Anticardiolipin antibodies in South African patients with lupus nephritis: a clinical and renal pathological study.

AIMS: This study was conducted prospectively to ascertain the prevalence of anticardiolipin antibodies (ACAs) in patients with lupus nephritis and to determine whether this subgroup of patients differed clinically and histologically from patients without the antibody. PATIENTS AND METHODS: 40 SLE patients (26 Blacks, 14 Indians, 37 females, 3 males) with evidence of renal involvement underwent clinical assessment and percutaneous renal biopsy. Special investigations included: urinary protein quantitation; radioisotope glomerular filtration rate (GFR); complement levels, and antinuclear antibodies and ACAs. Histology was reviewed by a single senior pathologist blinded to the ACA results. In addition to the standard WHO classification, specimens were examined for intrarenal thrombosis. RESULTS: The prevalence of ACA was 45% (18 of 40 patients). Thrombocytopenia was more frequent in patients with ACA (33 vs. 13.6%, p = 0.015). Patients with ACA did not differ from controls with regard to the incidence of thrombosis, neurological disorders, recurrent fetal loss, active disease and hypertension. Mean GFR and 24-hour urine protein (ACA vs. controls) were 51.3 versus 67 ml/min (NS) and 2.4 versus 3.7 g (NS), respectively. Intrarenal microvascular thrombosis (glomerular and arteriolar) occurred in 27.7% of ACA patients versus 9% of controls (p = 0.025). Apart from a higher incidence of class-III nephritis in the controls, standard histology (WHO classification) did not differ between the 2 groups. CONCLUSION: The prevalence of ACA in our patients with lupus nephritis was 45%. This subgroup did not differ from patients without the antibody apart from a higher incidence of thrombocytopenia and intrarenal microvascular thrombosis.

The association of antiphospholipid antibodies with severe early-onset pre-eclampsia.

OBJECTIVE: To confirm the association of antiphospholipid antibodies with early onset of severe pre-eclampsia before 30 weeks' gestation. STUDY DESIGN: Thirty-four patients with diastolic blood pressure levels > or = 110 mmHg and at least 2+ proteinuria before the 30th week of pregnancy were randomly chosen for inclusion in the study. Blood samples were taken for assessment of anticardiolipin antibodies (ACAs), lupus anticoagulant, syphilitic serology and antinuclear antibodies. Fifteen normal antenatal patients matched for age, parity and gestational age acted as control subjects. RESULTS: Four of the 34 women (11.7%) in the study group had elevated levels of both ACAs and lupus anticoagulant, compared with none in the control group. This was not found to be statistically different. CONCLUSION: Given the low incidence of positive ACAs in early-onset severe pre-eclampsia it is unlikely that they are implicated in its pathogenesis. It is possible that they represent a small subset of patients with alternative or combined pathology.

High mortality with systemic lupus erythematosus in hospitalized African blacks.

This survey was undertaken to determine the clinical spectrum and outcome of SLE in hospitalized African blacks in Durban, South Africa. We reviewed the hospital records of all patients with SLE who were seen during 1984 and 1990. Eighty-five patients were seen and their mean age at diagnosis was 33.3 years. The prevalence of the various diagnostic criteria was as follows: cutaneous, 68%; arthritis, 66%; renal, 65%; serositis, 29%; neuropsychiatric, 21%; haematological, 71%; immunological, 49%; anti-nuclear factor, 98%. Follow up data were not available in many patients but 25 (29%) are known to have died. The commonest causes of death were renal, infection, neurological and cardiac. This survey shows that SLE is being recognized more frequently in African Blacks and is associated with a high mortality.

Invasive amoebiasis is associated with the development of anti-neutrophil cytoplasmic antibody.

Features of tissue damage in invasive amoebiasis, in particular polymorphonuclear neutrophil (PMN) degranulation and vasculitis, bear resemblance to that seen in Wegener's granulomatosis, the latter being associated with the presence of anti-neutrophil cytoplasmic antibodies (ANCA). We therefore tested sera from patients with confirmed amoebic liver abscess (ALA) for the presence of ANCA by means of an indirect fluorescent antibody test using pure neutrophils as substrate. ANCA was detected in 97.4% of amoebic sera; the pattern of staining was cytoplasmic, homogeneous, without central accentuation (C-ANCA). A proteinase 3 (PR3) ELISA demonstrated PR3 specificity in 75% of C-ANCA-positive ALA sera. Possible explanations are (i) a cross-reacting antibody to a component of Entamoeba histolytica, or (ii) an antibody to PMN components released, and possibly modified, by the action of E. histolytica on PMN. It is possible that this antibody contributes to the pathogenesis of invasive amoebiasis.

Are anticardiolipin antibodies responsible for some of the complications of severe acute Plasmodium falciparum malaria?

What were first called simply false-positive Wassermann reactions and then lupus anticoagulant are now known as antiphospholipid or anticardiolipin antibodies (ACA). These are known to cause a tendency to thrombosis and are frequently present in many neurological conditions and infections. The pathological significance of these antibodies in acute infections, if any, is unknown. We investigated the presence of these antibodies in Plasmodium falciparum malaria in an endemic area in Natal/KwaZulu, and attempted to correlate the presence of this antibody with cerebral manifestations. Immunoglobulin G-anticardiolipin antibodies measured by enzyme-linked immunosorbent assay occurred significantly more frequently in 62 patients with acute Plasmodium falciparum malaria (33.9%) than in 37 control subjects (2.7%) (P < 0.0001). There was no significant difference in the mean parasite loads in those patients who were positive for ACA (1.75%) and those who were negative (1.59%) (P = 0.83). No correlation was found between parasite load and ACA levels in the patient group, or between the number of cerebral manifestations in patients with and without the antibody. The frequency of splenomegaly was not significantly different in patients with and without ACA (P = 0.06). We conclude that there is a high prevalence of ACA in acute falciparum malaria. The pathological significance of this antibody and its relationship to complications, especially cerebral ones, warrant greater attention and may improve the understanding of cerebral malaria and its management.

Antinuclear antibodies in systemic sclerosis. Clinical and ethnic associations.

Antinuclear antibodies were detected, using a sensitive immunofluorescence test, in 96% of 160 patients with systemic sclerosis. Analysis of the patterns of staining revealed that a speckled pattern was commonest (66%), followed by nucleolar staining (37%). In 15% these two co-existed, and in 26% the speckling was of the fine, grainy type, indicative of Scl 70 antibody. Centromere antibody was found in 12%. Black patients made up 54% of the series, and centromere antibody was notably absent from this group, which also had more Scl 70 and nucleolar antibodies than did Indian patients. These serological findings correspond with the clinical features, there being far fewer blacks than Indians with limited cutaneous involvement. The ethnic differences found suggest a genetic influence on the expression of the disease and its auto-antibodies.

Liver function in early congenital syphilis: does penicillin cause a deterioration?

In this prospective study, neonates with clinical congenital syphilis were investigated to determine if penicillin therapy caused a deterioration in liver function. The relationship between circulating immune complexes and liver involvement was monitored, and the efficacy of steroid therapy as an adjunct in the treatment of congenital syphilis was investigated. Thirty neonates with clinical congenital syphilis were randomly assigned into two groups: one group received penicillin therapy only, and the other group penicillin and prednisone as an adjunct. Twenty-one infants who did not have clinical or serological syphilis, born to seropositive mothers, served as a "control" group. Liver function tests, full blood counts, and immunological studies were performed at various intervals up to 3 months of age. Although the symptomatic groups differed significantly from the asymptomatic group in most of the parameters measured, there were no significant differences noted between the two symptomatic groups at any time point. No direct relationship between penicillin therapy and either deteriorating liver function or the presence of circulating immune complexes could be demonstrated. Also, prednisone therapy did not modify any of the parameters studied.

Kaposi's sarcoma associated with acquired immunodeficiency syndrome presenting as a vulval papilloma. A case report.

A patient with acquired immunodeficiency syndrome (AIDS)-associated Kaposi's sarcoma presenting with a vulval neoplasm is reported. Although more common in black than white people, Kaposi's sarcoma infrequently presents with gynaecological symptoms or lesions. In this case report the management of Kaposi's sarcoma presenting as a vulval neoplasm in a young woman with a positive antibody test to HIV is discussed and the need to screen young women with vulval neoplasms for this infection is highlighted.

Sexually transmitted pathogens and colposcopic findings in asymptomatic HIV-1 antibody-positive blood donors.

Sixteen asymptomatic human immunodeficiency virus (HIV-1) antibody-positive female blood donors were examined for sexually transmitted diseases by lower genital tract microbiological tests and colposcopy. Two donors had generalised lymphadenopathy, and in 13 (81.2%) human papillomavirus was detected on histological examination. In 5 (31.2%) Neisseria gonorrhoeae was cultured. Sexually transmitted pathogens were found in all but 3 subjects and multiple agents were detected in 9. The high prevalence of sexually transmitted diseases coupled with the generally poor response to counselling has a frightening potential for spread of HIV locally.

The clinical and lymphocyte status of HIV antibody-positive black blood donors.

Forty-seven HIV antibody-positive black blood donors presented for assessment and counselling at King Edward VIII Hospital, Durban. Thirteen were found to have generalised lymph node enlargement and 1 had a tuberculous pulmonary infiltrate. Significant reduction in helper T-cell numbers and in the helper-suppressor ratios was noted. Counselling appeared to produce disturbingly few positive effects.

Circulating auto-antibodies to neutrophil cytoplasmic antigens in vasculitis. A report of 3 cases.

Three patients are described who presented with symptoms and signs of a vasculitic illness but in whom a definite diagnosis was not made until the application of a test to detect auto-antibodies to neutrophil cytoplasmic antigens. There has long been a need for a diagnostic marker for the groups of diseases which fall into the broad classification of systemic vasculitides. Diagnosis of the patients as having either Wegener's granulomatosis or microscopic polyarteritis by the finding of this auto-antibody enabled a positive approach to treatment with combinations of immunosuppressive agents. In addition, serial measurement of the auto-antibody titres enabled monitoring of disease activity.

Circulating immune complexes in typhoid fever.

Levels of circulating IgG- and IgM-containing immune complexes were studied in patients with typhoid fever. Raised levels of both were always found at the time of presentation; they fell towards normal over 3-4 weeks. In 1 patient with a less favourable clinical course the immune complexaemia lasted longer than in the others.

The phytohaemagglutinin response and lymphocyte subpopulations in young Blacks and Indians with insulin-dependent diabetes mellitus.

The lymphocyte transformation response to phytohaemagglutinin (PHA) and the relative numbers of T, B and null lymphocytes were studied in 32 insulin-dependent diabetics and 32 healthy matched controls. The mean stimulation index (Sl) of the 18 patients with poorly controlled diabetes mellitus was significantly lower than that of controls. No difference was seen in the mean Sl values of well-controlled diabetics compared with controls. Neither the well-controlled group nor the poorly controlled group showed any significant differences in the mean counts of the various lymphocyte subpopulations when compared with controls.

Application of the leucocyte adherence inhibition test to the assessment of cell mediated immunity in invasive amoebiasis.

The leucocyte adherence inhibition (LAI) test was assessed as a means for measuring specific cell mediated immunity (CMI) in invasive amoebiasis. The LAI test and the amoebic gel diffusion (AGD) test were performed on 20 patients admitted to hospital with amoebic liver abscess (ALA) and 24 control subjects with no demonstrable clinical amoebiasis. The AGD results were acceptable for such a study in an endemic area as all the proven ALA subjects gave positive responses while all except one of the controls gave a negative reaction. A percentage adherence in the LAI test of more than 80% was considered to be negative and the mean percentage adherence of leucocytes for the control subjects was found to be 86.0 +/- 4.9 while that for the experimental group was found to be 76.1 +/- 15.4; the difference between these groups is statistically significant. It was noticed that the LAI test response was possibly linked with severity of disease in the ALA subjects. The LAI test has been found to be a relatively rapid test of specific CMI and although fastidious, it does not require the use of radio-isotopes.