334 This case suggests that increased urinary prostaglandin excretion is not specific to Bartter’s syndrome but may appear in other clinical situations where the biological disturbances are similar. H. NIVET B. GRENIER de Pédiatrie Service B, J. C. ROLLAND Hôpital G. de Clocheville, 37000 Tours, France Y. LEBRANCHU INSERM FRA no. 8. URIA, Institut Pasteur, Paris
TABLE I-BACTERIA
ISOLATED FROM SPUTUM AT THE BEGINNING
(B) AND END (E) OF CYSTIC FIBROSIS
F. DRAY
BACTERIAL CONTENT AND IONIC COMPOSITION OF SPUTUM IN CYSTIC FIBROSIS
SIR,—Burns and May’ proposed the following pattern for the bacteriology of cystic fibrosis: Stage 1.—Staphylococcus aureus is the initial bacterial pathogen, and damage caused by it renders the lungs susceptible to infection by other species. Stage 2.-Control of S. aureus by antibiotics allows the influx of Hœmophilus influenzœ. Stage 3.-Pseudomonas ceruginosa is introduced and continued chemotherapy encourages its establishment. Stage 4.-P. œruginosa supplants S. aureus and H. influenza, becoming the sole pathogen.
suggested that patients are abnormally susrespiratory pathogen from birth.2 I have examined these ideas by quantitative culture3 of sputum from 20 patients seen at the Cystic Fibrosis Treatment and Research Center, University of Oregon Health Sciences Center from 1965 to 1977. The results accord with the original hypothesis of Burns and May.4,5 A current summary of the sputum bacterial flora of these patients is shown in table I. In 13 of the 20 patients the sputum bacterial flora changed as the hypothesis of Burns and May predicted. In 4 patients the sputum bacterial flora did not change, neither supporting nor refuting the hypothesis. In 2 patients the flora changed from S. aureus alone to S. aureus and a gram negative bacillus which was not P. ceruginosa. The change in 1 patient was contrary to the hypothesis, from S. aureus and P. ceruginosa to S. aureus alone at the time of death. In total, the changes in only 3 of 20 patients contradicted the hypothesis of Burns and May. Whether the consistency of the sputum in cystic fibrosis can be explained by its ionic composition is disputed.6-9 None of May
ceptible
et al. then to any
1. Burns, M. W., May, J. R. Lancet, 1958, i, 270. 2. May, J. R., Herrick, N. C., Thompson, D. Archs Dis. Childh. 1972, 47, 908. 3. Kilbourn, J. P., Campbell, R. A., Grach, J. L., Willis, M. D. Am. Rev. resp. Dis. 1968, 98, 810. 4. Kilbourn, J. P. Lancet, 1970, ii, 878. 5. Kilbourn, J. P. ibid. 1974, i, 405. 6. Matthews, L. W., Spector, S., Lemm, J., Potter, J. L. Am. Rev. resp. Dis.
1963, 88, 199. Potter, J. L., Matthews, L. W., Spector, S., Lemm, J. ibid. 1967, 96, 83. Potter, J. L., Matthews, L. W., Lemm, J., Spector, S. Ann. New York Acad. Sci. 1963, 106, 692. 9. Chernick, W. S., Barbero, G. J. Pediatrics, 1959, 24, 739. 7. 8.
* E. coli replaced P. ceruginosa. Abbreviations in parentheses represent additional potential respiratory pathogens isolated in significant numbers from the last sputum culture obtained before the patient died. c.A.=Candida albicans; E.c.=Escherichia coli;
H.I.=Hœmophilus influenzœ, S.P.=Streptococcus pneumoniœ; P.nt.=Proteus mirabilis.
these studies described the bacterial flora as well as the sputum ionic composition. Preliminary data (table II) shows a correlation between the ionic composition (Ca++, Na+, K+, and Cl-) and the categories of sputum bacterial flora suggested by Burns and May: (S. aureus; S. aureus/P. ceruginosa; P. ceruginosa). As in earlier work, Na+ and Cl- were approximately equal in concentration; the concentration of K+ was 1/2-1/3 that of Na+; and the concentration of Ca+’ was 1/40-1/200 that of Na+. In addition the concentration of Ca++ (0.00185 mmol/ml) in the sputum with S. aureus alone is twice that in sputum with P. œruginosa/S. aureus (0.0008 mmol/ml) or P. ceruginosa alone (0.00055 mmol/ml).. This preliminary data suggests that one of the primary sputum abnormalities in cystic fibrosis may be increased Ca++ which makes the sputum susceptible to colonisation by S. aureus. After infection the Ca++ concentration is reduced and the lung becomes susceptible to colonisation by other microorganisms including H. influenzae, P. aruginosa, and Escherichia coli. 3178 S. W. Fairmount Boulevard, Portland, Oregon 97201, U.S.A.
TABLE 11-BACTERIAL AND IONIC COMPOSITION OF SPUTUM FROM CYSTIC FIBROSIS PATIENTS
s.A.=Staphylococcus aureus.
E.c.=Escherichia coli.
A.s.==Atpha4taemolytic Streptococcus
H.i.=Hamophilus influenzœ. P.A.=Pseudomonas ceruginosa.
N.B.=Neisseria sp. and/or Branhemella sp.
J. P. KILBOURN
TABLE I-BACTERIA
ISOLATED FROM SPUTUM AT THE BEGINNING
(B) AND END (E) OF CYSTIC FIBROSIS
F. DRAY
BACTERIAL CONTENT AND IONIC COMPOSITION OF SPUTUM IN CYSTIC FIBROSIS
SIR,—Burns and May’ proposed the following pattern for the bacteriology of cystic fibrosis: Stage 1.—Staphylococcus aureus is the initial bacterial pathogen, and damage caused by it renders the lungs susceptible to infection by other species. Stage 2.-Control of S. aureus by antibiotics allows the influx of Hœmophilus influenzœ. Stage 3.-Pseudomonas ceruginosa is introduced and continued chemotherapy encourages its establishment. Stage 4.-P. œruginosa supplants S. aureus and H. influenza, becoming the sole pathogen.
suggested that patients are abnormally susrespiratory pathogen from birth.2 I have examined these ideas by quantitative culture3 of sputum from 20 patients seen at the Cystic Fibrosis Treatment and Research Center, University of Oregon Health Sciences Center from 1965 to 1977. The results accord with the original hypothesis of Burns and May.4,5 A current summary of the sputum bacterial flora of these patients is shown in table I. In 13 of the 20 patients the sputum bacterial flora changed as the hypothesis of Burns and May predicted. In 4 patients the sputum bacterial flora did not change, neither supporting nor refuting the hypothesis. In 2 patients the flora changed from S. aureus alone to S. aureus and a gram negative bacillus which was not P. ceruginosa. The change in 1 patient was contrary to the hypothesis, from S. aureus and P. ceruginosa to S. aureus alone at the time of death. In total, the changes in only 3 of 20 patients contradicted the hypothesis of Burns and May. Whether the consistency of the sputum in cystic fibrosis can be explained by its ionic composition is disputed.6-9 None of May
ceptible
et al. then to any
1. Burns, M. W., May, J. R. Lancet, 1958, i, 270. 2. May, J. R., Herrick, N. C., Thompson, D. Archs Dis. Childh. 1972, 47, 908. 3. Kilbourn, J. P., Campbell, R. A., Grach, J. L., Willis, M. D. Am. Rev. resp. Dis. 1968, 98, 810. 4. Kilbourn, J. P. Lancet, 1970, ii, 878. 5. Kilbourn, J. P. ibid. 1974, i, 405. 6. Matthews, L. W., Spector, S., Lemm, J., Potter, J. L. Am. Rev. resp. Dis.
1963, 88, 199. Potter, J. L., Matthews, L. W., Spector, S., Lemm, J. ibid. 1967, 96, 83. Potter, J. L., Matthews, L. W., Lemm, J., Spector, S. Ann. New York Acad. Sci. 1963, 106, 692. 9. Chernick, W. S., Barbero, G. J. Pediatrics, 1959, 24, 739. 7. 8.
* E. coli replaced P. ceruginosa. Abbreviations in parentheses represent additional potential respiratory pathogens isolated in significant numbers from the last sputum culture obtained before the patient died. c.A.=Candida albicans; E.c.=Escherichia coli;
H.I.=Hœmophilus influenzœ, S.P.=Streptococcus pneumoniœ; P.nt.=Proteus mirabilis.
these studies described the bacterial flora as well as the sputum ionic composition. Preliminary data (table II) shows a correlation between the ionic composition (Ca++, Na+, K+, and Cl-) and the categories of sputum bacterial flora suggested by Burns and May: (S. aureus; S. aureus/P. ceruginosa; P. ceruginosa). As in earlier work, Na+ and Cl- were approximately equal in concentration; the concentration of K+ was 1/2-1/3 that of Na+; and the concentration of Ca+’ was 1/40-1/200 that of Na+. In addition the concentration of Ca++ (0.00185 mmol/ml) in the sputum with S. aureus alone is twice that in sputum with P. œruginosa/S. aureus (0.0008 mmol/ml) or P. ceruginosa alone (0.00055 mmol/ml).. This preliminary data suggests that one of the primary sputum abnormalities in cystic fibrosis may be increased Ca++ which makes the sputum susceptible to colonisation by S. aureus. After infection the Ca++ concentration is reduced and the lung becomes susceptible to colonisation by other microorganisms including H. influenzae, P. aruginosa, and Escherichia coli. 3178 S. W. Fairmount Boulevard, Portland, Oregon 97201, U.S.A.
TABLE 11-BACTERIAL AND IONIC COMPOSITION OF SPUTUM FROM CYSTIC FIBROSIS PATIENTS
s.A.=Staphylococcus aureus.
E.c.=Escherichia coli.
A.s.==Atpha4taemolytic Streptococcus
H.i.=Hamophilus influenzœ. P.A.=Pseudomonas ceruginosa.
N.B.=Neisseria sp. and/or Branhemella sp.
J. P. KILBOURN
