A neutrophil-dependent pathway for the generation of a neutral peptide mediator: partial characterization of components and control by alpha-1-antitrypsin.

A biologically active neutral peptide mediator is cleaved from a plasma protein substrate by an alpha-1-antitrypsin-inhibitable serine protease apparently residing on the membrane of the human neutrophil. The peptide mediator has an approximate mol wt of 1,000, and is distinguished from the kinin peptides by a neutral isoelectric point, susceptibility to inactivation by trypsin as well as chymotrypsin and activity on the isolated, atropinized, and antihistamine-treated guinea pig ileum with relatively little action on the estrous rat uterus. The neutrophil protease is fully inhibitable by DFP, trypsin inhibitors from lima or soy bean, and alpha-1-antitrypsin and is associated with the high mol wt fragments of the neutrophil and not the nuclear, lysosomal, or cytoplasmic subcellular fraction. The substrate has an approximate mol wt of 90,000 and is chromatographically separable from kininogen. The exquisite sensitivity of the neutrophil protease to alpha-1-antitrypsin was established both by inhibition with highly purified alpha-1-antitrypsin and by the inability of the protease to generate detectable neutral peptide in a homozygous (ZZ) alpha-1-antitrypsin-deficient patient without heat inactivation of the residual inhibitor. On the other hand, plasma from a (null) alpha-1-antitrypsin-deficient patient supported neutral peptide generation and revealed an additional factor which inactivated neutral peptide.

A human neutrophil-dependent pathway for generation of angiotensin II. Purification of the product and identification as angiotensin II.

A human neutrophil lysosomal protease interacts at physiologic pH with a 62,000--67,000-mol wt plasma protein substrate to generate a vasoactive, smooth muscle-contracting "neutral" peptide. The peptide product of this system, previously designated the "neutral" peptide-generating pathway, was generated from purified components and purified by Bio-Gel P2 gel filtration and reverse-phase high performance liquid chromatography with a 50--60% yield of starting activity. The purified peptide had an amino acid composition of Asx, Pro, Val, Ile, Tyr, Phe, His, Arg, a composition identical to that of angiotensin II. The peptide and synthetic angiotensin II each filtered at 48--52% bed volume on Bio-Gel P2, had an isoelectric point of Ph 7.8--8.1 at 4 degrees C, migrated 3 cm toward the cathode during pH 6.4 low-voltage paper electrophoresis, and had a retention time of 44.8 min during reverse-phase high-performance liquid chromatography. In addition, the functional activity of the peptide at each purification step correlated with angiotensin II content determined by specific radioimmunoassay. The amino acid sequence of 25 nmol of the peptide was Asp-Arg-Val-Try-Ile-His-Pro-Phe, the same covalent structure as that of angiotensin II. Therefore, under physiologic conditions, in the absence of renin or angiotensin converting enzyme, a human neutrophil neutral protease cleaves a plasma protein to yield angiotensin II. This pathway provides a mechanism through which the neutrophil may alter local blood flow during inflammation by generation of a potent vasoactive peptide.

Purification and characterization of a human neutrophil neutral protease. The neutral peptide-generating protease.

A human neutrophil neutral protease which generates a low molecular weight peptide from a plasma protein substrate and cleaves the basic amino acid ester substrates alpha-N-p-tosyl-l-arginine methyl ester HCl, alpha-N-benzoyl-l-arginine-methyl ester HCl, and alpha-N-carbobenzoxy-l-lysine-p-nitrophenyl ester has been purified to homogeneity and distinguished from the known lysosomal neutrophil proteases. The starting activity was obtained from purified human neutrophils by homogenization, sedimentation by low-speed centrifugation, and high salt elution of the insoluble material. Purification was achieved by aprotinin-affinity chromatography, precipitation at low ionic strength, and gel filtration. The overall recovery, relative to the activity in the starting eluate of the neutrophil fraction, was congruent with50% with a 200- to 400-fold increase in specific activity. After treatment with diisopropylfluorophosphate to eliminate autodegradation, sodium dodecyl sulfate-polyacrylamide gel electrophoresis of reduced and unreduced protein gave a single protein band of 29,000-30,000 mol wt. The isoelectric point determined in sucrose gradients ranged from pH 7.8 to 8.3 with a peak at pH 8.0. This neutrophil protease, like cathepsin G and elastase, is composed of a single polypeptide chain of congruent with30,000 mol wt, but differs from cathepsin G and elastase in its less cationic isoelectric point and its failure to cleave synthetic substrates presenting an aromatic amino acid ester linkage and alanyl peptide bonds, respectively.

Identification of a human neutrophil angiotension II-generating protease as cathepsin G.

A human neutrophil protease, initially termed neutral peptide-generating protease, has been shown to cleave angiotensin II directly from angiotensinogen and has been identified as leukocyte cathepsin G. When purified neutrophils were disrupted by nitrogen cavitation and fractionated by differential centrifugation, 44 and 24% of the angiotensin II-generating activity was in the lysosomal and undisrupted cell fractions, respectively. Cytochalasin B-treated human neutrophils stimulated with N-formyl-L-methionyl-L-leucyl-L-phenylalanine released beta-glucuronidase, lysozyme, and angiotensin II-generating protease in a dose-dependent fashion, consistent with localization of this protease to the neutrophil granule. Individually purified angiotensin II-generating protease and cathepsin G had similar proteolytic and esterolytic activity for angiotensinogen and N-benzoyl-L-tyrosine ethyl ester on a weight basis, exhibited identical mobilities by SDS-gradient polyacrylamide gel electrophoresis and pH 4.3 disc-gel electrophoresis, and gave precipitin lines of antigenic identity on Ouchterlony analysis with goat antibody to the angiotensin II-generating protease. Thus, the angiotensin II-generating protease of human neutrophils has been identified as cathepsin G on the basis of subcellular localization, substrate specificity, physicochemical characteristics, and antigenic identity.

Human mast cell carboxypeptidase. Purification and characterization.

A carboxypeptidase activity was recently identified in highly purified human lung mast cells and dispersed mast cells from skin. Using affinity chromatography with potato-tuber carboxypeptidase inhibitor as ligand, mast cell carboxypeptidase was purified to homogeneity from whole skin extracts. The purified enzyme yielded a single staining band of approximately 34,500 D on SDS-PAGE. Carboxypeptidase enzyme content estimated by determination of specific activity, was 0.5, 5, and 16 micrograms/10(6) mast cells from neonatal foreskin, adult facial skin, and adult foreskin, respectively. Human mast cell carboxypeptidase resembled bovine carboxypeptidase A with respect to hydrolysis of synthetic dipeptides and angiotensin I, but was distinguished from carboxypeptidase A in its inability to hydrolyze des-Arg9 bradykinin. The amino acid composition of human mast cell carboxypeptidase was similar to the composition of rat mast cell carboxypeptidase. The amino-terminal amino acid sequence of mast cell carboxypeptidase demonstrated 65% positional identity with human pancreatic carboxypeptidase B, but only 19% with human carboxypeptidase A. Thus, human mast cell carboxypeptidase is a novel member of the protein family of zinc-containing carboxypeptidases, in that it is functionally similar but not identical to bovine carboxypeptidase A, but has structural similarity to bovine and human pancreatic carboxypeptidase B.

A human lung mast cell chymotrypsin-like enzyme. Identification and partial characterization.

We have used a high performance liquid chromatography assay, which detects chymotryptic cleavage of the phe8-his9 bond of angiotensin I to yield angiotensin II, in order to examine human lung mast cells for the presence of chymotryptic activity. Mast cells, purified from human lung by enzymatic dispersion, countercurrent elutriation, and Percoll gradient centrifugation, were lysed or challenged with goat anti-human IgE. In multiple experiments angiotensin II-converting activity was detected in lysates of 10-99% pure mast cell preparations. Regression analysis of net percent release values of histamine and the angiotensin I-converting activity from dose-response experiments demonstrated a correlation between the two parameters, indicating that the chymotrypsin-like enzyme is a constituent of the mast cell secretory granule. The chymotryptic activity was completely inhibited by 10(-3) M phenylmethylsulfonylfluoride but not by 10(-3) M Captopril, and the pH optimum of activity was 7.5-9.5. Gel filtration of released material separated the activity from tryptase and demonstrated an approximate molecular weight of 30-35,000. The mast cell enzyme, like a human skin chymotrypsin-like proteinase, can be distinguished from leukocyte cathepsin G by lack of susceptibility to inhibition by bovine pancreatic trypsin inhibitor. Thus, an enzyme with limited chymotryptic specificity is present in human lung mast cells. The Michaelis constant of the enzyme for angiotensin I of 6.0 X 10(-5) M is similar to that of endothelial cell angiotensin-converting enzyme and is consistent with a reaction of physiologic importance.

Inhibition of angiotensin-converting enzyme by des-Leu10-angiotensin I: a potential mechanism of endogenous angiotensin-converting enzyme regulation.

Des-Leu10-angiotensin I is a nonapeptide generated from angiotensin I by the action of carboxypeptidase-like activities residing in the human platelet and mast cell. This nonapeptide was found to inhibit rabbit lung angiotensin-converting enzyme (peptidyl-dipeptide hydrolase, EC 3.4.15.1) with a Ki of 3.1 X 10(-7) M. The mechanism of inhibition was competitive. Inhibition of human serum angiotensin-converting enzyme by des-Leu10-angiotensin I was comparable in magnitude to inhibition by bradykinin and angiotensin III. These results suggest that limited proteolysis of angiotensin I by cells resident in vascular tissue may result in the generation of an endogenous inhibitor of angiotensin-converting enzyme. Such pathways may play roles in controlling levels of vasoactive peptides at local vascular sites.

Identification of chemoattractant activity for lymphocytes in blister fluid of patients with bullous pemphigoid: evidence for the presence of a lymphokine.

Bullous pemphigoid is characterized by the dermal infiltration of lymphocytes, which precedes the striking influx of eosinophils as the lesion evolves into the bullous phase. This finding prompted a search for chemoattractant activity for lymphocytes in the blister fluid of untreated individuals with bullous pemphigoid. We found such activity in the bullous fluids of 6 consecutive patients but not in a patient with pemphigus vulgaris. This lymphocyte chemoattractant activity separates into 4 peaks upon Sephadex G-100 chromatography and the peak of 56,000 daltons was further evaluated. Upon quaternary aminoethyl Sephadex-anion exchange chromatography this peak elutes at 4-8 ms and with preparative isoelectric focusing it demonstrates an isoelectric point of 8.6-9.0. This activity was susceptible to degradation by trypsin and neuraminidase, but was stable upon heating to 56 degrees C for 30 min. Its chemoattractant activity is predominantly chemokinetic by checkerboard analysis. As defined by chromatography, stability, and functional characteristics, this activity is similar to a recently described human lymphocyte chemoattractant lymphokine. This finding suggests that products of activated lymphocytes are present in blister fluids of patients with bullous pemphigoid and may contribute to the early influx of lymphocytes in this disease.

Erythema multiforme: microvascular damage and infiltration of lymphocytes and basophils.

The sequence of alterations occurring in recurrent erythema multiforme was studied with clinical observations, 1-micrometer tissue sections, and immunofluorescence techniques. Lesions evolved through 3 stages: an initial red papule, a vesicle surmounting a red papule, and a target (iris) lesion. Focal endothelial cell swelling was present in clinically normal skin. In the red papule, endothelial cytoplasmic swelling, vacuolization, and nuclear hypertrophy with luminal obliteration of superficial venules developed. These venular alterations were more marked with endothelial cell necrosis, and involved deeper venules as well in vesicular and target lesions. Lymphocytes surrounded the venules and infiltrated the lower epidermis in the red papule and the vesicular lesions. Venular damage was correlated with the degree of infiltration by lymphocytes, apparently the primary effector cell, suggesting the venule as a primary target of injury. Hypogranulated basophils were noted around venules in vesicular and target lesions. Fibrin deposits were identified within and interstitially beneath the vesicles. The presence of lymphocytes, basophils, and interstitial fibrin deposition is similar to the changes of cutaneous delayed-type hypersensitivity and suggests a role for cell-mediated immunity in the pathogenesis of erythema multiforme.

In vitro pemphigus vulgaris model using organotypic cultures of human epidermal keratinocytes.

Using the Combi-ring-dish (CRD), a new culture device, organotypic cultures of human epidermal keratinocytes were grown on bovine eye lens capsules. In these highly differentiated cultures, typical suprabasal acantholysis was induced by pemphigus vulgaris antibodies. This in vitro pemphigus vulgaris model may be used to analyse keratinocyte-derived factors causing acantholysis in experimental pemphigus.

Angiotensin I conversion by human and rat chymotryptic proteinases.

Human skin chymotrypsin-like proteinase, human neutrophil cathepsin G, rat mast cell chymase, and rat salivary gland tonin are cell-derived serine proteinases of similar size with specificity for amino acids of aromatic residues. Each enzyme was examined for its ability to convert angiotension I to angiotensin II and to cleave a panel of synthetic substrates. Skin chymotryptic proteinase, cathepsin G, and tonin cleaved the phe8-his9 bond of angiotensin I and converted angiotensin I to angiotensin II without further degradation. In contrast, chymase formed relatively small amounts of angiotensin II because it preferentially cleaved the tyr4-ile5 bond of angiotensin I. The rank order of angiotensin I converting activity was skin chymotryptic proteinase greater than tonin greater than cathepsin G greater than chymase. The Km and Kcat for angiotensin I conversion by the human skin enzyme were 6.6 X 10(-5) M and 50 s-1, respectively. The angiotensin I converting activity of human skin chymotryptic proteinase is equal to or greater than the peptidyl dicarboxypeptidase angiotensin-converting enzyme. Substrate specificities of each enzyme were further distinguished by use of benzoyl-L-tyrosine ethyl ester. A limited immunologic characterization of each enzyme was performed with monospecific goat antiserum to cathepsin G and chymase by Ochterlony gel diffusion. Each antiserum gave a precipitin line against its respective immunogen without evidence of cross-reactivity against the other enzymes. Human skin chymotryptic proteinase, cathepsin G, and tonin provide unique pathways for the generation of angiotensin II in tissue and may be of significance in regulation of biologic processes of the tissue microenvironment. The kinetic constants of the human skin chymotryptic proteinase for angiotensin I conversion, are consistent with the potential to carry out a reaction of physiologic importance.

Bullous pemphigoid, an ultrastructural study of the inflammatory response: eosinophil, basophil and mast cell granule changes in multiple biopsies from one patient.

We have studied by electron and light microscopy the inflammatory reaction in lesions at various stages of clinical development from a patient with bullous pemphigoid. The evolution of clinical lesions was associated with a sequence of histopathologic events which began with alterations of mast cells and proceeded to infiltration, first with lymphocytes and later with eosinophils and basophils. Mast cells in the papillary and reticular dermis demonstrated a unique, focal, irregular loss of granule contents. Intact eosinophils demonstrated intracytoplasmic losses of granule contents and karyorrhectic and karyolytic eosinophils had released membranebound granules. Partially and completely degranulated basophils were present within a fibrin gel which formed in the dermis. Thus, the sequence of histopathologic events in the pathogenesis of bullous pemphigoid includes mast cell granule alterations and release of granule contents from eosinophils which are undergoing nuclear and cytoplasmic damage.

Human skin mast cell carboxypeptidase: functional characterization, cDNA cloning, and genealogy.

We functionally characterized human skin mast cell carboxypeptidase A (MC-CPA), and explored its evolutionary relationship to other carboxypeptidases to understand further the structural basis for the substrate preferences of this enzyme. Purified human skin MC-CPA displayed more activity than did bovine pancreatic carboxypeptidase A (CPA) against carboxyl-terminal leucine residues, about equal activity with phenylalanine and tyrosine residues, and no activity with tryptophan or alanine. To correlate kinetic data with structure, we isolated and sequenced a cDNA encoding MC-CPA from human skin, and directly sequenced 30% of the purified protein. These sequences agreed with that of human lung MC-CPA, and further support the evidence for a single MC-CPA gene in humans. Four amino acid replacements, resulting in a net positive change in non-hydrogen atoms in the S1' subsite of MC-CPA, were associated with less alteration in substrate specificity, relative to bovine CPA, than might be expected from studies using rat CPA1 and CPA2. We noted two consensus N-linked glycosylation sites in human MC-CPA that are not found in rat and mouse MC-CPA, or in bovine CPA; that at least one of these sites is glycosylated in vivo was verified by N-glycosidase F treatment, lentil lectin binding, and Concanavalin A-Sepharose chromatography. Evolutionary trees constructed from the known carboxypeptidase sequences suggested that MC-CPA most likely evolved from a carboxypeptidase B-like enzyme, independent of the pancreatic CPA. Thus, in the carboxypeptidase gene family, MC-CPA displays a unique genealogy and several amino acid replacements in its S1' binding pocket that result in substrate specificity quite similar to bovine CPA.

Lamellar body-enriched fractions from neonatal mice: preparative techniques and partial characterization.

Several problems have frustrated the isolation of lamellar bodies (LB) from mammalian epidermis. We obtained pellets enriched in intact LB by utilizing the staphylococcal epidermolytic toxin to provide intact, outer epidermal sheets, by controlled homogenization in a cell disrupter, and by passage of homogenates through a graded series of nuclepore filters (Science 221:962, 1983). Such preparations contained more intact LB than did fractions prepared by a variety of differential or sucrose/metrizamide discontinuous centrifugation methods. Initial characterization of the enzymatic content of this fraction revealed it to be enriched in certain hydrolytic enzymes (acid phosphatase, carboxypeptidase, cathepsin B, acid lipase, sphingomyelinase, and phospholipase A), but strikingly depleted in all sulfatases, beta-glucuronidase, and the non-lysosomal protease, plasminogen activator. Thus, LB show some properties of lysosomes, although certain characteristic lysosomal enzymes are strikingly absent. Lamellar body fractions contained 2-3 times more lipid per unit weight than did homogenates, and were enriched in phospholipids, free sterols, and glycosphingolipids, but not in other neutral lipids or ceramides. In summary, whereas some of the enzymes in LB could participate in the metabolism of LB lipid precursors to hydrophobic barrier constituents, others may attack intercellular constituents, ultimately resulting in desquamation. The lipid profile of these organelles suggests that they deliver precursors of permeability barrier lipids to intercellular domains.

Lymphocyte subsets and Langerhans cells/indeterminate cells in erythema multiforme.

A peroxidase-antiperoxidase study using monoclonal antibodies directed against T and B lymphocytes and Langerhans cells/indeterminate cells (LC/IC) was undertaken in order to understand more clearly the changes observed in erythema multiforme. At the various stages of development, from normal skin to target lesions, the quantity of inflammatory cells differed, but in each case the number of T8+ (cytotoxic/suppressor) cells was greater than the number of T4+ (helper/inducer) cells in the epidermis, whereas the latter exceeded the former in the dermis. Concomitant with the initial epidermis changes, there was an increase in the number of T6+ (LC/IC) cells in the upper and lower epidermis. With slight to moderate basal unit destruction, the number of LC/IC in the upper epidermis exceeded those in the lower epidermis. With severe basal unit destruction, there was a loss of LC/IC in the lower epidermis as detected by T6 reactivity. In fully formed blisters, the LC/IC in the upper half of the epidermis were decreased in parallel with the degree of epidermal necrosis. The character of the lymphocytic inflammatory infiltrate and redistribution in LC/IC are similar to those findings described in allergic contact dermatitis. The clinical, histologic, and immunopathologic changes in erythema multiforme appear to be due in part to cellular immune mechanisms with the lymphocyte as the predominant effector cell, and our data suggest a possible role for LC/IC in this disorder.

Combined total body X-ray irradiation and total skin electron beam radiotherapy with an improved technique for mycosis fungoides.

Twelve consecutive patients with advanced stage mycosis fungoides (MF) were treated with combined total body X ray irradiation (TBI) and total skin electron beam radiotherapy (EBRT). Six had generalized plaque disease and dermatopathic nodes, three had tumor stage disease and node biopsy positive for mycosis fungoides, and three had erythroderma/Sezary syndrome. The treatment regimen consisted of split course total body X ray irradiation, given in twice weekly 15 cGy fractions to 75 cGy, then total skin electron beam radiation therapy given in once weekly 400 cGy fractions to a total dose of 2400 cGy. Underdosed areas and areas of greatest initial involvement were boosted 400 cGy twice weekly for an additional 1200 cGy. This was followed by a second course of total body X ray irradiation, to a total dose of 150 cGy. The total skin electron beam radiotherapy technique is a modification of an established six position EBRT technique for mycosis fungoides. Measurements to characterize the beam with and without a lexan scattering plate, demonstrated that the combination of no-plate beams produced better dose uniformity with a much higher dose rate. This improved technique is particularly advantageous for elderly and/or frail patients. Nine (75%) of the 12 patients achieved complete response (CR). The other three had significant improvement with greater than 80% clearing of their disease and resolution of symptoms. All six patients with generalized plaque disease achieved complete response and remained free of disease from 2 to 16 months. Two of three node positive patients also achieved complete response; one, with massive biopsy-documented mycosis fungoides nodal disease and deep open tumors, remained relapse-free over 2 years. Only one of the three patients with erythroderma/Sezary syndrome achieved a complete response, which was short lived. Therapy was well tolerated. No significant hematological toxicity occurred. Although total body X ray irradiation and total skin electron beam radiotherapy produced excellent palliation of patients with advanced stage mycosis fungoides, new strategies to provide more effective systemic treatment are needed.

The pulmonary and systemic circulatory response to dopamine infusion.

1. The pulmonary and systemic circulatory responses to dopamine infused at 8, 15, 25 and 30 mug/kg per min were studied in eight mongrel dogs.2. Mean pulmonary artery pressure, mean left atrial pressure, mean aortic pressure, mean aortic flow and the electrocardiogram were monitored in openchest preparations. Pulmonary vascular resistance, systemic vascular resistance and stroke volume were calculated.3. Significant increases in mean pulmonary and aortic pressures were noted at dopamine infusions of 25 and 30 mug/kg per min. The left atrial pressure fell significantly at 15 mug/kg per min and rose significantly at 30 mug/kg per min. Mean aortic flow increased at all four doses, while heart rate showed no change. Pulmonary vascular resistance did not change significantly at any dose level, but systemic vascular resistance fell slightly at 8 and 15 mug/kg per min and rose significantly at 30 mug/kg per min. Stroke volume was significantly elevated at infusions of 25 and 30 mug/kg per min.4. The systemic circulatory response to dopamine is similar to that described by previous investigators.5. The increased pulmonary pressures without change in resistance suggest a dopamine-induced increase in smooth muscle tension in the pulmonary vasculature.

Photosensitivity due to drugs.

Photosensitivity reactions induced by drugs may be phototoxic or photoallergic in nature. Acute phototoxic reactions are by far the more common, and are generally characterised by erythema and oedema followed by hyperpigmentation and desquamation. Chronic repeated injury of this type may result in fragility, blistering and milia formation or even actinic keratoses and skin cancers. The photochemical mechanisms involved differ with the chemical photosensitiser involved. They include photoaddition of the chemical to biological targets such as DNA, the formation of toxic products due to absorption of the action spectrum by the photosensitising molecule, or the activation of toxic oxygen species or free radicals. Subsequent activation of the complement pathways may participate in the photoresponse to certain agents. Photoallergic reactions are uncommon. They represent an acquired altered reactivity dependent on a circulating antibody or a cell-mediated hypersensitivity process. Clinically, they are characterised by an immediate wheal and flare or a delayed papular to eczematous process. Some of the same drugs which cause phototoxic responses occasionally produce photoallergic reactions.

The impact of managed care on graduate medical education and academic medical centers.

The goal of this article is to examine the present and future impact of managed care on graduate medical education (GME) and academic medical centers. Obviously, the later 2 entities are closely intertwined and will share in the consequences of changes in our medical care systems. However, there are differences in the funding of medical schools as compared with GME provided by teaching hospitals, and an appreciation of the vital issues and concerns requires that each be discussed separately.