1261
cular and pituitary hormone production in these
workers. workers not currently using oral connormal F.S.H. and L.H. results. had traceptives of the testicular-biopsy results evaluation Preliminary men indicated loss of spermatoaffected the of severely with no evidence of inflammation or severe gonia, The 2
women
and the Oil, Chemical, and Atomic Workers Union, Local 1-5. We thank Dr William Palmer, Dr Louis Brahen, and Dr Edward Smuckler for advice on pathology, Dr John Linfoot for assistance with endocrine assays, and Dr Ken Dod, Claire Lalor, and Mary Ann Gustavson for administrative support.
Requests for reprints should be addressed to D. W., 2521 Channing Way, University of California, Berkeley, California 94720, U.S.A. REFERENCES
fibrous.
included in the comparison who had of 10 million-30 million had exposures sperm-counts between one and three years-an observation that supports the notion of a direct relationship between length of exposure and degree of oligospermia. The 3
men not
DISCUSSION
Chemically reduced male infertility related to occupation has seldom been reported. Lancranjan et al.3 reported that lead-poisoned workers had lowered spermcounts, decreased sperm motility, and a higher proportion of abnormal forms. Diminished libido and difficulty in erection and- ejaculation were also found. Kepone, an organochlorine insecticide, severely poisoned workers in Virginia in 1975. Most of the affected workers had severe neurological abnormalities, and some were also reported to be infertile.4 The chemical suspected in the present investigation to be the cause of infertility had previously been shown to produce sterility in animals. D.B.C.P. was shown by Torkelson et al. to be toxic to the testes of rats, guineapigs, and rabbits. In the rat testis it caused degeneration of the seminiferous tubules, increase in Sertoli cells, reduced sperm-count, and abnormal sperm morphology. Rats with these effects also showed hepatic and renal degeneration. D.B.C.P. was found to produce these changes through skin absorption as well as ingestion or inhalation. Faidysh et al.6 showed that D.B.c.p. damaged the testes, liver, and kidneys of rats, but these organs regenerated in the survivors. Airborne concentrations of D.B.C.P. in the factory we investigated are believed to be lower than the 1 p.p.m. limit recommended by Torkelson et al.5 D.B.C.P. levels measured in early 1977 in the A.C.D. were 0-4 p.p.m. (averaged for an eight-hour day). These measurements 7 were made with personal air-sampling devices. Research is being continued at this plant, together with studies in other areas. Follow-up studies of the affected workers are being planned. Our findings have raised a number of important issues. One is the significance of duration and intensity of exposure. Although all severely affected workers (group A) were, or had been, production workers for at least three years. the shortest time of exposure associated with oligospermia was only one year. Another question is whether the observed sterility is reversible in man as it has been shown to be in animals. Finally, since D.B.C.P. is carcinogenic in animals8 and mutagenic in bacterial systems,9 the possibility of such damage in man must also be considered seriously. How big a problem D.B.c.p.-induced infertility is we do not yet know, but our communications with medical officers of other companies manufacturing D.B.C.P. clearly indicate that it extends beyond the formulating plant described here. This
study
would not have been possible without the support and Occidental Chemical Company, Western Division,
cooperation of the
Amelar, R. D., Dubin, L., Walsh, P. C. Male Infertility. Philadelphia, 1977. Odell, W. D., Swerdloff, R. S. West. J. Med. 1976, 124, 446. Lancranjan, I., Popescu, H. I., Gavanescu, O., Klepsch, I., Servanescu, M. Archs envir. Hlth, 1975, 30, 396. 4. Zavon, M. Personal communication. 5. Iorkelson, T. R., Sadek, S. E., Rowe, V. K., Kodama, J. K., Anderson, H. H., Loquvam, G. S., Hine, C. H. Toxicol. appl. Pharmac. 1961, 3, 545. 6. Faidysh, E. V., Rakhmatullaev, N. N., Varshavskii, V. A. Medskii Zh. Uzbek. 1970, 1, 64. 7. Rappaport, S., Spear, R. Personal communication. 9. Olson, W. A., Habermann, R. T., Weisburger, E. K., Ward, J. M., Weis-
1. 2. 3.
9. 10.
burger, J. H. J. natn. Cancer Inst. 1973, 51, 1993. Rosenkranz, H. S. Bull envir. Contam. Toxicol. 1975, 14, 18. Scharnweber, C., Joyner, R. Personal communication.
Hypothesis IS PRIMARY BILIARY CIRRHOSIS AN IMMUNE COMPLEX DISEASE? H.C. THOMAS
B.
J. POTTER
SHEILA SHERLOCK
Department of Medicine, Royal Free Hospital,
London
immune complexes are present in the circulation of patients with primary biliary cirrhosis and result in the activation of complement by the classical pathway. Such large complexes are capable of producing tissue damage. The granulomatous lesions surrounding the small bile-ducts within the liver of patients with primary biliary cirrhosis and the vasculitis, rheumatoid arthritis, and associated lesions are all compatible with immune complex injury. It is postulated that such large complexes could be formed in the vicinity of the bile-ducts by an antigen absorbed from the bile or biliary epithelium. Complexes reaching the systemic circulation might be responsible for the associated extra-hepatic diseases.
Summary
Large
INTRODUCTION
biliary cirrhosis is a disease of unknown largely affects middle-aged women. Insidious cholestasis, usually presenting as pruritus, continues slowly to deep jaundice and ultimately liver failure. 1-4 The disease may remain in an asymptomatic stage for many years. In the liver small bile-ducts are destroyed and surrounded by granulomas.3 Associated diseases include rheumatoid arthritis, arteritis, glomerulitis, and sicca syndrome.6-9 There is a familial clustering of cases 11 Serum-immunoglobulin-M (IgM) is raised and over 90% of patients have a serum mitochondrial antibody.l2 We think that primary biliary cirrhosis might be related to immune complex liver injury and we PRIMARY
aetiology,
which
consider how many of the features described above could be explained by this hypothesis. EVIDENCE FOR THE PRESENCE OF IMMUNE COMPLEXES
The Clq-binding assays3 detected immune complexes in the serum of most patients with primary biliary cirr-
1262
hosis irrespective of the stage of the histological lesion.’4 The complexes were both small and large, having sedimentation coefficients-of 8-11S and greater than 20S. The large complexes are characteristic of primary biliary cirrhosis; the smaller ones are also found in hepatitis-B positive and negative chronic active hepatitis and alcohol-induced hepatitis. These small complexes are probably related to food and commensal bacterial antigens which are absorbed from the gut and which accumulate because of the liver’s phagocytic function is impaired in various diseases.’S These small complexes are probably formed in the presence of an antigen excess, do not fix complement, and do not therefore cause important tissue damage. We suggest that the large complexes, which are found in primary biliary cirrhosis, fix complement and are responsible for tissue damage. Large complexes of this type when injected into the tissues of animals result in granuloma formation,16 which is the characteristic lesion in the early stages of primary biliary cirrhosis. There is a positive correlation between serum-IgM concentration and the level of Clq binding of the patient’s serum.14 This suggests that the larger complexes may contain antigen complexed with an IgM antibody and raises the possibility that the macroglobulina;mia which is characteristic of primary biliary cirrhosis" may represent a specific response to the antigen involved in the complex formation. A response which predominantly involves the IgM class indicates that the antigen is a lipopolysaccharide. The relation between the serum mitochondrial antibody and the complexes has not been determined. However, this antibody does exist in IgM, IgG, and IgA classes. 18 It has been more difficult to demonstrate immune complexes in the liver parenchyma. However, in the 1960s Popper and his group demonstrated extracellular aggregates of immunoglobulin and complement in the lesions of patients with primary biliary cirrhosis, 19
(dq BINDING) AND COMPLEMENT (dq, c3) IN CHRONIC LIVER DISEASE
IMMUNE COMPLEXES
CATABOLISM
I
I
*r
cular and pituitary hormone production in these
workers. workers not currently using oral connormal F.S.H. and L.H. results. had traceptives of the testicular-biopsy results evaluation Preliminary men indicated loss of spermatoaffected the of severely with no evidence of inflammation or severe gonia, The 2
women
and the Oil, Chemical, and Atomic Workers Union, Local 1-5. We thank Dr William Palmer, Dr Louis Brahen, and Dr Edward Smuckler for advice on pathology, Dr John Linfoot for assistance with endocrine assays, and Dr Ken Dod, Claire Lalor, and Mary Ann Gustavson for administrative support.
Requests for reprints should be addressed to D. W., 2521 Channing Way, University of California, Berkeley, California 94720, U.S.A. REFERENCES
fibrous.
included in the comparison who had of 10 million-30 million had exposures sperm-counts between one and three years-an observation that supports the notion of a direct relationship between length of exposure and degree of oligospermia. The 3
men not
DISCUSSION
Chemically reduced male infertility related to occupation has seldom been reported. Lancranjan et al.3 reported that lead-poisoned workers had lowered spermcounts, decreased sperm motility, and a higher proportion of abnormal forms. Diminished libido and difficulty in erection and- ejaculation were also found. Kepone, an organochlorine insecticide, severely poisoned workers in Virginia in 1975. Most of the affected workers had severe neurological abnormalities, and some were also reported to be infertile.4 The chemical suspected in the present investigation to be the cause of infertility had previously been shown to produce sterility in animals. D.B.C.P. was shown by Torkelson et al. to be toxic to the testes of rats, guineapigs, and rabbits. In the rat testis it caused degeneration of the seminiferous tubules, increase in Sertoli cells, reduced sperm-count, and abnormal sperm morphology. Rats with these effects also showed hepatic and renal degeneration. D.B.C.P. was found to produce these changes through skin absorption as well as ingestion or inhalation. Faidysh et al.6 showed that D.B.c.p. damaged the testes, liver, and kidneys of rats, but these organs regenerated in the survivors. Airborne concentrations of D.B.C.P. in the factory we investigated are believed to be lower than the 1 p.p.m. limit recommended by Torkelson et al.5 D.B.C.P. levels measured in early 1977 in the A.C.D. were 0-4 p.p.m. (averaged for an eight-hour day). These measurements 7 were made with personal air-sampling devices. Research is being continued at this plant, together with studies in other areas. Follow-up studies of the affected workers are being planned. Our findings have raised a number of important issues. One is the significance of duration and intensity of exposure. Although all severely affected workers (group A) were, or had been, production workers for at least three years. the shortest time of exposure associated with oligospermia was only one year. Another question is whether the observed sterility is reversible in man as it has been shown to be in animals. Finally, since D.B.C.P. is carcinogenic in animals8 and mutagenic in bacterial systems,9 the possibility of such damage in man must also be considered seriously. How big a problem D.B.c.p.-induced infertility is we do not yet know, but our communications with medical officers of other companies manufacturing D.B.C.P. clearly indicate that it extends beyond the formulating plant described here. This
study
would not have been possible without the support and Occidental Chemical Company, Western Division,
cooperation of the
Amelar, R. D., Dubin, L., Walsh, P. C. Male Infertility. Philadelphia, 1977. Odell, W. D., Swerdloff, R. S. West. J. Med. 1976, 124, 446. Lancranjan, I., Popescu, H. I., Gavanescu, O., Klepsch, I., Servanescu, M. Archs envir. Hlth, 1975, 30, 396. 4. Zavon, M. Personal communication. 5. Iorkelson, T. R., Sadek, S. E., Rowe, V. K., Kodama, J. K., Anderson, H. H., Loquvam, G. S., Hine, C. H. Toxicol. appl. Pharmac. 1961, 3, 545. 6. Faidysh, E. V., Rakhmatullaev, N. N., Varshavskii, V. A. Medskii Zh. Uzbek. 1970, 1, 64. 7. Rappaport, S., Spear, R. Personal communication. 9. Olson, W. A., Habermann, R. T., Weisburger, E. K., Ward, J. M., Weis-
1. 2. 3.
9. 10.
burger, J. H. J. natn. Cancer Inst. 1973, 51, 1993. Rosenkranz, H. S. Bull envir. Contam. Toxicol. 1975, 14, 18. Scharnweber, C., Joyner, R. Personal communication.
Hypothesis IS PRIMARY BILIARY CIRRHOSIS AN IMMUNE COMPLEX DISEASE? H.C. THOMAS
B.
J. POTTER
SHEILA SHERLOCK
Department of Medicine, Royal Free Hospital,
London
immune complexes are present in the circulation of patients with primary biliary cirrhosis and result in the activation of complement by the classical pathway. Such large complexes are capable of producing tissue damage. The granulomatous lesions surrounding the small bile-ducts within the liver of patients with primary biliary cirrhosis and the vasculitis, rheumatoid arthritis, and associated lesions are all compatible with immune complex injury. It is postulated that such large complexes could be formed in the vicinity of the bile-ducts by an antigen absorbed from the bile or biliary epithelium. Complexes reaching the systemic circulation might be responsible for the associated extra-hepatic diseases.
Summary
Large
INTRODUCTION
biliary cirrhosis is a disease of unknown largely affects middle-aged women. Insidious cholestasis, usually presenting as pruritus, continues slowly to deep jaundice and ultimately liver failure. 1-4 The disease may remain in an asymptomatic stage for many years. In the liver small bile-ducts are destroyed and surrounded by granulomas.3 Associated diseases include rheumatoid arthritis, arteritis, glomerulitis, and sicca syndrome.6-9 There is a familial clustering of cases 11 Serum-immunoglobulin-M (IgM) is raised and over 90% of patients have a serum mitochondrial antibody.l2 We think that primary biliary cirrhosis might be related to immune complex liver injury and we PRIMARY
aetiology,
which
consider how many of the features described above could be explained by this hypothesis. EVIDENCE FOR THE PRESENCE OF IMMUNE COMPLEXES
The Clq-binding assays3 detected immune complexes in the serum of most patients with primary biliary cirr-
1262
hosis irrespective of the stage of the histological lesion.’4 The complexes were both small and large, having sedimentation coefficients-of 8-11S and greater than 20S. The large complexes are characteristic of primary biliary cirrhosis; the smaller ones are also found in hepatitis-B positive and negative chronic active hepatitis and alcohol-induced hepatitis. These small complexes are probably related to food and commensal bacterial antigens which are absorbed from the gut and which accumulate because of the liver’s phagocytic function is impaired in various diseases.’S These small complexes are probably formed in the presence of an antigen excess, do not fix complement, and do not therefore cause important tissue damage. We suggest that the large complexes, which are found in primary biliary cirrhosis, fix complement and are responsible for tissue damage. Large complexes of this type when injected into the tissues of animals result in granuloma formation,16 which is the characteristic lesion in the early stages of primary biliary cirrhosis. There is a positive correlation between serum-IgM concentration and the level of Clq binding of the patient’s serum.14 This suggests that the larger complexes may contain antigen complexed with an IgM antibody and raises the possibility that the macroglobulina;mia which is characteristic of primary biliary cirrhosis" may represent a specific response to the antigen involved in the complex formation. A response which predominantly involves the IgM class indicates that the antigen is a lipopolysaccharide. The relation between the serum mitochondrial antibody and the complexes has not been determined. However, this antibody does exist in IgM, IgG, and IgA classes. 18 It has been more difficult to demonstrate immune complexes in the liver parenchyma. However, in the 1960s Popper and his group demonstrated extracellular aggregates of immunoglobulin and complement in the lesions of patients with primary biliary cirrhosis, 19
(dq BINDING) AND COMPLEMENT (dq, c3) IN CHRONIC LIVER DISEASE
IMMUNE COMPLEXES
CATABOLISM
I
I
*r
