was
prescribed for
a
nursing home
patient. The nurse inadvertently dis¬ pensed 5% fluorouracil, and the patient was treated for several weeks
before the error was noted. It is easy to see how this error could be repeated, for both medications are packaged in a gray box and are in a gray tube; on cursory examination, they might be mistaken for one another. Another factor, of course, is the similarity of the two trade names (Lidex vs Effudex) as well as their strengths, which can easily be con¬ fused by pharmacy or nurse. As physi¬ cians, we are obligated to see that our patients receive the proper medica¬ tions and correct dosages. A high index of suspicion might have alerted both physicians sooner to the possi¬ bility of a switched medication. It is not the purpose of this letter to find fault in either of these cases but to bring attention to a hazard in ther¬ apy. In addition, we can offer no solutions to the problem other than the obvious ones, which include care¬ ful prescription writing and pharma¬ ceutical attention. The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Department of the Army or the Department of Defense.
MAJ Donald E. Clemons, MC, USA LTC John L. Aeling, MC, USA COL Donald D. Nuss, MC, USA Denver
Chemotherapy for Kaposi
Sarcoma
To the Editor.\p=m-\I read with
great
interest the article "Chemotherapy for Advanced Kaposi Sarcoma" in the Archives (111:1331-1333, 1975) by Lanzotti et al. It was a well-written article that detailed combination chemotherapy of advanced Kaposi sarcoma. However, the authors stated that their case represented "the first verified response of visceral Kaposi sarcoma to chemotherapy reported in the literature." I should like to point out that I reported two patients in 1974 (Chest 66:522-525) who responded to chemotherapy with intravenously administered vinblastine. One patient had marked pulmonary infiltrates and the other had pericardial involvement. While treatment was only palliative, both patients still experienced a marked regression of their disease
with chemotherapy. Internal involvement in non-African Kaposi sarcoma is being recognized with increasing frequency, and experience with chemotherapy has been limited in this advanced stage of the disease. Successful combination chemotherapy for internal involvement in Kaposi sarcoma as described by Lanzotti et al is an advancement in the treatment of the disease and future cases will no doubt be helped by their report. Paul I. Dantzig, MD Utica, NY
In Reply. Thank you for calling attention to your article "Thoracic Involvement of Non-African Kaposi's Sarcoma" (Chest 66:522-525, 1974). This article was not in print at the time our manuscript was submitted for publication. We are pleased to hear that the two cases in the cited report demonstrated response of the thoracic lesions treated with vinblastine. Unfortunately, documentation of response of the thoracic lesions is not
provided through follow-up films or other data. Response
x-ray of the
visceral lesions to vinblastine is mentioned almost coincidentally in case 1 and stated unclearly in case 2. Victor J. Lanzotti, MD Houston
Treatment of Plantar Warts With Bleomycin
To the Editor.\p=m-\Newmethods for the treatment of warts appear from time
to time.
Thus, it is not surprising that another is available. For the past year, I have been injecting bleomycin sulfate (Blenoxane) into recurrent or recalcitrant plantar warts with great success.
One always hesitates to herald the of anything in the treatment of warts with any more than casual enthusiasm. However, as a trial, it was decided to treat with the bleomycin sulfate only those plantar warts that (1) were of twelve (or more) months' duration; (2) had been treated with any of the common methods but that had recurred; (3) were grouped together, forming a mosaic pattern (ie, were mosaic warts); and (4) occurred on patients who were more than 12 years old. Twenty-five patients had plantar use
Downloaded From: http://archderm.jamanetwork.com/ by a University of British Columbia Library User on 06/16/2015
warts that
satisfied these criteria. six-month follow-up period, only three of the patients showed evidence of some warty growth; they received a second (or a third) injection of bleomycin sulfate to complete the After
a
cure.
The material used was a 1% solution of bleomycin sulfate in normal saline solution. This solution is fairly stable (for six to eight weeks) when kept refrigerated at about 4 C. The surface of each wart was pared down until glistening tissue was visible. Bleo¬ mycin sulfate was then injected into it with the use of a jet injector (eg, two injections for a wart 0.5 cm in diame¬
ter).
Mosaic warts were given as many as injections, depending on their size. The jet injector used delivered 0.1 ml per injection, so that the amount of bleomycin sulfate injected would range from 0.1 to 1.0 mg, depending on the size of the warty area. (It had previously been determined that a dose of from 100 to 200 mg of bleo¬ mycin sulfate, given on a cumulative basis, produced atrophy; the small amounts used for the treatment of warts are inoffensive.) After the injection, the site was occluded for 24 hours with plastic tape. The injection gave little or no discomfort at the time, but, in about 48 hours, consid¬ erable swelling and pain when pres¬ sure was applied were noted. At this time, an incision with a No. 11 blade released the tension in the hemorrhagic bulla lying beneath the warty tissue. At the end of two weeks, the dried-out tissue was easily dissected away, leaving a bumpy base that epithelialized within seven to ten days. There were no complications or side effects for the 25 patients treated. All the participants expressed the opinion that there was less pain and discom¬ fort with this method of treatment than with any other methods that had been used. It is to be noted that the wart must be pared before injection and that a quarter-inch spacer must be used on the jet injector to decrease the depth that the bleomycin sulfate reaches and also to ensure the "splay¬ ing" of the solution as it enters the wart. I do not suggest bleomycin sulfate for the treatment of all plantar warts, but it has a definite place in the treatment of those warts that have been unsuccessfully treated by other means. Arthur L. Hudson, MD, FRCP(C) Toronto ten
prescribed for
a
nursing home
patient. The nurse inadvertently dis¬ pensed 5% fluorouracil, and the patient was treated for several weeks
before the error was noted. It is easy to see how this error could be repeated, for both medications are packaged in a gray box and are in a gray tube; on cursory examination, they might be mistaken for one another. Another factor, of course, is the similarity of the two trade names (Lidex vs Effudex) as well as their strengths, which can easily be con¬ fused by pharmacy or nurse. As physi¬ cians, we are obligated to see that our patients receive the proper medica¬ tions and correct dosages. A high index of suspicion might have alerted both physicians sooner to the possi¬ bility of a switched medication. It is not the purpose of this letter to find fault in either of these cases but to bring attention to a hazard in ther¬ apy. In addition, we can offer no solutions to the problem other than the obvious ones, which include care¬ ful prescription writing and pharma¬ ceutical attention. The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Department of the Army or the Department of Defense.
MAJ Donald E. Clemons, MC, USA LTC John L. Aeling, MC, USA COL Donald D. Nuss, MC, USA Denver
Chemotherapy for Kaposi
Sarcoma
To the Editor.\p=m-\I read with
great
interest the article "Chemotherapy for Advanced Kaposi Sarcoma" in the Archives (111:1331-1333, 1975) by Lanzotti et al. It was a well-written article that detailed combination chemotherapy of advanced Kaposi sarcoma. However, the authors stated that their case represented "the first verified response of visceral Kaposi sarcoma to chemotherapy reported in the literature." I should like to point out that I reported two patients in 1974 (Chest 66:522-525) who responded to chemotherapy with intravenously administered vinblastine. One patient had marked pulmonary infiltrates and the other had pericardial involvement. While treatment was only palliative, both patients still experienced a marked regression of their disease
with chemotherapy. Internal involvement in non-African Kaposi sarcoma is being recognized with increasing frequency, and experience with chemotherapy has been limited in this advanced stage of the disease. Successful combination chemotherapy for internal involvement in Kaposi sarcoma as described by Lanzotti et al is an advancement in the treatment of the disease and future cases will no doubt be helped by their report. Paul I. Dantzig, MD Utica, NY
In Reply. Thank you for calling attention to your article "Thoracic Involvement of Non-African Kaposi's Sarcoma" (Chest 66:522-525, 1974). This article was not in print at the time our manuscript was submitted for publication. We are pleased to hear that the two cases in the cited report demonstrated response of the thoracic lesions treated with vinblastine. Unfortunately, documentation of response of the thoracic lesions is not
provided through follow-up films or other data. Response
x-ray of the
visceral lesions to vinblastine is mentioned almost coincidentally in case 1 and stated unclearly in case 2. Victor J. Lanzotti, MD Houston
Treatment of Plantar Warts With Bleomycin
To the Editor.\p=m-\Newmethods for the treatment of warts appear from time
to time.
Thus, it is not surprising that another is available. For the past year, I have been injecting bleomycin sulfate (Blenoxane) into recurrent or recalcitrant plantar warts with great success.
One always hesitates to herald the of anything in the treatment of warts with any more than casual enthusiasm. However, as a trial, it was decided to treat with the bleomycin sulfate only those plantar warts that (1) were of twelve (or more) months' duration; (2) had been treated with any of the common methods but that had recurred; (3) were grouped together, forming a mosaic pattern (ie, were mosaic warts); and (4) occurred on patients who were more than 12 years old. Twenty-five patients had plantar use
Downloaded From: http://archderm.jamanetwork.com/ by a University of British Columbia Library User on 06/16/2015
warts that
satisfied these criteria. six-month follow-up period, only three of the patients showed evidence of some warty growth; they received a second (or a third) injection of bleomycin sulfate to complete the After
a
cure.
The material used was a 1% solution of bleomycin sulfate in normal saline solution. This solution is fairly stable (for six to eight weeks) when kept refrigerated at about 4 C. The surface of each wart was pared down until glistening tissue was visible. Bleo¬ mycin sulfate was then injected into it with the use of a jet injector (eg, two injections for a wart 0.5 cm in diame¬
ter).
Mosaic warts were given as many as injections, depending on their size. The jet injector used delivered 0.1 ml per injection, so that the amount of bleomycin sulfate injected would range from 0.1 to 1.0 mg, depending on the size of the warty area. (It had previously been determined that a dose of from 100 to 200 mg of bleo¬ mycin sulfate, given on a cumulative basis, produced atrophy; the small amounts used for the treatment of warts are inoffensive.) After the injection, the site was occluded for 24 hours with plastic tape. The injection gave little or no discomfort at the time, but, in about 48 hours, consid¬ erable swelling and pain when pres¬ sure was applied were noted. At this time, an incision with a No. 11 blade released the tension in the hemorrhagic bulla lying beneath the warty tissue. At the end of two weeks, the dried-out tissue was easily dissected away, leaving a bumpy base that epithelialized within seven to ten days. There were no complications or side effects for the 25 patients treated. All the participants expressed the opinion that there was less pain and discom¬ fort with this method of treatment than with any other methods that had been used. It is to be noted that the wart must be pared before injection and that a quarter-inch spacer must be used on the jet injector to decrease the depth that the bleomycin sulfate reaches and also to ensure the "splay¬ ing" of the solution as it enters the wart. I do not suggest bleomycin sulfate for the treatment of all plantar warts, but it has a definite place in the treatment of those warts that have been unsuccessfully treated by other means. Arthur L. Hudson, MD, FRCP(C) Toronto ten
