Letters to Editor
infections of the GI tract. Therefore, whenever
these patients have acute and unspecific abdominal
complaints, the diagnosis of intussusception should also
be considered.[1,2] Computed tomography (CT) is a very
useful imaging method for diagnosis of intussusception
and can be quite helpful in this group of patients. We
present a 43-year-old HIV2 patient (CD4+: 7/mm3 and
undetectable viral load) with known cutaneous Kaposi’s
sarcoma for a year, admitted to our hospital with an
acute abdominal pain. CT images revealed a typical
bowel-within-bowel appearance [Figure 1a-c], with
two adjacent bowel walls of the outer intussuscipiens
(double arrows) and the inner intussusceptum (arrow),
associated with invaginated mesenteric fat and vessels
(solid arrowhead),[3-5] suggesting multiple small bowel
intussusceptions probably caused by Kaposi’s sarcoma.
This was later confir med by surgical specimens
(enterectomy with biopsies disclosed sixteen tumoral
lesions due to Kaposi’s sarcoma in the whole extension
of the small bowel). So whenever you see a target-like
image in a CT abdominal scan, look for the radiologist
and keep in mind intussusception!
P Diana Afonso, Rute Lourenço
Department of Radiology, Hospital Garcia de Orta,
Lisbon, Portugal
Address for correspondence:
Dr. P Diana Afonso, E-mail: p.diana.a@gmail.com
REFERENCES
1. Wetter A, Schaudt A, Lehnert T, Schmidt-Matthiesen A, Jacobi V, Vogl TJ.
Small-bowel intussusception as a rare differential diagnosis in HIV-positive
patients with acute abdominal pain. Eur Radiol 2006;16:952-3.
2. Farrier J, Dinerman C, Hoyt DB, Coimbra R. Intestinal lymphoma
causing intussusception in HIV(+) patient: A rare presentation. Curr Surg
2004;61:386-9.
3. Kim YH, Blake MA, Harisinghani MG, Archer-Arroyo K, Hahn PF, Pitman
MB, et al. Adult Intestinal Intussusception: CT appearances and identification
of a causative lead point. Radiographics 2006;26:733-44.
4. Irish MS, Shellnut J. Intussusception: Surgical Perspective eMedicine Clinical
Reference; 2006.
5. Lvoff N, Breiman RS, Coakley FV, Lu Y, Warren RS. Distinguishing features
of self-limiting adult small-bowel intussusception identified at CT. Radiology
2003;227:68-72.
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Journal of Global Infectious Diseases / Jan-Mar 2011 / Vol-3 / Issue-1 97
Public Health Controversies:
Common Characteristics
Sir,
Public health interventions have propensity to be embroiled
in controversies. There are public health controversies
such as climate change, if it is science or myth,[1] or Avian
flu–culling birds–public health versus livelihood issues[2]
or latest H1N1 pandemic–if it was pharma industry
influenced scare,[3] etc. All such controversies are very
engrossing. Being in public health for decades, we know
that controversies are intrinsic to public health issues.
They can hardly be settled once and for all to everybody’s
satisfaction. We have been witnessed to the fact that public
health controversies erupt like a phoenix, and get fiercely
debated and they abruptly die down, either because it
simply gets eclipsed by new bigger controversy or passage
of time–makes it irrelevant, hence it gets buried but never
get resolved. It is simply not possible, because people have
taken positions on two opposing point of views and refuse
to part away their stand.
When a public health debate is on with divided opinions
among the experts, one needs to take a cautious approach.
One needs to start with the conviction that there is nothing
“right” and “wrong” in a public health debate, because the
argument is never on the basics of public health but rather
its application or management part of it. It has the issues
like mode of intervention (vaccine, mass chemotherapy,
and behavior change) and its applications to human
population are the bone of contention.
Controversies are bound with every public health
intervention, because target groups are communities, and
because of sociological and economic dynamics that are
inherent in any target communities somewhere someone
is bound to be affected directly or indirectly. Controversies
are intrinsic to public health, take any public health issue, it
has always been surrounded with controversy, public heath
professionals cannot agree on one set of intervention not
because of individual opinion but because of multifactorial
nature of public health problems and their possible
interventions. Hence since historical times, there have been
two opposing point of views on any given public health
problems irrespective of old or new. Malaria control,[4]
Tb control,[5] family planning[6]–all have been testimonial
witness to 100 years of debates and controversy, yet none
of them has been resolved to everybody’s satisfaction. The
1994 Plague outbreak in Surat in India still remains debated
if it was natural outbreak or was it a result of biological
weapon accident/experimentation.[7] The debate lingers
 Letters to Editor
on even till today. There is no way such debates can be
settled once for all. With new emerging diseases such as
swine flu and the most recent international controversy on
emergence of superbug that is resistant to all the known
antibiotics in the world called “New Delhi metallo beta-
lactamase” (NDM-1). Is it really originated in India?[8] All
such emerging diseases and many more that on the horizon
are sure to keep our legacy of we being “argumentative
specimen” intact and tradition will go on.
Let us forget global public health issues for a moment and
focus our attention on some thing as mundane issue as
garbage disposal in our cities. There we have problems in
organizing ourselves to make decision to plan and execute
a small coordinated activity of waste disposal of our own
making, in our own backyard. Attempt to resolving it, there
we have stirred hornet nest with heated arguments: who
should do?, how it is to be done?, and how much to pay and
by whom?–there you have the perfect recipe for the debate
and controversy arising of small public health activity.
Morale of the story: If we cannot have consensus on a
minor public health activity in our own limited confines of
our own backyard without having controversies, how can
we even fathom that a global public health issue such as
climate change or H1N1 will be devoid of controversies.
Arguments on both point of views are equally valid, the
issue is how one presents it with dignity and mutual respect
with the supporting scientific evidence.
Rajan R Patil
School of Public Health, SRM University,
Potheri, Kattankulathur, Chennai, India
Address for correspondence:
Dr. Rajan R Patil, E-mail: rajanpatil@yahoo.com
REFERENCES
1. Keller CF. Global warming: The balance of evidence and its policy
implications. A review of the current state-of-the-controversy.
ScientificWorld J 2003;3:357-411.
2. Beard CW. Avian influenza debate continues. J Am Vet Med Assoc
2002;221:1546.
3. Girard M. More queries about H1N1 scandal. BMJ 2010;341:c3716.
4. Schapira A. DDT: A polluted debate in malaria control. Lancet
2006;368:2111-3.
5. Clemens JD, Chuong JJ, Feinstein AR. The BCG controversy. A
methodological and statistical reappraisal. JAMA 1983;249:2362-9.
6. Hout M. Abortion politics in the United States, 1972-1994: From single
issue to ideology. Gender Issues 1999;17:3-34.
7. Rubin GJ, Dickmann P. How to reduce the impact of “low-risk patients”
following a bioterrorist incident: Lessons from SARS, anthrax, and
pneumonic plague. Biosecur Bioterror 2010;8:37-43.
8. Kumarasamy KK, Toleman MA, Walsh TR, Bagaria J, Butt F, Balakrishnan
98 Journal of Global Infectious Diseases / Jan-Mar 2011 / Vol-3 / Issue-1
R, et al. Emergence of a new antibiotic resistance mechanism in India,
Pakistan, and the UK: A molecular, biological, and epidemiological study.
Lancet Infect Dis 2010;10:597-602.
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Tuberculous Mastitis: Still a
Diagnostic Dilemma
Sir,
Breast tuberculosis is a rare form of tuberculosis. In
developing countries, where tuberculosis is endemic, the
incidence is 0.25-4.5%.[1] In western countries, the reported
incidence is less than 1% of breast lesions examined
histologically. However, the disease is assuming significance
even in the developed countries because of the global
spread of AIDS.[2] The clinical diagnosis of tuberculous
mastitis is difficult because of nonspecific clinical and
radiological findings.[1] The disease is often overlooked
or misdiagnosed as carcinoma or pyogenic abscess.[2] We
would like to share three cases of tuberculous mastitis
diagnosed by fine needle aspiration cytology (FNAC) over
a very short period of two months.
Case 1. A 39-year-old female presented with a 2 × 2 cm
firm mobile lump in upper outer quadrant of right breast
for six months. Clinical examination and ultrasonography
suggested the diagnosis of fibroadenoma.
Case 2. A 23-year-old female presented with the complaint
of lump in left breast for four months. Local examination
revealed 1 × 0.8 cm soft, mobile swelling in upper outer
quadrant of left breast which was clinically diagnosed as
fibroadenoma.
Case 3. A 45-year-old female presented with tender lump in
periareolar region of right breast for five months. The lump
was irregular and firm to hard. Clinical examination and
ultrasonography revealed an irregular mass and suggested
the possible diagnosis of carcinoma.
FNA was performed in these patients. All the cases on
cytology showed features of necrotizing granulomatous
mastitis [Figure 1]. ZN staining was positive in two cases
(case 1 and 2). HIV test was nonreactive in all the three
patients. No primary site could be ascertained in the patients.