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EVIDENCE OF ACQUIRED IMMUNE DEFICIENCIES IN MEDITERRANEAN LYMPHOMA
709
be produced by diseases such as periarteritis nodosa in which the small vessels of the intestinal tract are affected by primary systemic vasculitis or arteritis. 12 The vascular damage in anaphylactoid (allergic) purpura, typified by the Henoch-Schonlein syndrome, and in purpura due to some drug allergies is classified as intrinsic vascular damage, which presumably results from the allergic process. Wintrobe postulated that an antigen-antibody reaction may inhibit endothelial enzymes necessary for the viability of the vessel walls.l3 Submucosal haematomas in the bowel, most often the small intestine, also result from exudation of blood from damaged vessels, vasculitis and perivasculitis of the small blood vessels being seen on histopathological examination. In contrast to Henoch-Schonlein purpura, in which the colon is infrequently involved and symptomatic improvement much less rapid, the disease seen in our patients affected the colon primarily and resolved rapidly. The presence of petechiae in the mouth and oropharynx in case i and of submucosal haemorrhage in the stomach and duodenum in case n suggests that our pa-
tients may also have had an allergic vasculitis in of the gastrointestinal tract other than the colon.
areas
Requests for reprints should be addressed to R. B. T., Waterbury Hospital, 64 Robbins Street, Waterbury, Connecticut, 06720. REFERENCES 1.
Ecker, J. A., Williams, R. G., McKittrick, J. E., Failing, R. M. Am. J. Gastroent.
2. Tedesco,
1970, 54, 214. J., Barton,
F.
R. W.,
Alpers,
D. H. Ann. intern. Med.
1974, 81,
429. 3. Tedesco, F. J. Am. J. dig. Dis. 1975, 20, 295. 4. Tures, J. D., Townsend, W. F., Rose, H. D. J. Am. med. Ass. 1976, 236, 948. 5. Stanley, J. R., Melson, G. L., Tedesco, J. F. Radiology, 1974, 111, 519. 6. Schapiro, R. L., Newman, A. ibid. 1973, 108, 263. 7. Keating, J., Frank, A. L., Barton, L. C., Tedesco, F. J. Am. J. Dis. Child.
1974, 128, 369. 8. Hyson, E., Burrell, M. I., Toffler, R. Gastroint. Radiol. 1977, 2, 183. 9. Knudsen, E. T. Br. med. J. 1969, i, 846. 10. Berk, R. N., Millman, S. J. Radiology, 1971, 99, 539. 11. Penner, A., Berheim, A. I. ibid. 1967, 89, 250. 12. Feller, E., Rickert, R., Spiro, H. M. in Small Vessel Disease of the Gut, Vascular Disorders of the Intestine (edited by S. J.Boley, S. S. Schwartz, and I.. F. Williams, Jr.); p. 483. New York, 1971. 13 Mescon, H., Quintilian, A., Jr. in Purpura: A Review of Selected Clinical and Pathophysiologic Aspects, The Peripheral Blood Vessels (edited by J. L. Orbison and D. E. Smith); p. 232. Baltimore, 1963.
Hypothesis EVIDENCE OF ACQUIRED IMMUNE DEFICIENCIES IN MEDITERRANEAN LYMPHOMA A Possible
Aetiological Link
TAHSEEN I. AL-SALEEM
Department of Pathology, College of Medicine, University of Baghdad, Iraq Patients with Mediterranean lymphoma (M.L.) had a significant reduction in humoral immunity (IgG and IgM) as well as impaired cellular immunity (50% were anergic to three antigens—P.P.D., mumps, and dinitrochlorobenzene). Any hypothesis for the pathogenesis of M.L. has to account for the peculiar geographic distribution of the disease, the age and sex incidence, the plasma-cell nature of the tumours, the associated heavy plasmacytic proliferation with relatively intact intestinal mucosa, involvement of the proximal small intestine, and alpha-chain production in a large proportion of patients. All areas in which M.L. is common are currently involved in the seventh cholera pandemic. Vibrio choleræ toxin inhibits both immediate and delayed immune reaction in vitro through its effect on cyclic adenosine monophosphate. V. choleræ antigens stimulate the proliferation of IgA-producing immunocytes in the mucosa without deeply penetrating the mucosa. The proximal small bowel is usually affected by the disease but there is little epithelial damage. The population in endemic areas is continuously exposed to V. choleræ antigens and toxins. It is suggested that such exposure, under certain genetic or other circumstances, may produce a state of immunosuppression in the gut thus accelerating, predisposing to,
Summary
or
producing lymphoplasmacytic neoplasia. INTRODUCTION
DIFFUSE mucosal
lymphoplasmacytic proliferation
in
Mediterranean lymphoma 1may or may not be associated with the presence of alpha heavy chains (A.H.C.) in the serum or other biological fluids.3-1’ In some patients there is no evidence of frank neoplasia. The clinical syndrome is characterised by chronic diarrhoea, abdominal pain, clubbing, and evidence of intestinal obstruction late in the course of the disease .3 13 It mainly affects young adults in low socioeconomic groups.13 The male to female ratio is closer to unity in M.L. than in most other malignant lymphomas. As well as abnormal immunoglobulin concentrations, patients usually have hypoalbuminxmia and hypolakxmia; in some, concentrations of alkaline phosphatase are high.3 There is radiologically and pathologically demonstrable mucosal abnormality, with thickening and polypoid changes and sometimes superimposed multicentric tumour masses, almost always in the upper small intestine. In the early phases of the disease, lymphoplasmacytic proliferation is non-dystrophic and usually limited to the lamina propria. There are various degrees of villous atrophy, but the enterocytes are generally intact. 1 2 16 In more advanced cases, immature plasma-cells appear and cross the muscularis mucosa, and frank lymphoplasmacytic neoplasms are formed.l-3 12 16 Involvement of the mesenteric lymph-nodes is very common but the liver, spleen, and peripheral lymph-nodes are rarely affected, except late in the disease. 12 15 17 Experience in the College of Medicine, Baghdad, as well as elsewhere, indicates a good prognosis if the disease is diagnosed early. Long-lasting clinicopathological and immunological remissions have been reported in some patients after antibiotic therapy alone, particularly
with tetracycline. 13 17 The North
prevalence of M.L. is high in the Middle East, Africa,13 and southern Africa.14 Cases are less
in the Mediterranean part of Europe," 18 19 and south-east Asia 13 and rare in South America.2° The few cases reported from other parts of Europe and the U.S.A. of "alpha heavy-chain disease" (A.H.C.D.), seem
common
710 to represent other- clinicopathological entities produced by lymphoproliferative processes associated with abnormal alpha-chain production." The frequency ofM.L. in Iraq, with or without alpha heavy chains, is high.3 17 Small-intestinal primaries constitute about 50-60% of all non-Hodgkin’s lymphomas recorded in the Teaching Hospital, University of Baghdad, and about 40% of those in the tumour registry of Baghdad. In the registry, 89% of all malignant small-intestinal tumours are lymphomas. Reports on the immunological studies in M.L. are meagre and fragmentary. Most of them were done on patients with A.H.C.D., and low levels of IgG and IgM 13 These results of studies of cellular were reported.10 11 immunity were either abnormal"’ 19 or inconsistent.14 I believe that a systematic study of immunity in M.L. would contribute to our understanding of the pathology and pathogenesis of the disease.
the three antigens were anergic to all of them (table I). Comparable anergy was found only in patients with advanced Hodgkin’s disease (not shown in the tables). Except for much lower serum-IgM and, as expected, the apparently high concentrations of IgA in A.H.c.D., immunological abnormalities were similar in both types of M.L.
Pathogenesis ofM.L. The geographic distribution and involvement of mainly low socioeconomic groups suggested that chronic infection (bacterial, viral, and parasitic) or genetic factors might be involved in pathogenesis.13 Chronic diarrhoea during infancy with permanent impairment of immune processes has also been postulated as being responsible for the development of M.L. later in life. 20 However, no pathogenic organism has been identified.13 Most bacterial and parasitic infections encountered in those with
PATIENTS AND METHODS
All patients were diagnosed by pathology as having M.L. with or without A.H.C. IgG, IgA, and IgM were estimated by radial immunodiffusion, and immunoselection was used to identify free A.H.C.17 A battery of skin tests, including two recall antigens (P.P.D. [medium strength] and mumps) were used (table I). Active sensitisation and rechallenge with TABLE I-POSITIVE SKIN REACTIONS IN PATIENTS WITH M.L.
M.L. are
found in low socioeconomic groups
throughout the world. Also any hypothesis suggesting an infectious aetiology has to account for the fact that M.L. mainly involves the upper small intestine," whereas most microorganisms tend to inhabit the terminal portions of the small intestine and the large bowel. Furthermore, while most bacterial and parasitic infestations cause mucosal damage, patients with M.L. tend to have intact intestinal epithelium.3 HYPOTHESIS
I believe that
repeated exposure of the intestinal Vibrio cholerae toxin and/or other biologiepithelium enterotoxins similar may produce local (and poscally sibly later) general impairment of immunity and thus predispose the patient to the development of lymphoto
plasmacytic neoplasia. Cholera dinitrochlorobenzene (D.N.C.B.) were carried out. Age and sex matched healthy volunteers or patients admitted for minor illnesses-e.g., hernias and benign skin lesions-and patients with other types of lymphoma, were also studied. RESULTS
Patients with M.L. (with or without A.H.c.D.) had statistically significant reductions in serum IgG and IgM (table n). Patients with Hodgkin’s disease and non-intestinal non-Hodgkin’s lymphoma did not have low serumimmunoglobulins. In fact, IgG levels were significantly increased in patients with Hodgkin’s disease (not shown in the tables). However, 50% of patients challenged with TABLE II-SERUM-IMMUNOGLOBULINS
(mean +S.E., I.U./ml) IN
PATIENTS WITH M.L. I
r
-
The current pandemic of cholera is caused by the El Tor strain of V. cholera. In the early 60s, the epidemic swept westwards from Indonesia to involve the traditional endemic areas in the Indian subcontinent and, later, the Middle East. Shortly afterwards, North Africa and Southern Europe were involved. 21 Currently, the pandemic also involves west and east subsaharan Africa. A large number of El Tor organisms is
needed to produce clinical disease. 22 The clinical picture of acute watery diarrhoea and electrolyte imbalance can be explained on the grounds of impaired function of the cell membrane of the intestinal epithelium. This impairment is caused by the potent effect of the V. cholera toxin on adenylcyclase activity. Cholera toxin permanently binds to cell membrane receptors for various hormones and chemical substances and increases intracellular cyclic A.M.P. This increases gut electrolyte secretion.22 Treatment consists of fluid and electrolyte replacement. Tetracycline therapy is useful in limiting the severity of the disease. Vibrio cholera organisms tend to inhabit the upper small intestine because they can resist the effects of bile. The organisms remain limited to the epithelial surface and deep in the crypts of Lieberkfihn .22 The toxin probably does not penetrate beyond the mucosa.23 The enterotoxin is very potent biologically, but undergoes natural
711
degradation forming choleragenoid which is antigenic but lacks the biological effects of the enterotoxin. The effect of enterotoxin on cyclic A.M.P. has been experimentally demonstrated in many cell systems’"—e.g., platelets, lipocytes, thyroid cells, and lymphocytes. In even in small amounts, the toxin interferes with both immediate and delayed immune reactions.24 In addition, and for reasons yet not quite clear, choleragenoid-sensitised cells fail to induce T-cell-mediated cytolysis.25 In vivo, the enterotoxin seems to interfere with antibody-mediated killing of V. cholera. The clinical importance of these observations is not established yet. However, cholera infection produces little or no inflammatory changes in the intestinal mucosa. 2226 Immunity to cholera after infection is generally short-lived, and attempts at oral vaccination were not successful. 27 Orally administered cholera toxoid does not produce sensitised immunocytes in Peyer’s patches, and takes a long time to produce immunity. However, after intraperitoneal priming, laboratory animals respond quickly to the local application of the toxoid with proliferation of IgA-antibody-containing plasma-cells limited to the mucosa. If the toxoid is given by the oral route, the effect is more pronounced in the jejunum and duodenum. Specific IgA-antibody-producing immunocytes were observed in the thoracic duct, but "homed" to the intestinal mucosa. 28
vitro,
DISCUSSION
the intestinal epithelium is V. cholerae continuously exposed antigen and enterotoxins.z’ The toxin seems to be permanently attached to the cell membrane of the enterocyte. It is not known yet what happens to the immunocytes which are present in the lamina propria at the time of exposure to the toxin, but if the implications of the in-vitro experiments are accepted, a permanent impairment of the immune reactivity of these lymphocytes is likely.29 On repeated exposure, in at least some individuals who may be genetically or otherwise susceptible, permanent impairment of immunity may develop at a local and later possibly systemic level. If both the suppressor and helper T lymphocytes are affected, one would expect the development of both aproliferative and proliferative syndromes, and possibly later frank neoplasms as a result of mutation in the proliferating clones or in response to another agent -i.e., an oncogenic virus. This situation resembles the hereditary impairment of the lymphoproliferative X-linked locus which leads to either hypogammagloIn cholera-endemic
areas
to
bulinsemia or immunoproliferative syndromes, including immunoblastic lymphomas of the small intestine. 30 The epidemiological evidence implicating V. cholerae in M.L. is analogous to that linking endemic malaria with Burkitt’s lymphoma.31Burkitt’s lymphoma is quite common in Iraq and almost always presents as an intestinal or abdominal primary. 32 The sex and age incidence of M.L. is consistent with that of cholera infection in newly involved geographic areas. Recent reports of M.L. and A.H.C.D. coincide chronologically and geographically with the westward extension of the current cholera pandemic. The epidemiological maps of cholera21 and M.L. and A.H.C.D.13 are almost identical. Thus, all Asian Middle Eastern countries,1 36 10 11 North Africa9 12 (excluding Egypt), Mediterranean parts of Europe," 18 and
sub-saharan Africa14 are reporting>more cases ofM.L. and A.H.C.D. Fewer cases were reported from the Indian-subcontinent6 and South East Asia." The earliest reports started to appear in the late 1960s and early 1970s, almost the same time as the present cholera pandemic swept through the same geographic area. The fact that many patients with M.L. have a long history of diarrhoea is not at variance with the postulated role for cholera. Cases of cholera can remain unrecognised or unreported long before the official announcement of an epidemic.21 M.L. and A.H.C.D. are rarely reported in the Indian subcontinent where cholera is endemic; however, exposure during infancy and childhood in such population may produce a permanent immunity.27 Egypt, the largest Arab country in Africa, had not reported cholera officially during the seventh pandemic,21 and M.L. or A.H.C.D. have not, to my knowledge, been reported from Egypt. M.L. and A.H.C.D. are being reported with increasing frequency from the same areas. Thus, the number of reported cases has steadily increased in recent years. However, the lack of well-established tumour registries in some countries makes it difficult to determine whether there is a true increase in the incidence or just increased recognition of M.L. The same reservation applies to the impression of an increased frequency of M.L. in Iraq in recent years. According to my hypothesis, one would expect the incidence of M.L. to gradually reach a plateau as cholera becomes endemic and the population is exposed to its antigens during infancy and childhood, thus gradually developing a modified, possibly protective, immune response.
recently
The plasmacytic nature of M.L. and its proximal localisation suggests a response to an antigenic substance taken orally and an effect limited to the immunocytes of the mucosa. Though A.H.C.-producing plasma-cells have been demonstrated in the bone-marrow and peripheral blood, the disease remains limited to the mucosa, probably for a long time before the onset of frank neoplasia.3 Thus, I postulate a "homing" process similar to that reported in experimental immunisation with cholera toxoid.27 The intense lymphoplasmacytic proliferation may be’more common in the population of the affected area than would be expected from the number of clinically overt cases. I have seen this abnormality as an "incidental" finding at necropsy. Others have reported it to be commonly seen in medicolegal necropsies.33 A gradual transition to neoplasia was suggested in a similar study from Southern Iran.2o It is hard to tell whether the immune deficiency of both the B and T systems in M.L. is a primary or secondary event. However, there was total anergy and severe hypogammaglobullnxmia even in patients with superficial mucosal lymphoplasmacytic proliferation. If more sensitive techniques-e.g., lymphocyte transformation-are used, more patients will probably display evidence of impaired immunological reactivity. This immune deficiency seems to be acquired, as none gave a Family history of unusual repeat childhood infections. studies generally have not been rewarding. " 17 Most of the patients with intestinal form of A.H.C.D. have IgA sub-class-l fragments." IgA antibody is formed in response to cholera antigens,28 but the subclass has not been identified.34 Besides, there are no reports of a search for V. cholerx in A.H.C.D., and such cultures were
712
patients, since cholera suspected. However, negative cultures do not not
,
carried
out
in
our
was not
rule out the possibility of causal relations, since in endemic areas brief exposures would be expected. Whether these repeated exposures, and the postulated immune suppression which follows, accelerate a preexisting immunoproliferative process, predispose to its occurrence by infective agents-e.g., viruses--or initiate it by the V. cholerae antigens themselves, is not known. Why do proliferating plasma-cells produce abnormal alpha-chain fragments rather than complete immunoglobulins ? Can there be a modification of the secretory activity of these plasma-cells? Does a modification of the secretory activity of the intestinal mucosa account for the high levels of alkaline intestinal isoenzyme in M.L.? What other enterotoxin-producing bacteria can be implicated? Is the response to tetracycline reported in some patients with A.H.c.D.13 related to the chemoprophylactic effects on V. cholerce infection ?35 I believe that because of the widespread extension of the present cholera pandemic and the efforts to contain it with new, possibly oral, vaccines, this hypothesis should be carefully tested. Animals, genetically susceptible to autoimmune diseases-e.g., the NZB micemay be useful as experimental models.
phosphatase
Methods and Devices AUTOMATIC LANCET FOR CAPILLARY BLOOD SAMPLING R. R. HOLMAN
R. C. TURNER
Department of the Regius Professor of Medicine, Radcliffe Infirmary, Oxford OX2 6HE CAPILLARY blood-samples are often taken when a small of blood is needed-e.g., blood-counts in haematoor antenatal clinics, glucose estimations in diabetic clinics, logy or in neonates and children where venous sampling is not easy. It has been suggested that diabetic patients should take their own blood-samples at home for plasma-glucose assay. 1-3 However, a manual jab with a needle can be quite painful.
quantity
I thank Dr A. F. Naji, Director of Laboratories, St. Alexis Hospital, for his critical review of the article. Immunoglobulin estimations and skin tests were carried out with the help of Ibrahim Zardawi, Dr Maha Kamal, Dr Khalida Al-Mousawi, and Dr Nabeel Al-Tawil. Miss Kathleen Collins provided secretarial assistance.
Automatic lancet, with finger against finger-guard. Button has just been pressed by thumb, releasing the lancet, which has instantly been withdrawn after pricking the finger.
REFERENCES 1.
Eidelman, S., Parkins, R. A., Rubin, C. E. Medicine, Baltimore, 1966, 45,
2. 3.
Rappaport, H., Ramot, B., Hulu, N., Park, J.
11. K.
Cancer, 1972, 29, 1502.
Al-Saleem, T., Zardawi, I. Lancet, 1978, i, 775. Rambaud, J. C., Bognel, C , Prost, A., Bernier, J. J., LeQuintrec, Y., Lambling, A., Danon, F., Hurez, D., Seligmann, M. Digestion, 1968, 1, 321. 5. Rambaud, J. C., Matuchansky, C. Lancet, 1973, i, 1430. 6. Doe, W. F., Henry, K., Hobbs, J. R., Avery Jones, E., Dent, C E., Booth, C. C. Gut, 1972, 13, 947. 7. Doe, W F Br. J. Cancer, 1975, 31, suppl II, p. 350. 8. Ramot, B., Hulu, N. ibid. suppl. II, p 343.
4.
9. 10.
Seligmann, M. Archs intern. Med. 1975, 135, 78. Shahid, M. J., Alami, S. Y., Nassar, V. H., Balikian, J. B., Salem, A.
A.
Cancer, 1975, 35, 848. 11. Kharazmi, A., Haghighi, P., Haghshenas, M., Nasr, K., Abadi, P., Rezai, H R Clin. exp Immun. 1976, 26, 124 12. Tabbane, S., Tabbane, F., Cammoun, M., Mourali, N Cancer, 1976, 38,
1989. 13. Rambaud, J. C., Seligmann, M. Clins Gastroent. 1976, 5, 341. 14 Lewin, K. J., Kahn, L. B., Novis, B. H. Cancer, 1976, 38, 2511. 15. Salem, P. A., Nassar, V. H., Shahid, M., Hajj, A., Alami, A. S., Balikar, J., Salem, A. ibid. 1977, 39, 2081. 16. Gahan, A., Lecestre, M. J., Scotto, J., Bognel, C., Matuchansky, C., Rambaud, J. C. ibid 17. Al-Bahrani, Z., Al-Saleem, T., Al-Mondhiry, H , Bakir, F., Yahia, H., Taha, I., King, J. Gut (in the press). 18. Bonomo, L., Damacco, F., Marano, R., Bonomo, G. M. Am. J. Med. 1972,
52, 73 Pittman, F. E., Tripathy, K., Isobe, T., Bolanos, O M., Osserman, E. F., Pittman, J. C., Lotero, H. R., Duque, E. E. ibid. 1975, 58, 424. 20. Dutz, W., Asvadi, Sh., Sadri, Sh., Kahout, E. Gut, 1971, 12, 804. 21. Kamal, A. M. in Cholera (edited by D Barua and W. Burrows), p. 1. Phila19.
delphia, 1974. 22. Carpenter, C. C. J. Jr., Greenough, W. B. III, Gordon, R. S. Jr. ibid. p. 129. 23. Pierce, N. F., Greenough, W. B. III, Carpenter, C C J. Jr. Bact Rev. 1971, 35, 1. 24. Lichtenstein, L. M., Henney, C. S., Bourne, H. R , Greenough, W. B. III.
J. clin. Invest. 1973, 52, 691. 25. Forman, J., Finkelstein, R. A. J. Immun. 1977, 118, 1655 26. Pastore, G., Schiraldi, G., Fera, G., Sforza, E., Schiraldi, O.
Am. J. dig. Dis.
1976, 21, 613. 27. Finkelstein, R. A. Curr.
Top. Microbiol. Immun. 1975, 69, 138. 28. Pierce, N. F., Gowans, J.L.J. exp. Med. 1975, 142, 1550.
An automatic device for pricking the finger has been developed. A sterile, disposable lancet (’Monolet’, Sherwood) is placed on a spring-loaded arm mounted in a hand-held apparatus. A finger is pressed against a disposable finger-guard, and pressure on a button releases the spring-loaded arm. The lancet penetrates the skin to a controlled depth and is immediately withdrawn. The apparatus can be fired either by pressing the firing-knob with a thumb or finger (see accompanying figure), or by inverting the apparatus and pressing the knob on any convenient surface. The speed with which the finger is pricked and the instantaneous withdrawal of the lancet means that this method is virtually painless. We think that this automatic lancet will be especially useful in pxdiatrics, in laboratories where several
technicians occasionally take blood-samples, and for diabetic patients who wish to take blood-samples at home. The
automatic
lancet ’Autolet’
ford, Woodstock, Oxordshire. We
can are
be obtained from Owen Mumgrateful to Mr B. A. Stone for
technical assistance. REFERENCES E. A. M., Allison, S. P., Tattersall, R. B Lancet, 1978, i, 732 2. Sōnksen, P. H., Judd, S. L., Lowy, C. ibid. p. 729. 3. Howe-Davies, S., Holman, R. R., Philips, M., Turner, R. C. Br. med. J. 1978, ii, 59.
1. Walford, S., Gale,
Hadden, J. W. Ann. N.Y. Acad. Sci. 1975, 256, 252. Purtilo, T. D., DeFlorio, D. Jr., Hutt, L. M., Bhawan, J., Yang, J., Otto, R., Edwards, W. New Engl. J. Med. 1977, 297, 1077. 31. O’Connor, G. T. Am. J. Med. 1970, 18, 679. 32. Al-Saleem, T., Gailani, F. Iraq med. J. 1976, 24, 49. 33. Jawahiry, K. J Fac. Med. Baghdad (in the press). 29. 30.
34. Pierce, N. F. Personal communications. 35. Carpenter, C. C. J. Prev. Med. 1974, 3, 456.
be produced by diseases such as periarteritis nodosa in which the small vessels of the intestinal tract are affected by primary systemic vasculitis or arteritis. 12 The vascular damage in anaphylactoid (allergic) purpura, typified by the Henoch-Schonlein syndrome, and in purpura due to some drug allergies is classified as intrinsic vascular damage, which presumably results from the allergic process. Wintrobe postulated that an antigen-antibody reaction may inhibit endothelial enzymes necessary for the viability of the vessel walls.l3 Submucosal haematomas in the bowel, most often the small intestine, also result from exudation of blood from damaged vessels, vasculitis and perivasculitis of the small blood vessels being seen on histopathological examination. In contrast to Henoch-Schonlein purpura, in which the colon is infrequently involved and symptomatic improvement much less rapid, the disease seen in our patients affected the colon primarily and resolved rapidly. The presence of petechiae in the mouth and oropharynx in case i and of submucosal haemorrhage in the stomach and duodenum in case n suggests that our pa-
tients may also have had an allergic vasculitis in of the gastrointestinal tract other than the colon.
areas
Requests for reprints should be addressed to R. B. T., Waterbury Hospital, 64 Robbins Street, Waterbury, Connecticut, 06720. REFERENCES 1.
Ecker, J. A., Williams, R. G., McKittrick, J. E., Failing, R. M. Am. J. Gastroent.
2. Tedesco,
1970, 54, 214. J., Barton,
F.
R. W.,
Alpers,
D. H. Ann. intern. Med.
1974, 81,
429. 3. Tedesco, F. J. Am. J. dig. Dis. 1975, 20, 295. 4. Tures, J. D., Townsend, W. F., Rose, H. D. J. Am. med. Ass. 1976, 236, 948. 5. Stanley, J. R., Melson, G. L., Tedesco, J. F. Radiology, 1974, 111, 519. 6. Schapiro, R. L., Newman, A. ibid. 1973, 108, 263. 7. Keating, J., Frank, A. L., Barton, L. C., Tedesco, F. J. Am. J. Dis. Child.
1974, 128, 369. 8. Hyson, E., Burrell, M. I., Toffler, R. Gastroint. Radiol. 1977, 2, 183. 9. Knudsen, E. T. Br. med. J. 1969, i, 846. 10. Berk, R. N., Millman, S. J. Radiology, 1971, 99, 539. 11. Penner, A., Berheim, A. I. ibid. 1967, 89, 250. 12. Feller, E., Rickert, R., Spiro, H. M. in Small Vessel Disease of the Gut, Vascular Disorders of the Intestine (edited by S. J.Boley, S. S. Schwartz, and I.. F. Williams, Jr.); p. 483. New York, 1971. 13 Mescon, H., Quintilian, A., Jr. in Purpura: A Review of Selected Clinical and Pathophysiologic Aspects, The Peripheral Blood Vessels (edited by J. L. Orbison and D. E. Smith); p. 232. Baltimore, 1963.
Hypothesis EVIDENCE OF ACQUIRED IMMUNE DEFICIENCIES IN MEDITERRANEAN LYMPHOMA A Possible
Aetiological Link
TAHSEEN I. AL-SALEEM
Department of Pathology, College of Medicine, University of Baghdad, Iraq Patients with Mediterranean lymphoma (M.L.) had a significant reduction in humoral immunity (IgG and IgM) as well as impaired cellular immunity (50% were anergic to three antigens—P.P.D., mumps, and dinitrochlorobenzene). Any hypothesis for the pathogenesis of M.L. has to account for the peculiar geographic distribution of the disease, the age and sex incidence, the plasma-cell nature of the tumours, the associated heavy plasmacytic proliferation with relatively intact intestinal mucosa, involvement of the proximal small intestine, and alpha-chain production in a large proportion of patients. All areas in which M.L. is common are currently involved in the seventh cholera pandemic. Vibrio choleræ toxin inhibits both immediate and delayed immune reaction in vitro through its effect on cyclic adenosine monophosphate. V. choleræ antigens stimulate the proliferation of IgA-producing immunocytes in the mucosa without deeply penetrating the mucosa. The proximal small bowel is usually affected by the disease but there is little epithelial damage. The population in endemic areas is continuously exposed to V. choleræ antigens and toxins. It is suggested that such exposure, under certain genetic or other circumstances, may produce a state of immunosuppression in the gut thus accelerating, predisposing to,
Summary
or
producing lymphoplasmacytic neoplasia. INTRODUCTION
DIFFUSE mucosal
lymphoplasmacytic proliferation
in
Mediterranean lymphoma 1may or may not be associated with the presence of alpha heavy chains (A.H.C.) in the serum or other biological fluids.3-1’ In some patients there is no evidence of frank neoplasia. The clinical syndrome is characterised by chronic diarrhoea, abdominal pain, clubbing, and evidence of intestinal obstruction late in the course of the disease .3 13 It mainly affects young adults in low socioeconomic groups.13 The male to female ratio is closer to unity in M.L. than in most other malignant lymphomas. As well as abnormal immunoglobulin concentrations, patients usually have hypoalbuminxmia and hypolakxmia; in some, concentrations of alkaline phosphatase are high.3 There is radiologically and pathologically demonstrable mucosal abnormality, with thickening and polypoid changes and sometimes superimposed multicentric tumour masses, almost always in the upper small intestine. In the early phases of the disease, lymphoplasmacytic proliferation is non-dystrophic and usually limited to the lamina propria. There are various degrees of villous atrophy, but the enterocytes are generally intact. 1 2 16 In more advanced cases, immature plasma-cells appear and cross the muscularis mucosa, and frank lymphoplasmacytic neoplasms are formed.l-3 12 16 Involvement of the mesenteric lymph-nodes is very common but the liver, spleen, and peripheral lymph-nodes are rarely affected, except late in the disease. 12 15 17 Experience in the College of Medicine, Baghdad, as well as elsewhere, indicates a good prognosis if the disease is diagnosed early. Long-lasting clinicopathological and immunological remissions have been reported in some patients after antibiotic therapy alone, particularly
with tetracycline. 13 17 The North
prevalence of M.L. is high in the Middle East, Africa,13 and southern Africa.14 Cases are less
in the Mediterranean part of Europe," 18 19 and south-east Asia 13 and rare in South America.2° The few cases reported from other parts of Europe and the U.S.A. of "alpha heavy-chain disease" (A.H.C.D.), seem
common
710 to represent other- clinicopathological entities produced by lymphoproliferative processes associated with abnormal alpha-chain production." The frequency ofM.L. in Iraq, with or without alpha heavy chains, is high.3 17 Small-intestinal primaries constitute about 50-60% of all non-Hodgkin’s lymphomas recorded in the Teaching Hospital, University of Baghdad, and about 40% of those in the tumour registry of Baghdad. In the registry, 89% of all malignant small-intestinal tumours are lymphomas. Reports on the immunological studies in M.L. are meagre and fragmentary. Most of them were done on patients with A.H.C.D., and low levels of IgG and IgM 13 These results of studies of cellular were reported.10 11 immunity were either abnormal"’ 19 or inconsistent.14 I believe that a systematic study of immunity in M.L. would contribute to our understanding of the pathology and pathogenesis of the disease.
the three antigens were anergic to all of them (table I). Comparable anergy was found only in patients with advanced Hodgkin’s disease (not shown in the tables). Except for much lower serum-IgM and, as expected, the apparently high concentrations of IgA in A.H.c.D., immunological abnormalities were similar in both types of M.L.
Pathogenesis ofM.L. The geographic distribution and involvement of mainly low socioeconomic groups suggested that chronic infection (bacterial, viral, and parasitic) or genetic factors might be involved in pathogenesis.13 Chronic diarrhoea during infancy with permanent impairment of immune processes has also been postulated as being responsible for the development of M.L. later in life. 20 However, no pathogenic organism has been identified.13 Most bacterial and parasitic infections encountered in those with
PATIENTS AND METHODS
All patients were diagnosed by pathology as having M.L. with or without A.H.C. IgG, IgA, and IgM were estimated by radial immunodiffusion, and immunoselection was used to identify free A.H.C.17 A battery of skin tests, including two recall antigens (P.P.D. [medium strength] and mumps) were used (table I). Active sensitisation and rechallenge with TABLE I-POSITIVE SKIN REACTIONS IN PATIENTS WITH M.L.
M.L. are
found in low socioeconomic groups
throughout the world. Also any hypothesis suggesting an infectious aetiology has to account for the fact that M.L. mainly involves the upper small intestine," whereas most microorganisms tend to inhabit the terminal portions of the small intestine and the large bowel. Furthermore, while most bacterial and parasitic infestations cause mucosal damage, patients with M.L. tend to have intact intestinal epithelium.3 HYPOTHESIS
I believe that
repeated exposure of the intestinal Vibrio cholerae toxin and/or other biologiepithelium enterotoxins similar may produce local (and poscally sibly later) general impairment of immunity and thus predispose the patient to the development of lymphoto
plasmacytic neoplasia. Cholera dinitrochlorobenzene (D.N.C.B.) were carried out. Age and sex matched healthy volunteers or patients admitted for minor illnesses-e.g., hernias and benign skin lesions-and patients with other types of lymphoma, were also studied. RESULTS
Patients with M.L. (with or without A.H.c.D.) had statistically significant reductions in serum IgG and IgM (table n). Patients with Hodgkin’s disease and non-intestinal non-Hodgkin’s lymphoma did not have low serumimmunoglobulins. In fact, IgG levels were significantly increased in patients with Hodgkin’s disease (not shown in the tables). However, 50% of patients challenged with TABLE II-SERUM-IMMUNOGLOBULINS
(mean +S.E., I.U./ml) IN
PATIENTS WITH M.L. I
r
-
The current pandemic of cholera is caused by the El Tor strain of V. cholera. In the early 60s, the epidemic swept westwards from Indonesia to involve the traditional endemic areas in the Indian subcontinent and, later, the Middle East. Shortly afterwards, North Africa and Southern Europe were involved. 21 Currently, the pandemic also involves west and east subsaharan Africa. A large number of El Tor organisms is
needed to produce clinical disease. 22 The clinical picture of acute watery diarrhoea and electrolyte imbalance can be explained on the grounds of impaired function of the cell membrane of the intestinal epithelium. This impairment is caused by the potent effect of the V. cholera toxin on adenylcyclase activity. Cholera toxin permanently binds to cell membrane receptors for various hormones and chemical substances and increases intracellular cyclic A.M.P. This increases gut electrolyte secretion.22 Treatment consists of fluid and electrolyte replacement. Tetracycline therapy is useful in limiting the severity of the disease. Vibrio cholera organisms tend to inhabit the upper small intestine because they can resist the effects of bile. The organisms remain limited to the epithelial surface and deep in the crypts of Lieberkfihn .22 The toxin probably does not penetrate beyond the mucosa.23 The enterotoxin is very potent biologically, but undergoes natural
711
degradation forming choleragenoid which is antigenic but lacks the biological effects of the enterotoxin. The effect of enterotoxin on cyclic A.M.P. has been experimentally demonstrated in many cell systems’"—e.g., platelets, lipocytes, thyroid cells, and lymphocytes. In even in small amounts, the toxin interferes with both immediate and delayed immune reactions.24 In addition, and for reasons yet not quite clear, choleragenoid-sensitised cells fail to induce T-cell-mediated cytolysis.25 In vivo, the enterotoxin seems to interfere with antibody-mediated killing of V. cholera. The clinical importance of these observations is not established yet. However, cholera infection produces little or no inflammatory changes in the intestinal mucosa. 2226 Immunity to cholera after infection is generally short-lived, and attempts at oral vaccination were not successful. 27 Orally administered cholera toxoid does not produce sensitised immunocytes in Peyer’s patches, and takes a long time to produce immunity. However, after intraperitoneal priming, laboratory animals respond quickly to the local application of the toxoid with proliferation of IgA-antibody-containing plasma-cells limited to the mucosa. If the toxoid is given by the oral route, the effect is more pronounced in the jejunum and duodenum. Specific IgA-antibody-producing immunocytes were observed in the thoracic duct, but "homed" to the intestinal mucosa. 28
vitro,
DISCUSSION
the intestinal epithelium is V. cholerae continuously exposed antigen and enterotoxins.z’ The toxin seems to be permanently attached to the cell membrane of the enterocyte. It is not known yet what happens to the immunocytes which are present in the lamina propria at the time of exposure to the toxin, but if the implications of the in-vitro experiments are accepted, a permanent impairment of the immune reactivity of these lymphocytes is likely.29 On repeated exposure, in at least some individuals who may be genetically or otherwise susceptible, permanent impairment of immunity may develop at a local and later possibly systemic level. If both the suppressor and helper T lymphocytes are affected, one would expect the development of both aproliferative and proliferative syndromes, and possibly later frank neoplasms as a result of mutation in the proliferating clones or in response to another agent -i.e., an oncogenic virus. This situation resembles the hereditary impairment of the lymphoproliferative X-linked locus which leads to either hypogammagloIn cholera-endemic
areas
to
bulinsemia or immunoproliferative syndromes, including immunoblastic lymphomas of the small intestine. 30 The epidemiological evidence implicating V. cholerae in M.L. is analogous to that linking endemic malaria with Burkitt’s lymphoma.31Burkitt’s lymphoma is quite common in Iraq and almost always presents as an intestinal or abdominal primary. 32 The sex and age incidence of M.L. is consistent with that of cholera infection in newly involved geographic areas. Recent reports of M.L. and A.H.C.D. coincide chronologically and geographically with the westward extension of the current cholera pandemic. The epidemiological maps of cholera21 and M.L. and A.H.C.D.13 are almost identical. Thus, all Asian Middle Eastern countries,1 36 10 11 North Africa9 12 (excluding Egypt), Mediterranean parts of Europe," 18 and
sub-saharan Africa14 are reporting>more cases ofM.L. and A.H.C.D. Fewer cases were reported from the Indian-subcontinent6 and South East Asia." The earliest reports started to appear in the late 1960s and early 1970s, almost the same time as the present cholera pandemic swept through the same geographic area. The fact that many patients with M.L. have a long history of diarrhoea is not at variance with the postulated role for cholera. Cases of cholera can remain unrecognised or unreported long before the official announcement of an epidemic.21 M.L. and A.H.C.D. are rarely reported in the Indian subcontinent where cholera is endemic; however, exposure during infancy and childhood in such population may produce a permanent immunity.27 Egypt, the largest Arab country in Africa, had not reported cholera officially during the seventh pandemic,21 and M.L. or A.H.C.D. have not, to my knowledge, been reported from Egypt. M.L. and A.H.C.D. are being reported with increasing frequency from the same areas. Thus, the number of reported cases has steadily increased in recent years. However, the lack of well-established tumour registries in some countries makes it difficult to determine whether there is a true increase in the incidence or just increased recognition of M.L. The same reservation applies to the impression of an increased frequency of M.L. in Iraq in recent years. According to my hypothesis, one would expect the incidence of M.L. to gradually reach a plateau as cholera becomes endemic and the population is exposed to its antigens during infancy and childhood, thus gradually developing a modified, possibly protective, immune response.
recently
The plasmacytic nature of M.L. and its proximal localisation suggests a response to an antigenic substance taken orally and an effect limited to the immunocytes of the mucosa. Though A.H.C.-producing plasma-cells have been demonstrated in the bone-marrow and peripheral blood, the disease remains limited to the mucosa, probably for a long time before the onset of frank neoplasia.3 Thus, I postulate a "homing" process similar to that reported in experimental immunisation with cholera toxoid.27 The intense lymphoplasmacytic proliferation may be’more common in the population of the affected area than would be expected from the number of clinically overt cases. I have seen this abnormality as an "incidental" finding at necropsy. Others have reported it to be commonly seen in medicolegal necropsies.33 A gradual transition to neoplasia was suggested in a similar study from Southern Iran.2o It is hard to tell whether the immune deficiency of both the B and T systems in M.L. is a primary or secondary event. However, there was total anergy and severe hypogammaglobullnxmia even in patients with superficial mucosal lymphoplasmacytic proliferation. If more sensitive techniques-e.g., lymphocyte transformation-are used, more patients will probably display evidence of impaired immunological reactivity. This immune deficiency seems to be acquired, as none gave a Family history of unusual repeat childhood infections. studies generally have not been rewarding. " 17 Most of the patients with intestinal form of A.H.C.D. have IgA sub-class-l fragments." IgA antibody is formed in response to cholera antigens,28 but the subclass has not been identified.34 Besides, there are no reports of a search for V. cholerx in A.H.C.D., and such cultures were
712
patients, since cholera suspected. However, negative cultures do not not
,
carried
out
in
our
was not
rule out the possibility of causal relations, since in endemic areas brief exposures would be expected. Whether these repeated exposures, and the postulated immune suppression which follows, accelerate a preexisting immunoproliferative process, predispose to its occurrence by infective agents-e.g., viruses--or initiate it by the V. cholerae antigens themselves, is not known. Why do proliferating plasma-cells produce abnormal alpha-chain fragments rather than complete immunoglobulins ? Can there be a modification of the secretory activity of these plasma-cells? Does a modification of the secretory activity of the intestinal mucosa account for the high levels of alkaline intestinal isoenzyme in M.L.? What other enterotoxin-producing bacteria can be implicated? Is the response to tetracycline reported in some patients with A.H.c.D.13 related to the chemoprophylactic effects on V. cholerce infection ?35 I believe that because of the widespread extension of the present cholera pandemic and the efforts to contain it with new, possibly oral, vaccines, this hypothesis should be carefully tested. Animals, genetically susceptible to autoimmune diseases-e.g., the NZB micemay be useful as experimental models.
phosphatase
Methods and Devices AUTOMATIC LANCET FOR CAPILLARY BLOOD SAMPLING R. R. HOLMAN
R. C. TURNER
Department of the Regius Professor of Medicine, Radcliffe Infirmary, Oxford OX2 6HE CAPILLARY blood-samples are often taken when a small of blood is needed-e.g., blood-counts in haematoor antenatal clinics, glucose estimations in diabetic clinics, logy or in neonates and children where venous sampling is not easy. It has been suggested that diabetic patients should take their own blood-samples at home for plasma-glucose assay. 1-3 However, a manual jab with a needle can be quite painful.
quantity
I thank Dr A. F. Naji, Director of Laboratories, St. Alexis Hospital, for his critical review of the article. Immunoglobulin estimations and skin tests were carried out with the help of Ibrahim Zardawi, Dr Maha Kamal, Dr Khalida Al-Mousawi, and Dr Nabeel Al-Tawil. Miss Kathleen Collins provided secretarial assistance.
Automatic lancet, with finger against finger-guard. Button has just been pressed by thumb, releasing the lancet, which has instantly been withdrawn after pricking the finger.
REFERENCES 1.
Eidelman, S., Parkins, R. A., Rubin, C. E. Medicine, Baltimore, 1966, 45,
2. 3.
Rappaport, H., Ramot, B., Hulu, N., Park, J.
11. K.
Cancer, 1972, 29, 1502.
Al-Saleem, T., Zardawi, I. Lancet, 1978, i, 775. Rambaud, J. C., Bognel, C , Prost, A., Bernier, J. J., LeQuintrec, Y., Lambling, A., Danon, F., Hurez, D., Seligmann, M. Digestion, 1968, 1, 321. 5. Rambaud, J. C., Matuchansky, C. Lancet, 1973, i, 1430. 6. Doe, W. F., Henry, K., Hobbs, J. R., Avery Jones, E., Dent, C E., Booth, C. C. Gut, 1972, 13, 947. 7. Doe, W F Br. J. Cancer, 1975, 31, suppl II, p. 350. 8. Ramot, B., Hulu, N. ibid. suppl. II, p 343.
4.
9. 10.
Seligmann, M. Archs intern. Med. 1975, 135, 78. Shahid, M. J., Alami, S. Y., Nassar, V. H., Balikian, J. B., Salem, A.
A.
Cancer, 1975, 35, 848. 11. Kharazmi, A., Haghighi, P., Haghshenas, M., Nasr, K., Abadi, P., Rezai, H R Clin. exp Immun. 1976, 26, 124 12. Tabbane, S., Tabbane, F., Cammoun, M., Mourali, N Cancer, 1976, 38,
1989. 13. Rambaud, J. C., Seligmann, M. Clins Gastroent. 1976, 5, 341. 14 Lewin, K. J., Kahn, L. B., Novis, B. H. Cancer, 1976, 38, 2511. 15. Salem, P. A., Nassar, V. H., Shahid, M., Hajj, A., Alami, A. S., Balikar, J., Salem, A. ibid. 1977, 39, 2081. 16. Gahan, A., Lecestre, M. J., Scotto, J., Bognel, C., Matuchansky, C., Rambaud, J. C. ibid 17. Al-Bahrani, Z., Al-Saleem, T., Al-Mondhiry, H , Bakir, F., Yahia, H., Taha, I., King, J. Gut (in the press). 18. Bonomo, L., Damacco, F., Marano, R., Bonomo, G. M. Am. J. Med. 1972,
52, 73 Pittman, F. E., Tripathy, K., Isobe, T., Bolanos, O M., Osserman, E. F., Pittman, J. C., Lotero, H. R., Duque, E. E. ibid. 1975, 58, 424. 20. Dutz, W., Asvadi, Sh., Sadri, Sh., Kahout, E. Gut, 1971, 12, 804. 21. Kamal, A. M. in Cholera (edited by D Barua and W. Burrows), p. 1. Phila19.
delphia, 1974. 22. Carpenter, C. C. J. Jr., Greenough, W. B. III, Gordon, R. S. Jr. ibid. p. 129. 23. Pierce, N. F., Greenough, W. B. III, Carpenter, C C J. Jr. Bact Rev. 1971, 35, 1. 24. Lichtenstein, L. M., Henney, C. S., Bourne, H. R , Greenough, W. B. III.
J. clin. Invest. 1973, 52, 691. 25. Forman, J., Finkelstein, R. A. J. Immun. 1977, 118, 1655 26. Pastore, G., Schiraldi, G., Fera, G., Sforza, E., Schiraldi, O.
Am. J. dig. Dis.
1976, 21, 613. 27. Finkelstein, R. A. Curr.
Top. Microbiol. Immun. 1975, 69, 138. 28. Pierce, N. F., Gowans, J.L.J. exp. Med. 1975, 142, 1550.
An automatic device for pricking the finger has been developed. A sterile, disposable lancet (’Monolet’, Sherwood) is placed on a spring-loaded arm mounted in a hand-held apparatus. A finger is pressed against a disposable finger-guard, and pressure on a button releases the spring-loaded arm. The lancet penetrates the skin to a controlled depth and is immediately withdrawn. The apparatus can be fired either by pressing the firing-knob with a thumb or finger (see accompanying figure), or by inverting the apparatus and pressing the knob on any convenient surface. The speed with which the finger is pricked and the instantaneous withdrawal of the lancet means that this method is virtually painless. We think that this automatic lancet will be especially useful in pxdiatrics, in laboratories where several
technicians occasionally take blood-samples, and for diabetic patients who wish to take blood-samples at home. The
automatic
lancet ’Autolet’
ford, Woodstock, Oxordshire. We
can are
be obtained from Owen Mumgrateful to Mr B. A. Stone for
technical assistance. REFERENCES E. A. M., Allison, S. P., Tattersall, R. B Lancet, 1978, i, 732 2. Sōnksen, P. H., Judd, S. L., Lowy, C. ibid. p. 729. 3. Howe-Davies, S., Holman, R. R., Philips, M., Turner, R. C. Br. med. J. 1978, ii, 59.
1. Walford, S., Gale,
Hadden, J. W. Ann. N.Y. Acad. Sci. 1975, 256, 252. Purtilo, T. D., DeFlorio, D. Jr., Hutt, L. M., Bhawan, J., Yang, J., Otto, R., Edwards, W. New Engl. J. Med. 1977, 297, 1077. 31. O’Connor, G. T. Am. J. Med. 1970, 18, 679. 32. Al-Saleem, T., Gailani, F. Iraq med. J. 1976, 24, 49. 33. Jawahiry, K. J Fac. Med. Baghdad (in the press). 29. 30.
34. Pierce, N. F. Personal communications. 35. Carpenter, C. C. J. Prev. Med. 1974, 3, 456.