Document bOBNVrbxJB95LGGnYROq1pZjO

1654 Unreviewed Reports BRITISH MEDICAL JLMJ.KJV/U. y bWU F acial numbness as presentation of parotid tumour A 68 year old man presented with numbness in the distribution of his right mandibular nerve (3rd division of the trigeminal nerve). Taste and facial movements were normal. On examination there was a firm mass behind the angle of his jaw and a preauricular swelling; a biopsy specimen showed a squamous carcinoma. Tumours of the deep lobe of the parotid gland usually present with local pain or a mass inside the mouth.1 They may infiltrate posteriorly across the base of the skull, but spread to the mandibular nerve has not been reported. A neurilemma of the mandibular nerve is the main dif ferential diagnosis.--R mcr higgins, The Brook Hospital, London SE18 4LW. (Accepted 17 April 1984) Baker DC, CongJey J. Treatment of massive deep lobe parotid tumors. AmJ Surg 1979;138:576-8. . Periorbital oedema caused by nifedipine A 54 year old woman was started on a slow release formulation of nifedipine (Adalat Retard) as her blood pressure was uncontrolled by atenolol 100 mg and bendrofluazide 5 mg daily. After the first dose of nifedipine she developed severe periorbital oedema accom panied by facial flushing, paraesthesiae, headache, and dizziness which lasted six hours, recurring after her next dose. The patient was then given a single dose of 5 mg nifedipine, which caused identical symptoms. Clearly these were due to nifedipine itself and not to the slow release formulation. This side effect has not been reported. '--p H silverstone, Gravesend and North Kent Hospital, Kent DA 11 ODG. (Accepted 17 April 1984) 1 Terry RW. Nifedipine therapy in angina pectoris: evaluation of safety and side effects. Am HeartJ 1982;104:681-9. Magnesium induced neuropathy in patient undergoing haemodialysis A 42 year old woman undergoing regular dialysis developed crippling peripheral neuropathy, unresponsive to extended dialysis time. Her plasma magnesium concentration was 1'85 mmol/1 (4-5 mg/100ml) (normal 0'7-lT mmol/1 (L7-2-7 mg/100 ml)). She was therefore dialysed on magnesium free dialysis fluid, and within a month her symptoms cleared. The neuropathic features reappeared after she was inadvertently dialysed against her usual dialysis fluid (magnesium 0 85 mmol/1 (2T mg/100 ml)). They cleared again, however, with magnesium free dialysis fluid and she remains well. Hypermagnesaemia may have a role in neuropathy in patients undergoing dialysis.1--rasheed ahmad, Sefton General Hospital, Liverpool L15 2HE. {Accepted 30 April 1984) ' 1 Steward WK, Flemming LW, Anderson DC, et al. Proc Eur Dial Transplant Assoc 1967;4:285-92. ./ ' ;. bladder.--t i davidson, r garnham, Mount Vernon Hospital, Northwood, Middx HA6 2RN. {Accepted 30 April 1984) 1 Miggar MS, Kariholu PL, Bhat DN, Fazili F, Yousuf M, Muhajid S. Tuberculosis of gallbladder. J Indian Med Assoc 1980;74:196-7. Mesothelioma due to domestic exposture to asbestos Two sisters, who lived in adjacent mobile homes, developed pleural mesotheliomas. One recovered after undergoing pleurectomy, but in the other the diagnosis was made post mortem. The only history of exposure to asbestos was that both had some years previously cleaned an outhouse roof made of corrugated white asbestos cement to remove moss growth. This was done as a dry process (with a wire brush and paint scraper) and without wearing masks, and the roof was described afterwards as "lovely and white." Exposure to asbestos on domestic premises may constitute an un recognised hazard.--G C FERGUSON, H WATSON, Northampton General Hospital, Northampton NN1 5BD. {Accepted 9 May 1984) Inaccurate home blood sugar monitoring in Raynaud's syndrome A 43 year old man with chronic pancreatitis had poorly controlled insulin dependent diabetes despite good motivation and finger prick monitoring at home with a Hypocount meter. On three occasions metered finger prick samples indicated hypoglycaemia (T9,0'2,0 6 mmol/1 (34, 3-6, 11 mg/100 ml)), but his only symptoms were of mild Raynaud's syndrome. Glucose concentrations in earlobe and venous blood were in the normal range (4-1,3'6,4'9 mmol/1 (74,65, 88 mg/100 ml)), and no subsequent earlobe blood showed any disparity with simultaneous venous samples. Raynaud's syndrome may cause intermittently falsely low finger prick sugar concentra tions; this should be considered if therapeutic decisions are safely to be based on the results of metered non-venous samples.--J E macsweeney, a forbes, Middlesex Hospital, London WIN 8AA. {Accepted 10 May 1984) No link between acute pericarditis and HLA factors Acute pericarditis is usually idiopathic or viral. It may also be secondary to various other diseases.1 HLA factors help in modu lating immune responses and may be important in determining susceptibility to viral infections. We studied 29 men and nine women with viral or idiopathic acute pericarditis. They were typed for 12 HLA-A, 20 HLA-B, and 5 HLA-C antigens. The distribution of antigens was compared with that found in normal healthy in dividuals. No significant differences were found; this excludes any strong association between known HLA-ABC factors and non specific viral or idiopathic acute pericarditis.--reinhold bartraM, County Central Hospital of Frederiksborg, Denmark, ARNE SVEJGaard, State University Hospital, Copenhagen Denmark, etal. (Accepted 14 May 1984) Tuberculosis in a functioning gall bladder Of the 49 reported cases of tuberculous cholecystitis; gall stones were present in 46 and cystic duct obstruction in the rest.- The resistance of the intact gall bladder to tuberculous infection has been attributed to bile acid concentration sufficient to inhibit growth of tubercle bacilli.1 A 48 year old Asian woman resident in the UK for nine years was investigated for chronic cholecystitis. Oral cholecystogram and ultrasonogram were normal,- but because of persistent symptoms laparotomy was performed and a thick walled gall bladder removed. Histology confirmed tuberculosis witlvacid fast bacilli. Tuberculosis may- thus occur -in a-functioning gall 1 Shabetai R. The pericardium. New York: Grune and Stratton Inc, 1981: 108-53 and 348-65. - 1. - ; "Unreviewed Reports" aims at publishing very brieffindings quickly, without the usual external peer review. Each item should be no more - than lOQ words long, with a title of up to 10 words, only one reference, -and no more than two named authors (et al ls allowed). Authors of . - papers about side effects must have reported them to the Committee on ?: Safety ofMedicines and themanufacturers. Correspondence asking for ' further details about these items should be sent directly to the authors, who should be willing to supply answers.: , ; ;; THT BRITISH MEDICAL JOURNAL VOLUME 289 14 JULY 1984 establishing the diagnosis of hyaline membrane disease. . This conclusion differs from findings that we have published based on 295 infants,1 in which the lecithin :sphingomyelin ratio measured on pharyngeal secretions obtained within six hours of birth identified babies with hyaline membrane disease (figure).2 3 80 s S 7-0- E 60 aw. 5-0 c k B .y* problems Hyaline membrane disease Controls ns 50 Mean 2-8 (SD) (MJ` 64 (0-5) 181 (1-2) Comparisons of pharyngeal lecithin :sphingomyelin ratio in babies with mixed respiratory problems (transient tachypnoea and pneumonia), hyaline membrane disease, and controls. There is a signi ficant difference in the proportion of immature lecithin :sphingomyelin ratios (< 1-8) between infants with hyaline membrane disease and those with mixed respiratory disorders (48/64:6/50, X2=44-6,p< 0-0001). There was a highly significant difference in the proportion of immature lecithin sphingo myelin ratios (< 1-8) between infants with hyaline membrane disease and those with other respiratory disorders (predominantly ^transient tachypnoea and pneumonia) (p< 0-0001). A lecithin sphingomyelin ratio of <1-8 detected 75% (48 out of 64) of cases of hyaline membrane disease with a false positive rate of 3% (eight out of 231). Thus the sensitivity of the test is 75% and the specificity is 97% (223/231).1 It is not always possible to assign a respiratory diagnosis with certainty to a newborn infant managed on intermittent positive pressure ventilation from birth since this treatment frequently obscures both clinical and radiological diagnostic features. In such infants a measurement of pulmonary surfactant is of particular value in supporting the clinical diagnosis. It is unacceptable, in our view, however, to include such babies in any study aiming at evaluating the diagnostic reliability of a test of surfactant status. It is not clear how many babies in Dr James's series labelled as having hyaline membrane disease or congenital pneumonia were in fact ventilated from birth. None of the 64 infants independently identified as having hyaline membrane disease in our series were on intermittent positive pressure ventilation from birth onwards. The lecithin :sphingomyelin ratio is ideally suited for confirming the comparability of Before either the diagnosis or aetiology can infants randomly allocated to trials ofsurfactant be accepted, however, further information is therapy,5 high frequency ventilation (un required. Was the diagnosis confirmed in published results), and other treatments. We both cases by a pathologist with particular cannot agree with the conclusion of Dr James experience in mesothelioma histology ? In a and colleagues that pulmonary surfactant recent review of cases diagnosed as meso deficiency is unreliable in establishing the thelioma by local pathologists in the USA, only diagnosis of hyaline membrane disease. 26% could be accepted as definite, probable, or even possible by a member of the meso P A Jenkins thelioma reference panel.1 The importance of W Tarnow-Mordi accurate diagnosis is underlined by the pro J D Baum' longed survival of one of the sisters after Department of Paediatrics, John Radcliffe Hospital, Oxford 0X3 9DU pleurectomy, as surgery has rarely been found to influence survival of patients with diffuse mesothelioma. * Jenkins PA, Baum JD. Respiratory distress syndrome. In: Wald NJ, ed. Antenatal arid neonatal screening. Oxford: Oxford University Press, 1984:298-313. * Gluck L, Kulovich MV, Borer RC, Brenner PH, Anderson CG, Spellacy WN. Diagnosis of the respiratory distress syndrome by amniocentesis. Am 3 Obstet Gynecol 1971;109:440-5. 3 Barr PA, Jenkins PA, Baum JD. Lecithin/sphingo myelin ratio in hypopharyngeal aspirate of newborn infants. Arch Dis Child 1975;50:856-61. 3 Anonymous. Glossary of terms. In: Wald NJ, ed. Antenatal and neonatal screening. Oxford: Oxford University Press, 1984:552-4. 3 Wilkinson AR, Jeffrey JA, Jenkins PA. Controlled trials of dry surfactant in preterm infants. Arch Dis Child 1982;57:802. Dr Ferguson and Dr Watson suggest that the mesotheliomas arose from wire brushing of a white asbestos cement roof. This is to ignore the strong epidemiological evidence now accumulating that chrysotile, as distinct from amphibole asbestos, plays little or no part in mesothelioma aetiology. Acheson and Gardner in their 1983 report to the UK Health and Safety executive stated; "Subsequent evidence has supported our previous view that peritoneal mesothelioma for practical purposes never, and pleural mesothelioma rarely, has occurred in man in relation to exposure to chrysotile Treatment of myopia alone."3 Was a microscopic study of the lung fibre burden carried out in the fatal case ? Sir,--I want to try to correct some of the exaggeration of Mr Thomas Stuart-Black Kelly's letter (2 June, p 1692). Firstly, myopia is not a disease and cannot be regarded as anything more than an error of refraction except in its higher degrees, when there may indeed be retinal and other complications. It is the fundus changes rather than the degree In 1976 Milne reported the cases of two sisters living in Australia who died of meso thelioma in which most careful questioning failed to find any exposure to asbestos.1 For most of us nowadays some casual contact with asbestos is inevitable. But post hoc does not always mean propter hoc, and not all cases of mesothelioma are due to exposure to asbestos. of myopia that is the disease, and although only likely with errors in excess of 7 dioptres (a small minority of myopes) such changes Cape Industries Ltd, London W1Y 4AB Kevin Browne can be absent in higher myopes and can occur in low myopes or rarely hypermetropes. Secondly, myopia is a useful condition, TBA Industrial Products Ltd, Rochdale, Lancs OL12 7EQ T Goffe especially for ophthalmic surgeons or others doing fine, close work. Myopes come into their own in middle age when others need reading glasses. Finally, the rationale of Mr Kelly's alter native medicine is that bifocals will abolish the need for the growing child to accommodate --that is, to hinder a most useful function of the eye which has not been proved to be a cause of high myopia. All I would advise is 1 Browne K. Asbestos-related mesothelioma: epidemio logical evidence for asbestos as a promoter. Arch Environ Health 1983;38:261-6. * Wright WE, Sherwin RP, Dickson EA, Bernstein L, Fromm JB, Henderson BE. Malignant mesothelioma: incidence, asbestos exposure, and reclassification of histopathology. BrJ IndMed 1984;41:39-45. 3 Acheson ED, Gardner MJ. Asbestos: the control limit for asbestos. London: HMSO, 1983. * Milne JEH. Thirty two cases of mesothelioma in Victoria, Australia: a retrospective survey related to occupational asbestos exposure. Br J Ind Med 1976;33:115-22. that the growing child wears the normal correction for his myopia so that he sees the *,*Dr Ferguson and Dr Watson reply below. blackboard clearly and does not screw up his --Ed, BMJ. eyes. Also, so that he does not bury his nose in his book, he should wear the glasses even for reading, thereby building up the normal relation between convergence and accommoda tion. Otherwise exophoria or divergent strabismus may ensue. . John Primrose Sir,--Lack of space prevented us from stating that the relation between asbestos exposure and the development of mesothelioma in these two sisters had not been definitely established, particularly because a study of the lung fibre Ilford, Essex burden was not carried out in the fatal case. . , ,. In: both of our cases the diagnosis of mesothelioma was made by our consultant pathologists, and reference to the failure of Mesothelioma due to domestic exposure local American pathology services to diagnose to asbestos ; - T this condition correctly may not be appropriate. We would, of course, be happy to arrange for Sir,--The unreviewed report by Dr G C histological slides from these cases to be Ferguson and Dr H Watson (2 June, p 1654) submitted to any reference pathologist. of two sisters who both developed pleural ? Prolonged survival with or without surgery mesotheliomas is of considerable - interest; does not rule out mesothelioma--Law et al Several occurrences of two or more cases of . found two patients who survived up to eight mesothelioma within the nuclear family have years from diagnosis.1 The basic question is been reported, and this is probably not simply whether short term heavy non-occupational due to a shared source of asbestos exposure.1.! exposure/to asbestos is a causative factor in dr. Meet, r