C1 esterase inhibitor: clinical clues to the pathophysiology of angioedema.
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Angioedema↗
Biomedical subjects
M M Frank
Publications and source records attributed to M M Frank.
Immunoregulatory disorders associated with hereditary angioedema. I. Clinical manifestations of autoimmune disease.
Occasional reports have appeared linking hereditary angioedema (HAE) with autoimmune diseases. We have systematically evaluated 157 patients for manifestations of autoimmunity. Nineteen of these patients (12%) had clinical immunoregulatory diseases including glomerulonephritis (five patients), Sjögren's syndrome (three), inflammatory bowel disease (three), thyroiditis (two), systemic lupus erythematosus (one), drug-induced lupus (one), rheumatoid arthritis (one), juvenile rheumatoid arthritis with IgA deficiency (one), incipient pernicious anemia (one), and sicca syndrome (one). All eight patients with HAE who developed an autoimmune disease with a known human histocompatibility antigen association developed a disease associated with their histocompatibility antigen haplotype (p = 0.014). Although only four patients developed Sjögren's syndrome or sicca syndrome, an additional nine manifested part of the sicca complex. We also found patients with HAE with features suggestive of an immune-based abnormality. These features included idiopathic pancreatitis (three patients), Raynaud's disease (two), partial lipodystrophy (one), chronic chorioretinitis (one), and alopecia universalis (one).
Adolescent↗
Immunoregulatory disorders associated with hereditary angioedema. II. Serologic and cellular abnormalities.
Hereditary angioedema is defined biochemically by a deficiency in the functional activity of the inhibitor of Cl, Cl esterase inhibitor (Cl INH). Deficiency of this regulator of the early classic pathway of complement results in chronic activation of this cascade with a resultant deficiency of C4 and C2. Ninety-seven patients with either complicated (associated with autoimmune disorders) or uncomplicated hereditary angioedema were evaluated for laboratory evidence of immunoregulatory defects. Specific cellular and humoral abnormalities were found and included increased mean total lymphocyte counts, increased mean Leu 4+ (total) and Leu 3+ (helper) T cells, an increased mean Leu 3/Leu 2 (helper/suppressor T cell) ratio, polyclonal B cell activation, and evidence of circulating immune complexes. C4 functional titers were negatively correlated with percent Leu 3+ cells and absolute Leu 3+ cell numbers. We failed to detect any evidence of immune deficiency in this population, and yet a statistically significant number of patients demonstrated elevated levels of antibodies to Epstein-Barr virus antigens when patients were compared to a control group. Thus, early classic complement pathway activation and/or partial complement component deficiency may effect T cell subpopulations and B cell activation. However, additional predisposing factors (e.g., genetic or viral) appear necessary for the development of a particular autoimmune disease in hypocomplementemic patients.
Adolescent↗
Danazol-induced cystitis: an undescribed source of hematuria in patients with hereditary angioneurotic edema.
From 1975 through 1983, 69 patients with hereditary angioneurotic edema were treated with danazol, a semisynthetic anabolic steroid. Hematuria developed in 13 of these patients (19 per cent). Careful evaluation of the genitourinary tract showed the presence of a distinct form of hemorrhagic cystitis in 10 patients. Clinically, 9 patients presented with microscopic and 1 with intermittent gross hematuria. Irritative bladder symptoms were reported by 2 patients. Neither the dose nor duration of danazol therapy correlated with the severity of the cystoscopic or pathological findings. Cystoscopically, a rather nonspecific pattern of erythema, submucosal telangiectasia and neovascularity was observed. Histopathologically, bladder biopsy typically showed numerous dilated submucosal vessels with hemorrhage, mucosal ulceration and occasional inflammatory cells. These changes regressed in all but 1 patient when danazol therapy was discontinued. Further studies are needed to elucidate the role of danazol itself or of the danazol-hereditary angioneurotic edema interaction in the pathogenesis of these abnormalities.
Adult↗
Serum sickness and haematopoietic recovery with antithymocyte globulin in bone marrow failure patients.
We have evaluated 33 patients with various bone marrow dyscrasias treated with horse antithymocyte globulin (ATG) (Upjohn) to determine the relationship of haematopoietic response to the occurrence of serum sickness. Patients received ATG intravenously over 10 or 28 d at a dose of 15 mg/kg/d. Total or partial haematological responses were noted in 12 of 33 patients. Twenty-eight patients developed clinical signs of serum sickness 6-14 d after the first infusion of ATG, while five patients did not. Twenty-five of these patients were evaluated by immunochemical assays for circulating immune complexes (C1q-binding assay) and 21 patients for serum complement (C3, C4 and CH50 assay) levels. There was a direct correlation between increases in immune complex levels, decreases in serum complement levels, and the development of the clinical signs and symptoms and serum sickness. Twenty-one of 28 patients who developed serum sickness failed to show haematological improvement. However, haematopoietic recovery occurred in all five patients who did not manifest serum sickness (P less than 0.05) and in four patients who failed to develop immune complexes. These findings indicate that the development of serum sickness is not required for a haematopoietic response with ATG and may indeed impair recovery.
Adolescent↗
Anticomplement receptor activity in the serum of patients with primary biliary cirrhosis.
Patients with primary biliary cirrhosis have a defect in the receptor mediated clearance of complement coated erythrocytes by fixed macrophages of the reticuloendothelial system. To investigate the probable mechanism of this defect peripheral blood monocytes were isolated from nine patients with primary biliary cirrhosis and seven control subjects and the ability of these cells to form rosettes with complement coated, IgM-sensitised sheep erythrocytes was assessed. Primary biliary cirrhosis peripheral blood monocytes formed rosettes to the same extent as control peripheral blood monocytes (71.0 +/- 7.1% [SEM] versus 73.3 +/- 4.3%) suggesting normal complement receptor function of primary biliary cirrhosis peripheral blood monocytes. When primary biliary cirrhosis or control peripheral blood monocytes were preincubated with primary biliary cirrhosis serum, however, the per cent of peripheral blood monocytes that formed rosettes was decreased: 2.4 +/- 0.8 and 3.1 +/- 1.3 fold respectively. To study this phenomenon further, fractions containing IgG or IgM synthesised by cultures of control or primary biliary cirrhosis lymphocytes were prepared. Rosette formation was not affected by exposure to fractions containing control or primary biliary cirrhosis IgG or control IgM, but was markedly inhibited (6.0 +/- 4.8 fold) by exposure to fractions containing primary biliary cirrhosis IgM. Similar results were obtained when freshly isolated peripheral blood monocytes or peripheral blood monocytes that had been cultured for 7-10 days--that is, macrophages, were used. Assuming that one can draw inferences concerning the status of fixed macrophages from data obtained using peripheral blood monocytes, the results of this study suggest that the complement specific defect in reticuloendothelial system clearance function in primary biliary cirrhosis is not caused by abnormality in the functional status of complement receptors on fixed macrophages but rather by a factor present in the serum of patients with primary biliary cirrhosis that has the capacity to inhibit the adherence of complement coated erythrocytes to complement receptors present on the surface of fixed macrophages. This serum factor does not appear to be a complement component but rather a product of peripheral blood mononuclear cells, other than IgG.
Cells, Cultured↗
Studies of the interaction of antibody and complement with encapsulated bacteria.
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Animals↗
Characterization of the hematopoietic defect in paroxysmal nocturnal hemoglobinuria.
We studied the relationship between paroxysmal nocturnal hemoglobinuria (PNH) and bone marrow failure using in vitro hematopoietic colony culture assays. Most of 17 patients with PNH showed decreased colony formation, by erythroid burst-forming cells (BFU-E) and granulocyte-macrophage colony-forming cells (CFU-C) in methylcellulose, disproportionate to their degree of bone marrow biopsy cellularity. Only a minority of the hematopoietic progenitors were sensitive to complement-mediated lysis in vitro. In contrast, normoblasts from maturing erythroid bursts removed from culture and exposed to acidified serum were sensitive to complement-mediated lysis. The size of bursts and the sensitivity of their progeny correlated strongly, suggesting that the PNH defect was acquired in culture as a function of the generational age of erythroid precursor cells. In addition, BFU-E of PNH patients were very sensitive to 3H-thymidine suicide, in comparison with normal individuals and patients with other hemolytic anemias, indicating that a large proportion of primitive erythroid progenitors in PNH bone marrow were in cell cycle. All of these results imply that acquisition of the PNH defect during erythropoiesis may lead to intramedullary destruction of developing erythroid cells. The increased demand that results on the progenitor pool may lead to stem cell depletion and bone marrow failure.
Adolescent↗
Membrane attack complex of complement in rheumatoid synovial tissue demonstrated by immunofluorescent microscopy.
Rheumatoid and osteoarthritic synovial membranes were examined for evidence of terminal complement pathway activation. Using antiserum highly specific for C9 neoantigen, immunofluorescent microscopy was employed to study synovial membrane specimens from 4 patients with rheumatoid arthritis, one patient with psoriatic arthritis, and 5 patients with osteoarthritis. C9 neoantigen was detected in 3 of the 4 rheumatoid membranes, the one psoriatic membrane, and one of the 5 osteoarthritic membranes. Activation of the terminal pathway of complement through C9 should be added to the spectrum of immunologic events known to occur in some rheumatoid synovial membranes.
Adult↗
Quantitation of activation of the human terminal complement pathway by ELISA.
We have devised an enzyme-linked immunosorbent assay (ELISA) to quantitate fluid phase terminal complement pathway activation. Upon activation to form C5b-9, terminal complement components express neoantigens not present in the unassembled individual components. Expression of one of these neoantigens occurs at the step of C9 activation. C9 neoantigen is present in fluid phase SC5b-9 complexes, membrane-bound MC5b-9 complexes, and in in vitro polymerized C9. Under physiologic conditions, the presence of C9 neoantigen indicates that the terminal complement pathway is activated through the terminal component C9. In our assay for C9 neoantigen, we used rabbit antiserum to polymerized C9 rendered specific for C9 neoantigenic determinants by serial absorption with human serum, human C9, and other terminal complement components bound to Sepharose. Using the IgG from this antiserum, we devised a sandwich ELISA to bind SC5b-9 from solution onto polystyrene plates. The ELISA plates were developed with the use of goat antiserum to native C9 epitopes followed by a swine anti-goat IgG-alkaline phosphatase conjugate. Quantitation of SC5b-9 in solution was performed by comparing sample OD to a standard curve generated with human SC5b-9 that was purified from zymosan-activated serum. The assay was sensitive to as little as 100 ng of SC5b-9/ml and should be useful for screening plasma, serum, cerebrospinal fluid, or other biological fluids for the presence of terminal complement pathway activation.
Antibody Specificity↗
Decay-accelerating factor is present on paroxysmal nocturnal hemoglobinuria erythroid progenitors and lost during erythropoiesis in vitro.
A glycoprotein that regulates the deposition of C3b on the erythrocyte surface, called decay-accelerating factor or DAF, is absent from the red blood cells (RBC) of patients with paroxysmal nocturnal hemoglobinuria (PNH), explaining in part their abnormal sensitivity to complement. We used a specific antiserum to DAF, flow microfluorometry, and clonogenic assays for erythroid progenitor cells to study PNH erythropoiesis in vitro. By fluorescence-activated cell sorter analysis, all RBC from normal individuals are DAF+. In contrast, the RBC of six patients with PNH showed discrete populations of DAF- cells (10-44%; x +/- SEM = 31 +/- 6%). The DAF- RBC population was partly eliminated by prior acidified serum lysis. To determine whether erythropoietic progenitors expressed DAF, bone marrow cells were sorted by flow microfluorometry and the separated DAF+ and DAF- populations then cultured in vitro. In two normal individuals, but also in six patients with PNH, erythroid colonies formed only from cells in the DAF+ fraction. However, a variable proportion of the normoblast progeny of these DAF+ progenitor cells from patients with PNH was DAF-. Individual bursts removed from cultures of PNH bone marrow showed two discrete populations by fluorescence; the majority of normoblasts were DAF-, only 3 of 27 individual bursts had greater than 50% DAF+ cells, and in three patients, DAF- normoblasts averaged 79%. In contrast, the progeny of individual bursts from normal individuals comprised a unimodal DAF+ population. In each PNH patient, one normal burst (greater than 80% DAF+ normoblasts) was detected, possibly reflecting a normal residual population of erythroid progenitors. By the criterion of DAF expression, there was no evidence of separate populations of normal and PNH type progenitor cells. The phenotypically normal erythroid progenitors of PNH bone marrow acquire the PNH characteristics during differentiation in vitro.
Adult↗
IgG bearing covalently bound C3b has enhanced bactericidal activity for Escherichia coli 0111.
The mechanism was sought by which bactericidal IgG for E. coli 0111 (strain 12015) increases the bactericidal efficiency of C5b-9. IgG did not affect the distribution of C3 deposition on the O-Ag capsule and the outer membrane of 12015, suggesting that bactericidal IgG was not directing complement activation to different sites on the bacterial surface. However, one-fifth of the C3 that was deposited in the presence of IgG attached covalently to the antibody molecule. Covalent complexes between purified C3b and IgG were prepared in order to study the role of C3b-IgG in the bactericidal reaction. 8-10-fold less C3b-IgG than IgG was necessary to sensitize 12015 for serum killing. When aggregates were eliminated from the C3b-IgG and IgG preparations by sucrose density gradient ultracentrifugation, C3b-IgG remained three- to fourfold more effective than IgG on a molecule-for-molecule bound basis in mediating the serum bactericidal reaction. These results suggest that formation of C3b-IgG during the serum bactericidal reaction is critical for killing, and have important implications for the development of effective bactericidal vaccines.
Antibodies, Bacterial↗
Abnormal clearance of immune complexes from the circulation of patients with primary sclerosing cholangitis.
The ability of fixed macrophages of the reticuloendothelial system to clear circulating immune complexes was studied in 6 patients with primary sclerosing cholangitis, 5 patients with various other forms of chronic liver disease, and 12 normal control subjects. Autologous red cells were radiolabeled with 51Cr and sensitized with anti-Rh(D) immunoglobulin G in vitro. After intravenous infusion of the labeled antibody-coated red cells, the radioactivity content of timed blood specimens was measured. The time required by the reticuloendothelial system to clear one-half the labeled cells from the circulation (t1/2) was then determined. The t1/2 clearance times were significantly prolonged in all 6 patients with primary sclerosing cholangitis, whereas the clearance times in 4 of the 5 liver disease control patients were either normal or shortened. Serum immunoglobulin G and immunoglobulin M immune complex levels did not correlate with t1/2 clearance times. These results suggest that in primary sclerosing cholangitis there is a defect in the ability of fixed macrophages of the reticuloendothelial system to mediate clearance of circulating particles that have been opsonized with immunoglobulin G. This finding further supports recent data that incriminates the immune system in the pathogenesis of primary sclerosing cholangitis.
Adult↗
Cutaneous manifestations of serum sickness in patients receiving antithymocyte globulin.
We have prospectively evaluated the cutaneous manifestations of serum sickness in thirty-five patients treated with horse antithymocyte globulin for bone marrow failure. Twenty-one patients (21/35) were treated with antithymocyte globulin (15 mg/kg/day) for 10 days, and fourteen of thirty-five patients were treated with antithymocyte globulin (15 mg/kg/day) for 14 days and then every other day for an additional 14 days. Clinical evidence of serum sickness developed in thirty patients and included fever and malaise (100%), cutaneous eruptions (93%), arthralgias and myalgias (67%), gastrointestinal complaints (67%), and lymphadenopathy (13%). Cutaneous findings consisted of morbilliform eruptions (n = 19), urticaria (n = 1), or a combination of these two reaction patterns (n = 8). Cutaneous manifestations of serum sickness began on day 7 +/- 1 and lasted for 12 +/- 2 days for the group as a whole. Biopsies of lesional skin revealed mild perivascular lymphohistiocytic infiltrates by light microscopy in these leukopenic patients. Direct immunofluorescence microscopy of lesional skin from patients with serum sickness demonstrated immunoreactants in seven of nine subjects (78%). Immunoreactants were confined to the walls of dermal blood vessels and consisted of IgM (7/9), C3 (6/9), IgE (5/9), and IgA (4/9). IgG (horse or human) was not identified in any of these specimens. Twenty-one patients (21/28) also developed an erythematous eruption on the sides of the fingers, toes, palms, and soles 12 to 48 hours prior to their morbilliform eruption. This study describes the cutaneous manifestations of human serum sickness occurring during therapy with horse antithymocyte globulin, documents a cutaneous sign of serum sickness, and suggests that the cutaneous eruptions associated with human serum sickness are immunologically mediated.
Antilymphocyte Serum↗
Multimeric complement component C9 is necessary for killing of Escherichia coli J5 by terminal attack complex C5b-9.
We studied the molecular composition of the complement C5b-9 complex required for optimal killing of Escherichia coli strain J5. J5 cells were incubated in 3.3%, 6.6%, or 10.0% C8-deficient serum previously absorbed to remove specific antibody and lysozyme. This resulted in the stable deposition after washing of 310, 560, and 890 C5b67 molecules per colony-forming unit, respectively, as determined by binding of 125I-labeled C7. Organisms were then incubated with excess C8 and various amounts of 131I-labeled C9. Plots of the logarithm (base 10) of E. coli J5 cells killed (log kill) vs. C9 input were sigmoidal, confirming the multihit nature of the lethal process. When C9 was supplied in excess, 3300, 5700, and 9600 molecules of C9 were bound per organism for cells bearing 310, 560, and 890 C5b-8 complexes, respectively, leading to C9-to-C7 ratios of 11.0:1, 10.8:1, and 11.4:1 and to log kill values of 1.3, 2.1, and 3.9. However, at low inputs of C9 that lead to C9-to-C7 ratios of less than 3.3:1, no killing occurred, and this was independent of the number of C5b-9 complexes bound. Formation of multimeric C9 at C9-to-C7 ratios permissive for killing was confirmed by electron microscopy and by binding of 125I-labeled antibody with specificity for multimeric but not monomeric C9. These experiments are the first to demonstrate a biological function for C9 polymerization and suggest that multimeric C9 is necessary for optimal killing of E. coli J5 cells by C5b-9.
Cell Membrane↗
Defective reticuloendothelial system Fc-receptor function in patients with acquired immunodeficiency syndrome.
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Acquired Immunodeficiency Syndrome↗
A study of human serum sickness.
Twelve patients with bone marrow failure, who were undergoing therapy with daily intravenous infusions of horse antithymocyte globulin, were studied for the development of serum sickness. Eleven of 12 patients developed typical signs and symptoms of serum sickness 8-13 days after the initiation of treatment. These included fever, malaise, cutaneous eruptions, arthralgias, gastrointestinal disturbances, and lymphadenopathy. Eleven of 12 patients developed high levels of circulating immune complexes during serum sickness. All 12 patients also had concomitant decreases of serum C3 and C4 levels. In addition to urticarial and/or morbilliform eruptions, 8 of 11 patients also developed a serpiginous band of erythema along the sides of the fingers, hands, toes, or feet as an early cutaneous sign of serum sickness. Direct immunofluorescence of lesional skin biopsies during serum sickness revealed deposits of immunoglobulin or complement in the walls of small cutaneous blood vessels in 3 of 5 patients. These findings indicate that circulating immune complexes play a central role in the pathophysiology of human sickness.
Animals↗
New developments in immunopathology with special reference to complement and immune complexes.
The last few years have seen rapid advances in our understanding of immune phenomena, and these are now being translated into a new understanding of immunopathology. This paper reviews a number of areas where important new knowledge has been gained in the area of complement and immune complexes as a cause of disease. An understanding of the role of the metabolism of complement proteins has led to an understanding of how these proteins interact with receptors to cause phagocytosis. New understanding of the lysis-producing steps has led to new diagnostic tests for complement-induced damage as well as new knowledge of how complement functions to kill microorganisms. New methods for purifying anaphylatoxins have made these proteins available for study in man. A model of serum sickness in man has allowed for the more detailed understanding of how immune complexes cause disease and has led to the appreciation of new clinical signs of immune-complex-mediated disease in man.
Antigen-Antibody Complex↗