A liposomal steroid nano-drug for treating systemic lupus erythematosus.

BACKGROUND: Glucocorticoids have been known for years to be the most effective therapy in systemic lupus erythematosus. Their use, however, is limited by the need for high doses due to their unfavorable pharmacokinetics and biodistribution. We have previously developed a novel liposome-based steroidal (methylprednisolone hemisuccinate (MPS)) nano-drug and demonstrated its specific accumulation in inflamed tissues, as well as its superior therapeutic efficacy over that of free glucocorticoids (non-liposomal) in the autoimmune diseases, including the adjuvant arthritis rat model and the experimental autoimmune encephalomyelitis mouse model. OBJECTIVES: In the present work we have evaluated the therapeutic effect of the above liposome-based steroidal (MPS) nano-drug in the MRL-lpr/lpr murine model of SLE and compared it with similar doses of the free MPS. METHODS: MRL-lpr/lpr mice were treated with daily injections of free MPS or weekly injections of 10% dextrose, empty nano-liposomes or the steroidal nano-drug and the course of their disease was followed up to the age of 24 weeks. RESULTS: Treatment with the steroidal nano-drug was found to be significantly superior to the free MPS in suppressing anti-dsDNA antibody levels, proliferation of lymphoid tissue and renal damage, and in prolonging survival of animals. CONCLUSION: This significant superiority of our liposome based steroidal nano-drug administered weekly compared with daily injections of free methylprednisolone hemisuccinate in suppressing murine lupus indicates this glucocorticoid nano-drug formulation may be a good candidate for the treatment of human SLE.

Rituximab induces resolution of recurrent diffuse alveolar hemorrhage in a patient with primary antiphospholipid antibody syndrome.

Diffuse alveolar hemorrhage (DAH) is a rare manifestation of primary antiphospholipid antibody syndrome (APS). We describe a patient with primary APS and refractory recurrent episodes of DAH. The patient was admitted 15 times due to recurrent episodes of DAH in a period of 18 months. Multiple immunosuppressive drugs did not improve his condition. Two years after his presentation, he was treated with rituximab (two doses of 1 g, 2 weeks apart). Six months later, the attacks of DAH have gradually disappeared. In a follow-up of more than 2 years after he received rituximab, the patient has had no further admissions due to DAH. Levels of antiphospholipid antibodies were measured during follow-up of 4 years. Anti-ß2 glycoprotein IgG titer decreased to normal 6 months after therapy but anticardiolipin (aCL) antibody titer increased. We conclude that rituximab caused a dramatic clinical response in this patient. Anti-ß2 glycoprotein IgG correlated better with the clinical response in this patient than aCL.

A single germline VH gene segment of normal A/J mice encodes autoantibodies characteristic of systemic lupus erythematosus.

These experiments tested the hypothesis that unmutated germline genes from normal mice can encode autoantibodies. We found that the unmutated VHIdCR gene segment, which encodes a large proportion of antiarsonate antibodies in A/J mice, also encodes antibodies with the ability to bind to DNA and cytoskeletal proteins. After Ars immunization, at a time when the VHIdCR gene segment mutates and antibody affinity for the hapten increases, reactivity with the autoantigens was lost. Six antibodies obtained after immunization with Ars bound both the Ars and DNA. Results of competitive inhibition assays suggested that the same variable region site in the antibodies bound to both Ars and DNA. The properties of the individual germline-encoded antibodies, which include reactivity to both DNA and cytoskeletal proteins, suggest that autoantibodies characteristic of SLE might be a subset of antibodies encoded by unmutated germline V genes.

Immunochemical similarities between monoclonal antibacterial Waldenstrom's macroglobulins and monoclonal anti-DNA lupus autoantibodies.

Six monoclonal IgM from patients with Waldenstrom's macroglobulinemia that react with Klebsiella polysaccharides were tested for their ability to bind to nucleic acid antigens. One of the macroglobulins bound to the polynucleotide poly(G), and one bound to poly(G), poly(I), and single-stranded DNA. The reaction with the polynucleotides was specifically inhibited by the Klebsiella polysaccharide K30. A monoclonal lupus anti-DNA antibody (16/6) was found to react weakly with the Klebsiella polysaccharides K30 and K21. Five of the Waldenstrom macroglobulins shared an idiotypic determinant with the 16/6 anti-DNA antibody. The reaction between the macroglobulins and the antiidiotype serum was specifically inhibited by Klebsiella polysaccharides, an indication that the idiotypic marker was in the antigen-binding site of the macroglobulins. These results indicate the existence of widely dispersed conserved variable region genes that encode idiotypically related immunoglobulins with the capacity to bind to both bacterial polysaccharides and nucleic acids. Such genes can be expressed by patients with either Waldenstrom's macroglobulinemia or systemic lupus erythematosus.

Lines of T lymphocytes induce or vaccinate against autoimmune arthritis.

The pathophysiology of autoimmune arthritis was studied by selecting and isolating lines of effector T lymphocytes from rats administered an arthritogenic dose of Mycobacterium tuberculosis in complete Freund's adjuvant to induce adjuvant arthritis. Irradiated rats were intravenously inoculated with a cell line characterized by proliferative reactivity to Mycobacterium tuberculosis and, to a lesser degree, to rat collagen type II. This produced arthritis in all the irradiated rats. Nonirradiated recipients failed to develop arthritis. However, such rats, and those recovering from cell-mediated arthritis, were resistant to subsequent attempts to induce adjuvant arthritis. Lines of T lymphocytes selected for responsiveness to other antigens had no effect. Therefore, a line of T lymphocytes responsive to bacteria or to collagen type II could either induce autoimmune arthritis or serve as an agent of vaccination against it.

Suppression of experimental autoimmune diseases and prolongation of allograft survival by treatment of animals with low doses of heparins.

The ability of activated T lymphocytes to penetrate the extracellular matrix and migrate to target tissues was found to be related to expression of a heparanase enzyme (Naparstek, Y., I. R. Cohen, Z. Fuks, and I. Vlodavsky. 1984. Nature (Lond.). 310:241-243; Savion, N., Z. Fuks, and I. Vlodavsky. 1984. J. Cell. Physiol. 118:169-176; Fridman, R., O. Lider, Y. Naparstek, Z. Fuks, I. Vlodavsky, and I. R. Cohen. 1987. J. Cell. Physiol. 130:85-92; Lider, O., J. Mekori, I. Vlodavsky, E. Baharav, Y. Naparstek, and I. R. Cohen, manuscript submitted for publication). We found previously that heparin molecules inhibited expression of T lymphocyte heparanase activity in vitro and in vivo, and administration of a low dose of heparin in mice inhibited lymphocyte traffic and delayed-type hypersensitivity reactions (Lider, O., J. Mekori, I. Vlodavsky, E. Baharav, Y. Naparstek, and I. R. Cohen, manuscript submitted for publication). We now report that treatment with commercial or chemically modified heparins at relatively low doses once daily (5 micrograms for mice and 20 micrograms for rats) led to inhibition of allograft rejection and the experimental autoimmune diseases adjuvant arthritis and experimental autoimmune encephalomyelitis. Higher doses of the heparins were less effective. The ability of chemically modified heparins to inhibit these immune reactions was associated with their ability to inhibit expression of T lymphocyte heparanase. There was no relationship to anticoagulant activity. Thus heparins devoid of anticoagulant activity can be effective in regulating immune reactions when used at appropriate doses.

Homology of the NH2-terminal amino acid sequences of the heavy and light chains of human monoclonal lupus autoantibodies containing the dominant 16/6 idiotype.

The NH2-terminal amino acid sequences have been determined by automated Edman degradation for the heavy and light chains of five monoclonal IgM anti-DNA autoantibodies that were produced by human-human hybridomas derived from lymphocytes of two patients with systemic lupus erythematosus. Four of the antibodies were closely related to the idiotype system 16/6, whereas the fifth antibody was unrelated idiotypically. The light chains of the 16/6 idiotype-positive autoantibodies (HF2-1/13b, HF2-1/17, HF2-18/2, and HF3-16/6) had identical amino acid sequences from residues 1 to 40. Their framework structures were characteristic of VKI light chains. The light chain of the 16/6 idiotype-negative autoantibody HF6-21/28 was characteristic of the VKII subgroup. The heavy chains of the 16/6 idiotype-positive autoantibodies had nearly identical amino acid sequences from residues 1 to 40. The framework structures were characteristic of the VHIII subgroup. In contrast, the GM4672 fusion partner of the hybridoma produced small quantities of an IgG with a VHI heavy chain and a VKI light chain. The heavy chains of the lupus autoantibodies and the light chains of those autoantibodies that were idiotypically related to the 16/6 system had marked sequence homology with WEA, a Waldenstrom IgM that binds to Klebsiella polysaccharides and expresses the 16/6 idiotype. These results indicate a striking homology in the amino termini of the heavy and light chains of the lupus autoantibodies studied and suggest that the V regions of the heavy and light chains of the 16/6 idiotype-positive DNA-binding lupus auto-antibodies are each encoded by a single germ line gene.

The future of the treatment of systemic lupus erythematosus.

Despite recent advances, patients with systemic lupus erythematosus (SLE) still experience considerable morbidity and mortality. To try and improve their prognosis, varied novel biological interventions and immune manipulations are being developed. They may hold promise in particular for patients whose disease is organ-threatening and refractory to conventional treatment. In addition, awareness of the tendency of lupus patients to develop accelerated atherosclerosis as well as newly gained insights into the underlying mechanisms, may lead to better control of risk factors, earlier diagnosis of prevalent cardiovascular disease and more effective treatment. Infections also remain a significant threat that may be amenable to improved preventive measures. Evidence related to a better management of lupus patients by specialists, the need to address the impact of commonly associated stress and depression and other significant developments are also presented and discussed.

Alveolar hemorrhage in cryoglobulinemia--an indicator of poor prognosis.

OBJECTIVE: Alveolar vasculitis is an unusual event in the course of cryoglobulinemia (CG). The inflammatory process involving the alveolar capillary walls may result in severe alveolar hemorrhage and consequently lead to a grave outcome. The objective of this study was to evaluate the occurrence of this unusual finding in CG. METHODS: We reviewed the records of all patients with CG who developed acute alveolitis, registered their associated clinical and laboratory parameters and evaluated the possible impact these parameters may have on their prognosis. In addition we scanned the Medline for similar cases. RESULTS: Of the 125 patients with CG who were hospitalized in our medical center during the last 23 years, 4 (3.2%) developed alveolar hemorrhage. All patients exhibited extreme fatigue, fever with clinical and radiological evidence of alveolitis. Of the 4 new cases, 1 had type II CG and 3 had type III CG. Of our 4 patients, 3 developed concomitant acute renal failure necessitating hemodialysis. A literature survey resulted in 6 additional cases. All 10 patients experienced acute respiratory insufficiency and eight had at least one episode of hemoptysis. In the other 2 patients the bronchoalveolar lavage (BAL) fluid contained hemosiderin laden macrophages. Five of the 10 patients had concomitant hepatitis C virus (HCV) infection; 2 patients were seen prior to modern identification of the HCV; however, liver abnormalities were not described. Of the 10 patients 5 patients had type II CG and 5 others had type III. Of the 7 patients in whom outcome was available, 6 died from their illness. Acute renal failure or exacerbation of antecedent glomerular disease occurred in 8 patients. CONCLUSIONS: Alveolitis is a rare manifestation of CG, presenting as an overwhelming systemic illness and portends a poor prognosis with a high mortality rate.

IgA deficiency associated with chronic hepatitis C virus infection. A cause or an effect?

OBJECTIVE: To evaluate the role of IgA in hepatitis C virus (HCV) infection. We have tested serum IgA levels in patients with antibodies to HCV. DESIGN: A retrospective study. PATIENTS: The IgA levels were tested in serum samples from 94 patients with antibodies to HCV examined during 1989-1990. RESULTS: Low IgA levels were found in 16/94 (17%) patients. In three of these 16 patients (3.2% of the original 94), no IgA was detected by radial immunodiffusion. In nine of 16 patients, previous pre-HCV infection serum samples with undetectable anti-HCV antibodies were available. In four of these nine patients, IgA deficiency was found in the preinfection serum, while in the remaining five patients, previous IgA levels were normal and the occurrence of anti-HCV was associated with the recent development of IgA deficiency. CONCLUSIONS: The results of this study indicate that IgA deficiency is a risk factor for HCV infection in some patients, whereas in others it might be caused by the viral disease.

Disseminated mycobacterial disease caused by Mycobacterium szulgai.

Disseminated mycobacterial disease due to Mycobacterium szulgai occurred in a previously healthy young man. The clinical picture included fever, mediastinal and generalized lymphadenopathy, hemoptysis, and skin lesions but was dominated by progressive multifocal osteomyelitis. Immunological studies revealed a decrease in T-lymphocyte reaction to mitogens, but this was tested late in the course of the disease and may have been secondary. In spite of repeated surgical drainage and treatment with multiple antituberculous drugs for a period of two years, new lesions continue to appear mainly in the bones. Mycobacterium szulgai was isolated from 28 bone specimens, as well as from skin lesions and sputum. To the best of our knowledge, this is the first report of disseminated disease due to this organism.

Schönlein-Henoch syndrome in adults and children.

Sixty-one patients (15 adults and 46 children) with Schönlein-Henoch syndrome (SHS) were seen at the Hadassah University Hospital over the last 20 years. The presentation, clinical course, and prognosis of these patients were studied. The disease course was generally similar in children and adults, except for the epidemiological background and the pattern of skin and joint involvement. In these nonselected patients, the disease was self-limited, and progressive renal failure was not found. The long-term prognosis was excellent for both adults and children.

Low-dose heparin inhibits acute graft versus host disease in mice.

We have studied the effect of low-dose heparin on GVHD, marrow engraftment and graft-versus-leukemia (GVL) effects in an experimental murine model. Recipient (C57BL/6 x BALB/c) F1 mice were transplanted with C57BL/6 marrow and/or spleen cells and treated with daily sc injection of 5 micrograms heparin for 30 days. We have shown that heparin in low doses attenuates the severity of acute GVHD and reduces the mortality rate from 69 to 37.5% without abrogating the GVL effect induced by the allograft and without impairing marrow engraftment.

Quinine alone versus quinine plus a pyrimethamine-sulfadoxine combination in the treatment of Plasmodium faliciparum cerebral malaria.

Fifty-two patients with severe chloroquine resistant Plasmodium falciparum malaria were treated in a randomized double blind study with either quinine and a single dose of pyrimethamine-sulfadoxine (Fansidar) or quinine alone. Although no statistically significant differences were observed, the 25 patients who received both drugs responded faster and had a more favorable outcome (no deaths) when compared to the 27 who received quinine alone (2 deaths).

Gastric-Mucocutaneous gammadelta T cell lymphoma: possible association with Epstein-Barr virus?

Gammadelta T cell lymphoma is usually either subcutaneous or hepato-splenic and involvement of other extranodal sites is rare. Here we report an unusual case of gammadelta T cell lymphoma involving the subcutaneous tissue, vocal cords, gastric mucosa and the central nervous system with a rapidly progressive clinical course and fatal outcome. Epstein-Barr virus (EBV) was shown to be present in the tumor cells, and is thought to play a role in the pathophysiology of this particular case of lymphoma.

Primary non-Hodgkin's lymphoma of the lung presenting as bronchiolitis obliterans organizing pneumonia.

A 44-year-old man presented with fever, dyspnea, and bilateral cavitary lung lesions. Following percutaneous transthoracic CT guided needle biopsy of the lung, a diagnosis of bronchiolitis obliterans organizing pneumonia (BOOP) was made and the patient was treated with corticosteroids. Despite a good initial response he developed new lung lesions within six months, associated with a lack of response to corticosteroids. Due to further deterioration and the development of Guillian-Barre' syndrome an open lung biopsy was performed and revealed T-cell rich, B-cell non Hodgkin's lymphoma with BOOP. We suggest that BOOP may be the presenting manifestation of primary lung lymphoma. We recommend that when BOOP has an atypical course or does not respond to corticosteroids open lung biopsy should be performed in order to exclude pulmonary lymphoma.

Plasma immunoglobulins in patients with severe ovarian hyperstimulation syndrome.

OBJECTIVE: To assess immunoglobulin (Ig) concentrations in plasma and ascitic fluid of patients with severe ovarian hyperstimulation syndrome (OHSS). DESIGN: Controlled clinical study. SETTING: Tertiary medical center. PATIENT(S): Ten patients with severe OHSS after ovulation induction for IVF and 10 controls who had undergone similar ovulation induction and did not develop OHSS. INTERVENTION(S): Three blood samples were obtained from each OHSS patient: one at the time of hospitalization for severe OHSS, one when significant clinical improvement was evident, and one at the first follow-up visit after discharge from the hospital. Blood samples were drawn from control patients 6-8 days after ET. Ascitic fluid was obtained from all patients with OHSS by therapeutic paracentesis. MAIN OUTCOME MEASURE(S): Immunoglobulin concentrations were assayed by radial immunodiffusion. RESULT(S): Significantly lower levels of gamma-globulins, specifically IgG and IgA, were detected in the plasma of patients with severe OHSS, whereas alpha- and beta-globulin levels as well as IgM levels were not significantly different from those in controls. Both IgG and IgA levels increased as patients clinically improved. Ascitic fluid contained high IgG, moderate IgA, and negligible IgM levels. CONCLUSION: Severe OHSS is characterized by hypogammaglobulinemia, attributed to leakage of medium-molecular-weight immunoglobulins such as IgG and IgA to the peritoneal cavity.

Koch's postulates and autoimmunity: an opposing viewpoint.

Autoimmunity is characterized as a state of abnormal specific humoral and cell-mediated responses against constituents of body tissues. One time-honored approach to explaining the pathogenesis of autoimmunity has been application of the Koch's postulates, on loan from the field of microbiology suggesting that autoantibodies and/or autoreactive T cells are the presumed "pathogens" of autoimmunity, and that passive transfer of these autoimmune factors to susceptible animals will result in the induction of the autoimmune disease. We suggest that autoimmunity is not in many cases due to the presence of factors leading to the autoimmune response in those susceptible. Instead, it is the lack of a factor which leads to the development of autoimmunity, a factor (cytokine, protein, gene, etc.) which is present in the healthy individual and normally protects in from disordered immune regulation. We propose to direct more research into therapeutic modulation of autoimmunity by administration of putative "protective factors", rather than by attempts to depress or remove autoreactive cells and antibodies from the autoimmune.

Case report: spurious hypokalemia in myeloproliferative disorders.

Four patients with myeloproliferative disorders and hypokalemia due to an artifactual in vitro phenomenon are described. Hypokalemia was due to an increased potassium uptake by the abnormal white blood cells. Spurious hypokalemia may explain in part the electrolyte disturbances found in many leukemic patients.

Coexistent chronic myeloid leukemia and IgA monoclonal gammopathy: report of a case and review of the literature.

The coexistence of Philadelphia negative chronic granulocytic leukemia (CGL) of the neutrophilic type and IgA monoclonal gammopathy is reported in a patient. The possible relation between the two proliferative processes is discussed in the light of current knowledge on the pluripotent stem cell and the clonal origin of CGL.