Edema and Oral Acyclovir

No. 4

Correspondence

Reichenstein was a small mining town in the county of Glatz, Silesia. Gold was mined there for centuries from gold containing arsenical ores (arsenopyrite and lollingite), with arsenical fumes precipitating with the rain to contaminate the drinking water. Later, only arsenic was produced. For centuries, a high incidence of serious disease was known in this town. Yet, not until 1898 was this Reichenstein disease recognized as chronic arsenicism.'" In 1928, a new water supply was provided that was low in arsenic, and smelting methods changed, so Reichenstein disease is alleged to have disappeared if one believes a 1940 German report by Geyer cited by Neubauer.^ Because arsenic is known to have a carcinogenic lag of up to 50 years, however, one wonders about the accuracy of this wartime German article. In 1989, when I was in the Silesian capital of Wroclaw for the Polish Dermatologic Congress, 1 inquired about Reichenstein without success. What is the modern history of Reichenstein and Reichenstein disease? What makes this question difficult is the historical aspects ofthe four partitions of Poland (the fourth in 1939 by Russian and German troops beginning World War II). I hope that Drs. Lin, Imaeda, or Stewart or another dermatologic gazetteer can answer this question.

ever, should be under control very soon due to the stable conditions of today. Within the current millennium, the overlords in Glatz have changed well over a dozen times.' Before 1278, the area belonged to the Kingdom of Bohemia when it was handed over to Poland where it belonged to several feudal lords until 1322. It was then sold back to Bohemia by Duke Boleslaw III. Thereafter, it was held by the then Kings of Bohemia o f t h e House of Luxemburg or their relatives. In 1500 or 1501, the County of Glatz was sold to Ulrich Count Hardegg (of Austria) who himself sold it in 1534 to the future Emperor Ferdinand I (1503-1564) (of Hapsburg). The latter had to pawn it for a while, but finally again incorporated it into the Kingdom of Bohemia, which by then was already Hapsburg territory (since 1526). During the subsequent two centuries the county had several members of the imperial family, one archbishop of Salzburg, and other members of Bohemian and German nobility as titular lords (Grafen, i.e.. Counts of Glatz). In 1742, during the raging War of Austrian Succession, Silesia was invaded by Frederick II (17121786) of Prussia to whom Maria Theresa (1717-1780) of Austria had to cede the area. The territory remained with Prussia until 1945 when it returned to Poland again. The changing back and forth of overlords antedated the classical partitions of Poland by centuries.

Robert A. Schwartz, M.D., M.P.H. Newark, New Jersey

Karl Holubar, M.D. Vienna, Austria

References 1. Lin AN, Imaeda S. A dermatologic gazetteer. Int J Dermatol. 1990;29:468-471. 2. Stewart WD. Geographic dermatology. Int J Dermatol. 1990;29:477-478. 3. Neubauer O. Arsenical cancer: A review. Br J Cancer. 1947;1:192-251. 4. Schwartz RA, StoU HL Jr. Sqamous cell carcinoma. In: Fitzpatrick TB, et al., eds. Dermatology in General Medicine, 4th ed. New York: McGraw-Hill (in press). . , ^•j-; ••

Dr. Stewart Replies to Dr. Schwartz Thank you for your inquiry about Reichenstein and its disease, and for your comments on the game of names. I cannot go any further than you have, although 1 agree that a modern review would be of interest in view of the changed exposure to arsenic in the town's drinking water. It has been suggested that there is a genetic susceptibilitv to arsenical carcinogenesis, and perhaps one could study families formerly affected and still living in the town. William D. Stewart, M.D. Vancouver, British Columbia, Canada

Reichensteiner Krankheit-Reichenstein Disease I fully confirm the remarks of Dr. Schwartz regarding chronic aisenicism in the Reichenstein area over the centuries as amply outlined b> Mavci in 1933.' During my own reference to this problem in 1975,^ 1 could not find any more recent post-World War II follow-up reporls on the incidence of chronic arsenicism in this particular area ol Silesia I should like to comment upon the political situation in the County of Glatz (about J600 square kilometers), which is a typical example of changing sovereignity frequently found in Central Europe. In recent history, as outlined by Dr. Schwartz, this fact has surely prevented a closer follow-up ofthe above disease, which, how-

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References 1. Mayer RL. Toxicodermien I. In: Jadassohn J, ed. Handbuch der Haut- und Geschlechtskrankheiten. Berlin: Springer, 1933;4:1252. 2. Holubar K. Das Basaliom. In: Jadassohn J, ed. Handbuch der Haut- und Geschlechtskrankheiten (supplementary edition). Berlin: Springer, 1975;3:235-39O. 3. Meyers Grosses Konversations-Lexikon Bibliographisches Institut Leipzig and Vienna 1907. Vol. 8. 6th ed. Glashlille bis Hautflugler, 12-13.

Edema and Oral Acyclovir To the Editor: A 75-year-old woman received furosemide (40 mg/day orally) and spironolactone (50 mg twice a day orally) because of chronic hepatic failure secondary to occlusion of the major hepatic veins (BuddChiari syndrome). She experienced crops of painful vesicles on an erythematous basis located on the right periorbital and temporal areas. A diagnosis of herpes zoster was made and treatment with oral acyclovir (800 mg five times a day) was instituted. Four days after starting acyclovir therapy, the patient experienced nausea, vomiting, headache, ascitis, and peripheral edema. A 4-cm hepatomegaly was found. Serum blood urea nitrogen and creatinine levels were normal and were similar to the values before acyclovir therapy. A complete blood cell count, urinalysis, and electrocardiogram were normal. Serum aspartate-amino-transferase (AST) and alanine-amino-transferase (ALT) values were normal, as they were before acyclovir therapy. Acyclovir withdrawal together with doubling ofthe furosemide dosage was followed by the disappearance of edema within 2 weeks. Five months after discharge, the patient's condition remains stable. Peripheral edema is an exceedingly rare side effect of oral acyclovir. The development of peripheral edema has been reported in two patients receiving oral acyclovir therapy for herpes zoster: one with congestive heart failure and one with systemic lupus erythematosus and chronic renal insufficiency.' These two cases and ours have in common the development of fluid retention induced by acyclovir in patients with a limited ability to eliminate excessive amounts of

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water. The conditions of all three patients improved when acyclovir was interrupted and the dose of diuretic therapy was increased. None ofthe three patients had a significant deterioration in renal function. The accumulation of acyclovir crystals in the lower nephron after a rapid bolus injection of acyclovir may result in renal blockage in rats.-^ To our knowledge, however, these effects have not been tested in humans, but one would expect that very high doses of orally administered acyclovir would be needed to induce this phenomenon. On the other hand, acyclovir might reduce the eificacy of diuretics.' Thus, we suggest that acyclovir therapy should be used carefully in patients with impaired elimination of excess fluid or those receiving diuretic therapy. Drug Names acyclovir; Zovirax furosemide; Lasix-, SK-Furosemide spironolactone; Aldactone Susana Medina, M.D. Antonio Torrelo, M.D. Agustin Espana, M.D. Antonio Ledo, M.D. Madrid, Spain References 1. Hisler BH, Daneshvar SA, Aronson PJ, Hashimoto K; Peripheral edema and oral acyclovir. J Am Acad Dermatol. 1988;5;1142-1143. 2. Tucker WE; Preclinical toxicology profile of acyclovir; An overview. Am J Med. 1982;(Suppl 1A)73;27-3O.

Vol. 30

Sebaceous Hyperplasia of the Chest To the Editor; Lesions of sebaceous hyperplasia are well known. Standard reference books and articles note that these lesions occur on the face chiefiy on the forehead and cheeks. 1 was not able to find any reports of their occurrence in sites other than the face. The purpose of this communication is to document sebaceous hyperplasia involving the chest. Case Report A 44-year-old man presented with skin lesions ofthe face and chest. He was otherwise in good health. Physical examination revealed scattered melanocytic nevi and a 2-mm elevated, minimally yellowish, slightly umbilicated papule on the anterior chest. This lesion was biopsied to exclude basal cell carcinoma. Histologic examination of the specimen revealed enlarged hyperplastic sebaceous glands. Discussion The apparent paucity of lesions of sebaceous hyperplasia in areas other than the face is striking. The chief significance of these lesions on the chest would appear to be similar to their significance on the face, ie, differentiation from basal cell carcinoma. At least one major standard reference text still refers to these lesions as senile sebaceous hyperplasia. Senile is defined as pertaining to old age or manifesting senility. This seems to be an inaccurate term for a condition that affects many active middle-aged adults. Daniel J. Hogan, M.D. Miami, Florida

Society News New Members of the International Society of Dermatoiogy: Tropical, Geographic and Ecologic W. P. Daniel Su, Membership Chairman Joseph Albert, M.D. 657 Franklin Street Framingham, MA 01701 Miguel Moreno Armijo, M.D. Departamento Dermatoiogia Hospital General Universilario Po San Vicente s/n Salamanca 37007 Spain Sambit Natb Bliattacbarya, M.D. C4 Sarovar Apartments 26/H/12 Radha Madhav Dutta Garden Lane Beliaghata Calcutta 700010 India

Sara Ximena Diaz, M.D. Calle 110 A#5-43 Bogota Colombia Lucius C. Earles, III, M . D .

2600 S. Michigan Avenue Suite 315 Chicago, IL606I6 Agnes Morales Espinoza, M.D. 13 P. Quiambao Street Tierra Bella Diliman Quezon City Philippines

Anup Kumar Chaudhry, M.D. 22/11 KishanGanj Delhi 110007 India

Catalina Marques, M.D. C/Sant Elies 10-A-60-D Palma De Mailorea 07003 Spain

Jorge Luis Crespo, M.D. Keene Clinic 590 Court Street Keene, NH 03431

Purita Cban Noble, M.D. 95 Malvar Street Baguio City Philippines

Grace Oamil Ralleea, M.D. 94-542 Awamoi Street Waipahu. HI 96797 Kalatbur N. Sarveswari, M.D. 15 *U' Block Plot No. 4050-4th Main Road Anna-Nagar Madras 60040 Tamil Nadu 60040 India Parameswaran Nair Sasliidbaran, M.D. Dermatologists King Khalid Hospital P.O. Box 1120 Najran Saudi Arabia Natalie Shaffer, M.D. 59 Holtham Road Montreal H3X3N3 Canada Mauuel Cornillez Ty, M.D. 65 Tricom Building Gil Puyal Avenue Makati Metro Manila Manila Philippines

Reynaldo Lucero Ugalde, M.D. 67 Purdencio de Santos Street BF Homes, Phase VI-A Paranaque Metro Manila 1700 Philippines Enrique J. Uraga, M.D. PO Box 4193 Guayaquil. S.A. Ecuador Corazon Rubio Villaluz, M.D. Derm. Inst. ofthe Philippines MGF Champaea Building, 4th Floor 156 Amersolo Corner Pasay Road Lcgazpi VIg./Makati Philippines Rony Ziv, M.D. 6 Lilian St Tel-Aviv 64043 Israel