1203
accompanying medical report told of a therapeutic aborprevious day, involving an intrauterine prostaglandin administration, which was ineffective until followed by an intravenous prostaglandin drip. She was one of a coachload of similar patients, the rest of whom seemed perfectly well and were cheerfully singing in the bar. Faute de mieux, I prescribed four tablets of aspirin on the assumption that the symptoms were either hysterical, or an unusual side-effect of prostaglandins. In 30—40 min the symptoms had disappeared and the patient was eating a hearty An
tion the
meal. Since prostaglandins are supposed to disappear rapidly from the circulation, and since in any case aspirin is said to be an inhibitor of prostaglandin biosynthesis I am puzzled by the patient’s response to my treatment. Hertfordshire Area Health Authority, Hamilton House, 111 Marlowes, Hemel Hempstead, Herts, HP1 1EN
MICHAEL BALL
PROTHROMBIN-COMPLEX CONCENTRATE IN TREATMENT OF CLASSICAL HÆMOPHILIA WITH FACTOR-VIII ANTIBODY
SIR,-Successful use of activated and non-activated prothrombin-complex concentrates in the management of classical hemophiliacs with anti-factor-vm antibodies has been reported by several investigators.’-4 Failures have also been reported by Dr Bloom (Aug. 23, p. 369). However, the effect of such treat-
necessary to restrict its use to severe bleeding episodes, and (2) manufacturers should be encouraged to prepare prothrombincomplex concentrates free of factor vm for treatment of patients with antibody to factor viu. Centre pour Enfants Hémophiles, Croix Rouge Française, 78940-La Queue lez Yvelines, France.
SIR,-Dr Giraud and colleagues (Nov. 29,
p. 1088) report of babies born to mothers with severe hepatitis-B viral hepatitis. They observed the outcome and drew three conclusions, the second of which was that maternofetal contamination was likely to have been transplacental because the babies had been born by caesarean section and immediately separated from their mother. Although transplacental infection may occur, these cases did not confirm it. It is wrong to suggest that cxsarean section is an "immaculate" delivery in which the baby is not contaminated by the mother’s blood.- Infection could have occurred during delivery.
two cases
St Thomas’ Hospital, London SE1 7EH.
the inhibitor titre has not been stated in these reports. We have treated 2 patients with classical haemophilia, who also have antibody to factor-vm, with the French prothrombinCase 1.-This 11-year-old boy had a very painful haemarthrosis of the right knee. Aspiration was performed under the cover of two injections of 44 units/kg of factor ix given at 4-hourly intervals. Complete clinical and functional resolution was obtained within 3 days. Case 2.-This 6-year-old boy had a post-traumatic haematoma of the left costal cardiac region. His hasmatocrit was 25%, and he received two injections of 28.5units/kg of factor IX at 4-hourly intervals. Bleeding stopped immediately. Within 5 days his haematocrit had risen to 31 %.
In both cases treatment was monitored by standard tests of haemostasis. Antibody titres were determined at intervals by a modification of the method of Biggs and Bidwell6 and expressed in units as previously described.7 Both patients showed a striking decrease in the kaolin-activated partial thromboplastin-time and the prothromin-time, still present 4 hours after the second injection. No evidence of disseminated intravascular coagulation was observed, since the platelet-count and fibrin(ogen)-degradation products were stable. Before treatment, neither patient had clinical or laboratory signs of liver disease. This treatment was followed by an anamnestic resoonse in both cases. Patient 1 had a pretreatment titre of 1.8units, which rose to 85 units 15 days after treatment. Patient 2 had a titre of 0.2 units before treatment, and after 15 days the antibody level was 0.8 units. Although no factor-vm antigen could be detected by rocket immunoelectrophoresis, the anamnestic response may have been due to the presence of small amounts of factor vm in the concentrate. These two observations confirm that non-activated factor-tx concentrate may be effective in controlling bleeding in patients with classical haemophilia complicated by antibody (inhibitor) and was used without thrombotic complication or disseminated intravascular coagulation. Although clinically active, this material can trigger an anamnestic response. Thus, (1) it is 1. Kurczynski, E. M., Penner, J. A. New Engl. J. Med. 1974, 291, 164. 2. Sultan, Y., Brouet, J. C. ibid. p.1087. 3. Abildgaard, C. F., Britton, M., Roberts, R. Blood, 1974, 44, 933. 4. Bloom, A. L., Hutton, R. D. Lancet, 1975, ii, 370. 5. Soulier, J. P., Steinbuch, M. in Handbook of Haemophilia (edited by K. M. Bnnkhous and H. C. Hemker); p. 531. Amsterdam, 1975. 6. Biggs, R., Bidwell, E. Br. J. Hœmat. 1959, 5, 379. 7. Allain, J. P., Frommel, D. Blood, 1973, 43, 437.
P. ALLAIN
HEPATITIS-B VIRUS INFECTION OF CHILDREN BORN TO MOTHERS WITH SEVERE HEPATITIS
J. W. SCOPES
DIAGNOSIS OF ALPHA1-ANTITRYPSIN DEFICIENCY
ment on
complex concentrate P.P.S.B.’
J.
I G. R. KRIEGER
SIR,—Dr Millward-Sadler and his colleagues (Nov. 22,
p.
1050) refer to the frequent association between serum-ot-antitrypsin deficiency and retention of the antitrypsin as diastaseresistant periodic-acid/Schiff (P.A.S.) positive globular inclusions within the cytoplasm of liver cells.’2 They report, however, two patients in whom liver-cell inclusions, morphologically identical to those seen in «,-antitrypsin deficiency, were associated with normal serum--a,-antitrypsin levels and phenotype. Immunochemical staining of the inclusions in these two cases was negative for «,-antitrypsin. Intracytoplasmic globular inclusions in liver cells have been reported under a variety of experimental conditions3-’ although the staining characteristics of the inclusions is not always recorded. In man, P.A.s.-positive intracytoplasmic globules are often found in hepatomas;6unfortunately a,-antitrypsin concentrations have not been recorded in such cases. Mallory illustrates a paper on alcoholic cirrhosis with a figure (his fig. 4) which depicts intracytoplasmic globular inclusions in liver cells, interpreted as decolorised bile.8 Globular inclusions ultrastructurally quite different from those of &agr;1-antitrypsin deficiency, but of similar morphology on light microscopy, have been described in a patient without evidence of K,-antitrypsin deficiency9 (serum electrophoresis normal, no relevant family history, but serum-cxcantitrypsin not determined during life). It seems, therefore, that the presence of diastase-resistant P.A.s.-positive globules in the cytoplasm of liver cells is not exclusively diagnostic of a,-antitrypsin deficiency. This appearance, on light microscopy, simply reflects the retention of a cell product with the appropriate staining characteristics as globular cytoplasmic inclusions similar to the Russell bodies that are most often found in plasma cells. DeLellis, R. A., Balogh, K., Merk, F. B., Chirife, A. M. Archs Path. 1972, 94, 308. 2. Ward, A. M., Underwood, J. C. E.J. clin. Path. 1974, 27, 467. 3. Rosin, A., Doljanski, L. Br. J. exp. Path. 1944, 25, 111. 4. Weld, J. T., Von Glahn, W. C., Mitchell, L. D. Proc. Soc. exp. Biol. Med. 1941, 48, 229. 5. Fisher, E. R., Fisher, B. Am. J. Path. 1954, 30, 987. 6. Ishak, K. G., Glunz, P. R. Cancer, 1967, 20, 396. 7. Norkin, S. A., Campagna-Pinto, D. Archs Path. 1968, 86, 25. 8. Mallory, F. B. Am. J. Path. 1933, 9, 557. 9. Underwood, J. C. E.J. clin. Path. 1972, 25, 821. 1.
1204
Despite these reservations about the specificity of these globular inclusions, I would encourage those engaged in the diagnostic histopathology of the liver to include the P.A.S. stain after diastase treatment as a routine; the inclusions are easily missed in sections stained by haematoxylin and eosin. If globular inclusions are present, the patient must be screened for «,-antitrypsin deficiency by immunochemical examination of serum.
Department of Pathology, University of Sheffield Medical School, Beech Hill Road,
J.
Sheffield S10 2RX.
C. E. UNDERWOOD
LYMPHOCYTE TRANSFORMATION IN VITRO TO PARAMYXOVIRUS ANTIGENS IN MULTIPLE
SCLEROSIS
SIR,-Current evidence for a relationship between measlesvirus infection and the development of multiple sclerosis (M.S.) is based upon two types of experimental data: (1) the finding of increased measles-antibody titres in the serum and cerebrospinal fluid of M.S. patients1-3 and (2) the lack of migration-inhibition factor (M.i.F.) production when lymphocytes from m.s. patients are challenged in the direct leucocyte-migration-inhibition assay with measles-virus antigen4and some other paramyxovirus antigens.6The direct M.I.F. test is, however, only one way to evaluate cell-mediated immunity to specific antigens. We have now examined cellular immune reactivity among 21 m.s. patients and 21 controls by means of an in-vitro lymphocyte-transformation assay with paramyxovirus
antigens. Peripheral-blood lymphocytes isolated from patients and normal controls were cultured for six days in round-bottomed microtitre plates (50 000 lymphocytes per well); lymphocyte transformation was quantitated by 14[C}-thymidine pulse labelling during the last 24 hours of culture and subsequent liquid scintillation counting. The antigens used were: (1) parainfluenza type 1 (American Type Culture Collection), (2) measles antigen (Edmonston-Enders strain) and control antigen (Microbiological Associates), (3) mumps antigen and control (Eli Lilly Company). Antigens were also prepared from Eschericha coli, Staphylococcus aureus, and Candida albicans. All of the M.s. patients and all of the control-cell donors had strongly positive responses to antigens prepared from E. coli, Staph. aureus, and C. albicans. In both patient and control groups, 13 of 21 persons showed positive responses to one or more dilutions of the measles-virus antigen. The distribution of the counts in the maximal response to any antigen dilution was unrevealing (t test) between the two groups. 14 of the M.s. patients and 15 of the normal controls responded positively to parainfluenza type 1, and the distribution of the maximal responses between the two groups was similarly unrevealing. The response to mumps viral antigen was positive for 20 out of 21 persons in both the control and the patient groups. Howdistribution of the maximum responses between the groups was found to be different and the difference was t test). M.s. patients evinced found to be significant (P
accompanying medical report told of a therapeutic aborprevious day, involving an intrauterine prostaglandin administration, which was ineffective until followed by an intravenous prostaglandin drip. She was one of a coachload of similar patients, the rest of whom seemed perfectly well and were cheerfully singing in the bar. Faute de mieux, I prescribed four tablets of aspirin on the assumption that the symptoms were either hysterical, or an unusual side-effect of prostaglandins. In 30—40 min the symptoms had disappeared and the patient was eating a hearty An
tion the
meal. Since prostaglandins are supposed to disappear rapidly from the circulation, and since in any case aspirin is said to be an inhibitor of prostaglandin biosynthesis I am puzzled by the patient’s response to my treatment. Hertfordshire Area Health Authority, Hamilton House, 111 Marlowes, Hemel Hempstead, Herts, HP1 1EN
MICHAEL BALL
PROTHROMBIN-COMPLEX CONCENTRATE IN TREATMENT OF CLASSICAL HÆMOPHILIA WITH FACTOR-VIII ANTIBODY
SIR,-Successful use of activated and non-activated prothrombin-complex concentrates in the management of classical hemophiliacs with anti-factor-vm antibodies has been reported by several investigators.’-4 Failures have also been reported by Dr Bloom (Aug. 23, p. 369). However, the effect of such treat-
necessary to restrict its use to severe bleeding episodes, and (2) manufacturers should be encouraged to prepare prothrombincomplex concentrates free of factor vm for treatment of patients with antibody to factor viu. Centre pour Enfants Hémophiles, Croix Rouge Française, 78940-La Queue lez Yvelines, France.
SIR,-Dr Giraud and colleagues (Nov. 29,
p. 1088) report of babies born to mothers with severe hepatitis-B viral hepatitis. They observed the outcome and drew three conclusions, the second of which was that maternofetal contamination was likely to have been transplacental because the babies had been born by caesarean section and immediately separated from their mother. Although transplacental infection may occur, these cases did not confirm it. It is wrong to suggest that cxsarean section is an "immaculate" delivery in which the baby is not contaminated by the mother’s blood.- Infection could have occurred during delivery.
two cases
St Thomas’ Hospital, London SE1 7EH.
the inhibitor titre has not been stated in these reports. We have treated 2 patients with classical haemophilia, who also have antibody to factor-vm, with the French prothrombinCase 1.-This 11-year-old boy had a very painful haemarthrosis of the right knee. Aspiration was performed under the cover of two injections of 44 units/kg of factor ix given at 4-hourly intervals. Complete clinical and functional resolution was obtained within 3 days. Case 2.-This 6-year-old boy had a post-traumatic haematoma of the left costal cardiac region. His hasmatocrit was 25%, and he received two injections of 28.5units/kg of factor IX at 4-hourly intervals. Bleeding stopped immediately. Within 5 days his haematocrit had risen to 31 %.
In both cases treatment was monitored by standard tests of haemostasis. Antibody titres were determined at intervals by a modification of the method of Biggs and Bidwell6 and expressed in units as previously described.7 Both patients showed a striking decrease in the kaolin-activated partial thromboplastin-time and the prothromin-time, still present 4 hours after the second injection. No evidence of disseminated intravascular coagulation was observed, since the platelet-count and fibrin(ogen)-degradation products were stable. Before treatment, neither patient had clinical or laboratory signs of liver disease. This treatment was followed by an anamnestic resoonse in both cases. Patient 1 had a pretreatment titre of 1.8units, which rose to 85 units 15 days after treatment. Patient 2 had a titre of 0.2 units before treatment, and after 15 days the antibody level was 0.8 units. Although no factor-vm antigen could be detected by rocket immunoelectrophoresis, the anamnestic response may have been due to the presence of small amounts of factor vm in the concentrate. These two observations confirm that non-activated factor-tx concentrate may be effective in controlling bleeding in patients with classical haemophilia complicated by antibody (inhibitor) and was used without thrombotic complication or disseminated intravascular coagulation. Although clinically active, this material can trigger an anamnestic response. Thus, (1) it is 1. Kurczynski, E. M., Penner, J. A. New Engl. J. Med. 1974, 291, 164. 2. Sultan, Y., Brouet, J. C. ibid. p.1087. 3. Abildgaard, C. F., Britton, M., Roberts, R. Blood, 1974, 44, 933. 4. Bloom, A. L., Hutton, R. D. Lancet, 1975, ii, 370. 5. Soulier, J. P., Steinbuch, M. in Handbook of Haemophilia (edited by K. M. Bnnkhous and H. C. Hemker); p. 531. Amsterdam, 1975. 6. Biggs, R., Bidwell, E. Br. J. Hœmat. 1959, 5, 379. 7. Allain, J. P., Frommel, D. Blood, 1973, 43, 437.
P. ALLAIN
HEPATITIS-B VIRUS INFECTION OF CHILDREN BORN TO MOTHERS WITH SEVERE HEPATITIS
J. W. SCOPES
DIAGNOSIS OF ALPHA1-ANTITRYPSIN DEFICIENCY
ment on
complex concentrate P.P.S.B.’
J.
I G. R. KRIEGER
SIR,—Dr Millward-Sadler and his colleagues (Nov. 22,
p.
1050) refer to the frequent association between serum-ot-antitrypsin deficiency and retention of the antitrypsin as diastaseresistant periodic-acid/Schiff (P.A.S.) positive globular inclusions within the cytoplasm of liver cells.’2 They report, however, two patients in whom liver-cell inclusions, morphologically identical to those seen in «,-antitrypsin deficiency, were associated with normal serum--a,-antitrypsin levels and phenotype. Immunochemical staining of the inclusions in these two cases was negative for «,-antitrypsin. Intracytoplasmic globular inclusions in liver cells have been reported under a variety of experimental conditions3-’ although the staining characteristics of the inclusions is not always recorded. In man, P.A.s.-positive intracytoplasmic globules are often found in hepatomas;6unfortunately a,-antitrypsin concentrations have not been recorded in such cases. Mallory illustrates a paper on alcoholic cirrhosis with a figure (his fig. 4) which depicts intracytoplasmic globular inclusions in liver cells, interpreted as decolorised bile.8 Globular inclusions ultrastructurally quite different from those of &agr;1-antitrypsin deficiency, but of similar morphology on light microscopy, have been described in a patient without evidence of K,-antitrypsin deficiency9 (serum electrophoresis normal, no relevant family history, but serum-cxcantitrypsin not determined during life). It seems, therefore, that the presence of diastase-resistant P.A.s.-positive globules in the cytoplasm of liver cells is not exclusively diagnostic of a,-antitrypsin deficiency. This appearance, on light microscopy, simply reflects the retention of a cell product with the appropriate staining characteristics as globular cytoplasmic inclusions similar to the Russell bodies that are most often found in plasma cells. DeLellis, R. A., Balogh, K., Merk, F. B., Chirife, A. M. Archs Path. 1972, 94, 308. 2. Ward, A. M., Underwood, J. C. E.J. clin. Path. 1974, 27, 467. 3. Rosin, A., Doljanski, L. Br. J. exp. Path. 1944, 25, 111. 4. Weld, J. T., Von Glahn, W. C., Mitchell, L. D. Proc. Soc. exp. Biol. Med. 1941, 48, 229. 5. Fisher, E. R., Fisher, B. Am. J. Path. 1954, 30, 987. 6. Ishak, K. G., Glunz, P. R. Cancer, 1967, 20, 396. 7. Norkin, S. A., Campagna-Pinto, D. Archs Path. 1968, 86, 25. 8. Mallory, F. B. Am. J. Path. 1933, 9, 557. 9. Underwood, J. C. E.J. clin. Path. 1972, 25, 821. 1.
1204
Despite these reservations about the specificity of these globular inclusions, I would encourage those engaged in the diagnostic histopathology of the liver to include the P.A.S. stain after diastase treatment as a routine; the inclusions are easily missed in sections stained by haematoxylin and eosin. If globular inclusions are present, the patient must be screened for «,-antitrypsin deficiency by immunochemical examination of serum.
Department of Pathology, University of Sheffield Medical School, Beech Hill Road,
J.
Sheffield S10 2RX.
C. E. UNDERWOOD
LYMPHOCYTE TRANSFORMATION IN VITRO TO PARAMYXOVIRUS ANTIGENS IN MULTIPLE
SCLEROSIS
SIR,-Current evidence for a relationship between measlesvirus infection and the development of multiple sclerosis (M.S.) is based upon two types of experimental data: (1) the finding of increased measles-antibody titres in the serum and cerebrospinal fluid of M.S. patients1-3 and (2) the lack of migration-inhibition factor (M.i.F.) production when lymphocytes from m.s. patients are challenged in the direct leucocyte-migration-inhibition assay with measles-virus antigen4and some other paramyxovirus antigens.6The direct M.I.F. test is, however, only one way to evaluate cell-mediated immunity to specific antigens. We have now examined cellular immune reactivity among 21 m.s. patients and 21 controls by means of an in-vitro lymphocyte-transformation assay with paramyxovirus
antigens. Peripheral-blood lymphocytes isolated from patients and normal controls were cultured for six days in round-bottomed microtitre plates (50 000 lymphocytes per well); lymphocyte transformation was quantitated by 14[C}-thymidine pulse labelling during the last 24 hours of culture and subsequent liquid scintillation counting. The antigens used were: (1) parainfluenza type 1 (American Type Culture Collection), (2) measles antigen (Edmonston-Enders strain) and control antigen (Microbiological Associates), (3) mumps antigen and control (Eli Lilly Company). Antigens were also prepared from Eschericha coli, Staphylococcus aureus, and Candida albicans. All of the M.s. patients and all of the control-cell donors had strongly positive responses to antigens prepared from E. coli, Staph. aureus, and C. albicans. In both patient and control groups, 13 of 21 persons showed positive responses to one or more dilutions of the measles-virus antigen. The distribution of the counts in the maximal response to any antigen dilution was unrevealing (t test) between the two groups. 14 of the M.s. patients and 15 of the normal controls responded positively to parainfluenza type 1, and the distribution of the maximal responses between the two groups was similarly unrevealing. The response to mumps viral antigen was positive for 20 out of 21 persons in both the control and the patient groups. Howdistribution of the maximum responses between the groups was found to be different and the difference was t test). M.s. patients evinced found to be significant (P
