A purpuric drug eruption caused by carbromal.
- SourceAvailable from: nih.govBritish medical journal 06/1955; 1(4924):1258-9.
Article: Cutaneous pseudovasculitis.[Show abstract] [Hide abstract]
ABSTRACT: Cutaneous pseudovasculitis represents a heterogeneous collection of disorders that are capable of simulating cutaneous vasculitis and can be broadly classified into diseases that produce hemorrhage (petechiae, purpura, and ecchymoses) or vessel occlusion with resultant livedo, cyanosis, ulcers, digital necrosis, and/or gangrene. Overlap is not uncommon, but if present, one mechanism dominates. Hemorrhagic pseudovasculitis is due to vessel wall dysfunction (incompetence), which can be related to diverse factors that include vessel wall deposition of metabolic substances (amyloid, calcium), nutritional deficiencies (scurvy), nonvasculitic inflammatory purpura (pigmented purpuric dermatitis, arthropod, viral and drug reactions), degeneration of the vessel wall and supporting stroma (senile/solar purpura), direct vessel wall invasion of infective organisms, coagulation-fibrinolytic disorders (eg, thrombocytopenia), and vessel wall trauma. Cyanotic-infarctive pseudovasculitis is due vaso-occlusion by emboli, thrombi, or fibrointimal hyperplasia (endarteritis obliterans) and includes varied conditions such as purpura fulminans, Coumadin necrosis, antiphospholipid antibody syndrome, cardiac myxoma, cholesterol embolization, calciphylaxis, and radiation arteritis. Delayed and inappropriate diagnosis of pseudovasculitis leads to incorrect management and exposure to potentially deleterious treatment modalities such as corticosteroids and cytotoxic agents. The diagnosis of a pseudovasculitic disorder requires a high index of suspicion and should always be part of the differential diagnosis of vasculitis. Skin biopsy is a crucial step in differentiating pseudovasculitis from authentic vasculitis; absence of histologic evidence of vasculitis, particularly after multiple biopsies, should direct evaluation and diagnosis towards pseudovasculitis.American Journal of Dermatopathology 03/2007; 29(1):44-55. · 1.43 Impact Factor
Article: Toxic cataract.British medical journal 01/1960; 2(5161):1231-2.
MARcH 12, 1955
precedent history of urinary symptoms favoured the
diagnosis of tuberculous epididymal disease.
scopic haematuria occurred in 30%
non-tuberculous epididymitis and was probably due to
Sterile pyuria was noted in 10% of the cases
of non-tuberculous epididymitis:
more common in the tuberculous cases.
or coccal infection of the urine was commonly present
in the non-tuberculous cases but occurred also in 26%
of the tuberculous.Tubercle bacilii were isolated from
the urine in 12 of 22 cases so examined.
A scrotal sinus was rare in the cases of non-tuberculoIis
epididymitis but developed in 35% of the tuberculous
Prostatic and vesicular nodularity was noted in
36°% of the non-tuberculous cases and in 70%o of tne
cases of tuberculous epididymitis.
elsewhere in the body, either concurrent or precedent,
was found in 76% of the tuberculous cases. The majority
of the cases of non-tuberculous epididymitis were treated
expectantly and ran a benign course.
cases were treated by surgical excision-before strepto-
mycin and the adjuvant drugs were available.
the patients were dead within a few years.
The differential diagnosis between the two conditions
is sometimes difficult and is apparent only after the lapse
of time: full urological investigation is advisable.
of the cases of
it was considerably
Army Med Dept. Bull., 1943. Suppl. 10.
Borthwick, W. M. (1947).
Campbell, M. F. (1928). Amer. J. med. Scd., 176, 386.
Handley, R. S. (1946).
Lancet, 1, 779.
Jtirvinen, A. (1944).
Acta chir. scand.. Suppl. 90.
McGavin, D. (1943).
Proc. roy. Soc. Med., 36, 323.
Morson, C. (1933).
Ibid., 26, 793.
Robinson, R. H. 0. B. (1943).
Ross, J. C. (1953).
Stevens, A. R. (1923).
Brit. J. Urol., 19, 132.
Ibid., 36, 324.
Brit. J. Urol., 25, 277.
J. Urol., 10, 85.
A PURPURIC DRUG ERUPTION
CAUSED BY CARBROMAL
PETER BORRIE, M.D., M.R.C.P.
A ssistant Physician in the Skin Department,
St. Bartholomew's Hospital, London
hypnotic, belonging to the class of open-chain ureides
and closely related chemically to chloral, bromvaletone,
and " sedormid."
larized by Bayer Products Ltd. under the name of
The first report that the substance caused a
drug eruption did'not appear until 1921 (Loeb, 1921),
and the purpuric nature of the eruption was well enmpha-
sized in the same paper.
Since then, further cases have
been described by Continental authors.
approach to a description of the condition in the English
language, however, is in a paper by Sneddon (1952),
where it is cited as a differential diagno6is to purpuric
Usually it is merely alluded to by
including carbromal in a list of drugs capable of causing
purpura-for example, Brain (1950); while it has even
been stated that carbromal does not cause purpura at all
(Ackroyd, 1949; Beckman, 1952).
ally agreed that carbromal has no effect on the blood
platelets, as has sedormid, which is a well-recognized
cause of thrombocytopenic purpura.
Carbromal is becoming increasingly popular in this
couLntry as a nocturnal sedative.
It was introduced in 1910 and popu.
However, it is gener-
It can be purchased
by the general public without a doctor's prescription,
and seems to be the first choice of the chemist when
asked for "something to make me sleep."
being sold as 5-gr. (320-mg.) tablets, carbromal is sold
under a variety of trade names, such as "persomnia,"
containing, inter alia, 3 gr. (200 mg.) of carbromal,
" dormiprin," containing 2 gr. (130 mg.), and " som-
being fairly widely advertised to the public.
In view of these facts, it was thought that a full
description of the drug eruption caused by carbromal
might be of value, and this paper deals with six such
cases seen in the skin department of St. Bartholomew's
Hospital in the first half of 1954.
1 gr. (65 mg.).
Finally, it is also
Case 1.-A spinster aged 40 complained of a very irritating
rash that had been present for four weeks.
on the thighs and was still spreading. On examination well-
defined patches, irregular in shape and size, were found on
the thighs, buttocks, and lower trunk, consisting of petechiae
and linear purpuric streaks, erythema, pigmentation, and
Over the hips the eruption had become
confluent and thickened.
Increased capillary fragility was
Five weeks previously she had begun taking per-
somnia, two tablets nightly. A patch test with 1% carbromal
in propylene glycol was negative, but the eruption cleared
in two weeks after stopping the drug.
capillary fragility was still present a fortnight later.
Case 2.-A man aged 53 complained of a very irritating
rash, present for six weeks, which had begun around the
ankles, the inside of the knees, and over the hips, and which
had spread steadily ever since.
skin, with the exception of the soles, hands, and face, was
affected by an eruption consisting of petechiae and linear
purpuric streaks, erythema, pigmentation, and branny scaling.
On the trunk, thighs, and upper arms these elements were
aggregated into well-defined, irregularly shaped patches of
On the forearms and lower legs the eruption
was mainly petechial, in some areas diffuse and in the others
Over the inner aspect of the knee-joints, the
hips, and shoulders the eruption formed a slightly thickened
Marked increased capillary fragility was present. He
had been taking person1nia, one or two tablets nightly, for
A patch test to 1% carbromal in propylene
glycol was negative, but the eruption cleared completely in
four weeks on stopping the drug.
Case 3.-A married woman aged 52 complained of an
irritating eruption, present for three months, which began
round the right ankle in the region of her varicose veins.
On examination an eruption was seen on the legs, trunk,
and upper arms,
streaks, erythema, pigmentation, and branny desquamation.
On the thighs, trunk, and upper arms the eruption was.
patchy; over the shoulders, hips, and knees it was confluent
and thickened; and on the lower legs it was profuse and
She had begun taking persomnia, two or three
tablets nightly, six months previously.
drug the eruption cleared completely in two weeks.
Case 4.-A single woman aged 27 complained of an
irritating eruption, which had been present for three months.
On examination a grossly excoriated eczematous reaction
was seen affecting the legs, thighs, and upper arms.
eruption had coincided with extreme domestic difficulties and
cleared completely in four weeks as a result of bland local
applications, mild sedation, and sick-leave. She was referred
again, one week after returning to work, with a relapse of
This time, however, the eruption was mainly
petechial, together with some erythema, pigmentation, and
branny scaling, patchy on the thighs, trunk, and upper arms,
and diffusely purpuric on the lower legs and forearm.
had begun on the feet, had spread suddenly in a few days,
It had begun
On examination the whole
Slight increased capillary fragility was
On stopping this
MARCH 12, 1955
ERUPTION CAUSED BY CARBROMAL
and was extremely irritating.
was present, and persisted for a month after the eruption
She had started to take carbromal three or
four tablets nightly, three months previously-that is to say,
two months after the onset of the original eczematous rash.
Patch tests to a saturated solution of carbromal in propylene
glycol were negative, but the eruption cleared a month after
stopping the drug.
Case 5.-A married woman aged 50 complained of a non-
irritant rash, present for four months, which had begun on
the thighs and which had steadily spread.
well-defined, irregularly shaped patches of varying size, con-
sisting of petechiae, erythema, pigmentation, and branny
scaling, were seen on the limbs and trunk.
were seen between the patches and they were particularly
marked and profuse on the lower part of the legs. Increased
capillary fragility was present.
bromal, one tablet nightly, for a year. The eruption cleared
after stopping this drug, at which time the
capillary fragility had also disappeared.
Case 6.-A man aged 42 complained of an eruption which
had been present for three months and which had been
irritating for one month.
Increased capillary fragility
She had been taking car-
It had appeared first on the feet
trunk. On examin-
ation the eruption
was found to con-
ation, and branny
scaling, diffuse and
~~~4 ~~~mainly purpuric on
i n to
had appeared one
spread suddenly to
The eruption in a typical case.
Three weeks before the eruption he had begun taking car-
two tablets nightly
tablet a night about three months later-that is, a few weeks
before the eruption cleared.
tablets a night just before the eruption appeared for the
The carbromal was stopped when he was first
seen and the eruption cleared in three weeks, at which time
increased capillary fragility, which had been present at first,
could no longer be demonstrated
ated solution of carbromal in propylene glycol was negative.
The eruption was remarkably constant in all six cases and
warrants no further description
plained of by five of the patients, but was completely absent
in the sixth
The dose of carbromal varied between 3 and
20 g. (0.2 and 1.3 g.) nightly, but in all cases was within the
therapeutic range (Martindale, 1952) and bore no relation-
ship to the severity of the eruption.
fragility was constantly present, and in two of the cases
persisted for some weeks after the* eruption had cleared,
but in no case was any haematological abnormality found.
patients obtained the drug on a doctor's prescription.
Unless the purpuric element in the eruption is recognized
but reduced the dose to one
He increased the dose to two
A patch test to a satur-
Severe irritation was com-
tests were uniformly negative.
one of the
logically identical with that produced by carbromal and in
which irritation is usually present, must be considered in
the differential diagnosis.
The first of these is the purpuric
textile dermatitis, first described 'by Hodgson and Hellier
(1946), occurring among British troops in north-west Europe.
(Peterkin, 1948, Sneddon, 1952).
been a new article of clothing, but many garments have been
incriminated, such as a vest, shirt, bathing-dress, pair of
riding-breeches, and a suit.
is not a dye, appears to be some chemical used in processing
the clothing, which can, while the clothing is still new,
second condition the eruption appears for no discernible
reason, persists for anything from two months to a year, and
Treatment has no effect.
(1954) has suggested that these three varieties of purpuric
dermatosis, due to external
allergens, and of purely endogenous origin, may be a changn
comparable to the eczema reaction. To regard the eruption
as a particular variety of skin change which may have a
number of causes appears to be the most rational approach.
The final diagnosis of a carbromal drug eruption must
rest on the effect of stopping the drug.
leading, since a positive result is difficult to obtain, and a
test dose is out of the question in an eruption which may
persist for up to a month after the responsible drug has been
Nevertheless, improvement in the intensity of
both the eruption and the irritation is obvious within a few
days to a week of stopping the drug, and the condition
clears completely in, at the most, a month.
Six cases of purpuric eruption caused by the ingestion
of carbromal in therapeutic doses are described, and
the differential diagnosis is discussed.
It is emphasized that the use of this drug as a nocturnal
sedative is increasing in this country, and that it may be
purchased without a doctor's prescription.
Invariably the cause has
The causative factor, which
contact causes, to ingested
Patch tests are mis-
Ackroyd, J. F. (1949).
Beckman, H. (1952).
Brain, R. T. (1950).
vol. 4, p. 503.
Hodgson, G. A., and Hellier, F. F. (1946).
Loeb, H. (1921).
Arch. Derm. Syph. (Bert.), 131, 128.
Martindale, W. H. (1952).
Pharmaceutical Press, London.
Peterkin, G. A. G. (1948).
Excerpta med. (Amst.), Sect. XlII, 6, 340.
Clin. Sci., 7, 249.
Pharmacology in Clinical Practice,
In British Encyclopaedia of Medical Practice, 2nd ed.,
J. roy. Army med. Cps, 87, 110.
1st ed., p. 438.
The Extra Pharmacopoeia, 23rd ed., 1, 1024.
Arch. Derm. Syph. (Chicago), 58, 249.
I. B. (1952).
Brit. J. Derm., 66, 262.
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