[Endocrinologic and metabolic complications of Alagille syndrome]

BACKGROUND

Patients with gastrointestinal and hepatobiliary disorders, either congenital or acquired early in childhood, are at high risk for various endocrine and metabolic abnormalities.

CASE REPORT

A 27-year-old woman with Alagille's syndrome presented with progressive jaundice and gait disturbances following surgery and ingestion of oral contraceptives. On physical examination, short stature, facial dysmorphism and neuromuscular symptoms such as polyneuropathy and spinocerebellar ataxia were noted. Serum concentrations of total bilirubin (54 mg/dl) and alkaline phosphatase were markedly increased, whereas serum levels of haptoglobin, zinc, vitamin D and E were decreased. Although prehepatic or intrahepatic etiologies of jaundice were more likely in this patient, posthepatic etiologies were ruled out by abdominal ultrasound and endoscopic retrograde cholangio-pancreaticography. Based on a working diagnosis of acute drug-induced cholestasis, treatment with high doses of lipid-soluble vitamins and ursodeoxycholic acid was initiated. In response to therapy, her abnormal laboratory results normalized and her neurologic symptoms markedly improved.

CONCLUSION

This clinicopathological conference of a patient with Alagille's syndrome illustrates the clinical presentation and therapy of metabolic and endocrine complications in chronic cholestasis.

High grade malignant lymphoma with clinical characteristics and immunophenotype of natural killer cells

The malignant proliferation of natural killer (NK) cells which are morphologically characterized as large granular lymphocytes (LGL) is a well known clinical entity which was named after its morphological appearance as LGL-leukemia/lymphoma. Similar to non-malignant NK-cells, these tumors can be divided into those which express the CD3-T-cell receptor complex and those which do not. The CD3-positive type of LGL-leukemia is immunophenotypologically characterized by the expression of CD16, and variably CD 56 and CD 57, and generally follows a more indolent course. In contrast, malignant proliferations of CD3-negative LGL express either CD16 or CD 56, and only occasionally CD 57 on their cell surface. Clinically, CD3-negative NK-lymphomas tend to progress rapidly. We report here the case of a high grade malignant lymphoma which was characterized by an immunophenotype typical for CD3-negative NK-cells (CD2+, CD3-, CD16+, CD56(+), CD57-). The disease proved to be rapidly fatal despite aggressive chemotherapy. Interestingly, the patient suffered from a high turn over pancytopenia, which also characterizes NK-cell leukemias/lymphomas of the LGL-type. However, our patient's lymphatic cells appeared highly immature, and cytoplasmic granules, characteristic for LGL-cells, could not be discerned either microscopically or electronmicroscopically. Furthermore, the malignant lymphatic population had the T-cell receptor beta-chain rearranged. We therefore concluded that our patient might have suffered from a malignant proliferation of a putative precursor cell intermediate between T-cells and NK-cells.

Specific T-cell factor production and lymphocytes in the direct surroundings of a subcutaneous allogeneic tumor

Antigen-specific T-cell factors (TCF) play a role in the initiation of cellular immune responses. In allogeneic mouse-tumor models lymphocytes from the direct tumor surroundings of both euthymic and nude mice produce TCF. These lymphocytes produce TCF when collected already 1 day after subcutaneous (sc) injection of tumor cells. In contrast to euthymic mice, draining lymph nodes and spleen of nude mice did not contain TCF-producing lymphocytes at any stage after sc tumor cell injection. In sensitized euthymic mice TCF production by lymphocytes is significantly higher in the direct tumor surroundings than in draining lymph nodes or spleen. At 2 and 5 days after tumor cell injection, the mononuclear cell infiltrate of the tissue surrounding the tumor in euthymic mice showed low expression of Thy 1, CD3, TCR alpha beta, TCR gamma delta, CD4, CD8, and asialo GM1, whereas several lymphocytes and mast cells were positive for monoclonal antibody (mAb) 14-30 (directed against TCF). In both euthymic and nude mice, sc injected tumor cells showed apoptosis. In conclusion, the direct tumor surroundings are the first (and, for nude mice, the only) site of TCF production, sc injection of tumor cells attracts mAb 14-30-positive lymphocytes and renders mast cells positive for mAb 14-30.

Interaction of tumour cells with cultured stromal cells from human bone marrow

Adhesion of tumour cells to cultured bone marrow stromal cells has been studied in an in vitro model system. Stromal cells were isolated from bone marrow aspirates. Immunohistochemical and electron microscopical analysis revealed a uniform cell monolayer of myofibroblastic cells, expressing fibroblast antigens and smooth muscle actin. Cell interactions with tumour cells lines showed different patterns. The K562 cells bound in low numbers to stromal cells. HEL-DR- and HL60 cells adhered to stromal cells showing an enlarged cell contact area (spreading) attenuated by distinct contact sites and they invaded the monolayer. Adhesion molecules, important for cell contacts, were detected on tumor cells. Different VLA antigens were detected on tumour cells, but on stromal cells only VLA-5 and CD29 were found. In vitro inhibition studies with mAbs against adhesion molecules indicated two major pathways for binding of tumour cells to stromal cells: VCAM-1/VLA-4 and fibronectin/VLA-5. Variation in inhibition of mAbs to VLA-4 and VCAM-1 indicated the existence of critical epitopes in the adhesion of tumour cells.

High prevalence of antibodies to histones among patients with primary biliary cirrhosis

Histones are small, basic proteins involved in the packing of DNA into the eucaryotic nucleus. Using an immunodot assay and an enzyme-linked immunosorbent assay (ELISA), sera from patients with liver disease were tested for antibodies to the five individual histones H1, H2A, H2B, H3 and H4. Histones extracted from calf thymus and separated into individual fractions by gel exclusion chromatography were either immobilized on nitrocellulose or adsorbed to microtitre plates and the resulting immune complexes examined via a streptavidin-biotin bridge. Of the liver disease sera tested, only specimens obtained from primary biliary cirrhosis patients contained antibodies reactive with histones. The predominant reactivity was to histone H1 and H2B, and amounted to 74% for IgM antibodies, and 60% for IgG antibodies. Our data indicate that antibodies specific for histones might represent a novel serological marker for primary biliary cirrhosis.

Importance of ghrelin in hypothalamus-pituitary axis on growth hormone release during normal pregnancy in the rat

Ghrelin is a hormone mainly produced in the stomach and its first discovered action was connected with regulating growth hormone secretion. It was found that ghrelin injection increases growth hormone release and that this action is dose-dependent. Ghrelin may influence growth hormone secretion both by central and peripheral action. Ghrelin acts via its receptors named growth hormone secretagogue receptors (GHSR). Ghrelin receptors were found in almost all tissues including the central nervous system. Besides influence on growth hormone secretion, ghrelin also regulates food intake and energy metabolism centrally as well as peripherally. In our study, active ghrelin and growth hormone levels in serum were measured. We also investigated gene expression of proghrelin, growth hormone releasing hormone (GHRH) and growth hormone receptor (GH-R) in the hypothalamus and the active form of ghrelin receptor (GHSR-1a) in hypothalamus and pituitary. Expression of growth hormone and growth hormone releasing hormone receptor (GHRH-R) in the pituitary were also measured. The results of our study indicate that active ghrelin and growth hormone levels in serum increased during pregnancy. Expression of ghrelin in hypothalamus and its receptor also increased in hypothalamus and pituitary during pregnancy. We also observed that growth hormone gene expression rose in pituitary, while its receptor mRNA level in hypothalamus decreased. Additionally, growth hormone expression in placenta decreased during pregnancy. Moreover, GHRH in hypothalamus and its receptor in pituitary showed reduced levels during pregnancy. Our results may indicate that ghrelin is a important factor influencing growth hormone release during pregnancy.