744 Our observations suggest that, in some patients at least, correction of the bleeding-time is possible with D.D.A.V.P., and that this correlates with clinically normal haemostasis and may be of use in monitoring therapy with D.D.A.V.P. An alternative explanation is that von Willebrand’s disease may be usefully subdivided by the type of response to D.D.A.v.P. C. MENON Department of Haematology, E. W. BERRY Auckland Hospital, Auckland 1, New Zealand P. OCKELFORD _
__
CANDIDA PERITONITIS AND CIMETIDINE
In unilateral occlusion
or
hasmodynamically significant
stenosis the appearance and extension of fluorescence are retarded in the ipsilateral supraorbital area in comparison with the contralateral one. The difference between sides-often amounting to several seconds-is easily observed and can be recorded with stopwatches. If the internal carotid occlusion is bilateral we would expect appearance-times to be delayed on both sides, though we have not yet seen a case. Compression of the superficial temporal arteries for 30 s after fluorescein injection is easily achieved manually just above the mandibular condyloid process. This procedure is mandatory for reducing the arterial supply from the external carotid territory to the supraorbital skin areas, the fluores’
pattern of which will, during temporal compression, on blood-flow and pressure in the supraorbital branch from the ophthalmic artery of the internal carotid territory. We have not found it necessary to compress bilaterally the facial artery at the mandibular base. Indeed the diagnosis of occlusive disease even in the external carotid arteries may be feasible with bilateral compression limited to the superficial temporal arteries. This fluorescein test depends on direct visual observation and permits immediate diagnostic evaluation in acute cases. The pattern can be recorded at the same time by dynamic fluorescein angiography and sequential photography or continuous video-recording, as done in studies of peripheral arterial disease. 1-3 The correspondence, obtained in seven cases, between supraorbital fluorescein examinations and X-ray arteriography and isotope studies has been good. The test, which does not need much cooperation from the conscious patient and is practicable in unconscious patients too, has proved superior to, and more reliable than, determination of the fluorescein arm-toretina time. The simultaneous observation of both supraorbital areas eliminates the error, due to variations in cardiac output, associated with two different retinal examinations. Patients with a history of allergy and unconscious patients whose allergy history is unknown should have prophylaxis with a corticosteroid and an antihistamine before injection of fluorescein. cence
SIR,-Candida peritonitis is
an
uncommon
complication
following bowel perforation.’ We have seen two cases and report them to raise the question whether immune function is not impaired with cimetidine. A 57-year-old man had a perforated peptic ulcer 3 days after starting cimetidine. A pure culture of Candida kruseii was grown from the peritoneal cavity. 10 days later an extensive right-upper-quadrant abscess was drained of pus filled with pseudohyphx of C. kruseii. Cimetidine 300 mg every 6 h had been administered from 3 days before to 10 days after perforation. Amphotericin B 25 mg daily for 14 days was associated with cure. A 72-year-old woman with pneumococcal meningitis had a perforated ulcer on the 5th hospital day whilst on penicillin. Only C. albicans was grown from the peritoneal cavity. Cimetidine 300 mg was given every 6 h. On the 7th postoperative day peritonitis and left sub-hepatic abscess yielding pure cultures of C. albicans was detected at reoperation for fever. Amphotericin B 20 mg daily for 3 weeks was given. The patient died of neurological complications of meningitis. At necropsy there was no evidence of candidiasis. Candida peritonitis is rarely reported, and these two cases represent half our experience in seven years in a large referral hospital. We conclude that cimetidine may be associated with increased risk of progressive candidal disease and the isolation of fungi from perforations should prompt aggressive antifungal therapy in this clinical setting. Recent work suggests that a unique leucocyte function involving the small granules is required to kill hyphal forms of fungi. The effect of cimitidine on this special leucocyte function has not been studied. We intend to pursue this problem in our laboratories. Leucocyte-function tests would be insensitive to an acquired defect as usually performed, such as phagocytosis and hyphal killing of yeast forms.
Letterman Army Medical Center, Presidio of San Francisco, California 94129, U.S.A.
FRED R. STARK NICHOLAS NINOS JOHN HUTTON RONALD KATZ MELVIN BUTLER
SUPRAORBITAL FLUORESCEIN TEST IN DIAGNOSIS OF INTERNAL-CAROTID-ARTERY DISEASE
SIR,-We have devised
a simple method for rapid assessof occlusive internal-carotid-artery disease-viz., direct observation of fluorescence and its extension in the supraorbital skin areas after intravenous injection of sodium fluorescein (6 ml 10% solution) during bilateral compression of the superficial temporal artery. A mercury vapour lamp (e:g., ’Fluotest Forte’, Hanau) with special blue filter (hardened Schott glass filter BG12) is used as illumination source for fluorescence excitation, and the observer should wear yellow barrier filters such as ski-goggles to see the yellow-green fluorescence.
ment
1. 2.
Bayer, A. S., and others. Am. J. Med. 1976, 61, 832. Diamond, R. D. and others. J. clin. Invest. 1978, 61, 349, 360.
depend mainly
Stureby Sjukhus Geriatric Unit, S-122 86 Enskede, Stockholm, Sweden; and Neurological Department, Sodersjukhuset, Stockholm
FREDRIK LUND
HOLGER FAHLGREN THOMASINE MANNERFELT
RENAL THRESHOLD FOR GLUCOSE IN AFRICAN DIABETICS
SIR,-I read with interest the article by Dr Umez-Eronini and colleagues (July 1, p. 12) on an insulin-reaction test for the diagnosis of low renal threshold for glucose in African diabetics. I have in my clinic thirty adult diabetics, all with normal renal function, who have been on an insulin regimen with normal or near-normal 24 h blood-glucose pattern for periods of 6 months to 1 year. Before this regimen was started every patient had an oral glucose-tolerance test with concurrent urinalysis to exclude low renal threshold for glucose. No patient has had a low threshold, and among these patients, who have now been aglycosuric for at least 6 months, there have been only three admissions for hypoglycaemia. Low renal threshold for glucose is not, in my experience, a common feature among Nigerian diabetics. The three cases I have seen were female pregnant diabetics, and there was no difficulty in their management. Instead of water and urine in the proportion of 10 drops of water to 5 of urine in the ’Clinitest’ for urine sugar, a ratio of 13 drops of water to 2 of urine, hence diluting the urine, is used. 1. 2. 3.
Lund, F., Lund, S. Bibl. anat. 1975, 13, 210. Lund, F. Acta chir. scand. 1976, suppl. 465, p. 60. Lund, F. Bibl. anat. 1977, 16, 257.
__
CANDIDA PERITONITIS AND CIMETIDINE
In unilateral occlusion
or
hasmodynamically significant
stenosis the appearance and extension of fluorescence are retarded in the ipsilateral supraorbital area in comparison with the contralateral one. The difference between sides-often amounting to several seconds-is easily observed and can be recorded with stopwatches. If the internal carotid occlusion is bilateral we would expect appearance-times to be delayed on both sides, though we have not yet seen a case. Compression of the superficial temporal arteries for 30 s after fluorescein injection is easily achieved manually just above the mandibular condyloid process. This procedure is mandatory for reducing the arterial supply from the external carotid territory to the supraorbital skin areas, the fluores’
pattern of which will, during temporal compression, on blood-flow and pressure in the supraorbital branch from the ophthalmic artery of the internal carotid territory. We have not found it necessary to compress bilaterally the facial artery at the mandibular base. Indeed the diagnosis of occlusive disease even in the external carotid arteries may be feasible with bilateral compression limited to the superficial temporal arteries. This fluorescein test depends on direct visual observation and permits immediate diagnostic evaluation in acute cases. The pattern can be recorded at the same time by dynamic fluorescein angiography and sequential photography or continuous video-recording, as done in studies of peripheral arterial disease. 1-3 The correspondence, obtained in seven cases, between supraorbital fluorescein examinations and X-ray arteriography and isotope studies has been good. The test, which does not need much cooperation from the conscious patient and is practicable in unconscious patients too, has proved superior to, and more reliable than, determination of the fluorescein arm-toretina time. The simultaneous observation of both supraorbital areas eliminates the error, due to variations in cardiac output, associated with two different retinal examinations. Patients with a history of allergy and unconscious patients whose allergy history is unknown should have prophylaxis with a corticosteroid and an antihistamine before injection of fluorescein. cence
SIR,-Candida peritonitis is
an
uncommon
complication
following bowel perforation.’ We have seen two cases and report them to raise the question whether immune function is not impaired with cimetidine. A 57-year-old man had a perforated peptic ulcer 3 days after starting cimetidine. A pure culture of Candida kruseii was grown from the peritoneal cavity. 10 days later an extensive right-upper-quadrant abscess was drained of pus filled with pseudohyphx of C. kruseii. Cimetidine 300 mg every 6 h had been administered from 3 days before to 10 days after perforation. Amphotericin B 25 mg daily for 14 days was associated with cure. A 72-year-old woman with pneumococcal meningitis had a perforated ulcer on the 5th hospital day whilst on penicillin. Only C. albicans was grown from the peritoneal cavity. Cimetidine 300 mg was given every 6 h. On the 7th postoperative day peritonitis and left sub-hepatic abscess yielding pure cultures of C. albicans was detected at reoperation for fever. Amphotericin B 20 mg daily for 3 weeks was given. The patient died of neurological complications of meningitis. At necropsy there was no evidence of candidiasis. Candida peritonitis is rarely reported, and these two cases represent half our experience in seven years in a large referral hospital. We conclude that cimetidine may be associated with increased risk of progressive candidal disease and the isolation of fungi from perforations should prompt aggressive antifungal therapy in this clinical setting. Recent work suggests that a unique leucocyte function involving the small granules is required to kill hyphal forms of fungi. The effect of cimitidine on this special leucocyte function has not been studied. We intend to pursue this problem in our laboratories. Leucocyte-function tests would be insensitive to an acquired defect as usually performed, such as phagocytosis and hyphal killing of yeast forms.
Letterman Army Medical Center, Presidio of San Francisco, California 94129, U.S.A.
FRED R. STARK NICHOLAS NINOS JOHN HUTTON RONALD KATZ MELVIN BUTLER
SUPRAORBITAL FLUORESCEIN TEST IN DIAGNOSIS OF INTERNAL-CAROTID-ARTERY DISEASE
SIR,-We have devised
a simple method for rapid assessof occlusive internal-carotid-artery disease-viz., direct observation of fluorescence and its extension in the supraorbital skin areas after intravenous injection of sodium fluorescein (6 ml 10% solution) during bilateral compression of the superficial temporal artery. A mercury vapour lamp (e:g., ’Fluotest Forte’, Hanau) with special blue filter (hardened Schott glass filter BG12) is used as illumination source for fluorescence excitation, and the observer should wear yellow barrier filters such as ski-goggles to see the yellow-green fluorescence.
ment
1. 2.
Bayer, A. S., and others. Am. J. Med. 1976, 61, 832. Diamond, R. D. and others. J. clin. Invest. 1978, 61, 349, 360.
depend mainly
Stureby Sjukhus Geriatric Unit, S-122 86 Enskede, Stockholm, Sweden; and Neurological Department, Sodersjukhuset, Stockholm
FREDRIK LUND
HOLGER FAHLGREN THOMASINE MANNERFELT
RENAL THRESHOLD FOR GLUCOSE IN AFRICAN DIABETICS
SIR,-I read with interest the article by Dr Umez-Eronini and colleagues (July 1, p. 12) on an insulin-reaction test for the diagnosis of low renal threshold for glucose in African diabetics. I have in my clinic thirty adult diabetics, all with normal renal function, who have been on an insulin regimen with normal or near-normal 24 h blood-glucose pattern for periods of 6 months to 1 year. Before this regimen was started every patient had an oral glucose-tolerance test with concurrent urinalysis to exclude low renal threshold for glucose. No patient has had a low threshold, and among these patients, who have now been aglycosuric for at least 6 months, there have been only three admissions for hypoglycaemia. Low renal threshold for glucose is not, in my experience, a common feature among Nigerian diabetics. The three cases I have seen were female pregnant diabetics, and there was no difficulty in their management. Instead of water and urine in the proportion of 10 drops of water to 5 of urine in the ’Clinitest’ for urine sugar, a ratio of 13 drops of water to 2 of urine, hence diluting the urine, is used. 1. 2. 3.
Lund, F., Lund, S. Bibl. anat. 1975, 13, 210. Lund, F. Acta chir. scand. 1976, suppl. 465, p. 60. Lund, F. Bibl. anat. 1977, 16, 257.
