Correspondence.

Group C Streptococcal Infection in a Prosthetic Joint

To the Editor: We read with interest the case report by Kleshinski et al (1) describing a group C streptococcal infection in a prosthetic joint. We recently observed the same type of infection in a 81-year-old woman who had had a left hip prosthetic replacement 10 years earlier. The prosthesis had functioned without problems, until she suddenly developed flu-like symptoms with fever and associated pain in the left hip. Blood cultures were negative, but she had leukocytosis and C-reactive protein 200 mg/L (normal < 10). Culture of fluid from the left hip showed growth of beta-hemolytic streptococci group C. Initially, she had been treated with cefuroxime, but the therapy was consequently changed to benzylpenicillin. After two weeks of intravenous therapy, she was discharged on oral penicillin. Follow-up showed that the pain, in the hip had diminished, while both C-reactive protein and sedimentation rate had also decreased. There has been no loosening of the prosthesis and she continues long-term treatment with oral penicillin.

Streptococcal group C infections in prosthetic joints indeed seem exceedingly rare, although the case described by Kleshinski et al is not quite the first of its kind to be reported, as two infections with group C streptococci are included in a series of prosthetic joint infections analyzed at the Mayo Clinic. (2) Since the Lancefield group is not reported for all streptococcal joint replacement infections, group C streptococci infection might be involved, although none was included in a recent review on streptococcal arthritis in general. (3)

Torbjorn Sundkvist, MD

Department of Infectious Diseases

Robert von Essen, MD

Department of Microbiology

Sunderby Hospital

971 80 Lulea

Sweden

References

(1.) Kleshinski J, Georgiadis GM, Duggan JM : Group C streptococcal infection in a prosthetic joint. South Med J 2000; 93:1217-1220

(2.) Infections Associated With Indwelling Medical Devices. 3rd Ed. Waldvogel FA, Bisno AL (eds). Washington, DC, ASM Press, 2000, p 179

(3.) Schattner A, Vosti KL: Bacterial arthritis due to beta-hemolytic streptococci of serogroups A,B,C,F, and G. Medicine (Baltimore) 1998; 77:122-139

Leptomeningeal Carcinomatosis in Metastatic Prostate Cancer

To the Editor: Leptomeningeal involvement with prostate cancer is a rare clinical entity. (1) This letter summarizes the second case we have seen within the past year. A 66-year-old Hispanic man was originally diagnosed with metastatic prostate cancer in March 1997. The PSA level was 33.4 ng/mL, Gleason score was 8 of 10, and there was involvement of the left seminal vesicle. Bone scan was negative. The patient was considered to have stage C disease. Lupron and flutamide were started, and the PSA declined to 0.25 ng/mL by August 1997. In August 1998, the PSA had increased to 47 ng/mL, and routine bone scan was positive in multiple sites. Flutamide withdrawal was associated with a continued increase in the PSA level. In September 1998, external beam radiation was administered to the left proximal femur and left sacrum, for painful metastatic disease visible on plain x-ray examination. In October 1998, the patient received one 4 mCi dose of strontium 89. In March 1999, the patient started on an approved phase I I experimental study of thalidomide, 200 mg/day orally.

After 13 weeks of thalidomide therapy, the patient came for routine follow-up with a palsy of the right 7th cranial nerve, and partial palsy of the right 12th cranial nerve. The patient was oriented to person, place, time, and situation, although mentation was slowed. The serum PSA level had increased to 1131 ng/mL. MRI showed diffuse dural enhancement and an approximately 1 cm dural based lesion in the right fossa with adjacent brain edema. Lumbar puncture showed a glucose value of 87 mg/dL (serum glucose level was 147 mg/dL), protein 55 mg/dL, WBC 0/[mm.sup.3], RBC 47/[mm.sup.3], and six malignant cells, consistent with adenocarcinoma. The CSF PSA level was 28 ng/mL. The cells seen within the CSF specifically were not compatible with a lymphomatous process. Pertinent negative findings included the absence of nuchal rigidity on physical examination.

This individual represents the 12th case published of prostate cancer involving the leptomeninges. (1-4) This is our second case within a 12-month period. We believe that like other malignancies such as ovarian cancer--where treatment options have expanded within a cohort of patients with persistent metastatic disease (5)--the rate of occurrence of this syndrome in prostate cancer may increase.

Sattva Neelapu, MD

William D. Figg, PharmD

William Dahut, MD

Eddie Reed, MD

Medicine Branch

Division of Clinical Sciences

National Cancer Institute

National Institutes of Health

Bldg 10, Room 5A01

9000 Rockville Pike

Bethesda, MD 20892

(Supported in part by the US government and the Office on Research in Minority Health of the National Institutes of Health.)

References

(1.) Reed E, Matthews D, Dyer V, et al: Meningeal carcinomatosis in metastatic prostate cancer: a case report. The Prostate Journal 1999; 2:99-102

(2.) Ehya H, Hajdu SI, Melamed MR: Cytopathology of nonlymphoreticular neoplasms metastatic to the central nervous system. Acta Cytologica 1981; 25:599-610

(3.) Fischer-Williams M, Bosanquet FD, Daniel PM: Carcinomatosis of the meninges: a report of 3 cases. Brain 1955; 78:42-49

(4.) Mahadevia PS, Kiely TM: Meningeal carcinomatosis secondary to prostatic carcinoma: case report. J Urol 1980; 124:154-155

(5.) Reed E: Ovarian cancer: molecular abnormalities. The Encyclopedia of Cancer. Bertino JR (ed). San Diego, Calif. Academic Press, Inc, 1996, pp 1192-1200

Chronic Pain and Its Management in Primary Care

To the Editor: In the October 2000 issue, khouzam (1) discussed the pharmacologic and nonpharmacologic methods of pain control in primary care. The various pharmacologic methods of pain control were thoroughly reviewed. However, minimum discussion was devoted to the nonpharmacologic treatment of chronic pain. Only TENS treatment, psychotherapy, and spiritual intervention were briefly discussed. However, 74% of American adults use other complementary and alternative medical therapies (CAM) along with conventional care, according to the Landmark Report on Public Perceptions of Alternative Health Care. (2) Therefore, to update and complete this review, other popular alternative therapies to control chronic pain should have been discussed. These include chiropractic therapy, acupuncture, and massage therapy.

Studies suggest that a large number of mainstream physicians are referring patients for CAM therapies. The reasons frequently cited by physicians are: (1) the patient's lack of response to conventional treatment, (2) belief in efficacy, and (3) fewer adverse effects. (3) Astin et al (3) performed a comprehensive literature search of 25 studies, and found that acupuncture had the highest rate of physician referral (43%) among CAM therapies, followed by chiropractic (40%) and massage (21%). In addition, approximately half of the surveyed physicians believed in the efficacy of chiropractic therapy (53%), acupuncture (51%), and massage therapy (48%). Conditions for which physicians used or made referrals for CAM therapies included chronic pain, hack problems, arthritis, headaches, and chronic illnesses. Based on these findings, chiropractic therapy, acupuncture, and massage therapy should be included in a review of nonpharmacologic treatments for chronic pain.

Laura Smith, RN, BSN

Northern Illinois University 

5803 Shadowood Dr

Crystal Lake, IL 60012

References

(1.) Khouzam HR: Chronic pain and its management in primary care. South Med J 2000; 93:946-952

(2.) The Landmark Report on Public Perceptions of Alternative Care. Sacramento, Ca, Landmark Healthcare, Inc, 1998

(3.) Astin J, Marie A, Pelletier K, et al: A review of the incorporation of complementary and alternative medicine by mainstream physicians. Arch Intern Med 1998; 158:2303-2310