saline. To enhance sensitivity, 200 tL of. Table 2. Amniotic Fluid a2-Macrogiobulin. Concentrations in Non-Normal. Pregnancies. Case. Anencephaly. 16. 15-16.
References ,,,,,uL
u0
200
NCI
‘1
.00
I
t
mmol/L
MaCI
I
1. Hoag, G. N., Amies, D. R., and Colquhoun, B. P.D.,The production of creatine kinase isozyme BB in sara of a patient with prostatic carcinoma and in tissue homogenates. Clin.
11,2 (1978). 2. Jockers-Wretou, V., Biochem. .5
U
and Pfleiderer,
4
(1978). 3. Tsung, S. A., Creatine kinase patterns in human tissue obtained
V
0
Fig. 2. The 0
5 F,a,iun
10
IS
20
Numb.,
5 Fraction
10
15
20
Numb.,
corresponding elution pattern
of CK isoenzymes
from malignant
lym-
phoma of the testis
Fig. 1. The column-chromatographic (Sephadex DEAE-50) elution pattern of CK to the predominance of CK1 previously isoenzymesin normaltesticular tissue reported (1) for apparent histologically Elution was stepwise with Iris (50 mmol/L) connormal tissue adjacent to the embryonal taining, per liter, 100 mmol of NaCI (pH 7.0),200 mmol NaCI (pH 7.0),and 400 mmol
NaCI (pH 8.0).
CK activity: U/L per 0.2 g of tissue
and one sample of lymphoblastic lymphosarcoma of the testicle. The normal testicular tissues were obtained at autopsy with the cause of death not related to a testicular lesion. The lymphoblastic lymphosarcoma was obtained by removal of the diseased testicle from a patient who was otherwise normal. The latter histopathologic diagnosis was made by the Section of Surgical Pathology, University Hospital, Saskatoon,
Canada. The specimens were prepared and handled as described by Wong and Swallen (5). The electrophoretic pattern was determined both by agarose (Corning ACT, Medfield, MA 07052) and cellulose acetate procedures (Beckman Instruments, Toronto, Ontario M8Z 5T2). All samples were column-chromatographed, with discontinuous-gradient elution with increasing salt concentrations, as previously described (1). The CK activity in the eluted fractions was analyzed by using “A-Gent” (Abbott Laboratories, South Pasadena, CA 91030) reagents and a discrete analyzer (ABA-100, Abbott Laboratories). Figure 1 shows a typical columnchromatographic pattern for the CK isoenzymes in the four normal testicles. CK3 predominates, with a lesser amount of CK1. We saw no peak corresponding to CK2 on column chromatography, nor did we see a band on electrophoresis in the region corresponding to this fraction. This is different from the adjacent non-neoplastic tissue in the case of embryonal testicular carcinoma (1), in which CK1 exceeded CK3. Because these tissues were considered normal, the consistent pattern in this study evidently reflects the CK isoenzyme production when testicular structure and function are normal. The absence of CK2, the presence of CK1 and CK3, and the predominance of CK3 are in contrast
G.,
Quantitation of creatine kinases isoenzymes in human tissues and serum by an immunological method. Clin. Chim. Acta 58, 223
P.ak
testicular carcinomatous tissue. The testicular tissue from the patient with the lymphoblastic lymphosarcoma contained only CK1 activity (Figure 2); only CK3 was detected in the patient’s serum. In an attempt to ascertain the origin of the CK1 in the malignant testicular lymphoma, we measured the CK isoenzymes of normal peripheral blood lymphocytes before and after culture with the mitogens concanavalin A (Con-A) and phytohemagglutinin (PHA). Neither the normal or the blast-transformed lymphocytes contained any CK. These studies suggest that lymphocytes are an unlikely source of CK1. However, it is well known that lymphocytes are very heterogenous in regard to their functional activity (6). Thus, it would seem reasonable to assume that populations of lymphocytes may vary in their biochemical activity as well. For instance, it is possible that the specific clone of lymphocytes present in the testicular lymphoma we described contained CK1, even though CK isoenzymes were not detected in the populations of peripheral blood lymphocytes that were studied. Alternatively, nonlymphocytic elements such as seminiferous tubular tissue could have been the source of CK1 in our case. Thus the precise origin of CK1 in lymphoblastic lymphosarcoma of testicle awaits further investigation of similar cases and of malignant lymphomata from other sites. It would also be of interest to study the CK isoenzyme content of testicular tumors of non-lymphocytic origin such as seminoma. The predominance of the CK1 fraction may represent a common end-stage isoenzyme alteration, or the CK1 might represent the isoenzyme composition of a specific cell type that has become neoplastic. The neoplasms of testicular tissue may assist in determining the cellular origin of serum CK fractions and whether a specific CK isoenzyme may be correlated to a specific cell lineage.
isoenzyme at surgery.
Clin. Chem. 22,173 (1976). 4. Yasmineh, W. G., Pyle, R. B., Hanson, N. Q., and Hultman, B. K., Creatine kinase isoenzymes in baboon tissues and organs. Clin. Chem. 22, 63 (1976). 5. Wong, R., and Swallen, T. 0., Cellulose acetate electrophoresis of creatine phosphokinase isoenzymes in the diagnosis of myocardial infarction. Am. J. Clin. Pathol.
64,209 (1975). 6. Chess, L.,and lymphocyte
Schlossman, S. F.,Human
subpopulations.
Ado. Immunol.
25, 213 (1977).
Gordon N. bag Rajpal Singh Christopher R. Franks W. Earle DeCoteau Rheumatic Cancer University University Saskatoon,
Disease Unit and Clinic Hospital of Saskatchewan Saskatchewan, Canada
Typhoid Fever Toxemia with Associated Destruction of Skeletal
Muscle To the Editor: A 23-year-old woman was admitted here with watery and bloody diarrhea, fever, chills, diaphoresis, disorientation, agitation, and inability to stand up. Other vital signs were normal. The admitting diagnosis was acute encephalitis with possible bacterial sepsis. Empiric
broad-spectrum antibiotic therapy was begun, but proved ineffective. She was placed
in enteric
isolation,
and during
her first 6 days in the hospital she had hallucinations, fever of 40-41 #{176}C, tachycardia, anorexia, hyperpnea, and diaphoresis. Most striking was the marked rigidity of her extremities, with intermittent agitation. Pneumonia was suspected because of patchy infiltrates of both lungs. She developed metabolic acidosis and hypoxia with arterial po2 values of 50-60 mmHg. Her urine specimens were dark amber in color and positive for hemoglobin and (or) myoglobin. On the 6th hospital day, a culture of blood grew out a Gram-negative rod, which serologically agglutinated with Salmonella group D antisera. The organism was identified as Salmonella typhi with biochemical tests. Choram-
CLINICALCHEMISTRY,Vol.26,No. 9, 1980
1361
CHI.OR 4
0 HOSPITAL
2
16
20
24
DAY
Fig. 1. Enzyme data on patient course of hospital stay
during
Chior.’ Indicates the day when chloramphenlcol administration was begun; CX, creatine kinase; W, lactate dehydrogenase;ALT, alanine aminotransferase (EC 2.6.1.2); AST. aspartate aminotransferase (EC 2.6.1.1); Alk. phos., alkaline phosphatase (EC3.1.3.1)
seen before day 10 probably came from skeletal muscle. About 0.4% of the CK in normal skeletal muscle is the MB isoenzyme (2). In view of the suspected large amount of skeletal muscle damage that was occurring, the significant amount of CK-MB we saw was not surprising in the samples with up to 240fold the upper-reference activity of CK. It is unlikely that the CK-MB came from the myocardium, because there was no clinical, biochemical, or electrocardiographic evidence of myocarditis, pericarditis, or myocardial injury. Also, the LD isoenzyme patterns in all specimens showed only an increased LD-5 isoenzyme; LD-1 and LD-2 were normal. This case illustrates that, in typhoid fever, an increased CK-MB in serum can occur without myocardial injury. The percentage of circulating C K-MB seen in this patient points to skeletal muscle injury rather than heart. Also noteworthy are the greatly increased serum CK activities, which have been observed infrequently in typhoid fever (3, 4). References
1.Robbins,S. L., phenicol was administered, and her temperature returned to normal within 24 h. By the 13th day, the patient was alert, oriented, and able to eat. She continued to make an unremarkable recovery and was discharged on the 25th day. Many laboratory studies were done and remarkable findings were pancytopenia before the 6th day and reticulocytosis after chloramphenicol was started. The serum enzyme tests were of particular interest, especially the greatly increased creatine kinase (CK; EC 2.7.3.2) activities (Figure 1). Serum CK-MB isoenzyme, assayed on days 6 to 10 by electrophoresis on agarose (Corning ACI; Corning Medical, Medfield, MA 02052), appeared as an intensely fluorescent band. On dilution of the specimens to the useable analytical range for creatine kinase, their CK-MB activities were found to be about 1% of the total CK activity. Lactate dehydrogenase (LD; EC 1.1.1.27) isoenzymes in the same specimens showed marked increases in the LD-5 fraction. LD-1 and
LD-2 werenormal. The increasedactivities of LD and CK and the abnormal isoenzyme patterns were unusual and probably are ascribable in part to the marked agitation and rigidity of skeletal muscles; however, the more significant process occurring was probably Zenker’s hyaline degeneration of skeletal muscle (1), in which skeletal muscle necrosis begins with acidophilic hyalinization of the affected sarcomeres followed by shredding of the muscle fibers and spillage of the intracellular contents into the peripheral blood. The increased serum CK-MB activity
1362 CLINICALCHEMISTRY.
and Cotran,
R. S., The
musculoskeletal system. In Pathologic Basis of Disease, W. B. Saunders Co., Philadelphia, PA, 2nd ed., 1979,pp 1466. 2. Yasmineh, W. G., Ibrahim, G. A., Abbasnezhad, M., et al., Isoenzyme distribution of creatine kinase and lactate dehydrogenase in serum and skeletal muscle in Duchenne muscular dystrophy, collagen disease, and other muscle disorders. GUn. Chem. 24, 1985-1989(1978). 3. Hoffman, T. A., Ruiz, C. J., Counts, G.W., et al., Waterborne typhoid fever in Dade County, Florida. Am. J. Med. 59,481-487
(1975). 4. David, C. B., and Tolaymat,
A., Typhoid
fever: Unusual presentation. J. Pediatr. 533 (1978).
93,
John A. Lott Carl E. Speicher Leona W. Ayers Dept. of Pathol. Ohio State University Columbus, OH 43210
Determination of a2-Macroglobuiln in Amniotic Fluid in Diagnosis of Neural Tube Defect
Table 1. Concentration of a2-Macroglobuiin in Amniotic
Fluid as Related to Gestational Age in Normal-Outcome Pregnancies a Gestational age, weeks
12-14
No.
AMG concn, mg/I
cases
Range
5
15
21
16
21
