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Salt saga continued.

Dr Brian M J Cantwell and colleagues (16 July, p 179) reported the association between induction chemotherapy of non-Hodgkin's lymphoma and the development of pulmonary embolus. Two days after we had read their article one of our patients with a high grade lymphoma who had recently begun chemotherapy was admitted with a history of gradually increasing shortness of breath on exercise which had developed over the preceding three days. There was no associated haemoptysis, chest pain, or calf swelling. His chest radiograph showed bilateral hilar lymphadenopathy due to lymphoma and an electrocardiogram showed no abnormal results. On clinical examination his pulse rate was 84 beats per minute and regular and his respiratory rate 18 breaths per minute. The jugular venous pressure was not raised and heart sounds were normal. He showed no evidence of cardiac failure. Investigations showed that he had a haemoglobin concentration of 102 g/l and a white cell count of 2 0x 109/l. Apart from the history of breathlessness, no laboratory or clinical findings supported a diagnosis of pulmonary embolus. Indeed, previous tests of respiratory function had shown a reduced transfer factor of 17, thought to be related to his treatment with bleomycin, which together with the low haemoglobin concentration might have accounted for his shortness of breath. Bearing in mind Dr Cantwell's and colleagues' short report, however, we performed a ventilationperfusion scan urgently. This showed multiple ventilation-perfusion mismatches that were considered to be diagnostic of multiple pulmonary emboli. He was given heparin and subsequently warfarin. He improved noticeably and was able to continue with his chemotherapy. Interestingly, plasma concentrations of protein C and protein S, both important vitamin K dependent anticoagulant and profibrinolytic agents, have been shown to decrease in patients receiving chemotherapy for breast cancer,' and this may also be relevant to lymphoma. We believe that this case exemplifies the value of the clinically oriented short report, the merits of which are to increase awareness of hitherto unrecognised or unappreciated clinical scenarios. Its message can be quickly put into clinical practice, as witnessed by our recent experience.