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Home , Lorazepam, Mefenamic acid

time, 3 months earlier. The physician, but was currently taking ophilia, thrombocytopenia, agranulo- the hotel manager and a close friend (Ponstan). The first cytosis, pancytopenia, marrow hypo- were all certain that the patient had not cycle of this drug had been uneventful. plasia and , but pancreatitis is consumed for several years. The second cycle, 250 mg four times a not mentioned.6 day for 4 days, had ended 4 days before Although our case does not establish Comments admission. The only other drugs she had mefenamic acid as a cause of pancreati- We have been unable to find any taken were prednisone (orally) and be- tis, physicians prescribing the drug other recorded case of over- clomethasone dipropionate (as a nasal should encourage patients to report ab- dose. Our patient took more than 10 spray) for 2 weeks for rhinitis. This dominal symptoms and should investi- times the recommended dose. treatment had been stopped 6 weeks gate these reports if indicated. The clinical picture 8 to 12 hours after before admission. ADRIANUS A. VANWALRAVEN, MD ingestion of the tablets resembled that of She was in severe pain and her Resident hypnotic withdrawal . Although breathing was shallow. Her blood pres- MARORITA EDELS. MD SAMANTHA FONG self-poisoning is fre- sure was normal and showed no postur- Ottawa General Hospital quent, confusion has rarely been de- al drop. Bowel sounds were distant. Ottawa, Ont. scribed.4 As triazolam is a short-acting There was marked tenderness in the benzodiazepine, overdose may be fol- epigastrium and left upper quadrant but References lowed by a precipitous fall in the drug's no guarding, rigidity or rebound tender- I. MALLORY M, KERN F: Drug-induced pancreatitis: a critical review. Gastroenterology 1980; 78: 813-820 serum concentration and the clinical ness. There was no tenderness to percus- 2. Drugs for . Med Left Drugs Ther 1979; 21: features of hypnotic withdrawal. In fact, sion of the flanks. Rectal examination 81-83 our patient was initially thought to be revealed no occult blood in the stool. 3. ANDERSON ABM, FRASER IS, HAYNES P1, TuRN. BULL AC: Trial of -synthetase inhibitors in suffering from . Nega- The only abnormal laboratory finding primary dysmes.orrhea. Lancet 1978; 1: 345-348 tive results of screening for beuzodiaze- was a high serum amylase level, 3315 4. KAPADIA L, ELDER MG: in treatment (normally 20 to 110) lU/l, and radi- of primary spasmodic dysmenorrhca. A double-blind pines (as a result of the short half-life of crossover study. Ibid: 348-350 the drug) may mean that physicians ologic investigation (roentgenography 5. BUDOFF PW: Use of mefenamic acid in the treatment of miss this diagnosis. and ultrasonography) failed to reveal primary dysmenorrhea. JAMA 1979; 241: 2713-2716 any abnormality. 6. Around North America with mefenamic acid. Med Leo B. TRAPPLER, MD, FRCP[CJ She was treated with analgesics (pe- Drugs Ther 1978; 20: 104 T. BEZEREDI, MD. FRCP[CJ Department of psychiatry thidine) and intravenous fluids. Within van.uver General Hospital a week she was free of pain and eating. Recurrent herpes simplex van.uver, BC At the time of discharge from hospital her serum amylase level was within To the editor: The persistent negative References normal limits. reports in the lay press and by doctors 1. VELDICAMP w, SmAw RN, METZLER CM, DEMIS- The clinical and laboratory data indi- who are interviewed on radio and televi- 5JAN06 Hv: Efficacy and residual effect evaluation of a cate that this patient suffered an epi- sion regarding the lack of a cure or new hypnotic, triazolam. J Clan Pharmacol 1974; 14: sode of acute pancreatitis. There was no treatment for recurrent herpes simplex 102-111 2. 5INGH AN, SAXENA B: Double-blind crossover compar- evidence of a precipitating event except has created a tremendous psychologic ison of triazolam and in hospitalized psychi- the recent exposure to mefenamic acid. burden for patients with this disease. atric patients with . Curr The, Res 1980; 27: To implicate a drug as a cause There are many diseases for which 627-633 of an 3. CHATWIN JC, JOHNS wL: Triazolam: an effective illness requires demonstration that the there is no cure but there is treatment. hypnotic in general practice. Curr The, Res 1977; 21: illness occurs during exposure to that For the past 2 years I have treated 207-214 4. vLAcHoS P, KENTARCHOU F, POULOS L, ALOUPO- drug, that it subsides on withdrawal recurrent herpes simplex types 1 and 2 GIANNIS G: poisoning. Toxicol Left 1978; 2: of the drug, and that the event is repro- with cryotherapy. I see the patient 109-110 ducible with re-exposure. Using these within 24 hours of the first evidence of criteria a recent review established aza- a recurrence, at which point the herpet- thioprine, , sulfonamides, fu- ic blisters are still intact. Theoretically Pancreatitis caused rosemide, estrogens and tetracycline as most of the herpesviruses are in the by mefenamic acid pancreatitis-inducing drugs.' The au- epidermal cells then,' so they are in the thors found less convincing evidence best location for topical therapy. I touch To the editor: A 32-year-old woman with respect to chlorthalidone, steroids the vesicles for at least 5 seconds and up was admitted to hospital because of and ethacrynic acid. Mefenamic acid to 10 seconds with a cotton-tipped ap- abdominal pain for 10 hours. She de- was not mentioned. A computerized plicator that has been dipped in liquid scribed the sudden onset of severe, search of the medical literature yielded . This causes mild discomfort. burning epigastric pain radiating no references to the association of mefe- Over the next 2 days the blisters dry through to her back. It was continuous namic acid and pancreatitis. and scab, then they usually clear within and aggravated by movement and deep Because of evidence that primary 4 days. breathing. She had vomited bilious ma- dysmenorrhea may be due to excess It has been my observation that there terial several times but not blood. The uterine activity mediated by prosta.. are several advantages to this treat- woman did not have a history of hyper- glandins, drugs thought to inhibit pros- ment. First, the duration of a recur- lipidemia, cholecystitis or peptic ulcer taglandin synthesis and action are cur- rence is substantially decreased - from disease. She had no food intolerance, rently popular for treating dysmenorr- 10 to 14 days with no treatment to 3 to had never smoked and drank little alco- hea.2 Some studies suggest they are 4 days with cryotherapy. Second, the hol (none within the past month). She more effective than conventional incidence of secondary bacterial infec- had had an appendectomy and had analgesics,35 although this is disputed.2 tion is negligible, possibly because cryo- borne four children. Despite serious reservations concerning therapy destroys bacteria in the area The woman suffered from dys- its toxicity mefenamic acid is one of and dries the fluids that are a good menorrhea, far which she had under- those drugs currently being marketed medium for the growth of bacteria. gone dilation and curettage a year ear- with this indication in mind.5 Reported Third, the frequency of recurrence is lier. She had tried a number of other adverse effects include leukopenia, eosin- decreased; perhaps the cryotherapy de- 894 CMA JOURNAL/APRIL 15, 1982/VOL. 126 stroys some of the herpesviruses or their ed me in September 1981 with com- which one attack generally confers ex- host cells. Fourth, some patients have a plaints of sore throat, fever and malaise. cellent immunity but recurrence or rein- total remission; however, whether the Her tonsils were large, red and covered fection is likely in a small proportion of remission is spontaneous or due to treat- in exudate. Several large, soft, tender cases, with most recurrences being sub- ment cannot yet be stated. Fifth, the submandibular lymph glands were pal- clinical and only a few presenting in the positive approach to treatment ("Yes, pable. Culture of a throat swab pro- classic fashion. there is something that can be done but duced no growth. The leukocyte count it may not cure you"), in contrast to the was 10.7 X 10'/l (79% were lym- I am grateful to Drs. E.B. Paul and W. totally negative approach ("Sorry, there phocytes, and 60% of these were atypi- Sinukoff for information regarding the first is nothing that works"), gives the pa- cal). A test for heterophil antibody (Mo- episode of illness in these patients. tient an immeasurable psychologic lift. nospot) gave positive results. J.A. MCSHERRY, MB, CH B The patient no longer feels scourged Her medical record showed she had Director with an incurable (venereal) disease. Student health service attended the student health service 9 Queen's University Even if the patient has recurrences, it is months before with identical complaints Kingston, Ont. evident from the first treatment that and similar clinical findings. Culture of their length has been decreased by 50% a throat swab had been unproductive. References to 75%. This in itself is positive. It gives The leukocyte count had been 6.5 X hope that a total remission may occur. i0'/l (39% had been lymphocytes, and I. FRY J: Infectious mononucleosis: some new observations One must presume that at some point 40% of these had been atypical). A from a 15-year study. J Fain Prac: 19B0; 6: lOB7-10B9 2. CHANG R5, MADDOCK R: Recurrence of infectious in the future an antiherpes vaccine or Monospot test had given positive results mononucleosis (C). Lancet 19B0; 1: 704 antibiotic will be developed that will then but negative results 2 weeks later, 3. HOAGLAND Ri: General features of infectious mononu- when the leukocyte count cleosis. In GLADE PR (ed): Infectious Mononucleosis, cure this disease, but until that time was normal. Lippincott, Philadelphia, 1973: 3-4 physicians must lift some of the gloom Case 2: A 20-year-old woman consult- 4. EVANS AS, NIEDERMAN JC, MCCOLLUM RW: Sero- that pervades the herpes problem. ed me in January 1982 because of sore epidemiologic studies of infectious mononucleosis with Epstein-Barr virus. N Engi J Med 1965; 279: Cryotherapy offers a safe, positive throat, fatigue and tender neck glands. 1121-1127 approach to this disease and does not Her tonsils were large and red and 5. EPSTEIN MA, ACHONG BG, BARR YM: Virus particles seem to act purely as a placebo. showed some exudate. Several large, in cultured lymphoblasts from Burkitt's lymphoma. fleshy, tender glands were palpable in Lance: 1964; 1: 702-703 I.E. ADAM, MD, FRCPfCJ 6. RICKINSON AB, JARvIs JE, CRAWFORD DH, EPSTEIN the left submandibular region. Culture MA: Observations on the type of infection by the EB 1081 Caning Ave. virus in peripheral lymphoid cells of patients with Ste. 403 of a throat swab was unproductive. The infectious mononucleosis. mt J Cancer 1974; 14: Ottawa, Ont. leukocyte count was 12.4 X 10./l (30% 704-715 Reference were atypical lymphocytes). A Mono- spot test gave positive results. I. RAAB B, LORINCz AL: Genital herpes simplex - concepts and treatment. J Am Acad Dermatol 1981; 5: She had experienced a similar illness, 249-263 diagnosed as infectious mononucleosis, 1 Prescribing year earlier. Then the leukocyte count of tranquillizers had been 15.9 X l0'/l (78% were lym- Recurrent infectious phocytes, and many were atypical). A To the editor: Two articles and an mononucleosis Monospot test gave positive results. A editorial that appeared in the Journal leukocyte count 4 months later was (1981; 125: 1225-1226; 1229-1232; To the editor: There appears to be an normal. 1211) could easily lead readers to con- unwritten consensus within the medical clude that tranquillizers are being indis- profession to the effect that infectious Comments criminately prescribed to women. There mononucleosis, like lightning, never Each episode of illness described in are many reasons why the data present- strikes twice in the same place. I wonder these cases can reasonably be diagnosed ed do not support this conclusion. if this view is accurate or whether it is as one of infectious mononucleosis. This The investigation by Bass and Bask- such a gross oversimplification that it prompts me to suggest that recurrence erville has methodologic deficiencies. It inhibits a real appreciation of the epide- may happen more often than is at pre- is a chart review without patient con- miology of infectious mononucleosis. sent accepted, and to conjecture that it tact; in such a study it is difficult to I have obtained a history of previous goes unrecognized owing to doubt about assess the appropriateness of manage- infection in a small proportion of the the veracity of a patient's history or ment in specific cases. The article class- patients with infectious mononucleosis failure to consider infectious mononu- ifies patients by "specific emotional that I have treated, and discussion with cleosis as a serious possibility when an complaints" that are, in fact, quite my colleagues leads me to conclude that unequivocal history of previous infection nonspecific. "Crying, feeling 'down', un- my experience is far from unusual, al- is given. Other sources of confusion may happy, nervous, worried, restless or though solid evidence of reinfection ap- be that so many episodes are subclinical4 tense" can indicate anything from a pears to be lacking. A review of the and that a patient's leukocyte count may normal brief emotional fluctuation to a literature on this topic has been unfruit- not be typical or even suggestive at the severe . Exactly why ful, producing evidence of proven recur- time of presentation. this deficiency is cited in the text as a rence in only five cases."2 This suggests The Epstein-Barr virus belongs to the virtue is hard to understand. Finally, that recurrence is rare or rarely diag- group consisting of herpesvirus hominis having isolated four factors that corre- nosed or perhaps is a common event that types 1 and 2, varicella-zoster and cy- late with a prescription for an anxiolyt- is ignored as it does not apparently fit tomegalovirus.5 It has been shown to ic, the authors descend into speculation the known facts. exhibit latency and reactivation in cell that does not include a well documented I wish to report two cases that satis- culture.' Can this be extrapolated to phenomenon: male physicians have dif- fied Hoagland's diagnostic criteria.3 indicate at least the possibility of reac- ficulty recognizing their own emotional tivation in vivo? problems. They also (naturally) identify Case reports Perhaps infectious mononucleosis more closely with patients of the same Case I: A 19-year-old woman consult- should be considered as a disease in sex. These two factors make it more

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