Authors: Zhihui Xie, Chandra C. Ghosh, Roshni Patel, Shoko Iwaki, Donna Gaskins, Celeste Nelson, Nina Jones, Philip R. Greipp, Samir M. Parikh and Kirk M. Druey
Abstract:
The systemic capillary leak syndrome (SCLS) is an extremely rare disorder characterized by transient episodes of hypotensive shock and anasarca thought to arise from reversible microvascular barrier dysfunction. Although the high prevalence of a monoclonal gammopathy of unknown significance (MGUS) in SCLS suggests a pathogenic contribution of endogenous immunoglobulins, the mechanisms of vascular hyperpermeability remain obscure. Herein, we report clinical and molecular findings on 23 subjects, the largest SCLS case series to date. Application of episodic SCLS sera, but neither the purified immunoglobulin fraction nor sera obtained from subjects during remission, to human microvascular endothelial cells caused vascular endothelial cadherin (VE-cadherin) internalization, disruption of inter-endothelial junctions, actin stress fiber formation, and increased permeability in complementary functional assays without inducing endothelial apoptosis. Intravenous immunoglobulin (IVIG), one promising therapy for SCLS, mitigated the permeability effects of episodic sera directly. Consistent with the presence of endogenous, non-immunoglobulin, circulating permeability factor(s) constrained to SCLS episodes, we found that two such proteins, vascular endothelial growth factor (VEGF) and angiopoietin 2 (Ang2), were elevated in episodic SCLS sera but not in remission sera. Antibody-based inhibition of Ang2 counteracted permeability induced by episodic SCLS sera. Comparable experiments with anti-VEGF antibody (bevacizumab) yielded less interpretable results, likely due to endothelial toxicity of VEGF withdrawal. Our results support a model of SCLS pathogenesis in which non-immunoglobulin humoral factors such as VEGF and Ang2 contribute to transient endothelial contraction, suggesting a molecular mechanism for this highly lethal disorder.
Citation:
Zhihui Xie, Chandra C. Ghosh, Roshni Patel, Shoko Iwaki, Donna Gaskins, Celeste Nelson, Nina Jones, Philip R. Greipp, Samir M. Parikh, and Kirk M. Druey. Vascular endothelial hyperpermeability induces the clinical symptoms of Clarkson disease (the systemic capillary leak syndrome) Blood blood-2011-08-375816; published ahead of print March 12, 2012, doi:10.1182/blood-2011-08-375816
http://bloodjournal.hematologylibrary.org/content/early/2012/03/12/blood-2011-08-375816.abstract