å¡ ORIGINAL
ARTICLE
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Human Myeloma Cell Line (KHM-4) Established from A Patient with Multiple Myeloma Associated with Hyperammonemia Hiromitsu Matsuzaki, Fumihiko Matsuno, Minoru Yoshida, Hiroyuki Hata, Koushiro Okazaki* and Kiyoshi Takatsuki A cell line of plasma cells with high ammonia (NH3) production (KHM-4) was established from a patient with multiple myeloma complicated by hyperammonemia and abnormal serum concentrations of amino acids. Surface marker studies of KHM-4 cells showed that the cells were positive for cytoplasmic immunoglobulins (IgA kappa), HLA-DR, and T 10. Secretion of ammonia by the KHM-4 cells was detected by the addition of L-glutamine and L-arginine into the culture medium of amino acid-free RPMI 1640. In the presence of L-glutamine, KHM-4 cells secreted a greater amount of ammonia than the T cell line, CEM. However, production of ammonia by L-arginine was not observed in other cell lines. These observations provide evidenceMedicine for the existence of a peculiar (Internal 31: 339-343, 1992) amino acid metabolism in the myeloma cells causing hyperammonemia and serum amino acid disturbance. Key words: amino acid, ammonia, arginine, glutamine
Introduction with a huge plasmacytoma of the right chest wall in September 1988. Despite intensive chemotherapy, her Hyperammonemia occurs inand a diverse range ofhyperam discondition did not improve she developed orders such as liver failure (1, 2), Reye's syndrome (3), monemia (100-160 /ig/dl) and somnolence. The serum inborn errors of urea synthesis (4), homocitrullinuria levels of valine, leucine, isoleucine, threonine, cystine, syndrome (5), lysinuric protein intolerance (6), and glutamine, arginine, histidine, tryptophan, transient hyperammonemia of the newborn citrulline, (7). It may and ornithine were significantly low. the also occur as a complication of urinaryHowever, tract infection (8), asparaginase therapy valproic acid (10), Her concentrations somnolenceoftransiently glycine(9), and improved asparticafter acid therapy intensive were high. and systemic carnitine (ll). Recently, we to chemotherapy, but shedeficiency died of complications related encountered and secondary reported two patients with pleural effusion to myeloma cellsmultiple in May 1989. myelomarevealed Autopsy who hadalmost hyperammonemia, normal liver histology serum amino (12).acid disturbances, and disturbance of consciousness (12). Cell culture. Heparinized pleural effusion fluid from Malignant cells have to be very difficult the patientplasma was layered onto proved the Ficoll-Conray (specific to establish; however, we established a myeloma cell gravity, 1.078), and centrifuged at 400g for 30 minutes. line (KHM-4) patient with hyperammonemia. The interphasefrom cells,one which consisted almost entirely of In this study, wewere analyzed the mechanism hyperammyeloma cells, collected and seededof into culture monemia using KHM-4 cells. plates at approximately 106cells/ml after washing with complete and medium. In primary culture and the early Materials Methods passages, RPMI 1640 medium containing 20% fetal Case report.(FCS) A 51-year-old withthe IgAcells kappa calf serum was used,female and when began type multiple myeloma was readmitted to our to grow steadily, the medium was changed to hospital RPMI 1640 containing 10% FCS. Throughout the study, the
From the Second Department of Internal Medicine and * Department of Central Clinical Laboratory, Kumamoto University Medical Scho Kumamoto Received for publication July 1, 1991; Accepted for publication October 4, 1991 Reprint requests should be addressed to Hiromitsu Matsuzaki, M.D., the Second Department of Internal Medicine, Kumamoto University Medical School, 1-1-1 Honjo, Kumamoto 860, Japan Internal Medicine Vol. 31, No. 3 (March 1992) 339
Matsuzaki et al cells were maintained under conditions of 5% CO2 in humidified air at 37°C. Immunologic Marker Studies. Measurements of the following cell surface markers were performed: HLA DR, CD 2 (T ll), CD 10 (CALLA), CD 19 (B 4), CD 20 (B 1), CD 38 (T 10), and PCA-1 (Becton Dickinson, Mountain View, CA). Cytoplasmic immunoglobulins Assay were analyzed for ammonia by immunoperoxidase in the culture media. stain. KHM-4 cells were inoculated onto culture plates at 2 x 106cells/ml in RPMI 1640 with or without amino acid. After 4 or 8 hours of culture, ammonia levels in the culture media were measured by the enzymatic glutamate dehydrogenase method using Kyowa-Medix reagents and an autoanalyzer (RA-XT, Kyowa-Medix, Tokyo). T cell line (CEM), B cell line [KHM-2B (13)], and two myeloma cell lines [KHM-1A (14) and KMS-12-PE (15)] were used as Results the controls. Morphology of cultured cells. Myeloma cells were col-
lected and cultured from the patient's pleural effusion. KHM-4 cells floated in the culture medium as single cells or soft clusters. In Wright-Giemsa-stained smears, KHM 4 cells were morphologically similar to typical plasma blasts, with nuclei containing nucleoli and basophilic cytoplasm (Fig. 1A). Immunoperoxidase studies showed that KHM-4 cells reacted with antibodies against alpha (Fig. IB)markers. and kappa chainscells (Fig. 1C)positive of immunoglobulin. Surface KHM-4 were for HLA DR and CD 38 (T 10) but negative forCD 2 (T ll), CD 10 (CALLA), CD 19 (B 4), CD 20 (B 1), and PCA-1 (data not shown). Secretion of ammonia. Fresh myeloma cells from the pleural effusion secreted ammonia into the culture medium of RPMI 1640 without L-glutamine, and its concentration increased almost linearly from the time of cell seeding (Fig. 2). To determine the effect of amino acids on the accumulation of ammonia, each amino acid of the same concentration as RPMI 1640 medium was added to the amino acid-free culture medium. After an 8 hour culture of KHM-4 cell without amino acid, the ammonia level in the culture medium was 145 ± 35 /ig/dl,
Fig. 1. Cytologic appearance of KHM-4 cells with typical plasma cell features (A; Wright-Giemsa stain). Immunoperoxidase staining of KHM-4 cells for alpha (B), kappa (C), and lambda chain (D) of immunoglobulin. KHM-4 cells were positive for alpha and kappa chains negative for lambda chain. 340
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Vol. 31, No. 3 (March
1992)
AmmoniaProducing Myeloma similar to the level prior to culture. A slight increase in ammonia by L-cystine (262 ± 69/^g/dl), a significant increase by L-arginine (338 ± 55 //g/dl), and a marked in crease by L-glutamine (1,393 ± 51 jug/dl) were detected; however, other amino acids such as asparagine, aspartic acid, glutamic acid glycine, histidine, hydroxyproline, isoleucine, leucine, lysine, methionine, phenylalanine, proline, serine, threonine, tryptophan, tyrosine, and Avaline smaller of ammonia secretion was also(Fig. detected didamount not induce the secretion of ammonia 3). in the culture medium of CEM cells with the addition of L-glutamine (Fig. 4). In the presence of L-arginine, no increase of ammonia was detected in the culture medium of CEM cells (Fig. 4) and cell lines, KHM-1A, KHM-2B, and KMS-12-PE (data not shown). These data indicate that the metabolism of arginine by KHM-4 cells is qualitatively different from that of other cell lines. Figure 5 shows the dose effect of L-glutamine and L-arginine on the accumulation of ammonia. Accumu lation of ammonia by KHM-4 cells was detected during
1357 Hours of culture
Fig. 2. Accumulation curve of ammonia per 2 x 106 cells/ml in RPMI 1640 without L-glutamine. Ammonia in the supernatant of cultures of fresh myeloma cells from the patient increased linearly from the time of cell seeding.
Hours of culture Fig. 4. Accumulation curve of ammonia in RPMI 1640 with L-glutamine (300^g/ml) and L-arginine (200^g/ml). CEM cells secreted a smaller amount of ammonia in the presence of L glutamine but not in the presence of L-arginine. Fig. 3. Accumulation curve of ammonia from KHM-4 cells in RPMI 1640 with amino acids. KHM-4 cells secreted a significant amount of ammonia in the presence of L-glutamine (300/ig/ml) and L-arginine (200 /ig/ml).
Hours of culture Internal
Medicine
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31, No. 3 (March
1992)
341
Matsuzaki et al The cause of hyperammonemia in this patient seems to be directly related to the myeloma cells, due to the production of ammonia by KHM-4 cells in the presence of normal serum concentrations of L-glutamine and L-arginine. It is suggested that serum amino acid alterations are a more important factor than hyperammonemia in the induction of disturbance of consciousness in hepatic failure. In particular, the decrease in branched-chain amino acids (leucine, isoleucine, and valine) and the increase in aromatic amino acids (phenylalanine and tyrosine) which results in a low Fischer ratio, is regarded as the most important factor. Serum amino acid al terations and a low Fischer ratio (1.29; normal range 2.6-4.3) were detected in our patient. The branched chain amino acids had a very low concentration, but the aromatic amino acids were not increased. However, the concentration of tyrosine was low. We demontrated that the arginine metabolism of KHM-4 cells was completely different from that of other cell lines. KHM-4 may become a useful tool for the biochemical analysis of hyperammonemia and serum amino acid alterations in multiple myeloma. Supported in part by Grant-in-Aid for Cancer Research (61-2) from the Ministry of Health and Welfare, and a grant (01770902) from the Ministry of Education, Science, and Culture of Japan References Fig. 5. Dosc-rcspeonsc curves of L-glutamine and L-arginine on 1) Hoyumpa AM, Desmond PV, Avant GR, Roberts RK, Schenker S. Hepatic encephalopathy. Gastroenterology 76: 184, 1979. accumulation of ammonia from KHM-4 and CEM cells. 2 x 106cells/ml 2) Zieve L. The mechanism of hepatic coma. Hepatology 1: 360, in RPMI 1640 with two time serial dilutions of amino acids were1981. in 3) Shannon DC, DeLong GR, Bercu B, et al. Studies on the patho cubated for 8 hours. physiology of encephalopathy in Reye's syndrome: Hyperam monemia in Reye's syndrome. Pediatrics 56: 999, 1975. short incubation time (8hrs) at normal serum concen 4) Brusilow SW, Batshaw ML, Waber LV. Neonatal hyperam trations of L-glutamine and L-arginine, which approxi monemic coma. Adv Pediatr 29: 69, 1982. 5) Shih VE, Efron M, Moser HW. Hyperornithinemia, hyperam mately correspond to the 2~4 dilution shown in Fig. 5. monemia and homocitrullinuria. A new disorder of amino acid Discussion metabolism associated with myoclonic seizures and mental retar dation. Am J Dis Child 116: 83, 1969. 6) Simmell O, Peerheentupa J, Rapola J, Visakorpi K, Eskelin LE. Hyperammonaemia is mainly seen in hepatic failure Lysinuric protein intolerance. Am J Med 59: 229, 1975. (1, 2) and congenital metabolic disorders (4-6), however, 7) Ballard RA, Vinocur B, Reynolds JW, et al. Transient hyperam monemia of the preterm infant. N Engl J Med 229: 920, 1978. there was no evidence of liver dysfunction or an occult 8) Samtoy B, DeBeukelaer MM. Ammonia encephalopathy second congenital metabolic disorder in this patient, and the liver ary to urianry tract infection with Proteus mirabilis. Pediatrics 65: 294, 1980. was found to be almost normal at autopsy (12). Tsunoda 9) Moure JMB, Whitecar JP Jr, Bodey GP. Electroencephalogram et al. have reported four cases of multiple myeloma with changes secondary to asparaginase. Arch Neurol 23: 365, 1970. hyperammonemia and disturbance of consciousness in 10) Coulter DL, Allen RJ. Secondary hyperammonaemia: A possible mechanism of valproate encephalopathy. Lancet i: 1310, 1980. which liver function was within the normal (16). The mechanism of hyperammonemia was notrange known, ll) Chapoy PR, Angelini C, Brown WJ, StiffJE, Shug AL, Cederbaum but they suggested that the plasma of some patients with SD. Systemic carnitine deficiency - a treatable inherited lipid multiple myeloma contained unidentified factors which storage disease presenting as Reye's syndrome. N Engl J Med 303: 1389, 1980. increased the plasma ammonia concentration. We de 12) Matsuzaki H, Uchiba M, Yoshimura K, et al. Hyperammonemia monstrated that KHM-4 cells established from the patient in multiple myeloma. Acta Haematol 84: 130, 1990. 13) Matsuzaki H, Hata H, Aso N, et al. Establishment and charac with multiple myeloma and hyperammonemia secreted terization of acute B-cell lymphocytic leukemia cell line showing ammonia in the presence of L-glutamine and L-arginine. 342
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Vol. 31, No. 3 (March
1992)
Ammonia Producing Myeloma and amylase-non-producing KMS-12-BM, were established from (8; 14) and (14; 18) chromosome translocation. Acta Haematol 84:156,1990. a patient, having the same chromosome marker, t (ll; 14) (ql3; Matsuzaki Hata H,73: Takeya M, Takatsuki K. Establishment q32). Br J H, Haematol 199, 1989. 16) S, Sasaki A, Sakurabayashi I, Miura Y. Coma, and Tsunoda characterization of R, anMiwa amylase-producing human myeloma hyperviscosity hyperammonemia and myelofibrosis in cell line. Blood syndrome, 72: 978, 1988. Ohtsuki Yawata H, Sugihara T, Mori Namba M. a patientT,with IgG, Y, A, Wada type multiple myeloma. JpnM, J Clin Hematol Two human myeloma cell lines, amylase-producing KMS-12-PE 30: 361, 1989 (in Japanese).
Internal
Medicine
Vol. 31,
No. 3 (March
1992)
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ARTICLE
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Human Myeloma Cell Line (KHM-4) Established from A Patient with Multiple Myeloma Associated with Hyperammonemia Hiromitsu Matsuzaki, Fumihiko Matsuno, Minoru Yoshida, Hiroyuki Hata, Koushiro Okazaki* and Kiyoshi Takatsuki A cell line of plasma cells with high ammonia (NH3) production (KHM-4) was established from a patient with multiple myeloma complicated by hyperammonemia and abnormal serum concentrations of amino acids. Surface marker studies of KHM-4 cells showed that the cells were positive for cytoplasmic immunoglobulins (IgA kappa), HLA-DR, and T 10. Secretion of ammonia by the KHM-4 cells was detected by the addition of L-glutamine and L-arginine into the culture medium of amino acid-free RPMI 1640. In the presence of L-glutamine, KHM-4 cells secreted a greater amount of ammonia than the T cell line, CEM. However, production of ammonia by L-arginine was not observed in other cell lines. These observations provide evidenceMedicine for the existence of a peculiar (Internal 31: 339-343, 1992) amino acid metabolism in the myeloma cells causing hyperammonemia and serum amino acid disturbance. Key words: amino acid, ammonia, arginine, glutamine
Introduction with a huge plasmacytoma of the right chest wall in September 1988. Despite intensive chemotherapy, her Hyperammonemia occurs inand a diverse range ofhyperam discondition did not improve she developed orders such as liver failure (1, 2), Reye's syndrome (3), monemia (100-160 /ig/dl) and somnolence. The serum inborn errors of urea synthesis (4), homocitrullinuria levels of valine, leucine, isoleucine, threonine, cystine, syndrome (5), lysinuric protein intolerance (6), and glutamine, arginine, histidine, tryptophan, transient hyperammonemia of the newborn citrulline, (7). It may and ornithine were significantly low. the also occur as a complication of urinaryHowever, tract infection (8), asparaginase therapy valproic acid (10), Her concentrations somnolenceoftransiently glycine(9), and improved asparticafter acid therapy intensive were high. and systemic carnitine (ll). Recently, we to chemotherapy, but shedeficiency died of complications related encountered and secondary reported two patients with pleural effusion to myeloma cellsmultiple in May 1989. myelomarevealed Autopsy who hadalmost hyperammonemia, normal liver histology serum amino (12).acid disturbances, and disturbance of consciousness (12). Cell culture. Heparinized pleural effusion fluid from Malignant cells have to be very difficult the patientplasma was layered onto proved the Ficoll-Conray (specific to establish; however, we established a myeloma cell gravity, 1.078), and centrifuged at 400g for 30 minutes. line (KHM-4) patient with hyperammonemia. The interphasefrom cells,one which consisted almost entirely of In this study, wewere analyzed the mechanism hyperammyeloma cells, collected and seededof into culture monemia using KHM-4 cells. plates at approximately 106cells/ml after washing with complete and medium. In primary culture and the early Materials Methods passages, RPMI 1640 medium containing 20% fetal Case report.(FCS) A 51-year-old withthe IgAcells kappa calf serum was used,female and when began type multiple myeloma was readmitted to our to grow steadily, the medium was changed to hospital RPMI 1640 containing 10% FCS. Throughout the study, the
From the Second Department of Internal Medicine and * Department of Central Clinical Laboratory, Kumamoto University Medical Scho Kumamoto Received for publication July 1, 1991; Accepted for publication October 4, 1991 Reprint requests should be addressed to Hiromitsu Matsuzaki, M.D., the Second Department of Internal Medicine, Kumamoto University Medical School, 1-1-1 Honjo, Kumamoto 860, Japan Internal Medicine Vol. 31, No. 3 (March 1992) 339
Matsuzaki et al cells were maintained under conditions of 5% CO2 in humidified air at 37°C. Immunologic Marker Studies. Measurements of the following cell surface markers were performed: HLA DR, CD 2 (T ll), CD 10 (CALLA), CD 19 (B 4), CD 20 (B 1), CD 38 (T 10), and PCA-1 (Becton Dickinson, Mountain View, CA). Cytoplasmic immunoglobulins Assay were analyzed for ammonia by immunoperoxidase in the culture media. stain. KHM-4 cells were inoculated onto culture plates at 2 x 106cells/ml in RPMI 1640 with or without amino acid. After 4 or 8 hours of culture, ammonia levels in the culture media were measured by the enzymatic glutamate dehydrogenase method using Kyowa-Medix reagents and an autoanalyzer (RA-XT, Kyowa-Medix, Tokyo). T cell line (CEM), B cell line [KHM-2B (13)], and two myeloma cell lines [KHM-1A (14) and KMS-12-PE (15)] were used as Results the controls. Morphology of cultured cells. Myeloma cells were col-
lected and cultured from the patient's pleural effusion. KHM-4 cells floated in the culture medium as single cells or soft clusters. In Wright-Giemsa-stained smears, KHM 4 cells were morphologically similar to typical plasma blasts, with nuclei containing nucleoli and basophilic cytoplasm (Fig. 1A). Immunoperoxidase studies showed that KHM-4 cells reacted with antibodies against alpha (Fig. IB)markers. and kappa chainscells (Fig. 1C)positive of immunoglobulin. Surface KHM-4 were for HLA DR and CD 38 (T 10) but negative forCD 2 (T ll), CD 10 (CALLA), CD 19 (B 4), CD 20 (B 1), and PCA-1 (data not shown). Secretion of ammonia. Fresh myeloma cells from the pleural effusion secreted ammonia into the culture medium of RPMI 1640 without L-glutamine, and its concentration increased almost linearly from the time of cell seeding (Fig. 2). To determine the effect of amino acids on the accumulation of ammonia, each amino acid of the same concentration as RPMI 1640 medium was added to the amino acid-free culture medium. After an 8 hour culture of KHM-4 cell without amino acid, the ammonia level in the culture medium was 145 ± 35 /ig/dl,
Fig. 1. Cytologic appearance of KHM-4 cells with typical plasma cell features (A; Wright-Giemsa stain). Immunoperoxidase staining of KHM-4 cells for alpha (B), kappa (C), and lambda chain (D) of immunoglobulin. KHM-4 cells were positive for alpha and kappa chains negative for lambda chain. 340
Internal
Medicine
Vol. 31, No. 3 (March
1992)
AmmoniaProducing Myeloma similar to the level prior to culture. A slight increase in ammonia by L-cystine (262 ± 69/^g/dl), a significant increase by L-arginine (338 ± 55 //g/dl), and a marked in crease by L-glutamine (1,393 ± 51 jug/dl) were detected; however, other amino acids such as asparagine, aspartic acid, glutamic acid glycine, histidine, hydroxyproline, isoleucine, leucine, lysine, methionine, phenylalanine, proline, serine, threonine, tryptophan, tyrosine, and Avaline smaller of ammonia secretion was also(Fig. detected didamount not induce the secretion of ammonia 3). in the culture medium of CEM cells with the addition of L-glutamine (Fig. 4). In the presence of L-arginine, no increase of ammonia was detected in the culture medium of CEM cells (Fig. 4) and cell lines, KHM-1A, KHM-2B, and KMS-12-PE (data not shown). These data indicate that the metabolism of arginine by KHM-4 cells is qualitatively different from that of other cell lines. Figure 5 shows the dose effect of L-glutamine and L-arginine on the accumulation of ammonia. Accumu lation of ammonia by KHM-4 cells was detected during
1357 Hours of culture
Fig. 2. Accumulation curve of ammonia per 2 x 106 cells/ml in RPMI 1640 without L-glutamine. Ammonia in the supernatant of cultures of fresh myeloma cells from the patient increased linearly from the time of cell seeding.
Hours of culture Fig. 4. Accumulation curve of ammonia in RPMI 1640 with L-glutamine (300^g/ml) and L-arginine (200^g/ml). CEM cells secreted a smaller amount of ammonia in the presence of L glutamine but not in the presence of L-arginine. Fig. 3. Accumulation curve of ammonia from KHM-4 cells in RPMI 1640 with amino acids. KHM-4 cells secreted a significant amount of ammonia in the presence of L-glutamine (300/ig/ml) and L-arginine (200 /ig/ml).
Hours of culture Internal
Medicine
Vol.
31, No. 3 (March
1992)
341
Matsuzaki et al The cause of hyperammonemia in this patient seems to be directly related to the myeloma cells, due to the production of ammonia by KHM-4 cells in the presence of normal serum concentrations of L-glutamine and L-arginine. It is suggested that serum amino acid alterations are a more important factor than hyperammonemia in the induction of disturbance of consciousness in hepatic failure. In particular, the decrease in branched-chain amino acids (leucine, isoleucine, and valine) and the increase in aromatic amino acids (phenylalanine and tyrosine) which results in a low Fischer ratio, is regarded as the most important factor. Serum amino acid al terations and a low Fischer ratio (1.29; normal range 2.6-4.3) were detected in our patient. The branched chain amino acids had a very low concentration, but the aromatic amino acids were not increased. However, the concentration of tyrosine was low. We demontrated that the arginine metabolism of KHM-4 cells was completely different from that of other cell lines. KHM-4 may become a useful tool for the biochemical analysis of hyperammonemia and serum amino acid alterations in multiple myeloma. Supported in part by Grant-in-Aid for Cancer Research (61-2) from the Ministry of Health and Welfare, and a grant (01770902) from the Ministry of Education, Science, and Culture of Japan References Fig. 5. Dosc-rcspeonsc curves of L-glutamine and L-arginine on 1) Hoyumpa AM, Desmond PV, Avant GR, Roberts RK, Schenker S. Hepatic encephalopathy. Gastroenterology 76: 184, 1979. accumulation of ammonia from KHM-4 and CEM cells. 2 x 106cells/ml 2) Zieve L. The mechanism of hepatic coma. Hepatology 1: 360, in RPMI 1640 with two time serial dilutions of amino acids were1981. in 3) Shannon DC, DeLong GR, Bercu B, et al. Studies on the patho cubated for 8 hours. physiology of encephalopathy in Reye's syndrome: Hyperam monemia in Reye's syndrome. Pediatrics 56: 999, 1975. short incubation time (8hrs) at normal serum concen 4) Brusilow SW, Batshaw ML, Waber LV. Neonatal hyperam trations of L-glutamine and L-arginine, which approxi monemic coma. Adv Pediatr 29: 69, 1982. 5) Shih VE, Efron M, Moser HW. Hyperornithinemia, hyperam mately correspond to the 2~4 dilution shown in Fig. 5. monemia and homocitrullinuria. A new disorder of amino acid Discussion metabolism associated with myoclonic seizures and mental retar dation. Am J Dis Child 116: 83, 1969. 6) Simmell O, Peerheentupa J, Rapola J, Visakorpi K, Eskelin LE. Hyperammonaemia is mainly seen in hepatic failure Lysinuric protein intolerance. Am J Med 59: 229, 1975. (1, 2) and congenital metabolic disorders (4-6), however, 7) Ballard RA, Vinocur B, Reynolds JW, et al. Transient hyperam monemia of the preterm infant. N Engl J Med 229: 920, 1978. there was no evidence of liver dysfunction or an occult 8) Samtoy B, DeBeukelaer MM. Ammonia encephalopathy second congenital metabolic disorder in this patient, and the liver ary to urianry tract infection with Proteus mirabilis. Pediatrics 65: 294, 1980. was found to be almost normal at autopsy (12). Tsunoda 9) Moure JMB, Whitecar JP Jr, Bodey GP. Electroencephalogram et al. have reported four cases of multiple myeloma with changes secondary to asparaginase. Arch Neurol 23: 365, 1970. hyperammonemia and disturbance of consciousness in 10) Coulter DL, Allen RJ. Secondary hyperammonaemia: A possible mechanism of valproate encephalopathy. Lancet i: 1310, 1980. which liver function was within the normal (16). The mechanism of hyperammonemia was notrange known, ll) Chapoy PR, Angelini C, Brown WJ, StiffJE, Shug AL, Cederbaum but they suggested that the plasma of some patients with SD. Systemic carnitine deficiency - a treatable inherited lipid multiple myeloma contained unidentified factors which storage disease presenting as Reye's syndrome. N Engl J Med 303: 1389, 1980. increased the plasma ammonia concentration. We de 12) Matsuzaki H, Uchiba M, Yoshimura K, et al. Hyperammonemia monstrated that KHM-4 cells established from the patient in multiple myeloma. Acta Haematol 84: 130, 1990. 13) Matsuzaki H, Hata H, Aso N, et al. Establishment and charac with multiple myeloma and hyperammonemia secreted terization of acute B-cell lymphocytic leukemia cell line showing ammonia in the presence of L-glutamine and L-arginine. 342
Internal
Medicine
Vol. 31, No. 3 (March
1992)
Ammonia Producing Myeloma and amylase-non-producing KMS-12-BM, were established from (8; 14) and (14; 18) chromosome translocation. Acta Haematol 84:156,1990. a patient, having the same chromosome marker, t (ll; 14) (ql3; Matsuzaki Hata H,73: Takeya M, Takatsuki K. Establishment q32). Br J H, Haematol 199, 1989. 16) S, Sasaki A, Sakurabayashi I, Miura Y. Coma, and Tsunoda characterization of R, anMiwa amylase-producing human myeloma hyperviscosity hyperammonemia and myelofibrosis in cell line. Blood syndrome, 72: 978, 1988. Ohtsuki Yawata H, Sugihara T, Mori Namba M. a patientT,with IgG, Y, A, Wada type multiple myeloma. JpnM, J Clin Hematol Two human myeloma cell lines, amylase-producing KMS-12-PE 30: 361, 1989 (in Japanese).
Internal
Medicine
Vol. 31,
No. 3 (March
1992)
343
