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FAILURE OF LYSINE TREATMENT IN RECURRENT HERPES SIMPLEX LABIALIS
942 whose two husbands had both died of sarcoidosis. A patient of mine with a cardiomyopathy had a positive macrocyte electrophoretic migration test, which indicated that she had either sarcoidosis, Crohn’s disease, or systemic lupus erythematosus.I A biopsy of her left ventricle in 1967 showed no granulomas (Mr M. Braimbridge) and she had negative Mantoux and Kveim tests in 1972. Two years after her heart lesion had been diagnosed pulmonary sarcoidosis was diagnosed in her husband. The successful passage of human cell suspension from sarcoid and Crohn’s tissue into mice, and the finding of mycobacteria in these animals, reported at the conference by Dr D. N. Mitchell, seem very relevant. I thank Prof. E.
J. Field and Mr E. A. Caspary for performing the
M.E.M. test.
St. Luke’s Hospital, Guildford, Surrey GU1 3NT
GERALD A. MACGREGOR
FAILURE OF LYSINE TREATMENT IN RECURRENT HERPES SIMPLEX LABIALIS
SIR,-Herpes simplex virus (H.s.v.) infections are not lifethreatening but the recurrent herpetic lesions are distressing. A wide variety of treatments has been tried2 but there is still no convincing one. Tankersley3 demonstrated that H.s.v. multiplication was reduced in cell-culture media containing high concentrations of L-lysine, suggesting an inhibitory effect of this aminoacid on virus replication. Kagan4 -.í’.dministered L-Iysine to a few papatients with oral herpes and ’observed rapid resolution of the lesions, and Dr 0. Jessen in this department has had some success with L-Iysine in herpes simplex episodes complicating bacterial meningitis. These observations motivated our study of L-lysine in recurrent herpes simplex. The patients, otherwise healthy, had had at least three herpes-simplex episodes in the preceding year. They were recruited via a request in a newspaper or from general practitioners or dermatologists. Only patients with prolabial and perioral lesions entered the study. The diagnosis was based upon a thorough history, though in some cases the lesions were seen by us. Informed consent was obtained. 198 patients were admitted to the study. 52 patients did not return the first questionnaire and 27 provided insufficient information. The final material comprised 119 patients (103 females) aged 16-80 (median 36). The trial ran for 48 weeks. The trial was double-blind, placebo-controlled, and randomised. At his first visit the patient was given a questionnaire and tablets containing 500 mg L-lysine monohydrochloride or starch powder. The tablets were identical in shape, colour, and taste and were randomised and coded before the study started. Each treatment series consisted of eleven tablets. The patients were told to take two tablets at the first symptom of recurrence of herpes and to continue with one tablet morning and evening until all eleven were gone. When the lesion was healed, the questionnaire and any residual tablets were returned and a new questionnaire and another box with tablets were dispatched. The questionnaire yielded information on the duration of the episode from start (burning, itching, tingling [prodrome] and/or erythema) to finish, when the crust had gone and discomfort and swelling had disappeared (slight erythema could still be present). The patient classified the lesion, when at its worst, as follows: (1) itching, burning, tingling, or tenderness but no visible lesion; (2) erythema with induration (papule) and/or vesicles; (3) vesicles with exudation and/or crust, lesion 15 mm or less, measured along the largest diameter; (4) vesicles with exudation and/or crust, lesion greater than 15 mm. Statistical comparisons were by the two-tailed Mann-Whitney ranksum test.
251 treated episodes of recurrent herpes simplex labialis were covered. Only episodes where treatment was started on the day the first symptoms appeared were admitted for analysis. If more than two tablets were returned or the data were
2.
Caspary, E. A., Field, E. J. Br. med. J. 1971, ii, 143. Spruance, S. L., Overall, J. C. Jr., Kern, E. R. et al. New Eng. J. Med. 1977,
3. 4.
Tankersley, R. W. Jr. J. Bact. 1964, 87, 609. Kagan, C. Lancet, 1974, i, 37.
1.
297, 69.
RESULTS
—————————————————————t——————————)_________f—————————]________
lysine (L) 46 females and 7 males, median age 35 (16-80); placebo (P) 46 females and 5 males, median age 36 (19-699. *On
on
inadequate the episode was excluded. 61 episodes were excluded (29 lysine, 32 placebo). The lysine-treated patients did not differ significantly from the placebo-treated with regard to rate of healing or the appearance of the lesion at its worst, either for the initial treatall treatments (table). The median recurrence-free intervals in the lysine and placebo treated groups were 57 (8-185) and 53 (11-154) days, rements or for
spectively. We found no effect of lysine 500 mg twice a day in recurrent labialis. However, in the herpetic lesion virus multiplication begins in the prodromal stage so any therapy must begin immediately symptoms develop. We have now started an investigation of lysine prophylaxis. The dose of lysine might have been too low but 500 mg was the largest amount of lysine that could be contained in the biggest standard tablet, and administration more than twice daily was considered too inconvenient for the patients.
herpes
We thank Severin Olesen Larsen, Statens Seruminstitut, Copenhagen, for Lene Fischer for technical assistence.
department of biostatistics, analysis of the data, and Ms NILS MILMAN JENS SCHEIBEL OVE JESSEN
Department of Infectious Diseases, Rigshospitalet, Copenhagen, Denmark
SACROILIAC DISEASE AND LOW BACKACHE IN WOMEN
SIR,-Our experienceI-3 of quantitative sacroiliac scintigra-
phy (Q.s.s.) for detection of early sacroiliitis does not support the findings and conclusions of Dr Davis and Dr Lentle (Sept. 2, p. 496). Although our normal sacroiliac/sacral uptake ratios, recorded 4 h after injection of 99"’Tc-pyrophosphate, are very similar to those of Lentle et al.,4 our data in the spondylitis cases are not. The figure shows the ratio of maximum activity at
the sacroiliac joints
over
that in the
sacrum
for 20 HLA B27
positive patients (11 men and 9 women) with sacroiliitis according to radiological stage5 compared with the normal range (mean+s.D.) in a control population (8 men and 30 women). In both the control and the disease group the values are variable, making differentiation difficult in an individual case.
The finding that in a homogeneous group of HLA B27 positive cases with clinical sacroiliitis Q.s.s. cannot distinguish 1.
Walravens, M., Goddeeris, T., Dequeker, J., De Roo, M. J. beige Radiol. 1975, 58, 510. 2. Dequeker, J., De Roo, M. J, nucl. Med. 1978, 19, 119. 3. Dequeker, J., Goddeeris, T., Walravens, M., De Roo, M. Radiology, 1978, 128, 687. 4. Lentle, B. C., Russell, A. S., Percy, J. S., Jackson, F. I. J. nucl. Med. 1977, 18, 529. 5. Kellgren, J. H. Epidemiology of Chronic Rheumatism, vol. II; atlas of standard radiographs of arthritis. Blackwell, 1963.
J. Field and Mr E. A. Caspary for performing the
M.E.M. test.
St. Luke’s Hospital, Guildford, Surrey GU1 3NT
GERALD A. MACGREGOR
FAILURE OF LYSINE TREATMENT IN RECURRENT HERPES SIMPLEX LABIALIS
SIR,-Herpes simplex virus (H.s.v.) infections are not lifethreatening but the recurrent herpetic lesions are distressing. A wide variety of treatments has been tried2 but there is still no convincing one. Tankersley3 demonstrated that H.s.v. multiplication was reduced in cell-culture media containing high concentrations of L-lysine, suggesting an inhibitory effect of this aminoacid on virus replication. Kagan4 -.í’.dministered L-Iysine to a few papatients with oral herpes and ’observed rapid resolution of the lesions, and Dr 0. Jessen in this department has had some success with L-Iysine in herpes simplex episodes complicating bacterial meningitis. These observations motivated our study of L-lysine in recurrent herpes simplex. The patients, otherwise healthy, had had at least three herpes-simplex episodes in the preceding year. They were recruited via a request in a newspaper or from general practitioners or dermatologists. Only patients with prolabial and perioral lesions entered the study. The diagnosis was based upon a thorough history, though in some cases the lesions were seen by us. Informed consent was obtained. 198 patients were admitted to the study. 52 patients did not return the first questionnaire and 27 provided insufficient information. The final material comprised 119 patients (103 females) aged 16-80 (median 36). The trial ran for 48 weeks. The trial was double-blind, placebo-controlled, and randomised. At his first visit the patient was given a questionnaire and tablets containing 500 mg L-lysine monohydrochloride or starch powder. The tablets were identical in shape, colour, and taste and were randomised and coded before the study started. Each treatment series consisted of eleven tablets. The patients were told to take two tablets at the first symptom of recurrence of herpes and to continue with one tablet morning and evening until all eleven were gone. When the lesion was healed, the questionnaire and any residual tablets were returned and a new questionnaire and another box with tablets were dispatched. The questionnaire yielded information on the duration of the episode from start (burning, itching, tingling [prodrome] and/or erythema) to finish, when the crust had gone and discomfort and swelling had disappeared (slight erythema could still be present). The patient classified the lesion, when at its worst, as follows: (1) itching, burning, tingling, or tenderness but no visible lesion; (2) erythema with induration (papule) and/or vesicles; (3) vesicles with exudation and/or crust, lesion 15 mm or less, measured along the largest diameter; (4) vesicles with exudation and/or crust, lesion greater than 15 mm. Statistical comparisons were by the two-tailed Mann-Whitney ranksum test.
251 treated episodes of recurrent herpes simplex labialis were covered. Only episodes where treatment was started on the day the first symptoms appeared were admitted for analysis. If more than two tablets were returned or the data were
2.
Caspary, E. A., Field, E. J. Br. med. J. 1971, ii, 143. Spruance, S. L., Overall, J. C. Jr., Kern, E. R. et al. New Eng. J. Med. 1977,
3. 4.
Tankersley, R. W. Jr. J. Bact. 1964, 87, 609. Kagan, C. Lancet, 1974, i, 37.
1.
297, 69.
RESULTS
—————————————————————t——————————)_________f—————————]________
lysine (L) 46 females and 7 males, median age 35 (16-80); placebo (P) 46 females and 5 males, median age 36 (19-699. *On
on
inadequate the episode was excluded. 61 episodes were excluded (29 lysine, 32 placebo). The lysine-treated patients did not differ significantly from the placebo-treated with regard to rate of healing or the appearance of the lesion at its worst, either for the initial treatall treatments (table). The median recurrence-free intervals in the lysine and placebo treated groups were 57 (8-185) and 53 (11-154) days, rements or for
spectively. We found no effect of lysine 500 mg twice a day in recurrent labialis. However, in the herpetic lesion virus multiplication begins in the prodromal stage so any therapy must begin immediately symptoms develop. We have now started an investigation of lysine prophylaxis. The dose of lysine might have been too low but 500 mg was the largest amount of lysine that could be contained in the biggest standard tablet, and administration more than twice daily was considered too inconvenient for the patients.
herpes
We thank Severin Olesen Larsen, Statens Seruminstitut, Copenhagen, for Lene Fischer for technical assistence.
department of biostatistics, analysis of the data, and Ms NILS MILMAN JENS SCHEIBEL OVE JESSEN
Department of Infectious Diseases, Rigshospitalet, Copenhagen, Denmark
SACROILIAC DISEASE AND LOW BACKACHE IN WOMEN
SIR,-Our experienceI-3 of quantitative sacroiliac scintigra-
phy (Q.s.s.) for detection of early sacroiliitis does not support the findings and conclusions of Dr Davis and Dr Lentle (Sept. 2, p. 496). Although our normal sacroiliac/sacral uptake ratios, recorded 4 h after injection of 99"’Tc-pyrophosphate, are very similar to those of Lentle et al.,4 our data in the spondylitis cases are not. The figure shows the ratio of maximum activity at
the sacroiliac joints
over
that in the
sacrum
for 20 HLA B27
positive patients (11 men and 9 women) with sacroiliitis according to radiological stage5 compared with the normal range (mean+s.D.) in a control population (8 men and 30 women). In both the control and the disease group the values are variable, making differentiation difficult in an individual case.
The finding that in a homogeneous group of HLA B27 positive cases with clinical sacroiliitis Q.s.s. cannot distinguish 1.
Walravens, M., Goddeeris, T., Dequeker, J., De Roo, M. J. beige Radiol. 1975, 58, 510. 2. Dequeker, J., De Roo, M. J, nucl. Med. 1978, 19, 119. 3. Dequeker, J., Goddeeris, T., Walravens, M., De Roo, M. Radiology, 1978, 128, 687. 4. Lentle, B. C., Russell, A. S., Percy, J. S., Jackson, F. I. J. nucl. Med. 1977, 18, 529. 5. Kellgren, J. H. Epidemiology of Chronic Rheumatism, vol. II; atlas of standard radiographs of arthritis. Blackwell, 1963.