Adrenal insufficiency is a contraindication for omalizumab therapy in mast cell activation disease: risk for serum sickness

Omalizumab is an effective therapeutic humanized murine IgE antibody in many cases of primary systemic mast cell activation disease (MCAD). The present study should enable the clinician to recognize when treatment of MCAD with omalizumab is contraindicated because of the potential risk of severe serum sickness and to report our successful therapeutic strategy for such adverse event (AE). Our clinical observations, a review of the literature including the event reports in the FDA AE Reporting System, the European Medicines Agency Eudra-Vigilance databases (preferred search terms: omalizumab, Xolair®, and serum sickness) and information from the manufacturer’s Novartis database were used. Omalizumab therapy may be more likely to cause serum sickness than previously thought. In patients with regular adrenal function, serum sickness can occur after 3 to 10 days which resolves after the antigen and circulating immune complexes are cleared. If the symptoms do not resolve within a week, injection of 20 to 40 mg of prednisolone on two consecutive days could be given. However, in MCAD patients whose adrenal cortical function is completely suppressed by exogenous glucocorticoid therapy, there is a high risk that serum sickness will be masked by the MCAD and evolve in a severe form with pronounced damage of organs and tissues, potentially leading to death. Therefore, before the application of the first omalizumab dose, it is important to ensure that the function of the adrenal cortex is not significantly limited so that any occurring type III allergy can be self-limiting.

Rabbit antithymocyte globulin-induced serum sickness disease and human kidney graft survival

BACKGROUND

Rabbit-generated antithymocyte globulins (ATGs), which target human T cells, are widely used as immunosuppressive agents during treatment of kidney allograft recipients. However, ATGs can induce immune complex diseases, including serum sickness disease (SSD). Rabbit and human IgGs have various antigenic differences, including expression of the sialic acid Neu5Gc and α-1-3-Gal (Gal), which are not synthesized by human beings. Moreover, anti-Neu5Gc antibodies have been shown to preexist and be elicited by immunization in human subjects. This study aimed to assess the effect of SSD on long-term kidney allograft outcome and to compare the immunization status of grafted patients presenting with SSD following ATG induction treatment.

METHODS

We analyzed data from a cohort of 889 first kidney graft recipients with ATG induction (86 with SSD [SSD(+)] and 803 without SSD [SSD(-)]) from the Données Informatisées et Validées en Transplantation data bank. Two subgroups of SSD(+) and SSD(-) patients that had received ATG induction treatment were then assessed for total anti-ATG, anti-Neu5Gc, and anti-Gal antibodies using ELISA assays on sera before and after transplantation.

RESULTS

SSD was significantly associated with long-term graft loss (>10 years, P = 0.02). Moreover, SSD(+) patients exhibited significantly elevated titers of anti-ATG (P = 0.043) and anti-Neu5Gc (P = 0.007) IgGs in late post-graft samples compared with SSD(-) recipients.

CONCLUSION

In conclusion, our data indicate that SSD is a major contributing factor of late graft loss following ATG induction and that anti-Neu5Gc antibodies increase over time in SSD(+) patients.

FUNDING

This study was funded by Société d'Accélération du Transfert de Technologies Ouest Valorisation, the European FP7 "Translink" research program, the French National Agency of Research, Labex Transplantex, the Natural Science and Engineering Research Council of Canada, and the Canadian Foundation for Innovation.

Cutaneous finding in anti thymocyte globulin induced serum sickness

Polyclonal anti-thymocyte globulin (ATG) is used as an immunosuppressive agent in the treatment of aplastic anemia (AA). Serum sickness is a recognized side effect of ATG. We observed abnormal skin manifestation in patient with aplastic anemia who had been treated with ATG. We conclude that abnormal immune function caused by aplastic anemia and ATG and corticosteroids may aggravate the signs of serum sickness.

Delayed allergic reaction to natalizumab associated with early formation of neutralizing antibodies

BACKGROUND

Natalizumab is a new therapeutic option for relapsing-remitting multiple sclerosis. As with other antibody therapies, hypersensitivity reactions have been observed. In the Natalizumab Safety and Efficacy in Relapsing-Remitting Multiple Sclerosis (AFFIRM) trial, infusion-related hypersensitivity reactions developed in 4% of patients, usually within 2 hours after starting the infusion.

OBJECTIVE

To report a significant, delayed, serum sickness-like, type III systemic allergic reaction to natalizumab.

DESIGN

Case report describing clinical follow-up and the serial measurement of antinatalizumab antibodies.

PATIENT

A 23-year-old man with relapsing-remitting multiple sclerosis developed a fever, arthralgias, urticarial exanthema, and a swollen lower lip during several days after his second infusion of natalizumab.

RESULTS

The patient developed a delayed, serum sickness-like, type III systemic allergic reaction to natalizumab. Five weeks after initiation of this therapy, he tested positive for antinatalizumab antibodies and exhibited persistent antibody titers 8 and 12 weeks later. His symptoms completely resolved with a short course of oral glucocorticosteroids.

CONCLUSION

Clinicians and patients should be alert not only to immediate but also to significantly delayed substantial allergic reactions to natalizumab.

Decay-accelerating factor but not CD59 limits experimental immune-complex glomerulonephritis

The complex balance between the pro-activating and regulatory influences of the complement system can affect the pathogenesis of immune complex-mediated glomerulonephritis (ICGN). Key complement regulatory proteins include decay accelerating factor (DAF) and CD59, which inhibit C3 activation and C5b-9 generation, respectively. Both are glycosylphosphatidylinositol-linked cell membrane proteins, which are widely distributed in humans and mice. Chronic serum sickness induced by daily immunization with horse spleen apoferritin over 6 weeks was used to induce ICGN in DAF-, CD59- and DAF/CD59-deficient mice, with wild-type littermate mice serving as controls. Both DAF and DAF/CD59-deficient mice had an increased incidence of GN relative to wild-type controls associated with significantly increased glomerular C3 deposition. Disease expression in CD59-deficient mice was no different than wild-type controls. DAF- and DAF/CD59-deficient mice also had increased monocyte chemoattractant protein-1 mRNA expression and glomerular infiltration with CD45(+) leukocytes. Our findings suggest that activation of C3 is strongly associated with experimental ICGN while downstream formation of C5b-9 is of lesser pathogenic importance in this model.

Polyclonal Antibody-Induced Serum Sickness in Renal Transplant Recipients: Treatment with Therapeutic Plasma Exchange

Serum sickness is an immune-complex mediated illness that frequently occurs in patients after polyclonal antibody therapy (ATGAM or thymoglobulin). Serum sickness presents with significant morbidity but is self-limited and resolves with prolonged steroid therapy. We present five renal transplant patients who developed serum sickness after polyclonal antibody treatment with severe symptoms that persisted after being started on systemic steroids. These patients underwent one or two courses of therapeutic plasma exchange (TPE) with subsequent complete resolution of their symptoms. Renal transplant recipients with serum sickness after polyclonal antibody therapy may benefit from TPE by accelerating their time to recovery and thereby reducing overall morbidity.

Pediatric bupropion-induced serum sicknesslike reaction

This reports the first 2 cases of serum sicknesslike reaction to bupropion in children (age 12 and 14). Serum sicknesslike reactions are an example of immune-complex medicated disease. The cardinal symptoms of serum sickness are fever, lymphadenopathy, arthralgias or arthritis, and urticaria. Symptoms usually resolve without long-term sequela following discontinuation of the exogenous antigen. It is likely that serum sicknesslike reactions to bupropion are either relatively rare or underrecognized and underreported. Between May 1998 and May 2001, GlaxoSmith Kline received 172 reports of seizures (a well-known adverse drug reaction) and only 37 reports of serum sicknesslike reactions (Wooltorton 2002). We do not know if children and adolescents are more prone than adults to develop serum sicknesslike reactions to bupropion. Luckily, the reported cases of serum sicknesslike reactions to bupropion have not caused irreversible morbidity or mortality. Nevertheless, the symptoms are painful, temporarily disfiguring and disabling, and warrant prompt medical attention. Parents and patients should be educated about this potential side effect at the onset of treatment, because symptoms are similar to many infectious childhood illnesses, and the treatment of serum sicknesslike reactions to bupropion should include the discontinuation of bupropion.

Complement Factor H Limits Immune Complex Deposition and Prevents Inflammation and Scarring in Glomeruli of Mice with Chronic Serum Sickness

Factor H is the major complement regulator in plasma. Abnormalities in factor H have been implicated in membranoproliferative glomerulonephritis in both humans and experimental animals. It has been shown that factor H on rodent platelets functions analogously to human erythrocyte complement receptor 1 in its role to traffic immune complexes to the mononuclear phagocyte system. C57BL/6 factor H-deficient mice (Cfh(-/-)) and wild-type (wt) controls were immunized daily for 5 wk with heterologous apoferritin to study the chronic serum sickness GN model. Immunizations were started in 6- to 8-wk-old mice, which was before the development of spontaneous membranoproliferative glomerulonephritis in some Cfh(-/-) animals. Glomerular deposition of IgG immune complexes in glomeruli was qualitatively and quantitatively increased in Cfh(-/-) mice compared with wt mice. Consistent with the increase in glomerular immune complexes and possibly because of alternative pathway complement activation, Cfh(-/-) mice had increased glomerular C3 deposition. Wt mice developed no glomerular pathology. In contrast, Cfh(-/-) mice developed diffuse proliferative GN with focal crescents and glomerulosclerosis. In addition, there was significantly increased expression of collagen IV, fibronectin, and laminin mRNA in Cfh(-/-) glomeruli. These data show a role for platelet-associated factor H to process immune complexes and limit their accumulation in glomeruli. Once deposited in glomeruli, excessive complement activation can lead to glomerular inflammation and the rapid development of a scarring phenotype.

Participation of the interstitium in acute immune-complex nephritis: interstitial antigen accumulation, cellular infiltrate, and MHC class II expression

Bovine serum albumin (BSA) injected into the rabbits induces acute immune complex glomerulonephritis. Since albumin is filtered and reabsorbed in the tubules, we investigated whether tubulointerstitial cells participate in the pathogenesis of this experimental condition. For this purpose, we induced immune-complex nephritis in 45 rabbits with the injection of 125I-BSA and urinary BSA excretion, glomerular and tubulointerstitial BSA accumulation, lymphocyte infiltration, proliferative activity and MHC class II antigens were examined 2, 4-5 and 6-8 days after immunization. Proteinuria developed day 6-8. BSA was found in urine from day 2 (mean +/- SE; 1089 +/- 339 micro g/24 h) and peaked on day 4 after immunization (2249 +/- 1106). BSA content (cpm/g tissue) in tubulointerstitium (TI) and glomeruli were similar at day 2 (457 +/- 45 and 407 +/- 75, respectively), but afterward increased significantly in TI, reaching a peak level on day 5 (1026 +/- 406) while remained unchanged in glomeruli (388 +/- 95). At the same time, preceding the onset of proteinuria, maximal intensity of the lymphocyte infiltration, proliferative activity and MHC class II antigen expression in tubular cells, monocytes/macrophages and interstitial cells were observed. Our study shows that antigen is excreted in the urine and concentrated in TI in association with overexpression of MHC class II molecules and lymphocyte infiltration. These findings occur prior to the development of proteinuria and suggest that the tubulointerstitial cells play a critical role in the pathogenesis of this model.

Severe serum sickness-like reaction to oral penicillin drugs: three case reports

BACKGROUND

Because the use of heterologous sera has diminished, the incidence of serum sickness has declined. However, serum sickness-like reactions to nonprotein drugs continue to occur.

METHODS

We report three cases of severe serum sickness-like reactions in adults to oral penicillin drugs.

RESULTS

In each patient, significant symptom resolution occurred within 24 hours of starting therapy with oral corticosteroids.

CONCLUSIONS

Serum sickness-like reactions to oral penicillin drugs may be more common than reported in the literature and can be very severe. No specific laboratory finding is universally present or definitively diagnostic. As with classic serum sickness, the diagnosis of serum sickness-like reaction is made clinically. In severe cases such as those presented here with debilitating joint symptoms or life-threatening angioedema, a diagnostic-therapeutic trial of prednisone, 40 to 60 mg at least once daily, is warranted.

Cyclosporin A reduces expression of adhesion molecules in the kidney of rats with chronic serum sickness

Treatment with cyclosporin A (CsA) improves proteinuria and reduces renal cellular infiltration in chronic serum sickness (CSS). We examined if these effects were associated with a reduced renal expression of CD54 and its ligands, interferon-gamma (IFN-gamma), tumour necrosis factor-alpha (TNF-alpha) and MHC class II molecules. We studied two groups of rats in which CSS was induced by daily injections of ovalbumin (OVA): a group treated with CsA (OVA.CsA group, n = 11) and a group that received no treatment (OVA.CSS group, n = 11). An additional group of five rats (control group) received only phosphate buffer. Immunostaining techniques were used to follow CSS and to study the expression of CD54, CD18, CD11b/c, IFN-gamma, TNF-alpha and MHC class molecules. Proteinuria (mg/24 h) was reduced from 248.2 +/- 73.1 (OVA.CCS group) to 14.5 +/- 13.1 with CsA treatment (P < 0.0001). The renal expression of CD54 and its ligands (CD18 and CD11b/c) was reduced by 50% to 75%. Correspondingly, there was a 60% to 85% reduction in the number of infiltrating leucocytes. The number of cells expressing TNF-alpha, IFN-gamma and MHC II molecules was also reduced. CsA reduces expression of CD54 and its ligands. This effect is associated with a reduction of cellular infiltration, IFN-gamma, TNF-alpha-producing cells and with MHC II expression in the kidney. These findings suggest that expression of adhesion molecules plays a critical role in CSS and underline the importance of cellular immunity in this experimental model.

Expression of adhesion molecules in chronic serum sickness in rats

Peripheral blood leukocytes infiltrate the kidney in chronic serum sickness (CSS). We therefore studied the expression of CD54 and its ligands CD18 and CD11b/c in CSS in 10 rats with CSS, 6 rats immunized similarly who did not developed proteinuria (no-CSS group), and 10 normal rats (control group). Intense (6 to 35 times more than controls) leukocyte infiltration was observed in CSS. The CSS group over-expressed CD54 in glomeruli and interstitium in association with increments in CD18- and CD11b/c-positive cells ranging 2.5 to 7 times the number found in controls. 75% of infiltrating leukocytes expressed CD18 and 87% expressed CD11b/c. The non-CSS group had leukocyte infiltration and expression of adhesion molecules similar to control group. Adherence of CD43-positive cells to renal tissues was 4 times higher in renal tissue from CSS rats than to normal kidney. Pretreatment with corresponding Mabs reduced adherence by half. We concluded that over-expression of CD54 and its ligands CD18 and CD11b/c in infiltrating leukocytes occur in CSS. Binding experiments suggest the functional relevance of these molecules.

[Role of hyperbaric oxygenation in mechanisms correcting the immunological reactivity in endotoxic shock and serum sickness]

The adaptation effect of hyperbaric oxygenation (3.0 Ata for 60 min) on white rats and mice with acute serum sickness is due to stimulation of non-pathogenic circulating immune complexes which do not fix the complement nor induce immune injuries to the kidneys. This promotes recovery of nephron ultrafiltration and decreases proteinuria. Hyperbaric oxygenation stimulates immunity in endotoxin shock by activating the humoral immunity and specific immune response.

False increase in C-reactive protein attributable to heterophilic antibodies in two renal transplant patients treated with rabbit antilymphocyte globulin

Increased serum C-reactive protein (sCRP) is a sensitive marker of renal graft rejection. We describe the cases of two children with uncomplicated renal transplantation who had false-positive sCRP values on analyzers using rabbit anti-CRP but values within the reference range with anti-CRP from other animal species. Cross-reaction with heterophilic antibodies was suggested by clinical and biological signs of serum sickness and daily treatment with rabbit antilymphocyte globulin (ALG). The interference depended on the serum concentration of the cross-reactant and was removed by subtotal IgG adsorption to Protein A or Protein G or by immunoadsorption using rabbit ALG or total IgG in non-immune rabbit serum. Anti-rabbit IgG and IgM antibodies were detected in both patients. These are the first reported cases of cross-reaction with heterophilic antibodies in a turbidimetric CRP assay.

Serum anti-rabbit and anti-horse IgG, IgA, and IgM in kidney transplant recipients

BACKGROUND

The therapeutic efficacy of horse antilymphocyte globulins (ALG) or of rabbit antithymocyte globulins (ATG), used for both the prevention and treatment of allograft rejection has been well documented. However, clinical use of these heterologous antibodies can result in the production of antibodies against horse or rabbit proteins and in the development of serum sickness via circulating immune complexes.

METHODS

We studied the production of human IgG, and IgM anti-rabbit and anti-horse globulins, in 240 serum samples from 111 kidney transplant recipients, of whom 89 were treated with ALG or ATG (Mérieux-France) as prophylaxis.

RESULTS

Up to 8.9% of the patients had anti-ALG and/or -ATG antibodies before the first transplantation. This proportion increased significantly after. Preimmunization did not appear to be predictive of the occurrence of clinical serum sickness, yet sensitization increased, after transplantation, in up to 71% of the subjects who developed this disorder (P = 0.02). In patients receiving a second transplant, pretransplantation antibody levels were not modified by the immunosuppressive therapy applied. No relationship was found between early rejection and antiglobulin antibodies.

CONCLUSIONS

Serum anti-rabbit and/or -horse antibodies were demonstrated in a significant proportion of kidney recipients, even before transplantation, possibly due to environmental exposure. A classical pattern of IgM increase was observed when the patients developed an immune response to ALG or ATG, and an IgA response after ALG. These results suggest that patients receiving ALG/ATG should be monitored for the production of anti-ALG/ATG immunoglobulins.

Serum sickness after wasp venom immunotherapy: clinical and biological study

We describe a case of a man who developed serum sickness during wasp venom immunotherapy. Remarkable features were unusually severe neurological symptoms, multiple relapses in the absence of rechallenge, parallel course between clinical symptoms, serum levels of specific reagins and their antibodies, and a dramatic response to plasma exchange therapy. Desensitization is widely used and can cause a wide range of adverse effects; however, systemic vasculitis is a very rare complication and we are not aware of any case similar to ours, with serum sickness after injection of highly purified hymenoptera antigen. Clinicians should be aware of such a possibility.

[Cefaclor therapy followed by serum sickness-like symptoms]

Cefaclor is an oral cefalosporin for a wide range of gram-positive and gram-negative infection. A retrospective study of cefaclor toxicoderma cases at the Department of Dermatology of Heim Pál Children's Hospital found 11 cases. After the administration of the drug, serum sickness like syndromes were observed. The characteristic symptoms were: erythema multiforme like urticaria, polyarticular swelling and oedema of joints and fever. Laboratory findings were: arised activity of the liver enzymes. After the acute symptoms urticaria factitia appeared.

T cell subsets in immunologically-mediated glomerulonephritis

Until recently, research on the pathogenesis of glomerulonephritis has been mainly focused on the characterization of humoral immune responses in the initiation of glomerular injury. However, there is a growing recognition that both cellular and humoral immune responses, in varying proportions, are involved in the pathogenesis of immunologically-mediated glomerulonephritis. T lymphocytes are essential cellular elements of cell-mediated immunity. Both in experimental models of immune-mediated renal disease and in histopathological analyses of human nephropathies, the involvement of T cells has been demonstrated in the immunoregulation of nephritogenic immune responses and in the immune injury in the kidney. T cell activation resulting in either delayed-type hypersensitivity, cytolytic reactions, abnormal expression of major histocompatibility complex (MHC) molecules, or B cell activation can result in glomerulonephritis. These different types of responses are exerted by distinct T cell subsets defined by cell surface markers and cytokine profiles. CD4+ T cells in vivo are functionally heterogeneous with respect to cytokine production and the CD45 isoforms that are found on their surface. Like CD4+ T cells, CD8+ T cells may also be heterogeneous at the level of cytokine production. The roles of CD4+ and CD8+ cells and their cytokine profiles in glomerulonephritis have not been extensively investigated yet, but such studies might improve the understanding of the pathogenesis and possibly lead to new therapeutic approaches of human glomerulonephritis. In this review the role of distinct T lymphocyte subsets in experimental and human glomerulonephritis will be discussed.

Monocyte chemoattractant protein-1 in chronic proliferative immune complex nephritis

In rats with chronic serum sickness, proliferative immune complex glomerulonephritis progresses in three discrete stages, designated mild, moderate, and severe. One distinguishing immunopathologic feature, the progressive increase in the number of glomerular macrophages, is closely correlated with decreasing kidney function. We hypothesized that monocyte chemoattractant protein-1, a beta-subfamily chemokine with potent monocyte-specific chemotactic activity, might contribute to this macrophage accumulation. Immunohistochemical methods were used to identify monocyte chemoattractant protein-1 in kidney tissue sections. Total RNA was extracted from the kidneys of rats at each stage of chronic serum sickness, and age-matched controls, and Northern blot analysis was performed with a rat monocyte chemoattractant protein-1 cDNA probe. Tissue staining localized monocyte chemoattractant protein-1 to the glomerular capillary wall and mesangium in chronic serum sickness. Minimal quantities of monocyte chemoattractant protein-1 mRNA were detected in the kidneys of normal control rats, with marked increases in mRNA as chronic serum sickness nephritis progressed to the moderate stage. There was then an apparent decrease in monocyte chemoattractant protein-1 mRNA in the severe stage. The degree of protein staining and mRNA levels paralleled each other. We conclude that monocyte chemoattractant protein-1 is a potentially important chemotactic agent in chronic serum sickness nephritis.

Atheroarteritis: a combined immunological and lipid imbalance

This report traces the development of our knowledge about immune-complex arteritis from the early 20th Century to the present time. The emphasis is on the work which began with the seminal observations of serum sickness by Longcope, MacKenzie, and Rich, to the pathogenetic studies of serum sickness arteritis in rabbits by several groups including the outstanding contributions by Dixon and coworkers concerning the role of circulating immune complexes. This work was followed by investigations of the relationship to atherosclerosis revealed by the sustained studies by Minick et al. on serum sickness arteritis in hypercholesterolemic rabbits. This pioneering research work has more recently been of pivotal value in understanding the arteritis observed in certain primate species such as the cynomolgus and the nemestrina, in human lupus erythematosus, and in organ transplantation arteritis. More recently it has become apparent that one of the microscopic hallmarks of this type of immune complex injury is the concentic micro-architecture of the inflammatory arterial lesions, for which, when they are also lipid containing, we have coined the term artheroarteritis. The contributions of the neoantigens from glycosylated LDL and oxidized LDL to the development of this type of atheroarteritis are considered. New frontiers in this area of research are being opened by the PDAY study which offers new opportunities to link circulating immune complexes and new antigens to arheroarteritis with its accelerated stenotic arterial lesion development.

Inducible osteonecrosis in a rabbit serum sickness model: deposition of immune complexes in bone marrow

We established inducible osteonecrosis in a rabbit serum sickness model. Osteonecrosis with marrow necrosis could be induced by the intravenous injection of horse serum in two doses separated in time by a period of three weeks. In this model, osteonecrosis could be successfully produced in rabbit femoral metaphysis. The incidence of marrow necrosis was 45% (9 of 20 rabbits) and trabecular necrosis occurred in 6 of 20 rabbits (30%) at 7 days after the second injection of the horse serum. In bone marrow of the femoral metaphysis, extravasation of erythrocytes and the formation of micro-thrombi in arterioles were often observed in an early stage of the present model and both findings correlate well each other (p = 0.0001). Immune complexes could be demonstrated using immunohistochemistry in bone marrow of the femoral metaphysis as well as in glomeruli of the kidney. Extravasation of erythrocytes in bone marrow of the femoral metaphysis was observed in 8 of 12 (67%) cases with immune complex deposition in the sinusoidal space of the femoral metaphysis and in 12 of 21 (57%) cases with immune complex deposition in glomeruli of the kidney. Immune complex deposition both in the sinusoidal space of femoral bone marrow (p = 0.0385) and in glomeruli of the kidney (p = 0.0209) closely related to extravasation of erythrocytes and microthrombi in arterioles in the early stage of this model. Early microcirculatory injury (extravasation of erythrocytes and microthrombi in arterioles) adjacent to osteonecrosis could be induced by immune complex deposition in femoral bone marrow and might be predictable characteristics for the inducible osteonecrosis in the present serum sickness model. The important findings in this study were that early microcirculatory injury was closely related to the deposition of immune complexes in femoral bone marrow, and that early microcirculatory injury associated with immune complex deposition was located close to osteonecrotic regions.

Serum-sickness-like reaction associated with minocycline therapy in adolescents

OBJECTIVE

To describe a serum-sickness-like reaction in five adolescents treated with minocycline.

CASE SUMMARY

Five adolescents developed a rash and arthralgias/arthritis after taking minocycline for 10-30 days. Symptoms resolved gradually after the medication was stopped.

DISCUSSION

Serum sickness is not described in the pharmacology literature as an adverse effect of minocycline, and in the English literature there are only two case reports. The migration inhibitory factor assay and mast cell degranulation test were positive in four of the five patients. The results of these assays were consistent with a role for minocycline in causing these reactions.

CONCLUSIONS

Clinicians should be aware of the possibility of serum-sickness-like reaction as an adverse effect of minocycline.

Arthritis associated with circulating immune complexes following administration of intravenous immunoglobulin therapy in a patient with chronic inflammatory demyelinating polyneuropathy

Intravenous immunoglobulin is viewed as a relatively safe treatment for several neurologic disorders. I report arthritis associated with elevated circulating immune complexes and abnormalities of serum complement components which is a rare complication with modern preparations of immunoglobulin-gamma.

Role of the extracellular matrix in the development of glomerulosclerosis in experimental chronic serum sickness

Glomerulosclerosis is a severe complication of many immunologically mediated kidney diseases and is associated with a poor prognosis with respect to renal function. The aim of this study was to elucidate the role of the extracellular matrix (ECM) in the development of glomerulosclerosis in experimental immune complex glomerulonephritis. Induction of chronic serum sickness by repetitive injections of human IgG into preimmunized Wistar rats leads to the development of immune complex nephritis and glomerulosclerosis. At an early stage of the disease fibrinogen accumulation was observed along the endothelial cells, presumably related to damage of the endothelial lining. mRNA levels for several collagen types, laminin B1 and B2, and fibronectin were increased in both whole-kidney tissue and in isolated glomeruli, but morphological changes were not observed. In situ hybridization experiments demonstrated increased ECM mRNA levels in glomerular and tubular cells. Starting at week 15, glomerular mesangial matrix expansion and thickening of the glomerular basement membrane (GBM) was observed. ECM components were abundantly present. Coagulation factors were not observed at this point. ECM mRNA levels were decreased as compared to week 0, but were still above normal. Focal and segmental end-stage sclerotic lesions developed at weeks 25-30, in which fibronectin and fibrinogen were the major constituents. Other ECM components were found peripherally from these lesions in the remnants of the mesangial matrix and GBM. Sclerotic matrices did not demonstrate an increase of cellular-fibronectin, and other constituents from the circulation were not present in the lesions. Glomerular ECM mRNA was decreased to normal levels. However, a dramatic increase of ECM mRNA expression was observed at sites of inflammatory infiltrate in the perivascular, interstitial, and periglomerular regions. In conclusion, the development of glomerulosclerosis in chronic serum sickness rats is preceded by mesangial matrix expansion in which several ECM components are increasingly expressed. Steady state mRNA levels for these components are increased before morphological changes are detectable. In the final stage there is a specific accumulation of exogenous fibronectin in the glomerular end-stage sclerotic lesions. Simultaneously, an interstitial inflammatory reaction takes place leading to increased ECM production in the tissue surrounding the damaged glomeruli.

The immune reaction to heterologous serum causes osteonecrosis in rabbits

Osteonecrosis (ON) was produced experimentally in rabbits by intravenous injection of horse serum. Eighty adult rabbits were used: 16 were injected twice with isotonic saline (Group A), 24 were injected once with saline and once with horse serum (Group B), and 40 were injected twice with horse serum (Group C). Both femurs of each rabbit were obtained from 2 h to 7 weeks after the final injection an were subjected to histological examination. No pathological changes were seen in Groups A and B. In Group C, 5 of 15 rabbits (33%) showed ON (necrosis of trabecula and bone marrow) in the femoral metaphysis. In Group C, the early major pathological findings in bone marrow are extravasation of erythrocytes in sinusoidal spaces and microthrombi in small arteries and arterioles near the lesion of extravasation. Immune complexes were demonstrated in the kidney within 24 h of the final injection of horse serum. The present study suggests that immunological reaction associated with serum sickness may play an important role in inducible ON and this model will contribute toward clarifying the pathogenesis of ON.

Serum sickness-like reactions to cefaclor: role of hepatic metabolism and individual susceptibility

In an effort to explain the increased incidence of serum sickness-like reactions (SSLR) in patients receiving cefaclor, we used an in vitro murine microsomal system as a surrogate for in vivo hepatic drug biotransformation. Lymphocytes from three groups of subjects were exposed to a nonselective mixture of cefaclor metabolites. After an 18-hour incubation of lymphocytes with these metabolites, cells were examined for viability by trypan blue exclusion. The subject groups consisted of patients with a previous history of SSLR after cefaclor therapy (n = 19), patients who experienced adverse reactions to cefaclor suggestive of immediate hypersensitivity (n = 11), and control subjects who had previously tolerated at least two courses of cefaclor therapy without adverse effect (n = 9). Additionally, immediate family members of six subjects with cefaclor-associated SSLR were studied. Lymphocyte killing was 100% greater than baseline (i.e., a non-drug-containing control) in subjects with SSLR compared with those with immediate hypersensitivity reactions (4% cell death above baseline; p < 0.001) and nonaffected control subjects (6% cell death above baseline; p < 0.001). Family studies were consistent with a pattern of maternal inheritance; five of six mothers who had not received cefaclor had a positive (i.e., > or = 35% cell death above baseline) in vitro cytotoxic response. Other studies confirmed the requirement for biotransformation of the parent drug to elicit cell death, demonstrated specificity of the reaction to cefaclor, illustrated a lack of cross-reactivity to cephalexin in subjects with SSLR to cefaclor, and verified the reproducibility of the reaction over time in an affected subject. Our findings indicate that cefaclor associated SSLR may be a unique adverse drug reaction that requires biotransformation of the parent drug and may result from inherited defects in the metabolism of reactive intermediates. Furthermore, this condition can be retrospectively confirmed with an in vitro lymphocyte-based cytotoxicity assay.

Serum sickness due to bovine serum albumin sensitization during in vitro fertilization

Of 32 women included in the in vitro fertilization (IVF) program in our hospital in 1987, in whom a medium containing bovine serum albumin (BSA) (Menezo's medium) was employed for rinsing follicles, 5 (15%) developed a symptom complex compatible with serum sickness within 8-12 days after oocyte retrieval by echographic puncture. All the patients had specific IgG antibodies against BSA, and intradermal skin testing with BSA and Menezo's medium were positive. We could not demonstrate the presence of specific IgE against BSA in serum by RAST, probably due to the presence of high levels of specific IgG antibodies, which can interfere in the RAST procedure. Statistical analysis showed that the volume of Menezo's medium was significantly greater (p < 0.05) in patients developing the disease. The risk of disease development is directly related to the amount of heterologous protein administrated.

Glomerular macrophage phagocytic activity in experimental immune complex nephritis

In rats with the proliferative immune complex glomerulonephritis of chronic serum sickness, kidney function deteriorates in three clearly distinguishable and discrete stages: mild, moderate and severe. The macrophage component of glomerular inflammation in each stage is also quantitatively and qualitatively distinct, with abnormal phenotypic markers appearing in the moderate stage and increasing in the severe stage. To determine whether there were distinct functional differences among macrophages from the three stages, Fc gamma receptor-mediated phagocytic capacity was measured. The phagocytic capacity of glomerular macrophages increased significantly in the moderate stage, then significantly decreased, as rats progressed to severe chronic serum sickness. This decline in phagocytic function was not associated with a decrease in the expression of Fc gamma receptors on the glomerular macrophage cell surface. Furthermore, the phagocytic function of peritoneal macrophages from rats with severe chronic serum sickness was not impaired. Whether or not this attenuation of glomerular macrophage phagocytic capacity is the cause, or result, of renal disease progression remains unclear. It may indicate a potentially protective role for intraglomerular macrophages, and can serve as an additional functional marker of disease progression.

Effects of glomerular macrophages on mesangial cells in rat serum sickness glomerulonephritis: a comparison of histological and co-culture studies

Effects of glomerular macrophages on mesangial cell proliferation at different stages of experimental serum sickness nephritis (SSN) in the rat were examined using a direct co-culture system. The results were compared with the manifestations of glomerular tissue at the same points in time during the course of the SSN, especially with regard to glomerular infiltration and glomerular cell proliferation. Macrophages were isolated from the glomeruli at different points in time during the course of the SSN. While the number of glomerular macrophages increased during the sensitization, the proliferating cell nuclear antigen/cyclin positivity of the glomerular tissue was increased after cessation of the antigenic sensitization. The effect of macrophages on mesangial cell proliferation was relatively diminished during the sensitization but was augmented thereafter. Proliferating cells were mostly attached by macrophages, suggesting the importance of the proximity of macrophages for mesangial proliferation. These results suggest that mesangial cell proliferation is largely influenced by macrophage function variability in the glomeruli during the course of SSN.

Immune events in lymphoid tissues during experimental glomerulonephritis

To investigate immune events within lymphoid tissues and their role in relation to glomerular disease, systemic lymphoid tissues from rats with accelerated experimental anti-GBM glomerulonephritis or with primed serum sickness glomerulopathy were studied. Following disease induction, changes in leukocytic populations within lymphoid tissues were analysed over a 28 day time course by immunoperoxidase labelling with monoclonal antibodies. In anti-GBM glomerulonephritis there was rapid and severe renal injury and pulmonary hemorrhage (Good-pasture's syndrome). In these rats, antigen (rabbit IgG) was deposited on the GBM and within germinal centres of lymphoid tissues. From day 3 onwards, there was a significant increase in the number of T cells, presumably CD4+ T helper cells, present within enlarged germinal centres of kidney draining lymph nodes, axillary lymph nodes and spleen (p < 0.05) which peaked at day 14 (up to 28% of total cells) when there was intense deposition of rat IgG and C3 on the GBM. Similarly, increased numbers of ED1+ macrophages were evident in both germinal centres and T cell areas (paracortex and periarteriolar lymphoid sheath). Notably, the appearance of IL-2R expression in germinal centres and T cell areas was apparent from day 7 onwards. This was the time when widespread renal interstitial infiltration, cellular immune activation and severe renal functional and histological injury developed. In addition, antigen deposited in germinal centres was found to be associated with CD4+, CD5-, ED1- cells, most probably antigen presenting dendritic cells. In contrast, in acute serum sickness there was no antigen deposited in germinal centres and only mild renal injury and minor changes within lymphoid tissues.(ABSTRACT TRUNCATED AT 250 WORDS)

[Occurrence of antifibrinogen antibodies in serum of individuals diagnosed with serum sickness]

Occurrence and antifibrinogen antibodies level have been determined in sera of 50 individuals with serum sickness and in 50 blood donors constituting the control group. Antifibrinogen antibodies have been detected in blood of 41 (82%) blood recipients. Titre of these antibodies have ranged from 1:8 to 1:512, and their agglutination potency has ranged from 5 to 67 Dunsford's units. Immediately after serum sickness diagnosis a decrease in both level and agglutination potency of these antibodies has been noted. Further treatment with full blood constantly increased both the level and agglutination potency of antifibrinogen antibodies. It is probable, that fibrinogen and its degradation products present in the given blood stimulated antibodies production. This hypothesis is fortified by the observation, that stable decrease in both the level and agglutination potency of antifibrinogen antibodies in patients with serum sickness treated with washed erythrocytes. Antifibrinogen antibodies of a titre ranging from 1:4 to 1:16, and agglutination potency of 5-18 Dunford's units have been detected in 14 blood donors constituting a control group. Specificity of the detected antifibrinogen antibodies as well as their IgG character have been also confirmed.

The effect of cyclosporin A on disease progression in proliferative immune complex glomerulonephritis

In rats with the proliferative immune complex glomerulonephritis of chronic serum sickness, kidney function deteriorates in three discrete and readily distinguishable stages: Mild, Moderate, and Severe. The mononuclear cell composition of glomerular inflammation is also different in each stage. The immunosuppressive drug, cyclosporin A, was administered to rats with chronic serum sickness in order to investigate the relationship between glomerular immunopathology and pathophysiology in proliferative immune complex nephritis. When introduced after the onset of proteinuria, daily treatment with cyclosporin A failed to prevent the progression from Moderate to Severe nephritis, which is characterized by the abnormal differentiation and local proliferation of glomerular macrophages, as well as grave deterioration in kidney function. In contrast, when cyclosporin A therapy started before the onset of proteinuria, the course of proliferative glomerulonephritis was altered significantly. Although the levels of proteinuria and macrophage accumulation that are characteristic of the Moderate stage of nephritis were not reduced, progression to Severe nephritis did not occur. The number of glomerular macrophages appeared to increase in two separate phases in this chronic serum sickness model of proliferative immune complex glomerulonephritis. The first phase, which coincided with the onset of proteinuria, did not require T cells and culminated only in moderate hypercellularity and proteinuria. The second increase in the number of glomerular macrophages, which was accompanied by the expression of abnormal macrophage phenotypes, was closely linked to the development of severe kidney insufficiency. The protective effect of cyclosporin A therapy was consistent with, although not conclusive proof for, the hypothesis that local T cell activation may contribute to the progression of proliferative immune complex glomerulonephritis. Since cyclosporin A can also directly influence the responses of macrophages and mesangial cells, the effect of the drug on the course of nephritis in this model might not be related to its immunosuppressive action.

Serum sickness related to current procedures of in vitro fertilization--a case report

A variety of cutaneous and systemic adverse reactions related to procedures of in vitro fertilization (IVF) have been reported, among them skin reactions secondary to LHRH agonists--attributed to nonspecific histamine release--and a serum sickness-like syndrome which appears to be related to heterologous sera contained in the rinsing solution for graafian follicles. We report here the case of a 41-year-old woman who on two occasions suffered from clinical features consistent with serum sickness after being submitted to current IVF protocols. A specific IgG-mediated reaction against bovine serum albumin (BSA) was demonstrated. The avoidance of BSA or other heterologous sera in the rinsing solutions for graafian follicles is advisable in all IVF protocols, since it adds an unnecessary risk of developing immune complex-related illness.

Heparin causes partial removal of glomerular antigen deposits by a mechanism independent of its anticoagulant properties

We have previously reported that heparin can enhance the removal of antigen from the glomeruli of rats with chronic serum sickness glomerulonephritis. We have performed two studies to investigate the relevance of anticoagulation to this effect. The first experiment was essentially a repeat of those described before, but instead of using heparin, anticoagulation was achieved using Ancrod, which causes depletion of fibrinogen. The amount of antigen in the glomeruli of these rats at the end of the experiment did not differ from controls. In the second experiment, both kidneys were excised from rats with glomerulonephritis induced by a radiolabelled cationic antigen. Of each pair of kidneys, one was perfused for 30 min at 5 ml/min with Hank's balanced salt solution (HBSS) at 37 degrees C. The other was perfused with HBSS to which a total of 4500 units of heparin had been added. The antigen content of isolated glomeruli was subsequently measured. In every case, the kidney perfused with heparin had less antigen per glomerulus than the control contralateral kidney. The ability of heparin to enhance removal of glomerular immune complex deposits is therefore not mediated by anticoagulation.

An immunodominant haptenic epitope of carbamazepine detected in serum from patients given long-term treatment with carbamazepine without allergic reaction

An anticarbamazepine antibody was detected in the serum of a patient with severe carbamazepine-induced serum sickness. We found that the patient's T cells and IgG antibody recognized an epitope which appeared in subjects showing an allergic reaction, as well as that in subjects who showed no allergic reaction, after long-term carbamazepine therapy. These results show that an anti-carbamazepine immune response does not occur in the majority of subjects who undergo long-term carbamazepine therapy without developing allergic symptoms, although the immunodominant haptenic epitope of carbamazepine is present in their sera.

Attempts to induce immune-mediated cerebral arterial injury for an experimental model of moyamoya disease

To examine the possible role of immune complex-mediated reactions in moyamoya disease, a novel experimental system using a serum sickness vasculitis model combined with intracisternal administration of antibodies or antigens was developed. Twenty-eight male Japanese white rabbits were divided into four experimental groups. Group I was treated twice with intravenous injections of heterologous serum. In group II, intracisternal administration of antibodies or antigens was combined with the second injection of serum. Group III received a single intravenous injection of antigens simultaneously with intracisternal administration of antibodies. Group IV was a technical control group. Cerebral arteritis, although likely in the initial process, was induced only in groups II and III. This study suggests that the cerebral arteries rarely develop arteritis in a serum sickness model alone. The cerebral arteries may require additional intracisternal administration of antibodies or antigens to induce in situ deposition of immune complexes around them.

Acute serum sickness in normal and C6 deficient rabbits: role of membrane attack complex

Acute serum sickness was induced in New Zealand White (NZW) and in C6 deficient (C6D) rabbits, to compare the histology, immunofluorescence, especially distribution of poly C9 (MAC), and electron microscopic characteristics of the disease in each strain. Glomerulonephritis and albuminuria of comparable extent occurred in 13/17 NZW and 4/8 C6D rabbits. In NZW rabbits with albuminuria an early intense glomerular infiltration by mononuclear cells was associated with focal small fine granular glomerular basement membrane (GBM) deposits of IgG and BSA and more diffuse and larger deposits of C3 and MAC. After the disappearance of monocytes and decrease in mesangial cell proliferation, development of large subepithelial GBM deposits rich in all immune reactants was observed in NZB rabbits. In C6D rabbits with albuminuria a similar monocytic infiltrate occurred, but no association with IgG and C3 GBM immune deposits was noted. No deposits of MAC and no large subepithelial GBM 'humps' were observed in C6D rabbits. We conclude that the exudative (monocytic) phase of glomerular injury and albuminuria in acute serum sickness nephritis are not dependent upon terminal complement components, but the subsequent formation of large subepithelial GBM deposits does not occur in this model in the absence of MAC.