465 LETTERS TO THE EDITOR
ment, I would be very interested in hearing
views of other Academy members who have
studied the Statement.
DANIEL A. LAcozzlNo, M.D.
3030 Hoyt
Everett, Washington 98201
School Absenteeism and Child Health
To ma EDITOR:
Drs. Moore and Frank have reported that
the rate of school absenteeism in Charlestown,
Massachusetts, increased subsequent to the
establishment of a comprehensive health center
in the area.’ One might speculate that the
presence of the center itseff was responsible
for part or all of this increase. Many children
who were not acutely ill and who would not
ordinarily have visited the doctor might have
been absent from school in order to keep
ap-pointments for follow-up or maintenance care
or for social or other ancillary services. The
more comprehensive the services provided at
the center, the more such visits a well child
would be likely to make and the more school
he might miss as a consequence.
This suggests that, under some
circum-stances, school absenteeism may not be an
ap-propriate measure of the level of health in a
group of children. It serves, too, as a reminder
to the pediatrician that a visit to the doctor
may mean a day’s absence from school-a fact
we may tend sometimes to overlook in
sche-duling appointments.
DANIEL S. BLUMENTHAL, M.D.
Field Operations Branch
Nutrition Program
Center for Disease Control U.S. Public Health Service Atlanta, Georgia 30333
REFERENCE
1. Moore, C. T., and Frank, K.: Comprehensive health services for children : An exploratory study of benefit. Pediatrics, 51 :17, 1973.
EDITOR’S Norx:
Drs. Moore and Frank commented as
fol-lows:
The possible confounding association
be-tween health center utilization and
absentee-ism for well child problems is similar to some
of the possible causes of bias which we
out-lined in the discussion of our article. A
condi-lion of selection for the study was that each
child have a complete checkup at the health
center prior to inclusion in the study. To some
degree, this may have decreased the effect of
the bias which Dr. Blumenthal describes.
However, we agree that this is a possible cause
of our findings and support his contention that
medical care may occasionally serve to disrupt
the child’s daily activities.
GORDON T. MOORE, MD.
KENNETH Fix, M.D.
Cambridge Hospital
Cambridge, Massachusetts 02139
Thyroid Abscess in Childhood
To THE EDITOR:
In a recent article by Kirkland et al’
de-scribing the nature of solitary thyroid nodules
in 30 children, one child with thyroid abscess
was reported. The authors reviewed 35 cases
of abscesses in childhood, four of which were
reported after 1950. We recently studied a
child with thyroid abscess in whom the clinical
course was characterized by multiple
recur-rences.
The patient was a 5 4/12 year-old-girl who
developed progressive swelling in the anterior
portion of the neck two weeks after the onset
of intermittent low grade fever, rhinorrhea, and
cough. There were no complaints of pain,
dysphagia, dyspnea, or hoarseness.
On admission, temperature was 103 F;
pulse, 120/minute; blood pressure, 110/80
mm Hg; weight, 35 pounds (weight age 3 6/
12 years) ; and height, 43 inches (height age
4 10/12 years) . A tender, erythematous, hard,
nonfluctuant, midline mass measuring 5 by 3
cm was palpated in the anterior neck just
below the thyroid cartilage. The left
submandi-bular lymph nodes were also markedly
en-larged and tender.
Laboratory data showed a hemoglobin of
11.8 gm/100 ml, leukocyte count of 19,700/
cu mm with 75% segmented neutrophils, 17%
lymphocytes, and 8% monocytes, and
erythro-cyte sedimentation rate of 63 mm/mm. Two
blood cultures showed no growth and throat
culture grew normal flora. Tine test was
nega-tive. Thyroid function tests are shown in Table
I (first occurrence).
She responded to intravenous aqueous
peni-cillin, 250,000 units every six hours for four
LETTERS TO THE EDITOR 466
TABLE I
THYROID FUNCTION TESTS
Fifst Occurrence Second Occurrence Asymptomatic Third Occurrence
PB! og/l00 ml 9.7 8.1 8.0 8.7
F4! (D)* g/100 ml 35 4.8 6.2 4.8
TSHoU/ml - - 8.7
Antithyroglobulin <1:16 - <1:16 <1:16
antibody
Antithyroid - - Neg
-antibody (Coons)t
RAI Uptake
Pre TSH 4 hr 12% - 7%
-24hr 17% - 14%
-Post TSHt 4 hr - 30%
-Thyroid Scan
Pre TSH No uptake
L lobe
- No uptake
L lobe
-Post TSH - - No uptake
L lobe
-* Thyroxine determination by Murphy-Pattee method and expressed as iodine (Bioscience Laboratories).
t Antithyroglobulin antibody (Coons) determination through the courtesy of Robert M. Blizzard. M.D.
t
Bovine TSH 10 units qd X 2.in the size of the mass. She was discharged six
days after admission on oral potassium
phen-oxymethyl penicillin, 400,000 units every six
hours.
Ten days after discharge from the hospital,
while still receiving oral penicillin, the mass increased in size and again became
erythema-tous. It remained nonfluctuant. There was no
fever, and she was clinically euthyroid.
Ther-apy was changed to oral dicloxacillin, 200 mg
every six hours. Four days later, she was again
hospitalized with a fluctuant, 3 by 4 cm, tender
erythematous mass in the anterior neck and she
was afebrile. She was maintained on the same
dose of dicloxacillin, and on the next hospital
day, she underwent incision and drainage of the
mass, under general anesthesia. Surgery
reveal-ed bloody, purulent material which on gram
stain showed very few gram-positive cocci.
Bac-terial culture grew Streptoccocus viridans. Acid
fast and fungal cultures showed no growth. Her
thyroid function tests were as shown in Table
I (second occurrence) . She was discharged on
the fourth hospital day and continued on oral
dicloxacillin, 200 mg every six hours for an
additional two weeks.
Two weeks after therapy had been
discon-tinued, there was slight erythema around the
incision but no induration. She had remained
afebrile and was clinically euthyroid. Table I
(asymptomatic) shows the results of thyroid function tests.
After three months without therapy, she
de-veloped a 3 by 3 cm area of induration and
erythema around the incision with no local or
constitutional symptom. She received a ten-day
course of oral potassium phenoxymethyl peni-cillin, 400,000 units every six hours, with
re-gression of swelling and erythema. In Table I
(
third occurrence) are shown the thyroid func-tion tests during this relapse. When last seenthree weeks after this course of therapy, she was euthyroid, and there was minimal
indura-tion without erythema around the incision.
In contrast to the patient described by
Kirk-land et al.,’ our patient showed constitutional symptoms during her initial presentation. Most
of the reported cases follow this clinical
pat-tern.” 2 J addition, the clinical course in our
patient was characterized by recurrences as has been previously reported.” With each
episode of suppuration, there was an increase
in the protein bound iodine (PBI - thyroxine
iodine (T4I) difference (Table I) .
Antihyro-globulin antibody and antithyroid antibody
(Coons) were not detectable. Even though the radioiodine uptake (RAT) was normal and
in-creased with thyrotropin (TSH)
administra-tion (Table I) , the left lobe of the thyroid
gland remained nonfunctional.
N. OLATUNJI OLAMBIWONNU, M.D.
ROBERT PENNY, M.D.
S. DOUGLAS FRASIER, M.D.
467 LETTERS TO THE EDITOR
The University of Southern California School of Medicine
and the Los Angeles County
-USC Medical Center 1129 North State Street
Los Angeles, California 90033
(EDIToR’s Nom: Although we try to limit
letters to 300 words, as stated in the box on
page 462, this one seemed to merit extra space.)
REFERENCES
1. Kirkland, R. T., Kirkland, J L., Rosenberg, H.
S., Harberg, F. J., Librik, L., and Clayton,
C. W. : Solitary thyroid nodules in 30
chil-dren and report of a child with a thyroid
ab-scess. Pediatrics, 51 :85, 1973.
2. Cochrane, R. C., and Nowak, S. J. C. : Acute
thyroiditis with report of ten cases. New Eng. J- Med., 210:935, 1934.
3. Szego, P. L., and Levy, R. P. : Recurrent acute suppurative thydroiditis. Canad. Med. Assoc.
J., 103:631, 1970.
Lead Poisoning: Status
of the
FEP and Other TestsTo THE EDITOR:
The recent articles by Piomelli et al.’ and
Chisolm2 represent another welcomed
investi-gation and discussion on the use of free
eryth-rocyte porphyrin (FEP) test in the control of
lead poisoning. These investigators, however,
have greatly overstated the potential of this
test as a primary screening tool in community
lead control programs.
The policy statement of the Surgeon General
of the Public Health Service, developed in
con-sultation with Dr. Chisolm, has established
that “The prime goal of screening programs is
the prevention of lead poisoning” [emphasis
added].3 For this purpose, a blood lead level of 40&g/100 ml has been judged to be the
most reliable indicator of recent or current
ex-cess exposure to lead; and it can be used to
initiate preventive environmental controls to
reduce the exposure before toxicity results.
As Piomelli at al.’ and Chisolm2 have
ob-served, the FEP concentration in blood is an
index of metabolic toxicity due to lead and not
a measure of early exposure to lead. When
blood FEP is elevated, an adverse response to
lead has already occurred. This is a most
im-portant distinction and further evaluation of
the data collected by Piomelli et al’
demon-strates the consequences of using the FEP test
in primary screening of children for lead
ex-posure. Of the 568 children in the New York
study with undue lead absorption (40g/100
ml) , only 354 or 62.3% had positive FEP tests. If the FEP test had been used as the primary
screening method, the other 214 children or
37.7% would have been missed and preventive
services through control of their hazardous
en-vironments denied them. The aim of all health
professionals, epidemiologists, and clinicians
alike, must be the prevention of this childhood
disease.
It must also be recognized that the
discus-sion of the advantages of the FEP analysis as
a “pre-screening test” is based on an
admin-istrative decision of the New York City Health
Department which does not provide for routine
medical or environmental follow-up of
chil-dren with blood lead levels below 60g/100
ml. This decision is contrary to the
recommen-dations of both the Surgeon General3 and the
American Academy of Pediatrics and should
not be advocated for general use in other corn-munities without this clear understanding.
It is desirable for a laboratory test to be
simple, accurate, and economical, but it must
above all else provide information necessary to
accomplish the primary objectives of a screen-ing program. While the FEP test may be used in certain phases of a childhood lead control
program, it is not now a suitable alternative
to blood lead tests as the primary screening
in a preventive community program.
ROBERT D. FISCHER, M.D.
Medical Advisor
Department of Health, Education, and Welfare
Bureau of Community Environmental
Management
Parklawn Building, Room 16-79
5600 Fishers Lane
Rockville, Maryland 20852
References
1. Piomelli, S., Davidow, B., Guinee, V. F.,
Young, P., and Gay, C.: The FEP (free
erythrocyte porphyrins) test: A screening
micromethod for lead poisoning. Pediatrics, 51:254, 1973.
2. Chisolm, J. J.: Screening for lead poisoning in
children. Pediatrics, 51 :280, 1973.
3. U_S. Public Health Service: Medical aspects of childhood lead poisoning. The Surgeon
General’s policy statement. Pediatrics, 48:
464, 1971.
