112 P.M.N. FUNCTION TESTS
ileocxcal area, and undergoing resection, the presence or absence of granulomas in the bowel wall did not affect the recurrence-rate. Whether this is at odds with reports which show such a difference, or whether this reflects a difference between the large and small bowel or, perhaps, other factors, needs further investigation.
*
(or ranges) of: cells/high-power field, t cells ingested by each p.M.N., t% non-viable intra-p.M.N. Candida albicans yeast cells.
Means
followed by tobramycin and, later, carbenicillin, with repeated fresh-frozen plasma infusions, failed to improve the clinical picture or affect the blood cultures. On day 22 the infant received a transfusion of 2x1010 P.M.N.s. A remarkable improvement occurred within a few hours: the lethargic state began to regress, together with the jaundice and other signs of infection. On the following day, for the first time since admission, the patient gained weight, blood cultures became sterile, and peripheral smears reverted to normal. P.M.N. function studies after transfusion were noteworthy in that both chemotactic and killing values surpassed normal ranges (table). The clinical improvement seems to be related not only to the direct microbicidal activity of the transfused cells but also to the immunostimulant effect induced by the same P.M.N.S since transfused P.M.N.s rapidly disappear from the bloodstream. If the efficacy of this therapy is confirmed, P.M.N. transfusion could be considered in the treatment of neonatal sepsis. Department of Pædiatraics, University of Rome, and Transfusion Centre, "Fatebenefratelli" Hosptial, Rome, Italy
F. LAURENTI G. LA GRECA R. FERRO G. BUCCI
GRANULOMAS IN CROHN’S DISEASE
SIR,-Several groups have tried to correlate the pathological findings in Crohn’s disease with the clinical outcome. The sarcoid-like granuloma is an intriguing aspect of this disease because of its possible, yet obscure, relationship to the patient’s immune response. Two reports,I,2 dealing primarily with Crohn’s colitis, indicate a more favourable prognosis in patients with granulomatous disease. As part of a continuing interest in this entity3 we have studied the outcome of 63 patients after resection for primary ileoca’cal Crohn’s disease between 1955 and 1975. Pathological specimens were studied by one of us (G.G.) and classified,
accepted pathological criteria, as possessing or lacking granulomas. Recurrence of Crohn’s disease was defined as the need for a secondary bowel resection to control the disease. Follow-up data were analysed actuarially, and follow-up was considered complete if the patient had recurrence or if his status was known as of 1975. By this definition follow-up was 94% (59/63) complete. 29 of these patients had had granulomas in the bowel wall of the original surgical specimen and on
34 had not. There was virtually no difference in the rate of recurrence, as we have defined it, between these two groups of patients after primary resection. The recurrence-rates for patients having and not having granulomas were 7% and 6%, respectively, at two years, 16% and 16% at five years, and 27% and 25% at eight years. Both groups of patients were comparable in terms of age, sex, and duration of disease before primary resection. Thus, in our patients with Crohn’s disease confined to the 1 Ward, M., Webb, J. M.J. clin. Path. 1977, 30, 126. 2. Glass, R. E., Baker, M. N. W. Gut, 1976, 17, 75. 3. Homan, W. P., Dineen, P. Ann. Surg. 1978, 187, 530.
Departments of Surgery and Pathology, Cornell University Medical College, New York, N.Y. 10021, U.S.A.
WILLIAM P. HOMAN GEORGE F. GRAY, JR. PETER DINEEN
REITER’S SYNDROME COMPLICATING SALMONELLA ENTERITIDIS INFECTION
SIR,-In October, 1977, there was an outbreak of Salmonella enteritidis infection in Stockholm affecting 2800 patients, mainly schoolchildren. Reactive arthropathy was noted in about 2% of the patients. Of these, a 12-year-old boy, had classical Reiter’s syndrome. The boy fell ill on Oct. 9 with enteric symptoms, 3 days after having eaten food contaminated with S. enteritidis. The enteric symptoms faded within a week. On Oct. 16 the boy complained of dysuria and had an inflamed urethral orifice. Urine culture was sterile. On Oct. 17 he had bilateral conjunctivitis and arthralgia which developed into painful swellings of several joints. The conjunctivitis and dysuria cleared rapidly but the arthritis lasted 5 months. Initially the fever was of septic type but a low-grade fever persisted for 3 months. Stool cultures yielded S. enteritidis but urine and blood were sterile several occasions, and so was an aspirate from an inflamed left knee joint. The erythrocyte-sedimentation rate rose to a maximum of 117 mm/h. The peak titre ofO-antibodies specific against S. enteritidis was 1/2070 enzyme-linked immunosorbent assay. Serum-protein electrophoresis showed an intense inflammatory reaction with a relative decrease of C3 and C4 complement. Circulating immune complexes were found in serial serum specimens during the first month of illness. Immune complexes were tested by C1q binding capacity of serum (Dr R. Norberg, National Bacteriological Laboratory, Stockholm). HLA typing was A19, B27, C- (Dr E. Moller, Huddinge Hoson
pital, Stockholm). The cause of Reiter’s syndrome remains unknown, but the syndrome may follow non-specific urethritis with an estimated frequency of 0.8%1 and shigella dysentery (0.2—1.5%2,3). The syndrome seldom seems to follow salmonella infection, but it has been described in children sporadically-i.e., in two cases after enteritis due to S. enteritidis4,5 and one case due to S. typhimurium.6 The Stockholm case occurred in an epidemic afflicting 2800 patients, suggesting a low incidence of Reiter’s syndrome after salmonella infection. Reiter’s syndrome is rare in children, but the incidence of diarrhoea associated with this syndrome seems to be higher in children than adults.’7 HLA B27 has been found in 76% of patients with Reiter’s syndrome,8 as it was in this case. The significance of the circulating immune complexes found during the first month of illness in our patient is uncertain. It may be important to an immunologically susceptible individual when the disease process is triggered by an infectious agent such as S. enteritidis. Hospital for Infectious Diseases, Roslagstulls Hospital, 114 89 Stockholm, Sweden
H. BRIEM B. EVENGÅRD
M. JONSSON
1. Csonka, G. Br. med. J. 1958, i, 1088. 2. Paronen, I. Acta med. scand. 1948, suppl. 212. 3. Noer, H. R. J. Am. med. Ass. 1966, 197, 963. 4. Neiman, N., Pierson, M., Ginsbourger, N. Rev. méd. Nancy, 1959, 84, 302. 5. Iveson, J. M. I., Nanda, B., Hancock, A. H., Ponwall, P. J., Wright, V. Ann.
rheum. Dis. 1975, 34, 364. 6. Jones, R. A. K. Br. med. J. 1977, ii, 1391. 7. Lockie, G. N., Hunder, G. G. Arthr. Rheum. 1971, 14, 767. 8. Brewerton, D. A., Caffrey, M., Nicholls, A., Walters, D., Oates, D. C. O. Lancet, 1973, u, 996.
J. K., James,
ileocxcal area, and undergoing resection, the presence or absence of granulomas in the bowel wall did not affect the recurrence-rate. Whether this is at odds with reports which show such a difference, or whether this reflects a difference between the large and small bowel or, perhaps, other factors, needs further investigation.
*
(or ranges) of: cells/high-power field, t cells ingested by each p.M.N., t% non-viable intra-p.M.N. Candida albicans yeast cells.
Means
followed by tobramycin and, later, carbenicillin, with repeated fresh-frozen plasma infusions, failed to improve the clinical picture or affect the blood cultures. On day 22 the infant received a transfusion of 2x1010 P.M.N.s. A remarkable improvement occurred within a few hours: the lethargic state began to regress, together with the jaundice and other signs of infection. On the following day, for the first time since admission, the patient gained weight, blood cultures became sterile, and peripheral smears reverted to normal. P.M.N. function studies after transfusion were noteworthy in that both chemotactic and killing values surpassed normal ranges (table). The clinical improvement seems to be related not only to the direct microbicidal activity of the transfused cells but also to the immunostimulant effect induced by the same P.M.N.S since transfused P.M.N.s rapidly disappear from the bloodstream. If the efficacy of this therapy is confirmed, P.M.N. transfusion could be considered in the treatment of neonatal sepsis. Department of Pædiatraics, University of Rome, and Transfusion Centre, "Fatebenefratelli" Hosptial, Rome, Italy
F. LAURENTI G. LA GRECA R. FERRO G. BUCCI
GRANULOMAS IN CROHN’S DISEASE
SIR,-Several groups have tried to correlate the pathological findings in Crohn’s disease with the clinical outcome. The sarcoid-like granuloma is an intriguing aspect of this disease because of its possible, yet obscure, relationship to the patient’s immune response. Two reports,I,2 dealing primarily with Crohn’s colitis, indicate a more favourable prognosis in patients with granulomatous disease. As part of a continuing interest in this entity3 we have studied the outcome of 63 patients after resection for primary ileoca’cal Crohn’s disease between 1955 and 1975. Pathological specimens were studied by one of us (G.G.) and classified,
accepted pathological criteria, as possessing or lacking granulomas. Recurrence of Crohn’s disease was defined as the need for a secondary bowel resection to control the disease. Follow-up data were analysed actuarially, and follow-up was considered complete if the patient had recurrence or if his status was known as of 1975. By this definition follow-up was 94% (59/63) complete. 29 of these patients had had granulomas in the bowel wall of the original surgical specimen and on
34 had not. There was virtually no difference in the rate of recurrence, as we have defined it, between these two groups of patients after primary resection. The recurrence-rates for patients having and not having granulomas were 7% and 6%, respectively, at two years, 16% and 16% at five years, and 27% and 25% at eight years. Both groups of patients were comparable in terms of age, sex, and duration of disease before primary resection. Thus, in our patients with Crohn’s disease confined to the 1 Ward, M., Webb, J. M.J. clin. Path. 1977, 30, 126. 2. Glass, R. E., Baker, M. N. W. Gut, 1976, 17, 75. 3. Homan, W. P., Dineen, P. Ann. Surg. 1978, 187, 530.
Departments of Surgery and Pathology, Cornell University Medical College, New York, N.Y. 10021, U.S.A.
WILLIAM P. HOMAN GEORGE F. GRAY, JR. PETER DINEEN
REITER’S SYNDROME COMPLICATING SALMONELLA ENTERITIDIS INFECTION
SIR,-In October, 1977, there was an outbreak of Salmonella enteritidis infection in Stockholm affecting 2800 patients, mainly schoolchildren. Reactive arthropathy was noted in about 2% of the patients. Of these, a 12-year-old boy, had classical Reiter’s syndrome. The boy fell ill on Oct. 9 with enteric symptoms, 3 days after having eaten food contaminated with S. enteritidis. The enteric symptoms faded within a week. On Oct. 16 the boy complained of dysuria and had an inflamed urethral orifice. Urine culture was sterile. On Oct. 17 he had bilateral conjunctivitis and arthralgia which developed into painful swellings of several joints. The conjunctivitis and dysuria cleared rapidly but the arthritis lasted 5 months. Initially the fever was of septic type but a low-grade fever persisted for 3 months. Stool cultures yielded S. enteritidis but urine and blood were sterile several occasions, and so was an aspirate from an inflamed left knee joint. The erythrocyte-sedimentation rate rose to a maximum of 117 mm/h. The peak titre ofO-antibodies specific against S. enteritidis was 1/2070 enzyme-linked immunosorbent assay. Serum-protein electrophoresis showed an intense inflammatory reaction with a relative decrease of C3 and C4 complement. Circulating immune complexes were found in serial serum specimens during the first month of illness. Immune complexes were tested by C1q binding capacity of serum (Dr R. Norberg, National Bacteriological Laboratory, Stockholm). HLA typing was A19, B27, C- (Dr E. Moller, Huddinge Hoson
pital, Stockholm). The cause of Reiter’s syndrome remains unknown, but the syndrome may follow non-specific urethritis with an estimated frequency of 0.8%1 and shigella dysentery (0.2—1.5%2,3). The syndrome seldom seems to follow salmonella infection, but it has been described in children sporadically-i.e., in two cases after enteritis due to S. enteritidis4,5 and one case due to S. typhimurium.6 The Stockholm case occurred in an epidemic afflicting 2800 patients, suggesting a low incidence of Reiter’s syndrome after salmonella infection. Reiter’s syndrome is rare in children, but the incidence of diarrhoea associated with this syndrome seems to be higher in children than adults.’7 HLA B27 has been found in 76% of patients with Reiter’s syndrome,8 as it was in this case. The significance of the circulating immune complexes found during the first month of illness in our patient is uncertain. It may be important to an immunologically susceptible individual when the disease process is triggered by an infectious agent such as S. enteritidis. Hospital for Infectious Diseases, Roslagstulls Hospital, 114 89 Stockholm, Sweden
H. BRIEM B. EVENGÅRD
M. JONSSON
1. Csonka, G. Br. med. J. 1958, i, 1088. 2. Paronen, I. Acta med. scand. 1948, suppl. 212. 3. Noer, H. R. J. Am. med. Ass. 1966, 197, 963. 4. Neiman, N., Pierson, M., Ginsbourger, N. Rev. méd. Nancy, 1959, 84, 302. 5. Iveson, J. M. I., Nanda, B., Hancock, A. H., Ponwall, P. J., Wright, V. Ann.
rheum. Dis. 1975, 34, 364. 6. Jones, R. A. K. Br. med. J. 1977, ii, 1391. 7. Lockie, G. N., Hunder, G. G. Arthr. Rheum. 1971, 14, 767. 8. Brewerton, D. A., Caffrey, M., Nicholls, A., Walters, D., Oates, D. C. O. Lancet, 1973, u, 996.
J. K., James,
