Correspondence

Mycobacterium tuberculosis presenting as sternal osteomyelitis
2000;45(2):135-37

Sepsis and the systemic inflammatory response syndrome
2000; 45 (3) 178-82

A case of spigelian hernia at an unusually high anatomical location
2000;45 (3): 196-7

Sir: We read with interest the case report in the Journal of sternal osteomyelitis. It is indeed a very rare site for tuberculosis, especially without a previous history of exposure to the disease.

The authors had mentioned that the patient had no risk factors for immunosuppression-induced infection. It would be interesting to know if the patient had had a BCG vaccination in the past. A strongly positive mantoux test in the absence of a previous vaccination is strongly suggestive of TB, especially in Caucasian (1). It is true that atypical mycobacteria can cause a positive mantoux test. However, in the absence of predisposing factors for atypical mycobacterial infection could it have been worthwhile treating the patient with antituberculous drugs after excision biopsy of the axillary lymph node, which might have cured the patient and, thereby, prevented a radical surgical procedure.

1. Fauci AS, Braunwald E, Isselbacher KJ, Wilson JD, Martin JB, Kasper DL, Hauser SL, Longo DL . Principles of Internal Medicine 1998:1009 The McGraw-Hill Company

We are grateful to Drs Somasekar for noticing an omission in our report. The patient had had a previous history of BCG vaccination which made the positive mantoux test of dubious significance.

It was felt, prior to microbiological diagnosis, that the clinical picture was suggestive of an atypical mycobacteria (such as M.fortuitum or M. chelonae) and chemotherapy was empirically commenced on that basis. With the benefit of hindsight we should, of course, have commenced therapy appropriate for mycobacterium tuberculosis at an earlier stage. Atypical mycobacteria would, however, appear to be an increasingly prevalent cause of bony osteomyelitis.

Sir: The comments of Mr Wolowczyk and Mr Lamont are of course pertinent. The consensus definitions of sepsis and systemic inflammatory response syndrome (SIRS) were necessary because of the increasing numbers of trials in patients with an infection. Most of the therapeutic compounds being tested at that time had been shown to be effective in either an endotoxin or live bacteria infusion models of septic shock in animals. It was therefore generally believed that these compounds would be most efficacious in patients who had sepsis. At the same time it was appreciated that some patients who appeared to have an infection undoubtedly did not. There is no specific treatment for SIRS unlike sepsis where at least antibiotics would be expected to be of some value.

While one can argue about the merits of the particular values that dictate the presence of either sepsis or SIRS according to the definition, I do believe that it has been useful to have agreement in what constitutes an abnormal situation. Prior to the definitions patients were enrolled into sepsis studies with slightly differing criteria for example pyrexia greater than 38.5°C rather than 38.0°C, or white count greater than 10 rather than 12 x 10⁹/l. While these are only small differences it is useful to have agreed entry criteria between similar studies since it allows easy comparison at least of the controls. The same arguments apply for the multitude of organ dysfunction scores that are currently in use.

As is suggested in the letter SIRS is a minor inflammatory insult in many cases and clearly some clinical interpretation of the definition is required. I also agree that there are other methods to assess minor inflammatory responses. There are problems with all such definitions and scoring systems and re-evaluation is always needed. For instance I often get SIRS when walking up a flight of stairs. More seriously, as far as I am concerned, according to the APACHE II score I also have a defined mortality risk during my intensive care ward round since I now qualify for age points.

A case of spigelian hernia at an unusually high anatomical location
2000;45 (3): 196-7

Sir: We would like to thank Mr Chandran for his comments. It is clear from the report that the hernia in this case occurred between the internal oblique and transversus abdominis muscles with the neck of the sac arising at the seminal line. While this area may have weakened by a drain inserted following gastric surgery through a midline incision some 28 years previously, the hernia is not incisional as such defects penetrate all fascial and muscle layers of the abdominal wall. The patient had not been aware of a lump before presentation and has been recently started on Warfarin thus the reason for entertaining an abdominal wall haematoma in our differential diagnosis. We find CT helpful in this circumstance so as to avoid unnecessary and inappropriate surgery in patients who are anti-coagulated.

CORRESPONDENCE