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VARICOCELE
461
VARICOCELE SlR,-Your leading article of Aug. 25 reopens some questions which I think have been answered already. In the paper of mine quoted,1 I suggested that a varicocele acts as a radiator at body temperature which follows the movements of the testes and thus disturbs local thermoregulation. This would explain why a unilateral varicocele usually affects spermatogenesis in both testes since all these structures are very close together in the scrotum. It has always been my impression that the contraction and relaxation of the scrotum, and the movements of the testes away from the mass of the body or closer to it, are at least as " " important for testicular thermoregulation as the pre-cooling of the arterial blood-supply. Hence the wearing of any support, even a ventilated one, would be undesirable since it would still interfere with these mechanisms. In the same paper a few cases are quoted, and I have seen many since, in which the abandoning of a scrotal support resulted in improvement of the semen. I was a little puzzled by your statement that subfertility is only found in longstanding cases of varicocele. There is evidence that varicoceles usually make their appearance at or soon after puberty. Since most semen analyses are carried out on married men it would seem that many of the cases in question must have had their varicoceles for a number of years, and one would need to define the term longstanding
closely. Certainly experience
more
shows that many men in their early or not wear a scrotal support can already be subfertile because of their varicoceles, and may recover if they are treated, either by the general measures I discussed in my paper, or by surgery.
middle twenties who do
London,
H. A. DAVIDSON.
W.1.
PHENOLPHTHALEIN REACTION SIMULATING DISSEMINATED (SYSTEMIC) LUPUS ERYTHEMATOSUS the SIR,-In following case a diagnosis of disseminated lupus erythematosus (D.L.E.) was made but subsequent events
refuted it.
A 62-year-old lady was admitted to the ward as an emergency. The general practitioner’s diagnosis was D.L.E., which was confirmed clinically in the ward. She had a four weeks’ history of a rash which did not itch, blister, or change in distribution. For 3 weeks she had had joint pains predominantly in both knees, and a swinging temperature for one week. She felt generally unwell; her appetite was poor, She was constipated, but micturition and sleep were unaffected. No history of any drug being taken was recorded-but she was not specifically asked about laxatives at the time. One year previously she had had a similar episode lasting one week. She did not look ill but she had a temperature of 101.2F, and an extensive maculopapular rash, most prominent on the anterior aspects of both thighs, forearms, and abdomen. In places macules had become confluent, but, when discrete, measured 0-5-2 cm. in diameter; they were symmetrically distributed, pink, with irregular edges. Itching was especially severe over the medial aspects of both thighs. There was no scaling vesiculation or ulceration. A faint pericardial rub was heard over the left sternal edge. The heart was of normal size, and there was no murmur. Pulserate was 96, and blood-pressure 100/60 mm. Hg. Both knee-joints were tender, and movements were restricted by pain, but there was no joint swelling. No other joints were affected. A diagnosis of disseminated lupus erythematosus was made and the patient was treated with bed rest and soluble aspirin. On admission her haemoglobin was 69%, packed-cell volume 33%, and white cell-count 6100 per c. mm. Neutro1.
Practitioner, 1954, 173, 783.
phils 62%, lymphocytes 39%, basophils 1%, monocytes 6%, eosinophils 2%. E.S.R. 32 mm. per hr. Anti-streptolysin titre 80 Todd units. Rose and latex tests negative. No L.E. cells, total protein 5-9 g. per 100 ml. (albumin 3-9, globulin 2.0). Electrophoresis normal. Serum-calcium 9-1mg. per 100 ml. The urine, electrocardio-
X-rays of chest and knee-joints were within normal limits. At the end of a week all signs and symptoms had disappeared, but the rash and joint pains suddenly reappeared on the eighth day of admission, although the pericardial rub did not. It was then noticed that all her initial investigations were normal, and that there was no real evidence for D.L.E. or any other collagen disease such as rheumatoid arthritis or polyarteritis nodosa. On further investigation the patient said she had been constipated the previous day and took her usual laxative, which she had been taking for years. This laxative was ’Brooklax’, containing phenolphthalein and chocolate. When the rash had again settled, the patient was given a test dose of P.A.P. (phenolphthalein in paraffin emulsion). This was followed by a recurrence of the rash and joint pains, confirming the diagnosis of phenolphthalein hypersensitivity. Phenolphthalein is a constituent of many proprietary laxatives and is used in vast amounts. It is known to give two types of reaction: (a) excessive purgation followed by abdominal colic, palpitation, and occasionally collapse; and (b) various skin rashes.1 These eruptions are usually polychromatic, ranging from pink to purple. They may be localised or generalised macular plaques varying in size from a few millimetres to several centimetres. There is often severe itching and burning, producing vesiculation and ulceration. Lesions often leave a residual pigmentation. If the drug is taken again, the rash appears in the same sites as before and because of this is described as gram, and
"
fixed drug reaction." Generalised systemic effects are very rare. Weiss et awl.2 reported a patient who had prominent systemic reactions and developed a generalised bluish-black pigmentation. Other abnormalities are vesicles or superficial ulcerations on the mouth, or skin of genitals,l and subungual discoloration.33 Systemic reactions are probably rare because of the poor absorption of phenolphthalein and the greater cathartic action preventing excessive absorption.45 Drug eruptions with systemic reactions and a clinical picture identical to systemic lupus erythematosus have, however, been described in relation to other drugs-e.g., hydrallazine 6and occasionally penicillin.g In our patient there was obviously a hypersensitivity reaction producing the malaise, pyrexia, rash, joint pains, and pericardial rub. All these symptoms settled fairly rapidly on stopping the drug, but flared up immediately on taking the drug again. There were three unusual features: first, that she should have taken such a long time (several a
develop her hypersensitivity to phenolphthalein; the second, apparent remission between her first attack 1 year ago and her present one; and third, at no stage did she have a raised eosinophil count. My thanks are due to Dr. L. Beilin, of King’s College Hospital, and Dr. M. Feiwel, of St. Mary’s Hospital for their constructive criticism; and to Dr. R. J. Harrison for permission to record this case. Westminster Hospital, K. J. B. LEWIN. London, S.W.1.
years)
to
Wise, F., Abramowitz, E. W. Arch. Derm. Syph. 1922, 5, 297. Weiss, R. S., Kile, R. ibid. 1935, 32, 915. Campbell, J. G. Brit. J. Derm. 1931, 43, 186. Blatt, M. L., Steigmann, F., Dyniewiez, J. M. P. J. Pediat. 1943, 22, 719. Fantus, I. B., Phyniewicz, J. M. J. Amer. med. Ass. 1938, 110, 796. 6. Dunstan, H. P., Taylor, R. D., Corcoran, A. C. ibid. 1954, 154, 41. 7. Perry, M., jr., Shroeder, A. H. ibid. p. 670. 8. Symmers, W. St. C. Proc. R. Soc. Med. 1962, 5, 20.
1. 2. 3. 4. 5.
VARICOCELE SlR,-Your leading article of Aug. 25 reopens some questions which I think have been answered already. In the paper of mine quoted,1 I suggested that a varicocele acts as a radiator at body temperature which follows the movements of the testes and thus disturbs local thermoregulation. This would explain why a unilateral varicocele usually affects spermatogenesis in both testes since all these structures are very close together in the scrotum. It has always been my impression that the contraction and relaxation of the scrotum, and the movements of the testes away from the mass of the body or closer to it, are at least as " " important for testicular thermoregulation as the pre-cooling of the arterial blood-supply. Hence the wearing of any support, even a ventilated one, would be undesirable since it would still interfere with these mechanisms. In the same paper a few cases are quoted, and I have seen many since, in which the abandoning of a scrotal support resulted in improvement of the semen. I was a little puzzled by your statement that subfertility is only found in longstanding cases of varicocele. There is evidence that varicoceles usually make their appearance at or soon after puberty. Since most semen analyses are carried out on married men it would seem that many of the cases in question must have had their varicoceles for a number of years, and one would need to define the term longstanding
closely. Certainly experience
more
shows that many men in their early or not wear a scrotal support can already be subfertile because of their varicoceles, and may recover if they are treated, either by the general measures I discussed in my paper, or by surgery.
middle twenties who do
London,
H. A. DAVIDSON.
W.1.
PHENOLPHTHALEIN REACTION SIMULATING DISSEMINATED (SYSTEMIC) LUPUS ERYTHEMATOSUS the SIR,-In following case a diagnosis of disseminated lupus erythematosus (D.L.E.) was made but subsequent events
refuted it.
A 62-year-old lady was admitted to the ward as an emergency. The general practitioner’s diagnosis was D.L.E., which was confirmed clinically in the ward. She had a four weeks’ history of a rash which did not itch, blister, or change in distribution. For 3 weeks she had had joint pains predominantly in both knees, and a swinging temperature for one week. She felt generally unwell; her appetite was poor, She was constipated, but micturition and sleep were unaffected. No history of any drug being taken was recorded-but she was not specifically asked about laxatives at the time. One year previously she had had a similar episode lasting one week. She did not look ill but she had a temperature of 101.2F, and an extensive maculopapular rash, most prominent on the anterior aspects of both thighs, forearms, and abdomen. In places macules had become confluent, but, when discrete, measured 0-5-2 cm. in diameter; they were symmetrically distributed, pink, with irregular edges. Itching was especially severe over the medial aspects of both thighs. There was no scaling vesiculation or ulceration. A faint pericardial rub was heard over the left sternal edge. The heart was of normal size, and there was no murmur. Pulserate was 96, and blood-pressure 100/60 mm. Hg. Both knee-joints were tender, and movements were restricted by pain, but there was no joint swelling. No other joints were affected. A diagnosis of disseminated lupus erythematosus was made and the patient was treated with bed rest and soluble aspirin. On admission her haemoglobin was 69%, packed-cell volume 33%, and white cell-count 6100 per c. mm. Neutro1.
Practitioner, 1954, 173, 783.
phils 62%, lymphocytes 39%, basophils 1%, monocytes 6%, eosinophils 2%. E.S.R. 32 mm. per hr. Anti-streptolysin titre 80 Todd units. Rose and latex tests negative. No L.E. cells, total protein 5-9 g. per 100 ml. (albumin 3-9, globulin 2.0). Electrophoresis normal. Serum-calcium 9-1mg. per 100 ml. The urine, electrocardio-
X-rays of chest and knee-joints were within normal limits. At the end of a week all signs and symptoms had disappeared, but the rash and joint pains suddenly reappeared on the eighth day of admission, although the pericardial rub did not. It was then noticed that all her initial investigations were normal, and that there was no real evidence for D.L.E. or any other collagen disease such as rheumatoid arthritis or polyarteritis nodosa. On further investigation the patient said she had been constipated the previous day and took her usual laxative, which she had been taking for years. This laxative was ’Brooklax’, containing phenolphthalein and chocolate. When the rash had again settled, the patient was given a test dose of P.A.P. (phenolphthalein in paraffin emulsion). This was followed by a recurrence of the rash and joint pains, confirming the diagnosis of phenolphthalein hypersensitivity. Phenolphthalein is a constituent of many proprietary laxatives and is used in vast amounts. It is known to give two types of reaction: (a) excessive purgation followed by abdominal colic, palpitation, and occasionally collapse; and (b) various skin rashes.1 These eruptions are usually polychromatic, ranging from pink to purple. They may be localised or generalised macular plaques varying in size from a few millimetres to several centimetres. There is often severe itching and burning, producing vesiculation and ulceration. Lesions often leave a residual pigmentation. If the drug is taken again, the rash appears in the same sites as before and because of this is described as gram, and
"
fixed drug reaction." Generalised systemic effects are very rare. Weiss et awl.2 reported a patient who had prominent systemic reactions and developed a generalised bluish-black pigmentation. Other abnormalities are vesicles or superficial ulcerations on the mouth, or skin of genitals,l and subungual discoloration.33 Systemic reactions are probably rare because of the poor absorption of phenolphthalein and the greater cathartic action preventing excessive absorption.45 Drug eruptions with systemic reactions and a clinical picture identical to systemic lupus erythematosus have, however, been described in relation to other drugs-e.g., hydrallazine 6and occasionally penicillin.g In our patient there was obviously a hypersensitivity reaction producing the malaise, pyrexia, rash, joint pains, and pericardial rub. All these symptoms settled fairly rapidly on stopping the drug, but flared up immediately on taking the drug again. There were three unusual features: first, that she should have taken such a long time (several a
develop her hypersensitivity to phenolphthalein; the second, apparent remission between her first attack 1 year ago and her present one; and third, at no stage did she have a raised eosinophil count. My thanks are due to Dr. L. Beilin, of King’s College Hospital, and Dr. M. Feiwel, of St. Mary’s Hospital for their constructive criticism; and to Dr. R. J. Harrison for permission to record this case. Westminster Hospital, K. J. B. LEWIN. London, S.W.1.
years)
to
Wise, F., Abramowitz, E. W. Arch. Derm. Syph. 1922, 5, 297. Weiss, R. S., Kile, R. ibid. 1935, 32, 915. Campbell, J. G. Brit. J. Derm. 1931, 43, 186. Blatt, M. L., Steigmann, F., Dyniewiez, J. M. P. J. Pediat. 1943, 22, 719. Fantus, I. B., Phyniewicz, J. M. J. Amer. med. Ass. 1938, 110, 796. 6. Dunstan, H. P., Taylor, R. D., Corcoran, A. C. ibid. 1954, 154, 41. 7. Perry, M., jr., Shroeder, A. H. ibid. p. 670. 8. Symmers, W. St. C. Proc. R. Soc. Med. 1962, 5, 20.
1. 2. 3. 4. 5.