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Effectiveness of lymphocytapheresis in a patient with ankylosing spondylitis
09553886190 $3.00+0.00 Copyright 0 1990 Pergamon press plc
Trunsfus. Sci. 1990; 11:97-101 printed in Great Britain. All rights reserved
Effectiveness of ymphocytapheresis in a Patient with Ankylosing Spondylitis Toyoji Ueo, MD* Kaori Kobori, MD* Hideo Okumura, MD* Kazuhiko Ito, MDt Hisahiro Yoshidat Mihoko Norioka, MD t Kazuya Shimizu, MD* Takao Yamamuro, MD*
unknown; however some evidence suggests the presence of immunological disturbances in this disease. There is a strong linkage between HLA-B27 and AS. HLA-B27 is a class 1 HLA antigen which acts as a target in cell-mediated inflammatory responses. Antibodies raised against Klebsiella pneumoniae was found to be cytotoxic to HLA-B27positive lymphocytes of patients with AS, levels of serum IgA and secretory IgA are raised in AS, and circulating immune complexes may be present.’ Sulfasalazinc, an immunomodulating agent, is effective in AS.2 We attempted immunomodulation by means of lymphocyte depletion using a cell separator in a patient with AS who suffered uncontrolled severe pain.
n Immunomodulation by lymphocytapheresis (LCA) was carried out in a patient with ankylosing spondylitis (AS) who suffered severe pain in joints and back. LCA was performed once a week and 3 x 109lymphocytes were extracted each time. Fifteen courses of LCA were completed. The joint score was gradually decreased and the improvement was maintained 11 months after treatment. The population of NK cells detected by Leu-7 and Leu- 11 monoclonal antibodies decreased and HLA-DR positive CD3 cells increased during and after the treatment. The effectiveness of LCA in AS may confirm the participation of immunological mechanisms in the pathogenesis of AS. n
PATIENT AND METHODS INTRODUCTION
A 28-yr-old man suffered a low back pain at 16 yr that was diagnosed as herniated disc syndrome. He was treated by epidural injection of steroid. After the episode, he suffered joint pain in the bilateral knee and shoulder. The joint pain spread to the other joints, and he was treated with gold compounds with a suspected diagnosis of rheumatoid arthritis. At 21 yr, he visited Kyoto University Hospital complaining of a spastic motor disturbance of the lower extremities. Au arachnoidal cyst was detected on the
Ankylosing spondylitis (AS) is a chronic systemic inflammatory disease that usually begins in the sacroiliac joints and progressively ascends into spinal column with resultant body fusion. Central large synovial joints are also frequently affected. The pathogenesis of AS is still From the ‘Department of Orthopedic Surgery and tDepartmem of Tmnafusion Medicine, Paculty of Medicine KyotoUniversity, 53 Kawahara-Cho, Shogoin, SakyoKu, kyoto 606, Japan. Received 9f89; Accepted 12/89.
97
98
Transfus. Sci.
Vol. 11, No. 1
thoracic spinal cord and was excised. Because arthritic change of the sacroiliac joints was observed by x-ray and examination of HLA typing of the patient revealed positive B27, his disease was diagnosed as AS for the first time. At 27 yr, back pain and arthralgia increased and was not controlled by medicine including steroid and NSAID. He was admitted to Kyoto University Hospital in October 1987. Radiologic evaluation revealed complete fusion of the sacroiliac joints and several intervertebral joints of the cervical spine. No laboratory abnormalities were observed in immunogloburin (&A, IgM, IgG), hematologic studies, liver and renal studies. Rheumatoid factor was negative. CRP was 11 mg/dL, ESR was 40 mm/hr. A series of LCA was carried out. A CS-3000 (Travenol Ltd, Tokyo, Japan) was used for cell separation. LCA was performed once weekly for 15 weeks. Each procedure required approximately 3 hr and mean number of 3 x lo9 lymphocytes were removed. The serum removed with the lymphocytes was separated by centrifugation at the end of each procedure and stored in a freezer, and then used as replacement plasma in the next procedure. No blood or commercially obtained plasma protein fractions were transfused. Before each LCA procedure, he was assessed in terms of the joint score by Lansbury’s method, chest expansion measured at the level of the fourth intercostal space, finger to floor distance (FFD) in maximum flexion of the trunk. Levels of C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) were checked with every LCA procedure. Lymphocyte subsets detected by the cell surface antigens were studied at every fifth procedure and at follow up time. The surface antigens of lymphocytes were detected by a fluoresceinactivated cell counter (Ortho Spectrum 3, Ortho Diagnostic Systems K.K., Tokyo, Japan) using two-color staining of the following monoclonal antibodies: Leu-2a/Leu- 15, (suppressor T-cell); Leu-
2a+/Leu-15+, (cytotoxic T-cell); Leu-2a+/ Leu- 15-, CDB, (suppressor/cytotoxic Tcells); Leu-2a+,b5 Leu-3a/Leu-8, (helper T-cells); Leu-3+/Leu-8-, (suppressor inducer T-cells); Leu-3+/Leu-8+, CD8, (helper/inducer T-cells); Leu-3a+,6,7 Leu4/HLA-DR, (activated T-cells); Leu-4+/ HLA-DR+, (CD3 pan-T cells); Leu-4+, (HLA-DR positive cells); HLA-DR+, Leu7/Leu-11 (NK cells)8 (Becton Dickinson Overseas, Tokyo). RESULTS
The changes of clinical parameters including joint score, chest expansion, and FFD are presented in Figs 1 and 2. The severe pain decreased gradually except initial flare up at the 66th procedures. After the cessation of LCA, the clinical symptoms showed steady improvement even at 11 months posttreatment. The change of FFD did not
0
. . . ,.,,.. lot. 3 5 7
9
No. of LCA
11
. . . . 13 15
. IM
..?b 3M
SM
IIM
Follow-up
Figure 1. Change of joint score during and
after treatment. Joint score was calculated by the method of Lansbury. LCA: lymphocpapheresis.
No. of LCA
Follow-up
Figure 2. Changes of the finger to floor
distance (FFD) and difference of the chest circumference during deep breathing.
Effectivenessof LCA on AS
No. 01 LCA
99
Fottow-up No. of LCA
Figure 3. Changes of erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP). CRP decreased during follow-up time coinciding with joint score.
show a consistent pattern, but decreased back pain enabled the patient to flex the spine to achieve FFD of 23 cm 11 months after treatment. Chest expansion was improved slightly by 2 cm. ESR did not show any change, but levels of CRP decreased during followup, coinciding with improvement of joint score (Fig. 3). Changes of subpopulations of CD3, CD4, CD8 positive lymphocyte were not observed during and after LCA. The CD4/CD8 ratio did not decrease after LCA treatment (Fig. 4). Helper and suppressor T-cells detected by two-color staining also did not show any particular fluctuations in the peripheral blood (Fig. 5). The subpopulation of suppressor inducer T-cells tended to increase after the cessation of LCA. Cytotoxic T-cells did not change. Significant changes of lymphocyte subpopulations were observed in acti-
Follow-up
Figure 5. Changes of helper and suppressor cells. No particular changes were observed in the populations of these cells during and after the treatment. There was no relationship between helper/suppressor ratio and joint score.
vated antigen bearing cells and NK cells. The activated T-cells (double-stained cells with CD3 and HLA-DR) increased gradually during and after LCA treatment. HLA-DR positive cells in the lymphocyte population were also increased (Fig. 6). NK cells of the Leu-1 l+/ Leu-7+ subset showed a gradual decrease
24.0
0.0
P-
,..,.......,..
1st. 3
5
7
9
I,
NO. of LCA
13
1.IM
15
3M
. 5M.
0.0 11M
Follow-up
Figure 6. Activated T-cells detected by both positive HLA-DR and CD3 antigen increased during and after the treatment. HLA-DR positive cells also increased.
% 2.5
loo
1
80
24.0
5
18.0
3
12.0 6.0
NO. of LCA
Follow-up
Figure 4. Changes of CD3, CD4 and CD8 cells during and after treatment. Considerable changes were not observed including CD4/ CD8 ratio. CD3: Pan-T cell. CD4: helper/ inducer cell. CD8: suppressorkytotoxic cell.
NO. 01 LCA
Follow-up
Figure 7. Changes of NK cells. Considerable decreasing during and after the treatment was observed in Leu-ll+/Leu-7+ subset in NK cells.
100 Transfus.Sci. Vol. 11, No. 1
during and after LCA treatment, but increased temporarily 1 - 3 months after cessation of the treatment [Fig. 7). DISCUSSION While the pathogenesis of AS is unknown, it is now recognized that AS is not an immunologically silent disorder.‘j9 The HLA-B27 antigen stimulated research in AS. It was reported that a specific Klebsiella serotype has an intimate relationship with B27 positive lymphocytes of patients.‘O There appears to be sharing of a homologous amino acid sequence by HLA-B27 and Klebsiella pneumoniae. I1 Antibodies raised against certain strains of Kelbsiella were found to be cytotoxic to HLA-B27-positive lymphocytes of patients with AS. Since HLA-B27 is a class 1 HLA antigen that controls the response of cytotoxic T-lymphocytes, some disorders of cell-mediated immune responses could be anticipated. Cytotoxic T-lymphocytes might recognize certain bacterial antigens in association with HLA-B27 and this interaction might lead to an inflammatory episode during the initial stages of the disease.12 A further clue to the immunological basis of the pathogenesis may come from the efficacy of drug therapy using sulfasalazine. Sulfasalazine is thought to be a immunomodulator, decreasing numbers of T-cells, decreasing mitogen-induced lymphocyte activation, l3 and changing natural killer activity.r4 LCA in AS has not previously been reported. We experienced favorable results in the treatment of rheumatoid arthritis by LCA, that were supported by changes of immunological parameters.15 The experience encouraged us to treat AS with LCA. The joint pain improved gradually except at initial stage of LCA series and at a few months after the treatment. The improvement lasted 11 months after the treatment. The value of CRP also decreased, along with joint score. There were also changes of lymphocyte subpopulations, specially in NK cells and HLA-DR antigen-bearing cells.
NK cells detected by both Leu-7 and Leu11 antibodies decreased gradually during LCA and the low level of population were still maintained 11 months after the There were no obvious treatment. changes in CD4 and CD8 positive cells. A different pattern of changes in subpopulations lymphocyte were observed in a series of LCA performed in patients with rheumatoid arthritis.15 In that series, CD4 positive cells decreased significantly and CD8 positive cells remained unchanged, resulting in a significantly decreased CD4/CD8 ratio after cessation of LCA treatment. NK cells bearing Leu-7 antigen increased significantly and Leu-1 1 positive cells did not change. The differences observed in NK cells might suggest a participation of NK cells in the etiology of AS. Increased populations of HLA-DR positive cells were observed after LCA treatment in both AS and rheumatoid arthritis. Doubly stained cells with CD3 and HLA-DR antibodies also increased during treatment in this patient. That change might have occurred because lymphocyte activation induced by continuous lymphocyte depletion. The very favorable clinical results and definite changes of immunological parameters observed after LCA treatment may support the hypothesis that immunological disorders are important in the pathogenesis of AS. REFERENCES Rosenbaurn JT, Theofilopoulos A, McDe-
vitt HO, Perreira A, Carson D, Cahn A: Presence of circulating immune complexes in Reiter’s syndrome and ankylosing spondylitis. Clin Immunol Zmmunopathol 1981; 18:291-297. Dougados M, Boumier P, Amor B: Sulfasalazine in ankylosing spondylitis: A double blind controlled study in 60 patients. Br Med 1 1986; 293:911-914. Landy A, Gartland GL, Clement LT: Characterization of a phenotypically distinct subpopulation of Leu-2+ cells that suppresses T cell proliferative responses. 1 Immunol 1983; 131:2757-2761. Clement LT, Grossi CE, Gartland GL: Morphologic and phenotypic features of
Effectiveness of LCA on AS
5.
6.
7.
8.
9.
the subpopulation of Leu-2+ cells that suppresses B cell differentiation. I Immunoll984; 133:2461-2468.. Clement LT, Dagg MK, Landay A: Characterization of human lymphocyte subpopulations: alloreactive cytotoxic T lymphocyte precursor and effector cells are phenotypically distinct from Leu-2+ suppressor cells. 1 Clin Zmmunol 1984; 4:395--402. Gatenby PA, Kansas GS, Kian CY, Evans RL, Engleman EG: Dissection of immunoregulatory subpopulations of T lymphocytes within the helper and suppressor sublineages in man. j Zmmunol 1982; 129: 1997-2000. Damle NK, Mohagheghpour N, Engleman EG: Soluble antigen primed inducer T cells activate antigen-specific suppressor T cells in the absence of antigenpulsed accessory cells: Phenotypic definition of suppressor-inducer and suppressor-effector cells. / Immunol 1984; 132644650. Lamer LL, Le AM, Phillips JH, Warner NL, Babcock GF: Subpopulations of human natural killer cells defined by expression of Leu-7 (HNK-1) and Leu- 11 (NK-15) antigens. 1 Immunol 1983; 131:1789-1796. Kinsella TD, Espinoza L, Vasey FB: Serum complement and immunoglobulin levels in sporadic and familial ankylosing spondylitis. ] Rheumatoll975; 2: 308313.
101
10. Seager K, Bashir HR, Ceczy AF: Evidence for a specific B27-associated cell surface marker on lymphocytes of patients with ankylosing spondylitis. Nature 1979; 277:68-70. 11. Schwimmbeck PL, Oldstone MBA: Molecular mimicry and autoimmune disease as the pathogenetic mechanism of ankylosing spondylitis and Reiter’s syndrome. Clin Res 1987; 35:141A. 12. Ceczy AF, Mcguigan LE, Sullivan JS, Edmonds JP: Cytotoxic T lymphocytes against disease-associated determinants(s) in ankylosing spondylitis. I Exp Med 1986; 164:932-937. 13. Rubinstein A, Das KM, Melamed J, Murphy RA: Comparative analysis of systemic immunological parameters in ulcerative colitis and idiopathic proctitis: Effects of sulfasalazine in vivo and in vitro. Clin Exp Immunol 1978; 33:217224. 14. Gibson PR, Jewel1 DP: Sulfasalazine and derivatives, natural killer activity and ulcerative colitis. Clin Sci 1985; 69: 177184. 15. Ueo T, Ito K, Yoshida H, Okumura H, Yamamuro T: Immunomodulatory effects of lymphocytapheresis in patients with rheumatoid arthritis, in Oda T, Shiokawa Y, Inoue N(eds): Therapeutic Plasmapheresis, vol. 6. Cleveland, ISA0 Press, 1987, pp. 610-614.
Trunsfus. Sci. 1990; 11:97-101 printed in Great Britain. All rights reserved
Effectiveness of ymphocytapheresis in a Patient with Ankylosing Spondylitis Toyoji Ueo, MD* Kaori Kobori, MD* Hideo Okumura, MD* Kazuhiko Ito, MDt Hisahiro Yoshidat Mihoko Norioka, MD t Kazuya Shimizu, MD* Takao Yamamuro, MD*
unknown; however some evidence suggests the presence of immunological disturbances in this disease. There is a strong linkage between HLA-B27 and AS. HLA-B27 is a class 1 HLA antigen which acts as a target in cell-mediated inflammatory responses. Antibodies raised against Klebsiella pneumoniae was found to be cytotoxic to HLA-B27positive lymphocytes of patients with AS, levels of serum IgA and secretory IgA are raised in AS, and circulating immune complexes may be present.’ Sulfasalazinc, an immunomodulating agent, is effective in AS.2 We attempted immunomodulation by means of lymphocyte depletion using a cell separator in a patient with AS who suffered uncontrolled severe pain.
n Immunomodulation by lymphocytapheresis (LCA) was carried out in a patient with ankylosing spondylitis (AS) who suffered severe pain in joints and back. LCA was performed once a week and 3 x 109lymphocytes were extracted each time. Fifteen courses of LCA were completed. The joint score was gradually decreased and the improvement was maintained 11 months after treatment. The population of NK cells detected by Leu-7 and Leu- 11 monoclonal antibodies decreased and HLA-DR positive CD3 cells increased during and after the treatment. The effectiveness of LCA in AS may confirm the participation of immunological mechanisms in the pathogenesis of AS. n
PATIENT AND METHODS INTRODUCTION
A 28-yr-old man suffered a low back pain at 16 yr that was diagnosed as herniated disc syndrome. He was treated by epidural injection of steroid. After the episode, he suffered joint pain in the bilateral knee and shoulder. The joint pain spread to the other joints, and he was treated with gold compounds with a suspected diagnosis of rheumatoid arthritis. At 21 yr, he visited Kyoto University Hospital complaining of a spastic motor disturbance of the lower extremities. Au arachnoidal cyst was detected on the
Ankylosing spondylitis (AS) is a chronic systemic inflammatory disease that usually begins in the sacroiliac joints and progressively ascends into spinal column with resultant body fusion. Central large synovial joints are also frequently affected. The pathogenesis of AS is still From the ‘Department of Orthopedic Surgery and tDepartmem of Tmnafusion Medicine, Paculty of Medicine KyotoUniversity, 53 Kawahara-Cho, Shogoin, SakyoKu, kyoto 606, Japan. Received 9f89; Accepted 12/89.
97
98
Transfus. Sci.
Vol. 11, No. 1
thoracic spinal cord and was excised. Because arthritic change of the sacroiliac joints was observed by x-ray and examination of HLA typing of the patient revealed positive B27, his disease was diagnosed as AS for the first time. At 27 yr, back pain and arthralgia increased and was not controlled by medicine including steroid and NSAID. He was admitted to Kyoto University Hospital in October 1987. Radiologic evaluation revealed complete fusion of the sacroiliac joints and several intervertebral joints of the cervical spine. No laboratory abnormalities were observed in immunogloburin (&A, IgM, IgG), hematologic studies, liver and renal studies. Rheumatoid factor was negative. CRP was 11 mg/dL, ESR was 40 mm/hr. A series of LCA was carried out. A CS-3000 (Travenol Ltd, Tokyo, Japan) was used for cell separation. LCA was performed once weekly for 15 weeks. Each procedure required approximately 3 hr and mean number of 3 x lo9 lymphocytes were removed. The serum removed with the lymphocytes was separated by centrifugation at the end of each procedure and stored in a freezer, and then used as replacement plasma in the next procedure. No blood or commercially obtained plasma protein fractions were transfused. Before each LCA procedure, he was assessed in terms of the joint score by Lansbury’s method, chest expansion measured at the level of the fourth intercostal space, finger to floor distance (FFD) in maximum flexion of the trunk. Levels of C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) were checked with every LCA procedure. Lymphocyte subsets detected by the cell surface antigens were studied at every fifth procedure and at follow up time. The surface antigens of lymphocytes were detected by a fluoresceinactivated cell counter (Ortho Spectrum 3, Ortho Diagnostic Systems K.K., Tokyo, Japan) using two-color staining of the following monoclonal antibodies: Leu-2a/Leu- 15, (suppressor T-cell); Leu-
2a+/Leu-15+, (cytotoxic T-cell); Leu-2a+/ Leu- 15-, CDB, (suppressor/cytotoxic Tcells); Leu-2a+,b5 Leu-3a/Leu-8, (helper T-cells); Leu-3+/Leu-8-, (suppressor inducer T-cells); Leu-3+/Leu-8+, CD8, (helper/inducer T-cells); Leu-3a+,6,7 Leu4/HLA-DR, (activated T-cells); Leu-4+/ HLA-DR+, (CD3 pan-T cells); Leu-4+, (HLA-DR positive cells); HLA-DR+, Leu7/Leu-11 (NK cells)8 (Becton Dickinson Overseas, Tokyo). RESULTS
The changes of clinical parameters including joint score, chest expansion, and FFD are presented in Figs 1 and 2. The severe pain decreased gradually except initial flare up at the 66th procedures. After the cessation of LCA, the clinical symptoms showed steady improvement even at 11 months posttreatment. The change of FFD did not
0
. . . ,.,,.. lot. 3 5 7
9
No. of LCA
11
. . . . 13 15
. IM
..?b 3M
SM
IIM
Follow-up
Figure 1. Change of joint score during and
after treatment. Joint score was calculated by the method of Lansbury. LCA: lymphocpapheresis.
No. of LCA
Follow-up
Figure 2. Changes of the finger to floor
distance (FFD) and difference of the chest circumference during deep breathing.
Effectivenessof LCA on AS
No. 01 LCA
99
Fottow-up No. of LCA
Figure 3. Changes of erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP). CRP decreased during follow-up time coinciding with joint score.
show a consistent pattern, but decreased back pain enabled the patient to flex the spine to achieve FFD of 23 cm 11 months after treatment. Chest expansion was improved slightly by 2 cm. ESR did not show any change, but levels of CRP decreased during followup, coinciding with improvement of joint score (Fig. 3). Changes of subpopulations of CD3, CD4, CD8 positive lymphocyte were not observed during and after LCA. The CD4/CD8 ratio did not decrease after LCA treatment (Fig. 4). Helper and suppressor T-cells detected by two-color staining also did not show any particular fluctuations in the peripheral blood (Fig. 5). The subpopulation of suppressor inducer T-cells tended to increase after the cessation of LCA. Cytotoxic T-cells did not change. Significant changes of lymphocyte subpopulations were observed in acti-
Follow-up
Figure 5. Changes of helper and suppressor cells. No particular changes were observed in the populations of these cells during and after the treatment. There was no relationship between helper/suppressor ratio and joint score.
vated antigen bearing cells and NK cells. The activated T-cells (double-stained cells with CD3 and HLA-DR) increased gradually during and after LCA treatment. HLA-DR positive cells in the lymphocyte population were also increased (Fig. 6). NK cells of the Leu-1 l+/ Leu-7+ subset showed a gradual decrease
24.0
0.0
P-
,..,.......,..
1st. 3
5
7
9
I,
NO. of LCA
13
1.IM
15
3M
. 5M.
0.0 11M
Follow-up
Figure 6. Activated T-cells detected by both positive HLA-DR and CD3 antigen increased during and after the treatment. HLA-DR positive cells also increased.
% 2.5
loo
1
80
24.0
5
18.0
3
12.0 6.0
NO. of LCA
Follow-up
Figure 4. Changes of CD3, CD4 and CD8 cells during and after treatment. Considerable changes were not observed including CD4/ CD8 ratio. CD3: Pan-T cell. CD4: helper/ inducer cell. CD8: suppressorkytotoxic cell.
NO. 01 LCA
Follow-up
Figure 7. Changes of NK cells. Considerable decreasing during and after the treatment was observed in Leu-ll+/Leu-7+ subset in NK cells.
100 Transfus.Sci. Vol. 11, No. 1
during and after LCA treatment, but increased temporarily 1 - 3 months after cessation of the treatment [Fig. 7). DISCUSSION While the pathogenesis of AS is unknown, it is now recognized that AS is not an immunologically silent disorder.‘j9 The HLA-B27 antigen stimulated research in AS. It was reported that a specific Klebsiella serotype has an intimate relationship with B27 positive lymphocytes of patients.‘O There appears to be sharing of a homologous amino acid sequence by HLA-B27 and Klebsiella pneumoniae. I1 Antibodies raised against certain strains of Kelbsiella were found to be cytotoxic to HLA-B27-positive lymphocytes of patients with AS. Since HLA-B27 is a class 1 HLA antigen that controls the response of cytotoxic T-lymphocytes, some disorders of cell-mediated immune responses could be anticipated. Cytotoxic T-lymphocytes might recognize certain bacterial antigens in association with HLA-B27 and this interaction might lead to an inflammatory episode during the initial stages of the disease.12 A further clue to the immunological basis of the pathogenesis may come from the efficacy of drug therapy using sulfasalazine. Sulfasalazine is thought to be a immunomodulator, decreasing numbers of T-cells, decreasing mitogen-induced lymphocyte activation, l3 and changing natural killer activity.r4 LCA in AS has not previously been reported. We experienced favorable results in the treatment of rheumatoid arthritis by LCA, that were supported by changes of immunological parameters.15 The experience encouraged us to treat AS with LCA. The joint pain improved gradually except at initial stage of LCA series and at a few months after the treatment. The improvement lasted 11 months after the treatment. The value of CRP also decreased, along with joint score. There were also changes of lymphocyte subpopulations, specially in NK cells and HLA-DR antigen-bearing cells.
NK cells detected by both Leu-7 and Leu11 antibodies decreased gradually during LCA and the low level of population were still maintained 11 months after the There were no obvious treatment. changes in CD4 and CD8 positive cells. A different pattern of changes in subpopulations lymphocyte were observed in a series of LCA performed in patients with rheumatoid arthritis.15 In that series, CD4 positive cells decreased significantly and CD8 positive cells remained unchanged, resulting in a significantly decreased CD4/CD8 ratio after cessation of LCA treatment. NK cells bearing Leu-7 antigen increased significantly and Leu-1 1 positive cells did not change. The differences observed in NK cells might suggest a participation of NK cells in the etiology of AS. Increased populations of HLA-DR positive cells were observed after LCA treatment in both AS and rheumatoid arthritis. Doubly stained cells with CD3 and HLA-DR antibodies also increased during treatment in this patient. That change might have occurred because lymphocyte activation induced by continuous lymphocyte depletion. The very favorable clinical results and definite changes of immunological parameters observed after LCA treatment may support the hypothesis that immunological disorders are important in the pathogenesis of AS. REFERENCES Rosenbaurn JT, Theofilopoulos A, McDe-
vitt HO, Perreira A, Carson D, Cahn A: Presence of circulating immune complexes in Reiter’s syndrome and ankylosing spondylitis. Clin Immunol Zmmunopathol 1981; 18:291-297. Dougados M, Boumier P, Amor B: Sulfasalazine in ankylosing spondylitis: A double blind controlled study in 60 patients. Br Med 1 1986; 293:911-914. Landy A, Gartland GL, Clement LT: Characterization of a phenotypically distinct subpopulation of Leu-2+ cells that suppresses T cell proliferative responses. 1 Immunol 1983; 131:2757-2761. Clement LT, Grossi CE, Gartland GL: Morphologic and phenotypic features of
Effectiveness of LCA on AS
5.
6.
7.
8.
9.
the subpopulation of Leu-2+ cells that suppresses B cell differentiation. I Immunoll984; 133:2461-2468.. Clement LT, Dagg MK, Landay A: Characterization of human lymphocyte subpopulations: alloreactive cytotoxic T lymphocyte precursor and effector cells are phenotypically distinct from Leu-2+ suppressor cells. 1 Clin Zmmunol 1984; 4:395--402. Gatenby PA, Kansas GS, Kian CY, Evans RL, Engleman EG: Dissection of immunoregulatory subpopulations of T lymphocytes within the helper and suppressor sublineages in man. j Zmmunol 1982; 129: 1997-2000. Damle NK, Mohagheghpour N, Engleman EG: Soluble antigen primed inducer T cells activate antigen-specific suppressor T cells in the absence of antigenpulsed accessory cells: Phenotypic definition of suppressor-inducer and suppressor-effector cells. / Immunol 1984; 132644650. Lamer LL, Le AM, Phillips JH, Warner NL, Babcock GF: Subpopulations of human natural killer cells defined by expression of Leu-7 (HNK-1) and Leu- 11 (NK-15) antigens. 1 Immunol 1983; 131:1789-1796. Kinsella TD, Espinoza L, Vasey FB: Serum complement and immunoglobulin levels in sporadic and familial ankylosing spondylitis. ] Rheumatoll975; 2: 308313.
101
10. Seager K, Bashir HR, Ceczy AF: Evidence for a specific B27-associated cell surface marker on lymphocytes of patients with ankylosing spondylitis. Nature 1979; 277:68-70. 11. Schwimmbeck PL, Oldstone MBA: Molecular mimicry and autoimmune disease as the pathogenetic mechanism of ankylosing spondylitis and Reiter’s syndrome. Clin Res 1987; 35:141A. 12. Ceczy AF, Mcguigan LE, Sullivan JS, Edmonds JP: Cytotoxic T lymphocytes against disease-associated determinants(s) in ankylosing spondylitis. I Exp Med 1986; 164:932-937. 13. Rubinstein A, Das KM, Melamed J, Murphy RA: Comparative analysis of systemic immunological parameters in ulcerative colitis and idiopathic proctitis: Effects of sulfasalazine in vivo and in vitro. Clin Exp Immunol 1978; 33:217224. 14. Gibson PR, Jewel1 DP: Sulfasalazine and derivatives, natural killer activity and ulcerative colitis. Clin Sci 1985; 69: 177184. 15. Ueo T, Ito K, Yoshida H, Okumura H, Yamamuro T: Immunomodulatory effects of lymphocytapheresis in patients with rheumatoid arthritis, in Oda T, Shiokawa Y, Inoue N(eds): Therapeutic Plasmapheresis, vol. 6. Cleveland, ISA0 Press, 1987, pp. 610-614.