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We prospectively assessed the value of anti-neurtrophil cytoplasmic autoantibodies (ANCA) and nuclear or perinuclear anti-neutrophil autoantibodies measured by indirect immunofluorescence microscopy and antimyeloperoxidase autoantibodies measured by a solid-phase assay in the diagnosis of idiopathic (pauci-immune) necrotizing-crescentic glomerulonephritis (NCGN) and renal vasculitis at our institution. A diagnosis was established on the basis of clinical and renal biopsy findings, and follow-up continued for at least 6 months. ANCA were measured at the conclusion of the study. Of the 111 study patients, 28 had NCGN and renal vasculitis. The immunofluorescence assay had 50% sensitivity and 79% specificity. The combination of the enzyme-linked immunosorbent assay for antimyeloperoxidase autoantibodies and the immunofluorescence assay for cytoplasmic ANCA had 78% sensitivity and 84% specificity. A firm diagnosis was established before the determination of ANCA in 26 of the 28 patients with NCGN and renal vasculitis. The antimyeloperoxidase autoantibody values would have suggested the diagnosis in the other two patients. Of these 28 patients, 5 had negative ANCA results. High antimyeloperoxidase autoantibody values were detected in patients with NCGN and renal vasculitis, whereas lower values were less specific and were detected mainly in patients with anti-glomerular basement membrane antibody disease and lupus glomerulonephritis.

The clinical spectrum of seventy-six consecutive c-ANCA positive patients is described and its relation to clinical classification schemes for Wegener’s granulomatosis (WG) is investigated. c-ANCA detection by immunofluorescence (IF) is compared to detection by two different ELISA systems.

Alteration of creatine kinase BB-isoenzyme (CK-BB) was investigated in the vulnerable CA1 region of the hippocampus of ischemic and postischemic gerbil brains using immunoelectron microscopy. CK-BB existed in the neuronal perikarya, dendrites and axons as well as in astroglias in the normal gerbil brain. Immunocytochemical reaction products were associated with microtubules and polyribosomes. Propagation of ischemic and postischemic damage with disintegration of microtubules was observed in the dendro-somatic direction in neurons, which progressed in parallel with dispersion and loss of the immunocytochemical reaction for CK-BB in the dendroplasm. After reperfusion for longer than 24 h, CK-BB was also observed in the extracellular space. The present result supported the notion that loss of the immunohistochemical reaction for CK-BB which has been observed by light microscopy after cerebral ischemia, was at least partly due to dispersion of this enzyme caused by disintegration of microtubules and extracellular leakage of this enzyme, although other processes, including degradation of CK-BB per se, were also possible. The loss of CK-BB from the neuronal structure may delay the recovery from ischemic damage and may eventually lead to neuronal death.

Serologic tests are frequently ordered as the initial step in the diagnosis of celiac disease. Newly developed tests for deamidated gliadin antibodies and tissue-transglutaminase antibodies measured by enzyme linked immunosorbent assay (ELISA) have better accuracy than native gliadin antibodies for celiac disease. In contrast to ELISA, multiplex immunoassay measures multiple autoantibodies simultaneously thereby decreasing processing time and facilitating panel testing. In this study, we compared multiplex immunoassay and ELISA methods for diagnostic accuracy of deamidated gliadin antibodies and tissue transglutaminase antibodies. Serum samples from 92 biopsy-proven, untreated celiac patients (46% with total villous atrophy and 54% with partial villous atrophy) and 124 biopsy-proven non-celiac controls were tested by multiplex immunoassay (QUANTA Plex Celiac IgA and IgG Profile, INOVA Diagnostics, Inc) and ELISA methods (QUANTA Lite, INOVA Diagnostics, Inc) for deamidated gliadin IgA and IgG and tissue-transglutaminase IgA and IgG antibodies. The sensitivity, specificity and accuracy of each single test and the combination of tests are summarized in the table below. The combination tests did not increase the sensitivity dramatically. Diagnostic indices of the tests and the combination tests measured by multiplex methods did not differ significantly from those measured by ELISA. The two methods showed excellent agreement for all tests except tissue-transglutaminase IgG. In conclusion, the multiplex immunoassay method is as accurate as the combination of ELISAs for celiac disease diagnosis and has practical advantages for testing in the clinical laboratory. Diagnostic indices of serologic tests for celiac disease diagnosis by Multiplex versus ELISA methods

Primary biliary cirrhosis is a progressive disease of the liver characterized by the immunologic destruction of bile ducts; effective therapy is lacking. We therefore evaluated the safety and efficacy of low-dose cyclosporine in 29 patients with primary biliary cirrhosis without evidence of damage to the lobular architecture (precirrhotic disease) or portal hypertension. The patients were randomly assigned to receive either cyclosporine (4 mg per kilogram of body weight per day) or placebo. After one year 17 of the 19 patients assigned to cyclosporine had improvement or stability in their degree of fatigue, and 18 in their degree of pruritus. In contrast, among the 10 patients assigned to placebo, fatigue increased in 4 (P less than 0.06) and pruritus worsened in 6 (P less than 0.001). Those assigned to cyclosporine also had significant decreases in serum levels of bilirubin, alanine aminotransferase, alkaline phosphatase, gamma globulin, and the titer of antimitochondrial antibodies. For the 20 patients who have completed two years in the study, liver biopsies (coded specimens) showed evidence of histologic progression in only 1 of 13 patients in the cyclosporine group, as compared with 5 of 7 in the placebo group (P less than 0.003). No patient has permanently discontinued cyclosporine because of side effects; however, signs of nephrotoxicity developed in 12 of 19, and 9 of 19 had increased blood pressure. We conclude that in patients with precirrhotic primary biliary cirrhosis, immunosuppressive therapy with cyclosporine is promising and deserves further evaluation.

Previous studies have described significant elevations in the concentrations of secretory immunoglobulin A (sIgA) in bronchial washings obtained from cancerous lungs. To date, there have been no prospective investigations examining the predictive value of sIgA measurements in clinically relevant settings. Our goal was to determine if measurement of sIgA in bronchoalveolar lavage (BAL) at the time of bronchoscopic evaluation of potentially malignant lung nodules might prospectively predict the presence of cancer. We observed no significant increase in the sIgA obtained from eight BALs obtained from cancerous lungs as ***compared with BALs taken from these same patients' contralateral cancer-free lungs. We also saw no significant difference in BAL (sIgA) obtained from patients eventually found to have cancer (N = 8) as compared with those found to have noncancer diagnoses (N = 6). In light of these findings, we think it unlikely that measurement of sIgA will be clinically useful in the diagnosis of pulmonary malignant neoplasms.

Background The pathogenic significance of antineutrophilic cytoplasmic antibodies (ANCA) in Wegener's granulomatosis is controversial. Their presence is influenced by the extent, severity, and activity of the disease at the time of sampling. The objective of this study was to determine the frequency of ANCA in patients with active Wegener's granulomatosis and to assess the influence of disease severity on test results. Methods Baseline serum samples from the 180 participants in a multicentric prospective trial were tested for ANCA by indirect immunofluorescence, direct enzyme-linked immunosorbent assay (ELISA), and capture ELISA. Disease activity was measured using the Birmingham Vasculitis Activity Score for Wegener's granulomatosis. All patients had active disease at enrollment. Patients were categorized as having severe (n=128) or limited (n=52) Wegener's granulomatosis. Results When all ANCA detection methods were combined, 166 patients (92%) were ANCA positive, including 96% with severe disease and 83% with limited disease. Conclusion ANCA are detectable in nearly all patients with active severe Wegener's granulomatosis, but approximately 1 of 5 patients with active limited disease are ANCA negative. Immunofluorescence and both direct and capture ELISAs are required for optimal detection, suggesting that ANCA are not recognized equally well by all testing methods.

Rationale We developed a quantitative immunoassay using microsphere photometry to enable simultaneous, quantitative measurement of IgG antibodies to 24 Streptococcus pneumoniae serotypes as an aid in evaluating the immune response to pneumococcal vaccination in children and adults. Methods Pneumococcal polysaccharide antigens (24 serotypes, ATCC, Rockville, MD) were coupled covalently to polystyrene microspheres (Luminex Corp., Austin, TX). Each polysaccharide was coupled to a different fluorescent microsphere, and the microspheres were mixed to create a single immunosorbent reagent. This reagent was used to capture antibodies to S. pneumoniae in patient's sera, standards and controls. After incubating with the immunosorbent, bound antibodies were detected with R-phycoerythrin conjugated, goat anti-human IgG antibody using a flow microfluorometer (Luminex Corp.). The concentrations of IgG antibodies to each serotype were determined from standard curves using a primary reference material (10 serotypes, US Reference Pneumococcal Antiserum, FDA, Bethesda, MD)or a secondary reference material (14 serotypes, in-house preparation). Testing for antibodies to all 24 serotypes was completed in 2 hours. Results Measurements of anti-pneumococcal antibodies in sera from 80 healthy adults agreed with published data for the 10 standardized serotypes. The immunoassay detected concentrations ranging from 0.005 to 7.8 micrograms/ml. Interassay reproducibility across different serotypes ranged from 4.8 to 11.9%. Conclusions The microsphere immunoassay we describe is accurate and reproducible, and is suitable for clinical evaluation of patients treated with pneumococcal vaccines. Quantitative results are available for all serotypes in current vaccines.

Evolution, progression and recovery of neural damage during and following cerebral ischemia were investigated in the gerbil after occlusion of a posterior communicating artery and by using the immunohistochemical reaction for tubulin and creatine kinase BB-isoenzyme which are enriched in the neuronal structure and the reaction for astroprotein which is specific for astrocytes. The transcardiac perfusion study with India ink revealed marked hypoperfusion diffusely in the hippocampus and moderately in the thalamus on the occluded side. The earliest immunohistochemical lesion, manifested as loss of the reaction for tubulin and creatine kinase BB-isoenzyme in dendrites and nerve cell bodies, was found in the CA1 and CA2 region of the hippocampus after ischemia for 4 min, while it took 10 min before the earliest lesion became visible in the ventral nucleus of the thalamus and it took over 1 h before scattered lesions evolved in granular cells of the dentate gyrus. The staining with hematoxylin-eosin was much less sensitive in detection of early ischemic lesions. After re-establishment of blood flow to the posterior communicating artery, the ischemic lesions which were visualized with the reaction for tubulin or creatine kinase BB-isoenzyme disappeared or reduced the size, if the ischemic period was brief. Beyond a certain ischemic period, the lesion expanded further during the early postischemic period. The reaction for astroprotein visualized reactive astrocytes even in the area without any abnormalities with other reactions, an evidence of subtle ischemic insults.

The authors describe the development of a double antibody radioimmunoassay specific for human secretory IgA (sIgA), and they report the results of measurements of serum sIgA concentrations in patients with chronic, nonalcoholic liver disease or carcinoma. Above-normal sIgA concentrations (greater than 25 micrograms/mL) were found in 22 of 38 sera from patients with chronic active liver disease and in 37 of 40 sera from patients with primary biliary cirrhosis. Markedly increased concentrations (greater than 118 micrograms/mL) were specific for primary biliary cirrhosis. Above-normal sIgA concentrations were found frequently in patients with colorectal (29/86, 34%), pancreatic (38/70, 54%), gastric (11/30, 37%), or mammary (6/46, 13%) carcinoma. An above-normal concentration of sIgA was more specific for hepatic metastases than an above-normal alkaline phosphatase activity in each type of carcinoma. The authors conclude that measurement of sIgA in serum is a useful diagnostic test in patients with chronic liver disease suspected of having primary biliary cirrhosis or in patients with carcinoma suspected of having hepatic metastases.

We describe the development of specific immunoassays for IgG4 protein and for allergen-specific IgG4 antibodies. We also measured the concentrations of IgG4 protein and determined the frequencies of detectable IgG4 antibodies to several common allergens in sera from adults and children with asthma and from nonallergic subjects. Serum concentrations of IgG4 protein increase with age but are not different in children with asthma and nonallergic children, nor does a raised serum concentration predict a severe clinical course in childhood asthma. IgG4 antibodies to milk and egg are common in children and adults and are more common in children with asthma than in nonallergic children less than 3 years of age. The presence of detectable IgG4 antibodies or a raised concentration of IgG4 protein in serum is not useful empirically as a diagnostic indicator of asthma but more likely results from antigen exposure occurring at mucosal surfaces.

A new method to measure the concentrations of IgG antibodies to phospholipase A 2 in sera from patients treated with honeybee venom immunotherapy is described. This method utilizes a microcentrifugal analyzer to detect inhibition of PLA 2 enzymatic activity by antibodies in serum standards and unknowns. Sera from radkeepers with known concentrations of specific antibodies, measured by radioimmunoprecipitation, were used to construct a logit-log standard curve for the immunoenzyme assay. The standard curve was linear for concentrations between 2.3 and 20.0 μg/ml. The concentrations of specific antibodies measured by enzyme inhibition correlated well with the concentrations as measured by radioimmunoprecipitation, r = 0.959 (least squares linear regression), n = 32. Interassay variation was 10.1% at 10 μg/ml. The immunoenzyme method is rapid and does not require radiolabeled reagents.

A prospective randomized trial involving 91 patients undergoing cardiopulmonary bypass compared the effects of bubble oxygenators (with and without methylprednisolone sodium succinate) and membrane oxygenators on complement activation and transpulmonary sequestration of leukocytes. Patients were divided as follows: Group I, 30 patients, bubble oxygenator; Group II, 31 patients, bubble oxygenator and methylprednisolone sodium succinate (30 mg/kg); Group III, 30 patients, membrane oxygenator. In Group I, C3a increased from 323 +/- 171 ng/ml during cardiopulmonary bypass to 1,564 +/- 785 ng/ml at 25 minutes after bypass (p less than 0.0001). A significant decrease in C3a was found in Groups II and III compared to Group I (p less than 0.0001). C5a did not change significantly during cardiopulmonary bypass in any group. Reestablishment of pulmonary circulation at the end of bypass produced significant transpulmonary leukocyte sequestration in Group I; the median cell difference was 1,700/microliter. Transpulmonary sequestration was significantly (p less than 0.0001) less in Group II (median cell difference = 200/microliter) and in Group III (median cell difference = 400/microliter) than in Group I. We conclude that cardiopulmonary bypass with a bubble oxygenator alone initiates significantly (p less than 0.0001) more C3a activation and leukocyte sequestration than when methylprednisolone sodium succinate (30 mg/kg) is given 20 minutes before the start of cardiopulmonary bypass with a bubble oxygenator or when a silicone membrane oxygenator is used.

The distribution of creatine kinase BB-isoenzyme in the human central nervous system (CNS) was investigated immunohistochemically and the findings were compared with the distributions of tubulin and astroprotein. Creatine kinase BB-isoenzyme existed both in neurons and astrocytes, and was universally distributed within the CNS. Tubulin was visualized only in the neuronal elements, namely perikarya, dendrites and axons, while astroprotein was exclusively visualized in astrocytes. A combination of immunohistochemistry for structural and soluble proteins may be a useful tool for the investigation of pathophysiological conditions within the CNS.

We have developed an immunoradiometric assay for IgE antibodies to Staphylococcus aureus (Staph IgE-Ab) which uses purified cell walls (PCW) from the Wood 46 strain of S. aureus as an immunosorbent. We compared Wood 46 PCW and whole organisms (WO) as immunosorbents for Staph IgE-Ab by performing tests on sera from patients with atopic dermatitis (AD) or the hyperimmunoglobulin E syndrome (hyper IgE syndrome). Sera with Staph IgE-Ab demonstrated dose-dependent binding to PCW and WO, but the ratio of specific to non-specific binding was much greater with PCW. Mean non-specific binding to WO was greater than to PCW, 5% versus 2%; and non-specific binding to WO varied directly with the serum concentration of IgE. Results of tests on patients' sera indicated that PCW are required in screening assays for Staph IgE-Ab to avoid false positive results caused by high levels of non-specific binding to WO.

A 57-year-old woman with IgA deficiency and Still's disease was the proband in a 20-member, three-generation kindred in which we studied the possible linkage of IgA deficiency with her HLA-A1-B8 haplotype. The presence of paternal A1-B8 haplotype complicated the analysis. Known maternal HLA-A1-B8 haplotype, present in three of the children of the proband, was associated with IgA deficiency, whereas all five family members with exclusively paternal A1-B8 had normal IgA. Of three third-generation family members whose A1-B8 haplotype was of indeterminate origin--that is, potentially either maternally or paternally derived--two had IgA deficiency and one did not.

Two employees developed allergic rhinitis and bronchial asthma which was occupationally related to raising crickets. Skin tests, bronchial challenge, radioallergosorbent test (RAST), in vitro histamine release and a passive transfer test supported the presence of type I hypersensitivity to cricket allergens. Skin tests of other employees and patients of an allergy clinic suggested that cricket emanations are potent allergens.

Metastable creatine kinase MM isoenzyme was isolated and partially purified from homogenates of myocardium and skeletal muscle by gradient elution on carboxymethyl cellulose. This variant isoenzyme migrated between the MM and MB isoenzymes on agarose electrophoresis, accounted for 3.5% of the total creatine kinase activity in each tissue, was not a macromolecule, and had stable electrophoretic mobility only in borate buffer (0.02 mol/L). By comparison, the creatine kinase isoenzymes with similar "atypical" electrophoretic mobility in serum specimens were complexes of the BB isoenzyme and immunoglobulin G. These complexes were measured by a radioimmunoassay specific for the creatine kinase B-subunit and eluted predominantly with the MB isoenzyme in a commercial anion-exchange reagent system.

Eleven commercially available kits for detecting human chorionic gonadotropin (hCC) in urine or serum were tested for analytic sensitivity and for susceptibility to interference by albumin and luteinizing hormone. The assays included several slide tests and tube tests that utilize agglutination or agglutination inhibition techniques, one radioreceptor assay and three radioimmunoassays. The analytic sensitivity for hCG varied from approximately 3 lU/ml for some slide tests to less than 0.005 lU/ml for one radioimmunoassay. Interference by albumin was observed with only one slide test; luteinizing hormone at premenopausal physiologic concentrations did not interfere with any of the assays. In our opinion, rapid slide and tube tests for hCG are adequate for routine pregnancy testing; however, the greater analytic sensitivity of radioreceptor assays or radioimmunoassays is a significant advantage in excluding the diagnosis of ectopic pregnancy or in establishing the diagnosis of early intrauterine pregnancy.

Experimental cerebral ischemia was produced in gerbils by occlusion of the right common carotid artery in the neck. The evolution of the ischemic lesions was followed from five minutes to six hours by using the immunohistochemical techniques for tubulin and creatine kinase BB-isoenzyme. The earliest lesion was found in the subiculum-CA1 and CA2 regions of the hippocampus in five minutes. There was loss of staining in the apical dendrites and perikarya of the pyramidal cells. The earliest lesion in the cerebral cortex, visible in ten minutes, was a laminar loss of staining for tubulin. Evolution of the ischemic lesions in the thalamus and caudoputamen was delayed. However, in two hours widespread ischemic lesions were seen there. Evolution of the ischemic lesions was slightly slower with the reaction for creatine kinase BB-isoenzyme as compared to the reaction for tubulin, but was far more sensitive than hematoxylin-eosin staining. The distribution of ischemic lesions detected by the immunohistochemical method compared to ischemic areas detected by an India ink perfusion study suggested that both the extent of regional ischemia and regional difference in tissue vulnerability were contributing factors for the emergence of early ischemic lesions. The mechanism for prompt disappearance of the immunohistochemical reaction for tubulin is not clear, but the present investigation demonstrates the usefulness of the immunohistochemical technique for detecting early ischemic lesions and provides a possible biochemical mechanism for cellular damage after ischemic insults.

To assess the etiologic role of cockroach antigen in bronchial asthma, 46 asthmatic subjects were studied using in vitro assays for total and cockroach-specific IgE antibodies (IgEcr) and the responsiveness of the skin and bronchial tree to the antigen challenge in vivo. Asthmatic subjects were divided into skin test-positive (PCR) and skin test-negative (NCR) groups according to immediate skin response to cockroach antigen. The 28 in the PCR group showed high total IgE (1,901 ng/ml) and a high cockroach-specific IgE antibody level (329%) in the serum compared to the 10 in the NCR group (IgE: 915 ng/ml, IgEcr: 84%) (p < 0.001). Bronchial challenge with the antigen revealed immediate asthmatic reaction (3033) and late asthmatic reaction (1633) in the PCR asthmatics, whereas the NCR asthmatics showed neither immediate asthmatic reaction (213 showed questionable decrease in FEV1) nor late asthmatic reaction (p < 0.001). A marked increase in peripheral eosinophils (758% vs 121%) was noted following antigen inhalation in the skin test-positive asthmatics (p < 0.025). The results indicate that cockroach antigen causes antigen-specific IgE-mediated bronchial asthma and peripheral eosinophilia in specifically sensitized asthmatic subjects.

On epidemiologic grounds, respirable particles from chilled-water air-conditioning systems in textile production plants have been implicated as a cause of hypersensitivity pneumonitis. We have purified the antigen from scum growing in this chilled water by antibody-affinity chromatography by use of IgG isolated from a pool of serum obtained from three workers with disease. Two patients with the disease, three coworkers without the disease, and two unexposed control subjects inhaled a dose of the purified antigen approximately equivalent to that amount calculated to be inhaled during an 8-hour work shift. Both workers with disease experienced fever, malaise, cough, and dyspnea 6 to 8 hours after the aerosol challenge. In these two patients the exposure evoked a transient decrease in circulating lymphocytes, predominately T cells. Before challenge the patients' peripheral blood mononuclear cells demonstrated a blastogenic response to the antigen. The responding cells had disappeared from the circulation 24 hours after the challenge. Seventy-two hours after the challenge, mononuclear cells that were producing large amounts of specific IgG antibody appeared in the circulation. We conclude that the same antigen(s) that react with IgG antibody produced an acute episode of the disease, that specific antigen-recognition cells disappear from the peripheral blood after exposure to the antigen (presumably because they are attracted to the lung), and that antibody-forming cells appear in the peripheral blood approximately 2 days after a challenge. These antigen-specific reactions of circulating mononuclear cells may be specific for the disease, but studies on a larger number of cases are needed to be certain.

T-cell chronic lymphocytic leukemia (T-CLL) accounts for about 2% of the various types of CLL and can be subtyped into helper/inducer (h/i) and cytotoxic/suppressor (c/s) cell membrane phenotypes. Seven patients with CLL were shown to have T-CLL with a h/i cell membrane phenotype; four with monoclonal antibody reagents and three by demonstration of the E-rosette receptor and focal acid alpha naphthyl acetate esterase activity. The clinical courses, treatment responses, and laboratory findings of these seven patients were reviewed to determine the prognosis and unique clinicopathologic features of this subtype. Two patients presented with skin rashes, and five were diagnosed during evaluation for other medical problems. Initially, four patients had splenomegaly and two had lymphadenopathy, but none of the patients had hepatomegaly. Morphologic examination revealed uniform, small lymphocytes in three patients, and the lymphocytes had nuclear indentations in four patients. Sera from the three patients tested were negative for antibody to the human T-cell leukemia/lymphoma virus I. Peripheral blood mononuclear cells from one patient showed normal interleukin-2 production and lacked antibody-dependent cell-mediated cellular cytotoxicity and natural killer activity. Cytogenetic analysis was done on one patient, revealing an abnormal clone with several chromosomal abnormalities, including an X; 14 translocation with a break point at 14q11. All patients required chemotherapy, and all died a median of 21 months from the time of diagnosis. The findings in these patients, in addition to those in 31 patients described in the literature, indicate that h/i T-CLL is associated with a poor prognosis and has distinct clinical and pathologic features that separate it from c/s T-CLL, adult T-cell leukemia/lymphoma, the cutaneous T-cell lymphomas, and B-CLL.

Blastogenesis of autoreactive T lymphocytes in the autologous mixed lymphocyte reaction has been shown to be decreased in patients with primary biliary cirrhosis, but the mechanisms underlying this abnormality are not known. To investigate further the abnormal autologous mixed lymphocyte reaction in primary biliary cirrhosis, we measured the activation of autoreactive helper/inducer and suppressor/cytotoxic T lymphocytes concurrently with blastogenesis in 35 patients with primary biliary cirrhosis and 18 healthy controls. Blastogenesis was diminished in autologous mixed lymphocyte reaction cultures from primary biliary cirrhosis patients compared to the control subjects (25,273 +/- 20,259 dpm vs. 36,004 +/- 14,951 dpm, p less than 0.02), but cultures from patients with primary biliary cirrhosis contained significantly increased percentages of activated helper/inducer and suppressor/cytotoxic T lymphocytes: 20.6 +/- 7.9 vs. 15.5 +/- 5.3%, p less than 0.008, and 9.8 +/- 7.8 vs. 5.4 +/- 3.0%, p less than 0.02, respectively. These findings were not related to the histologic stage of liver disease or to the serum bilirubin concentration and were not associated with abnormalities of lymphocyte subsets in fresh peripheral blood specimens. We conclude that the percentage of autoreactive T lymphocytes in autologous mixed lymphocyte reaction cultures from peripheral blood is increased in patients with primary biliary cirrhosis and diminished blastogenesis in autologous mixed lymphocyte reaction cultures is not due to the loss of autoreactive T lymphocytes from peripheral blood. Diminished blastogenesis reflects a diminished proliferative response of activated, autoreactive T lymphocytes in primary biliary cirrhosis. Possible mechanisms that may account for the paradoxical findings of decreased blastogenesis and increased activation of autoreactive T lymphocytes in primary biliary cirrhosis are discussed.(ABSTRACT TRUNCATED AT 250 WORDS)

After occlusion of the right common carotid artery in the gerbil, we monitored the progression of ischemic damage and postischemic damage and the repair process in the brain immunohistochemically by using tubulin, creatine kinase BB-isoenzyme (CK-BB), and neuron-specific enolase as the neuronal markers and astroprotein, glial fibrillary acidic protein, and CK-BB as the astrocytic markers. The earliest ischemic lesion was detected in the hippocampus and the cerebral cortex after ischemia for 5 minutes as loss of the reaction in the neuropil, nerve cell bodies, and dendrites. The reaction disappeared more promptly in the dendrites than in the nerve cell bodies. The reaction for tubulin was the most sensitive for detection of the neuronal ischemic damage. After an ischemic period of 30 minutes and subsequent reestablishment of cerebral circulation, the immunohistochemical lesions affecting the neuronal structure expanded during the first 3 hours and then slowly afterward for up to 12 hours. Reactive astrocytes were already identified 24 hours after reperfusion. The current investigation demonstrated that early ischemic damage can be clearly visualized by use of the immunohistochemical technique soon after the onset of cerebral ischemia but that considerable heterogeneity exists not only in different anatomic regions but also within the neuronal structure. This technique has potential for further investigation of cerebral ischemia or other pathophysiologic conditions when used in combination with other morphologic, physiologic, or biochemical techniques.

Analytic variability affects the accuracy of measurements of specific IgE antibodies, but the frequency of false results attributable to analytic variability is not well documented. We have monitored the accuracy of the results generated in our laboratory by testing aliquots of positive serum pools and a negative serum pool submitted blindly for the measurement of IgE antibodies to 16 different allergens, including foods; weed, grass, and tree pollens; mites, molds, and epithelia; and Hymenoptera venoms. Positive serum pools were prepared to contain modest amounts of IgE antibodies. Tests were performed by immunometric assays with microcrystalline cellulose allergen immunosorbents. Frank false-positive and false-negative results were very uncommon when binding levels were classified by a ratio-based reporting scheme. False-borderline results were more common. A borderline result is truly equivocal and may or may not indicate the presence of low levels of IgE antibodies. Analytic variability adds uncertainty to the measurement of small quantities of IgE antibodies regardless of the classification scheme used to report test results.

• Serum creatine kinase B (CKB) concentrations were measured every 12 hours for five days in 38 patients during acute cerebrovascular diseases and in nine controls. Mean CKB concentration was 6.2 ± 0.8 ng/mL. The fluctuation of the CKB concentration following ischemic stroke was as notable as the elevation immediately after the ischemic event. The two abnormalities were observed in 13 of 17 patients with acute cerebral infarction, and the extent of abnormalities roughly correlated with the volume of tissue damage. The profiles were normal for patients with transient vascular events. Patients with subarachnoid hemorrhage demonstrated wide fluctuation along with high CKB concentration. Although transient elevation of the CKB concentration in some patients with subarachnoid hemorrhage was observed after angiography or clinical worsening, the fluctuation in patients with ischemic stroke was not associated with worsening of neurologic conditions or recurrence of ischemic events.

Relatively few laboratory tests are of proven value in the differential diagnosis and management of allergic diseases. Immunoassays for IgE and for IgE antibodies are the mainstays. Measurement of IgE in serum is advocated as a first-order laboratory test in the differential diagnosis of allergic disease in children and adults. The usefulness of laboratory tests for IgE antibodies in serum, once a subject of debate in the clinical allergy literature, is now firmly established. Confusion, in respect to the use of these tests, is most evident in clinical situations which have been the subject of limited clinical investigation, e.g., the use of tests for IgE antibodies to screen for allergic disease, the indications for their use in patients treated with allergen immunotherapy, and the diagnostic specificity of IgE antibodies to foods as an indicator of food-induced allergic symptoms. Confusion is also apparent in the interpretation of borderline test results, i.e., results which may indicate the presence of low titers of IgE antibodies, and in defining the optimum format for reporting results to maximize the analytical sensitivity of the test method. This review addresses the ambiguities noted above in the interpretation of results. The paragraphs that follow also consider the possible uses of laboratory tests for inflammatory mediators of immediate hypersensitivity, for IgG antibodies to allergens, and of tests designed to evaluate the in vitro functions of lymphocytes in patients with allergic disease.

A 53-year-old white man had fever, malaise, and dyspnea on exertion. His chest roentgenogram was normal, but pulmonary function tests showed impaired diffusion capacity and a gallium scan showed marked uptake in the lungs. Results of an open-lung biopsy documented Pneumocystis carinii pneumonia. Immunologic test results were consistent with the acquired immunodeficiency syndrome. The patient denied having homosexual contact or using intravenous drugs. Twenty-nine months before the diagnosis of pneumocystis pneumonia was made, the patient had had 16 transfusions of whole blood, platelets, and fresh-frozen plasma during coronary artery bypass surgery at another medical center. This patient is not a member of any currently recognized high-risk group and is believed to have contracted the acquired immunodeficiency syndrome from blood and blood-product transfusions.

Cellular distribution of creatine kinase BB-isoenzyme and tubulin was investigated immunohistochemically with tissue sections from various areas of the gerbil brain. Both the reaction for creatine kinase BB-isoenzyme and tubulin visualized nerve cell bodies, dendrites and axons. While the reaction for tubulin was similar between nerve cell bodies and their dendrites, the reaction for creatine kinase BB-isoenzyme tended to be more intense in dendrites. While the reaction for tubulin could be seen in nerve cell bodies of different sizes, the reaction for creatine kinase BB-isoenzyme was more intense in larger neurons. Both the reaction for creatine kinase BB-isoenzyme and tubulin visualized astrocytic cytoplasm but only in the corpus callosum and in the white matter of limited areas. Visualization of dendrites to their peripheries with the reaction for creatine kinase BB-isoenzyme may indicate participation of this isoenzyme in maintainance of high energy-phosphates locally within dendrites. A combination of the immunohistochemical procedure for creatine kinase BB-isoenzyme and tubulin may be very useful for demonstration of various pathophysiological states of the central nervous system which affect dendrites.

Primary sclerosing cholangitis is a chronic, cholestatic liver disease in which immune mechanisms are thought to play a role in the pathogenesis. We have determined the frequencies and functional phenotypes of autoreactive T-lymphocytes in peripheral blood specimens from patients with primary sclerosing cholangitis and healthy adults as an indicator of autoreactivity in primary sclerosing cholangitis. We found a significant increase in the percentage of autoreactive suppressor/cytotoxic T-lymphocytes that become activated in the T-, non-T-autologous mixed lymphocyte reaction in primary sclerosing cholangitis patients (p less than 0.002). Blastogenesis in autologous mixed lymphocyte reaction cultures from primary sclerosing cholangitis patients was significantly decreased (p less than 0.02), and the magnitude of the decrease correlated directly with the percentage of activated suppressor/cytotoxic T-lymphocytes (r = 0.56, p less than 0.01). The percentage of autoreactive, suppressor T-lymphocytes was increased in autologous mixed lymphocyte reaction cultures from primary sclerosing cholangitis patients (p less than 0.0001); and suppression of mitogen-induced blastogenesis by autologous concanavalin A-treated mononuclear cells was significantly enhanced. These results, which were unrelated to the histologic stage of liver disease and the presence or absence of active colitis, document the presence of an expanded population of T-lymphocytes in the peripheral blood of patients with primary sclerosing cholangitis that became activated on exposure to autologous major histocompatibility antigens in the autologous mixed lymphocyte reaction. We hypothesize that these autoreactive cells may be a marker or may participate as effector cells in cell-mediated autoimmunity in primary sclerosing cholangitis.

The cause of hypotension after reversal of heparin by protamine has not been well defined. In this study we evaluated complement activation (C3a and C4a) by the heparin-protamine complex in 46 consecutive patients (40 received protamine sulfate to reverse heparin, and six did not) during and after coronary angiography. In patients receiving protamine sulfate, there was a significant increase in C3a over the value before protamine sulfate administration (P less than .001) or in patients who did not receive protamine sulfate (P less than .05): 807 +/- 100 ng/ml vs. 274 +/- 75 ng/ml. There were no significant changes in C4a after protamine sulfate administration. These results indicate that the alternate complement pathway is activated when protamine sulfate is administered after coronary angiography. This may induce hypotension as well as platelet aggregation and thrombus formation and may contribute to coronary instability. Therefore, in unstable patients, heparin reversal by protamine should not be done routinely.

The overall performances of several enzyme reagent kits for alkaline phosphatase, creatine kinase, lactic dehydrogenase, and aspartate aminotransferase were evaluated using an ABA-100 Bichromatic Analyzer. Interassay precision using this instrument with commercial reagents compared well with published data for similar analyses performed at university hospitals and referral laboratories. Significantly poorer precision with lower limits of linearity was observed when reagents recommended for use at 30 C were used at 37 C. Significant differences in measured levels of creatine kinase, lactic dehydrogenase, and aspartate aminotransferase due to different lots of expendable cuvettes were found for elevated levels of these enzymes. All kit reagents met manufacturers' claims for stability; however, different absolute levels of lactic dehydrogenase were observed with one kit reagent on successive days. Slight hemolysis affected creatine kinase levels measured with some reagent kits significantly more than others.

Measurements of the BB isoenzyme of creatine kinase in serum may be useful in the diagnosis or monitoring of patients who have some types of cancer, and the distribution of creatine kinase isoenzymes in homogenates of certain sarcomas has been evaluated as an aid in the morphologic diagnosis of these neoplasms. The cellular distribution of the B and M polypeptide subunits of creatine kinase in normal and neoplastic tissues were evaluated by an immunoperoxidase technic to determine whether the BB isoenzyme is present in neoplastic epithelial cells and whether immunoperoxidase stains for these polypeptides are useful in microscopic diagnosis. The results indicated that the B polypeptide is distributed very widely in epithelial cells and that normal and neoplastic ductal epithelia from many tissues contain the BB isoenzyme. Normal and neoplastic acinar epithelia contained varying amounts of the B polypeptide, but usually less than ductal epithelia of the same tissues. Large amounts of the B polypeptide were found in tissue sections from malignant fibrous histiocytomas, and of the M polypeptide in sections from an alveolar rhabdomyosarcoma.

We report three patients (followed up for 13, 9, and 12 years) who had multiple episodes of disseminated histoplasmosis. Clinically, all three patients had high yields of positive cultures and all developed corticoadrenal insufficiency; all survived the recurrent relapses. One patient had unilateral progressive panophthalmitis, with ocular cultures positive for Histoplasma capsulatum. These relapses occurred despite conventional treatment with large doses of amphotericin B. Prolonged remissions were associated with using small doses of this drug. One patient had a long-term remission while taking ketoconazole daily for more than four years. These patients did not have conditions associated with immunosuppression. Lymphocyte proliferation to mitogens and, in one patient, to histoplasmin, was markedly reduced at the time of relapse and when tested preceding a relapse. All three patients showed a reversal to normal lymphocyte proliferation at the time of the longest last remission.

The effect of radiographic contrast agents on the central nervous system was evaluated by measurement of serum creatine kinase B-subunit (CKB) levels with use of radioimmunoassay in 58 patients who underwent computed tomographic (CT) scanning and 46 patients who underwent cerebral angiography for evaluation of cerebrovascular diseases, brain tumors, and other neurologic disorders. In 11 patients (10.6%), the CKB increased to abnormally high levels within 4 hours after the radiographic procedures, and the median value after 30 minutes was significantly higher than the corresponding precontrast value (P less than 0.01). Eight of the 11 patients had recent ischemic cerebrovascular diseases, and 7 of the 11 had undergone CT scanning. On the basis of the information available in the literature, elevation of the serum CKB levels may be interpreted as reflecting breakdown of the blood-brain barrier and neural damage. Intravascularly administered radiographic media are generally safe, but the results of the current investigation suggested the potential for detrimental effects, particularly in patients with recent cerebrovascular diseases.

• The concentration of creatine kinase BB isoenzyme (CK BB) was measured by radioimmunoassay in CSF from 306 patients with various neurologic disorders. Levels above 2.0 ng/ml were not found in patients without neurologic disease. Whereas mean CSF CK BB level was less than 2.0 ng/mL in groups of patients with systemic malignant neoplasms, latent syphilis, peripheral neuropathy, disk disease, polyradiculopathy, myelopathy, multiple sclerosis, neurodegenerative disease, encephalopathy, and hydrocephalus, it was elevated in groups of patients with convulsive disorder, CNS neoplasm, cerebrovascular disease, vasculitis, and meningoencephalitis.