Minilaparoscopy-guided spleen biopsy in systemic disease with splenomegaly of unknown origin

With the advent of a minimally invasive laparoscopy technique, the advantages of diagnostic laparoscopy are being rediscovered. We report here on four patients with systemic disease of unknown origin and splenomegaly, in whom minilaparoscopy-guided splenic biopsy yielded a definitive diagnosis. Four patients with unclear systemic disease were studied using diagnostic minilaparoscopy and guided spleen biopsy, after failure of diagnostic work-up. Minilaparoscopic spleen biopsy revealed the diagnosis of a B-cell non-Hodgkin's lymphoma in two cases. In one patient, who had a history of Still's disease, the spleen biopsy showed granulocytic infiltration in the spleen typical of an acute episode of Still's disease. One patient with a known immunodeficiency syndrome (stage C III) showed multiple hypodense lesions in the spleen. Biopsy allowed a diagnosis of mycobacterial infection, with identification of Mycobacterium tuberculosis. No major complications occurred in any of the four cases; post-biopsy bleeding was observed in three of the four, but was easily managed by argon plasma coagulation or application of fibrin glue, or both. We recommend the use of spleen biopsy as a diagnostic tool in splenopathy of unknown origin if previous diagnostic methods have failed to yield a definitive diagnosis.

[Coping in patients after liver transplantation with regard to their membership in a self-group]

BACKGROUND

Within the past 15 years, liver transplantation has proven itself to be the treatment of choice among patients with terminal liver disease. The one-year survival rate is about 80 %; after 8 years 61 % of the patients are still alive. The present study investigates the influence of active or depressive coping on the physical and mental quality of life in two different groups of patients after liver transplantation.

METHODS

Members (n = 65) and non-members (n = 20) of a German self-help group were asked to fill out a postal survey. Patients were included if their liver transplantation was conducted 6 to 36 months ago. The health-related quality of life was surveyed using the SF-36 and coping strategies were investigated with the Freiburg questionnaire on coping with illness.

RESULTS

All patients had a good physical and mental quality of life compared with a German normative sample. Members of the self-help group showed substantially higher active coping with illness (p < 0.0001), but only depressive coping correlates (negatively) with physical as well as with mental health-related quality of life (r between -0.24 and -0.68). This was true for both groups investigated.

CONCLUSION

Based on an overall good health-related quality of life, depressive coping as well as aspects of the social environment contribute considerably in determining the well-being and quality of life in patients after liver transplantation.

Nachweis von SLA/LP-Autoantikörpern bei Patienten mit primär biliärer Zirrhose als Marker für eine sekundäre autoimmune Hepatitis (Overlapsyndrom)

BACKGROUND AND OBJECTIVE

The aim of this study was to evaluate whether the presence of SLA/LP-autoantibodies in PBC-patients gives evidence for a secondary AIH, also called AIH/PBC-overlap-syndrome.

PATIENTS AND METHODS

Out of 233 consecutive patients with PBC who had been followed between October 1980 and April 2000, we evaluated the data of anti-SLA/LP-positive patients and compared them to patients with an anti-SLA/LP-negative AIH/PBC overlap syndrome as well as to patients with a classical course of AIH and PBC.

RESULTS

In total we could identify nine PBC patients with anti-SLA/LP antibodies (six women/three men) or 3.9% of the study population, Anti-SLA/LP-positive PBC patients were slightly younger at diagnosis in comparison to anti-SLA/LP-negative PBC-patients (49.9 vs. 53.2 years). Transaminases and gamma-globulins were significantly higher in anti-SLA/LP-positive PBC-patients in comparison to anti-SLA/LP-negative PBC-patients (mean: 235 vs. 55 IU/l and 27.6 vs. 19.5 g/l). Anti-SLA/LP-positive patients significantly more frequently had an HLA-type that is characteristic for AIH (B8; DR3; DR4). Immunosuppressive therapy reduced inflammatory activity and cholestasis significantly. Relapses were frequent after reduction or discontinuation of immunosuppressive therapy.

CONCLUSION

The presence of SLA/LP autoantibodies in PBC patients has a high specificity for a secondary AIH (AIH/PBC overlap syndrome). These patients have a good response to immunosuppressive therapy. The autoantibody profile and immunogenetics may help in future to identify PBC patients that benefit most from immunosuppressive therapy.

Prediction of progressive liver fibrosis in hepatitis C infection by serum and tissue levels of transforming growth factor-beta

Although many patients with chronic viral hepatitis C infection suffer from progressive liver disease, the rate of fibrosis progression is highly variable and some patients do not show any measurable progression. However, our ability to predict which patients progress is very limited. Since transforming growth factor-beta (TGF-beta) is a key mediator of liver fibrogenesis, we assessed the predictive role of TGF-beta for fibrogenesis in chronic hepatitis C. We studied 39 patients with chronic hepatitis C in whom two liver biopsies were taken at least 12 months apart, and who did not receive therapy during this period. TGF-beta was measured by bioassay and by ELISA in serum samples taken at the time of the first biopsies, and TGF-beta was determined semiquantitatively by immunostaining of liver biopsy sections. Fibrosis was scored blinded in the biopsy samples by two pathologists independently. There was a close correlation between TGF-beta serum levels and the rate of fibrosis progression. Patients with no progression of fibrosis had significantly lower (59 ng/mL +/- 22) TGF-beta serum levels than patients with progressive disease (115 ng/mL +/- 20), and a TGF-beta level below 75 ng/mL was predictive for stable disease. Immunohistology for TGF-beta in biopsy samples was also predictive for progressive liver disease with fibrosis progression found in those patients displaying staining of hepatocytes and sinusoidal cells. No such correlation was found with other markers such as procollagen III peptide, viral load or transaminase levels. These results further support the role of TGF-beta in liver fibrogenesis, and offer an opportunity to predict clinical disease progression, which may help in selecting patients who are in need of therapeutic interventions.

Hepatocellular expression of a dominant-negative mutant TGF-beta type II receptor accelerates chemically induced hepatocarcinogenesis

The potent growth-inhibitory activity of cytokines of the transforming growth factor-beta (TGF-beta) superfamily and their widespread expression in epithelia suggest that they may play an important role in the maintenance of epithelial homeostasis. To analyse TGF-beta mediated tumor suppressor activity in the liver, we generated transgenic mice overexpressing a dominant negative type II TGF-beta receptor in hepatocytes under control of the regulatory elements of the human C-reactive protein gene promoter. Transgenic animals exhibited constitutive and liver-specific transgene expression. The functional inactivation of the TGF-beta signaling pathway in transgenic hepatocytes was shown by reduced TGF-beta induced inhibition of DNA synthesis in primary hepatocyte cultures. Liver morphology and spontaneous tumorigenesis were unchanged in transgenic mice suggesting that interruption of the signaling of all three isoforms of TGF-beta in hepatocytes does not disturb tissue homeostasis in the liver under physiological conditions. However, following initiation with the carcinogen diethylnitrosamine and tumor-promotion with phenobarbital transgenic mice exhibited a moderate albeit significant increase in the incidence, size and multiplicity of both preneoplastic tissue lesions in the liver and of hepatocellular carcinomas. These results give in vivo evidence for a tumor suppressor activity of the endogenous TGF-beta system in the liver during chemical hepatocarcinogenesis.

Autoimmunity to the p53 protein is a feature of systemic lupus erythematosus (SLE) related to anti-DNA antibodies

The induction of anti-DNA autoantibodies in systemic lupus erythematosus (SLE) patients is problematic because mammalian DNA is poorly immunogenic at best. Here we demonstrate a chain of connected antibodies in SLE patient sera that could account for the induction of anti-DNA antibody, and possibly for some of the pathogenic features of SLE. We now report that SLE patients, in addition to anti-DNA, produce antibodies to the carboxy-terminal domain of the tumour suppressor molecule p53; this p53 domain recognizes damaged DNA. Hence, these anti-p53 antibodies could mimic damaged DNA immunologically. Indeed, SLE sera do contain anti-idiotypic antibodies to a prototypic anti-p53 antibody. Moreover, SLE anti-DNA antibodies also recognize this type of anti-p53 antibody. Indeed, binding of affinity-purified anti-DNA both to DNA and to the anti-p53 antibody could be blocked by a p53 peptide derived from the DNA-binding domain. This mimicry of the p53 DNA-binding domain by the SLE anti-DNA antibodies is functional: activation of the p53 molecule could be inhibited by such anti-DNA antibodies. Thus, anti-DNA antibodies may arise in SLE patients by a chain of idiotypic autoimmunity centered around p53 autoimmunity. The SLE anti-DNA and anti-p53 antibodies can functionally block p53 activation, and so could affect apoptosis.

A bioinformatical approach suggests the function of the autoimmune hepatitis target antigen soluble liver antigen/liver pancreas

Antibodies to a soluble liver antigen/liver pancreas (SLA/LP) appear to be highly specific for the diagnosis of autoimmune hepatitis. The SLA/LP target antigen was recently identified as a hitherto unknown gene encoding 474 amino acid residues. The function of this antigen remains unclear, because it does not share sequence homology with proteins of known function stored in any of the publicly accessible databases. Therefore we used a new theoretical method called fold recognition and could show that the SLA/LP sequence is compatible with the architecture of the superfamily of pyridoxal phosphate (PLP; vitamin B6)-dependent transferases. Its function is likely to be that of a serine hydroxymethyltransferase and may be an important enzyme in the thus far poorly understood selenocysteine pathway.

Autoimmune hepatitis in the elderly

OBJECTIVES

Autoimmune hepatitis (AIH) is widely believed to be a disease of young women and menopause. Little is known about the frequency and clinical characteristics in patients aged > or =65 yr.

METHODS

We reviewed charts of 120 consecutive outpatients with known AIH to identify patients who were diagnosed at the age of 65 or older. These 20 patients (median age, 69 yr) were compared to the same number of younger patients (median age, 24 yr) with well-documented AIH from the same cohort.

RESULTS

Seventeen percent (20/120) of our patients were > or =65 yr at the time of diagnosis. In the older patients median time to diagnosis was significantly longer than in the younger patients (8.5 vs 3.5 months). Patients most commonly presented with an acute icteric hepatitis. Complete remission was achieved to a similar extent (18/20 and 17/20 patients). Fewer older patients expressed human leukocyte antigen A1-B8 (p = 0.005).

CONCLUSIONS

Diagnosis of AIH often seems to be delayed in the elderly, presumably because AIH is erroneously considered to be a disease of young age. Presentation with acute icteric hepatitis is similar to that of younger patients, supporting the assumption that beneficial effects of hormonal changes associated with menopause are not as pronounced in AIH as in other autoimmune diseases. Human leukocyte antigen type seems to have an influence on the age of onset of AIH. Prognosis is excellent, and AIH should be considered in the older patient to avoid delayed initiation of immunosuppressive therapy.

Long-term management and prognosis of autoimmune hepatitis (AIH): a single center experience

BACKGROUND

Controlled trials have firmly established the need for immunosuppressive therapy in autoimmune hepatitis. However, reports about long-term management and prognosis of the disease are scarce.

PATIENTS AND METHODS

We reviewed the charts of 103 consecutive patients with a well-documented long-term course of autoimmune hepatitis who had been carefully managed over a mean observation period of 95 months (12-405 months).

RESULTS

Under immunosuppressive therapy 94 patients (91.2%) reached complete remission after a mean treatment duration of 3 +/- 3 months. 28 of the 103 patients (27.2%) were eligible for a trial of treatment withdrawal after a mean treatment duration of 32.2 months (range: 12-81 months). 21 of these patients (75%) had a relapse following treatment withdrawal. 13.6% of patients had intolerance of or severe side effects to azathioprine. There was no increase in tumor risk during a cumulative observation period of 423 patient-years of azathioprine therapy. Corticosteroid side effects occurred mostly during induction therapy, but were usually minor and resolved upon dose reduction. During a cumulative observation period of 842 patient-years no liver related deaths occurred and no patient had to be referred to liver transplantation, even though 30 patients (29.1%) had histological evidence of cirrhosis at presentation. The overall 5- and 10-year survival of patients with autoimmune hepatitis was identical to an age- and sex-matched control population.

CONCLUSION

Our study shows that the majority of patients with AIH do achieve a complete remission within 3 months, but require long-term or permanent immunosuppressive therapy that is usually well tolerated. Long-term survival in well-managed patients is excellent.

[Safety and value of minilaparoscopy in high risk patients]

INTRODUCTION

Coagulopathies and thrombocytopenia may constitute contraindications for percutaneous liver biopsy. We investigated the safety and value of visually guided liver biopsy using minilaparoscopy in patients with coagulation disorders.

PATIENTS AND METHODS

We studied 50 patients requiring a liver biopsy, but whose risk of severe bleeding complications was considered too high for the following reasons: INR > 1.5 (40%), platelets 50/nl (36%) or both (18%), other coagulopathies (6%). Indications for liver biopsy were: Hepatopathy of unknown etiology (38%), fulminant liver failure (18%), virus induced hepatitis (6%) and evaluation for liver transplantation (38%). Patients underwent minimally invasive diagnostic laparoscopy and liver biopsies were obtained with a Silverman or Menghini needle. Bleeding was stopped or prevented by coagulation with the argon beamer or a monopolar probe or application of fibrin glue.

RESULTS

Macroscopical assessment of the liver was possible in all patients. A liver biopsy was performed in 47/50. 46/47 biopsy specimens were large enough to allow reliable histological evaluation. The diagnostic procedure had major therapeutic consequences in 35/40 patients. No relevant bleeding from the liver biopsy site occurred.

CONCLUSION

We demonstrated that laparoscopically guided liver biopsy is safe even in patients with a very high risk of bleeding complications because of coagulation disorders. It is therefore an attractive and preferable alternative to transjugular liver biopsy.

Chemoenzymatic synthesis of isogalactofagomine

A new chemoenzymatic synthesis of optically pure isogalactofagomine 2 starting from achiral starting materials is presented. Dimethyl 4-hydroxypyridine-3,5-dicarboxylate (7) was synthesized and converted to the corresponding saturated piperidine 8. Then the key step of the synthesis was carried out: Lipase M catalyzed hydrolysis of the prochiral diester 8 to cause formation of an asymmetric monoacid with at least 98% enantiomeric excess. Reduction of the acid, saponification of the remaining ester, and radical iododecarboxylation gave an iodide that after substitution with silver trifluoroacetate and hydrolysis gave 2.

Investigation of the slow inhibition of almond beta-glucosidase and yeast isomaltase by 1-azasugar inhibitors: evidence for the 'direct binding' model

(-)-1-Azafagomine [(3R,4R,5R)-4,5-dihydroxy-3-hydroxymethylhexahydropyridazine; inhibitor 1] is a potent glycosidase inhibitor designed to mimic the transition state of a substrate undergoing glycoside cleavage. The inhibition of glycosidases by inhbitor 1 and analogues has been found to be a relatively slow process. This 'slow inhibition' process was investigated in the inhibition of almond beta-glucosidase and yeast isomaltase by inhibitor 1 and analogues. Progress-curve experiments established that the time-dependent inhibition of both enzymes by inhibitor 1 was a consequence of relatively slow dissociation and association of the inhibitor from and to the enzyme, and not a result of slow interchanges between protein conformations. A number of hydrazine-containing analogues of inhibitor 1 also inhibited beta-glucosidase and isomaltase slowly, while the amine isofagomine [(3R,4R,5R)-3,4-dihydroxy-5-hydroxymethylpiperidine; inhibitor 5] only inhibited beta-glucosidase slowly. Inhibitor 1 and related inhibitors were found to leave almond beta-glucosidase with almost identical rate constants, so that the difference in K(i) values depended almost entirely on changes in the binding rate constant, k(on). The same trend was observed for the inhibition of yeast isomaltase by inhibitor 1 and a related inhibitor. The values of the rate constants were obtained at 25 degrees C and at pH 6.8.

[Infectious osteoarthritis due to Propionibacterium acnes. Two new cases]

INTRODUCTION

Propionibacterium acnes is an anaerobic germ, usually found as a saprophyte of the skin and the mucosa. It may be responsible for iatrogenic or spontaneous osteoarhritis.

EXEGESIS

We report two new cases of septic arthritis induced by P. acnes: a case of iatrogenic spondylodiscitis and a case of spontaneous septic arthritis of the lumbar facet joints. The two patients were immunocompetent, without acne.

CONCLUSION

Except for patients with criteria of the SAPHO syndrome (synovitis-acne-pustulosis-hyperostosis-osteomyelitis), osteoarthritis caused by P. acnes is increasingly described. The number of these infections is probably underestimated because of the technical problems involved in isolating P. acnes in the laboratory.

[Value of mini-laparoscopy]

Mini-laparoscopy uses 1.9 mm diameter optical instruments allowing examination of the abdomen following a single puncture. It is an extremely safe and only minimally invasive technique allowing accurate staging of liver disease as well as sensitive detection of tumor dissemination. It can be performed as an outpatient procedure. Its most common indication is for accurate staging of liver fibrosis, where it is much superior to all other techniques.

Identification of target antigen for SLA/LP autoantibodies in autoimmune hepatitis

BACKGROUND

Autoantibodies are a hallmark of autoimmune hepatitis, but most are not disease specific. Autoantibodies to soluble liver antigen (SLA) and to liver and pancreas antigen (LP) have been described as disease specific, occurring in about 30% of all patients with autoimmune hepatitis, but no standardised assays are available. Methods We tested 2000 serum samples from patients with various liver diseases and controls for SLA autoantibodies by inhibition ELISA. Serum samples positive for SLA antibodies were used for immunoscreening of cDNA expression libraries. Identified clones were tested against a panel of serum samples positive for SLA and LP autoantibodies and control serum samples, and the epitope mapped by deletion mutants and exonuclease digestion.

FINDINGS

SLA and LP autoantibodies were identical. Of 2000 serum samples screened, 35 were positive for SLA autoantibodies. These positive samples came from patients with autoimmune hepatitis; three from patients with an overlap syndrome (primary biliary cirrhosis and secondary autoimmune hepatitis). Expression cloning and absorption experiments identified a 422 aminoacid protein present in two splice variants as the sole target antigen. Aminoacids 371-409 were critical for immune recognition.

INTERPRETATION

The identified cDNA encodes the primary target antigen of SLA/LP autoantibodies. The SLA/LP antigen has a previously unknown aminoacid sequence, and presumably codes for an unindentified enzyme, suggested to be UGA-suppressor tRNA-associated protein. SLA/LP autoantibodies are disease specific and recognise a dominant epitope, suggesting a specific antigen-driven immune response. Identification of the SLA/LP target antigen will allow establishment of a reliable, widely available diagnostic assay. Furthermore, its role in the pathogenesis of autoimmune hepatitis can now be studied.

Enantiospecific synthesis of 1-azafagomine

For the first time the two enantiomeric forms of the glycosidase inhibitor 1-azafagomine have been synthesised starting from D- and L-xylose. D-Xylose was converted to the 2,3,5-tribenzylfuranose, which upon reductive amination with tert-butyl carbazate gave the protected 1-hydrazino-1-deoxypentitol in high yield. N-acetylation, mesylation of the 4-OH, removal of the Boc group, cyclisation and deprotection gave (+)-1-azafagomine ((+)-1). By a similar sequence of reactions, L-xylose was converted to (-)-1-azafagomine ((-)-1). Enzymatic and other routes to optically pure 1-azafagomine were also studied. Compound (-)-1 is a potent competitive glycosidase inhibitor, while (+)-1 has no biological activity. The inhibition of almond beta-glucosidase by (-)-1 was found to be slow owing to a slow binding step of inhibitor to enzyme, with no subsequent conformational rearrangement. The rate constants for binding and release were found to be 3.3 x 10(4)M(-1)s(-1) and 0.011 s(-1), respectively, yielding Ki = 0.33 microM.

Combined therapy with azathioprine, prednisolone, and ursodiol in patients with primary sclerosing cholangitis. A case series

BACKGROUND

No established medical therapy alters the progressive course of primary sclerosing cholangitis.

OBJECTIVE

To explore the potential usefulness of combined therapy with azathioprine, steroids and ursodeoxycholic acid (UDCA) in primary sclerosing cholangitis.

DESIGN

Case series.

SETTING

University hospital in Mainz, Germany.

PATIENTS

15 patients with primary sclerosing cholangitis.

INTERVENTION

Azathioprine (1 to 1.5 mg/kg of body weight per day), prednisolone (1 mg/kg per day initially, tapering to 5 to 10 mg per day) and UDCA (500 to 750 mg per day).

MEASUREMENTS

Clinical and laboratory evaluation, liver biopsy, and endoscopic retrograde cholangiography (a >30% change in stenosis was considered significant).

RESULTS

After a median observation period of 41 months (range, 3 to 81 months), liver enzyme levels declined significantly in all patients. Six of 10 patients with follow-up liver biopsies showed histologic improvement. Significant radiographic deterioration was seen in only 1 of 10 patients who had endoscopic retrograde cholangiography. In 7 patients previously treated with UDCA alone, liver enzyme levels declined significantly only after immunosuppressive therapy was added. Adverse drug reactions led to the withdrawal of study medications in 2 patients.

CONCLUSIONS

Combined immunosuppressive therapy may alter the progression of primary sclerosing cholangitis. Our observations suggest a benefit from adding immunosuppressive drugs to UDCA therapy. A randomized trial is warranted.

Clinical significance of autoantibodies to soluble liver antigen in autoimmune hepatitis

BACKGROUND/AIMS

Classification of autoimmune hepatitis (AIH) into different subgroups according to autoantibody status has been proposed: type I (ANA/SMA), type II (LKM-1) and type III (anti-SLA). However, whether type III AIH forms a clinically distinct disease entity remains controversial. The aim of this study was to evaluate the subclassification of AIH into ANA/SMA and anti-SLA positive patients with regard to clinical, biochemical and histologic differences.

METHODS

Ninety-seven consecutive patients with a well-documented long-term course of AIH with ANA/SMA and/or anti-SLA autoantibodies were studied. Clinical, biochemical and histological features of patients with ANA/SMA and/or anti-SLA autoantibodies were compared in a secondary analysis of data acquired prospectively.

RESULTS

Anti-SLA autoantibodies were found in 21.6% of patients. Anti-SLA-positive patients tended to have lower transaminases (mean: 153 vs. 247 IU/l), gamma-globulins (25 vs. 31%) and bilirubin (1.8 vs. 3.3 mg/dl) in comparison to ANA/SMA positive patients, but there was a large overlap. HLA-type A1 B8 was more frequent in anti-SLA positive patients, while there was no difference in HLA DR3 and DR4 allotype. Response to immunosuppressive therapy was excellent, but relapse occurred frequently. Diagnosis of anti-SLA positive AIH was often delayed (mean: 68 months from first elevation of transaminases) since testing for anti-SLA autoantibodies is currently not generally available.

CONCLUSIONS

ANA/SMA and anti-SLA positive patients share most clinical, biochemical, histologic and prognostic features. Distinction between type I and type III AIH is therefore clinically not helpful. However, testing for anti-SLA autoantibodies helps in the diagnosis of AIH in many patients who may otherwise be misdiagnosed.

Synthesis and deconvolution of the first combinatorial library of glycosidase inhibitors

A combinatorial library of 125 compounds with a structure consisting of 1-azafagomine linked at N-1 via an acetic acid linker to a variable tripeptide was synthesised. The library was synthesised by Merrifield split and mix synthesis of the peptide, followed by capping with chloroacetate, regioselective nucleophilic substitution with 1-azafagomine and cleavage from the polymeric support. The library was screened for inhibition of beta-glucosidase, alpha-glucosidase and glycogen phosphorylase and found to display beta-glucosidase inhibition. Deconvolution of the library revealed that some inhibition was caused by all library members but the strongest inhibitor was clearly a compound having three hydroxyproline residues in the peptide fragment. This compound was a weaker but more selective inhibitor than 1-azafagomine itself.

Cellular and humoral immune responses against autoreactive T cells in multiple sclerosis patients after T cell vaccination

Myelin basic protein (MBP)-reactive T cells may play an important role in the autoimmune pathogenesis of multiple sclerosis (MS). MBP-reactive T cells can be specifically targeted by T cell vaccination, a procedure whereby MS patients are immunized with attenuated autologous MBP reactive T cells. T cell vaccination induces immune responses to the vaccine cells together with a depletion of MBP reactive T cells. Forty-nine MS patients were treated with T cell vaccination in an extended phase I trial to study the safety, immune responses and clinical effects of T cell vaccination. In the present paper the immune responses towards the vaccine cells were characterized. Substantial long-term in vitro proliferative responses were observed in all treated patients. Some patients, immunized with different clones, displayed distinct proliferative reactivity against the various vaccine clones, suggesting unequal immunogenic properties of these clones. Reactive TCRalphabeta(+), CD8(+)and CD4(+)T cells, and to a lesser extent, gammadelta T cells and NK cells were observed to in vitro stimulation with the vaccine cells. A small fraction only of CD8(+)T cells expressed cytolytic and inhibitory anti-clonotypic reactivity against the vaccine cells. Stimulation with the vaccine clones predominantly induced expression of pro-inflammatory cytokines in these mixed cultures, although one vaccine clone consistently induced production of IL-4. CD4(+)T cells are the major cytokine-producing cells in these anti-vaccine lines. We could not detect upregulated antibody responses to the vaccine cells in most patients, although a temporary antibody response was observed in one patient. In conclusion, immunization with attenuated autoreactive T cells induces a complex cellular response specifically targeted at the vaccine cells, but no antibody responses. These data provide further insights into the mechanisms of T cell vaccination and improve our understanding of the complex regulatory networks of autoreactive T cells.