373
she was taking 10 times the recommended dose. When she stopped taking senna aminotransferases fell by 70% within a week and ranged from 20 to 40 U/l subsequently. When she took senna alkaloids again 2 months later liver function rapidly deteriorated (ALT >280 U II); she improved once more when the drug was again stopped.2 She has not been taking laxatives for 10 months and her liver tests are normal. Sennosides, the major substrates of senna leaf and fruit, are split to rhein anthron in the intestine by Escherichia coli and other intestinal bacteria. Rhein anthron can be absorbed by the mucosa, glucuronidated or sulphated, and excreted via urine and faeces.3 Rhein anthron is structurally similar to danthron (figure), a well-known hepatotoxic laxative.’ Moreover, anthraquinones in rhubarb, a major function of which is rhein anthron, have been incriminated in liver disease The worldwide use (and abuse) of senna alkaloids and lack of reports on hepatotoxicity prompt us to speculate that the hepatitis in our patient was due to a "nonpredictable type II reaction"6 in an
unusually susceptible person. Department of Medicine II, Klinikum Grosshadern, University of Munich, 8000 Munich 70, Germany
ULRICH BEUERS ULRICH SPENGLER GERD R. PAPE
HJ, Maddrey WC Toxic and drug-induced hepatitis In: Schiff L, Schiff ER, eds Diseases of the liver Philadelphia Lippincott, 1987 591-667 Consensus. Criteria of drug-induced liver disorders. J Hepatol 1990, 11: 272-76
1 Zimmerman 2
3 4
Steinegger E, Hansel R Lehrbuch der Pharmakognosie und Phytopharmazie Berlin: Springer, 1988 413-39. Tolman KG, Hammar S, Sannella JJ. Possible hepatotoxicity of Doxidan Ann Intern
Med 1976; 84: 290-92. 5 Streicher E Akutes Nierenversagen und Ikterus nach einer Vergiftung mit Rhabarberblattern Dtsch Med Wschr 1964, 89: 2379-81 6 Popper H, Rubin E, Gardiol D, Schaffner F, Paronetto F Drug-induced liver disease: a penalty for progress Arch Intern Med 1965, 115: 128-36
Cytomegalovirus encephalitis and ganciclovir SIR,-Dr Power and colleagues (Nov 24, p 1282) suggest a pathogenic function for cytomegalovirus (CMV) in Rasmussen’s encephalitis and possible antiviral treatment. We describe a case that supports this view. In January, 1989, a previously healthy 10-month-old girl was admitted with status epilepticus and fever (385°C). She was given intravenous phenobarbitone (20 mg/kg, followed by 5 mg/kg per day). After this treatment, complex partial seizures of the left side of the body ensued, which progressed to generalised tonic-clonic seizures and persisted for ten days. Electroencephalography (EEG) revealed slow background activity, generalised spike-and-wave discharges lasting 30-40 s, and sharp waves and spikes in the right centromidtemporal regions. Cerebrospinal fluid examination and computed tomography were normal. Serum was IgM positive for CMV with a complement fixing titre of 64, CMV was cultured from urine. The patient was discharged on phenobarbitone (5 mg/kg per day). In July,
1989, the child had several episodes of generalised convulsions; valproic acid (22 mg/kg per day) was added. CMV culture and serological tests were negative, and the complement fixation titre was 128. Cerebral magnetic resonance imaging showed, in T2 weighted images, small hyperintense areas in the perivascular occipital regions. The patient remained well up to November, 1990, when she had numerous episodes of generalised
tonic-clonic convulsions combined with left-sided complex partial seizures. EEG showed generalised spike-and-wave discharges and isolated spikes in the right leads. Seizures persisted despite intravenous phenobarbital. Serum ionised calcium was low (0-32 mmol/1, normal range 0’9-1’15). CMV class-specific (IgG, IgA, IgM) antibodies were not detected/ but after four days typical CMV cytopathic effects were found. Immunological studies showed a decrease in total lymphocytes, and three days after recurrence of seizures ganciclovir was given (15 mg/kg per day). Seizure control was immediately achieved. Subsequently, valproic acid was tapered and EEG progressively returned to normal. Daily ganciclovir was continued for three weeks and then weekly for one month. Repeated CMV cultures were negative, while specific IgG and IgA became positive. This case supports a pathogenic role for CMV,z associated with alterations in neuronal calcium metabolism,3as the cause for epileptic discharges. The therapeutic efficacy of ganciclovir sustains this hypothesis. We thank Dr A. Torre for viral cultures and Dr S. Mattia for
serological
tests.
Paediatric Department, "La Sapienza" University, Rome, Italy 1.
2 3
PAULO IANNETTI GIOVANNI NIGRO CARLO IMPERATO
Nigro G, Mattia S, Midulla M. Simultaneous detection of specific serum IgM and IgA antibodies for rapid serodiagnosis of congenital or acquired cytomegalovirus infection Serodiagn Immunother Infect Dis 1989; 3: 355-61. Iannetti P, Balducci L, Busmco L, Midulla M. Herpetic encephalitis with associated cytomegalovirus infection and myoclonus Lancet 1977; ii. 1227. Seisjo BB, Weiloch T Epileptic brain damage pathophysiology and neurochemical pathology Adv Neurol 1986, 44: 813-47
Skin test for HPV type 16
proteins in cervical intraepithelial neoplasia
SiR,—Screening tests for active and latent high-risk human virus (HPV) infections are not reliable. Classic intracutaneous (ic) tests with viral fusion proteins have not yet been used to detect HPV; such tests might help to determine cellmediated immune responses’ in vivo against viral proteins and thus elucidate the epidemiology and course of HPV infection. The HPV16open-reading frames E4 and L1(N-terminal part, Ll/1/2; C-terminal part, L1/232) were cloned into pEX vectors, expressed in Escherichia coli C600/537 as MS2-polymerase fusion proteins, prepared by extraction with 7 mol/1 urea and purified by gel extraction. Protein solutions (protein content about 300 Ilgjml) were sterilised and stored in aliquots. Control proteins were identically prepared from extracts of bacteria containing the pEX expression vector without viral insert. Skin tests were done in volunteers, with local ethics committee approval. The test procedure included ic injection of 0-03 ml of each protein solution as well as injections of control solutions and testing of recall antigens (Merieux ’Multitest’). The tests were done in seven women with cervical intraepithelial neoplasias (CIN) for at least 1 year and positive filter hybridisation for HPV 16/18; one patient was also HPV 16 positive by polymerase chain reaction (PCR), but negative for HPV/6/11/31/33/35 (’ViraType’, GIBCO/BRL). Ten controls (four male physicians and six women) with no history of and no clinical evidence for genitoanal warts were also tested. The female controls had no cervical cytological abnormality, had negative hybridisaton tests for all HPV types, and were negative for HPV 16 by PCR. Biopsy samples of positive skin-test sites were taken on days 2, 3, 7, and 8 and examined by routine histopathology, immunocytochemistry, and immunofluorescence. Blood samples were obtained from volunteers immediately before injection.
papilloma
In all individuals the multitest results were normal. None of the controls reacted to HPV fusion proteins. In contrast, five of seven patients with CIN had clearly positive reactions to L1/23/2 (p = 0-0034, Fisher’s exact test, two-tailed probability). Three of these and one other reacted to Ll/1/2 (p = 0-0147), one patient reacted to neither protein fragment. No reactivity to E4 or the control proteins was seen. 5 of 9 positive reactions had a biphasic course with an early as well as a late response. Early response (skin-coloured vheals of up to 5 mm diameter) arose 24 h after
she was taking 10 times the recommended dose. When she stopped taking senna aminotransferases fell by 70% within a week and ranged from 20 to 40 U/l subsequently. When she took senna alkaloids again 2 months later liver function rapidly deteriorated (ALT >280 U II); she improved once more when the drug was again stopped.2 She has not been taking laxatives for 10 months and her liver tests are normal. Sennosides, the major substrates of senna leaf and fruit, are split to rhein anthron in the intestine by Escherichia coli and other intestinal bacteria. Rhein anthron can be absorbed by the mucosa, glucuronidated or sulphated, and excreted via urine and faeces.3 Rhein anthron is structurally similar to danthron (figure), a well-known hepatotoxic laxative.’ Moreover, anthraquinones in rhubarb, a major function of which is rhein anthron, have been incriminated in liver disease The worldwide use (and abuse) of senna alkaloids and lack of reports on hepatotoxicity prompt us to speculate that the hepatitis in our patient was due to a "nonpredictable type II reaction"6 in an
unusually susceptible person. Department of Medicine II, Klinikum Grosshadern, University of Munich, 8000 Munich 70, Germany
ULRICH BEUERS ULRICH SPENGLER GERD R. PAPE
HJ, Maddrey WC Toxic and drug-induced hepatitis In: Schiff L, Schiff ER, eds Diseases of the liver Philadelphia Lippincott, 1987 591-667 Consensus. Criteria of drug-induced liver disorders. J Hepatol 1990, 11: 272-76
1 Zimmerman 2
3 4
Steinegger E, Hansel R Lehrbuch der Pharmakognosie und Phytopharmazie Berlin: Springer, 1988 413-39. Tolman KG, Hammar S, Sannella JJ. Possible hepatotoxicity of Doxidan Ann Intern
Med 1976; 84: 290-92. 5 Streicher E Akutes Nierenversagen und Ikterus nach einer Vergiftung mit Rhabarberblattern Dtsch Med Wschr 1964, 89: 2379-81 6 Popper H, Rubin E, Gardiol D, Schaffner F, Paronetto F Drug-induced liver disease: a penalty for progress Arch Intern Med 1965, 115: 128-36
Cytomegalovirus encephalitis and ganciclovir SIR,-Dr Power and colleagues (Nov 24, p 1282) suggest a pathogenic function for cytomegalovirus (CMV) in Rasmussen’s encephalitis and possible antiviral treatment. We describe a case that supports this view. In January, 1989, a previously healthy 10-month-old girl was admitted with status epilepticus and fever (385°C). She was given intravenous phenobarbitone (20 mg/kg, followed by 5 mg/kg per day). After this treatment, complex partial seizures of the left side of the body ensued, which progressed to generalised tonic-clonic seizures and persisted for ten days. Electroencephalography (EEG) revealed slow background activity, generalised spike-and-wave discharges lasting 30-40 s, and sharp waves and spikes in the right centromidtemporal regions. Cerebrospinal fluid examination and computed tomography were normal. Serum was IgM positive for CMV with a complement fixing titre of 64, CMV was cultured from urine. The patient was discharged on phenobarbitone (5 mg/kg per day). In July,
1989, the child had several episodes of generalised convulsions; valproic acid (22 mg/kg per day) was added. CMV culture and serological tests were negative, and the complement fixation titre was 128. Cerebral magnetic resonance imaging showed, in T2 weighted images, small hyperintense areas in the perivascular occipital regions. The patient remained well up to November, 1990, when she had numerous episodes of generalised
tonic-clonic convulsions combined with left-sided complex partial seizures. EEG showed generalised spike-and-wave discharges and isolated spikes in the right leads. Seizures persisted despite intravenous phenobarbital. Serum ionised calcium was low (0-32 mmol/1, normal range 0’9-1’15). CMV class-specific (IgG, IgA, IgM) antibodies were not detected/ but after four days typical CMV cytopathic effects were found. Immunological studies showed a decrease in total lymphocytes, and three days after recurrence of seizures ganciclovir was given (15 mg/kg per day). Seizure control was immediately achieved. Subsequently, valproic acid was tapered and EEG progressively returned to normal. Daily ganciclovir was continued for three weeks and then weekly for one month. Repeated CMV cultures were negative, while specific IgG and IgA became positive. This case supports a pathogenic role for CMV,z associated with alterations in neuronal calcium metabolism,3as the cause for epileptic discharges. The therapeutic efficacy of ganciclovir sustains this hypothesis. We thank Dr A. Torre for viral cultures and Dr S. Mattia for
serological
tests.
Paediatric Department, "La Sapienza" University, Rome, Italy 1.
2 3
PAULO IANNETTI GIOVANNI NIGRO CARLO IMPERATO
Nigro G, Mattia S, Midulla M. Simultaneous detection of specific serum IgM and IgA antibodies for rapid serodiagnosis of congenital or acquired cytomegalovirus infection Serodiagn Immunother Infect Dis 1989; 3: 355-61. Iannetti P, Balducci L, Busmco L, Midulla M. Herpetic encephalitis with associated cytomegalovirus infection and myoclonus Lancet 1977; ii. 1227. Seisjo BB, Weiloch T Epileptic brain damage pathophysiology and neurochemical pathology Adv Neurol 1986, 44: 813-47
Skin test for HPV type 16
proteins in cervical intraepithelial neoplasia
SiR,—Screening tests for active and latent high-risk human virus (HPV) infections are not reliable. Classic intracutaneous (ic) tests with viral fusion proteins have not yet been used to detect HPV; such tests might help to determine cellmediated immune responses’ in vivo against viral proteins and thus elucidate the epidemiology and course of HPV infection. The HPV16open-reading frames E4 and L1(N-terminal part, Ll/1/2; C-terminal part, L1/232) were cloned into pEX vectors, expressed in Escherichia coli C600/537 as MS2-polymerase fusion proteins, prepared by extraction with 7 mol/1 urea and purified by gel extraction. Protein solutions (protein content about 300 Ilgjml) were sterilised and stored in aliquots. Control proteins were identically prepared from extracts of bacteria containing the pEX expression vector without viral insert. Skin tests were done in volunteers, with local ethics committee approval. The test procedure included ic injection of 0-03 ml of each protein solution as well as injections of control solutions and testing of recall antigens (Merieux ’Multitest’). The tests were done in seven women with cervical intraepithelial neoplasias (CIN) for at least 1 year and positive filter hybridisation for HPV 16/18; one patient was also HPV 16 positive by polymerase chain reaction (PCR), but negative for HPV/6/11/31/33/35 (’ViraType’, GIBCO/BRL). Ten controls (four male physicians and six women) with no history of and no clinical evidence for genitoanal warts were also tested. The female controls had no cervical cytological abnormality, had negative hybridisaton tests for all HPV types, and were negative for HPV 16 by PCR. Biopsy samples of positive skin-test sites were taken on days 2, 3, 7, and 8 and examined by routine histopathology, immunocytochemistry, and immunofluorescence. Blood samples were obtained from volunteers immediately before injection.
papilloma
In all individuals the multitest results were normal. None of the controls reacted to HPV fusion proteins. In contrast, five of seven patients with CIN had clearly positive reactions to L1/23/2 (p = 0-0034, Fisher’s exact test, two-tailed probability). Three of these and one other reacted to Ll/1/2 (p = 0-0147), one patient reacted to neither protein fragment. No reactivity to E4 or the control proteins was seen. 5 of 9 positive reactions had a biphasic course with an early as well as a late response. Early response (skin-coloured vheals of up to 5 mm diameter) arose 24 h after
