Anti-neutrophil cytoplasmic antibody positivity in five children with systemic lupus erythematosus--what is the importance of this finding?

Juvenile systemic lupus erythematosus (JSLE) is a systemic autoimmune chronic disease that can affect any part of the body. It is characterized by the formation of antibodies against nuclear antigens. Vasculitis may be found in SLE, but it scarcely complies with anti-neutrophil cytoplasmic antibodies (ANCA)-associated vasculitis (AAV) criteria. We report five cases of severe JSLE associated with AAV diagnosed between 1991 and 2013 in three university-based tertiary care centers. The patients (3 girls and 2 boys, aged 12 to 17) presented with a severe clinical picture and the following features: cytopenia (n=5), autoimmune hepatitis (n=3), lupus nephritis (n=1), pancreatitis (n=1), secondary antiphospholipid syndrome (n=2), impending respiratory failure (n=2), and gastrointestinal bleeding (n=1). All patients were proteinase 3 (PR3) ANCA positive, while two of them were myeloperoxidase (MPO) and PR3 ANCAs positive at the same time. They were treated with corticosteroids and immunosuppressive drugs. Remission of the disease was achieved in three patients. The course of the disease was worsening in two patients and we included rituximab (anti-CD20) in therapy. All of our patients presented as the most severe SLE patients, who must be diagnosed as soon as possible and treated very intensively. Since the comorbidity of JSLE and AAV occurs very rarely in children, presentation of such patients, their clinical pictures, treatment, and the course of the diseases are experiences that can be of great help.

Childhood-onset systemic lupus erythematosus in Croatia: demographic, clinical and laboratory features, and factors influencing time to diagnosis.

OBJECTIVES: Childhood-onset systemic lupus erythematosus (cSLE) presents with diverse clinical features and often with non-classical symptoms that may delay diagnosis and increase risk of morbidity and mortality. This paper aims to analyse incidence, and clinical and laboratory features of cSLE in Croatia between 1991 and 2010, and to identify factors influencing time to diagnosis. RESULTS: Medical records at three university-based tertiary care centres were analysed retrospectively for 81 children with cSLE (68 girls). Mean age at onset was 13.4±2.8 yr (interquartile range 3), and annual incidence varied from 1-15 per million at risk. The most frequent clinical and laboratory features were musculoskeletal symptoms (80%) and increased erythrocyte sedimentation rate (96%). The most frequent immunological laboratory findings were the presence of antibodies against histones (86%), double-stranded DNA (73%), and Sm protein (64%), as well as low levels of C3 complement (69%). Haematuria was present in 58% of children, proteinuria in 56%, and biopsy-confirmed lupus nephritis in 43%. Median time from symptom onset to diagnosis was 2 months (range 0-96). Time to diagnosis was inversely associated with ECLAM score (p<0.001), but it showed no association with age, gender, clinical features or distance from the nearest paediatric centre. CONCLUSIONS: This is the first large-scale, in-depth study of clinical and laboratory features of cSLE in Croatia. Among all demographic, laboratory and clinical features examined, ECLAM score alone was inversely associated with time to diagnosis. This highlights the need to improve detection of children with fewer symptoms early in the course of the disease, therefore serious consequences for prognosis could be avoided.

Polyarteritis nodosa in Croatian children: a retrospective study over the last 20 years.

To analyze the disease characteristics, treatment modalities and outcome of polyarteritis nodosa (PAN) in Croatian children. Cross-sectional study included all children with PAN diagnosed according to EULAR/PRES/PRINTO criteria during the last two decades. PAN was diagnosed in 12 patients (6 girls and 6 boys) mean age (±SD) 11.33 ± 3.08 years. The share of PAN among all vasculitides was 3.8 %. Systemic PAN was diagnosed in 7 children (58 %), microscopic polyangiitis in 3 (25 %), cutaneous PAN in 2 (17 %). The most consistent symptoms were skin involvement (90 %) and arthritis/arthralgia (60 %). The CNS was affected in 33 % of patients. Inflammatory markers (C-reactive protein and erythrocyte sedimentation rate [ESR]) were elevated in all patients, and anti-neutrophil cytoplasmatic antibodies were positive in all patients with microscopic polyangiitis. Therapy mode for all patients was corticosteroids. Immunosuppressive drugs were used as additional therapy for patients with severe symptoms. Two patients (17 %), both suffering from microscopic polyangiitis, died due to renal failure during the follow-up. In comparison with available studies, we found a difference in distribution of childhood polyarteritis nodosa as well as some clinical characteristics (e.g., higher prevalence of neurological and pulmonary symptoms), while other researched features, laboratory and treatment were similar.

Decrease in circulating DNA, IL-10 and BAFF levels in newly-diagnosed SLE patients after corticosteroid and chloroquine treatment.

Arsenal of pattern-recognition receptors alongside antibody production machinery make B cells vulnerable to autoimmune response if an autoantigen elicits both pathways in a self-sustained fashion. Systemic lupus erythematosus is an autoimmune disease characterized by autoantibodies to DNA, RNA and related structures. Murine studies demonstrated autoreactive B cell activation upon TLR9 stimulation with DNA-containing immune complexes. This activation could be abolished with chloroquine, a drug used in SLE treatment that also blocks TLR9 signaling. We investigated whether chloroquine modulates TLR9 expression, circulating DNA levels and B cell-related cytokines in newly discovered, untreated SLE patients. TLR9 was measured in peripheral blood B cells by flow cytometry, serum DNA by real-time PCR, and IL-10 and BAFF by ELISA before treatment, after 3weeks on corticosteroids, and 3months after introduction of chloroquine. We found that circulating DNA is higher in SLE patients than in controls in every time-point and decreases significantly after chloroquine treatment. Untreated patients had higher serum IL-10 than controls or patients on corticosteroids. Also, corticosteroids decreased and chloroquine completely abolished CpG-mediated CD86 upregulation on B cells and IL-10 secretion in PBMC culture. Providing the TLR9 pathway activation demonstrates its importance in pathogenesis of human SLE, this data supports continuation of chloroquine in SLE treatment protocol. In addition, observed modulation of cytokine and DNA levels after immunomodulatory treatment prompts for inclusion of untreated patients in studies of human immune disorders.

Effect of spinal and general anesthesia on serum concentration of pro-inflammatory and anti-inflammatory cytokines.

BACKGROUND: Surgery induces release of neuroendocrine hormones, cytokines and acute phase proteins. The aim of this study was to assess the effect of spinal and general anesthesia on serum concentration of pro-inflammatory and anti-inflammatory cytokines, and cytokines which are secreted by Th1 helper lymphocytes. METHODS: 30 patients with American Society of Anesthesiologists status I and II who were scheduled for TURP (Transurethral Resection of the Prostata) were anesthetized in regional (spinal) or general anesthesia. Peripheral venous blood samples were collected 2 h before surgery on the first, third and fifth postoperative days. We measured pro-inflammatory cytokines, anti-inflammatory cytokines and cytokines which are secreted by Th1 helper lymphocytes in order to establish differences in patients before and after surgery. RESULTS: Statistically significant differences were found in serum levels of interleukin-2 (IL-2) between general and spinal anesthesia (p=0.043). The concentration of IL-2 was continuously elevated in general anesthesia, but not in spinal anesthesia. It is important to note that the preoperative serum IL-2 concentration in general anesthesia group was significantly higher in comparison to spinal anesthesia group (p=0.028). There was also statistically significant increase of interleukin-6 (IL-6) in spinal (p=0.043) and general anesthesia (p=0.03) in comparison to preoperative value. CONCLUSION: Surgery-related postoperative release of the pro-inflammatory cytokine IL-6 was increased in patients after spinal and general anesthesia. In our study, increased levels of the typical Th1 cytokine IL-2 were found in patients anesthetized by general anesthesia compared to spinal anesthesia. Serum concentrations of other pro-inflammatory cytokines, anti-inflammatory cytokines and cytokines which are secreted by Th1 helper lymphocytes showed no statistical difference before and after surgery under general and spinal anesthesia.

Position statement: Assessment strategy for implementation of the Immunology curriculum of the European Board of UEMS Medical Biopathology.

The assessment strategy for implementation of the Union of European Medical Specialists' (UEMS) Immunology curriculum is based on a combination of formative and summative assessments. The strategy comprises a combination of workplace-based assessments and knowledge-based assessments designed to ensure acquisition of key learning outcomes as defined in the curriculum. The purpose of this paper is to explicitly link the assessment strategy to the curriculum.

Cytokines and growth factors in mostly atherosclerotic patients on hemodialysis determined by biochip array technology.

BACKGROUND: The lifespan of patients with chronic renal failure (CRF) is reduced, and coronary artery disease is the leading cause of morbidity and mortality in these patients. The progression of atherosclerosis is accelerated and angiogenesis is impaired in CRF. Risk factors that could contribute to further understanding of vascular pathology include markers of inflammation and growth factors. The purpose of this study was to determine the levels of cytokines (IL-2, IL4, IL-6, IL-8, IL-10, IL-1 alpha, IL-1 beta), vascular endothelial growth factor (VEGF), epidermal growth factor (EGF), interferon-gamma (IFN gamma), tumor necrosis factor-alpha (TNFalpha) and monocyte chemotactic protein-1 (MCP-1) in patients on chronic hemodialysis (HD; n=75), and to compare values with those of control subjects (n=113). METHODS: Evidence((R)) biochip array analyzer was used for quantification of plasma concentrations in samples. RESULTS: Significant differences were found between the control subjects and HD patients. IL-2 (p<0.001), IL-4 (p<0.001) and EGF (p<0.001) levels were higher in controls than in HD patients, while IL-6 (p<0.001), IL-8 (p=0.081), IL-10 (p=0.008), TNFalpha (p<0.001), IL-1 beta (p<0.001) and MCP-1 (p<0.001) levels were higher in HD patients. We also found IL-2 (p=0.015) and IL-1 alpha (p=0.035) levels to be significantly higher in males than females, while IL-4 (p=0.025) and IL-1 beta (p=0.049) levels were significantly higher in females. Among HD patients, IL-2 levels were higher in patients under the age of 50 years (p<0.048). It was also higher in female than in male patients (p<0.035) and in patients on HD for more than 10 years (p<0.009). IL-6 levels were higher in patients over the age of 50 years (p<0.047). Patients with previous glomerulonephritis had the highest level of IL-6 compared to patients with previous pyelonephritis and diabetes mellitus (p<0.063). IL-6 levels were higher in patients with concomitant hepatitis C virus (HCV) infection (p<0.036) and in patients with developed atherosclerosis (p<0.003). IL-8 levels were higher in patients over the age of 50 years (p<0.003) and in the group with previous glomerulonephritis (p<0.031). IL-10 levels were higher in the group with developed atherosclerosis (p<0.045). EGF was the highest in the group of patients with previous diabetes mellitus compared to pyelonephritis and glomerulonephritis groups (p<0.073). TNFalpha levels were higher in the patient population on HD for more than 10 years (p<0.032) and in the concomitant HCV group (p<0.073). IL-1 beta levels were higher in the HCV group (p<0.088). CONCLUSIONS: Plasma concentrations of some cytokines and growth factors could serve as useful diagnostic and prognostic parameters for patients with CRF on HD.

Serum autoantibodies to desmogleins 1 and 3 in patients with oral lichen planus.

AIM: To determine the presence of circulating autoantibodies to desmoglein (Dsg) 1 and Dsg 3 in patients with oral lichen planus. METHODS: Serum concentrations of circulating autoantibodies to Dsg 1 and Dsg 3 were determined by ELISA in 32 patients with erosive form and 25 patients with reticular form of oral lichen planus, 13 patients with acute recurrent aphthous ulcerations and 50 healthy controls. Indirect immunofluorescence analysis was also performed. RESULTS: Concentrations of circulating autoantibodies to both Dsg 1 and Dsg 3 detected in the sera of patients with erosive form of oral lichen planus were significantly increased in comparison with those in healthy controls, patients with recurrent aphthous ulceration, and those with reticular oral lichen planus (P<0.001 for both anti-Dsg autoantibodies). Indirect immunofluorescence also revealed significantly more positive findings in patients with erosive oral lichen planus (18 positive of 22 tested) than in healthy controls (1 positive of 20 tested; P<0.001), patients with recurrent aphthous ulceration (1 positive of 10 tested; P<0.001), and those with reticular oral lichen planus (3 positive of 15 tested; P<0.001). CONCLUSION: Humoral autoimmunity seems to be involved in the pathogenesis of oral lichen planus. The differences in the serum concentration of desmoglein autoantibodies suggested that pathological mechanisms in erosive and reticular forms of oral lichen planus might not be the same.

Clinical usefulness of cellular antigen stimulation test in detection of aspirin allergy.

Acetylsalicylic acid, commonly known as aspirin, can induce some hypersensitive reactions with clinical symptoms such as urticaria, angioedema, acute bronchospasm, and rarely anaphylactic shock. At present, detection of aspirin allergy is still rather difficult and requires an adequate clinical history and sensitive in vivo and in vitro tests. The aim of the study was to evaluate the diagnostic utility of cellular antigen stimulation test (CAST) in the detection of allergic reaction mediated by aspirin. Fifty patients (39 women and 11 men) with a history of hypersensitivity reaction to aspirin were included in the study. Positive scratch test to aspirin was found in 72% (36/50) and positive CAST in 58% (29/50) of patients. Both skin scratch test and CAST positive results were recorded in 48% (24/50%) and negative results in 20% (9/45) of patients. The level of agreement between skin scratch test and CAST was fair with Cohen's kappa of 0.269 (0.95% CI 0.004-0.533). The observed between-test agreement was 66%. It is concluded that CAST-ELISA might be of value as an additional test for the detection of aspirin nonallergic hypersensitivity in suspected individuals.

Antineutrophil cytoplasmic antibodies (ANCA): diagnostic utility and potential role in the pathogenesis of vasculitis.

Antineutrophil cytoplasmic antibodies (ANCA) are a heterogeneous group of circulating antibodies directed toward the cytoplasmic constituents of neutrophils and monocytes. ANCA have been described in various diseases including idiopathic systemic vasculitides, connective tissue diseases, inflammatory bowel diseases, autoimmune liver diseases, infectious diseases, and some drugs. ANCA recognize different target antigens such as proteinase 3 (PR3-ANCA), myeloperoxidase (MPO-ANCA), cathepsin G, lactoferrin, bactericidal/permeability-increasing protein (BPI), and some others. However, only PR3-ANCA and MPO-ANCA are closely associated with systemic vasculitides, in particular Wegener's granulomatosis, microscopic polyangiitis and its renal limited manifestation, and Churg-Strauss syndrome. Both in vitro and in vivo experimental data strongly support a pathogenic role for ANCA in vasculitis and glomerulonephritis.