SCABIES - Continued

contacts. Scabies is treated by applying cream or lotion containing 1% lindane (Kwell*) or 10% cromatiton (Eurax*), or benzyl benzoate ointment to the entire body below the chin. The medication is washed off 24 hours after application. À repeat treatment 7-10 days later is generally recommended. Because of the long incubation period in which transmission

can occur, treatment of close contacts in an institutional setting or all members of a family of an infested individual should be considered.

*Use of trade names is for identification only and does not constitute endorsement by the Public Health Service, U.S. Department of Health, Education, and Welfare.

In March 1975, 2,671 Vietnamese orphans were airlifted to the States. In the following 12 weeks, examination of several Vietnamese orphans revealed Pneumocystis carinii infection. A telephone and mail survey of the immigration centers, orphan placement services, and physicians reporting orphans with pneumocystosis yielded a total of 7 cases. The clinical and epidemiological features of these cases are summarized below.

The first case occurred on March 6; 4 occurred during April; 1 occurred in early May; and the last reported case occurred on May 23, 1975. Five of the orphans were male and 2 were female; their ages ranged from 2 weeks to 4 months. Two were reported from Washington; 2 from Colorado; 2 from Minnesota; and 1 from New York. Six of the 7 orphans were chronically ill; 5 of the 7 died.

Case summaries were available for 5 of the cases. All 5 patients presented with progressive respiratory failure, cyanosis, hypoxia, and tachypnea. They all had radiographic evidence of diffuse interstitial pneumonitis and were positive for P. carinii by lung biopsy. Each received pentamidine isethionate 4 mg/kg/day intramuscularly, Two patients recovered following treatment. A third patient's P. carinii responded to therapy, but he died of a hemorrhage secondary to a gastric ulcer.

(Reported by AI Eidelman, MD, The Hospital of Albert Einstein College of Medicine, New York City; GS Giebink, MD, University of Minnesota; CE Stracener, MD, Col, MC, Madigan Army Medical Center, Tacoma, Washington; TM Vernon, MD, State Epidemiologist, Colorado Dept of Health; BS Levy, MD, Acting State Epidemiologist, Minnesota Dept of Health, Minneapolis; TL Nghiem, MD, PhD, State Epidemiologist, Washington Dept of Social and Health Services, Olympia; and Parasitic Diseases Branch, Parasitic Diseases and Veterinary Public Health, Bur of Epidemiology, CDC.) Editorial Note

Since Chagas first described P. carinii in 1909, the organism has been reported from almost all continents (1). Infection with P. carinii usually occurs in 2 types of patients: in

immunoincompetent or immunosuppressed persons, as is most familar to physicians in the United States, and in debilitated infants, as is seen most often in developing nations(2,3,4,5). The latter (called endemic pneumocystosis) was first recognized in European orphanages between 1950 and 1960 (1). It appears as a plasma cell pneumonia during the first year of life; symptoms appear between the 6th week to the 12th week, with a peak morbidity in the 12th to 16th weeks. Predisposing factors are prematurity, immaturity, marasmus, and malnourishment. Institutionalized infants are also at an increased risk in areas where they receive inadequate nutrition and medical care (1).

The population of Vietnamese orphans airlifted to United States included a large number of 2 week to 4 monthold infants. The 7 cases of P. carinii pneumonia reported here are typical of endemic P. carinii as all were 4 months of age or younger, and 6 of the 7 were severely malnourished.

Since all of the Vietnamese orphans are now 12 months of age or older, they are passing out of the high risk period. In addition, adequate nutrition has been provided, and many of the infants are no longer in institutions. When caring for any debilitated infants, especially institutionalized ones, P. carinii should be considered in the differential diagnosis of respiratory distress.

References

1. Post C, Dutz W, Nasarian I: Endemic Pneumocystis carinii pneumonia in South Iran. Arch Dis Child 39:35-39, 1964

2. Dutz W, Jennings-Khodadad E, Post C, Kohout E, Nasarian I, Esmaili H: Marasmus and Pneumocystis carinii in institutionalized infants. Z. Kinderheilk 117:241-258, 1974

3. Hughes W, Price RA, Sisko F, Havron WS, Kafatos AG, Schonland M, Smythe PM: Protein-calorie malnutrition. Am J Dis Child 128:4452, 1974

4. Ruskin J, Remington JS: Pneumocystis carinii infection in the immunosuppressed host. Antimicrobial Agents and Chemotherapy-1967:

70-76

5. Walzer P, Schultz MG, Western K, Robbins JR: Pneumocystis carinii pneumonia and primary immune deficiency disease of infancy and childhood, J Pediatr 82:416-422, 1973

Cerebrospinal fluid analysis showed a protein of 120 mg%, glucose 49 mg% (serum glucose 121 mg%), 18 red blood cells/mm3, and 1,072 white blood cells/mm3 with 82% polymorphonuclear leukocytes and 18% lymphocytes. Intravenous ampicillin 400 mg/kg/day was begun but was discontinued on July 13 when admission blood and spinal fluid cultures were reported as negative. The patient improved rapidly and was discharged on the third hospital day.

The 23-year-old mother (patient 3) and 15-year-old male cousin (patient 4) of patient 2 had self-limited febrile illnesses and did not require hospitalization. None of the patients developed rash, myalgias, jaundice, or renal failure.

Investigation revealed that patient 1 had daily contact with 2 raccoons trapped by the woman's father in May 1975. She fed and watered the raccoons and frequently came in contact with objects contaminated by their urine. The only other animal at the home was a dog that had been vaccinated against leptospirosis and had not been ill. The raccoons and the dog were not available for serologic testing at the time of the investigation. No epidemiologic link could be established between the first patient and the other 3 ill persons. In June patients 2, 3, and 4 worked on a dairy farm where a pasture was frequently flooded after moderate to heavy rainfall. While attending the cattle in the pasture and in the barn, all 3 patients routinely went barefoot. Patients 2 and 4 also swam in a stream that traversed the pasture

and were exposed to numerous domestic animals at the home of patient 4. Although the father of patient 2 also worked on the farm, he always wore boots while working; his serum specimen as well as 1 taken from his 2-year-old daughter was negative for leptospiral agglutinins. Four family members of patient 4, none of whom worked on the farm, were negative for leptospiral agglutinins.

No signs of acute leptospirosis had been observed in the herd, which had been vaccinated against L. pomona twice annually. However, an unvaccinated herd is pastured across the road from the dairy farm. After heavy rains, runoff and excreta from this herd flow into the pasture where the dairy cows are located.

(Reported by FJ Vann, MD, and RA Vinson, MD, Vero Beach; CC Flood, MD, Indian River County Health Dept; GR Hoff, PhD and CL Nayfield, MD, State Epidemiologist, Florida Div of Health; Bacterial Immunology Branch, Bacteriology Div, Bur of Laboratories; Field Services Div and Bacterial Zoonoses Branch, Bacterial Diseases Div, Bur of Epidemiology, CDC.)

Editorial Note

Patients 1 and 2 were brought to the attention of health authorities because serum specimens submitted to the state health department for arboviral serology were screened for leptospiral agglutinins. This screening program was begun because leptospiral infections are often misdiagnosed as arboviral infections. At CDC, serum specimens negative for arboviral antibodies are also screened for leptospiral agglutinins; 8-10% of these have leptospiral microscopic agglutination titers of 1:200. Aseptic meningitis is probably the most common initial diagnosis in cases of anicteric leptospirosis.

L. canicola has been isolated from both dogs and raccoons, but the latter appeared to be the most likely source of patient 1's infection because of her direct contact with raccoon urine.

Although the exact source of the infection for patients 2, 3, and 4 could not be confirmed, cattle represented the most likely reservoir. In patients 2 and 3, the highest agglutination titers were to L. pomona, a serotype frequently associated with cattle. Vaccination of domestic animals against leptospirosis may lessen but not eliminate the ability of such animals to serve as reservoir hosts for leptospires. Both immunized dogs and cattle have been implicated in outbreaks of human leptospirosis (1, 2).

References

1. Feigin RD, Lobes LA, Anderson D, Lickering L: Human leptospirosis from immunized dogs. Annals Intern Med 79:777-785, 1973

2. Center for Disease Control: Leptospirosis Annual Summary, 1972, Issued February, 1974

Collaborative studies that began in 1969 by the Gulf South Research Institute (GSRI) in New Iberia, Louisiana, and the Public Health Service Hospital in Carville, Louisiana, found that the 9-banded armadillo (Dasypus novemcinctus) is susceptible to disseminated infection following inoculation with Mycobacterium leprae from human tissue (1). The incubation period was 14 years. Because of the unique susceptibility of this animal and the great concentration of bacilli that develop in its tissues, the armadillo rapidly became an important model of leprosy and the source of large numbers of organisms for research purpo

Louisiana

Further research by GSRI on the histology of uninoculated armadillos has recently determined that 14 9-banded armadillos trapped in southern Louisiana in 1974 and 1975 have infection with acid-fast bacilli similar to M. leprae (2).

Invasion of dermal nerves, typical of leprosy, has been confirmed in postmortem examination of 7 animals; examination of tissues from the remaining 7 has not been completed. Attempts to culture the bacilli on 7H10 and LowensteinJensen media have been unsuccessful. Lepromin prepared from the tissues of these wild-caught armadillos gave Mitsuda (Continued on page 23)