CORRESPONDENCE

is approximately one half that at introduction 3 years ago. Most pa- tients have been able to reduce their dosage for maintenance ther- apy, and initial doses today are less than 3 years ago. Genzyme’s clini- cal sales representatives do not make treatment recommendations to patients. As with our communi- cations with physicians, we pro- vide interested patients with com- plete, unbiased information.

Of particular concern is the con- ceit that “physicians should not prescribe high doses and insur- ance companies should not pay for them.” Current data does not war- rant such a sweeping and dogmatic conclusion. Capable physicians should examine the data and pre- scribe what they believe is ulti- mately best for their patients. Some patients may require higher doses than others to achieve mean- ingful improvement in a reason- able period of time. In the end, it would be very unfortunate for pa- tients if access to effective doses were denied despite the patients’ needs and physicians’ decision.

Richard A. Moscicki, MD Vice President

Medical, Clinical, and Regulatory Affairs

Genxyme Corporation Cambridge, Massachusetts

Jan van Heek President

Biotherapeutics Genxyme Co?-poration

Cambridge, Massachusetts

1. Zimran A, Elstein D, Kannae, R, et al. Low-dose enzyme replacement therapy for Gaucher’s

disease: effect of age, sex, genotype and clinical features on response to treatment. Am J Med.

1994;97:3-13. 2. Hollak CEM, Aerts JMFC, van Weely S, et al.

Enzyme supplementation therapy for type I Gaucher disease. Efficacy of very low dose alglucerase in 12 patients. Blood. 1993;82:33a.

3. Barton NW, Brady RO. Gaucher disease: skeletal responses to enzyme replacement therapy. Gaucher Clinical Perspectives, special edition.

1994;2:8-11, 4. Beutler 6. Economic malpractice In the treatment of Gaucher’s disease. Am J Med.

1994;97:1-2. Submitted August 24, 1994 and accepted August

30, 1994.

HEPATITIS C VIRUS, CRYOGLOBULINEMIA, AND ALPHA INTERFERON To the Editor:

The classical approach to the therapy of mixed cryoglobulinemia has been with corticosteroids or immunosuppressor drugs, but re- sults have not been impressive. In 1987 Bonomo et al’ suggested the utility of alpha interferon in the therapy of essential mixed cryo- globulinemia. A more recent paper from Taillan et al2 reported a quite similar result in patients having mixed cryoglobulinemia associated with hepatitis C virus infection. We studied a patient with mixed cryo- globulinemia, hepatitis C virus in- fection, and excellent response to low-dose alpha-interferon.

A 36-year-old man presented with recurrent purpura and arthral- gia over 2 years. On admission, he had palpable purpura and bilateral knee and ankle arthritis. Aspartate aminotranferase was 58 IU/L, ala- nine aminotransferase was 108 IU/L, rheumatoid factor was 460 IU, and type-II cryoglobulinemia was present. The cryocr’it was 8%. Hepatic biopsy showed chronic ac- tive hepatitis. Prednisone and aza- thioprine were instituted, without obvious response. Five months later, bouts of purpura and arthri- tis remained. A second-generation enzyme-linked immunosorbent as- say (ELISA) and a recombinant im- munoblot assay (RIBA II) for HCV antibodies were positive, both in serum and in cryoprecipitate. Previous therapy was withdrawn and alpha interferon 3 X 10” IU three times a week was begun. Ten days after, symptoms disappeared, and, by the fourth week, interferon dosage was halved (1.5 X 10” IU three times a week). By the 12th week, akmin and aspartate amino- tranferase levels were normal and the cryoglobulin had disappeared. After 6 months, the patient re- mained well.

In the last few years, a consider- able amount of progress has been

made in the field of viral agents causing hepatitis and its relation- ship to other processes, like hepa- tocarcinoma. Recently, Agnello et al’ pointed out the close relation- ship between hepatitis C virus and mixed cryoglobulinemia. Another paper, from Misiani et al,4 reached a similar conclusion. Both papers commented on the potential role of alpha-interferon therapy, instead of the more conventional tlierapy with corticosteroids or immunosuppres- sors. That suggestion was coinci- dent with our fmdings or those of Taillan et al’ in 2 patients with mixed cryoglobulinemia and he- patitis C virus infection. We con- sider that all of these findings rein- force Bloch’s” statement that we need a prospective, controlled study to confirm these promising, preliminary reports.

Julio Gonzalez, MD Pascual Sesma, MD

Juan Antonio Gawido, MD Hospital ‘A. Mar&de”

Few01 (CoruYia), Spain

1. Bonomo L, Casato M, Afeltra A, Caccavo D. Treatment of idiopathic mixed cryoglobulinemia

with alpha Interferon. Am J Med. 1987;83: 726-730.

2. Taiilan B, Ferrari E, Garnler G, et al. Low-dose interferon alpha for mlxed cryoglobulinemla

associated with hepatitis C virus. Am J Med. 1992;93:476.

3. Agnello V, Chung RT, Kaplan LM. A role for hepatitis C virus infectlon in type II cryoglob-

ulinemia. NEJM. 1992;327:1490-1495.

4. Mnlsianl R, Bellavita P, Fenili D, et al. Hepatitis C virus lnfectlon in patients with essential mixed

cryoglobulinemla. Ann Intern Med. 1992;117: 573-577. 5. Bloch KJ. Cryoglobulinemia and hepatitis C virus.

NEJM. 1992;327:1521-1522. Editorial.

Submitted March 23, 1993 and accepted March

31. 1993.

THE DIAGNOSIS OF ALLERGY TO RIFAMPICIN CONFIRMED BY SKIN TEST To the Editor:

Harland et al’ described a case of anaphylaxis to rifampin in a 33- year-old man with diabetes melli- tus and renal failure, and cited 6

October 1994 The American Journal of Medicine@ Volume 97 403