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Preparation of scabies eggs for electron microscopy
Volume 10 Number 5, Part 1 May, 1984
competence and unethical referrals are made by dermatologists, as well as by all other physicians. That is a serious allegation, and should be raised when there is substantive reason to do so, but it certainly should not be treated as a trivial inference. The more substantive issue of the validity of the patient's self-assessment of her warts is not so easily addressed. It would have been highly desirable for an unbiased physician to have examined the patient to assess the physical status of the warts. On the other hand, much of the medical practice is based on our acceptance of patient self-reports unless we have reason to believe otherwise. We prescribe medications and the patient may telephone us in several days to state that the pain, or itch, or scabs, or cough, or fever, or malaise, or diarrhea, has gone away. We accept that patient's self-report. Certainly patients may give us invalid self-reports for a myriad of social, psychologic, and interpersonal reasons--we all encounter such circumstances in clinical practice. In the case at hand, the patient's self-report could indeed have been invalid. On the other hand, we are not presented with any cogent clinical reason to question the veracity of the patient. We might speculate that if the patient had reported that a conventional treatment like an injection or ointment had cured her warts, we would not raise the spector of the patient's credibility. But when the patient reports that an unusual therapy, hypnosis, cures her warts, we question her veracity. Is it the patient whom we challenge or the treatment? All o f the above discussion of the points raised by the correspondents does nothing to further our scientific analysis of the efficacy of hypnotherapy for the treatment of warts. The clinical reports suggest that hypnotherapy may be efficacious. Probable psychophysiologic mechanisms for the efficacy of hypnosis have been elucidated. Thus there is reasonable scientific justification to submit this treatment method to rigorous clinical experimental evaluation.
E. Mansell Pattison, M.D. Department of Psychiatry and Health Behavior Medical College of Georgia Augusta, GA 30912
Possible interaction of epinephrine with propranolol To the Editor: The perspicacious eye of Alan Greenwald provided a note that is perhaps worthy of expansion) Attention was called to work by Foster and Aston 2 at New York University. A series of six cases were presented. All patients
Correspondence
839
were taking propranolol (Inderal) for various problems unrelated to their reasons for cutaneous surgery. Each received lidocaine with epinephrine as their local anesthetic in concentrations and amounts equal to those many dermatologists commonly might use in practice. In each case a substantial hypertensive response developed, which response was followed in all but one by a significant bradycardia. In one case of a woman given 13 ml of 0.5% lidocaine with 1:200,000 epinephrine, the hypertensive episode was followed within 1 minute by cardiac arrest requiring intubation and cardiopulmonary resuscitation. Electroshock reverted the patient to nodal rhythm and she survived. Epinephrine has both an alpha adrenergic or pressor effect of vasoconstriction and beta adrenergic effects of vasodilation and cardiac acceleration. What seems to be going on is that propranolol (and other nonselective beta blockers) augment the pressor response to epinephrine by blocking the normal decrease in peripheral resistance ~hat would ordinarily result from epinephfine's /32 stimulation (/3z receptors are extracardiac whereas 131 receptors are chiefly cardiac). This results in a rise in blood pressure. The bradycardia represents a compensatory vagai reflex. This reflex vagal bradycardia can be blocked by atropine) It would seem prudent to add beta blockers to the caveat list before undertaking cutaneous surgery with epinephrine. Clearly many patients do not have a complete blockade and will not fall into a susceptible category. And since beta blockers differ in their sites of action not all will behave similarly. Until guidelines are clarified, caution must be used.
Philip M. Catalano, M.D. I416 59th St. West Bradenton, FL 33529
REFERENCES 1. Greenwald A: Propranolol-epinephrine interaction. J Dermatol Surg Oncol 9:713, 1983. 2. Foster CA, Aston SJ: Propranolol-epinephrine interaction: A potential disaster. Plast Reconstr Surg 72:71-78, 1983. 3. Gilman AG, Goodman LS, Gilman A, editors: Goodman and Gilman's The pharmacological basis of therapeutics. New York, 1980, Macmillan Publishing Co., Inc.
Preparation of scabies eggs for electron microscopy To the Editor: In a recent paper by W. B. Shelley and E. D. Shelley (J AM ACAD DEgMATOL9:673-679, 1983), impressive pictures of the eggshell of the scabies mite were presented.
840
Journal of the American Academy of Dermatology
Correspondence
REFERENCE 1. Van Neste D, Mrena E, Marchal G: Life cycle of scabies mite. Ann Dermatol Venereol 108:355-361, 1981.
Lichen planus and chronic active hepatitis To the Editor:
Fig. 1. Skin specimen of hyperkeratotic scabies fixed in glutaraldehyde and processed for scanning electron microscopy. (Original magnification, x 4,500.) In a previously published paper/eggs were fixed in Bouin's fluid and air-dried. After this fixation procedure the outer surface appeared as a smooth, progressively crackled structure. Since then I had the opportunity to study other skin specimens of hyperkeratotic scabies that had been immediately fixed in glutaraldehyde and processed for scanning electron microscopy (dehydration in acetone and critical point drying before gold coating). With this procedure, the egg surface appeared to be covered by numerous small droplets (Fig. 1). As these droplets were also found on the wails of the burrow, they are thought to represent a mixture of genital secretions and remnants of keratinocyte debris. Interestingly, clustering of droplets was observed in limited areas on the outer surface of the egg. The real significance of this structure has not been clearly understood so far. Anyway, significant progress will be made only when fully detailed technical information on the fixation procedure is available; indeed, for example, when the specimens are pretreated with xylene as published in the paper by Shelley and Shelley, the structure of the egg surface appears to be completely different and shows the presence of flat-topped papillary structures. The biologic function and significance of this are not clearly defined. It is to be hoped that further fine structural analysis will clarify intimate mechanisms of egg development in scabies.
Dr. D. Van Neste Universitd Catholique de Louvain UCL 3033mUnitd de Dermatologie Professionnelle Clos Chapelle Aux-Champs 30 1200 Bruxelles Belgium
We read the paper by Powell et al, " P r i m a r y Biliary Cirrhosis and Lichen Planus" ( J AM ACAD DERMATOL 9:540-545, 1983) with great interest. W e would suggest to extend the investigation in lichen planus (LP) patients also to chronic active hepatitis (CAH). In our experience LP patients have CAH in a high percentage of cases (11.3%), 1 and those with lichen erosivus even oftener (9 of 11 consecutive patients of ours), whereas in southern Europe CAH has a prevalence of only 0.1%. 2 The disease may affect skin and liver simultaneously, but it reveals itself on the skin long before the first enzymatic signs of liver disorder become apparent. In fact, in our LP patients CAH occurred even 18 years after LP was first diagnosed (range, 6-216 months). We have never observed a genuine case of primary biliary cirrhosis (PBC) in our LP patients. This may be due to a genetic factor (it would be interesting to know whether in Dr. Powell's series there were PBC patients of Italian ancestry) or to the high prevalence of hepatitis B virus (HBV) infection in Italy. Sixty percent o f our LPyCAH patients proved to be carriers o f hepatitis B surface antigen (I-IBsAg) andyor other 1-113V markers, whereas the prevalence in the general population in our geographic area is 34%. 2 Patients with chronic liver diseases mostly with HBV etiology carry serum antibodies to the basal ceils of squamous epithelia) A metaplasia of the hepatocyte induced by the integrated HBV genome may express an antigen normally characteristic of the epidermal basal cell that may b e c o m e the target of the cytotoxic reaction in LP.
Alfredo Rebora, M.D. Franco Rongioletti, M.D. University of Genoa, Department of Dermatology Viale Benedetto XV, 7 Genoa, ltaly
REFERENCES 1. Rebora A, Rongioletti F: Lichen planus and. chronic active hepatitis. A retrospective survey. Acta Derm Venereol (Stockh) 64:52-56, 1984. 2. Dardanoni L, Bergamini F, Giusti G: Tentativo di elaborazione di un quadro epidemiologico dell'epatite di tipo B in Italia. Ann Sclavo. (In press.) 3. Senkey R, Biberfeld G, Buligenen L, et al: Autoan-
competence and unethical referrals are made by dermatologists, as well as by all other physicians. That is a serious allegation, and should be raised when there is substantive reason to do so, but it certainly should not be treated as a trivial inference. The more substantive issue of the validity of the patient's self-assessment of her warts is not so easily addressed. It would have been highly desirable for an unbiased physician to have examined the patient to assess the physical status of the warts. On the other hand, much of the medical practice is based on our acceptance of patient self-reports unless we have reason to believe otherwise. We prescribe medications and the patient may telephone us in several days to state that the pain, or itch, or scabs, or cough, or fever, or malaise, or diarrhea, has gone away. We accept that patient's self-report. Certainly patients may give us invalid self-reports for a myriad of social, psychologic, and interpersonal reasons--we all encounter such circumstances in clinical practice. In the case at hand, the patient's self-report could indeed have been invalid. On the other hand, we are not presented with any cogent clinical reason to question the veracity of the patient. We might speculate that if the patient had reported that a conventional treatment like an injection or ointment had cured her warts, we would not raise the spector of the patient's credibility. But when the patient reports that an unusual therapy, hypnosis, cures her warts, we question her veracity. Is it the patient whom we challenge or the treatment? All o f the above discussion of the points raised by the correspondents does nothing to further our scientific analysis of the efficacy of hypnotherapy for the treatment of warts. The clinical reports suggest that hypnotherapy may be efficacious. Probable psychophysiologic mechanisms for the efficacy of hypnosis have been elucidated. Thus there is reasonable scientific justification to submit this treatment method to rigorous clinical experimental evaluation.
E. Mansell Pattison, M.D. Department of Psychiatry and Health Behavior Medical College of Georgia Augusta, GA 30912
Possible interaction of epinephrine with propranolol To the Editor: The perspicacious eye of Alan Greenwald provided a note that is perhaps worthy of expansion) Attention was called to work by Foster and Aston 2 at New York University. A series of six cases were presented. All patients
Correspondence
839
were taking propranolol (Inderal) for various problems unrelated to their reasons for cutaneous surgery. Each received lidocaine with epinephrine as their local anesthetic in concentrations and amounts equal to those many dermatologists commonly might use in practice. In each case a substantial hypertensive response developed, which response was followed in all but one by a significant bradycardia. In one case of a woman given 13 ml of 0.5% lidocaine with 1:200,000 epinephrine, the hypertensive episode was followed within 1 minute by cardiac arrest requiring intubation and cardiopulmonary resuscitation. Electroshock reverted the patient to nodal rhythm and she survived. Epinephrine has both an alpha adrenergic or pressor effect of vasoconstriction and beta adrenergic effects of vasodilation and cardiac acceleration. What seems to be going on is that propranolol (and other nonselective beta blockers) augment the pressor response to epinephrine by blocking the normal decrease in peripheral resistance ~hat would ordinarily result from epinephfine's /32 stimulation (/3z receptors are extracardiac whereas 131 receptors are chiefly cardiac). This results in a rise in blood pressure. The bradycardia represents a compensatory vagai reflex. This reflex vagal bradycardia can be blocked by atropine) It would seem prudent to add beta blockers to the caveat list before undertaking cutaneous surgery with epinephrine. Clearly many patients do not have a complete blockade and will not fall into a susceptible category. And since beta blockers differ in their sites of action not all will behave similarly. Until guidelines are clarified, caution must be used.
Philip M. Catalano, M.D. I416 59th St. West Bradenton, FL 33529
REFERENCES 1. Greenwald A: Propranolol-epinephrine interaction. J Dermatol Surg Oncol 9:713, 1983. 2. Foster CA, Aston SJ: Propranolol-epinephrine interaction: A potential disaster. Plast Reconstr Surg 72:71-78, 1983. 3. Gilman AG, Goodman LS, Gilman A, editors: Goodman and Gilman's The pharmacological basis of therapeutics. New York, 1980, Macmillan Publishing Co., Inc.
Preparation of scabies eggs for electron microscopy To the Editor: In a recent paper by W. B. Shelley and E. D. Shelley (J AM ACAD DEgMATOL9:673-679, 1983), impressive pictures of the eggshell of the scabies mite were presented.
840
Journal of the American Academy of Dermatology
Correspondence
REFERENCE 1. Van Neste D, Mrena E, Marchal G: Life cycle of scabies mite. Ann Dermatol Venereol 108:355-361, 1981.
Lichen planus and chronic active hepatitis To the Editor:
Fig. 1. Skin specimen of hyperkeratotic scabies fixed in glutaraldehyde and processed for scanning electron microscopy. (Original magnification, x 4,500.) In a previously published paper/eggs were fixed in Bouin's fluid and air-dried. After this fixation procedure the outer surface appeared as a smooth, progressively crackled structure. Since then I had the opportunity to study other skin specimens of hyperkeratotic scabies that had been immediately fixed in glutaraldehyde and processed for scanning electron microscopy (dehydration in acetone and critical point drying before gold coating). With this procedure, the egg surface appeared to be covered by numerous small droplets (Fig. 1). As these droplets were also found on the wails of the burrow, they are thought to represent a mixture of genital secretions and remnants of keratinocyte debris. Interestingly, clustering of droplets was observed in limited areas on the outer surface of the egg. The real significance of this structure has not been clearly understood so far. Anyway, significant progress will be made only when fully detailed technical information on the fixation procedure is available; indeed, for example, when the specimens are pretreated with xylene as published in the paper by Shelley and Shelley, the structure of the egg surface appears to be completely different and shows the presence of flat-topped papillary structures. The biologic function and significance of this are not clearly defined. It is to be hoped that further fine structural analysis will clarify intimate mechanisms of egg development in scabies.
Dr. D. Van Neste Universitd Catholique de Louvain UCL 3033mUnitd de Dermatologie Professionnelle Clos Chapelle Aux-Champs 30 1200 Bruxelles Belgium
We read the paper by Powell et al, " P r i m a r y Biliary Cirrhosis and Lichen Planus" ( J AM ACAD DERMATOL 9:540-545, 1983) with great interest. W e would suggest to extend the investigation in lichen planus (LP) patients also to chronic active hepatitis (CAH). In our experience LP patients have CAH in a high percentage of cases (11.3%), 1 and those with lichen erosivus even oftener (9 of 11 consecutive patients of ours), whereas in southern Europe CAH has a prevalence of only 0.1%. 2 The disease may affect skin and liver simultaneously, but it reveals itself on the skin long before the first enzymatic signs of liver disorder become apparent. In fact, in our LP patients CAH occurred even 18 years after LP was first diagnosed (range, 6-216 months). We have never observed a genuine case of primary biliary cirrhosis (PBC) in our LP patients. This may be due to a genetic factor (it would be interesting to know whether in Dr. Powell's series there were PBC patients of Italian ancestry) or to the high prevalence of hepatitis B virus (HBV) infection in Italy. Sixty percent o f our LPyCAH patients proved to be carriers o f hepatitis B surface antigen (I-IBsAg) andyor other 1-113V markers, whereas the prevalence in the general population in our geographic area is 34%. 2 Patients with chronic liver diseases mostly with HBV etiology carry serum antibodies to the basal ceils of squamous epithelia) A metaplasia of the hepatocyte induced by the integrated HBV genome may express an antigen normally characteristic of the epidermal basal cell that may b e c o m e the target of the cytotoxic reaction in LP.
Alfredo Rebora, M.D. Franco Rongioletti, M.D. University of Genoa, Department of Dermatology Viale Benedetto XV, 7 Genoa, ltaly
REFERENCES 1. Rebora A, Rongioletti F: Lichen planus and. chronic active hepatitis. A retrospective survey. Acta Derm Venereol (Stockh) 64:52-56, 1984. 2. Dardanoni L, Bergamini F, Giusti G: Tentativo di elaborazione di un quadro epidemiologico dell'epatite di tipo B in Italia. Ann Sclavo. (In press.) 3. Senkey R, Biberfeld G, Buligenen L, et al: Autoan-