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Salie MT, Rampersadh K, Muhamed B, Engel KC, Zühlke LJ, Dale JB, Engel ME. Utility of Human Immune Responses to GAS Antigens as a Diagnostic Indicator for ARF: A Systematic Review. Front Cardiovasc Med 2021; 8:691646. [PMID: 34355030 PMCID: PMC8329041 DOI: 10.3389/fcvm.2021.691646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Accepted: 06/23/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Previous studies have established that streptococcal antibody titer is correlated with a diagnosis of acute rheumatic fever (ARF). However, results vary in the usefulness of GAS antibodies, particularly anti-streptolysin-O (ASO) and anti-DNase B, in confirming a recent GAS infection. Therefore, we sought to provide, from published studies, an evidence-based synthesis of the correlation of streptococcal serology to establish the usefulness of immunological data in aiding the diagnosis of ARF. These findings are anticipated to have implications where echocardiography is not freely available, especially where ARF is rampant. Methods: We conducted a comprehensive search across a number of databases. Applying a priori criteria, we selected articles reporting on studies, regardless of study design, that evaluate the levels of antibodies against GAS-specific antigens in ARF subjects against control values or a published standard. Data were extracted onto data extraction forms, captured electronically, and analyzed using Stata software. Risk of bias was assessed in included studies using the Newcastle-Ottawa Scale (NOS). Results and Conclusion: The search strategy yielded 534 studies, from which 24 met the inclusion criteria, reporting on evaluation of titers for SLO (n = 10), DNase B (n = 9), anti-streptokinase (ASK) (n = 3) amongst others. Elevation in titers was determined by comparison with controls and upper limit of normal (ULN) antibody values as determined in healthy individuals. Meta-analysis of case-controlled studies revealed moderate odds ratio (OR) correlations between ARF diagnosis and elevated titers for SLO (OR = 10.57; 95% CI, 3.36-33.29; 10 studies) and DNAse B (OR = 6.97; 95% CI, 2.99-16.27; 7 studies). While providing support for incorporating SLO and DNase B in the diagnosis of ARF, we present the following reflections: an elevation in SLO and DNase B levels are not consistently associated with an ARF diagnosis; increasing the number of GAS proteins in the test is warranted to improve sensitivity; paired (acute and convalescent) samples could provide a more accurate indication of a rising titer. Use of community-based controls as a standard is not a reliable marker by which to gauge recent GAS infection.
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Affiliation(s)
- M Taariq Salie
- Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Kimona Rampersadh
- Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Babu Muhamed
- Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.,Division of Cardiology, Children's National Health System, Washington, DC, United States
| | - Kélin C Engel
- Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Liesl J Zühlke
- Children's Heart Disease Research Unit, Department of Paediatrics, University of Cape Town, Cape Town, South Africa
| | - James B Dale
- Division of Infectious Diseases, University of Tennessee Health Science Center (UTHSC), Memphis, TN, United States
| | - Mark E Engel
- Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
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Hobbs CV, Khaitan A, Kirmse BM, Borkowsky W. COVID-19 in Children: A Review and Parallels to Other Hyperinflammatory Syndromes. Front Pediatr 2020; 8:593455. [PMID: 33330288 PMCID: PMC7732413 DOI: 10.3389/fped.2020.593455] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Accepted: 10/15/2020] [Indexed: 12/18/2022] Open
Abstract
During the COVID-19 pandemic, children have had markedly different clinical presentations and outcomes compared to adults. In the acute phase of infection, younger children are relatively spared the severe consequences reported in adults. Yet, they are uniquely susceptible to the newly described Multisystem Inflammatory Syndrome in Children (MIS-C). This may result from the developmental "immunodeficiency" resulting from a Th2 polarization that starts in utero and is maintained for most of the first decade of life. MIS-C may be due to IgA complexes in a Th2 environment or a Th1-like response to COVID-19 antigens that developed slowly. Alternatively, MIS-C may occur in vulnerable hosts with genetic susceptibilities in other immune and non-immune pathways. Herein, we present a brief overview of the host immune response, virologic and genetic factors, and comparable inflammatory syndromes that may explain the pathophysiology leading to drastic differences in clinical presentation and outcomes of COVID-19 between children and adults.
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Affiliation(s)
- Charlotte V Hobbs
- Division of Infectious Disease, Department of Pediatrics, Batson Children's Hospital, University of Mississippi Medical Center, Jackson, MS, United States.,Department of Microbiology, University of Mississippi Medical Center, Jackson, MS, United States
| | - Alka Khaitan
- Department of Pediatrics, The Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Brian M Kirmse
- Division of Medical Genetics, Department of Pediatrics, Batson Children's Hospital, University of Mississippi Medical Center, Jackson, MS, United States
| | - William Borkowsky
- Division of Infectious Diseases, Department of Pediatrics, New York University Langone Health, New York, NY, United States
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Thomé R, Bombeiro AL, Issayama LK, Rapôso C, Lopes SCP, da Costa TA, Di Gangi R, Ferreira IT, Longhini ALF, Oliveira ALR, da Cruz Höfling MA, Costa FTM, Verinaud L. Exacerbation of autoimmune neuro-inflammation in mice cured from blood-stage Plasmodium berghei infection. PLoS One 2014; 9:e110739. [PMID: 25329161 PMCID: PMC4201583 DOI: 10.1371/journal.pone.0110739] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2014] [Accepted: 09/16/2014] [Indexed: 01/24/2023] Open
Abstract
The thymus plays an important role shaping the T cell repertoire in the periphery, partly, through the elimination of inflammatory auto-reactive cells. It has been shown that, during Plasmodium berghei infection, the thymus is rendered atrophic by the premature egress of CD4+CD8+ double-positive (DP) T cells to the periphery. To investigate whether autoimmune diseases are affected after Plasmodium berghei NK65 infection, we immunized C57BL/6 mice, which was previously infected with P. berghei NK65 and treated with chloroquine (CQ), with MOG35-55 peptide and the clinical course of Experimental Autoimmune Encephalomyelitis (EAE) was evaluated. Our results showed that NK65+CQ+EAE mice developed a more severe disease than control EAE mice. The same pattern of disease severity was observed in MOG35-55-immunized mice after adoptive transfer of P. berghei-elicited splenic DP-T cells. The higher frequency of IL-17+- and IFN-γ+-producing DP lymphocytes in the Central Nervous System of these mice suggests that immature lymphocytes contribute to disease worsening. To our knowledge, this is the first study to integrate the possible relationship between malaria and multiple sclerosis through the contribution of the thymus. Notwithstanding, further studies must be conducted to assert the relevance of malaria-induced thymic atrophy in the susceptibility and clinical course of other inflammatory autoimmune diseases.
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Affiliation(s)
- Rodolfo Thomé
- Department of Structural and Functional Biology, Institute of Biology, University of Campinas, Campinas, Brazil
| | - André Luis Bombeiro
- Department of Structural and Functional Biology, Institute of Biology, University of Campinas, Campinas, Brazil
| | - Luidy Kazuo Issayama
- Department of Structural and Functional Biology, Institute of Biology, University of Campinas, Campinas, Brazil
| | - Catarina Rapôso
- Department of Histology and Embryology, Institute of Biology, University of Campinas, Campinas, Brazil
| | - Stefanie Costa Pinto Lopes
- Department of Genetics, Evolution and Bioagents, Institute of Biology, University of Campinas, Campinas, Brazil
| | - Thiago Alves da Costa
- Department of Structural and Functional Biology, Institute of Biology, University of Campinas, Campinas, Brazil
| | - Rosária Di Gangi
- Department of Structural and Functional Biology, Institute of Biology, University of Campinas, Campinas, Brazil
| | - Isadora Tassinari Ferreira
- Department of Structural and Functional Biology, Institute of Biology, University of Campinas, Campinas, Brazil
| | | | | | | | | | - Liana Verinaud
- Department of Structural and Functional Biology, Institute of Biology, University of Campinas, Campinas, Brazil
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Olive C, Clair T, Yarwood P, Good MF. Protection of mice from group A streptococcal infection by intranasal immunisation with a peptide vaccine that contains a conserved M protein B cell epitope and lacks a T cell autoepitope. Vaccine 2002; 20:2816-25. [PMID: 12034109 DOI: 10.1016/s0264-410x(02)00205-0] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Infection with group A streptococci (GAS) can lead to rheumatic fever (RF) and rheumatic heart disease (RHD) which are a major health concern particularly in indigenous populations worldwide, and especially in Australian Aboriginals. A primary route of GAS infection is via the upper respiratory tract, and therefore, a major goal of research is the development of a mucosal-based GAS vaccine. The majority of the research to date has focused on the GAS M protein since immunity to GAS is mediated by M protein type-specific opsonic antibodies. There are two major impediments to the development of a vaccine-the variability in M proteins and the potential for the induction of an autoimmune response. To develop a safe and broad-based vaccine, we have therefore focused on the GAS M protein conserved C-region, and have identified peptides, J8 and the closely related J8 peptide (J14), which may be important in protective immunity to GAS infection. Using a mucosal animal model system, our data have shown a high degree of throat GAS colonisation in B10.BR mice 24h following intranasal immunisation with the mucosal adjuvant, cholera toxin B subunit (CTB), and/or diptheria toxoid (dT) carrier, or PBS alone, and challenge with the M1 GAS strain. However, GAS colonisation of the throat was significantly reduced following intranasal immunisation of mice with the vaccine candidate J8 conjugated to dT or J14-dT when administered with CTB. Moreover, J8-dT/CTB and J14-dT/CTB-immunised mice had a significantly higher survival when compared to CTB and PBS-immunised control mice. These data indicate that immunity to GAS infection can be evoked by intranasal immunisation with a GAS M protein C-region peptide vaccine that contains a protective B cell epitope and lacks a T cell autoepitope.
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Affiliation(s)
- Colleen Olive
- Cooperative Research Centre for Vaccine Technology, The Queensland Institute of Medical Research, PO Royal Brisbane Hospital, Brisbane, QLD 4029, Australia.
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Guilherme L, Oshiro SE, Faé KC, Cunha-Neto E, Renesto G, Goldberg AC, Tanaka AC, Pomerantzeff PM, Kiss MH, Silva C, Guzman F, Patarroyo ME, Southwood S, Sette A, Kalil J. T-cell reactivity against streptococcal antigens in the periphery mirrors reactivity of heart-infiltrating T lymphocytes in rheumatic heart disease patients. Infect Immun 2001; 69:5345-51. [PMID: 11500404 PMCID: PMC98644 DOI: 10.1128/iai.69.9.5345-5351.2001] [Citation(s) in RCA: 78] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
T-cell molecular mimicry between streptococcal and heart proteins has been proposed as the triggering factor leading to autoimmunity in rheumatic heart disease (RHD). We searched for immunodominant T-cell M5 epitopes among RHD patients with defined clinical outcomes and compared the T-cell reactivities of peripheral blood and intralesional T cells from patients with severe RHD. The role of HLA class II molecules in the presentation of M5 peptides was also evaluated. We studied the T-cell reactivity against M5 peptides and heart proteins on peripheral blood mononuclear cells (PBMC) from 74 RHD patients grouped according to the severity of disease, along with intralesional and peripheral T-cell clones from RHD patients. Peptides encompassing residues 1 to 25, 81 to 103, 125 to 139, and 163 to 177 were more frequently recognized by PBMC from RHD patients than by those from controls. The M5 peptide encompassing residues 81 to 96 [M5(81-96) peptide] was most frequently recognized by PBMC from HLA-DR7+ DR53+ patients with severe RHD, and 46.9% (15 of 32) and 43% (3 of 7) of heart-infiltrating and PBMC-derived peptide-reactive T-cell clones, respectively, recognized the M5(81-103) region. Heart proteins were recognized more frequently by PBMC from patients with severe RHD than by those from patients with mild RHD. The similar pattern of T-cell reactivity found with both peripheral blood and heart-infiltrating T cells is consistent with the migration of M-protein-sensitized T cells to the heart tissue. Conversely, the presence of heart-reactive T cells in the PBMC of patients with severe RHD also suggests a spillover of sensitized T cells from the heart lesion.
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Affiliation(s)
- L Guilherme
- Heart Institute, InCor, School of Medicine, University of São Paulo, São Paulo, Brazil.
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Abstract
Group A streptococci are model extracellular gram-positive pathogens responsible for pharyngitis, impetigo, rheumatic fever, and acute glomerulonephritis. A resurgence of invasive streptococcal diseases and rheumatic fever has appeared in outbreaks over the past 10 years, with a predominant M1 serotype as well as others identified with the outbreaks. emm (M protein) gene sequencing has changed serotyping, and new virulence genes and new virulence regulatory networks have been defined. The emm gene superfamily has expanded to include antiphagocytic molecules and immunoglobulin-binding proteins with common structural features. At least nine superantigens have been characterized, all of which may contribute to toxic streptococcal syndrome. An emerging theme is the dichotomy between skin and throat strains in their epidemiology and genetic makeup. Eleven adhesins have been reported, and surface plasmin-binding proteins have been defined. The strong resistance of the group A streptococcus to phagocytosis is related to factor H and fibrinogen binding by M protein and to disarming complement component C5a by the C5a peptidase. Molecular mimicry appears to play a role in autoimmune mechanisms involved in rheumatic fever, while nephritis strain-associated proteins may lead to immune-mediated acute glomerulonephritis. Vaccine strategies have focused on recombinant M protein and C5a peptidase vaccines, and mucosal vaccine delivery systems are under investigation.
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Affiliation(s)
- M W Cunningham
- Department of Microbiology and Immunology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma 73104, USA
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Cunningham MW, Antone SM, Smart M, Liu R, Kosanke S. Molecular analysis of human cardiac myosin-cross-reactive B- and T-cell epitopes of the group A streptococcal M5 protein. Infect Immun 1997; 65:3913-23. [PMID: 9284171 PMCID: PMC175558 DOI: 10.1128/iai.65.9.3913-3923.1997] [Citation(s) in RCA: 90] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
The group A streptococcal M protein is an important virulence determinant eliciting protective and autoimmune responses against the streptococcus and cardiac myosin, respectively. In this report, the major human cardiac myosin-cross-reactive T-cell epitopes of M5 protein are identified and localized to myosin-like repeats within the M5 molecule. BALB/c mice were immunized with human cardiac myosin, and the dominant myosin-cross-reactive T-cell epitopes of M5 protein were identified with a panel of 23 overlapping peptides spanning the A, B, and C repeat regions of M5 protein. Human cardiac myosin-cross-reactive T-cell epitopes of M5 protein were localized to several sequences in the M5 peptides NT4 (GLKTENEGLKTENEGLKTE), NT5 (KKEHEAENDKLKQQRDTL), B1B2 (VKDKIAKEQENKETIGTL), B2 (TIGTLKKILDETVKDKIA), B3A (IGTLKKILDETVKDKLAK), and C3 (KGLRRDLDASREAKKQ). The NT4 repeated sequence LKTEN was highly homologous with a site conserved in cardiac myosins, the B repeat region peptides were 47% homologous to human cardiac myosin amino acid sequence, and the C3 sequence RRDL was identical to a highly conserved site in skeletal and cardiac myosins. Immunization of BALB/c mice with each of the overlapping M5 peptides revealed myosin-cross-reactive B-cell epitopes throughout the A and C repeat regions and one major epitope in the B repeat region containing the previously reported Gln-Lys-Ser-Lys-Gln (QKSKQ) epitope. The data suggest that the M5 peptides elicited higher antibody titers to cardiac myosin than to skeletal myosin and that several sites in the A and B repeat regions of M5 protein induced myocardial inflammatory infiltrates.
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Affiliation(s)
- M W Cunningham
- Department of Microbiology and Immunology, University of Oklahoma Health Sciences Center, Oklahoma City 73190, USA.
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El-Demellawy M, El-Ridi R, Guirguis NI, Abdel Alim M, Kotby A, Kotb M. Preferential recognition of human myocardial antigens by T lymphocytes from rheumatic heart disease patients. Infect Immun 1997; 65:2197-205. [PMID: 9169751 PMCID: PMC175303 DOI: 10.1128/iai.65.6.2197-2205.1997] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Acute rheumatic fever (ARF) and rheumatic heart disease (RHD) are autoimmune sequelae of upper respiratory infections with group A streptococci (GAS). To gain a better understanding of the pathogenesis of these diseases, we examined the in vitro proliferative responses of peripheral blood mononuclear cells (PBMC) from RHD patients to human myocardial proteins in a T-cell Western assay. A number of myocardial proteins fractionated by sodium dodecyl sulfate-polyacrylamide gel electrophoresis were recognized by PBMC from both patients and controls. However, PBMC from a significant percentage of RHD patients (40%) responded to a discrete band of myocardial proteins migrating with an apparent molecular mass of 50 to 54 kDa while none of the control subject PBMC responded to this protein band (P < or = 0.0001). To further investigate the link between infections with GAS and autoimmune carditis, we studied the proliferative responses of PBMC from patients and controls to myocardial proteins before and after in vitro stimulation of the cells with opsonized GAS isolated from ARF patients. Priming of PBMC with rheumatogenic GAS caused the percentage of RHD patients responding to the 50- to 54-kDa myocardial proteins to increase from 43 to 90% (P < or = 0.0284). By contrast, PBMC from control subjects failed to recognize the 50- to 54-kDa myocardial proteins even after stimulation with the opsonized streptococci (P < or = 0.0001). The assay sensitivity was increased from 40 to 90% after priming of a patient's cells with opsonized GAS, but the positive predictive value was 100% in both unprimed and primed cultures. Antibodies generated to partially purified 50- to 54-kDa myocardial proteins did not cross-react with either streptococcal homogenates, purified M protein, myosin, laminin, or vimentin, suggesting a lack of cross-reactivity at the humoral level. This study suggests that the 50- to 54-kDa myocardial proteins contain a putative antigen that is preferentially recognized by T cells from RHD patients and demonstrates that exposure to streptococcal antigens enhances the ability of patients to recognize these proteins.
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Affiliation(s)
- M El-Demellawy
- Veterans Affairs Medical Center and Department of Surgery, The University of Tennessee, Memphis 38104, USA
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Abstract
The ability of bacteria to cause immunopathological damage in the host may take a variety of forms. These pathways may be conveniently grouped under three major headings: (1) organisms that can cause damage via shared antigenic determinants between host and bacterium; (2) those organisms that suppress the host’s response; and (3) organisms that release substances with specific biological properties or have receptors for specific tissue sites. The group A streptococcus is among the most versatile of these bacteria because it appears that it may use all three pathways in various streptococcal-related disease states. In rheumatic fever and chorea it appears that cross-reactive antigens play a major role in inducing immunopathological damage in that there is both a heightened humoral and cellular reaction by the host to these cross-reactive determinants. Recent evidence also indicates that rheumatic fever individuals express certain B cell antigens that may be associated with susceptibility to the disease. In the other complications of streptococcal infections, namely poststreptococcal glomerulonephritis, the bacterium uses both suppression of the host’s immune response and the excretion of a particular protein common to all nephritis-associated strains to achieve its immunopathological damage. In this context, other examples of bacterial-host interactions will be discussed as evidence for the common pathways used by microbes to cause immunopathological damage in the host.
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Carapetis JR, Currie BJ, Good MF. Towards understanding the pathogenesis of rheumatic fever. Scand J Rheumatol 1996; 25:127-31; discussion 132-3. [PMID: 8668953 DOI: 10.3109/03009749609080000] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Acute rheumatic fever results from an immunological response to group A streptococcal infection, but the exact nature of this response, and of the underlying host and organism characteristics, continues to evade researchers. Earlier models of rheumatic fever pathogenesis emphasised the importance of humoral immunity, but more recent work suggests that cellular immunity may play a primary role. Greater understanding of these disease mechanisms is allowing researchers to move towards the development of a vaccine for rheumatic fever.
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Guilherme L, Cunha-Neto E, Coelho V, Snitcowsky R, Pomerantzeff PM, Assis RV, Pedra F, Neumann J, Goldberg A, Patarroyo ME. Human heart-infiltrating T-cell clones from rheumatic heart disease patients recognize both streptococcal and cardiac proteins. Circulation 1995; 92:415-20. [PMID: 7634457 DOI: 10.1161/01.cir.92.3.415] [Citation(s) in RCA: 145] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND beta-Hemolytic streptococcal infection in developing countries still causes thousands of causes of rheumatic heart disease, demanding surgical valve correction. Antigenic mimicry between self and streptococcal components has been proposed as the triggering factor leading to autoimmunity in individuals with genetic susceptibility. Although heart streptococcal-M protein cross-reactive antibodies have been demonstrated, heart tissue damage seems to be T lymphocyte-dependent. We studied the infiltrating T lymphocytes in rheumatic heart lesions with the aim of understanding the role of cellular immune response at the site of the lesions. METHODS AND RESULTS We obtained 107 T-cell clones from surgical fragments of cardiac tissue from four rheumatic heart disease patients. We tested their capacity to recognize streptococcal M protein-derived synthetic peptides and heart proteins. We found eight infiltrating T-cell clones from all four patients that simultaneously recognize streptococcal M and heart proteins. Among the M-protein sequences tested, only synthetic peptides corresponding to regions 1 through 25, 81 through 103, and 163 through 177 were simultaneously recognized with heart protein fractions. Interestingly, regions 81 through 103 and 163 through 177 have been known to bear heart cross-reactive epitopes at the antibody level. Five of these clones are CD4+, and one is CD8+. CONCLUSIONS The presence of heart-M protein cross-reactive T-cell clones in rheumatic heart lesions suggests their direct involvement in the pathogenesis of this disease. The dissection of protective and pathogenic epitopes of streptococcal M protein is an important step in allowing the development of a safe anti-streptococcal synthetic vaccine.
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Affiliation(s)
- L Guilherme
- Instituto do Coração, Hospital das Clinicas, Faculdade de Medicina, Universidade de São Paulo Brazil
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Abstract
Over the past 25 years, the clinical course of Kawasaki disease has been defined, the prevalence and nature of the cardiovascular effects widely understood, and pathological changes in the most severe cases well described. However, the aetiology and pathogenesis of this puzzling disease have remained unclear, thus specific therapy is not yet available. Because of some close clinical similarities between this disease and streptococcal scarlet fever, particular attention has been paid to the possible role of Streptococcus pyogenes as an aetiological agent in this illness. Until now, however, group A beta-haemolytic streptococci have never been consistently isolated from any patients; in addition, the titre of anti-streptolysin 0 is not raised, and lack of response to antibiotics is a feature of this disease. Our long series of investigations over more than 10 years, which will be covered in the present review, were performed in an attempt at elucidating causative agent(s) of Kawasaki disease. This has led to our firm belief in the probable role of S. pyogenes in the pathogenesis of this disease, despite the lack of fulfillment of Koch's postulates, on the basis of the following findings. Patients with Kawasaki disease recovering from the acute, febrile phase of the illness exhibited an exaggerated cell-mediated reactivity, as measured by the macrophage migration inhibition test, to group A beta-haemolytic streptococci, their pyrogenic exotoxin and streptolysin 0 as well as to several mammalian muscle cell extracts which are allegedly related antigenically to the cell wall and/or cytoplasmic membrane of S. pyogenes. Protoplast-like "spherical bodies" varying in diameter from 0.5 to 1.5 microns, and devoid of cell walls, were detected in the buffy coats of peripheral blood from patients with this disease, and stained distinctly by immuno-electron microscopy using, as a primary antibody, a rabbit antiserum to S. pyogenes- derived protoplasts, and followed by absorption with protoplasts from Staphylococcus aureus and Escherichia coli. Newborn mice infected with S. pyogenes having no capacity to confer cell-mediated immunity even in adult murine hosts, and reinfected 4-6 weeks later with another strain of the same species of bacteria which is able to elicit cellular immunity, showed a lack of humoral response to streptococcal antigens, leaving intact cell-mediated immunity. Such a biased immunological characteristic is an exact counterpart of that of Kawasaki disease patients.(ABSTRACT TRUNCATED AT 400 WORDS)
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Affiliation(s)
- T Akiyama
- Department of Microbiology, Kitasato University School of Medicine, Sagamihara, Japan
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Tsuchiya N, Williams RC. Molecular mimicry--hypothesis or reality? West J Med 1992; 157:133-8. [PMID: 1279899 PMCID: PMC1011230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
A number of observations support molecular mimicry as a possible pathogenetic mechanism in diseases such as acute rheumatic fever, reactive arthritis after enteric infection or associated with Reiter's syndrome, myasthenia gravis, or even in rheumatoid arthritis. Molecular mimicry can be defined as a sharing of epitopes in linear or 3-dimensional presentation on disparate proteins from entirely different sources--for instance, group A streptococcal membranes and human cardiac myosin. How exposure to or infection with organisms sharing molecular similarity with antigens of the human host can evade tolerance and actually induce a self-reacting humoral or cellular immune response is still not clear; however, a large body of evidence has now been accumulated that documents apparent molecular mimicry mechanisms in these disorders. In some diseases, the molecular mimicry appears to involve human target organs and specific components of the infectious organism, whereas in others the host HLA cell surface molecules appear to share antigens with presumed bacterial or viral initiators of disease.
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Affiliation(s)
- N Tsuchiya
- Department of Medicine and Physical Therapy, University of Tokyo School of Medicine, Japan
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Stollerman GH. Rheumatogenic streptococci and autoimmunity. CLINICAL IMMUNOLOGY AND IMMUNOPATHOLOGY 1991; 61:131-42. [PMID: 1914256 DOI: 10.1016/s0090-1229(05)80019-4] [Citation(s) in RCA: 64] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
The uniqueness of the group A streptococcus in initiating a cardiodestructive disease in a limited segment of the human species, regardless of race or ethnic group, makes the quest for a unique host response to a specific streptococcal antigen an intriguing and persisting challenge for clinical investigators, particularly for those investigators interested in autoimmunity. New methodology is making possible more incisive research approaches. The defined streptococcal antigens that turn out to be epitopes identical with host tissues, such as the M protein/cardiac myosin model or the hyaluronate in the capsule of mucoid rheumatogenic strains, offer the opportunity for more incisive clinical investigations. The isolation and cultivation of cardiotoxic T cell clones directed against such epitopes shared by host and parasite may eventually be possible. We may then learn more about whether autoimmunity is indeed a factor in the pathogenesis of rheumatic heart disease.
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Baker BS, Powles AV, Malkani AK, Lewis H, Valdimarsson H, Fry L. Altered cell-mediated immunity to group A haemolytic streptococcal antigens in chronic plaque psoriasis. Br J Dermatol 1991; 125:38-42. [PMID: 1873200 DOI: 10.1111/j.1365-2133.1991.tb06036.x] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
The proliferative lymphocyte response to sonicated group A, beta-haemolytic streptococci (Strep-A) was measured by thymidine incorporation in 78 patients with psoriasis (guttate, chronic plaque or both). Lymphocytes from 72 of these patients were also cultured with streptokinase/streptodornase (SK/SD), and 20 of the patients with chronic plaque psoriasis were further tested with PPD, Candida albicans and sonicated Streptococcus mutans, a bacterial type not associated clinically with psoriasis. The median stimulation index (SI) of the psoriasis group to the Strep-A preparation was significantly higher than that of a group of 27 non-psoriatic individuals (P less than 0.05). Within this group, only the patients with chronic plaque psoriasis (n = 42) showed a significantly increased proliferative response compared to the non-psoriatic controls (median SI = 123.8 and 31.9, respectively, P less than 0.01). Although the lymphocyte response of the chronic plaque group to SK/SD was also markedly higher than that of the control group, this difference did not reach statistical significance. In addition, these patients did not show significantly increased responses to any of the other antigens tested, including S. mutans. No correlation was observed between the degree of proliferation to Strep-A and disease extent or activity. Similarly, ASO titres, which were raised in 11 out of 23 guttate and three out of nine chronic plaque psoriasis patients tested, did not correlate with the proliferative responses observed.
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Affiliation(s)
- B S Baker
- Department of Dermatology and Immunology, St. Mary's Hospital and Medical School, London
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20
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Hafez M, Abdalla A, el-Shennawy F, al-Tonbary Y, Sheaishaa A, el-Morsi Z, Tawfik S, Settien A, Abou el-Khair M. Immunogenetic study of the response to streptococcal carbohydrate antigen of the cell wall in rheumatic fever. Ann Rheum Dis 1990; 49:708-14. [PMID: 2241288 PMCID: PMC1004209 DOI: 10.1136/ard.49.9.708] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
An immunogenetic study of the response to streptococcal carbohydrate antigen of the cell wall was carried out on members of 15 multiplex families each having more than one sib affected with rheumatic heart disease. They comprised 30 parents and 61 sibs (32 with rheumatic disease and 29 without). Fifty healthy unrelated subjects served as controls. A history was taken and clinical examination carried out. Rheumatic activity was determined and HLA typing was carried out for nine A antigens, 15 B antigens, and six DR antigens. The immune response of lymphocytes to streptococcal polysaccharide antigen of the cell wall of group A beta haemolytic streptococci in vitro was studied by tritiated thymidine uptake. The results were statistically and genetically analysed. It was found that (a) all subjects with rheumatic disease were highly responsive to the streptococcal polysaccharide antigen of the cell wall, the sib pairs being mostly HLA identical; (b) all low responders had no rheumatic disease and their phenotypes were mostly different from those of the rheumatic member of their sib pair; (c) correlation of immune responsiveness (high or low) between HLA-identical sibs was significant, but insignificant between haplotype identical and non-identical sibs; (d) the gene responsible for high responsiveness to the streptococcal polysaccharide antigen of the cell wall is recessive and closely linked to HLA. In conclusion, it was found that exposure to pharyngeal infection with group A beta haemolytic streptococci may lead to acute rheumatic fever in those with an inherited recessive gene responsible for high responsiveness to the streptococcal polysaccharide antigen of the cell wall.
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Affiliation(s)
- M Hafez
- Department of Pediatrics, Faculty of Medicine, Mansoura University, Egypt
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21
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Alarcon-Riquelme ME, Alarcon-Segovia D, Loredo-Abdala A, Alcocer-Varela J. T lymphocyte subsets, suppressor and contrasuppressor cell functions, and production of interleukin-2 in the peripheral blood of rheumatic fever patients and their apparently healthy siblings. CLINICAL IMMUNOLOGY AND IMMUNOPATHOLOGY 1990; 55:120-8. [PMID: 2137738 DOI: 10.1016/0090-1229(90)90073-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
We studied CD4 and CD8 T cell subsets, suppressor cell function, production of IL-2, and immune contrasuppressor cell activity in 21 patients with rheumatic fever (RF), both at the time of their first acute episode and 3 months later (recovery phase). As controls we studied their healthy sibling nearest in age, as well as age- and sex-matched unrelated normal subjects. In the acute phase we found CD4+ T cells to be high, concanavalin A-induced suppression to be low, and production of IL-2 to be significantly decreased, as compared to the normal unrelated controls. The addition of contrasuppressor cells (VV+) to cell cocultures resulted in an increase in proliferation by mononuclear cells (MNC) in response to streptococcal M antigen but not to C carbohydrate antigen. In the recovery phase, CD4+ T cells became normal, CD8+ T cells rose above normal, and the suppressor cell functions (concanavalin-A-induced and spontaneously expanded), as well as the production of IL-2, fell further. Siblings were found to have increased CD8+ T cells and decreased production of IL-2, as compared to the unrelated controls. These findings indicate that important immunoregulatory disturbances occur during the acute phase of rheumatic fever, some of which persist, accentuate, or change during the recovery phase. The findings in siblings could be related either to streptococcal infection or to a familial immunoregulatory aberration.
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Affiliation(s)
- M E Alarcon-Riquelme
- Department of Immunology and Rheumatology, Instituto Nacional de la Nutrición Salvador, Zubirán, Mexico
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22
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Bhatia R, Narula J, Reddy KS, Koicha M, Malaviya AN, Pothineni RB, Tandon R, Bhatia ML. Lymphocyte subsets in acute rheumatic fever and rheumatic heart disease. Clin Cardiol 1989; 12:34-8. [PMID: 2912606 DOI: 10.1002/clc.4960120106] [Citation(s) in RCA: 26] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Lymphocyte subsets in 53 patients with acute rheumatic fever and 78 patients with chronic rheumatic heart disease were compared with 20 normal control subjects and 39 patients suffering from uncomplicated streptococcal pharyngitis to obtain information about the pathogenesis of the disease. Twenty patients with rheumatic fever were followed for 24 weeks to evaluate changes occurring over the course of the disease. Total leukocyte and lymphocyte counts were increased in patients with rheumatic fever and to a lesser extent in those with rheumatic heart disease, when compared with controls. The difference between the two groups was significant. Patients with acute rheumatic fever had an increased number of B cells and a smaller increase in total T and T-helper-inducer (CD-4) cells. The proportion of B cells increased, while that of T-suppressor-cytotoxic (CD-8) cells fell. An increased number and proportion of B cells was also seen in patients with rheumatic heart disease. Total T and T-helper lymphocyte percentages and numbers were significantly higher in patients with rheumatic fever compared with those of patients with rheumatic heart disease. Follow-up studies at 6, 12, and 24 weeks revealed no significant differences from the entry point studies, although there was a trend toward reduction in the degree of derangement from normal values. Patients with uncomplicated streptococcal pharyngitis, however, did not show perturbations in the T-cell and T-subset counts. Our study suggests that the immunoregulatory defect in acute rheumatic fever is characterized by a relative reduction of suppressor T cells with an absolute increase in helper T cells and B cells, resulting in an increased cellular as well as humoral immune response.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- R Bhatia
- Department of Medicine, All India Institute of Medical Sciences, New Delhi
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Froude J, Gibofsky A, Buskirk DR, Khanna A, Zabriskie JB. Cross-reactivity between streptococcus and human tissue: a model of molecular mimicry and autoimmunity. Curr Top Microbiol Immunol 1989; 145:5-26. [PMID: 2680297 DOI: 10.1007/978-3-642-74594-2_2] [Citation(s) in RCA: 30] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
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24
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Benatar A, Beatty DW, Human DG. Immunological abnormalities in children with acute rheumatic carditis and acute post-streptococcal glomerulonephritis. Int J Cardiol 1988; 21:51-8. [PMID: 3220602 DOI: 10.1016/0167-5273(88)90008-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Immunological functions were investigated in 10 children with acute rheumatic fever and 11 children with acute nephritis to try and elucidate the cause of heart damage in acute rheumatic fever. Children with acute rheumatic fever and carditis showed an increase in serum IgG, IgA and antistreptococcal antibodies during the acute stage. Lymphocyte transformation responses to phytohaemagglutinin and streptococcal antigens were reduced but this was due to a serum suppressor effect. After recovering from acute rheumatic fever a lymphocytosis and an increased lymphocyte blastogenic response to streptococcal antigen were found. T-cells, T-helper cells and T-suppressor cells showed some changes in acute rheumatic fever but these were not statistically significant in our study. None of the changes in immunological responses that were seen in acute rheumatic fever were found in acute nephritis. These results support the hypothesis that an abnormal immune response to streptococcal products is involved in the development of carditis and the other phenomena observed in acute rheumatic fever.
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Affiliation(s)
- A Benatar
- Department of Paediatrics and Child Health, University of Cape Town, South Africa
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25
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Chopra P, Narula J, Kumar AS, Sachdeva S, Bhatia ML. Immunohistochemical characterisation of Aschoff nodules and endomyocardial inflammatory infiltrates in left atrial appendages from patients with chronic rheumatic heart disease. Int J Cardiol 1988; 20:99-105. [PMID: 3042638 DOI: 10.1016/0167-5273(88)90319-1] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Fifty left atrial appendages collected fresh during closed mitral valvotomy in patients with chronic rheumatic heart disease, were analysed to determine the frequency of Aschoff nodules and characteristics of mononuclear inflammatory infiltration. Fifty-six percent of specimens demonstrated Aschoff nodules with no clinical or laboratory evidence of acute rheumatic activity in the patients undergoing surgery. Endomyocardial infiltration contained predominantly T cells and occasionally B cells. The relative proportions of T helper-inducer, T suppressor-cytotoxic lymphocytes and macrophages were 45.1 +/- 7.6, 23.5 +/- 4.8 and 29.3 +/- 9.6%, respectively. Frequent presence of Aschoff nodules and heavy mononuclear infiltrates in chronic rheumatic heart disease suggests a possibility of subclinical ongoing carditis.
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Affiliation(s)
- P Chopra
- Department of Pathology and Cardiology, All India Institute of Medical Sciences, New Delhi
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26
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Lowry PJ, Gammage MD, Gentle TA, Baynham MI, Thompson RA, Littler WA. Suppressor T lymphocyte function in patients with idiopathic congestive cardiomyopathy. BRITISH HEART JOURNAL 1987; 57:458-61. [PMID: 2954574 PMCID: PMC1277200 DOI: 10.1136/hrt.57.5.458] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Suppressor T lymphocyte function was examined in 11 patients with idiopathic congestive cardiomyopathy and in 11 age and sex matched patients with a similar degree of heart failure resulting from ischaemic heart disease. Suppressor T lymphocyte function was also assessed in a control population of 11 normal subjects. Suppressor T lymphocyte function was reduced in both groups of patients with heart failure but not significantly, and a wide range of suppression was demonstrated in all groups. These data do not support the hypothesis that there is a defect in T lymphocyte function in patients with congestive cardiomyopathy, but they do suggest that there may be a non-specific reduction in T lymphocyte suppressor function associated with heart failure in general.
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27
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Read SE, Reid HF, Fischetti VA, Poon-King T, Ramkissoon R, McDowell M, Zabriskie JB. Serial studies on the cellular immune response to streptococcal antigens in acute and convalescent rheumatic fever patients in Trinidad. J Clin Immunol 1986; 6:433-41. [PMID: 3536986 DOI: 10.1007/bf00915249] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Acute rheumatic fever (ARF) has the characteristics of an autoimmune disease, triggered by cross-reactive antigens shared by the group A streptococcus and a variety of tissues including the heart, endothelium, and basal ganglia. Using two parameters of cellular reactivity, migration inhibition and blastogenic transformation, ARF patients from Trinidad show significant lymphocyte reactivity to streptococcal antigens, particularly those from an ARF associated streptococcal strain. This reactivity, studied over a 2-year period, peaked at 1 to 6 months after the acute onset and remained significantly elevated for at least 2 years. The reactivity is directed mainly toward a nonionic detergent extractable material in the cell membrane. These studies suggest a possible streptococcal strain specificity in ARF and demonstrate persistent sensitization, which explains the increased susceptibility to recurrences in the 2 years following the acute episode.
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28
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Ayoub EM, Barrett DJ, Maclaren NK, Krischer JP. Association of class II human histocompatibility leukocyte antigens with rheumatic fever. J Clin Invest 1986; 77:2019-26. [PMID: 3486889 PMCID: PMC370563 DOI: 10.1172/jci112531] [Citation(s) in RCA: 135] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
The association of class I and II HLA antigens with rheumatic fever and its manifestations was examined in 72 patients, including 48 blacks and 24 Caucasians. No significant association was found between class I antigens and rheumatic fever. In contrast, HLA-DR2 and HLA-DR4 phenotypes were encountered in a significantly higher frequency in black and Caucasian patients with rheumatic fever, respectively, compared with the control populations (P less than 0.005). The most significant association (P less than 0.005) of these DR antigens with a major manifestation of rheumatic fever was found for mitral insufficiency. In addition, a significant association was encountered between persistent elevation of antibody to the group A streptococcal carbohydrate and HLA-DR4 in Caucasian patients (P less than 0.04) or HLA-DR2 in the black patients (P less than 0.001). The frequency of HLA-DR2/4 heterozygotes among patients with rheumatic fever did not differ significantly from controls. These findings support the concept of a genetically determined susceptibility to rheumatic fever and, particularly, to rheumatic heart disease. The association of the clinical manifestations of rheumatic fever and the immune hyperresponsiveness to a streptococcal antigen could be ascribed to a disease-associated immune-response gene which is in linkage disequilibrium with the DR2 and DR4 alleles of HLA-DR locus on chromosome six.
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29
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Zabriskie JB, Gibofsky A. Genetic control of the susceptibility to infection with pathogenic bacteria. Curr Top Microbiol Immunol 1986; 124:1-20. [PMID: 3519099 DOI: 10.1007/978-3-642-70986-9_1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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30
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Benderly A, Etzioni A. Role of the immune system in the etiology of rheumatic fever. SURVEY OF IMMUNOLOGIC RESEARCH 1985; 4:319-24. [PMID: 3939158 DOI: 10.1007/bf02918740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
In order to summarize all the data regarding the immunological findings in RF we have elaborated the following theory about the pathogenesis of RF (fig. 1). The disease will develop only after repeated beta-hemolytic group A streptococcal throat infection in susceptible individuals. In these people, who have a specific immune response to repeated streptococcal infection due to their DR region, a decrease in suppressor activity will develop. This will lead to an increased specific humoral and cellular immune response to streptococcal antigen which cross-reacts with specific human tissue as the heart or the brain. Alternatively or concomitantly specific autoantibodies against these tissues are made. These antibodies together with the cellular response will cause the clinical manifestation seen in RF. This is only a proposed theory and still much more work has to be done to solve the enigma regarding the pathogenesis of RF.
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31
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Zabriskie JB. Rheumatic fever: the interplay between host, genetics, and microbe. Lewis A. Conner memorial lecture. Circulation 1985; 71:1077-86. [PMID: 3995703 DOI: 10.1161/01.cir.71.6.1077] [Citation(s) in RCA: 79] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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32
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Marboe CC, Knowles DM, Weiss MB, Fenoglio JJ. Monoclonal antibody identification of mononuclear cells in endomyocardial biopsy specimens from a patient with rheumatic carditis. Hum Pathol 1985; 16:332-8. [PMID: 3156802 DOI: 10.1016/s0046-8177(85)80227-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
A 17-year-old woman with rheumatic carditis underwent endomyocardial biopsy both prior to and following treatment with prednisone and aspirin. Frozen sections from the endomyocardial biopsy specimens were studied with monoclonal antibodies by an indirect immunofluorescence technique to define the composition of the inflammatory infiltrate in the myocardium and to determine whether the composition of the infiltrate is distinctive and diagnostically useful. The specimen from the initial biopsy contained a heterogeneous infiltrate composed of T lymphocytes, macrophages, B lymphocytes, and mast cells. T lymphocytes predominated, and the ratio of T-helper to T-cytotoxic/suppressor cells was 2.0. Following treatment the overall cellularity of the infiltrate was diminished, but the infiltrate remained heterogeneous; T cells predominated, and the T-helper to T-cytotoxic/suppressor ratio was reversed, to 0.59. The composition of the inflammatory infiltrate in this case of rheumatic carditis distinguishes it immunologically from other "idiopathic," presumably virus-associated, forms of myocarditis.
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33
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Hafez M, Chakravarti A, el-Shennawy F, el-Morsi Z, el-Sallab SH, Al-Tonbary Y. HLA antigens and acute rheumatic fever: evidence for a recessive susceptibility gene linked to HLA. Genet Epidemiol 1985; 2:273-82. [PMID: 4054602 DOI: 10.1002/gepi.1370020305] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
From 60 probands with acute rheumatic fever (ARF), 19 multiplex families segregating for ARF were ascertained. The parents and rheumatic and normal sibs of the probands in these 19 families were also studied. HLA typing using the microlymphocytotoxic assay was then performed on the 60 unrelated probands, the multiplex families, and 234 unrelated controls using 23 antigens from the HLA-A and -B loci. The controls lacked a past history of ARF and were from the same geographic locality. Calculations of relative risk demonstrate an increase of HLA-B5 antigen in the 60 patients, but the result might not be significant from the point of view of multiple comparisons. Nevertheless, affected sib pairs from the multiplex families show 93% concordance for both or one HLA haplotype. A formal linkage analysis demonstrates that a recessive etiology is most likely (lod score of 3.3) with approximately 68% of cases being due to a gene closely linked to HLA and in linkage disequilibrium with HLA-B5. The remaining 32% of cases are due to other familial factors such as polygenic inheritance or common environmental factors. The results confirm a strong genetic predisposition to ARF and its heterogeneous nature in families.
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34
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Anand IS, Ganguly NK, Khanna AK, Chakravarti RN, Wahi PL. Humoral immunity in experimental immune carditis. Pathology 1984; 16:291-9. [PMID: 6514397 DOI: 10.3109/00313028409068540] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
An experimental model of carditis has been produced in the rhesus monkey by giving 12 weekly injections of a streptococcal membrane antigen. There was histological evidence of focal myocarditis, subendocardial infiltration with lymphomononuclear cells and in one animal myocardial granuloma formation. No valvular lesions were seen. Humoral immune responses monitored throughout the experiment showed that anti-heart antibodies appeared in circulation after the 2nd injection, attained maximal titres by the 6th injection, and thereafter the titres declined. The anti-membrane antibodies appeared slightly later and these titres kept rising till sacrifice. By the 6th injection there was evidence of complement consumption and appearance of circulating immune complexes. It is concluded that these immunological responses might have a role to play in the pathogenesis of carditis.
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35
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36
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Zabriskie JB, Friedman JE. The role of heart binding antibodies in rheumatic fever. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 1983; 161:457-70. [PMID: 6346818 DOI: 10.1007/978-1-4684-4472-8_26] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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37
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Anand IS, Ganguly NK, Khanna AK, Chakravarti RN, Wahi PL. Pathogenesis of immune-mediated carditis in monkeys. ADVANCES IN MYOCARDIOLOGY 1983; 4:215-26. [PMID: 6602357 DOI: 10.1007/978-1-4757-4441-5_19] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
An experimental model of carditis has been produced in the rhesus monkey by giving 12 weekly injections of streptococcal membrane antigen. Carditis was produced in as short a period as 14 weeks. There was evidence of myocarditis, endocarditis, and, in two animals, myocardial granuloma formation. No valvular lesions were seen. Measurement of immune responses showed that heart cross-reactive antibodies started appearing in the circulation after the second injection. By the sixth injection, there was evidence of complement consumption and appearance of circulating immune complexes. Antibody-dependent cell cytotoxicity started operating after the second injection, and by the sixth injection, peripheral lymphocytes had acquired hypersensitivity to membrane antigen. It is concluded that some of these immunologic responses might have played a role in the genesis of carditis.
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38
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Reddy KS, Rao PS, Bhatia ML. Immunopathogenesis of rheumatic fever and rheumatic heart disease-current concepts. Indian J Pediatr 1982; 49:849-62. [PMID: 6763600 DOI: 10.1007/bf02976980] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
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39
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Persellin ST, Ramirez G, Moatamed F. Immunopathology of rheumatic pericarditis. ARTHRITIS AND RHEUMATISM 1982; 25:1054-8. [PMID: 6751335 DOI: 10.1002/art.1780250904] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Immunologic mechanisms have been implicated in the endocarditis, myocarditis, and arthritis of acute rheumatic fever. However, pericarditis, a major manifestation of acute rheumatic fever with a clinical incidence of 5-10%, has not been studied. We have evaluated a patient who had this febrile disease with arthritis and pericarditis. Pericardial tissue showed extensive deposition of IgG, IgM, and C3 both on the pericardial surface and within the walls of pericardial blood vessels. Our findings of immunoglobulins and complement within the inflamed pericardium suggest an immune-mediated mechanism for the pericarditis of acute rheumatic fever.
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40
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Williams RC, Raizada V, Prakash K, van de Rijn I, Zabriskie JB, Stobo JD, Sharma KB. Changes in T-lymphocyte subsets during acute rheumatic fever. J Clin Immunol 1982; 2:166-72. [PMID: 6214565 DOI: 10.1007/bf00915218] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Relative proportions and numbers of helper [OKT4(+)] and suppressor [OKT8(+)] peripheral blood lymphocytes were examined in 32 young patients during the acute phase of rheumatic fever. No significant decrease in percentage T cells during acute rheumatic fever was noted in comparison to normal children controls from the same population. A decrease in absolute numbers of OKT4(+) T cells was also noted in acute rheumatic subjects not receiving corticosteroids (P less than 0.05). In addition, a significant decrease was documented in both proportions and total numbers of OKT8(+) putative suppressor cells during acute rheumatic attacks. C-reactive protein binding to T-lymphocyte subsets showed no preferential reactivity in vivo for suppressor or helper T cells. Antigen-reactive T lymphocytes identified with the T29 mouse hybridoma reagent showed similar proportions and numbers in rheumatic children as were noted in controls. The present data indicate profound alterations in both helper- and suppressor-cell types in the peripheral blood profile of children with acute rheumatic fever.
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41
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Hamilton JA, Zabriskie JB, Lachman LB, Chen YS. Streptococcal cell walls and synovial cell activation. Stimulation of synovial fibroblast plasminogen activator activity by monocytes treated with group A streptococcal cell wall sonicates and muramyl dipeptide. J Exp Med 1982; 155:1702-18. [PMID: 6804590 PMCID: PMC2186715 DOI: 10.1084/jem.155.6.1702] [Citation(s) in RCA: 38] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Group A streptococcal peptidoglycan has previously been shown to be arthritogenic in rats and has been implicated as a structure present in a class of possible etiologic agents for rheumatoid arthritis. The present study reports that conditioned medium from human monocytes, after interaction with cell wall sonicates of four group A streptococcal strains, stimulates the plasminogen activator (PA) activity of nonrheumatoid synovial fibroblasts. Low concentrations of N-acetylmuramyl-L-alanyl-D isoglutamine (muramyl dipeptide) can also generate this synovial activator (SA) activity from human monocytes. Preliminary biochemical data suggest that the SA activity is distinct from interferon-gamma, interleukin 1, and interleukin 2. These results indicate that agents that are arthritogenic in rats can modulate human synovial fibroblast functions via monocytes. The findings are proposed to have possible significance for an understanding of the cellular interactions involved in the formation and function of the rheumatoid pannus, because PA has been invoked as possibly being generally important for the processes of cell migration, tissue remodeling, and inflammation.
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42
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43
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Anderson JL, Greenwood JH, Kawanishi H. Evaluation of suppressor immune regulatory function in idiopathic congestive cardiomyopathy and rheumatic heart disease. Heart 1981; 46:410-4. [PMID: 6457616 PMCID: PMC482669 DOI: 10.1136/hrt.46.4.410] [Citation(s) in RCA: 29] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Several diseases with autoimmune features have recently been shown to be characterised by defects in suppressor cell immune regulation. Aberrant immune mechanisms of primary importance have been sought but not yet demonstrated for idiopathic congestive cardiomyopathy and rheumatic heart disease. We tested whether defective immunoregulatory function might explain certain features of these diseases. Peripheral blood mononuclear cells from patients with both diseases showed normal proliferative responses in the mixed leucocyte reaction. Concanavalin A induced similar suppressor activity, quantified in mixed leucocyte reaction as a suppression index, among control subjects, patients with rheumatic heart disease, and patients with idiopathic congestive cardiomyopathy. Similarly, patient serum supported induction of suppressor activity in normal leucocytes equal to that of control serum. A chronic immunoregulatory defect thus does not appear necessary for the development of idiopathic congestive cardiomyopathy or rheumatic heart disease.
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Gray ED, Wannamaker LW, Ayoub EM, el Kholy A, Abdin ZH. Cellular immune responses to extracellular streptococcal products in rheumatic heart disease. J Clin Invest 1981; 68:665-71. [PMID: 7024311 PMCID: PMC370847 DOI: 10.1172/jci110301] [Citation(s) in RCA: 33] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
The lymphocyte transformation responses to purified preparations of two extracellular products of group A streptococci (blastogen A and nuclease B), to phytohemagglutinin, and to Candida albicans antigen were measured in tonsillar and peripheral blood lymphocytes from patients with rheumatic heart disease (RHD) and suitably matched nonrheumatic (control) subjects. The mean phytohemagglutinin dose responses of tonsillar and peripheral lymphocytes from RHD patients were essentially indistinguishable from those of controls. In contrast, the responses of tonsillar and peripheral blood lymphocytes to the two extracellular products of group A streptococci were significantly lower in RHD patients than in nonrheumatic control subjects. Candida antigen produced very little stimulation of lymphocytes in any of the subjects. The geometric means of antibody levels against streptolysin O, nuclease B, and nicotinamide adenine dinucleotidase showed no consistent differences between the control group and the group of RHD subjects. Group A streptococci were isolated from the tonsils of approximately 25% of both groups of subjects. The RHD patients clearly had a depressed cellular immune response to the two purified streptococcal extracellular antigens. The equal frequency in recovery of group A streptococci from tonsils and the absence of consistent difference in titers of humoral antibodies to streptococcal extracellular antigens, particularly nuclease B, suggest that this differential response is not due to a lower level of stimulation by repeated exposure to group A streptococcal products.
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Abstract
A genetically controlled antigen-presentation function in macrophages is proposed to explain the induction phase of streptococcal carditis. Antigenic determinants in strains of beta-haemolytic streptococci causing rheumatic fever are selected by macrophages, through the operation of immune response (Ir) genes, to be presented to T lymphocytes. Cross-reactivity between the selected determinants and heart tissue components generates clones of autoreactive T cells. Autoimmunity will develop if, coincidental with the presentation of the relevant antigenic determinant, regulation of T-cell production is disturbed. This hypothesis explains the capacity of different strains of streptococcus to produce rheumatic fever and also the variability in host susceptibility to the disease.
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Lyampert IM, Smirnova MN, Bazanova EA. The cytotoxic effect in delayed-type hypersensitivity on autologous adherent cells (macrophages) of lymph nodes and spleen. Cell Immunol 1980; 52:325-33. [PMID: 7002320 DOI: 10.1016/0008-8749(80)90353-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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Yoshinoya S, Pope RM. Detection of immune complexes in acute rheumatic fever and their relationship to HLA-B5. J Clin Invest 1980; 65:136-45. [PMID: 6765956 PMCID: PMC371348 DOI: 10.1172/jci109643] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
Employing five radioimmunoassays for immune complexes, the sera of 45 acute and 27 postacute follow-up sera from patients with acute rheumatic fever were examined. All patients experienced actue polyarthritis. Complexes were detected in 89% of acute-phase sera by one assay, 51% by two, 29% by three, and 7% by four. Immune complex values decreased significantly at followup, although some abnormalities persisted. There was no correlation between extra-articular manifestations and the occurrence of circulating immune complexes. Those positive for HLA-B5 demonstrated a significantly more pronounced immune response as measured by circulating immune complexes. The data indicate that circulating immune complexes occur frequently in adults with acute rheumatic fever. The relative frequency of immune complexes detected by multiple techniques in B5-positive, compared with B5-negative, patients suggests a genetic basis for the development of immune complexes in these patiemts.
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Srivastava DC, Kumar KK. Immunological basis in the aetiology of rheumatic fever (a review). Indian J Pediatr 1979; 46:368-71. [PMID: 397924 DOI: 10.1007/bf02749271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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49
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[Recent progress in the fight against acute arthritic rheumatism and future perspectives: WHO Memorandum]. Bull World Health Organ 1979; 57:235-64. [PMID: 312158 PMCID: PMC2395774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
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Williams RC, Kilpatrick KA, Kassaby M, Abdin ZH. Lymphocytes binding C-reactive protein during acute rheumatic fever. J Clin Invest 1978; 61:1384-93. [PMID: 659600 PMCID: PMC372661 DOI: 10.1172/jci109056] [Citation(s) in RCA: 24] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Lymphocytes binding C-reactive protein (CRP) were studied in 31 patients with acute rheumatic fever and 30 controls who were children. Marked elevations in both proportions and absolute numbers of CRP-binding lymphocytes were recorded in rheumatic fever (P less than 0.001). No clear correlation was noted between plasma CRP as quantitated by radioimmunoassay and proportions or numbers of CRP-binding cells. Double-labeling experiments indicated that 60-80% of CRP-binding lymphocytes also showed Fc receptors reacting with fluorescein-conjugated IgG aggregates. Passage of lymphocytes over Ig--anti-IgG columns, removed cells bearing surface Ig but not CRP-binding lymphocytes. Studies of T-cell subpopulations indicated no overlap between Tmicron- and CRP-binding cells; however about half of Tgamma-cells showed concurrent CRP binding. "Active" T-cell rosetting cells did not bind CRP. A 12-15-h incubation of lymphocytes at 37 degrees C in 5% CO2-air showed persistence of CRP binding in substantial proportions of cells particularly in acute rheumatic fever. CRP-binding lymphocytes may represent a marker for immunologically committed cells in acute rheumatic fever.
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