like radioactive iodine and antithyroid drugs, has certain advantages and disadvantages in the treatment of hyperthyroidism and that the ther¬ apy recommended should be tailored to each individual patient. Frank O. Becker, MD Steven G. Economou, MD
Rush-Presbyterian-St. Luke's Medical Center
Chicago 1. Caswell
HT, Maier WP: Results of surgical treatment for hyperthyroidism. Surg Gynecol Obstet 134:218\x=req-\ 220, 1972. 2. Griffiths NJ, Murley RS, Gulin R, et al. Thyroid function following partial thyroidectomy. Br J Surg 61:626-632, 1974. 3. Hagen GA: Treatment of thyrotoxicosis with 131-I and post-therapy hypothyroidism. Med Clin North Am 52:417-421, 1968. 4. Michie W, Pegg CAS, Beirsher PD: Prediction of hypothyroidism after partial thyroidectomy for thyrotoxicosis. Br Med J 1:13-17, 1972. 5. Nofal MM, Bierwaltes WH, Patno ME: Treatment of hyperthyroidism with sodium iodide I 131: A 16-year experience. JAMA 197:605-610, 1966.
Hypothyroidism and Stress To the Editor.\p=m-\Therecent report by
Mataverde et al (230:1014, 1974) is
in pointing out a commonly encountered but not well recognized problem. A less common problem, but one that may have been a factor in the case presented, is the exacerbation of hypothyroidism during periods of stress. An early report1 describes five patients who developed "acute myxedema" following pneumonia. Subsequent work2 has shown that during stress thyroxine (T4) turnover is increased fivefold while plasma T4 levels were maintained within normal limits, thus suggesting an increase in T4 secretory rate. It was thought that the increased turnover was the result of an increase in free T, caused by a decrease in thyroxine-binding prealbumin (TBPA). More recent work3 has confirmed that TBPA does indeed decrease with acute infections, but this was dissociated in time from changes in free T4. It was concluded that the alterations in free T4 with stress (which increased T4 turnover) was due to an inhibition of T4 bind¬
timely
ing. Regardless of its cause, the rapid T4 turnover during stress could have important clinical consequences in the hypothyroid patient whose gland is already secreting maximally.2 The routine prophylactic use of levothyroxine sodium in patients with fixed T4 outputs cannot yet be recommended, and certainly does not approach the addisonian in clinical importance. However, the possibility of an inade¬ quate
response to stress associated
with a worsening hypothyroid state should be kept in mind, especially in the hypothyroid patient who has not
yet begun levothyroxine therapy.
Elliott Eisenbud, MD University of California at Davis 1. Hausmann W, Karlish AJ: Acute myxoedema precipitated by pneumonia. Br Med J 2:1063-1065, 1961. 2. Gregerman RI, Solomon N: Acceleration of thyroxine and triiodothyronine turnover during bacterial pulmonary infections and fever. J Clin Endocrinol Metab
27:93-104, 1967. 3. Lutz JH, Gregerman RI, et al: Thyroxine-binding proteins and thyroxine turnover interrelationships during acute infectious illness in man. J Clin Endocrinol Metab 35:230-249, 1972.
Radionuclide Detection of Metastatic Calcification To the Editor.\p=m-\The article "Radionuclide Detection of Diffuse Interstitial Pulmonary Calcification" (230:992, 1974) was of special interest to me since it coincided with my report of a similar case in the Journal of Nuclear Medicine (15:1057, 1974). My patient, who had hypercalcemia, hyperphosphatemia, and renal failure in association with a poorly differentiated malignancy of the bone marrow showed a dense and diffuse uptake of technetium 99m-labelled polyphosphate throughout the lungs and stomach during the course of a bone scan. Calcification of the stomach and kidneys was proven histologically on tissues removed through simple biopsy procedures but biopsy of the lung (a more formidable procedure) did not seem justified. More recently I have observed another patient, a woman of 33, with
hypercalcemia,
hyperphosphatemia
and renal failure due to vitamin D intoxication. She, too, showed diffuse uptake of 99mTc-labelled polyphosphates throughout the lungs during a bone scan and had histologically proved metastatic calcification of the kidneys. Both of these patients are getting along well with treatment, so there is no immediate prospect of ob¬ taining a sample of lung tissue for microscopic examination. Grames and his colleagues do not say whether the autopsy on their first patient showed metastatic calcifica¬ tion of the stomach. This is a puzzling omission in view of the uptake of pyrophosphate in the stomach, which is so well illustrated in their reproduc¬ tion of the bone scan. Taken together, these cases (and there is reason to believe there are others not yet reported) show that metastatic calcification of the lungs and stomach can now be recognized
through scanning after the intra¬ venous injection of a technetiumphosphate complex. Biopsy may no longer be necessary for confirmation. Since the scanning procedure can eas¬ ily be repeated without discomfort to the patient, it may prove to be a use¬ ful guide to the progress of treat¬ ment.
May I utter one tiny objection, di¬ rected as much to the accompanying editorial (230:1018) as to Grames's article? Do we really need the term "diffuse interstitial pulmonary calci¬ fication"? Why not stick with "meta¬ static calcification" and specify the organ involved? "Metastatic calcifica¬ tion" may not be an entirely satisfac¬ tory term but it has been with us for a long time and is simple, versatile, and generally understood. FRCP(C) Royal Jubilee Hospital
A. G. Richards, MD,
Victoria, British Columbia
The American Alcoholic To the Editor.\p=m-\Iwould like to comon Dr. Donald W. Goodwin's review of The American Alcoholic by William Madsen (229:1112, 1974). I believe Dr. Goodwin missed the whole point of the book, which is really an excellent description of Alcoholics Anonymous (AA) and an excellent account of the success of AA in helping to overcome this addiction, particularly in view of the notable failure of psychiatry. I agree that Mr. Madsen does spend considerable time on reference, but I believe he is trying to gather as many ideas and details as possible about the disease in one place. The bibliography is certainly exhaustive, and those of us who are actively engaged in handling alcoholics will find much of the material in this book of great value. ment
G. W. Richmond, MD
San Francisco
Legal Systems
in the
United States
To the Editor.\p=m-\AngelaRoddey Holder (230:1327, 1974) attributed to Charles Dickens a statement made by one of his characters, the beadle, in Oliver Twist, and she cleaned up the grammar a little bit. What the beadle, Mr. Bumble, said was actually "The law is a ass, a idiot." And sometimes it surely is\p=m-\evenif it is, as Ms. Holder shows, "a system, not a collection of traps and snares."
Downloaded From: http://jama.jamanetwork.com/ by a Florida International University Medical Library User on 06/06/2015
Harry L. Arnold, Jr., MD Honolulu
Rush-Presbyterian-St. Luke's Medical Center
Chicago 1. Caswell
HT, Maier WP: Results of surgical treatment for hyperthyroidism. Surg Gynecol Obstet 134:218\x=req-\ 220, 1972. 2. Griffiths NJ, Murley RS, Gulin R, et al. Thyroid function following partial thyroidectomy. Br J Surg 61:626-632, 1974. 3. Hagen GA: Treatment of thyrotoxicosis with 131-I and post-therapy hypothyroidism. Med Clin North Am 52:417-421, 1968. 4. Michie W, Pegg CAS, Beirsher PD: Prediction of hypothyroidism after partial thyroidectomy for thyrotoxicosis. Br Med J 1:13-17, 1972. 5. Nofal MM, Bierwaltes WH, Patno ME: Treatment of hyperthyroidism with sodium iodide I 131: A 16-year experience. JAMA 197:605-610, 1966.
Hypothyroidism and Stress To the Editor.\p=m-\Therecent report by
Mataverde et al (230:1014, 1974) is
in pointing out a commonly encountered but not well recognized problem. A less common problem, but one that may have been a factor in the case presented, is the exacerbation of hypothyroidism during periods of stress. An early report1 describes five patients who developed "acute myxedema" following pneumonia. Subsequent work2 has shown that during stress thyroxine (T4) turnover is increased fivefold while plasma T4 levels were maintained within normal limits, thus suggesting an increase in T4 secretory rate. It was thought that the increased turnover was the result of an increase in free T, caused by a decrease in thyroxine-binding prealbumin (TBPA). More recent work3 has confirmed that TBPA does indeed decrease with acute infections, but this was dissociated in time from changes in free T4. It was concluded that the alterations in free T4 with stress (which increased T4 turnover) was due to an inhibition of T4 bind¬
timely
ing. Regardless of its cause, the rapid T4 turnover during stress could have important clinical consequences in the hypothyroid patient whose gland is already secreting maximally.2 The routine prophylactic use of levothyroxine sodium in patients with fixed T4 outputs cannot yet be recommended, and certainly does not approach the addisonian in clinical importance. However, the possibility of an inade¬ quate
response to stress associated
with a worsening hypothyroid state should be kept in mind, especially in the hypothyroid patient who has not
yet begun levothyroxine therapy.
Elliott Eisenbud, MD University of California at Davis 1. Hausmann W, Karlish AJ: Acute myxoedema precipitated by pneumonia. Br Med J 2:1063-1065, 1961. 2. Gregerman RI, Solomon N: Acceleration of thyroxine and triiodothyronine turnover during bacterial pulmonary infections and fever. J Clin Endocrinol Metab
27:93-104, 1967. 3. Lutz JH, Gregerman RI, et al: Thyroxine-binding proteins and thyroxine turnover interrelationships during acute infectious illness in man. J Clin Endocrinol Metab 35:230-249, 1972.
Radionuclide Detection of Metastatic Calcification To the Editor.\p=m-\The article "Radionuclide Detection of Diffuse Interstitial Pulmonary Calcification" (230:992, 1974) was of special interest to me since it coincided with my report of a similar case in the Journal of Nuclear Medicine (15:1057, 1974). My patient, who had hypercalcemia, hyperphosphatemia, and renal failure in association with a poorly differentiated malignancy of the bone marrow showed a dense and diffuse uptake of technetium 99m-labelled polyphosphate throughout the lungs and stomach during the course of a bone scan. Calcification of the stomach and kidneys was proven histologically on tissues removed through simple biopsy procedures but biopsy of the lung (a more formidable procedure) did not seem justified. More recently I have observed another patient, a woman of 33, with
hypercalcemia,
hyperphosphatemia
and renal failure due to vitamin D intoxication. She, too, showed diffuse uptake of 99mTc-labelled polyphosphates throughout the lungs during a bone scan and had histologically proved metastatic calcification of the kidneys. Both of these patients are getting along well with treatment, so there is no immediate prospect of ob¬ taining a sample of lung tissue for microscopic examination. Grames and his colleagues do not say whether the autopsy on their first patient showed metastatic calcifica¬ tion of the stomach. This is a puzzling omission in view of the uptake of pyrophosphate in the stomach, which is so well illustrated in their reproduc¬ tion of the bone scan. Taken together, these cases (and there is reason to believe there are others not yet reported) show that metastatic calcification of the lungs and stomach can now be recognized
through scanning after the intra¬ venous injection of a technetiumphosphate complex. Biopsy may no longer be necessary for confirmation. Since the scanning procedure can eas¬ ily be repeated without discomfort to the patient, it may prove to be a use¬ ful guide to the progress of treat¬ ment.
May I utter one tiny objection, di¬ rected as much to the accompanying editorial (230:1018) as to Grames's article? Do we really need the term "diffuse interstitial pulmonary calci¬ fication"? Why not stick with "meta¬ static calcification" and specify the organ involved? "Metastatic calcifica¬ tion" may not be an entirely satisfac¬ tory term but it has been with us for a long time and is simple, versatile, and generally understood. FRCP(C) Royal Jubilee Hospital
A. G. Richards, MD,
Victoria, British Columbia
The American Alcoholic To the Editor.\p=m-\Iwould like to comon Dr. Donald W. Goodwin's review of The American Alcoholic by William Madsen (229:1112, 1974). I believe Dr. Goodwin missed the whole point of the book, which is really an excellent description of Alcoholics Anonymous (AA) and an excellent account of the success of AA in helping to overcome this addiction, particularly in view of the notable failure of psychiatry. I agree that Mr. Madsen does spend considerable time on reference, but I believe he is trying to gather as many ideas and details as possible about the disease in one place. The bibliography is certainly exhaustive, and those of us who are actively engaged in handling alcoholics will find much of the material in this book of great value. ment
G. W. Richmond, MD
San Francisco
Legal Systems
in the
United States
To the Editor.\p=m-\AngelaRoddey Holder (230:1327, 1974) attributed to Charles Dickens a statement made by one of his characters, the beadle, in Oliver Twist, and she cleaned up the grammar a little bit. What the beadle, Mr. Bumble, said was actually "The law is a ass, a idiot." And sometimes it surely is\p=m-\evenif it is, as Ms. Holder shows, "a system, not a collection of traps and snares."
Downloaded From: http://jama.jamanetwork.com/ by a Florida International University Medical Library User on 06/06/2015
Harry L. Arnold, Jr., MD Honolulu
