- Email: [email protected]
HAZARD TO BRONCHOSCOPISTS
448
urinary tract (UTI). 2.4 In a further unreported series this finding has been confirmed, and antibody eluted from such blots cross-reacted with immunoblots of E coli, P mirabilis, and K pneumoniae. We suggest that microbial infection is a basic mechanism for the induction of autoantibodies reacting against host peptides, such as the E2 component of the pyruvate dehydrogenase complex in PBC, provided that lysis exposes the immune system to the corresponding homologous intramicrobial peptides. (The paracrystalline arrangement of the E2 core of this complex might render it especially antigenic.) Such lysis might depend on the route of infection and/or the strain of the infecting organism. This would not necessarily lead to autoimmune disease, and indeed most patients with cirrhosis have significant antibody titres to E coli,s but we think it significant that patients with PBC have an increased susceptibility to recurrent UTI compared with women with other forms of chronic liver disease.6 Academic Department of Medicine and Department of Microbiology, Royal Free Hospital and School of Medicine, London NW3 2PF; and Biochemistry Department, King’s College, London W8
A. K. BURROUGHS
P. BUTLER W. BRUMFITT H. BAUM
J, Baum H, Berg PA. Mitochondrial antibodies in primary biliary cirrhosis, species and non-species specific determinants of M2 antigen. Hepatology 1985; 5: 763-69. 2. Baum H, Palmer C. The PBC-specific antigen. Molec Aspects Med 1985; 8: 201-34. 3. Burroughs AK, Butler P, Biagini M. Flannery GR, Brumfitt W, Baum H Antimitochondrial antibodies in primary biliary cirrhosis recognise both specific peptides and shared epitopes of the M2 antigen Gut 1988; 29: A1431 (abstr). 4. Baum H. The nature of the mitochondrial antigens of PBC and their possible relation to the aetiology of disease. Sem Liv Dis (in press). 5. Simjee A, Hamilton-Miller JMT, Thomas HC, et al. Antibodies to Escherichia coli in 1. Lindenborn-Fotinos
6.
chronic liver disease. Gut 1975; 16: 871-75 Rosenstein IJ, Epstein O, et al. Bactenuna and cirrhosis. Gut 1984; 25: 133-37.
Burroughs AK,
primary biliary
HEALTH HAZARD FROM MERCURY SOAP
SIR,-Pregnant women and the developing fetus may acquire mercury’ through occupational exposure or ingestion of contaminated fish or grain by the mother, mercuric ions being readily absorbed through the gastrointestinal tract, although normally metallic mercury is not. After birth mercury vapourand to a lesser extent inhaled aerosols of mercuric salts, are readily absorbed by the lungs; in contrast, although mercury can be absorbed through the skin, this is usually too slow a process to be of much importance except in unusual circumstances. Most commercially available gammaglobulin preparations (but not the Sandoz product) contained merthiolate33 (sodium ethylmercurithiosalicylate), used as a bacteriostatic agent, at least until 1980. Since I wrote describing a case of mercury intoxication4 in a baby with eczema who was being treated with topical 1 % ammoniated mercury, a further source of topical mercury poisoning has come to light. Mercuric iodide soap, especially the Roberts brand of medicated soap, is still widely available within the European Community in cities with substantial black populations, who use it to lighten their skin, and in its main African markets such as Nigeria. Its sale was banned within the EEC in 1976. The risk of toxic effects is increased by the practice, advised in the instructions supplied with the soap, of leaving the lather on the skin, commonly all night. Paediatric Department, St Mary’s Hospital,
Newport, Isle of Wight PO30 5TG
BJ, Longo LD. Mercury toxicity in the pregnant women, fetus and newborn infant: a review. Am JObstet Gynecol 1976; 126: 390-409. Moutinho ME, Tompkins AL, Rowland TW, Banson BB, Jackson AH. Acute mercury vapor poisoning: fatality in an infant. Am J Dis Child 1981; 135: 42-44. Matheson DS, Clarkson TW, Gelfand EW Mercury toxicity (acrodynia) induced by long-term injection of gammaglobulin. J Pediatr 1980; 97: 153-55. Mucklow ES. Mercury as a health hazard. Arch Dis Child 1988; 63: 1416-17. Murdoch A. Mercury health risk in soap used to lighten skin. Independent Dec 29, 1988 5.
1. Koos
2. 3. 4 5.
E. S. MUCKLOW
HAZARD TO BRONCHOSCOPISTS
SIR,-Hazards to the patient from diagnostic fibreoptic bronchoscopy and biopsy are well described and include haemorrhage, hypoxia, and pneumothorax. We describe a case where a bronchoscopist became ill after transmission of an adenovirus during this procedure. A 23-year-old man who smoked presented after two weeks of shortness of breath with a dry, non-productive cough. He was orthopnoeic and breathless on exertion. Examination revealed inspiratory crepitations at both lung bases and X-ray showed fine reticular shadowing throughout both lungs. Forced expiratory volume in 1
s was
191and forced vital
capacity was 261(predicted
4-15,4-95, respectively). Haematological and biochemical tests were and sputum culture was negative. At fibreoptic bronchoscopy induction of anaesthesia with intravenous diazepam led to profuse coughing. The bronchial tree was inflamed but no abnormality was seen other than thick mucus throughout the airways. Transbronchial biopsy specimens showed acute suppurative inflammation of the airways and adjacent alveoli. No microorganisms were found on gram-stain and subsequent culture of the bronchial aspirates. Six days after the procedure the bronchoscopist had a severe influenza-like illness with productive cough, rigors, and shortness of breath. Adenovirus titres in the patient’s blood collected on the day after bronchoscopy were 256 (complement fixation test) and adenovirus was grown from a throat swab of the bronchoscopist during his illness. The patient improved and chest X-ray returned
normal
normal. There was a temporal relation between bronchoscopy and infection of the bronchoscopist with adenovirus. The British Thoracic Society has issued guidelines (Newsletter no 3, winter, 1988: 4) for protection of operators from the risk of transmission of infection during bronchoscopy, including the use of gown, mask, and goggles. Our case illustrates the need for such protection in all cases, even in the absence of risk factors for transmission of HIV. Transmission of viral infection can occur during bronchoscopy, which is relevant in HIV and hepatitis infection. to
I thank Dr
J. E. Stark for allowing me to report his patient.
Papworth Hospital, Papworth Everard, Cambridge CB3 8RE
A. MORICE
VARIATION IN RESTRICTION MAP OF HHV-6 GENOME
SIR,-Professor Becker and colleagues (Jan 7, p 41) report the isolation of new T-lymphotropic human herpesviruses from patients with lymphoproliferative disorders or AIDS. A cytopathic effect was observed in cultures of peripheral blood lymphocytes from these patients and in umbilical cord blood cells on co-culture. Electronmicroscopy revealed typical herpesvirus particles. The viruses produced a cytolytic infection of CD 4cells within the primary cultures and could infect a CD’‘ line in vitro. All of the above features are shared by isolates of human herpesvirus type 6 (HHV-6).’-3 DNA extracted from virions hybridised with the pZVH14 clone ofHHV-6.4 Becker et al refer to their isolates as human T-lymphotropic herpesvirus (HTLHV), not HHV-6, because the pZVH14 probe detected two DNA fragments of about 5 and 23 kb after HindIII digestion of DNA and not the more usual 9 kb fragment found in the original (prototype) isolate.’ We have detected HHV-6 DNA sequences in tissue samples from two patients with lymphoma.s In both cases the pZVH14 probe hybridised under high stringency with two DNA fragments of 7 and 23 kb after HindIII digestion. This was due to the absence of the 5’ HindIII site which defines the pZVH 14 clone and the presence of an additional HindIII site within the 5’ internal EcoRI fragment. Despite this, digestion with a variety of other restriction enzymes and hybridisation with the pZVH14 probe revealed fragments which were shared by the genomes we detected and by the 1102, A72, and prototype virus genomes. All these genomes, except for the prototype isolate which was not tested, also hybridised to the p91 clone of the 1102 isolate which
urinary tract (UTI). 2.4 In a further unreported series this finding has been confirmed, and antibody eluted from such blots cross-reacted with immunoblots of E coli, P mirabilis, and K pneumoniae. We suggest that microbial infection is a basic mechanism for the induction of autoantibodies reacting against host peptides, such as the E2 component of the pyruvate dehydrogenase complex in PBC, provided that lysis exposes the immune system to the corresponding homologous intramicrobial peptides. (The paracrystalline arrangement of the E2 core of this complex might render it especially antigenic.) Such lysis might depend on the route of infection and/or the strain of the infecting organism. This would not necessarily lead to autoimmune disease, and indeed most patients with cirrhosis have significant antibody titres to E coli,s but we think it significant that patients with PBC have an increased susceptibility to recurrent UTI compared with women with other forms of chronic liver disease.6 Academic Department of Medicine and Department of Microbiology, Royal Free Hospital and School of Medicine, London NW3 2PF; and Biochemistry Department, King’s College, London W8
A. K. BURROUGHS
P. BUTLER W. BRUMFITT H. BAUM
J, Baum H, Berg PA. Mitochondrial antibodies in primary biliary cirrhosis, species and non-species specific determinants of M2 antigen. Hepatology 1985; 5: 763-69. 2. Baum H, Palmer C. The PBC-specific antigen. Molec Aspects Med 1985; 8: 201-34. 3. Burroughs AK, Butler P, Biagini M. Flannery GR, Brumfitt W, Baum H Antimitochondrial antibodies in primary biliary cirrhosis recognise both specific peptides and shared epitopes of the M2 antigen Gut 1988; 29: A1431 (abstr). 4. Baum H. The nature of the mitochondrial antigens of PBC and their possible relation to the aetiology of disease. Sem Liv Dis (in press). 5. Simjee A, Hamilton-Miller JMT, Thomas HC, et al. Antibodies to Escherichia coli in 1. Lindenborn-Fotinos
6.
chronic liver disease. Gut 1975; 16: 871-75 Rosenstein IJ, Epstein O, et al. Bactenuna and cirrhosis. Gut 1984; 25: 133-37.
Burroughs AK,
primary biliary
HEALTH HAZARD FROM MERCURY SOAP
SIR,-Pregnant women and the developing fetus may acquire mercury’ through occupational exposure or ingestion of contaminated fish or grain by the mother, mercuric ions being readily absorbed through the gastrointestinal tract, although normally metallic mercury is not. After birth mercury vapourand to a lesser extent inhaled aerosols of mercuric salts, are readily absorbed by the lungs; in contrast, although mercury can be absorbed through the skin, this is usually too slow a process to be of much importance except in unusual circumstances. Most commercially available gammaglobulin preparations (but not the Sandoz product) contained merthiolate33 (sodium ethylmercurithiosalicylate), used as a bacteriostatic agent, at least until 1980. Since I wrote describing a case of mercury intoxication4 in a baby with eczema who was being treated with topical 1 % ammoniated mercury, a further source of topical mercury poisoning has come to light. Mercuric iodide soap, especially the Roberts brand of medicated soap, is still widely available within the European Community in cities with substantial black populations, who use it to lighten their skin, and in its main African markets such as Nigeria. Its sale was banned within the EEC in 1976. The risk of toxic effects is increased by the practice, advised in the instructions supplied with the soap, of leaving the lather on the skin, commonly all night. Paediatric Department, St Mary’s Hospital,
Newport, Isle of Wight PO30 5TG
BJ, Longo LD. Mercury toxicity in the pregnant women, fetus and newborn infant: a review. Am JObstet Gynecol 1976; 126: 390-409. Moutinho ME, Tompkins AL, Rowland TW, Banson BB, Jackson AH. Acute mercury vapor poisoning: fatality in an infant. Am J Dis Child 1981; 135: 42-44. Matheson DS, Clarkson TW, Gelfand EW Mercury toxicity (acrodynia) induced by long-term injection of gammaglobulin. J Pediatr 1980; 97: 153-55. Mucklow ES. Mercury as a health hazard. Arch Dis Child 1988; 63: 1416-17. Murdoch A. Mercury health risk in soap used to lighten skin. Independent Dec 29, 1988 5.
1. Koos
2. 3. 4 5.
E. S. MUCKLOW
HAZARD TO BRONCHOSCOPISTS
SIR,-Hazards to the patient from diagnostic fibreoptic bronchoscopy and biopsy are well described and include haemorrhage, hypoxia, and pneumothorax. We describe a case where a bronchoscopist became ill after transmission of an adenovirus during this procedure. A 23-year-old man who smoked presented after two weeks of shortness of breath with a dry, non-productive cough. He was orthopnoeic and breathless on exertion. Examination revealed inspiratory crepitations at both lung bases and X-ray showed fine reticular shadowing throughout both lungs. Forced expiratory volume in 1
s was
191and forced vital
capacity was 261(predicted
4-15,4-95, respectively). Haematological and biochemical tests were and sputum culture was negative. At fibreoptic bronchoscopy induction of anaesthesia with intravenous diazepam led to profuse coughing. The bronchial tree was inflamed but no abnormality was seen other than thick mucus throughout the airways. Transbronchial biopsy specimens showed acute suppurative inflammation of the airways and adjacent alveoli. No microorganisms were found on gram-stain and subsequent culture of the bronchial aspirates. Six days after the procedure the bronchoscopist had a severe influenza-like illness with productive cough, rigors, and shortness of breath. Adenovirus titres in the patient’s blood collected on the day after bronchoscopy were 256 (complement fixation test) and adenovirus was grown from a throat swab of the bronchoscopist during his illness. The patient improved and chest X-ray returned
normal
normal. There was a temporal relation between bronchoscopy and infection of the bronchoscopist with adenovirus. The British Thoracic Society has issued guidelines (Newsletter no 3, winter, 1988: 4) for protection of operators from the risk of transmission of infection during bronchoscopy, including the use of gown, mask, and goggles. Our case illustrates the need for such protection in all cases, even in the absence of risk factors for transmission of HIV. Transmission of viral infection can occur during bronchoscopy, which is relevant in HIV and hepatitis infection. to
I thank Dr
J. E. Stark for allowing me to report his patient.
Papworth Hospital, Papworth Everard, Cambridge CB3 8RE
A. MORICE
VARIATION IN RESTRICTION MAP OF HHV-6 GENOME
SIR,-Professor Becker and colleagues (Jan 7, p 41) report the isolation of new T-lymphotropic human herpesviruses from patients with lymphoproliferative disorders or AIDS. A cytopathic effect was observed in cultures of peripheral blood lymphocytes from these patients and in umbilical cord blood cells on co-culture. Electronmicroscopy revealed typical herpesvirus particles. The viruses produced a cytolytic infection of CD 4cells within the primary cultures and could infect a CD’‘ line in vitro. All of the above features are shared by isolates of human herpesvirus type 6 (HHV-6).’-3 DNA extracted from virions hybridised with the pZVH14 clone ofHHV-6.4 Becker et al refer to their isolates as human T-lymphotropic herpesvirus (HTLHV), not HHV-6, because the pZVH14 probe detected two DNA fragments of about 5 and 23 kb after HindIII digestion of DNA and not the more usual 9 kb fragment found in the original (prototype) isolate.’ We have detected HHV-6 DNA sequences in tissue samples from two patients with lymphoma.s In both cases the pZVH14 probe hybridised under high stringency with two DNA fragments of 7 and 23 kb after HindIII digestion. This was due to the absence of the 5’ HindIII site which defines the pZVH 14 clone and the presence of an additional HindIII site within the 5’ internal EcoRI fragment. Despite this, digestion with a variety of other restriction enzymes and hybridisation with the pZVH14 probe revealed fragments which were shared by the genomes we detected and by the 1102, A72, and prototype virus genomes. All these genomes, except for the prototype isolate which was not tested, also hybridised to the p91 clone of the 1102 isolate which