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THE ADVANCE OF VENEREAL DISEASES
639
than the others, whereas in general disorders all nails are likely to be affected equally. The condition is, of course, caused by temporary interference with nail growth. P. D. SAMMAN. TRANYLCYPROMINE AND INTRACRANIAL HÆMORRHAGE
SIR,-It is now clear that treatment with tranylcypromine occasionally precipitates sudden severe headache, which not only may mimic, but can actually be due to a subarachnoid hxmorrhage. Although this is probably the result of paroxysmal hypertension and may be regarded as a toxic effect of the drug, the same management and investigations may be needed as in other cases of spontaneous subarachnoid haemorrhage. Thus, lumbar puncture is necessary to exclude or establish the diagnosis of subarachnoid haemorrhage in a patient who has severe headache and/or meningism while on treatment with tranylcypromine or one of the other monoamineoxidase inhibitors. The importance of this is illustrated by the following case: A woman of 65, a former mental nurse, gave a history of involutional depression for which she had been treated elsewhere twelve years previously. She had apparently been taking ’Tuinal’ gr. 9 each night for years. In May, 1963, she presented the typical signs of agitated depression and severe anxiety, and tranylcypromine 10 mg. and trifluoperazine 1 mg. (‘ Parstelin’) t.d.s. was prescribed. The patient was asked to report again in a week, but four days later there was an urgent call from her home and she was found to be in the throes of a typical " parstelin headache ". This had come on suddenly after she had taken the 13th tablet; she had not eaten any cheese nor had she had any dexamphetamine. Parstelin was stopped and she was told to lie flat in bed for two days and that her pain would pass off. This in fact happened; but forty-eight hours after the original attack, the headache became more severe and was accompanied by vomiting. On May 25 the patient was admitted to hospital. She was conscious, but had distinct meningism, and her temperature was 100°F. Her bloodpressure was 130/70 mm. Hg and there were no other abnormal clinical signs. Lumbar puncture showed heavily bloodstained fluid under pressure of 120 mm. with xanthochromic superfluid. Four days later, the patient was still very ill and there were periods of mental confusion. In addition, an intracranial bruit was heard over the right orbit and the right side of her neck. This bruit was heard on several occasions by different members of the hospital medical staff over the course of ten days, but was then not heard again. The patient’s general condition improved, and, because of the bruit and the normal blood-pressure, bilateral carotid arteriography was thought to be justified. This was done on June 6, and showed no definite abnormality. It was decided not to proceed with vertebral arteriography, particularly in view of the patient’s age. Her condition continued to improve and she recovered completely. Similar cases have now been reported in your correspondence columns and elsewhere, including 1 which was fatal after rupture of a posterior communicating aneurysm in a patient who was taking tranylcypromine alone. Thus, natant
if a patient on anti-depressant therapy has a subarachnoid haemorrhage, the possibility of an underlying aneurysm still exists, although the decision as to whether or not cerebral arteriography should be undertaken is a matter for individual consideration. Nevertheless, we should like to stress the importance of doing at least a lumbar puncture in susnected cases. M. L. E. ESPIR LOGAN MITCHELL. 1.
McClure, J. L. Lancet, 1962, i, 1351.
TRANYLCYPROMINE AND CHEESE
SIR,-In view of this may be of interest. A
woman
of 26
was
correspondence the following case
discharged
from
hospital
on one
tablet
(10 mg.) of tranylcypromine (’ Parnate ’) twice a day. During a period of 9 weeks she reported occasional headaches. Although her depression was improving she became more restless and agitated, and her medication was changed to ’Parstelin ’ (tranylcypromine plus trifluoperazine) one tablet twice daily. She returned after four weeks complaining of frequent attacks of disabling severe occipital headaches, with choking feelings in the neck and pounding sensations of the heart. The symptoms appeared to be increasing in intensity with every attack. It was discovered that she relished cheese and ate large quantities of it at any time of the day. Parstelin was discontinued, and she reported herself symptom-free after a week.
Much evidence is accumulating about the side-effects of tranylcypromine : in the meantime, caution is required in its use till further investigations are completed. Middlewood Hospital, Sheffield.
S. S. MAAN.
THE ADVANCE OF VENEREAL DISEASES to read Dr. de Glanville’s that little had been written or (Aug. 31) stating An on article dealing with this published genital herpes. aspect of venereology, will appear in the September issue of the British Journal of Venereal Diseases. At the St. Mary’s clinic, which has the largest turnover of
SIR,-Iwas interested
letter
new cases
per average of 5-6
annum
of all clinics in this country, I
see an
cases of genital herpes for every 1 of primary This shows the importance which this disease has in syphilis. the differential diagnosis of primary syphilis. Dr. Catterall (July 20) should have included molluscum contagiosum among the associated conditions in venereal disease, since I see on an average one case a month of this condition. His suggestion that carcinoma of the genitalia is acquired by sexual transmission is mistaken. Department of Venereal Diseases, DAVID C. HUTFIELD. St. Mary’s Hospital, London, W.2.
DETERMINATION OF SERUM-SODIUM LEVELS BY FLAME PHOTOMETRY SIR,-Several correspondents have described discrepancies produced by protein in the estimation of
sodium. In this laboratory the values obtained from an EEL flame photometer, using a 1:500 aqueous dilution of plasma, are consistently higher, by 3± 1 mEq. per litre, than those from anAutoAnalyzer’, which uses a plasma dialysate. The EEL result agrees best with the stated figure for various commercial control sera and with the modal values of several clinical chemical surveys in this country. This EEL photometer also shows an oddity of calibration. A series of standard solutions, diluted 1:500, are used to obtain a calibration curve. When the 200 mEq. per litre standard is used to set the galvanometer on 100, the line is markedly curved. But if the 160 mEq. per litre standard be used to set the galvanometer on 80,a straight-line calibration is obtained. Stewart and coworkers,l determining magnesium by atomic absorption spectrophotometry, point out that changes in the viscosity and surface tension of the aspirated solutions will alter the population of atoms in the flame. Both protein and trichloracetic acid affect these properties. The change in emission may well vary from one photometer to another, noted by Dr. van Leeuwen and others.2 Department of Biochemistry, Royal Perth Hospital, T. WEARNE. Perth, Western Australia.
1.
as
J.
Stewart, W. K., Hutchinson, F., Fleming, Laura W. J. Lab. clin. Med. 1963, 61, 858. 2. van Leeuwen, A. M., van Daatselaar, J. J., de Vries, L. A. Lancet, July 13, 1963, p. 94.
than the others, whereas in general disorders all nails are likely to be affected equally. The condition is, of course, caused by temporary interference with nail growth. P. D. SAMMAN. TRANYLCYPROMINE AND INTRACRANIAL HÆMORRHAGE
SIR,-It is now clear that treatment with tranylcypromine occasionally precipitates sudden severe headache, which not only may mimic, but can actually be due to a subarachnoid hxmorrhage. Although this is probably the result of paroxysmal hypertension and may be regarded as a toxic effect of the drug, the same management and investigations may be needed as in other cases of spontaneous subarachnoid haemorrhage. Thus, lumbar puncture is necessary to exclude or establish the diagnosis of subarachnoid haemorrhage in a patient who has severe headache and/or meningism while on treatment with tranylcypromine or one of the other monoamineoxidase inhibitors. The importance of this is illustrated by the following case: A woman of 65, a former mental nurse, gave a history of involutional depression for which she had been treated elsewhere twelve years previously. She had apparently been taking ’Tuinal’ gr. 9 each night for years. In May, 1963, she presented the typical signs of agitated depression and severe anxiety, and tranylcypromine 10 mg. and trifluoperazine 1 mg. (‘ Parstelin’) t.d.s. was prescribed. The patient was asked to report again in a week, but four days later there was an urgent call from her home and she was found to be in the throes of a typical " parstelin headache ". This had come on suddenly after she had taken the 13th tablet; she had not eaten any cheese nor had she had any dexamphetamine. Parstelin was stopped and she was told to lie flat in bed for two days and that her pain would pass off. This in fact happened; but forty-eight hours after the original attack, the headache became more severe and was accompanied by vomiting. On May 25 the patient was admitted to hospital. She was conscious, but had distinct meningism, and her temperature was 100°F. Her bloodpressure was 130/70 mm. Hg and there were no other abnormal clinical signs. Lumbar puncture showed heavily bloodstained fluid under pressure of 120 mm. with xanthochromic superfluid. Four days later, the patient was still very ill and there were periods of mental confusion. In addition, an intracranial bruit was heard over the right orbit and the right side of her neck. This bruit was heard on several occasions by different members of the hospital medical staff over the course of ten days, but was then not heard again. The patient’s general condition improved, and, because of the bruit and the normal blood-pressure, bilateral carotid arteriography was thought to be justified. This was done on June 6, and showed no definite abnormality. It was decided not to proceed with vertebral arteriography, particularly in view of the patient’s age. Her condition continued to improve and she recovered completely. Similar cases have now been reported in your correspondence columns and elsewhere, including 1 which was fatal after rupture of a posterior communicating aneurysm in a patient who was taking tranylcypromine alone. Thus, natant
if a patient on anti-depressant therapy has a subarachnoid haemorrhage, the possibility of an underlying aneurysm still exists, although the decision as to whether or not cerebral arteriography should be undertaken is a matter for individual consideration. Nevertheless, we should like to stress the importance of doing at least a lumbar puncture in susnected cases. M. L. E. ESPIR LOGAN MITCHELL. 1.
McClure, J. L. Lancet, 1962, i, 1351.
TRANYLCYPROMINE AND CHEESE
SIR,-In view of this may be of interest. A
woman
of 26
was
correspondence the following case
discharged
from
hospital
on one
tablet
(10 mg.) of tranylcypromine (’ Parnate ’) twice a day. During a period of 9 weeks she reported occasional headaches. Although her depression was improving she became more restless and agitated, and her medication was changed to ’Parstelin ’ (tranylcypromine plus trifluoperazine) one tablet twice daily. She returned after four weeks complaining of frequent attacks of disabling severe occipital headaches, with choking feelings in the neck and pounding sensations of the heart. The symptoms appeared to be increasing in intensity with every attack. It was discovered that she relished cheese and ate large quantities of it at any time of the day. Parstelin was discontinued, and she reported herself symptom-free after a week.
Much evidence is accumulating about the side-effects of tranylcypromine : in the meantime, caution is required in its use till further investigations are completed. Middlewood Hospital, Sheffield.
S. S. MAAN.
THE ADVANCE OF VENEREAL DISEASES to read Dr. de Glanville’s that little had been written or (Aug. 31) stating An on article dealing with this published genital herpes. aspect of venereology, will appear in the September issue of the British Journal of Venereal Diseases. At the St. Mary’s clinic, which has the largest turnover of
SIR,-Iwas interested
letter
new cases
per average of 5-6
annum
of all clinics in this country, I
see an
cases of genital herpes for every 1 of primary This shows the importance which this disease has in syphilis. the differential diagnosis of primary syphilis. Dr. Catterall (July 20) should have included molluscum contagiosum among the associated conditions in venereal disease, since I see on an average one case a month of this condition. His suggestion that carcinoma of the genitalia is acquired by sexual transmission is mistaken. Department of Venereal Diseases, DAVID C. HUTFIELD. St. Mary’s Hospital, London, W.2.
DETERMINATION OF SERUM-SODIUM LEVELS BY FLAME PHOTOMETRY SIR,-Several correspondents have described discrepancies produced by protein in the estimation of
sodium. In this laboratory the values obtained from an EEL flame photometer, using a 1:500 aqueous dilution of plasma, are consistently higher, by 3± 1 mEq. per litre, than those from anAutoAnalyzer’, which uses a plasma dialysate. The EEL result agrees best with the stated figure for various commercial control sera and with the modal values of several clinical chemical surveys in this country. This EEL photometer also shows an oddity of calibration. A series of standard solutions, diluted 1:500, are used to obtain a calibration curve. When the 200 mEq. per litre standard is used to set the galvanometer on 100, the line is markedly curved. But if the 160 mEq. per litre standard be used to set the galvanometer on 80,a straight-line calibration is obtained. Stewart and coworkers,l determining magnesium by atomic absorption spectrophotometry, point out that changes in the viscosity and surface tension of the aspirated solutions will alter the population of atoms in the flame. Both protein and trichloracetic acid affect these properties. The change in emission may well vary from one photometer to another, noted by Dr. van Leeuwen and others.2 Department of Biochemistry, Royal Perth Hospital, T. WEARNE. Perth, Western Australia.
1.
as
J.
Stewart, W. K., Hutchinson, F., Fleming, Laura W. J. Lab. clin. Med. 1963, 61, 858. 2. van Leeuwen, A. M., van Daatselaar, J. J., de Vries, L. A. Lancet, July 13, 1963, p. 94.