A Comparison of Splenic Pathologic Change and Immune Function in HBV-Related Portal Hypertension and Chinese Budd-Chiari Syndrome Patients with Hypersplenism.

The difference of splenic pathologic alterations and immune function changes in portal hypertension (PHT) with different etiology is unclear. We aimed to investigate the differences between the hypersplenic patients with hepatitis B virus (HBV)-related PHT and Budd-Chiari syndrome (B-CS). A total of 93 patients with hypersplenism due to Chinese primary B-CS (B-CS group), 105 patients with hypersplenism due to HBV-related cirrhosis (HBV/PHT group), and 31 healthy people (control group) were included in this study retrospectively. The peripheral bloods and paraffin sections of the spleen from part of patients were analyzed by flow cytometry and immunohistochemistry. Hypersplenism and PHT were more serious in HBV/PHT group than in B-CS group. In the peripheral blood, the percentages of regulatory T cell (15.1% vs. 8.1% vs. 2.2%, p = 0.0021) and myeloid-derived suppressive cells (2.8% vs. 0.8% vs. 0.9%, p = 0.009) were higher, but CD4+ T and CD8+ T cells were lower in HBV/PHT group compared with B-CS and control groups. In spleen, the percentages of CD4+ T and CD8+ T cells were lower, but CD68+ macrophages were higher in HBV/PHT group than in B-CS group. Moreover, CD86, inducible nitric oxide synthase, Toll-like receptor 4, and tumor necrosis factor-α expression in the spleen, as well as the plasma lipopolysaccharide (LPS) level (677.7 vs. 311.1 vs. 222.1 ng/mL, p = 0.0022), were significantly higher in HBV/PHT group than in B-CS and control groups. The HBV/PHT group showed more severe immunosuppression and immune dysfunction and more substantial hypersplenism and splenic phagocytosis than B-CS group.

Patterns of splenic arterial enhancement on computed tomography scan are related to portal venous hypertension.

OBJECTIVES: We have previously shown that patterns of splenic arterial enhancement on computed tomography scan change following liver transplantation. We suggested that this is related to changes in portal venous pressure. The aim of this study was to see if similar patterns occur in patients with and without portal hypertension and in patients before and after portal systemic shunts (transjugular portosystemic shunts). METHODS: We evaluated contrast enhanced computed tomography scans in patients being evaluated for liver disease and compared those from patients with and without portal hypertension. In addition we evaluated patients who had computed tomography scans before and after transjugular portosystemic shunts shunts. Splenic arterial enhancement was evaluated using Hounsfield units (pixel counts). RESULTS: Twenty-four patients with clinically significant portal hypertension were compared to 91 without. Mean splenic pixel count was significantly lower in patients with clinically significant portal hypertension (88.2 ± 17.7 vs. 115.2 ± 21.0; m ± SD, P < 0.01). Computed tomography scans were available in 18 patients pre- and post-transjugular portosystemic shunts. Pixel counts were significantly higher in the post-transjugular portosystemic shunts scans (99.7 ± 20.9 vs. 88.9 ± 26.3; P < 0.05). CONCLUSION: This study supports the hypothesis that changes in portal venous pressure are related to changes in splenic arterial enhancement. We suggest that this reflects changes in the splenic micro-circulation. This mechanism may be part of the innate immune response and may also be important in the pathogenesis of hypersplenism.

Pneumococcal vaccination in celiac disease.

INTRODUCTION: Celiac disease (CD) is an immune-mediated disorder associated with gluten exposure in genetically predisposed subjects. Areas covered: Infectious disease is one of the causes of morbidity and mortality in CD patients. Invasive streptococcus pneumoniae (pneumococcus) is a particularly dangerous morbid condition in both the general population and celiac patients. Pneumococcal vaccination is the most effective means for its prevention. Expert opinion: In CD, evaluation of spleen function should be useful to select patients who may benefit from vaccination to reduce the risk of pneumococcal disease. Different strategies could be employed: physicians could search for signs of hyposplenism on peripheral blood smear or abdominal ultrasound. However, the best strategy to identify which patients will benefit from pneumococcal vaccination has not yet been defined.

Individualized Immunosuppressive Protocol of Liver Transplant Recipient Should be Made Based on Splenic Function Status.

BACKGROUND: Lymphocyte subsets play important roles in rejection in liver transplant recipients, and the effect of splenic function on these roles remains unknown. The aim of this study was to explore the feasibility to adjust immunosuppressive agents based on splenic function status through detecting the lymphocyte subsets in liver transplantBeijing recipients. METHODS: The lymphocyte subsets of 49 liver transplant recipients were assessed in the 309th Hospital of Chinese People's Liberation Army between June 2014 and August 2015. The patients were divided into splenectomy group (n = 9), normal splenic function group (n = 24), and hypersplenism group (n = 16). The percentages and counts of CD4+ T, CD8+ T, natural killer (NK) cell, B-cell, regulatory B-cell (Breg), and regulatory T-cell (Treg) were detected by flow cytometer. In addition, the immunosuppressive agents, histories of rejection and infection, and postoperative time of the patients were compared among the three groups. RESULTS: There was no significant difference of clinical characteristics among the three groups. The percentage of CD19+CD24+CD38+ Breg was significantly higher in hypersplenism group than normal splenic function group and splenectomy group (3.29 ± 0.97% vs. 2.12 ± 1.08% and 1.90 ± 0.99%, P = 0.001). The same result was found in CD4+CD25+FoxP3+ Treg percentage (0.97 ± 0.39% vs. 0.54 ± 0.31% and 0.56 ± 0.28%, P = 0.001). The counts of CD8+ T-cell, CD4+ T-cell, and NK cell were significantly lower in hypersplenism group than normal splenic function group (254.25 ± 149.08 vs. 476.96 ± 225.52, P= 0.002; 301.69 ± 154.39 vs. 532.50 ± 194.42, P= 0.000; and 88.56 ± 63.15 vs. 188.33 ± 134.51, P = 0.048). Moreover, the counts of CD4+ T-cell and NK cell were significantly lower in hypersplenism group than splenectomy group (301.69 ± 154.39 vs. 491.89 ± 132.31, P= 0.033; and 88.56 ± 63.15 vs. 226.00 ± 168.85, P = 0.032). CONCLUSION: Splenic function status might affect the immunity of liver transplant recipients, that should be considered when we make immunosuppressive protocols.

Treatment of suspected hyper-reactive malarial splenomegaly (HMS) in pregnancy with mefloquine.

Malaria infections in pregnancy are associated with adverse outcomes for both mother and child. There are few data on hyper-reactive malarial splenomegaly, an aberrant immunological response to chronic or recurrent malaria in pregnancy. This retrospective assessment reviewed the impact of mefloquine treatment on pregnant women with suspected hyper-reactive malarial splenomegaly in an area of low malaria transmission in the 1990s, showing significant reductions in spleen size and anemia and anti-malarial antibody titers without any notable negative effect on treated women or their newborns.

The expression and significance of CD4+CD25+CD127low/- regulatory T cells and Foxp3 in patients with portal hypertension and hypersplenism.

BACKGROUND/AIMS: To study the expression of CD4+CD25+CD127low/- regulatory T cells and Foxp3 in patients with portal hypertension (PH) and hypersplenism, and explore the significance of Treg in immunomodulation of hypersplenism. METHODOLOGY: Testing of CD4+CD25+CD127low/- regulatory T cells and CD3+CD4+CD8+ T cells in peripheral venous blood with flow cytometry in 20 patients with PH and hypersplenism; testing for Foxp3 in spleen tissue of 30 patients with PH and hypersplenism with immunohistochemistry. RESULTS: The percentage of CD4+CD25+CD127low/-/CD4+ in patients with PH and hypersplenism was 5.3%+-3.0%. It was obviously increased compared with normal control samples 2.5%+-0.9%, with significant difference (p=0.001). There was a negative correlation between CD4+CD25+CD127low/-/CD4+ rate and CD3+CD4+ (r=-0.630, p=0.003; r=-0.561, p=0.01). The spleen tissue Foxp3 expression (IOD=293.1+-180.0) in patients with PH and hypersplenism were markedly improved compared with the normal expressions of spleen-cutting groups (IOD=115.2+-84.1), the difference was significant (p<0.01). CONCLUSIONS: The percentage of CD4+CD25+CD127low/- Treg and Foxp3 in patients with PH and hypersplenism was significantly increased, suggesting that they may take part in the regulation of immune function and be related to the change of T lymphocyte subsets in patients with PH and hypersplenism, which may have an important clinical significance.

NF-κB p65 and c-Rel subunits promote phagocytosis and cytokine secretion by splenic macrophages in cirrhotic patients with hypersplenism.

Transcription factors of the nuclear factor-kappa B (NF-κB) family play a key role in various biological processes. In this study, we explored the role of NF-κB in the dysfunction of splenic macrophages in hypersplenism due to liver cirrhosis. By using confocal microscopic analysis, Western Blot, TransAM NF-κB ELISA, and chromatin immunoprecipitation (ChIP), we observed that NF-κB p65, p52, and c-Rel were activated in macrophages in patients with hypersplenism (hypersplenic macrophages). Transfection of hypersplenic macrophages with a κB/luciferase reporter plasmid showed that NF-κB complexes were functional. Using co-immunoprecipitation studies, we demonstrated that p65/c-Rel dimers were activated in hypersplenic macrophages. NF-κB activation inhibitor JSH-23 and the small interfering RNA (siRNA)-mediated p65, and c-Rel gene silencing significantly blocked phagocytosis and secretion in hypersplenic macrophages. Using promoter analysis and RNA interference, we found that many phagocytotic and hepatic fibrogenetic regulators, including interleukin (IL)-1α, IL-1ß, interferon-γ (IFN-γ), transforming growth factor-ß1 (TGF-ß1), and tumor necrosis factor-α (TNF-α), were regulated by NF-κB p65 and c-Rel in hypersplenic macrophages. Our findings demonstrate that NF-κB p65 and c-Rel play an important role in phagocytosis and secretion in hypersplenic macrophages. Activation of NF-κB p65 and c-Rel may be considered an important regulator of hypersplenism and liver cirrhosis.

[Changes in splenic macrophage function of hypersplenism due to portal hypertension].

OBJECTIVE: To investigate the changes in function of splenic macrophages of hypersplenism due to portal hypertension (PH), and to provide experimental evidence for exploring the immune function of spleen in PH. METHODS: Twelve patients with hypersplenism due to PH and four patients with traumatic rupture of spleen, from September 2005 to March 2006, were enrolled into PH group and control group, respectively. Splenic M phi were isolated and purified by anchoring cultivation from all the patients, and were resuspended by RPMI-1640. Phagocytosis, cytokine secretion and antigen processing and presenting of splenic M phi were detected by Vybrant Phagocytosis Assay, the human TNF-alpha Elispot kits and DQ ovalbumin. RESULTS: Compare to the normal splenic M phi, the phagocytosis rate, antigen presentation positive cells and secretion positive cells, were all significantly increased in PH splenic M phi (86.4 +/- 7.1 vs. 61.8 +/- 4.1, 26.3 +/- 1.6 vs. 15.6 +/- 1.8, 387.0 +/- 24.3 vs. 240.3 +/- 13.0, P<0.01). CONCLUSIONS: The phagocytosis, cytokine secretion and antigen processing and presenting of splenic M phi in PH spleen were all significantly increased, and the M phi retained at activated state. It means that the PH spleen still possessed the immune function, but these functions might be in disorder. It still needs more research to get the precious evaluation for immune function in the PH spleen.

Changes in count and function of splenic lymphocytes from patients with portal hypertension.

AIM: To investigate changes in numbers and proliferative function of splenic lymphocytes in patients with hypersplenism due to portal hypertension (PH), to provide evidence for further study of immune status of the spleen during PH. METHODS: Twelve spleens from patients with hypersplenism due to PH served as the PH group, and four spleens from cases of traumatic spleen rupture were regarded as the control group. After weighing the spleen, lymphocytes were separated and counted using a cell counting plate to calculate the lymphocyte count per gram of spleen tissue (relative quantity) and total lymphocyte count in whole spleen (absolute quantity). The immunohistochemical SP method was used to observe the density and distribution of lymphocytes in the spleen. The MTT method was used to observe changes in lymphocyte proliferative function. RESULTS: As compared to the control group, the splenic lymphocytes in the PH group showed that: (1) There was no difference in distribution but a significant decrease in density; (2) the number of lymphocytes per gram of spleen (relative quantity) decreased significantly [(0.822 +/- 0.157) x 10(8) vs (1.174 +/- 0.254) x 10(8), P < 0.01]; (3) with the significant increase in the weight of the PH spleen (832.6 +/- 278.2 g vs 211.7 +/- 85.6 g, P < 0.01), the total quantity of lymphocytes (absolute quantity) increased significantly [(0.685 +/- 0.072) x 10(11) vs (0.366 +/- 0.057) x 10(11), P < 0.01]; and (4) the proliferative function of lymphocytes was enhanced: T lymphocytes, (0.022 +/- 0.005 vs 0.015 +/- 0.003, P < 0.05), and B lymphocytes (0.034 +/- 0.006 vs 0.023 +/- 0.001, P < 0.01). CONCLUSION: Although lymphocyte density in the spleen decreased in patients with PH, the total quantity of lymphocytes increased because spleen weight increased greatly, along with the proliferating function. With respect to changes in lymphocytes, PH spleens may still have immune function, although it may be disordered. However, complete evaluation of the immune function of the spleen in PH requires more research.

Sites and kinetics of donor thrombopoiesis following transplantation of whole bone marrow and progenitor subsets.

INTRODUCTION: Little is known about the sites and kinetics of thrombopoiesis following bone marrow transplant. The spleen is a site of hematopoiesis in a healthy mouse, and hematopoietic activity increases in response to stress. We hypothesized that the spleen is a major site of early post-transplant thrombopoiesis. METHODS: We transplanted whole bone marrow (WBM) or lineage depleted progenitor subsets fractionated based on expression of c-kit and Sca-1 from transgenic mice expressing green fluorescent protein into lethally irradiated C57BL/6 recipients. We also transplanted whole bone marrow cells into healthy and splenectomized mice. Post-transplant megakaryopoiesis was assessed by measuring circulating platelet number, percent donor-derived platelets, bone marrow cellularity, splenic weight, megakaryocyte size, and megakaryocyte concentration from hour 3 to day 28 post transplant. RESULTS: Following transplant, circulating donor-derived platelets were derived only from c-kit expressing subsets. Donor-derived platelets first appeared on post-transplant day five. Splenectomy reduced the number of these earliest circulating platelets. Splenic megakaryopoiesis increased dramatically from day 7-14 post-transplant. However, splenectomy accelerated platelet engraftment during this time frame. CONCLUSION: Overall, these results demonstrate that the first platelets are produced by c-kit expressing megakaryocyte progenitors in the bone marrow and spleen. After post-transplant day 5, the net effect of the spleen on thrombopoiesis is to slow engraftment due to immune effects or hypersplenism.

[Expression and significance of Toll-like receptor 4 of splenic macrophage in patients with hypersplenism due to portal hypertension].

OBJECTIVE: To observe the change in expression of Toll-like receptor 4 (TLR4) of splenic macrophage in patients with hypersplenism due to portal hypertension (PH), and investigate the role of TLR4 of splenic macrophage in hypersplenism. METHODS: Splenectomy was performed on 20 patients with hypersplenism due to PH (hypersplenism group) and 6 patients with rupture of spleen by trauma (control group) and the specimens of spleen were collected. The splenic macrophages were isolated by adhibit wall method. The expression of TLR4 of splenic macrophage was detected by immunohistochemical method (SABC), and the result was analyzed by the image analysis system. The phagocytosis of splenic macrophage was measured by chicken red blood cell (CRBC) phagocytosis assay. The level of serum endotoxin was detected before the operation by limulus assay. The results of these 2 groups were compared, and correlation analysis was made among different results of the hypersplenism group. RESULTS: The expression of TLR4 of splenic macrophage was 109 +/- 32 in the hypersplenism group, significantly higher than that of the control group (62 +/- 5, P < 0.01). The rate of phagocytosis and index of phagocytosis of splenic macrophage in the hypersplenism group were 12.6% +/- 3.0% and 0.146 +/- 0.035 respectively, both significantly higher than those of the control group (6.9% +/- 0.5% and 0.076 +/- 0.008 respectively, both P < 0.01) The level of endotoxin of the hypersplenism group was 0.28 EU/ml +/- 0.21 EU/ml, significantly higher than that of the control group (0.054 EU/ml +/- 0.014 EU/ml, P < 0.05). The rate of phagocytosis and the index of phagocytosis of splenic macrophage were notably positively correlated with the expression of TLR4 (r = 0.601, P < 0.01 and r = 0.553, P < 0.05), and the level of endotoxin (r = 0.724 P < 0.01 and r = 0.506, P < 0.05). The expression of TLR4 of splenic macrophage was positively correlated with the level of endotoxin (r = 0.525, P < 0.05). CONCLUSION: The expression of TLR4 of splenic macrophage in patients with hypersplenism due to PH was increased significantly. It may be one of the important factors of hypersplenism due to PH that "endotoxemia-->increase of expression of TLR4 of splenic macrophage (activation of TLR of splenic macrophage)-->increased destruction of red blood cells by macrophage".

Immune restoration in children after partial splenectomy.

Splenectomy (SE) is recognized to be a therapeutical approach in treating children with severe autoimmune diseases (chronic idiopathic thrombocytopenia; hemolytic anemia) or hypersplenism because of portal hypertension. Nevertheless, removal of a main immune organ results in elevated infection risk for these patients. Partial splenectomy (PSE) was developed as a therapeutical compromise to retain immunologically active spleen tissue. Here, we document the analysis of immune parameters obtained from children after both partial and total splenectomy, which have been followed up for a period of more than 6 years: (i) Lymphocytes from both groups of patients failed to produce IgG in response to pokeweed mitogen in vitro. This was observed in 11/20 splenectomized patients even 10 years after operation, whereas in PSE patients a restoration of this parameter after 1-2 years was seen. (ii) In patients after PSE, but not in splenectomized persons, an elevated number of HLA-class II positive cells had been detected suggesting a different situation of immune regulation following this operation. However, in parallel with an improvement of B cell in vitro activity this parameter was found to achieve normal values. Our findings indicate that partial splenectomy may be a therapeutical alternative, if the therapeutic goal can be achieved by this procedure.

Autoimmunity, inflammatory bowel disease and hyposplenism.

The presence or absence of nine autoantibodies were assessed in 44 patients with ulcerative colitis (17 with hyposplenism) and 22 patients with Crohn's disease (eight with hyposplenism). The purpose of the study was to determine whether hyposplenism in inflammatory bowel disease is associated with an increased tendency to autoimmunity, or whether autoimmunity is linked not to hyposplenism itself but to the underlying bowel disease. The results strongly suggest that the latter hypothesis is correct. There was a much higher frequency of autoantibodies in patients with ulcerative colitis than in those with Crohn's disease (P < or = 0.01), suggesting that autoimmune factors are more important in the pathogenesis of ulcerative colitis than in Crohn's disease.

Variable expression of IgG2 deficiency.

Sustained and significant reversal of antibody deficiencies is uncommon, although it has been noted in some cases during childhood and after viral infections. We report a case of reversal of IgG2 deficiency after splenectomy. A 46-year-old man who suffered recurrent sinusitis despite antibiotic therapy was noted to have IgG2 deficiency and cutaneous anergy. Replacement therapy with intravenous immunoglobulin ameliorated his symptoms. After 13 months of therapy, the patient had a diagnostic laparotomy and splenectomy because of portal hypertension, hypersplenism, and consideration of underlying malignancy. No evidence of malignancy or infection, including human immunodeficiency virus, active cytomegalovirus, or Epstein-Barr virus infection, was found. After splenectomy, the patient's serum IgG2 level normalized without replacement therapy. Subsequently, it fell, then normalized once more, and remains normal. The patient also demonstrated positive reactions to delayed hypersensitivity testing after splenectomy, but, subsequently, became anergic and remains anergic at the present time. Since the splenectomy he has remained clinically well without antibiotics or immunoglobulin replacement. In vitro analysis of his lymphocyte function demonstrated impaired T cell proliferation as well as an intrinsic B cell differentiation defect. This case demonstrates the potentially dynamic nature of IgG subclass deficiencies.

[Dacie syndrome and other splenomegalies without apparent cause]. / El síndrome de Dacie y otras esplenomegalias sin causa aparente.

Some enlarged spleens do not seem to be related with known pathogenetic mechanisms (passive congestion, functional workload, malignant infiltration and inflammatory or storage disorders). Non-tropical idiopathic splenomegaly (Dacie's syndrome) is a form of hypersplenism of unknown origin that evolves into a non-Hodgkin lymphoma, after a variable interval, in 20% of the patients. Tropical idiopathic splenomegaly (or hyperreactive malarial splenomegaly) develops when a chronic malarial challenge triggers an abnormal immunological response consisting in decreased suppressor T lymphocytes and increased amounts of circulating immunoglobulin M and immunocomplexes, which are cleared by the splenic macrophages. This peculiar response to malaria seems to be linked to particular HLA antigens. Other confusing splenomegalies are seen in Felty's syndrome, in populations subjected to recurrent infections, and in some families. Overlapping findings and diseases suggest chronic antigenic stimulation as a common feature, with diverse responses depending on the host. A small percentage (probably less than 3%) of normal individuals has minimal splenomegaly without any clinical significance.

Tropical splenomegaly syndrome associated with cytomegalovirus infection.

The tropical splenomegaly syndrome (TSS) is characterized by massive splenomegaly with hypersplenism, moderate hepatomegaly, and lymphocytic infiltration of the hepatic sinusoids. In previous reports this syndrome has been shown to be a consequence of a disordered immunologic response of the host to malarial infection. Treatment with antimalarial drugs has resulted in a decrease in malarial antibody titers and a reduction in splenic size. We report a child who had TSS associated with cytomegalovirus infection rather than malaria. Our results suggest that TSS may be precipitated by a variety of infections producing chronic antigenic stimulation and perhaps by autoantigenic stimulation as well.

Influência de anticorpos sobre a evoluçäo da doença esquistossomótica com hiperesplenismo / Antibodies influence on the evolution of schistosomiasis with hyperesplenism

Os autores apresentam um caso clínico de esquistossomose com hiperesplenismo onde o anticorpo humoral a frio, IgM, interferiu na evoluçäo clínica da doença. A esplenomegalia, o hiperesplenismo e a eletroforese de proteínas foram analisadas nos comentários. A funçäo hepatocelular mostrou-se normal como também foram normais a avaliaçäo pulmonar, a espirometria, a hemogasimetria, a semiologia e a radiologia torácica. O coagulograma evidenciou alteraçäo do tempo de protrombina, da tromboplastina ativada e da lise de euglobulina. O fibrinogênio e a fibrina séricas foram normais. Testes de Coombs indiretos a frio evidenciaram anticorpo tipo IgM. A identificaçäo de anticorpos feita por um painel de hemácias demonstrou para os diversos antígenos utilizados apenas anti-l positivo. O antígeno i evidenciado pelos testes poderia interferir com os títulos de Ag l resultando elevaçäo de anticorpos IgM pela resposta humoral anômala. Os anticorpos IgM possuem sítios de ligaçäo com as hemácias, que provavelmente desencadeariam ativaçäo do complemento com lise das mesmas. As fraçöes séricas complementares desviadas para essas funçöes prejudicariam, possivelmente, o fenômeno de coagulaçäo sangüínea. O retardo originado da atividade de protrombina para trombina poderia ser explicado pelo desvio da funçäo dos componentes do complemento ativado pelo anticorpo IgM, apesar do uso intramuscular prolongado de vitamina K. A esplenomegalia seria a provável responsável pelo fato assinalado, pois, na evoluçäo pós-esplenectomia tais açöes desapareceram sobre a coagulaçäo, apesar da persistência do anticorpo na doente

Hepatitis B e antigen in the absence of hepatitis B surface antigen.

Hepatitis B e antigen (HBeAg) was detected by agar gel diffusion in the serum of four Ugandan adults (three patients with tropical splenomegaly syndrome and one healthy adult) who did not have detectable hepatitis B surface antigen (HBsAg) by radioimmunoassay. Two of them had antibody to hepatitis B core antigen, and the other two had antibody to HBsAg. Detection of HBeAg by a relatively insensitive immunodiffusion test in the absence of HBsAg detectable by a sensitive radioimmunoassay suggested that production or removal of these two antigens may occur independently.