Immunoglobulin in clinically uninvolved skin in systemic lupus erythematosus: association with renal disease

James Neil Gilliam, MD-the career arc of a patient-oriented translational clinical investigation changemaker in rheumatologic skin disease

James Neil Gilliam, MD, was an American academic physician who was trained in internal medicine, dermatology, dermatopathology and rheumatology. This "quadruple-threat" profile of postgraduate medical training provided him with a rather unique perspective on genetically-complex, environmentally-impacted human autoimmune disorders such as lupus erythematosus (LE). Both the skin and vital internal organs can be damaged by LE autoimmunity. And, LE is clinically-expressed quite variably from one individual to another making prognosis difficult. As such it can be very challenging to know what the optimal treatment approach might be for new patients presenting with this potentially-fatal disorder. Dr. Gilliam's major career focus was to better understand the complex relationships that exist between the clinical expression of LE in the skin and vital internal organs. In the late 1970s, Dr. Gilliam first described a new clinical form of LE skin disease that he designated as "subacute cutaneous LE." Subacute cutaneous LE would subsequently serve as the linchpin for a new classification scheme for LE skin disease that would later become known as the "Gilliam classification" of LE skin disease. In addition, he was among the first to apply modern immunologic insight to the classification of cutaneous LE. This work was carried out in the Divisions of Dermatology and Rheumatology and the Department of Dermatology at the University of Texas Southwestern Medical School in Dallas, Texas (UT Southwestern) starting in 1972. Dr. Gilliam served as the Founding Chairman of the Department of Dermatology at UT Southwestern in 1982, 2 years before his untimely death. Dr. Gilliam's clinical research accomplishments were matched by his ability to identify and encourage like-minded young people. A high percentage of his trainees went on to successful academic research careers and leadership positions in American Dermatology. Dr. Gilliam's untimely death from cancer deprived several generations of dermatologists and rheumatologists the benefit of his warm support and insightful guidance. In addition, American Dermatology and Rheumatology leadership organizations were deprived of his strong leadership skills.

Cutaneous lupus erythematosus: Reflecting on practice-changing observations over the past 50 years

Several historical observations have led to the current understanding of the diagnosis, evaluation, and management of patients with cutaneous lupus erythematosus. Seminal advances in the management of this disease include the development of a classification system for cutaneous lupus, the use of a validated scoring system to assess patient disease activity, and expansion of knowledge of the action spectrum of this disease; further, observations regarding certain medications as potential causes of subacute cutaneous lupus erythematosus, the risk of progression from "pure" cutaneous disease to systemic disease, and traditional versus newer therapies are reviewed with closer inspection.

IgG and IgA with potential microbial-binding activity are expressed by normal human skin epidermal cells

The innate immune system of the skin is thought to depend largely on a multi-layered mechanical barrier supplemented by epidermis-derived antimicrobial peptides. To date, there are no reports of antimicrobial antibody secretion by the epidermis. In this study, we report the expression of functional immunoglobulin G (IgG) and immunoglobulin A (IgA), previously thought to be only produced by B cells, in normal human epidermal cells and the human keratinocyte line HaCaT. While B cells express a fully diverse Ig, epidermal cell-expressed IgG or IgA showed one or two conservative V_HDJ_H rearrangements in each individual. These unique VDJ rearrangements in epidermal cells were found neither in the B cell-derived Ig VDJ databases published by others nor in our positive controls. IgG and IgA from epidermal cells of the same individual had different VDJ rearrangement patterns. IgG was found primarily in prickle cells, and IgA was mainly detected in basal cells. Both epidermal cell-derived IgG and IgA showed potential antibody activity by binding pathogens like Staphylococcus aureus, the most common pathogenic skin bacteria, but the microbial-binding profile was different. Our data indicates that normal human epidermal cells spontaneously express IgG and IgA, and we speculate that these Igs participate in skin innate immunity.

Correlation of cutaneous immunoreactants in lesional skin with the serological disorders and disease activity of systemic lupus erythematosus

Detection of immunoreactants including IgG, IgM, IgA, and C3 by direct immunofluorescence (DIF) from skin is useful for distinguishing lupus lesions from other skin disorders. Despite their diagnostic value, the type and number of cutaneous immunoreactants as they relate to serological disorders and disease severity has been poorly studied. We examined 36 patients with systemic lupus erythematosis (SLE) with positive DIF (DIF+) and 28 patients with negative DIF (DIF-) tests performed on lesional skin. Among DIF+ patients, the most frequent patterns of immunoreactants were IgM alone (36%) and the coexistence of IgM with C3 (28%). IgM was the highest detected individual immunoreactant (86%). As classified by number, 17 of 36 DIF+ patients had one immunoreactant (= 1), while the remaining patients had two to four immunoreactants (>1). Compared with DIF- patients, DIF+ patients were more likely to have severe disease as indicated by lower serum C3 levels and a higher SLE disease activity index (SLEDAI). The coexistence of IgM with any other immunoreactants indicated a more severe disease than that present in the DIF- group, whereas the IgM-alone group was comparable with the DIF- group in both serum C3 levels and SLEDAI. These findings were also applicable in the comparison of patients with more than one (>1) immunoreactant and patients with no (DIF-) and one ( = 1) immunoreactant. Collectively, the presence of multiple immunoreactants in lesional skin implies a more severe disease activity of SLE, while a single immunoreactant may be equal to the absence of immunoreactants (DIF-) in terms of predicting disease activity.

IgG and IgM autoantibody differences in discoid and systemic lupus patients

Systemic lupus erythematosus (SLE) patients with discoid lupus erythematosus (DLE) were reported to have milder disease. To test this observation, we used sandwich arrays containing 98 autoantigens to compare autoantibody profiles of SLE subjects without DLE (DLE-SLE+) (N=9), SLE subjects with DLE (DLE+SLE+) (N=10), DLE subjects without SLE (DLE+SLE-) (N=11), and healthy controls (N=11). We validated differentially expressed autoantibodies using immunoassays in DLE-SLE+ (N=18), DLE+SLE+ (N=17), DLE+SLE- (N=23), and healthy subjects (N=22). Arrays showed 15 IgG autoantibodies (10 against nuclear antigens) and 4 IgM autoantibodies that were differentially expressed (q-value<0.05). DLE-SLE+ subjects had higher IgG autoantibodies against double-stranded DNA (dsDNA), single-stranded DNA (ssDNA), double-stranded RNA (dsRNA), histone H2A and H2B, and SS-A (52 kDa) compared with all other groups including DLE+SLE+ subjects (P<0.05). Immunoassays measuring anti-dsDNA, -ssDNA, and -SS-A (52 kDa) IgG autoantibodies showed similar trends (P<0.05). Healthy and DLE+SLE- subjects expressed higher IgM autoantibodies against alpha beta crystallin, lipopolysaccharide, heat-shock cognate 70, and desmoglein-3 compared with DLE+SLE+ and DLE-SLE+ subjects. IgG:IgM ratios of autoantibodies against nuclear antigens progressively rose from healthy to DLE-SLE+ subjects. In conclusion, lower IgG autoantibodies against nuclear antigens in DLE+SLE+ versus DLE-SLE+ subjects suggest that DLE indicates lower disease severity. Higher IgM autoantibodies against selected antigens in healthy and DLE+SLE- subjects may be nonpathogenic.

Imunofluorescência direta e indireta

A imunofluorescência é um valioso instrumento auxiliar no diagnóstico das dermatoses bolhosas autoimunes e desordens inflamatórias, uma vez que seus achados clínicos e histopatológicos podem não ser determinantes. Consiste em um método laboratorial factível, que requer profissionais técnicos experientes, e detecta imunocomplexos in situ e/ou circulantes, que podem estar envolvidos na patogênese de tais enfermidades cutâneas.

Lupus band test in uninvolved oral mucosa in systemic lupus erythematosus

In 42 patients with systemic lupus erythematosus, clinically normal oral mucosa was investigated with direct immunofluorescence technique for the presence of immunoglobulins G, A and M and complement factor C3 in the mucosal basement membrane zone (the lupus band test, LBT). Punch biopsies were performed in the posterior part of the hard palate (n = 39) or the lower labial mucosa (n = 3). The immunopathological observations were compared with clinical and serological data. The LBT was positive for IgM in 45% of the patients and trace amounts of IgM were found in another 19%. In 7 cases (17%) either IgG, IgA or C3 were found in addition to IgM and these patients all had a severe form of the disease, while the presence of IgM only was not correlated to clinical parameters.

IgM deposition in skin biopsies from patients with primary biliary cirrhosis

Immunofluorescence studies on skin biopsies from 14 patients with primary biliary cirrhosis (PBC) showed granular papillary deposition of IgM in all. In addition, 6 patients had C3 deposition. Control patients with various other liver diseases, idiopathic high plasma levels of igM and extrahepatic cholestasis were only sporadically positive for IgM and not at all for C3. IgM deposition in dermal papillae in PBC does not merely reflect high plasma IgM levels or cholestasis but probably represents an immunochemically abnormal IgM population.

Collagen vascular diseases: cutaneous manifestations in ophthalmology

PURPOSE

To describe the effects of collagen vascular diseases on the eyelids and periorbital tissues.

METHODS

Retrospective review of dermatologic pathology slides at Massachusetts General Hospital and eye pathology slides at Massachusetts Eye and Ear Infirmary, Boston, Massachusetts.

RESULTS

A spectrum of dermatologic manifestations of collagen vascular diseases was observed, affecting the eyelids and periorbital region.

CONCLUSIONS

Collagen vascular diseases may present complicated diagnostic and clinical challenges for the practicing ophthalmologist. Familiarity with the cutaneous periocular manifestations of these diseases may facilitate early recognition, diagnosis, and ophthalmologic intervention where necessary.

The composition of the lupus band test (LBT) on the sun-protected non-lesional (SPNL) skin in patients with cutaneous lupus erythematosus (CLE)

The objective of this study was to analyse the different immunoreactants at the dermo-epidermal junction (DEJ) of patients with cutaneous lupus erythematosus (CLE). Sun-protected non lesional (SPNL) skin biopsies from 65 patients with specific cutaneous manifestations of LE and from 18 patients with other dermatologic diseases were tested using the direct immunofluorescence (DIF) technique. Nineteen out of 65 patients with CLE were affected by systemic LE (SLE). We used the conventional chi-squared test to analyse statistical differences between CLE-SLE and CLE-non-SLE groups in the immunological composition of lupus band test (LBT). C3 was the most common component while IgM were the most frequent immunoglobulins (Igs) of LBT in LE patients. No immunoreactants could be demonstrated at the DEJ in patients with other dermatologic diseases. No statistical differences could be found between CLE-SLE and CLE-non-SLE groups as regards the detection of the different immunoreactants at the DEJ. A positive LBT (even for the presence of only one immunoreactant at the DEJ) performed on SPNL skin represents a useful and specific criterion to distinguish patients with lupus erythematosus (LE) from those without LE. We also believe in a prognostic value of a positive LBT on SPNL skin when the deposition of at least two immunoreactants is demonstrated, and especially if the deposits are composed of IgG.

How reliable is the basement membrane phenomenon in the diagnosis of systemic lupus erythematosus?

BACKGROUND

Although the basement membrane (BM) phenomenon is considered a good test to differentiate between systemic (SLE) and discoid lupus erythematosus (DLE), our observations question its reliability.

METHODS

Direct immunofluorescence stain was done to detect immunoglobulins and complement deposits in 10 SLE patients and in 10 healthy controls. Specimens were taken from the normal skin of the dorsa of hands.

RESULTS

The group of SLE patients showed deposits of IgG in 4, IgM in 7, IgA in 1, C3 in 7, and C4 in 1 patient. The group of healthy controls showed IgM in 2, C3 in 5, C4 in 2 cases, but no IgG or IgA deposits.

CONCLUSION

A positive BM phenomenon test could be found in normal individuals and may be due to the effect of ultraviolet rays. We think that the BM phenomenon has a limited reliability in diagnosing SLE.

Deposition of membrane attack complex in cutaneous lesions of lupus erythematosus

BACKGROUND

The membrane attack complex (MAC; C5b-9) localizes in the basement membrane zone (BMZ) of cutaneous lesions from patients with lupus erythematosus (LE) and has been implicated in the pathogenesis of this disease.

OBJECTIVE

Our purpose was to compare the frequency of MAC deposition with that of immunoglobulin and C3 deposition (lupus band).

METHODS

We studied 56 skin biopsy specimens from 42 patients with LE by direct immunofluorescence.

RESULTS

MAC was deposited in a granular pattern at the BMZ in 29 of 38 biopsy specimens (76%) from lesional skin; 5 of 38 specimens (13%) had focal or weak segmental deposition and 4 of 38 (11%) were negative. In contrast, IgG, IgM, IgA, and C3 were detected in 16 of 38 specimens (42%), 30 of 38 (79%), 4 of 38 (11%), and 22 of 38 (58%), respectively. None of the uninvolved skin biopsy specimens was MAC positive, although 4 of 18 (22%), 5 of 18 (28%), 1 of 18 (6%), and 2 of 18 (11%) were positive for IgG, IgM, IgA, and C3, respectively.

CONCLUSION

MAC deposition in lesional skin appears to be a relatively sensitive and specific marker for cutaneous LE and may be useful as an adjunct to the "lupus band" test.

Cross-reactivity of the subunit of the Sm ribonucleoprotein autoantigen with proline-rich polypeptides

Using recombinant fusion proteins representing different regions of the human Sm B/B' polypeptide, the 4B4 monoclonal anti-Sm antibody was found to bind a C-terminus epitope that is proline-rich. 4B4 cross-reacted with the p24 gag protein of HIV-1 and with other polypeptides rich in proline residues, including collagen. BALB/c mice immunized with human collagen not only produced antibodies to the immunizing antigen but also antibodies to Sm. This immune mouse serum also recognized C-terminus B/B' fusion proteins. These data suggest that the Sm B/B' antigen contains a poly-Pro epitope that is shared by several autoantigens and retroviral proteins. These sites may be important in the induction of autoantibodies through molecular mimicry.

Evaluation of clinically normal appearing skin for systemic infectious diseases in human immunodeficiency virus seropositive patients

The observation of a human immunodeficiency virus (HIV)-infected patient with cutaneous ulcers which contained both fungal and viral pathogens, and in which the fungal organisms were grown in culture yet could not be demonstrated microscopically, suggested the possibilities: 1) that the skin lesions might have been primarily caused by the viral pathogen, and 2) that the concurrent presence of that fungal pathogen was coincidental and perhaps secondary to fungemia. Assuming that these postulates are valid, it is reasonable to hypothesize that fungal organisms would have been detected if perilesional or distal, clinically normal appearing, skin had been evaluated. This hypothesis could be further assessed by performing a prospective study of clinically normal appearing skin for pathogens of suspected systemic infectious diseases in HIV seropositive patients. Since the quantity of infectious pathogens in nonlesional skin may be limited, it might be difficult to grow the organisms in culture or demonstrate them microscopically using standard methods. Therefore, in addition to routine cultures and histologic evaluation, immunohistochemical techniques using monoclonal antibodies to pathogen antigens and DNA amplification techniques based upon the polymerase chain reaction should be used to enhance the detection of the infectious pathogens.

Immunopathologic findings in systemic sclerosis patients: clinical and immunopathologic relationships

Direct immunofluorescence (DIF) of the skin biopsy specimens was performed in 62 patients with systemic scleroderma: 26 cases of acrosclerosis (group 1), 26 cases of diffuse scleroderma (group 2) and ten cases of transitional form acrosclerosis-diffuse scleroderma (group 3). If epidermal nuclear fluorescence and lupus band test (LBT) were considered, the results were positive in 15.3% in group 1, 42.3% in group 2, and 10% in group 3. LBT was positive in 13.5% of the cases in groups 1 and 2 and negative in group 3. The immunoglobulin deposits at the dermoepidermal consisted mainly of IgM or a combination of IgG and IgM. There was no correlation between the LBT and antinuclear antibodies as detected by indirect immunofluorescence (IIF) or double immunodiffusion (DID).

Immunopathologic studies of cutaneous lupus erythematosus

The studies, as outlined above, strongly suggest that there may be several pathophysiologic mechanisms resulting in the development of cutaneous lupus lesions. It appears that all lupus lesions are associated predominantly with a T-cell infiltrate. Based upon the studies of the neonatal lupus infants, it has been hypothesized that the U1RNP and Ro(SS-A) autoantibodies of maternal origin play a direct pathologic role in the genesis of the annular polycyclic SCLE lesions and this may be mediated by antibody-dependent cellular cytotoxicity mechanisms in which the antibody binds to the respective antigen present on the keratinocyte plasma membrane and the effector cells are T cells derived from the infants. Other studies, using direct immunofluorescence techniques, have demonstrated an association of cutaneous lupus lesions occurring in the presence of immunoglobulin and complement at the dermal/epidermal junction (positive lupus band test) in which the neoantigen of the complement membrane attack complex (C5b-C9) is detected. These data have been interpreted as indicating that immunoglobulin and complement, perhaps in the form of immune complexes, may play a role in the pathogenesis of some cutaneous lupus lesions. Additional studies have determined that there is a substantial number of lupus patients with cutaneous disease, without antinuclear antibodies, who fail to demonstrate the deposition of immunoglobulin and complement at the dermal/epidermal junction. Furthermore, other studies have indicated that ultraviolet light is capable of inducing lesions in lupus patients that histologically are identical to those of cutaneous lupus erythematosus but that failed to demonstrate the deposition of the immunoglobulin and complement components. Since discoid lupus lesions demonstrate a preponderance of T cells, it has been proposed that some of these lesions are the direct result of a T-cell cytotoxic event. However, the nature of the autoantigens responsible for this putative T cell-mediated cytotoxic response is unknown at the present time. The role of ultraviolet light in the genesis of the cutaneous lupus lesions appears to involve, within the epidermis, the generation of autoantigen macromolecules which then react with autoantibodies or specific T cells of the lupus host.

Immune deposits in normal skin of patients with systemic lupus erythematosus: relationship to the serum capacity to solubilize immune complexes

Immunofluorescent deposits at the dermal-epidermal junction (DEJ) of the skin (lupus band test or LBT) were evaluated in 134 patients with various connective tissue diseases. LBT was found positive in 23 of 32 (71.8%) patients with systemic lupus erythematosus (SLE), in 3 of 53 (5.6%) patients with rheumatoid arthritis (RA), and in 1 of 5 cases of mixed connective tissue disease (MCTD). No deposits were found in patients with systemic sclerosis and with vasculitis. In patients with SLE a positive LBT showed a direct correlation with serum Clq binding activity (ClqBA) and with hypocomplementemia. The mean ClqBA was 13.49 +/- 12.85 and 2.38 +/- 2.27% in SLE patients with positive and negative band test, respectively (P less than 0.005). Likewise depressed mean serum levels of C3 and C4 were detected in patients with skin deposits (P less than 0.005). Sera from SLE patients showed an overall decreased capacity to solubilize preformed immune complexes when compared to normal sera. Furthermore 10 band-positive patients were less able to solubilize immune complexes than sera from LBT-negative lupus patients (45 +/- 16 and 62 +/- 11%, respectively; P less than 0.01). Also the capacity to inhibit the precipitation of immune complexes was decreased in SLE patients with negative LBT (P less than 0.05). In conclusion our data suggest that in SLE patients a decreased complement-mediated solubilization of immune complexes is involved in the persistence of high levels of circulating immune aggregates and, considered its correlation with positive LBT, may be responsible for the deposits of immunoglobulins at the dermal-epidermal junction of the skin.

Lupus lung

The morphologic findings from 18 autopsy lungs of systemic lupus erythematosus were studied. Each case revealed varying degrees of pleuropulmonary disease. A universal feature was visceral pleural thickening, while findings present in more than one half of the cases included pulmonary congestion (17/18) and edema (15/18), pleural adhesions (11/18) and pleural effusions (10/18) and intraalveolar hemorrhage (10/18). Also seen were bronchopneumonia (9/18), interstitial fibrosis (6/18), cytomegalovirus infection (3/18), interstitial pneumonitis (2/18), hyaline membranes (2/18), and acute vasculitis (1/18) and pleuritis (1/18). These results, together with those of previously reported studies of lupus lung, establish that although certain characteristic pleuropulmonary disease processes are frequently found at autopsy, none is a highly specific marker for the disease.

Nucleoprotein autoantibodies in lupus erythematosus

Autoantibodies against deoxyribonucleic acid (DNA) and ribonucleic acid (RNA) proteins are commonly detected in patients with lupus erythematosus (LE). Antibodies against native DNA are frequently detected in a subset of LE patients with a high prevalence of renal disease. Single-stranded DNA antibodies are also commonly detected in patients with systemic lupus erythematosus (SLE) but recent evidence indicates that approximately 25% of patients with benign, cutaneous (discoid) lupus also possess single-stranded DNA IgM autoantibodies. LE patients also frequently possess antibodies directed against a variety of ribonuclear proteins (RNP). These RNA protein autoantibodies are generally divided into two groups. One group is termed snRNPs (small nuclear ribonuclear protein); the other is termed scRNPs (small cytoplasmic ribonuclear protein). Anti-RNA protein autoantibodies occur as frequently in patients with SLE as do native DNA antibodies. Furthermore, in contradistinction to nDNA antibodies, lupus patients generally make large quantities (detected by gel precipitin techniques) of anti-RNP antibodies. The anti-RNP antibodies are directed against proteins that bind with specific RNA nucleotides. The best evidence at present indicates that these RNA proteins containing the specific RNA nucleotides are involved in RNA processing and post-translational activities such as protein synthesis. Furthermore, these SLE autoantibodies are now being employed, together with other autoantibody systems detected in other connective tissue diseases, to define the biological role of the respective RNA proteins.

Pathogenesis of cutaneous lupus erythematosus

Antibody-dependent mechanisms of tissue damage are the principle mechanism of disease in systemic and cutaneous lupus erythematosus. Antibody-dependent mechanisms of keratinocyte damage appear to be a primary pathogenetic factor in all forms of papulosquamous cutaneous lupus. Photosensitive papulosquamous lupus syndromes, such as subacute cutaneous LE, neonatal LE, "ANA-negative" LE, and complement-deficient LE are all strongly associated with antibodies to the ribonucleoprotein SSA. Evidence is accumulating that antibodies to SSA (and perhaps to SSB) induce antibody-dependent cell-mediated cytotoxicity (ADCC) of basal keratinocytes in all of these lupus syndromes. Evidence is also growing that autoantibodies in cutaneous LE syndromes are directly involved in disease pathogenesis, and are not simply markers of disease subsets. The relationship of the photosensitive anti-SSA-associated LE syndromes to more classical discoid LE or to acute papulosquamous LE in SLE patients remains to be studied. In both discoid LE and acute LE, basal keratinocyte damage can be seen, just as in the anti-SSA-associated photosensitive LE syndromes, but other antigen-antibody systems may be involved in initiating keratinocyte damage, or other cytotoxic mechanisms may produce keratinocyte damage characteristic of these syndromes.

The immunologic diagnosis of chronic active "autoimmune" hepatitis: distinction from systemic lupus erythematosus

We have evaluated the immunologic characteristics often associated with systemic lupus erythematosus in a series of patients with a variety of different liver diseases. Antibody to double-stranded DNA as measured by the Farr assay was detected frequently in patients with various forms of liver disease. No patient with liver disease, including those with a presumed immunologic etiology, was found to have antibody to double-stranded DNA using more specific assays. Other immunologic phenomena such as the presence of immunofluorescent staining at the dermal-epidermal junction in the lupus band test, circulating immune complexes and the presence of antinuclear antibody were present in a number of patients with different forms of liver disease. The absence of antibody to double-stranded DNA in patients with liver disease suggests that there may be a true immunologic distinction between systemic lupus erythematosus and chronic active ("lupoid") hepatitis.

Prognostic significance of subepidermal immune deposits in uninvolved skin of patients with systemic lupus erythematosus: a 10-year longitudinal study

The detection by direct immunofluorescence of subepidermal immune deposits in clinically normal skin of patients with systemic lupus erythematosus has become known as a positive lupus band test (LBT). To gain a better understanding of the relation between the LBT and prognosis in systemic lupus erythematosus (SLE) a prospective longitudinal study has been carried out in 51 SLE patients covering a 10-year period. A total of 223 LBTs were obtained from clinically normal skin of the medial volar forearm on these 51 patients (average, 4.4 per patient) and the results correlated with clinico-pathologic features of the disease and outcome. Findings from the initial LBT (obtained while on no systemic therapy) were used to divide patients into LBT-positive and LBT-negative groups. With the exception of patients subsequently treated with daily doses of prednisone greater than 40 mg or cytotoxic agents, the patients in the LBT-positive group usually remained LBT-positive. The LBT-negative patients usually remained LBT-negative on repeated testing. A comparison of clinical features in the two groups revealed a 55% prevalence of lupus nephropathy in the LBT-positive group as opposed to 23% in the LBT-negative group (p = 0.025). Although the two groups had similar serum creatinine levels at the time of the initial LBT, the maximum serum creatinine (mean, 3.0 mg/dl) in the LBT-positive group was significantly higher than the maximum (mean, 1.2 mg/dl) in the LBT-negative group (p = 0.04). Furthermore, only 9% of renal biopsies in the LBT-negative group showed diffuse proliferative glomerulonephritis in contrast to 65% of biopsies in the LBT-positive group (p = 0.007). Lastly, the two groups were compared with regard to outcome; 10-year survival from the time of diagnosis was 95% in the LBT-negative group as opposed to only 54% in the LBT-positive group (p = 0.007). These findings indicate that a positive LBT has predictive value in that it identifies a subset of SLE patients with more aggressive renal disease and significantly decreased long-term survival.

Immunoglobulin deposits in the epidermis of patients with primary Sjögren's syndrome. A consecutive study

In biopsies from macroscopically healthy skin, IgG deposits were demonstrated in the intercellular areas of the epidermis by a direct immunofluorescence technique, in 17 of 25 consecutive patients with primary Sjögren's syndrome. Intercellular epidermal deposits of IgA were found in 4 and of IgM in 1 of the 25 patients. Deposits of IgG in the dermal blood vessel walls were found in 9 patients, IgA in 1 and IgM in 3 patients. In 3 of 23 patients with secondary Sjögren's syndrome intercellular IgG deposits were found in the epidermis, and in 2 of these 3 patients IgA deposits were likewise demonstrated. No immunoglobulin deposits were found in the dermo-epidermal junction zone in patients with primary and secondary Sjögren's syndrome. No deposits of immunoglobulin were found intercellularly in epidermis or in dermal blood vessel walls in 23 sex and age matched healthy controls. Blood samples obtained simultaneously from all patients and controls showed no correlation of serum IgG levels with deposits in the skin. We conclude that investigation for IgG deposits in the intercellular area of the epidermis and/or in the dermal vessel walls in macroscopically healthy skin may be of diagnostic help in patients with chronic inflammatory connective tissue disease.

Vesiculobullous systemic lupus erythematosus. Report of two cases and a review of the literature

Vesicles and bullae complicating systemic lupus erythematosus (SLE) are relatively uncommon. Two young women with SLE presented with vesiculobullous eruptions on sun-exposed areas that resembled dermatitis herpetiformis (DH) histologically. There were active visceral manifestations of SLE in both patients, including mesangioproliferative glomerulonephritis. Granular deposits of IgG and/or IgM, along with IgA, were demonstrated along the basement membrane of skin by direct immunofluorescence microscopy. Review of fifteen additional cases of vesiculobullous SLE reported in the literature suggests that this cutaneous manifestation of SLE is associated with a high incidence of IgA deposits in skin and glomerulonephritis. The following criteria for the diagnosis of a distinct subset of vesiculobullous skin lesions occurring in patients with SLE are proposed: (1) a diagnosis of SLE based upon American Rheumatism Association (ARA) criteria; (2) vesicles and bullae arising upon but not limited to sun-exposed skin; (3) histopathology compatible with DH; (4) negative indirect immunofluorescence for circulating basement membrane zone (BMZ) antibodies; (5) direct immunofluorescence reveals IgG and/or IgM and often IgA at the BMZ.

The clinical and histopathologic spectrums of urticarial vasculitis: study of forty cases

Urticarial skin lesions may occur in patients as a manifestation of necrotizing vasculitis. We describe a series of forty patients with idiopathic chronic urticaria and histologic features of necrotizing vasculitis. On the basis of clinical evaluation, we have classified urticarial vasculitis into two major groups: (1) hypocomplementemic (sixteen patients, ten of whom had evidence of renal disease) and (2) normocomplementemic (twelve patients with systemic disease and twelve with only cutaneous involvement). Most patients with hypocomplementemia presented with arthritis, and some had abdominal pain or airway compromise. Although patients with normocomplementemia and systemic disease had a less severe clinical course, four exhibited renal disease that was characterized by microhematuria and proteinuria. Direct immunofluorescence microscopy of the skin aids in assessing renal involvement in some cases of hypocomplementemic urticarial vasculitis, particularly when IgG and IgM are deposited at the basement membrane. There seems to be a spectrum of disease in urticarial vasculitis, ranging from benign cutaneous lesions to systemic disease.

Systemic lupus erythematosus in hereditary deficiency of the fourth component of complement

Three patients from two families with complete hereditary deficiency of the fourth component of complement (C4) and systemic lupus erythematosus are described. The syndrome presented by these patients is characterized by early onset in life; exquisite sensitivity to sunlight and to cold exposure, the latter resulting Raynaud's phenomenon; and skin lesions involving not only exposed areas of the body but also palms and soles and presenting as butterfly rashes, maculopapular eruptions, and lesions similar to those of chronic discoid lupus erythematosus, with marked scaling, atrophy, and scarring. Lupus erythematosus (LE) cell tests were negative and antinuclear antibody (ANA) titers low or negative. The male patient of our series died at the age of 31/2 years from septicemia, whereas the two girls, aged 18 and 11 years, respectively, were alive at the time of writing. The C4-deficient gene is associated with HLA-Aw32, Bw38, and Bf S in one family and with HLA-A30, B18, DR7, and Bf S1 in the other family; the latter is the second family in which this HLA haplotype has been found to be associated with hereditary C4 deficiency.

Clearing of subacute cutaneous lupus erythematosus around molluscum contagiosum lesions

A patient with widespread subacute cutaneous lupus erythematosus (SCLE) developed halos of uninflamed, normal-appearing skin around lesions of molluscum contagiosum. A biopsy confirmed the lack of active lupus erythematosus (LE) in the halo area (neither basal layer liquefaction nor inflammatory infiltrate was present). Direct immunofluorescence of the halo area showed only weak staining with IgG and C3. In contrast, adjacent skin, clinically involved with cutaneous LE, showed both active LE by light microscopy and strong staining with IgG and C3. We feel the molluscum contagiosum lesions that developed in areas of active SCLE somehow suppressed the clinical, histologic, and immunologic expression of SCLE in he surrounding skin. This observation might offer some insight into the poorly understood pathophysiologic mechanisms involved in cutaneous LE.

Renal localization of the membrane attack complex in systemic lupus erythematosus nephritis

The membrane attack complex (MAC) of the complement system was localized in both glomeruli and peritubular regions of 22 kidneys manifesting systemic lupus erythematosus (SLE) nephritis. A similar distribution was observed for immune complex markers (IgG, Clq, and C3) and MAC in glomeruli, although the deposits of MAC were more discrete and showed lesser immunofluorescence staining intensity compared with immunoglobulins and complement components. In contrast, peritubular immune complexes were present in only 7 out of 22 kidneys, involved comparatively small clusters of tubules, exhibited weaker immunofluorescence staining than MAC, and failed to correlate with interstitial foci of inflammation. Granular or irregular, linear aggregates of the MAC were observed at the periphery of larger groups of tubules contiguous to areas of interstitial inflammation. Comparable amounts of IgG, Clq, C3, and MAC were present in blood vessel walls in areas of fibrinoid necrosis. These data suggest that the MAC is a direct mediator of tissue injury occurring in renal glomeruli, tubules, and blood vessels. The discordance between immune complexes and MAC localized in the peritubular region, but not in glomeruli or blood vessels, raises the possibility that both immune complexes and nonimmune agents, such as bacterial antigens, may activate the classical or alternative complement pathways and thereby play a role in the pathogenesis of tubulointerstitial lesions of SLE nephritis.