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Immunoglobulin G deposits in the choroid plexus of a child with systemic lupus erythematosus
Volume 85 Number 3
B r i e f clinical and laboratory observations
385
n u m b e r s of the retarded admitted for whatever reason, no consistent either d o w n w a r d or upward trend is observed that could otherwise explain e v e n in part the change in P K U admissions we have observed. It could be argued that the heightened awareness that m e n t a l retardation due to P K U is preventable by early detection and t r e a t m e n t may h a v e induced an appreciable n u m b e r o f p a r e n t s to k e e p e v e n t h e i r s e r i o u s l y retarded P K U children at h o m e rather than admit t h e m to institutions. N o r m a l or near normal intelligence, however, has been reported in follow-up studies on children detected in the newborn period and promptly begun on the restricted phenylalanine d i e t . 5-7 W o u l d n o t ,
We are grateful to the institution superintendents, the public health laboratory directors, and all others who helped, including the secretarial staff at Windham College.
therefore the regimen of early treatment m a d e possible by the screening of the n e w b o r n infant seem the likely reason for the reduction in P K U admissions to our institutions, which coincides so closely in this study with the particular times the screening programs were actually begun in the localities where t h e children were born? A t any rate, the burden o f p r o o f at this time would s e e m to be upon any who doubted the wisdom of the c o n t i n u a n c e o f the P K U s c r e e n i n g p r o g r a m s o f the n e w b o r n infant.
4.
Immunoglobulin G deposits in the choroidplexus of a child with systemic lupus erythematosus Joanna H. Sher, M.D.,* and Louis P. Pertschuk,
D.O., Brooklyn, N. Y.
D E P O SI T I O N of i m m u n o g l o b u l i n s in the choroid plexus has been reported in four adults who died of systemic lupus e r y t h e m a t o s u s (SLE). 1' 2 It has been proposed that interference with the m o v e m e n t of cerebrospinal fluid (CSF) constituents by these deposits may be part of the pathophysiologic m e c h a n i s m underlying the neurological and psychologic s y m p t o m s of SLE. The relationship of these choroid plexus deposits to other nervous system lesions in SLE is unknown.
From the Department o f Pathology, State University of New York, Downstate Medical Center, and the hTstitute o f Pathology, Kings County Hospital Center. *Reprintaddress:Department of Pathology, 451 Clarkson A venue,Brooklyn, N. Y. 11203.
REFERENCES
1.
2.
3.
5.
6.
7.
MacCready, R. A., and Hussey, M. G.: Newborn phenylketonuria detection program in Massachusetts, Am. J. Pub. Health 54: 2075, 1964. Becroft, D. M. O., and Horn, C. R.: The Guthrie screening test for phenylketonuria: A report on two years participation in the national programme, New Zealand Med. J. 69: 212, 1969. Berman, J. L., Cunningham, G. C., Day, R. W., et al.: Causes for high phenylalanine with normal tyrosine, Am. J. Dis. Child. 117: 54, 1969. Webb, J. F., Khazen, R. S., Hanley, W. B., et al.: PKU screening--is it worth it? Can. Med. Assoc. J. 108: 328, 1973. Kang, E. S., Sollee, N. D., and Gerald, P. S.: Results of treatment and termination of the diet in phenylketonuria (PKU), Pediatrics 46: 881, 1970. Hudson, F. P., Mordaunt, V. L., and Leahy, I.: Evaluation of treatment begun in first three months of life in 184 cases of phenylketonuria, Arch. Dis. Child. 45: 5, 1970. Hanley, W. B., Linsao, L. S., and Netley, C.: The efficacy of dietary therapy for phenylketonuria, Can. Med. Assoc. J. 104: 1089, 1971.
T h e f o l l o w i n g case, in w h i c h i m m u n o g l o b u l i n (Ig) deposits were found in the choroid plexus of a 10-yearold girl with SLE is the first such report in a pediatric patient and the first instance in which pathologic lesions were also found within the brain. CASE REPORT
At the age of five this girl developed painful swelling of the knees, ankles, neck, wrists, and fingers. A diagnosis of juvenile Abbreviations used SLE: systemic lupus erythematosus CSF: cerebral spinal fluid Ig: immunoglobulin IF: immunofluorescence C3: third component of complement CNS: central nervous system rheumatoid arthritis was made and aspirin was prescribed. When she was six, she was hospitalized elsewhere for "pneumonia"; a pericardial friction rub and pleural effusions were noted. She was then relatively well until she was nine years of age, when she was found to have hematuria and albuminuria. A renal biopsy showed diffuse thickening of glomerular capillary walls ,with focal hypercellularity. Granular deposits of IgG, IgE, and coml~lement were seen on immunofluorescence (IF) and the biopsy was interpreted as being consistent with the membranous form of lupus nephritis. Antinuclear antibody titer was
386
Brief clinical and laboratory observations
The Journal of Pediatrics September 1974
Fig. 1. Choroid plexus of control stained with IgG/fluorescein conjugate. A few autofluorescent epithelial nuclei are seen and there is nonspecific fluorescence within the core of the villi. (xl00.) 1:5120 and a decrease in circulating third component of complement (C3) was noted. Although LE cell preparations were negative, a diagnosis of SLE was made and treatment with prednisone was started. Seven months following this hospitalization the child was readmitted because of personality changes in the form of phobias, nervousness, and visual hallucinations. A fine tremor of the hands was noted; there were transient signs of cerebellar ataxia. Examination of the CSF revealed clear fluid under normal pressure. One polymorphonuclear leukocyte was seen. The chloride value was 123 mEq/1; glucose, 38 mg/100 ml; protein, 27 mg/100 ml. Gram stain and culture were negative. Following an increase in the dose of prednisone, there was mild clinical improvement and she returned home. Her final hospitalization occurred two weeks before her eleventh birthday. There was a one-day history of sore throat, high fever, epistaxis, and hematemesis. Despite intensive therapy with antibiotics, intravenous fluids, prednisone, and transfusions she died within five hours of admission. At autopsy there were fibrinous adhesions of the pericardium, pleura, and spleen. The heart was enlarged, weighing 230 gm. The lower lobes of both lungs were consolidated by pneumonia. Nasopharyngeal and palatal ulcers were found and there was blood in the respiratory and gastrointestinal tracts. The thymus was atrophic, with absence of corticomedullary demarcations, and was populated only by spindle shaped cells. A membranous glomerulonephritis was present with granular deposits of IgG, IgM, IgA, and C3 in the glomerular basement membrane and the mesangium, Examination of the brain showed multiple, disseminated, microscopic foci of encephalomalac'ia, which were predominantly perivenous. There was focal angiitis, largely phlebitis, in
the basal ganglia and brainsmm. The choroid plexus appeared unremarkable on routine bistologic examination. MATERIALS
AND METHOD
Choroid plexus was obtained from the fourth ventricle at autopsy prior to immersing the brain in formalin. Control choroid plexus was taken from five young adults who had died of causes unrelated to central nervous system (CNS) or i m m u n e complex diseases. Unfixed frozen sections were processed by the direct fluorescent antibody technique of Coons and Kaplan a with the'use of fluorescein-conjugated goat antibody to h u m a n IgG, IgM, IgA, and C3 (Hyland Laboratories, Costa Mesa, Calif.) ; these had been checked for specificity by immunoelectrop horesis. Molar ratios of fluorescein to protein were 2.0, 2.8, 2.7, and 2.9, respectively. Each conjugate was diluted with phosphate-buffered saline, pH 7.2, containing 4% bovine serum albumin, to reach a working solution containing 100 p~g of antibody per milliliter.4,5 Antifibrin and antialbumin conjugates were also employed. Prepared sections were then examined with a Leitz fluorescent microscope (Labolux) equipped with an Osram HBO 200 high-pressure mercury vapor lamp, a 2.0 m m BG 12 excitation filter, and a I( 530 barrier filter. RESULTS All control sections were negative, showing only slight autofluorescence of the epithelial nuclei and slight nonspecific fluorescence in the core of the villi (Fig. 1). See-:
Volume 85 Number 3
Brief clinical and laboratory observations
387
Fig. 2. Choroid plexus of a 10-year-old girl with SLE. IgG/fluorescein conjugate by direct immunofluorescence. Note extensive granular fluorescence apparently localized in the subepithelial basement membrane. ( xl00. ) tions of the patient's choroid plexus showed no deposition of IgM, IgA, C3, fibrin, or albumin. Sections stained for IgG showed extensive granular fluorescence consistent with deposition in the subepithelial basem e n t m e m b r a n e (Fig. 2). DISCUSSION Atkins and co-workers 1 were the first to describe immunoglobulins in the choroid plexus of two adults with SLE; IgG was detected in one patient, and IgG and IgM in the other. No histologic abnormalities relating to SLE were found in the CNS of these patients. Lampert and Oldstone 2 found IgG in the choroid plexus of two more adults with SLE but did not report any neuropathologic findings. Using an experimental model of hybrid (NZB X W)F z mice, known to develop a disease strikingly similar to SLE, these latter authors found both IgG and C3 in the choroid plexus and correlated these deposits with circulating antibodies to nuclear antigens. When ultrastructural studies were performed on patients and mice, l, 2 electron-dense deposits were found within, or adjacent to, the epithelial and endothelial basement membranes o f the choroid plexus. These deposits closely resembled those seen in the glomeruli of patients with immune complex diseases. In the present case, deposits of IgG were apparently concentrated in the subepithelial basement membrane of the choroid plexus. Unfortunately, formalin fixation precluded the performance of I F studies on brain tissue
so that any r e l a t i o n s h i p b e t w e e n the vasculitis a n d perivenous encephalomalacia could not be ascertained. Such a relationship, if it exists, awaits new studies. T h e p r e s e r v a t i o n o f a p p r o p r i a t e s a m p l e s o f CNS tissue in an unfixed, frozen state during postmortem examination of patients dying with SLE and the performance of I F studies might well help to elucidate the pathogenesis underlying the clinical syndrome o f " l u p u s cerebritis." Such studies must be done on patients with and without evidences of CNS disease if meaningful data are to be obtained. Mr. Robert Simowitz, Department of Photography, Kings County Hospital Center, prepared the photomicrographs. REFERENCES
1. 2.
3.
4. 5.
Atkins, C. J., Kondon, J. J, and Anismorio, F. P.: Choroid plexus in systemic lupus erythematosus, Ann. Intern. Med. 76: 65, 1972. Lampert, P. W., and Oldstone, M. B. A.: Host immunoglobulin G and complement deposits in the choroid plexus during spontaneous immune complex disease, Science 180: 408, 1973. Coons, A. H., and Kaplan, M. H.: Localization of antigen in tissue cells. Improvements in a method for detection of antigen by means of fluorescent antibody, J. Exp. Med. 91: 1, 1950. Beutner, E. H., Holborow, E. J., and Johnson, J. G.: Quantitative studies of immunofluorescent staining, Immunology 12: 327, 1967. Beutner, E. H., Sepulveda, M. R., and Barnett, E. V.: Quantitative studies of immunofluorescent staining, Bull. WHO 39: 587, 1968.
B r i e f clinical and laboratory observations
385
n u m b e r s of the retarded admitted for whatever reason, no consistent either d o w n w a r d or upward trend is observed that could otherwise explain e v e n in part the change in P K U admissions we have observed. It could be argued that the heightened awareness that m e n t a l retardation due to P K U is preventable by early detection and t r e a t m e n t may h a v e induced an appreciable n u m b e r o f p a r e n t s to k e e p e v e n t h e i r s e r i o u s l y retarded P K U children at h o m e rather than admit t h e m to institutions. N o r m a l or near normal intelligence, however, has been reported in follow-up studies on children detected in the newborn period and promptly begun on the restricted phenylalanine d i e t . 5-7 W o u l d n o t ,
We are grateful to the institution superintendents, the public health laboratory directors, and all others who helped, including the secretarial staff at Windham College.
therefore the regimen of early treatment m a d e possible by the screening of the n e w b o r n infant seem the likely reason for the reduction in P K U admissions to our institutions, which coincides so closely in this study with the particular times the screening programs were actually begun in the localities where t h e children were born? A t any rate, the burden o f p r o o f at this time would s e e m to be upon any who doubted the wisdom of the c o n t i n u a n c e o f the P K U s c r e e n i n g p r o g r a m s o f the n e w b o r n infant.
4.
Immunoglobulin G deposits in the choroidplexus of a child with systemic lupus erythematosus Joanna H. Sher, M.D.,* and Louis P. Pertschuk,
D.O., Brooklyn, N. Y.
D E P O SI T I O N of i m m u n o g l o b u l i n s in the choroid plexus has been reported in four adults who died of systemic lupus e r y t h e m a t o s u s (SLE). 1' 2 It has been proposed that interference with the m o v e m e n t of cerebrospinal fluid (CSF) constituents by these deposits may be part of the pathophysiologic m e c h a n i s m underlying the neurological and psychologic s y m p t o m s of SLE. The relationship of these choroid plexus deposits to other nervous system lesions in SLE is unknown.
From the Department o f Pathology, State University of New York, Downstate Medical Center, and the hTstitute o f Pathology, Kings County Hospital Center. *Reprintaddress:Department of Pathology, 451 Clarkson A venue,Brooklyn, N. Y. 11203.
REFERENCES
1.
2.
3.
5.
6.
7.
MacCready, R. A., and Hussey, M. G.: Newborn phenylketonuria detection program in Massachusetts, Am. J. Pub. Health 54: 2075, 1964. Becroft, D. M. O., and Horn, C. R.: The Guthrie screening test for phenylketonuria: A report on two years participation in the national programme, New Zealand Med. J. 69: 212, 1969. Berman, J. L., Cunningham, G. C., Day, R. W., et al.: Causes for high phenylalanine with normal tyrosine, Am. J. Dis. Child. 117: 54, 1969. Webb, J. F., Khazen, R. S., Hanley, W. B., et al.: PKU screening--is it worth it? Can. Med. Assoc. J. 108: 328, 1973. Kang, E. S., Sollee, N. D., and Gerald, P. S.: Results of treatment and termination of the diet in phenylketonuria (PKU), Pediatrics 46: 881, 1970. Hudson, F. P., Mordaunt, V. L., and Leahy, I.: Evaluation of treatment begun in first three months of life in 184 cases of phenylketonuria, Arch. Dis. Child. 45: 5, 1970. Hanley, W. B., Linsao, L. S., and Netley, C.: The efficacy of dietary therapy for phenylketonuria, Can. Med. Assoc. J. 104: 1089, 1971.
T h e f o l l o w i n g case, in w h i c h i m m u n o g l o b u l i n (Ig) deposits were found in the choroid plexus of a 10-yearold girl with SLE is the first such report in a pediatric patient and the first instance in which pathologic lesions were also found within the brain. CASE REPORT
At the age of five this girl developed painful swelling of the knees, ankles, neck, wrists, and fingers. A diagnosis of juvenile Abbreviations used SLE: systemic lupus erythematosus CSF: cerebral spinal fluid Ig: immunoglobulin IF: immunofluorescence C3: third component of complement CNS: central nervous system rheumatoid arthritis was made and aspirin was prescribed. When she was six, she was hospitalized elsewhere for "pneumonia"; a pericardial friction rub and pleural effusions were noted. She was then relatively well until she was nine years of age, when she was found to have hematuria and albuminuria. A renal biopsy showed diffuse thickening of glomerular capillary walls ,with focal hypercellularity. Granular deposits of IgG, IgE, and coml~lement were seen on immunofluorescence (IF) and the biopsy was interpreted as being consistent with the membranous form of lupus nephritis. Antinuclear antibody titer was
386
Brief clinical and laboratory observations
The Journal of Pediatrics September 1974
Fig. 1. Choroid plexus of control stained with IgG/fluorescein conjugate. A few autofluorescent epithelial nuclei are seen and there is nonspecific fluorescence within the core of the villi. (xl00.) 1:5120 and a decrease in circulating third component of complement (C3) was noted. Although LE cell preparations were negative, a diagnosis of SLE was made and treatment with prednisone was started. Seven months following this hospitalization the child was readmitted because of personality changes in the form of phobias, nervousness, and visual hallucinations. A fine tremor of the hands was noted; there were transient signs of cerebellar ataxia. Examination of the CSF revealed clear fluid under normal pressure. One polymorphonuclear leukocyte was seen. The chloride value was 123 mEq/1; glucose, 38 mg/100 ml; protein, 27 mg/100 ml. Gram stain and culture were negative. Following an increase in the dose of prednisone, there was mild clinical improvement and she returned home. Her final hospitalization occurred two weeks before her eleventh birthday. There was a one-day history of sore throat, high fever, epistaxis, and hematemesis. Despite intensive therapy with antibiotics, intravenous fluids, prednisone, and transfusions she died within five hours of admission. At autopsy there were fibrinous adhesions of the pericardium, pleura, and spleen. The heart was enlarged, weighing 230 gm. The lower lobes of both lungs were consolidated by pneumonia. Nasopharyngeal and palatal ulcers were found and there was blood in the respiratory and gastrointestinal tracts. The thymus was atrophic, with absence of corticomedullary demarcations, and was populated only by spindle shaped cells. A membranous glomerulonephritis was present with granular deposits of IgG, IgM, IgA, and C3 in the glomerular basement membrane and the mesangium, Examination of the brain showed multiple, disseminated, microscopic foci of encephalomalac'ia, which were predominantly perivenous. There was focal angiitis, largely phlebitis, in
the basal ganglia and brainsmm. The choroid plexus appeared unremarkable on routine bistologic examination. MATERIALS
AND METHOD
Choroid plexus was obtained from the fourth ventricle at autopsy prior to immersing the brain in formalin. Control choroid plexus was taken from five young adults who had died of causes unrelated to central nervous system (CNS) or i m m u n e complex diseases. Unfixed frozen sections were processed by the direct fluorescent antibody technique of Coons and Kaplan a with the'use of fluorescein-conjugated goat antibody to h u m a n IgG, IgM, IgA, and C3 (Hyland Laboratories, Costa Mesa, Calif.) ; these had been checked for specificity by immunoelectrop horesis. Molar ratios of fluorescein to protein were 2.0, 2.8, 2.7, and 2.9, respectively. Each conjugate was diluted with phosphate-buffered saline, pH 7.2, containing 4% bovine serum albumin, to reach a working solution containing 100 p~g of antibody per milliliter.4,5 Antifibrin and antialbumin conjugates were also employed. Prepared sections were then examined with a Leitz fluorescent microscope (Labolux) equipped with an Osram HBO 200 high-pressure mercury vapor lamp, a 2.0 m m BG 12 excitation filter, and a I( 530 barrier filter. RESULTS All control sections were negative, showing only slight autofluorescence of the epithelial nuclei and slight nonspecific fluorescence in the core of the villi (Fig. 1). See-:
Volume 85 Number 3
Brief clinical and laboratory observations
387
Fig. 2. Choroid plexus of a 10-year-old girl with SLE. IgG/fluorescein conjugate by direct immunofluorescence. Note extensive granular fluorescence apparently localized in the subepithelial basement membrane. ( xl00. ) tions of the patient's choroid plexus showed no deposition of IgM, IgA, C3, fibrin, or albumin. Sections stained for IgG showed extensive granular fluorescence consistent with deposition in the subepithelial basem e n t m e m b r a n e (Fig. 2). DISCUSSION Atkins and co-workers 1 were the first to describe immunoglobulins in the choroid plexus of two adults with SLE; IgG was detected in one patient, and IgG and IgM in the other. No histologic abnormalities relating to SLE were found in the CNS of these patients. Lampert and Oldstone 2 found IgG in the choroid plexus of two more adults with SLE but did not report any neuropathologic findings. Using an experimental model of hybrid (NZB X W)F z mice, known to develop a disease strikingly similar to SLE, these latter authors found both IgG and C3 in the choroid plexus and correlated these deposits with circulating antibodies to nuclear antigens. When ultrastructural studies were performed on patients and mice, l, 2 electron-dense deposits were found within, or adjacent to, the epithelial and endothelial basement membranes o f the choroid plexus. These deposits closely resembled those seen in the glomeruli of patients with immune complex diseases. In the present case, deposits of IgG were apparently concentrated in the subepithelial basement membrane of the choroid plexus. Unfortunately, formalin fixation precluded the performance of I F studies on brain tissue
so that any r e l a t i o n s h i p b e t w e e n the vasculitis a n d perivenous encephalomalacia could not be ascertained. Such a relationship, if it exists, awaits new studies. T h e p r e s e r v a t i o n o f a p p r o p r i a t e s a m p l e s o f CNS tissue in an unfixed, frozen state during postmortem examination of patients dying with SLE and the performance of I F studies might well help to elucidate the pathogenesis underlying the clinical syndrome o f " l u p u s cerebritis." Such studies must be done on patients with and without evidences of CNS disease if meaningful data are to be obtained. Mr. Robert Simowitz, Department of Photography, Kings County Hospital Center, prepared the photomicrographs. REFERENCES
1. 2.
3.
4. 5.
Atkins, C. J., Kondon, J. J, and Anismorio, F. P.: Choroid plexus in systemic lupus erythematosus, Ann. Intern. Med. 76: 65, 1972. Lampert, P. W., and Oldstone, M. B. A.: Host immunoglobulin G and complement deposits in the choroid plexus during spontaneous immune complex disease, Science 180: 408, 1973. Coons, A. H., and Kaplan, M. H.: Localization of antigen in tissue cells. Improvements in a method for detection of antigen by means of fluorescent antibody, J. Exp. Med. 91: 1, 1950. Beutner, E. H., Holborow, E. J., and Johnson, J. G.: Quantitative studies of immunofluorescent staining, Immunology 12: 327, 1967. Beutner, E. H., Sepulveda, M. R., and Barnett, E. V.: Quantitative studies of immunofluorescent staining, Bull. WHO 39: 587, 1968.