18
SYSTEMIC LUPUS ERYTHEMATOSUS ASSOCIATED WITH KLINEFELTER’S SYNDROME R. S T E R N , J. F I S H M A N , H. B R U S M A N . and H. G. KUNKEL
Studies in estrogen metabolism were carried out in 2 males with systemic lupus erythematosus (SLE) who also had Klinefelter’s syndrome. Although these studies revealed elevated levels of urinary estrogens in 1 patient, abnormalities of estradiol metabolism suggesting persistent estrogen stimulation were detected in both. This report notes an association between SLE and Klinefelter’s syndrome and suggests that chronic estrogenic stimulation may be significant in the development of SLE in these 2 patients. A high female incidence is well recognized in a variety of human disorders involving immunologic aberrations including the connective tissue group. I n systemic lupus erythematosus (SLE) the ma1e:female ratio is approximately 1 t o 9 (1). T h e occurrence in a male with SLE of a syndrome characterized by the presence
From the Rockefeller University, New York. New York, and the Albert Einstein College of Medicine, Bronx, New Y ork. Supported by grants AI 02330 and RR-102 from the National Institutes of Health. R. Stern, M.D.: Postdoctoral Fellow, the Rockefeller University; J. Fishman, Ph.D.: Professor of Biochemistry, Albert Einstein College of Medicine; H. Brusman, M.D.: formerly a Postdoctoral Fellow, the Rockefeller University, presently a Resident in Pathology, the New York Hospital; H. G. Kunkel, M.D.: Professor, the Rockefeller University. Address reprint requests to R. Stern, M.D., Memorial SloanKettering Cancer Center, 1275 York Avenue, New York, New York 10021. Submitted for publication May 18, 1976; accepted August 23, 1976.
Arthritis and Rheumatism, Vol. 20, No. 1 (January-February 1977)
of small male genitalia, gynecomastia, and lack of secondary sexual characteristics, i.e. Klinefelter’s syndrome, is of special note (2-4). In the present report two additional cases of SLE associated with Klinefelter’s syndrome are noted. In addition, data are presented suggesting that these 2 patients have been under chronic estrogenic stimulation.
MATERIALS AND METHODS At the time of study neither patient was receiving corticosteroids or any sex hormone. Neither had ever taken immunosuppressive drugs other than corticosteroids. Urinary estrogens were measured by radioimrnunoassay frop 24-hour urine collections. Following hydrolysis with 8-glucuronidase and estrogen extraction, 24-hour urinary estrogens were measured by radioimmunoassay with specific antisera for estrone, estradiol, and estriol. Values for 20 normal males for estrone, estradiol, and estriol were determined (Table 1) ( 5 ) . Because urinary estrogen levels in Klinefelter’s syndrome are frequently within the normal range (6,7),the metabolism of trace labeled estradiol was also studied in these patients. Estradiol 6-7-*H was injected intravenously (8) and urine was collected over 3 days. The recovery of total radioactivity in the glucosiduronate and nonglucosiduronate fractions of the urine was measured as previously described (8). In brief, a sample of the combined 3-day collection was treated with 8-glucuronidase and this glucosiduronate fraction was extracted with ether. The remaining activity was considered the nonglucosiduronate fraction. The pattern of radioactivity in the glucosiduronate fraction, the major urinary fraction, as various estrogen metabolites-estradiol (E2), estrone (El), estrio1 (E3). 2 methoxy El, and 2-OH El-was also determined (8).
19
there was scanty axillary and pubic hair. The penis measured 1 inch in length. A small amount of breast tissue was present bilaterally. Laboratory examination revealed a normal CBC and urinalysis. Creatinine clearance was 80-90 cms/min/l .73 mz of body surface area. Twenty-four-hour urine collections were normal on all but one occasion when 350 mg of protein were present. ESR was 40 mm/hour. There was diffuse hypergammaglobulinemia, a positive LE cell test, and 4+ positive antinuclear fluorescence. Total hemolytic complement was normal. Antibodies t o native D N A were detected by hemagglutination in a 1/64 titer. Because of small genitalia and a lack of secondary sexual characteristics, a buccal smear was performed and revealed many Barr bodies. A karyotype analysis of fifty dividing lymphocytes revealed that all had the chromosomal complement 47, XXY. The patient was treated with aspirin, but was readmitted 6 months later because of arthritis and fever. At this time both anemia and leukopenia were present. A kidney biopsy revealed IgG and PIC deposits in the mesangium and within the basement membrane. Treatment with adrenalcortical steroids promptly relieved his symptoms, and all laboratory tests returned to normal. Later he was given methyl testosterone, 5 mg per day, and after 1 year had considerable penile growth.
Case 2
Fig 1. Patienr I with SLE and Klinefelter’s syndrome.
Case 1 This 24-year-old white male (Figure 1) was well until the summer of 1967, when he noted onset of stiffness and pain in multiple joints. In February 1968 he was admitted to a local hospital with fever and arthralgias. In October 1968 he was admitted to the Rockefeller University Hospital for evaluation. He denied rash or sun sensitivity, oral ulcers, alopecia, history of renal disease, or proteinurea. There was n o family history for arthritis. O n examination the most striking findings were a female habitus, obesity, and a malar rash. Joint inflammation was not detected. N o facial hair was present and
This 41-year-old white male was referred t o the Rockefeller University Hospital in 1971 with a diagnosis of Klinefelter’s syndrome, porphyria cutaneous tarda, and SLE. He had a 2-year history of painful swelling of his hands and knees. Recently he had noted episodes of pleuritic-like chest pain. Further questioning revealed recent onset of hyperpigmentation of the face and dorsum of the hands. Both sun exposure or relative mild trauma resulted in blister formation. On several occasions he had noted red urine. There was a history of chronic alcoholism, but n o history of liver disease, jaundice, renal disease, proteinuria, or hypertension. He did not complain of abdominal pain or paraesthesias. There was no family history of arthritis, skin disease, or renal disease. Physical examination was notable for hyperpigmentation over the hands and face with areas of hypopigmentation over the dorsum of the hands. N o jaundice was detectable. There was n o hepatomegaly o r splenomegaly. Both testes and penis were small; gynecomastia was detectable on the right. Neurologic examination was within normal limits, as was musculoskeletal examination. Laboratory examination was remarkable for a normal CBC and urinalysis as well as normal liver function tests. However an LE cell test was positive, as was the serum fluorescent antinuclear antibody test (4+). Antibodies to native D N A and double-stranded R N A were detected by hemagglutination in titers of 1/32 and 1/16 respectively. Total hemolytic complement was normal. Twenty-fourhour urine collections revealed a normal creatinine clearance and protein excretion. Several urinary uroporphyrinogen determinations were elevated, whereas corprophyrinogen, A aminolevulinic acid, and prophobilinogen levels were normal. BSP was abnormal (9.2%). Because of an unusual body build and lack of secondary sexual characteristics, a buccal smear and karyotype were
STERN ET AL
20
performed. These confirmed the 47 XXY chromosomal complement. His course has been marked by episodes of pleuritic chest pain with patchy alopecia, leukopenia, anemia, and hypocomplementemia. Because there has been no renal involvement, he has been treated with nonsteroidal antiinflammatory agents.
RESULTS The values for 24-hour urinary estrogen measurements in these 2 patients with Klinefelter’s syndrome and SLE are shown in Table 1. Although Case 1 had elevated levels of all urinary estrogens, the value of 20.2 pg per 24 hours for estriol is markedly abnormal and clearly falls within the range of a normal menstruating female (luteal phase). These measurements, though, failed to detect increased estrogens in Case 2. However studies utilizing trace labeled estradiol revealed abnormalities of estrogen metabolism in both these patients. Previous studies have shown that the pattern of radioactivity in the urinary glucosiduronate fraction as various metabolites of estradiol is the same in normal males and females (8). As Table 2 shows, in normals about 20% of the radioactivity was found as both estrone and 2-OH estrone, and 15% was found as estriol. Lesser amounts were found as estradiol. In both patients with SLE associated with Klinefelter’s syndrome, more than 35% of the label in this fraction was found as estriol, whereas only 7.4% and 10% were found as 2-OH estrone.
DISCUSSION Both SLE and Klinefelter’s syndrome are relatively rare disorders. The frequency of SLE is estimated at between 5.7 and 40 per 100,OOO (l), depending on diagnostic criteria, and the frequency of Klinefelter’s syndrome is estimated at 1.7 per 100,000 (9). Because the sex ratio in SLE is markedly female and because the reason for this predominance is speculative, the coincidence of these two disorders raises the question of the role of endogenous female sex hormones in the development of SLE. Most previous studies in Klinefelter’s syndrome have failed to document abnormal sex hormone levels. Estrogens are usually in the normal adult male range and testosterone levels are frequently in the low-normal to normal range (6,7). Examination of 24-hour urines for estrogens in these 2 patients detected elevated levels only in Case 1, who had estriol levels in the normal female range. It is interesting that the typical clinical characteristics of Klinefelter’s syndrome were more pronounced
Table 1. Urinary Estrogens
Age-matched normal males (1 8) Case I Case 2
Estrone
Estradiol
Estriol
3.0 f 4.2 6.58 2.25
2.7 f 0.18 4.3 I 1.93
3.4 f 0.52 20.2 2.10
All measurements recorded as pg/24 hours.
in this patient than in the one with normal 24-hour urinary estrogens. Studies of estrogen metabolism were then carried out. These studies utilized radiolabeled estradiol and examined its oxidation to estrone and subsequent conversion to either a number of inactive compounds or to estriol (Figure 2). This latter compound has recently been shown to be as active an estrogenic compound as estradiol (10). In both these male patients more than 35% of the label in the glucosiduronate fraction was found as estriol. This result contrasts with the 10-15% found in normal males and females. Similar studies in patients with alcoholic liver disease showed that the conversion of estradiol to estriol was slightly elevated but still within the normal range (1 1). These findings raise the possibility that chronic estrogenic stimulation exists in both of these 2 males. Studies in otherwise normal patients with either SLE or Klinefelter’s syndrome are currently being carried out. It is also interesting that the amount of label in the glucosiduronate fraction found as 2-OH estrone was reduced in these patients. This compound has little estrogenic activity (12) but considerable binding affinity as measured by binding for uterine estrogen receptors (13). That is, although 2-OH estrone has 10% the binding affinity of estradiol, it has only 0.1% its uterotrophic potency. Thus 2-OH estrone’s binding affinity far exceeds its biologic activity, and the compound may function as an endogenous antiestrogen. As Figure 2 shows, the metabolism of estradiol may proceed in alternative pathways, either toward estriol or toward 2-OH estrone. Table 2. Urinary Estrogen Metabolites After Intravenous Estradiol Trace
Normal males(2I) Case I Case 2
Estrone
Estradiol
Estriol
2-OH Estrone
22.2 f 3.2 8.6 7.8
11.6 f 3.3 10.83 5.0
15.8 f 6.6 37. I 35.7
18.8 f 6.8 10.2 7.4
All figures represent the percentage of glucosiduronates.
SLE A N D KLINEFELTER’S SYNDROME
OH
&+& HO
HO
€2
El 2-OH El
Fig 2. Normal metabolic pathway of estmdiol (E2),showing its oxidation to estrone ( E l ) and subsequent conversion either to the active compound estriol (E3)or to 2-OH estrone (%OH El)
The findings in these 2 patients of excess transformation of estradiol to estriol and of reduced metabolism to 2OH estrone suggest that the direction of estrogen metabolism in these patients is toward continuing estrogenicity and away from termination of activity. The possibility that female sex hormones play a role in the development of human autoimmune phenomena has often been raised. There are some reports noting the appearance and disappearance of rheumatic symptoms and serologic abnormalities in women taking birth control pills (14.15). However controlled prospective studies in the general population have had varied results. One such study (16) documented the development of positive antinuclear antibodies after the start of oral contraceptives. However another study (17) examined the occurrence of rheumatic symptoms in women attending a large birth control clinic and found no significant relationship between ANA and the use of contraceptives. Studies in animals have suggested that estrogens may play a role in the regulation of immune responses. These studies have shown that although estrogens suppress cell-mediated immunity they may enhance humoral immunity (18,Ig). A series of experiments demonstrated that estrogen therapy can prolong allogenic skin graft survival (20). In these studies untreated mice rejected allogenic skin grafts in 13 days. Similar animals pretreated with sublethal radiation retained these grafts for an average of 18 days. However, if animals were treated with both sublethal radiation and pharmacologic doses of either estradiol or estriol, average graft survival was prolonged to 44 and 32 days respectively. Treatment with estrogens can enhance the growth of a transplanted tumor (20), and furthermore, administration of estradiol to neonatal mice can produce a runting syndrome with thymic involution, lymphoid hypoplasia, and death (21).
21
A limited number of studies of immune function in humans have not been as convincing in demonstrating a suppressive effect of estrogens. Certain in vitro studies on normal human peripheral lymphocytes indicated a suppression of PHA stimulation in the presence of diethyl stilbesterol (22). However another study (23) examined the effect of in vitro estrogens on the ability of normal human peripheral lymphocytes to respond to allogenic lymphocytes in the mixed lymphocyte culture. This study found suppression of stimulation only at estrogen concentrations considerably above physiologic levels. Similar findings were noted in the case of lymphocyte response to various mitogens. Another consideration in these patients with Klinefelter’s syndrome and SLE is the possibility that their autoimmune state is related to the chromosomal aberrations. Although previous studies in Klinefelter’s syndrome have failed to show an increased incidence of autoantibodies (24), similar studies in gonadal dysgenesis ( 2 5 ) and Down’s syndrome (26) revealed an increased incidence of both Hashimoto’s thyroiditis and antithyroid antibodies. But Fialkow suggests (27) that, because increased titers of antithyroid antibodies are found in normal parents of patients with gonadal dysgenesis (24), autoantibodies may in fact be directly responsible for aneuploidy; and anti-ova antibodies have been described in such patients (24). The possibility that both aneuploidy and autoimmunity are related through a third factor, e.g. viral infection, is not ruled out. Finally, 1 of the present patients with Klinefelter’s syndrome and SLE also had porphyria cutaneous tarda, probably symptomatica. This association has been noted previously (28).
ACKNOWLEDGMENT The authors thank Dr. A. Kappas for his helpful suggestions.
REFERENCES 1. Dubois EL: The clinical picture of systemic lupus er-
ythematosus, Lupus Erythematosus. Edited by EL Dubois. Second edition. Los Angeles, University of Southern California press, 1974, p p 232-242 2. Ortiz-Neu C, LeRoy EC: The coincidence of Klinefelter’s syndrome and systemic lupus erythematosus. Arthritis Rheum 12:241-246, 1966 3. Landwirth J, Berger A: Systemic lupus erythematosus and Klinefelter’s syndrome. Am J Dis Child 126:851-853, 1973
22
4. Dubois EL, Kaplan BJ: SLE and Klinefelter’s syndrome. Lancet 1:93, 1976 5. Fishman J: Unpublished data 6. Paulsen CA: Testbook of Endocrinology. Edited by R H Williams. Philadelphia, Saunders, 1968, p 405 7. Paulsen CA, Gordon DL, Carpenter RW, et al: Klinefelter’s syndrome and its variants: a hormonal and chromosomal study. Recent Prog Horm Res 24:321-363, 1968 8. Zumoff B, Fishman J, Cassouto J , et al: Influence of age and sex on normal estradiol metabolism. J Clin Endocrino1 Metab 28:937-941, 1968 9. Caldwell PD, Smith DW: The XXY (Klinefelter’s) syndrome in childhood: detection and treatment. J Pediatr 80250-258, 1972 10. Anderson J N , Peck EJ, Clark JH: Estrogen-induced uterine responses and growth: relationship to receptor estrogen binding by uterine nuclei. Endocrinology 26: 160-167, 1975 I I . Zumoff B, Fishman J, Gallagher T F , et al: Estradiol metabolism in cirrhosis. J Clin Invest 47:20-25, 1968 12. Gordon S, Cantrall EW, Cekleniak AB, et al: The hypocholesteremic effect of estrogen metabolites. Steroids 4:267-27 I , 1964 13. Martucci C, Fishman J: Uterine estrogen receptor binding of catecholestrogens and of estretrol. Steroids (in press) 14. Bole G G , Freedlander MH, Smith CK: Rheumatic symptoms and serologic abnormalities induced by oral contraceptives. Lancet 1:323-326, 1969 15. Schleicher EM: LE cells after oral contraceptives. Lancet 1:821-822, 1968 16. Kay DR, Bole GG, Ledger WJ: Antinuclear antibodies, rheumatoid factor and C-reactive protein in serum of normal women using oral contraceptives. Arthritis Rheum 14:239-248, 1971
STERN ET AL
17. Gill D: Rheumatic complaints of women using anti-ovulatory drugs. J Chronic Dis 21:435-444, I968 18. Von Haam E, Rosenfeld I: Effect of estrone on antibody production. J Immunol 43:109-117, 1942 19. Stern K , Davidsohn I: Effect of estrogen and cortisone on immune hemoantibodies in mice of inbred strains. J Immunol 74:479-483, 1955 20. Thompson JS, Crawford MK, Reilly RW, et al: Effect of estrogenic hormones on immune responses in normal and irradiated mice. J lmmunol 98:331-335, 1967 21. Reilly RW, Thompson JS, Bielski RK, et al: Estradiol induced wasting syndrome i n neonatal mice. J lmmunol 98:321-330, 1967 22. Ablin RJ, Bruns G R , Guinan P, et al: The effect of estrogen on the incorporation of SH-thymidine by PHA stimulated human peripheral blood lymphocytes. J Immunol 1 1 31705-707, 1974 23. Schiff RI, Mercier D, Buckley R: Inability of gestational hormones to account for the inhibitory effects of pregnancy plasmas on lymphocyte responses in oitro. Cell Immunol 2069-80, 1975 24. Vallotten MB, Forbes AP: Autoimmunity in gonodal dysgenesis and Klinefelter’s syndrome. Lancet 1 :648-65 I , 1967 25. Williams ED, Engel E, Forbes AP: Thyroiditis and gonadal dysgenesis. N Engl J Med 270805-810, 1964 26. Nielsen J: Immunologic aberrations in patients with aneuploid chromosomal abnormalities and their parents. Humangenetik 16: 171- 176, 1972 27. Fialkow PJ: Autoimmunity: a predisposing factor to chromosomal aberrations. Lancet 1:474-475, 1964 28. Cram DL, Epstein JH, Tuffanelli DL: Lupus erythematosus and porphyria. Arch Dermatol 108:779-784, 1973
SYSTEMIC LUPUS ERYTHEMATOSUS ASSOCIATED WITH KLINEFELTER’S SYNDROME R. S T E R N , J. F I S H M A N , H. B R U S M A N . and H. G. KUNKEL
Studies in estrogen metabolism were carried out in 2 males with systemic lupus erythematosus (SLE) who also had Klinefelter’s syndrome. Although these studies revealed elevated levels of urinary estrogens in 1 patient, abnormalities of estradiol metabolism suggesting persistent estrogen stimulation were detected in both. This report notes an association between SLE and Klinefelter’s syndrome and suggests that chronic estrogenic stimulation may be significant in the development of SLE in these 2 patients. A high female incidence is well recognized in a variety of human disorders involving immunologic aberrations including the connective tissue group. I n systemic lupus erythematosus (SLE) the ma1e:female ratio is approximately 1 t o 9 (1). T h e occurrence in a male with SLE of a syndrome characterized by the presence
From the Rockefeller University, New York. New York, and the Albert Einstein College of Medicine, Bronx, New Y ork. Supported by grants AI 02330 and RR-102 from the National Institutes of Health. R. Stern, M.D.: Postdoctoral Fellow, the Rockefeller University; J. Fishman, Ph.D.: Professor of Biochemistry, Albert Einstein College of Medicine; H. Brusman, M.D.: formerly a Postdoctoral Fellow, the Rockefeller University, presently a Resident in Pathology, the New York Hospital; H. G. Kunkel, M.D.: Professor, the Rockefeller University. Address reprint requests to R. Stern, M.D., Memorial SloanKettering Cancer Center, 1275 York Avenue, New York, New York 10021. Submitted for publication May 18, 1976; accepted August 23, 1976.
Arthritis and Rheumatism, Vol. 20, No. 1 (January-February 1977)
of small male genitalia, gynecomastia, and lack of secondary sexual characteristics, i.e. Klinefelter’s syndrome, is of special note (2-4). In the present report two additional cases of SLE associated with Klinefelter’s syndrome are noted. In addition, data are presented suggesting that these 2 patients have been under chronic estrogenic stimulation.
MATERIALS AND METHODS At the time of study neither patient was receiving corticosteroids or any sex hormone. Neither had ever taken immunosuppressive drugs other than corticosteroids. Urinary estrogens were measured by radioimrnunoassay frop 24-hour urine collections. Following hydrolysis with 8-glucuronidase and estrogen extraction, 24-hour urinary estrogens were measured by radioimmunoassay with specific antisera for estrone, estradiol, and estriol. Values for 20 normal males for estrone, estradiol, and estriol were determined (Table 1) ( 5 ) . Because urinary estrogen levels in Klinefelter’s syndrome are frequently within the normal range (6,7),the metabolism of trace labeled estradiol was also studied in these patients. Estradiol 6-7-*H was injected intravenously (8) and urine was collected over 3 days. The recovery of total radioactivity in the glucosiduronate and nonglucosiduronate fractions of the urine was measured as previously described (8). In brief, a sample of the combined 3-day collection was treated with 8-glucuronidase and this glucosiduronate fraction was extracted with ether. The remaining activity was considered the nonglucosiduronate fraction. The pattern of radioactivity in the glucosiduronate fraction, the major urinary fraction, as various estrogen metabolites-estradiol (E2), estrone (El), estrio1 (E3). 2 methoxy El, and 2-OH El-was also determined (8).
19
there was scanty axillary and pubic hair. The penis measured 1 inch in length. A small amount of breast tissue was present bilaterally. Laboratory examination revealed a normal CBC and urinalysis. Creatinine clearance was 80-90 cms/min/l .73 mz of body surface area. Twenty-four-hour urine collections were normal on all but one occasion when 350 mg of protein were present. ESR was 40 mm/hour. There was diffuse hypergammaglobulinemia, a positive LE cell test, and 4+ positive antinuclear fluorescence. Total hemolytic complement was normal. Antibodies t o native D N A were detected by hemagglutination in a 1/64 titer. Because of small genitalia and a lack of secondary sexual characteristics, a buccal smear was performed and revealed many Barr bodies. A karyotype analysis of fifty dividing lymphocytes revealed that all had the chromosomal complement 47, XXY. The patient was treated with aspirin, but was readmitted 6 months later because of arthritis and fever. At this time both anemia and leukopenia were present. A kidney biopsy revealed IgG and PIC deposits in the mesangium and within the basement membrane. Treatment with adrenalcortical steroids promptly relieved his symptoms, and all laboratory tests returned to normal. Later he was given methyl testosterone, 5 mg per day, and after 1 year had considerable penile growth.
Case 2
Fig 1. Patienr I with SLE and Klinefelter’s syndrome.
Case 1 This 24-year-old white male (Figure 1) was well until the summer of 1967, when he noted onset of stiffness and pain in multiple joints. In February 1968 he was admitted to a local hospital with fever and arthralgias. In October 1968 he was admitted to the Rockefeller University Hospital for evaluation. He denied rash or sun sensitivity, oral ulcers, alopecia, history of renal disease, or proteinurea. There was n o family history for arthritis. O n examination the most striking findings were a female habitus, obesity, and a malar rash. Joint inflammation was not detected. N o facial hair was present and
This 41-year-old white male was referred t o the Rockefeller University Hospital in 1971 with a diagnosis of Klinefelter’s syndrome, porphyria cutaneous tarda, and SLE. He had a 2-year history of painful swelling of his hands and knees. Recently he had noted episodes of pleuritic-like chest pain. Further questioning revealed recent onset of hyperpigmentation of the face and dorsum of the hands. Both sun exposure or relative mild trauma resulted in blister formation. On several occasions he had noted red urine. There was a history of chronic alcoholism, but n o history of liver disease, jaundice, renal disease, proteinuria, or hypertension. He did not complain of abdominal pain or paraesthesias. There was no family history of arthritis, skin disease, or renal disease. Physical examination was notable for hyperpigmentation over the hands and face with areas of hypopigmentation over the dorsum of the hands. N o jaundice was detectable. There was n o hepatomegaly o r splenomegaly. Both testes and penis were small; gynecomastia was detectable on the right. Neurologic examination was within normal limits, as was musculoskeletal examination. Laboratory examination was remarkable for a normal CBC and urinalysis as well as normal liver function tests. However an LE cell test was positive, as was the serum fluorescent antinuclear antibody test (4+). Antibodies to native D N A and double-stranded R N A were detected by hemagglutination in titers of 1/32 and 1/16 respectively. Total hemolytic complement was normal. Twenty-fourhour urine collections revealed a normal creatinine clearance and protein excretion. Several urinary uroporphyrinogen determinations were elevated, whereas corprophyrinogen, A aminolevulinic acid, and prophobilinogen levels were normal. BSP was abnormal (9.2%). Because of an unusual body build and lack of secondary sexual characteristics, a buccal smear and karyotype were
STERN ET AL
20
performed. These confirmed the 47 XXY chromosomal complement. His course has been marked by episodes of pleuritic chest pain with patchy alopecia, leukopenia, anemia, and hypocomplementemia. Because there has been no renal involvement, he has been treated with nonsteroidal antiinflammatory agents.
RESULTS The values for 24-hour urinary estrogen measurements in these 2 patients with Klinefelter’s syndrome and SLE are shown in Table 1. Although Case 1 had elevated levels of all urinary estrogens, the value of 20.2 pg per 24 hours for estriol is markedly abnormal and clearly falls within the range of a normal menstruating female (luteal phase). These measurements, though, failed to detect increased estrogens in Case 2. However studies utilizing trace labeled estradiol revealed abnormalities of estrogen metabolism in both these patients. Previous studies have shown that the pattern of radioactivity in the urinary glucosiduronate fraction as various metabolites of estradiol is the same in normal males and females (8). As Table 2 shows, in normals about 20% of the radioactivity was found as both estrone and 2-OH estrone, and 15% was found as estriol. Lesser amounts were found as estradiol. In both patients with SLE associated with Klinefelter’s syndrome, more than 35% of the label in this fraction was found as estriol, whereas only 7.4% and 10% were found as 2-OH estrone.
DISCUSSION Both SLE and Klinefelter’s syndrome are relatively rare disorders. The frequency of SLE is estimated at between 5.7 and 40 per 100,OOO (l), depending on diagnostic criteria, and the frequency of Klinefelter’s syndrome is estimated at 1.7 per 100,000 (9). Because the sex ratio in SLE is markedly female and because the reason for this predominance is speculative, the coincidence of these two disorders raises the question of the role of endogenous female sex hormones in the development of SLE. Most previous studies in Klinefelter’s syndrome have failed to document abnormal sex hormone levels. Estrogens are usually in the normal adult male range and testosterone levels are frequently in the low-normal to normal range (6,7). Examination of 24-hour urines for estrogens in these 2 patients detected elevated levels only in Case 1, who had estriol levels in the normal female range. It is interesting that the typical clinical characteristics of Klinefelter’s syndrome were more pronounced
Table 1. Urinary Estrogens
Age-matched normal males (1 8) Case I Case 2
Estrone
Estradiol
Estriol
3.0 f 4.2 6.58 2.25
2.7 f 0.18 4.3 I 1.93
3.4 f 0.52 20.2 2.10
All measurements recorded as pg/24 hours.
in this patient than in the one with normal 24-hour urinary estrogens. Studies of estrogen metabolism were then carried out. These studies utilized radiolabeled estradiol and examined its oxidation to estrone and subsequent conversion to either a number of inactive compounds or to estriol (Figure 2). This latter compound has recently been shown to be as active an estrogenic compound as estradiol (10). In both these male patients more than 35% of the label in the glucosiduronate fraction was found as estriol. This result contrasts with the 10-15% found in normal males and females. Similar studies in patients with alcoholic liver disease showed that the conversion of estradiol to estriol was slightly elevated but still within the normal range (1 1). These findings raise the possibility that chronic estrogenic stimulation exists in both of these 2 males. Studies in otherwise normal patients with either SLE or Klinefelter’s syndrome are currently being carried out. It is also interesting that the amount of label in the glucosiduronate fraction found as 2-OH estrone was reduced in these patients. This compound has little estrogenic activity (12) but considerable binding affinity as measured by binding for uterine estrogen receptors (13). That is, although 2-OH estrone has 10% the binding affinity of estradiol, it has only 0.1% its uterotrophic potency. Thus 2-OH estrone’s binding affinity far exceeds its biologic activity, and the compound may function as an endogenous antiestrogen. As Figure 2 shows, the metabolism of estradiol may proceed in alternative pathways, either toward estriol or toward 2-OH estrone. Table 2. Urinary Estrogen Metabolites After Intravenous Estradiol Trace
Normal males(2I) Case I Case 2
Estrone
Estradiol
Estriol
2-OH Estrone
22.2 f 3.2 8.6 7.8
11.6 f 3.3 10.83 5.0
15.8 f 6.6 37. I 35.7
18.8 f 6.8 10.2 7.4
All figures represent the percentage of glucosiduronates.
SLE A N D KLINEFELTER’S SYNDROME
OH
&+& HO
HO
€2
El 2-OH El
Fig 2. Normal metabolic pathway of estmdiol (E2),showing its oxidation to estrone ( E l ) and subsequent conversion either to the active compound estriol (E3)or to 2-OH estrone (%OH El)
The findings in these 2 patients of excess transformation of estradiol to estriol and of reduced metabolism to 2OH estrone suggest that the direction of estrogen metabolism in these patients is toward continuing estrogenicity and away from termination of activity. The possibility that female sex hormones play a role in the development of human autoimmune phenomena has often been raised. There are some reports noting the appearance and disappearance of rheumatic symptoms and serologic abnormalities in women taking birth control pills (14.15). However controlled prospective studies in the general population have had varied results. One such study (16) documented the development of positive antinuclear antibodies after the start of oral contraceptives. However another study (17) examined the occurrence of rheumatic symptoms in women attending a large birth control clinic and found no significant relationship between ANA and the use of contraceptives. Studies in animals have suggested that estrogens may play a role in the regulation of immune responses. These studies have shown that although estrogens suppress cell-mediated immunity they may enhance humoral immunity (18,Ig). A series of experiments demonstrated that estrogen therapy can prolong allogenic skin graft survival (20). In these studies untreated mice rejected allogenic skin grafts in 13 days. Similar animals pretreated with sublethal radiation retained these grafts for an average of 18 days. However, if animals were treated with both sublethal radiation and pharmacologic doses of either estradiol or estriol, average graft survival was prolonged to 44 and 32 days respectively. Treatment with estrogens can enhance the growth of a transplanted tumor (20), and furthermore, administration of estradiol to neonatal mice can produce a runting syndrome with thymic involution, lymphoid hypoplasia, and death (21).
21
A limited number of studies of immune function in humans have not been as convincing in demonstrating a suppressive effect of estrogens. Certain in vitro studies on normal human peripheral lymphocytes indicated a suppression of PHA stimulation in the presence of diethyl stilbesterol (22). However another study (23) examined the effect of in vitro estrogens on the ability of normal human peripheral lymphocytes to respond to allogenic lymphocytes in the mixed lymphocyte culture. This study found suppression of stimulation only at estrogen concentrations considerably above physiologic levels. Similar findings were noted in the case of lymphocyte response to various mitogens. Another consideration in these patients with Klinefelter’s syndrome and SLE is the possibility that their autoimmune state is related to the chromosomal aberrations. Although previous studies in Klinefelter’s syndrome have failed to show an increased incidence of autoantibodies (24), similar studies in gonadal dysgenesis ( 2 5 ) and Down’s syndrome (26) revealed an increased incidence of both Hashimoto’s thyroiditis and antithyroid antibodies. But Fialkow suggests (27) that, because increased titers of antithyroid antibodies are found in normal parents of patients with gonadal dysgenesis (24), autoantibodies may in fact be directly responsible for aneuploidy; and anti-ova antibodies have been described in such patients (24). The possibility that both aneuploidy and autoimmunity are related through a third factor, e.g. viral infection, is not ruled out. Finally, 1 of the present patients with Klinefelter’s syndrome and SLE also had porphyria cutaneous tarda, probably symptomatica. This association has been noted previously (28).
ACKNOWLEDGMENT The authors thank Dr. A. Kappas for his helpful suggestions.
REFERENCES 1. Dubois EL: The clinical picture of systemic lupus er-
ythematosus, Lupus Erythematosus. Edited by EL Dubois. Second edition. Los Angeles, University of Southern California press, 1974, p p 232-242 2. Ortiz-Neu C, LeRoy EC: The coincidence of Klinefelter’s syndrome and systemic lupus erythematosus. Arthritis Rheum 12:241-246, 1966 3. Landwirth J, Berger A: Systemic lupus erythematosus and Klinefelter’s syndrome. Am J Dis Child 126:851-853, 1973
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4. Dubois EL, Kaplan BJ: SLE and Klinefelter’s syndrome. Lancet 1:93, 1976 5. Fishman J: Unpublished data 6. Paulsen CA: Testbook of Endocrinology. Edited by R H Williams. Philadelphia, Saunders, 1968, p 405 7. Paulsen CA, Gordon DL, Carpenter RW, et al: Klinefelter’s syndrome and its variants: a hormonal and chromosomal study. Recent Prog Horm Res 24:321-363, 1968 8. Zumoff B, Fishman J, Cassouto J , et al: Influence of age and sex on normal estradiol metabolism. J Clin Endocrino1 Metab 28:937-941, 1968 9. Caldwell PD, Smith DW: The XXY (Klinefelter’s) syndrome in childhood: detection and treatment. J Pediatr 80250-258, 1972 10. Anderson J N , Peck EJ, Clark JH: Estrogen-induced uterine responses and growth: relationship to receptor estrogen binding by uterine nuclei. Endocrinology 26: 160-167, 1975 I I . Zumoff B, Fishman J, Gallagher T F , et al: Estradiol metabolism in cirrhosis. J Clin Invest 47:20-25, 1968 12. Gordon S, Cantrall EW, Cekleniak AB, et al: The hypocholesteremic effect of estrogen metabolites. Steroids 4:267-27 I , 1964 13. Martucci C, Fishman J: Uterine estrogen receptor binding of catecholestrogens and of estretrol. Steroids (in press) 14. Bole G G , Freedlander MH, Smith CK: Rheumatic symptoms and serologic abnormalities induced by oral contraceptives. Lancet 1:323-326, 1969 15. Schleicher EM: LE cells after oral contraceptives. Lancet 1:821-822, 1968 16. Kay DR, Bole GG, Ledger WJ: Antinuclear antibodies, rheumatoid factor and C-reactive protein in serum of normal women using oral contraceptives. Arthritis Rheum 14:239-248, 1971
STERN ET AL
17. Gill D: Rheumatic complaints of women using anti-ovulatory drugs. J Chronic Dis 21:435-444, I968 18. Von Haam E, Rosenfeld I: Effect of estrone on antibody production. J Immunol 43:109-117, 1942 19. Stern K , Davidsohn I: Effect of estrogen and cortisone on immune hemoantibodies in mice of inbred strains. J Immunol 74:479-483, 1955 20. Thompson JS, Crawford MK, Reilly RW, et al: Effect of estrogenic hormones on immune responses in normal and irradiated mice. J lmmunol 98:331-335, 1967 21. Reilly RW, Thompson JS, Bielski RK, et al: Estradiol induced wasting syndrome i n neonatal mice. J lmmunol 98:321-330, 1967 22. Ablin RJ, Bruns G R , Guinan P, et al: The effect of estrogen on the incorporation of SH-thymidine by PHA stimulated human peripheral blood lymphocytes. J Immunol 1 1 31705-707, 1974 23. Schiff RI, Mercier D, Buckley R: Inability of gestational hormones to account for the inhibitory effects of pregnancy plasmas on lymphocyte responses in oitro. Cell Immunol 2069-80, 1975 24. Vallotten MB, Forbes AP: Autoimmunity in gonodal dysgenesis and Klinefelter’s syndrome. Lancet 1 :648-65 I , 1967 25. Williams ED, Engel E, Forbes AP: Thyroiditis and gonadal dysgenesis. N Engl J Med 270805-810, 1964 26. Nielsen J: Immunologic aberrations in patients with aneuploid chromosomal abnormalities and their parents. Humangenetik 16: 171- 176, 1972 27. Fialkow PJ: Autoimmunity: a predisposing factor to chromosomal aberrations. Lancet 1:474-475, 1964 28. Cram DL, Epstein JH, Tuffanelli DL: Lupus erythematosus and porphyria. Arch Dermatol 108:779-784, 1973
