Eosinophilia-myalgia syndrome masquerading as facial pain

Abstract

Eosinophilia and severe myalgia occurring in patients taking oral preparations of L-tryptophan (LT) is a recently recognized condition. It is now termed eosinophilia-myalgia syndrome (EMS) by the Centers for Disease Control (CDC). The CDC defines the characteristic signs and symptoms of EMS as 1) an eosinophil count greater than 1,000 cells per cubic millimeter, 2) generalized myalgia at some point during the course of the illness of sufficient severity to affect a patient’s ability to pursue his or her usual daily activities, and 3) absence of any infection or neoplasm that could account for 1 or 2 above. Presenting symptoms may also include subjective weakness, fever, arthralgia, shortness of breath, rash, peripheral edema, and pneumonia.“’ L-Tryptophan is an essential amino acid found in dietary protein and is a precursor to the neurotransmitters serotonin. It is available over the counter in many formulations and has been widely prescribed for the treatment of premenstrual syndrome, insomnia, and depression.’ A nationwide recall of LT-containing products (LTCP) was intiated on November 17, 1989, by the Food and Drug Administration (FDA). The current focus of studies on LTCP by the FDA is a search for chemical or microbial contaminants. L-Tryptophan is produced in Japan for ultimate sale and consumption in the United States, and the production practices of the Japanese pharmaceutical companies are now under close scrutiny by the FDA.2 Three hundred sixty cases of suspected EMS have been reported to the CDC by November 21, 1989, including a fatal case in the state of New York. Case-control studies were initiated in Minnesota and New Mexico that yielded a statistically significant association between the use of LTCP and EMS. The mechanism of the disease has not