Clinical aspects of IgE myeloma

IgE glycosylation and impact on structure and function: A systematic review

The impact of human IgE glycosylation on structure, function and disease mechanisms is not fully elucidated, and heterogeneity in different studies renders drawing conclusions challenging. Previous reviews discussed IgE glycosylation focusing on specific topics such as health versus disease, FcεR binding or impact on function. We present the first systematic review of human IgE glycosylation conducted utilizing the PRISMA guidelines. We sought to define the current consensus concerning the roles of glycosylation on structure, biology and disease. Despite diverse analytical methodologies, source, expression systems and the sparsity of data on IgE antibodies from non-allergic individuals, collectively evidence suggests differential glycosylation profiles, particularly in allergic diseases compared with healthy states, and indicates functional impact, and contributions to IgE-mediated hypersensitivities and atopic diseases. Beyond allergic diseases, dysregulated terminal glycan structures, including sialic acid, may regulate IgE metabolism. Glycan sites such as N394 may contribute to stabilizing IgE structure, with alterations in these glycans likely influencing both structure and IgE-FcεR interactions. This systematic review therefore highlights critical IgE glycosylation attributes in health and disease that may be exploitable for therapeutic intervention, and the need for novel analytics to explore pertinent research avenues.

Direct digital sensing of protein biomarkers in solution

The detection of proteins is of central importance to biomolecular analysis and diagnostics. Typical immunosensing assays rely on surface-capture of target molecules, but this constraint can limit specificity, sensitivity, and the ability to obtain information beyond simple concentration measurements. Here we present a surface-free, single-molecule microfluidic sensing platform for direct digital protein biomarker detection in solution, termed digital immunosensor assay (DigitISA). DigitISA is based on microchip electrophoretic separation combined with single-molecule detection and enables absolute number/concentration quantification of proteins in a single, solution-phase step. Applying DigitISA to a range of targets including amyloid aggregates, exosomes, and biomolecular condensates, we demonstrate that the assay provides information beyond stoichiometric interactions, and enables characterization of immunochemistry, binding affinity, and protein biomarker abundance. Taken together, our results suggest a experimental paradigm for the sensing of protein biomarkers, which enables analyses of targets that are challenging to address using conventional immunosensing approaches.

Human Monoclonal IgE Antibodies-a Major Milestone in Allergy

PURPOSE OF REVIEW

Bound to its high affinity receptor on mast cells and basophils, the IgE antibody molecule plays an integral role in the allergic reaction. Through interactions with the allergen, it provides the sensitivity and specificity parameters for cell activation and mediator release that produce allergic symptoms. Advancements in human hybridoma technologies allow for the generation and molecular definition of naturally occurring allergen-specific human IgE monoclonal antibodies.

RECENT FINDINGS

A high-resolution structure of dust mite allergen Der p 2 in complex with Fab of the human IgE mAb 2F10 was recently determined using X-ray crystallography. The structure reveals the fine molecular details of IgE 2F10 binding its 750 Å2 conformational epitope on Der p 2. This review provides an overview of this major milestone in allergy, the first atomic resolution structure of an authentic human IgE epitope. The molecular insights that IgE epitopes provide will allow for structure-based design approaches to the development of novel diagnostics, antibody therapeutics, and immunotherapies.

Allergen immunotherapy: The growing role of observational and randomized trial "Real-World Evidence"

BACKGROUND

Although there is a considerable body of knowledge about allergen immunotherapy (AIT), there is a lack of data on the reliability of real-world evidence (RWE) in AIT, and consequently, a lack of information on how AIT effectively works in real life.

METHODS

To address the current unmet need for an appraisal of the quality of RWE in AIT, the European Academy of Allergy and Clinical Immunology Methodology Committee recently initiated a systematic review of observational studies of AIT, which will use the RELEVANT tool and the Grading of Recommendations Assessment, Development and Evaluation approach (GRADE) to rate the quality of the evidence base as a whole. The next step will be to develop a broadly applicable, pragmatic "real-world" database using systematic data collection. Based on the current RWE base, and perspectives and recommendations of authorities and scientific societies, a hierarchy of RWE in AIT is proposed, which places pragmatic trials and registry data at the positions of highest level of evidence.

KEY RESULTS

There is a need to establish more AIT registries that collect data in a cohesive way, using standardized protocols.

CONCLUSIONS

This will provide an essential source of real-world data that can be easily shared, promoting evidence-based research and quality improvement in study design and clinical decision-making.

30 years of sublingual immunotherapy

Allergen Immunotherapy (AIT) was introduced in clinical practice on an empirical basis more than 100 years ago. Since the first attempts, AIT was administered subcutaneously. Indeed, other routes of administration were proposed and studied, in particular to improve the safety, but only the sublingual route (SLIT) achieved a credibility based on evidence and was then accepted as a viable "alternative" option to the subcutaneous route. SLIT was largely used in clinical trials and clinical practice in this last 30 years. Thus, a large amount of data is available, coming from either controlled trials and postmarketing surveillance studies. It is clear that SLIT is overall effective, but it is also clear that the efficacy is not "class-related," as derived from meta-analyses, but restricted to each specific product. The 30-year lasting use of SLIT allowed to clarify many clinical aspects, such as efficacy, safety, use in asthma, regimens of administration, and optimal doses. In parallel, the mechanisms of action of AIT were elucidated, and new indications were proposed (eg food allergy, atopic dermatitis). In addition, the introduction of molecular-based diagnosis, allowed to better refine the prescription of SLIT, based on specific sensitization profiles. The present article will describe the origin and evolution of SLIT for respiratory allergy, taking into account the clinical context that suggested this form of treatment, the recently developed aspects, the future perspectives and unmet needs, This is not, therefore, a systematic review, rather a narrative historical description of the past history, and a look forward to the future opportunities.

Combining Affinity Selection and Specific Ion Mobility for Microchip Protein Sensing

The sensitive detection of proteins is a key objective in many areas of biomolecular science, ranging from biophysics to diagnostics. However, sensing in complex biological fluids is hindered by nonspecific interactions with off-target species. Here, we describe and demonstrate an assay that utilizes both the chemical and physical properties of the target species to achieve high selectivity in a manner not possible by chemical complementarity alone, in complex media. We achieve this objective through a combinatorial strategy, by simultaneously exploiting free-flow electrophoresis for target selection, on the basis of electrophoretic mobility, and conventional affinity-based selection. In addition, we demonstrate amplification of the resultant signal by a catalytic DNA nanocircuit. This approach brings together the inherent solution-phase advantages of microfluidic sample handling with isothermal, enzyme-free signal amplification. With this method, no surface immobilization or washing steps are required, and our assay is well suited to monoepitopic targets, presenting advantages over conventional ELISA techniques.

Identification of IgE

Progress in protein chemistry in the 1950s revealed that the biologic activities of proteins, such as hemoglobin and enzymes, are based on partial structures in the protein molecules. This principle suggested to us the possibility that the human antibodies responsible for induction of reaginic hypersensitivity reactions might have unique structures that are lacking in the antibody molecules involved in immunity and that the differences in the structures of human antibody molecules can be recognized by the immune systems of experimental animals. Our studies were based on the hypothesis that reaginic antibody activity is associated with a unique immunoglobulin isotype, which is now called IgE. As expected, identification of IgE facilitated the analysis of immunologic mechanisms of reaginic hypersensitivity. Subsequent studies revealed that IgE specifically bound to basophilic granulocytes and mast cells through the Fc portion of the molecules and that cross-linking of the cell-bound IgE antibody molecules by allergen induced the release of bioactive mediators, such as histamine and leukotrienes, which initiate allergic reactions.

A CASE OF EOSINOPHILIC LYMPHFOLLICULOSIS OF THE SKIN (KIMURA'S DISEASE)

Eosinophilic lymphfolliculosis of the skin (Kimura's disease) in a 31-year-old male is reported. He had two subcutaneous tumors, 10 x 9 x 3 cm and 9 x 7 x 2 cm in size, in the right retroauricular and submaxillary areas respectively. Histopathologic examination of the tumors showed marked infiltration of eosinophils, mast cells and lymphocytes, and angiomatous proliferation of blood vessels from the dermis to the skeletal muscular tissue. In subcutaneous adipose tissue, there were numerous lymphfollicles with germinal centers in which IgE deposition with reticular appearance was observed by immunofluorescent technique. Study of the peripheral blood showed marked eosinophilia and an increase of serum IgE level. These findings suggest the possibility that Type 1 allergic reaction may be involved in the histogenesis of eosinophilic lymphfolliculosis of the skin, although there is no direct evidence for the existence of antigens which react to IgE antibody in the skin lesion.

[Hyperviscosity syndrome]

Hyperviscosity syndrome is a life-threatening complication. Clinical manifestations include neurological impairment, visual disturbance and bleeding. Measurement of plasma or serum viscosity by a viscometer assesses the diagnosis. Funduscopic examination is a key exam because abnormalities are well-correlated with abnormal plasma viscosity. Etiologies are various but symptomatic hyperviscosity is more common in Waldenström's macroglobulinemia and multiple myeloma. Prompt treatment is needed: treatment of the underlying disease should be considered, but generally not sufficient. Symptomatic measures aim to not exacerbate blood viscosity while urgent plasmapheresis effectively reduces the paraprotein concentration and relieves symptoms.

The evolution of allergen and non-specific immunotherapy: past achievements, current applications and future outlook

Recent epidemiological studies estimated that more than 30% of European suffer from allergic rhinitis or conjunctivitis, while up to 20% suffer from asthma and 15% from allergic skin conditions, while for many other regions the prevalence is increasing. Allergen immunotherapy represents the only available treatment that can modify the allergic disease process, and thus is worth considering as a treatment in affected individuals. A beneficial effect of allergen immunotherapy has been shown in both adults and children affected by allergic rhinitis, allergic conjunctivitis, allergic asthma and hymenoptera venom allergy. The present study represents an overview on allergen immunotherapy, focusing on the principal aspects of the use of immunotherapy in the past, its recent clinical applications and future outlook.

Low IgE monoclonal gammopathy level in serum highlights 20-yr survival in a case of IgE multiple myeloma

This report describes the diagnosis, follow-up, and problems measuring serum immunoglobulin E (IgE) levels in a case of IgE myeloma with 20-yr survival. Serum and urine protein electrophoresis, immunofixation, and the N Latex IgE test were used to characterize the monoclonal proteins. The diagnosis of multiple myeloma in a 56-yr-old man was based on 5.4 g/24 h of monoclonal free lambda chain in urine and bone marrow findings of 23.5% plasma cells (19% mature and 4.5% atypical). IgE lambda monoclonal protein in serum measured 506,000 microg/L (210 833 IU/mL). The lack of other clinical findings of multiple myeloma places this case in the category of 'smoldering or indolent myeloma'. Measurement of serum IgE levels was complicated by the need to predilute serum to avoid antigen excess. Following chemotherapy, the patient went into clinical remission, eventually dying of complications of emphysema. This case expands the recognized clinical spectrum of IgE multiple myeloma.

IgE multiple myeloma

IgE multiple myeloma is a rare disease characterized by a high frequency of Bence-Jones proteinuria and plasma cell leukaemia when compared to other isotypes of monoclonal proteins. Only 35 cases have been reported. We describe a 70-year-old woman with a stage III IgE kappa multiple myeloma presenting with a sacral plasmacytoma. Immunological and biochemical studies showed IgE kappa producing tumoral plasma cells. Serum total IgE was high without clinical symptoms suggesting an hyperIgE syndrome or mast cell activation. The patient underwent surgical removal of the sacral tumor and monthly melphalan-prednisone treatment together with intravenous pamidronate infusions. Magnetic Resonance Imaging (MRI) of the dorsolumbar spine revealed an epidural process leading to T6-T9 radiotherapy. Bone densitometry showed a decreased bone mineral content supporting the management of myeloma-related osteoporosis with bisphosphonate infusions. A good partial response with plateau-phase and increase of bone mineral content was achieved after 1 year of treatment and still persists after a 28 months follow-up.

Ifosfamide in plasma cell leukemia: a report of two cases and review of the literature

We report two patients with primary plasma cell leukemia (PLC) treated with a single agent, ifosfamide. One patient had a total disappearance of plasma cells (PC) from the peripheral blood and the bone marrow and disappearance of the myeloma protein, is disease free 8 months after completion of treatment, and alive 14 months after diagnosis. The second patient had a partial response with persistence of plasma cells in the bone marrow lasting 7 months, after which she had a frank relapse of the disease. We suggest that ifosfamide may be an active agent in plasma cell malignancies and needs further evaluation in multiple myeloma.

Spinal epidural involvement in haematological tumors: clinical features and therapeutic options

Haematological malignancies that may cause epidural spinal cord compression (SCC) include plasma cell dyscrasias, lymphomas and infrequently leukemias. Bone lesions are the major clinicopathologic manifestations in plasma cell dyscrasias but are evident in less than 30% of patients with SCC due to lymphomas. The incidence of SCC in solitary plasmacytomas is between 43 to 71%, in contrast to 7.4 to 16% in multiple myeloma where vertebral involvement is always present. The incidence of SCC in Hodgkin's disease and in non-Hodgkin's lymphomas is about 4 and 2.5% respectively. Spinal computed tomography, myelography and magnetic resonance imaging serve for establishing a definite diagnosis, assessment of tumor location within the spinal canal, delineation of the involved spinal levels, evaluation of spinal stability and for detection of extraosseous paravertebral extension. Treatment planning is based on the information obtained above, combined with clinical considerations. The primary modalities of therapy are radio- and chemotherapy. Surgery is reserved for those cases presenting with SCC when tissue diagnosis is unavailable, recurrence of SCC after previous irradiation and for spinal instability or compression of the neural elements by impinging bone fragments.

Survival of twenty-two months in a patient with primary plasma cell leukaemia treated with melphalan and prednisolone

In the majority of cases plasma cell leukaemia is a rapidly fatal disease with a mean survival time of five months. There have been reports of increased survival using various regimens of chemotherapy although most cases eventually relapse. We describe a patient with primary plasma cell leukaemia who responded to a combination of oral melphalan and prednisolone with control of the disease in the bone marrow but relapsed with extramedullary disease in the central nervous system and testes, and died 22 months after diagnosis. Melphalan poorly penetrates the central nervous system and its testicular penetration is unknown.

Plasma cell leukemia: an evaluation of response to therapy

Forty-three patients with plasma cell leukemia were seen at the Mayo Clinic. Twenty-five (58 percent) had primary plasma cell leukemia (diagnosis first made in the leukemic phase) and 18 (42 percent) had secondary plasma cell leukemia (leukemic transformation of a previously diagnosed multiple myeloma). Patients with secondary plasma cell leukemia were older, had a greater incidence of lytic bone lesions, had a lower platelet count, and had a larger M-protein in the serum than did patients with primary plasma cell leukemia. The median survival was 6.8 months for patients with primary plasma cell leukemia and 1.3 months for patients with secondary plasma cell leukemia. In patients with primary plasma cell leukemia, multiple alkylating agents produced a higher response rate than did melphalan, but the median time from treatment to progression or death was not significantly improved with such therapy. Review of the literature also suggests that the response rate is higher with combination chemotherapy than with single alkylating agents. Patients with secondary plasma cell leukemia usually show resistance to any type of chemotherapy and have a short survival.

Rheology of paraproteinaemias and the plasma hyperviscosity syndrome

The proper understanding of the causes, pathophysiology, diagnosis and management of the plasma hyperviscosity syndrome is based on good knowledge of malignant paraproteinaemias, properties of immunoglobulins, rheology of blood in the microcirculation, and modern plasma separation techniques. This multifaceted syndrome complicates less than ten per cent of IgA and IgG myelomas, and up to one-third of Waldenström's macroglobulinaemias. A few cases of HVS have also been reported in association with polyclonal hypergammaglobulinaemias. Excessive paraproteinaemia may cause the plasma HVS, especially when paraproteins are extraordinarily large, asymmetrical or cryosensitive, or if they aggregate into hyperviscous macroaggregates. The resultant severe microcirculatory impairment is mainly due to the combined effects of plasma hyperviscosity, significant plasma volume expansion and intense red cell aggregation. The individually variable general symptoms, bleeding tendency, ocular, neurological, cardiovascular, and renal manifestations and laboratory parameters of the HVS are summarized briefly. The majority of patients present hyperviscosity manifestations when the plasma viscosity exceeds 5-6 mPa.s. Plasmapheresis or plasma exchange have established themselves as efficient and safe modes of therapy of hyperviscosity and hypervolaemia. The therapeutic guidelines for the plasma HVS are briefly discussed with regard to recent experience with developing plasma separation techniques. Diagnostic and therapeutic advances combined with increasing haemorheological knowledge have greatly improved the proper management of this potentially lethal complication of paraproteinaemias.

IgE myelomatosis. Presentation of a new case and summary of literature

This paper describes a case of IgE (kappa) myeloma in a 39 year old female patient who has been observed for a period of eight years to the present. The findings and the course of disease in this patient were compared with 18 other case reports published since the discovery of IgE in 1966. In contrast to myelomas of other immunoglobulin classes, patients with IgE myelomas are somewhat younger and anaemia and hyperproteinaemia are more pronounced. A plasma cell leukaemia is more frequent and the ratio of light chains has shifted in favour of the kappa chains.

Diagnosis of allergy: in vitro testing

Relatively few laboratory tests are of proven value in the differential diagnosis and management of allergic diseases. Immunoassays for IgE and for IgE antibodies are the mainstays. Measurement of IgE in serum is advocated as a first-order laboratory test in the differential diagnosis of allergic disease in children and adults. The usefulness of laboratory tests for IgE antibodies in serum, once a subject of debate in the clinical allergy literature, is now firmly established. Confusion, in respect to the use of these tests, is most evident in clinical situations which have been the subject of limited clinical investigation, e.g., the use of tests for IgE antibodies to screen for allergic disease, the indications for their use in patients treated with allergen immunotherapy, and the diagnostic specificity of IgE antibodies to foods as an indicator of food-induced allergic symptoms. Confusion is also apparent in the interpretation of borderline test results, i.e., results which may indicate the presence of low titers of IgE antibodies, and in defining the optimum format for reporting results to maximize the analytical sensitivity of the test method. This review addresses the ambiguities noted above in the interpretation of results. The paragraphs that follow also consider the possible uses of laboratory tests for inflammatory mediators of immediate hypersensitivity, for IgG antibodies to allergens, and of tests designed to evaluate the in vitro functions of lymphocytes in patients with allergic disease.

IgE myeloma associated with plasma cell leukaemia

A patient presented with plasma cell leukaemia and was found to have an IgE secreting multiple myeloma. IgE myeloma is very rare with only 18 cases recorded. However, this case is the fifth recorded of IgE myeloma associated with plasma cell leukaemia. Since plasma cell leukaemia only occurs in 1.6% of all cases of myeloma, it seems certain that this is a significant association.

Cloning and sequence determination of the gene for the human immunoglobulin epsilon chain expressed in a myeloma cell line

Messenger RNA has been isolated from cells of the human myeloma line 266BL which synthesizes IgE of the myeloma ND. A fraction enriched in mRNA for the epsilon heavy chain was copied into DNA and the DNA was cloned in Escherichia coli. A chemically synthesized oligonucleotide probe, based on the experimentally determined sequence of the specific message, was used to screen colonies. The largest epsilon chain cDNA cloned, 2.0 kilobases, was characterized by restriction endonuclease mapping and DNA sequence analysis. It appears to encode the complete amino acid sequence of the epsilon chain, including a signal peptide at the NH2 terminus as well as untranslated sequences at the 5' and 3' ends of the mRNA. The missing part of the previously published amino acid sequence of the ND epsilon chain was determined from the DNA sequence.

Immunoglobulin E-rheumatoid factor in the serum of patients with rheumatoid arthritis, asthma, and other diseases

A solid-phase radioimmunoassay was developed to detect immunoglobulin (Ig)E antibodies that bound to human IgG. IgE-rheumatoid factor activity was found in the serum of 18 of 20 patients with seropositive rheumatoid arthritis, 1 of 4 patients with seronegative rheumatoid arthritis, 3 of 32 patients with seronegative rheumatoid arthritis, 3 of 32 patients with asthma, and in 1 patient with hypocomplementemic vasculitis and iodide sensitivity. Immunopathologic implications of IgE-rheumatoid factor are discussed.

Histologic and clinical findings in human scabies

The epidermal histological findings in the primary scabetic lesion are hyperkeratosis, acanthosis, and spongiotic edema and vesiculation. The dermal changes consist of perivascular and diffuse cell infiltrates, mainly mononuclear cells, and sometimes eosinophilic granulocytes. The number of mast cells are slightly greater in primary scabetic lesions compared with secondary lesions and normal skin. Vasculitis is found in those cases showing tissue eosinophils, severe dermatitis, and many mites. A nodular lesion shows perivascular infiltrates mainly containing histiocytes, some with atypical and hyperchromatic nuclei and a few in mitosis, and some lymphocytes and cells with pyroninophilic cytoplasm. Secondary scabetic lesions show acanthosis and perivascular inflammatory cell infiltrates, mainly mononuclear cells, whereas clinically normal skin presents very slight perivascular and diffuse mononuclear cell infiltrates in half of the patients. Both the number of circulating eosinophilic granulocytes and serum IgE concentrations correlate with the severity of the skin reaction. Ten of 60 patients with scabies had markedly increased numbers of circulating eosinophilic granulocytes during scabies infestation. In most of the patients, however, the number of circulating eosinophils decreased after scabies treatment.

IgE lambda paraproteinaemia associated with a pleomorphic lymphoproliferative disorder

A new case of IgE lambda paraproteinaemia is described in which the immunoproliferative disorder was lympho-plasmacytoid, rather than myelomatous in type. The patient, an 81-year-old woman, lacked both organomegaly and bone lesions. The peripheral white blood count was 30 X 10(9)/l (43% lymphocytes and 37% lymphoplasmacytoid cells) and the bone marrow was heavily infiltrated with mononuclear cells with 50% lymphocytes and 50% lymphoplasmacytoid cells). Detailed immunological marker analysis of both peripheral blood and marrow showed an increased population of morphologically normal T cells, together with neoplastic population of B cells. The neoplastic cells were shown to re-express surface immunoglobulin after stripping with anti-E anti-serum, and to synthesis Ig in radio-incorporation experiments. The immunological characteristics of the neoplastic cells are considered in relation to B-cell maturation and it is shown that the immunological phenotype was of the intermediate type to be expected in association with a lympho-plasmacytoid proliferation.

Immunoglobulin E (IgE) multiple myeloma: a case report and review of the literature

A case of immunoglobulin E (IgE) myeloma with clinical features of "classic" myeloma is presented. Skeletal roentgenograms showed osteoporosis and compression fractures of the vertebrae but no osteosclerosis. Protein analyses revealed an M component of the IgE kappa type with a concentration of 3.1 g/dl. Although morphologic examination revealed that the plasma cells were not so differentiated, well-developed Golgi apparatus and abundant rough-surfaced endoplasmic reticulum were observed. An indirect immunofluorescence technique showed characteristic apple green fluorescence. The E myeloma protein of our patient had no antibody activity. Treatment with melphalan or cyclophosphamide resulted in a decrease in the serum IgE level and in the level of Bence Jones protein in the urine. The clinical and laboratory features of IgE myeloma were summarized and compared with those of other classes of myeloma.

The expanding spectrum of clinical and laboratory features of IgE myeloma. (Report of a case and review of the literature)

A new case of IgE myeloma is described. Patient G.M., a 60-year-old woman, complained with a 3-months' history of generalized bone pain, weight loss, profound weakness and severe anemia. A bone survey revealed multiple lytic lesions, and a heavy replacement by plasma cells was disclosed in the bone marrow examination of a sternal sample. In addition, an IgE serum M-component and gamma-type Bence Jones proteinuria were identified by immunochemical studies. The disease course was rapid, death occurring within 6 months of clinical onset. A molecular weight of 188,500 daltons was calculated for the purified protein G.M., whereas the molecular weights of its subunits were found to be 72,000 for the epsilon chains and 43,000 for the gamma chain dimers. This case is compared with 15 reported cases of IgE monoclonal gammapathy, an expanding clinical and laboratory spectrum emerging from the review of the literature.

"Benign" monoclonal IgE gammopathy

So far IgE monoclonal paraproteins have been found only in patients with malignant diseases, though there are benign monoclonal paraproteins of other immunoglobulin classes. A patient with osteoporosis first seen in Paris in 1965 was found to have a paraprotein type lambda. In 1977 immunoelectrophoresis identified this as IgE lambda paraprotein, and immunodiffusion studies showed precipitin bands identical with those in patients with IgE myeloma. This patient seemed to have a benign monoclonal IgE gammopathy which had existed for 14 years. Though the possibility of transition into multiple myeloma cannot be excluded, this case suggests that a monoclonal expansion of IgE lymphocytes need not produce malignant change.

Subpopulations of circulating B cells and regulatory T cells involved in in vitro immunoglobulin E production in atopic patients with elevted serum immunoglobulin E

The B lymphocyte subpopulations producing immunoglobulin (Ig)E and the regulatory T cells modulating this IgE production in normals, and in atopic patients with respiratory allergy, atopic dermatitis, and markedly elevated serum IgE levels (>5,000 ng/ml), were investigated. Peripheral blood lymphocytes (PBL) were separated into T and B cell fractions and the ability of B cells to produce IgE in the presence or absence of pokeweed mitogen (PWM) and/or T cells ws determined. The patients had a circulating population of cells which spontaneously produced up to 6 ng of IgE in vitro (per 4 X 10(5) non-E-rosetting cells) in the absence of T lymphocytes and PWM. PBL from normals did not possess such cells. This IgE synthesis occurred primarily (>75%) over the first 72 h of culture. There was a wide range in their activity between patients and from the same patient studied on repeated occasions (from <300 to 6,000 pg per culture). This spontaneous IgE production was inhibited by PWM (mean inhibition, 37%) or normal T lymphocytes (mean inhibition, 42%). The patients lacked T lymphocytes capable of inhibiting this spontaneous IgE synthesis in 7 of 13 experiments. Functionally distinct B cells were identified in the patients and normals that responded to PWM with IgE production in vitro and required T-helper cell activity. Patients had normal PWM-responsive B cell IgE biosynthetic activity and T-helper function for these B cells. Suppressor T cell activity for PWM-driven IgE synthesis was also evaluated. Both the normals' and the patients' T lymphocytes provided similar levels of T cell suppressor function for PWM-driven IgE production. Patients with elevated serum IgE possessed these inhibitory T cells at times when the T lymphocytes which suppressed spontaneous igE production were absent from their PBL.

Secretion in dissociated human pulmonary mast cells. Evidence for solubilization of granule contents before discharge

Mast cells were enzymatically dissociated from human lung fragments that had been sensitized with serum from human allergic to ragweed and were enriched by isopyknic and velocity gradient sedimentation. Electron microscope examination showed that the mast cells were well preserved at the end of the dissociation and isolation and that the majority of their secretory granules contained crystalline structures. These structures exhibited three patterns--scrolls, gratings, and lattices--which all could be found in the same granule. The period of crystalline structures was found to be bimodal, with maxima at 150 and 75 A. Both periods were observed in gratings that had been tilted and in scrolls that had been cut obliquely, indicating that the various gross patterns are composed of the same basic substructure. After the mast cells were stimulated by rabbit anti-human IgE to release histamine, the contents of the granule were transformed from a crystalline to an amorphous state, and only granules with amorphous contents were seen discharging from the cell. Clusters of intermediate filaments were present around the granules with amorphous contents, both deep in the cytoplasm and discharging at the cell surface. Discharge occurred both by fusion of granule membranes with the plasma membrane and by fusion of granule membranes with other granule membranes that ultimately were continuous with the plasma membrane. After discharge, the granule residue was fibrillar. Cells challenged with anti-human IgE in calcium-free medium neither released histamine nor demonstrated morphologic changes in their granules. We conclude that the crystalline state represents a storage form for materials that are solubilized before fusion of the granule membrane with the plasma membrane and discharge.

Atopy as a minimal immunodeficiency?

Despite impressive recent advances in the understanding of the chemical and cellular bases of the reaginic response, the pathogenesis of atopic diseases still remains a matter of speculation. The frequent finding of atopic diseases in some primary immunodeficiencies such as selective IgA deficiency and the Wiskott-Aldrich syndrome offers a unique opportunity for studying the immune mechanisms underlying the genesis of atopy. Recent studies in subjects with selective IgA deficiency have challenged the well known hypothesis that atopy is the result of defective "immune exclusion" by the secretory immune system. A number of immunological features found in the primary immunodeficiencies associated with atopic disorders suggest that defective homeostatic mechanisms regulating reaginic responses may play a major role in the pathogenesis of atopy. A thorough analysis of these disease combinations may help to generate new working hypotheses concerning the immune pathogenesis of atopic diseases.

Monoclonal IgE with renal failure

Only four cases of immunoglobulin E (IgE) monoclonal "gammapathies" have been reported previously. Discussed here is a 57 year old man who presented with hypertension and the nephrotic syndrome. A monoclonal IgE-kappa component (0.6 mg/ml), which did not appear as an M spike on protein electrophoresis, was demonstrated by immunoelectrophoresis in the serum and urine. The patient's condition deteriorated rapidly due to renal failure, and he died five weeks after the diagnosis was made. Pathologic examination disclosed extensive glomerular lesions, but amyloid was not detected by light or electron microscopy. The possible relationship between the monoclonal gammapathy and kidney impairment is discussed.

IgE myeloma presenting with classical myeloma features

A patient with IgE myeloma, presenting with bone lesions and modest anemia without plasma cell leukemia or hepatosplenomegaly, is described. The findings are compared with those of other patients with this and the more common forms of multiple myeloma.

Massive polyclonal hyperimmunoglobulinemia E, eosinophilia and increased IgE-bearing lymphocytes

A patient (E.M.) with marked eosinophilia and hyperimmunoglobulin E (IgE) has been followed for 4 years. Peripheral blood eosinophilia reached levels in excess of 18,000 cells/mm3 and serum IgE concentration increased to more than 210,000 units/ml (about 0.48 mg IgE/ml). The IgE has both lambda and kappa light chains and is therefore considered polyclonal. The patient has an increase in peripheral blood lymphocytes which stain for surface IgE. Transfer of the patient's plasma (plasmsEM) to a rhesus monkey did not induce peripheral boood eosinophilia. The half life of IgEEM in a rhesus monkey was 2.2 days, which is similar to the half life of myeloma IgE in human subjects. The condition was not associated with defined morbidity except for mild persistent pruritus. Various studies revealed no evidence for atopic parasitic, immune deficiency or neoplastic disease.