Rapid detection of dengue viral antigens by counterimmunoelectrophoresis.

Counterimmunoelectrophoresis (CIE) was applied to detect dengue viral antigen in an experimental system and in clinical situations. In the experimental system, all four types of dengue viruses (dengue 1 to 4) were detected when tested against rabbit hyperimmune sera. With homologous antibody, antigen could be detected when hemagglutinating titer was as low as 1:20. In clinical situations, 67% of the sera of patients with dengue hemorrhagic fever collected on day 4 after onset of fever were positive by CIE. Antigens could be detected most frequently from day 4 to day 7. In 11% of the cases, antigens were found to persist as long as 38 days. Validity of this detection was confirmed in some cases by immunologic methods. Virtues of CIE are its technical simplicity, rapidity, and economy.

Lupus transverse myelopathy: better outcome with early recognition and aggressive high-dose intravenous corticosteroid pulse treatment.

Seven patients with transverse myelopathy (TM) were found to have systemic lupus erythematosus (SLE). Four patients had no prior diagnosis of SLE. All patients had positive antinuclear antibody (ANA). All patients had a spinal syndrome which progressed to TM with cervical or thoracic levels. The diagnosis of TM was confirmed with neurological tests and neuro-radiographic studies. Delay in diagnosis and treatment resulted in a poor outcome. Four patients died and one remained wheelchair-bound. Only two patients who received high-dose IV pulse steroid within 1 week of onset of TM had a good outcome, with full ability to ambulate without assistance. Our experience suggests that early diagnosis with early treatment using high-dose IV steroid affects the mortality and improves the outcome.

Malignant tumor with chest wall pain mimicking Tietze's syndrome.

Chest pain is commonly caused by musculoskeletal chest wall disorders. Tietze's syndrome is a relatively rare cause of chest wall pain characterised by non-suppurative, painful swelling of the upper costal cartilages. The diagnosis should be based on these classic clinical features after excluding other potential causes of pain. A patient who was diagnosed with Tietze's syndrome but was found to have squamous cell carcinoma of the mediastinum with unknown primary site invading the sternum and anterior chest wall is presented for discussion.

Lymphocyte subset T4/T8 ratio in systemic lupus erythematosus: correlation with disease activity, laboratory abnormalities and treatment.

Lymphocyte subsets were studied in forty-nine patients with SLE using monoclonal antibodies and flow cytometry. A decrease in T4+ reactive cells (helper/inducer) was the most frequent observation. Decreased T4/T8 ratios were seen in patients with increasing clinically active disease, patients with positive anti-DS-DNA, positive anti-RNP antibodies and patients with low CH50 activity. However, low T4/T8 ratios were seen in patients with negative anti-Sm. Low T4/T8 ratios were also observed in patients taking prednisone at more than 10 mg/day and in patients treated with immunosuppressive drugs.

Mycophenolate mofetil (CellCept): an alternative therapy for autoimmune inflammatory myopathy.

OBJECTIVES: Mycophenolate mofetil (MMF) is a new immunosuppressive agent currently being used for the prevention of renal allograft rejection. MMF is a specific inhibitor of lymphocytes and is well tolerated leading to its use in other autoimmune diseases. We have used MMF for the treatment of seven patients with inflammatory myopathy and are hereby reporting our results. CASE SERIES: All of our patients were females (age 17-65 yr). They were symptomatic upon presentation and met classification criteria for idiopathic inflammatory myopathy. Inflammatory markers such as erythrocyte sedimentation rate and C-reactive protein as well as creatine kinase were significantly elevated in all the patients, indicating active disease. Corticosteroids were concomitantly being administered (20-60 mg/day of prednisone). Initial therapy with conventional immunosuppressives was either ineffective or had significant adverse effects leading to their discontinuation. MMF was started in doses of 500 mg twice a day and titrated up to 1 g twice a day. RESULTS: Our patients have exhibited an impressive serological response to therapy with MMF and six patients had a marked improvement in their weakness. One patient had incomplete improvement in her weakness and has required additional therapies. MMF has been well tolerated during the treatment period (12-36 months). CONCLUSION: A striking clinical and laboratory response of active myositis in six out of seven patients in this series illustrates that MMF can be effectively used in management of autoimmune inflammatory myopathy and may be a suitable alternative to the conventional immunosuppressive agents.

Cause of death in systemic lupus erythematosus: a pattern based on age at onset.

We reviewed the causes of death in 50 patients treated for systemic lupus erythematosus at the University of Mississippi Medical Center between 1973 and 1985. Two groups of patients could be distinguished based on the age at onset but not on the duration of disease. Younger patients more often died of active renal disease an infectious complications, while older patients died of other organ involvement, inactive renal disease, and miscellaneous causes. Common causes of infection were gram-positive cocci and gram-negative bacilli. Atherosclerotic cardiovascular disease was an infrequent cause of death, and no patients died of malignancy. Patients who died had more multisystemic involvement, with serositis and renal, central nervous system, and hematologic manifestations than patients who were alive at last follow-up.

Association between relapsing polychondritis and systemic lupus erythematosus.

Relapsing polychondritis (RP) is an autoimmune disorder with chondritis as a prominent clinical feature. This disease has been found to coexist in some patients with systemic lupus erythematosus (SLE) or vice versa. We report a patient with clinical criteria fulfilling the diagnosis of RP. She had elevated levels of anti-dsDNA and decreased levels of CH50 during the 6-month observation, without clinical manifestations of SLE except for arthritis. We also reviewed all 16 cases of previously described patients with RP and SLE. From our study, we conclude that chondritis is rare in patients with SLE. If immunologic abnormalities usually found in SLE are detected in patients with RP, clinicians should observe patients for other manifestations of SLE.

Lupus nephritis: efficacy of monthly pulse therapy with intravenous methylprednisolone.

Fourteen patients with severe systemic lupus erythematosus and nephritis were treated with high-dose intravenous methylprednisolone (IVMP) pulse therapy. Six patients (group 1) received one or two courses of 1 gm of IVMP when they were acutely ill with rapidly progressive renal failure or with multisystemic disease. All patients had a poor outcome; three died and three had end-stage renal disease. Eight patients (group 2) were treated with repeated pulses of 1 gm of IVMP for four to 21 months. Six of the eight patients had a favorable outcome, with four in complete remission and two in partial remission. One of the eight patients had partial response with stable renal disease at 16 months after pulse therapy. Only one patient had no response, with gradual worsening of renal function. All patients in both groups had rapid improvement of levels of anti-DNA and CH50 after pulse therapy was started. Patients in group 2 were compared to 21 randomized patients (group 3) with comparable severity of disease. Renal function deteriorated in group 3, with a mean duration of disease of 82.5 +/- 56.4 months. Renal function improved in group 2, with a mean duration of disease of 87.8 +/- 46.8 months. We conclude that repeated monthly pulse therapy with IVMP in severe SLE was effective and that major side effects can be avoided with proper timing of pulsing.

Listerial infections in patients with systemic lupus erythematosus.

Infection with Listeria monocytogenes is known to occur more frequently in immunosuppressed patients, including those receiving high-dose prednisone or cytotoxic therapy for collagen vascular disease. We reviewed three cases of listeriosis and systemic lupus erythematosus (SLE) seen at our institution, in addition to five cases reported in the English literature. Seven of the eight patients had non-CNS listerial infections. All patients but one had associated risk factors of either renal failure or pregnancy. From our review, we found that listeriosis is uncommon in SLE, and patients without renal failure or pregnancy do not seem to be at increased risk for listeriosis. Although most patients were treated with high-dose prednisone, with or without cytotoxic drugs, the role of immunosuppression by these drugs as a risk factor for listeriosis remained unclear.

Naturally-ocurring low molecular weight IgM in patients with rheumatoid arthritis, systemic lupus erythematosus, and macroglobulinemia. II. Structural studies and comparison of some physicochemical properties of reduced and alkylated IgM, and low molecular weight IgM.

Some physicochemical properties of naturally occurring low molecular weight IgM (LMW IgM), IgM and their subunits obtained by reduction-alkylation were compared. On the basis of analytical ultracentrifugation, SDS polyacrylamide electrophoresis, analytical Sephadex chromatography, and heavy (H) and light (L) chain composition purified LMW IgM had an S20,W constant of approximately 8S, a molecular weight of 195,000 to 205,000 and a structural formula H2L2. Reduction and alkylation of IgM (IgM RA) by two techniques produces two components which could be distinguished by analytical ultracentrifugation, sucrose density ultracentrifugation, and gel filtration studies. IgM RA-cys had an estimated molecular weight similar to LMW IgM and IgM-2ME had physical properties similar to IgG. The molecular weights of H and L chains of IgM and LMW IgM were similar: 69,000 to 75,500 and 26,000 to 27,000, respectively. Unlike LMW IgM and IgM RA-cys, the less dense IgM RA reduced with 2ME dissociated into half subunits, and free H and L chains in SDS gel electrophoresis, indicating that it lacked intra-subunit disulfide bonds. J chain was not detected in LMW IgM or in the chromatographically purified reduced-alkylated subunits from a patient whose IgM contained J chain. Carbohydrate analyses of IgM, LMW IgM, and reduced-alkylated IgM products did not demonstrate differences in individual sugars or in the percentage of total carbohydrate. The different sedimentation and gel filtration properties of the two components obtained by reduction-alkylation of IgM could not be attributed to variations in peptide chain or carbohydrate content, rather they are probably dependent on conformational changes resulting from variable, reduction of intra-subunits disulfide bonds.

Quantitation of dengue precipitating antibody by inhibition countercurrent immunoelectrophoresis.

The inhibition countercurrent immunoelectrophoresis test was employed to detect dengue virus antibody in patients' sera. Anti-dengue type 2 titers determined by inhibition countercurrent immunoelectrophoresis correlated well with hemagglutination inhibition titers. In secondary cases, more than fourfold increases in precipitating antibodies were observed. The control sera were negative except for sera from a few patients with systemic lupus erythematosus, which showed low titers. Simultaneous detection of dengue virus antigen and antibody in sera collected during the acute phase could confirm at least 90% of cases. This method is recommended as a routine technique to quantitate antibody in sera from suspected cases of dengue hemorrhagic fever.