352
C
orres
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ence
The Editors will be pleased to receive and consider for publication correspondence containing information of interest to physicians or commenting on issues ofthe day. Letters ordinarily should not e-xceed 500 words and must be typewritten, doublespaced, and submitted in duplicate (the original typescript and one copy). Authors will be given the opportunity to review the editing of their correspondence before publication.
An Easy and Inexpensive Way to Lower Cholesterol?
Primary Biliary Cirrhosis Coexisting With Sarcoidosis-or Possibly Sj'ogren's Syndrome?
TO THE EDITOR: After reading the article by Press and colleagues describing the cholesterol-lowering effects of the nutritional supplement chromium picolinate in the January 1990 issue,I I treated ten hypercholesterolemic patients with a regimen of chromium picolinate (200 itg chromium daily, a nutritional dose), niacin (l to 2 grams per day, a pharmacologic dose), and dietary advice. After four weeks of this therapy, the average response was as follows:
TO THE EDITOR: Leff and colleagues recently reported the case of a 40-year-old woman with coexistence of primary biliary cirrhosis and sarcoidosis. I It is difficult to determine whether the pulmonary granulomas of this case were due to primary biliary cirrhosis or to coexistent sarcoidosis, however. Pulmonary manifestations in primary biliary cirrhosis can be attributed to the emergence of a granulomatous disorder in the lungs similar to sarcoidosis.2 The patient had few symptoms or laboratory data that helped make the diagnosis of sarcoidosis. We agree that the case may represent the coexistence of primary biliary cirrhosis and sarcoidosis and, from the rheumatologic point of view, would like to make some comments. Lymphocytic interstitial pneumonitis, or so-called pseudolymphoma, which is commonly associated with Sjogren's syndrome, may occur in patients with primary biliary cirrhosis, as Leff and co-workers mentioned in their article. Pseudolymphoma is most common in women in their 40s and often manifested as a tumorlike mass (coin lesion) in a chest radiograph. In these patients granulomas are sometimes observed.3 Did this patient have any immunologic or histologic evidence of Sj6gren's syndrome? Even if there were dry eyes and dry mouth, we must be circumspect in diagnosing sicca complex as Sj6gren's syndrome because sarcoidosis has been associated with dry eyes and mouth.4 Minor salivary gland biopsy is used also for diagnosing sarcoidosis, with results showing typical noncaseating granulomas in about half of patients.4 We are intrigued with the possibility of the coexistence ofsarcoidosis and Sj6gren's syndrome.5 An association of thyroiditis, Addison's disease, Sj6gren's syndrome, and sarcoidosis-TASS syndrome-has also been reported from California.6 It could be speculated that the histologic or clinical similarities among primary biliary cirrhosis, sarcoidosis, and Sjogren's syndrome suggest a continuum of disease.
* Total cholesterol levels dropped from 7.78 mmol per liter (301 mg per dl) to 5.92 mmol per liter (229 mg per dl) (24%). * Low-density lipoprotein (LDL) cholesterol levels dropped from 5.66 mmol per liter (219 mg per dl) to 4.14 mmol per liter (160 mg per dl) (27%). * Triglyceride levels dropped from 1.78 mmol per liter (158 mg per dl) to 1.02 mmol per liter (90 mg per dl) (43%). * High-density lipoprotein (HDL) levels were unchanged at 1.32 mmol per liter (51 mg per dl); the ratio of LDL to HDL improved substantially, however.
Obviously, these anecdotal data do not allow us to judge the relative contribution of chromium alone to the success of this regimen; nevertheless, the response was certainly clinically notable and comparable to pharmacologic treatment with prescription medications. One patient was treated initially only with niacin; subsequent treatment with a lower dose of niacin plus chromium yielded a better response. The treatment with chromium picolinate was convenient (one capsule daily), inexpensive, and was not associated with any discernible side effects. Patient acceptance was excellent. Asymptomatic, insulin-resistant hyperinsulinemia is common in the Western world and appears to be an independent risk factor for cardiovascular disease.2'3 By promoting tissue insulin sensitivity, good chromium nutrition may provide an additional protective benefit for many hypercholesterolemic persons. We need controlled studies to assess the efficacy of chromium picolinate use alone, or as an adjunct to diet and niacin, in the treatment of hypercholesterolemia and
HIDETO AKAMA, MD Division ofRheumatology Department of Internal Medicine Keio University School of Medicine 35 Shinanomachi, Shinjuku-ku Tokyo 160, Japan TADASHI YOSHIDA, MD SHINICHI KAWAI, MD Division of Rheumatic Disease Tokyo Metropolitan Ohtsuka Hospital Tokyo 170, Japan
hypertriglyceridemia. JEOFFRY B. GORDON, MD 4747Mission Blvd, Suite 4 San Diego, CA 92109
REFERENCES 1. Press RI, Geller J, Evans GW: The effect of chromium picolinate on serum cholesterol and apolipoprotein fractions in human subjects. West J Med 1990; 152:
41.45
2. Reaven GM: Role of insulin resistance in human disease. Diabetes 1988; 37:1595-1607 3. Type2diabetesorNIDDM: Looking forabettername (Editorial). Lancet 1989; 1:589-591
REFERENCES 1. Leff JA, Ready JB, Repetto C, Goff JS, Schwarz MI: Coexistence of primary biliary cirrhosis and sarcoidosis. West J Med 1990; 153:439-441 2. Spiteri MA, Clarke SW: The nature of latent pulmonary involvement in primary biliary cirrhosis. Sarcoidosis 1989; 6:107-110 3. Crystal RG: Interstitial lung disease, chap 63, In Wyngaarden JB, Smith LH Jr (Eds): Cecil Textbook of Medicine, 18th Ed. Philadelphia, Pa, WB Saunders, 1988, pp
421.435
4. Drosos AA, Constantopoulos SH, Psychos D, et al: The forgotten cause of sicca complex-Sarcoidosis. J Rheumatol 1989; 16:1548-1551
THE WESTERN JOURNAL OF MEDICINE * MARCH 1991
*
154 * 3
5. Justiniani FR: Sarcoidosis complicating primary Sjogren's syndrome. Mt Sinai J Med (NY) 1989; 56:59-61 6. Seinfeld ED, Sharma OP: TASS syndrome: Unusual association of thyroiditis, Addison's disease, Sj6gren's syndrome and sarcoidosis. J R Soc Med 1983; 76:883885 *
*
*
Drs Leff and Schwarz Respond TO THE EDITOR: Dr Akama and colleagues raise the interesting possibility that the patient we described as having coexistence of primary biliary cirrhosis and sarcoidosis' may have had instead Sjogren's syndrome complicated by lymphocytic interstitial pneumonitis (LIP) with pulmonary granulomas. It is clear that primary biliary cirrhosis is associated with Sjogren's syndrome, which is indeed associated with noncaseating granulomas on biopsy and which may be indistinguishable from those seen in sarcoidosis. For the following reasons, however, we think this is an unlikely scenario in our patient: * The patient had no evidence of Sj6gren's syndrome (although no salivary gland biopsies were done) or the sicca complex. * There was no evidence on transbronchial lung biopsy of either LIP or pseudolymphoma to explain the pulmonary granulomas. * Chest computed tomography showed no evidence of an interstitial process that might be expected in the case of LIP. While we may have encountered a sampling error due to the bronchoscopic nature of the biopsies, we think the weight of the evidence suggests coexistent sarcoidosis.
353
-j .O.J
dures attendant to general medical practice. The decision was not contested and was thought to be in the best interests of the patients, the affected institutions, and the surgeon, since, unlike other reports of this nature,' no changes in practice or technique seemed likely to assure no further transmission. No further associated cases have been identified. Orange County Public Health investigates all hepatitis reports (about 1,000 per year) using a procedure initiated by the Centers for Disease Control for use in "sentinel counties" engaged in a special study of hepatitis frequency and epidemiology.2 Because the association of so many cases with a single physician does not occur commonly, it seems likely that some aspect of contact between the surgeon and patients resulted in transmission ofthe hepatitis B virus, even though no technical or procedural problems were identified. The surface antigen subtyping supports this conclusion but is not conclusive because the frequency of "ay" in the community is unknown. Physician transmission of hepatitis B presumably is rare but may go unrecognized. We think it is important to record such recognized clusters so that representative accounts of such occurrences can be found in the literature.3 THOMAS J. PRENDERGAST, Jr, MD, MPH Chief, Preventive Medical Services San Bernardino County Department of Public Health 351 N Mountain View Ave, Rin 303 San Bernardino, CA 92415-0010 SOL TEITELBAUM, MD Laboratory Director Humana Hospital of West Anaheim 3033 W Orange Ave Anaheim, CA 92805 BARBARA PECK, RN Epidemiology and Disease Control Division Orange County Public Health Department PO Box 355 Santa Ana, CA 92702
JONATHAN A. LEFF, MD MARVIN I. SCHWARZ, MD Division of Pulnonary Sciences University of Colorado Health Sciences Center 4200 E Ninth Ave Denver, CO 80262
REFERENCE 1. Leff JA, Ready JB, Repetto C, Goff JS, Schwarz MI: Coexistence of primary biliary cirrhosis and sarcoidosis. West J Med 1990; 153:439-441
Transmission of Hepatitis B by a Surgeon TO THE EDITOR: In 1987 Orange County Public Health learned of two acute cases of hepatitis B, and identified three additional reported cases from the previous two years, found by a review of public health records. All five persons had surgical procedures done by a surgeon who was a known hepatitis B carrier. The surgeon was found to have hepatitis B e antigen in the blood in addition to hepatitis B surface antigen. Furthermore, hepatitis B antigen was detected in sputum. Blood from three patients and the surgeon was available for typing of the surface antigen. All were type "ay." No other risk factors for hepatitis B were confirmed after careful histories were obtained from the patients. The surgeon's previous professional experience included doing multiple surgical procedures on persons at high risk of being hepatitis B carriers-dialysis patients. None of the specific surgical procedures were known to have included any recorded incident of blood exposure or other untoward event. For this reason, the surgeon, hospital infection control committee representatives, and the local health department disease control director met and agreed that the surgeon should be required by action of the local health department to discontinue surgical practice and to observe appropriate precautions while doing minor proce-
REFERENCES 1. Francis DP, Hadler SC, Prendergast TJ Jr, et al: Occurrence of hepatitis A, B, and non-A, non-B in the United States-CDC sentinel county hepatitis study I. Am J Med 1984; 76:69-74 2. Bell DM, Shapiro CM, Holmberg SD: Surgical practice in hospitals: HIV and the surgical team. Am Coll Surg Bull 1990; 75:14-15 3. Lettan LA, Smith SD, Williams D, et al: Transmission of hepatitis B with resultant restriction of surgical practice. JAMA 1986; 255:934-937
Correction TO THE EDITOR: While the text is clear, Figure 1 in our case report on McCune-Albright syndrome in the December issue may be misleading.1 Bromocriptine therapy was initiated in January 1985 before the decrement in prolactin values. We apologize for any confusion this may have caused readers of the journal. ARTHUR L. M. SWISLOCKI, MD University of California Service VA Medical Center (612/111) 150 Muir Rd
Martinez, CA 94553 CARLOS A. CAMARGO, MD ANDREW R. HOFFMAN, MD Stanford University School of Medicine
VA Medical Center 3801 Miranda Ave Palo Alto, CA 94304 REFERENCE 1. Swislocki ALM, Camargo CA, Hoffman AR: McCune-Albright syndrome-A case of primary hypogonadism obscured by hyperprolactinemic hypogonadotropic hypogonadism. West J Med 1990; 153:653-656
C
orres
on
ence
The Editors will be pleased to receive and consider for publication correspondence containing information of interest to physicians or commenting on issues ofthe day. Letters ordinarily should not e-xceed 500 words and must be typewritten, doublespaced, and submitted in duplicate (the original typescript and one copy). Authors will be given the opportunity to review the editing of their correspondence before publication.
An Easy and Inexpensive Way to Lower Cholesterol?
Primary Biliary Cirrhosis Coexisting With Sarcoidosis-or Possibly Sj'ogren's Syndrome?
TO THE EDITOR: After reading the article by Press and colleagues describing the cholesterol-lowering effects of the nutritional supplement chromium picolinate in the January 1990 issue,I I treated ten hypercholesterolemic patients with a regimen of chromium picolinate (200 itg chromium daily, a nutritional dose), niacin (l to 2 grams per day, a pharmacologic dose), and dietary advice. After four weeks of this therapy, the average response was as follows:
TO THE EDITOR: Leff and colleagues recently reported the case of a 40-year-old woman with coexistence of primary biliary cirrhosis and sarcoidosis. I It is difficult to determine whether the pulmonary granulomas of this case were due to primary biliary cirrhosis or to coexistent sarcoidosis, however. Pulmonary manifestations in primary biliary cirrhosis can be attributed to the emergence of a granulomatous disorder in the lungs similar to sarcoidosis.2 The patient had few symptoms or laboratory data that helped make the diagnosis of sarcoidosis. We agree that the case may represent the coexistence of primary biliary cirrhosis and sarcoidosis and, from the rheumatologic point of view, would like to make some comments. Lymphocytic interstitial pneumonitis, or so-called pseudolymphoma, which is commonly associated with Sjogren's syndrome, may occur in patients with primary biliary cirrhosis, as Leff and co-workers mentioned in their article. Pseudolymphoma is most common in women in their 40s and often manifested as a tumorlike mass (coin lesion) in a chest radiograph. In these patients granulomas are sometimes observed.3 Did this patient have any immunologic or histologic evidence of Sj6gren's syndrome? Even if there were dry eyes and dry mouth, we must be circumspect in diagnosing sicca complex as Sj6gren's syndrome because sarcoidosis has been associated with dry eyes and mouth.4 Minor salivary gland biopsy is used also for diagnosing sarcoidosis, with results showing typical noncaseating granulomas in about half of patients.4 We are intrigued with the possibility of the coexistence ofsarcoidosis and Sj6gren's syndrome.5 An association of thyroiditis, Addison's disease, Sj6gren's syndrome, and sarcoidosis-TASS syndrome-has also been reported from California.6 It could be speculated that the histologic or clinical similarities among primary biliary cirrhosis, sarcoidosis, and Sjogren's syndrome suggest a continuum of disease.
* Total cholesterol levels dropped from 7.78 mmol per liter (301 mg per dl) to 5.92 mmol per liter (229 mg per dl) (24%). * Low-density lipoprotein (LDL) cholesterol levels dropped from 5.66 mmol per liter (219 mg per dl) to 4.14 mmol per liter (160 mg per dl) (27%). * Triglyceride levels dropped from 1.78 mmol per liter (158 mg per dl) to 1.02 mmol per liter (90 mg per dl) (43%). * High-density lipoprotein (HDL) levels were unchanged at 1.32 mmol per liter (51 mg per dl); the ratio of LDL to HDL improved substantially, however.
Obviously, these anecdotal data do not allow us to judge the relative contribution of chromium alone to the success of this regimen; nevertheless, the response was certainly clinically notable and comparable to pharmacologic treatment with prescription medications. One patient was treated initially only with niacin; subsequent treatment with a lower dose of niacin plus chromium yielded a better response. The treatment with chromium picolinate was convenient (one capsule daily), inexpensive, and was not associated with any discernible side effects. Patient acceptance was excellent. Asymptomatic, insulin-resistant hyperinsulinemia is common in the Western world and appears to be an independent risk factor for cardiovascular disease.2'3 By promoting tissue insulin sensitivity, good chromium nutrition may provide an additional protective benefit for many hypercholesterolemic persons. We need controlled studies to assess the efficacy of chromium picolinate use alone, or as an adjunct to diet and niacin, in the treatment of hypercholesterolemia and
HIDETO AKAMA, MD Division ofRheumatology Department of Internal Medicine Keio University School of Medicine 35 Shinanomachi, Shinjuku-ku Tokyo 160, Japan TADASHI YOSHIDA, MD SHINICHI KAWAI, MD Division of Rheumatic Disease Tokyo Metropolitan Ohtsuka Hospital Tokyo 170, Japan
hypertriglyceridemia. JEOFFRY B. GORDON, MD 4747Mission Blvd, Suite 4 San Diego, CA 92109
REFERENCES 1. Press RI, Geller J, Evans GW: The effect of chromium picolinate on serum cholesterol and apolipoprotein fractions in human subjects. West J Med 1990; 152:
41.45
2. Reaven GM: Role of insulin resistance in human disease. Diabetes 1988; 37:1595-1607 3. Type2diabetesorNIDDM: Looking forabettername (Editorial). Lancet 1989; 1:589-591
REFERENCES 1. Leff JA, Ready JB, Repetto C, Goff JS, Schwarz MI: Coexistence of primary biliary cirrhosis and sarcoidosis. West J Med 1990; 153:439-441 2. Spiteri MA, Clarke SW: The nature of latent pulmonary involvement in primary biliary cirrhosis. Sarcoidosis 1989; 6:107-110 3. Crystal RG: Interstitial lung disease, chap 63, In Wyngaarden JB, Smith LH Jr (Eds): Cecil Textbook of Medicine, 18th Ed. Philadelphia, Pa, WB Saunders, 1988, pp
421.435
4. Drosos AA, Constantopoulos SH, Psychos D, et al: The forgotten cause of sicca complex-Sarcoidosis. J Rheumatol 1989; 16:1548-1551
THE WESTERN JOURNAL OF MEDICINE * MARCH 1991
*
154 * 3
5. Justiniani FR: Sarcoidosis complicating primary Sjogren's syndrome. Mt Sinai J Med (NY) 1989; 56:59-61 6. Seinfeld ED, Sharma OP: TASS syndrome: Unusual association of thyroiditis, Addison's disease, Sj6gren's syndrome and sarcoidosis. J R Soc Med 1983; 76:883885 *
*
*
Drs Leff and Schwarz Respond TO THE EDITOR: Dr Akama and colleagues raise the interesting possibility that the patient we described as having coexistence of primary biliary cirrhosis and sarcoidosis' may have had instead Sjogren's syndrome complicated by lymphocytic interstitial pneumonitis (LIP) with pulmonary granulomas. It is clear that primary biliary cirrhosis is associated with Sjogren's syndrome, which is indeed associated with noncaseating granulomas on biopsy and which may be indistinguishable from those seen in sarcoidosis. For the following reasons, however, we think this is an unlikely scenario in our patient: * The patient had no evidence of Sj6gren's syndrome (although no salivary gland biopsies were done) or the sicca complex. * There was no evidence on transbronchial lung biopsy of either LIP or pseudolymphoma to explain the pulmonary granulomas. * Chest computed tomography showed no evidence of an interstitial process that might be expected in the case of LIP. While we may have encountered a sampling error due to the bronchoscopic nature of the biopsies, we think the weight of the evidence suggests coexistent sarcoidosis.
353
-j .O.J
dures attendant to general medical practice. The decision was not contested and was thought to be in the best interests of the patients, the affected institutions, and the surgeon, since, unlike other reports of this nature,' no changes in practice or technique seemed likely to assure no further transmission. No further associated cases have been identified. Orange County Public Health investigates all hepatitis reports (about 1,000 per year) using a procedure initiated by the Centers for Disease Control for use in "sentinel counties" engaged in a special study of hepatitis frequency and epidemiology.2 Because the association of so many cases with a single physician does not occur commonly, it seems likely that some aspect of contact between the surgeon and patients resulted in transmission ofthe hepatitis B virus, even though no technical or procedural problems were identified. The surface antigen subtyping supports this conclusion but is not conclusive because the frequency of "ay" in the community is unknown. Physician transmission of hepatitis B presumably is rare but may go unrecognized. We think it is important to record such recognized clusters so that representative accounts of such occurrences can be found in the literature.3 THOMAS J. PRENDERGAST, Jr, MD, MPH Chief, Preventive Medical Services San Bernardino County Department of Public Health 351 N Mountain View Ave, Rin 303 San Bernardino, CA 92415-0010 SOL TEITELBAUM, MD Laboratory Director Humana Hospital of West Anaheim 3033 W Orange Ave Anaheim, CA 92805 BARBARA PECK, RN Epidemiology and Disease Control Division Orange County Public Health Department PO Box 355 Santa Ana, CA 92702
JONATHAN A. LEFF, MD MARVIN I. SCHWARZ, MD Division of Pulnonary Sciences University of Colorado Health Sciences Center 4200 E Ninth Ave Denver, CO 80262
REFERENCE 1. Leff JA, Ready JB, Repetto C, Goff JS, Schwarz MI: Coexistence of primary biliary cirrhosis and sarcoidosis. West J Med 1990; 153:439-441
Transmission of Hepatitis B by a Surgeon TO THE EDITOR: In 1987 Orange County Public Health learned of two acute cases of hepatitis B, and identified three additional reported cases from the previous two years, found by a review of public health records. All five persons had surgical procedures done by a surgeon who was a known hepatitis B carrier. The surgeon was found to have hepatitis B e antigen in the blood in addition to hepatitis B surface antigen. Furthermore, hepatitis B antigen was detected in sputum. Blood from three patients and the surgeon was available for typing of the surface antigen. All were type "ay." No other risk factors for hepatitis B were confirmed after careful histories were obtained from the patients. The surgeon's previous professional experience included doing multiple surgical procedures on persons at high risk of being hepatitis B carriers-dialysis patients. None of the specific surgical procedures were known to have included any recorded incident of blood exposure or other untoward event. For this reason, the surgeon, hospital infection control committee representatives, and the local health department disease control director met and agreed that the surgeon should be required by action of the local health department to discontinue surgical practice and to observe appropriate precautions while doing minor proce-
REFERENCES 1. Francis DP, Hadler SC, Prendergast TJ Jr, et al: Occurrence of hepatitis A, B, and non-A, non-B in the United States-CDC sentinel county hepatitis study I. Am J Med 1984; 76:69-74 2. Bell DM, Shapiro CM, Holmberg SD: Surgical practice in hospitals: HIV and the surgical team. Am Coll Surg Bull 1990; 75:14-15 3. Lettan LA, Smith SD, Williams D, et al: Transmission of hepatitis B with resultant restriction of surgical practice. JAMA 1986; 255:934-937
Correction TO THE EDITOR: While the text is clear, Figure 1 in our case report on McCune-Albright syndrome in the December issue may be misleading.1 Bromocriptine therapy was initiated in January 1985 before the decrement in prolactin values. We apologize for any confusion this may have caused readers of the journal. ARTHUR L. M. SWISLOCKI, MD University of California Service VA Medical Center (612/111) 150 Muir Rd
Martinez, CA 94553 CARLOS A. CAMARGO, MD ANDREW R. HOFFMAN, MD Stanford University School of Medicine
VA Medical Center 3801 Miranda Ave Palo Alto, CA 94304 REFERENCE 1. Swislocki ALM, Camargo CA, Hoffman AR: McCune-Albright syndrome-A case of primary hypogonadism obscured by hyperprolactinemic hypogonadotropic hypogonadism. West J Med 1990; 153:653-656
