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Cross-sensitization between ethylenediamine and ethylenediamine tetraacetic acid (EDTA)
Volume 7 Number 6 December, 1982
Correspondence
seriously consider that the basic problem in Kaposi's is genetic predisposition of homosexuals rather than immunosuppression induced by CMV, even though some psychiatrists may become "unglued" to hear this.
Michael Novak, M.D. 633 N. Central Ave. Glendale, CA 91203
REFERENCES 1. Drew WL, Mintz L, Miner RC, Sands M, Ketterer B: Prevalence of cytomegalovirus infection in homosexual men. J Infect Dis 143:188-192, 1981. 2. Friedman-Kien AE: Disseminated Kaposi's sarcoma syndrome in young homosexual men. J AM ACADDERMATOL 5:468-471, 1981. 3. Carney WP, Rubin RH, Hoffman RA, Hansen WP, Healy K, Hirsch MS: Analysis of T lymphocyte subsets in cytomegalovirus mononucleosis. J Immunol 126:21142116, 1981. 4. Provisor AJ, Iacuone JJ, Neiburger RG, Crussi FG, Baehner RL: Acquired agammaglobulinemia after a lifethreatening illness with clinical and laboratory features of infectious mononucleosis in three male children. N Engl J Med 293:62-65, 1975.
807
ment and what part is determined by our genes. To date no one has been able to show any genetic, hormonal, or developmental difference between populations of people who choose to be exclusively homosexual and populations who choose a heterosexual life-style. The' fact that the homosexual community is made up of individuals ranging from genius to moron, from philanthropist to thief, and indeed the entire spectrum of human accomplishment and emotion, would strongly suggest that the factors that lead one to his ultimate destiny in life are far too complex for simple biologic assay. We hope soon to be able to identify those factors which make individuals susceptible to this new immunosuppressive syndrome leading to Kaposi's sarcoma. I doubt seriously if we will soon discover a gene for genius, a gene for artistry, a gene for military brilliance, or a gene for homosexuality.
Marcus A. Conant, M.D. 350 Parnassus Ave. Suite 808 San Francisco, CA 94117
Reply
To the Editor: Dr. Novak correctly stresses the point that the individuals who are showing Kaposi's sarcoma and pneumocystis pneumonia in association with severe helper T cell immunodepression may well be genetically different from those individuals who have not contracted this syndrome. Clearly, whatever has happened in the gay community to predispose it to this catastrophe is a new plague which may be attacking susceptible individuals. The immunosuppressive syndrome, including Kaposi's sarcoma, has been noted primarily in major American cities such as New York, San Francisco, and Los Angeles. It is noteworthy that large cities in Europe, such as Rome, and in this country, such as New Orleans, have yet to report cases of this new condition. This suggests strongly the transmissibility of the causative factor. Further, only a few individuals are affected. San Francisco, with a population of 700,000, is estimated to have between 100,000 and 200,000 gay residents. To date we have only identified thirty-two cases of Kaposi's sarcoma. Clearly, not everyone is at equal risk of developing this disease. Dr. Novak suggests, however, that "maybe homosexuality is basically a genetic condition." This concept has been advanced since the time of Mendel. It, of course, addresses the basic psychologic question of what part of our nature is determined by our environ-
Cross-sensitization between ethylenediamine and ethylenediamine tetraacetic acid (EDTA) To the Editor: In an excellent review article on "Allergy and Adverse Drug Reactions," written by Paul P. VanArsdel and appearing on pages 833-845 of the May, 1982, issue of the JOURNAL,the author alleges on page 837 that the known contact sensitizer, ethylenediamine, cross-sensitizes with ethylenediamine tetraacetic acid (EDTA). This particular issue has come up before and was refuted in a letter to the Editor written by A. A. Fisher ~ wherein he stated, "and it [EDTA] certainly does not cross-react with ethylenediamine hydrochloride." We have also just completed an extensive literature search on the subject at issue and did not find any evidence to support the theory of a cross-reaction between EDTA and ethylenediamine. Because of the widespread use of EDTA in a variety of products, including drugs, foods, and cosmetics, and in order to avoid any false conclusions about the safety of EDTA, we believed it to be important to comment on this subject. Sepp A. Kortschak, Ph.D. 1330 Regal Row Dallas, TX 75247
808
Journal of the American Academy of Dermatology
Correspondence
REFERENCE 1. Fisher AA: Cross-reactions between ethylenediamine tetraacetate and ethylenediamine hydrochloride. J AM ACAD DERMATOL 1:560, 1979. (Letter to Editor,) To the Editor: In the May, 1982, issue, Dr. P. P. VanArsdel, Jr., in his fine review, "Allergy and Adverse Drug Reactions" (J AM ACAD DERMATOL 6:833-845, 1982), made the following statement: " A m o n g the contact sensitizers, ethylenediamine, a stabilizer used in some creams, is of special importance because it crosssensitizes with drugs used systemically, such as aminophylline, antihistamines of the ethylenediamine class, and ethylenediamine tetraacetic acid." However, as I have emphasized in my article in your JOURNAL, 1 "fortunately, ethylenediamine hydrochloride does not cross-react with the ubiquitous ethylenediamine tetraacetate ( E D T A ) . " This lack of crossreaction is extremely important because I have seen several patients who needlessly tried to avoid EDTA. Its avoidance is a practical impossibility and is completely unnecessary. For several years our North American Contact Dermatitis Group patch-tested with EDTA, and in not a single instance was there a significant reaction recorded. We, therefore, stopped testing with EDTA. Furthermore, in my own series of 100 patients with positive reactions to ethylenediamine hydrochloride, none reacted to EDTA. Not only does E D T A not cross-react with ethylenediamine hydrochloride, but also I personally have never seen any positive reactions to EDTA. ~ I have recently learned that some batches of EDTA are preserved with formaldehyde, and I believe that some of the so-called positive reactions to EDTA may be due to the presence of this preservative in the EDTA. Alexander A. Fisher, M.D. 45-14 48th St. Woodside, L.I., NY 11377
REFERENCES 1. Fisher AA: The antihistamines. J AM ACAD DERMATOL 3:303-306, 1980. 2. Fisher AA: Contact dermatitis: Questions and answers. Part I. Cutis 28:610, 1981. Reply To the Editor: My comments were based on statements made in the second edition of Dr. Fisher's authoritative text on con-
tact dermatitis? When it was published in 1973, the idea of cross-reactivity seemed logical and was based on a reasonably convincing paper published a few years earlier. I am grateful to Drs. Fisher and Kortschak for pointing out that EDTA is not a significant sensitizer and thus cross-reactivity with the hydrochloride is not a problem.
Paul P. VanArsdel, Jr., M.D. Department of Medicine University Hospital Rm 13 Seattle, WA 98195
REFERENCE 1. Fisher AA: Contact dermatitis, ed. 2. Philadelphia, 1973, Lea & Febiger, pp. 1-448. Public education program versus cost-effectiveness study
To the Editor: A recent editorial entitled "Strategies to Promote Direct Access: The Public Education Alternative TM provides a very thoughtful presentation of the complex problem of how specialists can resist the efforts of health policy experts to ration health care by limiting patient access to specialist care. The authors cite the controversy which exists between those who favor a public education program versus those who favor a study on the cost-effectiveness of dermatologic care, comparing such care delivered by primary care physicians to that delivered by dermatologists. The authors discount the study approach in favor of the educational approach. I would like to offer comments in favor of adopting both approaches since I feel strongly that the American Academy of Dermatology will eventually regret its decision not to document the cost-effectiveness of dermatologic care as delivered by dermatologists. Are dermatologists cost-effective in comparison with p r i m a r y care physicians.'? I believe they are and that this can be convincingly demonstrated using a prospective study for which I have submitted a detailed proposal to the Academy Board of Directors. The reasons 1 believe dermatologists are, in the overall, costeffective is because they possess visual expertise and combine this with superb training and an extraordinary commitment to continually upgrading their skills through programs of continuing education. In this way they are able to avoid or eliminate many costly laboratory studies, hospitalizations, and ineffective therapeutic modalities which those less knowledgeable will utilize. Certainly the evidence from studies such as those
Correspondence
seriously consider that the basic problem in Kaposi's is genetic predisposition of homosexuals rather than immunosuppression induced by CMV, even though some psychiatrists may become "unglued" to hear this.
Michael Novak, M.D. 633 N. Central Ave. Glendale, CA 91203
REFERENCES 1. Drew WL, Mintz L, Miner RC, Sands M, Ketterer B: Prevalence of cytomegalovirus infection in homosexual men. J Infect Dis 143:188-192, 1981. 2. Friedman-Kien AE: Disseminated Kaposi's sarcoma syndrome in young homosexual men. J AM ACADDERMATOL 5:468-471, 1981. 3. Carney WP, Rubin RH, Hoffman RA, Hansen WP, Healy K, Hirsch MS: Analysis of T lymphocyte subsets in cytomegalovirus mononucleosis. J Immunol 126:21142116, 1981. 4. Provisor AJ, Iacuone JJ, Neiburger RG, Crussi FG, Baehner RL: Acquired agammaglobulinemia after a lifethreatening illness with clinical and laboratory features of infectious mononucleosis in three male children. N Engl J Med 293:62-65, 1975.
807
ment and what part is determined by our genes. To date no one has been able to show any genetic, hormonal, or developmental difference between populations of people who choose to be exclusively homosexual and populations who choose a heterosexual life-style. The' fact that the homosexual community is made up of individuals ranging from genius to moron, from philanthropist to thief, and indeed the entire spectrum of human accomplishment and emotion, would strongly suggest that the factors that lead one to his ultimate destiny in life are far too complex for simple biologic assay. We hope soon to be able to identify those factors which make individuals susceptible to this new immunosuppressive syndrome leading to Kaposi's sarcoma. I doubt seriously if we will soon discover a gene for genius, a gene for artistry, a gene for military brilliance, or a gene for homosexuality.
Marcus A. Conant, M.D. 350 Parnassus Ave. Suite 808 San Francisco, CA 94117
Reply
To the Editor: Dr. Novak correctly stresses the point that the individuals who are showing Kaposi's sarcoma and pneumocystis pneumonia in association with severe helper T cell immunodepression may well be genetically different from those individuals who have not contracted this syndrome. Clearly, whatever has happened in the gay community to predispose it to this catastrophe is a new plague which may be attacking susceptible individuals. The immunosuppressive syndrome, including Kaposi's sarcoma, has been noted primarily in major American cities such as New York, San Francisco, and Los Angeles. It is noteworthy that large cities in Europe, such as Rome, and in this country, such as New Orleans, have yet to report cases of this new condition. This suggests strongly the transmissibility of the causative factor. Further, only a few individuals are affected. San Francisco, with a population of 700,000, is estimated to have between 100,000 and 200,000 gay residents. To date we have only identified thirty-two cases of Kaposi's sarcoma. Clearly, not everyone is at equal risk of developing this disease. Dr. Novak suggests, however, that "maybe homosexuality is basically a genetic condition." This concept has been advanced since the time of Mendel. It, of course, addresses the basic psychologic question of what part of our nature is determined by our environ-
Cross-sensitization between ethylenediamine and ethylenediamine tetraacetic acid (EDTA) To the Editor: In an excellent review article on "Allergy and Adverse Drug Reactions," written by Paul P. VanArsdel and appearing on pages 833-845 of the May, 1982, issue of the JOURNAL,the author alleges on page 837 that the known contact sensitizer, ethylenediamine, cross-sensitizes with ethylenediamine tetraacetic acid (EDTA). This particular issue has come up before and was refuted in a letter to the Editor written by A. A. Fisher ~ wherein he stated, "and it [EDTA] certainly does not cross-react with ethylenediamine hydrochloride." We have also just completed an extensive literature search on the subject at issue and did not find any evidence to support the theory of a cross-reaction between EDTA and ethylenediamine. Because of the widespread use of EDTA in a variety of products, including drugs, foods, and cosmetics, and in order to avoid any false conclusions about the safety of EDTA, we believed it to be important to comment on this subject. Sepp A. Kortschak, Ph.D. 1330 Regal Row Dallas, TX 75247
808
Journal of the American Academy of Dermatology
Correspondence
REFERENCE 1. Fisher AA: Cross-reactions between ethylenediamine tetraacetate and ethylenediamine hydrochloride. J AM ACAD DERMATOL 1:560, 1979. (Letter to Editor,) To the Editor: In the May, 1982, issue, Dr. P. P. VanArsdel, Jr., in his fine review, "Allergy and Adverse Drug Reactions" (J AM ACAD DERMATOL 6:833-845, 1982), made the following statement: " A m o n g the contact sensitizers, ethylenediamine, a stabilizer used in some creams, is of special importance because it crosssensitizes with drugs used systemically, such as aminophylline, antihistamines of the ethylenediamine class, and ethylenediamine tetraacetic acid." However, as I have emphasized in my article in your JOURNAL, 1 "fortunately, ethylenediamine hydrochloride does not cross-react with the ubiquitous ethylenediamine tetraacetate ( E D T A ) . " This lack of crossreaction is extremely important because I have seen several patients who needlessly tried to avoid EDTA. Its avoidance is a practical impossibility and is completely unnecessary. For several years our North American Contact Dermatitis Group patch-tested with EDTA, and in not a single instance was there a significant reaction recorded. We, therefore, stopped testing with EDTA. Furthermore, in my own series of 100 patients with positive reactions to ethylenediamine hydrochloride, none reacted to EDTA. Not only does E D T A not cross-react with ethylenediamine hydrochloride, but also I personally have never seen any positive reactions to EDTA. ~ I have recently learned that some batches of EDTA are preserved with formaldehyde, and I believe that some of the so-called positive reactions to EDTA may be due to the presence of this preservative in the EDTA. Alexander A. Fisher, M.D. 45-14 48th St. Woodside, L.I., NY 11377
REFERENCES 1. Fisher AA: The antihistamines. J AM ACAD DERMATOL 3:303-306, 1980. 2. Fisher AA: Contact dermatitis: Questions and answers. Part I. Cutis 28:610, 1981. Reply To the Editor: My comments were based on statements made in the second edition of Dr. Fisher's authoritative text on con-
tact dermatitis? When it was published in 1973, the idea of cross-reactivity seemed logical and was based on a reasonably convincing paper published a few years earlier. I am grateful to Drs. Fisher and Kortschak for pointing out that EDTA is not a significant sensitizer and thus cross-reactivity with the hydrochloride is not a problem.
Paul P. VanArsdel, Jr., M.D. Department of Medicine University Hospital Rm 13 Seattle, WA 98195
REFERENCE 1. Fisher AA: Contact dermatitis, ed. 2. Philadelphia, 1973, Lea & Febiger, pp. 1-448. Public education program versus cost-effectiveness study
To the Editor: A recent editorial entitled "Strategies to Promote Direct Access: The Public Education Alternative TM provides a very thoughtful presentation of the complex problem of how specialists can resist the efforts of health policy experts to ration health care by limiting patient access to specialist care. The authors cite the controversy which exists between those who favor a public education program versus those who favor a study on the cost-effectiveness of dermatologic care, comparing such care delivered by primary care physicians to that delivered by dermatologists. The authors discount the study approach in favor of the educational approach. I would like to offer comments in favor of adopting both approaches since I feel strongly that the American Academy of Dermatology will eventually regret its decision not to document the cost-effectiveness of dermatologic care as delivered by dermatologists. Are dermatologists cost-effective in comparison with p r i m a r y care physicians.'? I believe they are and that this can be convincingly demonstrated using a prospective study for which I have submitted a detailed proposal to the Academy Board of Directors. The reasons 1 believe dermatologists are, in the overall, costeffective is because they possess visual expertise and combine this with superb training and an extraordinary commitment to continually upgrading their skills through programs of continuing education. In this way they are able to avoid or eliminate many costly laboratory studies, hospitalizations, and ineffective therapeutic modalities which those less knowledgeable will utilize. Certainly the evidence from studies such as those