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LETTERS T o the Editor: 1. We wish to comment on the letter of Paul Young, M.D., and Thomas Rardin, M.D., Ashville, North Carolina (Arthritis Rheum 17:1059, 1974). Using the atomic absorption spectrophotometer, we have been determining plasma gold levels in patients with rheumatoid arthritis for over 5 years, including a large prospective protocol study. Our results have been reproducible with a high degree of accuracy and we have used the built-in standard as recommended by Lorber. We have been unable to establish any significant correlation between plasma gold levels and the clinical state of patients, whether it be therapeutic response or toxicity. Therefore we find it necessary to maintain some reservation about the validity of Dr. Lorber’s recommendations for maintaining the serum gold level at 300 mg percent by adjusting the dosage interval or the absolute dosage of each gold injection. Furthermore, from the standpoint of general clinical pharmacology, one would have to question any therapeutic drug maneuver that does not “become manifest until some time after the first 6 months of therapy and may require 24 months of therapy in order to become clearly apparent.” 2. Permit us an additional comment on an article in the same issue by Davis and Hughes (Significance of eosinophilia during gold therapy. Arthritis Rheum 17:964, 1974). In both a nine-year study retrospective and a four-year prospective protocol study, we could find no relationship between eosinophilia and gold toxicity. NORMAN 0.ROTHERMICH, M.D.

Case Report. CD is a 37-year-old housewife who suffers from SLE. This diagnosis is substantiated by the occurrence of polyarthritis, pleurisy, pericarditis, nephritis, strongly positive antinuclear antibody test, a positive LE cell preparation, an elevated sedimentation rate, hypergammaglobulinemia, and a depressed serum complement level. She had been taking prednisone, 5-15 mg daily for 2 years, when she developed pleuritis, pericarditis, and nephritis. Control of these complications required massive doses of corticosteroids. She had been taking 140 mg of prednisone daily for 2 weeks when she felt a painful snap in the region of the right heel while stepping up onto a curb. She herself noticed the defect in the tendo calcaneus. Examination confirmed the presence of a defect and inability to flex the right ankle actively. A diagnosis of ruptured tendo calcaneus was made and a short leg-walking cast was applied with the ankle flexed. T h e cast was removed 4 weeks later. At a recent followup visit, there was still a palpable defect present, the power of ankle flexion was reduced to about 75% of the opposite extremity, and there was a 2-cm reduction in the circumference of the right calf. This patient provides another example of tendon rupture during corticosteroid therapy. A better result might have been attained by surgical repair but at the time it was thought that her poor medical condition made operation too risky. Morgan and McCarty mention only 1 patient who sustained tendon rupture while taking corticosteroids for asthma. Melmed (2) reports another patient, admittedly 66 years old, who presented with spontaneous bilateral rupture of calcaneal tendons after taking betamethazone for 2 years for asthma.

VOL K. PHILIPS, M.D. WALDEMAR BERCEN, M.D.

THOMAS, M.D. Columbus Medical Center Research Foundation Columbus, Ohio

MARVIN H .

Tendon Ruptures To the Editor: Morgan and McCarty (1) report 2 patients with systemic lupus erythematosus treated with corticosteroids who sustained tendon ruptures. We have recently seen a similar patient with a ruptured tendo calcaneus.

REFERENCES 1. Morgan J, McCarthy DJ: Tendon ruptures in patients with systemic lupus erythematosus treated with corticosteroids. Arthritis Rheum 17:1033-1036, 1974 2. Melmed SP: Spontaneous bilateral rupture of the calcaneal tendon during steroid therapy. J Bone Joint Surg 47B: 104-105, 1965 A. H. WOODWARD,

BMBCh.

ANTHONY SLIWINSKI, M.D.

Georgetown University Hospital Washington, D.C. 20007

Letter: Plasma gold levels.

28 1 LETTERS T o the Editor: 1. We wish to comment on the letter of Paul Young, M.D., and Thomas Rardin, M.D., Ashville, North Carolina (Arthritis Rh...
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