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MARROW SUPPRESSION AND INTRAVENOUS CIMETIDINE
987 A 41-year-old seaman was airlifted to hospital with a twenty-four hour history of left-sided abdominal pain associated with rigors. His condition deteriorated in transit, and on
admission to the intensive-care unit he was comatose and in a of circulatory collapse. He had previously been well apart from a right-sided pylolithotomy in 1975. The initial clinical impression of gram-negative septicaemia complicating leftsided pylonephritis was confirmed when Escherichia coli was isolated from urine cultures and Proteus spp. from blood cultures. Treatment was started with intravenous gentamicin and ampicillin. Ten days after admission when the clinical state was improving, the patient vomited altered blood and haemoglobin fell from 12.5g/dl to 9-55 g/dl over four days. The patient was given three units of blood and intravenous cimetidine (200 mg every six hours). Although no gastrointestinal bleeding was observed, the haemoglobin fell from 11.5g/dl to 7.3g/dl over the next ten days, accompanied by a lowering of the white blood-cell count (13xl0"/l to 3 x 109/1) and the platelet count (130xl0"/l to 30 x 109/1). In the absence of any other obvious cause cimetidine was withdrawn, and recovery followed. The platelet level rose to a peak of 330x 109/1 on the tenth day and then remained normal. The white blood-cell count rose to a peak of 15 x 109/1 with 17% metamyelocytes and myelocytes on the third day, then levelled off at 7 x 109/1 with a normal differential count. The haemoglobin rose gradually over the next three weeks by 1.5 g/dl with a reticulocytosis of 15% ten days after withdrawal of cimetidine. The patient’s general condition gradually improved and he was discharged three weeks later. Although any profound illness, such as a gram-negative septicaemia, may produce some degree of marrow depression the timing in this case seems to implicate cimetidine. state
Sephadex G25 chromatography of tissue enkephalin standard. Void volume was determined by blue dextran.
extracts
and met-
Royal
Cornwall
Truro, Cornwall
species or just be non-specific protein interference. It is, however, highly unlikely to be one of the recognised larger endorphin species since immunoreactivity of alpha, gamma and beta endorphin could not be detected in the tumour extracts or in any of the column fractions. Tumours of the peripheral neuroendocrine system produce many hormones, particularly catecholamines and v.i.p. Both of these substances are present in brain and v.i.p. is also found in the gut.8 The distribution of enkephalin is similarand it is therefore not surprising that it should also be present in tumours of the adrenal medualla. The pharmacophysiology of enkephalin in man is unknown and our assay is not sensitive enough to detect plasma levels. However, in future patients with phaeochromocytomas or ganglioneuromas, a full evaluation of pain threshold, gut motility, and psychiatric state before and after surgery would be nftyfat trtt<*r<*’ct
Royal Postgraduate Medical School, Hammersmith Hospital, London W12 0HS
S. N. SULLIVAN S. R. BLOOM J. M. POLAK
MARROW SUPPRESSION AND INTRAVENOUS CIMETIDINE
SIR,-Several reports have warned that cimetidine may be associated with leucopenia and bone-marrow toxicity.1-4 We have seen a case in which giving intravenous cimetidine coincided with temporary bone-marrow suppression. 8. Bryant, M. G., Bloom, S. R., Polak, J. M., Albuquerque, R. H., Modlin, I., Pearse, A. G. E. Lancet, 1976, i, 991. 1. Craven, E. R., Whittington, J. M. Lancet, 1977, ii, 294. 2. Byron,J. W. ibid.p. 555. 3. Johnson, N. McI., Black, A. E., Hughes, A. S. B., Clarke, S. W. ibid. p. 1226. 4. Lopez-Luque, A., Rodriquez-Cuartero, A., Pérez-Gálvez, N., Pomares-Mora, J., Penã-Yáñez, A. ibid. 1978, i, 444.
Hospital (Treliske),
C. JAMES BRIAN J. PROUT
CORYNEBACTERIUM VAGINALE BACTERÆMIA IN A MAN
SIR,-Mr Abercrombie and his colleagues (April 8, p. 760) a case of Corynebacterium vaginale urinary-tract in-
reported
fection in a man. We have seen a case of bactersmia due to the same organism. A man of 57 was admitted for a transurethral prostatectomy. On admission, his midstream urine was sterile. Three days after operation the patient had pyrexia of 39.5C with rigors and burning on micturition. Blood cultures and urine were taken before treatment began. Microscopy of cathetersupplied urine showed 20 leucocytes/per high-power field but culture yielded an insignificant mixture of organisms (< 103 /ml). He was given oral co-trimoxazole (two tablets twice daily). Because of the pyuria another catheter-supplied urine was obtained two days later but this no longer contained pus. The growth was again insignificant, the pyrexia had resolved, and the patient was discharged nine days after operation. After seven days incubation, the blood-culture bottles showed turbidity and the three glucose broths and Robertson’s cooked-meat broth were subcultured on blood agar (CO2), blood agar (anaerobic), and MacConkey agar. Overnight incubation revealed a small, pleomorphic, predominantly gramnegative bacillus from all four bottles, sensitive to tissue levels of co-trimoxazole, penicillin, ampicillin, cephalosporins, erythromycin, and cloxacillin but resistant to sulphonamide and tetracycline. The National Collection of Type Cultures at Colindale identified the organism as Corynebacterium vaginale. The organism was probably present in the urine at the time of pyuria but was not isolated because the period of incubation was too short. Park et al.’ found that all isolates of C. vaginalis grew more quickly under increased CO2 tension, raising the question whether urine plates should be incubated in CO2 1.
Park, D. H., Fauber, M., Cook, C. B. Am. J. clin. Path. 1968, 49, 590.
admission to the intensive-care unit he was comatose and in a of circulatory collapse. He had previously been well apart from a right-sided pylolithotomy in 1975. The initial clinical impression of gram-negative septicaemia complicating leftsided pylonephritis was confirmed when Escherichia coli was isolated from urine cultures and Proteus spp. from blood cultures. Treatment was started with intravenous gentamicin and ampicillin. Ten days after admission when the clinical state was improving, the patient vomited altered blood and haemoglobin fell from 12.5g/dl to 9-55 g/dl over four days. The patient was given three units of blood and intravenous cimetidine (200 mg every six hours). Although no gastrointestinal bleeding was observed, the haemoglobin fell from 11.5g/dl to 7.3g/dl over the next ten days, accompanied by a lowering of the white blood-cell count (13xl0"/l to 3 x 109/1) and the platelet count (130xl0"/l to 30 x 109/1). In the absence of any other obvious cause cimetidine was withdrawn, and recovery followed. The platelet level rose to a peak of 330x 109/1 on the tenth day and then remained normal. The white blood-cell count rose to a peak of 15 x 109/1 with 17% metamyelocytes and myelocytes on the third day, then levelled off at 7 x 109/1 with a normal differential count. The haemoglobin rose gradually over the next three weeks by 1.5 g/dl with a reticulocytosis of 15% ten days after withdrawal of cimetidine. The patient’s general condition gradually improved and he was discharged three weeks later. Although any profound illness, such as a gram-negative septicaemia, may produce some degree of marrow depression the timing in this case seems to implicate cimetidine. state
Sephadex G25 chromatography of tissue enkephalin standard. Void volume was determined by blue dextran.
extracts
and met-
Royal
Cornwall
Truro, Cornwall
species or just be non-specific protein interference. It is, however, highly unlikely to be one of the recognised larger endorphin species since immunoreactivity of alpha, gamma and beta endorphin could not be detected in the tumour extracts or in any of the column fractions. Tumours of the peripheral neuroendocrine system produce many hormones, particularly catecholamines and v.i.p. Both of these substances are present in brain and v.i.p. is also found in the gut.8 The distribution of enkephalin is similarand it is therefore not surprising that it should also be present in tumours of the adrenal medualla. The pharmacophysiology of enkephalin in man is unknown and our assay is not sensitive enough to detect plasma levels. However, in future patients with phaeochromocytomas or ganglioneuromas, a full evaluation of pain threshold, gut motility, and psychiatric state before and after surgery would be nftyfat trtt<*r<*’ct
Royal Postgraduate Medical School, Hammersmith Hospital, London W12 0HS
S. N. SULLIVAN S. R. BLOOM J. M. POLAK
MARROW SUPPRESSION AND INTRAVENOUS CIMETIDINE
SIR,-Several reports have warned that cimetidine may be associated with leucopenia and bone-marrow toxicity.1-4 We have seen a case in which giving intravenous cimetidine coincided with temporary bone-marrow suppression. 8. Bryant, M. G., Bloom, S. R., Polak, J. M., Albuquerque, R. H., Modlin, I., Pearse, A. G. E. Lancet, 1976, i, 991. 1. Craven, E. R., Whittington, J. M. Lancet, 1977, ii, 294. 2. Byron,J. W. ibid.p. 555. 3. Johnson, N. McI., Black, A. E., Hughes, A. S. B., Clarke, S. W. ibid. p. 1226. 4. Lopez-Luque, A., Rodriquez-Cuartero, A., Pérez-Gálvez, N., Pomares-Mora, J., Penã-Yáñez, A. ibid. 1978, i, 444.
Hospital (Treliske),
C. JAMES BRIAN J. PROUT
CORYNEBACTERIUM VAGINALE BACTERÆMIA IN A MAN
SIR,-Mr Abercrombie and his colleagues (April 8, p. 760) a case of Corynebacterium vaginale urinary-tract in-
reported
fection in a man. We have seen a case of bactersmia due to the same organism. A man of 57 was admitted for a transurethral prostatectomy. On admission, his midstream urine was sterile. Three days after operation the patient had pyrexia of 39.5C with rigors and burning on micturition. Blood cultures and urine were taken before treatment began. Microscopy of cathetersupplied urine showed 20 leucocytes/per high-power field but culture yielded an insignificant mixture of organisms (< 103 /ml). He was given oral co-trimoxazole (two tablets twice daily). Because of the pyuria another catheter-supplied urine was obtained two days later but this no longer contained pus. The growth was again insignificant, the pyrexia had resolved, and the patient was discharged nine days after operation. After seven days incubation, the blood-culture bottles showed turbidity and the three glucose broths and Robertson’s cooked-meat broth were subcultured on blood agar (CO2), blood agar (anaerobic), and MacConkey agar. Overnight incubation revealed a small, pleomorphic, predominantly gramnegative bacillus from all four bottles, sensitive to tissue levels of co-trimoxazole, penicillin, ampicillin, cephalosporins, erythromycin, and cloxacillin but resistant to sulphonamide and tetracycline. The National Collection of Type Cultures at Colindale identified the organism as Corynebacterium vaginale. The organism was probably present in the urine at the time of pyuria but was not isolated because the period of incubation was too short. Park et al.’ found that all isolates of C. vaginalis grew more quickly under increased CO2 tension, raising the question whether urine plates should be incubated in CO2 1.
Park, D. H., Fauber, M., Cook, C. B. Am. J. clin. Path. 1968, 49, 590.