Acquired factor VIII inhibitors in nonhemophilic patients

Antibodies against factor VIII occur in about 15-35% of hemophilia A patients and induce refractoriness to factor VIII substitution. In most cases, these antibodies are of the IgG class. Strategies to avoid or to treat such inhibitors are controversial. In very rare cases, factor VIII inhibitors also develop in nonhemophilic patients. Although there are anecdotal reports that these antibodies may disappear spontaneously without occurrence of bleeding tendencies, in the majority of patients the clinical course is characterized by severe hemorrhages. From 1980 to 1995, we observed ten nonhemophilic patients with acquired factor VIII inhibitors at our hospital. In most cases, a sudden bleeding tendency was observed shortly after an injury or surgery. Coagulation tests showed a prolonged aPTT and a decreased F VIII level. Other deficiencies of blood-clotting factors and acquired or hereditary von Willebrand's disease were excluded. Therapy with F VIII concentrates did not produce the expected increase. Measurement of F VIII inhibitor levels in Bethesda units/ml (BU/ml) revealed maximal values in the range of 2-128 BU/ml. Immunosuppressive therapy with azathioprine or cyclophosphamide in combination with methylprednisolone led to complete disappearance of the inhibitor, normalization of the coagulation tests, and complete remission of the bleeding tendency in seven treated patients within 6 weeks. Although the clinical course is not predictable and inhibitors may disappear spontaneously, combined therapy with methylprednisolone and azathioprine or cyclophosphamide is recommended for patients with bleeding tendency. In pregnancy, therapy should be started only with methylprednisolone; post-partum, azathioprine should be used additionally if methylprednisolone as a single drug does not lead to complete remission. In emergency situations, therapy with high doses of human factor VIII concentrate may be used. When bleeding does not cease, the additional use of activated prothrombin-complex concentrates or porcine factor VIII is indicated. Possible side effects may include hepatitis and short-lived intravascular thrombin production.

Hyperprolactinemia in systemic lupus erythematosus?

The objective of this project was to determine the prevalence of hyperprolactinemia (HPRL) in systemic lupus erythematosus (SLE) and to evaluate the role of prolactin (PRL) as a disease-activity marker. We determined PRL in a cohort of 182 patients with SLE. Basal prolactin levels and clinical data (disease-activity index, sero-activity, medications) were analyzed in all patients. The findings show only mildly elevated PRL levels in four SLE-patients and normaprolactinemia in 98% (n = 178), without any association with disease activity. Our results differ from previous studies. HPRL appears not to be prevalent in SLE, nor to be associated with disease activity.

Novel 68 kDa autoantigen detected by rheumatoid arthritis specific antibodies

OBJECTIVE

To improve the understanding of the pathogenesis of rheumatoid arthritis (RA) by identifying novel, disease specific autoantibodies.

METHODS

Total protein preparations from synovial membranes were separated electrophoretically and immunoblotted. Sera from RA patients were screened for predominant immunoreactions by blotting. A 68 kDa antigen target of the most predominant reaction was detected and further characterised.

RESULTS

The dominant immunoreaction in most of the RA sera tested was with a 68 kDa antigen. The antigen is probably ubiquitously expressed. It has an isoelectric point of 5.1, is O-glycosylated, and is located in the endoplasmic reticulum, the cytoplasm, or both. Antibodies to the 68 kDa autoantigen were present in 64% of 167 RA patients tested, and could also be detected in seronegative RA patients, but were present in only 1% of 98 patients with other rheumatic diseases. They could not be detected in 55 healthy controls.

CONCLUSIONS

Because of its high sensitivity (64%) and specificity (99%), the anti-68 kDa autoantibody not only provides another valuable parameter for diagnosis, but also represents an antibody that may be involved in the pathological mechanisms leading to RA. This hypothesis can be tested by investigating if 68 kDa specific T cells are present in RA patients.

Cerebral microembolism in patients with Sneddon's syndrome

BACKGROUND

The pathogenesis of Sneddon's syndrome is unclear. This study addresses the question whether cerebral thromboembolism may be involved in the pathogenesis of the neurologic complications of the disorder. The study consisted of 13 patients with Sneddon's syndrome defined by both generalized livedo reticularis and a history of one or more cerebrovascular ischemic events; none had clinical or Doppler ultrasonographic evidence of atherosclerosis.

METHODS

Transcranial Doppler microembolic monitoring of the middle cerebral artery; blood screening for antiphospholipid antibodies (lupus anticoagulant, anticardiolipin antibodies).

RESULTS

Five patients (38%) showed clinically silent microembolism at transcranial Doppler monitoring, with individual microembolic event rates of the middle cerebral artery between 2 per hour and 33 per hour. In this group, the time since the last ischemic symptom was significantly shorter than in the eight patients without microemboli. Antiphospholipid antibodies were detected in three patients (23%), all of whom belonged to the microemboli-positive group.

CONCLUSIONS

These data suggest that the detectability of both clinically silent cerebral microembolism and antiphospholipid antibodies may provide paraclinical evidence of active disease in patients with Sneddon's syndrome. The results support the notion that an immune-mediated prothrombotic state facilitating the formation of arterial thrombi with subsequent cerebral embolization, and/or triggering in situ thrombosis of cerebral vessels, plays a pathogenetic role in the neurologic manifestations of this disorder.

[Systemic lupus erythematosus in men--a different prognosis?]

A retrospective analysis of 21 male and 82 female patients with systemic lupus erythematosus (SLE) was performed in order to identify sex-linked differences in disease manifestations. As organ manifestation, cardiac involvement was assessed in 12 of 21 male patients (57%) and in 18 of 82 females (22%; p < 0.05). Renal involvement occurred in 16 male (76%) vs 26 female patients (32%; p < 0.05). Endstage renal disease developed in 5 of the 21 men (24%), but only in 6 of the 82 women (7%) with SLE. The most striking clinical result was the high frequency of thrombembolic complications in male SLE-patients. Twelve out of 21 males (57%) experienced more than 30 thrombembolic events in contrast to 9 events in 5 out of 82 females (6%; p < 0.0001). Persisting elevated IgG-anti-cardiolipin antibodies were found in 48% of male and only 16% of female patients (p < 0.05). In conclusion, these data suggest that SLE in males is characterized by more frequent and severe organ involvement and especially by striking prevalence of partly life-threatening thrombembolic complications.

Effects of glucocorticoids in rheumatoid arthritis. Diminished glucocorticoid receptors do not result in glucocorticoid resistance

OBJECTIVE

Lymphocytes of patients with rheumatoid arthritis (RA) have diminished receptor density; thus, patients with RA should show partial resistance to glucocorticoids. We investigated the glucocorticoid sensitivity of lymphocytes in RA patients compared with healthy subjects.

METHODS

We determined the effects of glucocorticoids on lymphocyte proliferation and cytokine release.

RESULTS

Proliferation and cytokine release were inhibited in RA patients to the same extent as in healthy controls.

CONCLUSION

Diminished receptor density in RA patients does not result in glucocorticoid resistance.

Glucocorticoid receptors in rheumatoid arthritis

OBJECTIVE

Increasing evidence suggests that there is a close interrelationship between the immune system and the hypothalamic-pituitary-adrenal axis. One way these systems are linked is through specific receptor proteins for glucocorticoid hormones in lymphocytes. We sought to determine whether the levels of these receptors differ in patients with rheumatoid arthritis (RA), compared with levels in healthy subjects.

METHODS

We determined the density and affinity of lymphocyte glucocorticoid receptors, as well as basal cortisol levels, in 90 patients with active RA and in 200 healthy controls, using a whole cell binding assay.

RESULTS

The number of glucocorticoid receptors in RA patients was significantly lower than in controls (mean +/- SD 2,144 +/- 500 per cell versus 5,619 +/- 1,373 per cell; P less than 0.001), whereas there were no differences in binding affinity or cortisol levels. Glucocorticoid receptor density did not correlate with inflammatory disease activity.

CONCLUSION

Since glucocorticoids are potent immunosuppressive agents, the decrease in their receptors suggests an impairment of the immune-hypothalamic-pituitary-adrenal axis in patients with RA.

Immunoglobulin allotypes are not associated with HLA-antigens, autoantibodies and clinical symptoms in systemic lupus erythematosus. Members of the SLE Study Group

Immunoglobulin heavy chain (G1m, G2m, G3m, A2m) and kappa light chain (Km) allotype and phenotype frequencies of 323 central European Caucasian patients with systemic lupus erythematosus (SLE) were examined and correlated with various genetic, serologic and clinical markers of SLE. No significant associations were found between immunoglobulin allotypes or phenotypes and all 20 parameters tested (nephritis, vasculitis, arthralgias, photosensitivity, discoid lesions, central nervous system disease, Raynaud's phenomenon, sex, anti-Ro, anti-La, anti-nRNP, HLA-DR1-DR7, HLA phenotypes B8-DR3, B7-DR2). It could therefore be assumed that Gm, A2m and Km allotypes were not associated with HLA-antigens and had no influence on the serologic and clinical expression of SLE.

Ankylosing spondylitis: an autoimmune disease?

Identification of several autoantibodies in serum samples from patients with ankylosing spondylitis or suspected ankylosing spondylitis is reported. Five antibodies associated with ankylosing spondylitis were identified by applying cytoimmunofluorescence and immunoblotting techniques to antigen pools from insect tissue. At least one of these antibodies was found in 82% of serum samples from patients with ankylosing spondylitis. A 36 kD drosophila antigen, which showed the most common and most dominant reaction, was further purified and isolated. Thirty two (34%) of the serum samples from 95 patients with definite ankylosing spondylitis and 12 (28%) of the serum samples from 43 patients with suspected ankylosing spondylitis reacted with this antigen. Antibodies purified from the 36 kD antigen reacted specifically with a 69 kD antigen present in separations of total protein preparations from human lymphocytes and HeLa cells. The 36 kD antibody was not found in 29 patients with rheumatoid arthritis nor in 38 apparently healthy controls. The prevalence of the 36 kD antibody was comparable in HLA-B27 positive and negative patients. In addition, the same immunoreaction was found in patients with so called 'seronegative' spondylarthropathies, particularly of the ankylosing spondylitis-type, suggesting that this antibody is specific for ankylosing spondylitis or other 'seronegative' spondylarthropathies with the typical clinical and radiological changes of ankylosing spondylitis.

Hetero- and homozygosity of MHC class II gene products in systemic lupus erythematosus. The Members of the Deutsche Multizentrische SLE-Studie

An analysis of HLA class II antigens in 356 white patients with systemic lupus erythematosus (SLE) showed that all HLA-DR and -DQ homozygous and heterozygous combinations appear with frequencies expected from the observed gene frequencies. HLA-DR2 and HLA-DR3 gene frequencies were both increased in SLE, as were the odds ratios of all DR2 and DR3 hetero- and homozygous combinations. HLA-DR2/C4AQ0 heterozygotes were also not increased over expected values. Therefore, gene complementation at MHC loci does not contribute to susceptibility to SLE, but rather one or two MHC allele(s) in linkage with HLA-DR2 and HLA-DR3.

HLA antigens in ankylosing spondylitis associated with Crohn's disease. Increased frequency of the HLA phenotype B27,B44

In a consecutive case study 231 patients with Crohn's disease were investigated for ankylosing spondylitis (AS) and HLA-A, B, C, DR antigen association. Eighteen patients (7.8%) had definite AS according to the New York criteria; 13 (72%) were HLA-B27 positive. The phenotype B27,B44 was seen in 8 patients (44%) compared to only 3 (1%) of 300 controls (p less than 10(-7), and 1 (0.5%) of 213 patients with Crohn's disease without AS (p less than 10(-7). We conclude that patients with the phenotype B27,B44 are highly at risk (relative risk = 68.8) for the common manifestation of Crohn's disease and AS.

[Significant association of HLA-B8 with systemic lupus erythematosus and with specific serological markers]

Analysis of the HLA antigens of the A, B and C locus of 87 patients with systemic lupus erythematosus (SLE) revealed a significant elevation for HLA-B8 of 64% as compared to 22% in a healthy control group (n = 1850) (P less than 0.000001). Owing to the known linkage disequilibrium of this genetic marker with the HLA-A1 antigen, the HLA phenotype A1, B8 was found in 55% of the SLE patients (P less than 0.000001). Moreover, a significant association of the HLA-B8 in 82% (P less than 0.025) of Ro antibody-positive SLE patients (n = 22) and in 84% (P less than 0.025) of Ha antibody-positive patients (n = 19) was striking. A more frequent occurrence of this HLA antigen could also be detected in patients with a persistent nDNA antibody elevation and in patients with manifestation of the disease before the 40th year of life as compared to patients who manifested it later. An association of the HLA-B8 antigen with a raised disease activity of SLE can be inferred.

[Ormond's disease and chronic venous obstruction]

Excretory urography has been one of the most helpful tools in diagnosis of retroperitoneal fibrosis (RPF). Ventro-medial deviation of the ureters at the level of lower lumbar spine with urinary obstruction and pointed clinical stenosis of the upper part of the ureters have been considered diagnostic of RPF. It can be easily forgotten that RPF can become clinically apparent as vascular disease. Various types of RPF appearances will be discussed in the light of two examples.