Update: Eosinophilia-Myalgia Syndrome Associated with Ingestion of L-Tryptophan -- United States, through August 24, 1990
As of August 24, 1990, 1536 cases of eosinophilia-myalgia
syndrome
(EMS) had been reported to CDC from all 50 states, the District of
Columbia, and Puerto Rico (Figure 1) (1-5). Twenty-seven deaths
have
been reported in patients who met the surveillance case definition
and
who used L-tryptophan-containing products (LTCPs).
As of August 24, CDC had received 1117 completed report forms
from
state and territorial health departments. Ages of patients ranged
from
4 years to 85 years (median: 48 years); 1046 (94%) of the patients
were
non-Hispanic white, 19 (2%) were Hispanic, 12 (1%) were black, and
40
(4%) were from other or unknown racial/ethnic groups; and 930 (83%)
were female. One thousand sixty-eight (96%) patients had histories
of
LTCP ingestion preceeding onset of symptoms. Symptom onset during
or
after July 1989 was reported in 946 (85%). Eight (0.7%) patients
had
onset on or after February 1, 1990. Three hundred sixty (32%)
patients
had been hospitalized for their illnesses by the time the cases
were
reported.
Reported by: State and territorial health departments. Div of
Environmental Hazards and Health Effects, Center for Environmental
Health and Injury Control, CDC.
Editorial Note
Editorial Note: On November 17, 1989, the Food and Drug
Administration
(FDA) recalled all dietary supplements that provided a daily dose
of
L-tryptophan (LT) greater than or equal to 100 mg. By March 22,
1990,
this recall had been expanded to include all LTCPs at any dosage
except
some protein supplements, infant formulas and special dietary
foods,
and intravenous and oral solutions in which small amounts of LT are
needed for nutrient fortification.
The eight EMS cases reported with onset after February 1 appear
to
have resulted principally from continued use of LT by some persons
after the FDA recall rather than from long disease latency
following
cessation of LTCP exposure. One patient began use of LTCPs on March
20,
1990, and became ill 1 month later, indicating that some persons
may be
unaware of, or choose to ignore, the FDA recall.
National surveillance figures do not fully reflect the
proportion
of patients ultimately hospitalized as a result of EMS. Because
each
case is reported only once, information regarding hospitalization
of
patients requiring admission after their cases are reported is not
available.
The surveillance definition for reporting EMS cases to CDC
requires
the presence of severe, debilitating myalgias and eosinophilia
greater
than or equal to 1000 eosinophils per mm3. Recent unpublished
reports
indicate that this case definition may be overly restrictive for
clinical purposes. Many persons may have forms of EMS that are
either
less severe or in which the constellation of clinical findings does
not
include the intense eosinophilia or severe myalgias initially
identified as the hallmarks of epidemic EMS. Thus far, such cases
have
not been the object of national surveillance.
The failure of a case to meet criteria specified in the
surveillance definition does not preclude a clinical diagnosis of
EMS
in a person who manifests other features of EMS or who has either a
lower eosinophil count or milder myalgias. As in other diseases
with
multiple connective tissue manifestations, a set of clear-cut
diagnostic criteria with both high sensitivity and specificity may
be
difficult or impossible to establish. The physician's judgment and
appropriate weighing of all available information are important in
the
clinical diagnosis of EMS.
References
Eidson M, Philen RM, Sewell CM, Voorhees R, Kilbourne EM.
L-tryptophan and eosinophilia-myalgia syndrome in New Mexico.
Lancet
1990;335:645-8.
CDC. Eosinophilia-myalgia syndrome and L-tryptophan-containing
products--New Mexico, Minnesota, Oregon, and New York, 1989. MMWR
1989;38:785-8.
CDC. Update: eosinophilia-myalgia syndrome associated with
ingestion
of L-tryptophan--United States. MMWR 1989;38:842-3.
CDC. Update: eosinophilia-myalgia syndrome associated with
ingestion
of L-tryptophan--United States, as of January 9, 1990. MMWR
1990;39:14-5.
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