An autosomal screen for genes that predispose to celiac disease in the western counties of Ireland.

Celiac disease is a strongly heritable gastrointestinal illness that is an especially important model of the genetically complex multifactorial immune mediated diseases. The HLA component of celiac disease (a specific HLA-DQ heterodimer)is largely established and is relatively uncomplicated, and the environmental component (gluten and related grain storage proteins in the diet) is remarkably well understood. Previous family studies of celiac disease suggested that there is at least one important non-HLA locus. This locus may be a stronger genetic factor than HLA, and it apparently has a recessive mode of inheritance. We used a three step genome screening protocol to identify loci that contribute to celiac disease in the western counties of ireland, a region with the highest prevalence of celiac disease in the world. The most significant of several possible non-HLA loci that we found was on chromosome 6p about 30 cM telomeric from HLA. It has a multipoint maximum lod score of 4.66 (compared with 4.44 for HLA-DQ) and appears to have a recessive mode of inheritance. Our study localizes and provides strong evidence for linkage of at least one non-HLA locus to celiac disease and may serve as a prototype for an efficient approach to screening the human genome for loci that contribute to complex diseases.

Lymphocyte abnormality associated with HLA-B8 in healthy young adults.

We have reported that abnormal lymphocyte function in Sjogren's syndrome occurs almost exclusively in patients with HLA-B8. We now report that most clinically normal individuals with this antigen have a similar impairment of cellular immunity. This finding suggests that the lymphocyte abnormality in Sjogren's syndrome is not secondary to the disease process or medication and might have primary etiological significance. The lymphocyte abnormality is expressed as a decreased proliferative response to suboptimally stimulating concentrations of phytohemagglutinin (PHA) and concanavalin A (Con A). In contrast, the response to optimally stimulating concentrations of PHA and Con A is unaffected. The imparied mitogen responsiveness appears to be intrinsic to the T lymphocytes, as it can be demonstrated in purified T cell preparations.

Elevated salivary and synovial fluid beta2-microglobulin in Sjogren's syndrome and rheumatoid arthritis.

Beta2-Microglobulin is normally present in low concentrations in serum and other bodily fluids. By use of a radioimmunoassay, elevated concentrations of beta2--microglobulin were found in saliva and synovial fluid from patients with Sjogren's syndrome and rheumatoid arthritis, autoimmune inflammatory diseases that attack and destroy the salivary glands and articular tissues, respectively. Elevated beta2-microglobulin concentrations decreased in the saliva of two patients who simultaneously showed a clinical response to systemic treatment. Measurement of beta2-microglobulin in inflammatory fluids may offer a simple method of quantifying local activity in autoimmune states.

A modified double antibody sandwich enzyme-linked immunosorbent assay for measurement of alpha-1-antitrypsin in biologic fluids.

Alpha-1-antitrypsin (alpha 1AT) is the major protease inhibitor in human serum, and plays an important role protecting tissues from potentially harmful enzymes released during inflammatory reactions. Proteolytic enzymes such as leukocyte elastase are usually released and inactivated locally at the site of inflammation, so there has been much recent interest in measuring local alpha 1AT concentrations in biologic fluids. In this study, we developed a modified double antibody sandwich enzyme-linked immunosorbent assay (ELISA) and used it to measure alpha 1AT concentrations in several biologic fluids. The assay was sensitive to as little as 20 ng/ml of alpha 1AT. Serum concentrations measured by the ELISA correlated well with levels determined by radial immunodiffusion (RID) and the ELISA was far more sensitive than RID. In synovial fluid, higher concentrations determined by the ELISA compared with RID probably reflect interference of diffusion of alpha 1AT in the RID gel by hyaluronic acid and protease-inhibitor complexes. Synovial fluid did not interfere with the detection of added alpha 1AT by ELISA, but it did reduce the amount detected by RID by about 30% in 2 fluids. In saliva, alpha 1AT concentrations of less than 1 microgram/ml were easily quantified. Bronchoalveolar lavage fluids have been extensively studied because of the important role of alpha 1AT in pulmonary inflammatory processes. We found concentrations of 1-3 micrograms/ml in most samples with our assay. These levels were comparable to those previously reported with assays that required up to 50-fold concentration of the fluid. Neither saliva nor bronchoalveolar fluid significantly interfered with detection by ELISA of added alpha 1AT. This modified double antibody sandwich ELISA may have broad applications for studies of the role of alpha 1AT in health and disease.

Reversible melphalan-induced lung damage.

Pulmonary toxicity occurs after the administration of several different chemotherapeutic agents. Pulmonary toxicity due to melphalan alone has not been documented. In the patient we describe respiratory symptoms and pulmonary infiltrates developed twice within two weeks of the second course of a monthly melphalan and prednisone regimen. Open lung biopsy revealed interstitial pneumonitis. The infiltrates cleared on both occasions when melphalan was withheld. Special studies performed seven weeks after the last dose of melphalan had been given revealed that the patient's alveolar macrophages suppressed phytohemagglutinin induced blastogenesis of his peripheral lymphocytes. Melphalan itself did not stimulate the blastogenesis of the peripheral lymphocytes. Melphalan should be added to the list of therapeutic agents that induce pulmonary disease. However, the pathogenesis of the disease remains to be elucidated.

Human alveolar macrophages suppress the proliferative response of peripheral blood lymphocytes.

Human alveolar cells were isolated from bronchopulmonary lavage fluids obtained from patients undergoing clinically indicated bronchoscopy. Alveolar cells strongly suppressed the proliferation of peripheral blood lymphocytes in response to mitogens and antigens. Separation of the alveolar cells into adherent and nonadherent fractions indicated that the suppression was mediated by the adherent cells, or alveolar macrophages. Indomethacin at least partially relieved suppression, suggesting the involvement of prostaglandin synthesis. The suppression could be duplicated by supernatants obtained from unstimulated cultures of alveolar cells. Some specificity of suppression was apparent, in that not all proliferating cells were suppressed. T lymphocytes may be more readily suppressed than B lymphocytes, and the most susceptible cells may be a subpopulation of T lymphocytes.

Ultraviolet-A light in the treatment of rheumatoid arthritis.

Ultraviolet-A (UV-A) light penetrates the epidermis, reaches the macrophages and circulating mononuclear cells within the dermis, and has immunoregulatory effects in humans. We examined the effect of UV-A irradiation on disease activity in 26 patients with rheumatoid arthritis (RA) and on immunologic function in these patients and in 11 normal subjects. Ten joules/cm2/day of total body UV-A irradiation, given 5 days each week for 3 weeks, resulted in significant improvement in the duration of morning stiffness, fatigue, joint tenderness, joint swelling, grip strength, patient assessment of disease activity, and physician assessment of disease activity. Platelet counts decreased significantly in the RA patients. Phytohemagglutinin (PHA)-stimulated lymphocyte production of interleukin-2 (IL-2) increased significantly in the combined RA and normal groups. These results suggest that UV-A light may be effective in the treatment of patients with RA, but elucidation of its precise role will require further study including double-blind trials.

Celiac disease: clinical features and pathogenesis.

Celiac disease is a fascinating illness, from both a clinical and research perspective. Most clinicians consider a diagnosis of celiac disease when a young patient has classic signs and symptoms of steatorrhea and severe malabsorption. However, the typical gastrointestinal symptoms often are absent. The patient may only have subtle signs of chronic malnutrition or nonspecific gastrointestinal complaints. Celiac disease is not diagnosed commonly in the United States, at least in part because of a low clinical index of suspicion. A diagnosis of celiac disease is confirmed by a small bowel mucosa biopsy. A dramatic clinical response to a gluten-free diet verifies the diagnosis, and provides a cost-effective treatment free of significant side effects. Strict adherence to the prescribed diet usually results in a complete resolution of the symptoms and mucosal histopathologic changes. The serious, long-term complication of intestinal lymphoma also may be prevented. To the clinical investigator, celiac disease is an important model of the HLA-associated immune-mediated illnesses. A specific HLA-DQ heterodimer is found in 95% of patients, representing perhaps the strongest association of any illness with a specific class II HLA molecule. In addition, an important environmental trigger (gluten) has been identified, providing a unique opportunity to study the interaction of gene products and environmental factors in the pathogenesis of an immune-mediated disease.

T cell receptor gamma gene polymorphisms and class II human lymphocyte antigen genotypes in patients with celiac disease from the west of Ireland.

Although celiac disease has one of the strongest human lymphocyte antigen (HLA) class II associations of any human illness, it is clear that at least one gene that is not linked to the HLA region also is required for its pathogenesis. The occurrence of large numbers of gamma delta T cells in the bowel mucosa of patients and the recent description of T cell receptor (TCR) gamma chain polymorphic variants identified by restriction fragment length polymorphism analysis led the authors to examine TCR gamma genotypes in relation to HLA-DR, DQ genotypes in 89 patients with celiac disease and 55 control subjects from the West of Ireland. The overall frequency of TCR gamma genotypes in patients and control subjects was comparable. However, most of the patients had 1 of 3 HLA-DR3 genotypes (DR3/15, 3/7, or 3/3), and there was a significant alteration of the expected frequency of TCR gamma genotypes among patients with these three genotypes. The major differences were an increased association of HLA-DR3 homozygosity, with TCR gamma genotypes having a 16.0 kb fragment and an increased frequency of DR3/7 heterozygosity and decreased frequency of DR3/15 heterozygosity, respectively, in association with the TCR gamma 13.0/11.3 kb genotype. Based on their results, there is the possibility that an interaction between the products of two polymorphic and unlinked gene regions contributes to the pathogenesis of celiac disease.

Explantation of silicone breast implants.

Silicone gel-filled breast implants have been employed clinically for decades for aesthetic augmentation or postmastectomy reconstruction. Most patients and surgeons attest to the efficacy and safety of these devices. However, more recently in the medical literature and popular media, silicone gel-filled breast implants have been claimed to incite an array of clinical sequelae such as capsular formation, granulomatous disease, arthritis, arthralgia, fibromyalgia, autoimmune collagen vascular disease, human adjuvant disease, siliconosis, silicone-related disease, and silicone implant-associated syndrome. During a recent 24-month period, 25 referred patients underwent explantation of bilateral silicone gel-filled prostheses at the University of South Alabama. Patient-reported symptoms and signs included mastodynia, arthralgia, fibromyalgia, xerophthalmia, xerostomia, hypesthesia, and amblyopia. Clinical examination and mammography were reliable in diagnosing implant rupture, but only re-exploration reliably detected implant leakage. Most patients underwent concurrent replacement with saline-filled devices. Histopathologic analyses of all tissue samples revealed chronic inflammation. Subjective improvement of patient-reported symptoms and signs occurred over the course of months postoperatively. There was no mortality associated with explantation, with or without replacement, but an overall morbidity incidence of 20 per cent (5 of 25) was observed. Predicated upon review of the available scientific literature and analysis of this modest number of patients, the following perspectives are germane. 1) A small cohort of patients of status postimplantation of silicone gel-filled devices will manifest chronic morbidity. Identifying such patients prospectively remains problematic. 2) Whether or not silicone gel incites adverse systemic phenomena is unproven, although it has been implicated. 3) Symptomatic patients with silicone gel-filled implants in place should be considered for removal, with full knowledge of the morbidity associated with revisional procedures. 4) Patients currently undergoing breast augmentation or reconstruction employing prosthetics are perhaps best served by insertion of saline-filled devices. 5) Patient-physician dialogue regarding the risk-benefit analysis of prosthetic implantation is imperative. Patients consenting to such procedures must be willing to assume risks.

Systemic lupus erythematosus and dementia.

Comparison of Trail-making Parts A and B and the Shipley Conceptual Quotient of 18 index patients (M age = 29 years) and 18 controls indicated no dementia for the index patients.

Accelerated mixed lymphocyte culture test potentially useful for cadaver organ transplantation.

The mixed lymphocyte culture (MLC) test accurately predicts the strength of rejection of transplanted organs. Ironically, the MLC test can seldom be used in cadaver organ transplantation, where it would be most useful, because the test takes 4 to 6 days to get results. We have developed an accelerated MLC test using precultured cells, which gives interpretable results in 24-48 hr. Precultured cells become responsive to T cell growth factor, reflecting the generation of lymphoblasts during preculture. When 7 consecutive pairs of subjects were compared in the fast and conventional MLC tests, the response at 48 hr in the fast MLC was significantly correlated with the response in the conventional MLC test on days 5 and 6 (P less than 0.01). Precultured cells can be frozen in liquid nitrogen without loss of accelerated responsiveness and significant proliferation is also observed within 24 to 48 hr using frozen cultured cells. Thus, preliminary culture followed by cryopreservation provides the basis for a clinically useful fast MLC test for cadaver organ transplantation.

Surface markers of suppressor cells in the spontaneous immunodeficiency disease of senescent NZB/NZW F1 hybrid mice.

Aged NZB/NZW F1 hybrid (B/W) mice spontaneously develop severe immunodeficiency disease associated with worsening autoimmunity and malignancies of the immune system. The impaired immune response is mediated in part by markedly increased suppressor cell activity in the spleens of these animals. In male B/W mice, the suppressor cell is nonphagocytic, nonadherent to nylon wool columns and highly resistant to treatment with anti-Thy-1 + complement. We report here marked ablation of splenic suppressor activity by anti-Lyt-1.2 + complement and to a much smaller extent by anti-Ly-2.2. The suppressor activity is not affected by anti-IgM + complement. These data suggest that the suppressor cell activity in the spleens of aged male B/W mice are in the T cell line and may result from an underlying disorder of T cell maturation and differentiation.

Decreased lymphocyte reactivity to a suboptimal concentration of phytohemagglutinin in Sjögren's syndrome.

Significantly decreased lymphocyte reactivity to a suboptimal concentration of phytohemagglutinin (PHA) was found in patients with Sjögren's syndrome (SS), whereas the response to an optimal concentration was generally normal. Kinetic studies were performed on control lymphocytes. Only suboptimal PHA concentrations stimulated tritiated thymidine (3H-TdR) incorporation in proportion to the number of potentially reactive lymphocytes. Kinetic studies of SS patients suggested that their low reactivity was attributable to fewer functionally reactive lymphocytes rather than to a decreased rate of proliferation.