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Streptokinase) and Streptococcal Desoxyribonuclease on Fibrinous, Purulent, and Sanguinous Pleural Exudations

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Streptokinase) and Streptococcal Desoxyribonuclease on Fibrinous, Purulent, and Sanguinous Pleural Exudations THE EFFECT IN PATIENTS OF STREPTOCOCCAL FIBRINOLYSIN (STREPTOKINASE) AND STREPTOCOCCAL DESOXYRIBONUCLEASE ON FIBRINOUS, PURULENT, AND SANGUINOUS PLEURAL EXUDATIONS William S. Tillett, Sol Sherry J Clin Invest. 1949;28(1):173-190. https://doi.org/10.1172/JCI102046. Research Article Find the latest version: https://jci.me/102046/pdf THE EFFECT IN PATIENTS OF STREPTOCOCCAL FIBRINOLYSIN (STREPTOKINASE) AND STREPTOCOCCAL DESOXYRIBO- NUCLEASE ON FIBRINOUS, PURULENT, AND SAN- GUINOUS PLEURAL EXUDATIONS' By WILLIAM S. TILLETT AND SOL SHERRY (From the Department of Medicine, New York University College of Medicine, and the Third Medical Division of Bellevue Hospital, New York City) (Received for publication August 6, 1948) The results described in this article were ob- coccal groups C and G (3). The product is tained by the injection of concentrated and par- abundantly excreted into the culture medium in tially purified preparations derived from broth which the organisms are grown and is readily ob- cultures of hemolytic streptococci into the pleural tainable free from the bacterial cells in sterile cavity of selected patients who were suffering filtrates. from different types of diseases that gave rise to The fibrinolytic action, in tests conducted un- pleural exudations. The possibility has been ex- der optimal laboratory conditions, is unusually plored of utilizing two of the defined properties rapid in action on the fibrin coagulum of normal elaborated by hemolytic streptococci that have the human blood, requiring only a few minutes when unique capacity of causing rapid lysis of the solid whole plasma is employed as a source of fibrin, elements (fibrin and nucleoprotein) that are sig- and an even shorter time when preparations of nificant parts of exudates. In a companion ar- fibrinogen and thrombin of human origin are ticle, Christensen (1) has described additional used. The ultimate proteolytic nature of the steps in the purification of the materials employed fibrinolysis has been evident in the liberation of and has given quantitative methods of measure- breakdown products of protein digestion (4). ment of various increments concerned in the Another interesting feature of the phenom- fibrinolytic system, including trypsin inhibitor and enon is the high degree of activity of the strepto- specific antibodies, which have been employed in coccal lytic system in the presence of normal hu- this study. man blood as contrasted with its inaction or de- In the study of patients it was first necessary layed effect when tests are conducted with the to: (a) develop the investigation within non- blood of various animal species with the exception toxic but effective ranges of doses of the material of monkeys (3). Although studies of factors in- employed, and (b) determine whether or not the volved in streptococcal fibrinolysis have indicated enzymatic activities of the streptococcal products a basis for the differences in the behavior of blood were effectively operative when introduced di- from different animals, nevertheless the existence rectly into the site of the disease in the patients. of the difference has rendered impossible most This article is essentially limited to findings that experimental studies, in vivo, on animals and has are pertinent to the two aspects of the study men- limited them to observations conducted in pa- tioned above. tients, such as those initially described in this A brief description of the two streptococcal article. products that have been the subject of the in- The mechanism of the reaction has been a sub- vestigation is as follows: ject of study by various investigators. I. Streptococcal fibrinolysin (2) (Strepokinase) In an earlier report (2) it was noted that fibrin This has been found to be elaborated character- formed from mixtures of either human fibrinogen istically by strains of hemolytic streptococci and rabbit thrombin, or of rabbit fibrinogen and (Group A) causing acute infections in patients. human thrombin were susceptible to streptococcal It is also produced by some strains of strepto- lysis, whereas the fibrin derived from rabbit fibrinogen plus rabbit thrombin was unaffected. 1 This study was supported by a grant from the Na- tional Institute of Health, United States Public Health Milstone (5) demonstrated that an increment of Service. human serum present in the euglobulin fraction, 173 174 WILLIAM S. TILLETT AND SOL SHERRY was necessary for the reaction to occur and that if nism of fibrinolysis that may be responsible for preparations of human fibrinogen and thrombin the end results that we have observed. were highly purified no lysis would occur when Nomenclature. The fibrinolytic principle de- the streptococcal product was added. Further- rived from hemolytic streptococci is referred to more, if this human globulin fraction was added in this article as streptokinase. The kinase type to fibrin made up of rabbit components, lysis oc- of action of the streptococcal product has been curred. He referred to the euglobulin constituent consistently observed by several investigators. of human blood as "lysing factor" and suggested However, whether or not its complete activity that streptococcal fibrinolysis was mediated by the is solely that of kinase remains to be determined. same system as that involved in other examples of The term fibrin-lysing system has been employed fibrinolysis. as an objectively descriptive expression which Christensen (4), and Christensen and Mac- avoids the different recommendations of various Leod (6) have presented results concerning the investigators (6, 9-1 1). The activatable fibrin-ly- mechanism, and have concluded that the strepto- sing system may be closely identified with the coccal product to which they have given the name plasminogen of Christensen and MacLeod (6), streptokinase acts as a catalyst or kinase in caus- and the active fibrin-lysing system with their ing the transformation of a zymogen of normal term plasmin. human blood, designated by them plasminogen, into a proteolytic enzyme, designated plasmin. II. Streptococcal desoxyribonuclease Kaplan (7) has made extensive studies on several aspects of the mechanism of the strepto- In recent articles the occurrence of desoxy- coccal fibrinolysin-serum protease system. These ribonucleoprotein in significant amounts in puru- studies have in part dealt with the dissimilarity lent empyematous fluids was reported (12) and its depolymerization by a desoxyribosenuclease of serum protease and trypsin and also with the inhibition of streptococcal fibrinolysis by antipro- found to be present in the concentrated strepto- coccal flltrates was also described tease. The findings are predicated upon the (13). kinase nature of the action of the streptococcal The solid sediments of the samples of pus were found to contain as much as 30% to product and the identity of the protease of serum 70% nucleo- protein. Since the physical characteristics of as the lysing principle. Ratnoff (8), studying a proteolytic enzyme in human plasma, gave special desoxyribose nucleoprotein are fibrous and gel- attention to the fibrinolytic system activated by atinous, the similarity of its appearance to that the streptococcal product and obtained data indi- of fibrin became a matter of importance in identi- cating that the activation of plasma proteolytic fying the dual enzymatic systems with which we enzyme by streptococcal fibrinolysin behaved as were dealing; namely, fibrin substrate in the if it involved a stoichometric reaction. This fibrinolytic system, and nucleoprotein substrate finding implies that the streptococcal product may acted upon by nuclease. In each instance rapid take an active part in the lytic system rather than liquefaction of the respective solid substrate exert only a catalytic effect. occurred. Without developing the discussion of the mech- Each of the substrates mentioned has been anism, it is sufficient to state that the objective identified in varying amounts in different types of demonstration of changes in constituents of pleural exudation. For example, empyemal pus pleural exudates that have been effected by the of bacterial origin is high in its content of nu- streptococcal fibrin-dissolving system, acting cleoprotein, which is presumably derived from within the pleural cavity of patients, constitutes the leucocytes, while the constituent most con- definitive results around which this report cen- spicuously present in hemothorax is fibrin. Fi- ters. The conditions, unavoidably inherent in brinous pleural exudates such as may be en- the several factors that may be simultaneously op- countered in association with pneumonia, pul- erative in association with the processes of dis- monary neoplasm, and other diseases, or the ef- ease within patients, makes it impossible at the fusions of tuberculous pleurisy have been studied present time to analyze and identify the mecha- chiefly for the fibrinolytic effect, although from STREPTOKINASE AND STREPTONUCLEASE EFFECT IN PATIENTS 175 observations on preparations of the exudates which both scarlatinal toxin and fibrinolytic filtrates were stained by the Feulgen method (12), it is evi- injected into Dick positive and Dick negative individuals, no correlation was detected. From the limited observa- dent that varying amounts of nucleoprotein are tions, it seemed reasonable to assume that the primary present. toxicity of the fibrinolytic filtrate was due either to the fibrinolytic principle itself or to some contaminating prod- Streptococcal concentrates 2 uct other than
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