Anti-mumps IgM antibody positive rate with sudden sensorineural hearing loss using second-generation enzyme immunoassay: A retrospective, multi-institutional investigation in Hokkaido, Japan

OBJECTIVE

Although elevated anti-mumps IgM antibody levels were reported in 5.7%-7.2% of Japanese patients with sudden sensorineural hearing loss (SSNHL), there were several reports of false-positive cases, such as the continually IgM positive case and the IgM positive case in normal adults. To improve specificity, the new enzyme immuno assay (EIA) anti-mumps IgM antibody measurement kit was introduced in December 2009. This study re-examined the frequency of anti-mumps IgM antibody test positivity with SSNHL using the new measurement kit and compared the results with those from a previous report that used old kit.

METHODS

This is a retrospective multi-institutional study involving patients diagnosed with SSNHL who exhibited the anti-mumps IgM antibody. We compared the positive rate of anti-mumps IgM antibody and the annual average number of mumps cases per sentinel in Hokkaido between the patients in the present study and patients previously evaluated.

RESULTS

Overall, 100 patients with SSNHL were enrolled. One case (1.0%) was positive for anti-mumps IgM antibody. Of the 69 patients evaluated in the previous study, 5 cases (7.2%) were positive for anti-mumps IgM antibody. The positive rate of the anti-mumps IgM antibody in the present cases was significantly lower than that previously reported (p=0.042). The annual average number of mumps cases per sentinel in Hokkaido of the present and previous surveillance period was 34.47 and 42.77, respectively; no significant difference was seen in these data (p=0.4519).

CONCLUSION

The present study revealed that 1.0% of SSNHL was positive for the anti-mumps IgM antibody using the new EIA-IgM measurement kit. After the introduction of the new EIA-IgM measurement kit, anti-mumps IgM antibody positive rate with SSNHL significantly decreased, indicating that the proportion of asymptomatic mumps among etiology of SSNHL may be lower than those previously reported.

The autoimmune characteristics of progressive or sudden sensorineural hearing loss

Autoimmune sensorineural hearing loss (ASNHL) is a clinical syndrome that typically produces a bilateral rapidly progressive hearing loss. Autoantibodies and autoreactive T cells have been implicated in the etiopathogenesis of ASNHL. However, the identity of a specific or highly relevant inner-ear self-antigen is still required. In recent years, a role for antiphospholipid antibodies has been also suggested, assuming sudden/progressive hearing loss to be part of the primary antiphospholipid syndrome (APS). In this review, we address the need for specific diagnostic tools in order to establish an autoimmune origin for hearing loss. Moreover, the decision of whether anti-inflammatory drugs or anti-coagulation should be given is also discussed.

Case report: diffuse plane xanthoma with low C4 and systemic inflammatory symptoms

A normolipemic patient with diffuse plane xanthomas, IgG monoclonal gammopathy of unknown significance, low levels of C4, and systemic inflammatory symptoms is presented. Delay from disease onset to diagnosis is discussed.

Diagnostic tests for immunomediated hearing loss: a systematic review

OBJECTIVE

To quantitatively evaluate the diagnostic accuracy of diagnostic tests for immunomediated hearing loss.

DATA SOURCES

We searched Medline and the Cochrane Database of Systematic Reviews for potentially relevant studies.

STUDY SELECTION

Twenty-five studies met the inclusion criteria of this systematic review. The diagnosis of immunomediated hearing loss was based on the clinical presentation and the response to corticosteroid administration.

DATA EXTRACTION

The following data were extracted from the selected studies and entered into a standardised database: population demographics; exclusion and inclusion criteria; diagnostic tests; sensitivity; specificity; the number of true positive, true negative, false positive and false negative values; therapy used, including dose and duration; and delay between symptom onset and therapy commencement.

DATA SYNTHESIS

This systematic review combined data from 679 patients with immunomediated hearing loss, reported by 22 research teams. Substantial heterogeneity was found among the included studies; for this reason, summary sensitivity and specificity values were not computed.

CONCLUSIONS

The results of diagnostic tests for immunomediated hearing loss depend on many factors, and there is a risk of potential bias. This is the first time that such a systematic review has been presented; such a review is a more rigorous method of demonstrating the utility of the available diagnostic tests.

Sudden presentation of immune-mediated inner ear disease: characterization and acceptance of a cochleovestibular dysfunction

Since the McCabe report, growing indirect evidence has accumulated to indicate the implication of immune mechanisms in the pathogenesis of immune-mediated inner-ear disease (IMIED). A clinical study of a group of patients affected by this condition was performed in order to characterize the immune group, based on a recently reported profile, and compared with the vascular, viral and idiopathic aetiologies of sudden deafness. Patients affected by immune-mediated inner-ear disease had the best and the earliest recovery rate of hearing (p = 0.0028 and p = 0.017, respectively). However, this group of patients also had the higher rate of recurrence (p = 0.034), supporting the typical clinical course of the autoimmune disorders. On the basis of the results the criteria used in the diagnosis of the sudden presentation of the immune-mediated inner ear disease could be accepted leading to the characterization of this condition. Likewise, the role of the supporting cells in the pathogenesis of the IMIED is discussed.

[Acute autoimmune sensorineural hearing loss in pregnant women with Leśniowski-Crohn disease]

Acute sensorineural hearing loss may appear in some autoimmune diseases. Authors presented a case of 31 years old pregnant woman with Leśniowski-Crohn disease, in who acute total deafness of one ear and sensorineural hearing loss in the second ear appeared after she got pregnant. Immunological etiology was confirmed by presence of antinuclear and anti-type II collagen antibodies. Hearing level improvement after treatment with steroids was observed.

Immunologic work-up study for inner ear disorders: looking for a rational strategy

CONCLUSIONS

For the evaluation of a patient with suspected immune-mediated inner ear disease (IMIED), an exhaustive immunologic work-up study is not recommended if financial resources are limited. Analysis of antinuclear antibodies (ANA) and the immunophenotype of peripheral blood lymphocytes (PBL) proved to be the most useful tests in our population to support the clinical diagnosis of IMIED.

OBJECTIVE

Owing to the lack of specific serological markers for the diagnosis of IMIED, an exhaustive immunologic work-up study for patients with suspected IMIED is usually performed. The aim of this study was to estimate the use of resources and the costs involved in the routine laboratory tests used for the diagnosis of IMIED.

MATERIAL AND METHODS

This was a comparative study of two groups of patients with a high suspicion of diverse clinical forms of IMIED who were subjected to different serologic test designs. The cost of the classical immunologic work-up study used for the diagnosis of IMIED (n=125) was estimated in comparison with that of a more restricted examination, based on a recently reported high-risk profile, involving the analysis of ANA and PBL (n=57).

RESULTS

The diagnostic efficiency of the two protocols was similar. The cost of a complete immunologic work-up study was 241.77 euros and that of the limited analysis was 53.12 euros.

P0 antigen detection in sudden hearing loss and Ménière's disease: a new diagnostic marker?

OBJECTIVE

To evaluate the presence of IgG autoantibodies against the P0 antigen in patients affected by sudden hearing loss and Meniere's disease (MD).

MATERIAL AND METHODS

All patients underwent a tonal audiometric evaluation, tympanometry, evaluation of the stapedial reflex threshold with decay time, determination of auditory brainstem responses and a complete vestibular assessment involving evaluation of spontaneous and positional nystagmus (Frenzel glasses), a head thrust test and a caloric test (Fitzgerald-Hallpike technique). Blood samples were drawn from all patients for the immunologic assessment of IgG antibodies against the P0 antigen (30-kDa protein) of guinea pig inner ear extracts using a Western blot assay.

RESULTS

Ten patients affected by sudden hearing loss showed specific IgG antibodies against the P0 protein. Specifically, the P0 positive band was detectable in 5/45 patients with unilateral auditory impairment and in 5/5 of those with bilateral forms of auditory impairment. Among MD patients, the P0 positive band was detectable only in those with bilateral audiovestibular impairment (n = 10). Interestingly, in none of the 35 patients affected by monolateral MD were specific IgG antibodies against the P0 protein detectable.

CONCLUSION

The positive reactions to P0 in all bilateral MD and bilateral sudden hearing loss patients found in this study strongly indicate that these pathologies are the result of an ongoing autoimmune process directed against specific antigens of the inner ear.

Evaluation of anti-hsp70 antibody screening in sudden deafness

OBJECTIVE

To assess the diagnostic utility of anti-hsp70 antibody screening in sudden deafness.

DESIGNS

era from 27 patients with sudden deafness and 100 healthy blood donors were analyzed by Western blotting (WB) for the presence of antibodies against 68 kD heat shock protein (anti-hsp70).

RESULTS

19% of the patient sera and 14% of the control sera turned out positive, which was not significantly different.

CONCLUSIONS

The anti-hsp70 WB test lacks clinical utility for diagnostic screening in patients with sudden deafness.

Clinical associations of serum antiendothelial cell antibodies in patients with sudden sensorineural hearing loss

OBJECTIVES/HYPOTHESIS

The role of antiendothelial cell antibodies in systemic vasculitis has been reported. The aim of the study was to define the clinical associations of serum antiendothelial cell antibodies in patients with sudden sensorineural hearing loss.

STUDY DESIGN

A prospective study in patients with sudden sensorineural hearing loss.

METHODS

Serum samples were taken from 59 consecutive patients with sudden sensorineural hearing loss at time of presentation and from 28 normal control subjects. Indirect immunofluorescence assay was used to detect antiendothelial cell antibodies.

RESULTS

The prevalence of antiendothelial cell antibody detection was 54% (32 of 59 patients), with a statistically significant difference between patients and control subjects (P =.0004). Antiendothelial cell antibody positivity was significantly associated with absent recovery of hearing loss (P =.0020).

CONCLUSIONS

The cytotoxicity to endothelial cells of the inner ear by antiendothelial cell antibody-positive sera might play a role in causing the stria vascularis damage in immune-mediated sudden sensorineural deafness. The appearance of antiendothelial cell antibody is related to the poor outcome of hearing loss, and its detection could be helpful in the selection of particular patients with sensorineural hearing loss for specific immunosuppressive treatments.

[Lyme disease--a reason for sudden sensorineural hearing loss and vestibular neuronitis?]

BACKGROUND

Lyme disease has been described as one possible cause of sudden sensorineural hearing loss and vestibular neuronitis. The necessity of serological diagnosis and its therapeutic consequences have been discussed controversially.

PATIENTS AND METHODS

344 patients with acute sensorineural hearing loss and 66 patients with vestibular neuronitis were examined in retrospect. By means of ELISA (Enzygnost Borreliosis, Dade Behring Marburg) the specific prevalences of IgG- and IgM-antibodies against borrelia in serum were evaluated. The frequency of seroprevalences for both diseases were compared to those given in the literature. Neurootological findings of the seropositive patients were compared with those of seronegative and analysed statistically.

RESULTS

15.7 % of the patients with sudden sensorineural hearing loss had positive levels of IgG-antibodies. IgM-titers were elevated in 4.7 % of the patients. The seroprevalences for IgM and IgG were above those described by other investigators for the healthy population. Patients with positive IgM-antibodies showed more often low frequency hearing loss than IgG-positive patients. 18.2 % of the patients with neuronitis vestibularis had IgG- and 1.5 % IgM-antibodies against Borrelia. Whereas IgG occurred more often than known for the healthy population, IgM was within the limit for the healthy population. The seropositive group did not show any remarkable neurootological signs compared with the seronegative group.

CONCLUSIONS

Because of the elevated seroprevalences Borrelia infections may be one possible but very rare cause of sudden sensorineural hearing loss and vestibular neuronitis. Low frequency hearing loss may be a sign for an infection with Borrelia as an etiological factor especially in combination with seropositive titers. In case of the presence of IgM-antibodies, patients may be treated with oral antibiotics (Doxycyclin, Cefuroxim). In patients with neuronitis vestibularis a neuroborreliosis should be excluded by means of lumbar puncture.

Autoimmunity in sudden sensorineural hearing loss: possible role of anti-endothelial cell autoantibodies

In order to verify whether anti-endothelial cell autoantibodies (AECAs) can be used as serological markers of inner ear vasculitis in sudden sensorineural hearing loss (SSHL), 32 patients affected by idiopathic SSHL were investigated. All patients underwent a routine general physical examination and extensive audiovestibular, microbiological and immunological investigations. Fourteen normal subjects without a history of HL, autoimmune or metabolic disease served as controls. Detection of AECAs was performed using an indirect immunofluorescence technique. AECA-positive patients were treated with methylprednisone, while AECA-negative patients were treated with a combined regimen of steroids, plasma expander and aspirin. The average hearing recovery for 5 frequencies (0.25-4 kHz) was analyzed in each subject 1 month after treatment and every 3 months thereafter; median follow-up was 12 months (range 9-18 months). A total of 15/32 patients (46.8%; 11/19 females, 4/13 males) were AECA-positive and thus differed significantly from the normal population in whom only 2/14 tested cases were positive (p = 0.03). Severe hearing loss was associated with being AECA-positive in 8/11 cases. During follow-up, 25/32 patients improved their hearing and 17 of these patients were AECA-negative. The seven cases without hearing improvement were all AECA-positive. In patients with SSHL, immune-mediated vascular damage may have a pathogenetic role and AECAs may represent a serological marker of vasculitis even if they are not inner ear-specific and even if they represent an epi-phenomenon rather than the only cause of SSHL.

Autoimmune identification of sudden hearing loss

OBJECTIVE

To identify autoantibody bands using Western blotting in patients with idiopathic sudden sensorineural hearing loss (ISSNHL).

MATERIAL AND METHODS

All patients admitted to our emergency ward with ISSNHL during a 3-year period (n = 51) were included in a diagnostic laboratory protocol, which included a non-specific test battery for immune disorders and a Western blot (WB) for bovine cochlear antigen, and underwent corticosteroid therapy.

RESULTS

In 16 cases (31%) a band was identified in the WB. Cases with a positive WB showed abnormal results in a greater number of non-specific laboratory tests (3.6 +/- 1.3 vs 0.9 +/- 1.1; p < 0.001) and had greater hearing recovery (33.8% +/- 17.7% vs 50.6% +/- 18.5%; p < 0.01). Moreover, patients with a positive WB showed good correlations between the degree of hearing recovery and both early onset of treatment (0.5504x + 43.621; R2 = 0.8603; p < 0.01) and age (0.4053x + 56.298; R2 = 0.8952; p < 0.01). The non-specific test battery showed a sensitivity of 78% and a specificity of 94% for detecting an autoimmune disorder compared with WB.

CONCLUSION

A positive WB predicts a good response to corticosteroid therapy in ISSNHL patients. If it is not possible to perform a WB then the non-specific test battery has a good capability for predicting autoimmune disorders.

Sudden sensorineural hearing loss: supporting the immunologic theory

Sudden deafness constitutes a diagnostic challenge. Classically, 2 causes, viral and vascular, are considered in the origin of idiopathic sudden hearing loss. More recently added to the list of possibilities are rupture of the membranous labyrinth and immune-mediated sensorineural hearing loss. The latter can be either primary and localized to the inner ear or, in perhaps fewer than one third of cases, secondary to generalized systemic autoimmune disease. The purpose of the present review is to define immune-mediated sudden sensorineural hearing loss as a distinctive entity, on the basis of clinical, immunologic, and pathological findings, and suggest a profile of the typical patient.

Validity of the Western blot immunoassay for heat shock protein-70 in associated and isolated immunorelated inner ear disease

OBJECTIVE

To assess the validity of the Western blot immunoassay for heat shock protein-70 (hsp-70) for diagnosis of autoimmune inner ear disease.

STUDY DESIGN

Retrospective study of 53 patients affected by sudden deafness (n = 19), idiopathic progressive sensorineural hearing loss (n = 24), and Meniere's disease (n = 10) who were treated from 1995 to 1999. The clinical course and response to corticosteroid were evaluated.

METHODS

A purified hsp-70 antigen from bovine kidney cell line was used for the Western blot immunoassay.

RESULTS

Only five patients (9.4%) showed anti--hsp-70 antibodies: Two presented a sudden sensorineural hearing loss (sudden deafness group), two showed an idiopathic progressive sensorineural hearing loss (idiopathic progressive sensorineural hearing loss group), and one was affected by fluctuating hearing loss (Meniere's disease group). A systemic autoimmune condition was observed in 29.1% of patients with idiopathic progressive sensorineural hearing loss.

CONCLUSIONS

The low sensitivity of Western blot immunoassay for patients affected by idiopathic progressive sensorineural hearing loss and Meniere's disease may result from either the long time elapsed from the hearing loss and vertigo to the initial examination or from the increased percentage of cases of systemic autoimmune disease present in patients with idiopathic progressive sensorineural hearing loss. More studies to detect the immune-mediated inner ear disease in Western blot immunoassay-negative patients are required.

[Role of endothelial cell autoantibodies in the pathogenesis of sudden hear loss]

Sudden hearing loss can be found in systemic autoimmune diseases or it can be a symptom of an autoimmune disease of the inner ear. The present work has studied a group of patients with idiopathic sudden hearing loss to determine what role anti-endothelial cell antibodies (AECA) play as markers of immuno-mediated vasculitis of the inner ear. The study involved 32 patients with sudden deafness and 14 controls. The patients underwent otofunctional, neuroradiological, sero-microbiological and immunological testing. Using the indirect immunofluorescence technique, serum AECA were determined within 24 hours of hospitalization and three days after the onset of deafness. AECA positive patients (AECA+) were administered corticosteroid therapy (methylprednisone 1 mg/kg/die) for 1 month. A clinical follow-up was performed, including audiometry, 1 month after discharge and thereafter at three-month intervals (follow-up range: 8-18 months). AECA proved positive in 15/32 patients (47%) and in 2/14 of the controls (14%). The difference between the patients and the controls was statistically significant (p = 0.03). The 7 patient who showed no recovery after 1 month were all AECA+. None of the AECA+ patients showed other symptoms or a worsening of the hearing loss. In conclusion, the determination of non-specific autoantibodies vs. the inner ear, such as AECA, can be considered a useful clinical tool in differentiating between patients with idiopathic sudden hearing loss and those for which a diagnosis of immuno-mediated vasculitis of the inner ear is likely and for which prognosis is particularly unfavorable.

[Detection of humoral immune response to inner ear proteins in patients with sensorineural hearing loss]

BACKGROUND

The precise mechanism of inner ear disease is still unknown. An autoimmune reaction could be one of several possible pathogenic factors involved in progressive sensorineural hearing loss. Heat shock protein 70 is suggested to play an important role in the development of autoimmune diseases. The aim of this study is the investigation of humoral immune reactivity to inner ear components in patients with sensorineural hearing loss.

METHODS

The presence of antibodies to inner ear components was determined by immuno-blotting extracted bovine or human inner ear proteins. Study groups consisted of patients with idiopathic progressive sensorineural hearing loss (group A), patients with Menière's disease (group B), patients with sudden hearing loss (group C), patients with otosclerosis (group D), patients with Cogan's disease (group E), and individuals without hearing problems (group F).

RESULTS

40% of the patients with progressive sensorineural hearing loss showed reactivity against a 68-kDa protein extracted from bovine inner ear. In contrast to this, only 5% of healthy individuals and 10% with Menière's disease showed reactivity against the 68-kDa protein from bovine inner ear or against bovine heat shock protein 70. Some of the patients who showed reactivity against bovine inner ear proteins were tested with human inner ear and human heat shock protein 70; all of these showed reactivity. Approximately 6% of the patients with sudden hearing loss (group C), otosclerosis (group D), and Cogan's disease (group E) showed reactivity to inner ear proteins. A non-specific humoral immune reaction against inner ear proteins with molecular weights of 30, 40, 50, 60, and 220 kDa was observed in all patients.

DISCUSSION

These results indicate a humoral immune reactivity against heat shock protein 70, which might be responsible for the pathogenesis of progressive sensorineural hearing loss.

Inner ear autoantibodies and their targets in patients with autoimmune inner ear diseases

Immunological mechanisms are thought to play an important role in the pathogenesis of some cochleo-vestibular diseases. This study attempts to present further evidence of autoantibodies reactive against guinea pig inner ear proteins found in patients with autoimmune inner ear diseases (AIED) and specifically identifies the main target antigens of these antibodies. Sera from 110 patients with a clinical diagnosis of either rapidly progressive sensorineural hearing loss (n = 32). Ménière's disease (n = 41), sudden deafness (n = 6) or other aetiologies of hearing loss (n = 11) were screened by the Western blot technique. Forty-four percent of the patients' sera had antibodies to several inner ear proteins, of which the 30, 42 and 68 kDa proteins were found to be the most reactive. These highly reactive proteins were identified by gas-phase micro sequencing after digestion with trypsin and separation of peptide fragments by high-performance liquid chromatography. A partial sequence of each protein was determined. These data, together with those obtained from 2-dimensional gel electrophoresis followed by Western blotting, demonstrated that the 30 and 42 kDa inner ear proteins are the major peripheral myelin protein P0 and the beta-actin protein, respectively, while sequence analysis indicated that the 68 kDa protein is novel. These findings further support the hypothesis that several populations of antibodies may contribute to the enhanced immunological activity of AIED patients. They also add a new dimension to our knowledge of AIED and may open new avenues in the development of simple serological assays, which are easier to perform and more rapid than Western blotting.

Distribution of HLA-A, -B and -DRB1 alleles in patients with sudden sensorineural hearing loss

This study was performed to investigate the association between human leukocyte antigen (HLA) and susceptibility to sudden sensorineural hearing loss in the Korean population. HLA-A and HLA-B typing using a standard microlymphocytotoxicity technique and HLA-DRB1 genotyping were performed in 35 patients with sudden sensorineural hearing loss and in 206 healthy controls. Prednisone (usual dose 60 mg/day) was administered for 6 days and tapered for an additional 4-6 days. Both initial hearing levels at the onset of deafness and final hearing levels after treatment were examined and evaluated for association with HLA alleles. The frequency of HLA-DRB1*14 was increased in patients with sudden sensorineural hearing loss compared with controls (relative risk [RR] = 2.7, p = 0.016). The frequencies of HLA-A2, -A31, -B52, -B61, -DRB1*04, -DRB1*11 and -DRB1*12 were slightly higher than in the controls, but did not reach statistical significance. When an association between the treatment results and HLA alleles was also evaluated, the frequency of HLA-DRB1*04 was found to be increased in the patients who did not respond to steroid treatment compared with both patients who responded well to steroid (50%, vs 16%, p = 0.034) and controls (RR = 3.0, p = 0.046). These results suggest that there is an association between HLA-DRB1*14 and disease susceptibility and that the presence of HLA-DRB1*04 may be an useful marker for predicting a poor prognosis in Korean patients with sudden sensorineural hearing loss.

[The importance of IgG auto-antibodies, anti-collagen type II specific in Menière's disease and progressive hearing loss]

The Meniere's Disease and Progressive Hearing Loss were considered idiopathic. Both entities were produced by endo lymphatic hydrops and disruption of the membrane which contain type II collagen. The inner ear presented widely expression of type II collagen. These pathologies were probably autoimmune diseases. The aim of this work was to study the relationship of specific IgG to type II collagen in Meniere's disease, Progressive hearing loss, and compared with Sudden hearing loss patients, vascular vertigo patients and normal controls. Patients were divided by clinical findings in: 1 degree Meniere's disease (n:27), 2 degrees Progressive Hearing loss (n:20), 3 degrees Sudden hearing loss (n:15), 4 degrees Vascular Vertigo (n:9) and compared with normal controls (n:30) aged and sex matched. We have measured specific IgG to type II collagen by ELISA test. We considered positive the OD two or more SD above the mean of normal controls.

RESULTS

1 degree The Meniere's group presented IgG to type II collagen (+) in 22 out of 27 patients, p < .025; 2 degrees The Progressive Hearing loss presented IgG to type II collagen in all cases (n:20), p < .0005. The Sudden Hearing loss presented IgG to type II collagen (-) in all cases (n:15) p < .00001 and Vascular Vertigo (n:9) presented IgG to type II collagen (-) in 8 out of 9 cases, p < .0005. These results suggest strongly the notion that Meniere's diseases and Progressive hearing loss have specific IgG to type II collagen and these conditions were ascribed with in autoimmune process.

[Clinical significance of allergic reactions in glucocorticoid therapy]

BACKGROUND

Glucocorticoids are widely used in medicine. Within the last few years, however, patients have become very suspicious of corticoids. The attending physicians frequently has to use a great deal of persuasion prior to applying this very effective and often indispensable group of medication.

PATIENTS

We report on four patients who developed allergic reactions (i.e. erythema in face and on body, itching, flushing, drop in blood pressure, respiratory distress, cold sweats, etc.) immediately after intravenous administration of prednisolone-21 hydrogen succinate (Solu-Decortin H, SDH).

RESULTS

Three out of four patients had a positive reaction to an intracutaneous test with SDH, but no reaction to the additive sodium succinate. The prick test was negative in all patients. No specific IgE antibodies were detected in the serum of these patients. However allergic reaction to SDH must be presumed in at least three cases as it is difficult to detect glucocorticoid antibodies in serum and standardizes techniques are lacking. One female patient had a cross-reaction to prednisolon and dexamethasone. A renewed application of SDH was tolerated well by all patients when H1- and H2-receptors were blocked and calcium was administered to stabilize membranes.

CONCLUSIONS

Allergic reactions after glucocorticosteroid therapy are only occasionally mentioned in literature, appear more often when the agent is applied topically, and may lead to dangerous complications in patients if administered intravenously. Therefore, when allergic reactions result from glucocorticoid therapy (immediate reactions should be suspect), corticosteroid allergy should be considered as a differential diagnosis.

Anti-endothelial autoantibodies in patients with sudden hearing loss

OBJECTIVES/HYPOTHESIS

Sudden hearing loss (HL) can be caused by autoimmune disorders localized to the inner ear or secondary to systemic immune diseases. Studies in autoimmune animal strains showing HL have reported changes in the cochlear stria vascularis. The authors investigated the presence of antiendothelial cell antibodies (AECA) to see if immune-mediated vasculitis may play a role in human sudden HL.

STUDY DESIGN

A prospective study in patients with sudden HL.

METHODS

Fifteen consecutive patients (mean age, 32 y) affected by sudden HL and 14 normal subjects were included. Patients with familial deafness and metabolic diseases were excluded. Extensive audiovestibular, imaging, microbiological, immunological, and routine examinations were performed. AECA were detected on rat kidney tissue sections on the sera collected at -20 degrees C.

RESULTS

AECA were positive in 8 of 15 patients (53%) (2 of 5 men and 6 of 10 women), thus differing significantly from the normal control population, in which only 2 of 14 tested AECA positive (P = .023).

CONCLUSIONS

In patients with sudden HL, immune-mediated vascular damage can have a pathogenetic role and AECA might represent a serological marker of vasculitis.

Immune-mediated sensorineural hearing loss

A review is given on the way our knowledge of pathways of immune responses inside and in the immediate vicinity of the inner ear has gradually developed over the past two decades. Immune reactivity plays a more important role in the etiopathogenesis and natural course of various inner ear disorders than was thought originally. They comprise certain forms of fluctuating or rapidly progressive sensorineural hearing loss (SNHL) with or without endolymphatic hydrops. Patients may present themselves clinically with symptoms resembling Ménière's disease or even with sudden deafness. Immune-mediated audio-vestibular dysfunctioning is either a separate disease entity or part of a more generalized (auto-) immune process. The various attempts which have been made to develop methods or tests to confirm the diagnosis of immune-mediated SNHL are critically reviewed, including the treatment responses to immunosuppressive therapy. Various animal models are furthermore presented.

[Incidence and clinical relevance of antibodies to phospholipids, serotonin and ganglioside in patients with sudden deafness and progressive inner ear hearing loss]

Immunoserological assays of patients with sudden deafness and progressive hearing losses have revealed the presence of different antibodies, leading to the assumption that immunological processes may be involved. Recent investigations have demonstrated that these patients have phospholipid antibodies that can cause venous or arterial vasculopathies. In the present study we analyzed the incidence of these antibodies in patients with inner ear disorders. Sera of 55 patients with sudden deafness and 80 patients with progressive hearing loss were tested. Phospholipid antibodies were demonstrable in 49% of the patients with sudden hearing loss and 50% of the patients with progressive hearing loss. Serotonin and ganglioside antibodies were found in 53% of the patients with sudden hearing loss and 63% of the patients with progressive hearing loss. Since these three antibodies are also frequently found in patients with fibromyalgia syndrome (FMS) and chronic fatigue syndrome (CFS), 28 of the patients studied displayed symptoms typical for these disorders, including fatigue, myalgia, arthralgia, depressions, sicca symptoms and diarrhea. We now recommend questioning patients suffering from inner ear disorders for symptoms typical for FMS or CFS, since these diseases are often closely related to inner ear disorders. If symptoms are present, antibodies should be tested against phospholipids, serotonin and gangliosides. If present, the antibodies are diagnostic for each syndrome. Additionally these immunologic and serologic findings show that these antibodies may play a role in the etiology of hearing loss disorders.

Complement activation in sudden deafness

OBJECTIVE

To test whether complement activation is associated with sudden deafness.

DESIGN

Plasma samples obtained from patients in the acute phase of sudden deafness were analyzed for complement activation measured by C3bc levels and terminal complement complex. Comparisons were made with plasma samples from healthy controls.

PATIENTS

Twenty-five adult patients with unilateral sudden deafness. The criteria for inclusion were symptoms of hearing loss for not longer than 14 days and a hearing loss of 35 dB or more measured at entry.

RESULTS

Levels of C3bc were higher in patients compared with controls (P<.001). There were no differences in the formation of terminal complement complex in patients and controls.

CONCLUSIONS

The elevated levels of C3bc in patients with sudden deafness indicate an activation of the first part of the complement cascade and therefore suspected inflammatory causes. Measurements of C3bc levels might identify patients with sudden deafness who would benefit from treatment with anti-inflammatory drugs.

Sudden Deafness: Lack of Evidence for Systemic Viral Infection

The cause of sudden deafness remains unknown even though available evidence suggests that viral infection could be one factor involved. The presence of an interferon-inducible protein termed MxA in patients' leukocytes is a good marker of a systemic viral infection. This study included 20 patients with sudden deafness and 12 control subjects. Peripheral blood leukocytes obtained from the patients with sudden deafness did not express significantly higher levels of interferon-α/β-inducible MxA protein than control subjects. In addition, no measurable interferon-α activity was detected in any of the serum specimens. These findings suggest that sudden deafness is not commonly associated with a systemic viral infection.

Sudden deafness: lack of evidence for systemic viral infection

The cause of sudden deafness remains unknown even though available evidence suggests that viral infection could be one factor involved. The presence of an interferon-inducible protein termed MxA in patients' leukocytes is a good marker of a systemic viral infection. This study included 20 patients with sudden deafness and 12 control subjects. Peripheral blood leukocytes obtained from the patients with sudden deafness did not express significantly higher levels of interferon-alpha/beta-inducible MxA protein than control subjects. In addition, no measurable interferon-alpha activity was detected in any of the serum specimens. These findings suggest that sudden deafness is not commonly associated with a systemic viral infection.

Deficiency of naive T cells in patients with sudden deafness

BACKGROUND

Although there are a number of reports concerned with the role of immunity in the sudden onset of progressive sensorineural hearing loss, there are few references dealing with the involvement of immune-mediated mechanisms in sudden deafness.

OBJECTIVES

To study the phenotype of peripheral blood lymphocytes in a group of patients with sudden deafness by use of 3-color flow cytometry.

DESIGN

The study was carried out prior to the start of steroid therapy. Fourteen patients underwent a follow-up study once steroid therapy had been completed. Prospective analysis, case-control.

SETTING

Tertiary case referral center, ambulatory and hospitalized care.

PATIENTS

Twenty-two patients (13 men and 9 women; mean age, 45.3 years) were compared with 14 healthy control subjects (9 men and 5 women; mean age, 36 years). Patients were divided in 2 groups according to their response to steroid therapy.

RESULTS

Decreased numbers of both CD4+ helper cells (38.4% vs 45.5%; P = .04) and CD8+ cytotoxic cells (17.5% vs 22.3%; P = .02) were observed in patients and compared with those in the control subjects, as well as reduced numbers of CD4+CD45RA+ cells (14.4% vs 29.3%; P = .01) and CD8+CD45RA+ naive cells (18.2% vs 25.4%; P = .04). In the group of patients with a good response to steroid therapy (group 1), a tendency toward normalization of the CD4+ (pretreatment, 38.6%; posttreatment, 44.6%), CD4+CD45RA+ (pretreatment, 15.2%; posttreatment, 21.7%), and CD4+CD45RO+ (pretreatment, 21.1%; posttreatment, 18.2%) cell counts was observed, with a slight decrease in the CD8+ population (pretreatment, 18%; posttreatment, 15.7%). However, in patients with a poorer response (group 2), while there were increases in the CD4+ (pretreatment, 38%, posttreatment, 50%) and CD4+CD45RA+ (pretreatment, 12.8%; posttreatment, 16.7%) cell counts after steroid therapy, there was a significant increment in the CD4+CD45RO+ memory cell count (pretreatment, 14.1%; posttreatment, 28.5%) and low CD8+CD45RA+ counts (pretreatment, 14.6%; posttreatment, 15.5%). No differences were observed in the numbers of B or natural killer cells or in the presence of activation antigens CD25 and HLA-DR when pretreatment and posttreatment levels were compared.

CONCLUSION

These results demonstrate significant abnormalities in the subpopulations of lymphocytes in patients with sudden hearing loss, suggesting the existence of immune-mediated responses in the inner ear as possible etiopathogenic factors in this entity.

Autoimmune aberration in sudden sensorineural hearing loss: association with anti-cardiolipin antibodies

In view of the presence of autoantibodies against inner ear antigens, the pathogenesis of sudden deafness (SD) and progressive sensorineural hearing loss (PSNHL) is suggested to be of an autoimmune nature. However, microthrombosis of the inner ear may result from pathogenic anti-cardiolipin antibody (aCL) activity. We studied 30 patients (17 females and 13 males, age range 20-52 y), of whom 11 suffered from SD and 19 from PSNHL. All were clinically and serologically evaluated for association with autoimmune disorders (serological examination included: aCL, ANA, ENA, ANCA, proteinelectrophoresis, and complement levels). Twenty healthy matched subjects served as controls. None of the control group were aCL positive, whereas 8 out of 30 (27%) patients demonstrated low-moderate titers (P < 0.02), of whom 5 out of 8 suffered from SD. In addition, 2 aCL negative patients with PSNHL demonstrated hypergammaglubolinemia accompanied by hypocomplementemia, whereas none with SD had such abnormalities. Our data suggests that aCL is detected in patients with sudden sensorineural hearing loss and therefore may play an important role in the pathogenesis of this disability. If sustained by additional studies, these findings would warrant the consideration of anticoagulant therapy.

[Sudden deafness and increased toxoplasmosis IgM titer]

BACKGROUND

Prenatal damage of the inner ear due to infection with toxoplasma gondii is documented. Nevertheless, there are only a few references about postnatal acquired toxoplasmosis as a cause of inner ear damage.

PATIENTS

We report about a nine-year-old boy who suffered from unilateral hearing loss and tinnitus.

RESULTS

Examinations did not show any other sign of a possible cause of hearing loss except for a very high toxoplasmosis titer of 1:102400. Besides our usual therapy regime for acute hearing loss, we treated the patient with pyrimethamine and sulphadiazine. Antibody titer decreased but the sensorineural hearing loss did not change substantially. Fortunately the patient lost the tinnitus.

CONCLUSIONS

Acute Toxoplasmosis should be considered in the diagnostic process of sudden hearing loss, at least if there are appropriate clues in the medical history.

Detection of inner ear disease autoantibodies by immunoblotting

To define further the character of autoantibodies against the inner ear in patients with inner ear disease, Autoantibodies in sera from 82 patients with inner ear disease were investigated by immunoblotting. The inner ear antigens were extracted from Hartley guinea pigs. Brain, kidney, lung, heart and liver extracts were also prepared. Antibodies against the inner ear were found in 32 of 82 (39%) patients with inner ear disease. These sera reacted with the 30 and 58 kDa bands of the inner ear extracts. The 30 kDa band was detected in sera from patients with various inner ear diseases, while the 58 kDa band reacted with sera of patients with idiopathic progressive sensorineural hearing loss. Only two of the 52 normal control sera had a very faint band at 30 kDa. Sixteen of 32 positive sera were then used to probe Western blots of the brain, kidney, lung heart and liver extracts. The 58 kDa band was also found in the protein extracts of the brain, the lung, and the liver. On the other hand, preliminary purification of the 30 and 58 kDa proteins from the inner ear extracts were achieved by anion exchange chromatography. These results show that antibodies in sera from patients with inner ear disease reacted with at least two polypeptide bands (30 and 58 kDa) of guinea pig inner ear extracts, and the 58 kDa antigenic epitope was not cochlea specific.

Borreliosis as a cause of sudden deafness and vestibular neuritis in Sweden

Twenty-one patients with unilateral sudden deafness and 16 patients with vestibular neuritis, all with typical clinical history and findings, were investigated for a possible borrelia-cause. Only one patient, a patient with vestibular neuritis, had evidence of active borreliosis in terms of high antibody-titers in CSF, increased cell count and disturbed albumin ratio. To gain more knowledge about the etiological role of Borrelia burgdorferi in patients with hearing and vestibular symptoms, it is, despite this sparse finding, motivated to perform Borrelia testing in patients from tick-frequent areas. A reliable testing includes both serum and CSF analysis.

Sensorineural hearing loss of suspected autoimmune etiology: a report of three cases

The present paper reports three cases of sensorineural hearing loss of suspected autoimmune origin. Cases 1 and 2 were bilateral sensorineural hearing loss which responded to steroid therapy. Case 3 was bilateral fluctuant sensorineural hearing loss in conjunction with systemic lupus erythematosus. The pathogenesis of autoimmune sensorineural hearing loss is not yet fully understood. In two patients, hearing levels improved or stabilized following the use of osmotic expanders. The clinical results suggest that endolymphatic hydrops may participate in autoimmune sensorineural hearing loss.

[Drug therapy of acute inner ear hearing loss in childhood and adolescence]

Sensorineural hearing loss in early childhood may severely interfere with normal speech and language development. This by itself requires pursuit of an effective therapeutic procedure. Here we report the results of therapy with a rheological agent and procaine-HCl with or without the addition of steroids. Immunological testing was also studied for possible circulating antibodies in sera of affected children. Retrospective analysis of therapeutic results showed that the therapeutic procedure employed may be beneficial, since hearing improved considerably in some cases. Since an autoimmune-related sensorineural hearing loss has been postulated for some years, results presented here could be used as an argument for the presence of antibody-related inner ear disorders in early childhood. These findings suggest that circulating antibodies in children suffering from sensorineural hearing losses produce an inflammatory process involving inner ear structures. Circulating antibodies may also indicate a secondary immune reaction. However, sensory hearing loss occurring in early childhood may be steroid sensitive.

Immune-mediated sensorineural hearing loss

1. It is necessary to keep in mind that the etiology of immune-mediated SNHL involves various causes ranging from vasculitis to type II collagen-related disorders. 2. Clinical cases believed to involve sympathetic labyrinthitis are extremely rare. 3. The mechanism of occurrence of SNHL associated with autoimmune diseases should probably not be attributed to immunologic abnormalities in all cases. 4. Of the cases of SNHL associated with autoimmune diseases, only those associated with aortitis syndrome (Takayasu disease) are steroid-responsive. 5. The autoimmune SNHL described by McCabe is believed to be closely related to Cogan's syndrome. On the other hand, steroid-responsive SNHL includes three types: a systemic type associated with aortitis syndrome, a localized type not associated with any known autoimmune disease, and a syphilitic type. It is thought that sex differences and differences in such findings as the caloric response between the two disease entities is due to interracial differences in the degree of vasculitis.

The significance of herpes viral latency in the spiral ganglia

To better understand the pathogenesis of idiopathic sudden hearing loss (ISHL), the possibility of latent virus infection in the spiral ganglion cell was considered. Only few spiral ganglion cells showed positive viral antigen after systemic guinea pig-specific cytomegalovirus (GPCMV) inoculation indicating the absence of hearing loss but the possibility of a subsequent latent infection. By using a modern molecular biological technique we have detected the herpes simplex virus type-1 (HSV-1) DNA in human spiral ganglia. The concept of establishing viral latency in the spiral ganglion cells with periods of reactivation fits with the clinical picture seen in ISHL, even though the mechanism of reactivation still remains unclear.

Diagnostic and therapeutic dilemmas in rapidly progressive sensorineural hearing loss and sudden deafness. A reappraisal of immune reactivity in inner ear disorders

Sera from 76 patients with a clinical diagnosis of idiopathic rapidly progressive sensorineural hearing loss (SNHL) (n = 15), sudden deafness (n = 31) and with other etiologies of their hearing loss (n = 30) were analysed by western blot assay. Seventy-three percent of the cases with rapidly progressive SNHL had cross-reacting antibodies (27, 45, 50, 68 kD). The overall response to immunoprogressive therapy was effective in only 50% of cases. Sixty-five percent of the patients with sudden deafness also had cross-reacting antibodies (27, 45, 50, 80 kD). In these cases steroid therapy was more effective in re-establishing the hearing than no treatment, regardless of the western blot outcome. Spontaneous recovery occurred in approx. 50% of cases, but only in those with a positive assay. The antigenic epitopes detected with immunoblotting were not cochlea specific; they were also found in protein extracts of other organs (cranial nerves, kidney, brain).

[Human herpesvirus-6 antibodies in idiopathic facial nerve palsy and sudden deafness]

Human herpesvirus-6 (HHV-6) is the causative agent for exanthem subitum. This study investigated the relationship between idiopathic facial nerve palsy (Bell's palsy), sudden deafness and HHV-6 infection. Both Bell's palsy and sudden deafness are syndromes which causes are unknown. Both of them are suspected viral infection as causative agents. Paired sera from 22 patients of Bell's palsy and 39 patients of sudden deafness were examined for reactivity to HHV-6 by the indirect immunofluorescence test. On a case of Bell's palsy and two cases of sudden deafness each of the HHV-6 antibody titers was increased.

Human spumaretrovirus in the etiology of sudden hearing loss

The etiology of sudden sensorineural hearing loss, so called sudden deafness, has for long puzzled researchers. Recently we have studied the possibility that a hitherto relatively unknown retrovirus group consisting of human spumaretroviridae (HSRV) might be the causative agent of sudden deafness. During the last 3 months we have screened about 30 cases of sudden deafness. In 4 of them antibodies against HSRV were detected. Three of them had suffered from a flu-like condition about 2 weeks before the onset of hearing loss. In 2 cases the hearing of both ears was involved, in 1 case a relapsing hearing loss was observed, and 1 case developed a Meniere-like symptomatology with a fluctuant hearing loss. Vertigo was present in 3 patients and all suffered from tinnitus. Full recovery of hearing was observed in 4 of 6 affected ears whereas 2 ears became practically deaf with poor speech discrimination. At present it seems likely that a significant part of sudden deafness is caused by HSRV infection. The course of infection follows the spontaneous course of sudden deafness described by many authors. We encourage otologic units to screen for HSRV when assessing the etiology of sudden deafness.

[Cogan syndrome. Case report, review of the literature, therapy]

We present a case report of Cogan's syndrome and a review of the literature. Cogan's syndrome is most likely due to autoimmune disease primarily affecting the vestibulocochlear organ and cornea and secondarily resulting in systemic disease. 40% of patients develop bilateral complete deafness and 70% show signs of systemic disease mostly in the form of cardiovascular symptoms. The mortality rate of 10% is mainly due to vasculitis. It is important to consider Cogan's syndrome in the differential diagnosis of sudden hearing loss accompanied by ocular signs in young patients, as high morbidity and mortality rates are effectively lowered by early immunosuppressive treatment.

[Bilateral simultaneous sudden deafness--a report of five cases]

Five cases of bilateral simultaneous sudden deafness were reported. Two patients were male and three patients were female. The age of the patients ranged from five to 54 years. All the five cases were profoundly deaf on both sides. The elevation of the mumps virus antibody titer was found in the three cases out of four in those examined. The recovery pattern of hearing was seen symmetrically on both sides in four cases. Although complete recovery of hearing was obtained in one case and remarkable improvement was observed in two cases bilaterally, no improvement was seen in one case on either side. The last case showed remarkable improvement of hearing on one side with only a slight recovery on the other. Although the prognosis of the five cases of bilateral simultaneous sudden deafness was found comparable to that of the unilateral case by other investigators, the recovery was slower and the prognosis was less favorable in cases with the elevation of mumps antibody titer.

Immunological study on association between mumps and infantile unilateral deafness

The incidence of unilateral deafness in primary school children has been reported to be about 0.1%, but the cause of most of these cases has not been clarified, because parents and children themselves cannot recognize the onset of hearing loss occurring in one ear alone. This study was performed to clarify the possibility that mumps causes infantile unilateral deafness. The results were: 1) on dividing a total of 78 cases of infantile unilateral deafness according to age from 3 to 6 years, mumps infection rate in the 4-year-old group was nearly twice that in a randomly selected group; 2) on checking the neutralizing or ELISA IgG test of 31 cases with no history of mumps only, the 4-year-old group demonstrated a positive reaction to mumps more than the randomly selected group did. The above results suggested that unilateral deafness may be caused by asymptomatic mumps infection. To confirm this, we studied 5 infantile cases of sudden hearing loss by means of ELISA IgM antibody test and found a bilateral sudden deafness in children aged 1.9 years, caused by asymptomatic mumps infection.

Bilateral simultaneous sudden deafness

Although sudden deafness has many causes, it is often a sensorineural hearing loss with an abrupt onset and unknown origin. The majority of these latter cases are unilateral in their occurrences, while bilateral simultaneous involvement is rarely seen. During the past 13 years, we have treated 997 patients with sudden deafness. All patients were seen at our university hospital within 2 weeks after the onset of their hearing losses and were observed until the hearing level was fixed. Among them, 10 patients were found to have bilateral simultaneous onsets. The average age and the incidence of vestibular symptoms were similar to those with unilateral deafness. The hearing recovery was much better in the ear with the lesser deafness. No improvement was observed on the side with no sound perception. Those patients in whom common cold and fever seemed to trigger the onset of deafness were also noted to have high viral antibody titers, and were more commonly seen than were those cases with unilateral deafness.

[Progressive inner ear diseases--sequelae of a secondary autoimmune process? Significance of antibodies to endoplasmic reticulum]

In sera from patients with different forms of inner ear diseases antibodies against endoplasmic reticulum (anti-ER) could be detected by ELISA in association with antisarcolemmal (ASA) and antiendothelial antibodies (AEA). 36% of 296 patients with sensorineural hearing loss (SNHL), 30% of 20 patients with tinnitus, 21% of 48 patients with sudden deafness and 20% of 49 patients with Menière's disease had ASA. 94% of these ASA positive patients were also positive for anti-ER. The overall frequency of anti-ER was 57% of patients with SNHL, 60% of patients with tinnitus, 46% of patients with sudden deafness and 22% of patients with Menière's disease. Analysing the clinical course in 5 anti-ER positive and 11 anti-ER negative patients with SNHL it was shown that all 5 patients either had a progressive course and/or a systemic manifestation in contrast to only 4 of the anti-ER negative patients. Anti-ER antibodies were also detected in 38-53% of patients with different chronic inflammatory disorders of unknown aetiology (polymyalgia rheumatica, vasculitis, sarcoidosis, ankylosing spondylitis etc.) while only 6% of patients with typical autoimmune disorders (collagen diseases, lupoid hepatitis, primary biliary cirrhosis) and 8% of blood donors had this antibody. Therefore it can be concluded that anti-ER antibodies have no apparent relevance for the diagnosis of SNHL. They may be, however, indicative of a secondary autoimmune process triggered by a persistent infectious agent.