Treatment outcomes in a cohort of patients with mucosal-predominant pemphigus vulgaris.

BACKGROUND: Pemphigus vulgaris (PV) is a rare autoimmune blistering condition. Treatment typically combines corticosteroids with another immunosuppressive agent, such as azathioprine, mycophenolate mofetil (MMF) or rituximab. AIM: This study aims to compare these second agents for their clinical efficacy and steroid-sparing effect. METHODS: This was a single-centre, retrospective observational cohort study of 21 patients with oral PV over a 6-year period, 18 of whom were newly diagnosed. Of the latter, the first 13 were initially given azathioprine, progressing to MMF and then rituximab on treatment failure, while the next five patients started directly on MMF. RESULTS: Of the 13 newly diagnosed patients, 2/13 were intolerant of azathioprine, and only 1/11 was controlled, with a median time to treatment failure (MTTF) of 254 days. MMF was given to 17 patients, either de novo (5) or after azathioprine (12), and was significantly more effective, controlling activity in 4/17 patients, and for a significantly longer time (MTTF 395 days, P = 0.019). All 13 patients failing MMF received rituximab, seven required a second dose, and three, a third dose. All patients responded, with 11/13 able to cease steroids. Control was maintained for a similar time to MMF (MTTF 364 days, P = NS). Rituximab also had the best steroid-sparing effect followed by MMF, then azathioprine. Side-effects were common with azathioprine, while the other two agents were well tolerated. CONCLUSION: Rituximab was the most effective of the three immunosuppressives for PV, although repeat dosing was frequently required. These observations have significant implications for the choice of drugs for this condition.

Vancomycin-associated drug reaction with eosinophilia and systemic symptoms syndrome.

Drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome is a rare but potentially life-threatening multi-system disorder characterised by the delayed onset of fever, rash and internal organ involvement following the administration of a drug. We report three definite cases of vancomycin-associated DRESS syndrome occurring and review the literature regarding this syndrome.

Circulating phenotypic B-1 cells are decreased in common variable immunodeficiency and correlate with immunoglobulin M levels.

B-1 cells are innate-like lymphocytes characterized by spontaneous production of 'natural' polyspecific antibodies, often of self-specificity, and thought to be responsible for tissue homeostasis, mucosal protection, maintaining resting serum immunoglobulin (Ig)M levels and for early immunoglobulin production following infection. Although defined most clearly in mice, a human B-1 cell counterpart, defined by the phenotype CD19 or 20(+) CD27(+) CD43(+) CD69 or 70(-) , has been proposed recently, facilitating a study of their role in human humoral immunodeficiencies, such as common variable immunodeficiency (CVID). This study examined circulating B-1 cells in 27 CVID patients in comparison to age-matched controls (n = 28). Phenotypic putative B-1 cell proportions varied widely, but there was an overall 60-70% decrease in CVID (0·039 ± 0·033% of lymphocytes, mean ± standard deviation) compared with controls (0·110 ± 0·159% of lymphocytes, P = 0·0012). This decrease was, however, explained largely by concomitant loss of total CD27(+) memory B cells characteristic of CVID, although those with higher memory B cell proportions appeared to show a true decrease. No age-related effects were apparent in B-1 cell proportions. However, among CVID patients, there was a strong positive correlation between the B-1 cell proportion and serum IgM levels, a relationship that was not evident for IgA, nor was there a relationship between memory B cell proportions and serum IgM. Patients with CVID have fewer circulating putative phenotypic B-1 cells, which largely reflected the overall decrease in memory B cells. However, B-1 cell proportions correlated with resting serum IgM levels, suggesting a possible role in IgM deficiency in CVID.

Prevalence of paraproteinaemia in older Australians.

BACKGROUND: Estimates of the prevalence of paraproteinaemia vary, from 1% in persons aged over 25 years to 10% in those aged over 80 years, although there are limited data from well-defined populations. We sought to determine the prevalence of paraproteinaemia in Australians aged 50 years and over, and to determine risks factors for its presence. METHODS: We performed a population-based, cross-sectional study using data and serum collected in the Blue Mountains Eye Study. Serum samples from 2933 patients were analysed by capillary zone electrophoresis and, where indicated, immunosubtraction, which allowed for both quantitation and isotype detection. RESULTS: A paraprotein was detected in 134 of the 2933 samples, giving an overall prevalence of 4.6% (95% confidence interval, 3.8-5.3%). The presence of a paraprotein was strongly age-related (P(trend) = 0.001), with a prevalence of 2.8% in persons aged 50-59 years, rising steadily to 9.1% in those aged 80 years and over. The prevalence was significantly higher in men (5.9%) compared with women (4.0%) (P= 0.03). CONCLUSION: We conclude that approximately one in 20 Australians aged 50 years or over harbours a paraprotein, a prevalence that appears higher than from similar cohorts in other countries.

Invariant natural killer (iNK) T cell deficiency in patients with common variable immunodeficiency.

Common variable immunodeficiency (CVID) is a B cell immunodeficiency disorder characterized frequently by failure of memory B cell development and antibody secretion. A unifying cellular pathogenesis for CVID has not been forthcoming, but given the immunoregulatory role of invariant NK (iNK) T cells and their absence in several other immunodeficiencies, we quantified these cells in the blood of 58 CVID patients. There was a marked decrease in the proportion of iNK T cells in CVID patients compared with controls. This was particularly notable in those with low isotype-switched memory B cells, but subset analysis demonstrated no difference when stratified by specific clinical features. We propose that the decreased proportion of iNK T cells in CVID might be linked to the failure of memory B cell generation, which may contribute to reduced antibody production in these patients.

Decrease in phenotypic regulatory T cells in subsets of patients with common variable immunodeficiency.

Common variable immunodeficiencies (CVID) are a heterogeneous group of antibody deficiency disorders complicated by autoimmune, lymphoproliferative and/or granulomatous manifestations, suggesting variations in immunoregulation. We sought to quantify regulatory CD4 T cells (T(reg) cells) in the blood of CVID patients and to correlate the frequency with clinical manifestations and classification subgroups. Blood samples from 99 CVID patients in Freiburg, London and Sydney, who had been phenotyped clinically and stratified according to their memory B cell phenotype (Freiburg and Paris classification schemes), were analysed for the proportion of T(reg) cells, defined either as CD25(+)/forkhead box P3 (FoxP3)(+), CD25(+)/CD127(low)/FoxP3(+) or CD25(+)/CD127(low) CD4(+) T cells, and results compared with 49 healthy controls. Irrespective of the phenotype used to define them, there was a significant decrease in the T(reg) cell proportion in patients with granulomatous disease and immune cytopenias. This allowed the definition of a subgroup of CVID patients with abnormally low T(reg) cells, which had a higher rate of these two manifestations as well as autoimmune disease in general. There was also a significant reduction in the proportion of T(reg) cells in the Freiburg group Ia compared with other CVID patients and controls, but there were no differences between the Paris groups. The reduction in T(reg) cells in subsets of CVID patients may be relevant to their clinical manifestations, and may contribute to our understanding of the pathogenesis of CVID complications.

In vitro HIV-specific CTL activity from HIV-seropositive individuals is augmented by interleukin-12 (IL-12).

IL-12 production is reduced in HIV infection, and recombinant human IL-12 (rhIL-12) augments in vitro HIV-specific proliferative responses in PBMC from HIV-seropositive individuals. To determine whether rhIL12 could also augment HIV-specific CTL responses we studied 41 HIV-seropositive individuals. Recombinant hIL-12 increased the detectable in vitro HIV-specific CD8 CTL activity of PBMC taken from HIV-seropositive individuals with CD4 counts >500 cells/microl and from some individuals with lower CD4 counts. IL-12 increased cell recovery in cultures of PBMC from HIV-seropositive individuals with CD4 counts >500 cells/microl and also increased the precursor CTL frequency. However, the increase in HIV-specific CTL activity was not due to IL-2 or IFN-gamma production or an increase in the number of cells with surface markers characteristic of CTL effector cells. This study demonstrates that rhIL-12 augments in vitro HIV-specific CTL activity and provides evidence to justify further investigation within clinical trials of this cytokine in HIV infection.

Diagnostic value of classical and atypical antineutrophil cytoplasmic antibody (ANCA) immunofluorescence patterns.

BACKGROUND: The "classical" antineutrophil cytoplasmic antibody (C-ANCA) pattern seen on indirect immunofluorescence (IIF) is characterised by granular cytoplasmic staining showing central or interlobular accentuation, and is strongly associated with antiproteinase-3 antibodies (PR3-ANCA) and Wegener's granulomatosis. However, many laboratories report C-ANCA in the presence of any cytoplasmic IIF staining, regardless of pattern, which risks reducing the diagnostic value of this pattern. AIMS: To classify different cytoplasmic ANCA patterns and thus determine whether stringent application of the classical criteria for C-ANCA would produce better correlation between C-ANCA and (1) PR3-ANCA enzyme linked immunosorbent assay (ELISA) results; (2) a diagnosis of systemic vasculitis (including Wegener's granulomatosis). METHODS: 72 sera with cytoplasmic IIF collected over a two year period were analysed by IIF and a commercial PR3-ANCA ELISA kit. RESULTS: Three IIF patterns were defined: "classical/true" C-ANCA as described above (n = 27 (37.5%)); "flat" ANCA with homogeneous cytoplasmic staining (n = 21 (29%)); and "atypical" ANCA which included all other cytoplasmic patterns (n = 24 (33.5%)). Twenty five of the 27 true C-ANCA sera (92.5%) contained PR3-ANCA (p < 0.0001), but none of the 21 with flat ANCA and only one of the 24 with atypical ANCA. From clinical data on 23 of the 27 true C-ANCA positive patients, 20 (87%) had evidence of Wegener's granulomatosis or systemic vasculitis (p < 0.0001 v the other two patterns). However, none of 19 sera with flat ANCA and clinical data had evidence of systemic vasculitis. CONCLUSIONS: Restricting the term "c-ANCA" to the "classical" description of central/interlobular accentuation on IIF, will improve its correlation with PR3-ANCA positivity and a diagnosis of systemic vasculitis.

Measurement of Candida-specific blastogenesis: comparison of carboxyfluorescein succinimidyl ester labelling of T cells, thymidine incorporation, and CD69 expression.

Measurement of the T cell blastogenic response to Candida may be useful in the evaluation of patients with suspected immunodeficiency. The classic blastogenesis assay is based on uptake of [3H]thymidine by peripheral blood lymphocytes stimulated with Candida antigens for 5 days. An alternative approach involves staining peripheral blood lymphocytes with the intracellular fluorescent dye carboxyfluorescein succinimidyl ester (CFSE) and measuring mitotic activity by the successive twofold reductions in fluorescent intensity using flow cytometry (FCM). The two approaches were compared in 16 subjects who demonstrated various proliferative responses to Candida. FCM-derived indices all involved initial gating on CD3+ T cells and included 1) blastic transformation as measured by changes in light scatter, 2) cell division, measured by CFSE fluorescence, and 3) CD69 expression. A good correlation was found between [3H]thymidine uptake and CFSE-derived indices, irrespective of the analysis algorithm used to interpret CFSE division profiles. Furthermore, significant T cell proliferation occurred only in subjects who had had one or more symptomatic episodes of vaginal candidiasis whereas controls with no such history, and patients with chronic vaginal infection, showed minimal proliferation. The increase in proportion of CD69+ T cells in culture also correlated with the blastogenic response to Candida, but less well than mitotic indices. CFSE-derived indices of T cell blastogenesis to Candida are equivalent to [3H]thymidine-based assays and may allow useful laboratory distinction between subjects who have been exposed to and recovered from vaginal Candida infection, who have a strong proliferative response, from those with no exposure or chronic infection who demonstrate a poor response.

Influences on the lifespan of B cell subpopulations defined by different phenotypes.

The turnover of mature and immature B cells defined by a range of cell surface markers was investigated by feeding normal or bcl-2-transgenic (bcl-2-Tg) mice 5'-bromo-2-deoxyuridine (BrdUrd) for up to 6 weeks. In peripheral lymphoid tissue, B cells accumulated BrdUrd with a 50% labeling time of 4.3 weeks and a pattern of uptake indicative of the presence of both long-lived and short-lived cells. These two kinetic populations could be resolved into immature B220lo/heat-stable antigen (HSA)hi cells which labeled rapidly, and B220hiHSAlo cells which were uniformly long-lived with a half-life of about 6 weeks. During loading and pulse-chase experiments, BrdUrd uptake by cells within the mature B220hiHSAlo population clearly followed an exponential kinetic pattern, suggesting that their loss was governed by stochastic processes. Using other surface markers, the long-lived population could also be defined by high expression of IgD, representing cells in the follicular mantle zone of the spleen, and by the phenotype IgMhiIgDloHSAlo which most likely represented marginal zone memory B cells. CD23 expression on B cells did not differentiate well between long and short-lived cells. Only about half of newly labeled B cells appearing in the spleen progressed to the long-lived compartment, a proportion which was not altered significantly in bcl-2-Tg mice. The most likely explanation was that a combination of both positive and negative selection was operating at this site which was mediated by pathways not regulated by bcl-2. On the other hand, overexpression of bcl-2 did result in a two- to threefold increase in the rate of appearance of newly labeled B cells in the spleen, consistent with a possible role for this protein during early selection events within the bone marrow. Selection processes appeared to be very active in young mice during the shaping of the B cell repertoire, since B cells from 6-week-old non-Ig mice displayed a rapid rate of turnover irrespective of their surface phenotype, and a significant population of long-lived cells did not become evident until the mice had reached about 12 weeks of age.

B-cell activation versus tolerance--the central role of immunoglobulin receptor engagement and T-cell help.

The critical variables responsible for the decision between activation and tolerance in the B-cell compartment were studied in the well-characterised hen egg lysozyme:antilysozyme transgenic model. Mature B-cells exposed to a low antigenic signal, which resulted in a receptor occupancy of between 5% and 25%, remained 'indifferent' (i.e. were neither activated nor tolerant), had a normal lifespan and recirculated through B-cell follicles. When receptor occupancy reached a critical threshold of approximately 50%, the B-cells became activated and moved to the outer T-cell zones where they died. This threshold appeared to be lower in the case of immature B-cells. On addition of T-cell help, however, the B-cells were rescued, proliferated and secreted antibody. Thus the outcome of the interaction between B-cells and antigen (self or foreign) is determined largely by the degree of antigen receptor engagement and availability of T-cell help.

B cell life span: a review.

Debate has surrounded the subject of B cell life span since it was first measured in mice in the early 1970s. In the 25 years which have passed since then, it has become increasingly apparent that the methods employed to measure rates of B cell turnover, such as [3H]-thymidine labelling, cell transfer or cell ablation, brought about significant disruptions to normal physiology which in themselves might have affected B cell turnover. More recently the use of bromodeoxyuridine has overcome many of these methodological difficulties and has allowed rates of B cell renewal to be measured within B cell subpopulations defined by multiparameter flow cytometry. Such studies have largely resolved the issue, concluding that about 85% of peripheral B cells are phenotypically mature and display first-order exponential kinetics defined by a half-life of 5-6 weeks, whilst the remainder are short-lived with a life span of several days. This review examines both traditional and recent methods and discusses the influence of age, self-tolerance and randomness in the overall shaping of a kinetically stable mature B cell population.

The fate of self-reactive B cells depends primarily on the degree of antigen receptor engagement and availability of T cell help.

Self-reactive B cells from tolerant double-transgenic (Dbl-Tg) mice coexpressing hen egg lysozyme (HEL) and rearranged anti-HEL immunoglobulin genes have a relatively short life span when compared to normal B cells, irrespective of whether they are exposed to antigen in multivalent membrane-bound form (mHEL-Dbl-Tg mice) or soluble form (sHEL-Dbl-Tg mice). The factors responsible for determining the fate of these B cells after encounter with self-antigen were investigated using a cell-tracking technique in which anti-HEL Ig-Tg spleen cells were labeled with the intracellular dye 5-carboxyfluorescein diacetate-succinimidyl ester (CFSE) and injected either into non-Tg recipients or a variety of HEL-Tg hosts. In non-Tg recipients, HEL-binding B cells persisted in the circulation and could be detected in the follicles of the spleen for at least 5 d. On transfer into either mHEL-Tg or sHEL-Tg hosts, they underwent activation and then rapidly disappeared from the blood and spleen over the next 3 d, consistent with the short life span reported previously. Immunohistology of spleens from sHEL-Tg recipients indicated that the transferred B cells had migrated to the outer margins of the periarteriolar lymphoid sheath (PALS), where they were detectable for 24 h before being lost. The positioning of B cells in the outer PALS depended on a critical threshold of Ig receptor binding corresponding to a serum HEL concentration between 0.5 and 15 ng/ml, but was not restricted to endogenously expressed HEL in that the same migratory pattern was observed after transfer into non-Tg recipients given exogenous (foreign) HEL. Moreover, bone marrow-derived immature Ig-Tg B cells homed to the outer PALS of sHEL-Tg mice and then disappeared at the same rate as mature B cells, indicating that the stage of maturation did not influence the fate of self-reactive B cells in a tolerant environment. On the other hand, HEL-binding B cells transferred into sHEL-Dbl-Tg recipients persisted over the 3-d period of study, apparently due to insufficient availability of antigen, as indicated by the fact that the degree of Ig receptor downregulation on the transferred B cells was much less than in sHEL-Tg recipients. If T cell help was provided to Ig-Tg B cells at the time of transfer into sHEL-Tg recipients in the form of preactivated CD4+ T cells specific for major histocompatibility complex-peptide complexes on the B cell surface, HEL-binding B cells migrated through the outer PALS of the spleen to the follicle, where they formed germinal centers, or to adjacent red pulp, where they formed proliferative foci and secreted significant amounts of anti-HEL antibody. Taken together, these results indicated that the outcome of the interaction between self-antigen and B cells is largely determined by a combination of the degree of receptor engagement and availability of T cell help.

Differential regulation of early and late stages of B lymphocyte development by the mu and delta membrane heavy chains of Ig.

Regulation of B lymphocyte development by the mu-membrane (mu m) and delta-membrane (delta m) heavy chains of Ig was examined in an Ig transgenic mouse model. Mice were bred on a common C57BL/6 (B6) background, and expressed rearranged and hypermutated heavy and light chain transgenes encoding high-affinity receptors for the foreign antigen hen egg lysozyme (HEL). At no stage were they exposed to HEL. Variation of the Ig heavy chain construct yielded four different types of Ig transgenic mice in which developing B lineage cells either expressed mu m and delta m in the normal physiological sequence (mu m then mu m + delta m), or produced mu m alone, delta m alone or mu m + delta m from the onset of heavy chain expression in the bone marrow. Immature B220low, HSAhigh and mature B220high, HSAlow B cells were produced in all mice regardless of their developmental pattern of mu m and delta m expression. However, production of immature B cells was most efficient when mu m heavy chain was expressed alone during early B cell development. Thus expression of delta m during this period either in the presence or absence of mu m resulted in a 2- to 3-fold reduction in the numbers of immature B cells in the spleen as well as altered levels of surface B220 and HSA on these cells in spleen and bone marrow respectively. By contrast, normal maturationally regulated expression of delta m led to the presence of increased numbers of mature B cells in the spleen and lengthened the average lifespan of these cells as determined by in vivo incorporation of 5-bromo-2'-deoxyuridine. These results pointed to selective effects of mu m and delta m heavy chains on regulation of the early and late stages of B cell development respectively, and provided a rational basis for co-expression of mu m and delta m as well as the delayed expression of delta m during normal B cell development.

Whither the anergic B-cell?

The kinetics of potentially autoreactive B-cells were investigated in a double-transgenic model of self-tolerance. Two types of transgenic mice were created for this purpose. In the first the great majority of B-cells expressed the rearranged heavy and light chain genes encoding a high affinity receptor for hen egg lysozyme (HEL), while the second type expressed HEL in either soluble (sHEL) or membrane-bound (mHEL) form. Double-transgenic (Dbl-Tg) mice were produced either by mating the two types of founders or by transferring bone marrow cells from Ig-transgenic (Ig-Tg) donors into irradiated HEL-Tg recipients. The lifespan of B-cells from the Dbl-Tg mice was measured by oral loading with the thymidine analogue, 5-bromo-2'-deoxyuridine (BrdU) for periods varying from three days to six weeks. Experiments in various combinations of Dbl-Tg mice revealed a three-tiered hierarchy of B-cell unresponsiveness, each level of which was characterised by a different B-cell lifespan. Exposure to mHEL led to rapid deletion of B-cells at an immature stage in their development with a median lifespan of approximately 15 hours. B-cells exposed to sHEL above a critical tolerogenic threshold were not deleted in the bone marrow but migrated to the spleen in an anergic state where they died within three days. If the receptor occupancy of sHEL was below the tolerogenic threshold, B-cells were neither deleted nor rendered anergic (ie were "indifferent") and had a normal median lifespan of four to five weeks.(ABSTRACT TRUNCATED AT 250 WORDS)

Reduced life span of anergic self-reactive B cells in a double-transgenic model.

The life span of anergic self-reactive B cells was determined by 5-bromo-2'-deoxyuridine (BrdU) loading of tolerant double-transgenic (Dbl-Tg) mice produced by mating hen egg lysozyme (HEL)-transgenic mice with the corresponding immunoglobulin-transgenic (Ig-Tg) mice, the B cells of which express anti-HEL IgM and IgD. B cells from Dbl-Tg mice, despite being exposed to soluble antigen throughout their development, are not deleted, but persist in an anergic state. As a prelude to studying the life span of these anergic B cells, BrdU was administered to nontransgenic mice; B cells from the bone marrow, spleen, and lymph nodes displayed distinct kinetic profiles based on reciprocal expression of the B220 isoform of CD45 and heat-stable antigen (HSA). Thus, immature B220lo/HSAhi B cells incorporated BrdU rapidly suggesting recent generation from dividing precursors, whereas uptake by B cells expressing the mature B220hi/HSAlo phenotype was significantly slower, consistent with a longer life span. Such gating allowed analysis to be directed at the stable mature B cell population in transgenic mice. Comparison of BrdU uptake in Ig- and Dbl-Tg mice indicated that B cells from Dbl-Tg mice were renewed at a much higher rate (50% renewal times of 0.64 vs. 3.4 wk for total B cells, and 1.2 vs. 5.0 wk for mature B200hi/HSAlo cells from Dbl- and Ig-transgenic mice, respectively). This difference was even more marked when analysis in Dbl-Tg mice was restricted to HEL-binding cells, which had a 50% renewal time of 3-4 d compared with 4-5 wk for non-HEL-binding B cells. While the proportion of B cells in cell cycle, and the rate of entry of newly generated B cells into the spleen of Ig- and Dbl-Tg mice, were similar, B cell numbers were reduced in Dbl-Tg mice. It was therefore concluded that anergic B cells have a markedly decreased life span in the periphery. According to studies in radiation chimeras produced by reconstituting HEL-transgenic recipients expressing different serum levels of antigen with Ig-Tg bone marrow, the reduced life span of anergic B cells was associated with the anergic state per se, the serum concentration of HEL being important only in attaining the critical threshold necessary for tolerance induction. B cells rendered tolerant by exposure to soluble self-antigen therefore survive for a relatively short period in an anergic state once they have reached peripheral lymphoid tissue and fail to enter the long-lived compartment.(ABSTRACT TRUNCATED AT 400 WORDS)

Elimination of self-reactive B lymphocytes proceeds in two stages: arrested development and cell death.

In transgenic mice, self-reactive B lymphocytes are eliminated if they encounter membrane-bound self antigens during their development within the bone marrow. We show here that two separate and sequential events, arrested development and cell death, bring about B cell elimination. Developmental arrest is an early outcome of antigen binding in immature B cells, blocks acquisition of adhesion molecules and receptors important for B cell migration and activation, and is rapidly reversible by removal of antigen. Death of the arrested B cells occurs within 1 to 3 days and can be delayed by expression of a bcl-2 transgene, which results in escape of large numbers of self-reactive B cells from the bone marrow but fails to override the developmental arrest. These findings define a novel pathway for B cell elimination, involving an initial stage vulnerable to breakdown in autoimmune disease.