THE HETEROPHILE ANTIBODIES IN INFECTIOUS MONONUCLEOSIS AND AFTER THE INJECTION OF SERUM

C-Reactive Protein: Pathophysiology, Diagnosis, False Test Results and a Novel Diagnostic Algorithm for Clinicians

The current literature provides a body of evidence on C-Reactive Protein (CRP) and its potential role in inflammation. However, most pieces of evidence are sparse and controversial. This critical state-of-the-art monography provides all the crucial data on the potential biochemical properties of the protein, along with further evidence on its potential pathobiology, both for its pentameric and monomeric forms, including information for its ligands as well as the possible function of autoantibodies against the protein. Furthermore, the current evidence on its potential utility as a biomarker of various diseases is presented, of all cardiovascular, respiratory, hepatobiliary, gastrointestinal, pancreatic, renal, gynecological, andrological, dental, oral, otorhinolaryngological, ophthalmological, dermatological, musculoskeletal, neurological, mental, splenic, thyroid conditions, as well as infections, autoimmune-supposed conditions and neoplasms, including other possible factors that have been linked with elevated concentrations of that protein. Moreover, data on molecular diagnostics on CRP are discussed, and possible etiologies of false test results are highlighted. Additionally, this review evaluates all current pieces of evidence on CRP and systemic inflammation, and highlights future goals. Finally, a novel diagnostic algorithm to carefully assess the CRP level for a precise diagnosis of a medical condition is illustrated.

Are there specific antibodies against Neu5Gc epitopes in the blood of healthy individuals?

Strong discrepancies in published data on the levels and epitope specificities of antibodies against the xenogenic N-glycolyl forms of sialoglycans (Hanganutziu-Deicher Neu5Gcɑ2-3Galβ1-4Glc and related antigens) in healthy donors prompted us to carry out a systematic study in this area using the printed glycan array and other methods. This article summarizes and discusses our published and previously unpublished data, as well as publicly available data from the Consortium for Functional Glycomics. As a result, we conclude that (1) the level of antibodies referred to as anti-Neu5Gc in healthy individuals is low; (2) there are antibodies that seem to interact with Neu5Gc-containing epitopes, but in fact they recognize internal fragments of Neu5Gc-containing glycans (without sialic acids), which served as antigens in the assays used and; (3) a population capable of interacting specifically with Neu5Gc (it does not bind the corresponding NAc analogs) does exist, but it binds the monosaccharide Neu5Gc better than the entire glycans containing it. In other words, in healthy donors, there are populations of antibodies capable of binding the Neu5Gc monosaccharide or the inner core -Galβ1-4Glc, but very few true anti-Neu5Gcɑ2-3Galβ1-4Glc antibodies, i.e., antibodies capable of specifically recognizing the entire trisaccharide.

Human risk of diseases associated with red meat intake: Analysis of current theories and proposed role for metabolic incorporation of a non-human sialic acid

One of the most consistent epidemiological associations between diet and human disease risk is the impact of red meat consumption (beef, pork, and lamb, particularly in processed forms). While risk estimates vary, associations are reported with all-cause mortality, colorectal and other carcinomas, atherosclerotic cardiovascular disease, type II diabetes, and possibly other inflammatory processes. There are many proposed explanations for these associations, some long discussed in the literature. Attempts to explain the effects of red meat consumption have invoked various red meat-associated agents, including saturated fat, high salt intake, Trimethylamine-N-oxide (TMAO) generation by microbiota, and environmental pollutants contaminating red meat, none of which are specific for red meat. Even the frequently mentioned polycyclic aromatic carcinogens arising from high temperature cooking methods are not red meat specific, as these are also generated by grilling poultry or fish, as well as by other forms of cooking. The traditional explanations that appear to be more red meat specific invoke the impact of N-nitroso compounds, heme iron, and the potential of heme to catalyze endogenous nitrosation. However, heme can be denatured by cooking, high levels of plasma hemopexin will block its tissue delivery, and much higher amounts of heme likely originate from red blood cell breakdown in vivo. Therefore, red meat-derived heme could only contribute to colorectal carcinoma risk, via direct local effects. Also, none of these mechanisms explain the apparent human propensity i.e., other carnivores have not been reported at high risk for all these diseases. A more recently proposed hypothesis involves infectious agents in beef from specific dairy cattle as agents of colorectal cancer. We have also described another mechanistic explanation for the human propensity for risk of red-meat associated diseases that is consistent with most observations: metabolic incorporation of a non-human sialic acid N-glycolylneuraminic acid (Neu5Gc) into the tissues of red meat consumers and the subsequent interaction with inflammation-provoking antibodies against this "xenoautoantigen". Overall, we conclude that while multiple mechanisms are likely operative, many proposed theories to date are not specific for red meat, and that the viral and xenoautoantigen theories deserve further consideration. Importantly, there are potential non-toxic dietary antidotes, if the xenoautoantigen theory is indeed correct.

The serological diagnosis of glandular fever (infectious mononucleosis): a new technique

1. The agglutination titres for sheep and for horse erythrocytes of 100 normal sera and twenty-seven glandular fever sera have been determined.

2. The results of the sheep-cell agglutination tests on normal sera differed considerably from those of Stuart, Burgess, Lawson & Wellman (1934) whose technique was used. The reason for this difference was not determined. It was thought to have some bearing upon the interpretation of sheep-cell agglutination tests in the diagnosis of glandular fever.

3. Although in the glandular fever sera the horse-cell titre was usually higher than the sheep-cell titre, the normal range for horse cells was also higher, and in the diagnosis of glandular fever there did not appear to be any advantage in using horse cells instead of sheep cells.

4. The value of absorption tests in the diagnosis of glandular fever is discussed and a new technique described which has practical advantages over other methods although it does not embody any important new principles.

5. Of 300 normal sera examined by this technique, five contained small amounts of an antibody indistinguishable from glandular fever antibody and ten others contained a sheep-cell agglutinin apparently, though not certainly, different from any yet recognized in human serum.

6. A comparison of the results of the two tests on thirty-one samples of glandular fever serum showed the absorption test to be a more sensitive diagnostic test for glandular fever than the ordinary sheep-cell agglutination test.

Evidence for a novel human-specific xeno-auto-antibody response against vascular endothelium

Humans are genetically unable to synthesize the common mammalian sialic acid N-glycolylneuraminic acid (Neu5Gc). However, Neu5Gc can be metabolically incorporated and covalently expressed on cultured human cell surfaces. Meanwhile, humans express varying and sometimes high titers of polyclonal anti-Neu5Gc antibodies. Here, a survey of human tissues by immunohistochemistry with both a monospecific chicken anti-Neu5Gc antibody and with affinity-purified human anti-Neu5Gc antibodies demonstrates endothelial expression of Neu5Gc, likely originating from Neu5Gc-rich foods like red meats. We hypothesized that the combination of Neu5Gc incorporation and anti-Neu5Gc antibodies can induce endothelial activation. Indeed, the incubation of high-titer human sera with Neu5Gc-fed endothelial cells led to Neu5Gc-dependent antibody binding, complement deposition, endothelial activation, selectin expression, increased cytokine secretion, and monocyte binding. The proinflammatory cytokine tumor necrosis factor-alpha also selectively enhanced human anti-Neu5Gc antibody reactivity. Anti-Neu5Gc antibodies affinity-purified from human serum also directed Neu5Gc-dependent complement deposition onto cultured endothelial cells. These data indicate a novel human-specific mechanism in which Neu5Gc-rich foods deliver immunogenic Neu5Gc to the endothelium, giving anti-Neu5Gc antibody- and complement-dependent activation, and potentially contributing to human vascular pathologies. In the case of atherosclerosis, Neu5Gc is present both in endothelium overlying plaques and in subendothelial regions, providing multiple pathways for accelerating inflammation in this disease.

Multiple changes in sialic acid biology during human evolution

Humans are genetically very similar to “great apes”, (chimpanzees, bonobos, gorillas and orangutans), our closest evolutionary relatives. We have discovered multiple genetic and biochemical differences between humans and these other hominids, in relation to sialic acids and in Siglecs (Sia-recognizing Ig superfamily lectins). An inactivating mutation in the CMAH gene eliminated human expression of N-glycolylneuraminic acid (Neu5Gc) a major sialic acid in “great apes”. Additional human-specific changes have been found, affecting at least 10 of the <60 genes known to be involved in the biology of sialic acids. There are potential implications for unique features of humans, as well as for human susceptibility or resistance to disease. Additionally, metabolic incorporation of Neu5Gc from animal-derived materials occurs into biotherapeutic molecules and cellular preparations - and into human tissues from dietary sources, particularly red meat and milk products. As humans also have varying and sometime high levels of circulating anti-Neu5Gc antibodies, there are implications for biotechnology products, and for some human diseases associated with chronic inflammation.

Diversity in specificity, abundance, and composition of anti-Neu5Gc antibodies in normal humans: potential implications for disease

Human heterophile antibodies that agglutinate animal erythrocytes are known to detect the nonhuman sialic acid N-glycolylneuraminic acid (Neu5Gc). This monosaccharide cannot by itself fill the binding site (paratope) of an antibody and can also be modified and presented in various linkages, on diverse underlying glycans. Thus, we hypothesized that the human anti-Neu5Gc antibody response is diverse and polyclonal. Here, we use a novel set of natural and chemoenzymatically synthesized glycans to show that normal humans have an abundant and diverse spectrum of such anti-Neu5Gc antibodies, directed against a variety of Neu5Gc-containing epitopes. High sensitivity and specificity assays were achieved by using N-acetylneuraminic acid (Neu5Ac)-containing probes (differing from Neu5Gc by one less oxygen atom) as optimal background controls. The commonest anti-Neu5Gc antibodies are of the IgG class. Moreover, the range of reactivity and Ig classes of antibodies vary greatly amongst normal humans, with some individuals having remarkably large amounts, even surpassing levels of some well-known natural blood group and xenoreactive antibodies. We purified these anti-Neu5Gc antibodies from individual human sera using a newly developed affinity method and showed that they bind to wild-type but not Neu5Gc-deficient mouse tissues. Moreover, they bind back to human carcinomas that have accumulated Neu5Gc in vivo. As dietary Neu5Gc is primarily found in red meat and milk products, we suggest that this ongoing antigen-antibody reaction may generate chronic inflammation, possibly contributing to the high frequency of diet-related carcinomas and other diseases in humans.

An ox cell haemolysin test for the diagnosis of infectious mononucleosis

It is suggested that routine tests for infectious mononucloosis in a large number of apparently unrelated syndromes would disclose a frequent common aetiology and perhaps modify the present conception of the course of the disease.

A technique is suggested for a simple test involving tho demonstration of ox cell haemolysins which would make the testing of large numbers of sera practicable.

The results in sixty cases of infectious mononucleosis and 200 controls are evaluated. The test does not reduce significantly the proportion of serologically negative cases but may confirm the diagnosis before the characteristic sheep cell agglutinins are demonstrable.

The test is as sensitive and as specific as other serological tests for infectious mononucleosis and is very much easier to perform.

Direct detection of Epstein-Barr viral antigen in nasopharyngeal swabs from patients with infectious mononucleosis

OBJECTIVE

To determine whether direct immunologic detection of Epstein-Barr virus (EBV) early antigen diffuse component (EA-D) from nasopharyngeal swabs is a feasible approach to the development of a rapid diagnostic test for infectious mononucleosis (IM).

METHODS

Nasopharyngeal swabs from 20 patients presenting with a presumptive diagnosis of IM (having the classic triad of symptoms-acute pharyngitis, fever, and lymphadenopathy) and 5 controls were assayed for EA-D. EBV serologic testing and a heterophil antibody titer (HAT) test also were performed. EA-D was assayed by polyacrylamide gel electrophoresis and subsequent transfer to a nylon membrane, followed by immunoblotting with a monoclonal antibody.

RESULTS

EA-D was detected in 17 of 20 patients (85%) with presumptive diagnoses of IM and in 1 of 5 normal subjects and was highly significant in predicting IM (p < 0.01). There was no significant difference in numbers of positive and negative results using either EA-D assay or HAT test in patients with IM (p < 0.35). Pharyngeal exudate in the 17 pharyngitis patients with this variable documented was significantly correlated with positive EA-D (p < 0.01), but not with the HAT test (p < 1.00).

CONCLUSIONS

Immunologic detection of EBV-derived antigens from nasopharyngeal swabs is a potential early diagnostic tool for clinically suspected IM. Sensitivity and specificity in pediatric and adult populations, patients with other viral etiologies, and patients with streptoccocal pharyngitis should be determined in subsequent investigations.

Horse erythrocyte glycoprotein-latex reagent that reacts with infectious mononucleosis heterophile antibody

A sialoglycoprotein from horse erythrocytes was isolated in essentially homogeneous form and found to contain the neuraminidase-sensitive determinant of the horse erythrocyte for Paul-Bunnell heterophile antibodies of infectious mononucleosis. This reactivity was retained after covalent coupling of the antigen to latex particles. The latex reagent has greater stability (greater than 3 years) than either fresh or preserved horse erythrocytes. It can be used in a direct slide test; no absorption of the serum is necessary. The new test compared favorably with some standard tests for infectious mononucleosis antibody which use horse erythrocytes. Agreement of the latex test with the absorbed fresh horse cell test was 100%, and agreement with a stabilized horse erythrocyte spot test was 94%. The latex test also agreed 100% with a radioimmunoassay for the detection of heterophile antibody with 125I-labeled horse erythrocyte glycoprotein. The new latex test was compared with a bovine erythrocyte glycoprotein-latex test, and a correlation of 94% was observed. In addition, it was compared with the Wöllner test (enzyme-treated sheep cell-absorbed sheep cell agglutination test) with which it agreed in 92% of samples tested.

Immunochemical studies of infectious mononucleosis--X. Characterization of a glycoprotein from horse erythrocytes which reacts with Paul-Bunnell antibody

A highly purified preparation of horse erythrocyte glycoprotein was prepared from an aqueous ethanolic extract of hemoglobin-free membranes. The subunit apparent mol. wt was 30,000. In aqueous solution the glycoprotein formed globular aggregates of 93 +/- 16 A diameter. The glycoprotein had a receptor for the Paul-Bunnell antibody of infectious mononucleosis which was associated with an O-glycosidically linked oligosaccharide and dependent on the presence of N-glycolylneuraminic acid. In addition the glycoprotein had a neuraminidase-sensitive receptor for human peripheral blood lymphocytes. Fifty per cent inhibition of the rosetting of sheep red cells by 4 x 10(5) lymphocytes was caused by 30 microgram of glycoprotein.

Immunochemical studies of infectious mononucleosis. VII. Isolation and partial characterization of a glycopeptide from bovine erythrocytes

The major sialoglycopeptide released from bovine erythrocytes by papain has been purified and characterized. The glycopeptide contains 82% by weight carbohydrate in molar ratios of galactose - 5.5:N-acetylglucosamine - 3.6:sialic acid - 2.6:N-acetylgalactosamine - 1.0. The carbohydrate and amino acid composition is quite different from the glycoprotein extracted from bovine erythrocyte stroma with hot 75% ethanol. The glycopeptide is devoid of reactivity with Paul-Bunnell heterophile antibody of infectious mononucleosis - an activity expressed to high degree on the bovine erythrocyte and associated with glycoprotein. The glycopeptide does react, however, with another antibody found in infectious mononucleosis as well as most normal human sera tested.

A comparison of the Monospot with the Paul-Bunnell test in infectious mononucleosis and other diseases

The Monospot is a spot test designed for the diagnosis of infectious mononucleosis and its efficacy has been compared with that of the standard Paul-Bunnell test. Three out of 210 (1.4%) sera from normal persons and persons suffering from diseases other than infectious mononucleosis gave ;false' positive results when compared with the Paul-Bunnell test. Using 38 sera from patients with strong clinical and haematological evidence of infectious mononucleosis no false negative results were found with the Monospot test. The sera of 37 patients gave positive results with the Paul-Bunnell test: the one negative result was positive using serum taken a few days later.

Monospot: a differential slide test for infectious mononucleosis

Sera collected from 372 patients with suspected infectious mononucleosis were examined for heterophile antibodies by the Paul-Bunnell and the Monospot test. Comparison of results showed the latter to be simple, time saving, and of sufficient specificity for routine use in the general laboratory.

Horse agglutinins in infectious mononueleosis. 3. riterion for differential diagnosis

One hundred infectious mononucleosis and the same number of non-infectious mononucleosis sera were studied to evaluate the sensitivity and specificity of horse erythrocytes in the diagnosis of infectious mononucleosis. Titres of horse agglutinins in infectious mononucleosis sera ranged from 28 to 7,168 with a geometric mean of 550, whereas the corresponding sheep agglutinin titres ranged from less than 7 to 3,584, with a geometric mean of 126. Horse agglutinin titres of non-infectious mononucleosis sera ranged from less than 7 to 896, with a geometric mean of 59. Infectious mononucleosis sera tested with horse erythrocytes before and after absorption with guinea pig kidney and beef erythrocytes showed patterns different from those of non-infectious mononucleosis sera, even when sheep agglutinin titres were too low for satisfactory evaluation. After absorption with guinea pig kidney, horse agglutinin titres of infectious mononucleosis sera were uniformly higher than in the corresponding serum absorbed with beef erythrocytes. This was not the case for non-infectious mononucleosis sera. Results confirm our previously expressed view that horse erythrocytes are preferable to sheep erythrocytes in the serological diagnosis of infectious mononucleosis.

Infectious Mononucleosis

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