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A syndrome of acute onset of inflammation over interphalangeal joints heralding deforming osteoarthritis may be intermediate between degenerative and rheumatoid joint diseases. The syndrome appears predominantly in women of menopausal age and is remarkably symmetrical. In a prospective study of 170 propositi, later changes more characteristic of rheumatoid arthritis than of generalized or erosive osteoarthritis developed in 15.3%.

Shulman's syndrome includes fasciitis of rapid onset, sclerodermoid skin changes, absence of Raynaud's phenomenon, absence of visceral manifestations of progressive systemic sclerosis, hypergammaglobulinemia, transient eosinophilia, and a dramatic response to systemic corticosteroid therapy. Although this syndrome may be a variant of scleroderma, its dramatic responsiveness to corticosteroid therapy is a particularly distinguishing feature.

An outbreak of lymphocytic choriomeningitis (LCM) associated with pet hamsters adquired through nationwide distributor was recognized in New York in February 1974. In upstate a New York, 57 cases occurred in a four-month period. Complete information was obtained on 49 patients ranging in age from 3 to 70 years. Characteristic findings included fever (90%), headache (85%), and severe myalgia (80%). Typically, laboratory findings consisted of a normal blood cell count and cerebrospinal fluid with mononuclear leukocyte pleocytosis and moderate hypoglycorrhacia. Al patients had contact with hamsters from one distributor. Most of the hamsters were acquired in mid to late December 1973, but some as late as March 1974. From each of eight families in which hamsters were available, at least one hamster had detectable complement-fixing antibodies for LCM. Infection rates within families varied with location and type of hamster cage; open cages and cages situated in common living areas were associated with highest infection rates (45% and 52%, respectively). Severity of illness was not associated with direct contact with hamsters. Onset of illness occurred between 8 and 90 days after initial exposure to hamsters.

A patient given long-term total parenteral nutrition acquired a zinc deficiency severe enough to cause typical cutaneous manifestations of acrodermatitis enteropathica. This report, the first detailed one, to our knowledge, of such an association, adds to the accumulating evidence that supplementation of trace elements is needed in long-term parenteral nutrition. ( JAMA 235:2399-2402, 1976)

Seven patients with measles and chickenpox concurrently were observed. In five children evidence of viral interference was present, which resulted in a clearly discernible modification of one or the other exanthem. A phenomenon not previously described was observed in three patients; the number of varicella lesions were markedly diminished when the measles appeared concomitantly with the chickenpox. In a fourth similar patient there appeared to be later breakthrough of varicella lesions. In a single patient the chickenpox lesions appeared before those of the measles, and local sparing of skin by the rubeola rash about the varicella lesions was noted.

An atypical measles illness occurred in ten children who had received inactivated (killed) measles virus vaccine five to six years earlier. The illness is characterized by a two- to three-day prodrome of fever and complaints of pain (head, muscle, and abdomen, or both muscle and abdomen) followed by the development of a maculopapular rash with petechial, vesicular, and urticarial components. Peripheral edema and pneumonia occurred in almost all the children. In three instances, significant pleural effusions were noted. Serologic determinations established the diagnosis in all ten children, but measles virus was recovered from none of them.

In a study of dengue fever in Thailand, bone-marrow examinations showed hypocellularity early in the disease, followed by hypercullarity during recovery and normocellularity in convalescence. Thrombocytopenia due to megakaryocytic suppression was a characteristic. In 18 patients with early dengue, thrombocytopenia lasted one to four days; platelet counts in 8 were less than 50,000/cu cm. Petechiae or other bleeding manifestations were noted in 15 patients. Intensive hematologic studies of dengue infections in other geographic areas are suggested, to determine if thrombocytopenia is a universal characteristic of this and related virus diseases.

To the Editor.— I would like to describe briefly a case quite similar to those reported by Drs. Mandy and Ackerman (213:253, 1970).On Jan 31, 1969, a 42-year-old man was found unconscious in his car after taking 24 tablets of a secobarbital-butabarbital mixture together with much alcohol. He regained consciousness the next day, saying that he had wanted to commit suicide. Twenty-four hours after admission, "blisters" developed on heels, buttocks, and fingers. These were first described as "pressure sores" with an erythematous base, but they rapidly changed into large tense vesicles and bullae. The subsequent course was uneventful except for a pneumonia which subsided on antibiotic treatment. The skin lesions had healed by the time of discharge on Feb 13.We were impressed by the rapidity of development and peculiar distribution of the skin lesions. The body position while he was unconscious in the automobile, we learned later

It has been noted on occasion that chickenpox and measles may occur together or one may precede the other by a few days. Artenstein and Weinstein 1 estimated that about 15 such cases occurred in the state of Massachusetts in 1961. On the other hand, Merigan et al 2 noted the occurrence of both diseases within a few weeks in seven of 18 children who were admitted to a youth guidance center. It is probable that double infections are more likely to occur when the patients are young and when opportunity for intense exposure to both agents is present. The most remarkable thing about these cases of double infection is the finding that the first infection may diminish the severity of the rash of the second infection. Evidence for interference with measles rash by chickenpox is based on the finding of clear zones of normal skin encircling healing chickenpox crusts

Specificn be found in more than a third of patients with systemic sarcoidosis. These lesions represent dermal sarcoid granulomas and are capable of wide variation in clinical appearance, even though the microscopic picture is constant. Examination with eye and hand (for the infiltrate is often more easily palpated than seen) must be followed with microscopic verification. Jonathan Hutchinson described cutaneous sarcoid almost 70 years ago under the title of "Mortimer's malady." Hutchinson was not aware that these lesions on the skin reflected a systemic problem. Accurate diagnosis of sarcoidosis can be facilitated by the examination of material easily obtained from cutaneous lesions. Every patient with suspected sarcoidosis should be carefully examined for possible diagnostic dermal granulomas.

Diagnosis of systemic lupus erythematosus (SLE) was confirmed by the presence of lupus erythematosus cells in 75.7% of the patients, findings of skin biopsies in 6.0% and of renal biopsies in 1.2%, and by the clinical picture alone in 17.1%. Negroes comprised 34% of the subjects. Spontaneous remissions occurred in 35% of the patients. Proven familial SLE occurred in 2%. Myalgia was present in 48.2%. No history of cutaneous involvement at any time was found in 28%. Classic skin lesions of chronic discoid lupus at the onset of their illness were present in 10.8%. Urinary abnormalities were noted in only 46.1%. Uremia caused 34% of the 135 deaths and progressive central nervous system involvement caused 18.4%. The prognosis has markedly improved. The mean duration is now 94.8 months for the entire series versus 38.5 months in an untreated control group.

The diabetic state is usually manifested by the well-known vascular lesions occurring in the eye and kidney. However, there is also a skin manifestation with striking hues of brown, red, yellow, and purple due to vascular damage, which clamors for attention. This lesion is not only a sign of overt diabetes, but also of the "prediabetic" state and may occur several years before any abnormality in carbohydrate metabolism can be found. Necrobiosis lipoidica diabeticorum (NLD) usually appears in the pretibial region as an asymptomatic, nonulcerating, sclerotic plaque. Brownishred coloration gradually gives way to the more characteristic yellows and purples. Fine telangiectatic vessels can be seen through an atrophic "glazed" surface covered by slight scale (Figure, left ). Occasionally more wide-spread lesions occur (Figure, center ). A biopsy specimen is diagnostic when necrobiotic collagen surrounded by a granulomatous response, thickened vessel walls, and positive fat stains are found. About 60% of people with

But where the greater malady is fix'd The lesser is scarce felt. Shakespeare: King Lear , Act III, scene 4 Rabies in man is a uniformly fatal disease once clinical symptoms appear. In a human bitten by a potentially rabid animal, the only hope of rabies prevention lies in effective postexposure prophylaxis, which at the present time consists in the administration of antirabies serum (equine origin) followed, if indicated, by a course of duckembryo or nervous-tissue vaccine. Our hospital is located in an area with the greatest concentration of enzootic and epizootic rabies in the United States. 1 In 1963, over 31% of all rabid dogs in this country were reported from the US-Mexico border; of these 186 animals, 44 were from the city of El Paso alone. 2 Because of the high risk of rabies in the area, we have evolved a vigorous program of rabies prophylaxis, following the criteria

The anticonvulsive properties of carbamazepine (Tegretol) were investigated in 87 patients who suffered with various forms of epileptic seizures. All of these patients had been refractory to treatment with one or more of the standard antiepileptic drugs. This study demonstrated that carbamazepine is an effective anticonvulsant and particularly useful in the control of psychomotor (temporal lobe) epilepsy. Visual disturbances, primarily diplopia, and cutaneous reactions were the most common side effects observed in this group of patients. No irreversible untoward reactions were encountered. A review of the literature revealed that other investigators also found carbamazepine effective in the control of epileptic seizures. Several physicians reported serious and fatal hematopoietic disturbances in association with this therapy.

The effect of poverty on nutrition of preschool children was evaluated in 300 children randomly selected from 2,427 black children of poverty families living in south Memphis. Half of the children were found to be below the 25th percentile for height and weight on anthropometric charts. Anemia was common; 28% of the children less than 3 years of age had hemoglobin levels below 10 gm/100 ml, and 25% of the children older than 3 years had levels below 11 gm/100 ml. The extremely low family incomes and information gained by home visits indicated that lack of food was the main cause of growth retardation and anemia.