A study of familial lupus erythematosus-like disease and hereditary angio-oedema treated with danazol

Hereditary angioedema and lupus: A French retrospective study and literature review

Hereditary angioedema (HAE) is a rare genetic disorder that is primarily caused by a defect in the C1 inhibitor (C1-INH). The recurrent symptoms are subcutaneous edema and abdominal pain. Laryngeal edema, which can also occur, is life threatening if it goes untreated. HAE can be associated with some inflammatory and autoimmune disorders, particularly lupus. The aim of this study was to describe cases of lupus among HAE patients in France and to perform a literature review of lupus and HAE studies. Case detection and data collection (a standardized form) were performed, thanks to the French Reference Center for Kinin-related angioedema. Data were collected from 6 patients with type 1 HAE and lupus in France; no cases of systemic lupus erythematosus were reported. In the literature review, 32 cases of lupus combined with HAE were identified, including 26 female patients. The median patient age at the time of first reported HAE symptoms and at diagnosis were 17.5 years (range, 9-41 years) and 19 years (range, 9-64 years), respectively for our 6 patients and 14 years (range, 3-30 years) and 17 years (range, 7-48 years), respectively, for the literature review. The clinical manifestations of HAE were mainly abdominal pain (83% in our patients vs 47% in the literature) and edema of the limbs (83% vs 38%). The C4 levels were low (for 100% of our cases vs 93% in the literature). Eighteen patients in the literature demonstrated HAE symptoms prior to the lupus onset vs 5 for our patients. The mean patient age at lupus onset was 20 years (range, 13-76 years) for our patients and 19.5 years (range, 1-78 years) in the literature, respectively. In the literature, 81% of the patients had skin manifestations, 25% had renal involvement and 28% received systemic steroids to treat lupus. Treatment with danazol did not modify the clinical expression of lupus. The association between lupus and HAE is a rare but not unanticipated event. Patients are often symptomatic for HAE before developing lupus. Lupus cases associated with HAE share some characteristics of lupus cases related to other complement deficiencies, such as the absence of severity and the predominance of cutaneous symptoms.

The autoreactivity of B cells in hereditary angioedema due to C1 inhibitor deficiency

Patients with hereditary angioedema (HAE) tend to produce autoantibodies and have a propensity to develop immunoregulatory disorders. We characterize the profile of autoantibodies in a group of HAE patients and investigate their memory B cells' phenotype and activation status. We studied the activity status phenotype, Toll-like receptor (TLR)-9 expression and total phosphotyrosine in B cells isolated from HAE patients. Additionally, the following autoantibodies were assessed in the serum of 61 HAE patients: anti-nuclear, rheumatoid factor, anti-cardiolipin, anti-tissue transglutaminase, anti-endomysial, anti-Saccharomyces cerevisiae, anti-thyroid and anti-neutrophil cytoplasmic antibodies. In 47·5% of HAE patients we detected at least one of the tested autoantibodies. Expression of CD69, CD5 and CD21 was found to be significantly higher on memory B cells from HAE patients compared to healthy controls (4·59 ± 4·41 versus 2·06 ± 1·81, P = 0·04, 8·22 ± 7·17 versus 3·65 ± 3·78, P = 0·05, 2·43 ± 0·54 versus 1·92 ± 0·41, P = 0·01, respectively). Total phosphotyrosine in B cells from HAE patients was significantly higher compared to healthy controls (4·8 ± 1·1 versus 2·7 ± 1·3, P = 0·0003). Memory B cells isolated from the HAE group contained higher amounts of TLR-9 compared to healthy controls (8·17 ± 4·1 versus 4·56 ± 1·6, P = 0·0027). Furthermore, the expression of TLR-9 in memory B cells from HAE patients with autoantibodies was significantly higher than the control group (10 ± 4·7 versus 4·56 ± 1·6, P = 0·0002) and from that in HAE patients without autoantibodies (10 ± 4·7 versus 5·8 ± 0·9, P = 0·036). HAE patients have enhanced production of autoantibodies due most probably to the increased activation of B cells, which was found to be in association with a high expression of TLR-9.

Sex hormones and the immune system--Part 2. Animal data

Sex hormones have physiological and pathological (autoimmune conditions) effects on the immune system. Studies in experimental animal models of human autoimmune diseases have clearly shown that sex hormones regulate the expression, severity and course of autoimmune diseases. Sex hormones affect the function of T, B and NK cells, and macrophages. Precisely how sex hormones affect lymphocytes is a highly complex question. Sex hormones can modulate the immune system, perhaps directly (e.g. thymic reticular tissue), or indirectly via host and many oestrogen target tissues, including the central nervous system hypothalamic-pituitary axis (the neuroendocrine tissues). The effects of sex hormones on the immune system (immunosuppression or immunopotentiation) may vary, even with the same hormone. For example, oestrogen can increase IgA levels in the uterus, but decrease IgA levels in the vagina or have no effect in lacrimal tissues (Sullivan, 1989). Therefore the effects of sex hormones on the immune system cannot be generalized but must be evaluated independently. Some of the reasons for variability in results have been reviewed in detail elsewhere (Steinberg et al, 1979; Ansar Ahmed et al, 1985b). These include, dose of hormones, age and sex-hormonal status of animals, route and time of administration, the immunocompetence of the host, stress, the metabolism of hormones (e.g. metabolism of testosterone to oestrogen) resulting in alteration of biological activity, and differential response to various antigens. The initial encounter of sex hormones with the type of target cells, the variability of secondary messengers and gene activation events are other important considerations. The effects of sex hormones on the immune system to modulate immune responses are unequivocal. The burgeoning advances in cellular immunology, endocrinology and molecular biology, should provide a better understanding of: (1) the interactions of hormones with the immune system; (2) how hormones activate specific genes; and (3) how hormones influence intracellular communication. In a clinical situation, it is hoped that androgenic compounds which lack virilizing effects, but possessing the desired immunomodulatory effects, will eventually be synthesized. These hormone analogues, in combination with specific (non-toxic) oestrogen antagonists, may offer new therapeutic avenues.

The effect of danazol in the MRL/lpr mouse model of autoimmune disease

The purpose of the study was to determine if danazol was efficacious in the treatment of lupus MRL/MpJ (lpr) mice, as measured by longevity, proteinuria and serum amyloid protein (SAP) levels. Danazol, administered at an oral dose of 100 mg/kg, significantly prolonged survival of female MRL/MpJ (lpr) mice but had no effect on the mortality of their male counterparts. Medication with danazol began 40 days after birth of the mice and resulted in a significant decrease in proteinuria in female but not male lupus mice. The concentration of SAP, an acute phase reactant, was significantly decreased in danazol-treated female lupus mice at 80, 100, 120, 140 and 160 days of age when compared to vehicle-treated control mice. SAP levels in male lupus mice treated with danazol were significantly lower than normal control levels only at the 120 and 160 day time points. Measurements of mortality, proteinuria and SAP concentration indicate that danazol at 100 mg/kg is orally active in the treatment of MRL/MpJ (lpr) female, but not male mice.