Restriction fragment length polymorphism of two HLA-B-associated transcripts genes in five autoimmune diseases.

The restriction fragment length polymorphism of the two human HLA-B-associated transcripts (BATs) genes, BAT1 and BAT2, identifying polymorphic bands of 12, 8, 2.5, and 1.1 kb, and at 3.3, 2.7, 2.3, and 0.9 kb, respectively, was investigated in patients with primary biliary cirrhosis (PBC), systemic lupus erythematosus (SLE), pauciarticular juvenile rheumatoid arthritis (P-JRA), rheumatoid arthritis (RA), and primary Sjögren's syndrome (pSS), and in healthy Danes. The BAT2/RsaI 2.7-kb band fragment was more frequent in PBC, pSS, and SLE than in controls, but the p values did not reach significance when corrected for multiple comparisons. For pSS and SLE, the associations may be secondary to primary associations with HLA-B8 because the BAT2/RsaI 2.3-kb band, which is allelic to the BAT2/RsaI 2.7-kb band, is strongly negatively associated with HLA-B8 and HLA-DR3. The only significance obtained shows that the HLA-B8 frequency is increased in BAT2/RsaI 2.7-kb positive pSS patients as compared to the corresponding controls indicating that the HLA-B8 association may be strongest. No missing or extra DNA fragments were observed in the disease groups when compared with controls indicating that gross deletions or duplications of the BAT1 and BAT2 genes in the patients are unlikely. In conclusions, it cannot be excluded that the BAT2/RsaI 2.7-kb band may contribute to the susceptibility to PBC, pSS, and SLE.

Rational drug therapy recommendations for the treatment of patients with Sjögren's syndrome.

The aetiology of Sjögren's syndrome (SS) is unknown, and consequently curative treatments are not available. The immunopathogenesis of SS is partly clarified and immune-regulating drugs (IR) may therefore be of therapeutic value. However, the present understanding of SS is still too unclear to allow an exact and evidence-based algorithm for therapeutic decision making. Rational drug recommendations for the therapy of SS must, therefore, rely mostly on empirical data. Several IR drugs have been shown to be able to downregulate the immunopathological activity of primary SS, but it is not certain whether the diagnostic and cardinal manifestations from the eyes and mouth can be improved. In primary SS the disease-modifying qualities of IR and cytotoxic drugs, therefore, largely apply to the treatment of severe internal organ involvement, inflammatory vascular disease and malignant B lymphocyte disease. In secondary SS the IR therapy is directed against the basic immunoinflammatory connective tissue disease. Symptom-modifying therapies include drugs to stimulate and substitute for exocrine functions, and drugs to treat complications of the exocrine disease manifestations and to improve the various nonexocrine disease manifestations. The main drugs available for increasing lacrimal and salivary gland output are bromhexine and pilocarpine, respectively. However, exocrine substitutes, and in particular eye drops, are still the most important means of alleviating the sicca symptoms. They are also indispensable local treatment measures which may help to prevent mucosal complications.

Primary Sjögren's syndrome--clinical and laboratory markers of disease activity.

Primary Sjögren's syndrome is a chronic autoimmune disorder of the lacrimal and salivary glands, reflecting general involvement of the exocrine tissues and leading to functional impairment. This polyglandular disease is often associated with systemic extraglandular manifestations, and laboratory tests usually indicate polyclonal B-lymphocyte hyperactivity. Clinical and laboratory markers monitoring the disease processes are needed for improved management of primary Sjögren's syndrome. However, incomplete knowledge of the long-term course of inflammation as well as of clinical manifestations makes precise and simple directions for monitoring disease activity in primary Sjögren's syndrome difficult. This review describes potential primary (eg, salivary gland histopathology, autoantibodies, soluble interleukin-2 receptors, and beta 2-microglobulin) and secondary disease activity markers (clinical and laboratory signs of glandular and extraglandular organ damage) and their known associations. The importance of genetic characteristics, patient age, and symptom duration for the disease activity markers is indicated. The systematic use of primary and secondary disease activity markers will improve our understanding of primary Sjögren's syndrome and help create better guidelines for monitoring the disease.

Cytokine expression in labial salivary glands from patients with primary Sjögren's syndrome.

The presence and distribution of 7 cytokines was examined immunohistologically in labial salivary gland (LSG) specimens from patients with primary Sjögren's syndrome (SS) and control subjects. The cytokines interleukin (IL)-1 beta IL-6, tumor necrosis factor (TNF) alpha and interferon (IFN) gamma were identified in defined parts of LSG from patients but not in the corresponding parts of control glands: (a) LSG acinar epithelium expressed IL-1 beta, (b) blood vessels located in both normal LSG stroma and within lymphocytic infiltrates expressed IL-1 beta, IL-6 and IFN gamma, and (c) lymphocytic infiltrates expressed IL-1 beta, IL-6 and TNF alpha. All four cytokines were expressed by salivary ducts within both patient and control specimens, but with generally greater intensity in patients. IL-1 alpha, IL-4 and TNF beta (lymphotoxin) could not be detected in any of the specimens from patients or controls. The locations of cytokines in LSG suggests possible mechanisms of immunologically mediated parenchymal damage in primary SS.

Immunogenetics of rheumatoid arthritis and primary Sjögren's syndrome: DNA polymorphism of HLA class II genes.

We investigated the DNA restriction fragment length polymorphism (RFLP) of the Major Histocompatability Complex (MHC) class II genes: HLA-DRB, -DQA, -DQB, DPA, and -DFB in 24 patients with rheumatoid arthritis (RA), in 19 patients with primary Sjögren's syndrome (primary SS), and healthy Danes. The frequencies of DNA fragments associated with the following HLA class II genes were increased in RA when compared to normal controls: DRB1*04 (DR4) (relative risk, RR = 7.4, P less than 10(-3), DRB4*0101 (DRw53) (RR = 9.6, P less than 10(-3), DQA1*0301 (RR = 9.6, P less than 10(-3), DQB1*0301 (DQw7) (RR = 2.8, P less than 0.05, 'corrected' P greater than 0.05), and DQB1*0302 (DQw8) (RR = 4.5, P less than 10(-2). Negative associations were found between RA and DRB1*1501 (DR2/DRw15) (RR = 0.2, P less than 10(-2) and DQB1*0602 (DQw6) (RR = 0.2, P less than 10(-2), 'corrected' P greater than 0.05). The frequencies in RA of other HLA class II associated DNA fragments including DPA and DPB and the antigens DPw1-w6 defined by primed lymphocyte stimulation, did not differ significantly from those in controls. In primary SS, the frequency of HLA-B8 was significantly increased (RR = 9.0, P less than 10(-3). Positive associations were found between primary SS and DNA fragments associated with DRB1*03/13 (RR = 6.8, P less than 10(-3), DRB3*0101 (DRw52) (RR = 5.7, P less than 10(-2), DQA1*0501 (RR = 6.8, P less than 10(-3), DQB1*0201 (DQw2) (RR = 11.6, P less than 10(-5), and DQB1*0602 (DQw6) (RR = 2.7, P less than 0.05, 'corrected' P greater than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Interleukin-6 and tumour necrosis factor alpha are expressed by keratinocytes but not by Langerhans cells.

The presence of human cytokines was examined in parallel skin biopsies and epidermal single cell preparations obtained from normal individuals. Using biotin-avidin-peroxidase and immunofluorescence techniques and antibodies against recombinant cytokines, a granular intercellular/membrane-associated staining for interleukin-6 (IL-6) and tumour necrosis factor alpha (TNF alpha), but not IL-1 alpha or beta, was observed. An epidermal cytoplasmic staining pattern was also detected, which was most pronounced using the anti-rIL-6 antiserum. In the epidermal single cell preparations, membrane-associated staining was detected for both IL-6 and TNF alpha. Double staining revealed that CD1-positive Langerhans cells (LC) failed to express any of the examined cytokines. In vitro binding of rIL-6 or rTNF alpha to skin sections and epidermal single cell preparations indicated that the cell surface-associated IL-6 and TNF alpha originally demonstrated on keratinocytes were truly membrane-bound. Finally, co-cultivation of epidermal cells with an IL-6 responsive cell line, B9, and testing of epidermal cell supernatants in this assay, indicated that the in vivo membrane-bound IL-6 had biological activity.

Epidermal tumour necrosis factor alpha and interleukin 6-like activities in AIDS-related Kaposi's sarcoma. An immunohistological study.

Biopsies from 6 patients with AIDS and Kaposi's sarcoma (KS) in the tumour stage, and 6 healthy controls, were immunohistologically examined for the presence of tissue-bound tumour necrosis factor alpha (TNF alpha) and interleukin 6 (IL-6) in the skin. TNF alpha was demonstrated using specific polyclonal antiserum to human recombinant TNF alpha. IL-6 was visualized indirectly using a polyclonal antiserum to partially purified human crude supernatants of activated human blood monocytes, followed by absorption with recombinant human IL-6. The cytokines were found identically located in epidermal cell membranes in stratum granulosum and spinosum of the epidermis from unaffected skin in both AIDS patients and in controls. Biopsies from KS elements showed markedly increased epidermal staining for both TNF delta and IL-6. It was not possible to detect TNF alpha or IL6 in the endothelial cells of the tumour. The observation of increased amounts of epidermal-bound TNF alpha and IL-6 in AIDS-related KS elements supplements previous studies indicating that the skin plays an active immunoinflammatory role in patients with AIDS.

Essential fatty acid status in cell membranes and plasma of patients with primary Sjogren's syndrome. Correlations to clinical and immunologic variables using a new model for classification and assessment of disease manifestations.

In 41 primary Sjögren's syndrome patients we compared fatty acid levels within erythrocyte phospholipids, plasma phospholipids, plasma triglycerides and plasma cholesterol esters, with the immunopathological and clinical disease status. Docosahexaenoic acid was the essential fatty acid (EFA), the levels of which correlated (inversely) most closely with the clinical disease status (r=-0.33 to -0.50). Levels of dihomogammalinolenic acid and eicosapentaenoic acid correlated inversely to levels of IgM rheumatoid factors (r=-0.33) and anti-SSA/Ro antibodies (r=-0.40) respectively. Moreover, levels of anti-SSA/Ro antibodies (r=-0.34-0.40) correlated with levels of the proinflammatory arachidonic acid. Sigma n-3 EFA/sigma n-6 EFA ratios correlated significantly to the quantitative estimates of immunopathological and clinical disease status. Our data are in agreement with current understanding of pro- and anti-immunoinflammatory roles within EFA metabolism, and support the rationale for intervention studies.

Abnormal essential fatty acid metabolism in Darier's disease.

Fatty acid levels in plasma and erythrocyte cell membranes were determined in 13 Danish patients with Darier's disease and 21 Danish controls. Concentrations of the main dietary essential fatty acids, linoleic acid (18:2n-6) and alpha-linolenic acid (18:3n-3), were consistently modestly above normal; concentrations of the delta 6-desaturase metabolites of both linoleic and alpha-linolenic acids, however, were consistently and often significantly below normal. These results suggest that the capacity of the enzyme delta 6-desaturase activity is inadequate in patients with Darier's disease.

Decreased interleukin-1 responsiveness of blood lymphocytes in patients with primary Sjögren's syndrome.

Impaired immune regulation is considered to be involved in the pathogenesis of primary Sjögren's syndrome (primary SS). A qualitative T lymphocyte defect is suggested by previous reports of impaired lymphocyte proliferation, impairment of interleukin-2 (IL-2) production, and a decreased number of IL-2 receptors, whereas the capacity of monocytes to produce IL-1 is normal in most patients. We here report on the IL-1 sensitivity of monocyte-depleted mononuclear cells (MDC) from patients with primary SS. IL-1 responsiveness, evaluated by measuring the enhancing effect of an IL-1 standard on the proliferative response of the patient's MDC, was decreased compared to that of the control group, and there was a positive correlation between patients' IL-1 production and IL-1 sensitivity. The results confirm the notion of impaired T lymphocyte function in primary SS, and suggest a pathogenetic mechanism that involves both monocytes and T lymphocytes.

Epidermal IgG deposits in patients with chronic inflammatory connective tissue diseases: diagnostic value and correlation to clinical and immunological parameters in patients with primary Sjögren's syndrome.

Thirty-seven patients with primary Sjögren's syndrome (Primary SS), 12 patients with incipient primary SS, 100 patients with other chronic inflammatory connective tissue diseases (CTD) and 20 healthy controls had a punch biopsy taken from clinically unaffected skin from the buttock. Direct immunofluorescence examinations revealed intraepidermal IgG deposits in 68% of patients with primary SS, in 42% of patients with incipient primary SS, in 13% of patients with rheumatoid arthritis (RA, n = 31), in 15% of patients with systemic lupus erythematosus (SLE, n = 13), in 24% of patients with other well-defined CTD (n = 41), in 40% of patients with ill-defined CTD (n = 15) and in 10% of healthy controls. Immunoglobulin deposits along the dermoepidermal junction zone (DEJ) were not found in any of the patients with primary SS, but were present in 16% of the patients with RA and in 23% of the patients with SLE. In the patients with primary SS, no correlation was found between intraepidermal IgG deposits and age, disease duration, extraglandular manifestations, P-IgG concentration, ANA, rheumatoid factors or circulating immune complexes. Examination for intraepidermal IgG deposits seems valuable in the differential diagnosis between primary SS and RA or SLE, and it could supplement the lupus band test.

Natural killer cell functions are related to the cell membrane composition of essential fatty acids: differences in healthy persons and patients with primary Sjögren's syndrome.

To examine whether abnormalities in essential fatty acid (EFA) metabolism are associated with the impaired natural killer (NK) cell functions in primary Sjögren's syndrome, we measured the levels of phospholipid fatty acids in blood mononuclear cells with (MD) and without monocyte depletion (MC), and NK cell activity before and after indomethacin-boosting. We found MD levels of 20:3n6 (dihommo-gamma-linolenic acid), and basal and indomethacin-enhanced NK cell activity significantly reduced, in 10 primary Sjögren's syndrome patients as compared with 10 healthy controls. In the controls the relative (%) increase in indomethacin-enhanced NK cell activity correlated with the level of MD 18:2n6 (linoleic acid) (r = 0.97, p less than 0.001). In the patients the relative (%) indomethacin-enhanced NK cell activity correlated with the 20:4n6 (arachidonic acid)/20:3n6 ratio in the MC (r = 0.90, p less than 0.001). This ratio has been assumed to be an important determinant for the production of prostaglandin 1 and 2. The present data suggest that in healthy persons, as opposed to primary Sjögren's syndrome patients, the level of MD 18:2n6 is a determinant for the sensitivity of NK cells to monocyte-derived prostaglandins. Furthermore, in patients with primary Sjögren's syndrome the MC levels of 20:3n6 and 20:4n6 may be regulating factors for the production of NK cell suppressing prostaglandins.

High levels of complement fixing antibodies against cytomegalovirus in patients with primary Sjögren's syndrome.

Antibodies to cytomegalovirus (CMV) were examined in sera from 21 consecutive patients with primary Sjögren's syndrome (SS) and 19 consecutive patients with secondary SS, using a complement fixation (CF) test and an antibody capture enzyme-linked immunosorbent assay (ELISA). Sera from 15 CMV-negative subjects, 15 CMV-positive subjects, 3 patients with primary CMV infection and 3 patients with recurrent CMV infection served as controls. The prevalence of CMV antibodies in the patients with primary and secondary SS was found similar to the prevalence known to occur in the normal adult population. Unrelated to clinical parameters, 5 patients with primary SS (24%) had high levels of CF antibodies against CMV. Ig class antibodies to CMV were not elevated in these 5 patients. Preferential production of CF antibodies to CMV may be a pathogenetic factor in some patients with primary SS.

In vitro binding of IgG from patients with primary and secondary Sjögren's syndrome to different components of keratinized stratified squamous epithelia.

The ability of serum IgG from patients with Sjögren's syndrome (SS) to bind to keratinized stratified squamous epithelium of human skin or rat oesophagus was examined, using an indirect immunofluorescence technique. No in vitro binding of serum IgG to the cell membranes of normal human epidermis was demonstrated in 7 patients with primary SS and two normal controls. Thus, the intraepidermal in vivo IgG deposits previously found in 5 of the 7 patients could not be imitated in vitro. Examination for in vitro binding to rat oesophageal epithelium of serum IgG from 21 consecutive patients with primary SS, 19 consecutive patients with rheumatoid arthritis and secondary SS and 22 normal controls showed that antikeratin antibodies occur more frequently (p less than 0.001) in the patients with secondary SS compared to patients with primary SS and to normal controls.

Sjögren's syndrome: terminology.

In spite of our continuously improved pathobiological understanding, there is still no consensus on terminology and disease criteria in Sjögren's syndrome (SS). This survey points out discrepencies in the current description of the syndrome, and argues for a new classification model. We suggest that the present nomenclatures for the global disease (Sjögren's disease) and disease subsets (primary and secondary SS) be retained until additional pathobiological insights give rise to new and descriptive terms. We do find evidence, however, to support a new terminology and classification of the main immunoinflammatory manifestations of primary SS. Accordingly, three "exocrine" and four "non-exocrine" subgroups of disease manifestations are here defined. The usefulness of the proposed model should be evaluated in clinical studies and in a debate engaging all of the medical specialities involved.

Epidermal cell surface-associated IgG in patients with primary Sjögren's syndrome: in vitro evidence for immune complex binding.

In vivo deposits of IgG have previously been demonstrated in the epidermal intercellular area of clinically unaffected skin from 68% of patients with primary Sjögren's syndrome (primary SS). This study compared circulating IgG from patients with primary SS with that from secondary SS in their ability to bind normal human epidermal cells in vitro. We observed a granular pattern of IgG binding to the normal epidermal cell surfaces with 9 of 18 sera from patients with primary SS (50%), 3 of 19 sera from patients with SS secondary to rheumatoid arthritis (16%) (p = 0.025), and none of 24 normal control sera (p less than 0.001). In a subsequent analysis of polyethylene glycol separated sera from two normal controls and two primary SS patients, the epidermal IgG binding capacity was found only in the precipitates of the patients. These findings support our previous hypothesis that the in vivo intraepithelial IgG deposits in primary SS patients are due, at least in part, to cell surface-bound immune complexes.

Effect of auranofin on human platelet aggregation, release of serotonin, and cyclic-AMP formation.

Auranofin (Aur), a new oral gold compound valuable in treatment of patients with rheumatoid arthritis, is known to have an inhibitory effect on ADP- and epinephrine-induced platelet aggregation in vitro. This may be of clinical importance as platelets participate in thrombus formation and are believed to act as proinflammatory cells in the diseased synovial tissue of rheumatoid arthritis. In the present in vitro study it was confirmed that Aur inhibits both ADP- and adrenaline-induced platelet aggregation in a dose- and time-dependent manner. In addition, a time- and dose-dependent decrease in platelet release of serotonin as well as a pronounced increase in the production of cyclic-AMP was found to result from Aur incubation. Aur's inhibitory effect on platelets is probably mediated through cyclic-AMP stimulation. Future studies of Aur's platelet inhibitory effect should investigate the mechanisms by which cyclic-AMP formation is increased, since this may be of importance also for Aur's action on other cell types.

Classification of disease manifestations in primary Sjögren's syndrome: present status and a new proposal.

Establishing a model for classification of the clinical disease manifestations in primary Sjögren's syndrome is a challenge with important implications for handling individual patients and for describing and analyzing patient materials. Based on the pathobiology of primary SS we define three (1-3) "exocrine" and four (4-7) "nonexocrine" subgroups of disease manifestations. Accordingly, 1) "surface exocrine disease" includes the diagnostic features from eyes (keratoconjunctivitis sicca) and mouth (xerostomia), and the manifestations from upper airways (rhinitis sicca, xerotracheitis) and skin (xeroderma). Involvement of the excretory parenchyma of the lungs, hepatobiliary system, pancreas, intestinal tract and kidneys is designated 2) "internal organ exocrine disease". These manifestations are potentially severe, do not lead to subjective dryness, and none of them are diagnostic for the disease. We suggest 3) "monoclonal B-lymphocyte disease" (lymphoma) to be an exocrine disease manifestation because it originates mostly from the immunoinflammatory foci of the autoimmune exocrinopathy. The nonexocrine manifestations are subgrouped into: 4) "inflammatory vascular disease" (vasculitis and perivasculitis), 5) "noninflammatory vascular disease" (Raynaud), 6) "mediator-induced disease" (hematologic cytopenia, fever and fatigue) and 7) "autoimmune endocrine disease". Subdividing the seven subgroups leads to a third order of classification in which single and separate manifestations are placed. The descriptive and analytic power of the proposed model for classification of disease manifestations in primary Sjögren's syndrome should be evaluated in clinical studies.

Standardized assessment of disease status in patients with primary Sjögren's syndrome: the foundation for creating criteria for disease activity and damage?

Primary Sjögren's syndrome (pSS) is increasingly acknowledged as a disease entity with consistent pathogenesis and clinical presentation. This has encouraged proposals for uniform nomenclature, as well as for classification of disease subsets and clinical disease manifestations. The purpose of this literature survey is to analyse present pathogenetic and clinical data on pSS from the viewpoint of their usability for developing criteria for activity and damage. It appears that the routinely used tests for evaluating clinical disease manifestations in pSS probably measure both activity and damage. Moreover, no immunopathogenic marker has been shown to adequately represent all aspects of disease activity in pSS. The survey demonstrates the need for longitudinal studies in which potential markers of disease activity and damage are validated.