A case study of patient with a fixed eruption due to quinine contained in Tonic Water is described. Fixed eruptions are uncommon but not rare. They are usually not difficult to diagnose once the possibility is considered. A long and detailed history with subsequent re challenging (orally) with the suspected offending agent offers the best means of diagnosis although a 48 hour occlusive patch test at the site of the eruption sometimes may also be useful. Patient was advised to avoid all quinine containing beverages.peer-reviewe

Pace, Joseph L.

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54 A TONIC WITH RATHER UNPLEASANT SIDE EFFECTS JOSEPH L. PACE M.D., M.R.e.p. (u.K.) Dermato logist (Formerly Senior Registrar in Dermatology at the Manchester and SalfOf1Cl hospital). It was with a great deal of apprehen-sion and dismay tnat Samuel Brown, a factory worKer, aged forty two (42), and a fatncf of iour l.:iLlur",n, saw Cnns~mas ap-proaching. Not that Mr. Brown had any-tnmg aga,nst G{lLS~mas, but tnis unhappy roan and for reasons none too obvious to hImself or for that matter, to hls general practItlOner, the previous two Chr,stmas-es had been marred by an embarassing and most uhcomfortable problem: his scrotum had suddenly swelled up and be-come extremely pruritic, completely ruin-ing the hoLday perlod in the process. On both occas~ons he had lmploved after about two weeks, helped perhaps by a medicated powder prescnbed by his . doctor. He had been perfectly well throughout the rest of the year. The patient's doctor had diagnosed the conditlOn as first a "Sweat Rash" and subsequently "probably due to nerves" but as neither could dlg out any good psy-chological explanatlo11 for this curious seasonal nerve-rash, th~ patient was re-ferred for dermatolog.cal consultat.on to prevent a further recurrence if possible. The pati.ent had previously been well and there was no famIly history of D..,abetes. ExammatlOn dId not reveal any positive clinical findings. There was no history of drug ingestlOn whatsoever, and he dId not smoke, nor drink and neither did he partake of Liquorice or Saccharin. A fixed drug eruption was suspected, but questioning failed to reveal any of the more common causes (see table). Because of the "temporal profile" of events and the patient being a teetotaller, Phenol-phthalein first came under suspicion per-haps being ingested in the icing of Christ-mas cake, etc. However, challenge with an oral dose caused no undue side effect. Finally the diagnosis mas made: the patient was indeed a teetotaller, but con-trary to his usual custom of drinking only frUit squashes, m the numerous office par-hes held in the festive season, he would have a glass of colourless Tonic Water, so as not to be seen with fruit squash in the company of much less soberly incLned companions. Tonic Water is known to contain Quinine, a widely reported cause of fixed eruptions, and surely enough challenging the patient with Tonic Water orally, (but not as an occlusive patch test) resulted in an immediate relapse of his itchy problem. He was advised to avoid all quinme con-taining beverages and has since spent two perfectly happy Tonic-Waterless Christ-mases. A fixed eruption is a recurrent one that always appears in the same site(s) fol-lOWing admmlstration of the offe_.dmg agent. Its extent may increase/decrease slightly from time to time, and it may ap-pear soon after a drug is started or several months later. (Welsh 1961). The manifestations are usually cutaneous but occasionally confined to the mucosae. In the skin the common ap-pearance is of hyperpigmentation (subse-quent to several inflammatory episodes) with occas~onal re-8xacerbations of severe pfur;tus. Sometimes, the lesions may resemble urticaria, erythema nodosum and even alopecia areata. In negros diffuse hyper-melanosis may be the presenting symptom. In the mouth, bullous lesions of pemphi-goid appearance may break down to form local erosions. The mechanism of fixed eruptions form a faSCinating study. There appears to be an acquired highly specific local Sell-55 Causes of Fixed Drug Entlltions (Commfm Offenders UnderFred) Adapted from Welsh 196. I AntipYretics II Phenolphthalein IH CNS Depr2ssant5 IV Anti Microhials Antimalarials V Autonomic Nervous System VI Miscellaneous sitisation probably dependent more on cellular rather than humoral responses. Localised sensitisation would seem to oc-cur if only the immune cells of the dermis are involved as opposed to the universal sensitisation occuring following particip-ation of lymph nodes; e.g. poison ivy der-matitis. In favour of this theory in the fact that jf full thickness skin grafts are interchanged between the site of a fixed eruption. (A) and normal (B) the site of the fixed eruptions will move from (A) to (B) and will recur only at (B) on the next oc-casion. (Porter & Comaish 1969). Although any drug can cause a fixed eruption in the occasional patient, some are certainly more notorious than others in this respect. The classical rarely over-looked allergen is phenolphthalein, but it must be remembered that apart from laxatives, this is also an ingredient of Aspirin Phenyl Butazone OXY Phenbutazone Codeine In all its guises Barbiturates Tranquillizers: Librium Antihistamin"'s Ant' Convulsanis Sulphas T,:, tracYclines Quinine Both Sympatholytks - Mimetics Dig'talis Peritrate Liquorice Saccharin Whit~ Wine Lentils Egg White sweets, icing, and toothpaste. Other w~ll recognized causes include all antipyretics, especially phenylbutazone and codeine, an-tibiotics particularly tetracyclines and sul-phonamides, and barbiturates. (Welsh 1961). Chlordiazepoxide (Librium) and Oxyphenbutazone (Tanderil) are among the more recent additions. (Savin 1971). A patient with a fixed eruption due to quinine contained in Tonic Water is described. Fixed eruptions are uncommon but not rare. They are usually not dif-ficult to diagnose once the possibility is considered. A long and detailed history with subsequent re challenging (orally) with the suspected offending agent offers the best means of diagnosis although a 48 hour occlusive patch tost at the site of the erupt:on somet'mas may also he usefuL (Strizler & Kopf 1960). A refractory period may be present 56 when even oral exhibition of the offend-ing agent fails to induce a flare up. (l$rowne Ultl'iJ. References BROWNE, S.G., 1964. British Medical Journal 2 10U. PORTER, DJ. ~t CO~AISH, S., 1969. British Jour' nal of Dermato;o011 81.171. SAVIN, J.A., 1971. British Journal of Dermato;ogy 83,546. STRIZLER, C. & KOPF, W., 1960. Journal of Investigative Derm'2to\ogy 34.319. WELSH, A.L. The F,'xzd Eruption. Charles C. Thomas Springfield, 1971. SPORTS MEDiCINE PHYSICAL FITNESS AND REHABILITATION Their importance IIwithinll and lIoutsidell the realm of sport J. MUSCAT M.D. This article is differ,:mt from those normally published in this medical journal. Do not misinterpret the word sports. Sports Medicine should in-terest not only "sports doctors", viz. those doctors connected professionally w1th sports clubs to look after the physical wel-fare of the athletes and players, or those doctors who use their free time to relax by taking an active part themselves in some sporting activity. The fruits of sport medicine are beneficial also outside the field of sport; all non-spoI1tsmen in-distinctly, of whatever age group, can reap such fruits. National health programmes and physical rehabilitation programmes contr1bute in great measure towards the health, the physical fitness, the mental well-being and, therefore, the economy of a community and country. This article purports to be an appeal to Maltese medical graduates whatever be their speciality in actual practice, and, of course, particularily to those connected professionally with the various clubs and sports associations on the island to take an aotive interest in sports medicine to shake off that lethargy an-d apathy to all that is not ltinancially gainful; to emulate our counterparts, of other nations by organising ourselves into a constituted body of "sports medical officers", and thus qualifying for enrollment with the "Federation Inte;lnatiol1Jule De Medicine Sportive" (F.I.M.S.); with the prime intent of: 1) fostering the welfare and bet-t<;:)rm2nt of Maltese athletes and com-p3titors; 2) aiding scientifically the Maltese sportsmen to compete internation-ally with a relative measure of success; and 3) improving the pmsperity - physically and, indirectly, economically - of the Maltese people as a whole through courses of physical fitness and rehabilitation. In these last years Maltese sport has made big progress, gauged, of course, by Maltese standards. The introduction of "Physical Education" as a compulsory sub-ject in bo,th public and private primary and secondary schools should be regarded as a very important milestone in the annals of Maltese sport. One must not fail to mention and give full credit to 'the Malta OlympiC Committee. w:ho with the help, especiaIlyfinandal, rof the Olympic Solid-arity Movement, is leaving no stone un-turiied to propagate sport in Malta and to put it on a sound basis both tech-nically by providing experIenced coach3s and scientifically through "sports medical officers." Moreover, now the shorter work 

A tonic with rather unpleasant side effects

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A tonic with rather unpleasant side effects

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