Fulvio Invernizzi

Secondary and Essential Cryoglobulinemias

The clinical and immunochemical classification of 166 patients with cryo-globulinemia are presented. 52% of the cryoglobulins were detected in patients hospitalized because of various causes. The most

T-cell-mediated epineurial vasculitis and humoral-mediated microangiopathy in cryoglobulinemic neuropathy

We used immunohistochemistry to assess the role of humoral and cellular factors in endoneurial microangiopathy and epineurial vasculitis in 15 nerve biopsies of patients with axonal neuropathy and monoclonal or mixed cryoglobulinemia (CG). Deposition of immunoglobulins and cytolytic complement was detected in endoneurial capillaries of patients with mixed CG. Epineurial inflammatory infiltrates containing beta2-integrin-positive lymphocytes and monocytes surrounded arterioles expressing cell adhesion molecules, thus suggesting a cell-mediated pathogenesis of the epineurial vasculitis. On the other hand, the absence of immune complex deposition and polymorphonuclear elements suggests a minor role for the humoral mechanisms in the formation of the vasculitic lesions. This study indicates that both cell-mediated mechanisms and immune complexes/cryoglobulins are involved, although at different levels, in the pathogenesis of CG neuropathy.

A Long-Term Follow-Up Study in Essential Cryoglobulinemia

In a case series of 56 patients with essential cryoglobulinemia, 35 were followed-up for 4-13 years (mean 7 years). A membranous proliferative glomerulonephritis, which in about half the cases showed a progression to renal insufficiency, was the commonest complication, observed in more than one third of the patients. In 2 patients hepatic cirrhosis became manifest after a completely asymptomatic period and in 2 others a lymphoproliferative disease appeared 2 and 8 years after the onset of purpura. In 51% of patients the intial clinical pattern did not change. In searching for a correlation between the development of nephropathy and cryoglobulin characteristics, none was demonstrated studying the cryoglobulin level, the presence of autoantibody and the complement components.

Two‐dimensional electrophoretic analysis of cryoproteins: A report of 335 samples

Cryoproteins are defined as proteins precipitating at low temperature. Most frequently, the precipitate contains immunoglobulins (Igs), and are therefore called cryoglobulins. Three types of cryoglobulins have been described: type I contains a single monoclonal Ig, whereas type II is a mixture of a monoclonal Ig with polyclonal Igs, and type III is a mixture of polyclonal Igs of different isotypes, most frequently IgG and IgM. Type II and type III are also called mixed cryoglobulins. A new type of cryoglobulins, containing polyclonal IgG associated with a mixture of polyclonal and monoclonal IgM has recently been described after two‐dimensional polyacrylamide gel electrophoresis (2‐DE). This type of cryoglobulin has been called type II–III cryoglobulin. In this study, we report on 2‐DE analysis of 335 cryoproteins from patients with heterogeneous clinical conditions. In 69 out of 335 samples (20.7%), 2‐DE revealed patterns that were inadequate to characterize the cryoproteins. Out of 335 (79.3%) cryoproteins, 266 were identified according to their two‐dimensional patterns: 265 samples contained Igs and were diagnosed as cryoglobulins, and one sample consisted of fibrinogen, and was identified as cryofibrinogen. Among the 265 cryoglobulins, types I, II, and III were observed in 9 (3.4%), 69 (26%), and 116 (43.8%) cases, respectively, whereas type II–III was detected in 71 (26.8%) cases. Eleven of the latter consisted of oligoclonal Igs (IgM in 10 cases, IgA in 1 case) mixed with traces of polyclonal IgG. These cryoproteins were tentatively named type II–IIIvariant cryoglobulins. Taken together, our result clearly show that 2‐DE is a suitable technique to analyze cryoproteins.

High-dose methylprednisolone pulses in active lupus nephritis.

pressure about 15 mm Hg. At first, the fetuses reacted by bradycardia and moderate hypertension (mean arterial bloodpressure 80-100 mm Hg) maintained during !--1 1 h, followed by hypotension. The central venous pressure hardly changed during the procedure. We suggest that the breakdown of the fetal blood/brain barrier to albumin is due to a combination of the initial moderate hypertension and severe vasodilation during asphyxia.7 The permeability of the blood/brain barrier to albumin in asphyxiated babies would facilitate the transport of bilirubin from plasma to neurones and thus explain the increased susceptibility to kernicterus.

Abnormalities of in Vitro immunoglobulin synthesis by peripheral blood lymphocytes from patients with essential mixed cryoglobulinemia

Peripheral blood mononuclear cells from patients with essential mixed cryoglobulinemia (EMC) were studied for their ability to differentiate into cells containing cytoplasmic immunoglobulins (Ig) and to synthetize Ig after in vitro pokeweed mitogen activation. EMC lymphocytes showed a significant defective differentiation and Ig synthesis compared to normal controls. Coculture experiments carried out mixing enriched normal T- and EMC B-cell suspensions, and vice versa, showed that (a) the EMC B-cell-defective Ig synthesis still persisted after removal of suppressor activity by irradiation, both with autologous and with normal allogeneic T suspensions and (b) EMC T cells displayed a less efficient activity in helping Ig production by normal B lymphocytes. A comparable, reduced response was also found after activation with Staphylococcus aureus strain Cowan I. Taken together these results seem to indicate that in essential mixed cryoglobulinemia an impaired T-cell helper activity coexists with a B-lymphocyte impairment. The significance of these abnormalities in the pathogenesis of EMC is discussed.

A New Case of IgE Myeloma

A new case of IgE myeloma is described. A 77-year-old woman presented with bone pain and fatigue. Serum protein analysis revealed a paraprotein of the IgE kappa type; bone marrow aspirate and immunofluorescence confirmed the diagnosis; ultrastructural examination showed immature plasma cells. Treatment with prednisone, melphalan, cyclophosphamide and interferon alfa did not produce any improvement and the patient died 5 months after diagnosis. The patients clinical and laboratory data are compared with those of IgE myeloma cases reported in the literature.

Hepatitis C Virus and Immunoglobulin Gene Rearrangements: An Early Step in Lymphomagenesis?

A clonal expansion of peripheral blood mononuclear cells committed to IgM cryoprecipitating rheumatoid factor production has been demonstrated in hepatitis C virus (HCV)-associated mixed cryoglobulinemia (MC). To determine the role of HCV in B cell gene rearrangements we studied a series of 57 HCV-infected patients with and without MC. Clonal Ig gene rearrangements of both RNA and DNA were detected in 10 of the 13 patients with type II MC, 1 patient had gene rearrangement of the DNA only, and 2 had polyclonal patterns. 2 of the 17 patients with type III MC showed clonal rearrangement of both RNA and DNA, in 6 only the DNA was rearranged clonally and in 9 the patterns were completly normal. 14 of 27 patients with cryocrit <1% or without cryoglobulins had clonal DNA rearrangements without any in the RNA. These results suggest that clonal lesions in the DNA are related to HCV infection and that these changes antedate the appearance of mixed cryoglobulinemia.

Basophil activation in idiopathic mixed cryoglobulinemia

We studied basophil activation in patients affected by idiopathic mixed cryoglobulinemia in order to investigate the role of the basophil cell in the pathogenesis of the vasculitis typical of this disease. We selected 13 patients and we performed thein vitro basophil degranulation test with cryoprecipitate; in 5 cases the test was positive when it was performed in whole blood, while it was negative when it was performed with cells washed and resuspended in Tyrodes buffer. In 6 subjects it was not possible to perform the test because of the very low number of circulating basophil cells. Finally, in 2 subjects thein vitro basophil degranulation test with cryoprecipitate was negative; this result may be related to the very low levels of complement factors in the sera of these subjects. These findings sugges that the pathogenetic mechanism of vasculitis in idiopathic mixed cryoglobulinemia could be started by basophil activation.

Hypergammaglobulinemic Purpura of Waldenström: Characterization of Circulating Immune Complexes

Circulating immune complexes were detected in the sera of 7 patients with hypergammaglobulinemic purpura of Waldenström by the following methods: KgB-SP, mRF-LIA, Cc test, ClqBA. Analytical ultracentrifugation showed intermediate complexes between 7S and 19S (16S-19S); simple immunodiffusion of the complexes, purified by 2.5% PEG precipitation, revealed the presence of IgG3, IgA, IgM, Clq, C3 and C4. Constant high titers of rheumatoid activity in the sera in toto and after purification, and normal serum complement levels were also detected.