1143 INTRAVENOUS COPPER IN MENKES’ KINKY-HAIR SYNDROME
BILE CANALICULAR ANTIBODIES IN DISEASES OF KIDNEY AND URINARY TRACT
SiR—The letter by Dr Dekaban and Dr Steusing1 prompts us to report our experience with parenteral
immunofluorescence staining of double lines along the bile canaliculi is associated with various diseases (unpublished observation). The immunofluorescence pattern of the bile canaliculi in Linder et al.’s and Ablin et al.’s investigations is not recorded. A different staining pattern of the bile canaliculi, however, need not be the only reason for the difference between these findings. Another could be the use of liver from different species as antigen. Linder et al. and Ablin et al. used rabbit liver and I used ox liver. Of various livers, we found ox liver to be best for the demonstration of B.C.A. in patients with chronic liver disease. Another reason for the discrepancy could lie in the evaluation of the reactions. Many sera give a pericellular staining of hepatocytes, and this staining could be taken for staining of bile canaliculi.ó An exchange between interested laboratories of B.C.A.positive sera from patients with chronic liver disease and other diseases as controls in the investigation for B.C.A. would be one way to get comparable results between investigations in different laboratories. Blood Bank and Medical Department M,
University Hospital, DK 5000 Odense, Denmark.
HANS DIEDERICHSEN.
DECREASED FIBRINOLYTIC ACTIVITY AND
copper in a child with Menkes’ kinky-hair syndrome. The diagnosis was made in 1971 at the age of 11 months, when the boy, who had developed normally for the first 3-6 months, showed progressive cerebral deterioration, which ended in severe spastic tetraplegia. The scalp hair showed the typical " steely woolappearance, and pili torti were demonstrated- microscopically. At 32 months, serum-copper levels, determined for the first time, were between 38 and 50 (Lg. per 100 ml. (bathocuproine method, normal range 65-165). Serum-casruloplasmin was 13-15 mg. per 100 ml. (p-phenylenediamine-oxidase assay, normal range 30-60). No rise in copper levels was noted after 20 mg. and 200 mg. of copper sulphate were given by mouth, the latter dose being followed by vomiting after 60 minutes. 1 mg. of copper sulphate in 250 ml. of 5 % glucose solution was infused over 3 hours. Serum-copper levels were 38 (Lg. per 100 ml. immediately before and immediately after the infusion and 72 p.g. per 100 ml. 72 hours later. 0°4 ml. of a commercially available copper-sulphate solution in distilled water (250 (Lg. copper per ml.) was injected subcutaneously 1-3 times weekly without local irritation and without effect on serum-copper levels. In February, 1974, at age 3! years, the child was readmitted after a cerebral convulsion. The clinical state remained unchanged. Sharp-wave foci had developed in the electroencephalogram. Serum-copper was 56 (Lg. per 100 ml. and serumcaeruloplasmin 17 mg. per 100 ml. A sterile solution of copper sulphate in physiological saline was prepared, so that 1 ml. contained 1 mg. copper (stock solution). 1 ml. and 2 ml. of this solution were added to 250 ml. of 5% glucose solution and the infusions were repeated. The results Maximum copper and are shown in the accompanying figure. cxruloplasmin levels were reached only after a lag of 72-96 hours after the infusions. This may mean a reflux of copper bound to newly synthesised caeruloplasmin (and possibly other coppercontaining proteins) from the liver into the plasma. Similar results have been reported.2.3 From then on we tried to treat the child with subcutaneous in-
MALARIA
SIR,-Fibrinolytic activity measured by different tests, has been found to be consistently low in malaria/-1O but it was not known if this is due to decreased blood-fibrinolytic components or increased fibrinolytic inactivators. Plasminogen levels (determined by an immunological technique unaffected by plasmin inactivator 11) was studied in 89 specimens from 39 patients with acute falciparum malaria, of whom 3 had cerebral or pulmonary complications. The plasminogen levels in all our specimens were found to be normal, indicating that there is no increase in plasmin inactivator in malaria. Prolonged euglobulin lysis time 7-10 and low or absent fibrinolysis on fibrin plate by euglobulin 8-10 must be due to decreased bloodplasminogen-activator as euglobulin is freed from inactivator,12 and the present study indicates no increase in plasmin inactivators. Vascular endothelium is the most likely source of blood-plasminogen-activator, 12 and vasculitis leads to impaired fibrinolysis.13 In the light of other studies,7-10 our data reinforce the concept that vascular injury is an important pathological component of malaria.14 Department of Pathology, Faculty of Medicine, BENCHA PETCHCLAI Ramathibodi Hospital, UBOLRATANA PRATUMVINIT. Bangkok. Phrabudhabat Hospital, WISITH BENJAPONGES. Bangkok, Thailand. Eichelberger, J. W., Inman, M. M., Conrad, M. E. Blood, 1967, 29, 713. Borochovitz, D., Crosley, A. L., Metz, J. Br. med. J. 1972, ii, 710. Reid, H. A., Sucharit, P. Lancet, 1972, ii, 1110. Sucharit, P., Reid, H. A. S.E. Asian J. trop. Med. publ. Hlth, 1973, 4, 15. Pratumvinit, U., Petchclai, B. Am. J. clin. Path. 1974, 61, 458. Astrup, T., Thorsen, S. Med. Clins. N. Am. 1972, 56, 153. Cunliffe, W. J., Menon, I. S. Br. J. Derm. 1971, 84, 99. Maegraith, B., Fletcher, A. Adv. Parasit. 1972, 10, 49.
Dekaban, A. S., Steusing, J. K. Lancet, 1974, ii, 1523. Danks, D. M., Stevens, B. J., Campbell, P. E., Gillespie, J. M., Walker-Smith, J., Blomfield, J., Turner, B. ibid. 1972, i, 1100. 3. Bucknall, W. E., Haslam, R. H. A., Holtzman, N. A. Pediatrics, Springfield, 1973, 52, 653.
1. 2.
7. Dennis, L. H., 8. 9. 10. 11. 12. 13. 14.
Effect of
two copper
infusions
on serum
caeruloplasmin levels.
copper and
1144
jections of 1-0 ml. of the stock solution. Local irritation, however, prevented us from continuing. 1 ml. of the stock solution (1 mg. copper) was therefore diluted with 9 ml. of physiological saline and injected once weekly intravenously over 3-5 minutes. These injections had no side-effects. Serum-copper levels could be maintained between 85 and 123 (Lg. per 100 ml. (mean 97) and caeruloplasmin levels were between 21 and 39 mg. per 100 ml. (mean 30). After 9 months, 24-hour urinary excretion of copper was 29-95 (Lg. on three days preceding the weekly copper injection, and 120 and 270 jg. in 24 hours thereafter. Liver-function tests were normal, and no Kayser-Fleischer rings were seen on slit-lamp examination.
(father’s occupation on birth certificate) of 26 of their 32 adult patients with the 47,XYY karyotype who were ascertained from maximum-security hospital populations, and statistical analysis shows that the distribution of social classes does not differ significantly from the expected distribution in the general population in 1931. However, further analysis of the social-class distribution of their hospital control population (46,XY males) does reveal a significant difference from the distribution in the general population (x3=23-3, p < 0-005) and shows the usual preponderance of social-classes iv and v found in prison popu-
Thus, we were able to maintain normal serum-copper levels and subnormal caeruloplasmin levels by weekly intravenous injections of copper sulphate. The child’s clinical state, however, unfortunately did not improve.
lations.
Universitäts-Kinderklinik, 78 Freiburg im Breisgau, German Federal Republic. Städtische Kinderklinik, Baden-Baden, Germany.
H. WEHINGER I. WITT I. LÖSEL G. DENZ-SEIBERT.
C. SANDER.
SEX-CHROMOSOME ABNORMALITIES AND SOCIAL CLASS SiR,—There has recently been considerable interest in the possible association of sex-chromosome abnormalities, particularly the 47,XYY karyotype, with social class. Beckwith and King,1 in the course of their controversy at Harvard with the Walzer study, said " there are data suggesting that the rate of chromosomal non-disjunction, leading to the XYY karyotype, is increased among lower socioeconomic groups. This may be due to nutritional deprivation. Since the lower economic classes are represented in the prison population out of proportion to their numbers in the total population, the observed higher frequency of XYYs in prison may be the expected result." They did not, however, quote the source of these data. The emphasis on lower social class is strengthened in Dr Larry Miller’s pleato direct our resources where they are most needed in view of the fact that " the behavioural problems that have been associated with the XYY karyotype are conclusively correlated with socioeconomic status." The published data on social-class distribution in sexchromosomally abnormal individuals are, in fact, rather scanty. Casey et al.have given the social-class distribution 1. 2. 3.
Beckwith, J., King, J. New Scient. 1974, 64, 474. Miller, L. Lancet, 1975, i, 221. Casey, M. D., Blank, C. E., McLean, T. M., Kohn, P., Street, D. R. K., McDougall, J. M., Gooder, J., Platts, J. J. ment. Defic. Res. 1973, 16, 215.
Studies in our unit have yielded relevant information on series of unselected newborns, the first from the sexchromatin survey of 1959-61 on 20,725 infants4 and the second from a more recent chromosome survey of 11,680 infants. In these two surveys 69 children were found to have sex-chromosome abnormalities, and their social-class distribution is shown below, together with the expected numbers in each social-class group, based on the socialclass distribution of liveborn Scottish infants (Registrar General’s report) in the middle year of each survey.
two
A comparison of the combined totals for social classes iv and v with the combined totals for classes I, 11, and III reveals no significant difference within the different chromosomally abnormal groups: p==0’59 for 1959-61 (table i), p==0-42 for 1967-74 (table 11). However, the difference between social-class distribution in the controls and the
chromosomally abnormal was significant (1959-61 study x2=5-4, p0’02; 1967-74 study ==5-7, p0’02), the difference in each study being in the direction of fewer abnormalities in classes iv and v. Thus, neither in the newborn nor in the small proportion of XYYs found in maximum-security hospitals is there any evidence for a preponderance of lower socioeconomic classes. There is, nevertheless, a twenty-fold increase (0’1 % to 2-0%) in the frequency of XYYs from the newborn population to patients in maximum-security hospitals (unpublished data from our unit), but socioeconomic background does not appear to be the major factor accounting for this increase. We should like to thank Mr Andrew Carothers for advice the statistical analyses.
on
M.R.C. Clinical and Population
Cytogenetics Unit, Hospital, Edinburgh.
Western General
S. G. RATCLIFFE H. J. EVANS.
McLean, N., Harnden, D. G., Court Brown, W. M., Bond, J., Mantle, D. J. Lancet, 1964, i, 286. 5. Jacobs, P. A., Melville, M., Ratcliffe, S. G., Keay, A. J., Syme, J. Ann. hum. Genet. 1974, 37, 359.
4.
TABLE I-SOCIAL-CLASS DISTRIBUTION IN SEX-CHROMATIN
° SURVEY, 1959-6 1
TABLE II-SOCIAL-CLASS DISTRIBUTION IN CHROMOSOME SURVEY,
1967-1974
BILE CANALICULAR ANTIBODIES IN DISEASES OF KIDNEY AND URINARY TRACT
SiR—The letter by Dr Dekaban and Dr Steusing1 prompts us to report our experience with parenteral
immunofluorescence staining of double lines along the bile canaliculi is associated with various diseases (unpublished observation). The immunofluorescence pattern of the bile canaliculi in Linder et al.’s and Ablin et al.’s investigations is not recorded. A different staining pattern of the bile canaliculi, however, need not be the only reason for the difference between these findings. Another could be the use of liver from different species as antigen. Linder et al. and Ablin et al. used rabbit liver and I used ox liver. Of various livers, we found ox liver to be best for the demonstration of B.C.A. in patients with chronic liver disease. Another reason for the discrepancy could lie in the evaluation of the reactions. Many sera give a pericellular staining of hepatocytes, and this staining could be taken for staining of bile canaliculi.ó An exchange between interested laboratories of B.C.A.positive sera from patients with chronic liver disease and other diseases as controls in the investigation for B.C.A. would be one way to get comparable results between investigations in different laboratories. Blood Bank and Medical Department M,
University Hospital, DK 5000 Odense, Denmark.
HANS DIEDERICHSEN.
DECREASED FIBRINOLYTIC ACTIVITY AND
copper in a child with Menkes’ kinky-hair syndrome. The diagnosis was made in 1971 at the age of 11 months, when the boy, who had developed normally for the first 3-6 months, showed progressive cerebral deterioration, which ended in severe spastic tetraplegia. The scalp hair showed the typical " steely woolappearance, and pili torti were demonstrated- microscopically. At 32 months, serum-copper levels, determined for the first time, were between 38 and 50 (Lg. per 100 ml. (bathocuproine method, normal range 65-165). Serum-casruloplasmin was 13-15 mg. per 100 ml. (p-phenylenediamine-oxidase assay, normal range 30-60). No rise in copper levels was noted after 20 mg. and 200 mg. of copper sulphate were given by mouth, the latter dose being followed by vomiting after 60 minutes. 1 mg. of copper sulphate in 250 ml. of 5 % glucose solution was infused over 3 hours. Serum-copper levels were 38 (Lg. per 100 ml. immediately before and immediately after the infusion and 72 p.g. per 100 ml. 72 hours later. 0°4 ml. of a commercially available copper-sulphate solution in distilled water (250 (Lg. copper per ml.) was injected subcutaneously 1-3 times weekly without local irritation and without effect on serum-copper levels. In February, 1974, at age 3! years, the child was readmitted after a cerebral convulsion. The clinical state remained unchanged. Sharp-wave foci had developed in the electroencephalogram. Serum-copper was 56 (Lg. per 100 ml. and serumcaeruloplasmin 17 mg. per 100 ml. A sterile solution of copper sulphate in physiological saline was prepared, so that 1 ml. contained 1 mg. copper (stock solution). 1 ml. and 2 ml. of this solution were added to 250 ml. of 5% glucose solution and the infusions were repeated. The results Maximum copper and are shown in the accompanying figure. cxruloplasmin levels were reached only after a lag of 72-96 hours after the infusions. This may mean a reflux of copper bound to newly synthesised caeruloplasmin (and possibly other coppercontaining proteins) from the liver into the plasma. Similar results have been reported.2.3 From then on we tried to treat the child with subcutaneous in-
MALARIA
SIR,-Fibrinolytic activity measured by different tests, has been found to be consistently low in malaria/-1O but it was not known if this is due to decreased blood-fibrinolytic components or increased fibrinolytic inactivators. Plasminogen levels (determined by an immunological technique unaffected by plasmin inactivator 11) was studied in 89 specimens from 39 patients with acute falciparum malaria, of whom 3 had cerebral or pulmonary complications. The plasminogen levels in all our specimens were found to be normal, indicating that there is no increase in plasmin inactivator in malaria. Prolonged euglobulin lysis time 7-10 and low or absent fibrinolysis on fibrin plate by euglobulin 8-10 must be due to decreased bloodplasminogen-activator as euglobulin is freed from inactivator,12 and the present study indicates no increase in plasmin inactivators. Vascular endothelium is the most likely source of blood-plasminogen-activator, 12 and vasculitis leads to impaired fibrinolysis.13 In the light of other studies,7-10 our data reinforce the concept that vascular injury is an important pathological component of malaria.14 Department of Pathology, Faculty of Medicine, BENCHA PETCHCLAI Ramathibodi Hospital, UBOLRATANA PRATUMVINIT. Bangkok. Phrabudhabat Hospital, WISITH BENJAPONGES. Bangkok, Thailand. Eichelberger, J. W., Inman, M. M., Conrad, M. E. Blood, 1967, 29, 713. Borochovitz, D., Crosley, A. L., Metz, J. Br. med. J. 1972, ii, 710. Reid, H. A., Sucharit, P. Lancet, 1972, ii, 1110. Sucharit, P., Reid, H. A. S.E. Asian J. trop. Med. publ. Hlth, 1973, 4, 15. Pratumvinit, U., Petchclai, B. Am. J. clin. Path. 1974, 61, 458. Astrup, T., Thorsen, S. Med. Clins. N. Am. 1972, 56, 153. Cunliffe, W. J., Menon, I. S. Br. J. Derm. 1971, 84, 99. Maegraith, B., Fletcher, A. Adv. Parasit. 1972, 10, 49.
Dekaban, A. S., Steusing, J. K. Lancet, 1974, ii, 1523. Danks, D. M., Stevens, B. J., Campbell, P. E., Gillespie, J. M., Walker-Smith, J., Blomfield, J., Turner, B. ibid. 1972, i, 1100. 3. Bucknall, W. E., Haslam, R. H. A., Holtzman, N. A. Pediatrics, Springfield, 1973, 52, 653.
1. 2.
7. Dennis, L. H., 8. 9. 10. 11. 12. 13. 14.
Effect of
two copper
infusions
on serum
caeruloplasmin levels.
copper and
1144
jections of 1-0 ml. of the stock solution. Local irritation, however, prevented us from continuing. 1 ml. of the stock solution (1 mg. copper) was therefore diluted with 9 ml. of physiological saline and injected once weekly intravenously over 3-5 minutes. These injections had no side-effects. Serum-copper levels could be maintained between 85 and 123 (Lg. per 100 ml. (mean 97) and caeruloplasmin levels were between 21 and 39 mg. per 100 ml. (mean 30). After 9 months, 24-hour urinary excretion of copper was 29-95 (Lg. on three days preceding the weekly copper injection, and 120 and 270 jg. in 24 hours thereafter. Liver-function tests were normal, and no Kayser-Fleischer rings were seen on slit-lamp examination.
(father’s occupation on birth certificate) of 26 of their 32 adult patients with the 47,XYY karyotype who were ascertained from maximum-security hospital populations, and statistical analysis shows that the distribution of social classes does not differ significantly from the expected distribution in the general population in 1931. However, further analysis of the social-class distribution of their hospital control population (46,XY males) does reveal a significant difference from the distribution in the general population (x3=23-3, p < 0-005) and shows the usual preponderance of social-classes iv and v found in prison popu-
Thus, we were able to maintain normal serum-copper levels and subnormal caeruloplasmin levels by weekly intravenous injections of copper sulphate. The child’s clinical state, however, unfortunately did not improve.
lations.
Universitäts-Kinderklinik, 78 Freiburg im Breisgau, German Federal Republic. Städtische Kinderklinik, Baden-Baden, Germany.
H. WEHINGER I. WITT I. LÖSEL G. DENZ-SEIBERT.
C. SANDER.
SEX-CHROMOSOME ABNORMALITIES AND SOCIAL CLASS SiR,—There has recently been considerable interest in the possible association of sex-chromosome abnormalities, particularly the 47,XYY karyotype, with social class. Beckwith and King,1 in the course of their controversy at Harvard with the Walzer study, said " there are data suggesting that the rate of chromosomal non-disjunction, leading to the XYY karyotype, is increased among lower socioeconomic groups. This may be due to nutritional deprivation. Since the lower economic classes are represented in the prison population out of proportion to their numbers in the total population, the observed higher frequency of XYYs in prison may be the expected result." They did not, however, quote the source of these data. The emphasis on lower social class is strengthened in Dr Larry Miller’s pleato direct our resources where they are most needed in view of the fact that " the behavioural problems that have been associated with the XYY karyotype are conclusively correlated with socioeconomic status." The published data on social-class distribution in sexchromosomally abnormal individuals are, in fact, rather scanty. Casey et al.have given the social-class distribution 1. 2. 3.
Beckwith, J., King, J. New Scient. 1974, 64, 474. Miller, L. Lancet, 1975, i, 221. Casey, M. D., Blank, C. E., McLean, T. M., Kohn, P., Street, D. R. K., McDougall, J. M., Gooder, J., Platts, J. J. ment. Defic. Res. 1973, 16, 215.
Studies in our unit have yielded relevant information on series of unselected newborns, the first from the sexchromatin survey of 1959-61 on 20,725 infants4 and the second from a more recent chromosome survey of 11,680 infants. In these two surveys 69 children were found to have sex-chromosome abnormalities, and their social-class distribution is shown below, together with the expected numbers in each social-class group, based on the socialclass distribution of liveborn Scottish infants (Registrar General’s report) in the middle year of each survey.
two
A comparison of the combined totals for social classes iv and v with the combined totals for classes I, 11, and III reveals no significant difference within the different chromosomally abnormal groups: p==0’59 for 1959-61 (table i), p==0-42 for 1967-74 (table 11). However, the difference between social-class distribution in the controls and the
chromosomally abnormal was significant (1959-61 study x2=5-4, p0’02; 1967-74 study ==5-7, p0’02), the difference in each study being in the direction of fewer abnormalities in classes iv and v. Thus, neither in the newborn nor in the small proportion of XYYs found in maximum-security hospitals is there any evidence for a preponderance of lower socioeconomic classes. There is, nevertheless, a twenty-fold increase (0’1 % to 2-0%) in the frequency of XYYs from the newborn population to patients in maximum-security hospitals (unpublished data from our unit), but socioeconomic background does not appear to be the major factor accounting for this increase. We should like to thank Mr Andrew Carothers for advice the statistical analyses.
on
M.R.C. Clinical and Population
Cytogenetics Unit, Hospital, Edinburgh.
Western General
S. G. RATCLIFFE H. J. EVANS.
McLean, N., Harnden, D. G., Court Brown, W. M., Bond, J., Mantle, D. J. Lancet, 1964, i, 286. 5. Jacobs, P. A., Melville, M., Ratcliffe, S. G., Keay, A. J., Syme, J. Ann. hum. Genet. 1974, 37, 359.
4.
TABLE I-SOCIAL-CLASS DISTRIBUTION IN SEX-CHROMATIN
° SURVEY, 1959-6 1
TABLE II-SOCIAL-CLASS DISTRIBUTION IN CHROMOSOME SURVEY,
1967-1974
