677
osteoplastic flap or large craniotomy with contralateral burr holes may be used for drainage of pus and local instillation of antibiotics. In infants pus may be aspirated through the fontanelle. As soon as subdural empyema is suspected the greatest contribution any doctor can make to saving the patient’s life is to organise an immediate diagnostic burr hole and start the patient, when pus is retrieved, on massive antibiotic therapy with penicillin and chloramphenicol. The life will be saved or lost within the first few hours. CUTANEOUS T-CELL LYMPHOMAS Irt Sezary’s syndrome, generalised exfoliative erythroderma is associated with intense pruritus and the presence of abnormal mononuclear cells (Sezary cells) in peripheral bloody Some patients have focal skin lesions as well. The relation between this syndrome and other cutaneous lymphomas has excited great interest. The term cutaneous T-cell lymphomas2 has been coined to describe a group of disorders which have in common infiltration of the skin and/or formation of indurated plaques by neoplastic cells with T-lymphocyte characteristics.2They include Sezary’s syndrome, mycosis fungoides, and lymphomatoid papulosis.2 Other common features are involvement of the T-cell regions of the affected lymph-nodes and relative sparing of the bone-marrow. Sezary’s syndrome has been regarded as a leukæmic form of mycosis fungoides. Sezary cells have a characteristic highly convoluted (cerebriform) nucleus under the electron microscope. Two morphological types have been recognised-a small-cell and a large-cell variant. The small cell has a diploid or near-diploid chromosome complement whilst the large cell is often tetraploid. T-cell markers have been detected in both types,23 although in rare cases the receptors for sheep erythrocytes which are responsible for E-rosette formation are not present on the cell surface.4The small-cell variant of Sezary’s syndrome, often associated with lymphocytosis, commonly may be misdiagnosed as chronic lymphocytic leukaemia (C.L.L.). In classic C.L.L. the lymphocytes have B-cell characteristics, but Brouet et al.5 have described a type of C.L.L. with T-cell features. In T-c.L.L. the lymphoid cells are large and have numerous azurophil granules; such cells are not seen in B-C.L.L. or in Sezary’s syndrome. It is noteworthy that skin lesions seem quite common in T-c.L.L. (4 out of 11 cases in Brouet’s series5) whereas in B-c.L.L. they are rare. Although the skin lesions are histologically different in T-c.L.L. and Sezary’s syndromes (deep dermis in T-c.L.L. and upper dermis and epidermis in Sezary’s), T lymphocytes do home to the skin in both. Labelling with 3H-thymidine shows that Sezary cells proliferate in the skin.6 The lymphoid nature of the Sezary cells was first 1. Winkelmann, R. K., Linman, J. W. Am. J. Med. 1973, 55, 192. 2. Lutzner, M., Edelson, R., Schein, P., Green, I., Kirkpatrick, C., Ahmed, A. Ann. intern. Med. 1975, 83, 534. 3. Brouet, J. C., Flandrin, G., Seligmann, M. New Engl. J. Med. 1973, 289, 341. 4. Braylan, R., Variakojis, D., Yachnin, S. Br. J. Hœmat. 1975, 31, 553. 5 Brouet. J. C., Flandrin, G., Sasportes, G., Preud’homme, J. L., Seligmann, M. Lancet,
1975, ii, 890. van Vloten, W. A. J. Path. 1976, 118, 49.
6. Bosman, F. T.,
by their response in vitro to phytohæmagglutinin;’ however, according to recent work, the proliferative capacity of the Sezary cells in response to mitogens is generally poor.24 Multiple chromosome abnormalities have been found in these cells, but none of them consistently ; these findings, however, suggest that the Sezary cell may be neoplastic. Whether similar cells exist in normal tissues is not known. Morphologically similar cells have been reported in cultures of non-malignant skin8 and in rheumatoid synovial fluid.9 Research on the rare cutaneous T-cell lymphomas has contributed considerably to our understanding of the physiopathology of the T lymphocytes and has also led to a therapeutic innovation in Sezary’s syndrome-leucapheresis by continuous-flow blood-cell separator. Parevealed
tients suitable for this treatment are those with the small-cell variant associated with high peripheral lymphocyte counts.2 Neoplastic T lymphocytes have been removed in large quantities in such patients and, because the cells seem to migrate rapidly between tissues and blood and their proliferation-rate is slow, skin infiltration has been reduced substantially.2 This balance between blood and tissues has also been elegantly displayed in a patient with Sezary’s syndrome who had large spontaneous cyclic fluctuations in the peripheral lymphocyte count; the skin improved considerably when the lymphocyte-count reached its highest, and vice
versa.2 METAL SENSITIVITY
ORTHOPAEDIC surgeons use metallic implants for internal fixation of fractures and for replacement of joints. Corrosion, an early problem, is no longer troublesome but another complication-metal sensitivity-has come to light. Evans et al.l° suggested that loosening of a hip or knee prosthesis after secure fixation in the bone with acrylic cement might sometimes be due to sensitivity of the tissues to one of the metals in the alloy. The commonly used alloys contain cobalt, chrome, and nickel. Laboratory and clinical work11 12 has shown that, when two cobalt/chrome alloy surfaces rub together, cobalt and chrome are released locally, pass into the bloodstream and circulate throughout the tissues of the body, and are finally excreted in the urine. In patients sensitive to metal, the blood-vessels supplying the bone in which the prosthesis is inserted may show obliterative changes; and these result, the theory goes, in death of bone, weakening of the fixation between bone and prosthesis, and consequent loosening. Cobalt, chromium, and nickel can excite skin sensitivity, so patch tests were used to identify patients sensitive to metal. From a total of 14 patients with loose prostheses 9 were metal-sensitive as against none of 24 with stable prostheses. Of the 9 all were sensitive to cobalt and 1 to both cobalt and nickel. Jones et al.13 report similar findings but they sugCrossen, P. E., Mellor, J. E. L., Finley, A. G., Ravich, R. B. M., Vincent, P. C., Gunz, F. W. Am. J. Med. 1971, 50, 25. 8. Flaxman, B. A., van Scott, E. J., Foldman, L. I. Archs Derm. 1974, 109,
7.
577.
Leeuwen, A. W. F. M., Meyer, C. J. L. M., van de Putte, L. B. A., de Vries, E., de Man, J. C. H. Lancet, 1976, i, 248. 10. Evans, E. M., Freeman, M. A. R., Miller, A. J., Vernon-Roberts, B. J. Bone Jt Surg. 1974, 56B, 626. 11. Swanson, S. A. V., Freeman, M. A. R., Heath, J. C. Lancet, 1973, i, 564. 12. Coleman, R. F., Herrington, J., Scales, J. T. Br. med. J. 1973, i, 527. 13. Jones, D. A., Lucas, H. K., O’Driscoll, M., Price, C. H. G., Wibberley, B. J. Bone Jt Surg. 1975, 57B, 289. 9.
van
osteoplastic flap or large craniotomy with contralateral burr holes may be used for drainage of pus and local instillation of antibiotics. In infants pus may be aspirated through the fontanelle. As soon as subdural empyema is suspected the greatest contribution any doctor can make to saving the patient’s life is to organise an immediate diagnostic burr hole and start the patient, when pus is retrieved, on massive antibiotic therapy with penicillin and chloramphenicol. The life will be saved or lost within the first few hours. CUTANEOUS T-CELL LYMPHOMAS Irt Sezary’s syndrome, generalised exfoliative erythroderma is associated with intense pruritus and the presence of abnormal mononuclear cells (Sezary cells) in peripheral bloody Some patients have focal skin lesions as well. The relation between this syndrome and other cutaneous lymphomas has excited great interest. The term cutaneous T-cell lymphomas2 has been coined to describe a group of disorders which have in common infiltration of the skin and/or formation of indurated plaques by neoplastic cells with T-lymphocyte characteristics.2They include Sezary’s syndrome, mycosis fungoides, and lymphomatoid papulosis.2 Other common features are involvement of the T-cell regions of the affected lymph-nodes and relative sparing of the bone-marrow. Sezary’s syndrome has been regarded as a leukæmic form of mycosis fungoides. Sezary cells have a characteristic highly convoluted (cerebriform) nucleus under the electron microscope. Two morphological types have been recognised-a small-cell and a large-cell variant. The small cell has a diploid or near-diploid chromosome complement whilst the large cell is often tetraploid. T-cell markers have been detected in both types,23 although in rare cases the receptors for sheep erythrocytes which are responsible for E-rosette formation are not present on the cell surface.4The small-cell variant of Sezary’s syndrome, often associated with lymphocytosis, commonly may be misdiagnosed as chronic lymphocytic leukaemia (C.L.L.). In classic C.L.L. the lymphocytes have B-cell characteristics, but Brouet et al.5 have described a type of C.L.L. with T-cell features. In T-c.L.L. the lymphoid cells are large and have numerous azurophil granules; such cells are not seen in B-C.L.L. or in Sezary’s syndrome. It is noteworthy that skin lesions seem quite common in T-c.L.L. (4 out of 11 cases in Brouet’s series5) whereas in B-c.L.L. they are rare. Although the skin lesions are histologically different in T-c.L.L. and Sezary’s syndromes (deep dermis in T-c.L.L. and upper dermis and epidermis in Sezary’s), T lymphocytes do home to the skin in both. Labelling with 3H-thymidine shows that Sezary cells proliferate in the skin.6 The lymphoid nature of the Sezary cells was first 1. Winkelmann, R. K., Linman, J. W. Am. J. Med. 1973, 55, 192. 2. Lutzner, M., Edelson, R., Schein, P., Green, I., Kirkpatrick, C., Ahmed, A. Ann. intern. Med. 1975, 83, 534. 3. Brouet, J. C., Flandrin, G., Seligmann, M. New Engl. J. Med. 1973, 289, 341. 4. Braylan, R., Variakojis, D., Yachnin, S. Br. J. Hœmat. 1975, 31, 553. 5 Brouet. J. C., Flandrin, G., Sasportes, G., Preud’homme, J. L., Seligmann, M. Lancet,
1975, ii, 890. van Vloten, W. A. J. Path. 1976, 118, 49.
6. Bosman, F. T.,
by their response in vitro to phytohæmagglutinin;’ however, according to recent work, the proliferative capacity of the Sezary cells in response to mitogens is generally poor.24 Multiple chromosome abnormalities have been found in these cells, but none of them consistently ; these findings, however, suggest that the Sezary cell may be neoplastic. Whether similar cells exist in normal tissues is not known. Morphologically similar cells have been reported in cultures of non-malignant skin8 and in rheumatoid synovial fluid.9 Research on the rare cutaneous T-cell lymphomas has contributed considerably to our understanding of the physiopathology of the T lymphocytes and has also led to a therapeutic innovation in Sezary’s syndrome-leucapheresis by continuous-flow blood-cell separator. Parevealed
tients suitable for this treatment are those with the small-cell variant associated with high peripheral lymphocyte counts.2 Neoplastic T lymphocytes have been removed in large quantities in such patients and, because the cells seem to migrate rapidly between tissues and blood and their proliferation-rate is slow, skin infiltration has been reduced substantially.2 This balance between blood and tissues has also been elegantly displayed in a patient with Sezary’s syndrome who had large spontaneous cyclic fluctuations in the peripheral lymphocyte count; the skin improved considerably when the lymphocyte-count reached its highest, and vice
versa.2 METAL SENSITIVITY
ORTHOPAEDIC surgeons use metallic implants for internal fixation of fractures and for replacement of joints. Corrosion, an early problem, is no longer troublesome but another complication-metal sensitivity-has come to light. Evans et al.l° suggested that loosening of a hip or knee prosthesis after secure fixation in the bone with acrylic cement might sometimes be due to sensitivity of the tissues to one of the metals in the alloy. The commonly used alloys contain cobalt, chrome, and nickel. Laboratory and clinical work11 12 has shown that, when two cobalt/chrome alloy surfaces rub together, cobalt and chrome are released locally, pass into the bloodstream and circulate throughout the tissues of the body, and are finally excreted in the urine. In patients sensitive to metal, the blood-vessels supplying the bone in which the prosthesis is inserted may show obliterative changes; and these result, the theory goes, in death of bone, weakening of the fixation between bone and prosthesis, and consequent loosening. Cobalt, chromium, and nickel can excite skin sensitivity, so patch tests were used to identify patients sensitive to metal. From a total of 14 patients with loose prostheses 9 were metal-sensitive as against none of 24 with stable prostheses. Of the 9 all were sensitive to cobalt and 1 to both cobalt and nickel. Jones et al.13 report similar findings but they sugCrossen, P. E., Mellor, J. E. L., Finley, A. G., Ravich, R. B. M., Vincent, P. C., Gunz, F. W. Am. J. Med. 1971, 50, 25. 8. Flaxman, B. A., van Scott, E. J., Foldman, L. I. Archs Derm. 1974, 109,
7.
577.
Leeuwen, A. W. F. M., Meyer, C. J. L. M., van de Putte, L. B. A., de Vries, E., de Man, J. C. H. Lancet, 1976, i, 248. 10. Evans, E. M., Freeman, M. A. R., Miller, A. J., Vernon-Roberts, B. J. Bone Jt Surg. 1974, 56B, 626. 11. Swanson, S. A. V., Freeman, M. A. R., Heath, J. C. Lancet, 1973, i, 564. 12. Coleman, R. F., Herrington, J., Scales, J. T. Br. med. J. 1973, i, 527. 13. Jones, D. A., Lucas, H. K., O’Driscoll, M., Price, C. H. G., Wibberley, B. J. Bone Jt Surg. 1975, 57B, 289. 9.
van
