[Differential diagnosis of elevated liver transaminases in rheumatic diseases]. / Differenzialdiagnose der Transaminasenerhöhung bei rheumatischen Erkrankungen.

During laboratory monitoring of patients with rheumatic diseases it is not uncommon to notice elevated liver transaminase levels. From a rheumatological perspective there are multiple causes for this. Liver dysfunction can be the result of certain rheumatological diseases, such as systemic lupus erythematosus. Primary biliary cirrhosis and primary sclerosing cholangitis are associated with rheumatic diseases. On the other hand, hepatological diseases, such as hepatitis C and autoimmune hepatitis show rheumatological symptoms. The most common cause of elevation of liver transaminase levels in rheumatic patients is without doubt the anti-rheumatic therapy.

[Comorbidity of rheumatic and hepatic diseases]. / Komorbidität rheumatischer und hepatologischer Erkrankungen.

The correlation between rheumatic diseases and liver diseases is complex and often not given sufficient attention. There are, however, consequences for diagnosis and therapy. Rheumatic diseases can present with hepatic symptoms while liver diseases can exhibit rheumatic symptoms. Examples of liver diseases as a cause of rheumatic symptoms are viral hepatitis B and C, autoimmune hepatitis and hemochromatosis. As a result of rheumatic diseases, such as adult onset Still's disease and systemic lupus erythematosus, liver dysfunction can occur. Autoimmune hepatitis, primary biliary cirrhosis and primary sclerosing cholangitis are directly associated with rheumatic diseases and have to be distinguished by way of differential diagnosis. During antirheumatic therapy, serious hepatotoxic side effects have to be expected.

[Gastrointestinal tumors. Clinical manifestations of paraneoplastic rheumatic symptoms]. / Gastrointestinale Tumoren : Klinische Ausprägung paraneoplastischer rheumatischer Symptome.

Paraneoplastic syndromes, as syndromes associated with malignancy, can present unrelated to tumor invasion or metastases. They can occur with varying clinical appearance and are often indistinguishable from idiopathic rheumatic symptoms. Some musculoskeletal disorders are more associated with malignancies. The therapy of rheumatic syndromes can itself have an effect on the tumorigenic process. The clinical severity of paraneoplastic rheumatic symptoms can in many cases aid in the assessment of tumor activity and the response to therapy. While generally an extensive search for occult malignancies in every older rheumatoid patient in cases with no indications of malignancy is not advisable, knowledge of rheumatic symptoms associated with malignancies aids in the important early detection of tumors, while avoiding unnecessary examinations.

[Recommendations of the German rheumatology society on the use of tocilizumab in rheumatoid arthritis]. / Empfehlungen der Deutschen Gesellschaft für Rheumatologie zum Einsatz von Tocilizumab bei der rheumatoiden Arthritis (Februar 2010).

The humanized anti-IL-6 receptor monoclonal antibody tocilizumab (TCZ) represents a new therapy approach for moderately severe to severe cases of rheumatoid arthritis (RA). The IL-6 concentration in the synovial fluid and peripheral circulation of patients with RA is elevated. TCZ recognises the IL-6 binding site of human IL-6R and blocks the IL-6 signaling pathway. TCZ is capable of correcting a multitude of pathological processes in RA, as has been shown in a number of studies. TCZ treatment should be combined with methotrexate. If the latter cannot be administered, TCZ can also be used as a monotherapy. The recommended dose is 8 mg/kg once every 4 weeks; the minimum dose per infusion is 480 mg. Close monitoring, in particular for infectious complications, is necessary. Clinical effects of TCZ are usually seen several weeks following initiation of therapy. If no significant clinical response is seen within 6 months, TCZ therapy should be ceased.

A novel rat model of chronic fibrosing cholangitis induced by local administration of a hapten reagent into the dilated bile duct is associated with increased TNF-alpha production and autoantibodies.

BACKGROUND/AIM: The cholangiopathies represent hepatobiliary diseases in which bile-duct epithelial cells are targets for destructive processes, including immune-mediated damage. We describe a novel rat model of chronic fibrosing cholangitis induced by administration of the hapten reagent 2,4,6-trinitrobenzenesulfonic acid (TNBS) into the dilated bile duct. METHODS: The common bile duct was dilated due to a mild stenosis in 8-week-old female Lewis rats. TNBS (50 mg/kg) was injected during a second laparotomy. RESULTS: TNBS-treatment reproducibly resulted in chronic fibrosing cholangitis. In retrograde cholangiography the bile ducts showed irregularities, beading and strictures. Alkaline phosphatase levels remained abnormal throughout the study period. Immunohistochemical staining showed an increased number of macrophages, CD3+ T-lympbocytes and MHC class II antigen upregulation. The spontaneous interferon-gamma, tumor necrosis factor-alpha and interleukin-10 production of liver-derived mononuclear cells was increased. Anti-neutrophil cytoplasmic antibodies with specificity against myeloperoxidase, catalase and actin were found between 1 and 12 weeks after TNBS injection. CONCLUSIONS: We established a novel rat model of chronic fibrosing cholangitis with histologic, cholangiographic, serologic and immunologic similarities to human primary sclerosing cholangitis. This model may be used to study pathomechanisms of chronic cholangitis without concomitant inflammatory bowel disease.

[Acute mesenterial artery occlusion--an unusual symptom of primary antiphospholipid antibody syndrome]. / Akuter Mesenterialarterienverschluss als seltene Manifestation eines primären Antiphospholipid-Antikörpersyndroms.

BACKGROUND: The antiphospholipid-antibody syndrome (APS) is a thrombophilic disorder, in which venous and arterial thrombosis can occur. We report the rare case of a patient with mesenteric infarction due to primary APS. CASE REPORT: A 46-year-old male patient was admitted to the hospital because of severe abdominal pain. A laparotomy was performed and revealed infarction of a jejunal loop which was resected. At pathohistological examination mesenteric artery infarction was found. Preoperatively prolonged partial thromboplastin time led to coagulation analysis. Lupus anticoagulant and anticardiolipin antibodies were found. TREATMENT: The diagnosis of primary APS was made and the patient was treated with aspirin (100 mg/day) and low molecular weight heparin (2,500 IE/day) permanently. Eighteen months after mesenteric infarction the patient is free of further thromboembolic events.

Mycophenolate mofetil versus azathioprine in patients with chronic active ulcerative colitis: a 12-month pilot study.

OBJECTIVE: Ulcerative colitis (UC) is an inflammatory bowel disease (IBD) of unknown etiology frequently requiring long-term therapy for control of symptoms and prevention of relapse. Azathioprine (AZA) has been shown to be effective and safe in the treatment of chronic active UC. However, the alternatives to treatment with AZA are limited. Our aim was to compare the efficacy and safety of treatment with mycophenolate mofetil (MMF)/prednisolone versus standard immunosuppressive treatment with azathioprine (AZA)/prednisolone in patients with chronic active UC. METHODS: The study was designed as an open comparison of MMF versus AZA. Twenty-four patients with active UC (Rachmilewitz score > or =6 points) were randomly assigned to the MMF (20 mg/kg)/prednisolone or AZA (2 mg/kg)/prednisolone group. The initial prednisolone dosage was 50 mg and was tapered according to a standard protocol. Treatment was scheduled for 1 yr. RESULTS: The rates of remission were higher in the AZA/prednisolone group (n = 12) than in the MMF/prednisolone group (n = 12) throughout the study. Remission rates were 92% versus 67% after 4 wk, 92% versus 67% after 3 months, 92% versus 67% after 6 months, 83% versus 78% after 9 months, and 100% versus 88% after 1 yr. The number of patients not requiring steroids was higher in the AZA/prednisolone group than in the MMF/prednisolone group. Moreover, in the AZA/prednisolone group no severe adverse events were recorded, whereas in the MMF/prednisolone group two severe adverse events were observed: one patient discontinued MMF after 6 months because of recurrent upper airway infections, and one patient exhibited a bacterial meningitis after 9 months. CONCLUSIONS: Treatment with AZA/prednisolone appears to be more effective and safe compared to MMF/prednisolone in patients with chronic active UC. MMF might be an alternative treatment for patients with contraindications to AZA. To further evaluate the effects of MMF in active UC, a placebo-controlled double-blinded study appears warranted.

Irregular cytokine pattern of CD4+ T lymphocytes in response to Staphylococcus aureus in patients with Wegener's granulomatosis.

The initial stage of Wegener's Granulomatosis (WG) is often marked by symptoms of infection and it has been postulated that a bacterial infection could be the aetiologic factor of this disease. The objective of our work was to investigate T-cell-mediated immunity in WG by testing proliferative responses on bacterial antigens and particularly Staphylococcus aureus. We investigated the bulk proliferative response of peripheral blood lymphocytes (PBL) from patients with clinically active WG to gram-positive bacteria and purified proteinase 3 (PR-3), the major target antigen of c-ANCA. We generated S. aureus-specific PBL-derived T-cell lines and T-cell clones (TLC). In two WG patients 27 TLC were characterized in terms of reactivity to bacterial antigens/PR-3, phenotype, HLA class II restriction and pattern of cytokine secretion. Compared to coagulase-negative Staphylococci and beta-haemolytic Streptococci A, reactivity to S. aureus was significantly increased in all patients with WG. Using purified PR-3, we found a PBL proliferation in five out of 25 WG patients. The TLC were S. aureus-specific and did not cross-recognize Streptococci or coagulase-negative Staphylococci. The S. aureus-specific TLC were of the alphabeta-TCR+ CD4+ phenotype and HLA-DR-restricted. These TLC predominantly showed a Th2-type of cytokine secretion. Interestingly, seven of the S. aureus-reactive TLC also recognized the PR-3 antigen. From these data we conclude that Staphylococci-specific HLA-DR-restricted CD4+ T cells may play a key role in the initial triggering of immune responses in WG.

Analysis of epitope spreading over an eleven-year period in a patient with systemic lupus erythematosus.

During a period of more than eleven years serum samples of a patient with Systemic Lupus Erythematosus were collected and analyzed for anti-nuclear autoantibodies. High titer of anti-La/SS-B were detectable in all serum samples. The La/SS-B epitopes remained constant. Besides anti-La/SS-B antibodies all serum samples contained traces of anti-Ro/SS-A including anti-Ro52 and anti-Ro60 antibodies. During disease flares anti-Ro/SS A antibodies were upregulated and anti-dsDNA antibodies appeared, thus supporting the concept of an antigen driven intermolecular epitope spreading to Ro/SS-A and dsDNA.

Identification and characterization of autoantibodies against catalase and alpha-enolase in patients with primary sclerosing cholangitis.

Primary sclerosing cholangitis (PSC) is a chronic cholestatic liver disease of unknown aetiology. Recent studies have shown that genetic factors and both cellular and humoral immunological abnormalities are important in the pathogenesis of PSC. The most prominent autoantibodies in PSC are anti-neutrophil cytoplasmic antibodies (ANCA). The autoepitopes of ANCA in PSC are not well defined. The aim of this study was to identify corresponding ANCA autoantigens in patients with PSC. A biochemical approach with enrichment and partial purification of soluble neutrophil proteins, detection of autoantibodies by Western blot and partial amino acid sequencing were used. Two new autoantigen/autoantibody systems in patients with PSC were detected: catalase and alpha-enolase. The presence of catalase autoantibodies in 9/15 (60%) and alpha-enolase autoantibodies in 4/15 (27%) was confirmed by ELISA and Western blot. Furthermore, we showed immunoreactions of PSC sera with human biliary epithelial cells, showed the reduction of fluorescence in anti-catalase absorption experiments and observed partial co-localization of anti-catalase antibodies and PSC sera in double-staining experiments on biliary epithelial cells. The anti-catalase antibody-positive PSC patients had a more severe course of disease with a significantly higher alkaline phosphatase compared with the anti-catalase-negative PSC patients (P < 0.06). All ulcerative colitis control sera were anti-catalase antibody-negative. The identified antigens catalase and alpha-enolase can partly explain the ANCA fluorescence on ethanol-fixed and formaldehyde-fixed granulocytes in patients with PSC. Catalase is an important anti-oxidant enzyme and prevents cell damage from highly reactive oxygen-derived free radicals. Catalase autoantibodies might play a pathogenic role in patients with PSC. Our findings support the hypothesis that oxidative stress is one of the pathogenic mechanisms in patients with PSC.

Wegener's granulomatosis: anti-proteinase 3 antibodies are potent inductors of human endothelial cell signaling and leakage response.

Anti-neutrophil cytoplasmic antibodies (ANCAs) targeting proteinase 3 (PR3) have a high specifity for Wegener's granulomatosis (WG), and their role in activating leukocytes is well appreciated. In this study, we investigated the influence of PR3-ANCA and murine monoclonal antibodies on human umbilical vascular endothelial cells (HUVECs). Priming of HUVECs with tumor necrosis factor alpha induced endothelial upregulation of PR3 message and surface expression of this antigen, as measured by Cyto-ELISA, with a maximum occurrence after 2 h. Primed cells responded to low concentrations of both antibodies (25 ng-2.5 microg/ml), but not to control immunoglobulins, with pronounced, dose-dependent phosphoinositide hydrolysis, as assessed by accumulation of inositol phosphates. The signaling response peaked after 20 min, in parallel with the appearance of marked prostacyclin and platelet-activating factor synthesis. The F(ab)2 fragment of ANCA was equally potent as ANCA itself. Disrupture of the endothelial F-actin content by botulinum C2 toxin to avoid antigen-antibody internalization did not affect the response. In addition to the metabolic events, anti-PR3 challenge, in the absence of plasma components, provoked delayed, dose-dependent increase in transendothelial protein leakage. We conclude that anti-PR3 antibodies are potent inductors of the preformed phosphoinositide hydrolysis-related signal tranduction pathway in human endothelial cells. Associated metabolic events and the loss of endothelial barrier properties suggest that anti-PR3-induced activation of endothelial cells may contribute to the pathogenetic sequelae of autoimmune vasculitis characterizing WG.

Signal transduction pathways of membrane expression of proteinase 3 (PR-3) in human endothelial cells.

At present, the exact mechanism of the pathogenic effect of anti-PR-3 antibodies remains unknown. Interaction of anti-neutrophil cytoplasmic antibodies (ANCAs) with human umbilical vein endothelial cells (HUVECs) may play a key role. Recently we were able to show that ANCAs recognize their target antigen, PR-3, translocated into the membrane of HUVECs. The objective of this study was to investigate regulation, i.e. signal transduction pathways, of PR-3 expression in endothelial cells. HUVECs were isolated according to the method of Jaffe et al. and cultured under standard conditions. A cyto-enzyme-linked immunosorbent assay (ELISA) with unfixed cells was performed. Membrane-expressed PR-3 was detected by affinity-purified and monoclonal anti-PR-3 Ab. Tumour necrosis factor alpha (TNF-alpha)-induced membrane expression of PR-3 could be blocked with the RNA synthesis inhibitor actinomycin D, the protein kinase C (PKC) and proteinase A (PKA) inhibitor staurosporine, the specific PKA inhibitor calphostin C, the c-AMP-dependent PKA inhibitor KT5720 and the tyrosine kinase inhibitor genistein in a dose-dependent manner. The effect of calphostin C was the most significant. In addition, the effect of phorbol 12-myristate 13-acetate (PMA), a mediator of intracellular second messengers, was investigated. In our study, pretreatment of cells with PMA for 48 h led to a down-regulation of PR-3 expression. This effect, however, could be overridden by TNF-alpha stimulation, i.e. TNF-alpha-induced membrane expression of PR-3 was resistant to down-regulation of PKC. In conclusion, our data suggest that translocation of PR-3 in HUVECs is an active process depending on protein synthesis. PR-3 expression by HUVECs may involve a PKC reactive to cytokines such as TNF-alpha which induces PR-3 expression at a transcriptional level.

[Prostate carcinoma associated spontaneous factor VIII:C inhibitor hemophilia. Successful therapy of severe hemorrhagic complication with porcine factor VIII in a 75-year-old patient]. / Prostatakarzinom-assoziierte spontane Hemmkörperhämophilia. Erfolgreiche Therapie einer schweren Blutungskomplikation mit porzinem Faktor VIII bei einem 75jährigen Patienten.

Inhibitors of factor VIII are a rare condition in non-hemophiliacs, but they are frequently responsible for life threatening hemorrhage. Acquired factor VIII:C inhibitors represent the spontaneous development of autoantibodies that partially or completely neutralize the plasma coagulant activity of the clotting factor. The autoantibodies can arise in diverse clinical settings, in older adults they are frequently associated with immunologic disorders or malignancies. We report of a 75-year-old man with acquired factor VIII:C inhibitor associated with adenocarcinoma of the prostate and a successful treatment of a severe bleeding complication with porcine factor VIII. A 75-year-old man was admitted because of a hematoma of his right cheek and an isolated prolonged aPTT. Acquired factor VIII:C inhibitor was identified as the cause and immuno-suppressive therapy was begun. In the clinical course severe hemorrhaging occurred and was successfully treated with porcine factor VIII (Hyate:C). The initially high inhibitor titer of 32 Bethesda Units (BU) disappeared. As the cause of acquired factor VIII:C inhibitor a newly diagnosed adenocarcinoma of the prostate is likely. After complete remission of acquired factor VIII:C inhibitor radiation therapy was begun. Six months after severe hemorrhaging the patient was clinically stable and PSA levels were normal. This case demonstrates the necessity of a precise diagnosis and therapy regimen of this coagulopathy based on clinical and laboratory data. In the absence of hemorrhage immuno-suppressive therapy with corticosteroids is indicated, in a patient with severe bleeding and high inhibitor titer (> or = 5 BU) porcine factor VIII should be administered.

Characterization of target antigens from anti-neutrophil cytoplasmic antibodies in autoimmune hepatitis type-I.

The occurrence of anti-neutrophil cytoplasmic antibodies (ANCA) has been described in sera of patients with autoimmune hepatitis (AIH). The significance of this finding remains uncertain and the nature of the target antigen(s) has not yet been defined. We studied 32 sera from patients with AIH type-I and prepared extracts of human neutrophils to identify the target antigen(s). A 43 kDa dominant immunoreactive protein was found and identified as the cytoskeletal component actin. Initial studies to define the antigenic determinants identified three different actin domains.

Antineutrophil nuclear antibodies (ANNA) in primary biliary cirrhosis: their prevalence and antigen specificity.

Antineutrophil cytoplasmic antibodies (ANCA) are a group of autoantibodies first associated with Wegener's granulomatosis (WG). In autoimmune liver diseases, ANCA have been described recently in patients with primary biliary cirrhosis (PBC), autoimmune hepatitis (AIH) and primary sclerosing cholangitis (PSC). Controversy exists about the prevalence and specificity of ANCA in patients with autoimmune liver diseases. The purpose of this study was first to assess the prevalence of antineutrophil antibodies in patients with primary biliary cirrhosis and second to identify possible target antigens of antineutrophil antibodies. Sera from 33 patients with PBC, 75 patients with AIH, 16 patients with PSC, 90 control sera (chronic hepatitis B, chronic hepatitis C, alcoholic liver cirrhosis, systemic lupus erythematosus) and sera from healthy blood donors were enrolled in the present study. ANA and ANCA were detected using standard protocols, antibodies against the nuclear antigen SP100 were detected by ELISA with recombinant antigen, antibodies against neutrophil alpha-granules were detected by ELISA. P-ANCA were found in two of 33 PBC sera, both patients presented with PBC/AIH overlap syndrome. In six of 33 (18%) PBC sera a nuclear dot like immunofluorescence pattern (antineutrophil nuclear antibodies, ANNA) was observed. These dots were small in size and located all over the nucleus, the anti-SP100 fluorescence. This result was confirmed by IFT on HEp-2 cells and by ELISA. High tier antibodies against SP100 were found to be specific for patients with PBC. Comparing the IFT results on HEp-2 cells and human neutrophils, we found an excellent correlation (Spearman's rank correlation coefficient = 0.968, P < 0.001). ANCA were detected in AIH type-1 (75%), SLA-positive AIH (36%) and PSC (63%). AIH type-2 was found to be ANCA negative. All PSC contained no antibodies against neutrophil alpha-granules. Our results show: 1. P-ANCA in patients with PBC indicate a PBC/AIH overlap syndrome; 2. ANNA in patients with PBC are mostly directed against SP100; 3. neutrophil granule components are not the ANCA specific antigens in patients with PSC.