[Cholestasis after antiarrhythmic therapy with propafenone]

Propafenone, three times 150 mg/d over 33 days and two years later at the same dosage over six days, was administered to an 84-year-old man with ventricular extrasystoles (Lown IVa). Both times intrahepatic biliary stasis occurred, presumably a sign of a drug-allergic hepatitis. All other possible causes in the differential diagnosis were excluded. The lymphocyte transformation test demonstrated in vitro propafenone-sensitive patient-lymphocytes.

Epidemiology of primary biliary cirrhosis

A multi-national survey of the clinical and epidemiological aspects of primary biliary cirrhosis (PBC) has been conducted in 10 countries in Western Europe, surveying a population of over 24 million. The prevalence on 31 December, 1981 was 23/million, but this showed a marked variation from centre to centre for reasons which are not clear. The annual incidence of PBC has remained constant at about 4/million over the past 4 years, while the point prevalence has continued to rise, suggesting that the true prevalence may be rather higher than present figures suggest. The female: male sex ratio is 10:1, but in stages I & II this ratio is 6.5:1 compared with 11.4:1 in stages III & IV. Possible reasons for this are discussed.

Immunosuppressive serum factors in viral hepatitis. III. Prognostic relevance of rosette inhibitory factor and serum inhibition factor in acute and chronic hepatitis

Two immunosuppressive serum factors, serum inhibition factor (SIF) and rosette inhibitory factor (RIF), were studied in sera from patients with acute and chronic viral hepatitis. In a study of 30 patients with acute viral hepatitis, an association was found between RIF, SIF, and biochemical and virological parameters in 27 patients (90%), 25 of whom recovered completely; two had a protracted course. In three patients, the clinical course was not reflected by the immunosuppressive factors. In 26 patients with chronic persistent hepatitis, 3 had RIF and 7 had SIF of low activity. In patients with HBsAg-positive and -negative chronic active hepatitis, 32 of 47 had RIF and 24 had SIF. SIF activity was significantly increased in HBsAg positive as compared to -negative cases. There was no correlation between RIF and SIF activity at any stage of viral hepatitis. Although SIF was demonstrated in patients with various infectious and other inflammatory diseases, RIF was infrequently detected in nonviral liver disorders, and was not present in any of the nonhepatic diseases tested. It was confirmed that RIF is associated with the beta-lipoprotein fraction. RIF was easily separated from SIF by density gradient ultracentrifugation. The evaluation of SIF and RIF may be helpful in determining the outcome of acute viral hepatitis. In chronic hepatitis, RIF was a better indicator of disease activity than was SIF. These clinical data support previous findings that SIF may be related to the immune response whereas RIF is associated with liver cell damage.

Immunoenhancing effect of flavonoid compounds on lymphocyte proliferation and immunoglobulin synthesis

Flavonoid compounds are lipophilic agents which can interact with membrane lipids and may affect responsiveness of immune cells. We therefore studied whether cianidanol ((+)-catechin), the O-methyl-derivative (+)-3-methoxy-5,7,3',4'-tetrahydroxyflavan and palmitoyl-derivative (+)-3-palmitoyl-5,7,3',4'-tetrahydroxyflavan influence T and B cell functions. In addition, immunomodulatory property of ubiquinone 50 was also investigated. As controls were used cyclosporin A and inosine which are known to inhibit or enhance immune responses, respectively. The in vitro spontaneous, antigen and mitogen induced proliferation as well as immunoglobulin synthesis of peripheral blood mononuclear cells from healthy individuals was determined in the presence of different concentrations of the agents. All flavonoid compounds and ubiquinone 50 significantly increased (p less than 0.05 - less than 0.01) the spontaneous lymphocyte transformation but hardly affected antigen, alloantigen and mitogen induced proliferative response. Only cianidanol and O-methyl-derivative enhanced significantly (p less than 0.05 - less than 0.01) spontaneous, pokeweedmitogen and Staphylococcus aureus Cowan I induced immunoglobulin synthesis while the palmitoyl-derivative and ubiquinone 50 had only minor influence on B cell function. In contrast, Staphylococcus aureus induced immunoglobulin production was neither increased by inosine nor suppressed by cyclosporin A. These studies show that especially cianidanol and the O-methyl-derivative can exert an immunoenhancing effect on T and B cell functions.

Anti-actin antibodies of IgM and IgG class in chronic liver diseases detected by fluorometric immunoassay

Using a sensitive fluoroimmunoassay, anti-actin antibodies (AA) of the IgM and IgG classes were measured in 240 patients with various chronic liver diseases and in 211 patients with non-hepatic autoimmune muscle, heart, malignant and inflammatory bowel diseases. Thirty-two out of 40 patients (80%) with autoimmune chronic active hepatitis (CAH) had AA only of the IgG class (geom. mean X = 1.78, SEM +/- 0.07) and only three patients (8%) had both IgG and IgM AA, the latter in lower titres. In patients with primary biliary cirrhosis (PBC) and AMA-positive cholestatic CAH, AA of both IgM and IgG classes were equally represented (60% IgG and 64% IgM AA in PBC, 73% IgG and 51% IgM AA in cholestatic CAH) but the titres were very low (geom. mean IgG AA in PBC 1.035, SEM +/- 0.03, in cholestatic CAH 1.18, SEM +/- 0.02). In contrast to autoimmune (lupoid) CAH, AA were rare in HBsAg positive CAH (9/43, 21%) and only present in low titres. However, in six out of 21 patients with anti-HBs and anti-HBc-positive chronic active hepatitis, high AA of IgG class were found, suggesting the autoimmune type of liver disease. In NANB virus-induced chronic liver disease after blood transfusion, AA were only occasionally found (IgG antibodies 1/19, IgM antibodies 3/19) and none were found in the eight patients with sporadic NANB hepatitis. They were also rare in 30 patients with alcoholic liver disease (3/30, 10%).(ABSTRACT TRUNCATED AT 250 WORDS)

Use of ATPase-associated antigen (M2) for detection of antimitochondrial antibodies in primary biliary cirrhosis by fluorometric immunoassay

An indirect binding assay, the fluorometric immunoassay (FIAX), was established for the detection of anti-M2 antibodies which are specific markers for primary biliary cirrhosis (PBC). Submitochondrial particles (SMP) from beef heart and rat liver and the ATPase-associated antigen (M2) were used. The antigens were fixed to a cellulose acetate surface, SMP at a concentration of 2 mg/ml, ATPase at a concentration of 0.2 mg/ml. Sera were used at 1:60 and 1:120 and bound antimitochondrial antibodies (AMA) were demonstrated by fluorescent isothiocyanate labelled monospecific anti-human IgG, IgM and IgA antibodies. The fluorescent signals were proportional to the AMA titre in the serum samples and were measured in a fluorometer (FIAX 100). Of 94 patients with PBC, 92 had AMA against SMP from beef heart compared with 76 in the complement fixation test (CFT) and 84 in the immunofluorescence test (IFL). Ninety reacted with the ATPase-associated M2 antigen. Sera from patients known to have AMA of different specificities (anti-M1, anti-M3, anti-M5, anti-M6) reacted with SMP from beef heart and/or rat liver but not with M2.

Biological and immunological characterization of a human liver immunoregulatory protein

The liver immunoregulatory protein (LIP) was originally characterized as human liver-derived soluble factor which inhibited the alloantigen and phytohemagglutinin-induced proliferation of human lymphocytes (1). Soluble extracts prepared under the same experimental conditions from kidney, spleen, heart, lymph nodes, and erythrocytes did not exert any inhibitory activity (2). The purpose of this study was to characterize the immunobiological properties of LIP. In the primary one-way mixed lymphocyte culture, LIP depressed the generation of suppressor T cells which inhibited the lymphocyte proliferation induced by phytohemagglutinin or alloantigens. In addition, LIP suppressed in primary mixed lymphocyte culture the induction of cytotoxic T cells and memory cells as determined by cell-mediated lympholysis and secondary mixed lymphocyte culture, respectively. In the presence of LIP, the concanavalin A-mediated induction of suppressor T cells, the pokeweed mitogen-induced IgG synthesis in vitro and the cytolytic activity of K cells reacting in the antibody-dependent cell-mediated cytotoxicity were also inhibited. Cytotoxic effects could be excluded since the viability of human lymphoblastoid cells, hepatocytes, and allogeneically stimulated lymphocytes was not affected by LIP. LIP was shown to be different from other liver-derived substances like acute phase proteins, immunoregulatory alpha-globulins, C-reactive protein, lipoproteins, and F antigen. Furthermore, LIP is not identical to other serum components like the immunoregulatory rosette inhibition factor and the serum inhibitory factor (3). However, the characteristics described herein strongly indicate that LIP is very similar to the liver extract described by Chisari (4) and the liver-derived inhibitory protein (LIP) described by Grol and Schumacher (5).(ABSTRACT TRUNCATED AT 250 WORDS)

[Lung edema after administration of hydrochlorothiazide. A rare and life-threatening side effect]

Recurrent pulmonary oedema occurred in a 62-year-old woman after repeated intake of hydrochlorothiazide-triamterene tablets. Eight similar reports in the medical literature suggested it to be a rare case of intolerance to hydrochlorothiazide. The lymphocyte transformation test proved an allergic genesis: there was significant stimulation of patient lymphocytes by active agent/metabolite serum of hydrochlorothiazide but not triamterene.

Immunosuppressive serum factors in viral hepatitis. II. Further characterization of serum inhibition factor as an albumin-associated molecule

Immunosuppressive factor(s) in sera from patients with acute viral hepatitis B [serum inhibition factor(s) (SIF)] which functioned like an antiactivator of lymphocytes were further characterized and purified. The active moiety could be separated from immunoglobulins and other serum proteins by means of gel filtration, anion exchange, and affinity chromatography. The major SIF activity always copurified with albumin. Affinity chromatography with Cibacron blue agarose matrix followed by elution with 2 M NaCl proved an optimal procedure to obtain SIF-positive albumin fractions. The SIF moiety could be dissociated from albumin by use of 5 M NaCl or 6 M urea and was separated from protein by sequential molecular filtration and G-10 gel filtration indicating a low molecular weight substance. SIF activity of lower degree could also be detected in albumin-containing fractions derived from normal sera and exhibited similar biochemical properties as the factor which was isolated from patients' sera. The purified SIF fractions could not be stained with various protein dyes after sodium dodecyl sulfate-polyacrylamide gel electrophoresis. The active moiety was partially extractable with chloroform:methanol indicating a lipophilic nature. Common fatty acids or bile acids were excluded as causative factors by gas chromatographic-mass spectrometric and radioimmunologic analyses. These data suggest that the SIF effect is caused by an albumin-associated low molecular weight lipid or lipophilic peptide. SIF may be physiological immunoregulatory products of the immune system which are probably produced in response to a viral antigenic stimulus.

Immunosuppressive serum factors in viral hepatitis. I. Characterization of serum inhibition factor(s) as lymphocyte antiactivator(s)

Sera from patients with acute viral hepatitis B were found to inhibit the in vitro proliferation of normal lymphocytes induced by different mitogens and antigens. In addition, an effect on concanavalin A-induced T suppressor cell activity and pokeweed mitogen-stimulated IgG and IgM synthesis was demonstrated. Studies concerning the kinetics of serum immunosuppressive effects indicated that serum immunosuppressive factor (SIF) interfered with the intermediate phase of mitogen-induced lymphocyte activation which was defined by protein and RNA synthesis. Thus, when SIF-positive sera were added to lymphocytes, which were already activated by phytohemagglutinin, for 8, 12, or 18 hr, the inhibitory effect decreased in relation to the duration of lymphocyte activation. No inhibition could be demonstrated when SIF-positive sera were added 24 hr after initiation of mitogen stimulation. Furthermore, similar inhibitory effects were found measuring either uptake of [3H]uridine (RNA synthesis) or [3H]leucine (protein synthesis) in a 24 hr culture of phytohemagglutinin-stimulated lymphocytes or [3H]thymidine uptake (DNA synthesis) after 48 hr. These results indicate that SIF act(s) like an antiactivator and may belong to immunoregulatory physiologic serum factors.

Immune reactions in infective endocarditis. II. Relevance of circulating immune complexes, serum inhibition factors, lymphocytotoxic reactions, and antibody-dependent cellular cytotoxicity against cardiac target cells

Circulating immune complexes (IC) were detected in 35 out of 41 patients (85%) with infective endocarditis of known bacterial origin in contrast to only 9 out of 20 patients (45%) with endocarditis but negative blood cultures (p less than 0.05). Peak IC levels of 33.25 +/- 24.33 micrograms/ml in the early period fell significantly to 8.38 +/- 13.37 micrograms/ml after antibiotic treatment (p less than 0.001). High levels of IC coincided with relative hypocomplementemia. Erythrocyturia was observed in 51 of 58 IC-positive patients demonstrating peripheral sequelae of circulating IC. Incidence and concentrations of IC correlated neither with the mere presence of the rheumatoid factor nor with the titers of antimyolemmal antibodies, nor with antibody mediated cytolysis in the presence of complement. Serum inhibition factors (SIF) and E-rosette inhibitory factors (RIF) were not demonstrated, indicating that IC in endocarditis do not suppress phytohemagglutinin-induced lymphocyte proliferation or the E-rosetting of T cells. Significant lymphocytotoxicity against heterologous cardiac target cells without serum (LC) could be demonstrated in 11 out of 23 patients (48%) with endocarditis as compared to its absence in controls (n = 33, p less than 0.01). In assays of antibody-dependent cellular cytotoxicity (ADCC), either enhancement or blocking of lymphocytotoxicity by autologous serum or both was observed. The modulation of lymphocytotoxicity was most likely due to antimyolemmal antibodies, to IC, or to both, although effects of other serum factors cannot be ruled out completely.

Myasthenia gravis: overlap with 'polyendocrine' autoimmunity

81 patients with spontaneously acquired myasthenia gravis (MG) were investigated for the presence of autoimmune (AI) diseases and their sera were tested for a range of organ-specific autoantibodies. 77 of the patients were HLA-phenotyped. Antibody titres to acetylcholine receptors (AChR) were higher in non-thymomatous patients who possessed HLA-B8 (p less than 0.05) and/or -DR3 (p less than 0.05) as compared to patients lacking these HLA antigens. 3 out of 20 (15%) patients with ocular MG, 7/23 (30%) with generalized MG of early onset, 11/23 (48%) generalized MG of late onset and 5/14 (35%) patients with thymoma had either overt AI diseases or significant titres of organ-specific autoantibodies suggesting subclinical AI disease. In ocular MG, low titres and an infrequent finding of antibodies to AChR (32%) as well as the low prevalence of associated autoantibodies and AI diseases indicate that this subgroup of MG consists of patients with restricted AI reactivity. HLA-B8 and -DR3 were present in all the patients with associated AI disorders in the young onset group but in none of the patients with old age of onset. In the young group, 6 out of 7 patients with associated AI conditions were women whereas the sex ratio was about equal in the older cases in both, patients with and without associated AI diseases or autoantibodies. We conclude from these observations that ageing provides conditions that allow the breakdown of self tolerance. The simultaneous presence of HLA B8, DR3 and female sex provide important additional factors for early expression of MG.

Chronic active hepatitis in childhood with detection of liver-pancreas-specific autoantibodies

This paper describes a special form of chronic active hepatitis (CAH) with hypergammaglobulinemia in a ten-year-old girl. Because of unclear symptoms she was admitted to our hospital for exclusion of leukemia. However, further clinical and laboratory investigations suggested an autoimmune hepatitis although the typical antibodies could not be found in the immunofluorescence test. Only the detection of liver-pancreas-specific, complement-fixing autoantibodies (LP-antibodies) confirmed the diagnosis of an autoimmune hepatitis. Histology showed typical infiltrations of plasma cells and lymphocytes in the periportal area. LP-antibodies had been recently described in 20 adults with HBs-Ag-negative CAH[6]. To our knowledge this is the first report on LP-positive hepatitis in childhood. As a therapeutic response is likely, early immunosuppressive treatment is indicated.

ATPase-associated antigen (M2): marker antigen for serological diagnosis of primary biliary cirrhosis

Serum samples from 94 patients with primary biliary cirrhosis (PBC) and 17 patients with chronic cholestatic hepatitis (CCH) were tested in the fluorometric immunoassay (FIAX) against the nonorgan-specific ATPase-associated antigen (M2) and against submitochondrial from beef heart and rat liver, to evaluate the specificity and sensitivity of the M2 antigen for the diagnosis of PBC. As controls serum samples from 42 patients with other antimitochondrial antibody (AMA) specificity (against M1, M3, M5, and M6) as well as samples from 417 patients with various other hepatic and non-hepatic disorders were used. Serum samples from 91 of the 94 PBC patients (97%) and all 17 with CCH reacted with the M2 antigen. However, when SMP from rat liver and beef heart were tested in parallel in the FIAX, AMA could be detected in all PBC serum samples. None of the 42 patients with different types of AMA had reactions with the M2 antigen but all had reactions with SMP from rat-liver or beef-heart mitochondria or both. Among the other 417 patients with hepatic and non-hepatic disorders only 4(1%), all with collagen diseases, had anti-M2 antibodies.

Mitochondrial antibodies in primary biliary cirrhosis. VI. Association of the complement fixing antigen with a component of the mitochondrial F1-ATPase complex

The complement fixing antigen of the inner mitochondrial membrane previously shown to be associated with the mitochondrial ATPase could be further purified by subjecting the ATPase extracted from beef heart and brown fat mitochondria to ion exchange and gel filtration chromatography. Although the ATPase activity could be clearly dissociated from the complement fixing activity, subunits of the F1-ATPase complex were always found in the purified fractions. The alpha, gamma, delta and epsilon subunits of the complex could be excluded with high probability as target antigens in contrast to the beta band which was always found in association with the antigen activity. These findings imply that the active centre of the ATPase enzyme is not involved in the antibody reaction but molecules of the ATPase complex may have antigen binding capacity. Treatment of ATPase associated antigen with trypsin did not markedly affect the complement binding, while SMP's treated in the same way lost their antigen activity indicating that sera from patients with primary biliary cirrhosis (PBC) may have mitochondrial antibodies of different specificities reacting with trypsin sensitive as well as trypsin insensitive components of the inner membrane. The purified antigen reacted exclusively with sera from patients with PBC and may be therefore used as a marker antigen.

Immunological and clinical characterization of patients with untreated euthyroid and hypothyroid autoimmune thyroiditis. Antibody spectrum, response to TRH and clinical study

In a region of endemic goitres, 200 untreated patients in whom thyroid microsomal (MCHA) and/or thyroglobulin (TGHA) antibodies have been detected were analyzed and other organ specific autoantibodies were tested. Thyroid function was assessed by a TRH test in all of them. Patients with previous thyroid disease and patients with clinical or biochemical signs of thyrotoxicosis were excluded. In 58 (29%) of the patients diseases coexisted in which a high incidence of autoimmune reactions has been recognized. In the absence of the corresponding clinical disease, 13.7% of the patients had antibodies to parietal cells of the stomach, 3.1% had antibodies to adrenal cortex, 1% to steroid producing gonadal cells, 1% to pancreatic islet cells, and 0.5% of the patients had antibodies to striated muscle fibrils. The incidence of associated organ-specific autoantibodies was no higher in patients with hypothyroidism (34.6%) compared with patients who had a normal thyroid function (27.9%). The determination of a 'significant' thyroid antibody titre is discussed. In 24.5% of the 200 patients a form of hypothyroidism was recognized. Fifty of the patients with TGHA titres greater than or equal to 6400, and 56.2% of those with MCHA greater than or equal to 102 400 were hypothyroid. Patients with such titres of thyroid antibodies should be examined and followed up. Patients with associated islet cell or adrenal antibodies should be reinvestigated and followed up observing their glucose tolerance and adrenocortical function, respectively.

Diagnostic relevance of humoral and cell-mediated immune reactions in patients with acute viral myocarditis

Sera of 177 patients with acute myocarditis (10 coxsackie B 3/4, four influenza, four mumps, 15 cytomegalovirus, 144 undefined) were tested by indirect immunofluorescence for autoantibodies against heart and skeletal muscle and vital or air-dried adult cardiocytes. Antibody-dependent cytolysis, lymphocytotoxicity and antibody-dependent cellular lymphocytotoxicity were assessed using viral adult rat cardiocytes as target cells. Muscle-specific anti-sarcolemmal antibodies of the anti-myolemmal type--often associated with non-organ-specific anti-endothelial antibodies--were demonstrated in nine out of 10 patients with coxsackie B, in all patients with influenza and mumps and in 65 out of 144 patients with undefined myocarditis. In contrast, 13 out of 15 patients with cytomegalovirus myocarditis lacked anti-sarcolemmal antibodies but had low titre anti-inter fibrillary antibodies instead. In the presence of complement, anti-myolemmal antibodies induced cytolysis of vital cardiocytes, whereas hepatocytes remained unaffected. Titres of anti-myolemmal antibodies correlated with the degree of cardiocytolysis. The anti-myolemmal immunofluorescent pattern and the cytolytic serum activity could be absorbed with the respective viral antigens suggesting that these antibodies cross-react with moieties of the virus itself and may be both diagnostic and aetiological markers in acute viral myocarditis. Lymphocyte-mediated cytotoxicity against heterologous cardiac target cells could not be observed in our patients with myocarditis of proven viral aetiology. However, lymphocyte-mediated cytotoxicity was demonstrated in 10 ASA-positive and one ASA-negative patient with myocarditis of unknown origin. ASA-positive sera blocked lymphocytotoxicity in three of these patients.

Natural course of primary biliary cirrhosis. I. A morphological, clinical and serological analysis of 103 cases

Clinical, biochemical and serological data obtained in 103 patients with primary biliary cirrhosis (PBC) were analysed with respect to the four defined morphological stages. Evaluation of the initial biopsies (99 needle biopsies/4 wedge biopsies) revealed that most patients were in stage I (focal bile duct destruction). Unequivocal distinction between stages I and II was possible in most cases, while considerable overlapping of criteria was observed in stages II to IV. Morphological cholestasis, a characteristic sign of stage IV was already found in 7% of PBC I cases. Four out of 12 autopsy specimens showed micronodular biliary cirrhosis (Hanot's type) and eight specimens had a macronodular type of biliary cirrhosis. No predominant clinical symptoms were found in patients with PBC I or II, but pruritus was observed in about 30%. Increased serum alkaline phosphatase (AP) and IgM levels as well as a positive antimitochondrial antibody (AMA) test were typical features of all stages in up to 80-90%, but patients with normal AP or IgM or negative AMA have been observed, especially in stages I and II. Five of 57 patients at stage I had increased bilirubin levels and in three patients IgM and IgG were simultaneously elevated in stage I. The natural course of PBC, as it is reflected in histological staging, was studied in 30 patients in whom biopsies were regularly taken over a period of 2-18 years. About 80% of PBC I-cases lasted between 1 and 7 years before reaching stage II, while another 5-10 years were necessary for the development of stage III-IV. Thus it appears that in the vast majority of patients PBC lasts about 10-15 years and in some instances even more than 20 years. The finding in stage I and II of normal AP indicates a benign course, while morphological and biochemical cholestasis seems to be associated with a rather progressive course.

Development of adrenocortical failure in non-Addisonian patients with antibodies to adrenal cortex. A clinical follow-up study

Out of 1036 sera tested for the presence of antibodies to adrenal cortex using the indirect immunofluorescence (IFL) method, fifteen out of 323 patients with Graves' thyrotoxicosis, 6/105 Hashimoto's thyroiditis, 3/29 myxoedema, 2/49 asymptomatic autoimmune thyroiditis, 1/12 subacute thyroiditis, and 4/130 with myasthenia gravis were positive. Thirty antibody-positive non-addisonian patients were tested for subclinical adrenocortical failure and followed up over a period of 1-3.5 years. Three women with Graves' disease had biochemical signs of early Addison's disease at the first Synacthen test. Two young women with controlled Graves' thyrotoxicosis developed a diminished adrenocortical reserve within 2 and 3 years, respectively; one of them developed anovulatory cycles which did not respond to clomiphene treatment. Both patients had high titres of complement-fixing adrenal antibodies before the adrenal failure could be recognized by functional tests. One elderly female patient in whom a euthyroid goitre with adrenal and thyroid antibodies was detected in 1977, developed Graves' thyrotoxicosis in 1980. These observations indicate that antibodies to adrenal cortex have a high clinical significance and may allow the early diagnosis of Addison's disease even in the absence of specific clinical symptoms.

[Propafenon-induced cholestatic liver injury--a further example for allergic drug hepatitis (author's transl)]

In the course of cholestatic liver injury after propafenonhydrochloride medication, a high increase of the glutamatedehydrogenase up to the twenty fold of the normal range was followed by a marked raise of SGOT and SGPT. Cholestatic enzymes like gamma-glutamyl transpeptidase and alkaline phosphatase reached their maxima a week later. Within two weeks the hepatic cell enzymes and within four weeks the cholestatic enzymes have returned spontaneously to normal.

Assessment of antibody mediated cytolysis of adult cardiocytes isolated by centrifugation in a continuous gradient of Percoll in patients with acute myocarditis

Principal objections to conventional cytotoxicity assays in cardiac disease with myocytes as target cells are the use of fetal or neonatal myocardium, the cell-membrane of which does not express all antigenic determinants, and the use of trypsin as enzyme for isolation of the cells, since this alters the myolemmal membrane considerably. An improved and rapid procedure for the isolation of intact adult cardiocytes with collaggenase was developed. by means of a performed continuous self-generating silica sol and gradient centrifugation average enrichment of 81% vital myocytes was achieved by a single isopycnic procedure. The yield was improved to 94 +/- 3% vital cells by identical second centrifugation. Cardiocytes isolated by this method were used as target cells in an assay measuring the cytolytic activity of antibodies in the presence of complement: sera of patients suffering from acute viral myocarditis (Coxsackie B- and influenza-virus) with complement fixing antisacrolemmal antibodies (ASA) of the IgG- and IgM-type showed significant cardiocytolysis. ASA are postulated to play a role in the pathogenesis of acute Coxsackie B- and influenza-virus myocarditis.

Serological classification of chronic cholestatic liver disease by the use of two different types of antimitochondrial antibodies

Clinical and morphological features in fifteen patients with chronic cholestatic liver disease (mixed form) who had two different types of complement-fixing antimitochondrial antibodies were compared with those found in twenty-five patients with classic primary biliary cirrhosis (PBC). PBC-specific antimitochondrial antibody (M2) directed against an antigen of the inner mitochondrial membrane was always present in both groups. However, mixed-form cases had a second antimitochondrial antibody (M4) which fixed complement with a trypsin insensitive antigen probably located on the outer membrane. Histological lesions typical of chronic active hepatitis, often associated with granulomata formation and bileduct proliferation, and simultaneous increases in IgM and IgG were predominant features, indicating that these mixed-form cases may represent a separate clinical entity.

[Immune reactions in pseudo-lupus-syndrome. A long-term study (author's transl)]

23 patients with proven pseudolupus-syndrome were observed over a period of five years; titers of specific antimitochondrial antibodies (AMA) were tested in a follow-up study after the last intake of Venopyronum-Dragees (VPD), a drug combination of plant glycosides, horse-chestnut extracts and phenopyrazone. Cellular immune reactions against the eliciting drug, depended on the date of the acute phase and were examined in two patients after reexposure. High titers in the acute phase decreased rapidly in most of the cases within the first six months. After reexposure with VPD, AMA rose within three days up to the five fold compared with the initial titer. Only the analgetic component of VPD, phenopyrazone, was able to induce a significant increase of AMA-titer after reexposure. A specific cellular sensitivity to this substance could be demonstrated by lymphocyte stimulation in the presence of a phenopyrazone containing drug preparation. There was no chronic course of the disease; clinical exazerbation could be observed only after new intake of the drug. The analysis of drug history shows, that other pyrazolone containing drugs may also be able to induce a pseudolupus-syndrome.

[Epidemiology and clinical aspects of non-A, non-B hepatitis (author's transl)]

Among 288 patients with acute viral hepatitis investigated between 1970 and 1976 29 (10%) had non-A, non-B hepatitis. In 9 of these 29 patients posttransfusion hepatitis was proven, the remaining 20 patients had sporadic infections. The incubation period of posttransfusion hepatitis was 2--8 weeks in 7 patients and 12 and 16 weeks in the two other patients. Transaminases changed monophasically in 22 patients, bi- or multiphasic in 7. The disease took a subicteric course in a quarter of all cases. Out of the 29 patients 17 were followed up for 2 to 7 years, one or more recurrence occurred in 9 patients, usually within the first two years after onset of the disease. Five of these 9 patients had a biphasic rise of transaminases during the acute stage. The almost complete absence of autoantibodies in the course of the acute phase might be evidence of increased suppressor cell activity favouring a chronic course. Non-organ-specific autoantibodies were only rarely observed and were completely absent in patients with posttransfusion hepatitis.

Haemagglutinating anti-actin antibodies in acute and chronic liver disease

Anti-actin antibody was measured by the passive haemagglutination test in the serum of 118 patients with various forms of chronic cholestatic and non-cholestatic liver disease, and of 23 patients with acute hepatitis B or non-A, non-B. Tanned sheep erythrocytes and electrophoretically pure actin prepared from rabbit skeletal muscle were employed; absorption tests confirmed the specificity of positive reactions, defined from healthy controls as a titre of greater than 1/80. The presence of anti-actin activity in chronic liver disease corresponded generally to the immunofluorescent demonstration of smooth muscle antibody (P<0.01). However, in acute hepatitis, with one exception (later progressing to subacute disease) raised anti-actin titres were not found. Thus, the weak smooth muscle antibody occasionally demonstrable in this condition may be neither IgM in class, nor directed against actin. Anti-actin antibody was present in significantly high titre in 54% of 37 active chronic hepatitis patients and 79% of 24 ;mixed-form' cholestatic active chronic hepatitis, as compared with only 21% of 29 primary biliary cirrhosis patients, and 11% of alcoholic liver disease. Anti-actin antibody is therefore associated with chronic autoimmune parenchymal liver damage and its appearance may mark the transition from acute hepatitis. No raised anti-actin titres were seen in 10 primary biliary cirrhosis patients positive for mitochondrial antibody by indirect immunofluorescence, but negative by the complement fixation test. This result suggests that the cytoplasmic fluorescence observed is due to low titre mitochondrial antibody rather than cytoplasmic actin and that these patients do not represent a different disease entity. The generation of anti-actin antibody in chronic parenchymal liver disease, perhaps due to unmasking or schlepping of intracellular or SIg/HLA-associated actin, may characterise autoimmune events at hepatocyte level, point to prognosis, and aid in the differential diagnosis of individual patients.

[Immunsuppressive factors in sera and synovial fluids of patients with rheumatoid arthritis (author's transl)]

Serum inhibitory factors (SIF) have been demonstrated in several infectious diseases and autoimmune disorders. Most likely, they are caused by an immune reaction, and their persistence indicates a chronic course. Sera and synovial fluids of 31 patients with rheumatoid arthritis and of 33 patients with arthrosis were therefore studied, in order to determine whether immunosuppressive factors exist only in inflammatory diseases and whether their titers correlate with the activity of the disease. PHA-induced stimulation of normal peripheral blood lymphocytes, measured as 3H thymidine uptake, in the presence of patients' serum, was related to lymphocyte stimulation observed in the presence of control sera. Using the MIF-agarose assay, the effect of sera and synovial fluids on the tuberculin-induced migration inhibition was also studied. Sera of 27 of 31 patients with rheumatoid arthritis inhibited mitogen-induced normal lymphocyte thymidine uptake and abolsihed migration inhibition, probably by blocking MIF-production. High titers appeared to predict an unfavourable course. In contrast, sera of all 33 patients with degenerative joint disease failed to exert these effects. Synovial fluids of all patients, irrespective of the nature of the underlying joint disease, did not affect lymphocyte stimulation or leukocyte migration. Other factors, such as immune complexes, cytotoxic antibodies, or drug metabolites could be excluded as potential causes of the observed effects exerted by rheumatoid arthritis sera. These results indicate that the presence of serum factors inhibiting PHA-induced lymphocyte stimulation and leukocyte migration inhibition, respectively, may be used as a diagnostic tool in the differential diagnosis of rheumatoid arthritis.

Clinical significance of immunopathological findings in patients with post-pericardiotomy syndrome. II. The significance of serum inhibition and rosette inhibitory factors

Serum inhibition factors (SIF) that suppress phytohaemagglutinin-induced blast transformation of normal lymphocytes, and lymphocyte E-rosette inhibitory factors (RIF) that inhibit the T cell-specific property of E-rosette formation were determined in sixty-five patients before and after cardiac surgery. SIF was found in the first post-operative week in almost all patients; patients with complete post-pericardiotomy syndrome (PPS) still had these factors in the fourth postoperative week. The appearance of SIF correlated well with the intensity of the PPS. Persistence of SIF in eleven out of eighteen patients with clinically incomplete PPS reaffirms the probability that they had an 'immunologically' positive PPS. RIF was to be found in one third of the patients with complete or incomplete PPS and may be of prognostic value. The two factors were not identical.

Clinical significance of immunopathological findings in patients with post-pericardiotomy syndrome. I. Relevance of antibody pattern

Sera from sixty-five patients were collected before and after cardiac surgery to determine striated muscle antibodies (anti-heart and anti-skeletal), non-organ-specific antibodies, immunoglobulin and complement levels. According to the clinical features of pericarditis, fever and leucocytosis, patients were divided into three groups: (1) complete post-pericardotomy syndrome (PPS) (n = 19) with all three symptoms; (2) incomplete PPS with two symptoms (n = 18); and (3) no PPS with one or no symtpoms (n = 28). Almost all the patients with complete PPS, two thirds of the patients with incomplete PPS and one third of the patients with no PPS showed striated muscle antibodies. Anti-sarcolemmal antibodies predominated.

In patients with complete PPS, antibodies persisted beyond the fourth post-operative week and correlated well with symptoms. An even better correlation with the syndrome could be obtained by including the post-operative occurrence of anti-endothelial (AEA), smooth muscle (SMA), the pre- and post-operative frequency of antinuclear antibodies (ANA) and the increase in immunoglobulin concentrations after surgery in an immunological grading system. These criteria permitted a redistribution of the nineteen patients with an incomplete PPS: fourteen were immunologically positive for a PPS. Although autoantibodies are predominantly associated with PPS, their role in the pathogenesis of the syndrome is not clear. The complementary influence of surgical and non-surgical factors, such as the degree of myocardial damage, the time of ischemia during the operation and a possible viral infection by blood transfusion, is analysed.

Heterogeneity of anti-mitochondrial antibodies: characterization and separation of the antigen associated with the pseudolupus erythematosus syndrome

It could be shown that anti-mitochondria antibodies (AMA) found in drug-induced pseudolupus erythematosus syndrome (PLE) had a different specificity from those found previously in primary biliary cirrhosis (PBC). The PLE antigen could be easily separated from the PBC antigen either by isopycnic sucrose density gradient centrifugation of cytoplasmic extracts (supernatant 40) or purified sonicated rat liver or kidney mitochondria. The PLE antigen was firmly membrane-bound and, in contrast to the PBC antigen, not solubilized by treatment with various salts or enzymes. The ATP-ase complex, the probable target antigen of PBC-specific antibodies, did not react with sera from patients with the PLE syndrome. There is evidence that the PLE-associated antibodies (M3) occur exclusively in patients who have been sensitized to derivatives of pyrazolone or their metabolites, indicating that PLE antibodies may be specific markers for this type of drug allergy.

The effect of distractor strength versus rate of item presentation on retention in schizophrenics

Predictions made from Chapman & McGhie's attentional dysfunction theory of schizophrenia were compared with those made from Yates' slow information processing theory. Retention in a free-recall, short-term memory task was studied with 20 chronic nonparanoid schizophrenics and 20 psychiatric controls matched on age, educational level and intelligence as subjects. Schizophrenics performed consistently poorer than controls, but no differences between groups were found as a function of either variation in distractor strength or in item presentation rate. Thus, neither theory was supported, but several uncontrolled aspects of the task variable were suggested as possible reasons for some of these conflicting findings.

Histopathological features in mixed types of chronic aggressive hepatitis and primary biliary cirrhosis. Correlations of liver histology with mitochondrial antibodies of different specificity

A histopathological study was carried out on 27 patients with chronic inflammatory liver disease and clinical and/or biochemical evidence of cholestasis who had either mitochondrial antibodies against mitochondrial antigen fractions of 1.19 density ("PBC antigen"; 14 cases) or of 1.13 density ("CAH-PBC mixed-type antigen"; 13 cases). For comparison, the liver biopsies of 17 patients with chronic-aggressive hepatitis (CAH) and antinuclear and/or anti-smooth muscle antibodies but without cholestasis and mitochondrial antibodies, were evaluated. The 14 patients with mitochondrial antibodies against the PBC antigen showed the typical histological features of primary biliary cirrhosis (PBC). The 13 patients with mitochondrial antibodies against the CAH-PBC mixed-type antigen had heterogenous liver alterations. In 11 cases highly active CAH and/or active postnecrotic cirrhosis (AC) were found both with augmented ductular proliferation. Some of these cases showed distinct criteria of PBC as early bile duct lesions or absence of regular bile ducts. The liver histology of one case corresponded to classical PBC; another case to chronic persistent hepatitis. The CAH-patients without cholestasis and mitochondrial antibodies only occasionally showed bile duct proliferation. In conclusion, a high correlation was found between mitochondrial antibodies against the CAH-PBC mixed-type antigen and highly active CAH or early AC with augmented ductular proliferation. This represents an overlapping of CAH and PBC. In contrast, the cases with antibodies reacting to the PBC antigen showed the slowly progressive liver changes of typical PBC.