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FAILURE OF AUSTRALIA ANTIBODY TO PREVENT POST-TRANSFUSION HEPATITIS
553
FAILURE OF AUSTRALIA ANTIBODY TO PREVENT POST-TRANSFUSION HEPATITIS JOHN H. WALSH PAUL V. HOLLAND Blood Bank Department, Clinical Center, National Institutes of Health, Bethesda, Maryland 20014 ANDREW G. MORROW Clinic
National Heart Institute, National Institutes of Health, Bethesda
of Surgery,
ROBERT H. PURCELL
Laboratory of Infectious Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda
In a prospective study of 64 patients who received multiple transfusions at the time of open-heart surgery, the presence in the serum of Australia antibody was studied in relation to the development of post-transfusion hepatitis. Australia antibody developed in 2 of 32 patients with hepatitis and in 4 or 32 patients without hepatitis. Australia antigen was found in 4 of the patients with hepatitis but was not detected in those without hepatitis. The coexistence of both Australia antigen and Australia antibody was not demonstrated in any patient. In 2 patients Australia antibody, which was shown to be present before the onset of post-transfusion hepatitis, did not prevent the disease. The occurrence of hepatitis in patients with antibody to the Australia antigen suggests that such antibody does not completely protect against hepatitis, or, alternatively, that the hepatitis was caused by an agent serologically distinct from Australia antigen.
Summary
Introduction THE Australia antigen has been detected in sera from patients with serum and infectious hepatitis as well as other diseases. 1-3 In early studies from the N.I.H., the antigen was not found in sera from normal blood-donors but was identified in sera of patients with leukaemia and thalassasmia, virtually all of whom had received multiple transfusions.4 The Australia antigen is particulate, resembles a virus when examined by electron microscopy, and has been identified in the nuclei of liver cells of patients with viral hepatitis by use of a fluorescent-antibody technique.l55 It has been suggested that Australia antigen is an infectious agent which causes hepatitis in some peopleand that it is the virus responsible for both infectious and serum hepatitis.6 Antibody to the Australia antigen has been detected only in multiplytransfused patients, particularly those with haemophilia.4 7 A relationship between the presence of Australia antibody and the presence of clinical hepatitis has not been clearly established. We have investigated this relationship by examining the serial sera of multiplytransfused patients, with and without hepatitis, for the presence of Australia
antibody. Materials and Methods Sera were tested for Australia antibody and antigen by two methods. The micro-Ouchterlony technique of agargel diffusion employed by Blumberg and Riddel8 was used, with undiluted human sera as reagents. Modifications
included the use of 1% agarose and the buffer system of Prince2 virus protamine. In addition, a new complement-fixation technique 9 based on a modified microtitre method 10 was used. Where results differed, those obtained by the more sensitive complement-fixation technique were accepted. For the complement-fixation test, all sera were heated at 56°C for 30 minutes before testing. Twofold dilutions (1/2 to 1/16) of the serum to be tested were mixed with 4-8 units of Australia antigen or antibody, after which 1 -7 exact units of complement were added and the mixture was incubated overnight at 4°C before the addition of sensitised sheep red cells. The serum from a patient with chronic hepatitis of four years’ duration and the serum from a patient with acute myelogenous leukasmia were used as reagent sources of Australia antigen. Reagent antibodies to the Australia antigen were obtained from multiplytransfused patients. The specificity of these reagents was confirmed independently by Dr. B. Blumberg, Dr. R. McCollum, and Dr. D. Gocke. Selected sera were tested for the presence of IgM antibody to Australia antigen by treatment with 0-2M 2-mercaptoethanol, 0’6M ethanethiol 11 and by immunoelectrophoresis in agar. Sera were tested for complementfixing (c.F.) antibody to cytomegalovirus (c.M.v.) by the method of Rowe et al.,12 using the AD-169 strain of c.M.v. Sera were tested for complement-fixing antibody to the Epstein-Barr virus (E.B.v.) through the kindness of Dr. Paul Gerber. Patients studied were all members of a prospective
hepatitis study from whom serial blood specimens were obtained before and at weekly to monthly intervals after massive transfusion accompanying open-heart surgery.13 Hepatitis was diagnosed when: (1) the serum-s.G.P.T. value (or s.G.o.T. if S.G.P.T. was not obtained) exceeded 100 Karmen units (two and a half times the upper limits of normal) and an elevation above 80 units was demonstrated for 2 or more weeks between 2 and 26 weeks after operation ; and (2) when other possible causes for elevated transaminase levels were excluded. Results
A total of 665 sera were collected from 64 patients who received an average of 18 transfusions at the time of cardiac surgery. In none of these patients were Australia antigen or antibody found in pre-transfusion sera. 32 of the patients developed evidence of post-transfusion hepatitis. Australia antibody appeared in 2 (6%) of the patients with post-transfusion hepatitis and Australia antigen in 4 (12%). Australia antigen was not found in any of the 32 patients who did not develop hepatitis, but 4 (12%) produced
antibody. Australia antigen and antibody were never detected simultaneously or in sequential blood-specimens from the same patient.
Case-reports Case 1 A 55-year-old White male received 17 units of whole blood during a mitral-valve replacement in 1965, 10 years after receiving blood during a mitral commissurotomy. Antibody to Australia antigen was detected in the first serum specimen obtained 10 days after his current operation and in each serum sample obtained up to the 14th postoperative week (fig. 1). The patient had antibody to E.B.V. prior to operation and this was not subsequently restudied; he was seronegative (c.F. titre < 1/2) to c.M.v. both before and after transfusion with his open-heart operation. The patient developed anicteric hepatitis 10 weeks after operation, at a time when his serum level of Australia antibody was
554 to Australia antigen was high, he experienced the abrupt onset of icteric hepatitis accompanied by markedly elevated transaminase values, which returned to normal over the next 2 months (fig. 2). The patient had pre-existing antibody to E.B.V.; he was seronegative to c.M.v. before operation and up to the 7th postoperative week. to c.M.v. was first detected during the 9th postoperative week (titre of rose to in the 15th week, was
Antibody
1/64 1/16), 1/32 in the 21st week, and was still detectable (titre of 1/8) 176 weeks after transfusion. Incubation of the earliest postoperative serum specimens from these 2 patients with 2-mercaptoethanol or with ethanethiol did not destroy Australiaantibody activity tested by agar-gel diffusion in one case and by complement-fixation in the other. When untreated samples of these same serum specimens were subjected to immunoelectrophoresis, both IgM and IgG globulins were detected; but only the IgG component formed a precipitin line with Australia antigen. These findings suggest that most, if not all, of the Australia antibody was IgG. Discussion
Fig. 1-Case 1: serial S.G.P.T. values and C.F. titres of antibody to Australia antigen.
but diminishing. His transaminase levels returned the normal range 9 weeks after onset of his hepatitis.
high to
Case 2 A 46-year-old White male underwent aortic-valve replacement with cardiopulmonary bypass in January, 1966, and received 24 units of blood. 13 days postoperatively he was found to have antibody to Australia antigen, which continued to be present in all serial serum specimens obtained over the next 5 months. 6 weeks after operation, at a time when his serum level of antibody
Fig. 2-Case 2: serial S.G.P.T. values and C.F. titres of antibody to Australia antigen.
While Australia antigen has been closely associated with both serum and infectious hepatitis, 12 this association has not been demonstrated for the Australia antibody. Gocke and Kavey3 found that some patients with post-transfusion hepatitis, who had no detectable Australia antigen, occasionally had weak and inconsistent antibody to Australia antigen in their sera during convalescence. Hirschman et al.6 noted that, of 8 patients with haemophilia and Australia antibody, 5 had a history of hepatitis, but they did not detect antibody in the sera of convalescent patients who had infectious or serum hepatitis. Okochi and Murakamiobserved the development of Australia antibody after transfusion of Australiaantigen-positive blood in patients without evident hepatitis. By contrast, we have found high titres of antibody to Australia antigen concurrent with posttransfusion hepatitis in 2 patients. In neither patient was the antibody present prior to transfusion. In both it appeared before the transaminase level rose; Australia antibody became undetectable during the course of the hepatitis in one, but it persisted throughout and after the illness in the other. While we also observed 4 patients in whom Australia antibody developed without evidence of hepatitis, the presence of such antibody did not prevent the disease in the 2 present cases. In these 2 patients, high titres of antibody to Australia antigen were first detected 10 days and 13 days after massive transfusions. All of the antibody appeared to be of the IgG class; thus it is unlikely that the antibody response was a primary one. It is equally unlikely that the Australia antibody was passively transfused, since the titres were high, and we have not found antibody to Australia antigen in sera from over 1300 donors. In both patients, the antibody may represent an anamnestic response to prior exposure. Hirschman et al. have suggested that a single virus is responsible for both infectious and serum hepatitis and that the different incubation periods of these two forms of hepatitis may simply reflect different portals of entry. The studies of Krugman et al.14 do At Willowbrook not support such an hypothesis.
555
State School, children exposed to their MS-1 serum pool (which they believed to contain infectioushepatitis virus) were immune to rechallenge with the same pool but not to the MS-2 serum pool (which they believed to contain serum-hepatitis virus). Furthermore, Australia antigen was not detected in sera from children with MS-1 hepatitis but was demonstrable in sera from children with MS-2 hepatitis 15; they conclude that these findings further differentiate the two types of hepatitis which had been
previously-characterised by clinical, epidemiological, and immunological differences. If the Australia antigen represents a hepatitis virus, and if the respective antibody is protective, our findings also suggest that two or more serologically distinct agents can cause hepatitis, since in 2 patients evidence of moderate to severe hepatitis developed despite the presence of high levels of antibody to Australia antigen. If this is true, then the second agent (not Australia antigen) was responsible for the observed hepatitis. It is nevertheless possible that the hepatitis in these patients was caused by the Australia antigen and that its corresponding antibody does not afford protection. If the Australia antibody is directed toward a viral antigen, the circulating antibody may not have been protective because the hepatitis virus was intracellular. Liver-biopsy specimens were not available in this study to test for the presence of Australia antigen in hepatic cells. Another possibility is that, while the Australia antibody may have been directed against viral antigen, it may not have been directed against the infecting serotype; multiple serotypes of Australiaantigen-associated hepatitis virus may share a common complement-fixing antigen much as do members of the c.M.v. group. The description of a second Australia antigen specificity by Levene and Blumberg 16 supports this interpretation. Our 2 patients may have been infected with Australia-antigen-associated virus and c.M.v. simultaneously. Thus, while they may have been protected against the former, the latter may have produced the clinical disease. Patient 2 developed serological evidence of c.M.v. infection, but his clinical course was unusual for c.M.v.-associated illness. c.M.v. infection usually occurs within 2 to 5 weeks of exposure and is characterised by fever, an infectious-mononucleosis-like syndrome, and sometimes mild hepatitis; in the patients described by Lang and Hanshaw 11 with severe hepatitis associated with c.M.v. infection after open-heart operations, other possible aetiological agents such as Australia antigen were not ruled out. Lastly the appearance of Australia antibody in the sera of patients with hepatitis may indicate the presence of an infection but have nothing to do with immunitye.g., heterophile antibody in infectious mononucleosis. Since a hepatitis vaccine would be a potential goal of current investigation, we believe it important to examine in greater detail the role of circulating antibody in protection against Australia-antigen-positive
hepatitis. Addendum We have now seen a third patient with Australia antibody and post-transfusion hepatitis. A 26-year-old White female received 22 units of whole blood during correction of a tetrology of Fallot (she had received transfusions 20 years previously during a Blalock shunt procedure). Antibody to
was not present prior to or 6 days after this second operation, but was detected in serum drawn on the 14th postoperative day. Australia antibody was present in the following weekly serum samples up to the 6th week when she developed anicteric hepatitis with abnormal transaminase levels. The antibody to Australia antigen which appeared in this patient’s serum was clearly not passively transfused and did not prevent her post-transfusion hepatitis.
Australia antigen
We thank Mrs. D. Wong, Mrs. B. Brunell, Dr. J. Johnson, and Dr. H. Reynolds for technical assistance and advice; Dr. R. Chanock and Dr. P. Schmidt for suggestions in the preparation of this report; Dr. R. Reis for permission to publish clinical data; and Dr. H. Ticktin and Dr. R. Shulman for allowing us to submit patients to plasmapheresis for antisera. Requests for reprints should be addressed to Dr. P. V. H. REFERENCES
Blumberg, B. S., Sutnick, A. I., London, W. T. Bull. N.Y. Acad. Med. 1968, 44, 1566. 2. Prince, A. M. Proc. Natn. Acad. Sci., U.S.A. 1968, 60, 814. 3. Gocke, D. J., Kavey, N. B. Lancet, 1969, i, 1055. 4. Blumberg, B. S., Alter, H., Visnich, S. J. Am. med. Ass. 1965, 191, 541. 5. Millman, I., Zavatone, V., Gertsley, B. J. S., Blumberg B. S. Nature, Lond. 1969, 222, 181. 6. Hirschman, R. J., Shulman, N. R., Barker, L. F., Smith, K. O. J. Am. med. Ass. 1969, 208, 1667. 7. Okochi, D., Murakami, S. Vox sang, 1968, 15, 374. 8. Blumberg, B. S., Riddel, N. M. J. clin. Invest. 1963, 42, 867. 9. Purcell, R., Holland, P., Walsh, J., Wong, D., Morrow, A., Chanock, R. J. infect. Dis. 1969, 120, 383. 10. Sever, J. L. J. Immun. 1962, 88, 320. 11. Murray, E. S., O’Connor, J. M., Gaor, J. A. Proc. Soc. exp. Biol. Med. 1965, 119, 291. 12. Rowe, W. P., Hartley, J. W., Waterman, S., Turner, H. C., Huebner, R. J. ibid. 1956, 92, 418. 13. Walsh, J. H., Purcell, R. H., Morrow, A. G., Chanock, R. M., Schmidt, P. J. J. Am. med. Ass. (in the press). 14. Krugman, S., Giles, J. P., Hammond, J. ibid. Ass. 1967,200, 365. 15. Giles, J. P., McCollum, R. W., Berndtson, L. W., Krugman, S. New Engl. J. med. 1969, 281, 119. 16. Levene, C., Blumberg, B. S. Nature, Lond. 1969, 221, 195. 17. Lang, D. J., Hanshaw, J. B. New Engl. J. Med. 1969, 280, 1145. 1.
PSEUDOPOLYPOSIS IN ULCERATIVE COLITIS K. N. JALAN W. SIRCUS R. J. WALKER J. P. A. MCMANUS Gastro-intestinal Unit, Western General Hospital,
Edinburgh R.
Computer
J. PRESCOTT
and Statistics
Section, Department of Social Medicine, University of Edinburgh W. I. CARD
Department of Medicine in Relation to Mathematics and Computing, University of Glasgow
retrospective analysis of 399 patients with ulcerative colitis the clinical significance of pseudopolyposis has been examined. 75 patients had pseudopolyposis. Pseudopolyposis was more likely to occur in patients with In
Sum ary
a
and extensive disease. The outcome of severe attacks of ulcerative colitis in the presence of pseudopolyps was found to be more favourable. severe
Introduction
after
attack of ulcerative colitis postinflammatory proliferations of mucosa, islands of surviving epithelium, and epithelialised granulation DURING
or
an
FAILURE OF AUSTRALIA ANTIBODY TO PREVENT POST-TRANSFUSION HEPATITIS JOHN H. WALSH PAUL V. HOLLAND Blood Bank Department, Clinical Center, National Institutes of Health, Bethesda, Maryland 20014 ANDREW G. MORROW Clinic
National Heart Institute, National Institutes of Health, Bethesda
of Surgery,
ROBERT H. PURCELL
Laboratory of Infectious Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda
In a prospective study of 64 patients who received multiple transfusions at the time of open-heart surgery, the presence in the serum of Australia antibody was studied in relation to the development of post-transfusion hepatitis. Australia antibody developed in 2 of 32 patients with hepatitis and in 4 or 32 patients without hepatitis. Australia antigen was found in 4 of the patients with hepatitis but was not detected in those without hepatitis. The coexistence of both Australia antigen and Australia antibody was not demonstrated in any patient. In 2 patients Australia antibody, which was shown to be present before the onset of post-transfusion hepatitis, did not prevent the disease. The occurrence of hepatitis in patients with antibody to the Australia antigen suggests that such antibody does not completely protect against hepatitis, or, alternatively, that the hepatitis was caused by an agent serologically distinct from Australia antigen.
Summary
Introduction THE Australia antigen has been detected in sera from patients with serum and infectious hepatitis as well as other diseases. 1-3 In early studies from the N.I.H., the antigen was not found in sera from normal blood-donors but was identified in sera of patients with leukaemia and thalassasmia, virtually all of whom had received multiple transfusions.4 The Australia antigen is particulate, resembles a virus when examined by electron microscopy, and has been identified in the nuclei of liver cells of patients with viral hepatitis by use of a fluorescent-antibody technique.l55 It has been suggested that Australia antigen is an infectious agent which causes hepatitis in some peopleand that it is the virus responsible for both infectious and serum hepatitis.6 Antibody to the Australia antigen has been detected only in multiplytransfused patients, particularly those with haemophilia.4 7 A relationship between the presence of Australia antibody and the presence of clinical hepatitis has not been clearly established. We have investigated this relationship by examining the serial sera of multiplytransfused patients, with and without hepatitis, for the presence of Australia
antibody. Materials and Methods Sera were tested for Australia antibody and antigen by two methods. The micro-Ouchterlony technique of agargel diffusion employed by Blumberg and Riddel8 was used, with undiluted human sera as reagents. Modifications
included the use of 1% agarose and the buffer system of Prince2 virus protamine. In addition, a new complement-fixation technique 9 based on a modified microtitre method 10 was used. Where results differed, those obtained by the more sensitive complement-fixation technique were accepted. For the complement-fixation test, all sera were heated at 56°C for 30 minutes before testing. Twofold dilutions (1/2 to 1/16) of the serum to be tested were mixed with 4-8 units of Australia antigen or antibody, after which 1 -7 exact units of complement were added and the mixture was incubated overnight at 4°C before the addition of sensitised sheep red cells. The serum from a patient with chronic hepatitis of four years’ duration and the serum from a patient with acute myelogenous leukasmia were used as reagent sources of Australia antigen. Reagent antibodies to the Australia antigen were obtained from multiplytransfused patients. The specificity of these reagents was confirmed independently by Dr. B. Blumberg, Dr. R. McCollum, and Dr. D. Gocke. Selected sera were tested for the presence of IgM antibody to Australia antigen by treatment with 0-2M 2-mercaptoethanol, 0’6M ethanethiol 11 and by immunoelectrophoresis in agar. Sera were tested for complementfixing (c.F.) antibody to cytomegalovirus (c.M.v.) by the method of Rowe et al.,12 using the AD-169 strain of c.M.v. Sera were tested for complement-fixing antibody to the Epstein-Barr virus (E.B.v.) through the kindness of Dr. Paul Gerber. Patients studied were all members of a prospective
hepatitis study from whom serial blood specimens were obtained before and at weekly to monthly intervals after massive transfusion accompanying open-heart surgery.13 Hepatitis was diagnosed when: (1) the serum-s.G.P.T. value (or s.G.o.T. if S.G.P.T. was not obtained) exceeded 100 Karmen units (two and a half times the upper limits of normal) and an elevation above 80 units was demonstrated for 2 or more weeks between 2 and 26 weeks after operation ; and (2) when other possible causes for elevated transaminase levels were excluded. Results
A total of 665 sera were collected from 64 patients who received an average of 18 transfusions at the time of cardiac surgery. In none of these patients were Australia antigen or antibody found in pre-transfusion sera. 32 of the patients developed evidence of post-transfusion hepatitis. Australia antibody appeared in 2 (6%) of the patients with post-transfusion hepatitis and Australia antigen in 4 (12%). Australia antigen was not found in any of the 32 patients who did not develop hepatitis, but 4 (12%) produced
antibody. Australia antigen and antibody were never detected simultaneously or in sequential blood-specimens from the same patient.
Case-reports Case 1 A 55-year-old White male received 17 units of whole blood during a mitral-valve replacement in 1965, 10 years after receiving blood during a mitral commissurotomy. Antibody to Australia antigen was detected in the first serum specimen obtained 10 days after his current operation and in each serum sample obtained up to the 14th postoperative week (fig. 1). The patient had antibody to E.B.V. prior to operation and this was not subsequently restudied; he was seronegative (c.F. titre < 1/2) to c.M.v. both before and after transfusion with his open-heart operation. The patient developed anicteric hepatitis 10 weeks after operation, at a time when his serum level of Australia antibody was
554 to Australia antigen was high, he experienced the abrupt onset of icteric hepatitis accompanied by markedly elevated transaminase values, which returned to normal over the next 2 months (fig. 2). The patient had pre-existing antibody to E.B.V.; he was seronegative to c.M.v. before operation and up to the 7th postoperative week. to c.M.v. was first detected during the 9th postoperative week (titre of rose to in the 15th week, was
Antibody
1/64 1/16), 1/32 in the 21st week, and was still detectable (titre of 1/8) 176 weeks after transfusion. Incubation of the earliest postoperative serum specimens from these 2 patients with 2-mercaptoethanol or with ethanethiol did not destroy Australiaantibody activity tested by agar-gel diffusion in one case and by complement-fixation in the other. When untreated samples of these same serum specimens were subjected to immunoelectrophoresis, both IgM and IgG globulins were detected; but only the IgG component formed a precipitin line with Australia antigen. These findings suggest that most, if not all, of the Australia antibody was IgG. Discussion
Fig. 1-Case 1: serial S.G.P.T. values and C.F. titres of antibody to Australia antigen.
but diminishing. His transaminase levels returned the normal range 9 weeks after onset of his hepatitis.
high to
Case 2 A 46-year-old White male underwent aortic-valve replacement with cardiopulmonary bypass in January, 1966, and received 24 units of blood. 13 days postoperatively he was found to have antibody to Australia antigen, which continued to be present in all serial serum specimens obtained over the next 5 months. 6 weeks after operation, at a time when his serum level of antibody
Fig. 2-Case 2: serial S.G.P.T. values and C.F. titres of antibody to Australia antigen.
While Australia antigen has been closely associated with both serum and infectious hepatitis, 12 this association has not been demonstrated for the Australia antibody. Gocke and Kavey3 found that some patients with post-transfusion hepatitis, who had no detectable Australia antigen, occasionally had weak and inconsistent antibody to Australia antigen in their sera during convalescence. Hirschman et al.6 noted that, of 8 patients with haemophilia and Australia antibody, 5 had a history of hepatitis, but they did not detect antibody in the sera of convalescent patients who had infectious or serum hepatitis. Okochi and Murakamiobserved the development of Australia antibody after transfusion of Australiaantigen-positive blood in patients without evident hepatitis. By contrast, we have found high titres of antibody to Australia antigen concurrent with posttransfusion hepatitis in 2 patients. In neither patient was the antibody present prior to transfusion. In both it appeared before the transaminase level rose; Australia antibody became undetectable during the course of the hepatitis in one, but it persisted throughout and after the illness in the other. While we also observed 4 patients in whom Australia antibody developed without evidence of hepatitis, the presence of such antibody did not prevent the disease in the 2 present cases. In these 2 patients, high titres of antibody to Australia antigen were first detected 10 days and 13 days after massive transfusions. All of the antibody appeared to be of the IgG class; thus it is unlikely that the antibody response was a primary one. It is equally unlikely that the Australia antibody was passively transfused, since the titres were high, and we have not found antibody to Australia antigen in sera from over 1300 donors. In both patients, the antibody may represent an anamnestic response to prior exposure. Hirschman et al. have suggested that a single virus is responsible for both infectious and serum hepatitis and that the different incubation periods of these two forms of hepatitis may simply reflect different portals of entry. The studies of Krugman et al.14 do At Willowbrook not support such an hypothesis.
555
State School, children exposed to their MS-1 serum pool (which they believed to contain infectioushepatitis virus) were immune to rechallenge with the same pool but not to the MS-2 serum pool (which they believed to contain serum-hepatitis virus). Furthermore, Australia antigen was not detected in sera from children with MS-1 hepatitis but was demonstrable in sera from children with MS-2 hepatitis 15; they conclude that these findings further differentiate the two types of hepatitis which had been
previously-characterised by clinical, epidemiological, and immunological differences. If the Australia antigen represents a hepatitis virus, and if the respective antibody is protective, our findings also suggest that two or more serologically distinct agents can cause hepatitis, since in 2 patients evidence of moderate to severe hepatitis developed despite the presence of high levels of antibody to Australia antigen. If this is true, then the second agent (not Australia antigen) was responsible for the observed hepatitis. It is nevertheless possible that the hepatitis in these patients was caused by the Australia antigen and that its corresponding antibody does not afford protection. If the Australia antibody is directed toward a viral antigen, the circulating antibody may not have been protective because the hepatitis virus was intracellular. Liver-biopsy specimens were not available in this study to test for the presence of Australia antigen in hepatic cells. Another possibility is that, while the Australia antibody may have been directed against viral antigen, it may not have been directed against the infecting serotype; multiple serotypes of Australiaantigen-associated hepatitis virus may share a common complement-fixing antigen much as do members of the c.M.v. group. The description of a second Australia antigen specificity by Levene and Blumberg 16 supports this interpretation. Our 2 patients may have been infected with Australia-antigen-associated virus and c.M.v. simultaneously. Thus, while they may have been protected against the former, the latter may have produced the clinical disease. Patient 2 developed serological evidence of c.M.v. infection, but his clinical course was unusual for c.M.v.-associated illness. c.M.v. infection usually occurs within 2 to 5 weeks of exposure and is characterised by fever, an infectious-mononucleosis-like syndrome, and sometimes mild hepatitis; in the patients described by Lang and Hanshaw 11 with severe hepatitis associated with c.M.v. infection after open-heart operations, other possible aetiological agents such as Australia antigen were not ruled out. Lastly the appearance of Australia antibody in the sera of patients with hepatitis may indicate the presence of an infection but have nothing to do with immunitye.g., heterophile antibody in infectious mononucleosis. Since a hepatitis vaccine would be a potential goal of current investigation, we believe it important to examine in greater detail the role of circulating antibody in protection against Australia-antigen-positive
hepatitis. Addendum We have now seen a third patient with Australia antibody and post-transfusion hepatitis. A 26-year-old White female received 22 units of whole blood during correction of a tetrology of Fallot (she had received transfusions 20 years previously during a Blalock shunt procedure). Antibody to
was not present prior to or 6 days after this second operation, but was detected in serum drawn on the 14th postoperative day. Australia antibody was present in the following weekly serum samples up to the 6th week when she developed anicteric hepatitis with abnormal transaminase levels. The antibody to Australia antigen which appeared in this patient’s serum was clearly not passively transfused and did not prevent her post-transfusion hepatitis.
Australia antigen
We thank Mrs. D. Wong, Mrs. B. Brunell, Dr. J. Johnson, and Dr. H. Reynolds for technical assistance and advice; Dr. R. Chanock and Dr. P. Schmidt for suggestions in the preparation of this report; Dr. R. Reis for permission to publish clinical data; and Dr. H. Ticktin and Dr. R. Shulman for allowing us to submit patients to plasmapheresis for antisera. Requests for reprints should be addressed to Dr. P. V. H. REFERENCES
Blumberg, B. S., Sutnick, A. I., London, W. T. Bull. N.Y. Acad. Med. 1968, 44, 1566. 2. Prince, A. M. Proc. Natn. Acad. Sci., U.S.A. 1968, 60, 814. 3. Gocke, D. J., Kavey, N. B. Lancet, 1969, i, 1055. 4. Blumberg, B. S., Alter, H., Visnich, S. J. Am. med. Ass. 1965, 191, 541. 5. Millman, I., Zavatone, V., Gertsley, B. J. S., Blumberg B. S. Nature, Lond. 1969, 222, 181. 6. Hirschman, R. J., Shulman, N. R., Barker, L. F., Smith, K. O. J. Am. med. Ass. 1969, 208, 1667. 7. Okochi, D., Murakami, S. Vox sang, 1968, 15, 374. 8. Blumberg, B. S., Riddel, N. M. J. clin. Invest. 1963, 42, 867. 9. Purcell, R., Holland, P., Walsh, J., Wong, D., Morrow, A., Chanock, R. J. infect. Dis. 1969, 120, 383. 10. Sever, J. L. J. Immun. 1962, 88, 320. 11. Murray, E. S., O’Connor, J. M., Gaor, J. A. Proc. Soc. exp. Biol. Med. 1965, 119, 291. 12. Rowe, W. P., Hartley, J. W., Waterman, S., Turner, H. C., Huebner, R. J. ibid. 1956, 92, 418. 13. Walsh, J. H., Purcell, R. H., Morrow, A. G., Chanock, R. M., Schmidt, P. J. J. Am. med. Ass. (in the press). 14. Krugman, S., Giles, J. P., Hammond, J. ibid. Ass. 1967,200, 365. 15. Giles, J. P., McCollum, R. W., Berndtson, L. W., Krugman, S. New Engl. J. med. 1969, 281, 119. 16. Levene, C., Blumberg, B. S. Nature, Lond. 1969, 221, 195. 17. Lang, D. J., Hanshaw, J. B. New Engl. J. Med. 1969, 280, 1145. 1.
PSEUDOPOLYPOSIS IN ULCERATIVE COLITIS K. N. JALAN W. SIRCUS R. J. WALKER J. P. A. MCMANUS Gastro-intestinal Unit, Western General Hospital,
Edinburgh R.
Computer
J. PRESCOTT
and Statistics
Section, Department of Social Medicine, University of Edinburgh W. I. CARD
Department of Medicine in Relation to Mathematics and Computing, University of Glasgow
retrospective analysis of 399 patients with ulcerative colitis the clinical significance of pseudopolyposis has been examined. 75 patients had pseudopolyposis. Pseudopolyposis was more likely to occur in patients with In
Sum ary
a
and extensive disease. The outcome of severe attacks of ulcerative colitis in the presence of pseudopolyps was found to be more favourable. severe
Introduction
after
attack of ulcerative colitis postinflammatory proliferations of mucosa, islands of surviving epithelium, and epithelialised granulation DURING
or
an