Severe bradycardia due to interaction of timolol eye drops and verapamil.
Authors: S D Pringle, C J MacEwen
Journal: BMJ (1987)

Chronic renal failure associated with topical application of paraphenylenediamine Paraphenylenediamine ("para"), a derivative of paranitroaniline, is widely used as a hair dye.It has several toxic effects, ofwhich asthma and dermatitis are common.About 4% ofapparently normal subjects are sensitive to it, and 1% are acutely sensitive.'We report two cases of vasculitis and crescentic glomerulonephritis after prolonged topical application.Case 1 A 51 year old woman who habitually used a henna hair dye with a paraphenylenediamine base was admitted to hospital with chronic renal failure; creatinine clearance was 11 ml/min.Clinical examination showed uraemia, normotension, dependent oedema, and several small nodular lesions over her knuckles and elbows.Blood urea concentration was 32 mmol/l (192 mg/100 ml), serum creatinine 680 ptmol/l (7-7 mg/100 ml), and haemoglobin 86 g/l; she had proteinuria of 6 g/24 h.Biopsy of the skin lesions showed vasculitis, and percutaneous renal biopsy showed crescentic glomerulonephritis.Prednisolone 40 mg daily resulted in improvement initially, but poor compliance led to her readmission four years later in end stage renal failure.Despite peritoneal dialysis and steroid treatment she died from coliform bronchopneumonia.At postmortem examination there was no evidence of healed vasculitis; both kidneys were extremely small, and histologically there was considerable hyalinisation of the glomeruli.Many of the tubules were distended with colloid casts, and there was fine fibrosis with an infiltrate oflymphocytes in the interstitial tissue.The interlobar and arcuate arteries showed thickening oftheir walls but no evidence of arteritis.Case 2 A previously healthy 62 year old woman who had used a hair dye with a paraphenylenediamine base for two years was admitted to hospital in renal failure after three weeks of lethargy, anorexia, myalgia, and swelling of the ankles.She required emergency peritoneal dialysis for life threatening hyperkalaemia.Clinical examination showed uraemia, anaemia, signs of left basal consolidation, and considerable oedema of the legs.There were two small nodular lesions over her left elbow.Blood urea concentration was 61 mmol/l (366 mg/100 ml), serum creatinine 841 pmol/l (9-5 mg/100 ml), and haemoglobin 107 gIl.Biopsy of the lesions on her elbow showed allergic vasculitis, and she was therefore given prednisolone 20 mg daily.She remained oliguric and three weeks after admission developed non-reversible ventricular fibrillation while receiving haemodialysis.Postmortem examination showed occlusion of the right coronary artery by recent haemorrhage into an atheromatous plaque and a healed posterior wall myocardial infarct.The lungs were congested, and multiple white nodules 1-2 cm in diameter were noted throughout.Histologically these consisted of a granulomatous inflammatory process with central fibrinoid necrosis, and there was also fibrinoid necrosis and an acute inflammatory infiltrate in the vascular channels, consistent with Wegener's granulomatosis: Both kidneys were enlarged and pale with histological and immunological evidence of crescentic glomerulonephritis.