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Carriers for chronic granulomatous disease (CGD) and patients with lupus erythematosus (LE) share several characteristics: They are mostly females, they reduce nitroblue tetra-zolium (NBT) poorly in their neutrophils, and, in some cases, they have similar skin lesions. We thus investigated 19 female LE patients for the presence of laboratory findings characteristic of the carrier state for CGD. None of these patients turned out to have the combined abnormality of neutrophil bactericidal activity and neutrophil NBT-reduction that is diagnostic of CGD carrier state in the X-linked form. An increased frequency of CGD carriers among female LE patients thus appears to be unlikely. Why some CGD carriers develop skin lesions typical of LE remains unexplained.

In this report we describe a platelet alloantigen system that is carried on a novel platelet protein of 175 Kd. Antisera against the two alleles (Gova/Govb) were found in two patients who had received large numbers of platelet transfusions. The anti-Gov alloantibodies could not be detected using a whole platelet solid phase enzyme immunoassay, or by a platelet glycoprotein capture enzyme immunoassay using monoclonal antibodies against glycoproteins Ib/IX, Ia/IIa, and IIb/IIIa. Using radioimmunoprecipitation techniques, a protein was precipitated that migrated at 175 Kd (reduced). Under nonreduced conditions, a 150-Kd protein was detected with a minor component at 175Kd. The detection of the alloantigens was not activation-dependent. Using immunodepletion studies, we demonstrated that each alloantiserum recognized an epitope on a discrete population of the 175-Kd platelet protein. Family studies demonstrated that the alloantigens designated as Gova and Govb were inherited in an autosomal codominant fashion. The phenotypic frequencies were Gova/Gova, 26%; Gova/Govb, 55%; Govb/Govb, 19%; giving gene frequencies of 0.532 and 0.468 for Gova and Govb, respectively (n = 33).

A patient is shown to have acute granulocytic leukemia, bone marrow mosaicism, and cutaneous fibroblast mosaicism for trisomy 8, an inherited reciprocal translocation involving the short arms of chromosomes 7 and 20, and a family history of cancer. A normal sister who had the same balanced chromosome translocation was evaluated for a preleukemic state; the results were unremarkable. The inherited translocation and postzygotically derived trisomy 8 are thought to represent additive factors contributing to the development of leukemia in the patient.

Ovarian tumors comprise only 1% of all tumors in females below the age of 17 years. Of these, the epithelial tumors are the least common, being particularly rare before puberty and then increasing in frequency with advancing age after puberty. The youngest girl previously reported in the literature with an epithelial ovarian tumor was a 9-year-old child with an ovarian papillary cystadenocarcinoma. This is the only case thus far reported of a malignant ovarian epithelial tumor occurring before puberty. Only histologically benign appearing glands were detected in the resected tumor masses, on a second-look laparotomy following the use of multiagent chemotherapy.

Responses of physicians and parents to New York State-mandated newborn screening for sickle cell disease were solicited and evaluated. The index group comprised 25 infants born in western upstate New York. Each was found to have either sickle cell disease, hemoglobin SC disease, sickle beta-thalassemia, or hemoglobin C disease. In nondirective interviews the following factors were assessed: clinical course, the physician's policies of disease treatment and family counseling, the parents' reactions to the diagnosis and their level of understanding and compliance with medical recommendations, and the physicians' and parents' views on newborn screening. Newborn screening for sickle hemoglobin makes early prophylaxis and prompt treatment possible. Some morbidity may have been averted, judging from parental understanding of medical needs. Parents and physicians agreed that newborn screening for hemoglobinopathies is a valuable public health program. Suggestions for improving the New York state program included a need to increase communication among the screening laboratory, the hospital, and the physician; encouraging physicians to educate parents more fully, provide genetic counseling, and test parents and siblings of the identified neonate; and, most important, provide a well-delineated mechanism for follow-up of every infant with a potentially symptomatic hemoglobinopathy.

Using an oxygen electrode, oxygen consumption has been measured in peripheral blood neutrophils and the corresponding middle ear fluid neutrophils of 26 patients with acute suppurative otitis media. The data suggest that the middle ear fluid neutrophil is functional and is capable of producing an adequate oxygen burst in response to membrane stimulation by opsonized zymosan particles. Some middle ear neutrophils are actually capable of producing a greater respiratory burst than their counterparts in the peripheral blood. However, middle ear neutrophils do not show the increased metabolic activity at 40 degrees C, which blood neutrophils regularly displayed compared with tests performed at 37 degrees C. It is believed that this temperature (40 degrees C) is more physiological during infection and might explain why middle ear neutrophils may not always be capable of destroying bacteria, even though they are present in adequate numbers in the middle ear fluid in some cases of acute suppurative otitis media. Further studies are needed to determine the nature of the defect(s) present in middle ear neutrophil at 40 degrees C.

A 26-yr-old male with a lifelong history of atopic dermatitis and recurrent severe staphylococcal abscesses was found to have hyperimmunoglobulinemia E. Evaluation of both the humoral and cellular aspects of chemotaxis in vitro showed both neutrophils and monocytes to be normal. However, quantitative neutrophil migration in vivo was significantly suppressed using the patient's own serum as the attractant. This defective migration in vivo was partially corrected by serum from normal donors as the attractant and also partially corrected following plasma infusion in this patient. Evaluation of quantitative leukocyte migration in vivo may be most useful in patients suspected of defects of leukocyte mobility.

Live Newcastle disease virus (NDV) was used to investigate the in vitro effects of a viral infection on phagocytosis, chemiluminescence generation, superoxide production, oxygen consumption, NADPH-oxidase activity, and intracellular killing of bacteria by Ficoll-Hypaque separated human neutrophils. Phagocytosis of oil red O particles by NDV- treated PMN was inhibited by 50%. Chemiluminescence by PMN was inhibited 79% after zymosan stimulation and 86% after tetradeconyl phorbol acetate stimulation. Superoxide generation was inhibited by 68%. Oxygen consumption was inhibited in the presence of NDV by 37% after stimulation with phorbol myristate acetate, while membrane- associated NADPH-enzyme activity was decreased by 19%. The percent of surviving intracellular S. aureus was significantly elevated in NDV- treated PMN after 60 and 120 min of incubation. Purified bacterial neuraminidase markedly suppressed chemiluminescence, while neuraminic acid blocked the effects of the virus. These observations suggest that infections with myxoviruses may suppress a number of vital neutrophil functions. It appears that the effects may be partly mediated by the interaction of viral neuraminidase with the external neutrophil membrane.

Two siblings with hereditary Fletcher factor (prekallikrein) deficiency were studied for alterations of fibrinolysis, platelet function, skin inflammatory responses, permeability factor (PF/dil) formation and leukocyte chemotaxis. In vivo stimulation of fibrinolytic activity was normal; the bleeding time and platelet functions (adhesivity, aggregation, release reaction) were also normal. Both immediate (wheal-flare reaction to histamine, bradykinin, prostaglandin E1, physical agents) and delayed sensitivity skin test reactions were within normal limits. Migration of subjects' leukocytes to attractants in skin windows and in Boyden-type chambers was the same as that of control leukocytes. Serum complement components were essentially normal. One subject's leukocytes showed normal tissue factor production on stimulation by endotoxin, although prekallikrein deficiency did impair the endotoxin-stimulated generation of serum procoagulant activity. PF/dil caused increased vessel permeability in human skin; in vitro generation of PF/dil required both the Hageman factor and prekallikrein. The Fletcher factor-deficient subjects responded in a normal manner to PF/dil. Based on the Fletcher factor-coagulation assay, the biologic half-disappearance time of prekallikrein (after the transfusion of normal plasma in one of the subjects) was estimated at 35 hours. Therefore, these studies suggest that severe prekallikrein (Fletcher factor) deficiency in man is not associated with any clinically significant impairment in hemostasis, fibrinolysis, inflammatory responses or leukocyte function.

Neutrophil (PMN) bactericidal activity, phagocytosis, and nitroblue tetrazolium (NBT) reduction were evaluated in 18 children with untreated or relapsing acute leukemia and 20 children in hematologic remission. Half of the patients in relapse demonstrated abnormal PMN bactericidal activity, while remission patients had essentially normal PMN bactericidal activity. Phagocytosis of Staphylococcus aureus was normal in relapse and remission subjects. NBT reduction by PMN's of leukemic patients was significantly lower than that of controls, but there was no correlation between decreased NBT-reductase activity and decreased bactericidal power. Six patients in remission had received intensive chemotherapy for more than 4 years, and all demonstrated normal PMN functions. Among relapse patients with abnormal PMN bactericidal activity 63% eventually developed severe bacterial infections. By comparison, 20% of the relapse patients with normal PMN bactericidal activity subsequently developed severe infections. The PMN dysfunction observed in relapse patients suggests that abnormal PMN bactericidal activity may contribute the increased susceptibility to bacterial infections during leukemic relapse.

Since infants with malignant osteopetrosis often die from infection at an early age, we studied several aspects of host defense in five such infants. No consistent abnormality was found in cellular or humoral immunity. Monocyte cellular chemotaxis and phagocytosis were normal in four tested infants. However, all four of these infants had decreased intracellular bacterial killing by monocytes. Neutrophil function tests in five infants showed that two had defective bacterial phagocytosis and four had reduced cellular chemotaxis, decreased nitroblue tetrazolium reduction, and decreased intracellular bacterial killing. The severity of the decreased bactericidal capacity of granulocytes did not correlate with the number of circulating immature granulocytes. Our data suggest that abnormal function of circulating monocytes and granulocytes may contribute to impaired host resistance to infection. We postulate that this defect may reflect a more generalized inherited abnormality of phagocytic cells and perhaps osteoclasts that plays a role in the pathogenesis of infantile osteopetrosis.

The spontaneous reduction of nitroblue tetrazolium (NBT) was found to be significantly elevated in phagocytes of normal newborn in fants in the absence of infection. This was evident using both a simple histochemical test and a more elalborate quantitative test for NBT reduction. During phagocytosis of latex particles, the expected rise in NBT reduction was significantly greater in neonatal phagocytes than in phagocytes of control subjects. The increased NBT reducing activity of neonatal neutrophils makes it impossible to use the NBT histochemical test for tile detection of bacterial infection in that age group. However, NBT-reduction tests can be used with profit in the neonatal period to diagnose chronic granulomatous disease when a positive family history warrants such an investigation. [See pdf for the Figure]

The previously unreported combination of ring 18 chromosome, intestinal nodularlymphoid hyperplasia, severe hypogammaglobulinemia, and bone marrow hypoplasia was found in a deaf and mentally retarded 12-year-old girl. In addition to a quantitative deficiency of platelets, lymphocytes, and neutrophils, functional abnormalities of neutrophils were demonstrated by various recently developed in vitro tests. Defective stem cell maturation and the presence of faulty “bursal-equivalent” tissue are postulated as the basis for the hematologic and immunologic abnormalities.

Recent investigations have raised the possibility that growth hormone (GH) influences intra-uterine weight and length. Moreover, the hypoglycemic tendency of small for gestational age (FSGA) infants and their small size could result from GH deficiency. To verify these hypotheses, a prospective study of daily serum GH and glucose levels was conducted in 46 newborn infants, including 18 FSCA infants, 18-full-term, appropriate for gestational age (FAGA), and 10 premature (PR) infants. Two FSGA babies became hypoglycemic. Both manifested normal GH competence as evidenced by normal daily GH levels, adequate GH response to arginine provocation, and satisfactory growth for over 2 years. Eleven of 12 FSGA babies followed from 14 to 26 months showed no evidence of impaired linear growth. The FSGA babies had GH values similar in magnitude and pattern to those of FAGA and PR infants. During the second half of the first postnatal day, a significant rise in serum GH occurred in all infants regardless of their size or gestational age; this rise may be the result of the stimulating effect of early milk feedings. GH deficiency does not appear to contribute to either the small size or hypoglycemic tendency of FSGA newborn infants.

Nitroblue tetrazolium (NBT) reduction by phagocytic leukocytes was investigated histochemically in 296 subjects with and without infections. Among 130 patients with noninfectious diseases, osteogenesis imperfecta patients and their relatives, and hemophiliacs frequently displayed high NBT-reduction values in their neutrophils. Four percent of the other noninfected patients yielded NBT-reduction values higher than normal in their neutrophils and were considered to have "false-positive" NBT-reduction tests. Most patients with acute bacterial infections (83%) showed an increased percentage of NBT-positive neutrophils. In patients who did not respond to a bacterial infection by increasing their percentage of NBT-positive neutrophils, there was suggestive evidence of a state of neutrophil dysfunction. Eighty-four percent of patients with viral or tuberculous infections demonstrated normal percentages of NBT-positive neutrophils. Acute bacterial infections were most often associated with a high percent of NBT-positive neutrophils, while low values predominated in viral infections regardless of the patient's total leukocyte counts. The NBT histochemical test would appear to be a useful adjunct to microbiologic techniques in establishing the diagnosis in patients with suspected infection.

Neonatal polycythemia and related disorders were studied in 23 full-term infants small for gestational age (SGA), 23 full-term (F-AGA), and 18 preterm infants of birth weights appropriate for gestational age (P-AGA). SGA infants had significantly higher hemoglobin, hematocrit, erythrocyte count, and fetal hemoglobin concentration values than other babies. Half of the SGA infants were polycythemic (venous hematocrit greater than 60 per cent). Four of them, all male infants, had important clinical problems including respiratory difficulties, priapism, hypoglycemia, and hypocalcemia. SGA infants also demonstrated a significant decrease in reticulocyte count after the first postnatal day. In all infants, capillary hematocrits were consistently higher than venous hematocrits. All male SGA babies should have hematocrit determinations shortly after birth and be observed closely for the development of clinical complications, particularly if polycythemic.

A 6-year-old girl exhibiting a variety of clinical symptoms including an apparant inability to metabolize trimethylamine has been shown to possess a defective liver trimethylamine oxidizing system. The defect manifested itself in a Km for trimethylamine which was five times that characteristic of normal enzyme preparation.

A simple quantitative method for the measurement of leukotaxis in vivo is described. Duplicate skin chambers are placed over tape-stripped skin with 50% autologous serum--50% Hank's balanced salt solution as the attractant. Neutrophils predominate throughout 24 hr in this method with no change to mononuclear cells. A recommended modification of our original method is that chambers are sampled and removed after 8 hr rather than 24 hr since the majority of leukocyte migration occurs within the first 8 hr. Analysis of serum factors showed that heat-inactivation of the serum (56degreesC for 30 min) had no effect. However, depleting platelets or C5 from the serum removed approximately 90% of chemotactic activity for human neutrophils in vivo. Platelets, presumably through activity of their granules, enzymatically cleaves C5a from C5 in plasma. We conclude that C5a, after cleavage from C5, accounts for the majority of chemattractant activity in vivo.

immunoglobul in analysis can be normal in patients in whom functional specific antibodies are deficient, and indicate the need to assay functional elements of the immune system when immune deficiency is Suspected. The presence of normal cellular response to PHA, pokeweed, and SKSD differentiates this patient from Nezelof syndrome and place him in the category of ant ibody deficiency with normal immunoglobulins .

A child with Ph1-negative juvenile chronic myelogenous leukemia (CML) is presented. The only chromosomal abnormality in hematopoietic tissues consisted of an absent Y chromosome. While a missing Y chromosome in adult patients with CML may be associated with a better prognosis, the clinical course in our patient was as malignant as that usually observed in other children with Ph1-negative juvenile CML.

Spontaneous mitoses in the blood of 67 patients with acute leukemia were enumerated and their identity determined by cytogenetic methods. Most patients were children with acute lymphoblastic leukemia. Simultaneous 16- to 20-hour cultures of blood leukocytes (Bu) and of bone marrow (BM) cells were performed without phytohemagglutinin (PHA). Blood leukocytes were also cultured with PHA for 72 hours (BPHA). Mitoses in Bu cultures were counted, and karyotypic analysis performed on cells from the three culture types. In 21 control subjects, Bu cultures usually yielded no mitoses. Relapse and remission patients both displayed significantly more Bu mitoses than the controls. The karyotypes of Bu, BPHA, and BM mitoses in remission patients were normal. Fifty percent of relapse patients displayed cytogenetically abnormal leukemia cell lines; the percentage of their abnormal karyotypes was significantly higher in BM cells than in Bu or BPHA cells. The majority of the mitotic cells in Bu cultures from both relapse and remission patients appear to be of a nonleukemic origin. The number of mitoses could not be correlated with type of leukemia, hematologic parameters, or prognosis.

To the Editor.— A 2-month-old infant had a generalized seborrhea-like eruption, respiratory distress, and failure to gain weight since birth. Birth weight was 3,224 gm (7 lb 2 oz) and weight upon admission was 2,995 gm (6 lb 1 oz). Family history was significant in that a similar eruption, in addition to respiratory distress, developed in a sibling. At the age of 6 months, that sibling had respiratory failure requiring constant oxygen and respirator care and died at 16 months of age, of a Gram-negative septicemia. The infant was covered with erythematous papules topped by greasy scales that involved the entire body, sparing the palms and soles. He had respiratory distress; blood gas determinations showed hypoxia, requiring oxygen administration. A chest x-ray film revealed bilateral pulmonary infiltrates. A WBC count was elevated (15,300/cu mm), with 80% neutrophils. Immunoglobulins were normal and the child was blood type O-positive. E rosette-forming cells

• A 34-year-old man with chronic active hepatitis and pyoderma gangrenosum demonstrated abnormalities in neutrophil and monocyte function. Monocytes from this man had diminished chemotaxis and bacterial phagocytosis. These functions were significantly improved in vitro after one hour of incubation of monocytes with 10 5 hydrocortisone. Neutrophil function was normal for bactericidal activity and phagocytosis, but neutrophil chemotaxis was diminished. A plasma inhibitor was not found to explain these phagocyte alterations. ( Arch Dermatol 114:906-911, 1978)

Publisher Summary The measurement of bactericidal activity is considered the essential physiological tool that links the clinical expression of phagocytic defects with their biochemical and molecular etiology. Bactericidal activity measurements are often used as a diagnostic screening test in clinical medicine or as a logical source of reference when the inhibitors or enhancers of metabolic steps that influence bacterial killing in phagocytes are experimented. This chapter describes the intracellular killing of bacteria and fungi. It discusses three assay variants that should be applicable to most clinical or experimental laboratory situations. Killing assay using bacterial colony counts (Method 1) can easily be adapted for any bacterial strain by using modifications proposed by Leijh et al. The assessment of microbial killing by a fluorochrome assay (Method 2) is readily applicable to the study of fungi as well as bacteria and uses minuscule amounts of blood. A novel killing assay using a temperature-sensitive mutant as a target organism (Method 3) developed by Hooke confronts the problem of bacterial growth during the course of the assay.

An infant with recurrent purpura fulminans in the first year of life was found to have severe homozygous deficiency of protein C (less than 1% of normal levels). The episodes of purpura fulminans were controlled by infusions of fresh frozen plasma containing protein C. The requirement of frequent plasma infusions, however, eventually resulted in several complications secondary to hyperproteinemia. Factor IX concentrates rich in protein C were then given to maintain adequate levels of the factor while minimizing the amount of extraneous proteins. The patient has remained asymptomatic and free of complications for greater than 10 months while receiving these concentrates every 48 hours.

Leukocyte oxidative metabolism was investigated in 14 patients with osteogenesis imperfecta, 8 of whom complained of increased sweating and heat intolerance. Leukocyte respiration, measured in a Warburg apparatus, was significantly increased above control values. Hexose monophosphate shunt activity, determined by the amount of 1- 14 CO 2 produced by leukocytes from 1- 14 C-glucose, was also significantly elevated. A significant increase in nitroblue tetrazolium reduction was observed histochemically in neutrophils of patients, thus confirming the enhanced activity of the hexose monophosphate shunt-associated oxidative pathway in these leukocytes. In approximately 50 per cent of asymptomatic relatives of patients with osteogenesis imperfecta, nitroblue tetrazolium reduction by neutrophils was abnormally elevated. These data confirm previous findings that osteogenesis imperfecta is a generalized metabolic disease, of which an important component is an increase in cellular oxidative metabolism. Measurement of the hexose monophosphate shunt-linked respiration in leukocytes of relatives may help in delineating the genetic aspect of osteogenesis imperfecta.

We studied the in vitro effect of 3 Pis upon the deformability of red cells (RCD) from patients with homozygous sickle cell disease (SSD). The subjects were clinically stable and had not been transfused. The RCD was quantitated by measuring the filtration time (FT) of a red cell suspension through polycarbonate filters under aerobic conditions. Venous samples were incubated with one of 3 Pis (RA233 .12 mg/cc, pentoxifylline .18 mg/cc, aminophylline .1 and .02 mg/cc) and alone as a control. FTs were measured after 30 and 60 minutes of incubation. RA233 treated cells from 6 patients exhibited FTs of 190.6±86.3 secs at 30 min and 190±109.9 at 60 min versus control values of 274.6±131.3 and 323.5±119.5 respectively. These differences are significant (P < 0.05 & P < 0.005). The improvement at 30 versus 60 min with RA233 was not significantly different. Pentoxifylline and the 2 concentrations of aminophylline were each studied in 6 patients. All samples exhibited improved FTs but this did not attain statistical significance with these small groups. Six normal patients did not exhibit a significant change in FT with RA233. RA233, a PI, improves the deformability of oxygenated sickle cells in vitro. The mechanism of this alteration is not known. Further in vitro studies of RA233 and the other PIs are indicated to justify clinical trials of these agents in the prevention of the vasoocclusive symptoms of SSD.

Neutrophil (PMN) cellular chemotaxis was investigated in 8 children with Down's syndrome, their mothers and 13 adult controls. The new method used assessed separately the number of PMN's adhering to the Millipore filter of a Boyden chamber (“filter chemotaxis”, FC) and the number of PMN's migrating into its lower compartment (“compartment chemotaxis”, CC). “Total chemotaxis” (TC) was derived by adding FC and CC. Values are reported as percentage of the initial PMN number introduced into the chambers (X ± SEM): TC, which assesses best the chemotactic behavior of PMN's, was normal in all subjects, except a single patient who showed complete absence of cellular chemotaxis. Patients had significantly lower FC values than the control groups. Rather than indicating poor chemotaxis, this finding probably reflects decreased PMN adhesiveness to the Millipore filter. Abnormal PMN adhesiveness may contribute to the poor host defense against infections in Down's syndrome.

To the Editor.— We thank Dr. Elias for his timely comments. We agree that in our case it is difficult to define whether deficient cell-mediated immunity or the metabolic disturbances of uremia were responsible for the development of the staphylococcal scalded skin syndrome (SSSS). However, the suggestion that normal adults may develop SSSS is open to question. In the case reported by Rothenberg et al 1 and quoted by Dr. Elias, the evidence for normal immunity is scant. Their 64-year-old patient had staphylococcal septicemia, was a chronic alcoholic, had hypoalbuminemia, had treated advanced syphilis, and an atonic bladder, with chronic urinary tract infections. Furthermore, Rothenberg et al did not investigate cell-mediated immunity beyond performing a single skin test. It is difficult to classify their patient as a "normal" adult. Although uremia had been present in both our patient and the first adult in the case reported by Levine and Norden

A 54-year-old white man with chronic renal failure developed toxic epidermal necrolysis (TEN) due to an infection by Staphylococcus aureus of phage type 2. Analysis of host defenses in this patient revealed normal humoral immunity and neutrophil functions, but a deficiency in cell-mediated immunity. This deficit was characterized by negative delayed skin tests, no sensitization to 2,4-dinitrochlorobenzene, no phytohemagglutinin stimulation of peripheral lymphocytes, and inability of the patient's lymphocytes to release macrophage aggregation factor. This deficiency may have contributed to the development of the syndrome. It should be recognized that TEN may occur in an adult secondary to staphylococcal infections and that therapy with a penicillinase-resistant penicillin is needed.

Inhibition of several membrane-associated neutrophil (PMN) functions by corticosteroids has been suggested in previous reports. We evaluated the effect of hydrocortisone (HC) on phagocytosis by human PMNs with two widely utilized phagocytic assays. PMNs of adult volunteers were obtained by methylcellulose-hypaque separation. After a 30-minute pre-incubation with varying concentrations of HC, the cells were assayed either by Stoessel's Oil Red O method or by Tan's phagocytic-bactericidal method. Simultaneous control PMNs were pre-incubated with drug-free buffer. Trypan blue viability was satisfactory (> 93%) with up to 2 × 10-3M HC. Phagocytosis and bactericidal activity toward Staphylococcus aureus were unperturbed using up to 2 × 10-3M HC. By contrast, in the Oil Red O assay a significant inhibition of phagocytosis was observed with 2 × 10-3M HC (mean % inhibition ± SE 14.5 ± 1.6) and with 2 × 10-4M HC (17.9 ± 4.2, p < 0.025). With 2 × 10-2M HC profound inhibition of phagocytosis (76.1±5.1) occurred; similar inhibition (60 ± 12.5) was observed in the phagocytic-bactericidal assay. At 2 × 10-2M concentration, however, HC caused severe morphological cell alterations with over 60% of the PMNs trypan blue positive. Bactericidal activity remained normal at any HC concentration. Our data indicate that 1) in vitro exposure to HC affects phagocytosis by PMNs 2) it does not impair bactericidal activity 3) the Oil Red O phagocytic assay is more sensitive than the phagocytic-bactericidal test in detecting moderate phagocytic defects.

• The association of Fanconi's anemia (FA) and growth hormone (GH) deficiency is not commonly reported. These children may have the typical features of the FA syndrome, or may exhibit much variability in clinical and hematological findings. In a single family, members may have FA with or without GH deficiency. The genetic basis for this heterogeneity is unknown. We describe here two siblings with FA, one of whom had dwarfism due to GH deficiency. Combined treatment with GH and androgen (oxymetholone) resulted in strikingly greater acceleration of growth than did the use of GH alone. Pancytopenia was not influenced by hormone therapy. ( Am J Dis Child 133:291-293, 1979)

To the Editor. — Amygdalin (laetrile) tablets can release hydrocyanic acid on exposure to hydrolytic enzymes. To our knowledge, no fatality due to such poisoning has been reported to date. We wish to draw attention to the fact that when ingested accidentally by young children, amygdalin tablets may constitute a potentially fatal hazard. Report of a Case.— An 11-month-old girl accidentally ingested from one to five 500-mg amygdalin tablets. The tablets belonged to the child's father who has a malignant neoplasm. They were thought to be harmless by the parents and were contained in a vial along with an assortment of vitamin tablets. The patient became listless within half an hour after ingestion and vomited. Emesis was induced again by the mother who then rushed the child to the local hospital when her breathing became irregular and her state of consciousness became altered. An hour after ingestion, she was in

• Three patients with acrodermatitis enteropathica (AE), a disorder of zinc metabolism, demonstrated a zinc-responsive defect in chemotaxis of neutrophils and monocytes. Monocyte chemotaxis was depressed during a controlled period of zinc deficiency and increased to normal values after administration of oral zinc sulfate supplements that was sufficient to restore normal plasma zinc levels. In the only patient in whom neutrophils were also studied, a similar defect in chemotaxis of neutrophils was corrected by administration of zinc sulfate supplements. Preincubation of defective cells in vitro with zinc sulfate increased chemotaxis in an almost linear dose-response relationship. These findings suggest an important role for zinc in neutrophil and monocyte chemotaxis and demonstrate a correctable immune defect in AE. ( Arch Dermatol 113:422-425, 1977)

Haemophilus influenzae meningitis has been associated with anemia. Although the mechanism of this anemia has not been investigated, accelerated red cell destruction has been assumed because of the rapid decrease in hemoglobin in the absence of bleeding. To further define this pathophysiology, the RCD of patients with meningitis was studied by measuring the filtration time of washed red cells through polycarbonate filters. Eleven patients with Haemophilus influenzae meningitis, 3 with meningococcal meningitis, 9 with aseptic meningitis and 30 normal children were studied. The filtration time of the Haemophilus influenzae meningitis group (81.2 ± 96.1 secs) was significantly prolonged (P < 0.01) compared to the aseptic group (24.7 ± 6.4) and a group of normals (24.1 ± 5.3). The 3 children with meningococcal meningitis had filtration times of 73.5, 18.7 and 34.9 secs. Only 3 of 11 Haemophilus influenzae meningitis subjects fell within the normal range. Nine of 14 patients with bacterial meningitis were anemic versus 1/9 in the aseptic group. This study demonstrates that RCD is significantly diminished in children with bacterial meningitis. This decreased deformability may result in a diminished red cell survival and account for the postulated hemolytic anemia associated with this illness. The mechanism by which the RCD is altered remains to be elucidated.

704 CORRECTION OF NEUTROPHIL (PMN) DYSFUNCTION IN CHRONIC GRANULOMATOUS DISEASE (CGD) WITH AN IgG-OXIDASE CONJUGATE

Peritoneal irritation with casein is widely used to obtain neutrophil (PMNs) from rodents for investigations. Since casein forms aggregates, its phagocytosis could produce “fatigued” PMNs whose subsequent behavior might not reflect basic experimental conditions. We therefore studied the effect of casein upon yeast phagocytosis by human and rat PMNs, using a cytochemical method. Results are reported as means only, with corresponding P values. Following in vitro exposure to 8% sodium caseinate(9 experiments) human PMNs phagocytized less yeasts/100 cells than control PMNs (130 vs 410,P < 0.005); the number of phagocytic PMNs was also decreased (61% vs 96%, P < 0.005). With rat PMNs, 7 experiments yielded similar results (120 vs 270 yeasts/100 PMNs; 65.5% vs 96.0% phagocytic PMNs, P < 0.005). Elimination of casein aggregates by micro-filtration followed by reconcentration of the casein to 8% by ultrafiltration (4 experiments), partly corrected the phagocytosis inhibition (yeasts/100 PMNs with unfiltered 8% casein: 53; with filtered/reconcentrated 8% casein: 267; in controls: 471). Casein suspensions used to obtain peritoneal PMNs in rodents lead to significant cell fatigue as evidenced by a pronounced phagocytic defect. This dysfunction can be minimized by preventing casein aggregates through filtration and reconcentration of the casein suspension. Cell fatigue caused by particulate matter must be anticipated in studies of rodent phagocytes obtained from peritoneal exudates.

To evaluate the in vivo effect of prednisone on neutrophil (PMN) functions, prednisone (40 mg./day) was given orally for 3 days to 8 normal volunteers. PMN chemotaxis toward activated serum and PMN random migration were measured in modified Boyden chambers. NBT reduction after stimulation by phorbol myristate acetate was measured by use of flow-cytophotometry. Phagocytosis and bactericidal activity of Staphylococcus aureus were determined by the method of Tan et al. Twenty-four hours and 72 hours after the first prednisone dose the average absolute number of PMNs increased by 64% and 41% respectively from the initial 3.31 ± 1.0 × 109/1 (mean ± 1 SD). Chemotaxis was significantly decreased after 24 hours (P < 0.005) while the 72-hour chemotaxis returned to normal values in 2 subjects and remained low in the remaining 4. The increased random migration of PMNs which was found in 2 volunteers was also suppressed during the study period. Although phagocytosis of Staphylococcus aureus remained unaffected, bactericidal activity 72 hours after the first prednisone dose was significantly diminished as compared to initial values or to the values of untreated paired controls (P < 0.02). This decrease in bactericidal activity was observed following 30 minutes but not 120 minutes of PMN-bacteria interaction. NBT reduction by PMNs was not impaired. Short-term treatment with prednisone interferes with PMN chemotaxis and bactericidal activity and may therefore compromise host-defense mechanisms.

During remission, patients with acute lymphoblastic leukemia (ALL) may develop fungal infections. We investigated the possible contribution of drug-induced neutrophil (PMN) dysfunction to such infections before and after a single dose of vin-cristine (VCR) in 9 leukemic children in remission. At the time of “pulse” therapy, PMN yeast phagocytosis was performed before, 1 hour after and 24 hours after injection of VCR (2 mg/M2). Prednisone was omitted for 24 hours. Baker's yeast (Candida saccharomyces) phatocytosis was determined by a cytochemical technique. Slides were coded and read in blind fashion. Seven normal adults served as controls. Results are reported as number of yeast particles per 200 PMN (x ± SE). Yeast phagocytosis before VCR injection in ALL patients (865 ± 47) was not significantly lower than in the controls (948 ± 46, P > 0.1). Results obtained 1 hour (715 ± 67) and 24 hours (632 ± 63) after VCR administration showed a progressive and significant decrease in phagocytosis as compared with pre-VCR values (P < 0.025). In ALL patients during remission a significant defect in yeast phagocytosis develops immediately after VCR administration; this defect progresses further in the next 24 hours and may contribure to the propensity toward fungal infections observed in some patients.

Iron overload damages a wide variety of organ systems, and is accompanied by an increased susceptibility towards infections in some patients. The contribution of neutrophil (PMN) dysfunction to such infections has not been explored. We investigated PMN functions in seven chronically transfused children with documented iron overload (3 each with thalassemia major and sickle cell disease, and 1 with pure red cell aplasia). All patients had received monthly transfusions for over 6 years and had ferritin levels above 3000 ng/ml. A modification of Tan's technique was used to assay PMN bactericidal activity and phagocytosis towards Staphylococcus aureus 502 A. Results are reported in percent viable intracellular (IB) or extracellular (EB) bacteria after 30 or 120 minutes of incubation. PMN oxygen consumption (expressed as mM O2/109 PMNs) was measured by polarigraphy after stimulation with phorbol myristate acetate. All results (x ± SE) are indicated in the table below. PMN functions of iron overloaded patients appear to be normal. The abnormal propensity toward infections of such patients does not seem to be caused by a deterioration of their PMN phagocytic or bactericidal mechanisms.

Elevated hemoglobin (Hb) A2 levels are seen in heterozygous β thalassemia and rarely in pernicious anemia, Hb Zurich, and Hb Tacoma but have not been reported in homozygous sickle cell anemia (HSCA) in the English literature. We measured Hb A2 by cellulose acetate Hb electrophoresis and densitometry in 34 children with HSCA. Nine of them (26%) displayed Hb A2 levels of 3.2 to 4.7% (normal values for our laboratory: 0.7 - 3.0%). Their Hb values (7.4 to 9.2 g/dl) and reticulocyte counts (468 to 700 x 109/1) did not differ from those of the other 25 patients. Eight of these nine children showed normal to high MCVs ranging from 77 to 100 fl; one had an MCV of 63 fl. Globin chain separation by carboxymethylcellulose chromatography following the method of Cleggs and Weatherall was performed in five of the nine high HB A2 children including the one with the low MCV, and all showed a normal α/β chain ratio ranging from 0.91 to 1.05. The fetal Hb in these five subjects ranged from 1.2 to 6.6% and was not different from the values of the other 29 HSCA patients. An elevated Hb A2 level may be found in a significant proportion of HSCA patients. In addition to careful analysis of the MCV, globin chain synthesis studies may be necessary to differentiate these patients from subjects with sickle-β thalassemia.

Thrombocytosis as an initial feature of histiocytosis × has never been reported. In 8 of 12 patients with histiocytosis × seen at Children's Hospital of Buffalo in the past twenty years, platelet counts were available; seven of them were greater than 400 × 109/ 1 at diagnosis ( x ± SE = ± 54 × 109/ 1). All seven patients, who had an initial Lahey-Lucaya score averaging 3.1 (range: 2–4), are in disease-free remission ranging from 1 to 12 years. The eighth patient, who was thrombopenic at presentation and had a score of 7, is lost to follow-up. Following onset of therapy, platelet counts decreased progressively; they averaged 540 × 109 / 1 in treated but still symptomatic patients; 430 × 109/ 1 in treated, disease-free patients; and 375 × 109 / 1 in patients in complete remission and off all drugs. The difference between platelet counts at diagnosis and during remission is significant (P < 0.01). In the only patient who relapsed, thrombocytos is also recurred and disappeared again with subsequent remission. The etiology of the thrombocytosis is unknown, although in two cases, iron deficiency may have been contributory. Whether or not the heretofore undescribed initial thrombocytosis indicates a favorable prognosis is open to question.

In a six-year-old girl with a history of recurrent pulmonary infections and a mild bleeding tendency, a strikingly fishy smell was detected in the sweat and urine. She resembled a Turner syndrome phenotypically and had splenomegaly. Chromosomes were normal. Hematocrit was 30–34%, WBC 3,150–9,000/cu mm, platelet count 150,000–250,000/cu mm. Red blood cell (RBC) survival studies showed a slightly decreased half-time due to splenic sequestration; RBC volume was normal, but plasma volume was increased (60 ml/k). RBC's showed increased resistance to filtration through a 3 μ pore filter; this finding suggested increased cell membrane rigidity. Bleeding time was prolonged, platelet aggregation to collagen and adhesiveness to glass beads was decreased. Leukocyte adhesiveness to glass was decreased in 16 of 23 tests performed; other tests of leukocyte function were normal. The patient's mother, sister, maternal grandmother and maternal uncle also showed decreased leukocyte adhesiveness, but no other defects. Examination of the patient's urine by gas chromatography demonstrated the presence of excessive trimethylamine (TMA). This substance, a metabolite of choline, has a characteristic odor of decaying fish. When an oral choline load was given to the patient, she excreted large amounts of TMA in her urine as compared to a normal control. In addition, oral loading doses of TMA produced the fishy smell in the patient but not in the controls. This patient represents a new clinical and metabolic syndrome in which a disorder of choline metabolism, possibly due to TMA oxidase deficiency, may explain the defective membrane function of platelets, neutrophils and RBC's, and the accumulation of trimethylamine.