Cold dependent activation of complement in systemic lupus erythematosus. A unique cause for a discrepancy between clinical and laboratory parameters

A 31-year-old woman with systemic lupus erythematosus (SLE) was studied because she developed markedly reduced total hemolytic complement activity at a time when her disease was clinically inactive. Functional assays demonstrated reduced activities of C1, C4, and C2, but normal concentrations of C3 and the terminal (C5-9) components were present. Antigenic concentrations of C1, C4, and C2 were normal. Plasma or serum obtained from blood allowed to clot at 37 degrees C had normal complement activity. Complement activity was depleted when the patient's serum was incubated in the cold. At reduced temperatures, the patient's serum (or purified IgG) depleted complement activity of normal human sera. A second patient with SLE was also demonstrated to have this same phenomenon. Cryoglobulins were not detectable in these patients. These data indicate that in vivo the patients' complement was normal and that the observed in vitro reduction was caused by cold dependent activation of the classical pathway.

Role of antigen form in development of mucosal immunoglobin A response to Shigella flexneri Antigens

One major stumbling block in the development of an effective means to immunize against shigellosis and other enteric diseases has been the lack of a means to assess sequential mucosal immune responses to different potential immunogens. In the present study, we compared the abilities of live invasive organisms, noninvasive organisms, and nonviable antigen preparations of shigella to elicit mucosal immune responses. Whereas previous studies have found that effective immunity was produced best by vaccination with live invasive strains of shigella, in the present study, live noninvasive strains that did not produce any histopathological damage were consistently able to produce local (immunoglobulin A) immune responses as vigorous as those of the invasive strains. Further, acetone-killed shigella antigen was also an effective mucosal immunogen, whereas hot phenol-water-extracted shigella lipopolysaccharide was ineffective, possibly due to the method of preparation. A single oral or parenteral priming was ineffective in enhancing the mucosal immune response when restimulated 1 month later with the same antigen. However, a mucosal memory response was found to be present several months after a triple mucosal stimulation with a locally invasive vaccine strain.

No impairment of local intestinal immune response to keyhole limpet haemocyanin in the absence of Peyer's patches

The role of Peyer's patches in the local intestinal and serum antibody responses to keyhole limpet haemocyanin (KLH) was studied in rabbits with chronically isolated ileal loops. Four weekly doses of 400 microgram KLH were administered into loops prepared with and without Peyer's patches. Isotype-specific IgA and IgG anti-KLH in loop secretions collected twice each week and in sera collected weekly were assessed by enzyme-linked immunosorbent assay. Fluid IgA anti-KLH in loops without Peyer's patches first showed a statistically significant increase on day 25, 1 week later than control loops with Peyer's patches. However, some animals in the group without Peyer's patches showed a rise as early as day 7, and the differences from controls were not statistically significant at any time. No statistically significant rise in fluid or serum IgG anti-KLH occurred in either group. Thus, Peyer's patches were not essential for local intestinal antibody response to KLH, a soluble macromolecular antigen. The findings suggest that the innumerable small lymphoid nodules in the gastrointestinal tract, or other mechanisms of antigen processing, play an important role in local intestinal immune responses.

Extramedullary IgM plasmacytoma presenting in skin

An IgM-secreting extramedullary plasmacytoma with macroglobulinemia presented itself in the skin. Reactions of the plasmacytoid cells in dermal nodules to erythrocyte-antibody-complement complexes suggested that the neoplastic cells differentiated in situ. Large numbers of plasmacytoid neoplastic cells co-mingled with alpha naphthyl acetate esterase-positive histiocytes in a random and "territorial" distribution, which suggested a functional relationship between them. The subject of extramedullary cutaneous plasmacytoma is reviewed and discussed.

Whipple's disease: a review emphasizing immunology and microbiology

Whipple's disease is an important and fascinating problem of local immunity in the gastrointestinal tract. Does the disease occur when an organism that is rare in nature infects an individual or do patients with Whipple's disease have a definable defect in their immune response that permits infection by a more common agent? Data in recent years indicate that there is only one type of microorganism that causes Whipple's disease. It is rod-shaped by electron microscopy and has a definable antigenic pattern by immunofluorescence. Paradoxically (considering its geometry), it reacts most strongly with antisera directed to streptococcal antigens. Patients with Whipple's disease do not have a disorder of immunoglobulin synthesis and do not have immune complexes present in their gut walls. Further, although earlier studies indicated that a defective response of T-lymphocytes to PHA is consistently present in these patients even years after therapy, more recent studies have found no consistent defect in mitogenic responses to PHA, CON A, or PWM. Also, recent studies indicate that mononuclear cells from patients with Whipple's disease usually mediate antibody-dependent cell-mediated cytotoxicity as well as controls, although spontaneous cell-mediated killing may be decreased. All these studies suggest that the defect is not primarily of lymphocytes, rather it is more likely that a defect exists in monocytes and macrophages. Future studies on Whipple's disease should add to existing knowledge of how the immune processes intracellular microorganisms.

The detection of islet-cell antibodies by immunofluorescence in Bouin's-fixed, paraffin-embedded human pancreas

Pancreatic islet-cell antibodies have been demonstrated in the sera of insulin-dependent diabetic patients, with or without polyendocrine disease, by immunofluorescent microscopy in which cryostat sections of fresh-frozen human pancreas were used as the substrate. In the present study we used sections of Bouin's-fixed, paraffin-embedded, trypsin-treated human pancreas as the islet-cell substrate and compared the results to those obtained with cryostat sections. Twenty-four sera from insulin-dependent diabetic patients, one serum from a non-insulin dependent diabetic patient and five sera from normal individuals were tested. With serum samples containing islet- cell antibodies, Bouin's-fixed, paraffin-embedded tissue produced a more intense fluorescence, was easier to use and was more sensitive than the conventional cryostat method.

Variables affecting local immune response in ileal loops: role of immunization schedule, bacterial flora, and postsurgical inflammation

Several variables inherent in chronically isolated ileal (Thiry-Vella) loops in rabbits were studied for their effect on the local immune response of the intestine to live, locally invasive bacteria (Shigella X16). A much more vigorous local immunoglobulin A response to Shigella X16 was elicited when rabbits were immunized in their Thiry-Vella loops shortly after surgical creation of the loop than if a week were allowed to pass before they were immunized. Three major differences existed in Thiry-Vella loops on the day after surgery and a week later: (i) their microbial flora, (ii) nonspecific acute inflammation due to the surgery itself, and (iii) the histological appearance of the intestine. On day 1 after surgical creation of the Thiry-Vella loop, there were few bacteria in the loop, and the histology was that of normal small bowel except for mild acute inflammation due to the surgery. By day 6 after surgery, all loops contained large numbers of Pseudomonas aeruginosa and other aerobes, an atrophy of intestinal epithelium occurred, and the acute inflammation due to surgical trauma had subsided. By artificially colonizing Thiry-Vella loops with 10(8) or 10(10) live P. aeruginosa on the day of surgery, we found that the presence of these bacteria alone did not greatly diminish local immune responses to live Shigella. Furthermore, when the acute inflammation due to surgical trauma was recreated in loops 6 days old, no enhancement of the immune response was seen as compared to nontraumatized 6-day-old Thiry-Vella loops. The difference between immunization soon after surgery and a week later related to changes that occur in the loop itself with increased isolation. Finally, multiple immunizations of Thiry-Vella loops resulted in a more vigorous local immunoglobulin A response than a single immunization. These studies demonstrated that Thiry-Vella loop models can be useful in studying the kinetics of local immune responses by the intestine only if careful attention is paid to key variables inherent in the Thiry-Vella loop models themselves.

Enhancement by cholera toxin of IgA secretion from intestinal crypt epithelium

Studies of the effects of cholera toxin on the intestine have produced conflicting results regarding stimulation of IgA secretion. In the present study rabbit ileal loops were perfused with saline, and the IgA content of the perfusate was assessed by immunoradiometric assay. Crypt epithelial IgA content in biopsies was studied by immunofluorescence. Cumulative loop fluid IgA production 300 minutes after exposure to cholera toxin was 6216 +/- 993 microgram/cm compared with 4646 +/- 953 microgram/cm in controls (P < 0 . 20). However, rate of fluid IgA production above baseline at 300 minutes was 1742 +/- 181 microgram/h/cm in cholera loops and 1049 +/- 310 microgram/h/cm in controls, and the mean difference between the cholera and control loops was statistically significant (P < 0 . 05). In biopsies, mean rank of crypt epithelial IgA at 300 minutes was decreased compared with controls (P < 0 . 05). The findings of increased rate of fluid IgA production and decreased epithelial IgA suggest that a single dose of cholera toxin enhanced secretion of IgA from crypt epithelium into the intestinal lumen, although the magnitude of the enhancement was not great.

Immunofluorescence of deparaffinized, trypsin-treated renal tissues. Preservation of antigens as an adjunct to diagnosis of disease

The present study compares formalin-fixed, deparaffinized and trypsin-treated (DTT) renal tissue sections with frozen sections for detecting immune complex deposition. Both DTT and frozen sections from 52 renal biopsies were stained directly with fluorescein isothiocyanate-conjugated antihuman IgG, IgM, IgA, fibrinogen, and C3. DTT sections alone were stained indirectly for C3 using a double conjugate technique. Antigen presence or absence on DTT section was accurately detected in 90 per cent of biopsies for immunoglobulins and fibrinogen and in 75 per cent for C3 when compared to frozen section. Furthermore, antigen deposition was found in 21 per cent of biopsies only on DTT sections (usually because frozen tissue lacked glomeruli). Frozen sections alone were treated with reagents of the fixation-embedding process and directly stained for IgM and C3 to determine antigen stability. Alkaline or neutral formalin pH helped maximize antigen preservation. DTT sections are a valuable tissue source for adjunctive diagnosis of renal disease.

Enzyme-linked immunosorbent assay for immunoglobulin G and immunoglobulin A antibodies to Shigella flexneri antigens

An enzyme-linked immunosorbent assay has been developed to detect class-specific antibodies to Shigella flexneri lipopolysaccharide antigens. This enzyme-linked immunosorbent assay system has been used to measure antibodies present in serum or intestinal secretions without further purification. It is considerably more sensitive than passive hemagglutination, allowing detection of as little as 1.3 ng of specific immunoglobulin G antibody per ml in immune sera. Optimal conditions for this assay are outlined in this report.

Bridging hepatic necrosis. Etiology and prognosis

The probable etiology and outcome of bridging hepatic necrosis found on a liver biopsy performed within three months of the onset of clinical illness was evaluated in 42 consecutive patients with this finding. Eighteen of the patients (43%) had a probable drug etiology for their hepatitis. Ten patients had HBSAG-positive acute hepatitis. Fourteen patients had neither drug-induced disease nor proven HBSAg-positive hepatitis. One patient from the drug-induced group died, but the other 17 had complete clinical recovery. Eight of ten in the hepatitis B antigen-postive group cleared their antigen and had complete clinical recovery. Chronic hepatitis developed in two who remained persistently HGSAg positive. Eight of the patients in the group with unknown etiology recovered, while six developed evidence of active chronic liver disease. This incidence of active chronic liver disease is significantly greater than that found in the drug-induced group (P less than 0.02). We conclude that drug-induced hepatitiis accounts for a significant proportion of patients of acute hepatitis who have bridging hepatic necrosis on liver biopsy. However, in these drug-induced cases the finding of bridging hepatic necrosis does not appear to be associated with an increased risk of development of active chronic liver disease.

A modification of the automated immune precipitin method for quantitation of human serum immunoglobulins

The use of the automated immune precipitin method to measure human serum immunoglobulins has been reported by several groups. The authors encountered difficulties in evaluating the technic even when they incorporated such recent modifications as the use of polyethylene glycol to enhance the reaction. By altering the flow pattern and prediluting each specimen, they were able to increase sampling rate, decrease processing time, and decrease the frequency of line obstructions while obtaining reproducible standard curves without using polyethylene glycol. There was good correlation between the results obtained by their modification of the technic and those obtained by the Fahey radial immunodiffusion method. As with other automated immune precipitin systems, abnormally high values gave characteristic notched peaks and lipemic specimens were centrifuged in order to obtain the infranatant for quantitation. The present modification of the automated immune precipitin system provides a rapid, simple and efficient method to quantitate human serum immunoglobulins.

The Role of Peyer's Patches in the Local Immune Response of Rabbit Ileum to Live Bacteria

Chronic, isolated, ileal (Thiry-Vella) loops in rabbits have been used to study the role of Peyer's patches in the local immune response of the intestine to live, locally invasive bacteria. Three weekly doses of Shigella X16 were administered to these isolated loops and the IgA and IgG activity against shigella were measured in samples of sera and loop secretions by using an enzymelinked immunoassay technique. Secretions from loops containing a Peyer's patch exhibited a stronger early IgA response to the bacteria than did secretions from loops lacking a Peyer's patch. The enhanced early local immune response in loops containing a Peyer's patch may reflect more efficient processing of the antigen by the specialized follicle-associated epithelium that overlies Peyer's patches, or it may be a result of the increased chance of an antigen encountering immunocompetent cells among the large number of lymphocytes in the Peyer's patch. However, IgA against the bacteria in later fluids from both types of loops were comparable. the local immunity achieved in loops lacking a Peyer's patch may have resulted from local invasion of the epithelium with stimulation of lymphocytes in the lamina propria, or bacterial antigens may have been brought to mesenteric lymph nodes for processing. Alternatively, if small isolated lymphoid follicles (which are present throughout the intestine although not visible without histologic examination) have functional capabilities similar to those of Peyer's patches, they may play a role in the response seen in secretions from both types of loops. Clearly, Peyer's patches are important structures, but it is still unknown whether they can exert some unique influence on the local immune response of the gut, or whether they have gained eminence over smaller intestinal lymphoid structures by virtue of their prominence.

Local (immunoglobulin A) immune response by the intestine to cholera toxin and its partial suppression with combined systemic and intra-intestinal immunization

Chronically isolated Thiry-Vella (T-V) ileal loops in rabbits were used to study the local and systemic immune response to purified cholera toxin (CT). Immunization consisted of intraloop (i.l.), subcutaneous (s.c.), or combined i.l. and s.c. inoculation of CT. Fluid from the loops and sera were tested for neutralization of CT by the blueing test and for relative content of isotype-specific (immunoglobulins A [IgA] and G [IgG]) anti-CT. To demonstrate protection against CT, fluid production by the chronic T-V loops was measured after challenge with CT; an "acute" loop prepared from adjacent intestine at the time of challenge was also tested in some animals. The highest neutralizing titers in loop fluids were found in animals receiving i.l. or i.l. and s.c. inoculations, whereas titers in sera were highest in rabbits receiving s.c. or i.l. and s.c. inoculations. IgA anti-CT in fluids became greatest after i.l. inoculation alone and was lowest in s.c. animals. Combined s.c. and i.l. immunization was accompanied by reduced content of IgA anti-CT in fluids as compared with that obtained with i.l. inoculation alone. This finding strongly suggested a suppressive effect on local immunization by s.c. inoculation. While this suppression may have been due to a direct (toxigenic) effect of CT on lymphocytes, an immunogenic mechanism, probably mediated through suppressor T cells, is favored. Little IgG anti-CT was detected in any loop fluids, but high levels were found in sera after two s.c. inoculations or four i.l. inoculations. Neutralization titers for the fluid specimens showed much better correlation with IgA anti-CT values than with IgG anti-CT values. The chronic and acute T-V loops showed protection against fluid production after exposure to CT in systemically and locally immunized animals. However, IgG anti-CT usually appeared in both loops; leakage of serum antibodies because of surgical manipulation was felt, therefore, to invalidate these protection results as a demonstration of local immunity. In challenge studies in undisturbed chronic loops, only local immunization alone was found to result in definite protection.

Whipple's disease: demonstration by immunofluorescence of similar bacterial antigens in macrophages from three cases

Although it is widely accepted that Whipple's disease is caused by microorganisms, there is little agreement as to the exact nature of those microbes. Several different types of bacteria have been reported from patients with Whipple's disease causing some workers to speculate that Whipple's disease may be due to a variety of microorganisms. Using an indirect immunofluorescence technique, we have demonstrated bacterial antigens in the granules of the foamy macrophages from three patients with Whipple's disease. The macrophages in each case stained with several types of antibacterial grouping sera. Jejunal biopsies from three normal subjects and one from a patient with celiac-like disease did not show significant reactions with any of the antisera. When these same antisera were reacted with homologous and heterologous bacteria, numerous cross-reactions were seen. However, each organism only reacted with certain antisera resulting in a distinctive pattern of reaction which could identify it. Therefore, if a different organism was present in each case of Whipple's disease, the antisera should give dissimilar reactions from case to case, but if the same type of microbe was present in each case, a similar pattern of reaction should be seen. In fact, the reactions were remarkably similar from case to case. These results suggest that a single, antigenically definable microorganism is present in the jejunal tissue of patients with Whipple's disease.

Challenge of dogs with live enterotoxigenic Escherichia coli and effects of repeated challenges on fluid secretion in jejunal Thiry-Vella loops

Dogs were evaluated as experimental models for the study of diarrheal disease produced by enterotoxigenic Escherichia coli. Although a suitable whole model for orogastric bacterial challenge could not be developed, chronic jejunal Thiry-Vella loops were used to study the secretory effects of multiple jejunal challenges with enterotoxin of either Vibrio cholerae or E. coli. The heat-stable and heat-labile E. coli enterotoxins could be differentiated clearly in this model. Sequential weekly challenges over a four-week period showed a significant decrease in loop secretory response to homologous enterotoxin, although levels of antitoxin in serum remained unchanged, a finding suggesting a local immune response. Dogs challenged with E. coli enterotoxin were markedly protected against subsequent challenge with V. cholerae enterotoxin; the converse was not true. Histologic studies of the loops showed only minimal atrophy, and results of absorption studies in the loops were normal. These studies suggest that mongrel dogs are resistant to colonization by enterotoxigenic E. coli and partially resistant to challenge with enterotoxin, perhaps on an immune basis due to prior antigenic exposure. Multiple challenges with enterotoxin effect a decreased secretory response; this finding also suggests a local immune mechanism.

Arizona hinshawii osteomyelitis with antecedent enteric fever and sepsis. A case report with a review of the literature

A case of Arizona osteomyelitis of the spine which occurred 11 months after an episode of gastroenteritis and enteric fever is presented. As close biochemical and antigenic relative of Salmonella, Arizona infection produces a similar clinical course with gastrointestinal manifestations frequently preceding localized infections by several months. The boney lesion in the present case and in three of the four other cases of Arizona osteomyelitis described in the literature was a chronic inflammation which may have a xanthomatous component. The bone destruction caused by Arizona infection is less severe than that of tuberculosis or pyogenic osteomyelitis. Proposed treatment of Arizona osteomyelitis consists of debridement of the localized infection and long term antimicrobial therapy.

Intercurrent cytomegalovirus colitis in a patient with ulcerative colitis

Acute intercurrent CMV colitis developed in a patient with UC who was receiving prednisone. CMV infection was suggested by light and electron microscopic study of a rectal biopsy taken during the acute episode and was confirmed by serology done nine months later. The microscopic studies of plastic-embedded tissues demonstrated that infected cells were concentrated in a subendothelial location and were presumably macrophages. Epithelial and endothelial cells were not involved. Steroid therapy and the inflammation and repair process (granulartion tissue) of active UC may have predisposed the present patient to CMV colitis. CMV infection has been reported to be more common in patients with UC than in the general population. Detection of CMV colitis in patients with UC could be of special importance since alteration of immunosuppressive therapy may be indicated.

Atrophy of villi with hypertrophy and hyperplasia of Paneth cells in isolated (thiry-Vella) ileal loops in rabbits. Light-microscopic studies

Thiry-Vella loops in rabbit ileum were prepared by a new technique and were studied 18 hr to 49 days postisolation. The loops became grossly shortened after 14 days. Histologically, some shortening and blunting of villi was detectable as early as 4 days postisolation, and with prolonged isolation the changes became marked. Reduction in epithelial cell height and in brush border thickness were noted, and goblet cells were increased somewhat in size and prominence. Yet there was only slightly increased chronic inflammation in the mucosa and acute inflammation was uncommon, suggesting that mucosal injury was minimal. Furthermore, mean epithelial mitotic indices for the crypts did not rise and were generally reduced. Striking hyperplasia and hypertrophy of Paneth cells associated with mitotic figures in Paneth cells accompanied the atrophic changes in the villi. Reimplantation of loops into the bowel 3 weeks after isolation led to complete reversal of all changes, including hyperplasia of Paneth cells. On the other hand, regular perfusion of loops with a solution containing a large variety of nutrient substances failed to reverse the mucosal changes. It was concluded that atrophy of villi in isolated ileum of the rabbit occurred mainly because one or more substances contained in the chyme are needed to maintain normal mucosal architecture. These substances probably help regulate epithelial cell turnover and may well be endogenous in origin. Loss of substances in the chyme after loop isolation may also have led to Paneth cell hyperplasia. Alternatively, the Paneth cell changes and atrophy of villi might have been related in a cause and effect way.