Suzanne Alexander

Lupus erythematosus in two patients after griseofulvin treatment of Trichophyton rubrum infection.

Case 1. In November 1959, a mathematician aged twenty-two was referred by her practitioner for advice on her nails, one finger nail and all the toe nails having become thickened and discoloured during the preceding six months. She had chickenpox and measles in infancy and her tonsils were removed at tlie age of twelve. A carbuncle ofthe arm was treated with penicillin in 1954 and she had herpes zoster in 1958. Since the age of sixteen, she had sufFered from chilblains of the feet in winter. Otherwise, her general health had been good. The nails were thickened, ridged, opaque and yellowish. The skin of the toes was scaly. Microscopic examination of the nails showed mycelium and on culture Trichophyton rubrum was isolated. Griseofulvin 1 g. daily was prescribed. On the third day she felt unwell, on the fourth and fifth days she had dizziness and headache, and later she felt nauseated. By the tenth day she had developed diarrhoea, her temperature was 102-8° F. and a widespread rash had appeared. This started on the hands and feet and spread eentripetally. There was hepatomegaly, splenomegaly and generalized lymphadenopathy. Diagnoses considered were a drug eruption and glandular fever. The griseofulvin was stopped and the patient was admitted to hospital. The investigations were as follows :—Paul Bunnell test was negative, Hb. 81%, WBC. 4,800, neutrophils 2,900, no glandular fever cells were seen, ESR 87 mm. in 1 hr. (Westergren). Urine normal. Shigella sonnei was isolated from one stool, 3 subsequent stool cultures were negative. The diarrhoea ceased within twenty-four hours, the rash faded by the fourth day after admission and the pjTexia settled. Treatment consisted of rest in bed and chlorpheniramine maleate (Piriton) 8 mg. t.i.d. The patient was discharged feeling reasonably well after eleven days in hospital. She went home to Cornwall for the Christmas vacation and was seen again in January 1960. All her initial symptoms had subsided, but she felt tired and listless. Her spleen was still palpable and the ESR was 37 mm. in one hour. Small lumps, thought to be chilblains, were present on the dorsa of her hands. In March, 1960, four months after the original episode, these nodules were still present on the hands and were similar to the nodosites cutanees ephemeres described by Duperrat (1947) as occurring in lupus erythematosus. Atrophic

TINEA CAPITIS IN A PRIMARY SCHOOL.

THIS paper reports the iiivestigatious carried out on pupils and their environment during an outbreak of tinea capitis due to Microsporum audouini in a Primary School in which there were 170 children between the agt̂ s of 5 and 11 years. The outbreak became apparent when, at tlie beginning of February I9t):i, (i of a family of 7 children were aeen at St. Johns Hospital for Diseases of the Skin suffering from tinea cajntis. They presented with patchy eruptions on the head, face, neck, shoulder, knee and thighs. These lesions and lanugo hairs in affected areas were markedly fluorescent under Woods light and M. audouini was grown in cultures from them. As 4 of the children aged over ;•) years attended the same school, further dissemination of the fungus was likely and on enquiry it was found that several children at the school were attending other hospitals for treatment of scalp ringworm.

THE TREATMENT OF CHRONIC DISCOID LUPUS ERYTHEMATOSUS WITH A COMBINATION OE ANTIMALARIAL AND CORTKH)STEROID DRUGS.

THE treatment of chronic discoid lupus erythematosus (chronic L.E.) has been revolutionized by the introduction of antimalarial drugs (Prokoptchouk, 1040 : Page, 1951) ; 80% of cases are controlled, but relapse is frequent when treatment is stopped (Gold, 1960). Neither control nor relapse are related to the duration of the disease. Although some patients respond better to one antimalarial drug than to others (Cornblect, 1956; Pappenfort, 1956), most cases are equally well controlled by any of them. Above a certain level, increased dosage produces no greater benefit (Cliristiansen and Nielsen, 1956). There remains, however, a hard core of about 20% of cases in which some activity persists. Systemic corticosteroids can be used in this group of cases, but in view of their undesirable side effects and the relatively benign nature of chronic L.E., they have not been widely employed. It would seem reasonable to use a combination of antimalarial and corticosteroid drugs in this 20% if control can be obtained with a smaller dose of steroid than if the latter were given alone. Midana and Depaoli (1957) treated eighteen unselected cases of chronic L.E. with a combination of chloroquine and prednisone and found a quicker response than with chloroquine alone. The mixture was particularly useful when the scalp and extremities were involved.

(16) Klippel-Trenaunay syndrome

A.F., female, aged 3 years. Hospital case no. 44872. History. She was noticed to have a reddish patch on the left leg shortly after birth. The left leg is thinner than the right, but there is no increase in length. On examination a pale capillary angioma is present on the left leg with wasting of the quadriceps (Fig. I). Investigations. X-ray shows muscle wasting and decrease in subcutaneous fat. Bone texture normal.