[Autoimmune disorder secondary to DiGeorge syndrome: a long-term follow-up case report and literature review]

DiGeorge syndrome is the most common chromosome microdeletion disease. The classical complications include congenital heart disease, hypothyroidism, immunodeficiency, facial abnormalities, and hypocalcemia. According to whether there is an absence or hypoplasia of the thymus, DiGeorge syndrome can be divided into two types, complete DiGeorge syndrome and partial DiGeorge syndrome. The patient was a female born with congenital heart disease, facial abnormalities and cleft palate. When the patient went to school, she had learning difficulty and had problems in communication and personal social behavior. Breath-holding occurred when she was 6 years old. She got infections about 2-3 times a year, which was easy to be cured each time. Chromosome microdeletion test of peripheral blood showed the classical 22q11.2 microdeletion, and no evidence showed that she has thymus absence, thus her disease was diagnosed as partial DiGeorge syndrome. When the patient was 6 years old, the blood routine test showed slight thrombocytopenia, and reexaminations after that indicated the similar result. When 9 years old, she was found with anemia and severe thrombocytopenia. At the age of 10, the patient was admitted to our hospital, complaining of petechia in the body and mucous of mouth. According to the various examinations results, doctors eventually considered the situation as an autoimmune disorder phenomenon. After being treated by pulse-dose methylprednisolone for three days, the bleeding ceased. Then the patient orally took prednisone acetate and pulse-dose cyclophosphamide, however the thrombocyte and hemoglobin levels had not been back to a normal range. But when the dose of prednisone acetate was reduced, the blood platelet count declined again while the hemoglobin kept normal. The long-term follow-up of this case lasted for more than 20 years. Until now, the patient is taking orally prednisone acetate as a maintainance treatment, and the anemia has been improved since, but thrombocytopenia still exists. The mechanism of DiGeorge syndrome in combination with immunodeficiency is still unclear. The most likely reason is that this phenomenon has some relationship with the dysfunction of the thymus and finally had an effect on the function of T cells. The clinical manifestation is always stubborn and need treatment and follow-up visit for a long time.

Serum Levels of Soluble TNFα Receptors (sTNFR1 and sTNFR2) During Corticosteroid Treatment in Patients with Graves' Ophthalmopathy

TNFalpha was shown to play an important role in the autoimmune inflammatory process of Graves' ophthalmopathy (GO). In our previous study we found no significant changes in serum TNFalpha levels in GO patients. The aim of the present study was to estimate an influence of corticosteroids on serum levels of TNFalpha receptors (sTNFR1 and sTNFR2) in GO patients and to assess their potential as a guideline of immunosuppressive therapy. We detected serum sTNFRI and sTNFR2 in three groups of subjects: 18 patients with clinical symptoms of ophthalmopathy [Clinical Activity Score (CAS) > or = 4, anamnesis of GO > or = 1 yr], 16 patients with Graves' disease without ophthalmopathy (Gd) and 14 healthy volunteers. Corticosteroid therapy consisted of intravenous infusions of methylprednisolone (MP) and subsequent treatment with oral prednisone (P). The serum samples were collected 24 hours before MP, 24 hours after MP, 14 days of treatment with prednisone and after the end of the corticosteroid therapy. The levels of serum sTNFR1 and sTNFR2 were determined by ELISA. Serum levels of sTNFR1 were significantly higher in GO individuals as compared to the control group (p < 0.01). We have found a significant decrease in sTNFR1 concentration in corticosteroid-respondent patients (satisfactory clinical effect, decrease of CAS > or = 1) as compared to the pretreatment values after MP treatment (p < 0.05) and after 14 days of prednisone (p < 0.01). There were significant differences in sTNFR2 level after MP treatment (p < 0.02) and after corticosteroid administration (p < 0.05) between responders and non-responders. Baseline values of sTNFRI in GO individuals were positively correlated with CAS (r = 0.6, p < 0.02).

CONCLUSIONS

TNFalpha acting through its receptors plays an important role in the pathogenesis of Graves' ophthalmopathy. Moreover, the beneficial influence of corticosteroids on the course of GO may be explained, at least in part, by an inhibition of sTNFR1 and sTNFR2. Measurement of soluble TNFalpha receptors might potentially serve as an indicator in prognostic estimation of corticosteroids' efficacy.

The effect of glucocorticoids on canine lymphocyte marker expression and apoptosis

BACKGROUND

Glucocorticoids are commonly administered to dogs for the treatment of inflammatory disorders, autoimmunity and cancers such as lymphoma. Despite evidence of clinical efficacy, understanding of the effects of glucocorticoids on cells of the canine immune system is limited.

HYPOTHESIS

Glucocorticoids affect the expression of phenotypic markers on canine lymphocytes and induce apoptosis.

ANIMALS

Fifteen healthy mixed breed dogs.

METHODS

Prospective randomized study. Prednisone was administered orally for 3 days, and cells aspirated from the popliteal lymph node before prednisone administration, and on days 1, 3, 10, 17, 24, and 38, were labeled with antibodies against canine CD3, CD4, CD8alpha, CD18, CD21, CD45, CD45RA, and CD90 molecules, and analyzed by flow cytometry. Additional samples were cultured in media with prednisolone for 24 hours and analyzed by cytometry for marker expression, and by gel electrophoresis for DNA fragmentation.

RESULTS

Treatment of dogs with glucocorticoids resulted in reduced (p < or = .05) proportions of CD3 (days 1, 3, 17, and 24), CD4 (days 3 and 10), CD21 (day 1, 3, and 38), CD45RA (day 17) and CD90 (days 1, 10, and 17) expressing lymphocytes, and reduced intensity of CD18 (day 17) and CD45 (day 17 and 24) molecules on nodal lymphocytes. Culture oflymphocytes with prednisolone for 24 hours caused a significant reduction in the expression of all markers (p < or = .05) and DNA fragmentation.

CONCLUSIONS AND CLINICAL IMPORTANCE

Glucocorticoids significantly alter the expression of phenotypic markers on canine lymphocytes, and in vitro induce apoptosis. These findings identify potential mechanisms for clinical immunosuppression from glucocorticoid treatment.

Immunosuppression without steroids in liver transplantation is safe and reduces infection and metabolic complications: results from a prospective multicenter randomized study

BACKGROUND/AIMS

The purpose of this study was to evaluate the efficacy of a steroid-free immunosuppression protocol.

METHODS

From 2001 to 2004, 198 liver-transplant patients were randomized to receive immunosuppression with Basiliximab and cyclosporine, with (St Group) or without (NoSt Group) prednisone. The primary end points were acute rejection, and patient and graft survival. The secondary end points were infection, metabolic complications, and hepatitis C-virus recurrence.

RESULTS

Overall rejection rate was 15%, with no differences (St: 13% vs NoSt: 18%; P=0.33). Infection rate was similar in both groups (St: 51% vs NoSt: 47%; P=0.56), but diabetic patients in the St Group had a significantly higher rate of bacterial infections (St: 54% vs NoSt: 14%; P=0.005). The six-month protocol biopsies showed hepatitis C recurrence in 90% of patients, without differences between groups. Hypertension was more frequent in the St Group (St: 44% vs NoSt: 25%; P=0.006). De novo diabetes rate was higher in the St Group (month 1: St: 29% vs NoSt: 18%; P=0.06), with higher glycatedHb (5.1+/-1.1 vs 4.4+/-0.8; P=0.002). Six-month survival rates were similar (St: 89% vs NoSt: 94%, P=0.62).

CONCLUSIONS

Immunosuppression without steroids is safe and reduces infection and metabolic complications.

Significant improvement in the outcome of HCV-infected transplant recipients by avoiding rapid steroid tapering and potent induction immunosuppression

BACKGROUNDS/AIMS

Recurrent HCV-cirrhosis occurs in a substantial proportion of transplant recipients, with higher rates reported in patients who had recently received a transplant. Over-immunosuppression has been implicated in this more unfavorable outcome. To determine whether the implementation of specific measures aimed at reducing or avoiding negative predictive variables is associated with an improvement in the outcome of recurrent hepatitis C.

METHODS

Comparative study between a cohort of patients who had recently received a transplant (2001-2004) and a historical group of HCV-infected patients transplanted before the implementation of two simple measures (1999-2000): (i) use of dual initial immunosuppression (steroids + cyclosporine neoral or tacrolimus); (ii) slow steroid tapering (>6 months). Yearly biopsies were performed in these recipients, and only those with at least one protocol biopsy and those with cholestatic hepatitis (regardless of follow-up) were included in the study. End-point: rate of HCV-related severe disease (defined as bridging fibrosis, cirrhosis or fibrosing cholestatic hepatitis) within the first year post-transplantation.

RESULTS

Severe disease was significantly lower in this cohort compared to the historical group (26/90, 29% vs 25/52, 48%; p=0.02). While other factors remained unchanged between the two cohorts, the proportion of patients on triple-quadruple regimes and the number of boluses of methyl-prednisolone were lower and the duration of prednisone therapy longer in more patients who had recently received a transplant.

CONCLUSIONS

Improving the outcome of recurrent hepatitis C may be achieved by reducing overall immunosuppression and avoiding abrupt variations in immunosuppression.

Cyclosporine Monitoring With 2-Hour Postdose Levels in Heart Transplant Recipients

Cyclosporine therapeutic drug monitoring based on 2-hour postdose concentration (C2) compared with conventional trough concentration (C0) can improve clinical outcomes for de novo renal and liver transplant patients. However, in heart transplant patients, published studies are limited. To determine the clinical significance of C2 compared with C0 following orthotopic heart transplantation, the authors measured CsA at C0 and C2 and estimated CsA area under the curve (AUC) using Bayesian estimation and 4 sparse sample algorithms in a cross section of 31 adult patients receiving triple-drug immunosuppression with CsA, mycophenolate mofetil (MMF), and prednisone. CsA was measured using a validated HPLC method. Endomyocardial biopsies were graded based on the ISHLT system. Mean +/- SD values for CsA dose, C0, and C2 were 4.8 +/- 1.4 mg/kg/d, 240 +/- 62 microg/L, and 1319 +/- 469 microg/L, respectively. Correlation with AUC, using different estimation algorithms, was better for C2 (r(2) = 0.79-0.99) than for C0 (r(2)= 0.11-0.52). The mean +/- SD values for C0 (microg/L) and C2 (microg/L) for rejectors (n = 3) were 215 +/- 68 and 949 +/- 204 versus 242 +/- 62 and 1359 +/- 474 for the nonrejectors (P = 0.66 and 0.12, respectively). Fisher exact test P values using the median as threshold value for C0 and C2 (234 microg/L and 1251 microg/L, respectively) were 0.6 and 0.1. Analysis of the data revealed that C0 values in rejectors have wider variability than C2. There were no rejectors among the 16 patients exceeding the C2 median value; for C0, however, there was not an easily identifiable threshold value. There is a trend for a significant relationship between C2 and the incidence of rejection, but the number of rejectors was too small to reach statistical significance. A prospective concentration-control de novo study design is recommended as the most appropriate way to fully evaluate the potential utility of C2 monitoring in heart transplant patients.

Effects of Fluticasone on Systemic Markers of Inflammation in Chronic Obstructive Pulmonary Disease

Systemic inflammation is present in chronic obstructive pulmonary disease (COPD), which has been linked to cardiovascular morbidity and mortality. We determined the effects of oral and inhaled corticosteroids on serum markers of inflammation in patients with stable COPD. We recruited 41 patients with mild to moderate COPD. After 4 weeks during which inhaled corticosteroids were discontinued, patients were assigned to fluticasone (500 mcg twice a day), oral prednisone (30 mg/day), or placebo over 2 weeks, followed by 8 weeks of fluticasone at 500 mcg twice a day and another 8 weeks at 1,000 mcg twice a day. Withdrawal of inhaled corticosteroids increased baseline C-reactive protein (CRP) levels by 71% (95% confidence interval [CI], 16-152%). Two weeks with inhaled fluticasone reduced CRP levels by 50% (95% CI, 9-73%); prednisone reduced it by 63% (95% CI, 29-81%). No significant changes were observed with the placebo. An additional 8 weeks of fluticasone were associated with CRP levels that were lower than those at baseline (a 29% reduction; 95% CI, 7-46%). Inhaled and oral corticosteroids are effective in reducing serum CRP levels in patients with COPD and suggest their potential use for improving cardiovascular outcomes in COPD.

Alveolar and airway sites of nitric oxide inflammation in treated asthma

The goal of this study was to identify airway and alveolar site(s) of inflammation using exhaled nitric oxide (NO) as a marker in treated patients with asthma, including response to oral corticosteroids, and correlate these sites with expiratory airflow limitation. In 53 (24 male) patients with asthma, age 43 +/- 23 years (mean +/- SD) and all on inhaled corticosteroids, post 180 microg aerosolized albuterol, FEV(1) was 74 +/- 23% predicted and FEV(1)/FVC was 68 +/- 11%. Exhaled NO at 100 ml/second was 27 +/- 23 ppb (p < 0.001 compared with normal, 12 +/- 15 ppb). Bronchial NO maximal flux was 2.4 +/- 3.1 nl/second (p < 0.001 compared with normal, 0.85 +/- 0.55). Alveolar NO concentration was 7.0 +/- 7.4 ppb (p = 0.01 compared with the normal value, 3.2 +/- 2.0 ppb). There was no significant correlation between FEV(1) % predicted or lung elastic recoil and NO bronchial flux or alveolar concentration. However, there was a weak but significant correlation between NO bronchial flux and alveolar concentration (Spearman r = 0.50, p < 0.001). In 10 subjects with asthma on inhaled corticosteroids, 5 days of 30 mg prednisone resulted in isolated significant decreases in NO alveolar concentration, from 13 +/- 10 to 4 +/- 4 ppb (p = 0.002). Despite treatment, including inhaled corticosteroids, patients with asthma may have ongoing separate airway and alveolar sites of NO inflammation, the latter responsive to oral corticosteroids.

Glucocorticoid receptor up-regulation in early rheumatoid arthritis treated with low dose prednisone or placebo

OBJECTIVE

Low or medium dose prednisone in early rheumatoid arthritis (RA), albeit with significant variation in clinical efficacy, reduces the progression of joint damage. The glucocorticoid receptor (GR) number in peripheral mononuclear cells (PBMC) might be helpful to predict which patients will respond to low or medium dose prednisone and therefore do not or will not need higher doses. With this in mind we determined in a double blind, placebo controlled study at baseline and yearly the GR number in PBMC.

METHODS

Eighty-one early RA patients (disease duration less than one year) were included. All patients fulfilled the ACR criteria and were disease modifying antirheumatic drugs (DMARD) and glucocorticoid-naive. They were randomly assigned to treatment with 10 mg prednisone daily or placebo. From all patients disease activity (CRP, number of tender and swollen joints), the radiological joint score, bone mineral density, and the GR number in PBMC were measured annually.

RESULTS

In females the GR number was up-regulated over time in both the prednisone and the placebo group. The same trend was observed in males. No correlations were found between the GR number in the prednisone users at the start of their treatment and changes in radiological scores or bone density after 2 years of treatment. No correlations were found between the GR number at the start and the clinical characteristics after a follow-up of 2 years.

CONCLUSION

The GR number in the PBMC of early RA patients did not predict which patients would be prednisone responders based on clinical or radiological parameters. However, the up-regulation of the GR number in PBMC in early RA patients towards the GR number of healthy subjects during the first two years of their disease course seems to reflect a recovery or compensatory mechanism as a response to an ongoing inflammatory process. This recovery may be not enough to efficiently control the inflammatory situation.

Tumour necrosis factor-alpha concentration in severely asthmatic children

We assessed tumour necrosis factor-alpha (TNF-alpha) concentrations in 80 asthmatic children, 26 with severe asthma in early-phase reaction, 26 with severe asthma in late-phase reaction, 28 with severe asthma controlled in between attacks with oral prednisone and 20 matched control children. TNF-alpha was measured in patients' plasma and in a supernatant of lipopolysaccharide-stimulated (LPS) peripheral blood mononuclear (PBM) cells. TNF-alpha concentrations in plasma and the supernatant of LPS-stimulated cells were positively correlated and the concentration also correlated positively with the time lapse between the start of the asthma attack and the time of blood sampling. TNF-alpha concentration was significantly higher in the late-phase reaction group compared to the other groups, indicating a need to counteract its release and/or effects early in asthma patients.

Pharmacoimmunodynamic interactions of interleukin-10 and prednisone in healthy volunteers

OBJECTIVE

The pharmacoimmunodynamic interactions of recombinant human interleukin-10 and prednisolone were examined in 12 normal male volunteers.

METHODS

Single doses of interleukin-10 (8 microg/kg subcutaneous injection), interleukin-10 with prednisone (15 mg by mouth), placebo with prednisone, or placebo were administered. Drug concentrations yielded pharmacokinetic parameters. Response measurements included whole blood lipopolysaccharide-stimulated cytokine (tumor necrosis factor-alpha, interleukin-1beta) production, phytohemagglutinin-stimulated whole blood lymphocyte proliferation, and differential white blood cell counts (including monocytes, lymphocytes, and neutrophils). Extended indirect-response models were used to deal with diverse drug interactions in assessing single and joint effects of interleukin-10 and prednisolone.

RESULTS

No pharmacokinetic alterations in interleukin-10 or prednisolone were found. Dosing with interleukin-10 produced strong inhibition of ex vivo cytokine production for the 24-hour postdosing period, whereas prednisolone, the active form of prednisone, was partly inhibitory for only 3 hours. Prednisolone significantly inhibited (P < .05) ex vivo lymphocyte proliferation for 6 hours, whereas interleukin-10 failed to alter this measure. Their joint effects on these responses were inhibitory consonant with the stronger agent. Marked changes in various leukocyte kinetics occurred. The steroid caused monocytopenia, lymphocytopenia, and neutrophilia, with IC50 or SC50 values of 10 to 20 ng/mL. Interleukin-10 elevated monocytes and neutrophils and lowered lymphocyte counts, with IC50 or SC50 values of 0.7 to 1.3 ng/mL. Dynamic modeling showed loss of prednisolone effects on monocytes and additive steroid/interleukin-10 effects on lymphocytes and neutrophils, with neutrophils exhibiting greater changes in net response.

CONCLUSION

Interleukin-10 and prednisolone interacted favorably for the measured pharmacoimmunodynamic indices with no kinetic alterations but net responses that were similar to or greater than effects produced by the more strongly acting agent.

Standardized estimates from categorical regression models

We consider the problem of interpreting categorical regression models, such as the polytomous logistic model, the continuation-ratio model, the stereotype model, and the cumulative-odds model. We present a method to convert categorical regression coefficients into estimates of standardized fitted probabilities, probability differences and probability ratios. We use a delta-method approach to estimate standard errors. We then present a small simulation study to compare different transforms for setting confidence limits, and provide an illustration of our approach in an observational study of drug therapy of polymyositis.

[Effect of prednisone on skin tests with allergens]

A double blind study was carried out in 29 patients, 14 were treated with prednisone and 15 with placebo. Prednisone caused significant inhibition of the allergen-induced wheal and flare response, but did not suppress it. The control group, showed a significant rise in the allergen-induced wheal and flare response. The significance of the observed alterations is briefly discussed as well as their probable origin. It is suggested the use of prednisone in allergic patients who need symptomatic treatment, however, we must to think about the possibility for get false-negative results.

Long-term immunoregulatory effects of therapy with corticosteroids and anti-thymocyte globulin

Corticosteroids and anti-thymocyte globulin (ATG) have been extensively used in the treatment of autoimmune diseases, aplastic anemia and organ graft rejection; nonetheless, the precise mechanisms of action of these agents are unknown. Studies of their long term immunoregulatory effects, particularly in humans, have been limited. We examined the long term effects of therapy with ATG given for 2-4 weeks and prednisone for 2 months in 4 patients with newly diagnosed insulin dependent diabetes (IDD). Three matched newly-diagnosed untreated IDD patients and 17 healthy volunteers served as controls. No differences in total lymphocyte count, percentage of B cells, percentage of total T cells (CD3), helper-inducer T cells (CD4) or cytotoxic-suppressor cells (CD8), lymphocyte blastogenesis assays, or pokeweed mitogen-induced IgG secretion in T & B cell co-cultures were detected before therapy. A transient lymphopenia following ATG administration was the only immunological defect found in the first month of therapy. At 2 months, however, patients treated with ATG and prednisone had diminished immunoregulatory T cell function demonstrated by production of only 28 +/- 3% IgG expected in T & B co-culture, compared to 205 +/- 35% for untreated IDD patients and 107 +/- 13% for normals (p less than 0.01). This diminished IgG production resulted from excessive suppressor function, since co-cultures of T cells from treated patients with T and B cells from normal volunteers suppressed the latter's IgG production by 76 +/- 9%. This enhanced suppressor activity persisted for 3-6 months following therapy. Other immunological functions were not statistically different from those present at the inception of the study. Thus, treatment with corticosteroids and ATG produces long-term enhanced suppressor activity, a finding which suggests that treatment with combination ATG and Prednisone is a rational form of immunomodulation in conditions associated with decreased suppressor function.

A monoclonal antibody to prednisone: use of enzyme-linked immunosorbent assay (ELISA) for screening and characterization of antigenic determinants

ELISA technology using immobilized steroid conjugates has allowed the rapid screening and characterization of hybridoma supernatants. Although cortisol-3CMO-BSA was the immunogen, a monoclonal antibody with exceptionally high cross-reactivity (greater than 1000%) to prednisone was obtained. Characterization of the antigenic determinants shows a requirement for overall glucocorticoid 21-hydroxyl and 17 alpha-hydroxyl groups with additional high specificity for the 1,2-double bond and 11-position. There is potential use for this antibody in the assay of prednisone.

Exogenous IL2 partially reverts CML non-reactivity acquired during prophylactic immunosuppression with cyclosporin A of human allograft recipients

Proliferative and cytolytic lymphocyte responses and the influence of exogenous interleukin 2 (IL2) on cell-mediated lympholysis (CML) reactivity were evaluated in 12 allograft recipients. Responses were induced by mitogenic lectins or by donor and third-party cells. Patients were tested immediately before transplantation (Tx) and one and three months after grafting. Prophylactic immunosuppression consisted of Cyclosporin A (CyA) and low-dose prednisone (P). Analysis of post transplant cells revealed a reduced overall proliferative T cell responsiveness induced by both alloantigens and mitogenic lectins. No evidence for donor-specific reduction of MLC responses was seen. Overall CML reactivity of post-Tx lymphocytes was also impaired. This was accompanied by donor-specific CML non-reactivity in six of seven patients with quiescent grafts. In these patients, the cytolytic potential against donor cells could be restored when maximal T cell help via exogenous IL2 was provided.

Anti-thymocyte globulin and prednisone immunotherapy of recent onset type 1 diabetes mellitus

Increasing evidence that Type 1 (insulin dependent) diabetes mellitus is an autoimmune disease, together with successful cure/prevention in animal models of this disease (e.g. BB/W rat) has led to several trials of immunotherapy in recent onset Type 1 diabetes of man. In this communication we report our experience with short courses of prednisone and antithymocyte globulin (ATGAM) plus prednisone. Prednisone characteristically suppressed Ia positive T lymphocytes into the normal range, but had no long-lasting effect on T-cell phenotype. ATGAM plus prednisone markedly decreased the ratio of T4/T8 ("helper"/"suppressor-cytotoxic") positive T lymphocytes, and this remained suppressed for months. ATGAM treated patients had lower HbA1c on a lower dose of insulin 100 or more days following immune therapy (with 4 out of 5 patients requiring less than 0.2 U/Kg insulin/day). Two patients in the ATGAM treated group did not require insulin for more than 8 months; during remission they had normal fasting blood glucose values, but with abnormal glucose tolerance on oral glucose tolerance testing. Severe, though transient, thrombocytopenia was observed in 2 patients on ATGAM therapy which outweighed its clinical effects.

Surgical complications and skin test reactivity in patients with inflammatory bowel disease

One hundred patients with inflammatory bowel disease were admitted to the Mount Sinai Hospital, New York, for surgical treatment. These patients were studied to evaluate the association between skin test reactivity and postoperative complications. Skin tests were performed prior to surgery using four recall antigens. Sixty patients were found to be anergic. The postoperative complication rate was significantly higher in the anergic patients when compared with those patients who were able to react to at least one skin test antigen. Twenty-seven anergic patients had 34 complications and almost 60% of these complications were of the septic type. Only 11 patients who responded to the skin tests had postoperative complications. Complications in the anergic patients required longer hospitalization and more frequent operative correction. There were no deaths in this series. Although anergic patients with inflammatory bowel disease are prone to experience septic complications, their prognosis appears to be better than the morbidity and mortality reported in the literature for anergic patients with other conditions.