COLD AGGLUTININS (AUTOHEMAGGLUTININS) IN PRIMARY ATYPICAL PNEUMONIAS

Transient Cold Agglutinins in a Patient With COVID-19

Coronavirus disease 2019 (COVID-19) infection has been associated with various complications such as acute respiratory distress syndrome, acute kidney failure, myocardial infection, and thromboembolism. Cold agglutinin syndrome (CAS) has been associated with other viral infections such as Epstein-Barr virus (EBV), but there have been only a few reports of cold agglutination associated with COVID-19. In this report, we describe a case of transient cold agglutinin elevation in a COVID-19-infected patient. A 61-year-old man with hypertension, diabetes mellitus, and end-stage renal disease (ESRD) presented with shortness of breath, cough, and lethargy for five days. A clinical diagnosis of COVID-19 infection was made. The COVID-19 RNA qualitative real-time polymerase-chain-reaction (PCR) assay tested positive. During the hospital stay, he had progressive dyspnea requiring intubation and mechanical ventilation. During the third week of hospital stay, an acute drop in the hemoglobin (Hb) level to 4.5 g/dl (baseline Hb: 9 g/dl) was observed. The workup for acute anemia revealed a positive result for cold agglutinins, direct antibody test (C3d), and agglutination of the red blood cells were apparent on the peripheral blood smear. Further, cold agglutinin titers peaked during the third week of the onset of illness and significantly declined during the fifth week. These observational findings indicate that cold agglutinin titers might correlate with the disease activity.

New Insights in the Pathogenesis and Therapy of Cold Agglutinin-Mediated Autoimmune Hemolytic Anemia

Autoimmune hemolytic anemias mediated by cold agglutinins can be divided into cold agglutinin disease (CAD), which is a well-defined clinicopathologic entity and a clonal lymphoproliferative disorder, and secondary cold agglutinin syndrome (CAS), in which a similar picture of cold-hemolytic anemia occurs secondary to another distinct clinical disease. Thus, the pathogenesis in CAD is quite different from that of polyclonal autoimmune diseases such as warm-antibody AIHA. In both CAD and CAS, hemolysis is mediated by the classical complement pathway and therefore can result in generation of anaphylotoxins, such as complement split product 3a (C3a) and, to some extent, C5a. On the other hand, infection and inflammation can act as triggers and drivers of hemolysis, exemplified by exacerbation of CAD in situations with acute phase reaction and the role of specific infections (particularly Mycoplasma pneumoniae and Epstein-Barr virus) as causes of CAS. In this review, the putative mechanisms behind these phenomena will be explained along with other recent achievements in the understanding of pathogenesis in these disorders. Therapeutic approaches have been directed against the clonal lymphoproliferation in CAD or the underlying disease in CAS. Currently, novel targeted treatments, in particular complement-directed therapies, are also being rapidly developed and will be reviewed.

The History of Mycoplasma pneumoniae Pneumonia

In the United States in the 1930s, although the pathogen was not known, atypical pneumonia was clinically distinguished from pneumococcal pneumonia by its resistance to sulfonamides. Reimann (1938) reported seven patients with an unusual form of tracheo bronchopneumonia and severe constitutional symptoms. He believed the clinical picture of this disease differed from that of the disease caused by influenza viruses or known bacteria and instead suspected "primary atypical pneumonia." For many years, the responsible infectious agent was tentatively classified as a filterable virus that could pass through a Seitz filter to remove bacteria and was reported to be a psittacosis-like or new virus. After that, Eaton et al. (1942, 1944, 1945) identified an agent that was the principal cause of primary atypical pneumonia using cotton rats, hamsters, and chick embryos. Eaton et al. (1942, 1944, 1945) did not perform an inoculation study in human volunteers. During the 1940s, there were three groups engaged in discovering the etiology of the primary atypical pneumonia. (1) Commission on Acute Respiratory Diseases Diseases directed by John Dingle, (2) Dr. Monroe Eaton's group, the Virus Research Laboratory of the California State Public Health Department, (3) The Hospital of the Rockefeller Institute for Medical Research directed by Horsfall. During 1940s, the members of the Commission on Acute Respiratory Diseases concluded that the bacteria-free filtrates obtained from the patients, presumably containing a virus, could induce primary atypical pneumonia in human volunteers via Pinehurst trials. During 1950s, serological approaches for identification of the Eaton agent developed such as Fluorescent-Stainable Antibody, and at the beginning of the1960s, the Eaton agent successfully grew in media, and finally accepted as a cause of primary atypical pneumonia. Thus, technical difficulties with visualizing the agent and failure to recognize the full significance of the Pinehurst transmission experiments resulted in a lapse of 20 years before acceptance of the Eaton agent as Mycoplasma pneumoniae. This review describes the history of M. pneumoniae pneumonia with a special focus on the recognition between the 1930 and 1960s of the Eaton agent as the infectious cause.

HETEROGENETIC ANTIBODIES IN ACUTE HEPATITIS

A heterogenetic antibody showing fixation of complement with human liver and agglutination of sheep erythrocytes was found in certain cases of acute infective hepatitis. The antigen concerned in these reactions was apparently heat stable and alcohol soluble. Differences from other heterogenetic antigen-antibody systems have been noted. The possible relation of the heterogenetic antibody to liver damage was considered.

STUDIES ON THE ETIOLOGY OF PRIMARY ATYPICAL PNEUMONIA : A FILTERABLE AGENT TRANSMISSIBLE TO COTTON RATS, HAMSTERS, AND CHICK EMBRYOS

1. A filterable virus from certain cases of primary atypical pneumonia was transmitted to chick embryos by inoculation into the amnion of suspensions of bacteriologically sterile lung tissue or filtered sputum, and three strains were adapted by passage. 2. After intranasal inoculation into cotton rats or hamsters, suspensions of the infected chick embryo tissues produced pulmonary lesions which were similar to those seen after instillation of infective human material. 3. The agent propagated in chick embryos was specifically neutralizable by serum from patients recovered from primary atypical pneumonia and was not neutralized by the acute-phase specimens. 4. Passages of the virus in cotton rats and hamsters gave confusing results because of contamination with latent respiratory agents already present in the animals.

STUDIES ON THE ETIOLOGY OF PRIMARY ATYPICAL PNEUMONIA : III. SPECIFIC NEUTRALIZATION OF THE VIRUS BY HUMAN SERUM

Significant increases in neutralizing antibodies were demonstrated in 42 of a total of 69 persons with a clinical diagnosis of primary atypical pneumonia. Detailed titrations of virus-neutralizing antibodies in a representative group of 28 patients are presented. Increases of four- to 64-fold were demonstrated. Acute-phase titers were 4 or less in 83 per cent and convalescent titers were 16 or over in 86 per cent of these cases. Only about half of the number of patients having increases in neutralizing antibodies also developed cold agglutinins and agglutinins for the indifferent streptococcus No. 344. Patients from the Eastern United States as well as those from the Pacific Coast were shown to develop virus-neutralizing antibodies. Patients with pneumococcal pneumonia and pneumonias caused by influenza virus type A or viruses of the psittacosis group did not have significant increases in neutralizing antibodies for the virus of atypical pneumonia. Cold agglutinins appeared in 3 cases of type A influenzal pneumonia. Sera from persons with atypical pneumonia, when tested against the 3 most prevalent respiratory viruses isolated from cotton rats and hamsters, failed to neutralize these agents or showed no significant change in neutralization titer.

Studies on primary atypical pneumonia. II. Observations concerning the development and immunological characteristics of antibody in patients

By using the indirect method of fluorescent staining to study the antibody response in patients with primary atypical pneumonai associated with the development of cold agglutinin, it was found that the PAP antibody developed during the 2nd and 3rd week of the illness, and persisted for over a year, and is not related to the cold and streptococcus MG agglutinins. The development of the PAP fluorescent staining antibody paralleled the neutralizing antibody for the PAP virus as tested in cotton rats. The sensitivity of this specific serological test was indicated by the observation that 67 to 92 per cent of the patients in several outbreaks of PAP showed a rise of antibody titer during convalescence. Absorption of the sera with various tissue powders did not affect the PAP antibody detected by this method.

A comparison of the Aplysia lectin anti-I specificity with human anti-I and several other I-detecting lectins

BACKGROUND

Lectins displaying blood group specificity are important for blood group typing and antigen recognition. Their use in blood banks is especially widespread in situations where there is a shortage of specific antisera. This report describes the efficiency of Aplysia gonad lectin as a reliable reagent for the detection of I antigen, which is common on adult human cells but reduced in fetal, newborn, and rare adult red cells.

STUDY DESIGN AND METHODS

The selective hemagglutinating activity of the Aplysia lectin was compared with that of human anti-I and several I-reactive lectins, including two plant lectins, one galactophilic microbial lectin, and bovine spleen galectin.

RESULTS

The comparison has revealed that Aplysia gonad lectin, like human anti-I, strongly agglutinates and adsorbs to adult I-positive red cells, differentiating between them and fetal or rare I-negative adult red cells (although with less of a difference). In contrast to the plant and microbial lectins examined, its I-affinity does not depend on the presence of ABH or P system antigens and it clearly detects higher I antigen expression in Oh red cells. The hemagglutinating activity of Aplysia lectin as that of all the I-detecting proteins is enhanced at 4 degrees C, but unlike the human anti-I Aplysia lectin-induced hemagglutination is stable at room temperature.

CONCLUSIONS

The Aplysia lectin is a reliable anti-I reagent, which strongly agglutinates I-positive adult human red cells irrespective of their ABH or P system antigens. This lectin is usable at room temperature.

The hemagglutinating activities of Pseudomonas aeruginosa lectins PA-IL and PA-IIL exhibit opposite temperature profiles due to different receptor types

The two Pseudomonas aeruginosa lectins PA-IL and PA-IIL, which are very similar in subunit size, composition and properties, but differ in carbohydrate specificity, were shown to exhibit opposite temperature profiles in hemagglutination tests. The galactophilic PA-IL, which interacts with the erythrocyte I antigen (together with B or P system antigens), resembles Ii system-specific 'cold hemagglutinins' (including antibodies and lectins of animals and plants) in low (4 degrees C) temperature optimum, while the hemagglutination by the fucose- and mannose-binding PA-IIL (like that of antibodies and lectins which do not bind to these antigens) increases on raising the temperature from 4 to 37 degrees C and even to 42 degrees C. The preferential production of both P. aeruginosa lectins at 28 degrees C and their much stronger interaction with enzyme (protease or sialidase)-damaged cells, as well as the lower temperature optimum (4 degrees C) of PA-IL-binding to the host cells, may be associated with the saprophytic rather than parasitic designation of this bacterium.

Cold-induced augmentation of I blood group antigen interactions with galactophilic lectins

The I antigen appears on human cells in the postnatal period, by addition of N-acetyllactosamine (beta 1-6) branching to the fetal i antigen structure, which is specified by linear oligo N-acetyllactosamine (beta 1-3) chain. Concurrently with the I antigen appearance on adult human erythrocytes most human sera exhibit low levels of anti-I agglutinins. These antibodies induce hemagglutination mainly at low temperatures (4 degrees C) and scantly at body temperature. Therefore they were named "cold agglutinins". We have used these antibodies and several hemagglutinating galactophilic animal, plant, and microbial lectins that also react with the I antigen, to study whether the cold-favored agglutination of the I antigen-bearing cells is a peculiar property of the anti-I antibodies or a special trait of that antigen. It has been found that the interactions of all of the examined lectins, irrespective of their source, with the adult human erythrocytes significantly increased at 4 degrees C, in contrast to those of the same cells with diverse I-insensitive antibodies and lectins, which were significantly higher at room temperature.

A seroepidemiological study of Mycoplasma pneumoniae infections in Denmark over the 50-year period 1946-1995

The epidemiological pattern of Mycoplasma pneumoniae infections in Denmark over the 50-year period 1946-1995 is described. The study is based on blood specimens received at the central laboratory at Statens Serum Institut for titration of cold agglutinins (CA), initially for the diagnosis of CA positive primary atypical pneumonia, and during the 1960s of M. pneumoniae infection; in addition, specimens from the last 38 years were tested for antibodies specific to M. pneumoniae. By retrospective analysis of the test results compiled over the years it was found that intervals of regular periodicity have been interrupted by an era of changes in the pattern. Attention is paid to the significance of CA for this study, and the possible background of the epidemiological pattern is described.

THE ACTION OF ENZYMES FROM CLOSTRIDIUM TERTIUM ON THE I ANTIGENIC DETERMINANT OF HUMAN ERYTHROCYTES

A method was described for the partial purification of beta galactosidase and beta glucosaminidase from Clostridium tertium culture supernatants. Treatment of erythrocytes with preparations containing both enzymes decreases their ability to react with anti-I cold agglutinins, and with Type XIV antipneumococcal horse serum. Erythrocytes of blood group A₁ are altered more rapidly and extensively than are group O cells. The enzymatic treatment of stroma results in a decrease in ability to absorb anti-I agglutinins and the release of galactose and N-acetylglucosamine as monosaccharides. The data suggest that these two sugars may be structural units of the erythrocyte I determinant, but no direct evidence is available.

Rapid etiological diagnosis of pneumonia in young men

The major findings and conclusions of the present study are: 1. Evidence of the etiology of the pneumonia was established in 86% of 106 young men with pneumonia. Pneumococcus was the most common etiologic agent; it was detected definitely in 30% of the pneumonia patients, and possibly in another 20%, by blood culture, sputum culture, antigen detection, and serological methods. 2. Pneumococcal antigen detection from purulent pretreatment sputum samples was the best rapid diagnostic method for pneumococcus; it was capable of identifying 90% of the pneumococcal pneumonias definite by our criteria, whereas sputum Gram stain was positive in 65% of these. 3. Detection of adenoviral antigens from nasopharyngeal specimens (NPS) by EIA or IF method or adenovirus DNA by HYB method showed good specificity but a somewhat lower sensitivity than did adenovirus isolation from NPS. 4. Adenovirus antigens and DNA can be demonstrated also from sputum specimens. 5. EIA is slightly superior to the CF method in detecting antibody responses to adenovirus, but the detection of different antibody classes offers no additional diagnostic possibilities. 6. Isolation of Mycoplasma pneumoniae from bronchoalveolar fluid in pneumonia patients is a specific and sensitive method in the diagnosis of mycoplasmal pneumonia. 7. It seems possible to differentiate by clinical signs and symptoms and by high CRP (over 85mg/1) and WBC (over 10 x 10(9)/1) values pneumococcal pneumonias from viral, mycoplasmal and mixed pneumonias and from upper respiratory infections. Moderately elevated CRP values were observed in adenoviral (Mean 50 mg/1) and in mycoplasma (mean 59 mg/l) pneumonias, as well as in MRI (mean 44 mg/l).

Cooling mattress induced acute hemolytic anemia

We have reported a patient with Mycoplasma pneumonia, cold agglutinins, and a hemolytic anemia which was probably secondary to vigorous treatment of hyperpyrexia by a cooling mattress. Physicians caring for patients with Mycoplasma pneumonia should be alerted to the potential untoward effect of a cooling mattress on an individual with a high titer of cold agglutinins.

Possible influence of antibiotic therapy on usefulness of metabolic inhibition test for diagnosis of Mycoplasma pneumoniae infections

Certain antibiotics, if in serum, simulate specific antibody in the metabolic inhibition test for diagnosis of Mycoplasma pneumoniae infections. This effect is not eliminated by presence of serum or heat treatment.

Role of Biological Mimicry in the Pathogenesis of Rat Arthritis Induced by Mycoplasma arthritidis

Complement fixation (CF), immunofluorescence, and agar gel double-diffusion tests were used to demonstrate an antigenic relationship between rat tissues and Mycoplasma arthritidis. Rabbit antisera against six strains of M. arthritidis exhibited positive reactions in the CF test with an ethyl alcohol-saline extract of rat muscle, whereas only 6 of 18 antisera against other Mycoplasma species were positive. With the use of gel diffusion techniques, absorption of various M. arthritidis antigens with antiserum against rat muscle removed at least one precipitin band when the absorbed mycoplasma antigens were reacted against homologous antisera. Rabbit antiserum against M. arthritidis was conjugated with fluorescein isothiocyanate and reacted against frozen sections of muscle tissues of various animals. As controls, unlabeled normal rabbit serum and rabbit anti- M. arthritidis serum were included to determine the specificity of the reaction. Rat, hamster, and mouse skeletal muscle exhibited specific fluorescence, whereas chicken, beef, frog, and turtle muscles exhibited no specific fluorescence. Mice injected at birth with rat lymphocytes were found to be more susceptible to subsequent infection by M. arthritidis than were normal mice or mice injected at birth with mouse lymphocytes. These results indicate the occurrence of a heterogenetic antigen(s) common to M. arthritidis and rat tissues. Preliminary evidence suggests that this heterogenetic antigen(s) may enable the mycoplasmas to become established in their host.

Aethritis and arthralgia in infection with Mycoplasma pneumoniae

Joint involvement following infection with Mycoplasma pneumoniae is extremely uncommon. Four patients are presented in whom joint symptoms occurred, giving rise to diagnostic difficulties in three. It is suggested that these manifestations were due to M. pneumoniae.