Apoptosis of keratinocytes and serum DNase I activity in patients with cutaneous lupus erythematosus: relationship with clinical and immunoserological parameters.

BACKGROUND: Dysregulation of apoptosis has an important role in the induction of autoimmunity. OBJECTIVE: To evaluate the influence of keratinocyte apoptosis and deoxyribonuclease I (DNase I) activity on the clinical and immunoserological parameters of cutaneous lupus erythematosus (CLE). METHODS: We studied 69 CLE patients (39 with discoid LE (DLE), 12 with subacute CLE (SCLE), 12 with acute and 6 with intermittent CLE). Thirty of sixty-nine patients fulfilled criteria for systemic LE (SLE). Apoptotic index (AI) was evaluated immunohistochemically in lesional and non-lesional, photoprotected skin. Serum DNase I activity, antichromatin and anti-ENA antibodies were measured by ELISA. Disease activity was determined by SLEDAI-2K, SLICC/ACR, CLASI and RCLASI. RESULTS: AI in lesions was higher than in non-lesional skin (P < 0.001). There was no difference in AI between CLE and SLE patients. Patients with SCLE had higher lesional AI than patients with DLE (P < 0.05). We found a positive correlation between the lesional AI with CLASI A (P < 0.05) and RCLASI D (P < 0.05). CLE and SLE patients had significantly lower DNase I activity than healthy controls (P < 0.001). Patients with normal DNase I activity and low AI had significantly lower CLASI A than patients with decreased DNase I activity and/or elevated AI (P < 0.05). CONCLUSIONS: Increased keratinocyte apoptosis characterizes lesions of all CLE forms, especially of SCLE. AI correlates with CLE markers of acute and chronic inflammation. Normal level of apoptosis and DNase I activity simultaneously reduce the level of acute inflammation in CLE. Serum DNase I activity and AI might be important biomarkers in the evaluation of CLE patients.

Progressive multifocal leukoencephalopathy associated with mycophenolate mofetil treatment in a woman with lupus and CD4+ T-lymphocyte deficiency.

There is an increase in the number of patients with systemic lupus erythematosus (SLE) reported as developing progressive multifocal leukoencephalopathy (PML) while on intensive immunosuppressive therapy. A 39-year-old HIV-negative woman with a 10-year history of SLE presented with progressive left-side weakness while on maintenance therapy with oral prednisone and mycophenolate mofetil (MMF). On several occasions low CD4+ T-lymphocyte counts were found (68/µL). Brain magnetic resonance imaging (MRI) revealed a large lesion in the right subcortical fronto-parietal region and a smaller one in the left frontal subcortex, corresponding to the PML. In cerebrospinal fluid, polymerase chain reaction (PCR) for JC virus (JCV) was negative, but anti-JCV antibodies were highly positive. Diagnosis of probable PML was made and MMF was withdrawn. The patient's condition improved with marked reduction of left-side weakness and an increase in CD4(+) T-lymphocyte count (141/µL). Follow-up MRI showed regression of lesions and over the next 6 months the patient remained stable. In spite of the grave prognosis associated with PML, SLE patients can have an excellent outcome if immunosuppressants are discontinued as soon as the correct diagnosis is made. SLE patients with associated low CD4(+) T-lymphocyte counts should be monitored for the development of PML during immunosuppressive therapy in particular.

Anti-double stranded DNA and lupus syndrome induced by interferon-beta therapy in a patient with multiple sclerosis.

We present a 43-year-old woman with relapsing-remitting multiple sclerosis (MS) who developed lupus syndrome after 32 months of IFN-beta-1a therapy. She presented with malaise, myalgia, arthralgia and fever. Laboratory tests showed high erythrocyte sedimentation rate, anaemia and lymphopenia. Antibodies to double stranded DNA (dsDNA) of IgG, IgM and IgA classes were detected on Critidia luciliae. Additionally, high levels of anti-nucleosomal antibodies, low levels of anti-histone and anti-Ro/SSA antibodies were also found. Diagnosis of drug-induced SLE was established. Treatment with IFN-beta was discontinued and oral prednisone was started. Twelve weeks after cessation of IFN-beta therapy, the patient's symptoms completely resolved and autoantibodies disappeared. To the best of our knowledge, this is the first report of a patient with MS in whom treatment with IFN-beta induced lupus syndrome and antibodies to dsDNA and nucleosome.

Antiribosomal-P protein antibodies in a patient with systemic lupus erythematosus and non-Hodgkin's lymphoma: more than coincidental finding?

Patients with systemic lupus erythematosus (SLE) are at an increased risk of lymphomas, but mechanisms underlying this association are obscure. Recently, it has been shown that antiribosomal-P protein (anti-P) antibodies cross-react with phospholipids and enhance the production of cytokines which may influence lymphomagenesis. We report a 46-year-old woman who suffered high grade diffuse large B-cell non-Hodgkin's lymphoma (DLBCL) 28 months after the diagnosis of SLE. Development of lymphoma was associated with occurrence of serum monoclonal IgM, and pronounced prolongation of phospholipid-dependent clotting tests. Anti-P IgG antibodies were highly positive both on HEp-2 cells and in ELISA test. Anticardiolipin, anti-beta2 glycoprotein I, and antiprothrombin IgM antibodies have also been found in high concentrations. Complete remission of DLBCL and SLE, with normalisation of clotting tests, and disappearance of M component was achieved with administration of rituximab, cyclophosphamide, doxorubicin, vincristine and prednisone. The progression of SLE to DLBCL associated with presence of anti-P antibodies has not been previously reported. This association may not be coincidental, but further investigations are required to confirm this hypothesis.

Clinical and serological follow-up of 71 patients with anti-mitochondrial type 5 antibodies.

Antimitochondrial M5 type antibodies (AMA M5) have been described in patients with antiphospholipid syndrome (APS), thrombocytopenia and autoimmune hemolytic anemia. The aim of this study was to describe the clinical and immunological characteristics of a series of patients with AMA M5. We analyzed 71 patients with AMA M5 seen consecutively at our centres during the last 8 years. The clinical and immunological characteristics of diseases expression were compared with 70 consecutive disease control patients without AMA M5. Compared with the control group, AMA M5 positive patients presented higher prevalence of false positive VDRL test (P < 0.001) and thrombocytopenia (P = 0.002) with lower levels of anti-beta2 glycoprotein I antibodies. In AMA M5 patients (56 female, 15 male) a heterogeneous group of disorders were found. Twenty-seven (38%) patients fulfilled the Sapporo criteria for the classification of the APS. Laboratory criteria were met in 55 (77.5%), and clinical criteria in 31 (43.7%) patients. Six patients initially presented with non-criteria features of APS during follow-up period developed APS. Younger patients with AMA M5 should be carefully observed for the development of APS, even in the absence of serological criteria, while elderly must be screened for monoclonal gammopathy and hematological disorders.

Serum lipids and anti-oxidized LDL antibodies in primary antiphospholipid syndrome.

OBJECTIVE: The link between specific antibodies and atherogenesis in primary antiphospholipid syndrome (PAPS) is less strong than for thrombosis, although clearly the two processes are related and thrombosis is the main complication of atherosclerosis, a process known as atherothrombosis. The aim of this study was to investigate the influence of serum lipid levels and anti-oxidized LDL (oxLDL) antibodies on the clinical features of 42 patients with PAPS (mean age 40.45+/-13.37; 32 women and 10 men), and to compare them with 47 control subjects (mean age 39.68+/-13.93; 33 women and 14 men). METHODS: Total cholesterol, HDL and triglyceride concentrations were determined by enzymatic methods. LDL was calculated according to the Friedwald formula. Anticardiolipin, anti-oxidized LDL and anti-Beta2glycoprotein I antibodies were detected by ELISA. RESULTS: A significant association was found between arterial events and triglyceride, LDL and cholesterol concentrations, but multivariate analysis showed that cholesterol concentrations were the most important predictor of arterial events (p=0.012). Cerebrovascular insults were the most significantly associated with cholesterol concentrations (p=0.011). Myocardial infarctions were more frequently present in patients more than 40 years of age (p=0.032). No significant association of the investigated parameters with venous thromboses was found. Recurrent abortions were not associated with the presence or concentrations of the investigated parameters. Although patients had increased concentrations of anti-oxLDL antibodies, no significant association was found between the titres of anti-oxLDL antibodies and clinical features of APS. CONCLUSION: In patients with PAPS, lipid concentrations are a better predictor for arterial events than anti-oxLDL antibodies.

Heart and renal failure in renovascular hypertension caused by giant cell arteritis--case report.

We report a case of a male teenager with severe heart and acute renal failure as the dominant clinical manifestations of renovascular hypertension (RVH) caused by atypical giant cell arteritis (GCA). Unrecognized RVH and treatment of the consequent heart failure by angiotensin-converting enzyme inhibitors (ACEI) probably contributed to progression of renovascular disease to bilateral renal artery occlusion. Recurrent "flash" pulmonary edemas could not be prevented until surgical revascularization of the only functioning right kidney was achieved by an aortorenal bypass. Prompt post-operative normalization of heart function and arterial hypertension occurred despite the histopathological finding of the resected renal artery compatible with GCA and 4-year duration of significant renovascular disease. At the last check-up, the patient was asymptomatic, with normal arterial pressure on the prescribed treatment: carvedilol, hydrochlorothiazide, prednisolone 20 mg daily and aspirin. Subsequent follow-up is necessary to observe the evolution of GCA as an exceptionally rare cause of RVH.

Rothmund-Thomson syndrome. The first case with plantar keratoderma and the second with coeliac disease.

We report two unusual patients with Rothmund-Thomson syndrome (RTS), a rare genodermatosis. The first patient is a 5-year-old girl with congenital poikiloderma, photosensitivity, plantar punctate keratoderma, stunted growth and severe mental retardation. Plantar keratoderma associated with RTS has been reported only once. The second patient is a 21-year-old female presenting with rounded "moon" face, trunk obesity, coeliac disease, short stature and mild mental retardation. This is the first case of RTS associated with coeliac disease.

Purpura and leg ulcers in a patient with cryoglobulinaemia, non-Hodgkin's lymphoma, and antiphospholipid syndrome.

We report a 69-year-old Caucasian female with non-Hodgkin's lymphoma who subsequently developed leg ulcers as a manifestation of the antiphospholipid syndrome. Investigations revealed a mixed cryoglobulinaemia with monoclonal IgM-kappa and antiphospholipid activity with anticardiolipin antibodies, antimitochondrial type M5 antibodies and lupus anticoagulant. Significantly increased concentration of anticardiolipin antibodies was detected in the cryoprecipitate. Our case illustrates a connection between cryoglobulinaemia and lymphoproliferative and autoimmune disorders. Both cryoglobulins and anticardiolipin antibodies could participate in the vascular damage. Cutaneous manifestations in the presence of these disorders associated with non-Hodgkin's lymphoma have not been described previously.

Speckled antinuclear antibodies in keratinocytes--what does it mean?

OBJECTIVE: Epidermal in vivo nuclear staining is occasionally noted in the lupus band test (LBT) in patients with connective tissue diseases (CTD). The exact clinical significance of this finding remains unelucidated, especially in association with a positive LBT We have reviewed the clinical and serological characteristics of patients with in vivo-bound antinuclear antibodies (ANA) in keratinocytes. METHODS: Between 1990-1999 speckled IgG staining in keratinocyte nuclei was observed in 31 LBT specimens. We had detailed clinical and laboratory data for 22/31 patients. The present study comprises 22 patients with in vivo-bound ANA (8 cases with mixed CTD (MCTD), 10 with systemic lupus erythematosus (SLE), 2 with Sjögren's syndrome (SS), one with undefined CTD and one clinically healthy mother of a child with neonatal lupus erythematosus), and 22 consecutive CTD patients (2 MCTD, 15 SLE, 5 SS) without in vivo-bound ANA. Antinuclear, anti-dsDNA and anti-extractable nuclear antigens (ENA) antibodies were determined using indirect immunofluorescence and ELISA methods. RESULTS: A significant difference (p < 0.01) in anti-RNP antibodies between patients with and without in vivo-bound ANA was observed. Consequently, there was a strong association of in vivo-bound ANA and anti-RNP antibodies (p < 0.01). In SLE patients with in vivo-bound ANA the incidence of nephropathy was significantly lower (p < 0.01), regardless of LBT positivity. In SLE patients there were no differences in LBT positivity, anti-dsDNA antibodies and complement consumption between groups. CONCLUSION: Our study implies that the presence of speckled ANA in keratinocytes in LBT may be useful in the diagnosis of MCTD and in the prognosis of renal involvement, especially in SLE patients.

[Laboratory diagnosis of allergic inflammation]. / Laboratorijska dijagnostika alergijske inflamacije.

Monitoring of allergic inflammation includes direct examination of biopsy specimens from mucosa and epithelium, and indirect study by sputum, bronchoalveolar and nasal lavage fluid and peripheral blood. Although, some of these detection assays are not applicable to clinical use, it is now possible to measure a number of inflammatory mediators released from cells participating in allergic disease. The release of performed histamine from peripheral blood basophils challenged with specific antigen remains a valuable in vitro correlate of immediate hypersensitivity reactions. However, other mediators such as LTC4 and IL-4 are also generated by basophils upon IgE dependent activation. Tryptase and PGD2 are released from mast cells upon activation. Eosinophils contain in their granules proteins that cause damage to the bronchial epithelium: MBP and ECP. It is possible to measure soluble markers from other cells (T cells, macrophages, platelets, endothelial cells) involved in allergic inflammation. Detection of mediators have produced data that have significantly added to our understanding of the mechanisms and allowed better pharmacological control of allergic inflammation.