[Antidiarrheal drugs for chronic diarrhea]

Chronic diarrhea can be caused by multiple disease entities. Basic diagnostic tests are required in order to administer specific therapies whenever possible. If no specific treatment can be used, a symptomatic management should be initiated in order to prevent massive electrolyte- and water losses. Substances that can be used are loperamide, cholestyramine, bulking agents, probiotics, anticholinergic agents and in severe cases opioids. If used properly these agents can be prescribed longterm with an acceptable side effect profile.

S3-guideline "helicobacter pylori and gastroduodenal ulcer disease" of the German society for digestive and metabolic diseases (DGVS) in cooperation with the German society for hygiene and microbiology, society for pediatric gastroenterology and nutrition e. V., German society for rheumatology, AWMF-registration-no. 021 / 001

This guideline updates a prior consensus recommendation of the German Society for Digestive and Metabolic Diseases (DGVS) from 1996. It was developed by an interdisciplinary cooperation with representatives of the German Society for Hygiene and Microbiology, the Society for Pediatric Gastroenterology and Nutrition (GPGE), and the German Society for Rheumatology. The guideline is methodologically based on recommendations of the Association of the Scientific Medical Societies in Germany (AWMF) for providing a systematic evidence-based S 3 level consensus guideline and has also implemented grading criteria according to the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) process. Clinical applicability of study results as well as specifics for Germany in terms of epidemiology, antibiotic resistance status, diagnostics, and therapy were taken into account.

In vivo diagnosis of acute intestinal graft-versus-host disease by confocal endomicroscopy

BACKGROUND AND STUDY AIMS

Conventional histology with hematoxylin and eosin (H&E) staining is the accepted standard for diagnosing acute intestinal graft-versus-host disease (GvHD). Confocal endomicroscopy (CEM) is a noninvasive method that allows in vivo histology to be performed during endoscopy. The aim of this study was to evaluate CEM for the diagnosis of acute intestinal GvHD.

PATIENTS AND METHODS

This observational pilot study conducted between September 2006 and August 2008 included patients with acute diarrhea after stem cell transplantation, infectious diarrhea, or active ulcerative colitis. CEM (EC-3870CIFK, Pentax, Tokyo, Japan) was performed after intravenous injection of fluorescein 10% and topical application of acriflavine 0.05%.

RESULTS

A total of 35 patients with acute diarrhea after stem cell transplantation were examined. In 16 patients, CEM and histology showed no evidence of GvHD. In 14/19 patients with histologically confirmed GvHD, the diagnosis could already be established by CEM during ongoing endoscopy. In GvHD grade IV, near complete destruction of the colonic crypts ("flat mucosa") was visible. Control patients with infectious colitis (N = 15) or ulcerative colitis (N = 15) displayed inflammatory changes but no evidence of GvHD. Altogether, sensitivity of CEM was 74% and specificity was 100 %.

CONCLUSIONS

CEM improves rapid diagnosis of acute intestinal GvHD with high accuracy while performing endoscopy. Platelet transfusions and unnecessary biopsy acquisition can be avoided once acute intestinal GvHD has been diagnosed in vivo.

[S3-guideline "Helicobacter pylori and gastroduodenal ulcer disease"]

This guideline updates a prior concensus recommendation of the German Society for Digestive and Metabolic Diseases (DGVS) from 1996. It was developed by an interdisciplinary cooperation with representatives of the German Society for Microbiology, the Society for Pediatric Gastroenterology and Nutrition (GPGE) and the German Society for Rheumatology. The guideline is methodologically based on recommendations of the Association of the Scientific Medical Societies in Germany (AWMF) for providing a systematic evidence-based consensus guideline of S 3 level and has also implemented grading criteria according to GRADE (Grading of Recommendations Assessment, Development and Evaluation). Clinical applicability of study results as well as specifics for Germany in terms of epidemiology, antibiotic resistance status, diagnostics and therapy were taken into account.

CD2 deficiency partially prevents small bowel inflammation and improves parasite control in murine Toxoplasma gondii infection

AIM: To investigate whether bowel inflammation and/or parasite control is altered in the absence of the T cell adhesion molecule CD2.

METHODS: Wildtype (WT) and CD2 deficient (CD2^-/-) mice were infected with 100 cysts of Toxoplasma gondii (T. gondii) (ME49) by gavage. On d 7 after infection mice were killed. Necrosis and the number of parasites/cm ileum were determined. Cytokine levels of stimulated cells as well as sera were evaluated. Secondly, survival of WT vs CD2^-/- mice was analysed using Kaplan-Meier analysis.

RESULTS: CD2^-/- mice survived longer than WT mice (mean: 23.5 vs 7.1 d, P = 0.001). Further, CD2^-/- mice showed less weight loss and less ileal inflammation than WT mice at d 7 post infection. In addition, the number of parasites in the ileum was significantly lower in CD2^-/- mice than in WT mice (88 ± 12 vs 349 ± 58 cm, P < 0.01). This was paralleled by lower production of IFN-γ and IL-6 from TLA-stimulated mLN cells and increased IFN-γ production by splenocytes.

CONCLUSION: CD2 deficient mice are more resistant to T. gondii infection than WT mice. In contrast to most current immunosuppressive or biological therapies CD2 deficiency reduces intestinal inflammation and at the same time helps to control infection.

Ungewöhnlicher Fall einer akuten oberen gastrointestinalen Blutung: PEG-Implantationsmetastase eines Ösophaguskarzinoms - Fallbericht und Literaturübersicht

We present the case of a patient with an esophageal squamous cell carcinoma, who was treated primarily by radiotherapy. Due to dysphagia, the patient received a percutaneous endoscopic gastrostomy (PEG) without any sign of tumour at that time. Five months later the patient presented with an upper GI bleeding from a gastric ulcer, which histologically turned out to be a metastasis of the previously diagnosed squamous cell carcinoma. So-called "implantation metastases" at the percutaneous endoscopic gastrostomy site are rare and most of the cases have been described in patients with head and neck tumours. Moreover, the presentation as an upper GI bleed is very uncommon and needs the attention of both endoscopists as well as gastrointestinal oncologists. Clinicopathological features of this case with a brief review of the literature are presented.

[Quality of life assessment in Inflammatory Bowel Disease (IBD): German version of the Inflammatory Bowel Disease Questionnaire (IBDQ-D; disease-specific instrument for quality of life assessment) -- first application and comparison with international investigations]

BACKGROUND

Health-related quality of life (HRQOL) is an important outcome-parameter in health research and care. The aim of the working group Quality of Life in the Competence Network Inflammatory Bowel Disease (IBD; in the original German: "Kompetenznetz chronisch entzündliche Darmerkrankungen") is to generate instruments for assessment of HRQOL and its implementation as standards in clinical trials, health care and research in IBD.

METHODS

The Inflammatory Bowel Disease Questionnaire (IBDQ) is an international validated disease specific instrument for HRQOL-assessment. A German version of the IBDQ was elaborated and tested in 415 outpatients with Crohn's disease (CD, n = 306) and ulcerative colitis (UC, n = 109). The aim of the study was to compare the results of HRQOL-assessment (IBDQ-D) with international investigations, to correlate HRQOL results with disease activity and to preform a pretest of psychometric properties.

RESULTS

International data suggest that the IBDQ-D is a suitable instrument for HRQOL-assessment in CD and UC. For both disease a statistically significant negative correlation with disease activity was found. Tested psychometric properties do not suggest that a revision of the IBDQ-D is required. The IBDQ-D offers the HRQOL-assessment as an primary or secondary outcome in clinical trials in IBD in Germany.

Unusual case of a large midoesophageal diverticulum mimicking unstable angina pectoris

We describe a 77-year-old lady who presented with progressive retrosternal pain radiating to the left arm and the back. After exclusion of cardiac causes a large midoesophageal diverticulum was found on oesophago-gastro-duodenoscopy. Importantly, the retrosternal pain completely disappeared after endoscopic removal of impacted food from the diverticulum. After the surgical resection the patient became fully asymptomatic. This is the first example of angina-like chest pain which definitively resulted from a midoesophageal diverticulum. Therefore, midoesophageal diverticula should be considered as a rare differential diagnosis of exercise-induced retrosternal pain.

Migration of T cells in vivo: molecular mechanisms and clinical implications

T cells play an important role in the pathogenesis of chronic and autoimmune inflammatory diseases. They are found in high numbers in involved tissues, such as the lamina propria of the gut in patients with Crohn disease. Modifying T-cell number and function may therefore be of therapeutic value. In principle, two mechanisms may be responsible for the development of such T-cell infiltrates: 1) an increased rate of T-cell immigration into involved tissues or 2) an increased proliferation rate, decreased T-cell death (apoptosis) rate, and prolonged retention of T cells already in the tissue. Based on the theory that T cells selectively target affected tissues through organ-specific adhesion-molecule pathways, current anti-adhesion-molecule therapy aims to interfere selectively with T-cell entry to stop tissue damage. However, the traffic of labeled T cells in unmanipulated animals shows that the entry of T-cell subsets into tissues is not organ-specific, even under conditions of differing adhesion molecule and chemokine receptor expression. In contrast, within various tissues, both movement and survival of T-cell subsets differ considerably. These observations suggest that the differential expression of adhesion molecules and chemokine receptors on T cells serves at least two functions in vivo. First, during migration of T cells out of the bloodstream, the different adhesion-molecule pathways provide redundancy, which guarantees that T-cell subsets are able to enter the different tissues in sufficient numbers (security). Second, adhesion molecules and chemokine receptors mediate T-cell interactions within the tissue that are characteristic for each subset and each microenvironment and determine the nature of the ensuing immune response (selectivity). Shifting the focus of anti-adhesion-molecule therapy toward the T cells in diseased tissue may lead to new treatment options.

Role of T lymphocytes in rat 2,4,6-trinitrobenzene sulphonic acid (TNBS) induced colitis: increased mortality after gammadelta T cell depletion and no effect of alphabeta T cell depletion

BACKGROUND AND AIM

Indirect evidence suggests that CD4+ T cells have a pathogenic while gammadelta T cells have a protective role in the initiation and perpetuation of inflammatory bowel disease. To define the role of T cell subsets in a rat colitis model (2,4,6-trinitrobenzene sulphonic acid (TNBS)) we analysed colitis severity after effective depletion of T helper cells, alphabeta T cells, or gammadelta T cells.

METHODS

T helper cells, alphabeta T cells, or gammadelta T cells were depleted using previously described monoclonal antibodies directed at the CD4 molecule (OX38), the CD2 molecule (OX34, both depleting CD4+ T cells), the alphabeta T cell receptor (R73), and the gammadelta T cell receptor (V65). Depletion was verified by flow cytometry and/or immunohistology. Colitis was induced using intracolonic application of TNBS.

RESULTS

Surprisingly, depletion of T helper cells or alphabeta T cells had no influence on survival, macroscopic or microscopic scores, or myeloperoxidase activity following colitis induction. In contrast, depletion of gammadelta T cells resulted in significantly increased mortality (V65: 73%, n=15) compared with controls (30%, n=13; p<0.03). In addition, colitis was histologically more severe in the gammadelta T cell depleted group compared with controls (p<0.05).

CONCLUSIONS

T helper cells or alphabeta T cells did not influence the initiation or perpetuation of rat TNBS colitis. In contrast, gammadelta T cells had a protective role in rat TNBS colitis as depletion caused increased mortality.

Intestinal obstruction, progressive weight loss, and recurrent fever in two patients with mesenteric lesions

We describe 2 patients who presented with fever and incomplete intestinal obstruction. Previously, both patients had had laparotomies showing unresectable lesions in the root of the mesentery which were histologically diagnosed as sclerosing mesenteritis in the first and mesenteric fibromatosis in the second patient. In spite of aggressive immunosuppressive therapy the first patient deteriorated with high-grade fever and progressive weight loss. Similar symptoms occurred in the second patient. Computed tomographic scanning revealed necrotic lesions in both patients which histologically were found to be an angiocentric T-cell lymphoma in the first and a superinfected necrotizing fibroma in the second patient. It is therefore clinically and radiologically impossible to distinguish between the different causes of mesenteric lesions. Reoperation for further biopsies needs to be considered if such patients do not respond to medical treatment.

Treatment of Crohn's disease

The treatment of Crohn's disease depends on disease location and disease activity. It can be divided into medical and surgical treatment. While surgery is reserved for complications such as abscesses or failure of pharmacological treatment (fistulae, perianal disease, or strictures) medical treatment aims at induction and maintenance of remission. In order to achieve these goals supportive and therapeutic strategies must be used. Supportive measures include substitution of vitamins, particularly fat-soluble vitamins, and minerals in deficiencies due to resection or disease involvement of the small bowel. All patients on long-term steroids should receive calcium and vitamin D in order to prevent osteoporosis. Therapeutic options include drug treatment (corticosteroids, antibiotics, salicylates, and immunosuppressives), nutrition (parenteral or enteral), and endoscopy (dilatation of strictures). Depending on disease location different pharmacologic preparations of salicylates or corticosteroids should be used, e.g., enemas for distal colitis. The most potent drugs for long-term control are immunosuppressive agents, particularly azathioprine. It is the most widely investigated immunosuppressive agent in Crohn's disease and should be the first line treatment for patients with steroid refractory, chronic steroid dependent, fistulating, and stenosing courses. In the future, more potent drugs and better risk stratification criteria should improve the treatment of Crohn's disease.

Protection of trinitrobenzene sulfonic acid-induced colitis by an interleukin 2-IgG2b fusion protein in mice

BACKGROUND & AIMS

We have shown in previous studies that an interleukin 2 (IL-2)-IgG2b fusion protein suppresses both humoral and cellular immune reactions in a murine model of DTH reaction. We now analyze the effects of IL-2-IgG2b in a model of intestinal inflammation in mice induced by the hapten reagent 2,4, 6-trinitrobenzene sulfonic acid (TNBS) that mimics immunologic characteristics of human Crohn's disease.

METHODS

In TNBS-induced colitis, colonic and splenic T-cell subsets were characterized by immunohistochemistry and flow cytometry. Cytokine synthesis was studied by semiquantitative reverse-transcription polymerase chain reaction and intracellular cytokine staining in CD4(+) T cells.

RESULTS

When mice were treated with IL-2-IgG2b, improvement in both wasting disease and histopathologic signs of colonic inflammation was observed. An increase in the number of colonic CD4(+)/CD25(+) T cells and increased synthesis of the immunosuppressive cytokine IL-10 also occurred. The protective role of IL-10 was demonstrated by the finding that neutralization of IL-10 in vivo using IL-10-specific antibodies inhibited the IL-2-IgG2b effects in TNBS-induced colitis.

CONCLUSIONS

These studies show for the first time that the IL-2-IgG2b fusion protein can abrogate experimental colitis by local induction of IL-10-secreting T cells.

Human b cell differentiation: dependence on interactions with monocytes and T lymphocytes via CD40, CD80 (B7.1), and the CD2-Ligands CD48 and CD58 (LFA-3)

B cell differentiation depends on cellular interactions with T lymphocytes and monocytes via adhesion molecules (AM). In order to characterize AM which are required for B cell differentiation immunoglobulin production using unseparated peripheral blood mononuclear cells (PBMC) was studied. Unstimulated human PBMC were cultured for 9 days with mAb directed at CD2/CD48, /CD58, CD59, CD5/CD72, CD11a-CD18/CD54, CD28/CD80, CD86, CD40/CD40L, or rat CD2 (control). B cell differentiation was quantified measuring IgM and in some cases IgA, IgG, and IgE production. IgM levels were significantly reduced by mAb against CD40, CD48, CD58 and CD80. The reduction was not due to isotype switching to IgA, IgG or IgE. The role of CD40, CD48, CD58 and CD80 was further investigated after depletion of different cell types. Depletion of monocytes and NK cells resulted in no detectable IgM production irrespective of added mAbs. In contrast, IgM production was still present after depletion of T cells and NK cells. Only mAb against CD80 and CD48 significantly reduced IgM production, the reduction of IgM production by anti-CD40 mAb was less than in the presence of T cells. Importantly, anti-CD58 mAb had no effect on IgM production after T cell and NK cell depletion. Taken together, the AM CD40, CD48, CD58, and CD80 are involved in Ig production of unseparated PBMCs. In this model of B cell differentiation only the AM CD58 depend on the presence of T cells while CD48 and CD80 help was found to be T cell independent.

Effects of the anti-CD2 mAb OX34 on in vivo proliferation

In vitro studies indicate that CD2 plays an important role in the intestinal immune system with regard to T cell proliferation and T helper 2 differentiation. We asked whether anti-CD2 mAb induces T-cell proliferation in vivo. Rats received anti-CD2 mAb OX34 or control mAb over 3 days. Before exsanguination BrdU was injected. Lymphatic organs were processed for two-color immunohistology. OX34 depleted CD4+ but not CD8+ T cells in all organs. Remaining CD4+ T cells proliferated in the periarteriolar lymphocyte sheets. Surprisingly, OX34 led to strong proliferation of splenocytes in the red pulp. These cells were negative for markers of T cells, B cells, NK cells, macrophages, and myeloid cells. Taken together, the anti-CD2 mAb OX34 leads to proliferation of an as-yet-unidentified cell type in the red pulp of the spleen but not to proliferation of T cells.

Initiation and perpetuation of rat adjuvant arthritis is inhibited by the anti-CD2 monoclonal antibody (mAb) OX34

OBJECTIVE

The purpose of this study was to investigate the therapeutic potential of the anti-CD2 mAb OX34 first with regard to bone protection in established rat adjuvant arthritis (AA) and secondly with regard to prevention of AA induction.

METHODS

Established AA was treated with dexamethasone (1 mg/kg body weight) for two days plus OX34 mAb or control mAb over three days (2 mg and then 1 mg) starting at different time points of the disease. For prevention studies animals were injected as above with mAb before induction of AA. Arthritis score (AS), hindpaw thickness, and body weight were blindly measured three times per week. Flow cytometry and hindpaw radiography were performed at the end of the study (day 29).

RESULTS

Treatment of early AA with OX34 mAb combined with dexamethasone but not dexamethasone plus control mAb dramatically suppressed established AA as assessed by AS and hind paw thickness (> 65% and > 80% reduction, respectively; p < 0.05). Most importantly, early treatment in the course of AA almost completely prevented bone destruction in established AA. When given before AA induction OX34 alone prevented the initiation of arthritis compared with controls (AS reduction 83-95%, p < 0.05). In addition, OX34 plus dexamethasone treatment resulted in depletion of CD4+ T cells but not CD8+ T cells. IL2R+ and CD45RC- ('memory') T cells were significantly reduced.

CONCLUSIONS

Anti-CD2 mAb treatment prevents AA induction confirming the role of CD4+ T cells in the induction phase of AA. In addition, early OX34 plus dexamethasone treatment resulted in pronounced clinical improvement and joint protection. OX34 treatment therefore inhibits the initiation and the perpetuation of rat AA.

Anti-CD2 (OX34) MoAb treatment of adjuvant arthritic rats: attenuation of established arthritis, selective depletion of CD4+ T cells, and CD2 down-modulation

Anti-CD2 MoAbs have previously been shown to induce tolerance and to block B cell differentiation, T cell and monocyte activation. Since these immune functions are important in joint inflammation, we asked whether administration of the anti-CD2 MoAb OX34 has a beneficial effect on established rat adjuvant arthritis, a model of human rheumatoid arthritis, and how it affects CD2-bearing leucocyte subsets. Female Lewis rats with established adjuvant arthritis received a total of 5 mg OX34 or isotype-matched control MoAb starting on day 15 after adjuvant injection. Weight and arthritis score (AS) were measured in a blinded fashion. Peripheral blood cells were analysed for numbers of leucocyte subsets at various time points. Animals were killed on day 30 and lymphatic organs were processed for immunohistology. Clinically, OX34 treatment led to increased body weight and reduced AS. Although OX34 binds to CD4+ and CD8+ T cells in a comparable fashion, OX34 treatment reduced CD4+ T cells, but not CD8+ T cells. Among CD4+ T cells CD45RC+ ('naive') T cells virtually disappeared; CD45RC- ('recently activated') T cells were slightly reduced. A reduction of CD4+ T cells was also found in the lung, liver, bone marrow, spleen and lymph nodes. Down-modulation of the CD2 molecule by OX34, again, affected CD4+ T cells, suggesting a specific signal for CD4+ but not CD8+ T cells. In conclusion, the anti-CD2 MoAb OX34 attenuates established rat adjuvant arthritis. In spite of similar binding to CD4+ and CD8+ T cells, OX34 depletes only CD4+ T cells and down-modulates the CD2 molecule on these cells. These results suggest a therapeutic benefit from CD2-directed therapy for chronic types of arthritis.

Elevated serum concentrations of soluble selectin and immunoglobulin type adhesion molecules in patients with inflammatory bowel disease

Adhesion molecules mediate the extravasation of leukocytes and their accumulation in inflamed tissues. In the present study, serum concentrations of the selectin (sP- and sE-selectin) and immunoglobulin supergene family (sICAM-1 and sVCAM-1) of adhesion molecules were measured in 93 patients with inflammatory bowel disease (Crohn's disease, n = 65; ulcerative colitis, n = 28) and 58 age-matched normal controls. sP-selectin serum concentrations (mean +/- SEM ng/ml) of patients with Crohn's disease (399 +/- 33 ng/ml) and ulcerative colitis (385 +/- 42 ng/ml) were increased (P = 0.0067 and P = 0.0193, respectively) compared to controls (251 +/- 33 ng/ml). In contrast, E-selectin serum levels of patients with Crohn's disease (58 +/- 5 ng/ml) and ulcerative colitis (64 +/- 12 ng/ml) were not significantly higher than those of controls (53 +/- 5 ng/ml). sICAM-1 serum concentrations of patients with Crohn's disease (420 +/- 19 ng/ml) and those with ulcerative colitis (375 +/- 40 ng/ml) were elevated (P = 0.0001 and P = 0.0473, respectively) compared to controls (297 +/- 8 ng/ml). Further, sVCAM-1 levels of patients with Crohn's disease (664 +/- 43 ng/ml) and ulcerative colitis (963 +/- 162 ng/ml) were increased (P = 0.0222 and P = 0.0121, respectively) compared to controls (510 +/- 31 ng/ml). With few exceptions, serum levels of soluble adhesion molecules were not significantly correlated to disease activity indices or disease localization. Elevated circulating selectin and immunoglobulin supergene type adhesion molecules may compete with membrane-bound forms for their cognate ligands and thereby limit the rolling and stable adhesion of leukocytes.

Detection of a soluble form of the human adhesion receptor lymphocyte function-associated antigen-3 (LFA-3) in patients with chronic liver disease

BACKGROUND/AIMS

Multiple immune functions, such as cytotoxic reactions, B cell differentiation, and monocyte activation, are mediated via the adhesion receptor/ligand pairs CD2/lymphocyte function-associated antigen(LFA)-3 and LFA-1/ intercellular adhesion molecule(ICAM)-1. Since soluble forms of LFA-3 (sLFA-3) and ICAM-1 (sICAM-1) can interfere with these functions, we asked whether increased levels of sLFA-3 can be found in patients with different forms of chronic liver disease and/or hepatocellular carcinoma.

METHODS

sLFA-3 was measured in sera from 84 patients with chronic liver disease (39 with chronic viral liver disease, 30 with autoimmune liver disease, 12 with alcoholic cirrhosis, 3 with other causes of cirrhosis), 24 patients with hepatocellular carcinoma (15 with and 9 without cirrhosis), and 61 normal controls. From 36 of the patients with liver cirrhosis, arterial and hepatic venous serum samples were simultaneously obtained and tested for sLFA-3 and sICAM-1.

RESULTS

In comparison to controls, sLFA-3 levels were elevated in patients with liver cirrhosis due to autoimmune liver disease (p < 0.0001) and viral liver disease (p = 0.001), but not in patients with alcoholic cirrhosis. Increased sLFA-3 levels were also found in patients with hepatocellular carcinoma and liver cirrhosis. However, sLFA-3 was not significantly elevated in sera from patients with autoimmune liver disease, viral liver disease, and hepatocellular carcinoma without concomitant liver cirrhosis. No difference was found between arterial and hepatic venous serum levels of sLFA-3 and sICAM-1. sLFA-3 levels correlated positively with aspartate transaminase, alkaline phosphatase, bilirubin, sICAM-1, and inversely with albumin and cholinesterase.

CONCLUSIONS

Taken together, sLFA-3 serum concentrations of patients with liver cirrhosis due to autoimmune liver disease or viral liver disease and of patients with hepatocellular carcinoma and cirrhosis are significantly increased compared to controls. Elevated sLFA-3 and sICAM-1 levels might reflect the generalized inflammation in cirrhosis and by interference with cell-cell interactions sICAM-1 and sLFA-3 may limit the extent of inflammation.

Reduced serum levels of a soluble form of the human adhesion receptor CD58 (LFA-3) in patients with inflammatory bowel disease

The activation of monocytes, neutrophils, and B cells by T-lymphocytes appears to play a pivotal role in the pathophysiology of inflammatory bowel disease. The pan T cell marker CD2 and its ligand CD58 mediate these immune function. We asked whether serum levels of a soluble form of CD58 is altered in patients with inflammatory bowel disease. Soluble CD58 was measured in sera from 41 patients with Crohn's disease, 19 patients with ulcerative colitis, and 24 normal controls. Soluble CD58 levels were significantly decreased in sera from patients with ulcerative colitis and even more with Crohn's disease when compared to controls (p = 0.025 and p < 0.0001, respectively). Reduction of soluble CD58 serum levels correlated significantly with various humoral (e.g. erythrocyte sedimentation rate: r = -0.48, p = 0.0002) and clinical parameters of disease activity (e.g. CDAI: r = -0.44, p = 0.005). In conclusion, serum levels of soluble CD58 are reduced in patients with inflammatory bowel disease. Since soluble CD58 can block the CD2/CD58 interaction further studies have to show whether the reduction of soluble CD58 in patients with inflammatory bowel disease contributes to T cell adhesiveness in the mucosa.

Detection of soluble adhesion molecules in pleural effusions

PURPOSE

Multiple immune functions such as activation of T cells and monocytes or cytolysis of tumor cells are mediated via the adhesion receptor/ligand pairs CD2/LFA-3 and LFA-1/ICAM-1. Because soluble forms of LFA-3 (sLFA-3) and ICAM-1 (sICAM-1) can interfere with these functions, we asked whether increased levels of sLFA-3 and/or sICAM-1 can be found in malignant or inflammatory effusions compared with transudates.

METHODS

sLFA-3 and sICAM-1 levels were measured by enzyme-linked immunoassays in pleural effusions from 70 patients (6 transudates, 10 inflammatory, 47 malignant, and 7 other effusions). Twenty pleural fluid samples were tested in parallel for the complete sLFA-3 molecule or sLFA-3-domain 1 only.

RESULTS

Increased levels of sICAM-1 were found in all types of exudates compared with transudates. Highest levels of sICAM-1 were measured in malignant exudates, particularly in effusions caused by mesotheliomas, non-small lung cancers, and gynecologic malignancies. This was also true for sLFA-3. However, sLFA-3 levels were not increased in inflammatory effusions. sLFA-3 levels correlated significantly with protein, cholesterol, lactate dehydrogenase, and sICAM-1 levels. Comparison of sLFA-3-domain 1 and the complete sLFA-3 molecule revealed identical sLFA-3 levels, suggesting the absence of nonfunctional split products.

CONCLUSIONS

Elevated levels of the complete sLFA-3 molecule were found in malignant pleural effusions, while sICAM-1 level was elevated in both inflammatory and malignant effusions. Secretion of sICAM-1 and sLFA-3 by tumor cells might block T-cell-mediated immune functions such as tumor cytotoxicity. Alternatively, secretion of soluble adhesion molecules might reflect the generalized inflammation within the pleural space.

Characterization of a soluble form of CD58 in synovial fluid of patients with rheumatoid arthritis (RA)

Reduced levels of a soluble form of the adhesion receptor and CD2 ligand CD58 (sCD58) were previously described in RA patients. In order to understand the biological significance of this finding we biochemically characterized sCD58 in RA and asked how well sCD58 binds to CD2. sCD58 concentrations were measured in serum and synovial fluid (SF) samples of RA patients by two ELISAs, one detecting domain 1 of CD58 (CD58-D1), and the other one the complete molecule (CD58-D1 + D2). Small amounts of split sCD58-D1 were found in most RA sera, but not SF. In addition, split sCD58-D2 was detected in SF by affinity chromatography, SDS-PAGE, and Western blotting. Gel filtration gave similar peaks at 95-125 kD for RA sera, SF, and normal serum. Binding of SF-sCD58 to the CD2+ Jurkat variant JBB1 or recombinant CD2 was stronger than urinary sCD58 and reached binding of oligomeric recombinant CD58 at low concentrations. In conclusion, sCD58-split products were found in RA sera and SF. At concentrations as they occur in vivo, SF-sCD58 binds to CD2 much more strongly than urinary sCD58. It is conceivable that locally released sCD58 blocks the CD2/CD58 interaction under physiological conditions. Insufficient release of sCD58, e.g. in synovitis, might result in T cell accumulation and perpetuation of inflammation.

Decreased levels of a soluble form of the human adhesion receptor CD58 (LFA-3) in sera and synovial fluids of patients with rheumatoid arthritis

OBJECTIVE

Soluble forms of adhesion molecules (sAM) can block cellular interactions and potentially prevent the adhesion of mononuclear cells to inflammatory tissue. We therefore wondered whether levels of a soluble form of the CD2-ligand CD58 (sCD58) are decreased in patients with different types of joint disease.

METHODS

SCD58 concentrations were measured by an enzyme-linked immunosorbent assay (ELISA) of sera from 60 patients with rheumatoid arthritis (RA), 13 patients with osteoarthritis (OA), 16 patients with psoriatic arthropathy (PsA), 15 patients with spondylarthropathy (SpA), and 61 age-matched normal controls (NC). SCD58 was also determined in synovial fluid samples (SF) from 42 patients with RA, 12 with PsA, and 12 with SpA. Concentrations of sCD58 were correlated with clinical and laboratory measures of disease activity. Binding of biotinylated human albumin to recombinant CD58 or casein was assessed by a modified ELISA:

RESULTS

SCD58 levels were significantly reduced in sera from RA patients compared to NC (p < 0.0001), OA (p = 0.019), and SpA (p < 0.0001). Normal concentrations were found in sera from patients with OA, PsA, or SpA. SF sCD58 concentrations were generally lower than serum concentrations (between 18 and 28%). RA SF had significantly lower sCD58 levels than SpA SF (p = 0.01). Reduction of serum sCD58 levels correlated significantly with the ESR (r = 0.56; p < 0.0001), CRP (r = 0.4; p = 0.003), and TJS (r = 0.47; p = 0.0001). In addition, sCD58 serum levels correlated significantly with the reticulocyte count (r = 0.47; p = 0.02) and serum albumin (r = 0.42; p = 0.002). Accordingly, biotinylated human albumin bound to recombinant CD58 in a dose dependent fashion, but not to casein.

CONCLUSION

This study indicates that serum and SF sCD58 levels in patients with RA are reduced compared to the levels in normal controls and patients with OA or SpA. Decreased albumin concentrations due to systemic inflammation may lead to reduced sCD58 levels. Since sCD58 may normally mediate de-adhesion, such a reduction could result in increased T cell adhesiveness.

Lyme disease in a 74-year-old forest owner with symptoms of dermatomyositis

We describe a 73-year-old forest owner with widespread erythema, myalgia, and proximal muscle weakness. The clinical signs and the results of electromyography, magnetic resonance imaging, and a muscle biopsy were consistent with dermatomyositis. However, serology was positive for Borrelia burgdorferi. More importantly, B burgdorferi DNA was detected in skin by polymerase chain reaction techniques, and spirochete-like organisms were detected in the muscle by silver staining. Lyme disease with muscle involvement can mimic or trigger dermatomyositis and should be considered in the differential diagnosis of dermatomyositis.

A soluble form of the adhesion receptor CD58 (LFA-3) is present in human body fluids

The human adhesion receptor CD58 (LFA-3) is expressed on most human cell types. Here we report on a soluble form of CD58 (sCD58) in human serum, human urine, and culture supernatants of several cell lines. sCD58 partially purified from human serum, from supernatant of the Hodgkin cell line L428, and purified sCD58 from human urine were found to have a molecular mass of 40-70 kDa under denaturating conditions (sodium dodecyl sulfate-polyacrylamide gel electrophoresis and Western blotting). However, gel filtration of sCD58 purified from human urine gave a molecular mass of 118-166 kDa, suggesting a noncovalent homotrimer conformation or its association with other molecules. Using an enzyme-linked immunosorbent assay specific for CD58 we found that sera from patients suffering from different forms of hepatitis contained elevated sCD58 levels (n = 108). Accordingly, there was a fivefold increase of supernatant sCD58 when the hepatocellular carcinoma cell line Hep G2 was incubated with 25 ng/ml recombinant tumor necrosis factor-alpha in vitro. In contrast, sCD58 serum levels of 337 additional patients suffering from various other immunological disorders were not found to be raised. At high concentrations sCD58 binds to CD2-positive cells and inhibits rosette formation of human T cells to human erythrocytes. Thus, local release of large quantities of naturally occurring sCD58 may interfere with intercellular adhesion in vivo.

Biological response modifiers render tumor cells susceptible to autologous effector mechanisms by influencing adhesion receptors

Adhesion molecules such as CD2 and its ligand CD58 (LFA-3), as well as CD11a/18 (LFA-1) and CD54 (ICAM-1) regulate not only cell to cell attachment but also participate in lymphocyte activation, recirculation, and effector function including cytolytic activity towards tumor cells. We have investigated the role of CD2/CD58 and CD11a/18/CD54 interactions in cellular immune responses directed towards freshly recovered human T cell leukemias. Downregulation of CD54 and CD58 were observed to correlate with enhanced numbers of blasts in circulation and lack of susceptibility to killing by autologous cytotoxic lymphocytes. Furthermore, culturing tumor cells with recombinant TNF-alpha conditioned medium resulted in reinduction of CD54 and CD58 expression and susceptibility to lymphocyte mediated resulted in reinduction of CD54 and CD58 expression and susceptibility to lymphocyte mediated lysis in vitro. Our findings support the view that adhesion molecules play a pivotal role for tumor cell biology in vivo and stress the point that successful immunotherapy of malignant disease may be facilitated by influencing not only the immune response itself but also adhesion molecules on the malignant tumor targets.

Structural and functional epitopes of the human adhesion receptor CD58 (LFA-3)

CD58 (LFA-3), a heavily glycosylated protein of 40-70 kDa, is expressed on a broad range of hematopoietic and non-hematopoietic cells. It serves as a physiological ligand of the CD2 receptor, present on T cells and natural killer cells, and plays, thus, an important role in lymphocyte adhesion and T cell activation through CD2. Whereas several epitopes and their respective function are known for CD2, a similarly detailed characterization of CD58 is still lacking. We raised a panel of novel murine monoclonal antibodies (mAb) against recombinant human CD58 and describe here the identification of six structurally and/or functionally distinct epitopes on the CD58 molecule. All epitopes were found to be present in equal numbers on a wide range of CD58+ cells, none of them being differentially up-regulated following cell activation or malignant transformation. Two of these epitopes represent functionally relevant sites, involved in binding of CD58 to CD2 and T cell activation via CD2. One further epitope appears to be selectively involved in CD58-mediated activation, whereas the other three displayed no functional effects. The new mAb allow for the first time the detection of CD58 in enzyme-linked immunosorbent assays and immunofluorescence while bound to its receptor CD2 in human serum or on freshly isolated blood cells. Finally, one mAb was found to specifically cross-react with T11TS, the equivalent of CD58 in sheep.

Leptomeningeal metastasis: MR imaging

Seven patients with central nervous system neoplasia and leptomeningeal metastases, proved either at initial diagnosis or on follow-up with contrast material-enhanced computed tomography (CT), were evaluated with magnetic resonance (MR) imaging. In two patients, diffuse sulcal enhancement on CT scans was inapparent on T1- or T2-weighted MR images. Likewise, in four patients diffuse cisternal enhancement on CT scans was not identifiable with MR. Nodular or focal cisternal masses were identified with both CT and MR imaging in three patients; in two, however, MR imaging provided less information. Ependymal and subependymal metastases identified with CT (two patients) were indistinguishable on MR images from periventricular abnormalities of radiation therapy and/or hydrocephalus. These findings suggest that leptomeningeal metastasis may be so subtle or inapparent as to be overlooked with MR imaging alone. Thus, CT and MR imaging should be considered complementary techniques for initial diagnosis and follow-up of tumors with a propensity for leptomeningeal metastasis.

Multiple causes of pregnancy failure in hamsters precociously ovulated by human chorionic gonadotropin

Cycling adult female hamsters can be induced to mate and ovulate 24 h early by the injection of 20 IU human chorionic gonadotropin (hCG) at 1500 h on Day 3 (day before proestrus), but pregnancy is not established. Although there is evidence of decreased sperm transport in precociously ovulated females, this does not appear to be the primary cause of infertility. Reduced size and vascularity of corpora lutea (CL) in treated females suggests incomplete or failed CL activation. Control and hCG-treated females were killed by exsanguination under ether anesthesia at intervals for the first 5 days after mating. Serum luteinizing hormone (LH), follicle-stimulating hormone (FSH), prolactin, estradiol, and progesterone were measured by radioimmunoassay. Luteinizing hormone in treated animals was very high at 2200 h on Day 1 after mating (31 h after the hCG injection), due to endogenous release, and dropped below control levels thereafter. Follicle-stimulating hormone, by contrast, was significantly lower than controls at 2200 h on Day 1 and remained low until 2200 h on Day 3 after mating. Prolactin in treated animals was not different from that in controls, except for 1000 h on Day 4, when it showed a significant dip. Estradiol in treated animals was significantly higher than in controls at 2200 h on Day 1 (when LH was also high and FSH was low), and remained high at 1000 h and 2200 h on Day 2, dropping thereafter to control levels. Progesterone was initially at control levels but had dropped significantly by 1000 h on Day 2 and remained low for the next 24 h. These results suggest that pregnancy failure is due to inadequate activation of corpora lutea. This may be due to: 1) immaturity of follicles at the time of ovulation; 2) inappropriate timing of preovulatory events; 3) the luteolytic effects of high levels of LH or estradiol or both; 4) the low level of FSH in the early stages of corpus luteum development; or 5) a combination of the above. Abnormalities of prolactin secretion were not investigated in detail but cannot be ruled out at this time.

Seasonal reproduction in the mongoose, Herpestes auropunctatus. IV. Organ weight and hormone changes in the female

The mongoose, Herpestes auropunctatus, shows a well-defined breeding season in Hawaii. In this study, females were live-trapped throughout the year and sacrificed within 48 hr to obtain information about reproductive organ weights and gonadotropin levels. Pregnant females were found from February through September and lactating females from March through October. Body weight did not change significantly throughout the year, but anterior pituitary, adrenal, ovarian, and uterine weights were significantly reduced during the nonbreeding season. LH and FSH levels were extremely variable among individuals and, although mean values were higher during the breeding than during the non-breeding season, no significant differences could be demonstrated. After castration, there was not a clearcut rise in either LH or FSH, regardless of the season of the year, when animals were followed for up to l5 days. This contrasts with the male mongoose, where FSH rose significantly by 4 days after castration in either the breeding or nonbreeding season, while LH rose more slowly in the nonbreeding season but by l0 days after castration was significantly elevated and comparable to values in males castrated in the breeding season. We conclude that the female mongoose population shows less synchrony in changes in gonadotropin levels than the males, in spite of the well-defined breeding season.

Role of daylength in the regulation of reproductive function in the male mongoose, Herpestes auropunctatus

The male mongoose, Herpestes auropunctatus, displays a distinct seasonal reproductive rhythm in environments which show minimal changes in daylength. This investigation was designed to evaluate whether the reproductive system of the male mongoose was responsive to photoperiodic manipulations. Four experiments were conducted; two during the breeding season, one during the inactive season, and one during the recrudescence phase. Serum androgen levels and reproductive organ weights were similar in males exposed to either short (6L:18D) or control photoperiods (14L:10D) when the photoperiodic adjustment was initiated in April; however, serum androgen levels were significantly depressed after 60 days exposure to short photoperiods as were weights of prostate glands when the photoperiodic manipulation was initiated in May. An increase in the number of hours of light per day during the inactive season did not affect serum androgen levels or reproductive organ weights. Exposure to a very short photoperiod (2L:22D) during the recrudescence phase delayed, but did not prevent, the increase in serum androgen levels. Although the reproductive system of the male mongoose is responsive to daylength adjustments, the response is less pronounced when compared to the effects of photoperiod in other seasonal breeders.

Pseudoaneurysm complicating superficial temporal artery--middle cerebral artery bypass

A patient with transient ischemic attacks from occlusion of a left common carotid artery was treated with common carotid endarterectomy immediately followed by superficial temporal artery-middle cerebral artery bypass. Subsequent angiography demonstrated a pseudoaneurysm formation at the anastomotic site. To our knowledge, this is the first report of this complication occurring in a human being.

Selective suppression of the primary surge of follicle-stimulating hormone in the rat: further evidence for folliculostatin in porcine follicular fluid

Charcoal-extracted porcine follicular fluid (PFF), when injected at 1200 h on proestrus, blocked the primary FSH surge seen at 1700 and at 1830 h without affecting the LH surge. In contrast, if the injection was withheld until 1330 h, the FSH surge occurred in the normal way at 1700 h but was suppressed at the 1830 h autopsy. The suppression of FSH by 0.5 ml PFF at 1200 h had abated by 0400 h of estrus. The blockade of the primary surge of FSH at 1700 and 1830 h did not prevent ovulation, nor did it prevent the expected rise in serum progesterone or fall of estradiol levels. There appears to be a latency of at least 3.5 h, when PFF is administered ip, before FSH can be suppressed. This latency occurs whether the injection is carried out in intact proestrous rats or in acutely or chronically ovariectomized females.