- Email: [email protected]
Analysis of genes for bilirubin UDP-glucuronosyltransferase in Gilbert's syndrome
allele in late-onset familial Alzheimer’s disease. Proc Natl Acad Sci USA
1993; 90: 1977-81. 2 Saunders AM, Strittmatter WJ, Schmechel D,
3
et
al. Association of
apolipoprotein E allele e4 with late-onset familial and sporadic Alzheimer’s disease. Neurology 1993; 43: 1467-72. van Duijn CM, Deknijff P, Cruts M, et al. Apolipoprotein E4 allele in a population-based study of early-onset Alzheimer’s disease. Nat Genet 1994; 7: 74-78.
4 Wisniewski T, Frangione B. Apolipoprotein E: a pathologic chaperone protein in patients with cerebral and systemic amyloid. Neurosci Lett 1992; 135: 235-38. 5 Wisniewski T, Castaño EM, Golabek A, Vogel T, Frangione B. Acceleration of Alzheimer’s fibril formation by apolipoprotein E in vitro. Am J Pathol 1994; 145: 1030-35. 6 Ma J, Yee A, Brewer HB, Das S, Potter H. The amyloid associated proteins &agr;1-antichymotrypsin and apolipoprotein E promote the assembly of the Alzheimer’s &bgr;-protein into filaments. Nature 1994; 372: 92-94. 7 Miller DL, Papayannopoulos IA, Styles J, et al. Peptide compositions
Analysis of genes for bilirubin UDP-glucuronosyltransferase in Gilbert’s syndrome
Gilbert’s and
Crigler-Najjar syndromes are characterised by unconjugated hyperbilirubinaemia due to complete and partial absence of bilirubin UDP-glucuronosyltransferase (UGT). Nucleotide sequences of the genes for bilirubin UGT were analysed in six patients with Gilbert’s syndrome. All patients had a missense mutation caused by a single and the were substitution mutations heterozygous. In addition, relatives of patients with CriglerNajjar syndrome types I and II, and of those with Gilbert’s syndrome were analysed. All ten relatives with mild hyperbilirubinaemia were heterozygotes with respect to each defective allele. These results suggest that Gilbert’s syndrome is inherited as a dominant trait.
nucleotide
Lancet 1995; 345: 958-59
Bilirubin UDP-glucuronosyltransferase (UGT) is essential for the excretion of bilirubin from the liver into bile. Two isozymes of bilirubin UGT (UGTIA and UGTID) have been reported.’1 Both enzymes are encoded, as are other members of the family of UGT isozymes, by the UGTl gene complex, which contains multiple unique exon 1 and four common exons (exons 2-5).2 Crigler-Najjar syndrome types I and II, and Gilbert’s syndrome are associated with complete or partial absence of bilirubin UGT activity. The genetic mechanisms of Crigler-Najjar syndrome types I3,4,7 and II5,7 have been elucidated. These are autosomal recessive disorders. However, the genetic defect in Gilbert’s syndrome, which is the most common syndrome of the three and has a frequency of 5% of the population, is unknown. We have analysed the genetic background of six patients with Gilbert’s syndrome. The patient’s serum bilirubin was 52-86 jjbmoI/L (normal =sl7). All exons and their flanking regions of the UGTLA and UGTLD genes were sequenced with genomic DNA from
peripheral white blood cells. cDNA from the liver was used in case 2. The DNA fragments were amplified by PCR and sequenced directly.’ UGT activity was also measured.8 958
of the cerebrovascular and senile plaque core amyloid deposits of Alzheimer’s disease. Arch Biochem Biophys 1993; 301: 41-52. 8 Prelli F, Castraño EM, Pras M, Ferris SF, Frangione B. The role of apolipoprotein E in amyloid fibril formation. Soc Neurosci Abstr 1994; 20 (part 2): 1642. 9 Strittmatter WJ, Weisgraber KH, Huang DY, et al. Binding of human apolipoprotein E to synthetic amyloid &bgr; peptides: isoform-specific effects and implications for late-onset Alzheimer’s disease. Proc Natl Acad Sci USA 1993; 90: 8098-102. 10 Pepys MB. Amyloidosis. In: Frank MM, Austen KF, Claman HN, Unaue ER, eds. Immunological disease. 5th ed. Boston: Little Brown, 1995: 637-56.
Departments of Pathology (T Wisniewski MD, M Lalowski Ms, A Golabek nns, B Frangione MD) and Neurology (T Wisniewski), New York University Medical Center, New York, NY 10016, USA; and Biotechnology General Ltd (T Vogel PhD), Rehovot, Israel Correspondence to:
Dr Thomas Wisniewski
Each
patient was heterozygous for a point mutation In (table). four cases, the mutation was found in exon 1 of the UGT1A gene. In two other cases, a mutation was found in exon 4, which is common to both genes, and exon 1 of the UGTl D gene, respectively. All mutations were missense mutations due to a single nucleotide substitution. Two pairs of patients from the six independent families had identical mutations (Gly7lArg and Pro229Gln). Furthermore, the Gly71Arg was the same nucleotide substitution that was detected earlier in a patient with Crigler-Najjar type II in homozygous state.5 The UGTIA and UGTl D genes were also analysed in relatives of patients with types I and II disease,* and of those with Gilbert’s syndrome. All ten relatives with mild hyperbilirubinaemia were heterozygous for the allele that was defective in the original patients with these syndromes (data not shown). These results suggest that Gilbert’s syndrome is caused by a mutation in only one allele, that the mutations we found are responsible for the disease, and that the syndrome is inherited as a dominant trait. Homozygotes for these mutations may have phenotypically severe jaundice that is classified as CriglerNajjar syndrome types I or II, and the severe jaundice is inherited as a recessive trait.3-7 The mRNA encoding UGTLD occurs at low concentrations compared with that encoding !7GT.M,’ our patient (number 6) with a mutation in only the UGTID gene may have another mutation in a regulatory region of UGTLA gene. Heterozygotes for a particular mutation usually express half the normal enzyme activity. However, hepatic
*Average value of six controls was 0-207 (SE 0-016) nmol per min per mg protein. tBilirubin monoglucuronide in bile. ND=not done. Table : Defects in genes for bilirubin UGT in patients with Gilbert’s syndrome
activities of bilirubin UGT in the patients with Gilbert’s
syndrome were 21-6-26-9% of control (table). Bilirubin UGT may exist as a homo-tetramer. Random assembly of normal and mutated subunits into the tetramer may result in lower bibirubin UGT activity than expected in heterozygotes from the dominant-negative nature of the mutations.1O The dominant nature of Gilbert’s syndrome can be explained by the subunit structure of the enzyme. We are now doing expression studies in vitro with cultured cells to confirm our hypothesis for the mechanism of the genetic dominance of Gilbert’s syndrome. Part of this study was supported by grants-in-aid for scientific research from the Ministry of Education, Science and Culture in Japan (05670465, 05670977, and 06454268).
alteration in the code for bilirubin UDP-glucruronosyltransferase in the UGT1 gene complex of a Crigler-Najjar type 1 patient. J Clin Invest 1992; 90: 150-55. 5 Aono S, Yamada Y, Keino H, et al. Identifiation of defect in the genes of bilirubin UDP-glucruronosyltransferase in a patient with Crigler-Najjar syndrome type II. Biochem Biophys Res Commun 1993; 197: 1239-44. 6 Moghrabi N, Clarke DJ, Boxer M, Burchell B. Identification of an A-to-G missense mutation in exon 2 of the UGT1 gene complex that causes Crigler-Najjar syndrome type 2. Genomics 1993; 18: 171-73. 7 Aono S, Yamada Y, Keino H, et al. A new type of defect in the gene for bilirubin uridine 5’-diphosophate-glucuronosyltransferase in a patient with Crigler-Najjar syndrome type I. Pediatr Res 1994; 35: 629-32. 8 Heriwegh KP, Van de Vijver M, Fevery J. Assay and digitonin-activated bilirubin uridine diphosphate glucuronyltransferase from rat liver. Biochem J 1972; 129: 605-18. 9 Peters WH, Jansen PL, Nauta H. The molecular weights of UDPglucuronyltransferase determined with radiation-inactivation analysis. J Biol Chem 1984; 259: 11701-06. 10 Wilkie AOM. The molecular basis of genetic dominance. J Med Genet
genetic
1994; 31: 89-98. References
1 Ritter JK, Crawford JM, Owens IS. Cloning of two human liver bilirubin UDP-glucuronosyltransferase cDNAs with expression in COS-1 cells. J Biol Chem 1991; 266: 1043-47. 2 Ritter JK, Chen F, Sheen YY, et al. A novel complex locus UGT1 encodes human bilirubin, phenol, and other UDPglucuronosyltransferase isozymes with identical carboxyl termini. J Biol Chem 1992; 267: 3257-61. 3 Bosma PJ, Chowdhury NR, Goldhoorn BG, et al. Sequence of exons and the flanking regions of human bilirubin-UDP-glucuronosyltransferase gene complex with identification of a genetic mutation in a patient with Crigler-Najjar syndrome, type I. Hepatology 1992; 15: 941-47. 4
Ritter JK, Yeatman MT, Ferreira P, Owens IS. Identification of a
Indian kala-azar caused
by Leishmania
tropica
or visceral leishmaniasis, in India is generally assumed to be a result of infection with Leishmania
Kala-azar,
donovani. 15 parasite isolates collected over the past 10 years from patients with classical disease were typed by monoclonal antibodies, isoenzymes, and kDNA analysis. 4 were shown to be L tropica, a species historically
associated with cutaneous disease and more recently a mild "visceralising" disease from the Desert Storm experience. The results confirm that L tropica is a coendemic agent of visceral leishmaniasis in India, and may shed light on the rising frequency of therapeutic unresponsiveness to sodium antimony gluconate, which complicates treatment of this lethal disease. Lancet 1995; 345: 959-61
The
Indian state of Bihar, with the of West Bengal and Uttar Pradesh, neighbouring has recently experienced another cycle of intense transmission of kala-azar, with more than 80 000 cases officially reported in 1992. The species of leishmania responsible for past and current epidemics of visceral leishmaniasis in India is widely assumed to be Leishmania donovani. Species identification of visceral isolates was based originally on clinical manifestations that distinguished them from cutaneous disease strains. These classifications have since been validated, with few exceptions, by polymorphic biochemical, genetic, and northeast
states
Departments of Perinatology (S Aono PhD, H Keino PhD) and Genetics (Y Yamada PhD), Institute of Developmental Research, Aichi; Second Department of Internal Medicine (Y Adachi MD, T Nanno MD), Kinki University School of Medicine, Osaka; First Deprtment of Internal Medicine (E Uyama MD), Kumamoto University School of Medicine, Kumamoto; Department of Biochemistry (O Koiwai PhD), Aichi Cancer Centre Research Institute, Aichi; and Department of Biology (H Sato PhD), Shiga University of Medical Science, Otsu Shiga 520-21,
Correspondence
Japan
to: Dr Hiroshi Sato
serological markers. The exceptions’ include a few visceral isolates from children in Israel and Iraq, as well as 8 Bengali strains (4 visceral and 4 post-Kala-azar dermal leishmaniasis), isolated in 1973, which were all typed by excreted-factor serotyping and enzyme analysis as L tropica. The presence of L tropica in the Bengali patients was surprising because cutaneous lesions normally associated with L tropica had never been reported in the 1
of India endemic for visceral leishmaniasis. Because the culture history of these isolates was in doubt, and because there has since been no effort to classify a large number of visceral isolates from this region, the possibility that L tropica strains are co-endemic agents of visceral leishmaniasis in India has not received serious attention. area
We have typed by monoclonal antibodies and isoenzyme and kinetoblast (kDNA) analyses 15 isolates obtained over 10 years from patients being treated at the Rajendra Memorial Research Institute in Patna, Bihar. The only selection criteria for the isolates was that their short-term culture, which is routinely undertaken on all bone-marrow aspirates of suspected cases of visceral leishmaniasis, was done during the periodic visits of the overseas collaborators. The isolates were obtained from 10 men and 5 women, median age 14 (table), who presented with
moderately severe kala-azar, including malaise, fever, weight loss, hepatosplenomegaly, anaemia, and leucopenia. Bone-marrow smears were positive on Giemsa staining and culture, except for patient 12, who had only positive culture. All patients were initially treated with intramuscular sodium antimony gluconate 15-20 mg/kg per day for 30 days. Response was defined clinically as improvement in symptoms and decrease in splenomegaly, and parasitologically as absence of parasites in repeat bone-marrow aspirates. 6 of the 15 patients were unresponsive, and 1 (patient 7) required three courses to treat recurrent disease successfully. All unresponsive patients responded well to intramuscular pentamidine 3 mg/kg per day intramuscularly for 15-20 days. The high proportion of antimony non-responders is usual at the Rajendra Memorial Research Institute, which centre for unresponsive cases.
serves as a
referral
959
1993; 90: 1977-81. 2 Saunders AM, Strittmatter WJ, Schmechel D,
3
et
al. Association of
apolipoprotein E allele e4 with late-onset familial and sporadic Alzheimer’s disease. Neurology 1993; 43: 1467-72. van Duijn CM, Deknijff P, Cruts M, et al. Apolipoprotein E4 allele in a population-based study of early-onset Alzheimer’s disease. Nat Genet 1994; 7: 74-78.
4 Wisniewski T, Frangione B. Apolipoprotein E: a pathologic chaperone protein in patients with cerebral and systemic amyloid. Neurosci Lett 1992; 135: 235-38. 5 Wisniewski T, Castaño EM, Golabek A, Vogel T, Frangione B. Acceleration of Alzheimer’s fibril formation by apolipoprotein E in vitro. Am J Pathol 1994; 145: 1030-35. 6 Ma J, Yee A, Brewer HB, Das S, Potter H. The amyloid associated proteins &agr;1-antichymotrypsin and apolipoprotein E promote the assembly of the Alzheimer’s &bgr;-protein into filaments. Nature 1994; 372: 92-94. 7 Miller DL, Papayannopoulos IA, Styles J, et al. Peptide compositions
Analysis of genes for bilirubin UDP-glucuronosyltransferase in Gilbert’s syndrome
Gilbert’s and
Crigler-Najjar syndromes are characterised by unconjugated hyperbilirubinaemia due to complete and partial absence of bilirubin UDP-glucuronosyltransferase (UGT). Nucleotide sequences of the genes for bilirubin UGT were analysed in six patients with Gilbert’s syndrome. All patients had a missense mutation caused by a single and the were substitution mutations heterozygous. In addition, relatives of patients with CriglerNajjar syndrome types I and II, and of those with Gilbert’s syndrome were analysed. All ten relatives with mild hyperbilirubinaemia were heterozygotes with respect to each defective allele. These results suggest that Gilbert’s syndrome is inherited as a dominant trait.
nucleotide
Lancet 1995; 345: 958-59
Bilirubin UDP-glucuronosyltransferase (UGT) is essential for the excretion of bilirubin from the liver into bile. Two isozymes of bilirubin UGT (UGTIA and UGTID) have been reported.’1 Both enzymes are encoded, as are other members of the family of UGT isozymes, by the UGTl gene complex, which contains multiple unique exon 1 and four common exons (exons 2-5).2 Crigler-Najjar syndrome types I and II, and Gilbert’s syndrome are associated with complete or partial absence of bilirubin UGT activity. The genetic mechanisms of Crigler-Najjar syndrome types I3,4,7 and II5,7 have been elucidated. These are autosomal recessive disorders. However, the genetic defect in Gilbert’s syndrome, which is the most common syndrome of the three and has a frequency of 5% of the population, is unknown. We have analysed the genetic background of six patients with Gilbert’s syndrome. The patient’s serum bilirubin was 52-86 jjbmoI/L (normal =sl7). All exons and their flanking regions of the UGTLA and UGTLD genes were sequenced with genomic DNA from
peripheral white blood cells. cDNA from the liver was used in case 2. The DNA fragments were amplified by PCR and sequenced directly.’ UGT activity was also measured.8 958
of the cerebrovascular and senile plaque core amyloid deposits of Alzheimer’s disease. Arch Biochem Biophys 1993; 301: 41-52. 8 Prelli F, Castraño EM, Pras M, Ferris SF, Frangione B. The role of apolipoprotein E in amyloid fibril formation. Soc Neurosci Abstr 1994; 20 (part 2): 1642. 9 Strittmatter WJ, Weisgraber KH, Huang DY, et al. Binding of human apolipoprotein E to synthetic amyloid &bgr; peptides: isoform-specific effects and implications for late-onset Alzheimer’s disease. Proc Natl Acad Sci USA 1993; 90: 8098-102. 10 Pepys MB. Amyloidosis. In: Frank MM, Austen KF, Claman HN, Unaue ER, eds. Immunological disease. 5th ed. Boston: Little Brown, 1995: 637-56.
Departments of Pathology (T Wisniewski MD, M Lalowski Ms, A Golabek nns, B Frangione MD) and Neurology (T Wisniewski), New York University Medical Center, New York, NY 10016, USA; and Biotechnology General Ltd (T Vogel PhD), Rehovot, Israel Correspondence to:
Dr Thomas Wisniewski
Each
patient was heterozygous for a point mutation In (table). four cases, the mutation was found in exon 1 of the UGT1A gene. In two other cases, a mutation was found in exon 4, which is common to both genes, and exon 1 of the UGTl D gene, respectively. All mutations were missense mutations due to a single nucleotide substitution. Two pairs of patients from the six independent families had identical mutations (Gly7lArg and Pro229Gln). Furthermore, the Gly71Arg was the same nucleotide substitution that was detected earlier in a patient with Crigler-Najjar type II in homozygous state.5 The UGTIA and UGTl D genes were also analysed in relatives of patients with types I and II disease,* and of those with Gilbert’s syndrome. All ten relatives with mild hyperbilirubinaemia were heterozygous for the allele that was defective in the original patients with these syndromes (data not shown). These results suggest that Gilbert’s syndrome is caused by a mutation in only one allele, that the mutations we found are responsible for the disease, and that the syndrome is inherited as a dominant trait. Homozygotes for these mutations may have phenotypically severe jaundice that is classified as CriglerNajjar syndrome types I or II, and the severe jaundice is inherited as a recessive trait.3-7 The mRNA encoding UGTLD occurs at low concentrations compared with that encoding !7GT.M,’ our patient (number 6) with a mutation in only the UGTID gene may have another mutation in a regulatory region of UGTLA gene. Heterozygotes for a particular mutation usually express half the normal enzyme activity. However, hepatic
*Average value of six controls was 0-207 (SE 0-016) nmol per min per mg protein. tBilirubin monoglucuronide in bile. ND=not done. Table : Defects in genes for bilirubin UGT in patients with Gilbert’s syndrome
activities of bilirubin UGT in the patients with Gilbert’s
syndrome were 21-6-26-9% of control (table). Bilirubin UGT may exist as a homo-tetramer. Random assembly of normal and mutated subunits into the tetramer may result in lower bibirubin UGT activity than expected in heterozygotes from the dominant-negative nature of the mutations.1O The dominant nature of Gilbert’s syndrome can be explained by the subunit structure of the enzyme. We are now doing expression studies in vitro with cultured cells to confirm our hypothesis for the mechanism of the genetic dominance of Gilbert’s syndrome. Part of this study was supported by grants-in-aid for scientific research from the Ministry of Education, Science and Culture in Japan (05670465, 05670977, and 06454268).
alteration in the code for bilirubin UDP-glucruronosyltransferase in the UGT1 gene complex of a Crigler-Najjar type 1 patient. J Clin Invest 1992; 90: 150-55. 5 Aono S, Yamada Y, Keino H, et al. Identifiation of defect in the genes of bilirubin UDP-glucruronosyltransferase in a patient with Crigler-Najjar syndrome type II. Biochem Biophys Res Commun 1993; 197: 1239-44. 6 Moghrabi N, Clarke DJ, Boxer M, Burchell B. Identification of an A-to-G missense mutation in exon 2 of the UGT1 gene complex that causes Crigler-Najjar syndrome type 2. Genomics 1993; 18: 171-73. 7 Aono S, Yamada Y, Keino H, et al. A new type of defect in the gene for bilirubin uridine 5’-diphosophate-glucuronosyltransferase in a patient with Crigler-Najjar syndrome type I. Pediatr Res 1994; 35: 629-32. 8 Heriwegh KP, Van de Vijver M, Fevery J. Assay and digitonin-activated bilirubin uridine diphosphate glucuronyltransferase from rat liver. Biochem J 1972; 129: 605-18. 9 Peters WH, Jansen PL, Nauta H. The molecular weights of UDPglucuronyltransferase determined with radiation-inactivation analysis. J Biol Chem 1984; 259: 11701-06. 10 Wilkie AOM. The molecular basis of genetic dominance. J Med Genet
genetic
1994; 31: 89-98. References
1 Ritter JK, Crawford JM, Owens IS. Cloning of two human liver bilirubin UDP-glucuronosyltransferase cDNAs with expression in COS-1 cells. J Biol Chem 1991; 266: 1043-47. 2 Ritter JK, Chen F, Sheen YY, et al. A novel complex locus UGT1 encodes human bilirubin, phenol, and other UDPglucuronosyltransferase isozymes with identical carboxyl termini. J Biol Chem 1992; 267: 3257-61. 3 Bosma PJ, Chowdhury NR, Goldhoorn BG, et al. Sequence of exons and the flanking regions of human bilirubin-UDP-glucuronosyltransferase gene complex with identification of a genetic mutation in a patient with Crigler-Najjar syndrome, type I. Hepatology 1992; 15: 941-47. 4
Ritter JK, Yeatman MT, Ferreira P, Owens IS. Identification of a
Indian kala-azar caused
by Leishmania
tropica
or visceral leishmaniasis, in India is generally assumed to be a result of infection with Leishmania
Kala-azar,
donovani. 15 parasite isolates collected over the past 10 years from patients with classical disease were typed by monoclonal antibodies, isoenzymes, and kDNA analysis. 4 were shown to be L tropica, a species historically
associated with cutaneous disease and more recently a mild "visceralising" disease from the Desert Storm experience. The results confirm that L tropica is a coendemic agent of visceral leishmaniasis in India, and may shed light on the rising frequency of therapeutic unresponsiveness to sodium antimony gluconate, which complicates treatment of this lethal disease. Lancet 1995; 345: 959-61
The
Indian state of Bihar, with the of West Bengal and Uttar Pradesh, neighbouring has recently experienced another cycle of intense transmission of kala-azar, with more than 80 000 cases officially reported in 1992. The species of leishmania responsible for past and current epidemics of visceral leishmaniasis in India is widely assumed to be Leishmania donovani. Species identification of visceral isolates was based originally on clinical manifestations that distinguished them from cutaneous disease strains. These classifications have since been validated, with few exceptions, by polymorphic biochemical, genetic, and northeast
states
Departments of Perinatology (S Aono PhD, H Keino PhD) and Genetics (Y Yamada PhD), Institute of Developmental Research, Aichi; Second Department of Internal Medicine (Y Adachi MD, T Nanno MD), Kinki University School of Medicine, Osaka; First Deprtment of Internal Medicine (E Uyama MD), Kumamoto University School of Medicine, Kumamoto; Department of Biochemistry (O Koiwai PhD), Aichi Cancer Centre Research Institute, Aichi; and Department of Biology (H Sato PhD), Shiga University of Medical Science, Otsu Shiga 520-21,
Correspondence
Japan
to: Dr Hiroshi Sato
serological markers. The exceptions’ include a few visceral isolates from children in Israel and Iraq, as well as 8 Bengali strains (4 visceral and 4 post-Kala-azar dermal leishmaniasis), isolated in 1973, which were all typed by excreted-factor serotyping and enzyme analysis as L tropica. The presence of L tropica in the Bengali patients was surprising because cutaneous lesions normally associated with L tropica had never been reported in the 1
of India endemic for visceral leishmaniasis. Because the culture history of these isolates was in doubt, and because there has since been no effort to classify a large number of visceral isolates from this region, the possibility that L tropica strains are co-endemic agents of visceral leishmaniasis in India has not received serious attention. area
We have typed by monoclonal antibodies and isoenzyme and kinetoblast (kDNA) analyses 15 isolates obtained over 10 years from patients being treated at the Rajendra Memorial Research Institute in Patna, Bihar. The only selection criteria for the isolates was that their short-term culture, which is routinely undertaken on all bone-marrow aspirates of suspected cases of visceral leishmaniasis, was done during the periodic visits of the overseas collaborators. The isolates were obtained from 10 men and 5 women, median age 14 (table), who presented with
moderately severe kala-azar, including malaise, fever, weight loss, hepatosplenomegaly, anaemia, and leucopenia. Bone-marrow smears were positive on Giemsa staining and culture, except for patient 12, who had only positive culture. All patients were initially treated with intramuscular sodium antimony gluconate 15-20 mg/kg per day for 30 days. Response was defined clinically as improvement in symptoms and decrease in splenomegaly, and parasitologically as absence of parasites in repeat bone-marrow aspirates. 6 of the 15 patients were unresponsive, and 1 (patient 7) required three courses to treat recurrent disease successfully. All unresponsive patients responded well to intramuscular pentamidine 3 mg/kg per day intramuscularly for 15-20 days. The high proportion of antimony non-responders is usual at the Rajendra Memorial Research Institute, which centre for unresponsive cases.
serves as a
referral
959