Blood factor in acute disseminated lupus erythematosus; determination of gamma globulin as specific plasma fraction

Hal Holman of Stanford

Before age 35, Holman hit over 0.500 at the University of California Los Angeles (UCLA); was recruited by professional baseball; led the Association of Interns and Medical Students and the International Union of Students in Denmark; had his passport confiscated; was stripped of a prestigious internship; shadowed by the Federal Bureau of Investigation ; grilled before a Senate committee on subversive activities; made a major medical discovery; and was recruited to be the new Chief of Medicine at Stanford. Holman was involved in building a leading academic institution. He expanded what medical students and graduates learned and what they researched. Holman saw the collision course between the technological capacity to do more and the growing expectations of the public. Moreover, he anticipated the monetization of health care and how it would widen the gap between what we know and what we practice in health care. He reinvented himself in population health. In contrast to reductionist laboratory-based research, his work embraced complexity and made action researchable and research action-oriented. Some innovations did not survive as originally conceived, but their ethos became mainstream. These included evidence-based management, shared physician-patient decision-making, self-management, critical evaluation of medical technology and diagnostics, and chronic disease management. Through the rise of the twentieth century American biomedical medicine, medical education, and slow-motion health care delivery crises that still occur, Holman changed the debate in a time when the funding, the people, the technology, and the need made all things seem possible.

The history of lupus throughout the ages

The word lupus (Latin term for the wolf) was used indistinctively since the Middle Ages for several types of diseases characterized by ulcerous lesions, mainly in the lower limbs. In the middle of the 18th century, the French dermatologist Cazenave mentioned for the first time the term "lupus érythémateux," while Kaposi reported discoid lupus as a separate entity. The true turning point in the history of lupus occurred at the beginning of the 19th century, when the distinction between lupus vulgaris and cutaneous lupus in its modern sense emerged slowly. Major subsequent contributions from Kaposi, Sequiera and Balean, and Osler enabled the recognition of the systemic nature of the disease, with its modern history being marked by the recognition of DNA as the main target of antinuclear antibodies and the central role of interferons. Although many nonpharmacologic treatments have been used throughout the ages, glucocorticoids, hydroxychloroquine, and immunosuppressive agents mainly appeared in the second half of the 20th century. The beginning of the 21st century is now characterized by an in-depth understanding of the pathogenesis of the disease and the appearance of biologic and targeted treatments, paving the way for a better care of lupus patients.

A 50-year experience with autoimmune hepatitis: and where are we now?

BACKGROUND

Autoimmune hepatitis (AIH) as chronic active hepatitis became recognized in the 1940s as a progressive hyperglobulinemic disease affecting younger women attributed to persisting virus infection of the liver: autoimmunity then was barely on the horizon.

EARLY OBSERVATIONS

The lupus erythematosus (LE) cell reported in 1948 signified the presence of antinuclear autoantibodies, promoting perceptions of autoimmunity in certain chronic diseases. Recognition of LE cells in chronic hepatitis led to the designation of 'lupoid hepatitis', with autoimmunity further substantiated by anti-cytoplasmic autoantibodies detected by complement fixation. Next a serum reactant with smooth muscle of rodent stomach was found to have a wider distribution and became identified as an autoantibody to filamentous (F) actin. Therapy with corticosteroids proved effective, particularly combined with azathioprine. Various trials showed greatly improved survival and established modern therapy of AIH. An HLA-based predisposition (B8, DR3) was the first pointer to a genetic etiology.

RECENT ADVANCES

Recombinant or purified autoantigenic substrates have led to automated assays, which, together with improved immunofluorescence procedures, allow serological confidence in diagnosis and institution of effective immunosuppressive therapies. The liver-kidney 'microsomal' autoantigen reactive with cytochrome P450 2D6 distinguishes two serological types of AIH that appear pathogenetically distinct. Molecular characterization of antigens and epitopes remains wanting in type 1 AIH.

FUTURE PROSPECTS

The challenge remains with both types of AIH to elucidate in molecular terms the genetic and environmental basis of pathogenesis from initiation to ultimate progression and cirrhosis (when inadequately treated). Advancing technologies are bringing this goal closer to being attainable.

Novel method for quantitative ANA measurement using near-infrared imaging

Antinuclear antibodies (ANA) have been detected in patients with systemic rheumatic diseases and are used in the screening and/or diagnosis of autoimmunity in patients as well as mouse models of systemic autoimmunity. Indirect immunofluorescence (IIF) on HEp-2 cells is the gold standard for ANA screening. However, its usefulness is limited in diagnosis, prognosis and monitoring of disease activity due to the lack of standardization in performing the technique, subjectivity in interpreting the results and the fact that it is only semi-quantitative. Various immunological techniques have been developed in an attempt to improve upon the method to quantify ANA, including enzyme-linked immunosorbent assays (ELISAs), line immunoassays (LIAs), multiplexed bead immunoassays and IIF on substrates other than HEp-2 cells. Yet IIF on HEp-2 cells remains the most common screening method for ANA. In this study, we describe a simple quantitative method to detect ANA which combines IIF on HEp-2 coated slides with analysis using a near-infrared imaging (NII) system. Using NII to determine ANA titer, 86.5% (32 of 37) of the titers for human patient samples were within 2 dilutions of those determined by IIF, which is the acceptable range for proficiency testing. Combining an initial screening for nuclear staining using microscopy with titration by NII resulted in 97.3% (36 of 37) of the titers detected to be within two dilutions of those determined by IIF. The NII method for quantitative ANA measurements using serum from both patients and mice with autoimmunity provides a fast, relatively simple, objective, sensitive and reproducible assay, which could easily be standardized for comparison between laboratories.

Flow Cytometric Analysis of the LE Cell Phenomenon

A flow cytometry-based phagocytosis assay was developed and utilized to measure the LE cell phenomenon at the single cell level in vitro. Since the lupus erythematosus (LE) cell phenomenon is a special form of necro-phagocytosis in the presence of anti-dsDNA antibodies, dead substrate cells or chicken erythrocytes nuclei (CEN) served as targets that were labeled with propidiumiodide (PI). Phagocytes (PMN) were stained by anti-CD45 mAb FITC. After co-incubation phagocytosis was measured by flow cytometry. Flow cytometric analysis enabled the discrimination between PI+/CD45- targets, PI-/CD45+ phagocytes, and PI+/CD45+ phagocytes with engulfed targets. Maintaining the samples on ice significantly reduced the phagocytic uptake as compared to samples co-cultivated at 37 degrees C (p < 0.0002). The phagocytic up-take was lowest after substrate pre-treatment in normal serum as compared to samples with either no serum exposure or pre-treatment in LE-serum with anti-dsDNA antibodies (p < 0.05). Taken together, these data suggest the phagocytosis-based flow cytometry assay is suitable for analyzing the LE cell phenomenon. This method provides an interesting, simple and rapid new tool, and will possibly alleviate further studies on the LE cell phenomenon with modified cell models and/or conditions.

Historical reflections on autoimmune hepatitis

Autoimmune hepatitis (AIH), initially known as chronic active or active chronic hepatitis (and by various other names), first came under clinical notice in the late 1940s. However, quite likely, chronic active hepatitis (CAH) had been observed prior to this and was attributed to a persistently destructive virus infection of the liver. An earlier (and controversial) designation in 1956 as lupoid hepatitis was derived from associated L.E. cell test positivity and emphasized accompanying multisystem features and immunological aberrations. Young women featured prominently in early descriptions of CAH. AIH was first applied in 1965 as a descriptive term. Disease-characteristic autoantibodies were defined from the early 1960s, notably antinuclear antibody (ANA), smooth muscle antibody (SMA) and liver-kidney microsomal (LKM) antibody. These are still widely used diagnostically but their relationship to pathogenesis is still not evident. A liver and disease specific autoantigen has long been searched for but unsuccessfully. Prolonged immunosuppressive therapy with predisolone and azathioprine in the 1960s proved beneficial and remains standard therapy today. AIH like many other autoimmune diseases is associated with particular HLA alleles especially with the "ancestral" B8, DR3 haplotype, and also with DR4. Looking forwards, AIH is one of the several enigmatic autoimmune diseases that, despite being (relatively) organ specific, are marked by autoimmune reactivities with non-organ-specific autoantigens. New paradigms are needed to explain the occurrence, expressions and pathogenesis of such diseases.

The history of pediatric rheumatology

The care and study of children with rheumatic diseases began slowly in the 19th century, with the most attention centered on rheumatic fever. Other rheumatic diseases of children received little attention until the 1940s. Rheumatic diseases taken together remain a significant cause of chronic illness in children throughout the world. A number of other conditions that masquerade as rheumatic diseases in children also demand recognition and management. Although ultimate causes and cures of childhood rheumatic diseases remain elusive, advances in therapy have improved the outlook for affected children, and advances in biomedical research are adding to our basic understanding of the disease process involved. Pediatric rheumatology has become a well-organized, although underpopulated, specialty that enhances recognition and care of affected children and contributes to basic research knowledge in infectious disease, immunology, and genetics. This review focuses most prominently on the early history of pediatric rheumatology and its development as a specialty. The recent burgeoning of new biomedical science and new means of treatment will be better told in the historical perspective of years to come.

The precipitin reaction between DNA and a serum factor in systemic lupus erythematosus

The sera of certain patients with systemic lupus erythematosus contain an antibody-like substance capable of reacting with highly purified DNA preparations from widely divergent sources. Precipitin reactions have been demonstrated by double diffusion in agar and quantitative precipitin curves have been obtained. Complement was observed to be fixed in the reaction. Evidence was obtained that the serum factor possessed antigenic properties similar to those of gamma-globulins and migrated with this fraction on zone electrophoresis. The interaction of this factor with DNA exhibited certain specific characteristics which differ considerably from non-specific reactions between DNA and proteins in general. The DNA-precipitating factor appeared to be one of a number of related factors reacting with nuclear constituents of many different cells. It differed in certain respects from the "LE factor" which is responsible for the formation of "LE cells." The accumulated evidence, although not yet conclusive, favors the concept that the precipitating factor represents an antibody to DNA, and that it is one of a number of autoantibodies elicited in this disease.

Evaluation of anti-ds DNA antibody measurement by using commercial kits for use in a clinical laboratory

Three hundred and seventy-six consecutive antinuclear antibody-positive sera were tested for anti-ds DNA antibody by using three commercial kits which use 125 I recombinant DNA (radioimmunoassay), highly purified calf thymus DNA (enzyme linked immunosorbent assay) and Crithidia lucilliae (immunofluorescence assay) as substrates. All patients' sera, after reviewing medical records, were classified into three broad groups: Group I (systemic lupus erythematosus), Group II (rheumatic diseases and rheumatoid arthritis), and Group III (nonspecific ANA antibody test positive). A sensitivity, specificity, positive predictive test value and negative predictive test value for Group I against Group II-III (generally these two groups of sera should not show any anti-ds DNA antibody) combined showed for Crithidia lucilliae (IF assay) 58.8%, 93.6%, 82% and 82%, for 125 I recombinant DNA (RIA) assay, 75.8%, 94%, 86.2% and 88.7% and calf thymus highly purified DNA (ELISA) assay using positive cut-off value >100 U/mL, 97.5%, 35%, 42.9% and 24%. The 125 I recombinant DNA (RIA) assay based on the principle of the Farr technique, which is still considered to be the gold standard for anti-ds DNA antibody detection, showed the best specificity and sensitivity among all three methods tested in this study.

Antinuclear and anticytoplasmic antibodies. Concepts and misconceptions

Skin involvement is a common feature of several diseases in which circulating autoantibodies to nuclear and cytoplasmic antigens can be found. Patients with these diseases can be managed more efficiently if the physician is fully aware of the diagnostic and prognostic value of these various antinuclear and anticytoplasmic antibodies. The dermatologist, therefore, not infrequently, must face the bewildering task of ordering and interpreting the results of assays for an ever-increasing number of circulating autoantibodies. In this report, we have attempted to make this less burdensome for the clinician by pointing out the basis for some of the confusion that has arisen in this area. The confusion has resulted primarily from a failure to recognize the limitations of the various assays involved.

Lupus erythematosus (LE) factors recognize both nucleosomes and viable human leucocytes

The morphological LE test was completely inhibited by mixing LE-factor-positive sera with core mononucleosomes, the basic histone-DNA subunit of chromatin. Free DNA and free histones at physiological ionic strength were not inhibitory. The LE-factor-binding antigen was virtually completely regained by mixing DNA and the inner histones H2A, H2B, H3 and H4 in 2 M NaCl, followed by step dialysis to 0.15 M salt. Trypsin-digested core mononucleosomes did not inhibit the LE test, indicating that the antigenic site is located on the N-terminal region of the histones. Twenty-six out of twenty-seven LE-factor-positive sera contained antinuclear antibodies that cross-reacted with plasma membranes of viable leucocytes (referred to as X-ANA). By contrast, weak X-ANA activity was found in only two out of twenty-five LE-factor-negative sera with high ANA titres. Three LE-factor-positive sera were subjected to absorption with viable human leucocytes, which led to the complete disappearance of LE factor activity of all three sera. The data indicate that antibodies with LE factor activity recognize core mononucleosomes and a plasma membrane antigen of viable human leucocytes.

Recent progress in the study of autoantibodies to nuclear antigens

Autoantibodies to nuclear antigens can now be classified according to their immunologic specificities. They include antibodies that react with DNA, deoxyribonucleoprotein, nuclear histones, and nuclear acidic protein antigens. It has been established that there are several antinuclear antibodies that react with nuclear acidic proteins, and these include antibodies to Sm antigen, nuclear ribonucleoprotein, and SS-A and SS-B antigens. It has also been established that certain systemic rheumatic diseases, such as systemic lupus erythematosus, Sjögren's syndrome, and scleroderma, are characterized by antibodies of some specificities and not of others. Thus, distinct profiles of antibodies to nuclear antigens may be present, and these may be used as diagnostic aids. Further characterization of these specific nuclear antigen-antibody systems may help in unraveling the etiology and pathogenetic mechanims of these diseases.

Antinuclear antibodies (ANA): immunologic and clinical significance

The methods currently used for the detection of ANA have been analyzed, with emphasis on their practical application to the diagnosis of the CTD. The use of the indirect IF-ANA test was recommended as a screening procedure to detect ANA. The need to standardize the technique using a single substrate and fluorescent conjugates with uniform F/P ratios was stressed. Most importantly, the value of titrating ANA for the diagnosis of the CTD was discussed. ANA titers higher than 1/500 are usually very significant clinically, often found in spontaneous or drug-induced SLE and few other CTD. The immunologic aspects of ANA and their potential value as aids in the diagnosis and management of the CTD were discussed. Anti-nDNA antibodies have been found to have a high degree of specificity for SLE and high titers of these antibodies correlate well with low levels of serum complement and severity of kidney involvement. The spectrum of ANA in the sera from patients with SLE has been expanded with the finding of anti-Sm antibodies which, when detected by gel precipitation with prototype serum, have been found so far only in SLE. Some of these antibodies have been found to have prognostic significance. Patients with MCTD and a group of patients with SLE have high titers of serum ANA with specificity for an RNase-sensitive component of ENA. The group of SLE patients defined by the presence of these antibodies (anti-Mo) have a better prognosis and in general develop only mild nephritis or have no kidney involvement at all. High titers of pure antinucleolar antibodies probably are found almost exclusively in the sera of patients with scleroderma. Some ANA have organ specificity, and GS-ANA have been found in all patients with Felty's syndrome and in a large proportion of patients with RA. One of the great advances in the field has been the recognition that ANA can be induced in the human and in experimental animals by the use of a number of therapeutic agents. Some of these agents can also induce a clinical picture resembling spontaneous SLE, though kidney involvement does not occur or is extremely mild. It is interesting that the whole spectrum of ANA can be found in drug-induced LE except anti-nDNA antibodies which have been associated to the pathogenesis of immune complex nephritis in spontaneous SLE. There is no doubt that research on ANA has contributed a great deal to the understanding of the CTD and will continue to be a valuable tool for the clinician and the investigator.

Phase contrast and interferometric microscopy of the L. E. cell phenomenon

Alterations in the cellular morphology of polymorphonuclear leukocytes and lymphocytes under the influence of serum from patients having disseminated lupus erythematosus were observed under the phase contrast microscope. These changes appear to involve the cell nucleus without significant visible incorporation of cytoplasm. In the formation of the L.E. body, there is a loss of internal nuclear structure and a subsequent nuclear swelling and extrusion of the nuclear contents from the cell to form the free L.E. body. The possible incorporation of cytoplasmic substance cannot alone account for the large mass of the L.E. body as contrasted with the parent nucleus or nuclear lobe. Measurements of dry mass by means of the interference microscope show a two and one-half-fold increment in dry mass in L.E. bodies compared to parent lymphocyte nuclei. This confirms previous cytochemical studies, and establishes that an influx of protein into the leukocyte nucleus is an integral part of the L.E. phenomenon. That the accumulation of extraneous protein within the L.E. body is simultaneous with or subsequent to a disruption of the normal structure of the leukocyte nucleus is apparent from these studies, but the pathogenesis of this alteration is as yet unknown.

A cytochemical study of the L. E. bodies of systemic lupus erythematosus. I. Nucleic acids

The composition, with respect to nucleic acids, of the L.E. bodies resulting from the action of the plasma of patients with systemic lupus erythematosus on substrate leukocyte nuclei in different kinds of preparations was compared microspectrophotometrically with that of control lymphocyte nuclei. Binding of the basic dye methyl green to DNA was uniformly found to be depressed in L.E. bodies as compared with control nuclei. Since Feulgen-revealed DNA, which served as a standard of reference, was relatively unchanged in amount, the Feulgen:methyl green ratios of L.E. bodies were higher than those of lymphocyte nuclei. Acetylation, which covers basic groups of proteins, was found to increase methyl green uptake by DNA of L.E. bodies to values approximating those of control nuclei, with consequent revision, after acetylation of the Feulgen: methyl green ratios of L.E. bodies to values similar to those of lymphocyte nuclei. Ribonuclease was found to reduce methyl green staining; extraction with dilute acid had little effect. These data have been interpreted to indicate (a) the presence in L.E. bodies of DNA-associated proteins whose basic groups compete with the cationic dye for binding sites of DNA and so inhibit methyl green staining, and (b) the DNA itself is not detectibly altered in state or degree of polymerization. Photometric comparison of the mean Feulgen-stainable DNA content per L.E. body with that of control nuclei showed that DNA is not lost in the L.E. transformation of nuclei.

Role of gamma globulins in pathogenesis of renal lesions in systemic lupus erythematosus and chronic membranous glomerulonephritis, with an observation on the lupus erythematosus cell reaction

Utilizing the fluorescent antibody method for the histologic demonstration of localized gamma-globulins, we have made the following observations (in contradistinction to the lack of such findings in a variety of normal and pathologic, control kidneys). In systemic lupus erythematosus (a) gamma-globulins were localized in the thickened capillary walls, the "wire-loop" lesions, and the so called "hyaline thrombi" in glomeruli; (b) these sites of localization of gamma-globulins were correlated to a considerable degree with the pattern of accentuated eosinophilia of the glomeruli, as seen in hematoxylin-eosin sections, or with the pattern of PAS-positive areas in the glomeruli in sections stained with the periodic acid-Schiff reaction; (c) and gamma-globulins were localized rarely in large cytoplasmic granules in tubular epithelium and occasionally in glomerular capsular crescents, tubular protein casts, and inflammatory cells, particularly in the cytoplasm of cells identified as immature and mature plasma cells. In nephrotic glomerulonephritis (a) gamma-globulins were localized in the glomerular basement membrane and appertaining structures in chronic membranous glomerulonephritis; (b) gamma-globulins were apparently localized in the altered mesangium in chronic lobular glomerulonephritis; and (c) in the tubular protein casts, presumably representing abnormal glomerular filtrates, gamma-globulins were present in a lesser concentration and other serum proteins in a greater concentration than found in the glomeruli. In positive lupus erythematosus preparations the nuclei of leukocytes, while undergoing transformation and subsequent phagocytosis to form lupus erythematosus cells, were the sites of localization of gamma-globulin (presumably the lupus erythematosus factor) whereas in control preparations no nuclear localization of gamma-globulin occurred. These observations are discussed in relation to the pathogenesis of renal lesions in systemic lupus erythematosus, chronic membranous glomerulonephritis, and amyloidosis.