- Email: [email protected]
Gastroenteritis associated with Helicobacter pullorum
3
Martelli A, Ghia M, Mattioli F, Mereto E, Andrae U. Experimental evidence for a carcinogenic risk of cyproterone acetate to humans. Congresso Nationale di Farmacologia in Turin, Sept 5-6, 1994
4
WHO collaborative study of neoplasia and steroid Cancer 1989; 43: 254-59.
(poster). contraceptives. Int J
Progressive renal failure in two breast patients after high-dose ifosfamide
cancer
chemotherapy with autologous blood cell is reported to be beneficial for support progenitor with high-risk primary breast cancer or metastatic patients disease.’"* Ifosfamide is thought to be more active and less toxic than cyclophosphamide and doses of up to 24 g/m2 have been given, with central nervous system toxicity and renal tubular acidosis being the main non-haematological toxicities.3 We report two breast cancer patients with chronic progressive renal failure that followed high-dose ifosfamide. A 38-year-old woman was treated for stage II breast cancer with six cycles of chemotherapy consisting of cyclophosphamide, methotrexate, and fluorouracil followed by irradiation of the right chest wall. 24 months later she relapsed with metastases in lung and liver. After two conventionally dosed cycles with ifosfamide (cycle 1, 5 g/m2 on day 1; cycle 2, 5 g/m2 on days 1-2) and epirubicin (100 mg/m2), the creatinine clearance was 111 mL/min. After the first high-dose cycle in February, 1993 (ifosfamide 5 g/m2, days 1-3; epirubicin 100 mg/m2, day 4), the creatinine clearance fell to 85 mL/min. During the second high-dose cycle (May, 1993), the patient developed severe proximal renal tubular acidosis with a capillary blood pH of 7-21, base excess of -10-2 mmol/L, glycosuria, and proteinuria (0-57 g/L). Serum creatinine was 133 Ilmol/L and creatinine clearance was reduced to 49 mLJmin. At present, the patient has chronic renal failure with a serum creatinine of 477 SiR-High-dose
jumol/L. A 53-year-old woman with stage III breast cancer received two conventionally dosed chemotherapy cycles with ifosfamide (cycle 1, 4 g/m2 on day 1; cycle 2, 4 g/m2 on days 1-2) and epirubicin (100 mg/m2). Subsequently, her creatinine clearance was 86 mL/min. Following the firstdose escalated cycle (June, 1994) with ifosfamide (4 g/m’, days 1-3), epirubicin (60 mg/m2, days 1-3), and carboplatin (300 mg/m2, days 1-3), the creatinine clearance fell to 47 mL/min. During the second high-dose cycle (Aug 6, 1994), she developed generalised oedema, an increase in blood pressure to 230/130 mm Hg, proximal renal tubular acidosis (capillary blood pH 7-20, base excess -16-5 mmol/L), glycosuria, proteinuria (2-4 g/L), and progressive renal failure with a serum creatinine of 283 pmol/L and creatinine clearance of 24 mL/min. At present, the serum creatinine has risen to 460 )imoI/L. Ifosfamide was administered as a 24 h continuous intravenous infusion. Mesna was given at the same dose as ifosfamide by 24 h continuous intravenous infusion. After discontinuation of ifosfamide in the third and fourth cycles, mesna was given for 1 additional day at 50% of the ifosfamide dose. The cumulative doses of ifosfamide were 45 g/m2 in the first patient and 36g/m2 in the second patient. Nephrotoxicity of ifosfamide was first described in 1972. Reversible acute proximal tubular dysfunction is the most common and usually the most important feature of toxicity/ Repeated cycles of conventionally dosed ifosfamide (8 g/m2, day 1) are, however, reported to lead to non-progressive chronic glomerular damage.Severe chronic progressive renal failure occurred in these two patients with normal renal function following repeated cycles of high-dose ifosfamide with and without addition of carboplatin. We believe that progressive chronic renal failure is due to
cumulative toxicity of ifosfamide despite adequate treatment with mesna. Since end-stage renal failure is to be expected in both women and we are not aware of renal function followup studies in such patients, we would recommend that repeated cycles of high-dose ifosfamide be given only in patients in whom renal function remains unaffected despite
therapy. Alwin Krämer, Hartmut Goldschmidt, Uwe Hahn, Konrad Andrassy Department of Internal Medicine V, University of Heidelberg, 69115 Heidelberg, Germany; and Department of Nephrology, University of Heidelberg 1
2
3
4 5
Peters WP, Ross M, Vredenburgh JJ, et al. High-dose chemotherapy and autologous bone marrow support as consolidation after standarddose adjuvant therapy for high-risk primary breast cancer. J Clin Oncol 1993; 11: 1132-43. Eddy DM. High-dose chemotherapy with autologous bone marrow transplantation for the treatment of metastatic breast cancer. J Clin Oncol 1992; 10: 657-70. Fields KK, Elfenbein GJ, Perkins JB, et al. Two novel high-dose treatment regimens for metastatic breast cancer-ifosfamide, carboplatin, plus etoposide and mitoxantrone plus thiotepa: outcomes and toxicities. Semin Oncol 1993; 20: 59-66. Skinner R, Sharkey IM, Pearson ADJ, Craft AW. Ifosfamide, mesna, and nephrotoxicity in children. J Clin Oncol 1993; 11: 173-90. Stuart-Harris RC, Harper PG, Parsons CA, et al. High-dose alkylation therapy using ifosfamide infusion with mesna in the treatment of adult advanced soft-tissue sarcoma. Cancer Chemother Pharmacol 1983; 11: 69-72.
Gastroenteritis associated with Helicobacter
pullorum SiR-Helicobacter pylori is generally recognised as a leading of chronic gastritis; there is concern because of its association with ulceration and gastric neoplasms.’ Several other helicobacter species have been described, and some are considered rare agents of gastroenteritis in human beings. Findings presented here suggest that another species, H pullorum,2 first isolated from broiler chickens at slaughter, causes gastroenteritis in human beings. Helicobacter was cultured on a commercially available campylobacter-selective medium (Campylosel, bioMerieux). The plates were incubated for 48 hours at 37°C in an atmosphere containing 6% oxygen, 7% carbon dioxide, and 7% hydrogen. Strains of H pullorum were identified by phenotypic tests3 and dot-blot DNA hybridisation. Among 387 human faecal isolates of campylobacter referred by clinical microbiology laboratories for confirmatory testing, six strains of H pullorum were identified. One strain had been isolated from a 27-year-old man with diarrhoea after weight loss of 30 kg. A liver biopsy done because of persistent increases in liver enzymes (alanine aminotransferase, aspartate aminotransferase, and y-glutamyl transferase) and hepatomegaly on abdominal ultrasonography showed nonspecific changes. A second strain was isolated from a 21-year-old man who presented with fever, abdominal cramps, and haematemesis. Diffuse haemorrhages were observed in the gastric mucosa. The remaining 4 human isolates were from patients with selfreported gastroenteritis: a 36-year-old male AIDS patient, a 60-year-old man concomitantly infected with Campylobacter jejuni, a 17-month-old girl with diarrhoeal stools containing occult blood, and a 6-year-old refugee from a developing country. Helicobacter pullorum strains could be differentiated from related species of campylobacters by phenotypic tests. Isolates of H pullorum were unusually susceptible to polymyxin B, and all strains failed to grow on campylobacter-selective media containing polymyxin B. Culture conditions for the recovery of the organism, which is not at all fastidious, are fairly standard. However, cause
1569
pullorum does not grow on many of the older campylobacter-selective media. Furthermore, it may have been overlooked because it can easily be confused with C coli, with which it shares most phenotypic characteristics for campylobacter identification. Three C coli-like human isolates from Canada have been identified by partial 16S ribosomal RNA gene sequencing as H pullorum (F Dewhirst, Forsyth Dental Center, Boston, USA, personal communication). The possible public health importance of H pullorum may warrant increased use of cefoperazonevancomycin-type selective media for culturing of campylobacter and helicobacter, as well as the use of
H
additional identification
;
tests.
This work was supported in part by of Veterinary Public Health.
:
a
grant from the Swiss Federal Office
André P Burnens, John Stanley, Ruth Jacques Nicolet
Morgenstern,
National Reference Laboratory for Foodborne Diseases, Institute of Veterinary Pathology, and Institute for Veterinary Bacteriology, University of Berne, CH-3012 Berne, Switzerland; and Molecular Biology Unit, Virus Reference Division, Central Public Health Laboratory, London, UK
1 2
3
Taylor DN, Blaser MJ. The epidemiology of Helicobacter pylori infection. Epidemiol Rev 1991; 13: 42-59. Stanley J, Linton D, Burnens AP, et al. Helicobacter pullorum sp. nov.— genotype and phenotype of a new species isolated from poultry and from human patients with gastroenteritis. Microbiology (in press). Burnens AP, Nicolet J. Three supplementary diagnostic tests for Campylobacter species and related organisms. J Clin Microbiol 1993; 31: 708-10.
Mechanism of anti-inflammatory action of retinoids on keratinocytes SIR—Retinoids, which have anti-inflammatory and antiproliferative functions, are widely used with clinical benefit in inflammatory and/or proliferative skin diseases (psoriasis, acne, epidermotropic T lymphomas, skin cancers), both with local or systemic administration. The mechanism of their anti-proliferative effect is now at least partly understood,’ but their anti-inflammatory mechanism
ltiOLItLI11L)III L;UIIUtfILIdLlUfl
1
remains unclear. Results suggest a role for retinoids in inhibition of the nitric oxide transduction pathway in monocytes/ Nitric oxide has macrophages.2 emerged as an important mediator of inflammatory responses,3and has been shown to be required for activation of normal human keratinocytes (HK). This second messenger leads to the release of many pro-inflammatory mediators, including tumour necrosis factor a (TNF-a) and interleukin-6 (IL-6). Therefore, nitric oxide, TNF-a, and other cytokines produced by activated HK (IL-1, IL-6, IL-8) might be involved in inflammatory lesions in the above skin diseases, and in recruitment and activation of haematopoietic cells (lymphocytes, polymorphonuclear cells, and macrophages) in inflammation sites. To investigate whether retinoids exert their anti-inflammatory effect through regulation of the nitric oxide pathway, we studied the effects of tretinoin and isotretinoin on the nitric oxide pathway and on TNF-a secretion by human keratinocytes activated with lipopolysaccharides and interferon-y. Lipopolysaccharides are constituents of many bacterial walls, and the role of Propionibacterium acnes is well established in inflammation observed in acne. In psoriasis, bacterial superantigens are suspected to initiate skin lymphocyte infiltration. IFN-’y was used because it is released early during skin infection and has the ability to induce nitric oxide production in HK. Our results indicate that isotretinoin and tretinoin, when added 24 hours before lipopolysaccharides and IFN-’y or at
1570
Figure: Inhibition of nitrites human
BllIlrUlj L)
and TNF-a release from activated
keratinocytes after treatment with isotretinoin
the same time, led to a dose-dependent inhibition of nitrite release (reflecting nitric oxide pathway activation) and TNF-a synthesis by activated HK. The production of nitrites was reduced by 70% and TNF-a by 60% from activated keratinocytes (figure). The effect of the retinoic acid derivatives on cell activation depended upon their presence in the culture; elimination of the compounds resulted in restoration of HK capacity to produce nitric oxide and TNF-a. We then determined the effect of the retinoic acid derivatives on inducible nitric oxide synthase (iNOS) expressed by activated HK by means of 14C Larginine transformation to 14C L-citrulline (due to iNOS action), and demonstrated diminution of the intracellular enzymatic content (inhibition by 60% of mean iNOS activity with isotretinoin 2 u,mol/L), whereas retinoic acid derivatives had no direct effect on the isolated enzyme (data not shown). Furthermore, we tested the effect of retinoic acid on transcription of iNOS-specific mRNA with reverse transcriptase-polymerase chain reaction (RT-PCR method) by use of oligonucleotides of bases 1020-1040 and 1371-1390 of human iNOS cDNA sequence.’ Our data point to a 50-70% decrease in iNOS mRNA when activated HK was pretreated for 24 h with isotretinoin.
Martelli A, Ghia M, Mattioli F, Mereto E, Andrae U. Experimental evidence for a carcinogenic risk of cyproterone acetate to humans. Congresso Nationale di Farmacologia in Turin, Sept 5-6, 1994
4
WHO collaborative study of neoplasia and steroid Cancer 1989; 43: 254-59.
(poster). contraceptives. Int J
Progressive renal failure in two breast patients after high-dose ifosfamide
cancer
chemotherapy with autologous blood cell is reported to be beneficial for support progenitor with high-risk primary breast cancer or metastatic patients disease.’"* Ifosfamide is thought to be more active and less toxic than cyclophosphamide and doses of up to 24 g/m2 have been given, with central nervous system toxicity and renal tubular acidosis being the main non-haematological toxicities.3 We report two breast cancer patients with chronic progressive renal failure that followed high-dose ifosfamide. A 38-year-old woman was treated for stage II breast cancer with six cycles of chemotherapy consisting of cyclophosphamide, methotrexate, and fluorouracil followed by irradiation of the right chest wall. 24 months later she relapsed with metastases in lung and liver. After two conventionally dosed cycles with ifosfamide (cycle 1, 5 g/m2 on day 1; cycle 2, 5 g/m2 on days 1-2) and epirubicin (100 mg/m2), the creatinine clearance was 111 mL/min. After the first high-dose cycle in February, 1993 (ifosfamide 5 g/m2, days 1-3; epirubicin 100 mg/m2, day 4), the creatinine clearance fell to 85 mL/min. During the second high-dose cycle (May, 1993), the patient developed severe proximal renal tubular acidosis with a capillary blood pH of 7-21, base excess of -10-2 mmol/L, glycosuria, and proteinuria (0-57 g/L). Serum creatinine was 133 Ilmol/L and creatinine clearance was reduced to 49 mLJmin. At present, the patient has chronic renal failure with a serum creatinine of 477 SiR-High-dose
jumol/L. A 53-year-old woman with stage III breast cancer received two conventionally dosed chemotherapy cycles with ifosfamide (cycle 1, 4 g/m2 on day 1; cycle 2, 4 g/m2 on days 1-2) and epirubicin (100 mg/m2). Subsequently, her creatinine clearance was 86 mL/min. Following the firstdose escalated cycle (June, 1994) with ifosfamide (4 g/m’, days 1-3), epirubicin (60 mg/m2, days 1-3), and carboplatin (300 mg/m2, days 1-3), the creatinine clearance fell to 47 mL/min. During the second high-dose cycle (Aug 6, 1994), she developed generalised oedema, an increase in blood pressure to 230/130 mm Hg, proximal renal tubular acidosis (capillary blood pH 7-20, base excess -16-5 mmol/L), glycosuria, proteinuria (2-4 g/L), and progressive renal failure with a serum creatinine of 283 pmol/L and creatinine clearance of 24 mL/min. At present, the serum creatinine has risen to 460 )imoI/L. Ifosfamide was administered as a 24 h continuous intravenous infusion. Mesna was given at the same dose as ifosfamide by 24 h continuous intravenous infusion. After discontinuation of ifosfamide in the third and fourth cycles, mesna was given for 1 additional day at 50% of the ifosfamide dose. The cumulative doses of ifosfamide were 45 g/m2 in the first patient and 36g/m2 in the second patient. Nephrotoxicity of ifosfamide was first described in 1972. Reversible acute proximal tubular dysfunction is the most common and usually the most important feature of toxicity/ Repeated cycles of conventionally dosed ifosfamide (8 g/m2, day 1) are, however, reported to lead to non-progressive chronic glomerular damage.Severe chronic progressive renal failure occurred in these two patients with normal renal function following repeated cycles of high-dose ifosfamide with and without addition of carboplatin. We believe that progressive chronic renal failure is due to
cumulative toxicity of ifosfamide despite adequate treatment with mesna. Since end-stage renal failure is to be expected in both women and we are not aware of renal function followup studies in such patients, we would recommend that repeated cycles of high-dose ifosfamide be given only in patients in whom renal function remains unaffected despite
therapy. Alwin Krämer, Hartmut Goldschmidt, Uwe Hahn, Konrad Andrassy Department of Internal Medicine V, University of Heidelberg, 69115 Heidelberg, Germany; and Department of Nephrology, University of Heidelberg 1
2
3
4 5
Peters WP, Ross M, Vredenburgh JJ, et al. High-dose chemotherapy and autologous bone marrow support as consolidation after standarddose adjuvant therapy for high-risk primary breast cancer. J Clin Oncol 1993; 11: 1132-43. Eddy DM. High-dose chemotherapy with autologous bone marrow transplantation for the treatment of metastatic breast cancer. J Clin Oncol 1992; 10: 657-70. Fields KK, Elfenbein GJ, Perkins JB, et al. Two novel high-dose treatment regimens for metastatic breast cancer-ifosfamide, carboplatin, plus etoposide and mitoxantrone plus thiotepa: outcomes and toxicities. Semin Oncol 1993; 20: 59-66. Skinner R, Sharkey IM, Pearson ADJ, Craft AW. Ifosfamide, mesna, and nephrotoxicity in children. J Clin Oncol 1993; 11: 173-90. Stuart-Harris RC, Harper PG, Parsons CA, et al. High-dose alkylation therapy using ifosfamide infusion with mesna in the treatment of adult advanced soft-tissue sarcoma. Cancer Chemother Pharmacol 1983; 11: 69-72.
Gastroenteritis associated with Helicobacter
pullorum SiR-Helicobacter pylori is generally recognised as a leading of chronic gastritis; there is concern because of its association with ulceration and gastric neoplasms.’ Several other helicobacter species have been described, and some are considered rare agents of gastroenteritis in human beings. Findings presented here suggest that another species, H pullorum,2 first isolated from broiler chickens at slaughter, causes gastroenteritis in human beings. Helicobacter was cultured on a commercially available campylobacter-selective medium (Campylosel, bioMerieux). The plates were incubated for 48 hours at 37°C in an atmosphere containing 6% oxygen, 7% carbon dioxide, and 7% hydrogen. Strains of H pullorum were identified by phenotypic tests3 and dot-blot DNA hybridisation. Among 387 human faecal isolates of campylobacter referred by clinical microbiology laboratories for confirmatory testing, six strains of H pullorum were identified. One strain had been isolated from a 27-year-old man with diarrhoea after weight loss of 30 kg. A liver biopsy done because of persistent increases in liver enzymes (alanine aminotransferase, aspartate aminotransferase, and y-glutamyl transferase) and hepatomegaly on abdominal ultrasonography showed nonspecific changes. A second strain was isolated from a 21-year-old man who presented with fever, abdominal cramps, and haematemesis. Diffuse haemorrhages were observed in the gastric mucosa. The remaining 4 human isolates were from patients with selfreported gastroenteritis: a 36-year-old male AIDS patient, a 60-year-old man concomitantly infected with Campylobacter jejuni, a 17-month-old girl with diarrhoeal stools containing occult blood, and a 6-year-old refugee from a developing country. Helicobacter pullorum strains could be differentiated from related species of campylobacters by phenotypic tests. Isolates of H pullorum were unusually susceptible to polymyxin B, and all strains failed to grow on campylobacter-selective media containing polymyxin B. Culture conditions for the recovery of the organism, which is not at all fastidious, are fairly standard. However, cause
1569
pullorum does not grow on many of the older campylobacter-selective media. Furthermore, it may have been overlooked because it can easily be confused with C coli, with which it shares most phenotypic characteristics for campylobacter identification. Three C coli-like human isolates from Canada have been identified by partial 16S ribosomal RNA gene sequencing as H pullorum (F Dewhirst, Forsyth Dental Center, Boston, USA, personal communication). The possible public health importance of H pullorum may warrant increased use of cefoperazonevancomycin-type selective media for culturing of campylobacter and helicobacter, as well as the use of
H
additional identification
;
tests.
This work was supported in part by of Veterinary Public Health.
:
a
grant from the Swiss Federal Office
André P Burnens, John Stanley, Ruth Jacques Nicolet
Morgenstern,
National Reference Laboratory for Foodborne Diseases, Institute of Veterinary Pathology, and Institute for Veterinary Bacteriology, University of Berne, CH-3012 Berne, Switzerland; and Molecular Biology Unit, Virus Reference Division, Central Public Health Laboratory, London, UK
1 2
3
Taylor DN, Blaser MJ. The epidemiology of Helicobacter pylori infection. Epidemiol Rev 1991; 13: 42-59. Stanley J, Linton D, Burnens AP, et al. Helicobacter pullorum sp. nov.— genotype and phenotype of a new species isolated from poultry and from human patients with gastroenteritis. Microbiology (in press). Burnens AP, Nicolet J. Three supplementary diagnostic tests for Campylobacter species and related organisms. J Clin Microbiol 1993; 31: 708-10.
Mechanism of anti-inflammatory action of retinoids on keratinocytes SIR—Retinoids, which have anti-inflammatory and antiproliferative functions, are widely used with clinical benefit in inflammatory and/or proliferative skin diseases (psoriasis, acne, epidermotropic T lymphomas, skin cancers), both with local or systemic administration. The mechanism of their anti-proliferative effect is now at least partly understood,’ but their anti-inflammatory mechanism
ltiOLItLI11L)III L;UIIUtfILIdLlUfl
1
remains unclear. Results suggest a role for retinoids in inhibition of the nitric oxide transduction pathway in monocytes/ Nitric oxide has macrophages.2 emerged as an important mediator of inflammatory responses,3and has been shown to be required for activation of normal human keratinocytes (HK). This second messenger leads to the release of many pro-inflammatory mediators, including tumour necrosis factor a (TNF-a) and interleukin-6 (IL-6). Therefore, nitric oxide, TNF-a, and other cytokines produced by activated HK (IL-1, IL-6, IL-8) might be involved in inflammatory lesions in the above skin diseases, and in recruitment and activation of haematopoietic cells (lymphocytes, polymorphonuclear cells, and macrophages) in inflammation sites. To investigate whether retinoids exert their anti-inflammatory effect through regulation of the nitric oxide pathway, we studied the effects of tretinoin and isotretinoin on the nitric oxide pathway and on TNF-a secretion by human keratinocytes activated with lipopolysaccharides and interferon-y. Lipopolysaccharides are constituents of many bacterial walls, and the role of Propionibacterium acnes is well established in inflammation observed in acne. In psoriasis, bacterial superantigens are suspected to initiate skin lymphocyte infiltration. IFN-’y was used because it is released early during skin infection and has the ability to induce nitric oxide production in HK. Our results indicate that isotretinoin and tretinoin, when added 24 hours before lipopolysaccharides and IFN-’y or at
1570
Figure: Inhibition of nitrites human
BllIlrUlj L)
and TNF-a release from activated
keratinocytes after treatment with isotretinoin
the same time, led to a dose-dependent inhibition of nitrite release (reflecting nitric oxide pathway activation) and TNF-a synthesis by activated HK. The production of nitrites was reduced by 70% and TNF-a by 60% from activated keratinocytes (figure). The effect of the retinoic acid derivatives on cell activation depended upon their presence in the culture; elimination of the compounds resulted in restoration of HK capacity to produce nitric oxide and TNF-a. We then determined the effect of the retinoic acid derivatives on inducible nitric oxide synthase (iNOS) expressed by activated HK by means of 14C Larginine transformation to 14C L-citrulline (due to iNOS action), and demonstrated diminution of the intracellular enzymatic content (inhibition by 60% of mean iNOS activity with isotretinoin 2 u,mol/L), whereas retinoic acid derivatives had no direct effect on the isolated enzyme (data not shown). Furthermore, we tested the effect of retinoic acid on transcription of iNOS-specific mRNA with reverse transcriptase-polymerase chain reaction (RT-PCR method) by use of oligonucleotides of bases 1020-1040 and 1371-1390 of human iNOS cDNA sequence.’ Our data point to a 50-70% decrease in iNOS mRNA when activated HK was pretreated for 24 h with isotretinoin.