IMMUNOGLOBULIN LEVELS IN ETHIOPIAN PRESCHOOL CHILDREN WITH SPECIAL REFERENCE TO HIGH CONCENTRATIONS OF IMMUNOGLOBULIN E (IgND)

1118 means fixing the allergen to the red-cell surface no damage is done to the red-cell membrane which may allow non-specific absorption of y-globulin. Thus any uptake of immunoglobulin on to the antigen-linked redcells as detected by an antiglobulin reaction becomes meaningful. The full potential of the method has only become realised with the development of antiglobulin reagents specific for the different immunoglobulin classes and now the development and characterisation of specific anti-IgE (Bennich and Johannson 1967) is of the greatest significance. The correlation of IgE antibody titres to castor allergen in the patients studied, with their clinical status, with the passive cutaneous anaphylaxis reactivity in baboon skin and the heat-lability of the reacting antibody strongly support the reaginic nature of the measured antibody.

this

A. H.

was

supported by

a

Medical Research Council grant. REFERENCES

Bennich, H., Johansson, S. G. O. (1967) Nobel Symp. III, p. 199. Coombs, R. R. A., Fiset, M. L. (1954) Br. J. exp. Path. 35, 472. Howard, A. N., Mynors, L. S. (1953) ibid. 34, 525. Jonas, W. E., Lachmann, P. J., Feinstein, A. (1965) Int. Archs Allergy, 27, 321. Friedmann, P. S., Hunter, A., Coombs, R. R. A. (1968) Unpublished. Ishizaka, D., Ishizaka, T. (1967) J. Immun. 99, 1187. Ishizaka, K., Ishizaka, T., Hornbrook, M. M. (1966) ibid. 97, 840. Menzel, A. E. O. (1967) ibid. 99, 610. Johansson, S. G. O. (1968) Acta Univ. upsaliensis (in the press). Bennich, H. (1967) Immunology, 13, 381. Wide, L. (1968) ibid. 14, 265. Layton, J. L., Yamanaka, E., Greene, F. C., Perlman, F. (1963) Int. Archs Allergy, 23, 87. Stanworth, D. R., Humphrey, J. H., Bennich, H., Johansson, S. G. O. (1967) Lancet, ii, 330. Steele, A. S. V., Coombs, R. R. A. (1964) Int. Archs Allergy, 25, 11. Wide, L., Bennich, H., Johansson, S. G. O. (1967) Lancet, ii, 1105. World Health Organisation (1968) Bull. Wld Hlth Org. (in the press). —

—

—

belonging

to

the

Childrens

—

—

—

I-Field centres and stations Nutrition Unit.

Fig.

—

IMMUNOGLOBULIN LEVELS IN ETHIOPIAN PRESCHOOL CHILDREN WITH SPECIAL REFERENCE TO HIGH CONCENTRATIONS OF IMMUNOGLOBULIN E (IgND) TORE MELLBIN S. G. O. JOHANSSON M.D. Uppsala M.B. Uppsala BO VAHLQUIST M.D. Uppsala

of Pœdiatrics and the Blood Centre, University Hospital, Uppsala, Sweden, and the Children’s Nutrition Unit, Addis Ababa, Ethiopia

From the Department

The

D determined in three series of Ethiopian preschool children. The levels of IgG and IgD were significantly higher than those found in a group of Swedish children of the same age; the mean levels of IgD being five to six times higher than in the Swedish series. The concentrations of the new immunoglobulin class, IgE, were also studied. The levels of IgE were between sixteen and twenty times higher than in Swedish children, and in a group with verified infection with Ascaris lumbricoides the level was twenty-eight times higher. These findings favour the hypothesis that parasitic infestations are important factors in stimulating IgE

Summary

immunoglobulins G, A, M, and

were

production. Introduction

THE frequent reports of high incidences of raised serumimmunoglobulin levels in Africans compared with Europeans have been reviewed by Turner and Voller (1966) and Rowe et al. (1968). It is usually suggested that the

due to an intense challenge with bacterial, viral, protozoal, and helminthic infections and only to a minor extent, if at all, to racial differences. Very few studies using immunological techniques have been carried out on children (Rowe et al. 1968). Since conditions may vary from one African region to another, a further comparative study, of the levels of IgG, IgA, IgM, and IgD in Ethiopian and Swedish children, seemed warranted. Strikingly high levels of a new immunoglobulin, IgE* (Johansson, Bennich, and Wide 1968) which seems to be of importance in atopic allergy (Johansson 1967, Stanworth, Humphrey, Bennich, and Johansson 1967, Wide, Bennich, and Johansson 1967) have been found in cases of asthma and hay fever (Johansson 1967, Johansson and Bennich 1967), while bacterial and viral infections do not seem to influence the levels (Johansson and Bennich 1968). It seemed of especial interest to analyse the situation in African children with respect to this new

raised levels

are

immunoglobulin fraction. The serum samples were collected

as part of the activities at the Children’s Nutrition Unit (C.N.U.) in Addis Ababa. This unit, which represents a technical assistance programme between Sweden and Ethiopia, came into operation in 1962 (Agren et al. 1966) and has carried out investigations directed especially towards the incidence and type of undernutrition in children from birth up to and including the age of ten years. The investigations have also included an analysis of the general state of health of the children.

Material The C.N.U. has started field activities in various parts of Ethiopia, representing different cultures and living conditions (fig. 1). For this investigation, series of serum samples were chosen from Ijaji a typical medium-sized market village in the central Ethiopian highlands, and from Sidamo village, a more isolated rural community in the southern part of the country. Except for the age selection (table i) and the time period (autumn, 1964) the specimens from Ijaji and Sidamo were At

a nomenclature meeting at the World Health Organisation immunoglobulin reference centre at Lausanne in February, 1968, the designations yE-globulin and IgND were replaced with the designation IgE (yE) (World Health Organisation 1968).

1119 TABLE I-DISTRIBUTION OF THE CHILDREN ACCORDING TO SEX AND AGE

random from a very large number of sera. Serum also collected from a children’s home in Addis Ababa attached to the C.N.U. project. In this series sera from two different time periods were used, one collection of samples representing the situation in the latter part of 1964, shortly after C.N.U. had taken over the home (children’s home A), and October, 1966, when the incidence of parasites and other infections had been notably reduced and the nutritional status of the children had improved (children’s home B). In the determinations of immunoglobulins G, A, M, and D, the " children’s home A series was used with the addition of 11 sera from " children’s home B ". In the determinations of IgE, the material was enlarged by 14 more sera from children in Ijaji of the same age-group and with parasite eggs, mainly Ascaris lumbricoides, demonstrated in stool samples. The number of children in the main series, and their age and sex distribution are shown in table i. Detailed results of clinical, biochemical, and serological investigations and the incidence of parasitic and various other infections in the children’s home and the different areas of the C.N.U. project will be published elsewhere. Samples of capillary blood were collected, after a finger prick, into small plastic tubes. These were allowed to stand for about four hours to coagulate, after which the tubes were centrifuged. The serum was pipetted off and frozen imme-

sampled samples

at

diately. The samples were kept frozen during transport by car to the base laboratory in Addis Ababa, and subsequently by air to Sweden. They were stored at -20°C until analysis. The immunoglobulins G, A, M, and D were determined quantitatively by single radial immunodiffusion in agar gel using a modification (Johansson, Hogman, and Killander 1968) of the method of Mancini et al. (1965). IgE was determined by a radioimmunosorbent test (Wide and Porath 1966) as described by Johansson, Bennich and Wide (1968). Results

were

differences were noted in the different investigations, and so the results are presented without sex classification. The levels of immunoglobulins G, A, M, and D in sera from the Ethiopian children compared with Swedish children of the same age (Johansson and Berg 1967) are shown in fig. 2. No

IgG

IgG levels of the Ethiopian series were about twice high as those in healthy Swedish children. The

The

"

Fig. 2-Distributions of immunoglobulins G, A, M, and D in the Ethopian series compared with Swedish children (Johansson and Berg 1967).

sex

as

mean

levels

were

between 1422 and 1684 mg. per 100 ml.

compared with 778 mg. per 100 ml. in the Swedish series. This difference is highly significant (p < 0-001). IgA In the Ethiopian series the mean levels were slightly, but not significantly, increased-70-6-87-3 mg. per 100 ml. compared with a mean of 51-9 mg. per 100 ml. for the Swedish series. The Ethiopian values, however, form a peak between 44-8 and 89-6 mg. per 100 ml. with

Fig. 3-IgE in the Ethiopian series compared with Swedish children (Johansson 1968a

1120 TABLE

TABLE

II-IgE

IN

III-IgE

IN TWO GROUPS OF ETHIOPIAN CHILDREN COMPARED

THE ETHIOPIAN SERIES COMPARED CHILDREN (JOHANSSON 1968)

TO SWEDISH

of intestinal parasitic infestation on the IgE concentration, we divided the Ethiopian children into two groups (fig. 4, table ill). The lowest IgE levels, mean 860 ng. per ml., were found among the children with negative stool samples from the children’s home B (group i). The samples from children (group 11) with proven ascariasis, the most common parasitic infestation, showed the highest mean IgE level, 4400 ng. per ml. This concentration is twenty-eight times higher than that in Swedish children of the same age. The difference between groups i and II is highly significant (p < 0-001).

WITH SWEDISH CHILDREN

Discussion

range, while the percentage distribution of the values of the Swedish children gives a flatter profile, with only 35% in the same range.

60-81% in that IgM

The three Ethiopian series had slightly higher mean values (74-5-86-0 compared with 61-8 mg. per 100 ml. for the Swedish children) but the difference in the means was not significant. The distributions in these series were similar.

IgD The mean values in the Ethiopian series were five to six times higher than in healthy Swedish children. This difference is highly significant (p < 0-001). The percentage distribution of the values was very different. 44-63% of the Ethiopian children had levels of , 8 mg. per 100 ml., compared with only 2% in the Swedish series. The incidence of values < 1 mg. per 100 ml. was 57% in Swedish children, and 11%, 15%, and 11% in the three Ethiopian series.

IgE Remarkably high levels of IgE were found in all the four Ethiopian series studied (fig. 3, table 11) compared with the values in healthy, non-allergic, Swedish children (Johansson 1968). This was especially true for the samples from Ijaji, Sidamo, and children’s home A, where the IgE mean levels were 3150, 2480, and 2680 ng. per ml., respectively. These values are sixteen to twenty times higher than the mean value of 160 ng. per ml. for the Swedish series. The IgE mean level in the series children’s home B, representing the most healthy children, was

Fig. 4-IgE in two groups of Ethiopian children. Group i comprises children with negative stool samples, and group 11 children with demonstrated infestation with A. lumbricaides.

only

780 ng. per

ml.,

which corresponds to five times the mean level in the Swedish group. In both cases the difference from the level in Swedish children is highly

significant (p < 0’001). To investigate the influence

Raised levels of the immunoglobulins G, A, M, and D in Africans have been reported by several workers (Michaux 1966, Turner and Voller 1966, Rowe et al. 1968). In sera from adults in Gambia, Rowe et al. (1968) found mean levels of the immunoglobulins G, A, and M which were two to three times higher than those in European control groups. The same magnitude of difference was found in our series of Ethiopian and Swedish children of the same age. This is also true for IgD, which seems to be relatively more increased in African sera than the other three immunoglobulins. Rowe et al. (1968) detected IgD (i.e., a concentration higher than 1 mg. per 100 ml.) in all Gambian children aged between four and forty months. We found IgD in 88% of the Ethiopian children, which is significantly higher than the 43 % found in Swedish children in the same age-group. The difference in immunoglobulin pattern between African and European series is contributed to by a higher incidence, earlier exposure, and greater severity of various infections, and, especially with regard to IgD, the nutritional state may be of importance (Rowe et al.

1968). However, we found no significant differences between the immunoglobulin levels in the series from the children’s home, where the children were comparatively well nourished, and the series from Ijaji and Sidamo. Racial differences are considered to be of minor importance. A new immunoglobulin class, IgE, has been discovered (Johansson, Bennich, and Wide 1968) which Inseems to be of great importance in atopic allergy. creased levels of IgE have been found in sera from patients with asthma, hayfever, and atopic eczema. Common bacterial and viral infections do not seem to influence the IgE concentration. Extremely high levels of IgE were found in the Ethiopian samples studied. A mean level as much as twenty times higher than in the Swedish control group was found in one of the unselected series. Clinical investigation has not revealed a high incidence of atopic allergy among these Ethiopians, and has not been reported by other workers. There is a tendency to increasing IgE levels with increasing age for children between ten and twenty-four months. In healthy Swedish children (Johansson 1968) the increase in IgE level in this age-group was found to be rather low, from 31% to 39 % of the adult mean level. Thus, the influence of age on the IgE concentrations should be of minor importance in comparison to the influence of other factors involved. The most likely explanation for the raised IgE levels is the high incidence of parasitic infestation, especially ascariasis which is known to cause allergic symptoms. Preliminary results from the clinical studies show, in series larger than those reported here, an ascariasis

1121

frequency of 38% in Ijaji and 69% in Sidamo. These figures are based on a single stool sample from each child, which means that the true frequency will be A selected group of children with A. lumbricoides demonstrated in stool samples had a mean IgE level eggs of 4400 ng. per ml., compared with 860 ng. per ml. in a group of children with negative stools. In the different series the mean percentage of eosinophils was 10-0% in Ijaji, 15-3% in Sidamo, 7-6% in children’s home A, and 1-5% in children’s home B. The corresponding mean levels of IgE were 3150, 2480, 2680, and 780 ng. per ml. These findings favour the hypothesis that parasitic infestations, and especially ascariasis, may be important factors in stimulating the IgE production. Very little is known about how long after an allergic disease has subsided it is possible to find increased levels of IgE. We observed " healthy " Ethiopian children for only a short time, and previous parasitic infestations may explain the higher IgE level in this series compared with Swedish children. Several other factors may also be involved. Further studies are in progress using a radioallergosorbent test (Wide, Bennich, Johansson 1967) in an attempt to detect in the Ethiopian sera antibodies of the IgE class directed towards antigenic structures from various

ENCEPHALITIS A

J. D. MILLER

higher.

parasites. We thank Dr. H. Bennich, Institute of Biochemistry, Uppsala, for supply of IgE preparations, Dr. L. Wide, Department of Clinical Chemistry, University Hospital, Uppsala, for labelling and coupling of proteins, and Mrs. Stina Soderlund, Miss Birgitta Larsson, and Miss Britt Ytterberg for skilful technical assistance, and all the members, Ethiopian and Swedish, of the C.N.U. field staff for their cooperation under sometimes difficult conditions. This investigation was supported in part by the Swedish Medical Research Council (grant no. B68-16X-105-04). This is C.N.U. report No. 10. Requests for reprints should be addressed to S. G. 0. J., Blood Centre, University Hospital, Uppsala, Sweden. REFERENCES

Ågren, G., Almgård, G., Mellander, O., Vahlquist, B., Björnesjö,

K. B., Hofvander, Y., Jacobsson, K., Knutsson, K. E., Mellbin, T., Selinus, R. (1966) Ethiopian med. J. 5, 5. Johansson, S. G. O. (1967) Lancet, ii, 951. (1968) Int. Archs Allergy, 34, 1. Berg, T. (1967). Acta pœdiat. scand. 56, 572. — Bennich, H. (1967) Nobel Symp. III, p. 193. — — (1968) Unpublished. Wide, L. (1968) Immunology, 14, 265. Hogman, C. F., Killander, J. (1968) Acta path. microbiol. scand. (in the press). Mancini, G., Carbonara, A. O., Heremans, J. F. (1965) Immunochemistry, 2, 235. Michaux, J. L. (1966) Ann. Soc. belge Méd. trop. 46, 5. Rowe, D. S., McGregor, I. A., Smith, S. J., Hall, P., Williams, K.(1968) Clin. exp. Immunol. 3, 63. Stanworth, D. R., Humphrey, J. H., Bennich, H., Johansson, S. G. O. (1967) Lancet, ii, 330. Turner, M. W., Voller, A. (1966) J. trop. Med. Hyg. 69, 99. Wide, L., Bennich, H., Johansson, S. G. O. (1967) Lancet, ii, 1105. Porath, J. (1966) Biochim. biophys. Acta, 130, 257. World Health Organisation (1968) Bull. Wld Hlth Org. (in the press). —

—

—

—

—

—

" Thus, whatever course we take, we arrive at the same conclusion; viz., that there is no natural distinction between physic and surgery; that they are merely parts of one science and art; that the scientific principles are the same, and the same means must be used both by the physician and surgeon, because have the same ends to accomplish.... they " A French minister seems to have judged pretty correctly of the matter. The propriety of separating physic and surgery was strongly represented to him: ’I would elevate’, said the advocate of the measure, ’awall of brass between them.’ ‘ Pray, sir,’ rejoined the minister,on which side of the wall do you propose to place the patients.’ " Mr. LAWRENCE’S introductory lecture to the Spring Course of Surgery, at the New Theatre, Aldersgate Street.-Lancet, 1827, i, 629.

Four-year Survey *

M.B. Glasg., F.R.C.S.E., F.R.C.S.G. REGISTRAR, DIVISION OF NEUROSURGERY, INSTITUTE OF NEUROLOGICAL SCIENCES, GLASGOW

CONSTANCE A. C. ROSS M.D. Glasg., M.C.Path. CONSULTANT VIROLOGIST, REGIONAL VIRUS LABORATORY, RUCHILL HOSPITAL, GLASGOW N.W.

From the Institute

of Neurological Sciences, Glasgow

the four-year period 1964-67 120 Summary During of

patients suspected

having encephalitis

the Institute of Neurological Sciences, Glasgow. 52 were found to have diseases other than encephalitis. Of the remaining 68 patients the diagnosis of encephalitis was " confirmed " by positive virological and/or pathological findings in 20; the other 48 were finally given a presumptive diagnosis of encephalitis; in the latter group the illnesses were generally less severe than in the former group. Evidence of viral infection was obtained in 14 patients: 12 (86%) with herpes simplex (1 having concurrent infection with influenza type B), 1 with adenovirus, and 1 with measles. Histological examination of brain material from 8 of the patients with herpessimplex infection showed acute necrotising encephalitis in 6. The age of the patient seemed an important factor in prognosis of herpes encephalitis, adults having a worse prognosis than patients under 15 years of age.

were

seen

at

Introduction THE term " encephalitis " covers a wide range of clinical syndromes, from a mild illness characterised by headache, drowsiness, and pyrexia resolving within a few days, to a fulminating process leading to coma and death. Confirmation of the diagnosis of encephalitis is based on clinical, virological, and pathological evidence, and in practice cases separate broadly into two groups: those in whom a firm diagnosis can be made, and a much larger group in whom the diagnosis must remain presumptive. The purpose of the present report was to analyse a consecutive series of patients referred to the Institute of Neurological Sciences, Glasgow, with a provisional diagnosis of encephalitis, and to distinguish those in whom the diagnosis was: (a) confirmed by virological and/or pathological findings; (b) presumptive on the basis of clinical and nonspecific laboratory findings only; and (c) found to be other than encephalitis. The study also afforded an opportunity to assess the relative importance of various viral agents in the pathogenesis of encephalitis and compare the clinical features in cases confirmed virologically or pathologically with those not so confirmed. Patients and Methods The 120 patients in the present study comprised all cases referred to the Institute of Neurological Sciences with a possible diagnosis of encephalitis from Jan. 1, 1964, to Dec. 31, 1967. The clinical diagnosis was based on a combination of headache, drowsiness and confusion, pyrexia, nuchal rigidity, focal neurological signs, and epilepsy; in many cases lumbar puncture at the referring hospital had supported an initial diagnosis of encephalitis by disclosing increased protein and lymphocytes in cerebrospinal fluid (C.S.F.). These non-specific findings permitted a wide differential diagnosis, including surgically remediable lesions such as cerebral abscess, and thus almost * Present address: Hyperbaric Unit, University Department of Surgery, Western

Infirmary, Glasgow W.1.