BRIEF CLINICAL OBSERVATIONS
DEFICIENCYOF SERUM Cl SUBCOMPONENTSAND LOW FUNCTIONALACTIVITY OF Ci INHIBITOR IN A PATIENT WITH URTICARIAAND CRYOGLOBULINEMIA Deficiencies of the complement subcomponents of Cl, Clq, and Clr/Cls have been associated with lupus or lupus-like syndromes, renal and cutaneous diseases, and infections [l]. Dissimilar forms of the regulator of Cl, the Ci inhibitor (CiI), have been reported [l]; some patients had normal serum levels of CiI, but the protein was dysfunctional. Clinically, these individuals had hereditary angioedema (HAE). We describe an adult with cryoglobulinemia, urticaria, and edema together with partial deficiencies of Clq and Clr/Cls and low functional activity of the CiI. Case Report and Methods. A 36-year-old woman had a diagnosis of urticaria since September 1989. She had no previous atopic history and had noted the sudden onset of episodes of generalized urticaria with infrequent episodes of perioral swelling. The urticaria appeared unrelated to food ingestion or medication use. No family members had atopic or collagen vascular diseases nor any history of swelling or urticaria. Cell counts and results of liver function tests were all within normal limits. Serum levels of IgG and IgA were normal, and IgM was elevated (624 mg/dL; normal range, 70 to 280 mg/dL). Antinuclear antibody and antibodies to native DNA, Smith antigen, RNP, SCL-70, and centromere were negative. Standard radioimmunoassays for hepatitis A, B, and C on purified cryoglobulin and serum minus cryoglobulin showed the latter contained both antibody to hepatitis B surface antigen and antibody to hepatitis B core antigen. Results of a Monospot test for mononucleosis
L x c
is
t
I
t
,oj, y---y+ , 1
2
3
4
5
6
CI added (CM,, U/ml) Figure human U/mL
1. Comparison serum (N.H.S.) of human Cl.
of titers of serum Gil (Gil in both adjusted
and measurement of immune complexes by Clq binding and Raji cell assays were negative. Blood samples were collected in a warm syringe, then clotted in a warm syringe, then clotted and centrifuged at 37°C to collect the serum and preserve the cryoglobulin. The buffers, functional hemolytic complement and Cl1 assays, and radial immunodiffusion (RID) to quantitate serum proteins have been previously described [2-41. Results. The patient’s isolated cryoglobulin had a protein conApril
1992
The American
in our patient (P.G.) and in normal to 1.03 mg/dL), using 2, 3, and 5
centration of 0.26 mg/mL, and an IgM rheumatoid factor (12.9 mg/dL), IgG (11.2 mg/dL), and Clq (0.38 mg/dL) per mL of serum. Not detected by RID were CiI, Clr/Cls, C3, C4, and IgA. The patient’s serum demonstrated no activity in assays for CHs0. Functional hemolytic assays of individual components from the patient compared with a normal serum sample showed that Cl, C4, and C2 were each diminished by more than 95%, but that C3 was unaffected; this profile suggested a dysfunctional Journal
of Medicine
Volume
92
445
between the mixed cryoglobulin and a previous hepatitis B infection. We ruled out both autoantibodies to Cl and of complexes of CidCis with CiI. Whether the patient will eventually develop a connective tissue disease or a propensity for infections remains unclear at this time.
Figure 2. Comparison of our patient’s Cl subcomponents by Ouchterlony analysis. N = normal Cl; P = patient’s antisera to subcomponents Clq, Clr, and Cls.
On immunoelectrophoresis, the patient’s CiI protein appeared normal in form compared with a normal reference CiI. By RID, the serum concentration was 20.5 mg/dL (normal CT1 range, 15 to 35 mg/dL). Results of functional assays of the patient’s and normal serum CiI (both adjusted to 1.03 mg/dL) are shown in Figure 1. With 2, 3, and 5 U/mL of human Cl and normal reference CiI, the titers were 8,471,5,760, and 2,667 inhibition U/mL, respectively. For the patient, the titers were 189,159, and 116 inhibition U/mL. Using the patient’s serum minus cryoglobulin with 3 U/mL Cl, the CiI titer (ciI protein = 1.03 mg/dL) was 164. Incubation of 100 PL of cryoglobulin (0.26 mg/mL) with 100 PL of normal human serum at 37OC for 1 hour showed that most of the Cl, C4, and C2 was consumed, but only 13% of the C3. Isolated and EDTA-dissociated Cl from the patient’s serum and normal serum was analyzed by Ouchterlony plates (Figure 2); the patient’s Clr and Cls precipitin bands were significantly weaker compared with normal, and the patient’s Clq precipitated closer to the antigen well compared with normal, indicating antibody excess. By RID, the patient’s serum concentrations of CiI.
446
April
1992
The American
Journal
precipitated from Cl; a-q, a-r, and
serum a-s =
Clq and Cls were approximately one half of normal, and Clr was not detected without concentration of the serum. No free Cls was found in her serum, ruling out that low C4 and C2 levels were caused by free Cis. Columnpurified IgM and IgG fractions of the patient’s serum did not inhibit the patient’s or normal Cl hemolytic activity, ruling out autoantibodies to Cl. By chromatogor CiI-Cis raphy, no CiI-Cir complexes were detected in her serum. Comments. Although complement deficiencies are uncommon [l], our patient presented with uncomplicated urticaria that unexpectedly led to the rare diagnosis of Cl subcomponent deficiency with cryoglobulinemia. In addition, her serum CiI protein concentration was normal, but its activity in functional assays was greatly reduced compared with that of normal CiI. Patients with HAE may also have the same complement component profile: activated Cl, low levels of C4 and C2, and normal levels of C3. After our patient’s purified cryoglobulin was incubated with normal human serum at 37”C, Cl was activated and C4 and C2 were consumed, but C3 was not significantly consumed. No evidence was found of a causal relationship of Medicine
Volume
92
ANA M. LAMAS, M.D. PATRICIA I. ARNOLD, M.P.H. DUANE R. SCHULTZ, Ph.D. University of Miami School of Medicine Miami, Florida 1. Hereditary and acquired complement deficiencies in animals and man. In: lshizaka K, eta/, editors. Progress in allergy. Basel, Switzerland: S Karger, 1986. 2. Vroon DH, Schultz DR. Zarco RM. The separation of nine components and two inactivators of components of complement in human serum. Immunochemistry 1970; 7: 43-61. 3. Gigli I, Ruddy S, Austen KF. The stoichiometric measurement of the serum inhibitor of the first
component
of complement
by the inhibition of im-
mune hemolysis. J lmmunol 1968; 100: 1154-64. 4. Mancini G. Carbonara AO, Heremans JF. Immunochemical quantitation of antigens by single radial immunodiffusion. Immunochemistry 1965; 2: 235-54. Submitted
July 10. 1991, and accepted
July 19, 1991
AMYLOIDOSISIN HODGKIN’S DISEASE Secondary amyloidosis is known to occur in neoplastic diseases that can be accompanied by elements of inflammation, like Hodgkin’s disease (HD) [l] and renal cell carcinoma [2]. We report five patients with HD and amyloidosis of AA type from our population of 301 patients with HD seen at Cerrahpasa Medical Faculty within the last 10 years. To determine the frequency of amyloid deposition in lymph nodes, we reviewed the histologic sections in 301 consecutive patients over 15 years of age with HD registered at Istanbul University, Cerrahpasa Medical Faculty, Department of Pathology between 1980 and 1989. For inclusion in this study, a histolog-
DEFICIENCYOF SERUM Cl SUBCOMPONENTSAND LOW FUNCTIONALACTIVITY OF Ci INHIBITOR IN A PATIENT WITH URTICARIAAND CRYOGLOBULINEMIA Deficiencies of the complement subcomponents of Cl, Clq, and Clr/Cls have been associated with lupus or lupus-like syndromes, renal and cutaneous diseases, and infections [l]. Dissimilar forms of the regulator of Cl, the Ci inhibitor (CiI), have been reported [l]; some patients had normal serum levels of CiI, but the protein was dysfunctional. Clinically, these individuals had hereditary angioedema (HAE). We describe an adult with cryoglobulinemia, urticaria, and edema together with partial deficiencies of Clq and Clr/Cls and low functional activity of the CiI. Case Report and Methods. A 36-year-old woman had a diagnosis of urticaria since September 1989. She had no previous atopic history and had noted the sudden onset of episodes of generalized urticaria with infrequent episodes of perioral swelling. The urticaria appeared unrelated to food ingestion or medication use. No family members had atopic or collagen vascular diseases nor any history of swelling or urticaria. Cell counts and results of liver function tests were all within normal limits. Serum levels of IgG and IgA were normal, and IgM was elevated (624 mg/dL; normal range, 70 to 280 mg/dL). Antinuclear antibody and antibodies to native DNA, Smith antigen, RNP, SCL-70, and centromere were negative. Standard radioimmunoassays for hepatitis A, B, and C on purified cryoglobulin and serum minus cryoglobulin showed the latter contained both antibody to hepatitis B surface antigen and antibody to hepatitis B core antigen. Results of a Monospot test for mononucleosis
L x c
is
t
I
t
,oj, y---y+ , 1
2
3
4
5
6
CI added (CM,, U/ml) Figure human U/mL
1. Comparison serum (N.H.S.) of human Cl.
of titers of serum Gil (Gil in both adjusted
and measurement of immune complexes by Clq binding and Raji cell assays were negative. Blood samples were collected in a warm syringe, then clotted in a warm syringe, then clotted and centrifuged at 37°C to collect the serum and preserve the cryoglobulin. The buffers, functional hemolytic complement and Cl1 assays, and radial immunodiffusion (RID) to quantitate serum proteins have been previously described [2-41. Results. The patient’s isolated cryoglobulin had a protein conApril
1992
The American
in our patient (P.G.) and in normal to 1.03 mg/dL), using 2, 3, and 5
centration of 0.26 mg/mL, and an IgM rheumatoid factor (12.9 mg/dL), IgG (11.2 mg/dL), and Clq (0.38 mg/dL) per mL of serum. Not detected by RID were CiI, Clr/Cls, C3, C4, and IgA. The patient’s serum demonstrated no activity in assays for CHs0. Functional hemolytic assays of individual components from the patient compared with a normal serum sample showed that Cl, C4, and C2 were each diminished by more than 95%, but that C3 was unaffected; this profile suggested a dysfunctional Journal
of Medicine
Volume
92
445
between the mixed cryoglobulin and a previous hepatitis B infection. We ruled out both autoantibodies to Cl and of complexes of CidCis with CiI. Whether the patient will eventually develop a connective tissue disease or a propensity for infections remains unclear at this time.
Figure 2. Comparison of our patient’s Cl subcomponents by Ouchterlony analysis. N = normal Cl; P = patient’s antisera to subcomponents Clq, Clr, and Cls.
On immunoelectrophoresis, the patient’s CiI protein appeared normal in form compared with a normal reference CiI. By RID, the serum concentration was 20.5 mg/dL (normal CT1 range, 15 to 35 mg/dL). Results of functional assays of the patient’s and normal serum CiI (both adjusted to 1.03 mg/dL) are shown in Figure 1. With 2, 3, and 5 U/mL of human Cl and normal reference CiI, the titers were 8,471,5,760, and 2,667 inhibition U/mL, respectively. For the patient, the titers were 189,159, and 116 inhibition U/mL. Using the patient’s serum minus cryoglobulin with 3 U/mL Cl, the CiI titer (ciI protein = 1.03 mg/dL) was 164. Incubation of 100 PL of cryoglobulin (0.26 mg/mL) with 100 PL of normal human serum at 37OC for 1 hour showed that most of the Cl, C4, and C2 was consumed, but only 13% of the C3. Isolated and EDTA-dissociated Cl from the patient’s serum and normal serum was analyzed by Ouchterlony plates (Figure 2); the patient’s Clr and Cls precipitin bands were significantly weaker compared with normal, and the patient’s Clq precipitated closer to the antigen well compared with normal, indicating antibody excess. By RID, the patient’s serum concentrations of CiI.
446
April
1992
The American
Journal
precipitated from Cl; a-q, a-r, and
serum a-s =
Clq and Cls were approximately one half of normal, and Clr was not detected without concentration of the serum. No free Cls was found in her serum, ruling out that low C4 and C2 levels were caused by free Cis. Columnpurified IgM and IgG fractions of the patient’s serum did not inhibit the patient’s or normal Cl hemolytic activity, ruling out autoantibodies to Cl. By chromatogor CiI-Cis raphy, no CiI-Cir complexes were detected in her serum. Comments. Although complement deficiencies are uncommon [l], our patient presented with uncomplicated urticaria that unexpectedly led to the rare diagnosis of Cl subcomponent deficiency with cryoglobulinemia. In addition, her serum CiI protein concentration was normal, but its activity in functional assays was greatly reduced compared with that of normal CiI. Patients with HAE may also have the same complement component profile: activated Cl, low levels of C4 and C2, and normal levels of C3. After our patient’s purified cryoglobulin was incubated with normal human serum at 37”C, Cl was activated and C4 and C2 were consumed, but C3 was not significantly consumed. No evidence was found of a causal relationship of Medicine
Volume
92
ANA M. LAMAS, M.D. PATRICIA I. ARNOLD, M.P.H. DUANE R. SCHULTZ, Ph.D. University of Miami School of Medicine Miami, Florida 1. Hereditary and acquired complement deficiencies in animals and man. In: lshizaka K, eta/, editors. Progress in allergy. Basel, Switzerland: S Karger, 1986. 2. Vroon DH, Schultz DR. Zarco RM. The separation of nine components and two inactivators of components of complement in human serum. Immunochemistry 1970; 7: 43-61. 3. Gigli I, Ruddy S, Austen KF. The stoichiometric measurement of the serum inhibitor of the first
component
of complement
by the inhibition of im-
mune hemolysis. J lmmunol 1968; 100: 1154-64. 4. Mancini G. Carbonara AO, Heremans JF. Immunochemical quantitation of antigens by single radial immunodiffusion. Immunochemistry 1965; 2: 235-54. Submitted
July 10. 1991, and accepted
July 19, 1991
AMYLOIDOSISIN HODGKIN’S DISEASE Secondary amyloidosis is known to occur in neoplastic diseases that can be accompanied by elements of inflammation, like Hodgkin’s disease (HD) [l] and renal cell carcinoma [2]. We report five patients with HD and amyloidosis of AA type from our population of 301 patients with HD seen at Cerrahpasa Medical Faculty within the last 10 years. To determine the frequency of amyloid deposition in lymph nodes, we reviewed the histologic sections in 301 consecutive patients over 15 years of age with HD registered at Istanbul University, Cerrahpasa Medical Faculty, Department of Pathology between 1980 and 1989. For inclusion in this study, a histolog-
