[Differential diagnosis of elevated liver transaminases in rheumatic diseases]. / Differenzialdiagnose der Transaminasenerhöhung bei rheumatischen Erkrankungen.

During laboratory monitoring of patients with rheumatic diseases it is not uncommon to notice elevated liver transaminase levels. From a rheumatological perspective there are multiple causes for this. Liver dysfunction can be the result of certain rheumatological diseases, such as systemic lupus erythematosus. Primary biliary cirrhosis and primary sclerosing cholangitis are associated with rheumatic diseases. On the other hand, hepatological diseases, such as hepatitis C and autoimmune hepatitis show rheumatological symptoms. The most common cause of elevation of liver transaminase levels in rheumatic patients is without doubt the anti-rheumatic therapy.

[Comorbidity of rheumatic and hepatic diseases]. / Komorbidität rheumatischer und hepatologischer Erkrankungen.

The correlation between rheumatic diseases and liver diseases is complex and often not given sufficient attention. There are, however, consequences for diagnosis and therapy. Rheumatic diseases can present with hepatic symptoms while liver diseases can exhibit rheumatic symptoms. Examples of liver diseases as a cause of rheumatic symptoms are viral hepatitis B and C, autoimmune hepatitis and hemochromatosis. As a result of rheumatic diseases, such as adult onset Still's disease and systemic lupus erythematosus, liver dysfunction can occur. Autoimmune hepatitis, primary biliary cirrhosis and primary sclerosing cholangitis are directly associated with rheumatic diseases and have to be distinguished by way of differential diagnosis. During antirheumatic therapy, serious hepatotoxic side effects have to be expected.

[Gastrointestinal tumors. Clinical manifestations of paraneoplastic rheumatic symptoms]. / Gastrointestinale Tumoren : Klinische Ausprägung paraneoplastischer rheumatischer Symptome.

Paraneoplastic syndromes, as syndromes associated with malignancy, can present unrelated to tumor invasion or metastases. They can occur with varying clinical appearance and are often indistinguishable from idiopathic rheumatic symptoms. Some musculoskeletal disorders are more associated with malignancies. The therapy of rheumatic syndromes can itself have an effect on the tumorigenic process. The clinical severity of paraneoplastic rheumatic symptoms can in many cases aid in the assessment of tumor activity and the response to therapy. While generally an extensive search for occult malignancies in every older rheumatoid patient in cases with no indications of malignancy is not advisable, knowledge of rheumatic symptoms associated with malignancies aids in the important early detection of tumors, while avoiding unnecessary examinations.

Wegener's granulomatosis: anti-proteinase 3 antibodies are potent inductors of human endothelial cell signaling and leakage response.

Anti-neutrophil cytoplasmic antibodies (ANCAs) targeting proteinase 3 (PR3) have a high specifity for Wegener's granulomatosis (WG), and their role in activating leukocytes is well appreciated. In this study, we investigated the influence of PR3-ANCA and murine monoclonal antibodies on human umbilical vascular endothelial cells (HUVECs). Priming of HUVECs with tumor necrosis factor alpha induced endothelial upregulation of PR3 message and surface expression of this antigen, as measured by Cyto-ELISA, with a maximum occurrence after 2 h. Primed cells responded to low concentrations of both antibodies (25 ng-2.5 microg/ml), but not to control immunoglobulins, with pronounced, dose-dependent phosphoinositide hydrolysis, as assessed by accumulation of inositol phosphates. The signaling response peaked after 20 min, in parallel with the appearance of marked prostacyclin and platelet-activating factor synthesis. The F(ab)2 fragment of ANCA was equally potent as ANCA itself. Disrupture of the endothelial F-actin content by botulinum C2 toxin to avoid antigen-antibody internalization did not affect the response. In addition to the metabolic events, anti-PR3 challenge, in the absence of plasma components, provoked delayed, dose-dependent increase in transendothelial protein leakage. We conclude that anti-PR3 antibodies are potent inductors of the preformed phosphoinositide hydrolysis-related signal tranduction pathway in human endothelial cells. Associated metabolic events and the loss of endothelial barrier properties suggest that anti-PR3-induced activation of endothelial cells may contribute to the pathogenetic sequelae of autoimmune vasculitis characterizing WG.

[Recommendations of the German rheumatology society on the use of tocilizumab in rheumatoid arthritis]. / Empfehlungen der Deutschen Gesellschaft für Rheumatologie zum Einsatz von Tocilizumab bei der rheumatoiden Arthritis (Februar 2010).

The humanized anti-IL-6 receptor monoclonal antibody tocilizumab (TCZ) represents a new therapy approach for moderately severe to severe cases of rheumatoid arthritis (RA). The IL-6 concentration in the synovial fluid and peripheral circulation of patients with RA is elevated. TCZ recognises the IL-6 binding site of human IL-6R and blocks the IL-6 signaling pathway. TCZ is capable of correcting a multitude of pathological processes in RA, as has been shown in a number of studies. TCZ treatment should be combined with methotrexate. If the latter cannot be administered, TCZ can also be used as a monotherapy. The recommended dose is 8 mg/kg once every 4 weeks; the minimum dose per infusion is 480 mg. Close monitoring, in particular for infectious complications, is necessary. Clinical effects of TCZ are usually seen several weeks following initiation of therapy. If no significant clinical response is seen within 6 months, TCZ therapy should be ceased.

A human renal cancer line as a new antigen source for the detection of antibodies to cytoplasmic and nuclear antigens in sera of patients with Wegener's granulomatosis.

Autoantibodies directed against cytoplasmic antigens of neutrophils (ANCA), especially proteinase 3 (C-ANCA), have proved to be a useful clinical tool to support the diagnosis or to monitor disease activity in Wegener's granulomatosis (WG). Till now, human neutrophil granulocytes have represented the major antigen source used to detect antibodies in WG by the immunofluorescence technique (IFT). We have tested serum samples of 164 patients with different connective tissue diseases (50 suffering from clinically active WG) performing IFT on a human renal cancer line (SK-RC11) and have found antibodies against the nuclear and cytoplasmic antigens in 39 patients. C-ANCA+ sera displayed a characteristic diffuse cytoplasmic staining pattern. Antibody titers measured with human granulocytes were comparable to titers obtained using culture cells. Antibody binding could be inhibited by preabsorption with an extract of human granulocytes or purified proteinase 3. A protein of 29 kDa MW could be isolated by affinity purification using a SK-RC11 extract and a high-titer C-ANCA+ serum and antigenic identity was further confirmed by IFT using a monoclonal antibody to proteinase 3. Treatment of tumor cells with cytokines (interferon, tumor necrosis factor) led to a time dependent translocation of the antigen into the nucleus and back to the cytoplasm. The antigen was also expressed on the surface of live cells colocalized with MHC II. In addition, 21 WG patients had antibodies to cytoplasmic organelles identified by laser scanning microscopy as secretory vesicles of the Golgi complex, and five had antibodies to nuclear antigens. This is, to the best of our knowledge, the first report of proteinase 3 in human non-leukemic cells. Our data demonstrate, that the repertoire of antigens recognized by antibodies in WG sera is not limited to human neutrophils and monocytes and indicates a possible functional role of the antigenic proteins.

Translocation of the nuclear autoantigen La to cell surface: assembly and disassembly with the extracellular matrix.

La (SS-B) protein is known as one major antigenic target for autoantibodies from patients with certain autoimmune diseases such as Sjogren's syndrome or Lupus Erythematosus. La protein belongs to the so called "extractable nuclear antigens". Here we report that La antigen is not restricted to the nucleus as one might deduce from the exclusive nuclear staining pattern of patient anti-La antibodies but after stimulation of serum-starved cells with 10% fetal calf serum (FCS) appears and stays for at least 45 min at the outer surface of CV-1 cells being available for binding of anti-La antibodies. In addition we found that a minor part of La antigen associates with the extracellular fibronectin network. After addition of 10% FCS to serum starved cells this extracellular autoantigen disassembled from the extracellular matrix and was taken up again by the cells. Incubation of serum starved cells with mercuric chloride, a known potent inducer of autoantibodies, also resulted in a detachment of the extracellular matrix associated La protein. From our studies it becomes likely that La protein itself is the antigen during autoimmunization. Moreover, once developed, anti-La antibodies might be able to bind to cell surface expressed La protein resulting in a damage of these cells leading to the inflammational events known to occur during disease.

In vitro production of anti-neutrophilocyte-cytoplasm-antibodies (ANCA) by Epstein-Barr virus-transformed B-cell lines in Wegener's granulomatosis.

The frequent detection of anti-neutrophilocyte-cytoplasm-antibodies (ANCA) in patients with Wegener's granulomatosis (WG) led to the supposition that this disease might be of autoimmune nature. For some authors assume that Epstein-Barr virus (EBV) infection of human B-lymphocytes besides polyclonal activation could reveal the cryptic immune status against different autoantigens in patients with autoimmune diseases we investigated EBV-transformed B-lymphocytes from patients with Sjögren's syndrome, mixed connective tissue disease, WG and healthy blood donors. Two stable B-cell lines (Ho3, We1) could be established. Inhibition experiments showed that antibodies produced by transformed B-lymphocytes and serum ANCA (C-ANCA type) of 10 WG patients recognized the identical antigen. Stimulation of one clone (Ho3) with interleukin 6 (IL-6) led to a switch from IgM to IgG production. Antibodies produced by this clone also stained glomeruli of human frozen kidney sections. Western blot analysis using immunoaffinity purified antigen prepared from human granulocytes revealed a reaction with a protein of approx. 29 kD MW. Our data underscore some new aspects concerning the direct pathogenicity of C-ANCA confirming the hypothesis that the autoimmune B-cell repertoire in WG not only reflects a polyclonal B-cell activation but is shaped by antigen driven responses.

Correlation of synovial fluid interleukin 6 (IL-6) activities with IgG concentrations in patients with inflammatory joint disease and osteoarthritis.

Synovial fluids of patients with rheumatoid arthritis, osteoarthritis, psoriatic arthritis, reactive arthritis and Reiter's syndrome were examined for their concentrations of interleukin 6 (IL-6) in a proliferation assay with the IL-6 dependent hybridoma cell line B13.29 (subclone B9). IL-6 activity was significantly higher in the synovial fluids of patients with rheumatoid arthritis and psoriatic arthritis than in patients with osteoarthritis. Significant correlations were shown between the concentrations of synovial fluid IL-6 and IgG. These findings may contribute to the understanding of the enhanced immunoglobulin production by synovial mononuclear cells in patients with inflammatory joint disease.

Antibodies to cytoskeletal components in patients undergoing long-term hemodialysis detected by a sensitive enzyme-linked immunosorbent assay (ELISA).

To date only a few contradictory reports concerning the incidence of autoantibodies in patients undergoing long-term hemodialysis exist. The aim of the present study was to investigate the sera drawn from 45 patients with chronic renal failure, 39 of them on chronic hemodialysis (duration 1-17 years). Serum samples were tested for 15 autoantibodies, no antinuclear antibodies or antibodies to extractable nuclear antigens could be detected; all sera were also negative for antibodies to dsDNA, mitochondria, gastric parietal cells and smooth muscle. In contrast a high incidence of antibodies to cytoskeletal components could be demonstrated using a sensitive enzyme-linked immunosorbent assay that employed purified antigens. Antibodies of IgG-type (IgM-type shown in brackets) were detected against cytokeratin in 51.3% (15.4%), actin in 17.9% (5.1%), desmin in 28.2% (17.9%), vimentin in 15.4% (5.1%) and tropomyosin in 12.8% (5.1%) of the sera of patients on chronic hemodialysis. No association with diagnosis, duration of hemodialysis, age or interdialytic changes of body weight and antibody titers could be found. In a control group of 82 healthy blood donors no antibodies were detected. Positive correlations of incidence of antibodies to actin, desmin, vimentin and keratin suggests polyclonal activation of immune system in patients with chronic renal failure undergoing long-term hemodialysis. The mechanism is unknown.

In vitro interactions of c-ANCA (antibodies to proteinase 3) with human endothelial cells.

Several concepts concerning the pathogenicity of antineutrophil cytoplasmic antibodies (ANCA) exist, but till now only sparse data about ANCA-endothelial interactions are available. In this study we have investigated the expression of proteinase 3 (PR-3) in human umbilical endothelial cells (HEC) using purified anti-PR-3 antibodies (C-ANCA) of patients with Wegener's granulomatosis (WG) and monoclonal antibodies to PR-3 (human and murine) as probes. Performing cyto-ELISAs, laser scanning microscopy and Western blot we were able to show that treatment of HEC with IL-1-alpha led to an increased PR-3 expression in the cytoplasm and to a transient translocation into the EC-membrane. Representing an important missing link of ANCA-endothelial interactions, our data give a hint at a possible direct pathogenicity of anti-PR-3 antibodies in WG and other vasculitides.

[Acute mesenterial artery occlusion--an unusual symptom of primary antiphospholipid antibody syndrome]. / Akuter Mesenterialarterienverschluss als seltene Manifestation eines primären Antiphospholipid-Antikörpersyndroms.

BACKGROUND: The antiphospholipid-antibody syndrome (APS) is a thrombophilic disorder, in which venous and arterial thrombosis can occur. We report the rare case of a patient with mesenteric infarction due to primary APS. CASE REPORT: A 46-year-old male patient was admitted to the hospital because of severe abdominal pain. A laparotomy was performed and revealed infarction of a jejunal loop which was resected. At pathohistological examination mesenteric artery infarction was found. Preoperatively prolonged partial thromboplastin time led to coagulation analysis. Lupus anticoagulant and anticardiolipin antibodies were found. TREATMENT: The diagnosis of primary APS was made and the patient was treated with aspirin (100 mg/day) and low molecular weight heparin (2,500 IE/day) permanently. Eighteen months after mesenteric infarction the patient is free of further thromboembolic events.

[Prostate carcinoma associated spontaneous factor VIII:C inhibitor hemophilia. Successful therapy of severe hemorrhagic complication with porcine factor VIII in a 75-year-old patient]. / Prostatakarzinom-assoziierte spontane Hemmkörperhämophilia. Erfolgreiche Therapie einer schweren Blutungskomplikation mit porzinem Faktor VIII bei einem 75jährigen Patienten.

Inhibitors of factor VIII are a rare condition in non-hemophiliacs, but they are frequently responsible for life threatening hemorrhage. Acquired factor VIII:C inhibitors represent the spontaneous development of autoantibodies that partially or completely neutralize the plasma coagulant activity of the clotting factor. The autoantibodies can arise in diverse clinical settings, in older adults they are frequently associated with immunologic disorders or malignancies. We report of a 75-year-old man with acquired factor VIII:C inhibitor associated with adenocarcinoma of the prostate and a successful treatment of a severe bleeding complication with porcine factor VIII. A 75-year-old man was admitted because of a hematoma of his right cheek and an isolated prolonged aPTT. Acquired factor VIII:C inhibitor was identified as the cause and immuno-suppressive therapy was begun. In the clinical course severe hemorrhaging occurred and was successfully treated with porcine factor VIII (Hyate:C). The initially high inhibitor titer of 32 Bethesda Units (BU) disappeared. As the cause of acquired factor VIII:C inhibitor a newly diagnosed adenocarcinoma of the prostate is likely. After complete remission of acquired factor VIII:C inhibitor radiation therapy was begun. Six months after severe hemorrhaging the patient was clinically stable and PSA levels were normal. This case demonstrates the necessity of a precise diagnosis and therapy regimen of this coagulopathy based on clinical and laboratory data. In the absence of hemorrhage immuno-suppressive therapy with corticosteroids is indicated, in a patient with severe bleeding and high inhibitor titer (> or = 5 BU) porcine factor VIII should be administered.

Characterization of target antigens from anti-neutrophil cytoplasmic antibodies in autoimmune hepatitis type-I.

The occurrence of anti-neutrophil cytoplasmic antibodies (ANCA) has been described in sera of patients with autoimmune hepatitis (AIH). The significance of this finding remains uncertain and the nature of the target antigen(s) has not yet been defined. We studied 32 sera from patients with AIH type-I and prepared extracts of human neutrophils to identify the target antigen(s). A 43 kDa dominant immunoreactive protein was found and identified as the cytoskeletal component actin. Initial studies to define the antigenic determinants identified three different actin domains.