- Email: [email protected]
VIRUS STERILITY FOR HUMAN GROWTH HORMONE
729
toxoplasmosis7 on five fetuses between 19 and 23 weeks of gestation and confirmed to be normal at birth. Fetal blood was taken on 0-13 mol/1 sodium citrate solution, as were control samples and samples from adults. Two-dimensional crossed warfarin-treated immunoelectrophoresis with anti-factor-11 antibody for the second electrophoresis was used,8 with the addition oaf 255 mmol/1 calcium lactate in the first electrophoresis. In all the fetal samples the precipitating antibody for factor II revealed a single tiny peak at the same position as the normal prothrombin peak of the control plasma. Plasma samples from patients receiving warfarin showed two peaks. These data confirm that the low levels of vitamin-K-dependent proteins in fetuses are not a consequence of vitamin K deficiency. Direct measurement of plasma vitamin K in fetal and cord blood may give a definitive answer to questions about the advisability of prophylactic administration at birth. Cumulative distribution of maternal milk intake in babies with and without PIVKA II (p<0*01, Kolmogorov-Smirnov test).
Prenatal
Diagnosis Centre,
Hôpital Notre Dame de Bon Secours, 75014 Paris, France
maternal milk is lower than that in formula or cow’s milk.The relevance of limited supply of maternal milk during the first days of life for babies without supplementary feeding has not hitherto been considered. The amount of maternal milk received per feed was recorded in 78 of 162 exclusively breastfed infants (figure). The average daily intake in babies with PIVKA II was significantly lower than that in babies without PIVKA II. The average daily intake was below 100 ml in 57% of the babies in whom PIVKA II was detected and in only 20% of the babies without PIVKA II. 32% of the PIVKA II negative babies had received more than 200 ml of maternal milk per day as compared with 2% of the babies in whom PIVKA II was detected. Thus nutritional factors related to the kind of feed and to daily intake must be considered when the incidence of vitamin K deficiency in healthy babies is being evaluated. Departments of Neonatology, Gastroenterology, and Paediatric Haematology and Oncology, Zentrum für Kinderheilkunde,
University of Düsseldorf, 4000 Düsseldorf 1, West Germany
R. V. KRIES U. GÖBEL B. MAASE
1. Motohara K, Kuroki, Y, Kan H, Endo F, Matsuda, I. Detection of vitamin K deficiency by the use of an enzyme-linked immunosorbent assay for circulating abnormal prothrombin. Pediatr Res 1985; 19: 354-57. 2. Keenan WJ, Jewett Th, Glueck HI Role offeeding and vitamin K in hypoprothrombinemia of the newborn. Am J Dis Child 1971; 121: 524-33. 3 Göbel U, Sonnenschein-Kosenow S, Petrich C, von Voss H. Vitamin K deficiency in the newborn. Lancet 1977; ii: 187-88. 4. von Kries R, Zenses Ch, Göbel U. Immunoelectrophoretic determination of PIVKA II in capillary plasma. Haemostasis 1985; 15: 42-43. 5. van Dorm JM, Muller AD, Hemker HC. Heparin-like inhibitor, not vitamin K deficiency in the newborn. Lancet 1977; i: 852-53. 6 Malia RG, Preston FE, Mitchell VE Evidence against vitamin K deficiency in normal neonates Thromb Haemost 1980; 44: 159-60. 7. Haroon Y, Shearer MJ, Gunn WG, McEnery G, Barkhan P. The content of phylloquinone (vitamin K 1) in human milk, cow’s milk and infant formula foods determined by high-performance liquid chromatography. J Nutr 1982; 112: 1105-17.
SIR,-Dr Motohara and colleagues found that 215% of newborn babies showed evidence of circulating acarboxyprothrombin (PIVKA II) in cord blood. Previous workers have reported frequencies of 28%1 to 42%,2while others found no PIVKA II in cord plasma.3,4 Thus the advisability of routine prophylactic vitamin K for newborn babies remains controversial. We have low levels of vitamin-K-dependent coagulation factors in fetuses. In contrast to the pattern in vitamin-K-deficiency states, factor II and IX antigen activities correlated well with procoagulant activities. These data suggest that low levels of vitamin-K-dependent clotting factors found in fetal plasma may not be related ’to vitamin K 5
deficiency.5
We have demonstrated the absence of PIVKA II in fetal plasma during the second trimester of pregnancy. Fetal blood samples were obtained from the umbilical cord by direct puncture under ultrasound guidance.6 Sampling was done for prenatal diagnosis of
F. FORESTIER F. DAFFOS M. RAINAUT
1. Muntean W, Petek W, Rosanelli K, et al. Immunologic studies of prothrombin in newborns. Pediatr Res 1979; 13: 1262-65. 2. Bloch CA, Rothberg AD, Bradlow BA. Mother-infant prothrombin precursor status at birth. J Pediatr Gastroenterol Nutr 1984; 3: 101-03. 3 Van Doorm JM, Muller AD, Hemker HC. Heparin-like inhibitor, not vitamin-K deficiency in the newborn. Lancet 1977, i: 852-53. 4. Malia RG, Preston FE, Mitchell VE. Evidence against vitamin K deficiency in normal neonates Thromb Haemostas 1980, 44: 159-60. 5. Forestier F, Daffos F, Rainaut M, Solé Y, Amiral J Vitamin K dependent proteins in fetal hemostasis at mid trimester of pregnancy. Thromb Haemostas 1985; 53: 401-03 6. Daffos F, Capella-Pavlovsky M, Forestier F. A new procedure for fetal blood sampling in utero. Am J Obstet Gynecol 1984; 146: 985-87. 7. Desmonts G, Daffos F, Forestier F, Thulliez P, Capella-Pavlovsky M, Chartier M. Prenatal diagnosis of congenital toxoplasmosis. Lancet 1985; i: 500-03. 8. Clarke HG, Freeman TA. A quantitative immunoelectrophoresis method (Laurell electrophoresis). Protides Biol Fluids 1967; 14: 503-09.
VIRUS STERILITY FOR HUMAN GROWTH HORMONE
SIR,-The study by Dr Taylor and colleagues (Aug 3, p 260) on the preparation of human growth hormone "free from contamination with unconventional slow viruses", although done with impeccable scientific care, has nevertheless not confirmed the freedom from contamination indicated by the title of the article. Taylor et al have certainly demonstrated a very substantial reduction in virus infectivity during preparation of growth hormone according to the Lowry protocol; however, the experiments were done in a way that leaves unanswered the question of whether full sterility was in fact achieved. The total volume of the final purified product must be used for attempted virus transmission if an occasional, randomly distributed, infectious particle is not to be missed. Taylor tells me that the volume of the final product was 10 ml but that only 0-36 ml of this undiluted material was inoculated into animals (plus about 0-04 ml additional volume inoculated in the further 10-fold dilution series). There is thus only a 0-40/10 (=0-04) chance that a single infectious particle would have been detected. The probability was roughly doubled by the performance of replicate experiments, but that still produced less than a l-in-10 chance of detecting a single particle in the combined
experiments. There
are
4 known
cases
of Creutzfeldt-Jakob disease in the
population of about 15 000 recipients of pituitary-derived human growth hormone in the United States and United Kingdom. Because of some lots shared by the US patients virus contamination least three different lots of hormone is implicated. It is no means certain, that the extent of this contamination was not greater than the level of undetected virus in the experimental study discussed here-ie, only one or a very few infectious particles randomly distributed amongst individual ampoules of a contaminated lot. A long-term epidemiological study of the entire US recipient cohort that is now underway will determine the full extent of the problem. Should pituitary-derived growth hormone still be
of
at
hoped, but by
730
required in the future by patients who for any reason cannot take the synthetic product that is expected soon to be widely available, manufacturing protocols will need to be developed and experimentally tested in a manner that will rigorously guarantee the absence of any contaminating viruses. This issue is now under formal scrutiny by both the US Food and Drug Administration and the National Institutes of Health. Laboratory of
CNS Studies,
NINCDS, National Institutes of Health, Bethesda, Maryland 20205, USA
PAUL BROWN
1. Brown P,
Gajdusek DC, Gibbs CJ Jr, Asher DM. Potential epidemic of CreutzfeltJakob disease from human growth hormone therapy N Engl JMed 1985, 313: 728-31.
TRANSDERMAL NITRATES ’
SiR,-Your editorial (Sept 14, p 594) presents a good overview of of the main issues surrounding this form of treatment. As the manufacturers of ’Transiderm-Nitro’ (TTS-NG), we concur with your statement that "patients find transdermal nitrate therapy effective and acceptable’’, and this is ampl supported by clinical some
of patients. ,2
studies involving large numbers However, we believe "A clinical statement effect lasting for 24 hours is that your further comment. In addition to the papers you unproven" requires cite, we would draw your attention to those by Wiechmann et at3 and Scardi et al. Both of these show TTS-NG to have an effect at 24
hours. Whilst Wiechmann et al’s report refers to haemodynamic effects, that by Scardi et al states "In comparison with placebo, both TTS-NG doses (20 and 40 cm2) induced a statistically significant (p<0 . O1) increase in total duration of exercise, in exercise duration to 1 mm S-T segment depression, in maximum workload, and in total work performed at both 4 and 24 hours after dosing". It should also be noted that many of the issues raised in your editorial are equally applicable to oral long-acting nitrates. Ciba-Geigy Pharmaceuticals, Horsham,
J. G. DOMENET,
West Sussex RH12 4AB
Medical Director
H, Johnson LC. Therapy of angina pectoris with Nitroderm-TTS. Results ofa multicentre field study in 37 956 patients. Med Welt 1984; 35: 326-32. 2. Bridgman KM, Carr M, Tattersall AB. Post-marketing surveillance ofthe TransidermNitro patch in general practice. J Int Med Res 1984; 12: 40-45. 3. Wiechmann HW, Schuster P, Trieb G. Transdermal administration of glyceryl trinitrate by means of a new therapeutic system: haemodynamic effects in patients with coronary heart disease. Herzmedizin 1984; 7: 189-96. 4. Scardi S, Pivotti F, Fonda F, et al. Effect of a new transdermal therapeutic system containing nitroglycerin on exercise capacity in patients with angina pectoris. Am 1. Letzel
Heart J 1985; 110: 546-51.
and, besides the purpura, had an aplastic crisis (Hb 8’44 g/dl with no In all four cases liver function and coagulation tests normal. Other recent infections were excluded by tests for hepatitis A and B, infectious mononucleosis, cytomegalovirus, toxoplasmosis, mumps, and rubella. Blood cultures and throat and urine samples were sterile. Circulating immune complexes were not found. HPV was detected by counter-immunoelectrophoresis in the sera of the 33-year-old woman and the 11-year-old boy; these samples had been drawn on the day of admission. In both cases a later sample contained HPV antibody. The 11-year-old girl’s blood was sampled 4 days after the onset of purpura and 5 days after the onset of aplastic crisis. HPV was not found, but the presence ofantiHPV-IgM indicated recent infection.9 The 5-year-old girl with Henoch-Schönlein purpura also had an anti-HPV-IgM response. Vascular purpura has been reported in virus infections such as infectious mononucleosis and hepatitis B,1O cytomegalovirus" infection. HPV could be another cause. Fifth disease and vascular purpura concurrently in one family and aplastic crisis and vascular purpura coinciding in one patient suggest that the same virus is causing the different diseases. HPV could be a trigger for HenochSchonlein purpura, and its involvement could explain the childhood predominance, seasonal clustering, and joint pain seen in that disease. We suggest that HPV is a cause of vascular purpura and that it may be involved in some cases of Henoch-Schonlein purpura.
reticulocytes).
were
JEAN-JACQUES LEFRERE Centre National de Transfusion Sanguine, 6 rue Alexandre Cabanel, 75015 Paris, France; and Department of Haematology, Hôpital Saint-Louis, Paris
ANNE-MARIE COUROUCÉ
JEAN-YVES MULLER MICHAEL CLARK
JEAN-PIERRE SOULIER
1 Cossart YE, Field AM, Cant B, Widdows D Parvovirus-like particles in human sera. Lancet 1975; i: 72-73. 2. Couroucé AM, Ferchal F, Morinet F, Perol Y, Drouet J, Muller A, Soulier JP. Human parvovirus infection in France Lancet 1984; i: 160. 3. Anderson MJ, Davis LR, Hodgson J, et al Occurrence of infection with a parvoviruslike agent in children with sickle anaemia during a two-year period. J Clin Pathol 1982, 35: 744-49 4. Lefrère JJ, Courouce AM, Girot R, Bertrand Y, Soulier JP. Six cases of hereditary spherocytosis revealed by human parvovirus aplastic crisis Br J Haematol (in
press). JM, Mortimer PP, Vandervelde EM Febrile illness due to a parvovirus Br Med J 1980; 280: 1580-82. Anderson MJ, Jones SE, Fisher-Hoch SP, Lewis E, Hall SM, Bartlett CLR, Cohen BJ, Mortimer PP, Pereira MS Human parvovirus, the cause of erythema infectiosum (fifth disease)? Lancet 1983; i: 1378. Lefrère JJ, Couroucé AM Aplastic crisis and erythema infectiosum (fifth disease) in a familial human parvovirus (HPV) infection. Br Med J 1985; 290: 112. White DG, Woolf AD, Mortimer PP, et al. Human parvovirus arthropathy. Lancet
5. Shneerson 6.
7. 8.
1985; i: 419-21 9 Cohen BJ, Mortimer PP, Pereira MS Diagnostic assays with monoclonal antibodies for the serum parvovirus-like virus J Hyg (Camb) 1983; 91: 113-30. 10. Gocke DJ, Hsu K, Bombardieri S, et al. Vasculitis in association with Australian antigen J Exp Med 1971; 134: 330 11. Bamji A, Salisbury R Cytomegalovirus and vasculitis. Br Med J 1978; i: 623.
HUMAN PARVOVIRUS AND PURPURA
SIR,-Human parvovirus (HPV) was first found in serum of largely symptomless blood donors,I,2 and has subsequently been associated with aplastic crisis in patients with chronic haemolytic anaemias, 3,4 minor febrile illness,5fifth disease (erythema infectiosum), 6, and arthropathies. We report here four parvovirus infections with vascular purpura. 48 hours after the onset of fever, shivers, and rhinopharyngitis, three female patients (aged 5, 11, and 33 years) and one male (aged 11 years) had non-necrotic petechial purpura. The boy’s mother and sister presented at the same time with typical fifth disease. Purpura was present on the legs in all patients and extended to the abdomen in one case and to the thorax and upper limbs in two others. It resolved within a few days. There was no drug intake. Examination revealed no mucosal haemorrhage or associated exanthema. Cervical lymphadenopathy was present in two cases. The 5-year-old girl was diagnosed as having Henoch-Schonlein purpura, on the basis of lower limb petechial purpura, pain in large joints (knee, ankle, wrist), and intense abdominal pain. All four patients had a moderate, transient neutropenia. Platelet counts were above 150 x 109/1 and haemoglobin concentrations were normal except in the 11-year-old girl, who had 0-thalassaemia
SIR,-We describe here two cases of purpura associated with human parvovirus (HPV) B 19 infection. A 5-year-old girl was noticed to have bruising. She was afebrile but had a runny nose. A few days later red cheeks and a rash on the thighs developed. The bruising persisted and a blood test revealed a normal haemoglobin concentration and white cell count but a platelet count of 33 x 109/1. Bone marrow examination revealed increased numbers of megakaryocytes. Anti-HPV-IgM (above 100 units) and anti-HPV-IgG (34 units) were found in the serum. The platelet count rapidly’ returned to normal. A convalescent serum sample 17 days later contained anti-HPV-IgM (7 units) and anti-
HPV-IgG(60 units).
50-year-old man had a purpuric rash on his body and legs and He had had mild diarrhoea 5 days before the onset of rash. An acute serum sample contained anti-HPV-IgM (above 100 units) and anti-HPV-IgG (80 units). His platelet count was normal. The other positive findings were a low C4 and a positive glandular fever slide test, though Epstein-Barr virus IgM antibody was absent. A convalescent serum sample collected 22 days later, when A
joint pains.
there
was some
persistence of the rash, contained anti-HPV-IgM
(100 units) and anti-HPV-IgG (80 units).
toxoplasmosis7 on five fetuses between 19 and 23 weeks of gestation and confirmed to be normal at birth. Fetal blood was taken on 0-13 mol/1 sodium citrate solution, as were control samples and samples from adults. Two-dimensional crossed warfarin-treated immunoelectrophoresis with anti-factor-11 antibody for the second electrophoresis was used,8 with the addition oaf 255 mmol/1 calcium lactate in the first electrophoresis. In all the fetal samples the precipitating antibody for factor II revealed a single tiny peak at the same position as the normal prothrombin peak of the control plasma. Plasma samples from patients receiving warfarin showed two peaks. These data confirm that the low levels of vitamin-K-dependent proteins in fetuses are not a consequence of vitamin K deficiency. Direct measurement of plasma vitamin K in fetal and cord blood may give a definitive answer to questions about the advisability of prophylactic administration at birth. Cumulative distribution of maternal milk intake in babies with and without PIVKA II (p<0*01, Kolmogorov-Smirnov test).
Prenatal
Diagnosis Centre,
Hôpital Notre Dame de Bon Secours, 75014 Paris, France
maternal milk is lower than that in formula or cow’s milk.The relevance of limited supply of maternal milk during the first days of life for babies without supplementary feeding has not hitherto been considered. The amount of maternal milk received per feed was recorded in 78 of 162 exclusively breastfed infants (figure). The average daily intake in babies with PIVKA II was significantly lower than that in babies without PIVKA II. The average daily intake was below 100 ml in 57% of the babies in whom PIVKA II was detected and in only 20% of the babies without PIVKA II. 32% of the PIVKA II negative babies had received more than 200 ml of maternal milk per day as compared with 2% of the babies in whom PIVKA II was detected. Thus nutritional factors related to the kind of feed and to daily intake must be considered when the incidence of vitamin K deficiency in healthy babies is being evaluated. Departments of Neonatology, Gastroenterology, and Paediatric Haematology and Oncology, Zentrum für Kinderheilkunde,
University of Düsseldorf, 4000 Düsseldorf 1, West Germany
R. V. KRIES U. GÖBEL B. MAASE
1. Motohara K, Kuroki, Y, Kan H, Endo F, Matsuda, I. Detection of vitamin K deficiency by the use of an enzyme-linked immunosorbent assay for circulating abnormal prothrombin. Pediatr Res 1985; 19: 354-57. 2. Keenan WJ, Jewett Th, Glueck HI Role offeeding and vitamin K in hypoprothrombinemia of the newborn. Am J Dis Child 1971; 121: 524-33. 3 Göbel U, Sonnenschein-Kosenow S, Petrich C, von Voss H. Vitamin K deficiency in the newborn. Lancet 1977; ii: 187-88. 4. von Kries R, Zenses Ch, Göbel U. Immunoelectrophoretic determination of PIVKA II in capillary plasma. Haemostasis 1985; 15: 42-43. 5. van Dorm JM, Muller AD, Hemker HC. Heparin-like inhibitor, not vitamin K deficiency in the newborn. Lancet 1977; i: 852-53. 6 Malia RG, Preston FE, Mitchell VE Evidence against vitamin K deficiency in normal neonates Thromb Haemost 1980; 44: 159-60. 7. Haroon Y, Shearer MJ, Gunn WG, McEnery G, Barkhan P. The content of phylloquinone (vitamin K 1) in human milk, cow’s milk and infant formula foods determined by high-performance liquid chromatography. J Nutr 1982; 112: 1105-17.
SIR,-Dr Motohara and colleagues found that 215% of newborn babies showed evidence of circulating acarboxyprothrombin (PIVKA II) in cord blood. Previous workers have reported frequencies of 28%1 to 42%,2while others found no PIVKA II in cord plasma.3,4 Thus the advisability of routine prophylactic vitamin K for newborn babies remains controversial. We have low levels of vitamin-K-dependent coagulation factors in fetuses. In contrast to the pattern in vitamin-K-deficiency states, factor II and IX antigen activities correlated well with procoagulant activities. These data suggest that low levels of vitamin-K-dependent clotting factors found in fetal plasma may not be related ’to vitamin K 5
deficiency.5
We have demonstrated the absence of PIVKA II in fetal plasma during the second trimester of pregnancy. Fetal blood samples were obtained from the umbilical cord by direct puncture under ultrasound guidance.6 Sampling was done for prenatal diagnosis of
F. FORESTIER F. DAFFOS M. RAINAUT
1. Muntean W, Petek W, Rosanelli K, et al. Immunologic studies of prothrombin in newborns. Pediatr Res 1979; 13: 1262-65. 2. Bloch CA, Rothberg AD, Bradlow BA. Mother-infant prothrombin precursor status at birth. J Pediatr Gastroenterol Nutr 1984; 3: 101-03. 3 Van Doorm JM, Muller AD, Hemker HC. Heparin-like inhibitor, not vitamin-K deficiency in the newborn. Lancet 1977, i: 852-53. 4. Malia RG, Preston FE, Mitchell VE. Evidence against vitamin K deficiency in normal neonates Thromb Haemostas 1980, 44: 159-60. 5. Forestier F, Daffos F, Rainaut M, Solé Y, Amiral J Vitamin K dependent proteins in fetal hemostasis at mid trimester of pregnancy. Thromb Haemostas 1985; 53: 401-03 6. Daffos F, Capella-Pavlovsky M, Forestier F. A new procedure for fetal blood sampling in utero. Am J Obstet Gynecol 1984; 146: 985-87. 7. Desmonts G, Daffos F, Forestier F, Thulliez P, Capella-Pavlovsky M, Chartier M. Prenatal diagnosis of congenital toxoplasmosis. Lancet 1985; i: 500-03. 8. Clarke HG, Freeman TA. A quantitative immunoelectrophoresis method (Laurell electrophoresis). Protides Biol Fluids 1967; 14: 503-09.
VIRUS STERILITY FOR HUMAN GROWTH HORMONE
SIR,-The study by Dr Taylor and colleagues (Aug 3, p 260) on the preparation of human growth hormone "free from contamination with unconventional slow viruses", although done with impeccable scientific care, has nevertheless not confirmed the freedom from contamination indicated by the title of the article. Taylor et al have certainly demonstrated a very substantial reduction in virus infectivity during preparation of growth hormone according to the Lowry protocol; however, the experiments were done in a way that leaves unanswered the question of whether full sterility was in fact achieved. The total volume of the final purified product must be used for attempted virus transmission if an occasional, randomly distributed, infectious particle is not to be missed. Taylor tells me that the volume of the final product was 10 ml but that only 0-36 ml of this undiluted material was inoculated into animals (plus about 0-04 ml additional volume inoculated in the further 10-fold dilution series). There is thus only a 0-40/10 (=0-04) chance that a single infectious particle would have been detected. The probability was roughly doubled by the performance of replicate experiments, but that still produced less than a l-in-10 chance of detecting a single particle in the combined
experiments. There
are
4 known
cases
of Creutzfeldt-Jakob disease in the
population of about 15 000 recipients of pituitary-derived human growth hormone in the United States and United Kingdom. Because of some lots shared by the US patients virus contamination least three different lots of hormone is implicated. It is no means certain, that the extent of this contamination was not greater than the level of undetected virus in the experimental study discussed here-ie, only one or a very few infectious particles randomly distributed amongst individual ampoules of a contaminated lot. A long-term epidemiological study of the entire US recipient cohort that is now underway will determine the full extent of the problem. Should pituitary-derived growth hormone still be
of
at
hoped, but by
730
required in the future by patients who for any reason cannot take the synthetic product that is expected soon to be widely available, manufacturing protocols will need to be developed and experimentally tested in a manner that will rigorously guarantee the absence of any contaminating viruses. This issue is now under formal scrutiny by both the US Food and Drug Administration and the National Institutes of Health. Laboratory of
CNS Studies,
NINCDS, National Institutes of Health, Bethesda, Maryland 20205, USA
PAUL BROWN
1. Brown P,
Gajdusek DC, Gibbs CJ Jr, Asher DM. Potential epidemic of CreutzfeltJakob disease from human growth hormone therapy N Engl JMed 1985, 313: 728-31.
TRANSDERMAL NITRATES ’
SiR,-Your editorial (Sept 14, p 594) presents a good overview of of the main issues surrounding this form of treatment. As the manufacturers of ’Transiderm-Nitro’ (TTS-NG), we concur with your statement that "patients find transdermal nitrate therapy effective and acceptable’’, and this is ampl supported by clinical some
of patients. ,2
studies involving large numbers However, we believe "A clinical statement effect lasting for 24 hours is that your further comment. In addition to the papers you unproven" requires cite, we would draw your attention to those by Wiechmann et at3 and Scardi et al. Both of these show TTS-NG to have an effect at 24
hours. Whilst Wiechmann et al’s report refers to haemodynamic effects, that by Scardi et al states "In comparison with placebo, both TTS-NG doses (20 and 40 cm2) induced a statistically significant (p<0 . O1) increase in total duration of exercise, in exercise duration to 1 mm S-T segment depression, in maximum workload, and in total work performed at both 4 and 24 hours after dosing". It should also be noted that many of the issues raised in your editorial are equally applicable to oral long-acting nitrates. Ciba-Geigy Pharmaceuticals, Horsham,
J. G. DOMENET,
West Sussex RH12 4AB
Medical Director
H, Johnson LC. Therapy of angina pectoris with Nitroderm-TTS. Results ofa multicentre field study in 37 956 patients. Med Welt 1984; 35: 326-32. 2. Bridgman KM, Carr M, Tattersall AB. Post-marketing surveillance ofthe TransidermNitro patch in general practice. J Int Med Res 1984; 12: 40-45. 3. Wiechmann HW, Schuster P, Trieb G. Transdermal administration of glyceryl trinitrate by means of a new therapeutic system: haemodynamic effects in patients with coronary heart disease. Herzmedizin 1984; 7: 189-96. 4. Scardi S, Pivotti F, Fonda F, et al. Effect of a new transdermal therapeutic system containing nitroglycerin on exercise capacity in patients with angina pectoris. Am 1. Letzel
Heart J 1985; 110: 546-51.
and, besides the purpura, had an aplastic crisis (Hb 8’44 g/dl with no In all four cases liver function and coagulation tests normal. Other recent infections were excluded by tests for hepatitis A and B, infectious mononucleosis, cytomegalovirus, toxoplasmosis, mumps, and rubella. Blood cultures and throat and urine samples were sterile. Circulating immune complexes were not found. HPV was detected by counter-immunoelectrophoresis in the sera of the 33-year-old woman and the 11-year-old boy; these samples had been drawn on the day of admission. In both cases a later sample contained HPV antibody. The 11-year-old girl’s blood was sampled 4 days after the onset of purpura and 5 days after the onset of aplastic crisis. HPV was not found, but the presence ofantiHPV-IgM indicated recent infection.9 The 5-year-old girl with Henoch-Schönlein purpura also had an anti-HPV-IgM response. Vascular purpura has been reported in virus infections such as infectious mononucleosis and hepatitis B,1O cytomegalovirus" infection. HPV could be another cause. Fifth disease and vascular purpura concurrently in one family and aplastic crisis and vascular purpura coinciding in one patient suggest that the same virus is causing the different diseases. HPV could be a trigger for HenochSchonlein purpura, and its involvement could explain the childhood predominance, seasonal clustering, and joint pain seen in that disease. We suggest that HPV is a cause of vascular purpura and that it may be involved in some cases of Henoch-Schonlein purpura.
reticulocytes).
were
JEAN-JACQUES LEFRERE Centre National de Transfusion Sanguine, 6 rue Alexandre Cabanel, 75015 Paris, France; and Department of Haematology, Hôpital Saint-Louis, Paris
ANNE-MARIE COUROUCÉ
JEAN-YVES MULLER MICHAEL CLARK
JEAN-PIERRE SOULIER
1 Cossart YE, Field AM, Cant B, Widdows D Parvovirus-like particles in human sera. Lancet 1975; i: 72-73. 2. Couroucé AM, Ferchal F, Morinet F, Perol Y, Drouet J, Muller A, Soulier JP. Human parvovirus infection in France Lancet 1984; i: 160. 3. Anderson MJ, Davis LR, Hodgson J, et al Occurrence of infection with a parvoviruslike agent in children with sickle anaemia during a two-year period. J Clin Pathol 1982, 35: 744-49 4. Lefrère JJ, Courouce AM, Girot R, Bertrand Y, Soulier JP. Six cases of hereditary spherocytosis revealed by human parvovirus aplastic crisis Br J Haematol (in
press). JM, Mortimer PP, Vandervelde EM Febrile illness due to a parvovirus Br Med J 1980; 280: 1580-82. Anderson MJ, Jones SE, Fisher-Hoch SP, Lewis E, Hall SM, Bartlett CLR, Cohen BJ, Mortimer PP, Pereira MS Human parvovirus, the cause of erythema infectiosum (fifth disease)? Lancet 1983; i: 1378. Lefrère JJ, Couroucé AM Aplastic crisis and erythema infectiosum (fifth disease) in a familial human parvovirus (HPV) infection. Br Med J 1985; 290: 112. White DG, Woolf AD, Mortimer PP, et al. Human parvovirus arthropathy. Lancet
5. Shneerson 6.
7. 8.
1985; i: 419-21 9 Cohen BJ, Mortimer PP, Pereira MS Diagnostic assays with monoclonal antibodies for the serum parvovirus-like virus J Hyg (Camb) 1983; 91: 113-30. 10. Gocke DJ, Hsu K, Bombardieri S, et al. Vasculitis in association with Australian antigen J Exp Med 1971; 134: 330 11. Bamji A, Salisbury R Cytomegalovirus and vasculitis. Br Med J 1978; i: 623.
HUMAN PARVOVIRUS AND PURPURA
SIR,-Human parvovirus (HPV) was first found in serum of largely symptomless blood donors,I,2 and has subsequently been associated with aplastic crisis in patients with chronic haemolytic anaemias, 3,4 minor febrile illness,5fifth disease (erythema infectiosum), 6, and arthropathies. We report here four parvovirus infections with vascular purpura. 48 hours after the onset of fever, shivers, and rhinopharyngitis, three female patients (aged 5, 11, and 33 years) and one male (aged 11 years) had non-necrotic petechial purpura. The boy’s mother and sister presented at the same time with typical fifth disease. Purpura was present on the legs in all patients and extended to the abdomen in one case and to the thorax and upper limbs in two others. It resolved within a few days. There was no drug intake. Examination revealed no mucosal haemorrhage or associated exanthema. Cervical lymphadenopathy was present in two cases. The 5-year-old girl was diagnosed as having Henoch-Schonlein purpura, on the basis of lower limb petechial purpura, pain in large joints (knee, ankle, wrist), and intense abdominal pain. All four patients had a moderate, transient neutropenia. Platelet counts were above 150 x 109/1 and haemoglobin concentrations were normal except in the 11-year-old girl, who had 0-thalassaemia
SIR,-We describe here two cases of purpura associated with human parvovirus (HPV) B 19 infection. A 5-year-old girl was noticed to have bruising. She was afebrile but had a runny nose. A few days later red cheeks and a rash on the thighs developed. The bruising persisted and a blood test revealed a normal haemoglobin concentration and white cell count but a platelet count of 33 x 109/1. Bone marrow examination revealed increased numbers of megakaryocytes. Anti-HPV-IgM (above 100 units) and anti-HPV-IgG (34 units) were found in the serum. The platelet count rapidly’ returned to normal. A convalescent serum sample 17 days later contained anti-HPV-IgM (7 units) and anti-
HPV-IgG(60 units).
50-year-old man had a purpuric rash on his body and legs and He had had mild diarrhoea 5 days before the onset of rash. An acute serum sample contained anti-HPV-IgM (above 100 units) and anti-HPV-IgG (80 units). His platelet count was normal. The other positive findings were a low C4 and a positive glandular fever slide test, though Epstein-Barr virus IgM antibody was absent. A convalescent serum sample collected 22 days later, when A
joint pains.
there
was some
persistence of the rash, contained anti-HPV-IgM
(100 units) and anti-HPV-IgG (80 units).