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Growth sequences during recovery from infantile malnutrition
FIRST
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SESSION
2. Growth sequences during recovery from infantile malnutrition
gain at an accelerated rate. After more than a year of observation, most patients still show impairment in mental and motor skills and only prolonged studies might give an indication of the permanent effect of infantile malnutrition on eventual mental capacity.
Angel Cordano, ~ Juan M. Baertl,* and George G. Graham, ~ British American Hospital, L i m a , P e r u Introduced by Lawrence Finberg
DISCUSSION
Permanent growth deficits are assumed to follow malnutrition but little is known about actual growth during recovery from kwashiorkor and severe infantile marasmus. The length, weight, and head circumference of 17 patients with third degree malnutrition (over 40 per cent weight deficit) have been followed. They fall into two groups: Group A with 10 patients 6 to 13 months of age (average 9.2) and Group B with 7 patients 17 to 30 months of age (average 23.6). Group A stayed an average of 6.75 months in the hospital and was followed initially for 7.45 months; Group B, 4.7 and 6.45 months, respectively. In the hospital both made similar gains, most marked in weight (2.5 and 4 times normal for age) and head circumference (2.2 and 4.6 times normal). Gain in length was slightly below normal for age in both. During the first 3 months we noted an early spurt in head growth far in excess of linear growth and bone maturation, possibly the result of early resumption of brain development. During the initial follow-up period Group B made better gains in all measurements but in a further period of 6 months Group A showed an increased rate of gain also. "Make-up" potential certainly seems to exist but is quite variable. Weight is gained rapidly on a diet adequate in protein and rich in calories. Those with a deficit of 5 per cent or less in body length easily attained normal values, while those with deficits larger than 15 per cent seem to be condemned to permanent stunting despite gains which are close to normal for age. Those with 8 to 15 per cent deficits have shown a continuing tendency to
~By invitation, Asterisk indicates
DR. NATHAN B. TALBOT, Boston, Mass. The importance of this work, I think, lies in the fact that it illustrates the need to prevent retardation in growth and maturation in children, since once it has developed beyond a certain point it may become permanently irreversible. In this connection I am very much interested in the phenomenon which we have observed in a variety of circumstances with relation to the growth of children, namely, what we have called, for lack of a better term, a tendency to develop a pent-up growth urge under circumstances of growth retardation secondary to a variety of factors. Interestingly, these factors are quite varied in nature, including malnutrition, as illustrated here, hypothyroidism, Cushing's syndrome, or heavy cortisone therapy, and a variety of other states. I am wondering whether the authors have any thoughts on the mechanism responsible for this transient compensatory growth spurt following correction of the underlying difficulty. It is characterized grossly by extraordinarily rapid growth for a limited period of time. It reaches a maximum peak in the first few months, then gradually peters out despite all efforts to sustain it. The same phenomenon has been observed in basically normal short children following treatment with testosterone and in children with hypopituitarism when given human pituitary growth hormone. DR. JACK METCOFF, Chicago, Ill. There is art important feature about the paper presented by Dr. Cordano and associates. In addition to physical retardation the implication of mental retardation, I think, is of extreme importance for the future development of societies which have been subjected to technical delay in their maturation as a result o f malnutrition.
the same throughout.
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There is another interesting point with relation to your comment about copper deficiency. Have you had an opportunity to explore the problem of zinc deficiency? I ask this because the Naval Medical Research Unit just outside of Cairo has recently reported extensive zinc deficiencies in patients who have extraordinary retardation in linear growth--19 to 20-year (sic) old children, actually, who are perhaps 4 feet tall, and given replenishment with zinc have tremendous growth spurts. It might be significant that very minor trace metal deficiencies do exist which we are not cognizant of and these trace metal deficiencies have serious impact upon growth and developmental performance. DR. JULIUS ]3. RICHMOND, Syracuse, N. Y. Inasmuch as these children are reported to show some psychomotor retardation, I wonder if we could have a few words about the environments in which they are reared after nutritional restoration is accomplished. If they go back to an environment in which there is considerable understimulation, it may very well be that this would be a significant factor in the continuing psychomotor retardation. I wonder, therefore, if we could have a few comments about their environment. DR. CORDANO. The answer to Dr. Jack Metcoff is: Our work does not include evaluation on zinc as yet. The answer to Dr. Julius B. Richmond is: Even if it is true that the patients go back to an environment where understimulation is present, this does not seem to have a heavy influence on younger or older siblings of the patients, since they do behave as the average children in a similar environmental situation. Most of our patients after 21 months of follow-up continue to show some degree of psychomotor retardation and only a prolonged study of them will give us the real answer.
3. Thymic alymphoplasia and lymphocytic hypoplasia and increased susceptibility to injection D a v i d G i t l i n a n d J o h n M. Craig, Child r e n ' s Hospital a n d Boston L y i n g - i n Hospital, H a r v a r d Medical School, Boston,
Mass. Experimental studies of Waksman and associates (J. Exper. Med. 114: 997, 1961) and
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Miller (Lancet 2: 748, 1961) have revealed that thymectomy of the newborn rat or mouse results in lymphocytic hypoplasia of the tissues and an increased susceptibility to infection. We have observed 6 children with an inherited anomaly of the thymus, thymic alymphoplasia, which is analogous to the the condition evoked in thymectomized newborn animals. These children manifested a persistent lymphopenia and were characterized clinically by an unremitting course marked by pneumonia, moniliasis, and other infections usually beginning in the first 3 months of life; the disorder thus far has terminated fatally during infancy. These patients had lymphocytic hypoplasia of the tissues: the thymus was rudimentary, virtually devoid of small lymphocytes, and without Hassall's corpuscles, and the other lymphoid structures contained only sparse populations of small lymphocytes. The thymic alymphoplasia and general deficiency in small lymphocytes appear to be inherited characteristics and the evidence suggests that the primary defect is thymic alymphoplasia which resulted in generalized lymphocytic hypoplasia including lymphopenia. The children had agammaglobulinemia as well: plasma cells and germinal follicles were absent from the tissues, but the marked generalized paucity of small lymphocytes in these patients with thymic alymphoplasia resulted in an increased susceptibility to infection beyond that seen in the usual form of congenital agammaglobulinemia, or nonlymphopenic agammaglobulinemia. In nonlymphopenic agammaglobulinemia, the thymus as well as other lymphoid organs contains nearly normal numbers of lymphocytes. The contribution Of the small lymphocyte to resistance to infection was not replaceable by y-globulin therapy.
4. Thymic dysplasia in congenital agammaglobulinemia W i l l i a m C. Yakovae, Children's Hospital of Philadelphia, Philadelphia, Pa. A thymopathy characterized by small organ weight and size and absence of lymphocytes and Hassall's corpuscles has been encountered at necropsy in 2 white male infants aged 5 months and 6 months and a 13 week (9.5 cm. crownrump length) male abortus. Both infants suffered from recurrent respiratory infections, intermittent diarrhea, severe oral moniliasis, failure to thrive, lymphocytopenia, and markedly low or
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absent serum gamma globulin levels. A brother of one of these infants, having run a similar clinical course, died at 8 months; his thymus, unfortunately, was lost to study. The thymus of the fetus (brother to the infants who died at 5 months and 8 months) was a miniscule, rudimentary organ lacking both lymphocytes and Hassall's corpuscles; it was a replica, in miniature, of the thymopathy described above. In striking contrast were the findings observed in a normally developing thymus of a nonrelated abortus of approximately the same gestational age. These showed a cortex populated by an abundance of lymphocytes and a medulla with beginning development of Hassall's corpuscles. On the basis of these findings, it would appear that in congenital agammaglobulinemia a dysplastic process affects the thymus early in organogenesis. It is proposed that the subsequent immunologic deficits that develop in infancy might be a functional expression of this dysplastic process, one essentially of autothymectomy, having as a corollary Miller's now classical thymic ablation experiments in the newborn animal. DISCUSSION DR. CHESTER FINK, Dallas, Texas. Were any studies of delayed hypersensitivity, such as tuberculin tests, done on the two groups and, if so, was there any difference between the groups? DR. DONOUGH O'BRIEN, Denver, Colo. Dr. Craig, we presently have a child who corresponds to your lymphopenic group except it is of interest that his thymus was irradiated shortly after birth. It has been suggested that this child would profit by a splenic transplant. I wonder if you had considered this and would like to comment on the procedure. DR. JONATHAN T. LANMAN,Brooklyn, N. Y. In experimental animals which are populated with white cells during their period of immunologic tolerance, a disease has been described and is known as runt's disease. This disease shows certain characteristics similar to those seen in these patients. This includes diarrhea, which is admittedly nonspecific, and lymphoid hypoplasia, and certain other findings such as ruffled hair, which I doubt you could see in these individuals. I wonder if either of these men could discuss the possible relationship of these cases to runt's disease.
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DR. EDNA H. SOBEL, New York, N. Y. I would like to ask both Dr. Craig and Dr. Yakovac whether there were any normal children in the families they have described and the sexes of the unaffected children. Was the physical growth of the affected children retarded? If so, was there more retardation than could have been attributed to the recurrent infections? Dr. GITLIN. There was a question asked about delayed hypersensitivity in these two groups of patients. An earlier paper from our laboratory, which was published in Lancet, indicated quite clearly that there may be a marked inhibition of the delayed hypersensitivity response in children who have lymphopenic agammaglobulinemia: all of the 6 children with nonlymphopenic congenital agammaglobulinemia who were tested in this study developed delayed hypersensitivity, either natural or induced, and the one child who had lymphopenic agammaglobulinemia with thymic alymphoplasia did not develop any manifestation of delayed hypersensitivity, either natural or induced. Regarding the question that was asked about irradiation and splenic transplants, we did not do splenic transplants in this particular lymphopenic patient. We did, however, try a thymic transplant, but this was without noticeable effect upon the course of the patient. There is some unpublished information from Hitzig in Switzerland. He had a young infant with lymphopenic agammaglobulinemia to whom a fetal thymus was transplanted. There was a questionably significant rise in lymphocytes, but this patient subsequently died with infection a few weeks later. Regarding the questions asked about retardation of growth and normal children, there were normal children, of course, in the family in each of the cases discussed this morning, and there was no apparent abnormality of any kind, either retardation of growth or presence of infection in the normal siblings; there were both male and female normal siblings, although all of the lymphopenic children described by Dr. Craig today were males. The retardation of growth that occurred in our patients with lymphopenic agammaglobulinemia was presumably due to infection, and here enters the question of runting. The growth retardation bore a superficial resemblance to the runting that one sees in animals, but it could not have been on the basis of delayed hypersensitivity or antibody formation, because these individuals were not able to de-
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velop either; runting as a donor-versus-host reaction apparently was not a phenomenon in these particular children. DR. YAKOVAC. For my part, I only wish to answer Dr. Sobel's question. In our small series of two families all infants were males, including the fetus, and there are no unaffected survivors. DR. CRAIG. In reply to Dr. O'Brien's comment, there is one piece of data recently reported by Miller, which might be of interest to anyone wishing to transplant lymphoid tissue to an alymphopenic child. This is that thymic tissue, rather than a peripheral source of lymphocytes, should be used since there appears to be a considerable difference in the ability of the two types of cells to initiate antibody formation.
5. Ataxia-telangiectasia: A possible clinical counterpart of the animals rendered immunologically incompetent by thymectomy R. D. A. Peterson, "~ M. Blaw, ~ and R. A. Good, D e p a r t m e n t of Pediatrics, U n i v e r sity of Minnesota, Minneapolis, M i n n . Ataxia-telangiectasia, a syndrome first described by Louis-Barr in 1941, has now been observed an estimated 80 times. Serious repeated infections have occurred in almost 90 per cent of these patients and have generally accounted for their demise. The cause for the apparent increased susceptibility to infections has remained unexplained. Bruton and Boder each noted a decreased gamma globulin content in one each of their cases but in only 14 other cases are serum protein studies available. Six of 16 of the known gamma globulin levels are significantly low. No reports are available of further immunologic study of these patients. Of the few postmortem reports only one mentions the thymus gland and in that case it was significantly absent. We have recently had occasion to study extensively the immunologic capacity of a 9-yearold girl with this syndrome. She has a gamma globulin level of 200 mg. and is also deficient in B2A and B2M. She is able to reject a skin homograft but is quite unresponsive to a variety of antigenic stimuli. These patients may be of Aided by grants [rom the Arthritis and Rheumatism Foundation and the Minnesota Heart Association.
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70 1
considerable significance as they may represent the human counterpart of our animal models rendered immunologically unresponsive by early ablation of their thymuses. The benefit of simultaneous clinical and laboratory investigation is classically highlighted here. DISCUSSION DR. CI~ARLES KENNEDY, Philadelphia, Pa. I would like to make one very general comment. The syndrome described in this paper and one other, acanthocytosis, are the first of the cerebellar ataxias which have been found to be associated with biochemical abnormalities. For years, the group of disorders included under the term "Friedreich's ataxia" have been known to us by clinical manifestations and morbid anatomy only. Hopefully, the biochemical approach can be extended to other of the cerebellar ataxias and lead us to rational therapy. DI~. PETERSON. The relationship of the cerebellar ataxia to the rest of the syndrome of ataxia-telangiectasia remains unknown. Chickens that are rendered immunologically incompetent by treating the eggs with 19-nortestosterone are ataxic. We have examined their cerebellums by light microscopy and they appear normal. The general debilitation of these chickens may account for their ataxia. Sherman and Dameshek report that hamsters subjected to thymectomy in the newborn period are not only immunologically deficient as is expected according to present-day concepts but also often ataxic. They have not as yet examined the cerebellums of these animals. DR. ELI GOLD, Cleveland, Ohio. My question concerns the response of the child you studied and others you know of to vaccination or to viral infections. Do those with inadequate ability to develop delayed hypersensitivity have difficulty with virus infections? DR. PETERSON. The child reported upon here had been vaccinated during infancy without difficulty. She also had a normal case of chickenpox. Other patients with agammaglobulinemia likewise handle most viral infections quite normally. They have had measles, chickenpox, and polio without complication. Hepatitis is one viral infection which has been very destructive of these children. Several have died of liver failure after developing hepatitis. DR. H. G. DUNN, Vancouver, British Columbia, Canada. It seems that the situation in ataxiatelangiectasia is getting complicated, because there
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have been some features in other cases which might suggest reticulosis or collagen disease. Three years ago, at a meeting of the North Pacific Pediatric Society, Dr. Robert Aldrich of Seattle presented a case of ataxia-telangiectasia in which there was evidence of hyperplenism, with granulopenia. The child appeared to benefit from splenectomy and also from prednisone therapy. We have also had a patient with ataxiatelangiectasia whose recurrent pulmonary infections appeared to become less frequent during steroid therapy. I believe that the occurrence of thrombocytopenia and of lymphoma has also been reported in this disease. As you will be aware, Pelc and Vis in Belgium have described an abnormal substance in the amino acid chromatogram of the urine from patients with this syndrome, and Paine and Efron have confirmed this in one of their cases. It appears to be a substance which breaks down to proline and hydroxyproline on acid hydrolysis, and may therefore be derived from collagen. I should like to ask the authors whether they have had any experience with steroid therapy in these cases, and also whether they have confirmed the presence of the abnormal substance in the urine. DR. PETERSON. We have not completed our studies of this patient's urinary amino acid excretion. We have not treated any of our patients with agammaglobulinemia with steroids except two with leukemia. The limited capacity of these patients to resist infections would seem to make steroid treatment even more treacherous than in other patients. DR. PIiILLIP E. ROTIKMAN,Los Angeles, Calif. I have had the opportunity of observing one of these patients through the courtesy of Dr. Boder. The child's infections were confined to recurrent attacks of pneumonitis. The mechanism presented by the speaker cannot be disproved but bedside observations during mealtime suggest the additional possibility of aspiration pneumonitis. Difficulty in swallowing, coughing, pooling of oral secretions perhaps indicates a dysfunction of pharyngeal muscles similar to that of some patients with Riley-Day disease who have repeated attacks of pneumonitis. DR. PETERSON. We can define no abnormality of our patient's swallowing mechanism although she does have dysarthric speech. She also has otitis media and externa. I cannot say if others with this syndrome have a problem with aspiration pneumonia.
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DR. Luc LEMLr, Madison, Wis. I would like to make two comments. The first is regarding the possible role of the thymus gland in this syndrome. Dr. Guttman and I have recently published a paper on 3 siblings with ataxia-telangiectasia and associated hypogammaglobulinemia. One of these children--an 8-year-old girl who had agammaglobulinemia, died of staphylococcal pneumonia. At autopsy the thymus was found to be absent and, although the mediastinal lymph lymph nodes were enlarged, they were depleted of lymphocytes. This observation then seems to lend further support to the hypothesis which you have postulated. The second comment concerns the possible treatment of such children with corticosteroids. Therapy with hydrocortisone was tried in the case I have just mentioned. Instead of improving, the patient developed a fatal staphylococcal pneumonia. DR. P~TERSON. It is very interesting to hear that your patient lacked a thymus gland. As we learn more of thymus abnormalities it becomes increasingly important to examine this organ at postmortem. If it is not grossly present sections should be taken through various levels of the mediastinum and neck in an effort to find rudimentary thymus tissue. DR. ELENA ]~ODER,Los Angeles, Calif. I have a brief comment and a question. Dr. Robert P. Sedgwick and I have just completed a tabular analysis of 101 currently known cases of ataxiatelangiectasia, 49 published and 52 unpublished, including our own series which now totals 18. The paper of Drs. Peterson, Blaw, and Good is of particular interest in that it reports the first comprehensive immunologic study of a patient with this syndrome. The most frequent cause of death in ataxiatelangiectasia, as Dr. Peterson has already mentioned, is bronchiectasis complicated by pneumonitis, death from this cause occurring typically at adolescence. However, I would like to add that, with the increased number of autopsy reports that Dr. Sedgwick and I have gathered, it has become apparent that the cause of death may be neoplastic as well as pulmonary. In one of the 11 available autopsies Hodgkin's disease was found in association with bronchiectasis. In another, death was found to be due to a reticulure cell sarcoma with metastases in the central nervous system. In addition, in one of our originally reported cases, in which no autopsy was performed, there was an infiltrating undifferen~
Volume 63 Number 4 part 2
tiated round cell sarcoma of the neck suggestive of lymphosareolna or reticulum cell sarcoma, according to a biopsy report. I would be very much interested in Dr. Peterson's comments as to the possibility that the high incidence of neoplasia in patients with ataxia-telangiectasia, like their proneness to sinopulmonary infections, might in some way also be related to a thymic dysplasia. DR. PETERSON. The relationship between immunologic deficiency states and malignancy is unclear but real. Two children we have studied with the congenital sex-linked type of agammaglobulinemia have developed and died of acute lymphatic leukemia. In one the disease first manifested itself as a thymus enlargement and when an exacerbation occurred the thymus was again primarily involved. Certain mouse lymphatic leukemias have been demonstrated by Furth, Kaplan, and others to require an intact thymus gland in order to manifest themselves. Removal of the thymus from such mice before they clinically have leukemia prevents its development. Replacement with an isologous thymus permits the leukemia to develop. The role of the thymus in certain types of malignancies is thus significant. The mechanism of its function at present is unknown. DR. DAVID SHURTLEFF, Seattle, Wash. I would like to report that Dr. Aldrich's patient following splenectomy was treated with steroids and died of pneumococcal meningitis.
6. Testosterone production in a 3-yearold male with isosexual precocity Maria New, r Paula Pitt, ~" and Ralph E. Peterson, r T h e New York HospitalCornell Medical Center, New York, N. Y. J I n t r o d u c e d by H o w a r d W o r t h e n The daily production of testosterone and the daily urinary excretion of testosterone glucuronide of a S-year-old boy with complete idiopathic isosexual precocity were measured by a double isotope dilution derivative technique. Urine was collected after injection of testosterone-4-C1~, incubated with beta glucuronidase, and extracted with dichloromethane. The testosterone was isolated, acetylated with tritiumlabeled acetic anhydride, and purified to constant specific activity by paper chromatography and by formation of the benzhydrazone of testosterone acetate. The daily production of testos-
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terone was then calculated from the specific activity. This child produced 2 to 3 rag. of testosterone daily (one-half the daily production of a normal adult male). This was tripled by chorionic gonadotrophin; was markedly decreased by oral 17-oe ethinyl-19-nortestosterone (Norlutin) and ethinyl estradiol, but was unaffected by ACTH, prednisone, or oral 6-medroxy progesterone acetate (Provera). Intramuscular 6-medroxy progesterone acetate (Depo-Provera) suppressed testosterone production to one tenth of the baseline value. This was the least androgenic and least estrogenic drug tested which can suppress testosterone production and thereby arrest the progressive sexual development and advanced epiphyseal maturation. The clinical effects of the suppression of testosterone production with Depo-Provera are being evaluated. DISCUSSION DR. MARWN A. SCHULTZ, Pacific Palisades, Calif. We have used Depo-Provera in cases of precocious puberty and in 2 girls have noted a decrease in estrogen excretion following therapy. DR. ALFRED M. BONGIOVANNI,Philadelphia, Pa. In sexual precocity the urinary 17-ketosteroids are quite low, and this has been a matter of great mystery. In this small amount of 17ketosteroid there must be a very potent substance, and this has been very nicely demonstrated by Dr. New. I have one reservation that I would like to state having to do with Provera. We have been using Provera for 6y2 years and have been reluctant to report our results because we have the feeling that in approximately one half of our patients the Provera itself produces a rate of bone maturation which exceeds that of even the earlier period. Ours is a small series, but nonetheless it does concern us, and I think perhaps we should keep our eyes open in this particular matter. DR. A. CAMACHO, Detroit, Mich. Investigation done with Dr. Migeon shows that A4-androstenedione is converted peripherally to testosterone glucuronide in significant amounts. These data will be presented this afternoon at the endocrine section. If the androgenicity of testosterone is directly related to the concentration of this steroid in blood and if androstenedione is converted to testosterone and conjugated as testosterone glucuronide without permitting testosterone to circulate as biologically active unconjugated testos-
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terone, then the estimated production rate of testosterone by this technique would be an overestimation of the production of biologically active testosterone. I wonder if you would comment on this. DR. ROBERT A. ULSTROM,Minneapolis, Minn. My congratulations for using what I think is the most definitive type of methodology we have to use regarding production levels of steroid. By this method one can also learn something about the peripheral metabolism. I wonder if Dr. New has made any incidental observations regarding either the type of degradation or the duration of circulation of testosterone that might be any different in a child who is being subjected to virilization when the tissues are other than at a mature state; whether any different types of metaholites or a difference in metabolic rate of disposition might have been observed. Another question that I would like to ask is regarding the use of the same, identical compound as a basis for the isotope dilution calculation. Might one find different values if one of the metabolites had been used, rather than testosterone itself? DR. EDNA H. NOBEL,New York, N. Y. Would Dr. New give us an estimate of the amount of irradiation received by the child in the C 14labeled testosterone which he was given? It might be difficult to judge the effectiveness of a drug used for inhibition of sexual precocity from the rate of growth alone. We do not yet know to what extent growth hormone contributes to the normal adolescent growth spurt which, at least in boys, must be in part due to gonadal steroids. Inhibition of gonadotrophin production, or interference with the response of the gonads to gonadotrophins, would be expected to reduce the rate of production of testosterone by the testes. However, the rapid growth of a child with true sexual precocity might be a consequence of increased secretion of growth hormone as well as of gonadotrophins. DR. DAVID W. SMITH, Madison, Wis. Do you have information about gonadotrophin assays and the clinical response to the use of the suppressive steroidal agents? Also, what was the clinical response of the boy to the administration of Depo-Provera? DR. NEW. We have shown only that DepoProvera decreased the testosterone production. We have not observed this child long enough to estimate any clinical effects. He is undergoing a clinical trial at the present time. The only thing
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I can tell you is that when I saw him last he had been receiving Depo-Provera for 2 months. He had been shaved for urinary collections in the hospital, and when I saw him 2 months later the pubic hair had not grown back. He also no longer had acne. Insofar as epiphyseal maturation is concerned, we have not studied him long enough to be able to state any changes, and I am interested to know that Dr. Bongiovanni reports that the rate of maturation has not been changed by Depo-Provera. This would imply that the epiphyseal maturation must not be dependent upon testosterone. I have purposely used the term "testosterone production" rather than testosterone secretion rate because I know this assay does not distinguish between the production of z~4-andro stenedione and testosterone. I am not able to make a distinction between those substances. As for a study of the metabolites of this child and a normal child, we have not done this. We have not attempted to determine the production rate, using a metabolite other than testosterone glucuronide. Dr. Hudson in Australia did determine some production rates using these metabolites and came out with a figure similar to ours. We were never able to detect urinary gonadotrophins in this child. I admit that is inexplicable. At the moment an assay is being conducted for L H in his urine; but this has not been completed. As to the administration of isotopes to this child, Dr. Sobel, we very carefully went over this with a physicist who is a consultant to the Atomic Energy Commission. We delivered to the child about half a microcurie for each study. There were thirteen studies all together, spread over a period of 9 months, which is the time he was in the hospital. When the number of millirads that he received is calculated, allowing half a microcurie for each study, he received 0.03 millirads p e r week. The allowable dose for a child by the most current information that I could obtain is 30 millirads per week. A chest x-ray delivers 15 millirads to the skin. We therefore gave him some one one-hundredth of the allowable beta radiation. He excreted almost all of the labeled material within 24 hours. We have never been able to detect more than 3 per cent of the amount we had administered on the second day, and on
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the third day there was no excretion of any label at all.
7. C~, and C~ steroid excretion pre and post SU-4885 and o,p'DDD in a case of metastatic adrenocortical carcinoma. An 18-month follow-up Jacques R. Duchaxme, Gilles Leboeuf, ~ Robert A. Ayotte,r and Jacques C. Ducharme, r Department of Pediatrics, Universit6 de M o n t r 6 a l a n d L ' H 6 p i t a l SainteJustine, Montr6al, Qu6bec, C a n a d a A 4-year-old girl with progressive virilization, some cushingoid elements, and a large right suprarenal mass invading the kidney was studied. Urinary 17-ketosteroids were 308 mg. per 24 hours and rose to 448 mg. with SU-4885 administration. Plasma 17-OHCS were 37 /,g per 100 ml. and urinary 17-OHCS 4.1 mg. per 24 hours. I n the nonketonic fractions, compounds with o-glycol side chain in C~-C.o (acetaldehydogenic steroids) and A5-3fl-ol configuration (Oertel chromogens), largely A5-pregnenetriol, were elevated and rose with the blocking agent. Chromatography on alumina by gradient elution of each ketonic fraction revealed 163.0 rag. per 24 hours of dehydroepiandrosterone (DHA) in the sulfate fraction which rose to 207.0 rag. per 24 hours with SU-4885, while l 1-oxygenated 17-KS disappeared. A proportionately greater rise was noted in the free and glucuroniside fractions, although the total values for the free steroids were much lower. After right adrenalectomy and nephrectomy followed by x-ray therapy, steroid excretion reverted to normal while virilization partially regressed. However, as a result of the appearance of puImonary metastases 3.0 Gin. per day of o,pPDDDt was given_ Metastases cleared completely. A few months later, following reduction of o,pPDDD to 2.0 Gin. per day, virilization increased and pulmonary metastases reappeared and progressed despite increased dosage of o,pPDDD to 5.0 Gm. per day. Suppressive doses of dexamethasone arrested the progression and partial regression occurred. It is suggested that this tumor and functional metastatic tissue were ACTH dependant. Plasma ACTH determinations pre and post dexamethasone are being made. ~Supplied by the National Institutes of Health.
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DISCUSSION DR. LYTT I. G A m ) ~ , Syracuse, N. Y. These observations are very interesting to me. It was before this Society at that memorable meeting in French Lick, Indiana, in 1950, that the first physiologic study of the effect of DDD on mammals was presented by Dr. John Nichols and myself. It is a great pleasure to see what has happened in the interval with this drug and the new isomer. DR. SAMUEL SPECTOR, Cleveland, Ohio. In answer to the question raised, we had the opportunity of treating a 7-year-old girl with a combination of suppressive adrenal therapy (hydrocortisone) and o, prDDD, She too had pulmonary metastasis at onset of therapy. An apparent complete remission occurred which lasted 18 months and then the tumor escaped. It is interesting that with relapse she also exhibited crises of adrenal insufficiency characterized primarily by sodium loss. We did try an analogue, m,ptDDD, but had only a very short-lived response. The question I wish to raise and realize that you are probably not now in a position to answer is the state of your patient's "normal" adrenal, At necropsy, our patient's adrenal gland was small and cellularly completely disorganized so that no layers could be identified. DR. ALFRED M. BONGIOVANNI, Philadelphia, Pa. This is a very interesting report that Dr. Ducharme has made. There is a paucity of reports on the use of this drug in childhood, and I know that you must have done a lot more work. I was wondering about the response of the 17-ketosteroids to ACTH and also to such substances as dexamethasone, which you gave. I ask this because often there is more response to these substances in tumors than one supposes. DR. DUC~A~M~. Dr. Spector, we have not had the opportunity of examining the patient's second adrenal, but there was no evidence of its involvement at the time of operation. However, it is possible that at present the remaining adrenal may be either invaded by tumor or showing complete disorganization and severe atrophy. We were also somewhat surprised to see her enter adrenal insufficiency with a salt-losing state while receiving o,p'DDD since Woodward's original work in the dog had shown that DDD had a selective effect on the fascicular and reticular zones of the adrenal cortex. It is possible,
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however, that the isomer o,pPDDD affects also the glomerulosa. Dr, Bongiovanni, we have not done a standard ACTH test on this patient since we have felt that the test for pituitary reserve of ACTH might give somewhat the same information and since also the size of the tumor mass was such that operation could not be delayed. We can say, nevertheless, that there was a significant rise in her 17-ketosteroids after SU4885, mostly involving dehydroepiandrosterone glucuroniside. It was also interesting to note that after starting o,pPDDD administration there was nearly a 100 per cent rise in the 17-ketosteroids within a few days followed by a decrease in the latter to very low levels. We do not have qualitative separation of these urines after dexamethasone suppression but it would certainly be worthwhile to make this test.
8. Aromatic amine metabolism in disorders of the thyroid gland M. A. Lipton, ~ D. K. Manning, ~ J. J. Van Wyk, a n d F. S. French, ~ D e p a r t ments of Psychiatry a n d Pediatrics, U n i versity of N o r t h C a r o l i n a School of Medicine, Chapel Hill , N. C. Increased sensitivity to administered catechol amines and other biologically active amines has been demonstrated by other workers in hyperthyroid patients and animals. In order to investigate the possible mechanisms involved in this, studies were undertaken in normal and hyperthyroid children and adults. Four children with a total of 6 episodes of hyperthyroidism, 8 normal children, and 8 hyperthyroid adults were hospitalized for metabolic study on the Clinical Research Unit. Measurements were made of the 24 hour urinary excretion of epinephrine, norepinephrine, vanillyl mandelic acid, tryptamine, tyramine, and histamine. The results in hyperthyroid children and adults reveal highly significant increases in the urinary excretion of tryptamine, tyramine, and histamine. I n addition, hyperthyroid children show approximately 100 per cent increase in urinary norepinephrine and epinephrine levels and a 25 per cent decrease in urinary vanillyl mandelic acid. Hyper-
Supported by Grants A-5062 and 8-MOI-FR-46 [rom the National Institutes o[ Health.
October 1963
thyroid adults do not show this. The urinary amine abnormalities are corrected as the euthyroid state is achieved. These results are compatible with the hypothesis that the hyperthyroid state interferes with the degradation of aromatic amines. DISCUSSION DR. ROBERT E. GREEN1aERa, Palo Alto, Calif. Other investigators, such as D'Iorio and LeDuc, have previously shown that thyroxin will inhibit catechol-0-methyl transferase (COMT) in vitro. If this could be extended to in vivo studies, the reduction in VMA excretion you have reported could just as easily be explained on the basis of COMT inhibition rather than monoamine oxidase (MAO) inhibition. The determination of normetanephrine would have been more helpful, since it is formed by COMT only. COMT inhibition would not explain the increased urinary excretion of the other amines you studied, which raises the intriguing problem of amine storage. The observations of Kopin and Gordon (J. Pharmacol. & Exper. Therap. 138: 351, 1962) indicate that there are two pools of norepinephrine in adrenergic fibers, one releasable by tyramine (with mainly 0-methylated metabolites) and one releasable by reserpine (with 0-methylated and deaminated metabolites). Thus, striking differences in the nature of urinary metabolites of catecholamines could theoretically result from some alteration of storage mechanisms, possibly applicable to other amines similarly stored by unknown mechanisms. Finally, with respect to the activity of COMT during development, Studnitz reported that the relative amount of VMA was, if anything, increased in the newborn period of the human. Preliminary studies in our laboratory, with rabbits, would similarly indicate no age-dependent difference in the metabolism of exogenously administered radioactive norepinephrine. DR. DONALD B. C~EEK, Baltimore, Md. I would point out that our own work on the sympathetic nervous system with respect to the nature of acrodynia or pink disease has shown that inorganic mercurials, such as calomel, will potentiate the action of epinephrine. This action was demonstrated in the rat (Arch. Dis. Childhood 34: 501, 1959; Pediatrics 23: 302, 1959). We believe that this result is mediated through methyl transferase which needs the substrate S-adenosyl methionine to inactivate epinephrine.
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This substrate is inhibited by mercury (Axelrod and Tomchick: J. Biol. Chem. 233: 702, 1958). Thus, in view of the fact that acrodynia occurs in infants and young children and not in adults, one might predict that the methyl transferase pathway for children is more important than the monamine oxidase system. Such a prediction is in conflict with the conclusions of the present paper. DR. W. F. WESTLIN, Summit, N. J. Since guanethidine selectively interrupts adrenergic reflexes at the neuroeffector junction and produces catechol amine depletion in some tissues, without any known effects on the central nervous system, it would seem that this drug would provide a useful pharmacologic tool with which to estimate the contribution of adrenergic reflexes to the hyperthyroid syndrome. Did you give Ismelin (guanethidine) to any of your patients? DR. LIPTON. With respect to the first comment, reference was made to a report by LeDuc and D'Iorio on the inhibition of the methyltransferase system in hyperthyroid animals. They found such inhibition in hyperthyroid rats. We have suggested that our results in children may be due to a selective diminution of M A O activity with lesser involvement of the methyltransferase system. I n considering the difference between their results and our interpretation of our results, I think it is necessary to differentiate between the human with a spontaneous clinical course of thyrotoxicosis and the induced thyrotoxicosis of rats, particularly as these workers produced the condition. They used large doses of thyroid hormone to produce hyperthyroidism and kept the animals hyperthyroid for fairly long periods of time. I have very little doubt that if this is done for a long period the methyltransferase system will also be markedly depleted. Whether or not this would actually occur in clinical thyrotoxicosis is open to question. Our data do not seem to indicate this because the metanephrine and nor-metanephrine values are not strikingly diminished and the urinary V M A is within the normal range, or only very slightly decreased. With respect to the question of the effects of thyroid hormone on catechol amine storage, we too are not satisfied, as I indicated, that inhibition of monoamine oxidase activity tells the whole story of the defect in amine metabolism. Indeed, we have some data of our own that indicate that, as hyperthyroidism is induced in
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animals, the hypersensitivity to exogenous catechol amines comes about more rapidly than the diminution in monoamine oxidase activity. Likewise, as hyperthyroidism is cured, there is a loss of hypersensitivity to catechol amines more rapidly than there is a restoration of monoamine oxidase activity. There is, therfore, a time disparity here that makes us feel that monoamine oxidase inhibition is not by any means the entire explanation for the increased sensitivity to amines in hyperthyroidism. With respect to the issue of newborns I have had a private communication from Axelrod, who tells me that, in unpublished results, the catechol orthomethyltransferase system of newborn rats is one third that of adults and that it achieves adult values in several weeks. Now, our children are hardly newborn infants, and we are ourselves at a loss to explain why hyperthyroid children ranging from 8 to 15 years of age still seem to handle catechol amines differently from adults. Nonetheless, those are the conclusions which follow from the data we have obtained and presented. We did not give Ismelin (guanethidine). We did give reserpine to some of these children, particularly when it looked as if they were dangerously ill--that is, when we felt they might go into crisis. It is known that reserpine does deplete the catechol amines and, in large doses, will cause a decrease in the amount of V M A or in the amount of catechol amines which appear in the urine. We used only 0.25 mg. of reserpine daily, but despite the fact that we gave reserpine, the urinary catechol amine levels were still substantially higher than in the normal children. One might therefore extrapolate and state that if we had not used reserpine in the clinical management of some of these children, our levels would be still higher than those which we reported.
9. Thyroxine secretion rate during infancy: The effect o[ estrogen D. A. Fisher ~ and T. H. Oddie, ~ University of Arkansas School of Medicine, Little Rock, Ark.
Introduced by T. C. Panos During infancy 48 hour PB1131 values; thyroidal radioiodine release rates, and thyroxine 11~1 decay rates are increased over adult values.
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These data would seem to indicate relatively increased thyroxine secretion rates in spite of serum hormonal iodine and thyroidal radioiodine uptake rates generally similar to adult values. Thyroxine secretion rate was measured by the thyroidal 1131 blockage method in 17 premature infants 24 to 65 days of age and weighing 1,600 to 2,200 grams. Infants were given 1 mc. sodium 1131 intravenously and early thyroidal radioiodine uptake (ks) and 24 hour uptake were measured as previously described. K1 and 24 hour uptake values were normal in all infants. Thereafter measurements of daily thyroidal I TM release rate were made with and without potassium perchlorate on 10 to 15, 15 to 20, and 25 to 30 mcg. per kilogram per day intramuscular sodium 1-thyroxine. Thyroidal 1lal release was found to be proportional to the amount of thyroxine administered. Complete inhibition of thyroidal I131 release did not occur, however; a baseline secretion rate of 0.83 per cent per day was observed. Thyroxine secretion rate in 13 infants determined by calculation of the regression of thyroidal radioiodine release on thyroxine dose was 18.6 mcg. per kilogram per day. This value is 9 to 18 times greater on a microgram per kilogram per day basis and 2 to 5 times greater on a microgram per square meter per day basis than secretion rate measurements in adults. In .5 infants on 18.5 mcg. thyroxine per kilogram per day with suppression of thyroidal I TM release, daily intramuscular estradiol benzoate produced significant stimulation of radioiodine release and progressive saturation of serfim thyroxine-binding proteins indicated by increasing triiodothyronine I ~31 resin uptake during the 12 to 15 day period of estradiol benzoate therapy. This is interpreted to indicate
October 1963
direct hypothalamic stimulation of TSH release by the estradiol benzoate. DISCUSSION DR. RICtIARD L. DAY, Pittsburgh, Pa. I would like to ask what the body temperatures of these premature infants were. DR, JOHN F. CRIGLER, JR., Boston, Mass. Have you followed the regression curves of thyroidal I TM for longer intervals of time at one dose level? DR. HOSSEIN GHADIMI, Brooklyn, N. Y. The increased concentration of plasma tyrosine in newborn infants and especially in the premature has been reported d u r i n g the last year. In our laboratory we have found values as high as 19 rag. per cent on the twenty-eighth day and 30 rag. per cent on the seventh day of life have been observed. These values are about 20 to 30 times the normal values of infancy and childhood. Tyrosine is a precursor of thyroxin. I was wondering if there is any correlation between the high concentration of tyrosine and your observation of thyroid excretion. For instance, is high tyrosine the cause or effect of the increased activity of the thyroid gland? In your studies did you also determine the level of tyrosine in the plasma. DR. FISHER. The body temperature, Dr. Day, was controlled, in that all these children were in incubators. Their body temperatures were normal throughout the study period. The problem of prolonged single-dose administration has not been carried beyond about 14 days, during which time on a single dose the release rate seems to be linear on a semilog plot on three infants. We do not have the data regarding tyroslne.
PLENARY
SESSION
2. Growth sequences during recovery from infantile malnutrition
gain at an accelerated rate. After more than a year of observation, most patients still show impairment in mental and motor skills and only prolonged studies might give an indication of the permanent effect of infantile malnutrition on eventual mental capacity.
Angel Cordano, ~ Juan M. Baertl,* and George G. Graham, ~ British American Hospital, L i m a , P e r u Introduced by Lawrence Finberg
DISCUSSION
Permanent growth deficits are assumed to follow malnutrition but little is known about actual growth during recovery from kwashiorkor and severe infantile marasmus. The length, weight, and head circumference of 17 patients with third degree malnutrition (over 40 per cent weight deficit) have been followed. They fall into two groups: Group A with 10 patients 6 to 13 months of age (average 9.2) and Group B with 7 patients 17 to 30 months of age (average 23.6). Group A stayed an average of 6.75 months in the hospital and was followed initially for 7.45 months; Group B, 4.7 and 6.45 months, respectively. In the hospital both made similar gains, most marked in weight (2.5 and 4 times normal for age) and head circumference (2.2 and 4.6 times normal). Gain in length was slightly below normal for age in both. During the first 3 months we noted an early spurt in head growth far in excess of linear growth and bone maturation, possibly the result of early resumption of brain development. During the initial follow-up period Group B made better gains in all measurements but in a further period of 6 months Group A showed an increased rate of gain also. "Make-up" potential certainly seems to exist but is quite variable. Weight is gained rapidly on a diet adequate in protein and rich in calories. Those with a deficit of 5 per cent or less in body length easily attained normal values, while those with deficits larger than 15 per cent seem to be condemned to permanent stunting despite gains which are close to normal for age. Those with 8 to 15 per cent deficits have shown a continuing tendency to
~By invitation, Asterisk indicates
DR. NATHAN B. TALBOT, Boston, Mass. The importance of this work, I think, lies in the fact that it illustrates the need to prevent retardation in growth and maturation in children, since once it has developed beyond a certain point it may become permanently irreversible. In this connection I am very much interested in the phenomenon which we have observed in a variety of circumstances with relation to the growth of children, namely, what we have called, for lack of a better term, a tendency to develop a pent-up growth urge under circumstances of growth retardation secondary to a variety of factors. Interestingly, these factors are quite varied in nature, including malnutrition, as illustrated here, hypothyroidism, Cushing's syndrome, or heavy cortisone therapy, and a variety of other states. I am wondering whether the authors have any thoughts on the mechanism responsible for this transient compensatory growth spurt following correction of the underlying difficulty. It is characterized grossly by extraordinarily rapid growth for a limited period of time. It reaches a maximum peak in the first few months, then gradually peters out despite all efforts to sustain it. The same phenomenon has been observed in basically normal short children following treatment with testosterone and in children with hypopituitarism when given human pituitary growth hormone. DR. JACK METCOFF, Chicago, Ill. There is art important feature about the paper presented by Dr. Cordano and associates. In addition to physical retardation the implication of mental retardation, I think, is of extreme importance for the future development of societies which have been subjected to technical delay in their maturation as a result o f malnutrition.
the same throughout.
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There is another interesting point with relation to your comment about copper deficiency. Have you had an opportunity to explore the problem of zinc deficiency? I ask this because the Naval Medical Research Unit just outside of Cairo has recently reported extensive zinc deficiencies in patients who have extraordinary retardation in linear growth--19 to 20-year (sic) old children, actually, who are perhaps 4 feet tall, and given replenishment with zinc have tremendous growth spurts. It might be significant that very minor trace metal deficiencies do exist which we are not cognizant of and these trace metal deficiencies have serious impact upon growth and developmental performance. DR. JULIUS ]3. RICHMOND, Syracuse, N. Y. Inasmuch as these children are reported to show some psychomotor retardation, I wonder if we could have a few words about the environments in which they are reared after nutritional restoration is accomplished. If they go back to an environment in which there is considerable understimulation, it may very well be that this would be a significant factor in the continuing psychomotor retardation. I wonder, therefore, if we could have a few comments about their environment. DR. CORDANO. The answer to Dr. Jack Metcoff is: Our work does not include evaluation on zinc as yet. The answer to Dr. Julius B. Richmond is: Even if it is true that the patients go back to an environment where understimulation is present, this does not seem to have a heavy influence on younger or older siblings of the patients, since they do behave as the average children in a similar environmental situation. Most of our patients after 21 months of follow-up continue to show some degree of psychomotor retardation and only a prolonged study of them will give us the real answer.
3. Thymic alymphoplasia and lymphocytic hypoplasia and increased susceptibility to injection D a v i d G i t l i n a n d J o h n M. Craig, Child r e n ' s Hospital a n d Boston L y i n g - i n Hospital, H a r v a r d Medical School, Boston,
Mass. Experimental studies of Waksman and associates (J. Exper. Med. 114: 997, 1961) and
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Miller (Lancet 2: 748, 1961) have revealed that thymectomy of the newborn rat or mouse results in lymphocytic hypoplasia of the tissues and an increased susceptibility to infection. We have observed 6 children with an inherited anomaly of the thymus, thymic alymphoplasia, which is analogous to the the condition evoked in thymectomized newborn animals. These children manifested a persistent lymphopenia and were characterized clinically by an unremitting course marked by pneumonia, moniliasis, and other infections usually beginning in the first 3 months of life; the disorder thus far has terminated fatally during infancy. These patients had lymphocytic hypoplasia of the tissues: the thymus was rudimentary, virtually devoid of small lymphocytes, and without Hassall's corpuscles, and the other lymphoid structures contained only sparse populations of small lymphocytes. The thymic alymphoplasia and general deficiency in small lymphocytes appear to be inherited characteristics and the evidence suggests that the primary defect is thymic alymphoplasia which resulted in generalized lymphocytic hypoplasia including lymphopenia. The children had agammaglobulinemia as well: plasma cells and germinal follicles were absent from the tissues, but the marked generalized paucity of small lymphocytes in these patients with thymic alymphoplasia resulted in an increased susceptibility to infection beyond that seen in the usual form of congenital agammaglobulinemia, or nonlymphopenic agammaglobulinemia. In nonlymphopenic agammaglobulinemia, the thymus as well as other lymphoid organs contains nearly normal numbers of lymphocytes. The contribution Of the small lymphocyte to resistance to infection was not replaceable by y-globulin therapy.
4. Thymic dysplasia in congenital agammaglobulinemia W i l l i a m C. Yakovae, Children's Hospital of Philadelphia, Philadelphia, Pa. A thymopathy characterized by small organ weight and size and absence of lymphocytes and Hassall's corpuscles has been encountered at necropsy in 2 white male infants aged 5 months and 6 months and a 13 week (9.5 cm. crownrump length) male abortus. Both infants suffered from recurrent respiratory infections, intermittent diarrhea, severe oral moniliasis, failure to thrive, lymphocytopenia, and markedly low or
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absent serum gamma globulin levels. A brother of one of these infants, having run a similar clinical course, died at 8 months; his thymus, unfortunately, was lost to study. The thymus of the fetus (brother to the infants who died at 5 months and 8 months) was a miniscule, rudimentary organ lacking both lymphocytes and Hassall's corpuscles; it was a replica, in miniature, of the thymopathy described above. In striking contrast were the findings observed in a normally developing thymus of a nonrelated abortus of approximately the same gestational age. These showed a cortex populated by an abundance of lymphocytes and a medulla with beginning development of Hassall's corpuscles. On the basis of these findings, it would appear that in congenital agammaglobulinemia a dysplastic process affects the thymus early in organogenesis. It is proposed that the subsequent immunologic deficits that develop in infancy might be a functional expression of this dysplastic process, one essentially of autothymectomy, having as a corollary Miller's now classical thymic ablation experiments in the newborn animal. DISCUSSION DR. CHESTER FINK, Dallas, Texas. Were any studies of delayed hypersensitivity, such as tuberculin tests, done on the two groups and, if so, was there any difference between the groups? DR. DONOUGH O'BRIEN, Denver, Colo. Dr. Craig, we presently have a child who corresponds to your lymphopenic group except it is of interest that his thymus was irradiated shortly after birth. It has been suggested that this child would profit by a splenic transplant. I wonder if you had considered this and would like to comment on the procedure. DR. JONATHAN T. LANMAN,Brooklyn, N. Y. In experimental animals which are populated with white cells during their period of immunologic tolerance, a disease has been described and is known as runt's disease. This disease shows certain characteristics similar to those seen in these patients. This includes diarrhea, which is admittedly nonspecific, and lymphoid hypoplasia, and certain other findings such as ruffled hair, which I doubt you could see in these individuals. I wonder if either of these men could discuss the possible relationship of these cases to runt's disease.
October 1963
DR. EDNA H. SOBEL, New York, N. Y. I would like to ask both Dr. Craig and Dr. Yakovac whether there were any normal children in the families they have described and the sexes of the unaffected children. Was the physical growth of the affected children retarded? If so, was there more retardation than could have been attributed to the recurrent infections? Dr. GITLIN. There was a question asked about delayed hypersensitivity in these two groups of patients. An earlier paper from our laboratory, which was published in Lancet, indicated quite clearly that there may be a marked inhibition of the delayed hypersensitivity response in children who have lymphopenic agammaglobulinemia: all of the 6 children with nonlymphopenic congenital agammaglobulinemia who were tested in this study developed delayed hypersensitivity, either natural or induced, and the one child who had lymphopenic agammaglobulinemia with thymic alymphoplasia did not develop any manifestation of delayed hypersensitivity, either natural or induced. Regarding the question that was asked about irradiation and splenic transplants, we did not do splenic transplants in this particular lymphopenic patient. We did, however, try a thymic transplant, but this was without noticeable effect upon the course of the patient. There is some unpublished information from Hitzig in Switzerland. He had a young infant with lymphopenic agammaglobulinemia to whom a fetal thymus was transplanted. There was a questionably significant rise in lymphocytes, but this patient subsequently died with infection a few weeks later. Regarding the questions asked about retardation of growth and normal children, there were normal children, of course, in the family in each of the cases discussed this morning, and there was no apparent abnormality of any kind, either retardation of growth or presence of infection in the normal siblings; there were both male and female normal siblings, although all of the lymphopenic children described by Dr. Craig today were males. The retardation of growth that occurred in our patients with lymphopenic agammaglobulinemia was presumably due to infection, and here enters the question of runting. The growth retardation bore a superficial resemblance to the runting that one sees in animals, but it could not have been on the basis of delayed hypersensitivity or antibody formation, because these individuals were not able to de-
Volume 63 Number 4 part 2
velop either; runting as a donor-versus-host reaction apparently was not a phenomenon in these particular children. DR. YAKOVAC. For my part, I only wish to answer Dr. Sobel's question. In our small series of two families all infants were males, including the fetus, and there are no unaffected survivors. DR. CRAIG. In reply to Dr. O'Brien's comment, there is one piece of data recently reported by Miller, which might be of interest to anyone wishing to transplant lymphoid tissue to an alymphopenic child. This is that thymic tissue, rather than a peripheral source of lymphocytes, should be used since there appears to be a considerable difference in the ability of the two types of cells to initiate antibody formation.
5. Ataxia-telangiectasia: A possible clinical counterpart of the animals rendered immunologically incompetent by thymectomy R. D. A. Peterson, "~ M. Blaw, ~ and R. A. Good, D e p a r t m e n t of Pediatrics, U n i v e r sity of Minnesota, Minneapolis, M i n n . Ataxia-telangiectasia, a syndrome first described by Louis-Barr in 1941, has now been observed an estimated 80 times. Serious repeated infections have occurred in almost 90 per cent of these patients and have generally accounted for their demise. The cause for the apparent increased susceptibility to infections has remained unexplained. Bruton and Boder each noted a decreased gamma globulin content in one each of their cases but in only 14 other cases are serum protein studies available. Six of 16 of the known gamma globulin levels are significantly low. No reports are available of further immunologic study of these patients. Of the few postmortem reports only one mentions the thymus gland and in that case it was significantly absent. We have recently had occasion to study extensively the immunologic capacity of a 9-yearold girl with this syndrome. She has a gamma globulin level of 200 mg. and is also deficient in B2A and B2M. She is able to reject a skin homograft but is quite unresponsive to a variety of antigenic stimuli. These patients may be of Aided by grants [rom the Arthritis and Rheumatism Foundation and the Minnesota Heart Association.
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70 1
considerable significance as they may represent the human counterpart of our animal models rendered immunologically unresponsive by early ablation of their thymuses. The benefit of simultaneous clinical and laboratory investigation is classically highlighted here. DISCUSSION DR. CI~ARLES KENNEDY, Philadelphia, Pa. I would like to make one very general comment. The syndrome described in this paper and one other, acanthocytosis, are the first of the cerebellar ataxias which have been found to be associated with biochemical abnormalities. For years, the group of disorders included under the term "Friedreich's ataxia" have been known to us by clinical manifestations and morbid anatomy only. Hopefully, the biochemical approach can be extended to other of the cerebellar ataxias and lead us to rational therapy. DI~. PETERSON. The relationship of the cerebellar ataxia to the rest of the syndrome of ataxia-telangiectasia remains unknown. Chickens that are rendered immunologically incompetent by treating the eggs with 19-nortestosterone are ataxic. We have examined their cerebellums by light microscopy and they appear normal. The general debilitation of these chickens may account for their ataxia. Sherman and Dameshek report that hamsters subjected to thymectomy in the newborn period are not only immunologically deficient as is expected according to present-day concepts but also often ataxic. They have not as yet examined the cerebellums of these animals. DR. ELI GOLD, Cleveland, Ohio. My question concerns the response of the child you studied and others you know of to vaccination or to viral infections. Do those with inadequate ability to develop delayed hypersensitivity have difficulty with virus infections? DR. PETERSON. The child reported upon here had been vaccinated during infancy without difficulty. She also had a normal case of chickenpox. Other patients with agammaglobulinemia likewise handle most viral infections quite normally. They have had measles, chickenpox, and polio without complication. Hepatitis is one viral infection which has been very destructive of these children. Several have died of liver failure after developing hepatitis. DR. H. G. DUNN, Vancouver, British Columbia, Canada. It seems that the situation in ataxiatelangiectasia is getting complicated, because there
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have been some features in other cases which might suggest reticulosis or collagen disease. Three years ago, at a meeting of the North Pacific Pediatric Society, Dr. Robert Aldrich of Seattle presented a case of ataxia-telangiectasia in which there was evidence of hyperplenism, with granulopenia. The child appeared to benefit from splenectomy and also from prednisone therapy. We have also had a patient with ataxiatelangiectasia whose recurrent pulmonary infections appeared to become less frequent during steroid therapy. I believe that the occurrence of thrombocytopenia and of lymphoma has also been reported in this disease. As you will be aware, Pelc and Vis in Belgium have described an abnormal substance in the amino acid chromatogram of the urine from patients with this syndrome, and Paine and Efron have confirmed this in one of their cases. It appears to be a substance which breaks down to proline and hydroxyproline on acid hydrolysis, and may therefore be derived from collagen. I should like to ask the authors whether they have had any experience with steroid therapy in these cases, and also whether they have confirmed the presence of the abnormal substance in the urine. DR. PETERSON. We have not completed our studies of this patient's urinary amino acid excretion. We have not treated any of our patients with agammaglobulinemia with steroids except two with leukemia. The limited capacity of these patients to resist infections would seem to make steroid treatment even more treacherous than in other patients. DR. PIiILLIP E. ROTIKMAN,Los Angeles, Calif. I have had the opportunity of observing one of these patients through the courtesy of Dr. Boder. The child's infections were confined to recurrent attacks of pneumonitis. The mechanism presented by the speaker cannot be disproved but bedside observations during mealtime suggest the additional possibility of aspiration pneumonitis. Difficulty in swallowing, coughing, pooling of oral secretions perhaps indicates a dysfunction of pharyngeal muscles similar to that of some patients with Riley-Day disease who have repeated attacks of pneumonitis. DR. PETERSON. We can define no abnormality of our patient's swallowing mechanism although she does have dysarthric speech. She also has otitis media and externa. I cannot say if others with this syndrome have a problem with aspiration pneumonia.
October 1963
DR. Luc LEMLr, Madison, Wis. I would like to make two comments. The first is regarding the possible role of the thymus gland in this syndrome. Dr. Guttman and I have recently published a paper on 3 siblings with ataxia-telangiectasia and associated hypogammaglobulinemia. One of these children--an 8-year-old girl who had agammaglobulinemia, died of staphylococcal pneumonia. At autopsy the thymus was found to be absent and, although the mediastinal lymph lymph nodes were enlarged, they were depleted of lymphocytes. This observation then seems to lend further support to the hypothesis which you have postulated. The second comment concerns the possible treatment of such children with corticosteroids. Therapy with hydrocortisone was tried in the case I have just mentioned. Instead of improving, the patient developed a fatal staphylococcal pneumonia. DR. P~TERSON. It is very interesting to hear that your patient lacked a thymus gland. As we learn more of thymus abnormalities it becomes increasingly important to examine this organ at postmortem. If it is not grossly present sections should be taken through various levels of the mediastinum and neck in an effort to find rudimentary thymus tissue. DR. ELENA ]~ODER,Los Angeles, Calif. I have a brief comment and a question. Dr. Robert P. Sedgwick and I have just completed a tabular analysis of 101 currently known cases of ataxiatelangiectasia, 49 published and 52 unpublished, including our own series which now totals 18. The paper of Drs. Peterson, Blaw, and Good is of particular interest in that it reports the first comprehensive immunologic study of a patient with this syndrome. The most frequent cause of death in ataxiatelangiectasia, as Dr. Peterson has already mentioned, is bronchiectasis complicated by pneumonitis, death from this cause occurring typically at adolescence. However, I would like to add that, with the increased number of autopsy reports that Dr. Sedgwick and I have gathered, it has become apparent that the cause of death may be neoplastic as well as pulmonary. In one of the 11 available autopsies Hodgkin's disease was found in association with bronchiectasis. In another, death was found to be due to a reticulure cell sarcoma with metastases in the central nervous system. In addition, in one of our originally reported cases, in which no autopsy was performed, there was an infiltrating undifferen~
Volume 63 Number 4 part 2
tiated round cell sarcoma of the neck suggestive of lymphosareolna or reticulum cell sarcoma, according to a biopsy report. I would be very much interested in Dr. Peterson's comments as to the possibility that the high incidence of neoplasia in patients with ataxia-telangiectasia, like their proneness to sinopulmonary infections, might in some way also be related to a thymic dysplasia. DR. PETERSON. The relationship between immunologic deficiency states and malignancy is unclear but real. Two children we have studied with the congenital sex-linked type of agammaglobulinemia have developed and died of acute lymphatic leukemia. In one the disease first manifested itself as a thymus enlargement and when an exacerbation occurred the thymus was again primarily involved. Certain mouse lymphatic leukemias have been demonstrated by Furth, Kaplan, and others to require an intact thymus gland in order to manifest themselves. Removal of the thymus from such mice before they clinically have leukemia prevents its development. Replacement with an isologous thymus permits the leukemia to develop. The role of the thymus in certain types of malignancies is thus significant. The mechanism of its function at present is unknown. DR. DAVID SHURTLEFF, Seattle, Wash. I would like to report that Dr. Aldrich's patient following splenectomy was treated with steroids and died of pneumococcal meningitis.
6. Testosterone production in a 3-yearold male with isosexual precocity Maria New, r Paula Pitt, ~" and Ralph E. Peterson, r T h e New York HospitalCornell Medical Center, New York, N. Y. J I n t r o d u c e d by H o w a r d W o r t h e n The daily production of testosterone and the daily urinary excretion of testosterone glucuronide of a S-year-old boy with complete idiopathic isosexual precocity were measured by a double isotope dilution derivative technique. Urine was collected after injection of testosterone-4-C1~, incubated with beta glucuronidase, and extracted with dichloromethane. The testosterone was isolated, acetylated with tritiumlabeled acetic anhydride, and purified to constant specific activity by paper chromatography and by formation of the benzhydrazone of testosterone acetate. The daily production of testos-
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terone was then calculated from the specific activity. This child produced 2 to 3 rag. of testosterone daily (one-half the daily production of a normal adult male). This was tripled by chorionic gonadotrophin; was markedly decreased by oral 17-oe ethinyl-19-nortestosterone (Norlutin) and ethinyl estradiol, but was unaffected by ACTH, prednisone, or oral 6-medroxy progesterone acetate (Provera). Intramuscular 6-medroxy progesterone acetate (Depo-Provera) suppressed testosterone production to one tenth of the baseline value. This was the least androgenic and least estrogenic drug tested which can suppress testosterone production and thereby arrest the progressive sexual development and advanced epiphyseal maturation. The clinical effects of the suppression of testosterone production with Depo-Provera are being evaluated. DISCUSSION DR. MARWN A. SCHULTZ, Pacific Palisades, Calif. We have used Depo-Provera in cases of precocious puberty and in 2 girls have noted a decrease in estrogen excretion following therapy. DR. ALFRED M. BONGIOVANNI,Philadelphia, Pa. In sexual precocity the urinary 17-ketosteroids are quite low, and this has been a matter of great mystery. In this small amount of 17ketosteroid there must be a very potent substance, and this has been very nicely demonstrated by Dr. New. I have one reservation that I would like to state having to do with Provera. We have been using Provera for 6y2 years and have been reluctant to report our results because we have the feeling that in approximately one half of our patients the Provera itself produces a rate of bone maturation which exceeds that of even the earlier period. Ours is a small series, but nonetheless it does concern us, and I think perhaps we should keep our eyes open in this particular matter. DR. A. CAMACHO, Detroit, Mich. Investigation done with Dr. Migeon shows that A4-androstenedione is converted peripherally to testosterone glucuronide in significant amounts. These data will be presented this afternoon at the endocrine section. If the androgenicity of testosterone is directly related to the concentration of this steroid in blood and if androstenedione is converted to testosterone and conjugated as testosterone glucuronide without permitting testosterone to circulate as biologically active unconjugated testos-
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terone, then the estimated production rate of testosterone by this technique would be an overestimation of the production of biologically active testosterone. I wonder if you would comment on this. DR. ROBERT A. ULSTROM,Minneapolis, Minn. My congratulations for using what I think is the most definitive type of methodology we have to use regarding production levels of steroid. By this method one can also learn something about the peripheral metabolism. I wonder if Dr. New has made any incidental observations regarding either the type of degradation or the duration of circulation of testosterone that might be any different in a child who is being subjected to virilization when the tissues are other than at a mature state; whether any different types of metaholites or a difference in metabolic rate of disposition might have been observed. Another question that I would like to ask is regarding the use of the same, identical compound as a basis for the isotope dilution calculation. Might one find different values if one of the metabolites had been used, rather than testosterone itself? DR. EDNA H. NOBEL,New York, N. Y. Would Dr. New give us an estimate of the amount of irradiation received by the child in the C 14labeled testosterone which he was given? It might be difficult to judge the effectiveness of a drug used for inhibition of sexual precocity from the rate of growth alone. We do not yet know to what extent growth hormone contributes to the normal adolescent growth spurt which, at least in boys, must be in part due to gonadal steroids. Inhibition of gonadotrophin production, or interference with the response of the gonads to gonadotrophins, would be expected to reduce the rate of production of testosterone by the testes. However, the rapid growth of a child with true sexual precocity might be a consequence of increased secretion of growth hormone as well as of gonadotrophins. DR. DAVID W. SMITH, Madison, Wis. Do you have information about gonadotrophin assays and the clinical response to the use of the suppressive steroidal agents? Also, what was the clinical response of the boy to the administration of Depo-Provera? DR. NEW. We have shown only that DepoProvera decreased the testosterone production. We have not observed this child long enough to estimate any clinical effects. He is undergoing a clinical trial at the present time. The only thing
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I can tell you is that when I saw him last he had been receiving Depo-Provera for 2 months. He had been shaved for urinary collections in the hospital, and when I saw him 2 months later the pubic hair had not grown back. He also no longer had acne. Insofar as epiphyseal maturation is concerned, we have not studied him long enough to be able to state any changes, and I am interested to know that Dr. Bongiovanni reports that the rate of maturation has not been changed by Depo-Provera. This would imply that the epiphyseal maturation must not be dependent upon testosterone. I have purposely used the term "testosterone production" rather than testosterone secretion rate because I know this assay does not distinguish between the production of z~4-andro stenedione and testosterone. I am not able to make a distinction between those substances. As for a study of the metabolites of this child and a normal child, we have not done this. We have not attempted to determine the production rate, using a metabolite other than testosterone glucuronide. Dr. Hudson in Australia did determine some production rates using these metabolites and came out with a figure similar to ours. We were never able to detect urinary gonadotrophins in this child. I admit that is inexplicable. At the moment an assay is being conducted for L H in his urine; but this has not been completed. As to the administration of isotopes to this child, Dr. Sobel, we very carefully went over this with a physicist who is a consultant to the Atomic Energy Commission. We delivered to the child about half a microcurie for each study. There were thirteen studies all together, spread over a period of 9 months, which is the time he was in the hospital. When the number of millirads that he received is calculated, allowing half a microcurie for each study, he received 0.03 millirads p e r week. The allowable dose for a child by the most current information that I could obtain is 30 millirads per week. A chest x-ray delivers 15 millirads to the skin. We therefore gave him some one one-hundredth of the allowable beta radiation. He excreted almost all of the labeled material within 24 hours. We have never been able to detect more than 3 per cent of the amount we had administered on the second day, and on
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the third day there was no excretion of any label at all.
7. C~, and C~ steroid excretion pre and post SU-4885 and o,p'DDD in a case of metastatic adrenocortical carcinoma. An 18-month follow-up Jacques R. Duchaxme, Gilles Leboeuf, ~ Robert A. Ayotte,r and Jacques C. Ducharme, r Department of Pediatrics, Universit6 de M o n t r 6 a l a n d L ' H 6 p i t a l SainteJustine, Montr6al, Qu6bec, C a n a d a A 4-year-old girl with progressive virilization, some cushingoid elements, and a large right suprarenal mass invading the kidney was studied. Urinary 17-ketosteroids were 308 mg. per 24 hours and rose to 448 mg. with SU-4885 administration. Plasma 17-OHCS were 37 /,g per 100 ml. and urinary 17-OHCS 4.1 mg. per 24 hours. I n the nonketonic fractions, compounds with o-glycol side chain in C~-C.o (acetaldehydogenic steroids) and A5-3fl-ol configuration (Oertel chromogens), largely A5-pregnenetriol, were elevated and rose with the blocking agent. Chromatography on alumina by gradient elution of each ketonic fraction revealed 163.0 rag. per 24 hours of dehydroepiandrosterone (DHA) in the sulfate fraction which rose to 207.0 rag. per 24 hours with SU-4885, while l 1-oxygenated 17-KS disappeared. A proportionately greater rise was noted in the free and glucuroniside fractions, although the total values for the free steroids were much lower. After right adrenalectomy and nephrectomy followed by x-ray therapy, steroid excretion reverted to normal while virilization partially regressed. However, as a result of the appearance of puImonary metastases 3.0 Gin. per day of o,pPDDDt was given_ Metastases cleared completely. A few months later, following reduction of o,pPDDD to 2.0 Gin. per day, virilization increased and pulmonary metastases reappeared and progressed despite increased dosage of o,pPDDD to 5.0 Gm. per day. Suppressive doses of dexamethasone arrested the progression and partial regression occurred. It is suggested that this tumor and functional metastatic tissue were ACTH dependant. Plasma ACTH determinations pre and post dexamethasone are being made. ~Supplied by the National Institutes of Health.
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DISCUSSION DR. LYTT I. G A m ) ~ , Syracuse, N. Y. These observations are very interesting to me. It was before this Society at that memorable meeting in French Lick, Indiana, in 1950, that the first physiologic study of the effect of DDD on mammals was presented by Dr. John Nichols and myself. It is a great pleasure to see what has happened in the interval with this drug and the new isomer. DR. SAMUEL SPECTOR, Cleveland, Ohio. In answer to the question raised, we had the opportunity of treating a 7-year-old girl with a combination of suppressive adrenal therapy (hydrocortisone) and o, prDDD, She too had pulmonary metastasis at onset of therapy. An apparent complete remission occurred which lasted 18 months and then the tumor escaped. It is interesting that with relapse she also exhibited crises of adrenal insufficiency characterized primarily by sodium loss. We did try an analogue, m,ptDDD, but had only a very short-lived response. The question I wish to raise and realize that you are probably not now in a position to answer is the state of your patient's "normal" adrenal, At necropsy, our patient's adrenal gland was small and cellularly completely disorganized so that no layers could be identified. DR. ALFRED M. BONGIOVANNI, Philadelphia, Pa. This is a very interesting report that Dr. Ducharme has made. There is a paucity of reports on the use of this drug in childhood, and I know that you must have done a lot more work. I was wondering about the response of the 17-ketosteroids to ACTH and also to such substances as dexamethasone, which you gave. I ask this because often there is more response to these substances in tumors than one supposes. DR. DUC~A~M~. Dr. Spector, we have not had the opportunity of examining the patient's second adrenal, but there was no evidence of its involvement at the time of operation. However, it is possible that at present the remaining adrenal may be either invaded by tumor or showing complete disorganization and severe atrophy. We were also somewhat surprised to see her enter adrenal insufficiency with a salt-losing state while receiving o,p'DDD since Woodward's original work in the dog had shown that DDD had a selective effect on the fascicular and reticular zones of the adrenal cortex. It is possible,
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however, that the isomer o,pPDDD affects also the glomerulosa. Dr, Bongiovanni, we have not done a standard ACTH test on this patient since we have felt that the test for pituitary reserve of ACTH might give somewhat the same information and since also the size of the tumor mass was such that operation could not be delayed. We can say, nevertheless, that there was a significant rise in her 17-ketosteroids after SU4885, mostly involving dehydroepiandrosterone glucuroniside. It was also interesting to note that after starting o,pPDDD administration there was nearly a 100 per cent rise in the 17-ketosteroids within a few days followed by a decrease in the latter to very low levels. We do not have qualitative separation of these urines after dexamethasone suppression but it would certainly be worthwhile to make this test.
8. Aromatic amine metabolism in disorders of the thyroid gland M. A. Lipton, ~ D. K. Manning, ~ J. J. Van Wyk, a n d F. S. French, ~ D e p a r t ments of Psychiatry a n d Pediatrics, U n i versity of N o r t h C a r o l i n a School of Medicine, Chapel Hill , N. C. Increased sensitivity to administered catechol amines and other biologically active amines has been demonstrated by other workers in hyperthyroid patients and animals. In order to investigate the possible mechanisms involved in this, studies were undertaken in normal and hyperthyroid children and adults. Four children with a total of 6 episodes of hyperthyroidism, 8 normal children, and 8 hyperthyroid adults were hospitalized for metabolic study on the Clinical Research Unit. Measurements were made of the 24 hour urinary excretion of epinephrine, norepinephrine, vanillyl mandelic acid, tryptamine, tyramine, and histamine. The results in hyperthyroid children and adults reveal highly significant increases in the urinary excretion of tryptamine, tyramine, and histamine. I n addition, hyperthyroid children show approximately 100 per cent increase in urinary norepinephrine and epinephrine levels and a 25 per cent decrease in urinary vanillyl mandelic acid. Hyper-
Supported by Grants A-5062 and 8-MOI-FR-46 [rom the National Institutes o[ Health.
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thyroid adults do not show this. The urinary amine abnormalities are corrected as the euthyroid state is achieved. These results are compatible with the hypothesis that the hyperthyroid state interferes with the degradation of aromatic amines. DISCUSSION DR. ROBERT E. GREEN1aERa, Palo Alto, Calif. Other investigators, such as D'Iorio and LeDuc, have previously shown that thyroxin will inhibit catechol-0-methyl transferase (COMT) in vitro. If this could be extended to in vivo studies, the reduction in VMA excretion you have reported could just as easily be explained on the basis of COMT inhibition rather than monoamine oxidase (MAO) inhibition. The determination of normetanephrine would have been more helpful, since it is formed by COMT only. COMT inhibition would not explain the increased urinary excretion of the other amines you studied, which raises the intriguing problem of amine storage. The observations of Kopin and Gordon (J. Pharmacol. & Exper. Therap. 138: 351, 1962) indicate that there are two pools of norepinephrine in adrenergic fibers, one releasable by tyramine (with mainly 0-methylated metabolites) and one releasable by reserpine (with 0-methylated and deaminated metabolites). Thus, striking differences in the nature of urinary metabolites of catecholamines could theoretically result from some alteration of storage mechanisms, possibly applicable to other amines similarly stored by unknown mechanisms. Finally, with respect to the activity of COMT during development, Studnitz reported that the relative amount of VMA was, if anything, increased in the newborn period of the human. Preliminary studies in our laboratory, with rabbits, would similarly indicate no age-dependent difference in the metabolism of exogenously administered radioactive norepinephrine. DR. DONALD B. C~EEK, Baltimore, Md. I would point out that our own work on the sympathetic nervous system with respect to the nature of acrodynia or pink disease has shown that inorganic mercurials, such as calomel, will potentiate the action of epinephrine. This action was demonstrated in the rat (Arch. Dis. Childhood 34: 501, 1959; Pediatrics 23: 302, 1959). We believe that this result is mediated through methyl transferase which needs the substrate S-adenosyl methionine to inactivate epinephrine.
Volume 63 Number 4 part 2
This substrate is inhibited by mercury (Axelrod and Tomchick: J. Biol. Chem. 233: 702, 1958). Thus, in view of the fact that acrodynia occurs in infants and young children and not in adults, one might predict that the methyl transferase pathway for children is more important than the monamine oxidase system. Such a prediction is in conflict with the conclusions of the present paper. DR. W. F. WESTLIN, Summit, N. J. Since guanethidine selectively interrupts adrenergic reflexes at the neuroeffector junction and produces catechol amine depletion in some tissues, without any known effects on the central nervous system, it would seem that this drug would provide a useful pharmacologic tool with which to estimate the contribution of adrenergic reflexes to the hyperthyroid syndrome. Did you give Ismelin (guanethidine) to any of your patients? DR. LIPTON. With respect to the first comment, reference was made to a report by LeDuc and D'Iorio on the inhibition of the methyltransferase system in hyperthyroid animals. They found such inhibition in hyperthyroid rats. We have suggested that our results in children may be due to a selective diminution of M A O activity with lesser involvement of the methyltransferase system. I n considering the difference between their results and our interpretation of our results, I think it is necessary to differentiate between the human with a spontaneous clinical course of thyrotoxicosis and the induced thyrotoxicosis of rats, particularly as these workers produced the condition. They used large doses of thyroid hormone to produce hyperthyroidism and kept the animals hyperthyroid for fairly long periods of time. I have very little doubt that if this is done for a long period the methyltransferase system will also be markedly depleted. Whether or not this would actually occur in clinical thyrotoxicosis is open to question. Our data do not seem to indicate this because the metanephrine and nor-metanephrine values are not strikingly diminished and the urinary V M A is within the normal range, or only very slightly decreased. With respect to the question of the effects of thyroid hormone on catechol amine storage, we too are not satisfied, as I indicated, that inhibition of monoamine oxidase activity tells the whole story of the defect in amine metabolism. Indeed, we have some data of our own that indicate that, as hyperthyroidism is induced in
Abstracts
707
animals, the hypersensitivity to exogenous catechol amines comes about more rapidly than the diminution in monoamine oxidase activity. Likewise, as hyperthyroidism is cured, there is a loss of hypersensitivity to catechol amines more rapidly than there is a restoration of monoamine oxidase activity. There is, therfore, a time disparity here that makes us feel that monoamine oxidase inhibition is not by any means the entire explanation for the increased sensitivity to amines in hyperthyroidism. With respect to the issue of newborns I have had a private communication from Axelrod, who tells me that, in unpublished results, the catechol orthomethyltransferase system of newborn rats is one third that of adults and that it achieves adult values in several weeks. Now, our children are hardly newborn infants, and we are ourselves at a loss to explain why hyperthyroid children ranging from 8 to 15 years of age still seem to handle catechol amines differently from adults. Nonetheless, those are the conclusions which follow from the data we have obtained and presented. We did not give Ismelin (guanethidine). We did give reserpine to some of these children, particularly when it looked as if they were dangerously ill--that is, when we felt they might go into crisis. It is known that reserpine does deplete the catechol amines and, in large doses, will cause a decrease in the amount of V M A or in the amount of catechol amines which appear in the urine. We used only 0.25 mg. of reserpine daily, but despite the fact that we gave reserpine, the urinary catechol amine levels were still substantially higher than in the normal children. One might therefore extrapolate and state that if we had not used reserpine in the clinical management of some of these children, our levels would be still higher than those which we reported.
9. Thyroxine secretion rate during infancy: The effect o[ estrogen D. A. Fisher ~ and T. H. Oddie, ~ University of Arkansas School of Medicine, Little Rock, Ark.
Introduced by T. C. Panos During infancy 48 hour PB1131 values; thyroidal radioiodine release rates, and thyroxine 11~1 decay rates are increased over adult values.
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These data would seem to indicate relatively increased thyroxine secretion rates in spite of serum hormonal iodine and thyroidal radioiodine uptake rates generally similar to adult values. Thyroxine secretion rate was measured by the thyroidal 1131 blockage method in 17 premature infants 24 to 65 days of age and weighing 1,600 to 2,200 grams. Infants were given 1 mc. sodium 1131 intravenously and early thyroidal radioiodine uptake (ks) and 24 hour uptake were measured as previously described. K1 and 24 hour uptake values were normal in all infants. Thereafter measurements of daily thyroidal I TM release rate were made with and without potassium perchlorate on 10 to 15, 15 to 20, and 25 to 30 mcg. per kilogram per day intramuscular sodium 1-thyroxine. Thyroidal 1lal release was found to be proportional to the amount of thyroxine administered. Complete inhibition of thyroidal I131 release did not occur, however; a baseline secretion rate of 0.83 per cent per day was observed. Thyroxine secretion rate in 13 infants determined by calculation of the regression of thyroidal radioiodine release on thyroxine dose was 18.6 mcg. per kilogram per day. This value is 9 to 18 times greater on a microgram per kilogram per day basis and 2 to 5 times greater on a microgram per square meter per day basis than secretion rate measurements in adults. In .5 infants on 18.5 mcg. thyroxine per kilogram per day with suppression of thyroidal I TM release, daily intramuscular estradiol benzoate produced significant stimulation of radioiodine release and progressive saturation of serfim thyroxine-binding proteins indicated by increasing triiodothyronine I ~31 resin uptake during the 12 to 15 day period of estradiol benzoate therapy. This is interpreted to indicate
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direct hypothalamic stimulation of TSH release by the estradiol benzoate. DISCUSSION DR. RICtIARD L. DAY, Pittsburgh, Pa. I would like to ask what the body temperatures of these premature infants were. DR, JOHN F. CRIGLER, JR., Boston, Mass. Have you followed the regression curves of thyroidal I TM for longer intervals of time at one dose level? DR. HOSSEIN GHADIMI, Brooklyn, N. Y. The increased concentration of plasma tyrosine in newborn infants and especially in the premature has been reported d u r i n g the last year. In our laboratory we have found values as high as 19 rag. per cent on the twenty-eighth day and 30 rag. per cent on the seventh day of life have been observed. These values are about 20 to 30 times the normal values of infancy and childhood. Tyrosine is a precursor of thyroxin. I was wondering if there is any correlation between the high concentration of tyrosine and your observation of thyroid excretion. For instance, is high tyrosine the cause or effect of the increased activity of the thyroid gland? In your studies did you also determine the level of tyrosine in the plasma. DR. FISHER. The body temperature, Dr. Day, was controlled, in that all these children were in incubators. Their body temperatures were normal throughout the study period. The problem of prolonged single-dose administration has not been carried beyond about 14 days, during which time on a single dose the release rate seems to be linear on a semilog plot on three infants. We do not have the data regarding tyroslne.