Antineutrophil cytoplasmic antibody-associated vasculitis predominantly manifesting tubulointerstitial nephritis: A case report

The common histopathology of antineutrophil cytoplasmic antibody-associated vasculitis comprises pauci-immune crescentic glomerulonephritis with concomitant tubulointerstitial nephritis. Tubulointerstitial nephritis in the absence of glomerular involvement in patients with antineutrophil cytoplasmic antibody-associated vasculitis is uncommon. We report a case of antineutrophil cytoplasmic antibody-associated vasculitis-associated acute kidney injury manifesting as tubulointerstitial nephritis without glomerulonephritis. A 75-year-old woman with fever, cough, and myalgia developed kidney dysfunction with inflammatory reactions and tubular-type proteinuria, without glomerular hematuria. A kidney biopsy revealed tubulointerstitial nephritis with arteritis. We ruled out important underlying etiologies of tubulointerstitial nephritis, including infection, drug reactions, and autoimmune diseases. Since chest high-resolution computed tomography demonstrated mild interstitial pneumonia in bilateral lower lung fields, myeloperoxidase antineutrophil cytoplasmic antibody was measured and found to be positive. Therefore, we diagnosed the patient with antineutrophil cytoplasmic antibody-associated vasculitis-associated tubulointerstitial nephritis but not glomerulonephritis, and interstitial pneumonia. The patient's kidney function and symptoms markedly improved with prednisolone treatment. Clinicians should maintain high-level vigilance for antineutrophil cytoplasmic antibody-associated vasculitis as a possible underlying component of tubulointerstitial nephritis, particularly when kidney function deteriorates with tubulointerstitial injuries without glomerular features.

AB0186 IMPROVEMENT OF RADIOGRAPHIC JOINT DESTRUCTION IN PATIENTS WITH EARLY RHEUMATOID ARTHRITIS IN THE LAST DECADE

Background

The paradigm shift has caused in the treatment for rheumatoid arthritis (RA) before the last decade [1]. The advent of high-dose MTX and biologics has maked it possible to treat RA with early and aggressive therapy, and prevent the joint destruction [2].

Objectives

To aim of this study, we investigated the joint destruction and clinical outcomes in patients with early RA every 5 years in the last decade.

Methods

81 patients with early RA (within 1 year from their onset of RA) enrolled retrospectively in this study. The number of patients with early RA were 21 in 2009, 23 in 2014, and 37 in 2019, respectively. They had 17 males and 64 females. Mean age was 59 years (19-92) at the first visit to our department. The following items were investigated: age, disease duration from onset to consultation, anti-cyclic citrullinated peptide antibody (ACPA) positivity (positivity was defined as >4.5 U/ml), CRP, DAS28CRP4, medications, and modified total sharp score (mTSS) at the time of initial consultation and 1 year later. Kruskal-Wallis test was used for statistics (PASW 25 software, SPSS Institute Inc., Chicago, IL, USA, p<0.05).

Results

The ACPA positivity rates were 71.4% (15/21) in 2009, 78.3% (18/21) in 2014, and 78.4% (29/37) in 2019, respectively. The mean value of DAS28CRP4 was 4.7 (2.4-6.8) in 2009, 4.2 (1.2-6.2) in 2014, and 4.2 (2.1-6.7) in 2019 at the time of the first visit to our department respectively. DAS28CRP4 under 2.6 was 29% (6/21) in 2009, 61% (14/23) in 2014, and 54% (20/37) in 2019 1 year after the first visit. The mean improvement of DAS28CRP4 (ΔDAS28CRP4) was -1.2 (-3.9 - 2.1) in 2009, -1.5 (-4.0 - 1.7) in 2014, and -1.7 (-4.1 - 0.4) in 2019, respectively. It had tended to improve gradually, however, it was not significantly different (p= 0.20, Figure 1).

Figure 1.

Mean value of improvement of mTSS and DAS28CRP4 (ΔmTSS and ΔDAS28CRP4) from initial visit to 1 year later at 2009, 2014 and 2019.

The changing of mTSS for a year (ΔmTSS) was 4.2 (0-17) in 2009, 0.9 (0-10) in 2014, and 0.6 (0-4) in 2019, respectivly. ΔmTSS in 2014 and 2019 was significantly lower compared to that in 2009 (p<0.05, Figure 1).

One year after the first visit to our department, the mean dose of MTX increased to 9.2 mg/week (2-14) in 2014 and 8.7 mg/week (4-16) in 2019 compared to 6.6 mg/week (2-8) in 2009 (p=0.19). The mean dose of PSL decreased 4.2 mg/day (1-8) in 2014, and 3.8 mg/day (1-10) in 2019 compared to 4.9 mg/day (2-10) in 2009, respectively (p=0.11). On the other hand, biological DMARDs were introduced in 24% (5/21) in 2009, 13% (3/23) in 2014, and 13% (1/37) in 2019, respectively.

Conclusion

Jonit destruction has been already reported to begin in patients with early-stage of RA [1, 2]. Based on the results of this study, joint desctruction in early RA was decreased in the last decade, because of more early and aggressive therapy for early RA with increasing mean dose of MTX gradually, not biologic DMARDs in real world. In addition, the mean dose of PSL in 2014 and 2019 decreased compared to that in 2009. The intensive therapy for early RA at our hospital has shown the improvement of joint destruction in the last decade.

References

[1]Emery P, Breedveld FC, Dougados M, et al. Early referral recommendation for newly diagnosed rheumatoid arthritis: evidence based development of a clinical guide. Ann Rheum Dis 2002;61:290–297.

[2]Smolen JS, Landewé RBM, Bijlsma JWJ, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2019 update. Ann Rheum Dis 2020;79:685-699.

Disclosure of Interests

None declared

AB0181 RADIOGRAPHIC DESTRUCTION OF CARPAL BONE IN PATIENTS WITH EARLY RHEUMATOID ARTHRITIS

Background

The pharmacotherapy for rheumatoid arthritis (RA) has changed dramatically and caused a paradigm shift with the advent of methotrexate (MTX) and biological disease-modifying antirheumatic drugs (bDMARDs).

Before the paradigm shift of RA therapy, the frequency of carpal collapse was high in patients with RA.

It has been reported that certain numbers of patients with RA rapidly advance the destruction of the carpal bones during the early onset in the natural course of it [1].

Another report showed that hand function was positively correlated with disease activity[2]

In Japan, bDMARDs were approved in 2003, and the maximum allowable dose of MTX was raised from 8 mg/week to 12 mg/week in 2012.

We hypothesize early aggressive therapy for the patients with early RA may have improved outcomes of carpal bone destruction in this last decade.

In this study, we investigated the change of drug therapy and carpal height ratio (CHR) in patients with early RA in the last decade.

Objectives

The aim of this study was to investigate CHR and drugs for the patients with early RA who developed it and started the therapy in 2009, 2014, and 2019.

Methods

Patients with early RA diagnosed in our department in 2009, 2014, and 2019 were included in the study.

The CHR was measured at the first visit and two years later on radiographs of both hands.

The drug history for RA was obtained in the medical records retrospectively.

All statistical analyses were performed with EZR version 1.55.

Results

This study included 43 cases (36 females, 7 males). The number of cases in 2009, 2014, and 2019 was 16, 13, and 14, respectively.

The mean age at the time of initial examination was 55 years (30-72).

There was no significant difference in the mean value of DAS28-CRP at the time of the first visit in each year.

The left hand CHR of initial diagnosis was 0.554 (0.484-0.632), 0.551 (0.490-0.618), and 0.567 (0.517-0.632) in 2009, 2014, and 2019, respectively, with no significant difference.

Two years later, the left-hand CHR was 0.541 (0.475-0.651), 0.549 (0.502-0.617), and 0.562 (0.528-0.591), respectively, with no significant difference.

There was also no significant difference in the amount of change.

The right hand CHR of initial diagnosis was 0.525 (0.475-0.607), 0.539 (0.459-0.589), and 0.557 (0.506-0.635) in 2009, 2014, and 2019, respectively, with no significant difference.

Two years later, the right-hand CHR was 0.532 (0.444-0.627), 0.529 (0.478-0.588), and 0.548 (0.491-0.593), respectively, with no significant difference.

There was also no significant difference in the amount of change.

The DAS28-CRP of initial diagnosis for cases in 2009, 2014, and 2019 was 4.68 (3.11-6.83), 4.19 (1.21-6.15), and 4.23 (2.41-6.38), respectively.

The DAS28-CRP at 2 years after treatment for cases in 2009, 2014, and 2019 was 2.12 (0.96-3.60), 2.25 (1.13-4.81), and 2.04 (0.99-3.45), respectively.

Although DAS28-CRP was improved, there was no significance among the three groups.

The usage rate of MTX was 56.3% in 2009, 76.9% in 2014, and 50% in 2019, with mean doses of 6.2 mg (2-8 mg), 8.6 mg (4-12 mg), and 9.1 mg (4-16 mg), respectively. There was no significant difference in the rate and dosage of MTX use in each year.

bDMARDs were used in one case in 2009, two cases in 2014, and one case in 2019.

Conclusion

In this study, DAS28-CRP showed a trend of improvement in this decade, but there was no obvious improvement in the progression of carpal collapse.

Further early aggressive therapy may be necessary to prevent the destruction of the carpal bones.

References

[1]Ochi T, Iwase R, Yonemasu K, Matsukawa M, Yoneda M, Yukioka M, et al. Natural course of joint destruction and fluctuation of serum C1q levels in patients with rheumatoid arthritis. Arthritis and rheumatism. 1988 Jan; 31(1):37-43.

[2]Palamar D, Er G, Terlemez R, Ustun I, Can G, Saridogan M. Disease activity, handgrip strengths, and hand dexterity in patients with rheumatoid arthritis. Clinical rheumatology. 2017; 36(10):2201-2208.

Disclosure of Interests

None declared

Development of Alveolar Hemorrhage After Pfizer-BioNTech COVID-19 mRNA Vaccination in a Patient With Renal-Limited Anti-neutrophil Cytoplasmic Antibody-Associated Vasculitis: A Case Report

Since the coronavirus disease 2019 (COVID-19) pandemic continues and a new variant of the virus has emerged, the COVID-19 vaccination campaign has progressed. Rare but severe adverse outcomes of COVID-19 vaccination such as anaphylaxis and myocarditis have begun to be noticed. Of note, several cases of new-onset antineutrophil cytoplasmic antibody-associated vasculitis (AAV) after COVID-19 mRNA vaccination have been reported. However, relapse of AAV in remission has not been recognized enough as an adverse outcome of COVID-19 vaccination. We report, to our knowledge, a first case of renal-limited AAV in remission using every 6-month rituximab administration that relapsed with pulmonary hemorrhage, but not glomerulonephritis, following the first dose of the Pfizer-BioNTech COVID-19 vaccine. The patient received the COVID-19 vaccine more than 6 months after the last dose of rituximab according to the recommendations. However, his CD19+ B cell counts were found to be increased after admission, indicating that our case might have been prone to relapse after COVID-19 vaccination. Although our case cannot establish causality between AAV relapse and COVID-19 mRNA vaccination, a high level of clinical vigilance for relapse of AAV especially in patients undergoing rituximab maintenance therapy following COVID-19 vaccination should be maintained. Furthermore, elapsed time between rituximab administration and COVID-19 mRNA vaccination should be carefully adjusted based on AAV disease-activity.

Additive combination of actarit and methotrexate in the treatment of refractory rheumatoid arthritis

Abstract The objective of this study was to evaluate the efficacy and safety of an additive combination of a disease-modifying antirheumatic drug (DMARD) actarit and low-dose methotrexate (MTX) in patients with active rheumatoid arthritis (RA) unresponsive to MTX. Thirty-four patients with active RA, who had been unsuccessfully treated with MTX for at least 3 months were enrolled on a 24-week course of actarit (300 mg/day) and MTX (2.5-10 mg/week). Disease activity was evaluated by physical global assessments using conventional measures (Japan Rheumatism Association), and the American College of Rheumatology (ACR) criteria of improvements in RA. Thirty-two patients completed this study. No severe adverse drug reactions were seen. Patients whose RA did not respond to MTX alone responded to the combination therapy, with a significant improvement in the duration of morning stiffness, grip strength, swollen joint counts, patient's articular pain score, modified health assessment questionnaire (M-HAQ) score, score of both patient's and physician's global assessments, and C-reactive proteins (CRP). Sixteen patients (50.0%) and 9 patients (31.0%) showed a significant improvement in overall conventional measures, and ACR response criteria, respectively, and 60.0% of RA patients who received MTX for more than 1 year showed improvement in ACR definition. Patients who responded to the combination treatment within the first 12 weeks showed persistent improvement for the remaining part of the 24 week period. Our results indicate that the additive combination of actarit and MTX is safe, and without serious adverse effects, and has an excellent efficacy in patients with active and refractory RA.

Synthesis and properties of a new class of nucleosides with spin source

Novel spin-labeled ribonucleosides 1-5 were synthesized to investigate stability and behavior of N-tert-butyl aminoxyl radical on nucleobase. Site selective lithiation of tri-O-protected ribonucleosides followed by the reaction with 2-methyl-2-nitrosopropane (MNP) resulted in introduction of N-tert-butylhydroxylamino group into various positions of purine or pyrimidine nucleus. Oxidation of the obtained hydroxylamines with Ag2O led to formation of 1-5. EPR study showed that the unpaired electron of the aminoxyl radical was delocalized into the nucleobase and hyperfine structures were dependent on the position of the radical.

Morphine metabolism in the opium poppy and its possible physiological function. Biochemical characterization of the morphine metabolite, bismorphine

We identified a novel metabolic system of morphine in the opium poppy (Papaver somniferum L.). In response to stress, morphine is quickly metabolized to bismorphine consisting of two morphine units, followed by accumulation in the cell wall. This bismorphine binds predominantly to pectins, which possess high galacturonic acid residue contents, through ionical bonds. Our newly developed method using artificial polysaccharides demonstrated that bismorphine bridges are formed between the two amino groups of bismorphine and the carboxyl groups of galacturonic acid residues, resulting in cross-linking of galacturonic acid-containing polysaccharides to each other. The ability of bismorphine to cross-link pectins is much higher than that of Ca2+, which also acts as a cross-linker of these polysaccharides. Furthermore, we confirmed that cross-linking of pectins through bismorphine bridges leads to resistance against hydrolysis by pectinases. These results indicated that production of bismorphine is a defense response of the opium poppy. Bismorphine formation is catalyzed by anionic peroxidase that pre-exists in the capsules and leaves of opium poppies. The constitutive presence of morphine, together with bismorphine-forming peroxidase, enables the opium poppy to rapidly induce the defense system.

Molecular Design of a New Class of Spin-Labeled Ribonucleosides with N-tert-Butylaminoxyl Radicals

We designed a new type of spin-labeled nucleosides with an N-tert-butylaminoxyl radical which is introduced to the nucleobase directly. Purine and pyrimidine ribonucleosides containing the aminoxyl radical such as 1a-d, 2, 3, and 4 were synthesized to investigate the stability and behavior of the N-tert-butylaminoxyl radical on a nucleobase. Lithiation of tri-O-silylated 6-chloropurine ribonucleoside (5) followed by reaction with 2-methyl-2-nitrosopropane (MNP) gave the key compound 6a, which was further converted to 6b-d. Oxidation of the obtained 6a-d and their triols (7a-d) with Ag(2)O led to formation of the corresponding stable spin-labeled nucleosides (8a-d and 1a-d), which were confirmed by EPR spectroscopy. Similarly, the precursors of spin-labeled pyrimidines (13, 20, and 23) were synthesized by site-selective lithiation of tri-O-protected pyrimidine derivatives (9, 18, and 21) followed by the reaction with MNP and deprotection. An EPR study showed that the aminoxyl radicals (2, 3, and 4) were stable and that their hyperfine structures were dependent on the position of the radical. Electron densities of pyrimidine also affected hyperfine structures.

Two cases of tinea corporis by infection from a rabbit with Arthroderma benhamiae

The first cases of tinea corporis with Arthroderma benhamiae in Japan are reported. A 7-year-old girl and a 30-year-old mother in Shimane prefecture suffered from dermatophyte infections on the neck, shoulder, arms and leg. Three isolates from the two patients and a rabbit by which they supposedly were infected, were identified as Trichophyton mentagrophytes. On the bases of mating tests using the tester strains of both the African race and the Americano-European race of A. benhamiae, they were identified as A. benhamiae African race mating type (-). Our results are the first to indicate that both races of A. benhamiae exist in Japan.

Sylvian fissure and medial temporal lobe structures in patients with schizophrenia: a magnetic resonance imaging study

Volumes of the medial temporal lobe structures (i.e. the amygdala, hippocampus, and parahippocampal gyrus), Sylvian fissure, and inferior horn of the lateral ventricle relative to the cerebral hemisphere were measured in 24 patients with schizophrenia and 23 normal controls using magnetic resonance imaging. The patients had significantly larger Sylvian fissures and inferior horns bilaterally than the controls. In the patients the right Sylvian fissure size showed a significant positive correlation with the duration of illness. Moreover, earlier onset of illness was significantly correlated with decreased volume of the left medial temporal lobe structures. These results replicate previous finding of inferior horn enlargement and suggest the significance of the Sylvian fissure and the medial temporal lobe structures in pathophysiology of schizophrenia.

Insight into acid-mediated asymmetric spirocyclization in the presence of a chiral diol

Asymmetric spirocyclization based on intramolecular conjugate addition using a combination of a Lewis acid and an optically active cyclohexane-1,2-diol has been studied in connection with 1) the effect of substituents on the cyclohexane-1,2-diol and 2) the effect of substituents on the substrate. This reaction was found to be both thermodynamically and kinetically controlled under restricted conditions.

A novel method of preparing amine-modifying C-4' oxidized nucleotide

A novel method of preparing C-4' oxidized nucleotide, a monomeric model of an alkali labile lesion (1) has been studied. The C-4' selenated 4a and 4b were found to be effective in preparing 3, a monomeric model of 1, by the reaction with NBS (N-bromosuccinimide). The successive reaction of 3 with amine at room temperature afforded the alpha,beta-unsaturated gamma-methylene-gamma-lactam (2) in good yield.

[A case of systemic lupus erythematosus with pulmonary hypertension]

A 15 year-old girl was admitted to the hospital because of fever, polyarthlargia, dry cough, dyspnea, butterfly rash and multiple oral aphthas. The diagnosis of systemic lupus erythematosus (SLE) was made based on renal disorders, pancytopenia, positive antinuclear antibody and positive for antibodies to double-stranded DNA. On admission, she developed progressive dyspnea with highly active SLE. The patient was complicated with both pulmonary hypertension (PH) and interstitial pneumonitis (IP), judging from increased pulmonary sound by an auscultation, interstitial shadows especially at bilateral lower lung and enlarged shadow of right atrium in a chest rentgenogram, ground glass pattern of bilateral middle to lower lung in a chest computed tomographic scan, increased pulmonary artery pressure, 53 mmHg, by an ultrasound cardiograph (UCG). Combination of methylprednisolone pulse therapy, cyclosporin A and plasma exchanges was effectively administered, which resulted in improvement of disease activity of SLE, IP and PH. However, two months later, although disease activity of SLE was completely reduced, recurrence of PH by UCG and multiple pulmonary embolism (PE) which was observed by a chest rentgenogram and a pulmonary blood flow scintigraphy was further complicated. Administration of cyclophosphamide pulse therapy and warfarin therapy improved both PE and PH. The patient had PH at the different clinical course of SLE; 1) PH maybe induced by severe IP at the active phase of SLE and 2) PH brought about from multiple PE at the inactive phase of SLE. Thus, the case is thought to be suggestive of elucidating the pathogenesis of PH of several systemic autoimmune diseases including SLE.

Primary ileal plasmacytoma arising in mixed low- and high-grade B-cell lymphoma of mucosa-associated lymphoid tissue type

We report an extremely rare case of primary ileal plasmacytoma accompanied by mixed low- and high-grade B-cell lymphoma of mucosa-associated lymphoid tissue (MALT) type. The radiographic and macroscopic features of the tumor were characterized by two constricting lesions in the ileum. Histologic examination of the resected specimen showed that one constrictive lesion was plasmacytoma and the other MALT lymphoma was low and high grade. The plasmacytoma seemed to have differentiated from the MALT lymphoma.

[A case of mixed connective tissue disease with microscopic polyarteritis nodosa associated with perinuclear-antineutrophil cytoplasmic antibody and anti-glomerular basement membrane]

A 46-year-old female was admitted to our hospital due to general fatigue, systemic edema and dyspnea with history of systemic sclerosis (SSc). The patient was diagnosed as mixed connective tissue disease (MCTD) based on Raynaud phenomenon, a high anti-RNP antibody level and clinical symptoms and laboratory findings suggesting SSc, dermatomyositis (DM) and systemic lupus erythematosus (SLE). After the admission, both alveolar hemorrhage and a rapidly progressive glomerulonephritis (RPGN) also developed and laboratory findings showed a positive remark of myeloperoxydase-antineutrophil cytoplasmic antibody (MPO-ANCA) and anti-glomerular basement membrane (GBM) antibody. She was therefore re-diagnosed as microscopic polyarteritis nodosa (microscopic PAN) combined with MCTD and treatment with high dose prednisolone and steroid pulse therapy dramatically improved general conditions and lung symptoms, but maintenance dialysis was persistent because of irreversible renal failure. However, 3 months after the admission, she died of acute exacerbation of interstitial pneumonitis that was unresponsive to steroid pulse therapy. Autopsy revealed interstitial pneumonitis with alveolar hemorrhage and crescentic glomerulonephritis (CrGN), in which immunofluorescent microscopy showed no deposition in agreement with pauciimmune type. The histological findings supported the diagnosis; primary microscopic PAN combined with MCTD, which is a quite rare case, to our knowledge. Furthermore, co-existence of MPO ANCA and anti-GBM antibody, clinical and histological findings of the case also lead us to reconsider the relevance of these antibodies to pathogenesis and/or categories of microscopic PAN and Goodpasture's syndrome.

Hepatocyte growth factor is a potent trigger of neutrophil adhesion through rapid activation of lymphocyte function-associated antigen-1

Recruitment of neutrophils into tissue occurs in several pathologic processes such as inflammation, atherosclerosis, thrombosis, and ischemia. In inflammation, the adherence of neutrophils to the endothelium depends on neutrophil integrins. Integrin-mediated adhesion is tightly regulated, ie, integrins do not function if neutrophils are not triggered by certain activation stimuli. We investigated the role of hepatocyte growth factor (HGF) in the adhesion of neutrophils to endothelial cells in inflammation. Our results showed that (a) HGF induced not only lymphocyte function-associated antigen-1 (LFA-1)-mediated adhesion of neutrophils to endothelial cells but also transmigration of neutrophils in a concentration-dependent manner; (b) HGF functionally transformed neutrophil integrin LFA-1 to active form and reduced surface L-selectin expression level; (c) HGF induced F-actin polymerization and cytoskeletal rearrangement within seconds; (d) genistein, a tyrosine kinase inhibitor, as well as wortmannin, a phosphoinositide 3 (PI 3)-kinase inhibitor, inhibited both F-actin polymerization and LFA-1-mediated adhesion of neutrophils to endothelial cells; and (e) neutrophils in cutaneous inflamed tissue highly expressed HGF and serum levels of HGF were elevated in patients with Behçet's disease, which is associated with neutrophilic vasculitis and marked neutrophil accumulation. Our results indicate that HGF plays a pivotal role in integrin-mediated adhesion and transmigration of neutrophils to sites of acute inflammation through cytoskeletal rearrangement activated by tyrosine kinase and PI 3-kinase signaling.

Heparan sulfate proteoglycan on endothelium efficiently induces integrin-mediated T cell adhesion by immobilizing chemokines in patients with rheumatoid synovitis

OBJECTIVE

To clarify the role of heparan sulfate proteoglycan (HSPG) and chemokines in integrin-mediated T cell adhesion to endothelial cells in the synovium of patients with rheumatoid arthritis (RA).

METHODS

Endothelial cells were purified from RA synovium. Expression of heparan sulfate, chemokines, and adhesion molecules on the endothelium was assessed by immunohistochemical analysis or flow cytometry. The effects of chemokines and heparan sulfate on T cell adhesion to RA endothelium were estimated with relevant antibodies and signaling inhibitors. Production of chemokines from synovial T cells was detected by Northern blotting and enzyme-linked immunosorbent assay.

RESULTS

The endothelium in RA synovium highly expressed HSPG. The soluble form of chemokines, macrophage inflammatory protein 1beta (MIP-1beta), induced T cell adhesion to the endothelial cells. When MIP-lalpha and MIP-1beta were immobilized on RA endothelial cells, a more efficient integrin-mediated adhesion of T cells was induced compared with their soluble form. The induced T cell adhesion was reduced by pretreatment with either heparitinase, anti-MIP-lalpha antibody, or anti-MIP-lbeta antibody, indicating that these chemokines were bound to heparan sulfate on the cells. T cell adhesion was also inhibited by pertussis toxin, wortmannin, and cytochalasin B. MIP-lalpha and MIP-1beta were found on vessels in RA synovium in vivo, which were spontaneously produced from T cells purified from RA synovium.

CONCLUSION

Endothelial cells in RA synovium characteristically express HSPG, which is involved in T cell integrin triggering by "posting" chemokines, which are produced by synovial T cells, and by "relaying" them to their receptors on T cells, which activate G protein-dependent phosphoinositide 3-kinase and actin-dependent integrin triggering.

Constitutive chemokine production results in activation of leukocyte function-associated antigen-1 on adult T-cell leukemia cells

Adult T-cell leukemia (ATL) is characterized by massive infiltration of circulating ATL cells into a variety of tissues, a finding often associated with poor prognosis. Leukocyte migration from circulation into tissue depends on integrin-mediated adhesion to endothelium, and integrins are tightly regulated by several stimuli, such as inflammatory chemokines. However, the exact mechanisms that enhance adherence of leukemic cells to the endothelium and infiltration into tissues remain to be fully understood. We investigated the mechanisms of extravasation of leukemic cells using ATL cells and report the following novel features of endogenous chemokine-induced adhesion of ATL cells to the endothelium. ATL cells spontaneously adhered to endothelial cells without exogenous stimulation. Integrin leukocyte function-associated antigen-1 (LFA-1) on ATL cells was spontaneously activated. ATL cells produced high amounts of chemokines, macrophage inflammatory protein-1alpha (MIP-1alpha), and MIP-1beta. Adhesion of ATL cells to endothelial cells and the expression of activated form of LFA-1 were reduced by pretreatment with pertussis toxin, wortmannin, or anti-MIP-1alpha and MIP-1beta antibodies or transfection with antisense of MIP-1alpha or MIP-1beta. Spontaneous polymerization of cytoskeletal F-actin was observed in ATL cells, which was also inhibited by pertussis toxin and wortmannin. We propose that ATL cells adhere to endothelial cells through an adhesion cascade similar to normal leukocytes and that the chemokines produced by ATL cells are involved in triggering integrin LFA-1 through cytoskeletal rearrangement induced by G-protein-dependent activation of phosphoinositide 3-kinases in an autocrine manner. These events result in a strong adhesion of ATL cells to the endothelium and spontaneous transendothelial migration.

Distinct phenotype of leukemic T cells with various tissue tropisms

There is an emerging concept, the validity of which remains to be proven, that preferential expression of selective adhesion molecules on particular T cell subsets may result in tissue-specific migration. L-selectin, cutaneous lymphocyte-associated Ag (CLA), and integrin alpha4beta7 are proposed to be involved in selective migration of T cell subsets into peripheral lymph nodes, skin, and gastrointestinal mucosa, respectively. Adult T cell leukemia (ATL) is associated with lymphoid infiltration of tissues and secondary lymphoid organs. To clarify the role of these putative homing molecules in vivo, we assessed their expression on circulating ATL cells from patients with lymph node, skin, and gut involvement. L-selectin expression was significantly higher on peripheral ATL cells in patients with lymphadenopathy than in patients without it. CLA was highly expressed on peripheral ATL cells compared with normal T cells: its expression was also significantly higher on peripheral ATL cells from patients with skin involvement compared with cells from patients without it. beta7 was particularly highly expressed on peripheral ATL cells from patients with gastrointestinal involvement. In summary, the differential expression of beta7 and beta1 on peripheral ATL cells correlates with the presence of gastrointestinal involvement. Similarly, the presence of skin involvement is associated with the expression of CLA(high)beta7low on peripheral ATL cells. These results, which are consistent with the molecules CLA and alpha4beta7 mediating preferential T cell migration to the skin and gastrointestinal mucosa, respectively, may allow for a refinement of the classification of lymphoid neoplasms on the basis of differential expression of homing molecules.

Saccadic eye movements and regional cerebral blood flow in schizophrenic patients

This study examined saccadic eye movements, using simple stationary targets, in schizophrenic patients. The targets were eight black points or eight arabic-numbered points placed in randomized order on the circumference of a circle. Self-paced eye movements during clockwise tracking of these points, by 23 patients and 23 controls, were recorded using an infrared eye-mark recorder. Then the relationship between the saccades and clinical symptoms was investigated. Finally, the relationship between the performance of the saccades and resting regional cerebral blood flow (rCBF) was examined using single photon emission computed tomography with 99mTc-hexamethyl propyleneamine oxime (HMPAO). The results indicate that patients track with significantly fewer correct scores and more deviant scores than controls, in agreement with our previous study. There were two groups of patients: an ordinary group who obtained a full-target-hitting score at a 200-ms setting and a fast group who obtained the full score at 100 ms but not at 200 ms. Some patients displayed significantly more hypermetria than controls. Significant correlations were found between hallucination and delusion symptoms and correct score. With respect to relative rCBF, fast-group patients showed significantly decreased rCBF in the left limbic and inferior parietal areas as compared with ordinary group patients. These findings suggest that some schizophrenic patients view the stationary targets too fast and this may be related to dysfunction in the limbic-parietal association area in the left hemisphere.

Asymmetry of the ventricle and age at the onset of schizophrenia

The relationship between lateral ventricular size or its asymmetry and age at the onset of schizophrenia was investigated in 20 schizophrenic patients diagnosed according to DSM-III-R criteria. The ventricle-brain ratio (VBR) was determined using three transaxial slices of magnetic resonance image (MRI) and asymmetry of the lateral ventricle was evaluated from the laterality index of the lateral ventricular area: (left-right/left+right) x 100. Each age at the onset of the prodromal and active phase according to DSM-III-R criteria was determined for each patient. The results showed that asymmetry of the ventricle, but not VBR, was significantly correlated inversely with age at the onset of both the prodromal phase and active phase. Neither asymmetry nor VBR correlated with the duration of illness, age at MRI scanning, or severity of clinical symptoms. It would thus appear that greater asymmetry of the ventricle is associated with earlier onset of schizophrenia.

Proteus syndrome: report of the first Japanese case with special reference to differentiation from Klippel-Trenaunay-Weber syndrome

This is the first report of a Japanese girl with Proteus syndrome. She presented with growth acceleration and precocious development of the left breast as well as macrodactyly, hemihypertrophy, a subcutaneous preaxillary mass, portwine stains, connective tissue nevi, and a depigmented macule. All these abnormalities were confined to the left side of her body. Although most of the manifestations fit those of Proteus syndrome, the presence of the portwine stains and hemihypertrophy also suggested Klippel-Trenaunay-Weber syndrome. The findings in our patient suggest that the most important characteristic distinguishing Proteus syndrome from Klippel-Trenaunay-Weber syndrome is the presence of functional abnormalities such as a growth spurt and precocious breast development. Proteus syndrome may be genetically different from the Klippel-Trenaunay-Weber syndrome.

Papillomavirus-infected keratinous cyst on the sole. A histologic, immunohistochemical, and electron microscopic study

A 17-year-old boy had a keratinous cyst on the sole. The keratinous cyst and its overlying epidermis had solitarily scattered keratinocytes, which contained a peculiar intracytoplasmic inclusion body above the lower spinous layer. Immunohistochemistry and electron microscopy revealed that the nuclei of these cells had virions of papillomavirus. These virions appeared above the spinous layer. The inclusion bodies were highly eosinophilic masses in the viable layer, and slightly basophilic, fine granules in the cornified layer. Their number at any time was usually one. Their histologic and ultrastructural features and their N-(7-dimethylamino-4-methylcoumarinyl)-maleimide staining property were different from those of keratohyalin and from those of amyloid or hyaline body. Also the keratinous cyst was associated with colloid bodies, showing the lamellated figure in the subepithelial area.

A case of secondary cutaneous amyloidosis: epidermal keratinocytes produce amyloid in the cytoplasm

A case of secondary localized cutaneous amyloidosis associated with a seborrheic keratosis is reported. Amyloid was observed both in the stroma and in the tumor. Light and electron microscopy revealed amyloid within the cytoplasm of the tumor cells. This intracytoplasmic amyloid was seen in basaloid cells or in the border areas between basaloid cells and squamous cells, but it was not seen in squamous cells. The amyloid was positive for anti-keratin antibody and contained disulfide bonds. It is suggested that either abnormal keratinization or the degeneration of basaloid cells produced abnormal keratin proteins that formed this amyloid.

Paget's disease of the male breast--report of a case and histopathologic study

We report a 61-year-old male with mammary Paget's disease. Physical examination revealed a slightly exudative erythema at the areola and a reddish, enlarged left nipple. No tumor or left axillary lymph nodes was palpable. He underwent a left modified radical mastectomy. Histologically, there was an intraductal carcinoma in the upper portion of the mammary ducts. The axillary lymph nodes that were examined were free of metastasis. Paget cells had neither estrogen nor progesterone receptors. We speculated that the histogenesis of Paget cells involved carcinoma cells that invaded the epidermis of the nipple.

Prurigo pigmentosa successfully treated with minocycline

Five patients with prurigo pigmentosa were treated with 100-200 mg minocycline daily. The eruption and pruritus rapidly resolved within a few days or up to a week. There has been no recurrence after stopping medication and we conclude that minocycline is effective for prurigo pigmentosa and safer than dapsone.

Expression of Schwann cell characteristics in pigmented nevus. Immunohistochemical study using monoclonal antibody to Schwann cell associated antigen

A monoclonal antibody to the Schwann cell associated antigen (AHMY1) and a monoclonal antibody to neurofilament proteins (NFP) (AHNF1) each were produced. Using AHMY1, AHNF1, and anti-S-100 antibody, 90 pigmented nevi were examined immunohistochemically to clarify the relationship between nevus cells and Schwann cells. All nevus cells had S-100 protein, but did not have neurofilament proteins. The nevic corpuscle and Type C nevus cell were positively stained with AHMY1 indicating the presence of the Schwann cell associated antigen, while Type A and B nevus cells were entirely negative. This suggests that the nevic corpuscle and Type C nevus cell are closely related to the Schwann cell and differ from Type A and B nevus cells in their development.

Effects of thermal denaturation on the longitudinal relaxation time (T1) of water protons in protein solutions: study of the factors determining the T1 of water protons

The factors determining the longitudinal relaxation time (T1) of water protons in protein solutions were investigated by analyzing the effects of thermal denaturation on the T1 of the water protons. We treated the water protons and the protein protons "on a protein surface" as a dipole-dipole coupled two-spin system where relative translational diffusion is the dominant mechanism, and measured the change in the time development of the nuclear Overhauser effect (NOE) factors of the water protons. The T1 of the water protons was shortened markedly when the proteins were thermally denatured. Our analysis indicates that this relaxation enhancement is due to an increase in the value of the translational correlation time as well as the fraction of hydration water molecules, though the influence of "proton exchange" between the water protons and the labile protein protons cannot be completely neglected.

Bile acid metabolism in isolated rat hepatocytes: studied by gas-liquid chromatography-mass spectrometry-selected ion monitoring

Bile acid contents in isolated rat hepatocytes were determined by gas-liquid chromatography-mass spectrometry-selected ion monitoring with the use of deuterium-labeled internal standards. This allowed us first to monitor the actual amounts of not only major but also minor bile acid components present with sufficient sensitivity and specificity and to follow the changes of individual bile acids in cultured rat hepatocytes simultaneously. In freshly isolated rat hepatocytes, cholic and beta-muricholic acids were the major components, comprising 35 and 46% of the total bile acids, respectively. These two bile acids were found to be most actively synthesized during the first 2 h of incubation and continued to increase thereafter for up to 6 h (the end of the period studied). In contrast, chenodeoxycholic and alpha-muricholic acids, which are the precursors of beta-muricholic acid, showed slight increases only in the first hour of incubation and decreased thereafter. These results suggested that the conversion to beta-muricholic acid from chenodeoxycholic acid via alpha-muricholic acid occurred rapidly in cultured rat hepatocytes. The secondary bile acids such as deoxycholic, hyodeoxycholic, and 3 alpha, 12 beta-dihydroxy-5 beta-cholanoic acids declined steadily from the start of incubation, which supported the findings that further hydroxylation of these dihydroxy bile acids occurs in rat liver.

Pseudotail associated with spinal dysraphism

A 5-year-old girl had a caudal appendage and her left buttock was larger than the righ buttock. X-ray examination revealed spina bifida and bony defect of sacrum; computed tomography demonstrated the extension of the tumor from subcutaneous tissue to the spinal canal. Histologically, the pseudotail contained lobulated fatty tissue which was consistent with lipoma. It emphasizes the fact that even lesions that are not situated in the median line should be carefully explored before excision.

Immunohistochemical studies of selected skin diseases and tumors using monoclonal antibodies to neurofilament and myelin proteins

Several skin diseases and tumors were immunohistochemically studied with the use of monoclonal antibodies against myelin proteins and neurofilament proteins. In prurigo nodularis, many nerve fibers were found embedded in dense inflammatory cell infiltration. Abnormal innervation was observed in piloleiomyoma. The axons were demonstrated within the cytoplasm of granular cells of granular cell schwannoma. In neurofibroma, tumor cells had myelin proteins in their cytoplasms. Many cells and fibers that contained myelin proteins were demonstrated in nevus cell nevus, especially in compound nevus and intradermal nevus, and it was suggested that schwannian cells may be the origin of some nevus cells.

Epithelial hyperplasia of the larynx. A 10-year review of 88 patients

A retrospective review of 88 patients with epithelial hyperplasia of the larynx seen at the Department of Otolaryngology Kurume University during the 10-year period from 1971 to 1980 was completed. The results are summarized as follows: 1) The incidence was much higher in males (78 patients) than in females (10 patients). 2) The average age was 56.8 years. 3) The lesion was located on the vocal fold in 84 cases, the ventricular fold in 3, and both vocal and ventricular folds in 1. 4) Fifty-three patients underwent surgical treatments in our hospital. Three of them developed recurrence and 6 developed carcinoma. 5) On histological re-examination, the lesions were classified into three types: simple hyperplasia (Type I), dysplasia (Type II) and carcinoma (Type III). No relationship was found between the macroscopic appearance and the histological type.

Conservation, restoration and rehabilitation of voice in treating patients with carcinoma of the larynx. A 10-year review of 244 patients

We reviewed clinical records of 244 patients with carcinoma of the larynx treated during the 10 years from 1971 to 1980 in the Department of Otolaryngology, Kurume University Hospital. Of the 244 patients, 111 patients (45.5%) were treated with their voice conserved and 133 underwent total laryngectomy. In the latter, information on the modality of speech communication was obtained from 73 patients. Forty-nine (67%) of these 73 patients was able to speak by some means but the remaining 24 (33%) had no means to speak.