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SIR—We report a case of Zieve's syndrome initially diagnosed as polymyalgia rheumatica (PMR). A 59-yr-old woman was referred by her general practitioner with myalgia and a raised plasma viscosity (PV) of 2.25 [normal range (NR) 1.57-1.75], as a case of PMR unresponsive to prednisolone therapy (15 mg o.d.) given for a 2 month period. At the initial hospital consultation, PMR was considered unlikely as her myalgia was generalized, so prednisolone was withdrawn. Although the patient was tearful, examination was otherwise unremarkable. Over the subsequent 8 weeks, her aching worsened, then nausea, vomiting, abdominal pain and dark urine with mild jaundice developed. Her haemoglobin had fallen within 2 weeks from 14.9 to 8.8 g/dl with no evidence of haemorrhage. A reticulocytosis was noted (5.8%; NR < 2), and fragmented erythxocytes were seen on the blood film. Other investigations at this time were: PV 2.13 mPa, bilirubin 41 /zmol/1 (NR 5-17), alanine aminotransferase 68IU/1 (NR 10-60), alkaline phosphatase 216IU/1 (NR 40-140), yGT 1049 IU/1 (NR 7-64), cholesterol 31.1mmol/l (NR < 5.2), triglyceride 19.2mmol/l (NR < 2.3), sodium 129mmol/l (NR 130-155), ferritin 1529/ig/l (NR 15-300). Urea, creatinine, electrolytes, amylase, calcium, urine and serum osmolalities, creatinine phosphokinase, thyroid function tests, immunoglobulins, vitamin Bi2, folate, white cell count, platelets, coagulation screen, Coomb's test, viral serology and hepatic autoantibodies were normal. A CT scan of the abdomen showed fatty infiltration of the liver and a normal pancreas. Her husband informed us that she had been drinking at least one bottle of sherry per week recently due to domestic difficulties. A diagnosis of Zieve's syndrome was made and the need for abstinence from alcohol discussed with the patient. Subsequently, her myalgia resolved within 2 weeks with haematological and biochemical abnormalities returning to normal, as shown in Fig. 1. The ferritin level also returned to normal and the PV fell to 1.55 mPa. Zieve's syndrome consists of jaundice, hepatic dysfunction, hyperlipidaemia and transient haemolytic anaemia associated with alcohol abuse [1], although the latter may not be suspected [2, 3]. Red blood corpuscle metabolism has been found to be abnormal [2,4-9], predisposing to haemolysis, possibly though a circulating haemolysin, such as lysolecithin [1] which is elevated in such patients [10]. Hyperlipidaemia often precedes the episode of haemolysis and in our case lipaemic serum was noted in several samples during the 4 month period prior to the full-blown presentation. Unfortunately, retrospective measurement of lipids was not possible. Haemolysis is thought to be precipitated by a rapid fall in lipids [2, 10], which is supported in part by our case as the reticulocytosis peaked after the fall in lipids. Cholesterol has been shown to have an inhibitory effect on the action of lysolecithin [11] and it is postulated that lysolecithin acts only when lipid levels fall. A raised PV has not been reported previously. This led to an initial diagnosis of PMR in our patient,

A Case of Zieve's Syndrome Presenting with Myalgia: Not to be Confused with Polymyalgia Rheumatica