A1-Antitrypsin and Serum Albumin in Tear Fluids in Acute Adenovirus Conjunctivitis

Br J Ophthalmol: first published as 10.1136/bjo.72.5.390 on 1 May 1988. Downloaded from

British Journal of Ophthalmology, 1988, 72, 390-393

a1-Antitrypsin and serum albumin in tear fluids in acute adenovirus conjunctivitis

A K GUPTA,' G S SARIN,' M D MATHUR,2 AND B GHOSH' From the 'Guru Nanak Eye Centre, Maulana Azad Medical College, and the 2Department ofMicrobiology, Govind Ballabh Pant Hospital, New Delhi, India

SUMMARY The a1-antitrypsin and serum albumin levels in tear fluids were measured by electroimmunodiffusion in 76 healthy subjects and 63 patients with acute adenovirus conjunctivitis. They were found to be significantly increased during the acute phase of the disease. There was a correlation between increased severity of disease and increased levels of both the proteins. There was no significant difference in the tear a1-antitrypsin and serum albumin levels in viral isolation-positive and isolation-negative patients. The raised levels of the two proteins in tears may reflect conjunctival inflammation rather than infection, since both isolation-positive and isolation- negative patients had the raised levels. The levels of the two proteins returned to normal with clinical improvement.

'a1-antitrypsin controls the activity of diverse pro- and who attended the Eye Centre mainly for the teolytic enzymes.' It is found in tears, saliva, purpose of refraction. In the control group were 40 perilymph, bile, synovial fluid, and amniotic fluid.'5 males and 36 females with a mean age of 35-7 (SD

It plays a significant part in regulating the immune 17-6) years (range 8 to 60 years), and the diseased http://bjo.bmj.com/ response by inhibiting the transformation and migra- group comprised 48 males and 15 females with mean tion of lymphocytes.6 Its role in corneal ulcer and age of 30 9 (SD 11.7) years (range 5 to 63 years). The other corneal diseases has been studied.7"9 However, diagnosis of acute adenovirus conjunctivitis was only a few limited studies are available on its level in established by detailed clinical examination including patients with conjunctival disease.79 slit-lamp biomicroscopy, bacterial culture, and viral The levels of tear immunoglobulin," serum culture. immunoglobulin," complement component,"2 and Clinically the patients presented with sudden onset on September 30, 2021 by guest. Protected copyright. tear lysozyme'3 have been reported by us in patients of unilateral or bilateral pain, redness, and watery with acute adenovirus conjunctivitis. Here we report discharge with no visual deterioration. Ocular exami- our observations on tear a1-antitrypsin level in this nation showed lid oedema, conjunctival congestion, disease. Serum albumin levels in tear fluids have been and chemosis of bulbar conjunctiva, with frequent measured because they indicate leakage of serum subconjunctival haemorrhages. There was no proteins into tears. The findings on adenovirus corneal involvement in any patient as confirmed by culture have been described elsewhere. 14 fluorescein staining and subsequent slit-lamp examination with cobalt blue filter. Material and methods The patients were subgrouped as mild or severe according to the clinical presentation. The patients The present study was carried out among 76 healthy with mild conjunctivitis had minimal lid oedema, subjects and 63 patients with clinically diagnosed conjunctival congestion, and no subconjunctival acute adenovirus conjunctivitis attending the out- haemorrhage or chemosis of the bulbar conjunctiva. patient department of Guru Nanak Eye Centre, New However, patients with severe conjunctivitis had Delhi. The control group comprised healthy subjects moderate lid oedema, extensive conjunctival conges- who had no evidence of ocular or systemic disease tion, and chemosis of bulbar conjunctiva and subconjunctival haemorrhage. All such patients who Correspondence to Dr A K Gupta, VI/10, Maulana Azad Medical showed any positive bacterial culture were excluded College, Kotla Road, New Delhi-10 002, India. from the study. 390 Br J Ophthalmol: first published as 10.1136/bjo.72.5.390 on 1 May 1988. Downloaded from

a,-Antitrypsin and serum albumin in tearfluids in acute adenovirus conjunctivitis 391 Specific tests adopted for the identification of patients with conjunctivitis were compared with the adenovirus were: haemagglutination, haemaggluti- respective levels in healthy controls. The tear a,- nation inhibition, haemadsorption, complement antitrypsin levels in healthy controls were 4-4 mg/l in fixation test, and serum inhibitory titre against males and 4-0 mg/l in females, and the difference in adenovirus.'415 The reference standard antigen and the two sexes was not statistically significant the antisera were obtained from the National (p<050). Similarly serum albumin levels in tear Institutes of Health, Bethesda, USA. The typing of fluidswas 11-5 mg/l in males and 12*7 mg/l in females, adenovirus was done by the numbering system andthe difference in the two sexes was not statistically proposed by Norrby.'6 Adenovirus types 2, 7, or 8 significant (p>0-40). In the patients with acute could be cultured from only 26 out of 63 patients.13 adenovirus conjunctivitis there was no significant Tear samples were also collected for a1-antitrypsin difference (p>0-50) when the tear a1-antitrypsin and serum albumin measurements from 41 patients level in males (45-3 mg/1) and females (50-3 mg/I) during the remission stage, when there was no clinical were compared. Similarly when the serum albumin evidence of conjunctivitis. levels in tear fluids in patients with conjunctivitis in Stimulated tear samples (100 to 200 iii) were males (141.2 mg/i) and females (151.7 mg/I) were collected by the method described previously" and compared, there was no significant difference stored at -20°C until assayed. The a1-antitrypsin and (p>0-60). serum albumin levels in tear fluid samples were Table 2 shows the tear a1-antitrypsin and serum quantified by electroimmunodiffusion. 8 Mono- albumin levels in mild and severe stages of clinically specific goat antihuman a1-antitrypsin and anti- diagnosed acute adenovirus conjunctivitis. There human serum albumin sera and their respective were significant increases (p<0.001) in comparison reference standards were obtained from Meloy with the respective levels in healthy controls both in Laboratories, Virgina, USA. The levels of the two mild and in severe stages for a1-antitrypsin and serum proteins in tear fluids were calculated from the albumin levels in tear fluids. calibration curve constructed by incorporating three The tear a1-antitrypsin and serum albumin levels known concentrations of the reference standards for in viral isolation-positive and viral isolation-negative every set ofdeterminations. The results were statistic- patients are given in Table 3. There was a statistically ally analysed by Student's t test. significant increase (p<0-001) in tear a1-antitrypsin levels when the levels in healthy controls were Results compared with the levels both in viral isolation- positive and viral isolation-negative patients. http://bjo.bmj.com/ The ac-antitrypsin and serum albumin levels in tear However, there was no statistically significant differ- fluids in patients with clinically diagnosed acute ence (p>0.20) between the tear a1-antitrypsin level adenovirus conjunctivitis and healthy controls are given in Table 1. The mean a1-antitrypsin level in healthy controls was 12*1 mg/I. The mean levels in Table 2 al-Antitrypsin andserum albumin levels in tear patients with acute adenovirus conjunctivitis was fluids in mg/i in mildandseverestages ofacuteadenovirus 47*8 mg/l for a1-antitrypsin and 144*5 mg/l for serum conjunctivitis on September 30, 2021 by guest. Protected copyright. albumin in tear fluids. There was a statistically No. a,-Antitiypsin Serum albumin significant difference when the tear a1-antitrypsin Of (p

392 A K Gupta, G S Sarin, M D Mathur, and B Ghosh

Table 4 al-Antitrypsin andserum albumin in tearfluids in virus conjunctivitis in an attempt to determine the mg/I in the acute and remission stages ofacute adenovirus relationship, if any, between conjunctival inflamma- conjunctivitis tion per se and tear ac-antitrypsin levels. A remarkable increase in and serum No. a,-Antitrypsin Serum albumin ac-antitrypsin of albumin was observed in tear fluids from inflamed cases Mean±SD Range Mean±SD Range eyes with acute adenovirus conjunctivitis. There is general agreement between the extent Acute 41 42-9±26-1 11-9-80-9 141-9±63-3 22.7-206.8 of con- Remission 41 4-8±1-7 1-7-8-8 12-9±5-2 70-34-0 junctival inflammation and the levels of the two proteins in tear fluids (Table 2). The levels of the two proteins in tear fluids during the remission stage fell in viral isolation-positive patients (53.7 mg/l) and to those found in healthy controls. It is therefore viral isolation-negative patients (44-0 mg/l). Similar likely that the high levels of a1-antitrypsin and serum results were observed in respect of serum albumin albumin in tear fluids in patients with acute adeno- levels in tear fluids in viral isolation-negative and virus conjunctivitis were due to the inflammation and viral isolation-positive patients. not inherent or pre-existent. The tear ac-antitrypsin levels were measured in 41 The origin of the proteins in tear fluids is not clear. patients during the acute and remission stages (Table Active transport, transudation from serum, local 4). The mean level-during the acute stage was 42-9 production, or some combination of these factors mg/l which decreased to 4-8 mg/l during the remission may be involved. The route(s) by which increased stage. There was a statistically significant difference amounts of a1-antitrypsin enters tears in eyes (p<0001) between the levels in the acute and inflamed from acute adenovirus conjunctivitis is remission stages. However, there was no significant unknown. The most likely explanation is that the a,- difference (p>0-20) between the tear al-antitrypsin antitrypsin and serum albumin leak passively from levels in healthy subjects and in the remission stage. blood vessels that supply inflamed eyes. In support of Similarly the level of serum albumin in tear fluids this interpretation is the observation that the ratio of during the acute phase was 141-9 mg/l and it serum albumin to ac-antitrypsin is the same in tear decreased to 12.9 mg/l during the remission stage. fluids from conjunctivitis patients with raised a,- There was no statistically significant difference antitrypsin levels as in healthy controls. (p>0-50) between the level of serum albumin in tear ac-Antitrypsin acts like an acute-phase reactant,

fluids in healthy controls and in the remission stage. and its level tends to rise in inflammatory condi- http://bjo.bmj.com/ tions.' It has been commented that because of the Discussion acute reactant nature its concentration may change dramatically in the presence of inflammation.' The Serum a1-antitrypsin is frequently increased in protease inhibitor may also have a protective malignancy,'9 acute infections,'" corticosteroid function. I It has been suggested that during infection therapy,2' rheumatoid arthritis,22 pregnancy,' ac-antitrypsin production increases to counteract oestrogen therapy,24 sarcoidosis,5 leprosy,' and endogenous or exogenous protease.9 I It is possible uveitis.2' There is good evidence that a1-antitrypsin is that there is an excessive load of proteases in tears in on September 30, 2021 by guest. Protected copyright. involved in the regulation of the immune system.6 acute adenovirus conjunctivitis which may be There are a few studies on the study of tear a,- counterbalanced by the release of ac-antitrypsin. antitrypsin levels in various ocular conditions. The raised ac-antitrypsin and serum albumin in Bacterial infections of the conjunctiva and cornea tear fluids in patients with acute adenovirus con- cause an increase of a1-antitrypsin level, and the junctivitis in the present study are probably an measurement of its level may help in the diagnosis of indicator of inflammation rather than infection, ocular inflammation.'" It has also been shown that because the levels of the two proteins were markedly tear ac-antitrypsin levels may rise in inflamed eyes in high in viral isolation-positive and viral isolation- the absence of corneal involvement, for example, in negative patients. It will be interesting to study the cases of rosacea keratitis and allergic conjunctivitis.7 9 level of these two proteins in other inflammatory In fact in cases of allergic conjunctivitis tear levels diseases of the cornea and conjunctiva. of both a1-antitrypsin and serum albumin were observed to approach serum Thanks are due to Dr A K Prasad, Head of the Respiratory Virology levels rapidly, indicating Department, Vallabhbhai Patel Chest Institute, New Delhi, for help a direct leak from inflamed vessels.7 in viral culture studies. The tear ac-antitrypsin level in healthy controls in the present study are comparable to the levels References reported by others.7-9 We have measured the levels in 1 Morse JO. Alpha-i antitrypsin deficiency. N Engl J Med 1978; the patients with clinically diagnosed acute adeno- 299: 1045-8. Br J Ophthalmol: first published as 10.1136/bjo.72.5.390 on 1 May 1988. Downloaded from a,-Antitrypsin andserum albumin in tearfluids in acute adenovirus conjunctivitis 393

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