Document GzdegGyVbj3o2E1Eyj0eaoEbY

SOME OF THE RECENT FINDIN G S CONCERNING YUSHO Masanori Kuratsune, M.D.,* * Yoshito Masuda,** and Junya Nagayama* * Abstract Analysis o f Yusho disease, which was first detected in 1958, has been limited and analyses have produced varying results. Yusho oil has been determined to con tain a high level of polychlorinated dibenrofurans (P C D F s). Nagayama et at. found that P C D F levels in the oil were especially high when the oil was contaminated with P C B 's used as a heat transfer medium. Their studies i also showed that the concentration o f P C D F 's is much i closer to that o f P C B 's in liver than in adipose tissues In | patients with Yusho. The current clinical state o f patients with Yusho is dicusssd at length. Subjective symptoms, dermatological findings, serum triglyceride levels, liver conditions, m ortality rates, and the effects on children bom to mothers v.ith Yusho are all reported. IN T R O D U C T IO N More than 7 years have passed since the outbreak of an epidemic of Yusho in 1958. According to the latest tabulation. Prof. Omee, current chief of the Study Group for the Therapy of Yusho, reported that a total number of 1,291 patients have been registered as Yusho in 22 prefectures of Western Japan by April 30, 1975 (ref. 1). We would like to describe some of the recent find ings concerning Yusho which we think to be particular ly relevant for understanding of toxicity of PC B 's. For more detailed information, readers ire advised to refer to original papers appearing mainly in the fourth and fifth reports of the study on Yusho and PCB (ref. 3|. Most of the patients described in these reports are those living in Fukuoka prefecture. Published information of patients living in other areas are unfortunately very few, so with a few exceptions no reference will be made to them. PCB's IN THE B O D IE S O F P A T IE N T S WITH YU SH O 1. Tissues First of all, the concentration of P C B 's retained in the tissues and fluids of patients with Yusho should be referred to before their current clinical state will be dis cussed. Although no accurate estimation is feasible because of the very limited number of analyses so far made, the concentration of PCB's in adipose tissues of patients seems to have been fairly high soon after the occurrence of poisoning--that is, in November 1968, at least 1 month after the discontinued use of the toxic rice oil by patients, as shown in table 1. The corresponding concen trations were considerably lower in 3 patients who died In the next year, 1969. However, no such marked dif ference could be seen between those who died in 1969 and the subsequent decedents, although cases 7 and 10, who died in 1970 or 1975, showed quite low levels of PCB's in adipose tissues. A s compared with the figures available from e nationwide survey on residual P C B 's in autopsied tissues, the levels noted in the recent dece dents are considered to be fairly close to the usual level of ordinary autopsied materials. Simitar facts were also noted for PCB concentration in the skin and liver. 2. Blood Since the analysis of P C B 's in blood started only after 1972, no figures are available in regard to the blood levels of PCB's in patients in the earlier stage of poison ing. As shewn in table 2, however, it is clear that the blood levels of patients had approached the level of ordinary persons already in 1972, although they were still significantly higher than that level. This fact as well as the previous fact of lowered tissue levels of P C B 's In recent decedents seem to be rather surprising if we con sider also that the majority of patients are still showing various clinical symptoms, as will be discussed later. *M asanorl K u rjis jn o and J jn y a N sgayam a are with the Deparvrwnt o* PcblicN'Health, Faculty of Medicine. K y u ih u Ur.iverairy. Div.ion of Analytical Chem istry, Daiichi College of Pha*maceutica1 Science. FukucSVa, Japan. V * * Y o s h it o M asuda it w ith D a iic h i College of Pnjfmaccjtieal Sciences. Fukuoka. Japan. 3. Gaschromatographic Patterns o f P C B 's in the B o d ie s. o f Patients Masuda first noted a peculiar com m on gas-chro matographic pattern of PCB fractions isolated frerr. vari ous tissues, blood, and breast milk of patients with Yusho and celled the attention of the Study Group for the Therapy of Yusho to it in early 1972. Figure 1 shows a typical e**'," l of such a pattern in compariso<" 14 f . E UX.JLW NPC00026436 753773 Table 1. P C B 's concentration in tissues of patients with Yusho and other diseases Case Time of death, operati on Stein Who1e Fat basis basis PCB's (ppm) Adipose tissue Whole Fat basis basis Liver Whdle Fat basis basis Refprence Case 1 High school boy Case 2, 3 Adult male, female Nov. 1968 Nov. 1968 * 76 (face) 13 (abdomen) 32, 46 (cheese-like substance from * acneform eruptions) 10 Case 4 July 1.3 3.7 0.14 9.5 Boy, 13 y r 1969 (mesentery) Case 5 July 1.2 8.7 2.8 15.1 0.2 10.4 w Male, 25 y r 1969 (mesentery) Case G Nov. 1.0 4.4 3.8 8.4 0.07 3.1 Male* 73 y r ' 1969 (mesentery) 11, 12 Case 7 Uoc. 0.6 0.8 0.7 0.9 0.07 1.3 Female, 48 yr 1970 (mesentery) Case 8, ' Male, 46 y r Case 9 Female, 33 y r May 1972 Sept. 1972 1.0 3.2 4.3 6.5 1.9 (subcutaneous) 2.9 0.08 0.4 Case TO Male, 72 yr April 1975 0.19 0.4 0.04 3.0 (mesentery) 14 National survey Males and females 25 - 49 y r 1973 0.04 - 1.7 (n a 54) *5* it 4* O.Z - 4 1).3 - 6.4 0.01 - 0.6 0.02 - 3.1 (n 48) (n 51) (n = 30) . NPC00026437 Table 2. PC B's in blood patients with Yusho, workers and ordinary persons Material No. of subjects Time of examination PCB's (ppb) Whole basis Refer mean + S.D. Range ence Whole blood Yusho patients 41 March - August 7 2-26 1973 7 Ordinary persons 37 1972 3 1-7 Plasma Yusho patients Normal persons Whole blood Yusho patients Normal persons 15 82 Jan. 1972 25 11 6.3 + 4.0 2-15 3.0 + 1.3 1- 7 4.8 + 2.9 1-12 2.8 + 1.5 1- 6 8 ` Whole blood Workers3 23 1972 364 + 262 60-920 9 aWorkers engaged in the production of Kanechlor 200-600, in the a ir con taining 0.05 to 0.2 mg/m3 of PCB's [Kanechlor-300 + Kanechlor-400 (1:1)]. Two o f them showed dermal signs. with ths common one seen in ordinary parsons, which is very much close to that of a mixture of Kanechlor 500 + 600 [1 = 1). It is easily notable that the peak 1. which appears immediately after p,p*-DDE in the gas chromato gram in figure 1, is very low in patients with Yusho as compared with ordinary persons, white the peak 5 is much more prominent in Yusho than in ordinary per sons. Masuda and his associates observed this peculiar pattern (designated as type " A " ) in blood of about 60 percent of patients with Yusho, and a somewhat simitar pattern (designated as type " B ") in about 37 percent (refs. 4.7,11,12). Takamatsu et al. also observed the seme peculiarity in the blood of patients with Yu sh o (ref. 8). It was further demonstrated that those patients who show the peculiar gas-chromatographic pattern as designated as pattern A by Masuda ct at. have a higher average concen tration of P C B 's in their blood than do other patients (refs. 4,7). Abe et al. (ref. 23) examined in 1974 the P C B residues In the plasma of 3 0 children born to 18 mothers w ho hed consumed Yusho oil at G oto Islands. Nagasaki prefecture. The specific gas-chromatographic pattern of type A was seen among 24 percent of the children and 44 percent of their mothers, but the pecu liarity seemsd somewhat less marked as compared with the one seen among patients in Fukuoka prefecture. The chemical and toxicological nature o f the com pound o r compounds yielding the above-mentioned peak 5 must be clarified but have not yet fully been ex amined. Masuda. however, considers the peak 5 to ba 3 ,4 ,2 *,3 ',4 ',5 r-hexachlorobiphenyl, judging from its retention time on the Apiezon L colum n developed b* Jensen and Sundstron (ref. 22). 16 NPC00026438 753775 A : Fatty t is s u e of Yjs k c ? a7;E:;t E : Fatty t is s u e of c r d h .apy per sc:: C : Kanechlor 500 + 6G0 (I:!) Figure 1. Gaschromatograms (ECO) of PC B's on SE-30. PO LYCH LO RIN A TED D IBEN ZO FU R A N S IN KAN ECH LO RS, "Y U S H O O IL/' A N D TISSU ES OF PATIENTS 1. Pofychforlnated Dibenzofurans in Kanechlors and ~Yu$ho o ff" Recently Nagayama ct al. analyzed Kanechlors and three samples of toxic "Y u sh o o il " used by three inde pendent families with Yusho for polychlorinated di* benzofurans (PCD F's) and polychlorinated dibenzo-pdioxins (PCDD's) (ref. 16). They did a column chroma tographic fractionation of P C D F 's and P C D D 's from a bulk of PCB's by using activated alumina as adsorbent, and n-hexane, n-hexane containing 20 percent carbon tetrachloride, or n-hexane containing 20 percent methylenchloride as eluent. The fractions thus obtained were subjected to gas-chromatographic and mass-spectrometric examination. Quantitative estimation of P C D F 's and P C D D 's was made by two m ethods, n amely by measuring the gas chromatographic peak heights and by measuring the gas chromatographic peak area of perchlorinated derivatives of these compounds. Although no P C D D 's were found in any 'of these samples, P C D F 's were found in ail of them. A s shown in table 3, KC-400 contained the highest concentration of PCDF's, about 16 ppm of P C D F 's consisting of dichloroup to pentachloro- dibenzofurans. A peak with the same retention time as that of 2.3,7,8-tetrachlorodibenzo' furans, which was kindly provided by Dr. J .G . Vos, was noted in its gas chromatogram. All of the three samples of ''Y u s h o o il" also containad about 5 ppm o f P C D F's, the major constituents of w hich were tetra- and pe.nta* chlorodibenzofurans. Here again, the peak with the same retention time as 2,3.7,8-tetrachlorodibenzofuran was noted. Kashimoto also found 1.6 pom of P C D F 's in another batch of "Y u sh o o il/ ' as shown in table 5 (ref. IS ). Table 4 summarized the concentrations of P C D F 's inKanachlor-400, reported by several authors. A s clearly noted, there is a fairly large discrepancy in their findings. Whether or not It was due to their analytical procedures or to batch difference cannot be decided at the present time. Another important fact was disclosed by Nagayama et al. They determined the concentration of P C B 's in "Y u sh o o il" as approximately 1,000 ppm or slightly less than 1,000 ppm, as shown in table 3. Since "Y u s h o o il" is known to have been contaminated with Kanechlor400, the ratio of the concentration of P C B 's to that of P C D F 's in " Yusho o il" is expected to ba about 1,000**0.018. The observed r3tio, approximately 1rC00 5. 17 NPC00026439 753776 Table 3. P C D F 's and PC B's in Kanechlors and Yusho oil PCDF's (ppm) PCB's (ppm) Sample Peak height method Perch!0rination method Peak height method Perch!0- rination method 300 1 1.5 Kanechlor 400 500 18 4 16.6 2.5 600 5 2.7 -- Yusho o il A B C 5 4.4 B30 870 4 5.1 900 920 5 5.2 1030 980 Table 4. Reported concentrations of P C D F 's In Kanechlor-400 Authors Concentration Year (PPM) Roach et a l. a Nagayama et al.^ Kashimoto et a l. c 1974 1975 1975 1 18 33 aRef. 17. bRef. 16. cRef. 1s8. was thus about 250 times Higher than expected (table 5). The reasons for this great discrepancy arc not clear yet. tt should be noted, however, that the sample of Kanechlor-400 analyzed was an "unused'* one, while die K3nech!or-400 present in "Y u sh o o il" was "u s e d " as heat transfer medium. This fact suggests a practically important possibility that Kanechlor-400 2nd probably other commercial PCB's, too, will increase their PCD.F concentration: when used as heat transfer medium. 2. P C D F 's in Tissues of Patients with Yusho Nagayama et at. (ref. 24) further examined the tissues of patients with Yusho for their possible content of PCDF's. Table G summarized their findings. Adipose tissues and liver from two ordinary persons who died of accidents contained no detectable am ount ( < 0.1 ppb) of PC D F's, but those from three patients with Y u sh o who. died in 19d9 or 1972 were all shown to contain PC D F's. Figures 2 and .3 show their gas-chromatograms and mass spectra. The concentration on a whole basis was 0.009 ppm on average for adipose tissues end 0.013 ppm for liver. T his seems to be a rather surprising fact because in the case o f P C B 's the concentration'on a whole basis is usually much lower in liver than in adipose tissues. When compared on fat basis, another interesting feet was noted that P C D F concentration was much high er in liver than in adipose tissue. Although the number 18 NPC00026440 753777 Table 5. Concentrations of PCB's and P C D F 's and their ratios in various materials Materials PCB's (ppm) PCDF's PCB's (ppm) PCDF's Reference Kanechlor-400 1,000,000 ca. 20 50,000 Yusho o il Aa ca. 1,000 5 200 Bb 134 1.6 84 to 18 Patient Adipose with tissue Yiistio L1ver 1.3 0.05 0.009 0.013 144 24 4 aSamples of the rice o il produced on February 5 or 6, 1968. sample of the rice o il produced on February 10, 1968. Table 6. P C B 's and P C D F 's in tissues of patients with Yusho and ordinary persons ( . Time PCB's (PPrc) PCDF's (ppm) Ratio Case o f Whole Fat Whole Fat PCB's/RCDF's Subjects Tissue No. death basis basis basis basis . Whole Fat 1 2 . Adipose 3 Yusho patients 1Liver Avg. 1 2 3 Avg. .Adipose 1 Ordinary \________ _ Persons vLiver 1 2 1969 1969 1972 1.4 1.3 1.2 3.4 0.013 8.5 0.006 2.1 0.007 1.3 4.7 0.009 1969 1969 1972 0.05 0.06 0.03 4.7 0.025 5.6 0.010 3.5 - 0.003 0.05 4.6 0.013 1975 1.0 1.4 1975 0.4 0.7 NO ND 1975 0.08 1.3 1975 0.02 1.0 NO ND 0.03 0.04 0.01 108 217 171 0.003 144 2.3 2 1.1 6 0.3 10 1.2 4 ND ND ND ND 113 213 210 157 2! 5 12 . j 41 i ( 19 NPC00026441 753778 Upper : ' PCDF FRACTION FROM Live r o f Yu s h o Pa t i e n t . Lo w e r : PCDF FRACTION FROM Yusho O i l . Figure 2. Gaschromatograms of PC D F fractions from liver of patient with Yusho and from "Y u sh o oil." of analyses made is quite limited and nothing can be said with certainty, this fact seems to deserve attention. A s shown in table 3, th e different behaviors in tissue dis tribution of the compounds caused a remarkable differ ence in ratio of PC B `s to P C D F 's between adipose tissues and liver. It was thus demonstrated that the concentre; tion of P C D F 's is much closer to that of P C B 's in liver ! than in adipose tissues in patients with Yusho. The : PC D F's identified in liver were mainly penta- and hexa\ chlorodibenzofurans; containing only a trace of tstra^chloroisomsrs. CURREN T CLIN ICAL STATE O F PATIEN TS WITH YU SH O In 1974, Prof. Urabe (ref. 2), fo rm srch ie f of the Study Group, reported that the dermal and mucosal signs that were most marked at the incipient stage of the poisoning had gradually been Improved, while symptom s such as general fatigue, poor appetite, in constant ab dominal pain, heavy headedness and headache, feeling o f . numbness and pain at the limbs, and cough and expecto ration o f sputum, all of which are considered to be due to some internal disturbances, have become more prom i nent year by year. In view of these tendencies together with the discovery of a characteristic gas-chromato graphic pattern of P C B 's remaining in the blood and tissues of patients, the diagnostic criteria fo r Y u sh o was revised in 1972 (ref. 2), as shown in table 7. A s com pared with the former one, the revised criteria describe briefly the dermal and mucosal lesions but newly refer to other noncutaneous objective signs and findings frpm several laboratory tests. It should be noted, however, that the new criteria do not refer to any specific liver function tests. 20 1 r* NPC00026442 753779 UPC00026443 Figure 3. G C -M S of P C D F 's fraction from liver of patient with Yusho (upper) and of synthesized P C D F 's (lower). 1. SuH/ectiva Symptoms Tab! 8 shows that a considerable portion of the patents are stilt suffering from various subjective symptoms in recent years. Koda and Masuda examined their possible association with PCB concentrations in blood, finding no positive association at all (ref. 4). Umeda also reported on various symptoms due to dis turbances of higher nsrvous activities (e.g., forgetfulness) complained of by most patients, but no definite associa tion between such symptoms and the blood levels of P C S 's was observed (ref. 5). 2. Dermatological Findings Koda and Masuda examined 72 patients with Yusho for dermatological signs and PCB levels In the blood from April 1973 to March 1974 (ref. 4J. A s shown in table 9, the majority of patients were stilt suffering from skin lesions such as pigmentation, deformation of nail, and hypersecretion of Meibomian gland even 5 years after the poisoning. They also demonstrated another im portant fact that group A, consisting o f patients whose blood sh o rn the S3s-chromatographic pattern A, had significantly higher prevalences o f dermatologic signs such as pigmentation, acneform eruption, and deformed nails than did group B, which consisted o f patients show* Ing no such typical gas-chromatographic pattern. Since group A had a higher average concentration of PCB's than group B, the dermal lesions seen among cur rent patients, contrary to the subjective symptoms, seem to be causally associated with the current level or pat* tern of P C B 's remaining in their blood. However, no conclusion could be readily made in this regard. F irsto f ail. the current excess of PC B's in the blood of patients is not remarkable in degree and is almost negligible as compared with the enormous elevation seen am ong the occupationally exposed workers, w ho nevertheless showed a rather low prevalence of dermal symptoms (table 2). it seems rather hard, therefore, to explain the p e rm rin o derm al tn jn n t h v nlewifPA PP.R tevplc in blood alone. The chemical peculiarity of such P C B 's and the presence of F C P F 's in the bodies of current patients -Seam to be particularly imnnrtanf in this cnnn*cripn. However, our present knowledge does not allow u s to continue discussion of the matter along this line without speculation. Furthermore, an entirely different explana* tion might also be possible. The skin lesions currently seen may merely be the persisting original skin lesions, the severity of which must have been determined pri marily by the amount of Intake of PC B 's; such intake must in turn be reflected by the current P C B levels In blood of patients. According to this explanation, the Table 8. Frequency of subjective symptoms complained by patients with Yusho from 1973 to 1974 Symptoms Proportion % Fatigue Headache Phymata in a rtic u la r region Fever Cough and sputum Digestive disorder Numbness of extremities Menstrual disturbance 51.4 41.7 8.3 2.8 56.9 4Q.3 -33.3 26.9 .(7/26) C alcu la te d by Kurats'jne from original figu re s published by K5da and Masuda {ref. 4). 23 NPC00026444 753781 Table 9. Prevalence of dermatological and other signs among patients with Yusho from April 1973 to to March 1974, in connection with concentration and g3schromatographic pattern of P C B's in blood Prevalence (:4)c Signs Group A Group B Group C Total (43 cases) (26 cases) (33 cases) (72 cases) Skin Pigmentation TM pf * Wail Acneform eruption Comedo Infection of skin Deformation of nail Alopecia Disorder in teeth Dypersecretion of Meibomian gland 51.2? 72.1? 95.3? 74.4 34.9b 34.9 32.6a 65.1* 0 18.6 93.0 109.2b? 57.7b 34,6 0 23.1 n .5 a 3 8 . 5a 3.8 7.7 80.8 0 0 66.6 0 0 0 0 0 0 0 100.0 30.6 50.0 80.6 56.9 20.8 29.2 23.6 52.8 1.4 13.9 88.9 PCB's in ^ " C`+(? Pn} 7.2 + 4.9 4.3 + 3.1 1.7 + 0.2 5.9 + 4.5 blond P a V r n Ad d d . S ig n if ic a n t (P < 0.05) difference. S ig n if ic a n t (P < 0.01) difference. C alculated by Kuratsune from figures published by Koda and Masuda (ref. 4). ^"A" means the characteristic gaschromatographic pattern of PCB's remaining in the body of most patients with Yusho. UBM means gas chromatographic patterns somewhat sim ila r to "A". "C" means patterns indistinguishable front those of normal persons. obssrved association of tha dermal lesions with current Mood levels of P C B 's is considered as a phenomenal one but ro t as a causal one. In order to evaluate these dif ferent possibilities, it seems essential to examine chemi cally and toxicologically the PC B's and P C D F 's still re maining in patients* bodies. 3. Serum Triglycsritfs One of the m ost dominant objective signs seen at the incipient stage of Yusho was a markedly increased concentration of serum triglyceride. Okum ura and his associates reported recently the results of their extensive followup study on 40 patients w ho were examined for 24 UPC00026445 7537B2 scrum triglyceride at least once a year successively for 6 years from 1969 to 1974 (ref. 19). A s shown in table 10, a group of 14 male patients has shown no significant change in serum triglyceride levels since 1969, still main taining levels as high as 160 118 mg/100 ml even in 1974. For 26 female patients, however, a significant de crease was seen in 1973 and 1974 when compared with the levels in the previous years. However, 42 percent of them still showed higher levels than 110 mg/100 ml in 1974. Oicumura et al. (ref. 20) examined the possible asso ciation between serum triglyceride levels and FC8 con centrations in blood in patients. A s shown in tsbls 11, they observed a significantly higher mean level of serum triglyceride in a group of patients who shov.ed the characteristic gas chromatographic pattern A, is com pared with other patients w ho did not show such a typi cal pattern. They also observed a significantly positive correlation between serum triglyceride levels and PCB concentrations In blood (r 0.485). Table 10. Results of followup study on serum triglyceride levels inpatients with Yusho^ Subjects Patients with Yusho PCB's No. Age pattern cases mean A 20 31.9 B 14 C 2 21.4 PCB's in blood (ppb) 8.6 + 5.2b 3.8 + 2.2 Triglyceride mg/100 ml Reference 134 + 60.0a 91 + 39.8d 20 Controls Controls C 37 34.5 2.8 + 1.6 74 + 29 19.21 aP < 0.05. bP < 0.005. Table 11. PCB's concentrations in blood and serum triglyceride levels in patients with Yusho in 1973 Patients Sex Age Ho, Hale 11 - 73 H Fanale 7 - 59 26 Triglyceride (mg/100 ml) Mean + S.D. 1969 1970 1971, 1972 1973 1974 159 + 57 166 + 55 169 + 60 174 + 69 164 + 68 160 + 118 155 + 75 161 + 70 155 + 80 153 + 63 129 + 50b 111 + 56b aCited from a report by Okumura et. al. (ref. 19). S ig n if ic a n t ly lower than in 1969, 1970, 1971, and 1972 (P < 0.05). 25 NPC00026446 753783 Hare again, a similar question can be raised in regard tc such observed correlation, as already discussed in con nection with the dermallesionsV Arc the current elevated levels of P C B 's Tn blood and their peculiarities in gaschromatographic patterns causally connected with the abnormally high serum triglyceride levels found in patients? Since, as mentioned, the female patients started to decrease in serum triglyceride concentration in recent years, a followup examination of P C B 's in their blood might give a good clue to answer the above ques tion. 4. U ve rof Patients with Yusho Both P C B 's and P C D F's are well-known toxic agents to the liver. P C D F 's seem to be particularly toxic be cause a single oral administration of P C D F 's as small as about 1 mq/kp could kill rabbits by severe liver necrosis (refs. 28,29). Therefore, it is reasonable to expect that patients with Yusho would have a severe liver damage. Okumura et a!, (ref. 30) performed detailed medical examinations on 24 patients soon after the onset but, unexpectedly, obtained no objective findings to indicate definite liver disorders. N o patients presented jaundice and onty three of them had palpable livers. However, an electron microscopic examination of liver biopsy speci mens conducted o n a patient in February 1959 revealed a marked hypertrophy of smooth endoplasmic reticu lum, indicating stimulated enzyme induction in the liver (ref. 31). Okumura examined 38 patients with various subjsctive symptoms for serum enzymes, including isozymss from 1971 to 1972 (ref. 32). A n increase in a fraction of lactate dehydrogenase (LDH-5) and high titers in thym ol turbidity tests were observed in some of the severe cases but no definite evidence for liver disorders was obtained. Recently Hirayama et al. (ref. 33) examined 121 adult patients with Yusho and 257 healthy adult controls for serum bilirubin, demonstrating a significant lower aver age concentration in the patient group than in the con trol. They also showed significantly negative correlations between serum bilirubin and blood P C B 's in concentra tion (r - -0.349, p<0.025) and similarly between serum bilirubin and serum triglyceride (r - -0.215, p<0.05). They considered th3t a lowered concentration of serum bilirubin in patients seemed mainly due to an accelerated bilirubin disposal from the blood. Hirayama et al. investigated 125 patients for Austra lia antigen and antibody by the immunoslectro- osmophoresis in 1971 iref. 34). The antigen was positive in three, while the antibody was negative in all of them, | indicating no difference at all in the prevalences between j the patients and healthy controls. This finding sssm s to | be important in connection with the future risk of j cancer which patients might experience. In view of all these findings. liver function tests cur rently available do not readily detect serious ever lesions in the patients, but it is highly desirable th3l adequate caution will continuously be paid to this well-known target organ of chlorinated hydrocarbons. / CHILDREN BORN TO M O TH ERS W ITH YU SH O The birth of unusual babies from mothers w ho took "Y u sh o o il " during pregnancy is already well known (refs. 25,26). Their clinical features ware dark brown pigmentation of the mucous membrane and the entire skin, gingival hypsrplasis with pigmentation, a tendency to be small for the date, eruption o f teeth at. birth, hyparsecretation cf the Meibomian gland, and edema of tha orbital area. Pigmentation of the skin disappeared in 2 to 5 months, followed by growth similar to that of normal babies. It seems noteworthy, however, that babies with the dark brown pigmented skin continued to be born for a few years after tha intake of "Y u s h o o il " w as discon tinued by mothers. Yoshimura reported on nine babies with such skin w ho were born to mothers with Y u sh o in Nagasaki prefecture from 1959 to 1972 (ref. 27). Three of such babies had been delivered by a patient from 1S59 to 1971. Abe et a), (ref. 23) recently reported on PC S levels in the plasma o f 30 children (aged 0 - 7 ) b o m to 13 mothers with Yusho in Nagasaki prefecture. Their examination was made in 1974. A s shown in table 12, the P C S levels of these children were significantly higher than those of ordinary children but lower than the levels of their mothers. Their gas-chromatographic patterns of P C B 's in plasma were already referred to earlier in this paper. Children fed on breast m ilk from mothers with Yusho tended to show a higher plasma concentration of P C B 's than those w ho were not fed on such milk. Yoshim ura also reported an interesting case, where a baby was thought to have suffered from Y u sh o due ex clusively to intake o f P C B 's through breast m ilk from a woman with Y usho (ref. 27). Very few data are available in regard to the concentration o f P C B 's in breast m ilk of mothers with Yusho. Masuda et al. found 0 .0 3 -- 0.06 ppm o f P C B 's in 5 samples of breast-milk collected from a woman with Y u sh o within 5 days after delivery in 1973 (ref. 12). Masuda also found about 0 .0 3 ppm of P C B 's in another sample of breast m ilk collected a few days after a woman with Yusho delivered a baby with no dermal signs (ref. 14). The P C B levels in breast m ilk from patients with Yusho ware therefore just within the normal range. However, the gas-chromatographic pat terns of these samples were quite unique, the same as that characteristic for Yusho. NPC00026447 753784 Table 12. Concentration of P C B 's in plasma of children born to mothers with Yusho Subjects PCB's in plasma (ppb) Subjects Range Mean + S.D. Mothers with Yusho Children born to above mothers Ordinary c h il dren 18 3-33 11.2 + 7.32 30 1 -2 0 6 .7 + 4 .28 14 1 -8 3.7 + 1.97 Ref erence 23 I f i i Table 13. Deaths seen among patients with Y u sh o ^ Cause of death Malignant neoplasms Stomach cancer Stomach cancer + liv e r cancer Liver cancer + liv e r cirrh o sis . Lung cancer Lung Tumor Breast cancer .Malignant lymphoma Cerebrovascular lesion Amyloidosis Osteodystrophi a f i brosa Myocardial degeneration + p ericarditis Status thymicolymphaticus Liver cirrhosis Suicide Senility Traffic accidents TOTAL Number 9 2 1h lb 1 1 1 2 3h i 'r h i l i 3 22 aCited from a report by Urage 1974 (ref. 2). bAutopsled cases. M O RTA LITY OF PATIENTS WITH YU SH O Omae reported in 1975 that 29 death*; occurred among 1,291 patients with Yusho up to April 3 0 ,19 7 5 (ref. 1). Causes of these deaths were not given, however. Urabe also reported on 22 deaths seen among 1,200 patients until September 13, 1973, and referred to their causes (ref. 2). A s shown in table 13, 9 of 22 deaths were caused by malignant neoplasms, suggesting a possible excess of deaths from cancer. Since some essentiat information needed for epidemiological analysis is not available to us, no further reference can be made with certainty to such a possibility at the present time. C O N C L U S IO N I A s mentioned earlier, we demonstrated the presence of P C D F 's in "Y u sh o oil" at a much higher concentra tion then expected. We also showed that P C D F 's are relatively more concentrated in liver. Although neither the chemical nature nor the toxicity of P C D F 's con tained in "Y u sh o o il" and in the bodies of patients are known yet, our findings clearly indicate the necessity to Ipay greater attention to P C D F 's for clarification of the nature of Yusho. Furthermore, our studies suggested the possible formation of PC D F 's from P C B 's when used as heat transfer medium. Beside this, another possibility that P C D F 's might be formed by heating P C B 's with peroxides, which are wall known to he formed during heating cooking oils, should also be investigated. REFERENCES 1. T. Omae, "Foreword, the Fifth Report of the Study for Yusho and PC B ," Fukuoka Acta Med., Vol. 65, No. 10 (October 1975), pp. 547-458 (in Japanese). Z H. Urabe, "Foreword, the Fourth Report of the Study on Yusho and P C S , " Fukuoka Acta /Med., Vol. 65, No. 1 (January 1974), pp. 1-4 (in Japanese). 3. "Fourth Report," Fukuoka Acta Med., Vol. 65, No. 1 (January 1974), pp. 1-95; "F ifth Report," Ibid., Vol. 66, No. 10 {October 1975), pp. 547-648. 4. H. Koda and Y . Masuda, "Relation Between PCB Level in the Blood and Clinical Sym ptom s of Yusho Patients," Fukuoka Acta Med., Vol. 66, No. 10 (October 1975), pp. 624-628 (in Japanese). 5. G. Umsda, "Clinical Aspects of PCB Poisoning," Rodo no Kagaku, Vol. 28 (1973), pp. 36-42 (in Japanese). 6. H. Kohda, 5. Asahi, and S. Toshitani, "Dermatologi cal Findings of the Patients With Yusho (PCB Poisoning) in General Examination in 1 9 7 2 ," Fukuoka Acta Med., Vol. 65, No. 1 (January 1974], pp. 81*83 (in Japanese). 7. Y. Masuda, R. Kagawa, K. Shimamura, M . Takada, and M . Kuratsune, "Polychlorinated Biphenyls in the Blood of Yusho Patients and Ordinary Persons/* Fukuoka Acta Mad., Vol. 65, No. 1 (January 1974), pp. 25-27 (in Japanese). 8. M. Takamatsu,' Y. Inoue, and S. Abe, "Diagnostic Meaning of the Blood P C B ," Fukuoka Acta Med., Vol. 65, No. 1 (January 1974), pp. 28-31 (in Japanese). 9. H. Hasesawa, M. Sato, and H. Tsuruta, " P C B C on centration in the Blood of Workers Handling P C B ," Rodo Ehei, Vol. 13, No. 10 (1972), pp. 50-55 (in Japanese). 10. M .G o to and K. Higuchi, "T he Sym ptom atology of Yusho (Chlorobiphenyls Poisoning) in Dermatolo gy." Fukuoka Acta Med., Vol. 60, No. 6 (June 1959), pp. 409-431 (in Japanese). 11. Y. Masuda; R. Kagawa, and M. Kuratsune, "C o m parison of Polychlorinated Biphenyls in Y u sh o Patients and Ordinary Persons," Bui/. Environ. Contam. Toxicol.. Vol. 11 (1974), pp. 213-216. 12. Y. Masuda, R. Kagawa, M . Kuratsune, "Po lych lorin ated Biphenyls in Yusho Patients and Ordinary Per sons/* Fukuoka Acta Med., Vol. 65, No. 1 (January 1974), pp. 17-24 (in Japanese). 13. Committee for Investigation and Study o f P C B and Others, "S tu d y on the Distribution of Concentra tions of Intracorporally Accumulated P C B " (1975) (in Japanese). 14. Y . Masuda, Unpublished data. 15. M. Asahi, H. Koda, and S. Toshitani, "Alteration in Skin Severity Grading of Yu sh o in the General E x amination in 1973 and 1974, and Presentation of a New Standard for the Skin Severity o f Y u sh o by Point Count System ," Fukuoka Acta Mad., Vol. 65, No. IQ (October 1975), pp. 629-634 (in Japanese). 16. J. Nagayama, Y. Masuda, and M. Kuratsune, "C h lo rinated Dibenrofurans in Kanechlors and Rice Oils Used by Patients With Y u sh o ," Fukuoka Acta Med., Vol. 66. No. 10 (October 1975), pp. 593-599. 17. J. A . G. Roach 2nd I. H. Pomerantz, 'T h e Finding of Chlorinated Dibenzofurarts in a Japanese PCB Sam ple," Bulk Environ. Co.itam. Toxicol., Vol. 12 (1974), pp. 338-342.18. T. Kashimoto, personal communication (1975). 19. M. Okumura, M. Yamanaka, S. Nakamuta, end H. Uzawa. "Consecutive S ix Year Follow -up S tu d y on Serum Triglyceride Levels in Patients With P C S Poisoning," Fukuoka Acta Med., Vol. 66, N o. 10 (October 1975), pp. 620-623 (in Janam**! . , 1 28 ( I ( I C NPC00026449 753786 20. M. Okumura, Y. Masuda, and S. Nakamuta. "C o r relation Batween Blood PCB and Serum Triglyceride Levels in Patients with PCB Poisoning." Fukuoka Acta Mid., Vol. 65, No. 1 (January 1974), pp. 84-87 (in Japanese). 21. H. Uzav/a, A. Notomi, S. Nakamuta, and Y. Ikeura, "Consecutive Three Year Follow Up Study of Serum Triglyceride Concentrations of 82 Subjects With PCB Poisoning," Fukuoka Acta Med., Vol. 63, No. 10 (October 1972). pp. 401-404 (in Japanese). 22. S. Jenssn and G. Sundstrn, "Structures and Levels of M ost Chlorobiphenyis in T w o Technical PCB Products and in Human Adipose Tissues," A M 8 IO , Vol. 3, No. 2 (1974), pp. 70-76. 23. S. Abe, Y. (noue, and M. Takamatsu, "Polychlorin ated Biphenyl Residues in Plasma of Yusho Children Bom to Mothers Who Had Consumed O il Contam inated by P C B ," Fukuoka Acta Med.t Vol. 66, No. 10 (October 1975), pp. 605-609 (in Japanese). 24. J. Nagayama, Y . Masuda, and M. Kuratsune, "P o ly chlorinated Dibenzofurans in Tissues of Patients with Y usho," paper 330 presented at the 34th Annual Meeting of Japanese Society o f Public Health, Yokohama, October 29-31, 1975, preprint, 215 pp., October 1975 (in Japanese). 25. I. Funatsu, F. Yamashita, Y . Ito, S. Tsugawa, T. Funatsu, T. Yoshikane, M. Hayashi, T. Kato, M . Yafcushiji, G. Okamoto, S. Yamasaki, T. Arima, T . Kuno. H. tde, and I, Ib e / 'P C B Induced Fetopathy. 1. Clinical Observation." Kurvrrta Med. J., Vol. 19 (1972). pp. 43-51. 26. I. Takt, S. Hisanaga, and Y. Amagase, "Report on Yusho (Chlorobiphenyis Poisoning) Pregnant W om en and Their Fetuses," Fukuoka Acta Med Vol. 60, No. 6 (June 1969), pp. 471-474 (in Japanese). 27. T. Yoshimura, "Epidemiological Study on Yusho Babies Bom to Mothers W ho Had Consumed Oil Contaminated by PCB," Fukuoka Acta Med., Vol. 65, No. 1 (January 1974), pp. 74-80 (in Japanese). 28. H . Bauer, K. H. Schulz, end U. Spiegelberg, "Berufliche Vergiftungen bei der Herstellung von Chlorphenot-Verbindungen," Arch. Gewerbepath. Gewerbehyg., Vol. 18 (1961), pp. 538-555. 29. H. T h . H o fm a n n , "Neuere Erfahrungen mit Hochtoxischen Chlorkohlenwasserstoffen," Arch, Exp. PathoL Pharmakol Vot. 232 (1958), pp. 228-230. 30. M. Okumura and S. Katsuki. "Clinical Observation on Yusho (Chlorobiphenyis Poisoning)," Fukuoka Acta Medu Vol. 60, No. 6 (June 1969), pp. 440-446 (in Japanese), 31. C. Hirayama, T. trisa, and T. Yamamoto, "F in e Structural Changes of the Liver in a Patient With C hlorobiph enyis Intoxication," Fukuoka Acta Med., Vol. 60. No. 6 (June 1969), pp. 455-461 (in Japanese). 32. M. Okumura, "Course of Serum Enzym e Change in PCB Poisoning," Fukuoka A era Med., Vol. 63. No. 10 (October 1972), pp. 395-400 (in Japanese). 33. C. Hirayama, M. Okumura, J, Nagai, and Y . Masuda, "Hypobilirubinemia in Patients With Polychlorin ated Biphenyls Poisoning," Cfintca Chtm. A cta, Vol. 55 (1974), pp. 97-100. 34. C. Hirayama, M. Nakamura, and M. Yoshinari, "Australia Antigen in Patients W ith P C B Poisoning," Fukuoka Acta Med., Vol. 63, No. 10 (October 1972), pp. 405-407 (in Japanese). DISCU SSIO N M R . A L L E N G R E Y (ItT Research Institute, Chicago, Illinois): Do you have any feel whether dibenzofurans concentrating in the body are more rapid in metabolism than the result of polychlorinated bi phenyls? D R . K U R A T S U N E : Unfortunately I have no definite idea. It is a more patent com pound than PCB, I guess. 1 really cannot say. D R . O R V IL L E P A Y N T E R (E P A , Washington, D.C): Are there any reproductive problems or ir regularities continuing fo r m any years after the ingestion of these materials? D R . K U R A T S U N E : There is some disturbance of men struation. There have been some disturbances and there have been some related problems. M S. D E B O R A H A. BARSO TT1 (University of Wiscon sin, Madison, Wisconsin): Were there are doings that suspected any widespread gastic ulcerations or an erosion in the patients--gastric ulcers? D R . K U R A T S U N E : No, 1 d o not think so. Some of the patients had very persistent disorders o f the intes tines, disorders o f the digestive system, but t do not know if they were suffering as a result of this or not. V O IC E : A n y residual changes in the sebaceous gland during the autopsy? D R. K U R A T SU N E : No, I do not know very much about it. V O IC E : I would like to ask one more question. Have y o u been able to specifically Identify any o f the dibenzofurans other than those In the body? D R . K U R A T S U N E : Y o u are asking if we could identify eny of the dibenzofurans? No. I 29 M NPC00026450 7537B7