COLCHICINE MYONEUROPATHY

1271 SKIN COLONISATION BY RECIPIENT CELLS STUDIED BY ANTI-HLA MONOCLONAL ANTIBODIES

BC

=

basal cells, SL = spinous layer, and GL

=

granular layer.

CD8 ratio in dennis could provide a good indicator of cyclosporin’s effectiveness and rejection risks. Whether this could be useful for

monitoring cyclosporin needs further work. Finally the progressive colonisation of the allograft by donor cells seems to account for the good long-term prognosis of these grafts after stopping cyclosporin. We thank Mrs Guibert and Miss Benardin for technical assistance, Dr Muller (Nantes Blood Transfusion Centre) for advice and Dr Bourel (Rennes Blood Transfusion Centre) for providing anti-HLA antibodies.

Department of Dermatology, Bum

Centre,

Blood Transfusion Centre, and Department of Haematology, Centre Hospitalier Régional de Nantes, 44035 Nantes, France 1. Czemielewski

B. DRENO M. MEIGNIER J. D. BIGNON N. MILPIED M. PANNIER P. LITOUX

J, Demarchez M, Prunieras M. Human Langerhans cells in epidermal explants and skin grafts onto "nude" mice. Arch Dermatol Res

cell culture, in vitro 1984; 276: 288-91.

2 Achauer BN, Hewitt CW, Black KS, et al. Long-term skin allograft survival after short-term cyclosporin treatment in a patient with massive bums. Lancet 1986; i: 14-15. 3. Dreno B, Milpied N, Harousseau JL, et al. Cutaneous immunological studies in diagnosis of acute GVH. Br J Dermatol 1986; 114: 7-15 4. Alsbjorn BF. Langerhans cell depleted allograft skin on excised bums. Lancet 1983; 1. 1106. 5 Knight SC, Bedford PA. Effect of cyclosporine and retinoid acid on dendntic cell function. Transplant Proc 1987; 19: 320. 6. Palay DA, Cluff CW, Wentworth PA, Ziegler HK. Cyclosporine inhibits macrophage-mediated antigen presentation. J Immunol 1986, 136: 4348-53 7. Kupiec-Weglinski JW, Filho MA, Strom TB, Tilney NL. Sparing of suppressor cells: a critical action of cyclosporine. Transplantation 1984; 38: 97-101. 8. Towpick E, Kupiec-Weglinski JW, Uhteg LC, Padberg W, Tilney NL. Immune responsiveness following skin grafting in cyclosporine treated rats. Transplant Proc 1987; 19: 497-98.

COLCHICINE MYONEUROPATHY

SiR,—Your Sept 19 editorial highlights a potentially important risk of long-term treatment with colchicine. We were the first to use colchicine in a controlled, trial in primary biliary cirrhosis (PBC)’ and now have patients who have taken the drug for over 7 years. We have been impressed by the lack of serious side-effects, particularly when compared with other drugs used to treat PBC.2 However, peripheral neuropathy has developed in two of our patients on colchicine treatment. A 61-year-old woman had peripheral weakness, dysaesthesiae, and diarrhoea 8 months after starting colchicine 0-5 mg twice daily. Nerve conduction studies confirmed a generalised peripheral neuropathy. Serum creatine kinase was not measured but she was in renal failure (blood urea 18-7 mmol/1, serum creatinine 220 umol/1) and had urinary tract tuberculosis. Colchicine was withdrawn, anti-tuberculosis therapy started, and her neuropathy clinically resolved. A 76-year-old woman with PBC took colchicine 05 mg twice daily for 7 years. A deterioration in her condition led to hospital admission, where routine neurological examination suggested a sensorimotor peripheral neuropathy. This was confirmed by nerve-conduction studies, which showed a lower limb axonal polyneuropathy. Electromyography revealed no evidence of a myopathy and serum creatine kinase levels and renal function were normal. Sural nerve biopsy demonstrated a reduction in large

fibres with grouping of thinly myelinated fibres consistent with regeneration; there were no changes of xanthomatous neuropathy.3 Although these changes are similar to those described by Kuncl et al in colchicine toxicity,’ they are non-specific. The patient deteriorated rapidly and died. At necropsy, the liver was found to be extensively replaced by primary liver cancer, a rare but recognised complication of PBC.’ Proximal muscle weakness and peripheral neuropathy may have other causes in PBC, such as osteornalacia,z xanthomatous neuropathy,3 and vitamin E deficiency.6 Our first case had features of colchicine-induced neuropathy, particularly in view of the renal failure, which appears to be a major risk factor.’ The second case, however, may have been due to a non-metastatic effect of the primary liver cancer. Our experience suggests that the differential diagnosis of peripheral neuropathy in PBC must now be widened to include all these possibilities. We endorse the fact that colchicine should not be given to patients in established renal failure. Nevertheless, having treated over fifty PBC patients with colchicine long-term we find significant side-effects to be rare; they should be balanced against the beneficial effects of the drug in this disease now reported in three controlled trials.7-9

myelinated

Liver Unit, Manchester M13 9WL

T. W. WARNES C. BABBS,

Department of Medicine, Victoria Hospital, Blackpool

F. I. LEE

Manchester

Royal Infirmary,

TW, Smith A, Haboubi NY, Johnson PJ, Hunt L. A controlled trial of colchicine in primary biliary cirrhosis. Hepatology 1984; 4: 1022 (abstr). Warnes TW. Treatment of primary biliary cirrhosis. Sem Liver Dis 1985; 5: 228-40. Thomas PK, Walker JG, Xanthomatous neuropathy in primary biliary cirrhosis. Brain 1965; 88: 1079-88. Kuncl RW, Duncan G, Watson D, Alderson K, Rogawski MA, Peper M Colchicine myopathy and neuropathy N Engl JMed 1987; 316: 1562-68. Johnson PJ, Krasner N, Portman B, Eddleston ALWF, Williams R. Hepatocellular carcinoma m Great Britain: Influence of age, sex, HBsAg status, and aetiology of underlying cirrhosis. Gut 1978; 19: 1022-26. Jeffrey GP, Muller DPR, Burroughs AK, et al. Vitamin E deficiency and its clinical significance in adults with primary biliary cirrhosis and other forms of chronic liver disease. J Hepatol 1987; 4: 307-17. Warnes TW, Smith A, Lee FI, Haboubi NY, Johnson PJ. Hunt L. A controlled tnal of colchicine in primary biliary cirrhosis. J Hepatol 1987; 5: 1-7 Kaplan MM, Alling DW, Zimmerman HJ, et al. A prospective trial of colchicine for primary biliary cirrhosis N Engl J Med 1986; 315: 1448-54. Bodenheimer H, Schaffner F, Pezzullo J. Colchicine therapy in primary biliary cirrhosis. Hepatology 1986; 6: 1172 (abstr).

1. Warnes

2. 3. 4. 5.

6.

7.

8. 9.

SiR,—Your Sept 19 editorial underlines the danger of misdiagnosing colchicine-induced neuropathy and myopathy. Kuncl et all reported twelve cases of neuromyopathy, probably induced by high plasma levels of colchicine that had been administered for months or years to patients with chronic renal failure. We have seen a very unusual case of nerve and muscle toxicity, after a short course of colchicine at moderate doses, in a patient with chronic alcohol-induced liver disease but with normal kidney function. A 64-year-old woman, with a limp due to late effects of poliomyelitis, had chronic autoimmune thrombocytopenic purpura, non-responsive to steroids; she had had a splenectomy; vincristine, vinblastine, and danazol had been given for the previous 34 months and she required multiple transfusions of platelets. She had recurrent petechiae and subcutaneous and articular haemotomas. She was on tolbutamide 750 mg daily because of steroid-induced diabetes mellitus. Results of laboratory tests were normal except for polymorphonuclear cell and platelet counts (112 and 6-0 x 109/1, respectively), serum glucose (3-38 mmol/1), cholinesterase (1845 IU/1, normal 2400-3800), x-gtutamyltranspeptidase 289 IU/1, alanine aminotransferase 43 IU/1, and alkaline phosphatase 311 IU/1. Vinca alkaloids had been stopped 6 months earlier. Danazol 800 mg daily and prednisone 15 mg daily were also stopped (Feb 16, 1985) and replaced, a week later, by oral colchicine 15 mg (0-02 mg/kg) daily.2 After 16 days, sudden muscle pains developed with severe bilateral proximal arm and leg weakness, normal sensation, and symmetrical hyporeflexia. Electromyography revealed a proximal myogenic and a distal mixed (both myogenic and neurogenic) pattern. Ulnar and peroneal motor-

1272 conduction velocities were slightly decreased. Sural nerve conduction velocity was normal. Repetitive stimulation and singlefibre electromyography revealed a myasthenic pattern (decreased

ALLELE

nerve

responses at

FREQUENCIES OF FIVE POLYMORPHIC DNA PROBES 21-OH DEFICIENCY FAMILIES

IN

low-frequency stimulation, post-tetanic facilitation).

The serum creatinine kinase rose to 416 IU/1. Colchicine levels were not assessed; muscle biopsy was not done because of the severe thrombocytopenia (15 x 103/1). Oral colchicine was stopped on the 21st day. Within 2 weeks CK levels had fallen to normal, and muscle strength and electromyographic patterns improved. The acute onset with myalgia and the complete recovery after colchicine withdrawal exclude myasthenia gravis and polymyositis. This is the first clinical report of the colchicine-induced neuromuscular transmission defect previously seen only in laboratory animals.3 The myopathy, neuropathy, and neuromuscular transmission defect were induced in this patient by a very short course of colchicine and there were no other signs of drug toxicity. Colchicine is monodemethylated by liver microsomes, and plasma levels of the drug are higher in patients with severe liver disease. Thus our patient’s liver disease and the microsomal enzyme-inhibiting activity of the tolbutamide she was taking may have played a part in her colchicine-induced neuropathy and

myopathy. Instituto Scientifico San University of Milan, Ospedale San Raffaele, 20132 Milan, Italy

Raffaele,

CARLO BESANA GIANCARLO COMI VITTORIO BALDINI GIANFRANCO CIBODDO ROSANGELA BIANCHI

1. Kuncl RW, Duncan G, Watson D, Alderson 2.

K, Rogawski MA, Peper M. Colchicine myopathy and neuropathy. N Engl J Med 1987; 316: 1562-68. Strother SV, Zuckerman KS, Lo Buglio AF Colchicine therapy of refractory immune thrombocytopenia. Blood 1982; 60 (suppl). 192A.

3. Turkanis SA transmission

Some effects of vinblastine and colchicine Brain Res 1973; 54: 324-29.

on

neuromuscular

PRENATAL DIAGNOSIS OF CONGENITAL ADRENAL HYPERPLASIA on congenital adrenal hyperplasia experience with DNA probes in early prenatal diagnosis of21-hydroxylase (21-OH) deficiency. Prenatal diagnosis by chorion villus biopsy has the advantage not only of early detection (and termination, if indicated) but also of the option of in-utero therapy,! which is not feasible when diagnosis is attempted later, by amniocentesis. Furthermore, prenatal diagnosis by measurement of 17-hydroxyprogesterone in amniotic fluid may not be reliable in the simple virilising form of 21-OH deficiency.2 Mornet et aP used DNA probes (a non-specific class I HLA probe and an HLA-DR probe) which yield autoradiographs that may be difficult to interpret; moreover, the risk of misdiagnosis due to recombination may be significant. To overcome these problems we have been using a battery of five probes (table): 21A-1-8 detects polymorphism at the disease locus; C4B550 and C4B-1-4detect polymorphism at the complement C4 loci, no more than 40 kb from the disease locus; and pB250 and pRTVl, two flanking probes, that are HLA-B specific and HLA-DR3 cDNA exon specific, respectively, and yield clear-cut autoradiographs. Four of the probes show high-frequency polymorphism with TaqI, and two of the four detect non-overlapping restriction fragments, so that only two Southern filters are required to determine if a family is informative for all five probes. The 21-OH gene probe itself was directly informative in only 3 of 17 families. Although this probe does not generally identify point

SiR,—Your Sept

prompts

us to

19 editorial

report

our

account for most 21-OH gene defects, it does detect deletion of both the functional gene (21-OHB) and the neighbouring pseudogene (2./-07-L4).’’ After digestion of DNA with TaqI and Southern hybridisation with the 21-OH probe, 21-OHB and 21-OHA can normally be disunguished by 3-7 kb and 3-2 kb hybridisation bands, respectively. The 21-OH gene probe identifies homozygotes by the absence of the 3-7 kb band. We can also identify a reduction in the intensity of the 3-7 kb band to half that of the 3-2 kb band, this pattern signifying inheritance of one haplotype with a 21-OHB deletion. In some cases, the absence or reduced intensity of the3-7 kb band seems to be due to replacement

sources are: 21A-1 8, C4B-550, and C4B-1 4 (our probes, unpublished), pRTVl1 (Bidwell et al4); pB250 (Strachan et aI5). tVar = vanous; majority alleles equivalent to serologically defined specificities4

*Probe

a nucleotide sequence at the 21-OHB locus by a defective sequence copied from the pseudogene. Either way, fewer than 20 % of families are informative when the 21-OH gene probe alone is

of

used. Restriction fragment length polymorphism at the 21-OHA and 21 -OHB loci is not very helpful so we have added linkage markers in the immediate vicinity of 21-OHB. pRTV1was informative in 60% (9/15) of the families investigated and C4B550 in 44% (7/16), and 87% (13/15) were informative for one or both probes. The fragments recognised by C4B550 do not overlap in size with the two 21-OH specific TaqI fragments so they can be detected on the same Southern filter. of prenatal diagnosis where the 21-OH gene probe is not directly informative but where both the C4 probe and the DR(3 probes are is shown in the figure. The affected child has inherited a paternal haplotype with a 5-4 kb TaqI allele at the C4B locus and a maternal haplotype with a 6-0 kb allele. The

An example

mutations, which

Pedigree and autoradiographs of Southern blots (A) Southern blots of Taql digested genomic DNA after hybridisation- with C4 probe C4B550 and 21-OH gene probe 21A-1-8.

Band

sizes

are

in

kilobases.

Fragments represent C4A (7-0), C4B (6-4, 6 0, 5 4), 21-OHB (3’7), and 27-O.M (3 2). (B) Same filter reprobed with an HLA-DRp probe pRTVl. Haplotypes are: a, c = A I B8 DR3; b = A24 B7 DR6; d = A2 B44 DR5.