Inflammatory bowel disease: incidence, prevalence, and disease characteristics in Barbados, West Indies.

BACKGROUND: The incidence of inflammatory bowel disease (IBD) may be lower among people of African descent than Caucasians. However, incidence studies among the former are uncommon and are often limited by incomplete case ascertainment or uncertainty about the size of the "at-risk" population. METHODS: We report the incidence and prevalence of IBD among people of African ancestry in Barbados from island-wide disease surveillance over a 25-year period beginning January 1980. RESULTS: The annual incidence of IBD age standardized to the world population was 1.85 per 100,000 person-years (95% confidence interval [CI] 1.53-2.22) for ulcerative colitis (UC) and 0.70 per 100,000 person-years (0.51-0.95) for Crohn's disease (CD). These incidence rates increased to 2.09 and 0.76 when standardized to the US population. The UC incidence rate increased from 1.3 in 1980-1984 to 2.3 in 1995-1999, and decreased to 1.6 in 2000-2004. The CD incidence rate followed a similar trend, rising from 0.3 in 1980-1984 to 1.3 in 1990-1994 before decreasing to 0.6. IBD prevalence in December 2004 was 44.3 per 100,000 person-years (36.7-53.0) for UC and 16.7 per 100,000 person-years (12.2-22.4) for CD. In the island-nation of Barbados, with a population in 2000 of 270,000, we expect between 4.3 and 6.1 new cases of UC and between 1.5 and 2.6 new cases of CD each year. CONCLUSIONS: The reported rates are generally lower than reported for European and North American Caucasians, and are similar to The French West Indies--the only other IBD disease register in the Caribbean.

Evaluation of a commercial latex agglutination assay for serological diagnosis of leptospirosis.

Leptospirosis is a febrile zoonosis of worldwide distribution. A latex agglutination assay was evaluated in two studies, the first using a panel of well-characterized sera from patients with leptospirosis and from patients with other disease states and the second, a prospective hospital-based study, evaluating sera from 186 consecutive patients admitted to hospital with acute febrile illness. The confirmed leptospirosis serum panel included paired acute- and convalescent-phase specimens from 40 cases, of which 34 gave positive latex tests (case sensitivity, 85%; 95% confidence interval [95% CI], 70 to 94%). The other diseases represented in the panel of 112 specimens from nonleptospirosis patients included autoimmune diseases, brucellosis, dengue, melioidosis, malaria, syphilis, toxoplasmosis, viral hepatitis, and a number of other viral infections. The specificity of latex agglutination using this panel was 81% (95% CI, 73 to 87%). Among the patients with acute febrile illness, there were 25 cases of leptospirosis and 161 patients with other diagnoses. The sensitivity and specificity of latex agglutination in this group were 88% (95% CI, 72 to 97%) and 98% (95% CI, 95 to 100%), respectively. In this evaluation, the two distinct groups of specimens gave similar results for sensitivity, but specificity was different in each study. The sensitivity and specificity observed for the hospital study were similar to those obtained in evaluations of other rapid tests in the same population. The results of this study suggest that multiple evaluations of new diagnostic assays should be performed, because performance characteristics may vary in different populations.

Helicobacter pylori infection in the Caribbean: update in management.

Helicobacter pylori infection of the stomach is one of the commonest chronic infections worldwide and in the Caribbean, over 50% of the population are affected. H pylori is probably transmitted from person to person by oro-faecal and oro-oral means. H pylori is directly associated with peptic ulcer disease, chronic antral gastritis, gastric carcinoma and B-cell lymphoma of the stomach. In patients with peptic ulcers and H pylori infection, eradication of infection with antibiotics significantly decreases recurrence of ulcers. All patients with H pylori related disease should be tested and treated if positive. The treatment of H pylori infection has evolved over the years but at present triple therapy which includes two antibiotics is recommended.

Two methods for rapid serological diagnosis of acute leptospirosis.

Leptospirosis is a common and underdiagnosed zoonosis. Two rapid assays for serological diagnosis of acute leptospirosis in diagnostic laboratories, the immunoglobulin M (IgM)-dipstick assay and the indirect hemagglutination assay (IHA), were evaluated and compared with standard assays. Sera were examined from 104 patients admitted to a hospital for investigation in a leptospirosis diagnostic protocol. Specimens for serology were taken on days 1 and 4 of the patients' hospital stay. Antibodies were detected using an IgM-enzyme-linked immunosorbent assay (ELISA), microscopic agglutination test (MAT), an IgM-dipstick assay, and an IHA. Fifty-one patients were found to have leptospirosis. The sensitivity of the IgM-dipstick assay was 98%, its specificity was 90.6%, its positive predictive value was 90.9%, and its negative predictive value was 98%. The sensitivity of the IHA was 92.2%, its specificity was 94.4%, its positive predictive value was 95.9%, and its negative predictive value was 92.7%. The standard IgM-ELISA and MAT, were positive in the first samples tested from 67 and 55% of the cases, respectively, and the rapid IgM-dipstick assay and IHA were positive in 71 and 49%, respectively, in the first sample tested. Both rapid assays are highly sensitive and specific. Neither requires specialized equipment, and both are suitable for use in diagnostic laboratories.

Helicobacter pylori infection in the Caribbean: update in management

Helicobacter pylori infection of the stomach is one of the commonest chronic infections worldwide and in the Caribbean, over 50 of the population are affected. H pylori is probably transmitted from person to person by oro-faecal and oro-oral means. H pylori is directly associated with peptic ulcer disease, chronic antral gastritis, gastric carcinoma and B-cell lymphoma of the stomach. In patients with peptic ulcers and H pylori infection, eradication of infection with antibiotics significantly decreases recurrence of ulcers. All patients with H pylori related disease should be tested and treated if positive. The treatment of H pylori infection has evolved over the years but at present triple therapy which includes two antibiotics is recommended.

Cytotoxic effects of cleansing solutions recommended for chemical lavage of pulp exposures.

PURPOSE: To evaluate the in vitro cytotoxic effects of three cleansing solutions used for chemical lavage of pulp exposures. MATERIALS AND METHODS: The immortalized odontoblast cell line (MDPC-23) was plated (30,000 cells/cm2) and incubated for 72 hrs in 24-well dishes. After counting the cell number under inverted light microscopy, 20 microl of the experimental and control solutions were added to 980 microl of fresh culture medium. Then, hydrogen peroxide (3%, H2O2), sodium hypochlorite (6%, NaOCl) or calcium hydroxide-saline solution (5g of Ca(OH)2 in 10 ml of sterile distilled water) were added to wells for experimental Groups 1, 2 and 3, respectively. The positive and negative control groups received Syntac Sprint bonding agent (SS) and phosphate buffered saline (PBS), respectively. Following incubation for 120 min the cell number was counted again, the cell morphology was evaluated by scanning electron microscopy (SEM) and the cell metabolism was determined by the methyltetrazolium (MTT) assay. The scores obtained from cell counting and MTT assay were analyzed with an ANOVA followed by Fisher's PLSD tests. RESULTS: H2O2, NaOCl solutions, and SS bonding agent were more cytotoxic than Ca(OH)2 or PBS. In the groups with H2O2 or SS, only a few cells remained attached to the bottom of wells. The difference between these two groups was not statistically significant. H2O2, NaOCl and SS depressed the mitochondrial enzyme response by 97.7%, 97.3%, and 95.0%, respectively. On the other hand, Ca(OH)2 depressed the metabolic activity of cells by only 5%. While H2O2, NaOCl and SS caused extreme changes on the cell morphology, neither Ca(OH)2 nor PBS promoted dramatic changes in the cell morphology.

Detection of dengue infection in patients investigated for leptospirosis in Barbados.

The annual incidence of leptospirosis in Barbados is approximately 13 severe cases/100,000. The peak incidence occurs in October to December of each year, coinciding with the months of heaviest rainfall. During the second half of 1995, an epidemic of dengue type 1 infection produced almost 1,000 laboratory-confirmed cases. During the same period, leptospirosis mortality was twice the average, suggesting that some cases of leptospirosis were being misdiagnosed and treated inappropriately. Sera from patients investigated for dengue or leptospirosis were analyzed retrospectively to determine the extent of misdiagnosis. During 1995 and 1996, 31 of 139 and 29 of 93 patients, respectively, were confirmed as having leptospirosis. Sera from the remaining leptospirosis-negative patients were tested for IgM antibodies to dengue virus. During 1995 and 1996, 48 of 108 patients and 21 of 64 patients, respectively, were found to have dengue. In 1997, sera from all patients investigated for leptospirosis were also tested prospectively for IgM antibodies to dengue: 38 of 92 leptospirosis-negative patients (41%) were dengue IgM-positive, while 2 of 25 leptospirosis cases also had serologic evidence suggesting acute dengue infection. A second large outbreak of dengue caused by serotype 2 occurred in 1997. During the 1995 and 1997 dengue epidemics in Barbados, dengue cases outnumbered leptospirosis cases investigated in the leptospirosis diagnostic protocol. During 1997, patients investigated but negative for dengue were also tested for anti-leptospiral IgM: 7.3% (19 of 262) were IgM-positive. Substantial misdiagnosis of both dengue and leptospirosis can occur and greater public awareness and clinical suspicion of the similar presentations of these two diseases are necessary.

Antioxidant flavonols from fruits, vegetables and beverages: measurements and bioavailability.

Flavonols are polyphenolic secondary plant metabolites that are present in varying levels in commonly consumed fruits, vegetables and beverages. Flavonols have long held an interest for nutritionists, which has increased following a Dutch study in the early 1990's showing that dietary intake of flavonols was inversely correlated with the incidence of coronary heart disease. The main factors that have hindered workers in the field of flavonol research are (i) the accurate measurement of these compounds in foods and biological samples, and (ii) a dearth of information on their absorption and metabolism. This review aims to highlight the work of the authors in attempting to clarify the situation. The sensitive and selective HPLC procedure to identify and quantify common flavonols and their sugar conjugates is described. In addition, the results of an on-going screening program into the flavonol content of common produce and beverages are presented. The bioavailability of dietary flavonols is discussed with reference to an intervention study with onions, as well as pilot studies with tea, red wine and cherry tomatoes. It is concluded that flavonols are absorbable and accumulate in plasma and that consuming high flavonol-containing varieties of fruits and vegetables and particular types of beverages could increase their circulatory levels.

Antioxidant flavonols from fruits, vegetables and beverages: measurements and bioavailability

Flavonols are polyphenolic secondary plant metabolites that are present in varying levels in commonly consumed fruits, vegetables and beverages. Flavonols have long held an interest for nutritionists, which has increased following a Dutch study in the early 1990's showing that dietary intake of flavonols was inversely correlated with the incidence of coronary heart disease. The main factors that have hindered workers in the field of flavonol research are (i) the accurate measurement of these compounds in foods and biological samples, and (ii) a dearth of information on their absorption and metabolism. This review aims to highlight the work of the authors in attempting to clarify the situation. The sensitive and selective HPLC procedure to identify and quantify common flavonols and their sugar conjugates is described. In addition, the results of an on-going screening program into the flavonol content of common produce and beverages are presented. The bioavailability of dietary flavonols is discussed with reference to an intervention study with onions, as well as pilot studies with tea, red wine and cherry tomatoes. It is concluded that flavonols are absorbable and accumulate in plasma and that consuming high flavonol-containing varieties of fruits and vegetables and particular types of beverages could increase their circulatory levels.

Cytotoxic effects of current dental adhesive systems on immortalized odontoblast cell line MDPC-23.

OBJECTIVES: Evaluate the cytotoxic effect of the three dental adhesive systems. METHODS: The immortalized mouse odontoblast cell line (MDPC-23) was plated (30,000 cell/cm2) in 24 well dishes, allowed to grow for 72 h, and counted under inverted light microscopy. Uncured fresh adhesives were added to culture medium to simulate effects of unset adhesive. Three adhesives systems were applied for 120 min to cells in six wells for each group: Group 1) Single Bond (3M), Group 2) Prime & Bond 2.1 (Dentsply), and Group 3) Syntac Sprint (Vivadent). In the control group, PBS was added to fresh medium. The cell number was counted again and the cell morphology was assessed under SEM. In addition, the adhesive systems were applied to circles of filter paper, light-cured for 20 s, and placed in the bottom of 24 wells (six wells for each experimental materials and control group). MDPC-23 cells were plated (30,000 cell/cm2) in the wells and allowed to incubate for 72 h. The zone of inhibition around the filter papers was measured under inverted light microscopy; cell morphology was evaluated under SEM; and the MTT assay was performed for mitochondrial respiration. RESULTS: The fresh adhesives exhibited more toxic (cytopathic effects) to MDPC-23 cells than polymerized adhesives on filter papers, and as compared to the control group. The cytopathic effect of the adhesive systems occurred in the inhibition zone around the filter papers, which was confirmed by the MTT assay and statistical analysis (ANOVA) combined with Fisher's PLSD test. In the control group, MDPC-23 cells were dense on the plastic substrate and were in contact with the filter paper. In the experimental groups, when acid in the adhesive systems was removed by changing the culture medium, or when the adhesives were light-cured, some cells grew in the wells in spite of the persistent cytotoxic effect. SIGNIFICANCE: All dentin adhesive systems were cytotoxic odontoblast-like cells. Both acidity and non-acidic components of these systems were responsible for the high cytopathic effect of those dental materials.

Surveillance of leptospiral carriage by feral rats in Barbados.

Rodents, particularly rats, are widely held to be the source of most human cases of leptospirosis. Feral rats were trapped at sites throughout Barbados during two six month surveys: from October to March 1986/87 and from October to March 1994/95. During the first survey, 63 rats were trapped, of which 26 (41%) were identified as Rattus rattus and 37 (59%) as Rattus norvegicus. In the second study, 100 rats were trapped, of which R. rattus comprised 24% (24) and R. norvegicus 76% (76). Cultures of blood, urine and kidney were made in EMJH medium. Leptospires were isolated from 12/63 (19%) and from 16/100 (16%) of the rats during 1986/87 and 1994/95, respectively; 27/28 isolates were recovered from the kidneys or urine or both, while only one isolate was recovered from the blood. During the first study, isolates were identified as serovars copenhageni (11) and arborea (1), while in the second study, serovars copenhageni (9), arborea (5) and bim (1) were identified; one isolate was lost before it could be identified. In the first study, antibodies were detected by microscopic agglutination at a titre of > or = 100 in 26/62 (42%) of rats tested, while in the second survey, 5/100 (5%) of rats had similar titres. In two surveys, conducted eight years apart, we confirmed that rats in Barbados are commonly infected with leptospires, and that viable organisms are found in the kidneys and urine, evidence of chronic infection and thus excretion of leptospires in rodent urine. Moreover, the predominant serovar isolated was copenhageni, of which Rattus spp. are the worldwide reservoir. There was little evidence that rats act as a reservoir for the serovar bim, the most common cause of human leptospirosis in Barbados.

Surveillance of leptospiral carriage by feral rats in Barbados

Rodents, particularly rats, are widely held to be the source of most human cases of leptospirosis. Feral rats were trapped at sites throughout Barbados during two six month surveys: from October to March 1986/87 and from October to March 1994/95. During the first survey, 63 rats were trapped, of which 26 (41) were identified as Rattus rattus and 37 (59) as Rattus norvegicus. In the second study, 100 rats were trapped, of which R. rattus comprised 24(24) and R. norvegicus 76(76). Cultures of blood, urine and kidney were made in EMJH medium. Leptospires were isolated from 12/63 (19) and from 16/100 (16) of the rats during 1986/87 and 1994/95, respectively; 27/28 isolates were recovered from the kidneys or urine or both, while only one isolate was recovered from the blood. During the first study, isolates were identified as serovars copenhageni (11) and arborea (1), while in the second study, serovars copenhageni (9), arborea (5) and bim (1) were identified; one isolate was lost before it could be identified. In the first study, antibodies were detected by microscopic agglutination at a titre of > or = 100 in 26/62 (42) of rats tested, while in the second survey, 5/100 (5) of rats had similar titres. In two surveys, conducted eight years apart, we confirmed that rats in Barbados are commonly infected with leptospires, and that viable organisms are found in the kidneys and urine, evidence of chronic infection and thus excretion of leptospires in rodent urine. Moreover, the predominant serovar isolated was copenhageni, of which Rattus spp. are the worldwide reservoir. There was little evidence that rats act as a reservoir for the serovar bim, the most common cause of human leptospirosis in Barbados.

Surveillance of leptospiral carriage by feral rats in Barbados

Rodents, particularly rats, are widely held to be the source of most human cases of leptospirosis. Feral rats were trapped at sites throughout Barbados during two-six month surveys: from October to March 1986/87 and from October to March 1994/95. During the first survey, 63 rats were trapped, of which 26 (41 percent) were identified as Rattus rattus and 37 (59 percent) as Rattus norvegicus. In the second study, 100 rats were trapped, of which R. rattus comprised 24 percent (24) and R. norvegicus 76 percent (76). Cultures of blood, urine and kidney were made in EMJH medium. Leptospires were isolated from 12/63 (19 percent) and from 16/100 (16 percent) of the rats during 1986/87 and 1994/95, respectively; 27/28 isolates were recovered from the kidneys or urine or both, while only one isolate was recovered from the blood. During the first study, isolates were identified as serovars copenhageni (11), arborea (1), while in the second study, serovars copenhageni (9), arborea (5) and bim (1) were identified; one isolate was lost before it could be identified. In the first study, antibodies were detected by microscopic agglutination at a titre of > or = 100 in 26/62 (42 percent) of rats tested, while in the second survey, 5/100 (5 percent) of rats had similar titres. In two surveys, conducted eight years aparts we confirmed that rats in Barbados are commonly infected with leptospires, and that viable organisms are found in the kidneys and urine, evidence of chronic infection and thus excretion of leptospires in rodent urine. Moreover, the predominant serovar isolated was copenhageni, of which Rattus spp. are the worldwide reservoir. There was little evidence that rats act as a reservoir for the serovar bim, the most common cause of human leptospirosis in Barbados.(AU)

Severe primary HIV-1 infection among black persons in Barbados.

Descriptions of primary HIV-1 infection have so far been based on Caucasians living in industrialized nations. Due to studies of leptospirosis in the predominantly black population of Barbados, serum was available for patients admitted with acute febrile illnesses to the Queen Elizabeth Hospital (QEH). By searching the medical records of 510 adult patients with known HIV-1 infection we identified 10 patients who had stored serum from an admission for an acute febrile illness that predated or coincided with their first HIV-1-positive test. Serological testing confirmed primary HIV-1 infection in 9 and was suggestive in the 10th patient. The clinical features of these 10 patients were in keeping with previous descriptions of primary HIV-1 infection but differed from leptospirosis cases seen at the QEH. One patient died during his seroconversion illness and another died 3 months after seroconversion. The findings suggest that severe primary HIV-1 infection could be a relatively uncommon occurrence, that the condition may be misdiagnosed, and that cases may not occur until the AIDS epidemic is established.

PIP: A retrospective review was conducted of the medical records of 510 HIV-1-positive adult patients who had attended the Queen Elizabeth Hospital (QEH) to determine whether any had been admitted for an illness compatible with a diagnosis of primary HIV-1 infection. A serum bank, created from patients who had been admitted with acute febrile illnesses and investigated for leptospirosis, provided serological evidence for primary HIV-1 infection in 10 patients. Serological testing of the serum samples confirmed primary HIV-1 infection in nine patients and was suggestive in the tenth. The clinical features of the 10 patients fit the earlier descriptions of primary HIV-1 infection, but differed from the leptospirosis cases seen at the QEH. One patient died during his seroconversion illness and another died 3 months after seroconversion. These findings suggest that severe primary HIV-1 infection could be a relatively uncommon occurrence, that the condition may be misdiagnosed, and that cases may not occur until the AIDS epidemic is established.

Epidemiology of Helicobacter pylori infection in Barbados.

The epidemiology of Helicobacter pylori infection in Barbadian patients and controls was studied. H. pylori was isolated from biopsies from 50/100 (50%) adult patients undergoing endoscopy for investigation of upper gastrointestinal tract symptoms. Urease was detected in biopsies from 54 patients and gastritis was detected by histology in 71 patients. Serology was performed using a commercial ELISA method. Using an IgG concentration of 10 U/ml as a threshold, antibodies were detected in 78% of 100 patients undergoing endoscopy, 72% of 230 blood donors and 22% of 50 children. The mean antibody concentration was significantly higher in patients (92 U/ml) than in blood donors (49 U/ml) or in children (9.5 U/ml). Culture-positive patients (120 U/ml) had higher IgG concentrations than culture-negative patients (64 U/ml). Using isolation of H. pylori or a positive biopsy urease test as a measure of true prevalence of infection, the sensitivity of serology was 96%, the specificity 42%, positive predictive value 67% and negative predictive value 90%. Seroprevalence increased with age, to a peak of more than 90% in blood donors aged 50-59 years and in patients aged over 60 years. The epidemiology of H. pylori in Barbados is similar to that in developed countries, where few children are infected, but resembles other developing countries in the high seroprevalence observed in middle-aged adults. Our results confirm the utility of serology for detecting H. pylori by a non-invasive technique.

Remission of a chemotherapy resistant tumor of low malignant potential with tamoxifen.

Low Malignant Potential (LMP) tumor of the ovary represents 15% of all ovarian tumors. The prognosis is excellent even in patients with extensive tumor involvement. However 20% of the patients die of disease in a 20 year period. Management of patients after surgery is not defined. Chemotherapy has shown response rates of 20% but no improvement in survival. Toxicity has been reported. We present a case of chemotherapy resistant LMP tumor with serologic response to tamoxifen, no evidence of disease and an excellent quality of life. Hormonal therapy may be considered in the treatment of LMP tumors.

Evaluation of the polymerase chain reaction for early diagnosis of leptospirosis.

Early diagnosis of leptospirosis is important because severe leptospiral infection can run a fulminant course. The polymerase chain reaction (PCR) was evaluated for the detection of leptospires in clinical samples from patients with acute leptospiral infection. Blood and urine samples from 71 patients with leptospirosis were examined by PCR, culture or serology. Samples from 44 (62%) patients with the diagnosis of leptospirosis were positive by PCR as compared to 34 (48%) by culture. The presence of leptospires was demonstrated by PCR in 13 patients before the development of antibodies, as well as in two patients who were seronegative during their illness and at autopsy. Samples from 16 patients without leptospirosis were seronegative and culture negative, and also negative by PCR. We conclude that PCR is a rapid, sensitive and specific means of diagnosing leptospiral infection, especially during the first few days of the disease.

A twelve-year study of leptospirosis on Barbados.

Between November 1979 and December 1991, 398 cases of severe leptospirosis were confirmed on Barbados (range for 1980-1991 23-56; mean 32.7; incidence 13.3/100,000/year). For the six-year periods 1980-1985 and 1986-1991 there was no significant change in incidence with time. Incidence is unlikely to change significantly in the next decade. Monthly average case numbers ranged from 1.4 (July) to 4.3 (November). The average (2.8) for June to December (the 7 wetter months) was not significantly higher than that (2.5) for January to May (the 5 drier months). The age range was 7-86. There were three times as many male cases (302) as female (96), and nearly 10 times as many in those < 35. Although the highest number of cases (69) was in males aged 15-24, the highest incidence was in the older age groups, particularly the male 65-74 year-olds, and the female 55-64 year-olds. Leptospirosis was the proven cause of death in 55 (13.8%) hospital patients (annual range 0-13, mean 4.5). Some of a further 39 fatalities might have been cases. Death from leptospirosis was nearly twice as common among the women as among the men. Only one patient under 20 years of age died. Leptospira were isolated and identified from 117 (29.4%) of the 398 sick patients. The infecting organisms were bim (serogroup Autumnalis--75), copenhageni (Icterohaemorrhagiae-26), arborea (Ballum-14) and bajan (Australis-2). These infecting serovars could not be distinguished clinically, but infection was milder in children than in adults. Despite its predominance in surveyed children, serogroup Panama was virtually absent in this study. Rainfall is the major factor affecting the distribution of cases; not surprisingly, sanitation workers and agricultural workers appear to be the groups at highest risk. The general lack of clear-cut risk factors reflects the ubiquity of leptospires in the environment and the fact that the disease is not entirely occupational.

Neuroleptic malignant syndrome among acute psychiatric admissions in Barbados.

The main features of the Neuroleptic Malignant Syndrome (NMS), a complication of neuroleptic therapy, are fever, muscle rigidity, autonomic dysfunction, and an alteration in consciousness level. We describe five cases of NMS comprising 0.6% of acute neuroleptically-treated admissions to a psychiatric hospital over a one-year period. All patients, four females aged 26 to 63 years, and one male, aged 65 years, were of African origin and received multiple neuroleptic drugs, at least one of which was a depot preparation. Four were being treated for functional psychiatric disorders while one had dementia. All patients had fever and depressed consciousness level while four had rigidity and autonomic dysfunction. Serum creatine phosphokinase was elevated in 4 cases, and there was indirect evidence of myoglobinuria in 3 cases suggested by a positive urine dipstick test for blood despite the absence of red cells on microscopy. Rhabdomyolysis was associated with renal failure in one case. Both bromocriptine mesylate and dantrolene sodium were given in two cases. Three patients died in hospital, one with persistent rigidity and progressive decubitus ulceration, one from peritonitis following peritoneal dialysis, and another suddenly. Early recognition of NMS is important; it should be considered in any patient on neuroleptic therapy who develops fever, rigidity or alteration in consciousness level.