Relation between HLA DRB1 alleles and corticosteroid resistance in giant cell arteritis

OBJECTIVE

To evaluate the clinical usefulness of genomic HLA typing during the first two years of established giant cell arteritis (GCA).

METHODS

HLA typing was performed by PCR-SSO in 41 selected white patients with GCA confirmed by biopsy. Patient data were compared with those of a control group of 384 bone marrow donors (relative risk, p value and chi 2 test for each allele). Clinical features at onset and response to treatment over a two year period were evaluated in relation to the genetic pattern.

RESULTS

DRB1*04 was significantly increased in the GCA group (frequency of 48.78% compared with 19.79% in controls, p < 0.001). The distribution of the DRB1*04 subtypes in the GCA group was similar to that in controls. No clinical or biological differences were found in association with HLA at the time of diagnosis. Over the two year follow up, nine patients presented resistance to corticosteroid treatment and eight of these (88.88%) had DRB1*04 (p < 0.001).

CONCLUSIONS

GCA seems to be associated with HLA DRB1*04 (regardless of the subtype) and this association appears to be accompanied by corticosteroid resistance, suggesting that genomic typing may be useful to identify patients eligible for early alternative treatment to corticosteroid drugs.

[HCV RNA clearance after treatment with interferon-alpha in chronic hemodialysis patients with or without coinfection by HGV/HGBV-C]

Patients on maintenance hemodialysis are frequently infected with hepatitis C virus (HCV). The long-term effect of alpha interferon therapy has not yet been assessed, or the influence of co-infection with the newly discovered hepatitis G/hepatitis GB virus-C (HGV/HGBV-C) upon therapy outcome. Eleven anti-HCV and HCV RNA-positive hemodialysis patients, 3 of whom had HGV/HGBV-C infection were given 3 mega-units of alpha 2b recombinant interferon subcutaneously 3 times weekly for six months. The mean follow-up after cessation of therapy was 24 +/- 8 months (range: 18-30 months). Sustained serum HCV RNA clearance, as assessed by PCR analysis, occurred in 5/11 patients (45.5%). Two had received a cadaveric kidney transplant at 16 and 18 months post-treatment and were treated by immunosuppressive therapy; HCV RNA remained undetectable in both serum and a liver biopsy. HCV was eradicated in 3 of the 6 patients infected with HCV genotype 1b, which is less sensitive to alpha-interferon than other HCV genotypes. Among the 3 patients infected with both HCV and HGV/HGBV-C, alpha-interferon cleared the HCV RNA from one patient, but not the HGV/HGBV-C RNA. In view of the high rate of HCV eradication after alpha-interferon therapy and its fair tolerance, we suggest that HCV RNA-positive dialysis patients should be treated before transplantation, regardless of their aminotransferase levels or liver histological score, since alpha interferon therapy after renal allografting is associated with an unacceptable rate of renal failure. Our preliminary data indicate that HGV/HGBV-C does not interfere with sustained HCV RNA clearance.

[Endoscopic treatment of subcutaneous fat necrosis secondary to pancreatic-vascular fistula: apropos of a case]

PATIENT AND METHOD

We report the case of a 68-year-old man who presented a pancreatic tumor with a pancreato-vascular fistula and a Weber-Christian syndrome. Pancreatic enzymes levels at the admission were high: amylasemia 2,470 IU/L (N < 110) and lipasemia 11,700 IU/L (N < 220). The treatment consisted in total parenteral nutrition and somatostatin (100 micrograms x 3/day). Because we noted neither clinical nor biological improvement after 10 days of treatment, we performed an endoscopic retrograde pancreatography. During this examination, we put a 7 French diameter prosthesis through the Wirsung stenosis.

RESULTS

No problem arose after endoscopy: since the day after the endoscopy, pancreatic enzymes decreased by half and become normal in 4 days; arthralgias and cutaneous injuries, both caused by cytosteatonecrosis, disappeared respectively in 5 and 10 days. There is no evidence of subsequent recurrence after 3 months of follow-up.

CONCLUSION

Pancreatic endoscopic prosthesis can replace the surgical treatment of pancreato-vascular fistula with a good efficacy.

Baseline level and early suppression of serum HCV RNA for predicting sustained complete response to alpha-interferon therapy

The relationship between serum hepatitis C virus (HCV) RNA and the outcome of alpha-interferon (alpha-IFN) therapy in patients with chronic hepatitis C has important implications for therapeutic research and clinical care. Serum HCV RNA was tested for HCV genotype and quantified by a standardized reverse transcriptase-polymerase chain reaction assay as a measure of viral load in a cohort of 130 patients with chronic hepatitis C treated with alpha-IFN at a standard dose of 3 million units three times a week scheduled for 6 (n = 50) or 12 months (n = 76). Twenty-one of 126 evaluable patients (16.7%) developed a sustained complete response to alpha-IFN according to biochemical and virological criteria. The 3 pretreatment independent factors associated with a sustained complete response were a low baseline serum HCV RNA concentration, non-1 HCV genotype, and female sex. A multivariate logistic regression model, with pretreatment and month 1 variables, showed that a lower baseline serum HCV RNA concentration, female sex, and a greater suppression of RNA were the significant predictors of sustained complete response. The lowest baseline serum HCV RNA concentration was observed in patients with genotype 2 infection and the greatest decrease in HCV RNA from baseline to month 1 in those with genotype 3. The findings suggest that measuring HCV RNA in serum before and soon after beginning treatment can be helpful for selecting patients who are most likely to have a sustained complete response to standard schedule of alpha-IFN and for identifying patients in whom alternative strategies should be examined.

High rate of hepatitis C virus clearance in hemodialysis patients after interferon-alpha therapy

To gain insight into the long-term effect of interferon-alpha (IFN-alpha) therapy on hepatitis C virus (HCV) RNA-positive hemodialysis patients, 23 subjects were given 3 MU of IFN-alpha 3 times a week for 6 (n = 12) or 12 months (n = 11). They were followed for 19 months after cessation of therapy. Sustained serum HCV RNA clearance occurred in 42% of patients treated for 6 months and in 64% of those treated for 12 months. HCV was eradicated from 6 of 13 patients infected with HCV genotype 1b and from 2 of 6 patients also infected with hepatitis G virus. HCV RNA remained undetectable in both serum and a liver biopsy of 2 patients who were given cadaveric kidney transplants after IFN-alpha treatment. These data suggest that HCV RNA-positive dialysis patients can be considered for treatment while receiving dialysis, particularly those awaiting transplant.

Genes of the major histocompatibility complex class II influence the outcome of hepatitis C virus infection

BACKGROUND & AIMS

The host's immune response may influence the course of hepatitis C virus (HCV) infection. The aim of this study was to investigate the distribution of HLA class II alleles in white subjects who spontaneously recovered from HCV infection compared with that in patients with persistent infection.

METHODS

HLA-DRB1 and -DQB1 typing were performed in 103 consecutive patients with persistent HCV infection (HCV antibody positive, HCV RNA positive) and in 25 subjects with transient HCV infection (HCV antibody positive, persistently negative HCV RNA).

RESULTS

No significant differences between subjects with transient or persistent infection were observed for age, sex, source of infection, or HCV serotype. The frequency of DQB1*0301 and DRB1*1101 alleles was higher in patients with transient infection than in those with persistent infection (84% vs. 30.8%, 40% vs. 9.8%; P < 0.01 and P < 0.02, respectively [Bonferroni correction]). DRB1 and DQB1 alleles did not influence viral load as an independent factor. Mean Knodell's scores were lower in patients with DQB1*0301 allele (6.12 +/- 0.4) than in those negative for DQB1*0301 (7.37 +/- 0.3; P < 0.05).

CONCLUSIONS

Our results suggest that host- rather than virus-related factors are probably involved in the spontaneous clearance of HCV.

[Systemic manifestations of hemorrhagic rectocolitis: apropos of a case of hemorrhagic rectocolitis associated with multiple sclerosis]

Extra-intestinal manifestations of inflammatory bowel diseases are frequent and numerous. We report a case of ulcerative colitis associated with multiple sclerosis, ankylosing spondylitis and pyoderma gangrenosum. This observation shows the rare association of ulcerative colitis-multiple sclerosis, and extra-intestinal manifestations of inflammatory colitis are discussed.

Involvement of calcium in macrophage leukotriene release during experimental cirrhosis

The aim of the present study was to assess the mechanism of 5-lipoxygenase metabolites (LT) secretion by peritoneal macrophages in rats wih CC14 induced cirrhosis. After stimulation with calcium ionophore A23187 or opsonized zymosan, [3H] arachidonic acid labeled macrophages from cirrhotic rats presented a significantly greater secretion of LT than macrophages from healthy controls. In addition, the phorbol ester TPA (protein kinase C activator) increased LT production only in macrophages from cirrhotic animals and not in controls. Although Ca2+ is thought to be involved in 5 lipoxygenase activation, the role of Ca2+ in LT production was studied. The use of a Ca2+-free medium as well as the addition of TMB-8 (an inhibitor of intra-cellular Ca2+ movements and of plasma membrane Ca2+ fluxes) resulted in a fall in LT production greater for macrophages from cirrhotic animals than for controls. The measurement of cytosolic Ca2+ concentration by cytofluorimetry showed that Fluo-3 loaded macrophages from cirrhotic rats had a greater cytosolic CA2+ concentration than macrophages from control animals both in basal conditions and after A23187 stimulation. Study of 45Ca2+ uptake suggest, that extra-cellular Ca2+ is implicated in the elevated cytosolic Ca2+ observed in macrophages from cirrhotic animals as compared to healthy controls. The greater Ca2+ concentration observed in macrophages from cirrhotic rats was not related to a difference in phospholipase C activation because inositol phosphate production did not differ between macrophages from healthy and cirrhotic animals. Taken together these results suggest that as compared to healthy animals, the greater LT production during cirrhosis could be dependent upon a difference in 5-lipoxygenase activation related to a rise in cytosolic Ca2+ concentration independently of inositol phosphates generation.

[Parvovirus B19 infection. New physiopathological approaches]

Knowledge of the pathophysiological mechanisms governing Parvovirus B19 infection has been modified with the recent discovery of its cellular receptor. The cell lines susceptible to infection can be identified on the basis of the nature and distribution of the virus in the human organism. The Parvovirus B19 can undergo two types of cycles within the host cell. The first is a complete cycle within the infected cell leading to cell death by lysis. In the second, the cycle aborts and cell death is caused by an association of immunological phenomena and the accumulation of viral proteins toxic to the cell. It is not known why complete cycles are restricted to a single erythrocyte line. These new data not only give a more precise explanation of the classical clinical expression of the disease, but also suggest possible mechanisms for the pathogenic power of the Parvovirus B19, some of which have already been proposed on the basis of clinical observations.