1036 C.S.F. FINDINGS
monitor and did not use any medication. Twenty-one hours after the episode had begun, the patient converted to a regular sinus rhythm and has since remained well with a normal
electrocardiogram. We feel that smoke inhalation should be added to the list of factors contributing to paroxysmal atrial fibrillation and premature ventricular contractions. Department of Pediatrics, Kaiser Foundation Hospitals,
*Means of more than one tube.
Panorama City, California 91402, U.S.A.
of this patient have not yet been examined. In cirrhosis factor-xu concentrations may decrease;4 but the slight disturbance of liver function in this patient cannot explain the defect in Hageman factor. The nutritional state of the patient was good, with no clear deficiency of vitamins. 5 Deficiency of factor xn is not usually clinically important: Congenital deficiences of Hageman factor may cause profound changes in vitro (prolonged blood-clotting) but corresponding findings in vivo have not been reported. In normal conditions factor xn promotes clotting and fibrinolysis. Our patient’s clotting-time was prolonged, and we think the recurrent bleedings might have been at least partly due to Hageman factor deficiency. To rule out the possibility of coincidence, factor-xn concentrations need to be studied in a larger number of patients with subarachnoid haemorrhage and abnormal clotting-times. S. KOVALAINEN V. V. MYLLYLÄ Department of Neurology, U. TOLONEN University of Oulu, SF-90220 Oulu 22, Finland E. HOKKANEN
HAROLD N. BASS BARBARA F. HILDRETH
NEUTROPHIL CYTOCHROME b IN CHRONIC GRANULOMATOUS DISEASE
SIR,-We thank Dr Borregaard and his colleagues, who report spectral evidence of a cytochrome b in granulocyte preparations isolated from patients with chronic granulomatous disease (C.G.D.) in your issue of May 5 (p. 949), for allowing us independently to study cells from these patients. We are pleased that they have confirmed the presence of a cytochrome b as a major spectroscopic component in difference spectra of human neutrophils. Consequent upon their findings we have re-examined the spectral characteristics of granulocytes from four of our patients with C.G.D., and present these data here with our current views on the role of this cytochrome b in the microbicidal oxidase system of neutrophils.
PAROXYSMAL ATRIAL FIBRILLATION AND EXPOSURE TO SMOKE
SIR,-Paroxysmal atrial fibrillation is most likely in patients with mitral stenosis, ischxmic heart-disease, thyrotoxicosis, or Wolff-Parkinson-White syndrome, or as a result of digitalis intoxication or potassium depletion. We have seen a boy with atrial fibrillation and occasional premature ventricular contractions (P.v.c.s) during an episode of smoke inhalation. Textbooks of cardiologyl-3 do not mention smoke inhalation as a factor in either type of arrhythmia. Our patient was a sixteen-year-old boy who had been exposed for about four minutes to dense smoke coming from a trash fire in a tightly enclosed corridor of his school. As he was leaving the area of the fire, he noted "skipped heart beats" but otherwise complained of no discomfort. His mother brought him to hospital about three hours after the incident because of an irregular pulse. When we examined him, his apical pulse was distinctly irregular with a rate of 72/min; bloodpressure 116/80 mm Hg, and temperature 365°C. There were no heart murmurs, and the first and second sounds varied in intensity. The patient was not dyspnoeic and the remainder of the physical examination was normal. The electrocardiogram showed atrial fibrillation with occasional P.v.c.s and a ventricular rate of 78/min. A chest X-ray was normal as were an echocardiogram, throat culture, complete blood count, sedimentation rate, antistreptolysin titre, s.G.o.T., creatine phosphokinase MB, and thyroxine. Because the apical pulse was not rapid and the patient had previously been in good health with no known exposure to drugs, alcohol, or coffee, we placed him on an external cardiac 5. Glueck, H. I., Roehill, W. Ann. intern. Med.
1966, 64, 390.
1. Marriott, H. J. L., Myerburg, R. J. in The Heart, Arteries and Veins (edited by J. W. Hurst, R. B. Logue, R. C. Schlant, and N. K. Wenger); p. 517. New York, 1974. 2. Silber, E. N., Katz, L. N.; p. 466. New York, 1975. 3. Fowler, N. O. Cardiac Diagnosis and Treatment; p. 889. Hagerstown, Maryland, 1976.
Dithionite difference spectra of granulocytes from a normal subject (control) and five patients with C.G.D.
Spectra A-D are cells from male patients (B, C, and D correspond patients G, M and Q in ref. 1, respectively; spectrum B is the onginal, the other spectra are new observations). Spectra E and F are of cells from the female patient with C.G.D. (patient U in ref. 1). The cells in E were recovered from the pellet and in F, from the interface after centrifugation on a gradient of ficoll/hypaque. Figures in parentheses indicate the percentage of eosinophils in the cell preparations. Absor-
bance scale marker=0-046 of full scale.
1037 We confirmed that granulocytes from their patients have a normal spectrum, including the characteristic absorption bands of a cytochrome b with a-band at 557 nm and y-band at 427 nm. In none of our male patients with classical C.G.D., including the repeat studies on two of them, have we seen evidence of the cytochrome b (see figure). In cells from the young Asian girl (patient U in ref. 1) from which we originally described the cytochrome b as abnormal or lacking, we now believe we can detect it. The uncertainty stems from the presence of a large absorption peak at 452 nm with a smaller broad band at about 560 nm which tend to obscure the characteristic pattern of absorption of the cytochrome b. We originally speculated that the 452 nm peak resulted from one of the many oxidation states of myeloperoxidase, which absorbs strongly in difference spectra of neutrophils, but now believe that it is probably due to the peroxidase of contaminating eosinophils. This peak at about 450 nm becomes more prominent as the percentage of eosinophils in the granulocyte preparations increases (figure) and has similar spectral characteristics to that of guineapig eosinophil peroxidase.2 One of us (A. W. S.), with Fortunata, had found that the neutrophils of patients with C.G.D. are less dense than normal, and an abnor-
mally high proportion are retained above a density gradient of ’Ficoll-Hypaque’ (unpublished). Eosinophils pass through this gradient, causing a relative enrichment of these cells in the purified granulocyte preparations. The spectrum obtained from the cells of this girl that were retained above the layer of ficoll-hypaque, which contained 47% neutrophils, 34% lymphocytes, and 16% monocytes, but no eosinophils, was very similar to that obtained with normal neutrophils (F in figure). Similar cell preparations from our male patients did not reveal any spectroscopic evidence of the cytochrome b. It is evident that C.G.D. is a syndrome rather than a single disease entity, the unifying characteristics of which are a predisposition to infection which is secondary to defective function of the microbicidal oxidase system. We believe this oxidase system to be an electron-transport chain in which the cytochrome b is one component. Failure of the system as a whole could then result from defective activation of the system, absence of any of the separate components, or failure of coordination of their interrelated functions. Examples ot multiple distinct defects causing malfunction of a complex elec3 tron-transport chain are readily observed in bacteria. Different genes cannot be expected to code for the same phenotypic expression, and one would predict different defects in the system in groups of patients demonstrating different modes of inheritance. Too few patients have as yet been studied to permit accurate assessment of the genetics of this disease and we would welcome the opportunity of examining material from other patients and their families. Our preliminary impression is that the b cytochrome seems to be missing in a major group of patients where the mode of inheritance appears to be X linked, and is present where it is autosomal recessive. The boy described by Borregaard et al., in whom the cytochrome is present and where the inheritance appears to be X linked, is at obvious variance with this scheme. However, he was born on Bornholm where the population is highly inbred, which confuses the genetic data, and this case could represent another disease entity originating from the island. The role of the cytochrome b in this oxidase system is supported by the observation that it undergoes reversible reduction and oxidation upon stimulation of the cells with phorbol myristate acetate,4 a fatty-acid derivative which activates the oxidase system.5 Detailed investigation of the molecular obser1
vations conferred by the different genotypes that together constitute the syndrome of C.G.D. should help to elucidate its partners in this process. We thank the Wellcome Trust for financial support. Division of Cell Pathology, Clinical Research Centre, Harrow, Middlesex HA1 3UJ
ANTHONY W. SEGAL
Department of Biochemistry, University of Bristol
OWEN T. G. JONES
TYPE-14 PNEUMOCOCCAL VACCINE FOR PREVENTION OF GONORRHŒA
SIR,-In their interesting article
type-14 pneumococci and group-B streptococci type III Major Fischer and his colleagues (Jan. 13, p. 75) suggest the possible immunisation of infants with pneumococcal vaccines to prevent neonatal group-B streptococcal infections. There is a similar relation between type-14 pneumococcal capsular polysaccharide and the core oligosaccharide moiety of the R-type lipopolysaccharide (L.P.S.) of Neisseria gonorrhma. Methylation analysis of gonococcal L.P.S. core oligosaccharides has shown that 2,3,4,6-tetra-O-methyl-trglucosamine (1 mol) are the only fully methylated glycose derivatives. Thus two-Dgalactopyranose and one D-glucosamine units are present as non-reducing end groups in the gonococcal core.’ These exposed non-reducing end groups are considered the immunodominant groups in gonococcal L.P.s. for the following reasons:’I
(a) the reaction between gonococcal L.P.S. and homologous hen antiis inhibited by lactose; (b) gonococcal L.P.S. is reactive with antibody to synthetic lactose antigens; (c) absorption of antigonococcal L.P.s. antiserum on a lactose-substituted affinity column removes about 80‘y of the antibody reactive with gonococcal L.P. S. serum
Pneumococcal capsular polysaccharide, obtained from Streptococcus pneumoniae type-14 similarly contains antigenic n-galacto-pyranose end groups.2 Experiments in our laboratories have shown3 that gonococcal L.P.s. reacts with antiserum raised in horses to Strep. pneumonice type-14; that horse antiserum to Strep. pneumonix type-14, but not type 3 or 8, agglutinates N. gonorrhaeae (22/22 strains) (unpublished) ; and that antiserum prepared in hens to pneumococcal polysaccharide forms a precipitin band in gel when reacted against gonococcal L.P. S. or lysates ofN. gonorrhxce. Our previous studies 4,5 have indicated that R-type L.P.S. of N. gonorrhaeae is chemically and immunochemically similar in all strains examined
date, and therefore represents the com-
antigen of N. gonorrhwa. In addition, that R-type L.P.S. is protective against challenge with different strains of N. gonorrhaeae colony type 1 in the intracerebral mouse model and the chick-embryo neutralisation test.3 We suggest that the capsular polysaccharide of Strep. pneumoniæ type 14 be tested as a vaccine against gonorrhoea’ perhaps in a close population study, on males and females at risk. Such a vaccine has already been licensed and is readily availmon
able in the U.S.A., and it is non-toxic and known
genic in man. Centre for Disease Control, Health and Welfare Canada, Ottawa, Canada, K1A 0L2; and National Research Council, Ottawa
B. B. B. B. DIENA DIENA F.E. ASHTON M.B. PERRY
1. Perry, M. B., Daoust, V., Johnson, K. G., Diena, B. B., Ashton, F. E. in Immunobiology ofNeisseria gonorrhœœ, p. 101. American Society for Micro-
A. W., Jones, O. T. G., Webster, D., Allison, A. C. Lancet, 1978, ii, 446. 2 Desser, R. K., Himmelhoch, S. R., Evans, W. H., Januska, M., Mage, M., Shelton, E. Archs biochem. biophys. 1972, 148, 452. 3 Haddock, B A., Jones, C. W.Bact.Rev. 1977, 41, 47. 4 Segal, A. W., Jones, O. T. G. Biochem. Biophys. Res. Comm. (in the press). 5 Repine, J. E., White, J. G., Clawson, C. C., Holmes, B. M. J. lab. clin. Med.
1974, 83, 911.
biology, Washington, D.C., 1978. 2. Lindberg, B., Lönngren, J., Powell, D. A. Carbohydrate Res. 1977, 58, 177. 3. Diena, B. B., Ashton, F. E., Ryan, A., Wallace, R., Perry, M. B. Can. J. Microbiol. 1978, 24, 117. 4. Perry, M. B., Daoust, V., Diena, B. B., Ashton, F. E., Wallace, R. Can. J Biochem. 1975, 53, 623. 5. Wallace, R., Ashton, F. E., Ryan, A., Diena, B. B., Malysheff, C., Perry, M. B. Can. J. Microbiol. 1978, 24, 124.