268 while attempting to give the injection. The patient was using monotard insulin, but since the solution had been aspirated into the syringe, the initial fault clearly did not lie with the needles. The patient stated that there was no delay between filling the syringe with monotard and giving the injection, and also that new syringes with attached needles were used for each injection. On some occasions the needle was blocked while he attempted to adjust the dose before injection and on others the blockage happened during the injection itself. An explanation might be that occasionally the insulin was not completely in suspension, either after a large vial had been used several times or with specific isolated vials. Surgical Division Laboratory, Needle Industries Ltd., Redditch, Worcestershire B98 7AB
A. M.
POWELL
DIABETES MELLITUS PRESENTING WITH ALOPECIA AREATA TOTALIS
SIR,-Diabetes mellitus has only occasionally been dealopecia areata;1,2 a frequency of 2% has been reported.’ As a presenting symptom of diabetes mellitus, alopescribed in
cia areata totalis has not been recorded in the standard works of reference on diabetes.444 A 27-year-old Indian man acquired an excessive and steady loss of scalp hair in a diffuse pattern. Within a week he was completely bald. He had not been under any mental stress and there was no family history of alopecia areata. At about the same time polydipsia and polyuria developed. There was no family history of diabetes mellitus.
PAINLESS MYOCARDIAL INFARCTION IN DIABETES
SIR,-We agree with you’ that attributing painless myocardial infarction in diabetics to damage of cardiac pain fibres by autonomic neuropathy needs further evaluation. We have seen2 two diabetics, known to have severe clinical autonomic neuropathy confirmed by autonomic-function tests,3 who nevertheless had painful acute myocardial infarction. Indeed, a third patient, a 34-year-old male diabetic with florid autonomic neuropathy (impotence, postural hypotension, gustatory sweating, diarrhoea, and gastric atony) and abnormal cardiovascular reflexes-namely, a Valsalva ratio of 1.00, a rise in diastolic blood-pressure to sustained handgrip of 5 mm Hg, and a postural fall in systolic blood-pressure of 30 mm Hg-has recently had a painful myocardial infarction. Thus, contrary to traditional teaching, severe diabetic autonomic neuropathy need not be associated with painless myocardial infarction. Although Faerman et a1.4 have found histological changes in cardiac autonomic nerve fibres in diabetics with painless myocardial infarction, their data are by no means conclusive, as you rightly point out. Other explanations for the painless myocardial infarction have been proposed. Friedberg5 suggested that microangiopathy in the myocardium of diabetics causes diminished bloodflow without actual infarction and that subsequent coronaryartery occlusion may therefore result in complete ischmmia of an area of myocardium which is already severely compromised, with little or no pain. Alternatively, the difference in incidence of painless infarction between diabetics and nondiabetics might be due to the fact that diabetics may come into hospital more often for other reasons and that silent myocardial infarctions are detected incidentally. Diabetic and Dietetic
Royal Infirmary, Edinburgh EH3 9YW
Department,
I. W. CAMPBELL D. J. EWING B. F. CLARKE
ISLET-CELL ANTIBODIES IN SPANISH DIABETICS
Alopecia areata totalis at presentation and complete regrowth of scalp hair after insulin therapy.
Apart from loss of hair from the whole scalp, with loss of the middle third of the right eyebrow as well, the physical examination was normal. His fasting blood-sugar was 281 mg/dl. Following a 50 g glucose load, the blood-sugar at 1 h and 2 h, were 494 and 428 mg/dl, respectively, thus confirming the diagnosis of diabetes mellitus. A routine hsemogram and Venereal Disease Research Laboratory test were normal. He was put on a 1500 calorie diabetic diet and started on lente insulin zinc suspension injection, 16 units daily. On this treatment the polyuria and polydipsia abated. The 2 h postprandial blood-sugar was between 105 and 200 mg/dl. After 2 months of insulin therapy, short hairs grew over the occiput, and hair growth gradually became more profuse (see
figure). University Department of Medicine I, Singapore General Hospital, Singapore 3
T. C. AW J. S. CHEAH
SIR,-Islet-cell antibodies (i.c.A.) were first found in 1974 by Bottazzo et allin the sera of patients with multiple autoimmune endocrinopathies. In 1975 Lendrum et al.’ found these antibodies in the sera of more than 50% of newly diagnosed diabetic children. Later, a tendency to develop insulin dependency was demonstrated in adults with non-insulin-dependent diabetes who had I.C.A. in their sera.8 A relationship between tissue type HLA-B8 and persistence of I.C.A. has been claimed in diabetes9 and also between I.C.A. and the presence of immune complexes in the sera of recent-onset diabetics.1o 1, J.C.A. has been studied in British," Danish,9 and Italian’ populations, and the frequency of positive reactions has been very similar when the patients are classified by the same criteria. We have looked for J.C.A. in 205 Spanish diabetics with diabetes of recent-onset (duration of illness less than 8 weeks), insulin-dependent diabetes, or non-insulin-dependent diabetes 1. 2. 3.
1354. 4. Faerman, I., Faccio, E., Milei, J., Nunez, R., Jedinsky, M., Fox, D., Rapaport, M. Diabetes, 1977, 26, 1147. 5. Friedberg, C. K. Diseases of the Heart. p. 800. Philadelphia, 1966. 6. Bottazzo, G. F., Florin-Chnstensen, A., Doniach, D. Lancet, 1974, ii, 1279. 7. Lendrum, R., Walker, G., Gamble, R. ibid. 1975, i, 880. 8. Irvine, W. J., McCallum, C. J., Gray, R. S., Duncan, L. J. P. ibid. 1977,
i, 1025. Christy, M., Nerup, J., Bottazzo,-G. F., Doniach, D., Platz, P., Svejgaard, A., Ryder, L. P., Thomsen, M. ibid. 1976, ii, 142. 10. Irvine, W. J., Al-Khateeb, S. F., Di Mario, V., Feek, C. M., Gray, R. S., Edmond, B., Duncan, L. J. P. Clin. exp. Immun. 1977, 30, 16. 11. Lendrum, R., Walker, G., Cudworth, A. G., Theophanides, C., Pike, D. A., Bloom, A., Gamble, D. R. Lancet, 1976, ii, 1273. 9.
1. 2. 3. 4.
Muller, S. A., Winkelmann, R. K. Archs Derma. 1963, 88, 290. Fenske, N. A., Johnson, S. A. M. Postgrad. Med. 1976, 60, 79. Malins, J. Clinical Diabetes Mellitus. London, 1968. Oakley, W. G., Pyke, D. A., Taylor, K. W. Diabetes and its Management. Oxford, 1975.
Lancet, 1978, ii, 1241. Campbell, I. W., Ewing, D. J., Clarke, B. F. Acta diabet. lat. (in the press). Ewing, D. J., Campbell, I. W., Burt, A. A., Clarke, B. F. Lancet, 1973, u,
A. M.
POWELL
DIABETES MELLITUS PRESENTING WITH ALOPECIA AREATA TOTALIS
SIR,-Diabetes mellitus has only occasionally been dealopecia areata;1,2 a frequency of 2% has been reported.’ As a presenting symptom of diabetes mellitus, alopescribed in
cia areata totalis has not been recorded in the standard works of reference on diabetes.444 A 27-year-old Indian man acquired an excessive and steady loss of scalp hair in a diffuse pattern. Within a week he was completely bald. He had not been under any mental stress and there was no family history of alopecia areata. At about the same time polydipsia and polyuria developed. There was no family history of diabetes mellitus.
PAINLESS MYOCARDIAL INFARCTION IN DIABETES
SIR,-We agree with you’ that attributing painless myocardial infarction in diabetics to damage of cardiac pain fibres by autonomic neuropathy needs further evaluation. We have seen2 two diabetics, known to have severe clinical autonomic neuropathy confirmed by autonomic-function tests,3 who nevertheless had painful acute myocardial infarction. Indeed, a third patient, a 34-year-old male diabetic with florid autonomic neuropathy (impotence, postural hypotension, gustatory sweating, diarrhoea, and gastric atony) and abnormal cardiovascular reflexes-namely, a Valsalva ratio of 1.00, a rise in diastolic blood-pressure to sustained handgrip of 5 mm Hg, and a postural fall in systolic blood-pressure of 30 mm Hg-has recently had a painful myocardial infarction. Thus, contrary to traditional teaching, severe diabetic autonomic neuropathy need not be associated with painless myocardial infarction. Although Faerman et a1.4 have found histological changes in cardiac autonomic nerve fibres in diabetics with painless myocardial infarction, their data are by no means conclusive, as you rightly point out. Other explanations for the painless myocardial infarction have been proposed. Friedberg5 suggested that microangiopathy in the myocardium of diabetics causes diminished bloodflow without actual infarction and that subsequent coronaryartery occlusion may therefore result in complete ischmmia of an area of myocardium which is already severely compromised, with little or no pain. Alternatively, the difference in incidence of painless infarction between diabetics and nondiabetics might be due to the fact that diabetics may come into hospital more often for other reasons and that silent myocardial infarctions are detected incidentally. Diabetic and Dietetic
Royal Infirmary, Edinburgh EH3 9YW
Department,
I. W. CAMPBELL D. J. EWING B. F. CLARKE
ISLET-CELL ANTIBODIES IN SPANISH DIABETICS
Alopecia areata totalis at presentation and complete regrowth of scalp hair after insulin therapy.
Apart from loss of hair from the whole scalp, with loss of the middle third of the right eyebrow as well, the physical examination was normal. His fasting blood-sugar was 281 mg/dl. Following a 50 g glucose load, the blood-sugar at 1 h and 2 h, were 494 and 428 mg/dl, respectively, thus confirming the diagnosis of diabetes mellitus. A routine hsemogram and Venereal Disease Research Laboratory test were normal. He was put on a 1500 calorie diabetic diet and started on lente insulin zinc suspension injection, 16 units daily. On this treatment the polyuria and polydipsia abated. The 2 h postprandial blood-sugar was between 105 and 200 mg/dl. After 2 months of insulin therapy, short hairs grew over the occiput, and hair growth gradually became more profuse (see
figure). University Department of Medicine I, Singapore General Hospital, Singapore 3
T. C. AW J. S. CHEAH
SIR,-Islet-cell antibodies (i.c.A.) were first found in 1974 by Bottazzo et allin the sera of patients with multiple autoimmune endocrinopathies. In 1975 Lendrum et al.’ found these antibodies in the sera of more than 50% of newly diagnosed diabetic children. Later, a tendency to develop insulin dependency was demonstrated in adults with non-insulin-dependent diabetes who had I.C.A. in their sera.8 A relationship between tissue type HLA-B8 and persistence of I.C.A. has been claimed in diabetes9 and also between I.C.A. and the presence of immune complexes in the sera of recent-onset diabetics.1o 1, J.C.A. has been studied in British," Danish,9 and Italian’ populations, and the frequency of positive reactions has been very similar when the patients are classified by the same criteria. We have looked for J.C.A. in 205 Spanish diabetics with diabetes of recent-onset (duration of illness less than 8 weeks), insulin-dependent diabetes, or non-insulin-dependent diabetes 1. 2. 3.
1354. 4. Faerman, I., Faccio, E., Milei, J., Nunez, R., Jedinsky, M., Fox, D., Rapaport, M. Diabetes, 1977, 26, 1147. 5. Friedberg, C. K. Diseases of the Heart. p. 800. Philadelphia, 1966. 6. Bottazzo, G. F., Florin-Chnstensen, A., Doniach, D. Lancet, 1974, ii, 1279. 7. Lendrum, R., Walker, G., Gamble, R. ibid. 1975, i, 880. 8. Irvine, W. J., McCallum, C. J., Gray, R. S., Duncan, L. J. P. ibid. 1977,
i, 1025. Christy, M., Nerup, J., Bottazzo,-G. F., Doniach, D., Platz, P., Svejgaard, A., Ryder, L. P., Thomsen, M. ibid. 1976, ii, 142. 10. Irvine, W. J., Al-Khateeb, S. F., Di Mario, V., Feek, C. M., Gray, R. S., Edmond, B., Duncan, L. J. P. Clin. exp. Immun. 1977, 30, 16. 11. Lendrum, R., Walker, G., Cudworth, A. G., Theophanides, C., Pike, D. A., Bloom, A., Gamble, D. R. Lancet, 1976, ii, 1273. 9.
1. 2. 3. 4.
Muller, S. A., Winkelmann, R. K. Archs Derma. 1963, 88, 290. Fenske, N. A., Johnson, S. A. M. Postgrad. Med. 1976, 60, 79. Malins, J. Clinical Diabetes Mellitus. London, 1968. Oakley, W. G., Pyke, D. A., Taylor, K. W. Diabetes and its Management. Oxford, 1975.
Lancet, 1978, ii, 1241. Campbell, I. W., Ewing, D. J., Clarke, B. F. Acta diabet. lat. (in the press). Ewing, D. J., Campbell, I. W., Burt, A. A., Clarke, B. F. Lancet, 1973, u,
