Tolnaftate

Differential Diagnosis for Chronic Fatigue Syndrome.

TO THE EDITOR: I have just read the recent article on chronic fatigue syndrome (CFS). (1) While the authors present an excellent framework for the evaluation and management of patients with chronic fatigue, they have overlooked a differential diagnosis. Celiac disease, also known as gluten-sensitive enteropathy (GSE), may present as CFS (2-5) and is highly treatable.

A study (2) reported that 2 percent of 100 patients who met diagnostic criteria for CFS actually had occult GSE. Neither patient reported symptoms typical of celiac disease and both had normal hematologic and serum protein analysis. Both patients were under treatment for hypothyroidism and were euthyroid. One article (3) presents a case report of a patient with occult celiac disease who fit the criteria for CFS. This author suggested that autoantibodies against endomysium (transglutaminase) and gliadin be routinely evaluated in patients presenting with chronic fatigue. Another study (4) found a high prevalence of GSE in patients with vague chronic symptoms such as fatigue and lassitude.

A review article (5) on celiac disease suggests that patients with fatigue should be screened for GSE. Certainly patients with iron deficiency and symptoms such as diarrhea should be evaluated for GSE. I propose that GSE be considered in the evaluation of patients who meet the criteria for CFS.

REFERENCES

(1.) Craig T, Kakumanu S. Chronic fatigue syndrome: evaluation and treatment. Am Fam Physician 2002;65:1083-90.

(2.) Skowera A, Peakman M, Cleare A, Davies E, Deale A, Wessely S. High prevalence of serum markers of coeliac disease in patients with chronic fatigue syndrome. J Clin Pathol 2001;54:335-6.

(3.) Empson M. Celiac disease or chronic fatigue syndrome--can the current CDC working case definition discriminate? Am J Med 1998;105:79-80.

(4.) Hin H, Bird G, Fisher P, Mahy N, Jewell D. Coeliac disease in primary care: case finding study. BMJ 1999;318:164-7.

(5.) Fasano A. Celiac disease: the past, the present, the future. Pediatrics 2001;107:768-70.

IN REPLY: Thank you to Dr. Nelsen for bringing up this item. This would increase our differential diagnosis that must be included to successfully exclude diseases that may mimic chronic fatigue syndrome.

Using a Metal Detector to Track a Swallowed Penny

TO THE EDITOR: During a phone conversation with my wife, she informed me that our four-year-old son, Charlie, had swallowed a penny. I asked her the usual questions: "Is he okay?," "Is he breathing all right?," "Swallowing his saliva?," "Talking?" She answered yes to all these questions, but added that he was scared and was crying.

My first thought was to have a radiograph taken to localize the penny. Then I had another thought. Because I was almost out the door to go home, I told my wife to keep Charlie calm. I told her that the main thing we needed to know was where the penny was in the gastrointestinal tract, and that if he was breathing, talking, and swallowing normally, the penny was at least past the vital areas. I told her I would try to locate the coin with the metal detector when I got home.

Arriving home about 15 minutes later, our 12-year-old son, John, greeted me at the door and said, "Dad, the penny is at the bottom of his chest, but not in his stomach." I asked him to show me how he knew that. He asked Charlie, who thought the process pretty neat, to lie down on the floor on his back with arms and legs stretched out. John then moved the metal detector slowly back and forth over Charlie. When it got over the xiphoid, it beeped.

As a test, I then hid pennies under Charlie at other locations: hand, leg, and pelvis. The metal detector pinpointed each of them. I then had Charlie try to drink some liquid. After I was sure he was having no problem, I asked him to eat some semisolid, then solid foods. All went down fine. I decided to watch him until morning.

Just before bedtime, we checked Charlie again with the metal detector. The coin had moved into the stomach, as evidenced by beeps over an area 4 cm below the xiphoid near the midline. By morning, the coin had moved even further, as evidenced by metal detector beeps in the right lower quadrant. After lunch, Charlie had a bowel movement. He sat on a plastic grocery bag stretched over the toilet seat, and out came the penny with the stool.

Erythrasma and Common Bacterial Skin Infections

TO THE EDITOR: I read with great interest the article entitled, "Common Bacterial Skin Infections," (1) and I would like to make an additional comment concerning cutaneous erythrasma and its causative organism, Corynebacterium minutissimum. (2) Erythrasma is a cutaneous disorder of which the lesions may present as patches that are asymptomatic and well defined, or irregular in shape and size and red in color. The lesions may become brownish and appear slightly raised from the surrounding skin with the appearance of central clearing. Interdigital erythrasma is a common bacterial infection of the foot.

In some studies, up to 30 percent of patients with interdigital erythrasma have been found to have a coexisting dermatophyte or Candida albicans infection, usually noted in the third and fourth interspaces. (2) Areas of the body that favor C. minutissimum growth are moist, occluded intertriginous areas such as the axillae, inframammary areas, and interspaces of the toes, as well as the intergluteal and crural folds. Factors such as a warm climate, poor hygiene, obesity, hyperhidrosis, advanced age, compromised host status, and diabetes mellitus also play a role in the occurrence of this organism.

The differential diagnosis of erythrasma includes psoriasis, dermatophytosis, candidiasis, and intertrigo. Examination with Wood's light shows a coral-red fluorescence and is the diagnostic procedure of choice; however, microscopic examination and cultures may be required in certain instances when the Wood's light examination is negative, yet the organism is still suspected and a detection and treatment algorithm has been proposed. (2)

The most effective treatment is erythromycin (250 mg, four times daily for 14 days) with cure rates (both clinical and bacteriologic) as high as 100 percent. In patients with interdigital involvement or hidden reservoirs, some form of local therapy is recommended, such as clindamycin (Cleocin) or Whitfield's ointment applied once daily during the course of oral therapy and continued for two weeks after the physical clearance of these areas. Interestingly, a literature search of the treatment of interdigital erythrasma, antifungal agents that have been proposed for topical treatment, such as tolnaftate (Tinactin), haloprogin (Halotex), clotrimazole (Lotrimin), bifonazole (Canesten), and econazole (Spectazole), yield poor and inconclusive results in the treatment of this condition. (2)

REFERENCES

(1.) Stulberg DL, Penrod MA, Blatny RA. Common bacterial skin infections. Am Fam Physician 2002;66: 119-24.

(2.) Holdiness MR. Management of cutaneous erythrasma. Drugs 2002;62:1131-41.

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