Effect of therapeutic dosages of prednisone on human immunoglobulin G metabolism

Refractory postoperative Staphylococcus hominis bacteremia in a patient with an ACTH-producing pancreatic neuroendocrine neoplasm: a case report

Background

Staphylococcus hominis (S. hominis) is an opportunistic pathogen that is often highly resistant to antibiotics and is difficult to treat. In patients diagnosed with an adrenocorticotropic hormone (ACTH)-producing tumor that compromises the immune system due to hypercortisolemia, cancer treatment and infection control should be considered simultaneously. This report presents a case of refractory postoperative S. hominis bacteremia requiring the prolonged administration of several antibiotics in a patient with an ACTH-producing pancreatic neuroendocrine neoplasm (pNEN).

Case presentation

A 35-year-old man visited a neighboring hospital for a thorough examination after experiencing weight gain and lower limb weakness for several months. Enhanced computed tomography revealed a pancreatic tail tumor and bilateral adrenal enlargement. Elevated plasma ACTH and serum cortisol were noted. Biopsy under endoscopic ultrasonography revealed the tumor as an ACTH-producing pNEN. The patient was transferred to our hospital for further treatment. Pneumocystis pneumonia was noted and treated with sulfamethoxazole and adjunctive glucocorticoids. Hypercortisolism was controlled with metyrapone and trilostane. Somatostatin receptor scintigraphy and ethoxybenzyl magnetic resonance imaging detected other lesions in the pancreatic head. A total pancreatectomy was performed given that the lesions were found in both the pancreatic head and tail. Plasma ACTH and serum cortisol levels decreased immediately after the resection. Pathological examination revealed that the pancreatic tail tumor was NEN G2 and T3N1aM0 Stage IIB and the pancreatic head lesions were SSTR-positive hyperplasia of the islet of Langerhans cells. On postoperative day 11, catheter-associated bacteremia occurred. Initially, meropenem hydrate and vancomycin hydrochloride were administered empirically. S. hominis was identified and appeared sensitive to these antibiotics according to susceptibility testing. However, S. hominis was repeatedly positive in blood cultures for more than one month, despite treatment with several antibiotics. Eventually, with the combined use of three antibiotics (meropenem hydrate, vancomycin hydrochloride, and clindamycin phosphate) for more than 3 weeks, the S. hominis-associated bacteremia improved. He was discharged 79 days after surgery.

Conclusions

Our patient with an ACTH-producing pNEN was immunocompromised and needed meticulous attention for infectious complications even after successful tumor removal. Specifically, S. hominis bacteremia in such patients demands intensive treatments, such as with combinational antibiotics.

Estrogen, the Peripheral Immune System and Major Depression – A Reproductive Lifespan Perspective

Major depression is a significant medical issue impacting millions of individuals worldwide. Identifying factors contributing to its manifestation has been a subject of intense investigation for decades and several targets have emerged including sex hormones and the immune system. Indeed, an extensive body of literature has demonstrated that sex hormones play a critical role in modulating brain function and impacting mental health, especially among female organisms. Emerging findings also indicate an inflammatory etiology of major depression, revealing new opportunities to supplement, or even supersede, currently available pharmacological interventions in some patient populations. Given the established sex differences in immunity and the profound impact of fluctuations of sex hormone levels on the immune system within the female, interrogating how the endocrine, nervous, and immune systems converge to impact women’s mental health is warranted. Here, we review the impacts of endogenous estrogens as well as exogenously administered estrogen-containing therapies on affect and immunity and discuss these observations in the context of distinct reproductive milestones across the female lifespan. A theoretical framework and important considerations for additional study in regards to mental health and major depression are provided.

Case Report-Secondary Antibody Deficiency Due to Endogenous Hypercortisolism

Therapeutic corticosteroids have an immunosuppressive function involving several pathways, including lymphocytopenia and hypogammaglobulinemia. While these effects have been well-described in patients that received corticosteroids for therapeutic reasons, the effects of endogenous corticosteroids on the immune system are less well-understood. Here, we describe a 21-year old patient with hypercortisolism due to an ACTH producing thymic tumor. In this patient, we observed a decrease in some of the immunoglobulin classes, and in specific B and T cell populations that resembled effects caused by corticosteroid treatment. IgG levels were restored following treatment and normalization of the hypercortisolism.

Primary immune deficiency diseases as unrecognized causes of chronic respiratory disease

BACKGROUND

More than half of all primary immune deficiency diseases (PIDD) affect antibody production and are well known as causes of recurrent sinusitis and lung infections. Chronic and recurrent infections of the upper and/or lower airways can contribute to inflammatory and obstructive processes in the lower airways which are initially reversible and considered "asthma", but can eventually cause irreversible remodeling and chronic obstructive pulmonary disease (COPD). Conversely, several lines of evidence suggest that many patients who present with a diagnosis of asthma have an increased incidence of infection, suggesting underlying host-defense defects. Asthma and respiratory infections in the first decades of life are recognized as risk factors for development of COPD, but when patients present with COPD as adults, underlying primary immune deficiency disease may be unrecognized.

MAIN FINDINGS AND CONCLUSIONS

Detection of PIDD as a potentially treatable underlying contributor to recurrent/acute exacerbations and morbidity of COPD, and provision of immunoglobulin (Ig) G replacement therapy, when appropriate, may decrease the progression of COPD. Decreasing the severity and rate of exacerbations and admissions should improve the quality of life and longevity of an important subset of patients with COPD, while decreasing costs. Major steps toward achieving these goals include developing a high index of suspicion, more frequent use and appropriate interpretation of screening tests such as quantitative immunoglobulins and vaccine responses, and prompt institution of IgG replacement therapy when antibody deficiency has been diagnosed.

Suppression of the immune system by oral glucocorticoid therapy in bronchial asthma

The effect of systemic glucocorticoid therapy on immune parameters was studied in patients with bronchial asthma. Patients were divided into two groups: 1) those receiving oral glucocorticoid; 2) control patients who did not receive systemic glucocorticoid treatment. The glucocorticoid dose varied between 5 and 70 mg per day. Patients had been taking oral therapy for at least 1 year. Glucocorticoid treatment was associated with an increased frequency of respiratory tract infections. Therefore, we need to define immune parameters which may predict an increased risk of infections. In this study, we analyzed several surface markers on lymphocytes and monocytes by flow cytometry. A significant reduction of the ratio of peripheral blood CD4+ to CD8+ T cells was associated with the administration of oral glucocorticoids. Furthermore, the expression of the HLA-DR molecule on monocytes was reduced in patients with systemic glucocorticoid therapy compared to control patients. Moreover, the capacity to elaborate cytokines by peripheral blood mononuclear cells upon stimulation was greatly reduced after exposure to glucocorticoids in vivo and in vitro. In addition, the humoral immune response was affected, because reduced IgG, IgM, and IgA levels were observed in patients receiving oral glucocorticoids. These results indicate that systemic glucocorticoid treatment in patients with bronchial asthma is associated with cellular and humoral immunosuppression which results in an increased risk of bacterial and viral infections.

Humoral immunity in steroid-dependent children with asthma and hypogammaglobulinemia

OBJECTIVE

To determine primary and secondary antibody responses in children with hypogammaglobulinemia attributed to corticosteroid use.

RESULTS

In seven patients with steroid-dependent asthma and significant hypogammaglobulinemia (IgG concentration, 275 to 443 mg/dl), antibody responses to protein and polysaccharide antigens were shown to be normal, as were primary and secondary responses to a neoantigen, bacteriophage phi X174.

CONCLUSIONS

Patients with asthma, and with hypogammaglobulinemia resulting from steroid therapy, have normal humoral immunity, and immunoglobulin replacement therapy is not indicated.

In vitro and in vivo effect of glucocorticoids on IgE and IgG subclass secretion

Hydrocortisone (HC) as well as its synthetic derivatives have been shown to strongly enhance interleukin-4 (IL-4)-induced in vitro IgE synthesis. To investigate possible effects on IgG subclasses, peripheral blood mononuclear cells (PBMC) were incubated with different glucocorticosteroids in the absence or presence of IL-4. The glucocorticoids alone led to a strongly enhanced secretion of IgG1, IgG2 and IgG3, but not IgG4. The addition of IL-4 induced marked increases in IgG1 and IgG4, no changes in IgG3, but a consistent decrease in IgG2 synthesis. In order to find out whether these profound in vitro effects of corticosteroids are also reflected by changes in antibody serum levels during steroid treatment, 10 healthy volunteers took 25 mg prednisone for 7 consecutive days. We could not observe any significant changes of IgE or IgG subclass serum levels during or after this period. However, cell cultures performed after the glucocorticoid treatment revealed a marked decrease in the ability to produce IgG4 and a significantly lower potential to produce IgE in response to IL-4 alone or IL-4 and HC. We conclude that, although strongly implicated by the in vitro results, glucocorticosteroid treatment does not result in an increased allergy risk.

Autoantibodies to recombinant lipocortin-1 in rheumatoid arthritis and systemic lupus erythematosus

Corticosteroids may mediate some of their anti-inflammatory effects via induction of a specific 38 kD protein, lipocortin-1. Autoantibodies to lipocortin-1 were measured by enzyme linked immunosorbent assay (ELISA) in 90 healthy subjects and in 63 patients with rheumatoid arthritis (RA), 36 with systemic lupus erythematosus (SLE), 26 with polymyalgia rheumatica, and 13 with chronic airways disease. Sixteen patients with RA receiving prolonged, high steroid doses (prednisolone greater than 7.5 mg/day) had raised IgM antilipocortin-1 levels, while 19 patients with RA untreated with steroids had normal levels. This association was independent of disease activity. In SLE, raised antilipocortin-1 levels were associated with active disease and were independent of steroid treatment. Antilipocortin-1 antibody levels were not raised in patients with polymyalgia rheumatica and chronic airways disease. Thus steroid treatment alone appears insufficient to induce antilipocortin-1 antibodies, unless an underlying autoimmune state is also present. In RA, antilipocortin-1 antibodies may impair anti-inflammatory actions of steroids and render some patients 'steroid resistant'.

Analysis of the action of corticosteroid treatment in immunologic infertility: a preliminary report and an alternative hypothesis

The presence of sperm antibodies can be demonstrated in 8-10% of the male partners of infertile couples. The therapeutic schedule with which the highest pregnancy rate has been obtained in these cases is that proposed by Shulman, which uses methylprednisolone (MP). If treatment with corticosteroids (CS) is effective, the way in which it acts is not entirely clear. In this study we report the results of 16 treatment cycles with CS administered to eight male patients having sperm antibodies in their serum, in which several parameters of humoral immunity were evaluated. The results are conflicting: several parameters (such as IgG concentration) underwent only slight variations after 7 days of therapy, whereas in 12 cycles out of 16, the Tray agglutination test (TAT) indicated that a reduction or disappearance of the antibodies had been obtained. This confirms the usefulness of CS in immunological infertility, and allows us to hypothesize that the beneficial effect may be found in a reduction of inflammation rather than in a suppression of the immunological response, since CS are well known to have these two kinds of effect.

Effects of intraperitoneal 6% dextran 70 on serum immunoglobulin levels, peripheral cell populations, and lymphocyte subpopulations in women undergoing gynecologic surgery

Twelve women underwent elective major gynecologic surgery for benign, non-pregnancy-related conditions. No perioperative or postoperative "anti-adhesion" adjuvants were used. Serum immunoglobulin levels (IgG, IgM, IgA) and peripheral cell counts, including lymphocyte subpopulations, were measured in each patient during the immediate preoperative and postoperative periods as well as 5 to 8 weeks later. These results were compared to a treatment population of 16 women who underwent similar surgery and received 150 ml 6% dextran 70 intraperitoneally at the conclusion of the procedure. There was a decrease in the level of all serum immunoglobulins measured in the immediate postoperative period in both groups (not statistically different). At 5 to 8 weeks postoperatively there was a greater level of IgM in the control population than in the dextran-treated group (P = 0.03). Alterations in the peripheral cell counts, including lymphocyte subpopulations, were similar in the two groups. The use of intraperitoneal 6% dextran 70 did not result in postoperative alterations in the human immune system different from those induced by the surgical procedure itself.

The effect of corticosteroids upon the number and organ distribution of "background" immunoglobulin-secreting cells in mice

The influence of the synthetic corticosteroid dexamethasone sodium phosphate (DEXA) upon the immunoglobulin (Ig)-secreting cells was studied in not intentionally immunized BALB/c mice. This was done for IgM-, IgG-, and IgA-secreting cells in spleen, mesenteric lymph nodes (MLN), and bone marrow (BM). A single injection of DEXA (16 to 144 mg/kg body wt) markedly reduced the number of Ig-secreting cells in spleen and MLN within 1 day, but hardly affected their number in the BM. The decrease was immediately followed by a recovery and, at the highest doses and especially in MLN, by an overshoot. Two weeks after the initial decrease a second decrease was found. When mice were subjected to daily treatment with DEXA during 1 week, initially a recovery pattern was found in spleen and MLN similar to that found after a single injection of a high dose. In this case, however, the effects were less dose dependent, and the overshoot reaction was followed by a period of subnormal numbers of Ig-secreting cells which lasted at least 1 week. This late effect of DEXA not only occurred in spleen and MLN, but also in the BM. The most prominent effect of daily treatment with DEXA was the long-lasting decrease of the number of IgG-secreting cells starting 1 week after withdrawal of treatment. This decrease was associated with a severely decreased serum IgG level.

Effects of dexamethasone therapy on serum immunoglobulin levels and peripheral cell counts in women undergoing conservative benign gynecologic surgery

Twenty women undergoing conservative gynecologic surgery were treated perioperatively with high-dose dexamethasone (DEX) for 72 hours. Serum immunoglobulin levels (IgG, IgM, IgA) and peripheral cell counts, including lymphocyte subpopulations, were measured in each patient during the immediate preoperative and postoperative periods as well as 5 to 8 weeks later. These results were compared with the levels of a control population of 16 women undergoing conservative, non-pregnancy-related gynecologic surgery for benign conditions. There was a decrease in the level of all serum immunoglobulins measured in the immediate postoperative period in both groups, with a greater statistical decrease in the control group (P less than 0.001). statistically significant transient alterations in the peripheral cell counts occurred in the DEX group, as compared with the control group (P less than 0.001). The use of DEX was not associated with any postoperative infectious morbidity.

Free light chains in serum during short course immunosuppression after corneal transplantation

The effect of low doses of prednisone on the serum concentration oflight chains, IgG, IgA and IgM in nineteen corneal transplanted patients was investigated. Prednisone in doses of 30 mg daily for 6 days had an instantaneous effect on the concentration of light chains resulting in a mean decrease of 16.5% in relationship to the pre-treatment values. Decrease in the prednisone dose to 15 mg daily was followed by normalization of the light chain concentration. The effect of prednisone on the IgG concentration was less pronounced and more delayed. A mean decrease for IgG of 9.0% of the pre-treatment values was found. Minimum IgG concentration was found 3 weeks later than the minimum for light chains. Differences in the metabolization rate of light chains and IgG is suggested as an explanation for this. The concentration of IgA and IgM was unchanged during treatment. Correlation between corneal rejection and changes in the level of light chains or IgG was not found.

Metabolism of autologous and homologous IgG in rheumatoid arthritis

The metabolism of radioiodinated IgG was studied in 20 patients with rheumatoid arthritis and 11 normal controls using autologous IgG and homologous IgG pooled from normal donors. Fractional catabolic rates in the controls were 4.44% of the autologous- and 4.29% of the homologous-labeled protein per day. The corresponding rates in the rheumatoid patients were 9.67% of the autologous- and 8.64% of the homologous-labeled protein per day. Extravascular catabolism occurred only in the rheumatoid group and accounted essentially for the entire increased catabolism of IgG observed in these patients. 10 patients were especially hypercatabolic, with fractional catabolic rates for autologous IgG greater than 10%. Moreover, they catabolized their autologous IgG significantly faster than the homologous IgG (12.6 vs. 9.9%). The increment of catabolism of autologous over homologous IgG also occurred in the extravascular compartment. These highly hypercatabolic patients had a significantly increased number of manifestations of extra-articular disease. The hypercatabolism of IgG could not be correlated with age, weight, sex, duration of disease, joint erosions, corticosteroid therapy, erythrocyte sedimentation rate, rheumatoid factor titer, serum IgG concentration, or circulating immune complexes as measured by the Raji cell radioimmunoassay. Conceivable sites of extravascular catabolism and possible causes of faster catabolism of autologous (rheumatoid) than of homologous (normal) IgG are discussed.

Effects of corticosteroids on immunity in man. I. Decreased serum IgG concentration caused by 3 or 5 days of high doses of methylprednisolone

To study the effects of methylprednisolone on immune mechanisms in the absence of other immunosuppressive agents or immunologically mediated diseases, we gave 17 normal adult male volunteers 96 mg of methylprednisolone daily for 3-5 days and compared results with 12 untreated controls who were studied simultaneously, 86% of treated volunteers had significant decreases in the concentrations of serum IgG. 2-4 wk after methylprednisolone, the treated volunteers had a mean decrease in IgG of 22% compared with a decrease of only 1% in untreated controls. Likewise, significant decreases in IgA concentration occurred in 43% of treated volunteers, whereas significant decreases in IgM occurred in only 14%. The lowest immunoglobulin levels occurred during the 2nd wk after a 3 day course of methylprednisolone and during the 3rd wk after a 5 day course of drug. Slightly decreased plasma concentration of [(125)I]IgG was seen in six of seven volunteers who received a 5 day course but in only one of four who received a 3 day course of drug. However, an increase in the rate of plasma clearance of IgG occurred only during the treatment period itself. During the period when the serum concentration of IgG was falling, the specific activity of IgG in the serum was relatively higher in treated men than in controls indicating decreased entry of newly synthesized IgG into the circulation. These findings suggest that a short course of methylprednisolone treatment causes a pronounced and sustained decrease in serum IgG due to increased catabolism during drug administration and to decreased synthesis during and for a variable time after drug administration.