Biomedical subjects
Publications and source records attributed to D D Munro.
Two patients developed classical erythema multiforme while taking oral terbinafine. A case of Stevens-Johnson syndrome occurring after terbinafine therapy has recently been described, but there have been no published reports of an association with erythema multiforme until now.
A case of low-grade B-cell malignant lymphoma with a prolonged restriction to the skin is described. A rearrangement of the immunoglobulin heavy-chain gene was detected using molecular techniques. The histology showed many similarities to primary mucosal lymphomas and this may represent a skin counterpart of these tumours.
A case of relapsing polychondritis (RPC) with strongly positive antibodies to both native and denatured type II collagen is reported. This is only the second report of the use of cyclosporin A in the treatment of RPC.
We describe an adult with progressive LCH who received oral etoposide as primary treatment. The response is documented and the strategical implications of this drug in Langerhans-cell histiocytosis discussed. Langerhans-cell histiocytosis (LCH) is the term recognized since 1987 for the group of diseases previously designated histiocytosis X. It is not now regarded as a malignant neoplastic process and there is some evidence to suggest that it is due to abnormal immunity, but cytotoxic drugs and steroids are still the mainstay of systemic treatment. Etoposide (VP16) is a semisynthetic epipodophyllotoxin derivative effective in the treatment of malignancies of the monocyte-macrophage lineage and used in resistant or relapsed childhood LCH. There are no previous reports of its use as firstline monotherapy in adults with LCH.
A group of 16 male patients with infertility had dermatitis of the scrotum and groins giving lichenified oedematous skin; the resulting thickening and loss of rugosity produced a characteristic appearance that we have termed wash leather scrotum. Treatment of the dermatosis resulted in an improvement in sperm count and motility in most patients, and 5 couples produced one or more pregnancies.
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The clinical and histologic features of 26 cases of erythema induratum are reviewed. The characteristic cutaneous lesions on the legs of middle-aged women were violaceous, indurated nodules, 1 to 2 cm in diameter, which were painful, occasionally ulcerated, and could heal with scarring. The diagnosis was confirmed in all patients by a strongly positive Mantoux test result (1:10,000 dilution) and by clearing of lesions after antituberculosis therapy. The histologic features were varied but were predominantly those of a vasculitis with a paraseptal and lobular panniculitis. Although it was not possible to fulfill the required criteria for diagnosing tuberculosis in these lesions, we believe there is sufficient circumstantial evidence to support the hypothesis that erythema induratum is a true tuberculid.
The pharmacokinetics of methotrexate was studied in 23 patients with chronic plaque psoriasis. Ten patients received a single oral does and 13 patients a single intramuscular injection of 25 mg methotrexate. Serum methotrexate was measured for 24 hours following administration of the drug using a magnetizable solid-phase radio-immunoassay. The disappearance of methotrexate from the serum fitted a two-compartment model with a distribution phase half-life of 1.18 +/- 0.12 h and an elimination phase half-life of 5.35 +/- 0.62 h following the oral dose and 1.45 +/- 0.22 h and 4.71 +/- 0.32 h, respectively following the intramuscular dose. Peak serum methotrexate concentrations varied greatly between patients but the mean area below the curve for the two routes of administration did not differ significantly. In a further 18 psoriatic patients receiving long-term maintenance methotrexate therapy there was no consistent relationship between salivary and serum methotrexate levels.
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The clinical course of 20 patients with 22 thoracic hydatid cysts operated on from 1957 to 1984, was reviewed. Follow-up extended to 27 years (mean, 11.6 +/- 1.5 years [+/- the standard error of the mean]) and was 90% complete. Most patients originated from countries in the Mediterranean region; 5 were native Canadians. The diagnosis was suspected in all but 3 patients preoperatively. Fourteen patients had 16 primary lung cysts, 4 had infected liver cysts with intrathoracic extension, 1 had synchronous unruptured liver and lung cysts, and 1 had a thymic cyst. Nine cysts were intact, whereas 13 had ruptured preoperatively. A variety of surgical procedures was performed, including eight wedge resections and nine lobectomies. There were no early deaths, and perioperative complications were infrequent. One patient with a hepatic cyst that had ruptured into the right pleural space and right lower lobe died at 7 months of massive echinococcosis of the liver and intraabdominal sepsis. There has been no evidence of thoracic recurrence in any of our long-term survivors, although 1 patient had undergone enucleation of a left lung cyst in Greece 15 years prior to her reoperation here for a lingular recurrence. We conclude that thoracic hydatid disease is a rare entity in northeastern North America. The prevalence of ruptured cysts and infected hepatic cysts involving the lung was higher than in most other series, thereby necessitating more aggressive surgical treatment. Nevertheless, morbidity was low, and recurrence of disease was uncommon in long-term follow-up.
Spin lattice relaxation time (TI) measured with a low field strength magnetic resonance imager in 51 patients with severe psoriasis did not correlate with the histological findings of liver biopsies taken during treatment with oral methotrexate. Liver TI measurement at low magnetic field is of no value as a screening procedure in monitoring methotrexate induced liver damage.
Twelve patients with treatment-resistant mosaic plantar warts were treated with aggressive cryotherapy under a general anaesthetic. Seven patients (58%) had complete cure, two patients (16%) experienced substantial but incomplete clearing of their warts and the remaining three patients (25%) had no improvement. The procedure was well tolerated and post cryotherapy pain was acceptable to the patients.
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Patients with empyema not responding to simple chest-tube drainage and antibiotic therapy have been managed by a "Clagett"-type procedure that consists of open-window thoracostomy, antibiotic irrigation and closure of the window. The results of such treatment were reviewed. Of the 103 patients with empyema treated between 1967 and 1983, 41 underwent open-window thoracostomy. Twenty-eight (group 1) had empyema after pneumonectomy, 13 (group 2) did not; however, 9 of the 13 in group 2 had undergone lobectomy. The mean follow-up was 46 months for group 1 and 42 months for group 2. When surgical closure of the open-window thoracostomy was attempted, the success rate in group 1 was 85% for those without concomitant bronchopleural fistula, but only 36% in patients with a fistula. In group 2 the respective success rates were 50% and 57%. Unsuccessful closure resulted in chronic fistulas in four patients in each of the two groups. Six deaths in group 1 and two in group 2 were related to the original disease, but one was an operative death. These results demonstrate both the effectiveness and limitations of open-window thoracostomy in the management of these difficult cases.
A middle aged man suffered with insulin dependent diabetes, autoimmune Addison's disease, myxoedema, and severe ulcerative colitis, for which he had undergone subtotal colectomy with formation of an ileostomy. Granuloma annulare confined to the anterior abdominal wall was diagnosed in 1981. In 1983 an episode of severe colicky pain and excessive working of the ileostomy occurred associated with severe hyperglycaemia and increased irritation of the granuloma annulare. Laparotomy disclosed adhesions and numerous white nodules over bowel, mesentery, and peritoneum histologically identical with the skin lesions. Two further episodes of subacute small bowel obstruction occurred, and a repeat laparotomy showed widespread intra-abdominal granuloma annulare. Visceral granuloma annulare appears not to have been reported before, and in this patient exacerbation of the skin lesion was associated with poor diabetic control.
A patient who developed a fixed drug eruption due to paracetamol is reported. There is only one previous account of this eruption occurring as a consequence of paracetamol therapy.
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