Letters to Editor Address for correspondence: Dr. Apostolos Zarros, Box 318, 111 West George str., G2-1QX, Glasgow, Scotland, United Kingdom. E-mail: [email protected]
REFERENCES 1. 2. 3.
4.
5.
Abbott A. Greek crisis spurs research reforms. Nature 2011;475:13-4. Malone J. Greek science: Hope in crisis. Lancet 2012;380:326-7. Botis J, Chatzigeorgiou A, Chatzilymperis G, Kalafatakis K, Katsouni E, Mylonas N, et al. Inform, conform, reform and do not deform: A four axons’ framework for the Hellenic academic institutions facing the Greek crisis challenge. J Nat Sci Biol Med 2013;4:268-9. Patricio M, de Burbure C, Costa MJ, Schirlo C, ten Cate O. Bologna in Medicine Anno 2012: Experiences of European medical schools that implemented a Bologna two-cycle curriculum - an AMEE-MEDINE2 survey. Med Teach 2012;34:821-32. Epstein RM. Assessment in medical education. N Engl J Med 2007;356:387-96.
Access this article online Quick Response Code:
Website: www.jnsbm.org
DOI: 10.4103/0976-9668.149246
Tissue antinuclear antibodies in renal biopsies of patients with systemic connective tissue disorders Sir, Although localization of immunoglobulins (Igs) has been observed in nuclei of nonkeratotic cells in skin biopsies from patients with systemic lupus erythematosus (SLE), reports of nuclear Ig localization or tissue antinuclear antibodies (ANA) or in vivo ANA (i.e., in vivo binding of autoantibodies to the cell nucleus) as examined by direct immunofluorescence microscopy (DIFM) in kidney are almost nonexistent from Indian subcontinent. The present retrospective study describes nuclear localization of Igs in renal biopsies from 19 patients with systemic connective tissue disorders, studied by DIFM at our department from 1998 to December 2006. 279
DIFM of renal biopsies from 19 patients i.e., only 0.6% of the total renal biopsies submitted over a period of 9 years revealed in vivo nuclear localization of immunoreactants. These 19 patients included clinically diagnosed 15 cases of SLE and one case of polymyositis, dermatomyositis, scleroderma and mixed connective tissue disorder each. In vivo ANA was observed in nuclei of glomerular visceral and parietal epithelium, tubular epithelium, and interstitial cells. The extent of localization varied, with very few nuclei fluorescing in one case to >60% nuclei in other case [Figure 1]. Speckled (12 biopsies) or diffuse (seven biopsies) patterns of nuclear localization were observed in these biopsies as shown in Table 1. ANA in vivo was found to be positive with IgG as the most common immunoreactant (18 cases) with evidence of complement activation (C3 positivity) in one case. Serum samples from each of these patients, obtained concurrently with the biopsy, were also evaluated for the presence of ANAs by indirect immunofluorescence using Hep2 cell lines. Twelve out of 19 cases showed morphological similar pattern of ANA in vivo in kidney biopsies as well as in serum ANA on Hep 2 cell lines i.e., speckled pattern in seven and diffuse pattern in five cases [Table 1]. In remaining seven cases the pattern of nuclear localization in the kidney, was not the same as that observed for ANA using the patient’s serum. Twelve out of 15 kidney biopsies from SLE patients showed lesion of lupus nephritis class-IV with some degree of tubular destruction and mild to moderate interstitial inflammation. Most studies in which DIFM have been used to evaluate immune complex lesions in renal biopsies from patients with lupus nephritis have not described nuclear localization of Igs in the kidney. In vivo nuclear deposition of Igs is a true reaction in vivo between
Figure 1: Direct immunofluorescence photomicrograph of kidney biopsy from a patient of systemic lupus erythematosus showing diffuse antinuclear antibodies (ANA) pattern in cell nuclei (ANA in vivo) (arrows) and lupus class IV lesions (*) (×400)
Journal of Natural Science, Biology and Medicine | January 2015 | Vol 6 | Issue 1
Letters to Editor
Table 1: Details of the patients showing in vivo ANA in renal biopsies with serum ANA test results Case no.
Age/sex
1 2 3 4 5
25/female 43/female 9/female 18/female 30/male
6
37/male
7 8 9
20/female 52/female 35/female
10
60/female
11 12 13 14 15 16 17 18 19
10/female 50/female 16/female 12/male 40/male 32/female 25/female 38/female 40/female
Clinical diagnosis (according to ACR criteria)
Class of positive immunoreactant Renal biopsy diagnosis and morphologic pattern of nuclear (light + direct immuno-fluorescence localization microscopy) IgG IgA IgM C3
SLE SLE SLE SLE Polymyositis
Lupus nephritis class-IV Lupus nephritis class-IV Lupus nephritis class-IV Lupus nephritis class-IV Membranous glomerulopathy Dermatomyositis Immune complex crescentic glomeulonephritis SLE Lupus nephritis class-IV SLE Lupus nephritis class-IV Scleroderma Immune complex with RPRF crescentic glomerulonephritis MCTDwith RPRF Immune complex crescentic glomerulonephritis SLE Lupus nephritis class-II SLE Lupus nephritis class-II SLE Lupus nephritis class-IV SLE Lupus nephritis class-IV SLE Lupus nephritis class-IV SLE Lupus nephritis class-III SLE Lupus nephritis class-IV SLE Lupus nephritis class-IV SLE Lupus nephritis class-IV
Serum ANA results
Speckled pattern on Hep 2
Diffuse pattern on Hep 2
4+speckled 4+speckled 4+speckled 3+diffuse 4+diffuse
— — — — —
— — — — —
— — — — —
— 3+ — — 2+
4+ — 1+ 1+ —
2+speckled
—
—
—
2+
—
3+diffuse 3+diffuse 3+speckled
— — 3+speckled
— — —
— — —
4+ — 2+
— 2+ —
—
—
—
3+speckled
2+
—
4+speckled 2+speckled 3+speckled 4+diffuse 3+speckled 4+diffuse 2+speckled 2+speckled 4+diffuse
— — — — — — — — —
— — — — — — — — —
— — — — — — — — —
1+ — — — —
— 2+ 3+ 4+ 2+ 2+ — — 4+
2+ 3+ —
ACR: American college of rheumatology, Ig: Immunoglobulin, ANA: Antinuclear antibodies, RPRF: Rapidly progressive renal failure, SLE: Systemic lupus erythematosus, MCTD: Mixed connective tissue disorder
ANAs to certain specificities and cell nuclei or is an artifactual process, is still a matter of debate.[1] Some authors advocate that in patients possessing high titers of ANAs, these might diffuse from the vascular compartment of the biopsy, during sectioning and washing procedures, and localize in nuclei artifactually at the time of processing.[2,3] However, in murine models of SLE it has been demonstrated that ANA can penetrate the intact cells and bind to nuclei in vivo. Whatever the mechanism, the phenomenon of Ig nuclear localization in renal biopsies should be noted. We show that this phenomenon can occur in other ANA positive autoimmune diseases such as polymyositis, dermatomyositis and scleroderma. And also 1/19 cases showed complement deposition, i.e., activation of the complement cascade, triggered by the IgG and nuclear antigen complex formed in vivo. It would be interesting to study this phenomenon prospectively to see if in vivo ANA correlates with SLE disease activity scores.
Department of Immunopathology, PGIMER, Chandigarh, India Address for correspondence: Dr. Ranjana Walker Minz, Department of Immunopathology, PGIMER, Sector-12, Chandigarh, India. E-mail: [email protected]
REFERENCES 1. 2.
3.
McCoy RC. Nuclear localization of immunoglobulins in renal biopsies of patients with lupus nephritis. Am J Pathol 1972;68:469-78. Parone o F, Koffler D. Immunofluorescent localization of immunoglobulins, complement, and fibrinogen in human diseases. I. Systemic lupus erythematosus. J Clin Invest 1965;44:1657-64. Kramers K, van Bruggen MC, Rijke-Schilder TP, Dijkman HB, Hylkema MN, Croes HJ, et al. In vivo ANA is a fixation artifact: Nucleosome-complexed antinucleosome autoantibodies bind to the cell surface and are internalized. J Am Soc Nephrol 1996;7:946-54.
Access this article online Quick Response Code:
Seema Chhabra, Shreekant Bharti, Ranjana Walker Minz, Ranjeet Bhardwaj, Neelam Pasricha Journal of Natural Science, Biology and Medicine | January 2015 | Vol 6 | Issue 1
Website: www.jnsbm.org
DOI: 10.4103/0976-9668.149250
280
Copyright of Journal of Natural Science, Biology & Medicine is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
REFERENCES 1. 2. 3.
4.
5.
Abbott A. Greek crisis spurs research reforms. Nature 2011;475:13-4. Malone J. Greek science: Hope in crisis. Lancet 2012;380:326-7. Botis J, Chatzigeorgiou A, Chatzilymperis G, Kalafatakis K, Katsouni E, Mylonas N, et al. Inform, conform, reform and do not deform: A four axons’ framework for the Hellenic academic institutions facing the Greek crisis challenge. J Nat Sci Biol Med 2013;4:268-9. Patricio M, de Burbure C, Costa MJ, Schirlo C, ten Cate O. Bologna in Medicine Anno 2012: Experiences of European medical schools that implemented a Bologna two-cycle curriculum - an AMEE-MEDINE2 survey. Med Teach 2012;34:821-32. Epstein RM. Assessment in medical education. N Engl J Med 2007;356:387-96.
Access this article online Quick Response Code:
Website: www.jnsbm.org
DOI: 10.4103/0976-9668.149246
Tissue antinuclear antibodies in renal biopsies of patients with systemic connective tissue disorders Sir, Although localization of immunoglobulins (Igs) has been observed in nuclei of nonkeratotic cells in skin biopsies from patients with systemic lupus erythematosus (SLE), reports of nuclear Ig localization or tissue antinuclear antibodies (ANA) or in vivo ANA (i.e., in vivo binding of autoantibodies to the cell nucleus) as examined by direct immunofluorescence microscopy (DIFM) in kidney are almost nonexistent from Indian subcontinent. The present retrospective study describes nuclear localization of Igs in renal biopsies from 19 patients with systemic connective tissue disorders, studied by DIFM at our department from 1998 to December 2006. 279
DIFM of renal biopsies from 19 patients i.e., only 0.6% of the total renal biopsies submitted over a period of 9 years revealed in vivo nuclear localization of immunoreactants. These 19 patients included clinically diagnosed 15 cases of SLE and one case of polymyositis, dermatomyositis, scleroderma and mixed connective tissue disorder each. In vivo ANA was observed in nuclei of glomerular visceral and parietal epithelium, tubular epithelium, and interstitial cells. The extent of localization varied, with very few nuclei fluorescing in one case to >60% nuclei in other case [Figure 1]. Speckled (12 biopsies) or diffuse (seven biopsies) patterns of nuclear localization were observed in these biopsies as shown in Table 1. ANA in vivo was found to be positive with IgG as the most common immunoreactant (18 cases) with evidence of complement activation (C3 positivity) in one case. Serum samples from each of these patients, obtained concurrently with the biopsy, were also evaluated for the presence of ANAs by indirect immunofluorescence using Hep2 cell lines. Twelve out of 19 cases showed morphological similar pattern of ANA in vivo in kidney biopsies as well as in serum ANA on Hep 2 cell lines i.e., speckled pattern in seven and diffuse pattern in five cases [Table 1]. In remaining seven cases the pattern of nuclear localization in the kidney, was not the same as that observed for ANA using the patient’s serum. Twelve out of 15 kidney biopsies from SLE patients showed lesion of lupus nephritis class-IV with some degree of tubular destruction and mild to moderate interstitial inflammation. Most studies in which DIFM have been used to evaluate immune complex lesions in renal biopsies from patients with lupus nephritis have not described nuclear localization of Igs in the kidney. In vivo nuclear deposition of Igs is a true reaction in vivo between
Figure 1: Direct immunofluorescence photomicrograph of kidney biopsy from a patient of systemic lupus erythematosus showing diffuse antinuclear antibodies (ANA) pattern in cell nuclei (ANA in vivo) (arrows) and lupus class IV lesions (*) (×400)
Journal of Natural Science, Biology and Medicine | January 2015 | Vol 6 | Issue 1
Letters to Editor
Table 1: Details of the patients showing in vivo ANA in renal biopsies with serum ANA test results Case no.
Age/sex
1 2 3 4 5
25/female 43/female 9/female 18/female 30/male
6
37/male
7 8 9
20/female 52/female 35/female
10
60/female
11 12 13 14 15 16 17 18 19
10/female 50/female 16/female 12/male 40/male 32/female 25/female 38/female 40/female
Clinical diagnosis (according to ACR criteria)
Class of positive immunoreactant Renal biopsy diagnosis and morphologic pattern of nuclear (light + direct immuno-fluorescence localization microscopy) IgG IgA IgM C3
SLE SLE SLE SLE Polymyositis
Lupus nephritis class-IV Lupus nephritis class-IV Lupus nephritis class-IV Lupus nephritis class-IV Membranous glomerulopathy Dermatomyositis Immune complex crescentic glomeulonephritis SLE Lupus nephritis class-IV SLE Lupus nephritis class-IV Scleroderma Immune complex with RPRF crescentic glomerulonephritis MCTDwith RPRF Immune complex crescentic glomerulonephritis SLE Lupus nephritis class-II SLE Lupus nephritis class-II SLE Lupus nephritis class-IV SLE Lupus nephritis class-IV SLE Lupus nephritis class-IV SLE Lupus nephritis class-III SLE Lupus nephritis class-IV SLE Lupus nephritis class-IV SLE Lupus nephritis class-IV
Serum ANA results
Speckled pattern on Hep 2
Diffuse pattern on Hep 2
4+speckled 4+speckled 4+speckled 3+diffuse 4+diffuse
— — — — —
— — — — —
— — — — —
— 3+ — — 2+
4+ — 1+ 1+ —
2+speckled
—
—
—
2+
—
3+diffuse 3+diffuse 3+speckled
— — 3+speckled
— — —
— — —
4+ — 2+
— 2+ —
—
—
—
3+speckled
2+
—
4+speckled 2+speckled 3+speckled 4+diffuse 3+speckled 4+diffuse 2+speckled 2+speckled 4+diffuse
— — — — — — — — —
— — — — — — — — —
— — — — — — — — —
1+ — — — —
— 2+ 3+ 4+ 2+ 2+ — — 4+
2+ 3+ —
ACR: American college of rheumatology, Ig: Immunoglobulin, ANA: Antinuclear antibodies, RPRF: Rapidly progressive renal failure, SLE: Systemic lupus erythematosus, MCTD: Mixed connective tissue disorder
ANAs to certain specificities and cell nuclei or is an artifactual process, is still a matter of debate.[1] Some authors advocate that in patients possessing high titers of ANAs, these might diffuse from the vascular compartment of the biopsy, during sectioning and washing procedures, and localize in nuclei artifactually at the time of processing.[2,3] However, in murine models of SLE it has been demonstrated that ANA can penetrate the intact cells and bind to nuclei in vivo. Whatever the mechanism, the phenomenon of Ig nuclear localization in renal biopsies should be noted. We show that this phenomenon can occur in other ANA positive autoimmune diseases such as polymyositis, dermatomyositis and scleroderma. And also 1/19 cases showed complement deposition, i.e., activation of the complement cascade, triggered by the IgG and nuclear antigen complex formed in vivo. It would be interesting to study this phenomenon prospectively to see if in vivo ANA correlates with SLE disease activity scores.
Department of Immunopathology, PGIMER, Chandigarh, India Address for correspondence: Dr. Ranjana Walker Minz, Department of Immunopathology, PGIMER, Sector-12, Chandigarh, India. E-mail: [email protected]
REFERENCES 1. 2.
3.
McCoy RC. Nuclear localization of immunoglobulins in renal biopsies of patients with lupus nephritis. Am J Pathol 1972;68:469-78. Parone o F, Koffler D. Immunofluorescent localization of immunoglobulins, complement, and fibrinogen in human diseases. I. Systemic lupus erythematosus. J Clin Invest 1965;44:1657-64. Kramers K, van Bruggen MC, Rijke-Schilder TP, Dijkman HB, Hylkema MN, Croes HJ, et al. In vivo ANA is a fixation artifact: Nucleosome-complexed antinucleosome autoantibodies bind to the cell surface and are internalized. J Am Soc Nephrol 1996;7:946-54.
Access this article online Quick Response Code:
Seema Chhabra, Shreekant Bharti, Ranjana Walker Minz, Ranjeet Bhardwaj, Neelam Pasricha Journal of Natural Science, Biology and Medicine | January 2015 | Vol 6 | Issue 1
Website: www.jnsbm.org
DOI: 10.4103/0976-9668.149250
280
Copyright of Journal of Natural Science, Biology & Medicine is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
