1012
,
If the baby completes the feed with the low-fat foremilk from the second breast, then the average composition is further affected. Moreover, it is assumed in the report that milk obtained, unphysiologically, by manual or mechanical expressions, has the same composition as the milk the baby would have obtained from the breast ("suckled milk"). If baby foods are to be based on the composition of expressed milk, then it needs to be shown conclusively that expressed milk and suckled milk are the same thing. We find it difficult to see why it was thought necessary to repeat the previous analytical work in the light of the enormous practical difficulties in obtaining realistic figures for "average human milk composition". The introduction to the report (paragraphs 1.5 and 1.6) shows that the working-party was only too well aware of these difficulties, yet the report concludes that "the analyses ... can therefore be used with some confidence in suggesting nutritional guidelines for the composition of infant milkfoods." Department of Pædiatrics, University of Oxford, John Radcliffe Hospital,
A. LUCAS J. GIBBS J. D. BAUM
Oxford OX3 9DU
Amyloidosis should be suspected when scintigraphy with Tc-99m diphosphonate shows a positive activity of soft tissues, and this examination is very useful for the diagnosis of amyloid cardiomyopathy. Scans were done by I)r Domenech-Torne and Dr Setoam-Qmnque. from the Centro’l’. de Isotopos Radioactivos, Barcelona. Centro de
JOSE L.
Diagnostico
y Tratamiento Atarazanas, Cludad Sanitaria de la S.S. Francisco
Barcelona, Spain
Franco,
BADA LIBERTO PADRO CARLOS CERVERA
RENAL IMMUNE COMPLEXES IN EPIDEMIC NEPHROPATHY SIR,-Epidemic nephropathy is a benign hxmorrhaoc fever seen in Scandinavia and Finland.’ Its clinical symptoms suggest an acute general infection, with hsemorrhagic interstiua) nephritis as the major clinical manifestation, but there is also meningeal, myocardial, and hepatic involvement.’ The xtiology is unknown, but is probably viral. The disease is related to the "hsemorrhagic fever with renal syndrome" that was studied during the Korean war.2 Because of contradictory reports of immune complexes in haemorrhagic fevers3we did im-
SCANNING FOR SOFT-TISSUE AMYLOID
SIR,-Dr Kula and his colleagues (Jan. 8, p. 92) have described two patients with amyloidosis who showed "excessive, diffuse soft-tissue localisation when individual limbs were scanned 5-6 h after administration of 10 mCi technetium-99m diphosphonate". We have seen a patient with pattern-1 sporadic amyloidosis (primary type) with peripheral neuropathy and a malabsorption syndrome, diagnosis being made by oral, intestinal, and sural-nerve biopsy. Electrocardiography suggested left posterior hemiblock-a finding not typical of amy-
Scintigraphy
of right
thigh.
Positive localisation of Tc-99m
patient loid
with
diphosphonate
over
soft tissues in
amyloidosis.
cardiomyopathy. Vectorcardiography and echocardiogram
were
normal.
’
with 10 mCi Tc-99m diphosphonate radioisotope showed that ratio of activity in bone to activity in soft tissues was lower than normal, because of higher soft-tissue localisation, most evident in both thighs (see figure). Unlike Dr Kula and his colleagues we could not demonstrate positive localisation of Tc-99m diphosphonate over the heart. This accords with our cardiac examination, which indicated that the heart was not affected by amyloid deposits. A
Lähdevirta, J. Ann. clin. Res. 1971, 3, suppl. 8. Gajdusek, D. C. J. Pediat. 1962, 60, 841. 3. Maiztegui, J. I., Laguens, R. P., Cossio, P. M., Casanova, M. B., de la Vega, M. T., Ritacco, V., Segal, A., Fernández, N. J., Arana, R M. J. infect Dis. 1975, 132, 35. 4. Boonpucknavig, V., Bhamarapravati, N., Boonpucknavig, S., Futrakul, P. Tanpaichitr, P. Archs Path. Lab. Med. 1976, 100, 206. 1. 2.
scan
Immunofluorescence and
electron-microscope findings. Top: granular deposits in a renal glomerulus, 14 days after the onset of fever, mainly along capillary-basement membrane and to a lesser extent in the mesangium. Immunofluorescence microscopy, antibody specific for IgG. (320.) Middle: glomerular basement membrane with an irregular outlme of epithehal side. Note granular material inside membrane at toot processses (arrow). (14 000.) Bottom: mesangial deposition of dark material (arrow). 7000.I ,
,
If the baby completes the feed with the low-fat foremilk from the second breast, then the average composition is further affected. Moreover, it is assumed in the report that milk obtained, unphysiologically, by manual or mechanical expressions, has the same composition as the milk the baby would have obtained from the breast ("suckled milk"). If baby foods are to be based on the composition of expressed milk, then it needs to be shown conclusively that expressed milk and suckled milk are the same thing. We find it difficult to see why it was thought necessary to repeat the previous analytical work in the light of the enormous practical difficulties in obtaining realistic figures for "average human milk composition". The introduction to the report (paragraphs 1.5 and 1.6) shows that the working-party was only too well aware of these difficulties, yet the report concludes that "the analyses ... can therefore be used with some confidence in suggesting nutritional guidelines for the composition of infant milkfoods." Department of Pædiatrics, University of Oxford, John Radcliffe Hospital,
A. LUCAS J. GIBBS J. D. BAUM
Oxford OX3 9DU
Amyloidosis should be suspected when scintigraphy with Tc-99m diphosphonate shows a positive activity of soft tissues, and this examination is very useful for the diagnosis of amyloid cardiomyopathy. Scans were done by I)r Domenech-Torne and Dr Setoam-Qmnque. from the Centro’l’. de Isotopos Radioactivos, Barcelona. Centro de
JOSE L.
Diagnostico
y Tratamiento Atarazanas, Cludad Sanitaria de la S.S. Francisco
Barcelona, Spain
Franco,
BADA LIBERTO PADRO CARLOS CERVERA
RENAL IMMUNE COMPLEXES IN EPIDEMIC NEPHROPATHY SIR,-Epidemic nephropathy is a benign hxmorrhaoc fever seen in Scandinavia and Finland.’ Its clinical symptoms suggest an acute general infection, with hsemorrhagic interstiua) nephritis as the major clinical manifestation, but there is also meningeal, myocardial, and hepatic involvement.’ The xtiology is unknown, but is probably viral. The disease is related to the "hsemorrhagic fever with renal syndrome" that was studied during the Korean war.2 Because of contradictory reports of immune complexes in haemorrhagic fevers3we did im-
SCANNING FOR SOFT-TISSUE AMYLOID
SIR,-Dr Kula and his colleagues (Jan. 8, p. 92) have described two patients with amyloidosis who showed "excessive, diffuse soft-tissue localisation when individual limbs were scanned 5-6 h after administration of 10 mCi technetium-99m diphosphonate". We have seen a patient with pattern-1 sporadic amyloidosis (primary type) with peripheral neuropathy and a malabsorption syndrome, diagnosis being made by oral, intestinal, and sural-nerve biopsy. Electrocardiography suggested left posterior hemiblock-a finding not typical of amy-
Scintigraphy
of right
thigh.
Positive localisation of Tc-99m
patient loid
with
diphosphonate
over
soft tissues in
amyloidosis.
cardiomyopathy. Vectorcardiography and echocardiogram
were
normal.
’
with 10 mCi Tc-99m diphosphonate radioisotope showed that ratio of activity in bone to activity in soft tissues was lower than normal, because of higher soft-tissue localisation, most evident in both thighs (see figure). Unlike Dr Kula and his colleagues we could not demonstrate positive localisation of Tc-99m diphosphonate over the heart. This accords with our cardiac examination, which indicated that the heart was not affected by amyloid deposits. A
Lähdevirta, J. Ann. clin. Res. 1971, 3, suppl. 8. Gajdusek, D. C. J. Pediat. 1962, 60, 841. 3. Maiztegui, J. I., Laguens, R. P., Cossio, P. M., Casanova, M. B., de la Vega, M. T., Ritacco, V., Segal, A., Fernández, N. J., Arana, R M. J. infect Dis. 1975, 132, 35. 4. Boonpucknavig, V., Bhamarapravati, N., Boonpucknavig, S., Futrakul, P. Tanpaichitr, P. Archs Path. Lab. Med. 1976, 100, 206. 1. 2.
scan
Immunofluorescence and
electron-microscope findings. Top: granular deposits in a renal glomerulus, 14 days after the onset of fever, mainly along capillary-basement membrane and to a lesser extent in the mesangium. Immunofluorescence microscopy, antibody specific for IgG. (320.) Middle: glomerular basement membrane with an irregular outlme of epithehal side. Note granular material inside membrane at toot processses (arrow). (14 000.) Bottom: mesangial deposition of dark material (arrow). 7000.I ,
