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Journal of Global Infectious Diseases / Jan-Mar 2011 / Vol-3 / Issue-1 97

Letters to Editor

infections of the GI tract. Therefore, wheneverthese patients have acute and unspecic abdominalcomplaints, the diagnosis of intussusception should alsobe considered.[1,2] Computed tomography (CT) is a veryuseful imaging method for diagnosis of intussusceptionand can be quite helpful in this group of patients. Wepresent a 43-year-old HIV

2patient (CD4+: 7/mm3 and

undetectable viral load) with known cutaneous Kaposissarcoma for a year, admitted to our hospital with anacute abdominal pain. CT images revealed a typicalbowel-within-bowel appearance [Figure 1a-c], withtwo 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 bowelintussusceptions probably caused by Kaposis sarcoma.This was later confirmed by surgical specimens(enterectomy with biopsies disclosed sixteen tumorallesions due to Kaposis sarcoma in the whole extensionof the small bowel). So whenever you see a target-likeimage in a CT abdominal scan, look for the radiologistand keep in mind intussusception!

P Diana Afonso, Rute Loureno

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, Haris inghani MG, Archer-Arroyo K, Hahn PF, Pitman

MB, et al. Adult Intestinal Intussusception: CT appearances and identication

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 identied at CT. Radiology2003;227:68-72.

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DOI:10.4103/0974-777X.77307

Public Health Controversies:

Common Characteristics

Sir,Public health interventions have propensity to be embroiledin controversies. There are public health controversies

such as climate change, if it is science or myth,[1] or Avianuculling birdspublic health versus livelihood issues[2]or latest H1N1 pandemicif it was pharma industryinuenced scare,[3] etc. All such controversies are veryengrossing. Being in public health for decades, we knowthat controversies are intrinsic to public health issues.They can hardly be settled once and for all to everybodyssatisfaction. We have been witnessed to the fact that publichealth controversies erupt like a phoenix, and get ercelydebated and they abruptly die down, either because itsimply gets eclipsed by new bigger controversy or passageof timemakes it irrelevant, hence it gets buried but neverget resolved. It is simply not possible, because people havetaken positions on two opposing point of views and refuseto part away their stand.

When a public health debate is on with divided opinionsamong the experts, one needs to take a cautious approach.One needs to start with the conviction that there is nothingright and wrong in a public health debate, because theargument is never on the basics of public health but ratherits application or management part of it. It has the issueslike mode of intervention (vaccine, mass chemotherapy,

and behavior change) and its applications to humanpopulation are the bone of contention.

Controversies are bound with every public healthintervention, because target groups are communities, andbecause of sociological and economic dynamics that areinherent in any target communities somewhere someoneis bound to be affected directly or indirectly. Controversiesare intrinsic to public health, take any public health issue, ithas always been surrounded with controversy, public heathprofessionals cannot agree on one set of intervention notbecause of individual opinion but because of multifactorial

nature of public health problems and their possibleinterventions. Hence since historical times, there have beentwo opposing point of views on any given public healthproblems irrespective of old or new. Malaria control,[4]Tb control,[5] family planning[6]all have been testimonialwitness to 100 years of debates and controversy, yet noneof them has been resolved to everybodys satisfaction. The1994 Plague outbreak in Surat in India still remains debatedif it was natural outbreak or was it a result of biologicalweapon accident/experimentation.[7] The debate lingers

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98 Journal of Global Infectious Diseases / Jan-Mar 2011 / Vol-3 / Issue-1

Letters to Editor

Tuberculous Mastitis: Still a

Diagnostic Dilemma

Sir,Breast tuberculosis is a rare form of tuberculosis. Indeveloping countries, where tuberculosis is endemic, the

incidence is 0.25-4.5%.[1]In western countries, the reportedincidence is less than 1% of breast lesions examinedhistologically. However, the disease is assuming signicanceeven in the developed countries because of the globalspread of AIDS.[2] The clinical diagnosis of tuberculousmastitis is difcult because of nonspecic clinical andradiological ndings.[1] The disease is often overlookedor misdiagnosed as carcinoma or pyogenic abscess.[2] Wewould like to share three cases of tuberculous mastitisdiagnosed by ne needle aspiration cytology (FNAC) overa very short period of two months.

Case 1. A 39-year-old female presented with a 2 2 cmrm mobile lump in upper outer quadrant of right breastfor six months. Clinical examination and ultrasonographysuggested the diagnosis of broadenoma.

Case 2. A 23-year-old female presented with the complaintof lump in left breast for four months. Local examinationrevealed 1 0.8 cm soft, mobile swelling in upper outerquadrant of left breast which was clinically diagnosed asbroadenoma.

Case 3. A 45-year-old female presented with tender lump in

periareolar region of right breast for ve months. The lumpwas irregular and rm to hard. Clinical examination andultrasonography revealed an irregular mass and suggestedthe possible diagnosis of carcinoma.

FNA was performed in these patients. All the cases oncytology showed features of necrotizing granulomatousmastitis [Figure 1]. ZN staining was positive in two cases(case 1 and 2). HIV test was nonreactive in all the threepatients. No primary site could be ascertained in the patients.

on even till today. There is no way such debates can besettled once for all. With new emerging diseases such asswine u and the most recent international controversy onemergence of superbug that is resistant to all the knownantibiotics in the world called New Delhi metallo beta-lactamase (NDM-1). Is it really originated in India?[8] Allsuch emerging diseases and many more that on the horizon

are sure to keep our legacy of we being argumentativespecimen intact and tradition will go on.

Let us forget global public health issues for a moment andfocus our attention on some thing as mundane issue asgarbage disposal in our cities. There we have problems inorganizing ourselves to make decision to plan and executea small coordinated activity of waste disposal of our ownmaking, in our own backyard. Attempt to resolving it, therewe have stirred hornet nest with heated arguments: whoshould do?, how it is to be done?, and how much to pay andby whom?there you have the perfect recipe for the debateand controversy arising of small public health activity.

Morale of the story: If we cannot have consensus on aminor public health activity in our own limited connes ofour own backyard without having controversies, how canwe even fathom that a global public health issue such asclimate change or H1N1 will be devoid of controversies.Arguments on both point of views are equally valid, theissue is how one presents it with dignity and mutual respectwith the supporting scientic 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 policyimplications. A review of the current state-of-the-controversy.ScienticWorld J 2003;3:357-411.

2. Beard CW. Avian influenza debate continues. J Am Vet Med Assoc2002;221:1546.

3. Girard M. More queries about H1N1 scandal. BMJ 2010;341:c3716.

4. Schapira A. DDT: A polluted debate in malaria control. Lancet2006;368:2111-3.

5. Clemens JD, Chuong JJ, Feinstein AR. The BCG controversy. Amethodological and statistical reappraisal. JAMA 1983;249:2362-9.

6. Hout M. Abortion politics in the United States, 1972-1994: From singleissue to ideology. Gender Issues 1999;17:3-34.

7. Rubin GJ, Dickmann P. How to reduce the impact of low-risk patientsfollowing a bioterrorist incident: Lessons from SARS, anthrax, andpneumonic plague. Biosecur Bioterror 2010;8:37-43.

8. Kumarasamy KK, Toleman MA, Walsh TR, Bagaria J, Butt F, Balakrishnan

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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