Reproducibility of patch tests

Journal of the American Academy of Dermatology

732 Correspondence inal group 27 of the 37 patients had Sezary syndrome. The statistics for this group reveal a 74.1% survival rate at 42 months and a median survival of 57.8 months (personal communication, Therakos, West Chester, Pa.) .This more than favorably compares with the results of Lamberg et al.! who demonstrated a median survival of 30 months in a similar group. Francis X. DiSpaltro, MD Steven Armus, MD Emil Bisaccia, MD Department ofPhotopheresis Morristown Memorial Hospital Morristown, NJ 07960

REFERENCE 1. Lamberg SI, Green SB, Byar DP, et al. Clinical staging for

cutaneous T-cell lymphoma. Ann Intern Med 1984;100: 187-92.

Reproducibility of patch tests To the Editor: We read with interest the article by Gollhausen et al. (J AM ACAD DERMATOL 1989;21:1196202). The simultaneous patch tests with Finn Chambers (attached with Scanpor surgical tape) with a series of 39 substances and 48-hour exposure time by 35 patients gave only 56.2% concordant reactions. We have performed a comparative study with 10 common contact allergens. Wehaveused Testpflaster (Beiersdorf AG, Hamburg, Germany). Two hundred thirty-six consecutive patients were simultaneously tested: one row of patches was removed after 24 hours and the other after 48 hours; in this day the first reading was made. The

second reading was made at 72 hours. We have used a semiquantitative method of Bandmann and Dohn! with a score of 0 to ++++. Crescendo reactions exhibiting at least an infiltrated erythema were regarded as positive. A total of 134 reactions to the 10 substances tested in duplicate were observed (Table I). Concordant reactions at both 24 hours and 48 hours were found in 125 cases (93.3%). Discordant reactions were seen in nine cases (6.7%); in seven cases (5.2%) a positive allergic reaction developed only after 48 hours' occlusion and in two cases (1.5%) only after 24 hours' exposure. 2 A similar comparative study with 24 hours and 48 hours of exposure time was done by Kalimo and Lammintausta. 3 They found concordant reactions in 74%. The principal reason for our study was to evaluate the differences in patch test results with different exposure times. The majority ofreactions were concordant. On the other hand, although we had different occlusion times, the reproducibility of patch tests was high. Therefore the results of Gollhausen et al. are interesting but surprising for us. The differences in results could beonly partly explained with some distinctions between our method and that of Gollhausen et al.; we used other patch test materials and our allergen series was smaller. We conclude that further investigation that is multicenter in scope and with a larger patient base is necessary to establish the reproducibility of patch tests. Jffina MacMCkova, MD, and Ondfej Seda, MD pI Dermatological Clinic Medical School of Charles University 128 00 Prague 2, Vysehradska 49 Czechoslovakia

Table I. Positive allergic reactions to the 10 allergens after final evaluation Discordant reactiom

Concordant reactions

Only after 24 hr

Only after 48 hr

Substance

exposure

exposure

Wool alcohols Cobalt nitrate Formaldehyde Nickel sulfate Isopropyl-p-phenylenediamine Potassium dichromate Neomycin Balsam of Peru ParaOOns mix Colophony Total

0 0 0 0 0 0 0 1 0 1

0 2 0 0 0 2 2 0 1 0

:2

'7

After both 24 and 48 hr exposure

10

Total

10

22

24

24 9 29

24 9

1

5

15 5

5

125

1

31

7

16 6 6 134

Volume 25 Number 4 October 1991

Corresponde~e

733

REFERENCES

his works in which he has not bothered. to mention him-

1. Bandmann HJ, Dohn W. Epicutantestung. Munchen: Bergamnn Verlag, 1967. 2. Machackova J, et ai. Epikutanni.testy: expozice alergemi 24 a 48 bodin. Srovmivaci studie. Cs Dermatol (In press.) 3. Kalimo K, Lammintausta K. 24 and 48 hour allergen exposure in patch testing. Comparative study with 11 common contact allergens and NiCli. Contact Dermatitis 1984; 10;25-9.

self.

There is much evidence in John Hunter's own writings to prove that he repeatedly and deliberately inoculated patients with venereal matter. There is good reason to as~ sume, therefore, that Hunter performed the crucial experiment on some person other than himself. E. S. Benjamin, MD Cape Town. South Africa

Dermatology and the history of ideas To the Editor: In the August 1990 issue of the JOURNAL (1990;23:311-5) John Wolf in his commentary states: " ... ill-fated self-experimentation of John Hunter ... he inoculated his penis with pus from a patient suffering from gonorrhea ... he died of syphilitic heart disease in 1793." (p. 314)

However, a contrary view was expressed by Qvist1: "There is no evidence to show that John Hunter ever suffered from venereal disease and there are good reasons to believe that this inoculation experiment was performed not on himself but on some other individual." The allegations that John Hunter suffered from venereal disease and that he inoculated himself with the disease can be refuted by consideration of his autopsy findings, the clinical features of his illness, and Hunter's own description of the inoculation experiment. John Hunter's autopsy was performed. by Everard Home and showed. advanced generalized atherosclerosis with calcified coronary arteries and ossified carotid and vertebral arteries. Prof. J. L. Turk states that in his opinion "there is no evidence in the autopsy report ofany pathological changes that might have been caused by syphilis and that there is no doubt that Hunter died as a result of coronary artery disease of atheromatous origin."l (p. 46) The clinical features of John Hunter's illness were myocardial and cerebral ischemia. In Everard Home's opinion John Hunter suffered from angina for the last 20 years of his life. The inoculation experiment is recorded in detail in his famous treatise but a careful study of this workshows that the actual subject of the experiment is never identified. Experiments made to ascertain the Progress and Ef· fects of the Veneral Poison: "... Two punctures were made on the penis with a lancet dipped in venereal matter from a gonorrhoea... " Hunter did not state that he inoculated himself. He simply stated that two punctures were made. The complete absence of the first person in the description of the experiment is striking and important because Hunter's works abound in the use of the personal pronoun. There are few pages in all his works in which he has not used it. Nearly all his observations were personal. Itis remarkable that this experiment, supposed by so many to have been performed on himself, should be just the one section in aU

REFERENCE 1. Qvist G. John Hunter 1728-1793. London: William Heinemann, 1981:43, 45-50.

Palmoplantar pustular lesions in mycosis fungoides To the Editor: We have read with interest the briefcommunication by Moreno et at, "Palmoplantar Pustulosis as a Manifestation of Cutaneous T Cell Lymphoma (MycosisFungoides)" (JAM ACADDBRMATOL 1990;23:7589). The authors reported. a case of mycosis fungoides (MF) with palmoplantar pustular lesions; the biopsy specimen revealed the characteristic histopathologic features of MF. They mentioned that there was no prior report of pustular cases of MF showing involvement of palms and soles. However, we have previously reported similar pustular lesions in a 4S-year-old Japanese man. l Our patient was unique in that there was a monoclonal neoplastic proliferation of CDS T cells instead of CD4 T cells that are commonly found in MF. Moreover, the MF in our case was aggressive like other reported cases of the suppressor T cell type of MF2 ; it showed a fulminant clinical course including the involvement of the central nervous system after the development of the palmar pustular lesions. Therefore of interest to us in relation to the unique paImoplantar pustular lesions of MF is the T cell subset of the neoplastic cells in the case of Moreno et ai. as well as the detail of the later clinical course; it was simply stated that the patient died 3 months later of Pseudomonas aeruginosa sepsis, a unusual infection that occurs mostly in patients with debilitated clinical conditions. Hachiro Tagami, MD Setsuya Aiba, MD Kyoko Ohkouchi. MD Department ofDermatology, Tohoku University School ofMedicine, Sendai, Japan

REFERENCES 1. Ohkouchi K, Aiba S, Tagami H. OKT8-reactive cell mycosis fungoides. Arch DermatoI 1986;122:20-3.