Gamma-1 globulin levels in rheumatic fever

Gamma-1 Globulin Levels in Rheumatic Fever

By RICHARD HONC AND CLARK D. WEST

Gamma-1A serum levels were found to be elevated in 74 per cent of 31 cases of acute rheumatic fever, more frequently than in rheumatoid arthritis, acute glomerulonephritis, and non-complicated streptococcal infections. Some patients with clinically inactive rheumatic fever also demonstrated increased gamma-1A. This finding could not be correlated with the severity of cardiac damage nor was it associated with continuing clinically inapparent activity. Surprisingly, gamma- 1M increase was observed in only 13 per cent of the cases.

Elevate nivellos de gamma-1A in le sero esseva trovate in 74% de 31 casos de acute febre rheumatic, lo que esseva plus frequente que le mesme constatation in casos de arthritis rheumatoide, acute glomerulonephritis, e non-compli- cate infectiones streptococcal. Certe pa- tientes con clinicamente inactive febre rheumatic etiam monstrava elevate gamma-lA. Iste constatation non esseva in correlation con le severitate de dam- nos cardiac, e ill0 non esseva associate con continuante sed clinicamente in- apparente activitate. 11 es surprendente que augment0 de gamma-1A esseva ob- servate in solmente 13% del casos.

S A RESULT of newer techniques of serum analysis, it is now known A that antibody activity resides in at least three serum proteins, gamma2, gamma-lA, and gamma-1M globulins," collectively termed the immunoglobulins. The development of a method for quantitation of the gammal, globulins1 has led to extensive investigation of their levels a t various age$ in immunoglobulin deficiency states;2 and in other disease states. This study is concerned with the gammal globulin concentrations in rheumatic fever. The data reveal a disproportionate tendency for gamma-lA globulin increase in acute rheumatic fever as compared to serum levels in rheumatoid arthritis, acute glomerulonephritis and uncomplicated group A streptococcal infection.

MATERIALS AND METHODS Clinical Material

Serums were obtained from patients admitted to the Cincinnati Children's Hospital, the Cincinnati General Hospital and the Convalescent Hospital for Children. Serums from patients with acute rheumatic fever, inactive rheumatic fever, chorea, acute glomerulonephritis, rheumatoid arthritis, uncomplicated group A beta hemolytic streptococcal infection, non-streptococcal tonsillitis and congenital heart disease were studied. The specimens were drawn during the acute phases of illness in all cases except in inactive rheumatic fever and congenital heart disease. Children with uncomplicated group A streptococcal

From The Children's Hospital Research Foundation and the Department of Pediatrics, University of Cincinnati College of Mdicine.

This inoestigation was supported in part by Public Health Service Research Grant AI-03429 and Research Career Program Award 5-K3-AI-11,511 (Dr. Hong) f rom the Na- tional Institute of Allergy and Infectiow Diseases.

*Gamma, globulin is called the 7s gamma globulin by some workers. Gamma,, is also known as &,, and gamma,, as /IzM or 19s gammal globulin.

128

A4RTHRITIS A N D RHEUMATISM, VOL. 7, N O . 2 (APRIL), 1964

GAMMA-I GLOBULIN LEVELS IN RHEUMATIC FEVER 129

Table 1.-Gamma, Globulin Levels in Normal Children (Unitdml.) Age in Years

Percentile 4-9 ( 3 8 ) * 10-15 (25)

95 75 50 25

Gamma 1-A 21.2 15.5 12.4 9.1

Gamma I - M

26.7 18.3 13.7 9.1

95 14.4 14.9 75 10.8 10.7 50 8.9 8.5

7.0 6.1 25 . _ _ _ _ _ _ _ _ ~ __-_____ -

*Number in parenthesis is number of children tested.

infection were seen in the out-patient clinics of the Cincinnati General and Cincinnati Children’s Hospitals. The diagnosis of beta hemolytic streptococcal infection was established by naso-pharyngeal culture.* All children have remained free of poststreptococca1 complications to date (four to six months).

Zmmunoglobulin Levah Gamma-1A and gamma-lM levels were determined by a technique recently devised in

this laboratory.1 The absence of pure preparations of these proteins for standardization of this method in terms of milligrams has required that their serum concentration be expressed in units per milliliter based on a standard antiserum. It should be noted that units of gamma-lh bear no quantitative relation to units of gamma-1M. Gamma-2 levels were measured by a modification of this technique in which pure gamma-2 globulin is employed as a standard, thus permitting the levels to be expressed in grams per cent.3

The levels of the immunoglobulins in normal children used for comparison were those obtained in a previous study in which 108 children were teqted.2 Additional normal values were obtained in the course of the present study using serum from 25 children between the ages of 9 and 15. The normal values, expressed in percentiles for these two groups, are given in table 1.

RESULTS Gamma-1A elevation was an extremely common finding in acute rheu-

matic fever, while gamma-1 macroglobulin levels tended to be normal. These trends are shown in fig. 1 and 2 where serum levels of gamma-lA and gamma-lM in normal subjects and in children with acute rheumatic fever are plotted against the age.

In table I1 the gamma-1 immunoglobulin levels are compared with those obtained in rheumatoid arthritis, acute glomerulonephritis, uncomplicated group A streptococcal infection and other diseases in which acute and chronic inflammation is present. Elevated levels are defined as those greater than two standard deviations from the mean for age. The incidence of this elevation of gamma-1A was 74 per cent (23/31) for acute rheumatic

‘Typing of streptococci was performed by the Ohio State Health Laboratories, Colum- bus, Ohio.

130 HONG AND WEST

A

50

.c, u) ] A

Y 30 U I

A

A

A 0

O Y 0 00 8

0s” 0 0

A

A A

0 A b A

0 0

A

A A

A A

A RHEUMATIC FEVER lOCONTROL 1

A

A A o brb 4 O A 0

0 0

0 0 0 0 0 0 A’ 0

0 0 0 O 0 8 OO 0 0

0 0

I I I 1 I I I I I I 1

4 5 6 7 8 9 10 I I 12 13 14 15

AGE I N YEARS Fig. 1.-Gamma-1A levels in acute rheumatic fever.

fever, whereas most other conditions listed were associated with the same degree of gamma-lA elevation less frequently. Levels were elevated in 55 per cent of children with rheumatoid arthritis and 41 per cent of those with acute glomerulonephritis. With acute infections resulting in inflammation comparable in severity to that seen in rheumatic fever, gamma-lA was infrequently elevated. Examples are strep pharyngitis, erythema multiforme, H. influenzae meningitis, broncho-pneumonia, staph abscess, cellulitis and erysipelas. In all of these conditions, the determinations were made at the time the patient was acutely ill or early in convalescence.

On the other hand, chronic infection with marked exudative inflammatory changes extending over a longer period than most cases of rheumatic fever often caused elevation of gamma-1 A. An example is chronic pneumonia associated with fibrocystic disease of the pancreas in which 75 per cent of the cases had elevated levels. Not shown in the table are the results on patients with long-standing and chronic infections such as appendiceal abscess, histoplasmosis and subacute bacterial endocarditis; in each of these, gamma-lA was also elevated.

Gamma-1M elevation was not a prominent feature of the acute rheumatic state; only four of 31 patients (13 per cent) had this increase. Macro- globulin elevation was also uncommon in the other acute inflammatory conditions but was relatively common in rheumatoid arthritis (27 per cent).

The gamma-lA levels in rheumatic fever returned to normal with clinical improvement. The pattern of response for one of three patients followed through the acute phase to convalescence is shown in fig. 3. This figure also shows the continued elevation of the gamma-1A level observed in a

GAMMA-I GLOBULIN LEVELS IN RHEUMATIC FEVER 13 1

30 \

0 CONTROL

- . I I I I I I

4 5 6 7 8 9 10 I I I2 13 14 15

AGE IN YEARS Fig. e.-Gamma-lM levels in acute rheumatic fever.

patient who showed no clinical improvement during the period of observation.

Carditis was not necessarily associated with higher serum gamma-1A levels. No correlation could be made between the degree of gamma-lA elevation and the severity of the clinical course when gamma-1A was in the range of 20 to 40 units/ml. When the serum levels exceeded 40 units/ml., a severe illness attended by protracted cardiac failure with poor response to therapy was the rule. Levels of above 40 units/ml. were observed in 6 of 7 severely ill patients. In two of the most severely ill, there was also a gamma-1M elevation. Except for these general trends, there was no close correlation between severity of disease, degree of cardiac damage, and gamma-1 immunoglobulin levels. Gamma-1M was elevated only once without concomitant gamma-lA increase.

In seven of sixteen patients who had inactive rheumatic disease as determined by clinical and laboratory evaluation, the gamma-1A was elevated (table 2) . All had been symptom free for at least four months. No correlation could be found between severity of heart damage and persistence of gamma-1A elevation. One patient with severe mitral stenosis requiring mitral commissurotomy at 14 years of age had a normal gamma-lA level (11 units/ml.) at the time of surgery. Another patient, who despite repeated at- tacks of acute rheumatic fever never developed clinically detectable valvular disease, maintained a persistently elevated level of gamma-1A (36 units/ml.).

Gamma-2 levels were usually markedly increased also. Normal percentiles for gamma-2 globulin determined by the quantitative immunoelectrophoretic technique have not been established as iet. However, in comparison with the range of values given by Zak and Good4 determined by the quantitative precipitin reaction, most ( 19/27) patients showed impressive elevation of gamma globulin. In fig. 4, the serum gamma-2 levels in patients with acute rheumatic fever are plotted against the gamma-lA serum values. It

132, HONG AND WEST

Table 2.-Gamma, lmmunoglobulin Levels in Rheumatic Fever and Reluted Conditions

Acute rheumatic fever 74 (23731 ) t 13 (4/31)1 Inactive rheumatic fever 44 (7/16) 12 (2/16) Rheumatoid arthritis 55 (12/22) 27 (6/22) Acute glomerulonephritis 41 (16139) 10 (4/’39) Group A strep tonsillitis 21 (4/19) 0 (0/19) Non-strep tonsillitis 25 (4/16) 19 (3/16) Congenital heart disease 0 (0/13) 7 ~ 1 3 ) Chorea 0 (0/3) 0 (0/3) Erythema multiforme 0 (0/2) 0 (0/2) H. influenza meningitis 0 (0/3) - Bronchopneumonia 13 ( W ) - Staph abscess 0 (0/2) - Cellulitis and erysipelas 0 (0/2) -

chronic pneumonia 75 (3/4) -

% Elevated Gamma-1A* % Elevated Gamma-1M* ~ _ _ _ _ _ _

Fibrocystic disease-

_ _ _ _ _ _ _ ~ -__- .___

‘Greater than $2 SD. t (Number of cases elevated/number of cases studied).

can be seen that gamma-lA and gamma-2 levels vary independently. Seven children whose levels were within the range of normal for gamma-1A showed elevation of gamma-2 globulin levels. One child whose gamma-lA was 26 units/ml. had a serum gamma-2 level which was below the mean value.

DISCUSSION Previous studies in acute rheumatic fever have demonstrated increased

gamma-2 levels and increased numbers of. bone marrow plasma cells.z,ti This study reveals the elevation of another immunoglobulin, gamma-l A, in a large percentage of cases of acute rheumatic fever. In comparison with related diseases and those with a comparable degree of inflammation, there is an inordinant frequency of gamma-1A hyperresponsiveness in acute rheumatic fever. Neither uncomplicated group A streptococcal infection nor non- rheumatic heart disease are as frequently associated with gamma-1A increase. It is of interest to note that acute glomerulonephritis, despite its common etiology with the &hemolytic streptococcus and its avowed “hypersensitivity” origin, is associated with serum hyper-gamma-1A globulinemia much less frequently than acute rheumatic fever. The difference is statistically significant (X2 = 6.4, P < .02). Rheumatoid arthritis is also less often associated with pronounced gamma-lA elevation. Although our data are insufficient to estab- lish a positive correlation, we have the impression that serum gamma-lA globulin levels are related more to the degree of active inflammation in rheumatoid arthritis, whereas, in acute rheumatic fever such a correlation could not be made.

As would be expected, with clinical improvement the immunoglobulin levels returned to normal. In the three patients from whom serial samples were obtained, the return to normal required one or two months and was

GAMMA-I GLOBULIN LEVELS IN RHEUMATIC FEVER 1 33

Onset

\J2 +3{ S.D.

I 2 3 4 5 6 months

Fig. 3.--Serial immunoglobulin levels in rheumatic fever. A-A = serial values determined in a patient in whom active rheumatic disease persisted. 0-0 = Serial values determined as clinical remission occurred. S. D.: standard deviation.

roughly correlated with the fall in sedimentation rate and C-reactive protein. In three patients with chorea, a disease in which laboratory manifestations of acute rheumatic fever are usually absent, the gamma-lh levels were normal.

The significance of the elevation of gamma-1A in patients with clinically inactive rheumatic fever is unknown. It is not correlated with the severity of heart damage, not does it seem to indicate continuing low grade rheumatic activity undetectable by available methods. The data show that gamma-1 macroglobulin is infrequently elevated in rheumatic fever. This is surprising and unexplained. However, studies in our laboratory have demonstrated that the gamma-1 immunoglobulins do not necessarily vary in a parallel manner. This is in keeping with current concepts of different cells of origin for the immunoglobulins and suggests that serum levels are controlled independentI~.~,~

The gamma-1A elevation is not specific enough to warrant widespread use of this determination as a diagnostic test. However, in certain cases, the serum determination is helpful in differential diagnosis. When acute rheumatic fever is manifested by monarticular arthritis without carditis and can- not be differentiated from early acute osteomyelitis, the finding of elevated

134

4.0 -

3.5 - 3.0 -

- 2.5- # 5i - N 20-

).o

1.5 -

1.0 -

0.5 -

HONC AXD wm-r

I

1

q

io I

i I

0 I 0

01 0 O

____------------- +-&-----r ---- ----P-

i i j

' 4 . 0 CnI 0

I 0 I 0 0 0 0 0

0

I

I

I I

0

4.0 -

3.5 - 3.0 -

- 2.5- # 5i - N 20-

).o

1.5 -

1.0 -

0.5 -

I

1

q

io I

i I

0 I 0

01 0 O

___------- ------- +-&-----r--------P-

i i j

' 4 . 0 CnI 0

I 0 I 0 0 0 0 0

0

I

I

I 1 1 60

r,A(units/ml)

Fig. 4.-Gamma-lA levels compared with gamma-2 levels. Dotted lines show upper ranges of normal. Independent variation of gamma-2 from gamma-1A can easily be seen.

gamma-lh is more suggestive of the rheumatic process, since in our experi- ence gamma-1A elevation occurs late in the course of osteomyelitis, if at all. The finding of a normal gamma-lA level speaks strongly against the diagnosis of acute rheumatic fever.

The inciting mechanism which elevates gamma-1A in acute rheumatic fever is unknown. Present knowledge of the antibody activity of gamma-lA offers no explanation for its increase. There is recent evidence to suggest that gamma-1A is associated with reagin activitye9 Whether other antibody func- tions can be ascribed to this protein is unknown at the present time. One unconfirmed reportlo has related antibody activity to polio, typhoid, para- typhoid, diphtheria, tetanus and blood group substances to gamma-1A. Im- munohistochemical studies utilizing fluorescein labeled anti-gamma-1A antiserum failed to demonstrate localization of gamma-1A in the auricular ap- pendage of a patient with mitral stenosis.'l Similar studies by Kaplan et a1.12 showed gamma-2 globulin accumulation in the auricular appendages of 16 per cent of rheumatic fever patients who required surgery.

Increased imunoglobulin levels in acute rheumatic fever can be interpreted in two ways, ( a ) either as a manifestation of the rheumatic state per se, or ( b ) as a sign of a basic tendency of an individual to respond to various anti-


genic stimuli with increased antibody formation and, as a result, to mani- test a disproportionate tendency to develop hypersensitivity disease. Although definite proof for either hypothesis is lacking at present, certain observa- tions may be more consistent with the latter concept. The fact that rheumatic fever is acquired by only a small percentage of all those infected with group A B-hemolytic streptococcus suggests an individual response to a common stimulus. Studies which use the response to Brucella immunization to characterize the antibody response of individuals have also suggested a relation between an individual's reaction to antigen and his susceptibility to rheumatic fever. In a prospective study, Rejholec15 immunized 998 normal boys with Brucella abortus. Twelve of this group later developed rheumatic fever. The anti-Brucella titres were elevated to a greater degree in those who acquired rheumatic fever (1:SO) than in those who did not (1:40). While the incidence of sore throats was independent of the anti-Brucella response, the observed incidence of acute rheumatic fever was over three times the expected in those children whose anti-Brucella titres exceeded 1:SO. Meise1asl6 tested five patients with acute rheumatic fever and all showed high antibody titres (1:320-2560). Although the number of patients tested was small and controls from the same age group were not employed, the findings were consistent with those of Rejholec.

In our studies, serial determinations in 9 children with uncomplicated group A P-hemolytic streptococcal infection showed that there was little change in the gamma-1A values from the first examination to the second (two to three weeks later). If there was a high serum level, it was present on the initial specimen which was obtained within the first 48 hours of clinical illness. In no case did a normal value of gamma-lA increase more than a few units during the period of observation. This would suggest that streptococcal infection per se has little effect on the serum gamma-lh level and that the immunoglobulin response may be more dependent upon the host response than the offending organism.

One wonders if it might be possible, by employing a battery of antigens, to predict in humans a susceptibility to hypersensitivity disease. In this re- gard, it is of interest to note that not all antigens provoke abnormally high antibody titres in rheumatic subjects. Studies employing diphtheria,17 inffu- enza,ls pneumococcallo and tuberculinlg antigens have shown no difference in the antibody response between convalescent rheumatics and controls. No adequate explanation for the variability in response is available at the mo- ment.

The degree of antibody response has been shown in one type of experimental hypersensitivity disease to be of importance in determining the ac- quisition and duration of disease. Dixon,20 in the production of experimental glomerulonephritis, showed that the development of either acute or chronic disease in rabbits was related to the amount of antibody which the animals produced to foreign protein injections. Animals which showed no antibody formation did not develop renal disease. Rabbits responding with much anti-

136 HONG AND WEST

body developed acute self-limiting disease, whereas animals with antibody formation just adequate to neutralize the injected antigen developed subacute or chronic glomerulonephritis.

SUMMARY Gamma-1 globulin levels weie determined in 31 cases of acute rheumatic

fever and compared with the levels in rheumatoid arthritis, acute glomeru- lanephritis, uncomplicated group A streptococcal infection and other diseases in which acute and chronic inflammation is present.

Seventy-four per cent of patients with acute rheumatic fever had elevations of gamma-lA more than two standard deviations from the mean. In related conditions, similar elevations were seen less frequently; Rheumatoid arthritis, 55 per cent; acute glomerulonephritis, 41 per cent; uncomplicated streptococcal tonsillitis, 21 per cent. The acute inflammatory response produced by pneumonia, cellulitis, abscess and meningitis was rarely accompa- nied by elevated gamma-1A; the level, on the other hand, was frequently elevated in long-standing chronic infection.

Gamma-1M elevation was not a common feature in acute rheumatic fever, being found in only 13 per cent of the cases studied.

Seven of 16 (44 per cent) children who were thought to have clinically inactive rheumatic fever showed elevation of gamma-1A; the serum level was not related to the severity of valvular damage and did not appear to suggest subclinical activity.

In the rheumatics, increases in gamma-lA globulin were not always ac- companied by parallel increases in gamma-2 globulin.

The reason for the disproportionate elevation of gamma-lA is unknown. It may be a manifestation of the disease or the individual's manner of im- mune response. The data are consistent with either hypothesis.

ACKNOWLEDGMENT We should like to express our appreciation to Dr. Samuel Kaplan and the Division of

Cardiology, Children's Hospital, Cincinnati, for permission to ytudy their patients and help in obtaining serum specimens for analysis.

REFERENCES 1. West, C. D., Hinrichs, V., and Hinkle,

N. H.: Quantitative determination of the serum globulins beta 2A and beta 2M by immunoelectrophoretic analysis. J. Lab. & Clin. Med. 58:137-148, 1961.

2. \Vest, C. D., Hong, R., and Holland, N. H.: Immunoglobulin levels from the newborn period to adulthood and in immunoglobulin deficiency states. J. Clin. Invest. 41:2054-2064, 1962.

3. Hong, R., and West, C . D.: An immunoelectrophoretic technique for gamma globulin determination (in manu-

script). 4. Zak, S. J., and Good, R. A,: Immuno-

chemical studies of human serum gamma globulins. J. C. I. 38:579- 586, 1959.

5. Good, R. A., Campbell, B.: Relationship of bone marrow plasmacytosis to the changes in the serum gamma globulin in rheumatic fever. A. J. Med. 9 : 3 S 342, 1950.

6. Anderson, H. C., Kunkel, H. G., and McCarty, M.: Quantitative antistrep- tokinase studies in patients infected with Group A hemolytic streptococci:


A comparison with serum antistreg- tolysin and gamma g!obulin levels with special reference to rheumatic fever. J. C. I. 27:425434, 1948.

7. Burtin, P.: A study of serum proteins related to immunity and their cellular origin, in Wolstenholme, G. E. W., and O’Connor, M. (Eds.), Ciba Foundation Symposium on Cellular Aspects of Immunity. Boston, Little, Brown & Co., 1963, pp. 213-224.

8. Fahey, J. L., Dutcher, F., and Good- man, H. C.: Cell nuclei and gamma niacroglobulins. Proc. Roy. SOC. Med. 53:627-629, 1960.

9. Heremans, J. F., and Vaernian, J. P.: Beta 2A globulin as a possible car- rier of allergic reaginic activity. Na- ture 193: 1091-1002, 1962.

10. Schultze, H. E.: The synthesis of anti- bodies and proteins, in Peeters, H. (Ed.), Protides of the Biological Fluids, New York, Elsevier Press, Inc., 1960, pp. 1-17.

11. Hong, R.: Unpublished data. 12. Kaplan, M. H., and Dallenbach, F. D.:

Immunologic studies of heart tissue, 111. Occurrence of bound gamma globulin in auricular appendages from rheumatic hearts. Relationship to certain histopathologic features of rheumatic heart disease. J. Exper. Med.

13. Diamond, Eugene: Hereditary and‘ environmental factors in the pathogenesis of rheumatic fever. Pediatrics 19:908-913, 1957.

14. Uchida, I.: Familial incidence of rheu-

113:1-16, 1961.

matic fever and rheumatic heart disease, in Keith, J. D., Rowe, R., and Vlad, P., Heart Disease in Infancy and Childhood, New York, The Mac- millan Company, 1958.

15. Rejholec, V.: Incidence of rheumatic fever in relation to immunologic re- activity. Ann. Rheu. Dis. 16:23-30, 1957.

16. Meiselas, L. E., Zingale, S. B., Lee, S. L., Richman, S . , and Siegel, M.: Antibody production in rheumatic diseases; The effect of brucella antigen. J. c. I. 40:18721881, 1961.

17. Kuhns, W. J., McCarty, M.: Studies of diphtheria antitoxin in rheumatic fever subjects: Analysis of reactions to the Schick Test and of antitoxin responses following hyperimmuniza- tion with diphtheria toxoid. J. C. I. 33: 759-767, 1954.

18. Miller, J. M., Kibrich, S., and Massell, B. F.: Antibody response to non- streptococcal antigens as related to rheumatic fever susceptibility. J . C .

19. Quinn, R. W., Seastone, C. V., and Dickie, H. A,: Antibody production and tuberculin sensitivity in individuals with a history of rheumatic fever. J. Immunol. 70:493-495, 19%.

30. Dixon, F. J., Feldman, J. D., and Vaz- quez, J. J.: Experimental glomerulonephritis, the Pathogenesis of a laboratory model resembling the spectrum of human glomerulonephritis. J. Ex- per. Med. 113:899-920, 1961.

I. 32:691-695, 1953.

Richard Hong, M.D., Senior Researoh Associate, Children’s Hospital Re.wwch Foundation, Department of Pediatrics, Univemity of Cincinnati College of Medicine, Cincinnati,

Ohio.

Clark D. West, M.D., Professor of Pediatrics, Childrm’s Hos- pital Research Foundation, Department of Pediatrics, Uni- versity of Cincinnati College of Medicine, Cincinnati, Ohio.

Gamma-1 globulin levels in rheumatic fever

Documents

Transcript of Gamma-1 globulin levels in rheumatic fever