Effects of 42 months of GH treatment on bone mineral density and bone turnover in GH-deficient adults.

OBJECTIVE: To study the effects of GH treatment for up to 42 months on bone mineral density (BMD) and bone turnover. DESIGN AND METHODS: BMD with dual energy X-ray absorptiometry, serum type I procollagen carboxy-terminal propeptide (PICP), serum type I collagen carboxy-terminal telopeptide (ICTP) and serum IGF-I were assessed in 71 adults with GH deficiency. There were 44 men and 27 women, aged 20 to 59 (median 43) years. Thirty-two patients completed 36 months and 20 patients 42 months of treatment. RESULTS: The BMD increased for up to 30-36 months and plateaued thereafter. In the whole study group, the maximum increase of BMD was 5.0% in the lumbar spine (P<0. 001), 5.9% (P<0.01) in the femoral neck, 4.9% (NS, P>0.05) in the Ward's triangle and 8.2% (P<0.001) in the trochanter area. The serum concentrations of PICP (202.6+/-11.5 vs 116.3+/-5.4 microg/l; mean+/-s.e.m.) and ICTP (10.5+/-0.6 vs 4.4+/-0.3 microg/l) doubled (P<0.001) during the first 6 months of GH treatment but returned to baseline by the end of the study (130.0+/-10.4 and 5.6+/-0.7 microg/l respectively), despite constantly elevated serum IGF-I levels (39. 6+/-4.1 nmol/l at 42 months vs 11.9+/-0.9 nmol/l at baseline; P<0.001). The responses to GH treatment of serum IGF-I, PICP, ICTP (P<0.001 for all; ANOVA) and of the BMD in the lumbar spine (P<0.05), in the femoral neck and the trochanter (P<0.001 for both) were more marked in men than in women. At the end of the study the BMD had increased at the four measurement sites by 5.7-10.6% (P<0.01-0.001) in patients with at least osteopenia at baseline and by 0.1-5.3% (NS P<0.05) in those with normal bone status (P<0.001 for differences between groups; ANOVA). Among patients who completed 36-42 months of treatment, the number of those with at least osteopenia was reduced to more than a half. The response of BMD to GH treatment was more marked in young than in old patients at three measurement sites (P<0. 05-<0.001; ANOVA). In the multiple regression analysis the gender and the pretreatment bone mass appeared to be independent predictors of three measurement sites, whereas the age independently determined only the vertebral BMD. CONCLUSIONS: GH treatment in GH-deficient adults increased BMD for up to 30-36 months, with a plateau thereafter. Concurrently with the plateau in BMD the bone turnover rate normalized. From the skeletal point of view GH-deficient patients exhibiting osteopenia or osteoporosis should be considered as candidates for GH supplementation of at least 3-4 years.

Mannan binding lectin deficiency and concomitant immunodefects.

OBJECTIVE: To determine the prevalence of a mannan binding lectin (MBL) deficiency in children with increased susceptibility to infections and to investigate whether other coexisting immunodeficiencies affecting opsonisation are needed to render MBL deficiency clinically significant. PATIENTS AND METHODS: 343 serum samples were collected from 266 children with repeated infections, a single episode of severe infection, or prolonged symptoms relating to infection. The concentrations of MBL, immunoglobulin G (IgG), M (IgM), A (IgA), and IgG subclasses (IgG1-4) were analysed. RESULTS: MBL deficiency was found in nine children (3.2%), seven of whom had repeated infections or a single episode of severe infection. In two, initial symptoms and signs suggestive of infection eventually led to the diagnosis of an autoimmune disease--Still's disease in one and pauciarticular juvenile rheumatoid arthritis in the other. Among the children with MBL deficiency and infections, concomitant IgG subclass deficiency was detected in five and a transient low level of one or two IgG subclasses in two. Prevalence of an IgG subclass deficiency in children with MBL deficiency was higher than in those without (56% and 22%, respectively). CONCLUSIONS: MBL deficiency alone is not an independent risk factor for infection but may be manifested in association with another humoral immunodeficiency affecting opsonisation. Among children with MBL deficiency, those with juvenile rheumatoid arthritis were overrepresented. This calls for further study.

Serum mannan-binding lectin (MBL) in patients with infection: clinical and laboratory correlates.

In this study, we determined the serum levels of mannan-binding lectin (MBL) in patients with suspected or documented infection to characterize the possible role of MBL in the susceptibility to infection. We also investigated the kinetics of MBL during the infection and correlated the concentrations of MBL with those of acute-phase reactants C-reactive protein (CRP) and group II phospholipase A2 (PLA2-II) and cytokines interleukin-1(IL-1). interleukin-6 (IL-6) and tumor necrosis factor alpha (TNF-alpha). The frequency of MBL deficiency in the patients with signs of infection did not differ from that of controls. In four patients with MBL deficiency, the infections were caused by common pathogens and the outcome was normal. The mean MBL concentration in the patients with signs of infection was significantly higher than in the healthy controls (9.88 and 4.48 mg/l, respectively; p < 0.05). The highest mean MBL concentration was observed in patients with clinically or microbiologically documented bacterial infection. During follow-up, the MBL concentration altered individually in different patients, but no particular change in pattern in the MBL concentration could be demonstrated in any patient group. Of the acute-phase reactants in the circulation, only CRP and IL-1 showed a weak, albeit significant, negative correlation with the concentration of MBL. In conclusion, the deficiency of MBL was not shown to be an independent risk factor for infection in the adult population studied. The concentration of MBL did not follow the change in pattern of other acute-phase reactants and cytokines during the acute phase response. Therefore, measurement of the MBL concentration as an acute-phase reactant is not useful in the diagnosis or follow-up of infection. On the other hand, the deficiency of MBL can be detected reliably by serological methods even during an infection.

Growth hormone, osteoblasts, and marrow adipocytes: a case report.

Though growth hormone stimulates markers of bone formation in adults, its in vivo effect on osteoblasts is unknown. We have used histomorphometry of fluorochrome-labeled iliac crest biopsies along with biochemical markers to assess bone formation and resorption rates before and after treatment with growth hormone (Genotropin; 3. 0 IU/day for 6 months) in combination with calcitonin (Miacalcin nasal: 200 IU daily) in a man with osteonecrosis and decreased spinal bone mineral density (BMD). Treatment resulted in increases in indices of bone formation and a marked increase in osteoblast number and osteoid surface, with a concomitant decrease in the number and size of marrow adipocytes. There was no change in spinal or total BMD. These data confirm the stimulatory effect of growth hormone on the osteoblast population and suggest that this may occur by the commitment of early precursor cells to the osteoblastic as opposed to the adipocytic lineage.

Antibody reactivity against thyroid peroxidase and myeloperoxidase in autoimmune thyroiditis and systemic vasculitis.

Potential cross-reactivity between thyroid peroxidase (TPO) and myeloperoxidase (MPO) molecules was evaluated by analysing the binding of 199 TPO antibody- and MPO antibody-positive sera to TPO and MPO molecules. Sera from six patients with autoimmune thyroiditis (AITD) and four patients with systemic vasculitis (SV) with different TPO-MPO antibody findings were then chosen for further analyses. All six patients with AITD had TPO antibodies in enzyme immunoassay (EIA) and four of them had simultaneously MPO antibodies in EIA. In AITD patients antibody binding to TPO could not be inhibited by adding native MPO to the serum diluent, suggesting that the possible cross-reactive epitopes were exposed in the denaturated MPO molecule. Similarly, the MPO ab reactivity of patients with systemic vasculitis could not be inhibited by native TPO. To study whether TPO and MPO antibodies recognize linear epitopes, the binding of antibodies to synthetic TPO and MPO peptides was analysed. Several TPO and MPO peptides were reactive, including peptides reacting with both TPO and MPO antibody-positive sera. One of the most cross-reactive peptides contained AA 586-601 in TPO, showing also particularly high AA homology (88%) with MPO (AA 594-609). The results suggest that TPO and MPO molecules contain cross-reactive epitopes that are exposed in denaturated molecules and may thus cause false positive antibody findings in solid phase EIA assays.

Perinuclear antineutrophil cytoplasmic antibody in rheumatoid arthritis: a marker of severe disease with associated nephropathy.

OBJECTIVE: To evaluate the clinical significance of antineutrophil cytoplasmic antibodies (ANCA) in patients with rheumatoid arthritis (RA), and especially in those with clinically suspected or histologically proven nephropathy. METHODS: A total of 246 RA patients with (n = 149) and without (n = 97) histologically proven (n = 99) or clinically suspected (n = 50) nephropathy were studied for the presence of ANCA by immunofluorescence and enzyme immunoassay. RESULTS: Perinuclear ANCA (pANCA) were found in 52 (21%) of the 246 patients. Patients with clinically suspected or histologically proven nephropathy were significantly more frequently positive for pANCA (30% versus 7%; P < 0.00005) and had significantly higher mean (+/- SD) pANCA log titers (103 +/- 5.6 versus 27 +/- 3.0; P = 0.0011) than patients without clinically evident renal disease. Positivity for pANCA was associated with clinical and laboratory findings indicating severe basic disease and increased inflammatory activity. Irrespective of this association, pANCA acted as a significant and independent predictor of RA-associated nephropathy. CONCLUSION: Perinuclear ANCA in RA indicate severe disease with increased inflammatory activity. There is an especially strong and independent association between pANCA and RA-associated nephropathy.

Age-dependent variation in the serum concentration of mannan-binding protein.

Mannan-binding protein (MBP) is an acute phase reactant, and its deficiency is associated with the common opsonic defect and suspectibility to infections and atopic constitution. The aim of this study was to investigate the changes occurring in the serum level of MBP in infancy and during later childhood. We studied the serum concentration of MBP in 611 Finnish children of different ages and 110 adults by using an enzyme immunoassay. In an analysis of successive serum samples from infants at the day of birth and at the ages of 1 and 5 months, and at 1 and 2 years, the serum concentration of MBP increased significantly after birth, and was at its highest (the mean and median were 8.13 and 8.49 mgl-1, respectively) at the age of 1 month. After that, it declined to the initial level until the age of 5 months. The MBP concentration continued to decrease during childhood, and after the age of 12 years the MBP values reached the adult level. In Finnish adults the mean and median concentrations of MBP were 4.48 and 4.02 mgl-1, respectively, which seem to be higher than those reported previously in other populations. The high concentration of MBP in infants may best be explained by exposure to novel environmental antigens in early childhood, which suggests a protective role for MBP during the period of immaturity of the immunosystem. In older children the high level of MBP can probably be explained by childhood infections and the ensuing need of MBP.

Serum levels of interleukins 2, 6 and 8, soluble interleukin-2 receptor and intercellular adhesion molecule-1 during treatment with interleukin-2 plus interferon-alfa.

In the present study we evaluated the haematological and immunological changes in 4 patients with advanced melanoma and 6 patients with advanced renal cell carcinoma treated with subcutaneous interleukin (IL)-2 and interferon (IFN)-alfa-2b. Serum samples taken before and during six weeks' courses of IL-2 plus IFN-alfa were assayed for the presence of IL-2, soluble IL-2-receptor (sIL-2R), soluble intercellular adhesion molecule-1 (sICAM-1), IL-6 and IL-8. In addition, whole blood counts were taken. Eosinophilia occurred in all patients, lymphocytosis in 8 patients. The higher maximum level of IL-2 during treatment seemed to be connected to longer survival: it was a median of 578 pg/ml in the patients with a median survival of 7 months, and 1025 pg/ml in the patients who survived a median of 15 months. Conversely, an increase in sIL-2R was an unfavourable sign: it was a median of 8-fold and 3-fold in the patients with a median survival of 7 and 16 months, respectively. During treatment, sICAM-1 levels paralleled with those of sIL-2R. There was major intraindividual and interindividual variation in serum IL-6 and IL-8 levels with no distinctive kinetic pattern. Thus, no definite conclusions could be drawn. However, it seems worthwhile to measure IL-2, sIL-2R and sICAM-1 during immunotherapy; their prognostic value should be further evaluated in a larger patient population.

Effect of interferon-alpha on immunoglobulin production by peripheral blood mononuclear cells in multiple myeloma.

To test a hypothesis that interferon-alpha (IFN) treatment might restore normal immunoglobulin (Ig) production in multiple myeloma (MM), the effect of IFN on Ig isotype (IgG and IgA) production by peripheral blood (PB) and bone marrow (BM) mononuclear cells (MNCs) in MM patients was analyzed by ELISA. IFN at a concentration of 1000 U/ml was found to enhance IgA production by PB MNCs in IgA-MM and had a trend to stimulate IgG production in IgG-MM. The effect of IFN on nonparaprotein Ig isotype production was more variable, with mostly neutral or inhibitory effects being seen in both the MM subtypes. In contrast to the influences observed in MM patients, IFN at the same concentration inhibited both IgG and IgA production by PB MNCs in healthy controls. In studying BM cells, IFN was found to reduce IgA production in IgA-MM, but had a neutral effect on IgG production in IgG-MM. In the controls, the production of both the IgG and the IgA isotypes by BM MNCs was decreased by IFN. On the basis of these results it seems that the disease itself somehow affects the Ig-producing cells in MM, when measured as different responses of the cells to exogenous IFN in vitro. The results do not support the hypothesis that IFN treatment could restore normal Ig production in MM patients.

Suppression of lymphocyte proliferation in vitro by bovine caseins hydrolyzed with Lactobacillus casei GG-derived enzymes.

BACKGROUND: Processing of proteins in the gut and activation of T-cell suppression leads to systemic hyporesponsiveness to ingested protein antigens. OBJECTIVE: The study was designed to determine whether lactobacilli, a major part of human intestinal microflora, can contribute to degradation of food antigens in the gut and modify their immunoactivities. METHODS: Lymphocyte transformation tests were carried out in healthy adults to determine the mitogen-induced lymphocyte proliferative responses to bovine caseins hydrolyzed with pepsin and trypsin and to bovine caseins additionally hydrolyzed with enzymes derived from Lactobacillus casei strain GG (ATCC 53103). RESULTS: In experiments done with caseins hydrolyzed with pepsin and trypsin, beta- and alpha(s1)-caseins significantly suppressed the proliferation of lymphocytes at 0.1 and 10 micrograms/ml, respectively, when compared with corresponding control cultures without these hydrolysates. In contrast, kappa-casein significantly stimulated the proliferation of lymphocytes at 10 micrograms/ml. In experiments done with caseins additionally hydrolyzed with L. casei GG-derived enzymes, there was one consistent effect on lymphocyte proliferation: suppression by alpha(sl)-, beta-, and kappa-caseins at 0.1, 10, and 1000 micrograms/ml, respectively. CONCLUSIONS: Hydrolysis of caseins with L. casei GG-derived enzymes generates molecules with suppressive effects on lymphocyte proliferation. In addition, intestinal bacteria can be beneficial in the downregulation of hypersensitivity reactions to ingested proteins in patients with food allergy.

Circulating autoantibodies to a 240 kD fetal brain protein.

Antibodies (IgG and IgM) recognizing a 240 kD antigen of the cat fetal brain were found in sera of healthy people and in sera (IgG) obtained at uncomplicated delivery from the umbilical cord of the newborn infant. The method applied was immunoblotting. Using the same method, the 240 kD antigen could not be detected in the adult brain or other fetal tissues. It seems that the antigen is specific for the fetal brain. The role of the antigen and the origin of generation and significance of function of the antibodies in the circulation are the objects of our further studies.

Effect of proctocolectomy on serum antineutrophil cytoplasmic antibodies in patients with chronic ulcerative colitis.

AIMS: To study the effect of proctocolectomy on the antineutrophil cytoplasmic antibody (ANCA) titres in association with ulcerative colitis. METHODS: Serum samples were taken from 15 patients with ulcerative colitis immediately before and at a mean of 24 months after proctocolectomy. Indirect immunofluorescence for ANCA and enzyme immunoassays for myeloperoxidase and proteinase-3 antibodies were employed. A liver biopsy was taken from every patient during the proctocolectomy, and serum liver enzyme activities were also determined. RESULTS: Before proctocolectomy, 13 of the 15 patients had perinuclear antineutrophil cytoplasmic antibodies (p-ANCA). Additionally, one patient had a low tire of classical cytoplasmic ANCA and one had granulocyte specific antinuclear antibodies. After proctocolectomy, the ANCA titres decreased in 10 patients, in two of whom they became negative. The titres remained the same in four patients with positive ANCA and increased twofold in one patient. Only one patient was proteinase-3 antibody positive and all 15 patients were myeloperoxidase antibody negative. The clinical condition improved in all patients, irrespective of the ANCA status after proctocolectomy. Seven patients, all of whom were positive for p-ANCA before proctocolectomy, had histological liver abnormalities. No correlation was observed between serum liver enzyme levels and ANCA staining patterns or titres. CONCLUSIONS: Proctocolectomy decreased the ANCA titres in the majority of our patients, suggesting that reduction of the inflammation or the available antigenic material modifies the immune disturbance related to ulcerative colitis.

Thyroid antibodies in association with thyroid malignancy II: Qualitative properties of thyroglobulin antibodies.

Qualitative properties of thyroglobulin (Tg) antibodies, in association with thyroid malignancy, suspected malignancy or other thyroid diseases, were studied in 177 patients. Retrospective clinical analysis revealed 137 patients to have thyroid carcinoma and 40 to have other thyroid diseases. Serum Tg was assayed by an immunoradiometric method. Thyroid microsomal (AMC) and Tg antibodies were measured by the particle agglutination method and the avidity of Tg antibodies by enzyme immunoassay (EIA). Assessment of the qualitative properties of Tg antibodies revealed that the high-avidity antibodies especially seem to bind circulating Tg. Thus any Tg value from a sample with detectable Tg antibodies is unreliable and should be interpreted with caution.

Tolerability and kinetics of a solvent-detergent-treated intravenous immunoglobulin preparation in hypogammaglobulinaemia patients.

The tolerability and kinetics of a solvent-detergent-treated 6% intravenous immunoglobulin (IVIG) preparation were studied in 15 hypogammaglobulinaemia patients during 3-4 regular substitution infusions of 9-48 g, the mean dose being 359 mg/kg. The infusions were well tolerated, and the trough serum IgG levels achieved were comparable to two commercial IVIG preparations. The stepwise increase of the infusion rate up to 5 mg/kg/min and the use of this IVIG as a 12% solution were possible without serious adverse events in all the 6 studied hypogammaglobulinaemia patients. This greatly reduced the time needed for the infusions.

Increased chemiluminescence of whole blood and normal T-lymphocyte subsets in severe nodular acne and acne fulminans.

To investigate the inflammatory and immunological aspects of severe acne, we examined the luminol-enhanced chemiluminescence of whole blood, T-cell subsets and natural killer cell functions in 11 patients with severe nodular acne and 4 patients with acne fulminans. In patients with severe nodular acne, the active phase of the disease, compared to the values in remission (means 47 mV, SD 24.8 and 32 mV, SD 8.3, p < 0.05). The patients with acne fulminans also showed high values in the active phase of the disease (mean mV 68.3, SD3.5) compared to remission (mean 30.5 mV, SD 15.3). No marked alterations were seen in the percentages of T-helper cells, T-suppressor cells or DR-positive lymphocytes or in the levels of soluble interleukin 2 receptor. The percentages and activities of natural killer cells did not show any significant changes either. Five patients (4 with severe nodular acne and one with acne fulminans, accounting for 33% of all patients) carried HLA Cw6 antigen, which is a significantly increased frequency compared to health controls (pc = 0.015). The present chemiluminescence results suggest that peripheral blood neutrophils are activated in patients with severe acne.

Hematopoietic growth factors stimulate paraprotein isotype production by bone marrow mononuclear cells in an aggressive case of multiple myeloma.

We describe a patient with multiple myeloma (MM), whose bone marrow (BM) cells were capable of spontaneous paraprotein isotype secretion, which could be strongly stimulated by hematopoietic growth factors (GFs), such as interleukin-6 (IL-6), granulocyte-macrophage colony-stimulating factor (GM-CSF), G-CSF and IL-3. Ig production by BM cells from another five MM patients and four control patients with non-malignant hematological diseases could not be stimulated by these GFs. The results indicate that GFs, at least in some instances, can activate tumoral plasma cells in patients with MM. This possibility should be taken into account when the utility and effectiveness of GFs in the treatment of MM is evaluated.

Circulating myeloperoxidase may cause false negative findings in the analysis of myeloperoxidase antibodies in systemic vasculitis.

In systemic vasculitis reliable detection of myeloperoxidase antibodies (MPO-Abs) is of great clinical importance in the diagnosis and follow-up of patients. We have studied whether circulating myeloperoxidase (MPO) could have an effect on MPO-Ab findings. Serum MPO and MPO-Abs were measured in 50 healthy individuals, 35 patients and in the follow-up samples from two patients with Wegener's granulomatosis. Heating the sera at 56 degrees C for 30 min reduced the concentration of immunoreactive MPO both in control and patient sera. In 71% of the patient sera heating made initially negative MPO-Abs detectable. In a few cases with severe vasculitis the antibody findings remained totally negative. These results, together with the data from the follow-up samples from two patients with Wegener's granulomatosis, revealed that the serological diagnosis of vasculitis may be considerably delayed if only native samples are analysed for MPO-Abs. These findings are of considerable clinical significance for the interpretation of MPO-Ab results. Circulating myeloperoxidase affects MPO-Ab measurements, causing false negative findings in MPO-Ab assays. Therefore, it is recommended to denaturate circulating MPO by heating the sera before the analysis of MPO-Abs and to re-evaluate the cut off-values.

A prospective study of humoral immune responses to cow milk antigens in the first year of life.

Previous studies have shown that in cow milk allergy the specific immune response to dietary cow milk antigens is deficient. This study aimed at delineating the development of humoral immune response to cow milk antigens in healthy infants. Twenty-five healthy newborns were enrolled, and seen at scheduled visits at the ages of three, six and eleven months, and they formed two groups: those breastfed and those fed adapted cow milk formulae. The local immune response in the gut was approximated using the ELISPOT assay of circulating antibody secreting cells. At the age of three months, in the formula fed group, cells secreting specific IgA to cow milk antigens were detected despite low levels of IgA serum antibodies. The total number of IgA secreting cells increased with age (p = 0.001). The milk in the infant diet directly influenced this development so that the age related increase was significantly greater in the formula fed group (p = 0.04). The results indicate that diet has a significant effect on the developing immune system, and that healthy infants are able to respond in an antigen specific fashion to dietary antigens, which may be central in attaining clinical tolerance of such antigens.