1105 We have studied all children referred to Bristol hospitals during an M. pneumonia epidemic lasting 18 months. 9 (20%) out of 44 children with serologically proven M. pneumoniae infection had rashes. 6 children had an erythematous macular rash on the trunk and limbs, and this was usually fading at the time of referral. In 1 of the 6 Stevens-Johnson syndrome developed and there were 3 additional cases of the syndrome. In 3 of the 4 cold agglutinins were sought and all 3 were positive. These findings do not clarify the role of cold agglutinins in the pathogenesis of mycoplasma-associated mucocutaneous reactions. 1 of the children with Stevens-Johnson syndrome, a girl of 11 years, had extensive toxic epidermal necrolysis with typical "scalded skin" erythema, blistering, and epidermal stripping. This rare complication caused significant fluid depletion, but the skin healed within 14 days with no further major problem. The conjunctival ulceration, however, caused healing and fibrosis of such intensity that severe conjunctival shrinkage syndrome, corneal scarring, and visual impairment ensued. 1 case of Stevens-Johnson syndrome was not associated with lower-respiratory-tract infection, which supports Lind’s view that M. pneumonia infection can cause rashes without clinical evidence of respiratory disease.
Cherry et al.2 found no published cases of Stevens-Johnson syndrome associated with M. pneumoniae in girls; 2 of our cases were
females.
Although patients with Stevens-Johnson syndrome usually recover fully we recommend that, in view of the possibility of permanent eye damage, all children with the syndrome should be referred to an ophthalmologist. Royal Devon and
Exeter
Hospital,
Exeter EX2 5DW
Gloucestershire Royal Gloucester GL1 3NN
MEASUREMENT OF LACTOFERRIN IN PANCREATIC JUICE described a protein in pancreatic juice of calcifying pancreatitis;’ this was later identified as lactoferrin,2 a glycoprotein mainly secreted by mammary glands and found in various external secretions.3 Indirect
SIR,-In 1971
men
we
with chronic
immunofluorescence studies revealed lactoferrin in acinar cells of normal pancreatic tissue and in acinar cells of men with chronic calcifying pancreatitis.4 However, the fluorescence was more striking in pathological material. Dr Fedail and colleagues (Jan.. 28, p. 181) have confirmed that lactoferrin secretion is increased in pancreatic juice of patients with chronic
pancreatitis. Since lactoferrin secretion is not increased in pancreatic in acute pancreatitis,s a practical and accurate assay for lactoferrin in pancreatic juice might be a useful diagnostic test. We have compared a double-diffusion technique with a cancer or
radioimmunoassay. The radioimmunoassay was done with pure human lactoferrin (kindly given by Dr P. Masson) labelled with 125by the chloramine-T method. Separation of bound and free lactoferrin was achieved by a double-antibody technique. The sensitivity of the assay was 1 ng/ml. The antilactoferrin prepared in the laboratory was used after a dilution of 1/50 000. ’Immunoplates LC’ (low-concentration) ’Partigen’ lactoferrin and pure standard lactoferrin (titrating 4 mg/dl) were kindly prepared by Dr Baudner (Behring Institute,. Marburg).
1.
PETER G. F. SWIFT
Hospital, DAVID W. STEVENS
Clemente, F., Ribeiro, T., Colomb, E., Figarella, C., Sarles, H. Biochim. biophys. Acta, 1971, 251, 456. 2. Colomb, E., Estevenon, J. P., Figarella, C., Guy, O., Sarles, H. ibid. 1974, 342, 306. 3. Masson, P. La lactoferrine. Paris, 1970. 4. Colomb, E., Pianetta, C., Estevenon, J. P., Guy, O., Figarella, C., Sarles, H. Digestion, 1976, 14, 242. 5. Estevenon, J. P., Sarles, H., Figarella, C. Scand. J. Gastroent. 1975, 10, 327.
SERRATIA MARCESCENS COLONISING THE GUT
SIR,-During an outbreak of hospital cross-infections by multiply resistant Serratia marcescens this organism was occasionally recovered from stools as well as from the site of clinical infection. The spread of Klebsiella pneumoniae from a gastrointestinal-tract reservoir to extraintestinal sites is well documented,’ but S. marcescens does not usually colonise the gut of adults.2 We extended our observation by taking rectal swabs from patients admitted during the outbreak; the swab was streaked on selective media and the plate was inspected caused
after 24 and 48 h incubation at 37°C; the isolates were identified and antibiotic susceptibilities were determined by standard methods. 120 rectal cultures were obtained from 57 patients. The stools of 5 patients were colonised with multiply resistant S. marcescens. 2 patients were colonised or infected at extraintestinal sites at the time the first stool culture was obtained; the other 3 patients later became colonised or infected at extraintestinal sites. As with K. pneumonice, gastrointestinal colonisation by S. marcescens may, by serving as a reservoir for cross-infection, be an important step in the development of hospital-acquired infection. Infectious Disease Section, Department of Medicine, Veterans Administration Hospital, University of Oregon Health Science Center, Portland, Oregon 97207, U.S.A.
STEPHEN R. JONES MERIDITH AMON CATHERINE FALVEY KATHRYN PATRICK
Comparative 1.
Stevens, D, Swift, P. G. F., Johnston, P. G. B., Kearney, P. J., Corner, B. D., Burman, D. Archs Dis. Childh. 1978, 53, 38. 2 Cherry, J. D., Hurwitz, E. S., Welliver, R. C. J. Pediat. 1975, 87, 369. 1. Selden, R., and others Ann. intern. Med. 1971, 74, 6737. 2. Farmer, J. J, and others Lancet, 1976, ii, 455.
measurement of lactoferrin.
Radioimmunoassay (e);
assay
by
radial immunodiffusion
(0).
Abs-
cissa ; pancreatic juice from patients with chronic pancreatitis (1-6) and controls values.
(7-12).
The dotted line represents the limit of normal
1106 The two samples of lactoferrin (Dr Masson and Dr Baudner) were immunologically identical on testing by doublediffusion technique, and the precipitating lines between each immune serum and each lactoferrin fused completely. The immunoplates contained twelve wells. Three were filled with 2 x 20 A of standard lactoferrin diluted 1/2 (20 g/ml), 1/4, and 1/6. The other wells contained 2 x 20 .1 of the different pancreatic juices, concentrated by lyophilisation or alcoholic precipitation. The protein content (measured by optical density at 280 nm with an extinction coefficient of Efïfi 20) ranged from 9 to 47 mg/ml juice. The plates were allowed to diffuse 48 h at 20 °C and then washed with isotonic saline for 3 days. The plates were stained for 1 min in 0-1% amidoschwarz (Merck) and then destained in 10% acetic acid. A standard curve was constructed by plotting the square of the diameter of the rings of precipitation against the lactoferrin concentration, and lactoferrin concentrations of samples of pancreatic juice were read off from this standard curve. By this method it is possible to visualise a lactoferrin concentration of about 2 Lg/ml to 25 fLg/ml. These results are shown in the figure, expressed as a percentage of total protein. The data obtained by radial immunodiffusion and those given by radioimmunoassay were in good agreement. The two assays confirm the increased lactoferrin concentration in juice from men with chronic pancreatitis. In six normal juices the range is from 0.002 to 0-02% with a mean of 0.013%, and in six juices from men with chronic calcifying pancreatitis from 0.033 to 0.92% with a mean of 0-23%. The assay of lactoferrin on immunoplates may be as accurate as radioimmunoassay, and can be easily set up in the
The crucial question is-how do the minor hazards of interrupting whole-body irradiation compare with anaesthetic complications in a patient who will often already have received considerable cytotoxic chemotherapy? Cape Town Leukæmia Centre and Departments of Hæmatology and Radiotherapy,
PETER JACOBS HELEN S. KING
Groote Schuur Hospital, Observatory, Cape Town, South Africa
=
laboratory. Unité de Recherches de
Pathologie Digestive
(INSERM U31),
C. FIGARELLA
TRIMETHYLAMINE METABOLISM IN LIVER DISEASE
SiR,—Trimethylamine (T.M.A.), a highly volatile amine, is responsible for the odour of rotting cartilaginous marine fish. The major source of T.M.A. in man is the metabolism of dietary choline by intestinal bacteria. T.M.A. formed in this way is normally absorbed into the splanchnic venous system and is converted to the stable non-volatile T.M.A.-N-oxide by the hepatic enzyme amine oxidase.2.3 Any T.M.A. not oxidised enters the systemic circulation where it is excreted in urine, breath, and sweat, normally in minute quantities. Interference with the hepatic metabolism of T.M.A. could be expected in patients with cirrhosis of the liver, because of impaired hepatocellular function or because of the presence of portasystemic venous shunts. This would result in increased levels of T.M.A. entering the systemic vascular system to be excreted in increased amounts in both breath and urine. In a pilot study to investigate this possibility, urinary trimethylamine excretion was measured in patients with liver disease.
J. P. ESTEVENON
46 chemin de la Gaye, 13009 Marseille, France
H. SARLES
1. Gruger, E. H. J. agric. Food Chem. 1972, 20, 781. 2. Lintzel, W. Biochem. Z. 1934, 273, 244. 3. de la Huerga, J., Popper, H. J. clin. Invest. 1951, 30,
GENERAL ANÆSTHESIA FOR HIGH-DOSE TOTAL-BODY IRRADIATION
SIR,-Dr Whitwam and his colleagues (Jan. 21,
p. 128) deof general anaesthesia for patients undergoing whole-body irradiation. In the light of our experience with this form of radiotherapy we are concerned that our British colleagues should have found it necessary to resort to general anaesthesia. In our bone-marrow transplantation programme the patients with refractory or relapsed acute leukaemia are irradiated over a 2 h period from alternate sides of the body to a dose of 1000 rad determined in the midplane at the level of the pelvis, and special attention is given to protection of the ,hands from undue exposure. We can appreciate that there are benefits of general anaesthesia in this setting, but do not think that it is routinely necessary. We find premedication with metoclopramide for 48 h before irradiation and chlorpromazine immediately before exposure is remarkably effective. We cannot claim that our patients do not become nauseous, but we have never had to discontinue irradiation for this reason, although further anti-emetics may occasionally be required after the first hour; we have certainly not encountered the situation where therapy needed to be interrupted twenty times. On the day of radiotherapy the patients receive diphenoxylate and codeine phosphate as prophylaxis against the diarrhoea that may follow from radiation sickness. The doses are adjusted to meet individual requirements. Our greater concern, however, is the effect that anaesthetic agents may have on the liver; for example, cytotoxic drugs are hepatotoxic’ and, particularly when combined with radiation (unpublished) may result in hepatitis.
scribe the
1.
use
Penta, J. S., 247.
von
Hoff, D. D., Muggia,
F. M. Ann.
intern.
Med.
1977, 87,
T.M.A. responses to choline
463.
Cherry et al.2 found no published cases of Stevens-Johnson syndrome associated with M. pneumoniae in girls; 2 of our cases were
females.
Although patients with Stevens-Johnson syndrome usually recover fully we recommend that, in view of the possibility of permanent eye damage, all children with the syndrome should be referred to an ophthalmologist. Royal Devon and
Exeter
Hospital,
Exeter EX2 5DW
Gloucestershire Royal Gloucester GL1 3NN
MEASUREMENT OF LACTOFERRIN IN PANCREATIC JUICE described a protein in pancreatic juice of calcifying pancreatitis;’ this was later identified as lactoferrin,2 a glycoprotein mainly secreted by mammary glands and found in various external secretions.3 Indirect
SIR,-In 1971
men
we
with chronic
immunofluorescence studies revealed lactoferrin in acinar cells of normal pancreatic tissue and in acinar cells of men with chronic calcifying pancreatitis.4 However, the fluorescence was more striking in pathological material. Dr Fedail and colleagues (Jan.. 28, p. 181) have confirmed that lactoferrin secretion is increased in pancreatic juice of patients with chronic
pancreatitis. Since lactoferrin secretion is not increased in pancreatic in acute pancreatitis,s a practical and accurate assay for lactoferrin in pancreatic juice might be a useful diagnostic test. We have compared a double-diffusion technique with a cancer or
radioimmunoassay. The radioimmunoassay was done with pure human lactoferrin (kindly given by Dr P. Masson) labelled with 125by the chloramine-T method. Separation of bound and free lactoferrin was achieved by a double-antibody technique. The sensitivity of the assay was 1 ng/ml. The antilactoferrin prepared in the laboratory was used after a dilution of 1/50 000. ’Immunoplates LC’ (low-concentration) ’Partigen’ lactoferrin and pure standard lactoferrin (titrating 4 mg/dl) were kindly prepared by Dr Baudner (Behring Institute,. Marburg).
1.
PETER G. F. SWIFT
Hospital, DAVID W. STEVENS
Clemente, F., Ribeiro, T., Colomb, E., Figarella, C., Sarles, H. Biochim. biophys. Acta, 1971, 251, 456. 2. Colomb, E., Estevenon, J. P., Figarella, C., Guy, O., Sarles, H. ibid. 1974, 342, 306. 3. Masson, P. La lactoferrine. Paris, 1970. 4. Colomb, E., Pianetta, C., Estevenon, J. P., Guy, O., Figarella, C., Sarles, H. Digestion, 1976, 14, 242. 5. Estevenon, J. P., Sarles, H., Figarella, C. Scand. J. Gastroent. 1975, 10, 327.
SERRATIA MARCESCENS COLONISING THE GUT
SIR,-During an outbreak of hospital cross-infections by multiply resistant Serratia marcescens this organism was occasionally recovered from stools as well as from the site of clinical infection. The spread of Klebsiella pneumoniae from a gastrointestinal-tract reservoir to extraintestinal sites is well documented,’ but S. marcescens does not usually colonise the gut of adults.2 We extended our observation by taking rectal swabs from patients admitted during the outbreak; the swab was streaked on selective media and the plate was inspected caused
after 24 and 48 h incubation at 37°C; the isolates were identified and antibiotic susceptibilities were determined by standard methods. 120 rectal cultures were obtained from 57 patients. The stools of 5 patients were colonised with multiply resistant S. marcescens. 2 patients were colonised or infected at extraintestinal sites at the time the first stool culture was obtained; the other 3 patients later became colonised or infected at extraintestinal sites. As with K. pneumonice, gastrointestinal colonisation by S. marcescens may, by serving as a reservoir for cross-infection, be an important step in the development of hospital-acquired infection. Infectious Disease Section, Department of Medicine, Veterans Administration Hospital, University of Oregon Health Science Center, Portland, Oregon 97207, U.S.A.
STEPHEN R. JONES MERIDITH AMON CATHERINE FALVEY KATHRYN PATRICK
Comparative 1.
Stevens, D, Swift, P. G. F., Johnston, P. G. B., Kearney, P. J., Corner, B. D., Burman, D. Archs Dis. Childh. 1978, 53, 38. 2 Cherry, J. D., Hurwitz, E. S., Welliver, R. C. J. Pediat. 1975, 87, 369. 1. Selden, R., and others Ann. intern. Med. 1971, 74, 6737. 2. Farmer, J. J, and others Lancet, 1976, ii, 455.
measurement of lactoferrin.
Radioimmunoassay (e);
assay
by
radial immunodiffusion
(0).
Abs-
cissa ; pancreatic juice from patients with chronic pancreatitis (1-6) and controls values.
(7-12).
The dotted line represents the limit of normal
1106 The two samples of lactoferrin (Dr Masson and Dr Baudner) were immunologically identical on testing by doublediffusion technique, and the precipitating lines between each immune serum and each lactoferrin fused completely. The immunoplates contained twelve wells. Three were filled with 2 x 20 A of standard lactoferrin diluted 1/2 (20 g/ml), 1/4, and 1/6. The other wells contained 2 x 20 .1 of the different pancreatic juices, concentrated by lyophilisation or alcoholic precipitation. The protein content (measured by optical density at 280 nm with an extinction coefficient of Efïfi 20) ranged from 9 to 47 mg/ml juice. The plates were allowed to diffuse 48 h at 20 °C and then washed with isotonic saline for 3 days. The plates were stained for 1 min in 0-1% amidoschwarz (Merck) and then destained in 10% acetic acid. A standard curve was constructed by plotting the square of the diameter of the rings of precipitation against the lactoferrin concentration, and lactoferrin concentrations of samples of pancreatic juice were read off from this standard curve. By this method it is possible to visualise a lactoferrin concentration of about 2 Lg/ml to 25 fLg/ml. These results are shown in the figure, expressed as a percentage of total protein. The data obtained by radial immunodiffusion and those given by radioimmunoassay were in good agreement. The two assays confirm the increased lactoferrin concentration in juice from men with chronic pancreatitis. In six normal juices the range is from 0.002 to 0-02% with a mean of 0.013%, and in six juices from men with chronic calcifying pancreatitis from 0.033 to 0.92% with a mean of 0-23%. The assay of lactoferrin on immunoplates may be as accurate as radioimmunoassay, and can be easily set up in the
The crucial question is-how do the minor hazards of interrupting whole-body irradiation compare with anaesthetic complications in a patient who will often already have received considerable cytotoxic chemotherapy? Cape Town Leukæmia Centre and Departments of Hæmatology and Radiotherapy,
PETER JACOBS HELEN S. KING
Groote Schuur Hospital, Observatory, Cape Town, South Africa
=
laboratory. Unité de Recherches de
Pathologie Digestive
(INSERM U31),
C. FIGARELLA
TRIMETHYLAMINE METABOLISM IN LIVER DISEASE
SiR,—Trimethylamine (T.M.A.), a highly volatile amine, is responsible for the odour of rotting cartilaginous marine fish. The major source of T.M.A. in man is the metabolism of dietary choline by intestinal bacteria. T.M.A. formed in this way is normally absorbed into the splanchnic venous system and is converted to the stable non-volatile T.M.A.-N-oxide by the hepatic enzyme amine oxidase.2.3 Any T.M.A. not oxidised enters the systemic circulation where it is excreted in urine, breath, and sweat, normally in minute quantities. Interference with the hepatic metabolism of T.M.A. could be expected in patients with cirrhosis of the liver, because of impaired hepatocellular function or because of the presence of portasystemic venous shunts. This would result in increased levels of T.M.A. entering the systemic vascular system to be excreted in increased amounts in both breath and urine. In a pilot study to investigate this possibility, urinary trimethylamine excretion was measured in patients with liver disease.
J. P. ESTEVENON
46 chemin de la Gaye, 13009 Marseille, France
H. SARLES
1. Gruger, E. H. J. agric. Food Chem. 1972, 20, 781. 2. Lintzel, W. Biochem. Z. 1934, 273, 244. 3. de la Huerga, J., Popper, H. J. clin. Invest. 1951, 30,
GENERAL ANÆSTHESIA FOR HIGH-DOSE TOTAL-BODY IRRADIATION
SIR,-Dr Whitwam and his colleagues (Jan. 21,
p. 128) deof general anaesthesia for patients undergoing whole-body irradiation. In the light of our experience with this form of radiotherapy we are concerned that our British colleagues should have found it necessary to resort to general anaesthesia. In our bone-marrow transplantation programme the patients with refractory or relapsed acute leukaemia are irradiated over a 2 h period from alternate sides of the body to a dose of 1000 rad determined in the midplane at the level of the pelvis, and special attention is given to protection of the ,hands from undue exposure. We can appreciate that there are benefits of general anaesthesia in this setting, but do not think that it is routinely necessary. We find premedication with metoclopramide for 48 h before irradiation and chlorpromazine immediately before exposure is remarkably effective. We cannot claim that our patients do not become nauseous, but we have never had to discontinue irradiation for this reason, although further anti-emetics may occasionally be required after the first hour; we have certainly not encountered the situation where therapy needed to be interrupted twenty times. On the day of radiotherapy the patients receive diphenoxylate and codeine phosphate as prophylaxis against the diarrhoea that may follow from radiation sickness. The doses are adjusted to meet individual requirements. Our greater concern, however, is the effect that anaesthetic agents may have on the liver; for example, cytotoxic drugs are hepatotoxic’ and, particularly when combined with radiation (unpublished) may result in hepatitis.
scribe the
1.
use
Penta, J. S., 247.
von
Hoff, D. D., Muggia,
F. M. Ann.
intern.
Med.
1977, 87,
T.M.A. responses to choline
463.
