Imunofluorescência direta de pele e mucosas: análise comparativa, clínica e histológica, de 180 exames / Direct immunofluorescence of skin and mucous membrane: clinical and histological correlation in 180 patients

O exame de imunofluorescência direta (IFD) é recurso propedêutico adicional no diagnóstico diferencial das doenças cutâneas bolhosas, auto-imunes e näo-imune-mediadas. Nós revimos os resultados de 180 exames de IFD de pele e mucosas, de pacientes atendidos no Hospital das Clínicas da Universidade de Campinas, as biopsias correspondentes, e os comparamos às observaçöes clínicas. As dermatoses foram assim classificadas: 1) bolhosas acantolíticas (n=38); 2) bolhosas subepidérmicas (n=39); 3) inflamatórias näo-bolhosas - a) colagenoses (n=53), b) outras (n=32); 4) vasculites (n=10); 5) miscelânea (n=8). Os achados clínicos e laboratoriais, a biopsia, a evoluçäo e a resposta terapêutica foram analisados, e o papel desempenhado pela IFD foi assim classificado: 1) definiu o diagnóstico; 2) complementou o diagnóstico estabelecido; 3) näo contribuiu para o diagnóstico. Virtualmente todos os casos de pênfigo mostravam-se positivos. Neles, a IFD, unicamente, auxiliou a excluir os poucos diagnósticos diferenciais formulados. Quanto às dermatoses bolhosas subepidérmicas, a IFD foi crucial. Seu emprego foi crítico em quatro pacientes com lúpus bolhoso, pois as lesöes cutâneas precederam as manifestaçöes sistêmicas e a doença revestiu-se de marcada gravidade. A IFD foi negativa em 39 por cento dos pacientes com lúpus eritematoso sistêmico e em 53 por cento daqueles com lúpus eritematoso discóide, particularmente quando sob tratamento. Nas demais colagenoses, e nas vasculites, a IFD da pele näo contribui com qualquer elemento de valor para os demais parâmetros. Concluindo, a técnica mostrou-se essencial na investigaçäo das doenças auto-imunes e bolhosas cutâneas. A otimizaçäo da sua aplicaçäo pode ser alcançada num trabalho e cooperaçäo entre os setores envolvidos, minimizando os fatores geradores de erro

Anticuerpos anticitoplasma de neutrófilos (ANCA): su utilidad en el diagnóstico de las vasculitis autoinmunes / Anti-neutrophil cytoplasmic antibodies (ANCA): their usefulness in autoimmune vasculitis prognosis

Se determinó la asociación de ANCA con distintos tipos de entidades clínicas utilizando como técnica de tamizaje la inmunofluorescencia indirecta (IFI). Se determinó la especificidad antigénica utilizando enzimoinmunoanálisis (EIA). Se detectaron los isotipos de la inmunoglobulinas involucradas y su asociación con las manifestaciones clínicas. Para ello se examinaron los sueros de 102 pacientes con diagnóstico confirmado de vasculitis, de enfermedades del tejido conectivo, insuficiencia respiratoria y desórdenes renales. Se incorporó otra serie de 144 pacientes con distintas enfermedades que involucran o que pueden involucrar órganos y sistemas del mismo modo que las vasculitis inmunes. Del total de muestras, 29 fueron reactivadas por IFI y de éstas se estudiaron 16 por EIA, siendo 14 reactivas. Se detectó ANCA en 8/11 (73 por ciento) sueros de pacientes con granulomatosis de Wegener (GW); 7 presentaron cANCA (87,5 por ciento) y 1 pANCA. En Lupus Eritematoso Sistémico (LES), 4/32 (12,5 por ciento) fueron reactivos para ANCA (1 cANCA y 3 pANCA), y en Poliarteritis Nodosa (PAN) 6/8 (75 por ciento) fueron reactivos para pANCA. La imagen cANCA se asoció en forma significativa (p < 0,01) a GW respecto de las demás enfermedades y/o pacientes con manifestaciones clínicas relacionadas a vasculitis. Al agrupar los pacientes con LES, PAN, Hepatitis Autoinmune (3/8) e Insuficiencia Renal de causa desconocida (3/7), la imagen pANCA se asoció significativamente (p < 0,01) a estas enfermedades, en comparación al resto de los ANCA reactivos. El antígeno PR3 se asoció 1/1 con cANCA y 1/1 con pANCA, 12/16 MPO dieron imágenes pANCA y 2/12 imágenes pANCA no reaccionaron con ninguno de los antígenos estudiados. La asociación entre IgG ANCA con IgA e IgM Anca en el total de los pacientes fue no significativa (p > 0,01). En los tres casos clínicos reactivos para IgG e IgM se observó correlación entre su presencia y la afectación renal. El estudio sistemático de los ANCA y en particular de su especificidad antigénica, podrá sumar parámetros de evolución y pronóstico a los ya existentes y también mejorar el entendimiento de la fisiopatogenia de los fenómenos vasculíticos en diferentes enfermedades

Anticuerpos anticitoplasma de neutrófilos (ANCA): su utilidad en el diagnóstico de las vasculitis autoinmunes / Anti-neutrophil cytoplasmic antibodies (ANCA): their usefulness in autoimmune vasculitis prognosis

Se determinó la asociación de ANCA con distintos tipos de entidades clínicas utilizando como técnica de tamizaje la inmunofluorescencia indirecta (IFI). Se determinó la especificidad antigénica utilizando enzimoinmunoanálisis (EIA). Se detectaron los isotipos de la inmunoglobulinas involucradas y su asociación con las manifestaciones clínicas. Para ello se examinaron los sueros de 102 pacientes con diagnóstico confirmado de vasculitis, de enfermedades del tejido conectivo, insuficiencia respiratoria y desórdenes renales. Se incorporó otra serie de 144 pacientes con distintas enfermedades que involucran o que pueden involucrar órganos y sistemas del mismo modo que las vasculitis inmunes. Del total de muestras, 29 fueron reactivadas por IFI y de éstas se estudiaron 16 por EIA, siendo 14 reactivas. Se detectó ANCA en 8/11 (73 por ciento) sueros de pacientes con granulomatosis de Wegener (GW); 7 presentaron cANCA (87,5 por ciento) y 1 pANCA. En Lupus Eritematoso Sistémico (LES), 4/32 (12,5 por ciento) fueron reactivos para ANCA (1 cANCA y 3 pANCA), y en Poliarteritis Nodosa (PAN) 6/8 (75 por ciento) fueron reactivos para pANCA. La imagen cANCA se asoció en forma significativa (p < 0,01) a GW respecto de las demás enfermedades y/o pacientes con manifestaciones clínicas relacionadas a vasculitis. Al agrupar los pacientes con LES, PAN, Hepatitis Autoinmune (3/8) e Insuficiencia Renal de causa desconocida (3/7), la imagen pANCA se asoció significativamente (p < 0,01) a estas enfermedades, en comparación al resto de los ANCA reactivos. El antígeno PR3 se asoció 1/1 con cANCA y 1/1 con pANCA, 12/16 MPO dieron imágenes pANCA y 2/12 imágenes pANCA no reaccionaron con ninguno de los antígenos estudiados. La asociación entre IgG ANCA con IgA e IgM Anca en el total de los pacientes fue no significativa (p > 0,01). En los tres casos clínicos reactivos para IgG e IgM se observó correlación entre su presencia y la afectación renal. El estudio sistemático de los ANCA y en particular de su especificidad antigénica, podrá sumar parámetros de evolución y pronóstico a los ya existentes y también mejorar el entendimiento de la fisiopatogenia de los fenómenos vasculíticos en diferentes enfermedades (AU)

Correlation between ANA determinations on tissue substrate, WiL-2 cell substrate, and precipitin antibody by double diffusion.

Four hundred fifty-five sera from patients with various connective tissue diseases were screened for the presence of fluorescent antinuclear antibodies (ANA) on two different substrates-mouse kidney sections and WiL-2 cell smears-and precipitin antibodies by using WiL-2 cell extracts as an antigenic source. The antigen for the precipitin was prepared as for extractable nuclear antigen tests. Of 258 sera from systemic lupus erythematosus cases, 73% were positive for ANA on mouse kidney sections, 98% on Wil-2 cell smears, and 47% by precipitin tests. However, 33 sera which were ANA negative on mouse kidney sections were positive on WiL-2 cell smears and also positive for precipitin antibodies. WiL-2 cells used as ANA substrates increased the frequency of ANA in connective tissue diseases, and there was a strong correlation between the WiL-2 cell ANA and the presence of precipitin antibodies. Twenty-four of these 33 sera had anti-SSA/Ro antibody. Some sera containing anti-SSB/La or anti-nRNP antibodies were ANA negative on mouse kidney sections, but all were positive on WiL-2 cells.

Anticorpos antinucleares em crianças com conectivopatias / Antinuclear antibodies in children with connective tissue diseases

A presença de anticorpos antinucleares foi pesquisada no soro de 85 crianças com diferentes conectivopatias: 40 casos de artrite reumatóide juvenil (ARJ), (15 do tipo sistêmico, 12 pauciarticular e 13 poliarticular); 15 casos de lúpus eritematoso (LES); dez de dermato/polimiosite, dez de febre reumática (FR) e dez de vasculite. Anticorpos antinucleares (AAN) foram encontrados em 38% dos soros pesquisados com a seguinte distribuiçäo: LES - 100%, ARJ - 40%, DM/PM - 40% e negativa em FR vasculite. Vários padröes de fluorescência nuclear foram observados. Anticorpo anti-histona foi encontrado em quatro crianças com ARJ e oito com LES; anti-nDNA em 20% dos casos de LES; do grupo anti-ENA, detectou-se anti-SM em quatro pacientes com LES, anti-nRNP em uma criança com ARJ, quatro com LES e uma com DM/PM, anti-PCNA, anti-SS/B e anti-rRNP foram encontrados em uma criança com LES

Cutaneous immunopathology

Direct and indirect immunofluorescence tests performed on skin biopsy specimens and serum have enriched the diagnostic skills of the practicing pathologist. Specific patterns of immunoglobulin and complement deposition have clarified the diagnostic entities within the group of vesicobullous diseases. The pemphigus group of diseases is characterized by antibodies, usually IgG, directed against the intercellular substance of squamous epihelium. The pemphigoid group of bullous diseases is characterized by antibody, usually IgG directed against the basement membrane zone. The basement membrane zone deposition of immunoglobulin or complement is linear and localized to the lamina lucida. In dermatitis herpetiformis, granular or speckled IgA deposition in the upper papillary dermis is characteristic; however, other patterns of deposition may occur. Abnormal microfibrillar bundles in the upper papillary dermis have recently been identified in patients with dermatitis herpetiformis.Immunofluorescence studies of patients with lupus erythematosus are important not only in diagnosis but also in prognosis. The diseased skin of lupus patients contains deposits of immunoglobulin, ussually IgG or IgM, at the basement membrane zone in more than 90 per cent of the cases. In discoid lupus erythemathoss, clinically normal skin does not contain such deposits. However, in systemic lupus erythematosus, normal sun exposed skin contains these deposits in approximately 80 per cent of the cases and normal nonsun exposed skin contains them in 50 per cent the cases. Direct immunofluorescence of normal skin may demonstrate basement membrane zone deposition of immunoglobulin in mixed connective tissue disease and other autoimmune diseases with anti-DNS antibodies.The skin of psoriatic patients may demonstrate in vivo bound IgG within the stratum corneum. Similar circulating antistratum corneum antibodies are found in normal subjects; however, these antibodies do not appear to have access to epidermal binding sites. Patients with lichen planus characteristically have large globular deposits of immunoglobulin and complement in the epidermis and dermis in diseased skin. Granular deposition of IgM and IgG at the basement membrane zone in lichen planus may lead to cofusion with lupus erythematosus.Deposition of immunoglobulin and complement is found in and about vessels in early lesions of cutaneous vasculitis. Negative findings in older lesions may be due to immune co.

Cutaneous immunopathology. The diagnostic use of direct and indirect immunofluorescence techniques in dermatologic disease

Direct and indirect immunofluorescence tests performed on skin biopsy specimens and serum have enriched the diagnostic skills of the practicing pathologist. Specific patterns of immunoglobulin and complement deposition have clarified the diagnostic entities within the group of vesiculobullous diseases. The pemphigus group of diseases is characterized by antibodies, usually IgC directed against the intercellular substance of squamous epithelium. The pemphigoid group of bullous diseases is characterized by antibodies, usually IgC directed against the basement membrane zone. The basement membrane zone deposition of immunoglobulin or complement is linear and localized to the lamina lucida. In dermatitis herpetiformis, granular or speckled IgA deposition in the upper papillary dermis is characteristic; however, other patterns of deposition may occur. Abnormal microfibrillar bundles in the upper papillary dermis have recently been identified in patients with dermatitis herpetiformis. Immunofluorescence studies of patients with lupus erythematosus are important not only in diagnosis but also in prognosis. The diseased skin of lupus patients contains deposits of immunoglobulin, usually IgC or IgM at the basement membrane zone in more than 90 per cent of the cases. In discoid lupus eryhtematosus, clinically normal skin does not contain such deposits. However, in systemic lupus erythemaosus, normal sun exposed skin contains these deposits in approximately 80 per cent of the cases and normal nonsun exposed skin contains them in 50 per cent of the cases. Direct immunofluorescence of normal skin may demonstrate basement membrane zone and other autoimmune diseases with anti-DNA antibodies. The skin of psoriatic patients may demonstrate in vivo bound IgC within the stratum corneum. Similar circulating antistratum corneum antibodies are found in normal subjects; however, these antibodies do not appear to have access to epidermal blinding sites. Patients with lichen planus characteristically have large globular depositis of immunoglobulin and complement in the epidermis and dermis in diseased skin. Granular deposition of Ig M and IgC at the basement membrane zone in lichen planus may lead to confusion with lupus erythematosus. Deposition of immunoglobulin and complement is found in and about vessels in early lesions of cutaneous vasculitis. Negative findings in older lesions may be due to immune complex degradation and removal.Further information.

Mixed connective tissue disease in childhood. A clinical and serologic survey.

Mixed connective tissue disease is a syndrome with overlapping clinical features of SLE, scleroderma, and polymyositis. Only one other child with MCTD has been described in detail. In this study 14 children with MCTD are described. Each had overlapping clinical findings that evolved over an extended period of observation, and all 14 had high serum titers of speckled ANA and antibodies to RNP. A serologic survey of 127 children with various rheumatic diseases confirmed the specificity of high titer of speckled ANA and antibodies to RNP for MCTD in children. Significant cardiac and renal involvement, and thrombocytopenia, may be more common in affected children than in adults with MCTD, may lead to longer therapy with higher doses of a corticosteroid, and may contribute to a more serious prognosis than in adults.