REAC’rIVE CHANGES OF ENZYME ACTIVITIES Ih- SERUhI ANT) LTVER AS SYMPTOIUS OF “ACUTE SYNDROJIE”

f j y W. H. Hauss and H. J . Jdeppclmanri Medicul Clinic (,f the CJiziversily (f Mirnster, Miinder, Germanj

In 1Y.54 LaDue el ul. made the interesting and important observation that a rise in glutamic-oxalacetic transaminase activity takes place in the serum of patients following myocardial infarction. Since that time numerous authors (Chinski el aL., Hsich and Blumenthal, Kattus ef ul., LaDue and Wr6blewski, Ostrow el ul., Siege1 and Bing) have dealt with the behavior of serum enzymes after myocardial infarction.

We investigated the respective activities of glutamic-oxalacetic transaminasc ((;(IT), lactic dehydrogenase (LDH), aldolasc (ALD), tributyrinase (TRI), and cholinesterase (CHE) in serum (Hauss, Leppelmann and Siillmann, Hauss and Lcppelmann). We were concerned primarily with the problem whet her the change in serum enzyme activities represents a specific symptom of myo- cardial infarction or whether this change is merely a nonspecific symptom of general occurrence in acute diseases attending the “acute syndrome”, as it. was termed by Hauss, including high temperature, leukocyte increase, changes in hemogram, increase in blood sedimentation rate, blood sugar and rest nitrogen, and variations in serum protein.

FIC~URES 1 to 3 demonstrate our findings in cases of myocardial infarction, operative intervention, and infectious diseases. I n these figures the normal range (mean i standard deviation) has been illustrated by hatching.

The characteristic behavior of CJOT, LDH, ALD, TRI, and CHE in the serum of a patient with myocardial infarction is shown in FIGITHE 1 . GOT, LDH, and ALD rise after such an attack, while TRI and CHE fall. All en- zyme concentrations return to the normal range within 2 to 3 weeks.

The means of the postoperative serum enzyme activities in 18 patients are shown i n FIGURE 2. It will be seen that thc activities of L D H and ALD rise after operative intervention, while those of TRI and CHE fall. A statistical cvaluation (1 distribution of Student) served to demonstrate that the observed differences are not thc result of chance. The change in serum enzyme levels was both independent of the type of operation (inguinal herniorrhaphy, t repana- tion, nephrcctomy, laparotomy, or lobectomy) and also independent of the type of narcosis (ether, nitrous oxide, potentiated anesthesia, or local anes- thesia). However. it is known that the GOT levcl in the serum riscs after operative intervention (Nydick ef al., Ostrow el d.). It therefore follows that the serum activities of the enzymes investigated by us react in the same way after operation and after myocardial infarction. The activities of GOT, LDH, and ALD increase, while those of TKI and CHE decrease.

The serum enzyme levels in various acute infections (including meningitis purulenta, pleural cmpyema, angina tonsihris, paratyphoid fcvcr 13, a n d enteritis) are shown in FIGURE 3. Of course, quantitative differences are observed, depending upon the severity of the disease but, in principlc, the

250

We did riot determine the G O T activities after operation.

Hauss 81 Leppelmann : Changes of Enzyme Activities

1,6

12

0.8

0,4

25 1

-

Glutamic oxalacetic t ransaminase

-

-

- / / / A / / - 7 / 1 / / -

1 I I I I I 6 I

3 5 ? 10 15 20 30 - Days after myocardial infarction FIGTJRE 1. Reaction of serum enzyme activities after myocardial infarction.

same reaction is found as in myocardial infarction and operation: a rise in GOT, LDH, and ALD, and a fall in TKI and (‘HE. Extreme values were obtained in a severe case of lobar pneumonia. In the first days of the disease, we meas- ured the following values (pmole/hr./ml. serum) : GOT, 21.16; LDH, 41.2; A T B , 5.4; TRI, 48.5; CHE, 92.0.

252

180

Annals New York Academy of Sciences

-

I- 0-L I

u 0

E 80 L Tri butyrinase 0)

m I

One of our patients suffering from myocardial infarction acquired a pul- monary embolism after the change in serum enzyme activities brought about by the infarction had returned to normal. As may be seen from FXUKE 1, the myocardial infarction and the pulmonary embolism caused the same change in serum enzyme activities, apart from the absence of ALD increase in myo- cardial infarction.

Our findings thus demonstrate that myocardial infarction is followed by an increase of GO?', TBH, and ALL), as well as by a decrease of TRI and CHE in serum, and that serum enzymes in cases of surgery, infectious diseases, and pulmonary embolism react in the same manner as in myocardial infarction. I t is indeed i rue that certain quantitative and temporal differences may be observed, depending upon the severity of the complaint; nevertheless, the reaction remains, in principle, the same for all these acute diseases: namely, a rise in GOT, LDH, and ALD and a fall in TRI and CHE. Tt is nonspecific, since it occurs in a variety of acute diseases.

Hauss & Leppelmann : Changes of Enzyme Activities 253

Glutamic oxalacetic transominase

%------

7

1 C hol i n ester as e

I , I L L . l

3 ? 11 15 19 23 - Days after onset of infect ion - Purulent meningitis - Paratyphoid fever B --+ Em py em a .+--a Enter i t i s

......* Angina tons i l la r i s

FIGURE 3. Reaction of serum enzyme activities after variou.: :: :t:rtious diseases

2.54 Annals New York Academy of Sciences ~

%yo t a rd la I in fa rct ion Pulmonary ernboltsrn

Glutomic oxaiocetic

7-777-/-TT7-7-7 0.3 -

t l

, , I

10 30 50 70 30 - Days after acute onset o f the d i sease FIGURE 4. Reaction of serum enzyme activities after myocardial infarction a i d after

Ixilmonary emhl i sm in the same patient.

Other workers (Rudolph el aZ., Ostrow cri al., Ticktin ef a,l., Conrad) also established an increase in GOT following pulmonary, renal, splenic, and mesen- teric infarction, acute pancreatitis, crush injuries, burns, hcmolytic crisis, and surgery.

hiyocardial infarct, operative intervention, infectious diseases: pulmonary embolism, and other acute affections are characterized by a series of further

Hauss & Leppelmann: Changes of Enzyme Activities 2.55 common nonspecific symptoms. In these diseases the organism reacts with rise in temperature, leukocyte increase, changes in hemogram, serum protein variations, increase of blood sedimentation rate, blood sugar and rest nitrogen elevation, and other symptoms which, taken together, we have termed the acute syndrome, the causes of which are very complex. The serum enzyme changes are further symptoms of the acute syndrome.

In our view the reason for the change in serum enzyme activities has not yet been completely elucidated.

Nydick, et al. assume that COT leaks out of the cardiac muscle subsequent to myocardial infarction, thus elevating the level of this enzyme in the serum. This view is based upon the two following findings:

(1) Subsequent to infarction, the GOT disappears from the affected portion of the cardiac muscle, simultaneously reappearing in the serum. I t may be demonstrated by experiment on a dog that the GOT content of the cardiac muscle displaying infarction is inversely proportional to the size of the infarc- tion, and that the older the cardiac infarction, the lower the GOT content of the affected cardiac muscle (Nydick et al., Jennings and Wartman).

(2) A rough correlation has been found to exist between the size of the myo- cardial infarction and the GOT increase in the serum: the larger the infarc- tion, the greater the increase in GOT activityiii the serum (Agress ef al., Kattus el al., LaDue and Wrbblewski).

In our opinion it may well be possible that the elevation in GOT activity in the serum following myocardial infarction is due, a t least in part, to leakage from the necrotic cardiac muscle. However, the four following results lead us to believe that enzyme leakage from the cardiac muscle is not the sole faLtor responsible for the entire observed phenomenon.

(1) In addition to the increase in GOT, LDH, and ALD activity, a fall in TRI and CHE is regularly observed in myocardial infarction, surgery, and acute diseases. It is thus necessary to find an explanation for the phenomenon aj a whole that also explains this fall in enzyme activity. This fall cannot be explained by means of the mechanical conception of enzyme leakage from the infarcted heart muscle.

After injection, the serum level was 10 times the normal value. After 1 hour the greater part of the LDH had already disappeared from the serum. Assuming a degradation or an elimination from the serum at this rate, the LDH content of the infarcted cardiac muscle portion would not suffice to maintain the L’DH level in the serum a t 3 to 6 times normal value for a period of 5 to 7 days. Human cardiac muscle contains nearly 220,000 units of LDH/gm.; the normal LDH activity in the serum amounts to about 400 units per ml. (LaDue). The destruction of 1 gm. cardiac muscle would cause an LDH activity of 100 uinits/ml. in 2.2 1. serum. An LDH increase of 1500 units/ml. often observed in myocardial infarction presupposes the destruction of 15 gm. cardiac muscle. Supposing a degradation or an elimination rate of LDH from the serum even much less than 10 times the normal value, a destruction of 15 gm. cardiac muscle per hour would be necessary to maintain a serum level of 1500 units; that is, a destruction of 24 X 15 gm. = 360 gm./day. The elevation of the

(2) Wr6blewski and LaDue injected LDH intravenously into a dog.

- M u s c l e necrosis *--. Typhoid vaccine ....... Diphther ia toxin

%

...... ........ ....

Normal

- Pusfeure//o infect ion

a- -4 Peritonitis Tu be r cu I o s i s ........ _ _ _ _ ~ ~~ ~

Normal \ A l d o l a s e ...... ...... ........ ~~~

.... Normal ......... Glutamic - 20 "-? d e h yd rog e n a s e

+20

Normal

Normal

t 20 t

Prot eol y t ic ...... ............ oc t i v i t y .............

-

I ............... -

Normal

- 20 - 40

FIGU

\

a, - &-I- After acute lesion

RE 5. Reaction of enzyme activities in the liver after various acute lesions.

serum LDH level to 1500 units for 3 days would require 3 X 360 gm. = 1080 gm. heart muscle.

( 3 ) The enzyme variations occur not only after myocardial infarction, but also in a variety of acute illnesses in which no cell de$truction takes place; that is, neither in the heart nor in any other organ (for example. meningitis and angina tonsillaris).

(4) Finally, we (Hauss, Leppelmami, and Planitz) were able to prove in animal experiments with 265 rats and 31 guinea pigs that, following acute lesion,

A normal human heart weighs about 300 gm.

Hauss & Leppelmann: Changes of Enzyme Activities 257 extensive enzyme activity changes occur in the liver, an organ of great impor- tance in enzyme metabolism, at the same time as the change noted in the serum enzyme activities. In a model experiment for myocardial infarction muscle necrosis was induced experimentally in several groups of 15 rats each. Two similar groups were injected with typhoid vaccine and diphtheria toxin respectively, and other rats were infected with Pusteurella bacteria. The guinea pigs were treated with tubercle bacilli. A foreign-body peritonitis was produced in further groups of rats by injecting quartz powder into the abdom- inal cavity. The rat? were sacrificed aL intervals of 1 to 5 days following the acute lesion, the guinea pigs 10 to 12 weeks after TB infection.

After sacrifice, we determined the respective activities of LDH, ALD, glutamic dehydrogenase (GDH), TRI, CHE, and also the proteolytic activity ( E P ~ o T ) in the liver. The experimental results were evaluated by comparing the respective mean values from 15 experimental animals with those from 15 normal animals, the percentage increase or decrease of enzyme activity in the liver after acute lesion then being noted. In these experiments, the t distribu- tion (Student) was also employed as a basis for the statistical calculation. We assumed statistical significance whenever the probability p was lower than 0.05. The results are depicted graphically in FIGURE 5 (for details, see Hams, Leppelmann, and Pliinitz) .

This figure shows that the same changes in enzyme activities regularly occur in the liver following various acute afflictions. The same reaction always occurs subsequent to lesion of different types: a rise in LDH activity (in the case of tuberculosis, also in proteolytic activity); a fall in ALD, GDH, and TRl activity; and a primary decrease in CHE, followed by a secondary rise in CHE.

FIGURE 6 shows the factors influencing the enzyme level in the cell and in the serum. Enzyme degradation and formation in the organ cells, especially

Enzyme degrodation Enzyme formation

Enzyme level in the ce l l

Permeability of the ce l l membranes

Enzyme level in the serum

/ Elimination

\ Degradation

in urine and bi le Factors that influcnce the enzyme level in the cell and in the serum.

in the serum

FIGURE 6 .

258 Annals New York Academy of Sciences

in the liver, and the permeability of the cell membranes are significant for the enzyme level in the cell. The permeability of the cell membranes, the enzyme elimination in urine and bile, and the enzyme degradation in the serum in- fluence the enzyme level in the serum.

We are thus of the opinion that. variations of enzyme activity in the serum following myocardial infarction are not to be interpreted solely as consequences of enzyme leakage from the necrotic cardiac muscle cells; these changes are rather to be regarded as a more general phenomenon. A complex react.ion of the organism sets in after cardiac infarction, as it does after many other acute diseases. It is this complex reaction that. gives rise to a number of symptoms (such as leukocytosis and increase in blood sedimentation rate), and causes the change in enzyme activities. We interpret this reaction as a “ vege fa f in~ Gesumf umschabtung” in Hoff’s sense.

Summary Changes in enzyme activity in human serum set in following myocardial

infarction arid other acute diseases; thus, glutamic-oxalacetic transaniinase, lactic dehydrogenase, and aldolase rise, while tributyrinase and cholinesterase fall. The enzyme activity in rat liver undergoes a uniform reaction after various acute lesions: there is an increase in lactic dehydrogenase activity, a decrease in aldolase, glutamic dehydrogenase, and tributyrinase activities, and a primary fall and secondary rise in chohesterase.

The enzyme activity changes in the serum due to myocardial infarction and other acute causes are nonspecific; they make their appearance as part of the “acute syndrome” (Hauss). The assumption that the increase in glutamic- oxalacet ic t ransaminase, lactic dehydrogenase, and aldolase in the serum may be explained by leakage of these enzymes from the infarctecl cardiac muscle does not appear to us to be a sufficient explanat ion to account. for the phenom- enon in its entirety, and especially not for the decrease in tributyrinase and cholinesterase. We prefer to believe that the enzyme activity changes in the serum represent a complex nonspecific reaction on the part of the organism toward a variety of excitations. The changes in enzyme activity observed in the liver of animals subjected to acute lesions serve as a proof of this interpre- t a t ion.

Kefererlccs :l(;iisss, C . M., H. I . JACOHS, H. l i . GIASSNER, M. Li. LEDEKER, by. G . CLARK, I . M’aiiir-

LEWSK1, il. KARMEN J. S. l ~ l > r i e . 1955. Serum trausatninase levels in exlwri- mental inyocardial infarction. Circulation. 11: 71 1.

CHINSKI, M., G. 2. SIIMAGRANOFF & S. SHERRY. 1956. Serum transaminasc :ictivit\,. Observation in a large group of patients. J. Lab. Clio. Med. 47: 108.

CONRAD, F. G. 1957. Transaminase. N e w E,ngl. J . Med. 256: 602. kIAlJSS, Mi. 1%. 1954. Angina Pectoris. Thiemc. Stuttgart, Germany. Hmss, W. H., H. J. LEPPELYANN & H. SUI.I,YANN. 1956. Reiz1)eantsortutig. Vcrhantll.

tleut. Ges. inn. Metl. 62: 322. HAIJSS, W. H. & H. J . LEPPELMANN. C I m iinclerung von Fernieiilaktivit~il~n in1

Serum als Xustlruck einer unspedischen Reaktion tics Organisnius. Klin. Wochschr. 35: 65.

1957. iiber Schwaiikungen von L’er mentaktivitaten in der Leber bei esperimen!e!len Eingriffen und bei Infektionskranli heiten. Klin. Wochschr. 35: 957.

1957.

Hauss, W. H., H. J. LEI’PELMANN & H. I’LXNTTZ.

Hauss & Leppelmsnn: Changes of Enzyme Activities 2.59 HOFF, F. 1956. Klinische Physiologie und Pathologie. Thieme. Stuttgart, Germany. HsIEIi, K. M. & H. T. BLUMENTHAL. 1956. Serum lactic dehydrogenase levels in various

disease states. JENNINGS, R. B. & W. B. WARTMAN. 1957. Reactions of the myocardium to obstruction

of the coronary arteries. Med. Clin. N. Am. : 3. KATTUS, A. A., R. WATANABE I& C. SEMENSON. 1957. Diagnostic and prognostic signifi-

cance of serum transaminase levels in coronary occlusive disease. Circulation. 16: 502. LADUE: J. S. 1957. Laboratory aids in diagnosis of myocardial infarction. J. Am. Med

Assoc. 166: 1776. LADUE, J. S. & F. WR6BLEWSKI. Significance of the serum ghtamic omlacetic

transaminase activity following acute myocardial infarction. LADUE, J. S., E'. WR6BLEWSKI & A. KARMEN. 1954. Serum glutamic oxalacetic trans-

aminase activity in human acute transmural myocardial infarction. Science. 120: 497. NYDICK, I., F. WR6BLEWSKI & J. s. LADUE. Evidence for increaqed serum glutamic

oxalacetic transaminase activity following graded myocardial infarcts in dogs. Circula- tion. 12: 161.

OSTROW, B. H., D. STEINBERG, H. E. TICKTIN, G. N. P o u s & J. M. EVANS. 1956. Serum glutamic oxalacetic transaminase in coronary disease.

RUDOLPH, I.. A., R. DUTTON & J. A. SCHAEFER. 1955. Glutamic oxalacetic transaminase levels in experimental tissue damage. J. Clin. Invest. 34: 960.

SIEGEL, A. & R. J. BING. 1956. Plasma enzyme activity in myocardial infarction in dog and man.

TICKTIN, H. E., B. H. OSTROW & J. M. EVANS. 1956. Serum glutamic oxalacetic transami- nase in trauma.

WR~BLEWSKI, F. & J. S. LADUE. 1955. Lactic dehydrogenase activity in blood. Proc. SOC. Exptl. Biol. Med. 90: 210.

Proc. Soc. Exptl. Biol. Med. 91: 626.

1955. Circulation. 11: 871.

1955.

Circulation. 14: 790.

Proc. SOC. Exptl. Biol. Med. 91: 604.

Clin. Research Proc. 4: 102.