Ronan T Swords MRCPISpecialist Registrar in HaematologyDepartment of HaematologyBeaumont Hospital

John P Quinn MRCPISpecialist Registrar in HaematologyDepartment of HaematologyBeaumont Hospital

John R O’Donnell FRCPathConsultant HaematologistDepartment of HaematologyBeaumont Hospital

Published Online, 28 Sept 2004, www.theannals.comDOI 10.1345/aph.1E274

REFERENCES

1. Okamoto H, Teramura M, Kamatani N. Myelodysplastic syndrome asso-ciated with low-dose methotrexate in rheumatoid arthritis. Ann Pharma-cother 2004;38:172-3. DOI 10.1345/aph.1D117

2. Pointud P, Prudat M, Peron JM. Acute leukemia after low dose metho-trexate in a patient with rheumatoid arthritis. J Rheumatol 1993;20:1215-6.

3. Rosenthal NS, Farhi DC. Myelodysplastic syndromes and acute myeloidleukemia in connective tissue disease after single-agent chemotherapy.Am J Clin Pathol 1996;106:676-9.

4. Yetgin S, Ozen S, Saatci U, Bakkaloglu A, Besbas N, Kirel B. Myelo-dysplastic features in juvenile rheumatoid arthritis. Am J Hematol 1997;54:166-9.

5. Nam E-J, Kang Y-M, Kang H-R, Kim J-H, Rho H-J, Lee M-K, et al.Rheumatoid arthritis associated with myelodysplastic syndrome: a casereport. J Korean Med Sci 1999;14:319-22.

Transient ischemic attack secondary to hypertensive crisis related toPanax ginseng

TO THE EDITOR: Transient ischemic attack (TIA) is a sudden, focal neu-rologic deficit lasting <24 hours, presumably of vascular origin, and con-fined to an area of the brain or eye perfused by a specific artery. Typicalsymptoms include hemiparesis, hemiparesthesia, dysarthria, dysphasia,diplopia, circumoral numbness, imbalance, and monocular blindness. Asof June 2004, we present the first case of TIA manifesting as fugaxamaurosis in the context of a hypertensive crisis related to the consump-tion of monopreparations of Korean Panax ginseng.

Case Report. A 64-year-old white man complained of fugax amaurosis forless than one hour on 2 occasions spaced 2 days apart, with arterial BP readings of200/120 and 220/130 mm Hg, respectively. The medical history was unremark-able, with no toxic habits or family antecedents of cardiovascular disease. The pa-tient had performed monthly self-measurement of blood pressure since 1986, withBP <140/90 mm Hg.

He used a daily sachet of an instant preparation of Ginseng Forte-Dietisa (500mg Korean Ginseng, or P. ginseng) during 13 days for asthenia. There were noother prescribed or nonprescribed drugs or herbal products or drugs of abuse.Upon examination, BP was 195/95 mm Hg. The rest of the vital signs were nor-mal, as were heart auscultation, chest X-ray, carotid doppler ultrasound, and braincomputed tomography. Visual acuity, color vision, visual fields, pupils, ocularmotility, intraocular pressure, biomicroscopy, and funduscopy were normal.

Laboratory testing showed the complete blood cell count, blood biochemistry,and urinary sediment to be normal. Anticardiolipin and anti-β2-glycoprotein I anti-bodies were negative. One week after cessation of the P. ginseng product, the BPreturned to its previous level (<140/90 mm Hg). After one year of follow-up, thepatient remained normotensive.

Discussion. The causal relationship between Ginseng Forte-Dietisaand fugax amaurosis/TIA is probable in this case.1 Although fugaxamaurosis/TIA induced by ginseng has not been described to date, it isjustified by the high increase in BP observed, and isolated cases of hy-pertension have been reportedly associated with both ginseng mono-preparations and combination products.2 The hemodynamic effects ofginseng have not been adequately evaluated, and previous results arecontradictory—describing that it can cause hyper- and hypotension—perhaps due to the inability to identify the active ingredients.3 A cleartemporal relationship was observed with the patient’s use of the herbalpreparation and the TIA. This was the first time that the patient had taken

P. ginseng; the reaction, including the increase in BP, disappeared afterginseng withdrawal, and other alternative causes were discarded. More-over, the patient had never suffered hypertension before taking ginseng,and he presented no further such problems in the year after withdrawalof the product.

Monopreparations of ginseng are rarely associated with adverse effectsor interactions, and the cases documented are usually mild and transient.2

However, it has been reported that, although toxicity at usual doses ap-pears to be low, ginseng is not universally benign and may be associatedwith several relatively serious adverse effects and some drug interac-tions. On the other hand, well-conducted clinical trials do not support theefficacy of ginseng in relation to any traditional or modern therapeuticclaims.3,4 Moreover, a recent study reported the association of dietarysupplements, including ginseng, to adverse events comprising all levelsof severity, organ systems, and age groups.5

Inocencia Martínez-Mir MD PhDSenior Researcher, Hospital ManagementValencia University General Hospital Consortium (GUH Foundation)Avda. Tres Cruces s/n. 46014 Valencia, Spainmartinez_ino@gva.es

Elena Rubio MD PhDSpecialist in Clinical PharmacologyAssistant ProfessorValencia University General Hospital Consortium and Department of Pharmacology, Valencia University

Francisco J Morales-Olivas MD PhDSpecialist in Clinical PharmacologyAssistant ProfessorDepartment of Pharmacology, Valencia University

Vicente Palop-Larrea MD PhDSpecialist in Family and Community MedicineService of Internal MedicineHospital de la RiberaValencia

Published Online, 12 Oct 2004, www.theannals.comDOI 10.1345/aph.1E213

REFERENCES

1. Naranjo CA, Busto U, Sellers EM, Sandor P, Ruiz I, Roberts EA, et al. Amethod for estimating the probability of adverse drug reactions. ClinPharmacol Ther 1981;30:239-45.

2. Thompson J, Ernst E. Panax ginseng. A systematic review of adverse ef-fects and drug interactions. Drug Saf 2002;25:323-44.

3. Caron MF, Hotsko AL, Robertson S, Mandybur L, Kluger J, White CM.Electrocardiographic and hemodynamic effects of Panax ginseng. AnnPharmacother 2002;36:758-63. DOI 10.1345/aph.1A411

4. Ernst E. The risk–benefit profile of commonly used herbal therapies:Ginkgo, St. John’s Wort, Ginseng, Echinacea, Saw palmetto, and Kava.Ann Intern Med 2002;136:42-53.

5. Palmer ME, Haller C, McKinney PE, Klein-Schwartz W, Tschirgi A,Smolinske SC, et al. Adverse events associated with dietary supple-ments: an observational study. Lancet 2003;361:101-6.

Comment: trimethoprim/sulfamethoxazole for treatment of severeStaphylococcus aureus infections

TO THE EDITOR: We read with great interest the article written by Adraand Lawrence.1 Ten years have elapsed since we published our reportfrom Tunisia about the efficacy of trimethoprim/sulfamethoxazole

1970 ■ The Annals of Pharmacotherapy ■ 2004 November, Volume 38 www.theannals.com

Comments on articles previously published are submitted to the authors of those arti-cles. When no reply is published, either the author chose not to respond or did not doso in a timely fashion. Comments and replies are not peer reviewed.–ED.