980 based: the staff of the department of chemical pathology, Westminster Medical School, University of London (especially Prof. J. R. Hobbs, and Dr D. Hampton), Dr P. C. Elwood (M.R.C. Epidemiology Unit, Cardiff), Miss Gill Gough, and the staff of Newquay Health Centre, Cornwall. Standard Chartered Bank, 28 Northumberland Avenue, London WC2N 5AG
THORNTON H. CROUCH
operative polyneuritis and experimental and clinical models of acute polyneuritis, supports the view that surgery provokes a release of nerve antigens. This event, rather than co-trimoxazole treatment, may have initiated case described by Grossman et al. Division of Neurology, Department of Medicine, Dartmouth Medical School, Hanover, New Hampshire, U.S.A.
acute
polyneuritis
in the
FREDERICK M. VINCENT
NEUROLOGICAL COMPLICATION OF LEVAMISOLE has been used to treat a variety of disSide-effects are uncommon, agranulocytosis being the most severe. We have seen a previously unreported neurological complication of levamisole treatment. An 18-year-old girl who had previously been in good health was given one tablet (150 mg) of levamisole because of an upper-respiratory-tract infection. At the end of the day she complained of a slight headache, but on the next day she felt completely well. A month later (Jan. 22, 1977) the same dose of levamisole was given when she had acute rhinitis. 6 h after taking the drug she had a severe headache, chest pain, fever, vomiting, and spastic contractions of muscles of the hands. These symptoms lasted for 8 h and were misinterpreted as manifestations of influenza. On the next day the patient made a full recovery; symptoms of the rhinitis disappeared. The same dose was given on Feb. 6 because of a small furuncle. 5 h later the girl suddenly became seriously ill with a severe headache, severe weakness, and incessant vomiting. In the next 3 h periodic breathing and frequent cramps of extremities developed; her temperature rose to 39°C; and for an hour she had motor aphasia. All these symptoms gradually disappeared over the next 15 h; slight asthenia remained. On Feb. 8 the girl returned to her studies at college. A neurologist could find nothing abnormal, and the girl is now symptom-free (5 months later). This reaction could reflect either a genetic defect of nervecell enzymes or an anaphylactoid response to levamisole (or a metabolite). Doctors should look out for neurological signs in patients on levamisole and withdraw the drug if such symp-
SIR,-Levamisole
PROPRANOLOL AND PEYRONIE’S DISEASE
eases.
toms
appear.
Institute of Rheumatism, Moscow, U.S.S.R.
J. A. SIGIDIN N. V. BUNCHUK
ACUTE POLYNEUROPATHY POSSIBLY ASSOCIATED WITH CO-TRIMOXAZOLE
SiR,—Dr Grossman and colleagues (Sept. 17, gest that co-trimoxazole may have caused
acute
616) sugpolyneuritis
p.
(Guillain-Barre syndrome) in a patient who had had cardiac surgery. They did not, however, consider the possibility that surgery itself was responsible. This has been reported.’-3 5-10% of the cases of acute polyneuritis in several large series1.2 followed surgical procedures which included intracranial, abdominal, orthopaedic, urological, and thoracic operations carried out with both spinal and general anaesthesia. The interval from the time of the operation to the development of the polyneuritis was 1-4 weeks, most cases developing after the second week. Surgery may either release nerve antigen, triggering an autoallergic response which culminates in polyneuritis, or alter-
natively may stimulate, through stress, an underlying process. Experimental allergic neuritis in animals develops approximately 2 weeks after immunisation with peripheral nerve fractions in Freund’s complete adjuvant. Rabies-vaccine-induced polyneuritis, which resembles both experimental allergic neuritis and classical acute polyneuritis, also takes 2 weeks to develop after challenge.2 The similarity of time interval in post1.
Wiederholt, W. C., Mulder, D. W., Lambert, E. H. Mayo Clin. Proc. 1964,
39, 427. 2. Arnason, B. G., Asbury, A. K. Archs Neurol. 1968, 18, 500. 3. Asbury, A. K., Arnason, B. G., Adams, R. D. Medicine, 1969,
48,
173.
SIR,—Osborne1 has described two patients on propranolol in whom Peyronie’s disease developed. We would like to report a further case. A 48-year-old truck driver had been treated for 20 months with propranolol for hypertension and ischxmic heart-disease. He presented with 8 months of pain on erection and progressive deviation of penis to the left. There was an easily palpable fibrous plaque at the base of the shaft of the penis on the left side associated with a fixed and fibrous band extending distally. With increasing use of propranolol as a first-line drug in the treatment of hypertension we may expect to see further cases. Medical Unit 1, Royal Melbourne Hospital, Victoria 3050, Australia
A. A. WALLIS R. BELL P. W. SUTHERLAND
HIGH URINE SPECIFIC GRAVITY INDUCED BY CARBENICILLIN
SIR,-A 20-year-old patient with severe burns had a sustained high urine specific gravity (sp. gr.) of 1042, daily urine output averaging .800 ml. Dehydration being moderate, we looked for another explanation. Three other conditions are known to increase urine sp. gr.-namely, heavy proteinuria, mellituria (glucose, mannitol), and excretion of contrast media. None applied to our patient. He was being given carbenicillin (’Pyopen’) 5 g intravenously every 4 h (30 g/day); if renal function is normal, 80% of the administered dose is found unchanged in the urine,2 so he was thus theoretically excreting 24 g each day (he had a normal serum-creatinine). To assess the influence of such amounts of carbenicillin on urine sp.gr. pyopen powder was dissolved in distilled water to a 3 g/dl concentration, reflecting the patient’s urine carbenicillin concentration: the sp. gr. of the solution was 1018. Thus, as a bedside rule, when a patient with normal kidney function is receiving carbenicillin, his real urine sp.gr. should be calculated by subtracting from the measured sp. gr. a factor equal to 6 times the urine carbenicillin concentration, the concentration being obtained by dividing 80% of the daily carbenicillin load by the 24 h urine volume. We also studied benzylpenicillin, about 80% of which is normally found unchanged in the urine.’ A 3 g/dl concentration of sodium penicillin G (50 megaunits/1) yielded a sp. gr. of 1014: the correction factor here becomes 4.7. Fluid management of severely burned patients relies partly on monitoring of urine sp. gr. Overhydration may ensue if the sp. gr. is misinterpreted.
Hôpital du Sacre-Coeur Montréal, Quebec, Canada
1. 2.
Osborne,
CLEMENT DEZIEL BERNARD DAIGNEAULT JULIEN MARC-AURELE GUY ALBERT ANDRE BRODEUR
D. R. Lancet, 1977, i, 1111. Goodman, L. S., Gilman, A. The Pharmacological Basis of Therapeutics,
p. 1146. New York, 1975.
THORNTON H. CROUCH
operative polyneuritis and experimental and clinical models of acute polyneuritis, supports the view that surgery provokes a release of nerve antigens. This event, rather than co-trimoxazole treatment, may have initiated case described by Grossman et al. Division of Neurology, Department of Medicine, Dartmouth Medical School, Hanover, New Hampshire, U.S.A.
acute
polyneuritis
in the
FREDERICK M. VINCENT
NEUROLOGICAL COMPLICATION OF LEVAMISOLE has been used to treat a variety of disSide-effects are uncommon, agranulocytosis being the most severe. We have seen a previously unreported neurological complication of levamisole treatment. An 18-year-old girl who had previously been in good health was given one tablet (150 mg) of levamisole because of an upper-respiratory-tract infection. At the end of the day she complained of a slight headache, but on the next day she felt completely well. A month later (Jan. 22, 1977) the same dose of levamisole was given when she had acute rhinitis. 6 h after taking the drug she had a severe headache, chest pain, fever, vomiting, and spastic contractions of muscles of the hands. These symptoms lasted for 8 h and were misinterpreted as manifestations of influenza. On the next day the patient made a full recovery; symptoms of the rhinitis disappeared. The same dose was given on Feb. 6 because of a small furuncle. 5 h later the girl suddenly became seriously ill with a severe headache, severe weakness, and incessant vomiting. In the next 3 h periodic breathing and frequent cramps of extremities developed; her temperature rose to 39°C; and for an hour she had motor aphasia. All these symptoms gradually disappeared over the next 15 h; slight asthenia remained. On Feb. 8 the girl returned to her studies at college. A neurologist could find nothing abnormal, and the girl is now symptom-free (5 months later). This reaction could reflect either a genetic defect of nervecell enzymes or an anaphylactoid response to levamisole (or a metabolite). Doctors should look out for neurological signs in patients on levamisole and withdraw the drug if such symp-
SIR,-Levamisole
PROPRANOLOL AND PEYRONIE’S DISEASE
eases.
toms
appear.
Institute of Rheumatism, Moscow, U.S.S.R.
J. A. SIGIDIN N. V. BUNCHUK
ACUTE POLYNEUROPATHY POSSIBLY ASSOCIATED WITH CO-TRIMOXAZOLE
SiR,—Dr Grossman and colleagues (Sept. 17, gest that co-trimoxazole may have caused
acute
616) sugpolyneuritis
p.
(Guillain-Barre syndrome) in a patient who had had cardiac surgery. They did not, however, consider the possibility that surgery itself was responsible. This has been reported.’-3 5-10% of the cases of acute polyneuritis in several large series1.2 followed surgical procedures which included intracranial, abdominal, orthopaedic, urological, and thoracic operations carried out with both spinal and general anaesthesia. The interval from the time of the operation to the development of the polyneuritis was 1-4 weeks, most cases developing after the second week. Surgery may either release nerve antigen, triggering an autoallergic response which culminates in polyneuritis, or alter-
natively may stimulate, through stress, an underlying process. Experimental allergic neuritis in animals develops approximately 2 weeks after immunisation with peripheral nerve fractions in Freund’s complete adjuvant. Rabies-vaccine-induced polyneuritis, which resembles both experimental allergic neuritis and classical acute polyneuritis, also takes 2 weeks to develop after challenge.2 The similarity of time interval in post1.
Wiederholt, W. C., Mulder, D. W., Lambert, E. H. Mayo Clin. Proc. 1964,
39, 427. 2. Arnason, B. G., Asbury, A. K. Archs Neurol. 1968, 18, 500. 3. Asbury, A. K., Arnason, B. G., Adams, R. D. Medicine, 1969,
48,
173.
SIR,—Osborne1 has described two patients on propranolol in whom Peyronie’s disease developed. We would like to report a further case. A 48-year-old truck driver had been treated for 20 months with propranolol for hypertension and ischxmic heart-disease. He presented with 8 months of pain on erection and progressive deviation of penis to the left. There was an easily palpable fibrous plaque at the base of the shaft of the penis on the left side associated with a fixed and fibrous band extending distally. With increasing use of propranolol as a first-line drug in the treatment of hypertension we may expect to see further cases. Medical Unit 1, Royal Melbourne Hospital, Victoria 3050, Australia
A. A. WALLIS R. BELL P. W. SUTHERLAND
HIGH URINE SPECIFIC GRAVITY INDUCED BY CARBENICILLIN
SIR,-A 20-year-old patient with severe burns had a sustained high urine specific gravity (sp. gr.) of 1042, daily urine output averaging .800 ml. Dehydration being moderate, we looked for another explanation. Three other conditions are known to increase urine sp. gr.-namely, heavy proteinuria, mellituria (glucose, mannitol), and excretion of contrast media. None applied to our patient. He was being given carbenicillin (’Pyopen’) 5 g intravenously every 4 h (30 g/day); if renal function is normal, 80% of the administered dose is found unchanged in the urine,2 so he was thus theoretically excreting 24 g each day (he had a normal serum-creatinine). To assess the influence of such amounts of carbenicillin on urine sp.gr. pyopen powder was dissolved in distilled water to a 3 g/dl concentration, reflecting the patient’s urine carbenicillin concentration: the sp. gr. of the solution was 1018. Thus, as a bedside rule, when a patient with normal kidney function is receiving carbenicillin, his real urine sp.gr. should be calculated by subtracting from the measured sp. gr. a factor equal to 6 times the urine carbenicillin concentration, the concentration being obtained by dividing 80% of the daily carbenicillin load by the 24 h urine volume. We also studied benzylpenicillin, about 80% of which is normally found unchanged in the urine.’ A 3 g/dl concentration of sodium penicillin G (50 megaunits/1) yielded a sp. gr. of 1014: the correction factor here becomes 4.7. Fluid management of severely burned patients relies partly on monitoring of urine sp. gr. Overhydration may ensue if the sp. gr. is misinterpreted.
Hôpital du Sacre-Coeur Montréal, Quebec, Canada
1. 2.
Osborne,
CLEMENT DEZIEL BERNARD DAIGNEAULT JULIEN MARC-AURELE GUY ALBERT ANDRE BRODEUR
D. R. Lancet, 1977, i, 1111. Goodman, L. S., Gilman, A. The Pharmacological Basis of Therapeutics,
p. 1146. New York, 1975.
