Viruses and autoimmunity

An Unusual Case of Anti-GBM Antibody Elevation in HIV-Associated Nephropathy

Introduction. The most commonly seen glomerular disease in HIV infected patients is HIV-associated nephropathy (HIVAN); however, a multitude of other nephropathies can occur in HIV infection with an almost equal cumulative frequency. We report an unusual case of a patient with clinical and histological evidence of HIVAN in which the diagnosis was initially confounded by the finding of an elevated serum anti-glomerular basement membrane (anti-GBM) antibody. Case Presentation. We present a case of a 27-year-old African American female with a history of schizophrenia, cocaine abuse, and HIV infection who upon admission to our hospital was found to have severe acute kidney injury requiring hemodialysis. Urine studies revealed nephrotic range proteinuria and a serological workup was positive for anti-GBM antibody elevation with a value of 91 units (normal: 0–20 units). A renal biopsy revealed HIVAN with no evidence of crescentic glomerulonephritis or anti-GBM disease. Conclusion. This case highlights the need for careful interpretation of anti-GBM antibody tests in HIV infected patients with kidney disease and, in particular, the need for biopsy confirmation of the diagnosis prior to starting therapy. More research is needed to study the prognostic correlation between the degree of anti-GBM antibody elevation in HIVAN and disease severity.

HIV infection increases the risk of heparin-induced thrombocytopenia

The incidence of heparin-induced thrombocytopenia in human immunodeficiency virus (HIV)-infected inpatients was compared with that in a control group that was not known to be infected with HIV in a retrospective cohort study. HIV-infected patients receiving heparin therapy, especially unfractionated heparin therapy, were at increased risk of developing heparin-induced thrombocytopenia, compared with HIV-uninfected patients.

The Uncertain Significance of Anti–Glomerular Basement Membrane Antibody Among HIV-Infected Persons With Kidney Disease

Glomerular lesions that complicate patients with human immunodeficiency virus (HIV) infection include HIV-associated nephropathy, membranous glomerulopathy, and immune-complex glomerulonephritides. This case series presents 3 patients with clinically significant renal disease and positive test results for anti-glomerular basement membrane (anti-GBM) antigen. Characteristic histological findings that would suggest anti-GBM antibodies have a significant role in the pathological state of each patient's kidney disease were absent. In addition, each patient recovered without specific treatment for anti-GBM disease. This case series suggests that anti-GBM antibodies likely are related to the B-cell expansion previously described in patients with HIV infection. We propose that clinicians interpret results of anti-GBM antibody tests carefully for patients with HIV infection, considering biopsy before empiric therapy, particularly in a clinical presentation that is atypical for Goodpasture disease.

Relationship between the number and impact of stressful life events and the onset of Graves' disease and toxic nodular goitre

BACKGROUND

In the last few decades, several studies have suggested a possible association between Stressful Life Events (SLEs) and the onset of Graves' Disease (GD). However, others have criticised this association and it has not yet been possible to prove it unequivocally. At present, we are not aware of studies correlating SLE and non autoimmune thyrotoxicosis.

OBJECTIVE

To assess possible associations between SLEs, the onset of GD and the onset of non autoimmune thyrotoxicosis (toxic nodular goitre, TNG).

DESIGN

A case-control retrospective study.

PATIENTS

This study included 93 subjects, divided into three groups of 31 each: GD, TNG and control (CG). The GD and TNG patients had thyroid disease diagnosed within the last 12 months, with clinical and biochemical confirmation. In the CG, psychopathological and endocrine disturbances had been ruled out. All three groups consisted of nine males (29%) and 22 females (71%). The mean age was 38.4 +/- 10.9 years in the GD group, 48.3 +/- 11.1 years in the TNG group and 41.1 +/- 11.8 years in the CG group. SLEs were evaluated (number and impact) for the 12 months preceding the onset of symptoms of thyroid disease.

MEASUREMENTS

SLE occurrences and their impact on each group of cases were measured. To assess SLEs, we used the Life Experiences Survey (LES). Our statistical analysis included descriptive techniques and parametric and/or nonparametric comparative tests. P < 0.01 was considered statistically significant. Odds ratios were also calculated.

RESULTS

Patients with GD had a significantly greater number of SLEs compared to the TNG group and the CG (P < 0.001). The number and impact of negative SLEs were significantly higher in GD compared to TNG and CG (P < 0.001). The difference between TNG and CG was not significant (P > 0.01). GD had a higher impact of positive SLEs than TNG (P = 0.004), and no significant differences were found between the GD group and CG. Neutral SLEs were similar in the three groups.

CONCLUSIONS

These results suggest that SLEs are a precipitating factor of the onset of GD. We also demonstrated that SLEs do not seem to have any conclusive relationship with the onset of TNG.

Clinical implications of autoantibodies in HIV infection

OBJECTIVE

To study the frequency and specificity of autoantibodies in HIV-infected subjects and their association with rheumatic manifestations, immunodeficiency, and prognosis.

DESIGN

Prospective study of sequentially selected HIV-infected patients. Indirect immunofluorescence reading was performed by two independent observers blinded for the patient diagnosis. Enzyme-linked immunosorbent assay (ELISA) was performed using coded serum samples.

SETTING

The study was performed at the Infectious Disease and Rheumatology Divisions of a tertiary care university hospital.

PATIENTS

One hundred sequentially selected HIV-infected patients formed group A. Controls included 80 non-HIV-infected high-risk individuals (group B), 20 herpesvirus-infected patients (group C), and 30 healthy blood donors (group D).

MAIN OUTCOME MEASURES

Patients were followed for 2 years and evaluated for the presence of immunodeficiency, rheumatic manifestations, circulating autoantibodies and total CD4+ cell count. Indirect immunofluorescence was used to investigate antinuclear antibodies, antibodies to native DNA, smooth muscle, parietal cell, glomeruli, thyroid, and neutrophil cytoplasm. Agglutination was used to detect antibodies to erythrocytes and rheumatoid factor. ELISA was used to determine antibodies to cardiolipin and denatured DNA. CD4+ lymphocytes were counted by flow cytometry. Immunoglobulin (Ig) G, IgM and IgA serum levels were determined by radial immunodiffusion.

RESULTS

HIV-infected patients presented higher overall frequency of autoantibodies than the other groups. No difference was observed between immunodeficient and asymptomatic HIV-infected patients. The most frequent specificities were antibodies to cardiolipin and to denatured DNA. Ig serum levels did not correlate with the occurrence of autoantibodies. The presence of autoantibodies was associated with lower CD4+ cell counts and with higher mortality within 2 years. Rheumatic manifestations were observed in 35 HIV-infected patients and were not associated with the occurrence of autoantibodies or the presence of immunodeficiency.

CONCLUSIONS

HIV infection is associated with an increased incidence of autoantibodies. Although not related to the occurrence of rheumatic manifestations, the presence of autoantibodies was significantly associated with lower CD4+ lymphocyte counts and increased mortality, which implies prognostic significance to this phenomenon in the context of HIV infection.

Life events, daily stresses and coping in patients with Graves' disease

OBJECTIVE

The contribution of stress to the aetiology of Graves' disease (GD) remains controversial. We have therefore examined life events, daily stress and coping in patients with this disease. We wished to determine whether the clinical presentation of Graves' hyperthyroidism is associated with preceding stressful events.

DESIGN

A prospective controlled study. Ninety-five patients with newly diagnosed GD were compared to matched controls.

METHOD

A self-reporting questionnaire recalling life events, daily stress and coping in the twelve months preceding the diagnosis.

RESULT

More Graves' disease patients than controls reported negative events (P < 0.0005), whereas the number of subjects reporting positive events and neutral events were similar in both groups. Graves' disease patients also experienced more negative events (P < 0.0001) and perceived them with higher ratings (P < 0.0001). Each group had similar coping ability in terms of the number of coping methods and magnitude of utilization of these methods. Similarly, Graves' disease patients reported more daily hassle (P < 0.001) and had higher hassle scores (P < 0.001).

CONCLUSION

Patients with Graves' disease experienced greater psychological stress and adverse events prior to the onset of the disease. As stress may alter the immune system, it could play an important role in precipitating the disease in subjects predisposed to autoimmune thyroid disorders.

Analysis of the human T-cell response to picornaviruses: identification of T-cell epitopes close to B-cell epitopes in poliovirus

Little is known about the nature and specificity of T-cell-mediated responses to picornaviruses in humans. In this study, the nature of the T-cell response to seven picornaviruses, including polioviruses, coxsackieviruses B3 and B4, human rhinovirus 14, and encephalomyocarditis virus, was determined. Twenty-nine individuals responded to poliovirus type 3, coxsackievirus B3, and encephalomyocarditis virus by proliferation of T cells, and from such cultures, 130 virus-specific T-cell lines were established. T-cell lines generated in response to encephalomyocarditis virus were exclusively strain specific. However, the majority of T-cell lines established in response to viruses, other than encephalomyocarditis virus, were cross-reactive to each other. Their cross-reactivity was confirmed in 2 of the 30 picornavirus-specific clonally derived T-cell lines from two subjects, but the majority of these lines were serotype specific. T-cell epitopes adjacent to each of the B-cell antigenic sites in VP1 of poliovirus type 3 were identified. The response to the region adjacent to B-cell antigenic site 1 (residues 97 to 114) was dominant between individuals. The localization of this major CD4 T-cell epitope may permit the construction of chimeric viruses utilizing the natural picornavirus T-cell response to augment production of antibody specific for inserted sequences.

Autoimmune diseases: overview and current concepts of pathogenesis

No single theory or mechanism can adequately explain all features or pathogenesis of autoimmune diseases. The clinically wide spectrum of autoimmune diseases is best considered as the mosaic of autoimmunity and the many factors involved are genetic, hormonal, immunological, and environmental. These multifactorial considerations help to explain not only the diversity of various clinical diseases encountered but also the differences in clinical manifestations from patient to patient within the same disease group.