Nefropatía IgA con proliferación extracapilar y ANCA positivos / IgA nephropathy with crescentic glomerulonephritis and anca positive

Presentamos un caso de nefropatía IgA diagnosticado por biopsia renal que presentaa los 2 años de seguimiento un empeoramiento de la función renal asociadohistológicamente a un brote extracapilar. Las determinaciones inmunológicas practicadasen aquel momento revelaron la presencia de anticuerpos anti-citoplasma delneutrófilo (ANCA) positivos a títulos altos (P-ANCA anti-MPO IgA y P-ANCA anti-MPO IgG). La paciente inició tratamiento sustitutivo con hemodiálisis y un año mástarde recibió un trasplante de riñón de donante cadáver con buen resultado. A losdos años del mismo, se mantiene con un sedimento de orina normal, una proteinurianegativa y una función renal normal bajo tratamiento inmunosupresor pero sedetectan de forma mantenida P-ANCA IgG e IgA positivos por inmunofluorescenciaindirecta (IFI) y títulos altos de IgG e IgA anti-MPO por ELISA. Creemos que la determinaciónde P-ANCA anti-MPO IgG, y en menor medida de P-ANCA anti-MPOIgA, en los casos de nefropatía IgA que presentan un empeoramiento rápido de lafunción renal puede indicar la existencia de un brote extracapilar de la enfermedadde base o de una vasculitis de pequeño vaso asociada, y confiere un mal pronósticorenal. El mantenimiento de P-ANCA positivos con títulos altos de IgG anti-MPOdurante todo el seguimiento sugiere que la determinación secuencial que ANCA IgGen esta entidad no es útil en la monitorización de la actividad clínica

We present a case of IgA nephropathy diagnosed by renal biopsy that presentsafter 2 years of folow-up an impairment of the renal function associate histoligicallyto a crescentic glomerulonephritis. The immunologic determinations showedof high titers of antineutrophil cytoplamic antibodies (ANCA) (P-ANCA IgG anti-MPO and P-ANCA IgA anti-MPO). The patient began treatment with haemodyalisisand one year later she received a cadaveric kidney transplantation with goodresult. Two years later she had normal urine sediment, negative proteinuria, normalrenal function but high titers of IgG and IgA PANCA anti-MPO. In summary,we believe that the determination ANCA in acute renal failure due to IgA nephropathy can indicate the existence of a IgA crescentic glomerulonephritis superimposedor an associated small vessel vasculitis and it confers a worse prognosis.The positive maintenance of IgG P-ANCA anti-MPO IgG anti-MPO titers duringthe course suggests that the sequential determination of ANCA in this entityis not useful to the monitoring of the clinical activity

[IgA nephropathy with crescentic glomerulonephritis and ANCA positive]. / Nefropatía IgA con proliferación extracapilar y ANCA positivos.

We present a case of IgA nephropathy diagnosed by renal biopsy that presents after 2 years of folow-up an impairment of the renal function associate histoligically to a crescentic glomerulonephritis. The immunologic determinations showed of high titers of antineutrophil cytoplamic antibodies (ANCA) (P-ANCA IgG antiMPO and P-ANCA IgA anti-MPO). The patient began treatment with haemodyalisis and one year later she received a cadaveric kidney transplantation with good result. Two years later she had normal urine sediment, negative proteinuria, normal renal function but high titers of IgG and IgA PANCA anti-MPO. In summary, we believe that the determination ANCA in acute renal failure due to IgA nephropathy can indicate the existence of a IgA crescentic glomerulonephritis superimposed or an associated small vessel vasculitis and it confers a worse prognosis. The positive maintenance of IgG P-ANCA anti-MPO IgG anti-MPO titers during the course suggests that the sequential determination of ANCA in this entity is not useful to the monitoring of the clinical activity.

[Anti-glomerular basement membrane antibody mediated disease: revision of 32 cases and follow-up at one year of the diagnosis]. / Enfermedad por Ac anti-MBG: revisión de 32 casos y seguimiento al año del diagnóstico.

Anti-basement membrane antibody mediated disease is an unfrequent entity but with a high mortality and morbidity. We present a revision of 32 patients diagnosed of anti-basement membrane antibody mediated disease between 1983 and 1997, and their evolution at one year of the diagnosis. The clinical pattern of presentation was as a Goodpasture's syndrome (glomerulonephritis and lung haemorrhage) in 15 patients and glomerulonephritis without lung involvement in 17. We reviewed retrospectively the features at the clinical presentation, the different treatments, and the delay of the starting of it since the beginning of the symptoms, in order to evaluate a prognosis dats of the disease. After the retrospective study we deduce that anti-basement membrane antibody mediated disease has a high mortality although the different regimes of treatment applied (25%), and the need of renal replacement therapy at one year of diagnosis is also high (70.8%). The renal survival at one year of the diagnosis is low and the response to therapy depends on the serum creatinine value at the diagnosis. The contribution of immunocompetent leucocytes to renal hypercellularity suggests that both humoral and cell-mediated immunity play a role in this disease.

Enfermedad por Ac anti-MBG: revisión de 32 casos y seguimiento al año del diagnóstico / Anti-basement membrane antibody mediated disease: revision of 32 cases and follow-up at one year of the diagnosis

La enfermedad por anticuerpos antimembrana basal es una entidad poco frecuente pero con una elevada mortalidad y morbilidad. Presentamos una revisión de 32 pacientes diagnosticados de enfermedad por anticuerpos antimembrana basal entre 1983-1997 y su evolución al año del diagnóstico. Según la forma de presentación clínica, 15 pacientes se manifestaron en forma de síndrome de Goodpasture (glomerulonefritis y hemorragia pulmonar) y 17 únicamente como glomerulonefritis. Revisamos retrospectivamente la forma de presentación clínica, el tipo de tratamiento administrado y la demora en el inicio del mismo desde el inicio de los síntomas para valorar el pronóstico de la enfermedad. De la observación retrospectiva del estudio se deduce que la enfermedad por anticuerpos antimembrana basal tiene una elevada mortalidad a pesar de los distintos regímenes de tratamiento aplicados (25 por ciento), siendo la necesidad de tratamiento sustitutivo renal al año del diagnóstico muy elevada (70,8 por ciento). La supervivencia renal al año del diagnóstico es baja y la respuesta al tratamiento depende de las cifras de creatinina en el momento del diagnóstico. El estudio histológico muestra que leucocitos inmunocompetentes contribuyen a las lesiones renales proliferativas, lo que apoya el papel de la inmunidad celular en esta enfermedad mediada clásicamente por la inmunidad humoral (AU)

Comparison of anti-PR3 capture and anti-PR3 direct ELISA for detection of antineutrophil cytoplasmic antibodies (ANCA) in long-term clinical follow-up of PR3-ANCA-associated vasculitis patients.

A total of 118 sera from 11 patients with anti-neutrophil cytoplasmic antibodies against proteinase-3- (PR3-ANCA) associated vasculitis were retrospectively screened by anti-PR3 capture and anti-PR3 direct ELISA tests. We studied the relationship between capture and direct ELISA scores and the clinical activity of PR3-ANCA-associated vasculitis patients during follow-up. We also studied the ability of the anti-PR3 capture ELISA to detect positive values of PR3-ANCA in clinical vasculitis relapses. Only capture ELISA presented a significant relationship (p < 0.05) with clinical activity of PR3-ANCA-associated vasculitis patients over time. Capture ELISA appears to be a reliable method for detecting clinical relapses in this group of patients. Our results indicate that the new capture ELISA test is more effective than direct ELISA in the follow-up of patients with PR3-ANCA-associated vasculitis and in the detection of relapses.

ELISA ANCA-GBM de detección rápida. Una herramienta de urgencia en el diagnóstico precoz de las glomerulonefritis rápidamente progresivas (gnrp) de tipo i y iii / The ANCA-GMB ELISA screening test: a rapid test for the diagnosis of rapide progressive glomerulonephritides

Las glomerulonefritis rápidamente progresivas (GNRP) de tipo I y III son formas de GNRP necrotizante asociadas a anticuerpos anti-membrana basal glomerular (anti-GBM) y a anticuerpos anticitoplasma del neutrófilo (ANCA) anti-proteinasa3 (anti-PR3) y anti-mieloperoxidasa (anti-MPO). Estas enfermedades tienen asociado una progresión rápida hacia la insuficiencia renal.En este estudio hemos comparado los ELISAs semicuantitativos para la detección de anticuerpos anti-GBM, ANCA anti-PR3 y anti-MPO y la técnica de inmunofluorescencia (IFI) con el ELISA rápido para la detección conjunta (en un tiempo de 30 minutos) de estos anticuerpos en pacientes con alta sospecha de GNRP. El valor diagnóstico de estos ELISAs semicuantitativos y de la técnica de IFI en el diagnóstico de pacientes con GNRP tipo I o III es conocido. El test estos de detección rápida no ha mostrado diferencias significativas con los resultados de ELISA anti-GBM, anti-PR3 o anti-MPO para los tres anticuerpos (p > 0,05). Asimismo, no se han encontrado diferencias significativas en los resultados del test rápido para anticuerpos anti-PR3 y anti-MPO respecto a los valores de IFI para C-ANCA y P-ANCA (p > 0,05). Su validez como herramienta diagnóstica de las GNRP tipo I y III comparada con los ELISAs semicuantitativos y la técnica de IFI ha sido, igualmente, confirmada.De los resultados de este estudio se desprende que el test de detección rápida es una herramienta tan útil como el ELISA semicuantitativo anti-GBM en el diagnóstico de GNRP tipo I y también lo es en el diagnóstico de GNRP tipo III comparado con las técnicas de IFI y ELISA semicuantitativo anti-PR3 o anti-MPO. Pero además, el test rápido tiene la ventaja añadida de procurar resultados en sólo 30 minutos y la comodidad de combinar tres resultados de tres anticuerpos diferentes en un solo test. (AU)

Circulating soluble adhesion molecules in ANCA-associated vasculitis.

BACKGROUND: To evaluate whether changes in concentrations of soluble (s) E-selectin, sP-selectin, sL-selectin, intercellular adhesion molecule 1 (sICAM-1), and vascular cell adhesion molecule 1 (sVCAM-1) reflect disease activity in patients with ANCA-associated vasculitis and whether serum levels of these adhesion molecules are related to the degree of renal failure in patients with chronic renal failure (CRF). SUBJECTS AND METHODS: A sandwich ELISA was used to measure these soluble adhesion molecules in (i) sera from 20 patients with antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (10 patients with Wegener's granulomatosis (WG) and 10 patients with microscopic polyangiitis (MPA)), obtained at the time of diagnosis and during the remission period; (ii) sera from 40 patients with CRF not undergoing haemodialysis. RESULTS: At the time of diagnosis, serum levels of sE-selectin, sICAM-1 and sVCAM-1 (88+/-42 ng/ml, 437+/-184 ng/ml, 1720+/-1174 ng/ml respectively) were significantly higher in patients with ANCA-associated vasculitis than in healthy controls (P<0.0001, P=0.002 and P=0.001 respectively). Serum sP-selectin values did not differ from those obtained in normal donors. In contrast, sL-selectin levels (940+/-349 ng/ml) were significantly lower in patients than those recorded in healthy controls (P<0.0001). A significant decrease in concentrations of sE-selectin, sP-selectin, sICAM-1, and sVCAM-1 was observed between active and remission phases (P<0.0001, P=0.002, P=0.001 and P=0.001 respectively). No significant differences were observed in sL-selectin levels between active and remission phases. sL-selectin concentrations (802+/-306 ng/ml) during the remission phase remained lower than those observed in healthy controls (P<0.0001). No correlation was observed between serum creatinine and sE-selectin, sP-selectin, sICAM-1 and sVCAM-1 in patients of the CRF group. A slight negative correlation was established between creatinine and sL-selectin concentration. CONCLUSIONS: Increased serum levels of sE-selectin, sICAM-1, and sVCAM-1 and decreased levels of sL-selectin in active ANCA-associated vasculitis, and the normalization of sE-selectin, sICAM-1, and sVCAM-1 during the remission phase suggest that the concentration of soluble levels of these adhesion molecules reflects disease activity. The decrease in sP-selectin levels between active and inactive phases also suggest that this receptor may reflect clinical activity. The lack of correlation between serum levels of sE-selectin, sP-selectin, sICAM-1, and sVCAM-1 and the degree of renal failure in patients with CRF suggests that the mechanism of clearance of these molecules is not renal.

[Rapid-detection GBM-ANCA ELISA. An emergency tool for the early diagnosis of type I and II rapidly progressive glomerulonephritis]. / ELISA ANCA-GBM de detección rápida. Una herramienta de urgencia en el diagnóstico precoz de las glomerulonefritis rápidamente progresivas (GNRP) de tipo I y III.

Rapidly progressive glomerulonephritides (RPGN) are forms of necrotizing glomerulonephritis associated with anti-glomerular basement membrane (anti-GBM) and anti-neutrophil cytoplasmic antibodies (ANCA) against the antigens proteinase-3 (anti-PR3) and myeloperoxidase (anti-MPO). RPGN have a course of rapid progression to renal failure. We compared the results from the semiquantitative ELISAs for anti-GMB antibodies, PR3-ANCA and MPO-ANCA and the indirect immunofluorescence technique (IIF) against a new rapid assay (30 minutes) for the same antibodies in patients with clinically suspected RPGN. The semiquantitative ELISAs for anti-GBM antibodies and PR3-ANCA and MPO-ANCA have a proven diagnostic significance in patients with RPGN I and III. There were no significant differences between the ANCA-GBM screening test and the results from the semiquantitative ELISAs (p > 0.05). We did not find significant differences between the results for PR3-ANCA and MPO-ANCA from the ANCA-GBM screening test with C-ANCA and P-ANCA IIF values (p > 0.05). We also corroborated that the ANCA-GBM screening test is a diagnostic tool for RPGN I and III as useful as the semiquantitative ELISAs and the IFF technique. The ANCA-GBM ELISA screening test is a tool as useful as the semiquantitative ELISA against anti-GBM antibodies for diagnosis of RPGN I. The comparison of the screening ELISA with the IIF technique and the semiquantitative ELISAs against PR3-ANCA and MPO-ANCA showed similar utility for diagnosis of RPGN III. The advantages of the new screening assay are that three antibodies are tested at the same time, yielding results in only 30 minutes.

[Anti-glomerular basement membrane disease: a new disease causing fever of unknown origin?]. / Enfermedad por anticuerpos anti-membrana basal: una nueva enfermedad causante de fiebre de origen desconocido?

Antiglomerular basement membrane disease is an autoimmune disorder characterized by the presence of antibodies directed against glomerular basement membrane. Pyrexia of unknown origin (PUO) is defined as temperatures higher than 38.3 degrees C on several occasions, with a duration of more than 3 weeks, and failure to reach a diagnosis despite 1 week of in-patient investigation. There is a large list of causes of PUO including infections, malignancies and autoimmune diseases, but antiglomerular basement disease has not been described as a cause. We present the first case of antiglomerular basement disease which presented with PUO.

Serum levels of soluble interleukin-2 receptor in patients with ANCA-associated vasculitis.

Serum soluble interleukin-2 receptor (sIL-2R) concentrations were determined using the ELISA method in 19 cases of ANCA-associated vasculitis. These patients were classified as 7 cases of Wegener's granulomatosis (WG) and 12 cases of microscopic polyangiitis (MPA). Elevated levels of sIL-2R were present in the sera of these patients. Levels of serum sIL-2R were not significantly different in patients with WG and MPA either in the active or inactive phase, so the results were expressed as a unified ANCA associated vasculitis group. Concentrations of serum sIL-2R were significantly higher in ANCA-associated vasculitis during the active phase than during the inactive phase (p<0.05), and serum sIL-2R levels were significantly increased in these patients, in the active or inactive stage, compared with a group of healthy subjects (p<0.05). In patients with vasculitis, serum sIL-2R levels correlated with serum levels of C-reactive protein (p<0.05). In the active phase, concentrations of serum sIL-2R correlated to creatinine concentrations. No correlation was found between sIL-2R and ANCA levels in any of the stages of the disease. These findings suggest cellular immune activation in ANCA associated vasculitis.

High prevalence of antithyroid antibodies in anti-glomerular basement membrane antibody-mediated disease.

Anti-glomerular basement membrane antibody (anti-GBM Ab)-mediated disease and autoimmune thyroiditis are characterized by the presence of organ-specific antibodies. The diagnosis of autoimmune thyroiditis is usually based on the presence of serum antithyroid antibodies. Few studies have addressed the relationship between anti GBM-Ab mediated disease and autoimmune thyroid pathology. Given that this disorder is often asymptomatic, associations of the two pathologies may be under-diagnosed. This study investigated the prevalence of serum antithyroid antibodies (antithyroglobulin (anti-TG) and anti-thyroid peroxidase (anti-TPO)) in patients with anti-GBM Ab-mediated disease. Antithyroid antibodies presence was investigated in sera from 35 patients in whom anti-GBM Ab-mediated disease had been diagnosed. Anti-glomerular basement membrane antibodies and anti-thyroid antibodies (anti-TG and anti-TPO) were assayed using an enzyme-linked immunosorbent assay. Forty-five percent of patients with anti-GBM Ab-mediated disease (16/35) had positive antithyroid antibody titers. Eighteen percent (3/16) suffered from subclinical hypothyroidism. In conclusion, the high prevalence of antithyroid antibodies in these patients suggests a possible pathogenic link between autoimmune thyroiditis and anti GBM Ab-mediated disease.

Enfermedad por anticuerpos anti-membrana basal ¿una nueva enfermedad causante de fiebre de origen desconocido? / Antiglomerular basement membrane disease presented with fever of unknown origin

La enfermedad por anticuerpos anti-membrana basal es una enfermedad autoinmune caracterizada por la presencia de anticuerpos dirigidos contra antígenos de la membrana basal glomerular. La fiebre de origen desconocido es un cuadro febril de duración superior a 2 ó 3 semanas, con determinaciones de temperatura superiores a 38,3-° C en varias ocasiones, sin haber llegado al diagnóstico etiológico tras una semana de investigación clínica. Existe una larga lista de causas de fiebre de origen desconocido que incluyen infecciones, neoplasias y enfermedades autoinmunes, pero no ha sido previamente descrita la enfermedad por anticuerpos anti-membrana basal glomerular como entidad etiológica. Presentamos por primera vez un caso de enfermedad por anticuerpos anti-membrana basal que debuta en forma de fiebre de origen desconocido (AU)

Relationship between ANCA and disease activity in small vessel vasculitis patients with anti-MPO ANCA.

BACKGROUND: We analysed the usefulness of antineutrophil cytoplasmic antibodies (ANCA) as a marker of clinical activity in patients with small vessel vasculitis associated with anti-myeloperoxidase (MPO) ANCA. METHODS: We studied a group of 25 patients, 15 with microscopic polyangitis and 10 with renal limited vasculitis, so-called rapidly progressive glomerulonephritis type III. The clinical and serological follow-up was accomplished quarterly over an average of 2.79 +/- 2.08 years (range 0.25-6 years). ANCA was analysed by indirect immunofluorescence and enzyme-linked immunosorbent assays (ELISAs). RESULTS: At the time of diagnosis, all patients were ANCA positive (P-ANCA and anti-MPO). Following a standardized treatment, all patients except one achieved complete remission of vasculitis in <3 months. One patient suddenly died during the active phase (1 month of follow-up) and with positive ANCA. Seroconversion from positive to negative occurred in 24/25 patients (96%). Eighteen of these 24 patients (75%) achieved the seroconversion within the first 6 months. During the follow-up, two patients had four major relapses, all of them associated with positive ANCA. ANCA seroconversion from negative to positive was observed in one patient with microscopic polyangitis without clinical relapse of vasculitis. CONCLUSION: ANCA should be used in conjunction with other markers of disease activity in the management of microscopic polyangitis and renal limited vasculitis patients with anti-MPO ANCA.

[Usefulness of anti-neutrophil cytoplasmic antibodies, anti-proteinase 3 and anti-myeloperoxidase in management of small vessel vasculitis]. / Valor de los anticuerpos anticitoplasma del neutrófilo, antiproteinasa 3 y antimieloperoxidasa en el seguimiento de las vasculitis de pequeño vaso.

BACKGROUND: Analysis of usefulness of antineutrophil cytoplasmic antibodies (AN-CA) as a marker of clinical activity in small vessel vasculitis. PATIENTS AND METHODS: 33 patients, 10 patients with Wegener's granulomatosis (WG) and 23 with microscopic polyangiitis (MPA) and rapidly progressive glomerulonephritis type III (RPGN III). The clinic and serologic follow-up was accomplished every 3 months during an average of 19 (SD, 24) months (range 3-52 months. The serologic follow-up included the determination of ANCA by indirect immunofluorescence (IFI) and ELISA, as well as the serum level of C reactive protein (RCP). RESULTS: At the time of diagnosis all patients were ANCA positive by IFI and ELISA. The seroconversion of ANCA from positive to negative was produced in 30/33 patients (90%). Twenty-six out of these 30 patients (87%) achieved the seroconversion within the first 6 months. During the follow-up 4 patients had a major relapse, all with positive ANCA. In 2 patients, one of each group, seroconversion from negative to positive was not associated with clinical relapse of vasculitis. CONCLUSION: ANCA should be used in conjunction with other indices of disease activity in patients with small vessel vasculitis.

[antineutrophil cytoplasmic autoantibodies in inflammatory bowel disease]. / Anticuerpos anticitoplasma de neutrófilo en la enfermedad inflamatoria del intestino.

BACKGROUND: The aim of the present study was to determine the prevalence and diagnostic usefulness of antineutrophil cytoplasmic antibodies (ANCA) in a Spanish population of patients with inflammatory bowel disease from the province of Tarragona. PATIENTS AND METHODS: One hundred and fifty-six sera obtained from 116 patients with inflammatory bowel disease (75 ulcerative colitis and 41 Crohn's disease) and 40 healthy controls were tested using an indirect immunofluorescence assay. RESULTS: ANCA were detected in 65% of patients with ulcerative colitis but in only 12% of patients with Crohn's disease (p < 0.01), and 2.5% of control subjects (p < 0.01). The overall sensitivity of the test for the diagnosis of ulcerative colitis was 65% with a specificity of 88% and a positive predictive value of 91%. Among patients with ulcerative colitis there was no relationship between the presence or titre of ANCA and the duration, the clinical course, the extent, the disease activity or the need for medical treatment. CONCLUSIONS: In the population studied, ANCA occur more commonly in ulcerative colitis than in Crohn's disease, as reported in other populations. Their determination in patients with inflammatory bowel disease may be useful to differentiate ulcerative colitis from Crohn's disease.

Antineutrophil cytoplasmic antibodies in primary Sjögren's syndrome: prevalence and clinical significance.

OBJECTIVE: To evaluate the prevalence of cytoplasmic (c) and perinuclear (p) antineutrophil cytoplasmic antibodies (ANCA) in patients with primary Sjogren's syndrome (SS), and to correlate the presence of ANCA with extraglandular and immunological manifestations related to SS. METHODS: In a cross-sectional study, we included 82 consecutive patients (75 female and seven male; mean age 61 yr; range 33-87 yr) attending our unit. All patients fulfilled four or more of the diagnostic criteria for SS proposed by the European Community Study Group in 1993. Extraglandular manifestations such as arthralgia and/or arthritis, Raynaud's phenomenon, autoimmune thyroiditis, peripheral neuropathy, renal involvement and cutaneous vasculitis were also recorded. Serum samples were examined by indirect immunofluorescence (IIF) and by ELISA using as substrates myeloperoxidase (MPO) and proteinase 3 (PR3). RESULTS: ANCA were detected in nine (11%) patients: seven had pANCA and two an atypical pattern. These two atypical ANCA became cANCA when paraformaldehyde fixation was applied. ELISA findings showed that two patients had antibodies against MPO, and no patient had antibodies to PR3. The most common extraglandular manifestations in the ANCA-positive patients were articular involvement in six (66%) patients, peripheral neuropathy in five (55%), Raynaud's phenomenon in four (44%) and cutaneous vasculitis in four (44%). Of the four patients with cutaneous vasculitis and ANCA, two had a mononuclear inflammatory vascular disease (MIVD) in the biopsy specimen. When compared with patients without ANCA, those with these antibodies had a higher prevalence of cutaneous vasculitis (44% vs 8%, P = 0.01), Raynaud's phenomenon (44% vs 8%, P = 0.01) and peripheral neuropathy (55% vs 7%, P < 0.001). CONCLUSION: ANCA positivity can be found in patients with primary SS and its detection is associated with the presence of clinical manifestations attributable to vascular involvement (cutaneous vasculitis, peripheral neuropathy and Raynaud's phenomenon).

Circulating soluble adhesion molecules in patients with classical polyarteritis nodosa.

The objective was to evaluate whether changes in circulating soluble adhesion molecule levels reflect disease activity in patients with systemic polyarteritis nodosa (PAN). A sandwich ELISA was used to measure soluble (s) intercellular adhesion molecule 1 (sICAM-1), vascular cell adhesion molecule 1 (sVCAM-1), E-selectin, L-selectin and P-selectin in sera and plasma from 22 patients with active PAN, in sera from 13 of these patients taken serially during follow-up, and in sera from 13 healthy controls. At the time of diagnosis, sICAM-1, sVCAM-1 and sE-selectin levels (488.5 +/- 201.3, 1176.5 +/- 514.1 and 60.6 +/- 27 ng/ml, respectively) were significantly higher in patients than in controls (P < 0.0001, P = 0.001 and P = 0.003, respectively). In contrast, sL-selectin levels tended to be lower in patients than in controls. Within the first 7 days after starting treatment, there was a significant increase in sICAM-1 concentrations, which fell thereafter, but did not completely reach normal levels when patients achieved clinical remission. sE-selectin also remained elevated during follow-up. Only sVCAM-1 decreased, tending to reach normal values in inactive disease. Increased levels of sICAM-1, sVCAM-1 and sE-selectin, and decreased levels of sL-selectin, in active PAN suggest immune and endothelial stimulation during disease activity. Abnormal levels of soluble adhesion molecules in clinically inactive patients might reflect persistence of immune activation and/or endothelial cell exposure to a remaining inflammatory microenvironment.