A randomized, double-blind trial of nystatin therapy for the candidiasis hypersensitivity syndrome.

BACKGROUND: Candida albicans infection has been proposed to cause a chronic hypersensitivity syndrome characterized by fatigue, premenstrual tension, gastrointestinal symptoms, and depression. Long-term antifungal therapy has been advocated as treatment for the syndrome, which is most often diagnosed in women with persistent or recurrent candida vaginitis. METHODS: To determine the efficacy of nystatin therapy for presumed candidiasis hypersensitivity syndrome, we conducted a 32-week randomized, double-blind, cross-over study using four different combinations of nystatin or placebo given orally or vaginally in 42 premenopausal women who met present criteria for the syndrome and had a history of candida vaginitis. The outcomes studied were the changes from base line in scores for vaginal, systemic, and overall symptoms and in the results of standardized psychological tests. RESULTS: The three active-treatment regimens (oral and vaginal nystatin, oral nystatin and vaginal placebo, and oral placebo and vaginal nystatin) and the all-placebo regimen significantly reduced both vaginal and systemic symptoms (P less than 0.001), but nystatin did not reduce the systemic symptoms significantly more than placebo. On average, the scores for systemic symptoms improved 25 percent with the three active-treatment regimens and 23 percent with the all-placebo regimen, a difference of only 2 percent (95 percent confidence interval, -3 to 7 percent). As expected, the three active-treatment regimens were more effective than placebo in relieving vaginal symptoms (P less than 0.001). All four regimens reduced psychological symptoms and global indexes of distress; there were no significant differences among the treatment regimens. CONCLUSIONS: In women with presumed candidiasis hypersensitivity syndrome, nystatin does not reduce systemic or psychological symptoms significantly more than placebo. Consequently, the empirical recommendation of long-term nystatin therapy for such women appears to be unwarranted.

Struma ovarii: a case report.

A patient with struma ovarii and hyperthyroidism is described. She was treated for Graves' hyperthyroidism at age 22 and received thyroxine for post-operative hypothyroidism. Twenty years later she became thyrotoxic and was treated with antithyroid drugs and radioiodine. Diagnosis of struma ovarii was made by radioiodine profile scanning and an ovarian tumour was removed. This had the pathological features of struma ovarii and autoradiographic evidence of pre-operatively administered 125I was seen in the lesion. The patient had positive results for long acting thyroid stimulator (LATS) and LATS-protector (LATS-P) pre- and post-operatively. Bioassays for thyroid stimulators were positive post-operatively but radioreceptor assays for TsAb were consistently negative. It is suggested that profile scanning is an appropriate investigation for diagnosis. It is not clear whether the lesion was autonomous or being stimulated by circulating thyroid stimulators.

Intraoperative identification of parathyroid glands: appraisal of methylene blue staining.

Methylene blue administered intravenously in a dose of 5 mg/kg of body weight was employed as an aid to the intraoperative identification of parathyroid glands in 90 patients undergoing surgery for hyperparathyroidism. Staining occurred in 95 percent of adenomas and 86 percent of hyperplastic glands. Normal and suppressed glands stained in 71 and 70 percent of cases, respectively. There were no adverse side effects from the technique. We conclude that preoperative intravenous infusion of methylene blue is a valuable technique that facilitates identification of parathyroid tissue at operation.

Radiation pneumonitis following electron beam radiotherapy.

A case of radiation pneumonitis is reported. The problem presented in a postmastectomy breast patient after completion of 5000 rads of high-energy electron beam radiotherapy. Within 7 months the lungs showed almost complete clearing and clinical symptoms had disappeared.

Cecil Joll Lecture, 1979. Respiratory obstruction in thyroid surgery.

The causes of respiratory obstruction before, during, and after thyroid surgery are outlined and their clinical features described. The dangers of postoperative respiratory obstruction are emphasised and the measures necessary to prevent it if possible, to anticipate it, and treat it are discussed in detail.

The diagnosis of primary hyperparathyroidism.

Certain clinical features arouse suspicion of primary hyperparathyrodism, but a firm diagnosis depends upon laboratory tests. Hypercalcaemia associated with a raised or detectable level of parathyroid hormone (PTH) in the serum is diagnostic. Facilities for obtaining PTH estimations are available everwhere in the United Kingdom through the Supraregional Assay Service.

Agranulocytosis secondary to methimazole therapy: report of two cases.

Seventy-three cases of thyrotoxicosis were treated at Lloyd Noland Hospital with methimazole, propylthiouracil or both. Two cases of agranulocytosis occurred (2.7%) secondary to methimazole. Both responded to hospitalization, reverse isolation, and antibiotic coverage with complete recovery of the peripheral blood picture. The toxicity of methimazole is noted. The need for careful monitoring of blood counts during therapy and immediate discontinuance of the drug at the first clinical sign of granulocytopenia is stressed.

The aetiology and diagnosis of malignant tumours of the thyroid gland.

Known aetiological factors of thyroid tumours are: genetic, hormonal, irradiation and auto-immune thyroiditis. Some medullary carcinomas are familial. Thyroid-stimulating hormone plays a significant part in the initiation and maintenance of many well-differentiated thyroid carcinomas. Small doses of irradiation in childhood and probably also in adolescence may induce a papillary or follicular carcinoma. Some malignant lymphomas develop in a previous auto-immune thyroiditis. Diagnosis of a malignant thyroid tumour is usually obvious once there has been extrathyroidal spread. Intrathyroidal tumours are suspect if they are hard and irregular. The real diagnostic problem is the clinically solitary nodule which is smooth, firm and mobile in a euthyroid patient. Ultrasound and scanning may increase or decrease the suspicion of malignancy but excisional biopsy is the only certain diagnostic procedure.