An immunohistochemical analysis of naturally occurring chancroid

Haemophilus ducreyi is a major cause of genital ulcer disease in many developing countries and is associated with augmented transmission of human immunodeficiency virus (HIV). However, the mechanisms through which H. ducreyi produces ulceration are poorly understood. The characteristics of the host response to H. ducreyi and the pathobiology of its potential contribution to increased HIV susceptibility are not known. Chancroid ulcer biopsies from 8 patients were analyzed histologically and immunohistochemically. All biopsies had perivascular and interstitial mononuclear cell infiltrates that extended deep into the dermis. The infiltrate, which contained macrophages and CD4 and CD8 lymphocytes, was consistent with a delayed hypersensitivity type cell-mediated immune response. The recruitment of CD4 T lymphocytes and macrophages may in part explain the facilitation of HIV transmission in patients with chancroid.

A comparison of five health status instruments in patients with systemic lupus erythematosus (SLE)

The aim of the present investigation was to assess and compare health status instruments in SLE. One hundred and twenty-five patients completed five health status instruments: the Health Assessment Questionnaire (HAQ), Functional Ability Index, the Fatigue Severity Scale (FSS), the Disability Days Measure (DDM), the Centre for Epidemiological Studies-Depression Scale (CES-D), and the Medical Outcomes Study (MOS) Short Form Health Survey during their Clinic visit. Disease activity was measured using the SLE Disease Activity Index (SLEDAI). All instruments described a spectrum of quality of life outcomes in these patients. An inter-instrument correlation analysis revealed that components of the MOS correlated significantly with each of the other instruments used. There was no correlation between any of the instruments used and the SLEDAI. We conclude that health status assessment as measured by the MOS short form is a valid independent outcome measure in patients with SLE.

Lack of correlation among the 3 outcomes describing SLE: disease activity, damage and quality of life

OBJECTIVE

The aim of the this study was to correlate three outcome measures in patients with SLE, namely disease activity, damage, and quality of life.

METHODS

One hundred and five SLE patients completed the Medical Outcome Survey (MOS) SF-20 during their regular clinic visit. Disease activity (SLEDAI) and damage (SLICC/ACR Damage Index) were assessed according to a standard protocol. Statistical analyses included the Pearson correlation coefficients, a logistic regression, and a linear regression analysis.

RESULTS

There was no correlation between the SLEDAI and SLICC/ACR DI. There was no correlation between the SLICC/ACR DI and any of the MOS domains by Pearson correlation. Although a statistical correlation was demonstrated between the SLEDAI score and the social functioning and health perception domains of the MOS SF-20, there were not clinically important.

CONCLUSION

Thus, the three outcomes of disease activity, accumulated damage, and health status remain important independent outcome measures in the assessment of prognosis in patients with SLE.

Cloning and characterisation of angiotensin-converting enzyme from the dipteran species, Haematobia irritans exigua, and its expression in the maturing male reproductive system

The angiotensin-converting enzymes (ACE) are involved in the regulation of the specific maturation or degradation of a number of mammalian bioactive peptides. A carboxydipeptidase similar to mammalian ACE has now been identified in the adult stage of the haematophagous fly, Haematobia irritans exigua (buffalo fly), a close relative of the horn fly of North America. The enzyme was purified by lectin-affinity chromatography and ion-exchange chromatography and migrated as a doublet of 70 kDa upon reducing SDS/PAGE. Unlike mammalian ACE, the fly carboxydipeptidase (HieACE) is not membrane bound. The amino acid sequence of an internal peptide from HieACE and a conserved amino acid region present in all mammalian ACE were used to design degenerate oligonucleotide primers suitable for PCR. A DNA fragment amplified from adult buffalo fly cDNA was used to identify a cDNA clone that encoded the enzyme. The cDNA sequence encodes a carboxydipeptidase with 41-42% amino acid identity to the mammalian testicular ACE. The active-site regions of mammalian ACE are conserved in the deduced amino acid sequence of HieACE. Enzymatically, HieACE is very similar to its mammalian counterparts, with comparable Km and V(max) values for the synthetic substrate, benzoylglycylglycylglycine, and similar patterns of inhibition by EDTA, ACE inhibitor peptide and captopril. HieACE also specifically activates angiotensin I to angiotensin II and degrades other mammalian ACE substrates such as bradykinin, substance P and cholecystokinin-8. In the adult fly, HieACE is expressed in the compound ganglion and in the posterior region of the midgut. Similar to the mammalian system, expression of this enzyme is induced in the maturing male reproductive system, which suggests conservation of ACE function in these species.

Response to methotrexate in a patient with idiopathic eosinophilic fasciitis, morphea, IgM hypergammaglobulinemia, and renal involvement

A 35-year-old man with idiopathic eosinophilic fasciitis (EF) and morphea developed renal disease characterized by microscopic hematuria, nephrotic range proteinuria, and rapidly progressing hypertension, an association that has not previously been reported in EF. Initial clinical symptoms of EF began in July 1989; peripheral eosinophilia peaked at 30% in August 1990; an abnormal urinalysis was first observed in March 1992 and subsequently a renal biopsy was performed. Renal biopsy demonstrated focal segmental glomerulosclerosis and a subepithelial immune-type deposit. Partial fasciectomy and a course of methotrexate resulted in overall functional improvement of his extremities. Proteinuria and hematuria was reduced during methotrexate therapy.

Mortality studies in systemic lupus erythematosus. Results from a single center. II. Predictor variables for mortality

OBJECTIVE

To analyze the factors associated with mortality in patients with systemic lupus erythematosus (SLE), followed prospectively in a single center.

METHODS

The study included 665 patients with SLE followed over a 20-year period according to a standard protocol. Clinical laboratory information has been entered into a database. Univariate analysis was carried out to identify prognostic factors of death. The Cox proportional hazard regression model was used to estimate risk ratio of death.

RESULTS

Renal damage, thrombocytopenia, lung involvement, systemic lupus erythematosus disease activity index (SLEDAI) > or = 20 at presentation, and age > or = 50 at diagnosis were predictive factors for mortality in the univariate as well as in the multivariate analyses. Hypertension and ischemic heart disease were significantly associated with death only in the univariate analysis.

CONCLUSION

Renal damage, thrombocytopenia, SLEDAI > or = 20 at presentation, lung involvement, and age > or = 50 at diagnosis are prognostic factors associated with mortality.

Mortality studies in systemic lupus erythematosus. Results from a single center. I. Causes of death

OBJECTIVE

To study the causes of death in patients with SLE, followed prospectively in a single center.

METHODS

The study population comprised 665 patients with systemic lupus erythematosus (SLE). Causes of death were determined by review of hospital files, autopsy reports, and death certificates. Nonparametric lifetable models were used to calculate Kaplan-Meier estimates of survival probabilities.

RESULTS

One hundred and twenty-four patients (18.6%) had died. The primary causes of death were active SLE in 20 (16%), infection in 40 (32%), acute vascular event in 19 (15.4%), sudden death in 10 (8.1%), organ failure in 6 (4.8%), malignancy in 8 (6.5%), others in 8 (6.5%), and unknown in 13 (10.5%). Death as a result of active SLE was more common in patients who died within 5 years of diagnosis compared to those dying after 5 years (p = 0.021), and deaths due to vascular events and end organ failure not related to active lupus were more frequent in the late death group (p = 0.028). The overall 5, 10, 15, and 20 year survival rates were 93, 85, 79, and 68%, respectively. Patients with SLE had a 4.92 fold increased risk for death compared with the general population.

CONCLUSION

Survival rates continue to improve in SLE but causes of mortality vary at different stages.

Does injectable gold retard radiologic evidence of joint damage in psoriatic arthritis?

The aim of this investigation has been to assess whether gold therapy prevents radiologic progression of psoriatic arthritis (PsA) over a period of 2 y. Eighteen patients (11 males, 7 females, mean age 42 y, DD 6.5 y) who were initiated on intramuscular gold during their attendance at the Psoriatic Arthritis Clinic were studied. For each gold-treated patient, 2 matched control patients, who had never had gold therapy, were identified from the PsA database. The control patients were similar to the patient population in gender, age, disease duration, number of actively inflamed joints, radiologic score and other medications used, and were followed in the clinic for at least 24 months. Actively-inflamed joint count decreased by > or = 40% in 9 of 18 gold-treated patients at 12 months. Seven patients continued gold for 24 months, while 11 discontinued gold for either lack of efficacy (4) or side effects (7). A comparison of the change in radiographic evidence of damage in the peripheral joints between the 18 gold-treated patients and the 36 controls revealed that there was no statistical difference in disease progression. These results suggest that gold therapy does not prevent the progression of damage in patients with psoriatic arthritis.

Sequential protocol biopsies in renal transplant patients. Clinico-pathological correlations using the Banff schema

Twenty-five renal transplant patients on a triple immunosuppressive regimen of cyclosporine, azathioprine, and prednisone underwent protocol graft biopsies at 1, 2, 3, 6, and 12 months after transplant regardless of renal function. The histological diagnosis was made with the Banff schema. As reported previously, protocol biopsies revealed a high prevalence of subclinical rejection, as well as "borderline" inflammation, despite levels of CsA considered to be in the therapeutic range. Every biopsy was given a score for the severity of the histological changes (the Banff Score for Inflammatory Changes [BSI]), which permitted the generation of a cumulative BSI over the year of follow-up for each patient. At the end of 1 year, normal histology and excellent renal function (mean serum creatinine < 110 mumol/L) were seen only in transplant patients with the lowest cumulative BSI (P < 0.001). These results suggest that repeated inflammation in the renal allograft, even if subclinical, can lead to its dysfunction. Moreover, it would appear that, at least for the present, protocol biopsies may be required to assess adequately the effectiveness of current immunosuppressive therapies in renal transplant patients.

Longterm methotrexate therapy in psoriatic arthritis: clinical and radiological outcome

OBJECTIVE

To determine whether methotrexate (MTX) therapy for 24 months prevents progression of radiographic damage in psoriatic arthritis (PsA).

METHODS

Patients who were given MTX during their attendance at the psoriatic arthritis clinic were enrolled in the study. Patients who had never had MTX and who were matched by damage, actively inflamed joints, sex, and disease duration were identified from the PsA database as controls. The outcome measure was increase in the number of damaged joints.

RESULTS

The study population comprised 38 patients (16 F, 22 M) with a mean age of 44.6 years and disease duration of 11.4 years. Twenty-three patients continued therapy for 24 months. Clinical evaluation revealed that 45% of the patients had > or = 40% improvement in actively inflamed joint count at 6 and 24 months. Radiographs were available for 19 of the 23 patients who took MTX for 24 months, and they were compared to their respective controls. Radiographic damage scores at 24 months showed an increase in the damage score in 63% of the patients. Compared to the matched controls, there was no statistically significant difference in the progression in damage.

CONCLUSION

Our results suggest that compared to other regimens, MTX conferred no advantage with respect to clinical response or longterm damage even after 24 months of therapy.

Antineutrophil cytoplasmic antibodies in systemic lupus erythematosus

OBJECTIVE

To evaluate the prevalence of cytoplasmic (c) and peripheral (p) antineutrophil cytoplasmic antibodies (ANCA) using the indirect immunofluorescence (IIF) slide kit (INOVA) in patients with systemic lupus erythematosus (SLE) to correlate the presence of ANCA with disease activity and to determine if ANCA is associated with specific clinical manifestations.

METHODS

One hundred and fourteen consecutive patients with SLE seen at The Wellesley Hospital Lupus Clinic, Toronto, Ontario in May and June, 1992 were assessed clinically, and blood drawn for routine serology and ANCA. Disease activity was measured using the SLE Disease Activity Index (SLEDAI). ANCA was measured by IIF.

RESULTS

Of the 114 patients, 12 (10.5%) had c-ANCA and 29 patients (25.4%) had p-ANCA. The titers of ANCA varied from 1:20 to 1:160. SLEDAI was 0 in 6 patients (5%), and 108 patients had some disease activity. Eighty-eight patients (77%) had mild to moderate active disease (SLEDAI < 10), and 20 (18%) patients had severe active disease (SLEDAI > or = 10).

CONCLUSION

No correlation was found between the presence of ANCA and SLEDAI either when analyzed as active-inactive (p = 0.75) or when correlated with degrees of disease activity (1-10: > 10) (p = 0.77). No correlation was found between p and c ANCA and the presence of vasculitis, renal, or CNS disease at the time of the assessment or at any time during the course of the disease. Thus ANCA was not associated with SLE disease activity or the presence of vasculitis in SLE.

Familial nephropathic systemic amyloidosis caused by apolipoprotein AI variant Arg26

A point mutation in the apolipoprotein AI (apoAI) gene causing autosomal dominant non-neuropathic systemic amyloidosis is described in a previously unreported Canadian family of British origin with five affected individuals in three generations. Amyloid deposits in the renal biopsy from the proband, a 31-year-old female presenting with hypertension and renal failure, stained immunospecifically with antiserum to apoAI. The plasma of all family members with amyloidosis contained both wild-type apoAI and a variant bearing one additional positive charge. Sequencing of the apoAI gene demonstrated that the proband was a heterozygote for a single base substitution in exon 3, changing codon 26 from GGC(Gly) to CGC(Arg). Concordance of the mutant allele with the presence of variant plasma apoAI and clinical features of amyloidosis was demonstrated. This is the third family in which this amyloidotic mutation has been described, but the distribution of amyloid deposits and their clinical effects are clearly determined by other genetic and/or environmental factors.

Loss of anionic sites on the glomerular basement membrane in transplant glomerulopathy

We studied anionic sites on the glomerular basement membrane in patients with chronic renal transplant rejection having clinical and histological features of transplant glomerulopathy. All patients had significant proteinuria (greater than 1 g/24 h as well as light- and electron-microscopic features very like focal segmental glomerulosclerosis, though no patient had that disease in the native kidney. A significant reduction in the density and absolute number of anionic sites was observed compared with controls and with patients having stable graft function. The findings suggest that the loss of anionic sites may play an important part in the pathogenesis of transplant glomerulopathy.

Histological findings in early routine biopsies of stable renal allograft recipients

Seventy renal allograft biopsies were done in 31 patients, routinely at 1, 2, and 3 months posttransplant, and as clinically indicated, using an automated biopsy "gun." The histological diagnosis was made according to the Banff schema, which emphasizes tubulitis and vascular inflammation over mononuclear cell infiltration. Fifty-three biopsies satisfied histological inclusion criteria. Twenty-nine biopsies were obtained from stable patients, defined as those in whom serum creatinine had changed < 10% in 2 weeks, and in whom immunosuppression (cyclosporine, azathioprine, and prednisone) had not been increased in that interval. Of these biopsies, 30% (9/29) showed rejection, which could not have been predicted from pretransplant (HLA mismatch, panel-reactive antibody titer) or posttransplant (cyclosporine and serum interleukin 2 receptor levels) variables. The significance of these early subclinical rejection episodes is unknown, and their effects on long-term graft histology and function are being examined in a controlled study.

Inflammatory pseudotumor of the liver in a patient with chronic sclerosing cholangitis

Inflammatory pseudotumor of the liver (IPL) is a rare fibro-inflammatory mass of unknown etiology, resembling a neoplasm. We report the occurrence of such a lesion in a young male Cambodian refugee to Canada who had a history of chronic cholangitis. Imaging studies suggested an intrahepatic abscess. Our report suggests that the lesion in this patient may have resulted from chronic portal pyemia.

Cross-infection by non-encapsulated Haemophilus influenzae

From October, 1988, to January, 1989, 18 patients admitted to an acute medical chest ward were infected with an ampicillin-resistant beta-lactamase-producing strain of Haemophilus influenzae. All 18 isolates were non-encapsulated strains of biotype III and showed identical cell envelope protein profiles, as judged by sodium dodecyl sulphate-polyacrylamide gel electrophoresis. The organism was not isolated from repeated environmental samples but there was strong circumstantial evidence that a spirometer was a common iatrogenic source of the cross-infection.