Prolonged impairment of polymorphonuclear cells functions in one infant with transient zinc deficiency: a case report

BACKGROUND

Zinc is an essential trace element for the immune system. The zinc deficiency diminishes antibody- and cell-mediated responses in man. Lymphopenia and thymic atrophy are usually the early hallmarks of zinc deficiency. Surprisingly, only scarce data are available about polymorphonuclear cells (PMNs) functions in infants with zinc deficiency. We present the results of immunological analyses in one infant with transient zinc deficiency due to decreased zinc concentration in mother milk resulting in severe lactogenic acrodermatitis enteropathica.

MATERIAL/METHODS

Nine repeated examination of oxidative burst of PMNs and immunoglobulin levels using nitroblue tetrazolium dye test, chemiluminescence, flow cytometry and nephelometry were performed in the infant with severe zinc deficiency during 28 months period.

RESULTS

The unusual prolonged but transient impairment of PMNs respiratory burst accompanied with hypogammaglobulinaemia developed since the age of 2.5 months. Dramatic improvement of the skin was observed within days with total resolution of skin lesions on the 9th day of zinc therapy, but decreased PMNs respiratory burst persisted until the age of 23 months.

CONCLUSIONS

We conclude that zinc deficiency may lead to prolonged impairment of polymorphonuclear cells functions and hypogammaglobulinaemia.

[Prevalence of hepatitis G virus infection (HGV) in intravenous immunoglobulin recipients in the Czech Republic]

The prevalence of hepatitis G virus (HGV) in the serum of intravenous immunoglobulin (IVIG) recipients was studied and risk related to HGV positivity was considered. Although its pathogenicity is unclear, HGV is likely to cause liver disease or lymphoproliferation. Twenty (23%) of 86 tested MG patients were HGV RNA positive. Of the HGV positive patients, three (15%) showed mild elevation of liver enzymes and one (5%) was diagnosed with chronic lymphatic leukaemia prior to the institution of MG replacement. It can be concluded that the HGV prevalence among IVIG recipients is high but is not associated with signs of either liver disease or lymphoproliferation.

Exposure to silica and risk of ANCA-associated vasculitis

BACKGROUND

Exposure to silica dust is considered to be one of etiological factors of antineutrophil cytoplasmic antibodies (ANCA) -associated vasculitis (AAV).

METHODS

Subjects exposed to silica dust in Central Bohemia and followed in the Department of Occupational Medicine, Charles University, were selected for study. A group of 86 men exposed to SiO2 for at least 5 years were examined. The association between occupational exposure to silica dust and ANCA positivity is analyzed.

RESULTS

The subjects had a mean age of 66.7 years, and mean exposure to silica of 22.3 years. ANCA were detected significantly more frequently in patients group (17.1%; P-ANCA 18x, C-ANCA 3x) than in controls (n = 28, mean age 64.2 years, P-ANCA 1x, i.e., 3.6%). ANCA positivity was found less frequently (7.1%) in the group with history of SiO2 exposure without signs of pronounced silicosis, than in the group with simple (30.3%) or complicated silicosis (36.0%). Odds ratio for ANCA positivity and relative risk estimate in patients with silicosis were highly significant. Among possible predictor factors for ANCA positivity, silicosis and tuberculosis were relevant. No typical AAV was present among the patients.

CONCLUSION

Long-term silica exposure may be one of the exogenous factors contributing to ANCA production, however, silica exposure alone, without typical silicosis, was not associated with ANCA positivity.

[Auto- and alloreactivity of T lymphocytes in myelodysplastic syndrome]

BACKGROUND

Successful therapy with ATG and cyclosporine A in some myelodysplastic syndrome (MDS) patients led us to study the existence of T cells attacking autologous hemopoietic cells. In our study, we attempted to give the direct prove of autoreactive T cells in MDS (autoreactivity analysis). Simultaneously, we analysed the capacity of MDS patients to respond to allogeneic cells from unrelated individuals (alloreactivity analysis).

METHODS AND RESULTS

Autoreactive lymphocytes directed against own bone marrow mononuclear cells were analysed using the modification of cell mediated cytotoxic reaction. With one exception we did not confirm the presence of autoreactive T cells among 10 patients examined. Analysis of alloreactivity was performed by means of standard cell mediated cytotoxic reaction and mixed lymphocyte reaction. Surprisingly, the cytotoxic response to allogeneic cells was negative in 11 MDS patients from 16 analysed. When comparing refractory anaemia (RA) and refractory anaemia with ring sideroblasts (RARS) patients, the proportion of negative results was higher in RA (78 %) than in RARS (40 %). In mixed lymphocyte reaction, the response of MDS cells to allogeneic cells of unrelated individual was positive in all tested patients. The preliminary testing of TNF and IFNgamma secretion examined in supernatants of effector cells showed impaired levels of both cytokines in RA and normal levels in RARS in accordance with the findings achieved in alloreactivity analysis.

CONCLUSIONS

Autoreactive T cells were not found in MDS patients using our experimental arrangement. Analysis of alloreactivity showed the defect in effector--cytotoxic--phase of cell mediated cytotoxic reaction in the majority of MDS patients. The initial phase of this reaction represented in vitro by mixed lymphocyte reaction gave normal results. The possible reasons of disturbed alloreactivity and its relevance to immunity in MDS are commented in discussion.

Effects of human plasma proteins on maturation of monocyte-derived dendritic cells

Dendritic cells (DC) are a promising tool for vaccine therapy due to their unique properties as antigen presenting cells and their ability to prime naïve T cells. Increasing evidence suggests that maturation stage of DC critically influences the fate of the immune response. Generation of monocyte-derived DC for clinically applicable immunotherapy requires the use of well-defined components and stringent culture conditions. An alternative strategy is to use human autologous serum. However, its constituents are not stable and reflect the inflammatory condition of the donor. In order to investigate whether DC properties are influenced by proteins present in the plasma, we matured human monocyte-derived DC with four main plasma components: fibrinogen, fibronectin, plasminogen or C-reactive protein. These purified proteins were added at various concentrations on day 6 after the initial differentiation induced by IL-4 and GM-CSF. The maturation was assessed by phenotyping of maturation-associated marker (CD83) and co-stimulatory molecule CD86 as well as IL-12 production. Functional properties of DC were assessed by endocytic activity and mixed leukocyte culture. Our results indicate that fibrinogen had DC-maturation effect comparable to poly-I:C, TNF-alpha and PGE(2) as a positive control, but it failed to induce IL-12 production. The other plasma proteins had no effect on DC maturation. CRP at high concentration had rather inhibitory effect on DC induced lymphocyte function. We conclude that none of the tested plasma components and acute phase proteins sufficiently induce fully competent mature DC. This finding is important for the preparation of human DC-based vaccines supplemented by autologous sera.

[Glucocorticoids and their effect on dendritic cell function]

BACKGROUND

Dendritic cells represent the most effective antigen presenting cells and they are the only cell type capable of initiating the primary immune response. They use several sets of germ-line encoded receptors to differentiate between self and non-self and to detect the presence of danger signals. Danger signals are mainly represented by microbial pathogens but it can be also a necrotic or malignant cell. At various stages of their lifecycle dendritic cells play a key role in maintaining the peripheral tolerance towards self-antigens and in the initiation of an effective immune response. Glucocorticoids have been widely used in the treatment of autoimmune or inflammatory disorders and their immunosuppressive effect has been mainly attributed to the inhibition of lymphocytes functions.

METHODS AND RESULTS

In this study, we discuss the effects of glucocorticoids on in vitro generated myeloid dendritic cells and on peripheral blood myeloid and plasmacytoid dendritic cells subsets.

CONCLUSIONS

Experimental results point to the profound suppressive effect of glucocorticoids on the antigen presenting functions of dendritic cells and to contribute to better understanding of glucocorticoids-mediated immunosuppressive effect.

[Primary biliary cirrhosis--specific anti-mitochondrial antibodies]

Primary biliary cirrhosis is a chronic liver disease, characterized by the destruction of the epithelial cells of the sublobular, interlobular and septal bile ducts and with the development of cirrhosis. The presence of anti-mitochondrial antibodies against the subunits of mitochondrial 2-oxoacids dehydrogenases is characteristic for patients with primary biliary cirrhosis. The aim of this work was to study the effect of anti-mitochondrial antibodies upon activity of the isolated mitochondrial pyruvate dehydrogenase complex after the incubation with serum from patients with primary biliary cirrhosis.

GROUP OF PATIENTS AND METHODS

The activity of the purified bovine pyruvate dehydrogenase complex was studied spectrophotometrically in presence of the serum (1: 1000) from five patients with primary biliary cirrhosis and from ten disease free controls.

RESULTS

The activity of the pyruvate dehydrogenase was decreased after incubation with the serum from patients with primary biliary cirrhosis. No similar inhibitory effect was found after incubation with serum from controls.

DISCUSSION

The inhibitory effect of the anti-mitochondrial antibodies upon activity of pyruvate dehydrogenase may broaden the spectrum of diagnostic methods in patients with primary biliary cirrhosis. Further investigations are necessary to assess the possible application of this method for monitoring of changes during the course of the disease and for assignation of the disease prognosis.

[Immunotherapy--perspectives in therapy of ovarian carcinomas]

OBJECTIVE

To summarise recent knowledge and clinical studies of immunotherapy in the treatment of malignant ovarian epithelial tumors.

DESIGN

A literature review.

SETTING

Department of Gynecology and Obstetrics, Charles University Prague, 2nd Medical Faculty, University Hospital Motol. Department of Immunology Charles University Prague, 2nd Medical Faculty, University Hospital Motol.

ABSTRACT

Combination of surgery and chemotherapy has been the usual standard of therapeutic protocols in ovarian cancer patients. However, this therapy is still not sufficient to eliminate all of the tumour cells. Immunotherapy seems to be an effective approach in combination with surgery and chemotherapy. Immunotherapy includes three types of strategies: cytokine therapy, monoclonal antibody therapy and vaccine therapy, especially vaccines with dendritic cells. All of them are shortly reviewed in this article. IFNalpha, IFNgamma, IL-2, GM-CSF are examples of cytokine therapy. Representatives of monoclonal antibody therapy include trastuzumab (monoclonal antibody against HER-2/neu peptide, MAb B.43.13 (antibody against CA 125), or radiolabeled antibody--pemtumomab (90Yttrium-CC49). Cancer vaccination is used in experiments because it should be effective in presenting tumour cells as foreign cells to effector cells of the immune system. Otherwise, tumour cells are not usually recognised by the immune system as dangerous cells. The efficiency of immunotherapy depends on tumor size and previous therapy. It seems to be effective in potentiation of primary chemotherapy or as a consolidation treatment of minimal residual disease. Immunotherapy is still at the experimental level, but in the future it could be a useful part of protocols for the treatment of ovarian cancer.

Daily oral versus pulse intravenous cyclophosphamide in the therapy of ANCA-associated vasculitis--preliminary single center experience

The aim of the multicentric randomized trial CYCLOPS is to optimize the treatment of induction of remission in patients with generalized, but not immediately life-threatening ANCA (antineutrophil cytoplasmic antibodies) -associated vasculitis. This will be achieved by reducing the dose of cyclophosphamide by administering it as intermittent pulses. The lower cumulative dose will be very probably accompanied with lower toxicity, whereas the effectivity should be comparable. We have enrolled 28 patients to the study. At present, 18 of them are suitable for evaluation. Our preliminary results show that pulse intermittent administration of cyclophosphamide is safer from the point of morbidity and mortality due to infectious complications. In our hands, this treatment modality does not seem to be less effective than the conventional daily oral cyclophosphamide. However, unambiguous results and treatment recommendations will not be available until the final evaluation of all patients enrolled in the trial.

Antineutrophil cytoplasmic antibodies, anti-Saccharomyces cerevisiae antibodies, and specific IgE to food allergens in children with inflammatory bowel diseases

Differential diagnosis between ulcerative colitis (UC) and Crohn's disease (CD) is difficult in the initial phases in pediatric patients with inflammatory bowel diseases (IBD). This study was performed to determine the significance of anti-neutrophil cytoplasmic antibodies (ANCA) and anti-Saccharomyces cerevisiae antibodies (ASCA) in IBD. ANCA were specified with regard to their antigenic specifity, significance to the diagnosis, and correlation of titer with the disease activity. The occurrence of food allergy was questioned, too. Serum samples from 44 children with UC (n = 23) or CD (n = 21) and from disease-control children (coeliac disease, n = 21) were analyzed for IgG ANCA, ANCA target antigens, IgA and IgG ASCA, and IgE to food allergens. Results show that ANCA occur more frequently in UC than in CD and disease-control (74, 24, and 10%, respectively). The presence of ANCA does not reflect disease activity. Antigenic specificity does not differ in any group. IgA-ASCA are found more often in patients with CD (76% versus 17% in UC). The testing for both ANCA and ASCA enabled clear-cut differential diagnosis between UC and CD based on the high specificity (ANCA+ ASCA- 92.5% for UC, ANCA- ASCA+ 93.2% for CD). Specific IgE to food allergens were found in 8.7, 14.3, and 23.8% of patients with UC, CD, and coeliac disease, respectively. We conclude that combined testing of ANCA and ASCA represents a valuable tool in the differential diagnosis between UC and CD in pediatric patients, minimizing invasive diagnostic procedures. Monitoring of ANCA, its specificity, and titer determination does not bring more information. Testing for specific IgE to food allergens may be considered in individual patients.

Lung transplantation for cystic fibrosis: immune system and autoimmunity

BACKGROUND

In the current study we focused on changes in the immune parameters of patients with CF after lung transplantation (Tx), with particular emphasis on the interaction of the immune system, infection, the autoimmune phenomenon observed in some CF patients, and immunosuppression.

MATERIAL AND METHODS

Seven transplant patients with CF were investigated, 3 men and 4 women; the average age at Tx was 24.2 years (20.2-32.3). The parameters of both humoral immunity (immunoglobulins, complement, CRP, antinuclear and antineutrophil cytoplasmic antibodies) and cellular immunity (T and B lymphocytes, NK cells) were traced.

RESULTS

We observed marked initial hyperimmunoglobulinemia, with a sharp drop in immunoglobulin levels within 1 month after Tx. Positivity for antineutrophil cytoplasmic antibodies (ANCA) was found in 3 patients before Tx. A strong ANCA positivity persisted 2 months after Tx despite deep introductory immunosuppression. In one patient ANCA positivity, after a transient negative result at months 2 and 12 after Tx, reappeared one year after Tx. The Burkholderia cepacia infections found in 2 patients proved to be lethal.

CONCLUSIONS

In our series of CF lung transplant recipients, we found Burkholderia cepacia infection to be a risk factor. The robust appearance of autoantibodies and their persistent positivity for many months despite deep immunosuppression is a remarkable feature observed in some CF patients.

Biological properties of copolymer of 2-hydroxyethyl methacrylate with sulfopropyl methacrylate

Interaction of organism with non-toxic implanted polymers depends on the physicochemical properties of the implant surface, which influence the adsorption of bioactive proteins and subsequently adhesion and growth of cells. The synthetic hydrogels are known as poorly adhesive surfaces. In this study we demonstrated the adsorption of albumin, fibrinogen, fibronectin, basic fibroblast growth factor, heparin-binding epidermal growth factor-like growth factor and epidermal growth factor to poly(2-hydroxyethyl methacrylate) (pHEMA) and copolymer of 2-hydroxyethyl methacrylate (HEMA) and potassium salt of 3-sulfopropyl methacrylate (SPMAK). The adhesion and growth of 3T3 cells and human keratinocytes on surface of these polymers was tested without and with pretreatment of polymers with heparin-binding epidermal growth factor-like growth factor. The adhesion of mixture of human granulocytes and monocytes to these surfaces was also tested. The strips of both polymers were subcutaneously and intracerebrally implanted into the rat and the extent of foreign body reaction and brain biocompatibility was evaluated. The results showed the extensive adsorption of basic fibroblast growth factor and heparin-binding epidermal growth factor-like growth factor to copolymer containing SPMAK. However the adhesion (and growth) of cells to this type of copolymers was very low. Preadsorption of human plasma to pHEMA clearly stimulated the leukocyte adhesion in contrary to copolymer containing SPMAK. The extent of foreign-body reaction was significantly higher against the pHEMA compared to tested copolymer p(HEMA-co-SPMAK). In conclusion, the tested copolymer was a poorly adhesive substrate that is only poorly recognized by the non-specific immunity, although the adsorption of basic growth factors to this substrate is highly significant. Both polymers were well tolerated by the brain tissue. The phenotype of surrounding neurons was more close to the control neurons in the brain tissue surrounding the p(HEMA-co-SPMAK) implants.

Human epidermal Langerhans cells are selectively recognized by galectin-3 but not by galectin-1

Langerhans cells are dendritic antigen-presenting cells residing predominantly in the epidermis. Since endogenous galactoside-binding lectins with the jelly-roll motif (galectins) are known to trigger cellular responses, including mediator release, we investigated by lectin histochemistry the cells' capacity to bind two common members of this family, i.e. galectin-1 and -3. Actually, surrounding keratinocytes express a high level of galectin-3, and these cells can be considered as donors of this lectin to Langerhans cells. Employing biotinylated galectin-1 and -3, and concomitantly an antibody against CD1a as a second marker, to visualize the position of Langerhans cells in the human epidermis, the expression of galectin-3-reactive glycoligands in contrast to the lack of binding of galectin-1 was observed. Although the functional consequences of this selectivity are unclear, these results reveal an example for differential cellular reactivity towards two related endogenous lectins.

Immunological investigation in children with juvenile chronic arthritis

BACKGROUND

Immunological investigation is a part of the complex view on a child with juvenile chronic arthritis (JCA). We analyzed the data of a cohort of children with JCA in order to determine the real contribution of this investigation to their diagnosis and therapy.

MATERIAL AND METHODS

We included the investigation of humoral immunity and autoantibodies of 78 children with JCA. 18 children completed investigation of both humoral and cellular immunity of paired peripheral blood (PB) and synovial fluid (SF). Humoral immunity consisted from immunoglobulins, complement, circulating immune complexes, rheumatoid factors, soluble HLA I. molecules and antinuclear and antineutrophil cytoplasmic antibodies. Cellular immunity included cytometric studies of CD3, CD4, CD8, CD16/CD56, CD19, CD20, 23, CD3 HLA DR+, CD45 RA, CD45 RO, alpha/beta and gamma/delta T cells. To observe the status of Th1/Th2 balance in children with JCA, the cytokines IL-4, IFN gamma, TNF alpha and IL-6 were measured in the tissue culture of the synovial cells.

RESULTS

The parameters of humoral immunity in serum showed wide variability. We could not confirm particular changes specific for the forms or stage of the disease. ANCA were positive in 21 out of 78 children with JCA, 3 times both in PB and SF. More typical pattern could be followed in the comparison of PB and SF, with immunoglobulins and complement always found lower in SF than in PB. The cellular immunity was represented by the activation of lymphocytes mainly in SF, reverse ratio of CD45 RA and RO cells in PB and SF with marked predominance of memory T cells in the joint. High levels of sHLA in SF are the nonspecific marker of activation, the same is true for high levels of TNF alpha and IL 6 in SF cell culture supernatant.

CONCLUSION

The described changes in immunological parameters of humoral and cellular immunity are not specific for JCA. In the individual cases they can contribute to the diagnosis and monitoring of the disease. The investigation of sHLA molecules and cytokine profile should be restricted only for research.

Influence of plasma exchange on serum levels of cytokines and adhesion molecules in ANCA-positive renal vasculitis

BACKGROUND

Increased serum levels of proinflammatory cytokines may contribute to the organ damage in active antineutrophil cytoplasmic antigen (ANCA)-positive renal vasculitis. Plasma exchange (PE) may influence the activity of vasculitis not only by removing pathogenic autoantibodies, but also by lowering the serum levels of circulating cytokines.

METHODS

Serum levels of IL-1beta, IL-1ra, IL-6, IL-8, ICAM-1 and VCAM-1 were measured using ELISA in 10 patients with active ANCA-positive renal vasculitis (5 patients with Wegener's granulomatosis, WG, and 5 patients with microscopic polyangiitis, MPA) during the course of therapeutic PE. Cytokines and adhesion molecules were measured in samples of serum obtained at the beginning and at the end of the 1st, 3rd and 5th PE and in samples of filtrate obtained during the same PE.

RESULTS

In comparison with controls, patients with ANCA had higher serum levels of IL-1ra, IL-8, ICAM-1 and VCAM-1 before the 1st PE. Serum levels of IL-6, IL-8, ICAM-1 and VCAM-1 were increased in patients with MPA, and the serum levels of all the cytokines and adhesion molecules measured in patients with WG were increased. At the end of the PE course there were decreases in the serum levels of IL-1ra and VCAM-1 in ANCA patients and IL-1ra and ICAM-1 in WG patients. Single PE in ANCA patients led only to a decrease in serum levels of ICAM-1 and VCAM-1. On the other hand, there was no change in serum levels of IL-1beta and IL-8, and the serum levels of IL-1ra and IL-6 even increased at the end of a single PE, in spite of high levels of all cytokines and adhesion molecules in the plasma filtrate.

CONCLUSION

Serum levels of soluble adhesion molecules decrease after PE, but serum levels of proinflammatory cytokines are not reduced even by a PE course. Removal of these substances by PE is obviously counteracted by their increased production, possibly further stimulated by the contact of blood with the synthetic membrane. The insufficient influence of PE on the elimination of proinflammatory cytokines may partially explain its limited effect in some patients with ANCA-positive renal vasculitis.

[Dendritic cells and their use in the therapy of neoplastic diseases]

Dendritic cells (DC) constitute a heterogeneous leukocyte population. Their main function is to capture and process antigens (Ag) and present them to immunocompetent cells. Heterogeneity of DC is reflected at several levels. Myeloid and lymphoid lineage of the DC can be distinguished according to the precursor cell they originate from. The functional differentiation is of the great importance. DC can induce either specific immune reaction or tolerance to certain Ag. It depends upon the microenvironment where the processing of Ag takes place. Phenotypic and functional differences between the subtypes of DC are being extensively investigated for the purpose of their use in the immunotherapy of various diseases, tumors in particular. It appears that one of the causes of the specific anti-tumor immunity failure is the insufficient function of DC in vivo in patients with malignant diseases. Recent technology advances has enabled to generate and cultivate DC in sufficient amounts in vitro from their precursors. Coculturing of DC with the tumor Ag in the presence of cytokine mixture leads to the efficient Ag presentation and to the generation of specific cytotoxic lymphocytes capable of killing tumor cells. Subsequent application of these tumor Ag pulsed DC to the laboratory animals, and to the patients in first clinical studies, can induce regression of malignant disease. On the other side the ability of DC to induce tolerance to certain Ag is the subject of investigation in the field of immunotherapy of hypersensitivity states induced either by outer Ag (allergy) or inner Ag (autoimmune diseases). In this review we summarize source and ontogeny of DC, their morphology, phenotype, function and different ways of their generation in vitro. We emphasize the use of DC in the clinical practice aimed at the immunotherapy of tumor diseases.

[Secondary hemophagocytic syndrome in a systemic disease]

20 year old man 2 years treated for the seropositive rheumatoid arthritis was admitted for fever accompanied with jaundice, anemia and leukopenia. The underlying disease has been compensated already for long period of time, before his admission only Prednisone (in the dose of 5 mg daily) and Methotrexate (15 mg once a week) was given. His physical examination of admission was without any significant abnormalities, out of the routine laboratory examination the value of leukocytes count was 2.1 x 10(9)/L, erythrocytes 3.7 x 10(12)/L, hemoglobin 95 g/l, hematocrit 0.29, platelets 156 x 10(9)/L. Since admission to hospital the hepatic enzymes ALT, AST, GMT, ALP were about ten times elevated comparing to normal values, the coagulation examination has shown the decrease of Quick test to 55%. With respect to the permanent leukopenia the bone marrow aspiration was taken with the finding of the increase number the RES elements (18.4%) with the signs of hemophagocytosis. The phagocytic reticulum absorbs blood elements erythrocytes, normoblasts, granulocytes, platelets. According to the literature experience we started the combination of the immunosuppressive treatment consisting of corticosteroids and Cyclosporine. Already the day following the application of the high dose of corticosteroids the fever subsided, icterus went away gradually with the normalization of the liver tests. After 20 days of hospitalisation the patient was discharged in good shape. Now, after 4 months the is stabilized on the follow-up treatment of Prednisone a Cyclosporine.

Cyclosporine A versus methotrexate in the treatment of polymyositis and dermatomyositis

OBJECTIVE

To determine the effectiveness and tolerance of treatment with cyclosporine A (CyA) or methotrexate (MTX) added to corticosteroids in patients with severe, active polymyositis (PM) and dermatomyositis (DM).

PATIENTS AND METHODS

Thirty-six patients (20 with DM, 16 with PM) were enrolled into the study and randomized in MTX (n = 17) and CyA (n = 19) groups. Muscle endurance and functional test (MEFT), clinical assessment (CA), global patient's assessment (GPA), muscle MRI, serum CK, myoglobin, IL-1Ra, and autoantibody status were used to assess the response to therapy after 1, 3, and 6 months.

RESULTS

Significant improvement in MEFT, CA, GPA, and muscle MRI was found in both groups. Patients treated with MTX showed insignificantly better response than patients with CyA. CK levels in the MTX group decreased significantly after 1, 3, and 6 months, whereas a significant reduction in the CyA group was first observed after 6 months. IL-1Ra serum levels significantly dropped in the CyA group after two weeks, whereas in the MTX group the significant decrease was first seen after 3 months of treatment. Good correlation was found between each of the clinical parameters (MEFT, CA, and GPA), none of them showed any correlation with CK or IL-1Ra levels.

CONCLUSIONS

Administration of MTX or CyA added to corticosteroids was associated with clinical and laboratory improvement. Changes in CK and IL-1Ra levels were not associated with parameters of clinical disease severity measured in this study.

Detection of alpha(beta)-N-acetyl-D-galactosamine-binding sites in kidney--relation to Henoch-Schönlein-associated IgA nephropathy

Henoch-Schönlein purpura is the most common vasculitis of childhood, accompanied by the deposition of IgA1 immunoglobulins into the glomerular mesangium. The actual molecular mechanism of IgA deposition is not clear, but the altered glycosylation of O-linked oligosaccharides of the hinge region of IgA1 is generally considered as the crucial etiopathogenic factor. The oligosaccharides of this glycoprotein from healthy persons are principally of mucin-type Galbeta1,3GalNAcalpha-O-glycan core structure, frequently sialylated. The patient's IgA hinge region saccharide is an incomplete GalNAcalpha-O-glycan only. This study investigates the presence of binding sites for alpha-GalNAc and beta-GalNAc in frozen sections of kidney with and without nephropathy prompted by the possibility for a lectin mechanism of IgA deposition to mesangium. Neoglycoproteins prepared as conjugates with derivatized alpha- or beta-GalNAc moieties as histochemically crucial ligands and biotinylated bovine serum albumin as a carrier were employed for this purpose. The result of the experiments demonstrated expression of specific and accessible binding sites for both alpha- and beta-GalNAc in tubules but not in glomeruli of kidney samples both with and without nephropathy. These findings imply no involvement of a lectin mechanism of IgA1 binding to mesangium, unless a temporary alteration of accessibility of binding sites for probes in glomeruli occurs or the linkage region beyond the monosaccharide is pivotal for a receptor whose binding site may accommodate a peptide epitope in addition to the O-linked alpha-GalNAc residue.

Binding sites for carrier-immobilized carbohydrates in the kidney: implication for the pathogenesis of Henoch-Schönlein purpura and/or IgA nephropathy

BACKGROUND

Henoch-Schönlein purpura is a common vasculitis of childhood affecting the skin, joints, gastrointestinal tract, and kidney. The mesangial deposition of IgA1 is the most critical factor for the prognosis of patients with this disease. The aberrant glycosylation of the IgA1 subclass with the absence of terminally located galactose and presence of only alpha-N-acetylgalactosamine in O-linked oligosaccharides in the hinge region of IgA1 represents a prominent difference from the normal IgA1. These alterations prompt the supposition that the sugar part may guide IgA deposition by recognition of endogenous lectins on the mesangium.

METHODS

Owing to the limited knowledge about the expression of carbohydrate-binding sites in the human kidney we initiated the study of this aspect with a class of tools which are suitable to map the lectinome of cells. Employing biotinylated neoglycoconjugates, glycosaminoglycans, and sulphated polysaccharides we monitored the presence of accessible carbohydrate-binding sites in control kidneys represented by tumour-free areas of kidneys with Grawitz tumour and in biopsies from patients with Henoch-Schönlein purpura-associated IgA nephropathy.

RESULTS

Using frozen sections, no expression of any tested carbohydrate-binding site(s) was observed in the endothelial and the mesangial cells in glomeruli of the control kidneys as well as in the biopsies from Henoch-Schönlein purpura IgA nephropathic kidneys, in contrast to the tubules. The N-acetylgalactosamine-binding sites were expressed only in the inner layer of Bowman's capsule of 20% of glomeruli of the control kidney from one patient with Grawitz tumour and one biopsy from a patient with Henoch-Schönlein purpura-associated IgA nephropathy. However, the macrophages in the glomeruli of patients with IgA nephropathy and interstitial macrophages from both studied groups, i.e. without and with IgA nephropathy, harbour capacity to recognize carrier-immobilized alpha-N-acetylgalactosamine. Access to this binding site for the neoligand conjugate can be blocked by the monoclonal antibody MEM-18 recognizing CD14 antigen.

CONCLUSION

The possibility for a participation of macrophage deposition of IgA1 in mesangium via a lectin mechanism involving this binding capacity warrants further studies.

Coexpression of binding sites for A(B) histo-blood group trisaccharides with galectin-3 and Lag antigen in human Langerhans cells

Galectin-3 is an immunomodulatory protein with binding capacity for various glycoconjugates including IgE. It has been shown to be produced by epidermal keratinocytes and is present on the surfaces of skin Langerhans cells (LC). Therefore, it may have a role in the pathogenesis of various skin diseases, such as atopic dermatitis. To study the expression of galectin-3 in LC, we used, in addition to specific antibodies, a panel of synthetic, carrier-immobilized, specific oligosaccharides of the A- and B-histo-blood group, which are recognized by this lectin. In the mean time, Birbeck granules were visualized with an anti-Lag antibody. The double labeling experiments showed a remarkable colocalization of signals for Lag antigen (Birbeck granules) and galectin-3, as well as the binding sites for A- and B-histo-blood group trisaccharides. The specificity of the oligosaccharide binding was demonstrated by the lack of binding by Le(c), Le(d) (H blood group antigen), and sLe(x), which are not recognized by galectin-3. These results suggest that galectin-3 is present in Birbeck granules, where it retains reactivity for its glycoligands.

Primary Sjögren's syndrome in children and adolescents: proposal for diagnostic criteria

OBJECTIVE

Primary Sjögren's syndrome (pSS) in childhood is a rare disease. Diagnostic criteria are available for adult patients only. In order to establish diagnostic criteria for juvenile pSS an analysis of 7 girls and one boy suffering from pSS with early onset is reported. Due to the rarity of the disease, data on patients with pSS reported in the literature are included in the proposal for modified diagnostic criteria.

METHODS

The diagnosis of pSS was established according to the criteria for adulthood pSS, duly modified, which include clinical symptoms and laboratory immunological evaluation.

RESULTS

The average age of our patients at clinical onset was 13.5 years (range: 10-17 yrs.). Clinical signs included systemic (fever, fatigue) as well as local (parotitis, vulvovaginitis, conjunctivitis) symptoms. Paralysis due to hypokalemia linked to renal tubular acidosis and central nervous system (CNS) involvement was seen in one patient. Asymptomatic renal tubular acidosis was diagnosed in another 2 patients. Autoimmune hepatitis was present in 2 patients. All patients had laboratory abnormalities: hyperimmunoglobulinemia IgG, high titers of antinuclear antibodies (anti-SS-A and/or anti-SS-B) and elevated serum amylases. Sicca syndrome was never seen during childhood, although it developed later in 3 patients, after 7 to 10 years of follow-up.

CONCLUSIONS

It has been stressed that the classical diagnostic criteria for adult Sjögren's syndrome, especially sicca syndrome, are not applicable to a pediatric onset of the disease. On the other hand, the presence of typical laboratory abnormalities can allow the diagnosis of these patients in the early stages. Both laboratory and clinical symptoms typical for childhood are included in our proposal for diagnostic criteria applicable to juvenile pSS. Life-threatening conditions such as hypokalemic paralysis, CNS involvement and hepatitis may also occur in children. Sicca syndrome tends to develop much later in pediatric patients.

Antineutrophil cytoplasmic antibodies in children

To define the diagnostic meaning of antineutrophil cytoplasmic antibodies (ANCA) positivity in children, we analysed 1485 consecutive sera sent for routine immunological investigation to our department from January to August 1996. Using this large screening, we identified the most typical clinical disorders associated with ANCA in childhood. Out of 1485 indirect immunofluorescence (IIF) tests for ANCA, 143 were ANCA positive, 70 had a cytoplasmic IIF pattern (c-ANCA), and 73 a perinuclear IIF pattern (p-ANCA). The ANCA associated diseases in childhood were cystic fibrosis (CF) (31 c-ANCA, 7 p-ANCA positive out of 71 CF children investigated), juvenile chronic arthritis (JCA) (21 p-ANCA positive out of 78), auto-immune hepatitis (AIH) (4 c-ANCA and 12 p-ANCA positive out of 19), and ulcerative colitis (UC) (2 c-ANCA, 5 p-ANCA positive out of 15). In cases of c-ANCA positivity we determined the antigenic specificity of ANCA for proteinase 3 and/or bactericidal/permeability increasing protein. Borderline anti-proteinase 3 levels were found in CF, and in high levels in one boy with Wegener granulomatosis. Bactericidal/permeability increasing protein was characteristic target antigen in children with CF. p-ANCA positive children were further tested for the specificity for myeloperoxidase, which was detected mostly in children with JCA.

CONCLUSION

The spectrum of diseases associated with ANCA in children includes, besides the diagnostic associations typical for adults, several typical pediatric entities, mainly juvenile chronic arthritis and cystic fibrosis.

Cytokines and adhesion molecules in renal vasculitis and lupus nephritis

BACKGROUND

Plasma levels of some pro-inflammatory cytokines and soluble adhesion molecules have been suggested to be useful parameters to assess the activity of antineutrophil cytoplasmic antibody (ANCA)-positive vasculitis and lupus nephritis. We hypothesized that the renal activity of these diseases is better reflected by the urinary excretion and fractional excretion of these molecules.

METHODS

Plasma levels and urinary excretion of tumour necrosis factor-alpha (TNF-alpha), interleukin (IL)-6, IL-8, and the soluble cell adhesion molecules sICAM-1 and sVCAM-1 were measured by enzyme-linked immunosorbent assay (ELISA) in 14 patients with ANCA-positive renal vasculitis (eight active, ANCA-A; six in remission, ANCA-R), six patients with active lupus nephritis (LN), 15 patients with IgA nephropathy (IgAN) and nine healthy subjects. Fractional excretion of selected cytokines and adhesion molecules was also calculated.

RESULTS

Patients with ANCA-A had increased urinary excretion and fractional excretion of TNF-alpha (9.27 +/- 3.19% vs 0.58 +/- 0.02%, P < 0.01), IL-6 (120.79 +/- 65.83% vs 1.89 +/- 0.34%, P < 0.01) and increased fractional excretion of IL-8 (23.34 +/- 6.38% vs 2.56 +/- 1.07%, P < 0.01) and sVCAM-1 (0.81 +/- 0.33% vs 0.03 +/- 0.02%, P < 0.01) compared with controls. Urinary excretion of TNF-alpha and IL-6 and fractional excretion of TNFalpha, IL-6 and IL-8 were higher in ANCA-A than in ANCA-R. Patients with LN had increased plasma TNF-alpha (20.52 +/- 2.01 pg/ml vs 12.33 +/- 0.23 pg/ml, P < 0.05) and sVCAM-1 (1537.88 +/- 276.36 ng/ml vs 692.26 +/- 44.42 ng/ml, P < 0.05) and increased urinary excretion of TNF-alpha (2.81 +/- 0.51 microg/mol creat vs 0.98 +/- 0.05 microg/mol creat, P < 0.01), IL-8 (35.78 +/- 14.03 microg/mol creat vs 12.46 +/- 5.19 microg/mol creat, P < 0.05) and sVCAM-1 (48.98 +/- 20.20 microg/mol creat vs 2.92 +/- 1.35 microg/mol creat, P < 0.01) compared with controls. Patients with IgAN had, in comparison with controls only increased plasma TNF-alpha (18.10 +/- 0.57 pg/ml vs 12.33 +/- 0.23 pg/ml, P < 0.05).

CONCLUSIONS

Urinary excretion and fractional excretion, but not plasma levels, of selected pro-inflammatory cytokines (TNF-alpha, IL-6 and IL-8) were increased in patients with active ANCA-positive renal vasculitis, but not in ANCA positive vasculitis in remission. These parameters may be useful to monitor the activity of this disease.

Aberrant expression of KOR-SA3544 antigen in childhood acute lymphoblastic leukemia predicts TEL-AML1 negativity. The Pediatric Hematology Working Group in the Czech Republic

The antigen KOR-SA3544 is physiologically expressed exclusively on granulocytes. Aberrant expression of KOR-SA3544 has been invariably found in BCR/ABL-positive acute lymphoblastic leukemia (ALL) and in some BCR/ABL-negative ALL. In an interim analysis of a prospective clinical and cytometric study data of 73 children with newly diagnosed or relapsed ALL with and without TEL/AML1 fusion are presented. KOR-SA3544 expression over 3% was detected in the majority of TEL/AML1-negative patients with newly diagnosed common or preB ALL (19 of 31) and not in TEL/AML1-positive patients (0 of 18, P < 0.0001). The level of expression of KOR-SA3544 was 0.02-90% (median 6.0%) and 0.03-2.4% (median 0.23%) in TEL/AML1-negative and TEL/AML1-positive patients, respectively. All five newly diagnosed patients with DNA index > or =1.16 and <1.6 exhibited high levels of KOR-SA3544 expression. Membrane expression of CD79a was found to correlate with TEL/AML1 negativity, although less significantly than KOR-SA3544 (P = 0.03). Furthermore, our data confirm that TEL/AML1 positivity correlates with non-hyperdiploidy and low presenting age. In conclusion, KOR-SA3544 correlated strongly with TEL/AML1 negativity, it was a better predictor of TEL/AML1 status than other factors tested and was found at high levels in hyperdiploidy. In combination with age, KOR-SA3544 predicted TEL/AML1 status in 86% newly diagnosed preB/cALL patients.

[Soluble cytokinin receptors in renal vasculitis and lupus nephritis]

BACKGROUND

Activation of various cytokines, e.g. TNF alpha, IL-1 and/or IL-6 may play important role in the pathogenesis of renal vasculitis and lupus nephritis (LN). Systemic effects of these cytokines may be modulated by their circulating soluble receptors. Plasma levels of cytokine receptors may thus be also markers of the activation of these cytokines.

METHODS AND RESULTS

Plasma levels of TNF alpha, its soluble receptor p75 (sTNF-RII), IL-6 and soluble IL-6 receptor (sIL-6R) were measured using ELISA in 17 pts with ANCA-positive renal vasculitis (12 active-ANCA-A, 7 in remission ANCA-R), 9 pts with active lupus nephritis (LN) and 5 healthy subjects. Pts with LN had in comparison with controls increased plasma levels of TNF alpha, sTNF-RII, IL-6 and sIL-6R. Pts with ANCA-A had also in comparison with controls increased plasma levels of TNF alpha, sTNF-RII and sIL-6R, but plasma levels of IL-6 were not significantly increased dut to great standard deviation. Pts with ANCA-R had in comparison with controls increased plasma levels of sTNF-RII, but plasma levels of TNF alpha were in ANCA-R significantly lower than in ANCA-A. While the ratio TNF alpha/sTNF-RII was significantly lower in all groups of pts than in controls, the ratio IL-6R/sIL-6R was in comparison with controls significantly increased only in LN.

CONCLUSIONS

While increased plasma levels of TNF alpha may be nonspecific marker of the activity of ANCA-positive renal vasculitis and LN, plasma levels of sTNF-RII are increased also in pts with ANCA-positive renal vasculitis in remission. Increased plasma levels of sTNF-RII may interfere with systemic effects of TNF alpha, but may also prolong the lifetime of its active form. Plasma levels of sIL-6R are increased both in ANCA-A and in LN, but their increase is, however, much less pronounced than that of sTNF-RII and cannot effectively block systemic effects of IL-6.

Antineutrophil cytoplasmic autoantibodies (ANCA) in children with cystic fibrosis

Anti-neutrophil cytoplasmic antibodies (ANCA) represent a useful diagnostic tool in patients with small vessel vasculitis. Circulating ANCA specific for bactericidal/permeability increasing protein (BPI) have been recently reported in adult patients with cystic fibrosis (CF), an autosomal recessive disorder caused by mutations in the cystic fibrosis transmembrane regulator (CFTR) gene with consequent impaired function of a transmembrane chloride channel. To contribute to the better understanding of the significance of ANCA in this disease, we investigated ANCA presence and antigenic specificity in children with CF. Results were correlated with clinical status, immunological data, age and genotype. The indirect immunofluorescence pattern of a total of 71 children with CF indicated that 31 were c-ANCA positive, while seven were p-ANCA positive. In further ELISA studies of ANCA antigenic specificity, 51 out of 66 investigated samples were positive for BPI, and 14 out of 28 were positive for proteinase 3 (PR3). We found an association between levels of antibodies against PR3 with age and Pseudomonas infection. We did not, however, find any correlation between CFTR genotypes, Pseudomonas infection or paediatric parameters and the level of anti-BPI antibodies. High positivity of anti-BPI antibodies were seen even among the youngest CF patients, before the development of clinical signs of CF, indicating that formation of ANCA might be a very early event in the disease. Both anti-BPI and anti-PR3 antibodies may play a significant, although variable role, in the pathogenesis of CF.

[CD5-positive B lymphocytes and antinuclear antibodies]

BACKGROUND

The production of natural autoantibodies incl. antinuclear antibodies (ANA) is ascribed to lymphocytes which have a CD5 molecule on their surface. The role of CD5 positive B lymphocytes in the induction of autoimmunity is obscure so far. The authors focused their attention on the incidence of antinuclear antibodies (AA) in subjects with different diseases and sought a relationship with the ratio of CD5 positive B lymphocytes in the peripheral blood stream.

METHODS AND RESULTS

CD5 positive lymphocytes were assessed on a flow cytometer using monoclonal anti CD5 and anti CD19 antibodies. Antinuclear antibodies are detected by indirect fluorescence on a substrate of human leucocytes and HEP-2 cells. In a group of 134 subjects the authors did not provide evidence of a direct relationship between the relative number of CD5 positive B lymphocytes in the peripheral blood stream and the presence of ANA (IgG, IgA, IgM), not even in 33 patients with autoimmune diseases. In 86 patients the authors revealed that antinuclear antibodies type IgM predominate in patients with repeated respiratory infections. In systemic diseases the isotype IgG predominates (p = 0.01). After immunosuppressive treatment with a favourable clinical effect the ANA isotype IgG disappears and isotype IgM is found more frequently. The incidence of the ANA isotype IgM is significantly higher in healthy subjects aged over 60 years than in younger subjects (12.5%/6.1%, p = 0.06), and more frequent in women (p = 0.05).

CONCLUSIONS

The presence of antinuclear antibodies is not associated with the amount of CD5 positive B lymphocyte in the peripheral blood stream.

Autoimmunity to polymorphonuclears: functional consequences of the binding of antibodies to membrane and cytoplasmic target antigens of polymorphonuclear leukocytes

Antineutrophil autoantibodies reacting with cytoplasmic antigens are associated with various types of vasculitides, whereas antibodies reacting with neutrophil membrane antigens are mostly related to autoimmune neutropenias. The aim of this study was the investigation of the effect of monoclonal antibodies (MoAbs) reacting with surface and cytoplasmic antigens of polymorphonuclear leukocytes (PMN) known to be targets for autoantibodies in human diseases. Blood of healthy volunteers was tested for several phagocytic functions in the presence of MoAbs against surface (CD16, CD11b, CD18, NB1) and cytoplasmic (proteinase 3; PR3) molecules. Candidacidal activity was significantly inhibited in the presence of all MoAbs but isotypic control. Phagocytic activity was inhibited by anti-CD11b and/or anti-CD18 MoAbs. Zymosan-induced chemiluminescence was reduced by MoAbs anti-CD16, CD18, and NB1, enhanced by anti-PR3 MoAb, and less enhanced by anti-CD11b. In conclusion, antimembrane antibodies diminished phagocytic functions at multiple steps; in contrast, anticytoplasmic MoAb promoted activation of oxidative burst in addition to impairment of microbicidal activity. This fact may be related to different pathogenic aspects of diseases associated with antimembrane and anticytoplasmic antibodies.

[The effect of plasmapheresis on cytokine serum levels and adhesion molecules in ANCA-positive renal vasculitis]

BACKGROUND

Increased serum levels of proinflammatory cytokines may contribute to the organ damage in active ANCA-positive renal vasculitis (ANCA-A). Plasma exchange (PE) may influence the activity of vasculitis not only by removal of pathogenic autoantibodies, but also by lowering of serum levels of circulating cytokines.

METHODS AND RESULTS

Serum levels of IL-1, IL. 1ra, IL-6, IL-8, ICAM-1 and VCAM-1 were measured using ELISA in 10 pts with active ANCA-positive renal vasculitis (5 pts with Wegener's granulomatosis-WG, 5 pts with microscopic polyangiitis-MPA) during the course of therapeutic PE. Cytokines and adhesion molecules were measured in samples of serum obtained in the beginning and at the end of the 1st, 3rd and 5th PE and in the samples of filtrate obtained during the same PE. Pts with ANCA had before the 1st PE in comparison with controls higher serum levels of IL-1ra, IL-8, ICAM-1 and VCAM-1. There were increased serum levels of IL-6, IL-8, ICAM-1 and VCAM-1 in pts with MPA and increased serum levels of all measured cytokines and adhesion molecules in pts with WG. At the end of the course of PE there was the decrease of serum levels of IL-ira and VCAM-1 in pts with ANCA and IL-1ra and ICAM-1 in WG. Single PE led in pts with ANCA only to the decrease of serum levels of ICAM-1 and VCAM-1. On the other hand, there was no change of serum levels of IL-1 and IL-8 serum levels of IL-1ra and IL-6 even increased at the end of single PE, in spite of high levels of all cytokines and adhesion molecules in plasmafiltrate.

CONCLUSIONS

Serum levels of soluble adhesion molecules decrease after PE, but serum levels of proinflammatory cytokines are not reduced even by the course of PE. Removal of these substances by PE is obviously counteracted by their increased production, possibly further stimulated by the contact of blood with synthetic membrane. Insufficient influence of PE on the elimination of proinflammatory cytokines may partially explain its limited effect in some patients with ANCA-positive renal vasculitis.

[Cytokines and adhesion molecules in renal vasculitis and lupus nephritis]

BACKGROUND

Plasma levels and urinary excretion of proinflammatory cytokines and soluble adhesion molecules may be useful parameters of the activity of ANCA-positive renal vasculitis and lupus nephritis.

METHODS AND RESULTS

Plasma levels and urinary excretion of TNF alpha, IL-6, IL-8, ICAM-1 and VCAM-1 were measured by ELISA in 14 patients (pts) with ANCA-positive renal vasculitis (8 active-ANCA-A, 6 in remission ANCA-R), 6 pts with active lupus nephritis (L.N), 15 pts with IgA nephropathy (IgAN) 10 pts with autosomal dominant polycystic kidney disease and 9 healthy subjects (Co). Fractional excretion (FE) of selected cytokines and adhesion molecules was also calculated. Pts with LN had in comparison with controls increased plasma levels of ICAM-1, VCAM-1, IL-6, IL-8 and TNF alpha, increased urinary excretion of VCAM-1, IL-8 and TNF alpha and increased fractional excretion of VCAM-1 and IL-8. Patients with ANCA-A had in comparison with controls increased plasma concentrations of ICAM-1 and VCAM-1, increased urinary excretion of VCAM-1, IL-6 and TNF alpha and increased fractional excretion of VCAM-1, IL-6, IL-8 and TNF alpha. Patients with ANCA-R had in comparison with controls higher plasma levels of ICAM-1, VCAM-1, IL-6 and TNF alpha, increased urinary excretion of VCAM-1 and TNF alpha and increased fractional excretion of VCAM-1, IL-6 and TNF alpha.

CONCLUSIONS

Patients with ANCA-positive renal vasculitis had in contradistinction to pts with active LN increased fractional excretion of IL-6 and TNF alpha. Both cytokines are probably produced in renal vasculitis locally in the kidney. Increased plasma levels of soluble adhesion molecules and increased plasma levels and fractional excretion of proinflammatory cytokines in patients with ANCA-positive renal vasculitis in clinical remission may explain the strong propensity of these patients to develop relapses of the diseases on withdrawal of immunosuppressive treatment.

[Clinical spectrum of the antiphospholipid syndrome]

Antiphospholipid syndrome (APS) is characterized by multiple arterial and venous thromboses, repeated spontaneous abortions and thrombocytopenia, together with the presence of antiphospholipid antibodies in serum. We present three patients, two men and a woman, at the age of 43, 24 and 23 years respectively. The younger man and the woman had secondary APS and systemic lupus erythematosus, the older man had primary APS. The symptoms and course of the disease were different. The older man lives 17 years after the onset of first symptoms with multiple neurologic disorders, the younger man is symptomless. The woman died several months after the acute onset of the disease.

[Successful transplantation of fetal blood in a boy with leukocyte integrin deficiency syndrome]

The authors describe the first successful case of transplantation of haematopoietic stem cells in a patient with severe congenital immunodeficiency-the syndrome of deficiency of leukocytary integrins (LAD), leukocyte adhesion deficiency) in the Czech Republic and, at the same time, the first successful transplantation of umbilical blood in this disease in the world. The six-year boy was completely cured by the transplantation of haematopoietic stem cells contained in umbilical blood sampled during delivery of his healthy brother with identical HLA system. The pretransplantation myeloablative preparation was performed by a combination of busulfan, cyclophosphamide and etoposide. The relatively uncomplicated posttransplantation course was secured by preventive administration of antibiotics and immunoglobulins. The reattachment of the stem cells, estimated from the peripheral blood picture, occurred 25 days after the transplantation, the success of the intervention was confirmed by reaching physiological values of originally null expression of integrins on leukocytes of the patient 30 days after the transplantation. The transplantation of umbilical blood is a very promising therapeutic method especially in children with leukemia, congenital severe immunodeficiencies o inborn errors of metabolism.

Successful HLA-identical sibling cord blood transplantation in a 6-year-old boy with leukocyte adhesion deficiency syndrome

A 6-year-old boy with the severe form of the leukocyte adhesion deficiency syndrome (LAD) received a transplant of cord blood (CBT) from his HLA-identical brother. The donor was proved healthy by successful prenatal diagnosis. CBT was performed after conditioning with etoposide, busulfan and cyclophosphamide. After hematopoietic recovery complete chimerism was proved as well as the normal expression of CD11x/CD18 complex on circulating leukocytes. The only post-transplant complication was a mild pneumonitis resolving on the corticosteroid therapy. Thirteen months after CBT the boy is in good health and shows no signs of immunodeficiency. As far as we know this is the first report of successful CBT in a patient with LAD syndrome.

Effect of phagocytosis of pHEMA particles and of heat-killed Candida albicans on expression of carbohydrate-binding sites such as endogenous lectins in phagocytes

Phagocytosis of particles is an integral part of the defence system. Besides clearing the environment of foreign material this mechanism may affect the expression of physiologically relevant epitopes such as carbohydrate-binding sites, e.g. lectins. To determine the effect of particle design on the expression of such determinants in human monocytes and peritoneal macrophages either in suspension or after adherence, the binding of labelled (neo)glycoproteins was comparatively studied after exposure to poly (2-hydroxyethyl methacrylate) particles and heat-inactivated Candida albicans cells. A stimulatory effect of phagocytosis on extent of expression of binding sites for (neo)glycoproteins in phagocytic cells was observed. The levels of responsiveness varied according to the type of particle, adherence of the cell adding a further regulatory parameter. These results support the notion of a potential influence of the chemical structure and/or the form of an engulfed particle on phagocyte differentiation.

[The first case of leukocyte integrin deficiency syndrome in the Czech Republic and successful prenatal diagnosis in the affected family]

The syndrome of leukocyte adhesion deficiency (LAD) is a rare congenital immunodeficiency which is usually manifested from birth by serious infections of the skin and mucosal membranes. The molecular basis of the disease is heterogeneous: quantitative or qualitative disorders of the beta 2 integrin sub-unit are involved which lead to the absence or substantially reduced expression of adhesive molecules of the CD11/CD18 complex on leukocytes. The authors describe the case of a boy who suffered from this syndrome. The diagnosis was established at the age of four years, based on the typical clinical picture and confirmed by examination of integrins on lymphocytes and granulocytes which were zero. During the mother's subsequent pregnancy prenatal diagnosis was made by puncture of the umbilical cord during the 22nd week of gestation. Affection of the foetus by this syndrome was ruled out by examination of integrin expression on foetal leukocytes, a normal finding was confirmed also after delivery. During delivery umbilical blood was collected which was frozen and later used for therapeutic transplantation to the sibling suffering from LAD. This is the first case of this syndrome in the Czech Republic and first prenatal diagnosis which led to aimed collection of umbilical blood used for treatment of this rare immunodeficiency.

[Renal vasculitis and glomerulonephritis with anti-neutrophil cytoplasmic antibody positivity]

BACKGROUND

Anti-neutrophil cytoplasmic antibodies (ANCA) define pathogenetically related group of renal vasculitides and glomerulonephritides mostly with serious prognosis. If unrecognized, these life-threatening diseases may cause loss of independent renal function and other dangerous extrarenal complications (e. g. pulmonary haemorrhage). We concentrated on the diagnosis, treatment and log-term follow-up of these patients.

METHODS AND RESULTS

Renal biopsy was performed in 46 ANCA-positive patients. Age and sex distribution, type of ANCA, organ involvement, renal biopsy findings, renal function and effect of therapy were analyzed in these patients. Twenty three patients suffered from renal vasculitis, most commonly Wegener's granulomatosis (14 patients) and microscopic polyarthritis (7 patients). IgA nephropathy (7 patients) and idiopathic necrotizing/crescentic glomerulonephritis (8 patients) prevailed in patients with limited renal involvement. Renal morphology and function was most seriously impaired in patients with Wegener's granulomatosis. Immunosuppressive treatment was able to control the activity of the disease with the negativization of ANCA and improvement or stabilization of renal function in more than 90% of patients.CONCLUSIONS. ANCA-positive renal vasculitis and glomerulonephritis is relatively common. Clinical signs of extrarenal involvement are present in about 50% of patients with ANCA-positive glomerulonephritis. Rapidly introduced immunosuppressive treatment effectively controls renal and extrarenal manifestations of the disease.

[The effect of recombinant erythropoietin on candidicidal activity of polymorphonuclear leukocytes in hemodialyzed patients]

BACKGROUND

Some investigations, incl. ours, provided evidence that recombinant erythropoietin (rHU-EPO) used in the treatment of anaemia in dialyzed patients has an impact also on some immunological parameters. The objective of the present work was to study mechanisms of the effect of rHU-EPO on neutrophil leukocytes.

METHODS AND RESULTS

The candicidal activity (CI) of polymorphonuclear leukocytes in whole blood (CI-WB), after isolation of cells in the presence of pooled serum (CI-PMN) was assessed and parallel tests were performed in the presence of rHU-EPO in vitro in a concentration of 2 U/ml (CI-WB/E, CI-PMN/E) in anaemic patients before treatment with EHU-EPO (group A, n = 16), after achieving the target haematocrit (0.30-0.35) (group T, n = 14) and in healthy controls (group C, n = 8). The candicidal activity in group A was lower than in controls in whole blood; after removal of uraemic serum it reached normal values. Addition of rHU-EPO in vitro had a marked stimulating effect (CI-WB = 0.16 +/- 0.06, WB/E = 0.22 +/- 0.06*, PMN = 0.23 +/- 0.11*, PMN/E 0.34 +/- 0.1**). After achievement of the desirable Ht the candidacidal activity became normal and isolation of the cells did not change it. In this group a stimulating effect of rHU-EPO in vitro was apparent, contrary to the control group (group T: CI-WB = 0.22 +/- 0.05, WB/E = 0.29 +/- 0.05*, PMN = 0.21 +/- 0.04, PMN/E = 0.27 +/- 0.06*, group C: CI-WB = 0.21 +/- 0.06, WB/E = 0.21 +/- 0.06, PMN = 0.22 +/- 0.06 PMN/E = 0.21 +/- 0.05) (*/**p < 0.01/0.001).

CONCLUSIONS

The results of the investigation indicate that during treatment with rHU-EPO phagocytic functions in dialyzed patients attain normal levels. This effect may be also due to the direct effect of rHU-EPO on neutrophil leukocytes of dialyzed patients.

[Diagnostic and pathogenic significance of antineutrophil cytoplasmic antibodies in vasculitides]

OBJECTIVES

The study represents a complex report on diagnostic and pathogenic significance of antineutrophil cytoplasmic autoantibodies (ANCA). Our report is founded on the results of our clinical and experimental studies.

METHODS

ANCA was examined by indirect immunofluorescence, or ELISA-anti MPO. The data for evaluation of diagnostic ANCA associations were gained by means of questionnaires. The experimental part involved examination of the impact of sera containing ANCA and monoclonal antibodies (MoAb) against proteinase 3 and control MoaB specific for neutrophils.

RESULTS

Within the course of 1 year we have examined 1010 samples, ANCA was found in 65 patients: 26 cases of systemic vasculitis, 12 cases of other autoimmune diseases, 9 cases of isolated glomerulonephritis, 7 cases of inflammatory intestinal diseases, 6 cases of ophthalmic inflammatory diseases, and 6 cases of other diseases. Vasculitis of small vessels found in our group of patients are concomitted by ANCA positivity in 90% (Wegener's granulomatosis 15/16, Churg--Strauss's syndrome 3/5, MPA 9/9), vasculitis of medium vessels 12% (classical polyarteritis nodosa 1/2, Kawasaki disease 0/2, Henoch--Schönlein's purpura 0/4, Takayasu's arteritis 1/4). The ANCA-containing sera inhibit the candidacidal activity by 65% in average. THe inhibitory impact is yielded by anti-proteinase MoAb, in contrast to the control MoAb.

CONCLUSION

c-ANCA in high concentration is specific for active form of Wegener's granulomatosis, other types of ANCA in low titres are not of diagnostic value for vasculitis. ANCA is concomitted especially by small vessels vasculitis. The proved inhibition of microbicidal PMN activity by ANCA can participate in some clinical signs of immunodeficiencies in vasculitis. (Tab. 5, Ref. 18.).

[Adhesion molecules and cytokines in vasculitides]

Renal vasculitis syndromes include particular characteristic changes in concentrations of some cytokines in plasma or urine. Preliminary results suggest that the systemic lupus erythematodes with affliction of the kidneys is specifically concomitted by the increase in IL-8, both in plasma and urine. ANCA-positive renal vasculitis syndromes appear to coincide with a typical increase in the synthesis of interleukin-6 in the kidneys. We suggest that the monitoring of individual cytokine levels in plasma and urine will enable to study in greater detail the immunopathogenesis of renal vasculitis syndromes and the extent of local production of cytokines which may cause further progression of renal lesions. (Fig. 4, Tab. 1, Ref. 10.).

[The spectrum of diseases associated with antineutrophil cytoplasmic antibodies]

BACKGROUND

Antineutrophil cytoplasmic antibodies (ANCA) are considered as a diagnostic marker of systemic vasculitis and rapidly progressing glomerulonephritis. They are frequently associated with other pathological conditions. The author's objective was to analyze a group of patients examined at the Department of Clinical Immunology of the First Medical Faculty Charles University in the course of one year and evaluation of the diagnostic asset of the ANCA examination.

METHODS AND RESULTS

ANCA was assessed in serum using the method of indirect immunofluorescence. In cases of p-ANCA the ELISA test was used to assess antimyeloperoxidase antibodies. Clinical data were evaluated on the basis of analysis of a questionnaire sent to doctors of patients where ANCA was detected. In 1992 1010 specimens were examined and in 115 ANCA was detected. This was the case in a group of 65 patients with the following diagnoses: systemic vasculitis 26x, systemic immunopathological diseases 12x, renal diseases 9x, inflammatory bowel diseases 7x, inflammatory eye diseases 6x, monoclonal paraproteinaemia 2x, other 4x. The patients had renal affections (45%), affections of the joints (20%), skin (18%), eyes (14%), lungs (12%), GIT (11%), ENT (9%), and nerves (9%). Type c in titres above 1:160 was always associated with the diagnosis of Wegener's granulomotosis, in other instances c- or x-types titres of 1:20 were involved. Antibodies against myeloperoxidase were detected in four instances.

CONCLUSIONS

The authors confirmed that c-ANCA in high concentrations are specific for the predominantly active form of Wegener's granulomatosis. The group of patients with p-ANCA is too small to generalize the diagnostic impact. Low ANCA concentrations are found in many other diseases. The importance of ANCA can be evaluated only in a clinical context and the importance of their presence must not be overestimated.

Antineutrophil cytoplasmic antibody-positive sera inhibit candidacidal activity of granulocytes

Antineutrophil cytoplasmic antibodies (ANCA) are suspected of being involved in the pathogenesis of tissue injury in systemic vasculitis. We have investigated the effect of 10 sera from 8 patients with ANCA-associated diseases on the capacity of neutrophils derived from healthy persons to kill ingested Candida albicans. ANCA-containing sera inhibited candidacidal activity by 55-80% in comparison to control sera. This phenomenon could lead to the depression of antimicrobial resistance of patients with ANCA and could be involved in the pathogenesis of granuloma formation.

[Serum antineutrophil cytoplasmic antibodies inhibit the ability of granulocytes to kill C. albicans]

BACKGROUND

According to several experimental studies, antineutrophil cytoplasmic antibodies (ANCA) are involved in the pathogenesis of tissue injury in some systemic vasculitis and glomerulonephritis by stimulating oxygen radical release and secretion of lysosomal enzymes from neutrophilic granulocytes. In our work, we studied the effect of ANCA-positive sera on the ingestion and killing of C. albicans by granulocytes from healthy persons. METHODS AND RESULTS. Neutrophils isolated from the blood of healthy persons were incubated with live C. albicans in ratio 1:1 in the presence of pooled sera (controls) and 10 sera from 8 patients with ANCA-associated diseases: 6x Wegener's granulomatosis, 1x idiopathic rapidly progressive glomerulonephritis, 1x rapidly progressive glomerulonephritis concomitantly ANCA and anti-GBM (glomerula bas. membrane) positive. ANCA-positive sera did not influence the ingestion of C. albicans, but strongly inhibited killing of C. albicans (55-80% in comparison to controls). Sera from 2 patients in the time of ANCA-negativization showed lower inhibition (5 and 35%, respectively).

CONCLUSIONS

We demonstrated inhibitory effect of ANCA-positive sera on candidacidal activity of neutrophils from healthy persons. This fact could be one of the pathogenetic mechanisms of granuloma formation in Wegener's granulomatosis. Results of our experiment could be an additional rationale for the administration of trimethoprim/sulfamethoxazole as prevention of relapses of systemic vasculitis.

[The Churg-Strauss syndrome with rapidly progressive glomerulonephritis positive for antineutrophil cytoplasmic antibodies]

Renal failure developed in a patient treated for worsening spastic dyspnoea, high erythrocyte sedimentation rate and enlarged peribronchial lymph nodes by the antituberculotic regimen. Renal biopsy disclosed rapidly progressive glomerulonephritis with 95% crescents, granulomatous periglomerulonephritis vasculitis and eosinophilic interstitial infiltrates. On the basis of the positivity of antineutrophil cytoplasmic antibodies (ANCA), eosinophilia and profound ventilatory impairment the diagnosis of Churg-Strauss syndrome was established. The patient was treated by plasma exchanges and combined immunosuppression with the profound effect on erythrocyte sedimentation rate, eosinophilia a negativization of ANCA and preservation of at least minimal renal function. Further therapy was complicated by steroid diabetes, repeated leucopenia and exacerbation of spastic bronchitis and eventually by the massive gastrointestinal haemorrhage from asymptomatic gastric ulcer. There were no signs of inflammation in renal autopsy specimens with prevailing glomerulosclerosis a periglomerular fibrosis. Renal impairment is rare in Churg-Strauss syndrome and it is only exceptionally the cause of renal failure.

[Nephrologic aspects of HIV infection]

The authors present a review of nephrological complications of HIV infection. The latter can be divided into electrolyte disorders and disorders of the water balance, acute renal failure, non-specific affections of the glomeruli, tubules and renal vessels and so-called HIV nephropathy. While the three former groups of complications are non-specific, coincidental, HIV nephropathy is obviously a specific complication of HIV infection. It is characterized by the nephrotic syndrome with rapid progression to irreversible renal failure. As to the histological appearance, it is focal segmental glomerulosclerosis. Survival of asymptomatic HIV infected patients in a dialyzation programme does not differ from other patients. The prognosis in case of developed AIDS is, however, unfavourable. Transplantation of HIV positive donors and recipients is not recommended. The authors present also basic data on the possible nephrotoxicity of the most frequently used preparations in the treatment of HIV infected subjects.

[New findings in chronic granulomatous disease]

Chronic granulomatous disease is a rare hereditary disease characterized by repeated infections affecting in particular the skin, lymph nodes and internal organs. Histological examination in the affected tissues reveals a granulomatous inflammation. The aetiological agents of infection are most frequently staphylococci, G-bacteria, Candida and Aspergillus. From the immunological aspect it is an inborn immunodeficiency affecting professional phagocytes (monocytes and granulocytes) which are unable to kill some ingested microorganisms. The molecular basis of the defect is affection of the NADPH oxidase enzyme complex at various sites which explains the genetic heterogeneity of the disease. The condition is usually manifested in early childhood, it has a variable course; if untreated, the affected subjects frequently die in child age. By early diagnosis of the disease and suitable therapy the quality of life of the patients can be improved, serious complications can be prevented and the patients may reach adult age. The submitted paper is a review of contemporary knowledge of the disease, in particular its molecular basis and ensuing classification, as well as possible diagnosis and treatment of the disease. Several case-histories are presented.

[Rapidly progressing glomerulonephritis with antibodies against cytoplasm of neutrophilic leukocytes]

The authors describe the clinical, laboratory and morphological findings, the clinical course and response to treatment in three patients with rapidly progressing glomerulonephritis where positive antibodies against the cytoplasm of neutrophil granulocytes (ANCA) were found. The authors confront their own clinical experience with data in the literature. Examination of ANCA is not only a significant contribution towards a more accurate diagnosis of renal vasculitis, but also an indicator of the activity of the disease and thus of the effectiveness of immunosuppressive treatment.