- Email: [email protected]
Tryptic activity of the duodenal juice inaplastic anemia
60
January, 1967 T h e Journal o[ P E D I A T R I C S
Tryptic acti.'ty of the duodenal juice"in aplastic anemia Sinasi Ozsoylu, M.D., and Gonul Argun, M.D. ANKARA~
TURKEY
R E c E N T L Y Shwachman and his colleagues t reported a new syndrome, "pancreatic insufficiency and bone m a r r o w dysfunction," in which bone m a r r o w hypoplasia and absence of pancreatic exocrine secretions were said to occur. T h e bone m a r r o w of one of their patients (A. R.) was repeatedly so hypocellular that a diagnosis of aplastic anemia was seriously considered at the age of 4 months. However, the authors From the Hacettepe Children's Hospital Medical Center, Ankara University, Hacettepe Medical School, Ankara, Turkey.
did not determine the pancreatic enzyme activity in patients with aplastic anemia. We assayed the tryptic activity of duodenal juice in 6 patients with aplastic anemia. T h e tryptic activity was found to be decreased significantly in 5 and was at a low normal level in 1.
MATERIAL AND METHOD F r o m 2 patients with congenital (Fanconi) and 4 patients with acquired types of aplastic anemia, duodenal juice was obtained under fluoroscopic examination. T h e duode-
Table I. Aplastic anemia cases
Patient's identification
Age and sex
S.T. 64/48864
12 years Female
H.G. 65/1027
Hemoglobin (Gm./lO0 ml.)
White blood cell count
Platelets
7.83
4,200
32,000
9 years Female
3.10
2,000
30,000
M.B. 64/8193
16 years Male
4.5
3,400
24,000
K.D. 63/27740
11 years Male
14.34
4,800
60,000
G.G. 64/3614
11 years Female
14.7
5,800
55,000
H.O.
10 years Female
1,700
32,000
Vol. 70, No. 1, pp. 60-64
8.90
Differential counts Polymorphonuclear LymphoBand [orms leukocytes cytes
4
5
2
32
64
24
76
20
75
48
52
33
65
8
92
Volume 70 Number 1
Tryptic activity in aplastic anemia
nal juice from 22 patients with hematologic and other disorders served as controls. The p H of the duodenal juice, which was measured with Nydrazid paper, was the most reliable guide to the catheter tip's position. The tryptic activity of the juice was determined by the method of Anderson and Early? Serial dilutions of the duodenal juice were done in such a way that its content in the different tubes was as follows: ninth, 0.32 c.e.; eighth, 0.16 c.c.; seventh, 0.08 c.c.; sixth, 0.04 c.c.; fifth, 0.02 c.c.; fourth, 0.01 c.c.; third, 0.005 c.c.; second, 0.0025 c,c.; and first, 0.00125 c.e. RESULTS
In 5 out of the 6 patients with aplastic anemia, tryptic activity was found only in the last 2 to 4 tubes (ninth, eighth, seventh, and sixth), in which the duodenal juice concentration was high. Tryptic activity, as measured by gelatin liquefaction, was observed as far as the fifth tube in only one patient with aplastic anemia (Table I). With but 2 exceptions, all of the samples in the control series demonstrated tryptic activity at least as far as the fourth tube. The tryptic activity of the 2 exceptional patients in the control group showed liquefaction as far as the fifth tube (Table I I ) .
Bone
marrow
6 1
DISCUSSION In the pancreatic insufficiency and bone marrow dysfunction syndrome, granulocytopenia with some degree of thrombocytopenia and anemia were the essential hematologic findings. Deficiencies of trypsin, lipase, and amylase in the duodenal juice were found in all of the patients with this syndrome? In our aplastic anemia patients, although lipase activity of the duodenal juice was not assayed, the tryptic activity was significantly decreased, and amylase activity was found to be normal. None of our patients had serious infection or bleeding, either of which might decrease the duodenal juice tryptic activity. Although 2 of the patients with aplastic anemia died, we do not have any autopsy material from them to compare the pancreatic histologic findings with those reported in patients with the pancreatic insufficiency and bone marrow" dysfunction syndrome. Chronic protein malnutrition is still fairly frequent in this part of the world; it is not associated with malabsorption, but can cause changes in the pancreas? However, in none of our patients was there any evidence of chronic protein malnutrition. Furthermore, tryptic activity of the duodenal juice was found to be normal in 3 children
Length o[ time on steroid and teslosterone
pH o[ the duodenal juice
Tubes in which tryptic activity observed
Very hypocellular, rare normoblasts and myelocytes. No megacaryocytes seen. Relative lymphocytosis
Not started
7.8
9th and 8th
Very hypocellular, rare myeloid and erythroid precursors, no megacaryocytes seen
Only 5 days
8.1
9th to 7th
Hypocellular and fatty marrow, rare erythroid and myeloid precursors, no megacaryocytes seen
10 months
8.4
9th and 8th
Originally was very hypocellular, not repeaeed recently
18 months
8.1
9th to 7th
9 months
8.1
9th to 5th
11 months
8.4
9th to 6th
Originally was aplastic repeatedly. Not repeated recently Not tested by us
62
Ozsoylu and Argun
Table II. Tryptic
The fournaI o[ Pediatrics January 1967
a c t i v i t y of t h e c o n t r o l cases
Patient's identification I
Age and sex
Hemoglobin (Gm./lO0 ml.)
White blood ceil count
PIateIets
N.E. 63/8400
8 years Female
12.4
13,400
Many on smear
I.K. 60/19935
16 years Male
13.35
6,000
Many on smear
D.M. 65/18342
18 mos. Male
13.05
11,200
Many on smear
D.K. 65/15682
9 mos. Male
12.6
12,600
Many on smear
L.C. 64/5748
18 mos. Female
12
6,000
Many on smear
C.E. 65/20873
15 years Male
4.65
1,300
30,000
M.Y. 65/13612
6 mos. Male
10.65
9,600
Many on smear
Z.O. 63/10948
6 years Male
3.83
5,800
Many on smear
It. Y. 61/18731
5 years Male
6.35
6,800
Many on smear
M.Y. 64/36507
12 years Female
9.35
15,100
44,000
M.C. 64/50590
12 years Male
6.35
1,800
35,000
Y, D. 65/12767
8 years Female
15,000
32,000
S.K. 65/7195
15 years Female
5.45
3,900
76,000
H. A . A . 65/8002
14 years Male
9.85
17,000
Many on smear
H.D. 64/48753
14 years Male
19,000
Many on smear
H.S. 65/1869
6 years Male
8.75
8,300
Many on smear
M.G. 65/46864
9 years Male
9.20
600
36,000
M.B. 65/52702
7 years Male
6.35
1,000
16,000
H.C. 65/41015
6 years Female
6.65
7,800
Many on smear
O.T. 65/42984
12 years Male
6.35
13,100
Many on smear
M.M. 65/41927
13 years Male
8.90
5,800
30,000
M.Y. 65/42417
10 mos. Female
6.50
8,000
84,000
10.8
12.3
Volume 70 Number 1
Tryptic activity in aplastic anemza
pH of the duodenal juice
Tubes in which tryptic activity was seen
8.4
9th to 4th
Nephrotic syndrome
8.4
9th to 4th
Congenital hypoplastic left kidney with pyeIonephritis
8.5
9th to 4th
Malnutrition and bronchopneumonia
8.2
9th to 3rd
Malnutrition, gastroenteritis, bronchopneumonia
8.2
9th to 4th
Malnutrition, rectovaginal fistula, left renal aplasia, ectopia of bladder
8.4
9th to 5th
ttepatosplenomegaly, iron-deficiency anemia, hypersplenism
8.7
9th to 5th
Bronchopneumonia
8.3
9th to 3rd
Congenital hypoplastic anemia
8.1
9th to 3rd
Congenital hypoplastic anemia
7.8
9th to 4th
Acute myeloblastic leukemia
8.1
9th to 4th
Acute stem cell leukemia
7.8
9th to 2nd
Idiopathic thrombocytopenic purpura
7.8
9th to 4th
Thalassemia intermedia
8.3
9th to 3rd
Malabsorption
8.1
9th to 4th
Rheumatoid arthritis
7.3
9th to 1st
Rheumatoid arthritis
8.2
9th to 3rd
Acute stem cell leukemia
8.1
9th to 3rd
Acute stem cell leukemia
8.3
9th to 2nd
Iron deficiency anemia and encephalomyelitis
7.8
9th to 4th
Malabsorption, bronchopneumonia0 iron deficiency anemia
8.4
9th to 3rd
Thrombocytopenia
8.1
9th to 2nd
Iron deficiency anemia and thrombocytopenia
Diagnosis
63
64
Ozsoylu and Argun
of the control group who had severe malnutrition. Some of the control subjects had diseases in which some bone marrow dysfunction might be expected, but their tryptic activity was found to be normal. In the treatment of our patients, methyl testosterone, 2 mg. per kilogram sublingually, and prednisolone, 2 mg. per kilogram orally, were generally used. Pancreatitis following corticosteroid therapy has been reported in children. ~ One patient (H. G.) had received corticosteroid and testosterone for only 5 days before his duodenal juice was aspirated. There was no apparent relation between the decrease of tryptic activity in the duodenal juice and the time of administration of these drugs to our patients. Some of the control patients (H. D., N.E., H.Y., and M . Y . ) who had been on corticosteroid therapy for a longer time (weeks or months) showed no significant decrease in pancreatic tryptic activity. In addition, tryptic activity of the duodenal juice was found to be normal in 3 patients with acute leukemia to whom testosterone and corticosteroid were given together for 8 to 20 days during the aplastic phase of the disease. It is rather difficult to envisage any causal relation between pancreatic exocrine deficiency and bone marrow function. There is some evidence that pancreatin with sodium bicarbonate has some effect on vitamin B12 and fat absorption in humans2 Pancreatic juice has also been shown to be effective in iron absorption2, 7 Since vitamin Ba2 and iron are both hemopoietic factors, any disturbance of these factors would be expected to affect the bone marrow.
The Journal of Pediatrics January 1967
So far we do not have any good explanation for the decrease in the tryptic activity of duodenal juice in patients with aplastic anemia. However, we believe that these findings might be useful in the differential diagnosis of questionable cases of aplastic anemia, if these observations are confirmed by others. SUMMARY
Six cases of aplastic anemia with decreased tryptic activity of duodenal juice are presented. These cases are compared with examples of the bone marrow dysfunction and pancreatic insufficiency syndrome. Possible etiologic factors for this unexpected finding are briefly mentioned. The patient (H. O.) with aplastic anemia was referred to us by Dr. Ayhan Okcuoglu for tryptic activity determination. REFERENCES
1. Shwachman, H., Diamond, L. K., Oski, F. A., and Khaw, K.: The syndrome of pancreatic insufficiency and bone marrow dysfunction, J. PEI)IAT.65: 645, 1964. 2. Anderson, D. H., and Early, M. V.: Method of assaying trypsin suitable for routine use in diagnosis of congenital pancreatic insufficiency, J. Dis. Child. 63: 89i, 1942. 3. Shaper, A G.: Chronic pancreatic disease and protein malnutrition, Lancet h 1223, 1960. 4. Oppenheimer, E. H., and Boitnott, J. K.: Pancreatitis in children following adrenal corticosteroid therapy, Bull. Johns Hopkins Hospital 107: 297, 1960. 5. Veeger, W., Ables, J., Hellemans, N., and Nieweg, H. O.: Effect of sodium bicarbonate and pancreatin on the absorption of vitamin B~2 and fat in pancreatic insufficiency, New England J. Med. 267: 1341, 1962. 6. Davis, A. E., and Badenock, J.: Iron absorption in pancreatic disease, Lancet 2: 6, 1962. 7. T6nz, O., Weiss, S., Strahm, H. W., and Rossi, E.: Iron absorption in cystic fibrosis, Lancet 2: 1096, 1965.
January, 1967 T h e Journal o[ P E D I A T R I C S
Tryptic acti.'ty of the duodenal juice"in aplastic anemia Sinasi Ozsoylu, M.D., and Gonul Argun, M.D. ANKARA~
TURKEY
R E c E N T L Y Shwachman and his colleagues t reported a new syndrome, "pancreatic insufficiency and bone m a r r o w dysfunction," in which bone m a r r o w hypoplasia and absence of pancreatic exocrine secretions were said to occur. T h e bone m a r r o w of one of their patients (A. R.) was repeatedly so hypocellular that a diagnosis of aplastic anemia was seriously considered at the age of 4 months. However, the authors From the Hacettepe Children's Hospital Medical Center, Ankara University, Hacettepe Medical School, Ankara, Turkey.
did not determine the pancreatic enzyme activity in patients with aplastic anemia. We assayed the tryptic activity of duodenal juice in 6 patients with aplastic anemia. T h e tryptic activity was found to be decreased significantly in 5 and was at a low normal level in 1.
MATERIAL AND METHOD F r o m 2 patients with congenital (Fanconi) and 4 patients with acquired types of aplastic anemia, duodenal juice was obtained under fluoroscopic examination. T h e duode-
Table I. Aplastic anemia cases
Patient's identification
Age and sex
S.T. 64/48864
12 years Female
H.G. 65/1027
Hemoglobin (Gm./lO0 ml.)
White blood cell count
Platelets
7.83
4,200
32,000
9 years Female
3.10
2,000
30,000
M.B. 64/8193
16 years Male
4.5
3,400
24,000
K.D. 63/27740
11 years Male
14.34
4,800
60,000
G.G. 64/3614
11 years Female
14.7
5,800
55,000
H.O.
10 years Female
1,700
32,000
Vol. 70, No. 1, pp. 60-64
8.90
Differential counts Polymorphonuclear LymphoBand [orms leukocytes cytes
4
5
2
32
64
24
76
20
75
48
52
33
65
8
92
Volume 70 Number 1
Tryptic activity in aplastic anemia
nal juice from 22 patients with hematologic and other disorders served as controls. The p H of the duodenal juice, which was measured with Nydrazid paper, was the most reliable guide to the catheter tip's position. The tryptic activity of the juice was determined by the method of Anderson and Early? Serial dilutions of the duodenal juice were done in such a way that its content in the different tubes was as follows: ninth, 0.32 c.e.; eighth, 0.16 c.c.; seventh, 0.08 c.c.; sixth, 0.04 c.c.; fifth, 0.02 c.c.; fourth, 0.01 c.c.; third, 0.005 c.c.; second, 0.0025 c,c.; and first, 0.00125 c.e. RESULTS
In 5 out of the 6 patients with aplastic anemia, tryptic activity was found only in the last 2 to 4 tubes (ninth, eighth, seventh, and sixth), in which the duodenal juice concentration was high. Tryptic activity, as measured by gelatin liquefaction, was observed as far as the fifth tube in only one patient with aplastic anemia (Table I). With but 2 exceptions, all of the samples in the control series demonstrated tryptic activity at least as far as the fourth tube. The tryptic activity of the 2 exceptional patients in the control group showed liquefaction as far as the fifth tube (Table I I ) .
Bone
marrow
6 1
DISCUSSION In the pancreatic insufficiency and bone marrow dysfunction syndrome, granulocytopenia with some degree of thrombocytopenia and anemia were the essential hematologic findings. Deficiencies of trypsin, lipase, and amylase in the duodenal juice were found in all of the patients with this syndrome? In our aplastic anemia patients, although lipase activity of the duodenal juice was not assayed, the tryptic activity was significantly decreased, and amylase activity was found to be normal. None of our patients had serious infection or bleeding, either of which might decrease the duodenal juice tryptic activity. Although 2 of the patients with aplastic anemia died, we do not have any autopsy material from them to compare the pancreatic histologic findings with those reported in patients with the pancreatic insufficiency and bone marrow" dysfunction syndrome. Chronic protein malnutrition is still fairly frequent in this part of the world; it is not associated with malabsorption, but can cause changes in the pancreas? However, in none of our patients was there any evidence of chronic protein malnutrition. Furthermore, tryptic activity of the duodenal juice was found to be normal in 3 children
Length o[ time on steroid and teslosterone
pH o[ the duodenal juice
Tubes in which tryptic activity observed
Very hypocellular, rare normoblasts and myelocytes. No megacaryocytes seen. Relative lymphocytosis
Not started
7.8
9th and 8th
Very hypocellular, rare myeloid and erythroid precursors, no megacaryocytes seen
Only 5 days
8.1
9th to 7th
Hypocellular and fatty marrow, rare erythroid and myeloid precursors, no megacaryocytes seen
10 months
8.4
9th and 8th
Originally was very hypocellular, not repeaeed recently
18 months
8.1
9th to 7th
9 months
8.1
9th to 5th
11 months
8.4
9th to 6th
Originally was aplastic repeatedly. Not repeated recently Not tested by us
62
Ozsoylu and Argun
Table II. Tryptic
The fournaI o[ Pediatrics January 1967
a c t i v i t y of t h e c o n t r o l cases
Patient's identification I
Age and sex
Hemoglobin (Gm./lO0 ml.)
White blood ceil count
PIateIets
N.E. 63/8400
8 years Female
12.4
13,400
Many on smear
I.K. 60/19935
16 years Male
13.35
6,000
Many on smear
D.M. 65/18342
18 mos. Male
13.05
11,200
Many on smear
D.K. 65/15682
9 mos. Male
12.6
12,600
Many on smear
L.C. 64/5748
18 mos. Female
12
6,000
Many on smear
C.E. 65/20873
15 years Male
4.65
1,300
30,000
M.Y. 65/13612
6 mos. Male
10.65
9,600
Many on smear
Z.O. 63/10948
6 years Male
3.83
5,800
Many on smear
It. Y. 61/18731
5 years Male
6.35
6,800
Many on smear
M.Y. 64/36507
12 years Female
9.35
15,100
44,000
M.C. 64/50590
12 years Male
6.35
1,800
35,000
Y, D. 65/12767
8 years Female
15,000
32,000
S.K. 65/7195
15 years Female
5.45
3,900
76,000
H. A . A . 65/8002
14 years Male
9.85
17,000
Many on smear
H.D. 64/48753
14 years Male
19,000
Many on smear
H.S. 65/1869
6 years Male
8.75
8,300
Many on smear
M.G. 65/46864
9 years Male
9.20
600
36,000
M.B. 65/52702
7 years Male
6.35
1,000
16,000
H.C. 65/41015
6 years Female
6.65
7,800
Many on smear
O.T. 65/42984
12 years Male
6.35
13,100
Many on smear
M.M. 65/41927
13 years Male
8.90
5,800
30,000
M.Y. 65/42417
10 mos. Female
6.50
8,000
84,000
10.8
12.3
Volume 70 Number 1
Tryptic activity in aplastic anemza
pH of the duodenal juice
Tubes in which tryptic activity was seen
8.4
9th to 4th
Nephrotic syndrome
8.4
9th to 4th
Congenital hypoplastic left kidney with pyeIonephritis
8.5
9th to 4th
Malnutrition and bronchopneumonia
8.2
9th to 3rd
Malnutrition, gastroenteritis, bronchopneumonia
8.2
9th to 4th
Malnutrition, rectovaginal fistula, left renal aplasia, ectopia of bladder
8.4
9th to 5th
ttepatosplenomegaly, iron-deficiency anemia, hypersplenism
8.7
9th to 5th
Bronchopneumonia
8.3
9th to 3rd
Congenital hypoplastic anemia
8.1
9th to 3rd
Congenital hypoplastic anemia
7.8
9th to 4th
Acute myeloblastic leukemia
8.1
9th to 4th
Acute stem cell leukemia
7.8
9th to 2nd
Idiopathic thrombocytopenic purpura
7.8
9th to 4th
Thalassemia intermedia
8.3
9th to 3rd
Malabsorption
8.1
9th to 4th
Rheumatoid arthritis
7.3
9th to 1st
Rheumatoid arthritis
8.2
9th to 3rd
Acute stem cell leukemia
8.1
9th to 3rd
Acute stem cell leukemia
8.3
9th to 2nd
Iron deficiency anemia and encephalomyelitis
7.8
9th to 4th
Malabsorption, bronchopneumonia0 iron deficiency anemia
8.4
9th to 3rd
Thrombocytopenia
8.1
9th to 2nd
Iron deficiency anemia and thrombocytopenia
Diagnosis
63
64
Ozsoylu and Argun
of the control group who had severe malnutrition. Some of the control subjects had diseases in which some bone marrow dysfunction might be expected, but their tryptic activity was found to be normal. In the treatment of our patients, methyl testosterone, 2 mg. per kilogram sublingually, and prednisolone, 2 mg. per kilogram orally, were generally used. Pancreatitis following corticosteroid therapy has been reported in children. ~ One patient (H. G.) had received corticosteroid and testosterone for only 5 days before his duodenal juice was aspirated. There was no apparent relation between the decrease of tryptic activity in the duodenal juice and the time of administration of these drugs to our patients. Some of the control patients (H. D., N.E., H.Y., and M . Y . ) who had been on corticosteroid therapy for a longer time (weeks or months) showed no significant decrease in pancreatic tryptic activity. In addition, tryptic activity of the duodenal juice was found to be normal in 3 patients with acute leukemia to whom testosterone and corticosteroid were given together for 8 to 20 days during the aplastic phase of the disease. It is rather difficult to envisage any causal relation between pancreatic exocrine deficiency and bone marrow function. There is some evidence that pancreatin with sodium bicarbonate has some effect on vitamin B12 and fat absorption in humans2 Pancreatic juice has also been shown to be effective in iron absorption2, 7 Since vitamin Ba2 and iron are both hemopoietic factors, any disturbance of these factors would be expected to affect the bone marrow.
The Journal of Pediatrics January 1967
So far we do not have any good explanation for the decrease in the tryptic activity of duodenal juice in patients with aplastic anemia. However, we believe that these findings might be useful in the differential diagnosis of questionable cases of aplastic anemia, if these observations are confirmed by others. SUMMARY
Six cases of aplastic anemia with decreased tryptic activity of duodenal juice are presented. These cases are compared with examples of the bone marrow dysfunction and pancreatic insufficiency syndrome. Possible etiologic factors for this unexpected finding are briefly mentioned. The patient (H. O.) with aplastic anemia was referred to us by Dr. Ayhan Okcuoglu for tryptic activity determination. REFERENCES
1. Shwachman, H., Diamond, L. K., Oski, F. A., and Khaw, K.: The syndrome of pancreatic insufficiency and bone marrow dysfunction, J. PEI)IAT.65: 645, 1964. 2. Anderson, D. H., and Early, M. V.: Method of assaying trypsin suitable for routine use in diagnosis of congenital pancreatic insufficiency, J. Dis. Child. 63: 89i, 1942. 3. Shaper, A G.: Chronic pancreatic disease and protein malnutrition, Lancet h 1223, 1960. 4. Oppenheimer, E. H., and Boitnott, J. K.: Pancreatitis in children following adrenal corticosteroid therapy, Bull. Johns Hopkins Hospital 107: 297, 1960. 5. Veeger, W., Ables, J., Hellemans, N., and Nieweg, H. O.: Effect of sodium bicarbonate and pancreatin on the absorption of vitamin B~2 and fat in pancreatic insufficiency, New England J. Med. 267: 1341, 1962. 6. Davis, A. E., and Badenock, J.: Iron absorption in pancreatic disease, Lancet 2: 6, 1962. 7. T6nz, O., Weiss, S., Strahm, H. W., and Rossi, E.: Iron absorption in cystic fibrosis, Lancet 2: 1096, 1965.