1596
RSV epidemics mean a sudden increase in the demand for hospital beds and intensive care. Rates of respiratory infection in
staff increase, as do nosocomial infection rates.4 The need for an effective vaccine is pressing and it is to be hoped that research into the virus at a molecular level with monoclonal antibody technology will speed up the development of one. Children’s Hospital, Sydney 2050, Australia
L. M. DE SILVA
1. De Silve LM, Hanlon MG. Respiratory syncytial virus: a report of a 5-year study at a Children’s Hospital. J Med Virol 1986; 19: 299-305. 2. Anestad G. Surveillance of respiratory viral infections by rapid immunofluorescence diagnosis, with emphasis on virus interference. Epidemiol Infect 1987; 99: 523-31. 3. De Silva LM, Siu I. Respiratory syncytial virus. Med J Aust 1990; 152: 672-73. 4. Hall CB, Douglas RG, Geiman JM, Messner MK. Nosocomial respiratory syncytial virus infections. N Engl J Med 1975; 293: 1343-46.
Omental milky spots
Clinical
SIR,-Dr Koten and Dr den Otter (Nov 9, p 1189) suggest that omental milky spots are an intestinal thymus. We agree that these spots have an essential role in the development of abdominal immunity but we do not think that they are primary lymphoid organs. The most populous elements in milky spots are macrophages.1 Macrophages covering the milky spots face the peritoneal cavity, where they trap circulating antigens and transfer information to lymphocytes in the central part of the milky spotS.2 This functional cellular zonation seems to correspond to the structural relation between macrophages lining the lymph sinus wall and lymphocytes in the germinal centre of the lymph node. As the human body grows the intensity of the milky spots reduces, probably because of the widening of the omental area.3 However, in inflammatory conditions the milky spots increase in number and in size, and they cede macrophages to the peritoneal cavity. We propose that omental milky spots are omentum-associated lymphoid tissues that participate in the immunity of the peritoneal cavity rather than that of the gut. Division of Clinical Sciences, John Curtin School of Medical Research, Australian National University,
Canberra, Australia
course
after treatment with
lymphocytes.
ALT, alanine aminotransferase; WBC, white blood cells.
tomography. Laparoscopic liver biopsy was done 17 days after delivery and formalin-fixed haematoxyhn and eosin stained sections of liver were examined. Microscopically, sections of liver showed fibrous obliteration or narrowing of the lumen of central veins with necrosis of liver cells. The liver showed changes typical of veno-occlusive disease. No dietary, toxic, or other extrinsic causes of this disease were foundAfter treatment with lymphocyte therapy lymphopenia was noted between late January and early September, 1991 (figure). Serum IgG (600-700 ng/dl) concentrations were low until late August, 1991. We cannot be sure about the exact cause of veno-occlusive liver disease in this patient. However, lymphocyte immunisation might have played a part in its development. This case may be rare, but it has caused us to be concerned about the safety of lymphocyte
therapy. Department of Internal Medicine, Department of Obstetrics and Gynaecology and Department of Clinical Pathology, Osaka City University Medical School, Osaka 545, Japan
Third
MASATAKA SHIMOTSUMA* MAX SIMPSON-MORGAN
SHIN YA
NAKAJIMA
TETSUO KUROKI KENZO KOBAYASHI
*
Present address: First Department of Surgery, Kyoto Prefectural University of Medicine, Kyoto 602, Japan. 1. Shimotsuma M, Takahashi T, Kawata M, Dux K. Cellular subsets of the milky spots m the human greater omentum. Cell Tissue Res 1991; 264: 599-601. 2. Shimotsuma M, Hagiwara A, Takahashi T, Kawata M, Shields JW. Surface structure and cell zonation in human omental milky spots. Lymphology 1990, 23: 207-08. 3. Shimotsuma M, Kawata M, Hagiwara A, Takahashi T. Milky spots m the human greater omentum: macroscopic and histological identification. Acta Anat (Basel) 1989; 136: 211-16.
Lymphocyte transfusion
as cause
of
veno-occlusive liver disease SIR,-Mueller-Eckhardt et all reported that polyvalent intravenous immunoglobulin is advantageous in the prevention of recurrent abortion and that lymphocyte therapy is associated with the possibility of HLA immunisation. No major side-effects have been reported with lymphocyte therapy. We describe a patient in whom veno-occlusive disease of the liver developed after giving birth, and who had received lymphocyte therapy for the prevention of recurrent abortion. A 38-year-old woman who had had recurrent abortions received four injections of lymphocytes that had been obtained from her husband; the injection series was completed on Jan 21, 1991. She shared three D histocompatibility antigens (DQW1, DRW6, DRW52) with her husband. Injected lymphocytes were not treated with mitomycin C or irradiation. She had twin girls on August 16, 1991, at 37 weeks’ gestation. The next day right upper quadrant tenderness, ascites, and hepatomegaly developed. At that time liver abnormalities were noted-alanine aminotransferase was 687 IU/1 and asparate aminotransferase was 557 IU/1, with peak values of 2360 and 2470 IU/1, respectively, four days after delivery (figure). She had no history of liver disease. Antinuclear antibodies, anti-smooth muscle antibodies, and lupus erythematosus test were negative. Density of the liver was reduced on computed
1. Mueller-Eckhardt G, Heine O, Potten B IVIG to prevent recurrent spontaneous abortion. Lancet 1991; 337: 424-25. 2. Rollins BJ. Hepatic veno-occlusive disease. Am J Med 1986; 81: 297-306.
Pancreatic enzyme supplements in fibrosis
cystic
SIR,-Dr Owen and colleagues (Nov 2, p 1153) recommend that manufacturers of pancreatic enzyme preparations should alter their advice on dosage for patients with cystic fibrosis (CF). They refer to the number of capsules that may be required to achieve satisfactory bowel action. However, many patients find it difficult to swallow the large number of capsules needed for digestion of fat and protein. Some manufacturers have developed more concentrated products and we have compared a standard pancreatin preparation (’Creon’, Duphar) with ’Pancrease HL’ (Cilag) which contains about three times the lipase, six times the protease, and twice the amylase activity of standard pancreatin:
*BP
units/capsule. In a pilot group of ten patients fat-balance studies were done while they were on their usual (standard) medication and after one month on the high enzyme product. Patients were invited to titrate dosage against gastrointestinal symptoms and stool patterns. At the start of the pancrease HL therapy it was suggested that one capsule be taken for every three of creon, no patient receiving less than one high enzyme capsule per food intake. All patients reported satisfaction with symptom control on their fmal reported doses of both preparations. In the nine patients who completed this study, fat and protein digestibility was maintained at lower capsule doses by pancrease HL. Murphy et all have shown that stool energy loss is
RSV epidemics mean a sudden increase in the demand for hospital beds and intensive care. Rates of respiratory infection in
staff increase, as do nosocomial infection rates.4 The need for an effective vaccine is pressing and it is to be hoped that research into the virus at a molecular level with monoclonal antibody technology will speed up the development of one. Children’s Hospital, Sydney 2050, Australia
L. M. DE SILVA
1. De Silve LM, Hanlon MG. Respiratory syncytial virus: a report of a 5-year study at a Children’s Hospital. J Med Virol 1986; 19: 299-305. 2. Anestad G. Surveillance of respiratory viral infections by rapid immunofluorescence diagnosis, with emphasis on virus interference. Epidemiol Infect 1987; 99: 523-31. 3. De Silva LM, Siu I. Respiratory syncytial virus. Med J Aust 1990; 152: 672-73. 4. Hall CB, Douglas RG, Geiman JM, Messner MK. Nosocomial respiratory syncytial virus infections. N Engl J Med 1975; 293: 1343-46.
Omental milky spots
Clinical
SIR,-Dr Koten and Dr den Otter (Nov 9, p 1189) suggest that omental milky spots are an intestinal thymus. We agree that these spots have an essential role in the development of abdominal immunity but we do not think that they are primary lymphoid organs. The most populous elements in milky spots are macrophages.1 Macrophages covering the milky spots face the peritoneal cavity, where they trap circulating antigens and transfer information to lymphocytes in the central part of the milky spotS.2 This functional cellular zonation seems to correspond to the structural relation between macrophages lining the lymph sinus wall and lymphocytes in the germinal centre of the lymph node. As the human body grows the intensity of the milky spots reduces, probably because of the widening of the omental area.3 However, in inflammatory conditions the milky spots increase in number and in size, and they cede macrophages to the peritoneal cavity. We propose that omental milky spots are omentum-associated lymphoid tissues that participate in the immunity of the peritoneal cavity rather than that of the gut. Division of Clinical Sciences, John Curtin School of Medical Research, Australian National University,
Canberra, Australia
course
after treatment with
lymphocytes.
ALT, alanine aminotransferase; WBC, white blood cells.
tomography. Laparoscopic liver biopsy was done 17 days after delivery and formalin-fixed haematoxyhn and eosin stained sections of liver were examined. Microscopically, sections of liver showed fibrous obliteration or narrowing of the lumen of central veins with necrosis of liver cells. The liver showed changes typical of veno-occlusive disease. No dietary, toxic, or other extrinsic causes of this disease were foundAfter treatment with lymphocyte therapy lymphopenia was noted between late January and early September, 1991 (figure). Serum IgG (600-700 ng/dl) concentrations were low until late August, 1991. We cannot be sure about the exact cause of veno-occlusive liver disease in this patient. However, lymphocyte immunisation might have played a part in its development. This case may be rare, but it has caused us to be concerned about the safety of lymphocyte
therapy. Department of Internal Medicine, Department of Obstetrics and Gynaecology and Department of Clinical Pathology, Osaka City University Medical School, Osaka 545, Japan
Third
MASATAKA SHIMOTSUMA* MAX SIMPSON-MORGAN
SHIN YA
NAKAJIMA
TETSUO KUROKI KENZO KOBAYASHI
*
Present address: First Department of Surgery, Kyoto Prefectural University of Medicine, Kyoto 602, Japan. 1. Shimotsuma M, Takahashi T, Kawata M, Dux K. Cellular subsets of the milky spots m the human greater omentum. Cell Tissue Res 1991; 264: 599-601. 2. Shimotsuma M, Hagiwara A, Takahashi T, Kawata M, Shields JW. Surface structure and cell zonation in human omental milky spots. Lymphology 1990, 23: 207-08. 3. Shimotsuma M, Kawata M, Hagiwara A, Takahashi T. Milky spots m the human greater omentum: macroscopic and histological identification. Acta Anat (Basel) 1989; 136: 211-16.
Lymphocyte transfusion
as cause
of
veno-occlusive liver disease SIR,-Mueller-Eckhardt et all reported that polyvalent intravenous immunoglobulin is advantageous in the prevention of recurrent abortion and that lymphocyte therapy is associated with the possibility of HLA immunisation. No major side-effects have been reported with lymphocyte therapy. We describe a patient in whom veno-occlusive disease of the liver developed after giving birth, and who had received lymphocyte therapy for the prevention of recurrent abortion. A 38-year-old woman who had had recurrent abortions received four injections of lymphocytes that had been obtained from her husband; the injection series was completed on Jan 21, 1991. She shared three D histocompatibility antigens (DQW1, DRW6, DRW52) with her husband. Injected lymphocytes were not treated with mitomycin C or irradiation. She had twin girls on August 16, 1991, at 37 weeks’ gestation. The next day right upper quadrant tenderness, ascites, and hepatomegaly developed. At that time liver abnormalities were noted-alanine aminotransferase was 687 IU/1 and asparate aminotransferase was 557 IU/1, with peak values of 2360 and 2470 IU/1, respectively, four days after delivery (figure). She had no history of liver disease. Antinuclear antibodies, anti-smooth muscle antibodies, and lupus erythematosus test were negative. Density of the liver was reduced on computed
1. Mueller-Eckhardt G, Heine O, Potten B IVIG to prevent recurrent spontaneous abortion. Lancet 1991; 337: 424-25. 2. Rollins BJ. Hepatic veno-occlusive disease. Am J Med 1986; 81: 297-306.
Pancreatic enzyme supplements in fibrosis
cystic
SIR,-Dr Owen and colleagues (Nov 2, p 1153) recommend that manufacturers of pancreatic enzyme preparations should alter their advice on dosage for patients with cystic fibrosis (CF). They refer to the number of capsules that may be required to achieve satisfactory bowel action. However, many patients find it difficult to swallow the large number of capsules needed for digestion of fat and protein. Some manufacturers have developed more concentrated products and we have compared a standard pancreatin preparation (’Creon’, Duphar) with ’Pancrease HL’ (Cilag) which contains about three times the lipase, six times the protease, and twice the amylase activity of standard pancreatin:
*BP
units/capsule. In a pilot group of ten patients fat-balance studies were done while they were on their usual (standard) medication and after one month on the high enzyme product. Patients were invited to titrate dosage against gastrointestinal symptoms and stool patterns. At the start of the pancrease HL therapy it was suggested that one capsule be taken for every three of creon, no patient receiving less than one high enzyme capsule per food intake. All patients reported satisfaction with symptom control on their fmal reported doses of both preparations. In the nine patients who completed this study, fat and protein digestibility was maintained at lower capsule doses by pancrease HL. Murphy et all have shown that stool energy loss is
