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Letters to the Editor

The Vicious Path of Varicella in a Family

to the editor: Varicella affects several million U.S. residents annually and is usually a self-limiting illness. Adults have higher morbidities and mortalities than children. Immigrants from tropical and subtropical climates are less likely to be infected as children, thereby resulting in greater susceptibility as adults. Increased use of varicella vaccine in children and susceptible adults, particularly in the immigrant population, will decrease the number of cases and should also decrease the associated morbidity and mortality.

We present the case of a Guaynese man who had resided in the United States for 14 years and who was the fifth person in his household to contract varicella. The index case was his four-year-old granddaughter who had been exposed to a preschool friend. Subsequently, his 37-year-old son, his two-year-old grandson and his 28-year-old daughter contracted the illness before he did. All of the cases were limited to cutaneous involvement, with the exception of the son, who died as a result of pneumonitis. None of the patients received antiviral therapy before hospitalization.

FIGURE. Diffuse vesicular eruption in varying stages.

Our patient was a 61-year-old man with a history of diabetes mellitus who had pain on swallowing and a vesicular rash on the abdomen, extremities and face. On day 3 of his illness, he was diagnosed as having uncomplicated varicella. He was afebrile, had an extensive vesicular rash (see figure) and had a normal chest radiograph. He was admitted two days later for intravenous administration of acyclovir, 10 mg per kg every eight hours. On day 3 of hospitalization, he had multiple episodes of diarrhea. Stool evaluation was negative and findings on sigmoidoscopy were unremarkable. The diarrhea was thought to be secondary to acyclovir therapy and responded to treatment with Imodium. The patient did well with treatment and was discharged on day 12 of his illness.

Before the introduction of varicella vaccine in 1995, about 4 million cases of varicella occurred yearly in the United States, with 4,000 to 9,000 hospitalizations and 100 deaths per year in nonimmunocompromised persons. Although less than 5 percent of varicella cases occur in adults, patients over 20 years of age account for more than one half of the fatalities related to varicella.¹ The Centers for Disease Control and Prevention (CDC) reported three deaths in 1997 in young women exposed to varicella by their unvaccinated preschool-aged children. The CDC reemphasized the use of varicella vaccine, varicella immune globulin when indicated and antiviral therapy.

Varicella vaccine was approved by the U.S. Food and Drug Administration in March of 1995 for use in healthy persons one year of age and older. The American Academy of Pediatrics, the American Academy of Family Physicians and the Advisory Committee on Immunization Practices of the U.S. Public Health Service have recommended a strategy of universal immunization of children 12 to 18 months of age. Older susceptible persons should also be vaccinated, especially those who are in close contact with persons at risk of developing serious varicella-related complications (i.e., health care personnel and contacts of immunocompromised persons). The vaccine is not approved for use in pregnant women or in immunocompromised patients.

The best defense for persons who cannot be vaccinated is to immunize those contacts likely to expose them to varicella. Varicella zoster-immune globulin can reduce the severity of symptoms when administered to individuals within 72 hours of exposure. It is indicated for those at high risk for complications: newborns whose mothers develop varicella within four days before and up to two days after delivery; healthy susceptible adults; and children and adults who are immunosuppressed due to their primary disease (malignancies, infection with human immunodeficiency virus) or secondary to therapy (steroids, chemotherapy, etc.).

Oral acyclovir has been shown to decrease the severity of varicella in children if given within 24 to 48 hours after the onset of rash.¹ Adverse effects of acyclovir include neurologic abnormalities (encephalopathy, tremors) and renal abnormalities.² Gastrointestinal disturbances, such as nausea, vomiting and bloating, have been reported.³ Diarrhea has been described in one series with diarrhea of one to four days' duration developing in 52 (35 percent) of 148 patients receiving acyclovir.³

This case highlights the need to initiate varicella immunizations in immigrant populations, as well as the need to administer antiviral therapy as soon as possible in the adult population. Vaccination might have prevented varicella infection in the children and subsequent exposure in the adults. Physicians should be aware of the higher risk of varicella susceptibility in patients from warmer climates and the need to initiate antiviral therapy as soon as possible in the adult population.

DEBORAH S. ASNIS, M.D.
The New York Flushing Hospital Medical Center
4500 Parsons Blvd.
Flushing, NY 11355

PHILIP LARUSSA, M.D.
Columbia University, College of Physicians and Surgeons
New York, NY

REFERENCES

1. Varicella-related deaths among adults--United States, 1997. MMWR Morb Mortal Wkly Rep 1997;46:409-12.
2. Arndt KA. Adverse reactions to acyclovir: topical, oral, and intravenous. J Am Acad Dermatol 1988; 18(1 Pt 2):188-90.
3. Choo DC, Chew SK, Tan EH, Lim MK, Monteiro EH. Oral acyclovir in the treatment of adult varicella. Ann Acad Med Singapore 1995;24:316-21.

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Richter's Hernia with Bowel Perforation

to the editor: In 1785, Richter¹ described hernias in which only part of the bowel wall was strangulated. Since only a small part of the circumference of the bowel is involved in such cases, gangrene can occur without intestinal obstruction. At our hospital, we recently saw what could be the first case of perforated Richter's hernia, with generalized peritonitis, in a patient who was 11 weeks and three days pregnant.

This 29-year-old woman, gravida 5, para 0, abortus 4, presented to the emergency department with diffuse abdominal pain of five days' duration. She had a previous right inguinal hernia that had been repaired six years earlier. In addition to being pregnant, she had a slightly tender and reddened right groin mass that she ascribed to the worsening of a recurrent hernia, which had troubled her over the past year. She had experienced bloating, nausea, vomiting and constipation over the past two days. Her clinical findings were compatible with an acute surgical abdomen.

FIGURE. Ileal perforation 3 cm proximal to the tented bowel wall, which was pinched by the Richter's herniation.

A single upright abdominal film revealed free peritoneal air. On celiotomy, a knuckle of distal ileum was released from its incarceration in a recurrent inguinal hernia. A small perforation was noted (see figure) 3 cm proximal to the incarcerated piece. The involved bowel was resected and the hernia was repaired from the inside. Her pregnancy and allergy to penicillin limited our choice of postoperative antibiotics, but with delayed surgical closure of her abdominal incision combined with judicious antibiotic use, she underwent an uncomplicated recovery. However, she was not able to carry her pregnancy to term. She miscarried at 15 weeks.

In a matched, comparative study of Richter's hernias and non-Richter's type incarcerated hernias, Kadirov and colleagues² noted that patients with Richter's hernias had greater preoperative delay, rate of bowel resection, length of hospital stay and postoperative morbidity and mortality rates. They concluded that early operative intervention is the mainstay of successful management and that awareness of the misleading clinical presentation of Richter's hernias is of utmost importance. Our own patient presented with bowel perforation and generalized peritonitis.

Initially uncommon, Richter's herniations are now being reported with increased frequency as trocar site complications after laparoscopic procedures.^3,4 With increased awareness and careful operative care of trocar sites, they should be effectively avoided.

Whether the peritonitis and surgical intervention were factors in our patient's eventual miscarriage is unknown. Nevertheless, it is possible that early repair of the inguinal hernia recurrence might have prevented the complication.

URIEL R. LIMJOCO, CAPT, MC, USNR
JOHN MICHAEL GRUBBS, LCDR, MC, USNR
MICHAEL D. THOMAS, LCDR, MC, USNR
U.S. Naval Hospital, Box 788250
Marine Corps Air Ground Combat Center
Twentynine Palms, CA 92278-8250

REFERENCES

1. Nyhus LM, Harkins HN, eds. Hernia. Philadelphia: Lippincott, 1964.
2. Kadirov S, Sayfan J, Friedman S, Orda R. Richter's hernia--a surgical pitfall. J Am Coll Surg 1996;182:60-2.
3. Radcliffe AG. Richter's herniation of the small bowel through the trocar site following laparoscopic surgery [Letter]. J Laparoendosc Surg 1993;3:520-2.
4. Hass BE, Schrager RE. Small bowel obstruction due to Richter's hernia after laparoscopic procedures. J Laparoendosc Surg 1993;3:421-3.

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A Novel Technique to Remove the Common Dog Tick

TO THE EDITOR: A potential complication of tick removal is separation of the tick head from the body with retention of the head in the wound as a source of late infection. Several studies^1,2 report a correlation between the duration of tick attachment and the likelihood of transmission of infection. Ticks embed themselves by inserting their hourglass-shaped hypostome (sucker) into the skin of the host and then secreting cement around it.³ When a tick is removed intact, the secreted adhesive material sometimes appears as a translucent white membrane attached to the tick's head. The dominant species of tick varies by geographic region, and some species are more difficult to remove intact than others.⁴ I suggest a mechanical rotation technique that removes the entire Demacentor variabilis (dog tick) more reliably than other common methods.

Two approaches to tick removal have been described⁴: (1) application of a noxious stimulus to induce the tick to withdraw spontaneously and (2) mechanical removal. An example of the first approach is suffocation with petroleum jelly. The low respiration rate of the tick (three to 15 times per hour) makes interruption of respiratory gas exchange a slow prospect at best. Touching a recently extinguished match to the abdomen of the tick has also been suggested, but this approach may precipitate regurgitation of infectious material into the host's tissues. I agree with other authors who have not found either of these methods to be reliable. Another unsuccessful approach involves subcutaneous injection of local anesthetic.⁵ Failure to dislodge ticks using this approach is not surprising since the mechanism of adherence to the host does not depend on a muscular action.

The most frequently reported mechanical method of removal involves grasping the tick thorax with forceps and applying gentle, constant traction.^3,5 This "traction" method may leave body parts behind if impatiently applied or if the tick is a fragile variety, and this technique may not be tolerated by children. Some physicians advocate surgical removal of the involved host tissue with the tick by punch biopsy needle.⁶ This technique would remove the entire tick, but it may be unnecessarily traumatic.

I propose a technique of mechanical removal involving rotation, which may be more reliable for rapid removal of the entire tick, including the head. The tick thorax is gripped delicately with a fine forceps or hemostat. The abdomen should not be squeezed since this may cause regurgitation. Then, being careful not to apply traction to the host's skin, the tick is rotated approximately two revolutions about the long axis of its body. Concomitant rotation and traction, as suggested by some physicians,⁷ may flex the hypostome, leaving it embedded in the host. Micrography of the tick hypostome indicates a surface textured by rows of conical "denticles" pointing backward.^5,11 Shearing forces applied by rotation might be more effective than tensile forces in removing this type of structure intact. My practice has been to rotate the tick counterclockwise, although the directionality or consistency of direction of rotation is probably unimportant.

My success rate of complete live tick removal using the rotational technique has been 100 percent in 23 efforts, compared with about 50 percent in approximately 40 previous attempts in adults, children and domesticated animals. It is important to note that the rotational technique is fast and painless compared with direct traction, which occasionally causes marked discomfort.

In summary, ticks should be removed as soon as possible to reduce the likelihood of transmission of infectious disease. Rotation of the tick without traction may prove to be a superior method to straight traction in facilitating complete removal of the tick.

LEX SCHULTHEIS, M.D., PH.D.
The Johns Hopkins Hospital
Tower 711 600 N. Wolfe St.
Baltimore, MD 21287

REFERENCES

1. Falco RC, Fish D, Piesman J. Duration of tick bites in a Lyme disease-endemic area. Am J Epidemiol 1996;143:187-92.
2. Sood SK, Salzman MB, Johnson BJ, Happ CM, Feig K, Carmody L, et al. Duration of tick attachment as a predictor of the risk of Lyme disease in an area in which Lyme disease is endemic. J Infect Dis 1997;175:996-9.
3. Needham GR. Evaluation of five popular methods for tick removal. Pediatrics 1985;75:997-1002.
4. Crawford KL. Ticks. Md State Med J 1971;20:95-6.
5. Lee MD, Sonenshine DE, Counselman FL. Evaluation of subcutaneous injection of local anesthetic agents as a method of tick removal. Am J Emerg Med 1995;13:14-6.
6. Oteo JA, Martinez de Artola V, Gomez-Cadinanos R, Casas JM, Blanco JR, Rosel L. Evaluation of methods of tick removal in human ixodidiasis [Spanish]. Rev Clin Esp 1996;196:584-7.
7. Pfenninger JL, Fowler GC. Procedures for primary care physicians. St. Louis: Mosby, 1994.
8. Sixl W, Dengg E, Waltinger H. Scanning electron microscopy studies of ticks. IV. Haemaphysalis inermis Birula, 1895 [German]. Acta Zool Pathol Antverp 1972;55:67-9. *

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