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Background Waldenstrom's macroglobulinemia (WM) is a rare malignancy characterized by bone marrow infiltration by lymphoplasmacytic cells and the presence of a monoclonal IgM paraprotein. The interactions of lymphoplasmacytic cells with other cells in their microenvironment, including mast cells and endothelial cells, support their survival and proliferation and can induce resistance to therapy. von Willebrand factor (vWF) plays a key role in primary hemostasis but is also a marker of endothelial “stimulation.” High levels of vWF have been associated with an adverse prognosis in patients with symptomatic WM and might reflect the interactions between lymphoplasmacytic cells and other cells of their microenvironment. Materials and Methods Considering vWF and ADAMTS-13 (a disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13) as markers of endothelial dysfunction and activation, we evaluated the prognostic importance of vWF and ADAMTS-13 antigen levels in the serum of patients with previously untreated symptomatic WM to validate vWF as a possible prognostic marker for progression-free and overall survival. We also validated the measurement of vWF in the serum instead of citrated plasma and investigated the possible correlations of ADAMTS-13 antigen levels with disease characteristics. The analysis included 42 patients with symptomatic WM and 19 matched healthy controls. Results The serum levels of vWF antigen provided significant prognostic information, and patients with levels ≥ 200 IU/dL had a very poor prognosis compared with patients with lower levels. The ADAMTS-13 antigen levels were decreased in WM patients and correlated with the IgM levels, β2-microglobulin, and extent of bone marrow infiltration. Conclusion vWF levels measured in the serum could become an important prognostic marker in patients with WM and requires further investigation.

The hyper-immunoglobulin M (HIGM) syndrome comprises a group of rare inherited immunodeficiency disorders characterized by normal or elevated levels of serum IgM with low or absent levels of serum IgG, IgA, and IgE. Patients with this syndrome usually present with a history of recurrent infections or opportunistic infections. Here, we report two male cousins from homozygote twin mothers. The first cousin presented with no signs or symptoms other than neutropenia, which was accidentally found in a routine blood test. Immunological workup in this patient showed undetectable IgG and IgA levels and normal IgM levels. The second cousin had a history of recurrent infections, and at the time of admission, he was diagnosed with Pneumocystis jirovecii infection. The immunologic workup of this patient showed undetectable IgG, decreased IgA, and increased IgM level. Due to their interesting family relationship, genetic analysis was performed, which detected a novel mutation in exon 2 (c.266 del G) of the CD40 ligand gene (CD40LG).

Chronic idiopathic neutropenia (CIN) is a granulocytic disorder associated with presence of activated, myelosuppressive T-lymphocytes. In the present study we have evaluated constituents of humoral immunity in CIN patients (n=48) compared to healthy controls (n=52). CIN patients displayed lower serum IgG levels due to a reduction in IgG1, IgG3, IgG4 but not IgG2, lower IgA and increased IgM levels compared to controls. The proportion of CD19+ cells did not differ between patients and controls; however the proportion of the naive IgD+/CD27- B-cells was increased and the proportion of class-switched memory IgD-/CD27+ B-cells was decreased in the patients. The percentage of CD40+ B-cells did not differ between patients and controls and no aberrations in the CD40-meadiated signal transduction pathway or in CD40-gene polymorphisms were identified. These data provide further evidence that immune disturbances are associated with the pathophysiology of CIN and point out for the first time the implication of the B-cell system.

The immune responses to antigens from different stages of the Epstein-Barr virus (EBV) life cycle were investigated in systemic lupus erythematosus (SLE), rheumatoid arthritis (RA), Sjogren's syndrome (SS), and systemic sclerosis (SSc) to gain knowledge of EBV's involvement in the etiology of systemic autoimmune diseases (SADs) and for an overview of the humoral immune responses against EBV. Investigations were performed by the use of ELISA. IgM, IgA, and IgG antibody binding to 11 EBV antigens: EBNA1, EBNA2, BALF5, EAD, BALF2, EA/R, VCA p18, VCA p23, gB, gp350, and gp42 were examined in serum pools from SAD patients and healthy controls (HCs). Increased antibody levels against the 11 EBV antigens in the SAD pools were seen compared to the HC pool. Specifically, SLE was characterized by strongly increased IgA to EAD both compared to HCs and other SADs, and RA was characterized by increased IgM levels to several EBV antigens. The SADs may be partly distinguished by their differential immune responses to various antigens in the EBV life cycle. All together, these findings support an association between EBV infection and SADs.

Schizophrenia is characterized by an interrelated activation of the immune-inflammatory response system (IRS) and the compensatory immune-regulatory system (CIRS), which downregulates the IRS. Deficit schizophrenia is characterized by a deficit in IgM-mediated autoimmune responses to tryptophan catabolites. The presence and correlates of IgM isotype antibodies to oxidative-specific epitopes (OSEs), nitroso (NO), and nitro (NO2) adducts in schizophrenia remain unknown. This study measured IgM antibodies to malondialdehyde (MDA), azelaic acid, phosphatidylinositol, oleic acid, NO-tryptophan, NO-albumin, NO-cysteinyl, and NO2-tyrosine in a sample of 80 schizophrenia patients, divided into those with and those without deficit schizophrenia, and 38 healthy controls. Deficit schizophrenia was characterized by significantly lower IgM antibody levels to all OSEs as compared with non-deficit schizophrenia and controls. Lowered IgM antibodies to MDA coupled with increased IgM levels to NO-cysteinyl and NO2-tyrosine strongly predict deficit schizophrenia versus non-deficit schizophrenia with an area under the ROC curve of 0.913. A large part of the variance (21.2–42.2%) in the negative symptoms of schizophrenia and excitation is explained by IgM antibody titers to MDA (inversely) and NO-cysteinyl and/or NO2-tyrosine (both positively). Lower IgM antibodies to MDA are significantly associated with impairments in episodic memory including direct and delayed recall. These findings further indicate that deficit schizophrenia is a distinct phenotype of schizophrenia, which is characterized by lower natural IgM antibody levels to OSEs and relative increments in nitrosylation and nitration of proteins. It is concluded that deficits in natural IgM attenuate CIRS functions and that this impairment may drive negative symptoms and impairments in episodic memory and thus deficit schizophrenia.

This experiment was conducted to evaluate the combined effects of manganese-amino acid complex and arginine supplementation on the immune competence of broilers. On the day of hatch 640 male Cobb 500 broiler chicks assigned to two study groups (immune stimulate and non-stimulated). A 2 × 2 factorial arrangement of treatments was used with two manganese sources (MnSO4 or manganese-amino acid complex - MnAA) and two digestible Arg:Lys ratios (1.12 or 1.20). The treatments are: IM (80 ppm MnSO4); MnAA (40 ppm MnSO4 + 40 ppm MnAA); IM+Arg: 80 ppm MnSO4+ L-Arg (Arg:DigLys 1.20); MnAA+Arg: 40 ppm MnSO4 + 40 ppm MnAA + L-Arg (Arg:Lys 1.20). For treatments 1 and 2, the digestible Arg:Lys ratio was 1.12, considered normal for corn-soybean meal-based diets. Birds in the immune stimulated group received a dose of Salmonella Enteritidis vaccine. For growth performance and lymphoid organ development, no significant results were observed. Non-stimulated birds fed diets with Arg supplementation had higher percentage of mucosal T helper, T helper and T cytotoxic, compared to the normal Arg:Lys ratio (1.12). In the immune stimulated birds, broilers fed exclusive IM diet had a higher amount of T helper, T cytotoxic, activated T cytotoxic, and APC cells compared to broilers fed MnAA. The inorganic Mn diets, resulted in higher humoral antibody level (increased IgM levels) only when associated with supplementation of L-Arg. However, the use of an associated Mn source, could support high levels of IgM in commercial levels of Arg. No differences were observed to macrophage phagocytic activity analyses.

A 68-year-old woman developed a meningoencephalitis 18 days after a tick bite. IgG and IgM antibodies against tick-encephalitis virus were demonstrated, by enzyme-linked immunoabsorbent assay, in both serum and cerebrospinal fluid (csf). Lymphoplasmocytic pleocytosis was present in csf for over six weeks, as was an increased IgM level. Three weeks after the onset of neurological symptoms and clearing of the encephalitis there occurred multiple peripheral pareses in the left leg which were slow to regress. Retrospectively, IgM and IgG antibodies against Borrelia burgdorferi were demonstrated in deep-frozen serum and csf. Since IgG antibodies against Borrelia burgdorferi, locally synthesised in csf, could also be demonstrated, it must be assumed that the patient had a double infection. It is suggested that in confirmed cases of tick-encephalitis with an atypical course an additional infection with Borrelia should be considered, because if present the latter can be successfully treated with high doses of penicillin.

The immunotoxic effects of tributyltin chloride (TBTC) were examined in the offspring of Sprague-Dawley rats exposed in utero from day 8 of gestation, through lactation and post-weaning until pups reached the age of 30 days (male and female), 60 days (female) and 90 days (male). Daily oral (gavage) doses of 0.025, 0.25 and 2.5 mg/kg body weight/day were administered in olive oil 7 days/week. Immunologic endpoints were investigated at the termination of each study. Statistically significant results (P

We describe a 5-year-old boy with red-pink, firm, nodular lesions, with central resolution and prominent borders, localized to the face, backs of the hands, extensor surfaces of the arms and legs, and the buttocks. He also had recurrent bacterial respiratory infections. Quantitative immunoglobulin levels revealed hypogammaglobulinemia and increased IgM levels. Histopathologic examination of a nodular lesion revealed perivascular and periadnexal granulomas composed of epithelioid cells surrounded by a mantle of lymphocytes; three cultures for fungi and acid-fast bacilli were negative. Clinical, histopathologic, and immunologic studies supported a diagnosis of hyper-IgM (HIM) syndrome. The boy was treated with pulsed-dose antibiotics and intravenous gamma globulin every 3 weeks, with improvement of clinical symptoms. Skin lesions were treated with topical corticosteroids, with immediate recurrence upon cessation of therapy. To the best of our knowledge, this is the first description of cutaneous granulomas in HIM syndrome.

We assessed the performance of IgG avidity in the diagnosis of acute, chronic and recent [reinfection] on top of chronic schistosomal infections in patients treated with praziquantel. Immunoglobulin levels were studied in 111 patients with Schistosoma mansoni infection and 28 partially cured patients [not responding to the first dose of praziquantel treatment and almost cured after a second one]. Before treatment all patients with schistosomiasis had elevated IgG levels, 75% of them also had increased IgM levels. Avidity index was high among all age groups. The increased IgM/IgG ratio and avidity index among children with schistosomiasis before treatment support the idea of reinfection. Treatment had no significant effect on the studied parameters. We conclude that unlike IgM and IgG antibody levels, IgG avidity test cannot be used to distinguish between recent and chronic infections.

Salivary immunoglobulins and albumin were analysed in smoking and non-smoking immunocompetent and immunodeficient individuals. Stimulated and unstimulated saliva were compared as between individuals with selective immunoglobulin A deficiency (IgAd), common variable immunodeficiency (CVI) and immunocompetent individuals. Immunocompetent smokers showed increased levels of sIgA in unstimulated saliva, when compared with non-smoking immunocompetent individuals. In stimulated saliva, the immunocompetent smokers showed decreased levels of IgG and IgM. IgAd smokers showed decreased levels of albumin in unstimulated saliva, when compared with non-smoking IgAd individuals. The non-smoking individuals with IgAd showed increased levels of IgM in both unstimulated and stimulated saliva, when compared with immunocompetent smokers. The non-smoking CVI individuals showed decreased levels of IgG, IgA and IgM in unstimulated and stimulated saliva, as expected, when compared with the same group of immunocompetent individuals. The decreased levels of albumin in unstimulated saliva in IgAd smokers and comparable to that of the IgG non-smoking IgAd individuals support the observation of locally produced immunoglobulins that protect the oral mucosa. Instead of sIgA, non-smoking immunodeficient individuals with IgAd compensate with increased IgM levels in stimulated saliva. The increased levels of sIgA in unstimulated saliva in immunocompetent smokers may be a reflection of the protection of the oral mucosa.

In view of the reported association of insulin-dependent diabetes mellitus (IDDM) with viral infections, (non-) islet-specific immune changes, and partial immunodeficiencies, we used immunonephelometry to measure circulating levels of IgM, IgG, and IgA in a registry-based group of IDDM patients under age 40 years at clinical onset (n = 397) and in age-matched nondiabetic siblings (n = 316) and control subjects (n = 322). Overall, IgM and IgA concentrations were higher, and IgG concentrations lower, in patients than in control subjects or siblings (P < 0.001). In siblings, IgM concentrations were higher than in control subjects (P < 0.001). Using age-adjusted reference intervals, abnormal Ig concentrations were noted in 27% of the patients at onset versus only 10% of the siblings and 7% of the control subjects (P < 0.001). For onset between 20 and 40 years (n = 220), 30% of the patients presented either increased IgM levels (21%) or decreased IgG levels (11%). Both independent phenomena occurred regardless of diabetes-associated immune and genetic markers. In patients and siblings, IgM levels were positively correlated with pancreatic lipase activity. In diabetic children (0-9 years; n = 65), a subgroup presented increased IgA levels (15%) in association with the highest HLA DQ-linked genetic risk and elevated IgM levels. The changes in total Ig concentrations at onset were largely reversed under insulin therapy. They may reflect exposure to environmental triggers, such as viral infections, or to (relative) insulinopenia prior to clinical disease onset. Whatever their cause, different serum Ig levels exist in different age groups of recent-onset IDDM patients.

Impaired BKV-specific immunity is associated with development of BKV-associated nephropathy. Suitable immunological parameters to identify patients at risk, however, are still debated. We monitored 18 kidney-transplant recipients through the course of self-limited BKV-reactivation (n = 11) and BKV-associated nephropathy (n = 7). BKV-specific cellular immunity directed to nonstructural small and Large T-antigen, and structural VP1-3 was analyzed in an interferon-γ Elispot assay. BKV-specific IgM and IgG were measured using an enzyme-linked immunosorbent assay simultaneously. BKV-specific cellular immunity directed to five BKV-proteins increased significantly from diagnosis to resolution of BKV-reactivation (p < 0.001). Patients with self-limited BKV-reactivation developed BKV-specific T cells without therapeutic interventions, and cleared BKV-reactivation within a median period of 1 month. Patients with BKV-associated nephropathy, however, showed BKV-specific T cells after a median period of 5 months after therapeutic interventions only, and cleared BKV-reactivation after a median period of 8 months. Anti-structural T cells were detected earlier than anti-nonstructural T cells, which coincided with BKV-clearance. Patients with BKV-associated nephropathy showed the highest frequencies of BKV-specific T cells at recovery, the highest increase in BKV-specific IgG and persistence of increased IgM levels (p < 0.05). Our results suggest prognostic values of BKV-specific immune monitoring to identify those patients at risk of BKV-associated nephropathy and to aid in the management of therapeutic interventions.

Pseudomonas aeruginosa is the most common bacterium of postburn infection. In the present study we investigated the immune mechanism of susceptibility to this type of postburn infection and also examined the efficacy of IL-18 treatment. C57BL/6 mice were challenged with P. aeruginosa on day 7 after burn injury. Although the burn-injured mice showed a poor survival rate after bacterial challenge, they retained their IFN-γ production. The burned mice showed lower serum IgM levels and a poor IgM response following P. aeruginosa challenge in comparison with the sham mice, whereas IL-18 treatment after burn injury (alternate day injections for 1 wk) greatly improved the serum IgM levels, which are P. aeruginosa-independent natural IgM before bacterial challenge, thereby increasing the survival rate after the challenge. IL-18 treatment also induced specific IgM to P. aeruginosa in the sera 5 days after bacterial challenge in the burned mice. Interestingly, CD43+CD5−CD23−B220dim cells, namely B-1b cells, increased in the liver after the IL-18 treatment and were found to actively produce IgM in vitro without any additional stimulation. Furthermore, the IL-18 treatment up-regulated the neutrophil count and the C3a levels in the blood as a result of the increased IgM level, which may thus play a critical role in the opsonization and elimination of any invading bacteria. IL-18 treatment for the burned mice and their resultant natural IgM production were thus found to strengthen the host defense against P. aeruginosa infection.

ADAMTS-13 is a protease, member of the ADAMTS family (A Disintegrin and Metalloproteinase with ThromboSpondin type 1 repeats-13), which cleaves the cell bound large ultrapolymeric von Willebrand factor (vWF) strings. Circulating ADAMTS-13 is primarily synthesized and released from hepatic stellate and endothelial cells. Acquired functional deficiency of ADAMTS-13, usually due to inhibitory IgG autoantibodies, results in excessive platelet aggregation and disseminated vWF/platelet-rich thrombus formation. A possible association of low levels of ADAMTS-13 Ag with arterial thrombosis and endothelial dysfunction has also been reported. Hivert and colleagues (Blood 2012;120:3214-21) and our group have shown that increased levels of vWF, the only known substrate of ADAMTS-13, are associated with poorer prognosis in patients with symptomatic Waldenstrom’s Macroglobulinemia (WM). Thus, our aim was to investigate the possible association of ADAMTS-13 antigen (Ag) levels with features of WM and possible biologic implications of the ADAMTS-13 / vWF interaction in WM patients’ prognosis. Our study included 42 patients with symptomatic WM who were treated and followed in the Department of Clinical Therapeutics of the University of Athens (Greece), from 1999 to 2012, 22 patients with asymptomatic WM and 19 healthy controls of matched gender and age. For the purpose of this study we used stored serum, which had been collected before initiation of any therapy. ADAMTS-13 antigen levels were measured using a commercially available kit (R&D Systems, Minneapolis, MN, USA), which has a detection limit for ADAMTS-13 13 (ng/mL) with intra- and inter-Assay Precisions of The median age of patients with symptomatic WM was 65 years (range: 37-83 years) and 54% were males. Anemia (Hb 3 mg/dl in 56%, while 7.5% had serum LDH ≥250 U/L and 58% had serum albumin The median levels of ADAMTS-13 in patients with symptomatic WM were 848 ng/ml (range 471-1622 ng/ml), while those of patients with asymptomatic WM were 875 ng/ml (range 280.5-1466 ng/nl) and of healthy controls were 1170 ng/ml (range 770-1598 ng/ml). Thus, there was a statistically significant difference in the levels of ADAMTS-13 between patients with either symptomatic or asymptomatic WM and normal individuals (p0.5 for both), and thus, a direct link between increased vWF Ag levels, which are found in patients with WM, and compensatory ADAMTS-13 Ag levels cannot be supported by our data. The levels of ADAMTS-13 Ag had no prognostic association with overall or progression free survival in patients with symptomatic WM. In conclusion, this is the first evaluation of ADAMTS-13 Ag levels in the serum of patients with WM, in which we found that the levels of ADAMTS-13 Ag are lower compared to healthy controls and these reduced levels inversely correlate with IgM levels, beta2-microglobulin and the degree of bone marrow infiltration. Levels of ADAMTS-13 do not increase in compensation to increased levels of vWF Ag, a marker of endothelial activation and this fact may have biological implications yet to be investigated. Disclosures No relevant conflicts of interest to declare.

Background Different organochlorines and lead (Pb) have been shown to have immunomodulating properties. Children are at greater risk for exposure to these environmental toxicants, but very little data exist on simultaneous exposures to these substances. Methods We investigated whether the organochlorine compounds (OC) dichlorodiphenylethylene (DDE), hexachlorobenzene (HCB), hexachlorocyclohexane (γ-HCH), the sum of polychlorinated biphenyls (ΣPCBs) and Pb were associated with immune markers such as immunoglobulin (Ig) levels, white blood cell (WBC), counts of lymphocytes; eosinophils and their eosinophilic granula as well as IgE count on basophils. The investigation was part of a cross-sectional environmental study in Hesse, Germany. In 1995, exposure to OC and Pb were determined, questionnaire data collected and immune markers quantified in 331 children. For the analyses, exposure (OC and Pb) concentrations were grouped in quartiles (γ-HCH into tertiles). Using linear regression, controlling for age, gender, passive smoking, serum lipids, and infections in the previous 12 months, we assessed the association between exposures and immune markers. Adjusted geometric means are provided for the different exposure levels. Results Geometric means were: DDE 0.32 μg/L, ΣPCBs 0.50 μg/L, HCB 0.22 μg/L, γ-HCH 0.02 μg/L and Pb 26.8 μg/L. The ΣPCBs was significantly associated with increased IgM levels, whereas HCB was inversely related to IgM. There was a higher number of NK cells (CD56+) with increased γ-HCH concentrations. At higher lead concentrations we saw increased IgE levels. DDE showed the most associations with significant increases in WBC count, in IgE count on basophils, IgE, IgG, and IgA levels. DDE was also found to significantly decrease eosinophilic granula content. Conclusion Low-level exposures to OC and lead (Pb) in children may have immunomodulating effects. The increased IgE levels, IgE count on basophils, and the reduction of eosinophilic granula at higher DDE concentrations showed a most consistent pattern, which could be of clinical importance in the etiology of allergic diseases.

Immunoglobulin M (IgM) is a major component of the teleost humoral immune system. Despite the significance of IgM levels as an immune parameter, there are relatively few studies on changes induced in its total levels in serum. This study examines the effects of several immunomodulators (vitamin A, chitin, yeast cells or levamisole, which act as immunostimulants, and crowding, hypoxia or anaesthetics, which act as stressors) upon the total serum IgM levels of non-immunized gilthead seabream (Sparus aurata L.). Total serum IgM levels of fish fed with the assayed immunostimulant-supplemented diets were statistically higher than those in fish fed a non-supplemented diet, especially in the case of levamisole. On the other hand, serum IgM levels of fish subjected to different stressors were not affected by crowding, hypoxia or certain anaesthetics. However, benzocaine and a narcotic dose of 2-phenoxyethanol provoked a great reduction, while quinaldine sulphate increased IgM levels to a significant degree. These results show how the seric IgM levels can be differently affected by some immunomodulators and the important role they may play in the regulation of total circulating IgM levels in seabream. The possibility of using total serum IgM for assessing immunostimulation, disease diagnosis and stress symptoms during fish farming is discussed.

TO THE EDITOR: In lymphoplasmacytic lymphoma/Waldenstrom's macroglobulinemia (LPL/WM), the immunophenotype of the neoplastic population generally does not show positivity for CD5, CD23, or CD10 monoclonal antibodies, with only 5-20% showing positivity. However, this immunophenotypic particularity does not exclude a diagnosis of Waldenstrom's macroglobulinemia; moreover, CD5 and/or CD23 monoclonal antibody positivity can characterize a subset of patients with high IgM values; these patients are at risk for hyperviscosity-related complications. WM was first described by Jan Waldenstrom in 1944 [1] and is classified as an indolent B-cell lymphoplasmacytic lymphoma (LPL) or LPL/WM [2]. It is a lymphoproliferative neoplasm characterized by the presence of a serum IgM monoclonal component associated with bone marrow lymphocytic infiltration. According to the Workshop on WM held in Athens in 2002 [2], the diagnosis (Table 1) is principally based on the following two essential findings: 1) the quantitative presence of any serum IgM monoclonal component and 2) bone marrow infiltration by lymphoid cells with a lymphoplasmacytic aspect. Table 1 Diagnostic criteria for Wladenstrom's macroglobulinemia and IgM monoclonal gammopathy of undetermined significance. In WM patients, the serum IgM monoclonal component concentration varies widely. However, while finding a monoclonal IgM component is a prerequisite for the LPL/WM diagnosis, it is not a specific feature of WM. In fact, an IgM monoclonal component can be found in other lymphoproliferative disorders, such as chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL), splenic marginal zone lymphoma (SMZL), diffuse large cell lymphoma (DLCL), mantle cell lymphoma (MCL), myeloma and IgM monoclonal gammopathy of undetermined significance (IgM-MGUS)(Table 1). The lymphomatous nature of bone marrow infiltration must be confirmed using flow cytometry and immunohistochemistry to define the immunophenotype. Bone marrow infiltration, usually intertrabecular, is represented by small lymphocytes with evidence of clonal plasmacytoid differentiation. Mast cells are often present, supporting growth of the lymphoplasmacytic population [3]. WM does not show cytogenetic chromosome marker alterations, with most patients displaying a normal karyotype. However, various numerical and structural abnormalities have been described, of which the most frequent is deletion of the long arm of chromosome 6q [4]. Recently, a MYD88 L265P mutation has been observed in more than 90% of WM patients. This has an important diagnostic impact and will improve understanding of the WM pathophysiological mechanism and is likely to improve therapeutic outcomes [5]. We report the case of a 74-year-old male who had a clinical history of uric acid arthropathy, prostatic hypertrophy, and diabetes mellitus type II. In 2003, laboratory tests showed the presence of the serum IgM-κ monoclonal component (1.5 g/dL), increased β2-microglobulin level (β2-M, 2.84 mg/dL), increased ESR (62 mm/h), decreased IgA (22 mg/dL) and IgG levels (387 mg/dL), and significantly increased IgM level (up to 3,190 mg/dL). Blood cell count, differential leukocyte counts, and LDH enzyme level were normal. The bone marrow aspirate (Fig. 1) and immunohistochemistry of the bone marrow biopsy suggested a lymphoproliferative disease with immune secretion, that is, LPL/WM with clinical features suggesting a slow progression. Immunologically, the B-lymphoid population showed positivity for CD5 (Fig. 2) and CD23 (Fig. 3) monoclonal antibodies, in addition to positivity for the classic surface IgM, CD19, CD20, and CD22 monoclonal antibodies, using both flow cytometry and immunohistochemistry; CD10 monoclonal antibody by flow cytometry showed negativity. Fig. 1 Bone marrow aspirate. Lymphocytes with lymphoplasmacytoid appearance (arrows). Fig. 2 (A) Bone marrow flow cytometry finding of CD5+ lymphoplasmacytic lymphoma/WM. (B) Immunohistochemistry of bone marrow biopsy showing CD5+. Fig. 3 (A) Bone marrow flow cytometry finding of CD23+ lymphoplasmacytic lymphoma/WM. (B) Immunohistochemistry of bone marrow biopsy showing CD23+. In 2004, laboratory tests showed values of serum IgM-κ monoclonal component 3,000 mg/dL) and decrease in IgG and IgA levels persisted, while the blood cell and differential leukocyte counts were normal. In 2005, the patient had leukocytosis and lymphocytosis. In 2004 and 2005, bone marrow aspirate and biopsy showed disease stability. In 2006, serum IgM-κ increased as high as 4.0 g/dL; thus, therapy with an alkylating agent (chlorambucil at 4-6 mg/day) was started. The therapy decreased the serum IgM-κ to 1.3 g/dL with the disappearance of splenomegaly. Subsequent checks showed stability of serum IgM-κ with values not higher than 2.0 g/dL, while the increased β2-M and IgM and decreased IgG and IgA persisted; the cell blood and differential leukocyte counts remained normal. In 2012, serum IgM-κ, started to increase again (2.6 g/dL), as well as β2-M (5.6 mg/dL); moreover, the patient was anemic (Hb level, 109 g/L), and leukocytosis (white blood cell count, 16.0×109/L) and lymphocytosis (lymphocytes, 75%) were present. In 2013, the patient was hospitalized for weight loss, anemia, lymphocytosis, and an increase in IgM and CRP (5.8 mg/dL). In the years following the diagnosis, the neoplastic B-lymphocytes showed persistent positivity for CD5 and CD23 and negativity for CD10. LPL is a diagnosis of exclusion. The immunological arrangement has an important role in the differential diagnosis of B-cell lymphoproliferative diseases. In WM, the clonal neoplastic proliferation is represented by memory B cells from postgerminal centers after somatic hypermutation. The differential diagnoses were CLL/SLL, MCL, MZL, and plasma cell myeloma. Furthermore, there is a diagnostic overlap between LPL/WM, IgM MGUS, and smoldering WM. In LPL/WM, the immunological framework is essential to distinguish it from other B-lymphoproliferative diseases with bone marrow involvement and an accompanying IgM monoclonal component. A neoplastic B-lymphoid population expressing CD5 and CD23 positivity simultaneously can suggest a diagnosis of CLL, while positivity for CD5 with simultaneous negativity for CD23 may suggest MCL. A condition of follicular non-Hodgkin lymphoma generally is characteristic for CD10 positivity [6]. In LPL/WM, the typical immunophenotype of the lymphoid population is represented by the following positive panel of monoclonal antibodies: CD19, CD20, CD22, FMC7, BCL2, CD38, CD79a, and monotypic light chains surface [7]. Usually, the immunophenotype of sIgM+, CD5-, CD10-, CD19+, CD20+, CD22+, and CD23-, in association with non-paratrabecular bone marrow infiltration, is diagnostic of WM [7, 8]. In WM, the infiltration pattern and the degree of plasmacytic differentiation can be varied. Given the neoplastic population variability, the positivity of associated antigens PAX5 and CD79a may indicate the correct diagnosis [9]. The present case is reported for immunological peculiarity of the lymphoid population, with CD5 and CD23 positivity and CD10 negativity to monoclonal antibodies. In LPL/WM, monoclonal antibodies CD5, CD10, and CD23 are generally negative. Only 5-20% of cases are positive, while single positivity for CD5 or CD23 is seen in approximately 50% of cases [10, 11]. CD5 and CD23 positivity of the neoplastic lymphoid population is not always easily detectable or acknowledged as definitively positive. The difficulty can be related to data interpretation skills, mainly with flow cytometry [8]. Indeed, low positivity levels observed in some laboratories may not be recognized, while in other laboratories, they may be interpreted as unequivocally positive [12]. Clinical case reports have shown that in LPL/WM, CD5 and CD23 positivity in a lymphoid population can show high IgM values (≥3,000 mg/dL) [11]. This can have important clinical and biological implications because CD23 positivity identifies patients with a great disease burden and at risk of developing important hyperviscosity-related complications. It is also appropriate to test the lymphoid population for CD52 positivity that may be present in many LPL/WM cases. This has an important therapeutic implication for possible therapy with monoclonal anti-CD52 antibody (alemtuzumab) that may have a clinical benefit in a substantial number of patients [13]. This case shows that LPL can display a heterogeneous B-lymphoid neoplastic population, which may show CD5, CD23, and CD10 positivity or CD10 negativity; in these cases, diagnosis of WM is not excluded [11]. Moreover, the presence of CD5+ and/or CD23+ can help to define a subgroup of patients with a high IgM value that may help trigger of possible paraprotein-related complications.

BACKGROUND: The aetiology and pathogenesis of collagenous colitis are unknown. Autoimmunity has been suggested, but no serological findings have supported such a theory. AIMS AND METHODS: Serum from 38 collagenous colitis patients and 38 matched healthy controls was analysed for autoantibodies--that is, antinuclear antibodies, antineutrophil cytoplasmic antibodies, smooth muscle and mitochondrial antibodies, rheumatoid factor and antibodies to thyroglobulin and microsomal antigen, together with antibodies to endomysium, gliadin, and cardiolipin. The serum values of IgA, IgG, IgM, and IgG-subclasses, and complement factors C3 and C4 were also determined. RESULTS: In patients with collagenous colitis the mean value of IgM was significantly increased 2.5 g/l (95% CI; 1.9, 3.2) compared with 1.4 g/l (95% CI; 1.2, 1.7) in controls (p = 0.002). Antinuclear antibodies occurred in nine of 38 patients compared with three of 38 controls, this difference was not statistically significant (p = 0.11). The results of all other immunoglobulins, complement factors, and specific antibodies showed no statistical difference between patients and controls. CONCLUSIONS: No firm evidence for an autoimmune genesis in collagenous colitis is found in this study, although the findings of a positive ANA-titre in some patients and an increased IgM level might give some support for this hypothesis.

One hundred and three splenectomized patients were assessed for evidence of recurrent splenic function using pitted erythrocyte counts and Howell Jolly Body assessments. They were compared to 85 control subjects of comparable age and sex. Recurrent splenic function was identified in twelve of those splenectomized for trauma (48%), in four of those who underwent splenectomy incidental to another operative procedure (19%) and in seven of those who underwent elective splenectomy (12%). It is suggested that recurrent splenic function represents splenosismultiple peritoneal splenic implants. In the trauma group, patients with splenosis had higher lgM levels than those without splenosis.

A lupuslike disease with cutaneous manifestations secondary to the use of chlorpromazine (Thorazine) is presented. Skin biopsy specimens demonstrated classic findings consistent with lupus erythematosus and abundant mucin deposition in the cutaneous lesions—a finding not previously reported to occur in drug-induced lupuslike disease. Laboratory and serologic examinations included a positive antinuclear antibody titer, presence of single-stranded deoxyribonucleic acid (DNA), absence of double-stranded DNA, presence of antihistone antibodies, normal complement level, increased IgM level, and prolongation of partial thromboplastin time. These data confirmed our clinical and histologic diagnosis. Cessation of the medication (chlorpromazine) led to resolution of the skin abnormalities. Electron microscopy revealed electrondense drug metabolites in vascular endothelial cells, as well as tubuloreticular inclusion bodies. This is only the second reported case of chlorpromazineinduced lupuslike disease with cutaneous manifestations.

Increases of serum 19S IgM globulin were detected in adolescent patients admitted for narcotic detoxification. The mean IgM level was 294 ± 130 mg. per cent compared to 164 ± 63 mg. per cent in a control group. Twenty-six of the 64 adolescent narcotic users (40.6 per cent) had IgM levels above 290 mg. per cent, the upper limit of normal. There was no evidence of cytomegalovirus infection, infectious mononucleosis, primary biliary cirrhosis, mixed cryoglobulinemia, or cold agglutinins. The presence of Australia antigen in 2 patients and elevated serum glutamic oxaloacetic transaminase (SGOT) levels in 19 suggests that the increased IgM levels may be related to the presence of chronic persistent hepatitis. Heroin use should be considered as an important cause of elevated serum IgM, especially in association with relatively normal levels of IgG and IgA.

Serum immunoglobulin concentrations were measured for 44 patients who had sickle cell syndromes and for 19 normal black individuals. Most patients who had sickle cell syndrome had significantly elevated IgA levels. In addition, patients who had sickle cell anemia had elevated IgG levels, and patients who had sickle-beta-Thalassemia or other sickle combinations (SC, SD, SO) had significantly elevated IgM levels. None of these patients had a monoclonal gammopathy. The elevated immunoglobulin levels could be the result of chronic reticuloendothelial stimulation by chronic extravascular hemolysis or by potentiation by the inflammation secondary to cholecystitis and cholelithiasis. The reason patients with sickle cell anemia do not have increased IgM levels could be due to their functional asplenia.

In a group of 46 patients with retinitis pigmentosa (RP), we studied the levels of IgM, the presence of a rheumatoid factor (RF), the circulating immune complexes (CIC) and the alterations in the complement system. Our results showed increased IgM levels in two patients (226 and 260 mg/dl), the presence of RF in three patients (205, 187 and 80 IU/ml), the existence of CIC in 43.5% of the subjects, reduced levels of the complement components C3 and C4 (p less than 0.001) and of the haemolytic activity CH50 (p less than 0.001) when compared with a control group consisting of 100 healthy subjects. We found a statistically significant correlation between the values of C3 and CIC (p less than 0.01), C4 and CIC (p less than 0.01) and between CH50 and CIC (p less than 0.001).

The antineoplastic activity of cell surface substance from Staphylococcus epidermidis ATCC-31432 (CSS-subfraction 2) in mice and its influence on the activation of human leucocytes was studied. After in vitro incubation with CSS-subfraction 2, human polymorphonuclear leucocytes were evidently stimulated. In vivo (Balb/c-mice) intraperitoneal application of subfraction 2 of CSS induced a considerable splenomegaly and greatly increased IgM levels indicating a strong immuno-stimulating activity. In order to evaluate antineoplastic effects of CSS-subfraction 2, we used sarcoma L-1 cells (Balb/c-mouse origin) which cause heavy tumor colonization of the lung. After single systemic injection of subfraction 2 of CSS, the number of lung tumor-cell colonies drastically decreased. The combination of this immunomodulating therapy with a temporary anticoagulation resulted in a further reduction of tumor colonies in the lungs of Balb/c-mice.