found to be in status epilepticus in the emergency department and was given 0.25 mg per kg of diazepam (Valium) intravenously, which stopped the convulsions. She responded to painful stimulation and was aroused by stimulation by her mother. Blood chemistries were within normal limits. A blood culture was obtained. A cerebrospinal fluid analysis was performed, which showed clear colorless spinal fluid with a glucose level of 66 mg per dL (normal range: 40 to 70 mg per dL), protein of 43 mg per dL (normal range: 15 to 45 mg per dL), red blood cell count of 10 per mm³, white blood cell count of 70 per mm³with 50 percent lymphocytes. The electroencephalogram and computed tomographic scan were within normal limits.

The child became more responsive and the postictal state cleared, but she was ataxic with falling to her right side. The Bactogen panel for Haemophilus influenzae, Neisseria meningitidis and Streptococcus pneumoniae was negative. She was discharged and followed through outpatient office visits. Complete blood count on discharge revealed a white blood cell count of 11,400 per mm³, with 36 percent lymphocytes and 14 percent atypical lymphocytes. Blood and spinal fluid cultures were negative for growth. The patient was extremely fatigued and would sleep for long periods after participating in activities. An EBV antibody profile was submitted. Spinal fluid polymerase chain reaction results for herpes types 1 and 2 were negative. Two weeks after discharge, she appeared normal with her gait disturbance resolved. The EBV profile was positive, showing a viral capsid antigen (VCA)IgM value of 20 arbitrary units (AU) with a positive reading defined as a value of 20 AU or greater; a VCAIgG value greater than 170 AU (positive defined as a value of 20 AU or greater) and a nuclear antigen antibody greater than 200 AU (positive defined as a value of 20 AU or greater). The patient continues to do well at follow-up.

Because there are few distinguishable clinical features, a clinical diagnosis of viral encephalitis may be difficult to make. Evaluation of the cerebrospinal fluid of a child with encephalitis will typically show a lymphocytic pleocytosis with mild protein elevation and normal glucose level.³ Altered consciousness and generalized seizure are the most common presenting symptoms of postinfectious encephalitis.⁵ Cerebellar ataxia may occur with or follow viral infections of the nervous system. Most patients with neurologic complications recover within several months.²

It is possible that invasion of the nervous system by EBV-infected cells may commonly occur but only occasionally produce significant neurologic disease. The mechanism of injury may be the result of infected cells infiltrating neural tissue or inducing an inflammatory reaction that secondarily causes symptoms.^3,6

MICHAEL W. SIMON, M.D., PH.D.
2647 Regency Road
Lexington, KY 40503

REFERENCES

Grose C, Henle W, Henle G, Feorino PM. Primary Epstein-Barr-virus infections in acute neurologic disease. N Engl J Med 1975;292:392-5.

Joncas JH, Chicoine L, Thivierge F, Bertrand M. Epstein-Barr virus antibodies in the cerebrospinal fluid. A case of infectious mononucleosis with encephalitis. Am J Dis Child 1974;127:282-5.

Ho DD, Hirsch MS. Acute viral encephalitis. Med Clin North Am 1985;69:415-29.

Bennett DR, Peters HA. Acute cerebellar syndrome secondary to infectious mononucleosis in a fifty-two-year-old man. Ann Intern Med 1961;55:147-9.

Hoyne RM. Involvement of the central nervous system in infectious mononucleosis. Report of a case with ataxia and nystagmus. Arch Neurol Psychiat 1950;63:606-10.

Blaw ME, Sheehan JC. Acute cerebellar syndrome of childhood. Neurology 1958;8:538-42.

Patient Compliance: In Search of the Real Question in Diabetes Care

TO THE EDITOR: Primary care physicians handle more than 75 percent of all ambulatory visits made by patients with diabetes, a disease that affects 16 million Americans, kills 160,000 annually and accounts for one of every $7 related to health care.¹ A recent article in Diabetes Care² reported that primary care providers rate diabetes as "harder to treat" than five other chronic conditions. Explanations ranged from the characteristics of diabetes itself, to the lack of support from the health care system, to "horrible struggles" [sic] with patients because of food restrictions, to patients who fail to follow medical recommendations.

The treatment of patients with diabetes has undergone dramatic changes over the past 10 years. Major studies have shown that the culprit of complications is chronic hyperglycemia and not any particular food.³ These studies have emphasized the importance of tailoring treatments to the individual patient's needs and lifestyle, with no one treatment plan privileged over another--as long as the goal of normalizing blood glucose is attained. Furthermore, the American Diabetes Association has eliminated the use of the term "diabetic diet," which it now considers inappropriate because numerous factors are known to influence metabolic response to food. Yet, often times physicians (and even patients) attribute unexplained hyperglycemia to patients "cheating" on prescribed diets that frequently exclude sugar and other specific foods. Noncompliance is considered a major barrier in treating patients with diabetes. While several studies address the other side of the patient noncompliance equation,⁴a few^1,5 examine the medical adequacy of recommendations.

Our study⁶ involved focus groups within two Internet-based diabetes support groups using the cited information² as a generating tool. Participants commented on physicians' statements, and both sets of statements were compared. Unlike physicians, patients perceived the following factors as major barriers to compliance: (1) physicians' insufficient knowledge about diabetes (making vague statements such as "Your diabetes is mild," "You [patients with type 2 diabetes] shouldn't use insulin," or "Stay away from sugar"), (2) physicians' limited ability to handle psychosocial aspects of diabetes and (3) physicians' tendency to blame patients for treatment failures.

Albeit preliminary, our findings should warn physicians about oversimplifying barriers to diabetes care. If medical recommendations are inappropriate, compliance would be counterproductive. Furthermore, compliance itself might be inadequate in addressing a disease that requires a dynamic relationship between technical expertise of treatment and the experiential knowledge about living with diabetes.⁶ Quality diabetes care calls for patients' active participation and change within the health care system, as well as for a major restructuring at the level of physician education,¹ in medical school and continuing education. An encompassing approach to diabetes care should serve as a foundation to rethink barriers to treatment, improve the quality of medical interventions, decrease the financial burden of diabetes and orient research resources.

CLAUDIA CHAUFAN, M.D.
Department of Community Studies
University of California in Santa Cruz
Santa Cruz, CA 95064

REFERENCES

Hirsh I. Diabetes Education (for Doctors). Clinical Diabetes 1999;17:50-1.

Larme AC, Pugh JA. Attitudes of primary care providers toward diabetes: barriers to guideline implementation. Diabetes Care 1998;21:1391-6.

American Diabetes Association: Implications of the UKPDS. Diabetes Care 1999;22:S27-31.

Street RL Jr. Information-giving in medical consultations: the influence of patients' communicative styles and personal characteristics. Soc Sci Med 1991;32:541-8.

Ross F. Patient compliance-whose responsibility? Soc Sci Med 1991;32:89-94.

Chaufan C. Looking through patients' eyes: the other barriers to treatment [Abstract]. Diabetes 1999;48:A160.

Comment on the Family Physician as Hospitalist

TO THE EDITOR: I read with interest the letter on the role of the family physician as a hospitalist.¹ I joined a practice in Washington, N.J., in 1984, but well before that, this group of physicians had been rotating hospital care of patients on a weekly basis. The rotation continues, and the physician on hospital duty has only the hospital as the primary responsibility for that assigned week. We do not have the inherently disjointed coverage problems because we do not share on-call arrangements with other practices. The physician on call handles all the admissions for that week, as well as all the calls for the practice at large. At the office, we have extended hours of operation that include Saturday hours, so the calls generally do not become onerous.

I could not agree more with Drs. Guyn. As a rule, our patients are pleased with their inpatient care. The on-call rotation exposes our patients to other members of our practice. This improves our outpatient care by increasing patient identification with the group and not just with one physician. It also reminds the physicians that this is a group practice--continuity is preserved.

The hospitalist movement has appeared under the shadow of managed care. Attempting to reach goals of hospital days per 1,000 insured lives of less than 200 days per year brings with it concern for the present process of inpatient care. Decreasing use of hospital services will increase outpatient care. In the future, who will feel adequately trained and experienced to handle the smaller number of patients on our inpatient services? The future may reveal a shared physician caring for the inpatients of several practices.

JAMES E. GOODWIN, M.D.
Warren Hills Health Center
Washington, NJ 07882

REFERENCES

Guyn J, Guyn T. The family physician as a hospitalist [Letter]. Am Fam Physician 1999;60:502-3.

Correction

An item in "Tips from Other Journals" in the July 1999 issue contains an error. The review on page 286, "Comparison of Drugs Used to Treat Chronic Hypertension," incorrectly states that persons who are taking diuretics should not take ACE inhibitors (fourth sentence of the first full paragraph on page 288). This phrase should have been omitted from the text.

Clarification

A statement about metformin and radiographic contrast material in the article "Evaluation of Asymptomatic Microscopic Hematuria in Adults" (September 15, 1999, page 1143) requires clarification. Starting with the third sentence of the third complete paragraph on page 1148, the paragraph should have read as follows: "Because of potential exacerbation of acute renal failure and lactic acidosis, metformin should be discontinued at the time of radiologic studies involving intravascular administration of iodinated contrast materials and withheld for 48 hours subsequent to the procedure. It should be reinstituted only after renal function has been reevaluated and found to be normal." The statement in the article reflected current recommendations at the time the article was written. However, a new recommendation had been issued by January 1999, according to Bristol-Myers Squibb.

*These corrections have been made to the online version of AFP. The links above will take you to the corrected items, which remain part of the online issues in which they were originally published.

Send letters to Jay Siwek, M.D., Editor, American Family Physician, 11400 Tomahawk Creek Parkway, Leawood, KS 66211-2672; fax:913-906-6080; e-mail: afplet@aafp.org. Please include your complete address, telephone number and fax number. Letters should be double-spaced, fewer than 500 words and limited to one table or figure and six references. Please submit a word count. Letters submitted for publication in AFP must not be submitted to any other publication. Possible conflicts of interest must be disclosed at time of submission. Submission of a letter constitutes transfer of copyright to the American Academy of Family Physicians. The editors may edit letters to meet style and space requirements.

Copyright © 2000 by the American Academy of Family Physicians.
This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Contact afpserv@aafp.org for copyright questions and/or permission requests.

February 1, 2000 Contents | AFP Home Page | AAFP Home | Search