Expressão aumentada do receptor Fc de IgA (CD89) e da cadeia g associada, avaliadas respectivamente por citometria de fluxo e por “immunobloting”, foram encontradas em fagócitos do sangue de pacientes com bacteremia por germes gram-negativos, em comparação com controles e pacientes com bacteremia por gram-positivos. A Mr do CD89 avaliada por SDS-PAGE estava diminuída, com núcleo protéico de 32kDa, sugerindo alteração de glicosilação. O aumento da expressão do CD89 correlacionou-se com aumento dos níveis séricos de IL-6. A cadeia g estava fosforilada nos neutrófilos, sugerindo participação do CD89 na sepsis por gram-negativos. / The expression and function of FcaRI (CD89) were analyzed on blood monocytes and neutrophils of patients with gram-positive and gram-negative bacteremia. Eighteen patients with gram-positive bacteremia, sixteen patients with gram-negative bacteremia and twenty healthy individuals were studied. CD89 expression were analyzed by flow cytometry using specific stained antibodies. Analysis of the surface iodinated CD89 molecules by SDS-PAGE and of the CD89 g-associated chain by immunoblotting also were performed. A marked increase in expression of the a and g subunits of the FcaRI were found on both types of cells in patients with gram-negative bacteremia, but not in patients with gram-positive bacteremia. This increase was independent of serum IgA levels. FcaRI Mr was lower on cells from gram negative patients than on cells from controls (50-65 kDa vs 55-75 kDa) despite of similar 32 kDa backbone, indicating altered glycosylation. Increased levels of FcaRI on blood phagocytes correlated with enhanced serum IL-6 levels, but not with IFN-g or TNF-a levels. The CD89 g-associated chain was phosphorylated on neutrophils, suggesting an engagement of CD89 during gram negative sepsis.

Made available in DSpace on 2016-08-16T18:18:40Z (GMT). No. of bitstreams: 1 TESE DE MONICA VIRGINIA VIEGAS LIMA.pdf: 3470227 bytes, checksum: 3f31c4cece76460417d5f04acc93728f (MD5) Previous issue date: 2012-12-18 / FUNDAÇÃO DE AMPARO À PESQUISA E AO DESENVOLVIMENTO CIENTIFICO E TECNOLÓGICO DO MARANHÃO / Saliva is a useful biological fluid with potential for diagnosis and monitoring of systemic disease because it reflects states of health and disease. Our objective was to evaluate the immunological and biochemical changes in saliva of pediatric patients with cancer, in diabetic patients and to investigate which plant species are most frequently used by diabetics as hypoglycemic. In immunological and biochemical evaluations Cancer patients consisted of 32 children with cancer and 115 children without cancer and the diabetic sample consisted 93 diabetic patients and 49 non diabetic. To assess the ethnopharmacological data 107 diabetics were interviewed using a standard questionnaire and semi-structured interview. The salivary biochemistry was determined by colorimetric assays and The IgA concentration was determined by Enzyme-Linked Immunosorbent Assay - ELISA. DMFT index was employed n dental evaluation. Children with cancer showed an increase in alkaline phosphatase, T4, TSH and glucose and decreased insulin and total IgA. Glucose, urea, calcium, total IgA, IgA anti-mutans IgA anti-insulin and DMFT index was higher in diabetic patients. 16 plant species have been reported for the treatment of diabetes, and pata de vaca , sweet olive, tamarind and insulin were the most used. We conclude the plant species most frequently mentioned have its efficacy as hypoglycemic scientifically attested and saliva can be used to monitor diabetics and cancer patients, which casts new perspectives in the monitoring and treatment of patients with hyperglycemic diseases. / A saliva é um fluido biológico que vem sendo utilizado na avaliação de doenças sistêmicas, pois reflete estados de saúde e doença. Investigamos as principais alterações imunológicas e bioquímicas na saliva em pediátricos com neoplasias, em pacientes diabéticos e ainda as espécies vegetais mais utilizadas pelos diabéticos como hipoglicemiantes. Foram avaliados 2 crianças com neoplasias e 115 crianças sem neoplasia e 93 pacientes diabéticos e 49 não diabéticos. Na avaliação etnofarmacológica foram entrevistados 107 diabéticos quanto ao uso de plantas no tratamento da diabetes e sintomas associados, utilizando-se questionário padrão e entrevista semi-estruturada. A bioquímica salivar foi determinada por método colorimétrico e a produção de anticorpos IgA foi determinada por ensaio imunoenzimático - ELISA. Na avaliação odontológica utilizou-se o índice CPO-D. Crianças com neoplasias apresentaram aumento na concentração de fosfatase alcalina, T4, TSH e glicose e uma diminuição de insulina e IgA total. Glicose, uréia, cálcio, IgA total, IgA anti-mutans, IgA anti-insulina e o índice CPO-D foram maiores em pacientes diabéticos. Foram relatadas 16 espécies vegetais para tratamento do diabetes, sendo que pata de vaca, azeitona doce, insulina e tamarindo foram as mais utilizadas. Concluímos que as espécies vegetais mais frequentemente mencionadas como coadjuvantes no tratamento da diabetes apresentam eficácia cientificamente comprovada como hipoglicemiantes, e ainda que a saliva pode ser utilizados no acompanhamento de diabéticos e crianças com neoplasias e o que lança novas perspectivas no acompanhamento e no tratamento de pacientes com doenças hiperglicemiantes.

Abstract The aim of this work was to describe the clinical features and clinical course of Henoch-Schönlein purpura (HSP) in a prospective setting, to compare the efficacy of cyclosporine A (CyA) and methylprednisolone (MP) pulses for the treatment of severe HSP nephritis (HSN) and to study the effect of prophylactic prednisone treatment given at disease onset on the long-term outcome. A total of 223 children with newly diagnosed HSP were followed up prospectively for 6 months. Patients with severe HSN also had extrarenal symptoms more frequently during this time. Protein loss via the intestine was more common than previously described, occurring in 3% of the patients. HSN developed in the early course of the disease. The results suggest that weekly urine dipstick tests are indicated for 2 months after HSP onset and individually for over 6 months in cases of HSN or HSP recurrences. Prednisone did not affect the frequency or timing of the appearance of HSN. The efficacy of CyA and MP treatments was evaluated in a trial with a mean follow-up time of 6 years involving 24 paediatric patients (11 CyA, 13 MP), 15 of whom were randomized and 9 were treated according to the given protocol without randomization. Oral CyA was not inferior to intravenous MP pulses and proved to be an efficient, safe steroid-sparing treatment for severe HSN. All the CyA-treated patients achieved remission of nephrotic-range proteinuria within 3 months, while remission was achieved more slowly in the MP group and only in 6/13 (46%) with the initial treatment. There was no difference in the renal biopsy findings two years after initiation of the therapy. The 8-year outcome of HSP was assessed by means of a health questionnaire in 160 (94%) of the 171 former patients in the randomized placebo-controlled prednisone trial and in 138 (81%) with urine analysis and measurement of blood pressure. HSP carried a good prognosis, although skin relapses occurred up to a decade after the initial onset and could be accompanied by late-onset nephritis. Hypertension and/or renal abnormalities were recorded in 13% of the patients, being more frequent in those with an initial occurrence of HSN (OR 4.3, p=0.009, 95% CI 1.4–14.0) and warranting long-term follow-up of HSN patients. Early prednisone treatment did not affect the long-term outcome of HSP and should not be routinely used. / Tiivistelmä Väitöskirjan tarkoituksena oli kuvata Henoch-Schönleinin purppuran (HSP) oireita ja taudinkulkua, verrata siklosporiini A:n (CyA) ja metyyliprednisolonipulssihoidon (MP-pulssihoidon) tehoa vaikean HSP-nefriitin (HSN) hoidossa ja selvittää taudin alussa annetun prednisonihoidon vaikutusta pitkäaikaisennusteeseen. Taudinkulkua seurattiin prospektiivisesti 6 kuukauden ajan diagnoosista 223 lapsipotilaan aineistossa. Potilailla, joilla oli vaikea HSN, esiintyi myös muita oireita pitempään. Proteiinin menetystä suolistoon esiintyi 3 %:lla, mikä on aiemmin kuvattua yleisempää. HSN ilmaantui taudin alkuvaiheessa. Tutkimustulosten perusteella viikoittainen virtsanäytteiden seuranta riittää 2 kuukauden ajan taudin alusta. Seuranta-aikaa tulee pidentää yksilöllisesti yli 6 kuukauden, jos potilaalla todetaan HSN tai HSP uusiutuu. Prednisonilla ei todettu olevan vaikutusta HSN:n yleisyyteen tai ilmaantumisaikaan. CyA- ja MP-hoitojen tehoa vaikeaan HSN:n seurattiin 24 lapsipotilaan aineistossa (11 CyA, 13 MP) 6 vuoden ajan. Potilaista 15 satunnaistettiin hoitoryhmiin ja 9 hoidettiin tutkimussuunnitelman mukaan ilman satunnaistamista. Suun kautta otettu CyA vaikutti hoidoista tehokkaammalta, sillä kaikilla potilailla nefroottistasoinen valkuaisvirtsaisuus hävisi kolmessa kuukaudessa. MP-hoitoa saaneista vain 6/13 (46 %) pääsi remissioon MP-hoidolla ja hekin CyA-hoidettuja hitaammin. Kaksi vuotta tutkimuksen alusta otettujen munuaisbiopsioiden histologisissa löydöksissä ei ollut eroa ryhmien välillä. Varhaisen kortisonihoidon pitkäaikaisvaikutuksia arvioitiin 8 vuotta lumekontrolloidun prednisonihoitotutkimuksen jälkeen, jolloin aiemman tutkimuksen 171 potilaasta 160 (94 %) vastasi terveyskyselyyn ja 138 (81 %) osallistui virtsa-analyysin ja verenpaineen mittauksen sisältäneeseen seurantatutkimukseen. HSP:n ennuste oli hyvä, vaikka taudin iho-oireet saattoivat uusia jopa 10 vuoden ajan ja taudin uusiutumisen yhteydessä saattoi ilmaantua myöhäinen HSN. Kohonnut verenpaine ja/tai valkuais-/verivirtsaisuus todettiin 13 %:lla. Ne olivat yleisempiä potilailla, joilla oli ollut HSN taudin alkuvaiheessa (OR 4.3, p=0.009, 95 % CI 1.4–14.0). Siten HSN-potilaiden pitkäaikaisseuranta on tarpeen. Varhaisella kortisonihoidolla ei ollut vaikutusta taudin ennusteeseen, minkä vuoksi kortisonia tulee käyttää HSP-potilaiden hoidossa vain harkiten.

Toute maladie rénale chronique (MRC) se caractérise par le développement de lésions de fibrose rénale et d’une perte de fonction qui peut, à terme conduire vers l’insuffisance rénale chronique terminale. miR-21-5p est un microARN ubiquitaire impliqué dans le processus de fibrose, notamment rénale. Toutefois, des données expérimentales contradictoires suggèrent que miR-21-5p joue un rôle ambivalent dans la constitution des lésions rénales de fibrose.L’objectif de ce travail est de préciser l’implication de miR-21 au cours des lésions rénales aigües, en s’appuyant sur un modèle murin de toxicité rénale du cisplatine, ou chroniques chez l’homme au cours de la néphropahtie à dépôts mésangiaux d’IgA (maladie de Berger).Dans un premier travail, une cohorte rétrospective de patients porteurs d’une néphropathie à dépôts mésangiaux d’IgA a été caractérisée de façon systématique sur le plan clinico-biologique et anatomo-pathologique (classification d’Oxford). L’expression rénale de trois fibromiR (miR-21-5p, miR-199a-5p et miR-214-3p) est associée aux lésions de fibrose rénale (p ≤ 0,02). Parmi ces microARN, miR-21-5p semble le plus pertinent car il présente des amplitudes de variation d’expression plus importantes selon le niveau de fibrose, il est également associé aux lésions de sclérose glomérulaire (p = 0,001) et son niveau d’expression tissulaire rénale est associée à une moins bonne survie rénale.Un second travail a été mené en utilisant un modèle murin d’insuffisance rénale aiguë secondaire à l’injection intra-péritonéale de cisplatine chez des animaux invalidé pour miR-21a-5p. Deux schémas d’injections ont été réalisés afin explorer le rôle de miR-21a-5p au cours de lésions rénales aiguës (injection d’une dose unique de 10mg/kg de cisplatine) ou subaiguës (injections répétées de 7 mg/kg de cisplatine). Les souris ayant reçu une injection unique de cisplatine ne présentent pas de différence significative d’urée sanguine, de marqueurs de souffrance rénale (NGAL, KIM-1), d’inflammation (TNF-α, IL-6) et de stress oxydant (HO-1, NRF2), ni d’activité apoptotique selon leur statut sauvage ou invalidé pour miR-21a-5p. Le modèle d’injections répétées de cisplatine a, quant à lui, permis de mettre en évidence des lésions plus importantes chez les souris miR-21-/-. En effet, les souris miR-21-/- cisplatine présentent une urée sanguine plus élevée (1,92 g/l ±, 0,72 versus 0,66 g/l ± 0,15 p = 0,014) et une expression rénale de NGAL plus importante (RQ = 118,1 ± 44,8 versus RQ = 45,4 ± 37,7, p= 0,018) que le souris sauvages cisplatine. Enfin les lésions rénales de nécrose tubulaire aiguë observées sont plus sévères chez les souris miR-21-/-.Ainsi ces résultats montrent qu’une forte expression rénale de miR-21-5p est associée à la fibrose et au pronostic rénal chez des patients porteurs d’une néphropathie à dépôts mésangiaux d’IgA. Dans notre modèle expérimental, les souris déficientes pour miR-21a-5p présentent une sensibilité variable au développement de lésions rénales induites par le cisplatine en fonction du type d’administration, aigu ou subaigu. Ces résultats confirment que miR-21-5p joue un rôle ambivalent au cours des lésions rénales, protecteur à la phase précoce d’une agression rénale aiguë et délétère lorsque le processus se prolonge dans le temps. miR-21-5p est présent dans les fluides biologiques, et constitue ainsi un candidat potentiel en tant que biomarqueur de la fibrose rénale. De plus, miR-21-5p constitue une cible thérapeutique innovante, ayant montré son efficacité dans différents modèles murins de fibrose rénale. / Independently of the cause, active CKD leads to the development of fibrotic lesions, responsible for a loss of renal function and ultimately, end-stage renal failure. MiR-21-5p is a ubiquitous microRNA involved in the process of fibrosis, especially renal fibrosis. However, contradictory experimental data suggest that miR-21-5p plays an ambivalent role in the regulation of renal fibrosis.The aim of this work was to investigate the involvement of miR-21 in chronic renal lesions based on human renal samples and in acute lesions by using a murine model of renal toxicity induced by cisplatin.In a first part of the work, a retrospective cohort of patients with IgA nephropathy has been systematically characterized clinically, biologically and pathologically (according to Oxford classification). The renal expression of three FibromiRs (miR-21-5p, miR-199a-5p and miR-214-3p) is associated with renal fibrosis lesions (p ≤ 0.02). Among these microRNAs, miR-21 appears to be the most relevant as it displayed larger amplitudes of variation, it was also associated with glomerular sclerosis (p = 0.001) and its strong expression was associated with lower renal survival.A second part of the work was carried out on a murine model of acute renal failure secondary to the intraperitoneal injection of cisplatin. Two injections schemes were established to investigate the role of miR-21-5p in acute renal lesions (injection of a single dose of 10 mg/kg cisplatin) or subacute (repeated injections of 7 mg/kg cisplatin). After a single injection of cisplatin, no significant difference in blood urea, renal (NGAL, KIM-1), inflammation (TNF-α, IL-6) and oxidative stress (HO-1, NRF2) nor apoptotic activity was observed in miR21-/- mice compared to wild-type mice. In a model of repeated injections of cisplatin, we observed more renal lesions in miR-21-/- mice. Indeed, miR-21-/- mice treated with cisplatin exhibited higher blood urea (1.92 g / l ±, 0.72 versus 0.66 g / l ± 0.15 p = 0.014) and an increased renal expression of NGAL (RQ = 118.1 ± 44.8 versus RQ = 45.4 ± 37.7, p = 0.018) compared to wild-type mice.Thus, these results demonstrate that an increased renal expression of miR-21-5p is associated with fibrosis and renal prognosis in patients with IgA nephropathy. In an experimental model, of cisplatin-induced renal injury, mice deficient for miR-21a-5p exhibit a higher sensitivity when cisplatin was administered several times. These results confirm that miR-21-5p plays an ambivalent role in renal lesions and seems to be protective at an early stage, or deleterious when the process is prolonged over time. As miR-21-5p is present in biological fluids, it might be an efficient biomarker of renal fibrosis. Moreover, miR-21-5p is an innovative therapeutic target validated in several murine models of renal fibrosis.

Infants are born with naive immune systems, making them susceptible to a variety of infections. In order to protect the newborn infant it is important that mothers be able to pass protective IgA antibodies to their infants through breast milk. B cells that produce IgA enter the mammary tissue during lactation and secrete IgA into the milk. During pregnancy, the mammary tissue expresses high levels of chemokines, molecules that allow lymphocytes to selectively home to specific tissues. The chemokine CCL28 has been shown to be upregulated during both pregnancy and lactation, and is vital for the ability of IgA-producing B cells to home to the mammary tissue during lactation. The aim of this study was to determine whether CCL28 expression is regulated by prolactin signaling.

The mucosal system, which forms a barrier between internal organ systems and the external environment, is frequently exposed to pathogenic microorganisms. Immunoglobulin A (IgA) antibody secreting cells (ASCs) localize in the lamina propria, and produce IgA antibodies which help protect mucosal tissues. The concept of a common mucosal immune system in which IgA ASCs have the ability to populate any mucosal site has been proposed (1, 2). However, recent research has suggested that IgA ASCs primed in different mucosal sites might possess different sets of chemokine receptors, and therefore migrate specifically to particular mucosal locations (3). In this study, the specific compartmentalization of IgA ASCs in two mouse salivary glands: sublingual gland (SLG), and submandibular gland (SMG) was studied. It was observed that SLG had 12 times more IgA ASCs per gram of gland than that of SMG (p<0.01). This suggested that IgA ASCs migrated to the two salivary glands with different efficiencies. Since the migration of lymphocytes is mediated by interactions between tissue specific chemokines and chemokine receptors, I hypothesized that the specific compartmentalization of IgA ASCs in the SLG and SMG was mediated by the differential expression of IgA ASC attracting chemokines. Quantitative PCR was used and showed that SLG expressed high levels of CCL28 and its receptor CCR10, which correlated to the distribution of IgA ASCs in the two salivary glands. In agreement with QPCR data, reduced levels of IgA ASCs were found in the SLG of CCR10 deficient mice when compared to wild type (WT) mice. Adoptive transfer of CCR10 deficient mice with WT spleen cells reconstituted the WT phenotype. It was therefore concluded that the interaction between CCL28 and CCR10 play an important role in mediating the migration of IgA ASCs into SLG. These results suggested that the accumulation of IgA ASC to distinct salivary glands is a highly selective process. These data also suggested that homing within mucosal sites is not common but rather a highly regulated process with specific subsets of cells homing to different tissues within the mucosal immune system.

Le but de ce projet, en collaboration avec Héma-Québec, était de développer une méthode point de service (POC) pour la quantification des immunoglobulines A (IgA) dans un petit volume de plasma humain. Les IgA jouent un rôle important au niveau de notre système immunitaire, surtout au niveau des bio fluides sur les muqueuses comme la salive. On peut les retrouver normalement dans le plasma à des concentrations plus grandes que 2000 ng/mL pour la majorité des gens. Dans le cas d’une personne immunosupprimée, une concentration plus basse que 500 ng/mL est observée. La déficience en IgA est souvent associée à des maladies auto-immunes comme la maladie de Crohn. Ces individus peuvent éprouver un choc anaphylactique à la suite d’une transfusion de sang, ce qui nous motive à utiliser la résonance des plasmons de surface (SPR) sur place à des collectes de sang et dans les milieux hospitaliers. Pour réaliser ce capteur d’immunodéficience en IgA, un anticorps primaire spécifique aux IgA fut lié à un peptide formant une monocouche auto-assemblée sur une surface d’or du capteur SPR. Un deuxième anticorps a été utilisé pour quantifier spécifiquement cet analyte dans une matrice humaine complexe. Plusieurs étapes ont été optimisées pour obtenir une limite de détection basse, soit l’étape d’immobilisation de l’anticorps de capture, le type d’anticorps, le pH pour l’immobilisation, la détection secondaire, la validation dans différentes matrices biologiques, parmi d’autres. Le capteur a été validé avec quelques échantillons cliniques et la réponse SPR fut comparée avec ELISA. Ainsi, nous anticipons que cette méthode pourrait être utile à des collectes de sang pour assurer les réserves de sang déficient en IgA. / The goal of this project, in collaboration with Héma-Québec, was to develop a point-ofcare (POC) method to quantify immunoglobulin A (IgA) in a small volume of human plasma. Immunoglobulin A play an important role in immunity, specifically in biofluids on mucosaes like saliva. It can generally be found in plasma at concentrations higher than 2000 ng/mL for most people. In the case of an immunosuppressed individual, a concentration under 500 ng/mL is observed. IgA-deficiency is often associated with autoimmune diseases, such as Crohn’s disease. These individuals may experience an anaphylactic shock following a blood transfusion, which motivated us to use surface plasmon resonance (SPR) on site at blood drives and in a hospital setting. SPR quantifies the interactions between biomolecules. It is a complementary technique to ELISA that can test more rapidly individuals susceptible of being IgA-deficient in a hospital setting or at blood drives. To develop an IgA SPR sensor, a specific capture antibody to IgA was bound to a peptide monolayer on the gold surface. A second antibody was used to specifically quantify IgA in a complex matrix. Multiple steps were optimized to achieve the low detection limits required for IgA detection, such as the capture antibody immobilisation step, type of antibody, pH of immobilisation buffer, secondary detection, validation in different biological matrices, among others. The SPR sensor was validated with a few clinical samples, and compared to ELISA, to demonstrate the potential. As such, we envision that this rapid method may be used at blood drives to ensure sufficient reserves of IgA-deficient blood.

A deficiência de imunoglobulina A (DIgA) é a imunodeficiência primária mais comum com prevalência de 1: 223 a 1:1000 em estudos epidemiológcos, sendo menos freqüente em populações asiáticas. As manifestações clínicas variam desde indivíduos assintomáticos até aqueles com manifestações atópicas, auto-imunes ou infecciosas. Entre estas últimas destacam-se os acometimentos dos tratos respiratório e digestório. Associação com outras imunodeficiências primárias tem sido reportada, em especial a imunodeficiência comum variável e a deficiência de subclasses de imunoglobulina G. Os objetivos deste estudo foram a avaliação dos pacientes com DIgA, diagnosticados na infância, após a segunda década da vida e a avaliação diagnóstica de seus familiares quanto aos aspectos clínicos e laboratoriais. A metodologia utilizou, para o diagnóstico de DIgA, o critério adotado pelo ESID/PAGID (1999). Foi realizada a avaliação das concentrações de imunoglobulina A(IgA) e imunoglobulina M (IgM), na saliva e a pesquisa de auto-anticorpos séricos (Anti-tireóide, FR,FAN) nos pacientes e familiares com DIgA. Realizou-se uma curva de distribuição de IgM salivar em indivíduos normais para comparação com os pacientes DIgA. Os resultados mostraram a avaliação dos 34 pacientes (19 do sexo feminino) com deficiência de imunoglobulina A (DIgA) com idade superior a 10 anos (variação: 10 à 52 anos), sendo 27 deles diagnosticados na infância e 7 familiares dos 62, que responderam à convocação. Considerando-se todos os indivíduos com DIgA, processos infecciosos (de repetição ou graves) ocorreram em 91,2%, manifestações atópicas em 58,8% e auto-imunidade em 52,9%. Manifestações clínicas de auto-imunidade foram observadas em 14/18 indivíduos, sendo que sete foram diagnosticados após 10 anos de idade, por ocasião da realização da pesquisa. Auto-anticorpos foram observados em 10 pacientes, sendo quatro pacientes assintomáticos. Fator reumatóide não foi detectado nesta casuística. Tireoidopatias (seis casos) e artropatias (quatro casos) foram as manifestações clínicas auto-imunes mais observadas. As concentrações de IgM salivar mostraramse elevadas em todos, exceto cinco casos. A comparação dessas concentrações nos grupos com e sem auto-imunidade não mostrou diferença significante (p= 0,48). As conclusões desta pesquisa mostraram os processos infecciosos como as manifestações clínicas mais freqüentes nos pacientes com DIgA, observando-se, porém, uma relevante presença de auto-imunidade nestes pacientes quando reavaliados após a segunda década de vida. Este fato alerta para a necessidade de avaliação rotineira de fenômenos auto- imunes nestes pacientes, durante seguimento. As concentrações de IgM salivar foram semelhantes em pacientes com DIgA com e sem auto-imunidade. Auto-anticorpos foram detectados independentemente da presença de sintomatologia clínica, sendo os mais encontrados aqueles relacionados à tireóide. Os familiares de primeiro grau dos pacientes com DIgA devem ser avaliados, tanto para diagnóstico de imunodeficiências como para detecção de fenômenos auto-imunes, permitindo assim o diagnóstico e abordagens precoces de ambas condições. / IgA deficiency (IgAD) is the most frequent primary immunodeficiency. Its prevalence varies from 1:223 to 1:1000 in epidemiological studies, but in asiatic populations it is uncommon. The clinical manifestations of IgAD are spectral, ranging from asymptomatic patients to recurrent infections, allergic symptoms and/or autoimmunity conditions. The most common infections frequently associated to IgAD involve respiratory and gastrointestinal tracts. The association with other primary immunodeficiency such as common variable immunodeficiency and immunoglobulin G subclasses deficiency has been reported. The aim of this study is to describe clinical and laboratorial evolution regarding autoimmune manifestations in IgAD patients diagnosed during the first years of life and after the second decade and their relatives diagnosed during this study. Laboratorial data included immunoglobulins A and M levels in saliva and auto-antibody screening in immunoglobulin A deficient relatives and patient. The criterion adopted for IgAD diagnosis was defined by Pan-American Group for Immunodeficiency and European Society for Immunodeficiency. The results showed 34 (19 female) immunoglobulin A deficient patients (IgAD) over 10 years of age (range: 10-52 years), 27 of them diagnosed during their childhood, and seven adults detected among 62 screened relatives. Recurrent infections were diagnosed in 91.2% of cases, atopic manifestations in 58.8% and autoimmune clinical manifestation in 52.9%. Autoimmune clinical manifestations were observed in 14 of our 18 IgA deficient patients and relatives with autoimmunity phenomena and seven of them diagnosed only over 10 years old during the study. Auto-antibodies were observed in (10/18) of patients and relatives, with four of them (asymptomatic) showing only the presence of auto-antibodies. Thyroid and osteo-articular involvement (six and four cases, respectively) were the most frequent clinical autoimmune manifestations. The rheumatoid factor was not detected in this casuistic. Auto-antibodies had no statistical difference among patients with or without autoimmunity phenomena. High salivary IgM concentrations were detected in all IgA deficient patients and relatives, except five cases. The comparison of these concentrations in the groups with and without autoimmunity did not show significant difference (p=.0, 48). In conclusion, recurrent infections were the most frequent clinical manifestations of IgA deficient patients and also autoimmune diseases, after the second decade of life. This fact at this series reinforced the necessity of active search for autoimmune conditions diagnosis in these patients. IgM levels showed no statistical difference among IgA deficient patients and relatives with or without autoimmunity. Auto-antibodies, mainly anti-thyroid antibodies, were detected in patients independently of autoimmunity clinical manifestation presence. This study showed the importance of the first degree relatives of IgA deficient patients evaluation, focusing as immunodeficiency as autoimmune disease, permiting an earlier diagnosis of both conditions and an adequate approach to optimize the clinical management and improvement of quality of life of IgAD patients.

INTRODUÇÃO: A deficiência de IgA (DIgA) é a imunodeficiência primária mais comum e caracteriza-se pela presença de concentrações de IgA sérica abaixo de 7 mg/dL e níveis normais de IgM e IgG. A maioria dos indivíduos acometidos não apresenta doença aparente embora alguns possam apresentar infecções recorrentes ou crônicas de mucosas, atopia e/ou doenças autoimunes (DAIs). Presumivelmente, a doença resulta de um defeito na troca de isótipo para IgA ou de falha na maturação de linfócitos produtores de IgA. A imunodeficiência comum variável (ICV) constitui uma deficiência primária de anticorpos caracterizada por níveis séricos baixos de IgG, IgA e/ou IgM, ao lado de valores normais ou diminuídos de linfócitos B e/ou T, levando a infecções crônicas ou recorrentes principalmente dos tratos respiratório e gastrintestinal. Embora a fisiopatologia da ICV ainda não esteja esclarecida, em muitos pacientes ela pode ser decorrente de algum defeito intrínseco de linfócitos B. De modo especial, as células B de memória (CD27+) têm sido correlacionadas com alguns aspectos clínicos da doença. Números elevados de células B de memória com persistência de IgM (CD27+IgM+) parecem estar correlacionados com a presença de infecções, enquanto valores diminuídos de células B de memória clássicas ou class-switched (CD27+IgG-IgM-) parecem estar associados a baixos níveis de IgG e presença de autoimunidade. A progressão de DIgA para ICV tem sido descrita em alguns pacientes embora não constitua regra geral. Uma hipótese é a de que uma base genética comum e a associação com DAIs possam constituir fatores de risco para a progressão de DIgA para ICV. Há relato anterior de que a persistência de células B imaturas IgM+ IgD+ em alguns pacientes com DIgA estava associada à progressão para ICV. Adicionalmente, há evidências de que a diminuição de células B de memória em uma proporção de pacientes com ICV esteja associada à presença de autoimunidade. OBJETIVOS: comparar em pacientes com DIgA e ICV várias subpopulações de células B e analisar a relação entre estas populações celulares e a presença de DAIs em ambos grupos. MÉTODO: Este estudo incluiu 56 pacientes adultos de ambos sexos com DIgA e ICV, distribuídos em grupos de acordo com a associação com DAI: grupo DIgA sem DAI (14 pacientes), grupo DIgA com DAI (14 pacientes), grupo ICV sem DAI (14 pacientes) e grupo ICV com DAI (14 pacientes). As seguintes subpopulações de células B foram determinadas por citometria de fluxo de quatro-cores: células B naive (CD19+IgM+), células B de memória clássicas ou class-switched (CD27+IgM-IgD-) e células B de memória imaturas (CD27+IgM+ or CD27+IgD+). Na análise estatística foi aplicado o teste de ANOVA; valores significativos foram determinados pela correção de Bonferoni. RESULTADOS: os grupos analisados foram homogêneos quanto à idade e distribuição de gêneros. Os valores de linfócitos totais e de células B naive foram similares nos quatro grupos estudados. Os pacientes com deficiência de IgA e ICV com DAIs associadas apresentaram valores igualmente aumentados de células B de memória imaturas CD27+IgM+ e CD27+IgD+ quando comparados a pacientes sem doenças autoimunes. CONCLUSÕES: estes resultados sugerem que a persistência de células B de memória imaturas possa estar relacionada à presença de autoimunidade em pacientes com DIgA e ICV. Especula-se se a persistência destas células em pacientes com DIgA e DAI associada possa constituir fator preditivo da progressão de DIgA para ICV. / INTRODUCTION: IgA deficiency (IgAD) is the most common primary immunodeficiency disorder and is characterized by serum IgA concentration below 7 mg/dL and normal serum IgM and IgG levels. Most of the affected individuals have no apparent disease, whereas selected patients suffer from recurrent or chronic mucosal infections, atopy and/or autoimmune diseases (AIDs). This defect is presumed to result from impaired class-switching to IgA or from maturational failure of IgA-producing lymphocytes. Common variable immunodeficiency (CVID) is a primary antibody deficiency disease characterized by low serum levels of IgG, IgA and/or IgM, and normal or decreased B and/or T cell numbers, leading to chronic or recurrent infections, noted mostly in the respiratory and gastrointestinal tract. While the pathophysiology of CVID remains elusive, in many patients it may be due to an intrinsic B cell defect. Memory B cells (CD27+) in particular, have been noted to correlate with certain clinical aspects of the disease. High numbers of IgM+ memory B cells (CD27+IgM+) appear to correlate with the presence of infections, whereas decreased numbers of classic (class-switched) memory B cells (CD27+IgG-IgM- ) correlate with lower serum IgG levels and increased rates of autoimmune features. Progression from IgAD to common variable immunodeficiency (CVID) has been reported in some patients, but is not a general rule. It is postulated that a common genetic base and association with AIDs could be risk factors for progression from IgAD to CVID. OBJECTIVES: The aim of this study was to compare B cell subpopulations of patients with IgAD and with CVID, and to assess the relationship between these populations and the presence of autoimmune diseases in both group of patients: . METHOD: The study included 56 adult patients of both genders with IgAD or CVID. Patients were grouped, according to the association with autoimmune disease,as follows: group IgAD with AID (14 patients), group IgAD without AID (14 patients), group CVID with AID (14 patients) and group CVID without AID (14 patients). We determined by immunophenotyping of lymphocytes by four-colour cytometry the following subpopulations of B cells: naïve B cells (CD19+IgM+), class-switched memory B cells (CD27+IgM-IgD-) and immature B memory cells (CD27+IgM+ or CD27+IgD+). Statistical analysis was performed by the ANOVA test; significant P-values were determined by means of Bonferonis correction. RESULTS: there is no statistically significant difference between the average ages and the gender of patients between the groups. the distribution of the sample values seem to indicating that, there is no statistically significant difference in the CD19 levels between the groups. patients with AID represent greater values of CD27 IgM+ and CD27+ IgD+ than patients without AID, independent of the group studied. CONCLUSIONS: These results suggest that the persistence of immature memory B cells in patients with IgAD and CVID can be related to autoimmune diseases. We speculate if the persistence of immature B cells can constitute risk factor to progression of IgAD for CVID.

A deficiência de imunoglobulina A (DIgA) é a imunodeficiência primária mais comum com prevalência de 1: 223 a 1:1000 em estudos epidemiológcos, sendo menos freqüente em populações asiáticas. As manifestações clínicas variam desde indivíduos assintomáticos até aqueles com manifestações atópicas, auto-imunes ou infecciosas. Entre estas últimas destacam-se os acometimentos dos tratos respiratório e digestório. Associação com outras imunodeficiências primárias tem sido reportada, em especial a imunodeficiência comum variável e a deficiência de subclasses de imunoglobulina G. Os objetivos deste estudo foram a avaliação dos pacientes com DIgA, diagnosticados na infância, após a segunda década da vida e a avaliação diagnóstica de seus familiares quanto aos aspectos clínicos e laboratoriais. A metodologia utilizou, para o diagnóstico de DIgA, o critério adotado pelo ESID/PAGID (1999). Foi realizada a avaliação das concentrações de imunoglobulina A(IgA) e imunoglobulina M (IgM), na saliva e a pesquisa de auto-anticorpos séricos (Anti-tireóide, FR,FAN) nos pacientes e familiares com DIgA. Realizou-se uma curva de distribuição de IgM salivar em indivíduos normais para comparação com os pacientes DIgA. Os resultados mostraram a avaliação dos 34 pacientes (19 do sexo feminino) com deficiência de imunoglobulina A (DIgA) com idade superior a 10 anos (variação: 10 à 52 anos), sendo 27 deles diagnosticados na infância e 7 familiares dos 62, que responderam à convocação. Considerando-se todos os indivíduos com DIgA, processos infecciosos (de repetição ou graves) ocorreram em 91,2%, manifestações atópicas em 58,8% e auto-imunidade em 52,9%. Manifestações clínicas de auto-imunidade foram observadas em 14/18 indivíduos, sendo que sete foram diagnosticados após 10 anos de idade, por ocasião da realização da pesquisa. Auto-anticorpos foram observados em 10 pacientes, sendo quatro pacientes assintomáticos. Fator reumatóide não foi detectado nesta casuística. Tireoidopatias (seis casos) e artropatias (quatro casos) foram as manifestações clínicas auto-imunes mais observadas. As concentrações de IgM salivar mostraramse elevadas em todos, exceto cinco casos. A comparação dessas concentrações nos grupos com e sem auto-imunidade não mostrou diferença significante (p= 0,48). As conclusões desta pesquisa mostraram os processos infecciosos como as manifestações clínicas mais freqüentes nos pacientes com DIgA, observando-se, porém, uma relevante presença de auto-imunidade nestes pacientes quando reavaliados após a segunda década de vida. Este fato alerta para a necessidade de avaliação rotineira de fenômenos auto- imunes nestes pacientes, durante seguimento. As concentrações de IgM salivar foram semelhantes em pacientes com DIgA com e sem auto-imunidade. Auto-anticorpos foram detectados independentemente da presença de sintomatologia clínica, sendo os mais encontrados aqueles relacionados à tireóide. Os familiares de primeiro grau dos pacientes com DIgA devem ser avaliados, tanto para diagnóstico de imunodeficiências como para detecção de fenômenos auto-imunes, permitindo assim o diagnóstico e abordagens precoces de ambas condições. / IgA deficiency (IgAD) is the most frequent primary immunodeficiency. Its prevalence varies from 1:223 to 1:1000 in epidemiological studies, but in asiatic populations it is uncommon. The clinical manifestations of IgAD are spectral, ranging from asymptomatic patients to recurrent infections, allergic symptoms and/or autoimmunity conditions. The most common infections frequently associated to IgAD involve respiratory and gastrointestinal tracts. The association with other primary immunodeficiency such as common variable immunodeficiency and immunoglobulin G subclasses deficiency has been reported. The aim of this study is to describe clinical and laboratorial evolution regarding autoimmune manifestations in IgAD patients diagnosed during the first years of life and after the second decade and their relatives diagnosed during this study. Laboratorial data included immunoglobulins A and M levels in saliva and auto-antibody screening in immunoglobulin A deficient relatives and patient. The criterion adopted for IgAD diagnosis was defined by Pan-American Group for Immunodeficiency and European Society for Immunodeficiency. The results showed 34 (19 female) immunoglobulin A deficient patients (IgAD) over 10 years of age (range: 10-52 years), 27 of them diagnosed during their childhood, and seven adults detected among 62 screened relatives. Recurrent infections were diagnosed in 91.2% of cases, atopic manifestations in 58.8% and autoimmune clinical manifestation in 52.9%. Autoimmune clinical manifestations were observed in 14 of our 18 IgA deficient patients and relatives with autoimmunity phenomena and seven of them diagnosed only over 10 years old during the study. Auto-antibodies were observed in (10/18) of patients and relatives, with four of them (asymptomatic) showing only the presence of auto-antibodies. Thyroid and osteo-articular involvement (six and four cases, respectively) were the most frequent clinical autoimmune manifestations. The rheumatoid factor was not detected in this casuistic. Auto-antibodies had no statistical difference among patients with or without autoimmunity phenomena. High salivary IgM concentrations were detected in all IgA deficient patients and relatives, except five cases. The comparison of these concentrations in the groups with and without autoimmunity did not show significant difference (p=.0, 48). In conclusion, recurrent infections were the most frequent clinical manifestations of IgA deficient patients and also autoimmune diseases, after the second decade of life. This fact at this series reinforced the necessity of active search for autoimmune conditions diagnosis in these patients. IgM levels showed no statistical difference among IgA deficient patients and relatives with or without autoimmunity. Auto-antibodies, mainly anti-thyroid antibodies, were detected in patients independently of autoimmunity clinical manifestation presence. This study showed the importance of the first degree relatives of IgA deficient patients evaluation, focusing as immunodeficiency as autoimmune disease, permiting an earlier diagnosis of both conditions and an adequate approach to optimize the clinical management and improvement of quality of life of IgAD patients.