Patterns of cytokine production in psoriatic synovium.

OBJECTIVE: To determine patterns of cytokine production and mRNA expression in synovium from patients with psoriatic arthritis (PsA) and to compare the profile of cytokine production in PsA explants with those derived from rheumatoid (RA) and osteoarthritic (OA) synovia and psoriatic skin. METHODS: Cytokine levels were measured in supernatants from synovial and dermal explant cultures at Day 10 by ELISA. Cytokine mRNA expression in PsA whole tissue was determined by multi-gene assay. Cytokine levels in explant supernatants were compared between PsA, RA and OA, and psoriatic skin. Synovial tissues were scored histologically by a pathologist blinded to the clinical diagnosis. RESULTS: PsA explants released elevated levels of interleukin (IL)-1beta, IL-2, IL-10, interferon (IFN)-gamma, and tumor necrosis factor (TNF)-alpha, but not IL-4 or IL-5. A similar pattern of gene expression was detected in whole synovial tissue. These cytokine levels were greater in PsA than RA, despite higher histopathologic scores in RA explants. Production of IL-1beta, IFN-gamma, and IL-10 were strongly correlated. Levels of IFN-gamma, IL-1beta, and IL-10 were higher in psoriatic synovium than psoriatic dermal plaques. CONCLUSION: The cytokine profile in PsA is characterized by the presence of Th1 cytokines and the monokines TNF-alpha and IL-1beta and very elevated levels of IL-10. The higher levels of these cytokines in PsA compared to RA suggest the presence of different underlying mechanisms.

A long-term study of hydroxychloroquine withdrawal on exacerbations in systemic lupus erythematosus. The Canadian Hydroxychloroquine Study Group.

The ability of antimalarials to moderate severe disease activity in systemic lupus erythematosus (SLE) is plausible but undemonstrated. We evaluated the long-term effectiveness of maintaining treatment with hydroxychloroquine sulphate (HCQ) to prevent major flares in quiescent SLE. Forty-seven patients with quiescent SLE who had been randomized to take HCQ (n = 25) or placebo (n = 22) as part of a 24-week withdrawal trial were evaluated for an additional 3 years. The primary outcome was time to a major flare of SLE which resulted in either the institution of or an increase in the current dosage of prednisone of 10 mg/day or more, or institution of therapy with immunosuppressive agents. Secondary outcomes included the specific subtype of these major flares (glomerulonephritis, vasculitis or other) and hospitalization for an exacerbation of SLE. An intent-to-treat analysis was conducted. Over the 42 months of study, 11 of 22 (50%) patients randomized initially to placebo, and seven of 25 (28%) patients randomized to continue treatment experienced a major flare. The relative risk of major flare for those randomized to continue HCQ compared with controls was 0.43 (95% CI: 0.17, 1.12). The relative risks for subtypes of flares were 0.26 (95% CI: 0.03, 2.54) for nephritis, 0.51 (95% CI: 0.09, 3.08) for vasculitis and 0.65 (95% CI: 0.17, 2.41) for flares characterized by other symptoms. The relative risk of hospitalization for major flare for patients randomized to continue hydroxychloroquine was 0.58 (95% CI: 0.13, 2.60). While the results are not statistically significant, they are compatible with the clinical belief that HCQ has a long-term protective effect against major disease flares in SLE and suggest that on average, HCQ use reduces major flares by 57% (95% CI: 83% reduction to 12% increase).

Monoclonal gammopathies antigen driven in autoimmune diseases.

An important link exists between cancer, autoimmune diseases and immune deficiency. This presentation will review some data concerning clonal growth in B lymphocytes, with focus on the occurrence of autoantibody f2p4vity in the monoclonal proteins, which are the products of the clonally expanded lymphocyte plasma cell population. The role of antigen in causing or promoting monoclonal B cell growth is considered for several different forms of monoclonal gammopathies benign, malignant, and secondary. There is recent demonstration of M-proteins and clonal growth complicating HIV infections and some autoimmune conditions which illustrate well the link between cancer, autoimmunity and immune deficiency.

Asplenia in systemic lupus erythematosus: a simple coincidence?

Two patients with asplenia and systemic lupus erythematosus are described. Both patients presented with unusual symptoms of the disease. The possible association of asplenia, presumably congenital, and systemic lupus erythematosus is discussed.

Asplenism and systemic lupus erythematosus.

Although functional hyposplenism, secondary to Fc-receptor blockage by circulating immune complexes saturation, has been described in systemic lupus erythematosus (SLE), only few cases of complete asplenism have been reported. We observed a 60-year-old woman with congenital asplenism who presented with active SLE. The course and the clinical characteristics of such patients are reviewed and the relationship between the asplenic state and initiation and severity of SLE are discussed. These patients are at high risk for fatal pneumococcemia and pneumococcal vaccine is recommended even if long term results are still conflicting.

Epilepsy etiology with special emphasis on immune dysfunction and neurovirology.

The etiology of epilepsy remains in most cases an enigma. Based on the finding of a genetically dependent immune dysfunction in focal epilepsies, brain specimens from 16 patients, ranging in age from 6 to 39 years and operated on for therapy-resistant focal, mainly temporal lobe epilepsy were analyzed for the presence of viral DNA. The PCR technique was used for detection of viral DNA from the herpes virus group. HSV-1 was found in 44% CMV in 50%, and HHV-6 in 25%. Three patients were positive for more than one of these viruses. The control material, consisting of only 4 brain tissue samples, showed DNA from HSV-1 in one case. Until more brain samples from controls have been examined, caution must be taken before a viral etiology is applied to focal epilepsy.

Laboratory diagnosis and monitoring in chronic systemic autoimmune diseases.

The testing done in the diagnostic immunology laboratory contributes to the management of patients with systemic autoimmune diseases. In these diseases the interaction between environmental factors and a genetically dysregulated immune system produces a continually variable level of disease activity. Improved techniques now allow the clinical scientist to assess the integrity of a patient's immune system and to ascertain qualitative or quantitative disturbances in its activation and expression. Cellular and humoral immunity may become independently activated or dysfunctional in certain disease processes, although the generation of amplifying proteins may result in the full clinical expression of immunity and autoimmune inflammation. Autoimmune diseases can, in part, be characterized according to the activation pattern of gene expression encoding the amplifying and proinflammatory cytokines. Modern therapy is increasingly aimed at determining ways to influence discrete elements of the immune apparatus; therefore, it is important to identify and characterize the patterns of expression of the immune system mediators serially in chronic autoimmune disease states. Newer diagnostic procedures stemming from observations in basic and clinical research are expanding the useful database on patients, but they must be carefully evaluated to prove their applicability and efficacy. Because blood samples are the best available specimens for testing, one must consider all the possible sampling problems and pitfalls of using results from peripheral blood to judge changes in function of the lymphoid system.

Autonomic neuropathy in systemic lupus erythematosus: cardiovascular autonomic function assessment.

AIM: To assess the prevalence and the nature of autonomic neuropathy (AN) in 17 patients with inactive or mild active systemic lupus erythematosus (SLE). METHODS: Patients were tested using questionnaires related to possible AN symptoms, and four non invasive cardiovascular autonomic function tests at rest, during lying to standing, and sustained handgrip. Eleven age matched normal subjects were also enrolled as a control group. RESULTS: At least one abnormal cardiovascular autonomic function test was observed in 15 of the 17 patients. The two groups did not differ in deep-breathing (parasympathetic, PS) and handgrip tests (sympathetic, S) although responses in patients with SLE tended towards abnormal values. Statistical differences were found in standing-heart rate ratio (R-R ratio) (PS) with a lower ratio in the group with SLE (p < 0.01) and in standing blood pressure with a higher decrease in systolic blood pressure (p < 0.05) in patients with SLE. No correlation was found between AN, age, disease duration and presence of Raynaud's phenomenon. CONCLUSION: In inactive or mild active SLE, AN could represent residual abnormalities of autonomic nervous system involvement and/or could be related to glucocorticoids.

A method for analysis of gene expression patterns.

mRNA can be copied into cDNA with the use of reverse transcriptase so that the relative abundance of individual mRNAs is reflected in the cDNA product. With further manipulation a replica of the mRNA expression pattern can be duplicated into a radioactive double-stranded DNA probe. DNA from a series of genes inserted into plasmids can be fixed to a membrane using a slot blot manifold and probed with the RNA-derived DNA probe. The intensity of the hybridization signal for a given gene is a result of its relative abundance in the RNA-derived DNA probe. Quantitation can be achieved through the use of housekeeping genes as baseline monitors. Inclusion of vector sequences can negate any spurious hybridization to vector rather than insert sequences. We have successfully used this method to obtain gene expression patterns for RNA isolated from diverse sources including rodent tissues, various cell lines, and Drosophila and Caenorhabditis elegans samples. Northern blots have verified the results obtained. The pattern of expression of many genes can be determined from as little as 10 micrograms of total RNA, making this method ideally suited for studies in which RNA is rare or in short supply.

Anti-gammaglobulin factors in human sera revealed by enzymatic splitting of anti-Rh antibodies. Vox Sang 1963;8:133-52.

Human sera were found that contained antibody activity which caused agglutination of red cells or particles sensitized with immunoglobulin G that had first been degraded by pepsin proteolysis. The agglutinating activity was specific for a determinant that was not present on the untreated, native immunoglobulin. It was found most frequently in sera from rheumatoid arthritis patients and its titre showed some correlation with disease activity.

Steroid interactions affecting metabolic activities of a T-lymphocyte line.

A glucocorticoid sensitive T-lymphocyte cell line (CEM) was used to study in vitro interaction effects of steroidal compounds on their metabolic activity. Mixtures of steroidal hormones and related substances were added to the cells and assessed in short-term culture experiments by the incorporation of 3H dTr. Dose ranges were selected to include the linear portion of the dose-response curve of each of the potentially interactive substances. Evidence for synergy, additivism or antagonism was obtained for each of the various steroid combinations studied using algebraic and geometric calculations.

Can experienced clinicians predict the outcome of lupus nephritis?

The ability of four experienced clinicians to predict short-term outcome (serum creatinine level at 1 year) and long-term outcome (renal insufficiency) was evaluated in 87 patients with lupus nephritis. The correlational agreement and the accuracy of their predictions were contrasted with the actual outcomes observed and with statistically generated prognostic regression models. In contrast to previously published data, all four clinicians predicted both short-term outcomes (P < 0.001) and long-term outcomes (P < 0.02) well. The clinicians' predictions approximated that of a statistically generated computer model for both agreement and accuracy for renal function at 1 year. The four clinicians identified nearly identical clinical variables as important in determining prognosis. Provision of biopsy data to the clinicians improved short-term and long-term prediction slightly. The value of the statistical models was 'validated' by demonstrating that three of the four clinical variables identified by the models, but not by the clinicians, could enhance clinical prediction (P < 0.05). In addition, the extent of tubulo-interstitial involvement on biopsy, a predictor that has recently received increased attention, could improve the long-term clinical predictions of all four clinicians (P < 0.05).

Immune reactivity in aging-autologous mixed lymphocyte responses.

The level of activity in the autologous mixed lymphocyte reaction (AMLR) was studied in populations of young and old subjects. AMLR activity was reduced in the older age group. A subpopulation of the older age group who had Alzheimer's disease was shown to have the lowest AMLR values. Within this group, those with a history indicating a more rapid development of CNS-related disability from senescence showed the weakest AMLR responses. The AMLR values correlated neither with sex, nutritional status nor history of infections. This impairment of a central regulating immune reaction may be a significant variable in manifestations of the aging process.

Synovial inflammation induced by a local allergic reaction.

A rat model has been developed to examine the possible role of homocytotropic antibodies in initiating or exacerbating synovial inflammation. The technique, passive synovial anaphylaxis, involves passively sensitizing rat knee joints with specific IgE, then challenging intravenously with the corresponding antigen while monitoring for signs of inflammation. Swelling of the sensitized joints reached maximum 2 h after the challenge, then gradually decreased to prechallenge levels by 24 h. Radioisotopic joint scans detected a passive synovial anaphylaxis induced increase in local blood flow and exudation within the joints. The degree of swelling correlated directly with the amount of antigen specific IgE in the sensitizing serum, and individual joints remained sensitized for up to 36 days after the IgE injection.

Joint inflammation provoked by a local synovial allergic reaction.

Homocytotropic antibody was stimulated in animals by administering protein antigens in a vaccine with B. pertussis adjuvant. The titers of the allergic antibody responses were judged by passive cutaneous anaphylaxis reactions. Sera or globulin fractions containing high titers of antibody activity were injected into the knee joints of experimental animals. After sufficient delay for unfixed proteins to be cleared from the knee joints, animals were challenged intravenously with the corresponding antigen. The resultant local reaction of swelling and warmth (passive synovial anaphylaxis) was judged visually and by scanning procedures. Histological studies showed evidence of mast cell degranulation concurrent with synovial reaction.

The frequency of Leu 1+B cells in autoantibody positive and negative autoimmune diseases and in neonatal cord blood.

There is increasing evidence supporting the involvement of Leu 1+B cells in the development of human autoimmune diseases. In this study, the frequency of Leu 1+B cells has been analysed by a multiparameter FACS machine in newborn cord blood, and in the peripheral blood of several autoimmune patients and their healthy adult controls. Higher frequencies were observed in systemic lupus erythematosus (SLE), in seropositive rheumatoid arthritis (RA) and in newborn cord blood compared to control adults and seronegative RA. No relationship was observed between the frequency of Leu 1+B cells, and the age, sex and medication of the subjects.

Expression of c-myc protein in skin and synovium in psoriasis and psoriatic arthritis.

Monoclonal antibody against c-myc protein was used in the avidin-biotin-peroxidase complex procedure to examine frozen sections of psoriatic and normal skin and psoriatic synovium for the presence of c-myc protein. A significantly greater percentage (88%) of epithelial cells from psoriatic skin lesions stained for c-myc than uninvolved skin (62%) from both psoriatics and normals (p less than 0.001). The intensity of the stain appeared weaker in normal skin specimens. Greater than 95% of psoriatic hyperplastic synovial lining cells stained strongly for c-myc. In all cases, the c-myc staining was confined to the nuclei with no evidence of cytoplasmic staining.