48 RECURRENT POST-PARTUM HÆMOLYTIC URÆMIC SYNDROME woman presented after an uneventful in a pregnancy ending straightforward delivery, at term, of a normal infant. There was no evidence of significant preeclamptic toxaemia. 2 days post partum the haemoglobin was reduced. Petechial haemorrhages and jaundice were subsequently noted. Urine output and microscopy were normal, but culture revealed a moderate growth of Staphylococcus pyogenes. She was transfused and discharged, but was readmitted 3 days later with severe vaginal bleeding. At dilatation and curettage no products of conception were detected. Her haemoglobin was 7.0 g/dl; reticulocytes 7.5%, white cells 7.6x109/1 (61% neutrophils), and platelets 60x109/1. The red cells showed marked fragmentation. The fibrinogen was 102 mg/dl, prothrombintime and activated partial thromboplastintime (a-P.T.T.) both normal. Blood-urea 52 mg/dl. Urine output and examination normal. The patient was given blood, diazepam and heparin. 6 days after admission, she complained of lower abdominal pain and shortly afterwards had, in rapid succession, three grand-mal epileptic convulsions. There were no localising signs and the c.s.F. was normal. Blood studies were little changed from the previous figures. The patient’s haemoglobin and platelet-count returned to normal over the next 4 weeks. 30 months later she wanted a second child and was referred for advice. Blood tests were normal as was kidney function (creatinine clearance 65 ml/min). She was advised against conception but this advice was reversed because she was very keen for a second child and because there was nothing to suggest that the disorder would
SIR,-An 18-year-old
recur.
5 years after the first delivery she became pregnant but miscarried at 13 weeks. Management of the miscarriage was uneventful. Laboratory studies 10 days before and 2 weeks after the miscarriage were normal. Monthly clinical and laboratory assessments during the third pregnancy showed normal progress, and she was delivered without complication of a normal child. There was no excessive bleeding immediately postpartum. Laboratory results were normal for the post-partum state, but heparin was given prophylactically at a dose of 5000 units subcutaneously every 4 h (see figure). 18 h after delivery the platelet-count had fallen to 140 x 109/1 and 24 h postpartum the count was 126 x 109/1. Concurrent with this mild thrombocytopenia, the patient did not feel well and complained of myalgia including back pain. A urinary-tract infection was considered probable, and treatment was started. Before antibiotic therapy the urine showed 910 000 red cells/ml, 90 000 leucocytes/ml, and granular casts in moderate numbers. No bacterial growth was obtained. The heparin dosage was increased and changed to constant intravenous infusion. The patient got worse and had an episode of paroxysmal atrial tachycardia. 42 h after delivery there was clinical evidence of a mild bleeding diathesis. The patient complained of a sore throat and muscle pains and vomited and had diarrhoea. The urine output fell to 520 ml over 18 h although the bloodpressure was normal. Laboratory investigations showed haemoglobin 14.66 g/dl, white cells 20x 109/1, platelets 26x109/1, prothrombin-time 24.6 s (control 11-3), a-P.T.T. incoagulable (control 33.2 s), thrombin-time 73-8 s (control 10-7), factor v 44%, factor vm 112%, factor vu 36%, fibrindegradation products 10-40 µg/ml, and blood-urea 555 mg/dl. Mild-to-moderate red-cell fragmentation was observed on the peripheral-blood smear. The heparin dose was lowered and 750 ml fresh-frozen plasma was administered. 48 h after delivery the blood-urea was 90 mg/dl, and the haematological and coagulation abnormalities were still present. 72 h after delivery the patient was still clinically ill. The following day improvement in both laboratory and clinical findings was observed (see figure). Fibrinogen kinetic studies revealed a turnover-rate of 52 h (normal 6-9 days). 5 days after delivery and 4 days after the onset of the microangio-
Clinical
course.
pathic ha’molytic process the patient felt well. Haemoglobin ’ normal and platelets 96x10 VI. Red-cell fragmentation persisted. The coagulation studies continued to reveal adequate heparinisation. The patient was discharged, 17 days after delivery, with normal hæmatological findings (including red-cell fragmentation) and renal function. Oral anticoagulants were continued for 3 months during which time the patient remained well. Sterilisation by tubal ligation was recommended. Department of Hæmatology, School of Pathology, South African Institute for Medical Research and University of Witwatersrand, Johannesburg, South Africa; and Department of Medicine, University of Witwatersrand and Johannesburg General Hospital
E. D. GOMPERTS
L. SESSEL V. DU PLESSIS C. HERSCH
ISOLATION OF DENGUE VIRUSES IN MOSQUITO CELL CULTURES UNDER FIELD CONDITIONS
SIR,—An increase in dengue virus activity in the Caribbean has
an opportunity to evaluate a mosquito cell line of virus isolation. The cell line LSTM-AP-61, derived from Aedes pseudoscutellaris, not only supports the multiplication of several flaviviruses but also has been used for the isolation of certain arboviruses from wild-caught mosquitoes and human serum and organs.’-3 During the investigation of an outbreak of dengue fever in Dominica, mosquito cell cultures were transported from the P.A.H.O./W.H.O. Caribbean Epidemiology Centre in Trinidad and inoculated on the spot with sera from suspected acute cases. The cells were held at room temperature (approximately 25 °C) for 2 days before transport to Trinidad for incubation at the optimal 28 °C. Cytopathic effect (C.P.E.) was evident from 4 to 8 days after inoculation, and complement-fixation tests on cell-culture fluids, using type-specific sera, showed by day 8 that dengue type 1 was the virus involved. In Trinidad the same sera were again inoculated into mosquito cell cultures, into LLCMK2 cells (a continuous monkey kidney cell line), and, at the same time, intracerebrally into mice. The mosquito cell system detected type 1 dengue virus in 3 of 20 sera on each occasion, with C.P.E. slightly delayed after the sera had been transported. Both LLCMK2 cell cultures and mouse inoculation detected virus in only 1 of the sera; this serum was positive on day 5 in LSTM-AP-61 and on day 11 on the continuous monkey kidney line. Isolations were made in mosquito cell cultures from a
provided
as a means
1.
Varma, M. G. R., Pudney, M., Leake, C. J.
Trans. R. Soc. trop. Med.
Hyg.
1974, 68, 374. 2. Varma, M. G.
R., Pudney, M., Leake,
C.
J., Peralta,
P. H.
Intervirology,
1975/76, 6, 50. 3.
Pudney, M., Leake, C. J., Varma, M. G. R. Paper read at 2nd international symposium Arctic Arboviruses, held at Mont Gabriel, Canada, in 1977.
SIR,-An 18-year-old
recur.
5 years after the first delivery she became pregnant but miscarried at 13 weeks. Management of the miscarriage was uneventful. Laboratory studies 10 days before and 2 weeks after the miscarriage were normal. Monthly clinical and laboratory assessments during the third pregnancy showed normal progress, and she was delivered without complication of a normal child. There was no excessive bleeding immediately postpartum. Laboratory results were normal for the post-partum state, but heparin was given prophylactically at a dose of 5000 units subcutaneously every 4 h (see figure). 18 h after delivery the platelet-count had fallen to 140 x 109/1 and 24 h postpartum the count was 126 x 109/1. Concurrent with this mild thrombocytopenia, the patient did not feel well and complained of myalgia including back pain. A urinary-tract infection was considered probable, and treatment was started. Before antibiotic therapy the urine showed 910 000 red cells/ml, 90 000 leucocytes/ml, and granular casts in moderate numbers. No bacterial growth was obtained. The heparin dosage was increased and changed to constant intravenous infusion. The patient got worse and had an episode of paroxysmal atrial tachycardia. 42 h after delivery there was clinical evidence of a mild bleeding diathesis. The patient complained of a sore throat and muscle pains and vomited and had diarrhoea. The urine output fell to 520 ml over 18 h although the bloodpressure was normal. Laboratory investigations showed haemoglobin 14.66 g/dl, white cells 20x 109/1, platelets 26x109/1, prothrombin-time 24.6 s (control 11-3), a-P.T.T. incoagulable (control 33.2 s), thrombin-time 73-8 s (control 10-7), factor v 44%, factor vm 112%, factor vu 36%, fibrindegradation products 10-40 µg/ml, and blood-urea 555 mg/dl. Mild-to-moderate red-cell fragmentation was observed on the peripheral-blood smear. The heparin dose was lowered and 750 ml fresh-frozen plasma was administered. 48 h after delivery the blood-urea was 90 mg/dl, and the haematological and coagulation abnormalities were still present. 72 h after delivery the patient was still clinically ill. The following day improvement in both laboratory and clinical findings was observed (see figure). Fibrinogen kinetic studies revealed a turnover-rate of 52 h (normal 6-9 days). 5 days after delivery and 4 days after the onset of the microangio-
Clinical
course.
pathic ha’molytic process the patient felt well. Haemoglobin ’ normal and platelets 96x10 VI. Red-cell fragmentation persisted. The coagulation studies continued to reveal adequate heparinisation. The patient was discharged, 17 days after delivery, with normal hæmatological findings (including red-cell fragmentation) and renal function. Oral anticoagulants were continued for 3 months during which time the patient remained well. Sterilisation by tubal ligation was recommended. Department of Hæmatology, School of Pathology, South African Institute for Medical Research and University of Witwatersrand, Johannesburg, South Africa; and Department of Medicine, University of Witwatersrand and Johannesburg General Hospital
E. D. GOMPERTS
L. SESSEL V. DU PLESSIS C. HERSCH
ISOLATION OF DENGUE VIRUSES IN MOSQUITO CELL CULTURES UNDER FIELD CONDITIONS
SIR,—An increase in dengue virus activity in the Caribbean has
an opportunity to evaluate a mosquito cell line of virus isolation. The cell line LSTM-AP-61, derived from Aedes pseudoscutellaris, not only supports the multiplication of several flaviviruses but also has been used for the isolation of certain arboviruses from wild-caught mosquitoes and human serum and organs.’-3 During the investigation of an outbreak of dengue fever in Dominica, mosquito cell cultures were transported from the P.A.H.O./W.H.O. Caribbean Epidemiology Centre in Trinidad and inoculated on the spot with sera from suspected acute cases. The cells were held at room temperature (approximately 25 °C) for 2 days before transport to Trinidad for incubation at the optimal 28 °C. Cytopathic effect (C.P.E.) was evident from 4 to 8 days after inoculation, and complement-fixation tests on cell-culture fluids, using type-specific sera, showed by day 8 that dengue type 1 was the virus involved. In Trinidad the same sera were again inoculated into mosquito cell cultures, into LLCMK2 cells (a continuous monkey kidney cell line), and, at the same time, intracerebrally into mice. The mosquito cell system detected type 1 dengue virus in 3 of 20 sera on each occasion, with C.P.E. slightly delayed after the sera had been transported. Both LLCMK2 cell cultures and mouse inoculation detected virus in only 1 of the sera; this serum was positive on day 5 in LSTM-AP-61 and on day 11 on the continuous monkey kidney line. Isolations were made in mosquito cell cultures from a
provided
as a means
1.
Varma, M. G. R., Pudney, M., Leake, C. J.
Trans. R. Soc. trop. Med.
Hyg.
1974, 68, 374. 2. Varma, M. G.
R., Pudney, M., Leake,
C.
J., Peralta,
P. H.
Intervirology,
1975/76, 6, 50. 3.
Pudney, M., Leake, C. J., Varma, M. G. R. Paper read at 2nd international symposium Arctic Arboviruses, held at Mont Gabriel, Canada, in 1977.
