EXPERIENCE AND REASON-BRIEFLY RECORDED 829
component. This suggests host factors might be
more important determinants of an associated
arthritis developing than the particular virus
involved. However, the congenital heart lesion
in our patient would not appear to be related
to the development of viral arthritis and no
as-sociated disorder was apparent in Dr. Ward’s
case. These findings may also be interpreted to
indicate arthritis represents a rare complication of varicella infection.
SUMMARY
The second case of chicken pox with
associ-ated arthritis is described. Clinical features, as
well as the results of serological investigation
and synovial fluid analysis, are reported. The
differential diagnosis and rarity of this
compli-cation is discussed.
LAWRENCE M. MULHERN, M.D.
Division of Rheumatology GILBERT A. FRIDAY, M.D. Department of Pediatrics
J
OlIN A. PERRI, M.D.Department of Orthopedic Surgery Mercy Hospital
1400 Locust
Pittsburgh, Pennsylvania 15219
REFERENCES
1. Bullowa, J. C. M., and \Vishik, S. M. :
Compli-cations of varicella. Amer. J. Dis. Child., 49: 923, 1935.
2. \Vard, j. R., and Bishop, B. : Varicella arthritis. J.A.M.A., 212:1954, 1970.
Elevation
of
Serum
Urea
Nitrogen
in Hypothyroidism
The occurrence of an elevated serum urea
nitrogen (SUN) in a hypothyroid patient
prompted us to review the records of patients
with hypothyroidism in whom a SUN or
non-protein nitrogen (NPN) was obtained prior to
treatment. The initiating case and the results of
the record review are the subject of this report.
CASE HISTORY
P. L. weighed 3,908 gm ( 8.6 pounds
)
at birthand was the product of a 21-year-old, gravida one, Caucasian female, following a 10-month gestation period. He was initially seen at the Johns Hopkins Hospital at 5.5 months of age and was referred for evaluation of anemia. A history of constipation and infrequent crying was obtained.
The family history was unremarkable.
Physical examination revealed a length of 64.8
cm (25.5 inches), a weight of 7,454 gm
(
16.4pounds), a head circumference of 43.9 cm (17.3
inches
)
, and an immature upper lower ratio of1.71 (normal 1.62). The anterior fontanelle was
open, the blood pressure was 85/60 mm of Hg, the
pulse was 120 beats per minute, and the
respira-tions, 30 per minute. He had a broad thick tongue protruding from his open mouth, dry skin, and a small umbilical hernia. The Moro, suck, and grasp
reflexes and muscle tone were normal; and the
re-mainder of the examination was within normal lim-its.
Laboratory evaluation revealed a hemaglobin of 8.6 gm/100 ml, hematocrit of 27%, a T4 of 0.8 g
/100 ml, a bone age of 37 weeks’ gestation,
ab-sence of thyroid antibodies, and no visualization of the thyroid gland on scan. In addition lie was found to have an elevated SUN
(
31 and 29 mg/100 ml), but the serum creatinine (0.8 mg/l00
ml
)
, urinalysis, creatinine clearance, IVP, voidingcmncystourethrogram, and two urine cultures were normal.
After 4.5 months of thyroid therapy his length increased 14 cm (5.5” ), his weight, 3,818 gm
(
8.4 pounds)
and his SUN decreased to 20 mg/100 ml.RESULTS OF RECORD REVIEW
The records of 19 additional patients, seen
in the Pediatric Endocrine Clinic at the Johns
Hopkins Hospital, with hypothyroidism and
SUN or NPN determined prior to therapy were
reviewed (Table I).
Thyroid dysgenesis was the etiology of
hypo-thyroidism in 13 (seven females and six
males) . Four of these 13 had SUN or NPN
val-ues that were above the range of normal and
three of these four were less than 2 years of
age. Cholesterol values were elevated in six of
the patients, and five of the six were older than
2 years of age. Only two patients had both an
elevated SUN or NPN and cholesterol value.
Three patients had SUN or NPN values which
were at the upper limit of normal, amid one of
the three had an elevated cholesterol value. If
it is assumed that the PBI-T4 difference is 1
p.g/100 ml, then all patients with elevated SUN
or NPN values and five of the six patients with
elevated cholesterol values had corrected T4
values of 0.9 .tg/100 ml or less.
In seven (five females and two males) of the
20 patients, thyroiditis was the etiology of the
hypothyroidism. All patients were 9.5 years of
age or older. None of these patients had
ele-vated SUN or NPN values. Three of the seven
830 UREA NITROGEN IN HYPOTHYROIDISM
one of the three had an NPN value which was
at the upper limit of normal. Assuming a
PBI-T4 difference of 1 .ig/100 ml, two of the three patients with elevated cholesterol values had corrected T4 values of 0.9 p.g/100 ml or less.
Repeat SUN or NPN determinations in three
of the four patients who had elevated values
were within the range of normal when the
pa-tients were adequately treated. The fourth pa-tient whose SUN was never repeated has been
followed for 7 years post-therapy and is in
good health.
DISCUSSION
The data are suggestive that a relationship
may exist between elevated SUN values, the age of the patient, and the degree of
hypothy-roidism. Elevation of SUN values appeared to
occur prior to 2 years of age, as three of the
four patients with elevated values were less than
2 years of age. All of the patients with elevated
SUN or NPN values had corrected T4 values
of 0.9 ig/100 ml or less. Similarly cholesterol
elevation tended to occur after 2 years of age,
as eight of the nine patients with elevated
cho-lesterol values were greater than 2 years of
age. The tendency, in hypothyroidism, for
cho-lesterol elevation to occur after 2 years of age
has been noted previously.’ Interestingly,
seven of nine patients with elevated cholesterol
values also had corrected T4 values of 0.9
i.g/100 ml or less.
Crispell, et al.23 have demonstrated that a
decrease in protein synthesis occurs in
myx-edema; and Ford, et al. and Papper, et al.
indicate that renal function is subnormal in
myxedema. A decrease in amino acid
utiliza-tion, protein synthesis, combined with impaired
TABLE I
ThYRoID lhSGENEsIS PATIENTS*
Sex C’..4.
PBI T
,zg/lck;’ semi Cholesterol NPN mg/1tX ml mg/100
SUN
ml
Post Rx m
NPN
g/100 ml SUN
Time Post Rx
M 5.5nio 0.8 190 31 2O 4.5mo
1I IO.Oiiio 1.8 300 56 34 1’2.Omo
F 14.0 limo (lLI 4.8%) 140 5 - t
1I 7.5 yr 0.7 35 2 15 4.0 nio
F 6.() vk 0.4 - 20 -
-F 6.5vr 1.4 406 40 31 5.Omo
rI tL.5vr ‘2.4 20 20 14 9.Omo
F 7.0vk 1.4 180 13
lE 10(1 immo .9 155 6
1I 1.5yr 1.9 3.50 14
F l.Syr 3.1 155 9
F 6.7 yr 0.2 445 15
F 6.Svr 1.8 292 17
M 9.5vr 1.9
TIIYII0IDITIs PATIENTS
546 40
F 9.6yr 0.9 395 17
F 10.’Jyr 0.5 195 19
F 1I.Oyr (ItAl 1.5%) 195 19
1L H.7 yr L6 220 12
F 13.3yr 2.5 - 10
F 17..5yr 2.3 944 35
* Normal
t Patient has been followed for 7 years and is in good health. Cholesterol 275 tng/100 ml or less.
NPN ‘22-40 tng/100 tnt. SUN 5-’20 mg/100 nil.
PBI 4.0-8.0 jsg/100 ml.
EXPERIENCE AND REASON-BRIEFLY RECORDED 831
urea excretion could result in an elevation of
SUN. If in hypothyroidism the growth rate is
reduced to one-half, then precursor
accumula-tion would be 3.3 times greater before 2 years
of age than after 2 years of age.#{176}Thus
im-paired protein synthesis as reflected by an ele-vated SUN would likely be manifested before
2 years of age.
Hypothyroidism is felt to result in
choies-terol elevation by greater impairment of
cho-lesteroi excretion than synthesis.6’
Sui MARY
Four of 20 patients with hypothyroidism had
elevated SUN or NPN values and three of
these four were less than 2 years of age. Nine
of the patients had elevated cholesterol values amid eight of these nine were older than 2 years
of age. Only two of the patients had both
val-ues elevated. SUN or NPN values at the upper
limit of normal were found in four additional
patients and were associated with an elevated
cholesterol value in two. All of the patients
with elevated SUN or NPN values and seven
of the nine patients with elevated cholesterol values had corrected T4 values of 0.9 g/100 nil or less.
ROBERT PENNY, M.D.
ROBERT M. BLIZZARD, M.D.
Department of Pediatrics
Johns Hopkins University
School of Medicine
725 .\‘. Wolfe
Baltimore, Maryland 21205
This work was supported by U.S. Public Health Service Grant NICHD 0-1852.
Dr. Penny is supported by Traineeship Grant TI
AM5219 from the U.S. Public Health Service.
REFERENCES
1. Wilkins, L. : The Diagnosis and Treatment of
Endocrine Disorders in Childhood and
Ado-lescence, ed. 3. Springfield, Illinois: Charles C Thomas, page 111, 1965.
2. Crispell, K. R., Parson, W., and Hollifield, G. : A study of the rate of protein synthesis before and during the administration of
L-Triiodothy-ronnie to patients with myxedema and
0 The average growth rate during the first 2
years of life is 19.1 cm per ‘ear and a decrease to
one-half would yield a rate 9.5 cm per year. After
2 spears of age the growth rate averages 5.7 cm per ear and a decrease to one-half would yield a rate of 2.9 cm per year. Therefore, 9.5 cm/2.9 cm = 3.3.
healthy volunteers using N-15 Gtvcine. J.
Clin. Invest. 35: 164, 1956.
3. Crispell, K. R., Williams, G., Hollifield, G., amid Parson, W. : Alterations of protein metabolism
in myxedema. J. Chron. Dis., 14:507, 1961.
4. Ford, R. V., Owens, J. C., Curd, G. W., Jr.,
Moyer, J. H., and Spurr, C. L.: Kidney func-tion in various thyroid states. J. Ctin. Endocr., 21:548, 1961.
5. Papper, S., and Lancestremere, R. G. : Certain
aspects of renal function in myxedema. J.
Chron. Dis., 14:495, 1961.
6. Rosenman, R. II., Byers, S. C., and Friedman,
M. : The mechanism responsible for the
al-tered blood cholesterol content in deranged
thyroid states. J. Clin. Endocr., 12: 1287, 1952.
7. Williams, R. H. : Textbook of Endocrinology,
ed. 3. Philadelphia: W. B. Saunders Co., p.
257, 1962.
Low
Voltage
Skin
Burns
The hazards accompanying the increasing
use of line-operated electrical devices for
di-agnosis and therapy as well as the more
common hospital appliances such as
elec-trically operated beds, television sets, radio
sets, and so forth have been recently
reemphasized.’ Most physicians are aware of
the dangers of alternating current (60 Hz AC)
or of high voltage direct current (DC) ,
espe-cially in relation to cardiac function. However,
few physicians seem to be aware of the hazards
of low voltage direct current. A standard text2
on laboratory safety fails to mention the
sub-ject. Low voltage direct current is used with
many different types of miniature electronic
devices and iontophoresis. Equipment failure
or misuse can result in accidental injury. \Ve
have recently had such an experience.
When Gibson and Cooke published their
plans for inducing sweat by the iontophoresis
of pilocarpine, we built our own equipment
and have used it successfully in several
thou-sand determinations during the past 1 1 years.
We recently had two accidents in which patients
were burned during iontophoresis. The bums
happened on the same day and involved two
separate patients, one an inpatient, the other
an outpatient. Both burns occurred under the
pilocarpine electrode, varied from 3 to 5 mm in
diameter, blistered, and healed slowly. One