A distinct subgroup of cardiomyopathy patients characterized by transcriptionally active cardiotropic erythrovirus and altered cardiac gene expression.

Recent studies have detected erythrovirus genomes in the hearts of cardiomyopathy and cardiac transplant patients. Assessment of the functional status of viruses may provide clinically important information beyond detection of the viral genomes. Here, we report transcriptional activation of cardiotropic erythrovirus to be associated with strongly altered myocardial gene expression in a distinct subgroup of cardiomyopathy patients. Endomyocardial biopsies (EMBs) from 415 consecutive cardiac erythrovirus (B19V)-positive patients with clinically suspected cardiomyopathy were screened for virus-encoded VP1/VP2 mRNA indicating transcriptional activation of the virus, and correlated with cardiac host gene expression patterns in transcriptionally active versus latent infections, and in virus-free control hearts. Transcriptional activity was detected in baseline biopsies of only 66/415 patients (15.9 %) harbouring erythrovirus. At the molecular level, significant differences between cardiac B19V-positive patients with transcriptionally active versus latent virus were revealed by expression profiling of EMBs. Importantly, latent B19V infection was indistinguishable from controls. Genes involved encode proteins of antiviral immune response, B19V receptor complex, and mitochondrial energy metabolism. Thus, functional mapping of erythrovirus allows definition of a subgroup of B19V-infected cardiomyopathy patients characterized by virus-encoded VP1/VP2 transcripts and anomalous host myocardial transcriptomes. Cardiac B19V reactivation from latency, as reported here for the first time, is a key factor required for erythrovirus to induce altered cardiac gene expression in a subgroup of cardiomyopathy patients. Virus genome detection is insufficient to assess pathogenic potential, but additional transcriptional mapping should be incorporated into future pathogenetic and therapeutic studies both in cardiology and transplantation medicine.

Prevalence of erythrovirus genotypes in the myocardium of patients with dilated cardiomyopathy.

Parvovirus B19 (PVB19) is a member of the human erythrovirus family detected frequently in endomyocardial biopsies from patients with dilated cardiomyopathy. Human erythroviruses cluster into three genotypes 1-3 which share a high degree of homology between major structural proteins and may cause indistinguishable infections clinically and serologically. In human cardiac tissue erythrovirus genotypes other than PVB19 have not yet been reported. Three hundred seventeen consecutive patients with symptomatic dilated cardiomyopathy (median left ventricular ejection fraction: 28.6%, range 5-45%) who underwent endomyocardial biopsy for the elucidation of the etiology, were analyzed using a new consensus PCR assay designed for the detection of the three erythrovirus genotype sequences. Endomyocardial biopsies of 151 (47.6%) patients were erythrovirus-positive. Genotype 1 specific sequences were detected in 43/151 (28.5%) of positive biopsy samples, whereas genotype 2-specific sequences so far considered rare in human disease and not yet been described in human heart tissue was identified in 108/151 (71.5%) of virus-positive endomyocardial biopsies with a preference in patients above 50 years of age. In spite of younger age, systolic left ventricular dysfunction of genotype 1-positive patients was significantly reduced as compared to genotype 2-positive patients (24.4+/-10.4% vs. 31.0+/-9.5%, P=0.0001) at the initial presentation. The data show that two genetically distinct erythrovirus variants with a different age distribution are detectable in endomyocardial biopsies of patients with dilated cardiomyopathy. The erythrovirus genotype 2, not described previously in human heart tissue, is highly prevalent in the heart but the less prevalent genotype 1 is associated with more severe disturbed cardiac function.

Expression of cell adhesion molecules in dilated cardiomyopathy: evidence for endothelial activation in inflammatory cardiomyopathy.

BACKGROUND: Dilated cardiomyopathy (DCM) is pathogenically linked to inflammatory cardiomyopathy (InfCM), which is characterized by intramyocardial infiltration. The transendothelial migration of immunocompetent cells is mediated by cell adhesion molecules (CAMs). METHODS AND RESULTS: We investigated the expression pattern of CAMs (immunoglobulin superfamily, 32 selectins, and beta1- and beta2-integrins) in endomyocardial biopsies from DCM patients (n=152; left ventricular ejection fraction <40%) using immunohistochemistry. Whereas few specimens obtained at autopsy (controls; n=14) presented enhanced expression regarding single endothelial CAMs (human leukocyte antigen [HLA] class I, 7%; HLA-DR, 14%; CD29, 14%), none demonstrated concurrent abundance of >3 CAMs (inflammatory endothelial activation), nor did any control tissue prove positive for InfCM (>7.0 CD3+ lymphocytes per 1 mm2). In comparison, 64% (n=97) of the DCM biopsies were evaluated positive for InfCM and 67% (n=101) for inflammatory endothelial activation, respectively. Whereas expression of HLA class I, HLA-DR, intercellular cell adhesion molecule-1, and CD29 was distributed homogeneously within a patient's serial sections, immunoreactivity of vascular cell adhesion molecule-1, lymphocyte function antigen-3, and the selectins was accentuated on single vascular endothelia. Sixty-six percent of the DCM biopsies presented CD29 abundance also within the extracellular matrix and the sarcolemma. CD62P and CD62E were present in 16% and 40% of the DCM patients, respectively. Endothelial CAM representatives correlated with one another (P<0.05), except for CD62P with HLA. Endothelial CAM expression correlated with intramyocardial infiltrates phenotyped by the corresponding counterreceptors. CONCLUSIONS: Inflammatory endothelial activation is present in 67% of DCM patients. Because CAM expression correlates with the immunohistological diagnosis of InfCM and counterreceptor-bearing intramyocardial infiltrates, evaluation of endothelial CAMs might be of diagnostic significance in InfCM.

Immunohistological evidence for a chronic intramyocardial inflammatory process in dilated cardiomyopathy.

OBJECTIVE: To determine whether immunohistochemical analysis of cardiac biopsies from patients presenting clinically as dilated cardiomyopathy (DCM) show a chronic inflammatory process. DESIGN: Comparative case control study. SETTING: Tertiary referral centre. PATIENTS: Biopsies from 170 patients with DCM and 85 control patients with other cardiac diseases. RESULTS: Nine patients had sufficient interstitial inflammatory cells to be called borderline myocarditis on conventional histology, leaving 161 patients with DCM. In 78 patients with DCM (48%) there were T lymphocytes in the myocardium. In 48 (62%) of these 78 T lymphocyte densities were in the range 2-14 per high power field (HPF), equivalent to 7-50 per mm2 of tissue. In 43 (89%) interstitial and endothelial immune activation was demonstrated by MHC expression. In 30 patients with T cell counts in the range 1.5-2.0 per HPF, 80% also showed endothelial activation. Lymphocyte density correlated with increased expression of MHC class I and II antigens and the adhesion molecules ICAM, VCAM, ELAM, LFA-3, and GMP140. In all control biopsies the T lymphocyte density was less than 1.0 per HPF (less than 2-5 per mm2 of tissue). CONCLUSIONS: Nearly half the patients with DCM had increased T lymphocyte density and immune activation of endothelial and interstitial cells in their cardiac biopsies. A chronic autoimmune process is still active within the myocardium in a significant percentage of patients with DCM. Immunohistochemical analysis of cardiac biopsies will enhance the sensitivity of cardiac biopsy and is essential for the diagnosis of myocarditis.

[Male subfertility and conventional in vitro fertilization in Germany 1990 to 1993]. / Männliche Subfertilität und konventionelle In-vitro-Fertilisation in Deutschland 1990 bis 1993.

A retrospective study was carried out to compare the results of in vitro fertilisation (IVF) in 20936 patients with different sperm parameters who underwent IVF in Germany between 1990 and 1993. The study was designed to evaluate prognostic factors for IVF outcome, such as sperm parameters and pre-treatment diagnosis. The percentage of subfertile sperm parameters ( < 10 millions sperm per ml and/or < 30% progressive mobility and/or < 30% normal morphology) increased from 31.4% in 1990 to 51.1% in 1993. The fertilisation rate per puncture varied between 87.9% in patients with normozoospermia and 38.7% in patients with severe oligo-astheno-teratozoospermia (OAT). The fertilisation rate in patients with tubal indication was significantly higher than in patients with male indication and comparable spermatozoa. The pregnancy rate per embryo transfer was 23% in patients with normozoospermia and 13.8% in patients with "severe OAT syndrome" in the IVF semen parameters. On the other hand, patients with male sterility as pre-treatment diagnosis showed significantly higher chances of pregnancy than patients with a tubal factor (24% versus 20%, p < 0.05). Comparing percoll and swim-up preparation techniques, we found significantly higher fertilisation rates in normozoospermia and significantly higher pregnancy rates in subfertile patients after percoll sperm preparation. The results of the study demonstrated that patients with moderate subfertile sperm parameters have good chances of fertilisation and pregnancy following conventional IVE. It seems reasonable to set the boundary at a sperm count of 10 millions sperm/ml with 30% progressive motility and 30% normal morphology. Below these limits intracytoplasmic sperm injection shows better IVF outcome.

Chronic inflammation in the myocardium of patients with clinically suspected dilated cardiomyopathy.

Dilated cardiomyopathy continues to be an etiologically unknown heart muscle disease. Recent clinical and experimental data have suggested a causal relation to viral myocarditis. The clinical diagnosis, however, is unspecific, and diagnostic yield of the histologic evaluation of endomyocardial biopsies by light microscopy according to the Dallas classification is poor. The authors analyzed the biopsy specimens of 120 patients with suspected dilated cardiomyopathy by immunohistologic methods to obtain a more sensitive and specific identification and quantification of infiltrating lymphocytes, indicating an activated immunologic process within the myocardium. Increased lymphocytic infiltrates and inflammatory endothelial activation were demonstrated in patients with clinically suspected dilated cardiomyopathy. These findings are associated with the often seen progression of ventricular dysfunction. Further studies are necessary to prove whether these immunohistologically positive patients will improve under immunosuppressive therapy.

Immunohistological characterization of infiltrating lymphocytes in biopsies of patients with clinically suspected dilated cardiomyopathy.

Experimental and clinical data suggest a relationship between myocarditis and dilated cardiomyopathy. One postulated mechanism is a viral infection triggering a host response with autoimmune features directed against the heart, resulting in an initial myocarditis which is followed by dilated cardiomyopathy. Until now, the importance of myocarditis as an aetiological factor in the pathogenesis of isiopathic cardiomyopathy has been unknown. This investigation was undertaken to determine immunohistologically the frequency of lymphocytic infiltrations in endomyocardial biopsies of patients with clinically suspected dilated cardiomyopathy. T-lymphocytic subsets and other immunological features were also analysed to explore possible relationships between immunohistologically documented myocarditis and dilated cardiomyopathy.

[Dilated cardiomyopathy--a chronic myocarditis? Immunohistological characterization of lymphocytic infiltrates]. / Dilatative Kardiomyopathie--eine chronische Myokarditis? Immunohistologische Charakterisierung lymphozytärer Infiltrate.

Experimental and clinical data suggest a relationship between myocarditis and dilated cardiomyopathy. One postulated pathomechanism is a viral infection triggering a host response with autoimmune features directed against the heart, resulting in an initial myocarditis which is followed by a dilated cardiomyopathy. Until now, the importance of an undetected myocarditis as an etiological factor in the pathogenesis of idiopathic cardiomyopathy is unknown. This investigation was undertaken to determine the frequency of lymphocytic infiltrations in endomyocardial biopsies of patients with dilated cardiomyopathy by immunohistological methods and to analyze T lymphocytic subsets and other immunological features in order to search for possible relationships between immunohistological-documented myocarditis and dilated cardiomyopathy. In our study, 48 of 130 biopsies (37%) from patients with clinically proven dilated cardiomyopathy contained lymphocytic infiltrates when stained by the immunoperoxidase method with lymphocyte surface markers (Table 1). 23% (n = 30) of these biopsies contained more than 2.0 (range: 2.0 to 13.8) T lymphocytes per high power light microscopy field (x 400), in 14% (n = 18) 1.5 to 2.0 cells/HPH were seen (Table 2). 82 biopsies (63%) with less than 0.8 cells/HPF were regarded as negative (dilated cardiomyopathy). By histological analysis, only seven cases (5%) were classified as borderline myocarditis by conventional histological evaluation according to the Dallas classification. In the other patients, our results were consistent with the clinical diagnosis of dilated cardiomyopathy (Table 1). 71% of biopsies with lymphocytic infiltrates contained activated T cells when analysed with activation markers in serial sections (Table 2). Activated macrophages were seen in 52% of biopsies with T cell infiltrations, but only in 31% of tissues containing normal numbers of lymphocytes (Table 2). In biopsy specimens with lymphocytic infiltrates HLA-class I and II antigen expression was increased. An enhanced HLA-DR antigen staining was seen in 80% on interstitial cells and vascular endothelium while HLA class I was found at an increased level in 67% (Table 3). In negative biopsies, an enhanced class I staining was seen in only 14%, class II in 30%. Because of the specific identification of lymphocytes by immunocytochemical methods, lymphocytic infiltrates are easily detected, even if the infiltrate is sparse or focal (Figure 1). The considerable interobserver variability in the quantitation of lymphocyte counts, which is a main problem in hematoxylin and eosin stained sections is negligible when lymphocyte quantitation is performed by immunoperoxidase staining. Thus, our data indicate that in about 37% of patients with clinical suspected idiopathic cardiomyopathy an ongoing or reactivated myocarditic process is involved.(ABSTRACT TRUNCATED AT 400 WORDS)