The beneficial effect of plasmapheresis in mixed connective tissue disease with coexisting antiphospholipid syndrome.

The authors report a rare case of a female patient with mixed connective tissue disease (MCTD) with coexisting antiphospholipid syndrome (APS). Five years after the diagnosis of MCTD high concentrations of anticardiolipin (anti-CL) and anti-ß2-glycoprotein (anti-ß2GPI) autoantibodies were present in the patient's serum without thrombotic events. Epstein-Barr virus (EBV) reactivation provoked APS, with the clinical manifestations of livedo reticularis, digital gangrene and leg ulcers. Skin biopsy from the necrotic area showed multiple fibrin microthrombi in the superficial vessels. Corticosteroid pulse therapy, and plasma exchange in combination with synchronized cyclophosphamide was administered, which led to improvement of the digital gangrenes, while no new lesions developed. The number of CD27high plasma cells decreased, and the previous high levels of autoantibodies also normalized in the peripheral blood. In the case of MCTD with coexisting APS combination therapy, including plasmapheresis has beneficial effects.

Distinct phenotypes in mixed connective tissue disease: subgroups and survival.

The aim of the present study was to assess the autoantibody profile, dominant clinical symptoms and cluster characteristics of different mixed connective tissue disease (MCTD phenotypes. Two-hundred-and-one patients with MCTD were followed-up longitudinally. Five clinical parameters, Raynaud's phenomenon, pulmonary artery hypertension (PAH), myositis, interstitial lung disease (ILD), erosive arthritis and five auto-antibodies besides anti-U1RNP, antiendothelial cell antibodies (AECA), anti-CCP, anti-cardiolipin (anti-CL), anti-SSA/SSB and IgM rheumatoid factor (RF) were selected for cluster analysis. The mean age of patients was 52.9 ± 12.4 years and the mean follow-up of the disease was 12.5 ± 7.2 years. Patients were classified into three cluster groups. Cluster 1 with 77 patients, cluster 2 with 79 patients and cluster 3 with 45 patients. In cluster 1 the prevalence of PAH (55.8%; p < 0.001), Raynaud's phenomenon (92.2%; p < 0.001) and livedo reticularis (24.6%, p < 0.001) was significantly greater than in cluster 2 and 3. In cluster 2, the incidence of ILD (98.7%; p < 0.001), myositis (77.2%; p < 0.001), and esophageal dysmotility (89.8%; p < 0.001) was significantly greater than that in cluster 1 and 3. In cluster 3, anti-CCP antibodies were present in 31 of 45 patients (68.8%) with erosions. Anti-CCP antibodies were present in 37 of 42 patients (88.0%) with erosions. PAH, angina, venous thrombosis was observed in cluster 1 and pulmonary fibrosis in cluster 2, musculosceletal damage, gastrointestinal symptoms and osteoporotic fractures were most frequent in cluster 3. Cumulative survival assessment indicated cluster 1 patients having the worst prognosis. Cluster analysis is valuable to differentiate among various subsets of MCTD and useful prognostic factor regarding the disease course.

Clinical and immunoserological characteristics of the transition from primary to overlap antiphospholipid syndrome.

Antiphospholipid syndrome (APS) is a distinct clinical entity characterized by arterial and venous thromboembolic events, recurrent fetal loss and the presence of antiphospholipid antibodies in the patients' sera. In primary APS, there is no detectable underlying disease, while overlap APS is associated with clinical syndromes including systemic autoimmune diseases, infections, or malignancies. We carried out a retrospective analysis of serological and clinical manifestations as well as assessed outcome-measures in 165 patients with primary APS. Thrombotic manifestations and possible signs of autoimmune diseases were determined at the time of the diagnosis, followed by the analysis of recurrent thrombotic events and effects of therapy during the follow-up period. Among the 165 patients with primary APS at onset, 105 patients (63%) remained primary APS after a mean 5.2 years of follow-up. In 14% of the patients, subsequently APS became associated with various characteristics of undifferentiated connective tissue disease. Finally 23% of patients evolved into a definitive systemic autoimmune disease during a mean 9.75 years of follow-up. Recurrent thrombotic events were registered in 24% of patients. Our results suggest that primary APS may be considered as a potential early phase of a dynamic transition towards a well-defined systemic autoimmune disease.

Impaired regulatory T-cell homeostasis due to vitamin D deficiency in undifferentiated connective tissue disease.

OBJECTIVE: The aim of this study was to perform a quantitative and functional analysis of natural CD4+CD25(high)Foxp3+ regulatory T cells (nTregs) and CD4+IL-17+ T cells, and to assess the serum levels of proinflammatory cytokines in patients with undifferentiated connective tissue disease (UCTD) before and after 5 weeks of 0.5 µg/day alfacalcidol supplementation. METHODS: Twenty-five patients with UCTD were enrolled in an open-label trial of alfacalcidol. Plasma levels of 25-hydroxyvitamin D [25(OH)D] were assessed by a high-performance liquid chromatography (HPLC) method. Flow cytometry was used for the quantification of nTregs and the IL-17 expression of T-helper (Th)17 cells. The serum concentrations of cytokines interleukin (IL)-12, interferon (IFN)-γ, IL-23, IL-17, IL-6, and IL-10 were measured by an enzyme-linked immunosorbent assay (ELISA). RESULTS: Treatment with alfacalcidol raised 25(OH)D levels from a mean of 23.5 ± 5.6 to 34.5 ± 7.4 ng/mL (p = 0.059; NS). Alfacalcidol treatment decreased both Th1- (IL-12 and IFN-γ) and Th17-related (IL-23, IL-17, IL-6) cytokine levels in UCTD patients, while the soluble IL-10 level increased (IL-12: 156.7 ± 75.2 vs. 87.5 ± 42.1 pg/mL, p < 0.001; IFN-γ: 41.5 ± 12.0 vs. 21.7 ± 9.9 pg/mL, p < 0.001; IL-23: 385.2 ± 82.2 vs. 210.0 ± 69.3 pg/mL, p < 0.001; IL-17: 37.8 ± 9.6 vs. 17.8 ± 4.5 pg/mL, p = 0.009; IL-6: 39.4 ± 11.3 vs. 23.5 ± 6.3 pg/mL, p < 0.001, IL-10: 8.4 ± 3.0 vs. 21.4 ± 9.7 pg/mL, p < 0.001). Alfacalcidol improved the Th17/nTreg imbalance, as it inhibited the IL-17 expression of Th17 cells, and increased the number of nTregs. The alfacalcidol might increase the capacity of nTreg cells to suppress the proliferation of autologous CD4+CD25⁻ cells. CONCLUSION: Our findings support the idea that vitamin D influences the Th17/nTreg imbalance in vitamin D-insufficient patients with UCTD and could be beneficial in the management of the disease.

The complex role of vitamin D in autoimmune diseases.

Vitamin D, besides having well-known control functions of calcium and phosphorus metabolism, bone formation and mineralization, also has a role in the maintenance of immune-homeostasis. The immune-regulatory role of vitamin D affects both the innate and adaptive immune system contributing to the immune-tolerance of self-structures. Impaired vitamin D supply/regulation, amongst other factors, leads to the development of autoimmune processes in animal models of various autoimmune diseases. The administration of vitamin D in these animals leads to improvement of immune-mediated symptoms. Moreover, in human autoimmune diseases, such as multiple sclerosis, or rheumatoid arthritis the pathogenic role of vitamin D has been described. The review aims at describing the complex immune-regulatory role of vitamin D from the cellular level through autoimmune animal models and depicting the known contribution of vitamin D in the pathogenesis of human autoimmune diseases.

Use of three lumen catheter facilitates bowel movement after pancreato-duodenectomy.

BACKGROUND/AIMS: The advantages of jejunal nutrition in postoperative bowel paralysis following pancreato-duodenectomy were analyzed. METHODOLOGY: Patients resected for pancreatic cancer received 25 kcal/kg/day and were followed up for 10 days postoperatively. Nasojejunal tube ensured enteral feeding in 16 patients (Gr. I), 6 patients (Gr. II) were nourished parenterally. Laboratory parameters, outcome were compared. Bowel movements were registered. Patients of Gr.1 received 25 kcal/kg parenterally. Jejunal nutriment (1.5 cal/mL) followed gradually up to 1500mL. Parenteral nutriment decreased reflecting enteral intake. Patients of Gr. II were nourished parenterally only for 8 days. Laboratory data were measured preoperatively, on the 1st, 4th, 10th days. RESULTS: The first stool appeared on the 4th day in Gr. I In Gr. II the bowel movement was delayed by 8 days. Laboratory data from the 1st, and 10th days were compared. In Gr. I serum total protein increased from 48.06 to 58.7g/L (p<0.001), serum albumin from 27.5 to 32.2g/L (p<0.02), CRP decreased from 117.8 to 74.1mg/L (p<0.035). No changes were significant in Gr. II. Length of hospitalization, weight loss did not differ between the 2 groups. CONCLUSIONS: Immediately postoperative use of a three-luminal tube ensured early enteral nutrition, improved serum total protein, albumin values and facilitated bowel movements.

Cytotoxic endothelial cell antibodies in mixed connective tissue disease.

We examined the presence of anti-endothelial cell antibodies in the sera of 44 patients with mixed connective tissue disease (MCTD). Warm antibodies against endothelial cells were found in 45.4% of patients; the presence of these antibodies was positively correlated with anti-monocyte antibodies (P less than 0.01) but not with anti-lymphocytic antibodies. Strong correlations were found between the presence of these antibodies and abnormalities of pulmonary ventilatory capacity, neurophysiologic and myocardial function. Anti-endothelial antibodies were related to the high rate of spontaneous abortion noted in female MCTD patients. The identification of the antigen identified by MCTD sera in endothelial cells would help in understanding disease manifestations.

Expression of HLA-DR antigens by thyroid cells: the effect of Graves' IgG.

We have investigated factors which influence HLA-DR expression on thyroid cells. While bTSH (100 mU/ml) did not enhance HLA-DR expression, it increased when brought about by IFN-gamma. Graves' IgG showed a dose-dependent (0.1-2 mg/ml) increase in DR expression and at a concentration of 2 mg/ml prolonged the time for which DR was expressed. The pathway of DR induction by Graves' IgG apparently differs from that by IFN-gamma. The humoral response in Graves' disease, by inducing DR expression, may be instrumental in propagating thyroid specific autoimmunity.

Methimazole blocks Graves' IgG but not interferon-gamma HLA-DR expression by thyroid cells.

We have expanded our early observation that a potent Graves' IgG preparation induces HLA-DR expression on thyroid cells, by showing that four randomly-selected Graves' IgG's were also capable of inducing DR antigens on thyroid cells. The effect of Graves' IgG was specific to thyroid cells, as it did not induce MHC Class II molecule expression on endothelial cells whereas interferon-gamma and immune complexes did so. The anti-thyroid drug methimazole was capable of rapidly reducing Graves' IgG-induced DR expression but to a much lesser extent than brought about by interferon-gamma. We conclude that Graves' IgG propagates thyroid-specific autoaggression by continued induction of DR antigens and than an important means whereby methimazole brings about remission is by reducing this induction.

Alterations of primary haemostasis in mixed connective tissue disease (MCTD).

Willebrand-factor antigen level and structure analysis, ristomycin-cofactor assay, beta-thromboglobulin and thromboxane metabolite estimations were performed in 22 patients with mixed connective tissue disease to evaluate the incidence and the possible role of haemostatic alterations in the complications occurring during the course of the disease. High levels of Willebrand-factor antigen and ristomycin-cofactor activity were detected in patients with thrombocytopenia, previous thrombotic event, pulmonary vascular lesions and usually in the presence of circulating anti-endothelial antibodies. Increased platelet activation could have been found in antibody positive cases and in patients with thrombocytopenia as well. The documented alterations of endothelial and platelet functions may play important role in the vascular complications of mixed connective tissue disease.

Anti-endothelial cell antibodies in mixed connective tissue disease: frequency and association with clinical symptoms.

OBJECTIVE: Anti-endothelial cell antibodies (AECA) have been described in a number of systemic autoimmune-inflammatory diseases. However, little is known about the relationship of AECA with mixed connective tissue disease (MCTD). METHODS: Using an ELISA, the presence of AECA was evaluated in the sera of 33 patients with MCTD and of 30 healthy subjects as controls. Serum levels of AECA were correlated with clinical activity, as well as the existence of various organ manifestations. RESULTS: Significantly increased AECA production was observed in MCTD patients (OD = 0.337+/-0.193) compared to controls (OD = 0.136+/-0.065). In addition, patients with active MCTD exerted significantly elevated serum AECA levels (OD = 0.487+/-0.090) than did patients with inactive MCTD (OD = 0.135+/-0.040) or controls. MCTD patients with pulmonary hypertension had a tendency of increased serum AECA levels (OD = 0.452+/-0.080) compared to patients without this manifestation (OD = 0.307+/-0.039). Sera of MCTD patients with AECA concentrations higher or lower than the mean serum AECA level in controls+2SD (OD = 0.266) were considered as AECAhigh (n = 19/33) and AECAlow (n = 14/33), respectively. Interestingly, all patients with active disease had AECAhigh, while all inactive MCTD patients had AECAlow sera. IgG purified from ten MCTD sera (OD = 0.415+/-0.290) showed a tendency to up-regulate E-selectin expression on cultured human umbilical vein endothelial cells (HUVEC) compared to IgG from control sera. In addition, AECAhigh MCTD sera exerted significantly increased stimulatory effect on endothelial E-selectin expression (OD = 0.651+/-0.190) compared to AECAlow (OD = 0.178+/-0.110) or control sera (OD = 0. 131+/-0.080). CONCLUSION: AECA may activate endothelial cells by the up-regulation of E-selectin expression and thus may be implicated in the pathogenesis of MCTD. Furthermore, serum AECA may be a useful marker of endothelial activation and clinical activity in this disease.

Five-year follow-up of 665 Hungarian patients with undifferentiated connective tissue disease (UCTD).

OBJECTIVE: To determine the clinical symptoms and the panel of autoantibodies of patients with early undifferentiated connective tissue disease (UCTD) followed for at least 1 year. METHODS: 716 UCTD patients with manifestations suggestive but not diagnostic of specific connective tissue disease (CTD) were recruited and followed up between 1994-1999. The patients with early UCTD were subdivided into those with isolated Raynaud's phenomenon (RP) (50 patients), unexplained polyarthritis (31 patients) and "true" UCTD (665 patients). UCTD was diagnosed on the basis of clinical manifestations suggestive of a connective tissue disease and the presence of at least one non-organ specific autoantibody. The patients' sera were tested for anti-nuclear (ANA), as well as for nine different specific autoantibodies (anti-dsDNA, -Sm, -RNP, -SSA, -SSB, -Scl-70, -centromere, -Jo1 and -PM-Scl). RESULTS: The most common clinical manifestations of UCTD included RP, arthritis/arthralgias, pleuritis/pericarditis, sicca symptoms, cutaneous involvement (photosensitivity, rash), central nervous symptoms, peripheral neuropathy, fever, vasculitis, less pulmonary involvement and myositis. 230 of the 665 true UCTD patients (34.5%) developed a defined CTD (28 systemic lupus erythematosus [SLE], 26 mixed connective tissue disease [MCTD], 19 progressive systemic sclerosis [PSS], 45 Sjögren's syndrome, 3 polymyositis/dermatomyositis [PM/DM], 87 rheumatoid arthritis [RA], and 22 systemic vasculitis. 435 of 665 patients (65.4%) remained in the UCTD state, and 82 of 665 patients (12.3%) achieved complete remission with symptoms not reappearing within the 5-year period. The highest probability of evolution to a defined CTD was during the first 2 years after onset: of 230 UCTD patients 183 (79.5%) developed major organ symptoms and signs. In particular skin and cardiac complications seemed to spread during the follow-up period in those patients who progressed to SLE. The condition of 18/50 patients with isolated RP evolved to UCTD and 3 of 31 patients with unexplained polyarthritis progressed to definite CTD (2 patients RA and one MCTD). CONCLUSION: In our study most of the UCTD patients did not develop a definite CTD, but during the follow-up period we found new clinical and serological manifestations. One-third of the UCTD patients showed progress into different types of specific CTD.

The investigation of the monocyte-mediated tumor-specific rosette formation and cytotoxic capacity of patients with thyroid cancer.

Fourteen patients suffering from highly differentiated thyroid cancer and 10 patients with autoimmune thyroid disease were tested in the present study. The tumor-specific autologous rosette formation of peripheral monocytes was determined and was found to be increased in cancer patients. Using the monocytes as effector and the covered, prelabelled autologous red blood cells as target, a cytotoxic assay was carried out. The rosette formation and cytotoxic ability correlated with the time passed since the operation, present clinical stage and the expansion of tumor found during the operation. In Hashimoto thyreoditis and Graves' disease elevated rosette formation and normal cytotoxic ability were detected.

The clinical usefulness of the fingers-to-palm ratio in different hand microcirculatory abnormalities.

A non-invasive nuclear medicine technique was developed to screen patients with painful hands so as to separate patients with a normal from those with an abnormal microcirculation of the hands in different clinical conditions. Such a technique is important, as the other methods available are either subjective or rather complicated. The study population consisted of 10 healthy individuals, 23 patients with Raynaud's syndrome and 15 patients with mixed connective tissue disease (MCTD). Sixty gamma-camera images of the hands (1 s each) were recorded after a bolus injection of 99Tcm-DTPA via a dorsal foot vein. Regions of interest were drawn on the summed images around the fingers and the palmar region. The fingers-to-palm ratio was then calculated from the total counts inside these regions of interest separately for each hand. The mean fingers-to-palm ratio was 0.94+/-0.18 (0.71-1.25) for the healthy group, 0.57+/-0.22 (0.21+/-1.11) for the MCTD group and 0.40+/-0.14 (0.18-0.77) for the Raynaud's patients. Analysis of variance showed these differences to be highly significant (P < 0.001). There were also significant differences between 6 MCTD patients in an active (mean 0.48) and nine patients in an inactive (mean 0.66) clinical state (two-sample t-test: P < 0.05). There were no significant differences between the fingers-to-palm ratios of the left and right hands of the same patients (one-sample t-test). Of the 23 primary Raynaud's patients, capillary microscopic data were pathological in only eight (34%). We conclude that our method is able to differentiate between patients with normal and those with abnormal microcirculation of the hands. Although measurement of the fingers-to-palm ratio is not a specific method, it is useful both for staging and in the follow-up of patients.

Osteoporosis in mixed connective tissue disease.

The existence of osteoporosis in 58 postmenopausal women with mixed connective tissue disease (MCTD) was investigated. The mean bone mineral density assessed by dual energy X-ray absorptiometry in the lumbar spine was decreased in 25.8% of the patients, reflecting osteoporosis (T score < -2.5). In the femoral neck there was no significant difference between the BMD of MCTD patients and that of age-matched, healthy postmenopausal women. Low bone mineral density was found among patients on, as well as off, corticosteroids. The extent of bone loss was associated with disease duration, as well as corticosteroid therapy. Serum osteocalcin levels were lower in MCTD patients than in controls. Lower serum oestradiol, testosterone and dehydroepiandrosterone sulphate levels were detected in MCTD patients than in controls. Thus, MCTD may be associated with increased bone loss. Pathogenic factors may include the disease itself, corticosteroid therapy, impaired osteoblast function, and low serum sex hormone levels.

Evidence for lysosomal matrix in the juxtaglomerular cell granules.

A systematic histochemical analysis of the matrix composition of juxtaglomerular cell granules was carried out. The behaviour of kidney lysosomes under similar conditions has been examined in parallel. The tubular protein droplets produced by the i.p. administration of egg albumen were chosen as lysosome-model. Identical pattern of histochemical reactions has been demonstrated both in kidney lysosomes and juxtaglomerular granules indicating the presence of separate lipoprotein and glycoprotein components. The ammoniated silver carbonate method for lysosomes was also positive in juxtaglomerular cell granules. These results support on a non-enzymatic basis the concept that secretory granules and lysosomes are evolutionary homologues.

Changes in the nutritional state and immune-serological parameters of esophagectomized patients fed jejunaly with glutamine-poor and glutamine-rich nutriments.

BACKGROUNDS/AIMS: In our former study we investigated the effect of glutamine-rich (I) and glutamine-poor (II) jejunal diet in operated patients with acute pancreatitis. In the glutamine-rich diet group clinical benefit and fast recovery of IgG, IgM, serum proteins, retinol-binding protein, albumin could be measured. In the present study the effects of the two types of jejunal diets I and II have been compared on the basis of changes in some immune parameters of 36 patients treated with subtotal esophagectomy for malignancy. METHODOLOGY: In randomized controlled trial data of two groups, I. patients with glutamine-rich Stresson Multi Fibre diet (23 patients) and II. patients with Nutrison Multi Fibre glutamine-poor diet (13 patients) were analyzed. Levels of serum proteins were measured by laser nephelometry, CD markers of lymphocytes by flow cytometry, phagocyte activity by chemiluminescence. RESULTS: Level of proteins decreased on the 2nd postoperative day in both groups, then gradually increased postoperatively. In increase of level of serum protein, retinol-binding protein, prealbumin there was no difference between the two groups. CONCLUSIONS: In patients treated with subtotal esophagectomy, the glutamine-rich enteric diet did not result in faster recovery in levels of prealbumin, retinol-binding protein, immunoglobulins and in outcome of patients than the glutamine-poor nutriment.

[Clinical observations in mixed connective tissue disease]. / Klinikai megfigyelések kevert kötöszöveti betegségben.

The authors report their observations gathered by follow-up studies of many years duration on 67 patients suffering from mixed connective tissue disease. The period preceding the overt disease, its duration and its characteristic symptoms were examined. Concerning the severity of the clinical course, the authors distinguished between a less and a more severe form of the disease. Organ specific manifestations occurring in the two types of the disorder, the number of active phases per year, therapeutic tools and the prognosis were analysed. The authors assume that the more severe form of the disease may have some traits resembling those of systemic lupus erythematosus, but in the meantime, in the less severe type of the disease some features shared by rheumatic disorders can be found.

[Pregnancy in mixed connective tissue disease]. / Terhesség kevert kötöszöveti betegségben.

The authors carried out a retrospective study of the pregnancy of 31 women suffering from mixed connective tissue disease (MCTD). They summed up the number of growing children, stillborns, and spontaneous abortion in the period before and after commencement of the disease process. Their results point to a rather marked occurrence of spontaneous abortion even in the period before the actual disease process. In the majority of patients there were observable clinical signs which, retrospectively, was an autoimmune disease process, but now known as the appearance of MCTD. In the period following the disease only a smaller percentage of patients became pregnant, not on account of their age or previous spontaneous abortions, but rather because of their symptoms. They investigated those clinical abnormalities which could be reasons for the adverse conditions for fetal development in MCTD.

[Reflections on non-differentiated collagenosis or non-differentiated autoimmune syndrome]. / Gondolatok a Nem Differenciált Collagenosisról (NDC), illetve a Nem Differenciált Autoimmun Syndromáról (NAS).

The authors review the Non-Differentiated Collagenosis (NDC) described by Gyula Petrányi 29 years ago, and try to establish whether it is still necessary to maintain this clinical picture. Relying on data from special literature and on their own findings, the authors conclude that the maintenance of the NDC terminology is justified by the fact that poly-systemic autoimmune diseases take time to develop and that at certain stages of this development it is almost impossible to make a firm decision as to which clinical picture the process will lead to. The authors discuss the clinical and immunological features of NDC, the implications for the patients and things to be done in order to recognise the NDC disease process. They also emphasize a more frequent occurrence of the features of NDC than is generally stated, and that such patients need regular, competent and devoted medical attention.