Antibodies to cytoplasmic antigens in lupus erythematosus

Seven patients with classic cutaneous lupus ery-thematosus are described. Three of these patients had features satisfying four of the American Rheumatism Association (ARA) preliminary criteria for the diagnosis of systemic lupus erythematosus (SLE). Their sera, however, lacked antinuclear antibodies but demonstrated precipitating antibodies reactive against cytoplasmic RNP (La) and non-nucleic acid (Ro) antigens. Four additional ANA-negative patients lacking significant skin disease but having a lupus-like multisystem disease were found to have antibodies to soluble cytoplasmic antigens. Thirty-three of 130 ANA-positive SLE patients, but none of 16 discoid lupus patients, possessed these anticytoplasmic antibodies. These findings suggest that antibodies to Ro and La may be a marker for systemic disease in ANA-negative patients with 1) cutaneous lupus and 2) a distinct sub-population of patients with a lupus-like syndrome without skin disease.     

Antiphospholipid antibodies in a series of 25 cases of lupus without antinuclear antibodies. Comparison with a series of 91 lupus patients with antinuclear antibodies

Twenty-five patients with at least 3 of 1982 ARA criteria of SLE but without the ANA, were compared with 91 patients with 4 or more of the ARA criteria of lupus with positive ANA. The ANA-negative group was characterised by the low incidence of skin involvement, serous effusions and alopecia, and a relatively high incidence of thrombocytopaenia and venous and arterial thrombosis. Three types of antiphospholipid antibodies were looked for: the VDRL, antiprothrombinase and anticardiolipin antibodies by an immuno-enzymatic method. The VDRL was the only antibody which was significantly commoner in the ANA-negative group. Statistical studies showed that the three methods of demonstrating antiphospholipid antibodies detected crossed but not identical specificities. In the ANA-positive group only the antiprothrombinase was associated with a high incidence of venous thrombosis and stroke. In the ANA-negative group, only the anticardiolipin antibodies were associated with a high incidence of arterial or venous thrombosis. Two subgroups may be identified in the group of ANA-negative lupus patients: firstly, those with high anticardiolipin antibody titres with a high incidence of thrombotic and haematological complications, and, secondly, patients with low anticardiolipin antibody levels with a high incidence of cutaneous involvement, serous effusions and Raynaud's phenomenon.     

A novel autoantigen to differentiate limited cutaneous systemic sclerosis from diffuse cutaneous systemic sclerosis: the interferon-inducible gene IFI16

OBJECTIVE: To investigate the presence and clinical significance of autoantibodies against the interferon-inducible gene IFI16 in systemic sclerosis (SSc), systemic lupus erythematosus (SLE), and other autoimmune diseases. METHODS: Immunohistochemical analysis was used to evaluate the expression of IFI16 in skin biopsy specimens obtained from patients with SSc and patients with SLE. Levels of antibodies against IFI16 in sera from 82 patients with SSc and 100 patients with SLE were determined by enzyme-linked immunosorbent assay. Other autoimmune diseases such as primary Sj?gren's syndrome (SS), rheumatoid arthritis (RA), chronic urticaria, and hepatitis C virus (HCV) infection were also examined. RESULTS: Expression of IFI16 was greatly increased and was ubiquitous in all layers of the epidermis and in the dermal inflammatory infiltrates of lesional skin from both patients with SLE and patients with SSc. Patients with SLE, those with primary SS, and those with SSc exhibited significantly higher anti-IFI16 IgG antibody levels compared with normal controls (for SLE, P < 0.002; for primary SS, P < 0.001; for SSc, P < 0.0005). Anti-IFI16 titers above the ninety-fifth percentile for control subjects were observed in 26% of the patients with SLE, 50% of those with primary SS, and 21% of those with SSc (28% of patients with limited cutaneous SSc [lcSSc] versus 4% of patients with diffuse cutaneous SSc [dcSSc]). In contrast, the prevalence of anti-IFI16 was 4% in patients with RA, 5% in those with chronic urticaria, and 13% in those with HCV infection. CONCLUSION: The results of this study provide evidence that an IFN-inducible gene, IFI16, may be involved in the pathophysiologic mechanisms of connective tissue disorders such as SSc. Moreover, a strict correlation with lcSSc was also demonstrated, thus providing a novel tool in the differential diagnosis of lcSSc from dcSSc.     

Cutaneous sensitivity and in vitro responsiveness of lymphocytes in patients with disseminated coccidioidomycosis.

Sixty-eight of 74 patients with disseminated coccidioidomycosis demonstrated cutaneous reactivity to intradermal injectionof coccidioidin. Lymphocytes of all patients with positive skin test results underwent blast transformation in vitro in response to coccidioidin. No correlation was found between the size of skin test induration and the magnitude of in vitro lymphocyte response. Six patients with disseminated disease failed to demonstrate cutaneous reactivity to coccidioidin; however, lymphocytes of three of these patients responded with blast transformation in vitro. The lymphocyte reactivity of two of these three patients was abrogated by addition of autologous plasma to the culture medium. Autologous plasma did not block the patient's in vitro response to phytohemagglutinin or allogeneic lymphocytes, and blocking did not appear to be attributable to direct neutralization of coccidioidin.     

Hypersensitivity to molybdenum as a possible trigger of ANA-negative systemic lupus erythematosus.

After implantation of two metal plates a 24 year old woman developed fever of unknown origin and successively more symptoms of an ANA-negative systemic lupus erythematosus (SLE). These symptoms resolved after removal of the plates and recurred during patch testing of the metal components, which showed a reaction to molybdenum. A lymphocyte transformation test indicated a delayed-type hypersensitivity to molybdenum. Subsequent progressive flare ups of SLE appeared without molybdenum reexposure. This is the first report suggesting the existence of a hypersensitivity to molybdenum, which may act as another environmental trigger for SLE.     

Two cases of antinuclear antibody negative lupus showing increased proportion of B cells lacking RP105

B cells lacking RP105 molecule, a member of the Toll-like receptor family, were increased in the peripheral blood of 2 patients with antinuclear antibody (ANA) negative systemic lupus erythematosus (SLE). The increased proportion of RP105-lacking B cells was associated with disease activity in patients with ANA-negative SLE. When there are no significant serological markers for SLE, analysis of expression of RP105 may be helpful in evaluation of activity in ANA-negative SLE. We describe a new approach, using phenotyping of B cells, to evaluate activity of ANA-negative SLE.     

Do antinuclear antibodies in primary biliary cirrhosis patients identify increased risk for liver failure?

BACKGROUND & AIMS: Primary biliary cirrhosis (PBC) is a chronic cholestatic liver disease with a variable clinical course. Identification of serologic markers associated with increased risk of liver failure would assist in management of PBC patients. The objective of this study was to identify antinuclear antibody (ANA) markers that may be used to predict PBC outcome. METHODS: Indirect immunofluorescence was used to identify ANAs in 492 PBC patients. chi2 and Kaplan-Meier analyses were used to examine the association between ANAs and liver failure. RESULTS: A greater percentage of ANA-positive, compared to ANA-negative, PBC patients developed liver failure (41% vs 25%, P = .005). The presence of anti-centromere antibodies was associated with liver failure (anti-centromere antibody positive vs negative, 58% vs 33%, P = .001). The time to liver failure was shorter in ANA-positive, compared with ANA-negative, patients (log rank score 5.8, P = .02). After 8.9 years (the median follow-up for patients without liver failure), 68% of ANA-positive and 81% of ANA-negative patients were free of liver failure. Anti-centromere antibodies were also associated with a shorter time to liver failure (log rank score 8.4, P = .004). After 8.9 years, 52% of anti-centromere antibody positive and 74% of anti-centromere antibody negative patients were without liver failure. CONCLUSIONs: ANAs in general, and anti-centromere antibodies in particular, are associated with liver failure in PBC. PBC patients with ANAs may be candidates for treatment with experimental therapies to prolong the interval between diagnosis and liver failure. ANA-negative patients, who appear to have a relatively benign clinical course, should perhaps be treated with ursodeoxycholic acid alone.     

DNA antibodies and complement in SLE patients

Sixty-seven patients with systemic lupus erythematosus (SLE) were followed up for 3-19 months (mean 12) in a prospective study. The activity of SLE was estimated on clinical grounds and correlated with DNA antibody and complement levels. The disease reactivations consisted mostly of articular and cutaneous symptoms. There were 17 relapses and 22 complicating infections during the follow-up period. The levels of antibodies to native, double-stranded (ds) DNA (P less than 0.001) and antibodies to denatured, single-stranded (ss) DNA of IgG class (P less than 0.001) and C3 (P less than 0.001) correlated best with disease activity, which was estimated on the clinical symptoms and signs. These assays were not reliable, however, in predicting minor exacerbations. The levels of IgM class ss-DNA antibodies were significantly higher in SLE patients without nephritis than in SLE nephritis patients. In most cases, the combination of IgG class ss-DNA antibody and complement (C3 and CH50) determinations differentiated SLE relapse from infection.     

Diagnosis of lupus nephritis by skin immunofluorescence, in the absence of extrarenal manifestations of systemic lupus erythematosus.

Six patients with glomerulonephritis were found to have granular deposits of complement and/or immunoglobulins at the dermalepidermal junction of normal skin. No patient had extrarenal clinical manifestations of systemic lupus erythematosus (SLE). The only serologic test suggestive of SLE was a positive antinuclear antibody (ANA) reaction; results of complement and antinative deoxyribonucleic acid (DNA)-antibody tests were repeatedly normal. The patients with glomerulonephritis had a favorable initial response to therapy with prednisone with or without azathioprine. These patients may represent a variant of SLE in which the diagnosis can only be established by a direct immunofluorescence test of normal skin. Alternatively, they may constitute a separate new clinical entity. Because of the favorable response to therapy, we suggest that skin immunofluorescence be performed in patients who present with unexplained glomerulonephritis and a positive ANA.     

系统性红斑狼疮患者循环抗皮肤基底膜带抗体及其与临床的相关性研究

目的了解抗皮肤基底膜带(BMZ)抗体在系统性红斑狼疮(SLE)患者循环中的存在情况,探讨其与临床的相关性。方法采用间接免疫荧光法检测70例SLE患者血清抗BMZ抗体,并分析其与SLE的临床表现、免疫指标的相关性。结果47例(67%) SLE患者存在循环抗BMZ抗体,其中IgG>IgM>IgA;抗体主要结合于盐裂皮肤的表皮侧,少数可结合于真皮侧或表、真皮两侧;伴皮肤损害的SLE患者循环抗BMZ抗体阳性率明显高于无皮肤损害者(P<0.05);病情处于活动期或伴肾脏损害、关节炎、脱发、光敏感、抗dsDNA抗体阳性的SLE患者与病情处于稳定期或不伴以上临床表现、抗dsDNA抗体阴性的患者比较,其抗BMZ抗体的阳性率差异无显著性。结论SLE患者循环中存在较高发生率的抗BMZ抗体,具有抗体/抗原的异质性;抗BMZ抗体的出现与SLE皮肤损害有关,而与病情活动、其他临床表现、抗dsDNA抗体无关;抗BMZ抗体可能参与了SLE皮肤损害的免疫机制。     

The composition of the lupus band test (LBT) on the sun-protected non-lesional (SPNL) skin in patients with cutaneous lupus erythematosus (CLE)

The objective of this study was to analyse the different immunoreactants at the dermo-epidermal junction (DEJ) of patients with cutaneous lupus erythematosus (CLE). Sun-protected non lesional (SPNL) skin biopsies from 65 patients with specific cutaneous manifestations of LE and from 18 patients with other dermatologic diseases were tested using the direct immunofluorescence (DIF) technique. Nineteen out of 65 patients with CLE were affected by systemic LE (SLE). We used the conventional chi-squared test to analyse statistical differences between CLE-SLE and CLE-non-SLE groups in the immunological composition of lupus band test (LBT). C3 was the most common component while IgM were the most frequent immunoglobulins (Igs) of LBT in LE patients. No immunoreactants could be demonstrated at the DEJ in patients with other dermatologic diseases. No statistical differences could be found between CLE-SLE and CLE-non-SLE groups as regards the detection of the different immunoreactants at the DEJ. A positive LBT (even for the presence of only one immunoreactant at the DEJ) performed on SPNL skin represents a useful and specific criterion to distinguish patients with lupus erythematosus (LE) from those without LE. We also believe in a prognostic value of a positive LBT on SPNL skin when the deposition of at least two immunoreactants is demonstrated, and especially if the deposits are composed of IgG.     

High risk of human papillomavirus type 16 infections and of development of cervical squamous intraepithelial lesions in systemic lupus erythematosus patients

OBJECTIVE: To determine rates of human papillomavirus (HPV) infections, abnormal cervical smears, and squamous intraepithelial lesions (SIL) among women with systemic lupus erythematosus (SLE). METHODS: We investigated 30 women with SLE, 67 with abnormal smears from colposcopy clinics, and 15 community subjects with normal smears. Polymerase chain reaction results for viral DNA and HPV-16 sequencing data were correlated to cytology and colposcopic findings. RESULTS: SLE and colposcopy patients were more likely (P < 0.05) to be HPV positive (15 [54%] and 37 [67%] patients, respectively) and HPV-16 DNA positive (16 [57%] and 17 [31%] patients, respectively) than community subjects (0% HPV DNA positive and 1 [6%] HPV-16 DNA positive). SLE patients were also more likely to be HPV-16 DNA positive than colposcopy patients (P < 0.05). SLE patients with a high HPV-16 viral load more frequently had SIL (n = 6) than those with a low HPV-16 viral load (n = 1; P < 0.05). HPV and HPV-16 DNA positivity were not associated with previous or current drug therapy for SLE patients. All HPV-16 DNA sequences from 6 SLE and 5 colposcopy patients were the European-type variant. Eighteen (60%) SLE patients had a previous or current cervical abnormality. At the time of study, 5 (17%) SLE patients had an abnormal cervical smear and 8 (27%) had SIL. For those diagnosed with SLE for >10 years, the rate of SIL was 44% lower than those with SLE for <5 years (odds ratio 0.56, 95% confidence interval 0.1-3.5). CONCLUSION: UK women with a recent SLE diagnosis had disturbingly elevated levels of HPV infections (particularly with European HPV-16 variants at a high viral load), abnormal cervical cytology, and SIL.     

Outcome of incomplete systemic lupus erythematosus after 10 years

The objective was to identify cases of incomplete systemic lupus erythematosus (SLE) within a defined population in southern Sweden, risk factors for development of complete SLE (> or = 4 classification criteria) and study outcome of the patients. During prospective retrieval of SLE cases within a defined population in southern Sweden, 28 patients (26 women, two men) with incomplete SLE (< 4 ACR criteria) were identified between 1981 and 1992. All patient records were reviewed and clinical and laboratory data were extracted from standardized formats. Organ damage was defined according to the SLICC/ACR damage index. During follow-ups, 16 of 28 patients developed complete SLE (median 13 years; range 10-20 years). The time to develop complete SLE varied between one and ten years with a median time of 5.3 years. Three patients were anti-DNA positive at inclusion; only one of them developed complete SLE. False positive Wasserman reaction and anti-cardiolipin antibodies (aCl) were only found in patients who developed complete SLE (P < 0.04; Fisher exact test). Six patients had malar rash from the start and they all had complete SLE at follow-up (P < 0.04; Fisher exact test). Of eight patients with arthritis, three developed complete SLE. Thrombocytopenia was only found in two patients, both developing complete disease. At follow-up, patients that developed complete SLE had high SLICC damage scores (mean 1.5) compared with patients that remained as incomplete SLE (mean 0.16). In conclusion, in this follow-up study of patients with incomplete SLE 57% developed complete disease after a median time of 5.3 years. Malar rash and aCl were predictors of complete SLE. Individuals that developed complete SLE were more prone to organ damage.     

Enzyme immunoassay for antibodies to native DNA. Specificity and quality of antibodies

An enzyme immunoassay was developed to detect antibodies to native DNA; DNA coating conditions that maximized sensitivity, specificity, and reproducibility were selected. Sera of patients with systemic lupus erythematosus (SLE) were positive more frequently by this immunoassay than by the Crithidia luciliae assay or by counterimmunoelectrophoresis. By enzyme immunoassay, 94% of sera with active SLE and 70% of sera from patients with inactive SLE were positive, as were 16% from those suspected of having SLE, and 2.5% of normal persons. Specificity for native DNA was shown for both SLE and normal sera by inhibition studies and by S1 nuclease treatment of polystyrene-bound native DNA. The enzyme immunoassay correlated more with serum hemolytic complement levels that did the other 2 assays, suggesting that it detects biologically more relevant anti-DNA antibodies than do the other 2 tests.     

Antinuclear antibody-negative systemic lupus erythematosus in a case with pregnancy

We described a 30-year-old pregnant woman developing antinuclear antibodies (ANA)-negative systemic lupus erythematosus (SLE) accompanied with arthritis, malar rash, lymphopenia, autoimmune hemolytic anemia, pericardial and pleural effusion, proteinuria and seizures. All serum autoantibodies except anti-Ro antibody were negative. An artificially induced abortion was performed to prevent SLE deterioration. Steroid and cyclophosphamide therapy were effective for this patient. During the 2-year follow-up period, her ANA and other SLE-related autoantibodies in serum remained negative. This case suggests that ANA may not be required in the pathogenesis of SLE, even in the case with pregnancy, and ANA-negative SLE may also have a dangerous clinical course.     

Enzyme immunoassay for antibodies to native DNA

An enzyme immunoassay was developed to detect antibodies to native DNA; DNA coating conditions that maximized sensitivity, specificity, and reproducibility were selected. Sera of patients with systemic lupus erythematosus (SLE) were positive more frequently by this immunoassay than by the Crithidia luciliae assay or by counterimmunoelectrophoresis. By enzyme immunoassay, 94% of sera with active SLE and 70% of sera from patients with inactive SLE were positive, as were 16% from those suspected of having SLE, and 2.5% of normal persons. Specificity for native DNA was shown for both SLE and normal sera by inhibition studies and by S1 nuclease treatment of polystyrene-bound native DNA. The enzyme immunoassay correlated more with serum hemolytic complement levels than did the other 2 assays, suggesting that it detects biologically more relevant anti-DNA antibodies than do the other 2 tests.     

Abnormalities of delayed hypersensitivity in systemic lupus erythematosus

Abnormalities of delayed hypersensitivity were found in patients with active systemic lupus erythematosus (SLE). The following immune responses were noted in 39 patients with SLE compared to 30 normal controls: (1) delayed hypersensitivity skin test responses to purified protein derivative (PPD) and trichophyton were significantly reduced in the patients with SLE, (2) in vitro lymphocyte transformation to PPD was normal, (3) the majority of patients with SLE had circulating antibodies to native deoxyribonucleic acid (nDNA), (4) these patients did not exhibit increased skin test responses or lymphocyte transformation to nDNA. The impairment in delayed hypersensitivity to PPD and trichophyton suggests that skin testing with PPD is inadequate to screen patients with SLE for tuberculosis. Furthermore, frequent infections which occur in some patients with SLE may result in part from their impaired cellular immune responses. The dissociation between skin response and lymphocyte transformation to PPD suggests that defects in cellular immunity may be selective. The dissociation between humoral and cellular immunity to nDNA suggests that control mechanisms exerted on one or both of these responses may be defective in SLE.     

The prevalence and significance of positive antinuclear antibodies in patients with fibromyalgia syndrome: 2-4 years' follow-up

The aim of this study was to ascertain whether fibromyalgia patients with positive ANA develop other features of connective tissue disease over 2-4 years' follow-up. Patients attending our clinic with a diagnosis of fibromyalgia were identified. All ANA-positive patients (n = 12) were recruited and matched for age and sex with 12 ANA-negative FMS patients. As further control groups, patients with a diagnosis of osteoarthritis (OA) were included. A screening questionnaire for possible features of connective tissue disease was sent to all participants. Patients who had three or more positive criteria were invited for further assessment. The ANA-positive rate was 12/137 (8.8%) in FMS and 20/225 (8.9%) in OA patients. All ANA positivity was at a low titre. Fourteen out of 20 (70%) FMS patients and 17/30 (56.7%) OA patients had three or more criteria (P = 0.34). No significant differences in the number of the positive criteria were found between those who were ANA positive or negative in both groups. On full assessment we found one patient who fulfilled the criteria for SLE from the ANA-positive FMS group and one in the ANA-negative group who fulfilled the criteria for primary Sj?gren's syndrome. Of the patients with OA, one who was ANA positive was diagnosed as having rheumatoid arthritis. The results from our study show that ANA (at least in low titre) is not a good predictor of the future development of connective tissue.     

ANA-negative systemic lupus erythematosus.

The presence of antinuclear antibodies (ANA) in serum is generally considered a decisive diagnostic sign of systemic lupus erythematosus (SLE). Ten patients with clinical signs of disease but persistent negative tests for ANA are examined in this study. Hair fall, Raynaud's phenomenon and recurrent oral ulcers were common in the ANA-negative group. ANA-negative SLE seems to be a subgroup of SLE that has not previously been given adequate attention.     

Presence of cutaneous interferon-alpha producing cells in patients with systemic lupus erythematosus

Systemic lupus erythematosus (SLE) patients have increased levels of interferon-alfa (IFN-alpha) in the circulation but a reduced number of functionally intact natural IFN-alpha producing cells (IPC) in peripheral blood. In search for tissue localisation of activated IPC, we investigated skin biopsies from SLE patients for the occurrence of such cells. Eleven SLE patients with inflammatory skin lesions and six healthy controls were biopsied. An immunohistochemical technique (IH) and in situ hybridisation (ISH) were used to detect intracellular IFN-alpha protein and IFN-alpha mRNA, respectively. In all 11 biopsies from SLE lesions, a high number of IPC were detected by IH. In the nonlesional SLE biopsies we could also demonstrate IPC in 10/11 patients. In 6/11 SLE patients, IFN-alpha mRNA containing cells could be detected in the specimens. A low number of IPC were detected in 1/6 healthy controls by IH, but no ISH positive cells were seen. Our results demonstrate that SLE patients have active IPC in both dermal lesions and in noninflammatory skin. A recruitment of IPC from blood to peripheral tissues may explain the low number of circulating natural IPC in SLE patients. Because the type I IFN system is involved in the SLE disease process, these results are of interest for the understanding of the pathogenesis in SLE.