Search

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.

This article recounts the clinical background and the legacy of tuberculosis chest surgery, the historical alliance of two McGill teaching hospitals, and the timing of and way in which a joint medical-surgical decision to attempt the first human lung transplantation in Canada was made. The experimental phase, involving the use of identical twin calves, was accomplished with the help of L'Ecole de médecine vétérinaire de Québec. The reasons are given for the universal failure of all the early cases, and an updated summary is provided of the remarkable results obtained in the last decade.

Cyclopiazonic acid (CPA) has been reported to inhibit the Ca(2+)-ATPase of the sarcoplasmic reticulum (SR) in skeletal and smooth muscle. In the present study the effect of CPA on [Ca2+]i and force in rat urinary bladder smooth muscle was examined. The fluorescent Ca2+ indicator Fura-2 was used to monitor intracellular Ca2+, simultaneously with isometric force production. Addition of CPA to unstimulated muscles bathed in 2.5 mM Ca2+ containing Krebs solution resulted in a significant and sustained increase in [Ca2+]i from 99 +/- 7 to 273 +/- 51 nM. This increase in [Ca2+]i was dependent upon the presence of extracellular Ca2+ since when CPA was added to muscles in Ca(2+)-free media it produced only a small, transient increase in [Ca2+]i that was not sustained. Peak force levels produced by transmural stimulation, carbachol and high KCl solution were not altered by the presence of CPA, however, the increase in [Ca2+]i associated with these contractions was larger when CPA was present. In response to transmural stimulation, the times taken for both force and [Ca2+]i to rise to 50% of their peak values were attenuated in the presence of CPA. Conversely, there was no effect of CPA on the times taken for force or [Ca2+]i to fall to 50% of their stimulated values upon the cessation of stimulation. Under control conditions both carbachol and high KCl could initiate transient increases in [Ca2+]i and force in the absence of extracellular Ca2+. In the presence of CPA, the response to carbachol was virtually completely inhibited, however, the response to high KCl was only partially inhibited. The ability of CPA to inhibit the carbachol response in Ca(2+)-free media suggests that this response is due to release of Ca2+ from the SR. The incomplete inhibition of the response to KCl indicates other Ca2+ storage sites may also be mobilised by sarcolemmal depolarisation. Although the mechanism whereby CPA induces a large, sustained rise in [Ca2+]i remains unknown, the data lend support to the suggestion that depletion of intracellular Ca2+ storage sites may activate a Ca2+ entry pathway across the sarcolemma.

Longitudinal smooth muscle strips taken from the urinary bladders of Sprague-Dawley rats, aged approximately 6 months and 24 months, were examined under a variety of conditions. Force development in response to electrical field stimulation and to cumulative addition of Ca2+ in the continual presence of 64 mM. KCl was the same in both adult and aged preparations. In response to cumulative additions of carbachol, however, it was observed that there was a shift to the right of the dose-response curve and a decrease in maximal force in the aged muscle strips. The maximal velocity of shortening was significantly lower in muscles from aged animals than in those from young adult animals. The metabolic tension cost during isometric contraction was, however, the same in both groups suggesting that the decline in Vus is largely due to factors not influencing energetic cost. The aged muscles also exhibited a lower basal metabolic rate and a reduced contribution of aerobic glycolysis to total metabolic energy production during both quiescence and stimulation under normoxic conditions than did muscles from young adult animals. They were, however, able to increase their rate of lactate production to the same levels as young adult muscles when stimulated under anoxic conditions.

Guttate psoriasis may be precipitated by acute streptococcal infection, usually of the upper respiratory tract. We have studied the immune response to streptococci in 26 patients presenting with a first or recurrent episode of acute guttate psoriasis (AGP), using immunoblotting. Eighteen of 26 patients studied had a demonstrable response to a wide range of streptococcal antigens using this approach, compared with 14 of 26 patients who demonstrated a response using more conventional antistreptococcal antibody tests. Patients with AGP had a significantly higher antibody detection score using immunoblotting than did control subjects (P < 0.005). We conclude that immunoblotting is a useful technique in studying this condition and may be of benefit in exploring the immunopathogenesis of AGP.

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.

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.

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.

We measured plasma sex-hormone binding globulin (SHBG) and testosterone levels in a pilot study of eight women aged 21-41 years who complained of diffuse hair loss; and subsequently in a larger group of fifteen patients of a similar age range. There was a significant reduction in SHBG levels in both groups of patients when compared ot controls, but testosterone values were normal.

Serum testosterone, sex hormone binding globulin (SHBG) and prolactin were measured in thirty-eight women with acne which persisted or started after the age of 18 years. One or more of these levels were abnormal in 76% of patients. Increased testosterone or low SHBG were present alone or in combination in 60% of patients. This group was presumed to have a raised level of non-protein bound, metabolically-available testosterone. Hyperprolactinaemia, which was present in 45% of patients, may be important in view of the reported association with increased adrenal androgens. The hormonal abnormalities may be causally related to the acne and a greater understanding of them may lead to better treatment.

A ratchet-controlled micrometer screw gauge has been used to measure the changes in skin thickness produced by topical corticosteroids. Measurable thinning of the mouse ear followed repeated daily application of corticosteroids. This response in the animal was used to assess the atrophic potential in a variety of standard formulations. The same compounds were applied to human skin and the changes in thickness measured. Patterns of response and the rank order of thinning obtained from the animal model were found to parallel closely the human results.

Azathioprine treatment benefited 19 (66%) out of 29 patients suffering from severe psoriasis. Haematological complications were not troublesome and results of biochemical liver function tests remained normal. Minimal cholestasis was seen in two cases and portal fibrosis of a reversible degree in eight. Liver biopsies should be undertaken at regular intervals if azathioprine therapy is continued so that structural liver damage may be detected at an early and reversible stage.

Twenty-three patients with carcinoma of the lung and a brain metastasis had both the primary and secondary tumors surgically removed (combined operation). Results revealed that 52% of the patients were unimproved and died during the first 6 months. Operation improved short-term survival in 26%. Five patients (22%) lived longer than 2 years, and 3 of them (13%) are alive and well 10 or more years following operation.

Alopecia areata occurs more often in Down's syndrome than would be expected by chance, sixty cases being found among 1000 patients with this syndrome compared with one case among 1000 subnormal controls. Because alopecia areata is associated with some organ-specific autoimmune disease and thyroid antibodies are often found in Down's syndrome sera from affected patients were examined for the presence of fluorescent autoantibodies. Antibodies against thyroid components tended to be present in female mongols with alopecia areata in comparison with females in a normal population but not in male mongols. Futhermore, eight out of 23 female mongols (35%) with alopecia areata had antibodies against thyroid components compared with two out of 23 female mongols (9%) without alopecia areata.

In this paper we present the first record of familial incidence in angioma serpiginosum observed in two families. The clinical and histological features are described.

Women with persistent or late onset acne vulgaris were divided into two treatment groups. The first received continuous low dose prednisolone to suppress ACTH-dependent androgen secretion and the second was treated with cyclical oestrogens with medroxyprogesterone to elevate sex hormone binding globulin (SHBG). In both groups there was a significant improvement in the severity of the acne after 4 months' treatment. Although pre-existing hormonal abnormalities were corrected, the improvement in the acne did not correlate with the baseline hormone levels. However, suitable oestrogen-progesterone combinations or low dose prednisolone may be given, alone or in combination, to suppress free circulating androgens in these patients with a high probability of improving their acne.

The development of topical corticosteroids has enabled many dermatoses to be more effectively treated than previously, but there is also no doubt that misuse of these preparations can lead to troublesome local effects and potentially serious systemic problems. The most effective assay for comparing different compounds has been their vasoconstrictive activity, and this on the whole correlates well with clinical effect. To be effective, corticosteroid must be absorbed and the importance of concentration, occlusion, the type of vehicle, added penetrants such as urea and the anatomical site, on the amount of absorption and therefore on clinical activity has been demonstrated. Ointments have been shown to be more effective than creams but because of the considerable choice of potencies now available most dermatologists tend to prescribe the different formulations according to the wishes of the patient. For the same reason, dilution of the commercially marketed preparations is now not generally recommended. The main therapeutic activity of topical corticosteroids is their nonspecific anti-inflammatory effect, thought to be primarily a result of their action on the chemical mediators of inflammation. They have also been shown to be antimitotic which may well be relevant not only to the treatment of scaling dermatoses but also to their dermal thinning effect resulting from inhibition of fibroblasts. Combinations of corticosteroids with antibacterial and antifungal agents have been shown to be very effective in flexural eruptions and secondarily infected dermatoses. As a general rule, the use of topical corticosteroids in outpatients, unless badly misused, is not associated with any significant risk of adrenal axis suppression, but care must be exercised as to the amount prescribed, especially if large areas of the body are to be treated with highly potent preparations. Certain groups such as young children and patients with liver failure, and certain anatomical sites such as the flexures and face appear much more prone to side effects, and in these cases mild or moderate compounds should be used in preference to the stronger preparations.

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.

We report the case of a 75-year-old lady with recurrent primary cutaneous Merkel cell tumours. The condition can be misdiagnosed as lymphoma or anaplastic carcinoma, and the definitive diagnosis can be made only by electron microscopy of fresh tissue. This is the first reported case in the British literature.

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.

In a study of 24 patients with alopecia areata, scalp biopsies were examined for immunofluorescence; all were negative. A number of other tests also failed to confirm an auto-immune aetiology for this disease. A possible explanation lies in the heterogeneity of alopecia areata, only a small proportion of cases being of the auto-immune type.

Twenty-three patients with bronchogenic carcinoma and a brain metastasis had their primary and secondary tumors treated surgically. The 10 men and 13 women had an average age of 52 years. Fifteen patients presented with a lesion of the lung and eight patients presented initially with neurological findings of an intracranial mass lesion. The most common histological type of tumor was adenocarcinoma (48%), followed by squamous cell carcinoma, undifferentiated small cell carcinoma, and bronchoalveolar carcinoma. Twelve patients (52%) had a poor result and died during the first six months. Surgery appeared to improve short-term survival in six patients (26%). Five patients (22%) had a good result and lived longer than 2 years without significant neurological deficit. Three patients (13%) are alive 10 or more years following surgery.

Members of two different families were found to have the dysplastic naevus syndrome and coexistent endocrine abnormalities. The dysplastic naevus syndrome is probably inherited as an autosomal dominant trait and has been associated with other primary malignancies. This is the first time that it has been described in association with endocrine abnormalities.

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.

The prolonged use of self-administered corticotrophin in the form of 'CMC ACTH' (Crookes) or 'Synacthen Depot' (Ciba) has been considered in twenty-seven patients with severe subactute of chronic eczema. Complications were not troublesome and the therapeutic response was good. Many of the patients were able to control their disease fully without the effort and discomfort of additional local treatment and patients' acceptance of the treatment was high.

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.

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.

Methotrexate has been of proven value in the management of patients with severe psoriasis. Its long-term use, however, can be complicated by progressive hepatic damage which has necessitated regular liver biopsies. We have looked into the efficacy of liver ultrasonography as a non-invasive screening procedure to select those patients who may be developing liver changes. Eighty-seven investigations on 82 patients were performed, comparing liver ultrasound results with liver biopsy. Eight of these showed a degree of hepatic damage which was sufficient to indicate cessation of methotrexate, and all of these were detected by ultrasonography. Our results indicate that patients whose last liver biopsy was normal could be allowed an extended interval between biopsies provided their intervening ultrasound scans remained normal.