Clomipramine treatment of panic disorder: pros and cons.

BACKGROUND: Controlled trials suggest that clomipramine may be a highly effective antipanic drug. Lowering the starting dose may alleviate troublesome initial side effects and increase acceptability and compliance. METHOD: Fifty-eight patients with DSM-III-R panic disorder with or without agoraphobia underwent 13 weeks of clomipramine treatment. Starting at 10 mg/day, the dose was gradually increased to a mean dose of 97 mg/day. RESULTS: While completers showed highly significant improvement, the benefits were severely limited by a high dropout rate due to adverse reactions occurring mostly during the first 2 weeks of treatment. CONCLUSION: Given the alternatives, clomipramine should not be used as a first-line antipanic medication.

Necrotizing fasciitis: the role of Staphylococcus epidermidis, immune status and intravascular coagulation.

An 83 year old Caucasian woman with necrotizing fasciitis (NF) of the right hand is described. Staphylococcus epidermidis was the only organism cultured. Serology failed to demonstrate Streptococcus pyogenes, the common pathogen of NF. Despite antibiotic therapy, gangrene supervened, necessitating digital amputation. Staphylococcus epidermidis is usually non-pathogenic, but review of the literature indicates that it is relatively commonly found with other pathogens in NF. Accordingly, studies of immune status were undertaken. Apart from reduced myeloperoxidase production (30-50% of normal levels), all humoral, cell-mediated and neutrophil function tests were normal. This is the first report of Staphylococcus epidermidis as the sole isolate in NF and also the only study of immune status of NF patients. It is concluded that a non-virulent organism (e.g. Staphylococcus epidermidis) may be pathogenic in the face of advanced age alone. Elevated fibrin degradation productions were also demonstrated in the patient, consistent with lysis of localized intravascular thrombus. The role of anticoagulation in NF is discussed.

Ketotifen--a therapeutic agent of eosinophilic fasciitis?

A 30-year-old male with eosinophilic fasciitis (EF) associated with morphoea and vitiligo is described. The patient showed a partial response to prednisone, but did not respond to hydroxychloroquine, D-penicillamine and cimetidine. In the light of reports of increased plasma histamine levels, and a putative role of mast cells in the pathogenesis of EF, ketotifen (a mast cell stabilizer) was prescribed. This non-toxic drug has allowed the patient to continue hard physical labour without further relapses and without corticosteroid therapy.

Relevance of DMS-III depressive subtype and chronicity of antidepressant efficacy in atypical depression. Differential response to phenelzine, imipramine, and placebo.

One hundred ninety-four nonmelancholic depressed outpatients with features of atypical depression took part in a 6-week randomized trial of imipramine hydrochloride, phenelzine sulfate, and placebo. Their courses of illness were also rated for chronicity. Significantly more patients responded to phenelzine (71%) than to imipramine (48%), which benefited significantly more patients than placebo (26%). Both chronicity and DMS-III diagnosis predicted response on several outcome measures. For example, patients with dysthymic disorder responded better to treatment than did those with major depression, suggesting that dysthymic disorder can be treated with medication. Placebo response correlated inversely with chronicity, regardless of DMS-III diagnosis. Atypical depression and longitudinal course of illness may add to the usefulness of DMS-III depressive diagnosis as a predictor of antidepressant response.

Sarcoid dactylitis in black South African patients.

Six black South Africans with sarcoid dactylitis are described. By the term sarcoid dactylitis we mean sarcoid involvement of the bone and soft tissue of the fingers. Three of the six patients developed dactylitis during the course of chronic sarcoid. These patients had multisystem disease. In all three patients dactylitis developed after the diagnosis of sarcoid was established. However, in the other three patients dactylitis was the presenting feature of sarcoidosis, and none of these patients had evidence of chronic fibrotic sarcoid elsewhere. This finding is at variance with the observation that bony sarcoid is always a feature of chronic, poor prognosis, fibrotic sarcoid of all organ systems; these patients may form a sub-group with bony involvement and good prognosis. The significance, however, of this latter localized presentation of sarcoid is that clinically and histologically it is easily confused with tuberculoid leprosy and has been misdiagnosed.

A newly recognized feature of ectrodactyly, ectodermal dysplasia, clefting (EEC) syndrome: comedone naevus.

A 21-year-old Black South African man with clinical features of ectrodactyly, ectodermal dysplasia, cleft lip/palate (EEC) syndrome is described. The patient had the following anomalies: hypoplastic, peg-shaped teeth; fine, silky hair; absent lacrimal puncta resulting in secondary photophobia, blepharitis and corneal opacities. The hands and feet showed absent digits, symphalangism and displacement of bone consistent with ectrodactyly. In addition, the patient had extensive comedone naevus, a feature not previously reported in EEC syndrome. We stress that the dysplastic ectodermal features of EEC syndrome are not typical of either hidrotic or anhidrotic ectodermal dysplasia but fall into a class of their own. Clefting of the lip and palate were absent due, it is postulated, to the variable expressivity of EEC syndrome.

Pityriasis rotunda. A cutaneous sign of malignant disease in two patients.

The term pityriasis rotunda refers to strikingly circular scaly lesions, with the histologic appearance of ichthyosis vulgaris. Pityriasis rotunda has been described in the Japanese, South African blacks, and West Indian blacks. The condition occurs only in association with certain serious systemic illnesses, usually tuberculosis, or malignant neoplasms or less severe diseases of the female genital tract (eg, fibroids, ovarian cyst). We describe two South African blacks with pityriasis rotunda and neoplasms. The cutaneous lesions cleared when the primary neoplasm was treated.

Cutis verticis gyrata with metabolic abnormalities.

An adult Black South African man with forme fruste pachydermoperiostosis is described. The patient had cutis verticis gyrata, hyperhidrosis, sebaceous plugging and an acneform rash. Basal and dynamic endocrine studies revealed that the hypothalamic, pituitary, thyroid, adrenal, gonadal axes and growth hormone secretion were all normal, but urinary excretion of 17-hydroxy-and corticosteroids, and the prolactin response to thyrotropin-releasing hormone were depressed. Urinary levels of asparagine were markedly elevated and serum levels were subnormal indicating a possible renal leak of this amino acid; glutamic acid and ornithine were present in smaller quantities in the urine. All other tests of proximal and distal renal tubular function were normal. There is no evidence from our studies to suggest a hormonal basis for pachydermoperiostosis. The amino aciduria may be a chance association of, or an (additional) occasional manifestation of the syndrome.

Fungating Bowen's disease with presumed arsenic intoxication. A case report.

A patient with a bizarre fungating tumour of the anterior abdominal wall is described. The lesion had the histological features of Bowen's disease and also had the appearance of a basal cell carcinoma with sebaceous differentiation. In addition, the patient had 'raindrop' pigmentation typical of chronic arsenic intoxication. As far as we know, Bowen's disease has once previously been reported in a Black patient in South Africa. We have not encountered any other description in the literature of Bowen's disease presenting as a fungating tumour.

Unusual aspects of febrile neutrophilic dermatosis (Sweet's syndrome). Case reports.

Two patients with febrile neutrophilic dermatosis (FND) of Sweet's syndrome are described. One patient had acute myeloblastic leukaemia and FND antedated any changes in the peripheral blood. The second patient had bullous lesions which healed, with clinical cutis laxa (acquired anetoderma). In this patient FND had persisted for 8 years and histological examination of the skin lesions showed inflammation of the subcutaneous fat. To our knowledge this represents the first report of panniculitis due to FND.

Extensive botryomycosis in a patient with diabetes and chronic active hepatitis.

Extensive botryomycosis was diagnosed in a patient with diabetes mellitus with chronic active hepatitis. Peptostreptococcus organisms and Staphylococcus aureus grew from the sulfur granule cultures. The patient's neutrophils showed notable inhibition of chemotaxis toward endotoxin-activated normal serum. The patient's serum also had an inhibitor to neutrophil chemotaxis, This inhibiting substance was probably antistreptolysin O. Results of other tests of neutrophil function and skin tests to evaluate cell-mediated immunity were normal.

Rapidly fatal lymphangioma-like Kaposi's sarcoma.

A 34-year-old black South African male was treated for lymphangioma-like clinical Kaposi's sarcoma. The disease followed a rapidly fatal course and was characterized by unexplained recurrent pleural effusions and severe refractory anaemia due to the presence of dilated vascular channels in the bone marrow. Definitive diagnosis was only made at autopsy. Lymphangiomatous changes in the skin without spindle cell formation caused diagnostic difficulties.

The radiological features of lymphangioma-like Kaposi's sarcoma. A case report.

A case of lymphangioma-like Kaposi's sarcoma is described, together with the lymphangiographic and arteriographic features. Persistent pleural effusions developed, for which a cause is postulated.

Histiocytosis and a leukaemoid response. A case report.

A patient with all the clinical signs of Letterer-Siwe disease is reported. The patient was unusual in that he had a severe leukaemoid reaction. To our knowledge, only 2 similar patients with reticulo-endotheliosis, histiocytic skin infiltration and leukaemoid reaction have been reported. It is possible that the disorder may represent a variant of the histiocytic proliferative disorders, characterized by both histiocytic and myeloid hyperplasia, and is thus similar to myelomonocytic leukaemia. However, it differs from the latter condition in that there is proliferation of monocytes and granulocytes in soft tissues rather than in the blood.

Schizophrenia and albinism.

A female albino with squamous cell carcinoma and schizophrenia is reported. The association of schizophrenia and albinism is exceptionally rare; the observation that schizophrenia is characterised by hypermelanosis is questioned.

Chronic myeloid leukaemia in South African blacks.

A study on 25 South African Black patients with chronic myelogenous leukaemia (CML), who were followed for 3 1/2 years, is reported. The Ph chromosome was found in 19 of 20 patients studied. Males predominated in a ratio of 2,5:1. Several unusual clinical features were encountered: significant lymphadenopathy, congestive cardiac failure and skin lesions. Patients with lymphadenopathy responded to busulphan therapy no differently from patients without lymphadenopathy. Nine patients had congestive cardiac failure, and in 7 of these a cause could not be found. Three untreated patients became pregnant, indicating that CML per se does not cause infertility. The haematological measurements were similar to those of previous reports; however, the marked splenomegaly suggests that South African Black patients present themselves for treatment rather late in the disease. The median survival time of 34 months is similar to that of previous reports of larger series from other parts of the world.