[Enteroviral infections in adults treated with rituximab: A new case of chronic meningitis and myofasciitis and literature review]. / Infections à entérovirus de l'adulte traité par rituximab : un nouveau cas de méningite et myofasciite chronique et revue de la littérature.

INTRODUCTION: Chronic enterovirus infections can occur in primary immunodeficiency with hypogammaglobulinemia. They usually associate meningitis and myofasciitis. Such infections have also been described in adults with rituximab-induced hypogammaglobulinemia. CASE REPORT: We report the case of a 33-year-old woman who was given rituximab for immune thrombocytopenia and developed rituximab-induced hypogammaglobulinemia (IgG 4.4g/L). One year after the last rituximab infusion, she developed lower limbs myofasciitis, followed two months later by a chronic lymphocytic meningitis. PCR in the serum and the cerebrospinal fluid at the time of the meningitis and the myofasciitis were positive to the same enterovirus (echovirus 11) while it was negative in the fascia biopsy. Under treatment with intravenous immunoglobulins, all symptoms and laboratory abnormalities improved and enterovirus PCR became negative. CONCLUSION: We report a case of chronic enterovirus infection associating meningitis and myofasciitis in an adult with rituximab-induced hypogammaglobulinemia. Outcome was favorable under treatment with intravenous immunoglobulins.

Membrane-bound hemagglutinin mediates antibody and complement-dependent lysis of influenza virus-treated human platelets in autologous serum.

Influenza A virus-treated human platelets were lyzed in autologous serum. Lysis required the presence of antibody and occurred predominantly through activation of the classical complement pathway. Binding of the virus followed by its elution at 37 degrees C resulted in a dose-dependent desialation of the cells with a maximal release of 45% of total platelet sialic acid. In contrast, platelets that had been treated with Vibrio cholerae neuraminidase and from which 55% of total sialic acid had been removed were not lyzed in autologous serum and did not bind C3 as shown in binding assays using radiolabeled monoclonal anti-C3 antibody. Thus, the immune-mediated lysis of virus-treated platelets in autologous serum did not involve neoantigens expressed by desialated cells. To assess the effect of viruses on the platelet surface, treated platelets were incubated with galactose oxidase and sodium [3H]borohydride prior to separation and analysis of the labeled glycoproteins by SDS-PAGE. Viral treatment resulted in a desialation of each of the surface glycoproteins. At the same time, a labeled component of Mr 72,000 (nonreduced) and Mr 55,000 (reduced) was observed that was not present when V. cholerae-desialated platelets were examined in the same way. Immunoblotting experiments performed using antiwhole virus and anti-hemagglutinin antibodies demonstrated this component to be viral hemagglutinin. Involvement of membrane-bound hemagglutinin in antibody and in complement-mediated lysis of virus-treated platelets in autologous serum was supported by the increased lytic activity of a postvaccinal serum containing an elevated titer of complement fixing anti-hemagglutinin antibodies. Binding of a viral protein to the platelet surface provides a model for immune thrombocytopenias occurring during acute viral infections at the time of the specific immune response.

[Surgical complications in kidney transplantation]. / Complications chirurgicales de la transplantation rénale.

Kidney transplantation has become the treatment of choice for patients with end stage renal disease since it offers an excellent quality of life. Moreover, the economic impact is considerable, particularly beyond the first year. Indeed, the annual cost of a successful renal transplantation is ten fold lower than haemodialysis. But surgical complications remain one of our main concerns. Surgical complications are various. They may be non-specific as haematomas, incision-induced hernias and wound infections. They may also be directly related to the procedure as vascular thrombosis and urinary fistula in the early postoperative period or arterial stenosis and ureteral obstruction in the late post-operative period. The accurate diagnosis and the appropriate management of these complications are the most important tasks for the surgical team. This review is based upon our experience in kidney transplantation and upon the medical published data.

Structure-function relationships in the inhibitory effect of heparin on complement activation: independency of the anti-coagulant and anti-complementary sites on the heparin molecule.

Fluid phase heparin inhibits formation of the classical and alternative pathway C3 convertase of complement in assays performed either with purified complement proteins or in whole serum. Experiments using oligosaccharides of homogeneous mol. wt obtained by mild nitrous hydrolysis of heparin, demonstrated that the inhibitory activity of heparin increased exponentially with mol. wt for fragments containing between 4 and 14 saccharidic units and that fragments of mol. wt above 4700 (greater than 14 saccharidic units) had a similar anti-complementary activity to that of native heparin. Fragments of homogeneous mol. wt (octasaccharides) separated by ion exchange chromatography on the basis of negative charges, exhibited increasing inhibitory activity with increasing sulfate content. Over-sulfation of fragments of defined mol. wt resulted in a constant enhancement of the relative capacity of each fragment species to inhibit formation of the classical and alternative pathway C3 convertases. A synthetic pentasaccharide representing the minimal critical sequence responsible for the binding of heparin to anti-thrombin III exhibited a similar inhibitory capacity on formation of the C3 convertases as another synthetic pentasaccharide that was devoid of anti-Xa activity. These studies contribute to define a minimal structure of the heparin molecule with C3b- and C4b-binding capacity and definitively establish the independency of the anti-coagulant and anti-complementary sites on the heparin molecule.

Heparin prevents formation of the human C3 amplification convertase by inhibiting the binding site for B on C3b.

Fluid-phase heparin prevents generation of the C3 amplification convertase of human complement, C3b, Bb most likely by inhibiting the formation of the bimolecular complex between cell-bound C3b and B. The effect of heparin on the binding of B to C3b was examined using 125I-labelled B and C3b-bearing sheep erythrocytes (EsC3b). In the absence of heparin, B bound to EsC3b with an affinity of 0.5-1 X 10(6) M-1 in the presence of 5 mM Mg2+. Incremental amounts of heparin (100-700 micrograms/10(7) EsC3b) inhibited the binding of 125I-B to C3b in a dose-dependent manner. Scatchard analysis of the binding data in the presence of four inhibitory concns of heparin revealed that heparin did not affect the binding affinity of B for C3b but decreased the number of C3b sites recognized by B on the cells. No inhibition of binding occurred in the presence of totally (N- and O-) desulfated heparin which has no anticomplementary activity. These results demonstrate that heparin prevents generation of the C3 amplification convertase by binding to cell-bound C3b and masking the binding site for B on C3b.

Sulfonated dextran inhibits complement activation and complement-dependent cytotoxicity in an in vitro model of hyperacute xenograft rejection.

In the present study, we demonstrate that a substituted soluble dextran derivative bearing 73% carboxylic groups and 15% benzylamide sulfonate groups, termed CMDBS25, inhibits complement activation and complement-mediated damage in an in vitro model of xenogeneic rejection. Incubation of porcine aortic endothelial cells with normal human serum resulted in time-dependent complement consumption as assessed by C3a generation in the fluid phase and deposition of activated complement fragments C3, C5 and of C5b-9 on target cells. The presence of C5b-9 membrane attack complex was associated with 51Cr release from prelabelled endothelial cells. The addition of 5-25 mg of CMDBS25/ml under the experimental conditions used, inhibited complement activation and C3a generation in a dose-dependent fashion. CMDBS25 (25 mg/ml) totally suppressed iC3b, C5 and C5b-9 cytolytic complex deposition on cells and inhibits by 42% lysis of target endothelial cells. Native dextran had no effect. Our observations document the anti-complementary properties of sulfonated dextran derivatives and their potential as therapeutic agents for the prevention of complement-dependent hyperacute xenograft rejection.

Rhizobium tropici nodulation factor sulfation is limited by the quantity of activated form of sulfate.

Rhizobium tropici is a broad host-range symbiont of Phaseolus vulgaris. This bacterium produces a mixture of sulfated and non-sulfated N-methylated pentameric nodulation (Nod) factors. To understand the genetic bases of the partial sulfation of R. tropici Nod factors, which might be involved in the broad host-range of this species, we introduced in R. tropici CFN299 the recombinant plasmid pGMI515 carrying a set of nodulation (nod) genes of R. meliloti, including those involved in the sulfation of R. meliloti Nod factors. The CFN299 (pGMI515) transconjugant produced only sulfated Nod factors, but approximately half of them were no more N-methylated. Mutations in R. meliloti nodH gene did not decrease the Nod factor sulfation whereas inactivation of the nodPQ genes restored the production of a mixture of sulfated and non-sulfated molecules. These results suggest that the limiting step in R. tropici Nod factor sulfation is the production of activated sulfate donors. Mutations in the R. meliloti nodFEG and nodH genes did not change the N-methylation pattern, whereas mutations in nodPQ increased the degree of N-methylation, suggesting a metabolic link between sulfation and methylation of R. tropici Nod factors.

Assessment of complement activation in clinical samples. Comparison of immunochemical and functional measurements of complement components with quantitation of activation fragments.

We have compared functional and immunochemical measurements of complement components with assays measuring the generation of activation fragments, for the assessment of classical pathway activation in vitro and in vivo. The generation of the C3a, C3b/C3bi cleavage fragments of C3, and of the C4d cleavage fragment of C4 measured by ELISA and RIA, was correlated with the decrease in total complement hemolytic activity (CH50) and in functional activity of C3 and C4 in normal human serum in which the classical pathway had been activated with aggregated IgG. The decrease in CH50 in in vitro activated serum was also correlated with the generation of C5a and soluble SC5b-9 complexes. In contrast, no or little increase in the concentration of C3a, C3b/C3bi and C4d was observed in plasma samples from patients with low CH50 and with low levels of immunochemical C3 and C4, indicating that fragment quantitation assays provide no information on the presence and extent of complement activation in vivo. Analysis of samples from patients expressing the four C4 genes and patients having one or two C4 null alleles indicated that a ratio of hemolytic C4 to C2 > or = 1 was indicative of complement activation without C4 deficiency, whereas a ratio below 1 was indicative of C4 deficiency with or without classical pathway consumption. Classical pathway activation and C4 deficiency in clinical samples are best predicted by the concomitant assessment of immunochemical levels of C3 and C4 and hemolytic levels of C4, C2 and C3.

Complement activation by gp160 glycoprotein of HIV-1.

The ability of the gp160 envelope glycoprotein of HIV-1 to activate human complement and to bind C3 fragments was investigated by incubating mammalian-derived recombinant gp160 with seronegative serum and by quantitating the binding of C3b/iC3b to the protein using a biotinylated monoclonal antibody directed against a neoepitope expressed by cleaved human C3. Recombinant gp160 activated complement in a dose- and time-dependent fashion. Complement activation occurred through the classical pathway, independently of antibodies, and required C1q. Binding of anti-HIV IgG to rgp160 prior to exposure of the envelope glycoprotein to serum resulted in enhanced complement activation. Complexes of rgp120 with anti-HIV IgG also cleaved C3 in serum, resulting in deposition of C3b on gp120. These results provide a basis for C3-mediated facilitation of viral entry into target cells expressing receptors for fragments of human C3.

Deleterious effects of cardiopulmonary bypass. A prospective study of bubble versus membrane oxygenation.

A number of hematologic and immunologic parameters that reflect erythrocyte and platelet damage and host defense mechanisms against infection were studied in 20 patients undergoing cardiopulmonary bypass during coronary operations. The patients were randomly assigned to a group in which a bubble oxygenator or a hollow-fiber membrane oxygenator was used. Hemolysis, thrombocytopenia, and significant release of beta thromboglobulin occurred in patients from the bubble oxygenator group and, to much lesser extent, in patients from the membrane oxygenator group. Polymorphonuclear leukocytes and monocytes from bubble oxygenator patients demonstrated increased generation of reactive oxygen species in the resting state and in the presence of the stimulating agents N-formyl-methionyl-leucyl-phenylalanine, concanavalin A, and opsonized zymosan, as compared with cells from membrane oxygenator patients. No difference was found between bubble and membrane oxygenator patients in the time of occurrence or intensity of leukopenia during bypass, of leukocytosis at the end of bypass, nor in the rate of complement activation, as assessed by quantitation of plasma C3a antigen. Complement activation was dependent on the alternative pathway. Immunoglobulin M concentration significantly decreased during bypass in both groups of patients. The serum opsonizing capacity for endotoxin and serum bactericidal activity for Serratia marcescens were decreased in both groups, mainly because of hemodilution, although they were additionally affected by bubble oxygenation. Several deleterious hematologic consequences of cardiopulmonary bypass can be minimized by the use of a membrane oxygenator. However, complement activation remains a potential risk factor even in membrane oxygenator patients and requires further investigation to obtain better hemocompatible materials for cardiopulmonary bypass circuits.

Molecular weight dependency of the acquired anticomplementary and anticoagulant activities of specifically substituted dextrans.

Dextran that had been substituted with carboxylic and benzylamine sulphonated groups was fractionated by gel chromatography into fractions, of narrow molecular weight distribution from 6000 to 190,000 daltons and of similar chemical composition. The fractions exhibited anticomplementary and anticoagulant activities that rapidly increased with molecular weight and tended to plateau above approximately 20,000 and 40,000 daltons respectively. Anticoagulant activity was lower than that of heparin, whereas the capacity of the fractions to inhibit formation of the classical and alternative C3 convertases in a purified system was similar to that of heparin and their ability to inhibit CH50 in whole serum was higher than that of heparin. The data argue for a random distribution of structurally independent anticoagulant and anticomplementary sites along the macromolecular chains of substituted dextrans.

Effect of substituted dextran derivative on complement activation in vivo.

A soluble dextran derivatized with carboxylic groups (73%) and benzylamide sulphonate groups (15%), termed CMDBS 25, exhibited significant anticomplementary activity in the absence of anticoagulant activity. The polysaccharide inhibited both classical and alternative pathway-dependent complement activation in human and rat serum in vitro. Simultaneous administration of CMDBS 25 (100 mg) and crushed Sephadex G25 (20 mg) into normal Lewis rats suppressed systematic complement consumption that was induced by Sephadex in the animals by 98% for 1 h. Two consecutive injections of 100 mg of CMDBS at 1 h interval resulted in total suppression of systemic complement activation for 2 h and in 50% suppression for an additional 2 h. Infusion of CMDBS alone was well tolerated and had no effect on CH50 in serum in vivo. Our results demonstrate that CMDBS 25 exhibits anticomplementary properties in vivo and suggest that the polymer represents a potential therapeutic agent for pathological conditions associated with complement activation.

Anticomplementary activity of dextran derivatives.

Substitution with carboxylic and benzylamine sulphonated groups conferred on dextran both antithrombic activity and the capacity to inhibit formation of the amplification C3 convertase of complement. In dextrans substituted with carboxylic groups (greater than 40%), a high content of sulphonate (greater than 10%) resulted in both anticomplementary and antithrombic properties whereas a lower content of sulphonate resulted in high anticomplementary but weak antithrombic activity. The anticomplementary activity of highly substituted dextrans was similar to that of heparin, although anticoagulant activity was much lower than in heparin, confirming independent structural requirements for both activities in the heparin molecule.

Specific antibodies enhance Sephadex-induced activation of the alternative complement pathway in human serum.

Sephadex beads, which resemble cellulose in their basic chemical structure, were used to study the molecular mechanisms by which cellulosic dialysis membranes activate the alternative complement pathway in normal human serum. Sera from different individuals were found to vary in the extent of activation which occurred following incubation with a fixed amount (surface area) of polymer. Preadsorption of serum with an excess of Sephadex at 2 degrees C resulted in loss of activation when the absorbed serum was interacted with fresh Sephadex beads. Acid eluted proteins from absorbed Sephadex restored the capacity of preadsorbed serum to activate complement in the presence of fresh Sephadex. Adsorption of the immunoglobulin G (IgG) fraction and of F(ab')2 fragments from IgG prepared from the plasma of a normal individual with Sephadex, resulted in the specific binding of some IgG and F(ab'2) molecules to the particles. IgG and F(ab')2 coated beads activated complement in Sephadex-adsorbed serum. Thus, specific anti-dextran IgG antibodies trigger activation of the alternative complement pathway by Sephadex in human serum. The effect is independent of the Fc region of IgG. These results suggest that specific antibodies could be important in determining complement activation in vivo in patients undergoing haemodialysis with cellulosic membranes.

Regulation by sulphonate groups of complement activation induced by hydroxymethyl groups on polystyrene surfaces.

Reducing the complement-activating capacity of a polymer surface is important in improving its blood compatibility. Polystyrene surfaces bearing hydroxymethyl (CH2OH) groups activate the alternative pathway of complement. This activation depends strongly on the density of the groups. Polystyrene surfaces bearing sulphonate (SO3-) groups adsorb proteins, resulting in an apparent activation. Polystyrene surfaces bearing both types of groups in close proportions are not activators in human serum, due to the adsorption of a protein of the alternative pathway, which has a protecting effect, not found when a polymer surface bearing hydroxyl groups is mixed in serum with another polymer surface bearing SO3- groups. In the presence of purified proteins of alternative pathway, C3 convertase activity can be created on each of these surfaces by deposition of C3b, but their susceptibility to inactivation by regulatory proteins H and I depends on the types of chemical groups present on the surface and whether the surfaces were passivated or not before C3b deposition.

[Homozygotic C5 deficiency disclosed by purulent Neisseria meningitidis meningitis]. / Déficit homozygote en C5 révélé par une méningite purulente à Neisseria meningitidis.

The complement system functions to protect the individual against infectious agents. Deficiencies of the late-acting complement proteins C5-C8 are associated with an increased susceptibility to Neisseria infection. This paper describes a deficiency in C5 in a Caucasoid family from the north of France that was revealed by the occurrence of a N. meningitidis meningitis in the homozygous C5-deficient propositus.

[Paroxysmal nocturnal hemoglobinuria. Increase in proteins of the alternative complement pathway]. / Hémoglobinurie paroxystique nocturne. Elévation des protéines de la voie alterne du complément.

Increased activity of the complement alternative pathway proteins C3, B and H was found in the sera of 16 patients with paroxysmal nocturnal haemoglobinuria (PNH). This increased activity might depend on protein hypersynthesis secondary to in vivo low-grade complement consumption by abnormal erythrocytes in PNH patients, despite the fact that serum levels of C3d were found to be normal. B and H activities were directly related; however, the B/H ratio was higher in patients whose sera had been taken early after an episode of haemoglobinuria. Activation of the alternative pathway, which is known to result in vitro lysis of PNH erythrocytes, only accounts for part of the events leading to chronic haemolysis and haemoglobinuria in vitro.

[Components of the classical complement pathway in systemic lupus erythematosus]. / Les composants de la voie classique du complément au cours du lupus érythémateux disséminé.

Measurements of complement components in sera from patients with systemic lupus erythematosus (SLE) and some of their relatives indicated that decreased levels of CH50, C4 and C2 were mostly related to a genetic deficiency at one or both of the loci coding for C4, at least in those patients in whom decreased C4 levels were associated with normal C1 hemolytic activity. C4 deficiency is either isolated or associated with complement activation. In some patients with C4 deficiency, complement activation could only be demonstrated by measuring plasma level of the C3 cleavage fragment, C3a des Arg. Decreased concentration and/or hemolytic activity of C4 and C2 in SLE cannot be used to assess the activity of the disease.

[Phase II trial evaluating the effect of megestrol acetate-prednisolone combination in the treatment of anorexia during the palliative-care phase of lung cancer]. / Essai de phase II évaluant l'effet d'une association acétate de mégestrol et prednisolone dans le traitement de l'anorexie au cours du cancer bronchique en phase palliative.

OBJECTIVES: Anorexia is one of the most frequent complaints in patients who have reached the palliative-care phase of lung cancer. Megestrol acetate (or medroxyprogesterone acetate) and corticosteroids have been used with success, but the effect of their combination remains unknown. We conducted a phase II trial to assess the impact of combination therapy. PATIENTS AND METHODS: Patients with lung cancer given palliative care and who developed anorexia with or without weight loss were given 320 mg/d megestrol acetate in 2 doses and 40 mg/d prednisolone in one dose in the morning for 1 month. The principal outcome criterion was anorexia assessed on a visual analog scale prior to treatment and then at day 15 and day 30. Variation in daily calorie intake and weight were also recorded. We used an Armitage sequential plan to determine the number of inclusions necessary and the preference method (closed schema) to evaluate the principal outcome criterion. RESULTS: Inclusions were stopped after the eighth patient (giving p<0.05) as we observed a significant improvement in patient appetite. Daily calorie intake improved significantly (p<0.0001), by 39.18% the first 15 days and 16.57% more the next 15 days. Body weight improved significantly by 5.4% in one month (p=0.5). No treatment-related complication occurred during the study period or during the six consecutive months. CONCLUSIONS: The megestrol acetate-prednisolone combination was found to improve anorexia in patients with lung cancer in the palliative-care phase and allowed a significant improvement in calorie intake and body weight.

[Lupus and protein deficiencies of the classical complement pathway]. / Lupus et déficits en protéines de la voie classique du complément.

Deficiencies in proteins of the classic complement pathway are particularly frequent in patients with autoimmune diseases, notably systemic lupus erythematosus (SLE). The C4 component is a polymorphous glucoprotein coded by two closely linked genes, C4A and C4B, located within the HLA complex. C4, and in particular the C4A isotype plays a major role in maintaining immune complexes in solution. Fifty percent of patients with SLE are homozygous or heterozygous to the silent allele C4 AQO. Hereditary CE deficiency is often complicated by lupus-related diseases which may be associated with repeated infections. The biological particularity of SLE associated with complement protein deficiencies is the frequency of anti-SSA (Ro) antibodies.