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VINDESINE FOR PSORIASIS?
773
Symptoms in relation to start and end of treatment with erythromycin or placebo in contacts of whooping-cough cases. C = cough; S = spasms of coughing; W = whoop; A = diagnosis of whoopingcough by GP; D = disturbed sleep; V = vomiting.
trial onset. 2 contacts acquired clinical whooping-cough (cough with spasmodic bouts and whoop) despite erythromycin, and 1 of these was experiencing minor symptoms when the trial began. In 3 others, spasmodic cough without whoop developed. B. pertussis was isolated from 2 contacts, 1 after receiving erythromycin for 10 days, the other at the start of erythromycin treatment in a contact (the twin of a culture-positive case) who remained symptom-free. Symptoms worsened in several contacts after erythromycin was discontinued. It is possible that symptoms were delayed by the antibiotic, although such a pattern is compatible also with the natural course of pertussis. We conclude that chemoprophylaxis, even if effective, is likely to have limited application as a community control measure; there may be no household contacts at risk or they may already have the disease. It appears, also, that erythromycin is not a reliable method of preventing pertussis in household contacts, and that chemoprophylaxis, even if a successful method could be established, is unlikely to be of general value in the community. Further study is needed to determine its possible role in closed communities where a case may be rapidly identified and treatment started quickly. Failure of erythromycin prophylaxis and treatment has recently been documented elsewhere.3 We thank Dr P. Freeling, St. George’s Hospital Medical School; Dr D. W. Gau, Middlesex Hospital Medical School; Dr D. G. Fleck, St. George’s Hospital; and Dr D. A. Leigh, High Wycombe General Hospital for their help; all the general practitioners and health visitors who did the field work; and
Abbott Laboratories for providing Communicable Diseases Unit, St George’s Hospital, London SW17 0QT
10% of the body surface, and topical steroids, tar preparations, and intralesional steroids had been tried. When seen here, he had psoriatic involvement of approximately 10% body surface, including scalp, gluteal folds, fingers, and navel; he also displayed oncholysis. Especially disturbing to the patient were the itching scalp lesions. He was put on vindesine, within a phase II study for treatment of the lung cancer. He received 2 0 mg/m2and 1 0 mg/mbody surface area by intravenous push on two consecutive days every week. In 4 weeks, after four courses of the vindesine treatment, he reported remarkably decreased itching, which was followed by gradual disappearance of all visible signs of psoriasis by the fifth month on this regimen. He has been in complete remission of his psoriatic lesions for 6 months to date, though vindesine treatment was discontinued 4 months ago. Although spontaneous disappearance of psoriasis cannot be ruled out1 the finding of complete remission of psoriasis resistant to standard treatment in a cancer patient treated with vindesine suggests that this drug should be clinically evaluated in severe and resistant
psoriasis. Cancer Research and Treatment Center and Department of Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico 87131, U.S.A.
ROBERT HARDI MILAN SLAVIK
CULTURED THYMUS FRAGMENT TRANSPLANT IN CHRONIC CANDIDIASIS COMPLICATED BY ORAL CARCINOMA mucocutaneous candidiasis is characterised by a candida infection of the mucous membranes, scalp, skin, persistent and nails, often associated with endocrinopathy. The defect probably involves the T-cell system. Most tests of specific immune function are associated with lack of responsiveness to candida antigens. When stimulated by candida, the patient’s mononuclear cells usually fail to proliferate and do not generate migration inhibitory factor.2We have seen a patient with an 18-year history of chronic mucocutaneous candidiasis, complicated by Addison’s disease and an intraoral verrucous carcinoma. At the time of radical excision of his tumour, he received a transplant of cultured thymic fragments (CTF).3Now, nearly 3 years later, he remains free of cancer and has acquired in vitro responsivity to candida antigens. Mucocutaneous candidiasis was noted at age 16; a year later, Addison’s disease supervened. Despite transfer factor, ampho-
SIR,—Chronic
erythromycin and placebo. MARY SPENCELY H. P. LAMBERT
VINDESINE FOR PSORIASIS?
1. Lennard TWJ, Lennard AL. Spontaneous disappearance of psoriasis as presenting feature of oat cell carcinoma of the lung. Br Med J 1980; 281: 1460-61. 2. Kirkpatrick CA, Rich RR, Bennett JE. Chronic mucocutaneous candidiasis: Model building in cellular immunity. Ann Intern med 1971; 74: 955-78. 3. Hong R, Schulte-Wissermann H, Horowitz SD. Thymic transplantation for relief of disease. Surg Clin North Am 1979; 59: 299-312
immunodeficiency
SIR,—Many cytotoxic agents (azauridine triacetate, azathioprine, razoxane, 6-mercaptopurine, methotrexate, mycophenolic acid, and nitrogen mustard) have been found useful in the treatment of severe
psoriasis resistant
to other therapy. To our knowledge vinca alkaloids have not been tried in this disease. A patient of ours was treated with vindesine for adenocarcinoma of the lung; his longstanding psoriasis showed dramatic improvement. Vindesine has significant activity in a wide range of malignancies, and it has less bone marrow toxicity than vinblastine and is less neurotoxic than eincristine. A 77-year-old man was referred here in December, 1979, for avestigation of suspicious lung lesions noticed on routine chest X-ray. Primary adenocarcinoma of the lung was diagnosed. The rstient had had psoriasis for about 10 years, at times affecting up to
Halsey; XA, Welling MA, Lehman RM. Nosocomial pertussis: a failure of erythromycin treatment and prophylaxis. Am,7J Dis Child 1980; 134: 521-22.
Fungating lesion in right buccal space.
Symptoms in relation to start and end of treatment with erythromycin or placebo in contacts of whooping-cough cases. C = cough; S = spasms of coughing; W = whoop; A = diagnosis of whoopingcough by GP; D = disturbed sleep; V = vomiting.
trial onset. 2 contacts acquired clinical whooping-cough (cough with spasmodic bouts and whoop) despite erythromycin, and 1 of these was experiencing minor symptoms when the trial began. In 3 others, spasmodic cough without whoop developed. B. pertussis was isolated from 2 contacts, 1 after receiving erythromycin for 10 days, the other at the start of erythromycin treatment in a contact (the twin of a culture-positive case) who remained symptom-free. Symptoms worsened in several contacts after erythromycin was discontinued. It is possible that symptoms were delayed by the antibiotic, although such a pattern is compatible also with the natural course of pertussis. We conclude that chemoprophylaxis, even if effective, is likely to have limited application as a community control measure; there may be no household contacts at risk or they may already have the disease. It appears, also, that erythromycin is not a reliable method of preventing pertussis in household contacts, and that chemoprophylaxis, even if a successful method could be established, is unlikely to be of general value in the community. Further study is needed to determine its possible role in closed communities where a case may be rapidly identified and treatment started quickly. Failure of erythromycin prophylaxis and treatment has recently been documented elsewhere.3 We thank Dr P. Freeling, St. George’s Hospital Medical School; Dr D. W. Gau, Middlesex Hospital Medical School; Dr D. G. Fleck, St. George’s Hospital; and Dr D. A. Leigh, High Wycombe General Hospital for their help; all the general practitioners and health visitors who did the field work; and
Abbott Laboratories for providing Communicable Diseases Unit, St George’s Hospital, London SW17 0QT
10% of the body surface, and topical steroids, tar preparations, and intralesional steroids had been tried. When seen here, he had psoriatic involvement of approximately 10% body surface, including scalp, gluteal folds, fingers, and navel; he also displayed oncholysis. Especially disturbing to the patient were the itching scalp lesions. He was put on vindesine, within a phase II study for treatment of the lung cancer. He received 2 0 mg/m2and 1 0 mg/mbody surface area by intravenous push on two consecutive days every week. In 4 weeks, after four courses of the vindesine treatment, he reported remarkably decreased itching, which was followed by gradual disappearance of all visible signs of psoriasis by the fifth month on this regimen. He has been in complete remission of his psoriatic lesions for 6 months to date, though vindesine treatment was discontinued 4 months ago. Although spontaneous disappearance of psoriasis cannot be ruled out1 the finding of complete remission of psoriasis resistant to standard treatment in a cancer patient treated with vindesine suggests that this drug should be clinically evaluated in severe and resistant
psoriasis. Cancer Research and Treatment Center and Department of Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico 87131, U.S.A.
ROBERT HARDI MILAN SLAVIK
CULTURED THYMUS FRAGMENT TRANSPLANT IN CHRONIC CANDIDIASIS COMPLICATED BY ORAL CARCINOMA mucocutaneous candidiasis is characterised by a candida infection of the mucous membranes, scalp, skin, persistent and nails, often associated with endocrinopathy. The defect probably involves the T-cell system. Most tests of specific immune function are associated with lack of responsiveness to candida antigens. When stimulated by candida, the patient’s mononuclear cells usually fail to proliferate and do not generate migration inhibitory factor.2We have seen a patient with an 18-year history of chronic mucocutaneous candidiasis, complicated by Addison’s disease and an intraoral verrucous carcinoma. At the time of radical excision of his tumour, he received a transplant of cultured thymic fragments (CTF).3Now, nearly 3 years later, he remains free of cancer and has acquired in vitro responsivity to candida antigens. Mucocutaneous candidiasis was noted at age 16; a year later, Addison’s disease supervened. Despite transfer factor, ampho-
SIR,—Chronic
erythromycin and placebo. MARY SPENCELY H. P. LAMBERT
VINDESINE FOR PSORIASIS?
1. Lennard TWJ, Lennard AL. Spontaneous disappearance of psoriasis as presenting feature of oat cell carcinoma of the lung. Br Med J 1980; 281: 1460-61. 2. Kirkpatrick CA, Rich RR, Bennett JE. Chronic mucocutaneous candidiasis: Model building in cellular immunity. Ann Intern med 1971; 74: 955-78. 3. Hong R, Schulte-Wissermann H, Horowitz SD. Thymic transplantation for relief of disease. Surg Clin North Am 1979; 59: 299-312
immunodeficiency
SIR,—Many cytotoxic agents (azauridine triacetate, azathioprine, razoxane, 6-mercaptopurine, methotrexate, mycophenolic acid, and nitrogen mustard) have been found useful in the treatment of severe
psoriasis resistant
to other therapy. To our knowledge vinca alkaloids have not been tried in this disease. A patient of ours was treated with vindesine for adenocarcinoma of the lung; his longstanding psoriasis showed dramatic improvement. Vindesine has significant activity in a wide range of malignancies, and it has less bone marrow toxicity than vinblastine and is less neurotoxic than eincristine. A 77-year-old man was referred here in December, 1979, for avestigation of suspicious lung lesions noticed on routine chest X-ray. Primary adenocarcinoma of the lung was diagnosed. The rstient had had psoriasis for about 10 years, at times affecting up to
Halsey; XA, Welling MA, Lehman RM. Nosocomial pertussis: a failure of erythromycin treatment and prophylaxis. Am,7J Dis Child 1980; 134: 521-22.
Fungating lesion in right buccal space.