Microthrombotic renal involvement in an SLE patient with concomitant catastrophic antiphospholipid syndrome: the beneficial effect of rituximab treatment.

Antiphospholipid syndrome is characterized by multiple arterial and/or venous thrombotic events, recurrent fetal losses in the presence of antiphospholipid antibodies (aPL). Catastrophic antiphospholipid syndrome is a life-threatening, rare subset of antiphospholipid syndrome when the thrombotic events affect at least three organs, and clinical manifestations develop simultaneously or within a week. Diagnostically, small vessel occlusions can be detected by histopathology in the presence of aPL. Our case report describes an 18-year-old man who has been treated for antiphospholipid syndrome associated with systemic lupus erythematosus (SLE) since 2011. The clinical findings were dominated by recurrent deep vein thrombosis, and severe proteinuria caused by lupus nephritis, accompanied by mild serological and laboratory findings. The patient was hospitalized in March 2014 because of severe thrombocytopenia and infective diarrhoea. At this time the renal functions deteriorated rapidly. Simultaneously, left upper extremity paresis was observed; computed tomography showed ischaemic lesions in the territory of the middle cerebral artery. Abdominal discomfort and pain occurred. On computed tomography scan ischaemic lesions were seen in the spleen, the right kidney and the coeliac trunk. Laboratory and serological findings verified the presence of aPL and anti-DNA antibodies, anaemia and thrombocytopenia. Based on the above-mentioned clinical and laboratory findings, the diagnosis of catastrophic antiphospholipid syndrome was established. Anticoagulation, corticosteroids and plasma exchange treatment, as well as haemodiafiltration were initiated. Although the thrombotic cascade decelerated following these interventions, we could not see an improvement in the renal function. Rituximab treatment was started, leading to a significant improvement in renal function. After 5 weeks of treatment the patient was discharged from hospital.

Decreased peroxisome proliferator-activated receptor γ level and signalling in sebaceous glands of patients with acne vulgaris.

Little is known about the altered lipid metabolism-related transcriptional events occuring in sebaceous glands of patients with acne vulgaris. Peroxisome proliferator-activated receptor (PPAR)γ, a lipid-activated transcription factor, is implicated in differentiation and lipid metabolism of sebocytes. We have observed that PPARγ and its target genes, ADRP (adipose differentiation related protein) and PGAR (PPARγ angioprotein related protein) are expressed at lower levels in sebocytes from patients with acne than in those from healthy controls (HCs) Furthermore, endogenous PPARγ activator lipids such as arachidonic acid-derived keto-metabolites (e.g. 5KETE, 12KETE) are increased in acne-involved and nonacne-involved skin of patients with acne, compared with skin from healthy individuals. Our findings highlight the possible anti-inflammatory role of endogenous ligand-activated PPARγ signaling in human sebocyte biology, and suggest that modulating PPARγ- expression and thereby signaling might be a promising strategy for the clinical management of acne vulgaris.

Detection of factor XIII-A is a valuable tool for distinguishing dendritic cells and tissue macrophages in granuloma annulare and necrobiosis lipoidica.

BACKGROUND: Factor XIII subunit A (FXIII-A) is used as a diagnostic marker in a wide range of dermatological diseases ranging from inflammatory lesions to malignancies, although neither the cell types responsible for its expression nor the mechanism(s) resulting in its local accumulation in pathological conditions have been characterized. OBJECTIVE: In this study, we aimed to gain information on the cells showing an immunohistochemical reaction for FXIII-A and answer the question whether macrophages and/or dendritic cells are labelled for FXIII-A. METHODS: We carried out our studies on samples of granuloma annulare (GA) and necrobiosis lipoidica (NL), the prime examples for granulomatous skin lesions with a non-infectious background in which extracellular matrix remodelling is a key feature without any sign of malignant transformation. We used markers for macrophages and dendritic cells in combination with the detection of FXIII-A in double labelling immunohistochemical reactions. RESULTS: We demonstrated that FXIII-A positivity clearly distinguishes macrophages (CD163+/FXIII-A+) from dendritic cells (CD11c+/FXIII-A-) not only in the normal dermis as previously described by Zaba et al. (J Clin Invest 2007; 117: 2517-2525) but also in the pathological conditions of GA and NL. Detecting the expression of DC-SIGN/CD209 and mannose receptor molecules on FXIII-A+ macrophages we confirmed that FXIII-A is expressed in the alternatively activated macrophages. However, while DC-SIGN/CD209 was invariably expressed on FXIII-A+ cells both in normal and pathological conditions of GA/NL (98.7% vs. 93.5/96%), mannose receptor was only partially coexpressed with FXIII-A (94.8% vs. 74.7/52.2%), suggesting that FXIII-A+ macrophages do not represent a homogenous population. CONCLUSIONS: FXIII-A selectively marks macrophages and distinguishes them from dendritic cells. The presence of FXIII-A is not a disease-specific marker but indicates a possible common mechanism of macrophage activation in various dermatological diseases.

Correlation among metallothionein expression, intratumoural macrophage infiltration and the risk of metastasis in human cutaneous malignant melanoma.

BACKGROUND: The formation of metastases and the efficacy of systemic therapies in cutaneous malignant melanoma (CMM) depend on the characteristics of the tumour cells and the host immune response. Aberrant expression of metallothionein (MT) has been observed in several types of cancers with poor prognoses. OBJECTIVE: To perform an immunohistochemical study on primary CMM comparing the MT expression of tumours without metastases (n = 23) to that of samples with haematogenous metastases (n = 23) and to examine the correlation between MT staining and immunological markers relevant in CMM progression. METHODS: The immunohistochemical labelling of different tumour sections was analysed using tissue microarrays for the evaluation of the suitability of this method in future studies. RESULTS: Our results suggest that MT overexpression is significantly more frequent in primary CMM with haematogenous metastases (P = 0.018) and that the overexpression is independent of the Breslow tumour thickness (R = 0.102, P = 0.501). Interestingly, MT overexpression of the tumour cells was correlated with the presence of tumour-infiltrating CD68(+) macrophages (P = 0.003), a known predictive factor for melanoma progression, thereby suggesting a role for MT in the development of a defective host immune response. Furthermore, the presence of CD163(+) macrophages infiltrating the tumours correlated with metastasis formation (P < 0.001), whereas the presence CD1a(+) dendritic cells surrounding the tumours was associated with a lower risk of haematogenous spread (P = 0.003). CONCLUSION: Our results demonstrate that MT may represent a suitable prognostic factor that can characterize the metastasising ability of CMM and the tumour-promoting host immune response.

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.

Factor XIII in bronchoalveolar lavage fluid from children with chronic bronchoalveolar inflammation.

BACKGROUND: Extravascular activation of the coagulation system and consequent fibrin deposition is involved in the pathomechanism of chronic bronchoalveolar inflammatory diseases. The turnover of extravascular fibrin is attenuated by its cross-linking with activated factor XIII (FXIII). OBJECTIVES: Determination of cellular and plasmatic forms of FXIII and their correlation with D-dimer level in the bronchoalveolar lavage fluid (BALF) from healthy children and from children with bronchoalveolar inflammation. PATIENTS AND METHODS: Highly sensitive immunoassays were used for the quantitation of cellular and plasma FXIII and D-dimer in the BALF of children with recurrent wheezy bronchitis and fibrosing alveolitis. BALF was investigated for FXIII-containing cells by flow cytometry. RESULTS AND CONCLUSIONS: In the BALF of controls a low amount of the cellular form of FXIII (FXIII A2) and D-dimer were measured, while plasma FXIII (FXIII A2B2) was absent. Alveolar macrophages represented the single cell population in BALF that contained FXIII. In the BALF of both patients' groups the concentration and the total amount of FXIII A2 was significantly elevated, and plasma FXIII also appeared in the BALF of most patients. The D-dimer concentration was also elevated in the patients' groups and it correlated both with plasma FXIII and neutrophil count. These findings suggest that FXIII A2 is released from activated or injured alveolar macrophages into the bronchoalveolar lining fluid and in bronchoalveolar inflammatory diseases, FXIII A2B2 also leaks out from the capillaries. By cross-linking fibrin and inhibitors of fibrinolysis to fibrin, FXIII might be a key regulator of fibrin turnover in the extravascular compartment.

Phase II trial of sequential radiation and interleukin 2 in the treatment of patients with metastatic renal cell carcinoma.

We have previously demonstrated that local tumor irradiation effectively enhanced the therapeutic effect of interleukin 2 (IL-2) therapy in an experimental murine renal adenocarcinoma model. Based on these preclinical studies, we have designed and initiated a Phase II trial of irradiation combined with IL-2 for the treatment of metastatic renal cell carcinoma. Patients received 800 cGy to the primary or metastatic lesions on days 1 and 15 followed by IL-2 (600,000 IU/kg i.v.) every 8 h on days 4-8 and 18-22. Sixteen patients were entered; all completed treatment and are therefore evaluable for toxicity and response. Two partial remissions were seen for a response rate of 12.5% (95% confidence interval, 0-28.7). There was no increase in toxicity over that which is anticipated from IL-2 alone. The antitumor activity seen in this trial is consistent with what would be expected from high-dose IL-2 alone.

The mechanism of local tumor irradiation combined with interleukin 2 therapy in murine renal carcinoma: histological evaluation of pulmonary metastases.

We have demonstrated that tumor irradiation enhanced the therapeutic effect of interleukin 2 (IL-2) on pulmonary metastases from a murine renal adenocarcinoma, Renca. To investigate the mechanism of interaction between tumor irradiation and IL-2 therapy, we have histologically evaluated the effects of each therapy alone or in combination on Renca pulmonary metastases. Following treatment of established lung metastases with irradiation and IL-2 therapy, lung sections were processed for H&E or immunohistochemical staining. We found that tumor irradiation or IL-2 therapy locally induced vascular damage, resulting in multifocal hemorrhages and mononuclear cell mobilization in the lung tissue. This effect was amplified in lungs treated with the combined therapy. Immunohistochemistry showed that irradiation produced a macrophage influx into irradiated tumor nodules, and systemic IL-2 therapy induced T-cell infiltration in tumor nodules. Lungs treated with the combined therapy exhibited massive macrophage, T-cell, and natural killer cell mobilization in disintegrating tumor nodules and in the lung tissue. This combined therapy caused a decrease in the number of proliferating tumor cells and an increase in the number of apoptotic cells, which were more marked than with either therapy alone. We suggest that the macrophages mobilized by radiation-induced tissue injury could play a role in phagocytosis of apoptotic tumor cells, processing and presenting of tumor antigens for a systemic immune response activated by IL-2. Tumor destruction may result from the concomitant action of activated T cells, natural killer cells, and macrophages infiltrating the tumor nodules.

Evidence for the presence of angiotensins in normal, unstimulated alveolar macrophages and monocytes.

The presence of angiotensins was demonstrated in normal unstimulated alveolar macrophages and monocytes from both mice and rats. These peptides were partially purified from cell homogenates by ion exchange chromatography and identified as being [Ile5] angiotensin I (Ang I), [Ile5] angiotensin II (Ang II) and to a lesser extent [Ile4] angiotensin III (Ang III) using high performance liquid chromatography (HPLC). Based on the present data both alveolar macrophages and monocytes expressed Ang I as quantified by a specific and sensitive radio-immunoassay (RIA) from the HPLC eluates. In contrast to this, alveolar macrophages from both mice and rats exhibited a fairly low, if detectable Ang II content. It seems reasonable to suggest that, in contrast to monocytes, macrophages do not generate and/or incorporate Ang II appreciably, at least in their resting stage. Although it is still not obvious whether these mononuclear phagocytes generate or simply capture angiotensin(s) from the blood pool or from the tissues; they must serve as in vivo target cells for the angiotensin system, at least for the plasma or tissue clearance of these molecules.

Effect of lymphokine on the activation and Fc receptor expression of rat macrophages.

Lymphocyte supernatant (LS) containing lymphokine (LK) activated rat peritoneal macrophages (PM) and at the same time enhanced their Fc receptor (FcR) activity. The signs of the early activation could not be observed on alveolar macrophages (AM) but the augmented FcR expression occurred under the effect of lymphokine. The LK-induced macrophage activation and the enhancement of erythrocyte-antibody (EA) rosette formation were found to be independent of each other. In the presence of soybean trypsin inhibitor (STI) the crude lymphokine-induced augmented EA rosette formation was only slightly diminished. However, it did not seem likely that the LK components of molecular weight over 15,000 could enhance the number of rosettes under the effect of protease inhibitor. These data indicate that the macrophage proteases play an important role in the generation of EA rosette formation enhancing breakdown product(s) during the macrophage-lymphokine interaction.

Morphological and immunohistochemical characteristics of dimethylnitrosamine-induced malignant mesenchymal renal tumor in F-344 rats.

Mesenchymal renal tumors in F-344 newborn rats were induced by a single dose of dimethylnitrosamine. The induced tumors were successfully transplanted into adult rats under the renal capsule. Neither the primary nor the transplanted neoplasms from various generations of grafts changed their morphological features during the tumor passage, having the same cellularity with high mitotic activity and the tendency to invade the host kidney rapidly. On the basis of lectin histochemistry and immunohistology, the tumor proved to be a mesenchymal neoplasm without any obvious capacity of the proliferating cells to differentiate into any well-known organoid element normally found in mature renal parenchyma. However, the proliferating neoplastic cells were found to have a strong vimentin positivity with desmin expression. Ultrastructurally, myofilaments with attachment bodies characteristic of smooth muscle cells were generally present in various amounts in many tumor cells. In addition, on the basis of the physiological data and on kidney/tumor renin activity obtained, it is interesting to note that the tumor-graft-invaded kidneys retained their enzyme activity, despite the obvious loss of renal tissue including glomeruli. However, the immunohistochemical findings with anti-renin antibody have clearly shown that this is not due to a renin-producing tumor but rather to the surviving (probably) non-neoplastic arterioles retaining the capacity to produce renin. Although these arterioles have mostly been found next to necrotic areas, commonly occurring in dimethylnitrosamine-induced transplantable renal tumors, the question of a possible physiological role of renin in tumor necrosis or in angiogenesis has remained open.

Apoptosis in the human inner ear. Detection by in situ end-labeling of fragmented DNA and correlation with other markers.

The aim of this study was to obtain baseline data on the recently described special form of single cell death, apoptosis, in normal human inner ears. For this purpose, in situ end-labeling of the fragmented DNA was applied, in conjunction with apoptosis-related markers, to detect cellular elements showing programmed cell death in decalcified and paraffin-embedded tissues. Over 20 specimens were analyzed which were obtained from autopsy cases with no history of acoustic lesions confirmed by histopathology. Based on staining results, we saw no apoptotic signs in the majority of normal adult inner ears. An apoptotic cell captured in the Reissner's membrane of the cochlea from an old patient may, however, indicate an age-related subtle cell loss with the process of apoptosis. Nevertheless, the fact that more apoptosis was not found in our cases suggests that this phenomenon does not contribute significantly to the tissue homeostasis in the adult inner ear under normal conditions. These data are in accordance with our immunohistochemical findings on the p53 nucleoprotein, and proliferating cell nuclear antigen expression since there was no staining in any of the cellular elements, including the mesenchymal cells. This reflects a stationary and stable condition of cells of the vestibular and the cochlear structures, probably to maintain their integrity and the fine sensory functions. As opposed to the above findings, during inner ear development, the epithelial cells lining the cochlear lumen, the ossifying cartilage of the temporal bone, and the mesenchymal cells show different degrees of proliferation in combination with single cell death as signs of maturation of the vestibular and the cochlear apparatus. In addition, apoptosis has been demonstrated in cells of the cochlear stria vascularis from an adult patient treated with high doses of cisplatin, vinblastine and bleomycin prior to death. Furthermore, a wide range of apoptosis could be induced experimentally in a normal ear by an external perfusion of actinomycin D (ActD), which is known to produce programmed cell death in many cell types of different origins. The potential role of cytostatic agents in the apoptotic process of the inner ear needs, however, to be confirmed in large-scale specimens from patients treated with genotoxins. The fact, however, that apoptotic cells are also seen in association with ActD indicates that the fine sensory structure of the cochlea may also be a target for certain chemotherapeutic agents when administered in high doses.

Association of idiopathic inflammatory myopathy and Crohn's disease.

We describe a rare case of concurrent polymyositis and Crohn's disease in a female patient. A 69-year-old female presented in December 2007 with a 5-month history of proximal muscle weakness, pain, fatigue and difficulty in walking and swallowing. Blood tests revealed elevated creatine kinase (3,429 U/l) and lactate dehydrogenase (2,013 U/l) levels. Magnetic resonance imaging found lumbar disc protrusion. Review by immunologists showed a diagnosis of idiopathic inflammatory myopathy. Though electromyography and muscle biopsy at this point were non-specific, corticosteroid treatment was commenced. Her condition worsened precipitously leading to hospitalisation under immunologists. As the provisional diagnosis was polymyositis, we commenced 1.5 mg/kg per day corticosteroid but her muscle power did not improve. Recurrent abdominal symptoms lead to ultrasonography showing intestinal inflammation. While tumour markers were elevated, thorough investigation failed to identify a tumour. Corticosteroid therapy was continued. Persistent abdominal symptoms lead to repeat colonoscopy and biopsy confirming Crohn's disease. Repeat electromyography and muscle biopsy confirmed the diagnosis of polymyositis. Her corticosteroids were tapered off and 5-aminosalicylic acid and azathioprine were started. Her myositic symptoms gradually abated with improvement in her Crohn's disease. She is now able to walk independently and takes 8 mg/day corticosteroids and her muscle enzyme levels are normal. Remember rare systemic associations when dealing with immune-mediated disease. Consider myositis in the differential diagnosis of Crohn's disease associated myopathy. Treating Crohn's disease may lead to improvement in steroid-resistant myositis where the two are associated.

Effect of angiotensin II on the Fc receptor activity of rat macrophages.

Angiotensin II (At II) in the concentration range of 10(-5) to 5 x 10(-7) M inhibited active and passive erythrocyte-antibody (EA) rosette formation on monolayers of rat peritoneal macrophages (PM) but stimulated it in the range of 10(-7) -10(08) M. Cytochalasin B (CB) and vinblastin (Vb) inhibited the dose-dependent biphasic effect of At II on the Fc receptor (FcR) expression of macrophages. The hormone acts on the last step of rosette formation, i.e. on the binding of sheep red blood cells (SRBC) but does not interfere with the binding of 125I-Ig to FcR. The influence of At II on macrophage rosette formation can be modified by changes in the density of FcR-Ig complexes on the surface of target cells, by the nature of the immunoglobulin (sub)classes involved in rosette formation, and by the biological properties of rosette-forming corpuscular antigen. Based upon the above results we suggest that At II exerts its effect on the contractile elements associated with the cytoskeleton of the macrophage.

[Correlation between the extrarenal renin-angiotensin system and the mononuclear phagocyte system]. / Extrarenális renin-angitotensin rendszer és a mononukleáris phagocyta szisztéma kapcsolata.

Authors survey the cyto-biological effect of extra-renal renin-angiotensin system on the basis of literature data and of their own previous results. It is established that renin and angiotensins in extra-renal localisation take part mainly in inflammatory process. In this respect, one of the important target cell group of angiotensin system is the certain elements of mononuclear phagocyte system, on which angiotensin II has cytokine-like effect. Renin-angiotensins detected by authors in non-activated alveolar mono-phages and monocytes raise the possibility, that these cells also have independent, intra-cellular regulating renin-angiotensin.