LETTERS TO THE EDITOR
IMMUNOGLOBULIN CHARACTERIZATION To The Editor: I was very surprised not to find in the paper of Brasher et al, "Immunoglobulin Characterization of Human Pancreatic Fluid" (Am J Dig Dis 20:454--459) any mention of our papers publisher four years ago on the same subject and well documented. As you will note in the references (1, 2), we studied the pancreatic juices of 5 normal subjects and 6 subjects with chronic calcifying pancreatitis. Only 2 patients were studied in Brasher's article. We were able to demonstrate and to estimate serum proteins in the external pancreatic secretion of man. In normal patients, albumin represents 1.26 -+ 0.36% of total proteins of pancreatic juice; IgG 0.23 + 0.039, IgA 0.18 -+ 0.034, IgM 0.12 + 0.00. Transferin and a2 macroglobulin are present but were not estimated. We found an increased level of serum proteins in pathological juices: 12.47% of total proteins compared to 1.8% in normal ones; (albumin 8.16% Ig 2.84%; IgA 0.83% and IgM 0.91%). In the pathological cases as in the normal ones the albumine/IgA and albumin/IgG ratios favor the hypothesis of a local synthesis of these immunoglobulins. DR C. FIGARELLA Institut National de La Sante Et De La Recherche Medicale Unite de Recherches de Pathologic Digestive France
which dealt with quantitation of three of the immunoglobulin classes in pancreatic fluid. These studies are not Nrictly comparable. Dr. Figarella's study reported immunoglobulin levels in pancreatic fluid from "normal" patients who were undergoing biliary tract surgery for cholelithiasis. In all five subjects collection of pancreatic fluid was terminated at 12 to 24 hours following surgery and no mention was made of the possible effect of general anesthesia on protein secretion of the pancreas. In our study we made multiple examinations on sequential samples of pancreatic fluid from an established fistula. Despite these differences both studies document that immunoglobulins are present in pancreatic fluid and may be quantitated by appropriate in vitro procedures. GEORGE W . BRASHER, MD WALTER P. DYCK, MD A . MICHAEL SPIEKERMAN, PhD REFERENCES 1. Clemente F, Ribeiro T, Colomb E, Figarella C, Sarles H: Comparaison des proteines de sues pancreatiques humains normaux et pathologiques. Dosage des proteines seriques et mise en evidence d'une proteine particuliere darts la panereatite chronique ealcifiante. Biochym Biophys Acta 251:456-466, 1971 2. Clemente F, Ribeiro T, Figarella C, Sarles H: Albumine, IgG et IgA dans le suc pancreatique humain normal chex l'adulte. Clin Chim Acta 33:317-324, 1971
PELVIC ACTINOMYCOSIS, PRESENTING AS A RECTAL STRICTURE
REFERENCES 1. Clemente F, Ribeiro T, Columb E, Figarella C. et Sarles H: Comparaison Des Proteines De Sues Panereatiques Humains Normaux Et Pathologiques. Dosage Des Proteines Seriques Et Mise En Evidence D'Une Proteine Partieuliere Dans La Pancreatite Chronique Calcifiante. Biochym Biophys Aeta 251:456-466, 1971 2. Clemente F, Ribeiro T, Figarella C, et Sarles H: Albumine, IgG Et IgA Dans Le Suc Pancreatique Humain Normal Chez L'Adulte. Clin Chim Acta 33:317-324, 1971
Response by the Author: The authors wish to express their appreciation to Dr. Figarella for calling attention to her study (1, 2) Digestive Diseases, 11ol.21, No. 1 (January 1976)
To the Editor: Pelvic actinomycosis, although rare, is a well-described entity with over 250 cases in the literature (1, 2). The following report illustrates such a case in which the major manifestations were related to the gastrointestinal tract and a rectal stricture. It is hoped that by presenting this case, this disease will be considered in other patients presenting with similar complaints. Case history: A 40-year-old white female was admitted to Martin Army Hospital, Fort Benning, Georgia with a one-month history of crampy, left lower abdominal pain and a low grade fever. The
77
LETTERS TO THE EDITOR
pain was associated with intermittent abdominal distention and relief was obtained by the passage of flatus or a bowel movement. Past medical history and review of systems was noncontributory except for a history of a penicillin allergy manifested by uriticaria and wheezing. Pertinent physical findings included an obese white female who appeared chronically ill. The temperature was 101~ rectally. Tenderness was present in the lower quandrant and there was tenderness on rectal examination. Three pelvic examinations were negative. Laboratory studies revealed a hematocrit of 34%, hemoglobin of 10.3 g/100 ml, white blood cell count of 18,000/ram 3 with 79% polymorphonucleocytes, 7% bands, 15% lymphocytes. Erythrocyte sedimentation rate was 45 ram/hr. Serum albumin was 3.0 g/100 ml. Urinalysis and urine culture were negative. Six blood cultures were negative. Stool ova and parasite and stool culture were also negative. Proctoscopic examination showed a narrowed area at 14 cm with normal mucosa. A barium enema demonstrated a 3-cm stricture of the proximal rectum (Figure 1). The patient was explored on October 30, 1972. Multiple abscesses involving both the adnexa and ovaries and surrounding rectum were noted. A hysterectomy and bilateral salpingo-oophorectomy was performed. The pathological examination revealed an inflammatory exudate with actinomycoses sulfur granules. A culture of the exudate grew actinomycoses. Postoperatively, the patient was treated with cephalothin, 12 g intravenously
daily for 3 weeks, then clindamycin, 300 mg orally for 4 months. She had a benign postoperative course and in the 289 year follow up period has had no evidence of recurrence of an actinomycotic infection. Actinomycoses, a chronic superative infection, is caused by the organism Actinomycoses israeli ~bovis), This organism is a normal inhabitant of the mouth and gastrointestinal tract but not of the urogenital system. In this patient the rectal involvement was secondary to an actinomycotic pelvic abscess formed by the extension of the infection from the left adnexa. The pathogenesis of the pelvic infection with this organism is thought to be either an ascending infection from the lower genital tract or spread to the pelvis from an intestinal lesion or site such as the appendix (3). In this patient, however, the appendix and rectal mucosa were normal and the endometrium showed no evidence of infection. The patient's complaints suggested a colonic process. Proctoscopy and barium enema confirmed the presence of an extrinsic lesion involving the rectum. The negative pelvic examination by experienced physicians is best explained by the marked obesity of this patient. The diagnosis of actinomycosis was made as in the majority of other reported cases at the time of surgery. Standard treatment of this disease is 10-20 million units of penicillin intravenously for at least 4-6 weeks. Recurrences years later are not uncommon (4). Because of the well documented history of penicillin allergy, the patient was treated with cephalothin initially then long-term clindamycin therapy
(5). MICHAEL K O Z O W E R , M D
Department of Medicine State University of New York at Buffalo Buffalo, New York
REFERENCES
Fig 1. Lateral x-ray showing proximal rectal stricture.
78
I. Stevenson AE: Acfinomycosis of ovaries and fallopian tubes. J Obstet Gynecol Br Commonw 64:345-347, 1957 2. Brady HH, Doughterty CM, Mickal A: Actinomycosis of the female genital tract. Obstet Gynecol 23:580-583, 1964 3. Henderson SR: Pelvic actinomycosis associated with an intrauterine devices Obstet Gynecol 41:726--732, 1973 4. Farrior HL, Rathbun LS, Doolan JJ, Turner FG: Pelvic actinomycosis. Am J Obstet Gynecol [03:908-909, 1969 5. Rose HD, Rytel MW: Actinomycosis treated with clindomycin. JAMA 221:1052, 1972 Digestive Diseases, VoI, 21, No. 1 (January 1976)
IMMUNOGLOBULIN CHARACTERIZATION To The Editor: I was very surprised not to find in the paper of Brasher et al, "Immunoglobulin Characterization of Human Pancreatic Fluid" (Am J Dig Dis 20:454--459) any mention of our papers publisher four years ago on the same subject and well documented. As you will note in the references (1, 2), we studied the pancreatic juices of 5 normal subjects and 6 subjects with chronic calcifying pancreatitis. Only 2 patients were studied in Brasher's article. We were able to demonstrate and to estimate serum proteins in the external pancreatic secretion of man. In normal patients, albumin represents 1.26 -+ 0.36% of total proteins of pancreatic juice; IgG 0.23 + 0.039, IgA 0.18 -+ 0.034, IgM 0.12 + 0.00. Transferin and a2 macroglobulin are present but were not estimated. We found an increased level of serum proteins in pathological juices: 12.47% of total proteins compared to 1.8% in normal ones; (albumin 8.16% Ig 2.84%; IgA 0.83% and IgM 0.91%). In the pathological cases as in the normal ones the albumine/IgA and albumin/IgG ratios favor the hypothesis of a local synthesis of these immunoglobulins. DR C. FIGARELLA Institut National de La Sante Et De La Recherche Medicale Unite de Recherches de Pathologic Digestive France
which dealt with quantitation of three of the immunoglobulin classes in pancreatic fluid. These studies are not Nrictly comparable. Dr. Figarella's study reported immunoglobulin levels in pancreatic fluid from "normal" patients who were undergoing biliary tract surgery for cholelithiasis. In all five subjects collection of pancreatic fluid was terminated at 12 to 24 hours following surgery and no mention was made of the possible effect of general anesthesia on protein secretion of the pancreas. In our study we made multiple examinations on sequential samples of pancreatic fluid from an established fistula. Despite these differences both studies document that immunoglobulins are present in pancreatic fluid and may be quantitated by appropriate in vitro procedures. GEORGE W . BRASHER, MD WALTER P. DYCK, MD A . MICHAEL SPIEKERMAN, PhD REFERENCES 1. Clemente F, Ribeiro T, Colomb E, Figarella C, Sarles H: Comparaison des proteines de sues pancreatiques humains normaux et pathologiques. Dosage des proteines seriques et mise en evidence d'une proteine particuliere darts la panereatite chronique ealcifiante. Biochym Biophys Acta 251:456-466, 1971 2. Clemente F, Ribeiro T, Figarella C, Sarles H: Albumine, IgG et IgA dans le suc pancreatique humain normal chex l'adulte. Clin Chim Acta 33:317-324, 1971
PELVIC ACTINOMYCOSIS, PRESENTING AS A RECTAL STRICTURE
REFERENCES 1. Clemente F, Ribeiro T, Columb E, Figarella C. et Sarles H: Comparaison Des Proteines De Sues Panereatiques Humains Normaux Et Pathologiques. Dosage Des Proteines Seriques Et Mise En Evidence D'Une Proteine Partieuliere Dans La Pancreatite Chronique Calcifiante. Biochym Biophys Aeta 251:456-466, 1971 2. Clemente F, Ribeiro T, Figarella C, et Sarles H: Albumine, IgG Et IgA Dans Le Suc Pancreatique Humain Normal Chez L'Adulte. Clin Chim Acta 33:317-324, 1971
Response by the Author: The authors wish to express their appreciation to Dr. Figarella for calling attention to her study (1, 2) Digestive Diseases, 11ol.21, No. 1 (January 1976)
To the Editor: Pelvic actinomycosis, although rare, is a well-described entity with over 250 cases in the literature (1, 2). The following report illustrates such a case in which the major manifestations were related to the gastrointestinal tract and a rectal stricture. It is hoped that by presenting this case, this disease will be considered in other patients presenting with similar complaints. Case history: A 40-year-old white female was admitted to Martin Army Hospital, Fort Benning, Georgia with a one-month history of crampy, left lower abdominal pain and a low grade fever. The
77
LETTERS TO THE EDITOR
pain was associated with intermittent abdominal distention and relief was obtained by the passage of flatus or a bowel movement. Past medical history and review of systems was noncontributory except for a history of a penicillin allergy manifested by uriticaria and wheezing. Pertinent physical findings included an obese white female who appeared chronically ill. The temperature was 101~ rectally. Tenderness was present in the lower quandrant and there was tenderness on rectal examination. Three pelvic examinations were negative. Laboratory studies revealed a hematocrit of 34%, hemoglobin of 10.3 g/100 ml, white blood cell count of 18,000/ram 3 with 79% polymorphonucleocytes, 7% bands, 15% lymphocytes. Erythrocyte sedimentation rate was 45 ram/hr. Serum albumin was 3.0 g/100 ml. Urinalysis and urine culture were negative. Six blood cultures were negative. Stool ova and parasite and stool culture were also negative. Proctoscopic examination showed a narrowed area at 14 cm with normal mucosa. A barium enema demonstrated a 3-cm stricture of the proximal rectum (Figure 1). The patient was explored on October 30, 1972. Multiple abscesses involving both the adnexa and ovaries and surrounding rectum were noted. A hysterectomy and bilateral salpingo-oophorectomy was performed. The pathological examination revealed an inflammatory exudate with actinomycoses sulfur granules. A culture of the exudate grew actinomycoses. Postoperatively, the patient was treated with cephalothin, 12 g intravenously
daily for 3 weeks, then clindamycin, 300 mg orally for 4 months. She had a benign postoperative course and in the 289 year follow up period has had no evidence of recurrence of an actinomycotic infection. Actinomycoses, a chronic superative infection, is caused by the organism Actinomycoses israeli ~bovis), This organism is a normal inhabitant of the mouth and gastrointestinal tract but not of the urogenital system. In this patient the rectal involvement was secondary to an actinomycotic pelvic abscess formed by the extension of the infection from the left adnexa. The pathogenesis of the pelvic infection with this organism is thought to be either an ascending infection from the lower genital tract or spread to the pelvis from an intestinal lesion or site such as the appendix (3). In this patient, however, the appendix and rectal mucosa were normal and the endometrium showed no evidence of infection. The patient's complaints suggested a colonic process. Proctoscopy and barium enema confirmed the presence of an extrinsic lesion involving the rectum. The negative pelvic examination by experienced physicians is best explained by the marked obesity of this patient. The diagnosis of actinomycosis was made as in the majority of other reported cases at the time of surgery. Standard treatment of this disease is 10-20 million units of penicillin intravenously for at least 4-6 weeks. Recurrences years later are not uncommon (4). Because of the well documented history of penicillin allergy, the patient was treated with cephalothin initially then long-term clindamycin therapy
(5). MICHAEL K O Z O W E R , M D
Department of Medicine State University of New York at Buffalo Buffalo, New York
REFERENCES
Fig 1. Lateral x-ray showing proximal rectal stricture.
78
I. Stevenson AE: Acfinomycosis of ovaries and fallopian tubes. J Obstet Gynecol Br Commonw 64:345-347, 1957 2. Brady HH, Doughterty CM, Mickal A: Actinomycosis of the female genital tract. Obstet Gynecol 23:580-583, 1964 3. Henderson SR: Pelvic actinomycosis associated with an intrauterine devices Obstet Gynecol 41:726--732, 1973 4. Farrior HL, Rathbun LS, Doolan JJ, Turner FG: Pelvic actinomycosis. Am J Obstet Gynecol [03:908-909, 1969 5. Rose HD, Rytel MW: Actinomycosis treated with clindomycin. JAMA 221:1052, 1972 Digestive Diseases, VoI, 21, No. 1 (January 1976)
