Alpha-chain disease: an immunoproliferative disease of the secretory immune system

Roles of syndecan-1, bcl6 and p53 in diagnosis and prognostication of immunoproliferative small intestinal disease

AIM: To evaluate roles of syndecan-1, bcl6 and p53 in diagnosis and prognostication of immunoproliferative small intestinal disease (IPSID) and to study profiles of kappa (κ) and lambda (λ) light chains and IgA heavy chain.

METHODS: The study consisted of 11 cases of IPSID and similar number of controls which included 11 of normal intestinal mucosa and 11 of high grade B cell lymphoma of ileum. The parameters analyzed included clinical profiles, biochemical and other laboratory investigations, radiologic and histological findings including immunohistochemistry.

RESULTS: All IPSID cases had demonstrable serum IgA heavy chain and heavy mucosal plasma cell infiltration. According to Galian’s histological staging, there were 4 patients with stage A and 7 with stage B. κ and λ light chains were over-expressed in 7 patients; 1 stage A patient had H pylori-positive active gastritis and eradication of H pylori led to disease remission. Stage A biopsies had higher expression for syndecan-1, while stage B had higher expression for bcl6 and p53. Syndecan-1, κ and λ light chains and IgA heavy chain showed inverse relationship with bcl6 and p53. All patients were treated with doxycycline. CHOP regime was added in 5 patients who developed frank lymphoma. Three died of the disease due to extensive organ infiltration.

CONCLUSION: Certain immunomarkers like syndecan-1, κ and λ light chains and IgA heavy chain could be of much help in identifying early stage IPSID. Stage B IPSID showed higher expression for bcl6 and p53 than stage A IPSID. bcl6 and p53 expressions correlated with a more advanced disease stage and aggressive tumour behavior.

An overview of monoclonal gammapathies

The neoplastic proliferation of single clones of plasma cells causes synthesis of very large amount of monoclonal immunoglobulins consisting of only one type of heavy either the gamma, alpha, mu, delta or epsilon chain or only kappa or lambda light chains. Each monoclonal immunolobulin differs idiotypically from each other. These monoclonal immunoglobulins are also called paraproteins and are frequently associated with a broad heterogeneous group of plasma cell dyscrasias. Occasionally their presence is observed in a few benign conditions and in old age. In the present review a detailed account of different types of monoclonal gammapathies are described.

Alpha-heavy chain disease, Mediterranean lymphoma, and immunoproliferative small intestinal disease: a review of clinicopathological features, pathogenesis, and differential diagnosis

There are a number of clinical syndromes associated with chronic diarrhea, malabsorption, and lymphoplasmacytic proliferation of the small intestine. In Middle-Eastern and Mediterranean countries immunoproliferative small intestinal disease is endemic, whereas in other parts of the world (including Northwestern Europe and North America) celiac sprue, and other sprue-like syndromes refractory to dietary gluten withdrawal, predominate. All of these syndromes appear to involve chronic stimulation of intestinal mucosa-associated lymphoid tissue and are associated with a heightened risk of malignant transformation. The clinicopathological features of these diseases, and distinction of the Middle Eastern syndromes from those more common in the Western hemisphere, have been reviewed.

Latent Epstein-Barr virus infection is an unlikely event in the pathogenesis of immunoproliferative small intestinal disease

BACKGROUND

The observed seasonal and geographic variations in the incidence of immunoproliferative small intestinal disease (IPSID) suggest that environmental factors contribute to its pathogenesis. One such environmental factor, the Epstein-Barr virus (EBV), has been associated with other B-cell lymphoproliferative disorders.

METHODS

IPSID tissues obtained at the time of initial diagnosis were retrieved from the American University of Beirut pathology archives (1972-1983) and examined for EBV genetic information by colorimetric in situ hybridization (ISH) and polymerase chain reaction (PCR). Eight patients were identified, four of whom also had serologic and immunohistochemical evidence of alpha-heavy chain disease. Thirteen tissue samples from these eight patients were available for study: eight were intestinal and five were nodal. Non-Hodgkin's B-cell lymphoma cases (nine) were randomly selected from the same archive to serve as a control for EBV in that geographic location. The ISH method used a probe to the "W" repetitive region of EBV, with the human placental DNA probe as a control for sample preparation. The PCR method amplified a 110 base pair region in the long internal direct repeat with amplification of beta-actin as control for DNA preservation. Both assays used formalin fixed paraffin embedded Raji cells as a positive control.

RESULTS

Neither ISH nor PCR demonstrated EBV in any of the eight patients with IPSID: The results for one of seven control blocks with adequate DNA preservation were positive when PCR was used but were negative when ISH was used.

CONCLUSIONS

These findings do not support a role for EBV in the induction of B-cell proliferation in IPSID:

Immunoproliferative small intestinal disease: portrait of a potentially preventable cancer from the Third World

PURPOSE

To review the recent progress in the understanding of clinical and laboratory characterization as well as management of immunoproliferative small intestinal disease (IPSID).

DATA IDENTIFICATION

A literature search was conducted using Index Medicus, MEDLINE (1962 to 1989), and bibliographies of identified relevant articles.

STUDY SELECTION

All international comprehensive reviews, reported epidemiologic or immunologic studies, and prospective clinical trials published or abstracted in English were selected.

RESULTS OF DATA SYNTHESIS

A high incidence of lymphoma primarily in the gastro-intestinal tract in Third World countries has stimulated enormous epidemiologic and pathogenetic interests globally. IPSID, with a distinctive biologic marker (alpha heavy chain para-protein), affects the young underprivileged population of those countries. The initially benign-appearing antibiotic-responsive immunoproliferative lesions often evolve to fatal high-grade lymphomas. Roles of environmental and host factors in this evolutionary course are emerging. Recently demonstrated malignant potentials form the early onset of pathogenesis have given a new dimension to the traditional management strategy of IPSID.

CONCLUSIONS

Epidemiologic, immunologic, and pathogenetic data that have emerged over the last 25-year study of IPSID have improved our understanding about the complexity of infection-immunity-cancer interrelationships, comparable to those that have arisen from the study of the acquired immunodeficiency syndrome. Early detection and institution of antimicrobial-based treatment regimens with judicious and consistent follow-up can save the lives of many young patients whose manpower is badly needed in Third World countries.

Genomic alterations in a case of alpha heavy chain disease leading to the generation of composite exons from the JH region

Human alpha heavy chain disease (HCD) is characterized by the presence in patient's serum of a short Ig alpha chain devoid of light chains. We analyzed the serum protein, the alpha HCD mRNA and the productive rearranged H chain gene from the leukemic cells of a new case (YAO) of alpha HCD. The abnormal YAO alpha 1 Ig was devoid of VH and CH1 domains and started at the beginning of the hinge region. The alpha HCD mRNA was shorter than normal alpha mRNA and the cDNA prepared from YAO mRNA encoded a leader sequence, an insert of 70 nucleotides and the CH2 and CH3 exons. The origin of the inserted sequence was assessed by cloning and sequence analysis of the alpha 1 productive gene. It started with a leader exon, a leader-VH intron and the first 11 bp of a VH exon. Then the VH region was deleted and replaced by a 19-nucleotide sequence that turned out to correspond to the 3' part of a modified JH5 exon. It was followed by a 221-bp sequence homologous to the JH5-psi JH3 intron and by an inserted sequence of unknown origin. The 3' part of this insertion and the remnant of a JH6 exon delineated a third exon that was followed by a relatively conserved JH6-C alpha intron. These two composite exons were flanked by splicing sites and accounted for the 70-nucleotide insert of the cDNA. The genomic nucleotide sequence also revealed a large deletion in the switch CH1 region which eliminated normal splicing sites and resulted in splicing of the third exon directly to the CH2 exon.

Elevated serum IgA associated with immunoproliferative enteropathy of Basenji dogs: lack of evidence for alpha heavy-chain disease or enhanced intestinal IgA secretion

Immunoglobulin isotypes in serum and intestinal secretions of Basenji dogs with chronic diarrhea, asymptomatic Basenji dogs, and healthy control dogs were quantitated and their molecular sizes characterized to detect alpha-chain, gamma-chain, or mu-chain fragments. Quantitation of immunoglobulin isotypes in serum showed that affected Basenjis have significantly elevated serum IgA values as compared to asymptomatic Basenjis and normal control dogs. However, IgA concentrations in intestinal wash fluids were not significantly different for the three groups. Immunoelectrophoresis (IEP) and polyacrylamide gel electrophoresis (PAGE) demonstrated that virtually all IgA was in the dimeric form. Using IEP and immunoselection, we were unable to detect evidence for the presence of alpha-chain or other heavy-(H)-chain fragments. Hyperimmune serum obtained from rabbits immunized with serum or a globulin fraction of affected Basenjis also failed to detect H-chain fragments. The results of this study indicate that immunoproliferative enteropathy of Basenjis resembles closely the nonsecretory form of human immunoproliferative small intestinal disease (IPSID).

Clinical and pathological evolution of alpha chain disease to immunoblastic lymphoma and response to COMP chemotherapy

A small adolescent with alpha heavy chain disease presenting as malabsorption and evolving to immunoblastic lymphoma is reported. The pathological evolution is documented by serial endoscopy and small intestinal biopsy. Clinical and pathological remission was obtained by the use of COMP combination chemotherapy.

Alpha-chain disease. Report of a case from Taiwan

The occurrence of alpha-chain disease (alpha-CD) in a Chinese patient, a resident of Taiwan, is reported. The patient's clinical features were characterized by severe malabsorption and ran a rapidly deteriorated course. Duodenal biopsy showed total villous atrophy with a heavy infiltration of the lamina propria by lymphoplasmacytic cells. Colonic biopsy revealed immunoblastic lymphoma. alpha-CD protein was demonstrated in the patient's serum and concentrated urine by the immunoselection method, and also detected in the cellular infiltrate by immunoperoxidase technique. Postmortem examination disclosed that the lymphoma involved not only the entire gastrointestinal tract and mesenteric nodes, but also the retroperitoneal and peripheral lymph nodes. Immunoperoxidase studies support the concept of a common clonal origin of the lymphoplasmacytic proliferation and immunoblastic lymphoma in alpha-CD.