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SLE precipitated by antibiotics in Sjdgren's syndrome

BRITISH MEDICAL JOURNAL

21 FEBRUARY 1976

Only one patient with apparently localised may have been due to the fact that in that disease had a high value. It appears that the study pyridoxine was omitted from the commeasurement of calcitonin may have important mercially available tablet. Our own results SIR,-In his letter (17 January, p 152) about diagnostic, therapeutic, and prognostic indica- suggest that pyridoxine does not detract from the recent article on this subject by my tions as a marker in breast cancer. the antidepressant properties of L-tryptophan. colleagues and myself (15 November, p 385) We thank Mr Jack Desty of Cambrain Chemicals Dr J R Sewell makes four main points: (1) Our OMEGA L SILVA Ltd for supplying the L-tryptophan tablest (Opticase of systemic lupus erythematosus (SLE) KENNETH L BECKER max) and other trial materials and we are grateful to the other staff members of our department for did not meet current diagnostic criteria for Veterans Administration Hospital their co-operation. and George Washington University, SLE; (2) neither LE cells, abnormalities in Washington DC BAPUJI RAO DNA binding, nor pericarditis are specific to A D BROADHURST SLE; (3) the abnormalities in DNA binding Silva, 0 L, Chisholm, R C, and Becker, K L, Clinical Research, 1975, 28, 596A. we reported might have been due to treatment West Suffolk Hospital, Bury St Edmunds, Suffolk with an anti-inflammatory drug; and (4) the patient's second disease exacerbation was a IJensen, K, et al, Lancet, 1975, 2, 920. 2 Clinical Psychiatry Committee of the Medical consequence of pneumonia. We wish to make Tryptophan and depression Research Council, British Medical Jouirnal, 1965, the following comments in reply. 1, 881. F, Lancet, 1975, 2, 868. (1) Our patient has shown the following SIR,-The report of a double-blind multicentre 3Winston, 4MacSweeney, D A, Lancet, 1975, 2, 510. disease features at some time in the course of study from four Scandinavian hospitals,' her illness: polyarthritis without deformity, with its subsequent elaboration by Dencker Raynaud's phenomenon, rash, pericarditis, at the symposium held recently at the Royal more than two classical LE cells in a blood College of Physicians (leading article, 31 Warfarin and Distalgesic interaction film, and DNA binding of 600°. The first five January, p 242) is a remarkable development of these are included in the preliminary in the evolution of the psychopharmacological SIR,-A 28-year-old woman who had develcriteria for the classification of SLE proposed role of the amino-acid tryptophan. Encouraged oped a venous thrombosis after a Pott's by the American Rheumatism Association by this, we are making a preliminary report on fracture was referred to this laboratory for (1971), four of which were considered neces- a comparative evaluation of L-tryptophan supervision of anticoagulant therapy. On 31 1975 her prothrombin ratio (BCR) sary for diagnosis. In a "short report" we and imipramine using a randomised double- December was 3 2 and the dose of warfarin was lowered were of necessity succinct, and the Raynaud's blind design. So far 16 inpatients with depressive illness, to 6 mg daily. On 7 January her BCR was 1 54 phenomenon and rash were not specifically broadly selected on the criteria adopted by so the dose was increased to 7 mg. On 19 mentioned in the article. (2) We would certainly agree with Dr Sewell the Clinical Psychiatry Committee of the January BCR was 3 35 and warfarin was that neither pericarditis, nor the finding of LE Medical Research Council.2 have completed omitted for a day. She denied either any cells in a blood film, nor an abnormal DNA the trial successfully. The second and the change in dietary habits or taking any drugs binding are specific to SLE-we did not third of these criteria were modified to the except for two Distalgesic tablets in the evenextent that the previous duration of the illness ing of 18 January. On 20 January she presented suggest that they were. (3) Before the patient's later disease exacer- should not be less than four weeks and that with haematuria and loin pain and had taken bation she had been taking ibuprofen and this the patient should not have received any "a few more" Distalgesic tablets on 19 January. was continued subsequently when she was specific treatment for the present episode of BCR was 5-2 and 2 mg of vitamin K1 was well apart from her joint symptoms and DNA illness. The Hamilton rating scale for de- given intravenously. The haematuria and pain binding was normal. Thus the 600o DNA pression was used to quantify the depression ceased on 21 January. I had been unable to explain why she had binding in her blood could not be explained on admission to the trial and at the end of out of control, but in the light of the by anti-inflammatory drug administration, four weeks. All patients received a fixed gone Orme and others although co-trimoxazole, as we stated in the regimen of medication-either six 25-mg communication fromI Dr Massume that it was article, may well have precipitated the two tablets of imipramine daily and 12 tablets of (24 January, p 200) now L-tryptophan placebo or six tablets of imi- because of warfarin and Distalgesic interaction. exacerbations of her disease. (4) The confusion, pyrexia, and weakness in pramine placebo and 12 tablets of L-tryptophan, R VAUGHAN JONES the second episode described in our patient each containing 0 5 g of the amino-acid responded only to the administration of high- together with 5 mg of pyridoxine hydrochloride District Laboratory, St Peter's Hospital, dose steroids, and this clinical improvement ,and 10 mg of ascorbic acid. Thus each patient Chertsey, Surrey occurred in parallel with change in DNA received a total of six tablets three times a day. To ensure further the double-blind nature of binding and fall in antinuclear factor titre. Had the clinical features been the result of pneu- the trial the patients were instructed to discuss the possible side effects with a staff member Myasthenic syndrome during treatment monia this would have been the case. other than the rater, as we observed initially with practolol D M GRENNAN that the subjects taking genuine imipramine could reveal themselves because of their SIR,-We wish to report an apparent complicaCentre for Rheumatic Diseases, common anticholinergic side effects. Glasgow tion of practolol therapy. As can be seen in the accompanying table The patient, born in 1921, was a wheezy our results are consistent with those of Jensen bronchitic hypertensive whose blood pressure in and his colleagues.' It was shown that there 1969 was persistently elevated (220-195/120-105 High plasma calcitonin levels in was no statistically significant difference mm Hg). Practolol was given in increasing doses, breast cancer between the two groups and that L-tryptophan with bendrofluazide 5 mg and Slow-K 600 mg His blood pressure on practolol 2400 mg SIR,-Dr R C Coombes and his colleagues and imipramine were equally effective in the daily. had fallen to 140/70 mm Hg and he remained daily (25 October, p 197) report increased levels of treatment of these cases of depression. well October 1972, when he presented with until immunoreactive calcitonin in the plasma of Our trial differs from that carried out by an eight-month history of double vision on watching 23 out of 28 patients with metastatic carcinoma Jensen and his colleagues in that they used football matches or long films, culminating in a of the breast. We have recently completed a L-tryptophan without added vitamins. Win- two-day episode of bilateral ptosis. All the above similar study1 and are pleased to be able to ston3 has postulated that the good results symptoms were relieved by rest. There was no of a recent trial4 of L-tryptophan in depression evidence symptomatically or on examination of confirm their findings. In our laboratory 44 women aged 30-91 years with histologically proved breast cancer Hamilton rating scale scores before and after treatment with L-tryptophan and imipramine were studied; 29 had widespread metastatic involvement and the others had localised t value of Imipramine (n 7) L-Tryptophan (n =9) Time disease. Three-quarters of the patients with intergroup of t value Significance differences Mean Significance t value Mean rating metastatic disease who were not receiving current therapy had high plasma calcitonin On 0-77 (NS) 22-86 25 33 values (up to 1070 ng/l; normals