Document wrZV7KReEpRboXk2069r3vZY4

?/ n :] '5 i - I I 1 "^ ':; A ' .a ' \ .;! ,' f . ''i * ' > -,vV V>V^S l y UCLA CM n ^ SOME OF THE RECENT FINDINGS CONCERNING YUSHO Masanori Kuratsune, M.D.,* Yoshito Masuda,** and Junya Nagayama* td $i Abstract Analysis of 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 dibemofurans (PCOF'sI. Nagayama et al. found that PCDF levels in the oil were especially high when the oil was contaminated with PCR's used as a heat transfer medium. Their studies also showed that the concentration of PCDF's is much closer to that of PCB's in liver than in adipose tissues in patients with Yusho. The current clinical state of patients with Yusho is dicussed at length. Subjective symptoms, dermatological findings, serum triglyceride levels, liver conditions, mortality rates, and the effects on children born fo mothers with Yusho are all reported. INTRODUCTION 1, More than 7 years have passed since the outbroak of an epidemic of Yusho in 1968. According to the latest tabulation. Prof. Omae, 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. 11. Wt 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 PCB's. For more detailed information, readers arc advised to refer to original papers appearing mainly in the fourth and fifth repo'ts 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 arc unfortunately very few, so with a few exceptions no reference will be made to them. PCB's IN THE BODIES OF PATIENTS WITH YUSHO 1. Tissues First of all, the concentration of PCB'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 palientr seems to have been fairly high soon after the occurrenci 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 diet in the next year, 1969. However, no such marked dil ference could be seen between those who died in 196' and the subsequent decedents, although cases 7 and 1C who died in 1970 or 1975, showed quite low levels c PCB's in adipose tissues. As compared with the figurt available from a nationwide survey on residual PCB's i autopsied tissues, the levels noted in the recent dec* dents are considered to be fairly close to the usual levof ordinary autopsied materials. Similar facts were alt noted for PCB concentration in the skin and liver. 2. Blood Since the analysis of PCB's in blood started on after 1972, no figures are available in regard to the bloc levels of PCB's in patients in the earlier stage of poiso ing. As shown in table 2, however, it is clear that tl blood levels of patients had approached the level ordinary persons already in 1972, although they we Stilt significantly higher than that level. This fact as wi as the previous fact of lowered tissue levels of PCB's i recent decedepts seem to be rather surprising if we coi sider1 also that the majority of patients are still shovvin various clinical symptoms, as will be discussed later. 'Matjnym Kurafttme anil Junya Naqayama arc with the Di-paMn*-nt M Pulit-c Un.ildi. Faculty ol Medicine. Kyushu Untvrrury, Division ol Analytical Chemistry, Daiichi Coltego of Phami/iL'-uin ,-tl Sricnrp. FuSnot-fl. Japnn. Yoshito Merudii is with Daiichi College of Pharmaci-nlt' ; itieMii-n, Fukuoka. Japan. 3. Caschromatographic Patterns of PCB's in the Bod of Patients Masuria first noted a peculiar common gas-ch matographic pattern of PCB ftjciions isolated from v. OUJ tissues, blood, and breast milk of patients w Yusho and called the attention of the Study Group the Thciapy of Yusho to it in ejily 1972. Fiqun shows a typical example of such a pattern in compari 14 OSW 026909 <**//. hio 2. DSTf2. b^ STLCOPCB4010871 o CD Table 1. PCB's concentration in tissues of patients with Yusho and other diseases O Case Time of death, operation Skin Whole Fat basis basis PCB's (ppm) Adipose tissue Whole Fat basis basis Liver Whole Fat basis basis Ref erence Case 1 High school boy Case 2, 3 Adult male. female Case 4 Boy, 13 yr Case 5 Male, 25 yr Case 6 Male, 73 yr Case 7 Female, 48 yr Case 8 Male, 46 yr Case 9 Female, 33 yr Case 10 Male, 72 yr National survey Males and females 25 - 49 yr Nov. 1968 Nov. 1968 July 1969 July 1969 Nov. 1969 Dec. 1970 May 1972 Sept. 1972 April 1975 1973 1.2 8.7 1.0 4.4 0.6 0.8 1.8 3.2 0.04 - 1.7 .. (n = 54) 76 (face) 13 (abdomen) 32, 46 (cheese-like substance from acneform eruptions) 1.3 (mesentery) 2.8 (mesentery) 3.8 ' (mesentery) 0.7 (mesentery) 4.3 3.7 15.1 8.4 0.9 6.5 0.14 0.2 0.07 0.07 0.08 10 9.5 10.4 3.1 1.3 8.4 11, 12 1.9 (subcutaneous) 2.9 0.19 (mesentery) 0.4 0.04 3.0 14 0.2-4 (n = 47) 0 .3 - 6.4 0.01 - 0. 6 0.02 - 3.1 (n = 48) (n = 51) (n = 30) 13 0 T 6 9 ? 0 HSO % f. & *i ?/i `a A' c/ . -v. y vj''i (/: . V 1' \n\ ( ' Tabic 2. PCB's in blood patients with Yusho. workers and ordinary persons Material Whole blood . Yusho patients Ordinary persons No. of subjects Time of examination PCB's (ppb) Whole basis Refer mean + S.D. Range ence 41 March - August 7 2-7.6 1973 7 37 1972 3 1-7 Plasma Yusho patients Normal persons Whole blood Yusho patients Normal persons 15 82 Oan. 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 Workers9 23 1972 364 + 262 60-920 9 Workers engaged in the production of Kanechlor 200-600 in the air con taining 0.05 to 0.2 mg/nr of PCB's [Kanechlor-300 + Kanechlor-400 (1:1)]. Two of them showed dermal signs. '"'A y- v . A *' > !.*.; : >v ; V . i' with ihr common one seen in ordinary persons, 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, while the peak 5 is much more prominent in Yusho than in ordinary per sons. Masuda and his associates observed this peculiar pattern (designated as tyi>e "A") in blood of about 60 percent of patients with Yusho, and a somewhat similar pattern (designated as type "B") in about 37 percent (rets. 4,7,1 1,12). Takamatsu ct al. also observed the same peculiarity in the blood of patients with Yusho (ref. 8). It was further demonstrated that those patients who show the peculiar gas-chromatographic pattern as designated as pattern A !>y Masuda et al. have a higher average concen tration of PCB's in their blood than do other patients (refs. 4,7). Abe et al. (ref. 23) examined in 1974 the PCB residues in the plasma of 30 children bom to 18 mothers who had consumed Yusho oil at Onto 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 seemed somewhat less marked as compared with the one seen among patients in Fukuoka ptclecture. The chemical and toxicological nature ol the com pound or compounds yielding the above mentioned peak 5 must be clarified but have not yet lully been ex amined. Masuda. however, considers the peak 5 to be 3,4,2',3 ,4',5'-hcxachlorobiphenyl, judging from its retention lime on the Apieton L column developed bJensen and Sundstron (ref. 22). DSW 026911 16 STLCOPCB4010873 A : Fatty tissue of Yusho patient " B : Fatty tissue of ordinary person. C : Kanecmlor 500 + 600 (1:1) J* POLYCHLORINATED DIBENZOFURANS IN KANECHLORS, "YUSHO OIL," AND TISSUES OF PATIENTS1 1, Pulyclilorinated Dibemoturans in Kancchlors and "Yusho oil" Recently Nagayama ct al. analyzed Kancchlors and thri'i samples ol toxic "Yusho oil" used by three inde pendent families with Yusho lor polychlorinated ditxm/ofurans (PCDF's) and polychlorinated dilrenzo-pdioxms (PCDD's) (ref. 16). They did a column chroma tographic fractionation of PCDF's and PCDD's from a bulk of PCB's by using activated alumina as adsorbent, ind n-hexanc, n hexane containing 20 percent carbon tetrachloride, or nhexane containing 20 percent methylfnr.hloude as eluent. The fractions thus obtained were subjected to gas chromatographic and mass specuometric examination. Quantitative estimation ol PCDF's and PCDD's was made by two methods, namely by measuring the gas chromatographic peak heights and by measuring the gas chromatographic peak area of per- ~'tmaled derivatives of these compounds. -Although no PCDD's were found in any of these mules, PCDr s were found in all of llsem. As shown in sable 3, KC-400 contained the highest concentration of PCDF's, about 18 ppm of PCDF's consisting of dichloroup to pentachloro- dibenzofurans. A peak with the same retention time as that of 2,3,7,8-tetrachlorodibcnzofuraris, which was kindly provided by Dr. J. G. Vos, was noted in its gas chromatogram. All of the three samples of "Yusho oil" also contained about 5 ppm of PCDF's, the major constituents of which were tetra- and pentachlorodibenzofurans. Here again, the peak with the same retention time as 2,3,7,8-tetracMorodibenzoluran was noted. Kashimoto also found 1.C ppm of PCDF's in another batch of "Yusho oil," as shown in table 5 (ref. 18). Table 4 summarized the concentrations of PCDF's in K?nechlor-400, teported by several authors. As clearly noted, there is a (airly 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.PCB's in "Yusho oil" as approximately 1,000 ppm or slightly less than 1,000 ppm, as shown in table 3. Since "Yusho oil" is known to have been contaminated with Kancchlor400, the ratio of the concentration of PCB's to that of PCDF's in "Yusho oil" is expected to be about 1,000 0.018. The observed ratio, approximately 1.000 5, T7 OSW 026912 I T. S I STLCOPCB4010874 Tabic 3. PCDF's and PCB's in Kanechlors and Yusho oil PCDF's (ppm) PCB's (ppm) Sample P,eak height method Perchlori nation method Peak height method Perchlo- rination method 300 1 1 .5 Kanechlor 400 500 18 4 16.6 2.5 600 5 2.7 -- Yusho oil A B C 5 4.4 830 870 4 5.1 900 920 5 5.2 1030 980 Table 4. Reported concentrations of PCDF's in Kanechior-400 Authors Year Concentration (PPM) Roach et al.a Nagayama et al.b Kashiinoto et al .c 1974 1975 1975 . 1 18 33 aRef. 17. bRef. 16. cRef. 18. was thus about 250 times higher than expected (table 5). The reasons (or this great discrepancy are not clear yet. It should be noted, however, that the sample of Kanechlor 400 analysed was an "unused" one, while the Kanechlor-400 present in "Yusho oil" was "used" as heat transfer medium. This fact suggests a practically important possibility that Kancchlor-400 and probably other commercial PCB's, too, will increase their PCDF concentrations when used as heat transfer medium. 2. PCDF's in Tissues of Patients with Yus/in Nagayama rt al. (ref. 24) further examined the tissues of patients with Yusho for their possible content of PCDF's. Table 6 summarized their findings. Adipos tissues end liver from two ordinary persons who died r accidents contained no detectable amount (< 0.1 ppi of PCDF's, but Ihose from three patients with Yus* who died in 19d9 or 1972 were all shown to conta PCDF's. Figures 2 and 3 show their gas chromatograe and mass spectra. The concentration on a whole ha' was.0.009 ppm on average for adipose tissues and 0.0' ppm for liver. This seems to be a rather surprising fa because in the case of PCB's the concentration on whole basis is usually much lower in liver than in adipo tissues. When compared on fat basis, another interests fact was noted that PCDF concentration was ranch hig er in liver than in adipose tissue. Alihough the numb 10 DSW 026913 STLCOPCB4010875 Table 5. Concentrations of PCB's and PCDF's and their ratios in various materials Materials PCB's (ppm) PCDF's PCB's (ppm) P'CDF1 s Reference Kanechlor-400 Yusho oil Aa Bb 1,000,000 ca. 1,000 134 ca. 20 5 1.6 50,000 200 84 T6 18 Patient Adipose with tissue Yusho L(ver 1.3 0.05 0.009 0.013 144 24 '4 aSamples of the rice oil produced on February 5 or 6, 1968. bA sample of the rice oil produced on February 10, 1968. . n U Table 6. PCB's and PCDF's in tissues of patients with Yusho and ordinary persons Time PCB's (M1 PCDF's Ratio Case of Whole Fat Whole Fat PCB's/RCDF's Subjects Tissue No. death basis basis basis basis Whole Fat 1 2 Adipose 3 1969 1969 1972 1.4 1.3 1.2 3.4 0.013 0.03 108 113 8.5 0.006 0.04 217 213 2.1 0.007 0.01 171s 210 Yusho Avg. 1.3 4.7 0.009 0.003 144. 157 patients 1 1969 0.05 4.7 0.025 2.3 ' 2 2 2 1969 0.06 5.6 0.010 1.1 65 Liver 3 1972 0.03 3.5 0.003 0.3 10 12 Avg. 0.05 4.6 0.013 1.2 44 Adipose Ordtnary ' 0 persons Liver 1 2 1 2 1975 1975 1975 1975 1.0 0.4 0.08 0.02 1.4 0.7 1.3 1.0 ND NO ND ND ND . ND 4 ND ND DSW 026914 19 J f STLCOPCB4010876 .r^ 'O ?! Upper : PCDF FRACTION FROM Liver of Yusho Patient. Lower : PCDF FRACTION FROM Yusho Oil. Figure 2. Gaschromatograms of PCDF fractions from liver of patient with Yusho and from "Yusho oil." ,t V; 1 .: : ' 0 ot analyses made is quite limited and nothing can be said with certainly, this fact seems to deserve attention. As shown In table 6, these different behaviors in tissue dis tribution of the compounds caused a remarkable differ ence in ratio o* PCB's to PCDF's between adipose tissues and liver. It was thus demonstrated that the concentra tion of PCDF's is much closer to that of PCB's in liver than in adipose tissues in patients with Yusho. The F'CDF's identified in liver were mainly penta- and hexa- rhlorotlilwioofurans, containing only a pace of tetra- chloroisomers. t CURRENT CLINICAL STATE OF PATIENTS WITH YUSHO In 1974. Piof. Urabe (ref. 2). former chief 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 symptoms such as general fatigue, poor appetite, in constant ab dominal pain, heavy headedness and headache, feeling of numbness and pain at the limbs, and cough and expecto ration of sputum, all of which are considered to be due to some internal disturbances, have become more promi nent year by year. In view of these tendencies together with the discover^ of a characteristic gas chromato graphic pattern of PCB's remaining in the blood and tissues of patients, the diagnostic criteria for Yusho was revised in 1972 (ref. 2), as shown in table 7. As com pared with the former one. the revised criteria describe briefly the dermal and mucosal lesions but newly refer to other noncutancous objective signs and findings from several laboratory tests. It should be noted, however, that the new criteria do not refer to any specific liver function tests. 20 DSW 026915 STLCOPCB4010877 ct fT r Re l a t iv e in t e n s it y (Z ) o CO o figure 3. GC-MS of PCOF's fraction from liver of patient with Yusho (upper) tVJ O' and of synthesized PCDF's (lower). . \0 > ' > ; . J / A v .5 o t 'y Table 7. The diagnostic criteria for Yusho (revised in October, 1972). Yusho is considered as an acute or subacute poisoning with PCB. The general symptoms currently seen are retarded growth, neuroendocrine disturbances, phenomenon of enzyme induction, disturbances in the respiratory system, and abnormal lipid metab olism. As the local symptoms, acneform eruption and pigmentation as cutaneomucosal lesions and ocular symptoms are seen. 1. Conditions of attack Fact of ingestion of Kanemi rice oil contaminated with PCB and familial occurrence seen in most cases. 2. General symptoms a. Subjective symptoms 1) general fatigue ." 2) heavy headedness and headache 3) inconstant abdominal pain 4) feeling of numbness and pain at the limbs 5) swelling and pain at the joints 6) cough and sputum 7) changes in menstruation b. Objective symptom 1) bronchitis-like symptom 2) sensory neuropathy 3) bursitis 4) inhibition in growth and abnormal teeth in children ' 5) Smal1-For-Dates baby and pigmentation of the entire skin of newborns c. Results from clinical examination 1) abnormal properties and concentration of PCB in blood 2) increase of neutral lipids in blood 3) anemia, lymphocytosis, hypoalbuminemia 4) reduced velocity of the sensory nerve conduction and adrenocortical hypofunction 3. Cutaneomucosal signs . - a. Acneform eruption Black comedones and acneform eruptions which are seen at the face, buttocks, and other intertriginous sites and their suppurative tendency. b. Pigmentation Pigmentation of the face, palpebral conjunctiva, gingiva, and nails of the fingers and toes. , c. Ocular signs Swelling and hypersecretion of the Meibomian gland and palpebral edema. (Translation was made by Kuratsune) DSW 026917 22 STLCOPCB4010879 rv w Subjective Symptoms Toble 8 shows that a considerable portion of the patients are still suffering from various subjective symptoms in recent years. Koda and Masuda examined their possible association witlt PCB concentrations in blood, finding no positive association at all (ref. 4). Umi'da also reported on various symptoms due to dis turbances of higher nervous activities (e g., forgetfulness) complained of by most patients, but no definite associa tion between such symptoms and the blood levels of PCB'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. 4|, As shown in table 9, the majority of patients were still 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 of patients whose blood shows the gas-chromatographic pattern A, had ^~~nificantly higher prevalences of dermatologic signs i h as pigmentation, acneform eruption, and deformed hails than did group B, which consisted of 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 PCB's remaining in their blood. However, no conclusion could be readily made in this regard. First of all, the current excess of PCB's in the blood of patients is not remarkable in degree and is almost negligible as compared with the enormous elevation seen among the occupationally exposed workers, who nevertheless Showed a rather low prevalence of dermal symptoms (table 2). It seems rather hard, therefore, to explain the persisting dermal lesions by elevated PCB levels in blood alone. The chemical peculiarity of such PCB's and the presence of PCDF's in the bodies of curtent patients seem to be particularly important in this connection. However, our present knowledge does not allow us to continue discussion of the matter along this line without speculation. Furthermore, an entirely different explana tion miyht 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 PCB's; such intake must in turn be reflected by the current PCB levels in blood of patients. According to this explanation, the Tabic 8. Frequency of subjective symptoms complained by patients with Yusho from 1973 to 1974 Symptoms Proportion3 % Fatigue 51.4 Headache 41.7 Phymata in articular region 8.3 Fever 2.8 Cough and sputum 56.9 Digestive disorder 40.3 Numbness of extremities 33.3 Menstrual disturbance 26.9 n (7/26) ^Calculated by Kuratsune from original figures published by KOda and Masuda (ref. 4). OSH 026918 23 STLCOPCB4010880 Table 9. Prevalence of dermatological and other signs among patients with Yusho from April 7973 to to March 1974, in connection with rnnrontr-ption and gaschromatographic pattern of PCB's in blood Prevalence (%)c Si gns Skin Pigmentation Nail Acneform eruption Comedo Infection of skin Deformation of nail Alopecia Disorder in teeth Dypersecretion of Meibomian gland Group A Group B Group C Total (43 cases) (26 cases) (33 cases) (72 cases) 51.2? 72.r 95.3b 74.4b 34.9 34.9 32.6 65.la 0 18.6 93.0 0b 19.2b 57.7b 34.6 0b 23.1 11.5 38.5a 3.8 7.7 80.8 0 0 66.6 0 o 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 68.9 PCB's in Conc- (PPb) 7.2 + 4.9 4.3 + 3.1 1.7 + 0.2 5.9 + 4.5 l Avg. + S.D. blond Pattern Ad c" Significant (P < 0.05) difference. ^Significant (P < 0.01) difference. cCalculat-;d by Kuratsune from figures published by Koda and Masuda (ref. 4). d"A" means the characteristic gaschromatographic pattern of PCP's remaining in the body of most patients with Yusho. "B'` iiiear.s gas chromatographic patterns somewhat similar to "A". "C" means patterns indistinguishable from those of nori'Ml persons. - obscivcd asvnc.ijtion of try dermal lesions with cut rent blond levels ol PCU's is considered as a phenomenal one hot not as a causal one. I t order to evaluate these ridfeient possibilities. it seme. essential to examine chemi cally and loxicologic.iHy tlf PCG's ami PCDF'j still re maining in patterns' hodim, 3. Scrum Triglyceride One ol the most dominant ottjoctive signs seen the incipient stage of Yusho was a markedly ine'eas concentration of serum triglyceride. Okumnra arid I associates reported recently the results of their exiensi followup study on 40 patients who were examined I DSW 026919 STLCOPCB4010881 \ vm triglyceride at least once a year successively for 6 from 1969 10 1974 (ref. 19). As shown in table 10, t group ol 14 male patients has shown no significant change in serum triglyceride levels since 1969. still main taining levels as high as ICO f 118 mg/100 ml even in 1974. For ?6 female patients, howevei, a significant de crease was seen m 1973 and 1974 when compared with the levels in the previous years. However, 42 percent of them slid showed higher levels than 1 10 mg/100 ml in 1974. Okumura et al. (ref. 20) examined the possible asso ciation between serum triglyceride levels and PCB con centrations in blood in patients. As shown in table 11, they observed a significantly higher mean level of serum triglyceride in a group of patients who showed the characteristic gas chromatographic pattern A, as com pared with other patients who did not show such a typi cal pattern. They also observed a significantly positive correlation between serum triglyceride levels and PCQ concentrations in blood (r * 0.485). Table 10. Results of followup study on serum triglyceride levels in patients with Yusho^ Subjects Patients wi th Yusho Controls Controls PCB's No. Age pa ttern cases mean A 20 31.9 B 14 C 2 ..21.4 C 37 34.5 PCB's in blood (ppb) 8.6 + 5.2b 3.8 + 2.2 2.8 + 1.6 Triglyceride ttig/100 ml Reference 134 + 60.0a U 91 + 39.8 20 74 + 29 19.21 dP < 0.05. bP < 0.005. Table 11. PCB's concentrations in blood and scrum triglyceride levels in patients with Yusho in 1973 Patients Sex Age No. Hale 11 - 73 14 Female 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). ^ bSignificantly lower than in 1969, 1970, 1971, and 1972 (P < 0.05). 0Sw 0269^0 STLCOPCB4010882 if-* V* Hwc J similar question t.an raised in regard to such ohv.-rvud cofc-lopon, av olr* ady discussed in con nection with the dermal lesions. Ate the cutrent elevated levels ol PCB's in blood and their peculiarities in gas- chromatographic patterns causally connected with the abnormally high scrum triglyceride levels found in patients? Since, as mentioned, the female patients Started to decrease in strum triglyceride concentration in recent years, a followup examination of PCB's in their blood might give a good clue to answer the above ques tion. 4. Liver of Patients wit'i Yusho Both I'CEl's and PCDP's arc well-known toxic agents to the liver. PCDF's seem to be particularly toxic be cause a single oral administiation of PCDF's as small as about 1 nxj/kg could kill rabbits by severe liver necrosis (refs. 28,29). Thetelore, it is reasonable to expect that patients with Yusho would have a severe liver damage. Okumura et al. (ref. 30) performed detailed medical examinations on 24 patients soon after the onset but, unexpectedly, obtained no objective findings to indicate definite liver disorder; No patients presented jaundice and only three of them had palpable livers. Ffowevcr, an electron miccoscopic examination of liver biopsy speci mens conducted on a patient in February 1969 revealed a maikcd hypertrophy nI smooth endoplasmic reticu lum, indicating stimulated cneyrne induction in the fiver (ref. 31). Okumurj examined 38 patients with various subjec tive symptoms for semen enaymes, including isorymes from 197 1 ty 1972 (ref. 32). An iocioase ip a fraclion of lactale dehydrogenase (LDH-5) and high titers in thymol turbidity tests were observed in some of tire severe cases but no definite evident,'' 'o' liver disorders was obtained. Recently Fbtayqma et ni (ref. 33) examined 121 adult patients with Yusho amf 297 healthy adulr controls for seium bilirubin, demolishatinq a significant lower aver age ro'iu niln'.nui in the paimni group than in the contry1. They nl'y showed significantly negative correlations between serum bihiuliin and h'oori PCB's in concentra tion (r " -0.34!). p<0.P2b! arvl simihily between scrum bilirubin and si-rum |i ir;lv. ide (f - 0 215, p<0.05). They considered that a Ipw'rcd concentration of serum biliiubin *n patients seemed mainly due lo an accelerated bilnubin disposal bom the htoorl. Flirayama et al. inv sliqated 125 patients for Austra lia antigen anil antibody by the immunooloctro osmophoresh in 1971 (rrl. 34). 1 he antigen was positive in three, while the aniilmdy was negative in all ul them, indicating no iMIerence al all m the tin-valences IxMwren the pallet 's and healthy controls This l-ndi'iq si-oms to be inifioM.int in ronneri i: u* wuti tin hiruie : e.k ol C.i"ei-r wliii h o.ili'-nis -1."it11 i "tier ienr e In view of all these findings, livot function tests cur rently available do not readily detect serious liver lesions . in the patients, but it is highly desirable that adequate caution will continuously be paid to this well-known target organ ol chlorinated hydrocarbons. CHILDREN BORN TO MOTHERS WITH YUSHO The birth of unusual babies from mothers who took "Yusho oil" during pregnancy is already well known (refs. 25,26). Their clinical featur es were djrk browr pigmentation of the mucous membrane and the entire skin, gingival hyperplasis witli piqmentatiun, a tendency to be small for the date, eruption of teeth al birth hypersecrctation of the Meibomian gland, and edema o' the orbital area. Pigmentation of the skin disappeared ir 2 to 5 months, followed by growth similar to that o1 normal babies. It seems noteworthy, however, that babies with tin. dark brown pigmented skin continued to bo born for r few years after the intake of "Yusho oil" was discon tinued by mothers. Yoshimura reported on nine babio- with such skin who were born to mothers with Yusho ir Nagasaki prefecture from 1969 to 1972 (rel. 27). Thrc< of such babies had been delivered by a patient fron 1969 to 1971. Abe et al. (rel. 23) recently reported or PCB levels in the plasma ol 30 children (aged 0-7) borr to 18 mothers with Yusho in Nag-i' 'ki prefecture. The,' examination was made in 1974. As shown in table 12 the PCB levels of there children were s-gmlicantly highei than ll-iose ol ordinary children hut lower than the level- of theit mothers. Thee gas-chromatographic pattens o' PCB's in plasma were already referred to earlier in the. paper. Children fed on btcast mill; Irons mothers with Yusho tended to show a higher plasma concentration o` PCB's than those who were not fed on such milk. YoshiniurTi also lepoiled an interesting cjse, where a bahy was thought to have suffered bom Yusho due ex clusively to intake of PCB's through breast milk from a woman with Yusho (ref. 27). Very few data are available in regard to the conc'nbation of PCB's in btrasi milk o' mothers with Yusho., Mastitia et al. found 0.03 - 0 0b ppm of PCB's iu 0 samples of hicasl milk tollecied Iron a woman with Yusho within 5 days after delivery ir 1973 (ref. 12). Masutld also lound about 0 03 ppm o PCB's in another sample ol bieast milk collected a lev. days alter a woman with Yusho delivered a L-nby with nc dermal signs (rel. 14). The PCB levels in breast milk from patients with Yusho were therefore just within th< normal tango. However. the gas rlironiatiiqi nphic pvt Pm ns nt these Sampb-s were t|iii`r unique, th>- urn" o that t hai-( t-'i i-.r ,r im Yusho. . 26 DSW 026921 STLCOPCB4010883 r Table 12. Concentration ol PCB's in plasma of children born to mothers with Yusho . Subjects PCB1 s in p"lasma (PPb) Subjects Range Mean + S.D. Ref erence Mothers with Yusho Children born to above mothers Ordinary chil dren 18 3-33 11.2 + 7.32 30 1-20 6.7 + 4.28 23 14 1-8 3.7 + 1.97 r") Table 13. Deaths seen among patients with Yusho^ / Cause of death Malignant neoplasms Stomach cancer Stomach cancer + liver cancer Liver cancer + liver cirrhosis Lung cancer Lung Tumor Breast cancer Malignant lymphoma Cerebrovascular lesion Amyloidosis Osteodystrophia fibrosa Myocardial degeneration + pericarditis Status thymicolymphaticus Liver cirrhosis Suicide Seni1ity Traffic accidents TOTAL Number 9 2 1b r i i l 2 3b ' lb' lb 1D 1 1 1 3 22 aCited from a report by Urage 1974 (ref. 2). ^Autopsied cases. 27 DSM 026922 1 STLCOPCB4010884 MORTALITY OF PATIENTS WITH YUSHO Omae reported in 1975 that 29 deaths occurred among 1.291 patients with Yusho up to April 30, 1975 (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). As shown in table 13, 9 of 22 deaths were caused by malignant neoplasms, suggesting a possible excess of deaths Irom cancer. Since some essen tial 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. CONCLUSION As mentioned earlier, we demonstrated the presence of PCDF's in "Yusho oil" at e much higher concentra tion than expected. We also showed that PCDF's are relatively mote concentrated in liver. Although neither the chemical nature nor the toxicity of PCDF's con tained in "Yusho oil" and in the bodies of patients are known yet, our findings clearly indicate the necessity to pay greater attention to PCDF's lor clarification of the natuie of Yusho. Furthn more, our studies suggested the possible formation of PCDF's from PC8's when used as heat transfer medium. Beside this, another possibility that PCDF's might be formed by heating PCB's with peroxides, which are well known to be formed during heating cooking oils, should also be investigated. PCFERENCEC 1. T. Omae, "Foreword, the Fifth Report of the Study for Yusho ami PCD," Fukuoka Acta Med.. Vol. 66. No. 10 (October 19751, pp. &17-153 (in Japanese). 2. H. Urabe, "Foreword, the Fourth Rcuort ol the Study on Yusho anil PCB," Fukuoka Acta Med., Vol. 65, No. 1 (January 1374), pp. 1-4 (in Japanese). 3. "Founh Report," Fukuoka Acta Med., Vol. 65, No. 1 (January 1974). pp. 1-95; "Filth Report," Ibid., Vol. 6G. No. 10 (October 1-375). pp. 547-648. 4. H. Koda and Y. Masuda, "Relation Between PCB Level in the Blood and Clinical Symptoms of Yusho Patients," Fukuoka Acta Med., Vol. 66, No. 10 (October 1975), pp. 624 626 (in Japanese). 5. G. Umerfa, "Clinical Aspects of PCB Poisoning," llodo no Kc.aaku, Vol. 20 (1973), pp. 36 42 (in Japanese). G. fl. Kohda, S. Asalii. and S. Toslmani, "Dermatologi cal Findings pi iln; Patient' With Yusho (PCB Poisoning) in General Examin; Fukuoka Acta Med., Vol. 65, No. \ wanuary 197 pp, 81-83 (in Japanese). 7. Y. Masuda, R. Kagawa, K. Shimamura, M. Taka and M. Kuratsune, "Polychlorinated Biphenyls the Blood of Yusho Patients and Ordinary Peisor Fukuoka Acta Med., Vol. 65. No. 1 (January 19/ pp. 25-27 (in Japanese). 8. M. Takamatsu, Y. Inoue, and S. Abe, "DiagnoMeaning of the Blood PCB," Fukuoka Acta Mi Vol. 65, No. 1 (January 1974), pp, 28 31 Japanese). 9. H. Hascgawa, M. Sato, and H. Tsuru'a, "PCB C centration in the Blood of Workers Handling PC Rodo Eisei, Vol. 13, No. 10 (1972). pp. 50 55 Japanese). . 10. M. Goto and K. Higuchi, "The Symptomatology Yusho (Chlorobiphenyls Poisoning) in Dermal', gy," Fukuoka Acta Med.. Vol. GO, No. 6 (J> 1969), pp. 409 43' (in Japanese). 11. Y. Masuda, R. Kagawa, and M. Kuratsune, "Ci parison of Polychlorinated Biphenyls in Yu Patients and Ordinary Persons," Bull. Envir Contam. Toxicol., Vol. 1 1 (1974), pp. 213-216. 12. Y. Masuda, R. Kagawa, M. Kuratsune, "Polychlo ated Biphenyls in Yusho Patients and Ordinary ( . sons," Fukuoka Acta Med., Vol 65. No. 1 (Janu 1974), pp. 17 24 (in Japanese). 13. Committee lor Investigation and Study ol PCB . Others, "Study on the Distribution ol Concen lions of Intracorporally Accumulated PCB" (19 (in Japanese). 14. Y. Masuda, Unpublished data 15. M. Asahi, H. Koda, and S. Toshitani, "Alteratio' Skin Severity Grading ot Yusho in the General animation in 1973 and 1974, and Presentation c New Standard for the Skin Severity of Yusho Point Count System," Fukuoka Acta Med.. Vol f. No. UTlOctobci 1975), pp. 629 634 (m Japanese 16. J. Naqayama, Y. Masuda, and M. Kuratsune, "OF rinated Dibenvofurans in Kanechlors and Rice Oi Used by Patients With Yusho," Fukwrka Acta Mr* Vol. 66. No. 10 (October 1975), up. 593 699. 17. J. A. Ci. Roach and I. H. Pomciantz, "The Find of Chlorinated Dibenzofuvons in a Japanese P Sample,'' Bull. Environ. Contam. Toxicol . Vol (1974|, pp. 330 342. 18. T. Kashimoto, personal commui- ' .irion (1975), 19. -M. Okumuia, M. Yamanaka, S. Nakamuta. and Utawa, "Consecutive Six Year Follow up Study Serum Triglyceride Levels in Bjtients With P Poisoning,'* Fukuoka Acta Med., Vul. 66. No. (October 1975), pp. G70 67.1 bn Japan's': I. 28 DSW 026923 STLCOPCB4010885 r 20. M. Okumura. Y. Masuda, and S. Nakamuta, "Cor relation Between Blood PCB and Scrum Triglyceride Level* in Patients with PCB Poisoning," Fukuoka Acta Med., Vol. 65, No. 1 (January 1974), pp. 84-87 (in Japanese). 21. H. Uzawa, 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. Jensen and G. Sunriswon, "Structures and Levels of Most Chlorobiphcnyls in Two Technical PCB Products Bnd in Human Adipose Tissues," AMBIO, Vol. 3. No. 7 (1974), pp. 70-76. 23. S. Abe, Y. Inouc, and M. Takamatsu, "Polychlorin ated Biphenyl Residues in Plasma ol Yusho Children Born to Mothers Who Had Consumed Oil Contam inated by PCB," Fukuoka Acta Med., Vol. 66, No. 10 (October 1975), pp. 605-609 (in Japanese). 24. J. Nagayama. Y. Masuda, and M. Kuratsune, "Poly chlorinated Dibenzofurans in Tissues of Patients with Yusho," paper 330 presented at the 34th Annual Meeting of Japanese Society of Public Health, Yokohama, October 29-31, 1975, preprint, r> u 215 pp., October 1975 (in Japanese). 25. I. Funatsu, F. Yamashita, Y. Ito, S. Tsugawa, T. Funatsu, T. Yoshikanc, M. Hayashi, T. Kato, M. Yakushiji, G. Okamoto, S. Yamasaki, T. Arima, T. Kuno, H. Ide, and I. Ibe, "PCB Induced Fetopathy. 1. Clinical Observation." Kurume Med. J., Vol. 19 (19721, pp. 43 51. . 26. I. Taki, S. Hisanaga, and Y. Amagase, "Report on Yusho (Chlorobiphcnyls Poisoning) Pregnant Wom en and Their Fetuses," Fukuoka Acta Med Vol. 60, No. 6 (Juno 1969), pp. 47 1-474 (in Japanese). 27. T. Yoshimura, "Epidemiological Study on Yusho Babies Born to Mothers Who Had Consumed Oil Contaminated by PCB," Fukuoka Acta Mod., Vol. 65, No. 1 (January 1974), pp. 74-80 (in Japanese). 28. H. Bauer, K. H. Schulz, and U. Spiegelbery, "Bcnilliche Vctgifiungen bci der Herstellung von Chlorphenol-Verbindungen," Arch. Gcwerbepath. GcwcrbeUyg., Vol. 18 (1961), pp. 538-555. 29. H. Th. Hofmann, "Ncucre Erfahrungon mit Hochtoxischen Chlorkohlcnwasserstoffen," Arch. Fxp. Pathol. Pharniakol Vol. 232 (1958), pp. 228 230. 30. M. Okumuia and S. Katsuki, "Clinical Observation on Yusho (Chlorobiphcnyls Poisoning)," Fukuoka Acta Med., Vol. GO, No. 6 (June 19C9), pp. 440 446 (in Japanese). 3). C. Hirayama, T. Irisa, arid T. Yamamoto, "Fine Structural Changes o( the Liver in a Patient With Chlorobiphenyls Intoxication." Fukuoka Acta Mod.. Wpi. GO, No. 6 (June 1969). pp. 455 461 (in Japanese). 32. M. Okumuta, "Course ol Serum Enzyme Change in PCB Poisoning," Fukuoka Acte Med.. Vol. 63, No. 10 (October 1972), pp, 396-400 (in Japanese). 33. C. Hirayama, M. Okumura, J. Nagai, and Y. Masuda. "Hypobilirubincmia in Patients With Polychlorin ated Biphenyls Poisoning," Clinica Chim. Acta, Vol. 65 (1974), pp. 97-100. 34. C. Hirayama, M. Nakamura, and M. Yoshinari, "Australia Antigen in Patients With PCB Poisoning," Fukuoka Acta Med., Vol. 63. Nu. 10 (October 1972), pp. 405-407 (in Japanese). DISCUSSION MR. ALLEN GREY {IIT Research Institute, Chicago, Illinois): Do you have any (eel whether dibenrofurans concentrating in the body are more rapid in metabolism than the result of polychloiinated bi phenyls? DR. KURATSUNE: Unfortunately I have no definite idea. It is a more potent compound than PCB, I guess. I really cannot say. DR. ORVILLE PAYNTER (EPA, Washington, D.C): Are there any reproductive problems or ir regularities continuing for many years after the ingestion of these materials? DR. KURATSUNE: There is some disturbance of men struation. There have been some disturbances and there have been some related problems. MS. DEBORAH A. BARSOTTI (University of Wiscon sin, Madison, Wisconsin): Wete there are doings that suspected any widespread gastic ulcerations or an erosion in the pabcnts-gaslric ulcers? DR. KURATSUNE: No, I do not think so. Some of the patients had very persistent disorders of the intes tines, disorders of the digestive system, but I do not know if they were suffering as a result of this or not. VOICE: Any residual changes in the sebaceous gland during the autopsy? DR. KURATSUNE: No, I do not know very much about it. VOICE: I would like to ask one more Question. Have you been able to specifically identify any of the dilzonzofurans other than those in the body? DR. KURATSUNE: You are asking if we could identity any of the dibenzofurans? No. OSW 026924 29 V STLCOPCB4010886