Wim J. Stevens

ACQUIRED IMMUNODEFICIENCY SYNDROME IN A HETEROSEXUAL POPULATION IN ZAIRE

38 patients with the acquired immunodeficiency syndrome (AIDS) were identified in Kinshasa, Zaire, during a 3 week period in 1983. The male to female ratio was 1.1:1. The annual case rate for Kinshasa was estimated to be at least 17 per 100 000. Opportunistic infections were diagnosed in 32 (84%) patients, disseminated Kaposis sarcoma (KS) with opportunistic infection in 5 (13%), and disseminated KS alone in 1 patient. Immunological characteristics of these patients were as reported for cases in the USA and Europe, but immunological abnormalities were also found in 6 controls with infectious diseases but no symptoms of AIDS. Female AIDS cases were younger than male patients with AIDS (mean ages 28.4 vs 41.1 years, respectively), and were more often single (14/18 vs 2/20). Homosexuality, intravenous drug abuse, and blood transfusion did not appear to be risk factors in these patients. The findings of this study strongly argue that the situation in central Africa represents a new epidemiological setting for this worldwide disease--that of significant transmission in a large heterosexual population. Two instances of clusters of AIDS (not included in the above series) involving males and females with frequent heterosexual contact further implicate heterosexual transmission.

Increased Activity of Coagulation Factor XII (Hageman Factor) Causes Hereditary Angioedema Type III

Hereditary angioedema (HAE) is characterized clinically by recurrent acute skin swelling, abdominal pain, and potentially life-threatening laryngeal edema. Three forms of HAE have been described. The classic forms, HAE types I and II, occur as a consequence of mutations in the C1-inhibitor gene. In contrast to HAE types I and II, HAE type III has been observed exclusively in women, where it appears to be correlated with conditions of high estrogen levels--for example, pregnancy or the use of oral contraceptives. A recent report proposed two missense mutations (c.1032C-->A and c.1032C-->G) in F12, the gene encoding human coagulation factor XII (FXII, or Hageman factor) as a possible cause of HAE type III. Here, we report the occurrence of the c.1032C-->A (p.Thr328Lys) mutation in an HAE type III-affected family of French origin. Investigation of the F12 gene in a large German family did not reveal a coding mutation. Haplotype analysis with use of microsatellite markers is compatible with locus heterogeneity in HAE type III. To shed more light on the pathogenic relevance of the HAE type III-associated p.Thr328Lys mutation, we compared FXII activity and plasma levels in patients carrying the mutation with that of healthy control individuals. Our data strongly suggest that p.Thr328Lys is a gain-of-function mutation that markedly increases FXII amidolytic activity but that does not alter FXII plasma levels. We conclude that enhanced FXII enzymatic plasma activity in female mutation carriers leads to enhanced kinin production, which results in angioedema. Transcription of F12 is positively regulated by estrogens, which may explain why only women are affected with HAE type III. The results of our study represent an important step toward an understanding of the molecular processes involved in HAE type III and provide diagnostic and possibly new therapeutic opportunities.

Use of fluorescent dyes in the determination of adherence of human leucocytes to endothelial cells and the effect of fluorochromes on cellular function

A number of supravital fluorochromes are available to study leucocyte functions in vitro and in vivo. The fluorescein ester most widely used, fluorescein diacetate, has the disadvantage of rapid cellular efflux, whereas more recently developed fluorescent probes do not exhibit this inconvenient trait. However, their effect on cellular functions has not been thoroughly investigated in humans. In this study, we describe a simple and rapid fluorometric method for measuring cell adhesion to endothelium, comparing 5 different fluorochromes. Furthermore, we evaluated the effect of fluorescent dye labelling (with CFDA, CFSE, BCECF-AM, calcein-AM or DiI), on various cell functions, including, apart from adhesion, lymphocyte proliferation, granulocyte chemotaxis and superoxide production. calcein-AM and DiI proved to be the fluorochromes with the least effect on cellular function. BCECF-AM did not interfere with lymphocyte proliferation, but exhibited some influence on superoxide production and chemotaxis of granulocytes. CFDA showed a detrimental effect on both lymphocyte and granulocyte functions whereas CFSE gave intermediate results. In the adhesion assay, calcein-AM, CFSE and DiI performed comparably well. Since labelling with C12-DiI was homogeneous, this probe was also appropriate for the adhesion test, although somewhat higher background staining was present. We conclude that the fluorochromes are powerful tools when analysing the adhesion of human leucocytes to endothelial cells. However, since fluorochrome labelling can interfere with other cellular functions, the fluorescent probe has to be carefully chosen with regard to the cell type and function to be studied.

Cytokines and immune activation in systolic heart failure: the role of Type D personality.

The proinflammatory cytokine tumor necrosis factor-alpha (TNF-alpha) and its soluble receptors 1 (sTNFR1) and 2 (sTNFR2) are predictors of mortality in chronic heart failure (CHF) but the determinants of these increased levels of disease-promoting cytokines are largely unknown. Type D personality refers to the combination of the tendency to experience negative emotions (negative affectivity) and the tendency to inhibit the expression of emotions in social interaction (social inhibition). Type D is an independent predictor of cardiac events in coronary patients who are at risk for CHF. The present study examined the effect of Type D personality on TNF-alpha, sTNFR1, and sTNFR2 in 42 men with CHF (meanage=57.9+/-10.5 years). There was a significant multivariate effect of Type D on TNF-alpha measures (p=.006); i.e., circulating levels of TNF-alpha (4.8+/-0.9 versus 2.5+/-0.2 pg/ml, p=.003), sTNFR1 (1814+/-314 versus 1134+/-78 pg/ml, p=.014), and sTNFR2 (2465+/-243 versus 1874+/-118 pg/ml, p=.019) were significantly higher in Type D patients as compared to non-Type D patients. The effect size (ES) of Type D personality ranged from rather large (sTNFR1, ES=0.77; sTNFR2, ES= 0.73) to large (TNF-alpha, ES=0.90). After controlling for ischemic etiology and severity of heart failure, Type D personality emerged as an independent predictor of increased circulating levels of both TNF-alpha (OR=9.5, 95% CI 2.1-43.8, p=.004) and TNF-alpha receptors (OR= 6.1, 95% CI 1.4-25.8, p=.014). These findings are consistent with the prognostic power of Type D personality regarding long-term morbidity and mortality in patients with established coronary heart disease. This study suggests that individual differences in personality contribute to the psychoneuroimmunological aspects of heart failure.

LEUKOCYTOSIS, MONOCYTOSIS AND NEUTROPHILIA: HALLMARKS OF SEVERE DEPRESSION

To date, there has been a small number of reports that severe depression is accompanied by disturbances in total white blood cell (i.e. leukocytosis) and leukocyte subset (i.e. neutrophilia, monocytosis, lymphopenia) counts. These results, however, have not yet been validated in a large-scale, well-controlled study. To this end, we have counted the number of leukocytes, monocytes, lymphocytes and granulocytes (neutrophils, eosinophils, basophils) in 22 healthy controls and in 109 depressed inpatients. We noted leukocytosis in major depressed patients compared with normal subjects, whilst minor depressives manifested intermediate findings. Leukocytosis was significantly more pronounced in major depressed males compared with major depressed females. Major depression related leukocytosis appears to be characterized by neutrophilia and monocytosis. There was a significant positive relationship between the overall severity of illness on one hand, and the degrees of leukocytosis, neutrophilia and monocytosis on the other. The total number of both phagocytic cell populations (i.e. monocytes and neutrophils) was significantly and positively related. Our results might point to the existence of an inflammatory process in major depressed subjects, particularly in males.

The immune-inflammatory pathophysiology of fibromyalgia: increased serum soluble gp130, the common signal transducer protein of various neurotrophic cytokines

Fibromyalgia is a chronic, painful musculoskeletal disorder characterized by widespread pain, pressure hyperalgesia, morning stiffness and by an increased incidence of depressive symptoms. The etiology, however, has remained elusive. The aim of the present study was to examine the inflammatory response system (IRS) in fibromyalgia. Serum interleukin-6 (IL-6), soluble IL-6 receptor (sIL-6R), sgp130, sIL-1R antagonist (IL-1RA) and sCD8 were determined in 33 healthy volunteers and in 21 fibromyalgia patients, classified according to the American College of Rheumatology criteria. Severity of illness was measured with several pain scales, dolorimetry and the Hamilton Depression Rating Scale (HDRS). Serum sgp130 was significantly higher and serum sCD8 significantly lower in fibromyalgia patients than in healthy volunteers. Serum sIL-6R and sIL-1RA were significantly higher in fibromyalgia patients with an increased HDRS score (> or = 16) than in normal volunteers and fibromyalgia patients with a HDRS score < 16. In fibromyalgia patients, an important part of the variance in sCD8 (50.3%) and IL-1RA (19.3%) could be explained by the HDRS score; 74.3% of the variance in sIL-6R was explained by the combined effects of pain symptoms and the HDRS score; and 25.9% of the variance in serum sgp130 was explained by stiffness. The results support the contention that pain and stiffness in fibromyalgia may be accompanied by a suppression of some aspects of the IRS and that the presence of clinically significant depressive symptoms in fibromyalgia is associated with some signs of IRS activation.

Flow cytometric analysis of in vitro activated basophils, specific IgE and skin tests in the diagnosis of pollen-associated food allergy

Specific immunoglobulin E (IgE) and commercially available skin prick tests have been demonstrated to be unreliable methods to diagnose pollen‐associated food allergy. To evaluate the predictive value of the basophil activation test (BAT) in pollen‐associated food allergy, the apple‐mediated oral allergy syndrome (OAS) in patients with birch pollinosis was chosen as a representative model.

Contact allergic dermatitis and life-threatening anaphylaxis to chlorhexidine.

A 43-year-old nonatopic man was seen with a history of dyspnea, shock, and S-T segment elevations in the inferior leads of his electrocardiogram after disinfection of a drain insertion site with a chlorhexidine digluconate 2% solution. His personal history revealed a similar reaction 15 minutes after anesthesia was achieved with a preoperative administration of cephazolin; application of povidone-iodine; and the use of propofol, atracurium, and sufentanil. Macromolecular plasma expanders were not infused, and exposure to chlorhexidine was not mentioned. He also recalled two episodes of a rash at surgical incision areas, which, in the presence of an infiltrated, papular, and vesicular patch test for chlorhexidine digluconate 0.5% solution and Hibitane, was diagnosed as contact dermatitis to the antiseptic. Total serum IgE was 480 kU/L. Serum-specific IgE test results for latex, ethylene oxide, chloramine, penicilloyl G, penicilloyl V, and amoxicillin (Upjohn-Pharmacia CAP System, Brussels, Belgium) were negative. Lymphocyte transformation test results with chlorhexidine (10 mg/ ml), sufentanil (0.005 mg/ml), vecuronium (10 mg/ml), atracurium (10 mg/ml), propofol (10 mg/ml), and cephazolin (10 mg/ml) were negative (stimulation index ,2). Skin prick test (SPT), intradermal test (IDT), and subcutaneous test results with nonammoniated latex (IDT, 10–3 mg/ml), alcohol 70% (SPT, undiluted), 100 mg/ml povidone-iodine (SPT, undiluted), 50 mg/ml cephazolin (SPT, undiluted), 2.5 mg/ml bupivacaine (subcutaneous test, undiluted), 10 mg/ml propofol (IDT, 10–2 mg/ml), 2 mg/ml etomidate (IDT, 10–2 mg/ml), 5 mg/ml sufentanil (IDT, 10–2 mg/ml), 4 mg/ml vecuronium (IDT, 10–2 mg/ml) and 10 mg/ml atracurium (IDT, 10–2 mg/ml) were negative. A SPT result with chlorhexidine digluconate 2% in alcohol 70% was positive (SPT 10–4, wheal/flare, 5/13 mm). Patch test results showed a delayed hypersensitivity to cetrimide 0.1%, chloroxylenol 1%, chloramine 0.5%, and iodine 0.25%, but they were negative for hexamidine 0.15%, thiomerosal 0.1%, Mercurochrome 2%, eosine 50%, and Chlorophen. DISCUSSION

Significantly increased expression of T-cell activation markers (interleukin-2 and HLA-DR) in depression : further evidence for an inflammatory process during that illness

1. Recently, the authors have reported that severe depression may be accompanied by a systemic immune activation with an increase in the number of T cells expressing activation receptors. 2. The present large-scale study examines specific T (CD2+HLADR+ and CD7+CD25+) and B (CD7-CD25+) cell activation markers in depressed inpatients and normal volunteers together with the number of leukocytes and monocytes. 3. The authors have established that depression is characterized by a significantly increased expression of T cell activation receptors (CD7+CD25+) and by the appearance of previously unexpressed T cell surface markers (CD2+HLADR+). There was a significant and positive correlation between the number of CD7+CD25+ cells and monocytes, with the expression of the HLADR and CD25 T cell activation markers being significantly and positively correlated. Up to 64% of all depressed subjects exhibit an increased expression of these activation markers with a specificity of 91%. 4. The normal control group and the depressive sample constitute two discrete classes (i.e., qualitatively distinct groups) with respect to the expression of these activation markers and leukocytosis. 5. It is concluded that our results are compatible with the presence of T-cell activation in a considerable number of depressed patients.

Increased IL-17 production by peripheral T helper cells after tumour necrosis factor blockade in rheumatoid arthritis is accompanied by inhibition of migration-associated chemokine receptor expression

OBJECTIVES The contribution of IL-17-producing Th17 cells to the pathogenesis of T-cell-mediated inflammatory disorders such as RA and atopic dermatitis (AD) has to be viewed in relation to the role of Th1/Th2 cells and long-recognized key cytokines like TNF. We aimed to study the frequency and migration-associated phenotype of peripheral Th17, Th1 and Th2 cells in healthy individuals, RA and AD patients, and to study the influence of anti-TNF therapy in RA. METHODS Intracellular IL-17, IFN-γ and IL-4 production and CC-chemokine receptor CCR4 and CCR6 expression were analysed flow cytometrically in peripheral memory Th cells from healthy individuals, AD and RA patients. The latter were grouped by disease activity and presence or absence of adalimumab therapy. In RA patients initiating anti-TNF therapy, cytokine production by in vitro-stimulated peripheral mononuclear cells was measured by cytometric bead array. RESULTS The peripheral Th17 cell frequency is elevated in AD but not in RA. In RA, Th17 cells and IL-17 production increase after anti-TNF therapy, irrespective of disease activity. Th1 cells and IFN-γ production are elevated in remission and under anti-TNF therapy. CCR6 expression is up-regulated in Th17 cells, but RA patients in remission under anti-TNF therapy have significantly lower expression than those with active disease. CONCLUSIONS The increase in peripheral Th17 cells in RA patients after anti-TNF therapy is accompanied by a decrease in Th17-specific CCR6 expression, which might prevent homing of these potentially pro-inflammatory cells to the synovium.