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Still's Disease Associated with Adenovirus Infection and Defect in Adenovirus Directed Natural Killing

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Still's Disease Associated with Adenovirus Infection and Defect in Adenovirus Directed Natural Killing Ann Rheum Dis: first published as 10.1136/ard.48.9.781 on 1 September 1989. Downloaded from Annals of the Rheumatic Diseases 1989; 48: 781-786 Still's disease associated with adenovirus infection and defect in adenovirus directed natural killing ANTHONY S LUDER,' VERA NAPHTALI,2 EDNA BEN PORAT,2 AND NITZA LAHAT' From the 'Department of Pediatrics and Pediatric Research Unit and Immunolog1 Research Unit, Carmel Hospital (Faculty of Medicine, Technion-Israel Institute of Technology), and the Department of Virology, Rambam Hospital, Haifa, Israel SUMMARY Low natural killer (NK) activity towards adenovirus infected fibroblasts was detected in the peripheral blood of a child with Still's disease and was not normalised by the addition of interferon alfa or interleukin 2. NK cytotoxicity directed at K 562 target cells or polio infected fibroblasts was normal. This specific NK deficiency might have contributed to the development of the child's Still's disease. Systemic onset juvenile chronic arthritis (Still's arthritis. He had been born in Israel but had lived in disease) remains a common and puzzling problem.' Nigeria until this illness. At 6 months of age he had Although many attempts have been made to identify been successfully treated with chloroquine for a the important aetiological factors, the cause(s), febrile illness, diagnosed as malaria. At 9 months he as with other connective tissue disease, remains had a transient episode of swelling and tenderness of copyright. unknown.2 Among the large variety of putative the left elbow, which passed spontaneously after infectious agents studied3 are viruses. Febrile 12 hours. At 14 months he developed a swinging arthritides, usually self limited, can be caused by fever up to 41°C with rigors and a faint pink macular virus, including adenovirus.8 On rare occasions rash on the trunk, which appeared three times a day chronic erosive arthritides have followed infection with fever spikes. The child appeared well between with hepatitis B and rubella viruses.9 10 Success in spikes. He was admitted to hospital. Bilateral isolating viruses by culture in patients with rheum- serous otitis media was present, and the liver and atoid arthritis has been extremely limited, though spleen were palpable 3 cm below the costal margin. http://ard.bmj.com/ indirect methods ofviral identification have occasion- Lymph nodes, mucous membranes, and eyes were ally been successful. " Recently, parvovirus was normal. Investigations showed haemoglobin 103 g/l, detected in the synovium of one patient with mean cell volume 89 fl, leucocytes 12 900x 109/l rheumatoid arthritis,'2 and adenovirus isolated from (18% stab forms, 43% neutrophils) and 422x109/A a girl who developed juvenile rheumatoid arthritis. 13 platelets. The erythrocyte sedimentation rate was No other associations between juvenile rheumatoid accelerated at 145 mm in the first hour, C reactive arthritis or Still's disease and adenovirus infection protein grossly raised, ferritin was 1160 ,tg/l, while have been described as far as we know. Recent immunoglobulin and complement concentrations on September 25, 2021 by guest. Protected studies have emphasised the range of immune were normal. Blood culture studies were negative, disturbances commonly seen in these patients,3 14 as were extensive serological and skin antigen tests. defects which may also have important pathogenetic No autoantibodies were detected. Bone marrow significance. We report a case of Still's disease, in examination showed a myeloid:erythroid ratio of 4:1 which an initiating infection with adenovirus was and 23% of white cells were plasma cells. A recorded together with a defect in adenovirus diagnosis of Still's disease was made, and treatment directed natural killing. was started with aspirin 50 mg/kg with good clinical response. At the same time both parents, an elder Case report brother (5 years), and one grandmother became ill A 15 month old Ashkenazi-Jewish male child with a febrile flu-like illness, which resolved within presented with prolonged fever, rash, and transient 7-10 days. A urine virus culture obtained from the Accepted for publication 12 January 1989. patient at admission now grew adenovirus, but Correspondence to Dr Nitza Lahat. Immunology Research Unit. cultures of stool and throat were negative. All the ill Lady Davis Carmel Hospital. 7 Michal Street, Haifa 34362. Israel. family members showed greater than fourfold rises 781 Ann Rheum Dis: first published as 10.1136/ard.48.9.781 on 1 September 1989. Downloaded from 782 Luder, Naphtali, Ben Porat, Lahat in antiadenovirus titres, except the patient. Only antibodies. Less than 5% CD3t cells remained after two months after his remission and three months depletion of CD3 and CD4 lymphocytes. Less than after positive adenovirus culture was a fourfold rise 1% Leu llb cells were detected after Leu llb cell in titre observed. During one year of follow up there depletion. These subpopulations ofT or NK depleted have been three relapses, both associated with lymphocytes were used in cytotoxicity tests. Secretion subtherapeutic aspirin levels and both responding to of interleukin 2 was measured according to Kappler an increased dose. The isolation of adenovirus in et al.'7 combination with an apparently defective antibody The response of cytotoxic activity to exogenous response prompted us to investigate his immune interleukin 2 and interferon alfa (Israel Institute system in greater detail. for Biological Research, Ness Ziona, Israel) was measured by the method of Herberman. 18 Peripheral IMMUNE STUDIES blood lymphocytes were incubated with interleukin 2 Peripheral blood lymphocytes were isolated from for 18 hours and with interferon alfa for two hours, fresh heparinised blood by Ficoll-Hypaque density and then washed and suspended for the cytotoxicity gradient centrifugation. Phenotypes were studied by assays. Target cells for the cytotoxicity assays were indirect fluorescent staining using the following monoclonal antibodies: antihuman CD8 (T sup- pressor/cytotoxic), antihuman Leu 1 lb (natural killer (NK) cells), and antihuman Leu 12 (B cells). All Table 1 Immunological tests. Values are given as mean monoclonal antibodies were obtained from Becton- (SD) Dickinson (Mountain View, CA, USA). The cells cells CD8 cells NK* cells bearing these surface antigens were counted in fresh B cells CD3 cells CD4 (%) (%) (%) (%) (%) blood and after seven days' incubation with standard Patientt 13 52 39 21 9 adenovirus antigen in the highest dilution. Prolifera- Controlst 12 (4) 59 (8) 41 (7) 17 (10) 12 (5) tion was determined in peripheral blood lymphocyte cultures using optimal and suboptimal mitogen Proliferative responses to§: copyright. concentrations of phytohaemagglutinin (PHA-P, PHA* Con A* PWM* Staph A* Difco, Detroit, Michigan, USA), concanavalin A (25 Rg/ml) (10 &gIml) (I "giml) 0.03% (Sigma, St Louis, Missouri, USA), pokeweed Patient 47-2 (12-3) 25 (6.1) 11-2 (4.3) 7-4 (2-1) mitogen (Sigma, St Louis, USA), and Staphylo- Controls 39 9 (17-5) 28 (10-7) 9.7 (4-1) 5-1 (3-4) coccus aureus (Calbiochem, La Jolla, CA, USA) Interleukin 2 secretion (IU/ml) for 72 or 96 hours, or various dilutions of adenovirus Patient 7-9 (3-1) for seven days. This culture was performed on Controls 8-5 (5-1) isolated T cells+5% autologous monocytes. T cells NK cytotoxicity +Interleukin 2 +Interferon alfahttp://ard.bmj.com/ were isolated from non-adherent peripheral blood toward K 562 (10 lU/ml) (%) (1000 lU/mI) (%) lymphocytes after EAT rosetting. " Monocytes were cells (50:1) (%) isolated with rubber policemen from adherent peri- Patient 41 (6) 47 (5) 53 (8) Normal pheral blood lymphocytes. 16 The medium was RPMI 1640+10% fetal calf serum+1% antibiotics controlsWl 45 (12) 52 (8) 54 (9) (complete medium). We used standard adenovirus NK cytotoxicity toward polio infected fibroblasts (50:1) (%) antigen (Behringwerke AG, Germany) titre 1/64 Patient 37 (8) Normal controls (n= 15) 43 (7) on September 25, 2021 by guest. Protected and adenovirus isolated from the patient's urine on SLE* (n=2) 33 (10) human embryo fibroblasts. Identification of the Sjogren's syndrome (n=2) 41 (4) isolated virus was performed by complement fixation IBD* (n=2) 41 (5) test using high titre human serum. Eighteen hours Behqet's disease (n=2) 38 (9) before cultures were stopped [3Hlthymidine was *NK=natural killer; PHA=phytohaemagglutinin; Con A=con- added, and radioactivity incorporated into nascent canavilin A; PWM=pokeweed mitogen; Staph A=Staphylococcus DNA was read in a beta scintillation counter. aureus (strain Cowan A); SLE=systemic lupus erythematosus; Peripheral blood lymphocytes were subjected to IBD=inflammatory bowel disease. tThe patient's results presented were obtained in remission, but adherence on plastic Petri dishes.16 Non-adherent they are not significantly different from those obtained during cells were collected and used for cytotoxicity or were adenovirus infection. subjected to two cycles of monoclonal antibodies tIntrafamilial and extrafamilial controls. plus complement mediated lysis. The monoclonal §Measured in stimulation indices: cpm with mitogen/cpm without mitogen. antibodies used for this procedure were anti-CD3 lINK cytotoxicity test was performed in autoimmune inflammatory and anti-CD4 or Leu 1lb. Viable cells were investi- controls too, and patients with SLE and Sj6gren's syndrome had gated for fluorescence with the same monoclonal low values. Ann Rheum Dis: first published as 10.1136/ard.48.9.781 on 1 September 1989. Downloaded from Still's disease associated with adenovirus infection 783 A B Fig. 1 Cytotoxic lymphocyte responses towards (A) adenovirus 30 - - 60 infectedfibroblasts and (B) K 562 target cell line. Cytotoxicity tests 25 - 50 wereperformed at 100:1, 50:1, and j 25:1 effector:target ratios and are I0- presented as netpercentage of5 Cr 20 - ~40- Q releasedfrom target cells. The 0 x x patient was studied twicefor 0 adenovirus 15 - 30 specific cytotoxicity. 4U0 ---- = patient (I=acute C. ° stage; II=remission stage); 10- - 20 -*-* =mother ofpatient; N -* *.
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