LETTERS

Another cause of eosinophilia?

I thought that "Eosinophilia: What does it mean?" (June 2000) was very interesting and the listings in the tables were excellent. Many years ago, however, in the old century and millennium, we regularly expected to see eosinophilia in a child recovering from streptococcal infection, particularly scarlet fever. This occurred with or without antibiotics. Of course, at that time we used only penicillin. When I mentioned this on rounds in regard to a child with possible scarlatina, there were a number of guffaws. However, within two days the titers were returned and the skin began to peel. What is your opinion?

Lewis A. Barness, MD
Tampa, Fla.

The authors reply: We thank Dr. Barness for raising the question about the possible association of streptococcal infection and eosinophilia. Interestingly, infectious disease texts list streptococcal infection (primarily scarlatina) as a rare cause of mild eosinophilia, and we had included this reference in the manuscript we originally submitted to Contemporary Pediatrics. When challenged by reviewers on this point, we found we were unable to find any primary documentation. Significant eosinophilia with streptococcal disease seems ironic since many bacterial infections are associated with eosinopenia, probably related to release of endogenous stress hormones. To comment on this apparent clinical conundrum, we performed a MEDLINE search using "IL-5," "streptococcus," and "eosinophil" as key words and found no citations going back to 1966.

In the absence of data, we can only theorize and offer our undocumented explanations for the association of eosinophilia with streptococcal infections:

First, cytokines may be responsible. Group A streptococcus may transiently induce a T_H2 predominant cytokine response with subsequent IL-5 elaboration and eosinophil activation. The bacteria may induce production of other cytokines, such as GM-CSF, which stimulates bone-marrow eosinophil production.

Secondly, as streptococcus or associated exotoxins migrate through tissues, they may elicit a systemic release of eosinophil-attractive chemokines resulting in clinical findings like scarlatiniform rash.

Finally, some systemic manifestations of streptococcal disease may mimic the allergic-like response to parasitic infections.

We will continue to search for data documenting the frequency and mechanism of this association. We would be grateful to Dr. Barness if he would share any information he possesses. For now, we are left with yet another mystery involving the eosinophil.

Jeffrey J. Auletta, MD
Susan B. Shurin, MD
Cleveland, Ohio

Religion and health

I appreciated the August 2000 editorial, "Minimizing risk." Dr. McMillan summarized the comprehensive study on adolescent health risks published in June 1999 and raised the issue of spirituality and its protective effect in adolescent risk-taking behavior: Feeling part of a religious community is one of the factors that protects adolescents from attempting suicide. Having a religious identity and taking a pledge of virginity correlates with a delay in sexual activity.

These findings support what I see in my practice. I think most pediatricians in private practice recognize that teens who are connected to a spiritual community generally make better choices regarding risk-taking behavior. Wouldn't it be great to understand this connection? Research being done shows that the medical community is starting to realize the role of spirituality in the physical and emotional health of the adult population:

• In 212 studies examining the effects of religion on health outcomes, 75% showed a positive effect (Matthews DA, Larson DB: The Faith Factor: An Annotated Bibliography of Clinical Research on Spiritual Subjects, 1993)

• In a study sample of 1,900 female twin pairs raised apart, average age of 30 years, there was less depression, smoking, and alcohol abuse in those who were more religious (Kendler DS: Am J Psychiatry 1997;154:322)

• Of 5,000 high school seniors, those who attended religious services or considered religion important had the lowest rate of suicide and the highest rate of seat belt use (Wallace J et al: Health Education and Behavior 1998;25:721)

• Of 21,000 US adults with 10-year follow-up, the life expectancy of those who attended church more than once a week was seven years longer than those who never attended (Hummer RA: Demography 1999;36:273)

• In a study at Duke University that looked at 542 consecutive hospital admissions, those who attended religious services were 43% less likely to have had previous admissions and had briefer stays, 25 days vs. 11 days (Koenig HG: South Med J 1998;91:925).

The above research says something is going on. Wouldn't it be great for the AAP to create a task force to look at this issue more closely? If spirituality is healthy, maybe we need to understand why it is a good thing to encourage our families and adolescents to pursue. Does Dr. McMillan know of any other research that addresses this issue in the pediatric population? It's time to be more open to an area that medical schools have ignored in the past.

Patti Francis, MD
Lafayette, Calif.

The author replies: I thank Dr. Francis for her comments. She cites additional information suggesting a relationship between health or healthy lifestyles and participation in organized religion. There is increasing interest in this connection among both sociologists and medical researchers. At my own institution, a study is under way to explore the effect of spirituality on African-American women with breast cancer.

As Dr. Francis points out, it will be important to try to tease out what it is about spirituality or participation in organized religion that influences health and lifestyle choices. Religion or spirituality itself may be the important element, or it may be that religion is a surrogate for close family relationships or for inclusion in a supportive, nurturing community.

I am not aware of ongoing research efforts in this area on the part of pediatric researchers, but I agree that understanding the apparently very positive impact that being involved in religion and spirituality has on children and adolescents is an important goal for those who care for them.

Julia A. McMillan, MD
Baltimore, Md.

Help before a baby is born

I was very interested to read the letter entitled "The fetus: A patient or not" (October 2000, Letters). The discussion can be taken one step further when one considers all the infants who are "born dying." There are a number of unborn infants that "medical advancement" has allowed us to diagnose with incurable illness/genetic syndrome. The unfortunate parents are left with little choice and even less support. Typically they are advised to abort if possible and ethical.

To answer this call, we at Children's Hospital of San Diego developed a parent-driven program called the "Early Intervention Program." It is an extension of our Children's Hospice Program that allows parents to choose to continue the pregnancy to term and have control over what is or is not done for their child. We begin working with the parents as soon as they get the news of a lethal diagnosis for their unborn child. Support and anticipatory guidance are provided to the entire family (including siblings) throughout the pregnancy, at the delivery, and as long as necessary afterward. Our bereavement groups have stated that these parents cope better with the loss and are able to see the positives in the birth and life of their baby.

David Sine, MD
San Diego, Calif.

More fingernail dangers

In "Artificial fingernails: Too hot to handle" (November 2000), Drs. Shaikh and Nucci share some important medical concerns regarding these types of fingernails. I would like to share a recent experience that is instructive.

A 23-year-old with acrylic nails presented with a painful subungual hematoma. I attempted to drain the hematoma by using a high temperature fine tip cautery pin. Upon contact of the cautery pin with the nail, a spark occurred and the patient felt a burning sensation. I aborted my efforts to drain the hematoma with the cautery device and learned that, indeed, acrylic nails are flammable and can cause unexpected problems. Primary care and emergency room physicians need to be alerted to this danger.

Matthew Davis, MD
Cypress, Calif.

Fingernail products accounted for 30,153 of the more than 200,000 exposures to cosmetics and personal care products reported to the American Association of Poison Control Centers in 1999 (Litovitz TL et al: Am J Emerg Med 2000; 18:517). Therefore, we are grateful to Drs. Shaikh and Nucci for reviewing many of the potential health hazards within the cosmetic fingernail industry. Two additional dangers from artificial fingernail products merit discussion.

First, ingestion of nail glue removers containing nitroethane has been reported to produce severe and recurrent methemoglobinemia (Osterhoudt K et al: J Pediatr 1995;126: 819). Second, a more frequent injury among children has been mucosa and skin corrosion from methacrylic acid fingernail primers. Dr. Alan Woolf, in collaboration with the Consumer Product Safety Commission and the American Association of Poison Control Centers, has led the effort toward prevention of methacrylate injury (Woolf A et al: J Toxicol Clin Toxicol 1999;37:827). It is important to carefully differentiate between ingestion of mildly toxic nail polishes or polish removers, and often highly toxic artificial nail primers or glue removers. A wide variety of potentially toxic fingernail products are commercially available, and poison control centers may be an invaluable resource in identifying dangers.

Kevin C. Osterhoudt, MD
Fred M. Henretig, MD
Philadelphia, Pa.

Correction

In "Newborn discharge: A time to be especially thoughtful" in the October 2000 issue, the final sentence in Table 4, should read: "Caution parents to avoid bottle propping and introducing solids before 4 months of age and feeding honey before 12 months of age."

In last month's article, "What's new in the 2001 immunization schedule,"Contemporary Pediatrics inadvertently omitted the recommendation for pneumococcal conjugate immunization at 12 to 15 months. Here is the corrected version of that schedule.

Julia McMillan. Letters. Contemporary Pediatrics 2001;2:21.