clinical immunology - postgraduate medical journal · appropriate clinical studies mustbecompleted...

Postgrad Med J (1991) 67, 963 - 972 C The Fellowship of Postgraduate Medicine, 1991

Reviews in Medicine

Clinical immunology

R.J. Powell

Department ofImmunology, University Hospital, Queen's Medical Centre, Nottingham NG7 2UH, UK

Introduction

The breadth of coverage of this successful reviewseries, which commenced in January 1990, presentsparticular problems for the clinical immunologist,whose discipline has consequences for so manymedical specialties. A therapeutic approach hasbeen adopted in an attempt not only to give a themeto this review but also to minimize overlap withreviews from earlier in the series. Advances in thefield ofautoimmunity will be addressed in the latterpart ofthe review with discussion oftheir impact onpatient management. Chronic fatigue syndromehas appeared in several of the reviews in this seriesalready, and consequently only certain areas will behighlighted.

Monoclonal antibody therapy

The therapeutic possibilities of selectively attack-ing cell populations implicated in the pathogenesisof a variety of immunologically mediated diseaseshave always been attractive.

In vasculitis and autoimmune diseases

Antibodies to surface markers on lymphocytes,particularly mature T cells (anti-CD3) have anestablished role in the treatment ofclinical allograftrejection.' However, the use of mouse monoclonalantibodies in man often leads to the generation ofhuman anti-mouse antibodies. In a study of 8patients with multiple sclerosis, daily infusions ofeither mouse anti-CD2 (pan T cell marker) ormouse anti-CD4 (T helper phenotype) led to thegeneration of significant anti-idiotype activity in2 of 8 patients despite in vitro evidence ofimmuno-modulation while undergoing the infusions.2Therefore the long term or repeated use of suchtherapeutic antibodies can only be possible if theagents are rendered less immunogenic. Conse-quently, a brief report in the New England Journal

of Medicine describing the use of a geneticallyengineered 'humanized' form of rat antibody in apatient with systemic vasculitis was of particularinterest.3

In fact two monoclonals were given to establish along lasting remission in a patient with a previouslyintractable systemic vasculitis. The humanizedantibody was campath-lH which recognizes theCDw 52 cluster (expressed by many leucocytes),while the other was a rat antibody to the CD4molecule on T helper cells. The combination ofthese 2 antibodies significantly improved thedisease status yet no serological response to humanor rat immunoglobulins was identified. This formof combination therapy will have significant im-plications for the management of human autoim-mune diseases.A German group has published an elegant open

study on 10 patients with severe intractable rheu-matoid arthritis who received 7 daily infusions of amouse anti-CD4 monoclonal antibody.4 Studies ofthe kinetics of the peripheral mononuclear cellresponse demonstrated a drastic depletion ofCD4 + cells to as low as 25 cell/,il 1 hour after thefirst infusion, from mean starting CD4 + counts of820 ± 410/yl. The CD4 + cell numbers at 24 hoursafter the infusion had not reached initial levels andafter the full 7 days treatment a significant reduc-tion in CD4 + cells remained and persisted for 3-4weeks. Lymphocyte transformation assays showedreduced reactivity in 5 of the 9 patients whocompleted the course of infusions, whereas, incontrast, 4 individuals exhibited an unexpectedincrease in the T cell responses to the mitogen PHA(phytohaemagglutinin) and common antigens suchas tetanus and diphtheria toxoids and tuberculin(PPD). Clinical improvement was evident by theend of the 7 day treatment schedule as measured bythe number of swollen joints, Richie index andfunctional ability. Significant falls in the ery-throcyte sedimentation rate and C-reactive proteinwere apparent. This improvement lasted 6 monthsin 2 patients after 7 daily infusions and in a further2 subjects, after 2 cycles of 7 days therapy. Adversereactions included urticaria in 2 patients which ledCorrespondence: R.J. Powell, M.B., B.S., M.R.C.P.

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to the withdrawal from the protocol in one ofthem.Two additional patients experienced chills withfever suggesting a lymphokine release syndrome.Serum anti-mouse antibodies were detected in thepatients; however, the levels were considered to bequite low (< 1.7 mg/l) and repeat cycles of treat-ment were given to 4 patients without significantreactions. No episodes of infection were noted inthis patient group during observation periods up toone year.

In septic shock

Endotoxin is the lipopolysaccharide component ofGram-negative bacterial cell walls and when releas-ed from these bacteria into the circulation it canproduce the adverse systemic reactions we assoc-iate with septic shock.5 A human IgM monoclonalantibody (HA-lA) that binds specifically to thelipid A domain of endotoxin has been producedand its value in patients with sepsis and Gram-negative infection assessed.6 Five hundred andforty-three patients with presumed Gram-negativeinfection were enrolled in a randomized double-blind trial, to be given either a single infusion of100 mg dose ofHA- lA or a placebo, in addition tothe conventional therapy, for example antibiotics,fluid replacement, cardio-respiratory support; 200patients had subsequently proven Gram-negativebacteraemia with a significant reduction in deathsin the HA-lA treated group. In fact, there were49% fatalities in the placebo group and 30%fatalities in the recipients of HA-lA (P = 0.0014).Improved survival was demonstrable both in theseverely ill and the less severely ill patients. Nobenefit was noted in patients with sepsis whosubsequently proved not to have Gram-negativebacteraemia and no anti-HA-1A antibodies weredetectable. Use of this IgM monoclonal was notassociated with adverse reactions and it is partic-ularly valuable because it reacts with the endotoxinof many Gram-negative bacteria. The cost of thisreagent will be considerable but when compared tothe savings on intensive care therapy, it surely willgain a place in the treatment of this often fatalcondition.The cytokine, tumour necrosis factor (TNF) is

implicated in many disease states such as sepsis,cancer and burns. Phase one studies of a murinemonoclonal antibody to recombinant human TNFhas now been reported in patients with septicshock.7 This therapy was found to be safe andwithout side effects. Further studies are in progressand their results are keenly awaited. Interestingly arole for tumour necrosis factor in familial mediter-ranean fever has recently been suggested.8

Therefore, early clinical studies with monoclonalantibodies show great potential and the possibility

of using humanized xenogenic antibodies for suchtherapies should hold even greater promise.

Intravenous immunoglobulin therapy (IVIg)

IVIg infusions have become popular in the lastdecade either as replacement therapy for antibodydeficiency states, for example hypogammaglobu-linaemia, or in the treatment of various disorderscharacterized by vasculitis/autoimmunity.For antibody deficiency states the value of IVIg

every 3-4 weeks is accepted and has largelyreplaced intramuscular preparations due to greatercompliance, painless infusions and the ability togive larger doses. The prevention ofinfections evenin those patients with severe chest disease isnotable.9"10 The current generation ofIVIg prepara-tions with its low incidence of adverse reactions,has facilitated the establishment of home therapyIVIg where patients infuse safely in their ownhomes."

In acute Kawasaki syndrome IVIg is given toprevent coronary-artery lesions'2 and a single highdose infusion of IVIg appears superior to 4 smallerdoses of IVIg in preventing such lesions.'3How does IVIg mediate its therapeutic effects?

The role of anti-idiotypic antibodies will be dis-cussed in the autoantibody section under anti-neutrophil cytoplasmic antibodies but anotherpossible mechanism may be the enhancement ofantibacterial activities of phagocytic cells, e.g.neutrophils, consequent upon stimulation of therespiratory burst and promotion of bacterial kill-ing. '4 It is, of course, conceivable that the un-desirable reactions (chills, fever, etc.) observedduring IVIg infusions in hypogammaglobulin-aemic patients, which occur particularly when theyhave infection, may be related to phagocytic cellactivation. IVIg also appears to downregulatemonocyte IgG Fc receptors (FCRI and FCRII)which may impair their ability to phagocytoses.'5

Cl-inhibitor therapy

Patients with inherited or acquired Cl-inhibitordeficiency manifest episodes of angioedema andshould these involve the pharynx or larynx then theoutcome can be fatal. Until recently tranexamicacid and danazol for prophylaxis and infusions offresh frozen plasma for severe episodes involvingthe larynx or internal organs have been the thera-peutic options. A concentrate of purified Cl-inhibitor is now available (Cl anactivator, P,Behringwerke AG) and appears satisfactory forhereditary and acquired Cl-inhibitor deficiency

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CLINICAL IMMUNOLOGY 965

both as prophylaxis and in acute severe episodes.'6The price is considerable and this may limit its useto the more problematical cases.

Interferon therapy

The haematology review in this series discussed theuse of interferon alpha in clinical myeloid leu-kaemia'7 and in the gastroenterology review thevalue of interferon alpha in chronic hepatitis Binfection was enumerated.'8 A licence has recentlybeen granted for the use of interferon alpha in thetreatment ofchronic active hepatitis B. Currently 2types of interferon alpha are available, namely arecombinant version or the natural human productextracted from human lymphoblastoid cell cul-tures. The latter contains at least 22 naturallyoccurring alpha subtypes. Serum neutralizing anti-bodies occur infrequently with the natural productwhereas with the recombinant preparation a signi-ficant number develop such antibodies, which willinfluence efficacy and may be involved in thegeneration of adverse reactions.'9The addition of interferon gamma to pentava-

lent antimony in the treatment of refractory orsevere visceral leishmaniasis (kala-azar) is an in-teresting development. In the cutaneous and muco-cutaneous forms of leishmaniasis, the parasiteremains localized but in the visceral form of thedisease, growth ofthe parasite continues within themonocyte-macrophage system, resulting in fever,weight loss and hepatosplenomegaly. The greatmajority of patients with kala-azar respond topentavalent antimony; however, some have only atemporary response and others require severalcourses of treatment to achieve a satisfactoryoutcome. A few patients remain refractory even torepeated courses and the addition of interferongamma injections in combination with pentavalentantimony seems to herald promise in this proble-matical group.20 However, because this is predom-inantly a Third World disease its availability islikely to be limited.

Cytotoxic regimes for vasculitic diseases

'To pulse or not to pulse', was the title of anexcellent editorial in the American Journal ofMedicine.2' Cyclophosphamide is an effective treat-ment in certain vasculitic diseases but when usedorally (2 mg/kg) it has a low therapeutic/toxicprofile. Attempts to reduce the morbidity assoc-iated with oral administration has led to thedevelopment of protocols utilizing intermittenttherapy (pulse therapy) with larger doses of thedrug. The use of pulse cyclophosphamide hasproved a major improvement in the treatment of

lupus nephritis with sustained efficacy and decreas-ed toxicity.2223 The success in lupus nephritis hasled to a tendency to assume that pulse cyclophos-phamide will be comparable or superior to longterm daily dosage schedules in other vasculitides. Areport by Hoffman et al.,24 in the same issue as theeditorial, used high dose intravenous pulse cyclo-phosphamide with oral steroids in 14 patients withWegener's granulomatosis and noted initial benefitin almost all patients in the study. However, in themajority of cases, improvement was not sustained.This contrasts with the lower relapse rates reportedwith low dose oral cyclophosphamide treatmentprotocols.25 This led the authors to conclude thatdaily low dose oral cyclophosphamide and steroidsremain the treatment of choice for Wegener'sgranulomatosis. The implications for other non-systemic lupus erythematosus (SLE) vasculitides,for example polyarteritis, are considerable andappropriate clinical studies must be completed toestablish the optimum regimes for cyclophospha-mide in the various different vasculitides.

Therapy for individuals with humanimmunodeficiency virus infection

Recognition of the diverse immunological defectsassociated with infection by the human immuno-deficiency virus type 1 (HIV) has led to thedevelopment of novel approaches to its treatment.Antiviral agents directed against HIV itself, such aszidovudine (AZT or azidothymidine), a potentinhibitor of HIV replication, remain the mosteffective treatments. Unfortunately, clinical predic-tors of disease progression tend to be evidentrelatively late in the course ofHIV infections, whensignificant impairment of the immune system hasalready occurred. Consequently, laboratory mar-kers of disease progression in asymptomatic HIVpositive individuals are being assessed. CD4 lym-phocyte counts, serum HIV-1 p24 core antigen,P2-microglobulin and neopterin have all beenidentified as having predictive value for the pro-gression to AIDS.2632 The combination of CD4counts and p24 antigenaemia in predicting progres-sion to AIDS has recently been addressed.33 Thepresence of p24 antigenaemia is associated with amore rapid decline in the CD4 + lymphocytepopulation and in conjunction with CD4 counts isuseful in identifying those individuals at signi-ficantly greater risk of disease progression over a 4year period.The results of an American randomized double

blind trial of zidovudine to assess the value oftreating asymptomatic HIV infected adults withCD4 cell counts< 500 mm3 at entry to the studyhave been published.34 The study treatment groupsincluded AZT 500 mg/day, 1500 mg/day, or place-

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bo. AZT 1500 mg/day was associated with severe

haematological toxicity, but with 500mg AZTonly nausea was a problem. After a mean follow upof 55 weeks (range 19-107) 33 subjects assigned toplacebo had AIDS, compared with 11 on 500 mgAZT (confidence interval 1.4-5.6) and 14 of thosereceiving 1500 mg AZT (confidence interval 10-13.5). Whether such treatment will improve thesurvival for persons with HIV and whether healthcare services can afford the cost remains to bedetermined.

Inosine pranobex, a so-called immuno-modu-lant has also been tried in HIV infection35 in a

randomized placebo controlled trial of 866 HIVinfected people in Sweden and Denmark. Signifi-cantly fewer individuals progressed to acquiredimmunodeficiency syndrome (AIDS) during the 24week study period in the group who receivedinosine pranobex (3 g/day), than those who receiv-ed placebo (2 versus 17). This finding is interestingand will need validation. Certain features of thestudy require highlighting such as the alteration ofthe primary end point designated before the studybegan, to a new end point when the data was

analysed. Also no significant difference in thedecreases in CD4+ cell counts was observedbetween the groups or the level of p24 antigen-aemia. For further discussion of this provocativereport the reader is referred to an editorial entitled'Inosine pranobex - is a single positive trialenough?'36A review of combination anti-retroviral therapy

is beyond the scope of this immunological reviewbut the reader is referred to the proceedings of arecent symposium on this topic.37Although mouth ulceration in patients with

AIDS is common, some HIV positive individualsdevelop severe recurrent oral ulcers unrelated tomalignancy or fungal infection. Histologicallythese ulcers resemble those seen in Beh;et's diseaseand the beneficial effects ofthalidomide in Behcet'sulceration led to its use in AIDS with considerablesuccess.38 Thalidomide in childbearing women iscontra-indicated and the patients must be monitor-ed with regular conduction studies, to prevent thedevelopment of an irreversible painful peripheralneuropathy.

Strategies for the treatment of allergyVarious strategies are being developed for immu-nological intervention in IgE-mediated hypersensi-tivity reactions. The limitations to allergenimmunotherapy include problems with allergenidentification particularly with food and drugsensitivity. The possibility of severe adverse re-actions further restrict its use in the UK.39'40 Apeptide vaccine to provide a new form ofimmuno-

therapy in patients with IgE mediated reactionsseems much closer following a study by Stanworthet al.41 They immunized rabbits with a decapeptidesequence from within the CH4 domain of humanIgE conjugated with carrier molecules such askeyhole limpet haemacyanin (KLH) or tuberculinin Freund's adjuvant to obtain polyclonal antipep-tide antibodies. These antibodies were able toinhibit histamine release from rat mast cells both invivo and in vitro. Immunization of rats, previouslysensitized to ovalbumin with the peptide, reducedthe IgE antibody formation and the serum hista-mine concentration. Furthermore it abolished thesystemic anaphylactic reaction in response to aller-gen challenge. Clinical trials will be needed toexamine the value of this new immunotherapeutictechnique which should have exciting clinical pros-pects.A further strategy to reduce immediate hyper-

sensitivity responses might be to functionallyinactivate allergen reactive T cell clones. Staphy-lococcal enterotoxins are capable of stimulatingpowerful polyclonal proliferative responses and toinduce non-responsiveness of T lymphocytes ex-pressing the appropriate TCR Vp gene products.O'Hehir et al.42 have identified T cell clonesinvolved in the human responses to house dust mite(Dermatophagoides Spp) that express either Vp3 orVp6 gene products. Pre-treatment of clonal Vp3 +T cells with Staphylococcus aureus enterotoxins Bor C1 rendered them non-responsive to immuno-genic challenge with their natural ligand, namelyhouse dust mite, while retaining responsiveness toexogenous interleukin 2 (IL2). Similarly, exposureto the Vp6 + dust mite reactive T cells to thestaphylococcal enterotoxin of appropriate specifi-city, SEE, induced specific anergy. Toxicity ofstaphylococcal enterotoxins can be removed bychemical modification and therefore their abilityto functionally inactivate subpopulations ofT cellsexpressing antigen specific receptors with sharedcharacteristics may be of value in the treatment ofallergic disease.

Anti-idiotypic antibodies are involved in theregulation of a number of immune responsesincluding IgE production. In atopic patients, in-creased IgE synthesis may be related to defectiveproduction of regulatory anti-idiotype antibodies.Hebert et al.43 have reported higher levels ofanti-idiotype antibodies to monoclonal antibodiesdirected against rye grass pollens in normal individ-uals compared to untreated atopic patients.Specific immunotherapy with grass pollen extractsincreased the anti-idiotype antibody levels to thoseof normal volunteers. No details of the clinicalresponses to the specific immunotherapy weresupplied.

In summary, the prospects for allergy therapyseem good and the next decade should prove

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fruitful for at least one of these avenues of thera-peutic intervention.

Autoimnunity

Alcoholic liver disease

Autoimmune mechanisms may be implicated in thegeneration of alcoholic liver disease. The observa-tion that only 15-20% of alcoholics will developliver disease has not been fully explained. ACanadian group" compared the autoantibody pro-files in alcoholics with and without liver disease andin a group of patients with chronic active hepatitis(CAH). They noted a higher incidence of anti-bodies to nuclei, single and double-stranded DNAand anti-lymphocytic antibodies in the alcoholicswith liver disease than those without. Furthermore,the autoantibody profile in the alcoholics with liverdisease was not dissimilar to the CAH group,although the incidence of antinuclear antibodieswas less. Unfortunately, the alcoholic no liverdamage group were all male, whereas 20% of thealcoholic liver damage subjects were female andethical restrictions prevented liver biopsies in thealcoholic no liver damage group so that a 'clean'liver was defined by liver function tests alone.

Autoimmune polyendocrinopathy

Circulating organ specific autoantibodies are sero-logical markers for the destruction or impairmentof the relevant endocrine tissue cells in this condi-tion. Bottazzo's group have reported the presenceof organ specific cardiac antibodies in 17% ofpatients with autoimmune polyendocrinopathycompared to 1% of those with autoimmunityaffecting only one gland and 3.5% of normalsubjects.45 In addition, the prevalence of systemichypertension in the polyendocrinopathy group washigher in those with cardiac autoantibodies than inthose without (18% vs 3%). Prospective studies arenow required to confirm whether these cardiacorgan specific antibodies characterize a subgroupof patients with systemic hypertension.

IgA polyspecific autoantibodies in IgA nephropathy

The specificity ofcirculating and kidney bound IgAin patients with IgA nephropathy has recently beeninvestigated' and follows the demonstration ofserum antibodies to bovine serum albumin,47 andgliadin,48 alpha galactosyl49 and autoantibodies tocollagen type IV50 and rheumatoid factors5' in thesepatients. Evidence for the presence of viral anti-gens, for example cytomegalovirus, in the mesan-gium of patients with IgA nephropathy has alsobeen presented but not substantiated.52 However,

the study reviewed here suggests that these findingsmay result from the generation of polyspecific IgAantibodies and recommends considerable cautionshould be exercised when drawing conclusionsfrom the finding of apparently monospecific IgAantibodies in this condition.

Monoclonal autoantibodies in polyneuropathy

Monoclonal antibodies directed against myelinantigens are frequently detected in patients withpolyneuropathy and can result in distal weakness,tremor, ataxia and loss of proprioception. Co-localization along the myelin sheaths of peripheralnerve fibres of monoclonal proteins and Cl q, C3dand C5 has now been identified by immunostain-ing." A correlation between the numbers of fibreswith abnormally spaced myelin and the extent ofdeposition of terminal complement complex sug-gests that the terminal complex contributes to themyelin damage itself. Previously it was consideredthat the IgM monoclonal protein physicallyimpaired the myelin sheaths and the extent ofcomplement involvement was unclear.

Autoantibodies and autoantigens in type I diabetesmellitus

Accurate identification of the individuals who willdevelop insulin dependent diabetes mellitus(IDDM) is paramount if therapeutic strategies topreserve the maximum beta-cell mass are to besuccessful. Studies on the cohort recruited by theBart's-Windsor prospective family study of dia-betes' has allowed the sensitivity and predictivevalue of islet cell antibodies (ICA) measured byimmunofluorescence in Juvenile Diabetes Found-ation (JDF) units to be ascertained over an extend-ed follow-up period. In all 5 relatives with peakICA levels above 80 JDF units, IDDM developedwithin a 7-year follow-up. Survival without IDDMat 10 years was 27% among relatives with peakICA levels of 20-80 JDF units, and 82% for peakICA levels of 4-20 JDF units. The predictivevalues for IDDM development within 10 yearsranged from 40% (threshold 4 JDF units) to 100%(80 JDF units) and the sensitivity from 31% (80JDF units) to 88% (4 JDF units). It is unlikely thatany single centre could achieve a larger studygroup, but with the standardization of ICA anti-body testing in JDF units, pooling of data fromcomparable studies will now be possible.The search for the autoantigens relevant to the

pathogenesis ofIDDM continues. A 64 kD antigenrecognized by serum autoantibodies associatedwith IDDM has been pinpointed as glutamic aciddecarboxylase (GAD) which is the biosynthesizingenzyme of the neurotransmitter GABA (gammaamino butyric acid).55 A major autoantigen recog-

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nized by T cells isolated from patients with recentonset IDDM has also been identified.56 It appearsto be a 38 kD insulin-secretory granule proteinpresent in the islet P cells. The cataloguing of suchautoantigens, particularly those recognized by Tcells, may lead to specific immunotherapy fordiabetes, through the generation of peptide analo-gues of the antigenic epitopes or the T cell receptorsequences involved in their recognition.57

Autoantibodies in stif-man syndrome

Stiff-man syndrome is a rare disorder characterizedby progressive rigidity and painful spasms of theskeletal muscles. Auto-antibodies to glutamic aciddecarboxylase (GAD) were reported in a patientwith stiff-man syndrome, epilepsy and Type 1diabetes mellitus.58 GAD is an enzyme selectivelyconcentrated in neurones secreting the neurotrans-mitter gamma-aminobutyric acid (GABA) and inpancreatic beta cells. The same group systemati-cally studied a large group of these patients andobserved autoantibodies to GABA-ergic neuronesin 20 of 33 patients.59 GAD featured as theprincipal autoantigen. In those 20 positive patientsthere was striking association with organ specificautoimmune diseases, especially insulin dependentdiabetes mellitus. These findings strongly supportthe hypothesis that stiff-man syndrome is an auto-immune disease.

Anti-neutrophil cytoplasmic antibodies

The identification of autoantibodies to neutrophilcytoplasmic antigens (ANCA) in the sera ofpatients with an active systemic vasculitis, such asWegener's granulomatosis (WG) and polyarteritisnodosa (PAN), has provided a means of rapiddiagnosis in many patients.' Hitherto, no sero-logical test was available to differentiate the diseasespectrum of systemic vasculitis especially when theclinical presentation was atypical. The classicalanti-neutrophil cytoplasmic antibody (cANCA),detected by indirect immunofluorescence on nor-mal human neutrophils, is positive in the majorityof cases of WG and PAN at presentation.6' Alongitudinal study has demonstrated the value oftitration ofcANCA by immunofluorescence in themonitoring of disease activity in WG and PAN.62Titres of cANCA were markedly raised both atpresentation and at vasculitic relapse in 10 patients,but intercurrent episodes such as infection orpulmonary embolism were not associated withincreases in the cANCA titres. In contrast, in-creases in serum C-reactive protein (CRP) couldnot distinguish non-vasculitic illness from vas-culitic relapse. Previously only CRP had beencorrelated with increases in disease activity;6364however, C-reactive protein remains a better mea-

sure of recovery as its half-life is 8 hours comparedto that of IgG whose half-life is 3 weeks.The relationship between the immunofluores-

cence patterns ofcANCA and pANCA (perinuclearpattern) and the results of ELISA and solid-phaseradioimmunoassay remain unclear.65The classical cANCA immunofluorescence pat-

tern is rarely found in vasculitis other than due toWG and PAN. However, other distinct non-cANCA patterns have been noted in a variety ofconditions, such as rheumatoid arthritis, Felty'ssyndrome, Churg-Strauss syndrome and micro-scopic polyarteritis.

Furthermore the classic (isotype) antibody toneutrophil cytoplasmic antigens may also berelevant to clinical disease expression. Isolated IgMANCA is reported to occur in patients with severepulmonary haemorrhage and nephritis' and IgAwith IgG ANCA are found in adult Henoch-Schonlein purpura.67 The ANCA IgG subclassdistribution by radioimmunoassay in patients withsystemic vasculitis (including PAN and WG) showsa relative enrichment ofIgG 3 and depletion ofIgG2. When active and remission sera were compared,IgG 3 ANCA levels had fallen and IgG2 ANCAlevels increased with remission.68A pathogenetic role for ANCA in PAN and WG

is suggested by the correlations between ANCAtitre and disease expression. One might questionthe ability of these antibodies to penetrate viablecells to produce immunological effects. However,recent studies have unequivocally demonstratedthat antibody can enter viable human lympho-cytes,69'70 hence alter cell antigens and thus play adirect role in the immunopathological process.The presence of anti-idiotypes against ANCA in

normal immunoglobulin preparations used forintravenous infusion (IVIg) suggest that such IVIginfusion may have a therapeutic role in systemicvasculitis. Such anti-idiotypes have also been dem-onstrated in the sera of patients with vasculitiswhen they are in remission.7' A recent publicationconfirms the beneficial effect of IVIg infusions inpatients with systemic vasculitis who have activedisease despite conventional therapies.72 The roleof anti-enddthelial cell antibodies (AECA) in vas-culitis remains debatable but a combined role ofANCA and AECA in the generation of the vascu-litic process remains a strong possibility.73 AECAdo not appear to be mere epiphenomena conse-quent to inflammatory vascular injury as they arepresent in some vasculitic conditions such as WGand PAN yet not in essential mixed cryoglobulin-aemia.

Chronicfatigue syndrome

This disabling condition of unknown aetiology ischaracterized by extreme fatigue exacerbated by

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minimal physical activity, reduced powers of con-centration and short term memory loss. The searchcontinues for aetiological factors and worthwhileapproaches to therapy. Wider use of the termchronic fatigue syndrome (CFS) by doctors and thelay public rather than myalgic encephalomyelitis(ME) or post-viral fatigue syndrome, with theirimplications concerning unproven assumptionsabout aetiology, would be a valuable stride for-ward. Considerable interest in CFS continues andthis journal alone carried both a review" and anoriginal article76 on CFS in 1990. In addition, anarticle earlier in this series on 'Infection andInfectious Disease'77 paid considerable attention tothe condition. Since the latter, 2 contradictingarticles on the beneficial effects of intravenousimmunoglobulin therapy (IVIg) in CFS appearedin the same issue of the American Journal ofMedicine. A major difference between the studieswas the dose of IVIg, namely 1 mg/kg in theAmerican study, showing no benefit,78 whereas2 mg/kg was used in the Australian study79 whichshowed benefit in 43% of individuals. The Ameri-can study recruited predominantly female patientsfrom rheumatologists and infectious disease spec-ialists, used a published working case definition forCFS80 and has a 20% incidence ofadverse reactionsin both the IVIg and the placebo (1% albuminsolution) groups. In contrast, the Australian studyhad a major psychiatric input into the assessments,recruited virtually equal groups ofmale and femalepatients and all patients had chronic persistingsymptoms rather than a relapsing remitting course.In fact, the mean duration of symptoms was 47months in the Australian study. Such major differ-ences between the studies must leave the questionabout the beneficial effects of IVIg unanswered.The rationale behind the use of IVIg in both

studies was the concept of an immunoregulatorydefect in CFS. The American study concentratedon immunoglobulin subclass deficiencies whereasthe Australian study reported abnormal cell medi-ated immunity in 40 of 49 patients with CFS basedon reduced delayed type hypersensitivity skin testsand/or T cell lymphopenia. These immunologicalabnormalities may well be a consequence of thechronic illness rather than primary defects.

Subtle changes in natural killer cell (NK)phenotypes are reported in CFS, in particular anincrease in CD56bflOt+ cells which comprise lessthan 5% of the entire NK population in normalindividuals.8' However, changes in function relat-ing to altered phenotype expression can only

remain the object of speculation, but would becompatible with persisting viral infection. Continu-ing the theme ofpossible viral infection, enteroviralRNA sequences have been detected in the muscle ofsome patients with CFS by the polymerase chainreaction.82 In the 60 patients with CFS, 53% werepositive for enteroviral RNA sequences in muscleafter polymerase chain reaction amplification andhybridization with the probe EP2 compared to15% of41 controls. Persistent enteroviral infectionmay therefore occur in some patients with CFS andmay indeed have an aetiological role. However, thefindings of enteroviral sequences did not correlatewith duration of disease, age or raised titres ofantibodies to coxsackie viruses B1-5. Furthermorea study looking directly at serological tests avail-able for coxsackie B virus antibodies concludedthat they were unhelpful in the diagnosis of CFSand simply reflected the background in the popula-tion.83A study which has generated considerable inter-

est in the CFS patient population leading todemands for magnesium injections appeared in theLancet this year.' The study reported lower red cellmagnesium concentrations in CFS patients than inhealthy controls, and in a trial comparing 6 weeklyintramuscular magnesium sulphate and placeboinjections describe an improvement in 12 of 15 CFSmagnesium treated patients compared to 3 of 17CFS placebo treated patients. Only 0.3% of totalbody magnesium concentration is present inplasma and therefore measurement of erythrocytemagnesium to reflect the intracellular action wouldseem a reasonable approach. However, analyticalimprecision appears to reduce the usefulness of thisapproach, such that plasma magnesium remainsthe most useful indicator ofmagnesium status.85 Inparticular red cell magnesium content is dependenton the age of the erythrocyte, being highest innewly produced cells, and correlates poorly withplasma levels.86 It is not clear from the Lancet paperwhy the magnesium levels in the case control studyand those in the double-blind trial were performedin laboratories 'under slightly different conditions'such that according to the authors they are notcomparable. If we accept the findings of this studythen we must decide whether they are causal or theproduct of CFS itself. Certainly magnesium levelscan affect the energy status; however, stress, anx-iety and nervousness can themselves induce hypo-magnesaemia.8788 We must look forward to furtherstudies to help resolve these issues in CFS.

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2. Hafler, D.A., Ritz, J., Schlossman, S.F. & Weiner, H.L.Anti-CD4 and Anti-CD2 monoclonal antibody infusions insubjects with multiple sclerosis. Immunosuppressive effectsand human anti-mouse responses. J Immunol 1988, 141:131- 138.

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