Cerebrospinal fluid and the choroid plexus during acute immune complex disease

Angioedema as the presenting feature of systemic lupus erythematosus

A young female in her early 20s presented with low-grade fever for 1 month, puffiness of face and abdominal distension for 15 days. Evaluation revealed pancytopenia with normocellular marrow, hypocomplementaemia and Coomb's positive haemolytic anaemia. She had angioedema with laryngospasm and worsening facial oedema which had dramatic response to steroids. Further workup lead to a diagnosis of systemic lupus erythematosus with neuropsychiatric involvement. Treatment with pulse steroids and cyclophosphamide resulted in dramatic improvement of her symptoms with no recurrence of angioedema during her follow-up visits.

Formation, Clearance, Deposition, Pathogenicity, and Identification of Biopharmaceutical-related Immune Complexes

Vascular inflammation, infusion reactions, glomerulopathies, and other potentially adverse effects may be observed in laboratory animals, including monkeys, on toxicity studies of therapeutic monoclonal antibodies and recombinant human protein drugs. Histopathologic and immunohistochemical (IHC) evaluation suggests these effects may be mediated by deposition of immune complexes (ICs) containing the drug, endogenous immunoglobulin, and/or complement components in the affected tissues. ICs may be observed in glomerulus, blood vessels, synovium, lung, liver, skin, eye, choroid plexus, or other tissues or bound to neutrophils, monocytes/macrophages, or platelets. IC deposition may activate complement, kinin, and/or coagulation/fibrinolytic pathways and result in a systemic proinflammatory response. IC clearance is biphasic in humans and monkeys (first from plasma to liver and/or spleen, second from liver or spleen). IC deposition/clearance is affected by IC composition, immunomodulation, and/or complement activation. Case studies are presented from toxicity study monkeys or rats and indicate IHC-IC deposition patterns similar to those predicted by experimental studies of IC-mediated reactions to heterologous protein administration to monkeys and other species. The IHC-staining patterns are consistent with findings associated with generalized and localized IC-associated pathology in humans. However, manifestations of immunogenicity in preclinical species are generally not considered predictive to humans.

Circulating brain-reactive autoantibodies and behavioral deficits in the MRL model of CNS lupus

Brain-reactive autoantibodies (BRAA) are hypothesized to play a role in the neuropsychiatric manifestations that accompany systemic lupus erythematosus (SLE). The present study tests the proposed relation between circulating BRAA and behavioral deficits in lupus-prone MRL/lpr mice. Two age-matched cohorts born at different times were used to test the relationship in the context of altered disease severity. Significant correlations between autoimmunity and behavior were detected in both cohorts. These results are the first to report correlations between behavior and autoantibodies to integral membrane proteins of brain, supporting the hypothesis that BRAA contribute to the behavioral dysfunction seen in lupus.

B and T cells in the brains of autoimmune mice

Systemic lupus erythematosus (SLE) is an autoimmune disorder that can involve the central nervous system (CNS). Recently, we reported the presence of autoantibodies bound to the brain tissue of murine models of lupus; MRL/lpr and BXSB. We postulated that the source of these autoantibodies was in part due to in situ production, caused by the entry of B and T cells. Frozen brain sections of MRL/lpr and BXSB at 1 and 4 months of age were stained for CD3 (T cells) and CD19 (B cells) markers using an immunofluorescent antibody binding assay. Confocal fluorescence microscopy showed both CD3(+) and CD19(+) cells at 4 months of age only in MRL/lpr mice. There were no lymphocytes seen in the other autoimmune model, BXSB. Results suggest a difference in the mechanisms by which autoantibodies access the brain in these two autoimmune models of lupus.

Sustained normalization of cerebral blood-flow after iloprost therapy in a patient with neuropsychiatric systemic lupus erythematosus

We report the case of a 30-year-old caucasian woman affected by SLE who developed neurological symptoms (prosopagnosia and visual-spatial agnosia) after nine years of disease. Brain MRI showed no abnormalities while a brain SPECT scan showed diffuse uptake defects and hypoperfusion areas in the right and left frontal-parietal regions. At that time the patient was on hydroxychloroquine (400 mg/day) and oral prednisolone (0.5 mg/kg/day) as maintenance therapy. One year later the patient showed worsening of Raynaud's phenomenon with digital dystrophic lesions and was therefore treated with an intravenous infusion of Iloprost (1.5 ng/kg/min per 6h/day for 10 days consecutively), while baseline treatment remained unchanged. One month later the patient showed a dramatic improvement in her cognitive function and subsequent SPECT scans showed the gradual disappearance of perfusion abnormalities. This first report of Iloprost treatment in CNS lupus suggests the potential therapeutic usefulness of this drug in patients with SLE and functional CNS involvement.

Immunoglobulin binding to brain in autoimmune mice

Brain-reactive autoantibodies (BRAA) are thought to play an important role in central nervous system (CNS) manifestations of systemic lupus erythematosus (SLE). Previous studies have shown the existence of BRAA in human and murine SLE. This study was undertaken to establish and characterize the presence of autoantibody binding to brain of autoimmune mice. Laser confocal microscopy was performed on frozen brain sections to detect the presence of immunoglobulin (Ig) in the brain of MRL/lpr and BXSB mice and compare that to control strains of MRL/mp and C57BL/6 mice. There was a dramatic increase in fluorescence in the brains of MRL/lpr and BXSB at 4 months of age. There was little or no Ig detected in the brains of control mice. This increase in presence of Ig in the autoimmune mouse brain was paralleled by an increase in the serum titers of BRAA and anti-DNA autoantibodies as determined by ELISA. These studies provide another link between the existence of brain-reactive autoantibodies and altered CNS functioning.

Central nervous system involvement in systemic lupus erythematosus: cerebral imaging and serological profile in patients with and without overt neuropsychiatric manifestations

The aim of this study was to evaluate morphological and functional abnormalities by cerebral imaging in a series of systemic lupus erythematosus (SLE) patients with and without overt central nervous system (CNS) manifestations, and to detect possible relationships with clinical parameters and a large panel of autoantibodies, including those reactive against neurotypic and gliotypic antigens. 68 patients with SLE were investigated in a cross-sectional study which included clinical evaluation of symptoms, cerebral magnetic resonance imaging (MRI) and brain single photon emission tomography (SPECT) analysis, electroencephalography (EEG), and serological tests for antibodies directed against nuclear, cytoplasmic neuronal and glial cell-related antigens. The results of this study showed: (1) a significant positive association of (a) anti-glial fibrillary acidic protein (GFAP) serum antibodies with neuropsychiatric (NP) manifestations and (b) anti-serin proteinase 3 (anti-PR3/c-ANCA) serum antibodies with pathological cerebral SPECT; (2) the presence of significantly higher values of (a) SLICC organ damage index in patients with abnormal MRI and (b) SLAM activity index in patients with abnormal SPECT; and (3) the association of (a) abnormal MRI with nonactive NP manifestations and (b) combined abnormality of brain SPECT and MRI with the occurrence of overall overt NP manifestations and with those of the organic/major type. Neuropsychiatric manifestations, namely those of the organic/major type, appeared to be significantly associated to the presence of a serum antibody against GFAP, a gliotypic antigen. There was also evidence of an association between SPECT abnormality and the presence of anti-PR3 (c-ANCA). Furthermore, brain imaging by MRI and SPECT applied to SLE patients appears to express CNS involvement significantly related to specific categories of NP manifestations. The abnormalities detected by the two tests seem to be preferentially associated with different activity phases of the NP disorder or of the lupus disease.

The immune system can affect learning: chronic immune complex disease in a rat model

Evidence is presented that the immune system can affect central nervous system functioning, leading to changes in learning. Immune complex disease is induced in rats and their behavior tested using a Lashley maze. Significant differences in behavior were found between the animals with high disease activity and those with low disease activity and the non-disease controls. These changes were not due to uremia and are most likely due to the immune response. There is some evidence immune complex deposits in the choroid plexus may play some role, but not the sole or major role in the behavioral changes. This provides a model by which immunologic processes can cause neuropsychiatric manifestations in autoimmune diseases like lupus, as well as showing that immune processes can affect behavioral functioning.

Controversies in lupus: nervous system involvement

What have we learned about CNS lupus in recent years? An enormous amount of knowledge on pathophysiology of antiphospholipid antibodies, in particular, has been gathered. Although hard evidence of a direct pathogenetic role of these antibodies in cerebral lupus is still lacking, it is generally felt that the multiple microinfarctions found in the brains of lupus patients are related to their presence. Better understanding of the pathogenesis of cerebral lupus will come from the study of experimental models, as it has been possible to develop an antiphospholipid antibody syndrome in mice. Because no specific laboratory test for CNS lupus is yet available, diagnosing the condition remains a challenge to every clinician. Techniques including neuropsychometric testing, quantitative EEG, and SPECT scans have taught us more about cognitive dysfunction and psychosis in patients with SLE. These categories remain the most difficult to define. The concept of hypercoagulability in SLE patients has diverted the direction of therapy from immunosuppression towards anticoagulation. It is of utmost importance that randomised trials are commenced in order to determine the optimal mode of anticoagulation for various groups of lupus patients. It will be necessary to conduct such trials under strict inclusion criteria, based on well defined patient categories. Such an enterprise will require international co-operation of investigators.

Brain reactive monoclonal auto-antibodies: production and characterization

To determine the role of auto-antibodies in the pathogenesis of neuropsychiatric manifestations of systemic lupus erythematosus (NP-SLE), it will be necessary to characterize the diversity of auto-antibodies that exist. This can be done by producing a library of monoclonal, brain-reactive auto-antibodies. From such a library the antigens to which the antibodies bind, and whether there are any interesting relations between these antigens, can be determined. Behavioral effects can also be investigated. Toward these ends, brain-reactive monoclonal auto-antibodies (BRMA) were produced. The production and characterization of two monoclonal antibodies is presented in this study.

Acquired C1 inhibitor deficiency associated with systemic lupus erythematosus affecting the central nervous system

A 22 year old woman with systemic lupus erythematosus affecting the central nervous system had acquired C1 inhibitor deficiency. She was admitted for treatment of psychotic behaviour, but showed no signs of angioedema. The serum complement profile of the patient showed normal C3 concentration and a depletion of C4, C2, C1 inhibitor, and C1q. Her parents had normal complement profiles. An extremely reduced C4 concentration may lead to involvement of the central nervous system in systemic lupus erythematosus.

The effects of chronic serum sickness on albumin distribution and glucose utilization in rat brain

The level of cerebrospinal fluid (CSF) protein is elevated in diseases and disease models that are associated with circulating immune complexes such as serum sickness. Circulatory immune complexes are known to deposit in the basal lamina of fenestrated capillaries and may, as a result, affect both capillary bed and parenchymal function. Since the brain has both fenestrated and unfenestrated capillaries and immune complexes deposit to a varying extent in the fenestrated capillaries in chronic serum sickness, cerebral capillary permeability to protein may be altered in some brain areas and lead to the elevation of CSF proteins. In addition various other cerebrovascular and metabolic functions may also be affected by this condition. In this study either radio-iodinated serum albumin (RISA) or 2-[14C]deoxyglucose (14C-2DG) was intravenously injected into control Wistar rats and Wistar rats with chronic serum sickness; subsequently the tissue levels of radioactivity were measured by quantitative autoradiography in 4 brain areas with fenestrated capillaries and 11 brain areas with unfenestrated capillaries. The 2-min distribution of RISA, which demarcates the volume of circulating plasma in perfused microvessels and is generally proportional to local plasma flow, was the same in control and experimental rats. The passage of RISA from blood into brain over 30 min was negligible in both groups; thus cerebral capillary permeability to albumin was not detectably increased in any of these 15 brain areas by chronic serum sickness. The rate of local cerebral glucose utilization, an indicator of local metabolic and neural activity, was calculated from the 14C-2DG data and was virtually identical in control and experimental rats.(ABSTRACT TRUNCATED AT 250 WORDS)

Brain specific autoantibodies in murine models of systemic lupus erythematosus

Autoantibodies which bind to integral membrane proteins of brain were tested for their ability to bind to cross-reactive antigens on non-neural tissue. Both brain specific autoantibodies and antibodies which bind to cross-reactive antigens were found. There were two types of brain reactive autoantibodies which could not be adsorbed by non-neural tissue. One type was adsorbable by crude cell membrane preparations of brain. The second type was reactive against integral membrane proteins of brain, but not adsorbable by any of the crude membrane preparations tested. Autoantibodies of the first type reacted against integral membrane proteins with apparent molecular weights of 75, 70, 62, 50, 27, 24 and 20 kDa, as determined by gel electrophoresis and immunoblotting. As in previous studies, a diversity of brain reactive autoantibodies were found. The greatest numbers and strongest banding patterns were seen in the autoimmune strains of mice. The non-autoimmune strain displayed these autoantibodies at much lower levels. These results are the first to find brain specific autoantibodies, from autoimmune mice, against integral brain membrane antigens. The data support the idea that there is a sub-population of brain reactive autoantibodies which are involved in the pathogenesis of neuropsychiatric manifestations in immunologic disorders, particularly systemic lupus erythematosus.

Immune mechanisms in the primary and secondary vasculitides

Vasculitis, or angiitis, affects both the central and peripheral nervous systems and is increasingly recognized as a cause of neurologic dysfunction. The vascular inflammation may be systemic or organ restricted. Recent work has expanded our knowledge on the pathogeneses of vasculitis. Historically, immune complex mediated vasculitis is best defined but studies now delineate cell mediated immune mechanisms including T cell and endothelial cell interactions. Additional factors in the genesis of vascular inflammatory diseases are also being explored. There are numerous underlying etiologies ranging from primary immunologic disturbances to infections, malignancies, and toxins. In order to plan rational therapies, clinicians need to be aware of current work on the pathogeneses of vascular inflammation as well as exploring specific etiologies in their individual patients.

Characterization of brain-reactive autoantibodies in murine models of systemic lupus erythematosus

Using the Western blot technique we analyzed the sera of five strains of mice that develop a disease like systemic lupus erythematosus (SLE), along with two normal strains, for their binding specificities against isolated mouse integral brain membrane proteins. This report describes the distribution and frequency of the more than 200 brain-reactive autoantibodies in the 126 animals tested and verifies the hypothesis of diversity in anti-brain antibodies produced during autoimmune conditions such as SLE. These results emphasize the importance of characterizing the brain-reactive autoantibodies in the sera or cerebrospinal fluid of SLE patients with central nervous system involvement.

Circumventricular organs in chronic serum sickness: a model for cerebral lupus

The pathogenesis of the CNS manifestations of systemic lupus erythematosus (SLE) has been the subject of considerable investigation. The focus of many of these studies has concerned immune complex deposition within the choroid plexus (CP). Involvement of the other brain fenestrated vascular beds, the small, paraventricular circumventricular organs, has not been ascertained. For this purpose, chronic serum sickness, a good immunopathological experimental model of naturally occurring systemic immunological disorders such as SLE, was induced in Wistar rats by prolonged immunization with bovine serum albumin (BSA). The involvement of circumventricular vascular beds by immune deposits was ascertained immunohistochemically. The choroid plexus was found to be the most intensely involved circumventricular structure. Immune complex deposits were also present, in descending order of frequency, in the area postrema, subfornical organ, and pineal gland.

Autoimmune disease and cochlear pathology in the C3H/lpr strain mouse

The C3H/lpr autoimmune strain mouse is a model for spontaneous systemic lupus erythematosus. Inner ear structure and function were examined during systemic autoimmune disease progression to identify correlated auditory system pathology. Onset of the systemic disease occurred at 2-3 months of age and was characterized by elevated serum immune complexes, cryoglobulins, and antinuclear antibodies. Coincident with the onset of autoimmune disease was degeneration of the stria vascularis. Early edema of the stria occurred in the apex and progressed basalward with duration of the disease. By 10 months of age, stria vascularis area was smaller and auditory brainstem response thresholds were elevated. No degeneration of hair cells was seen at any age, suggesting that the stria vascularis may be the primary anatomic site of autoimmune auditory damage in this mouse model.

Acute polyradiculoneuropathy complicating systemic lupus erythematosus

Two elderly patients with systemic lupus erythematosus (SLE) are presented. Both developed an acute polyradiculoneuropathy which is an unusual complication of this disease. Features of their presentation are discussed.

Antibodies reactive with central nervous system antigens

The pathogenesis of the neuropsychiatric manifestations of systemic lupus erythematosus (SLE) remains an enigma. The observation that many of the lymphocytotoxic antibodies in SLE are also brain-reactive has led to the hypothesis that central nervous system (CNS) lupus, like the autoimmune hematologic manifestations of SLE, is due to the direct effects of autoantibodies to cell membrane antigens. Studies of neuron-reactive antibodies in SLE sera and cerebrospinal fluid support that hypothesis and suggest that the diffuse neuropsychiatric manifestations require the co-existence of serum antibodies to nerve cells and an alteration in the blood-brain barrier that allows those antibodies to enter the CNS.

Intrathecal IgG synthesis and blood-brain barrier impairment in patients with systemic lupus erythematosus and central nervous system dysfunction

Paired serum and cerebrospinal fluid specimens from 19 patients with SLE and central nervous system dysfunction were studied with respect to cerebrospinal fluid IgG index (a measure of intrathecal IgG synthesis), isoelectric focusing using immunoperoxidase staining techniques to detect oligoclonal IgG, and determination of the cerebrospinal fluid/serum albumin quotient (Q albumin) as a measure of blood-brain barrier integrity. Twenty-five patients without neurologic disease and 70 patients with a variety of non-SLE neurologic disorders were also studied for comparison. Of most interest was the observation that 42 percent of the patients with SLE had cerebrospinal fluid oligoclonal IgG, usually in association with elevation of the cerebrospinal fluid IgG index. In addition, two of the cerebrospinal fluid specimens that exhibited oligoclonal IgG also had increased titers of alpha-interferon. Q albumin was normal (under 9.0) in 12 of 13 patients with SLE, who had seizure, psychosis, or cranial neuropathy as principal central nervous system manifestations (mean +/- SD = 5.3 +/- 2.4), but was significantly elevated (mean +/- SD = 27.4 +/- 18.8, p less than 0.001) in five of six patients with diffuse, major central nervous system injury, for example, encephalopathy with coma, transverse myelopathy, paraparesis. Blood-brain barrier impairment was not correlated either with presence of circulating immune complexes or with other clinical or serologic evidence for extra-central nervous system disease activity. Taken together, the data suggest that, within the limitations of the techniques used, impairment of the blood-brain barrier in SLE may be secondary to the central nervous system lesion, rather than a result of systemic immune complex injury. In addition, substantial evidence is provided for an ongoing humoral immune response within the central nervous system in this disorder, which, in certain patients, may be associated with the production of intrathecal alpha-interferon.

Altered anion handling by choroid plexus in renal insufficiency

Abnormal localization of 99mTc pertechnetate was detected in the choroid plexus of patients with renal insufficiency despite the administration of potassium perchlorate. This was found in 8 of 21 studies on patients on conservative medical treatment, in 35 of 41 studies in patients on hemodialysis, in 12 of 22 studies in renal transplant recipients, and in 1 of 5 with acute renal insufficiency, but not in any of 33 persons free of renal disease. Abnormal retention of pertechnetate was also observed in the salivary glands of 21 renal patients. The increased localization of 99mTc pertechnetate could not be related to high blood levels of radioactivity, altered protein binding, increased erythrocyte labeling or to impaired gastrointestinal absorption of potassium perchlorate. It is proposed that this finding represents a manifestation of choroid plexus dysfunction resulting in altered handling of anions by this organ. A possible relation to neurological disease in chronic renal insufficiency is suggested.

Study of protein characteristics that influence entry into the cerebrospinal fluid of normal mice and mice with encephalitis

Entry of proteins into the cerebrospinal (CSF) from the blood is partially determined by the size of the protein. To determine whether other characteristics of proteins influence CSF entry, proteins or protein fragments were iodinated, inoculated intravenously, and serum and CSF were sampled at later times. The Fc fragment of immunoglobulin G (IgG) did not enter the CSF significantly better than the Fab fragment suggesting that choroidal Fc receptors are not of importance for selective immunoglobulin entry. To determine the role of protein charge on entry, bovine serum albumin [isoelectric point (pI) = 3.9] was chemically altered to provide an albumin with an average pI of 6 (A-6) and another with a pI of 8.5 (A-8). All albumins were of the same size on sodium dodecyl sulfate-polyacrylamide gel electrophoresis. A-8 entered the CSF approximately 10-fold better than the native albumin. A-6 was intermediate, entering approximately twofold better. At the time of increased CSF protein concentration during an acute viral encephalitis these differences were narrowed but not eliminated. It is concluded that charge is an important determinant of protein entry into the CSF.

Neurological complications of connective tissue and other "collagen-vascular" diseases

A variety of neurological complications may occur in the various connective tissue and "collagen-vascular" diseases. Most of these complications are due to vasculitis affecting various sites in the central or peripheral nervous system. While the evidence for definitive vasculitis in SLE is not strong, small vessel damage usually is present in anatomic sites which correlate well with clinical features. Although patients with rheumatoid arthritis also may have vasculitis, neurological complications are usually related to nerve compression by rheumatoid nodules or the arthritic process itself. Considerable controversy exists regarding the accuracy of various diagnostic tests. While corticosteroids are the mainstay of therapy for these conditions, there are no definitive studies proving their efficacy.

Binding sites for immune components in human choroid plexus

In immunologically mediated disorders such as systemic lupus erythematosus and experimental serum sickness, immunoglobulin and complement amy be localized in the choroid plexus. This report demonstrates the presence of binding activity for the Fc fragment of IgG in 34 of 36 samples of human choroid plexus. We suggest that the number, distribution, and avidity of these Ig receptors may modulate the occurrence and/or severity of central nervous system symptoms in patients with immunologically mediated systemic diseases.

Immune complexes in serum and in cerebrospinal fluid in African trypanosomiasis. Correlation with polyclonal B cell activation and with intracerebral immunoglobulin synthesis

The possible occurrence of immune complexes (IC) in serum and in cerebrospinal fluid (CSF) has been studied in 36 patients with African trypanosomiasis (Trypanosoma brucei gambiense). In serum, very high levels of IC were detectable by the (125)I-C1q-binding and by the conglutinin-binding assays with positive results in 94 and 87%, respectively, of untreated patients. Circulating IC were found in both early and late stages of the disease, without significant quantitative differences; their size was 15-25S. There was a significant negative correlation between C3 values and C1qBA. Our studies suggest that circulating IC occurring during trypanosomiasis may be the expression of a polyclonal B cell activation. Indeed, there was a significant correlation (P < 0.001) between the levels of circulating IC and either the levels of IgM (mean value 12.5+/-7.2 mg/ml) or with the levels of rheumatoid factor-like antiimmunoglobulin antibodies that were detected by solid phase radioimmunoassay in 74% of the patients.IC were detected in 31 of 35 CSF samples, with a marked elevation in patients with definite involvement of the central nervous system as compared with earlier stages of sleeping sickness. The occurrence of IC in CSF was not related to an impairment of the blood-brain barrier as shown by analysis of CSF/serum albumin ratios. The level of IC in CSF did not correlate with the serum level and, therefore, circulating IC do not appear to cross efficiently an unimpaired blood-brain barrier. The analysis of IgG, IgM, and albumin concentrations in serum and CSF demonstrates a marked intracerebral immunoglobulin synthesis in patients with manifestations of meningoencephalitis. There was a correlation between CSF-C1q binding assay and this local IgG synthesis. These data are consistent with a local formation of IC in CSF in patients with active meningoencephalitis. The results obtained in eight patients followed during therapy suggest that the presence of IC in CSF may be an indicator of a continuing central nervous system disease and that the quantitation of CSF-IC may be useful for monitoring patient care.