Sladjana Andrejevic

Antineutrophil cytoplasmic antibody (ANCA)-associated autoimmune diseases induced by antithyroid drugs: comparison with idiopathic ANCA vasculitides.

Clinical and serological profiles of idiopathic and drug-induced autoimmune diseases can be very similar. We compared data from idiopathic and antithyroid drug (ATD)-induced antineutrophil cytoplasmic antibody (ANCA)-positive patients. From 1993 to 2003, 2474 patients were tested for ANCA in the Laboratory for Allergy and Clinical Immunology in Belgrade. Out of 2474 patients, 72 (2.9%) were anti-proteinase 3 (PR3)- or anti-myeloperoxidase (MPO)-positive and their clinical and serological data were analyzed. The first group consisted of ANCA-associated idiopathic systemic vasculitis (ISV) diagnosed in 56/72 patients: 29 Wegeners granulomatosis (WG), 23 microscopic polyangiitis (MPA) and four Churg-Strauss syndrome. The second group consisted of 16/72 patients who became ANCA-positive during ATD therapy (12 receiving propylthiouracil and four receiving methimazole). We determined ANCA and antinuclear (ANA) antibodies by indirect immunofluorescence; PR3-ANCA, MPO-ANCA, anticardiolipin (aCL) and antihistone antibodies (AHA) by ELISA; and cryoglobulins by precipitation. Complement components C3 and C4, alpha-1 antitrypsin (α1 AT) and C reactive protein (CR-P) were measured by nephelometry. Renal lesions were present in 3/16 (18.8%) ATD-treated patients and in 42/56 (75%) ISV patients (p <0.001). Skin lesions occurred in 10/16 (62.5%) ATD-treated patients and 14/56 (25%) ISV patients (p <0.01). ATD-treated patients more frequently had MPO-ANCA, ANA, AHA, aCL, cryoglobulins and low C4 (p <0.01). ISV patients more frequently had low α1 AT (p = 0.059) and high CR-P (p <0.001). Of 16 ATD-treated patients, four had drug-induced ANCA vasculitis (three MPA and one WG), while 12 had lupus-like disease (LLD). Of 56 ISV patients, 13 died and eight developed terminal renal failure (TRF). There was no lethality in the ATD-treated group, but 1/16 with methimazole-induced MPA developed pulmonary-renal syndrome with progression to TRF. ANCA-positive ISV had a more severe course in comparison with ATD-induced ANCA-positive diseases. Clinically and serologically ANCA-positive ATD-treated patients can be divided into two groups: the first consisting of patients with drug-induced WG or MPA which resemble ISV and the second consisting of patients with LLD. Different serological profiles could help in the differential diagnosis and adequate therapeutic approach to ANCA-positive ATD-treated patients with symptoms of systemic disease.

Serum DNase I activity in systemic lupus erythematosus: correlation with immunoserological markers, the disease activity and organ involvement.

Abstract Background: Decreased activity of serum desoxyribonuclease I (DNase I) in systemic lupus erythematosus (SLE) has been reported, but its role as a biomarker in SLE is still unelucidated. Methods: Seventy-seven SLE patients (aged 39.6±13.1 years) were studied for serum DNase I activity, levels of antinuclear (ANA), anti-dsDNA [high-avidity ELISA, conventional ELISA and indirect immunofluorescence (IIF)], anti-nucleosome, anti-histone antibodies, complement components C3 and C4. SLE disease activity was evaluated by disease activity index (SLEDAI-2K). Thirty-five patients were serologically and clinically followed for 3–12 months (mean 5.6±2.8). Thirty-seven healthy blood donors were the control group. Results: DNase I activity in SLE patients was lower than in healthy controls (p<0.01). DNase I activity was in positive correlation with SLEDAI-2K (p<0.01), levels of ANA, anti-dsDNA, anti-nucleosome and anti-histone antibodies (p<0.01) and in negative correlation with C3 concentration (p<0.05). The highest correlation was found between DNase I activity and anti-dsDNA concentrations determined by high-avidity ELISA (r=0.624), followed by IIF (r=0.541) and conventional ELISA (r=0.405). In the follow-up study, DNase I activity also correlated with SLEDAI-2K (p<0.01). SLE patients with low DNase I activity more frequently had SLE-specific cutaneous lesions (p<0.05). Conclusions: Monitoring of DNase I activity simultaneously with SLEDAI-2K might be a useful tool in the follow-up of SLE. An increase of DNase I activity characterized relapse in most SLE patients, although it did not reach the levels of healthy individuals. A decrease of DNase I activity in SLE flare-ups might be a functional biomarker of a subset of patients with specific dysfunction of apoptotic chromatin degradation.

Immunoserological parameters in SLE: high-avidity anti-dsDNA detected by ELISA are the most closely associated with the disease activity.

We assessed the relationship between the serum levels of antibodies against double-stranded DNA (dsDNA), C1q, nucleosomes, histones, C3 and C4 complement components with one another, with organ involvement and overall disease activity in patients with systemic lupus erythematosus (SLE). One hundred seventy-five sera from 99 patients with SLE, 31 sera of patients with other connective tissue diseases, and 20 sera from healthy blood donors were tested. SLE disease activity was assessed by modified SLEDAI-2K (M-SLEDAI-2K), not including complement and anti-dsDNA descriptors. Anti-dsDNA antibodies were measured by indirect immunofluorescence on Crithidia luciliae (CLIFT), standard enzyme-linked immunosorbent assay (ELISA) and ELISA for high-avidity antibodies. The most significant risk factor for renal involvement were anti-C1q antibodies (OR = 3.88, p < 0.05), high-avidity anti-dsDNA antibodies for polyserositis (OR = 7.99, p < 0.01), anti-histone antibodies for joint involvement (OR = 2.75, p < 0.05), and low C3 for cytopenia (OR = 11.96, p < 0.001) and mucocutaneous lesions (OR = 3.32, p < 0.01). Multiple linear regression analysis showed that disease activity in SLE could be predicted by the levels of antibodies against dsDNA determined by standard (p < 0.05) and high-avidity (p < 0.001) ELISA, and inversely associated with concentration of C3 (p < 0.001). Using stepwise method, high-avidity anti-dsDNA antibodies were found to be in the closest association to M-SLEDAI-2K. Moreover, positive test for high-avidity anti-dsDNA antibodies appeared as an independent risk factor for moderately to severely active disease (M-SLEDAI-2K>5) (OR = 5.5, p < 0.01). The presence of high-avidity anti-dsDNA antibodies represented a risk for renal, joint, and most importantly for serosal involvement. Our results suggest that simple and reliable ELISA for high-avidity anti-dsDNA antibodies is the test of good clinical utility for the assessment of global SLE activity.

Autoantibodies to mitotic apparatus: association with other autoantibodies and their clinical significance.

The most important mitotic apparatus (MA) antigens are centrosome (CE), nuclear mitotic apparatus (NuMA-1, NuMA-2), midbody, and centromere F (CENP-F). We studied associations of anti-MA antibodies with other autoantibodies and their clinical significance. A total of 6270 patients were studied for the presence of anti-MA antibodies on HEp-2 cells. Sera positive for anti-MA were tested for anti-extractable nuclear antigens (ENA) antibodies. Anti-MA antibodies were detected in 56 (45 females and 11 males) of 6270 sera (0.9%). Of these 56, NuMA-1 was found in 23, NuMA-2 in 7, CE in 20, CENP-F in 5, and CENP-F/centrosome in 1 case. Anti-NuMA-1 were associated with anti-ENA antibodies (p < 0.001). Diagnoses were established in 43/56 patients: 22 connective tissue diseases, 7 infections, 6 autoimmune hepatitis, 3 vasculitis, 3 primary antiphospholipid syndrome, 1 malignancy, and 1 fever of unknown origin. The differential diagnosis of anti-NuMA-1-positive patients must include Sjögren’s syndrome, while patients with anti-CE antibodies must be observed for HCV infection.

Granulomatosis with Polyangiitis (Wegener's Granulomatosis) in Children: Report of Three Cases with Cutaneous Manifestations and Literature Review

Granulomatosis with polyangiitis (GPA), also known as Wegeners granulomatosis, is a rare disease in childhood. Of 39 GPA patients that we diagnosed during a 20‐year period, only 3 (7.7%) were younger than 18 years. We report the course of GPA in three girls whose disease started at the ages of 16, 11, and 6 years. All had cutaneous manifestations: the first had necrotizing vasculitis, the second had palpable purpura, and the third had right upper‐eyelid edema and infiltration and proptosis caused by extraocular pseudotumor, initially histologically misdiagnosed as orbital immunoglobulin G4 (IgG4)‐related disease. Unlike with skin vasculitis and glomerulonephritis, upper‐airway and orbital inflammation were resistant to immunosuppressive therapy. Our report emphasizes that children presenting with cutaneous vasculitis, chronic eyelid swelling, sinusitis, or hoarseness should be tested for antineutrophil cytoplasmic antibodies. We emphasize that the upper‐eyelid edema and infiltration, with histologic characteristics of orbital IgG4‐related disease, may be the initial presentation of localized GPA in children, a feature that, until now, has been described only in adults.

Intracardiac thrombosis and fever possibly triggered by ovulation induction in a patient with antiphospholipid antibodies

We report on a 28-year old patient with polycystic ovary syndrome (PCOS) who presented with fever and laboratory markers of inflammation. Her medical history was relevant for multiple ovulation inductions (OI) and ovarian hyperstimulation syndrome (OHSS). She had two miscarriages and one preterm delivery. Intracardiac thrombosis was diagnosed in the presence of antiphospholipid antibodies. We suggest that primary antiphospholipid syndrome (APS) was possibly triggered by OI.

Hashimoto's encephalopathy: A long-lasting remission induced by intravenous immunoglobulins

BACKGROUND Hashimotos encephalopathy (HE) is a rare autoimmune syndrome characterized by various neuropsychiatric manifestations, responsive to steroid treatment and associated with Hashimotos thyroiditis. There are only a few reports suggesting that intravenous immunoglobulins (IVIG) might represent an efficacious treatment modality for the severe steroid-resistant HE cases. We presented a patient with HE who developed a complete recovery after the IVIG therapy followed by a long-lasting remission. CASE REPORT We described herien a female patient with the one-year history of autoimmune thyroiditis before the development of neuropsychiatric manifestations. In May 1999, a 38-year-old woman presented at the Institute of Neurology, Clinical Center of Serbia, Belgrade, with the brain-stem syndrome which responded well to steroid treatment. After detailed examinations, the diagnosis of Hashimotos encephalopathy was established. Two years later, in June 2001, new manifestations (unsteadiness in gait, personality changes, seizures, and persistent headache) gradually developed during a 6-month period. Response to steroids was unsatisfactory and partial, since headaches and personality changes had continuously worsened. In January 2002, the patient received IVIG (0.4 g/kg body weight daily for 5 days). Gradual improvement was noticed and a complete recovery developed over the following weeks. Up to March 2009, during a 7-year follow-up period, remission persisted. CONCLUSION To our best knowledge, this is the first report of a long-lasting remission of Hashimotos encephalopathy after IVIG therapy. Therefore, this case further supports administration of IVIG, as a potentially beneficial treatment modality, in severe cases of Hashimotos encephalopathy which are completely or partially resistant to steroids.

Anti-neutrophil cytoplasmic antibodies (ANCA) specific for one or several antigens: useful markers for subtypes of ulcerative colitis and associated primary sclerosing cholangitis.

Abstract Background: Dysregulation of antimicrobial response may trigger inflammatory bowel diseases (IBD). This study analyzed specificity of anti-neutrophil cytoplasmic antibodies (ANCA) in IBD patients and its clinical significance. Methods: Data from 52 ulcerative colitis (UC) patients with 32 Crohn’s disease (CD) patients were compared. Primary sclerosing cholangitis (PSC) was present in 12/84 patients. ANCA, ANA and anti-smooth muscle antibodies (ASMA) were detected by IIF. ANCA were tested by ELISA for proteinase 3 (PR3), myeloperoxidase, bactericidal/permeability increasing protein, elastase, cathepsin G, lysozyme and lactoferrin. Results: pANCA were more frequently present in UC than in CD patients (p<0.001). ANCA titer correlated with the disease activity only in UC patients (p<0.05). UC patients more frequently had two or more ANCA specificities compared to CD patients (p<0.01). Multi-specific ANCA in medium and/or high concentrations were associated with long-lasting (p<0.05) and left-sided UC (p<0.001). Multi-specific ANCA with ANA and ASMA had sensitivity of 67% for PSC. Conclusions: Higher concentrations of multi-specific ANCA in long-lasting, left-sided UC suggest an influence of bacterial stimulation on the break of tolerance. Multi-specific ANCA with ANA and ASMA could be markers for PSC. ANCA specific to several antigens may worsen inflammation by reducing antimicrobial capacity of neutrophil proteases and cationic proteins.

STRESS-INDUCED RISE IN SERUM ANTI-BRAIN AUTOANTIBODY LEVELS IN THE RAT

Sera from Wistar rats subjected to different stress procedures were tested by ELISA for the presence of autoantibodies with specificity for neuron-specific enolase (NSE) and S100 protein that are preferentially localized in neurons and glia, respectively. Autoantibodies were present in sera of animals before exposure to stress, and raised with age. Anti-NSE and anti-S100 autoantibody levels were increased one day after termination of restraint (2 hours daily, 10 days) and electric tail shock (80 shocks daily, 19 days), and in fifth and tenth week of overcrowding stress. Differences between stressed and control animals were not present one month following restraint and electric tail shock and in twentieth week of overcrowding.

Triple IgE-positivity to hornet, wasp and bee venom in a patient with anaphylaxis: Diagnostic and therapeutic approach

Introduction: Triple-positivity (TP) or double-positivity (DP) for serum-specific immunoglobulin (Ig) E antibodies (sIgE) against hornet venom (HV), wasp venom (WV) and/or honeybee venom (BV) causes significant problem in selection of appropriate venom immunotherapy (VIT). However, DP/TP can be caused by cross-reactions resulting either from partial sequence identity of protein allergens in the venoms or may be related to crossreacting carbohydrate determinants (CCDs). Case report: A 60-year-old man was stung by wasp and two days later by hornet. In both cases, within 15 minutes he developed hypotension and generalized urticaria and he was successfully treated with epinephrine, corticosteroids and fluids. After eight weeks examination revealed negative skin prick test for all three venoms, but sIgE-determination (ELISA) showed triple sensitization to native BV (0.55 IU/ml), WV (3.35 IU/ml) and HV (0.37 IU/ml). He received VIT with venom mixtures for one year. In order to distinguish true multiple sensitization from cross-reactivity we performed the molecular-allergy testing by ImmunCAP with the CCD-free recombinant major allergens. We demonstrated a high sensitization to Antigen 5-rVes v5 of WV (31.4 kU/l), while sIgE to phospholipase A2rApi m1 of BV (0.15 kU/l) was negative. sIgE to CCD-MUXF3-bromelain (0.75 kU/l) explained the sIgE-positivity for native BV. After these findings a VIT with only wasp venom was initiated. Conclusion: Triple-IgE-positivity to native venoms detected by ELISA in our patient was caused by cross-reactivity to carbohydrate determinants. We recommend the molecular-allergy testing with the nonglycosylated recombinant allergens before starting the allergen-specific immunotherapy in patients with multiple-sIgEpositivity to native Hymenoptera venoms.