Severe hyponatraemia in hyperlipaemic diabetic ketosis.

709 The patient was kept warm in bed and the rash gradually faded during the course of a week. The discoloration lightened through red and brown, and on discharge from hospital only slight residual staining remained. There was no evidence of a falling haemoglobin, and after discharge she suffered no further symptoms. The cold agglutinins, however, were still present after a month. When reviewed three months later the haemoglobin was normal and cold agglutinins were absent. Comment Skin eruptions occur in about 5% of patients with infectious mononucleosis and these have been reviewed (McCarthy and Hoagland, 1964). A reticular discoloration of this kind seems not to have been previously reported. It is likely that this rash was related, firstly, to the cold agglutinins present, producing an area of particular stasis on exposure to the cold night, and, secondly to a bleeding tendency which caused the rash to become haemorrhagic. Although red cell autoantibodies acting in the cold are the rule in infectious mononucleosis they do not normally give rise to symptoms. Capra et al., (1969) found an indirect acting IgG anti-i antibody in 90% of patients with this disorder, and an IgM anti-i cold agglutinin may be present in between 7% (Jenkins et al., 1965) and 26% (Worlledge and Dacie, 1969) depending on the criteria used. These antibodies being directed mainly against fetal rather than adult red cells rarely cause a haemolytic anaemia. Anti-I, which is directed against adult rather than fetal red cells, does occur in infectious mono-nucleosis occasionally, and Worlledge and Dacie (1969) referred to 12 such cases with haemolytic anaemia reported in the literature. The present patient undoubtedly had a high titre anti-I, but there was no evidence of haemolytic anaemia. Mild thrombocytopenia is a fairly common manifestation of infectious mononucleosis. Carter (1965) found counts of less than 100,000/mm3 in 8 out of 57 patients. Haemorrhagic complications are very rare. The cause of the thrombocyto-penia is not clear but is likely to be abnormal consumption. Abnormalities of coagulation are very rare. The prolonged activated partial thromboplastin time was not further investigated , but there are at least three possible causes for it. It might have been caused by liver damage, as in the case described by Schumacher and Barcay (1962). This is unlikely since this patient's liver damage was very minor, and factor VII levels, which are usually the most sensitive to liver damage, were, on the …