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DIAGNOSTIC PRECIPITIN TEST IN ASPERGILLUS PULMONARY MYCETOMA
588
safety razor) within the area of the initial shaving is shaved again. The hair is transferred to a lightweight envelope and weighed. On the forearms the strips are 3 x 7-5 cm. and on the thighs 3 x 15 cm. After the hair has been taken for weighing, the rest of the selected area is shaved, so that if on the next occasion the strip shaved is not identical in position, little error will result. In a number of hirsute women, regular shaving of an area of skin on the face just in front of the ear has been possible. In this situation the shaving has been done at 4-weekly intervals. SEASONAL VARIATION
In 2 out of 3 normal men, and in 6 out of 7 hirsute -women, there was marked seasonal variation, the hair growing twice as quickly in summer as in winter (fig. 1). Similar but smaller seasonal variations of the growth of axillary hair have been reported by Hamiltonand Kinsell et al.2 CESTROGEN ADMINISTRATION
Mestranol and norethynodrel in various combinations have been given to 6 hirsute women. In 2 the rate of hair growth was considerably reduced, but it was never completely abolished. The results (fig. 2) suggest that the oestrogen is the effective hormone, but in this and a second patient it led to breakthrough bleeding when given alone. Mattingly et awl. have reported improvement in some patients treated with a combination of prednisone and ethinyl cestradiol. Further studies are now in progress to try to ascertain whether tlle oestrogen acts locally on the hair-follicles or by altering the level of plasma-testosterone. We
indebted to Dr. G. R. Venning of G. D. Searle & of norethynodrel and mestranol.
are
supplies
Co. for
J. H. CASEY Leverhulme Research Fellow
AUDREY MOXHAM Joseph Senior White Fellow, Royal College of Physicians of London
DIAGNOSTIC PRECIPITIN TEST IN ASPERGILLUS PULMONARY MYCETOMA THE diagnosis of aspergilloma, or aspergillus mycetoma, of the lungs is made from the typical radiographic picture of a rounded mass with an air-containing halo. The development of an aspergilloma may also be suggested by the appearance of an infiltration of gradually increasing size in damaged lung-e.g., in previously existing bullx, in open-healed cavities of treated pulmonary tuberculosis, or in bronchiectatic dilations. Aspergillus fumigatus is responsible for almost all cases, though other aspergillus species, such as A. niger, A. versicolor, A. nidulans and A. flavus have been described as possible causes.4 Culture of the sputum, however, may be of only limited diagnostic value, since, not infrequently, there is no communication between the aspergilloma and the bronchi. Furthermore, because of the ubiquity of
aspergillus patients with Precipitin tests5 in
air, positive cultures
are
bronchitis and other lung have been found helpful
obtained diseases. in the
1. 2.
Hamilton, J. B. Ann. N.Y. Acad. Sci. 1951, 53, 585. Kinsell, L. W., Bryant, D., Albright, F. J. clin. Endocrin. 1954, 18,
3. 4.
Mattingly, D., Mills, I. H., Prunty, F. T. G. Brit. med. J. 1960, i, 1298. Hinson, K. F. W., Moon, A. J., Plummer, N. S. Thorax, 1952, 7,
897. 317.
5. Pepys, J., Riddell, R. W., Citron, K. Amer. Rev. resp. Dis. 1959, 80, 167.
M., Clayton,
Y.
M., Short, E.
diagnosis.6-8 Thus, of 58 cases, precipitin reactions were obtained in 56 against extracts of A. fumigatus, and in 1 against A. nidulans: in only 1 was the reaction negative.6 patients with pulmonary aspergilloma give from precipitin arcs, which decrease rapidly after surgical removal,6and they do not as a rule give positive skin-test reactions, unless asthma is present. By contrast, almost all of the patients with asthma and pulmonary eosinophilia due to A. fumigatus give positive skin-test reactions, and two-thirds have precipitins-less than 6 arcs in the majority. 6 up to 15 to 20
J. D. N. NABARRO.
spores in the
(a) Aspergillus fumigatus aspergilloma: multiple precipitation arcs against A. fumigatus extract above, and no reaction to extract of A. flavus below. (b) Aspergillus nidulans infection: multiple precipitation arcs (some faint) to A. nidulans below, and no reaction to A. fumigatus above, (c) Aspergillus flavus aspergilloma: multiple precipitation arcs to A. flavus below, and no reaction to A. fumigatus above.
Most
Research Assistant Institute of Clinical Research, Middlesex Hospital Medical School, London, W.1
Electrophoresis of solutions of freeze-dried extracts (40 mg. per ml.) of cell-saps of A. fumigatus, A. nidulans, and A. flavus:
I.
We describe here 2 cases: one in which the precipitin positive with A. flavus antigens only (see figure), and in whom A. flavus was cultured from material aspirated on bronchoscopy; and another in whom the test was positive against A. niger, and A. niger was cultivated from the sputum. test was
CASE 1.-A handyman, aged 48 years, working in stables, lofts, and dusty places, was admitted to Preston Hall Chest Hospital on Aug. 6, 1963, with a history of many years of persistent productive cough, with occasional bloodstained sputum, dyspnoea, and malaise. He was pale and emaciated, and had pronounced torticollis and high kyphoscoliosis with flattening and little movement on the left side of the chest, over which bronchial breathing was heard. The erythrocyte-sedimentation rate was 55/200 in 1 hour (Westergren).
Radiography of the chest showed gross fibrosis of the upper left lung field with a large apical cavity suggesting old tuberculosis. Tomographs of the cavity showed a mass with an aircontaining halo typical of an aspergilloma. The patient’s sputum at the time was negative for tubercle bacilli and fungi, and he gave a negative Mantoux reaction (100 T.U.). Bronchoscopy showed that the left main bronchus was filled with thick 6. Longbottom, J. L., Pepys, J. J. Path. Bact. (in the press). 7. Gernez-Rieux, Ch, Biguet, J., Voisin, C., Capron, A., Balgairies, Tran van Ky, P. J. franç. Méd. Chir. thor. 1963, 17, 663. 8. Drouhet, E., Segretain, G., Pesle, G., Bidet, L. ibid. p. 655.
E.,
589 pus, and that its lateral wall was rigid, but not so rigid as to suggest a carcinoma. Washings of the left upper lung yielded A, fiavus. Subsequently A. flavus was frequently cultured from the sputum. Skin-prick tests with freeze-dried extracts of A. fumigatus and A. flavus were negative. The precipitin test on the patient’s serum (see figure) gave a positive reaction with multiple arcs to the extract of A, flavus and negative reactions to extracts of A. fumigatus and A. nidulans. CASE 2.-A man,
aged
56 years,
was
admitted
to
Hammer-
smith Hospital for investigation of recent haemoptysis and the
worsening over the last year of a chronic cough and expectoration. Radiography showed bilateral fibrosis and cavitation in the upper lung zones, with recent appearance of increased opacity in the left upper zone. Tomographs of the cavity showed a mass with an air-containing halo, typical of an aspergilloma. His sputum yielded A. niger on culture and was negative for tubercle bacilli. Skin tests gave a positive wealing reaction to A, niger, somewhat unusual in the absence of asthma, and a negative reaction to A. fumigatus. The precipitin test gave multiple specific arcs to an extract of A. niger.
Fig. I-Typical peripheral blood neutrophils from 2 cases of D (13-15) trisomy. Both cells show the anomalous nuclear projections (Wright’s stain; magnification x 3800, reduced x 3). are not
always readily available. In this report, specific neutrophils in D trisomy are diagnostic test of unusually
nuclear abnormalities of the described which provide a easy access.
Peripheral-blood smears were examined from six children
In a further patient, in whom A nidulans was cultured from a discharging empyema and after death from an erosion of the vertebral column 11 a specific reaction was obtained to A nidulans3 (see figure). The agar-gel precipitin test with extracts of A. fumigatus and of other aspergillus species, such as A. nidulans, A, flavus and A. niger may be of diagnostic value in aspergillus mycetoma. We should add that the presence of an aspergilloma does not preclude the presence of other pathological conditions of the lung.
(two bovs and four sirls’) with Droved trisomv of one of the chromosomes of the 13-15 group associated with the typical clinical features of the
D1-trisomy syndrome. Their ages ranged from 1 day to almost 5 years. In every case most of the neutrophils were abnormal in their nuclear structure. The
-
malies
.
JOAN L. LONGBOTTOM
M.R.C. Clinical Immunology Research Group, Institute of Diseases of the Chest, London, S.W.3 Preston Hall Chest Hospital, Maidstone, Kent
M.SC. N.Z.
M.B.
J. PEPYS W’srand, M.R.C.P., M.R.C.P.E. F. TEMPLE CLIVE M.B.
Lond.
NUCLEAR ABNORMALITIES OF THE NEUTROPHILS IN D1 (13-15)-TRISOMY SYNDROME WE wish to report an observation which may be useful in the diagnosis of D (13-15) trisomy. The basic clinical syndrome associated with this chromosomal abnormality has already been clearly delineated 10 and includes severe developmental and mental retardation and a number of
Fig. 2-Electron micrograph of part of peripheral blood-neutrophil from 2-month-old boy with D (13-15) trisomy. Two sessile nodules are indicated by arrows at the periphery of the nucleus. A pedunculated projection (P) is also shown. Normal specific granules (G) are see in the cytoplasm (uranyl/ lead acetate stain; magnification x
13,000, reduced
x
/,).
malformations, among which are eye anomalies, hare-lip and cleft palate, polydactyly, congenital heart-disease, and arhinencephaly. The clinical diagnosis of D trisomy syndrome, like the diagnosis of most chromosomal diseases, is not always straightforward. Since chromosomal studies are laborious and time-consuming, a rapid aid to the diagnosis of this disease would be desirable. We have found specific haemoglobin patterns in Di-trisomy syndrome in the newborn period while other authors 12 have described distinctive dermal-ridge patterns. However, both these studies require specialised techniques which Carre, I. J., Redmond, Aileen, Biggart, J. D., Mackenzie, D. W. R. Unpublished. 10. Smith, D. W., Patau, K., Therman, E., Inhorn, S. L., DeMars, R. I. J. Pediat. 1963, 62, 326. 11. Huehns, E. R., Hecht, F., Keil, J. V., Motulsky, A. G. Proc. nat. Acad Sci., Wash. 1964, 51, 89. 12. Uchida, I. A., Patau, K., Smith, D. W. Amer. J. hum. Genet. 1962, 14,
Fig. 3-Electron micrograph of another sessile nodule at higher magnification ( x 50,000, reduced x ,.).
ano-
nuclear projections (fig. 1). The number of projections ranged from 1 to 6 per cell; their appearance was extremely variable in both size (approximately 0-25 to 1-5 tL) and shape, some being sessile projections, others pedunculated. These projections were Feulgen-positive, indicating that they are part of the nucleus. Besides these obvious nuclear projections, the nuclear lobulation appeared abnormal: often the nucleus looked twisted, and the individual lobes were not
9.
345.
prominent
most
We would like to thank Dr. A. L. Furniss, Dr. I. G. Murray, Dr. J, C. Batten, and Dr. P. Stradling for provision of material and permission to auote their cases.
were
clearly separated.
In other cells several lobules appeared to grow out from a single point. The chromatin pattern of the nuclei was coarse and lumpy. This appearance could also be seen when the living cells were observed by phase-contrast microscopy. The cytoplasm and granules
safety razor) within the area of the initial shaving is shaved again. The hair is transferred to a lightweight envelope and weighed. On the forearms the strips are 3 x 7-5 cm. and on the thighs 3 x 15 cm. After the hair has been taken for weighing, the rest of the selected area is shaved, so that if on the next occasion the strip shaved is not identical in position, little error will result. In a number of hirsute women, regular shaving of an area of skin on the face just in front of the ear has been possible. In this situation the shaving has been done at 4-weekly intervals. SEASONAL VARIATION
In 2 out of 3 normal men, and in 6 out of 7 hirsute -women, there was marked seasonal variation, the hair growing twice as quickly in summer as in winter (fig. 1). Similar but smaller seasonal variations of the growth of axillary hair have been reported by Hamiltonand Kinsell et al.2 CESTROGEN ADMINISTRATION
Mestranol and norethynodrel in various combinations have been given to 6 hirsute women. In 2 the rate of hair growth was considerably reduced, but it was never completely abolished. The results (fig. 2) suggest that the oestrogen is the effective hormone, but in this and a second patient it led to breakthrough bleeding when given alone. Mattingly et awl. have reported improvement in some patients treated with a combination of prednisone and ethinyl cestradiol. Further studies are now in progress to try to ascertain whether tlle oestrogen acts locally on the hair-follicles or by altering the level of plasma-testosterone. We
indebted to Dr. G. R. Venning of G. D. Searle & of norethynodrel and mestranol.
are
supplies
Co. for
J. H. CASEY Leverhulme Research Fellow
AUDREY MOXHAM Joseph Senior White Fellow, Royal College of Physicians of London
DIAGNOSTIC PRECIPITIN TEST IN ASPERGILLUS PULMONARY MYCETOMA THE diagnosis of aspergilloma, or aspergillus mycetoma, of the lungs is made from the typical radiographic picture of a rounded mass with an air-containing halo. The development of an aspergilloma may also be suggested by the appearance of an infiltration of gradually increasing size in damaged lung-e.g., in previously existing bullx, in open-healed cavities of treated pulmonary tuberculosis, or in bronchiectatic dilations. Aspergillus fumigatus is responsible for almost all cases, though other aspergillus species, such as A. niger, A. versicolor, A. nidulans and A. flavus have been described as possible causes.4 Culture of the sputum, however, may be of only limited diagnostic value, since, not infrequently, there is no communication between the aspergilloma and the bronchi. Furthermore, because of the ubiquity of
aspergillus patients with Precipitin tests5 in
air, positive cultures
are
bronchitis and other lung have been found helpful
obtained diseases. in the
1. 2.
Hamilton, J. B. Ann. N.Y. Acad. Sci. 1951, 53, 585. Kinsell, L. W., Bryant, D., Albright, F. J. clin. Endocrin. 1954, 18,
3. 4.
Mattingly, D., Mills, I. H., Prunty, F. T. G. Brit. med. J. 1960, i, 1298. Hinson, K. F. W., Moon, A. J., Plummer, N. S. Thorax, 1952, 7,
897. 317.
5. Pepys, J., Riddell, R. W., Citron, K. Amer. Rev. resp. Dis. 1959, 80, 167.
M., Clayton,
Y.
M., Short, E.
diagnosis.6-8 Thus, of 58 cases, precipitin reactions were obtained in 56 against extracts of A. fumigatus, and in 1 against A. nidulans: in only 1 was the reaction negative.6 patients with pulmonary aspergilloma give from precipitin arcs, which decrease rapidly after surgical removal,6and they do not as a rule give positive skin-test reactions, unless asthma is present. By contrast, almost all of the patients with asthma and pulmonary eosinophilia due to A. fumigatus give positive skin-test reactions, and two-thirds have precipitins-less than 6 arcs in the majority. 6 up to 15 to 20
J. D. N. NABARRO.
spores in the
(a) Aspergillus fumigatus aspergilloma: multiple precipitation arcs against A. fumigatus extract above, and no reaction to extract of A. flavus below. (b) Aspergillus nidulans infection: multiple precipitation arcs (some faint) to A. nidulans below, and no reaction to A. fumigatus above, (c) Aspergillus flavus aspergilloma: multiple precipitation arcs to A. flavus below, and no reaction to A. fumigatus above.
Most
Research Assistant Institute of Clinical Research, Middlesex Hospital Medical School, London, W.1
Electrophoresis of solutions of freeze-dried extracts (40 mg. per ml.) of cell-saps of A. fumigatus, A. nidulans, and A. flavus:
I.
We describe here 2 cases: one in which the precipitin positive with A. flavus antigens only (see figure), and in whom A. flavus was cultured from material aspirated on bronchoscopy; and another in whom the test was positive against A. niger, and A. niger was cultivated from the sputum. test was
CASE 1.-A handyman, aged 48 years, working in stables, lofts, and dusty places, was admitted to Preston Hall Chest Hospital on Aug. 6, 1963, with a history of many years of persistent productive cough, with occasional bloodstained sputum, dyspnoea, and malaise. He was pale and emaciated, and had pronounced torticollis and high kyphoscoliosis with flattening and little movement on the left side of the chest, over which bronchial breathing was heard. The erythrocyte-sedimentation rate was 55/200 in 1 hour (Westergren).
Radiography of the chest showed gross fibrosis of the upper left lung field with a large apical cavity suggesting old tuberculosis. Tomographs of the cavity showed a mass with an aircontaining halo typical of an aspergilloma. The patient’s sputum at the time was negative for tubercle bacilli and fungi, and he gave a negative Mantoux reaction (100 T.U.). Bronchoscopy showed that the left main bronchus was filled with thick 6. Longbottom, J. L., Pepys, J. J. Path. Bact. (in the press). 7. Gernez-Rieux, Ch, Biguet, J., Voisin, C., Capron, A., Balgairies, Tran van Ky, P. J. franç. Méd. Chir. thor. 1963, 17, 663. 8. Drouhet, E., Segretain, G., Pesle, G., Bidet, L. ibid. p. 655.
E.,
589 pus, and that its lateral wall was rigid, but not so rigid as to suggest a carcinoma. Washings of the left upper lung yielded A, fiavus. Subsequently A. flavus was frequently cultured from the sputum. Skin-prick tests with freeze-dried extracts of A. fumigatus and A. flavus were negative. The precipitin test on the patient’s serum (see figure) gave a positive reaction with multiple arcs to the extract of A, flavus and negative reactions to extracts of A. fumigatus and A. nidulans. CASE 2.-A man,
aged
56 years,
was
admitted
to
Hammer-
smith Hospital for investigation of recent haemoptysis and the
worsening over the last year of a chronic cough and expectoration. Radiography showed bilateral fibrosis and cavitation in the upper lung zones, with recent appearance of increased opacity in the left upper zone. Tomographs of the cavity showed a mass with an air-containing halo, typical of an aspergilloma. His sputum yielded A. niger on culture and was negative for tubercle bacilli. Skin tests gave a positive wealing reaction to A, niger, somewhat unusual in the absence of asthma, and a negative reaction to A. fumigatus. The precipitin test gave multiple specific arcs to an extract of A. niger.
Fig. I-Typical peripheral blood neutrophils from 2 cases of D (13-15) trisomy. Both cells show the anomalous nuclear projections (Wright’s stain; magnification x 3800, reduced x 3). are not
always readily available. In this report, specific neutrophils in D trisomy are diagnostic test of unusually
nuclear abnormalities of the described which provide a easy access.
Peripheral-blood smears were examined from six children
In a further patient, in whom A nidulans was cultured from a discharging empyema and after death from an erosion of the vertebral column 11 a specific reaction was obtained to A nidulans3 (see figure). The agar-gel precipitin test with extracts of A. fumigatus and of other aspergillus species, such as A. nidulans, A, flavus and A. niger may be of diagnostic value in aspergillus mycetoma. We should add that the presence of an aspergilloma does not preclude the presence of other pathological conditions of the lung.
(two bovs and four sirls’) with Droved trisomv of one of the chromosomes of the 13-15 group associated with the typical clinical features of the
D1-trisomy syndrome. Their ages ranged from 1 day to almost 5 years. In every case most of the neutrophils were abnormal in their nuclear structure. The
-
malies
.
JOAN L. LONGBOTTOM
M.R.C. Clinical Immunology Research Group, Institute of Diseases of the Chest, London, S.W.3 Preston Hall Chest Hospital, Maidstone, Kent
M.SC. N.Z.
M.B.
J. PEPYS W’srand, M.R.C.P., M.R.C.P.E. F. TEMPLE CLIVE M.B.
Lond.
NUCLEAR ABNORMALITIES OF THE NEUTROPHILS IN D1 (13-15)-TRISOMY SYNDROME WE wish to report an observation which may be useful in the diagnosis of D (13-15) trisomy. The basic clinical syndrome associated with this chromosomal abnormality has already been clearly delineated 10 and includes severe developmental and mental retardation and a number of
Fig. 2-Electron micrograph of part of peripheral blood-neutrophil from 2-month-old boy with D (13-15) trisomy. Two sessile nodules are indicated by arrows at the periphery of the nucleus. A pedunculated projection (P) is also shown. Normal specific granules (G) are see in the cytoplasm (uranyl/ lead acetate stain; magnification x
13,000, reduced
x
/,).
malformations, among which are eye anomalies, hare-lip and cleft palate, polydactyly, congenital heart-disease, and arhinencephaly. The clinical diagnosis of D trisomy syndrome, like the diagnosis of most chromosomal diseases, is not always straightforward. Since chromosomal studies are laborious and time-consuming, a rapid aid to the diagnosis of this disease would be desirable. We have found specific haemoglobin patterns in Di-trisomy syndrome in the newborn period while other authors 12 have described distinctive dermal-ridge patterns. However, both these studies require specialised techniques which Carre, I. J., Redmond, Aileen, Biggart, J. D., Mackenzie, D. W. R. Unpublished. 10. Smith, D. W., Patau, K., Therman, E., Inhorn, S. L., DeMars, R. I. J. Pediat. 1963, 62, 326. 11. Huehns, E. R., Hecht, F., Keil, J. V., Motulsky, A. G. Proc. nat. Acad Sci., Wash. 1964, 51, 89. 12. Uchida, I. A., Patau, K., Smith, D. W. Amer. J. hum. Genet. 1962, 14,
Fig. 3-Electron micrograph of another sessile nodule at higher magnification ( x 50,000, reduced x ,.).
ano-
nuclear projections (fig. 1). The number of projections ranged from 1 to 6 per cell; their appearance was extremely variable in both size (approximately 0-25 to 1-5 tL) and shape, some being sessile projections, others pedunculated. These projections were Feulgen-positive, indicating that they are part of the nucleus. Besides these obvious nuclear projections, the nuclear lobulation appeared abnormal: often the nucleus looked twisted, and the individual lobes were not
9.
345.
prominent
most
We would like to thank Dr. A. L. Furniss, Dr. I. G. Murray, Dr. J, C. Batten, and Dr. P. Stradling for provision of material and permission to auote their cases.
were
clearly separated.
In other cells several lobules appeared to grow out from a single point. The chromatin pattern of the nuclei was coarse and lumpy. This appearance could also be seen when the living cells were observed by phase-contrast microscopy. The cytoplasm and granules