Articles | Departments | Patient Information

Letters to the Editor

Current Immunization Recommendations

TO THE EDITOR: I am writing about the article on current immunization recommendations.¹ I find it very distressing that the author gives outdated recommendations for the use of tetanus toxoid and influenza and pneumococcal vaccines. The author did not reference the guide for adult immunization from the American College of Physician's Task Force on Immunizations,² nor did he reference the Morbidity and Mortality Weekly Report's recommendations from the Advisory Committee on Immunization Practices (ACIP). The section on toxoid does not include the Task Force's recommendation for boosting, which is a single mid-life diphtheria toxoid (DT) booster at age 50 for patients who have completed the primary series.

The ACIP guide for adult immunizations³ recommends that the 50th birthday generally be used as a marker for reviewing the patient's immunization status. Patients at high risk for pneumonia should receive pneumococcal vaccination at age 50, and all patients with high-risk conditions should be reimmunized every six years.

The section on influenza vaccine in the AFP article also omits a discussion of health care workers of any age who come in close contact with patients who are at high risk, which I believe should have been included.

R. BROOKS GAINER II, M.D.
Morgantown Internal Medicine Group, Inc.
300 Wedgewood Dr.
Morgantown, WV 26505-2494

REFERENCES

1. Adkins SB III. Immunizations: current recommendations. Am Fam Physician 1997;56:865-74.
2. ACP Task Force on Adult Immunization, Infectious Diseases Society of America. Guide for adult immunization. 3d ed. Philadelphia: American College of Physicians, 1994.
3. Centers for Disease Control and Prevention. Prevention of pneumococcal disease: recommendations for the Advisory Committee on Immunization Practices (ACIP). MMWR Morb Mortal Wkly Rep 1997;46(RR-8):1-24.

IN REPLY: As I indicated in the article, it is important for all practicing physicians to keep abreast of the most recent recommendations for immunization practices. References that provide this information, including the Morbidity and Mortality Weekly Report, are listed on page 867 of my article.

The use of the single dose of DT in adults on their 50th birthday is one such recommendation. Providing booster doses of DT every 10 years is still acceptable and recommended by some groups.^1,2 Practitioners should decide how they will use DT to best care for their patients. Recommendation for booster doses of pneumococcal vaccine has been debated for several years. The recommendation to vaccinate every six years is reasonable for adult patients in high-risk groups.

At the institution where I work, all employees are offered and encouraged to receive the influenza vaccine. Individuals who are not in the health care profession but who have close contact with patients in high-risk groups should also be considered for routine influenza immunization. I believe that this is common knowledge among practicing physicians and other health care workers.

SAMUEL ADKINS III, M.D.
Department of Family Medicine
East Carolina University School of Medicine
Greenville, NC 27858-4354

REFERENCES

1. Diphtheria. In: Peters G, ed. 1997 Red Book: report of the Committee on Infectious Diseases. 24th ed. Elk Grove Village, Ill.: American Academy of Pediatrics, 1997:191-5.
2. Zimmerman RK. AAFP, AAP, and ACIP release 1997 Childhood Immunization Schedule [Special Medical Report]. Am Fam Physician 1997;55:342-6.

Herpes Esophagitis in an Immunocompetent Host

TO THE EDITOR: Herpes simplex virus is a common oral pathogen in immunocompetent patients. Herpes esophagitis, however, is usually an opportunistic infection but can also occur in immunocompetent hosts.

A 27-year-old female presented with complaints of fever, myalgia, sore throat and lingual swelling; she was given a prescription for erythromycin. Two days later, she complained of pleuritic chest pain and severe odynophagia. The patient had no history of oral contraceptive use or pregnancy, no recent antibiotic or corticosteroid use and no risk factors for human immunodeficiency virus (HIV) infection. Pill esophagitis was suspected, and azithromycin (Zithromax) was substituted for erythromycin. Four days later, the patient was prescribed nizatidine (Axid) for "esophagitis" and was referred to the author for GI evaluation.

Figure. Endoscopic photographs of the distal esophagus showing diffuse inflammation with active hemorrhage.

On physical examination, the patient was afebrile. Examinations of the oropharynx, heart and lungs were normal.

Esophagogastroduodenoscopy (EGD) showed a diffusely inflamed esophagus with hemorrhage and ulceration in the mid-esophagus (see figure). Histology showed severe ulcerative esophagitis without evidence of Candida organisms or viral infection.

The patient's clinical syndrome had nearly resolved when a viral culture, obtained at EGD, demonstrated herpes simplex virus infection. No antiviral therapy was prescribed.

The patient lives with her mother, who is immunosuppressed. Three days prior to the onset of the patient's symptoms, her mother had begun taking acyclovir (Zovirax) for culture-proven oral herpes simplex virus infection.

The true incidence of herpes esophagitis in immunocompetent hosts is underestimated. First, herpes esophagitis is not suspected in normal hosts, particularly in the absence of odynophagia or oropharyngeal lesions. Indeed, there have been reports of herpes esophagitis without oral involvement in normal hosts who have not suffered chest pain or odynophagia.¹ Additionally, patients with severe herpes gingivostomatitis may have unrecognized herpes esophagitis if they are not questioned about esophageal symptoms or have only subtle dysphagia because of limited oral intake. Since herpes esophagitis in immunocompetent hosts is self-limited, these patients may be misdiagnosed when they "respond" to gastric antisecretory treatment or other empiric measures.

Esophageal histology in immunocompetent patients with herpes esophagitis usually demonstrates intranuclear inclusions and giant cell formation, unlike in our case.^2,3 When these hallmarks of viral infection are absent--and viral infection is not clinically suspected--diagnostic confusion can result.⁴ Viral culture has greater diagnostic sensitivity than histology or cytology.^1,5 If our patient had not received a viral culture, her illness might have been erroneously attributed to severe gastroesophageal reflux disease.

Immunocompetent patients with herpes esophagitis do not require antiviral therapy; spontaneous recovery is expected.⁶ Our patient was most likely infected by her mother, although both women may have contracted herpes simplex virus infection from another source. Another report of a patient with herpes esophagitis presumes the virus was contracted from the patient's spouse, who had a prior "fever blister."⁷

Herpes esophagitis should be included in the differential diagnosis of patients with acute esophageal complaints. This diagnosis may spare the patient unnecessary therapies such as those our patient received. In addition, these patients can be cautioned against exposing themselves to individuals who are susceptible to opportunistic infections. Finally, immunocompetent patients with herpes esophagitis can be reassured that their acute and frightening symptoms will rapidly subside.

MICHAEL KIRSCH, M.D.
6221 Tourelle Dr.
Highland Heights, OH 44143

REFERENCES

1. Elliott SY, Kerns FT, Kitchen LW. Herpes esophagitis in immunocompetent adults: report of two cases and review of the literature. W V Med J 1993; 89:188-90.
2. Ginaldi S, Burgert W Jr, Paulk HT Jr. Herpes esophagitis in immunocompetent patients. Am Fam Physician 1987;36:160-4.
3. Chien RN, Chen PC, Lin PY, Wu CS. Herpes esophagitis: a cause of upper gastrointestinal bleeding in an immunocompetent patient. J Formos Med Assoc 1992;91:1112-4.
4. Cardillo MR, Forte F. Brush cytology in the diagnosis of herpetic esophagitis. A case report. Endoscopy 1988;20:156-7.
5. McBane RD, Gross JB Jr. Herpes esophagitis: clinical syndrome, endoscopic appearance, and diagnosis in 23 patients. Gastrointest Endosc 1991; 37:600-3.
6. Baehr PH, McDonald GB. Esophageal infections: risk factors, presentation, diagnosis, and treatment. Gastroenterology 1994;106:509-32.
7. Deshmukh M, Shah R, McCallum RW. Experience with herpes esophagitis in otherwise healthy patients. Am J Gastroenterol 1984;79:173-6.

Use of Melatonin for Insomnia

TO THE EDITOR:: The New England Journal of Medicine recently published a review article on melatonin.¹ In the article, the author reviews most of the published studies on this hormone and concludes, "There is now evidence to support the contention that melatonin has a hypnotic effect in humans. Its administration in doses that raise the serum concentrations to levels that normally occur nocturnally can promote and sustain sleep."

The October 1, 1997, issue of AFP also had an article regarding melatonin.² After reviewing some of the literature on this pineal hormone, Dr. Cupp concludes, "Until more is known about this drug, it should be used cautiously, if at all." Frankly, I didn't see anything in the article that would lead to this kind of overcautious final recommendation. Has melatonin been associated with deaths? With falls and fractures, accidents or loss of memory? Why not recommend the occasional use of melatonin to treat insomnia and jet lag? Millions of Americans safely and effectively use melatonin for this purpose. It's been over three years since it has been available to the public, and no serious side effects have been reported in the medical literature. The same certainly cannot be said about the benzodiazepines.

The public has become more and more interested in natural alternatives to drugs. However, patients are not getting balanced information about these alternatives. As long as some members of the medical establishment try to discredit the use of natural alternatives that may be effective, patients will continue to lose faith in doctors. Patients are getting smarter, and they are recognizing that doctors are sometimes the last people to learn about and accept these natural, alternative forms of therapy. The public is also starting to realize that the medical establishment may not be willing to give a fair opinion about these natural alternatives partly as a result of influence from pharmaceutical companies. If melatonin were to become more popular, what would happen to sales of pharmaceutical hypnotics?

RAY SAHELIAN, M.D.
P.O. Box 12619
Marina del Rey, CA 90295

REFERENCES

1. Brzezinski A. Melatonin in humans. N Engl J Med 1997;336:186-95.
2. Cupp MJ. Melatonin. Am Fam Physician 1997; 56:1421-5.

IN REPLY: Dr. Sahelian contends that melatonin has been used safely and effectively by millions of Americans; even so, melatonin has not been objectively evaluated in clinical trials involving large numbers of patients. Furthermore, it is likely that adverse effects of melatonin and other food supplements go unrecognized and are thus unreported, because patients often do not disclose their use of such products to their physicians or other health care professionals.¹

In addition to the adverse effects outlined in the article, a psychotic episode temporally associated with the use of melatonin was recently reported.² The patient who experienced this adverse reaction was also taking fluoxetine, which further indicates the potential for interactions between drugs and food supplements.

Like melatonin, l-tryptophan (a melatonin precursor that caused several deaths) was initially thought to be safe. Although I do not casually dismiss melatonin, I do maintain that, until objective evidence of safety and efficacy is available from properly designed studies, melatonin should be used with caution.

MELANIE CUPP, PHARM.D.
Department of Clinical Pharmacy
West Virginia University School of Medicine
1124 HSN, P.O. Box 9550
Morgantown, WV 26506-9550

REFERENCES

1. Eisenberg DM, Kessler RC, Foster C, Norlock FE, Calkins DR, Delbanco TL. Unconventional medicine in the United States. Prevalence, costs, and patterns of use. N Engl J Med 1993;328: 246-52.
2. Force RW, Hansen L, Bedell M. Psychotic episode after melatonin [Letter]. Ann Pharmacother 1997; 31:1408.

The editors of AFP welcome input concerning topics of current medical interest and feedback in response to articles and other material published in AFP. Send letters to Jay Siwek, M.D., Editor, American Family Physician, 8880 Ward Pkwy., Kansas City, MO 64114; fax: 816-333-0303; 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. Letters submitted for publication in AFP must not be submitted to any other publication. Letters pertaining to AFP subject matter must be received within two months of publication. Any financial associations or other 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 reserve the right to edit correspondence to meet style and space requirements.

Copyright © 1999 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.