- Email: [email protected]
Quantitation of IgA and IgM in umbilical cord serum of normal newborn infants
7 84
Brief clinical and laboratory observations
erally benign and the spinal fluid protein was not greatly elevated originally and decreased dramatically with therapy. No harboring loci could be found, such as parameningeal or intracerebral abscesses, subdural empyema, middle ear infection, or mastoid osteomyelitis. Cherry and Sheenan ~ suggested that the most likely cause of bacteriologic relapse in ampicillin-treated type B meningitis is inadequate penetration of the cerebrospinal fluid. This case points to low penetration and emphasizes the need for instituting and maintaining high dosage levels of ampieillin throughout the therapeutic coursei Only this case of H. influenzae type b meningitis has failed to respond to intravenous ampicillin in our experience; 60 other consecutive cases have been treated in our pediatric service during the past 24 months, at dosage levels of 200 to 400 rag. per kilogram per 24 hours, with good results.
The Journal of Pediatrics May 1969
3.
4.
5.
6. 7.
8.
9.
REFERENCES 1. Barrett, F. F., Eardley, W. A., Yow, M. D., and Leverett, H. A.: Ampicillin in the treatment of acute suppurative meningitis, J. PEDIAT.69: 343, 1966. 2. Fleming, P. C., Murray, J. D. M., Fujiwara,
Quantitation of IgA and IgM in umbilical cord serum of normal nevborn infants George W. Brasher, M.D., and Thomas F. Hartley, M.D. TEMPLE,
TEXAS
From the Scott and White Clinic.
10.
M. W., Prichard, J. S., and McNaughton, G. A.: Ampicillin in the treatment of bacterial meningitis, Antimicrob. Ag0ents & Chemother. --1966 6: 47, 1967. Mathies, A. W., Jr., Leedom, J. M., Thrupp , L. D., Ivler, D., Portnoy, B., and Wehrle, P. F.: Experience with ampicillin in bacterial meningitis, Antimicrob. Agents & Chemother: --1965 5: 610, 1966. Young, L. M., tIaddow, J. E., and Klein, J. O.: Relapse following ampicillin treatment of acute Hemophilus influenzae meningitis, Pediatrics 41: 516, 1968. Cherry, J. D., and Sheenan, C. P.: Bacteriologic relapse in Haemophilus influenzae meningitis, New England J. Med. 278: 1001, 1968. Greene, tI. L.: Failure of ampicillin in meningitis, Lancet 1: 861, 1968. Taber, L. H., Yow, M. D., and Nieberg, F. G.: Penetration of broad-spectrum antibiotics into cerebrospinal fluid, Ann. New York Acad. Sc. 145: 473, 1967. Klein, J. O., and Finland, M.: Ampicillin activity in vitro and absorption and .excretion in normal young men, Am. J. M. Sc. 245: 544, 1963. Thrupp, L. D., Leedom, J. M., Ivler, D., Wehrle, P. F., Portnoy, B., and Mathies, A, W.: Ampicillin levels in the cerebrospinal fluid during treatment of bacterial meningitis, Antimicrob. Agents & Chemother.-1965 5: 206, 1966. Gold, A. J,, Lieberman, E., and Wright, H. T.: Bacteriologic re!apse during ampicillin treatment of Hemophilus influenzae meniflgifts, J. PEBIAT. 74: 779, 1969.
I~ N o W Z E D G ~. concerning the synthesis of immunoglobulins by the h u m a n fetus has advanced rapidly during the past few years. N o longer is a newborn infant considered to be in an immunologic "null" State incapable of responding to antigenic stimuli? Smith and Eitzman 2 have shown that the newborn infant is capable of making antibodies Under appropriate conditions. O t h e r authors a, 4 have demonstrated that the h u m a n fetus is capable of synthesizing I g G a n d I g M at as early as 20 weeks of gestation. A logical extension of this line of thinking is that antigenie stimulation in the form of intrauterine infection should lead to the presence of increased immunoglobulins at the time of birth. Studies by Stiehm and associates s and
Volume 74 Number 5
Brie[ clinical and laboratory observations
Alford and co-workers s have suggested that quantitation of immunoglobulins in umbilical cord serum may be valuable in the diagnosis of intrauterine infections. The 3 major serum immunoglobulins, IgG, IgA, and IgM, have been quantitated by various immunochemicat techniques. The Mancini 7 technique of radial gel diffusion has proved useful for measuring these proteins in a variety of diseases. This and similar techniques have been used for quantitating the major immunoglobulins in umbilical cord serum, and recent studies have shown detectable levels of IgM. s-t~ Conflicting results, however, have been reported from studies of I g A - - w i t h most authors reporting "none" or "trace amounts" and others reporting that as m a n y as one third of all normal newborn infants have detectable levels of this immunoprotein? These conflicting results may represent variations in the sensitivity of the techniques used or changes in the proteins during storage, concentration, and handling. 11 Thus, an immunochemical technique that is sensitive enough to measure minute levels of the major immunoglobulins, one that requires minimal handling of the serum, would be useful for assaying samples of serum from the umbilical cord. Electroimmunodiffusion (EID) utilizes the principle o f antigen diffusion in an electrical field through a layer of agar containing specific antiserum. The immunoprecipitate formed is proportional to the antigen concentration and the duration of electrophoresis. This method has been used to measure minute amounts of immunoglobulin in various biologic fluids and to detect levels of IgG as low as 0.2 mg. per 100 ml., IgA as low as 0.5 mg. per 100 ml., and I g M as low as 0.8 mg. per 100 ml? 1 The purpose of this paper is to report the results of a study applying this immunochemical technique to the quantitation of immunoglobulins in serum from the umbilical cords of normal newborn infants. MATEKIALS
AND
METHODS
Between November 1, 1967, and March 1, 1968, serum was collected from the umbili-
785
cal cords of 97 unselected newborn infants, 52 males and 45 females, in the obstetrical unit of the Scott and White Memorial Hospital. At birth, 96 per cent of the male group weighed more than 2,500 grams; 82 per cent of the female group weighed more than 2,500 grams. Blood collected directly from the umbilical cord was placed in clean test tubes and allowed to clot. Following clot retraction, the serum was separated and stored at 4 ~ C. until studied. Previous investigation 1~ has shown that this method results in only minimal alterations of the immunoglobulin levels. Goat antisera specific for human IgA and I g M were obtained from Hyland Laboratories, Los Angeles, Calif. Standards were prepared by the appropriate dilution of normal serum in physiologic saline. The following standard concentrations were employed: IgA, 8.3, 4.2, and 2.1 mg. per 100 ml.; IgM, 24.4, 12.2, 6.1, and 3.0 rag. per 100 ml. IgA and I g M were quantitated by the eleetroimmunodiffusion technique.! 1 For each slide, 0.2 ml. of antisera was dispersed in 3.0 ml. of 2 per cent Bacto agar solution in a vernol buffer p H 8.6, 0.05 ~. Electrophoresis was performed in a Buchler apparatus at 150 volts for 90 minutes. Following electrophoresis, the slides were washed in saline for 24 hours to remove unprecipitated proteins; they were then washed in water for one hour, dried, and stained with 0.1 per cent thiazine red R in 1 per cent acetic acid to make the precipitates visible for measurement. A comparison of the lengths of the unknown precipitates with those of the standardized immunoglobulin precipitates measured on the same slide allowed quantitation of each unknown sample. Hemolysis was avoided, because this interferes with visual identification of the precipitate. RESULTS
IgA was detected in 29.9 per cent of the specimens examined. The amount ranged from 0 to 5.8 mg. per 100 ml., with a mean
786
Brief clinical and laboratory observations
The Journal o[ Pediatrics May 1969
Birth Weight Gm.
4500 4300 4100 3900
9
3?0O 35OO 3300
"
3100
9
2~0 2700 2500 2300
o
2100 1900
1700 i
IgA
I
2
3
4
5
6
l
8
9
10
rag. / lOB m I.
Fig. I. Cord serum Ievels of IgA compared with birth weight.
level of 0.7 mg. per 100 ml. and a standard deviation of _+1.4 rag. per 100 ml. When detected the mean level of IgA was 2.6 rag. per 100 m l . with a standard deviation of _+1.7 rag. per 100 ml. T h e levels of 3 specimens were beyond the upper limits of this technique and they were not included in the statistical analysis. Fig. 1 shows IgA concentration plotted against birth weight. I g M was detectable in all of the specimens studied: Levels ranged from 1.7 rag. per 100 ml. to 18.6 mg. per 100 ml. for the mean of 9.8 mg. per t00 ml. and a standard deviation of _+4.5 mg. per 100 ml. The values for 2 specimens were beyond the upper limits of this technique and were not included in the statistical analysis. Previous authors have not found a statistically significant correlation between I g M and weight at birth, and the scattergram (Fig. 2) fails to show such a correlation in this series.
DISCUSSION
In this study, I g M was detectable in all of the samples of umbilical cord serum which were examined. I g M in umbilical cord serum appears to be of fetal origin, and this finding lends further credence to the concept that the newborn infant is not immunologically primitive and, indeed, is capable of producing immunoglobulins. The nature of the antigenic stimulus for such I g M synthesis has not been explained fully and requires further clarification. Recently, Smith :~ summarized the known sources of antigenic stimulation during fetal life. These include : (1) isoantigens from the mother, such as light chain allotypes, G m allotypes, haptoglobin allotypes, etc., (2) maternal histocompatibility antigens on maternal leukocytes, (3) asymptomatic or symptomatic viral infections of the mother and fetus, and (4) prenatal infections such as rubella, syphilis, toxoplasmosis,
Volume 74 Number 5
Brie[ clinical and laboratory observations
787
Birth Weight 6m. 4500 4300 4100 3900
I B
3700' i
g
3500 3300
9
380
9
9
O
2900 2700
2500 2300 2100 1900 1700 IgM 1 rng./ 100mr.
2
3
4
5
6
7
8
9
10 11 12 13 14
15 16 ll
18_ 19 20
Fig. 2. Cord serum levels of IgM compared with birth weight:
and cytomegalic inclusion body disease. Studies by van Furth and associates 4 demonstrated that the human fetus is capable of synthesizing IgM from the twentieth week of gestation. The spleen was found to be the major site of IgM production. This was in accord with previous investigations by Silverstein, a who found the human fetus to respond to congenital syphilis with plasma cell proliferation and immunoglobulin production at as early as 6 months of gestation. The finding of measurable IgA in 29.9 per cent of the cord specimens was not unexpected because Smith and Eitzman 2 found this immunoprotein to appear at an intermediate point between IgM and IgG synthesis in some neonates following appropriate antigenic stimulus. This study confirms the work of Stiehm and Fudenberg, 9 who found detectable IgA in the serum from unbilicaI cords of one third of the normal newborn infants in their series.
The presence or absence of IgA could not be correlated with the neonatal course nor was it related to birth weight. One infant died at the age of 5 weeks. The clinical picture was similar to that of "crib death" and necropsy disclosed extensive interstitial pneumonitis. Levels of IgA and IgM from the umbilical cord were within the normal ranges. Recent studies, attempting to use levels of IgA and IgM from the umbilical cord in the retrospective diagnosis of transplacentally acquired in utero infections, have emphasized the importance of characterization of immunoglobulins in normal newborn infants, a, ~ Previous investigations have been hampered by the minute quantities of these immunoglobulins in umbilical cord serum; and a specific sensitive, immunochemieal procedure adaptable to the average laboratory has been needed. Previously, electroimmunodiffusion has been used to measure immunoproteins
788
Brief clinical and laboratory observations
in cerebrospinal fluid is a n d salivary gland secretions. 14 This study shows t h a t electroimmunodiffusion is a p r a c t i c a l i m m u n o chemical technique for the m e a s u r e m e n t of I g A a n d I g M in umbilical cord serum.
SUMMARY Electroimmunodiffusion has been used to measure i m m u n o p r o t e i n s in various biologic fluids. D u r i n g a p e r i o d of 4 months, electroimmunodiffusion was used to q u a n t i t a t e concentrations of I g A a n d I g M in serum collected f r o m the umbilical cords of 97 unselected n e w b o r n infants. All samples cont a i n e d I g M , ranging f r o m 1.7 to 18.6 rag. p e r 100 ml. with a m e a n of 9.8 + 4.5 mg. p e r 100 ml. D e t e c t a b l e I g A , ranging from 0.5 to 5.8 mg. p e r 100 ml. with a m e a n of 2.6 + 1.7 mg. per 100 ml., was f o u n d in 29.9 p e r cent of the specimens. These d a t a suggest t h a t the fetus is c a p a b l e of synthesizing I g A a n d I g M , a n d t h a t they are present in concentrations w h i c h c a n be m e a s u r e d by sensitive i m m u n o c h e m i c a l techniques.
REFERENCES 1. Editorial: Immunoglobulin synthesis by the human fetus, New England J. Med. 277: 485, 1967. 2. Smith, R. T., and Eitzman, D. V.: Development of the immune response. Characterization of the response of the human infant and adult to immunization with Salmonella vaccines, Pediatrics 33: 163, 1964. 3. Silverstein, A. M.: Congenital syphilis and the timing of immunogenesis in the human fetus, Nature 194: 196, 1962.
Priapism in a child with chronic granulocytic leukemia R o b e r t G. G r a w , Jr., M . D . , R o l a n d T. Skeel, M . D . , and
Paul P. Carbone, M.D. BETHESDA,
MD.
The Journal of Pediatrics May 1969
4. van Furth, R., Schuit, H. R. E., and Hijmans, W.: Immunological development of the human fetus, J. Exper. Med. 122: 1173, 1965. 5. Stiehm, E. R., Ammann, A. J., and Cherry, J. D.: Elevated cord macroglobulins in the diagnosis of intrauterine infections, New England J. Med. 275: 971, 1966. 6. Alford, C. A., Schaefer, J., Blankenship, W. J., Straumfjord, J. V., and Cassady, G.: A cor#elative immunologic, microbiologic and clinical approach to the diagnosis of acute and chronic infections in newborn infants, New England J. Med. 277: 437, 1967. 7. Mancini, G., Carbonara, A. O., and Heremans, J. F.: Immunochemical quantitation of antigens by single radial immunodiffusion, Internat. J. Immunochem. 2: 235, 1965. 8. Fulginiti, V. A., Sieb.er, O. F., Jr., Claman, H. N., and Merrill, D.: Serum immunoglobulin measurements during the first year of life and in immunoglobulin deficiency states, J. PEDIAT. 68: 723, 1966. 9. Stiehm, E. R., and Fudenberg, H. H.: Serum levels of immune globulins in health and disease: A survey, Pediatrics 37: 715, 1966. 10. Thorn, H., McKay, E., and Gray, D.: Immunoglobulins in umbilical cord plasma. I. Healthy infants, Arch. Dis. Childhood 42: 259, 1967. 11. Merrill, D., Hartley, T. F., and Claman, H,. N.: Electroimmunodiffusion (EID): A simple, rapid method for quantitation of immunoglobulins in dilute biological fluids, J. Lab. & Clin. Med. 69: 151, 1967. 12. Smith, R. T.: In Smith, R., Miescher, P. A., and Good, R. A., editors: Ontogeny of immunity, Gainesville, 1967, University of Florida Press. 13. Hartley, T. F., Merrill, D. A., and Claman, H. N.: Quantitation of immunoglobulins in cerebrospinal fluid, Arch. Neurol. 15: 472, 1966. 14. Clasnan, H. N., Merrill, D. A., and Hartley, T. F.: Salivary immunoglobulins: Normal adult values and dissociation between serum and salivary levels, J. Allergy 40: 151, 1967.
PRIAPISM has long been discussed in textbooks of m e d i c i n e a n d early hematologic writings as a frequent complication of leukemia. 1, ~ T h e sparsity of cases r e p o r t e d in the recent l i t e r a t u r e indicates, however, that the occurrence of this entity m a y h a v e been overemphasized. 3-~ O n l y one previous case of c h i l d h o o d leukemia c o m p l i c a t e d by priapism has been reportedfi Because of the infrequency of the simultaneous occurrence of
From the Leukemia Service, Medicine Branch, National Cancer Institute, National Institute of Health.
Brief clinical and laboratory observations
erally benign and the spinal fluid protein was not greatly elevated originally and decreased dramatically with therapy. No harboring loci could be found, such as parameningeal or intracerebral abscesses, subdural empyema, middle ear infection, or mastoid osteomyelitis. Cherry and Sheenan ~ suggested that the most likely cause of bacteriologic relapse in ampicillin-treated type B meningitis is inadequate penetration of the cerebrospinal fluid. This case points to low penetration and emphasizes the need for instituting and maintaining high dosage levels of ampieillin throughout the therapeutic coursei Only this case of H. influenzae type b meningitis has failed to respond to intravenous ampicillin in our experience; 60 other consecutive cases have been treated in our pediatric service during the past 24 months, at dosage levels of 200 to 400 rag. per kilogram per 24 hours, with good results.
The Journal of Pediatrics May 1969
3.
4.
5.
6. 7.
8.
9.
REFERENCES 1. Barrett, F. F., Eardley, W. A., Yow, M. D., and Leverett, H. A.: Ampicillin in the treatment of acute suppurative meningitis, J. PEDIAT.69: 343, 1966. 2. Fleming, P. C., Murray, J. D. M., Fujiwara,
Quantitation of IgA and IgM in umbilical cord serum of normal nevborn infants George W. Brasher, M.D., and Thomas F. Hartley, M.D. TEMPLE,
TEXAS
From the Scott and White Clinic.
10.
M. W., Prichard, J. S., and McNaughton, G. A.: Ampicillin in the treatment of bacterial meningitis, Antimicrob. Ag0ents & Chemother. --1966 6: 47, 1967. Mathies, A. W., Jr., Leedom, J. M., Thrupp , L. D., Ivler, D., Portnoy, B., and Wehrle, P. F.: Experience with ampicillin in bacterial meningitis, Antimicrob. Agents & Chemother: --1965 5: 610, 1966. Young, L. M., tIaddow, J. E., and Klein, J. O.: Relapse following ampicillin treatment of acute Hemophilus influenzae meningitis, Pediatrics 41: 516, 1968. Cherry, J. D., and Sheenan, C. P.: Bacteriologic relapse in Haemophilus influenzae meningitis, New England J. Med. 278: 1001, 1968. Greene, tI. L.: Failure of ampicillin in meningitis, Lancet 1: 861, 1968. Taber, L. H., Yow, M. D., and Nieberg, F. G.: Penetration of broad-spectrum antibiotics into cerebrospinal fluid, Ann. New York Acad. Sc. 145: 473, 1967. Klein, J. O., and Finland, M.: Ampicillin activity in vitro and absorption and .excretion in normal young men, Am. J. M. Sc. 245: 544, 1963. Thrupp, L. D., Leedom, J. M., Ivler, D., Wehrle, P. F., Portnoy, B., and Mathies, A, W.: Ampicillin levels in the cerebrospinal fluid during treatment of bacterial meningitis, Antimicrob. Agents & Chemother.-1965 5: 206, 1966. Gold, A. J,, Lieberman, E., and Wright, H. T.: Bacteriologic re!apse during ampicillin treatment of Hemophilus influenzae meniflgifts, J. PEBIAT. 74: 779, 1969.
I~ N o W Z E D G ~. concerning the synthesis of immunoglobulins by the h u m a n fetus has advanced rapidly during the past few years. N o longer is a newborn infant considered to be in an immunologic "null" State incapable of responding to antigenic stimuli? Smith and Eitzman 2 have shown that the newborn infant is capable of making antibodies Under appropriate conditions. O t h e r authors a, 4 have demonstrated that the h u m a n fetus is capable of synthesizing I g G a n d I g M at as early as 20 weeks of gestation. A logical extension of this line of thinking is that antigenie stimulation in the form of intrauterine infection should lead to the presence of increased immunoglobulins at the time of birth. Studies by Stiehm and associates s and
Volume 74 Number 5
Brie[ clinical and laboratory observations
Alford and co-workers s have suggested that quantitation of immunoglobulins in umbilical cord serum may be valuable in the diagnosis of intrauterine infections. The 3 major serum immunoglobulins, IgG, IgA, and IgM, have been quantitated by various immunochemicat techniques. The Mancini 7 technique of radial gel diffusion has proved useful for measuring these proteins in a variety of diseases. This and similar techniques have been used for quantitating the major immunoglobulins in umbilical cord serum, and recent studies have shown detectable levels of IgM. s-t~ Conflicting results, however, have been reported from studies of I g A - - w i t h most authors reporting "none" or "trace amounts" and others reporting that as m a n y as one third of all normal newborn infants have detectable levels of this immunoprotein? These conflicting results may represent variations in the sensitivity of the techniques used or changes in the proteins during storage, concentration, and handling. 11 Thus, an immunochemical technique that is sensitive enough to measure minute levels of the major immunoglobulins, one that requires minimal handling of the serum, would be useful for assaying samples of serum from the umbilical cord. Electroimmunodiffusion (EID) utilizes the principle o f antigen diffusion in an electrical field through a layer of agar containing specific antiserum. The immunoprecipitate formed is proportional to the antigen concentration and the duration of electrophoresis. This method has been used to measure minute amounts of immunoglobulin in various biologic fluids and to detect levels of IgG as low as 0.2 mg. per 100 ml., IgA as low as 0.5 mg. per 100 ml., and I g M as low as 0.8 mg. per 100 ml? 1 The purpose of this paper is to report the results of a study applying this immunochemical technique to the quantitation of immunoglobulins in serum from the umbilical cords of normal newborn infants. MATEKIALS
AND
METHODS
Between November 1, 1967, and March 1, 1968, serum was collected from the umbili-
785
cal cords of 97 unselected newborn infants, 52 males and 45 females, in the obstetrical unit of the Scott and White Memorial Hospital. At birth, 96 per cent of the male group weighed more than 2,500 grams; 82 per cent of the female group weighed more than 2,500 grams. Blood collected directly from the umbilical cord was placed in clean test tubes and allowed to clot. Following clot retraction, the serum was separated and stored at 4 ~ C. until studied. Previous investigation 1~ has shown that this method results in only minimal alterations of the immunoglobulin levels. Goat antisera specific for human IgA and I g M were obtained from Hyland Laboratories, Los Angeles, Calif. Standards were prepared by the appropriate dilution of normal serum in physiologic saline. The following standard concentrations were employed: IgA, 8.3, 4.2, and 2.1 mg. per 100 ml.; IgM, 24.4, 12.2, 6.1, and 3.0 rag. per 100 ml. IgA and I g M were quantitated by the eleetroimmunodiffusion technique.! 1 For each slide, 0.2 ml. of antisera was dispersed in 3.0 ml. of 2 per cent Bacto agar solution in a vernol buffer p H 8.6, 0.05 ~. Electrophoresis was performed in a Buchler apparatus at 150 volts for 90 minutes. Following electrophoresis, the slides were washed in saline for 24 hours to remove unprecipitated proteins; they were then washed in water for one hour, dried, and stained with 0.1 per cent thiazine red R in 1 per cent acetic acid to make the precipitates visible for measurement. A comparison of the lengths of the unknown precipitates with those of the standardized immunoglobulin precipitates measured on the same slide allowed quantitation of each unknown sample. Hemolysis was avoided, because this interferes with visual identification of the precipitate. RESULTS
IgA was detected in 29.9 per cent of the specimens examined. The amount ranged from 0 to 5.8 mg. per 100 ml., with a mean
786
Brief clinical and laboratory observations
The Journal o[ Pediatrics May 1969
Birth Weight Gm.
4500 4300 4100 3900
9
3?0O 35OO 3300
"
3100
9
2~0 2700 2500 2300
o
2100 1900
1700 i
IgA
I
2
3
4
5
6
l
8
9
10
rag. / lOB m I.
Fig. I. Cord serum Ievels of IgA compared with birth weight.
level of 0.7 mg. per 100 ml. and a standard deviation of _+1.4 rag. per 100 ml. When detected the mean level of IgA was 2.6 rag. per 100 m l . with a standard deviation of _+1.7 rag. per 100 ml. T h e levels of 3 specimens were beyond the upper limits of this technique and they were not included in the statistical analysis. Fig. 1 shows IgA concentration plotted against birth weight. I g M was detectable in all of the specimens studied: Levels ranged from 1.7 rag. per 100 ml. to 18.6 mg. per 100 ml. for the mean of 9.8 mg. per t00 ml. and a standard deviation of _+4.5 mg. per 100 ml. The values for 2 specimens were beyond the upper limits of this technique and were not included in the statistical analysis. Previous authors have not found a statistically significant correlation between I g M and weight at birth, and the scattergram (Fig. 2) fails to show such a correlation in this series.
DISCUSSION
In this study, I g M was detectable in all of the samples of umbilical cord serum which were examined. I g M in umbilical cord serum appears to be of fetal origin, and this finding lends further credence to the concept that the newborn infant is not immunologically primitive and, indeed, is capable of producing immunoglobulins. The nature of the antigenic stimulus for such I g M synthesis has not been explained fully and requires further clarification. Recently, Smith :~ summarized the known sources of antigenic stimulation during fetal life. These include : (1) isoantigens from the mother, such as light chain allotypes, G m allotypes, haptoglobin allotypes, etc., (2) maternal histocompatibility antigens on maternal leukocytes, (3) asymptomatic or symptomatic viral infections of the mother and fetus, and (4) prenatal infections such as rubella, syphilis, toxoplasmosis,
Volume 74 Number 5
Brie[ clinical and laboratory observations
787
Birth Weight 6m. 4500 4300 4100 3900
I B
3700' i
g
3500 3300
9
380
9
9
O
2900 2700
2500 2300 2100 1900 1700 IgM 1 rng./ 100mr.
2
3
4
5
6
7
8
9
10 11 12 13 14
15 16 ll
18_ 19 20
Fig. 2. Cord serum levels of IgM compared with birth weight:
and cytomegalic inclusion body disease. Studies by van Furth and associates 4 demonstrated that the human fetus is capable of synthesizing IgM from the twentieth week of gestation. The spleen was found to be the major site of IgM production. This was in accord with previous investigations by Silverstein, a who found the human fetus to respond to congenital syphilis with plasma cell proliferation and immunoglobulin production at as early as 6 months of gestation. The finding of measurable IgA in 29.9 per cent of the cord specimens was not unexpected because Smith and Eitzman 2 found this immunoprotein to appear at an intermediate point between IgM and IgG synthesis in some neonates following appropriate antigenic stimulus. This study confirms the work of Stiehm and Fudenberg, 9 who found detectable IgA in the serum from unbilicaI cords of one third of the normal newborn infants in their series.
The presence or absence of IgA could not be correlated with the neonatal course nor was it related to birth weight. One infant died at the age of 5 weeks. The clinical picture was similar to that of "crib death" and necropsy disclosed extensive interstitial pneumonitis. Levels of IgA and IgM from the umbilical cord were within the normal ranges. Recent studies, attempting to use levels of IgA and IgM from the umbilical cord in the retrospective diagnosis of transplacentally acquired in utero infections, have emphasized the importance of characterization of immunoglobulins in normal newborn infants, a, ~ Previous investigations have been hampered by the minute quantities of these immunoglobulins in umbilical cord serum; and a specific sensitive, immunochemieal procedure adaptable to the average laboratory has been needed. Previously, electroimmunodiffusion has been used to measure immunoproteins
788
Brief clinical and laboratory observations
in cerebrospinal fluid is a n d salivary gland secretions. 14 This study shows t h a t electroimmunodiffusion is a p r a c t i c a l i m m u n o chemical technique for the m e a s u r e m e n t of I g A a n d I g M in umbilical cord serum.
SUMMARY Electroimmunodiffusion has been used to measure i m m u n o p r o t e i n s in various biologic fluids. D u r i n g a p e r i o d of 4 months, electroimmunodiffusion was used to q u a n t i t a t e concentrations of I g A a n d I g M in serum collected f r o m the umbilical cords of 97 unselected n e w b o r n infants. All samples cont a i n e d I g M , ranging f r o m 1.7 to 18.6 rag. p e r 100 ml. with a m e a n of 9.8 + 4.5 mg. p e r 100 ml. D e t e c t a b l e I g A , ranging from 0.5 to 5.8 mg. p e r 100 ml. with a m e a n of 2.6 + 1.7 mg. per 100 ml., was f o u n d in 29.9 p e r cent of the specimens. These d a t a suggest t h a t the fetus is c a p a b l e of synthesizing I g A a n d I g M , a n d t h a t they are present in concentrations w h i c h c a n be m e a s u r e d by sensitive i m m u n o c h e m i c a l techniques.
REFERENCES 1. Editorial: Immunoglobulin synthesis by the human fetus, New England J. Med. 277: 485, 1967. 2. Smith, R. T., and Eitzman, D. V.: Development of the immune response. Characterization of the response of the human infant and adult to immunization with Salmonella vaccines, Pediatrics 33: 163, 1964. 3. Silverstein, A. M.: Congenital syphilis and the timing of immunogenesis in the human fetus, Nature 194: 196, 1962.
Priapism in a child with chronic granulocytic leukemia R o b e r t G. G r a w , Jr., M . D . , R o l a n d T. Skeel, M . D . , and
Paul P. Carbone, M.D. BETHESDA,
MD.
The Journal of Pediatrics May 1969
4. van Furth, R., Schuit, H. R. E., and Hijmans, W.: Immunological development of the human fetus, J. Exper. Med. 122: 1173, 1965. 5. Stiehm, E. R., Ammann, A. J., and Cherry, J. D.: Elevated cord macroglobulins in the diagnosis of intrauterine infections, New England J. Med. 275: 971, 1966. 6. Alford, C. A., Schaefer, J., Blankenship, W. J., Straumfjord, J. V., and Cassady, G.: A cor#elative immunologic, microbiologic and clinical approach to the diagnosis of acute and chronic infections in newborn infants, New England J. Med. 277: 437, 1967. 7. Mancini, G., Carbonara, A. O., and Heremans, J. F.: Immunochemical quantitation of antigens by single radial immunodiffusion, Internat. J. Immunochem. 2: 235, 1965. 8. Fulginiti, V. A., Sieb.er, O. F., Jr., Claman, H. N., and Merrill, D.: Serum immunoglobulin measurements during the first year of life and in immunoglobulin deficiency states, J. PEDIAT. 68: 723, 1966. 9. Stiehm, E. R., and Fudenberg, H. H.: Serum levels of immune globulins in health and disease: A survey, Pediatrics 37: 715, 1966. 10. Thorn, H., McKay, E., and Gray, D.: Immunoglobulins in umbilical cord plasma. I. Healthy infants, Arch. Dis. Childhood 42: 259, 1967. 11. Merrill, D., Hartley, T. F., and Claman, H,. N.: Electroimmunodiffusion (EID): A simple, rapid method for quantitation of immunoglobulins in dilute biological fluids, J. Lab. & Clin. Med. 69: 151, 1967. 12. Smith, R. T.: In Smith, R., Miescher, P. A., and Good, R. A., editors: Ontogeny of immunity, Gainesville, 1967, University of Florida Press. 13. Hartley, T. F., Merrill, D. A., and Claman, H. N.: Quantitation of immunoglobulins in cerebrospinal fluid, Arch. Neurol. 15: 472, 1966. 14. Clasnan, H. N., Merrill, D. A., and Hartley, T. F.: Salivary immunoglobulins: Normal adult values and dissociation between serum and salivary levels, J. Allergy 40: 151, 1967.
PRIAPISM has long been discussed in textbooks of m e d i c i n e a n d early hematologic writings as a frequent complication of leukemia. 1, ~ T h e sparsity of cases r e p o r t e d in the recent l i t e r a t u r e indicates, however, that the occurrence of this entity m a y h a v e been overemphasized. 3-~ O n l y one previous case of c h i l d h o o d leukemia c o m p l i c a t e d by priapism has been reportedfi Because of the infrequency of the simultaneous occurrence of
From the Leukemia Service, Medicine Branch, National Cancer Institute, National Institute of Health.