Gregory J. Dennis

Altered pattern of TCR/CD3-mediated protein-tyrosyl phosphorylation in T cells from patients with systemic lupus erythematosus. Deficient expression of the T cell receptor zeta chain.

Cellular immunity aberrations in patients with SLE are underscored by the abnormal early Ag receptor-mediated lymphocyte signal transduction pathway. To further characterize the T cell receptor (TCR)/CD3-initiated signaling defects, we studied 22 patients with SLE, 12 patients with other systemic rheumatic diseases, and 14 normal donors. The early (1 min) TCR/CD3-mediated tyrosine phosphorylation of cellular proteins with a molecular size between 36 and 64 kD was increased in 15 of 21 SLE patients, compared to normal or disease control subjects. The deficiency or absence of a band with a molecular size of approximately 16 kD in the immunoblots of SLE patients led us to investigate the expression of the TCRzeta chain. In immunoblots using anti-zeta antibodies we found that 10 of 22 lupus patients tested lacked the expression of TCRzeta, which was always present in control subjects (P < 0.001). Flow cytometric studies using permeabilized cells confirmed the deficiency or absence of the TCRzeta chain in lupus T cells. Using Northern blots we found that for eight patients tested, the TCRzeta mRNA was missing in three, decreased in three, and apparently normal in two patients (P < 0.003), but was always present in control subjects. Reverse transcriptase-PCR verified Northern blot results. We conclude that TCRzeta chain expression is either decreased or absent in the majority of patients with SLE, but not in patients with other systemic rheumatic diseases, regardless of disease activity, treatment status, or clinical manifestations. The previously described increases in TCR-initiated Ca2+ responses and the herein described increases in TCR-induced protein tyrosine phosphorylation and deficient TCRzeta expression may represent intrinsic defects modulating lupus T cell function.

Early events in lupus humoral autoimmunity suggest initiation through molecular mimicry.

The origins of autoimmunity in systemic lupus erythematosus (SLE) are thought to involve both genetic and environmental factors. To identify environmental agents that could potentially incite autoimmunity, we have traced the autoantibody response in human SLE back in time, prior to clinical disease onset, and identified the initial autoantigenic epitope for some lupus patients positive for antibodies to 60 kDa Ro. This initial epitope directly cross-reacts with a peptide from the latent viral protein Epstein-Barr virus nuclear antigen-1 (EBNA-1). Animals immunized with either the first epitope of 60 kDa Ro or the cross-reactive EBNA-1 epitope progressively develop autoantibodies binding multiple epitopes of Ro and spliceosomal autoantigens. They eventually acquire clinical symptoms of lupus such as leukopenia, thrombocytopenia and renal dysfunction. These data support the hypothesis that some humoral autoimmunity in human lupus arises through molecular mimicry between EBNA-1 and lupus autoantigens and provide further evidence to suspect an etiologic role for Epstein-Barr virus in SLE.

Fce receptor type I γ chain replaces the deficient T cell receptor ζ chain in T cells of patients with systemic lupus erythematosus

OBJECTIVE T cells from the majority of patients with systemic lupus erythematosus (SLE) express significantly lower levels of T cell receptor zeta chain, a critical signaling molecule. However, TCR/CD3 triggering of SLE T cells shows increased phosphorylation of downstream signaling intermediates and increased [Ca2+]i response, suggesting the presence of alternative signaling mechanisms. We investigated whether Fcepsilon receptor type I gamma chain (FcepsilonRIgamma) could substitute for TCR zeta chain and contribute to T cell signaling in SLE. METHODS T cells were purified from the peripheral blood of 21 patients with SLE and 5 healthy volunteers. The expression of FcepsilonRIgamma was investigated using immunoblotting, reverse transcriptase-polymerase chain reaction, and flow cytometry methods. Involvement of the FcepsilonRIgamma in T cell signaling was studied by immunoprecipitation and/or immunoblotting after TCR/CD3 stimulation. RESULTS Western blotting and densitometric analysis showed that the expression of FcepsilonRIgamma in SLE T cells was 4.3-fold higher than in normal T cells (P < 0.001). Flow cytometric analyses of T lymphocyte subsets revealed that the proportions of FcepsilonRIgamma+,CD3+, FcepsilonRIgamma+,CD4+, and FcepsilonRIgamma+, CD8+ cells were significantly greater in SLE patients than in healthy controls (P < 0.001). Immunoprecipitation of SLE T cell lysates with an anti-FcepsilonRIgamma antibody showed that FcepsilonRIgamma associates with the tyrosine kinase Syk and the CD3epsilon chain, suggesting that FcepsilonRIgamma is functionally involved in TCR signaling. CONCLUSION These results demonstrate that the FcepsilonRIgamma chain is expressed at high levels in a large proportion of SLE T cells. The increased expression of FcepsilonRIgamma chain in SLE T cells may account in part for the aberrant antigen receptor-initiated signaling and contribute to the diverse cellular abnormalities found in this disease.

Hydroxychloroquine sulfate treatment is associated with later onset of systemic lupus erythematosus.

Systemic lupus erythematosus (SLE) is a clinically diverse, complex autoimmune disease which may present with coincident onset of many criteria or slow, gradual symptom accrual. Early intervention has been postulated to delay or prevent the development of more serious sequelae. One option for treatment in this setting is hydroxychloroquine. Using 130 US military personnel who later met ACR SLE criteria, a retrospective study of onset, development and progression of SLE with and without pre-classification hydroxychloroquine (n = 26) use was performed. Patients treated with hydroxychloroquine prior to diagnosis had a longer (Wilcoxon signed rank test, P = 0.018) time between the onset of the first clinical symptom and SLE classification (median: 1.08 versus 0.29 years). Patients treated with prednisone before diagnosis also more slowly satisfied the classification criteria (Wilcoxon signed rank test, P = 0.011). The difference in median times between patients who received NSAIDs before diagnosis, as opposed to those who did not, was not different (P = 0.19). Patients treated with hydroxychloroquine also had a lower rate of autoantibody accumulation and a decreased number of autoantibody specificities at and after diagnosis. These findings are consistent with early hydroxychloroquine use being associated with delayed SLE onset. A prospective, blinded trial testing the capacity of hydroxychloroquine to delay or prevent SLE in high risk populations is warranted. Lupus (2007) 16, 401—409.

Development of Anti-dsDNA Autoantibodies Prior to Clinical Diagnosis of Systemic Lupus Erythematosus

Anti‐double stranded (dsDNA) antibodies are of considerable diagnostic value and are thought to be involved in the pathogenesis of systemic lupus erythematosus (SLE). Fluctuations in anti‐dsDNA antibody levels are also used as markers for disease activity and exacerbations. In this study we sought to evaluate the anti‐dsDNA antibody level in serum samples collected before the onset of SLE diagnosis. A total of 130 SLE patients were identified with stored serum samples available prior to diagnosis within the US Department of Defense serum repository. All 633 sera available from these patients were screened for anti‐dsDNA antibodies using an enzyme linked immunosorbant assay (ELISA). Within this cohort 55% of cases had detectable anti‐dsDNA antibodies prior to SLE diagnosis. The onset of anti‐dsDNA antibodies ranged from 9.3 years before to within the same month as diagnosis (with a mean onset 2.7 years before diagnosis). In order to assess for fluctuations in anti‐dsDNA levels relative to diagnosis, cases were selected with at least two positive samples, one within 6 months and a second greater than 6 months prior to diagnosis (n = 26). Seven of these cases also had samples available shortly after diagnosis (≤ 6 months) for comparison. Fifty‐eight percent of the 26 cases developed a significant rise in anti‐dsDNA antibody levels within 6 months of diagnosis. A significant decline in anti‐dsDNA levels ensued after diagnosis (and following treatment with corticosteroids) in all seven cases with samples available. Patients with a significant rise in anti‐dsDNA antibodies at diagnosis were more likely to have renal disease than those who did not (66.7% compared to 27.3%, χ2=3.94, P<0.05). These data suggest that anti‐dsDNA antibodies are present in SLE patient sera much earlier than previously suspected. In addition, the data are consistent with increases in anti‐dsDNA levels contributing to the onset of clinical illness in some patients with SLE.

Increased expression of functional Fas-ligand in activated T cells from patients with systemic lupus erythematosus.

The Fas ligand induces apoptosis upon binding to Fas/APO-1 (CD95) bearing target cells. Activation induced cell death (AICD) in T cells is mediated by upregulation of Fas ligand on the cell surface membrane upon crosslinking of the TCR. AICD is considered to be essential for the elimination of autoreactive T cells in the peripheral blood. To elucidate possible abnormalities in the process of AICD in human SLE, we studied the expression and function of Fas ligand in polyclonal T cell lines from patients with SLE, patients with other rheumatic diseases and normal controls. SLE T cells expressed on their surface significantly higher amounts of Fas ligand compared to the two control groups. Stimulation of the cells with anti-CD3 mAb lead to further increase in surface membrane Fas ligand expression in all three groups with SLE expressing the highest amounts. The percentage of increase was though lower in SLE T cells than in normal T cells or disease control cells. The T cells were examined for Fas ligand-mediated cytotoxicity in a 51Cr release assay using Fas-expressing normal T cells as target cells. There was no difference in SLE and control T cells with regard to specific 51Cr lysis, indicating that the Fas ligand expressed by the SLE T cells is functional. Our data show that activated T cells from patients with SLE express high amounts of functional Fas ligand with intact TCR-mediated upregulation. This could account for the high apoptotic rates that have been observed in lymphocytes from patients with SLE.

T cell signaling abnormalities in systemic lupus erythematosus are associated with increased mutations/polymorphisms and splice variants of T cell receptor ζ chain messenger RNA

OBJECTIVE T cells from patients with systemic lupus erythematosus (SLE) display antigen receptor-mediated signaling aberrations associated with defective T cell receptor (TCR) zeta chain protein and messenger RNA (mRNA) expression. This study was undertaken to explore the possibility that coding-region mutations/polymorphisms of the TCR zeta chain could account for its decreased expression and altered signaling in SLE T cells. METHODS TCR zeta chain mRNA from 48 SLE patients, 18 disease controls, and 21 healthy volunteers was reverse transcribed, amplified by polymerase chain reaction, and cloned, and complementary DNA (cDNA) was sequenced. DNA sequences from multiple clones were analyzed for silent single-nucleotide polymorphisms, mutations, and splice variations, to promote the identification of heterozygosity. RESULTS DNA sequence analysis revealed several widely distributed missense mutations and silent polymorphisms in the coding region of the TCR zeta chain, which were more frequent in SLE patients than in patients with other rheumatic diseases or healthy controls (P < 0.0001). Several of the missense mutations were located in the 3 immunoreceptor tyrosine activation motifs or the GTP binding domain, and this could lead to functional alterations in the TCR zeta chain. A splice variant of the TCR zeta chain with a codon CAG (glutamine) insertion between exons IV and V was found in half of the SLE and control samples. Two larger spliced isoforms of the TCR zeta chain, with an insertion of 145 bases and 93 bases between exons I and II, were found only in SLE T cells. We also identified various alternatively spliced forms of the TCR zeta chain resulting from the deletion of individual exons II, VI, or VII, or a combined deletion of exons V and VI; VI and VII; II, III, and IV; or V, VI, and VII in SLE T cells. The frequency of the deletion splice variants was significantly higher in SLE than in control samples (P = 0.004). These variations were observed in cDNA and may not reflect the status of the genomic DNA. CONCLUSION These findings demonstrate that heterogeneous mutations/polymorphisms and alternative splicing of TCR zeta chain cDNA are more frequent in SLE T cells than in T cells from non-SLE subjects and may underlie the molecular basis of known T cell signaling abnormalities in this disease.

Rapid clinical progression to diagnosis among African-American men with systemic lupus erythematosus.

The initial clinical course of systemic lupus erythematosus (SLE) is variable, ranging from relatively minor manifestations progressing over years to rapid onset of fulminate disease. We sought to identify factors associated with the rapid manifestation of SLE. Chart review of military medical records was used to identify 130 patients who met the American College of Rheumatology classification criteria for SLE. Demographics, clinical criteria date of occurrence, and the date of SLE classification (at least four clinical criteria) met were documented. Prospectively stored serum samples prior to the diagnosis were evaluated for SLE autoantibodies. Median time from the first recorded criteria to diagnosis was significantly shorter in African-American (AA) males compared with AA females and European American (EA) females and males combined. AA males were more likely to have nephritis as their first clinical symptom. Also, less time transpired between the first clinical criterion and SLE diagnosis in AA males with nephritis than in other groups presenting with nephritis. Even when cases presenting with nephritis were excluded, a diagnosis of SLE was made more rapidly in AA males. African-American men progress from initial clinical manifestations to SLE diagnosis more rapidly than other ethnic or gender groups.

Dermatomyositis and Malignant Melanoma

Patients with dermatomyositis may face an increased risk of malignancy. Malignant melanoma has been linked to dermatomyositis. We present a case of concomitant dermatoyositis and metastatic malignant melanoma and review the English literature concerning this topic. Analysis revealed that the development of dermatomyositis in patients with malignant melanoma heralds the diagnosis of metastatic disease. These patients face dismal prognoses.

Alveolar hemorrhage and pulmonary hypertension in systemic sclerosis: a continuum of scleroderma renal crisis?

Alveolar hemorrhage occurs as a complication of systemic inflammatory diseases. In addition to alveolar hemorrhage, patients with systemic sclerosis (SSc) may suffer from digital infarction, pulmonary hypertension, and renal crisis. Although a common pathogenesis of this disease that explains the variety of problems during a patients illness has yet to be identified, the unique characteristics of SSc may alter our approach to alveolar hemorrhage in this patient population. We describe a patient with SSc, who presented with pulmonary hypertension and alveolar hemorrhage complicated by features suggesting re-occurrence of scleroderma renal crisis. Our successful management of this patient, with complications that are usually of high morbidity, may be attributed to our judicious use of glucocorticosteroid therapy and maximization of angiotensin-converting enzyme inhibition. In view of the potential for glucocorticoids to precipitate scleroderma renal crisis, we suggest caution in the use of these medications for manifestations that may be similar in their pathogenesis.