Roberto Cattaneo

Treatment of lupus skin involvement with quinacrine and hydroxychloroquine

To evaluate the efficacy of hydroxychloroquine (HCQ) and quinacrine (Qn) association, at two different dosages, in treatment of lupus skin lesions not responding to HCQ alone. Thirty-four patients, affected by cutaneous and systemic lupus erythematosus, were retrospectively analysed. They were treated by HCQ (5 mg/Kg/qd) and Qn with two regimens: 100 mg/qd (29 cases) and 50 mg/qd (5 cases). Discoid lupus erythematosus (19 cases), acute malar rash (6 cases), chilblain lupus (4 cases) showed a significant improvement with combination therapy (P = 0.009, P = 0.019, and P = 0.04, respectively). Ten patients with subacute cutaneous lupus showed a partial response, whereas lupus profundus didn’t improve. The same overall response rate was recorded comparing two Qn regimens, but subjects taking 100 mg/qd improved more rapidly than the others (P = 0.001). Ten patients developed side effects, mainly represented by skin yellowish discolouration. Depression and severe headache with nausea, which were globally recorded in two cases, led to drug withdrawal. One additional case of hepatitis was recorded in a patient with preexisting Hepatitis C virus (HCV) infection. Combination of HCQ and Qn is rapidly effective at 100 mg/qd and well tolerated in the treatment of lupus skin lesions unresponsive to HCQ alone.

CHILBLAIN LUPUS ERYTHEMATOSUS IS ASSOCIATED WITH ANTIBODIES TO SSA/RO

Chilblain lupus erythematosus (CL) of Hutchinson is a subtype of lupus erythematosus (LE) characterized by erythematous lesions induced by cold, damp climates. A number of patients affected by CL eventually develop features of systemic lupus erythematosus (SLE). We report here 9 patients with chilblain cutaneous lesions, 6 of them were affected by SLE and 2 by SCLE. The onset of CL preceded the diagnosis of LE, from 1 to 10 years in 3 cases, it was concurrent in one case and was subsequent in the remaining 4 cases. Raynauds phenomenon and photosensitivity were other prominent clinical features in patients with CL. Nailfold capillaroscopy revealed pathological changes in every patient examined. ANA and anti-SSA/Ro antibodies were detected in all nine patients. Anti-SSB/La were detected in 2 cases, anti-Sm in one case, and anti-Sm and anti-RNP in a one case. Antibodies to dsDNA and complement consumption were found in the six patients with SLE. The fine specificity of anti-SSA/Ro was determined by immunoblotting: anti-60kD and anti-52 kD were detected in three sera, anti-60kD alone in 5 sera, while one serum did not blot. In conclusion, the present study suggests that chilblain LE is associated with SSA/Ro autoantibodies, as is SCLE, hypergammaglobulinemic purpura and neonatal lupus erythematosus.

Prevalence and clinical associations of anti-Ku antibodies in systemic autoimmune diseases

We retrospectively analysed the prevalence and clinical features associated to anti-Ku antibodies in patients affected by different autoimmune diseases. Anti-Ku antibodies are detected in 147 sera out of 7239 anti-ENA positive sera (2%). They are found in 2% of patients with systemic sclerosis (SSc) (8 out of 379), 1.8% of systemic lupus erythematosus (SLE) (7 out of 372) and 1.8% of undifferentiated connective tissue disease (UCTD) (9 out of 496) and more rarely in Sjögren Syndrome and rheumatoid arthritis. Most of anti-Ku positive patients were affected by UCTD and overlap syndromes, including polymyositis, SSc and SLE. Interstitial lung disease, myositis, articular symptoms, Raynaud’s phenomenon and sicca represents the main clinical features detected in our cohort. The rate and severity of pulmonary disease is similar to those found in other SSc patients. Isolated anti-Ku were detected in about 47% of sera. No clinical differences were observed between these patients and subjects with multiple anti-nuclear specificities. However, anti-Ku are usually detected in association with other serological markers in SLE and Sjögren Syndrome, while they occurred isolated in SSc and polymyositis.

CD70 expression on T-cell subpopulations: study of normal individuals and patients with chronic immune activation

CD70, the ligand of CD27, is a member of the TNF family, which includes molecules essential in the regulation of lymphocyte growth and survival. It is absent on resting lymphocytes but can be induced in vitro with activating stimuli. To extend information about its expression by different T-cell subpopulations, and its regulation in normal and pathologic conditions, highly purified T-cell subpopulations were studied: CD70 expression depended both on the activating stimulus and on the T-cell subset analyzed. PMA + Ionomycin induced CD70 on the large majority of CD8+ cells, but only on a minority of CD4+ cells (P < 0.002), and among these, preferentially on the CD45R0+ subset compared with the CD45RA+. The presence of CD4+ lymphocytes in cell cultures containing mixtures of T-cell subsets inhibited CD70 expression on CD8+ cells. On the contrary, stimulation with allogeneic cells induced CD70 expression also on CD4+ cells. Moreover, CD70 was found to be expressed by chronically in vivo activated T-cells, in conditions characterized by allogeneic and autoimmune reactions. These data suggest a possible role of CD70 in the pathogenesis of immune dysregulation; interestingly, this role may not be simply restricted to bind to, and signal through, CD27, since cross-linking of CD70 enhances the proliferative response induced by the stimuli used to elicit its expression.

Immune reconstitution after bone marrow transplantation for combined immunodeficiencies: down-modulation of Bcl-2 and high expression of CD95/Fas account for increased susceptibility to spontaneous and activation-induced lymphocyte cell death.

We have studied the regeneration of T cell subsets and function after BMT in 21 children affected by combined immunodeficiency after BMT. In the first months, the striking predominance of CD4+ cells displayed the primed CD45R0+ phenotype and a high number of activated (HLA-DR+) T cells were observed. Regeneration of naive CD4+CD45RA+ cells correlated with the recovery of proliferative responses to mitogens (ru2009=u20090.64, Pu2009<u20090.001). peripheral blood lymphocytes circulating after bmt undergo an increased process of in vitro cell death, resulting from two mechanisms: spontaneous apoptosis (SA), a consequence of defective production of IL-2 and down-regulation of Bcl-2 (Pu2009=u20090.02 vs healthy controls), and high susceptibility to activation-induced cell death (AICD) after restimulation with mitogens. In accordance with the role of CD95/Fas in this latter process, we have observed a high level of CD95 expression (Pu2009<u20090.001 vs healthy controls), correlated with AICD (Pu2009<u20090.001) but not with sa, and decreasing with time after bmt (Pu2009<u20090.001). both sa and aicd levels correlated with the presence of activated t cells and decreased with the progressive recovery of t cell proliferative response. therefore, the lymphocyte hyperactivated status might explain their susceptibility to apoptosis and contribute to the genesis of immunodeficiency that follows bmt.

CD3-CD4+ cells with a Th2-like pattern of cytokine production in the peripheral blood of a patient with cutaneous T cell lymphoma.

A case of cutaneous T cell lymphoma associated with mild eosinophilia and rise of IgE levels is reported. A population of CD3−CD4+ cells was observed in the peripheral blood. After activation, these purified CD3−CD4+ cells showed a Th2 pattern of cytokine production, secreting higher levels of IL-5 and IL-4 and lower levels of IFN-γ compared to the patient’s and controls’ CD3+CD4+ cells. Moreover, high levels of IL-5 and soluble CD30, a marker of Th2 cell activation, were detected in the patient’s serum.

Ontogeny of CD40 expression by activated peripheral blood lymphocytes in humans

The CD40 ligand (CD40L) is a molecule expressed by activated T cells which plays a critical role in the regulation of B-cell responses, including differentiation into Ig-producing cells. Using the specific monoclonal antibody TRAP1 we have evaluated the ontogeny of CD40L expression in 97 normal individuals between birth and 50 years of age. The expression of CD40L is a function of age; it is severely reduced at birth, progressively increases during the first months of life, and reaches a plateau in the second decade. This progressive attainment of the ability to express CD40L is due to a process of maturation of the CD4 + subset, being significantly correlated with the expression of the CD45RO antigen.

Defective expression of HLA class I and CD1a molecules in boy with Marfan-like phenotype and deep skin ulcers

We report the case of a boy with low expression of HLA class I molecules on peripheral blood mononuclear cells, which is associated with immunodeficiency. The patient, who had a Marfan-like phenotype, had chronic deep skin ulcers and sinobronchiectasis. Immunohistologic examination of the ulcerated skin showed a dense perivascular infiltrate composed of normal mature lymphocytes and macrophages. All cells in the infiltrate showed an apparently normal expression of HLA class I molecules, but intraepidermal dendritic Langerhans cells were negative for CD1a, an antigen that is a highly specific marker for these cells and is abundantly expressed in some self-healing forms of cutaneous lesions. It is therefore speculated that a defective expression of CD1a molecules can contribute to the chronic persistence of deep skin ulcers, which have already been reported in association with defective expression of HLA class I molecules.

CD4+ cells from patients with Common Variable Immunodeficiency have a reduced ability of CD40 ligand membrane expression after in vitro stimulation

Background: Common Variable Immunodeficiency (CVID) is characterized by defective antibody production. This has been variably attributed to intrinsic B‐cell defects or to T‐cell disfunctions. Recently, it has been reported that the expression of the CD40 Ligand (CD40L), a T‐cell surface molecule that plays a critical role in the cell‐contact‐mediated helper signals provided to B‐cells, is defective in a subset of patients with CVID.

Anti β2-glycoprotein I antibodies: Clinical significance

The introduction of anticardiolipin antibody (aCL) assay, described in 1983, was able to focus much attention on the study of patients suffering from thrombosis, repeated fetal loss and thrombocytopenia, and allowing the identification of the so called antiphospholipid syndrome (APS). The identification of β2 glycoprotein I (β22GPI) as an essential component of the antigenic complex recognized by aCL suggested that this molecule could be a direct target of the antibody response. Since then, different groups have described ELISAs for the detection of anti β2GPI antibodies, applied to the clinical evaluation of patients with APS, and showing an overall better specificity. Recently, anti β2GPI were also shown to bind apoptotic bodies resulting in an alteration of their physiological clearance with the triggering of TNFα release. This observation suggests that anti β2GPI may also modify the immunogenicity of apoptotic bodies and of the autoantigens that they contain.