Diabetic gustatory sweating successfully treated with topical glycopyrrolate: report of a case and review of the literature.

BACKGROUND: Gustatory sweating is a more common manifestation of diabetes mellitus than is appreciated. It is a distressing problem that has been difficult to treat safely. METHODS: Daily topical application of glycopyrrolate roll-on lotion was offered as an alternative to oral anticholinergic agents to an 87-year-old woman with long-standing type 2 diabetes mellitus who complained of profuse sweating after eating. RESULTS: Gustatory sweating was relieved by application of glycopyrrolate and reappeared when the glycopyrrolate was briefly withdrawn to confirm its therapeutic effect. CONCLUSION: For moderate to severe symptoms of diabetic gustatory sweating, topical application of glycopyrrolate is safe, effective, well tolerated, and convenient.

Systemic lupus erythematosus in the younger patient: survival studies.

One hundred eighty-two patients fulfilling the American Rheumatism Association criteria for the classification of systemic lupus erythematosus (SLE) were followed prospectively. Sixty-seven had the onset of SLE before age 21, 32 before age 16, and 35 between age 16 and 20. All patients received similar therapy. Only 4 patients received cytotoxic agents. Malar blush, cellular casts, and profuse proteinuria were significantly more common in the 0-15 compared to the adult group (age 21 or older). Five-year survival was 100% for children with membranous or focal lupus nephritis and 85% for diffuse proliferative lupus nephritis.

Nummular keratitis associated with infectious mononucleosis.

A 16-year-old boy had a severe case of infectious mononucleosis with a rising titer to the Epstein-Barr virus. The patient had developed a nummular keratitis apparently associated with this illness. Because infectious mononucleosis or infection by the Epstein-Barr virus is often subclinical, and many cases of nummular keratitis have been classified as idiopathic in the past, a possible association between the two in such cases should be considered.

Aseptic necrosis of bone in systemic lupus erythematosus. Relationship to corticosteroid therapy.

The relationship of corticosteroid therapy to the development of aseptic necrosis (AN) in 365 patients with systemic lupus erythematosus (SLE) was investigated. Seventeen patients (4.7%) were identified as having AN. The dosage of corticosteroids ingested during the initial period of therapy in patients with AN was tabulated and compared with that of 25 SLE control patients. There was a substantially greater dose of costicosteroids ingested in the first one, three, and six months of therapy in the patients with AN than in the control SLE group. Severity of disease and duration of therapy were not found to correlate with AN. Total corticosteroid dose was virtually identical in both groups. Thus, high initial corticosteroid dosages in patients with SLE seem to be associated with the development of AN.

Systemic lupus erythematosus. Management during pregnancy.

The course of 27 pregnancies in 13 patients with systemic lupus erythematosus (SLE) is presented. The overall incidence of fetal wastage was 33.3%, a figure significantly higher than that observed in the general population. Although serum C3 complement levels rise during normal pregnancy, mean C3 levels remain within the normal range. Since it is a fall in complement levels in patients with SLE which may herald the onset of symptoms and provide a guide to therapy, assay of serum C3 complement levels remains a valid monitoring device in management of these patients during pregnancy. Flares of SLE during pregnancy generally should be treated vigorously with corticosteroids rather than by therapeutic abortion. Continuation of corticosteroid treatment during the first 2 months postpartum is advised to limit the incidence of exacerbation of SLE activity following delivery.

Oral mucosal ulceration in systemic lupus erythematosus.

In 182 patients with systemic lupus erythematosus (SLE), oral mucosal ulceration occurred in 47 patients (26%), was usually painless (82%), and most often involved the hard palate (89%). Oral ulceration was associated with an increase in overall clinical activity, although this was not accompanied by significant changes in the levels or titers of C3, anti-DNA antibodies, and anti-nuclear antibodies. Necrotizing vasculitis was not observed. Microscopic changes were similar to the skin lesions of SLE and immunoglobulin and complement were found in both the basement membrane and blood vessel walls.

Corticosteroid treatment in systemic lupus erythematosus. Survival studies.

Survival rates of two groups of corticosteroid-treated patients with systemic lupus erythematosus (SLE) have been compared using life-table analysis. Group 1 consists of 209 SLE patients studied in New York City between 1957 and 1968; group 2 consists of 156 SLE patients studied in Connecticut between 1968 and 1976. A similar percentage of patients in each group was followed up closely by one of us. The five-year survival rate for group 1 was 70%, compared with 93% for group 2. The improved survival could not be explained by differences in racial composition, incidence of CNS manifestations, or incidence of severe renal disease. The markedly improved survival may be due to several factors, including a generally better understanding of the disease and the recent use of newer antibiotics. The management of the two groups was similar, except that group 2 patient's conditions were managed not only on the basis of clinical evidence of disease activity but also on the basis of the serum complement (C3) level and on the basis of the level of antibody to native DNA. The data suggest that the use of such serologic values may lead to improved survival.

Skin immunofluorescence in infective endocarditis.

Immunofluorescent microscopy was performed on the clinically normal skin of 3 patients with infective endocarditis, 3 patients with bacteremia, and 6 normal subjects. Perivascular deposition of immunoglobulin and complement was demonstrated in two of the three patients with infective endocarditis and in none of the bacteremic or control subjects.

Metastatic melanoma. Another cause of a solitary pulmonary nodule with an air bronchogram.

Distinct air bronchograms were seen in a solitary pulmonary nodule, a metastasis from a malignant melanoma of the scalp. Such a finding has been reported previously only in alveolar-cell carcinoma, pulmonary lymphoma, and pulmonary pseudolymphoma.

Treatment of rheumatoid arthritis with gold.

There have been three important double-blind studies evaluating the use of gold therapy in rheumatoid arthritis. Patients treated with gold have decreased number of joints with synovitis, decreased ring size, increased grip strength, and roentgenographic evidence of arrest or decrease in the progression of skeletal lesions. If a patient with active synovitis does not respond to nonsteroidal anti-inflammatory drugs after four months of treatment, he is a candidate for gold therapy. Maintenance gold therapy has been shown to sustain clinical improvement. Patients must be monitored with appropiate laboratory tests.

Aseptic necrosis presenting as wrist pain in SLE.

Aseptic necrosis of the wrist in systemic lupus erythematosus (SLE) is not rare. In 156 patients with SLE, aseptic necrosis occurred in 11 patients, of whom 3 (27%) had wrist involvement. Onset of pain was insidious and the symptoms were thought to be related to synovitis due to SLE. An average of 11 months elapsed before aseptic necrosis was correctly diagnosed. An awareness of this possibility is important in the management of any patient with SLE who complains of wrist pain.