Protease-activated receptor-4 inhibition protects from multiorgan failure in a murine model of systemic inflammation

Coagulation proteases may act as cell signaling molecules via protease-activated receptor (PAR) cleavage, subsequently affecting cellular and inflammatory responses. Activation of PARs in the setting of systemic inflammation and disseminated intravascular coagulation (DIC) might thus exacerbate the inflammatory response contributing to tissue and organ damage. To investigate the role of PAR-4 in these processes, we subjected mice to a model of systemic inflammation and DIC (Shwartzman reaction) in the absence or presence of a cell-penetrating pepducin antagonist of PAR-4 (P4pal-10). P4pal-10 dose-dependently diminished the severity of endotoxemia and preserved liver, kidney, as well as lung function. Moreover, systemic inflammation and local (neutrophilic) inflammatory responses were attenuated. In vitro migration assays and P4pal-10 treatment in neutropenic mice suggest an essential role for neutrophils in PAR-4-mediated pathology. P4pal-10 treatment of thrombocytopenic mice excluded the involvement of platelets in this phenomenon. These results uncover an important role for PAR-4 in the Shwartzman reaction and suggest that inhibition of PAR-4 signaling in neutrophils could be protective in systemic inflammation and DIC.

Loss of SLP-76 expression within myeloid cells confers resistance to neutrophil-mediated tissue damage while maintaining effective bacterial killing

The Src homology 2 domain-containing leukocyte phosphoprotein of 76 kDa (SLP-76) is an adaptor molecule critical for immunoreceptor and integrin signaling in multiple hemopoietic lineages. We showed previously that SLP-76 is required for neutrophil function in vitro, including integrin-induced adhesion and production of reactive oxygen intermediates, and to a lesser extent, FcgammaR-induced calcium flux and reactive oxygen intermediate production. It has been difficult to determine whether SLP-76 regulates neutrophil responses in vivo, because Slp-76(-/-) mice exhibit marked defects in thymocyte and vascular development, as well as platelet and mast cell function. To circumvent these issues, we generated mice with targeted loss of SLP-76 expression within myeloid cells. Neutrophils obtained from these animals failed to respond to integrin activation in vitro, similar to Slp-76(-/-) cells. Despite these abnormalities, SLP-76-deficient neutrophils migrated normally in vivo in response to Staphylococcus aureus infection and efficiently cleared micro-organisms. Interestingly, SLP-76-deficient neutrophils did not induce a robust inflammatory response in the localized Shwartzman reaction. Collectively, these data suggest that disruption of integrin signaling via loss of SLP-76 expression differentially impairs neutrophil functions in vivo, with preservation of migration and killing of S. aureus but reduction in LPS-induced tissue damage and vascular injury.

Local Shwartzman reaction in the rat induced by endotoxin and ischemia: potential model for skin necrosis in meningococcemia

The local Shwartzman reaction (LSR) is an inflammatory response in the skin that is considered a model for skin necrosis associated with meningococcemia. We tested the hypothesis that ischemia can act as the provocative agent to produce this response. In eight rats, bilateral inferior epigastric flaps were outlined. Within each flap, three injection sites were marked. Site 1 had 0.1 mL of endotoxin injected 24 h before surgery. The other two sites had either endotoxin or saline injected immediately before surgery. Both flaps were raised on their pedicle and one side rendered ischemic for 6 h and then reperfused. Animals were killed either 30 min or 48 h later and the tissue from each site examined. After 48 h of reperfusion, necrosis was grossly visible at the site of 24-h preischemia injection of endotoxin in three of four rats. No abnormalities were present at the other injection sites. Microscopically, all 24-h-delayed injection sites showed hemorrhage into all layers of the skin after both 30 min and 48 h of reperfusion. No hemorrhage was present at the other sites. These findings may serve as a potential model for the skin necrosis seen in meningococcemia.

Mac-1 signaling via Src-family and Syk kinases results in elastase-dependent thrombohemorrhagic vasculopathy

CD18 integrins promote neutrophil recruitment, and their engagement activates tyrosine kinases, leading to neutrophil activation. However, the significance of integrin-dependent leukocyte activation in vivo has been difficult to prove. Here, in a model of thrombohemorrhagic vasculitis, the CD18 integrin Mac-1 on neutrophils recognized complement C3 deposited within vessel walls and triggered a signaling pathway involving the Src-family kinase Hck and the Syk tyrosine kinase. This led to neutrophil elastase release, causing hemorrhage, fibrin deposition, and thrombosis. Mice genetically deficient in any of these components (C3, Mac-1, Hck, Syk, or elastase) were resistant to disease despite normal tissue neutrophil accumulation. Disease was restored in Mac-1-deficient mice infused with wild-type, but not kinase- or elastase-deficient, neutrophils. Elastase release in the inflamed tissue was reduced in Mac-1-deficient mice, and a deficiency of Mac-1 or the kinases blocked neutrophil elastase release in vitro. These data suggest that Mac-1 engagement of complement activates tyrosine kinases to promote elastase-dependent blood vessel injury in vivo.

Prevention of the localized and generalized Shwartzman reactions by an anticomplementary agent, cobra venom factor

Both localized and generalized Shwartzman reactions were induced in the same rabbits by simultaneous administration of preparatory intravenous and intradermal doses of endotoxin followed in 24 hr by the provocative dose. Control rabbits with more than 80% positive responses showed corresponding changes of platelet, white blood cell, fibrinogen, and hemolytic complement levels. Circulating fibrinogen and fibrin degradation products were detected shortly after the preparatory dose and persisted for at least 3 days. Rabbits given cobra venom anticomplementary factor showed hypocomplementemia (less than 10% of normal), leukocytosis, and elevated fibrinogen levels. After the administration of endotoxin, only one of 15 CVF-treated animals developed a Shwartzman reaction and that was mild. These rabbits showed only minor changes of platelet and fibrinogen levels throughout the experiment although their white blood cell responses were similar to those of the control group. No detectable fibrinogen and fibrin degradation products appeared in circulation, and the hemolytic complement activity increased gradually beginning with the preparatory dose of endotoxin. Thus depletion of terminal complement components (mainly C3) in rabbits is protective against the development of both localized and generalized Shwartzman reactions; its mechanism of action is probably through the sparing of platelets by inhibiting platelet-endotoxin interaction. The essential role of the complement system in Shwartzman reaction indicates that this coagulopathy probably represents a manifestation of immunologic injury.

Mast cell density during initiation and progression of the local Shwartzman reaction

OBJECTIVE AND DESIGN

To quantify the number of mast cells in the skin of rabbits during initiation and progression of the local Shwartzman reaction.

MATERIALS

Thirty New Zealand rabbits were divided in two groups (n = 15/group). One group was subjected to the Shwartzman reaction and the other group served as control. Subsequently, animals were further subdivided in six groups of five animals each according to time of euthanasia.

TREATMENTS

The local Shwartzman reaction was induced by two inoculations of Salmonella typhimurium lipopolysaccharide. Preparatory inoculation was given intradermally and, 24 h later, the provocative injection was administered intravenously. Controls were subjected to the same procedure but received saline. After provocative injection animals were killed at 1, 8, and 15 days.

METHODS

Skin samples were fixed in Carnoy's solution and mast cells were identified employing a low pH toluidine blue stain. Numbers of mast cells were determined per square millimetre and, subsequently, those cells degranulated were identified and quantified to obtain absolute values. A Student's t test was initially used to compare Shwartzman versus controls at each time point. Subsequently, an ANOVA test employing a factorial experiment was used to assess a possible interaction between time of euthanasia and treatments.

RESULTS

The values were transformed (natural logarithms) for appropriate statistical comparisons. Independent comparisons at each time point showed that Shwartzman groups had higher numbers of mast cells than controls at 1 and 8 days, but not at 15 days (5.71 +/- 1.00 Vs. 2.40 +/- 0.58, P < 0.005; 3.77 +/- 0.90 Vs. 2.33 +/- 0.56, P < 0. 025, and 2.61 +/- 0.25 Vs. 2.39 +/- 0.39, P > 0.05, respectively). Degranulated cells were numerous in Shwartzman groups, particularly at day 1 (3.48 +/- 0.78) and less obvious at day 8 (0.72 +/- 0.50), but were scarce by day 15 (-0.67 +/- 0.99) as well as controls (-0.68 +/- 0.91). The factorial experiment demonstrated that the Shwartzman reaction and time of euthanasia were independently significant (P < 0.005) but their interaction at day 1 was the major contributor (P < 0.005). Tukey's w pairwise comparisons of means confirmed that the Shwartzman group killed at day 1 was significantly different from the others (P < 0.05).

CONCLUSIONS

Mast cells significantly increase in the early stages of the local Shwartzman reaction. Thus, mast cells are a highly dynamic cell population, which have a prominent role during the acute phase of this lipopolysaccharide-induced inflammatory reaction but not during healing.

Shwartzman phenomenon in a patient with active systemic lupus erythematosus preceding fatal disseminated intravascular coagulation

The recurrence of widespread and diverse vascular lesions is a hallmark of systemic lupus erythematosus (SLE). Inflammatory and thrombotic mechanisms almost invariably associated with circulating antiphospholipid antibodies play a role in the pathogenesis of SLE-related vascular disease. Both mechanisms can coexist in the same patient. Vasculitis is most commonly induced by the local deposition of immune complexes. However, some SLE patients have an inflammatory complement-mediated vascular injury in the absence of immune complex deposition. We report on a fatal case of disseminated intravascular coagulation (DIC) in a young woman with active SLE. Hemorrhagic lesions due to localized intravascular coagulation (Shwartzman phenomenon) preceded disseminated intravascular coagulation accompanied by disseminated cardiac necrosis. Immune complex 'independent' and other mechanisms of vascular injury and states of hypercoagulability will be discussed.

Different pathways leading to cutaneous leukocytoclastic vasculitis in mice

To investigate the pathomechanisms of leukocytoclastic vasculitis (LcV) we compared mouse models of LcV with non-vasculitic irritant contact dermatitis (ICD). Criteria for LcV as met by the immune complex-mediated Arthus reaction (Art-r) were also fulfilled by the localized Shwartzman reaction (Shw-r) and by cutaneous Loxoscelism (Lox) (injection of venom from Loxosceles reclusa containing sphingomyelinase D). After depletion of PMN (by gamma-irradiation) vessel damage could not be elicited in these models, distinguishing them from models of direct endothelial insult (necrotizing ICD). Depletion of complement could only delay, but not inhibit the Art-r, and did not change ICD, Lox or the Shw-r. The Shw-r exclusively revealed a sustained local expression of vascular adhesion molecules for 24 h in the preparatory phase (LPS s.c.), not observed in the Art-r, in Lox or ICD. Subsequent challenge with LPS i.p. was associated with upregulation of Mac-1 and ICAM-1 on PMN, but not of VLA-4 or LFA-1 (FACS analysis). Cytokines which were able to replace LPS in priming for LcV in the Shw-r (TNF-alpha and IL-1beta) also induced sustained expression of adhesion molecules, whereas IL-12 and IFN-gamma did neither. Neutralizing IL-12 or IFN-gamma also inhibited neither LcV nor sustained expression of adhesion molecules, whereas anti-TNF-alpha inhibited both. Anti-TNF-alpha had no marked inhibitory effects in the Art-r, in Lox or ICD. Combined (but not separate) neutralization of both E-selectin and VCAM-1 by antibodies suppressed LcV independent from reducing influx of PMN, proving that their sustained expression is decisive for the Shw-r and interferes with normal diapedesis. Since Loxosceles venom is known to dysregulate diapedesis and degranulation of PMN in vitro, since adherent immune complexes activate PMN at the vessel wall, and since adhesion molecules are dysregulated in the Shw-r, we suggest that LcV develops when activation of PMN coincides with vascular alterations which interfere with normal diapedesis.

Exacerbation of vascular endothelial injury in the generalized Shwartzman reaction by the administration of anti-E-selectin antibody

Previously, we reported that the consecutive administration of lipopolysaccharide (LPS) into LPS-sensitized mice for the generalized Shwartzman reaction (GSR) induced systemic injury of vascular endothelial cells. The aim of this study was to investigate the participation of vascular adhesion molecules in the vascular endothelial injury of GSR. The administration of anti-E-selectin antibody in GSR-induced mice resulted in massive apoptosis of vascular endothelial cells and congestion in blood vessels. Further, marked hemorrhage was found in the pulmonary alveoli of those mice. GSR, especially lung injury, was definitely exacerbated by the administration of anti-E-selectin antibody. On the other hand, the administration of anti-VCAM-1 antibody did not induce such injury of vascular endothelial cells. The possible role of E-selectin in the exacerbation of vascular endothelial injury in GSR is discussed.

The potential role of the Arthus and Shwartzman reactions in the pathogenesis of pneumonic pasteurellosis

Pneumonic pasteurellosis (PP) is an economically important disease in cattle, sheep, and goats. Pasteurella haemolytica is commonly isolated from the severe fibrinopurulent pneumonia that characterize this respiratory syndrome. During infection, the bacteria produce leukotoxin (LKT) and lipopolysaccharide (LPS), both potent inducers of inflammation. Nonetheless, it has also been demonstrated that an exacerbated host's inflammatory response is responsible for the severe lung damage. Despite research in this field, the pathogenesis of PP is still incomplete. Two classical models of acute inflammatory response induced in laboratory animals, the Arthus and Shwartzman reactions, could explain the pathogenesis of the severe lung lesions that characterize PP.

Expression of Fas and Fas ligand on mouse renal tubular epithelial cells in the generalized shwartzman reaction and its relationship to apoptosis

Previously we reported that the consecutive injection of lipopolysaccharide (LPS) into LPS-sensitized mice for the generalized Shwartzman reaction (GSR) appeared to induce the injury of renal tubular epithelial cells via apoptosis. The aim of this study was to characterize the mechanism of renal tubular epithelial cell injury in GSR. The expression of Fas and Fas ligand was immunohistochemically detected on renal tubular epithelial cells from GSR-induced mice, although neither Fas nor Fas ligand was found in cells from untreated control mice or in cells from mice receiving a single injection of LPS. GSR-induced renal tubular epithelial cell injury was produced in neither Fas-negative MRL-lpr/lpr mice nor Fas ligand-negative MRL-gld/gld mice. The administration of anti-gamma interferon antibody together with a preparative injection of LPS prevented the expression of Fas and Fas ligand and the apoptosis of renal tubular epithelial cells. A provocative injection of tumor necrosis factor alpha into LPS-sensitized mice augmented Fas and Fas ligand expression and the apoptosis of renal tubular epithelial cells. The administration of tumor necrosis factor alpha to interleukin-12-sensitized mice resulted in Fas and Fas ligand expression and the apoptosis. Sensitization with interleukin-12 together with anti-gamma interferon antibody did not cause the apoptosis of renal tubular epithelial cells. It was suggested that the Fas/Fas ligand system probably plays a critical role in the development of renal tubular epithelial cell injury through apoptotic cell death.

Involvement of tumor necrosis factor-alpha, interleukin-1 beta, interleukin-8, and interleukin-1 receptor antagonist in acute lung injury caused by local Shwartzman reaction

A local Shwartzman reaction (LSR) was prepared in rabbit lung as a model of acute lung injury. To induce LSR, intratracheal injection of lipopolysaccharide (LPS) 10 micrograms into the lower lobe of the right lung, followed 24 h later by i.v. injection of LPS (10 micrograms/kg). In the lung with the LSR, myeloperoxidase activity, representing neutrophil accumulation, peaked at 1-2 h and was sustained for 48 h after challenge with i.v. LPS. The lung water content peaked at 12 h, and decreased gradually. Histological findings showed diffuse interstitial widening, intra-alveolar leukocyte infiltration with hemorrhage, and alveolar exudate formation. The production of tumor necrosis factor-alpha (TNF-alpha), interleukin-1 beta (IL-1 beta), interleukin-8 (IL-8), and IL-1 receptor antagonist (IL-1 Ra) in the lung was analyzed. TNF-alpha first elevated and peaked at 0.5 h (66.5 +/- 16.7 ng/g.lung), subsequently, IL-1 beta and IL-8 increased and peaked at 2 h (17.8 +/- 3.4 ng/g.lung and 336.9 +/- 49.6 ng/g.lung, respectively). IL-1Ra was present even before the challenge, and the production increased to show a dual peak (0.5 h, 1.5 +/- 0.2 micrograms/g.lung; and 2 h, 1.6 +/- 0.1 micrograms/g.lung), and a large concentration of IL-1Ra was sustained for 48 h. Immunohistochemistry showed that the cellular source of these cytokines was alveolar macrophages and infiltrating neutrophils. Thus, disclosing the kinetics of the generation of cytokines led to a better understanding of their roles, namely TNF-alpha as an initiator, IL-1 and IL-8 as amplifier and effector, and IL-1Ra as regulator of the intensity of acute inflammation.

Effect of soluble P55 tumour-necrosis factor binding fusion protein on the local Shwartzman and Arthus reactions

1. In this study, the effects of a protein synthesis inhibitor, cycloheximide, and a soluble tumour necrosis factor (TNF) binding/IgG fusion protein, p55-sf2, on the priming and challenge stages of the local Shwartzman reaction (LSR) were assessed and compared with their effects on the acute inflammatory response induced by recombinant human tumour necrosis factor-alpha (rhTNF), lipopolysaccharide (LPS) and a reversed passive Arthus (RPA) reaction in rabbit skin. 2. The LSR was induced in skin by giving an intradermal (i.d.) priming injection of LPS followed by two i.v. challenge injections 20 h and 22 h later. Accumulation of 51-Cr-labelled red blood cells and [125I]-albumin were measured at 24 h as markers of haemorrhage and oedema formation, respectively. 3. The RPA reaction was induced in the rabbit by giving i.d. injections of Arthus anti-serum (anti-bovine-gamma-globulin, BGG) followed 5 min later by an i.v. injection of the antigen (BGG). Oedema formation and the accumulation of 111In-labelled neutrophils produced in the RPA reaction and in response to i.d. injection of rhTNF and LPS were measured over the 4 h period after inducing the responses. 4. A single local injection of cycloheximide (10 micrograms/site) did not inhibit neutrophil accumulation or oedema formation produced by 100% Arthus anti-sera. Although LPS injected i.d. induced a marked dose-dependent neutrophil accumulation, there was little associated plasma leakage. Cycloheximide (10 micrograms/site) did not significantly inhibit the neutrophil accumulation induced by LPS (0.1 microgram/site). In the LSR, priming i.d. injections of LPS caused a dose-dependent increase in haemorrhage and plasma leakage at skin sites after challenge with LPS (two injections of 100 micrograms, i.v.). Co-injection of a single dose of cycloheximide (10 micrograms/site) with LPS (30 micrograms/site) caused a marked reduction in the amount of haemorrhage. Local cycloheximide (10 micrograms/site) administered immediately before LSR challenge did not affect the responses produced in the LSR. 5. Neutrophil accumulation induced by TNF (0.17 micrograms/site) was abolished by co-administration of p55-sf2 (3 micrograms/site) whereas neutrophil accumulation induced by i.d. LPS and produced in the RPA reaction was not affected. In the LSR, haemorrhage and oedema formation were inhibited by p55-sf2 (3 micrograms/site) when it was administered i.d. with the LPS priming injection, but not when given i.d. immediately before LSR challenge. 6. These data suggest that the acute neutrophil accumulation produced in the RPA reaction and in response to i.d. LPS may not be dependent on local protein synthesis or TNF production. On the other hand, haemorrhage appears to be dependent on local protein synthesis during the priming phase but not during the challenge stage of the LSR. Importantly, haemorrhage and plasma leakage appear to be dependent on local TNF generation during the priming phase but not during the challenge stage of the LSR. Thus TNF appears to play a key role in the LSR in rabbit skin.

Effects of thalidomide on the local Shwartzman reaction in mice and rabbits

The Shwartzman reaction is an animal model displaying histopathological vasculitis phenomena. Extravasation and swelling due to increased vascular permeability and cellular infiltration, which are hallmarks of the Shwartzman reaction, were evaluated as leakage of i.v.-injected Evans Blue dye and by histological and immunohistological characteristics in rabbits and mice. (+/-)-Thalidomide, (-)-thalidomide, (+)-thalidomide and dexamethasone inhibited the increase of vascular permeability in the local Shwartzman reaction. Histologically, the intensity of the Shwartzman reaction was reduced. In mice thrombus formation and leukocytoclastic vasculitis was inhibited by (+/-)-thalidomide and (+)-thalidomide. ICAM-1 expression was markedly reduced after (+)-thalidomide injection. Thalidomide and dexamethasone pretreatment reduced Mac-1 expression on perivascular infiltrated granulocytes. The inhibitory effect of thalidomide on vasculitis of the Shwartzman reaction may thus be related to reduction of adhesion molecule expression.

Local skin reactivity after induction of Shwartzman reaction in rabbits

A local Shwartzman response was elicited in rabbits by an intradermal injection of the Salmonella typhosa endotoxin lipopolysaccharide (LPS) followed 24 hours later by an intravenous challenge injection with zymosan. After the intravenous challenge, necrotizing vasculitis developed in the prepared skin sites which was characterized by microthrombi, accumulation of neutrophil granulocytes, fibrin deposition and extravasation of red blood cells. Evans' blue extravasation into the altered tissue was significantly reduced, and histologically, the intensity of the Shwartzman reaction in the skin was reduced by pretreatment with thalidomide and dexamethasone. The mechanism of reduction of an LPS-induced local Shwartzman reaction by thalidomide is discussed.

Lesions resulting from attempted Shwartzman reaction in turkey poults inoculated with Pasteurella multocida lipopolysaccharide

Five-week-old turkey poults were given two consecutive intravenous injections (24 hours apart) of highly purified Pasteurella multocida lipopolysaccharide (LPS) in an effort to induce a generalized Shwartzman reaction. There were no gross lesions, and microscopic lesions were limited to focal hepatic necrosis with heterophil infiltration. Hepatic lesions did not differ qualitatively from lesions in turkeys given a single dose of lipopolysaccharide. Margination of heterophils in the pulmonary vasculature was observed in turkeys 4 hours after a single injection of LPS, but it was not present in turkeys given the consecutive injections of LPS. To induce a dermal Shwartzman reaction, turkeys were given intradermal injections of LPS followed by an intravenous injection of LPS 24 hours later. Although no grossly visible hemorrhagic dermal necrosis occurred, microscopic lesions, including heterophil infiltration, vasculitis, thrombosis, and necrosis, were present. Thrombosis and vasculitis were observed only in turkeys given the intravenous and intradermal LPS, whereas the other inflammatory changes were observed in turkeys given the intradermal injection of LPS and intravenous water. Prominent lymphocytic perivascular cuffing at the site of dermal injection was present in all turkeys given intradermal LPS.

Biological activities of lipopolysaccharide isolated from Vibrio cholerae O139, a new epidemic strain for recent cholera in Indian subcontinent

Biological activities of lipopolysaccharide (LPS) isolated from Vibrio cholerae O139, a new causative agent for recent cholera epidemic in Indian subcontinent, were investigated in comparison with those of LPS from O1 V. cholerae. V. cholerae O139 LPS exerted mitogenic activity, lethal toxicity and Shwartzman reaction to the same extent as those observed for O1 V. cholerae LPS, although these activities except for lethal toxicity were obviously lower than those of Salmonella typhimurium LT-2 LPS used as a reference. It was, therefore, suggested that O139 LPS does not contribute to the high infective and pathogenic potentials of the V. cholerae O139 strain as in the case of O1 V. cholerae.

Characterization of neutrophil activation by repeated injection of endotoxin in rabbits. Role of neutrophils in the generalized Shwartzman reaction

The relationship between activated neutrophils and end-organ injury in endotoxemia was studied. The function of peripheral blood neutrophils (PMNs) in rabbits with the generalized Shwartzman reaction (GSR) was compared to that of PMNs rabbits receiving a single injection of endotoxin. The following results were obtained: (1) PMNs from rabbits with the GSR demonstrated enhanced adherence to endothelial cells and increased mitochondrial ATP production; (2) the GSR did not enhance chemotaxis and oxygen radical production of PMNs; (3) a single injection of endotoxin did not cause necrosis of visceral organs; (4) in vitro detachment of endothelial cells by PMNs was increased in rabbits with the GSR; (5) in vivo administration of monoclonal antibody (mAb) against CD11b/CD18 (Mac-1) suppressed the increase in PMN adherence; and (6) hemorrhagic necrosis did not occur when mAb to Mac-1 was injected. Thus, enhanced adherence of PMNs to endothelial cells appears to play a key role in endotoxin-induced end-organ injuries in this animal model.

Increased susceptibility of aged rats to haemorrhage and intravascular hypercoagulation following endotoxin administered in a generalized Shwartzman regime

Ageing rats are known to have an increased incidence of myocardial fibrosis and dyspnoea caused by pulmonary intravascular coagulation. In order to determine whether endotoxin can be responsible for such responses in ageing rats we have exposed rats of differing ages (2 months, 16 months and 24 months) to single or repeated (two doses 24 h apart; generalized Shwartzman regime) intravenous doses of endotoxin (E. coli 0111 B4). Only the 2-year-old rats reacted adversely. Two doses of endotoxin produced death, with focal myocardial necrosis, haemorrhage and pulmonary and hepatic intravascular coagulation. The increased susceptibility of aged rats to the toxic effects of endotoxin explains some of the changes found in the tissues of old rats. The sporadic nature of both cardiac failure and dyspnoea as a cause of morbidity and mortality in ageing rats may be related to the need for two endotoxin episodes in a period of 24 h to provoke a generalized Shwartzman reaction, an occurrence likely to be relatively uncommon under natural conditions.

Bilateral renal cortical necrosis in two patients with Neisseria meningitidis sepsis

Two patients who developed bilateral renal cortical necrosis as a consequence of Neisseria meningitidis infections are described: 1 patient had meningococcemia and the other had meningococcal meningitis. Both patients developed a Shwartzman-like reaction, disseminated intravascular coagulation and irreversible renal failure. Renal biopsy showed sclerosis of the majority of glomeruli; some glomeruli showed capillary congestion, thrombosis and an increased number of neutrophils; the intralobular arterioles showed thrombotic occlusions.

Shwartzman reaction

The local and generalized Shwartzman reactions are models of thrombohemorrhagic skin necrosis and DIC, respectively. An intravenous preparatory injection of endotoxin followed by an intradermal injection of endotoxin 24 hours later elicits a thrombohemorrhagic lesion only at the site of intradermal injection of endotoxin in the local Shwartzman reaction. Two intravenous injections of endotoxin spaced 24 hours apart induced a systemic generalized Shwartzman reaction characterized by coagulopathy, petechial hemorrhages, microthrombi, and decreased circulating platelets similar to DIC. Of particular interest is the observation that thrombohemorrhagic lesions of the Shwartzman reaction only develop at sites of intradermal injections of endotoxin. Microthrombi composed of platelets and leukocytes only adhere or accumulate in dermal vessels after an intradermal injection of endotoxin. Prior to the endotoxin injection, biopsies of skin show normal vessels without microthrombi or significant inflammation. Since endothelial cells line the small vessels in the dermis, where a Shwartzman reaction appears to be initiated, it is likely that endothelial cells are important for initiating a local Shwartzman reaction. IL-1 and TNF can substitute for the intradermal injection of endotoxin in the local Shwartzman reaction, induce endothelial cells to become thrombogenic, and can induce the expression of cell adhesion molecules on endothelial cells making endothelial cells more sticky for leukocytes. These observations suggest that endothelial cells play a central role in the local Shwartzman reaction and may be important in understanding diseases associated with thrombohemorrhagic skin necrosis.

Shwartzman reaction in the brain induced by Haemophilus somnus and Escherichia coli lipopolysaccharide in rabbits

Intracerebral inoculation of viable Haemophilus somnus resulted in suppurative or fibrino-suppurative meningitis of the brain and spinal cord in rabbits. Multiple fibrin thrombosis complicated with meningitis in the central nervous system was produced by intracerebral inoculation of H. somnus followed by intravenous inoculation with Escherichia coli lipopolysaccharide. The latter reaction may be attributable to a form of Shwartzman reaction.

Selective segmental hepatic necrosis produced by the Shwartzman mechanism in rabbits

In this study, a new experimental model for hepatic necrosis is presented using rabbits, and E. coli endotoxin as the Shwartzman reagent. A segment of the liver was chosen as a target site for the univisceral Shwartzman reaction. Endotoxin-Lipiodol emulsion was used as a preparative injection via the portal venous branch into the target segment by direct puncture. Provocation was made by an intravenous injection of endotoxin 24 h later. A marked and sharply demarcated necrotic area was produced selectively in the target segment; specific changes were not seen in other lobes of the liver or other parts of the body. This model, strongly enhanced by using Lipiodol, seems to be a subtype of the univisceral Shwartzman reaction of the liver.

Shwartzman reaction in the brain induced by fractions of Fusobacterium necrophorum and Escherichia coli lipopolysaccharide in rabbits

Multifocal fibrin thrombosis and suppurative meningitis in the central nervous system was induced by intracerebral inoculation with a cytoplasmic or supernatant fraction of Fusobacterium necrophorum followed by intravenous inoculation with Escherichia coli lipopolysaccharide endotoxin in rabbits. Formation of fibrin thrombosis was reduced by heparin administration. Single intracerebral inoculation with the cytoplasmic or supernatant fraction caused suppurative meningitis. Nervous lesions were often associated with fibrinoid degeneration of the blood vessels. Bacterial lipopolysaccharide endotoxin did not induce apparent meningitis or fibrin thrombosis. The formation of fibrin thrombosis in the central nervous system might be attributable to the Shwartzman reaction.

Vasoactive agents and production of thrombosis during intravascular coagulation. 3. Comparative effects of catecholamines

Epinephrine (E), isoproterenol (I), and dopamine (D) were compared with norepinephrine (N) for production of microthrombi during thrombin-induced disseminated intravascular coagulation (DIC) in rabbits. Only catecholamines acting on alpha-adrenoreceptors produced glomerular capillary thrombosis (GCT) typical of the generalized Shwartzman reaction (GSR). Epinephrine produced GCT three times (P less than 0.05) less severe than that produced by N, but beta-blockade with propranolol (P) rendered E equal to N in potency. I and D reduced fibrinogen consumption produced by thrombin. I (0.5-0.66 microgram/kg/min), as opposed to D, prevented the GSR produced by endotoxin in the pregnant rat and the cortisone-sensitized rabbit, and P increased the severity of the GSR in the pregnant rat. Alpha-adrenergic blockade with dibenzyline prevented the GSR produced by endotoxin in rats, whether pregnant, diabetic, or having a unilateral ureteral occlusion, and the classic reaction in rabbits, but not that produced in renal-hypertensive rats. Simultaneous alpha + beta stimulations by E triggered coronary and hepatic microthrombi, which were prevented by P. It is concluded that beta-adrenergic stimulation, as opposed to D-adrenergic stimulation, counterbalances alpha-adrenergic effects occurring in endotoxemia, which are required for production of the GSR in most models. These studies stress the risks and benefits of beta-blockade and provide additional evidence for the role of vasoactive agents and microcirculatory changes on selection of target organs for production of microthrombi during DIC.

Acute, massive, haemorrhagic adrenal necrosis experimentally produced by the Shwartzman mechanism in rabbits

Acute and severe haemorrhagic necrosis of the adrenal was produced experimentally in rabbits by means of intravenous injection of endotoxin after pretreatment by adrenocorticotropic hormone (ACTH) administration. The change occurred mainly in the zona fasciculata of the adrenal cortex, and its pathology was quite similar to that of the Shwartzman reaction. Numerous microthrombi were found in and around the lesion, but no marked changes were seen in other parts of the body. Heparin administration was very effective in preventing the necrosis. The pathogenesis of this lesion was postulated to be a univisceral Shwartzman mechanism in the adrenal. This seems to be a good experimental model for massive haemorrhagic necrosis of the adrenal in man, for example in the Waterhouse-Friderichsen syndrome, the pathogenesis of which has been assumed to involve intravascular clotting. It is suggested that hyperfunction of the adrenal cortex caused by ACTH administration could be a preparative condition for the Shwartzman reaction.

Interleukin 1: a common endogenous mediator of inflammation and the local Shwartzman reaction

In this study we investigated the role of interleukin 1 (IL 1) in the induction of inflammatory lesions and in the preparation and provocation of the local Shwartzman reaction. Both of these phenomena can be induced with a variety of agents. This suggested to us that a common endogenous mediator may be crucial to the development of these two lesions. When IL 1 was injected intradermally into shaved rabbit backs, 51Cr-labeled neutrophils accumulated at the injection site. Neutrophils began to accumulate less than 1 hr after injection, and the maximum rate of accumulation was observed by 4 hr. This activity was dose dependent. It was calculated that in all animals, 10(-14) mol of IL 1 induced significant neutrophil accumulation, whereas in many animals, as little as 10(-15) mol of IL 1 sufficed. When 4.2 X 10(-9) mol of E. coli 0111:B4 lipopolysaccharide W was injected i.v. 24 hr after an intradermal injection of IL 1 (2.9 X 10(-13) mol), a local Shwartzman reaction was seen 4 hr later at the intradermal injection site. IL 1 injected i.v. 24 hr after an intradermal injection of either IL 1 or lipopolysaccharide also produced a local Shwartzman reaction. These data indicate that IL 1 may be the common endogenous mediator of the inflammatory response, and IL 1 may serve in the same role for the preparation and provocation of the local Shwartzman reaction.

Local Shwartzman reaction in the rectal mucosa in acute diarrhoea

A microvascular lesion characterized by endothelial and platelet damage leading to intravascular coagulation, thrombosis and vascular dehiscence with haemorrhage was found in capillaries and venules in the rectal mucosal lamina propria of adults with acute diarrhoea. The lesion morphologically resembled the local Shwartzman reaction. There was no correlation between the prevalence of the vascular lesion and the presence of recognized enteric pathogens, but there was a significant correlation with the clinical severity of the illness. It is suggested that this vascular lesion could be the result of the failure of the epithelioluminal barrier in the colon and it may also be one of the determinants of the clinical severity of illness in adults with acute diarrhoea.

Determination of the presence of root-bound endotoxin using the local Shwartzman phenomenon (LSP)

The purpose of these studies was to determine, by attempting to elicit the local Shwartzman phenomenon (LSP), if the material extracted from periodontally involved root surfaces is actually endotoxin or only an endotoxin-like substance. A total of 719 periodontally involved teeth and 201 unerupted third molars yielded pooled samples of root surface grindings which were treated with the endotoxin extraction technique nonpyrogenic saline or pyrogen-free water. In the first study each of the reconstituted extracts was injected into the right palatal gingiva of New Zealand white rabbits which had demonstrated the ability to elicit an LSP. Commercial Salmonella enteritidis endotoxin was injected into the left (control) palatal gingiva. This was followed 18 hours later by a provoking injection of 200 to 300 microgram S enteritidis endotoxin in a marginal ear vein. In the second study, reconstituted extracts were injected into the right side of the abdomen of New Zealand white rabbits. The left (control) side received varying amounts of S enteritidis endotoxin. Twelve hours later each animal received a provoking injection of 400 microgram of S enteritidis endotoxin in a marginal ear vein. In both studies the animals were examined 6 hours later for visual signs of an LSP. After sacrifice, the tissues were prepared and histologic sections evaluated by two examiners who were unaware of how the specimens had been treated. The results indicated that a heat-stable, phenol-water extractable and highly irritating substance could be obtained from periodontally involved root surfaces. However, it is questionable if the substance extracted was actually endotoxin. If a true endotoxin, it was present only in extremely small amounts.

Protracted histopathological change of the liver necrosis induced by Shwartzman reaction. An experimental animal model of liver cirrhosis?

Severe pathological fibrotic change of rabbits treated with endotoxin was produced. The liver of the rabbits that died within 14 days showed severe architectural distortion through wide fibrotic band which could be called morphologically post necrotic liver cirrhosis. On the other hand, in the liver of the rabbits that remained alive more than 14 days thin septal nodular structures were observed. This experimental model is proposed as a tool for the further study of the pathogenesis of human liver cirrhosis.

[The role of prostaglandins in the pathogenesis of the Shwartzman phenomenon]

Schwartzman's phenomena, namely local and generalized reactions (SLR and SGR) were reproduced in two groups of rabbits weighing 1.5-2.5 kg. Use was made of endotoxin S. typhimurium obtained by the method of Bowen. Before endotoxin injection half of the animals of each group were given indomethacin (10 mg/kg). The coagulograms and thromboelastograms were examined after each endotoxin injection. Light and electron microscopy were used to study the animals' kidneys. Animals with the SLR and SGR demonstrated marked changes in the coagulogram and thromboelastogram characteristic of the development of the disseminated intravascular blood coagulation syndrome (DIC-syndrome). Animals' kidneys, particularly those in SGR, manifested gross structural and ultrastructural disorders, pronounced changes in microcirculation. Administration of indomethacin prevented the development of the DIC-syndrome. Besides, microscopic examination of the kidneys did not show fibrin release to the microcirculatory bloodstream. The data obtained indicate that the changes in hemostasis occurring in the SLR and SGR and microcirculatory disorders in the kidneys are linked with a dramatic intensification of prostaglandin synthesis, that develops in response to endotoxin injection.

Role of the acute phase response in the Shwartzman phenomenon

Following elicitation of the local Shwartzman reaction by intradermal injection of Salmonella enteritidis lipopolysaccharide (LPS) in mice, there was a marked acute phase response which was monitored by measuring the serum levels of serum amyloid P component (SAP) and C3. Prednisolone therapy had no effect on either the cutaneous lesion or the accompanying acute phase response. Also, in vivo complement depletion with cobra factor did not affect the lesion or the SAP response despite gross reduction in serum C3 levels. In contrast, administration of colchicine at the same time as LPS suppressed both the acute phase response and the Shwartzman reaction. Inhibition of the cutaneous reaction by colchicine was abrogated by injecting mice with casein, and unrelated acute phase stimulus, the day before challenge with LPS. These observations suggest that acute phase proteins may participate in pathogenesis of the Shwartzman phenomenon.

The Shwartzman phenomenon in equine species

The occurrence of the Local Shwartzman Reaction (LSR) in equine species has not previously been reported. The molecular mechanism appears identical to that reported for the rabbit and other species. The immunopathologic and histopathologic similarities of the experimentally induced LSR in horses and ponies to that of the hoof-laminae (an extension of the skin) lesion in naturally-occurring and/or carbohydrate induced laminitis may offer insight into the pathogenesis of this complex disease.

[Early changes in the kidney microcirculatory bed in the generalized Sanarelli-Shwartzman reaction]

Investigations of early changes of renal microcirculation in generalized Sanarelli-Schwartzmann's reaction revealed markedly manifest alterations in endotheliocytes, podocytes, basal membrane of the glomeruli accompanied by disorders in the permeability of their capillaries and disseminated microthrombosis.

A light- and electron-microscopic study of the so-called uni-visceral Shwartzman reaction

A morphological study was made on a particular model of Shwartzman reaction which was so designed as to occur mainly in the liver with minimal influence to the other parts of the body. The study was mainly focused on its mechanism; the role of the granulocytes, Kupffer cells, platelets and precipitated fibrin. It was revealed that Kupffer cells were severely damaged by the first, preparative injection and the most conspicuous finding after the second, provocative injection was marked granulocytic infiltration followed by massive hepatic cell necrosis. The infiltrating granulocytes sticked to the endothelium, degenerated Kupffer cells, or other granulocytes and, often aggregated around precipitated fibrin. The erythrocytes in the sinusoid also showed aggregation after the provocative injection of the endotoxin, which was, however, rather loose and easily washed out from the sinusoid by perfusion. It is suggested from the above observations that aggregation of granulocytes as well as precipitated fibrin plays an important role to disturb blood stream mechanically and leads to massive necrosis in the liver.

Patterns of vascular damage in the antibody-mediated rejection of skin xenografts in the mouse

Established rat skin grafts carried by immunosuppressed mice were acutely destroyed by an intravenous administration of mouse antirat lymphocyte serum. The histologic pattern of destruction was dependent on the amount of antiserum administered. At low doses (0.01 ml) an Arthus-like reaction was seen with early accumulation of granulocytes. At high doses (0.25 ml) a Shwartzman-like pattern occurred, with early intravascular thrombosis and without evident participation of granulocytes in the initial phases. Groups of mice that received intermediate doses showed graft changes that were transitional between these two types of destruction. Similar histologic patterns have been described in clinical transplantation. Our results show that they are not fundamentally different and that the severity of the triggering reaction determines which of either type will occur.

Antiplatelet drugs and the generalized Shwartzman reaction in the pregnant rat

Several antiplatelet drugs (aspirin, sulfinpyrazone, hydroxychloroquine, dipyridamole, BL-3459, pyridinolcarbamate) were assayed for their ability to prevent the generalized Shwartzman reaction initiated by endotoxin in the pregnant rat, and compared to glucocorticoids (dexamethasone, hydrocortisone). The drugs were administered in a single large dose a few hours before provocation of the reaction. In opposition to glucocorticoids and beside BL-3459 which interfere with other mechanisms involved in the phenomenon, the tested inhibitors of platelet aggregation were found incapable of preventing or reducing the severity of the Shwartzman reaction.

Extensive hepatic cell necrosis produced by the Shwartzman mechanism

Acute, severe, and extensive necrosis of the liver was produced in pregnant and non-pregnant female adult rabbits by the Shwartzman mechanism. Shwartzman reagent (E. coli endotoxin) was administered in various combinations by three routes of injection, the portal vein (mesenteric vein), the bile duct, and the ear vein. Morphologic changes of the extrahepatic organs were minimal. The similarity to massive necrosis in human liver and the effect of pregnancy on hepatic necrosis in rabbit and man were discussed. The lesion is presented as a new animal model for acute massive hepatic necrosis and is proposed as a third category of Shwartzman reaction, designated the univisceral type.

Electron microscopic observations of the kidney in the generalized Shwartzman reaction

Sequential changes in the kidney during the generalized Shwartzman reaction were studied electron microscopically. The first anatomical change was infiltration of neutrophils into the glomerular capillaries. Endothelial damage was not noticeable until the capillaries were filled with fibrin deposits. Fibrin appeared in the mesangium at almost the same time as in the capillary lumina, traversing through the endothelial fenestrae. Endothelial damage was more common in the mesangial portion than in the peripheral portion of the capillaries. Severe mesangiolysis developed after loss of endothelial cells had been followed by massive penetration of intracapillary contents. Later, signs of repair were evident in some parts of the damaged endothelium. The development of cortical necrosis coincided with the appearance of mesangiolysis and arteriolar thrombotic lesions.

The generalized Shwartzman reaction in association with E. coli enterotoxemia in a pig

A pig at the age of approx. 10 weeks died after four days of illness. Distinct necrotic changes were found both in the skin and the cortex of the kidneys. The histological examination revealed fibrinoid thrombi in skin vessels. In the kidneys similar thrombi were observed in capillaries of the glomeruli and in their afferent arterioles and in the interlobular arteries. In these vessels there were also a fibrinoid mural necrosis. These changes were in accordance with those expected to occur in the generalized Shwartzman reaction (GSR). The diagnosis of Escherichia coli enterotoxemia was based on the pathomorphological changes in the alimentary tract. The E. coli enterotoxemia was considered the cause of the GSR-changes.

The sequence of events in the development of bilateral renal cortical necrosis accompanying the generalized Shwartzman reaction

The generalized Shwartzman reaction, or Shwartzman-like conditions, were induced in a variety of experimental mammalian species by systemic injections of disintegrated cells of Gram negative bacteria, live Salmonella cholerae-suis or Liquoid. A comparative study of the renal lesions showed that the initial step in the development of bilateral cortical necrosis is stagnation and disintegration of red cells in glomerular capillaries. The glomerular “microthrombi” consist mainly of erythrocytic debris, which frequently has staining properties akin to those of fibrin; even wide-spread glomerular “thrombosis” is not accompanied by obvious destruction of renal parenchyma. A second step is necrotic mural lesions in afferent arteries, with ensuing thrombosis. These vascular lesions lead to the formation of individual infarcts which fuse to form total bilateral cortical necrosis in fulminant cases of the generalized Shwartzman reaction.

The local Shwartzman reaction in the rabbit. Immunopathologic findings in the skin

Four albino rabbits received two intradermal injections of endotoxin followed in 24 hours by an intravenous injection of endotoxin. All animals developed the local Shwartzman reaction, characterized by hemorrhagic necrosis over each intradermal injection site. Light microscopy of the Shwartzman lesion showed intense inflammation and vascular thrombosis. Frozen sections of the skin lesion revealed marked vascular deposition of fibrin with lesser amounts of IgG, IgM, C3, and albumin. Light microscopy was normal and immunofluorescence was negative in skin obtained prior to the initial injection of endotoxin and skin adjacent to the Shwartzman lesion. These findings suggest nonspecific trapping of serum proteins within vascular thrombi and indicate that immune mechanisms may not play a role in the pathogenesis of the local Shwartzman reaction.