transfusions were performed to supply the fetus
with erythrocytes which could not be destroyed by
3. Kleihauer-Betke stain technique stains erythrocytes
containing fetal hemoglobin dark red in cord blood
(arrows). Remaining adult erythrocytes are traceable
to prenatal transfusion.
dumping of erythrocytes was found with Coombs serum.
A Kleihauer-Betke5 stain revealed the cord blood to be
96% adult (transfused) hemoglobin. (Fig 3). Practically
the total peripheral circulation of the infant had been de¬
rived from transfused blood.
The cord bilirubin was 5.6/100 cc, and at 2 hours of life,
the infant received 20 cc of group O, Rh-negative, Kell-
negative, whole blood. This was repeated at 4 hours of
life. When the infant was 12 hours old, the bilirubin was
5.6 mg/100 cc, and at 19 hours of life, the bilirubin was
12.9/100 cc. When the infant was 24 hours old, an exchange
transfusion was carried out. Following this, the bilirubin
rose to 16.8 mg/100 cc and a second exchange transfusion
was carried out at 36 hours of life. The bilirubin decreased
daily and no further exchange transfusions were necessary.
When the infant was 20 days old, the hemoglobin was 7.2
gm/100 cc and the hematocrit reading was 22%. The in¬
fant was given a 35 cc transfusion of whole blood. The
infant was discharged at 35 days of age weighing 5 lbs
4 oz (2,382 gm). The infant received additional booster
transfusions at 5, 7, and 10 weeks of age. The anti-D titer
of the infant was 1:512 at 7 weeks and 1:128 at 10 weeks.
A bone marrow study made at 10 weeks of age revealed
normoblastic hyperplasia. At 11 weeks of age, the infant is
alert and healthy and weighs 8 lb (3,629 gm).
Comment
The maternal anti-D titer was the highest ever
recorded in the New York Hospital Blood Bank.
This case report represents an extremely highly
immunized obstetrical patient. There was evidence
of severe deterioration at a stage too early for pre¬
term delivery. (Spectrophotometric value of 0.68
at 460 m/* at 30 weeks gestation.) The intrauterine
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the potent antibodies. At delivery it was noted that
the cord hemoglobin consisted of almost entirely
transfused blood. This case has been presented to
demonstrate that this technique can be successful
in even the most severely immunized obstetrical pa¬
tients. The breech presentation did not appear to
make the procedure more difficult. This infant was
the third in this series who was saved by the intra¬
uterine transfusion procedure.
Generic and Trade Names of Drugs
Sodium diatrizoate—Hypaque Sodium.
Procaine penicillin G—Crysticillin, Depo-Penicillin. Diurnal Peni¬
cillin. Lenlopen, Parencillin, Procaine Penicillin G.
Methylergonovine Maléate—Methergine Maléate.
References
1. Liley, A.W.: Intrauterine Transfusion of Foetus in Haemo-
lytic Disease, Brit Med J 2:1107, 1963.
2. Queenan, J.T., and Wyatt, R.H.: Intrauterine Transfusion
of Fetus for Severe Erythroblastosis Fetalis, Amer J Obstet Gynec
to be published.
3. Bowman, J.M., and Friesen, R.F.: Multiple Intraperitoneal
Transfusion of Fetus for Erythroblastosis Fetalis, New Eng J
Med 271:703, 1964.
4. Duggin, E.R., and Taylor, W.W.: Fetal Transfusion in
Utero: Report of Case, Obstet Gynec 24:12, 1964.
5. Kleihauer, E.; Braun, H.; and Betke, K.: Demonstration von
fetalem Hemoglobin in den Erythrocyten eines Blutausstrichs,
Klin Wschr 35:637, 1957.
High Growth-Hormone Levels in
Diabetic Ketoacidosis
A Possible Cause of Insulin Resistance
Roger H. Unger, MD
THE demonstration by Roth, Glick, Berson, and
Yalow1 that 2-deoxyglucose administration is asso-
ciated with a rise in plasma-growth hormone con-
centration suggested that intracellular deficiency of
glucose is a stimulus to growth hormone release.
Since insulin lack would, presumably, create a simi-
lar deficit of intracellular glucose, it seemed possible
that severe diabetic ketoacidosis might be charac-
terized by excessive secretion of growth hormone.
An excess of endogenous growth hormone secondary
to insulin lack might well account for the high in-
sulin requirements so typical of the initial hours of
severe diabetic ketoacidosis. The subsequent rapid
decrease in insulin requirements which accompanies
adequate insulin therapy could be explained by a
decrease in growth-hormone secretion as insulin
permits glucose entry into cells.
The foregoing consideration prompted the follow-
ing investigation of growth-hormone concentration
From the University of Texas Southwestern Medical School,
and Veterans Administration Hospital, Dallas.
Reprint requests to 5323 Harry Hines Blvd., Dallas 75235.
This study was supported by Public Health Service grant A\x=req-\
2700, the Veterans Administration Cooperative Program, and the
Upjohn Co., Kalamazoo, Mich.
 (HGH) in diabetic patients before and after treat-
ment for diabetic ketoacidosis.
Methods
The six patients included in this study, were ad-
mitted consecutively to Parkland Memorial Hos-
pital or to the Veterans Administration Hospital,
Dallas, with a diagnosis of diabetic ketoacidosis. In
each patient, an aliquot of plasma was obtained on
admission prior to insulin administration for growth-
hormone assay, as well as for determination of
blood glucose, carbon dioxide, and acetone concen¬
trations. Growth hormone concentration was mea¬
sured in duplicate by the method of Glick and
associates.2 A subsequent plasma specimen was ob¬
tained in a fasting state just prior to the patient's
hospital discharge, at a time when the insulin re¬
quirements were considered to be at a minimal level.
Insulin concentration was determined by the radio-
immunoassay of Yalow and Berson3 in the only two
previously untreated diabetics.
Results
Plasma HGH Levels in Normal and Diabetic Sub¬
jects.—In 25 normal male subjects tested previously
in this laboratory, the mean fasting plasma HGH
was 0.4jUg/ml (standard deviation [SD] 0.24), and
in 38 normal females was 4.9^g/ml (SD 3.32). The
highest fasting value ever noted in our laboratory
in a normal male was 15/ig/ml, and in a female was
18.5/ig/ml. However, others have reported fasting
values as high as 50/ig/ml.1
In normal subjects, hyperglycemia is almost al¬
ways associated with a decline in plasma HGH level,
as was first noted by Roth et al.1 In this laboratory,
for example, the average HGH level in females one
hour after a glucose load is 1.9jag/ml, and the high¬
est value as yet encountered at that time was
5.6/ig/ml. In eight mild diabetics with fasting hy¬
perglycemia, the mean fasting HGH level was
slightly lower than in normal subjects (2/<.g/ml in
females).
Plasma HGH Levels in Ketoacidotic Subjects.—
The pertinent clinical and laboratory findings of
each case are Usted in the Table, along with the
plasma HGH levels before and after treatment for
ketoacidosis. In five of the six patients, the HGH
concentration was elevated in relation to the blood
glucose concentration. In three cases there was an
absolute elevation of striking proportions, and in
one patient, the level was 70/ig/ml, well within the
range of acromegalic subjects.4 This latter patient,
1, whose blood glucose level on admission was 792
mg/100 cc, and whose C02 level was less than 4
mEq/liter, required 1,400 units of insulin injection
during the initial phase of treatment. At the time
of discharge, when the diabetes was optimally con¬
trolled with 80 units of isophane insulin suspension
(NPH Insulin), his HGH was 3.6/ig/ml, a relatively
normal level.
The only other patients with C02 levels below 10
mEq/liter (patients 2 and 3) also had a pronounced
elevation of plasma HGH, 24^g/ml and 23ftg/ml,
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respectively. Although patient 2 required 650 units
of insulin injection during initial therapy, patient
3, a previously undiagnosed and untreated diabetic
required only 150 to 200 units during this phase of
treatment. His plasma contained measurable insulin
(12 microunits/ml).
The only patient with a low HGH level on ad¬
mission was patient 6, the least severely ketoacid-
otic member of the group. She was a new, previ¬
ously untreated diabetic, and was the only female
in the series. Her C02 level was 16 mEq/liter, and
her blood glucose level was 490 mg/100 cc. Although
300 units of insulin injection was administered dur¬
ing the initial phase of therapy, it seems likely that
she was overtreated, as she required glucose infu¬
sions because of hypoglycemia. Her plasma insulin
level on admission was 50 microunits/ml.
Comment
The foregoing results reveal the presence of a
high plasma HGH concentration in patients with
severe diabetic ketoacidosis prior to treatment with
insulin. These patients are not necessarily in dis¬
agreement with the findings of Roth, Glick, Yalow,
and Berson who reported no elevation in a patient
with presumably mild diabetic ketoacidosis.5 Since,
under normal circumstances, hyperglycemia results
in a suppression of growth hormone secretion,5
these high HGH levels, like those induced experi¬
mentally by 2-deoxyglucose administration,1 might
be due, directly or indirectly, to intracellular glu¬
cose deficiency. For example, glucose lack within
the HGH-producing cells or within the hypothala-
mic center which controls HGH release might be
the cause of the unrestrained HGH secretion, and
would imply insulin dependence of at least one of
these sites; on the other hand hypersécrétion of
HGH might be a consequence of the ketonemia,
acidosis, or other changes resulting from insulin lack
in insulin-dependent peripheral tissues. In either
case, it appears that the suppressive effect of glu¬
coseupon HGH secretion is ultimately insulin-de¬
pendent, and that in severe insulin lack this "nega¬
tive feedback" is inoperative, thus permitting
unrestrained growth hormone secretion despite hy¬
perglycemia. It is of interest, therefore, that Good-
ner and Freinkel have found in vitro studies that
the anterior pituitary is responsive to insulin.6
It should be pointed out, however, that the high
HGH levels could be the nonspecific consequence of
other factors, such as stress or the physical exertion
of tachypnea, rather than of insulin lack.
Irrespective of the cause of the increased plasma
HGH, two facts are clear. First, an elevation in
plasma HGH was present in the three severely ke-
toacidotic patients studied, and in the most severe
case (patient 1) the level was in a range which, in
the presence of hyperglycemia, would have been
anticipated only in acromegalic subjects. Second,
these elevations of HGH concentration were present
at a time when the insulin requirement of each pa¬
tient was many times his usual daily insulin dose.
Luft, Ikkos, Gemzell, and Olivecrona7 have demon-
 Growth Hormone Levels in Diabetic Ketoacidosis
Clinical Data Initial Laboratory Data Insulin Requirements Plasma HGH
Kuss-
maul Blood CO., 4+ Serum Final
Patient Respi¬ Glucose, mEq/ Acetone, Initial Daily Dose Before At
No. Coma ration Mg/100 Cc Liter Dilution Dose* Units/Day Treatment Discharge
Yes Yes 792 1:8 1,000-1,400 80 70 3.6
Yest No 576 1:32 650 53 07~
No No 680 150- 200 30 23 1.3
No No 510 13 1:4 400 55 9.2
Not Yes 510 18(?)j 740§ 25 8.8 4.2
No No 490 16 1:2 300!! 35 1.0
*
Required to lower blood glucose to 300 mg/100 cc or correct ketonemia. §New, previously untreated diabetic patient.
t Lethargic. ! Over-treatment.
t Probable laboratory error.

strated that the intramuscular administration of 10
mg of HGH to young hypophysectomized diabetics
causes rapid deterioration of diabetic control and an
increase in insulin requirements. According to
Parker, Utiger, and Daughaday,8 a 10-mg dose of
HGH produces plasma levels of HGH comparable
to those noted in patients 1, 2, and 3. It is, there¬
fore, entirely possible that endogenous HGH eleva¬
tions of the magnitude observed here were sufficient
to cause or contribute to the high insulin require¬
ments which characterized the early hours of ther¬
apy in these patients with ketoacidosis.
The foregoing suggestion is not intended to de¬
preciate the possible role of various other insulin-
opposing factors such as adrenoglucocorticoids, in¬
sulin antibodies, and the more controversial in
vitro-demonstrable inhibitors of insulin-like activ¬
ity, in raising insulin requirements. These studies
do, in fact, reveal a certain lack of correlation be¬
tween the insulin requirement and the HGH level
of these patients. For example, patients 6 and 3, the
previously undiagnosed and untreated diabetics,
each required less than 300 units of insulin in¬
jection, relatively modest doses compared to the
others, although patient 3 had a high HGH level of
23/ig/ml and patient 6 had a level of only 1/xg/ml.
Furthermore, patient 3, with an HGH level of 23/xg/
ml, required less than half as much insulin as pa¬
tient 2, whose HGH level was 24^g/ml. Finally, pa¬
tient 5, whose C02 of 18 mEq/liter is difficult to
reconcile with his clinical picture, received 740 units
of insulin injection, although hia HGH level was
not very high. He was, however, over-treated and
required hypertonic glucose infusions.
Since the initial requirement of patient 2 and of
the three other long-standing insulin-treated dia¬
betics, far exceeded those of the two previously un¬
treated patients (Table), one may wonder, in par¬
ticular, about the role of immunologie factors in
their insulin resistance. Although insulin antibodies
were present in all four patients who had been re¬
ceiving insulin prior to admission, it seems unlikely
that a titer sufficent to explain an insulin require¬
ment of several hundred units was present in any
member of this group. However, this question is
under further study.
But regardless of the relative importance of the
role of the various anti-insulin factors in determin¬
ing the insulin requirements in diabetic ketoacido-
sis, it seems reasonable to conclude that an ex¬
tremely high growth-hormone concentration, of the
magnitude encountered in at least one member of
this series, would constitute an insulin-opposing
force of considerable consequence.
Summary
Experimental evidence that lack of intracellular
glucose stimulates growth-hormone (HGH) secre¬
tion prompted studies to determine if the exclusion
of glucose from cells because of insulin lack, as in
diabetic ketoacidosis, is similarly accompanied by
increased plasma HGH. In the three most severely
ketoacidotic patients of this series, plasma HGH
was elevated despite intense hyperglycemia, and re¬
turned to normal after treatment. One patient, the
most insulin-resistant member of the group, had an
HGH level of 70/xg/ml, a value in an acromegalic
range, at a time when his blood glucose level was
792 mg/100 cc. By contrast, the least ketoacidotic
member of the group had a normal HGH level.
Plasma HGH may be elevated in severe ketoacid¬
osis, perhaps as a result of intracellular glucose
deficiency consequent to the insulin lack. The mag¬
nitude of the elevation of plasma HGH in such pa¬
tients would seem to be sufficient to play an impor¬
tant role in the marked increase in insulin require¬
ments characteristic of these patients.
Generic and Trade Names of Drug
Isophane insulin suspension—NPH Iletin, NPH Insulin.
References
1. Roth, J., et al: Secretion of Human Growth Hormone: Physi-
ologic and Experimental Modification, Metabolism 12:577-579,
1963.
2. Glick, S.M., et al: Immunoassay of Human Growth Hormone
in Plasma, Nature 199:784-787,1963.
3. Yalow, R.S., and Berson, S.A.: Immunoassay of Endogenous
Plasma Insulin in Man, J Clin Invest 39:1157-1175, 1960.
4. Utiger, R.D.; Parker, M.L.; and Daughaday, W.H.: Studies
on Human Growth Hormone: I. Radioimmunoassay for Human
Growth Hormone, J Clin Invest 41:254-261, 1962.
5. Roth, J., et al: Influence of Blood Glucose on Plasma Con-
centration of Growth Hormone, Diabetes 13:355-361, 1964.
6. Goodner, C.J., and Freinkel, N.: Studies of Anterior Pituitary
Tissue in vitro: Effects of Insulin and Experimental Diabetes Mel-
litus Upon Carbohydrate Metabolism, J Clin Invest 40:261-272,
1961.
7. Luft, R., et al: Effect of Human Growth Hormone in Hypo-
physectomized Diabetic Subjects, Lancet 1:721-722, 1958.
8. Parker, M.L.; Utiger, R.D.; and Daughaday, W.H.: Studies
on Human Growth Hormone: II. Physiological Disposition and
Metabolic Fate of Human Growth Hormone in Man, J Clin Invest
41:262-268, 1962

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