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Granzyme A and Perforin Expressed in the Lacrimal Glands of Patients With Sjögren's Syndrome
120
January, 1994
AMERICAN JOURNAL OF OPHTHALMOLOGY
eye. Confrontation visual fields, pupils, motility, and intraocular pressures were normal in each eye. Slit-lamp examination disclosed mild anterior chamber and vitreous cells bilaterally with no keratic precipitates or posterior synechiae. Ophthalmoscopy disclosed no abnor malities. Because of the ocular symptoms and head ache, a systemic examination was initiated. Pur ified protein derivative and rapid plasma reagin were nonreactive. Titers for toxoplasmosis and human immunodeficiency virus were negative. Fluorescent treponemal antibody absorption, angiotensin converting enzyme (6.6 units/1; normal range is 6.1 to 21.1 units/1), erythrocyte sedimentation rate, and HLA-B27 were normal. Urinalysis and chest x-ray disclosed no abnor malities, and sérologie studies for Lyme disease were negative. A lumbar puncture showed 25 nucleated cells/mm 3 with 95% lymphocytes. Results of all of the following cerebrospinal fluid studies were normal or negative: protein, glucose, Gram stain, acid-fast bacillus stain, cultures for aerobic and anaerobic bacteria, sérologie studies for cryptococci, VDRL, fluo rescent treponemal antibody absorption, immunoglobulin gamma index, and oligoclonal bands. Magnetic resonance imaging of the head with gadolinium disclosed no abnormalities. The patient was treated with prednisolone acetate, 1%, initially four times daily, then every hour, and cyclopentolate hydrochloride, 1%, three times daily, with no improvement in ocular symptoms. Ibuprofen-induced aseptic meningitis was di agnosed, and ibuprofen was discontinued. Ap proximately 24 hours after the last ibuprofen dose, the patient noted resolution of the head ache with marked improvement in ocular symp toms. On follow-up examination four days lat er, intraocular inflammation was essentially resolved. Noncorticosteroidal anti-inflammatory drugs decrease prostaglandin synthesis through inhi bition of the enzyme cyclo-oxygenase. A prostaglandin-mediated mechanism, however, is unlikely because many affected patients are previously and subsequently treated with other noncorticosteroidal anti-inflammatory drugs and do not develop aseptic meningitis. 3 A hypersensitivity reaction to noncorticoste roidal anti-inflammatory drugs should be con sidered when a patient has neurologic abnor malities after initiation of noncorticosteroidal anti-inflammatory drug therapy in the presence or absence of iridocyclitis.
References 1. Grimm, A. M., and Wolf, J. E.: Aseptic meningi tis associated with nonprescription ibuprofen use. DICP 23:712, 1989. 2. Lawson, J. M., and Grady, M. J.: Ibuprofen-in duced aseptic meningitis in a previously healthy patient. West. J. Med. 143:386, 1985. 3. Hoppmann, R. A., Peden, J. G., and Ober, S. K.: Central nervous system side effects of nonsteroidal anti-inflammatory drugs. Aseptic meningitis, psy chosis, and cognitive dysfunction. Arch. Intern. Med. 151:1309, 1991.
Granzyme A and Perforin Expressed in the Lacrimal Glands of Patients With Sjögren's Syndrome Kazuo Tsubota, M.D., Ichiro Saito, D.D.S., and N o b u y u k i Miyasaka, M.D. Department of Ophthalmology (K.T.), Tokyo Dental College; and Department of Virology and Immunolo gy (K.T., I.S., N.M.), Medical Research Institute, Tokyo Medical and Dental University. Inquiries to Kazuo Tsubota, Μ.Ό., Department of Oph thalmology, Tokyo Dental College, 11-13 Sugano 5 chôme, lchikawa-shi, Chiba, Japan 272. Tissue destruction of the lacrimal and sali vary glands is the cardinal feature of Sjögren's syndrome. Although lymphocyte infiltration accompanies this destruction, the mechanism of tissue destruction is not known. Recently, it has been suggested that granzyme A and perfo rin are associated with immune-mediated cytolysis in such autoimmune diseases as rheuma toid arthritis, where the expression of these compounds in synovial fluid lymphocytes caus es tissue destruction. 1 We have investigated whether granzyme A and perforin are associat ed with Sjögren's syndrome. Six patients with primary Sjögren's syn drome with severe keratoconjunctivitis sicca, all women ranging in age from 31 to 62 years, underwent lacrimal gland biopsy, which showed extensive lymphocytic infiltration and gland destruction. As controls, lacrimal gland biopsy tissues without glandular destruction from six non-Sjögren's dry eye patients who had no autoimmune background were used. Normal lacrimal glands from six age- and gen-
Correspondence
Vol. 117, No. 1
3 4
12
PERFORIN
121
since g r a n z y m e A a n d perforin are e x p r e s s e d b y t h e k n o w n signal to i n d u c e cytotoxic func tion, 2 a n d can b e p r o d u c e d b y C D 4 + T cells, 1 it a p p e a r s t h a t t h e s e c o m p o u n d s are associated w i t h a d e s t r u c t i v e role. T h e i m m u n o s u p p r e s sive effects of c y c l o s p o r i n e o n T cells are well k n o w n , w h i c h can in p a r t b e e x p l a i n e d b y its s u p p r e s s i v e activity of g r a n z y m e A a n d perfo rin. 2 T h u s , c y c l o s p o r i n e can b e a p o t e n t a g e n t in p r e v e n t i n g the d e s t r u c t i o n of t h e lacrimal g l a n d in S j ö g r e n ' s s y n d r o m e t h r o u g h t h e p a t h o g e n e t ic m e c h a n i s m p r o p o s e d in this s t u d y .
References
GRANZYME 202bp- ·
·
·
·
1. Griffiths, G., Alpert, S., Lambert, E., McGuire, J., and Weissman, I.: Perforin and granzyme A ex pression identifying cytolytic lymphocytes in rheu matoid arthritis. Proc. Natl. Acad. Sei. U.S.A. 89:549, 1992. 2. Liu, C , Rafii, S., Granelli-Piperno, A., Trapani, J., and Young, J.: Perforin and serine esterase gene expression in stimulated human T cells. J. Exp. Med. 170:2105, 1989.
ß-ACTIN Figure (Tsubota, Saito, and Miyasaka). Southern blot analysis of polymerase chain reaction amplified products of perforin, granzyme A, and ß-actin in lacrimal gland biopsy specimens from patients with Sjögren's syndrome (lanes 1 and 2), non-Sjögren's dry eye patient (lane 3), and normal healthy control (lane 4). All autoradiographs were exposed for four hours. The sizes of the amplification products were 214 base pairs for perforin, 252 base pairs for granzyme A, and 202 base pairs for ß-actin.
d e r - m a t c h e d a u t o p s y cases w e r e also u s e d . Re verse t r a n s c r i p t a s e p o l y m e r a s e c h a i n r e a c t i o n was u s e d to detect g r a n z y m e A a n d p e r f o r i n mRNA, w h i c h w e r e p r e s e n t in all six lacrimal g l a n d s of p a t i e n t s w i t h S j ö g r e n ' s s y n d r o m e b u t in n o n e of the c o n t r o l s . Since m R N A of ß - a c t i n was d e t e c t e d in b o t h S j ö g r e n ' s s y n d r o m e a n d control s a m p l e s , t h e n e g a t i v e r e s u l t s in t h e a u t o p s y cases w e r e n o t c a u s e d b y the d e g r a d a tion of mRNA itself after d e a t h (Figure). I m m u n o h i s t o c h e m i c a l s t a i n i n g also s h o w e d t h e local ized e x p r e s s i o n of b o t h s u b s t a n c e s in t h e infiltrating CD4 + T cells. The data d o n o t p r o v e t h a t g r a n z y m e A a n d perforin are directly i n v o l v e d in c e l l - m e d i a t e d d e s t r u c t i o n of the lacrimal g l a n d . H o w e v e r ,
Correspondence Correspondence concerning recent articles or other mate rial published in THE JOURNAL should be submitted within six weeks of publication. Correspondence must be typed double-spaced, on 8V2 x 11-inch bond paper with IVi-inch margins on all four sides and should be no more than two typewritten pages in length. Every effort will be made to resolve controversies between the correspondents and the authors of the article before publication.
Management of the Posterior Capsule During Pédiatrie Intraocular Lens Implantation EDITOR: In the article, " M a n a g e m e n t of the posterior capsule d u r i n g pédiatrie i n t r a o c u l a r lens im p l a n t a t i o n , " by E. G. Buckley, L. E. Klombers, J. H. Seaber, A. Scalise-Gordy, a n d R. Minzter (Am. J. O p h t h a l m o l . 115: 722, J u n e 1993), the a u t h o r s describe s i m u l t a n e o u s posterior capsular excision via a p a r s p l a n a a p p r o a c h a n d cat aract extraction w i t h i n t r a o c u l a r lens i m p l a n t a tion in pédiatrie p a t i e n t s as a m e t h o d to
January, 1994
AMERICAN JOURNAL OF OPHTHALMOLOGY
eye. Confrontation visual fields, pupils, motility, and intraocular pressures were normal in each eye. Slit-lamp examination disclosed mild anterior chamber and vitreous cells bilaterally with no keratic precipitates or posterior synechiae. Ophthalmoscopy disclosed no abnor malities. Because of the ocular symptoms and head ache, a systemic examination was initiated. Pur ified protein derivative and rapid plasma reagin were nonreactive. Titers for toxoplasmosis and human immunodeficiency virus were negative. Fluorescent treponemal antibody absorption, angiotensin converting enzyme (6.6 units/1; normal range is 6.1 to 21.1 units/1), erythrocyte sedimentation rate, and HLA-B27 were normal. Urinalysis and chest x-ray disclosed no abnor malities, and sérologie studies for Lyme disease were negative. A lumbar puncture showed 25 nucleated cells/mm 3 with 95% lymphocytes. Results of all of the following cerebrospinal fluid studies were normal or negative: protein, glucose, Gram stain, acid-fast bacillus stain, cultures for aerobic and anaerobic bacteria, sérologie studies for cryptococci, VDRL, fluo rescent treponemal antibody absorption, immunoglobulin gamma index, and oligoclonal bands. Magnetic resonance imaging of the head with gadolinium disclosed no abnormalities. The patient was treated with prednisolone acetate, 1%, initially four times daily, then every hour, and cyclopentolate hydrochloride, 1%, three times daily, with no improvement in ocular symptoms. Ibuprofen-induced aseptic meningitis was di agnosed, and ibuprofen was discontinued. Ap proximately 24 hours after the last ibuprofen dose, the patient noted resolution of the head ache with marked improvement in ocular symp toms. On follow-up examination four days lat er, intraocular inflammation was essentially resolved. Noncorticosteroidal anti-inflammatory drugs decrease prostaglandin synthesis through inhi bition of the enzyme cyclo-oxygenase. A prostaglandin-mediated mechanism, however, is unlikely because many affected patients are previously and subsequently treated with other noncorticosteroidal anti-inflammatory drugs and do not develop aseptic meningitis. 3 A hypersensitivity reaction to noncorticoste roidal anti-inflammatory drugs should be con sidered when a patient has neurologic abnor malities after initiation of noncorticosteroidal anti-inflammatory drug therapy in the presence or absence of iridocyclitis.
References 1. Grimm, A. M., and Wolf, J. E.: Aseptic meningi tis associated with nonprescription ibuprofen use. DICP 23:712, 1989. 2. Lawson, J. M., and Grady, M. J.: Ibuprofen-in duced aseptic meningitis in a previously healthy patient. West. J. Med. 143:386, 1985. 3. Hoppmann, R. A., Peden, J. G., and Ober, S. K.: Central nervous system side effects of nonsteroidal anti-inflammatory drugs. Aseptic meningitis, psy chosis, and cognitive dysfunction. Arch. Intern. Med. 151:1309, 1991.
Granzyme A and Perforin Expressed in the Lacrimal Glands of Patients With Sjögren's Syndrome Kazuo Tsubota, M.D., Ichiro Saito, D.D.S., and N o b u y u k i Miyasaka, M.D. Department of Ophthalmology (K.T.), Tokyo Dental College; and Department of Virology and Immunolo gy (K.T., I.S., N.M.), Medical Research Institute, Tokyo Medical and Dental University. Inquiries to Kazuo Tsubota, Μ.Ό., Department of Oph thalmology, Tokyo Dental College, 11-13 Sugano 5 chôme, lchikawa-shi, Chiba, Japan 272. Tissue destruction of the lacrimal and sali vary glands is the cardinal feature of Sjögren's syndrome. Although lymphocyte infiltration accompanies this destruction, the mechanism of tissue destruction is not known. Recently, it has been suggested that granzyme A and perfo rin are associated with immune-mediated cytolysis in such autoimmune diseases as rheuma toid arthritis, where the expression of these compounds in synovial fluid lymphocytes caus es tissue destruction. 1 We have investigated whether granzyme A and perforin are associat ed with Sjögren's syndrome. Six patients with primary Sjögren's syn drome with severe keratoconjunctivitis sicca, all women ranging in age from 31 to 62 years, underwent lacrimal gland biopsy, which showed extensive lymphocytic infiltration and gland destruction. As controls, lacrimal gland biopsy tissues without glandular destruction from six non-Sjögren's dry eye patients who had no autoimmune background were used. Normal lacrimal glands from six age- and gen-
Correspondence
Vol. 117, No. 1
3 4
12
PERFORIN
121
since g r a n z y m e A a n d perforin are e x p r e s s e d b y t h e k n o w n signal to i n d u c e cytotoxic func tion, 2 a n d can b e p r o d u c e d b y C D 4 + T cells, 1 it a p p e a r s t h a t t h e s e c o m p o u n d s are associated w i t h a d e s t r u c t i v e role. T h e i m m u n o s u p p r e s sive effects of c y c l o s p o r i n e o n T cells are well k n o w n , w h i c h can in p a r t b e e x p l a i n e d b y its s u p p r e s s i v e activity of g r a n z y m e A a n d perfo rin. 2 T h u s , c y c l o s p o r i n e can b e a p o t e n t a g e n t in p r e v e n t i n g the d e s t r u c t i o n of t h e lacrimal g l a n d in S j ö g r e n ' s s y n d r o m e t h r o u g h t h e p a t h o g e n e t ic m e c h a n i s m p r o p o s e d in this s t u d y .
References
GRANZYME 202bp- ·
·
·
·
1. Griffiths, G., Alpert, S., Lambert, E., McGuire, J., and Weissman, I.: Perforin and granzyme A ex pression identifying cytolytic lymphocytes in rheu matoid arthritis. Proc. Natl. Acad. Sei. U.S.A. 89:549, 1992. 2. Liu, C , Rafii, S., Granelli-Piperno, A., Trapani, J., and Young, J.: Perforin and serine esterase gene expression in stimulated human T cells. J. Exp. Med. 170:2105, 1989.
ß-ACTIN Figure (Tsubota, Saito, and Miyasaka). Southern blot analysis of polymerase chain reaction amplified products of perforin, granzyme A, and ß-actin in lacrimal gland biopsy specimens from patients with Sjögren's syndrome (lanes 1 and 2), non-Sjögren's dry eye patient (lane 3), and normal healthy control (lane 4). All autoradiographs were exposed for four hours. The sizes of the amplification products were 214 base pairs for perforin, 252 base pairs for granzyme A, and 202 base pairs for ß-actin.
d e r - m a t c h e d a u t o p s y cases w e r e also u s e d . Re verse t r a n s c r i p t a s e p o l y m e r a s e c h a i n r e a c t i o n was u s e d to detect g r a n z y m e A a n d p e r f o r i n mRNA, w h i c h w e r e p r e s e n t in all six lacrimal g l a n d s of p a t i e n t s w i t h S j ö g r e n ' s s y n d r o m e b u t in n o n e of the c o n t r o l s . Since m R N A of ß - a c t i n was d e t e c t e d in b o t h S j ö g r e n ' s s y n d r o m e a n d control s a m p l e s , t h e n e g a t i v e r e s u l t s in t h e a u t o p s y cases w e r e n o t c a u s e d b y the d e g r a d a tion of mRNA itself after d e a t h (Figure). I m m u n o h i s t o c h e m i c a l s t a i n i n g also s h o w e d t h e local ized e x p r e s s i o n of b o t h s u b s t a n c e s in t h e infiltrating CD4 + T cells. The data d o n o t p r o v e t h a t g r a n z y m e A a n d perforin are directly i n v o l v e d in c e l l - m e d i a t e d d e s t r u c t i o n of the lacrimal g l a n d . H o w e v e r ,
Correspondence Correspondence concerning recent articles or other mate rial published in THE JOURNAL should be submitted within six weeks of publication. Correspondence must be typed double-spaced, on 8V2 x 11-inch bond paper with IVi-inch margins on all four sides and should be no more than two typewritten pages in length. Every effort will be made to resolve controversies between the correspondents and the authors of the article before publication.
Management of the Posterior Capsule During Pédiatrie Intraocular Lens Implantation EDITOR: In the article, " M a n a g e m e n t of the posterior capsule d u r i n g pédiatrie i n t r a o c u l a r lens im p l a n t a t i o n , " by E. G. Buckley, L. E. Klombers, J. H. Seaber, A. Scalise-Gordy, a n d R. Minzter (Am. J. O p h t h a l m o l . 115: 722, J u n e 1993), the a u t h o r s describe s i m u l t a n e o u s posterior capsular excision via a p a r s p l a n a a p p r o a c h a n d cat aract extraction w i t h i n t r a o c u l a r lens i m p l a n t a tion in pédiatrie p a t i e n t s as a m e t h o d to