408
Brief clinical and laboratory observations
munity in the lower respiratory tract to tuberculin and mumps and influenza viruses, J Inf Dis 128:730, 1973. 7. Ogra PL: Effect of tonsillectomy and adenoidectomy on nasopharyngeal antibody response to poliovirus, N Engl J Med 284:59, 1971. 8. Oettgen HF, Silber R, Niescher PA, and Hirschhorn K: Stimulation of human tonsillar lymphocytes in vitro, Clin Exp Immunol'l:77, 1966. 9. Schwarz MR: Response of thymus and other human lyre-
Demonstration of parasitism in tissues by electrophoretic definition of parasite enzymes in host tissues David S. Zee, M.D., and William H.
The Journal of Pediatrics March 1975
phoid tissues to phytohemagglutinin, pokeweed mitogen and genetically dissimilar lymphoid cells, Proc Soc Exp Biol Med 125:701, 1967. 10. Steele RW, Hensen SA, Vincent MM, Fuccillo DA, and Bellanti JA: A 51Cr microassay technique for cell-mediated immunity to viruses, J Immunol 110:1502, 1973. 11. Vianna N J, Greenwald P, and Davies JNP: Tonsillectomy and Hodgkin's disease: the lymphoid tissue barrier, Lancet 1:431, 1971.
how this information may be applied to the .diagnosis of parasitic diseases in man. METHODS Ascarid species were obtained from intestines and identified by the morphologic appearance of adults and ova. Methods for preparation and electrophoresis of tissue homogenates, localization of M D H isozymes in starch gel, and determination of total M D H activity were similar to those previously described, s
Zinkham, M.D.,* Baltimore, Md.
Abbreviation used MDH: malate dehydrogenase THE DETECTION of extraintestinal parasites in host tissues m a y be e x t r e m e l y difficult. In visceral larva migrans, for e x a m p l e , a h u m a n disease f r e q u e n t l y caused by canine or feline nematode larvae (Toxocara species), precise identification of larvae or larval remnants in infested tissues is sometimes impossible. ~Thus the diagnosis is based upon indirect and nonspecific clinical and serologic information. 2, 3 A variety of host and parasite enzymes may exhibit different physical and chemical properties. Extremely sensitive and also specific electrophoretic techniques are now available for identifying a large n u m b e r of enzymes in homogenates or extracts of tissues. 4 If the molecular charges of enzymes common to the host and parasite are different, then electrophoretic methodology can be utilized as a technique for demonstrating intact or partially degraded parasites in host tissues. The purpose of this r e p o r t is to d e s c r i b e the u n i q u e elect r o p h o r e t i c p r o p e r t i e s of m a l a t e d e h y d r o g e n a s e of various ascarid species and of their hosts and to indicate
From the Departments of Pediatrics and Neurology of The Johns Hopkins University School of Medicine and The Johns Hopkins Hospital. Supported by Grant No. HD-O5263from the National Institutes of Child Health and Human Development. *Reprint address: TheJohns Hopkins Hospital, Baltimore, Md. 21205.
RESULTS Fig. 1 demonstrates the electrophoretic patterns of M D H in a variety of Ascarid species. The M D H patterns of Ascaridia columbae (pigeon), Ascaridia dissimilis (turkey), and Ascaridia galli (chicken) are similar except for slight variation in mobility of the most cathodal band. Toxascaris leonina (dog and cat) has a different electrophoretic pattern. Toxocara canis (dog) and Toxocara cati (cat) exhibit identical electrophoretic patterns with most of the activity residing in the cathodal area adjacent to the origin. Although the distribution of the three supernatant isozymes (1, 2, and 3) and the one mitochondrial isozyme (4) of Ascaris suum (pig) and Ascaris lumbricoides (human) is similar, the patterns differ from the zymograms exhibited by the other ascarid species. The electrophoretic mobilities of M D H isozymes in a variety of h u m a n tissues, including liver, muscle, and kidney, differed from the types of M D H present in Ascaris and Toxocara species. Fig. 2 illustrates the electrophoretic patterns of M D H in Ascaris suum and pig liver. Homogenates of pig liver and adult Ascaris display different electrophoretic forms of MDH. Furthermore, a mixture of a 1:20,000 dilution of adult worm in pig liver homogenate still exhibts the M D H isozymes unique to the parasite. The 1:20,000 dilution of worm in pig liver homogenate rePresents ap-
Volume 86 Number 3
B r i e f clinical and laboratory observations
(~-,)
A
B
C
D
E
p
G
H
409
(-)
t
4
ORIGIN
ORIGIN 3 2 1
(+)
9
(+)
Fig. 1. Isozyme patterns of homogenates of adult ascarid species obtained from intestines of infested animals, including A, Ascaridia columbae, B, Ascaridia galli, C, Ascaridia dissimilis, D, Toxascaris leonina, E, Toxocara carl F, Toxocara canis, G, Ascaris lumbrieoides, and H, Ascaris suum. proximately 50 /xg of parasite in 1 gm of liver tissue. Assuming that the weight of the Ascaris larva is about 0.1 /zg, then this method should detect 500 larvae in 1 gm of liver. When the MDH complement of h u m a n liver was compared to that of the Ascaris and Toxocara species, distinct electrophoretic differences were defined.
Q~ro ,,%'~FWORM + LIVER- I 0 R I G I N -- . . . . . . . . .
~
DISCUSSION The diagnosis of most tissue parasitic infestations, inc l u d i n g visceral larva migrans, d e p e n d s u p o n the d e m o n s t r a t i o n and identification of m a t u r e or immature parasities in biopsy tissues. This approach, however, often fails, even when one makes an exhaustive search of tissue sections in which many eosinophilic g r a n u l o m a t o u s lesions are present. In visceral larva migrans, for example, intact larva are sometimes difficult to find, so that morphologic identification of the parasite is impossible. An alternative diagnostic approach is the utilization of a variety of serologic and skin testing procedures. Unfortunately many of these techniques lack the sensitivity and specificity necessary to establish a diagnosis?, 3 Two of the tests commonly used to define the problem of visceral larva migrans, the indirect hemagglutination and the bentonite flocculation methods, are neither very sensitive nor very specific) The observations in the present study support the f e a s i b i l i t y of u t i l i z i n g the u n i q u e e l e c t r o p h o r e t i c characteristics of host and parasite enzymes to demonstrate tissue parasitism. Each of the ascarid species displayed MDH electrophoretic patterns which differed from those of natural hosts, as well as those of the human. In addition, the sensitivity of this approach should enable one to detect the n u m b e r of parasites occurring in tissues of hosts with naturally acquired in-
~o
~oo ,~ooo 89 ooo
(FINAL DILUTION OF WORM) Fig. 2. The complement of MDH isozymes in a homogenate of pig liver containing different dilutions of a homogenate of adult Ascaris suum. One gram of liver was homogenized in 4.0 ml of water. The resulting homogenate was centrifuged at 20,000 xg for 30 minutes at 4~ and the supernatant used for electrophoresis. A similar method was used to prepare a homogehate of the adult form of Ascaris suum. The worm homogenate was added in appropriate amounts to the pig liver homogenate to give the final dilutions of the worm listed in the figure. festations. Thus etectrophoretic analyses of enzymes in tissues and possibly serum from h u m a n s with extraintestinal forms of parasitism may provide the sensitivity and specificity necessary to diagnose and also classify a variety of diseases in which parasites invade h u m a n tissues. REFERENCES
1. Beaver PC, Snyder CH, Carrera GM, Dent JH, and Lafferty JW: Chronic eosinophilia due to visceral larva migrans, Pediatrics 9:7, 1952. 2. Kagan IG, Fox HA, Walls KW, and Healy GR: The parasitic diseases of childhood with emphasis on the newer diagnostic methods, Clin Pediatr 6:641, 1967.
410
3. 4.
Brief clinical and laboratory observations
Kagan IG: Current status of serologic testing for parasitic diseases, Hosp Practice 9:157, 1974. Markert CL, and Moller F: Multiple forms o f enzymes: tissue, ontogenetic, and species specific patterns, Proc Nat Acad Sci 45:753, 1959.
Galactokinase deficiency presenting as pseudotumor cerebri Nathan Litman, M.D., Alan I. Kanter, M.D., and Laurence Finberg, M.D., Bronx, N. Y.
D I S T U R B A N C E S in galactose m e t a b o l i s m f r o m defic i e n c y o f t h e e n z y m e galactose uridyl t r a n s f e r a s e m a y c a u s e cataracts a n d liver a n d b r a i n damage. T h e m o r e recently discovered deficiency of galactokinase has b e e n t h o u g h t to b e a b e n i g n c o n d i t i o n o t h e r t h a n c a u s ing cataracts. A 2 - m o n t h - o l d f e m a l e i n f a n t p r e s e n t e d w i t h a p i c t u r e o f p s e u d o t u m o r cerebri, cataracts, a n d a u r i n a r y r e d u c i n g s u b s t a n c e . S h e was f o u n d to be defic i e n t in g a l a c t o k i n a s e a n d was fed a lactose-free form u l a w i t h i m p r o v e m e n t in t h e physical a b n o r m a l i t i e s . It a p p e a r s t h a t g a l a c t o k i n a s e - d e f i c i e n t g a l a c t o s e m i a m a y n o t b e as b e n i g n as p r e v i o u s l y s u p p o s e d . CASE REPORT Patient V. E. was admitted at 7 weeks of age for evaluation of cataracts, rapidly enlarging head circumference, and a reducing substance in the urine.* This female infant was delivered from a gravida 3, aborta 1, para 2 A1 P2 woman during the thirtY-seventh week of gestation and weighed 2.4 kg. Head circumference measured 31.2 cm. The infant was fed a standard milk formula. There was no report of jaundice, vomiting, seizures, or liver enlargement during the neonatal period. At 4 weeks of age the infant weighed 2.6 kg and the head circumference measured 34.9 cm. Re-examination 2 weeks later demonstrated a further increase in head circumference to 37.5 cm. After admission to a local hospital, a subdural tap produced no fluid and an attempted ventricular tap was unsuccessful. Cataracts were noted for the first time and urinalysis revealed 4+ reducing substance which was not glucose. The infant was transferred to the Montefiore Hospital and
From The Department of Pediatrics, Montefiore Hospital and Medieal Center of the Albert Einstein College (~f Medicine. *The patient was referred to Montefiore Hospital and Medical Center by Dr. Hans Kunz who gave permission to publish our findings.
The Journal of Pediatrics March 1975
Zee DS, and Zinkham WH: Malate dehydrogenase in Ascaris suum: characterization, ontogeny, and genetic control, Arch Biochem Biophys 126:574, 1968.
Medical Center. She weighed 3.4 kg, her length was 54 cm, and her head circumference was 38 cm. Physical findings included very prominent scalp veins, a full anterior fontanelle, 5.5 by 3.5 cm; a posterior fontanelle, 1.5 by 1.5 cm; and sagittal suture, 0.75 cm in diameter. No bruits were heard, nor did the skull transilluminate. Bilateral lenticular cataracts were noted. The remainder of the physical and neurologic examination appeared within normal limits. The urine contained reducing substance, but was negative by glucose oxidase test. Feedings were changed to a nonlactose preparation (Pregestimil), and the urine became free of reducing substance within 12 hours. There was no family history of cataracts, seizure disorders, prolonged neonatal jaundice, mental retardation, or known galactosemia. Her parents are not related, and there are no Gypsy ancestors. A 3-year-old female sibling is healthy. Additional laboratory data included a hematocrit value of 28%, reticulocytes 4.9%, white blood cell count of 8500/mm 3, platelet count of 494,000/mm 3. Chemical determinations in serum included: calcium of 9.6 mg/dl; total protein of 5.0 gin/ dl, albumin 4.0, globulin 1.0; serum glutamic pyruvic transaminase 42 KU; total serum concentration of bilirubin 0.3 mg/dl; alkaline phosphatase 3.7 BL units. No abnormal concentration of tyrosine in the urine was found. No intracranial calcifications or abnormality of the sella turcica were noted in a roentgenogram of the skull. The parents' and sibling's levels of galactose kinase in blood are in the heterozygous range (Table I). Since discharge, the infant has been fed a lactose-free diet. There has been slight regression of her cataracts. Follow-up measurements of her head circumference have demonstrated a normal rate of growth and her sagittal suture has closed. DISCUSSION V o n R e u s s 2 in 1908 was t h e first to associate t h e ing e s t i o n o f milk w i t h t h e d e v e l o p m e n t o f liver disease, faiiure to thrive, a n d galactosemia. T w e n t y - f i v e years later, F a n c o n i 3 d e s c r i b e d a p a t i e n t w i t h c a t a r a c t s a n d a c o n d i t i o n h e t e r m e d g a l a c t o s e d i a b e t e s . I n 1956, Isselbacher and co-workers 4 reported galactose-1p h o s p h a t e uridyl t r a n s f e r a s e to b e a b s e n t in m o s t patients with galactosemia. Eleven years later Gitzelm a n n s in s e a r c h i n g for a galactose k i n a s e d e f i c i e n c y s t a t e in h u m a n b e i n g s d i s c o v e r e d t h a t F a n c o n i ' s original p a t i e n t h a d s u c h a c o n d i t i o n , n o t t h e e x p e c t e d t r a n s f e r a s e deficiency. F u r t h e r e l u c i d a t i o n o f t h e clinical a b n o r m a l i t i e s of galactose m e t a b o l i s m was m a d e
Brief clinical and laboratory observations
munity in the lower respiratory tract to tuberculin and mumps and influenza viruses, J Inf Dis 128:730, 1973. 7. Ogra PL: Effect of tonsillectomy and adenoidectomy on nasopharyngeal antibody response to poliovirus, N Engl J Med 284:59, 1971. 8. Oettgen HF, Silber R, Niescher PA, and Hirschhorn K: Stimulation of human tonsillar lymphocytes in vitro, Clin Exp Immunol'l:77, 1966. 9. Schwarz MR: Response of thymus and other human lyre-
Demonstration of parasitism in tissues by electrophoretic definition of parasite enzymes in host tissues David S. Zee, M.D., and William H.
The Journal of Pediatrics March 1975
phoid tissues to phytohemagglutinin, pokeweed mitogen and genetically dissimilar lymphoid cells, Proc Soc Exp Biol Med 125:701, 1967. 10. Steele RW, Hensen SA, Vincent MM, Fuccillo DA, and Bellanti JA: A 51Cr microassay technique for cell-mediated immunity to viruses, J Immunol 110:1502, 1973. 11. Vianna N J, Greenwald P, and Davies JNP: Tonsillectomy and Hodgkin's disease: the lymphoid tissue barrier, Lancet 1:431, 1971.
how this information may be applied to the .diagnosis of parasitic diseases in man. METHODS Ascarid species were obtained from intestines and identified by the morphologic appearance of adults and ova. Methods for preparation and electrophoresis of tissue homogenates, localization of M D H isozymes in starch gel, and determination of total M D H activity were similar to those previously described, s
Zinkham, M.D.,* Baltimore, Md.
Abbreviation used MDH: malate dehydrogenase THE DETECTION of extraintestinal parasites in host tissues m a y be e x t r e m e l y difficult. In visceral larva migrans, for e x a m p l e , a h u m a n disease f r e q u e n t l y caused by canine or feline nematode larvae (Toxocara species), precise identification of larvae or larval remnants in infested tissues is sometimes impossible. ~Thus the diagnosis is based upon indirect and nonspecific clinical and serologic information. 2, 3 A variety of host and parasite enzymes may exhibit different physical and chemical properties. Extremely sensitive and also specific electrophoretic techniques are now available for identifying a large n u m b e r of enzymes in homogenates or extracts of tissues. 4 If the molecular charges of enzymes common to the host and parasite are different, then electrophoretic methodology can be utilized as a technique for demonstrating intact or partially degraded parasites in host tissues. The purpose of this r e p o r t is to d e s c r i b e the u n i q u e elect r o p h o r e t i c p r o p e r t i e s of m a l a t e d e h y d r o g e n a s e of various ascarid species and of their hosts and to indicate
From the Departments of Pediatrics and Neurology of The Johns Hopkins University School of Medicine and The Johns Hopkins Hospital. Supported by Grant No. HD-O5263from the National Institutes of Child Health and Human Development. *Reprint address: TheJohns Hopkins Hospital, Baltimore, Md. 21205.
RESULTS Fig. 1 demonstrates the electrophoretic patterns of M D H in a variety of Ascarid species. The M D H patterns of Ascaridia columbae (pigeon), Ascaridia dissimilis (turkey), and Ascaridia galli (chicken) are similar except for slight variation in mobility of the most cathodal band. Toxascaris leonina (dog and cat) has a different electrophoretic pattern. Toxocara canis (dog) and Toxocara cati (cat) exhibit identical electrophoretic patterns with most of the activity residing in the cathodal area adjacent to the origin. Although the distribution of the three supernatant isozymes (1, 2, and 3) and the one mitochondrial isozyme (4) of Ascaris suum (pig) and Ascaris lumbricoides (human) is similar, the patterns differ from the zymograms exhibited by the other ascarid species. The electrophoretic mobilities of M D H isozymes in a variety of h u m a n tissues, including liver, muscle, and kidney, differed from the types of M D H present in Ascaris and Toxocara species. Fig. 2 illustrates the electrophoretic patterns of M D H in Ascaris suum and pig liver. Homogenates of pig liver and adult Ascaris display different electrophoretic forms of MDH. Furthermore, a mixture of a 1:20,000 dilution of adult worm in pig liver homogenate still exhibts the M D H isozymes unique to the parasite. The 1:20,000 dilution of worm in pig liver homogenate rePresents ap-
Volume 86 Number 3
B r i e f clinical and laboratory observations
(~-,)
A
B
C
D
E
p
G
H
409
(-)
t
4
ORIGIN
ORIGIN 3 2 1
(+)
9
(+)
Fig. 1. Isozyme patterns of homogenates of adult ascarid species obtained from intestines of infested animals, including A, Ascaridia columbae, B, Ascaridia galli, C, Ascaridia dissimilis, D, Toxascaris leonina, E, Toxocara carl F, Toxocara canis, G, Ascaris lumbrieoides, and H, Ascaris suum. proximately 50 /xg of parasite in 1 gm of liver tissue. Assuming that the weight of the Ascaris larva is about 0.1 /zg, then this method should detect 500 larvae in 1 gm of liver. When the MDH complement of h u m a n liver was compared to that of the Ascaris and Toxocara species, distinct electrophoretic differences were defined.
Q~ro ,,%'~FWORM + LIVER- I 0 R I G I N -- . . . . . . . . .
~
DISCUSSION The diagnosis of most tissue parasitic infestations, inc l u d i n g visceral larva migrans, d e p e n d s u p o n the d e m o n s t r a t i o n and identification of m a t u r e or immature parasities in biopsy tissues. This approach, however, often fails, even when one makes an exhaustive search of tissue sections in which many eosinophilic g r a n u l o m a t o u s lesions are present. In visceral larva migrans, for example, intact larva are sometimes difficult to find, so that morphologic identification of the parasite is impossible. An alternative diagnostic approach is the utilization of a variety of serologic and skin testing procedures. Unfortunately many of these techniques lack the sensitivity and specificity necessary to establish a diagnosis?, 3 Two of the tests commonly used to define the problem of visceral larva migrans, the indirect hemagglutination and the bentonite flocculation methods, are neither very sensitive nor very specific) The observations in the present study support the f e a s i b i l i t y of u t i l i z i n g the u n i q u e e l e c t r o p h o r e t i c characteristics of host and parasite enzymes to demonstrate tissue parasitism. Each of the ascarid species displayed MDH electrophoretic patterns which differed from those of natural hosts, as well as those of the human. In addition, the sensitivity of this approach should enable one to detect the n u m b e r of parasites occurring in tissues of hosts with naturally acquired in-
~o
~oo ,~ooo 89 ooo
(FINAL DILUTION OF WORM) Fig. 2. The complement of MDH isozymes in a homogenate of pig liver containing different dilutions of a homogenate of adult Ascaris suum. One gram of liver was homogenized in 4.0 ml of water. The resulting homogenate was centrifuged at 20,000 xg for 30 minutes at 4~ and the supernatant used for electrophoresis. A similar method was used to prepare a homogehate of the adult form of Ascaris suum. The worm homogenate was added in appropriate amounts to the pig liver homogenate to give the final dilutions of the worm listed in the figure. festations. Thus etectrophoretic analyses of enzymes in tissues and possibly serum from h u m a n s with extraintestinal forms of parasitism may provide the sensitivity and specificity necessary to diagnose and also classify a variety of diseases in which parasites invade h u m a n tissues. REFERENCES
1. Beaver PC, Snyder CH, Carrera GM, Dent JH, and Lafferty JW: Chronic eosinophilia due to visceral larva migrans, Pediatrics 9:7, 1952. 2. Kagan IG, Fox HA, Walls KW, and Healy GR: The parasitic diseases of childhood with emphasis on the newer diagnostic methods, Clin Pediatr 6:641, 1967.
410
3. 4.
Brief clinical and laboratory observations
Kagan IG: Current status of serologic testing for parasitic diseases, Hosp Practice 9:157, 1974. Markert CL, and Moller F: Multiple forms o f enzymes: tissue, ontogenetic, and species specific patterns, Proc Nat Acad Sci 45:753, 1959.
Galactokinase deficiency presenting as pseudotumor cerebri Nathan Litman, M.D., Alan I. Kanter, M.D., and Laurence Finberg, M.D., Bronx, N. Y.
D I S T U R B A N C E S in galactose m e t a b o l i s m f r o m defic i e n c y o f t h e e n z y m e galactose uridyl t r a n s f e r a s e m a y c a u s e cataracts a n d liver a n d b r a i n damage. T h e m o r e recently discovered deficiency of galactokinase has b e e n t h o u g h t to b e a b e n i g n c o n d i t i o n o t h e r t h a n c a u s ing cataracts. A 2 - m o n t h - o l d f e m a l e i n f a n t p r e s e n t e d w i t h a p i c t u r e o f p s e u d o t u m o r cerebri, cataracts, a n d a u r i n a r y r e d u c i n g s u b s t a n c e . S h e was f o u n d to be defic i e n t in g a l a c t o k i n a s e a n d was fed a lactose-free form u l a w i t h i m p r o v e m e n t in t h e physical a b n o r m a l i t i e s . It a p p e a r s t h a t g a l a c t o k i n a s e - d e f i c i e n t g a l a c t o s e m i a m a y n o t b e as b e n i g n as p r e v i o u s l y s u p p o s e d . CASE REPORT Patient V. E. was admitted at 7 weeks of age for evaluation of cataracts, rapidly enlarging head circumference, and a reducing substance in the urine.* This female infant was delivered from a gravida 3, aborta 1, para 2 A1 P2 woman during the thirtY-seventh week of gestation and weighed 2.4 kg. Head circumference measured 31.2 cm. The infant was fed a standard milk formula. There was no report of jaundice, vomiting, seizures, or liver enlargement during the neonatal period. At 4 weeks of age the infant weighed 2.6 kg and the head circumference measured 34.9 cm. Re-examination 2 weeks later demonstrated a further increase in head circumference to 37.5 cm. After admission to a local hospital, a subdural tap produced no fluid and an attempted ventricular tap was unsuccessful. Cataracts were noted for the first time and urinalysis revealed 4+ reducing substance which was not glucose. The infant was transferred to the Montefiore Hospital and
From The Department of Pediatrics, Montefiore Hospital and Medieal Center of the Albert Einstein College (~f Medicine. *The patient was referred to Montefiore Hospital and Medical Center by Dr. Hans Kunz who gave permission to publish our findings.
The Journal of Pediatrics March 1975
Zee DS, and Zinkham WH: Malate dehydrogenase in Ascaris suum: characterization, ontogeny, and genetic control, Arch Biochem Biophys 126:574, 1968.
Medical Center. She weighed 3.4 kg, her length was 54 cm, and her head circumference was 38 cm. Physical findings included very prominent scalp veins, a full anterior fontanelle, 5.5 by 3.5 cm; a posterior fontanelle, 1.5 by 1.5 cm; and sagittal suture, 0.75 cm in diameter. No bruits were heard, nor did the skull transilluminate. Bilateral lenticular cataracts were noted. The remainder of the physical and neurologic examination appeared within normal limits. The urine contained reducing substance, but was negative by glucose oxidase test. Feedings were changed to a nonlactose preparation (Pregestimil), and the urine became free of reducing substance within 12 hours. There was no family history of cataracts, seizure disorders, prolonged neonatal jaundice, mental retardation, or known galactosemia. Her parents are not related, and there are no Gypsy ancestors. A 3-year-old female sibling is healthy. Additional laboratory data included a hematocrit value of 28%, reticulocytes 4.9%, white blood cell count of 8500/mm 3, platelet count of 494,000/mm 3. Chemical determinations in serum included: calcium of 9.6 mg/dl; total protein of 5.0 gin/ dl, albumin 4.0, globulin 1.0; serum glutamic pyruvic transaminase 42 KU; total serum concentration of bilirubin 0.3 mg/dl; alkaline phosphatase 3.7 BL units. No abnormal concentration of tyrosine in the urine was found. No intracranial calcifications or abnormality of the sella turcica were noted in a roentgenogram of the skull. The parents' and sibling's levels of galactose kinase in blood are in the heterozygous range (Table I). Since discharge, the infant has been fed a lactose-free diet. There has been slight regression of her cataracts. Follow-up measurements of her head circumference have demonstrated a normal rate of growth and her sagittal suture has closed. DISCUSSION V o n R e u s s 2 in 1908 was t h e first to associate t h e ing e s t i o n o f milk w i t h t h e d e v e l o p m e n t o f liver disease, faiiure to thrive, a n d galactosemia. T w e n t y - f i v e years later, F a n c o n i 3 d e s c r i b e d a p a t i e n t w i t h c a t a r a c t s a n d a c o n d i t i o n h e t e r m e d g a l a c t o s e d i a b e t e s . I n 1956, Isselbacher and co-workers 4 reported galactose-1p h o s p h a t e uridyl t r a n s f e r a s e to b e a b s e n t in m o s t patients with galactosemia. Eleven years later Gitzelm a n n s in s e a r c h i n g for a galactose k i n a s e d e f i c i e n c y s t a t e in h u m a n b e i n g s d i s c o v e r e d t h a t F a n c o n i ' s original p a t i e n t h a d s u c h a c o n d i t i o n , n o t t h e e x p e c t e d t r a n s f e r a s e deficiency. F u r t h e r e l u c i d a t i o n o f t h e clinical a b n o r m a l i t i e s of galactose m e t a b o l i s m was m a d e
