Spontaneous reversal of acquired autoimmune dysfibrinogenemia probably due to an antiidiotypic antibody directed to an interspecies cross-reactive idiotype expressed on antifibrinogen antibodies. A Ruiz-Arguelles J Clin Invest. 1988;82(3):958-963. https://doi.org/10.1172/JCI113704. Research Article A young man with a long history of abnormal bleeding was seen in January 1985. Coagulation tests showed dysfibrinogenemia and an antifibrinogen autoantibody was demonstrable in his serum. This antibody, when purified, was capable of inhibiting the polymerization of normal fibrin monomers, apparently through binding to the alpha fibrinogen chain. 6 mo later the patient was asymptomatic, coagulation tests were normal, and the antifibrinogen autoantibody was barely detectable. At this time, affinity-purified autologous and rabbit antifibrinogen antibodies were capable of absorbing an IgG kappa antibody from the patient's serum, which reacted indistinctly with both autologous and xenogeneic antifibrinogen antibodies in enzyme immunoassays. It has been concluded that the patient's dysfibrinogenemia was the result of an antifibrinogen autoantibody, and that later on an anti-idiotype antibody, which binds an interspecies cross- reactive idiotype expressed on anti-human fibrinogen antibodies, inhibited the production of the antifibrinogen autoantibody which led to the remission of the disorder. Find the latest version: https://jci.me/113704/pdf Spontaneous Reversal of Acquired Autoimmune Dysfibrinogenemia Probably Due to an Antildiotypic Antibody Directed to an Interspecies Cross-reactive Idiotype Expressed on Antifibrinogen Antibodies Alejandro Ruiz-Arguelles Department ofImmunology, Laboratorios Clinicos de Puebla, Puebla, Puebla 72530, Mexico Abstract disorder. This anti-Id antibody was shown to react with xeno- geneic antifibrinogen antibodies, hence, its specificity is an A young man with a long history of abnormal bleeding was interspecies cross-reactive Id (IdX)' most likely encoded by seen in January 1985. Coagulation tests showed dysfibrinogen- germline V-region genes. emia and an antifibrinogen autoantibody was demonstrable in his serum. This antibody, when purified, was capable of inhib- Methods iting the polymerization of normal fibrin monomers, appar- ently through binding to the a fibrinogen chain. 6 mo later the Case report. A 22-yr-old male patient with a long history of abnormal patient was asymptomatic, coagulation tests were normal, and bleeding was referred to Laboratorios Clinicos de Puebla in January the antifibrinogen autoantibody was barely detectable. At this 1985. For 10 yr he had presented a moderate to severe bleeding ten- time, affinity-purified autologous and rabbit antifibrinogen an- dency characterized by recurrent bleeding for several days from lacera- tibodies were capable of absorbing an IgG kappa antibody tions or dental procedures, soft tissue hematoma formation after mild from the patient's serum, which reacted indistinctly with both trauma, and one episode of intraarticular bleeding. He had no family autologous and antibodies in enzyme history ofbleeding disorders or autoimmune diseases. Although he was xenogeneic antifibrinogen seen by several physicians, a definite diagnosis of his hemostatic abnor- immunoassays. It has been concluded that the patient's dysfi- mality was never established. When first studied in our clinic he had brinogenemia was the result of an antifibrinogen autoantibody, abnormally prolonged thrombin and reptilase times (16, 17), while the and that later on an antiidiotype antibody, which binds an in- clottable fibrinogen was < 10% of the total fibrinogen mass as detected terspecies cross-reactive idiotype expressed on anti-human fi- by immunological and thermoprecipitation methods (18). Reptilase- brinogen antibodies, inhibited the production of the antifibrin- induced fibrin polymerization (17) was null. Complete hemostatic test ogen autoantibody which led to the remission of the disorder. results are summarized in Table I. The physical examination revealed retinal vasculitis, and cryoglobulins were demonstrated in his serum. The diagnosis of dysfibrinogenemia of possible autoimmune origin Introduction was established. Other laboratory tests for autoimmunity, such as The presence of auto anti-Id directed towards Ids lupus erythematosus clot, antinuclear antibodies, antiplatelet antibod- antibodies, ies, direct antiglobulin test, Ig levels, and rheumatoid factor, were all expressed on antibodies against exogenous (1-3) as well as normal or negative. A 10-d course oflow-dose methylprednisolone was endogenous (4-8) antigens, has been widely documented in given and withdrawn gradually in 2 wk. 6 mo later, he was absolutely humans. In fact, it is presumable that the expression of au- asymptomatic and all the laboratory tests had returned to normal. He toimmune humoral immune responses might be modulated, has been in complete remission for 30 mo. ita, est, augmented, or depressed, by anti-Id antibodies (6, Demonstration, isolation, and characterization of the autoantifi- 9-1 1). The production of autoantibodies directed to fibrino- brinogen antibody. Detection of antifibrinogen antibodies was per- gen as a cause of dysfibrinogenemia has been observed in the formed by means of an enzyme-linked immunosorbent assay (19). past (12-15). In some instances, these antibodies interfere with Briefly, purified human fibrinogen (lot S4F-9545, Sigma Chemical fibrinogen clotting by inhibiting the cleavage of fibrinopep- Co., St. Louis, MO) was adsorbed to microtiter dishes (Nunc, Ros- tides A and B while in other instances kilde, Denmark) by overnight incubation in carbonate buffer. Serum by thrombin, they samples and controls were placed in triplicate wells and incubated for 2 block the polymerization of fibrin monomers after thrombin h. After washing the wells repeatedly, an alkaline phosphatase-labeled cleavage. goat anti-human Ig antibody (lot 123F-8860; Sigma) was added and its This report refers to a case of autoimmune dysfibrinogen- binding was demonstrated by the addition ofp-nitrophenyl-phosphate. emia that was due to an antibody that inhibited fibrin poly- Antifibrinogen antibodies were purified by affinity chromatography on merization, in which a spontaneously produced anti-Id au- columns containing purified human fibrinogen coupled to cyanogen toantibody caused the inhibition of the antifibrinogen autoan- bromide (CNBr)-activated Sepharose 4B beads (20). The chain speci- tibody and led to the clinical remission of the hemorrhagic ficity of the antifibrinogen antibody was analyzed by immunoblotting (21); native purified fibrinogen, as well as samples that were either reduced by 2-mercaptoethanol (2ME) (22) or cleaved by CNBr (23) Address all correspondence to Dr. Alejandro Ruiz-Arguelles, Labora- were electrophoresed onto 7.5% polyacrylamide gels and transferred to torios Clinicos de Puebla, Diaz Ordaz 808, Puebla, Pue. 72530, nitrocellulose sheets. Duplicate strips, each of which contained the Mexico. three different fibrinogen preparations, were reacted with the patient's Received for publication 25 August 1987 and in revised form 18 antifibrinogen antibody, and its binding was developed by using a April 1988. biotinylated anti-human IgG antibody (lot 60407; Vector Laborato- J. Clin. Invest. © The American Society for Clinical Investigation, Inc. 1. Abbreviations used in this paper: CNBr, cyanogen bromide; EIA, 0021-9738/88/09/0958/06 $2.00 enzyme immunoassay; IdX, cross-reactive Id; 2ME, 2-mercaptoeth- Volume 82, September 1988, 958-963 anol. 958 A. Ruiz-Arguelles Table L Coagulation Studies in the Patient When Symptomatic described above. To further confirm preliminary results, normal fi- and during Clinical Remission brinogen was treated with thrombin in the presence of either patient's or control serum samples according to Kehl et al. (27). After heat Result precipitation of fibrin (ogen), the supernatant was analyzed by hydro- phobic interaction HPLC using a TSK phenyl 5 PW column (2133- Normal or 510; LKB, Bromma Sweden) along with a sodium sulfate gradient as Test Symptomatic Remission control descibed by Regnier and Fausnaugh (28). Additionally, total fibrino- peptide release was measured through quantitating the guanidino Fibrinogen (immunodiffusion) group of arginine according to Crum et al. (29). (mg/dl) 206 270 200-500 Demonstration and isolation ofanti-Id antibodies. The affinity-pu- Fibrinogen (clottable) (mg/dl) 18 240 200-400 rified anti-human fibrinogen antibody isolated from the patient's Thrombin time (s) serum was coupled to CnBr-activated Sepharose and packed into col- umns. Domestically raised rabbit anti-human fibrinogen antibodies 25 NIH U 278 79 82 were also affinity-purified and coupled to Sepharose beads for chroma- 50NIHU 68 33 36 tography. Serum samples from the patient when in clinical remission Reptilase time (s) >300 20 20 and from healthy controls were loaded into the aforementioned col- One-stage prothrombin time (s) 47 32 34 umns and allowed to react for 1 h at neutral pH. After complete elution Factor V activity Normal Normal Normal of the unbound material, the pH of the eluent was gradually lowered Factor VIII activity Normal Normal Normal until all bound antibodies were obtained (20). The Ig heavy and light Factor VIII related antigen (%) 96 102 65-130 chain classes present in this material were analyzed by immunofixa- Platelet aggregation (%) tion as previously described, and their antibody specificity was assessed Adenosine diphosphate by