Patient history and drug reaction

Patient History and Drug Reaction To the Editor: I found the case report "Tagamet®-Induced Acute Dystonia," by Romisher et al [October 1987;16:1161-1164] to be incomplete and unconvincing. T h e a u t h o r s r e l a t e t h a t , ' A u r i n e s c r e e n for phenothiazines was obtained," and that a "urine ferric chloride assay for phenothiazines . . . was negative." T h e y finally state that a "toxicology screen was not obtained on other etiological agents ... " The reason for the latter was the "reliability of the patient's history." A 20-year-old patient's history of illicit drug ingestion is rarely reliable, especially for reporting the first k n o w n case of a new drug reaction. The urine screen for phenothiazines seems to have been solely the ferric chloride test, a test that is neither sensitive nor specific. Was there no reaction at all, or simply a color change not expected with phenothiazines? Was it done with actual 10% ferric chloride solution, FPN reagent, or Phenistix®? The sensitivity of these is believed to be 5 mg/100 mL urine. Phosphate and other inhibitors can cause a falsenegative reaction, but are less likely to do so with Phenistix ®. If the patient had surreptitiously or inadvertently ingested a high-potency phenothiazine, it is likely that a falsenegative ferric chloride test would have resulted due to the drug's low urine concentration.Z Also, I was unable to find any documentation on the ability of the ferric chloride test to detect the presence of thiothixenes or butyrophenones, both of which cause dystonic reactions in low doses. Even if the toxicological screening method of choice, urinary thin-layer chromatography, had been used, it too may have reported a false-negative. This is because, as the authors note and I have occasionally seen in emergency patients, a single dose of as little as 2 mg of haloperidol can cause a dystonic reaction up to 72 hours later, by which time the drug has been mostly eliminated. Trusting the patient's history seems a bit naive when trying to establish a new drug reaction. The author's testing procedures were unclearly reported; but even if properly done using thin-layer chromatography, they were not adequate to exclude a high-potency phenothiazine as the cause of the patient's reaction. The patient simply had a dystonic reaction of u n k n o w n etiology. Mark L DeBard, MD, FACEP Wright State University Medical School Emergency Department St Elizabeth Medical Center Dayton, Ohio

1. Henry RJ: Clinical Chemistry: Principles and Techniques. New York, Harper & Row, 1964, p 336-338. 2. Sonnenwirth AC, Jarett L: Gradwohl's Clinical Laboratory Methods and Diagnosis, ed 8. St Louis, CV Mosby, 1980, p 402-403.

In Reply: Dr DeBard raises some important issues in reply to our case report. The significance of such a unique drug reaction was not fully realized at the time of presentation. Thus, a "comprehensive" drug screen was not attained. Furthermore, to obtain assays on all patients is neither practical nor cost-effective in the m o d e m emergency setting. Ideally, we would have liked to assay for every possible etiologic drug agent of an acute dystonia, but this was not practical or even possible. Even if thin-layer chromatography had been used, there still would have been debate about the association of Tagamet ® with acute dyston~as. The history in this case was reliable and there was no ulterior motive or secondary gain in the presentation of this reaction. Dr DeBard is cynical about this patient's drug history. His statement that "a 20-year-old patient's history of illicit drug ingestion is rarely reliable ... ," is a biased, unsubstantiated conclusion that we do not share, particularly in this case. On the other hand, being able to establish good rapport with consistent history and examination findings was paramount in establishing this case. It should not be forgotten that within the realm of this case report there was a definite temporal relationship of Tagament ® use and the dystonic reaction. We believe our observation about the close association of Tagamet ® ingestion and the acute dystonic reaction was accurate and merited presentation in the literature. Stephen Romisher, MD James Dougherty, MD, FACEP Department of Emergency Medicine Akron General Medical Center Robert Felter, MD, FAAP Division of Emergency~Trauma Services Children's Hospital Medical Center of Akron Akron, Ohio

Rectal Bezoar From Sunflower Seeds To the Editor: We read with interest the case report "Popcorn Primary Colonic Phytobezoar" [January 1988;17:77-79], by Roberge, Squyres, and MacMath. We treated a 19-year-old previously healthy m a n with no 17:8 August 1988

significant medical or surgical history who complained of rectal pain and the lack of a bowel movement for two days after ingesting 16 oz of unshelled sunflower seeds. The patient was treated initially with a Fleet enema with mineral

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