1299 fused. So, I suspect, are the authors of the two reports. And yet should know which is to determine action, for very considerable sums of money could be spent on static and mobile coronary-care units, more of which the earlier report, quite clearly and separately from the quotation given, indicates should be provided. Are we, and the financially hard-pressed
TRAUMATIC RUPTURE OF THE LIVER IN A HÆMOPHILIAC PATIENT WITH FACTOR-VIII
we
Government
to
be
enlightened?
Garraway House, How Caple,
JOHN S. BRADSHAW
Hereford
LYMPHOCYTE SUBPOPULATIONS AFTER THYMECTOMY
S:R,—There have been several studies of the effects of thy-1
mectomy on
immunological function in adults. Kornfeld et al.’
impairment of cellular immune response, some imof pairment antibody production, and normal absolute lymphocyte-counts. Rule and Kornfeldstate that, in man, thymectomy beyond infancy caused lymphocytopenia only irregularly and transiently, with variable effects on immunological capacity. Zollinger et al.’ found no prolongation of skingraft rejection-time -in a group of thymectomised children. Lymphocyte transformation is also unaffected by thymectomy.4 We wish to report short-term observations on circulating lymphocyte subpopulations in a thymectomised adult who had myasthenia gravis. The patient was an African schoolgirl aged 16 years. She had had severe progressive disease for 7 months, with one episode of respiratory paralysis requiring assisted ventilation. Symptoms were inadequately controlled by large doses of anticholinesterase agents with prednisone. Thymectomy was performed by Prof. L. W. Baker on Oct. 16, 1975. Our method of lymphocyte typing has been described in detail elsewhere. Basically it involves identification of E rosettes and immunoglobulin-bearing lymphocytes in a combined procedure. Thus T cells, B cells, null cells, and cells carrying both markers can be accurately counted. Counts were made before thymectomy and frequently for 9 weeks therefound
no
after. The table shows total lymphocyte-counts, with subpopulations as percentages of the total count. The slow fall in numbers over the first 2 weeks was followed by a sharp rise (? compensatory mobilisation) which then showed a tendency to stabilise at a level higher than that before thymectomy. Despite these fluctuations there were no appreciable changes in the relative proportions of the groups. Thus thymectomy, while followed by fluctuation in lymphocyte numbers, had no selective effect on the lymphocyte subgroups. Natal Institute of Immunology, P. O. Box 2356 Durban 4000, South Africa
D. J. PUDIFIN JOCELYN COX
1. Kornfeld, P., Siegal, S., Weiner, L. B., Osserman, K. E. Ann. intern. Med. 1965, 63, 416. 2. Rule, A. H., Kornfeld, P. Mt. Sinai J. Med. 1971, 38, 538. 3.Zollinger, R. M., Lindem, M. C., Filler, R. M., Corson, J. M., Wilson, R. E. New Engl. J. Med. 1964, 270, 707. 4. Honsley, J., Oppenheim, J. J. Br. med. J. 1967, i, 679 5. Brain, P., Cox, J., Duursma, J., Pudifin, D. J. Clin. exp. Immun. 1976, 23, 248.
INHIBITORS
SIR,-A patient with haemophilia sustained a traumatic rupof the liver in a road accident. Treatment was complicated to both human and animal factor VIII. He refractoriness by was successfully treated with factor-vm inhibitor-bypassing ture
activity (F.E.I.B.A.) (supplied by Immuno AG, Vienna). A 20-year-old haemophiliac patient with a factor-vm level of less than 1% of average normal, who was known to have a factor-vm inhibitor present since 1973, sustained multiple lacerations and abrasions. On admission to hospital he was fully conscious and not shocked. Eight hours later haematuria developed, with right loin and right upper-quadrant abdominal tenderness, and hypotension. An emergency intravenous pyelogram indicated that there might be a clot in the collecting system of the right kidney. Because of a falling haemoglobin level and persisting hypotension, laparotomy was performed. He was bleeding from a tear of the posterior surface of the liver at the exit of the hepatic veins. The bleeding was arrested by packing with ’Sterispon’ sheets (absorbable gelatin sponge). Two abdominal drains were inserted. Postoperatively, he was given high-dose human factor-vm concentrate. On the fourth postoperative day his factor-vm inhibitor level rose sharply, rendering further human factor-vm therapy ineffective. Two plasma exchanges’ were performed by I.B.M. cell separator, but each failed to reduce the level of factor-vm inhibitor. Although he had porcine factor vmI in 1973, further treatment with this material was cautiously attempted.2 A severe febrile reaction ensued and plasma-factor-vm level was too low to measure. Next day he began to bleed from abdominal drain sites, and blood-transfusions were required. Treatment with F.E.I.B.A. (30 units/kg body-weight three times daily) was started and the prolonged whole-blood and activated partial thromboplastin times showed near-complete corrections. He continued to bleed heavily, however, and multiple whole-blood transfusions were needed. The plateletcount fell and platelet transfusions became necessary. F.E.I.B.A. was increased gradually to 75 units/kg three times daily. ’Cyklokapron’ (transhexanamic acid) 0-5 g three times daily, an antifibrinolytic agent, was given from the thirteenth postoperative day. Blood loss decreased sharply that day, and by the following day bleeding had ceased. He was treated with F.E.I.B.A. for a further four weeks, during which the laparotomy wound, lacerations, and abrasions healed uneventfully. There were no side-effects from F.E.I.B.A. He was discharged after six weeks and has remained well. Traumatic liver rupture carries a high mortality in normal persons,3 and recovery from this injury in a haemophiliac patient refractory to human and animal factor vm might be considered unlikely. In our patient we were impressed by the prompt correction of the whole-blood clotting-time and partial thromboplastin time after the start of F.E.I.B.A. therapy. Bleeding stopped completely seven days later at a time when massive platelet transfusions were given and transhexanamic acid was added. Normal healing followed. We suggest that F.E.I.B.A. should be evaluated in haemophi-
1. 2.
Strauss, H. S. New Engl. J. Med. 1969, 281, 866. Biggs R., MacFarlane, R. G. Treatment of Haemophilia and Other Coagulation Disorders. Oxford, 1966. 3. Longmire, W. P. Jr., Cleveland, R. J. Surg. Clin. N. Am. 1972, 52, 687.
TOTAL LYMPHOCYTE COUNT AND SUBPOPULATIONS BEFORE AND AFTER THYMECTOMY
’Oct. 3, 1975;
thymectomy (day 0) on Oct.
16
TRAUMATIC RUPTURE OF THE LIVER IN A HÆMOPHILIAC PATIENT WITH FACTOR-VIII
we
Government
to
be
enlightened?
Garraway House, How Caple,
JOHN S. BRADSHAW
Hereford
LYMPHOCYTE SUBPOPULATIONS AFTER THYMECTOMY
S:R,—There have been several studies of the effects of thy-1
mectomy on
immunological function in adults. Kornfeld et al.’
impairment of cellular immune response, some imof pairment antibody production, and normal absolute lymphocyte-counts. Rule and Kornfeldstate that, in man, thymectomy beyond infancy caused lymphocytopenia only irregularly and transiently, with variable effects on immunological capacity. Zollinger et al.’ found no prolongation of skingraft rejection-time -in a group of thymectomised children. Lymphocyte transformation is also unaffected by thymectomy.4 We wish to report short-term observations on circulating lymphocyte subpopulations in a thymectomised adult who had myasthenia gravis. The patient was an African schoolgirl aged 16 years. She had had severe progressive disease for 7 months, with one episode of respiratory paralysis requiring assisted ventilation. Symptoms were inadequately controlled by large doses of anticholinesterase agents with prednisone. Thymectomy was performed by Prof. L. W. Baker on Oct. 16, 1975. Our method of lymphocyte typing has been described in detail elsewhere. Basically it involves identification of E rosettes and immunoglobulin-bearing lymphocytes in a combined procedure. Thus T cells, B cells, null cells, and cells carrying both markers can be accurately counted. Counts were made before thymectomy and frequently for 9 weeks therefound
no
after. The table shows total lymphocyte-counts, with subpopulations as percentages of the total count. The slow fall in numbers over the first 2 weeks was followed by a sharp rise (? compensatory mobilisation) which then showed a tendency to stabilise at a level higher than that before thymectomy. Despite these fluctuations there were no appreciable changes in the relative proportions of the groups. Thus thymectomy, while followed by fluctuation in lymphocyte numbers, had no selective effect on the lymphocyte subgroups. Natal Institute of Immunology, P. O. Box 2356 Durban 4000, South Africa
D. J. PUDIFIN JOCELYN COX
1. Kornfeld, P., Siegal, S., Weiner, L. B., Osserman, K. E. Ann. intern. Med. 1965, 63, 416. 2. Rule, A. H., Kornfeld, P. Mt. Sinai J. Med. 1971, 38, 538. 3.Zollinger, R. M., Lindem, M. C., Filler, R. M., Corson, J. M., Wilson, R. E. New Engl. J. Med. 1964, 270, 707. 4. Honsley, J., Oppenheim, J. J. Br. med. J. 1967, i, 679 5. Brain, P., Cox, J., Duursma, J., Pudifin, D. J. Clin. exp. Immun. 1976, 23, 248.
INHIBITORS
SIR,-A patient with haemophilia sustained a traumatic rupof the liver in a road accident. Treatment was complicated to both human and animal factor VIII. He refractoriness by was successfully treated with factor-vm inhibitor-bypassing ture
activity (F.E.I.B.A.) (supplied by Immuno AG, Vienna). A 20-year-old haemophiliac patient with a factor-vm level of less than 1% of average normal, who was known to have a factor-vm inhibitor present since 1973, sustained multiple lacerations and abrasions. On admission to hospital he was fully conscious and not shocked. Eight hours later haematuria developed, with right loin and right upper-quadrant abdominal tenderness, and hypotension. An emergency intravenous pyelogram indicated that there might be a clot in the collecting system of the right kidney. Because of a falling haemoglobin level and persisting hypotension, laparotomy was performed. He was bleeding from a tear of the posterior surface of the liver at the exit of the hepatic veins. The bleeding was arrested by packing with ’Sterispon’ sheets (absorbable gelatin sponge). Two abdominal drains were inserted. Postoperatively, he was given high-dose human factor-vm concentrate. On the fourth postoperative day his factor-vm inhibitor level rose sharply, rendering further human factor-vm therapy ineffective. Two plasma exchanges’ were performed by I.B.M. cell separator, but each failed to reduce the level of factor-vm inhibitor. Although he had porcine factor vmI in 1973, further treatment with this material was cautiously attempted.2 A severe febrile reaction ensued and plasma-factor-vm level was too low to measure. Next day he began to bleed from abdominal drain sites, and blood-transfusions were required. Treatment with F.E.I.B.A. (30 units/kg body-weight three times daily) was started and the prolonged whole-blood and activated partial thromboplastin times showed near-complete corrections. He continued to bleed heavily, however, and multiple whole-blood transfusions were needed. The plateletcount fell and platelet transfusions became necessary. F.E.I.B.A. was increased gradually to 75 units/kg three times daily. ’Cyklokapron’ (transhexanamic acid) 0-5 g three times daily, an antifibrinolytic agent, was given from the thirteenth postoperative day. Blood loss decreased sharply that day, and by the following day bleeding had ceased. He was treated with F.E.I.B.A. for a further four weeks, during which the laparotomy wound, lacerations, and abrasions healed uneventfully. There were no side-effects from F.E.I.B.A. He was discharged after six weeks and has remained well. Traumatic liver rupture carries a high mortality in normal persons,3 and recovery from this injury in a haemophiliac patient refractory to human and animal factor vm might be considered unlikely. In our patient we were impressed by the prompt correction of the whole-blood clotting-time and partial thromboplastin time after the start of F.E.I.B.A. therapy. Bleeding stopped completely seven days later at a time when massive platelet transfusions were given and transhexanamic acid was added. Normal healing followed. We suggest that F.E.I.B.A. should be evaluated in haemophi-
1. 2.
Strauss, H. S. New Engl. J. Med. 1969, 281, 866. Biggs R., MacFarlane, R. G. Treatment of Haemophilia and Other Coagulation Disorders. Oxford, 1966. 3. Longmire, W. P. Jr., Cleveland, R. J. Surg. Clin. N. Am. 1972, 52, 687.
TOTAL LYMPHOCYTE COUNT AND SUBPOPULATIONS BEFORE AND AFTER THYMECTOMY
’Oct. 3, 1975;
thymectomy (day 0) on Oct.
16
