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Vaginitis complicating gold therapy for rheumatoid arthritis
700
Communications
cent) and 46,Xx separate culture mary explants. chromatin body
in brief
cell lines. The mosaicism was observed in two flasks which were established from two priThe analysis of 100 buccal cells showed a in 39’per cent of the cells.
Primary amenorrhea occurs in many different disorders. Abnormalities of chromosomes are the single largest group of definable disorders associated with primary amenorrhea. In a study of 50 patients with primary amenorrhea and a review of the literature (347 additional cases), Sartoi found that chromosome abnormalities were found in approximately one third of those studied. The karyotypes included absence or structural rearrangement of the X-chromosome, autosomal rearrangements, various types of mosaicism, and presence of the Y-chromosome in a phenotypic female. In sex chromosome abnormalities, mosaicism is a frequent finding. The detection of mosaicism depends on the number of cells analyzed per tissue and the number of tissues analyzed. If mitotic nondisjunction occurs late in embryogenesis, aneuploidy may not be detected if only a single tissue such as blood is studied. The cytogenetic finding in our patient is best explained by a late nondisjunctional event occuring during embryogenesis of the gonads. Lack of other somatic malformations is consistent with this interpretation. The sex chromosome mosaicism confined to an ovary appears to be responsible for some cases of primary amenorrhea. In a patient with gonadal dysfunction who has minimal somatic abnormality and a normal karyotype in blood and/or skin, the possibility of gonadal sex chromosome mosaicism should be investigated by chromosome analysis of gonadal tissue when such tissue is available. REFERENCES
I. Sarto, G. E.: Cytogenetics of fifty patients with primary amenorrhea, Ah. Jy OBSTET. GYNEC~L. 1lQi 14, 1974. 2 Goldstein. D. E.. Kellv. T. E.. lohanson. A. I.. and Blizzard. R. M.: Gonadal dysgenesis Gith 45,Xbl4&XX mosaicisnr demonstrated only in a streak gonad, J. Pediatr. QQr 604, 1977.
Vaginitis complicating gold therapy for rheumatoid arthritis JOSEPH
C. WEBSTER, JR., M.D., (MC) USA ALEXANDER G. JUDEN, JR., M.D., COLONEL (MC) USA, F.A.C.O.G. CAPTAIN
Department of Obstetrics and Gynecology, Center, Fort Sam Howton, Texas
Brooke
Army
The anti-inflammatory action of various topical steroids, including estrogens, is well recognized.* Topical estrogen was chosen in this case because its presence in the vagina is physiologic and because it is known to reduce the marked nonspecific inflammation and discomfort present after vaginal irradiation.’ We hope our report of this case will serve to point out the existence of vaginitis as a consequence of gold therapy and to stress that relatively simple therapy short of the systemic steroids used to treat the more serious side effects can be effective. REFERENCES
Reprint requests: Dr. Alexander G. Juden, Department of the Army, Brooke Army MedicaI Center, Fort Sam Houston, .I’exas 78234. 197EThe
A 29-year-old white secretary, gravida 3, para 3, was first given a diagnosis of rapidly progressive rheumatoid arthritis in August, 1972. She had noted morning stiffness of several joints for about 3 months, with swelling of the proximal interphalangea1 joints. Her RA factor titer was 1 : 320. with negative ANA test and roentgenograms. The erythrocyte sedimentation rate was 28. Initially, the Rheumatology Service administered salicylates and indomethacin without satisfactory results. However, gold thioglucose, 50 mg. weekly intramuscularly, produced dramatic relief of the joint symptoms. On this therapy, she noted marked vaginal pruritis and discomfort which resolved only after discontinuing gold therapy. Six courses of therapy between December, 1972, and August, 1976, produced the same vaginal symptoms. Papanicolaou smears done while she was on gold therapy revealed marked acute inflammation. Negative smear results were reported between the courses of gold injections. On each gynecologic referral for vaginal discomfort, normal saline wet preparations taken from the vaginal mucosa and ectocetvix exhibited a nonspecific inflammatory response. KOH preparations were consistently negative. Various topical and systemic antibiotic and antifungal preparations provided no improvement. Only cessation of gold therapy resulted in relief. She returned to the gynecology clinic in August, 1976, stating that her vaginal irritation had returned as usual with resumption of gold thioglucose injections. Dienestrol vaginal cream once daily was prescribed for 2 weeks and thrice weekly thereafter. She was asymptomatic when seen 2 weeks later and her vaginal secretions had changed from a clear, thin fluid, with abundant inflammatory cells on wet preparation, to a normal gross and microscopic appearance. Thereafter. she remained without vaginal discomfort during gold therapy.
Me&Cal
P AREN TERA L gold therapy for rheumatoid arthritis has had recognized adverse side effects since its use was
000%9378/78/06131-0700$00.10/0~
first published by Forestier’ in 1935. Systemic and topical steroids are used to treat the serious mucocmaneous eruptions such as stomatitis and exfoliative dermatitis. The vaginal mucosa is a recognized site of inflammation and discomfort consequent to gold therapy (Goodman and Gilman) but a search of the literature reveals such vaginitis has yet to inspire a report of specific therapy.
C.V.MosbyCo.
1. Forestier, J.: Rheumatoid arthritis and its treatment by gold salts, J. Lab. Clin. Med. ZQt 827, 1935. 2. Place, V., and Benson, H.: Local effects of topically applied steroids, J. Steroid Biochem. 6: 717, 1975. 3. Pitkin, R., and Btadbury, J.: The effect of topical estrogen on irradiated vaginal epithelium, AM. J. OBSTET. GYNECOL 92:
175,
lQ65.
Communications
cent) and 46,Xx separate culture mary explants. chromatin body
in brief
cell lines. The mosaicism was observed in two flasks which were established from two priThe analysis of 100 buccal cells showed a in 39’per cent of the cells.
Primary amenorrhea occurs in many different disorders. Abnormalities of chromosomes are the single largest group of definable disorders associated with primary amenorrhea. In a study of 50 patients with primary amenorrhea and a review of the literature (347 additional cases), Sartoi found that chromosome abnormalities were found in approximately one third of those studied. The karyotypes included absence or structural rearrangement of the X-chromosome, autosomal rearrangements, various types of mosaicism, and presence of the Y-chromosome in a phenotypic female. In sex chromosome abnormalities, mosaicism is a frequent finding. The detection of mosaicism depends on the number of cells analyzed per tissue and the number of tissues analyzed. If mitotic nondisjunction occurs late in embryogenesis, aneuploidy may not be detected if only a single tissue such as blood is studied. The cytogenetic finding in our patient is best explained by a late nondisjunctional event occuring during embryogenesis of the gonads. Lack of other somatic malformations is consistent with this interpretation. The sex chromosome mosaicism confined to an ovary appears to be responsible for some cases of primary amenorrhea. In a patient with gonadal dysfunction who has minimal somatic abnormality and a normal karyotype in blood and/or skin, the possibility of gonadal sex chromosome mosaicism should be investigated by chromosome analysis of gonadal tissue when such tissue is available. REFERENCES
I. Sarto, G. E.: Cytogenetics of fifty patients with primary amenorrhea, Ah. Jy OBSTET. GYNEC~L. 1lQi 14, 1974. 2 Goldstein. D. E.. Kellv. T. E.. lohanson. A. I.. and Blizzard. R. M.: Gonadal dysgenesis Gith 45,Xbl4&XX mosaicisnr demonstrated only in a streak gonad, J. Pediatr. QQr 604, 1977.
Vaginitis complicating gold therapy for rheumatoid arthritis JOSEPH
C. WEBSTER, JR., M.D., (MC) USA ALEXANDER G. JUDEN, JR., M.D., COLONEL (MC) USA, F.A.C.O.G. CAPTAIN
Department of Obstetrics and Gynecology, Center, Fort Sam Howton, Texas
Brooke
Army
The anti-inflammatory action of various topical steroids, including estrogens, is well recognized.* Topical estrogen was chosen in this case because its presence in the vagina is physiologic and because it is known to reduce the marked nonspecific inflammation and discomfort present after vaginal irradiation.’ We hope our report of this case will serve to point out the existence of vaginitis as a consequence of gold therapy and to stress that relatively simple therapy short of the systemic steroids used to treat the more serious side effects can be effective. REFERENCES
Reprint requests: Dr. Alexander G. Juden, Department of the Army, Brooke Army MedicaI Center, Fort Sam Houston, .I’exas 78234. 197EThe
A 29-year-old white secretary, gravida 3, para 3, was first given a diagnosis of rapidly progressive rheumatoid arthritis in August, 1972. She had noted morning stiffness of several joints for about 3 months, with swelling of the proximal interphalangea1 joints. Her RA factor titer was 1 : 320. with negative ANA test and roentgenograms. The erythrocyte sedimentation rate was 28. Initially, the Rheumatology Service administered salicylates and indomethacin without satisfactory results. However, gold thioglucose, 50 mg. weekly intramuscularly, produced dramatic relief of the joint symptoms. On this therapy, she noted marked vaginal pruritis and discomfort which resolved only after discontinuing gold therapy. Six courses of therapy between December, 1972, and August, 1976, produced the same vaginal symptoms. Papanicolaou smears done while she was on gold therapy revealed marked acute inflammation. Negative smear results were reported between the courses of gold injections. On each gynecologic referral for vaginal discomfort, normal saline wet preparations taken from the vaginal mucosa and ectocetvix exhibited a nonspecific inflammatory response. KOH preparations were consistently negative. Various topical and systemic antibiotic and antifungal preparations provided no improvement. Only cessation of gold therapy resulted in relief. She returned to the gynecology clinic in August, 1976, stating that her vaginal irritation had returned as usual with resumption of gold thioglucose injections. Dienestrol vaginal cream once daily was prescribed for 2 weeks and thrice weekly thereafter. She was asymptomatic when seen 2 weeks later and her vaginal secretions had changed from a clear, thin fluid, with abundant inflammatory cells on wet preparation, to a normal gross and microscopic appearance. Thereafter. she remained without vaginal discomfort during gold therapy.
Me&Cal
P AREN TERA L gold therapy for rheumatoid arthritis has had recognized adverse side effects since its use was
000%9378/78/06131-0700$00.10/0~
first published by Forestier’ in 1935. Systemic and topical steroids are used to treat the serious mucocmaneous eruptions such as stomatitis and exfoliative dermatitis. The vaginal mucosa is a recognized site of inflammation and discomfort consequent to gold therapy (Goodman and Gilman) but a search of the literature reveals such vaginitis has yet to inspire a report of specific therapy.
C.V.MosbyCo.
1. Forestier, J.: Rheumatoid arthritis and its treatment by gold salts, J. Lab. Clin. Med. ZQt 827, 1935. 2. Place, V., and Benson, H.: Local effects of topically applied steroids, J. Steroid Biochem. 6: 717, 1975. 3. Pitkin, R., and Btadbury, J.: The effect of topical estrogen on irradiated vaginal epithelium, AM. J. OBSTET. GYNECOL 92:
175,
lQ65.