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ARCUS SENILIS AND ALCOHOL INTAKE
SIR,-Dr Castelli and his colleagues (July 23, p. 153) reporta strongly positive association between alcohol consumptionand high-density-lipoprotein cholesterol in their multicentrestudy. They report a more modest positive association betweenalcohol and triglycerides, and a negative association with low-density-lipoprotein cholesterol.These results interest us because of our observations on the
positive association between alcohol intake and arcus senilis.In 1970’ we reported on the connection between arcus senilisand a variety of attributes and risk factors in coronary pa-tients. These included age, lifetime smoking, serum-choles-terol, total serum-lipids, diastolic blood-pressure, alcohol con-sumption, glucose tolerance, obesity, fat folds, exercise
experience, haematocrit, uric acid, and serum-magnesium.An expected, positive correlation between intensity of arcus
and age was noted and a negative association with obesity wasexplicable on the grounds that older patients were lighter. Apositive association between lifetime alcohol consumption andintensity of arcus was significant (P<0-01) in 534 subjects. Noassociation was noted with the other attributes studied, includ-ing serum-cholesterol and total serum-lipids.
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We concluded that the relationship between arcus and alco-hol merited further study. Our findings and the report from DrCastelli and his colleagues may be of interest in postulating arole for alcohol, high-density-lipoprotein cholesterol, and/ortriglycerides in the genesis of arcus senilis and particularly ofarcus in its precocious from. There is certainly no substantialevidence in the literature to support the common view that
abnormally raised low-density-lipoprotein cholesterol is xtio-logically associated with precocious arcus.
The Sisters of CharitySt. Vincent’s Hospital,Elm Park, Dublin 4
RISTEARD MULCAHYNOEL HICKEYBRIAN MAURER
LEVAMISOLE-INDUCED ALLERGY
SIR,-Dr Christiansen and his colleagues (May 21, p. 1111)described two patients who had febrile reactions to levamisole.In a similar case our patient had reaginic antibodies (type I
allergy) to levamisole.A 69-year-old woman with Wegener’s granulomatosis (lym-
phomatoid type) diagnosed by chest X-ray and lung biopsy,had recurrent pulmonary and urinary-tract infections. On twooccasions Diplococcus pneumonice and Escherichia coli werecultured from her blood. The patient’s cellular immunity wasimpaired, as shown by negative skin tests for delayed hyper-sensitivity low in-vivo response of lymphocytes to mitogens.To improve cellular immunity levamisole, 50 mg three times
daily for three days a week, was started. During the secondweek, after she had had two tablets the patient had chills,fever, and confusion. Withdrawal of the drug resulted in reso-
MAST-CELL SENSITISING ANTIBODY IN SERUM OF PATIENT
TREATED WITH LEVAMISOLE
*200 mast cells were evaluated in each experiment.
1. Hickey, N., Maurer, B., Mulcahy, R. Br. Heart J. 1970, 72, 449.
lution of all symptoms with 24 h. 14 days later a challenge of50 mg levamisole was given. 3 h later the patient had severechills and fever and became unconscious. Clinical and labora-
tory investigations, including urine and blood cultures, failedto reveal any cause; the symptoms resolved within 3 days.We looked for reaginic antibodies in the patient’s serum by
the indirect mast-cell degranulation test.1,2 Serum was testedfor ability to degranulate rat mast cells in the presence oflevamisole. As shown in the table, serum before treatment withlevamisole (June 25) was negative while serum after treatment(Nov. 16) caused degranulation. Incubation of active serum at56°C for 4 h rendered the serum inactive, which suggests thepresence of antibody of the IgE type. 3
These clinical and laboratory findings suggest that our pa-tient had a type-I allergy to levamisole. Levamisole is used inpatients with impaired cellular immune response such as
autoimmune and neoplastic diseases. Fever and chills are notuncommon in these clinical states, and allergy to levamisolecould be a precipitating factor.
University Department of Medicine B,Ichilov Medical Center
and Department of Human Microbiology,Tel-Aviv University Medical School,Tel-Aviv, Israel
ISRAEL YUSTNURITH VARDINONEDITH FIERSTETERLEON A. AVRAMOV
CYCLOPHOSPHAMIDE AND MALIGNANCY
SIR,-The correspondence in your columns (June 18, p.1306, July 23, p. 196) provides an opportunity for drawingattention to a change in prescribing recommendations forcyclophosphamide (’Endoxana’). Although present prescribinginformation does identify possible complications such as sub-sequent malignancies, particularly in relation to use in
non-malignant conditions, the latest data indicate that it is
appropriate to strengthen this warning. Therefore all futureprescribing information for endoxana will omit reference touse in non-malignant disease other than in life-threateningsituations. Naturally further details will be available from thisCompany if required, but it is hoped that this change will serveto increase awareness of possible secondary hazards.
WB Pharmaceuticals Limited,PO Box 23, Bracknell, Berkshire RG12 4YS.
P. A. KNOWLSONMedical Director
ZINC AND DIALYSIS ANÆMIA
SIR,-Dr Stewart and his colleagues (July 16, p. 139) areright to draw attention to the fact that dialysis anaemia is acomplex multifactorial problem. They found that dialysingagainst zinc concentrations of about 5 mol/1 initially, fallingto 1.5 5 [jLmol/t a year later, did not lead to anaemia, and theywonder whether we were somewhat hasty in ascribing ourproblems of dialysis anaemia to zinc concentrations which werenot markedly greater than theirs.We had two groups of dialysis patients being dialysed
against the same mains water. Thus any toxic agent present inmains water should have caused problems in both units.Anaemia occurred in the satellite unit only. The anaemia "epi-demic" coincided with the introduction of a galvanised-ironwater softener to the satellite unit, and occurred in associationwith the elution of zinc from the new water softener.4 The gal-vanised iron may have contained a metallic impurity whichwas eluted along with zinc and which we failed to detect. It isalso possible that zinc acted as a cofactor potentiating anaemiacaused by chloramines or some other impurity in the mainswater. It is however difficult in the face of the association we
1. Vardinon, N., Levanon, M., Schwartz, J. Acta allergol. 1967, 22, 28.2. Schwartz, J., Eyquem, A., Vardinon, N. Immun. Commun. 1975, 4, 243.3. Ishizaka, K., Ishizaka, T., Menzel, A. I. O. J. Immun. 1967, 99, 610.4. Patrie, J. J. B., Row, P. G. Lancet, 1977, i, 1178.
