A novel antinuclear antibody associated with a lupus-like paraneoplastic syndrome

Digital ischaemia as a presenting feature in metastatic ovarian cancer

A woman in her 50s presented with acute pain and discolouration in the fingertips of both hands, without other features of connective tissue disease. The history was otherwise significant for abdominal bloating, altered bowel habit, urinary urgency and fatigue. Inflammatory markers, antinuclear antibodies, serum protein electrophoresis and complement levels were all normal. The tumour marker CA125 was significantly elevated, prompting a CT abdomen and pelvis, which revealed a large right-sided adnexal mass with multiple enhancing peritoneal and omental nodules and moderate ascites, suggestive of disseminated primary ovarian cancer.Digital ischaemia (DI) can be associated with cancer in up to 15% of cases. An underlying cancer should be suspected in patients presenting with new or worsening symptoms of DI. Prompt treatment with anticancer therapies can achieve complete resolution of DI.

Chronic monoarthritis and foot-drop as a paraneoplastic syndrome in prostate cancer

Paraneoplastic rheumatic symptoms, caused by a malignancy, but not directly related to invasion by the tumor or its metastases are the result of a wide variety of tumor-derived biologic mediators. Recognition of paraneoplastic rheumatic syndromes is important, as it may lead to an early diagnosis of cancer. We report a 71-year-old patient with prostate cancer, presented with chronic monoarthritis of the left ankle and foot-drop. Monoarthritis and foot-drop was resistant to non-steroidal anti-inflammatory drugs and corticosteroids. After tumor resection, synovitis resolved and foot-drop disappeared almost totally.

Malignancies and soluble tumor antigens in rheumatic diseases

Paraneoplastic symptoms, caused by a malignancy, but not directly related to invasion by the tumor or its metastases are the result of a wide variety of tumor-derived biologic mediators like hormones, peptides, antibodies, cytotoxic lymphocytes, autocrine and paracrine mediators. Recognition of paraneoplastic syndromes is important, as it may lead to an early diagnosis of cancer. There is some evidence that systemic inflammatory diseases, such as rheumatoid arthritis (RA), lupus, scleroderma or dermatomyositis may increase the risk for the development of malignancies, predominantly lymphoproliferative disorders. However, reports are somewhat controversial. Immunosuppressive and cytotoxic drugs used in antirheumatic therapy, such as methotrexate, cyclophosphamide, azathioprine or anti-TNF biologicals may also lead to the development of such tumors. Tumor-associated antigens may be produced by inflammatory cells and their production may be increased in RA and other autoimmune diseases.

Paraneoplastic rheumatic syndromes

Paraneoplastic symptoms caused by a malignancy but not directly related to tumour invasion are the result of a wide variety of tumour-derived biologic mediators, such as hormones, peptides, antibodies, cytotoxic lymphocytes, autocrine and paracrine mediators. Recognition of paraneoplastic syndromes is important, as it may lead to an early diagnosis of cancer. On the other hand, the clinical severity of the symptoms can be used as a guide to the extent of response to underlying tumour therapy. The quality of life of the patient is affected, therefore the palliative treatment of paraneoplasia is very important.

Rheumatic syndromes associated with malignancy

The relation between rheumatic syndromes and an underlying malignancy is a complex one. As a result of autoimmunity, an aberrant immune response, or the use of immunomodulatory drugs, many of the rheumatic diseases appear to pose an increased risk for the development of malignancy. Unfortunately, for many of the same reasons, the presence of an underlying malignancy can result in the development of features of rheumatic disease. Awareness of the associations between rheumatic syndromes and malignancy will aid the clinician in the accurate diagnosis of underlying pathology, more effective treatment of both the symptoms and underlying disease, and appropriate surveillance for the development of later complications.

Paraneoplastic acral vascular syndrome: epidemiologic features, clinical manifestations, and disease sequelae

BACKGROUND

Acral vascular syndromes associated with malignancy have rarely been reported.

OBJECTIVE

Our purpose was to assess the clinical and evolving features of paraneoplastic acral vascular syndromes.

PATIENTS AND METHODS

Two cases of paraneoplastic gangrene are described and analyzed together with previously reported cases identified by a MEDLINE search.

RESULTS

Among the 68 patients identified, 40 had gangrene, 16 had acrocyanosis, and 12 had Raynaud's phenomenon. The male to female ratio was 0.89; median age was 59 years. Fingers were affected in 94%. Adenocarcinomas were the predominant associated malignancies (41%), and metastases were observed in 41%. The acral vascular syndromes in 48% of the patients definitively regressed after tumor treatment. Forty-four percent of the patients died within 2 years. A favorable cutaneous outcome was obtained with prostacyclin infusions in 6 patients.

CONCLUSION

A neoplastic origin of acral vascular syndrome should be considered in elderly patients, especially men, in the absence of usual causative conditions.

Paraneoplastic rheumatic syndromes

Malignant neoplasms are associated with a wide variety of paraneoplastic rheumatological syndromes. Among these, hypertrophic osteoarthropathy, carcinoma polyarthritis, dermatomyositis/polymyositis, and paraneoplastic vasculitis are the most frequently recognized. Other less known associations are based upon a smaller number of reported patients, and include fasciitis, panniculitis, erythema nodosum, Raynaud's syndrome, digital gangrene, erythromelalgia and lupus-like syndromes. Musculoskeletal manifestations of malignancy may coincide, follow or antedate the diagnosis of cancer, or herald its recurrence. The clinical course generally parallels that of the primary tumour, and treatment of the underlying malignancy often results in regression of the rheumatic disorder. Awareness that cancer can cause certain non-metastatic symptoms is important for early diagnosis and treatment of an occult neoplasm. Rheumatic manifestations suggesting a hidden cancer include: rapid onset of an unusual inflammatory arthritis clubbing or diffuse bone pains in a patient 50 years of age or older, chronic unexplained vasculitis, refractory fasciitis, Raynaud's syndrome unresponsive to vasodilator therapy, rapidly progressive digital gangrene or Lambert-Eaton myasthenic syndrome. Management consists of control of the underlying cancer and symptomatic treatment of the rheumatic syndrome with non-steroidal anti-inflammatory drugs or corticosteroids.

Clinical features and IgG subclass distribution of anti-p80 coilin antibodies

We examined the clinical features of patients presenting antinuclear autoantibodies against p80-coilin and the IgG subclass distribution of anti- p80-coilin antibodies. Sera from 365 Japanese patients were analysed. Immunoblotting and indirect immunofluorescence microscopy techniques were used with a polyclonal rabbit antiserum against p80-coilin. Eleven patients with anti-p80-coilin antibodies were found. All the patients were female and nine were in their twenties. None could be diagnosed with differentiated rheumatic disease except for one case of systemic scleroderma and another of Sjögren's syndrome. Most patients had general fatigue, arthralgia, headaches, dysmenorrhea, lymph node swelling and/or low grade fever such as chronic fatigue syndrome (CFS), and showed low complement. One patient fulfilled the criteria for CFS. All were younger females than those often diagnosed with rheumatic disease in previous reports. Patients' sera had a predominant distribution of subclass IgG(1)anti-p80-coilin antibodies and five sera had concomitant subclass IgG(2). Two rheumatic disease patients had a relatively high titer of IgG(2)anti-p80-coilin antibodies. The IgG(2)subclass of anti-p80-coilin antibodies may be a specific marker for systemic autoimmune disease.

Malignancy and Rheumatic Disease

BACKGROUND: A wide variety of clinically significant interactions occur between neoplastic and rheumatic diseases, and many are clinically significant. METHODS: The types of interactions between rheumatologic and neoplastic diseases and their clinical manifestations are reviewed and described. RESULTS: Several diseases included in the classic definition of rheumatology are associated with an increased incidence of specific neoplasms. Conversely, many neoplasms, by a variety of mechanisms, can cause or simulate many rheumatic diseases. CONCLUSIONS: Knowledge of the increased propensity for neoplasia in certain conditions and of the possibility that cancer may be the cause of specific rheumatologic syndromes will assist the physician in providing optimal clinical care to affected patients.

Ovarian cancer and gangrene of the digits: case report and review of the literature

Digital ischemia has been reported with various types of cancer, especially gastrointestinal. It is more common in elderly women than in any other group, and the most common symptom is a gangrenous finger (or fingers). More than half of the patients have metastatic involvement. Once the primary disease has been treated, when feasible, the digital symptoms usually regress or disappear. The presence of digital ischemia without other rheumatologic stigmata or vascular predisposition in an elderly patient should raise clinical suspicion of a paraneoplastic phenomenon. Herein we describe a 65-year old woman with digital ischemia associated with ovarian cancer. The diagnosis was established by biopsy after extremely high levels of cancer antigen 125 were detected.

Nuclear domain 10 (ND10) associated proteins are also present in nuclear bodies and redistribute to hundreds of nuclear sites after stress

The promyelocytic leukemia protein fused to the retinoic acid receptor alpha in t(15;17) acute promyelocytic leukemia, the primary biliary cirrhosis autoantigen, Sp100, as well as the incompletely characterized protein NDP55, are co-localized in specific immunohistochemically defined nuclear domains (ND10), which are potential equivalents of ultrastructurally defined nuclear bodies. We investigated whether the distribution of these proteins depends on environmental conditions and whether ND10 correlate with nuclear bodies. Certain nuclear bodies and ND10 react in a similar way and share antigens. Interferon exposure doubled the number of ND10 and increased the frequency of nuclear bodies, whereas herpes simplex virus infection or heat shock modify both. Redistribution of ND10-associated proteins to hundreds of small sites throughout the chromatin was inducible by stress in the form of heat shock and exposure to Cd++ ions. The change of distribution was rapid and independent of protein synthesis, and thus not part of the classical heat shock response. The very rapid redistribution of these proteins after heat shock, together with the development of ND10 upon interferon activation, raises the possibility that ND10 represent storage sites of certain matrix proteins readily accessible throughout the chromatin in response to stress or other effectors that induce global nuclear changes.

A patient with a high titer of antinuclear antibody and a functioning adrenal tumour

Reported is the case of a 60-year-old female who was referred to our rheumatology center because of a high titer of antinuclear antibodies (ANAs). Initially several lupus-like features suggested a diagnosis of undifferentiated connective tissue disease (UCTD). Immunofluorescence of the patient's serum showed a nuclear dot pattern. Counterimmunoelectrophoresis for antibodies to Sm, RNP, SS-A and SS-B were negative. Immunoblotting revealed a band at 53 kD which did not correspond to known autoantigens. Several months later the patient presented to the emergency room with symptoms due to a hypertensive crisis. Check-up finally revealed a cortisone-producing tumour of the right adrenal gland. The adenoma was removed by surgery and the patient did well again.

A case of Burkitt's lymphoma presenting with digital ischaemia

Paraneoplastic syndromes are rare in paediatric oncology. This report describes a four-year-old Cantonese child whose sole presenting symptom was acrocyanosis who was found to have Burkitt's lymphoma in association with the presence of positive antinuclear antibodies, antineutrophil cytoplasmic antibodies, antiendothelial antibodies and elevated serum immunoglobulin G concentrations. Digital ischaemia has not been described as a presenting symptom of Burkitt's lymphoma, although this association has been reported in 25 patients with other malignancies.

Multiple nuclear dots antinuclear antibodies are not specific for primary biliary cirrhosis

Multiple nuclear dots antinuclear antibodies display a specific immunofluorescence pattern on HEp-2 cells. They have been reported to be strongly associated with primary biliary cirrhosis, especially when sicca syndrome was present. To determine whether multiple nuclear dots antinuclear antibodies are specific for primary biliary cirrhosis, we studied the clinical, biochemical, immunological and morphological features of 38 patients between December 1983 and September 1990 who had serum multiple nuclear dots antinuclear antibodies detected in an immunology laboratory of a large medical center. Sufficient information was reliable in 36 patients; the group included 31 women and 5 men (mean age = 57.6 +/- 14.5, range = 30 to 87). Fifteen patients (42%) had primary biliary cirrhosis, 5 patients (14%) had type 1 autoimmune chronic active hepatitis, 4 patients (11%) had liver disease of unknown cause and 12 patients (33%) had various immunological disorders but no liver disease. Two of the patients with primary biliary cirrhosis (13%) had clinical sicca syndrome. Our study demonstrates the following: (a) serum multiple nuclear dots antinuclear antibodies are not specific for liver disease because they can be observed in one third of patients with various immunological disorders without liver involvement, and (b) serum multiple nuclear dots antinuclear antibodies are not specific for PBC because they can also be observed in type 1 autoimmune chronic active hepatitis. Our results also suggest that patent sicca syndrome is abnormally present in patients with primary biliary cirrhosis and multiple nuclear dots antinuclear antibodies.

Seronegative inflammatory arthritis in the myelodysplastic syndromes

The myelodysplastic syndromes (MDS) are a group of therapeutically refractory anemias resulting from a clonal stem cell disorder often associated with cytogenetic abnormalities. Immunologic abnormalities and occasionally vasculitis have been reported although no series has characterized an associated arthritis. All cases of MDS diagnosed in 1990 by bone marrow biopsy and followed up at the authors' institution were reviewed. Of the 28 consecutive patients, 8 had acute seronegative inflammatory arthritis temporally related to the initial discovery of cytopenia. Five patients had a symmetric polyarthritis resolving only with use of steroids or upon evolution to leukemia, and 3 had episodes of oligoarthritis with systemic features including fever, pleuritis, pericarditis, and hemolytic anemia. Arthrocenteses in 2 cases did not show crystals or infection. Serological studies were nondiagnostic. The arthritis and systemic features responded to steroids in all 5 treated patients. Inflammatory arthritis appears to be common in MDS. Most compelling is the apparent bone marrow response to steroids in 2 cases, possibly identifying a treatable subgroup.

Positive antinuclear antibodies in malignancies

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Conjunctival ulceration in Behçet's syndrome

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Immunological and ultrastructural studies of the nuclear coiled body with autoimmune antibodies

Studies with human autoimmune sera identified auto-antibodies reacting with a novel antigen of 80 kDa. In interphase mammalian cells, the 80-kDa antigen was enriched in nuclear coiled bodies and was used as a marker for this nuclear structure. This antigen was subsequently named p80-coilin. By light and electron microscopic immunocytochemistry, a number of other antigens were also localized to the coiled body, including components of small nuclear ribonucleoproteins which are involved in the processing of nucleolar and extranucleolar RNA. Although the function of the coiled body is unknown, the presence of these subcellular particles might indicate an involvement in RNA metabolism. The identification of a protein highly enriched in this structure and the availability of specific antibodies might help in its isolation and the study of its function.

Human autoantibody to a novel protein of the nuclear coiled body: immunological characterization and cDNA cloning of p80-coilin

Antibodies producing an unusual immunofluorescent pattern were identified in the sera of patients with diverse autoimmune features. This pattern was characterized by the presence of up to six round discrete nuclear bodies in interphase cell nuclei. Immunoblotting analysis showed that these sera recognized an 80-kD nuclear protein, and affinity-purified anti-p80 antibody from the protein band reproduced the fluorescent staining of nuclear bodies. Colloidal gold immunoelectron microscopy showed that the affinity-purified anti-p80 antibody recognized the coiled body, an ultramicroscopic nuclear structure probably first described by the Spanish cytologist Ramon y Cajal. Five cDNA clones were isolated from a MOLT-4 cell lambda gt-11 expression library using human antibody and oligonucleotide probes. The longest cDNA insert was 2.1 kb and had an open reading frame of 405 amino acids. A clone encoding a 14-kD COOH-terminal region of the protein was used for expression of a beta-galactosidase fusion protein. An epitope was present in this COOH-terminal 14-kD region, which was recognized by 18 of 20 sera with anti-p80 reactivity, and affinity-purified antibody from the recombinant protein also reacted in immunofluorescence to show specific staining of the coiled body. This is the first demonstration and molecular cloning of a protein that appears to have particular identification with the coiled body, and it was designated p80-coilin. Autoantibody to p80-coilin may be useful for the elucidation of the structure and function of the coiled body, and the availability of a cDNA sequence could be helpful in further studies to clarify the clinical significance of this autoantibody response.

Identification of a novel nuclear domain

For most known nuclear domains (ND), specific functions have been identified. In this report we used murine mAbs and human autoantibodies to investigate precisely circumscribed structures 0.2-0.3 micron in diameter which appear as "nuclear dots" distributed throughout the nucleoplasm. Nuclear dots are metabolically stable and resistant to nuclease digestion and salt extraction. The localization of nuclear dots is separate from kinetochores, centromeres, sites of mRNA processing and tRNA synthesis, nuclear bodies, and chromosomes. The nuclear dots, therefore, represent a novel ND. Nuclear dots break down as cells enter metaphase and reassemble at telophase. In interphase cells, nuclear dots are frequently "paired," and some are visible as "doublets" when stained with one particular antiserum. The number of dot doublets increased when quiescent cells were stimulated with serum although the total number of dots did not change substantially. One of the antigens was identified as a protein with a molecular mass of approximately 55 kD showing three charge isomers in the pI range of 7.4 to 7.7. Autoantibodies affinity purified from this nuclear dot protein (NDP-55) show nuclear dots exclusively. Nuclear dot-negative rat liver parenchymal cells became positive after chemical hepatectomy, suggesting involvement of the NDP-55 in the proliferative state of cells.

Raynaud's phenomenon and positive antinuclear antibodies in a malignancy

Both Raynaud's phenomenon and the presence of antinuclear antibodies are uncommon features of malignant disease and the association of both with a malignancy extremely rare. The case is reported of a 78 year old woman who presented with Raynaud's phenomenon and positive antinuclear antibodies related to adenocarcinoma of unknown primary site.