Subacute subdural haematoma complicating lumbar microdiscectomy.

There have been no previous reports of a spinal subdural haematoma occurring as a complication of spinal surgery. We highlight the pitfalls in the diagnosis and management of a subacute subdural haematoma resulting from a dural tear which occurred as a surgical complication of microdiscectomy.

The Fas receptor in HIV infection: expression on peripheral blood lymphocytes and role in the depletion of T cells.

OBJECTIVE: To analyse the role of the apoptosis-inducing Fas receptor in the depletion of CD4+ and CD8+ T cells in HIV-infected individuals. METHODS: Peripheral blood lymphocytes (PBL) obtained from HIV-infected subjects of all 1993 Centers for Disease Control and Prevention (CDC) stages and from non-infected controls were examined. A two-colour cytofluorometry was employed using monoclonal antibodies against Fas receptor (CD95) in combination with the surface markers CD4, CD8, CD28, CD26 and CD45RO. CD4+ and CD8+ T-cell-enriched PBL were used as target cells to assess their susceptibility to lysis by CD4+ cytotoxic T lymphocytes (CTL) which kill via the Fas pathway. RESULTS: Fas+PBL are more elevated in HIV-infected individuals than in HIV-negative controls and increase significantly from CDC stages A to C. Whereas Fas+CD4+ and Fas-CD4+ T-cell populations decline in parallel with the progression of HIV infection, the Fas+CD8+, but not of the Fas-CD8+ fraction, significantly increases. The Fas+CD8+ lymphocytes are susceptible to Fas-mediated lysis as they are efficiently killed by Fas-ligand+CD4+CTL. CONCLUSION: The Fas receptor may contribute, but not as a unique cause, to the decline of CD4+ T cells in HIV-infected individuals. This and the significant increase of the number of Fas+ CD8+ T cells indicates that Fas-mediated immune regulation is disturbed.

Mechanism and biological significance of CD4-mediated cytotoxicity.

It is now well established that CD4+ T cells can express cytotoxic activity. This type of cell-mediated cytotoxicity is associated with the Th1-, but not with the Th2-phenotype. While the activation of CD4+ CTL is MHC class II-restricted, the effector phase, i.e. the target cell killing is unrestricted and antigen non-specific. In analogy to CD8+ CTL, CD4-mediated target cell death is by DNA fragmentation. However, the molecular mechanism of killing differs from CD8-mediated lysis. Thus, CD4+ CTL preferentially lyse their targets via Fas-Fas ligand interaction, whereas the major cytotoxic effect of CD8+ CTL is by granule exocytosis, i.e. perforin and granzymes. Although CD8+ CTL can also express the FasL, their lytic activity through interaction with Fas is of less importance. Likewise, some CD4+ CTL may also kill by perforin/granzymes activity, but this pathway is of minor significance. The aims of CD8- or CD4-mediated lysis are also different. Thus, the major task of CD8+ CTL which recognize and kill their targets in the context of MHC class I molecules, is the lysis of virally infected cells and battling against tumor cells. CD4+ CTL, on the other hand, have an immunomodulatory role. Thus, they preferentially eliminate activated MHC class II-positive cells, i.e. APC, be they monocytes/macrophages, B cells or T cells. They may lyse these cells in order to prevent an overreaction of the ongoing immune response or in order to remove potentially hazardous cells upon completion of the immune response. The Fas-FasL pathway is particularly suitable for this task as myeloid or lymphoid cells express Fas only if activated, while FasL is preferentially expressed on activated CD4+ Th1 cells. Moreover, activated T cells eliminate themselves by the Fas-mediated pathway. Whether this happens by fratricide only, or also by suicide or both is open. Moreover, CD4+ CTL are particularly suitable for killing tumor cells as well, as they are efficient effectors in bystander lysis in contrast to CD8+ CTL. On the other hand, the non-specific killing via Fas-FasL interaction, which is an important reason for the bystander lysis, may have unwanted effects in that cells which should not be eliminated could be killed. Such reactions affecting various organs and cells, e.g. the liver, thyroid or islet cells of the pancreas could be an explanation for certain autoimmune diseases.

Macrophage response to viruses, protozoa, and fungi: secretory and cellular activities induced in resting unprimed bone marrow-derived mononuclear phagocytes.

The secretory (tumor necrosis factor, TNF-alpha; nitrite) and cellular response (mitochondrial respiration, TNF-alpha-independent tumoricidal activity) of a pure, lymphocyte-free population of resting, unprimed rat bone marrow-derived mononuclear phagocytes (BMM phi) to direct interaction with viruses, protozoa, and fungi was assessed and compared with that triggered by bacterial agents and interferon-gamma (IFN-gamma). Viruses (herpes simplex, vaccinia, poliomyelitis, vesicular stomatitis, lymphocytic choriomeningitis, Sendai), protozoa (Trypanosoma brucei, Giardia lamblia), and fungi (Penicillium, Trichosporon, Fusarium, Rhizopus, Aspergillus, Geotrichum species) affected primarily the secretion of TNF-alpha and mitochondrial respiration of BMM phi; their effects on the secretion of nitrite and on tumoricidal activity were at best marginal. Collectively, the macrophage response to viruses, protozoa, and fungi was less varied and less marked than that to bacterial agents (intact organisms, peptidoglycan, lipoteichoic acid, lipopolysaccharide) and IFN-gamma.

The interaction of macrophages and bacteria: Escherichia coli species, bacterial lipopolysaccharide, and lipid A differ in their ability to induce tumoricidal activity and the secretion of reactive nitrogen intermediates in macrophages.

The ability of nine Escherichia coli strains, and of bacterial lipopolysaccharide (LPS)3 and lipid A preparations, to elicit in a pure population of bone marrow-derived mononuclear phagocytes (BMM phi) tumoricidal activity and/or the generation of reactive nitrogen intermediates (RNI) was compared. Generally, low concentrations of E. coli organisms were able to trigger the generation of RNI: however, for induction of tumoricidal activity, higher concentrations were required. Nonisogenic E. coli species exhibited different ability; isogenic E. coli organisms that differed only in the expression of K antigen exhibited similar ability to elicit the macrophage activities. LPS proved to be highly efficient in triggering the secretion of reactive nitrogen intermediates; lipid A was clearly less potent, but evidence is presented to suggest that this was due to the diminished solubility of these reagents. On the other hand, all LPS and lipid A samples were very poor inducers of tumoricidal activity. Although RNI secretion and expression of tumoricidal activity are both strongly dependent on L-arginine, various evidence suggests that the two functions are not closely correlated and are induced by different bacterial structures.

The interaction of macrophages and bacteria: a comparative study of the induction of tumoricidal activity and of reactive nitrogen intermediates.

The abilities of various bacteria to induce in a pure population of bone marrow-derived mononuclear phagocytes (BMM phi) tumoricidal activity and/or the generation of reactive nitrogen intermediates (RNI) were comparatively assessed. Interaction of BMM phi with bacteria led to expression of these functional activities, indicating that the organisms were recognized as foreign. As the majority of bacteria elicited in BMM phi either tumoricidal activity (that is maintained for days) or the production of RNI, measured by the release of nitrite (that is short-lived), it appears that the two functions are under separate control. However, both functions are inhibited or even abrogated by arginase or the L-arginine analogue, NG-monomethyl-L-arginine, suggesting that their expression is dependent on L-arginine.