Serum antibodies to carbonic anhydrase I and II in patients with idiopathic chronic pancreatitis and Sjögren's syndrome

La néphrocalcinose : manifestation inaugurale d’un syndrome de Gougerot-Sjögren primitif

INTRODUCTION

Nephrocalcinosis is a rare complication of chronic tubulointerstitial nephritis observed in primary Sjögren's syndrome. It can precede subjective sicca symptoms.

OBSERVATION

We report the case of a 50-year-old woman who presented with a primary Sjögren's syndrome. The first symptoms appeared 10-years-ago while she was affected with a nephrocalcinosis.

CONCLUSION

Autoimmune investigations for Sjögren's syndrome should be initiated in any patient presenting with nephrocalcinosis and distal renal tubular acidosis.

Idiopathic chronic pancreatitis with periductal lymphoplasmacytic infiltration: clinicopathologic features of 35 cases

To clarify clinicopathologic features of idiopathic chronic pancreatitis with lymphoplasmacytic infiltration, we carried out a study of 35 cases. There were two histologic groups, which we have designated lymphoplasmacytic sclerosing pancreatitis and idiopathic duct-centric chronic pancreatitis. Lymphoplasmacytic sclerosing pancreatitis (22 cases) was a fibrosing process with diffuse lymphoplasmacytic infiltrates involving pancreatic lobules and ducts, adipose tissue, blood vessels, and common bile duct. Obliterative phlebitis was found in every case except for one. The histologic features were similar to other idiopathic fibrosclerosing disorders, and one patient also had retroperitoneal fibrosis. Affected patients tended to be elderly men. Idiopathic duct-centric chronic pancreatitis (13 cases) was characterized by inflammatory infiltrates (including neutrophils) that were denser in the lobules than in interlobular fibrotic areas. Neutrophils were also prominent in the ducts, and destruction of the duct epithelium was commonly seen. Patient ages were more broadly distributed than in lymphoplasmacytic sclerosing pancreatitis. Two patients had inflammatory bowel disease. We conclude that idiopathic chronic pancreatitis with lymphoplasmacytic infiltration, sometimes called autoimmune pancreatitis, consists of at least two different processes. One of these, lymphoplasmacytic sclerosing pancreatitis, is a histologically unique lesion and could be a pancreatic manifestation of idiopathic fibrosclerosing disorders.

High prevalence of autoantibodies against carbonic anhydrase II and lactoferrin in type 1 diabetes: concept of autoimmune exocrinopathy and endocrinopathy of the pancreas

INTRODUCTION

Dysfunction of the exocrine as well as the endocrine pancreas has been reported in type 1 diabetes. Lymphocytic infiltration of the exocrine pancreas is observed in approximately half of Japanese type 1 diabetic patients.

AIMS

To investigate the involvement of autoimmunity against the exocrine pancreas in type 1 diabetes.

METHODOLOGY

We examined autoantibodies against human carbonic anhydrase II (ACA) and lactoferrin (ALF), antigens in the pancreatic duct cells and the pancreatic acinus, respectively, in 43 type 1 diabetic patients and 20 type 2 diabetic patients using the enzyme-linked immunosorbent assay method.

RESULTS

Of 43 type 1 diabetic patients, ACA was detected in 28 patients (65%) and ALF was detected in 29 patients (67%). One or both of the antibodies were detected in 33 type 1 diabetic patients (77%). In contrast, neither ACA nor ALF were detected in type 2 diabetic patients.

CONCLUSIONS

The high prevalence of both ACA and ALF strongly suggests the involvement of autoimmunity against the exocrine pancreas as well as the endocrine pancreas in some type 1 diabetic patients. We propose that these conditions be referred to as autoimmune exocrinopathy and endocrinopathy of the pancreas.

A case of autoimmune pancreatitis responding to steroid therapy. Evidence of histologic recovery

We report a case of autoimmune pancreatitis without obvious evidence of autoimmunological participation, which responded well to steroid treatment and provided histologic and radiographic evidence for this improvement. A 68-year-old woman presented abdominal fullness, diffuse pancreatic swelling on abdominal computed tomography and ultrasonography, and diffuse narrowing of the main pancreatic duct on endoscopic retrograde pancreatography. Transgastric aspiration needle biopsy of the body of the pancreas performed under endoscopic ultrasonography showed severe atrophy of acinar cells, infiltration of T lymphocytes. She was diagnosed as having autoimmune pancreatitis without obvious evidence of autoimmunological participation. Administration of 30 mg/day of predonisolone was started. Computed tomography showed marked improvement of the diffuse swelling of the pancreas, and endoscopic retrograde pancreatograpy showed amelioration of the narrowing of the main pancreatic duct after the start of treatment. Pancreatic tissue obtained by needle biopsy after the start of treatment with predonisolone revealed marked histologic improvement, including amelioration of the fibrosis, and infiltration of inflammatory lymphocytes, and a substantial increase in the number of pancreatic acinar cells. The present report is the first to demonstrate histologic recovery of autoimmune pancreatitis after steroid therapy.

Idiopathic tumefactive chronic pancreatitis: clinical profile, histology, and natural history after resection

BACKGROUND & AIMS

Little is known about subjects with idiopathic tumefactive chronic pancreatitis (TCP), that is, chronic pancreatitis whose clinical presentation, usually with a mass or obstructive jaundice, suggests cancer.

METHODS

We independently reviewed clinical data and histology of 45 TCP (27 idiopathic, 18 alcohol induced) resected at Mayo Clinic (January 1985-March 2001). Follow-up data were obtained from medical records and mailed questionnaires.

RESULTS

Compared with alcoholic subjects, idiopathic TCP patients were older (58 +/- 2 vs. 48 +/- 3 yr, P < 0.001), had shorter symptom duration (median 3 vs. 24 wk, P < 0.001), were more likely to have no or mild abdominal pain (70% vs. 17%, P = 0.001), and were more often jaundiced (67% vs. 33%, P = 0.02). Three distinct histologic patterns were identified in TCP. Typical CP (n = 19) showed lobular atrophy, fat necrosis, and ductal changes (dilatation, protein plugs, and stones). Lymphoplasmacytic sclerosing pancreatitis (LPSP) (n = 14) was characterized by periductal lymphoplasmacytic infiltration, obliterative phlebitis, and cholangitis with edema. Idiopathic duct-centric CP (IDCP) (n = 12) had neutrophil-predominant lobular inflammation, without phlebitis. On correlation of clinical and histologic diagnosis, 17 of 18 (94%) patients with alcohol-induced TCP had typical CP, and 25 of 27 (93%) with idiopathic TCP had LPSP or IDCP. LPSP and IDCP were indistinguishable clinically except for higher incidence of jaundice in LPSP (93% vs. 42%, P = 0.005). In idiopathic TCP no recurrence of symptoms was observed after resection (median follow-up 49 mo).

CONCLUSIONS

Idiopathic TCP is clinically and histologically distinct from alcohol-induced TCP. It is unclear whether LPSP and IDCP, 2 unique patterns of histologic injury observed in idiopathic TCP, are part of the spectrum of the same disease or represent 2 or more different entities. Resection of mass prevents recurrence of symptoms in idiopathic TCP.

Salivary gland involvement in chronic pancreatitis of various etiologies

OBJECTIVE

Both the pancreas and salivary glands show many histological and functional similarities. Recently, autoimmune pathogenesis has been postulated in some chronic pancreatitis cases. To examine whether a cell-mediated phenomenon involving the pancreas has a secondary effect on the salivary glands, we assessed the frequency of salivary gland dysfunction in patients with chronic pancreatitis of various etiologies.

METHODS

Function of the salivary glands was examined by sialochemistry and salivary gland scintigraphy in patients with chronic pancreatitis (n = 33), Sjogren's syndrome (n = 45), and controls (n = 28). Etiologies of chronic pancreatitis were alcoholic (19 cases), idiopathic (seven cases), and autoimmune (seven cases).

RESULTS

Concentrations of Na+, amylase, and beta2-microglobulin in saliva were investigated. In submandibular and parotid gland scintigraphy, time-activity curves were generated, and the ratios of peak count density and washout were calculated. Concentrations of Na+ in saliva of patients with idiopathic chronic pancreatitis and of beta2-microglobulin in saliva of patients with idiopathic and autoimmune chronic pancreatitis were significantly elevated than those of the control group. In submandibular and parotid gland scintigraphy, the peak count density ratio of patients with all chronic pancreatitis and washout ratio of patients with alcoholic and idiopathic chronic pancreatitis were significantly lower than those of the control group.

CONCLUSIONS

Salivary gland function was frequently impaired in the course of chronic pancreatitis of various etiologies. Salivary gland dysfunction might be the result of a common pathophysiological effect of alcohol in patients with alcoholic chronic pancreatitis and the aggressive immune mechanism against the pancreatic and the salivary ducts in patients with autoimmune and idiopathic chronic pancreatitis.

Detection of oncogenes in chronic pancreatitis

BACKGROUND

The pathogenesis of chronic pancreatitis (CP) remains poorly understood. Recently, molecular biology has identified the genetic background for many patients with hereditary CP. In addition, a number of studies have focused on the detection of proto-oncogenes and tumour suppressor gene mutations in the pathogenesis of CP. So far, the use of these mutations (with the exception of mutations causing hereditary CP), as diagnostic and prognostic markers is still controversial.

DISCUSSION

It is well known that the risk of pancreatic cancer in patients with CP, especially the hereditary form, is high. At present, there is insufficient evidence to show a clear relationship between the development of pancreatic cancer and certain mutations. New biotechnological methods, such as DNA array expression analysis, expand our knowledge of the molecular pathogenesis of this disease and may help to develop specific diagnostic, prognostic and therapeutic tools. However, until long-term studies examine the safety and efficacy of certain genetic markers, long-term follow-up of patients with CP who harbour mutations is needed.

Autoantibodies in primary Sjögren's syndrome: new insights into mechanisms of autoantibody diversification and disease pathogenesis

Characterisation of autoantibodies and their target autoantigens in primary Sjögren's syndrome (SS) is an important entry point for studying this common systemic autoimmune disease. Diversification of anti-Ro/La responses is believed to occur by a process of determinant spreading following initiation of an autoimmune response to one component, possibly 52-kD Ro (Ro52). Recent evidence supports the ER-resident chaperone Grp78 as a potential candidate in the initiation of an autoimmune response against Ro52, by binding to a Grp78 binding motif in the COOH-terminal region of Ro52. The subsequent diversification of the anti-Ro/La response is influenced by distinct HLA class II alleles. Anti-salivary duct autoantibodies have been revisited and shown to be mimicked by cross-reactive isoantibodies to AB blood group antigens. Identification of autoantibodies that act as antagonists at M3-muscarinic receptors represents an important advance. As well as contributing to the sicca symptoms, the functional effects of these autoantibodies may explain associated features of autonomic dysfunction in patients with SS. Anti-M3 receptor autoantibodies occur in both primary and secondary SS and allow Sjögren's syndrome to be viewed as a disorder of anti-receptor autoimmunity.

Bile duct involvement in a case of autoimmune pancreatitis successfully treated with an oral steroid

In the case reported here, the characteristic features of AIP were evaluated by ultrasonography, computed tomography and endoscopic retrograde cholangiopancreatography, initially in the intrahepatic- and extrahepatic bile ducts, and later in the pancreas. In addition, histological examination revealed lymphocytic sclerosis around the intralobular bile ducts, as is reported in AIP, without chronic nonsuppurative destructive cholangitis or onion-skin-like appearance. Immunohistochemistry identified the infiltrating lymphocytes as T cells. Although hypergammaglobulinemia was observed with elevation of hepatobiliary and pancreatic enzymes, no other serological or physiological abnormalities suggestive of other systemic autoimmune diseases were detected. These findings progressed over a three-month period and were dramatically resolved within one month by steroid therapy. These observations support a novel clinical entity characterized by the presence of bile duct lesions similar to the pancreatic involvement seen in AIP that is distinct pathophysiologically, histologically, and therapeutically from the so-called autoimmune cholangitis or primary sclerosing cholangitis.

Immunohistochemical localization of pyruvate carboxylase and carbamyl-phosphate synthetase I in normal and neoplastic human pancreatic tissues

INTRODUCTION

It has been suggested that pyruvate carboxylase (PC) and carbamyl-phosphate synthetase I (CPS I) might be colocalized with carbonic anhydrase V (CA V), which is generally considered to provide HCO3- ions for PC and CPS I.

AIM

To examine the immunohistochemical staining of endogenous biotin; of three mitochondrial biotin-binding enzymes (namely, PC, CPS I, and propionyl CoA-carboxylase); and of cytosolic acetyl CoA-carboxylase in pancreatic tissues.

METHODOLOGY

Immunohistochemical analysis was performed on 23 samples of normal pancreas and 63 samples of neoplastic pancreatic tissues.

RESULTS

It was found that the distribution of PC, CPS I, and endogenous biotin was not related to that of CA V but was similar to that of CA II in normal centroacinar cells, intercalated duct cells, and intralobular duct cells. In addition, PC was detected unexpectedly in delta-cells of islets.

CONCLUSION

It seems likely that CA II plays a major role in the secretion of NaHCO3 into the pancreatic juice. Hence, it is possible that PC and CPS I in the centroacinar cells, intercalated duct cells, and intralobular duct cells are strongly activated and might use HCO3- ions provided by CA II and not by CA V. Among the pancreatic neoplasms examined, ductal adenocarcinomas exhibited significantly elevated immunoreactivity specific for the four biotin-binding enzymes.

Clinical relevance of autoimmune-related pancreatitis

Recently, a concept of 'autoimmune pancreatitis' (AIP) was proposed. Computed tomography, magnetic resonance imaging or ultrasonography show a diffusely enlarged pancreas with a so-called 'sausage-like' appearance. Hypergammaglobulinaemia, increased serum levels of total IgG or IgG4, positive autoantibodies such as antinuclear antibody, anti-lactoferrin antibody, anti-CA-II antibody, rheumatoid factor and anti-smooth muscle antibody, were often observed in patients with AIP. Microscopic findings showed fibrotic changes with infiltration of lymphocytes, plasmacytes and sometimes eosinophils in the pancreas. Major subgroups of lymphocytes infiltrating areas around pancreatic ducts were CD4(+) T-cells producing IFN-gamma. HLA-DR was expressed on pancreatic duct cells as well as CD4(+) cells. The diagnosis is made by a combination of clinical, laboratory and morphological findings. Laboratory data, pancreas images and diabetes mellitus in most patients do respond to steroid treatment. In conclusion, autoimmune-related pancreatitis appears to be a unique clinical entity. However, its importance in clinical practice needs further characterization.

Current issues in Sjögren's syndrome

Sjögren's syndrome is a chronic autoimmune and rheumatic disorder with prominent sicca complaints from the mucous membranes because of lack of proper exocrine secretions. There is no straightforward and simple diagnostic test for Sjögren's syndrome, although several classification criteria have been designed including several oral diagnostic tests. A new set of classification criteria in a joint effort by research groups in Europe and USA has recently been presented. A large number of autoantibodies have been reported in Sjögren's syndrome where, in some cases, the antibodies are correlated with the extent and severity of disease. The finding of serum autoantibodies directed against the muscarinic M3 receptor is an important advance in understanding the pathogenesis of not only the impaired glandular function but also associated features of autonomic dysfunction in some patients. The treatment of primary Sjögren's syndrome is still mainly symptomatic.

Experimental immune-mediated pancreatitis in neonatally thymectomized mice immunized with carbonic anhydrase II and lactoferrin

We previously reported that autoantibodies against carbonic anhydrase II and lactoferrin are frequently identified in patients with autoimmune-related pancreatitis. To clarify the role of carbonic anhydrase II and lactoferrin, we created animal models of autoimmune pancreatitis by immunizing neonatally thymectomized mice with carbonic anhydrase II and lactoferrin and also by transferring immunized spleen cells to nude mice. Neonatally thymectomized BALB/c mice were immunized with carbonic anhydrase II or lactoferrin followed by three booster injections (n = 10 in each group). We transferred whole, CD4+, or CD8+ spleen cells prepared from immunized neonatally thymectomized mice to nude mice (n = 5 in each group). Gene expression of IFN-gamma and IL-4 was investigated using semiquantitative reverse transcription-polymerase chain reaction. Terminal deoxynucleotidyl transferase-mediated dUTP-biotin nick end-labeling staining was used to examine apoptosis. In immunized neonatally thymectomized mice, the prevalence of inflammation was significantly higher in the pancreas. Inflammation was present in all mice receiving whole or CD4+ cells. There was no change in any of the mice receiving CD8+ cells or nonimmunized spleen cells. Carbonic anhydrase II or lactoferrin-immunized mice had apoptotic duct cells or acinar cells, respectively. Expression of the IFN-gamma gene was up-regulated in each group. Similar findings were observed in the salivary glands and liver. An immunologic mechanism against carbonic anhydrase II or lactoferrin is involved in the pathogenesis of these pancreatitis models, in which the effector cells are Th1-type CD4+ T cells.

ERCP features in 27 patients with autoimmune pancreatitis

BACKGROUND

Autoimmune pancreatitis has been proposed as a new clinical entity. However, the ERCP features of this entity have not been well described.

METHODS

Clinical and radiographic features in 27 patients with a diagnosis of autoimmune pancreatitis were evaluated.

RESULTS

All 27 patients were at first suspected to have pancreatic cancer. The patients were predominantly elderly men and presented with jaundice or mild symptoms and pancreatic enlargement, but no attack of acute pancreatitis. A cholestatic biochemical profile and serum IgG elevation were usually present. A diffusely or segmentally irregular and narrow main pancreatic duct and a positive response to corticosteroid therapy were characteristic. During observation without treatment, serial pancreatography in 2 patients demonstrated progression of diffuse, irregular narrowing of the main pancreatic duct over periods, respectively, of 2 and 6 months. Both the irregular narrowing of the main pancreatic duct and distal bile duct strictures improved in various degrees in response to corticosteroid therapy.

CONCLUSIONS

Segmental or diffuse irregular narrowing of the main pancreatic duct are ERCP features of autoimmune pancreatitis.

Autoimmune pancreatic disease: preparation of pancreatic juice for proteome analysis

The identification of pancreatic proteins is generally hampered by the high content and activity of proteases produced by this organ. The aim of this work was the development of a protocol for the analysis of pancreatic juice by two-dimensional (2-D) gel electrophoresis allowing consistent and reproducible protein analysis encompassed by high-resolution protein 2-D maps and subtle protein spot recognition without substantial losses due to proteases. Immobilized pH gradient (IPG) strips were used for the first dimension, the second dimension was performed by sodium dodecyl sulfate-polyacrylamide gel electrophoresis (SDS-PAGE). However, the key step was the sample preparation technique. Improvements were achieved by using several protease inhibitors (phenylmethylsulfonyl fluoride, aprotinin, L-1-chloro-3-[4-tosyl-amido]-7-amino-2-heptanine (TLCK)-HCI, Complete) to prevent degradation of the proteins. The application of different pH-ranges was a valuable step for getting an overview of the expressed protein pattern. These investigations resulted in well-resolved 2-D maps with a high reproducibility.

Primary Sjögren's syndrome: oral aspects on pathogenesis, diagnostic criteria, clinical features and approaches for therapy

Primary Sjögren's syndrome (pSS) is a chronic inflammatory systemic autoimmune disease affecting the exocrine glands and predominantly the salivary and lacrimal glands. The impaired gland function is assumed to be a result of progressive lymphocyte-mediated destruction of the exocrine gland tissue leading to the cardinal manifestations, hyposalivation and keratoconjunctivitis sicca (KCS), as well as devastating symptoms of oral and ocular dryness. Although primarily characterised as an exocrine dysfunction, non-exocrine organs may also be affected. The onset and course of pSS is usually insidious but may develop into a disabling disease, which profoundly affects the patient's general well being and quality of life. Moreover, pSS may even evolve into a lymphoid malignancy. The aetiology of pSS remains unknown but the pathogenesis of exocrine cell damage is apparently multi-factorial, including immunological, genetic, hormonal and viral components. Recent research also includes neurogenic aspects of exocrine gland dysfunction, including the interference of immune mediators with glandular response to neurotransmitters released from nerve fibres. pSS usually affects middle-aged women and the female:male ratio is 9:1. The prevalence varies from 0.29-4.8%, depending on the population sampled and the diagnostic criteria used. At present, there are no specific diagnostic tests for pSS and no universally accepted diagnostic criteria. The current therapy is primarily symptomatic. This review focuses on the current oral clinical, diagnostic, pathogenic and therapeutic aspects of pSS.

Evidence of primary beta-cell destruction by T-cells and beta-cell differentiation from pancreatic ductal cells in diabetes associated with active autoimmune chronic pancreatitis

OBJECTIVE

Diabetes associated with autoimmune chronic pancreatitis (ACP) is a subtype of diabetes that is responsive to corticosteroid treatment of progressive endocrine and exocrine dysfunction. However, little is known about pathological changes of islet and exocrine pancreas in ACP.

RESEARCH DESIGN AND METHODS

We examined pancreatic specimens obtained on biopsy from four diabetic men with ACP (mean [range]: age 62 years [48-78], duration of ACP 3 months [1-5], duration of diabetes 1 month [0-3]) morphologically, immunohistochemically, and morphometrically.

RESULTS

The pancreatic specimens in all cases exhibited inflammatory cell infiltration surrounding ductal cells and extensive fibrosis. Some islets were infiltrated with mononuclear cells with disrupted beta-cells. The subsets of T-cells infiltrated to the islets were mainly CD8(+). Islet beta-cell volume was decreased; the mean percentage area of beta-cells in the islets in four cases with ACP were 16% (range 13-20) (P = 0.0015 vs. type 2 diabetic patients, 48% [27-73], n = 8; P = 0.0002 vs. nondiabetic control subjects, 58% [39-77], n = 7). Preserved ductal cells were surrounded predominantly by CD8(+) or CD4(+) T-cells. Some cytokeratin 19-positive ductal cells contained insulin and glucagon, representing upregulated differentiation of islet cells from ductal cells. Insulin promoter factor-1 (IPF-1) was hyperexpressed in insulin-containing ductal cells.

CONCLUSIONS

Diabetes associated with ACP is caused by T-cell-mediated mechanisms primarily involving islet beta-cells as well as pancreatic ductal cells. In ACP, ductal islet precursor cells were associated with IPF-1 hyperexpression, suggesting a critical role of IPF-1 on islet cell differentiation and eventual beta-cell restoration.

Autoantibody studies of female patients with reproductive failure

The aim of this study was to investigate the prevalence and character of autoimmune derangements in women with reproductive failure. A total of 108 females (age range 17-43, mean 27.5 years), including 16 with primary menstrual cycle disturbances and polycystic ovaries (PCO), 20 with polycystic ovary syndrome (PCOS), 38 with endometriosis (E), and 34 with chronic anovulation, luteal phase insufficiency, subfertility or unexplained infertility (INF) were investigated. A control group of 392 women was formed from an unselected population sample (age range 17-43, mean 31.0 years). All sera were tested by indirect immunofluorescence method to assess common autoantibodies: nuclear (ANA), smooth muscle (SMA), parietal cell (PCA), thyroid microsomal (TMA), reticulin (ARA), mitochondrial (AMA) and liver/kidney microsomal autoantibodies (LKMA). Enzyme-linked immunosorbent assay was used to detect antibodies against beta2-glycoprotein I (anti-beta 2GPI) and carbonic anhydrase (anti-CA). Our results showed that 40.7% of patients' sera and 14.8% of control sera contained one or more common autoantibodies, ANA and SMA were most frequently detected (difference between two groups P<0.005). Anti-beta 2GPI were found in eight cases (7.4%), including two patients with INF but without other autoantibodies. Anti-CA were revealed in nine cases (8.3%) including patients' PCOS, E and INF. A comparison of patients' clinical data with antibody assay results did not reveal any significant associations. Our results indicate a high prevalence of autoimmune reactions in women with reproductive failure due to the most common causes PCO, PCOS and E as well as in unexplained infertility. This might reflect the propensity to develop autoimmune reactions in such patients, including pathogenic autoimmune reactions to specific target antigens.

Carbonic anhydrase isozymes in the human pancreas

Recently, an increasing number of carbonic anhydrase (CA) isozymes have been discovered in the human pancreas. These isozymes are classified as the CA family with various molecular structures and different subcellular localizations: cytoplasmic CA II, mitochondrial CA VB, secretory CA VI, membrane-bound CA IV, and transmembrane CA IX and XII. However, there is little evidence concerning their pathophysiological roles. Here, we reviewed the expression of CA isozymes in the human pancreas and proposed hypotheses related to their physiological and pathological roles.

Clinical analysis of autoimmune-related pancreatitis

OBJECTIVE

Several investigators have reported on autoimmune-related pancreatitis, but the clinical findings and pathophysiology still remain unclear. To clarify it, we analyzed eight patients with autoimmune pancreatitis.

METHODS

We evaluated clinical findings in eight patients (four men and four women) with autoimmune-related pancreatitis. Patients were aged 45-73 yr (mean, 57.5 yr). We examined blood chemistry and immunological studies, including autoantibodies against lactoferrin or carbonic anhydrase II, and compared ERCP images with clinical findings. In two patients, we studied the subset of lymphocytes infiltrating in the pancreas by immunohistochemistry and flow cytometry.

RESULTS

Four of eight patients had jaundice, two had renal dysfunction, two had abdominal pain, and two had back pain. Three patients were complicated with other autoimmune diseases. Three patients showed abnormal pancreatic exocrine function by an N-benzoyl-L-tyrosyl-para-aminobenzoic acid excretion test. Antinuclear antibody was detected in four of eight patients, antilactoferrin antibody in three of six, anticarbonic anhydrase II antibody in two of six, antismooth muscle antibody in two of seven, and rheumatoid factor in one of eight. All eight patients showed segmental stenosis of the main pancreatic duct by ERCP. Four patients showed stenosis of the common bile duct as well as the pancreatic duct. Microscopic findings showed infiltration of CD4-positive lymphocytes around the pancreatic duct, and HLA-DR was expressed on both CD4-positive cells and pancreatic duct cells. In two patients, stenosis of the pancreatic duct improved by prednisolone.

CONCLUSIONS

Autoimmune mechanism may be involved in some patients with idiopathic pancreatitis associated with hypergammaglobulinemia.

The characteristic appearance of non-alcoholic duct destructive chronic pancreatitis: a report of 2 cases

We report 2 patients with an unusual form of chronic pancreatitis, both of whom were treated for clinical suspicion of pancreatic malignancy. The surgical specimens revealed a dense lymphoplasmacytic infiltration of the main and interlobular branches of the pancreatic duct, causing sclerosis of the duct wall, diffuse irregular lumenal narrowing, extensive parenchymal fibrosis, and organ enlargement. Neither case showed calcifications, fat necrosis, or cyst formation, features usually seen in alcoholic pancreatitis, nor was there any evidence of neoplasia. One patient had an unusual form of acalculous cholecystitis, but without cystic duct inflammation or fibrosis. Both patients recovered well from the surgical procedure and have not had any complications or relapse of their symptoms. To the best of our knowledge, these cases are representative of the recently described non-alcoholic duct destructive chronic pancreatitis, which is thought to be immune-mediated.

Elevated serum levels of antibodies to carbonic anhydrase I and II in patients with chronic pancreatitis

An immune-mediated reaction to pancreatic structures has been postulated for the pathogenesis of chronic pancreatitis (CP). Several reports demonstrate the presence of antibodies to the pancreatic ductal epithelium in some patients suffering from CP. Serum antibodies to carbonic anhydrase I (anti-CA I) and II (anti-CA II) are present in patients affected by idiopathic CP. The aim of this study was to evaluate the presence of anti-CA I and anti-CA II in a series of patients with CP. We studied 78 consecutive CP patients (62 male, 16 female; mean age 48.6 +/- 10.2 years) referred to the Verona University Center for the Study of the Pancreas. As a control group, we studied 26 healthy subjects recruited from among the medical and nursing staff of the center. Serum anti-CA I and anti-CA II levels were quantified by enzyme-linked immunosorbent assay using a standard method with minor modifications. The mean absorbance of antibodies was higher in CP patients than in control subjects (anti-CA I: 0.064 +/- 0.042 vs. 0.047 +/- 0.015, p = 0.051; and anti-CA II: 0.038 +/- 0.02 vs. 0.029 +/- 0.014, p = 0.033). Positive results were arbitrarily defined as absorbance values >0.067 for anti-CA I and 0.047 for anti-CA II. We found anti-CA I and anti-CA II positivity in 21 of 78 (27%) and 20 of 78 (26%) of CP patients, respectively, and in only two of 26 control subjects (7.7%) (p = 0.032 and 0.039). Twenty-two of 26 subjects in the control group (84.6%) and 48 of 78 patients (61.5%) in the CP group tested negative for both antibodies (p = 0.03). None of the control subjects and 12 of 78 (16.6%) of the CP patients tested positive for both anti-CA I and anti-CA II. We observed a significant correlation between anti-CA I and anti-CA II serum levels in control subjects (R = 0.423; p = 0.016) and in CP patients (R = 0.584; p < 0.0001). No correlation was found between serum antibody levels and any of the following variables: length of disease, alcohol consumption, smoking habits, pancreatic surgery, pancreatic calcifications, diabetes, and steatorrhea. Serum levels of anti-CA I and anti-CA II are elevated in some patients suffering from CP.

Loss of TGF-beta signaling contributes to autoimmune pancreatitis

Recent observations suggest that immune response is involved in the development of pancreatitis. However, the exact pathogenesis underlying this immune-mediated response is still under debate. TGF-beta has been known to be an important regulating factor in maintaining immune homeostasis. To determine the role of TGF-beta in the initiation or progression of pancreatitis, TGF-beta signaling was inactivated in mouse pancreata by overexpressing a dominant-negative mutant form of TGF-beta type II receptor in the pancreas, under control of the pS2 mouse trefoil peptide promoter. Transgenic mice showed marked increases in MHC class II molecules and matrix metalloproteinase expression in pancreatic acinar cells. These mice also showed increased susceptibility to cerulein-induced pancreatitis. This pancreatitis was characterized by severe pancreatic edema, inflammatory cell infiltration, T- and B-cell hyperactivation, IgG-type autoantibodies against pancreatic acinar cells, and IgM-type autoantibodies against pancreatic ductal epithelial cells. Therefore, TGF-beta signaling seems to be essential either in maintaining the normal immune homeostasis and suppressing autoimmunity or in preserving the integrity of pancreatic acinar cells.

Autoimmune pancreatitis detected as a mass in the tail of the pancreas

A mass in the tail of the pancreas was detected in a 62-year-old male patient who had hypergammaglobulinaemia, and was positive for antinuclear antigen and anti-SS-A antibody. Endoscopic retrograde pancreatography revealed focal irregular narrowing of the main pancreatic duct in the tail of the pancreas. Dynamic computed tomography showed swelling of the pancreatic tail, which was enhanced on delayed phase. Autoimmune pancreatitis was suspected and corticosteroid therapy was commenced. This led to significant resolution of the pancreatic stricture. It is important to recognize this clinical entity as corticosteroid therapy may avoid unnecessary surgery.

Autoimmune-related pancreatitis is associated with autoantibodies and a Th1/Th2-type cellular immune response

BACKGROUND & AIMS

Although autoimmunity may be involved in some cases of pancreatitis, the mechanism is still unknown. To clarify this, we studied serum autoantibodies, subsets of lymphocytes, and the Th1/Th2 balance of cellular immune responses in patients with autoimmune-related pancreatitis (AIP).

METHODS

Seventeen patients with AIP (8 men and 9 women; age, 53.2 +/- 13.0 years) were studied. Autoantibodies including antilactoferrin (ALF) or carbonic anhydrase II antibody (ACA-II) were examined using the enzyme-linked immunosorbent assay (ELISA) or the indirect fluorescein antibody method. Intracellular cytokines (interferon gamma and interleukin 4) and subtypes of peripheral blood lymphocytes were examined by flow cytometry and ELISA.

RESULTS

More than one autoantibody was observed in all 17 patients. Serum antinuclear antibody was detected in 13 of 17 patients, ALF antibody in 13, ACA-II antibody in 10, rheumatoid factor in 5, and anti-smooth muscle antibody in 3, but antimitochondrial antibody in none. The serum levels of ACA-II and LF antibody were not correlated. HLA-DR(+)CD8(+) and HLA-DR(+)CD4(+) cells were significantly increased in peripheral blood (P < 0.05). CD4(+) cells producing interferon gamma and the secreted levels were significantly increased compared with those in controls (P < 0.05), but interleukin 4 was not increased.

CONCLUSIONS

An autoimmune mechanism against CA-II or LF, and Th1-type immune response, may be involved in AIP.

A study of anti-carbonic anhydrase II antibodies in rheumatic autoimmune diseases

Autoantibodies to human carbonic anhydrase II (CAII) were screened by ELISA in 109 sera from Asian Japanese patients with systemic lupus erythematosus (SLE), primary Sjögren's syndrome (Sjs), progressive systemic sclerosis (PSS) and dermatomyositis (DM). Anti-CAII antibodies were positive in 24.1% of SLE, 20.0% of primary Sjs, 16.7% of PSS and 25.0% of DM. On the other hand, sera from atopic dermatitis, bullous pemphigoid and psoriasis patients showed no activity for anti-CAII antibodies. CAII could be a common exonuclear autoantigen in subsets of rheumatic autoimmune diseases.

Causes of acute and recurrent pancreatitis. Clinical considerations and clues to diagnosis

The causes of acute pancreatitis are well documented and usually are divided into alcohol-induced, gallstone, miscellaneous, and idiopathic when no immediate cause is found. Clinically, the cause is either immediately discernable from the history and a few standard investigations, less obvious and requiring more detailed studies, or obscure and even speculative. The physician can whittle away at the idiopathic group by increasingly recognizing causes such as biliary sludge or microlithiasis, sphincter of Oddi dysfunction, hereditary pancreatitis, cystic fibrosis, or autoimmune causes. The prevalence of these and other rare conditions is the focus of intense research. Whether these increasingly recognized causes will significantly alter the current incidence of 10% to 30% of cases classified as idiopathic pancreatitis, only time will tell.

Autoimmune cholangiopathy

Currently available evidence is insufficient to classify PBC and AIC as separate diseases. The ultimate answer to the question of whether AIC, defined as AMA-negative PBC with ANA or SMA, is a disease distinct from AMA-positive PBC with or without ANA will require a detailed comparison of etiologic factors and pathogenetic mechanisms, once they are elucidated. It is intriguing to consider the suggestion of Heathcote that the term autoimmune cholangitis be adopted to describe PBC with or without detectable AMA. However, it is improbable that the venerable term PBC will be supplanted. Hepatologists will probably continue to use the terms AIC and AMA-negative PBC interchangeably, with little risk of being misunderstood.

Carbonic anhydrase in human pancreas: hypotheses for the pathophysiological roles of CA isozymes

Among more than ten isozymes of the carbonic anhydrase (CA) family, only cytoplasmic CA II and membrane-bound CA IX have been reported to be expressed in human pancreas. To study the mRNA expression of CA isozymes in human pancreas, reverse transcriptase-polymerase chain reaction (RT-PCR)-Southern blot analysis and cDNA sequencing following RT-PCR were employed. CA II, IV, VI, IX, and XII were clearly identified in polyA+ RNA from normal human pancreas by RT-PCR-Southern blotting. Results with cultured pancreatic tumor cell, lines suggest that CA II, IV, IX, and XII are expressed in the ductal cells, and CA VI is expressed in the acinar cells. We propose a hypothesis for the pathophysiological function of CA isozymes in human pancreas; (1) the intraluminal CA isozymes (CA IV, VI, and possibly XII) form a mutually complementary system with cytoplasmic CA II to regulate the luminal pH of the pancreatic duct system and work as a self-defense mechanism against pancreatitis; (2) CA II and other CA isozymes play a pathological role in the autoimmune process of idiopathic chronic pancreatitis.

Autoimmune pancreatitis, pancreatic mass, and lower gastrointestinal bleed

Autoimmune pancreatitis (AIMP) is a recently described clinical entity causing chronic pancreatitis. It often presents with diffuse enlargement of the pancreas and/or a focal mass at the head of the pancreas causing common bile duct obstruction and jaundice. In most instances, AIMP is mistaken for pancreatic cancer. A number of laboratory abnormalities such as positive antinuclear antibody, hypergammaglobulinemia, and antibody to carbonic anhydrase are often present in these patients. Currently, pancreatic biopsy demonstrating characteristic histopathologic changes is essential to establish the diagnosis. We report the first case of AIMP presenting as a pancreatic tail mass and lower gastrointestinal bleed.

The effects of vasculitis on the gastrointestinal tract and liver

Vasculitis can affect every organ of the digestive system. In many cases, it may first present with gastrointestinal symptoms. In several forms of vasculitis, including Churg Strauss syndrome, Henoch-Schönlein purpura, and lupus, the majority of patients have gastrointestinal involvement. The astute gastroenterologist should consider vasculitic causes of the symptoms seen in many patients. Making the correct diagnosis requires a thorough understanding of the potential role of vasculitis in causing these symptoms and the appropriate path to making a diagnosis. This article reviews the variety of manifestations of vasculitis on the digestive system, and emphasizes diagnosis and clinical manifestations.

Antibody to carbonic anhydrase II is present in primary biliary cirrhosis (PBC) irrespective of antimitochondrial antibody status

Antibody to carbonic anhydrase II, an enzyme abundantly present in biliary epithelium, has been proposed as a diagnostic marker for antimitochondrial antibody-negative PBC. In this study we determine its prevalence and clinical significance in a large series of patients with antimitochondrial antibody-positive and -negative PBC. Reactivity to carbonic anhydrase II was sought by Western immunoblotting in sera from 215 consecutive patients with PBC (26 antimitochondrial antibody-negative), 13 with autoimmune hepatitis, 25 with primary Sjögren's syndrome (pSS), 12 with systemic sclerosis, 19 with systemic lupus erythematosus and 73 healthy subjects. The prevalence of antibody to carbonic anhydrase II (titre 1:100) in PBC was 8%. No specific reactivity to carbonic anhydrase II was found in antimitochondrial antibody-negative PBC (7% versus 8% in antimitochondrial antibody-positive PBC). Ascites (P = 0.006) and Sjögren's syndrome (SS) (P = 0.022) in PBC were significantly associated with presence of the antibody. In patients with SS associated with PBC, the prevalence (19%) was similar to that observed in pSS (16%). At a serum dilution of 1:40, the prevalence of positive sera in PBC rose to 27% but disease specificity was reduced. Our findings in a large population of PBC patients rule out a relation between presence of antibody to carbonic anhydrase II and lack of antimitochondrial antibody. The higher prevalence of ascites found in positive patients warrants further evaluation.

Human carbonic anhydrase XII: cDNA cloning, expression, and chromosomal localization of a carbonic anhydrase gene that is overexpressed in some renal cell cancers

We report the cloning and characterization of a tumor-associated carbonic anhydrase (CA) that was identified in a human renal cell carcinoma (RCC) by serological expression screening with autologous antibodies. The cDNA sequence predicts a 354-amino acid polypeptide with a molecular mass of 39,448 Da that has features of a type I membrane protein. The predicted sequence includes a 29-amino acid signal sequence, a 261-amino acid CA domain, an additional short extracellular segment, a 26-amino acid hydrophobic transmembrane domain, and a hydrophilic C-terminal cytoplasmic tail of 29 amino acids that contains two potential phosphorylation sites. The extracellular CA domain shows 30-42% homology with known human CAs, contains all three Zn-binding histidine residues found in active CAs, and contains two potential sites for asparagine glycosylation. When expressed in COS cells, the cDNA produced a 43- to 44-kDa protein in membranes that had around one-sixth the CA activity of membranes from COS cells transfected with the same vector expressing bovine CA IV. We have designated this human protein CA XII. Northern blot analysis of normal tissues demonstrated a 4.5-kb transcript only in kidney and intestine. However, in 10% of patients with RCC, the CA XII transcript was expressed at much higher levels in the RCC than in surrounding normal kidney tissue. The CA XII gene was mapped by using fluorescence in situ hybridization to 15q22. CA XII is the second catalytically active membrane CA reported to be overexpressed in certain cancers. Its relationship to oncogenesis and its potential as a clinically useful tumor marker clearly merit further investigation.

Standardized assessment of disease status in patients with primary Sjögren's syndrome: the foundation for creating criteria for disease activity and damage?

Primary Sjögren's syndrome (pSS) is increasingly acknowledged as a disease entity with consistent pathogenesis and clinical presentation. This has encouraged proposals for uniform nomenclature, as well as for classification of disease subsets and clinical disease manifestations. The purpose of this literature survey is to analyse present pathogenetic and clinical data on pSS from the viewpoint of their usability for developing criteria for activity and damage. It appears that the routinely used tests for evaluating clinical disease manifestations in pSS probably measure both activity and damage. Moreover, no immunopathogenic marker has been shown to adequately represent all aspects of disease activity in pSS. The survey demonstrates the need for longitudinal studies in which potential markers of disease activity and damage are validated.

Characteristic pancreatic duct appearance in autoimmune chronic pancreatitis: a case report and review of the Japanese literature

We report a case demonstrating the progressive narrowing of the pancreatic duct, which is presumed to be characteristic of autoimmune pancreatitis, and we review the 37 cases of chronic pancreatitis in which autoimmunity was suggested as an etiological factor in the Japanese literature. A 55-year-old man presented with abdominal discomfort, jaundice, and diffuse swelling of the pancreas on ultrasonography. Serial endoscopic retrograde pancreatography demonstrated the progression of an irregular narrowing of the main pancreatic duct forming diffusely over the course of 2 months. Because the patient had hyperglobulinemia and tested positive for autoantibodies, he was diagnosed as a case of autoimmune chronic pancreatitis. Steroid therapy was carried out with excellent success.

Multiple pancreatic masses associated with autoimmunity

A 59-year-old woman was detected to have a high titer of serum gamma-globulin, positive antinuclear antibody and multiple pancreatic masses. In the course of 1 yr, Sjögren's syndrome developed, and her pancreatic masses spread diffusely and compressed the main pancreatic duct. A pancreatic biopsy by an exploration of the abdomen showed that many CD4 positive T-lymphocytes had infiltrated to the ducts and acinar cells expressing HLA-DR antigens. This suggested a diagnosis of autoimmune-related pancreatitis. She was treated with oral prednisolone, and a marked improvement of the above abnormal findings followed. In this report, a case of autoimmune-related multiple pancreatic masses associated with Sjögren's syndrome is presented, and a possible mechanism is discussed.

Autoimmune pancreatitis as a new clinical entity. Three cases of autoimmune pancreatitis with effective steroid therapy

The most common forms of chronic pancreatitis are related to alcohol ingestion, whereas the entity of non-alcohol-associated (idiopathic) pancreatitis is poorly understood. Autoimmunity has been suggested as a possible etiologic factor of idiopathic chronic pancreatitis. A total of 362 Japanese patients underwent endoscopic retrograde pancreatography (ERP) for suspected pancreatic disease, and 161 were diagnosed with chronic pancreatitis. Among them, we found three cases (1.86% incidence) of unique chronic pancreatitis, in which ERP revealed diffuse narrowing of the main pancreatic duct with an irregular wall. We diagnosed these three patients as having pancreatitis associated with an autoimmune mechanism morphologically and biochemically and started them on steroid therapy. The characteristics of the these three patients were as follows: hypergammaglobulinemia, eosinophilia, ultrasonography showing hypoehoic diffuse swelling in the pancreas (sausage-like appearance), ERP showing diffuse narrowing of the main pancreatic duct with irregular like thumbprint-like marks, reversible exocrine insufficiency, and positive anti-carbonic anhydrase II antibody. After one month of the treatment with steroids, pancreatitis dramatically improved morphologically and enzymatically. Here we describe these cases of the suspected autoimmune chronic pancreatitis. We must recognize the concept and the features of autoimmune pancreatitis in order to avoid unnecessary surgery as pancreatic cancer.

Antibodies to carbonic anhydrase in endometriosis: prevalence, specificity, and relationship to clinical and laboratory parameters

OBJECTIVE

To investigate the presence and clinical association of serum autoantibodies to carbonic anhydrase (CA) in women with and without endometriosis.

DESIGN

Sera were tested in an ELISA against human and bovine CAI and/or CAII isoenzymes and by Western immunoblotting of trypsin-digested fragments of human CAII as antigens. The ELISA positivity was defined as mean + 2 SD of 100 control sera. Positive sera also were tested for the presence of antiendometrial antibodies and antinuclear antibodies (ANA) by indirect immunofluorescence assays (IFA) on endometrial (ECC) and HEp-2 cells, antibodies to single-stranded (ss) and double-stranded (ds) DNA by the Farr-type RIA and Crithidia IFA, and extractable nuclear antigens (Sm, nRNP, Ro, and La) by an ELISA.

PATIENTS

Sera from 319 patients with laparoscopic diagnosed pelvic endometriosis (100 stage I, 95 stage II, 67 stage III, and 57 stage IV), 100 with other gynecologic disorders, and 100 control women were used.

RESULTS

In the ELISA, 113 of 319 (35.4%) endometriosis sera had elevated immunoglobulin G antibodies against nondenatured CA isoenzymes. The reactivity of sera from the endometriosis group was significantly higher (35%) in all four subgroups of patients than each of the nonendometriosis sera (< 12% and < 6%, respectively). No stage-dependent variation of an autoantibody pattern was evident. However, anti-CA autoantibodies were present in 66.3% of women with endometriosis-associated infertility. The frequency of anti-CA autoantibodies was significantly higher (by 51.7%) in women with antiendometrial antibodies detectable by IFA. In addition, in sera positive for anti-CA antibodies, the frequency of ANA also was increased (20/113 [17.6%]) with titers of 1:40 to 1:1,080. The ANA-positive sera were negative for anti-ssDNA, anti-dsDNA, anti-Sm, anti-nRNP, and anti-La. However, three sera were positive for anti-Ro antibodies. Immunoblotting study of autoantibody reactivity with trypsin-digested subfragments of human CAII revealed consistent immunoreactivity with 14 to 6.2-kd range CAII peptides.

CONCLUSIONS

[1] A subgroup of patients with endometriosis have autoantibodies directed to native and linear epitopes of the CA protein. [2] Prevalence of anti-CA antibodies was associated with antiendometrial antibodies and ANA. [3] Anti-CA antibodies were associated with a higher predictive value of the disease when all patient subgroups were considered together.