Antonio Miglietta

Long-term follow-up of patients with anti-HBe/HBV DNA-positive chronic hepatitis B treated for 12 months with lamivudine

BACKGROUND/AIMS Interferon alpha provides benefit in only a limited number of patients with chronic anti-HBe-positive hepatitis B. The aim of this study was to verify the long-term efficacy of lamivudine treatment of these patients and the incidence of lamivudine-resistant hepatitis B virus mutants. METHODS Fifteen consecutive patients with chronic anti-HBe-positive hepatitis B were treated with lamivudine 100 mg once daily for 52 weeks. Levels of alanine aminotransferase, HBV DNA, hepatitis B surface antigen, and IgM antibodies to hepatitis B core antigen were monitored during therapy and 12-month follow up. The polymerase gene was amplified by polymerase chain reaction and the region coding for YMDD amino acid motif was directly sequenced. RESULTS Only 2/15 patients (13%) had a sustained virological and biochemical response and improved histologically. Eleven out of 15 (74%) showed inhibition of viral replication and normalization of alanine aminotransferase levels during lamivudine treatment but relapsed 1-12 months after terminating therapy. In the two remaining patients (13%), HBV DNA initially became negative but reappeared in the serum after 24 weeks, and in both patients the emergence of YMDD mutants was demonstrated. CONCLUSIONS Our data confirm the antiviral efficacy of lamivudine in anti-HBe-positive patients, but response to a 1-year course was only transient as the majority of patients relapsed after therapy withdrawal. The lack of a sustained effect and the emergence of lamivudine-resistant mutants suggest that therapy for chronic hepatitis B should be based on a combination of several therapeutic agents.

Cryoglobulins and pyroglobulins: An overview

SummaryCryoglobulins are serum proteins with heterogeneous etiopathogenetic and immunochemical properties. What they have in common is temperature-dependent insolubility, in that at temperatures below 37 °C (often around 4 °C) they precipitate, and then redissolve at 37 °C. When the etiopathogenesis of the cryoglobulinemia is unknown, which is true for many patients, the condition is calledidiopathic oressential cryoglobulinemia, whereas it is termed secondary whenever it appears to be associated with one of several diseases. Cryoglobulinemia has indeed been found in patients with lymphoproliferative and autoimmune disorders, liver diseases, infectious (viral, bacterial, fungal and parasitic) diseases, and so on. Cryoglobulins are usually classified according to their immunochemical properties as single-type monoclonal, mixtures of a monoclonal Ig with non-immunoglobulin material (DNA, lipoprotein, complement), mixed with one monoclonal Ig or mixed polyclonal, in which constitutive Ig fractions are polyclonal. As compared with normal Ig, cryoimmunoglobulins have sometimes been found to exhibit a peculiar amino acid structure of their heavy chains, less often of their light chains as well, and to have a lower carbohydrate content. Such structural abnormalities may contribute to their loss of solubility at low temperatures, possibly associated to the steric changes induced by the low temperature, causing the precipitate to form. The most common clinical features of cryoglobulins are correlated with vasculitis in the various organs and sometimes with increased viscosity of the plasma. Signs and symptoms include purpura, ulcers of the extremities, arthralgia, proteinuria, hepatic damage, abdominal pain, congestive heart failure, mental confusion, oligo-anuria, hemorrhagic diathesis, and coma. Pyroglobulins are also serum proteins with temperature-dependent insolubility. However, although they precipitate out of serum heated at 56 °C for half an hour, they do not resolubilize when the serum is returned to 37 °C. Pyroglobulins have been mainly found in patients with lymphoproliferative diseases (especially Waldenström’s macroglobulinemia, with or without cryoglobulinemia), systemic lupus erythematosus, and neoplasia. So far, only single monoclonal IgG, IgM or IgA pyroglobulins have been described. Since they precipitate only at 56 °C, pyroglobulins do not cause clinical symptoms and they are usually discovered by chance.

Macrophages in skin cancer: quantitative and functional studies.

The number of tumor-infiltrating macrophages was estimated in 43 patients with skin cancer, including 18 cases of squamous cell and 25 cases of basal cell carcinoma. Macrophages were identified in cell cultures by 2 assays, namely phagocytosis and resistance to detachment by trypsin. The average percentage of adherent cells for the 2 groups of skin tumors was 4.5 ± 2.6 and 10.2 ± 5.2, respectively, and the difference was statistically significant. Follow-up studies after surgical excision of the primary neoplasm showed a relatively low macrophage content in 2 of the 4 cases in which local recurrences occurred. Preliminary functional studies suggested that soluble factors may be released by neoplastic cells, accounting for the inhibitory effect of tumor cell supernatants on macrophage Chemotaxis in vitro.

Effect of BCG immunotherapy on cell-mediated cytotoxicity in bladder cancer patients following surgical treatment.

Peripheral blood lymphocytes from bladder cancer patients display in vitro cytotoxicity against established bladder tumor target cells. Following surgery and after separation of lymphocytes in non-T and T with high affinity and low affinity for sheep erythrocytes fractions, the cytotoxic activity was significantly decreased in all subsets. After BCG therapy the cytotoxic capacity was restored and the effect was equally distributed in the different subpopulations. The monocyte-enriched fraction did not show any change in the cytotoxic activity after treatment.

Crioglobulinemia: Un modello di malattia da immunocomplessi. Studi immunochimici e strutturali

SummaryImmunological and structural studies were performed in 42 cases of cryoglobulinemia. Seven of them were immunochemically characterized as single-type cryoglobulins (3 IgG and 4 IgM), whereas the remaining 35 were mixed IgG-IgM cryoglobulins. Mixed cryoglobulins were divided into 2 groups, depending on the polyclonal (25 cases) or monoclonal (10 cases) character of the IgM component. All mixed cryoglobulins exhibited anti-gammaglobulin activity, which could be recovered in the IgM fraction after Chromatographic separation of the cryoglobulin components. Mixed cryoglobulins should therefore be considered cryoprecipitating immune complexes of the IgG/anti-IgG type. Since some single monoclonal IgG cryoglobulins may also possess rheumatoid factor activity, they are only apparently of the single type, their actual composition being IgG/IgG. In order to assess whether viral or nuclear denatured DNA might represent the primitive antigenic stimulus which gives rise to the chain reactions leading to cryoprecipitation, 12 mixed cryoglobulins were investigated. DNA was demonstrated in 3 cases (25 %) and it appeared closely associated to the cryoprecipitate, in that the addition of DNAse was able to abolish the positivity only at acid pH. Finally, preliminary studies on the amino-terminal sequence of 4 æ chains isolated from IgM monoclonal components of mixed IgM-IgG cryoglobulins showed a preferential association of the VKIII variable region subgroup with the IgM fractions tested.RiassuntoIn 42 casi di crioglobulinemia è stata eseguita una série di ricerche immunologiche e strutturali. Dal punto di vista immunochimico, 7 crioglobuline erano singole (3 di tipo IgG e 4 di tipo IgM), mentre le rimanenti 35 erano del tipo misto IgG-IgM. Le forme miste furono a loro volta suddivise in 2 sottogruppi a seconda del carattere policlonale (25 casi) o monoclonale (10 casi) della componente IgM. Tutte le crioglobuline miste possedevano attività anti-gammaglobulinica che, dopo separazione cromatografica delle due componenti, si ritrovava esclusivamente nella frazione IgM. Tali crioglobuline miste devono pertanto considerarsi come immunocomplessi crioprecipitanti del tipo IgG/anti-IgG. Poiché anche le crioglobuline singole IgG monoclonali possedevano attività reumatoide, esse costituiscono pure degli immunocomplessi e sono quindi in apparenza forme singole, ma in realtà forme miste IgG/IgG. Nel tentativo di stabilire se DNA denaturato virale o nucleare possa rappresentare lo stimolo antigenico primitivo che dà luogo alla série di reazioni culminanti nella formazione del crioprecipitato, sono state esaminate 12 crioglobuline miste isolate. In 3 casi (25 %) è stata dimostrata la presenza di DNA così intimamente associate al crioprecipitato, da essere accessibile all’azione della DNAsi solo a pH acido. Infine, studi preliminari sulla sequenza amino-terminale di 4 catene æ isolate da altrettante componenti IgM monoclonali di crioglobuline miste IgM-IgG hanno permesso di svelare un’associazione preferenziale del sottogruppo di regione variabile VKIII in tale frazione IgM.

The expanding spectrum of clinical and laboratory features of IgE myeloma

SummaryA new case of IgE myeloma is described. Patient G.M., a 60-year-old woman, complained with a 3-months’ history of generalized bone pain, weight loss, profound weakness and severe anemia. A bone survey revealed multiple lytic lesions, and a heavy replacement by plasma cells was disclosed in the bone marrow examination of a sternal sample. In addition, an IgE serum M-component and γ-type Bence Jones proteinuria were identified by immunochemical studies. The disease course was rapid, death occurring within 6 months of clinical onset. A molecular weight of 188,500 daltons was calculated for the purified protein G.M., whereas the molecular weights of its subunits were found to be 72,000 for the ε chains and 43,000 for the γ chain dimers. This case is compared with 15 reported cases of IgE monoclonal gammapathy, an expanding clinical and laboratory spectrum emerging from the review of the literature.

Double (lgAκ + IgGκ) Paraproteinaemia in a Single Patient: Immunofluorescence Evidence for a Common Plasma Cell Clone ‘Frozen’ at the Switch Phase

We present a patient with multiple myeloma and double (IgAk + IgGk) paraproteinaemia in the serum. Immunofluorescence analysis of bone marrow plasma cell with fluorochrome-conjugated goat antibodies s

Paraproteinemia and neoplasia

SummaryAccording to the various case series, both myelomatous and non-myelomatous paraproteinemias are associated with a second malignant neoplasia in afrequency that ranges between 10 and 22%. This association, with a frequency higher than that statistically expected, is 2 to 4 times higher when compared to the association between two tumors of other origin. The association paraproteinemia-neoplasia was found in 10% of cases of our series of 311 paraproteinemias. In this seriesepithelial neoplasias as associated with paraproteinemias more frequently than lymphoreticular neoplasias. As far as the Ig class is concerned, there appears to be a prevalence ofIgM paraproteinemias, which accounts for 22.5%, while it is only 9% in the general survey of paraproteinemias. The prevalence of the IgM class should be related to the high degree of association (approximately 50%) between the IgM paraproteinemias and lymphoreticular neoplasias. The frequent association with a second neoplasia, common to other malignancies of the B-cell line (chronic lymphocytic leukemia, myeloma), must be considered a greater risk in the prognostic evaluation of a paraproteinemia. This should make us more cautious in affirming the ‘benignancy’ of every non-meylomatous paraproteinemia.

α-Fetoprotein and Australia Antigen in Primary Liver Cancer

Sera from patients with neoplastic and non-neoplastic diseases, as well as from full-term newborns and pregnant women were examined for the presence of α-fetoprotein (α-FP) by counterimmunoelectrophor

Immune function in patients with multiple myeloma

SummaryImmunologic function was evaluated in 27 patients with multiple myeloma (MM). When tested for their ability to develop delayed hypersensitivity to a panel of skin test antigens, 2 out of 15 such patients were found to be anergic. The property of human peripheral blood T lymphocytes to form rosettes with sheep [total E and active or early or early rosette-forming cells (RFC)] and human erythrocytes (H-RFC) was also studied. In addition, rosette formation with mouse erythrocytes (M-RFC) was investigated as a B cell marker. Decreased proportions of total E-RFC were found in one third of the patients with MM when compared to normal volunteers. By contrast, both mean percentages and ranges of active E-RFC, H-RFC, and M-RFC in the MM patients overlapped those revealed in healthy controls. The rosette-forming ability of peripheral blood lymphocytes was tested before and after treatment with levamisole, thymosin, and transfer factor in healthy controls, as well as in some groups of patients with MM, active systemiclupus erythematosus and Hodgkin’s disease. A positive effect of all three immunomodulating agents could only be demonstrated on cells from T cell-deficient patients. It is suggested that the immunodeficiency syndrome associated with MM and related malignancies may reflect quantitative and possibly selective defects of lymphocyte subpopulations.