FRI0251 COMBINATION OF COMPUTED TOMOGRAPHY SCAN AND SERUM MYOSITIS SPECIFIC/ASSOCIATED AUTOANTIBODIES HELPS EARLY IDENTIFY AND TREAT PATIENTS WITH IPAF AND CTD-ILD

Background:

Interstitial lung diseases (ILD) could originate from idiopathic cause or secondary to connective tissue diseases (CTD). The most common causes of CTD associated ILD (CTD-ILD) include mixed connective tissue disease, systemic sclerosis (SSc), inflammatory myositis such as polymyositis (PM) and dermatomyositis (DM). Our preliminary data had demonstrated that ILD is not uncommon in patients with rheumatoid arthritis (RA) and Sjogren’s syndrome (SS) in Asia. Myositis-specific autoantibodies (MSAs) and myositis associate autoantibodies (MAAs) have been used for the early diagnosis of PM/DM and could be noticed in patients with idiopathic ILD. Our previous data also had identified that MSA/MAA were detected quite often in patients with CTD-ILD in addition to inflammatory myositis. Nonetheless, a specific group of ILD patients like interstitial pneumonia with autoimmune features (IPAF) are still challenging for pomologists, rheumatologist and radiologists, either in accurate diagnosis or treatment.

Objectives:

We aimed to identify the prevalence of serum MSA/MAAs and clinical diagnosis on imaging in patients with IPAF and CTD-ILD and define the correlation between MSA/MAA and clinical imaging features.

Methods:

Patients who had been suspected with autoimmune rheumatic diseases in the presence of interstitial lung diseases were included in this prospective study at a single medical center in Taiwan between February 2018 and November 2019. All enrolled patients had experienced clinical symptoms of ILD and been identified abnormalities on the chest plain films. All patients were inspected by both pulmonologists and rheumatologist. Computed tomography scans of chest had been reviewed by at least two pulmonary radiologists. Serological immunotherapy strips were performed to detect MSA/MAAs. Correlation analysis was performed among the different collected variables.

Results:

870 patients were reviewed by both pulmonologists and rheumatologists and received blood sampling including autoantibody profiling and MSA/MAA tests. The clinical diagnosis of CTD-ILD or IPAF were confirmed in 603 patients, who received 1078 chest CT scan due to clinically suspected CTD-ILD or IPAF. 33 patients received lung biopsies since other CTD-ILD or IPAF patients hesitate to receive invasive procedures. 78 patients had been admitted to intensive care units and received mechanical ventilation and were not suitable for lung biopsies. 22 of 33 patients received more than twice lung biopsies due to challenging diagnosis. 6 patients with CTD-ILD or IPAF had received extracorporeal membrane oxygenation (ECMO) due to ILD with secondary pulmonary infection and acute respiratory distress syndrome. The most commom detected MSA/MAA were anti-Ro-52 (27%), followed by anti-Ku (3.9%), and anti-Mi-2 (3.6%).

SS is the most common rheumatic disease in patients with CTD-ILD. MSA/MAAs were identified in patients with IPAF (36.4 %) in the absence of specific rheumatic diseases. Anti-nuclear antibody (27.4%), rheumatoid factor immunoglobulin M (21.6%) and anti-Ro (13.7%) were the most common autoantibodies identified in patients with IPAF. Anti-Ro-52 was positively corelated with nonspecific interstitial pneumonia in patients with CTD-ILD or IPAF, Phi= 0.371 and 0.326, both p < 0.001, respectively.

Conclusion:

Early diagnosis of CTD-ILD and IPAF is still challenging for both pulmonologists, rheumatologists and radiologists. Identifying how serum MSA/MAAs contribute clinical manifestations on chest CT imaging is warranted and help clinical physicians and patients recognize the necessity of lung biopsy to reduce comorbidity.

References:

[1]Jee AS, et al. J Clin Med 2017

[2]Wilfong EM, et al. Arthritis Rheumatol 2018

[3]Sambataro G, et al. Eur Respir Rev 2018

Disclosure of Interests:

None declared

Invasive aspergillosis in patients with systemic lupus erythematosus: a retrospective study on clinical characteristics and risk factors for mortality

Objective

The objective of this paper is to analyze the clinical features, outcomes, mortality risk factors, and all-cause mortalities of invasive aspergillosis (IA) in patients with systemic lupus erythematosus (SLE).

Methods

Medical records were reviewed to identify SLE patients with IA from January 2006 to June 2017, at Taipei Veterans General Hospital, Taiwan. A total of 6714 SLE patients were included. Clinical/laboratory parameters and treatment outcomes were analyzed.

Results

Four patients (19.0%) had definite and 17 had probable (81.0%) IA. Seven patients (33.3%) survived and 14 died (66.7%). Concurrently, there were 19 pneumonias (90.5%), 17 cases of other infections (81.0%), eight bacteremia (38.1%), nine cytomegalovirus (CMV, 42.7%) and six Candida (28.6%) infections. In all 55 blood cultures, 38 (69.1%) yielded gram-negative bacilli, of which carbapenem-resistant A. baumannii accounted for eight (21.1%); 17 (30.9%) yielded gram-positive cocci, of which methicillin-resistant S. aureus accounted for six (35.3%); and vancomycin-resistant Enterococcus accounted for four (23.5%). Daily steroid dose ≥ 20 mg (hazard ratio (HR) 2.00), recent pulse steroid therapy (HR 2.80), azathioprine (HR 2.00), rituximab (HR 2.00), plasmapheresis (HR 2.00), acute respiratory distress syndrome (HR 2.00), concurrent infections (HR 5.667) and CMV viremia (HR 1.75) were higher in the fatality group. All p values were less than 0.05. Septic shock ( n = 7, 50% in the fatality group) is the most common cause of mortality.

Conclusions

High daily steroid dosing, recent pulse steroid therapy, azathioprine, rituximab, concurrent infections, and CMV viremia were mortality risk factors for IA in SLE.

Sweet's syndrome as an initial presentation in systemic lupus erythematosus: a case report and review of the literature

Malar or discoid rash is the most frequent specific cutaneous lesion for systemic lupus erythematosus (SLE). Neutrophilic dermatosis as an initial presentation in SLE is unusual. We describe a 38-year old female patient who primarily suffered from erythematous tender plaques and fever. Examination of skin biopsy of the plaques showed dense neutrophilic infiltration in the dermis. Polyarthritis, heavy proteinuria, photosensitivity and positive antinuclear antibodies (ANA > 1:1280) concluded the diagnosis of SLE. The plaques disappeared completely after treatment with systemic corticosteroids. To our knowledge, this is the first reported SLE patient with Sweet's syndrome as the initial presentation in literature review.

Dehydroepiandrosterone suppresses interleukin 10 synthesis in women with systemic lupus erythematosus

OBJECTIVE

To study the effects of dehydroepiandrosterone (prasterone, DHEA) 200 mg/day on cytokine profiles in adult women with active systemic lupus erythematosus (SLE).

METHODS

In a double blind, randomised, placebo controlled study conducted as part of a larger multicentre study, 30 adult women with active SLE received oral DHEA 200 mg/day or placebo for 24 weeks. Baseline prednisone (<10 mg/day) and other concomitant SLE medications were to remain constant. The levels of cytokines including interleukin (IL) 1, IL2, interferon gamma, IL4, and IL10 were determined by ELISA. The mean change from baseline to 24 weeks of therapy was analysed.

RESULTS

The two groups (DHEA n = 15; placebo n = 15) were well balanced for baseline characteristics. Only IL1beta and IL10 could be detected in the serum of lupus patients; however, there was no significant mean (SD) difference in serum IL1beta before and after treatment (9.94 (8.92) v 9.20 (6.49) pg/ml). IL10 demonstrated a greater and significant reduction from baseline (9.21 (9.66) to 1.89 (1.47) pg/ml in the DHEA treatment group).

CONCLUSIONS

In a 24 week study of adult Chinese women with mild to moderate SLE, treatment with DHEA 200 mg once daily resulted in significant reduction of serum levels of IL10. This finding may suggest why DHEA could significantly reduce lupus flares.

Ruptured renal microaneurysms complicated with a retroperitoneal abscess for a patient with systemic lupus erythematosus

Renal artery aneurysm is extremely rare among patients with systemic lupus erythematosus.(SLE). Herein, we report on a 22-year-old male lupus patient who presented with acute abdominal pain, anemia and subsequent hypertension. Abdominal computed tomography revealed a peri-renal hematoma over the right kidney. A renal angiography revealed bilateral renal microaneurysms. The patient subsequently developed a right-side retroperitoneal abscess 4 weeks after hematoma formation and received an emergent laparotomy with drainage. Subsequent culture ofthe abscess-derived fluid revealed the presence of Proteus mirabilis and Escherichia coli. Following appropriate antipyretic and immunosuppressive drugs therapy, the patient recovered successfully. To the best of our knowledge, this is the first report of SLE associated with a retro-peritoneal abscess probably secondary to a ruptured renal microaneurysm.

Aspirin differentially regulates endotoxin-induced IL-12 and TNF-alpha production in human dendritic cells

OBJECTIVE

In the development of autoimmune diseases, dendritic cells (DC) play critical roles. Here, we examined the effect of aspirin on lipopolysaccharide (LPS)-induced DC activation.

METHODS

The monocyte-derived DC were established. The cytokine production was measured by ELISA, reverse transcriptase/polymerase chain reaction, or intracellular staining analyzed by flow cytometry. The expression of cell surface molecules was determined by flow cytometry.

RESULTS

Aspirin inhibited LPS-induced DC maturation and costimulatory molecules expression. Aspirin, at therapeutic concentrations, also decreased LPS-induced IL-12 and IL-10 production. In contrast, the LPS-induced TNF-alpha production was enhanced by aspirin. The differential effects of aspirin on IL-12 and TNF-alpha production may not be due to down-regulation of cyclooxygenase activities.

CONCLUSION

The various effects of aspirin on LPS-stimulated DC may influence the understanding of the diverse immunomodulatory mechanisms of this anti-inflammatory drug.

The expression and significance of intracellular T helper cytokines in systemic lupus erythematosus

To analyze the Th1 and Th2 paradigm of peripheral T helper cells in patients with systemic lupus erythematosus (SLE). The intracellular Th1 and Th2 cytokines were analyzed in fresh blood T cells from 20 SLE patients who had not yet received any treatment. Th1 and Th2 cells were quantitated based on their intracellular cytokine content as assessed by flow cytometry. Cytokine expressions were correlated with clinical features, laboratory findings, and disease activities. There was no difference in the expression of intracellular IFN-y, or IL-4 between SLE patients and healthy controls. However, the IL-2 and IL-10 levels were significantly higher and lower respectively in the lupus patients than in the control group. In addition, patients with arthritis had higher IFN-gamma expression than patients without arthritis. Moreover, patients with serositis or CNS involvement had higher IL-4 expression than in patients without these manifestations. There was no correlation between the SLEDAI scores and the cytokine expression levels. However, patients with serum anti-ds DNA antibodies had higher IL-10 levels than in those without these antibodies. The present study demonstrates that a Th1 pattern of intracellular cytokines predominates in patients with SLE prior to treatment. The pattern of particular intracellular T cell cytokines may suggest specific clinical manifestations and disease progression of SLE.

Endoscopic comparison of the gastroduodenal safety and the effects on arachidonic acid products between meloxicam and piroxicam in the treatment of osteoarthritis

Our objective was to evaluate the efficacy, the gastroduodenal safety, and the effects on arachidonic acid products of meloxicam, a new acidic enolic non-steroidal anti-inflammatory drug which preferentially inhibits cyclo-oxygenase-2 over cyclo-oxygenase-1, versus piroxicam in patients with osteoarthritis of the knee. Meloxicam 7.5 mg or piroxicam 20 mg daily was administered for 4 weeks in this double-blind parallel-groups randomised study. The efficacy for pain relief of the two tested medications was assessed by means of visual analogue scale and other clinical parameters. Pre- and post-treatment endoscopies were performed, and the findings were scored and recorded. The gastric fluid was aspirated at each time and prostaglandin E2, thromboxane B2 and leukotriene B4 were determined by ELISA. There was no significant difference between the groups regarding the primary efficacy. Changes in endoscopic findings by means of Lanza score showed statistically significant differences between the two treatment groups in favour of meloxicam at all sites--gastric, duodenal and total. Within-group comparisons showed a statistically significant difference (worsening) in gastric and total score with piroxicam, but no significant difference with meloxicam. The frequency of clinically relevant cases (total score >2) also showed a statistically significant worsening in the piroxicam group. The better GI tolerability of meloxicam was also suggested by fewer adverse GI events and no withdrawals due to adverse events compared with piroxicam. The pre-/post-study gastric juice concentration of PGE2, TXB2, and LTB4 in the meloxicam group was 135.2 +/- 85.8/71.2 +/- 32.2, 116.3 +/- 81.7/99.4 +/- 107.5 and 388 +/- 321/223 +/- 98 pg/ml respectively. The pre-/post-study gastric juice concentration of PGE2, TXB2 and LTB4 in the piroxicam group was 105.7 +/- 43.1/68.2 +/- 34.9, 94.0 +/- 50.9/105.9 +/- 121.1 and 625 +/- 1574/828 +/- 1464 pg/ml, respectively. Both meloxicam and piroxicam significantly inhibited gastric PGE2 levels after 4 weeks' treatment; however, there was no difference between these two groups. Neither of these medications had an effect on TXB2. Only meloxicam inhibited LTB4 concentration significantly, and the between-groups difference was significant. Meloxicam 7.5 mg once daily had better gastrointestinal tolerability and an efficacy comparable to that of piroxicam 20 mg over 4 weeks in patients with osteoarthritis of the knee.

Protective effect of lipophilic antioxidants on phorbol-induced acute lung injury in rats

OBJECTIVE

To determine whether the lipophilic antioxidant U-74389G can ameliorate the acute lung injury induced by phorbol myristate acetate (PMA) in our isolated lung model in rats, and to compare its activity with the intracellular enzymes superoxide dismutase (SOD) or catalase.

DESIGN

Randomized, controlled study.

SETTING

Animal-care facility procedure room.

SUBJECTS

Forty-two adult male Sprague-Dawley rats each weighing 250-350 g.

INTERVENTIONS

Typical acute lung injury was induced successfully by PMA during 60 mins of observation. PMA (2 microg/kg) elicited a significant increase in microvascular permeability (measured by using the capillary filtration coefficient Kfc), lung weight gain, the lung weight/body weight ratio, pulmonary arterial pressure, and the protein concentration of the bronchoalveolar lavage fluid.

MEASUREMENTS AND MAIN RESULTS

Pretreatment with 1 mg of U-74389G significantly attenuated the acute lung injury induced by PMA, all parameters having decreased significantly (p <.001). The protective effect of U-74389G was dose dependent, but SOD (6,000 U/kg) or catalase (50,000 U/kg) exhibited no protective effect.

CONCLUSIONS

U-74389G significantly ameliorates acute lung injury induced by PMA in rats.

Western and Chinese antirheumatic drug-induced T cell apoptotic DNA damage uses different caspase cascades and is independent of Fas/Fas ligand interaction

Spontaneous or therapeutic induction of T cell apoptosis plays a critical role in establishing transplantation tolerance and maintaining remission of autoimmune diseases. We investigated the mechanisms of apoptosis induced by Chinese and Western antirheumatic drugs (ARDs) in human T cells. We found that hydroxychloroquine, Tripterygium wilfordii hook F, and tetrandrine (Tet), but not methotrexate, at therapeutic concentrations can cause T cell death. In addition, Tet selectively killed T cells, especially activated T cells. Although ARD-induced cytotoxicity was mediated through apoptotic mechanisms, Fas/Fas ligand interaction was not required. We further demonstrated that the processes of phosphatidylserine externalization and DNA damage along the ARD-induced T cell apoptotic pathway could operate independently, and that selective inhibition of DNA damage by caspase inhibitors did not prevent T cells from undergoing cell death. Moreover, we found that Tet- and Tripterygium wilfordii hook F-induced T cell DNA damage required caspase-3 activity, and hydroxychloroquine-induced T cell DNA damage was mediated through a caspase-3- and caspase-8-independent, but Z-Asp-Glu-Val-Asp-fluomethyl ketone-sensitive, signaling pathway. Finally, the observation that ARD-induced activation of caspase-3 in both Fas-sensitive and Fas-resistant Jurkat T cells indicates that Fas/Fas ligand interaction plays no role in ARD-induced T cell apoptosis. Our observations provide new information about the complex apoptotic mechanisms of ARDs, and have implications for combining Western and Chinese ARDs that have different immunomodulatory mechanisms in the therapy of autoimmune diseases and transplantation rejection.

Excellent effect of steroid plus azathioprine in a young woman with pernicious anaemia and systemic lupus erythematosus

We describe a 29-year-old woman who developed pernicious anaemia 2 years after the diagnosis of systemic lupus erythematosus. This is a rare association despite the relationship between the autoimmune aetiologies of these two conditions. Seven other cases have been described, but our report demonstrates a case with an excellent response to steroid and azathioprine.

Infection of human dendritic cells by dengue virus causes cell maturation and cytokine production

Dengue virus (DV) infection is a major problem in public health. It can cause fatal diseases such as Dengue hemorrhagic fever and Dengue shock syndrome. Dendritic cells (DC) are professional APCs required for establishing a primary immune response. Here, we investigated the role of human PBMC-derived DC in DV infection. Using different techniques, including plaque assay, flow cytometry analysis, nested RT-PCR, and confocal microscope and electron microscope examinations, we show that DV can enter cultured human DC and produce virus particles. After entrance, DV could be visualized in cystic vesicles, vacuoles, and the endoplasmic reticulum. The DV-infected DC also showed proliferation and hypertrophy of the endoplasmic reticulum as well as the swollen mitochondria. In addition, the DV-stimulated DC could express maturation markers such as B7-1, B7-2, HLA-DR, CD11b, and CD83. Furthermore, the infection of DC by DV induced production of TNF-alpha and IFN-alpha, but not IL-6 and IL-12. Although DC underwent spontaneous apoptosis in the absence of feeding cytokines, this process appeared to be delayed after DV infection. Our observations provide important information in understanding the pathogenesis of DV infection.

Tuberculosis of skeletal muscle in a case of polymyositis

We describe a patient with polymyositis receiving corticosteroid therapy, who presented with persistent fever and mass lesion at the left thigh. Surgical exploration and mycobacterial culture proved to be Mycobacterium Tuberculosis infection involving the semitendinous muscle of the left thigh. Suitable surgical debridement, anti-TB medications, and sufficient corticosteroid administration resulted in a good control of both polymyositis and the tuberculous infection.

Plant alkaloid tetrandrine and its analog block CD28-costimulated activities of human peripheral blood T cells: potential immunosuppressants in transplantation immunology

BACKGROUND

T lymphocyte activation mediated by CD28 costimulation plays a critical role in graft rejection. Plant alkaloid tetrandrine, purified from a Chinese antirheumatic herb, is a potent immunosuppressant. Here, we examined its effects on several CD28-costimulated T-cell activities. In addition, such effects were readily compared with the effects of three tetrandrine analogs.

METHODS

T lymphocytes were purified from whole blood by negative selection. The stimuli that mimic CD28 costimulation included both anti-CD3 + anti-CD28 monoclonal antibody and PMA+anti-CD28 monoclonal antibody. The determination of CD28-costimulated cell proliferation was performed by tritium uptake, cytokine production by ELISA, cell surface interleukin 2Ra and CD69 expression by flow cytometry, and mixed leukocyte reaction by tritium uptake. Drug cytotoxicity was determined by trypan blue exclusion, propidium iodide staining, and MTT colorimetric assays.

RESULTS

Tetrandrine inhibited CD28-costimulated T-cell proliferation and cytokine production through a mechanism different from that of cyclosporine. In addition, tetrandrine down-regulated both T helper 1 and T helper 2 cytokine production in CD4+ and CD8+ T-cell subpopulations. By examining cytokine production and T-cell activation marker expression, we further demonstrated that, among tetrandrine and its analogs tested, dauricine was the most potent suppressor of CD28-costimulated T-cell activities. Furthermore, the different immunosuppressive activities of these compounds were not associated with their cytotoxic capacities. Finally, the unparalleled inhibitory potency of dauricine on both mixed leukocyte reaction and CD28-costimulated T-cell proliferation suggests that dauricine preferentially targeted CD28-costimulated T-cell activities.

CONCLUSIONS

This is the first report to show that tetrandrine and its analogs potently inhibited both PMA+CD28-costimulated and CD3 + CD28-costimulated activation of human peripheral blood T cells. Based upon their structural similarity and different immunosuppressive potency, these in vitro data also provide very useful information for further identification and development of more potent and less toxic immunosuppressants to achieve transplantation success.

Non-steroidal anti-inflammatory drugs with adverse psychiatric reactions: five case reports

Adverse drug reactions of non-steroidal anti-inflammatory drugs (NSAIDs) are quite prevalent, but there are few reports about possible adverse psychiatric reactions, which may be ignored or underestimated. We describe here five psychiatric outpatients, two with major depressive disorders, one bipolar disorder, one schizophrenic disorder and one anxiety disorder, who were treated with NSAIDs for pain due to rheumatoid arthritis, osteoarthritis or other painful neuromuscular conditions. All five patients developed a moderate to severe depressive state, three patients became obviously paranoid, and four had either thoughts of suicide or an attempt while undergoing co-administration of NSAIDs. The psychiatric symptoms remitted when the NSAIDs were stopped. The depressive and paranoid symptoms returned on seven occasions of re-use or re-challenge with the same or a different type of NSAID in all five patients. When the NSAIDs were stopped again, the patients had another remission of the adverse psychiatric reactions, and eventually recovered to their baseline mental states in clear temporal relationships. The cases presented suggest that NSAIDs can induce or exacerbate idiosyncratic reproducible adverse psychiatric symptoms in certain vulnerable patients, including those with a variety of psychotic or neurotic disorders, and also in elderly persons, but these undesirable side-effects were generally transient and disappeared on withdrawal of the NSAIDs.

Hormonal profiles and immunological studies of male lupus in Taiwan

The aims of this study were to describe hormonal profiles, cytokine production and Fc-gamma receptor (Fcgamma-R) distribution in male lupus patients in Taiwan, and to look for any differences between our patients and normal individuals. Sixteen newly diagnosed and untreated male lupus patients were studied. Hormonal profiles were determined by radioimmunoassay. Interleukin-1 (IL-1) and IL-1 receptor antagonist (IL-1ra) production from both monocytes and neutrophils was determined by ELISA and murine thymocyte proliferation assay. The FcgammaR distribution on both monocytes and neutrophils was detected by flow cytometer. There were no significant differences in FSH, LH, testosterone, oestradiol, and beta-HCG blood levels in male lupus patients compared with normal individuals; however, the prolactin level in lupus patients was significantly higher than in normal individuals. Furthermore, there was no difference in IL-1 and IL-1ra production from both monocytes and neutrophils among male and female lupus patients, and normal individuals. Male lupus patients have a significantly lower FcgammaRII distribution on both monocytes and neutrophils when compared with female lupus patients and normal individuals. It was concluded that the high prolactin level and low FcgammaR distribution may play a role in the pathogenesis and prognosis of male lupus.

Effects of anti-rheumatic herbal medicines on cellular adhesion molecules

OBJECTIVE

To test the hypothesis whether herbal medicines ameliorate inflammatory diseases via the modulation of cellular adhesion molecules (CAMs).

METHODS

Human neutrophils, synovial fibroblasts, and endothelial cells were incubated with different concentrations of Tripterygium Wilfordii Hook-f (TWH-f) or Tetrandrine in the presence or absence of interleukin 1 (IL1). The amount of soluble E-selectin, intercellular adhesion molecule-1 (ICAM-1) and vascular cellular adhesion molecule-1 (VCAM-1) secreted by cells were determined by ELISA. The cell surface expression of these three CAMs was detected by flow cytometry.

RESULTS

TWH-f at high concentration (50 ng/ml) has a significant (p<0.05) inhibitory effect on both the secretion and the expression of the cellular adhesion molecules. However, Tetrandrine did not demonstrate the same effects.

CONCLUSIONS

The cellular adhesion molecules of the endothelium and leucocytes may constitute excellent targets for the development of new anti-inflammation medicines. These results indicate that TWH could be a potential therapeutic agent in the treatment of inflammatory diseases.

Plant alkaloid tetrandrine downregulates protein kinase C-dependent signaling pathway in T cells

Tetrandrine, a purified traditional Chinese medicinal herb that acts as an immunosuppressant and a Ca2+ channel blocker, has been clinically used to treat patients with arthritis, silicosis and hypertension. Since T cells play a critical role as autoreactive and pathogenic population in autoimmune diseases, in this study, we examined the immunosuppressive effect of tetrandrine on human peripheral blood T cells. We showed that tetrandrine inhibited phorbol 12-myristate 13-acetate (PMA) + ionomycin-induced T cell proliferation, interleukin-2 secretion and the expression of the T cell activation antigen, CD71. Further investigation of the molecular mechanism demonstrated that tetrandrine inhibited the expression of the protein kinase C-dependent interleukin-2 receptor alpha chain and CD69 but not the expression of the Ca2+-dependent CD40 ligand and CD69. Interestingly, when tetrandrine and cyclosporin A were added together, significant synergism in the suppression of T cell activation was observed. Moreover, of the several tetrandrine analogues studied, hernandezine was the most potent inhibitor of protein kinase C signaling events. These results also suggest that the protein kinase C-inhibitory capacity of tetrandrine and its analogues may not be associated with their function as Ca2+ channel blockers. Lastly, we showed that, within therapeutic concentrations, tetrandrine and its analogues could induce cellular apoptosis, which is defective in autoimmune diseases. In conclusion, our findings provide novel information about the molecular mechanism of the immunosuppressive effect of tetrandrine and its analogues in human peripheral blood T cells.

Mechanism of immunosuppression of the antirheumatic herb TWHf in human T cells

OBJECTIVE

To investigate the immunosuppressive mechanism of Tripterygium wilfordii Hook-F (TWHf) in human T cells. TWHf, a traditional Chinese medicinal herb for rheumatoid arthritis, has been shown to inhibit the function of immune effector cells such as neutrophils, macrophages, and B lymphocytes.

METHODS

T cell survival was evaluated with trypan blue exclusion assay, morphologic changes with Wright's stain, the induction of endonuclease activity with DNA fragmentation assay, and the subdiploid DNA content with flow cytometry. T cell activation was measured with interleukin 2 (IL-2) ELISA and the expression of several surface molecules with flow cytometry.

RESULTS

At high dosages, TWHf caused inhibition of T cell proliferation and this mechanism was mediated through the induction of apoptosis. TWHf, in noncytotoxic dosages, was as potent as cyclosporin A and more potent than prednisolone and cyclophosphamide in inhibiting IL-2 production from activated T cells. TWHf also inhibited both phorbol 12-myristate 13-acetate induced IL-2Ralpha expression and ionomycin induced CD40 ligand expression. TWHf did not reverse downregulated expression of CD3 and CD4 by phorbol ester stimulation.

CONCLUSION

This is the first evidence that the immunosuppressive mechanism of TWHf in T cells was mediated through both downregulation of T cell receptor signaling pathway and induction of cellular apoptosis, which is defective in autoimmune diseases.

Cell surface markers and circulating cytokines in graft versus host disease

Graft versus host disease (GVHD) remains the major obstacle to the widespread application of allogeneic bone marrow transplantation (BMT) despite improvement in drug prophylaxis. T cells in the donor bone marrow recognize and react against host alloantigens and thereby initiate GVHD, but the precise mechanisms by which host tissues are damaged remain unclear. In the current study, we determined the cytokine secretion, cell population distribution, and cell surface markers expression by ELISA and flow cytometer, to understand further the pathophysiology of GVHD. Our results demonstrated that there was no significant change in the cell ratio of B-and T- lymphocytes, and helper/suppressor cells during GVHD development when compared to the condition before transplantation. Furthermore, the percentage of natural killer cells, the interleukin-2 receptor (IL-2R) or the HLA-DR antigen on both CD4 and CD8 positive cells presented no significant difference between pre-transplantation and during GVHD. The serum cytokine secretion of IL-1, TNF-alpha, IL-2, ICAM-1, endothelin, TGF-beta showed no difference before BMT and during GVHD. However, when patients in the developing of GVHD, there was significant difference in the serum levels of soluble IL-2R (slL-2R), epidermal growth factor (EGF), and platelet derived growth factor (PDGF). In addition, with patients who develop GVHD, the mixed lymphocyte reaction also presented a significant difference. This study indicated that some serum cytokines such as sIL-2R, growth factors, and the mixed lymphocyte reaction may be used as parameters for the early detection of the development of GVHD.

The clinical features and prognosis of male lupus in Taiwan

Our objective was to describe the clinical manifestations, laboratory data, and prognosis in male Chinese lupus patients in Taiwan. Seventy-two male lupus patients, diagnosed and followed in Tri-Service General Hospital between 1983 and 1996, were studied and their clinical data analyzed, retrospectively. The mean age at diagnosis was 34+/-16 y (mean+/-s.d., range: 13-82 y). The peak incidence of age at diagnosis was between 13 and 40 years. The three most frequent clinical manifestations were renal disease, 75%; malar rash, 61%; and arthritis, 53%. The three most frequent abnormal laboratory findings were anti-nuclear antibodies (ANA), 97%; hypocomplementemia, 76%; and anti-ds DNA, 57%. The 1-, 5-, and 10-year survival rates were 85%, 76%, and 75%, respectively. In summary, a higher frequency of renal disease, malar rash and photosensitivity, but a lower frequency of arthritis and lymphadenopathy were demonstrated in our 72 ethnic Chinese male Taiwanese lupus patients compared to previous reports of Caucasians. The prognosis seems to be similar to that of both Chinese and Caucasian males but seems to be poor when compared to either Chinese or Caucasian female lupus patients.

Protective agents used as additives in University of Wisconsin solution to promote protection against ischaemia-reperfusion injury in rat lung

1. An intervention to reduce ischaemia-reperfusion lung injury will be an important advance in transplant medicine. Although the mechanisms associated with producing ischaemia-reperfusion endothelial injury have not been completely elucidated, many of the injury mediators have been studied in detail. While no single pharmacological therapy is likely to be totally effective in eliminating this complex injury, we have developed a mixture of agents that are known to block pathways involved in producing ischaemia-reperfusion-associated lung vascular injury.2. The present study modified University of Wisconsin solution (UW) by adding one of the protective agents prostaglandin E1 (PGE1), dexamethasone (Dex) or dibutyryl cAMP (Bt2-cAMP), or a combination of these, to the perfusate of rat lungs exposed to 4 h of cold ischaemia followed by 1 h of reperfusion. Nine modified UW solutions were studied: (1) UW+Dex, (2) UW+PGE1, (3) UW+Bt2-cAMP, (4) UW+Dexx3, (5) UW+PGE1x3, (6) UW+Bt2-cAMPx3, (7) UW+Dex+PGE1, (8) UW+Dex+Bt2-cAMP, (9) UW+PGE1+Bt2-cAMP. These solutions were utilized in individual experiments to assess haemodynamic changes, lung weight gain, the capillary filtration coefficient (Kfc) and pathology in all lungs.3. The results indicate that lung weight gain and Kfc values were significantly lower than with UW alone in groups 1, 2 and 3, which contained only one additional protective agent. In groups 4, 5 and 6, which contain three times the concentration of each protective agent, both Kfc and lung weight gain were similar to those measured in groups 1, 2 and 3, i.e. lungs were protected but the protection was not dose dependent. In groups 7, 8 and 9, which contained two protective agents, lung weight gain and Kfc were greatly reduced compared with UW alone. Histopathological studies showed similar decreases in the injury profiles of lungs.4. Although UW contains several antioxidant protective agents such as allopurinol and glutathione, it did not provide effective protection in our ischaemia-reperfusion lung injury model. UW modified with an additive of PGE1, Dex or Bt2-cAMP attenuated ischaemia-reperfusion injury. Furthermore, UW containing two of these protective agents augmented the protection. Among the modified solutions, it appears that UW+PGE1+Bt2-cAMP protects the lungs to a greater extent than all other solutions used in our study. We suggest that preservation solutions containing PGE1-Bt2-cAMP will provide additional protective effects to organs stored for transplantation.

Interleukin-1 receptor antagonist modulates the progression of a spontaneously occurring IgA nephropathy in mice

Cytokines, such as interleukin-1 (IL-1), may play a key role in the pathogenesis of IgA nephropathy (IgAN). This study was conducted to evaluate the effects of IL-1 receptor antagonist (IL-1ra) in the treatment of a spontaneously occurring experimental IgAN in established phase. ddY mice (12/group) were injected twice daily with 3 mg/kg of IL-1ra, intraperitoneally, for 8 consecutive weeks. The placebo mice were injected with saline only. As normal controls, ddY mice, which were not treated with IL-1ra or saline, were killed at 6 weeks of age. Results showed a significant reduction of proteinuria in the IL-1ra-treated mice, compared with saline-treated mice (urinary albumin/creatinine, 0.24 +/- 0.04 v 0.39 +/- 0.03, P < 0.001). A significant improvement of renal 51Cr-EDTA (ethylenediaminetetra-acetic acid) clearance was observed in the IL-1ra-treated mice (t1/2, 12 +/- 2.7 minutes, compared with saline-treated mice 25 +/- 2.0 minutes, P < 0.001). Similarly, serum levels of creatinine (1.0 +/- 0.4 v 2.4 +/- 0.3 mg/dL, P < 0.001) and urea nitrogen (46 +/- 6 v 58 +/- 2 mg/dL, P < 0.01) were significantly lower in IL-1ra-treated mice than in saline-treated mice. In renal tissue studies, the IL-1ra-treated mice exhibited significantly decreased mesangial cell proliferation, compared with saline-treated mice (P < 0.001), as shown by light and electron microscopy. In addition, the IL-1ra-treated mice showed significantly lower glomerular expression of collagen type IV, fibronectin, laminin, and IL-6 (P < 0.001) than saline-treated mice, although they still showed higher glomerular expression of collagen type IV (P < 0.01), fibronectin (P < 0.01), laminin (P < 0.001), IL-1 (P < 0.001), and IL-6 (P < 0.01) than did normal control mice. Meanwhile, glomerular C3 deposition was significantly lower in IL-1ra-treated mice than in saline-treated mice (P < 0.001). These findings indicate that IL-1ra partially prevented the progression of spontaneously occurring IgAN in this experimental model. Data from these experiments also confirm the pathogenic effects of IL-1 in the established phase of IgAN in ddY mice.

Interleukin-1 in ischemia-reperfusion acute lung injury

Interleukin-1 (IL-1) is a proinflammatory cytokine produced by blood-borne and resident inflammatory lung tissue involved in the thrombotic occlusion of the pulmonary microcirculation and the increase of the vascular permeability following a wide variety of injuries and sepsis. The locally accentuated, organ-related activation of this cytokine seems to be responsible for the development of acute lung injury. The present study was conducted to determine if IL-1beta was produced in an ischemia-reperfusion (I/R) rat model subjected to lung injury. We measured sequential perfusate levels of IL-1beta by ELISA and we measured IL-1 gene expression in the rat lung tissue by a reverse-transcriptase polymerase chain reaction method. Little IL-1beta gene expression was observed in normal rat lung tissue. Perfusate IL-1beta slightly increased 2 h after induced ischemia and 3 h after reperfusion. IL-1beta gene expression rapidly increased as early as 30 min after ischemia and continued to increase for up to 120 min. IL-1beta gene expression was dramatically upregulated during reperfusion after cessation of ischemia, reached a peak at 1 h, and then gradually decreased (2 to 3 h) to near baseline levels. During ischemia, the increased IL-1 gene expression was not significantly different between the ventral and dorsal sites of the lung. However, IL-1 gene expression markedly increased on the dorsal part (the dependent site for a rat in a supine position) after reperfusion. From these results, it appears that IL-1 may have an important role in I/R lung injury.

Interleukin-1 and interleukin-1 receptor antagonist in systemic lupus erythematosus

Interleukin-1 (IL-1) is thought to play an important role in the immunopathology of systemic lupus erythematosus (SLE). IL-1 receptor antagonist (IL-1ra) exhibits a dose-responsive inhibition of IL-1 effects, and Fcr receptors play a key role in IL-1ra production. To clarify the relationship between IL-1, IL-1 receptor antagonist (IL-1ra) production, and Fcr receptors in SLE, fifteen untreated lupus patients (9 females and 6 males) were evaluated. IL-1 and IL-1ra production from both monocytes and neutrophils was determined by both a murine thymocyte proliferation assay and ELISA. The expression of Fcr receptors on both monocytes and polymorphonuclear cells was measured by flow cytometry. There was no significant difference between IL-1 beta and IL-1ra production from ex vivo monocytes between lupus patients and normals. However, serum IL-1ra was significantly higher in lupus patients than in normals. The expression of FcrRII (CD32) on monocytes was lower in lupus patients than in normals. There was no correlation between the expression of FcrRII and the serum immune complexes; the production of IL-1ra and the expression of CD32, serum immune complex levels, and serum IgG. Both serum IL-ra and the production of IL-1ra had no correlation to SLEDAI, C3, C4, C1q, or ESR. These observations suggest that although IL-1 and IL-1ra may not play a major role in the initiation of pathogenesis of lupus, the low FcrRII expression in lupus may reflect low immune complex clearance and contribute to disease pathogenesis.

PGE1, dexamethasone, U-74389G, or Bt2-cAMP as an additive to promote protection by UW solution in I/R injury

A method to reduce ischemia-reperfusion (I/R) injury can be an important criterion to improve the preservation solution. Although University of Wisconsin solution (UW) works as a lung preservation solution, its attenuation effect on I/R injury has not been investigated. We attempted to determine whether, by adding various protective agents, modified UW solutions will enhance the I/R attenuation by UW. We examined the I/R injury in an isolated rat lung model. Various solutions, e.g., physiological salt solution (PSS), UW, and modified UW solutions containing various protective agents such as prostaglandin E1, dexamethasone, U-74389G, or dibutyryl adenosine 3',5'-cyclic monophosphate were perfused individually to evaluate the I/R injury. Isolated rat lung experiments, with ischemia for 45 min, then reperfusion for 60 min, were conducted in a closed circulating system. Hemodynamic changes, lung weight gain (LWG), capillary filtration coefficient (Kfc), protein content of lavage fluid, concentration of cytokines, and lung histopathology were analyzed. Results showed that the acute I/R lung injury with immediate permeability pulmonary edema was associated with an increase in tumor necrosis factor-alpha (TNF-alpha) production. A significant correlation existed between TNF-alpha and Kfc (r = 0.8, P < 0.0001) and TNF-alpha and LWG (r = 0. 9, P < 0.0001), indicating that TNF-alpha is an important cytokine modulating early I/R injury. Significantly lower levels of Kfc, LWG, TNF-alpha, and protein concentration of lung lavage (P < 0.05) were found in the UW-perfused group than in the control group perfused with PSS. Modified UW promoted the protective effect of UW to further decrease Kfc, LWG, and TNF-alpha (P < 0.05). Histopathological observations also substantiated this evidence. In the UW+U-74389G group, bronchial alveolar lavage fluid contained lowest protein concentration. We conclude that the UW solution attenuates I/R injury of rat lung and that the modified UW solutions further enhance the effect of UW in reducing I/R injury. Among modified solutions, UW+U-74389G is the best. Further investigation of the improved effects of the modified UW solutions would be beneficial in lung transplantation.

Familial amyloidosis in one Chinese family: clinical, immunological, and molecular genetic analysis

Three members of a Taiwanese kindred developed severe, systemic, early onset (< age 25 years), biopsy-proven amyloidosis. Clinical features included upper and lower extremity sensorimotor neuropathy, abdominal pain, vomiting, corneal ulcerations, cardiomyopathy, and syncope. Immunohistochemical analysis indicated that the deposits consisted of transthyretin. Molecular genetic studies revealed a heterozygous codon 55 point mutation, resulting in a proline for leucine-substitution, a mutation previously associated with aggressive familial amyloidosis in a US kindred of Dutch and German descent. The clinical courses and echocardiographic findings are typical for many types of amyloidosis; the pathologic data and genetic studies were necessary to establish a precise diagnosis.

The effects of traditional antirheumatic herbal medicines on immune response cells

OBJECTIVE

Clinically, some traditional Chinese herbal medicines have been thought to be effective in treating rheumatic diseases such as rheumatoid arthritis and systemic lupus erythematosus. To examine the mechanism by which such herbal remedies might be effective, we investigated the ability of Tripterygium wilfordii Hook-f (TWHf) and tetrandrine (TTD) to affect human immune responsiveness in vitro.

METHODS

We measured the ability of these agents to affect cytokine secretion from monocytes or T cells, prostaglandin E2 (PGE2) secretion from monocytes, IgG production from B cells, and the phagocytosis of bacteria by neutrophils.

RESULTS

These studies revealed that both TWHf and TTD significantly inhibited interleukin-1 (IL-1), tumor necrosis factor-alpha (TNF-alpha), IL-6, and IL-8 secretion from monocytes, IgG secretion from B cells, and phagocytosis of bacteria by neutrophils; however, only TWHf inhibited IL-2 and IL-4 production from lymphocytes, and PGE2 secretion from monocytes.

CONCLUSION

TWHf and TTD exert a powerful suppressive effect on human immune responses. This action might account for their therapeutic effectiveness in rheumatic diseases, and might support broader and more rigorous clinical trials.

Acute myocarditis as an initial manifestation of systemic lupus erythematosus: a case report

A rare case of systemic lupus erythematosus with initial manifestation of myocarditis is reported here, found in a 24-year-old female who presented first with an episode of exertional dyspnea, later developing life-threatening arrhythmia, and left ventricular dysfunction. There were no classical clinical manifestations of SLE such as arthragia or malar rashes as initial symptoms. Subsequently, the only clue was traced with positive ANA screening test. Central nervous system manifestations were found and proteinuria was detected. We ordered intravenous "pulses" of methylprednisolone, followed by maintenance of daily glucocorticoid because the criteria of SLE seemed applicable. The patient responded well and rapidly. This initial manifestation for SLE is so rare and unusual that it has not previously been described.

The production and characterization of a modified recombinant interleukin-1 receptor antagonist

The increasingly complex cytokine network involves both positive and negative regulatory pathways. Natural inhibitors of cytokines are of great importance both as analytical tools and as potential therapeutic agents. Interleukin-1 (IL-1) inhibitory bioactivity including a specific receptor antagonist of IL-I (IL-1ra) has been described both in cultured cell supernatants and in human body fluids. In the current studies, the cDNA of IL-1ra from human monocytes was obtained by the techniques of mRNA isolation and reverse transcription/polymerase chain reaction (RT/PCR). The IL-1ra cDNA/pET-15b was transfected into DE3 cells and the recombinant protein expressed. The purified protein was demonstrated as a single band with molecular mass of 20 KD by SDS-PAGE; it had strong IL-1 inhibitory activity. This IL-1 inhibitor competed with IL-1 for their receptor as assessed by flow cytometer. The existence of this naturally occurring specific cytokine receptor antagonist may lead to a different perspective of the cytokine network. The availability of this recombinant IL-1 receptor antagonist allows us to test its role on the cytokine network, and on possible disease modification.

Heterogeneous clinical characteristics of identical twins concordant for systemic lupus erythematosus: a report of one pair of twins

Lupus is a mysterious disease without definite etiology and pathogenesis. The heterogeneous clinical manifestation of systemic lupus erythematosus (SLE) increases the delay and difficulty of diagnosis and the complexity of pathogenesis. Even in twins with identical genome and similar environmental milieu, the incidence of concordance for SLE is not high. Identical twins, concordant for SLE with discordance to disease onset and expression, are reported. Besides genetics, multiple factors are responsible for the pathogenesis of SLE.

Acceleration of skin graft healing by growth factors

A special local burn wound treatment, using a healing promotion factor, attempted to achieve earlier wound closure. Clinically it is not difficult to harvest autologous human platelet-derived wound healing factor (HPDWHF) from burn patients. Another study has proved that porcine pituitary extract (PPE) could be one of the supplements for growing human keratinocytes in vitro (Wang HJ, Chen TM, Tung YM et al. Burns 1995). Initially, using the ELISA immunoassay, we detected titres of platelet-derived growth factor heterodimer AB (PDGF-AB) and epidermal growth factor (EGF) in HPDWHF and PPE. After elevating a 6 X 9 cm2 flap on the backs of Sprague-Dawley (SD) rats 1 ml of heterologous HPDWHF and PPE were sprayed topically on the wound and followed by grafting six pieces of 1 cm2 autologous full-thickness skin. The flap wound was then closed with a piece of large-pore Biobrane interposed between the skin graft wound and the flap. On postgraft day 7, the wound was reopened to measure the area of the full-thickness skin graft (FTSG) using micrographic paper; the results are reported as the percentage of graft expansion beyond the original size. In the cytokine study, we found that the concentrations of PDGF-AB dimer in HPDWHF and PPE were 5222 +/- 102 and 375 +/- 12 pg/ml (both values are reported after a 1:10 dilution) (n = 3), whereas the EGF concentration was 245 +/- 9 pg/ml, and undetectable in undiluted PPE (n = 3), thereby proving that the PDGF-AB and EGF fibres in the HPDWHF were significantly higher than in the PPE Both the HPDWHF (n = 6, with each animal grafted with six skin graft samples) and PPE (n = 7) demonstrated significant accelerations of FTSG growth, with 14.41 +/- 1.08 per cent and 13.16 +/- 3.25 per cent increases in the FTSG size when compared to the sham control group 1.39 +/- 3.26 per cent (n = 5) (P < 0.05). Comparisons between the treatment groups showed no evidence to indicate that the HPDWHF is superior to the PPE in accelerating FTSG growth (P > 0.05). This supports the hypothesis that PDGF appears to transduce its signal through wound macrophages and may trigger the induction of positive autocrine feedback loops and synthesis of endogenous wound PDGF and other growth factors, thereby enhancing the cascade of tissue repair (Pierce GF, Mustoe TA, Altrock B et al. 1991; J Cell Biochem 1991; 45: 319-326), and the effect that PDGF-AB on wound healing is not dose dependent (Mustoe TA, Cutler NR, Allman RM et al. Arch Surg 1994; 129: 213-219). In future studies we expect to show that autologous HPDWHF and heterologous PPE will promote skin graft wound healing in burn patients since they contain a high concentration of PDGF-AB.

Cytokines and cell surface markers in prediction of cardiac allograft rejection

Endomyocardial biopsy is generally used to quantify heart allograft rejection and guide immunotherapy. Biopsy, however, is invasive, costly, and risky. Since rejection requires lymphocyte activation, the purpose of this study was to assess alternative methods to evaluate rejection dynamics by investigating serum levels of cytokines and cell surface markers after heart transplantation. Interleukin-2-receptor bearing CD4+T (IL-2R/CD4) cell levels were higher in the peripheral blood of human transplant recipients with rejection grade 2 (p < 0.02). HLA-DR/CD3 levels were somewhat higher in rejection grade 2. There was no correlation between biopsy scores and serum levels of tumor necrosis factor (TNF-alpha), IL-2, or percentage of T cell, NK cell, B cell, CD4+T cell, CD8+T cell, HLA-DR/CD4, HLA-DR/CD8, IL-2R/CD3, IL-2R/CD8. Interleukin-1 (IL-1 beta) was not detectable in all of the samples. The current studies suggest that monitoring lymphocyte IL-2R/CD4 and HLA-DR/CD3 levels is useful in predicting cardiac transplant rejection.

Cytokine production during hemodialysis: effects of dialytic membrane and complement activation

Interleukin-1 beta (IL-1 beta) and tumor necrosis factor-alpha (TNF-alpha) are closely associated with acute and chronic inflammatory processes in hemodialytic patients. However, the mechanisms concerning cytokine production by monocytes during hemodialysis are still conflicting. With the use of the more specific monoclonal antibody ELISA method, contamination detection and crossover protocol of complement-activating and noncomplement-activating hollow fibers, we were able to confirm augmented II-1 beta production by zymosan-stimulated monocytes with complement-activating hollow fiber as compared to noncomplement-activating hollow fiber before (1,411.9 +/- 865.7 +/- 149.9 pg/ ml/2 x 10(6) monocytes, p < 0.01). at the 15th minute (530.6 +/- 89.1 vs. 247.3 +/- 45.2 pg/ml/2 x 10(6) monocytes, p < 0.01) and at the end of dialysis (1,201.8 +/- 135.1 vs. 707.4 +/- 109.3 pg/ml/2 x 10(6) monocytes, p < 0.01). Similar results were observed with TNF-alpha production. IL-1 beta as well as TNF-alpha production decreased significantly at the 15th min of dialysis, thereafter they increased and approached the baseline levels towards the end of hemodialysis with both hollow fibers. Plasma C3a at the 15th minute correlated positively with postdialysis IL-1 beta and TNF-alpha production, while plasma C3a did not change in patients dialyzed with noncomplement-activating hollow fiber. Complement activation with complement-activating hollow fiber as well as monocyte-membrane interaction with complement-activating and noncomplement-activating hollow fiber might be involved in the pathogenesis of cytokine production during hemodialysis. Uremic toxin removal as well as stimulation of cytokine production inhibitor might contribute to the decreased cytokine production at the 15th minute of hemodialysis and monocyte-membrane interaction with or without complement activation resulted in augmented cytokine production toward the end of hemodialysis with both hollow fibers. We thus concluded that hollow fiber of bioincompatibility triggered much more cytokine production throughout the dialysis procedure.

X-linked agammaglobulinemia: a case report

A 20-year-old male was admitted with fever and hemoptysis. Agammaglobulinemia was found, with bronchiectasis and sinusitis. Clinical and laboratory evidence included immunological examinations, bone marrow and small intestinal biopsies. Results suggested a diagnosis of X-linked agammaglobulinemia. After treatment with antibiotics and intravenous human immunoglobuline, the clinical symptoms demonstrated progressive improvement. The case is reported along with a review of the literature.

Immunoregulatory effects of a synthetic monosaccharide

Investigative attempts to identify novel therapy for inflammatory connective tissue diseases continue to evolve. Amiprilose hydrochloride (amiprilose HCl) is a synthetic carbohydrate shown to have anti-inflammatory effects in animal models of inflammatory arthritis and in a multicenter clinical trial. Interleukin-1 (IL-1) is an important mediator of immune regulation, inflammation and joint destruction in arthritis. In the present study, the effects of amiprilose HCl on IL-1 activity, production and receptor distribution were investigated. Drug effects on IL-2 production and receptor distribution on lymphocytes were also explored. Potential regulation of IL-1 activity was determined by monitoring the effects of amiprilose HCl on IL-1 stimulated proliferation of murine thymocytes and human synovial cells. Inhibitory effects on IL-1 beta and IL-2 production by stimulated human peripheral blood monocytes were measured by ELISA and lymphocyte IL-1 beta and IL-2 receptor distribution were analyzed by flow cytometry. The results from in vitro studies demonstrated that low concentrations of amiprilose HCl (1-100 micrograms/ml) stimulated thymocyte proliferation and enhanced the proliferative response of IL-1 stimulated human synovial fibroblasts. IL-1 beta production in cultures of human peripheral blood monocytes was significantly decreased after exposure of the cultures to varying doses of amiprilose HCl as determined by ELISA. Exposure of mitogen activated human peripheral blood lymphocytes to amiprilose HCl resulted in decreased IL-2 production at high concentrations of drug as compared to control. However, at doses of amiprilose HCl previously found to stimulate thymocyte proliferation (1-10 micrograms/ml), increased levels of culture supernatant IL-2 were observed. No amiprilose HCl mediated changes in lymphocyte IL-1 beta or IL-2 receptor expression were observed. The regulatory effects of amiprilose HCl on cytokines support the potential of this drug as a therapeutic agent for the treatment of inflammatory arthritis.

Lupus in Chinese male: a retrospective study of 61 patients

BACKGROUND

Systemic lupus erythematosus (SLE) has traditionally been considered a disease of women, and is uncommon in men. In recent years, several large clinical series of male lupus patients have been reported. As no known data are available for lupus in males from Taiwan, a retrospective analysis of data from male lupus patients was done to determine whether these patients differed from other series of male or female SLE patients in the literature.

METHODS

Sixty-one male lupus patients, diagnosed and followed in Tri-Service General Hospital, between 1983 and 1993, were studied and their data analyzed, retrospectively.

RESULTS

The mean age of diagnosis was 30 +/- 17 (mean +/- SD, range: 13-81) years. The peak age of diagnosis was between 13 and 40 years. The mean duration of follow-up was 36 +/- 36 (range: 2-256) months. The 1-, 5- and 10-year survival rates were 84%, 76% and 75%, respectively. The frequency of clinical manifestations were renal disease, 75%; malar rash, 70%; arthritis, 60%; fever, 56%; photosensitivity, 48%; pleuritis, 39%; pericarditis, 31%; alopecia, 31%; mucosal ulcers, 29%; neuropsychiatric disease, 26%; discoid lupus, 21%; vasculitis, 15%; Raynaud's phenomenon, 10%; and lymphadenopathy, 2%. The frequency of abnormal laboratory findings were antinuclear antibodies (ANA), 95%; hypocomplementemia, 77%; antibodies to double-stranded DNA (anti-dsDNA), 57%; leukopenia, 44%; lupus erythematosus (LE) cells, 39%; anti-Ro, 39%; anti-Smith antibodies (anti-Sm), 19%; thrombocytopenia, 18%; rheumatoid factor, 17%; anti-ribonucleoprotein antibody (anti-RNP), 14%; autoimmune hemolytic anemia, 8%; false-positive venereal disease research laboratory test (VDRL), 6% and anti-La, 4%.

CONCLUSIONS

In a review of the 61 ethnic Chinese male lupus patients, a higher frequency of renal disease, malar rash and photosensitivity, but a lower frequency of arthritis and lymphadenopathy, compared to previous reports of Caucasians. There were no significant immunological differences from other series of male lupus, except a lower frequency of anti-dsDNA. In general, poor prognosis was noted for male lupus patients here.

Cellular signals for the induction of human interleukin-1 receptor antagonist

The polypeptide cytokine interleukin-1 (IL-1) mediates a broad spectrum of inflammatory, metabolic, physiologic, hematopoietic, and immunologic properties. An inhibitor of IL-1 (IL-1ra) has been purified from monocytes, and its DNA has been cloned. Human immunoglobulin G stimulates monocytes to make IL-1ra, but the monocyte receptor(s) for this induction remains a mystery. Therefore, the cellular Fc receptors (Fc gamma R) for IgG that induce IL-1ra production were tested. The Fc gamma R were defined and quantitated by flow cytometer. Anti-Fc gamma RIII (CD16), anti-Fc gamma RII (CD32), and anti-Fc gamma RI (CD64) had no blocking effect on IL-1ra production from monocytes after IgG stimulation. Monocytes express Fc gamma RI and II and respond as anti-CD32 to secrete IL-1ra; neutrophils express Fc gamma RII and III and respond as anti-CD16 to secrete IL-1ra; macrophages express Fc gamma RI, II, and III and respond as both anti-CD16 and anti-CD32 to secrete IL-1ra. These studies strongly suggested that both Fc gamma receptor II and III play a key role in IL-1ra production.

Acquired immunodeficiency syndrome with CNS toxoplasmosis: a case report

Central nervous system (CNS) toxoplasmosis is an important infectious complication of acquired immunodeficiency syndrome (AIDS) which appears to result from reactivation of a previously acquired infection and requires prolonged treatment. A 31-year-old male presented in a drowsy mental state and with an unstable gait. Computerized tomographic (CT) scan and magnetic resonance imaging (MRI) showed multiple nodular lesions in the cerebrum and cerebellum; the seropositivity for the human immunodeficiency virus (HIV-1) and high serum IgG toxoplasma titers were also demonstrated. A presumptive diagnosis of CNS toxoplasmosis was based on neurological signs and neuroradiological findings. This was confirmed by improvement in both clinical and neuroradiological pictures during treatment with pyrimethamine and clindamycin. Four months later, however the patient died of intracranial hemorrhage and massive upper GI bleeding.

Coexisting IgA nephropathy and leukocytoclastic cutaneous vasculitis associated with ankylosing spondylitis: a case report

A patient with ankylosing spondylitis and coexisting IgA nephropathy and leukocytoclastic cutaneous vasculitis is described. Renal biopsy demonstrated mesangial proliferative glomerulonephritis with prominent IgA, C3 and fibrin deposition in the glomeruli. Simultaneously, leukocytoclastic cutaneous vasculitis with prominent IgG, IgA and C3 deposition of dermal vessel wall was also observed in the skin biopsy specimen. Such associations have been previously reported in only four cases. This report once again indicates that antigenic mucosal stimulation may play an important role in the pathogenesis of ankylosing spondylitis.

An experimental model of osteoarthritis in rabbit

BACKGROUND

From both a microscopic and a metabolic view, experimental animal models are very important for study of the pathogenesis of osteoarthritis. A new, different operative procedure was used in rabbit models, and the pathologic findings were evaluated.

METHODS

Twelve New Zealand white rabbits were divided into six groups; eight were used as animal models and four, for drug efficacy study. Transection of the anterior cruciate and medial collateral ligaments on the left knee joint, and sham-operation were performed on the right knee joint. Rabbits were sacrificed post surgery from 4, 6, 8 and 12 weeks. Eight parameters from gross to microscopic findings were used in order to evaluate osteoarthritic changes. Indomethacin and aspirin were chosen for the drug efficacy experiment; the two rabbits of each group were sacrificed at the end of the sixth week post-surgery.

RESULTS

According to pathological findings, this operative procedure can produce osteoarthritic changes, visible both microscopically and macroscopically. There were osteoarthritic changes in the fourth week post-surgery group and, obviously, in the eighth week; these persisted until 12th weeks post-surgery. Neither indomethacin nor aspirin showed any effect in preventing osteoarthritis progression.

CONCLUSIONS

Transection of the anterior cruciate and medial collateral ligament rabbit model can produce osteoarthritic lesions in the knee joint. This model can be used for further biochemical and metabolic studies.

Positive antinuclear antibody in peripheral T cell lymphoma: a case report

The association of malignant lymphoma with positive antinuclear antibody is uncommon, and their relationship is not clear. Here a 35-year-old man is presented who initially had a high titer of antinuclear antibody; later, peripheral T cell lymphoma was found. It is suggested than an unexplained high antinuclear antibody titer may warrant searching for a malignancy.

Production of interleukin-1 (IL-1) and IL-1 inhibitor by human monocytes exposed to dengue virus

Dengue hemorrhagic fever-dengue shock syndrome, the most severe manifestation of an acute dengue virus (DV) infection, is endemic in Southeast Asia. Antibody-dependent enhancement of DV growth in mononuclear phagocytes is thought to be the mechanism whereby preexisting dengue antibodies confer excess risk for this outcome. Interleukin-1 (IL-1) may play an important role in the pathogenetic mechanisms that cause dengue fever and shock. It was shown that both IL-1 and tumor necrosis factor-alpha are secreted from monocytes within 4 h after DV infection. However, there was no increase in IL-1 secretion by virus-stimulated monocytes from dengue fever patients compared with healthy controls. Significant amounts of IL-1 were secreted by DV-infected monocytes in the presence of aggregated immunoglobulin or immune complexes. In addition, a new 600-kDa IL-1 inhibitor from the supernatants of DV-infected monocytes was identified. This inhibitor may cause immunosuppression and influence the process of DV infection.

Intermittent intravenous treatment of lupus nephritis with cyclophosphamide: a four-year experience with twenty-four patients

BACKGROUND

Renal involvement in systemic lupus erythematosus commonly leads to renal failure and death. We conducted a study to evaluate the efficacy and side effects of intermittent intravenous treatment with cyclophosphamide of patients with lupus nephritis.

METHODS

Twenty-four patients with lupus nephritis were recruited at Tri-Service General Hospital from 1988 to 1992. Cyclophosphamide was administered intravenously monthly for three months, and then every three months. 24-hour urinary protein, creatinine clearance, serum creatinine, blood urea nitrogen, C3 and C4 levels, serum albumin, hemoglobin, and dosage of prednisolone were recorded before each treatment. During treatment, the side effects were monitored.

RESULTS

Two patients progressed to renal failure within one year and one patient after three years. Fifteen patients completed therapy for one year. Among these 15 patients, the levels of hemoglobin, serum albumin, and C3 significantly increased at six months, then became stable; the level of C4 increased at 12 months. In contrast, the dosage of prednisolone decreased significantly at six months. There was no significant difference of creatinine clearance, 24-hour urinary protein, serum creatinine, and blood urea nitrogen before and after treatment. The most common side effects were nausea and vomiting. No severe side effect necessitated discontinuing therapy with cyclophosphamide.

CONCLUSIONS

Intermittent intravenous therapy in lupus nephritis with cyclophosphamide can significantly increase levels of hemoglobin, serum albumin, C3 and C4, and keep renal function stable. Poor response was found in a subset of patients. The side effects were mild in the present study.

Prevalence of rheumatic diseases in Taiwan: a population study of urban, suburban, rural differences

OBJECTIVE

To determine the prevalence of symptomatic rheumatic disease in rural, urban and suburban areas of Taiwan by a 2-staged population survey.

METHODS

Nine thousand subjects over 20 years old were sampled proportional to age and sex for the area from 3 administrative areas in Taiwan. A pretested questionnaire to screen for potential rheumatic disorders and/or disability was administered in the communities by health workers. Subjects who screened positive were examined by a rheumatologist who assigned a final diagnosis based on established criteria.

RESULTS

A total of 8998 persons over age 20 residing in Hen-San (rural area), Sien-Dien (suburban), and Cu-Tien (urban) were studied. Twenty-five percent (2272) of the population indicated rheumatic problems: 1124 of 2271 were evaluated by a rheumatologist with serological and radiological testing. The response rates were 49.7% in Hen-San, 50.7% in Sien-Dien and 48.5% on Cu-Tien. After age and sex adjustment, the prevalence of rheumatic symptoms in Hen-San, Sien-Dien, and Cu-Tien was 24.3, 18.4 and 26.3% respectively. It was significantly higher in rural Hen-San and urban Cu-Tien than in Sien-Dien. The prevalence of rheumatoid arthritis (RA) in Hen-San, Sien-Dien, and Cu-Tien was 0.26, 0.78, and 0.93%, osteoarthritis (OA) was 6.3, 5.8, 5.1%, ankylosing spondylitis (AS) was 0.54, 0.19, 0.4%, gout was 0.16, 0.67, 0.67%, respectively. The prevalence of RA in Sien-Dien and Cu-Tien was significantly higher than in Hen-San (p < 0.05) but were not statistically different for OA, AS and gout among those 3 sites. Only one case of systemic lupus erythematosus (SLE) was found in urban Cu-Tien for a prevalence of 0.033%.

CONCLUSION

Our results suggest that the prevalence of RA and AS is similar to that reported in Caucasians. We could not confirm anecdotal reports that SLE was common or that it is more common than RA in people of Chinese ancestry. The prevalence of OA of the hip is comparatively uncommon in our population. The difference in prevalence of rheumatism, RA, OA and gout in these areas suggests areas of further study.

Lupus nephritis: an analysis of 70 cases

BACKGROUND

The influence of renal morphology and clinical factors at biopsy on the development of renal failure in patients with lupus nephritis remain controversial. We investigated the relation between renal histologic finding and clinical manifestations, and evaluated prognostic factors and short-term prognosis among patients with lupus nephritis.

METHODS

Seventy patients with lupus nephritis were enrolled in the study from 1982 to 1992 at the Tri-Service General Hospital. Renal biopsy specimens from these patients were assessed according to the World Health Organization (WHO) classification, activity and chronicity indices, and clinical parameters. Survival was analyzed by using the day of renal biopsy as the starting point. The end point of renal survival was the date when patient started to receive regular hemodialysis.

RESULTS

In pathological finding, one patient was grouped as Class I (1.4%); 14, as Class II (20%); 15, as Class III (21.4%); 29, as Class IV (41.4%); 9, as Class V (12.9%), and 2, as Class VI (2.9%). The scores of activity indices were highest in Class IV. The blood levels of C3 and C4 in Class V were significantly higher than Class IV. The values of BUN and 24-hour urine protein in Class II were significant lower than Class IV. Patients who progressed to renal failure had significantly higher numbers of death, higher serum creatinine and chronicity index, less creatinine clearance, and higher numbers of hypertension at the time of biopsy. Nephrotic syndrome was not associated with renal failure. Patient and renal survivals did not differ among WHO classifications. The patient and renal survivals were 84%, 60% and 85%, 72% at one and five years, respectively. Seventeen patients (24.2%) progressed to end-stage renal disease and 21 patients (30%) died during the study period. The leading causes of death were sepsis and renal failure.

CONCLUSIONS

WHO classification had little correlation with clinical and renal information. At the time of biopsy the elevated serum creatinine and hypertension were good predictors for end-stage renal disease. Poor patient and renal survivals were found in this study.

The role of cytokines in heat stroke

Heat stroke is a disease characterized by high fever. Cytokines such as interleukin-1 (IL-1), interleukin-6 (IL-6) and tumor necrosis factor-alpha (TNF-delta) play a major role in fever production. In the current studies, eight patients with heat stroke were enrolled in a cytokine studies. Serum cytokine levels of these patients were determined by EIA methods, and in vitro IL-1 and IL-1 inhibitor production were determined by murine thymocyte proliferation assay and/or EIA. Significantly high levels of circulating IL-1, TNF-delta, and IL-6 were demonstrated. Positive correlations were demonstrated between the body temperature and the level of IL-1 beta, and the cooling time and level of serum IL-1 beta. In addition, monocytes from heat stroke patients after complete recovery, secreted a much higher amount of IL-1 than did normal volunteers. However, there was no difference in IL-1 inhibitor production. These results indicate that cytokines may play a major role in the pathogenesis of heat stroke, and the ability to make different amounts of IL-1 in response to exogenous stimulation appear to be risk factors for an attack of heat stroke.