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of the capacity of an ecosystem to support life in quantity andvariety", and leave "sustainability" for "able to be continued"? Ifsomething is able to be continued for long enough, it has to be

ecosustainable, so that the two meanings do ultimately converge;even so the distinction would reduce confusion. Health shouldtherefore be "an ecosustainable state".

Department of Public Health Medicine,University of Leeds,Leeds LS2 9LN, UK MAURICE KING

1. Taylor CE, Hall MF Health, population and economic development Science 1967,147: 651-57.

Fulminant Capnocytophaga canimorsus(DF-2) septicaemia

SIR,—There are 200 000 or so dog-bites in Britain every year,’and 800-1000 visits to our accident-and-emergency department arefor this reason. However, reports of infection due to an organismformerly known as "dysgonic fermenter type 2 (DF-2)" but nowcalled Capnocytophaga canimorsus remain rare;2,3 most have comefrom the United States. We report a case of fulminant C canimorsus

septicaemia in a previously well man after a dog-bite.A 56-year-old man was admitted to hospital unconscious, with a

36-h history of rigors and fever. He was unresponsive and agitated,had a temperature of 398°C, pulse 120/min, respiration 38/min,and blood pressure 60/40 mm Hg. After blood and urine were takenfor microscopy and culture,’ he was started on cefotaxime 2 g every8 h and erythromycin 500 mg every 6 h plus aggressive resuscitationwith intravenous fluids and inotropic agents. Clinical examination,lumbar puncture, chest X-ray, and urine analysis gave no clue to thefocus of infection. However, 18 h after admission, when the patientwas more lucid, he gave a history of a penetrating dog-bite to his lefthand by a puppy 2 days before admission. His hand had a 2-cmhealing scar on the dorsum with no evidence of local sepsis.

12 h after incubation both blood culture sets showed many longand slender gram-negative bacilli. Subcultures were then done foraerobic and anaerobic incubation. When, after 48 h, no growth wasseen, subcultures from the broth were repeated onto blood andchocolate agar plates and on to a non-selective modified New YorkCity (MNYC) agar plate, which was incubated in 5% CO2. After afurther 48 h tiny colonies were just apparent on the MNYC agar; allother subcultures, including those that had been incubated for 4days, remained negative. The MNYC plate yielded gram-negativebacilli similar to the ones seen earlier. The organism wassubsequently identified in our laboratory and confirmed by theNational Collection of Type Cultures, London, as C canimorsus.5The initial gram film of the blood cultures prompted a change in

the antibiotic regimen to ceftazidime 2 g every 8 h and

benzylpenicillin 1 ’8 g every 6 h, to cover the possibility of infectiondue to Pseudomonas spp, Haemophilus spp, Fusobacterium spp, orDF-2. Disseminated intravascular coagulation (DIC) developed 20h after admission; 4 h later he became dyspnoeic and when acuteadult respiratory distress syndrome (ARDS) was diagnosed he wastransferred to intensive care. By day 4, DF-2 septicaemia wasstrongly suspected, so he was treated with penicillin alone. Despiteearly improvement in the sepsis state and DIC, respiratory distressworsened and he died of respiratory failure 3 weeks later. Necropsyconfirmed ARDS and revealed multiple cerebral, hepatic, and renalinfarcts.

In this case septicaemia due to C canimorsus progressed rapidlyafter the dog-bite. Most infections have followed dog or cat bites.This organism is probably of low virulence since most affectedpatients were immunocompromised. Nevertheless, fatal sepsis hasoccurred in otherwise normal individuals,2,3 as in our patient.C canimorsus is a common oral commensal of animals, and it wasisolated from 24% of dogs and 17% of cats.6 Infections may well bemissed (only about fifty cases reported so far) because this

slow-growing fastidious organism is so difficult to isolate on solidmedia, because clinicians and microbiologists are unaware of it as aninvasive organism, or because penicillin is so often used after dog orcat bites. It is dangerous to ignore a penetrating animal bite; it maylook trivial and not apparently infected yet lead to fulminant

septicaemia. Early debridement and oral penicillin might have madeall the difference if our patient had sought prompt medical help.

Departments of Diabetes and Endocrinologyand Microbiology and PHLS Laboratory,

University Hospital,Queen’s Medical Centre,Nottingham NG7 2UH, UK

I. W. GALLENP. ISPAHANI

1. Baxter DN The deleterious effects of dogs on human health: dog associated injuriesCommun Med 1984; 6: 29-36.

2. Hickling H, Verghese A, Alvarez S. Dysgomc fermenter 2 septicemia. Rev Infect Dis1987; 9: 884-90

3. Zumla A, Lipscombe G, Corbett M, McCarthy M. Dysgonic fermenter-type 2 anemerging zoonosis, report of two cases and review. Q J Med 1988, 68: 741-52

4. Ispahani P, Pearson NJ, Greenwood D. An analysis of community and hospital-acquired bacteraemia in a large teaching hospital in the United Kingdom Q J Med1987; 63: 427-40

5. Brenner DJ, Hollis DG, Fanning GR, Weaver RE. Capnocytophaga canimorsus sp nov(formerly CDC group DF-2), a cause of septicaemia following dog-bite, andC cynodegmi sp nov, a cause of localised wound infection following dog-bite J ClinMicrobiol 1989; 27: 231-35

6. Westwell AJ, Kerr K, Spencer MB, Hutchinson DN. DF-2 infection. Br Med J 1989;298: 116-17.

Immunosuppression by HTLV-I infection

SIR,-Dr LaGrenade and her colleagues (Dec 1, p 1345) suggestthat there is immunosuppression by HTLV-1 in Jamaican childrenwith infective dermatitis. It it well known that various opportunisticinfections such as Pneumocystis carinii pneumonia (PCP) or

cryptococcal meningitis are often seen in patients with adult T-cellleukaemia. Kobayashi et aP first reported the development of PCPin a symptom-free HTLV-1 carrier. Twelve similar cases have beenrecorded by Japanese workers Immunosuppression in HTLV-1carriers is also suggested by the close association of strongyloidiasis,3increased risk of malignant disease,’* and disseminated metastasis ofearly uterine cancer. Tachibana et al6 showed a decreasedtuberculin skin reaction among HTLV-1 carriers in Japan.Although these facts strongly suggest immunosuppression byHTLV-1 infection, T-cell functions were not always shown to beabnormal. It is intriguing that LaGrenade et al report a persistentlymphocytosis in two patients and suggest that infective dermatitisis a preleukaemic syndrome. T-cell leukaemia developed after 6-18months in our patients with PCP and three subsequent PCP casesseen in HTLV-I carriers. Immunosuppression in HTLV-I carriersmay be a predictive sign of T-cell leukaemia or one of the factorsthat accelerates the development of this disease.

Department of Medicine,Kochi Medical School,Nankoku 783, Japan

H. TAGUCHIM. KOBAYASHII. MIYOSHI

1. Kobayashi M, Yoshimoto S, Fujishita M, et al. Association of Pneumocystis carinupneumonia and scabies. JAMA 1982; 248: 1973

2 Taguchi H, Mlyoshi I. Immune suppression in HTLV-I carriers a predictive sign ofadult T-cell leukemia. Acta Med Okayama 1989; 43: 317-21.

3. Nakada K, Kohakura M, Komoda H, et al. High incidence of HTLV-I antibody incarriers of Strongyloides stercoralis. Lancet 1984, i: 633.

4. Asou N, Kumagai T, Uekihara S, et al. HTLV-I seroprevalence in patients withmalignancy. Cancer 1986; 58: 903-07.

5. Taguchi H, Daibata M, Kitagawa T, et al. Generalised lymph node metastasis of earlyuterine cancer in an HTLV-I carrier. Cancer 1988, 62: 2614-17.

6. Tachibana N, Okayama A, Ishizaki J, et al Suppression of tuberculin skin reaction inhealthy HTLV-I carriers from Japan. Int J Cancer 1988; 42: 829-31

SIR,-Dr LaGrenade and colleagues suggest an associationbetween HTLV-1 infection and infective dermatitis in Jamaicanchildren. Before this report, clinical illness in children infected byHTLV-1 had rarely been described.1-3We report here a 9-year-old boy with a chronic skin illness and

cellular immune dysfunction who was found to have high-titreHTLV-1 antibodies. He lived in an orphanage in Haiti and hadbeen adopted at the age of 2 by a Belgian family. His history beforeadoption is not known. Upon arrival in Belgium, he had oozinglesions mainly in the skinfolds; these improved after topicalantibacterial, antifungal, and steroid therapy, but recurred whentreatment was discontinued. When seen for the first time in our

clinic, at the age of 8, he was in good general health but had extensiveoozing lesions in the retroauricular, axilliary, and inguinal folds, andscaling on other parts of his body. Swabs of the infected skinfolds