Search

Pemphigus vulgaris (PV) and pemphigus foliaceus (PF) are autoimmune blistering diseases characterized by a loss of cell-cell adhesion and by autoantibodies directed against epidermal cadherins. PF antigen has been established as desmoglein I which is located strictly on the desmosome, whereas the precise ultrastructural localization of PV antigen remains unclear and controversial to date. To further investigate this question, we compared the location of immune deposits in 14 patients with PV and 10 patients with PF by both direct and indirect immunoelectron microscopy (IEM). Inclusion criteria were based upon clinical features, histological level of cleavage and characterization of circulating antibodies by Western blot on epithelial bovine tongue extracts. IEM was performed on unfixed 0.7-mm slices of skin for the direct technique or on normal skin for the indirect technique using peroxidase labelling. In PF, by both direct and indirect IEM, immune deposits were located on the extracellular part of desmosomes (desmoglea) in all the samples studied. In PV, by both direct and indirect IEM, deposits were situated on the desmoglea and along large portions of the keratinocyte membrane without desmosomal structures in 15 of the 18 samples studied and only on the desmoglea in 3 samples. These results suggest that, in contrast to PF, the target antigen in PV is not always restricted to desmosomes. As various types of adherens junctions have been reported to mediate cell adhesion in the epidermis, the PV antigen could be a component of desmosomes and of other focal adhesions.

Objective: To determine, using a serotyping assay, whether the occurrence of extrahepatic immunologic disorders in patients with chronic hepatitis C is dependent on hepatitis C virus serotype., Design: Prospective study., Setting: Liver unit and virology laboratory of a university hospital., Patients: 59 consecutive patients with chronic hepatitis C., Measurements: Hepatitis C virus serotype was determined using a recently developed immunoenzymatic assay that detects antibodies directed to serotype-specific immunodominant epitopes. Cryoglobulin, rheumatoid factor, and numerous antitissue antibodies were sought. Biopsies of labial salivary glands were done in 49 of the 59 patients., Results: Prevalence was 59% for serotype 1, 10% for serotype 2, 12% for serotype 3, and 3% for mixed infection. Fifteen percent of patients could not be serotyped. Cryoglobulinemia was found in 36% of patients and rheumatoid factor was found in the serum of 71%. At least one antitissue antibody was found in the serum of 41% of patients; salivary gland biopsy showed lymphocytic capillaritis in 49% of patients. These immunologic abnormalities were seen in patients infected with any of the three serotypes, and prevalences of the abnormalities did not differ significantly among patients infected with different serotypes., Conclusions: We confirm that the prevalence of extrahepatic immunologic abnormalities is high in patients with chronic hepatitis C. These abnormalities may occur in patients infected with any of the three major hepatitis C virus serotypes now present in developed countries.

Recently, our group has shown that a 3-month course of intravenous immunoglobulin (2 g/kg/monthly) followed by 6 months of intramuscular immunoglobulins (IMIG, 16.5%, 0.35 ml/kg every 15 days) was able to slow or to stop the decline in the glomerular filtration rate, to reduce proteinuria, hematuria, leukocyturia and the histological index of activity on renal biopsy in patients with severe forms of IgA nephropathy (IGAN) and Henoch-Schönlein purpura (HSP). The aim of this open prospective trial was to evaluate the efficacy and safety of low-dose immunoglobulin therapy in moderate IGAN and HSP with permanent proteinuria. Fourteen patients with moderate IGAN [idiopathic IGAN: n = 11; chronic idiopathic HSP: n = 3] and permanent albuminuria were treated with polyvalent IMIG (16.5%) for 9 months (0.35 ml/kg once a week for 1 month, followed by 0.35 ml/kg every 15 days for a further 8 months). Eligibility criteria in the study were Lee histological stage I, II or III, albuminuria between 300 and 2,000 mg/day and a glomerular filtration rate > 70 ml/min/1.73 m2. IMIG were well tolerated and only 1 patient withdrew from the trial. No viral, renal or immunological side effects were observed. IMIG induced a significant decrease in albuminuria as well as in the histological activity index in the 11 cases in which a follow-up biopsy was performed. There was also a decrease in serum IgA, serum beta 2-microglobulin and IgA immune complex levels, and an increase in serum IgG1 levels. Twelve of the 13 evaluable patients improved during treatment.

Rheumatoid factor (RF) induces false-positive results in the detection of serum antibodies, especially of the IgM type. About 70% of the patients with chronic hepatitis C have abnormal levels of serum RF. The aim of this study was to determine whether the presence of serum RF could influence the detection of anti-HCV core IgM, using an assay designed not to pick up RFs by the addition of goat antibodies directed against human IgG in the sample diluent. Serum anti-HCV core IgM antibodies and RF were sought in 60 patients with chronic hepatitis C. Serum anti-HCV IgG antibodies and anti-HCV core IgM antibodies were also sought in 101 patients with high levels of RF. Anti-HCV core IgM antibodies were found in 45% and serum RF in 72% of the patients with chronic hepatitis C. Neither the prevalence nor the levels of RF differed significantly between IgM positive and negative patients. Eight percent of the 101 patients with raised RF had anti-HCV antibodies and two of them had anti-HCV core IgM antibodies. No patient without anti-HCV antibodies had anti-HCV core IgM antibodies. These results show that: a) the detection of anti-HCV core IgM in patients with chronic hepatitis C is independent of the presence of serum RF; b) high titers of serum RF are not responsible for false-positive results of anti-HCV IgM tests. The study suggests that the test used could be a confident tool for studies on the significance of anti-HCV core IgM antibodies in chronic hepatitis C.

Hepatitis C virus-related chronic hepatitis may be associated with various immunological disorders. The aim of this study was to determine prospectively the prevalence of the clinical, biochemical and pathological immunological abnormalities in a series of 61 consecutive patients with chronic hepatitis C, compared with those in 61 age- and sex-matched control subjects without markers of hepatitis C virus and hepatitis B virus infections and with those in 61 patients with chronic hepatitis B. The following investigations were systematically performed before any treatment: detection of serum cryoglobulinemia and rheumatoid factor, detection of a large variety of serum anti-tissue antibodies, biopsy of labial salivary glands, ophthalmological examination, dosage of thyroid-stimulating hormone and in vivo capillary microscopy. Cryoglobulinemia was found in 36% of the hepatitis C virus patients, four of whom had dermatological and/or neurological manifestations of vasculitis, and rheumatoid factor was present in 70%. Serum anti-tissue antibodies were detected in 41% of cases, mostly antinuclear and anti-smooth muscle antibodies. Liver-kidney microsomal and antithyroid antibodies were rare. Salivary gland lesions were found in 49% of the patients: all had lymphocytic capillaritis, sometimes associated with lymphocytic sialadenitis resembling that of Sjögren's syndrome, but without features of sicca syndrome and Ro/SSA antibodies. Five percent of the patients had lichen planus. The prevalences of cryoglobulinemia, rheumatoid factor and anti-tissue antibodies were significantly higher than those in the control group and patients with chronic hepatitis B.(ABSTRACT TRUNCATED AT 250 WORDS)

We studied tumor necrosis factor-alpha (TNF-alpha) levels in serial serum samples from 3 consecutive patients who had a complete form of POEMS (polyneuropathy, organomegaly, endocrinopathy, M protein, skin changes) syndrome and early weight loss. Serum TNF-alpha levels were compared with those of 10 patients with multiple myeloma (5) or Waldenström's macroglobulinemia (5). Elevated serum levels of TNF-alpha were found in the patients with POEMS syndrome (two- to eightfold increase in 10 of 11 samples) and not in those with other malignant plasma cell dyscrasias. These results are in keeping with the hypothesis of a role for nonimmunoglobulinic mediators in the pathogenesis of the POEMS syndrome, and are consistent with previous reports of TNF-alpha overproduction in inflammatory demyelinating neuropathies and cachectic states.

Objective: To determine if polyvalent IgG is promising therapy for severe IgG nephropathy., Design: Open prospective cohort study., Setting: Referral nephrology unit., Patients: 11 adult patients with severe IgA nephropathy (9 who had idiopathic disease and 2 who had Henoch-Schönlein purpura) and indicators of poor prognosis., Intervention: Patients were given high-dose immunoglobulins (2 g/kg each month) for 3 successive months, followed by intramuscular immunoglobulins (preparation content, 16.5%; 0.35 mL/kg every 15 days) for another 6 months., Measurements: Histologic changes were analyzed by comparing pre- and post-therapy renal biopsy specimens blindly, using an activity index (14-point scale), a sclerosis index (10-point scale), and a semiquantitative immunofluorescence test of immune deposits. Proteinuria, hematuria, leukocyturia, enzymuria, and global renal function (creatinine and polyfructosan clearances) were evaluated before and after intervention., Results: Proteinuria (median level before intervention, 5.20 g/d; median level after intervention, 2.25 g/d), hematuria, and leukocyturia decreased substantially. The decrease in glomerular filtration rate was greatly slowed or stopped (median rate of decline in glomerular filtration before, -3.78 mL/min per month; after, 0 mL/min per month). The histologic index of activity (median index before, 5; after, 2) and the staining intensity of glomerular IgA and C3 deposits also decreased. Immunoglobulin therapy was well tolerated., Conclusions: Immunoglobulin therapy may be effective in treating severe IgA nephropathy and protecting renal function. However, prospective controlled trials must confirm these preliminary results.

We determined the specificity and sequence of immunoglobulin molecules synthesized by monoclonal B cells from a patient with chronic lymphocytic leukaemia (CLL) who presented with a number of clinical and biological autoimmune symptoms. Heterohybrids obtained by fusion of CLL cells with the mouse X63-Ag 8.653 myeloma produced IgM lambda MoAbs directed to the cardiolipin/beta 2 glycoprotein I (beta 2GPI) complex and ssDNA. They were devoid of polyreactivity. Nucleotide sequence analysis of the variable domain of the mu chain indicated the utilization of the VH4 71.2 gene or one allotypic variant, DXP4 and JH3 segments. The lambda light chain used the single gene from the V lambda 8 subfamily, J lambda 3 and C lambda 3 genes. The VH gene displayed 11 nucleotide changes in comparison with its putative germline counterpart. However, these nucleotide changes correspond to variations observed in other published VH4 sequences, suggesting gene polymorphism rather than somatic mutation. DXP4 and JH3 were also in germline configuration. The VL gene exhibited a single replacement mutation in CDR1. These data suggest that the monoclonal CLL B cells in this patient retained VH and VL genes in germline configuration although they secreted a pathogenic anti-cardiolipin antibody associated with clinical symptoms, vasculitis and thrombosis, which may be provoked by antibodies to the phospholipid/beta 2GPI complex.

Lupoid sclerosis is a rare syndrome associating clinical symptoms of multiple sclerosis (MS), positive false tests for syphilis and positive tests for antinuclear and anticardiolipin antibodies. In a patient with lupoid sclerosis, antimyelin antibodies were detected by indirect immunofluorescence on human sciatic nerve sections. These antibodies were not found in the serum of control patients with MS nor in sera of patients with antiphospholipid autoantibodies and focal ischemic neurologic disease. The presence of such antimyelin antibodies may contribute to the underlying physiopathological mechanism of this syndrome.

Subepidermal autoimmune bullous dermatoses are defined by clinical, histological and immunological criteria, notably the presence of anti-basement membrane antibodies detectable in vivo by direct immunofluorescence. We report three cases where anti-basement membrane antibodies were not detectable in vivo by direct immunofluorescence but were detected in high titres by indirect immunofluorescence. This situation is extremely rare in the literature. The first case concerns a 69-year old woman seen for bullous and pruriginous lesions of the lower limbs of 2 months' duration. Histological examination found dermoepidermal bullae with, in their lumen, a serous fluid spotted with numerous polymorphonuclears. A search for anti-basement membrane antibodies was positive in significant titres (1,280; 320; 480) at indirect immunofluorescence on rabbit lip whereas five successive direct immunofluorescence test in perilesional skin and on the thigh medial surface remained negative. The second case is that of a 91-year old woman suffering from generalized pruritus associated with erythematous lesions predominant on the extension surfaces of the forearms and thighs, without any bullous lesion. Pathological examination only showed a superficial dermal lymphocytic infiltrate. Four direct immunofluorescence tests were negative, whereas a search for anti-basement membrane antibodies on rat oesophagus was positive at 1/1,280. The third case resembles the second one. It concerns a 72-year old woman who consulted for generalized pruritus of several months' duration which interfered with sleep and was incompletely relieved by emollients. There was no specific skin lesion. Pathological examination revealed nothing more than a discrete perivascular mononucleate infiltrate. Direct immunofluorescence tests performed on two occasions on the skin of the abdomen and of the medial thigh surface were negative.(ABSTRACT TRUNCATED AT 250 WORDS)

Complement activation was evaluated in ten patients undergoing cardiopulmonary bypass (CPB) and intraoperative blood salvage with a cell saver (CS) to assess the inflammatory response related to the CS. The washed red blood cell concentrate was reinfused after protamine injection. Plasma C3a was measured by radioimmunoassay preoperatively, 5 min before CPB, at 5, 60, and 90 min during CPB, 5 min after protamine infusion, at the end of surgery, and after 24 hr. In addition, a clinical score based on renal, pulmonary, neurologic, and myocardial postoperative evolution was given (0-8) to every patient. Results were compared with the C3a changes and clinical scores obtained from 26 routine (no CS) cardiac surgical patients. Results showed maximal C3a generation after protamine and no further activation in cases of CS concentrate reinfusion, which ranged from 400 ml to 2,000 ml. No difference in clinical score was observed between the CS (1 +/- 1) and control (0.85 +/- 0.6) groups. The authors conclude that the CS does not enhance complement activation resulting from extracorporeal circulation and can be safely used as a blood saving strategy in cardiac surgery.

We studied 11 consecutive patients with classical cicatricial pemphigoid (CP) using direct immunoelectron microscopy (IEM) and Western immunoblotting analysis. Direct IEM performed in the skin or gingival mucosa revealed in all 11 CP patients that immunoglobulins and complement deposits were usually thick and discontinuous along the dermoepidermal junction, mostly localized on the lamina densa and occasionally in the lamina lucida. By direct IEM, the ultrastructural aspect in CP differs from the pattern observed in bullous pemphigoid (BP) and from that of chronic epidermolysis bullosa acquisita (EBA). Nine CP patients were studied by Western immunoblotting and, of these nine, only two had detectable anti-basement membrane zone (BMZ) antibodies by indirect immunofluorescence on salt-split skin. By immunoblotting performed on protein extracts of heat-separated epidermis, eight out of the nine CP sera specifically reacted with two protein bands of approximately 230-240 kD and 180 kD, similar to those recognized by BP sera in co-migration experiments. By immunoblotting on skin BMZ extracts, none of these nine CP sera recognized the 290-kD major polypeptide of EBA antigen. Taken together, these results suggest that, in CP, the target-antigen, as identified on immunoblots, is similar to BP antigen, but with an abnormal expression within the dermoepidermal junction of patients, which may in part explain the scarring course of the disease.

Plasma levels of C3d, which is liberated by enzymatic cleavage of C3, are determined in 97 patients with primitive chronic glomerular nephritis. This level is indicative of an abnormally high consumption of C3. In all cases where C3 is low, C3d is found at abnormally high levels. When the level of C3 is normal, C3d may, however, be elevated: a more subtle interpretation of the pathologic significance of C3 in immune disease is thus possible.

A retrospective study of 134 cases of circulating "lupus anticoagulant" (LA) observed between 1975 and 1985 in the haemostasis laboratory of Henri Mondor Hospital is reported. In 66 p. 100 of cases the circulating anticoagulant was discovered fortuitously and auto-immune diseases were associated with the inhibitor only in 25 p. 100 of cases (mainly systemic lupus erythematosus). Thrombosis (venous, arterial or both) was found in 26 p. 100 of cases when auto-immune diseases were present and in 13.5 p. 100 of cases in the absence of these diseases. Spontaneous abortion was observed in 42 p. 100 of the women when the anticoagulant occurred in the course of an auto-immune disease and in 4 p. 100 when another or no underlying disease were identified. False-positive VDRL and thrombocytopenia were found associated with LA mainly in auto immune diseases. Anticardiolipin antibodies were positive in 37 p. 100 of 32 patients without any difference between auto-immune diseases and other pathologies. These results show that the "lupus anticoagulant" is a frequent coagulation abnormality even when auto-immune diseases are absent. The differences observed between auto-immune diseases and other pathologies in respect to clinical manifestations and biological findings associated with lupus anticoagulant suggest that the so-called "lupus anticoagulant" represents a group of antibodies with probably different specificities but which act in a similar manner in "in vitro" coagulation tests.

An authentic case of Waldenstrom's macroglobulinaemia without a tumoural syndrome is reported, with initial signs of peripheral pancytopenia. Complete and persistent remission appears to have followed multiple sequential chemotherapy. This very satisfactory and, according to data in the published literature, very rare result suggests that this type of treatment should be prescribed for all patients with macroglobulinaemia with poor prognostic clinical and histological characteristics.

Twenty-two patients (acute myeloid leukaemia 13, acute lymphoid leukaemia 5, chronic myeloid leukaemia 4) with an average age of 25 years (range 8-36 years), had received allogeneic bone marrow transplantation (BMT) from an HLA identical sibling. The BMT recipients were followed up for a period of 4-65 months. All patients were given cyclophosphamide, total body irradiation and methotrexate in order to prevent graft-versus-host disease (GvHD). Eleven of 22 patients exhibited chronic graft versus host disease (cGvHD) (extensive in five, limited in six at the time of the study) assessed by clinical and histological parameters. Serum samples were collected from these patients, before BMT (except in one case) and then every 2 or 3 months. Sequential studies to determine the presence of autoantibodies against cytoskeletal proteins (actin, tubulin, myosin), dsDNA and dDNA in these sera were performed by an ELISA method. Simultaneously, immunoelectrophoresis and measurement of complement fractions C3, C4 were performed on each sample. High levels of autoantibodies against cytoskeletal proteins were found in 10/11 patients with cGvHD and were absent in 11/11 patients without cGvHD; none of them exhibited anti-DNA activity. At the same time, C4 levels were decreased in seven of these patients with cGvHD. Monoclonal immunoglobulins IgG and IgM (2-15 g/l) were found in 8/11, but the antibody activity was never found to be located within the M component. These results show a direct relationship between the presence of these autoantibodies and occurrence of cGvHD and indicate that they may constitute an immunological marker related to this complication. However, their predictive value is not clearly evident in this retrospective series as in some patients they preceded clinical signs of cGvHD, whereas in others they were associated with the onset of cGvHD.

Immunoglobulin synthesis by pokeweed mitogen-stimulated lymphocytes from 62 nephrotic patients and 18 healthy controls was studied. Defective IgG production was observed in patients with the nephrotic syndrome related to minimal change disease, mebranous glomerulonephritis and membranoproliferative glomerulonephritis. The mean values of in vitro IgG synthesis were 20%, 61% and 32%, respectively, of that obtained in the control group. At the same time, serum IgG levels were significantly decreased in each group of patients. In minimal change disease, reduced IgG production and serum levels were fully reversible after recovery (off steroid therapy). The data indicate that a cellular defect of antibody production is a common and eventually transitory phenomenon associated with the acquired hypogammaglobulinemia found in patients with a variety of glomerulopathies.

Although anabolic androgens can be used to prevent acute attacks of hereditary angioneurotic oedema, these are still observed. When they are severe, and even more so when they involve the larynx or the abdominal viscera, an emergency treatment is necessary, ideally with the purified C1-inhibitor (C1-INH) administered by intravenous infusion. In a case with pseudo-surgical abdominal symptoms, this treatment was followed by an unusually dramatic regression of all symptoms. Serial laboratory examinations showed an increase in C1-INH and C2 plasma levels and in the number of basophils within less than 30 minutes; the increase in C4 levels occurred later. Thus, C1-INH is very effective in the treatment of acute hereditary angioneurotic oedema, but the product is not widely available; it should be reserved to severe forms affecting the larynx and the viscera.

Serum IgG subclass levels were measured using a competitive indirect immunoenzymatic assay with monoclonal antibodies in 22 acute myeloid leukemia patients at presentation and prior to specific therapy. Three patients had moderate IgG1 deficiency and 1 moderate IgG3 deficiency. Two of the three IgG1 deficient patients (and only one other) failed to respond to induction chemotherapy and the third died of bone marrow aplasia during induction.

Hereditary angioedema (HANE) is a rare, life-threatening disease due to the deficiency of C1 inhibitor (C1 Inh). Androgen therapy has been recently shown to be effective for prophylaxis of Hane attacks. Since life-long androgen therapy may be hazardous, this study was designed to define the minimal doses required for effectiveness. Ten patients from six different families were treated during cumulative 73 months by danazol and/for methandrostenolone. One tablet/day of either drug was the minimal requirement to prevent any attack in all patients. When 3 tablets/day were given, complement abnormalities were simultaneously rapidly reversed. When 1 tablet/day was given the biological effect was barely detectable, except for C2. Serum C2 levels may, therefore, represent the best criteria of androgen therapy effectiveness. Thus, an excellent clinical result can be obtained with much lower doses of androgens than previously stated. This result seemed important with respect to the serious dose-dependent risk of androgens.

The study deals with a family of 22 members spreading over four generations; 14 members suffer from hereditary angio-neurotic edema; all of them have been typed for 30 antigens of the A and B loci in the HLA System and for ABO and Rhesus erythrocyte markers. There is no connection between the disease and any of the markers considered. As for the HLA system, there should be at least 7 chromosomic recombinants to account for the relationship with one of the haplotypes involved.

Measurement of serum C3 does not provide precise informations concerning an eventual consumption of this complement component during an immunological process. An increased synthetic rate may compensate an accelerated catabolism. The study of breakdown products of C3, such as C3d is a more sensitive approach of the role of complement in some immunological disorders. Therefore C3d was measured in the serum of patients with chronic non systemic glomerular diseases. High values of serum C3d were found in all cases of hypocomplementemic glomerulonephritis. Circulating C3d was also increased to a lower extent, in patients with normocomplementemic nephritis such as minimal change disease, mesangial nephritis with IgA deposits and membraneoproliferative (type I) glomerulonephritis. The data suggested the involvement of complement in a number of glomerulonephritis. Participation of complement in immunological disorders particularly in chronic non systemic glomerulonephritis could require a reevaluation when functional tests are performed in addition to static measurements.

Since 1977, 22 patients with hereditary angioneurotic oedema have been treated with androgenic-anabolic steroids (danazol or stanozolol). The most frequent adverse reactions were myalgia, weight increase, changes in libido, and menstrual disorders in women. In view of these side-effects, it is suggested that patients about to undergo surgery (chiefly E.N.T. or stomatology) should be put, one week before the operation, on a 10-day high dosage treatment. Long-term treatment should be reserved to severe forms of the disease, with frequent attacks and visceral involvement, using the minimum effective dosage (which is always low) without trying to correct biochemical abnormalities. Stanozolol should be given by preference to men and danazol to women. Treatment is always more difficult in pre-menopausal women. With this method, the complications, notably hepatic disorders, are rare, and long-term treatment, when absolutely necessary, is well tolerated.

A case of benign monoclonal gammapathy associated with an auto-immune hyperlipidaemia and a chronic glomerulopathy is reported. Extraction of the monoclonal immunoglobulin made it possible to demonstrate its anti-lipoprotein antibody activity. Parallel changes in serum lipid levels and monoclonal immunoglobulin levels under the influence of melphalan confirmed the direction relationship between the lipid and protein disorders. The pathogenesis of the glomerulopathy and of the massive and prolonged activation of the classical complement pathway is more difficult to affirm. It is nevertheless possible that the renal involvement is due to an auto-immune complex disease.

Modifications of Factor VIII related antigen (F, VIII R. A.) were investigated in three hemophilic patients during the course of post transfusion hepatitis. F. VIII R. A. was found to be elevated and correlated with the increase of the S.G.P.T. During the acute phase of the disease the Factor VIII related protein was tested for its ristocetin cofactor activity, its electrophoretic mobility on crossed antigen-antibody electrophoresis and its elution pattern on Sepharose 4B columns; all these properties proved to be abnormal. Liver function tests and F. VIII R. A. were measured in 36 multitransfused hemophiliacs. There was a significant increase of the F. VIII R. A. in the plasma of patients with abnormal liver function tests. Only a few of the multitransfused hemophiliacs had clinical symptoms of hepatitis, although 72% had elevated transaminase levels.