0022-5347/91/1451-003iSC2 OO/O
Vo!. 145, 37-39, January 1991 Prznted in C.S.A.
T H EJ O U R N A L O F UROLOGY Copyright 0 1991 by AMERICAN UROLOGICAL ASSOCIATION, INC
TAMM-HORSFAEL AUTOANTIBODIES IN INTERSTITIAL CYSTITIS DURWOOD E. NEAL, J R , , 9. PATRICK DILWORTM
AND
M. BERNICE KAACK
From the Department of Urology, Delta Regional Primate Research Center, Couington, and Tulane University School of Medicine, New Orleans, Louisiana
ABSTRACT
Interstitial cystitis presents a diagnostic and therapeutic challenge. Although many etiologies, including autoimmunity, have been proposed its pathogenesis remains obscure. Tamm-Horsfall protein has been identified in the superficial urothelium of patients with interstitial cystitis demonstrating abnormal urothelial permeability. Eight patients with a clinical diagnosis of interstitial cystitis underwent cystoscopy and bladder biopsy. Characteristic cystoscopic findings were present, and each patient had chronic inflammation and mast cells by histopathological analysis. Preoperative anti-Tamm-Horsfall protein serum antibody (IgG) titers were determined by enzymelinked immunosorbent assay (range 500 to 8,000, mean 2,750). A control group of 8 patients with a negative urological history also had titers of 0 to 500 (p = 0.02). The humoral response to TammHorsfall protein in these patients suggests a role for Tamm-Horsfall protein in interstitial cystitis. Measurement of serum Tamm-Horsfall protein antibody may prove to be useful as a noninvasive diagnostic test in patients with this disease. KEYWORDS:bladder, cystitis, autoantibodies
Interstitial cystitis is a chronic inflammatory condition of the bladder that is difficult to diagnose and manage therapeutically. It was originally described by Hunner' but was alluded to in references dating to 1878.' There is disagreement in the urological community as to the criteria necessary to make the diagnosis. The National Institute of Arthritis, Diabetes, Digestive and Kidney Diseases Interstitial Cystitis Workshop on November 22,1988 at Bethesda, Maryland approved symptom guidelines for inclusion of patients in research on interstitial cystitis: pain associated with the bladder and/or urinary urgency. In addition cystoscopic findings must include the presence of diffuse glomerulations after distension of the bladder or the presence of a classical Hunner ulcer. The urinalysis is variable but the urine culture is ~ t e r i l e .This ~ . ~ includes culture for fastidious organisms, mycobacteria, chlamydia and vir ~ s e s .The ~ . ~differential diagnosis also includes carcinoma in sit^,^,^ ~ r e t h r i t i sendometriosis ,~ and bladder instability.'' In the past there has been a variety of theories regarding the etiology of this disease process but none has consistently proved valid. Among the possible causes is an autoimmune Process, which was first suggested in 1970 by Oravisto et al, who found that 85% of the patients with interstitial cystitis had antinuclear antibodies and that many of them had other manifestations of hypersensitivity.'' Silk discovered that 9 of 20 patients with interstitial cystitis had demonstrable bladder autoantibodies, with none being detected in control^.'^ Gordon et a1 showed similar findings in 1973 in a few patients with autoimmune disorders in addition to interstitial cystitis.13 Tamm-Horsfall protein is a g l ~ c o ~ r o t ethat i n is secreted by the ascending loop of Henle.14 It also has been called uromodulin and it is strongly immunosuppressive by inhibiting mitogen-induced or antigen-induced lymphocyte proliferation.15 It is believed that the carbohydrate moiety competes for binding at the carbohydrate receptor on lymphocytes. This protein also is a major component of matrix, in which free cells become entrapped, forming tubular casts.16 Antibody formation to Tamm-Horsfall protein has been found in a variety of disease states, particularly upper urinary tract infection (pyelonephritis), vesicoureteral reflux and other nonrenal causes of fever.17 The antibody titer, however, decreases to background levels Accepted for publication July 27, 1990. American Urological Association, Dallas, ~~~d at annual meeting Texas, May 7-11, 1989. 37
upon resolution of the infection or fever. Considering the immunosuppressive qualities of Tamm-Horsfall protein as well as the possible link between interstitial cystitis and autoimmune disease, there is a possible correlation between TammHorsfall protein and interstitial cystitis. MATERIALS AND METHODS
patients, ~ i ~patients h t with a clinical diagnosis of interstitial cystitis were studied. All patients had symptoms for more than year, and had the symptom complex of frequency, urgency, dysuria, nocturia and pelvic pain. urine culture showed no bacteria, and urinary cytology studies and for acid-fast bacilli were negative in all cases. N~ antibiotics had been administered for at least weeks before the study. serum for antibodies to Tarnm-Horsfall protein was drawn before cystoscopy and biopsies. ~ 1 patients 1 were female and average age was 44.4 years. Four patients had undergone previous intravesical therapy with either silver nitrate or dirnethylsulfoxide. Cystoscopy with the patient under general anesthesia was done in all cases. Hydrodistension was performed to a pressure of 70 cm. water and the bladder was emptied. The bladder then was evaluated for changes of interstitial cystitis. Petechial hemorrhages and submucosal glomerulations were seen throughout the bladder in each patient, with frank bleeding. Biopsies were taken at random throughout the bladder. ~t least 4 specimens were obtained from each patient using flexible biopsy forceps. Control serum samples were taken from 8 asymptomatic volunteers who had no urological history. There were 6 women and 2 men, with an average age of 46.3 years. p,,ifii,ation of Tamm-Horsfall protein. Tamm-Horsfall protein was purified from human urine by the method of Van Dijk et a1.18Briefly, the urine was initially filtered through Whatman No. 4 paper and salted out with solid sodium chloride to a concentration of 1.0 M. After overnight stirring a t 4C the precipitate was collected by centrifugation at 15,000 revolutions per minute and the supernatant was discarded. The precipitate was dialyzed against several changes of distilled water and lyophilized. The lyophilized material was dissolved in 0.01 M. phosphate buffer (pH 7.0) containing 4 M. urea and placed on a Sepharose 4B column (90 x 2.5 cm.). The sample was eluted with the same buffer and collected in 2 ml. fractions. Fractions 40 to 85 were pooled, dialyzed against distilled water and
38
NEAL, DILWORTH AND KAACK
lyophilized. The purity of the Tamm-Horsfall protein was determined by obtaining a single band near the 97.4 kdal. band in polyacrylamide gel electrophoresis. Enzyme-linked immunosorbent assay. Microtiter plates were coated with 50 p1. Tamm-Horsfall protein (50 pg./ml.) and incubated overnight a t 4C. The plates were then washed 4 times with phosphate buffered saline with 0.5% Tween 20. The first dilution was a t 1:100 followed by 1:500, and then serial dilutions of serum (1:1,000, 1:2,000, 1:4,000 and so forth) were added to the plates and they were incubated for 3 hours a t 376. Each plate contained at least 4 control wells to which phosphate buffered saline was added instead of serum. Four washes with phosphate buffered saline and 0.5% Tween 20 were repeated. Rabbit anti-human IgG (50 pl.) conjugated with peroxidase in a 1:1,000 dilution was added. This mixture was incubated for 45 minutes a t 37C. After another 4 washes 100 pl. O-phenylenediamine in acetate buffer (pH 5.0) were added. The plates were incubated for 15 minutes a t 37C, a t which time the reaction was stopped with 50 p1. 2.5 N. hydrochloric acid. The optical density was read in an enzyme immunoabsorbent assay densitometer a t a wavelength of 490 nm. The titer was considered to be the dilution of the well with an optical density of 1.5X the average control value. Each specimen was done in triplicate to obtain a mean antibody titer. Control sera were used with each assay on the day it was performed.
tal bladder infection and this also might be a source of TammHorsfall protein autoantibodies. In the absence of a glycosaminoglycan layer (or the presence of a defective one) TammHorsfall protein could be a source of continued antigenic stimulation of the immune system. In this scenario, then, measurement of Tamm-Horsfall protein autoantibodies would be a simple test to screen patients for interstitial cystitis. However, since there are other causes for the presence of serum TammHorsfall protein antibodies, as noted previously, the test would remain nonspecific. We believe that the diagnosis of interstitial cystitis in patients with classical symptoms could be made with more specificity if antibodies to Tamm-Horsfall protein are found. protein could Another possibility is that the be bound to its specific antibody in the urine and, thus, lose its immune modulating effects as uromodulin. This would allow other substances in urine to act as antigens to induce an autoimmune or local inflammatory reaction in the bladder, producing the signs and symptoms of interstitial cystitis. A large percentage of these patients have a positive skin test (patch test) to urine, making this theory plausible as well." The final possibility is that interstitial cystitis is a primary autoimmune disease, with the immune system reacting to Tamm-Horsfall protein as the antigen and the bladder serving as a nonspecific target organ. If true, this would explain all of the findings of autoimmune disease in these patients. Skin RESULTS reactions to urine also would be expected if Tamm-Horsfall At cystoscopy no patient had evidence of Hunner's ulcer. protein is the antigenic stimulus. Urinary diversion relieves the symptoms of the disease, probThe mean bladder capacity was 425 cc, with a range of 270 to 500 cc. Biopsies showed a chronic inflammatory cell infiltrate ably because the target organ is isolated from the antigenin all patients, with varying degrees of mastocytosis but the antibody reaction. Recurrent disease is noted in patients who have undergone bladder augmentationz3 and this has been exact numbers of mast cells were not quantitated. Autoantibody levels (IgG) are listed in the table for intersti- shown to occur in the bowel that is adjacent to the remaining tial cystitis patients a n d controls. Three separate enzyme- bladder. It is not surprising, then, that the symptoms resolve linked immunosorbent assay determinations were made from with supravesical urinary diversion, even when the bladder is each sample and the mean was used for calculation. In all cases left in situ. Clearly, further study is necessary to determine the role of the 3 samples for each patient differed a t most by only 1 dilution. The means and standard deviations for patients and Tamm-Horsfall protein in interstitial cystitis. If it truly is the controls were 2,750 f 3,273 and 163 213 (p = 0.0203, t test). etiological agent in an autoimmune process therapy might be Six patients had levels greater than 2 standard deviations above radically changed. In any case, the antibody is a disease marker that could be used to screen and follow patients. If the test the control mean. There was little correlation with the levels of Tamm-Horsfall could be adapted for easy laboratory access or for the office it protein autoantibodies and the symptoms except that in the 2 would facilitate establishment of the diagnosis and, ultimately, patients with low titers the symptoms remained mild over-all. therapy. The patients were not available for followup titers.
~amm- or sf all
+
REFERENCES DISCUSSION
At least 3 possibilities exist for the finding of Tamm-Horsfall autoantibodies in our small subset of patients with rather severe interstitial cystitis. One possibility is that the lamina propria and potentially deeper tissues might be exposed to urinary Tamm-Horsfall protein because of a defective glycosaminoglycan layer in the bladder. An abnormality in this mucosal barrier has been reported in interstitial cystitis and a number of investigators have postulated this to be the cause of the disaccount for the results of Fowler et al, who e a ~ e . ' This ~ , ~ could ~ found Tamm-Horsfall protein deposits in the lamina propria of the bladder of patients with interstitial cystitis as The bladder is capable of immunoglobulin production in experimenAntibody levels in 8 patients and 8 controls Patients
Controls
1. Hunner, G. L.: A rare type of bladder ulcer in women; report of cases. Boston Med. Surg. J., 172: 660, 1915. 2. Skene, A. J. C.: Diseases of Bladder and Urethra in Women. New York: William Wood & Co., p. 167, 1878. 3. Oravisto, K. J.: Epidemiology of interstitial cystitis. Ann. Chir. Gynaec. Fenn., 64: 75, 1975. 4. Messing, E. M. and Stamey, T . A.: Interstitial cystitis: early diagnosis, pathology, and treatment. Urology, 12: 381, 1978. 5. Hanash, K. A. and Pool, T . L.: Interstitial and hemorrhagic cystitis: viral, bacterial and fungal studies. J. Urol., 104: 705, 1970. 6. Hedelin, H. H., Mbrdh, P.-A,, Brorson, J. E., Fall, M., Mdler, B. R. and Pettersson, K. G.: Mycoplasma hominis and interstitial cystitis. Sex. Transm. Dis., 10: 327, 1983. 7. Lamm, D. L. and Gittes, R. F.: Inflammatory carcinoma of the bladder and interstitial cystitis. J . Urol., 117: 49, 1977. 8. Utz, D. C. and Zincke, H.: The masquerade of bladder cancer in situ as interstitial cystitis. J. Urol., 111: 160, 1974. 9. Schmidt, R. A,: The urethral syndrome. Urol. Clin. N. Amer., 12: 349,1985. 10. Perez-Marrero, R., Emerson, L. and Juma, S.: Urodynamic studies in interstitial cystitis. Urology, suppl. 4, 29: 27, 1987. 11. Oravisto, K. J., Alfthan, 0. S. and Jokinen, E. J.: Interstitial cystitis-clinical and immunological findings. Scand. J. Urol. Nephrol., 4: 37, 1970. 12. Silk, M. R.: Bladder antibodies in interstitial cystitis. J. Urol., 103: 307. 1970.
TAMM-HORSPALL AUTOANTIBODIES IN INTERSTITIAL CYSTITIS 13. Gordon, H . L., Rossen, R. D., Hersh, E. M. and Yium, J . J.: Immunoloaic of interstitial cystitis. J . Urol., 109: 228, - aspects 1973. 14. Fletcher, A. P., Neuberger, A. and Ratcliffe, W. A.: Tamm-Horsfall urinary glycoprotein. The chemical composition. Biochem. J., 120: 417,1970. 15. Pennica. D.. Kohr. W. J.. Kuane. W. J.. Glaister. D.. Aaaarwal, B B., Chen, E. Y. and ~ o e d d e i ,D. V.: 1dentificatlonUofhuman uromodulin as the Tamm-Horsfall urinary glycoprotein. Science, 236: 83, 1987. 16. Abrass, C. K. and Laird, C. W.: Tamm-Horsfall protein coating of free cells in urine. Amer. J . Kidney Dis., 9: 44, 1987. 17. Sandberg, T . and Fasth, A,: Association between fever and the antibody response to Tamm-Horsfall protein in urinary tract infection. Scand. J . Urol. Nephrol., 21: 297, 1987. 18. Van Dijk, W., Lasthuis, A. and Ferwerda, W.: Preparation and
19. 20. 21. 22. 23.
39
chemical characterisation of calf Tamm-Horsfall glycoprotein. Biochim. Biophys. Acta, 584: 121, 1979. Hurst, R. E., Roy, J . B., Bynum, R. L. and Parry, W. L.: Abnormal glycosaminoglycans excretion in patients with chronic interstitial cystitis. J . Urol., part 2, 133: 144A, abstract 124, 1985. Sant, 6. R., Ucci, A. A,, Jr. and Alroy, J.: Bladder surface glycosaminoglycans (GAGS) in interstitial cystitis. J . Urol., part 2, 135: 175A, abstract 287, 1986. Fowler, J . E., Jr., Lynes, W. L., Lau, J . L. T., Ghosh, L. and Mounzer, A,: Interstitial cystitis is associated with intraurothelial Tamm-Horsfall protein. J. Urol., 140: 1385, 1988. Clemmensen, 0 . J., Lose, G., Holm-Bentzen, M. and Colstrup, H.: Skin reactions to urine in patients with interstitial cystitis. Urology, 32: 17, 1988. McGuire, E. J., Lytton, B. and Cornog, J. L., Jr.: Interstitial cystitis following colocystoplasty. Urology, 2: 28, 1973.
Vo!. 145, 37-39, January 1991 Prznted in C.S.A.
T H EJ O U R N A L O F UROLOGY Copyright 0 1991 by AMERICAN UROLOGICAL ASSOCIATION, INC
TAMM-HORSFAEL AUTOANTIBODIES IN INTERSTITIAL CYSTITIS DURWOOD E. NEAL, J R , , 9. PATRICK DILWORTM
AND
M. BERNICE KAACK
From the Department of Urology, Delta Regional Primate Research Center, Couington, and Tulane University School of Medicine, New Orleans, Louisiana
ABSTRACT
Interstitial cystitis presents a diagnostic and therapeutic challenge. Although many etiologies, including autoimmunity, have been proposed its pathogenesis remains obscure. Tamm-Horsfall protein has been identified in the superficial urothelium of patients with interstitial cystitis demonstrating abnormal urothelial permeability. Eight patients with a clinical diagnosis of interstitial cystitis underwent cystoscopy and bladder biopsy. Characteristic cystoscopic findings were present, and each patient had chronic inflammation and mast cells by histopathological analysis. Preoperative anti-Tamm-Horsfall protein serum antibody (IgG) titers were determined by enzymelinked immunosorbent assay (range 500 to 8,000, mean 2,750). A control group of 8 patients with a negative urological history also had titers of 0 to 500 (p = 0.02). The humoral response to TammHorsfall protein in these patients suggests a role for Tamm-Horsfall protein in interstitial cystitis. Measurement of serum Tamm-Horsfall protein antibody may prove to be useful as a noninvasive diagnostic test in patients with this disease. KEYWORDS:bladder, cystitis, autoantibodies
Interstitial cystitis is a chronic inflammatory condition of the bladder that is difficult to diagnose and manage therapeutically. It was originally described by Hunner' but was alluded to in references dating to 1878.' There is disagreement in the urological community as to the criteria necessary to make the diagnosis. The National Institute of Arthritis, Diabetes, Digestive and Kidney Diseases Interstitial Cystitis Workshop on November 22,1988 at Bethesda, Maryland approved symptom guidelines for inclusion of patients in research on interstitial cystitis: pain associated with the bladder and/or urinary urgency. In addition cystoscopic findings must include the presence of diffuse glomerulations after distension of the bladder or the presence of a classical Hunner ulcer. The urinalysis is variable but the urine culture is ~ t e r i l e .This ~ . ~ includes culture for fastidious organisms, mycobacteria, chlamydia and vir ~ s e s .The ~ . ~differential diagnosis also includes carcinoma in sit^,^,^ ~ r e t h r i t i sendometriosis ,~ and bladder instability.'' In the past there has been a variety of theories regarding the etiology of this disease process but none has consistently proved valid. Among the possible causes is an autoimmune Process, which was first suggested in 1970 by Oravisto et al, who found that 85% of the patients with interstitial cystitis had antinuclear antibodies and that many of them had other manifestations of hypersensitivity.'' Silk discovered that 9 of 20 patients with interstitial cystitis had demonstrable bladder autoantibodies, with none being detected in control^.'^ Gordon et a1 showed similar findings in 1973 in a few patients with autoimmune disorders in addition to interstitial cystitis.13 Tamm-Horsfall protein is a g l ~ c o ~ r o t ethat i n is secreted by the ascending loop of Henle.14 It also has been called uromodulin and it is strongly immunosuppressive by inhibiting mitogen-induced or antigen-induced lymphocyte proliferation.15 It is believed that the carbohydrate moiety competes for binding at the carbohydrate receptor on lymphocytes. This protein also is a major component of matrix, in which free cells become entrapped, forming tubular casts.16 Antibody formation to Tamm-Horsfall protein has been found in a variety of disease states, particularly upper urinary tract infection (pyelonephritis), vesicoureteral reflux and other nonrenal causes of fever.17 The antibody titer, however, decreases to background levels Accepted for publication July 27, 1990. American Urological Association, Dallas, ~~~d at annual meeting Texas, May 7-11, 1989. 37
upon resolution of the infection or fever. Considering the immunosuppressive qualities of Tamm-Horsfall protein as well as the possible link between interstitial cystitis and autoimmune disease, there is a possible correlation between TammHorsfall protein and interstitial cystitis. MATERIALS AND METHODS
patients, ~ i ~patients h t with a clinical diagnosis of interstitial cystitis were studied. All patients had symptoms for more than year, and had the symptom complex of frequency, urgency, dysuria, nocturia and pelvic pain. urine culture showed no bacteria, and urinary cytology studies and for acid-fast bacilli were negative in all cases. N~ antibiotics had been administered for at least weeks before the study. serum for antibodies to Tarnm-Horsfall protein was drawn before cystoscopy and biopsies. ~ 1 patients 1 were female and average age was 44.4 years. Four patients had undergone previous intravesical therapy with either silver nitrate or dirnethylsulfoxide. Cystoscopy with the patient under general anesthesia was done in all cases. Hydrodistension was performed to a pressure of 70 cm. water and the bladder was emptied. The bladder then was evaluated for changes of interstitial cystitis. Petechial hemorrhages and submucosal glomerulations were seen throughout the bladder in each patient, with frank bleeding. Biopsies were taken at random throughout the bladder. ~t least 4 specimens were obtained from each patient using flexible biopsy forceps. Control serum samples were taken from 8 asymptomatic volunteers who had no urological history. There were 6 women and 2 men, with an average age of 46.3 years. p,,ifii,ation of Tamm-Horsfall protein. Tamm-Horsfall protein was purified from human urine by the method of Van Dijk et a1.18Briefly, the urine was initially filtered through Whatman No. 4 paper and salted out with solid sodium chloride to a concentration of 1.0 M. After overnight stirring a t 4C the precipitate was collected by centrifugation at 15,000 revolutions per minute and the supernatant was discarded. The precipitate was dialyzed against several changes of distilled water and lyophilized. The lyophilized material was dissolved in 0.01 M. phosphate buffer (pH 7.0) containing 4 M. urea and placed on a Sepharose 4B column (90 x 2.5 cm.). The sample was eluted with the same buffer and collected in 2 ml. fractions. Fractions 40 to 85 were pooled, dialyzed against distilled water and
38
NEAL, DILWORTH AND KAACK
lyophilized. The purity of the Tamm-Horsfall protein was determined by obtaining a single band near the 97.4 kdal. band in polyacrylamide gel electrophoresis. Enzyme-linked immunosorbent assay. Microtiter plates were coated with 50 p1. Tamm-Horsfall protein (50 pg./ml.) and incubated overnight a t 4C. The plates were then washed 4 times with phosphate buffered saline with 0.5% Tween 20. The first dilution was a t 1:100 followed by 1:500, and then serial dilutions of serum (1:1,000, 1:2,000, 1:4,000 and so forth) were added to the plates and they were incubated for 3 hours a t 376. Each plate contained at least 4 control wells to which phosphate buffered saline was added instead of serum. Four washes with phosphate buffered saline and 0.5% Tween 20 were repeated. Rabbit anti-human IgG (50 pl.) conjugated with peroxidase in a 1:1,000 dilution was added. This mixture was incubated for 45 minutes a t 37C. After another 4 washes 100 pl. O-phenylenediamine in acetate buffer (pH 5.0) were added. The plates were incubated for 15 minutes a t 37C, a t which time the reaction was stopped with 50 p1. 2.5 N. hydrochloric acid. The optical density was read in an enzyme immunoabsorbent assay densitometer a t a wavelength of 490 nm. The titer was considered to be the dilution of the well with an optical density of 1.5X the average control value. Each specimen was done in triplicate to obtain a mean antibody titer. Control sera were used with each assay on the day it was performed.
tal bladder infection and this also might be a source of TammHorsfall protein autoantibodies. In the absence of a glycosaminoglycan layer (or the presence of a defective one) TammHorsfall protein could be a source of continued antigenic stimulation of the immune system. In this scenario, then, measurement of Tamm-Horsfall protein autoantibodies would be a simple test to screen patients for interstitial cystitis. However, since there are other causes for the presence of serum TammHorsfall protein antibodies, as noted previously, the test would remain nonspecific. We believe that the diagnosis of interstitial cystitis in patients with classical symptoms could be made with more specificity if antibodies to Tamm-Horsfall protein are found. protein could Another possibility is that the be bound to its specific antibody in the urine and, thus, lose its immune modulating effects as uromodulin. This would allow other substances in urine to act as antigens to induce an autoimmune or local inflammatory reaction in the bladder, producing the signs and symptoms of interstitial cystitis. A large percentage of these patients have a positive skin test (patch test) to urine, making this theory plausible as well." The final possibility is that interstitial cystitis is a primary autoimmune disease, with the immune system reacting to Tamm-Horsfall protein as the antigen and the bladder serving as a nonspecific target organ. If true, this would explain all of the findings of autoimmune disease in these patients. Skin RESULTS reactions to urine also would be expected if Tamm-Horsfall At cystoscopy no patient had evidence of Hunner's ulcer. protein is the antigenic stimulus. Urinary diversion relieves the symptoms of the disease, probThe mean bladder capacity was 425 cc, with a range of 270 to 500 cc. Biopsies showed a chronic inflammatory cell infiltrate ably because the target organ is isolated from the antigenin all patients, with varying degrees of mastocytosis but the antibody reaction. Recurrent disease is noted in patients who have undergone bladder augmentationz3 and this has been exact numbers of mast cells were not quantitated. Autoantibody levels (IgG) are listed in the table for intersti- shown to occur in the bowel that is adjacent to the remaining tial cystitis patients a n d controls. Three separate enzyme- bladder. It is not surprising, then, that the symptoms resolve linked immunosorbent assay determinations were made from with supravesical urinary diversion, even when the bladder is each sample and the mean was used for calculation. In all cases left in situ. Clearly, further study is necessary to determine the role of the 3 samples for each patient differed a t most by only 1 dilution. The means and standard deviations for patients and Tamm-Horsfall protein in interstitial cystitis. If it truly is the controls were 2,750 f 3,273 and 163 213 (p = 0.0203, t test). etiological agent in an autoimmune process therapy might be Six patients had levels greater than 2 standard deviations above radically changed. In any case, the antibody is a disease marker that could be used to screen and follow patients. If the test the control mean. There was little correlation with the levels of Tamm-Horsfall could be adapted for easy laboratory access or for the office it protein autoantibodies and the symptoms except that in the 2 would facilitate establishment of the diagnosis and, ultimately, patients with low titers the symptoms remained mild over-all. therapy. The patients were not available for followup titers.
~amm- or sf all
+
REFERENCES DISCUSSION
At least 3 possibilities exist for the finding of Tamm-Horsfall autoantibodies in our small subset of patients with rather severe interstitial cystitis. One possibility is that the lamina propria and potentially deeper tissues might be exposed to urinary Tamm-Horsfall protein because of a defective glycosaminoglycan layer in the bladder. An abnormality in this mucosal barrier has been reported in interstitial cystitis and a number of investigators have postulated this to be the cause of the disaccount for the results of Fowler et al, who e a ~ e . ' This ~ , ~ could ~ found Tamm-Horsfall protein deposits in the lamina propria of the bladder of patients with interstitial cystitis as The bladder is capable of immunoglobulin production in experimenAntibody levels in 8 patients and 8 controls Patients
Controls
1. Hunner, G. L.: A rare type of bladder ulcer in women; report of cases. Boston Med. Surg. J., 172: 660, 1915. 2. Skene, A. J. C.: Diseases of Bladder and Urethra in Women. New York: William Wood & Co., p. 167, 1878. 3. Oravisto, K. J.: Epidemiology of interstitial cystitis. Ann. Chir. Gynaec. Fenn., 64: 75, 1975. 4. Messing, E. M. and Stamey, T . A.: Interstitial cystitis: early diagnosis, pathology, and treatment. Urology, 12: 381, 1978. 5. Hanash, K. A. and Pool, T . L.: Interstitial and hemorrhagic cystitis: viral, bacterial and fungal studies. J. Urol., 104: 705, 1970. 6. Hedelin, H. H., Mbrdh, P.-A,, Brorson, J. E., Fall, M., Mdler, B. R. and Pettersson, K. G.: Mycoplasma hominis and interstitial cystitis. Sex. Transm. Dis., 10: 327, 1983. 7. Lamm, D. L. and Gittes, R. F.: Inflammatory carcinoma of the bladder and interstitial cystitis. J . Urol., 117: 49, 1977. 8. Utz, D. C. and Zincke, H.: The masquerade of bladder cancer in situ as interstitial cystitis. J. Urol., 111: 160, 1974. 9. Schmidt, R. A,: The urethral syndrome. Urol. Clin. N. Amer., 12: 349,1985. 10. Perez-Marrero, R., Emerson, L. and Juma, S.: Urodynamic studies in interstitial cystitis. Urology, suppl. 4, 29: 27, 1987. 11. Oravisto, K. J., Alfthan, 0. S. and Jokinen, E. J.: Interstitial cystitis-clinical and immunological findings. Scand. J. Urol. Nephrol., 4: 37, 1970. 12. Silk, M. R.: Bladder antibodies in interstitial cystitis. J. Urol., 103: 307. 1970.
TAMM-HORSPALL AUTOANTIBODIES IN INTERSTITIAL CYSTITIS 13. Gordon, H . L., Rossen, R. D., Hersh, E. M. and Yium, J . J.: Immunoloaic of interstitial cystitis. J . Urol., 109: 228, - aspects 1973. 14. Fletcher, A. P., Neuberger, A. and Ratcliffe, W. A.: Tamm-Horsfall urinary glycoprotein. The chemical composition. Biochem. J., 120: 417,1970. 15. Pennica. D.. Kohr. W. J.. Kuane. W. J.. Glaister. D.. Aaaarwal, B B., Chen, E. Y. and ~ o e d d e i ,D. V.: 1dentificatlonUofhuman uromodulin as the Tamm-Horsfall urinary glycoprotein. Science, 236: 83, 1987. 16. Abrass, C. K. and Laird, C. W.: Tamm-Horsfall protein coating of free cells in urine. Amer. J . Kidney Dis., 9: 44, 1987. 17. Sandberg, T . and Fasth, A,: Association between fever and the antibody response to Tamm-Horsfall protein in urinary tract infection. Scand. J . Urol. Nephrol., 21: 297, 1987. 18. Van Dijk, W., Lasthuis, A. and Ferwerda, W.: Preparation and
19. 20. 21. 22. 23.
39
chemical characterisation of calf Tamm-Horsfall glycoprotein. Biochim. Biophys. Acta, 584: 121, 1979. Hurst, R. E., Roy, J . B., Bynum, R. L. and Parry, W. L.: Abnormal glycosaminoglycans excretion in patients with chronic interstitial cystitis. J . Urol., part 2, 133: 144A, abstract 124, 1985. Sant, 6. R., Ucci, A. A,, Jr. and Alroy, J.: Bladder surface glycosaminoglycans (GAGS) in interstitial cystitis. J . Urol., part 2, 135: 175A, abstract 287, 1986. Fowler, J . E., Jr., Lynes, W. L., Lau, J . L. T., Ghosh, L. and Mounzer, A,: Interstitial cystitis is associated with intraurothelial Tamm-Horsfall protein. J. Urol., 140: 1385, 1988. Clemmensen, 0 . J., Lose, G., Holm-Bentzen, M. and Colstrup, H.: Skin reactions to urine in patients with interstitial cystitis. Urology, 32: 17, 1988. McGuire, E. J., Lytton, B. and Cornog, J. L., Jr.: Interstitial cystitis following colocystoplasty. Urology, 2: 28, 1973.
