An immunohistological study of CD4+ lymphocyte subsets within inflammatory lesions with special reference to rheumatoid arthritis and inflammatory bowel disease.

The monoclonal antibodies (mAbs) WR16, UCHL1 and WR19 identify subsets of CD4+ lymphocytes that have been functionally characterized as suppressor inducer cells or helper inducer cells. These were applied as components of a panel of lymphocyte-specific mAbs for the phenotypic analysis of lymphocyte populations within biopsies taken from rheumatoid synovial membrane and normal and inflamed gut. The phenotype of peripheral blood lymphocytes from patients with rheumatoid arthritis were also compared to normal controls. The rheumatoid synovium was characterized immunohistologically by a lymphocytic infiltrate composed predominantly of CD4+ lymphocytes and a CD4:CD8 ratio of 2.4. The CD4+ population was composed of UCHL1+ cells to the exclusion of WR16+ cells. This finding was confirmed by double immunofluorescence staining using directly conjugated Leu-3a and WR16. The UCHL1+/WR16-/CD4+ phenotype was maintained in the synovial biopsies regardless of whether the patient had commenced treatment with disease modifying drugs. The absence of WR16+ cells within the rheumatoid synovium was shown to be a localized phenomenon as there was a slight elevation of circulating WR16+ lymphocytes in the peripheral blood of rheumatoids whilst the levels of UCHL1+ and WR19+ lymphocytes remained unchanged. As no appropriate normal control tissue is available for comparison to the rheumatoid synovium we also examined the lymphocytes present within Crohn's disease-involved bowel biopsies and compared them to normal gut tissue lymphocytes using WR16 and UCHL1 mAbs. The CD3+ lymphocytes present within normal tissue comprised a mixture of WR16+ and UCHL1+ cells. In contrast the CD3+ lymphocytes within Crohn's involved tissue were exclusively UCHL1+ as previously observed in the rheumatoid synovium. These data indicate that the CD4+ lymphocyte infiltrate present within inflammatory lesions of presumed distinct aetiology exhibit a localized selective loss of cells with the CD45R+/CD4+ suppressor inducer phenotype. This may be a consequence of the selective extravasation of CD4+ helper induced cells or more likely, in view of the previously documented loss of the p220 molecule identified by CD45R mAbs upon T-cell activation, the result of CD4+ T-cell activation at sites of inflammation.

An investigation of the action of disease modifying antirheumatic drugs on the rheumatoid synovial membrane: reduction in T lymphocyte subpopulations and HLA-DP and DQ antigen expression after gold or penicillamine therapy.

Synovial needle biopsy specimens from the knee joints of seven patients with rheumatoid arthritis (RA) were examined immunohistochemically before and after six months' treatment with either gold or penicillamine (disease modifying drugs, DMDs). There were significant reductions in the numbers of infiltrating T lymphocytes and a disproportionate fall in the numbers of lymphocytes of the helper/inducer subset when compared with those of the suppressor/cytotoxic subset. This resulted in a fall in the ratio of helper/inducer to suppressor/cytotoxic cells. The immunohistological changes correlated with improvements in erythrocyte sedimentation rate (ESR), serum immunoglobulins, visual analogue pain assessment, grip strength, and Ritchie articular index. A second group of nine patients with RA, already well established on DMD therapy, did not show similar changes after the six month period. The HLA class II antigens DR, DQ, and DP were widely expressed on lymphocytes, macrophages, and synovial lining cells of a group of patients with RA who had never received disease modifying drug therapy. After treatment there was a significant reduction in the expression of HLA-DP and DQ antigens.

Urinary monoclonal free light chains in primary Sjögren's syndrome: an aid to the diagnosis of malignant lymphoma.

Three patients, two with typical primary Sjögren's syndrome (SS) and the third with several features of SS, including abnormal sialography and reduced tear secretion, developed B cell non-Hodgkin's lymphoma (NHL) of parotid or lung, or both. Isoelectric focusing of concentrated urine specimens in agarose, followed by immunofixation, demonstrated the presence in each patient's urine of monoclonal free light chains of the same class as that shown on the tumour cells. In one patient the level of urinary free light chains was monitored and found to correlate with disease activity. Similar techniques showed no monoclonal light chains in the urine from a further 26 cases of SS with no clinical evidence of lymphoma. The detection of monoclonal urinary free light chains may provide an early diagnostic clue to the development of lymphoma in patients with SS and be a means of tumour monitoring.

Analysis of soluble HLA class II antigenic material in patients with immunological diseases using monoclonal antibodies.

A quantitative assay for soluble human HLA Class II antigenic material is described. The method is a double-determinant ELISA using 2 monoclonal antibodies which recognize different epitopes on the antigen. The first rat monoclonal antibody captures antigen onto the microplate where it is then recognized by a second mouse monoclonal antibody. Bound mouse immunoglobulin is then detected by an enzyme-linked rat polyclonal antibody. The assay has been used to measure soluble HLA Class II antigen in the sera from healthy individuals and patients with leukaemia, and has shown raised levels in acute lymphoblastic but not in chronic lymphocytic leukaemia. Similar material has been identified in synovial fluid of patients with active rheumatoid arthritis. The assay is specific and simple to perform and should be applicable to probing the nature of the soluble material and its mechanism of release.

Lymphoma in Sjögren's syndrome: urinary monoclonal free light chains as a diagnostic aid and a means of tumour monitoring.

Non Hodgkins lymphoma (NHL) is reported to be at least 40 times more common in Sjögren's syndrome (SS). Diagnosis may be difficult as blood and bone marrow haematology can remain normal, with no evidence of a serum paraprotein band or Bence-Jones proteinuria by routine electrophoresis. Using the technique of isoelectric focusing in agarose, followed by immunofixation, monoclonal free light chains can be found in the urine of 44% and 74% respectively of patients with NHL and B cell chronic lymphocytic leukaemia, but not in normal individuals. Three patients, two with typical severe primary SS and the third with several features of SS including abnormal sialography and reduced tear secretion, developed B cell NHL of parotid and/or lung. Using the above method on concentrated urine specimens, monoclonal free light chains of the same class as that demonstrated on the tumour cells were found to be present in each patient's urine. In one patient the level of urinary free light chains was monitored and found to correlate with disease activity. Using similar techniques no monoclonal light chains could be found in the urine from a further 10 cases of primary SS and 18 cases of SS secondary to rheumatoid arthritis, all of whom had no clinical evidence of lymphoma. Screening of SS patients' urine by the method described for monoclonal urinary free light chains may provide an early diagnostic clue to the development of lymphoma and be a means of tumour monitoring.

A double-blind, cross-over, study of oral N-acetylcysteine in Sjögren's syndrome.

Twenty-six patients with primary or secondary Sjögren's syndrome were treated in a double-blind, cross-over trial for a four week period with oral N-Acetylcysteine and placebo. Before treatment there were significantly elevated salivary lactoferrin levels in the patients when compared to 51 healthy controls (p = 0.0005), and significantly decreased levels of tear lysozyme when compared to 24 controls (p = 0.0003). Salivary sodium, potassium, inorganic phosphate, amylase and immunoglobulin G, A or M levels were not significantly different from control values. After treatment with N-Acetylcysteine, Sjögren's syndrome patients reported improvements in ocular soreness (p = 0.004), ocular irritability (p = 0.006), halitosis (p = 0.033) and daytime thirst (p = 0.033). N-Acetylcysteine, but not placebo improved the van Bijsterveld score (p = 0.026), but neither agent improved the Schirmer test, the tear break up time or any of the laboratory tests. These results suggest that N-Acetylcysteine may have a true therapeutic effect on the ocular symptoms of Sjögren's syndrome and be worthy of a longer study.

Lymphocytic interstitial pneumonia identified as lymphoma of mucosa associated lymphoid tissue.

The widespread interstitial pulmonary infiltration in two patients, showing the clinical, radiological and histological features of lymphocytic interstitial pneumonia (LIP), has been characterized by histological and immunological criteria as malignant lymphoma of follicle centre cell (FCC) origin with plasmacytic differentiation. One patient also had malignant lymphoma of the parotid glands which had been present for many years and was previously considered benign (benign lymphoepithelial lesion). The other patient had a long history of Sjögrens syndrome. The lymphomas in these patients are presented as typical examples of malignant lymphoma of mucosa-associated lymphoid tissue.