Findlay, G.H.

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872 S.A. MEDICAL JOURNAL 17 October 1959urine collected every 15 minutes by catheter for a 3-hour periodfollowing the test meal. Total amino acids were estimated in. the urine and plasma by the Van Slyke gasometric technique.Urinary creatinine was also estimated.It would appear that, in 4 of these cases, there was a tendencyfor the plasma amino acids to rise higher or remain at their maxi-mal concentration for a longer time after the test meal; in fact,these increases are significantly greater (p <0· 02) than those ofthe control series. This tendency is most pronounced in theseverely ill cases and is reduced with treatment.The same tendency also appears in the data on urinary aminoacid, viz. the most severely ill infants show the greatest urinaryexcretion of amino acids, and this excretion is reduced on treat-ment.More important for the purpose of this investigation, however,is the observation that in these cases of kwashiorkor, there appearsto be a relationship between the concentration of plasma aminoacid and the degree of amino-aciduria: wherever the plasmaconcentrations were highest, the urinary excretion of amino acidswas greatest. It would appear, therefore, that renal function,in so far as amino-aciduria is c'oncerned, is probably normal inkwashiorkor, but that the utilization of amino acids is altered,thereby causing the renal threshold to be exceeded. There is alsosome suggestion of a relationship between the urinary excretion ofamino acids and creatinine-presumably a common, renalmechanism. The explanation that this is an artifact resultingfrom errors inherent in the IS-minute urine collection interval,appears justified by further investigations.In an additional investigation 24-hour urine collections weremade throughout the treatment of 4 cases of kwashiorkor andcompared with collections made over a period of 2 weeks from anormal, active child of a similar age living in a home environmentand eating a mixed diet.It was observed that the urinary excretion of amino acidsincreases to a maximum within the first week of adequate treat-ment and is not related to fluctuations in creatinine excretion.These urinary amino acids were partitioned during 3 phases intreatment: on the first 2 days, on 2 days at maximal excretion,and on the final 2 days, at cure. These partitions confirm ourearlier observations that the increased amino-aciduria of infantswith kwashiorkor results from increases in the excretion of atleast 7 amino acids.SUMMARYRenal function and other studies suggest that the increased amino-aciduria of kwashiorkor is due to altered utilization of absorbedamino acids causing the renal threshold to be exceeded. As yet,we have no evidence of a defect in renal tubular function.PATCHY SEl\lJLE ELASTOMA OF THE LIP RESEMBLING LEUKOPLAKIAG. H. FIl\'DLAY, M.D., Section of Dermatology, Department of Medicine, University of Pretoria"In 1955 I was asked to see a 49-year-old spinster who was obsessedwith an opalescent spot which she had on the external vermilionof the lower lip. There was no atrophy or epithelial change,and the nature of this solitary focal lesion was not clear to me.. Histologically it consisted of an area of senile elastosis withoutany epidermal or other alteration (Fig. I). It was interesting tonote that whitening of the lip could result from elastosis alone,Fig. 1 Section of lower lip showing elastoma betwe~n the .epidermis andmuscle. 'Neigert's elasti.: stain.that the lesion could be a papular 'elastoma', and that no epithelialchange or leukoplakia need occur with it.Since then I have seen the same thing repeatedly, and alsoobserved nodular senile elastomas of the cheek suggesting neo-plasm. As a precancerous manifestation, lip elastosis is associatedwith loss of substance, chronic inflammation and a readily damagedhomy layer, thick, thin or scaly.' Whitening or leukoplakia isthen epithelial. Whitening from dermal change alone is never-theless seen at times in lichen sclerosus, though whitening on thelip or vulva usually cOJ;Iles from a thick and sodden horny layer,a thick Malpighian layer, or both. Whitening from an increasedgranular layer is a poorly substantiated possibility. Senile elastosison the open skin tends to look yellow, perhaps from the liberationof fluorescent pigments' or lipids, though in my experience lipidsare colourless. Perhaps the incident-light microscope may con-tribute in the study of these dermal colour changes."Elastic tissue and elastomas have interested a number of W,orkersin this country, and it may be of value to note at least a few ofthe contributions. Pepler and Brandt' and the present writer'have investigated the staining and enzymatic dissolution of elastitissue. Sacks' has also reported work on the same topic. Althoughthe "derivation of senile elastosis from elastic tissue was held bymyself and recently supported by Braun-Falco in Germany,7Gillman in Durban has taken the view that its parent substanceis collagen. B,- Marshall and Lurie'O have contributed to ourknowledge of another kind of focal elastoma, while Loewenthal"has studied the changes in certain rare varieties of connective-tissue naevus.REFERENCES1. Schuermann. H. (1955): Krankheiten der Mundschleimhaut und der Lippen,p. 131. Berlin: Urban and Schwarzenberg.2. Loomeiier, F. J. (1958): Nature, 182, 182.3. Oettle. A. G. (1959): S. Afr. Med. J., 33, 327.4. Pepler, W. J. and Brandt, F. A. (1954): Brit. J. Exp. Path., 35, 41.5. Fndlay, G. H. (1954): Brit. J. Derm., 66, 16.6. Sacks, N. (1954): S. Afr. J. Med. Sci., 19, 113.7. Btaun-Falco, O. and Salfeld, K. (1957): Bull. Soc. fran~. Derm. Syph., 64,586.8. GiIlman, T., Penn, J., Bronks, D. and Rom, M. (1955): Arch. Path., 59,733.9. GiIlman, T., Hathom, M. and Penn, J. i1l Tunbridge, R. E., ed. (1957):Co;mecrjve Tissue Sympo~ium. Oxford: Blackwell Scientific Publications.10. Marshall, J. and Lurie, H. I. (1957): Brit. J. Derm., 69, 315.11. Loewenthal, L. J. A. (1957): Dermatologica (Basel), 114, 81.

Patchy senile elastoma of the lip resembling leukoplakia

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Patchy senile elastoma of the lip resembling leukoplakia

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