Antibody activity against lipopolysaccharides, lipid A and proteins from Enterobacteriaceae in patients with chronic inflammatory liver diseases

These studies are concerned with detection of circulating antibodies against various defined enterobacterial antigens in patients with chronic inflammatory liver diseases such as chronic hepatitis type B (n = 46), chronic active hepatitis (CAH) of autoimmune type (n = 10), alcoholic cirrhosis (n = 24) and primary biliary cirrhosis (PBC) (n = 24) as well as in healthy individuals (n = 39). Anti-LPS and anti-lipid A were determined by hemolytic and hemagglutination assay. Immunoblot technique was used to investigate the antibody activity against plasmid encoded proteins from Yersinia enterocolitica. Persistent titers of anti-LPS up to serum dilution 1:32.768 were found with hemolytic and hemagglutination assay in patients with alcoholic cirrhosis or PBC and in healthy control. In contrast nearly 50% of patients with chronic hepatitis B had no hemolytic antibodies against the two LPS E. coli serotypes at the time of liver biopsy. Anti-lipid A was detectable in 58% of patients with alcoholic cirrhosis but in low titers in less than 10% in the other groups (p less than 0.001). Alcoholic cirrhosis was also associated with a high frequency of IgG and IgA antibodies against plasmid encoded proteins from Yersinia enterocolitica. The data indicate that the O-polysaccharides as strong antigens are physiologically exposed to the immune system while lipid A and enterobacterial proteins are solely immunogenic under abnormal conditions.

Liver membrane antibodies (LMA) recognize a 26-kD protein on the hepatocellular surface

Sera from 82 patients with chronic inflammatory liver diseases and from patients with systemic lupus erythematosus (SLE), rheumatoid arthritis (RA) and Hashimoto's thyroiditis were studied by immunoblotting against purified liver plasma membranes (LPM) and soluble liver protein (SLP) fractions from different species after previous separation by SDS-PAGE. Eighteen of 19 sera with LMA of IgG type in immunofluorescence assay and six LMA-negative sera (three sera from patients with RA) showed antibodies of the IgG or IgM classes against a protein with a molecular weight of 26 kD which was present in LPM and SLP fractions from rats, rabbits, pigs and humans. The reaction with 26-kD liver protein did not correlate with other known autoantibody-antigen systems. All sera were negative in the 26-kD region with liver mitochondria, liver microsomes and soluble proteins of kidney (with one exception), heart and gut from the rat. The 26-kD protein was purified by affinity chromatography on immobilized anti-26-kD protein antibodies from patients, eluted from the 26-kD band of immunoblots. Studies with purified 26-kD liver protein and with SLP as antigens after separation in two-dimensional electrophoresis confirmed that patient serum and experimental rabbit antiserum react with the same protein. Eluted patient antibodies and rabbit antisera showed a linear fluorescence pattern on isolated hepatocytes from rat and rabbit. The data indicate that one of the target antigens of LMA is a species-nonspecific 26-kD protein located on the hepatocellular surface.

Relation between Escherichia coli R(rough)-forms in gut, lipid A in liver, and primary biliary cirrhosis

Since antimitochondrial antibodies (AMA) specific to primary biliary cirrhosis (PBC) recognise enterobacterial proteins and can be induced by R(rough)-mutants of enterobacteriaceae a study was done to find out the prevalence of enterobacterial R-forms in stool samples of patients with chronic inflammatory liver diseases. Liver biopsy specimens were also examined for lipid A, a common antigenic component of the cell wall in gram-negative bacteria. In all stool samples from the 21 patients with PBC Escherichia coli R-forms constituted up to half of the total amount of E coli. In contrast E coli R-forms were detectable in the stools of only 1 healthy control (n = 20), and in 25% of patients with other cholestatic diseases (n = 10), chronic hepatitis type B (n = 15), type non-A, non-B hepatitis (n = 15), or chronic pancreatitis and fat malabsorption (n = 8). An immunoblot technique showed that E coli R-forms isolated from patients' stools contained PBC-specific AMA-reactive proteins with molecular weights of 70-80 kD and 50 kD. Deposits of lipid A, located primarily in the cytoplasm of hepatocytes, were found in 11 patients with PBC but not in the liver of patients with chronic viral hepatitis. Circulating antibodies against lipid A were found rarely and in low titres. The data support the hypothesis that intestinal enterobacterial R-forms are aetiologically important in PBC and that antigens released from the bacterial cell wall contribute to the pathogenesis of the disease.

HBcAg expressed on the surface of circulating Dane particles in patients with hepatitis B virus infection without evidence of anti-HBc formation

Circulating immune complexes composed of HBcAg and anti-HBc have been demonstrated recently in patients with hepatitis B virus replication. After dissociation of immune complexes by chaotropic ions, HBcAg was quantified radioimmunologically. In the present study, we describe 10 patients with hepatitis B virus replication, absent or delayed anti-HBc formation and exposed HBcAg in serum. Four of the 10 patients had acute hepatitis, and six patients had chronic persistent hepatitis. In seven of 10 patients, a secondary immune defect was apparent due to acquired immunodeficiency syndrome, leukemia, histiocytosis X, sarcoidosis or end-stage renal disease. Electron microscopy demonstrated that Dane particles from anti-HBc-negative patients were agglutinated after addition of monoclonal anti-HBc antibodies, whereas Dane particles from anti-HBc-positive sera did not show agglutination. Monoclonal HBsAg-specific antibodies aggregated Dane particles independent of the presence of anti-HBc. Circulating HBcAg was always associated with the Dane particle fraction after density gradient separation. Hepatitis B virus core proteins from patients with and without anti-HBc studied by immunoblotting after sodium dodecyl sulfate-gel electrophoresis showed identical patterns. Hepatocytes from anti-HBc-negative patients were positive for HBcAg but negative for immunoglobulin G by immunofluorescence technique. The data indicate that HBcAg may also be expressed on the surface of Dane particles, where it is commonly masked by anti-HBc.

Maternal weight, weight gain and birthweight at term in the rural Tanzanian village of Ilula

In an area-based study in a rural Tanzanian village, the relations of maternal weight and weight gain during pregnancy to birthweight were analysed for 331 term deliveries. The distribution of body-mass index, used as an indicator of maternal nutritional status, was similar to the pattern seen in Sweden, although mean maternal height (156 cm) was 9 cm below that of Swedish women. Mean initial weight measured at week 14 was 53 kg and total pregnancy weight gain was 6 kg. Women weighing greater than or equal to 60 kg in early pregnancy gained less weight (0.16 kg/week) than those weighing less than 50 kg (0.22 kg/week). Birthweight was correlated both with maternal weight in early pregnancy and with weight gain during pregnancy, but only 10% of the variation in birthweight was explained by these maternal factors. Mean maternal weight 24 h postpartum was equal to the weight at 14 weeks of pregnancy, implying, on the average, no net weight gain. Women with a positive net weight gain had heavier babies than women with a negative net weight gain. Maternal anthropometric characteristics are important underlying determinants of intrauterine growth and birthweight, but they explain only a minor part of the variation and are of little value for screening purposes in individual women.

A prospective area-based study of the outcome of pregnancy in rural Tanzania

A prospective area-based study on the outcome of pregnancy was carried out in the rural village of Ilula in Tanzania. A coverage of 99% (n = 719) regarding the ultimate outcome for mother and child was achieved, including deliveries that took place in hospital (9%), at the dispensary (67%) and at home (23%). There were four maternal deaths (6/1,000). The mean birth weight for singletons was 3,070 g and the low birth weight (less than 2,500 g) rate 13%. From a gestational age of 37 weeks onwards there was a definite slowing of fetal growth. Perinatal mortality rate was 82 per 1,000 born, half of the deaths occurring in low birth weight babies. Twinning occurred in 3.5% and the mean length of gestation at delivery for these pregnancies was 35.5 weeks. Twins constituted 6.8% of newborns but accounted for 23.0% of perinatal losses, making twin pregnancy a major contributor to perinatal mortality. Post-term pregnancies carried no significant increase in mortality. It is concluded that reliable area-based data on the outcome of pregnancy in Tanzania can be obtained at village level, with good coverage of the study population, by properly instructed and motivated local staff with moderate supervisory support.

Abnormalities of B cell activation and immunoregulation in patients with chronic inflammatory liver diseases

The immunoglobulin production capacities of peripheral blood lymphocytes obtained from patients with various chronic inflammatory liver diseases and from normal individuals were compared. Using a reverse hemolytic plaque assay, immunoglobulin-secreting cells (ISC) were counted immediately after isolation (immediate ISC) and again after 6-day, in vitro cultivation without stimulant (spontaneous ISC) or in the presence of pokeweed mitogen, PWM (PWM-induced ISC). An increased number of immediate ISC were observed in patients with chronic active hepatitis (CAH) of the autoimmune type (n = 7) or with CAH type B (n = 32), probably reflecting a defect of the in vivo suppressor cell system as previously demonstrated. In vitro preincubation of cells with 5 x 10(-8) M prednisolone reduced the increase in the number of immediate ISC in patients with CAH of the autoimmune type. On the other hand, lymphocytes obtained from patients with CAH-type NANB (n = 9) and with primary biliary cirrhosis (PBC) (n = 12) showed an impaired capacity to generate ISC upon stimulation with PWM. Spontaneous ISC from patients' lymphocytes were not significantly different from those of normal individuals. Using allogeneic co-cultures with lymphocytes from normal individuals and from patients with CAH NANB hepatitis or primary biliary cirrhosis, we observed no increase in suppressor cell activity. Therefore, the diminished responses to PWM are probably attributable to an alteration in the peripheral helper T-cell compartment.

Are antimitochondrial antibodies in primary biliary cirrhosis induced by R(rough)-mutants of enterobacteriaceae?

Antimitochondrial antibody (AMA)-positive serum samples from 45 patients with primary biliary cirrhosis (PBC) and AMA-negative serum samples from patients with chronic liver diseases, systemic lupus erythematosus, or rheumatoid arthritis were studied by an immunoblot technique with mitochondria from bovine heart and pig kidney and with several strains of gram-negative bacteria as antigens after separation by sodiumdodecylsulphate polyacrylamide gel electrophoresis. Serum from patients with PBC recognised up to three mitochondrial antigens with molecular weights of 70 kD, 50 kD, and 42 kD. Equivalent patterns were found with bands at 70-80 kD and 50-52 kD with Enterobacteriaceae as antigens. AMA-reactive polypeptides were localised in the ribosomal and membrane fractions from Enterobacteriaceae but differed from known outer membrane proteins. Conversely, PBC-specific mitochondrial antigens at 70 kD and 50 kD were recognised by rabbit antisera against Salmonella minnesota Rb and Rc mutants but not by antisera against wild-type Enterobacteriaceae. Absorption experiments and two-dimensional immunoblotting studies confirmed that mitochondria and gram-negative bacteria share identical PBC-specific determinants. It seems that PBC-specific antigens are expressed in gram-negative bacteria and that these antigens may be immunogenic in mutants with defective polysaccharide synthesis. The data support the hypothesis of a bacterial aetiology for PBC.

Antihypertensive effect of felodipine or hydralazine when added to beta-blocker therapy

In a double-blind randomized study, hydralazine (n = 59) or the new dihydropyridine calcium antagonist felodipine (n = 61) was added to previous treatment with beta-adrenoceptor blocking agents in a group of 120 patients with essential hypertension. Active treatment with either hydralazine or felodipine was given for 8 weeks after a 4-week placebo run-in period, at the end of which all patients had supine diastolic blood pressures greater than 95 mm Hg. Assessment of the results according to the intention to treat principle showed that felodipine was significantly more effective than hydralazine at the doses employed, reducing systolic blood pressure 10-19 mm Hg more than hydralazine and reducing diastolic blood pressure 5-11 mm Hg more than hydralazine (95% confidence intervals). The number of patients complaining of side effects, the number of complaints, and the number of patients that had to be withdrawn from treatment were numerically higher during treatment with hydralazine than with felodipine, but these differences were not statistically significant. Against this background it is concluded that felodipine is superior to hydralazine when added to an antihypertensive regimen consisting of beta-adrenoceptor blocking agents.

[Frequency and clinical relevance of delta virus infection in HBsAg carriers in the Berlin area]

The frequency of delta virus infection, immunoserological parameters and degree of liver inflammation were studied in 190 HBsAg carriers in the Berlin area from 1976 to 1986. Delta infection was detected in one of 50 HBsAg carriers (2%) in the period from 1976 to 1980. In contrast 19 of 140 HBsAg carriers (14%) with delta infection were found in the period from 1981 to 1986. This group included 12 Germans, 5 Turks and 2 Italians. Only 6 of these subjects belonged to a so-called risk group: 3 drug addicts, 2 homosexuals and 1 hemophiliac. Eighteen of the 20 patients with HDV infection showed progressive liver disease in the follow-up period. Nine cases developed complete liver cirrhosis over five years. Variable transaminase levels and elevation of immunoglobulin G were recorded. Humoral autoimmune phenomena were rarely observed. The increasing frequency of HDV infection in the Berlin area is presumably related to tourism, national origin and membership in specific risk groups. The data in our study underline the importance of effective prophylaxis by active immunization with HBsAg vaccines.

[Schoenlein-Henoch purpura in chronic HBsAG-positive hepatitis]

We report about a 40-year-old male patient suffering from a recurrent vasculitis with purpura since the age of 18. In 1983, a HBsAg-positive chronic active hepatitis with circulating immune complexes which contained HBsAg, immunoglobulin M and G as well as complement (C) was diagnosed. Serum and liver tissue were negative for HBcAg, HBeAg and hepatitis B virus (HBV) DNA; there was no evidence for HBV replication. HBsAg, IgM and C3 were demonstrable in the arteriolar walls of the skin. The results support the concept that complement activating immune complexes containing HBsAg and IgM anti HBs play a role in the pathogenesis of vasculitis as described here.

Expression of Pre-S-encoded proteins in sera of individuals chronically infected with hepatitis D virus

The sera of 16 individuals chronically infected with the hepatitis D virus were analyzed for hepatitis B virus (HBV) markers. The majority of these patients had a non-replicative form of viral type B hepatitis as indicated by negative tests for HBeAg and HBV-DNA. Pre-S-encoded proteins were detected in 13/16 sera. Sera that were negative for polymerized serum albumin did also not contain pre-S1-encoded proteins. The presence of pre-S-encoded proteins is probably predominantly associated with 22-nm HBsAg forms present in large amounts in sera of individuals with chronic type D hepatitis.

Absence of complement fixing antibodies against lipopolysaccharides from Escherichia coli in a subgroup of patients with Crohn's disease

Complement fixing antibodies against different Escherichia coli lipopolysaccharides were determined in patients with Crohn's disease and in healthy individuals and compared with antitetanus toxoid antibodies. All healthy individuals had antilipopolysaccharide antibodies, 10 of 27 patients with Crohn's disease had no antibodies and six had rapidly changing antibody titres. These abnormalities were found in patients with disease in the colon, with arthropathy and fistula. Antilipid A was found at lower titres in Crohn's disease. Neither antitetanus toxoid antibodies, nor immunoglobulin concentrations were different in patients with or without antilipopolysaccharide antibodies. There was no evidence for circulating immune complexes in patients lacking antilipopolysaccharide antibodies. Certain subgroups of patients with Crohn's disease have altered antibody levels to typical enteral antigens which most likely can be explained by local antibody binding to lipopolysaccharides at inflammatory sites, or by changes in immunoregulation in this disease.

Serological assessment of HBcAg and HBV DNA: its prognostic relevance in acute hepatitis B

Treatment of serum precipitates with sodium thiocyanate in patients with hepatitis B virus (HBV) replication results in liberation of circulating hepatitis core antigen (HBcAg) which can be demonstrated radioimmunologically. Follow-up investigations were performed in 80 patients with acute hepatitis B. Sera were examined for HBcAg. HBV DNA and conventional HBV markers. At the time of admission to hospital 34 of 80 (42%) patients were HBeAg positive. Twenty-six (76%) of the 34 HBcAg positive patients were HBV DNA positive, and circulating HBcAg was detectable in 25 of 34 (73%) HBcAg positive cases. In patients with uncomplicated courses of acute hepatitis B the serological HBcAg assay and HBV DNA became negative 1 to 8 weeks before elimination of HBeAg and up to 12 weeks earlier than the sera became negative for HBsAg. Five patients (6%) showed transition to chronic hepatitis B with persistence of HBsAg, HBeAg, HBV DNA and HBcAg in serum. One patient with acute hepatitis B and development of chronic hepatitis suffered from acquired immunodeficiency syndrome and showed delayed formation of anti-HBc. In this case uncomplexed HBcAg was demonstrable during the acute phase of hepatitis B. With the appearance of anti-HBc HBcAg circulated in a complexed form. The data indicate that serological determinations of HBcAg and HBV DNA can serve as prognostic markers in the early phase of acute hepatitis B. The demonstration of uncomplexed HBcAg in serum of a patient with inadequate formation of anti-HBc supports the hypothesis that circulating HBcAg is usually complexed by specific antibodies.

Fc gamma-receptor-mediated changes in the plasma membrane potential induce prostaglandin release from human fibroblasts

Binding of aggregated human immunoglobulin G (IgG) on diploid human fibroblasts leads to a rapid depolarization of the cells within 1-2 min. We resolved this membrane potential change into its plasma membrane and mitochondrial membrane components by measuring the transmembrane distribution of the lipophilic tritium-labelled cation tetraphenylphosphonium, [3H]Ph4P+. The responsibility of the plasma membrane for the membrane potential change, induced by binding of IgGs, is demonstrated. The IgG-induced membrane depolarization leads to the induction of prostaglandin E2 synthesis. Aggregated immunoglobulins (IgG) are specifically bound via the Fc portion because only binding of Fc fragments, in contrast to (Fab')2 fragments, leads to a stimulation of prostaglandin E2 synthesis comparable to that mediated by IgGs. Depolarization of the plasma membrane by short incubation of the fibroblasts in high-K+ buffer (5 min) results in a stimulation of prostaglandin E2 synthesis comparable to that mediated by either aggregated human IgGs or Fc fragments. Our previous results on Fc gamma-receptor-mediated antigen-IgG-antibody complex internalization showed that a maximum uptake of these complexes could be detected 60-90 min after binding. Therefore, we conclude that not internalisation but binding of aggregated IgGs to the Fc gamma receptors on human fibroblasts is the stimulus for plasma membrane depolarization leading to an enhanced prostaglandin E2 release.

Degradation of various amine compounds by mesophilic clostridia

From 60 species of the genus Clostridium tested 26 species were able to degrade one to three of the following compounds: betaine, choline, creatine, and ethanolamine. Degradation of betaine and choline was always associated with the formation of trimethylamine as one of the products. Creatine was converted to N-methylhydantoin and with one species (Clostridium sordellii) to sarcosine in addition. The diagnostic value of the ability of clostridial species to degrade the compounds mentioned is discussed. N,N-dimethylglycine, N,N-dimethylethanolamine or sarcosine were not metabolized by the strains tested.

Lack of efficacy of dried garlic in patients with hyperlipoproteinemia

The effects of dried garlic on blood lipids, apolipoproteins and blood coagulation parameters in hyperlipemic patients were studies in two controlled, randomized, double-blind studies. Both studies comprised placebo and therapy periods of 6 weeks each. The doses administered were 3 X 198 mg in Study I (34 patients) and 3 X 450 mg in Study II (51 patients). In both studies, the following serum parameters were measured every 3 weeks: total cholesterol, HDL (high density lipoprotein)- and LDL (low density lipoprotein)-cholesterol, triglycerides and several safety parameters. In addition, apolipoproteins A and B, euglobulin lysis time, fibrin split products, prothrombin time, whole blood coagulation time and fibrinogen levels were determined in the second study only. The results indicated that neither dosage of dried garlic showed any significant effect on any of the parameters measured. It is therefore concluded that, if there is any effect of garlic on the parameters measured, it is not apparent when using a dried preparation in the dosage studied.

Eclampsia in Sweden, 1976-1980

Among 480,969 births in Sweden during the period 1976 to 1980, 74 parturients with eclampsia were identified. The clinical characteristics of women developing eclampsia before 37 completed weeks of gestation differed markedly from those with eclampsia at term. In the pre-term group, subjective symptoms nearly always preceded the eclamptic attack, the newborns were generally small-for-gestational-age, the perinatal mortality was high, and the mothers more frequently had complications related to eclampsia. The only maternal death occurred in this group. In the term group the first convulsion often came unexpectedly without typical premonitory signs. The infants were with few exceptions within the average for gestational age. The general outcome for mothers and their babies was favorable and the length of hospital stay was on average 3 days longer than that of the overall obstetric population. Eclampsia cases in Sweden represent a small subfraction of parturients with hypertensive disorders of pregnancy. The incidence (29/100,000) in our material is, to our knowledge, the lowest yet reported. Despite the very regular attendance at the antenatal clinic, weekly from 36 weeks onwards, fewer than half of the patients had hypertension diagnosed 4 days or more prior to the eclamptic convulsion. A shortening of the intervals between the antenatal visits therefore does not seem warranted.

[Immunoserologic differentiation of chronic cholestatic hepatitis. Significance of antimitochondrial antibodies and hepatic membrane antibodies]

In 22 of 45 patients with chronic cholestatic liver inflammation and humoral immune phenomena, followed over 15 years with at least one liver biopsy, there was the histological picture of primary biliary cirrhosis (PBC), stages I to IV, with constantly demonstrable antimitochondrial antibodies (AMA) of M2-type. In 12 patients there were signs of PBC and chronic active hepatitis (CAH) in the liver histology, and they were M2-positive. Six of them also had M4-antibodies and were thus classified as 'mixed form'. The other six were seropositive for liver-membrane antibodies (LMA) and (or) antinuclear antibodies (ANA) and thus demonstrated an overlap between PBC and autoimmune or lupoid CAH. In five patients there was autoimmune CAH of lupoid type, in four of them with LMA or ANA without M2- or M4-antibodies. The remaining six patients had pericholangitis with persisting ANA and increased serum concentrations of immunoglobulin M without M2- and M4-antibodies, as well as LMA. Clinically a nondestructive polyarthritis predominated without definite signs of collagenosis. The listed immunoserological parameters make it largely possible to differentiate classical PBC, mixed forms or overlap of PBC and CAH, autoimmune CAH and nonpurulent cholangitis of pericholangitic type.

[Binding activity of circulating HBsAg particles for polymerized human albumin in acute hepatitis B]

The binding activity of circulating HBsAg particles to polymerized human serum albumin (pHSA) was determined by radioimmunoassay in 18 patients with acute hepatitis B at follow-up and compared with other hepatitis B virus (HBV) markers. All patients had serum HBsAg particles with binding sites for pHSA during the acute phase of disease. Elimination of HBsAg particles with pHSA receptors occurred within 1 to 8 weeks in uncomplicated courses and in one case with a protracted course of 16 weeks before total elimination of HBsAg. The pHSA-test became negative after elimination of HBsAg in most instances. Three patients developed chronic hepatitis with persistence of pHSA-binding HBsAg particles. Circulating HBcAg dissociated by chaotropic ions was detectable in the first week of observation in 4 of 15 patients who recovered and persisted in 3 cases with transition to chronic disease. The results show that acute hepatitis B is associated with circulating pHSA-binding HBsAg particles which can serve as a prognostic marker of the early phase of the disease.

A case of perazine-induced enteritis--allergy or pseudoallergy?

Almost all adverse reactions to neuroleptic drugs in the gastro-intestinal system can be explained by their peripheral cholinergic blocking action with subsequent inhibition of intestinal tone and peristalsis. As a rare condition, severe diarrhoea due to enteritis may occur. A case with this complication is presented, the etiology and pathogenetic factors are discussed.

Bacteriological studies on endodontic paper points

Four brands of endodontic paper points were subjected to tests for sterility, antibacterial activity, and suitability as vehicles for bacteriological sampling procedures. No brand showed growth in the sterility assay. One brand showed weak but reproducible antibacterial activity. Recovery of viable bacteria after absorption into the points varied and appeared to depend both on the brand of point and on the bacterial strain used. One brand appeared ineffectual for clinical bacteriological sampling procedures.