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The field of therapeutics has seen remarkable progress in the recent years, which has made mainstream drug treatment possible for collagen and rheumatic diseases. However, treatment of intractable cases where drug effectiveness is poor is a challenge. Furthermore, organ damage, concurrent illnesses or allergic reactions make adequate drug therapy impossible. For such cases, therapeutic apheresis is very significant, and it is important how this should be valued related to drug therapies. Therapeutic apheresis for collagen and rheumatic diseases involves the removal of factors that cause and exacerbate the disease; the aim of immunoadsorption, in particular, is to improve the clinical condition of patients with autoimmune disease by selectively removing pathogenic immune complexes and autoantibodies from their plasma. Immunoadsorption, in particular, unlike plasma exchange and DFPP, utilizes a high-affinity column that selectively removes autoantibodies and immune complexes, leaving other plasma components intact. There is no need to replenish fresh frozen plasma or blood products such as albumin and gamma globulin preparations. Immunoadsorption is thus superior in terms of safety, as the risk of infection or allergic reaction relating to these preparations can be avoided. We anticipate future investigations of application of synchronized therapy using drugs and therapeutic apheresis, most notably immunoadsorption, in combination to treat intractable clinical conditions such as collagen and rheumatic diseases. In this paper, our discussion includes the indications for immunoadsorption such as collagen and rheumatic diseases, the relevant conditions and types, as well as the latest understanding related to methods and clinical efficacy., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

The use of biological agents has grown exponentially in immune-mediated inflammatory diseases (IMID), often achieving a good control of disease progression and improving patients' quality of life. However, their use resulted in an increased risk of adverse events, including reactivation of chronic/latent infectious diseases. As for the risk of Cytomegalovirus (CMV) reactivation, very few data are available. We reviewed the literature reporting cases of CMV infection in IMID patients during biological therapy. Although the risk of CMV reactivation cannot be excluded, we concluded that there is no evidence to warrant CMV screening before starting a biological agent.

Collagen vascular diseases and vasculitides comprise various diseases, which may affect virtually every organ system. Therefore, their diagnosis and management is often an interdisciplinary challenge. Because of the heterogeneous symptoms, these diseases have significant overlap, which interferes with the clinical diagnosis and may require additional investigation. Therefore, a rational and comprehensive diagnostic work-up should be performed at the initial presentation before initiation of therapy. The detection of antinuclear (ANA) or anticell antibodies by indirect immunofluorescence microscopy on Hep2 cells is used to screen for autoantibodies in collagen vascular diseases. The molecular specificity of autoantibodies should be further characterized using immunoassays with recombinant or purified protein. When systemic autoimmune disease is suspected, the function of the frequently affected organs should be evaluated. The immunopathological findings should always be interpreted in the context of clinical, histological, and imaging data. The detection of autoantibodies is helpful for the initial diagnosis, provides prognostic information, may indicate involvement of organs or systems and some parameters may also be used for disease monitoring. The clinical significance of autoantibodies is emphasized by the fact that their detection constitutes diagnostic criteria for most collagen vascular diseases and several vasculitides. The screening for ANCA may be performed using immunoassays with recombinant myeloperoxidase and proteinase 3 or by indirect immunofluorescence microscopy on granulocytes. In this article, the current diagnostic tools and their relevance for the diagnosis and monitoring of systemic autoimmune diseases with primary skin involvement are reviewed.

B cells are able to present antigen, secrete cytokines and differentiate into (auto)antibody secreting cells and are therefore considered as an important therapeutic target in patients with autoantibody-mediated autoimmune disease. Benefits and limitations of B-cell-directed therapies and unmet medical needs are discussed in this minireview. B cell targeting broadens our armamentarium available to treat SLE and other connective tissue diseases. But further research addressing unmet medical needs is required and refractory patients receiving B cell-directed off-label therapeutics should be enrolled in registries to collect information on the value and safety of these drugs in rare autoimmune diseases., (© Georg Thieme Verlag KG Stuttgart · New York.)

Objectives: Pulmonary involvement of varying etiology is common in collagen vascular diseases (CVDs). Bronchoalveolar lavage fluid (BALF) cell differentials reveal information on the immune mechanisms involved in the CVDs. The aim of the present study was to evaluate BALF cell populations in CVD-associated ILD and to investigate possible correlation with pulmonary function., Methods: Fifty-seven patients (26 male and 31 female, mean age ± SD: 54.68±12.18 years) with CVD-associated interstitial lung disease were studied. Patients were divided into 6 groups based on underlying CVD. The study population also included a group of 10 healthy controls. BALF was examined in all individuals. Cell density, total cell number and differential cell count were recorded. BALF lymphocyte subsets were analysed by dual flow cytometry. Pulmonary function was assessed in all patients., Results: BALF differential cell count did not differ significantly among the different groups. Scleroderma patients showed the highest percentage of CD19 cells (p<0.001). The NK and NKT cell percentages were significantly higher in systemic lupus erythematosus and in Sjögren, respectively, compared to other CVDs and controls (p=0.001 and p<0.001). Also BALF neutrophil percentage correlated negatively with FVC (r=-0.356, p=0.011) and FEV1 (r=-0.336, p=0.017) and BALF NKT cell percentage correlated negatively with pO2 (r=-0.415, p=0.003)., Conclusions: Important variations observed in BALF cell populations suggest the implication of NK and NKT cells in the pathogenesis of lung involvement in CVDs.

Non-specific interstitial pneumonia (NSIP) belongs to the group of idiopathic interstitial pneumonias (IIP). However, NSIP can also be found in several other diseases. For example, the NSIP pattern is most commonly found in interstitial lung disease due to connective tissue disease. In this review, the definition and classification, aetiology, pathogenesis and histology, clinical symptoms, serological markers, lung function parameters, radiographic signs, treatment, and prognosis of NSIP are presented. Idiopathic NSIP as a distinct form of NSIP will be discussed separately., (© Georg Thieme Verlag KG Stuttgart · New York.)

In a previous study we found in 50% of patients with neuropsychiatric manifestations of systemic lupus erythematosus (NP-SLE) organ specific antibodies to 45-56 kD proteins in a 100,000 g supernatant (SN) from bovine brain mitochondria. Aim of the present study was to identify the corresponding target antigen. A 100,000 g SN from bovine brain mitochondria was applied to SDS-gel electrophoresis. A 50 kD band recognized by sera from patients with NP-SLE in the Western blot (WB) was excised from the gels and applied to mass spectrometry. The identified protein was expressed in Escherichia coli and retested against sera from eleven patients with NP-SLE (severe symptoms n=6, mild symptoms n=5), 26 SLE-patients without NP manifestations and 53 controls (patients with multiple sclerosis, epilepsy, healthy blood donors). Mass spectrometry of the 50 kD band revealed the presence of α-tubulin. Applying the recombinant α-tubulin in the WB, four of the eleven NP-SLE patients (36%), one of the 26 patients with SLE without NP manifestations (4%) and none of the 53 controls reacted with α-tubulin. The antibodies were more frequently found in patients with severe (50%) than with mild NP-SLE (20%). α-tubulin may be a novel marker autoantigen for a neuropsychiatric manifestation at least in a subgroup of patients with SLE. Whether anti-α-tubulin antibodies are of pathogenetic relevance has still to be clarified., (Copyright © 2010 Elsevier Inc. All rights reserved.)

In hematopoietic stem cell transplant (HSCT) recipients, the recognition of polymorphic antigens by the donor-derived immune system is an important mechanism underlying both graft-versus-host disease and graft-versus-leukemia (GVL) effect. Here we show that a subset of HSCT recipients (13.9%, n = 108) have antibodies directed to surface molecules of dendritic cells. We have used one such serum in conjunction with retroviral expression cloning to identify the highly polymorphic surface molecule immunoglobulin-like transcript 5 (ILT5) as one of the targets of dendritic cell-reactive antibodies. ILT5 reactive antibodies were found in 5.4% of HSCT patients but not in solid organ transplantation recipients, patients with collagen diseases, multiparous women, or polytransfused or healthy persons. We show that ILT5-specific antibodies can mediate killing of ILT5-bearing cells and furthermore demonstrate ILT5 expression in some leukemic cells, indicating that it might be a target for GVL effects. Thus, our results represent the first description of potent allogeneic antibody responses to a non-major histocompatibility complex cell surface molecule in hematopoietic stem cell transplanted patients and warrant further studies to elucidate the role of antibodies to polymorphic cell surface molecules in GVL and graft-versus-host responses.

The objective of this study is to investigate the clinical markers of life-threatening Pneumocystis pneumonia (PCP) in patients with collagen vascular diseases (CVD). The patients who contracted Pneumocystis jeroveccii were retrospectively selected from our medical charts and conditions related to the patients' death were reviewed. The findings indicated that lower levels of serum albumin and cholinesterase, increased alveolar-arterial oxygen gradient, intratracheal intubation, and necessity to treat in the intensive care unit were significantly related to deaths associated with PCP in CVD. A special attention should be paid to decreased serum albumin and cholinesterase as ominous predictors in PCP occurred in patients with CVD.

Introduction: Previous studies of interstitial lung disease (ILD) suggest that prognosis and therapeutic response are influenced by the presence of underlying collagen vascular disease (CVD). Yet, what proportion of patients presenting with ILD have CVD is largely unknown. We sought to determine the frequency of a new CVD diagnosis in an ILD referral population., Materials/patients and Methods: We retrospectively studied 114 consecutive patients evaluated at the Johns Hopkins Interstitial Lung Disease Clinic for the development of CVD., Results: In this retrospective cohort, nearly one-third of the 114 patients with confirmed ILD satisfied published criteria for a CVD diagnosis. Seventeen (15%) patients were diagnosed with a new CVD as a direct consequence of their ILD evaluation. Patients with new CVD diagnosis were younger than those without new CVD diagnosis: 51.4years (95% CI 45-58years) and 60years (95% CI 57-63), respectively (p=0.01). Moreover, an ANA>or=1:640 (p=0.03) and elevated levels of creatine phosphokinase (CPK) or aldolase (p<0.001) were associated with a new CVD diagnosis., Conclusions: Unrecognized collagen vascular disease may be more common than previously appreciated among patients referred with ILD. High titer ANA and an elevated CPK or aldolase are associated with a CVD diagnosis in this referral population.

B-cells play a central role in the pathogenesis of autoimmune diseases. As already discussed in other articles, besides the production of potentially pathogenic autoantibodies, B-cells may function as antigen-presenting cells, may induce T-cell activation and produce various cytokines. The feasibility of targeting B-cells in patients with severe and refractory autoimmune disorders, especially in patients with vasculitis or connective tissue diseases, has met growing interest among rheumatologists in recent years. The use of rituximab as a monoclonal antibody directed against CD20 positive B-cells has been reported in case reports and small patient series; however, these are hard to compare as different diseases are described and different doses and schedules of rituximab were used. It has to be considered that positive reports are more likely to be reported than patients who do not improve or experience side effects. Data on only a few indications from randomized, double-blind studies are available; however, even these results should be evaluated critically.

The analysis of cytokines (i.e. interleukins, interferons and colony-stimulating factors) has only flourished in the last 25 years subsequently revealing new insights into the pathogenesis of rheumatic diseases that revolutionised the management of patients with chronic rheumatic disorders. Tumour necrosis factor-alpha (TNF-alpha), interleukin-1 (IL-1) and interleukin-6 (IL-6) have been found to play a pivotal role in rheumatic inflammation. As early as in 1992 the first proof of concept study with a monoclonal antibody against TNF was able to demonstrate positive effects in rheumatoid arthritis. Since the approval of the first anti-TNF-alpha therapy, further agents against TNF and other proinflammatory cytokines were approved and even more biological drugs are under development aimed at modulating the disturbed immune system in patients with rheumatic diseases. To date the following biologics are approved for therapy of chronic rheumatic diseases: the TNF antagonists Etanercept, Infliximab and Adalimumab; Anakinra as an IL-1 receptor antagonist; the anti-CD20 monoclonal antibody Rituximab and the anti-CD80/86 fusion protein Abatacept. In the present article, we report on biological therapy modalities in rheumatic diseases as well as the recommendations for initiation of these agents.

This is the first part of a series of articles on the laboratory diagnostics of rheumatic diseases and will consider the systemic autoimmune diseases lupus erythematosus, Sjögren's syndrome, systemic sclerosis, dermato/polymyositis and mixed connective tissue disease (MCTD, SHARP syndrome). The basis for diagnostics is the presence of antinuclear antibodies (ANA). Initially, these antibodies are detected using a screening test. This must be followed by the identification of the patient's individual autoantibody specificities, which then yields important diagnostic clues. Disease activity may be monitored serologically by following the titers of selected autoantibodies and, in certain patients, by examining complement consumption.

Aim: The purpose of this paper was to verify whether there is any sign of involvement of the cardiovascular system in the early stages of collagen diseases., Methods: Seventeen patients (10 female and 7 male, average age 41.35 +/- 9.85 years) (group A) recruited at the Ambulatory of Internal Medicine for suspected collagen diseases with period of onset of the symptomatology less than 6 months, were analyzed. Ten patients were excluded from the study: 8 had been suffering from systemic lupus erythematosus (SLE) for a number of years, 2 were older than 80 and were suffering from concomitant pathologies (diabetes mellitus and hypertension) which would have invalidated the evaluation of valvular changes like thickening. The patients were followed up for 2 years. Clinical diagnosis was made in many cases many months after the observation using the criteria of the American Rheumatic Association (ARA). All patients were subjected to titration of the following autoantibodies by means of the immuno-fluorimetry method: ANA, anti-ENA (SSA, SSB, SM, SM-RNP, SCL-70, Jo-1), anti-nDNA, anti-histones. The cardiological evaluation was carried out by echography (Cardioline 12 leads) and echocardiographic examination (Aloka 2000 and HP sonos 5500 with 2.5 and 3.5 MHz probe) looking for thickening of both valvular flaps (> 3 mm for the mitral and > 2 mm for the aorta), myocardial involvement by studying global and regional kinesis of the left ventricle; pericardial involvement. The control group consisted of 17 healthy subjects with the same sex and age distribution (10 male, 7 female, average age 40.35 +/- 9.80 years) (group B)., Results: Eleven patients (64%) proved to be suffering from SLE, 3 (17%) from mixed collagen diseases (MC), 3 (17%) from systemic sclerosis (SS). Cardiac anomalies were observed in 12 patients: in 3 (17%) mitral valve thickening was observed (2 with SLE, 1 with SS), in 2 (11%) thickening associated with mitral valve insufficiency (with MC), in 1 (5%) isolated mitral valve insufficiency (with SLE), in 1 (5%) thickening and slight aortic insufficiency (with SLE), in 1 (5%) mitral valve vegetations (with SLE), in 2 (11%) pericardial effusion (with SLE), in 2 (11%) diastolic changes (with SS). The parameters relative to wall thickness between the 2 groups showed statistically significant differences (mitral 3.1 +/- 0.7 vs 2.3 +/- 0.4 P = 0.0005; aorta 1.7 +/- 0.2 vs 1.5 +/- 0.3 P = 0.03)., Conclusions: In patients observed in the early stages of collagen diseases, cardiac involvement was observed in 70% of cases, but the data require confirmation in a larger sample. The authors, however, believe that the early identification of such involvement is useful from both the diagnostic point of view and from the point of view of patient treatment.

Object: To evaluate a newly developed enzyme-linked immunosorbent assay (ELISA) (Hitazyme C. pneumoniae) detecting Chlamydophila pneumoniae-specific immunoglobulin M (IgM) antibody, we compared the assay with culturing, immunoblotting and the microimmunofluorescence (MIF) test., Patients and Methods: Two hundred five patients with stable chronic lung diseases without acute respiratory tract infections (ARTIs) and 116 healthy volunteers without ARTIs were enrolled in this study. Nasopharyngeal swab specimens and sera were obtained from all subjects for isolation and serological testing of C. pneumoniae., Results: C. pneumoniae IgM-positive results were observed in 16.5% of patients with stable chronic lung diseases and in 8.6% of asymptomatic healthy subjects. However, there were no positive cases with cell culture, immunoblot or MIF test. In addition, no cases with a significant increase in IgA or IgG antibody titer for the ELISA kit and MIF test between paired sera were observed in the followed-up groups. IgM-positive cases were more frequent among patients with chronic obstructive pulmonary disease (p=0.1566), collagen disease-associated interstitial lung disease (p<0.0001) and cryptogenic organizing pneumonia (p=0.0199) than among the healthy subjects., Conclusion: Our results indicate that IgM-positive results with the ELISA kit do not always reflect acute C. pneumoniae infections. Further studies are needed, to determine an appropriate cut-off level and the possible causes of the false-positive results in the ELISA kit, such as other underlying conditions.

Collagen XVII, or BP180, is a collagenous transmembrane protein and a structural component of the dermoepidermal anchoring complex. Molecular studies reveal that it has a globular cytosolic amino-terminal domain and flexible-rod extracellular carboxyterminal domain. The extracellular portion of collagen XVII is constitutively shed from the cell surface by ADAMs (proteinases that contain adhesive and metalloprotease domains). Cell biological analyses suggest that collagen XVII functions as a cell-matrix adhesion molecule through stabilization of the hemidesmosome complex. This concept is supported by investigations into human diseases of the dermoepidermal junction, in which collagen XVII is either genetically defective or absent (as in some forms of nonlethal junctional epidermolysis bullosa). Autoantibodies against collagen XVII (BP180) are seen in bullous pemphigoid, pemphigoid gestationis, mucous membrane pemphigoid, linear IgA disease, lichen planus pemphigoides and pemphigoid nodularis. In vivo and in vitro studies provide evidence for a pathogenic role of these autoantibodies, and suggest that the serum level and epitope specificity of these antibodies influences disease severity and phenotype. This review summarizes the structural and biological features of collagen XVII and its role in diseases of the basement membrane zone.

Earlier studies reported the associations among testosterone hormone, autoimmunity, and left-handedness. In the present study, sex differences in tuberculin reaction, a measure of cell-mediated hypersensitivity, serum free and total testosterone levels in controls and patients with autoimmune diseases were studied. There was a sex difference in right and left tuberculin reactions in controls, but not in patients. Both right and left tuberculin reactions were smaller in male and female patients than male and female controls. Free and total testosterone levels were higher in male controls than in male patients. Total testosterone levels were higher in female controls than in female patients. These results suggest that autoimmune diseases may be associated with a decrease in the blood testosterone concentrations.

Collagen-vascular diseases are associated with immune dysregulation and inflammation, leading to tissue destruction or compromise. Immunosuppression is more commonly associated with the drugs used to treat these disorders than with the diseases themselves. The newest agents being used to treat collagen-vascular diseases are the tumor necrosis factor (TNF)-alpha inhibitors. U.S. Food and Drug Administration-approved TNF-alpha inhibitors have differing effects on the immune system, reflecting their potency and mechanisms of action. They are particularly effective in breaking down granulomatous inflammation, which makes them effective treatment for sarcoidosis and Wegener's granulomatosis. This same property makes them likely to break down the host defense mechanism that normally contains pathogens such as mycobacteria and fungi in a dormant state, namely the physical and immunologic barrier formed by granulomas in the lung and elsewhere. The most common infection reported with the TNF-alpha inhibitors has been tuberculosis, which may manifest as pulmonary and/or extrapulmonary disease, with the latter being more common and severe than usual. Histoplasma capsulatum, Aspergillus, Cryptococcus neoformans, and Listeria monocytogenes have also been described in a number of cases, and their frequency is discussed.

The anti-double-stranded DNA (anti-dsDNA) antibody test incorporated in the 1982 revised American College of Rheumatology criteria for the classification of systemic lupus erythematosus needs updating to reflect current insights and technical achievements, including allowance for the presence of nonpathogenic anti-dsDNA antibodies. As we need to develop at least some measure of pathogenicity of anti-dsDNA antibodies, we propose that initial anti-dsDNA antibody screening is done by sensitive ELISA and supplemented by more stringent assays. Simultaneously the relevance of anti-dsDNA antibody presence needs to be restricted to clinical manifestations, thought to be caused by anti-dsDNA antibody and within an appropriate time frame.

CD40 and CD154 belong to the tumor necrosis factor (TNF) receptor superfamily and the TNF superfamily, respectively. Evidence is accumulating that indicates the importance of this receptor-ligand pair in the immunopathogenesis of autoimmune diseases. The CD40-CD154 interaction influences antigen presentation, tolerance, autoantibody production and tissue damage, all of which are relevant to the development and perpetuation of autoimmune diseases. Among the collagen diseases, the CD40-CD154 interaction has been intensively investigated in systemic lupus erythematosus (SLE) and rheumatoid arthritis (RA). In this article, both basic and clinical research suggesting the involvement of the CD40-CD154 interaction in SLE, RA, inflammatory myopathies, systemic sclerosis and antiphospholipid syndrome are reviewed. The results of clinical trials from CD40-CD154 blockade are also analyzed. CD40-CD154 blockade in animal models of autoimmune diseases has been reported to be a promising novel therapeutic approach and, thus, has attracted great attention from pharmaceutical companies. However, the development of CD40-CD154 blockers with both significant clinical efficacy and safety has not been successful and research advances in this field are eagerly awaited.

SLE T cells may play a key role in autoantibody production in SLE B cells. In addition, accumulating evidence has shown that SLE T cells participate in the attack on target cells or tissues through the overproduction of pro-inflammatory cytokines or an increase in cell-to-cell adhesion. Thus, the functional abnormality of SLE T cells appears to be pivotal to an understanding of SLE pathogenesis. Accumulating evidence suggests that potential defects may reside in the proximal signal transduction around the TCR-CD3 complex. We have demonstrated that the expression of TCR zeta chain is significantly decreased in peripheral blood T cells from SLE patients. To explore the mechanism of defective expression of TCR zeta chain, we examined mRNA of TCR zeta, and found that two alternatively spliced variants such as exon 7 (-) and short 3'-UTR are detected in SLE. We review the possible role of the TCR zeta defects in autoimmunity and discuss how the splicing variants lead to downregulated protein expression of TCR zeta chain.

Cytomegalovirus infection of the gastrointestinal tract is a rare serious complication in patients with collagen diseases receiving immunosuppressive agents. We report 3 such cases diagnosed by endoscopy followed by proper treatment. The patients include 38 and 53 years old females with systemic lupus erythematosus. They presented epigastric pain after pulse steroid therapy and combination therapy with steroids and cyclophosphamide, respectively. Their endoscopical findings were multiple small gastric erosions. The other patient was a 60-year-old female with polymyositis who developed rectal bleeding after steroid and imuran therapy. Her endoscopical finding was a discrete, irregular rectal ulcer. The diagnosis of all the patients was confirmed by biopsies of those lesions showing giant cell inclusion bodies and positive staining with anti- cytomegalovirus -antibodies. All patients were treated properly with ganciclovir. We should always keep in mind of a cytomegalovirus infection of the gastrointestinal tract in a patient with collagen disease receiving immunosuppressive agents.

Bullous pemphigoid (BP) is an acquired autoimmune subepidermal blistering disease against hemidesmosomal cytoplasmic BP230 and transmembrane BP180 proteins. Epitope mapping studies have shown that the membrane-proximal noncollagenous (NC) 16a domain of BP180 harbors clusters of antigenic sites recognized by the vast majority of BP sera. In this study, we developed an enzyme-linked immunosorbent assay (ELISA) using bacterial recombinant NC16a protein and evaluated its clinical benefit for diagnosis and monitoring disease activity. Fifty four (84.4%) of 64 sera from BP patients were positive, while only one (1.1%) of 91 sera from collagen disease patients and five (1.5%) of 336 sera from normal control barely exceeded the cut-off value. None of 69 pemphigus vulgaris sera and none of 42 pemphigus foliaceus sera exceeded the cut-off value. Thus, the sensitivity and specificity of NC16a ELISA were 84.4 and 98.9%, respectively. The correlation between ELISA scores and disease activity along the time course was examined using seven BP patients. NC16a ELISA scores tended to fluctuate in parallel with the disease activity along the time course and reflected the disease activity much better than indirect immunofluorescence. These findings indicate that NC16a ELISA will be a valuable tool not only for the diagnosis of patients with BP but also for the monitoring of the disease activity.

The distribution of leukocytes is regulated by the autonomic nervous system in humans and animals. The number and function of granulocytes are stimulated by sympathetic nerves whereas those of lymphocytes are stimulated by parasympathetic nerves. This is because granulocytes bear adrenergic receptors, but lymphocytes bear cholinergic receptors on the surface. These regulations may be beneficial to protect the body of living beings. However, when the autonomic nervous system deviates too much to one direction, we fall victim to certain diseases. For example, severe physical or mental stress --> sympathetic nerve activation --> granulocytosis --> tissue damage, including collagen diseases, inflammatory bowel diseases, and cancer. If we introduce the concept of immunomodulation by the autonomic nervous system, a new approach for collagen diseases, inflammatory bowel diseases, and even cancer is raised. With this approach, we believe that these diseases are no longer incurable.

Distinct, especially non-organ specific autoantibodies are closely associated with connective tissue diseases and in many cases are vital elements of the laboratory diagnostics of these disorders. Their inclusion into the common classification criteria is quite heterogeneous. None of the autoantibodies is 100% specific for a certain disease, and diagnostic specificity is usually reduced when application of the test is broadened and when more sensitive methods are used. In individual patients with scleroderma and/or myositis related diseases, typical autoantibodies usually exclude each other; however, there are characteristical exceptions from that rule. Evidence is accumulating that autoantibodies are detectable early during disease course and often even in preclinical stages. Variations of antibody levels during disease course are different in different systems and in some cases have been shown to correlate with disease activity. Negative results in sensitive screening assays are often essential to exclude a connective tissue disease. Although it has certain drawbacks and is being disputed, the indirect immunofluorescence assay with HEp-2 cells still serves as a standard first step in connective tissue disease-related antibody detection. In case of positive results in this assay, further steps should be performed carefully, considering the signs and symptoms of the suspected disease as well as the immunofluorescence pattern, and being aware of the peculiarities and limitations of the assay methods used.

In recent years there has been a continuingly increasing interest in novel research subjects, as yet poorly explored, either because they relate to aspects previously thought to be marginal with respect to classical fields of investigation, or because they require both specialized competence and intense cross-talk by researchers from disparate areas. The potential interaction between immunity and cancer has generated a remarkable number of studies, including those related to the newly explored immune-neuro-endocrine system. In this paper, we review a few autoimmune diseases as examples of a mutual relationship between immune diseases and malignancies. We also review our previous studies on patients with rheumatoid arthritis (RA). In particular, aiming to define the hormone-responsive or -sensitive status of synovial tissues and cells, we have inspected different endocrine end-points, including (1) high- and low-affinity sites of androgen and estrogen binding; (2) the activity of key enzymes of steroid metabolism; and (3) the hormonal profile of synovial fluids as an indication of local endocrine milieu. Overall, our data provide convincing evidence for synovial macrophage-like cells and a subset of T lymphocytes to be considered as target cells for gonadal steroids. This provides a basis for developing new strategies for alternative treatments of RA and possibly unveils novel perspectives in both research and the clinic for other autoimmune diseases as well. In addition, the association of autoimmunity and cancer may disclose promising new avenues of research linking steroid hormones, the immune system, and malignant transformation.

CD4+ HLA-DR+ T cells are known to be increasing in broncho-alveolar lavage fluid (BALF) from patients with sarcoidosis, and related to disease activity. Although there are several reports that the number of gammadelta T cells in peripheral blood from patients with sarcoidosis are increasing, contradictory assertions can be seen about the number of gammadelta T cells in BALF, and the clinical significance on the presence of gammadelta T cells in disease site of patients with diffuse lung disease including sarcoidosis. The absolute number of gammadelta T cells and CD4+ HLA-DR+ T cells in BALF were determined by flow cytometry in 107 patients with diffuse lung diseases; 56 with sarcoidosis, 36 with collagen vascular diseases with lung involvement and 15 with idiopathic pulmonary fibrosis. We also measured the number of the transferrin receptor-positive macrophages in BALF. The correlation between gammadelta T cells and activated (maybe antigen-specific) T cells and macrophages were evaluated. Sarcoidosis patients were also evaluated from the data of the number of gammadelta T cells in peripheral blood by flow cytometry and clinical backgrounds. A significant correlation between the numbers of these two cell types was detected in each of the three patient groups. The percentage of peripheral gammadelta T cells was markedly increased in 7 sarcoidosis patients, each of whom also showed affected organs other than lung, however, 5 individuals did not show an increased number of gammadelta T cells in BALF. The number of gammadelta T cells in BALF did not correlate with the number of transferrin receptor-positive macrophages in all three patient groups. These results suggest that the increased number of gammadelta T cells in diffuse lung diseases likely plays a role in immunosurveillance and contributes to the activation of antigen-specific alphabeta T cell.

We have earlier reported that diverse collagen vascular diseases, including arthritis, arteritis, thrombosis, myocarditis, myositis, sialo-/dacryoadenitis and dermatitis develop with the advent of autoantibodies in transgenic rats carrying the LTR-env-pX gene of human T lymphocyte virus type I (LTR-env-pX rats). To clarify the pathogenesis of these collagen vascular diseases, immunological features of LTR-env-pX rats were examined. In LTR-env-pX rats affected with these diseases, expression of CD80/86 on both tissue-infiltrating and peripheral T cells increased, compared with findings in non-transgenic rats with experimental inflammatory diseases. CD80/86 was also upregulated on peripheral T cells in LTR-env-pX rats prior to the development of diseases. Lymphocytes from LTR-env-pX rats showed an increase in autologous proliferation and were hyperreactive against several mitogens, including concanavalin A, immobilized anti-CD3 antibodies, and superantigens in vitro. Antigen-specific immune response was also enhanced in LTR-env-pX rats. The collective evidence indicates that lymphocytes of LTR-env-pX rats constitutively express surface molecules related to T cell activation and are immunologically hyperresponsive. Bone marrow cell transfer from LTR-env-pX rats to lethally irradiated non-transgenic rats revealed that these immunologically pre-activated and hyperresponsive lymphocytes play a critical role in the pathogenesis of several collagen vascular diseases, especially of dermatitis in LTR-env-pX rats., (Copyright 2001 S. Karger AG, Basel)

This study was designed to evaluate the distribution of lymphocyte subsets in lung specimens that were obtained by open-lung biopsy from 8 patients with idiopathic nonspecific interstitial pneumonia/fibrosis (NSIP) and 10 patients with pulmonary fibrosis associated with collagen vascular disorders (PF-CVD). Distributions of B lymphocytes, CD4-positive T lymphocytes, and CD8-positive T lymphocytes were evaluated immunohistochemically and compared with the cell composition in BALF. Correlation between CD4/CD8 ratios in bronchoalveolar lavage fluids (BALF) and CD4/CD8 ratios in lung tissues was also examined. B lymphocytes were mostly restricted in lymphoid follicles. CD4-positive T lymphocytes were observed inside and around lymphoid follicles and in the thick fibrotic wall of reconstructed alveoli with fibrosis. In contrast, CD8-positive T lymphocytes were diffusely distributed, especially in relatively thin alveoli. Correlation was weak between CD4/CD8 ratios in lung tissue and CD4/CD8 ratios in BALF. However, even in patients with very low CD4/CD8 ratios in BALF, many CD4 lymphocytes were observed in lung tissues, suggesting that CD8-positive lymphocytes diffusely distributed in thin alveolar architecture were more easily recovered in BALF than CD4-positive lymphocytes. Therefore, a low CD4/CD8 ratio in BALF may indicate that the alveolar structure was not severely reconstructed by fibrosis. This is the first report that compared lymphocyte subsets in lung tissues and in BALF.

To investigate the prevalence and clinical relevance of immunoglobulin (Ig) isotypes of antimyeloperoxidase (MPO) and antilactoferrin (LF) antibodies in collagen diseases, enzyme-linked immunosorbent assay was employed to detect the Ig isotypes of both antibodies. The purified proteins of MPO and LF were used as two major representative antigens for anti-neutrophil cytoplasmic antibodies (ANCA) with a perinuclear staining pattern by an indirect immunofluorescent technique. We examined 131 serum samples from 79 patients with rheumatoid arthritis (RA), 32 with systemic lupus erythematosus (SLE), 14 with progressive systemic sclerosis (PSS), 6 with polymyositis/dermatomyositis (PM/DM), and 5 with idiopathic crescentic glomerulonephritis who served as positive controls and 36 healthy subjects who served as controls. A limited number of patients with RA (4-10%), SLE (6-9%), and PSS (7-14%) but not PM/DM showed positive IgG or IgA anti-MPO antibody (MPO-ANCA) but not IgM MPO-ANCA. However, 10-20% of RA, 40-60% of SLE, 20-36% of PSS but none of the PM/DM patients showed positive IgG, IgA, or IgM anti-LF antibody (LF-ANCA). MPO- and LF-ANCA positivity in RA patients was correlated with markers of disease activity such as the erythrocyte sedimentation rate, C-reactive protein, and serum Ig levels. IgG LF-ANCA but not MPO-ANCA positivity in SLE patients also was correlated with the disease activity index but not with clinical features. Neither MPO- nor LF-ANCA positivity in PSS patients was correlated with any clinical features. Overall, both MPO- and LF-ANCA were found mainly in RA, SLE, and PSS patients but not in PM/DM patients. The Ig isotypes of MPO- and LF-ANCA frequently belonged to both IgG and IgA and rarely to the IgM class. Both MPO- and LF-ANCA positivity reflected disease activity in RA and SLE rather than specific organ involvement.

To investigate whether superantigens induce interstitial pneumonia associated with collagen vascular disease (CVD), staphylococcal enterotoxin B (SEB) was intratracheally administered to SCID mice reconstituted with peripheral blood mononuclear cells (PBMCs) from CVD patients that suffered lung complications. Although a slight accumulation of inflammatory cells into the perivascular area was seen in the lungs of SCID mice injected with PBMCs from CVD patients or healthy donors, SEB administration significantly increased the severity of inflammation in the lungs of SCID mice that received CVD patient PBMCs. Furthermore, human leukocytes were detected by immunohistochemistry in the lungs of SCID mice that received SEB after reconstitution with PBMCs from CVD patients but not in other groups of SCID mice. CD45RO(+) memory T cells comprised the majority of infiltrating human leukocytes. These results suggest the possibility that external superantigens may induce the development of interstitial pneumonia in patients that have a genetic background predisposition to autoimmune disease., (Copyright 2000 Academic Press.)