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Thrombocytosis and giant cell arteritis
Wald and colleagues imply that population measures could prevent more coronary disease, although there are no large clinical trials to support this. On the other hand, drug treatment is of proven value in coronary prevention. Because it is expensive it should be directed towards those most likely to derive benefit. We cannot agree that screening a population for IHD risk factors is a worthless exercise.
is a more rapid investigation than ESR, and is as readily available. Further studies are required to confirm this potentially important observation. N Price, L G Clearkin Department of Ophthalmology, Arrowe Park Hospital, Upton, Wirral, Merseyside L49 5PE, UK
F Game, R Neary
1
Central Pathology ST4 7PA, UK
2
1
Laboratory, North Staffordshire Hospital, Hartshill, Stoke on Trent
De Keyser J, De Klippel N, Ebinger G. Thrombocytosis and ischaemic complications in giant cell arteritis. BMJ 1991; 303: 825. Watts MT, Greaves M, Clearkin LG, Malia RG, Cooper SM. Anti-phospholipid antibodies and ischaemic optic neuropathy. Lancet 1990; 335: 613-14.
Klag MJ, Ford DE, Mead LA, et al. Serum cholesterol in young men and subsequent cardiovascular disease. N Engl J Med 1993; 328: 313-18.
Oral vitamin E for
Thrombocytosis and giant cell arteritis
refractory hand dermatitis
SiR-Claims have been made for the salutary effects of vitamin on multiple organ systems,l,2 but reports are lacking on the treatment of dermatitis with oral preparations of the vitamin as monotherapy. We report a patient with previously refractory palmar dermatitis who responded to treatment with oral vitamin E at a dose of 400 mg (400 IU) daily. A healthy 38-year-old white male physician presented with a 2-year history of hyperkeratosis and fissuring of the palmar aspect of both hands. He had moved from a humid subtropical climate to a desert climate shortly before onset of symptoms. There was no personal or family history of eczema or atopy, malnutrition, vegetarian or "fad" diets, or alcohol abuse. The history suggested no other inciting factors. Laboratory evaluation showed a normal complete blood count, differential, and erythrocyte sedimentation rate, and the serum Venereal Diseases Research Laboratory test was nonreactive. Environmental interventions included changing soaps, briefcases, and watchbands; keys reconfigured from nickel alloy to brass; steering wheel wraps; gloves during gym workouts; and a multivitamin supplement (100% recommended daily allowance [RDA]). Exclusion diet manipulations included periods of total abstinence from alcoholic beverages and unpeeled raw vegetables. Treatment E
SiR-We have reviewed data on patients with anterior ischaemic optic neuropathy (AION) to determine whether the described association between thrombocytosis and ischaemic complications of giant cell arteritisl might be useful in differentiating AION due to giant cell arteritis from nonarteritic AION. From our records we identified 17 patients with AION who had had a temporal artery biopsy (TAB) specimen taken, and where an erythrocyte sedimentation rate (ESR) and platelet count had been done before any treatment. TAB samples showed giant cell arteritis in 10 patients. In no patient was a negative biopsy at variance with the clinical diagnosis. There was a difference between platelet count and ESR between the arteritic and non-arteritic groups:
no defmite cut-off value for ESR between the arteritic and non-arteritic groups was found, whereas the platelet count showed no overlap of values and a sharp cut-off point at 350 x 109/L (figure). The diagnosis of giant cell arteritis is made clinically and can only be confirmed histologically. Non-specific investigations such as the ESR and IgG anticardiolipin antibodies2 are used to support the diagnosis. Our results suggest that the platelet count may also be useful in differentiating arteritic from non-arteritic AION. Furthermore, the platelet count appears to be more precise than the ESR in segregating the two groups,
Moreover,
was attempted with topical steroids (triamcinolone, fluocinonide, and clobetasol with occlusive dressings), moisturisers, topical antifungal agents, aloe, keratolytic agents, and prednisone. Minimal and transient clearing of symptoms was observed in the course of a 2-year follow-up. The patient was otherwise symptom-free, took no medications, and
maintained an active and athletic lifestyle. Patch testing was proposed but not done. In mid-1993, the patient initiated self-medication with over-the-counter oral vitamin E at a dose of 400 mg daily for primary prevention of coronary atherogenesis.1 After 9 days he noted his palmar dermatitis improving. His hands cleared completely for the first time in over 4 years and remained free of lesions for 4 months. During a winter vacation therapy was deliberately discontinued. Palmar fissuring was noted in the second week after supplementation ceased. Vitamin E was then resumed with healing of fissures after 1 week. Subsequent complete remission of signs and symptoms has been maintained with oral vitamin E supplementation of 400 mg per day. No other supplements or medications have been introduced. No other environmental, occupational, or psychological factors could be correlated with the clinical course.
Figure: Box and whisker plot of ESR (top) and platelet count (bottom) +
=
median; box contains
a
central 50% of values, whiskers indicate
maximum and minimum values.
672
Although case reports cannot prove causality, our patient’s recalcitrant hand dermatitis of 4 years’ duration cleared after initiation of vitamin E, recurred after the intervention was withdrawn, and subsequently cleared again with reinstitution of the vitamin. Recent prospective studies have suggested a role for vitamin E in the prevention of cardiac events, possibly
is a more rapid investigation than ESR, and is as readily available. Further studies are required to confirm this potentially important observation. N Price, L G Clearkin Department of Ophthalmology, Arrowe Park Hospital, Upton, Wirral, Merseyside L49 5PE, UK
F Game, R Neary
1
Central Pathology ST4 7PA, UK
2
1
Laboratory, North Staffordshire Hospital, Hartshill, Stoke on Trent
De Keyser J, De Klippel N, Ebinger G. Thrombocytosis and ischaemic complications in giant cell arteritis. BMJ 1991; 303: 825. Watts MT, Greaves M, Clearkin LG, Malia RG, Cooper SM. Anti-phospholipid antibodies and ischaemic optic neuropathy. Lancet 1990; 335: 613-14.
Klag MJ, Ford DE, Mead LA, et al. Serum cholesterol in young men and subsequent cardiovascular disease. N Engl J Med 1993; 328: 313-18.
Oral vitamin E for
Thrombocytosis and giant cell arteritis
refractory hand dermatitis
SiR-Claims have been made for the salutary effects of vitamin on multiple organ systems,l,2 but reports are lacking on the treatment of dermatitis with oral preparations of the vitamin as monotherapy. We report a patient with previously refractory palmar dermatitis who responded to treatment with oral vitamin E at a dose of 400 mg (400 IU) daily. A healthy 38-year-old white male physician presented with a 2-year history of hyperkeratosis and fissuring of the palmar aspect of both hands. He had moved from a humid subtropical climate to a desert climate shortly before onset of symptoms. There was no personal or family history of eczema or atopy, malnutrition, vegetarian or "fad" diets, or alcohol abuse. The history suggested no other inciting factors. Laboratory evaluation showed a normal complete blood count, differential, and erythrocyte sedimentation rate, and the serum Venereal Diseases Research Laboratory test was nonreactive. Environmental interventions included changing soaps, briefcases, and watchbands; keys reconfigured from nickel alloy to brass; steering wheel wraps; gloves during gym workouts; and a multivitamin supplement (100% recommended daily allowance [RDA]). Exclusion diet manipulations included periods of total abstinence from alcoholic beverages and unpeeled raw vegetables. Treatment E
SiR-We have reviewed data on patients with anterior ischaemic optic neuropathy (AION) to determine whether the described association between thrombocytosis and ischaemic complications of giant cell arteritisl might be useful in differentiating AION due to giant cell arteritis from nonarteritic AION. From our records we identified 17 patients with AION who had had a temporal artery biopsy (TAB) specimen taken, and where an erythrocyte sedimentation rate (ESR) and platelet count had been done before any treatment. TAB samples showed giant cell arteritis in 10 patients. In no patient was a negative biopsy at variance with the clinical diagnosis. There was a difference between platelet count and ESR between the arteritic and non-arteritic groups:
no defmite cut-off value for ESR between the arteritic and non-arteritic groups was found, whereas the platelet count showed no overlap of values and a sharp cut-off point at 350 x 109/L (figure). The diagnosis of giant cell arteritis is made clinically and can only be confirmed histologically. Non-specific investigations such as the ESR and IgG anticardiolipin antibodies2 are used to support the diagnosis. Our results suggest that the platelet count may also be useful in differentiating arteritic from non-arteritic AION. Furthermore, the platelet count appears to be more precise than the ESR in segregating the two groups,
Moreover,
was attempted with topical steroids (triamcinolone, fluocinonide, and clobetasol with occlusive dressings), moisturisers, topical antifungal agents, aloe, keratolytic agents, and prednisone. Minimal and transient clearing of symptoms was observed in the course of a 2-year follow-up. The patient was otherwise symptom-free, took no medications, and
maintained an active and athletic lifestyle. Patch testing was proposed but not done. In mid-1993, the patient initiated self-medication with over-the-counter oral vitamin E at a dose of 400 mg daily for primary prevention of coronary atherogenesis.1 After 9 days he noted his palmar dermatitis improving. His hands cleared completely for the first time in over 4 years and remained free of lesions for 4 months. During a winter vacation therapy was deliberately discontinued. Palmar fissuring was noted in the second week after supplementation ceased. Vitamin E was then resumed with healing of fissures after 1 week. Subsequent complete remission of signs and symptoms has been maintained with oral vitamin E supplementation of 400 mg per day. No other supplements or medications have been introduced. No other environmental, occupational, or psychological factors could be correlated with the clinical course.
Figure: Box and whisker plot of ESR (top) and platelet count (bottom) +
=
median; box contains
a
central 50% of values, whiskers indicate
maximum and minimum values.
672
Although case reports cannot prove causality, our patient’s recalcitrant hand dermatitis of 4 years’ duration cleared after initiation of vitamin E, recurred after the intervention was withdrawn, and subsequently cleared again with reinstitution of the vitamin. Recent prospective studies have suggested a role for vitamin E in the prevention of cardiac events, possibly