HLA class II haplotypes associated with pulmonary interstitial lesions of polymyositis/dermatomyositis in Japanese patients

To elucidate the immunogenetic background of idiopathic inflammatory myopathies (IIM) such as polymyositis (PM), dermatomyositis (DM) and any overlapping subsets, with other collagen vascular diseases, HLA class I antigens and class II alleles were determined and compared from individuals with various clinical and serological features of IIM, including pulmonary interstitial lesions (PI). Seventy-three Japanese patients with myositis (32 PM, 18 DM, 23 overlapped subsets) and 62 healthy unrelated controls were enrolled onto the study. Statistical differences between groups were determined by the Fisher's exact probability test. Serum fluorescent antinuclear antibody, rheumatoid factor (RF), anti-SS-A/Ro antibody, anti-Jo1 antibody and anti-U1 RNP antibody were examined using routine methods. PI was detected by chest X-ray and/or computed tomography. In patients with DM, the frequency of the HLA-DRB1*1302-DQA1*0102-DQB1*0604 haplotype was significantly higher than in the healthy controls (42.1% vs 17.7%), and in the patients with PM (42.1% vs 9.4%). Furthermore, the frequency of the HLA-DRB1*0405-DQA1*03-DQB1*0401 haplotype was higher in the PM patients with PI than in the controls (50.0% vs 17.7%), and PM without PI (50.0% vs 5.5%). These results suggest that in terms of HLA class II association, Japanese DM and PM, and PM with and without PI, belong to different clinical groups.

The coexistence of systemic sclerosis and rheumatoid arthritis in five patients. Clinical and immunogenetic features suggest a distinct entity

To elucidate the clinical characteristics and pathogenesis of scleroderma-rheumatoid arthritis (SSc-RA) overlap syndrome, we analyzed the clinical features of 5 patients with SSc-RA overlap. Their HLA phenotypes and genotypes were also determined. Generalized skin sclerosis, severe seropositive polyarthritis, pulmonary fibrosis, anti-topoisomerase I antibodies, and HLA-DR4,53;DQA1*0301;DBQ1*04 haplotype were observed in all of the patients. Similar clinical features were recognized in most of the 10 cases reported previously. Our case studies indicate that SSc-RA overlap may be a distinct entity.

[Systemic sclerosis with various gastrointestinal problems including pneumoperitoneum, pneumatosis cystoides intestinalis and malabsorption syndrome]

We describe here an experience of successful treatment of systemic sclerosis (SSc) complicated with various gastrointestinal (GI) problems including pneumoperitoneum, pneumatosis cystoides intestinalis and malabsorption syndrome. A 35-year-old female had developed selerodactyly since February, 1990. She had been treated under the diagnosis of SSc at other hospital. She had required several hospitalizations because of nausea, vomitting and abdominal distension, but her GI symptoms had gradually deteriorated. In April 1993, she was referred to our hospital and admitted for the treatment of her GI problems. On admission, she had systemic cutaneous sclerosis and marked abdominal distension without peritoneal signs was recognized. Chest and abdominal roentgenograms demonstrated massive free air under the diaphragm, marked dilation of small and large bowels, and multiple intestinal cysts (pneumatosis cystoides intestinalis ; PCI). We treated her GI problems with various modalities combined with medications, oxygen breathing, intravenous hyperalimentation and hyperbaric oxygen therapy. Pneumoperitoneum and PCI had disappeared after 8 courses of hyperbaric oxygen therapy and her GI symptoms had been well controled by intravenous hyper alimentation. Thereafter, she has been on intermittent parenteral nutrition through subcutaneous port inplantation. During the courses of this treatment, she developed an episode of Wernicke-Kolsakoff (W-K) syndrome which was considered to associate with malabsorption syndrome. The W-K syndrome had recovered by intravenous administration of vitamin B1.

[A case of systemic lupus erythematosus with various central and peripheral neurological disorders presenting with motor paralytic bladder as a major manifestation]

Myelopathy is a rare central nervous system manifestation in systemic lupus erythematosus (SLE). We present a case of SLE, who developed motor paralytic bladder and various other neurological abnormalities. A 29-year-old female with SLE was admitted to our hospital because of complete dysuria without any troubles on defecation. Accelerated hypertension had been noticed 2 weeks before the admission. Physical examinations revealed that she had muscle weakness in right brachial biceps, bilateral carpal extensor and flexor, and flexor muscles of bilateral lower extremities. Slight sensory disturbance was present on her soles. Bilateral Chaddok and Babinski's signs were positive. Electromyographic studies including nerve conduction velocities of her limbs were normal, however, neurogenic discharges were observed in anal sphincter muscles. Cystometry demonstrated atonic bladder, but any pathological findings such as lupus cystitis and interstitial cystitis were not observed in the biopsied specimens from her bladder. Antibodies to single-stranded DNA, U1 RNP, Sm and SS-A/Ro were positive in her serum, and lupus anticoagulant and anticardiolipin antibodies (IgG) were also detected. In her cerebral spinal fluid (CSF), elevated protein level and albuminocytologic dissociation were recognized, while glucose level was low. Magnetic resonance imaging (MRI) study detected high signal intensities in the inner part of medulla oblongata and in the spinal cord at second lumbar spine level. After two courses of methyl-prednisolone pulse therapy, the patient's neurological symptoms including dysuria had completely recovered and abnormal findings previously observed on MRI had also disappeared. After 7 months of the episode, she became normotensive. The proteins and glucose levels in her CSF had gradually returned to normal. Among patients with SLE, correlations of antiphospholipid antibodies with myelitis/myelopathy or accelerated hypertension have been reported. Therefore, possible roles of antiphospholipid antibodies were considered in the pathogenesis of neurologic abnormalities observed in our patient. In addition, low glucose level in CSF might be a good indicator for the diagnosis of lupus-associated myelopathy.

Abnormal expression of apoptosis-related antigens, Fas and bcl-2, on circulating T-lymphocyte subsets in primary Sjögren's syndrome

OBJECTIVE

To clarify the pathological role of the apoptosis-related molecules expressed on peripheral blood (PB) lymphocyte subsets in primary Sjögren's syndrome (SS).

METHODS

The levels of apoptosis-regulating proteins, Fas and bcl-2, were determined in the PB lymphocyte subsets from 21 patients with SS and 14 healthy controls by 2-color flow cytometry.

RESULTS

In the PB from SS patients, lymphocytopenia, especially CD4+ cell-lymphocytopenia, was prominent. As observed in previous studies, the percentages of CD4+ CD45RA+ cells were lower in the SS patients than in the controls, while activated (DR+) cells were increased in CD4+ cells from the patients. Fas+ cells were also increased in the patients' CD4+ cells and CD8+ cells, but not in their B cells or natural killer cells. Furthermore, we observed several positive correlations among the percentages of activated cells (DR+ cells or CD45RA-cells) and Fas+ cells recognized in the CD4+ and/or CD8+ cells from the patients. On the other hand, intra-cellular bcl-2 proteins measured as mean fluorescence intensity were significantly diminished in the CD4+ cells, CD8+ cells, CD19+ cells, CD45RO+ cells and Fas+ cells from 14 SS patients compared with 12 healthy controls. In addition, the numbers and/or percentages of CD4+ cells and Fas+ cells positively correlated with their expression of bcl-2 in SS patients.

CONCLUSION

The abnormal balance between Fas and bcl-2 expression detected in the PB lymphocyte subsets from SS patients relates, at least partially, to the lymphocytopenia observed in the patients.

[Pulmonary functions in patients with progressive systemic sclerosis]

We studied the correlations of pulmonary function with clinical symptoms or autoantibody profiles in patients with progressive systemic sclerosis (PSS). Percent vital capacity (% VC) was low in 40% of PSS patients and percent diffusing capacity of carbon oxide (% DLCO) was decreased in 76% of the patients. Eighty-five percent of the patients had abnormal pulmonary functions. The % DLCO was significantly low in male patients compared with female patients. The arterial partial pressure of oxygen (PO2) in patients with esophageal hypomotility was significantly lower than those without esophageal hypomotility. PSS with Sjögren's syndrome (SS) showed a significant decrease of the % VC (p < 0.05) and PO2 (p < 0.05), and of lung fibrosis was frequent in the patients compared with those without SS. Pulmonary fibrosis was recognized in 63% of PSS patients and was more frequent in the patients with anti-Scl-70 antibody than those without the antibody. The annual decrease of VC was 62 ml in PSS patients, and that of DLco was 0.12 ml/min/mmHg. The annual decrease of VC was more prominent in the PSS patients with severe pulmonary fibrosis or anti-Scl-70 antibody. The decrease of VC, however, was mild in the patients with anti-RNP antibody compared with those without the antibody.

Combinations of HLA-DPB1 and HLA-DQB1 alleles determine susceptibility to early-onset myasthenia gravis in Japan

HLA class II alleles in the DQA1, DQB1, DRB1, and DPB1 genes were investigated in Japanese patients with myasthenia gravis (MG) by digestion of polymerase chain reaction amplified DNAs with allele specific restriction endonucleases (PCR-RFLP). A significantly higher frequency of DQB1*03, which includes *0301, *0302, *0303 and determines the serological DQ3 specificity, was observed in female patients less than 30 years in age at onset of disease compared with healthy controls (90.5 vs. 53.2%). This study also confirms the high incidence of DPB1*0201 in early-onset female patients compared to the controls (85.7 vs. 40.3%). Moreover, 81.0% of the early onset female patients were found to carry both DQB1*03 and DPB1*0201, compared to 17.7% of the controls. Since DQB1*03 and DPB1*0201 are not in linkage disequilibrium, both these alleles are supposed to be synergistically involved in disease development in early-onset female MG. In contrast, no obvious association of HLA-DQA1, DQB1, DRB1 and DPB1 alleles with either late-onset patients or patients with thymoma was observed. Clearly, the genetic background of Japanese females with early onset MG is different from that of other patients with MG.

Thrombomodulin levels in the plasma and joint fluid from patients with rheumatoid arthritis

The hemostatic mechanism is thought to contribute to the inflammatory process of rheumatoid arthritis (RA). Thrombomodulin (TM), an inhibitor of blood coagulation, is synthesized by various cells which are recognized in the inflammatory lesions of RA. To elucidate a possible relation of TM with the process of RA, therefore, we measured soluble forms of TM in the plasma and joint fluid (JF) from RA patients by a recently developed sandwich enzyme immunoassay using monoclonal antibodies. TM levels in the plasma and JF were not significantly elevated in RA patients, although TM levels in plasma were positively correlated with those in JF. The plasma TM levels were related to renal functions (serum creatinine levels), but the levels showed no connection with systemic inflammatory indices of RA such as erythrocyte sedimentation rates, serum C-reactive protein levels and Lansbury's activity index. In the JF, TM levels were not correlated with the numbers of neutrophils or monocytes/macrophages associated with articular inflammations. Our results indicate that TM levels in the plasma and JF do not reflect systemic and articular inflammations of RA, and suggest that TM molecules in JF are mainly recruited from circulating TM.

Comparison of antinuclear antibody and other immunohematological profiles among primary Sjögren's syndrome, secondary Sjögren's syndrome associated with rheumatoid arthritis or systemic lupus erythematosus, and corresponding systemic disease

Sjögren's syndrome (SS) is currently classified into two groups (primary and secondary), because of differences in the disease in the two groups. We determined antinuclear antibody and other immunohematological parameters by using newer, more sensitive serologic methods on patients with primary SS, or secondary SS associated with rheumatoid arthritis (RA) or systemic lupus erythematosus (SLE), and patients with just the systemic disease free of SS. This study defined both distinctive and common features between primary SS and each systemic disease: High titers of fluorescent antinuclear antibodies (FANAs), anti-SS-A/SS-B antibodies, and rheumatoid factors (RFs), as well as leukocytopenia were considered the main features of primary SS. Elevated levels of RFs and C-reactive protein were prominent in RA patients. In contrast, high titers of FANAs and anti-single stranded or anti-double stranded DNA antibodies, positive anti-ribonucleoprotein or Sm antibodies, leukocytopenia, and hypocomplementemia were characteristic for SLE. Furthermore, patients with secondary SS plus RA or SLE were found to have mixed features of SS and the associated systemic disease. The results strongly suggest that patients with secondary SS have two separate diseases, SS and the associated systemic disease.

[Renal and cerebral infarctions in a patient with systemic lupus erythematosus without antiphospholipid antibodies]

Renal artery infarction is a very rare complication in patients with systemic lupus erythematosus (SLE), even in patients with antiphospholipid syndrome which often causes thromboembolism: Renal infarctions have only been reported in 4 SLE patients with antiphospholipid antibodies (aPL). Here we report a case of SLE without aPL who accompanied by renal and cerebral infarctions. A 42-year old Japanese woman with 8 year history of SLE manifested by arthralgia, central nervous system symptoms, positive-antinuclear and anti-DNA antibodies was admitted to our hospital for the treatment of progressive lupus nephritis. Physical examinations revealed hypertension (130-160/80-110 mmHg) without pitting pretibial edema. Laboratory evaluations showed proteinuria (3.7 g/day), normal serum creatinine level (0.9 mg/dl), low serum albumin level (2.3 g/dl) and high cholesterol level (317 mg/dl). Old cerebral infarctions were recognized by magnetic resonance imaging. However, hematological and immunological studies revealed that this case has neither a prolonged activated partial thromboplastin time, lupus anticoagulant nor anticardiolipin antibodies. Prednisolone was increased from 30 mg/every other day to 30 mg/day, and oral azathioprine, 50 mg/day, was started for the treatment of lupus nephritis. On the 11th day, she suddenly complained severe abdominal pain, which gradually localized on the right side. Computed tomography of the kidney suggested right renal infarctions, and arteriography of right renal artery confirmed both an obstruction of the ventral branch and a narrowing of the dorsal branch of right renal artery. No intra-cardiac thrombus was demonstrated by echocardiography. Following to the treatment with fibrinolytic agent and anticoagulant, her symptoms have improved.(ABSTRACT TRUNCATED AT 250 WORDS)

[Soluble IL-2 receptor levels in rheumatic diseases]

We measured soluble interleukin-2 receptors (sIL-2R) in plasma and/or joint fluid (JF) from patients with rheumatoid arthritis (RA: 16 patients), Sjögren's syndrome (SS: 24 patients) and Behçet's disease (BD: 23 patients). Plasma sIL-2R levels were significantly higher in RA patients (956 +/- 994 U/ml, p < 0.01) and SS patients (1025 +/- 1112 U/ml, p < 0.01) than 20 healthy subjects (338 +/- 159 U/ml), but not significantly increased in BD patients (408 +/- 329 U/ml). sIL-2R levels higher than the mean of healthy subjects +2 standard deviations were observed in 3 BD patients (13.0%), 7 RA patients (43.8%) and 10 SS patients (41.7%). sIL-2R levels positively correlated with erythrocyte sedimentation rates and C-reactive protein levels in RA patients, or IgM levels in SS. There was no significant correlation between plasma sIL-2R levels and disease activity, clinical symptoms, or other laboratory parameters in BD patients. However, sIL-2R concentrations in the JF from 4 BD patients (1644 +/- 198 U/ml: p < 0.05) or 16 RA patients (3946 +/- 5424 U/ml: p < 0.01) were significantly higher than corresponding plasma sIL-2R concentrations. Above results indicate that lymphocytes are being activated in patients with RA or SS and in the inflammatory lesions of BD patients, while the whole immunologic activation are relatively lower in BD than RA and SS.

HLA-DPB1 allele associates with early-onset myasthenia gravis in Japan

We investigated the HLA-DPB1 allele in 43 unrelated Japanese patients with myasthenia gravis (MG) using digestion of polymerase chain reaction (PCR)-amplified DNA with allele-specific restriction endonucleases (PCR-RFLP method). We found a higher frequency of the DPB1*0201 allele in female patients whose ages at onset were less than 30 years (83.3%) than in controls (35.6%). The study also included serologic typing of HLA-A, -B, -C, and -DR antigens in 72 patients with MG, and confirmed previous results demonstrating a strong association of HLA-DR53 with early onset of MG in females. These results indicate that both the DPB1*0201 allele and DR53 play key roles in the disease process of MG in early-onset females, and that the genetic background of Japanese females with early-onset MG is different from that of other patients with MG.

TaqI polymorphism of the epidermal growth factor receptor gene in Caucasoids and Japanese

Genetic polymorphism of the epidermal growth factor (EGF) receptor gene following Taq I digestion was compared between samples of genomic DNA from glioma-derived cell lines and Caucasoid and Japanese subjects. The same three allelic forms of the EGF receptor gene, marked by variant fragments of approximately 12.8, 11.6 and 10.8 kb in size were common to both ethnic groups and the 12.8- and 11.6-kb fragments were found in the glioma-derived cell line DNA. A further variant fragment of approximately 13.8 kb in size has been shown to be thus far restricted to the Japanese. These data suggest that most allelic forms of the EGF receptor gene recognized by Taq I restriction fragment length polymorphism have a long evolutionary history and probably do not predispose to development of malignant glioma.

Lack of deletion of complement C4 and steroid 21-hydroxylase genes in Japanese patients with primary Sjögren's syndrome

A null allele at C4A (C4AQO) is associated with primary Sjögren's syndrome (SS) in Japanese. Since a deletion of the C4A and CyP21A genes is reported to account for C4AQO in patients with systemic lupus erythematosus (SLE) in Caucasians, we studied the restriction fragment length polymorphism (RFLP) of genomic DNA to determine whether similar deletions of the C4A and CyP21A genes occur in Japanese patients with SS. Patients with C4AQO did not show the extensive deletion of C4A and CyP21A, which would be recognized by the appearance of 8.5 kb/HindIII and 6.4 kb/TaqI fragments hybridizing with a C4 probe. It is yet to be shown whether the lack of expression of C4A genes in Japanese patients with primary SS is due to point mutations, or to small deletions or insertions that were not detected by the RFLP approach.

Serum apolipoprotein H levels in systemic lupus erythematosus are not influenced by antiphospholipid antibodies

Anticardiolipin antibodies (aCL) were recently discovered to recognize a complex consisting of phospholipids and apolipoprotein H (apo H). In this study, we determined the serum apo H levels in 36 systemic lupus erythematosus (SLE) patients with or without antiphospholipid antibodies (aPL), including aCL and lupus anticoagulants, to clarify the possible effects of aPL on apo H levels in vivo. The apo H levels were low in SLE patients as compared with 22 healthy controls. However, no associations were found between apo H levels and circulating aPL or clinical features of the antiphospholipid antibody syndrome. A secondary hyperlipidemic state, which probably related to lupus nephritis (proteinuria) and/or prednisolone treatment, increased apo H levels in SLE patients.

Serum thrombomodulin and anticardiolipin antibodies in patients with systemic lupus erythematosus

Since thrombomodulin (TM) is a specific cell surface glycoprotein for vascular endothelial cells, serum TM (s-TM) might be a useful marker of endothelial cell damage. Antiphospholipid antibodies (aPL) frequently detected in systemic lupus erythematosus (SLE) have been associated with vascular occlusive diseases. Therefore we measured the s-TM in 60 patients with SLE, in 23 patients with other diseases including aPL (disease control group) and in 26 healthy subjects, by means of an enzyme immunoassay using monoclonal antibodies to human TM. A significant positive correlation was found between s-TM and serum creatinine levels in SLE patients (r = 0.813, p less than 0.001). When the s-TM level was divided by the serum creatinine level (TM/Cr) to exclude the effect of renal clearance, the TM/Cr ratios were significantly increased in SLE patients with active lupus nephritis (LN) compared to those without LN (p less than 0.05). The ratios did not correlate with the presence of aPL or antiphospholipid antibody syndrome (APLS) in SLE patients or in the disease control group, although a weak correlation between the TM/Cr ratios and IgG-anticardiolipin antibody titers was found in the SLE patients without LN (r = 0.449, p less than 0.01). The present results suggest that elevated TM/Cr ratios reflect renal and possibly extra-renal endothelial cell damage in SLE patients with active LN, but that s-TM levels do not associate with the presence of aPL or a history of APLS.

Sjögren's syndrome and pregnancy

We analyzed 117 histories of pregnancy obtained from 40 female patients with Sjögren's syndrome (SS) including 13 patients with primary SS and 27 patients with secondary SS. The frequency of spontaneous abortions did not differ in the 40 patients and those with primary SS compared with 129 healthy women. However, both spontaneous abortions and premature deliveries were significantly more frequent in the SS patients with systemic lupus erythematosus (SLE). Anti-SS-A and anti-SS-B antibodies were not associated with the outcomes of pregnancy although spontaneous abortions were more frequent in secondary SS patients with false positive serological tests for syphilis, anti-erythrocyte antibodies, thrombocytopenia or prolonged activated partial thromboplastin time. Neither congenital anomalies nor connective tissue disease was found in the 77 neonates of the patients. We concluded that SS does not influence the outcome of pregnancy except in patients with SLE or those with serological and hematological abnormalities related to lupus anticoagulants or antiphospholipid antibodies.

HLA class II antigens and DNA restriction fragment length polymorphism in myasthenia gravis in Japan

Human leukocyte phenotypes and genes in the HLA class II regions were studied in 46 Japanese patients with myasthenia gravis. When the HLA phenotypes of the patients with myasthenia gravis were compared with the controls, an increased frequency of HLA-DRw53 was observed in females less than 30 years of age. The genomic DNAs of the HLA-DRw53-positive patients and DRw53-positive controls were analyzed by using four complementary DNA probes for HLA class II genes. With DQB complementary DNA as the probe, a higher incidence of the 6.5-kb or 8.2-kb BamHI fragment was observed in the patients (76.0%) compared with the controls (19.0%). In contrast, no significant difference was observed between patients and controls when complementary DNAs for DRB, DQA, and DPB were used as probes. These results indicate that the genetic background of Japanese females with early-onset myasthenia gravis is different from other patients with myasthenia gravis, and that DQB genes can greatly influence the onset of myasthenia gravis.

Association of the complement allele C4AQ0 with primary Sjögren's syndrome in Japanese patients

We studied allotypes of the fourth component of complement (C4) and factor B in 76 patients with Sjögren's syndrome (SS) and in 63 normal subjects. C4A-null (C4AQ0) was found in 10 of 28 patients who had primary SS, compared with 1 of 63 control subjects (P less than 0.005). In contrast, no significant difference in the frequency of any C4 allotype was observed between patients with secondary SS and control subjects. An association of HLA-DRw53 with primary SS in Japanese patients has been reported. Since there is no linkage disequilibrium between DRw53 and C4AQ0, it is possible that at least 2 genes in the major histocompatibility complex may determine susceptibility to the development of primary SS in the Japanese population.

Reactivities of antiphospholipid antibodies to blood cells and their effects on platelet aggregations in vitro

To clarify the pathogenesis of antiphospholipid antibody (aPL) syndrome, the reactivities of anticardiolipin antibodies (aCL) in sera of patients with systemic lupus erythematosus (SLE) or other diseases to fresh, activated or destroyed blood cells were examined by the inhibition assay using an enzyme-linked immunosorbent assay. In addition, the effects of lupus anticoagulants (LA) in the patients' plasma and of immune complexes formed between LA and PL antigens on platelet aggregations were also determined. The IgG-aCL activity of patients' sera was markedly inhibited by pre-incubation with freeze-thawed blood cells, including erythrocytes (RBC), mononuclear cells (MNC) and platelets, but not fresh platelets or RBC. The aCL activity was slightly inhibited by fresh MNC, and was definitely inhibited by thrombin-activated platelets and polymorphonuclear cells (PMN) stimulated with phorbol 12-myristate 13-acetate (PMA). However, the activity was not inhibited by platelets stimulated with adenosine 5'-diphosphate (ADP; 10 microM). Twenty-two LA positive plasma and 17 LA negative plasma from patients similarly enhanced the aggregation of platelets which were obtained from healthy adults and stimulated with low concentrations of ADP (1 or 2 microM). However, such enhancement of platelet aggregation was not observed when high concentrations of ADP (5 microM) or collagen (2 micrograms/ml) were used as stimulators. In four of the 16 LA positive plasma examined, the mixture of plasma and phospholipid reagent for activated partial thromboplastin time induced platelet aggregations without the other stimulations, but the plasmas themselves did not induce such a reaction. The above results indicate that the aPL from patients do not react with intact blood cells in vitro, but they can react with activated or destroyed blood cells.(ABSTRACT TRUNCATED AT 250 WORDS)

[Regulation of coagulo-fibrinolytic activity and lupus anticoagulants in systemic lupus erythematosus]

We determined the following coagulo-fibrinolytic activities in 24 patients with systemic lupus erythematosus (SLE) and 20 healthy adults: prothrombin time (PT), activated partial thromboplastin time (A-PTT), factor VIII: coagulant activity), von Willebrand factor antigen (vWF: Ag), antithrombin-III (AT-III), plasminogen (PLG), alpha 2 plasmin inhibitor (alpha 2 PI), alpha 2-plasmin inhibitor-plasmin complex (PIC), protein C (PC: activity and antigen concentration), and protein S (PS: total PS and free PS). PLG, AT-III, PC antigen concentration and total PS were significantly decreased in ten female controls as compared with ten male controls. Therefore, we used the ten healthy females as controls and excluded two male SLE patients in the analysis of the correlations of coagulo-fibrinolytic activities with lupus anticoagulant (LA), clinical and laboratory features in 22 female patients with SLE. In the SLE patients, PT was significantly shortened, while A-PTT was prolonged. PLG, PC activity and antigen, and total PS were significantly increased, and free PS levels were decreased in SLE. The shortened PT and decreased free PS suggest hypercoagulable states in SLE patients. A significant prolongation of A-PTT and a decrease of F VIII activity were observed in the six LA-positive SLE patients, and the results were considered as known effects of LA. Furthermore, vWF: Ag, AT-III and PC antigen levels were significantly increased in the LA-positive patients as compared with LA-negative patients. These changes indicate both vascular endothelial cell damages and a compensatory increase in coagulation inhibitors in the LA-positive patients.

Expression of MHC class II antigens and other T cell activation antigens on T cells and salivary duct epithelial cells in the salivary gland of cases of Sjögren's syndrome

We studied infiltrating T cells and salivary duct epithelial cells in the sublingual glands of 10 patients with primary Sjögren's syndrome (SS) using monoclonal antibodies (MoAb) to T cell subsets (OKT-series), natural killer cells (Leu7) and activation antigens of T cells such as OKT10, OKT9, interleukin 2 receptor (anti-Tac antibody) and major histocompatibility complex (MHC) class II antigens (anti-DR and anti-DQ antigens). DR antigens were identified on salivary duct epithelial cells, suggesting that the cells might function as antigen-presenting cells (APC). Among the salivary duct epithelial cells, OKT8+ cells, which are known to be suppressor/cytotoxic cells, were found in 9 out of 10 patients. Three types of mononuclear cell infiltrations were also evaluated separately: (1) periductal foci, (2) periacinal foci and (3) lymph follicles. We found that the majority of the infiltrating cells in the central portion of the periductal foci were activated T cells (OKT3+, OKT4+, OKIa-1+, DR+ and DQ+), but OKT9, OKT10 and Tac antigens were rarely found in this portion. However, most of the infiltrating cells in the peripheral portion of the periductal foci were OKT10+, and some of them were also positive for OKT9 antigen (transferrin receptor). The results indicated that the T cells in the peripheral portion of the periductal foci are at an early or intermediate phase of activation, whereas the T cells around the salivary ducts are at a later phase. Infiltrating cells in the periacinal foci resembled the cells on the peripheral portion of the periductal foci. Cells within lymph follicles were mainly B cells although scattered OKT4+ or OKT8+ cells were also present.

Lupus cystitis and performation of the small bowel in a patient with systemic lupus erythematosus and overlapping syndrome

We describe a patient with systemic lupus erythematosus (SLE) and overlapping syndrome who had repeated gastrointestinal (GI) symptoms such as nausea, vomiting and malabsorption. With a subacute process, she developed paralytic ileus and contracted bladder, and died of perforation of the ileum. When 13 reported cases with lupus cystitis were reviewed, an extremely strong correlation between GI and urinary tract symptoms was observed, indicating the presence of a unique subgroup of SLE.

[A case of lupus nephritis resistant to steroid pulse therapy markedly improved by bolus intravenous cyclophosphamide therapy]

Bolus intravenous cyclophosphamide therapy (IVCY) has recently been the subject of considerable attention because it is occasionally very effective in the treatment of severe lupus nephritis. However only a few reports on this form of therapy have been noted in Japan. Described here is a patient with lupus nephritis accompanied by multi-organ disorders resistant to various therapies including methylprednisolone pulse therapy which responded dramatically to IVCY. The patient, a 37-year-old woman with a history of systemic lupus erythematosus (SLE) starting in 1984, was admitted to our hospital with increasing generalized edema and malaise in January 1987. Evaluation revealed hypoalbuminemia, hypoxemia, ascites, hypocomplementemia and leukopenia. The patient was treated with high-dose oral prednisolone, however the lupus nephritis deteriorated and a high urinary protein level, massive ascites, and pericardial and pleural effusions were noted. Involvement of the central nervous system (CNS) was also observed. Subsequently, she was treated with intravenous methylprednisolone pulse therapy and low-dose oral cyclophosphamide. As her disease was refractory to these treatments IVCY was initiated in May 1987, at a dose 0.5-0.8 g/m2. A total of 3 doses were given, and treatment was discontinued in October 1987 because of marked clinical improvement. After the final IVCY treatment she was discharged, and her subsequent clinical course over a year with a maintenance dose of prednisolone has been uneventful. Thus, IVCY seemed to be useful in the treatment of severe lupus nephritis. More rigorous comparisons of IVCY with other therapies are necessary.

Anticardiolipin antibodies by an enzyme-linked immunosorbent assay: fundamental studies on the conditions for antigen-application and specificity of the assay

We have established an enzyme-linked immunosorbent assay (ELISA) for anticardiolipin antibodies (aCL) using standard sera obtained from the Rayne Institute, St. Thomas' Hospital (London, U.K.). In this study, we compared several fundamental requirements for the assay with the standard assay as a reference, such as conditions for antigen application and test samples using our patients' samples. In addition, the specificity of our assay and cross-reactivities of aCL were also evaluated. In the standard assay, the concentration of antigen was optimal in the range of 30-100 micrograms/ml. The antigen-coating temperature was optimal at 4 degrees C for 16 hours. The method based on rapid evaporation of CL-ethanol solution can be used instead of the standard method. On the other hand, there was no significant difference in the results between physical conditions of the antigen (CL-ethanol solution vs. CL-micelles), between washing solutions (saline vs. PBS containing 0.05% Tween-20) and between test samples (sera vs. plasma). The aCL activity in our patients' samples was almost completely inhibited by pre-incubation of sera with either CL or phospholipid reagent for activated partial thromboplastin time (APTT). Interestingly, the aCL activity of the lupus anticoagulant was negative, but aCL-positive samples were also absorbed by the reagent for APTT. No inhibition of the aCL activity, however, was observed when patients' sera were preincubated with ss-DNA.

Lymphocyte subsets of the peripheral blood in Sjögren's syndrome and rheumatoid arthritis

Lymphocyte subsets were determined in the peripheral blood from twenty-three patients with primary Sjögren's syndrome (SS) and sixteen patients with clinically active rheumatoid arthritis (RA) by two-color flowcytometry using various monoclonal antibodies. In both diseases, T-cells (CD3+), suppressor/cytotoxic cells (CD8+) and their cytotoxic subset (CD8+CD11-) were decreased, as compared with thirty-one healthy controls. B-cells (CD 21+ and CD 3-DR+) and activated T-cells (CD 3+DR+) were increased in SS patients. Helper T-cells (CD 4+Leu8-), suppressor-inducer T-cells (CD4+Leu8+), suppressor T-cells (CD8+Leu 15+) and three natural killer (NK) cell subsets determined by both CD16 and Leu7 antibodies did not differ between controls and SS or RA, although Leu7+NK cells were significantly increased in SS patients. In addition, we found that the treatment with low-dose prednisolone decreased B-cells and suppressor-inducer T cells, and increased suppressor T-cells, cytotoxic T-cells and Leu7+NK cells. The results indicate similar changes in the proportion of lymphocyte subsets and suggest immunologically activated and deficient conditions in both diseases. Immunomodulating effects of the treatment with low-dose prednisolone on some of the lymphocyte subsets in patients with these diseases were also supported by the study.

Clinical trial of ambroxol (Mucosolvan) in Sjögren's syndrome

A clinical trial is described in which twelve patients with Sjögren's Syndrome (SS) were given a dose of 135 mg ambroxol (Mucosolvan) daily for eight weeks. Nine of the patients completed the trial. Three patients dropped out because they developed side effects (generalized rashes in two patients and stomatitis in one). The side effects, however, were mild and cleared off after cessation of treatment. Ambroxol improved sicca symptoms, especially ocular symptoms, in the SS patients, although lacrimal and salivary gland functions measured by Schirmer test or gum test were not changed. Furthermore, the treatment did not alter any chemical findings determined in the stimulated tear and saliva. Our results suggest that ambroxol is useful for the management of sicca symptoms in some patients with SS.

An autopsied case of systemic lupus erythematosus with pulmonary hypertension--a case report

The authors report an autopsied case of systemic lupus erythematosus (SLE) with pulmonary hypertension. The patient was a forty-five-year-old female who had been troubled by obstinate Raynaud's phenomenon for ten years before the definite diagnosis of pulmonary hypertension was made. Microscopic examination of the pulmonary vasculature yielded findings consistent with plexogenic pulmonary arteriopathy. However, the deposition of immune complexes in the pulmonary vascular endothelium was not detected by enzyme antibody study. This case suggests, therefore, that "pulmonary Raynaud's phenomenon" is a possible pathogenesis of pulmonary hypertension in patients with SLE.

Polymorphism of HLA-DR beta chains in DR4, -7, and -9 haplotypes: implications for the mechanisms of allelic variation

We have isolated and sequenced cDNA clones corresponding to the DR beta 1 and DR beta 2 loci from two homozygous B-cell lines typed as DR7 (Burkhart) and DR9 (ISK). These nucleotide sequences were compared to beta 1 and beta 2 chains of other DR haplotypes. The first-domain sequences of beta 2 chains are identical in DR4 and DR7 haplotypes. In addition, there is strong sequence homology within the 3' untranslated regions of beta 1 genes from DR4, -7, and -9 haplotypes, thus confirming the close evolutionary relationship among these three haplotypes. In contrast, the first-domain sequences of beta 1 molecules from these haplotypes are very different from each other and do not reflect the DR4, -7, -9 family relationship. Two explanations for the differences in degree of diversity between beta 1 and beta 2 chains are suggested. The differences may be a consequence of selection pressures; this implies functional differences for products of the beta 1 and beta 2 loci. Alternatively, closely linked segments of the human class II region may differ in their underlying rates of variation, independent of selection pressures, and this may in part account for the extraordinary diversity found in the beta 1 first domain.

Association between HLA and Sjögren's syndrome in Japanese patients

Japanese patients with primary Sjögren's syndrome (SS), patients with SS and rheumatoid arthritis (SS-RA), and patients with SS and connective tissue disease without RA (nonrheumatoid connective tissue disease [SS-CTD]) were typed for HLA antigens. Patients with primary SS and those with SS-RA had higher frequencies of DRw53 than did those who had SS-CTD; however, the group with SS-CTD showed a negative correlation with DRw52. These data indicate that Japanese and white patients with SS have different HLA specificities, and that genetic factors involved in the development of SS-CTD might be different from those in primary SS and SS-RA.

Familial Sjögren's syndrome in the Japanese: immunogenetic and serological studies

Serological abnormalities and HLA haplotypes were studied in a Japanese family of two patients with Sjögren's syndrome (SS) associated with other autoimmune diseases. In contrast to the reports in the U.S.A. and Europe, we found a significant excess of HLA-DRw53 antigen in the family members. Two family members, mother and niece of the probands, had suffered from other connective tissue diseases. Although none of the siblings of probands had manifestations of connective tissue diseases, two siblings had several autoantibodies. No consistent segregation, however, was found between the HLA haplotypes and the serological abnormalities in the relatives. Therefore, HLA alone can not explain the familial clustering of autoimmune diseases including SS and of autoantibodies.

Nucleotide sequence of an HLA-DQ alpha chain derived from a DRw9 cell line: genetic and evolutionary implications

Three families of human Ia molecules, DP, DQ, and DR, have previously been defined. A cDNA clone, pDSH-9.1, encoding the alpha chain of a DQ molecule derived from an HLA-DRw9 homozygous cell line has been isolated and sequenced. Comparison of the nucleotide and predicted protein sequence to those of other DQ alpha subunits reveals that DQ alpha subunits derived from DR4, -7, and -9 cells are very similar to each other but quite different from a DQ alpha subunit derived from a DRw6 cell line. These studies suggest that certain Ia haplotypes have a common evolutionary history. Furthermore, in the context of current serologic and biochemical knowledge, they suggest that the gene encoding the DQ alpha subunit is in strong linkage disequilibrium with the DR locus.

HLA-DS molecules and their relation to supertypic specificities

We have analyzed the structures of HLA-DS molecules from DR1, 2, 3, 4, 5, and 7 cell lines by two-dimensional gel electrophoresis and examined the relationship of HLA-DS molecules to those expressing the supertypic specificities MT1, MB3, and MT3. These studies have allowed us to conclude that the HLA-DS locus is as polymorphic as HLA-DR and that the MT1 and MB3 supertypic specificities reside on DS molecules. Furthermore, MT1 molecules from DR1, DR2, and DRw6 cell lines are structurally different as are MB3 molecules from DR4 and DR5 cell lines. In addition, studies using two MT3 specific reagents, a monoclonal antibody, 109d6, and an alloantiserum, Hon, suggest that MT3 is a cross-reactive determinant present on products of two different loci: a DS4 molecule and a DR7-like molecule.

Serologic dissection of HLA-D specificities by the use of monoclonal antibodies

To study the gene products of the HLA complex, we produced two monoclonal antibodies, termed HU-18 and HU-23. They were active in complement-dependent cytotoxicity and detected B-cell alloantigens encoded by a locus (or loci) linked to HLA. When three types of HLA-DR4 homozygous B-cell lines with different HLA-D specificities were tested for reactivity with HU-18 and HU-23, they displayed distinct reaction patterns depending on the HLA-D specificities they possessed: EBV-Wa (HLA-DYT homozygous), negative for both HU-18 and HU-23; KT2 and KOB (HLA-DKT2 homozygous), positive only for HU-18; and ER (HLA-Dw4 homozygous), positive for both. These differential reaction patterns were further confirmed by testing against a panel of 17 HLA-DR4-positive peripheral blood lymphocytes with known HLA-D specificities. Thus, these monoclonal antibodies allow us to identify HLA-DYT, HLA-DKT2, and HLA-Dw4 solely by serologic methods. This is the first clearcut serologic identification of these three HLA-DR4-associated HLA-D specificities, which have been indistinguishable by conventional serology and identified only by cellular techniques. It is hoped that immunochemical investigations using HU-18 and HU-23 will advance our understanding of the HLA-D region on a molecular level.

The role of three distinct Ia-like antigen molecules in human T cell proliferative responses: effect of monoclonal anti-Ia-like antibodies

Murine monoclonal antibodies (MoAb) to three distinct Ia-like molecules were studied for their inhibitory effects on antigen- and alloantigen-induced T cell proliferations. The MoAb were classified into three groups according to the molecules they recognized. Both the group I MoAb reacting with DR molecules and the group III MoAb were capable of inhibiting T cell proliferative responses to PPD- and HSV-Ag-pulsed APC, autologous B-LCL, and alloantigens. On th other hand, the group II MoAb, which reacted with a determinant on the molecule carrying MB1 determinants, was only capable of inhibiting T cell responses to alloantigens. These results suggest that the structure of the molecules correlates with the functional repertoire of the human Ia-like antigens.

The role of three distinct Ia-like antigen molecules in human T cell proliferative responses: effect of monoclonal anti-Ia-like antibodies

Murine monoclonal antibodies (MoAb) to three distinct Ia-like molecules were studied for their inhibitory effects on antigen- and alloantigen-induced T cell proliferations. The MoAb were classified into three groups according to the molecules they recognized. Both the group I MoAb reacting with DR molecules and the group III MoAb were capable of inhibiting T cell proliferative responses to PPD- and HSV-Ag-pulsed APC, autologous B-LCL, and alloantigens. On th other hand, the group II MoAb, which reacted with a determinant on the molecule carrying MB1 determinants, was only capable of inhibiting T cell responses to alloantigens. These results suggest that the structure of the molecules correlates with the functional repertoire of the human Ia-like antigens.

Association between the MB system and asthma in the Japanese

Twenty-three unrelated Japanese patients with asthma who showed a high total serum IgE level, a strong skin test response to Dermatophagoides farinae, and a high score on a radioallergosorbent test (RAST) using Dermatophagoides farinae were typed for HLA-A locus, -B locus, and -D region antigens. No significant difference in the frequencies of HLA-A, -B, and -DR antigens were observed between the asthma patients and the healthy controls. A significant difference in the frequency of MB3', however, was found between the asthma patients and the healthy controls (corrected p = 0.04, relative risk = 18.5).

HLA-linked susceptibility gene of Takayasu Disease

The HLA-A, B, DR and MB antigens were investigated in patients suffering from Takayasu disease (Aortitis syndrome). Out of twenty-one HLA-A and B antigens tested, only HLA-Bw52 was significantly deviated (30147, PF = 63.8%, RR = 7.8) from the controls (14/76, PF = 18.4%). Since in the Japanese, HLA-Bw52 is in positive linkage disequilibria with HLA-DR2 and MB1, the association of the DR2 and MB1 antigens with Takayasu disease was studied. The HLA-DR2 antigen was significantly increased (23/30, PF = 76.7%,, RR = 6.0) in patients compared with the control (18/51, PF = 35.3%). Moreover, an almost perfect association of MBI (29/30, PF = 96.7%, RR = 12.6) with Takayasu disease was demonstrated. This finding supports the hypothesis that the genes in the HLA-D region play a major role in determining the susceptibility to Takayasu disease.

Host factors and susceptibility to rubella virus infection: the association of HLA antigens

To examine the role of host-dependent factors to natural rubella infection, the positive rates of HAI antibody according to HLA-A and -B antigens were studied in 93 children, aged 9 to 10, who were exposed only to a recent epidemic (single-exposure group), and in 199 adult females, aged 18 to 23, who were exposed also to a former epidemic (dual-exposure group). Furthermore, the phenotype frequencies of HLA antigens were investigated in seronegative subjects in both groups, as well as in 58 adult female vaccinees, in comparison with those of the Japanese population. The seropositive rates by the HLA antigens, 38.7% and 73.4%, respectively, in each exposure group were found in subjects having some HLA antigens. Several of these candidate HLA antigens varied in phenotype frequencies in seronegative subjects of all three groups from those of the average Japanese. Although a few types were statistically significant, no contradictory findings in susceptibility were obtained among the groups during the study, which suggested strongly that subjects with HLA-Bw51 and -Bw16 are susceptible. In addition, when the seropositive rates were compared in all combinations of HLA-A and -B antigens classified according to expected susceptibility, the positive rates were arranged in order of susceptibility with significant statistical differences in several groups.

Association of B cell alloantigen with juvenile onset diabetes mellitus in the Japanese

Sixty-four Japanese insulin dependent juvenile onset diabetes mellitus (JOD) were studied in relation to HLA-A, B, and DR. Significant deviations were observed. HLA-Bw54 was increased (PF = 49.2%, RR = 6.4) and HLA-B5 was decreased (PF = 7.9%, RR = 0.19). Using radioimmunoassay, two HLA-DR antigens were investigated. Hon 7 antigen, so-called MT3 (WIA4x7), which has linkage disequilibrium between HLA-BW54, is highly associated (PF = 96.9%, RR = 27.8) with JOD found in the Japanese.

Antibody response following rubella immunization analyzed by HLA types

Possible association between HLA antigens and antibody response to rubella vaccine was examined in 71 seronegative adult females, aged from 18 to 23, immunized with QEF vaccine. High responders (HAI antibody titer greater than or equal to 1:32) with HLA-B15 were significantly higher in frequency than those without HLA-B15 (p < 0.05). On the other hand, subjects with HLA-A9 had a tendency toward low immune responsiveness, including all the three non-responders. These results suggest that the antibody response to rubella vaccine may be influenced by the host-genetic factors relating to HLA antigens.