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Letters to the Editor

Pneumococcal Vaccination in Elderly and At-Risk Patients

TO THE EDITOR: The article by Drs. King and Pippin¹ on initial antibiotic therapy in community-acquired pneumonia was a comprehensive review of drug therapy for patients with community-acquired pneumonia on an outpatient and inpatient basis and in younger versus older adults. However, since community-acquired pneumonia is a common infection and is the leading cause of death related to infectious disease, more emphasis could have been placed on the use of pneumococcal vaccination in controlling or preventing pneumococcal pneumonia in elderly and high-risk patients with chronic disease.

Fedson² showed in case-control studies and indirect cohort studies that pneumococcal vaccination is effective in preventing invasive pneumococcal disease in patients who are older or who are at higher risk. The Office of Technology Assessment has also shown that pneumococcal vaccination is cost-effective in preventing pneumococcal pneumonia in elderly persons.² The cohort study showed that patients who were discharged after being treated for pneumonia had a 6 to 9 percent probability of readmission with pneumonia within five years and that each such readmission could be prevented by immunizing discharged patients with pneumococcal vaccine. The study also showed that the costs of vaccination would equal approximately one third the costs of hospital care for unvaccinated patients who were discharged and then readmitted with pneumonia; the authors recommend that elderly patients be immunized with pneumococcal vaccine on discharge from the hospital.

Another article by Gable and colleagues³ evaluated the efficacy and cost savings of the pneumococcal pneumonia vaccine in a retrospective cohort study; the investigators concluded that the pneumococcal vaccine is effective in persons who have had pneumonia, persons who are at risk of developing pneumonia, and persons who are over 50 years of age.

Family physicians need to place greater emphasis on giving pneumococcal vaccine to the elderly and others who are at risk for pneumonia.

HENRY H. ANDERSON IV, M.D.
Southside Healthcare-Morrow
6185 Jonesboro Rd.
Morrow, GA 30260

REFERENCES

1. King DE, Pippin HJ Jr. Community-acquired pneumonia in adults: initial antibiotic therapy. Am Fam Physician 1997;56:544-50.
2. Fedson DS. Pneumococcal vaccination in the prevention of community-acquired pneumonia: an optimistic view of cost-effectiveness. Semin Respir Infect 1993;8:285-93.
3. Gable CB, Holzer SS, Engelhart L, Friedman RB, Smeltz F, Schroeder D, et al. Pneumococcal vaccine. Efficacy and associated cost savings. JAMA 1990;264:2910-5.

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Paresthesias

TO THE EDITOR: I would like to commend Dr. McKnight for an excellent review on paresthesias.¹ I am particularly pleased that he categorized pathoetiologies based on central and peripheral phenomena. However, a number of inaccuracies and omissions of valuable information warrant discussion.

Entrapment of the lateral femoral cutaneous nerve is not "usually" without motor deficit. This nerve is pure sensory, and weakness suggests polyneuropathy, plexopathy, radiculopathy or another type of mononeuropathy. Recognition of the absence of weakness is important, as lateral thigh numbness with motor impairment secondary to plexopathy may indicate occult malignancy compressing the lumbar plexus.² Tumor compressing the nerve at the root level with isolated paresthesias has been reported,³ indicating the merit of differentiation with electrodiagnostic testing.

Cubital tunnel syndrome is described in the article as being associated with leaning on the elbow and the presence of a shallow ulnar groove. In fact, cubital tunnel syndrome occurs when there is ulnar entrapment under the flexor carpi ulnaris in the proximal volar portion of the forearm. Entrapment at the ulnar groove results in compression at a more proximal, distinct site.⁴ Discrimination is important, as neurosurgical decompression must be precise to limit the extent of excision and accompanying morbidity.

The authors define the C6 dermatome as involving the lateral portion of the forearm, the thumb, and the index and middle fingers. It is commonly accepted that the C7 dermatome transmits afferent sensation from the entirety of the middle digit.⁵ As the authors point out, "Knowledge of sensory spinal root distribution and cutaneous nerve distribution is requisite to diagnosing paresthesias." In fact, the American Spinal Injury Association defines the C7 dermatome spinal cord injury sensory level as being the middle digit. The importance of knowing right and left sensory and motor levels cannot be overemphasized. These levels are invaluable in monitoring response to emergent methylprednisolone in traumatic myelopathies. Similarly, rostral ascension of a level in an acute or chronic situation may suggest syrinx progression to the medullary respiratory centers with potential imminent ventilatory failure.

I was disappointed that historical clues to suggest paresthesias in multiple sclerosis were not accompanied by solicitation of visual symptoms, spasms, bowel/bladder deficits, or onset of similar episodes disseminated in space and time, commonly occurring in young female patients.

Initial laboratory evaluation with an erythrocyte sedimentation rate was listed, but it is important to convey the critical and profound urgency of investigation mandated by an elevated rate, as systemic involvement of vasculitic mononeuropathy multiplex⁶ can rapidly ensue with fatal consequences.⁷

One final major concern is that of underappreciation of the value inherent to optimal evaluation with electromyography and nerve conduction studies. Electrodiagnosis can define severity and rate of progression, and can strongly suggest and differentiate axonal or demyelinating histopathology in peripheral polyneuropathies. Electrodiagnostic data can be invaluable in defining prognosis and can suggest the immediacy of further work-up or treatment. For example, data may suggest multifocal motor neuropathy with conduction block that is amenable to treatment and reversal of quadriparesis. Identical information can be collected in peripheral mononeuropathies to guide the neurosurgeon as to decompression of peripheral nerve, plexus, or root entrapment sites.

AARON S. GELLER, M.D.
28 Littell Rd.
Brookline, MA 02146

REFERENCES

1. McKnight JT, Adcock BB. Paresthesias: a practical diagnostic approach. Am Fam Physician 1997;56: 2253-60.
2. Suber DA, Massey EW. Pelvic mass presenting as meralgia peresthetica. Obstet Gynecol 1979;53: 257-8.
3. Flowers RS. Meralgia paresthetica. A clue to retroperitoneal malignant tumor. Am J Surg 1968;116: 89-92.
4. Kincaid JC. AAEE minimonograph: 31: the electrodiagnosis of ulnar neuropathy at the elbow. Muscle Nerve 1988;11:1005-15.
5. Haymaker W, Woodhall B, eds. Peripheral nerve injuries; principles of diagnosis. 2d ed. Philadelphia: Saunders, 1953.
6. Parry GJ. AAEM case report no. 11: mononeuropathy multiplex. Muscle Nerve 1985;8:493-8.
7. Mandell BF, Hoffman GS. Differentiating the vasculitides. Rheum Dis Clin North Am 1994;20:409-42.

IN REPLY: Our article, an overview of a complex neurologic disorder that is frequently seen by family physicians, was designed to provide a framework for these physicians to use when making a diagnosis.

Dr. Geller indicates that the lateral femoral cutaneous nerve is a pure sensory nerve, which is correct. The word "usually" should not have been in the article. Dr. Geller's points about weakness, etc., are also accurate. However, it was beyond the depth of this article to cover the entire neurologic spectrum of the persisting disorder. The purpose of the review article was to serve as an introduction for family physicians. A complete review of treatment could not have been placed on nine pages.

We researched the dermatomes mentioned by Dr. Geller in several sources that were validated by practicing neurologists. However--as one might expect--these sources did not completely agree, but they were the ones with which we felt most comfortable.

We appreciate Dr. Geller's point regarding our lack of emphasis on use of the erythrocyte sedimentation rate in diagnosis. However, we did not feel it was necessary to mention all of the specific diseases diagnosed through a given laboratory test or the potential significance of abnormal readings. Dr. Geller also mentioned our underappreciation of nerve conduction velocity studies and electromyography. We feel that these tests were mentioned correctly. It is our opinion that these tests serve best as useful adjuncts to the initial tests mentioned. Although the results can be very important, it is our experience that these tests rarely suggest a diagnosis that is not clinically apparent.

JERRY T. MCKNIGHT, M.D.
BOBBI B. ADCOCK, M.D.
Department of Family Medicine
University of Alabama School of Medicine
Capstone Medical Center
700 University Blvd., E.
Tuscaloosa, AL 35401

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Reflex Sympathetic Dystrophy

TO THE EDITOR: I am writing in response to the recent editorial on reflex sympathetic dystrophy.¹ Many of the references cited were written by Dr. Ochoa or his colleagues and do not, in my estimation, represent the opinion of the medical majority.

It is Dr. Ochoa's belief that the concept of reflex sympathetic dystrophy, for the most part, doesn't exist. He makes reference to "many patients with reflex sympathetic dystrophy, those who neither have organic neurologic damage nor malinger, harbor a primary psychiatric disorder in the realm of what used to be called 'psychosomatic disease . . . '" I recently attended a conference in Orlando, Fla., where more than 200 patients with reflex sympathetic dystrophy were present to learn about possible advances on the horizon for the treatment of this incurable and disabling problem. Perhaps Dr. Ochoa should be present at the next such meeting and address this group himself.

Dr. Ochoa fails to recognize the established work of many experts in the treatment of reflex sympathetic dystrophy. He also seems to feel that the use of sympathetic blockade is either useless or farcical and seems to castigate physicians who perform diagnostic tests and ridicule patients who do not have clear-cut neurologic symptoms. He should recognize that this disorder is one that does not allow for clear-cut findings to exist, which is why the diagnosis is so difficult and the treatment virtually impossible in certain instances.

Dr. Ochoa states that the disorder is neither reflex nor sympathetic nor dystrophy; perhaps that is why the experts in this field have changed the name of the disorder to "complex regional pain syndrome."

PHILLIP GETSON, D.O.
Cherry Hill Medical Associates, P.A.
712 Haddonfield Rd., Ste. 202
Cherry Hill, NJ 08002

REFERENCE

1. Ochoa J. Reflex sympathetic dystrophy: fact and fiction [Editorial]. Am Fam Physician 1997;56:2182-5.

IN REPLY: In response to Dr. Getson's letter regarding my editorial on reflex sympathetic dystrophy, I would like to offer the following comments:

After extensive literature review, I continue to question the validity of reflex sympathetic dystrophy as a pathophysiologically meaningful diagnostic entity. To further support my views, I urge readers to review the enclosed references.^1-6 The clinical entity labeled with the descriptive term "reflex sympathetic dystrophy" is heterogenous. A variety of organically and psychologically based disorders can yield the same symptom complex. Moreover, the concept of "sympathetically maintained pain" is disabled by current awareness that what had been thought of as a gold standard test--the sympathetic block--amounts to a placebo artifact.

This issue is more than a mere theoretic debate; my concern lies in the possibility of misdiagnosis and its attendant complications. If a label of "reflex sympathetic dystrophy" in any way denies or postpones a proper diagnosis or subjects a patient to unnecessary treatment, we have done our patient a great disservice.

As long as a lack of definitive evidence remains, it will be impossible to decide the bottom line; the debate continues and, indeed, remains necessary. As long as theoretic assumptions are the basis for empiric treatments that may fail or result in harm, our patients are at risk for needless suffering. Consider my proposal then, that for the time being we view reflex sympathetic dystrophy as a nonspecific symptom complex rather than a discrete pathophysiologic disease entity.

JOSE OCHOA, M.D., PH.D., D.SC.
Department of Neurology
Neuromuscular Unit
Good Samaritan Hosptial
1040 N.W. 22nd Ave., Ste. NSC 460
Portland, OR 97210

REFERENCES

1. Ochoa JL. Essence, investigation, and management of "neuropathic" pains: hopes from acknowledgement of chaos [Editorial]. Muscle Nerve 1993; 16:997-1008.
2. Teasell RW, Shapiro AP, Merskey H, Day FJ. Essence, investigation, and management of "neuropathic" pains: hopes from acknowledgement of chaos [Letters]. Muscle Nerve 1995;18:454-62.
3. Ochoa JL. Reflex? Sympathetic? Dystrophy? Triple questioned again [Editorial]. Mayo Clin Proc 1995;70:1124-6.
4. Chelimsky TC, Low PA, Naessens JM, Wilson PR, Amadio PC, O'Brien PC. Reflex sympathetic dystrophy [Letter]. Mayo Clin Proc 1996;71:524-5.
5. Landau WM. Reflex sympathetic dystrophy [Letter]. Mayo Clin Proc 1996;71:524-5.
6. Ochoa JL. Chronic pains associated with positive and negative sensory, motor, and vasomotor manifestations: CPSMV (RSD;CRPS?). Heterogenous somatic versus psychopathologic origins. J Contemp Neurol 1997;2(2).

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.

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