James N. Gilliam

Immunoglobulin in Clinically Uninvolved Skin in Systemic Lupus Erythematosus ASSOCIATION WITH RENAL DISEASE

23 of 42, or 55%, of patients with systemic lupus erythematous had immunoglobulin deposits along the epidermal basement membrane of uninvolved skin (positive lupus band test [LBT]). In patients with low serum complement levels, 91% had a positive LBT), as compared with 15% in those with normal complement levels. The LBT was positive in 70% of patients with clinical and laboratory evidence of renal disease, but in only 31% of patients without renal disease. 81% of patients with the more severe histologic forms of lupus nephritis, i.e., proliferative glomerulonephritis and membranous glomerulonephritis, and positive tests, whereas only 23% with mesangial glomerulitis or normal histologic findings were positive. Immunoglobulins of the same class found in the skin were detected in the glomeruli of patients examined by renal biopsy. These results suggest that there is a relationship between the occurrence of immunoglobulin in the epidermal basement membrane and the presence of the more severe forms of lupus nephritis.

Human Histocompatibility Antigen Associations in Subacute Cutaneous Lupus Erythematosus

We have identified a clinically distinct subset of lupus erythematosus patients marked by the presence of a histologically proven, nonscarring variety of cutaneous LE (subacute cutaneous LE) in which there is a very high frequency of the human leukocyte antigens (HLA) B8 and DR3. Differences in the configuration of their skin lesions allowed a separation of the patients into two clinical subgroups; annular and papulosquamous. HLA-B8 was increased in the annular subgroup (81%, corrected P (Pc) < 0.007) and combined group (65%, Pc < 0.004). HLA-DR3 was present in all 11 of the annular patients (10%, Pc < 0.00008). In addition, HLA-DR3 was present in increased frequencies in the papulosquamous subgroup (60%, Pc < 0.04) and combined group (77%, Pc < 0.00008). Thus, HLA-DR3 positive individuals have a relative risk of 10.8 for developing subacute cutaneous LE of either type and an even greater relative risk (67.1) for the annular variety. The HLA phenotype A1, B8, DR3 was also found more commonly in the annular (73%, P < 0.00008) and combined patient groups (46%, P < 0.004). These HLA associations, which are stronger than ever before reported for any form of LE, did not result from the concurrent presence of subclinical Sjögrens syndrome. Thus, subacute cutaneous LE can now be added to the growing list of HLA-B8, DR3-associated diseases that have autoimmune features.

High frequency of histocompatibility antigens HLA-DR3 and DR4 in herpes gestations.

Herpes gestationis (HG) is a rare, autoimmune, vesiculobullous disease of pregnancy or the puerperium characterized by the deposition of complement (and occasionally immunoglobulin) within the lamina lucida of the cutaneous basement membrane zone. We have studied 23 patients with a history of HG, 20 of whom had typical immunofluorescence findings during the active phase of their disease. HLA typing showed HLA-DR3 in 61% of patients (controls 22%, Pc less than 0.005) and the combination of DR3, DR4 in 43% (controls 3%, Pc less than 0.00001). The most striking finding of this study was that the greatest risk of HG is associated with the concurrent presence of two specific histocompatibility leukocyte antigen (HLA)-DR antigens.

Idiopathic atro hie blanche

Idiopathic atrophie blanche (segmental hyalinizing vasculitis; livedo reticularis with summer ulceration) is a chronic cutaneous disorder of young to middle-aged women that is characterized by persistent painful leg ulcerations. Primary lesions consist of purpuric macules and papules which undergo superficial ulceration, followed eventually by the development of irregular, atrophic, porcelain white scars with fine borders of ectatic vessels. We have studied twelve patients with idiopathic atrophie blanche by immunofluorescence, thin section light microscopy, and electron microscopy. All patients were examined extensively in order to rule out primary immunologic and vaso-occlusive disorders that may result in a similar clinical appearance. Subsequently, ten patients were treated for 1 to 12 years with combinations of phenformin and ethylestrenol. Each treated patient noted rapid improvement in existing lesions, significantly less pain, and a decrease in the development of new lesions. Side effects in all but two patients were minimal and well tolerated. Light and electron microscopic examination of early and well-developed lesions revealed fibrin plugs which first occlude superficial dermal vessels, followed by necrosis and obliteration of the affected vessel walls. Eventually, new vessel formation occurs in some areas of fibrin deposition. Polymorphonuclear leukocytes and mononuclear cells only rarely participate in this process. Although this disorder has previously been considered a localized form of cutaneous vasculitis, the absence of both leukocytes and nuclear fragmentation from the neighborhood of vascular structures in early lesions differentiates this disorder from immune complex-mediated necrotizing vasculitis. Thus the term vasculopathy describes this disorder more appropriately than the term vasculitis.

Diabetes is Associated with Autoimmunity in the New Zealand Obese (NZO) Mouse

The New Zealand Obese (NZO) mouse was studied as a potential model for autoimmune diabetes. NZO mice develop obesity, glucose intolerance, and insulin resistance, and have low-titer IgM antibodies to the insulin receptor. It is shown that they have circulating antibodies to both native DNA and denatured, singlestranded DNA. The antibody levels are higher in females, and, up to 6 mo of age, are comparable to those found in the related NZB × NZW F1 (NZB/W) mouse, a model for systemic lupus erythematosus. After 6 mo of age the antibody levels in NZO mice fall toward normal, in contrast to the persistently elevated levels in NZB/W mice. NZB/W mice are known to succumb to immune complex-mediated proliferative glomerulonephritis before 1 yr of age, whereas NZO mice survive. NZO kidneys exhibit light microscopic features of both diabetic and lupus nephropathies: glomerular proliferation, mesangial deposits, mild basement membrane thickening, glomerulosclerosis, eosinophilic nodules in some glomeruli, occasional hyalinization of the glomerular arterioles, and healing arteriolar inflammation. These changes are associated with glomerular deposition of immunoglobulin, especially IgM, in a granular pattern on fluorescent staining. The NZO mouse, therefore, has evidence of a generalized immune disorder and provides a model for studying the relationship between autoimmunity, obesity, and diabetes.

Antinuclear and anticytoplasmic antibodies: Concepts and misconceptions

Skin involvement is a common feature of several diseases in which circulating autoantibodies to nuclear and cytoplasmic antigens can be found. Patients with these diseases can be managed more efficiently if the physician is fully aware of the diagnostic and prognostic value of these various antinuclear and anticytoplasmic antibodies. The dermatologist, therefore, not infrequently, must face the bewildering task of ordering and interpreting the results of assays for an ever-increasing number of circulating autoantibodies. In this report, we have attempted to make this less burdensome for the clinician by pointing out the basis for some of the confusion that has arisen in this area. The confusion has resulted primarily from a failure to recognize the limitations of the various assays involved.

Comparison of circulating T and B lymphocytes in discoid versus systemic lupus erythematosus

Absolute numbers of T and B lymphocytes were determined in groups of patients with discoid and systemic lupus erythematosus (LE) and in normal subjects. Patients with discoid LE had normal numbers of T cells but significantly increased numbers of B cells when compared with both the normals (P<0.05) and the systemic LE patients (P<0.001). The systemic LE patients had significantly decreased numbers of T cells when compared with the discoid LE patients (P<0.05) and with normals (P<0.005). From these studies it is concluded that discoid LE patients differ from systemic LE patients by having (1) normal numbers of T lymphocytes and (2) increased numbers of B lymphocytes. The role of T-B-cell imbalance in determining the expression of this disease is discussed.

The differential effects of cyclophosphamide and 6-mercaptopurine on the renal disease and skin immunoglobulin deposits of the NZB-NZW F1 hybrid mice

The following differential effects of immunosuppressive therapy with Cyclophosphamide (CYCLOPH) and 6-mercaptopurine (6-MP) in the female NZB-NZW F1 hybrid strain have been observed: (1) CYCLOPH but not 6-MP significantly decreased antinuclear antibody level. (2) Both CYCLOPH and 6-MP significantly decreased glomerular cell proliferation. (3) Both CYCLOPH and 6-MP significantly arrested progression of glomerulosclerosis. (4) While CYCLOPH significantly diminished Ig deposition in the glomeruli, 6-MP had no effect on this phenomenon. (5) While CYCLOPH decreased subepidermal globulin deposition in the skin, 6-MP appeared actually to enhance subepidermal staining. Thus, the present studies demonstrated that CYCLOPH was superior to 6-MP in four of the five parameters studied. In the case of one parameter, Ig staining of the skin, 6-MP actually produced enhancement of the staining. Both CYCLOPH and azathioprine which is a derivative of 6-MP, are currently being used for the treatment of human SLE. The present findings suggest that of the two, CYCLOPH may be the drug of choice.