1466

other theories, two hypotheses that may explain the increased incidence of HAV infection in haemophiliacs derive from the fact that today’s preparations of FVIII contain much less anti-HAV than previous products. This could lead to loss of passive immunity against HAV from other sources. Alternatively, HAV may indeed be present in FVIII preparations but falling levels of neutralising antibody in plasma pools used for production could lead to survival of HAV in the final product, since the solvent/ detergent method would not be expected to inactivate a nonenveloped virus such as HAV. Because the evidence for a link between FVIII and the hepatitis A outbreak in Germany is still incomplete and the significance of HAV RNA in FVIII is not yet fully understood, an international panel of independent virologists, clinicians, an epidemiologist from the US Centers for Disease Control, and representatives of the manufacturer and the Belgian Blood Transfusion Service, met in Zurich on Oct 3, 1992, under support of Octapharma GmbH, a manufacturer of solvent/detergent-treated FVIII. The conference was chaired by a member of the Safety Committee of the German Society for Virology (W. H. G.). The working group identified methodological, virological, and epidemiological issues that need further analysis, and developed a plan to investigate the outbreak of hepatitis A in German patients. Results are expected to be available within the next year. Until more data are available, the group suggests that physicians consider precautionary measures, depending on the situation in their centre. Hepatitis A clusters have been observed in treatment centres in Italy, Germany, and Ireland, but not in other countries where similarly treated FVIII products are used, such as the USA, France, Norway, the UK, Switzerland, and Israel. In centres where HAV clusters have been observed, anti-HAV-negative patients should be passively immunised with immune serum globulin (0-06 ml/kg administered intramuscularly after FVIII injection, the dose being repeated every 4-6 months as long as the patient is still undergoing FVIII treatment) or given inactivated HAV vaccine where available. Centres where HAV outbreaks have not been documented are encouraged to look for HAV infection in recipients

Among

of FVIII, irrespective of manufacturer. Liver

Unit, Division of Medicine, Hadassah University Hospital, 91120 Jerusalem, Israel

D. SHOUVAL W. H. on

Institute of Medical Virology, University Clinics,

Giessen, Germany

GERLICH,

behalf of the

Working Group Hepatitis A and Clotting Factors*

on

*Other members are: H. H. Brackmann (Bonn), B. Flehmig (Tübingen), A. Gerritzen (Bonn), S. Lemon (Chapel Hill, North Carolina), J. L. Poplavsky (Brussels), A. Prince (New York), B. Robertson (Atlanta), S. Robinson (Düsseldorf), C. Shapiro (Atlanta), and G. Siegl (St Gallen,

Switzerland). Seeberg S, Brandberg A, Hermodsson S, Larsson P, Lundgren S. Hospital outbreak of hepatitisA secondary to blood exchange in a baby. Lancet 1981; i: 1155-56. 2. Hollinger FB, Khan NC, Oefinger PE, et al. Posttransfusion hepatitis type A. JAMA 1.

1983; 250: 2313-17. 3. Noble RC, Kane MA, Reeves SA, Roeckel I. Posttransfusion hepatitis A in a neonatal intensive care unit. JAMA 1984; 252: 2711-15. 4. Sheretz RJ, Russell BA, Reuman PD. Transmission of hepatitis A by transfusion of blood products. Arch Intern Med 1984; 144: 1579-80. 5. Lee KK, Vargo LR, Le CT, Fernando L. Transfusion-acquired hepatitis A outbreak from fresh frozen plasma in a neonatal intensive care unit. Pediatr Infect Dis J 1992; 11: 122-23. 6. Mannucci PM. Outbreak of hepatitis A

in Italian hemophilia patients treated with a solvent-detergent concentrate (abstr 180). Proceedings of 20th International Congress of World Federation on Hemophilia; Athens; 1992 Oct 12-17).

SIR,-Dr Gerritzen and colleagues and Mannucci et all have reported outbreaks of hepatitis A in patients with haemophilia in Italy and Germany, respectively. We describe here 9 cases of hepatitis A in Irish haemophilia A patients from May to September, 1992. Since August, screening for serum IgM antibody to HAV has revealed a further 8 seroconversions (by Nov 25, 1992). 343 patients with haemophilia are registered in the Republic of Ireland; 87 (25%) have haemophilia B, 144 severe haemophilia A, and 112 mild/moderate haemophilia A. All 17 IgM anti-HAVpositive patients have haemophilia A (12 severe, 3 moderate, 2

mild). Their ages are 0-9 years (n 7), 10-19 (6), 20-29 (0), 30-39 (2), and 40 + (2). They are widely dispersed throughout the country without obvious clustering. Since 1990, the only factor VIII and factor IX concentrates available in the Republic of Ireland have been those prepared by Octapharma, Vienna, from plasma, from Irish donors, collected by the Blood Transfusion Service Board (BTSB). Donors are screened for HIV and hepatitis B and C virus antibodies but not for alanine transferase activity. The first case of hepatitis A was reported on May 23. Our records show that Octavi (factor VIII concentrate) batch 20601214 (206) was introduced to our patients on March 21, batch 21303614 (213) on May 13, and batch 21402614 (214) on May 20. All 17 patients who became IgM anti-HAV positive had been infused with one or more of these products. All three batches contained plasma from BTSB plasma pool 9204. Of the 17 seroconversions, 14 were associated with the Dublin Haemophilia Centre, which treated or provided home therapy concentrate for 83 patients with batches 206, 213, and 214. 9 further recipients have proved IgM anti-HAV negative and of these 5 were positive, 2 were negative, and 2 remain to be tested for the IgG =

anti-HAV. The prevalence of hepatitis A in Ireland is difficult to assess because of uncertainty about reporting compliance. Department of Health returns reveal 935, 356, and 396 notifications for 1990,1991, and up to Sept 30, 1992, respectively. These numbers represent specified hepatitis A cases and hepatitis unspecified. Our experience shows a remarkable coincidence between the infusion of factor VIII concentrates prepared by Octapharma, Vienna, from a common lot of Irish donor plasma and the development of hepatitis A and the subsequent finding of IgM anti-HAV positivity in patients with haemophilia A. Most of the cases from Italy, Germany, and now Ireland received concentrates prepared by the solvent/detergent technique. Both Mannucci and Gerritzen and their colleagues drew attention to the point that because HAV is non-enveloped it is not destroyed by this procedure, which effectively inactivates HIV, and hepatitis B and C viruses. We have suspended use of Octapharma products to allow time to vaccinate anti-HAV-negative patients and to assess further information from the producers and other investigators. National Haemophilia Centre, St James’s Hospital, Dublin 8, Eire

I. J. TEMPERLEY

Cork

Haemophilia Centre, Regional Hospital, Cork

K. P. COTTER T. J. WALSH

J. POWER Virus Reference

Laboratory, University College, Dublin

I. B. HILLARY

PM, for the Medical-Scientific Committee, Fondazione dell’Emofilia. Outbreak of hepatitis A among/Italian patients with haemophilia. Lancet 1992; 339:

1. Mannucci

819.

Augmented tumour necrosis factor in Reye’s syndrome associated with dengue virus SIR,-Larrick and KunkeP have presented in-vitro evidence in support of the hypothesis that increased release of tumour necrosis factor (TNF) in salicylate-treated children with viral infection contributes to the pathogenesis of Reye’s syndrome. We report four children who had primary dengue virus infection with clinical features2 of Reye’s syndrome with increased augmented TNF concentration (table). None of the four children had received

salicylates. The four patients aged 8 months to 10 years were admitted with high temperature, vomiting, drowsiness (grades 1-3 by Lovejoy’s classification 3), behavioural changes, petechue, and hepatomegaly. Liver biopsy in cases 1 and 2 revealed microvesicular fatty infiltration of the hepatocytes with mild increase in lymphocytes. Case 1, after initial improvement, went into coma and hypovolaemic shock and died despite ventilatory support. Cases 2 and 3 were electively ventilated and recovered. Case 4 had

1467

BIQCHEMICALAND TNF FINDINGS IN SERUM OF FOUR PATIENTS WITH DENGUE-VIRUS-ASSOCIATED REYE’S SYNDROME

i

i

i

i

i

AST= aspartate aminotransferase, ALT= = alanine aminotransferase.

drowsiness and hypovolaemic shock but, with appropriate fluid and electrolyte therapy, recovered. All four cases were positive for dengue virus specific IgM antibodies in enzyme-linked immunosorbent assay.4 Cases 1 to 3 were studied retrospectively and case 4 prospectively. Encephalopathy was associated with increased liver aminotransferases, prolonged prothrombin time, and depressed platelet counts in all four patients, and 7 creased blood ammonia in the three patients tested. Cerebrospinal fluid was normal in all four. The four patients had increased serum TNF, which suggests a possible pathogenetic role for TNF in Reye’s syndrome. Many of the metabolic and biochemical effects associated with Reye’s syndrome may be reproduced with TNF alone in experimental models.5.6 In our four patients, the primary dengue virus infection progressed to encephalopathy and shock. A comparison of the clinical, epidemiological, and histopathological features of dengue shock syndrome and Reye’s syndrome shows many similarities. On the basis of our observations and the earlier demonstration of enhanced TNF in dengue shock syndrome,’ we hypothesise that a common pathophysiological pathway mediates via TNF in the development of both these syndromes. Departments of Paediatrics, and of Genetics and Cellular Biology, University of Malalya, 59100 Kuala Lumpur, Malaysia, and Department of Gastroenterology, Royal Adelaide Hospital for Children, Sydney, Australia

DQw3/- and DR4/9, DQw3/-, and the Chinese patient (Dr J.-H. Tsai, Taiwan) was DR4/-, DQw3/-. Thus all IAS patients possessed DR4. Nucleotide sequence analysis of HLA class II genes showed that one Chinese and two Korean IAS patients were DRB1*0406/DQA1*0301/DQB1*0302, as were the thirty-two Japanese patients. To examine the role of insulin as the possible target antigen we did autologous mixed lymphocyte reaction experiments in seven blood samples from IAS patients. When antigen-presenting cells were exposed to human insulin (40 (imol/1), 3H-thymidine incorporation was accelerated 10-20 fold 6 days after exposure to insulin, but not to glucagon (table). 40 Eunol/1 insulin had no effect on antigen-presenting cells (as stimulator) or T-cell-enriched fraction (as responder) alone.

PROLIFERATIVE RESPONSE OF T CELLS IN PRESENCE OF INSULIN

N. IYNGKARAN M. YADAV FATIMAH HARUN K. R. KAMATH

i

i

i

i

-

R=

1. Larrick JW, Kunkel SL. Is Reye’s syndrome caused by augmented release of tumour necrosis factor? Lancet 1986; ii: 132-33. 2. Communicable Disease Surveillance Centre. Reye’s Syndrome surveillance scheme: third annual summary report. BMJ 1985, 291: 329-30. 3. Lovejoy FH Jr, Smith AL, Breshan MJ, Wood JN, Victor DI, Adams PC. Clinical staging in Reye’s syndrome. Am J Dis Child 1974; 128: 36-41. 4. Yadav M, Kamath KR, lyngkaran N, Sinniah M. Dengue haemorrhagic fever and dengue shock syndrome: are they tumour necrosis factor-mediated disorders?. FEMS Microbiol Immunol 1991; 89: 45-50. 5. Yoder MC, Egler JM, Yudkoff M, Chatten J, Douglas SD, Polin RA. Metabolic and mitochondrial morphological changes that mimic Reye’s syndrome after endotoxin administration to rats. Infect Immun 1985; 47: 329-31. 6. Cerami A. Inflammatory cytokines. Clin Immun Immunopath 1992; 62: S3-S10.

HLA-DR4 genotype and insulin-processing in insulin autoimmune syndrome SiR,—The "insulin autoimmune syndrome" or Hirata diseasea combination of a high serum total immunoreactive insulin, insulin autoantibodies, and fasting hypoglycaemia-was first reported in Japan,! where it is the third leading cause of hypoglycaemia,

although it is a rare disorder in white populations. We have found this syndrome (IAS) to be associated invariably with HLA-DR4.2

responder cells (T lymphocyte fraction); S = stimulator cells(antigen-presenting cells), NT=not tested. Culture medium was RPMI1640 supplemented with 10% pooled normal AB serum. 50 000 irradiated penpheral blood mononuclear cells (antigen presenting) were Incubated with or without 40 wmol/I human insulin (I) (Novo Nordisk) or porcine glucagon (G) (Novo Nordisk) for 18 h at3TC and mixed with 50 000 enriched fraction cells from same donor. Mixed cells Incubated in 05% CO2 in a humidified air incubator for 6 days at 37*C Wells were pulsed with 1 )iC! 3H-thymidine dunng final 18 h of culture Results are mean (SD) counts/min for triplicate cultures 3H-thymidlne incorporation of S only, S + insulin, and R + insulin 554 (103), 886 (130), and 915 (252), respectively.

Our results suggested that insulin presented by HLA class II molecules coded by DRBI*0406, DQAI*0301 and/or DQB1 *0302 induces T-lymphocyte proliferation in IAS. Studies of the antigen processing and presentation and HLA-DR4-DQw8(w3) plus insulin peptide recognition of T-lymphocytes should now be possible to explain the development of autoimmunity. Diabetes Centre,

Tokyo Women’s Medical College, Tokyo 162, Japan

YASUKO UCHIGATA YASUE OMORI

Department of Transfusion Medicine and Immunohaematology, Faculty of Medicine, University of Tokyo

MIE NIEDA SHOJI KUWATA KATSUSHI TOKUNAGA TAKEO JUJI

We report here that one Chinese and two Korean patients with IAS

(and Japanese patients) possess an HLA class II genotype that allows autologous T lymphocytes to proliferate only after antigenpresenting cells are exposed to insulin. Detailed HLA typing (A, B, and C) of four additional Japanese patients with IAS are available from Y. U. Patient 29 was DR4/-, DQw3/w4; patient 30 was DQw3/w4; and patient 31 was DR4/w8, DQwl/w3; and patient 32 was DR1/4 (DQ not tested). The two Korean patients3 (one under the care of Dr H.-K. Min, Seoul) were

1. Hirata

Y, Ishizu H, Ouchi N,

et

al. Insulin

autoimmunity in

a case

of spontaneous

hypoglycemia. J Jpn Diabetes Soc 1970; 13: 312-20. 2. Uchigata Y, Kuwata S, Tokunaga K, et al. Strong association of insulin autoimmune syndrome with HLA-DR4. Lancet 1992; 339: 393-94, 3. Cho B-Y, Lee H-K, Koh C-S, Min H-K. Spontaneous hypoglycemia and insulin autoantibodies in a patient with Graves’ disease. Diabetes Res Clin Prac 1987; 3: 119-24. 4. Lee Y-J, Shin S-J, Torng J-K, Liu W-J, Tsai J-H. Insulin autoimmune syndrome m a methimzole-treated Graves’ patients with polyclonal antiinsulin autoantibodies: report of case. JFormosan Med Assoc 1987, 86: 164-70