[Subclinical renal involvement in rheumatoid arthritis]

No evidence of renal involvement was found in 104 patients with rheumatoid arthritis in routine laboratory tests, including serum creatinine, urea, uric acid, sodium, potassium, calcium, phosphorus, and urinalysis. In view of recent publications (1-9) which report renal involvement in rheumatoid arthritis, we studied 16 patients of our group (nonrandomized, 3 men and 16 women, average age 55.4 years, average duration of disease 11.9 years). We examined creatinine clearance, urinary excretion of alpha-2 microalbumin, beta-2 microglobulin, cystine, and urine concentration and acidity after a 10-hour fast. 10 patients had disturbances in 1 or more of the functions examined, in 9 of whom tubular functions were involved. In 6 there was no evidence of renal involvement. There was no correlation between renal involvement and past or present therapy, but there were direct correlations between renal involvement, duration of disease and age. Thus we found evidence for subclinical renal damage not revealed by routine laboratory tests in patients with rheumatoid arthritis. This damage should be taken into consideration when operation, examination with contrast material, or treatment with other nephrotoxic agents are being considered in these patients.

Case report: fatal seronegative rickettsial infection diagnosed by the polymerase chain reaction

A previously healthy man presented with a five day history of high fever and headache, later followed by rash and the appearance of jaundice. On the second hospital day, he suddenly developed seizures, lapsed into a coma, and died. Polymerase chain reaction (PCR) amplification revealed a 434 base pairs DNA fragment common to the genome of typhus and spotted fever group rickettsiae in the patient's blood (estimated at about 1 x 10(2) organisms/ml), and to a lesser degree in the cerebrospinal fluid. However, serological tests for rickettsiae remained negative. PCR techniques may confirm the diagnosis at an early stage, even though the rickettsemia may be minimal and the patient seronegative.

Acute oliguric renal failure complicating type A nonfulminant viral hepatitis. A case presentation and review of the literature

Nonfulminant acute renal failure very rarely complicates type A viral hepatitis. So far only eight patients have been described in the English language, Japanese, or Israeli literature who had type A viral hepatitis with renal failure without any association with "hepatorenal syndrome," pregnancy, or other types of viral hepatitis. We describe a 52-year-old man with type A viral hepatitis, proven by IgM anti-A virus antibodies complicated by oliguric renal failure, which required hemodialysis. The patient recovered completely after a few weeks. Kidney biopsy demonstrated interstitial nephritis with no glomerular involvement. Review of the literature in relation to the causes and the rarity of the renal failure is included.

Attenuation of anaphylactic shock and related mortality in guinea-pigs after administration of a potent protein kinase inhibitor, K252a

We examined whether protein kinases have a role in the expression of anaphylactic shock (AS). Guinea-pigs sensitized to ovalbumin were administered i.p. saline (control) or 10 micrograms/kg K252a, a potent protein kinase inhibitor, 30 min before challenge. The development of AS and mortality was observed for the next 2 h. In the K252a-treated group the incidence of AS fell to 53% from 100%, the maximum intensity was 62% less than the control, and mortality dropped to 16% from 50% of the animals. We suggest that protein kinases are involved in the expression of AS, and that inhibitors of these enzymes may protect against the symptoms of AS and allergy.

Mitral valve prolapse in young Israelis with thromboembolic brain disease

In order to establish the association between mitral valve prolapse (MVP) and the incidence of thromboembolic disease of the brain we reassessed 36 patients (less than or equal to 50 years old) who were hospitalized during 1983-85 because of cerebrovascular accidents. The patients underwent complete physical and neurological examinations, blood tests including coagulogram and two-dimensional echocardiogram. The control group comprised 117 patients without cerebrovascular events. In the study group, 4 patients (11.1%) had MVP compared with 10 (8.5%) in the control group. Of these four, only one male did not have any risk factor for thromboembolic event; among the other three the risk factors were systemic lupus erythematosus, hyperlipidemia, diabetes, hypertension and pregnancy. We conclude that our results are in accordance with most of the literature that MVP is not a risk factor for thromboembolic disease except in Greek and Italian populations, which are ethnically more homogeneous than other Western societies studied.

Stroke in Icelandic patients with hereditary amyloid angiopathy is related to a mutation in the cystatin C gene, an inhibitor of cysteine proteases

Cystatin C is an inhibitor of lysosomal cysteine proteases and consists of 120 amino acids. A variant of cystatin C lacking the first NH2-terminal residues and having one amino acid substitution at position 68 forms amyloid deposits mainly in the walls of brain arteries, causing fatal strokes in Icelandic patients with familial cerebral hemorrhage secondary to a form of an autosomal dominant amyloidosis. To understand the molecular basis of the genetic defect, the gene encoding cystatin C was isolated from genomic DNA libraries made from normal tissue and the brain of an Icelandic patient with hereditary cerebral hemorrhage with amyloidosis (HCHWA-I). The data indicate that the cystatin C gene encodes a polypeptide of 146 amino acids, of which the first 26 correspond to a secretory peptide signal sequence. The gene contains two intervening sequences that interrupt the coding region at amino acids 55 and 93. Comparison with genes encoding salivary cystatins and kininogen proteins show sequence homology and conservation of exon-intron structure. Except for a mutation in the second exon (CAG instead of CTG in the normal gene, resulting in the substitution of glutamine for a leucine residue), the gene cloned from the brain of the Icelandic patient is identical to the normal cystatin C gene. Thus, HCHWA-I is the first familial type of amyloidosis related to a point mutation in a gene encoding for an inhibitor. The mutation in the structural gene encoding cystatin C appears to be the primary defect in this inherited disorder causing amyloid fibril formation and accumulation followed by cerebral hemorrhage.

Fatal torsade de pointes following jaundice in a patient treated with disopyramide

A case of fatal torsade de pointes in a 53 year old patient treated with disopyramide is described. The arrhythmia followed the development of acute hepatocellular dysfunction and may have been due to failure of the liver to efficiently degrade the drug to its metabolites.

Therapeutic approaches in mixed cryoglobulinemia

In summary, one can say that, although EMCG is a perplexing and puzzling disease, and although there are more enigmas than solutions, we can establish a way of handling the disease, knowing how to divide it into benign or acute forms, and establishing a treatment attitude according to that knowledge. PP and its modifications, in combination with immunosuppressive agents, are the corner-stones to the acute form of the disease complicated by vasculitis, nephritis, chronic hepatitis and CNS involvement. Looking ahead, a new and more specific mode of treatment could emerge from our and others observations that the IgMs in the mixed cryoproteins are antiidiotypes to the IgGs. By producing autoantiidiotypes it might be possible to block some of the immune complex formation and to interfere with the cold precipitation, which is the basic pathophysiological process of essential mixed cryoglobulinemia.

Polymorphism of human immunoglobulin VH genes: a possible marker of autoimmune disease

Human DNA from 11 individuals was analysed by Southern blot for the immunoglobulin genes coding for the heavy chain variable region (VH). The analysis included two probes detecting the genes of subgroup VHII and VHIII. The VH genes pattern shows very little polymorphism whereas the VHIII genes showed a significant polymorphism. When DNA from four patients with Graves' disease was analysed, a VH band was found in DNA of all patients analysed, and of 50 per cent of SLE patients, whereas only 36 per cent of healthy people contained this VH band. This may serve as a new tool to study genetic markers of autoimmune diseases.

Systemic lupus erythematosus in 49 Israeli males: a retrospective study

Forty-nine male SLE patients, diagnosed and followed in seven medical centers in Israel between 1954 and 1983, were studied and analyzed retrospectively in order to determine whether the disease in males was clinically different from that reported in females both in Israel and in the world literature. The primary clinical and laboratory manifestations, the severity of the disease at the onset or at any time during the course of the disease, and the 1-15 year survival rates were not different from those described before in female SLE, although neurological involvement, nephritis, thrombocytopenia, vasculitis and hepatosplenomegaly were more prevalent in our series. However, more than half of the male patients (53%) had a benign course of disease characterized by long remissions requiring minimal or no medication. Long-term remission of serious renal involvement was observed completely in 14 and partially in 5 out of 33 patients. These results suggest that the male sex might alter the clinical course of SLE.

Disruption of the symphysis pubis and fatigue fractures of the pelvis in a patient with rheumatoid arthritis. A case report

A 40-year-old woman, who suffered from severe rheumatoid arthritis causing avascular necrosis of the femoral head and protrusio acetabuli of the right hip, developed a severe spontaneous disruption of the symphysis pubis concomitant with a stress fracture of the left ilium adjacent to the left sacroiliac joint. After successful total hip arthroplasty, the symphysiolysis improved, but a new stress fracture of the left superior pubic ramus developed. Fourteen months after operation both stress fractures are healed. Altered hip and pelvic girdle mechanics acting on osteoporotic bone may account for this sequence of events.

Gold-induced ileitis

We describe a patient with rheumatoid arthritis who developed severe ileitis after being treated with gold salts; the patient responded to elimination of the gold therapy and to BAL.

The effect of combination therapy (steroids, immunosuppressives, and plasmapheresis) on 5 mixed cryoglobulinemia patients with renal, neurologic, and vascular involvement

A prospective clinical study evaluated the effects of combined chemotherapy, steroids and plasmapheresis on 5 patients with mixed cryoglobulinemia with renal or neurologic and vasculitic manifestations. Treatment included prednisone (1mg/kg/day), chlorambucil (white blood cell count at greater than 3,000/mm3), and plasmapheresis (1 to 3 liters/week). There was healing of cutaneous ulcers (3/3), improvement in renal function (4/4), and diminution of purpura (2/2), but little improvement in peripheral neuropathy. Complications included leukopenia, perineal ulcers, and osteomyelitis.

Antiidiotypic activity in the IgM fractions of mixed cryoglobulins

To search for human antiidiotypic antibodies, cryoglobulins from 11 patients with mixed cryoglobulinemia, 7 of whom had evidence of prior hepatitis B virus infection were separated on Sephadex G-200. Each of the IgM, 8 of which were IgM kappa, was tested with the F(ab')2 fragments prepared from each of the IgG fractions in a solid phase assay by using binding of 125I Staph A protein after the addition of rabbit anti-IgM. Unlike rabbit anti-Fab, which reacted approximately to the same extent with all F(ab')2 fragments, the IgM varied in their binding to F(ab')2 fragments, reacting with 2 to 10 antigens. Nine reacted with their autologous antigen and in 5 instances autologous reactivity exceeded that with heterologous F(ab')2 fragments. Reactivity was not related to prior exposure to HBV. Though absorption with Cohn fraction II F(ab')2 fragments generally abolished reactivity, 1 IgM protein continued to react with nine F(ab')2 fragments and 4 others with the F(ab')2 fragment from a single patient. Even when they contained only a single type of kappa-chain, the IgM appeared to contain multiple antibodies since absorption with solid phase Fc fragments or IgG removed anti-Fc rheumatoid factor activity but failed to affect binding to F(ab')2 fragments. Five of 7 IgM were able to bind the Fv region of a monoclonal IgM kappa-protein. Some of the anti-Fab antibodies were directed against idiotypes since addition of HbsAg to F(ab')2 fragments from HBsAb-positive IgG resulted in a marked decrease in binding of the IgM fraction in 6 out of 7 studies, whereas no decrease was noted in 6 experiments with F(ab')2 fragments that were HBsAb negative. The possible existence of antibodies against other idiotypes or other determinants in the Fab region cannot be excluded.

Antiidiotypic activity in the IgM fractions of mixed cryoglobulins

To search for human antiidiotypic antibodies, cryoglobulins from 11 patients with mixed cryoglobulinemia, 7 of whom had evidence of prior hepatitis B virus infection were separated on Sephadex G-200. Each of the IgM, 8 of which were IgM kappa, was tested with the F(ab')2 fragments prepared from each of the IgG fractions in a solid phase assay by using binding of 125I Staph A protein after the addition of rabbit anti-IgM. Unlike rabbit anti-Fab, which reacted approximately to the same extent with all F(ab')2 fragments, the IgM varied in their binding to F(ab')2 fragments, reacting with 2 to 10 antigens. Nine reacted with their autologous antigen and in 5 instances autologous reactivity exceeded that with heterologous F(ab')2 fragments. Reactivity was not related to prior exposure to HBV. Though absorption with Cohn fraction II F(ab')2 fragments generally abolished reactivity, 1 IgM protein continued to react with nine F(ab')2 fragments and 4 others with the F(ab')2 fragment from a single patient. Even when they contained only a single type of kappa-chain, the IgM appeared to contain multiple antibodies since absorption with solid phase Fc fragments or IgG removed anti-Fc rheumatoid factor activity but failed to affect binding to F(ab')2 fragments. Five of 7 IgM were able to bind the Fv region of a monoclonal IgM kappa-protein. Some of the anti-Fab antibodies were directed against idiotypes since addition of HbsAg to F(ab')2 fragments from HBsAb-positive IgG resulted in a marked decrease in binding of the IgM fraction in 6 out of 7 studies, whereas no decrease was noted in 6 experiments with F(ab')2 fragments that were HBsAb negative. The possible existence of antibodies against other idiotypes or other determinants in the Fab region cannot be excluded.

Human monoclonal macroglobulins with specificity for Klebsiella K polysaccharides that contain 3,4-pyruvylated-D-galactose and 4,6-pyruvylated-D-galactose

Two human IgM myeloma proteins, IgMWEA and IgMMAY, were found to react with agar and Klebsiella polysaccharides that contain pyruvylated D-galactose (DGal). Quantitative precipitin data and precipitin inhibition studies with methyl alpha- and beta-glycosides of 4,6-pyruvylated-D-galactose showed their combining sites to be different, although each was directed against the pyruvylated-D-Gal, one reacting most specifically with Klebsiella polysaccharides with terminal nonreducing beta-linked 2,4 pyruvylated-D-Gal, whereas the other reacted equally well with Klebsiella polysaccharides that contain 3,4 beta-linked and 4,6 alpha-linked terminal nonreducing pyruvylated-DGal. Inhibition studies showed that both sites are directed toward one of the two space isomers of 3,4- or 4,6-pyruvylated DGal, the form in which the methyl group of the pyruvate is equatorial, or endo, and its carboxyl group axial, or exo, to the plane of the acetal ring. Coprecipitation studies showed the combining site of IgMWEA to be located on an (Fab')2 fragment and not on the (Fc)5mu fragment. The monoclonal peak in the serum of IgMMAY was specifically precipitated by Klebsiella polysaccharide. Myeloma proteins with specificities of this type may occur with reasonable frequency in humans and may be a consequence of clonal expansion from inapparent infection, carrier states, or disease produced by various Klebsiella organisms.