1078

became low 15 days after the start of heparin and was associated with severe arterial thrombosis and typical white clots in the arteries.3 It is noteworthy that negative platelet aggregation tests several months after an initial episode of HATT do not imply that heparin can be safely readministered; the sensitivity of these tests can be too low4 and the heparin-dependent platelet activating factor may re-appear within days of re-exposure. Thus, in a patient with previous HATT, long-term heparin therapy must always be contraindicated. In further deep vein thrombosis or pulmonary embolism, oral anticoagulants should be immediately started and heparin stopped when the prothombin ratio becomes greater than 2 -0, since this regimen has proved effective in these clinical settings.s The use of potent antiplatelet agents such as prostacyclin analogues has also been proposed.6

Haematology Laboratory and Cardiology Department, Centre Hôspitalier and Universitaire Trousseau, 37044 Tours Cedex, France, and Service of Cardiology, Centre Hôspitalier de Blois, Blois

YVES GRUEL MARC LANG LUC DARNIGE

GÉRARD PACOURET XAVIER DREYFUS JEAN LEROY BERNARD CHARBONNIER

1 Laster J, Cikrit D, Walker N. The

2.

heparin-induced thrombocytopenia syndrome: an update. Surgery 1987; 102: 763-70. Leroy J, Leclerc MH, Delahousse B, et al. Treatment of heparin-associated thrombocytopenia and thrombosis with low molecular weight heparin (CY 216).

Semin Thromb Hemost 1986; 11: 326-29. 3. Towne JB, Bernhard VM, Hussey C, et al. White clot syndrome: peripheral vascular complications of heparin therapy. Arch Surg 1973; 114: 372-77 4 Kelton JG, Sheridan D, Brain H, et al Clinical usefulness of testing for a hepann-dependent platelet aggregating factor in patients suspected heparinassodated thrombocytopenia. J Lab Clin Med 1984; 103: 606-12. 5. Gallus A, Jackaman J, Tillett J, et al. Safety and efficacy of warfarin started early after submassive venous thrombosis or pulmonary embolism Lancet 1986; ii: 1293-96. 6. Gruel Y, Lermusiaux P, Lang M, et al. Usefulness of Iloprost in the management of heparin-associated thrombocytopenia. Thromb Haemostas 1989; 62: 49 (abstr).

Effect of combination

chemotherapy with verapamil

SIR,-Expression of the multidrug resistance gene (MDR1) is seen in several healthy human tissues1,2 such as colon, kidney, and adrenal gland, as well as in several neoplastic tissues,1.3-5 including leukaemia5-7 and non-Hodgkin lymphomas.8 The MDR1 gene codes for P-glycoprotein, which in vitro functions as an energydependent efflux pump for anthracyclines, epipodophyllotoxins, and other hydrophobic compounds.’ Verapamil has proved to reverse multidrug resistance by binding to P-glycoprotein and, thereby, competitively blocking the binding of the cytotoxic drugs.’1 Since verapamil overcomes multidrug resistance in multiple myeloma and non-Hodgkin lymphoma,8 we decided to combine chemotherapy with verapamil in a heavily pretreated patient with refractory Hodgkin’s disease (HD) whose refractoriness, at least partly, might have resulted from the presence of the multidrug resistance phenotype. The 35-year-old man with stage IV HD of the nodular sclerosing type, diagnosed in April, 1987, was treated initially with two cycles of C-MOPP chemotherapy followed by 6 cycles of alternating C-MOPP/ABVD chemotherapy. Treatment led to partial remission with a decrease of pleural effusion and shrinkage of enlarged supraclavicular and mediastinal lymph-nodes. Fifteen months after diagnosis, however, severe pruritus developed and was the major clinical symptom. Although one cycle of CEP (lomustine 140 mg/day, etoposide 200 mg/day, and prednimustine 120 mg/day, days 1-4) led to a decrease of pruritus for 3 weeks, the patient became refractory to the next two cycles. At this time we demonstrated MDRl gene expression in peripheral blood lymphocytes, as shown by highly raised levels (30 U) of MDR1 RNA (figure), which is in contrast to healthy controls, who have negative or only very low (< 5 U) levels of MDRl RNA.4,6 On the assumption that malignant cells in this heavily pretreated patient also expressed this gene, we decided to add verapamil to the CEP regimen. CEP chemotherapy was given as before and

Determination of MDR1 gene expression. M DR1RNA levels of peripheral lymphocytes were determined by slot blot analysis (5) and compared with those from 4-6-fold multidrug resistant KB-8-5-cells Actin expression was used to ensure RNA loading.

verapamil was continuously infused (5 mg/h) on days 1-5. After a transient increase the pruritus completely disappeared on day 6. The initial increase might have been caused by a release of mediators due to therapy-induced cell lysis. 4 weeks later, however, pruritus reappeared. Another cycle of CEP combined with verapamil was given and once again he improved clinically, although this time the improvement was less pronounced. We conclude that the striking clinical improvement after the addition of verapamil to chemotherapy was probably due to circumvention of multidrug resistance, and we suggest that multidrug resistance may be of importance in HD.

Departments of Medicine I and II, University of Vienna, A-1090 Vienna, Austria

H. GISSLINGER R. PIRKER J. WALLNER H. WATZKE H. LUDWIG

1. Pastan I, Gottensman MM Multiple-drug resistance in human cancer. N Engl J Med 1987; 316: 1388-93. 2. Thiebaut F, Tsuruo T, Hamada H, Gottesman MM, Paston I, Willingham MC. Cellular localization of the multidrug-resistance gene product P-glycoprotein in normal human tissues. Proc Natl Acad Sci USA 1987, 84: 7735-38. 3 Gerlach JH, Bell DR, Karakousis C, et al P-glycoprotein in human sarcoma: evidence for multidrug resistance. J Clin Oncol 1987; 5: 1452-60. 4 Fojo AT, Ueda K, Slamon DJ, Poplack DG, Gottesman MM, Pastan I. Expression of a multidrug-resistance gene in human tumours and tissues. Proc Natl Acad Sci USA 1987; 84: 265-69. 5. Goldstein LJ, Galski H, Fojo A, et al. Expression of a multidrug resistance gene in human cancers. J Natl Cancer Inst 1989; 81: 116-24. 6. Ma DDF, Davey RA, Harman DH, et al. Detection of a multi-drug resistant phenotype in acute non-lymphoblastic leukaemia. Lancet 1987; i: 135-37. 7. Pirker R, Goldstein LJ, Ludwig H, et al. Expression of a multidrug resistance gene in blast crisis of chronic myelogenous leukemia. Cancer Commun 1989, 1: 141-44. 8 Dalton WS, Grogan TM, Meltzer PS, et al. Drug-resistance in muluple myeloma and non-Hodgkin’s lymphoma: detection of P-glycoprotein and potential circumvention by addition of verapamil to chemotherapy. J Clin Oncol 1989, 7: 415-24.

Megadose methylprednisolone for chronic idiopathic thrombocytopenic purpura SIR,-Since the outlook in childhood idiopathic thrombocytopenic purpura (ITP), both acute and chronic, is favourable, its treatment is controversial. The main objective should be to raise the platelet count rapidly to reduce the risk of haemorrhage, especially intracranial haemorrhage. Although this risk is very low (less than 1 %), especially in chronic cases, prediction is not possible.

The platelet count can be raised above 150 000 / l within 3 days in about 70% of acute ITP patients and in almost all within 2 weeks by megadose methylprednisolone (MDMP).1 However, not more than 81% (39-5% sustained and 41.9% non-persistent) of childhood chronic ITP is corrected with such treatrnent.2 Although intravenous ganunaglobulin (IVIG) is the generally accepted form of treatment for ITP, we have obtained good results with MDMP. Because of the high cost of IVIG we have not been able to compare the two treatments. We have had the opportunity to use MDMP in a 7-year-old boy with chronic ITP who had not had a sustained response to IVIG for

1079

18 months. He was referred to us from the Netherlands for continuation of IVIG, which was started after an unsuccessful 2-month course of prednisolone. Despite an initial increase in the

resulting in low cardiac output and cardiogenic shock. This drug life-threatening adverse effects in patients with cirrhosis, if dosage is not adjusted cautiously.

may have

platelet count, he had needed low-dose IVIG (6 g per dose) once a week for more than 18 months to maintain a platelet count of 20 000-30 OOO/ul). At referral the boy was covered with petechiae, had multiple ecchymoses, and was bleeding from the gums. The only abnormal laboratory finding was thrombocytopenia (less than 30 000/1). Because of active bleeding he was started the next day on oral methylprednisolone (30 mg/kg daily for 3 days followed by 20 mglkg for 4 days), each dose given before 0900 h. His platelet count reached 272 000/l within a week and remained over 124 000/ul during the 30 days of follow-up. MDMP was originally used intravenously for 35 days; now it is given for a week orally with as much success in acute as in chronic ITP (Ozsoylu S, Ertiirk G, unpublished results). No side-effects have been noted at such doses, unlike IVIG with which almost all patients have had side-effects. MDMP might be useful in cases refractory to IVIG. Department of Paediatrics, and Haematology Unit, Hacettepe University Faculty of Medicine, and Hacettepe Children’s Hospital, Ankara, Turkey

ŞINASI ÖZSOYLU GÖNÜL HIÇSÖNMEZ FERIDE DURU

1. Özsoylu Ş,

Irken G, Karabent A. High-dose intravenous methylprednisolone for childhood idiopathic thrombocytopenic purpura. Eur J Haematol 1989; 42: 431-35. 2. Özsoylu High-dose intravenous methylprednisolone for chronic idiopathic thrombocytopenic purpura. Acta Haematol 1989; 81: 112-23. 3. Nakamura S, Yoshido T, Ohtake S, Matsuda T. Hemolysis due to high dose intravenous gammaglobulin treatment for patients with idiopathic thrombocytopenic pupura. Acta Haematol 1986; 76: 115-18. 4. Kim HC, Park CL, Cowan JH III, et al. Massive intravascular hemolysis with intravenous immunoglobulin in bone marrow transplant recipients. Am JPediatr Hematol/Oncol 1988; 10: 69-74. 5 Potter M, Stockley R, Storry J, Slade R. ABO alloimmunisation after intravenous immunoglobulin infusion. Lancet 1988; i: 932-33. 6. Okubo S, Ishida T, Sasunaga K. Hemolysis after intravenous immune globulin therapy. relation to IgG subclasses of red cell antibody. Transfusion 1990; 30: 436-38. acute

Ş.

Cardiogenic shock associated with verapamil in a patient with liver cirrhosis StR,—Calcium channel blockers are widely used in the treatment of tachyarrhythmias, and hypertension. Sideeffects after oral intake are usually mild, though haemodynamic complications may occur if verapamil is given in overdose.’ A 57-year-old man was admitted to intensive care with cardiogenic shock. He was unconscious and cyanotic, and his arterial blood pressure was below 50 mm Hg. He had severe acidosis (pH 6,9, base excess - 26 mmol/1). Because of pacemaker action, his heart rate was 70/min. He also had hypovolaemia, hyperkalaemia, hypothennia (33°C), and renal failure. During treatment with high doses of dopamine, noradrenaline, sodium bicarbonate, and saline,

coronary heart disease,

circulation was stabilised and renal function returned within hours. Blood sample analysis revealed slightly raised levels of digitalis and a highly toxic plasma concentration of verapamil (1-9 mg/1). Therapeutic concentrations of verapamil are usually below 01 mg/1, and concentrations above 1 ’5 mg/1 are potentially lethal. No ethanol or psychotrophic drugs were found. The patient had cirrhosis of the liver after more than 30 years of heavy alcohol intake. He had been treated with verapamil and quinidine because of recurrent tachyarrhythmia since 1981. In 1983, after several cardiac arrests of unknown cause, a pacemaker was implanted. Verapamil was continued. During the 4 weeks before admission, the patient’s health slowly deteriorated and dizziness and dyspnoea increased. He abstained from drinking alcohol, but continued taking verapamil and digitalis. Verapamil is metabolised mainly in the liver at a high rate during the first pass. In patients with cirrhosis the clearance rate is reduced by about 75% because the liver’s capacity to remove the drug is impaired, thus prolonging the half-life and causing accumulation in plasma.4 The intake of 240 mg verapamil per day in this patient with cirrhosis of the liver led to toxic plasma concentrations of the drug,

G. STEHLE

Medical Clinic I and Nephrology Clinic, University of Heidelberg, D 6800 Mannheim, Germany

J. Buss T. PLÜGGE J. EIBACH J. J. LASSERRE I. KEHRY D. L. HEENE

EA, Spiller HA, Myers A. Calcium channel blocker toxicity. Ann Emerg Med 1990; 19: 649-53. 2. Horowitz BZ, Rhee KJ. Massive verapamil ingestion: a report of two cases and a review of literature. Am J Emerg Med 1989; 7: 624-31. 3. Strubelt O. Poisoning with verapamil and other calcium antagonists. Dtsch Med Wschr 1989; 114: 1623-27. 4. Finucci GF, Padrini R, Piovan D, et al. Verapamil pharmacokinetics and liver function 1. Ramoska

in patients with cirrhosis. Int J Clin Pharmacol Res 1988; 8: 123-26.

Absence of

reverse

transcriptase activity in

monocyte cultures from patients with breast cancer SIR,-In 1988 Al-Sumidaie and colleagues1 reported the detection of retrovirus-like particles in stimulated monocyte cultures from patients with breast cancer, on the basis of reverse transcriptase (RT) activity and electron micrograph appearances. We have tried, but failed, to confirm this work. Peripheral blood was drawn from 20 female patients with early stage breast cancer and from 4 healthy female volunteers with no history of breast disease. White cells were collected over ’Histopaque 1119’ (Sigma) and cultured for 2 days at 37°C to separate monocytes (adherent) from other leucocytes. Both cell populations were then cultured with and without 5’-azacytidine for 6 days at 37°C. No definite giant cells1 were observed when harvesting the cultures. Clarified culture supernatants were treated with polyethyleneglycol 6000 (PEG) to concentrate any virus present, and precipitates were tested for exogenous RT activity with three separate template primers: poly(rA).p(dT)iz-i8/poly(rC).p(dG)iz-i8,3 and poly(rG).p(dC)81 (the last with 3 I1Ci [3H]dCTP [53 Ci/mmol] as labelled nucleotide and no cold nucleotide triphosphates in the reaction mix). To increase sensitivity the reactions were incubated for 24 h.4 PEG-precipitates of HIV-1, of human T-cell leukaemia virus type I (HTLV-I), and of an uninfected cord lymphocyte culture were used as controls. Activity above twice negative control levels was detected with precipitates of 5 cultures (1stimulated monocyte, 3 stimulated other leucocyte, 1 unstimulated monocyte), all from a different breast cancer patient. This activity was seen only in reactions using poly(rA).p(dT)12-18 but was not confirmed either as true RT on subsequent comparative testing with poly(dA).p(dT)12-181 as template primer, or as being associated with particles of retroviral buoyant density on sucrose gradient analysis. HIV-1and HTLV-11 showed no significant RT activity with poly(rG).d(pC)g under the conditions used. Because of our negative RT results no electron microscopy was done. We thank Mr A. R. Qureshi (Edgware General Hospital) for his support and Dr Jon Clewley for helpful discussion.

Virus Reference Library, Central Public Health Laboratory, London NW9 5H1, UK

NICHOLAS HALLAM LINDSAY MCALPINE ELIZABETH PUSZCZYNSKA* GARY BAYLI SS

*Present address: National Institute of Biological Standards &

Control.

AM, Lemster SJ, Hart CA, Green CD, McCarthy K. Particles with properties of retroviruses in monocytes from patients with breast cancer. Lancet 1988; i: 5-9. 2. Hoffman AD, Banapour B, Levy JA. Characterization of the AIDS-associated retrovirus reverse transcriptase and optimal conditions for its detection in vinons. Virology 1985; 147: 326-35. 3. Rho HM, Poiesz B, Ruscetti FW, Gallo RC. Characterization of the reverse transcriptase from a new retrovirus (HTLV) produced by a human cutaneous T-cell lymphoma cell line. Virology 1981; 112: 355-60. 4. Lee MH, Sano K, Morales FE, Imagawa DT. Sensitive reverse transcriptase assay to detect and quantitate human immunodeficiency virus. J Clin Microbiol 1987; 25: 1717-21. 1. Al-Sumidaie