Radiographic course of pulmonary manifestations in Wegener's granulomatosis under immunosuppressive therapy

Eleven patients with generalized Wegener's granulomatosis were studied. Pulmonary involvement occurred 1 month earlier than a rapid rise of serum creatinine value. Under immunosuppressive therapy, nodules and infiltrations abated slower in patients with bronchopulmonary superinfection (mean, 30 days) compared with patients without superinfection (mean, 18 days). In the short run, radiographic course was a better indicator for therapeutic success than the course of cytoplasmatic antineutrophil cytoplasm antibody titer. If the pulmonary findings did not begin to clear within 1 week after treatment had been started, either superinfection or insufficient immunosuppression was present. In this situation, a more aggressive therapy in combination with antibiotics is suggested.

Comparison of serological tests for the detection of antibodies against Chlamydia trachomatis and Chlamydia pneumoniae in rheumatological patients

In cases of reactive arthritis, a suspected Chlamydia trachomatis infection is often detected by serological methods. However, mostly tests with genus-specific antigens are used, neglecting the fact that antibodies against Chlamydia pneumoniae are highly prevalent in the adult population. Therefore we tested sera of 129 patients with various rheumatological disorders and of 18 healthy persons in parallel with a genus-specific test (IPAZYME) and with the species-specific microimmunofluorescence test for C. trachomatis and C. pneumoniae antibodies. The data showed that 55% of the 64 IPA-positive results were caused by antibodies (IgG) against Chlamydia pneumoniae, only 6% by anti-Chlamydia trachomatis IgG and 20% by both specificities. For IgA antibodies, the percentages were 44%, 12.5% and 12.5% respectively. In 12 IPA-positive cases, the MIF showed no reaction. 58% of all 147 sera tested with MIF had IgG antibodies against C. pneumoniae, 5% had anti-C. trachomatis IgG and 8% IgG against both species. The percentages for IgA were 29%, 2% and 2%, respectively. IgM positivity in MIF disappeared after absorption with rheumatoid factor absorbent. No significant differences were found between the various groups of patients. The data suggest that due to the high prevalence of anti-C. pneumoniae antibody, genus-species tests cannot be used as screening tests for the serological diagnosis of C. trachomatis infections.

[Polymyositis and Jo-1 syndrome]

Polymyositis is a primarily clinical diagnosis. In 30-40% of patients, however, the specific anti-Jo-1 antibody (anti-histidyl-tRNA-synthetase) can be found. These cases are often associated with interstitial lung disease and other typical clinical manifestations. This symptomatology is called Jo-1-syndrome. Prognosis depends on early diagnosis, since Jo-1 associated interstitial lung disease resulting in pulmonary fibrosis is favorably influenced by immunosuppressive therapy, especially with corticosteroids. The present report concerns a patient with Jo-1-syndrome and beginning pulmonary fibrosis who was treated with methotrexate and prednisolone with good initial response. After 1 year the patient's condition had deteriorated, so that the therapy was changed to cyclophosphamide. Longterm results under this therapy remain to be evaluated.

Analysis of T cell receptor V beta regions expressed by rheumatoid synovial T lymphocytes

The T cell receptor (TCR) V beta gene segment repertoire of T lymphocytes derived from peripheral blood of two healthy individuals and synovial tissue, synovial fluid and peripheral blood of three rheumatoid arthritis (RA) patients was analyzed. A sensitive assay based on the amplification of cDNA by the polymerase chain reaction (PCR) was used to analyze the levels of expression of 20 TCR V beta gene segment families. The relative expression of V beta gene segments in lymphocytes derived from peripheral blood, synovial tissue and synovial fluid was conserved over 155 days in one patient. V beta 9 transcripts were undetectable in the cells of this individual. In the two other patients the frequency of V beta 2 transcripts in synovial T cells of affected joints was significantly higher than in their peripheral blood lymphocytes. Dominance of distinct rearrangements among the V beta 2 transcripts from the synovial cells of these patients support the idea that the synovial T cell response is driven by antigen.

[Rheumatoid arthritis--current research perspectives]

No other chronic inflammatory disease is currently receiving more attention from basic scientists than rheumatoid arthritis (RA). Topics of intense research are HLA disease association, peculiarities of the synovial T- and B-cell repertoire, changes of synoviocytes and cytokine profiles as well as animal models and new therapeutic strategies.

Sneddon's syndrome and phospholipid antibodies

We present a case of Sneddon's syndrome with high titers of antiphospholipid antibodies (APLA), in which the leading symptom was an incapacitating memory defect. MRI revealed vasculitic lesions of the central nervous system (CNS). Therefore immunosuppressive therapy was started with steroids and cyclophosphamide pulses. The transient beneficial effects of such a therapy will be discussed.

[Secondary Raynaud's phenomenon]

Raynaud's phenomenon (RP) is an episodic digital ischemia provoked by internal and/or external stressors. While the primary RP occurs independently of other diseases and appears to be mediated by a vegetative imbalance of the peripheral vasomotor tone, the secondary RP is often part of an underlying disorder, especially of collagen-vascular diseases such as SLE or scleroderma. Vascular involvement in the pathogenesis of connective tissue diseases is well known but poorly understood. Endothelium injury by autoantibodies and circulating immune complexes may play a central but not sufficient role in the pathogenesis of secondary RP. In this review, epidemiology and diagnosis of RP secondary to connective tissues diseases are described and new pathogenic concepts are discussed in view of current knowledge on endothelial function.

The B cell repertoire of patients with rheumatoid arthritis. Frequencies and specificities of peripheral blood B cells reacting with human IgG, human collagens, a mycobacterial heat shock protein and other antigens

Using a potent in vitro limiting dilution culture system, we have activated human peripheral blood B cells to proliferate and to differentiate into antibody-secreting cells (ASC). Under these conditions 25-100% of B cells are clonally expanded and produce IgM, IgG or IgA. Culture supernatants were tested for antibodies binding to human IgG-Fc fragments (RF), the 65-kD heat shock protein of Mycobacterium bovis (hsp60), human collagens type I, II, IV, V, transferrin, lactoferrin, albumins, and gelatine. All blood samples contained precursors of ASC (p-ASC) able to produce IgM binding to these antigens in frequencies above 0.03% of B cells. Most interestingly, a significant difference exists between rheumatoid arthritis (RA) patients and controls, concerning the relative frequencies of p-ASC able to produce monospecific or multireactive RF. Whereas most p-ASC(RF) in RA patients are monospecific (mean ratio 3.7), most p-ASC(RF) in healthy control persons are cross-reactive with at least one of five other antigens tested (mean ratio 0.2). The data suggest a disease-specific expansion of p-ASC committed to the production of monospecific rheumatoid factors.

Susceptibility to relapsing polychondritis is associated with HLA-DR4

OBJECTIVE

To determine the frequency of HLA class II antigens in Caucasian central European patients with relapsing polychondritis (RP).

METHODS

HLA class I, DR, and DQ specificities were identified in 41 patients with RP, and the frequencies were compared with those in 204 healthy, unrelated control subjects. HLA typing was performed using the standard complement-dependent microcytotoxicity assay. HLA-DR genotyping of 12 DR4-positive RP patients and 57 controls was performed by allele-specific oligonucleotide probing after amplification of genomic DNA by polymerase chain reaction.

RESULTS

A significant increase in DR4 antigen frequency was found in the patients (56.1%) as compared with that in healthy controls (25.5%) (Pcorr < 0.001). Genotyping of DR4-positive patients and controls revealed no predominance of any DR4 subtype.

CONCLUSION

There are important clinical similarities and overlaps between RP and rheumatoid arthritis (RA). In RA, the association with DR4 has been well established. Our findings show that although there is a DR4 association with RP, the situation is sufficiently distinct from that of RA to imply considerable differences in pathogenesis of the two conditions.

A comparative study of the iron-clearing properties of desferrithiocin analogues with desferrioxamine B in a Cebus monkey model

A comparative study of the iron-clearing properties of subcutaneously administered desferrioxamine B (DFO) with those of orally administered desferrithiocin sodium salt (1), desmethyl desferrithiocin (2), desazadesmethyl desferrithiocin sodium salt (3), desazadesmethyl desferrithiocin pivaloyloxymethyl ester (4), and desazadesmethyl-5,5-dimethyl desferrithiocin (5) in an iron-loaded Cebus monkey model and a non-iron overloaded bile duct-cannulated rat model is presented. All six drugs, which performed well in rodent studies, demonstrated increased efficiency in the Cebus monkey model. When administered to rodents at a daily dosage of 384 mumol/kg over a period of 10 days, drug 1 demonstrated severe renal toxicity. whereas drugs 3, 4, and 5 exhibited severe gastrointestinal (GI) toxicity. Under the same experimental protocol, drug 2 did not show significant toxic side effects. In addition, to further evaluate the iron-clearing properties of analogue 2, a dose-response study was performed in the primates that showed that iron excretion increased in a dose-dependent fashion.

[Preliminary results in a placebo-controlled, double-blind crossover clinical trial with human interleukin-2 (n-IL-2) in patients with variable immunodeficiency syndrome (CVID)]

Ten CVID patients with an in vitro defect for IL-2-synthesis were treated for 12 months in a placebo-controlled double-blind crossover therapy study with human natural IL-2 s.c. There were no severe side effects of n-IL-2 recorded. Serum levels of soluble IL-2 receptors were unaffected by the therapy. Serum IL-2 levels were only measurable in single patients during the therapy phase. Since verum and placebo groups did not differ with respect to requirement for intravenous gammaglobulin substitutions, n-IL-2 therapy was uneffective in switching on IgG synthesis in vivo. Nevertheless, there was an elevation in vitro of IgM synthesis in 5 patients and of IgG synthesis in 4 patients during n-IL-2 therapy after stimulation of patients' lymphocytes with staphylococcus aureus Cowan I (SAC) plus n-IL-2 or with Pokeweed Mitogen (PWM) without n-IL-2. Additionally, an elevated IL-2-synthesis in vitro was recorded after OKT3 stimulation for 3 CVID patients. There was a significant reduction of severe infections from 25 during the first 6 months of the study to 7 infections during the following 6 months, in the group of patients which received n-IL-2 first. In the second group, which received placebo first, there were no significant differences between placebo and n-IL-2 therapy phase detectable (25 infections during the first 6 months of the study and 24 severe infections in the second phase).(ABSTRACT TRUNCATED AT 250 WORDS)

HLA-DRB1 gene sequences in HLA-DR4 positive and negative patients with rheumatoid arthritis

The second exon of the DRB1 gene encoding for the first domain of the HLA-DR beta 1-chain was sequenced in 16 patients (10 DR4/DR1 positive, 6 DR4/DR1 negative) with seropositive rheumatoid arthritis (RA). We could confirm the strong association of susceptibility to RA with functionally equivalent conformations on otherwise distinct MHC molecules. At least one HLA-DR allele in all of the analysed DR4 or DR1 positive patients showed such an epitope with a minimal variability limited to residue 71. However, in HLA-DR4 and -DR1 negative patients such a similar epitope could not be detected.

[Anti-centriole antibodies and high neuron-specific enolase activity in a patient with Raynaud phenomenon, cerebrovascular lesions, and ischemic finger necrosis--a functional relationship?]

In a 49-year-old patient with acute thrombangitis obliterans, several vascular risk factors and associated features of collagen vascular disease, we observed anti-centriole autoantibodies and a strongly elevated neuron-specific enolase (NSE). The latter could not be attributed to an underlying malignant or neuroendocrine disease. The recent identification of NSE as a centrosomal protein suggests a causal relationship between anti-centriole autoantibodies and elevated serum NSE levels.

[Reduced "oxidative burst" in a granulocyte subpopulation in a case of Sweet syndrome]

Oxidative burst was defective in 50% of peripheral blood neutrophils in a case of Sweet syndrome with leukemoid granulocytosis. Phagocytosis was normal. We suggest that the decreased ability to produce oxygen radicals observed in this patient might lead to a compensatory recruitment of hematopoietic growth factors. Consecutive activation, increased chemotaxis and adhesion of polymorphonuclear granulocytes might be the cause of the neutrophilic dermal infiltrate of Sweet syndrome.

[Anti-neutrophil-cytoplasmic antibodies in rheumatoid arthritis: specificity and clinical relevance?]

Sera of 90 patients fulfilling the criteria of the American Rheumatism Association for the rheumatoid arthritis (RA) were screened for antibodies against neutrophil cytoplasmic antigens (ANCA) by an indirect immunofluorescence test. All sera were also tested for rheumatoid factor (Waaler-Rose-Test, WRT), C-reactive protein (CRP), antinuclear autoantibodies (ANA) on HEp-2 cells. 40% of the 90 sera showed ANCA-positive reactions. c-ANCA and p-ANCA types were both observed but the latter was by far more common (91%). The peculiarity of the p-ANCA pattern was a fine granular perinuclear staining. Antibodies against myeloperoxidase (MPO) were negative in all RA sera tested. So far we found a significant relationship between positive ANCA staining, functional Steinbrocker grades, and rheumatoid factor. No significant correlation was observed with extraarticular manifestation, CRP, therapeutic modalities (gold) or MHC antigens. Currently the nature of the neutrophil antigen involved is under investigation.

Complement split product C3d as an indicator of disease activity in systemic lupus erythematosus

In order to investigate, if complement levels can be used as an indicator of clinical activity in systemic lupus erythematosus (SLE), levels of C3, C4, CH50, and C3d were measured in 79 patients, 41 with inactive, 31 with moderately active and 7 with severely active disease. Our study shows that C3d, and particularly the C3d/C3 ratio, provide sensitive markers for disease activity in SLE. Since C3d is a direct measurement of complement turnover, it reflects complement activation better than C3, C4 and CH50.

Synthesis of the metabolite N-hydroxy-desferrioxamine B

N-Hydroxy-desferrioxamine B (5), a postulated metabolite of the microbial product desferrioxamine B (1), has been prepared by reduction of the intermediate oxime 6 with sodium cyanoborohydride. The oxime was obtained by selective oxidation of desferrioxamine B with hydrogen peroxide and a catalytic amount of sodium tungstate dihydrate. The iron complex derived from 5 enabled definite proof of the structure of one of four metabolites of desferrioxamine B found in urine samples of patients treated with this drug.

p-ANCA of undefined specificity in ulcerative colitis: correlation to disease activity and therapy

Sera of 108 patients with chronic inflammatory bowel disease (IBD) and 13 sera from patients with other gastrointestinal diseases were screened for antibodies against neutrophil cytoplasmic antigens (ANCA) by an indirect immunofluorescence test. 37 out of 64 sera (58%) from patients with ulcerative colitis (UC) produced a fine granular and perinuclear ANCA staining pattern ("snowdrift-like" p-ANCA) clearly different from the cytoplasmic ANCA fluorescence (c-ANCA) seen in active Wegener's granulomatosis (WG) and the typical p-ANCA pattern produced by anti-myeloperoxidase (MPO) autoantibodies. Only 1 of 44 sera from patients with Crohn's disease (CD) and none of the control sera showed positive "snowdrift-like" p- ANCA reactions. 31 out of the 37 p-ANCA positive sera (84%) were obtained from patients with high disease activity with and without longterm high dose steroids. p-ANCA titers became negative after longterm steroid therapy and following complete colectomy.

Increased expression of CD25 and adhesion molecules on peripheral blood lymphocytes of patients with Wegener's granulomatosis (WG) and ANCA positive vasculitides

Peripheral blood lymphocytes of 29 c-ANCA positive WG patients fulfilling the ACR classification criteria were examined for the expression of various leukocyte surface molecules by dual marker cytofluorometry (FACStar, Becton Dickinson). Activation markers such as CD25, HLA-DR, CD29 and adhesion molecules (ICAM-1 and LFA-3) were clearly elevated in this group in comparison to 40 healthy volunteers. Similar results were obtained for p-ANCA positives vasculitides (n = 13) and, unexpectedly, also for patients suffering from cholesteatoma, a chronic, bacterial infection of the middle ear (n = 21). The results are discussed in view of a pathogenic model for WG and vasculitic disorders.

Major histocompatibility complex haplotypes and complement C4 alleles in systemic lupus erythematosus. Results of a multicenter study

In a multicenter study more than 300 central European systemic lupus erythematosus (SLE) patients were examined for HLA-B, HLA-DR, and complement C4 phenotypes. For 174 SLE patients MHC haplotypes were determined by family segregation analysis, and for 155 patients C4 gene deletions were determined by TaqI restriction fragment length polymorphism. Two haplotypes, B8-C4AQ0-C4B1-DR3 and B7-C4A3-C4B1-DR2, were identified as risk factors for SLE. These findings were confirmed by applying the haplotype frequency difference (HFD) method, which uses nontransmitted haplotypes from the family study as internal controls. Furthermore, only HLA-DR2, but not DR3, B7, or B8, was significantly increased in SLE patients independently of the two risk haplotypes. C4A gene deletions, but not silent C4AQ0 alleles, were increased in SLE patients and neither C4BQ0 alleles nor C4B gene deletions were increased. The observed frequencies of homozygosity and heterozygosity for the two haplotypes and the frequencies of homozygotes for C4AQ0 and C4A deletions did not differ from the expected values, indicating that the risk for SLE is conveyed by single allele effects. In conclusion, there are two MHC-linked susceptibility factors for Caucasian SLE patients carried by the haplotypes B7-DR2 and B8-DR3. The results argue against C4Q0 alleles being the decisive factors increasing susceptibility to SLE.

Immunophenotypical alterations in a subset of patients with common variable immunodeficiency (CVID)

We investigated the expression of surface molecules on lymphocytes from 20 patients with CVID and 40 healthy subjects. Lymphocytes were analysed by dual colour flow cytometry. We identified a subset of patients (8 of 20) characterized by low CD4/CD8 ratio (less than 1.1), expansion of T cells co-expressing the activation marker HLA-DR and significant increase in CD8+ T cells co-expressing CD57. Expression of the adhesion molecules LFA-3 (CD58) and ICAM-1 (CD54) was significantly increased in this subgroup. In addition, within the CD4+ T cells the percentage of CD29+ (memory) cells was increased, while the CD45RA and LAM-1 (Leu-8) antigens were depressed. These results indicate that in a subgroup of CVID patients T cells are activated in vivo and the CD57+CD8+ lymphocyte subpopulation, supposed to comprise functional suppressor T cells, is expanded. We suggest a chronic viral infection in these patients, but it is not clear whether this is primary or secondary to the underlying defect.

Cerebral aneurysm in relapsing polychondritis

A 51-year-old woman with relapsing polychondritis involving auricular and nasal cartilage, hearing loss, vasculitic skin lesions and a cerebral aneurysm of the posterior cerebral artery is described. Cerebral aneurysm is a rare manifestation of relapsing polychondritis which to our knowledge has not yet been described.

Unusual sequence of immunoglobulin L-chain rearrangements in a gamma heavy chain disease patient

Patients with gamma heavy chain disease (gamma-HCD) generally produce incomplete immunoglobulin (Ig) gamma-heavy chains (gamma-HCD protein) which cannot associate with light chains (IgL). In most patients Bence Jones proteins (BJP) are not observed. However, in the 61-year-old patient WIN we found gamma l-HCD proteins and lambda BJP in serum and urine. WIN gamma l-HCD protein does not carry the Ig Fd region, has a molecular weight of 33.5 kDa, and the seven N-terminal amino acid residues are not translated from any of the known immunoglobulin heavy chain (IgH) gene sequences. These residues are followed by the C gamma l-hinge region. In DNA from peripheral blood lymphocytes of patient WIN we found bands representing dominant rearrangements in one of the two alleles of the IgH, Ig kappa and Ig lambda locus. Taken together, the data from protein and DNA analysis strongly suggest, albeit do not formally prove, that one dominant B-cell clone which carries a rearranged and a non-rearranged allele of each Ig locus produces gamma-HCD protein and lambda BJP. The productive lambda-gene rearrangement in this clone thus has not been preceded by abortive rearrangements in both kappa-locus alleles. Lymphocytes with an unusual sequence of IgL-chain gene activation seem to be involved in the case of gamma-HCD described here.

Possible role of IL-2 deficiency for hypogammaglobulinaemia in patients with common variable immunodeficiency

Common variable immunodeficiency (CVID) patients are unable to produce specific immunoglobulins after antigen contact in vivo. The aim of this study was to investigate whether in some cases of CVID a decreased de novo synthesis of IL-2 might be the cause of immunodeficiency and whether this deficiency can be corrected by IL-2 supplementation in vitro. Mononuclear cells from 17 CVID patients and from 10 healthy controls were cultured with monoclonal anti-CD3 antibody OKT3, pokeweed mitogen (PWM) or tetanus toxoid (TT) to stimulate IL-2 synthesis. In parallel, in vitro IgG and IgM synthesis was stimulated with Staphylococcus aureus Cowan I (SAC), PWM or TT in the presence or absence of IL-2. While lymphocytes of 11 out of 17 patients produced low to normal amounts of IL-2 upon stimulation with anti-CD3, only three patients showed low IL-2 production in response to PWM and five in response to TT. Regarding immunoglobulin synthesis in vitro, five patients completely failed to produce IgM or IgG upon stimulation with PWM, SAC or TT irrespective of the addition of IL-2. By contrast, four patients did not show any defect in vitro and synthesized normal amounts of IgM and IgG with any of the three stimuli. Finally, eight patients could be reconstituted for PWM-, SAC- and TT-induced IgM and/or IgG synthesis in vitro, by adding IL-2 to the culture system. This enhancing effect of IL-2 could be blocked by adding anti-IL-2 receptor antibodies to the cultures. Our findings indicate that a defective IL-2 synthesis after antigen stimulation may be one reason for the impaired immunoglobulin production in some cases of CVID.