Activated eosinophils in chronic inflammatory bowel disease

126

significant result (p

0-07 for tests, 95% confidence interval for the binomial parameter 71= 0024 for controls). In a separate series of experiments, no intrathecally produced antibodies (IA) to B burgdorferi were detected in cerebrospinal fluid. Both mumps and Lyme borreliosis may manifest as aseptic meningitis. Because a tick bite may remain unnoticed5 and transmission of B burgdorferi by vectors other than ticks is suspectedthe absence of a tick bite cannot exclude infection. On the other hand, mumps infection can occur without parotitis. Thus, we looked for a measure to differentiate between the conditions. In chronic forms of adult neuroborreliosis the production of IA is described.7,8 We have evidence that only a quarter of the children with B burgdorferi meningitis seen by us show production of IA (unpublished observation). Thus, the detected IgG quotients of specific anti-B burgdorferi antibodies cannot exclude the B burgdorferi meningitis. The high percentage of B burgdorferi seropositives in the aseptic mumps meningitis group points to a hitherto unrecognised cross-reactivity. It may also be the case that a mumps infection can induce production of antibodies to B burgdorferi in a latent, hitherto seronegative B burgdorferi infection.

76% of sera indicated immunity to all three types. We speculated that the Natal epidemic was due to a high burden of wild type virus resulting from a breakdown in sanitation services which had followed the extensive floods in the area some months previously. These natural experiments must teach us to ensure that the primary means of preventing outbreaks of poliomyelitis in communities where faecal-oral transmission is dominant is to eliminate reservoirs of wild-type virus. The only reservoir of poliovirus is the human gastrointestinal tract, and the only way to eliminate this reservoir is via gut immunity, which can be achieved effectively only with oral poliovaccine. Inactivated poliovaccine can never produce 100% immunity and the remnant of susceptibles will always remain vulnerable to the wild-type virus. In South Africa we introduced, in early 1989, a routine supplementary monovalent type 1 oral poliovaccine at birth in an attempt to ensure high levels of gut and serum immunity to type 1 poliovirus and to reduce the type 1 virus reservoir.4

M. M. MILLNER M. G. SCHIMEK R. R. MUELLEGGER

Saayman G, Küstner HGV, Boer P, Johnson S, Schoub BD, McAnerney JM. Poliomyelitis outbreak in South Africa, 1982 I: epidemiology. Trans R Soc Trop Med Hyg 1984; 78: 23-35. 2. Johnson S, Schoub BD, McAnerney JM, et al. Poliomyelitis outbreak in South Africa, 1982 II: laboratory and vaccine aspects. Trans R Soc Trop Med Hyg 1984; 78:

=

Department of Paediatrics, University of Graz, A-8036 Graz, Austria

Hygiene Institute, University of Vienna, Austria

G. STANEK

National Institute for Virology, Sandringham 2131, South Africa 1.

26-31. 3. Hukins G. The investigation of a polio epidemic in Natal/Kwazulu from December 1987 to June 1988. In: Proceedings of the 7th Epidemiological Congress of South

4. 1. Millner MM, Schimek MG, Spork D, Schnizer M, Stanek G. Lyme borreliosis in children: a controlled clinical study based on ELISA values. Eur J Pediatr 1989; 148: 527-30. 2. Guy EC, Bateman DE, Martyn CN, Heckels JE, Lawton NF. Lyme disease: prevalence and clinical importance of Borrelia burgdorferi specific IgG in forestry workers. Lancet 1989; i: 484-86. 3. Dattwyler RJ, Volkman DJ, Luft BJ, Halperin JJ, et al. Seronegative Lyme disease. N Engl J Med 1988; 319: 1441-46. 4. Clopper CJ, Pearson ES. The use of confidence of fiducial limits illustrated in the case of the binomial. Biometrika 1934; 26: 404-13. 5. Stanek G, Flamm H. Borrelia-Infektionen bei Kindern in Mitteleuropa. Pediatr Grenzgreb 1986; 25: 133-46. 6. Stanek G, Pleschette M, Flamm H, Hirschl AM, et al. European Lyme borreliosis. Ann NY Acad Sci 1988; 539: 274-82. 7. Ackermann R, Rehse-Küpper B, Gollmer E. Progressive Borrelia encephalomyelitis. Zentralbl Bakteriol Mikrobiol Hyg [A] 1986; 263: 297-300. 8. Rehse-Küpper B, Ackermann R. Demonstration of locally synthesized Borrelia antibodies in cerebrospinal fluid. Zentralbl Bakteriol Mikrobiol Hyg [A]1986; 263: 407-11.

Immunity to poliomyelitis SiR,—The 1988 poliomyelitis outbreak in Israel, reported on and discussed in your May 19 issue, illustrates the ability of wild-type poliovirus to ferret out susceptible individuals in any population, even those extensively immunised. South Africa experienced two kinds of poliomyelitis epidemic, both due to type 1 virus, in the 1980s. The 1982 epidemic in Gazankulu, a rural black selfgoverning territory in north-east South Africa, was clearly due to underimmunisation.1,2 260 paralytic cases and 42 deaths were reported, and in 74% of sera from patients a characteristic picture of high titres to the causative type 1 poliovirus with no demonstrable antibodies to types 2 and 3 was found. Furthermore, surrounding areas with similar populations, when surveyed at the time of that epidemic, were found to have immunity levels of 52% and an immunisation coverage, on history, of 52% .2 The second kind of poliomyelitis epidemic was, as in the Israel outbreak, not clearly due to underimmunisation. This epidemic, in Natal province, from December, 1987, to June, 1988, resulted in 437 paralytic cases and 46 deaths.3 However, only 16 of 129 (12-4%) sera from patients examined by us had the picture of high antibody titres to type 1 and no detectable antibodies to types 2 and 3. Indeed, type 2 antibodies were present in 81 4% and type 3 in 72-11 % of sera. Corroborating the high level of immunity in the population, were the fmdings of a survey of 194 children aged 2-2years in the same district at the time of the epidemic, but before the intensified immunisation campaign began, which revealed seropositivity rates of 84%, 95%, and 90% positivity to types 1, 2, and 3, respectively;

BARRY D. SCHOUB SYLVIA JOHNSON JO M. McANERNEY

Africa (Pretoria, 1989). Schoub BD, Johnson S, McAnerney JM, Gilbertson L, Klaassen KIM, Reinach SG. Monovalent neonatal polio immunization: a strategy for the developing world. J Infect Dis 1988; 157: 836-39.

eosinophils in chronic inflammatory bowel disease

Activated

present in the mucosa of normal human in increased numbers in chronic inflammatory bowel disease. They contain several granuleassociated proteins, including major basic protein, eosinophil cationic protein (ECP), peroxidase, and eosinophil derived neurotoxin, which can cause tissue damage. Ultrastructural evidence for the release of eosinophil major basic protein-containing crystalline cores has been documented in active Crohn’s disease.’ The monoclonal antibody EG2 recognises an epitope on the secreted form of ECP, the expression of which is associated with eosinophil activation. We report major differences between the frequency of activated ECP secreting eosinophils in the mucosa in active Crohn’s disease and ulcerative colitis. Biopsy specimens of normal transverse colon and terminal ileum were obtained during colonoscopy from children aged 1-17 years with a history suggestive of inflammatory bowel disease but in whom specimens proved to be normal on routine histological examination. Diseased tissue was obtained at operation from patients with chronic active inflammatory bowel disease unresponsive to medical management. Frozen sections were prepared and EG2 staining was detected by the alkaline phosphatase, anti-alkaline phosphatase method with fast red to localise antibody binding. In the absence of primary monoclonal anti-ECP antibody the only staining was attributable to endogenous alkaline phosphatase in the epithelial brush border. Results are expressed as a ratio of stained to unstained cells in random fields within the lamina propria, and counting (at least 500 cells) was done blind to the diagnosis. Counting was only possible where the ECP staining was intracellular. Cellular staining could be visualised above the staining of secreted ECP in the lamina propria interstitium. In 2 Crohn’s patients with severe ileitis, the extracellular staining was so strong that differential counts could not be done. The percentage of stained cells was higher in Crohn’s ileum and colon than in normal tissue (table). In contrast, no increase in EG2 staining was seen in ulcerative colitis. These observations are consistent with the hypothesis that granule proteins derived from activated eosinophils contribute to tissue damage in Crohn’s diseasebut not in ulcerative colitis. We

SIR,-Eosinophils

intestine and

are

are

seen

127

PERCENTAGE OF LAMINA PROPRIA EG2 STAINED CELLS IN INTESTINAL SPECIMENS

*Mean

(range) normal ileum. tp<0 005 tp<0 0 05 vs normal colon, p < 0 01 vs ulcerative colitis (Student’s t-test) §Counts only in 5 because of intense extracellular ECP staining in 2.

have also shown4 that activated T cells are commonly seen in Crohn’s disease but are much less frequently seen in ulcerative colitis. There is evidence that eosinophil differentiation and activation can be regulated by the products of activated T cells ;5 this and our results suggest that the lesion in Crohn’s disease represents a cell-mediated immune response, whereas the lesion in ulcerative colitis may reflect an alternative inflammatory process. Department of Paediatric Gastroenterology, St Bartholomew’s Hospital, London EC1A 7BE, UK

M.-Y. CHOY J. A. WALKER-SMITH C. B. WILLIAMS T. T. MACDONALD

1. Dvorak AM. Ultrastructural evidence for release of major basic protein-containing crystalline cores of esoinophil granules in vivo: cytotoxic potential in Crohn’s disease. J Immunol 1980; 125: 460-62. 2. Tai P-C, Spry CJF, Peterson C, Venge P, Olsson I. Monoclonal antibodies distinguish between storage and secreted forms of eosinophil cationic protein. Nature 1984; 309: 182-84. 3. Hallgren R, Colombel JF, Dahl R, et al. Neutrophil and eosinophil involvement of the small bowel in patients with celiac disease and Crohn’s disease: studies on the secretion rate and immunohistochemical localization of granulocyte granule constituents. Am J Med 1989; 86: 56-64. 4. Choy M-Y, Walker-Smith JA, Williams CB, MacDonald TT. Differential expression of CD25 (IL-2 receptor) on lamina propria T cells and macrophages in the intestinal lesions in Crohn’s disease and ulcerative colitis. Gut (in press). 5. Denburg JA, Dolovich J, Harnish D. Basophil, mast cell and eosinophil growth and differentiation factors in human allergic disease. Clin Exp Allergy 1989, 19: 249-54.

Response to doxorubicin/methotrexate/fluorouracil in advanced adenocarcinoma of pancreas

or

biliary tract SIR,-Pancreatic carcinoma has become an increasingly prevalent disease in most western countries

over the past two decades. It has poor prognosis. Without treatment the median survival is less than 3 months, and treatment may prolong survival by a few months at most. Almost all patients die within 2 years of diagnosis. When evidence of a possible synergistic effect from combining methotrexate and 5-fluorouracil sequentially became available’ we initiated a phase II study in inoperable pancreatic an

exceptionally

using the three-drug combination AMF-’Adriamycin’ (doxorubicin) 12 mg/m2 as a bolus followed by methotrexate 150 mg/m2 by 30 min infusion; then, 1 h later 5-fluorouracil 600 mg/m2 as a 30 min infusion. Citroforum factor rescue (15 mg orally every 6 h for eight doses) is started 24 h after methotrexate. Urine is neutralised with oral sodium bicarbonate. This treatment is given once a week for 3 weeks and then, after a 2-3 week rest period, the cycle is repeated. A similar treatment regimen has some promise in advanced colorectal cancerIn this short preliminary report we describe the two youngest patients in our study. Both had a good primary response to treatment, and one responded well after a second treatment period. A 22-year-old woman presented with right upper quadrant abdominal pain, nausea, vomiting, and severe general deterioration. Computed axial tomography revealed an enlarged liver full of metastases and a pancreatic tumour with a diameter of 3-5 cm. Laparoscopy confirmed extensive neoplastic growth in the liver. Histological examination of biopsy samples from the hepatic cancer

lesions

revealed

poorly

differentiated

adenocarcinoma.

Immunoperoxidase staining of the liver sample with monoclonal antibody against tumour marker CA19-9 was positive. 3 weeks after

the

onset of AMF treatment she was greatly improved and was symptom-free. In computed tomographic (CT) scans after 3

months of treatment the pancreatic tumour had disappeared and the metastatic lesions in the liver were much reduced. All laboratory tests were normal. 6 months after the onset of treatment a CT scan pointed to a complete response in the liver metastases also. Treatment was continued for a further 4 months. 4 weeks after withdrawal of treatment liver-function tests became abnormal and a scan confirmed regrowth of the primary tumour and of the liver metastases. The same treatment regimen was reintroduced but without any response. She died 2 months after cessation of the active therapy, 13 months after diagnosis. A 26-year-old woman presented with abdominal pain for a year. A CT scan revealed a tumour in the pancreas and she was operated on on July 1, 1987. Malignant tumour was detected in the pancreas with small multiple liver metastases. The tumour was a highly differentiated adenocarcinoma; it was thought to be a pancreatic carcinoma, although biliary tract cancer could not be excluded. After prophylactic cholecystojejunostomy and enteroanastomoses she was treated for a month with a small dose of 5-fluorouracil with no apparent effect. She was referred to our hospital and AMF treatment was started on Sept 15,1987. Treatment continued for 14 weeks. The primary tumour decreased in size (partial response). The liver metastases seen at surgery were not detectable by CT scan before or after the treatment. Since abdominal pain persisted after the combination treatment she received palliative radiotherapy into the primary tumour in January, 1988 (28 Gy, fourteen fractions). Thereafter she had no specific cancer therapy for 7 months. In August, 1988, an exploratory operation revealed no evidence of progression. A primary tumour, diameter 4 cm, in the head of the pancreas was detected with small metastatic nodules in the liver. In December, 1988, liver metastases had progressed and fine-needle biopsy confirmed metastases to the left side of the neck. She was treated again with AMF from December, 1988, to June, 1989, achieving complete remission of the neck lesion, and partial remission of the liver metastases; the primary lesion was unchanged. Now, 3 years after the primary diagnosis, the disease has stabilised at the stage of June, 1989, when the second chemotherapy period ended. The patient is still in excellent general condition. AMF is now being evaluated in clinical trials controlled with no treatment except palliative surgery in inoperable pancreatic carcinoma, and studies of adjuvant treatment after radical surgery cases have also been initiated. Department of Radiotherapy and Oncology, Helsinki University Central Hospital, SF-00290 Helsinki, Finland

SEPPO PYRHÖNEN

Third Department of Medicine, Helsinki University Central Hospital

MATTI VALTONEN

1. Fernandes DJ, Bertino JR. 5-fluorouracil-methotrexate synergy: enhancement of 5-fluorourodeoxyuridylate binding to thymidylate synthase by dihydropteroylpolyglutamates. Proc Natl Acad Sci USA 1980; 77: 5663-67. 2. Mulder JH, Smink T, van Putten LM. 5-fluorouracil and methotrexate combination chemotherapy: the effect of drug scheduling. Eur J Cancer Clin Oncol 1981; 17: 831-37. 3. Pyrhönen S, Kouri M. Treatment of advanced colorectal cancer with epirubicinsequential methotrexate-5-FU (EMF). Proceedings of 5th European Conference on Clinical Oncology (London, 1989): P-0651.

Cerebral metastasis presenting with aura

as

migraine

SIR,-From the International Headache Societyl have come proposed new classification and diagnostic criteria for headache disorders; these changes constitute a significant improvement over the previous classification2 and will provide a standard for scientific work. We report a case that met the proposed criteria for migraine with aura but where the diagnosis was cerebral metastasis. A 44-year-old right-handed woman previously in good health who was taking clonidine (recently prescribed for menopausal syndrome) sought advice for a 3-month history of moderate to severe intermittent bifrontal and left hemicranial pulsating headaches. They occurred about three times a week and lasted for