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Specificity of Skin Tests in Deep Fungus Infections1
SPECIFICITY OF SKIN TESTS IN DEEP FUNGUS INFECTIONS* LAWRENCE KATZENSTEIN, M.D.
Cross-reactions to antigens derived from fungi responsible for systemic mycoses were first noted both experimentally and clinically by Emmons, Olson,
and Ethridge (1) in 1945. They found that of eight guinea pigs infected with Blastomyces dermatitidis, seven gave positive skin reactions to blastomycin but all to histoplasmin. Of nine rabbits infected with Histoplasma capsulatum, all reacted to histoplasmin and eight to blastomycin. However, of seven guinea pigs infected with Coccidioides immitis, six were positive to coccidioidin and only
two to histoplasmin. Clinically, they noted that of 69 patients with atypical pulmonary lesions, and 67 with no disease of the lungs, the results of skin tests with histoplasmin and blastomycin were approximately the same in both groups. Of the 136 patients tested, 55 gave positive reactions to histoplasmin and 35 to blastomycin. These 35 reactors to blastomycin also gave positive reactions to histoplasmin. However, in a paper published in May 1947, Howell (2) continued the experimental work of Emmons, and came to different conclusions. He utilized three lots of histoplasmin, five of blastomycin, and heat-killed antigens prepared from yeast cultures of these two fungi. His protocols show that the number of guinea pigs experimentally infected with Blastomyces or Histoplasma which react to these antigens depends upon the "particular lot of antigen employed and upon
the dilution of this particular lot." He found that there is an initial titer for each antigen which gives positive reactions in about 90 per cent of animals infected with the homologous fungus, and less than 10 per cent of cross reactions. Also, "the level or degree of sensitivity of the animals employed to determine the titer of an antigen must be considered. That is, if the sensitivity level is low, a
high concentration of the antigen will have to be used to elicit a reaction, and therefore a false impression of the initial titer of the antigen will be obtained. Such high concentrations of antigen will produce a high percentage of cross reactions." In a clinical study in Tennessee, Christie and Peterson (3) found no false positive coccidioidin skin reactions in children and young adults. In this region coccidioidomycosis has not yet been reported. Of 125 individuals tested, many reacted definitely to histoplasmin, but none to coccidioidin. C. E. Smith (4) stated that coccidioidin is generally specific but occasionally may give false positive reactions in patients with other systemic mycoses. Martin (5) noted that blastomycin produces no false positive skin reactions though it may give a false negative reaction in a patient with a generalized infec* From the Department of Dermatology and Syphilology, University of Pennsylvania, Donald M. Pillsbury, Director. Read before the Eighth Annual Meeting of the Society for Investigative Dermatology, Atlantic City, New Jersey, June 10, 1947. Received for publication June 10, 1947. 249
250
THE JOURNAL OF INVESTIGATIVE DERMATOLOGY
tion. Butt and Hoffman (6) found no cross-sensitivity to blastomycin and sporotrichin in 8 patients with positive coccidioidin reactions. They also found 18 additional individuals with negative reactions to all 3 antigens. It thus appears from a survey of the available literature that there is much cross-sensitization experimentally and clinically between histoplasmin and blasto-
mycin, but coccidioidin is relatively specific. Because of the still unsettled nature of this problem, we wish to add the results of skin tests made on 36 patients suspected of infection with a deep mycosis. SKIN TESTING MATERIAL
Blastomycin, coccidioidin, histoplasmin, and sporotrichin were furnished by Conant and Callaway of Duke University Medical School. Their antigen is a saline suspension of the heat-killed fungus culture "diluted in sufficient saline to
give the vaccine the density of a light ground-glass appearance" (7). Keeney TABLE 1 ANTIGENS USED IN TESTING
Histoplasmin Coccidioidin Coccidioidin and histoplasmin Coccidioidin, histoplasmin, sporotrichin Coccidioidin and blastomycin Coccidioidin, histoplasmin, blastomycin
Total of negative reactors
NO. OP PTS.
8 2 5 1
4 4 24
of Johns Hopkins University School of Medicine supplied a 1—1,000 dilution of
a sterile broth filtrate of a culture of Sporotrichum Schenckii, and a 1-100 dilution of C. immitis. Similar coccidioidin was furnished by C. E. Smith of Leland Stanford University School of Medicine (4). Also blastomycin and histoplasmin, sterile broth filtrates in 1-] ,000 dilution, prepared by the Laboratory of the National Institute of Health, were utilized. TECHNIC
One-tenth of a cubic centimeter of one or more of the antigens was injected intradermally on the volar surface of the forearm. The test was read alter 24 and 48 hours, and in many instances after 7 days. A positive reaction consisted of an
inflammatory papule of at least 7 mm. in diameter. It was noted in 24 hours in all instances except 1, patient number 1, when it did not appear until 7 days after the injection. NEGATIVE REACTIONS
Of the 36 patients tested, 24 showed entirely negative reactions (47 tests). The distribution of these patients yielding negative reactions is indicated in Table 1.
TABLE 2 PT. NO.
AGE
SEX
NISTO.
1
22
M
+
BLASTO.
COCCI.
SPORO.
+
CLINICAL AND LABORATORY DATA
Routine chest film showed mass in superior mediastinum. Tuberculin test
(7 days)
negative.
2
60
M
3
9
M
+
+
—
—
—
—
Verrucous pustular placques on face and extremities positive for B. dermatitfdis on smear and culture. No systemic involvement. Post-pneumonic chronic cough. No parenchymal involvement on chest film
but prominence of both hilar regions. Tuberculin test negative. 4
12
M
+
—
Brother of patient No. 3. Chest film
—
showed calcified areas throughout both
lungs. Tuberculin test negative. 5
?
F
+
+
—
—
Mother of patients No. 3 and 4. Normal chest film. Tuberculin doubtful.
6
?
M
+
+
—
—
Father of patients No. 3 and 4. Normal chest film. Tuberculin negative.
7
35
M
+
—
—
+
—
8
62
M
Brother of patient No. 5. Chest film showed calcified areas in periphery and hilus of both lung fields.
—
—
Subacute neuroretinitis, bilateral. Chest film showed calcified nodes in the right
hilum. Tuberculin test positive. 9
28
F
-
+
Routine chest film showed nodular lesion
in right lung. Never lived in coccidioidal endemic focus. Tuberculin test negative.
10
50
+
F
Granulomatous placques about ankle.
—
Diagnosis of chromoblastomycosis confirmed by finding Phialophora pedrosoi on biopsy and culture (7). 11
17
M
—
—
—
+
Vegetative crusted lesion of tip of index finger, with violaceous nodules in linear distribution on hand, forearm, and arm. Marked improvement after ingestion
of potassium iodide. Culture taken after therapy was started, was sterile.
12
24
M
—
+
—
+ 251
Ulcerated nodules, in linear distribution, on left upper arm for 6 months. Sporotrichum schenckii found on culture.
252
THE 1OURNAL OF INVESTIGATIVE DERMATOLOGY POSITIVE 1IEACTIONS
Twelve patients showed positive skin reactions to one or more of the antigens. The details of these positive reactors are shown in Table 2. COMMENT
Of the 24 entirely negative reactors, only one patient, who later died, was proved
to have had a systemic mycosis. All 4 antigens gave negative reactions just one week before death, and at autopsy, widespread histoplasmosis was found. This anergic state when the disease is far advanced is well known (9). Including this one false negative result, the 47 negative reactions on 24 patients
may well serve as controls for the patients with positive reactions. They suggest that the antigens are not primary irritants and probably produce no false-positive reactions in individuals not suffering from a systemic fungus disease.
Among the 12 positive reactors on whom a total of 38 tests were done, 5 instances of cross-sensitization were noted. Three patients probably infected with histoplasmosis with a positive histoplasmin test, also reacted in a positive manner
to blastomycin. The patient with chromoblastomycosis also gave a positive reaction to blastomycin as did the patient with sporotrichosis who had a positive
sporotrichin test. So, in this small series of cases, blastomycin was the only antigen which showed evidence of cross-sensitivity. From my results it is impossible to evaluate the specificity and sensitivity of
the antigen which is a saline suspension of the heat-killed fungus culture, as compared with the antigen which is a sterile broth filtrate of the fungus culture. In further studies it will be desirable to standardize these antigens either by quantitative nitrogen determinations or by intradermal injections of serial dilutions in infected guinea pigs.
The cross-sensitization between histoplasmin and blastomycin suggests the possibility of their having a common antigen either in the polysaccharide or protein fraction. Further experimental and clinical testing would be necessary to evaluate this supposition. SiJMMAIIY
From skin tests with histoplasmin coccidioidin, blastomycin, and sporotrichin on 36 patients, the following conclusions are drawn: 1. These antigens in the dilutions noted are not primary irritants and probably give no false-positive reactions in individuals with no deep mycosis. 2. In a small series of 12 positive reactors, cross-sensitization occurred only
with blastomycin. This tends to confirm the results obtained by previous workers who found that there was cross-sensitization between histoplasmin and blastomycin, but that none developed in the use of coccidioidin or sporotrichin.
3. Suggestions are made for further studies which might explain this phenomenon.
253
SPECIFICITY OP SKIN TESTS IN DEEP FUNGUS INFECTIONS DISCUSSIONS
Dr. Harold C. Fishman: During an Army assignment in the San Joaquin Valley in 1945, I had the opportunity to study several hundred cases of coccidioidomycosis with Dr. Charles
E. Smith. They were all skin tested with coccidioidin, and most of them also with histoplasmin. Well over 60 per cent of the patients with proven coccidioidomycosis also gave a positive skin test with histoplasmin, although usually to a lesser degree than with cocciclioidin.
Dr. Leslie Smith: We have been very much interested in this subject, have done some work and are very very glad to see that somebody else has had the opportunity to study the problem. It has been our practice to test all patients with suspected deep mycoses simultaneously on the arm, at the same time, with sporotrichin, blastomycin and coccidioidin, because these happen to be our most common deep mycoses. On the whole the tests have been fairly specific, although not entirely so. We have had some cross reactions. I think it important in regard to coccidioidomycosis that we consider the frequency in certain parts of the country of positive reactions to coccidioidin in apparently healthy individuals. In various parts of Texas, Arizona, California, in particular, a good many positive reactions have been found in the Service among people who were not supposed to have deep
mycoses. We do not think this is a false positive reaction. The acute pulmonary form of coccidioidomycosis is apparently more common than most of us have been led to believe, —a number of cases have been found in the Southwest, particularly in California. Once the test becomes positive it is likely to remain so. I have an idea that study in other parts of the country might possibly reveal something similar, though to a lesser extent. There have been cases of acute pulmonary coccidioidomycosis reported sporadically from other parts of the country and I think the positive reaction should have consideration from that angle. Dr. Lawrence Katzenstein: The whole problem of who is infected with histoplasmosis and the particular significance of the histoplasmin skin test is undecided. Palmer (10) found instances varying from 4 to 61 per cent of positive reactors among nurses in five different cities. One way to attack the problem is to use antigens which are standardized on animals so one knows their titre. Using these antigens it may be possible to evaluate infected on non-infected individuals.
Note: I am greatly indebted to the donors of the antigens; also to the Pediatric,
Medical, and Ophthalmologic Services of the Hospital of the University of Pennsylvania; the Dermatologic Service of the Graduate Hospital of the University of Pennsylvania; Dr. David Cooper and Dr. Elizabeth Constant of Phila-
delphia, Pa.; and Dr. Jacob Schildkraut of Trenton, N. J. for the use of their patients in this study. BIBLIOGRAPHY 1. EMMONS, C. W., OLSON, B. J., AND ELDRIDGE, W. W.: Studies of Role of Fungi in Pul-
monary Disease; Cross Reactions of Histoplasmin. Pub. Health Rep. 60: 1383, 1945. 2. HOWELL, AEDEN, JR.: Studies of Fungus Antigens. Quantitative Studies of CrossReactions Between Histoplasmin and Blastomycin in Guinea
Pigs. Pub. Health Rep.
62: 631, 1947. 3. CHRISTIE,
A.,
Tuberculin. 4. 5.
PETERSON, J. C.: Pulmonary Calcification in Negative
Reactors to
Am. J. Pub. Health 35: 1131, 1945.
SMITH, C. E.: Coccidioidomycosis. M. Clin., North America, 27: 790, 1943. MARTIN, DONALD J.: The Application of Immunologic Principles to the Diagnosis
Treatment of
Certain Fungus Infections. J. Invest. Dermat. 4:471, 1941.
and
254
THE JOURNAL OF INVESTIGATIVE DERMATOLOGY
6. BUTT, E. M., AND HOFFMAN, A. M.: Healed or Arrested Pulmonary Coccidioidomycosis.
Correlation of Coccidioidin Skin Tests with Autopsy Findings. Am. J. Path. 21:485, 1945.
7. Manual of Clinical Mycology, Philadelphia, W. B. Saunders Co., 1945, p. 322. 8. WRIDMAN, FRm D., AND ROSENTHAL, L. H.: Chromoblastomycosis: A New and Important Blastomycosis in North America, Arch. Dermat. & SYPII. 43: 62, 1941. 9. CHRISITE, A., AND PETERSON, J. C.: Histoplasmin Sensitivity. J. Pediat. 29: 417, 1946.
10. PALMISE, CARROLL E.: Nontuberculous pulmonary calcification and sensitivity to histoplasmin. Pub. Health Rep., 60: 513, 1945.
THE JOURNAL OF INVESTIGATIVE DERMATOLOGY
94
linolenic acid extract. Arch. This pdf is a scanned copy UV of irradiated a printed document.
24. Wynn, C. H. and Iqbal, M.: Isolation of rat
skin lysosomes and a comparison with liver Path., 80: 91, 1965. and spleen lysosomes. Biochem. J., 98: lOP, 37. Nicolaides, N.: Lipids, membranes, and the 1966.
human epidermis, p. 511, The Epidermis
Eds., Montagna, W. and Lobitz, W. C. Acascopic localization of acid phosphatase in demic Press, New York. human epidermis. J. Invest. Derm., 46: 431, 38. Wills, E. D. and Wilkinson, A. E.: Release of 1966. enzymes from lysosomes by irradiation and 26. Rowden, C.: Ultrastructural studies of kerathe relation of lipid peroxide formation to tinized epithelia of the mouse. I. Combined enzyme release. Biochem. J., 99: 657, 1966. electron microscope and cytochemical study 39. Lane, N. I. and Novikoff, A. B.: Effects of of lysosomes in mouse epidermis and esoarginine deprivation, ultraviolet radiation and X-radiation on cultured KB cells. J. phageal epithelium. J. Invest. Derm., 49: 181, 25. Olson, R. L. and Nordquist, R. E.: Ultramicro-
No warranty is given about the accuracy of the copy.
Users should refer to the original published dermal cells. Nature, 216: 1031, 1967. version of1965. the material. vest. Derm., 45: 448, 28. Hall, J. H., Smith, J. G., Jr. and Burnett, S. 41. Daniels, F., Jr. and Johnson, B. E.: In prepa1967.
Cell Biol., 27: 603, 1965.
27. Prose, P. H., Sedlis, E. and Bigelow, M.: The 40. Fukuyama, K., Epstein, W. L. and Epstein, demonstration of lysosomes in the diseased J. H.: Effect of ultraviolet light on RNA skin of infants with infantile eczema. J. Inand protein synthesis in differentiated epi-
C.: The lysosome in contact dermatitis: A ration. histochemical study. J. Invest. Derm., 49: 42. Ito, M.: Histochemical investigations of Unna's oxygen and reduction areas by means of 590, 1967. 29. Pearse, A. C. E.: p. 882, Histochemistry Theoultraviolet irradiation, Studies on Melanin, retical and Applied, 2nd ed., Churchill, London, 1960.
30. Pearse, A. C. E.: p. 910, Histacheini.stry Thearetscal and Applied, 2nd ed., Churchill, London, 1960.
31. Daniels, F., Jr., Brophy, D. and Lobitz, W. C.: Histochemical responses of human skin fol-
lowing ultraviolet irradiation. J. Invest. Derm.,37: 351, 1961.
32. Bitensky, L.: The demonstration of lysosomes by the controlled temperature freezing section method. Quart. J. Micr. Sci., 103: 205, 1952.
33. Diengdoh, J. V.: The demonstration of lysosomes in mouse skin. Quart. J. Micr. Sci., 105: 73, 1964.
34. Jarret, A., Spearman, R. I. C. and Hardy, J. A.:
Tohoku, J. Exp. Med., 65: Supplement V, 10, 1957.
43. Bitcnsky, L.: Lysosomes in normal and pathological cells, pp. 362—375, Lysasames Eds., de Reuck, A. V. S. and Cameron, M. Churchill, London, 1953.
44. Janoff, A. and Zweifach, B. W.: Production of inflammatory changes in the microcirculation by cationic proteins extracted from lysosomes. J. Exp. Med., 120: 747, 1964.
45. Herion, J. C., Spitznagel, J. K., Walker, R. I. and Zeya, H. I.: Pyrogenicity of granulocyte lysosomes. Amer. J. Physiol., 211: 693, 1966.
46. Baden, H. P. and Pearlman, C.: The effect of ultraviolet light on protein and nucleic acid synthesis in the epidermis. J. Invest. Derm.,
Histochemistry of keratinization. Brit. J. 43: 71, 1964. Derm., 71: 277, 1959. 35. De Duve, C. and Wattiaux, R.: Functions of 47. Bullough, W. S. and Laurence, E. B.: Mitotic control by internal secretion: the role of lysosomes. Ann. Rev. Physiol., 28: 435, 1966. the chalone-adrenalin complex. Exp. Cell. 36. Waravdekar, V. S., Saclaw, L. D., Jones, W. A. and Kuhns, J. C.: Skin changes induced by
Res., 33: 176, 1964.
Cross-reactions to antigens derived from fungi responsible for systemic mycoses were first noted both experimentally and clinically by Emmons, Olson,
and Ethridge (1) in 1945. They found that of eight guinea pigs infected with Blastomyces dermatitidis, seven gave positive skin reactions to blastomycin but all to histoplasmin. Of nine rabbits infected with Histoplasma capsulatum, all reacted to histoplasmin and eight to blastomycin. However, of seven guinea pigs infected with Coccidioides immitis, six were positive to coccidioidin and only
two to histoplasmin. Clinically, they noted that of 69 patients with atypical pulmonary lesions, and 67 with no disease of the lungs, the results of skin tests with histoplasmin and blastomycin were approximately the same in both groups. Of the 136 patients tested, 55 gave positive reactions to histoplasmin and 35 to blastomycin. These 35 reactors to blastomycin also gave positive reactions to histoplasmin. However, in a paper published in May 1947, Howell (2) continued the experimental work of Emmons, and came to different conclusions. He utilized three lots of histoplasmin, five of blastomycin, and heat-killed antigens prepared from yeast cultures of these two fungi. His protocols show that the number of guinea pigs experimentally infected with Blastomyces or Histoplasma which react to these antigens depends upon the "particular lot of antigen employed and upon
the dilution of this particular lot." He found that there is an initial titer for each antigen which gives positive reactions in about 90 per cent of animals infected with the homologous fungus, and less than 10 per cent of cross reactions. Also, "the level or degree of sensitivity of the animals employed to determine the titer of an antigen must be considered. That is, if the sensitivity level is low, a
high concentration of the antigen will have to be used to elicit a reaction, and therefore a false impression of the initial titer of the antigen will be obtained. Such high concentrations of antigen will produce a high percentage of cross reactions." In a clinical study in Tennessee, Christie and Peterson (3) found no false positive coccidioidin skin reactions in children and young adults. In this region coccidioidomycosis has not yet been reported. Of 125 individuals tested, many reacted definitely to histoplasmin, but none to coccidioidin. C. E. Smith (4) stated that coccidioidin is generally specific but occasionally may give false positive reactions in patients with other systemic mycoses. Martin (5) noted that blastomycin produces no false positive skin reactions though it may give a false negative reaction in a patient with a generalized infec* From the Department of Dermatology and Syphilology, University of Pennsylvania, Donald M. Pillsbury, Director. Read before the Eighth Annual Meeting of the Society for Investigative Dermatology, Atlantic City, New Jersey, June 10, 1947. Received for publication June 10, 1947. 249
250
THE JOURNAL OF INVESTIGATIVE DERMATOLOGY
tion. Butt and Hoffman (6) found no cross-sensitivity to blastomycin and sporotrichin in 8 patients with positive coccidioidin reactions. They also found 18 additional individuals with negative reactions to all 3 antigens. It thus appears from a survey of the available literature that there is much cross-sensitization experimentally and clinically between histoplasmin and blasto-
mycin, but coccidioidin is relatively specific. Because of the still unsettled nature of this problem, we wish to add the results of skin tests made on 36 patients suspected of infection with a deep mycosis. SKIN TESTING MATERIAL
Blastomycin, coccidioidin, histoplasmin, and sporotrichin were furnished by Conant and Callaway of Duke University Medical School. Their antigen is a saline suspension of the heat-killed fungus culture "diluted in sufficient saline to
give the vaccine the density of a light ground-glass appearance" (7). Keeney TABLE 1 ANTIGENS USED IN TESTING
Histoplasmin Coccidioidin Coccidioidin and histoplasmin Coccidioidin, histoplasmin, sporotrichin Coccidioidin and blastomycin Coccidioidin, histoplasmin, blastomycin
Total of negative reactors
NO. OP PTS.
8 2 5 1
4 4 24
of Johns Hopkins University School of Medicine supplied a 1—1,000 dilution of
a sterile broth filtrate of a culture of Sporotrichum Schenckii, and a 1-100 dilution of C. immitis. Similar coccidioidin was furnished by C. E. Smith of Leland Stanford University School of Medicine (4). Also blastomycin and histoplasmin, sterile broth filtrates in 1-] ,000 dilution, prepared by the Laboratory of the National Institute of Health, were utilized. TECHNIC
One-tenth of a cubic centimeter of one or more of the antigens was injected intradermally on the volar surface of the forearm. The test was read alter 24 and 48 hours, and in many instances after 7 days. A positive reaction consisted of an
inflammatory papule of at least 7 mm. in diameter. It was noted in 24 hours in all instances except 1, patient number 1, when it did not appear until 7 days after the injection. NEGATIVE REACTIONS
Of the 36 patients tested, 24 showed entirely negative reactions (47 tests). The distribution of these patients yielding negative reactions is indicated in Table 1.
TABLE 2 PT. NO.
AGE
SEX
NISTO.
1
22
M
+
BLASTO.
COCCI.
SPORO.
+
CLINICAL AND LABORATORY DATA
Routine chest film showed mass in superior mediastinum. Tuberculin test
(7 days)
negative.
2
60
M
3
9
M
+
+
—
—
—
—
Verrucous pustular placques on face and extremities positive for B. dermatitfdis on smear and culture. No systemic involvement. Post-pneumonic chronic cough. No parenchymal involvement on chest film
but prominence of both hilar regions. Tuberculin test negative. 4
12
M
+
—
Brother of patient No. 3. Chest film
—
showed calcified areas throughout both
lungs. Tuberculin test negative. 5
?
F
+
+
—
—
Mother of patients No. 3 and 4. Normal chest film. Tuberculin doubtful.
6
?
M
+
+
—
—
Father of patients No. 3 and 4. Normal chest film. Tuberculin negative.
7
35
M
+
—
—
+
—
8
62
M
Brother of patient No. 5. Chest film showed calcified areas in periphery and hilus of both lung fields.
—
—
Subacute neuroretinitis, bilateral. Chest film showed calcified nodes in the right
hilum. Tuberculin test positive. 9
28
F
-
+
Routine chest film showed nodular lesion
in right lung. Never lived in coccidioidal endemic focus. Tuberculin test negative.
10
50
+
F
Granulomatous placques about ankle.
—
Diagnosis of chromoblastomycosis confirmed by finding Phialophora pedrosoi on biopsy and culture (7). 11
17
M
—
—
—
+
Vegetative crusted lesion of tip of index finger, with violaceous nodules in linear distribution on hand, forearm, and arm. Marked improvement after ingestion
of potassium iodide. Culture taken after therapy was started, was sterile.
12
24
M
—
+
—
+ 251
Ulcerated nodules, in linear distribution, on left upper arm for 6 months. Sporotrichum schenckii found on culture.
252
THE 1OURNAL OF INVESTIGATIVE DERMATOLOGY POSITIVE 1IEACTIONS
Twelve patients showed positive skin reactions to one or more of the antigens. The details of these positive reactors are shown in Table 2. COMMENT
Of the 24 entirely negative reactors, only one patient, who later died, was proved
to have had a systemic mycosis. All 4 antigens gave negative reactions just one week before death, and at autopsy, widespread histoplasmosis was found. This anergic state when the disease is far advanced is well known (9). Including this one false negative result, the 47 negative reactions on 24 patients
may well serve as controls for the patients with positive reactions. They suggest that the antigens are not primary irritants and probably produce no false-positive reactions in individuals not suffering from a systemic fungus disease.
Among the 12 positive reactors on whom a total of 38 tests were done, 5 instances of cross-sensitization were noted. Three patients probably infected with histoplasmosis with a positive histoplasmin test, also reacted in a positive manner
to blastomycin. The patient with chromoblastomycosis also gave a positive reaction to blastomycin as did the patient with sporotrichosis who had a positive
sporotrichin test. So, in this small series of cases, blastomycin was the only antigen which showed evidence of cross-sensitivity. From my results it is impossible to evaluate the specificity and sensitivity of
the antigen which is a saline suspension of the heat-killed fungus culture, as compared with the antigen which is a sterile broth filtrate of the fungus culture. In further studies it will be desirable to standardize these antigens either by quantitative nitrogen determinations or by intradermal injections of serial dilutions in infected guinea pigs.
The cross-sensitization between histoplasmin and blastomycin suggests the possibility of their having a common antigen either in the polysaccharide or protein fraction. Further experimental and clinical testing would be necessary to evaluate this supposition. SiJMMAIIY
From skin tests with histoplasmin coccidioidin, blastomycin, and sporotrichin on 36 patients, the following conclusions are drawn: 1. These antigens in the dilutions noted are not primary irritants and probably give no false-positive reactions in individuals with no deep mycosis. 2. In a small series of 12 positive reactors, cross-sensitization occurred only
with blastomycin. This tends to confirm the results obtained by previous workers who found that there was cross-sensitization between histoplasmin and blastomycin, but that none developed in the use of coccidioidin or sporotrichin.
3. Suggestions are made for further studies which might explain this phenomenon.
253
SPECIFICITY OP SKIN TESTS IN DEEP FUNGUS INFECTIONS DISCUSSIONS
Dr. Harold C. Fishman: During an Army assignment in the San Joaquin Valley in 1945, I had the opportunity to study several hundred cases of coccidioidomycosis with Dr. Charles
E. Smith. They were all skin tested with coccidioidin, and most of them also with histoplasmin. Well over 60 per cent of the patients with proven coccidioidomycosis also gave a positive skin test with histoplasmin, although usually to a lesser degree than with cocciclioidin.
Dr. Leslie Smith: We have been very much interested in this subject, have done some work and are very very glad to see that somebody else has had the opportunity to study the problem. It has been our practice to test all patients with suspected deep mycoses simultaneously on the arm, at the same time, with sporotrichin, blastomycin and coccidioidin, because these happen to be our most common deep mycoses. On the whole the tests have been fairly specific, although not entirely so. We have had some cross reactions. I think it important in regard to coccidioidomycosis that we consider the frequency in certain parts of the country of positive reactions to coccidioidin in apparently healthy individuals. In various parts of Texas, Arizona, California, in particular, a good many positive reactions have been found in the Service among people who were not supposed to have deep
mycoses. We do not think this is a false positive reaction. The acute pulmonary form of coccidioidomycosis is apparently more common than most of us have been led to believe, —a number of cases have been found in the Southwest, particularly in California. Once the test becomes positive it is likely to remain so. I have an idea that study in other parts of the country might possibly reveal something similar, though to a lesser extent. There have been cases of acute pulmonary coccidioidomycosis reported sporadically from other parts of the country and I think the positive reaction should have consideration from that angle. Dr. Lawrence Katzenstein: The whole problem of who is infected with histoplasmosis and the particular significance of the histoplasmin skin test is undecided. Palmer (10) found instances varying from 4 to 61 per cent of positive reactors among nurses in five different cities. One way to attack the problem is to use antigens which are standardized on animals so one knows their titre. Using these antigens it may be possible to evaluate infected on non-infected individuals.
Note: I am greatly indebted to the donors of the antigens; also to the Pediatric,
Medical, and Ophthalmologic Services of the Hospital of the University of Pennsylvania; the Dermatologic Service of the Graduate Hospital of the University of Pennsylvania; Dr. David Cooper and Dr. Elizabeth Constant of Phila-
delphia, Pa.; and Dr. Jacob Schildkraut of Trenton, N. J. for the use of their patients in this study. BIBLIOGRAPHY 1. EMMONS, C. W., OLSON, B. J., AND ELDRIDGE, W. W.: Studies of Role of Fungi in Pul-
monary Disease; Cross Reactions of Histoplasmin. Pub. Health Rep. 60: 1383, 1945. 2. HOWELL, AEDEN, JR.: Studies of Fungus Antigens. Quantitative Studies of CrossReactions Between Histoplasmin and Blastomycin in Guinea
Pigs. Pub. Health Rep.
62: 631, 1947. 3. CHRISTIE,
A.,
Tuberculin. 4. 5.
PETERSON, J. C.: Pulmonary Calcification in Negative
Reactors to
Am. J. Pub. Health 35: 1131, 1945.
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