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MICROBIAL-ANTIGEN DETECTION
598 TESTOSTERONE CREAM: USE OR ABUSE? SIR,-Hypospadias is a relatively common malformation in children, and, when it is associated with micropenis, surgical correction of the scrotal and perineal types is difficult. Local application of testosterone cream to the and has been phallus is reported to stimulate penile growth used prior to operation for hypospadias.2.3 Testosterone is well absorbed through the intact skin,4·6but we know of no data on plasma-testosterone levels during treatment of children with- testosterone cream. We have studied three prepubertal boys with normal but with micropenis and/or hypospadias who instructed to massage 2-5% testosterone cream in a water-miscible base into the penis daily in an attempt to produce phallic enlargement before surgery (table). Plasma-testosterone levels measured by radioimmuno6 assay before treatment were within the normal range for prepubertal boys and rose during treatment. The levels greatly exceeded those following 3 and 5 day stimulation
karyotype were
RESPONSE TO TESTOSTERONE CREAM
Patient A:
development
of
pubic hair during
treatment with
testosterone cream.
inadvisable. Unfortunately, penile circumference was not measured, and this, from our clinical observations, might have been a better measure of growth. If further studies confirm an increase in penile circumference, and if testosterone cream is used before early surgery to reduce the psychological stress of hypospadias, the duration of treatment should be kept to a minimum. We thank Prof. V. H. T. James and his staff, Steroid Labora-
testosterone cream are
tory, St. Mary’s Hospital, London, for the testosterone assays, and Miss J. Manly for preparing the testosterone cream. M. V.-L. is a research-fellow of the Belgian National Fonds voor Wetenschappelyk Onderzoek and a British Council scholar.
Queen Elizabeth Hospital for Children, London E2 8PS.
*
H.C.G. 1000 i.u. per day x 5. to Tanner.’
t Grades according
by human chorionic gonadotrophin (H.C.G.) in patients B and C and was slightly higher in patient A. Return to basal levels occurred within 8 weeks of stopping the cream in two patients, but the concentration in the third child could not be measured until six months after the treatment had stopped, by which time it had returned to the basal level. Pubic hair developed in all children (see figure), but penile length did not increase significantly. Our findings indicate that local application of testosterone cream produces systemic androgenic activity which could be harmful in prepubertal children but may be useful as replacement therapy for hypogonadism. The fact that penile length did not increase in our patients is unlikely to be due to the testosterone concentration of the cream being lower than in previously reported cases, because high plasma-testosterone levels did result. In view of the androgenic effects observed we feel that higher concentrations of Pettersson, F. Lancet, 1964, i, 675. Immergut, M., Boldus, R., Yannone, E., Bunge, R., Flocks, R. J. Urol. 1971, 105, 905. 3. Hinman, F. ibid. 1972, 107, 499. 4. Malkinson, F. D. J. invest. Derm. 1958, 31, 19. 5. Mavais-Jarvis, P., Bercovici, J. P. Therapeutique, 1972, 48, 403. 6. Furuyama, F., Mayes, D. M., Nugent, C. A. Clin. Endocr. 1970, 16, 415.
1. 2.
7. Growth at Adolescence.
Oxford,
1962.
CARYL W. DARBY M. VANDERSCHUEREN LODEWEYCKX BERNARD M. LAURANCE.
MICROBIAL-ANTIGEN DETECTION SIR,-Your leader of July 20 (p. 138) draws attention to the increasing interest in microbial-antigen detection as a diagnostic method in acute infections. Working in an area where acute infections account for a high proportion of hospital admissions, we have found this diagnostic approach to be clinically very valuable in a number of situations. Bacterial polysaccharides are only slowly degraded and persist in the cerebrospinal fluid of patients with meningococcal and pneumococcal meningitis for several days after the start of therapy 1,2and in the serum and urine of patients with pneumococcal pneumonia for days, or even weeks, after the start of treatment.3,4 Immunodiagnosis thus offers a means of establishing a bacteriological diagnosis in patients with purulent meningitis or lobar pneumonia who have been treated with antibiotics before admission to hospital, an increasing problem, even in developing countries. Typing of the organism responsible for meningococcal, pneumococcal, and streptococcal infections is often of both clinical and epidemiological interest. This can be easily and rapidly achieved by direct counter-current immunoelectrophoresis of biological fluids against monospecific antisera and does not require isolation of the causative organism.4 Determination of the presence and concentration of bacterial antigens in the serum of patients with coccal infections is of prognostic value. Edwards showed that the 1.
2. 3. 4.
Whittle, H. C., Greenwood, B. M., Davidson, N. McD., Tomkins, A., Tugwell, P., Warrell, D. A., Zalin, A., Bryceson, A. D. M., Parry, E. H. O., Brueton, M., Duggan, M., Oomen, J. M. V. Rajkovic, A. D. Am. J. Med. (in the press). Tugwell, P., Greenwood, B. M., Warrell, D. A. Unpublished. Kenny, G. E., Wentworth, B. B., Beasley, R. P., Foy, H. M. infect Immun. 1972, 6, 431. Tugwell, P., Greenwood, B. M. Unpublished.
599 presence of polysaccharide antigen in the serum of patients with group-C meningococcal infections was a very poor prognostic sign.5 We have likewise found that patients with group-A meningococcal meningitis who have antigen in the serum have a high incidence of complications, especially allergic vasculitis and arthritis.l Similarly, the prognosis of patients with pneumococcal pneumonia who have a high concentration of circulating antigen is worse than that of patients without antigenaemia.4,G We have also found that the rate of disappearance of antigen from the cerebrospinal fluid of patients with pyogenic meningitis is a valuable guide to the progress of treatment. Microbial-antigen detection has so far been used as a diagnostic technique in only a limited number of bacterial, viral, and fungal infections. This approach to the diagnosis of acute infections could perhaps be applied more widely. B. M. GREENWOOD P. TUGWELL H. C. WHITTLE.
Department of Medicine, Ahmadu Bello University,
Zaria, Nigeria.
STORAGE AND TRANSPORT OF SERUM FOR PROLACTIN RADIOIMMUNOASSAY
SIR,-The stability of serum-prolactin under different conditions of storage has not been documented. With increasing use of supraregional hormone-assay services the question of transport of samples arises and clearly the simplest way is to send the serum just as it is by ordinary post. To do this, however, one would need to know the TABLE I-SERUM-PROLACTIN LEVELS (jjLg. per litre) AFTER FOUR STORAGE AT -20°C, 4°C, ROOM, AND OUTSIDE TEMPERATURES
WEEKS’
second experiment the serum was initially stored at -20 °C, but aliquots were exposed to room and outside temperatures for ten, seven, and three days before a prolactin assay. The results are shown in tablesI and II. Prolactin was
assayed by double-antibody radioimmunoassay, using antiserum 65/5, kindly supplied by Prof. H. Friesen. Human prolactin for labelling was supplied by the National Institutes of Health, Bethesda, Maryland. There is undoubtedly a fall in serum-prolactin levels with prolonged storage at 4°C, room, and outside temperatures but the prolactin levels in normal subjects were still within the limits of assay sensitivity even after prolonged storage at temperatures other than -20°C. With short term (up to seven days) storage at room and outside temperatures there is no significant change, and ordinary postage is probably adequate. Endocrine Unit, Hammersmith Hospital, London W12 OHS.
S. NADER.
DIAGNOSIS OF INSULINOMAS BY SUPPRESSION TESTS
SIR,-The interesting article by Dr Turner and Mr (July 27, p. 188) has a great deal of clinical relevance diagnosis of fasting hypoglycaemia. However, the availability of an alternative marker of (3-cell secretion,
Harris in the
C-peptide immunoreactivity, will no doubt permit similar suppression studies to be performed without the need for the use of fish insulin, which is not readily available. The production of hypoglycxmia by regular insulin can now be followed by measurements of C-peptide immunoreactivity to ascertain whether (3-cell suppression occurs to the produced low blood-sugar levels. Studies such as those described by Dr Turner and Mr Harris are now under way and have been reported in abstract form at the American Diabetes Association meetings in Atlanta, Georgia, by Dr David Horowitz and his associates. 3411 North 5th Avenue, Phoenix, Arizona 85013, U.S.A.
TABLE II-SERUM-PROLACTIN LEVELS (g. per litre) AFTER STORAGE FOR TEN, SEVEN, AND THREE DAYS AT -20oC, ROOM, AND OUTSIDE TEMPERATURES
R.T. *
=
room
temperature.
O.T. =
outside temperature.
Unsatisfactory duplicates.
stability of the hormone at room and outside temperatures for varying periods of time. The stability of prolactin under such circumstances was looked at in two series of experiments. In one experiment room
after 5. 6.
NATURE OF NUCLEAR PROJECTIONS IN ADENOCARCINOMA OF THE BREAST SIR,-We were interested in the report by Professor Hsu and his colleagues (Aug. 17, p. 413) of nuclear projections associated with a long abnormal chromosome, and in fact we described this phenomenon in a carcinoma of the ovary in 1964.1 We have repeatedly observed nuclear projections in suitable preparations from malignant tumours of the ovary, breast, cervix uteri, gastrointestinal tract, bladder, &c., where there is a large marker chromosome whose long arm is at least as long as the whole of the no. 1 chromosomes. Protruding chromosome arms may be readily seen in metaphases, anaphases, and telophases in histological sections of these tumours2; the interphase nuclear projections are clearly seen only in preparations in which the cells are well-flattened, as in those made for chromosome studies and, less consistently, in smears for
diagnostic cytology. 3.4 We estimate that about 10-20% of malignant tumours have at least one long abnormal chromosome capable of producing nuclear projections in interphase and protruding arms in mitosis. Department of Cancer Research, Mount Vernon
serum was
stored
at
temperature, and outside temperature immediately and assayed four weeks later. In the
Edwards, E. A. J. Immun. 1971, 106, 314. Coonrod, J. D., Rytel, M. W. J. Lab. clin. Med. 1973, 81, 778..
Hospital,
Northwood,
-20 °C, 4°C,
separation
MARSHALL B. BLOCK.
Middlesex HA6 2RN. 1. 2. 3. 4.
N. B. ATKIN M. C. BAKER.
Atkin, N. B., Baker, M. C. Acta cytol. 1964, 8, 431. Brandão, H. J. S., Atkin, N. B. Br. J. Cancer, 1968, 22, 184. Uyeda, C. K., Davis, H. J., Jones, H. W. Jr. Acta cytol. 1966, 10, 331. Atkin, N. B. ibid. 1969, 13, 569.
karyotype were
RESPONSE TO TESTOSTERONE CREAM
Patient A:
development
of
pubic hair during
treatment with
testosterone cream.
inadvisable. Unfortunately, penile circumference was not measured, and this, from our clinical observations, might have been a better measure of growth. If further studies confirm an increase in penile circumference, and if testosterone cream is used before early surgery to reduce the psychological stress of hypospadias, the duration of treatment should be kept to a minimum. We thank Prof. V. H. T. James and his staff, Steroid Labora-
testosterone cream are
tory, St. Mary’s Hospital, London, for the testosterone assays, and Miss J. Manly for preparing the testosterone cream. M. V.-L. is a research-fellow of the Belgian National Fonds voor Wetenschappelyk Onderzoek and a British Council scholar.
Queen Elizabeth Hospital for Children, London E2 8PS.
*
H.C.G. 1000 i.u. per day x 5. to Tanner.’
t Grades according
by human chorionic gonadotrophin (H.C.G.) in patients B and C and was slightly higher in patient A. Return to basal levels occurred within 8 weeks of stopping the cream in two patients, but the concentration in the third child could not be measured until six months after the treatment had stopped, by which time it had returned to the basal level. Pubic hair developed in all children (see figure), but penile length did not increase significantly. Our findings indicate that local application of testosterone cream produces systemic androgenic activity which could be harmful in prepubertal children but may be useful as replacement therapy for hypogonadism. The fact that penile length did not increase in our patients is unlikely to be due to the testosterone concentration of the cream being lower than in previously reported cases, because high plasma-testosterone levels did result. In view of the androgenic effects observed we feel that higher concentrations of Pettersson, F. Lancet, 1964, i, 675. Immergut, M., Boldus, R., Yannone, E., Bunge, R., Flocks, R. J. Urol. 1971, 105, 905. 3. Hinman, F. ibid. 1972, 107, 499. 4. Malkinson, F. D. J. invest. Derm. 1958, 31, 19. 5. Mavais-Jarvis, P., Bercovici, J. P. Therapeutique, 1972, 48, 403. 6. Furuyama, F., Mayes, D. M., Nugent, C. A. Clin. Endocr. 1970, 16, 415.
1. 2.
7. Growth at Adolescence.
Oxford,
1962.
CARYL W. DARBY M. VANDERSCHUEREN LODEWEYCKX BERNARD M. LAURANCE.
MICROBIAL-ANTIGEN DETECTION SIR,-Your leader of July 20 (p. 138) draws attention to the increasing interest in microbial-antigen detection as a diagnostic method in acute infections. Working in an area where acute infections account for a high proportion of hospital admissions, we have found this diagnostic approach to be clinically very valuable in a number of situations. Bacterial polysaccharides are only slowly degraded and persist in the cerebrospinal fluid of patients with meningococcal and pneumococcal meningitis for several days after the start of therapy 1,2and in the serum and urine of patients with pneumococcal pneumonia for days, or even weeks, after the start of treatment.3,4 Immunodiagnosis thus offers a means of establishing a bacteriological diagnosis in patients with purulent meningitis or lobar pneumonia who have been treated with antibiotics before admission to hospital, an increasing problem, even in developing countries. Typing of the organism responsible for meningococcal, pneumococcal, and streptococcal infections is often of both clinical and epidemiological interest. This can be easily and rapidly achieved by direct counter-current immunoelectrophoresis of biological fluids against monospecific antisera and does not require isolation of the causative organism.4 Determination of the presence and concentration of bacterial antigens in the serum of patients with coccal infections is of prognostic value. Edwards showed that the 1.
2. 3. 4.
Whittle, H. C., Greenwood, B. M., Davidson, N. McD., Tomkins, A., Tugwell, P., Warrell, D. A., Zalin, A., Bryceson, A. D. M., Parry, E. H. O., Brueton, M., Duggan, M., Oomen, J. M. V. Rajkovic, A. D. Am. J. Med. (in the press). Tugwell, P., Greenwood, B. M., Warrell, D. A. Unpublished. Kenny, G. E., Wentworth, B. B., Beasley, R. P., Foy, H. M. infect Immun. 1972, 6, 431. Tugwell, P., Greenwood, B. M. Unpublished.
599 presence of polysaccharide antigen in the serum of patients with group-C meningococcal infections was a very poor prognostic sign.5 We have likewise found that patients with group-A meningococcal meningitis who have antigen in the serum have a high incidence of complications, especially allergic vasculitis and arthritis.l Similarly, the prognosis of patients with pneumococcal pneumonia who have a high concentration of circulating antigen is worse than that of patients without antigenaemia.4,G We have also found that the rate of disappearance of antigen from the cerebrospinal fluid of patients with pyogenic meningitis is a valuable guide to the progress of treatment. Microbial-antigen detection has so far been used as a diagnostic technique in only a limited number of bacterial, viral, and fungal infections. This approach to the diagnosis of acute infections could perhaps be applied more widely. B. M. GREENWOOD P. TUGWELL H. C. WHITTLE.
Department of Medicine, Ahmadu Bello University,
Zaria, Nigeria.
STORAGE AND TRANSPORT OF SERUM FOR PROLACTIN RADIOIMMUNOASSAY
SIR,-The stability of serum-prolactin under different conditions of storage has not been documented. With increasing use of supraregional hormone-assay services the question of transport of samples arises and clearly the simplest way is to send the serum just as it is by ordinary post. To do this, however, one would need to know the TABLE I-SERUM-PROLACTIN LEVELS (jjLg. per litre) AFTER FOUR STORAGE AT -20°C, 4°C, ROOM, AND OUTSIDE TEMPERATURES
WEEKS’
second experiment the serum was initially stored at -20 °C, but aliquots were exposed to room and outside temperatures for ten, seven, and three days before a prolactin assay. The results are shown in tablesI and II. Prolactin was
assayed by double-antibody radioimmunoassay, using antiserum 65/5, kindly supplied by Prof. H. Friesen. Human prolactin for labelling was supplied by the National Institutes of Health, Bethesda, Maryland. There is undoubtedly a fall in serum-prolactin levels with prolonged storage at 4°C, room, and outside temperatures but the prolactin levels in normal subjects were still within the limits of assay sensitivity even after prolonged storage at temperatures other than -20°C. With short term (up to seven days) storage at room and outside temperatures there is no significant change, and ordinary postage is probably adequate. Endocrine Unit, Hammersmith Hospital, London W12 OHS.
S. NADER.
DIAGNOSIS OF INSULINOMAS BY SUPPRESSION TESTS
SIR,-The interesting article by Dr Turner and Mr (July 27, p. 188) has a great deal of clinical relevance diagnosis of fasting hypoglycaemia. However, the availability of an alternative marker of (3-cell secretion,
Harris in the
C-peptide immunoreactivity, will no doubt permit similar suppression studies to be performed without the need for the use of fish insulin, which is not readily available. The production of hypoglycxmia by regular insulin can now be followed by measurements of C-peptide immunoreactivity to ascertain whether (3-cell suppression occurs to the produced low blood-sugar levels. Studies such as those described by Dr Turner and Mr Harris are now under way and have been reported in abstract form at the American Diabetes Association meetings in Atlanta, Georgia, by Dr David Horowitz and his associates. 3411 North 5th Avenue, Phoenix, Arizona 85013, U.S.A.
TABLE II-SERUM-PROLACTIN LEVELS (g. per litre) AFTER STORAGE FOR TEN, SEVEN, AND THREE DAYS AT -20oC, ROOM, AND OUTSIDE TEMPERATURES
R.T. *
=
room
temperature.
O.T. =
outside temperature.
Unsatisfactory duplicates.
stability of the hormone at room and outside temperatures for varying periods of time. The stability of prolactin under such circumstances was looked at in two series of experiments. In one experiment room
after 5. 6.
NATURE OF NUCLEAR PROJECTIONS IN ADENOCARCINOMA OF THE BREAST SIR,-We were interested in the report by Professor Hsu and his colleagues (Aug. 17, p. 413) of nuclear projections associated with a long abnormal chromosome, and in fact we described this phenomenon in a carcinoma of the ovary in 1964.1 We have repeatedly observed nuclear projections in suitable preparations from malignant tumours of the ovary, breast, cervix uteri, gastrointestinal tract, bladder, &c., where there is a large marker chromosome whose long arm is at least as long as the whole of the no. 1 chromosomes. Protruding chromosome arms may be readily seen in metaphases, anaphases, and telophases in histological sections of these tumours2; the interphase nuclear projections are clearly seen only in preparations in which the cells are well-flattened, as in those made for chromosome studies and, less consistently, in smears for
diagnostic cytology. 3.4 We estimate that about 10-20% of malignant tumours have at least one long abnormal chromosome capable of producing nuclear projections in interphase and protruding arms in mitosis. Department of Cancer Research, Mount Vernon
serum was
stored
at
temperature, and outside temperature immediately and assayed four weeks later. In the
Edwards, E. A. J. Immun. 1971, 106, 314. Coonrod, J. D., Rytel, M. W. J. Lab. clin. Med. 1973, 81, 778..
Hospital,
Northwood,
-20 °C, 4°C,
separation
MARSHALL B. BLOCK.
Middlesex HA6 2RN. 1. 2. 3. 4.
N. B. ATKIN M. C. BAKER.
Atkin, N. B., Baker, M. C. Acta cytol. 1964, 8, 431. Brandão, H. J. S., Atkin, N. B. Br. J. Cancer, 1968, 22, 184. Uyeda, C. K., Davis, H. J., Jones, H. W. Jr. Acta cytol. 1966, 10, 331. Atkin, N. B. ibid. 1969, 13, 569.