1407 ALLERGY TO &agr;-AMYLASE AND PAPAIN
SIR,-There have been reports of sensitisation and asthmatic symptoms in people exposed to proteolytic enzyme powders, such as trypsin,’ Bacillus subtilis protease (subtilopeptidase A)papain,3.4 and bromelin.5 With B. subtilis protease, used in biological washing powders, there was the possibility of an adjuvant effect from the associated non-biological detergent, but sensitisation and asthmatic symptoms have also occurred in factory workers who handled the material on its own. It is unlikely that the ability of proteases to cause allergic responses in those sensitised is directly related to their proteolytic activity, as I have found that heat-inactivated solutions of both B. subtilis protease2 and papain can still evoke positive skin prick-test reactions in sensitised individuals. Allergic pulmonary responses to bronchial provocation with subtilopeptidase6 persisted when the enzyme solution tested had been heattreated to destroy its proteolytic activity.’ These findings support the notion that proteases are allergenic primarily because of their large molecular weight, as proteins. However, there still remained a possibility that their proteolytic capacity might permit more ready access to tissues in the respiratory tract. Whether or not this is a factor, I have now found that ready sensitising capacity is not exclusive to enzymes that are
Effect of
post-cimetidine
serum on
lymphocyte P.H.A.
response.
added to phytohsemagglutinin (P.H.A.) stimulated lymphocyte cultures, obtained from a panel of four normal subjects at ment serum were
concentration of 10% and 40% (v/v). Skin from adult male Wistar rats was grafted onto adult male AS (Ag-B’) rats. Ten rats received 40 mg/kg of cimetidine intravenously or intraperitoneally and ten rats were treated orally. a
(Ag-B2)
In eight subjects the post-treatment serum markedly enhanced the P.H.A. response of the lymphocytes from the four blood-donors; no effect was seen for one subject and one serum suppressed the lymphocyte response (see figure). A matchedpairs t-test was applied to the results from all ten subjects. Values for t of 2.941 (p005) were obtained for serum concentrations of 10% and 40%, respectively. The non-significance of the 40% result could be attributed entirely to one subject whose serum suppressed lymphocyte responses. The sera from the two subjects who received cimetidine for 7 days both caused immunostimulation. Slight but insignificant prolongation of skin-graft survival in the cimetidine-treated rats was observed when compared with control animals. The results suggest that the serum of most subjects receiving cimetidine stimulates the in-vitro lymphocyte response to mitogens although there was no evidence that cimetidine accelerated rat skin-graft rejection. Some people on cimetidine may be non-responders or negative responders. The size of this minority is not yet known nor has the significance of this response been established. Variation in response to cimetidine between individuals may partly explain the differences in effect of the drug that have been published. Renal Transplant Unit,
MARY D. SMITH ELIZABETH COUHIG
Cardiff Royal Infirmary,
J. J. MILLER
Cardiff CF2 1SZ
J. R. SALAMAN
proteolytic. During a survey in an enzyme-handling factory, as well as finding individuals who had rhinitis and/or asthma after exposure to papain, and who gave positive skin prick-tests to papain, I also found evidence of a similar situation in workers exposed to dust from powdered fungal x-amylase (derived from Aspergillus oryzce). Of eight individuals tested, seven gave positive skin prick-test reactions to papain, and five to the ot-amylase, four of them giving positive reactions to both substances (see table). Four of the group had no atopic history, and gave negative prick-test reactions to common allergens (not shown). As with papain positive skin prick-test reactions to the a-amylase were not elicited in atopic or non-atopic control individuals unexposed to the powder. The prick-test reactions appeared to be specific to the fungal a-amylase and were not obtained with a-amylase derived from B. subtilis. Both enzyme powders were handled on the factory floor or in the laboratory less than once a month, about five times as much papain being used as a-amylase. In the factory highB., Green, G., Maycock, R. L., Hildreth, E. A. J. Allergy, 1967, 13, 11. 2. Flindt, M. L. H. Lancet, 1969, i, 1177. 3. Milne, J., Brand, S. Br. J. ind. Med. 1975, 32, 302. 4. Flindt, M. L. H. Lancet, 1978, i, 430. 5. Galleguillos, F., Rodriguez, J. C. Clin. Allergy, 1978, 8, 21. 6. Pepys, J., Longbottom, J. L., Faux, J. Lancet, 1969, i, 1181. 7. Flindt, M. L. H. Revta Tisiol. Neumonol. 1974, 13, 115. 1. Zweiman,
REACTIONS IN INDIVIDUALS SENSITISED TO PAPAIN
AND/OR
x-AMYLASE
I
J
i
i
I
’Results for 10 mg/ml concentrations (and, in parentheses, 1 mg/ml). 0=reaction no greater than control...=not tested. Papam P, (Powell & Scholeneld), papain B.P.C. (Koch-Light;, and x-amytase (900 SKB unitswere used.
1408 potency enzyme powder concentrates are diluted with a carrier powder while the laboratory does quality-control assays. The workplaces of the individuals are given in the table. The offices were immediately above the enzyme-handling plant. Individuals sensitised to both preparations said that, in respect both of causation and severity of symptoms, a-amylase was worse than papain. All those giving positive skin pricktests to sf-amylase had experienced symptoms, whereas two of those giving positive reactions to papain had had no symptoms, and of the four sensitised to both enzymes, only the two sensit-’ ised to x-amylase had experienced chest symptoms. An adjuvant effect from papain is unlikely because the two enzyme powders were handled infrequently and not at the same time. These findings have implications for a-amylase users, such as those in the flour milling and bakery industries, and they underline the importance of treating all enzyme preparations, proteolytic or not, as potentially allergenic and of taking precautions.8 Department of Occupational University of Manchester, Manchester M13 9PT
M. L. H. FLINDT
5 editorial you noted that cefuroxime be free of nephrotoxic side-effects, on animal and, drawing studies, you suggest that they may even have a protective effect. Previous studies have shown a similar protective effect by cephalothin against gentamicin
May
seem to
nephrotoxicity. 1.2 Accumulating data in patient trials, however, indicate that cephalothin plus an aminoglycoside, either gentamicin or tobramycin, is more nephrotoxic than the aminoglycoside alone. Klastersky et al. compared the combination of tobramycin and cephalothin with that of tobramycin and ticarcillin, and with ticarcillin and cephalothin, in a prospective randomised study in 186 patients with cancer. The incidence of nephrotoxicity was significantly increased (21%) in the cephalothin-tobramycin group. Two additional prospective studies4,5have compared gentamicin and/or tobramycin with cephalothin versus other aminoglycoside regimens and have also found significant increases in nephrotoxicity in cephalothin-containing groups. These studies point out the large unexplained discrepancy between animal and human data. To state that animal studies on the newer cephalosporins indicate that they are probably free of nephrotoxicity, and possibly protective, without at the same time indicating the discrepancy between human and animal data on cephalothin, is potentially misleading to the clinician prescribing these drugs. Division of Infectious Diseases, Washington University Medical Center, St. Louis, Missouri 63110, U.S.A.
SIR,-Dr Marks and Mr Power (Feb. 17, p. 371) have suggested that the risks of ocular toxicity related to chloroquine are acceptably low. However, our experience with 68 patients Flindt, M. L. H. Process Biochem. 1978, 13, no. 8 p. 3. Dellinger, P., Murphy, T., Pinn, V., Barza, M., Weinstein, L. Antimicrob.
Ag. Chemother. 1976, 9, 172. 2. Barza, M., Pinn, V., Tanguay, P., Murray, T. J. antimicrob. Chemother. 1978,4 suppl. A, p. 59. 3. Klastersky, J., Hensgens, C., Debusscher, L. Antimicrob. Ag. Chemother. 1975, 7, 640. 4. The E.O.R.T.C. International Antimicrobial Therapy Project Group. J. infect. Dis. 1978, 137, 14. 5.
Wade, J. C , and others. Lancet, 1978, ii, 604.
with chloroquine visual acuity. We conducted
retinopathy indicates
severe
deterioration of
questionnaire survey on 68 chloroquine retinopathy patients who had instituted a lawsuit against chloroquine manufacturers. The 68 patients, 39 men and 29 women, ranged in age from 20 to 73 years (mean 46). They had been treated with chloroquine for various diseases: 6 for discoid lupus erythematosus, 4 for rheumatoid arthritis, 1 for systemic lupus erythematosus, and 57 for chronic nephritis. Treatment of chronic nephritis with chloroquine has been practised only in Japan. The total dose of chloroquine base per patient ranged from 45 to 674 g (mean 274 g) and the duration of therapy ranged from 16 to 129 months (mean 51 months). The patients answered the questionnaire 41-156 months (mean 89 months) after the end of chloroquine therapy. All patients had visual-field defects and none showed improvement. Moreover, progression was noted in 10 patients after discontinuation of chloroquine therapy. Almost all patients showed seriously impaired visual acuity: 35 patients (51%) showed decreased visual acuity to below 6/60 and 14 of these showed impairment to below counting fingers. Information on serial change of visual acuity before, during, and after chloroquine therapy was available in 19 patients. Visual acuity decreased in 12 patients during chloroquine therapy (see figure). After cessation of therapy, visual acuity improved in only 1, and remained unchanged in 6 patients. The others showed progressive impairment, and in 5 of these the impairment became progressively worse for more than five years after discontinuation of chloroquine therapy. Other workers1,2 have previously reported irreversibility or progression of chloroquine retinopathy 2-3 years after discontinuation of therapy. Our study indicates not only that impaira
progresses more than five years after cessation of chlorobut also that the impairment of visual acuity after a mean of 89 months of discontinuation of chloroquine therapy is more serious than formerly reported.3 We, therefore, would like to emphasise the severity of ocular toxicity of chloroquine. ment
JAMES H. HINRICHS
PROGRESSION OF RETINOPATHY LONG AFTER CESSATION OF CHLOROQUINE THERAPY
8. 1.
=
Health,
CEPHALOSPORIN NEPHROTOXICITY
SIR,-In your and cefamandole
Sequential change of visual acuity after cessation of chloroquine therapy. CF counting fingers.
quine
Department of Public Health, Osaka University Medical School, 3-57, 4 Chome, Nakanoshima, Kita-ku, Osaka, Japan
SADAO OGAWA
Department of Public Health, Nara Medical University
NORIO KURUMATANI
Department of Public Health, Osaka University Medical School
NOBUAKI SHIBAIKE
Department of Education, Shiga University
SHIRO YAMAZOE
Hobbs, H. E., Sorsby, A., Freedman, A. Lancet, 1959, ii, 478. Mayer, W. Am. J. Ophthal. 1962, 53, 769. 3. Nylander, U. Acta ophthal. 1967, suppl. 92, p. 5.
1. 2.
SIR,-There have been reports of sensitisation and asthmatic symptoms in people exposed to proteolytic enzyme powders, such as trypsin,’ Bacillus subtilis protease (subtilopeptidase A)papain,3.4 and bromelin.5 With B. subtilis protease, used in biological washing powders, there was the possibility of an adjuvant effect from the associated non-biological detergent, but sensitisation and asthmatic symptoms have also occurred in factory workers who handled the material on its own. It is unlikely that the ability of proteases to cause allergic responses in those sensitised is directly related to their proteolytic activity, as I have found that heat-inactivated solutions of both B. subtilis protease2 and papain can still evoke positive skin prick-test reactions in sensitised individuals. Allergic pulmonary responses to bronchial provocation with subtilopeptidase6 persisted when the enzyme solution tested had been heattreated to destroy its proteolytic activity.’ These findings support the notion that proteases are allergenic primarily because of their large molecular weight, as proteins. However, there still remained a possibility that their proteolytic capacity might permit more ready access to tissues in the respiratory tract. Whether or not this is a factor, I have now found that ready sensitising capacity is not exclusive to enzymes that are
Effect of
post-cimetidine
serum on
lymphocyte P.H.A.
response.
added to phytohsemagglutinin (P.H.A.) stimulated lymphocyte cultures, obtained from a panel of four normal subjects at ment serum were
concentration of 10% and 40% (v/v). Skin from adult male Wistar rats was grafted onto adult male AS (Ag-B’) rats. Ten rats received 40 mg/kg of cimetidine intravenously or intraperitoneally and ten rats were treated orally. a
(Ag-B2)
In eight subjects the post-treatment serum markedly enhanced the P.H.A. response of the lymphocytes from the four blood-donors; no effect was seen for one subject and one serum suppressed the lymphocyte response (see figure). A matchedpairs t-test was applied to the results from all ten subjects. Values for t of 2.941 (p005) were obtained for serum concentrations of 10% and 40%, respectively. The non-significance of the 40% result could be attributed entirely to one subject whose serum suppressed lymphocyte responses. The sera from the two subjects who received cimetidine for 7 days both caused immunostimulation. Slight but insignificant prolongation of skin-graft survival in the cimetidine-treated rats was observed when compared with control animals. The results suggest that the serum of most subjects receiving cimetidine stimulates the in-vitro lymphocyte response to mitogens although there was no evidence that cimetidine accelerated rat skin-graft rejection. Some people on cimetidine may be non-responders or negative responders. The size of this minority is not yet known nor has the significance of this response been established. Variation in response to cimetidine between individuals may partly explain the differences in effect of the drug that have been published. Renal Transplant Unit,
MARY D. SMITH ELIZABETH COUHIG
Cardiff Royal Infirmary,
J. J. MILLER
Cardiff CF2 1SZ
J. R. SALAMAN
proteolytic. During a survey in an enzyme-handling factory, as well as finding individuals who had rhinitis and/or asthma after exposure to papain, and who gave positive skin prick-tests to papain, I also found evidence of a similar situation in workers exposed to dust from powdered fungal x-amylase (derived from Aspergillus oryzce). Of eight individuals tested, seven gave positive skin prick-test reactions to papain, and five to the ot-amylase, four of them giving positive reactions to both substances (see table). Four of the group had no atopic history, and gave negative prick-test reactions to common allergens (not shown). As with papain positive skin prick-test reactions to the a-amylase were not elicited in atopic or non-atopic control individuals unexposed to the powder. The prick-test reactions appeared to be specific to the fungal a-amylase and were not obtained with a-amylase derived from B. subtilis. Both enzyme powders were handled on the factory floor or in the laboratory less than once a month, about five times as much papain being used as a-amylase. In the factory highB., Green, G., Maycock, R. L., Hildreth, E. A. J. Allergy, 1967, 13, 11. 2. Flindt, M. L. H. Lancet, 1969, i, 1177. 3. Milne, J., Brand, S. Br. J. ind. Med. 1975, 32, 302. 4. Flindt, M. L. H. Lancet, 1978, i, 430. 5. Galleguillos, F., Rodriguez, J. C. Clin. Allergy, 1978, 8, 21. 6. Pepys, J., Longbottom, J. L., Faux, J. Lancet, 1969, i, 1181. 7. Flindt, M. L. H. Revta Tisiol. Neumonol. 1974, 13, 115. 1. Zweiman,
REACTIONS IN INDIVIDUALS SENSITISED TO PAPAIN
AND/OR
x-AMYLASE
I
J
i
i
I
’Results for 10 mg/ml concentrations (and, in parentheses, 1 mg/ml). 0=reaction no greater than control...=not tested. Papam P, (Powell & Scholeneld), papain B.P.C. (Koch-Light;, and x-amytase (900 SKB unitswere used.
1408 potency enzyme powder concentrates are diluted with a carrier powder while the laboratory does quality-control assays. The workplaces of the individuals are given in the table. The offices were immediately above the enzyme-handling plant. Individuals sensitised to both preparations said that, in respect both of causation and severity of symptoms, a-amylase was worse than papain. All those giving positive skin pricktests to sf-amylase had experienced symptoms, whereas two of those giving positive reactions to papain had had no symptoms, and of the four sensitised to both enzymes, only the two sensit-’ ised to x-amylase had experienced chest symptoms. An adjuvant effect from papain is unlikely because the two enzyme powders were handled infrequently and not at the same time. These findings have implications for a-amylase users, such as those in the flour milling and bakery industries, and they underline the importance of treating all enzyme preparations, proteolytic or not, as potentially allergenic and of taking precautions.8 Department of Occupational University of Manchester, Manchester M13 9PT
M. L. H. FLINDT
5 editorial you noted that cefuroxime be free of nephrotoxic side-effects, on animal and, drawing studies, you suggest that they may even have a protective effect. Previous studies have shown a similar protective effect by cephalothin against gentamicin
May
seem to
nephrotoxicity. 1.2 Accumulating data in patient trials, however, indicate that cephalothin plus an aminoglycoside, either gentamicin or tobramycin, is more nephrotoxic than the aminoglycoside alone. Klastersky et al. compared the combination of tobramycin and cephalothin with that of tobramycin and ticarcillin, and with ticarcillin and cephalothin, in a prospective randomised study in 186 patients with cancer. The incidence of nephrotoxicity was significantly increased (21%) in the cephalothin-tobramycin group. Two additional prospective studies4,5have compared gentamicin and/or tobramycin with cephalothin versus other aminoglycoside regimens and have also found significant increases in nephrotoxicity in cephalothin-containing groups. These studies point out the large unexplained discrepancy between animal and human data. To state that animal studies on the newer cephalosporins indicate that they are probably free of nephrotoxicity, and possibly protective, without at the same time indicating the discrepancy between human and animal data on cephalothin, is potentially misleading to the clinician prescribing these drugs. Division of Infectious Diseases, Washington University Medical Center, St. Louis, Missouri 63110, U.S.A.
SIR,-Dr Marks and Mr Power (Feb. 17, p. 371) have suggested that the risks of ocular toxicity related to chloroquine are acceptably low. However, our experience with 68 patients Flindt, M. L. H. Process Biochem. 1978, 13, no. 8 p. 3. Dellinger, P., Murphy, T., Pinn, V., Barza, M., Weinstein, L. Antimicrob.
Ag. Chemother. 1976, 9, 172. 2. Barza, M., Pinn, V., Tanguay, P., Murray, T. J. antimicrob. Chemother. 1978,4 suppl. A, p. 59. 3. Klastersky, J., Hensgens, C., Debusscher, L. Antimicrob. Ag. Chemother. 1975, 7, 640. 4. The E.O.R.T.C. International Antimicrobial Therapy Project Group. J. infect. Dis. 1978, 137, 14. 5.
Wade, J. C , and others. Lancet, 1978, ii, 604.
with chloroquine visual acuity. We conducted
retinopathy indicates
severe
deterioration of
questionnaire survey on 68 chloroquine retinopathy patients who had instituted a lawsuit against chloroquine manufacturers. The 68 patients, 39 men and 29 women, ranged in age from 20 to 73 years (mean 46). They had been treated with chloroquine for various diseases: 6 for discoid lupus erythematosus, 4 for rheumatoid arthritis, 1 for systemic lupus erythematosus, and 57 for chronic nephritis. Treatment of chronic nephritis with chloroquine has been practised only in Japan. The total dose of chloroquine base per patient ranged from 45 to 674 g (mean 274 g) and the duration of therapy ranged from 16 to 129 months (mean 51 months). The patients answered the questionnaire 41-156 months (mean 89 months) after the end of chloroquine therapy. All patients had visual-field defects and none showed improvement. Moreover, progression was noted in 10 patients after discontinuation of chloroquine therapy. Almost all patients showed seriously impaired visual acuity: 35 patients (51%) showed decreased visual acuity to below 6/60 and 14 of these showed impairment to below counting fingers. Information on serial change of visual acuity before, during, and after chloroquine therapy was available in 19 patients. Visual acuity decreased in 12 patients during chloroquine therapy (see figure). After cessation of therapy, visual acuity improved in only 1, and remained unchanged in 6 patients. The others showed progressive impairment, and in 5 of these the impairment became progressively worse for more than five years after discontinuation of chloroquine therapy. Other workers1,2 have previously reported irreversibility or progression of chloroquine retinopathy 2-3 years after discontinuation of therapy. Our study indicates not only that impaira
progresses more than five years after cessation of chlorobut also that the impairment of visual acuity after a mean of 89 months of discontinuation of chloroquine therapy is more serious than formerly reported.3 We, therefore, would like to emphasise the severity of ocular toxicity of chloroquine. ment
JAMES H. HINRICHS
PROGRESSION OF RETINOPATHY LONG AFTER CESSATION OF CHLOROQUINE THERAPY
8. 1.
=
Health,
CEPHALOSPORIN NEPHROTOXICITY
SIR,-In your and cefamandole
Sequential change of visual acuity after cessation of chloroquine therapy. CF counting fingers.
quine
Department of Public Health, Osaka University Medical School, 3-57, 4 Chome, Nakanoshima, Kita-ku, Osaka, Japan
SADAO OGAWA
Department of Public Health, Nara Medical University
NORIO KURUMATANI
Department of Public Health, Osaka University Medical School
NOBUAKI SHIBAIKE
Department of Education, Shiga University
SHIRO YAMAZOE
Hobbs, H. E., Sorsby, A., Freedman, A. Lancet, 1959, ii, 478. Mayer, W. Am. J. Ophthal. 1962, 53, 769. 3. Nylander, U. Acta ophthal. 1967, suppl. 92, p. 5.
1. 2.
