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SMALL-BOWEL CHANGES IN DERMATITIS HERPETIFORMIS
218
gluten-free diet, but the steatorrhoea dispatient gained 8 kg. in weight. The skin appeared condition improved with the gluten-free diet, and worsened loop operation. The operation was a simple one. The segment was in the when the patient resumed a normal diet. Case 2.-In February, 1966, we had a second patient, a man jejunum, about 1Bin. (4 cm.) below the duodenojejunal flexure. The operation was done about four weeks ago, and I aged 50 years, who had had dyspeptic symptoms, diarrhoea, and thought it a failure, but in the past week or so there has been dermatitis herpetiformis for 3 months. A jejunal-biopsy specia most dramatic improvement in the patient’s condition, and for The diarrhoea responded to a men showed a flat mucosa. the first time for years diarrhoea has almost ceased. We are in gluten-free diet. The jejunal mucosa did not change conthe process of having transit-times and serum-protein levels vincingly, and the skin disorder, in contrast to the results in our done postoperatively. Unfortunately we had not gone into the first patient, did not improve with this diet, but it improved I of and before this think, reversal, distinctly with dapsone. problem hyperchlorhydria Since seeing these two patients we have been studying smallin view of the fact that striking gastric hypersecretion occurs bowel structure and function in other patients with dermatitis after wide resections, that this is an investigation which should be done. herpetiformis. Some results are listed in the accompanying table. Patient 1 had steatorrhoea, malabsorption of several All in all, although it is wrong of course to draw definitive conclusions from one case, with this result before us I would nutrients, and protein loss from the intestinal wall. Patients 2 and 3 had the same malabsorption syndrome, but less most strongly support the opinion of Professor Ellis and his colleagues that there may be a place for this operation in cases extensively. of intestinal hurry after massive intestinal resections. The resemblance between our results and those of Dr. Wordsley Hospital, Marks and her colleagues is evident, and it seems probable near Stourbridge, that the conjunction of this skin disorder and this small-bowel M. HERSHMAN. Worcestershire. anomaly is not fortuitous. diarrhoea had occurred. His condition deteriorated the years, and finally it was decided to perform a reversed-
appalling over
with
treatment
a
and the
Our results will be
SMALL-BOWEL CHANGES IN DERMATITIS HERPETIFORMIS
University Departments of Medicine, Dermatology, and Pathology, St. Radboud Hospital, Nijmegen, Netherlands.
SIR,-The findings of Dr. Marks and her colleaguesare important in drawing attention again to the association of some skin diseases and mucosal abnormalities of the small bowel. Their observations on the conjunction of villous atrophy of the jejunum in nine of twelve patients with dermatitis herpetiformis agree quite well with our findings. Case l.-A man, aged 39 years, was admitted to this departof medicine in August, 1964, with megaloblastic anxmia.
ment
SMALL-BOWEL CHANGES IN
9
PATIENTS WITH DERMATITIS
HERPETIFORMIS
In 1961 he had been found to have dermatitis herpetiformis. The rash responded quickly to treatment with dapsone (diaminodiphenylsulphone, D.D.S.), started in 1962. In July, 1964, he complained of lassitude, glossitis, loss of weight, and loose motions. Megaloblastic anxmia and folic-acid deficiency were found. jejunal biopsy showed a fiat mucosa. The treatment with dapsone was stopped. The an2emia responded to folic acid, but the steatorrhoea and the flat jejunal mucosa did not There was little improvement in the jejunal mucosa after 1.
Marks, J., Shuster, S., Watson, A. J. Lancet, 1966, ii, 1280.
published shortly
in
more
detail elsewhere.2
J. H. M. VAN TONGEREN W. J. B. M. VAN DER STAAK P. H. M. SCHILLINGS.
VESICO-URETERAL REFLEX interested in Dr. Swapp’s article (Aug. 27, honoured that his work was stimulated by our article.3 We feel that the striking difference in incidence of reflux in the two articles is because of the differences in the type of clinical material studied. Dr. Swapp studied 12 patients with asymptomatic bacteriuria and found reflux in only 1, while we studied 12 patients during the acute pyelonephritic attack and found reflux in 5. The incidence of reflux varies depending upon the type of clinical material being studied. For example, Hodson and Edwardsfound 80-85% incidence of reflux but their clinical material consisted of patients who already had X-ray evidence of pyelonephritis. At the University of California our material was predominantly children with recurring urinary-tract infections associated with recurring attacks of chills and fever. In this group we found a 47% incidence of reflux. Gross and Sanderson5 studied similar patients and found 48% incidence of reflux. In many studies in which the clinical material consisted of milder cases of urinary tract infection-i.e., more cystitis and less pyelonephritis-the reported incidence of reflux is in the 25-33% range. Kjellberg, Ericsson, and Rudhe6 studied 598 enuretic patients and found a 5% incidence of reflux in those with purely nocturnal enuresis and 13% in those enuretics who also had urgency and frequency. Certainly the mildest type of urinary-tract infection is asymptomatic bacteriuria. To our knowledge, excepting the 12 cases reported by Dr. Swapp, no-one has investigated the incidence of demonstrable reflux in asymptomatic bacteriuric patients. Such a study would be very valuable indeed. Our guess would be that about 1 in 3 patients with asymptomatic bacteriuria have reflux. This is based on the work done by Kassand others in urinary-tract infection during pregnancy which shows that 6% of pregnant patients have bacteriuria, that 2% of pregnant patients develop clinical pyelonephritis
SIR,-We p. 466), and
were
we are
Tongeren, J. H. M., van der Staak, W. J. B. M., Schillings, P. H. M. Tijdschr. Geneesk. (in the press). 3. Hutch, J. A., Ayres, R. D., Noll, L. E. Am. J. Obstet. Gynec. 1963, 87, 2.
van
Ned.
478.
Hodson, C. J., Edwards, D. Clin. Radiol. 1960, 11, 219. Gross, K. E., Sanderson, S. S. Radiology, 1961, 77, 573. Kjellberg, S. R., Ericsson, N. D., Rudhe, U. The Lower Urinary Tract in Childhood. Chicago, 1957. 7. Kass, E. H. Archs intern. Med. 1960, 105, 194.
4. 5. 6.
gluten-free diet, but the steatorrhoea dispatient gained 8 kg. in weight. The skin appeared condition improved with the gluten-free diet, and worsened loop operation. The operation was a simple one. The segment was in the when the patient resumed a normal diet. Case 2.-In February, 1966, we had a second patient, a man jejunum, about 1Bin. (4 cm.) below the duodenojejunal flexure. The operation was done about four weeks ago, and I aged 50 years, who had had dyspeptic symptoms, diarrhoea, and thought it a failure, but in the past week or so there has been dermatitis herpetiformis for 3 months. A jejunal-biopsy specia most dramatic improvement in the patient’s condition, and for The diarrhoea responded to a men showed a flat mucosa. the first time for years diarrhoea has almost ceased. We are in gluten-free diet. The jejunal mucosa did not change conthe process of having transit-times and serum-protein levels vincingly, and the skin disorder, in contrast to the results in our done postoperatively. Unfortunately we had not gone into the first patient, did not improve with this diet, but it improved I of and before this think, reversal, distinctly with dapsone. problem hyperchlorhydria Since seeing these two patients we have been studying smallin view of the fact that striking gastric hypersecretion occurs bowel structure and function in other patients with dermatitis after wide resections, that this is an investigation which should be done. herpetiformis. Some results are listed in the accompanying table. Patient 1 had steatorrhoea, malabsorption of several All in all, although it is wrong of course to draw definitive conclusions from one case, with this result before us I would nutrients, and protein loss from the intestinal wall. Patients 2 and 3 had the same malabsorption syndrome, but less most strongly support the opinion of Professor Ellis and his colleagues that there may be a place for this operation in cases extensively. of intestinal hurry after massive intestinal resections. The resemblance between our results and those of Dr. Wordsley Hospital, Marks and her colleagues is evident, and it seems probable near Stourbridge, that the conjunction of this skin disorder and this small-bowel M. HERSHMAN. Worcestershire. anomaly is not fortuitous. diarrhoea had occurred. His condition deteriorated the years, and finally it was decided to perform a reversed-
appalling over
with
treatment
a
and the
Our results will be
SMALL-BOWEL CHANGES IN DERMATITIS HERPETIFORMIS
University Departments of Medicine, Dermatology, and Pathology, St. Radboud Hospital, Nijmegen, Netherlands.
SIR,-The findings of Dr. Marks and her colleaguesare important in drawing attention again to the association of some skin diseases and mucosal abnormalities of the small bowel. Their observations on the conjunction of villous atrophy of the jejunum in nine of twelve patients with dermatitis herpetiformis agree quite well with our findings. Case l.-A man, aged 39 years, was admitted to this departof medicine in August, 1964, with megaloblastic anxmia.
ment
SMALL-BOWEL CHANGES IN
9
PATIENTS WITH DERMATITIS
HERPETIFORMIS
In 1961 he had been found to have dermatitis herpetiformis. The rash responded quickly to treatment with dapsone (diaminodiphenylsulphone, D.D.S.), started in 1962. In July, 1964, he complained of lassitude, glossitis, loss of weight, and loose motions. Megaloblastic anxmia and folic-acid deficiency were found. jejunal biopsy showed a fiat mucosa. The treatment with dapsone was stopped. The an2emia responded to folic acid, but the steatorrhoea and the flat jejunal mucosa did not There was little improvement in the jejunal mucosa after 1.
Marks, J., Shuster, S., Watson, A. J. Lancet, 1966, ii, 1280.
published shortly
in
more
detail elsewhere.2
J. H. M. VAN TONGEREN W. J. B. M. VAN DER STAAK P. H. M. SCHILLINGS.
VESICO-URETERAL REFLEX interested in Dr. Swapp’s article (Aug. 27, honoured that his work was stimulated by our article.3 We feel that the striking difference in incidence of reflux in the two articles is because of the differences in the type of clinical material studied. Dr. Swapp studied 12 patients with asymptomatic bacteriuria and found reflux in only 1, while we studied 12 patients during the acute pyelonephritic attack and found reflux in 5. The incidence of reflux varies depending upon the type of clinical material being studied. For example, Hodson and Edwardsfound 80-85% incidence of reflux but their clinical material consisted of patients who already had X-ray evidence of pyelonephritis. At the University of California our material was predominantly children with recurring urinary-tract infections associated with recurring attacks of chills and fever. In this group we found a 47% incidence of reflux. Gross and Sanderson5 studied similar patients and found 48% incidence of reflux. In many studies in which the clinical material consisted of milder cases of urinary tract infection-i.e., more cystitis and less pyelonephritis-the reported incidence of reflux is in the 25-33% range. Kjellberg, Ericsson, and Rudhe6 studied 598 enuretic patients and found a 5% incidence of reflux in those with purely nocturnal enuresis and 13% in those enuretics who also had urgency and frequency. Certainly the mildest type of urinary-tract infection is asymptomatic bacteriuria. To our knowledge, excepting the 12 cases reported by Dr. Swapp, no-one has investigated the incidence of demonstrable reflux in asymptomatic bacteriuric patients. Such a study would be very valuable indeed. Our guess would be that about 1 in 3 patients with asymptomatic bacteriuria have reflux. This is based on the work done by Kassand others in urinary-tract infection during pregnancy which shows that 6% of pregnant patients have bacteriuria, that 2% of pregnant patients develop clinical pyelonephritis
SIR,-We p. 466), and
were
we are
Tongeren, J. H. M., van der Staak, W. J. B. M., Schillings, P. H. M. Tijdschr. Geneesk. (in the press). 3. Hutch, J. A., Ayres, R. D., Noll, L. E. Am. J. Obstet. Gynec. 1963, 87, 2.
van
Ned.
478.
Hodson, C. J., Edwards, D. Clin. Radiol. 1960, 11, 219. Gross, K. E., Sanderson, S. S. Radiology, 1961, 77, 573. Kjellberg, S. R., Ericsson, N. D., Rudhe, U. The Lower Urinary Tract in Childhood. Chicago, 1957. 7. Kass, E. H. Archs intern. Med. 1960, 105, 194.
4. 5. 6.