key: cord-009581-bvihkf1r authors: Hurd, Eric R.; Dowdle, Walter; Casey, Helen; Ziff, Morris title: Virus antibody levels in systemic lupus erythematosus date: 2005-11-22 journal: Arthritis Rheum DOI: 10.1002/art.1780150308 sha: doc_id: 9581 cord_uid: bvihkf1r Antibody titers to a group of viral antigens have been determined in sera from patients with systemic lupus erythematosus (SLE), control groups with inflammatory diseases and normals. Mean titers in SLE sera for all viruses tested were significantly greater than in four control groups, but not greater than in active tuberculosis, both by the complement‐fixation (CF) and hemagglutination‐inhibition (HI) methods. By the CF method, only measles virus showed significantly higher titers in SLE than in all control groups; by the HI method, measles antibody titers were higher in SLE than in all groups but tuberculosis. There was no correlation between antibody titers and gammaglobulin levels. The results indicated a moderate though variable overall hypereactivity in SLE to the viral antigens tested. lar in appearance to those seen in the brain tissue of patients with subacute sclerosing panencephalitis (6-9). In this condition, elevated measles antibody titers have been consistently demonstrated (8, 10-1 2), and measles virus, a myxovirus, has been isolated from brain tissue of patients with this disease (1 3-1 6). Because of the morphologic similarities of the tubular structures seen in SLE to those of the myxoviruses (17) (18) (19) , it seemed appropriate to measure virus antibody levels in patients with SLE, with particular emphasis on the myxovirus group. Recent studies (20) (21) (22) have reported elevated antibody levels to several viral antigens. In a preliminary study in this laboratory (23) of viral antibody titers in patients with lupus nephritis and matched normal controls, complement fixing antibody titers were significantly elevated to a number of myxoviruses, coronavirus OC 43 and herpes simplex virus. By the HI technic, significant elevations were observed in parainfluenza 1 and measles viruses, both myxoviruses. T h e overall trend of antibody titers in the SLE group as compared with normal controls was highly significant both by the CF and HI tests. In the present study, antibody titers have been studied by the same technics in patients with SLE and normal individuals. In addition, control studies have been carried out in groups of patients with a variety of chronic inflammatory diseases. Sera were collected from 20 patients who had welldocumented histories of SLE with nephritis and who were being followed in the Parkland Memorial Hospital Arthritis Clinic. The average age of the patients with SLE was 34 years (17 to 57). All had active disease. Seventeen were receiving prednisolone; the average daily dosage in the 20 patients was 14.8 mg (0 to 60 mg). All patients were ambulatory. Seventeen were black and 3 white. Control sera were obtained from: a) 20 age-and sex-matched hospitalized patients with far-advanced tuberculosis; all were receiving INH, 11 were black (B), 8 white (W) and 1 Latin American (LA); antinuclear fluorescence tests were negative in all; b) 28 patients with rheumatoid arthritis (RA) (10 B, 16 W, 2 LA); c) 13 patients with bronchial asthma (12 B, 1 W); d) 11 patients with miscellaneous diseases, including 5 with degenerative joint disease, 2 with polymyositis, 2 with chronic alcoholism, 1 with gout and 1 with psoriasis (5 B, 5 W, 1 LA); and e) 14 normal individuals (4 B, 10 W). Antibody titers were determined in the laboratories of the Virology Section of the Center for Disease Control, US Public Health Service, Atlanta, Ga. The complementfixation microtiter technic (24) was used to determine antibody titers to the following myxovirus antigens: purified ribonucleoprotein (soluble antigen) of mumps virus and influenza virus Types A and B; and unpurified whole-virus preparations of influenza virus Type C, parainfluenza virus Types 1, 2 and 3, mumps virus, measles and respiratory syncytial virus. Complement fixation tests were also performed with an RNA coronavirus (Infectious Bronchitis virus-like virus strain OC 43) and adeno and herpes simplex viruses, both DNA viruses. Antibody titers were also determined by the HI technic (25) to the following an-tigens: parainfluenza virus Types 1, 2 and 3, mumps virus, measles virus and coronavirus OC 43. All patients with SLE had positive antinuclear fluorescence (ANF) and LE cell tests. Twenty-two of the RA patients had positive sensitized sheep cell agglutination (SSCA) tests (range, 0 to 12396). Three of the patients with SLE and 2 of the tuberculosis group also had positive SSCA tests. The patients in each group were tested for individual viruses, two groups at a time using the following tests: a) to compare patients with SLE to those with tuberculosis subjects were matched according to age, and the observed differences for each pair were analyzed using the Wilcoxon Signed-Rank Test (26); b) for comparison of other groups, the Wilcoxon Rank-Sum Test (26) was also used, except the subjects were not matched. In cases where sample values were "tied,"-ie, appeared more than once, a test of equal binomial proportions (26) or Fisher's exact probability test (26) was applied. Correlations between 7-globulin level and individual virus titers were computed. When the sample size N exceeded 10, these were tested against the Null permutation distribution (27) . Spearman's p was tested when N was 7 10. Since the discrete nature of the data rendered methods based on normally distributed variables inappropriate, only distribution-free tests were applied. Geometric mean viral antibody titers measured by the CF test are shown in Table 2 . The average titer for each group is also shown. Similar titers measured by the HI test are shown in Table 3 . By the CF test (Table 4) , only measles virus showed significantly higher titers in SLE than in all the 5 control groups. Respiratory syncytial virus showed elevated titers with respect to 3 of the 5 control groups and in the case of the other viruses the eleva-tions were scattered. When compared with the normal group, patients with SLE were higher for parainfluenza 1, measles, herpes simplex and respiratory syncytial viruses. By the HI test (Table 5) , none of the six viruses studied showed a significantly higher antibody titer in SLE than in all the control groups examined. In the case of four of the vi- statistically significant correlations between these levels and viral antibody titers. When gammaglobulin level in the 6 patient groups was correlated with antibody titers for each of the 12 viruses tested by the C F method, only four of the 72 possible correlations of antibody titer with gammaglobulin level were significant at the .05 level. Among the 36 possible correlations by the H I method, only one was significant at the .05 level. No instance of a significant correlation between gammaglobulin level and antibody titer occurred in the SLE group. In the present study, an attempt has been made to compare viral antibody titers in SLE with those of control groups with inflammatory diseases as well as normal individuals. The data obtained demonstrate that patients with SLE have elevated antibody titers to a number of viruses when compared with certain control groups. However, with the exception of measles virus, there was no predilection for increased antibody response in this disease to any one specific virus among those tested. Of all 12 viral antigens tested by the C F test, only measles antibody levels were significantly higher in SLE than in all of the control groups. However, by the H I method, the measles antibody titer was not significantly higher than in the tuberculosis group though it was elevated with respect to the 4 other control groups. When geometric mean titers of all viruses tested were averaged for each patient group, the overall mean titer was higher in the SLE group than in 4 of the 5 control groups by both the C F and H I methods. However, it was not significantly higher in the tuberculosis group by either test. Except for the comparison with the tuberculosis group, it would appear that there is an overall hyperreactivity to viral antigens in the patients with SLE when compared with 3 control groups with inflammatory disease and with normal individuals. It was of considerable interest that patients with far-advanced tuberculosis formed the only group with respect to which the patients with SLE did not have an overall increase in viral antibody response. A high frequency of autoantibodies, particularly antinuclear antibodies and rheumatoid factor, has recently been reported by Lindquist, Coleman and Osterland in patients with chronic pulmonary tuberculosis (28). These authors suggested that factors such as chronicity of inflammation, tissue breakdown and the adjuvant effect of mycobacteria may play a role in the production of these autoantibodies. Injection of Freund's complete adjuvant (29) has, in fact, been shown to hasten the development of Coombs positive hemolytic anemia in NZB mice. Thus, the relatively high viral antibody titers seen in tuberculosis could be secondary to an adjuvant effect of the mycobacterial infection. It is unlikely that INH, which all of these patients were receiving, contributed to the antibody response since antinuclear antibody tests were negative in all of the patients in this group. The relatively elevated viral antibody titers observed in tuberculosis raises the question of the role of an adjuvant effect in the response of patients with SLE to viral antigens. There is some evidence that patients with SLE may have defective cellular immunity (30-32). Several lines of evidence for the presence of diminished cellular immunity have also been described in NZB and NZB-NZW F, hybrid mice. More-over, the development of autoantibodies in mice has been correlated with a deficient thymusdependent cellular immune system (33, 34). Diminished cellular immunity could facilitate chronic infection with a passenger virus, which might in turn exert an adjuvant effect on viral antibody formation. Viral infections have, in fact, been shown to enhance the formation of autoantibodies (35-39). A variety of antibodies to polynucleotides (native DNA, single-stranded DNA and single and double-stranded RNA) have been found in sera from patients with SLE (40, 41) . This has led to the speculation that these antibodies may have originated in response to viral infec- It should be pointed out that the viral antibody titers of the patients with RA measured in the present studies by the CF test might be falsely low because serum rheumatoid factor may exert a n inhibitory effect on C F (46). This possibility cannot be ruled out. However, similarly decreased antibody titers were also obtained by the HI method, which is not dependent on the complement system. T h e present study, using conventional serodiagnostic tests and common viral antigens, does not elucidate the nature of the cytoplasmic myxovirus-like tubular structures in the tissues of patients with SLE. However, it is possible that the tubular structures are evidence of chronic infection in S L E with a passenger virus of a type which might act as an adjuvant for the overall elevation in viral antibody titer observed. Fresco R: Tubular (myxovirus-like) structures in glomerular deposits from a case of lupus nephritis Systemic lupus erythematosus and myxovirus (correspondence) et alL Cytoplasmic tubular structures in kidney biopsies in systemic lupus erythematosus Endothelial inclusions in active lesions of systemic lupus erythematosus Ultrastructural observations regarding their possible viral nature Light and electron microscopic observation on the development of viral inclusions of Dawson's encephalitis (subacute sclerosing panencephalitis) Evidence of a pseudomyxovirus in the brain in subacute sclerosing leucoencephalitis Additional evidence of the relation between subacute inclusion-body encephalitis and measles virus Myxovirus as a possible etiologic agent in subacute inclusion-body encephalitis Measles virus antibody and antigen in subacute 18:8-20 Virus antibodies in subacute sclerosing panencephalitis: study of 22 patients Kolar 0: Reflections on the etiology and pathogenesis of subacute sclerosing panencephalitis Isolation of measles virus from cell cultures of brain from a patient with subacute sclerosing panencephalitis Subacute sclerosing panencephalitis: propagation of measles virus from brain biopsy in tissue culture Subacute sclerosing panencephalitis: structures resembling myxovirus nucleocapsids in cells cultured from brains Subacute sclerosing panencephalitis: isolation of measles virus from a brain biopsy The structure and composition of the myxovirus. 1. Electron microscope studies of the structure of myxovirus particles by negative staining techniques Immunoelectron microscopy of the morphogenesis of mumpsvirus Rapid laboratory diagnosis of paramyxovirus infections by electron microscopy Myxovirus antibody increases in human connective tissue disease Raised antibody titers to EB virus in systemic lupus erythematosus Antibodies to viral antigens in systemic lupus erythematosus Virus antibody levels in systemic lupus erythematosus United States Department of Health, Education and Welfare, United States Public Health Service, Washington, DC 25. 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Role of thyrnectomy, aging and involution of immunologic capacity Response of NZB and NZB/NZW spleen cells to mitogenic agents T h e effect of induced chronic viral infection on the immunologic diseases of New Zealand mice Cryoglobulinemia in infectious mononucleosis Antinuclear antibodies in infectious mononucleosis Immunologic abnormalities induced by postperfusion cytomegalovirus infection Inhibition of cellular immunity and enhancement of humoral antibody formation in mice infected with lactic dehydrogenase virus Antibodies to polynucleotides in human sera: antigenic specificity and relation to disease Antibodies to ribonucleic acid in systemic lupus erythematosus Histocompatibility antigens associated with systemic lupus erythematosus The pathogenesis of autoimmunity in New Zealand mice Induction of antinucleic acid antibodies by polyinosinic-polycytidylic acid Tolerance to polyinosinic-polycytidylic acid in NZB/NZW mice Comparison of the immune responsiveness of NZB and NZB x NZW F, hybrid mice with that of other strains of mice Relationship between anti-viral antibodies and rheumatoid factor in pregnant women We are very grateful to Dr Campbell Read for the statistical analysis of the data, and to Dr G . Hurst and Mr Vincent Steingrube at the State Tuberculosis Hospital at Tyler, Texas, for supplying sera from patients with faradvanced tuberculosis.