Immunopathological diagnosis of plasma-cell dyscrasia. Part II. "Secondary" monoclonal gammopathy

Two cases of secondary plasma-cell dyscrasia are presented: one is of undetermined cause and the other is due to hepatic schistosomiasis. Both of the patients showed a prominent IgG monoclonal spikes of more than 3000 mg/dl. One of them had multiple osteolytic bone lesions and pathological fractures, and histopathological picture showed a chronic inflammatory process. An additional case of marked polyclonal gammopathy due to schistosomiasis is also presented to illustrate the immunochemical differential between the physiological and altered immune responses. Schistosomiasis is postulated to be an important immunopathological cause of plasma-cell dyscrasia.

Studies on structural units of human monoclonal immunoglobulins

Twelve human monoclonal immunoglobulins were separated and purified through the use of cryoprecipitation, salt fractionation, electrophoretic separation and gel filtration. Monoclonal cryoglobulin was the easiest form of homogeneous immunoglobulin to isolate. IgG and IgM were generally purified by salt precipitation and ion exchange chromatography followed by G-200 gel filtration. IgA purification required tedious recycling procedures. The purification of IgD posed the most difficulty as it may degrade spontaneously. Monoclonal immunoglobulins differed markedly in their behaviour towards enzymatic digestion, due to a rather wide specificity of enzymes on the Fc fragment. IgG was usually enzyme-sensitive, while some IgA proteins were virtually enzyme-resistant. The Fab fragment usually retained its antigenicity, but Fc or Fc' often split into small peptides. The reductive cleavage of monoclonal proteins usually gave consistent results, and H and L chains were separated in all experiments. However, 5 to 15% of IgA was at times eluated in unreduced form, and the alpha chain was often filtered as a dimer form. L chains were always eluated as a monomer form.

Reappraisal of relative frequency of monoclonal immunoglobulins

Among 20,158 patients studied we detected 107 cases of primary and 84 cases of secondary plasma-cell dyscrasia (PCD). A strikingly high frequency of IgD myeloma was observed. The most common disease associated with the secondary cases was chronic hepatitis/liver cirrhosis. Monoclonal immunoglobulins have many special physicochemical properties which could easily escape detection or defy proper interpretation. It is speculated that the relative frequency of monoclonal immunoglobulins, both H chain class and L chain type, does not reflect the physiological serum level.

"Secondary" plasma-cell dyscrasia: a plea for change in terminology, with an illustrative case report

The demonstration of monoclonal, homogeneous immunoglobulin or its subunit is the hallmark of plasma-cell dyscrasia. Plasma-cell dyscrasia can be classified into two main groups: "primary" and "secondary". The increasing use of protein electrophoresis and immunoelectrophoresis has contributed to the increased frequency of secondary monoclonal gammopathy and to the better recognition of its clinical significance. Secondary monoclonal gammopathy usually stems from the reactive unbalanced proliferation of B cells resulting from chronic inflammatory diseases or from other malignancies. Only in some cases its cause is difficult to assert. A case of secondary plasma-cell dyscrasia of undetermined cause is presented. The patient had IgG kappa monoclonal gammopathy of 3580 mg/dl, and multiple osteolytic bone lesions. However the histopathological picture showed a chronic inflammatory process, and the diagnosis of multiple myeloma could not be established. The diagnostic problems in this case are discussed, with the recommendation that more strict and accurate immunochemical terms concerning monoclonal gammopathy be used.

Colorectal cancer and schistosomiasis

The risk of colorectal cancer is known to be increased in patients with long-standing schistosomal colitis. A retrospective review of clinical data and surgical specimens from 60 patients with schistosomal granulomatous disease of the large intestine but without carcinoma demonstrated that 36 of them had mild to severe grades of colonic epithelial dysplasia. This was either focal or diffuse in distribution and occurred in flat mucosa, in pseudopolyps, or in regenerating epithelium at the edges of ulcers. These dysplastic changes are regarded as the pathological basis for the malignant potential of schistosomal colitis, and they resemble the changes found in long-standing chronic ulcerative colitis.

Simultaneous studies of serum and urinary proteins for evaluation and diagnosis of glomerular damages in proteinuric patients

Simultaneous studies of serum and urinary proteins in 294 adult proteinuric patients are presented. Our data showed that these studies can provide valuable guides for clinical diagnosis. In the group of idiopathic nephrotic syndrome, hypoalbuminemia, hypogammaglobulinemia and hyper-alpha 2 globulinemia were most marked. Urinary protein electrophoresis (PEP) showed a well-selective pattern with albumin and beta globulin as the main constituents. In the other groups of proteinuric patients the hypoalbuminemia and hyper-alpha 2 globulinemia were milder and urinary PEP generally showed non-selective pattern. In the groups of acute glomerulonephritis and lupus nephropathy, C3 was generally decreased; polyclonal gammopathy was frequently encountered and alpha 1 acid glycoprotein was markedly increased. In the cases of chronic glomerulonephritis and diabetic nephropathy and the levels of gamma globulin, C3 and alpha 2 acid glycoprotein were usually within normal limits. Urinary protein selectivity index in this series of adult patients was not a useful diagnostic parameter.

Separation and purification of myeloma proteins

Three myeloma proteins, IgG lambda, IgA lambda and IgM lambda, were identified by protein electrophoresis (PEP), immunoglobulin quantitation and immunoelectrophoresis (IEP). Preparative block electrophoresis was generally carried out as an initial step to separate the myeloma proteins. The myeloma proteins thus separated were then passed through either diethylaminoethyl (DEAE) ion exchange chromatography and recycled in a Sephadex G-200 column, or first through gel filtration and recycled in DEAE. An attempt to bypass the step of preparative electrophoresis in the separation of IgG myeloma protein by passing the serum directly into a DEAE column was proved to be inappropriate. The IgM myeloma protein had a marked tendency to cryoprecipitate and to form euglobulin, and this property was utilized to separate the crude myeloma protein. The purified myeloma protein fractions were concentrated and dialyzed with Ultrafiltration (Amicon) and retested for purity with PEP, double diffusion (DD) and IEP. Some special physiochemical properties which affected the purification procedures are discussed.

Changes of serum protein and immunoglobulin in toxemia of pregnancy

The immune mechanism theoretically may play an important role in toxemia of pregnancy. Serum proteins, immunoglobulins and C3 were measured in 20 women with normal pregnancy and in 10 women with toxemia of pregnancy. Compared with the normal pregnancy, the toxemia group exhibited decreased albumin and IgG, and significant increases in alpha 1 globulin and IgE. The immunological implication of these changes deserves further investigation.

[Double diffusion (author's transl)]

Double diffusion is one of the most simple and widely used immunologic techniques. If performed properly, this test offers the unique advantage of not only enumerating the minimum number of antigen-antibody systems, but also indicating the relationship among various antigens. However, the reaction lines should be interpreted cautiously and over-reading be avoided.

[Immunoelectrophoresis (author's transl)]

Immunoelectrophoresis is a combined technique of electrophoresis and double diffusion. The test has been widely used to enumerate and analyze the antigenic components in mixtures, and it is indispensable in the study of monoclonal gammopathy. The interpretation of reaction lines needs basic immunochemical knowledge about immunoglobulin and principles of immunoprecipitation. When properly performed, immunoelectrophoresis will, in most instances, confirm the diagnosis and establish the class and type of M protein. However, the reaction lines should be interpreted cautiously, and the immunoelectrophoretic pattern must be correlated with that of electrophoresis and also with the immunoglobulins levels. The basic immunoelectrophoretic patterns of most frequently encountered monoclonal gammopathies are presented and some of the difficult problems are discussed in this report.

An immunochemical study of two Bence-Jones proteins

Two Bence-Jones proteins, one of kappa and the other of lambda type, from the urine of two myeloma patients were identified by protein electrophoresis (PEP) and immunoelectrophoresis (IEP). Urine specimens were concentrated and dialyzed with Ultrafiltration. The concentrated products were passed through a Sephadex G-100 column, and the fractions of Bence-Jones proteins were recycled in diethylaminoethyl (DEAE) ion exchange chromatography. Purified Bence-Jones proteins were mixed thoroughly with complete Freund adjuvant and inoculated into rabbits. The monospecific antisera to kappa and lambda chains were obtained by absorption with Bence-Jones proteins of the opposite types.

[Common variable immunodeficiency: an immunological study (author's transl)]

A 17-year-old school boy with recurrent sinopulmonary infection and diarrhea was found to have marked hypogammaglobulinemia. He had no family history of similar disorder. Serum IgG was measured 240 mg/dl, whereas all the other classes of immunoglobulins were undetectable with Mancini's technique. The polymorphonuclear leukocyte function and complement system were normal. Although the numbers of T and B lymphocytes were normal, we demonstrated that the patient's B cells were able to produce only IgG in subnormal amount and unable to secrete other classes of immunoglobulins. No hyperactive suppressor T cell function or inadequate helper T cell function was found. Therefore, the basic immmunopathogeneic mechanism was ascribed to intrinsic B cell defect.

Purification of soluble hepatocellular carcinoma extracts

When soluble hepatocellular carcinoma (HCC) extract prepared by 3 M KCl solution was passed through a column of Sephadex G-200, four fractions (designated as I, II, III, IV) could be obtained from the elution profile. By leukocyte migration inhibition assay, the active component of soluble HCC extract which represented tumor-associated antigen was shown to be contained in fractions I and II.

Evaluation of the relationships of prealbumin components in sera of patients with cancer

Serum proteins of cancer and control sera have been evaluated by the conventional Mancini method as well as by scanning densitometry measurements of components after separation by gradient PAGE. We established than in sera of cancer patients, prealbumin levels decrease and alpha 1-acid glycoprotein levels increase significantly. However, the Mancini method was not as sensitive as PAGE for quantitative evaluation of differences among sera of healthy adults, smokers, and patients with benign disease. We find that a more sensitive measure is the ratio between the two components (alpha 1-acid glycoprotein and prealbumin) and suggest that these values possibly may be useful as a CSI. In this study, the average CSI for healthy adults is 0.79, for heavy smokers, 1.24; for benign diseases, 1.67; and patients with various forms of cancer as follows: early lung, 4.17; late lung, 8.78; bladder, 8.92; colon, 13.77; breast, 2.43; and melanoma, 9.22.

Humoral components of immunological response in nephrotic syndrome

Serum and urine were collected from 58 patients with nephrotic syndrome. Immunoglobulins (IgA, IgG and IgM), complement (C3) and transferrin levels were measured by single radial immunodiffusion. The extent of glomerular injury was estimated by determining the selectivity of proteinuria. The relationship between the severity of glomerular damage and serum concentrations of immunoglobulins and complement was assessed. Higher IgM and lower IgG serum concentrations were found in nephrotic patients than in normal controls (157 +/- 108 mg+ vs 127 +/- 38 mg% for IgM, 929 +/- 537 mg% for IgG). The difference was statistically significant (p less than 0.05 for IgM, p less than 0.001 for IgG). No correlation was present between the selectivity of proteinuria and serum levels of IgA, IgM, IgG or C3. The results indicate that abnormalities in humoral components of the immune system are present in nephrotic patients and are probably related to a basic immunological defect in the patients rather than to the severity of glomerular damage.

Immunological diagnosis of IgD paraprotein

IgD monoclonal peaks are relatively small, with broad bases, and are preferentially of gamma-1 or beta mobility. Often IgDgamma paraproteins can only be detected after proper dilution or reduction of the patient's serum. Assay for Bence Jones protein should not be neglected, and if it is present, the co-existence of IgD monoclonal gammopathy should be suspected.

Fungi isolated from asthmatic homes in the Taipei area

Indoor fungi in Taipei were surveyed during 1969-1974 using Sabouraud's agar plates. No remarkable yearly variation of fungal incidence was observed. The fungal population was found to be different from home to home. The dominant members were Aspergillus, Penicillium, Mycelia sterila, Oospora, Rhodotorula, Hormodendrum and yeasts. The order of frequency of fungi found indoors was quite different from that of outdoor fungi. The fungal spores were more numerous during summer months, and this trend was more apparent for Aspergillus, Oospora, Rhodotorula, and Hormodendrum. The kind and the incidence of fungi found in asthmatic homes were not different from those detected in non-asthmatic homes, except that in asthmatic homes there were greater numbers of fungi.