HAPTENISATION OF SERUM PROTEINS BY ACETALDEHYDE

1340 2.

Jilg W, Schmidt M, Zachoval R,

Deinhardt F. Persistenz von Antikorpern gegen nach Impfung gegen Hepatitis-B. Dt Med

Hepatitis-B-Oberflachen-antigen 3

Wschr 1985, 110: 205-09. Jilg W, Schmidt M, Demhardt F, Zachoval R. Hepatitis B vaccination: How long does protection last? Lancet 1984; ii: 458.

Dienstag JL. Low-dose intradermal hepatitis B vaccine. JAMA 1986, 256: 351. Jilg W, Schmidt M, Deinhardt F, Zachoval R. Hepatitis B vaccination. How long does protection last? Lancet 1984; ii: 458. 7. Laplanche A, Courouce A-M, Jungers P, Benhamou E, Crosnier J Hepatitis B vaccination: how long does protection last? Lancet 1984; ii: 866.

5. 6.

INTRADERMAL VACCINATION AGAINST HEPATITIS B care personnel who have frequent contact with needles should be vaccinated against hepatitis B virus (HBV).1 The cost of the recommended course of three 20 J.1g intramuscular (im) doses of vaccine (Merck, Sharp, and Dohme, over 60) may, however, prohibit the widespread use of the vaccine. The immunogenicity of low-dose (2 J.1g) HBV vaccine administered by the intradermal (id) route has been demonstrated in 3 small trials.2-4 In view of the 10-fold reduction in cost with the id route, successive annual intakes of students at Oxford University Medical School have been offered id vaccination on entry to their clinical studies. We report here preliminary results. All students were tested for anti-HBs before vaccination. Seronegative individuals were vaccinated in the university medical toffice by nursing sisters experienced in id administration. Doses (2 ug in 0’ 1 ml) were given at 0,1, and 6 months. Six to ten weeks after the final dose, serum was collected for anti-HBs assay with a passive haemagglutination test (Serodia) against a known standard serum.

SIR,-Health

blood

or

HEPATITIS B ANTIBODY RESPONSES

SALIVARY DRUG MEASUREMENT: A CAUTIONARY TALE

SIR,-When collecting saliva for the monitoring of antiepileptic drug concentrations our hospital staff use a small amount of citric acid deposited on the tongue as a sialogogue. This practice interferes with the ’EMIT QST’ assay (Syva) of drug concentrations. Plasma from a patient on ethosuximide was found to have a drug concentration of about 1000 Ilffiol/l whereas two saliva specimens had ethosuximide concentrations of zero. The saliva was very acid (pH 1-7) and this was at first ascribed to gastric reflux. However, when a drug standard diluted in buffers of pH 20, 3,0, 4,0, 5,0, 6-0, and 7-0 was assayed it was found that the pH of the sample had no effect on the EMIT assay. Saliva that gave zero readings for ethosuximide was diluted with distilled water and, after correction for the dilution, a 1-in-4 dilution yielded a drug concentration close to 1000 Nxnol/1 whereas a 1-in-2 dilution yielded a result considerably less than 1000 Ilffiol/I. This suggested an inhibitor. Since citric acid had been used as a sialogogue and could have accounted for the low pH, we investigated possible interference by citric acid in the EMIT QST assay. Citric acid concentrations above 0.25 mol/1 inhibited the assay for ethosuximide and for

phenytoin: Drug Ethosuximide

Phenytoin The seroconversion rate to an antibody level > 10 mIU/ml was 89% (see table). 10 mIU/ml is regarded as the minimum protective level1 and our seroconversion rate was similar to that of other studies of id or im vaccination z Our results are also similar to those of a larger study of the vaccination of hospital personnel in a mental hospital where the standard im regimen was used (Dr E. A. C. Follett, personal communication). In that study, 4% of 493 individuals acquired < 10,9% > 10 < 100,28% > 100 < 1000, and 59% > 1000 mIU/ml of anti-HBs. Vaccination against HBV via the id route has been questioned.S Firstly, local injection-site reactions may occur-we found that none of our vaccinees were unwilling to complete their course becasue of local reactions and none reported any long-term adverse reactions. Secondly, the duration of protective antibody levels after id vaccination may be shorter than that after im vaccination.6,7 Persistence of anti-HBs after vaccination has been convincingly shown to depend on the magnitude of the initial antibody response irrespective of route of administration or dose of vaccine. More than 90 % of individuals whose initial post-vacination titre is > 1000 mIU/ml will still have > 10 mIU/ml 5 years later. 6-7 Half our sample had this high initial titre. Had we opted for the recommended im regimen, we could have vaccinated only 17 students for the same cost of vaccine. We conclude that id vaccination against HBV is a practical and cheap method of protection. Department of Virology, Public Health Laboratory, John Radcliffe Hospital, Oxford OX3 9DU

Oxford University Medical Officer

W. L. IRVING M. ALDER J. B. KURTZ

JAMA 1985, 254: 3203-06

0

21

81

100

Saliva of initial pH 6 59 had a pH of 1 -92 in the presence of citric acid 0-5 mol/1 and of 1-66 with 1 -0 mol/1. Thus a salivary pH of 1 -7 suggests that citric acid was present at about 1-0 mol/1, which would have resulted in 100% inhibition of the EMIT assay for ethosuximide (and for phenytoin). The enzyme used in EMIT QST is glucose-6-phosphate dehydrogenase (G6PD) from Leuconostoc mesenteroides. The effect of citric acid on this enzyme is unknown. Using the assay described by Beutlerl we demonstrated that human erythrocyte G6PD is 38 % inhibited by citric acid at 8 mmol/1 (the final concentration in the EMIT assay when a sample containing 1-0 mol/1 citric acid is assayed) and 100% inhibited at 15 mmol/l. To complete the study we compared samples of saliva taken from treated epileptic patients with and without the use of citric acid but the amount of citric acid given never again resulted in a salivary pH as low as 1 -7. In one case, the pH was 2-01, corresponding to a citric acid concentration of about 0-4 mol/l, which should have resulted in an inhibition of about 40% in the ethosuximide assay. 26% inhibition was found. In another the salivary pH was 3.02 and the drug concentration approximated, as expected, to that present in

plasma. Citric acid has a dose-related interfering effect on the EMIT assay for ethosuximide and phenytoin. Since only 25 )1 of saliva is needed citric acid should not be used as a sialogogue.

QST

Department of Biochemistry, Royal Hospital for Sick Children, Glasgow G3 8SJ

ROBERT D. PATON ROBERT W. LOGAN

1. Beutler E. Red cell metabolism. a manual of biochemical methods, 2nd ed. New York: Grune and Stratton, 1975: 66-69.

B. JUEL-JENSEN

1. Deinhardt F, Zuckerman AJ. Immunisation against hepatitis B: Report on a WHO meeting on viral hepatitis in Europe. J Med Virol 1985; 17: 209-17. 2. Miller KD, Gibbs RD, Mulligan MM, Nutman TB, Francis DP. Intradermal hepatitis B virus vaccine Immunogenicity and side effects m adults Lancet 1983; ii: 1454-56. 3 Zoulek G, Lorbeer B, Jilg W, Deinhardt F. Antibody responses and skin reactivity after intradermal hepatitis B virus vaccine. Lancet 1984; i 568. 4. Redfield RR, Innis BL, Scott RM, Cannon HG, Bancroft WH Clinical evaluation of low-dose intradermally administered hepatitis B virus vaccine. A cost reduction strategy.

% znhibition of assay with citric acid concentrations (mol/I) of: 0.125 0.25 05 1.0 0 0 50 100

HAPTENISATION OF SERUM PROTEINS BY ACETALDEHYDE

SIR,-Dr Williams and Dr Barry (Nov 1, p 1033) draw attention the modification of serum albumin and membrane proteins by acetaldehyde. Covalent binding of acetaldehyde may occur to most if not all serum proteins because of acetaldehyde’s reactivity with lysine, tyrosine, and valine residues in proteins.’ Acetaldehydehaptenated proteins can induce antibody formation at the to

1341 concentrations of acetaldehyde found in the plasma of alcoholics. The specificity of these antibodies seems to be independent of the nature of the carrier protein and is directed towards the acetaldehyde moiety. The potential conversion of all serum proteins into neoantigens could therefore lead to widespread manifestations of autoimmune disease and may explain the variability in the incidence of cirrhosis, diabetes, and other complications of chronic excessive alcohol consumption. Acetaldehyde haptenisation could allow the application of a simple assay for antibody levels and thus provide a true history of recent alcohol intake. In cases of chronic alcohol consumption, although acetaldehyde adducts would be cleared from the plasma with time, immunological memory in the form of B-cell clones might be retained. The resulting high antibody levels might be associated with complications should alcohol consumption be resumed.

pathophysiological

St John’s College, Cambridge CB2 1TP

A.

WHYTE

1. Stevens VJ, Fantl WJ, Newman CB, Cecami A, Peterson CM. Acetaldehydè adducts with hemoglobin. J Clin Invest 1981; 67: 361-69. 2. Israel Y, Hurwitz E, Niemela O, Arnon R. Monoclonal and polyclonal antibodies

against acetaldehyde-containing epitopes Natl Acad Sci USA 1986; 83: 7923-27.

in

acetaldehyde-protein

adducts. Proc

RENAL SCARRING AND NON-ATTACHING ESCHERICHIA COLI

SiR,—The virulence of uropathogenic Escherichia coli has been defined by the severity of acute urinary tract infection (UTI) produced by the bacteria rather than by the ability to cause renal scarring.E coli causing first-time acute pyelonephritis often belong to a limited number of O:K:H serotypes with the ability to resist the bactericidal effect of serum, produce haemolysin, and attach to uroepithelial cells. Indeed, adhesive capacity seems to be the marker most frequently associated with the pyelonephritogenic phenotype.2 Most attaching strains specifically bind to the Galoti-4Galp moiety of the globo-series glycolipid receptors. Since renal scarring is one severe end-point of UTI, it has been assumed that such damage results from infection with the most virulent bacteria. We have evaluated the frequency of attaching bacteria in patients with recurrent acute pyelonephritis in relation to the development of renal scarring. 77 girls were selected for study because of recurrent episodes of acute pyelonephritis, diagnosed by bacteriuria, fever, loin pain, and two of three laboratory criteria (raised C-reactive protein, increased sedimentation rate, or reduced renal concentrating capacity’). Renal scarring was defmed at urography as calyceal deformity combined with parenchymal reductionand vesicoureteral reflux was diagnosed by voiding cystourethrography.6 35 patients had renal scarring and 42 did not, and the average follow-up was 10 and 7 years, respectively. The ages at the first detected episodes of acute pyelonephritis were similar in the groups. Those with reflux were younger (median 2-2, range 0-3-6-5) than those without reflux (median 5-5, range 0-5-12) at the first pyelonephritic episodes. The median number of urographies was four (range two to nine) in the scarred and three (range two to five) in the non-scarred group. 142 isolates were available from the episodes of acute pyelonephritis. The analysis of bacterial determinants of scarring is complicated by the time lapse between the infection and radiological detection of the scar. During this time additional UTI episodes may occur. We included only the 58 isolates from infections before the detection of scarring. 60% of the scarred patients had had negative urography before the detection of scarring. The patients with renal scarring had a significantly higher frequency of non-E coli. The E coli strains were analysed for adhesive capacity, by haemagglutination and specific binding to latex beads coated with globotetraosylceramide .7 The frequency of positive reactions is shown in the table. The patients with scarring had a significantly lower frequency of E coli with adhesins specific for globo-series of glycolipid receptors than those without scarring. These results demonstrate significant differences between bacteria causing recurrent pyelonephritis in patients with and

FREQUENCY OF ATTACHING ESCHERICHIA COLI

IN PATIENTS WITH

AND WITHOUT RENAL SCARRING

*Measured

as specific bindmg to the globo-senes of glycolipids, for E coli strains. tFor frequency in non-scarred versus frequency in scarred group.

without renal scarring. The scarred patients were usually infected with poorly attaching bacteria. In the others scarring did not develop despite recurrent infections with attaching E coli. The strains causing renal scarring may have special virulence determinants (eg, mannose-specific adhesins8) but we favour the conclusion that development of renal scarring is associated with increased host susceptibility and that repeated infections with attaching bacteria may be insufficient to induce renal scarring in the resistant host. Department of Clinical Immunology, University of Goteborg, S-413 46 Goteborg, Sweden; and Departments of Paediatric Radiology and Division of Nephrology, Department of Paediatrics, East Hospital, Goteborg 1.

Svanborg-Edén C, Hagberg L, Adhesion of Escherichia coli

Hanson m

HELENA LOMBERG MIKAEL HELLSTRÖM

ULF JODAL CATHARINA SVANBORG EDÉN

LÅ,

urinary

T, Leffler H, Olling S. infection. In: Adhesion and 80) London Pitmans Medical,

Korhonen tract

microorganism pathogenicity (Ciba Found Symp 1980: 161-87.

2. Vaisanen-Rhen V, Elo J, Vaisanen E, et al P-fimbnated clones among uropathogenic Escherichia coli strains. Infect Immun 1984; 43: 149-55. 3. Leffler H, Svanborg-Edén C. Chemical identification of a glycosphingolipid receptor for Escherichia coli attaching to human urinary epithelial cells and agglutinating human erythrocytes FEMS Microbiol Lett 1980; 8: 127-34. 4. Jodal U, Lmdberg U, Lincoln K. Level diagnosis of symptomatic urinary tract infections in childhood Acta Paediatr Scand 1975, 64: 201-08. 5. Hodson C, Wilson S. Natural history of chronic pyelonephritic scarring. Br Med J 1965; ii: 191-94. 6 International reflux study report. Medical versus surgical treatment of primary vesicoureteral reflux: a prospective international reflux study in children. J Urol

1981, 125: 277-83. 7.

8

Lomberg H, Cedergren B, Leffler H, Nilsson B, Carlstrom A-S, Svanborg-Edén C. Influence of blood group on the availability of receptors for attachment of uropathogenic Escherichia coli. Infect Immun 1986; 51: 919-26 Harber MJ, Topley N, Jenner DE, et al. Virulence factors of urinary pathogens in relation to kidney scarring. In: Asscher AW, Brumfitt W, eds. Microbial diseases in nephrology. Chichester: John Wiley & Sons, 1986: 69-82

HALOPERIDOL-INDUCED DYSTONIA IN COCAINE ADDICTS

SIR,-Dystonic reactions are among the most severe adverse of neuroleptic drugs.1 3-10 % of patients have at least one dystonic reaction during the first few weeks of treatment,l,2 although for higher potency neuroleptic rates above 30 % have been reported.3,4 In one study 12 healthy volunteers were given a single 0 125 mg/kg intravenous dose of haloperidol and 4 experienced a dystonic reaction.4 As part of our studies on dopaminergic mechanisms of cocaine action we gave 7 male research volunteers aged 21-38 8 mg intramuscular doses of haloperidol on two consecutive days. Written consent, the volunteers being told about the possibility of dystonic reactions, was obtained. All were heavy cocaine users on a closed research ward; they had been free of drugs other than cocaine for at least 10 days. All patients had received intravenous cocaine within 72 h of the administration of haloperidol, both drugs were given under research conditions. None of the patients had any major psychiatric disorder, and only 1 reported any prior neuroleptic use. Of the 7 participating patients, 6 experienced acute dystonic reactions. In 4 the onset of dystonia was about 22 h after the first dose; in 2 patients the reaction was within 3 h of the second dose. In 4 patients the dystonia was characterised by torticollis; in 1 case this was accompanied by an oculogyric crisis, in 2 cases by buccolingual reactions

symptoms, and in 1 case by truncal musculature involvement. In both remaining cases of dystonia the dominant features were buccolingual, accompanied by mild oculogyric symptoms in 1. Extrapyramidal symptoms other than dystonia were much less