Late-onset rod myopathy associated with monoclonal gammopathy

A 31-yr-old woman presented with a severe and rapidly progressive myopathy affecting proximal limbs, neck flexors and respiratory muscles. Muscle biopsy revealed numerous atrophic fibres with marked structural alterations, without inflammatory infiltrate. By electron microscopy, atrophic fibres displayed many rods. A benign monoclonal gammopathy (IgG, lambda chain) was evident in serum. A sarcolemmal deposit of IgG, lambda chain was found by immunostaining. Plasmapheresis and immunosuppressive therapies produced a decrease in paraproteinemia and a partial clinical improvement. This observation is the third to associate monoclonal gammopathy with "late-onset rod myopathy". The pathogenetic role of paraproteinemia remains unclear.

A CD2+ subset of non-malignant peripheral blood lymphocytes from patients with Sézary syndromes overexpress the low-molecular-weight GTP-binding protein Rab2

The Rab branch of the Ras-related GTP/GDP-binding proteins currently includes at least 25 related members which are involved in the intracellular vesicular transport along the secretory and endocytic pathways in eukaryotic cells. The overexpression of the Rab2 protein in peripheral mononuclear cells is demonstrated from 13 out of 17 patients exhibiting a Sézary syndrome. Moreover, this phenomenon is detectable in other lymphoid and myeloid malignancies. Several lines of evidence are shown suggesting that the Rab2 overexpression can be related not to leukemic cells but to a subset of peripheral lymphocytes with a CD2+ phenotype. Our results provides strong evidence for the implication of a small GDP/GTP-binding protein in immunological events associated with neoplastic states. The precise cellular population involved in this process remains to be determined.

[Indications of plasma extraction during the treatment of monoclonal gammopathies]

Data from the french national registry show that about 20% of plasma exchange are performed to alleviate clinical manifestations related to a monoclonal Ig. Plasma removal has to be only considered as a part of therapy, the disease being controlled by cytotoxic drugs. However, owing to its delayed effect plasma exchange are useful to preserve the functional or vital prognosis. Technical aspects such as plasma volume removed or frequency of procedures will be scheduled according to monoclonal Ig specification: repartition between intra and extravascularly pools-allotypes-efficiency of chemotherapy. Hyperviscosity syndrome, interferences with hemostasis and vascular manifestations of cryoglobulins are the main established indications. Renal insufficiency of myeloma, peripheral neuropathies and unusual clinical symptoms associated with monoclonal gammapathy of undetermined significance should also be considered as possible indications. In contrast regression of amyloidosis deposits has not been reported.

Responsiveness of chronic lymphocytic leukemia B cells activated via surface Igs or CD40 to B-cell tropic factors

Recent studies performed in the laboratory have established that interleukin-4 (IL-4) used in combination with anti-CD40 monoclonal antibody (MoAb) 89 presented on Ltk- mouse fibroblasts stably expressing human Fc gamma RII/CDw32 (referred to as the CD40 system) sustains long-term proliferation of normal human B cells. In the present study, B-cell chronic lymphocytic leukemias (B-CLLs) activated through slgs or CD40 were examined for their capacity to proliferate and differentiate in response to various cytokines. Our results indicate that the outcome of IL-4 stimulation on the in vitro growth of B-CLL depends on the signalling pathway used for their activation. Whereas IL-4 did not display any growth-stimulatory effect on B-CLL activated by Ig cross-linking agents, it could stimulate DNA synthesis and enhance the viable cell recovery when leukemic B cells were cultured in the CD40 system. Most B-CLL samples were induced for IgM synthesis upon Staphylococcus aureus strain Cowan I stimulation. This Ig response was potentiated by IL-2 and antagonized by IL-4. Anti-CD40 MoAb used alone or in combination with cytokines (IL-1 alpha to IL-6, interferon gamma, tumor necrosis factor gamma, and transforming growth factor beta) failed to induce Ig secretion from B-CLL cells. No evidence for Ig isotype switching was obtained with the cytokines listed above, regardless of the mode of activation. Taken together, our results suggest that B-CLL cells can be partially released from their apparent maturation block by IL-2 and Ig cross-linking agents. In contrast, combinations of IL-4 and cross-linked anti-CD40 antibodies induced entry of B-CLL cell into cycle, but poorly stimulated their differentiation into Ig secreting cells.

Lack of Superiority of Steroids Plus Plasma Exchange to Steroids Alone in the Treatment of Polyarteritis Nodosa and Churg-Strauss Syndrome

OBJECTIVE

To define the most effective treatment for polyarteritis nodosa (PAN) and Churg-Strauss syndrome (CSS).

METHODS

We conducted a prospective, randomized, multicenter trial in which 78 patients were randomly assigned to receive either prednisone and plasma exchange (group A; n = 36) or prednisone alone (group B; n = 42) as first-line treatment of PAN and CSS. Patients with hepatitis B virus-related PAN were not included in this study. The end point of the study was control of the disease (recovery and remission) or death.

RESULTS

Clinical symptoms and laboratory findings did not differ statistically in the 2 groups at study entry. Initial control of the disease was similar in both groups. The assigned treatment was stopped in 16 patients because of lack of efficacy. Oral cyclophosphamide or dapsone therapy reversed the disease evolution in 7 of these 10 group A patients and in 4 of these 6 group B patients. At 7 years of followup, 56 patients had completely recovered (27 in group A, 29 in group B), 7 patients were in clinical remission, and 15 patients had died (19.2%; 6 group A patients and 9 group B patients). The prednisone-plasma exchange combination was no more beneficial than corticosteroids alone in preventing relapses over the long term. There was no significant difference in the 7-year cumulative survival rates of the two groups (83% and 79%, respectively).

CONCLUSION

Based on our data, we conclude that combined treatment with prednisone and plasma exchange is not superior to treatment with prednisone alone and must not be systematically employed for initial treatment of PAN and CSS. In most cases, cyclophosphamide as second-line treatment is effective and well tolerated.

Longterm followup after treatment of polyarteritis nodosa and Churg-Strauss angiitis with comparison of steroids, plasma exchange and cyclophosphamide to steroids and plasma exchange. A prospective randomized trial of 71 patients. The Cooperative Study Group for Polyarteritis Nodosa

We attempted to define the most effective treatment for polyarteritis nodosa and Churg-Strauss angiitis, with a prospective, randomized, multicenter trial of cyclophosphamide in conjunction with corticosteroids and plasma exchanges, compared to corticosteroids and plasma exchanges. A total of 71 patients who fulfilled clinical, histological and/or arteriographic diagnostic criteria were randomly designated to receive either prednisone and plasma exchanges (group A, n = 39) or cyclophosphamide, prednisone and plasma exchanges (group B, n = 32). The end points of the study were control of the disease (recovery and remission) and death. Upon study entry clinical and laboratory features did not differ in the 2 groups. Treatment was stopped in 19 patients because of ineffectiveness in 10 (9 in Group A) and side effects in 9 (8 in Group B). Initial control of the disease was similar in both groups. At 5 years, 27 patients had completely recovered and 14 patients were in clinical remission. The cyclophosphamide-prednisone-plasma exchange association was beneficial in preventing relapses during longterm followup. Nineteen deaths were reported during the followup period. There was no difference between the 10 year cumulative survival rates of the 2 groups (respectively, 72 and 75%). Thus, the association of cyclophosphamide with corticosteroids and plasma exchanges reduced the incidence of relapses and improved the quality of the clinical response to therapy.

A low-cost automated device incorporating a hollow fiber filtration cartridge for large-scale production of ghosts from human erythrocytes

Readily available elements were used to build an automatic apparatus dedicated to the preparation of erythrocyte ghosts. The apparatus is designed around a low-cost re-usable hollow-fiber filtration cartridge (marketed for therapeutic plasmapheresis). The apparatus is controlled by a simple programmer (based on a diode matrix and low cost timers and liquid level sensors): once the apparatus is loaded with whole red blood cells, washing of cells, as well as hemolysis and washing of ghosts, is performed by the machine in about 4.5 h without any operator intervention. Automatic filter cleaning takes a further 110 min.

Treatment of progressive systemic sclerosis by plasma exchange: long-term results in 40 patients

The efficacy of plasma exchanges (PE) during the course of scleroderma has only been investigated for short periods. The aim of this study was to follow patients over a long enough period to observe the course of the clinical and paraclinical symptoms in the short, medium, and long term. Forty patients, 24 women and 16 men, were treated by PE and observed for 1-3, 3-12 and over 12 months. Immunological, biological and clinical course and any undesirable side effects were evaluated using a detailed questionnaire. Concomitant therapies were reported and most frequently consisted of corticosteroids, colchicine, factor XIII or vasodilators (nifedipine, captopril). The therapeutic effectiveness of PE was assessed on the basis of improvements in cutaneous, digestive, joint, muscular, lung, cardiovascular and renal lesions. Our findings confirmed the effectiveness of short-term PE on scleroderma (52% of the patients improved during the first 3 months). However, this improvement was transient (5% improvement between 3 and 12 months and only 2.5% over 12 months) and limited to the cutaneous and muscular lesions. Thus, PE cannot be recommended for the treatment of progressive systemic sclerosis.

Complications of plasma exchange in the treatment of polyarteritis nodosa and Churg-Strauss angiitis and the contribution of adjuvant immunosuppressive therapy: a randomized trial in 72 patients

We recorded side effects and other complications of 813 plasma exchanges used in early treatment of polyarteritis nodosa and Churg-Strauss angiitis in a prospective study of 72 patients (22-75 years old). All the patients were also treated with a corticosteroid (1 mg/kg/day), and half were included in a randomized trial of cyclophosphamide (2 mg/kg/day during 1 year). Centrifugation was used in 678 plasma exchange sessions (83.4%) and filtration in 128 (15.7%) (no data were available about the technique used in seven cases). The replacement fluid in 745 sessions was 4% albumin and in 115 was fresh-frozen plasma; eight patients received both (47 sessions). Two hundred and fifty-one complications were reported in 60 patients during 206 (25.3%) of the 813 completed exchanges; 47 sessions (5.8%) were temporarily stopped as a result of complications. The most common problems were technical difficulties (in 90 sessions), moderate or severe hypotension (in 52), and allergy to the replacement fluid (in 51). Hepatitis B antigen appeared in one patient. In four patients, plasma exchange was stopped permanently because of the severe side effects. No patient died during a session. Twelve of the 72 patients died during the study, six in each of the two groups. In the group treated by a combination of corticosteroid and plasma exchange, deaths were related to the deleterious effects of the disease itself and occurred after 12.8 +/- 11.1 months (1-26 months). In the group treated by the same combination plus cyclophosphamide, four of the six deaths were due to severe infections, which were related to leukopenia in three patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Changes in plasma renin, insulin, aldosterone and arginine vasopressin during plasmapheresis

1. Nineteen patients with a spectrum of immunologically related disorders were studied before and immediately after plasmapheresis for changes in plasma aldosterone, insulin and arginine vasopressin (AVP). Renin was also measured in 11 of these patients by direct radioimmunoassay. 125% of the initial plasma volume was replaced, which corresponded to a predicted removal of 72% for any plasma constituent. 2. The initial, final (experimental) and final (predicted) concentrations (means +/- SEM) were 337 +/- 50, 185 +/- 23 and 100 +/- 16 pg/ml respectively for renin, 465 +/- 86, 146 +/- 38 and 124 +/- 22 pmol/l respectively for aldosterone, 218 +/- 35, 69 +/- 11 and 63 +/- 11 pmol/l respectively for insulin, 7.2 +/- 1.9, 6.1 +/- 0.5 and 1.8 +/- 0.2 pmol/l respectively for AVP. The predicted final concentration was calculated from the initial concentration and the fraction of plasma volume exchanged. The experimental final concentration was lower than the initial concentration for renin, aldosterone and insulin (P less than 0.001) but not for AVP. The predicted final concentration was lower than the experimental final concentration for AVP and renin (P less than 0.001) but not for aldosterone and insulin. Plasma volume, osmolality, glucose, sodium and potassium concentrations did not change significantly. 3. The concentrations of renin, aldosterone, insulin and AVP in the removed plasma were 84 +/- 17 pg/ml, 179 +/- 36, 98 +/- 15 and 4.8 +/- 0.7 pmol/l respectively. The amount subtracted expressed as percentage of the total amount present in plasma was markedly greater for AVP than for the three other plasma constituents.(ABSTRACT TRUNCATED AT 250 WORDS)

Side effects of therapeutic plasma exchange during treatment of polyarteritis nodosa. Comparison of filtration and centrifugation. 718 sessions in 63 patients

Between 1981 and 1984, 72 patients (22-75 years) were included in a prospective study for treatment of Polyarteritis Nodosa (PN) which associated therapeutic plasma exchanges (TPE), corticosteroids (CS) 1 mg/kg/day, and a randomized trial of cyclophosphamide (CP) 2 mg/kg/day. We observed the incidence and analysed side effects (SE) occurring during TPE considering the technology of plasma removal. Full data were available for 63 patients. Seven hundred and eighteen TPE were performed. Centrifugation was used in 594 PE (82.7 per cent) with intermittent flow centrifugation (IFC) 320 times (44.5 per cent) and continuous flow centrifugation (CFC) 274 times (38.2 per cent). Filtration (F) was used in 124 sessions (17.3 per cent). Replacement fluid was 4 per cent albumin in 650 TPE and fresh frozen plasma (FFP) in 89 TPE. A total of two hundred and eleven SE were reported in 53 patients (84.1 per cent) during 173 TPE (24.1 per cent). Forty-six TPE were temporarily stopped because of SE (6.4 per cent). The mean volumes of removed plasma (ml/kg/TPE) were: 60.7 +/- 8.7 ml/kg when CFC was used 54.5 +/- 20 ml/kg with F and 52.5 +/- 9.6 ml/kg with IFC (n.s.) Main SE were: technical difficulties in 80 TPE, moderate or severe hypotension in 47, allergy to replacement fluid in 39. Hepatitis B antigen appeared in one patient. No death occurred during TPE and SE were usually minor and transient.(ABSTRACT TRUNCATED AT 250 WORDS)

Plasma exchange in severe erythema nodosum leprosum

Four patients with severe erythema nodosum leprosum were treated by plasma exchange and/or fresh frozen plasma infusions after failure of classical therapy. After the procedures, the patients improved rapidly; with a follow-up between 4 and 7 years after the last plasma exchange, no clinical relapse was noted. The replacement fluids were variable; the most beneficial procedure seemed to be plasma exchange replaced with fresh frozen plasma. Elimination of circulating immune complexes, replacement of a lacking plasma factor are possible mechanisms of action. Plasma exchange may also work like a regulator of immune mechanisms, since it has been shown that there is a depression of suppressor cells in erythema nodosum leprosum.

Plasma Exchange in Severe Erythema Nodosum Leprosum

Four patients with severe erythema nodosum leprosum were treated by plasma exchange and/or fresh frozen plasma infusions after failure of classical therapy.

After the procedures, the patients improved rapidly; with a follow-up between 4 and 7 years after the last plasma exchange, no clinical relapse was noted. The replacement fluids were variable; the most beneficial procedure seemed to be plasma exchange replaced with fresh frozen plasma.

Elimination of circulating immune complexes, replacement of a lacking plasma factor are possible mechanisms of action. Plasma exchange may also work like a regulator of immune mechanisms, since it has been shown that there is a depression of suppressor cells in erythema nodosum leprosum.