BRITISH MEDICAL JOURNAL
9 SEPTEMBER 1978
treatment to the appearance of the jaundice conforms with other cases of drug-induced jaundice.
Kaklamanis, Ph, et al, J'ournal of Clinical Therapeutics, 1978, 1, suppl A, p 4677. Kelsey, W M, and Scharyj, M,Journal of the American Medical Association, 1967, 199, 586. 3 Tempero, K F, Crillo, V G, and Steelman, S L, British Journal of Clinical 2
Pharmacology, 1977, 4, suppl 1, p 31. (Accepted 7 July 1978)
Edmonton, London N9 JONATHAN S WARREN, BSC, MB, general practitioner
Contact allergy to clotrimazole Clotrimazole (Canesten; diphenyl-2-chlorophenyl-1-imidazolylmethane) is an effective broad-spectrum antifungal agent that has been used in Great Britain since 1973. In clinical trials only a few patients have been irritated by clotrimazole and no cases of contact allergy have been reported. I describe a patient who developed contact allergic dermatitis to clotrimazole.
Case history A 48-year-old policeman had had perineal and perianal pruritus for many years. In September 1977 he was prescribed Canesten cream, which he used intermittently for the next few months. In December, after applying Canesten cream, he noticed an increase in the pruritus accompanied by an erythematous, oozing rash over his scrotum, upper thighs, and natal cleft. He discontinued the Canesten, and Tri-Adcortyl cream was prescribed. His rash gradually improved. Patch tests were applied for 48 hours using the Finn Chamber method and inspected at 48 and 96 hours. At both times reactions were seen to
737
Canesten cream, 1 % clotrimazole in ethyl methyl ketone, and 1 % ethylene diamine in yellow soft paraffin. Results were negative with Canesten cream base and Tri-Adcortyl cream.
Comment Canesten cream consists of the active ingredient clotrimazole and the base, which contains Arlacel 60, Tween 60, spermaceti, Lanette 0, Eutanol G, benzyl alcohol, and demineralised water. During clinical trials of clotrimazole 1% cream Weutal found irritation in 5% of patients. In clinical evaluations of clotrimazole, Spiekermann and Young2 recorded adverse effects in 2-7% of patients, and Clayton and Connor3 reported that 15% of patients using clotrimazole cream experienced transient burning and irritation. No cases of allergic contact dermatitis were reported. Wahlberg4 obtained negative patch test results in patients with eczema using clotrimazole cream in concentrations 16 and 32 times greater than normal. Only one case of patch-test-proved contact allergy has been reported (J Ward-Jenkins, Bayer UK Limited, personal communication). The present patient had patch-test-proved contact allergic dermatitis to clotrimazole. As this effective antifumgal agent achieves more widespread use, more patients will be likely to develop allergy to clotrimazole. I
2
Weuta, H, Drugs Made in Germany, 1972, 15, 126. Spiekermann, P H, and Young, M D, Archives of Dermatology, 1976, 112,
350. Clayton, Y M, and Connor, B L, British Journal of Dermatology, 1973, 89, 297. 4 Wahlberg, J E, Munchener medizinische Wochenschrift, 1976, 118, 76. 3
(Accepted 12_July 1978) St John's Hospital for Diseases of the Skin, London WC2H 7BJ JAMES A ROLLER, MD, registrar
(We suggest to readers that any suspected adverse reaction to a new drug should be reported to the Committee on Safety of Medicines, preferably on a yellow card. Serious or unusual reactions to all drugs should also be reported.)
SHORT REPORTS Ingrowing toenails in infancy Ingrowing of the great toenail is common in older children and adults, and is generally attributed to convex cutting of the nail.' A more complex theory has been put forward suggesting that there is an imbalance between the nail and cuticle borders due to incurving of the medial side of the toe, influenced by inherited architecture and compounded by pointed-toe and high-heeled shoes. Careless cutting back of the corners of the nail then initiates chronic inflammation.2 The condition has not been described in infants, and we report two cases. Case reports Case I-A 10-week-old boy presented with bilateral acute paronychia of the great toenails of two weeks' duration (figure). There was no reason to believe that he had been wearing tight clothes or shoes; his toenails had never been cut; and he did not suck his toes. There was a family history of ingrowing toenails: the patient's paternal grandmother had required removal of both great toenails at the age of 2 years, and a maternal cousin had required antibiotic treatment for redness of the great toes at the age of 4 months, suggesting ingrowth of the nails. The boy was treated by avulsion of both great toenails under general anaesthesia; the infection settled completely, but the nails grew inwards again within two months. Tin foil placed beneath the toenail margin was unsuccessful in stopping this, and the problem is as yet unresolved. Case 2-A 6-week-old boy developed ingrowing of the right great toenail with surrounding inflammation, but no pus was produced. There was no family history. From birth he had been put down to sleep prone, and the changes in the toenail had occurred at the time when he had started kicking very actively. The condition was attributed to constant rubbing, and settled rapidly when he started to sleep on his back. Nevertheless, it recurred at the
age of 2+ years after he had been wearing narrow shoes; it responded to a course of co-trimoxazole.
Comment In their analysis of ingrowing toenails in different age groups, Murray and Bedi3 did not mention infants. The only suggestion of an inherited disorder in published reports, other than Lathrop's theory,2 is by Chapman,4 who describes a condition of overcurvature of the toenails as a result of which the nail cuts into the lateral nailfold; this occurs, however, in young adult life. Paronychia of the thumb may occur in infants as a result of sucking.5 The family history in case 1, and the recurrent nature of the condition in both cases, suggest that there may be an inherited tendency for the great toenails to grow inwards, perhaps requiring an additional
nAilolS-~ ~ ~ ~ ~ ~ ~ ~ .
~.~
~iiiigi
9 ..'. @ 'ff, | S *. ,:::::.
Case 1. Bilateral acute paronychia of great toeaais. Case 1. Bilateral acute paronychia of great toenails.
BRITISH MEDICAL JOURNAL
738
local insult such as sleeping prone in infancy; careless cutting, which may leave a spicule of nail, which penetrates the nailfold as the nail grows forwards; or compression in shoes. It would be of interest to look for a family history in adults with this condition. A conservative approach to the condition is preferable in infancy, with simple avulsion of the nail when necessary. The lack of certainty about the prognosis makes destructive surgery of the germinal matrix undesirable. We thank Mr M N Saad for permission to report case 1. The illustrations were prepared by Mr D Griffin.
Orr, C M S, and Photiou, S, Hospital Update, 1977, 3, 465. Lathrop, R G, Cutis, 1977, 20, 119. 3Murray, W R, and Bedi, B S, British Journal of Surgery, 1975, 62, 409. ' Chapman, R S, British Journal of Dermatology, 1973, 89, 317. 5 Verbov, J L, Practitioner, 1976, 217, 413.
I 2
(Accepted 53July 1978)
City Hospital, Nottingham F B BAILIE, FRcs, registrar in plastic surgery Wexham Park Hospital, Slough D M EVANS, FRcs, consultant plastic surgeon
Anterior T wave changes in the ECG of an athlete Electrocardiographic alterations are well recognised in athletes and may lead to diagnostic difficulties on occasions.' Information about the natural history of these changes when the athlete ceases strenuous activity is limited. Case report In 1972 a 24-year-old professional footballer who had played in top class competition since the age of 18 was found to have an abnormal ECG on routine examination (figure, A). He had not had a previous ECG. This finding led to a diagnosis of acute myocardial infarction and he was admitted to hospital elsewhere. He was asymptomatic and on examination was thin and muscular with a blood pressure of 110/70 mm Hg and a pulse rate of 65 beats/min; there were no abnormal physical signs. Over 3 weeks' enforced rest resulting from the diagnosis of infarction, the ECG returned to what would be considered normal for a thin, active, young man (figure, B). Cardiac enzyme concentrations and the chest x-ray film were normal and he was afebrile. Three months later he was still inactive and the ECG
ECG when first seen
ECG three weeks after A E
remained normal. He was referred to the Brompton Hospital for further investigation. Because his livelihood was threatened by the presumptive diagnosis of heart disease (possibly ischaemic), cardiac catheterisation, left ventriculography, and coronary arteriography were performed and all gave normal findings. He then returned to full training and has continued to play competitive football for the last five years. Subsequent yearly ECGs have shown the return of the initial changes (figure, C), which have remained stable. Echocardiography in 1977 showed a left ventricular cavity size of normal dimensions, a normal left ventricular filling pattern, and considerable septal thickening (>2 cm at end diastole).
Comment
Alterations in the electrocardiogram' and echocardiogram2 3 are common in professional athletes. The electrocardiogram may show increased voltage in both right and left precordial leads as well as T wave inversion and S-T elevation most commonly occurring in leads VI-4. The echocardiogram commonly shows increased left and right ventricular dimensions and septal hypertrophy is often present. Such septal hypertrophy is commonly seen in all forms of left ventricular hypertrophy4 and is not characteristic of any particular condition. This case is presented because the very considerable changes in the ECG of this athlete regressed during only three weeks of enforced inactivity. The initial ECG raised the possibility of organic heart disease and initially the regression of these changes during inactivity was misinterpreted as the evolution of an ischaemic or inflammatory myocardial lesion. Only when the changes reappeared with a return to activity did the nature of the initial changes become clear. The associated septal hypertrophy suggests that the so-called "right ventricular changes" commonly seen in athletes in lead VI-4 may be the result of septal hypertrophy causing repolarisation forces to be directed mainly posteriorly. It is important, particularly in athletes, that changes in the level of physical activity are considered when interpreting the electrocardiogram, and the meaning of serial electro-
cardiographic changes. 1 2 3 4
Lichtman, J, et al, Archives of Internal Medicine,
1973, 132, 763. Roeske, W R, et al, Circulation, 1976, 53, 286. Menapace, F J, et al, American Journal of Cardiology, 1977, 39, 276. Gibson, D G, et al, British Heart Journal, 1978, in press.
(Accepted 5_July 1978) Cardiac Department, Brompton Hospital, London SW3 R J C HALL, MB, MRcP, senior registrar (now consultant cardiologist, Royal Victoria Infirmary, Newcastle upon Tyne 1) R V GIBSON, MD, FRCP, consultant cardiologist
Hypercalciuria and recurrent urinary stone formation despite successful surgery for primary hyperparathyroidism
T:
3Bt
9 SEPTEMBER 1978
>'
4L
ECG two ears after B
C VI V2' V3 V5 V6 VI. The precordial leads from serial electrocardiograms. The limb leads did not alter during this period; the mean frontal QRS vector was +90' and mean frontal T wave vector 00 in all three tracings.
Hypercalciuria may persist after surgery for primary hyperparathyroidism despite restoration of the serum calcium concentration to normal. Associated urinary tract stone formation has been described.' We describe the first patient with this condition in whom the mechanism of persisting hypercalciuria has been defined.
Case history A 31-year-old driver presented in 1964 with bilateral radiopaque renal calculi. Hypercalcaemia and hypercalciuria were found. Eventually a benign parathyroid adenoma of mixed cell type was excised in 1966 (Professor G W Taylor). He became normocalcaemic but remained severely hypercalciuric (figure). Dietary calcium intake was about 25-30 mmol daily. Dietary calcium restriction and the addition of oral sodium cellulose phosphate corrected his hypercalciuria when he was under supervision in hospital. He did not adhere to dietary restriction or take medication regularly
9 SEPTEMBER 1978
treatment to the appearance of the jaundice conforms with other cases of drug-induced jaundice.
Kaklamanis, Ph, et al, J'ournal of Clinical Therapeutics, 1978, 1, suppl A, p 4677. Kelsey, W M, and Scharyj, M,Journal of the American Medical Association, 1967, 199, 586. 3 Tempero, K F, Crillo, V G, and Steelman, S L, British Journal of Clinical 2
Pharmacology, 1977, 4, suppl 1, p 31. (Accepted 7 July 1978)
Edmonton, London N9 JONATHAN S WARREN, BSC, MB, general practitioner
Contact allergy to clotrimazole Clotrimazole (Canesten; diphenyl-2-chlorophenyl-1-imidazolylmethane) is an effective broad-spectrum antifungal agent that has been used in Great Britain since 1973. In clinical trials only a few patients have been irritated by clotrimazole and no cases of contact allergy have been reported. I describe a patient who developed contact allergic dermatitis to clotrimazole.
Case history A 48-year-old policeman had had perineal and perianal pruritus for many years. In September 1977 he was prescribed Canesten cream, which he used intermittently for the next few months. In December, after applying Canesten cream, he noticed an increase in the pruritus accompanied by an erythematous, oozing rash over his scrotum, upper thighs, and natal cleft. He discontinued the Canesten, and Tri-Adcortyl cream was prescribed. His rash gradually improved. Patch tests were applied for 48 hours using the Finn Chamber method and inspected at 48 and 96 hours. At both times reactions were seen to
737
Canesten cream, 1 % clotrimazole in ethyl methyl ketone, and 1 % ethylene diamine in yellow soft paraffin. Results were negative with Canesten cream base and Tri-Adcortyl cream.
Comment Canesten cream consists of the active ingredient clotrimazole and the base, which contains Arlacel 60, Tween 60, spermaceti, Lanette 0, Eutanol G, benzyl alcohol, and demineralised water. During clinical trials of clotrimazole 1% cream Weutal found irritation in 5% of patients. In clinical evaluations of clotrimazole, Spiekermann and Young2 recorded adverse effects in 2-7% of patients, and Clayton and Connor3 reported that 15% of patients using clotrimazole cream experienced transient burning and irritation. No cases of allergic contact dermatitis were reported. Wahlberg4 obtained negative patch test results in patients with eczema using clotrimazole cream in concentrations 16 and 32 times greater than normal. Only one case of patch-test-proved contact allergy has been reported (J Ward-Jenkins, Bayer UK Limited, personal communication). The present patient had patch-test-proved contact allergic dermatitis to clotrimazole. As this effective antifumgal agent achieves more widespread use, more patients will be likely to develop allergy to clotrimazole. I
2
Weuta, H, Drugs Made in Germany, 1972, 15, 126. Spiekermann, P H, and Young, M D, Archives of Dermatology, 1976, 112,
350. Clayton, Y M, and Connor, B L, British Journal of Dermatology, 1973, 89, 297. 4 Wahlberg, J E, Munchener medizinische Wochenschrift, 1976, 118, 76. 3
(Accepted 12_July 1978) St John's Hospital for Diseases of the Skin, London WC2H 7BJ JAMES A ROLLER, MD, registrar
(We suggest to readers that any suspected adverse reaction to a new drug should be reported to the Committee on Safety of Medicines, preferably on a yellow card. Serious or unusual reactions to all drugs should also be reported.)
SHORT REPORTS Ingrowing toenails in infancy Ingrowing of the great toenail is common in older children and adults, and is generally attributed to convex cutting of the nail.' A more complex theory has been put forward suggesting that there is an imbalance between the nail and cuticle borders due to incurving of the medial side of the toe, influenced by inherited architecture and compounded by pointed-toe and high-heeled shoes. Careless cutting back of the corners of the nail then initiates chronic inflammation.2 The condition has not been described in infants, and we report two cases. Case reports Case I-A 10-week-old boy presented with bilateral acute paronychia of the great toenails of two weeks' duration (figure). There was no reason to believe that he had been wearing tight clothes or shoes; his toenails had never been cut; and he did not suck his toes. There was a family history of ingrowing toenails: the patient's paternal grandmother had required removal of both great toenails at the age of 2 years, and a maternal cousin had required antibiotic treatment for redness of the great toes at the age of 4 months, suggesting ingrowth of the nails. The boy was treated by avulsion of both great toenails under general anaesthesia; the infection settled completely, but the nails grew inwards again within two months. Tin foil placed beneath the toenail margin was unsuccessful in stopping this, and the problem is as yet unresolved. Case 2-A 6-week-old boy developed ingrowing of the right great toenail with surrounding inflammation, but no pus was produced. There was no family history. From birth he had been put down to sleep prone, and the changes in the toenail had occurred at the time when he had started kicking very actively. The condition was attributed to constant rubbing, and settled rapidly when he started to sleep on his back. Nevertheless, it recurred at the
age of 2+ years after he had been wearing narrow shoes; it responded to a course of co-trimoxazole.
Comment In their analysis of ingrowing toenails in different age groups, Murray and Bedi3 did not mention infants. The only suggestion of an inherited disorder in published reports, other than Lathrop's theory,2 is by Chapman,4 who describes a condition of overcurvature of the toenails as a result of which the nail cuts into the lateral nailfold; this occurs, however, in young adult life. Paronychia of the thumb may occur in infants as a result of sucking.5 The family history in case 1, and the recurrent nature of the condition in both cases, suggest that there may be an inherited tendency for the great toenails to grow inwards, perhaps requiring an additional
nAilolS-~ ~ ~ ~ ~ ~ ~ ~ .
~.~
~iiiigi
9 ..'. @ 'ff, | S *. ,:::::.
Case 1. Bilateral acute paronychia of great toeaais. Case 1. Bilateral acute paronychia of great toenails.
BRITISH MEDICAL JOURNAL
738
local insult such as sleeping prone in infancy; careless cutting, which may leave a spicule of nail, which penetrates the nailfold as the nail grows forwards; or compression in shoes. It would be of interest to look for a family history in adults with this condition. A conservative approach to the condition is preferable in infancy, with simple avulsion of the nail when necessary. The lack of certainty about the prognosis makes destructive surgery of the germinal matrix undesirable. We thank Mr M N Saad for permission to report case 1. The illustrations were prepared by Mr D Griffin.
Orr, C M S, and Photiou, S, Hospital Update, 1977, 3, 465. Lathrop, R G, Cutis, 1977, 20, 119. 3Murray, W R, and Bedi, B S, British Journal of Surgery, 1975, 62, 409. ' Chapman, R S, British Journal of Dermatology, 1973, 89, 317. 5 Verbov, J L, Practitioner, 1976, 217, 413.
I 2
(Accepted 53July 1978)
City Hospital, Nottingham F B BAILIE, FRcs, registrar in plastic surgery Wexham Park Hospital, Slough D M EVANS, FRcs, consultant plastic surgeon
Anterior T wave changes in the ECG of an athlete Electrocardiographic alterations are well recognised in athletes and may lead to diagnostic difficulties on occasions.' Information about the natural history of these changes when the athlete ceases strenuous activity is limited. Case report In 1972 a 24-year-old professional footballer who had played in top class competition since the age of 18 was found to have an abnormal ECG on routine examination (figure, A). He had not had a previous ECG. This finding led to a diagnosis of acute myocardial infarction and he was admitted to hospital elsewhere. He was asymptomatic and on examination was thin and muscular with a blood pressure of 110/70 mm Hg and a pulse rate of 65 beats/min; there were no abnormal physical signs. Over 3 weeks' enforced rest resulting from the diagnosis of infarction, the ECG returned to what would be considered normal for a thin, active, young man (figure, B). Cardiac enzyme concentrations and the chest x-ray film were normal and he was afebrile. Three months later he was still inactive and the ECG
ECG when first seen
ECG three weeks after A E
remained normal. He was referred to the Brompton Hospital for further investigation. Because his livelihood was threatened by the presumptive diagnosis of heart disease (possibly ischaemic), cardiac catheterisation, left ventriculography, and coronary arteriography were performed and all gave normal findings. He then returned to full training and has continued to play competitive football for the last five years. Subsequent yearly ECGs have shown the return of the initial changes (figure, C), which have remained stable. Echocardiography in 1977 showed a left ventricular cavity size of normal dimensions, a normal left ventricular filling pattern, and considerable septal thickening (>2 cm at end diastole).
Comment
Alterations in the electrocardiogram' and echocardiogram2 3 are common in professional athletes. The electrocardiogram may show increased voltage in both right and left precordial leads as well as T wave inversion and S-T elevation most commonly occurring in leads VI-4. The echocardiogram commonly shows increased left and right ventricular dimensions and septal hypertrophy is often present. Such septal hypertrophy is commonly seen in all forms of left ventricular hypertrophy4 and is not characteristic of any particular condition. This case is presented because the very considerable changes in the ECG of this athlete regressed during only three weeks of enforced inactivity. The initial ECG raised the possibility of organic heart disease and initially the regression of these changes during inactivity was misinterpreted as the evolution of an ischaemic or inflammatory myocardial lesion. Only when the changes reappeared with a return to activity did the nature of the initial changes become clear. The associated septal hypertrophy suggests that the so-called "right ventricular changes" commonly seen in athletes in lead VI-4 may be the result of septal hypertrophy causing repolarisation forces to be directed mainly posteriorly. It is important, particularly in athletes, that changes in the level of physical activity are considered when interpreting the electrocardiogram, and the meaning of serial electro-
cardiographic changes. 1 2 3 4
Lichtman, J, et al, Archives of Internal Medicine,
1973, 132, 763. Roeske, W R, et al, Circulation, 1976, 53, 286. Menapace, F J, et al, American Journal of Cardiology, 1977, 39, 276. Gibson, D G, et al, British Heart Journal, 1978, in press.
(Accepted 5_July 1978) Cardiac Department, Brompton Hospital, London SW3 R J C HALL, MB, MRcP, senior registrar (now consultant cardiologist, Royal Victoria Infirmary, Newcastle upon Tyne 1) R V GIBSON, MD, FRCP, consultant cardiologist
Hypercalciuria and recurrent urinary stone formation despite successful surgery for primary hyperparathyroidism
T:
3Bt
9 SEPTEMBER 1978
>'
4L
ECG two ears after B
C VI V2' V3 V5 V6 VI. The precordial leads from serial electrocardiograms. The limb leads did not alter during this period; the mean frontal QRS vector was +90' and mean frontal T wave vector 00 in all three tracings.
Hypercalciuria may persist after surgery for primary hyperparathyroidism despite restoration of the serum calcium concentration to normal. Associated urinary tract stone formation has been described.' We describe the first patient with this condition in whom the mechanism of persisting hypercalciuria has been defined.
Case history A 31-year-old driver presented in 1964 with bilateral radiopaque renal calculi. Hypercalcaemia and hypercalciuria were found. Eventually a benign parathyroid adenoma of mixed cell type was excised in 1966 (Professor G W Taylor). He became normocalcaemic but remained severely hypercalciuric (figure). Dietary calcium intake was about 25-30 mmol daily. Dietary calcium restriction and the addition of oral sodium cellulose phosphate corrected his hypercalciuria when he was under supervision in hospital. He did not adhere to dietary restriction or take medication regularly
