Procainamide-induced serologic changes in asymptomatic patients

Edmund Lawrence Dubois (1923-1985)

In the year 1950, Edmund Dubois was asked to evaluate eight patients who had positive results from a new blood test known as the LE cell prep. This was the springboard for him to launch a career that elucidated new and unique insights into the pathogenesis, clinical presentation, laboratory testing, and treatment of systemic lupus erythematosus. Between 1950 and 1985, he treated more than 2000 patients with the disorder and wrote the principal textbook on the subject.

Quinidine-induced rheumatic syndromes

Quinidine is a commonly used antiarrhythmic agent that is rarely associated with rheumatologic toxicity. However, quinidine-induced lupus, antinuclear antibody negative lupus-like syndrome, polymyalgia rheumatica-like illness, muscle weakness, and isolated creatine phosphokinase elevation have all been reported. We present one case of quinidine drug-induced lupus and another of a quinidine-induced polymyalgia rheumatica-like illness, and review the English literature for rheumatologic toxicity due to quinidine. Prompt recognition of quinidine associated rheumatologic toxicity is important because discontinuation of the medication leads to rapid resolution of clinical symptoms.

Case Report: Distinctive Immune Abnormalities in a Patient with Procainamide-Induced Lupus and Serositis

To gain insight into the immunopathogenesis of drug-induced autoimmune disorders, lymphocyte and immunoglobulin distributions and cytokine levels were monitored in the peripheral blood and pleural fluid of a patient with procainamide-induced lupus and pleural effusion. Approximately 80% of the B cells in both compartments were CD5+ compared to 10% to 25% in normal adults. CD4/CD8 ratio and percentage CD4 were normal in peripheral blood. Serum levels of IgG (particularly IgG2), IL-6, and soluble IL-2R were slightly elevated, and those of IgA were significantly elevated compared to normal controls. Analysis of the pleural effusion revealed an increased CD4/CD8 ratio because of an increased percentage of CD4+CD29+ helper memory T cells, lack of expression of the resting B-cell marker CD21, immune complex deposition and complement consumption, increased relative levels of ANA, abnormally high levels of IL-6 and soluble IL-2R, and detectable levels of IL-1b, IFN-g and TNF-a. These observations provide evidence for the involvement of CD5+ B cells and differential helper T-cell activity in procainamide-induced lupus and for an association between local lymphocyte activation and organ pathology.

Procainamide induces a transitory impairment of B cell mitogenesis in beagle dogs

Beagle dogs (3 to 6 years old) were treated with 100-150 mg procainamide HC1/kg/day. After 2, 5, and 9 months of treatment, peripheral blood lymphocytes were isolated and stimulated with pokeweed mitogen. The data demonstrated a suppression of mitogenesis only at 2 and 5 months after procainamide treatment. The lymphocytes from dogs treated for 9 months had a normal response to pokeweed mitogen. At no time during this experiment were any significant levels of serum antinuclear antibodies detected nor was any change in the number of cycling lymphocytes apparent in the experimental versus control groups. The resting membrane potential of both control and experimental groups was similar and pokeweed mitogen depolarized the cells from both groups.

Antinuclear antibodies during psoralens plus ultraviolet A (PUVA) therapy--are they worthwhile?

From 1979 to 1985, 497 patients with psoriasis were started on psoralens plus ultraviolet A (PUVA) therapy at Northwestern University. Two hundred sixty-nine of these received therapy for greater than 3 months and had at least two antinuclear antibody (ANA) determinations. We have found that the difference between the number of significantly positive ANAs pre-PUVA therapy (4 of 269) compared to post-PUVA therapy (16 of 269) was not statistically significant. Furthermore, of the patients who did develop a significantly positive ANA, not one was found to have any symptoms, signs, or laboratory evidence of systemic lupus erythematosus. We therefore suggest obtaining ANAs prior to initiating PUVA therapy and obtaining follow-up ANAs only if the initial ANA is significantly positive. Patients with pre-PUVA--positive ANAs can be started on PUVA therapy if there is no evidence of lupus erythematosus.

Quinidine induced lupus syndrome

Five patients with a lupus-like syndrome secondary to quinidine are described. Eleven other cases have previously been reported. The quinidine induced lupus syndrome is similar to that seen with procainamide and hydralazine treatment but occurs less frequently. The lower incidence may reflect a difference in the metabolism of quinidine. Quinidine should be considered as potentially responsible when multisystem disease appears in patients receiving this drug.

Effects of long-term procainamide therapy on immunoglobulin synthesis

Procainamide is a potent inducer of autoantibodies. In order to evaluate the immunologic effects of this drug in vivo, 23 cardiac disease patients who had received procainamide for at least 6 months and an equal number of matched cardiac disease control subjects were studied, and percentage of circulating T cell subsets, concanavalin A-induced suppressor cell activity, and pokeweed mitogen--stimulated generation of immunoglobulin-secreting cells was quantitated. There was no significant difference between patient and control groups in the percentage of T cell subsets defined by OKT4 and OKT8 monoclonal antibodies or in concanavalin A-induced suppressor cell activity. The numbers of pokeweed mitogen--induced immunoglobulin-secreting cells were markedly decreased in the patient group, as measured by the protein A-augmented reverse hemolytic plaque assay (3,000 +/- 644, mean +/- SEM in patients versus 10,826 +/- 1,529, mean +/- SEM in control subjects, P less than 0.005). Removal of the adherent cell fraction did not improve the hyporesponsiveness. When B and T cell fractions of 6 patients were mixed with normal T and B cell fractions, all of the patients demonstrated diminished B cell responses, and one-half also had diminished T cell responses. Addition of patient adherent cells to a co-culture of normal B cells with deficient patient T cells restored plaque formation to normal levels, suggesting that the T cell defect was correctable by a macrophage-derived factor. The data obtained suggest that procainamide exerts an immuno-suppressive action on both B and T cell function in patients receiving this drug.

Quinidine-induced photosensitive livedo reticularis-like eruption

A 39-year-old white man who was taking quinidine developed a purpuric eruption in a photodistributed livedo reticularis-like pattern. This is the fourth reported case of a similar eruption in patients taking quinidine. Possible pathophysiologic mechanisms for nonthrombocytopenic drug-induced purpuras are discussed.

Antinuclear antibodies as indicators for the procainamide-induced systemic lupus erythematosus-like syndrome and its clinical presentations

Fifty patients on a regimen of procainamide were studied in regard to the association between antinuclear antibodies (ANA) and the development of drug-induced systemic lupus erythematosus (SLE)-like syndrome. Four groups were identified: Group 1 was ANA-positive, with clinical manifestations (serologic and clinical findings); Group 2 was ANA-positive, without clinical manifestations (serologic findings only); Group 3 was ANA negative (no patients with clinical manifestations); and Group 4 had SLE persisting after discontinuance of procainamide. The leukocyte-specific ANA (LSANA) patterns were predominant, with peripheral LSANA confined to Groups 1 and 4. Furthermore, the titer of the homogeneous LSANA, to which peripheral LSANA converts on dilution, was clinically significant. A homogeneous LSANA titer of 160 or greater was seen essentially only in patients with clinical manifestations of the SLE-like syndrome. Serial ANA determinations are therefore necessary to monitor patients receiving procainamide.

Positive direct antiglobulin tests and immune hemolytic anemia in patients receiving procainamide

To characterize the autoimmune phenomena in patients receiving procainamide, we studied the prevalence of positive direct antiglobulin (Coombs') tests and immune hemolytic anemia in 100 such patients and compared them with 100 age-matched and sex-matched controls. There was a significant increase in the frequency of positive direct antiglobulin tests in patients receiving procainamide (21 vs. 10 per cent, P = 0.05). The mechanism of red-cell sensitization in patients receiving procainamide was the production of red-cell autoantibody, which was serologically indistinguishable from that seen in warm autoimmune hemolytic anemia. In contrast, positive direct antiglobulin tests in control patients were due to the presence of complement components. Red-cell autoantibody production secondary to procainamide was not correlated with a higher-than-expected frequency of antinuclear antibodies or the clinical syndrome of drug-induced lupus erythematosus. In the series of 100 patients receiving procainamide, we identified three cases of immune hemolytic anemia. In two of the three cases, the anemia resolved after the medication was discontinued and did not require steroid therapy. We conclude that procainamide often results in the production of red-cell autoimmune phenomena.

Specificity of anti-DNA antibodies in SLE--II. Relative contribution of backbone, secondary structure and nucleotide sequence to DNA binding

Fine specificity of a population of anti-DNA antibodies which bound both ssDNA and dsDNA with apparently equal affinity was studied in two SLE plasma. Sensitivity of DNA binding to increasing sodium chloride concentration indicated that electrostatic interactions occurred between antibody and phosphate moieties of DNA. Secondary nucleic acid structure was important to DNA binding as double-stranded synthetic deoxynucleotide polymers were more effective inhibitors than their substituent single-stranded polymers. Nucleotide bases were also found to play a role in recognition of DNA by these cross-reactive antibodies, as ssDNA binding was sensitive to increasing temperature which caused unstacking of the nucleotide bases. Differing patterns of reactivity with synthetic deoxynucleotide polymers with similar secondary structures but different nucleotide compositions further indicated the importance of nucleotide bases to dsDNA binding by cross-reactive anti-DNA antibodies in SLE plasma.

Immunomodulatory effect of procainamide in man. Inhibition of human suppressor T-cell activity in vitro

Procainamide (PA) induces the production of a number of autoantibodies in a high proportion of treated individuals and in some a syndrome closely resembling systemic lupus erythematosus. The mechanism underlying this action of PA is unclear. To examine the possibility that PA might induce autoantibody formation by altering normal immunoregulatory mechanisms, the action of this drug on an in vitro model of antibody formation in man was examined. PA was found to augment the generation of immunoglobulin-secreting cells (ISC) from human peripheral blood mononuclear cells (PBM) in response to pokeweed mitogen but had no effect on pokeweed mitogen-induced tritiated thymidine incorporation. When purified populations of B and T cells were used, PA enhanced the generation of ISC in B-cell cultures supported by untreated T cells but not by T cells treated with mitomycin C. These results indicate that PA augmented B-cell responses by inhibiting suppressor T-cell activity and not by augmenting helper T-cell or B-cell function. N-Acetyl-procainamide had no effect on the generation of ISC in this system. The effect of PA on concanavalin A (Con A)-induced suppressor cell activity was also examined to determine whether PA altered the generation or expression of suppressor T-cell function. PBM were cultured with 30 microgram/ml of Con A for 48 h to generate suppressor cells. When these were co-cultured with fresh PBM, the number of ISC generated was decreased by 58.1 +/- 3.4% (mean +/- SEM, n = 6). Cells that had been similarly incubated without Con A were not inhibitory. The addition of PA to the Con A-stimulated cultures inhibited the generation of suppressor cells as indicated by the fact that the response of fresh cells co-cultured with the Con A-stimulated cells was diminished by only 27.2 +/- 4.3%. In this system too, N-acetyl-procaimamide had no effect. By contrast, adding PA only to the co-culture of Con A-stimulated cells with fresh PBM had a less marked effect on suppressor cell function. These results indicate that the major action of PA is to inhibit the generation of suppressor T-cell activity. Such an effect may explain the capacity of this agent to induce autoantibody formation in treated individuals.

Immune regulatory abnormalities produced by procainamide

The pathogenesis of procainamide-induced autoantibody production is unknown. To test the effect of procainamide on the immune system, we studied in vitro suppressor cell function and immunoglobulin G (IgG) secretion in 11 patients who developed autoantibodies while taking procainamide. The procainamide group was compared with patients with spontaneous systemic lupus erythematosus (n = 15) and a normal control population (n = 40). Impaired in vitro suppressor cell function was found in 11 of 14 patients with spontaneous systemic lupus erythematosus but in none of the patients taking procainamide. However, total in vitro IgG secretion was significantly increased in the procainamide group with regard to the control and systemic lupus erythematosus groups. There was a direct correlation between the circulating anti-SS DNA antibody titer and in vitro IgG secretion. Furthermore, T cells isolated from the procainamide-treated patients stimulated IgG secretion by normal allogeneic peripheral blood lymphocytes. The added T cells did not affect in vitro suppressor cell function. We postulate that autoantibody production in patients taking procainamide is due to enhanced helper T cell function and not to impaired suppression. However, the development of clinical disease requires the participation of additional genetic or immunologic factors.

Systemic lupus erythematosus

A case of osteomyelitis of the mandible in a patient with systemic lupus erythematosus is described. Both the disease process and the treatment modalities must be understood for correct management.

Lymphocyte alteration by procainamide: relation to drug-induced lupus erythematosus syndrome

Sera from 11 (65%) of 17 patients with newly diagnosed procainamide-induced lupus contained cold-reactive lymphocytotoxic antibodies to normal human lymphocytes in titres of 1/2 to 1/128. In contrast, only 3 of 15 patients on long-term procainamide therapy without lupus and 3 of 65 normal men had serum lymphocytotoxic antibodies, none at a titre higher than 1/2. Antibody levels in the lupus patients declined quickly after procainamide was stopped, in parallel with their clinical improvement. Procainamide (3.75 x 10(-3) mol/l) suppressed by more than 80% in-vitro phytohaemagglutinin-induced 3H-thymidine incorporation by normal human blood lymphocytes. At 3.75 x 10(-4) mol/l, procainamide enhanced the mitogenic response to 160 +/- 20% of normal. Thus procainamide may interact with the lymphocyte membrane, possibly producing a lupus syndrome directly, by altering lymphocyte function, or indirectly, by generating autoantibodies reactive with normal membrane structures.

Avidity of antibodies in SLE: relation to severity of renal involvement

The avidity of antibodies to DNA in the sera of 8 patients with SLE was determined by saturation analysis and Scatchard plots. Five of the patients had severe lupus nephritis; the other 3 had relatively mild or no kidney disease. The Scatchard plots revealed components with high relative avidity in the patients with severe nephritis (K values 4.4-10.4 X 10(5) M-1 for nDNA), compared with the patients who had mild or no kidney disease (K values 0.3-1.8 X 10(5) M-1 for nDNA). Avidity measurements may be helpful in the evaluation and treatment of patients with SLE.

Antinuclear antibodies (ANA): immunologic and clinical significance

The methods currently used for the detection of ANA have been analyzed, with emphasis on their practical application to the diagnosis of the CTD. The use of the indirect IF-ANA test was recommended as a screening procedure to detect ANA. The need to standardize the technique using a single substrate and fluorescent conjugates with uniform F/P ratios was stressed. Most importantly, the value of titrating ANA for the diagnosis of the CTD was discussed. ANA titers higher than 1/500 are usually very significant clinically, often found in spontaneous or drug-induced SLE and few other CTD. The immunologic aspects of ANA and their potential value as aids in the diagnosis and management of the CTD were discussed. Anti-nDNA antibodies have been found to have a high degree of specificity for SLE and high titers of these antibodies correlate well with low levels of serum complement and severity of kidney involvement. The spectrum of ANA in the sera from patients with SLE has been expanded with the finding of anti-Sm antibodies which, when detected by gel precipitation with prototype serum, have been found so far only in SLE. Some of these antibodies have been found to have prognostic significance. Patients with MCTD and a group of patients with SLE have high titers of serum ANA with specificity for an RNase-sensitive component of ENA. The group of SLE patients defined by the presence of these antibodies (anti-Mo) have a better prognosis and in general develop only mild nephritis or have no kidney involvement at all. High titers of pure antinucleolar antibodies probably are found almost exclusively in the sera of patients with scleroderma. Some ANA have organ specificity, and GS-ANA have been found in all patients with Felty's syndrome and in a large proportion of patients with RA. One of the great advances in the field has been the recognition that ANA can be induced in the human and in experimental animals by the use of a number of therapeutic agents. Some of these agents can also induce a clinical picture resembling spontaneous SLE, though kidney involvement does not occur or is extremely mild. It is interesting that the whole spectrum of ANA can be found in drug-induced LE except anti-nDNA antibodies which have been associated to the pathogenesis of immune complex nephritis in spontaneous SLE. There is no doubt that research on ANA has contributed a great deal to the understanding of the CTD and will continue to be a valuable tool for the clinician and the investigator.

Clinicopathological study of a patient with procainamide-induced systemic lupus erythematosus

A patient who developed a multisystem involvement of systemic lupus erythematosus (SLE) after 9 years of procainamide therapy, during which time he ingested enormous amounts of the drug, is described. The patient first suffered from recurrent episodes of pleuritis and arthritis, after which he developed a characteristic SLE nephritis associated with a high level of antinative DNA antibodies and a low level of complement. He finally died from a complication of a nonbacterial endocarditis. Autopsy showed polyserositis and typical deposits of electron-dense material on the glomerular basement membrane, and confirmed the clinical diagnosis of Libman-Sacks endocarditis. The possibility that procainamide-induced SLE might have all the clinical, immunological, and pathological features of spontaneous SLE, especially in patients exposed to large doses of the drug for many years, is discussed.

Comparison of procainamide and mexiletine in prevention of ventricular arrhythmias after acute myocardial infarction

The incidence of ventricular arrhythmias after myocardial infarction has been compared in a controlled study of procainamide, mexiletine, and placebo. Sixty male patients who has sustained a myocardial infarction and had received lignocaine for ventricular tachycardia or ventricular ectopic beats which were R-on-T, multiform, or close-coupled took part. The efficacy of the drugs was evaluated by continuous 24-hour recordings of the electrocardiogram on the 4th and 10th days after admission to the study. Procainamide was given as 500 mg. 4-hourly and mexiletine as 250 mg. 8-hourly with corresponding placebo regimens for 12 days. 77% of patients receiving placebo showed serious ventricular rhythm disorders compared with 33% receiving antiarrhythmic therapy (p smaller than 0.05). Although only 35% of patients receiving procainamide achieved accepted therapeutic plasma concentrations compared with 95% of those receiving mexiletine, both drugs were equally effective antiarrhythmically. The only major adverse effect of therapy noted was development of a positive antinuclear factor in a procainamide-treated patient. These results demonstrate the efficacy of oral antiarrhythmic agents in the management of ventricular arrhythmias after acute myocardial infarction. Mexiletine has the advantage of less frequent administration and lower toxicity.

Long-term use of procaine amide following acute myocardial infarction

The safety of long-term prophylactic antiarrhythmic therapy with procaine amide was studied in 78 patients recovering from acute myocardial infarction. Patients were randomly allocated to a control or treatment group and followed monthly for up to 2 years with ambulatory ECG monitoring and measurement of serum drug level, antinuclear antibody (ANA) titer, LE preparation, blood count, BUN, and SGOT. Early reactions forced discontinuation of therapy in nine of 39 treated patients within the first 3 weeks. Late reactions were observed in 14 of 16 patients who took procaine amide for 3 months or longer. Every patient on therapy for 1 year or longer demonstrated elevation in ANA titer. Comparison of monitoring data between these two groups revealed no difference in the incidence of occasional or frequent premature ventricular beats. However, during the first 6 months, treated patients tended to have fewer major arrhythmias. There were fewer sudden deaths among treated patients, but this difference did not reach statistical significance at the 5% level. It is concluded that the high incidence of toxic reactions precludes widespread use of long-term prophylactic procaine amide therapy. More precise identification of a sudden death-prone population might justify such therapy in such selected cases.