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UPTAKE OF 35S-HEPARIN BY LYMPHOCYTES FROM CYSTIC-FIBROSIS PATIENTS
655 shake hands or ride in a bus without embarrassment, and the is certainly justified in the schoolchild whose writing hand drips so much that even with blotting paper beneath it the page is a mess of blushing smudges. J. R. GIBBS. Wadhurst, Sussex.
operation
hypersensitivity reactions of this type caused by D.P.H. and C.B.Z., respectively. We believe that in our patient both drugs gave rise to the hypersensitivity reaction. Despite the fact that the patch test gave only partial information in this case, we agree that skin testing deserves more attention as a diagnostic aid in drug-hypersensitivity reactions.
TESTS FOR DRUG ALLERGY
SIR,-Felix and Comaish1 state that patch and intracutaneous tests, although often disappointing in hyperreactions to systemically administered drugs, worth while because there are no better alternatives, apart from clinical challenge. We should like to describe the information that patch tests and lymphocyte transformation tests gave in- another type of hypersensitivity reaction to systemically administered drugs. The patient was a 39-year-old man with a temporodiencephalic epilepsy. He had been given carbamazepine 300 mg. and diphenylhydantoin 150 mg. a day for 3 weeks when he had an extensive erythematous, maculopapular
Departments of Medicine and Dermatology, University Hospital, Oostersingel 59, Groningen, Netherlands.
sensitivity
J. HOUWERZIJL G. C.
DE
GAST
J. P. NATER.
are
rash, generalised lymphadenopathy, slight oedema, hepatoThe leucocyte-count was and fever (40°C). with c.mm. 11,000 per 6% eosinophils and 8% atypical the in differential count. Antinuclear antilymphocytes bodies were not present. After discontinuation of the drugs the patient recovered within a month. Hypersensitivity reactions of this type due to diphenylhydantoin are well known. However, a similar reaction due to carbamazepine has also been reported.2 To determine which drug caused the reaction both patch tests and in-vitro transformation tests were performed. Patch tests by the method of the International Contact Dermatitis Research Group3 were done with diphenylhydantoin (D.P.H.) and carbamazepine (c.B.z.) 1% and 5% in’Vaseline’. In the patient, 5 months after the onset of his illness, patch tests were negative for D.P.H. 1 % and 5% but were +++ for C.B.Z. 1% and ++++ for Tests in four controls were all negative. C.B.z. 5%. from the + + + reaction revealed typical eczematous Biopsy skin response with spongiosis, striking vesicle formation, and perivascular lymphocyte infiltration. Results of lymphocyte-transformation tests are summarised in the table.
megaly,
LYMPHOCYTE-TRANSFORMATION TESTS
(d.p.m. MEANrLS.D.)
I I I I Lymphocyte-transformation tests were performed as described elsewhere.’ Diphenylhydantoin and carbamazepine were dissolved in propyleneglycol (10%) at a concentration of 10 (1.g. per ml.
Patch tests indicated carbamazepine as the only sensitising to the lymphocyte-transformation tests both seemed to be involved. Although some workers5 could not confirm their results, the publications of Holland and Mauer6 and Virolainen2 indicate that lymphocytetransformation tests are of value in the diagnosis of
drug, while according
1.
2 3.
4
Felix, R. H., Comaish, J. S. Lancet, 1974, i, 1017. Virolamen, M. Clin. exp. Immun. 1971, 9, 429. Malten, K. E., Fregert, S., Bandmann, H. J., Calnan, C. D. Cronin, E., Hjorth, N., Magnusson, B., Maibach, H. I., Meneghini, C. L., Pirila, V., Wilkinson, D. S. Berufsdermatosen, 1971, 19, 1. Gast, G. C. de, Houwen, B., Nieweg, H. O. Br. med. J. 1973, iv, 707.
5. MacKinney, A. A., Booker, H. E. Archs intern. Med. 1972, 129, 988. 6. Holland, P., Mauer, A. M. Lancet, 1964 i, 1368.
UPTAKE OF 35S-HEPARIN BY LYMPHOCYTES FROM CYSTIC-FIBROSIS PATIENTS
SIR,-In 1969 Danes and Beam1 proposed that the metachromasia noted in short-term white-blood-cell cultures from both cystic fibrosis (c.F.) homozygotes and heterozygotes probably reflected uptake of heparin from the culture-medium by pinocytosis and not, as in the stored genetic mucopolysaccharidoses, mucopolysaccharides. This hypothesis was recently confirmed by Robertson et al.2 Using 35S-heparin they demonstrated an increased uptake of heparin in short-term C.F. white-blood-cell cultures which corresponded to the observations made on the basis of staining. However, as mentioned in 1971 by Bafalluy et al.,3 any white blood-cell in culture can be overloaded with heparin. As the processes involved in endocytosis and exocytosis probably are inconstant within one cell and certainly in different cell types, standardisation of cytoplasmic retention of heparin may not be possible in order to eliminate the partial overlap between normals, C.F. homozygotes and obligatory hetero2 zygotes observed by Robertson et al. This report on 35S-heparin uptake2 again raised the question of the significance of cellular mucopolysaccharides in cystic fibrosis. Although the authors clearly stated that they did not measure cellular mucopolysaccharides, they stated that their findings were consistent with previous reports of increased mucopolysaccharide synthesis in C.F. cells. On the basis of the references cited,2 the relevance of mucopolysaccharides in the c.F. cultured cell is still unclear. Between 1968 and 1970 the mucopolysaccharide content of the cultured fibroblast was reported as normal4 and variable.5,6 Caudill et aJ.7 have reported an increase in 35S incorporation into cellular mucopolysaccharides in short-term white-blood-cell cultures from some c.F. families. A relative increase in dermatan sulphate with a normal total mucopolysaccharide content has been found in long-term C.F. lymphoid lines. Although such reports imply alteration in cellular mucopolysaccharides in the cultured C.F. cell, the significance of such variations to C.F. has not been determined. Such studies have demonstrated several abnormalities of the c.F. cell in culture. Although none of these cited reports are specific for C.F., the features of the cultured cell with a c.F. gene are being evolved. Such research should aid in delineating the basic defect in C.F. Department of Medicine, Cornell University Medical College, New York, New York 10021, U.S.A. B.
B. SHANNON DANES.
A. G.
Danes, S., Beam, Lancet, 1969, ii, 437. Robertson, J. A., Chernick, B., Segal, D. J., McCoy, E. E. ibid. 1974, i, 1256. 3. Bafalluy, E., Egozcue, J., Goday, C. ibid. 1971, i, 973. 4. Weismann, U., Neufeld, E. F. J. Pediat. 1970, 77, 685. 5. Danes, B. S., Bearn, A. G. Biochem. biophys. Res. Commun. 1969, 36,
1. 2.
919. 6. Matalon, R., Dorfman, A. ibid. 1968, 33, 954. 7. Caudill,M., Schafer, I., Stjernholm, R. Lancet, 1974, i, 32. 8. Danes, B. S., Backofen, J. E., Rottell, B. K. Biochem. Genet. the press).
(in
operation
hypersensitivity reactions of this type caused by D.P.H. and C.B.Z., respectively. We believe that in our patient both drugs gave rise to the hypersensitivity reaction. Despite the fact that the patch test gave only partial information in this case, we agree that skin testing deserves more attention as a diagnostic aid in drug-hypersensitivity reactions.
TESTS FOR DRUG ALLERGY
SIR,-Felix and Comaish1 state that patch and intracutaneous tests, although often disappointing in hyperreactions to systemically administered drugs, worth while because there are no better alternatives, apart from clinical challenge. We should like to describe the information that patch tests and lymphocyte transformation tests gave in- another type of hypersensitivity reaction to systemically administered drugs. The patient was a 39-year-old man with a temporodiencephalic epilepsy. He had been given carbamazepine 300 mg. and diphenylhydantoin 150 mg. a day for 3 weeks when he had an extensive erythematous, maculopapular
Departments of Medicine and Dermatology, University Hospital, Oostersingel 59, Groningen, Netherlands.
sensitivity
J. HOUWERZIJL G. C.
DE
GAST
J. P. NATER.
are
rash, generalised lymphadenopathy, slight oedema, hepatoThe leucocyte-count was and fever (40°C). with c.mm. 11,000 per 6% eosinophils and 8% atypical the in differential count. Antinuclear antilymphocytes bodies were not present. After discontinuation of the drugs the patient recovered within a month. Hypersensitivity reactions of this type due to diphenylhydantoin are well known. However, a similar reaction due to carbamazepine has also been reported.2 To determine which drug caused the reaction both patch tests and in-vitro transformation tests were performed. Patch tests by the method of the International Contact Dermatitis Research Group3 were done with diphenylhydantoin (D.P.H.) and carbamazepine (c.B.z.) 1% and 5% in’Vaseline’. In the patient, 5 months after the onset of his illness, patch tests were negative for D.P.H. 1 % and 5% but were +++ for C.B.Z. 1% and ++++ for Tests in four controls were all negative. C.B.z. 5%. from the + + + reaction revealed typical eczematous Biopsy skin response with spongiosis, striking vesicle formation, and perivascular lymphocyte infiltration. Results of lymphocyte-transformation tests are summarised in the table.
megaly,
LYMPHOCYTE-TRANSFORMATION TESTS
(d.p.m. MEANrLS.D.)
I I I I Lymphocyte-transformation tests were performed as described elsewhere.’ Diphenylhydantoin and carbamazepine were dissolved in propyleneglycol (10%) at a concentration of 10 (1.g. per ml.
Patch tests indicated carbamazepine as the only sensitising to the lymphocyte-transformation tests both seemed to be involved. Although some workers5 could not confirm their results, the publications of Holland and Mauer6 and Virolainen2 indicate that lymphocytetransformation tests are of value in the diagnosis of
drug, while according
1.
2 3.
4
Felix, R. H., Comaish, J. S. Lancet, 1974, i, 1017. Virolamen, M. Clin. exp. Immun. 1971, 9, 429. Malten, K. E., Fregert, S., Bandmann, H. J., Calnan, C. D. Cronin, E., Hjorth, N., Magnusson, B., Maibach, H. I., Meneghini, C. L., Pirila, V., Wilkinson, D. S. Berufsdermatosen, 1971, 19, 1. Gast, G. C. de, Houwen, B., Nieweg, H. O. Br. med. J. 1973, iv, 707.
5. MacKinney, A. A., Booker, H. E. Archs intern. Med. 1972, 129, 988. 6. Holland, P., Mauer, A. M. Lancet, 1964 i, 1368.
UPTAKE OF 35S-HEPARIN BY LYMPHOCYTES FROM CYSTIC-FIBROSIS PATIENTS
SIR,-In 1969 Danes and Beam1 proposed that the metachromasia noted in short-term white-blood-cell cultures from both cystic fibrosis (c.F.) homozygotes and heterozygotes probably reflected uptake of heparin from the culture-medium by pinocytosis and not, as in the stored genetic mucopolysaccharidoses, mucopolysaccharides. This hypothesis was recently confirmed by Robertson et al.2 Using 35S-heparin they demonstrated an increased uptake of heparin in short-term C.F. white-blood-cell cultures which corresponded to the observations made on the basis of staining. However, as mentioned in 1971 by Bafalluy et al.,3 any white blood-cell in culture can be overloaded with heparin. As the processes involved in endocytosis and exocytosis probably are inconstant within one cell and certainly in different cell types, standardisation of cytoplasmic retention of heparin may not be possible in order to eliminate the partial overlap between normals, C.F. homozygotes and obligatory hetero2 zygotes observed by Robertson et al. This report on 35S-heparin uptake2 again raised the question of the significance of cellular mucopolysaccharides in cystic fibrosis. Although the authors clearly stated that they did not measure cellular mucopolysaccharides, they stated that their findings were consistent with previous reports of increased mucopolysaccharide synthesis in C.F. cells. On the basis of the references cited,2 the relevance of mucopolysaccharides in the c.F. cultured cell is still unclear. Between 1968 and 1970 the mucopolysaccharide content of the cultured fibroblast was reported as normal4 and variable.5,6 Caudill et aJ.7 have reported an increase in 35S incorporation into cellular mucopolysaccharides in short-term white-blood-cell cultures from some c.F. families. A relative increase in dermatan sulphate with a normal total mucopolysaccharide content has been found in long-term C.F. lymphoid lines. Although such reports imply alteration in cellular mucopolysaccharides in the cultured C.F. cell, the significance of such variations to C.F. has not been determined. Such studies have demonstrated several abnormalities of the c.F. cell in culture. Although none of these cited reports are specific for C.F., the features of the cultured cell with a c.F. gene are being evolved. Such research should aid in delineating the basic defect in C.F. Department of Medicine, Cornell University Medical College, New York, New York 10021, U.S.A. B.
B. SHANNON DANES.
A. G.
Danes, S., Beam, Lancet, 1969, ii, 437. Robertson, J. A., Chernick, B., Segal, D. J., McCoy, E. E. ibid. 1974, i, 1256. 3. Bafalluy, E., Egozcue, J., Goday, C. ibid. 1971, i, 973. 4. Weismann, U., Neufeld, E. F. J. Pediat. 1970, 77, 685. 5. Danes, B. S., Bearn, A. G. Biochem. biophys. Res. Commun. 1969, 36,
1. 2.
919. 6. Matalon, R., Dorfman, A. ibid. 1968, 33, 954. 7. Caudill,M., Schafer, I., Stjernholm, R. Lancet, 1974, i, 32. 8. Danes, B. S., Backofen, J. E., Rottell, B. K. Biochem. Genet. the press).
(in