[MTX intolerance in children and adolescents with juvenile idiopathic arthritis]

Methotrexate (MTX) is the medication most commonly used for antirheumatic treatment in juvenile idiopathic arthritis. It has high efficacy, is usually well tolerated and has an excellent safety profile. However, intolerance symptoms frequently develop, which manifest as nausea, feelings of disgust, or abdominal complaints prior to or directly after application of the medication. A direct side effect can usually be easily excluded; however, the symptoms are limited to treatment with MTX. This MTX intolerance causes a significant reduction in the quality of life of affected patients, frequently puts the treating physician in an uncomfortable situation, and not uncommonly results in discontinuation of treatment. Conventional countermeasures such as antiemetics, change of route from subcutaneous to oral or vice versa, or, for example, taste masking, usually have only limited effect. Newer behavioral treatment strategies raise hopes of more effective symptom control.

IL-6 blockade in systemic juvenile idiopathic arthritis - achievement of inactive disease and remission (data from the German AID-registry)

BACKGROUND

Systemic juvenile idiopathic arthritis (sJIA) is a complex disease with an autoinflammatory component of unknown etiology related to the innate immune system. A major role in the pathogenesis has been ascribed to proinflammatory cytokines like interleukin-6 (IL-6), and effective drugs inhibiting their signaling are being developed. This study evaluates sJIA patients treated with the IL-6 inhibitor tocilizumab (TCZ) concerning clinical response rate, disease course and adverse effects in a real-life clinical setting.

METHODS

In 2009 a clinical and research consortium was established, including an online registry for autoinflammatory diseases (AID) ( https://aid-register.de ). Data for this retrospective TCZ study were documented by 13 centers.

RESULTS

From 7/2009 to 4/2014, 200 patients with sJIA were recorded in the AID-registry. Out of these, 46 (19 m, 27 f, age 1-18 years) received therapy with TCZ. Long term treatment (median 23 months) has been documented in 24/46 patients who were evaluated according to Wallace criteria (active disease 6/24, inactive disease 5/24, remission 13/24 cases). Under observation co-medication were used in 40/46 cases. Adverse events were reported in 11/46 patients. The clinical response rate (no clinical manifestation, no increased inflammation parameters) within the first 12 weeks of treatment was calculated to be 35%.

CONCLUSION

Out of 200 sJIA children reported in the German AID-registry, 46 were treated with TCZ, showing a clinical response rate of 35% during the first 12 weeks, and inactive disease and/or remission under medication in 75% after one year. Adverse events were seen in 24% and severe adverse events in 4%.

TRIAL REGISTRATION

The AID-Registry is funded by the BMBF (01GM08104, 01GM1112D, 01GM1512D).

Plasminogen deficiency

Plasminogen (plg) deficiency has been classified as (i) hypoplasminogenemia or 'true' type I plg deficiency, and (ii) dysplasminogenemia, also called type II plg deficiency. Both forms, severe hypoplasminogenemia and dysplasminogenemia, are not causally linked to venous thrombosis. Dysplasminogenemia does not lead to a specific clinical manifestation and probably represents only a polymorphic variation in the general population, mainly in Asian countries. Severe hypoplasminogenemia is associated with compromised extracellular fibrin clearance during wound healing, leading to pseudomembraneous (ligneous) lesions on affected mucous membranes (eye, middle ear, mouth, pharynx, duodenum, upper and lower respiratory tract and female genital tract). Ligneous conjunctivitis is by far the most common clinical manifestation. More than 12% of patients with severe hypoplasminogenemia exhibit congenital occlusive hydrocephalus. In milder cases of ligneous conjunctivitis, topical application of plg-containing eye drops, fresh frozen plasma, heparin, corticosteroids or certain immunosuppressive agents (such as azathioprine) may be more or less effective. Oral treatment with sex hormones was successful in two female patients with ligneous conjunctivitis. In severe cases with possibly life-threatening multi-organ involvement, true therapeutic options are not available at present. The plg-knockout mouse is a useful tool to study the many different properties of plg in a variety of settings, such as wound healing, tissue repair and tissue remodeling, virulence and invasiveness of certain bacteria in the human host, tumor growth and dissemination, as well as arteriosclerosis.

Persistent hypogammaglobulinemia following mononucleosis in boys is highly suggestive of X-linked lymphoproliferative disease--report of three cases

Hypogammaglobulinemia is a common symptom in different immunodeficiencies. It is, however, not usually associated with Epstein-Barr virus (EBV) infections. The X-linked lymphoproliferative disease (XLP) on the other hand shows immunological changes in response to the EBV. Here we report three previously healthy boys, all of which developed persistent hypogammaglobulinemia following severe acute infectious mononucleosis. All three patients revealed T-cell abnormalities including inverted CD4/CD8 and increased CD8(+) T-cell numbers. The number of IFN-gamma-producing T cells were markedly increased in the two patients studied so far. In addition, patient 2 showed mainly T cells, instead of B cells, to be infected with the EBV. Apart from an uncle of patient 3, who died of malignant lymphoma, family history was unremarkable in all cases. All three patients exhibited mutations in the SH2D1A gene, establishing the diagnosis of XLP. Protein expression was found on immunoblot analysis in one patient with a missense mutation. Development of persistent hypogammaglobulinemia after severe primary EBV infection seems to be a specific diagnostic sign for XLP even in males with unremarkable family history.

Addison's crisis in adolescent patients with previously diagnosed diabetes mellitus as manifestation of polyglandular autoimmune syndrome type II--report of two patients

We report on two female adolescents--both diagnosed with type 1 diabetes mellitus in early childhood--who presented with signs of severe metabolic decompensation. In both cases recompensation was difficult, and during the stay in hospital increasing discoloration of palmar creases was observed. ACTH testing demonstrated cortisol deficiency in both patients. In addition, autoimmune thyroiditis was diagnosed in one patient. As a polyglandular autoimmune syndrome was suspected, autoantibody studies were performed and the presence of autoantibodies against thyroid and adrenal tissue was established. Polyglandular autoimmune syndrome (PGA) type II can lead to subsequent manifestation of deficiencies of several endocrine glands. Although PGA type II usually presents at a more advanced age, adolescents may also present with the full spectrum of the disease. Especially in the presence of Addison's disease, life-threatening situations can develop rapidly. Coloration of palmar skin creases of patients with known type I diabetes mellitus should serve as a warning sign to be followed up with investigation of endocrine functions.

A closer look at the insertion within helix 54 of the 23S-rRNA of the genus Corynebacterium (and related taxa)

Direct sequencing of the insertion in helix 54 of the 23S-rRNA of different strains of 8 species of the genus Corynebacterium was performed in order to determine the extent of variations of these strains. The results demonstrated that there is considerable variation within different strains of a single species. While this clearly jeopardizes the usefulness of the insertion with regard to species-specific diagnostic probes, the variations were found to concentrate within two clearly defined regions comprising the ascending and descending parts of the distal helix of a putative stemlike secondary structure. The remainder of the insertion sequences seem to be fairly constant within a single species while displaying considerable differences toward sequences of other species of the same genus.

Ribocharin: a nuclear Mr 40,000 protein specific to precursor particles of the large ribosomal subunit

Using a monoclonal antibody (No-194) we have identified, in Xenopus laevis and other amphibia, an acidic protein of Mr 40,000 (ribocharin) which is specifically associated with the granular component of the nucleolus and nucleoplasmic 65S particles. These particles contain the nuclear 28S rRNA and apparently represent the precursor to the large ribosomal subunit in nucleocytoplasmic transit. By immunoelectron microscopy ribocharin has been localized in the granular component of the nucleolus and in interchromatin granules. During mitosis ribocharin-containing particles are associated with surfaces of chromosomes and are recollected in the reconstituting nucleoli in late telophase. We suggest that ribocharin is a specific component of precursor particles of the large ribosomal subunit, which dissociates from the 65S particle before passage through the nuclear envelope, and is reutilized in ribosome biogenesis.

Localization of ribosomal protein S1 in the granular component of the interphase nucleolus and its distribution during mitosis

Using antibodies to various nucleolar and ribosomal proteins, we define, by immunolocalization in situ, the distribution of nucleolar proteins in the different morphological nucleolar subcompartments. In the present study we describe the nucleolar localization of a specific ribosomal protein (S1) by immunofluorescence and immunoelectron microscopy using a monoclonal antibody (RS1-105). In immunoblotting experiments, this antibody reacts specifically with the largest and most acidic protein of the small ribosomal subunit (S1) and shows wide interspecies cross-reactivity from amphibia to man. Beside its localization in cytoplasmic ribosomes, this protein is found to be specifically localized in the granular component of the nucleolus and in distinct granular aggregates scattered over the nucleoplasm. This indicates that ribosomal protein S1, in contrast to reports on other ribosomal proteins, is not bound to nascent pre-rRNA transcripts but attaches to preribosomes at later stages of rRNA processing and maturation. This protein is not detected in the residual nucleolar structures of cells inactive in rRNA synthesis such as amphibian and avian erythrocytes. During mitosis, the nucleolar material containing ribosomal protein S1 undergoes a remarkable transition and shows a distribution distinct from that of several other nucleolar proteins. In prophase, the nucleolus disintegrates and protein S1 appears in numerous small granules scattered throughout the prophase nucleus. During metaphase and anaphase, a considerable amount of this protein is found in association with the surfaces of all chromosomes and finely dispersed in the cell plasm. In telophase, protein S1-containing material reaccumulates in granular particles in the nucleoplasm of the newly formed nuclei and, finally, in the re-forming nucleoli. These observations indicate that the nucleolus-derived particles containing ribosomal protein S1 are different from cytoplasmic ribosomes and, in the living cell, are selectively recollected after mitosis into the newly formed nuclei and translocated into a specific nucleolar subcompartment, i.e., the granular component. The nucleolar location of ribosomal protein S1 and its rearrangement during mitosis is discussed in relation to the distribution of other nucleolar proteins.

Drug-induced dispersal of transcribed rRNA genes and transcriptional products: immunolocalization and silver staining of different nucleolar components in rat cells treated with 5,6-dichloro-beta-D-ribofuranosylbenzimidazole

Upon incubation of cultured rat cells with the adenosine analogue 5,6-dichloro-1-beta-D-ribofuranosylbenzimidazole (DRB), nucleoli reversibly dissociate into their substructures, disperse throughout the nuclear interior, and form nucleolar "necklaces". We have used this experimental system, which does not inhibit transcription of the rRNA genes, to study by immunocytochemistry the distribution of active rRNA genes and their transcriptional products during nucleolar dispersal and recovery to normal morphology. Antibodies to RNA polymerase I allow detection of template-engaged polymerase, and monoclonal antibodies to a ribosomal protein (S1) of the small ribosomal subunit permit localization of nucleolar preribosomal particles. The results show that, under the action of DRB transcribed rRNA, genes spread throughout the nucleoplasm and finally appear in the form of several rows, each containing several (up to 30) granules positive for RNA polymerase I and argyrophilic proteins. Nucleolar material containing preribosomal particles also appears in granular structures spread over the nucleoplasm but its distribution is distinct from that of rRNA gene-containing granules. We conclude that, although transcriptional units and preribosomal particles are both redistributed in response to DRB, these entities retain their individuality as functionally defined subunits. We further propose that each RNA polymerase-positive granular unit represents a single transcription unit and that each continuous array of granules ("string of nucleolar beads") reflects the linear distribution of rRNA genes along a nucleolar organizer region. Based on the total number of polymerase I-positive granules we estimate that a minimum of 60 rRNA genes are active during interphase of DRB-treated rat cells.

Identification and localization of a novel nucleolar protein of high molecular weight by a monoclonal antibody

A monoclonal murine antibody (No-114) is described which reacts specifically with a polypeptide of molecular weight (Mr) 180 000 present in low-speed nuclear pellets from oocytes and somatic cells of Xenopus laevis and X. borealis and in isolated amplified nucleoli. Two-dimensional gel electrophoresis has revealed the acidic nature of this polypeptide (isoelectric at pH of ca 4.2 in the presence of 9.5 M urea). A relatively large proportion of the protein is extracted at elevated ionic strength (i.e., at 0.4-0.5 M alkali salt) in a form sedimenting at approx. 7-8S, compatible with a monomeric state. It is also extracted by digestion with RNase but not with DNase. In immunofluorescence microscopy, antibody No-114 stains intensely nucleoli of oocytes and all somatic cells examined, including the residual nucleolar structure of Xenopus erythrocytes which are transcriptionally inactive. During mitosis the antigen does not remain associated with the nucleolar organizer regions (NOR) of chromosomes but is released and dispersed over the cytoplasm until telophase when it re-associates with the reforming interphase nucleoli. At higher resolution the immunofluorescent region is often resolved into a number of distinct subnucleolar components of varied size and shape. Immunoelectron microscopy using colloidal gold-coupled secondary antibodies reveals that the Mr 180 000 protein is confined to the dense fibrillar component of the nucleolus. This conclusion is also supported by its localization in the fibrillar part of segregated nucleoli of cells treated with actinomycin D. We conclude that nucleoli contain a prominent protein of Mr 180 000 which contributes to the general structure of the dense fibrillar component of the interphase nucleolus, independent of its specific transcriptional activity.

Karyoskeletal proteins and the organization of the amphibian oocyte nucleus

We have investigated the existence of structural components in the nucleus of the oocyte of Xenopus laevis and other amphibia that are insoluble in non-denaturing detergents and buffers of low and high ionic strength. These cells are particularly suitable for such studies as they have a high frequency of extrachromosomal amplified nucleoli and pore complexes of the nuclear envelope. Using biochemical and immunological techniques, we have shown these structures to contain only two major proteins. These are a polypeptide of Mr 145000, which is located in a meshwork of filaments specific to the nucleolar cortex, and certain nucleoplasmic bodies probably derived therefrom, and a polypeptide of Mr 68000, which is the predominant constituent of the lamina-pore complex structure. We show that the latter protein is related to, but not identical to, lamina proteins ('lamins') of somatic cells, indicating cell type-specificity of the expression of polypeptides of the lamin family. In addition, we describe a protein of Mr 180000, which is the major constituent of the dense fibrillar component of the nucleolus. This can be partially solubilized in buffers of moderately high ionic strength. We interpret proteins of this category as karyoskeletal components involved in the architectural organization of specific functional topology within the nucleus. In contrast to previous reports for other cell types we have found no other prominent high-salt-insoluble structures in the nuclear interior, indicating the absence of an extended internal nuclear matrix in this kind of nucleus.

The 22 S cylinder particles of Xenopus laevis. II. Immunological characterization and localization of their proteins in tissues and cultured cells

Cylinder-shaped particles of 10 nm diameter were isolated from nuclei of Xenopus laevis oocytes and purified by sucrose gradient centrifugation and DEAE-Sephacel chromatography. Antibodies to protein constituents of these isolated particles were elicited in guinea pigs and examined by immunoblotting and immunoprecipitation techniques as well as by immunofluorescence microscopy. The antibodies reacted with only two out of the 12 constituent polypeptides characteristic for these particles when examined in the denatured state by the immunoblotting technique, including the largest component of Mr 30 000, but were able to precipitate the whole ensemble of these polypeptides in immunoprecipitation experiments, in agreement with the notion that these proteins form the 22 S particle complex. The antibodies displayed a rather narrow range of interspecies cross-reactivity, showing reaction with cells of other amphibia but not with avian and mammalian cells. In oocytes as well as in transcriptionally active somatic cells the antigen was localized in the nucleoplasm, excluding nucleoli, as well as in the cytoplasm, usually suggesting a higher concentration in the nucleoplasm. During mitosis, the proteins were dispersed throughout the cytoplasm whereas the chromosomes were negative. Inactive cells such as mature erythrocytes, spermatids and spermatozoa were negative. These immunolocalization findings support our conclusion based on fractionation studies that the cylindershaped particles and their protein constituents occur both in the nucleoplasm and the cytoplasm of a broad range of cell types.(ABSTRACT TRUNCATED AT 250 WORDS)

The 22 S cylinder particles of Xenopus laevis. I. Biochemical and electron microscopic characterization

Supernatant fractions obtained after high speed centrifugation (1 h at 100 000 X g) of homogenates from whole ovaries, oocytes as well as from separated nuclei and ooplasms of Xenopus laevis contain distinct 22 S particles which have been purified and characterized by sucrose gradient centrifugation, ion exchange chromatography on DEAE-Sephacel and fast protein liquid chromatography (FPLC). The purity of the particle fraction has been assessed by electron microscopy as well as one- and two-dimensional gel electrophoresis. The particles appear as hollow cylinders of 10 nm outer diameter and 16 nm length, showing a composition of four stacked annuli which often reveal 6 symmetrically distributed granular subunits of approximately 3 nm diameter. Biochemically the particles are characterized by a group of 12 polypeptides with Mr values from 22 000 to 30 000 which in urea-denatured state markedly differ in their isoelectric values, ranging from pH 5.4 to ca. 8.2. Tryptic peptide mapping has demonstrated that all 12 major polypeptides are different. No evidence for association with nucleic acids has been found. The particles are very stable and resist treatments with low and high salt buffers, chelating agents, various non-denaturing detergents, and 3 M urea. They occur in relatively high concentrations both in the nucleus and in the cytoplasm. Structurally and compositionally identical cylinder particles have also been found in cultures of kidney epithelial cells of Xenopus and in human carcinoma (HeLa) cells, indicating that this is a rather widespread component of diverse cell types and species. The significance of this particle and its relationship to morphologically similar particles described in the literature is discussed.

Cross-reaction of hnRNP-proteins of HeLa cells with nuclear proteins of Drosophila melanogaster demonstrated by a monoclonal antibody

A monoclonal antibody from clone T7 raised against total nuclear proteins from the Kc cell line of Drosophila melanogaster (Saumweber, H. Symmons. P. Kabisch, R. Will, H & Bonhoeffer, F, Chromosoma 80 (1980) 253) [1] showed positive immunofluorescent staining on interphase nuclei of HeLa and PTK2 cells. When this antibody was allowed to react with several nuclear protein fractions isolated from HeLa S3 cells, three polypeptides of molecular weights (MW) 44 000, 63 000 and 70 000 were identified as the corresponding antigens, all components of hnRNA containing ribonucleoprotein particles. Sucrose gradient fractionation of such particles after mild RNase treatment and subsequent analysis of the proteins by the immunoblotting method revealed that the 44 000 MW antigen was an integral part of the ribonuclease-resistant complex. The results support the view that hnRNA molecules are associated with certain proteins conserved during evolution which may play structural roles in the ribonucleoprotein organization.