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AMINOGENIC ALOPECIA
97 failure of renal vasoconstriction which may result from specific tachyphylaxis of the renal blood-vessels induced by high levels of endogenous angiotensin production. If this hypothesis is correct, the presence of a diuretic response to small doses of angiotensin probably resembles the angiotensin-infusion test of Kaplan and Silah 18 in that both may reflect the production of angiotensin at levels high enough to induce some degree of vascular tachyphylaxis. The major difficulty in accepting this hypothesis is the fact that similar paradoxical effects on renal function have been19 20reported with other pressor agents in patients with cirrhosis, hypertension, 21 22 and salt depletion.19 University of Melbourne Department of Medicine, W. J. LOUIS Royal Melbourne Hospital, A. E. DOYLE. Australia.
mainly
to a
FOLIC ACID AND NEUROLOGICAL DISEASE SIR,-We have read with interest the article by Grant et a1.23 Our investigations show that folate deficiency is very common amongst Nigerian patients with neurological disease. Of 15 consecutive patients with neurological disease 7 had low serum folic acid (S.F.A.) activity on Lactobacillus casei assay (normal range 8’0-62’3 m[Lg. per ml., intermediate range 6’07-9 m[kg. per ml.). In 13 of the patients in whom it was estimated, serum-vitamin-B12 concentration on L. leichmannii assay, was within normal limits for Nigerians (150-2125 (L(Lg. per ml.). Details of the patients are given in the accompanying table. 1 patient with low s.F.A. had packed-cell volume (P.c.v.) S,F.A.-ACTIVITY, SERUM-VITAMIN-BI2,
AND P.C.V. IN
15 PATIENTS WITH
NEUROLOGICAL DISEASE
The clinical features of the patients of Grant et al. with myelopathy living in a temperate climate are similar to those of
patients
with "
tropical myelopathy ".
Vitamin-B preparations, which generally contain little or no folic acid, are frequently prescribed to patients with neuropathies. Folic-acid supplements are likely to be useful adjuncts to treatment of these patients: in Nigeria, where pernicious anaEmia is extremely rare, there would be little danger of precipitating subacute combined degeneration of the cord. University of Ibadan and UniA. F. FLEMING versity of Lagos Medical School, T. O. DADA. Nigeria.
AMINOGENIC ALOPECIA was interested to see the preliminary communication Sir by Professor Shelley and Dr. Rawnsley1 describing five patients in whom alopecia was associated with the excretion of significant amounts of arginosuccinic acid in the urine. Since the publication of the article by Grosfeld et awl. on arginosuccinic aciduria in monilethrix I have studied five patients with typical manifestations of this condition. None of these subjects had any mental or physical defect apart from the monilethrix and associated follicular hyperkeratosis, or increased arginosuccinic acid excretion in the urine as compared with normal controls. Numerous separate samples were studied on different occasions A fluorometric technique employing over several months. condensation with orthophthalaldelyde,3 and quantitative spectrophotometric - ninhydrin determinations, on material obtained by Westall’s concentration methodyielded results no different from those obtained in normal controls. It is quite possible that increased arginosuccinic acid excretion in monilethrix may be intermittent; it is in any case not claimed to be as gross as in the patients originally described with arginosuccinic aciduria.5 Nevertheless it would be of interest to learn of other workers’ findings on abnormal aminoacid-excretion patterns in monilethrix and, as Professor Shelley and Dr. Rawnsley indicate, in other varieties of alopecia also. Their observation of absent cleavage enzyme in the red blood-cells of the patient with trichorrhexis nodosa is of canicular interest in view of the eenetic nature of this disease. University Department of Dermatology, Royal Victoria Infirmary, Newcastle upon Tyne 1. J. S. COMAISH.
SMOKE AND NASOPHARYNGEAL CANCER
less than 30%. In this preliminary work, bone-marrow examinations and therapeutic trials of folic acid were not
performed. The s.F.A. has been found to be in the low to intermediate range in 12-3% of 228 Nigerian blood-donors and in none of 50 healthy Europeans.24 Of the present series of patients with neurological disease, nearly half had low s.F.A. Folate deficiency seems to be particularly common in patients with spastic paraplegia in both Grant et al.’s series and our own. We agree with these authors that the deficiency is likely to be due to impaired appetite following neurological disease, but malnutrition may cause deficiency of other factors essential for nerve-function, to which the folate deficiency is incidental. Demonstration of folate deficiency does not imply a causal
relation. 18. Kaplan, N. M., Silah, J. G. J. clin. Invest. 1964, 43, 659; New Engl. J. Med. 1964, 271, 536. 19. Laragh, J. H. Circulation, 1962, 25, 203. 20. Laragh, J. H., Cannon, P. J., Bentzel, C. J., Sicinski, A. M., Meltzer, J. I. J. clin Invest. 1963, 42, 1179. 21. Brown, J. J., Peart, W. S. Clin. Sci. 1962, 22, 1. 22. Baldwin, D. S., Gombos, E. A., Chasis, H. J. Lab. clin. Med. 1963, 61, 832. 23. Grant, H., Hoffbrand, A. V., Wells, D. G. Lancet, 1965, ii, 763. 24. Fleming, A. F. Unpublished.
6
succinctly stated the case for hyperoestrogenism in Africans and raised the hoary problem of nature versus nurture in the aetiology of nasopharyngeal cancer. For at least four decades the population of South-East Asia has been exposed not so much to wood smoke alone (like the upland Kenyans) as to the products of the combusion of oil and wax SIR,-Your leading article
candles. In 1924 Dobson,7in the course of a comment upon the causes of nasopharyngeal tumours in the province of Kwang-tung, wrote: " Native houses in this region are not ventilated ... Tobacco smoke is universally present while guttering candles light the ancestral tablet and incense adds its quota. It is rare that one sees a kerosene lamp that does not smoke; open kerosene or clay lamps burning peanut oil are very general among the poor." In a recent series 8 of patients with nasopharyngeal cancer treated by arterial infusion chemotherapy in Hong Kong, some of the subjects admitted to having lived in cramped quarters lit by paraffin lamps, indicating that the influence of an environmental carcinogenic factor should still be considered. Published figures and opinions can be cited in support of 1. Shelley, W. B., Rawnsley, H. M. Lancet, 1965, ii, 1327. Grosfeld, J. C. M., Mighorst, J. A., Moolhuysen, T. M. G.
2.
F. ibid.
1964,
ii, 789.
Comaish, J. S. Unpublished. Westall, R. G. Biochem. J. 1960, 77, 135. Mighorst, J. A. Personal communication. 6. Lancet, 1965, ii, 833. 7. Dobson, W. M. Chin. med. J. 1924, 38, 786. 8. Anderson, J. M., Fung, J., Laing, D. Br. J. clin. Pract. 1965, 19, 565. 3. 4. 5.
mainly
to a
FOLIC ACID AND NEUROLOGICAL DISEASE SIR,-We have read with interest the article by Grant et a1.23 Our investigations show that folate deficiency is very common amongst Nigerian patients with neurological disease. Of 15 consecutive patients with neurological disease 7 had low serum folic acid (S.F.A.) activity on Lactobacillus casei assay (normal range 8’0-62’3 m[Lg. per ml., intermediate range 6’07-9 m[kg. per ml.). In 13 of the patients in whom it was estimated, serum-vitamin-B12 concentration on L. leichmannii assay, was within normal limits for Nigerians (150-2125 (L(Lg. per ml.). Details of the patients are given in the accompanying table. 1 patient with low s.F.A. had packed-cell volume (P.c.v.) S,F.A.-ACTIVITY, SERUM-VITAMIN-BI2,
AND P.C.V. IN
15 PATIENTS WITH
NEUROLOGICAL DISEASE
The clinical features of the patients of Grant et al. with myelopathy living in a temperate climate are similar to those of
patients
with "
tropical myelopathy ".
Vitamin-B preparations, which generally contain little or no folic acid, are frequently prescribed to patients with neuropathies. Folic-acid supplements are likely to be useful adjuncts to treatment of these patients: in Nigeria, where pernicious anaEmia is extremely rare, there would be little danger of precipitating subacute combined degeneration of the cord. University of Ibadan and UniA. F. FLEMING versity of Lagos Medical School, T. O. DADA. Nigeria.
AMINOGENIC ALOPECIA was interested to see the preliminary communication Sir by Professor Shelley and Dr. Rawnsley1 describing five patients in whom alopecia was associated with the excretion of significant amounts of arginosuccinic acid in the urine. Since the publication of the article by Grosfeld et awl. on arginosuccinic aciduria in monilethrix I have studied five patients with typical manifestations of this condition. None of these subjects had any mental or physical defect apart from the monilethrix and associated follicular hyperkeratosis, or increased arginosuccinic acid excretion in the urine as compared with normal controls. Numerous separate samples were studied on different occasions A fluorometric technique employing over several months. condensation with orthophthalaldelyde,3 and quantitative spectrophotometric - ninhydrin determinations, on material obtained by Westall’s concentration methodyielded results no different from those obtained in normal controls. It is quite possible that increased arginosuccinic acid excretion in monilethrix may be intermittent; it is in any case not claimed to be as gross as in the patients originally described with arginosuccinic aciduria.5 Nevertheless it would be of interest to learn of other workers’ findings on abnormal aminoacid-excretion patterns in monilethrix and, as Professor Shelley and Dr. Rawnsley indicate, in other varieties of alopecia also. Their observation of absent cleavage enzyme in the red blood-cells of the patient with trichorrhexis nodosa is of canicular interest in view of the eenetic nature of this disease. University Department of Dermatology, Royal Victoria Infirmary, Newcastle upon Tyne 1. J. S. COMAISH.
SMOKE AND NASOPHARYNGEAL CANCER
less than 30%. In this preliminary work, bone-marrow examinations and therapeutic trials of folic acid were not
performed. The s.F.A. has been found to be in the low to intermediate range in 12-3% of 228 Nigerian blood-donors and in none of 50 healthy Europeans.24 Of the present series of patients with neurological disease, nearly half had low s.F.A. Folate deficiency seems to be particularly common in patients with spastic paraplegia in both Grant et al.’s series and our own. We agree with these authors that the deficiency is likely to be due to impaired appetite following neurological disease, but malnutrition may cause deficiency of other factors essential for nerve-function, to which the folate deficiency is incidental. Demonstration of folate deficiency does not imply a causal
relation. 18. Kaplan, N. M., Silah, J. G. J. clin. Invest. 1964, 43, 659; New Engl. J. Med. 1964, 271, 536. 19. Laragh, J. H. Circulation, 1962, 25, 203. 20. Laragh, J. H., Cannon, P. J., Bentzel, C. J., Sicinski, A. M., Meltzer, J. I. J. clin Invest. 1963, 42, 1179. 21. Brown, J. J., Peart, W. S. Clin. Sci. 1962, 22, 1. 22. Baldwin, D. S., Gombos, E. A., Chasis, H. J. Lab. clin. Med. 1963, 61, 832. 23. Grant, H., Hoffbrand, A. V., Wells, D. G. Lancet, 1965, ii, 763. 24. Fleming, A. F. Unpublished.
6
succinctly stated the case for hyperoestrogenism in Africans and raised the hoary problem of nature versus nurture in the aetiology of nasopharyngeal cancer. For at least four decades the population of South-East Asia has been exposed not so much to wood smoke alone (like the upland Kenyans) as to the products of the combusion of oil and wax SIR,-Your leading article
candles. In 1924 Dobson,7in the course of a comment upon the causes of nasopharyngeal tumours in the province of Kwang-tung, wrote: " Native houses in this region are not ventilated ... Tobacco smoke is universally present while guttering candles light the ancestral tablet and incense adds its quota. It is rare that one sees a kerosene lamp that does not smoke; open kerosene or clay lamps burning peanut oil are very general among the poor." In a recent series 8 of patients with nasopharyngeal cancer treated by arterial infusion chemotherapy in Hong Kong, some of the subjects admitted to having lived in cramped quarters lit by paraffin lamps, indicating that the influence of an environmental carcinogenic factor should still be considered. Published figures and opinions can be cited in support of 1. Shelley, W. B., Rawnsley, H. M. Lancet, 1965, ii, 1327. Grosfeld, J. C. M., Mighorst, J. A., Moolhuysen, T. M. G.
2.
F. ibid.
1964,
ii, 789.
Comaish, J. S. Unpublished. Westall, R. G. Biochem. J. 1960, 77, 135. Mighorst, J. A. Personal communication. 6. Lancet, 1965, ii, 833. 7. Dobson, W. M. Chin. med. J. 1924, 38, 786. 8. Anderson, J. M., Fung, J., Laing, D. Br. J. clin. Pract. 1965, 19, 565. 3. 4. 5.