(Circulation. 1995;92:1604-1611.)
© 1995 American Heart Association, Inc.
Articles |
Therapy With Immunoglobulin Suppresses Myocarditis in a Murine Coxsackievirus B3 Model
Antiviral and Anti-inflammatory Effects
Presented in part at the 66th Scientific Sessions of the American Heart Association, Atlanta, Ga, November 11-14, 1993.
From the The Second Department of Internal Medicine, Faculty of Medicine, Toyama Medical and Pharmaceutical University, Toyama, Japan.
Correspondence to Chiharu Kishimoto, MD, PhD, The Second Department of Internal Medicine, Toyama Medical and Pharmaceutical University, 2630 Sugitani, Toyama 930-01, Japan.
 |
Abstract |
|---|
 Top Abstract IntroductionMethods Results Discussion References |
|---|
Background The treatment of some inflammatory diseases (eg, Kawasaki disease) with immunoglobulin has been demonstrated to be effective. Accordingly, to elucidate the mechanism underlying such actions of immunoglobulin, we examined its effects on murine coxsackievirus B3 (CB3) myocarditis.
Methods and Results An in vitro study showed dose-dependent suppression of CB3 by immunoglobulin. Immunoglobulin 1 g · kg-1 · d-1 IP was administered to CB3-infected C3H/He mice daily for 2 weeks, beginning simultaneously with virus inoculation in experiment 1 and on day 14 after virus inoculation in experiment 2. In both experiments, survival was higher in treated than in control mice; at the time of death, inflammatory cell infiltration and the severity of necrosis and calcification also were reduced. Notably, in experiment 1, immunoglobulin administration completely suppressed the development of myocarditis. Serum-neutralizing antibody titers in the treated mice were significantly higher than those in untreated mice in experiment 1 but not in experiment 2. The circulating antibodies of the treated mice were primarily of exogenous origin in experiment 1 and of exogenous and endogenous origins in experiment 2. The analysis of splenic lymphocyte subsets revealed a marked decrease of the B cell population in the treated mice.
Conclusions Immunoglobulin therapy completely suppressed acute CB3 myocarditis by transferring the neutralizing antibody into the host in the acute viremic stage and induced an anti-inflammatory effect in the subsequent aviremic stage; the reduction of the splenic B-cell population may be closely associated with an anti-inflammatory effect.
Key Words: myocarditis • immune system • viruses
|
Introduction |
|---|
|
TopAbstractIntroductionMethods Results Discussion References |
|---|
Infiltration of the myocardium with inflammatory cells occurs during infection with a variety of viruses.1 The infiltrate usually consists of mononuclear cells that are either focal or diffusely scattered in the myocardium. Myofiber necrosis is an important feature of this lesion. Myocyte hypertrophy has also been documented after myocardial necrosis.1 2 3 4
Enteroviruses, particularly coxsackievirus B (CB3), have been established as the predominant cause of viral myocarditis in humans,1 2 5 and viral myocarditis is considered to be a cause of dilated cardiomyopathy.1 2 5 Immune or autoimmune mechanisms may be involved in the pathogenesis of viral myocarditis and the subsequent cardiomyopathy.1 2 3 4 5 To address unresolved questions regarding the mechanisms operating in viral myocarditis, an experimental model of CB3 myocarditis in mice may be of great value.6
The therapeutic efficacy of high-dose immunoglobulin in inflammatory diseases, eg, Kawasaki disease,7 8 9 systemic vasculitis,10 and idiopathic thrombocytopenic purpura (ITP),11 has been reported. It recently was shown that immunoglobulin treatment in children with myocarditis has therapeutic value.12 Although the precise mechanisms responsible for the efficacy of this treatment are still unknown, immunoglobulin therapy is considered to have an immunosuppressive or anti-inflammatory effect. Because it has been established that the immune system is involved in myocarditis, studies have been undertaken in which immunosuppressive and anti-inflammatory agents have been used in both clinical and experimental settings. Accordingly, to clarify the precise immunologic mechanisms of such treatment, we investigated the effects of immunoglobulin on murine CB3 myocarditis and analyzed splenic lymphocyte subset populations.
|
Methods |
|---|
|
TopAbstractIntroductionMethods Results Discussion References |
|---|
In Vitro Study
Immunoglobulin (Venilon) was kindly supplied by Fujisawa Co, Ltd. Venilon is a sulfonated human immunoglobulin (classes G, A, and M) with Fc activity and is purified by Cohn's cold ethanol method.10 11 Antiviral activity was assayed by a plaque-reduction method. A sterile solution of immunoglobulin was prepared. Serially diluted immunoglobulin was incubated with 100 plaque-forming units (PFU) of CB3 at 37°C for 1 hour. The reaction was stopped at 4°C for 30 minutes. The sample was added to confluent monolayers of VERO (African green monkey kidney) cells in six-well plastic plates.
After 2 days of incubation at 37°C, the cells were fixed with acetic acid and methanol and stained with crystal violet; then the plaques were counted. Plaque formation was expressed as a percentage of the number of control plaques. The drug concentration required to reduce the number of plaques by 50% from the number in the control well (median inhibitory dose) was calculated from the graph relating plaque number and drug concentration on a semilog plot (linear regression).
In Vivo Study
Infection Protocol
The virus
stock of CB3 was prepared in cultures of VERO cells in
Eagle's minimum essential medium (EMEM). Virus suspensions were
centrifuged after the cytopathic effect had developed, and the
viral stock had a titer of more than 109 PFU/mL determined
in tissue cultures.
Two-week-old male, inbred, certified virus-free C3H/He mice (Shizuoka Laboratory Animal Center) were used. They were supplied, together with their dams; when they were 4 weeks old, the dams were removed. The animals were inoculated intraperitoneally with 0.1 mL virus suspension containing 103 PFU.
The studies were approved by the institution's Animal Care and Use Committee.
Treatment Protocol
Immunoglobulin
(Venilon, human immunoglobulin) was administered
intraperitoneally daily; the actual dose in each
experiment was calculated from the mouse weight at the beginning of the
experiment. From previous studies, the dose of immunoglobulin used was
1
g · kg-1 · d-1.7 8 9 13 14 15 16
Immunoglobulin antigenicity between different species does not seem to
be a problem.15 17 Fig 1
shows the
treatment protocol.
|
Experiment 1: early protocol. Mice (n=56) were randomized to two groups in which they received either no treatment (n=28) or treatment with immunoglobulin (n=28). Mice in the untreated group were injected intraperitoneally with 0.1 mL saline during the treatment period. Beginning simultaneously with the virus inoculation, treatment was given for 14 days. The mice were observed daily, and necropsy was performed immediately on those mice found dead. Seven mice in each group were killed on day 7 for virological study and for an age-matched study of cardiac pathology. Accordingly, the survival study covered 21 mice in each of the two groups. Mice surviving until the end of treatment period were killed. The thymus, spleen, and heart were weighed, and the organ-to-body-weight ratios were calculated. The organs were processed for pathological study.
Additional control groups were uninfected mice treated for 14 days with saline (n=5) and with immunoglobulin (n=5).
Experiment 2: late protocol. Mice surviving until 14 days after virus inoculation (n=50) were randomized to either of two groups: no treatment (n=25) or treatment with immunoglobulin (n=25). Treatment was given for 14 days, ie, until 28 days after virus inoculation. The mice were observed daily, and necropsy was carried out on those mice that died during the course of the experiment. At the end of the treatment period, the same procedure as that for experiment 1 was performed.
Additional control groups were age-matched uninfected mice treated for 14 days with saline (n=5) and with immunoglobulin (n=5), in parallel with late protocol.
Pathological Study
Tissues (heart, lung, liver, thymus, spleen, pancreas, and
muscle) were processed by standard methods, embedded in paraffin, cut
into 5-µm-thick sections, and stained with hematoxylin and eosin.
Myocardial lesions were graded by two of the authors (H.T. and C.K.)
blinded to the respective treatment groups to determine the severity of
cellular infiltration, necrosis, and calcification of the ventricles.
The mean value was cited.
The pathological criteria for grading the severity of myocardial infiltration, necrosis, and calcification were as follows: grade 1 (mild), one or two small foci; grade 2 (slight), several small foci; grade 3 (moderate), multiple small foci or several large foci; and grade 4 (severe), multiple large foci or diffuse infiltration, necrosis, or calcification.
To avoid postmortem changes and to match the time course, pathological studies were performed only in mice killed on days 7, 14, and 28. The other organs were evaluated for evidence of viral or other pathological lesions.
Virological Study
For the infectivity
assay, portions of the heart were weighed
and homogenized aseptically in 2 mL PBS. After a 15-minute
centrifugation at 1500g, virus titers in the
supernatants were determined by a plaque assay method.4 In
brief, VERO cells suspended (1x106/mL) in
EMEM with 5% FCS plus 100 µg/mL each penicillin and streptomycin
were placed in six-well plates and allowed to grow for 2 or 3 days
at 37°C in 5% CO2. After adsorption, the cells were
overlaid with 3 mL EMEM containing 5% FCS and 1% methylcellulose.
After a 2-day incubation at 37°C in a humidified atmosphere
containing 5% CO2, the cells were fixed with acetic
acid and methanol (1:3) and stained with 1% crystal violet; plaques
were then counted with an inverted microscope.
Serum-Neutralizing Antibody Titers
Blood was
obtained under sterile conditions from the
retro-orbital plexus, and the serum was inactivated at
56°C for 30 minutes. Each sample was titrated serially by determining
the fourfold dilution in 5 mL EMEM supplemented with 3% FCS that
protected the VERO cell monolayer against a challenge of 100 PFU of
CB3. The neutralizing antibody titer was expressed as the reciprocal
(log 4) of the highest serum dilution showing 50% plaque
reduction.
Experiment 3: lymphocyte subset protocol. This experiment was conducted to clarify the effects of treatment of immunoglobulin on the lymphoid organ in the host. Virus inoculation and immunoglobulin treatment of mice were the same as in experiments 1 and 2. For the analysis of splenic lymphocyte subsets by flow cytometry and an immunoperoxidase method, further control and treated groups of mice were killed on days 7 and 21. The mice killed in this study were not included in the pathological or virological study.
The lymphocyte immunostaining methods used were similar to those described previously.3 4 For flow cytometry, the spleen was mechanically dissociated in RPMI-1640 medium with a 23-gauge needle. After the erythrocytes were lysed with 0.83% NH4Cl in Tris buffer (pH 7.2), the lymphocyte fractions were obtained by Ficoll gradient centrifugation.
The B cells were determined by staining with fluorescein isothiocyanate (FITC)–labeled rabbit anti-mouse immunoglobulin. T cells were stained with monoclonal rat anti-Thy 1.2 (pan T, clone 30-H12,18 Becton-Dickinson) as the first layer of antibody and with FITC-labeled rabbit anti-mouse immunoglobulin as the second antibody. The antibodies were diluted 10-fold. The cells were centrifuged at 1500g for 3 minutes. After centrifugation, the cell pellet was suspended in 100 µL RPMI-1640 medium with 2.5% FCS or the first layer of antibody. After a 30-minute incubation at 4°C, the cells were washed three times and suspended in 100 µL of the second antibody. They were incubated at 4°C for 30 minutes; then they were washed twice and suspended in 0.5 mL RPMI-1640 medium with 2.5% FCS.
The percentage of positive fluorescent cells was determined by laser flow cytometry (FACScan, Becton-Dickinson). The percentage of T cells was obtained by subtracting the percentage of B cells from the values obtained after staining with monoclonal rat antibody and FITC-labeled rabbit anti-mouse immunoglobulin.
An indirect horseradish
immunoperoxidase technique was used for in situ
analysis of the distribution of splenic lymphocyte subsets, as
previously described.3 4 Spleens were quickly frozen
in
OCT compound. Sections 6 µm thick were cut from the frozen blocks.
Endogenous peroxidase activity was blocked with cold
methanol. Horseradish peroxidase activity was visualized with diamino
benzidine as chromogen. The monoclonal antibodies used are Thy 1.2 for
pan T cells18 and Bet-119 for B cells. Bet-1
reacts specifically to the allotypic marker of mouse
IgM.19 Three to four spleens were examined in each group.
Semiquantitative analysis of the distribution of the areas of
positive-stained cells in the T- or B-cell zone was performed; -
indicates nonreactive (no staining); 1+, 
10% stained; 2+,
25%
stained; 3+, 50% stained; and 4+, 90% stained.
Age-matched uninfected mice with and without immunoglobulin treatment were also prepared, and lymphocyte subsets in these groups were also examined.
Statistical Analysis
Survival was analyzed by the
Kaplan-Meier20
method. Statistical analysis of the data for body weight,
organ-to-body-weight ratios, histological
scores, and the percentage of lymphocyte subsets was determined by
ANOVA. When significant differences were found, the two-tailed
t test was used as a post-ANOVA test for establishing
differences. A value of P<.05 was considered statistically
significant.
|
Results |
|---|
|
TopAbstractIntroductionMethods Results Discussion References |
|---|
Antiviral Activity In Vitro
The percent plaque formation was 118±32% at an immunoglobulin concentration of 10-3.0 mg/mL, 64±18% at 10-2.5 mg/mL, 36±20% at 10-2.0 mg/mL, 12±6% at 10-1.5 mg/mL, and 0±0% at 10-1.0 mg/mL (each n=4). Linear regression analysis showed a good negative correlation of Y=-68.9-57.4 log10X (r=-.90, P<.01; Fig 2
) between PFU and the logarithms of immunoglobulin
concentrations. Thus, the dose of immunoglobulin inhibiting 50% of
plaques was 0.01 mg/mL.
|
In Vivo Study
Infection with CB3 produced a similar
pathological picture to that
reported
previously.3 4 6 21 22
In brief, 3 days after
virus inoculation, the mice appeared ill; some showed coat ruffling,
weakness, and irritability. Grossly, the myocardium had
pale yellow patches that correlated with the inflammation; necrosis and
calcification were seen microscopically.
Experiment 1
Mortality. Eleven mice in the control group and no
mice
in the treated group had died by day 14; the survival rate on day 14
was 47.6% (10 of 21) in the control group and 100% (21 of 21) in the
treated group. The difference between treated and control groups was
significant (P<.01, Fig 3).
|
Cardiac pathology. In the mice killed on days 7 and 14,
the
scores for cellular infiltration and myocardial necrosis were lower in
the immunoglobulin-treated group than in the control group (Fig
4, Table 1). Notably, there was no
myocarditis in any of the immunoglobulin-treated mice; ie,
immunoglobulin administration completely suppressed the development of
myocarditis.
|
|
Pathology of other organs. Pancreatitis,
probably
virus-induced, was noted in several mice in the untreated group but
in no mice in the treated group (Fig 5). No viral
lesions were noted in the lung, liver, muscle, spleen, or thymus in
either group. Notably, marked atrophy of lymphoid follicles (B-cell
areas) was noted in the spleens of immunoglobulin-treated
mice.
|
Serum-neutralizing antibody titers. Antibody
titers on
days 7 and 14 were significantly higher in the
immunoglobulin-treated group than in the untreated group (Table
2).
|
From in vitro analysis of origin of antibodies (fluorescent antibody technique), it was demonstrated that the circulating serum antibodies in immunoglobulin-treated mice on days 7 and 14 were primarily of human origin, ie, exogenous (data not shown).
Myocardial virus titers. No viruses were
recovered from the
hearts of immunoglobulin-treated mice; ie, an exogenous antibody
had neutralized CB3. On day 7, there was a significant difference
(P<.05) in myocardial virus titers between treated and
untreated groups. On day 14, the virus was not detected in the
myocardium in either group (Table 2
).
Organ weights. On day 7, body weight was greater, the
ratio
of heart to body weight was smaller, the ratio of thymus to body weight
was higher, and the ratio of spleen to body weight was smaller in the
treated mice than in the untreated mice (Table 3). On
day 14, body weight was greater, and the ratios of heart and spleen to
body weight were smaller in the immunoglobulin-treated group
than in the untreated group. Although no evidence was available, it
would seem that the reciprocal changes in thymus and spleen weights
seen in the immunoglobulin-treated group on day 7 are related to
the host response induced by high-dose immunoglobulin.
|
Uninfected groups. None of the uninfected mice in the two groups died throughout the entire period. Lymphoid follicle atrophy was observed in the spleens of the immunoglobulin-treated mice. No abnormal pathological changes were evident in other organs examined in either of these groups.
Experiment 2
Mortality. Fifteen mice in the control group and 10 in
the immunoglobulin-treated group had died by day 28; the difference
in the survival rates was not significant (Fig 6).
|
Cardiac pathology. Cellular infiltration and myocardial
necrosis in the treated group were less severe than in the control
group (Table 1).
Pathology of other organs. The results were similar to those in experiment 1. Pancreatitis was noted in several mice in both groups. Lymphoid follicle atrophy was also noted in the spleens of immunoglobulin-treated mice. No viral lesions were noted in other organs in either of the two groups.
Serum-neutralizing antibody titers. There was no
significant difference in the serum-neutralizing antibody titers on
day 28 between the two groups (Table 2). The circulating
antibodies in
immunoglobulin-treated mice were both endogenous and
exogenous (data not shown).
Organ weights. Body weight
was greater, and the ratio of
spleen to body weight was smaller in immunoglobulin-treated than in
untreated mice (Table 3).
Uninfected groups. No uninfected mice in the two groups died throughout the entire period. Lymphoid follicle atrophy was noted in the spleens of the immunoglobulin-treated mice. No abnormal pathological changes were evident in other organs examined in either of these groups.
Experiment 3
Before analysis of
lymphocyte subsets on day 7, 4 of 15
mice in the control untreated group and 0 of 15 in the treated group
had died; 4 of 12 mice in the untreated group and 3 of 12 in the
treated group had died on days 14 through 21 (Fig 7,
Table 4).
|
|
In the flow cytometric study, the percentages of B cells in treated mice were markedly decreased on days 7 and 21 compared with those in untreated mice. Differences in the percentage of pan T cells between control and treated groups on days 7 and 21 were not significant.
Mice treated with immunoglobulin showed a positive reaction with a great majority of the T-cell zone (marginal zone, paracortical area and periarterial sheath) in the Thy 1.2 (pan T) staining and with a great minority of the B-cell zone (lymphoid follicle) in the Bet-1 staining in the spleen. Untreated mice, however, showed a positive reaction with a great majority of the T-cell zone in the Thy 1.2 staining and with a great majority of the B-cell zone in the Bet-1 staining in the spleen.
Table 4 also shows the results
on day 7 for age-matched uninfected
mice with and without immunoglobulin treatment. The B-cell population
in immunoglobulin-treated mice also decreased significantly.
In summary, immunoglobulin administration produced a marked decrease of the splenic B lymphocyte subset population in treated mice during the course of CB3 infection.
|
Discussion |
|---|
|
TopAbstractIntroductionMethods Results Discussion References |
|---|
This study showed that immunoglobulin therapy completely suppressed CB3 myocarditis through an anti-CB3 effect in the acute viremic stage and partially suppressed the condition by an anti-inflammatory effect in the subsequent aviremic stage. The associated reduction of the splenic B cell subset may have been caused by a negative feedback of the high-dose immunoglobulin administration; splenic pathology revealed that immunoglobulin treatment produced marked atrophy of the lymphoid follicle (B-cell area) in CB3-infected mice. This finding may be of great value in aiding our understanding of the pathogenesis of CB3 myocarditis.3 4 6 21 22
As noted previously, immunoglobulin therapy is of value in the treatment of autoimmune and inflammatory diseases.7 8 9 12 13 14 15 16 The mechanisms responsible for its efficacy, however, are unknown. The prophylactic administration of immunoglobulin was reported to be of clinical value against respiratory syncytial virus in high-risk infants,23 and this effect was due to the capacity of immunoglobulin to neutralize this virus. The successful treatment of ITP with immunoglobulin appears to result from the blockade of Fc receptors.9 24 25 Intravenous immunoglobulin also was shown to act as a sump for activated complement components in Forssman shock syndrome.15 The rapidity of the effect of immunoglobulin in children with Kawasaki disease makes it doubtful that immunoglobulin is neutralizing a microorganism.7 13 14 This rapid effect in such children may be due to the neutralization of a microbial toxin by immunoglobulin, which acts as a superantigen that binds nonspecifically to major histocompatibility class II molecules or to certain viable regions of the T-cell–antigen receptor. Alternatively, this may result in the downregulation of the secretion of cytokines that increase inflammation or in the secretion of cytokines that downregulate inflammatory responses. More recently, the therapeutic efficacy of immunoglobulin in patients with dermatomyositis,16 in which a distinct myopathy is characterized by rash and a complement-mediated microangiopathy, was reported: immunoglobulin treatment improved the neuromuscular symptoms, resolved complement deposition on capillaries, and reduced the expression of intercellular adhesion molecule-1 and major histocompatibility class I antigens.16 Most recently, Drucker et al12 reported that, in a pediatric population, the use of high-dose intravenous immunoglobulin for the treatment of acute myocarditis, which complicated most cases of Kawasaki disease, was associated with improved recovery of left ventricular function and a tendency for better survival. Accordingly, clarification of the mechanisms underlying this treatment in myocarditis is warranted.
The present study points to two probable major mechanisms. First, polyclonal immunoglobulin could directly affect an infectious agent by the transfer of anti-viral antibody. This appears to be the mechanism that would explain the results in experiment 1; in vitro demonstration of the dose-dependent anti-CB3 activity of immunoglobulin, the lack of myocardial lesions in immunoglobulin-treated mice, and the higher serum levels of neutralizing antibody titers in the treated mice support this interpretation. We consider that an all-or-nothing effect of immunoglobulin in mortality and tissue pathology in experiment 1 was due to the exogenous antibodies present simultaneously with the beginning of the treatment. Second, regarding the mechanism whereby the anti-inflammatory effects of immunoglobulin are exerted, it is possible that immunoglobulin administration may alter immune responses, thus leading to a decrease in cardiac inflammation.26 27 28 29 The accepted mechanisms of action are reticuloendothelial system blockade and induction of idiotype–anti-idiotype networks. Reticuloendothelial system blockade implies that high concentrations of immunoglobulin could prevent antigen presentation and stimulation of immune responses by several mechanisms. Polyclonal immunoglobulin may bind to Fc receptors on macrophages and prevent internalization of the antigens. Exogenous proteins may occupy phagocytic vesicles to the exclusion of autoantigens, thus inhibiting autoimmune processes. An overabundance of immunoglobulin peptides may competitively prevent autoantigen peptides from binding to relevant major histocompatibility class I or II molecules. Polyclonal immunoglobulin-treated macrophages may show deficiencies in inflammatory cytokine secretion. Anti-idiotypic antibodies are antibodies to an antibody. Pooled normal serum should contain a wide variety of naturally occurring anti-idiotypes to self-antibodies. Some of these may be directed against the autoimmune effectors in myocarditis. We consider that the reduction of the splenic B-cell population in experiment 2 may have been caused by a negative feedback of the high-close immunoglobulin and was closely associated with an anti-inflammatory effect; this phenomenon may at least reflect changes in the immunologic environment in the immunoglobulin-treated host. Indeed, the decrease of the peripheral B-cell population in immunoglobulin-treated children with Kawasaki disease was documented.14
It is generally accepted that a biphasic disease process results when mice are infected with CB3.1 2 3 4 5 6 18 19 During the acute phase, viral replication in the myocardium results in myocardial necrosis and inflammation in the first week. After the virus has been eliminated from the myocardium, chronic inflammation results in progressive myocyte damage. It was suggested that the chronic phase results from a cell-mediated immune response to a neoantigen developed during the acute phase of the illness.1 2 3 4 5 6 21 22 Several investigators reported that, during the acute stage of myocarditis, sensitized T cells migrate toward the target organ, ie, the heart, where they may play a role in the development of myocarditis.1 2 3 4 5 6 21 22 Furthermore, it has been shown that both the expression of intercellular adhesion molecule-126 and the behavior of inflammatory cytokines27 28 29 play roles in the development of myocarditis. Autoantibodies against cardiac tissue components also were suggested to play a role in the development of this disease30 31 ; eg, in a clinical setting, the significant role played by autoantibodies against ventricular myosin was demonstrated in the sera of patients with myocarditis.30 31 Recently, Weller and Huber17 proposed the induction of idiotype–anti-idiotype networks by immunoglobulin as the mechanism whereby immunoglobulin protects against murine CB3 myocarditis. Most recently, it was implicated that a superantigen that selectively interacts with a T-cell receptor Vß component may be associated with the pathogenesis of CB3 myocarditis.32 Seko et al32 suggested the possibility of using antibodies specific for the T-cell receptor Vß gene products to prevent T-cell–mediated myocardial damage in the late stage of CB3 myocarditis. On the other hand, it was shown that normal pooled immunoglobulin contains antibodies against a major group of the superantigens, suggesting a possible immunoregulatory role for the exogenous antibodies in vivo.33 34 Therefore, changes in the immunologic environment induced by high-dose immunoglobulin, ie, the possible induction of antibodies against the superantigens,32 33 34 reduction of autoantibodies against the heart,17 30 31 suppression of both inflammatory cytokines27 28 29 and the expression of intercellular adhesion molecule-1,16 26 and suppression of major histocompatibility complexes,16 29 may lead to amelioration of myocarditis and improve survival.
In conclusion, immunoglobulin treatment suppressed CB3 murine myocarditis through the transfer of an anti-viral antibody and by exerting an anti-inflammatory effect. There is as yet no general agreement on effective treatment for viral myocarditis. Trials with steroids,35 nonsteroidal anti-inflammatory drugs,36 immunosuppressive agents,21 22 37 ß-blockers,38 angiotensin-converting enzyme inhibitors,39 and other therapeutic modalities have been attempted. Immunoglobulin is safer and better tolerated than corticosteroids or other immunosuppressive agents. Accordingly, more widespread clinical use of this treatment in patients with myocarditis of viral and unknown origins appears warranted.
|
Acknowledgments |
|---|
This work was supported in part by research grants from the Japanese Heart Foundation, an education fellowship from Toyama Medical and Pharmaceutical University, Iwaki fellowships from the Japanese Education of Science and Welfare (Nos. 01570478, 03670445, and 06670702), and the Uehara Memorial Foundation.
Received November 16, 1994; revision received February 19, 1995; accepted February 28, 1995.
|
References |
|---|
|
TopAbstractIntroductionMethods Results Discussion References |
|---|
1. Woodruff JF. Viral myocarditis: a review. Am J Pathol. 1980;101:427-484.
2. Reyes M, Lerner AM. Coxsackievirus myocarditis: with special reference to acute and chronic effects. Prog Cardiovasc Dis. 1985;27:373-394. [Medline] [Order article via Infotrieve]
3.
Kishimoto C, Misaki T, Crumpacker CS, Abelmann WH.
Serial immunologic identification of lymphocyte subsets in
murine coxsackievirus B3 myocarditis: different kinetics and
significance of lymphocyte subsets in the heart and in
peripheral blood. Circulation. 1988;77:645-653.
4.
Kishimoto C, Abelmann WH. In vivo significance
of T cells in the development of Coxsackievirus B3 myocarditis in mice:
immature but antigen-specific T cells aggravate cardiac
injury. Circ Res. 1990;67:589-598.
5. Abelmann WH. Viral myocarditis and its sequelae. Annu Rev Med. 1973;24:145-152.[Medline] [Order article via Infotrieve]
6. Kishimoto C, Kawai C, Abelmann WH. Immuno-genetic aspects of the pathogenesis of experimental viral myocarditis. In: Kawai C, Abelmann WH, eds. Cardiomyopathy 1987: Pathogenesis of Myocarditis and Cardiomyopathy: Experimental and Clinical Studies. Tokyo, Japan: University of Tokyo Press; 1987:3-7.
7. Newburger JW, Takahashi M, Beiser AS, Burns JC, Bastian J, Chung KJ, Colan SD, Duffy CE, Fulton DR, Glode MP, Mason WH, Meissner HC, Rowley AH, Shulman ST, Reddy V, Sundel RP, Wiggins JW, Colton T, Melish ME, Rosen FS. A single intravenous infusion of gamma globulin as compared with four infusions in the treatment of acute Kawasaki syndrome. N Engl J Med. 1991;324:1633-1639. [Abstract]
8. Jayne DR, Davies MJ, Lockwood CM. Treatment of systemic vasculitis with pooled intravenous immunoglobulin. Lancet. 1991;337:1137-1139. [Medline] [Order article via Infotrieve]
9. Clarkson SB, Bussel JB, Kimberly RP, Valinsky JE, Nachman RL, Unkeless JC. Treatment of refractory immune thombocytopenic purpura with an anti-Fc-receptor antibody. N Engl J Med. 1986;314:1236-1239. [Medline] [Order article via Infotrieve]
10. Bulletin of Fujisawa Co, Ltd [in Japanese]. Venilon. VEN (TOSHO) 1990;11:1-37.
11. Bulletin of Fujisawa Co, Ltd. Immunoglobulin Therapy for Kawasaki Disease [in Japanese]. VEN (KYO) 1990;10:1-81.
12.
Drucker NA, Colan SD, Lewis AB, Beiser AS, Wessel DL,
Takahashi M, Baker AL, Perez-Atayde AR, Newburger JW.
-globulin treatment of acute myocarditis in the pediatric
population. Circulation. 1994;89:252-257.
13. Newburger JW, Takahashi M, Burns JC, Beiser AS, Chung KJ, Duffy CE, Glode MP, Mason WH, Reddy V, Sanders SP, Sulman ST, Wiggins JW, Hicks RV, Fulton DR, Lewis AB, Leung DYM, Colton T, Rosen FS, Melish ME. The treatment of Kawasaki syndrome with intravenous gamma globulin. N Engl J Med. 1986;315:341-347. [Abstract]
14. Leung DYM, Burns JC, Newburger JW, Geha RS. Reversal of lymphocyte activation in vivo in the Kawasaki syndrome by intravenous gamma globulin. J Clin Invest. 1987;79:468-472.
15. Basta M, Kirshborm P, Frank MM, Fries LF. Mechanism of therapeutic effect of high-dose intravenous immunoglobulin: attenuation of acute, complement-dependent immune damage in a guinea pig model. J Clin Invest. 1989;84:1974-1981.
16.
Dalakas MC, Illa I, Dambrosia JM, Soueidan SA, Stein
DP, Otero C, Kinsmore ST, McCrosky S. A controlled trial of
high-dose intravenous immune globulin infusions as
treatment for dermatomyositis. N Engl J
Med. 1993;329:1993-2000.
17.
Weller AH, Hall M, Huber SA. Polyclonal
immunoglobulin therapy protects against cardiac damage in experimental
coxsackievirus-induced myocarditis. Eur Heart J. 1992;13:115-119.
18. Ledbetter JA, Herzenberg LA. Xenogeneic monoclonal antibodies to mouse lymphoid differentiation antigens. Immunol Rev. 1979;47:63-90. [Medline] [Order article via Infotrieve]
19. Velardi A, Kubagawa H, Kearney F. Analysis of the reactivity of four anti-mouse IgM allotype antibodies with µ+ B lineage cells at various stages of differentiation. J Immunol. 1984;133:2098-2103. [Abstract]
20. Kaplan EL, Meier P. Nonparametric estimation from incomplete observation. J Am Stat Assoc. 1958;53:457-462.
21.
Kishimoto C, Thorp KA, Abelmann WH.
Immunosuppression with high doses of cyclophosphamide reduces
the severity of myocarditis but increases the mortality in murine
Coxsackievirus B3 myocarditis.
Circulation. 1990;82:982-989.
22.
Kishimoto C, Abelmann WH. Absence of effects of
cyclosporine on myocardial lymphocyte subsets in
Coxsackievirus B3 myocarditis in the aviremic stage.
Circ Res. 1989;65:934-945.
23.
Groothius JR, Simoes EAF, Levin MJ, Hall CB, Long CE,
Rodriguez WJ, Arrobio J, Meissner HC, Fulton DR, Welliver RC, Tristram
DA, Siber GR, Prince GA, Raden MV, Hemming VG, for the Respiratory
Syncytial Virus Immune Globulin Study Group.
Prophylactic administration of respiratory syncytial
virus immune globulin to high-risk infants and young
children. N Engl J Med. 1993;329:1524-1530.
24. Sandilands GP, Atrah HI, Templeton G. In vivo and in vitro blocking of human lymphocyte Fc gamma-receptors by intravenous gamma globulin. J Clin Lab Immunol. 1987;23:109-115. [Medline] [Order article via Infotrieve]
25. Jungi TW, von Below G, Lerch PG, Spaeth PJ. Modulation of human monocyte Fc receptor function by surface-adsorbed IgG. Immunology. 1987;60:261-268. [Medline] [Order article via Infotrieve]
26. Seko Y, Matsuda H, Kato K, Hashimoto Y, Yagita H, Okumura K, Yazaki Y. Expression of intercellular adhesion molecule-1 in murine hearts with acute myocarditis caused by coxsackievirus B3. J Clin Invest. 1993;91:1327-1336.
27.
Zhang J, Yu ZX, Hilbert SL, Yamaguchi M, Chadwick DP,
Herman EH, Ferrans VJ. Cardiotoxicity of human recombinant
interleukin-2 in rats: a morphological study.
Circulation. 1993;87:1340-1353.
28.
Geng Y, Hansson GK, Holme E. Interferon- and
tumor necrosis factor synergize to induce nitric oxide
production and inhibit mitochondrial respiration in vascular
smooth muscle cells. Circ Res. 1992;71:1268-1276.
29. Smith SC, Allen PM. Expression of myosin-class-II major histocompatibility complexes in the normal myocardium occurs before induction of autoimmune myocarditis. Proc Natl Acad Sci U S A. 1992;98:9131-9135.
30. Lauer B, Padberg K, Schultheiss HP, Strauer BE. Autoantibodies against human ventricular myosin in sera of patients with acute and chronic myocarditis. J Am Coll Cardiol. 1994;23:146-153. [Abstract]
31. Maisch B, Bauer E, Cirsi M, Kochsiek K. Cytolytic cross-reactive antibodies direct against the cardiac membrane and viral proteins in coxsackievirus B3 and B4 myocarditis: characterization and pathogenetic relevance. Circulation. 1993;87(suppl IV):IV-49-IV-65.
32.
Seko Y, Yagita H, Okumura K, Yazaki Y. T-cell
receptor Vß gene expression in infiltrating cells in murine hearts
with acute myocarditis caused by coxsackievirus B3.
Circulation. 1994;89:2170-2175.
33. Takei S, Arora YK, Walker SM. Intravenous immunoglobulin contains specific antibodies inhibitory to activation of T cells by staphylococcal toxin superantigens. J Clin Invest. 1993;91:602-607.
34. Rich RR. Intravenous IgG: supertherapy for superantigens? J Clin Invest. 1993;91:378.
35. Tomioka N, Kishimoto C, Matsumori A, Kawai C. Effects of prednisolone on acute viral myocarditis in mice. J Am Coll Cardiol. 1986;7:868-872. [Abstract]
36. Rezkalla S, Khatib G, Khatib R. Coxsackievirus B3 murine myocarditis: deleterious effects of nonsteroidal antiinflammatory agents. J Lab Clin Med. 1986;107:93-95.
37.
O'Connell JB, Reap EA, Robinson JA. The effects
of cyclosporine on acute murine Coxsackie B3
myocarditis. Circulation. 1986;73:353-359.
38. Rezkalla S, Kloner RA, Khatib G, Smith FE, Khatib R. Effect of metoprolol in acute coxsackievirus B3 murine myocarditis. J Am Coll Cardiol. 1988;12:412-414. [Abstract]
39.
Rezkalla S, Kloner RA, Khatib G, Khatib R.
Beneficial effects of captopril in acute coxsackievirus B3
murine myocarditis. Circulation. 1990;81:1039-1046.
This article has been cited by other articles:
 |
|
 |
|
  L. T. Cooper, R. Virmani, N. M. Chapman, A. Frustaci, R. J. Rodeheffer, M. W. Cunningham, and D. M. McNamara National Institutes of Health-Sponsored Workshop on Inflammation and Immunity in Dilated Cardiomyopathy Mayo Clin. Proc., February 1, 2006; 81(2): 199 - 204. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 K. Shioji, Z. Yuan, T. Kita, and C. Kishimoto Immunoglobulin treatment suppressed adoptively transferred autoimmune myocarditis in severe combined immunodeficient mice Am J Physiol Heart Circ Physiol, December 1, 2004; 287(6): H2619 - H2625. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
Z. Yuan, C. Kishimoto, H. Sano, K. Shioji, Y. Xu, and M. Yokode Immunoglobulin treatment suppresses atherosclerosis in apolipoprotein E-deficient mice via the Fc portion Am J Physiol Heart Circ Physiol, July 11, 2003; 285(2): H899 - H906. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 K. Klingel, J.-J. Schnorr, M. Sauter, G. Szalay, and R. Kandolf {beta}2-Microglobulin-Associated Regulation of Interferon-{gamma} and Virus-Specific Immunoglobulin G Confer Resistance Against the Development of Chronic Coxsackievirus Myocarditis Am. J. Pathol., May 1, 2003; 162(5): 1709 - 1720. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 C. Kishimoto, H. Takada, H. Kawamata, M. Umatake, and H. Ochiai Immunoglobulin Treatment Prevents Congestive Heart Failure in Murine Encephalomyocarditis Viral Myocarditis Associated with Reduction of Inflammatory Cytokines J. Pharmacol. Exp. Ther., November 1, 2001; 299(2): 645 - 651. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 D. M. McNamara, R. Holubkov, R. C. Starling, G. W. Dec, E. Loh, G. Torre-Amione, A. Gass, K. Janosko, T. Tokarczyk, P. Kessler, et al. Controlled Trial of Intravenous Immune Globulin in Recent-Onset Dilated Cardiomyopathy Circulation, May 8, 2001; 103(18): 2254 - 2259. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 C. Kishimoto, N. Takamatsu, H. Kawamata, H. Shinohara, and H. Ochiai Immunoglobulin treatment ameliorates murine myocarditis associated with reduction of neurohumoral activity and improvement of extracellular matrix change J. Am. Coll. Cardiol., November 15, 2000; 36(6): 1979 - 1984. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
C. Kawai From Myocarditis to Cardiomyopathy: Mechanisms of Inflammation and Cell Death : Learning From the Past for the Future Circulation, March 2, 1999; 99(8): 1091 - 1100. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
C. Kishimoto, H. Takada, Y. Hiraoka, D. M. McNamara, and A. M. Feldman Intravenous IgG: Supertherapy for Myocarditis and Acute Dilated Cardiomyopathy • Response Circulation, February 23, 1999; 99(7): 975 - 978. [Full Text] [PDF]
|
|
|
|
|
|
D. M. McNamara, W. D. Rosenblum, K. M. Janosko, M. K. Trost, F. S. Villaneuva, A.J. Demetris, S. Murali, and A. M. Feldman Intravenous Immune Globulin in the Therapy of Myocarditis and Acute Cardiomyopathy Circulation, June 3, 1997; 95(11): 2476 - 2478. [Abstract] [Full Text]
|
|
|
|
 |
|
 K. Shioji, C. Kishimoto, and S. Sasayama Fc Receptor-Mediated Inhibitory Effect of Immunoglobulin Therapy on Autoimmune Giant Cell Myocarditis: Concomitant Suppression of the Expression of Dendritic Cells Circ. Res., September 14, 2001; 89(6): 540 - 546. [Abstract] [Full Text] [PDF]
|
|
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||