[Guideline for the joint swelling symptom--primary physician problem management and referral indications. German Society of Rheumatology "Quality Assurance" Committee]

The guideline "Joint Swelling" is addressed to primary care physicians--general practitioners, internists or orthopedists without special experience in rheumatology. It provides a framework for interviewing patients, as well as for physical, laboratory and imaging examinations and for selection of treatment appropriate to the level of primary care. Situations which call for urgent evaluation and criteria for referral to rheumatologists are described. The appendix contains comments on signs and symptoms to differentiate arthralgia from joint swelling and on the diagnostic value of a history of joint swelling without confirmation by the physician. Further recommendations for the evaluation of patient history and physical and technical examinations are given in a tabular form. The significance of laboratory and imaging procedures is discussed.

Clonal expansion and decreased occurrence of peripheral blood gamma delta T cells of the V delta 2J delta 3 lineage in multiple sclerosis patients

gamma delta T cells are implicated in autoimmune diseases but their precise function remains unclear. In multiple sclerosis (MS) brain tissue, gamma delta T cells co-localize with heat shock protein (hsp)65+ oligodendrocytes and are oligoclonally restricted in the V delta 2J delta 3 lineage. To investigate the homing properties and the degree of heterogeneity of V delta 2J delta 3+ gamma delta T cells in MS, peripheral blood lymphocytes (PBL) from 34 MS patients, 42 controls (14 autoimmune control patients, 28 healthy volunteers), and 11 lymphatic tissues of MS patients and controls were studied by RT-PCR and sequencing. V delta 2J delta 3 TCR rearrangement was detected in 27 out of 28 healthy controls, and was significantly less frequent in MS patients (24 out of 34) and autoimmune control patients (seven out of 14). It was present only in five out of 11 tissue specimens, none of them from MS patients. Direct sequencing and cloning/automated sequencing of the V delta 2J delta 3 PCR products indicated heterogeneity in healthy controls and oligoclonality in MS patients, but also in autoimmune control patients. Differences between MS patients and healthy controls were more accentuated in exacerbating hospitalized patients than in clinically stable outpatients participating in a clinical trial. Only one V delta 2J delta 3 sequence of a total of 85 different sequences obtained was shared between two MS patients. Taken together, evidence for clonal expansion of V delta 2J delta 3+ gamma delta T cells was found in PBL of MS patients. This T cell subset, previously shown to be present in 100% of chronic-active MS plaques, might home to the CNS in MS, resulting in its under-representation in the blood.

Kinetics of cytokine secretion by mononuclear cells of the blood from rheumatoid arthritis patients are different from those of healthy controls

Mononuclear cells from peripheral blood (PBMC) of rheumatoid arthritis (RA) patients and healthy controls were incubated with alpha-CD3. Cytokine secretion from 2 h to 72 h of incubation was measured by ELISA. There were no significant differences in secretion of T cell derived IL-2 and IL-4 in cultures from RA patients and controls. The macrophage-derived cytokines, IL-1 beta and tumour-necrosis factor-alpha (TNF-alpha) were secreted with a steep increase of concentration during the first 16 h of incubation by PBMC from RA patients. PBMC from healthy controls secreted both cytokines at a constantly rising rate with a maximum for TNF-alpha at 48 h and for IL-1 beta at 72 h. Interferon-gamma (IFN-gamma) is secreted in significantly reduced concentrations by PBMC from untreated RA patients compared with controls. Gold-salt treatment led to a slightly delayed and enhanced secretion of TNF-alpha and IL-1 beta, an enhanced secretion of IL-2 and a restored secretion of IFN-gamma.

[Interleukin-1 in the pathogenesis of chronic polyarthritis]

The cytokine interleukin-1 plays an important role in the production and modulation of the immune response in rheumatoid arthritis. It is produced by macrophages of the inflamed synovial tissue and induces the autocrine production of interleukin-1, amplifies the T-cell dependent immune response and has potent effects on inflammatory reactions of many non-lymphoid cell-systems. By means of a sensitive and specific ELISA interleukin(Il)-1 beta was measured in the peripheral blood and synovial fluid of patients with rheumatoid arthritis in comparison to controls in significantly increased levels (medium values: 280 pg/ml and 325 pg/ml versus less than 20 pg/ml). The Il-1 beta concentrations in the peripheral blood and in the synovial fluid were well correlated, but there was no correlation to other inflammation parameters like erythrocyte sedimentation rate or C-reactive protein, however, a good correlation to the nephelometrically measured rheumatoid factor (r = 0.71). In twelve hour cultures of adherent cells significantly increased spontaneous intracellular Il-1 beta-production was determined in synovial fluid macrophage cultures of rheumatoid arthritis patients compared to peripheral blood monocyte cultures of controls (median values 91.0 ng/10(6) cells versus 31.5 ng/10(6) cells). The secretion into the culture supernatant has to be stimulated by additional lipopolysaccharide. Interferon-gamma inhibits the spontaneous intracellular Il-1 beta-production of synovial fluid macrophages from rheumatoid arthritis patients. These findings may be of importance for the effect of the interferon-gamma therapy in the treatment of rheumatoid arthritis.

Spontaneous and LPS-stimulated production of intracellular IL-1 beta by synovial macrophages in rheumatoid arthritis is inhibited by IFN-gamma

In the peripheral blood (PB) as well as the synovial fluid (SF) of rheumatoid arthritis (RA) patients significantly elevated levels of interleukin 1 beta (IL-1 beta) were determined compared to controls by means of a sensitive and specific ELISA (median values: 280 pg/ml and 325 pg/ml vs. less than 20 pg/ml). In 12-h cell cultures of adherent cells, significantly increased spontaneous intracellular IL-1 beta production was determined in SF macrophage (SFM phi) cultures of RA patients compared to PB monocyte (PBMo) cultures of controls (median values: 91.0 ng/10(6) cells vs. 31.5 ng/10(6) cells). However, secretion must be elicited by additional stimulation with lipopolysaccharide (LPS). Interferon-gamma (IFN-gamma) significantly inhibited the spontaneous intracellular IL-1 beta production in SFM phi 12-h cultures of RA patients.

Interleukin-2 secretion by synovial fluid lymphocytes in rheumatoid arthritis

Interleukin-2 (IL-2) receptor bearing cells and soluble IL-2, measured in a bioassay with IL-2 dependent human T-cell blasts, were recognized in synovial fluid, but not in the peripheral blood of patients with rheumatoid arthritis (RA). After stimulation in vitro with appropriate concentrations of the mitogen concanavalin A (Con-A), comparable proportions of IL-2 receptor (IL-2R) bearing cells were seen in cultures of synovial fluid lymphocytes (SFL) and in cultures of peripheral blood lymphocytes (PBL). On the other hand, higher levels of secreted IL-2 were found in SFL cultures compared to corresponding PBL cultures of RA patients and normal donors. Specificity of the IL-2 bioassay was confirmed by blocking the T-cell blast proliferation (induced by SFL culture supernatants), by 83 +/- 4%, after addition of a monoclonal anti-IL-2R antibody. Despite the high levels of soluble IL-2, only a weak proliferative response was observed in the corresponding SFL cultures.

An ELISA for IgA-IgG and IgM-RF measurement. II. RF in several disease and control groups and under gold therapy in RA

The before introduced solid phase ELISA was employed for the RF determination in the sera of RA patients and controls. The threshold values for positive results (calculated as the 95% distribution percentile of healthy donors) were 8, 3, and 3 U/ml for IgA, IgG, and IgM-RF, respectively. The results confirm the validity of the assay with clear negative results in several negative control groups (healthy donors, patients of the oto-, rhino-, laryngeal ambulance, diabetes mellitus, degenerative arthropathies; n = 111, median IgA, IgG and IgM-RF values of less than or equal to 2, less than or equal to 2 and less than or equal to 1 U/ml, respectively; 25-75% distribution percentiles within the median value) and positive results in the positive control group (seropositive RA; n = 20, median IgA, IgG and IgM-RF values of 324, 479 and 170 U/ml, respectively). 16/24 patients with so-called seronegative RA (negative Latex Fixation Test or Waaler Rose Test) had positive results in the ELISA, two of them had rheumatoid nodules clinically. The IgG-RF activity in the ELISA appears to be a good parameter for the course control of RA under gold therapy. 10 RA patients with clinical improvement of disease (declining ESR, CRP, joint index) after six months of gold therapy (= 0.6 g total gold amount) had a decline of total RF activity of 70% in median, whereas 10 patients with no clear effect on disease activity had only a decline of 20% in median.

An ELISA for IgA, IgG and IgM-RF measurement. I. Parameters of the assay

A simple and rapid solid phase ELISA for the stepless determination of IgA, IgG and IgM-RF was developed. The ELISA works with Fc parts of human IgG as antigen. Specificity, validity and precision were tested. RF complex dissociation by urea and separation by gel filtration was performed in several samples to obtain information of the transfer of non-RF-IgG by pentameric IgM-RF. The RF-ELISA may give better information on the significance of RF of the three Ig classes in the clinical course of RA.

Superoxide anion production by monocytes and synovial fluid macrophages of patients with chronic inflammatory joint disorders

Peripheral blood monocytes (PBMo) and synovial fluid macrophages (SFMO) of patients with rheumatoid arthritis (RA), HLA B27-positive reactive oligoarthritis and controls were investigated for their capacity to generate superoxide anions (O2-) upon stimulation with phorbolmyristoacetate (PMA) in a cytochrome c (cyt c) microassay. PBMo of RA patients, patients with reactive arthritis and controls did not reveal any significant differences and also treatment of RA patients with gold salts or immunosuppressive therapy had no effect on the oxidative burst in PBMo. In contrast, in SFMO of RA patients treated only with nonsteroidal anti-inflammatory drugs (NSAID) we found significantly enhanced O2- release, compared with PBMo of the same group. Treatment with gold salts had no effect on this enhanced oxidative response, whereas immunosuppressive therapy with azathioprin or corticosteroids significantly reduced the O2- release of SFMO. In patients suffering from reactive arthritis we did not find significant differences between SFMO and PBMo. The O2- release of SFMO of this group was significantly reduced, when compared to that of SFMO of RA patients, treated with NSAID. These results indicated that SFMO but not PBMo in RA in cyt c microassay produce increased levels of activated oxygen species. In comparison to PBMo, SFMO of patients suffering from reactive arthritis do not show such an increased oxidative burst. These findings suggest that in RA, activated oxygen species have a local destructive effect in inflamed joints. This seems to be caused by activation of catalytic enzymes and complement components, as well as induction of release of interleukins or prostaglandins, contributing to the augmentation of the chronic inflammatory process.

Evidence for enhanced interleukin 2 (IL-2) secretion and IL-2 receptor presentation by synovial fluid lymphocytes in rheumatoid arthritis

Synovial fluid lymphocytes (SFL) and peripheral blood lymphocytes (PBL) from patients with rheumatoid arthritis (RA) and reactive oligoarthritis were investigated for activated T cells (Ia+SIg-), IL-2 receptor bearing cells (Tac+) and IL-2 production in vivo and in vitro. In contrast to negative results with blood, the synovial fluid of the arthritic joints contains considerable amounts of IL-2 activity (median: 11.8 mu/ml), elevated proportions of Ia+SIg- activated T cells (median: 12.5%) and of IL-2 receptor bearing cells (median: 2.5%). In vitro, after stimulation with several Concanavalin A (Con A) doses, SFL develop proportions of IL-2 receptor cells comparable to PBL. Furthermore, they produce higher values of IL-2 activity than comparable PBL cultures. The proportions of Ia+SIg- activated T cells increase only moderately after Con A stimulation compared to in vivo data, indicating different activated T cell subsets in the synovial fluid (Ia+SIg-, Tac+). The findings are discussed as an expression of an acute hyperactivation of lymphocytes in an inflamed joint.

[Detection of macrophage activity in the blood and synovia of chronic polyarthritis patients using an activated oxygen microassay]

A microassay was developed for the estimation of macrophage (M phi)-activation by released activated oxygen. From peripheral blood or synovia M phi are isolated. O-2 which is released by activated M phi is photometrically detected by cytochrome c reduction. Differences in O-2-production do not exist between monocytes of rheumatoid arthritis patients and controls. In contrast synovial M phi from rheumatoid arthritis patients show increased levels of O-2-production.

[A solid-phase ELISA with specificity for rheumatoid factors of classes IgA, IgG and IgM]

A solid phase ELISA was developed for the simple and rapid determination of rheumatoid factors (RF) of all major immunoglobulin classes. Micro-ELISA-plates were coated with human Fc-fragments and incubated with various dilutions of serum samples as well as with an international RF reference serum. Rheumatoid factors were quantitatively detected by rabbit antibodies (RaHIgA(alpha), RaHIgM(mu), RaHIgG(Fab] conjugated with alkaline phosphatase. The specificity of the ELISA was proved by means of binding inhibition of all rheumatoid factor classes by heat aggregated human IgG. A comparison of the IgM-RF titres of the latex fixation test with the IgM-RF concentration values of the ELISA yielded high correlation (r = .81).

Enumeration of T cell subsets and functional suppressor cell assays in patients with rheumatoid arthritis and HLA-B27-associated arthritis

Seronegative rheumatoid arthritis (RA) patients have increased proportions of OKT-4+ (helper) T cells and diminished proportions of OKT-8+ (suppressor/cytotoxic) T cells in the peripheral blood. This phenomenon corresponds to diminished inhibition of B cell activation by peripheral blood lymphocytes (PBL). Seropositive RA patients show a broad range of OKT-8+ T cell proportions (9%-45%) in the peripheral blood, resulting in a mean level comparable to that in controls. Inhibition of T cell activation by suppressor cells in peripheral blood is greater in this group than in controls. HLA-B27-positive arthritis patients show no significant differences from controls with respect to markers and functional suppressor cell assays. In the synovial fluid of all patients both OKT-8+ T cell proportions and functional suppressor cell activity are greatly increased.

Studies on immunoregulatory mechanisms in acute and chronic hepatitis B

Patients with acute hepatitis B and HBV-induced chronic hepatitis as well as normal control persons participated in the study. Hepatitis patients of both groups have decreased OKT4+/OKT8+T cell ratios due to an percental increase of OKT8+T cells in peripheral blood compared to the data of controls. Lymphocyte cultures of chronic hepatitis patients show reduced DNA synthesis after stimulation by allogeneic non-T cells, PHA, Con A and PWM. PWM-induced immunoglobulin secretion by B cells, determined by means of a reverse haemolytic plaque assay (RHPA) and a solid phase ELISA, showed comparable results in hepatitis B patients and controls. The AMLR, which is thought to reflect an autologous immunoregulatory phenomenon, is slightly impaired in cultures of hepatitis B patients in comparison to controls. Con A-induced suppressor cell activity on T cell reactions is decreased in hepatitis, whereas suppressor cell activity on B cell activation is within the same range as in cultures of controls. It is concluded from these data, that suppressor cell activity on T cell function is impaired in hepatitis B, whereas B cell functions and suppressor cell activity on B cell function are in the normal range. The results with the functional assays and the finding of increased proportions of OKT8+T cells in hepatitis B are considered to reflect properties of different T cell subpopulations, responsible for different immunoregulatory functions.

[Follow-up study on antibody dependent cell-mediated cytotoxicity and cell-mediated cytotoxicity to HBs-antigen conjugated target cells in patients with hepatitis B (author's transl)]

Results of a follow up study on ADCC and CMC to HBs antigen conjugated target cells in patients with hepatitis B are given. The cytotoxic reaction was measured immediately after onset of the disease, three weeks and three months thereafter CMC was increased over the whole observation period. The results in hepatitis B patients were significantly different to those in normal controls. The ADCC in the presence of an antiserum to HBs antigen was in patients with hepatitis B immediately after onset of the disease reduced in comparison to the controls; it increased during the three months to the values of the controls in patients with uncomplicated disease. Experiments with isolated lymphocyte populations showed that the ADCC is mainly dependent on Fc receptor bearing lymphocytes whereas the CMC is mediated by T-cells and Fc-receptor bearing cells.

In vitro studies on lymphocytotoxicity to synovial cells and Chang cells in rheumatoid arthritis patients and healthy controls

Lymphocytotoxicity to autologous or allogeneic synovial cells and Chang cells was studied in 27 patients with rheumatoid arthritis (RA), in 5 patients with osteoarthrosis of the hip or knee and in 17 healthy controls. Ficoll gradient-separated lymphocytes from the peripheral blood, T cells and non-T cells were used as effector cells. T lymphocytes were isolated as E-rosette forming cells 10 percent of which carried Fc- receptors. The differential counts for T and B cells in the peripheral blood of the RA and osteoarthrosis patients were approximately the same as in the blood of the healthy controls. The counts of Fc-receptor-bearing cells in the RA patients were, however, significantly higher. Cytotoxic reactivity of lymphocytes from RA patients, osteoarthrosis patients or healthy controls to synovial cells of autologous or allogeneic origin could not be demonstrated in our study, in which 125I-iododeoxyuridine labelled target cells were used in the microcytotoxicity test of Cohen et al. However, lymphocytes of the peripheral blood showed an increased cytotoxicity to Chang cells, an effect for which Fc-receptor bearing cells were responsible. Serum did not affect the cytotoxicity of lymphocytes. The results are interpreted as demonstrating an enhanced natural killer (NK) cell activity in RA patients; they do not indicate a specific cell mediated immune reaction to synovial cells.

Antibody-dependent cell-mediated cytotoxicity (ADCC) and cell-mediated cytotoxicity (CMC) to HBsAg-coated target cells in patients with hepatitis B and chronic hepatitis (CAH)

A new technique using HBsAg-coated Chang cells as target cells was developed in order to measure cell-mediated immune reactions to HBsAg. The specificity of cytotoxic reactions was tested in experiments using Chang cells conjugated with human serum albumin. Antibody-dependent cell-mediated cytotoxicity (ADCC) specific for the HBsAg-coated target cells was demonstrated up to dilutions of anti-HBsAg serum of 10,000 : 1, when lymphocytes from the peripheral blood of normal individuals were added to the target cells. Spontaneous cell-mediated cytotoxicity (CMC) to HBsAg-coated target cells was demonstrated for lymphocytes from patients with hepatitis B and from patients with chronic active hepatitis (CAH), but not for lymphocytes from healthy controls. The CMC of hepatitis B lymphocytes to HBsAg-coated target cells was inhibited in the presence of antiserum to HBsAg. In experiments using purified lymphocyte populations evidence is presented that the CMC is T-cell dependent. HLA-restriction of the CMC was not observed. The described cytotoxicity test system has the advantage that target cells conjugated with defined antigens are used and that relevant control target cells are available.

Kartagener's syndrome in sibs: clinical and immunologic investigations

In a sibship of ten children descending from a first cousin's marriage, two sibs were affected by Kartagener's syndrome with the typical symptoms of situs inversus, bronchiectasis, and polyposis nasi. Clinical investigation of the entire family revealed chronic infections of the paranasal sinus in five sibs and the mother, two of whom had bronchiectasis as well. Immunologically, a persistent cellular or humoral defect could not be detected in any of the family members. In the HLA system, only the two sibs with Kartagener's syndrome had identical HLA-types; all other family members had different combinations. A linkage between the loci for the HLA system and Kartagener's syndrome is discussed.

Studies on lymphocytotoxicity in acute and chronic liver disease

The cytotoxicity of lymphocytes from patients with chronic active hepatitis, chronic persistent hepatitis, acute hepatitis B and rheumatoid arthritis as well as from normal controls was studied in a microcytotoxicity assay according to COHEN et al. using 125I-iododeoxyuridine labeled embryonal liver cells and Chang cells as target cells. Unfractionated lymphocytes of the peripheral blood from patients with chronic active hepatitis and rheumatoid arthritis showed a high frequency of cytotoxic activity. The lymphocytotoxicity in chronic active hepatitis was significantly increased in comparison to normal controls at the EC/TC of 10:1 and 100:1. Specificity of the cytotoxic reaction to target cells could not be demonstrated. Addition of autologous serum to the cytotoxic assay blocked the lymphocytotoxicity in patients with chronic active hepatitis. A weak potentiating effect on lymphocytotoxicity was observed in patients with hepatitis B after addition of autologous serum. It is discussed that this reaction is due to the presence of HB-antigen in the serum since addition of HB-antigen from other sources increased also the lymphocytotoxicity in hepatitis B patients. This effect was observed neither in HB-antigen positive nor in HB-antigen negative patients with chronic active hepatitis or chronic persistent hepatisis.

The significance of cytotoxicity of lymphocyte populations in coloncarcinoma patients in comparison to normal controls using a new statistical method of evaluation

Lymphocytotoxicity was studied in patients suffering from colon carcinoma. 125Iododeoxyuridin-labeled established colon carcinoma cells were used as target cells in a cytotoxicity assay according to COHEN et al. (1). They were incubated with unfractionated lymphocytes of the peripheral blood, purified T cells or adherent cells as effector cells. The cytotoxic effect was measured in cpm, i. e. the radioactivity released from the target cells into the supernatant. The cpm were adjusted by eliminating the variables of spontaneous release and for maximal incorporated radioactivity of the target cells. The cytotoxic activity of lymphocytes to colon carcinoma target cells was dose-dependent. It was demonstrated for lymphocytes from colon carcinoma patients as well as for lymphocytes from healthy controls. Although adjusted cpm values were used for statistical analysis lymphocytes from the 20 colon carcinoma patients did not show a higher cytotoxic effect than lymphocytes from the 20 healthy controls. However, when the results were compared separately for each experiment consisting of 2 colon carcinoma patients and 3 healthy controls, statistical significant specific lymphocytotoxicity was demonstrated for lymphocytes from colon carcinoma patients. The plot diagram of the results and the statistical evaluation by the multivariate analysis of variance (Manova) offer a clear and comprehensible representation of the results. Particularly for statistical reasons, this representation is superior to the usual calculation of percent specific lysis. It was demonstrated in this study that the cytotoxic activity in the absence of autologous serum is a function of T cells of the peripheral blood. Adherent cells have a high cytotoxic activity regardless whether the cells were obtained from colon carcinoma patients or from healthy controls.

Studies on the Specificity of in Vitro Induced Lymphocytotoxicity to SV40-Transformed Fibroblasts

Cytotoxic effector lymphocytes were induced by in vitro immunization of lymph node and spleen cells from AKR-mice (H-2k) and from BALB/c-mice (H-2d) to syngeneic SV40-transformed fibroblasts. The T cell-dependent cytotoxicity was specific for target cells expressing the same H2-specificity as the immunizing cells. Nontransformed fibroblasts as stimulator cells did not induce efficient cytotoxicity to transformed or nontransformed target cells. Incubation with phytohemagglutinin during the sensitization period modified the specificity of the T cell-mediated lysis of syngeneic SV40-transformed fibroblasts: allogeneic as well as syngeneic target cells were destroyed by these effector cells. However, the polyclonal stimulant activates preferentially cytotoxicity to H2-matched target cells. The in vitro generation of cytotoxic effector cells was restricted to living SV40-transformed fibroblasts as immunizing cells; it was not possible to immunize lymphocytes in the presence of membrane proteins prepared from the SV40-transformed cells. The cytotoxicity of the in vitro immunized lymphocytes was inhibited by incubation with membrane protein preparations from syngeneic or allogeneic SV40-transformed fibroblasts.

Studies on the specificity of in vitro induced lymphocytotoxicity to SV40-transformed fibroblasts

Cytotoxic effector lymphocytes were induced by in vitro immunization of lymph node and spleen cells from AKR-mice (H-2k) and from BALB/c-mice (H-2d) to syngeneic SV40-transformed fibroblasts. The T cell-dependent cytotoxicity was specific for target cells expressing the same H2-specificity as the immunizing cells. Nontransformed fibroblasts as stimulator cells did not induce efficient cytotoxicity to transformed or nontransformed target cells. Incubation with phytohemagglutinin during the sensitization period modified the specificity of the T cell-mediated lysis of syngeneic SV40-transformed fibroblasts: allogeneic as well as syngeneic target cells were destroyed by these effector cells. However, the polyclonal stimulant activates preferentially cytotoxicity to H2-matched target cells. The in vitro generation of cytotoxic effector cells was restricted to living SV40-transformed fibroblasts as immunizing cells; it was not possible to immunize lymphocytes in the presence of membrane proteins prepared from the SV40-transformed cells. The cytotoxicity of the in vitro immunized lymphocytes was inhibited by incubation with membrane protein preparations from syngeneic or allogeneic SV40-transformed fibroblasts.

Lymphocytotoxicity to tumor target cells and interference of serum factors or tumor antigen with lymphocytotoxicity in patients suffering from different stages of breast carcinoma

The in vitro cytotoxicity of lymphocytes from patients suffering from breast carcinoma against autochthonous, allogeneic and established breast carcinoma cells was evaluated. Lymphocytotoxicity to breast carcinoma cells was observed in all stages of the disease. Control lymphocytes from healthy donors or patients suffering from other carcinoma are not cytotoxic for the breast carcinoma cell lines. A follow-up study of the cell mediated immune reactions before and after surgical removal of the breast carcinoma showed that the cytotoxic lymphocyte population which is demonstrated in the presence of the tumor disappears quickly after excision of the carcinoma. The non-reactivity of lymphocytes is not due to a general immune defect. Serum of the tumor bearers did not block the lymphocytotoxicity in early stage breast carcinoma; in metastatic disease inhibition occurred in more than half of the cases. Preincubation of lymphocytes with antigen preparations of allogeneic breast carcinoma cells did not inhibit the cytotoxicity to breast carcinoma cells whereas autologous serum preincubated with the antigen preparation diminished the lymphocyte reactivity to the target cells in some cases.

[Long term treatment of rheumatoid arthritis. Experiences with D-penicillamine in comparison with gold and immunosuppressive drugs (author's transl)]

In a controlled trial including 80 patients suffering from different stages of rheumatoid arthritis it was demonstrated that D-penicillamine therapy favourably influences the clinical course of the disease as compared to a control group treated with antirheumatic drugs. Particularly the therapy continued over one year resulted in a significant fall of the joint and activity index as well as of the BSR. Side effects were observed in more than half of the cases. Renal, hematological and severe exanthematic complications forced to discontinue the administration of D-penicillamine in 6 of 41 cases. As compared to other therapeutics our study indicates that D-penicillamine and gold treatment are equivalent drugs in rheumatoid arthritis whereas immunosuppressive drugs are reserved for severe cases of rheumatoid arthritis because of their strong side effects.

Clinical trial of Ro 6-0787, a monovalent specific hapten inhibitor of penicillin allergy

A second clinical trial of the compound Ro 6-0787, which is a specific monovalent penicilloyl hapten inhibitor of allergic reactions to penicillin has been conducted by investigators from 9 different European groups in 90 patients allergic to penicillin. The effect of a combined Ro 6-0787-penicillin therapy was considered as clinically successful in the large majority of cases, since treatment with penicillin could be pursued or resumed without allergic manifestation in 42 from 46 cases (91 percent). The effect of Ro 6-0787 alone on acute allergic manifestations after interruption of penicillin therapy was more difficult to evaluate but was nevertheless considered satisfactory in 17 from 26 patients (65 percent). A depression of skin hypersensitivity to PPL and/or penicillin and penicillin derivatives sometimes persisting for weeks and months was obvious in numerous allergic patients submitted to combined Ro 6-0787-penicillin treatment. A depressing effect on antipenicillin antibody titers detected by passive hemaglutination was also manifest in some patients. Failure to suppress allergic manifestations was reported in 11 cases, among which some may have been due to insufficient dosage of inhibiting hapten. The overall tolerance of Ro 6-0787 in allergic patients has been very good. Nevertheless, the major obstacle to a wider general use of Ro 6-0787 at the present time appears to be the occurrence of positive skin reactions to that compound in approximately 5 percent of patients allergic to penicillin. It is not yet ascertained whether the occasional positive skin reactions and urticaria to Ro 6-0787 may have been due to aggregation, or incomplete dissolution of the compound or whether it reflects hypersensitivity to another antigenic determinant. With the reservation that patients with positive skin test to Ro 6-0787 have for the time being to be excluded from combined treatment, this monovalent hapten certainly offers a new possibility to resume and/or pursue penicillin therapy in patients demonstrably allergic to that drug.

Studies on the cytotoxic effect of in vivo and in vitro immunized lymphocytes on liver target cells

Lymph node and spleen cells from mice immunized in vivo to allogeneic of syngeneic liver antigen are cytotoxic for syngeneic liver cells, but not for syngeneic fibroblasts or established liver cell cultures of allogeneic origin. The cytotoxic activity is mainly dependent on T-cell activity, but a non-T-cell-mediated cytotoxicity may also play a role. Lymphocytotoxicity is inhibited by preincubation of the lymphocytes with syngeneic liver antigen, but not with syngeneic kidney homogenate. The liver-specific lymphocytotoxicity corresponds to the in vivo function of lymphocytes in the development of experimental hepatitis. In vitro immunization of lymphocytes in a Mishell-Dutton culture system also induces liver-specific cytotoxicity. The results indicate that the natural tolerance to self antigens can be lost after invivo as well as in vitro immunization. The induction of self-reactivity of lymphocytes in these experiments may be attributed to regulatory mechanisms of the immune reaction at a cellular level.

Fractionation of antigen reactive cells from immunized mice on columns coated with antigen or anti-immunoglobulin sera

Immunocompetent cells obtained from NIP-RGG immunized mice were fractionated on bead columns coated with antigen or anti-immunoglobulin serum. The separated cell fractions were examined for their capacity to be stimulated by the antigen in short term culture, to produce antigen specific antibodies in the plaque assay and to bind radioactive labeled antigen. Cells which produce hapten specific antibodies or bind radioactive labeled hapten are removed from the cell population passed through a hapten-carrier complex coated column. Cells stimulated by the antigen to an increased DNA-synthesis are also retained by columns coated with the hapten-carrier-complex or the carrier alone; the fractionation seems to be carrier specific. The fractionation of cells is blocked by free antigen in the columnar fluid. However, the fractionation patterns of cells passed through anti-Ig-serum coated columns are different when antibody producing cells and cells stimulated by the antigen are compared. Whereas antibody producing cells and antigen binding cells are almost completely retained by anti-Ig-serum coated columns the cells which are stimulated by the hapten carrier complex are not removed from the passed cells. Studies to characterize the fractionated cell populations according to their sensitivity to anti-theta-serum, to the presence of Ig-receptors and to the phytohemagglutinin stimulation indicate that the antibody producing cells and the antigen binding cells have to be attributed to B-cells whereas the question whether the antigen stimulated cells are T- or B-cells cannot be definitely answered.