Immunoregulatory defects of V alpha 24V+ beta 11+ NKT cells in development of Wegener's granulomatosis and relapsing polychondritis.

The frequency of either CD4(-)8(-) (double negative; DN) or CD4(+) V alpha 24(+)V beta 11(+) NKT cells, the expression of CD1d and the binding of CD1d-tetramer loaded with alpha-galactosylceramide (alpha-GalCer) to NKT cells were analysed in peripheral blood mononuclear cells (PBMCs) of patients with Wegener's granulomatosis (WG), relapsing polychondritis (RP) and healthy subjects (HS). DN and CD4(+) V alpha 24(+)V beta 11(+) NKT cells as well as CD1d-alpha-GalCer tetramer-positive NKT cells, were significantly decreased in number in both WG and RP patients compared to those from HS. When cytokine profiles were analysed in these PBMCs upon stimulation with phorbol ester and calcium ionophore, CD4(+) T cells from patients with WG and RP exhibited a Th1 bias, whereas CD4(+) NKT cells from WG patients in remission showed a Th2 bias. These findings suggest that NKT cells (especially CD4(+) NKT cells) play a regulatory role in Th1 autoimmunity in patients with WG and RP. The reduction in NKT cell counts appears to be associated with the low responsiveness to alpha-GalCer. The dysfunction of NKT cells to recognize ligands such as alpha-GalCer may also contribute to the defects observed in NKT cells from WG and RP patients.

Churg-Strauss syndrome with pachymeningitis refractory to steroid therapy atone--a case report.

Churg-Strauss syndrome (CSS) is a rare syndrome of unknown cause, which is characterized by bronchial asthma and hypereosinophilia followed by systemic symptoms of angiitis. In 1951, Churg and Strauss first distinguished this disease from periarteritis nodosa. Our patient in particular was also complicated with otorhinological symptoms, which have less frequently been reported in CSS cases. We have detailed her clinical symptoms.

Histological findings in biopsies from patients with cytoplasmic-antineutrophil cytoplasmic antibody (cANCA)-positive Wegener's granulomatosis.

OBJECTIVE: Currently Wegener's granulomatosis (WG) is diagnosed from clinical features, a test for antineutrophil cytoplasmic antibody (ANCA) and histological confirmation. The purpose of our study was to evaluate histological findings, in particular those in the biopsy samples of head and neck region. METHODS: Fifty-one biopsy specimens from 24 WG patients who were confirmed to be positive for cANCA were examined retrospectively. RESULTS: Only 12 biopsies out of 51 biopsies (24%) were diagnosed as typical of WG, and diagnosis could be confirmed in only 10 patients (42%) as typical of WG from the results of multiple biopsy specimens. CONCLUSION: In the diagnosis of WG. biopsy can be utilized restrictedly only in the cases when cANCA is negative or clinical symptoms are atypical of WG.

Correlation between the levels of circulating adhesion molecules and PR3-ANCA in Wegener's granulomatosis.

OBJECTIVE: The adhesion of neutrophils to the vascular endothelial cells appears to be important for the pathogenesis of vasculitis in Wegener's granulomatosis (WG). To determine the pathological significance of the neutrophil adhesion, we have examined and evaluated the relationships between the levels of adhesion molecules and proteinase-3 anti-neutrophil cytoplasmic antibodies (PR3-ANCA), and between the levels of TNF-alpha and disease activities in WG. METHODS: sELAM-1 and sICAM-1 in sera from WG and healthy donors were detected by ELISA. SLex and LFA-1 on neutrophils were detected by flow cytometry. RESULTS: The level of sICAM-1 was significantly higher in active WG than in inactive WG, tending to reflect individual disease activities. There was no difference in the level of sELAM-1 between WG patients and healthy donors. CONCLUSION: Our study suggests that the adhesion of neutrophils to the vascular endothelium is significant for the pathogenesis of the vasculitis in WG.

A mitochondrial encephalo-myo-neuropathy with a nucleotide position 3271 (T-C) point mutation in the mitochondrial DNA.

We report three members of a family, who exhibited a phenotype similar to 'myoclonus epilepsy with ragged-red fibers' but had a genotype usually associated with 'mitochondrial encephalomyopathy with lactic acidosis and stroke-like episodes'. The patients, a 48-year-old female, and her two sons, aged 21 and 19 respectively, presented with photo-reactive syncopal episodes, disturbances of gait and writing, dysarthria and finger tremor since the 3rd and 2nd decade of life, respectively, that were accompanied also by numbness and weakness of the extremities. Subsequently, cerebellar ataxia and myoclonus were also noted. Electromyography revealed both myogenic and neurogenic muscular changes, and nerve conduction studies demonstrated a sensory-motor neuropathy. Biopsy showed ragged-red fibers with strongly stained SDH-positive vessels in skeletal muscles, and a marked loss of myelinated fibers of the sural nerves. Mitochondrial (mt) DNA analyses of peripheral blood, muscles and nerves revealed that all members had a heteroplasmic np3271 (T-C) point mutation in the mitochondrial tRNA-Leu gene (UUR). This family is unique, in that all patients presented with a myoclonus epilepsy with ragged-red fibers-like phenotype and had a distinctive peripheral neuropathy, while the detected mtDNA 327l (T-C) mutation has been reported to date only in rare cases of mitochondrial encephalomyopathy with lactic acidosis and stroke-like episodes

P-ANCA-positive Wegener's granulomatosis presenting with hypertrophic pachymeningitis and multiple cranial neuropathies: case report and review of literature.

An autopsy case of hypertrophic pachymeningitis and multiple cranial neuropathies is reported. A 53-year-old woman with paraplegia and various neurological signs which developed over a 2 year period was diagnosed as having an epidural mass with thickened dura mater extending from the lower cervical to the thoracic spinal cord. In addition, bilateral episcleritis, blephaloptosis, and blindness of the right eye with various cranial nerve deficits were found to be caused by the mass lesions involving the paranasal sinuses, orbit, and the cavernous sinus. Perinuclear antineutrophil cytoplasmic antibody (p-ANCA) was positive, but cytoplasmic antineutrophil cytoplasmic antibody (c-ANCA) was negative by enzyme-linked immunosorbent assay. The partially removed epidural mass with hypertrophied dura mater and biopsy of the paranasal lesions showed chronic granulomatous inflammation with vasculitis. The remaining lesions resolved with steroid therapy with remarkable neurological improvement. The positive p-ANCA test, paranasal involvement, the report of a similar histopathological case and a review of the literature on granulomatous pachymeningitis suggest the presence of p-ANCA-positive Wegener's granulomatosis with central nervous system involvement characterized by hypertrophic pachymeningitis and/or multiple cranial neuropathies.

Oculopharyngeal muscular dystrophy in a Japanese family with a short GCG expansion (GCG)(11) in PABP2 gene.

Clinicopathological and molecular genetic findings on a new Japanese family with oculopharyngeal muscular dystrophy are reported. The family has 54 members, ten of whom are affected (seven male and three female), in 3 generations. Three affected males, one affected female and one unaffected female of seven living siblings in the third generation were examined. Bilateral ptosis developed in the 4th and 5th decades in the three male cases, and in the 7th decade in the female, and this was followed by diplopia, nasal voice, dysphagia and muscle weakness. In addition, severe external ophthalmoplegia, dysphonia, and proximal amyotrophy were prominent in this family. Electromyographs revealed myogenic/neurogenic changes, and computed tomography disclosed selective muscle wasting with fatty replacement, predominantly in the lower extremities. Muscle biopsy in the four affected patients showed variation in fiber size, and the presence of small angulated fibers and occasional rimmed vacuoles. Electron microscopic examination revealed an accumulation of filamentous inclusions in muscle fiber nuclei. DNA analysis identified that (GCG)(6) in the PABP2 gene was expanded to (GCG)(11) in the four affected cases examined. All studies were negative in the one unaffected. These results confirm that OPMD is caused by GCG short expansion and provides insights into the genetic mechanisms which may contribute to adult onset myopathy, confined to oculopharyngeal muscles.

A case of bilateral optic neuropathy and recurrent transverse myelopathy associated with perinuclear anti-neutrophil cytoplasmic antibodies (p-ANCA).

A case involving a 52-year-old man having bilateral optic neuropathy and recurrent transverse myelopathy is reported. His clinical features resembled multiple sclerosis, but neuroimaging failed to show evidence of demyelination or inflammation in the brain or the optic nerves. The patient experienced sudden visual loss despite massive steroid therapy. Positive perinuclear anti-neutrophil cytoplasmic antibody (p-ANCA) is suggestive that optic neuropathy and recurrent transverse myelopathy may have been caused by some common inflammatory processes associated with p-ANCA, however, having a different etiology from multiple sclerosis.

The association between human leukocyte antigens (HLA) and cytoplasmic-antineutrophil cytoplasmic antibody (cANCA)-positive Wegener's granulomatosis in a Japanese population.

The present study examined the association between various human leukocyte antigens (HLA) and cytoplasmic-antineutrophil cytoplasmic antibody (cANCA)-positive Wegener's granulomatosis (WG) in Japanese subjects to determine whether HLA antigens are involved in the pathogenesis of this disease. The study involved 16 subjects with cANCA-positive WG treated in our department. HLA-typing of the lymphocytes was performed using a lymphocyte microcytotoxicity assay. Of the subjects with cANCA-positive WG, 62.5% (10/16) were positive for HLA-DR9, as compared to 26% of the healthy control subjects. This HLA-DR9 elevation was statistically significant (p < 0.01, Pc < 0.05); we also noted a weaker association between HLA-B55 and cANCA-positive WG (p < 0.05). The results indicate that an association may exist between certain HLA-class allotypes and WG.

Thyroplasty type I with ceramic shim.

To prevent side effects from a silicone shim in Isshiki thyroplasty type I, we used a ceramic shim in 10 patients with unilateral recurrent laryngeal nerve paralysis. No published reports have described the use of ceramic in this type of surgery. According to the degree of glottic insufficiency, ceramic shims of various heights were inserted into the fenestration made in the thyroid ala. All patients experienced subjective improvement of voice postoperatively. Laryngoscopies in most cases showed that glottic insufficiency improved postoperatively. In the postoperative examination, the maximum phonation time improved an average of 3.7 s, and the mean flow rate improved an average of 331 ml/s. We have analyzed the relationship of these improvements to the degree of glottic insufficiency and have compared our results with those of other investigators.

[Antineutrophil cytoplasmic antibody (C-ANCA) levels in relation to the treatment of Wegener's granulomatosis].

We assessed the clinical significance of cANCA in relation to the diagnosis and follow-up of Wegener's granulomatosis patients using NephroScholor C-ANC, the ELISA kit for the detection of cANCA. The NephroScholor C-ANC test for cANCA was revealed to be useful for the diagnosis of Wegener's granulomatosis, but slightly less sensitive than the indirect immunofluorescence assay using human neutrophils, which has been in widespread use for the detection of ANCAs. With NephroScholor C-ANC, the cANCA titer can be estimated conveniently and expressed quantitatively. When conventional immunosuppressive therapy with prednisolone and cyclophosphamide was applied, the patients' symptoms subsided as the cANCA titer decreased, and thus it also seemed useful for the follow-up of Wegener's granulomatosis patients. However, a rising ANCA titer during the course of the disease was not always correlated with the occurrence of a relapse as previously reported. Based on these findings, it is not recommended that treatment be changed immediately because of elevation of the ANCA titer alone, and it never seemed too late to increase immunosuppressive therapy, even after a clinical exacerbation was observed. Several treatments other than the conventional immunosuppressive therapy have often been applied for our patients, especially in the limited type of this disease, and these treatments, including sulfamethoxazole-trimethoprim alone, low-dose prednisolone alone, and cyclophosphamide alone, have often been useful. We conclude that the choice of therapy must depend on the severity or the condition of the individual patient, and this therapeutic policy should reduce unnecessary side effects of potentially toxic drugs.

[Clinical study of subglottic carcinoma].

Recently, therapy for laryngeal carcinoma has been becoming established, particularly in the early stage. The prognosis of laryngeal carcinoma is said to be better than that of other head and neck carcinomas. Laryngeal carcinoma is divided into 3 subtypes, supraglottic, glottic and subglottic, according to origin. We analyzed the subglottic carcinomas diagnosed and treated in our department between 1972 and 1990. During that period we treated 515 cases of laryngeal carcinoma, 204 cases of the supraglottic type, 284 cases of the glottic type, and 27 cases (5.2%) of the subglottic type. The 5-year survival rate in subglottic carcinoma was 44% (T1: 83%, T2:55%, T3: 17%, T4: 0%), worse than in the other types of laryngeal carcinoma. We think that there were 2 main reasons for the worse prognosis. The first was their high rate of local recurrence after radiation therapy particularly in the early stage. Although 15 T1 and T2 patients who received full dose (65Gy) radiotherapy had a complete response, 8 patients developed local recurrence. The results of the salvage operation were good in T1 cases, but were followed by death because of metastasis or second recurrence in 2 of the 3 T2 patients. The second reason for the worse prognosis appeared to be metastasis in the advanced cases. Five (50%) T3 and T4 patients developed metastasis to the lung, mediastinum and cervical lymph nodes, resulting in death. Thus, we believe that the main therapy for subglottic carcinoma, except T1, should be surgery to obtain a better outcome, and that adjuvant chemotherapy after irradiation or neck (paratracheal) dissection with total laryngectomy should be performed in advanced cases.

[Four cases of olfactory neuroblastoma treated with craniofacial surgery].

We report 4 cases of olfactory neuroblastoma with anterior cranial fossa extension treated by craniofacial surgery. Three patients have been alive and well for 4 years, 1 year and 11 months after the initial treatment without major surgical complications but one patient died of local recurrence 11 months after treatment. Multidisciplinary surgery for olfactory neuroblastoma with intracranial extension permits radical tumor excision and reconstruction of the anterior skull base. This one-stage procedure combining neurosurgery and plastic surgery with pre or post-operative radiotherapy is considered to be essential for eradicating this tumor.

[An ELISA for the detection of anti-neutrophil cytoplasmic antibodies using the cytoplasmic alpha-fraction--clinical use for the diagnosis of Wegener granulomatosis and for monitoring its activity].

Anti-neutrophil cytoplasmic antibodies (ANCA) have been reported to be a disease-specific marker for Wegener's granulomatosis (WG). In the present study we developed an enzyme-linked immunosorbent assay (ELISA) for detecting and quantifying ANCA. The cytoplasmic alpha-fraction of neutrophils obtained from healthy human donors was used as an antigen. The alpha-fraction was purified from supernatants of homogenized neutrophils by sucrose gradient centrifugation. Peroxidase conjugated rabbit anti-human IgG was used as a secondary antibody. Diluted sera from 13 patients with WG, 15 with Sjögren syndrome, 1 with polymorphic reticulosis, 3 with relapsing polychondritis, 4 with other collagen diseases, 4 with sinusitis and 18 healthy donors were examined. It was concluded that this ELISA was sufficiently specific and sensitive for WG, and the ELISA units correlated individually with the ANCA titers as determined by an indirect immunofluorescence technique. This ELISA provides precise ANCA quantitation and will be useful for the diagnosis of WG and for monitoring its activity.

[Clinical significance of anti-neutrophil cytoplasmic antibody (ANCA) for the diagnosis of Wegener's granulomatosis in the early stage].

In recent years, the prognosis of Wegener's granulomatosis (WG) has been dramatically improved by treatment with cyclophosphamide and glucocorticoids, if the diagnosis is made correctly in the early stage of the disease. However, it is often difficult to diagnose of WG relying only on clinical symptoms and histological confirmation with biopsy specimens. Anti-neutrophil cytoplasmic antibody (ANCA) has already been reported to have high sensitivity and specificity for WG. Since February, 1991, we examined this antibody level in the sera of patients suspected of having WG using an indirect immunofluorescence technique, and have experienced nine WG patients who were ANCA positive. Six of the 9 patients showed limited forms of WG before active generalized symptoms developed, and only 3 were diagnosed as having WG with pathologic findings from their biopsy samples. These results show that correct diagnosis of WG is possible with the aid of ANCA determination, even if the patient has a limited form of the disease and even without evidence of characteristic pathologic features of WG on biopsy specimens. Therefore, it is apparent that ANCA determination is a valuable tool for diagnosing WG as early as possible. In Japan, the ANCA test is not as yet a common laboratory examination and has only rarely been used as seromarker for the diagnosis and treatment of WG. We believe that ANCA determination is essential for the diagnosis of WG, especially in its early stage, which leads to a better prognosis for WG patients.

[Leukemic infiltration of the mastoid bone--cytologic examination of exudate in the tympanic cavity as a useful diagnostic method].

Although otologic involvement by leukemic infiltration was supposed to be unusual, increasing number of cases have been reported in recent years, probably due to the advance of chemotherapy, improved remission rate and longer survival of leukemic patients. Two cases of myelogenous leukemia with infiltration of mastoid bone were reported. One is 15-year-old girl with acute myelogenous leukemia, which had been well controlled for 1 year, developed a sudden onset of facial nerve palsy. The other is 30-year-old female with chronic myelogenous leukemia and blastic crisis, complained hearing loss. As both cases had exudate in the tympanic cavity, the punctures were carried out through the eardrum. The pathological study of these exudate cells revealed the involvement of mastoid bone by leukemia. The cytologic examination of exudate in the tympanic cavity is simple, time-sparing and of little burden to the patient. This technique is very useful and supposed to take the place of the exploratory surgery of mastoid cavity which is previously considered necessary for the correct diagnosis.

[Tumor-associated impairment of the processing of hepatoma cathepsin D].

Cathepsin D was purified to apparently homogeneous form from normal human liver and hepatoma. The purified enzyme could not be distinguished between normal liver and hepatoma in terms of specific activity, subunit composition, antigenicity, amino acid composition and tryptic peptides. However, the hepatoma enzyme exhibited more charge heterogeneity to give multiple acidic variant forms which were devoid or much less in the normal liver enzyme. When the hepatoma enzyme was treated with endo-beta-N-acetylglucosaminidase H, the acidic variant forms disappeared and were converted into forms identical to those of normal liver. The content of mannose-6-phosphate in the hepatoma enzyme was twice as much as that in the normal liver enzyme. Thus, charge heterogeneity found in hepatoma cathepsin D is ascribed to increased phosphorylation on oligosaccharides bound to the enzyme, most probably due to cancer-associated, impaired processing in carbohydrate moiety. A significant elevation of cathepsin D activity per tissue proteins was observed in hepatoma as compared to normal liver. In contrast, true specific activity per cathepsin D protein in hepatoma was significantly lowered than that of normal liver. The lower true specific activity in hepatoma tissue may be attributed to an increased content in an inactive, large-molecular precursor form of the enzyme.

Elevated activity and increased mannose-6-phosphate in the carbohydrate moiety of cathepsin D from human hepatoma.

A significant elevation of cathepsin D activity was observed in six human hepatoma tissues as compared to 12 normal human livers. In isoelectric focusing experiments, cathepsin D purified from normal liver exhibited three different forms, with isoelectric points of 5.6, 6.1, and 6.7, while cathepsin D purified from hepatoma contained another five to six more acidic forms in addition to the forms observed in normal liver cathepsin D. When the tumor enzyme was treated with endo-beta-N-acetylglucosaminidase H followed by isoelectric focusing, the acidic components disappeared and were converted to forms identical to those of the normal liver cathepsin D. Determination of the mannose-6-phosphate content showed that hepatoma cathepsin D contains twice as much mannose-6-phosphate as normal liver cathepsin D. Peptide mapping and amino acid analysis showed that the protein moiety of cathepsin D from hepatoma is almost identical with that from normal liver. These findings indicate that the appearance of acidic variants in hepatoma cathepsin D is mainly due to changes in the oligosaccharide chains of the enzyme, which are closely associated with the increase of mannose-6-phosphate in the tumor enzyme.