From the Divisions of Immunogenetics (P.L., W.A.R., M.M.Z., G.S., M.T.),
Endocrinology (D.F.), and Cardiology (G.J.B.), Department of Pediatrics, and
the Department of Pathology (G.T.), University of Pittsburgh School of
Medicine and Children's Hospital, Pittsburgh, Pa; and the Department of
Cardiac Surgery, Harvard Medical School and Children's Hospital
(P.D.N.), and the Department of Anesthesiology, Harvard Medical School and
Anesthesia/Critical Care Medicine Laboratories, Children's Hospital
(F.X.M.), Boston, Mass.
Correspondence to Massimo Trucco, MD, Children's Hospital of Pittsburgh, Rangos Research Center, 3705 Fifth Ave at DeSoto St, Pittsburgh, PA 15213.
Methods and Results—Myocardial, lymph node, and thymic tissue
samples were obtained from IDC patients who were undergoing heart
transplantation. Infiltrating immune-cell phenotypes and gene
expression of T-cell receptor (TCR)
Conclusions—A superantigen-mediated immune response is involved
in human heart disease. CVB3 may directly or indirectly trigger this
response, suggesting a possible mechanistic link between CVB infection
and myocarditis development progressing to IDC.
Enteroviruses, and especially CVB, are thought to be responsible for
>50% of myocarditis in North America and have been also implicated in
the pathogenesis of IDC.5 To date, the
association between enterovirus infection and heart disease has been
based primarily on serological studies demonstrating the presence of
CVB-specific neutralizing IgM and IgG antibodies in the sera of
patients suffering from acute myocarditis6 and
their persistence in the chronic phase.7 Attempts
to detect CVB in patients' cardiac tissue itself by use of
strain-specific monoclonal antibodies and molecular techniques has
varied considerably between different reports. Culturing CVB from
patients' myocardial tissue generally
fails.3 8 9 10 11 12 13 14 Autoantibodies against cardiac
antigens have been found in the mouse CVB3 model of the
disease,15 as well as in patients with IDC and
their relatives.16 However, a cell-mediated
immune response seems to play the most central role in further
expanding the virus-induced myocardial
damage.5 6 16
Although it is not yet known whether autoimmune mechanisms are the
cause of tissue injury or merely a reaction to autoantigens released
after the tissue damage has already occurred, they are considered the
most important mediators of the pathogenesis of myocardial inflammation
progressing to IDC.3 5 16 17 Although this is the
general consensus regarding IDC pathogenesis, a more specific process
explaining the immune reaction that leads to these clinical
consequences has remained elusive.
Superantigens are a class of bacterial and viral proteins that
elicit a powerful immune response by their ability to activate
T cells polyclonally.18 In their native
conformation, they preferentially bind outside of the MHC class II
binding groove on antigen-presenting cells, cross-linking the
lateral side of the class II molecule and the Vß portion of the
TCR.19 Thus, superantigen specificity is mainly
and almost entirely determined by the Vß element of the TCR,
bypassing the normal constraints of TCR specificity and MHC
restriction.20 Because of its ability to target
one or a limited number of Vß families, in vivo exposure to a
superantigen results in "skewing" of the T-cell repertoire,
manifested either by expansion of T cells expressing particular Vß
families or by deletion and/or anergy of specific T-cell
subsets.18 20 Because the T-cell repertoire
encompasses a limited number of families with Vß elements very
similar in sequence, any superantigen is able to activate a
large fraction of the pool of circulating T cells (5% to 30%), in
contrast to conventional antigens, which normally activate
We have had the opportunity to further investigate the immunological
mechanisms involved in the pathogenesis of acute myocarditis that
progressed to IDC in 3 children who subsequently received heart
transplants. To this aim, the presence of CVB and the
phenotypes of the immunocompetent tissue-infiltrating cells in
the diseased hearts and, when available, mediastinal lymph nodes and
thymus were analyzed.
The pathogenic scenario resulting from these analyses was
consistent with a CVB3-triggered, superantigen-mediated immune
reaction as a possible mechanism leading to heart failure.
Because of the rapid and progressive deterioration of
cardiopulmonary function (patients 2 and 3) and
cardiopulmonary arrest without response to
cardiopulmonary resuscitation (patient 1), the children were
placed on mechanical circulatory assist devices. They were listed for
heart transplantation after serial echocardiographic
examinations documented unremitting severe myocardial dysfunction
despite maximal circulatory support.
All 3 patients underwent orthotopic heart transplantation within a few
days of decompensation. Intraoperative courses were uncomplicated, and
early graft function was good.
The patients and the allograft hearts continue to function well
Bioptic specimens from the hearts of 3 additional patients (3 boys, 3,
8, and 9 years old) who clinically recovered from an episode of acute
IDC without evidence of CVB3 infection were used as controls.
All the specimens were obtained only if not used by the pathologist.
Their use for research was approved by the Institutional Review Boards
at the Children's Hospital of Boston or at Children's Hospital of
Pittsburgh. The latter Institutional Review Board also approved the use
of both heart tissue obtained at the autopsy of an infant who died of
renal dysplasia without histological and histochemical
evidence of other abnormalities and blood samples from subjects ranging
from 3 to 16 years of age who had been admitted to Children's Hospital
of Pittsburgh for orthopedic intervention. These samples were used as
"normal" controls for immunostaining and TCR
analyses, respectively.
PBMCs for in vitro stimulation studies were obtained from 9 adult blood
donors.
All the subjects were HLA class II molecularly
typed.23 24
Immunostaining Procedure
Mouse anti-human MAbs [MAbs to leukocyte common antigen, CD3 (pan–T
cells), CD4 (helper/inducer T cells), CD8 (cytotoxic/suppressor T
cells), and activated monocytes/macrophages
(Ber-MAC3)] were obtained from Dako Corp. The presence of different
strains of CVB was determined histologically by use of
MAbs (B1, IgG2a; B3, IgG2a; B4, IgG2b; and B6, IgG2a ascites, 1/1000
dilution) from Accurate Chemical & Scientific Corp.
Control sections were set up with irrelevant isotype-matched MAbs (IgG1
and IgG2a). Bound MAbs were detected with alkaline
phosphatase–anti-alkaline phosphatase followed by fast red TR alkaline
phosphatase substrate (Dako Corp).
Detection of CVB Genome
Evaluation of TCR V
Two microliters of the fluorescently labeled PCR
products corresponding to the TCR V
In Vitro PBMC Stimulation With CVB-Infected Vero Cell
Lysates
Noninfectious lysates from Vero cells exposed to CVB1, CVB3, CVB4, or
CVB6 (Virion Inc) were first tested in dose-response experiments to
select the concentration of 2 µL/mL used in the study. Cultures with
noninfected Vero cell lysates were used as negative controls, and
phytohemagglutinin at 5 mg/L was used for positive controls.
PBMCs were cultured at 37°C in 5% CO2 for 15
days and independently stimulated with each of the different lysates on
day 1 and every 3 days thereafter. Purified human interleukin-2
(Boehringer Mannheim) was added (5 IU/mL) on days 4, 8, and 12.
Twelve hours before harvesting, human interleukin-2 (5 IU/mL) was also
added to allow regeneration of potentially modulated
TCR.28 At days 4, 9, and 15 of in vitro culture,
portions of the cells were harvested, washed, and counted, and the
total RNA was extracted. Activated (CD71+) cells were isolated
from the remaining portion by immunomagnetic separation with DynaBeads
M-450 CD71 (Dynal, Inc). RNA extraction was performed directly on cells
bound to the beads, and the TCR repertoire was analyzed.
When an MAb specific for the CVB3 serotype was used, the
myocardium of these patients showed strong reactivity
compared with normal control heart (eg, Figure 2
Mediastinal Lymph Nodes
Thymus
Determination of the Presence of CVB Genome in Tissue
Samples
TCR V
The TCR V
In addition, the polyclonality of the infiltrating T cells belonging to
the most highly expressed Vß families was demonstrated by the results
of Genescan spectratype analysis and by DNA sequencing of
cloned CDR3 regions (data not shown).
TCR repertoires of the patients' PBMCs were found not to be skewed.
These data on PBMCs, however, are probably not conclusive because the
repertoires may have been affected by blood transfusions that the
patients had received before transplantation.
Specific TCR Vß Skewing of PBMCs Stimulated With CVB3-Infected
Vero Cell Lysates
In our study of the myocardial inflammatory infiltrates, the
immunohistochemical analysis showed the presence of a
population of activated helper (CD4+) and cytotoxic (CD8+) T
lymphocytes. In addition, strong and selective
immunostaining for the CVB3 serotype was observed not
only in the heart but also in the mediastinal lymph nodes and in the
thymus of the patients. More noteworthy, the analysis of the
TCR Vß repertoire of the tissue infiltrate showed a remarkable
skewing of 3 Vß gene families, 3, 7, and 13.1. Specimens from
different sections of the same organ (eg, left versus right ventricle
in patients 2 and 3) showed various degrees of inflammation. The
heterogeneous infiltration might explain why in some cases,
the magnitude of the specific skewing of these Vß families was lower
than in the other cases studied. Specimens from other sites of the same
organ might have been highly infiltrated and could show a more
impressive TCR Vß skewing. In addition, and perhaps for similar
reasons, CVB3 infection was ascertained immunologically in all the
specimens, but the presence of the CVB genome was detected by RT-PCR in
only 1 case. These aspects can be taken into consideration to explain
why a correct diagnosis of myocarditis may be made without the support
of histopathological and molecular evidence.
In certain autoimmune diseases22 36 37 and
malignancy,38 39 it has been shown that in situ
activated T cells carry a restricted set of rearranged TCR
genes, as we have found in the hearts of our patients. Although a
preferential usage of certain Vß families could be explained by the
presence of an oligoclonal T-cell response to a conventional antigen,
the polyclonality of the T-cell populations we have found in the
specimens studied, together with the presence of a nonrestricted V
The ability of lysates from CVB3-infected Vero cells to stimulate in
vitro T cells from healthy donors carrying the same 3 TCR Vß families
we have found skewed in vivo (ie, Vß3, 7, and 13.1) further supports
the hypothesis of a superantigen-driven immune response. Although
superantigen-mediated immune responses are notoriously not classically
MHC-restricted, the binding efficiency and presentation of
superantigens vary in the presence of different MHC
alleles,40 as well as in the presence of
different peptides lodged in the MHC molecule-binding
groove.41 To this point, however, due to the
limited number of donors we were able to test, we are not in the
position of associating positive or negative reactions against CVB3 to
any specific HLA allele. Nonetheless, it is certainly worthwhile to
note that the donors most reactive to CVB3 had DQA1*01 and DQB1*06
alleles in common with the myocarditis patients.
We do not yet know whether a protein of the CVB3 itself has
superantigenic properties or whether CVB3 infection transcriptionally
activates human endogenous retroviruses encoding
molecules with superantigen-like activity.42 This
has been proposed in cytomegalovirus infection.43
However, we were able to provide evidence that in vitro, a
CVB3-triggered, superantigen-driven response gave results very similar
to those observed in the pathogenic scenario of the cases of IDC
studied.
Some clear evidence exists in humans for virus-derived
superantigens.44 45 Evidence for a
superantigen-mediated preferential expansion of TCR Vß7–positive T
cells in patients suffering from type I diabetes was described a few
years ago,22 and more recently, a human
endogenous retrovirus distantly related to mouse mammary
tumor virus has been isolated from the same
specimens46 and was found to be able to trigger
in vitro a similar immune reaction.47
Our observations of a limited TCR Vß gene family usage in the
presence of variable CDR3 regions allow us to hypothesize that CVB3
might encode a superantigen (or upregulate an endogenous
superantigen-like molecule) whose relevance in myocarditis/IDC
pathogenesis and perhaps in other autoimmune diseases seems to be
clinically relevant and should be further evaluated.
Received December 16, 1997;
revision received March 20, 1998;
accepted April 21, 1998.
© 1998 American Heart Association, Inc.
Clinical Investigation and Reports
Idiopathic Dilated Cardiomyopathy
A Superantigen-Driven Autoimmune Disease
Abstract
Top
Abstract
Introduction
Methods
Results
Discussion
References
Background—Many cases of idiopathic
dilated cardiomyopathy (IDC) result from an
inflammatory myocarditis. The specific immunological mechanisms are not
yet defined. Various autoimmune diseases are associated with
superantigen-triggered immune responses, resulting in massive T-cell
activation and tissue damage. We studied 3 cases in a search for
evidence that such a phenomenon is also implicated in IDC. 
- and ß-chain variable
(V and Vß) regions were analyzed by
immunostaining and polymerase chain reaction. Similar
technical approaches were used to assay the tissues for the presence of
coxsackievirus B (CVB). In all the specimens analyzed, an
overexpression of the TCR Vß3, Vß7, and Vß13.1 gene families was
detected among the infiltrating T cells. These tissues were also found
to be CVB3-positive. In vitro exposure of peripheral blood
mononuclear cells to lysates of cells infected with CVB3 was capable of
stimulating expansion of the same TCR Vß families. The TCR V
repertoire was never found to be skewed.
Key Words: cardiomyopathy • immunology • myocarditis • viruses
Introduction
Top
Abstract
Introduction
Methods
Results
Discussion
References
Myocarditis exhibits
a wide spectrum of clinical manifestations, ranging from essentially
asymptomatic, transient inflammation to severe congestive
heart failure, dysrhythmias, and death. The overall prognosis of
myocarditis in children remains poor. In a comprehensive study, only 7
of 34 patients (21%) had resolution of their illness. Despite
intensive support, the overall mortality was
62%.1 Furthermore, myocarditis is a major cause
of sudden, unexpected death in adults <40 years old, with 
20% of
such individuals dying of this disease.2 There is
substantial evidence that viral and/or inflammatory myocarditis can
progress to IDC,3 which, second to
ischemic heart disease, is the most common indication for heart
transplantation.4 1
in 105 T cells. Various reports have demonstrated
the association of superantigens with the development of several human
pathological conditions, some autoimmune diseases
included.21 22
Methods
Top
Abstract
Introduction
Methods
Results
Discussion
References
Subjects
Patient 1 was a 51/2-year-old girl; patient 2, a
6-month-old boy; and patient 3, a 14-year-old boy. The
symptomatological course of the disease was similar in all of them:
healthy until the onset, these children began experiencing several days
of fever, vomiting, diarrhea, and dehydration, for which they received
antipyretics and oral and/or intravenous fluid rehydration.
Rapid progression to the signs and symptoms of congestive heart failure
led to hospitalization and cardiac evaluation. Findings included
radiographic features of cardiomegaly and pulmonary
edema, together with echocardiographic demonstration of
globally depressed ventricular function without evidence of
structural abnormalities or pericardial effusion. Cardiac
catheterization confirmed a poor global
ventricular function. Preliminary
histological analyses of a few
endomyocardial biopsies were not sufficiently
informative. All patients were diagnosed as having IDC. 2.5,
2, and 1.5 years after transplantation, respectively. Antirejection
therapy with azathioprine, prednisone, and either tacrolimus or
cyclosporine was used. The few episodes of clinically
silent rejection have responded to methylprednisolone.
Heart, lymph node, and thymus fragments obtained at the time of
transplantation were snap-frozen in isopentane chilled to -150°C and
stored at -80°C. Standard histological and
histochemical techniques were used to prepare 5-µm-thick frozen
sections. Before staining, the sections were exposed to absolute
acetone for 10 minutes.
For the detection of CVB genome, RT-PCR using a 5'-sense primer
(5'-CGGTACCTTTGTGCGCCTGT-3') and 3'-antisense primer
(5'-GAAACACGGACACCCAAAGTA-3') was performed.25 26
The amplified DNA was isolated and tested for the presence of CVB
sequences with nested primers P6 and P9.25 Twenty
clones were isolated and automatically sequenced with an ABI 377 DNA
Sequencer (Applied Biosystems Inc). and Vß Repertoires
The study of the TCR V and Vß gene segment usage of 29 TCR
V and 26 TCR Vß families and subfamilies was performed by RT-PCR
as previously described.22 and Vß gene families were
resolved by electrophoresis on an ABI 377 DNA Sequencer and
automatically analyzed by Genescan software (Applied Biosystems
Inc).27 For each tissue specimen, the
analysis was performed at least 3 times from RT-PCR to gel
reading. Genescan also allows the analysis of the different
lengths of the CDR3, inclusive of Vß, (N) Dß (N), and Jß
segments, the corresponding peaks, and their areas (spectratypes). In
the case of the most relevant specimens, DNA sequencing of the cloned
PCR products was also performed.
PBMCs from healthy adults were isolated from heparinized
peripheral venous blood with a Ficoll-Hypaque gradient
(1-Step Lymphoprep, Accurate Chemical & Scientific Corp). For each
donor, RNA was extracted from 3x106 cells. Also,
1x106 cells/mL were seeded into flat-bottom
24-well culture plates (Corning) and exposed to sonicated Vero cell
lysates in complete RPMI-1640 medium supplemented with 10% human AB
serum (Normolcera-Plus).
Results
Top
Abstract
Introduction
Methods
Results
Discussion
References
Immunohistochemical Analysis
Heart
The cardiac tissue from each of the patients studied showed a
considerable infiltration of leukocyte common antigen–positive white
blood cells that were mostly CD4+ and CD8+ T lymphocytes (Figure 1
). CD4+ cells were disseminated within
the affected tissue, whereas CD8+ elements were mostly clustered in
multifocal perivascular sites in which areas of cell damage were also
evident. Activated monocytes/macrophages were seen in
histological sections, as indicated by their morphology
and by their reactivity with Ber-MAC3 MAb (Figure 1).29 No signs of fibrosis or calcification were
found in the sections analyzed. However, the
histological scenario was notably
heterogeneous, with areas of significant T-cell
infiltration and parenchymal damage interspersed with areas of
apparently normal myocardium.
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Figure 1. Immunohistochemical analysis of heart of
patient 1. Infiltrating CD4+ (x20) and CD8+ (x40) lymphocytes are
seen (red) in areas of prominent myocyte necrosis. Ber-MAC3+ elements
within heart are also shown (x40). IgG1 is isotype control
(x20). ). Within the tissue, multifocal areas
were, in fact, characterized by the presence of myocytes and
infiltrating cells containing cytoplasmic granules that were positively
stained. The immunostaining for CVB1, CVB4, and CVB6
serotypes was negative (eg, Figure 2).
View larger version (115K):
[in a new window]
Figure 2. CVB immunostaining in heart, lymph
nodes, and thymus. CVB3 and CVB6 immunostaining in
normal heart; patient's heart, lymph node, and thymus (x20). Positive
reactions were revealed by anti-alkaline phosphatase, which
produces red/maroon color. Normal heart was negative and shows intact
architecture without signs of cell injury.
In patient 1, the architecture of the lymph nodes appeared
to be largely altered, such that we were unable to clearly distinguish
the primary and secondary germinal centers. Large nucleated cells
reacted with MAb specifically directed against CVB3, whereas MAbs
against CVB1, CVB4, and CVB6 were negative (eg, Figure 2
).
CVB3-positive elements, organized in cellular cords within the
lymphocytic component of the tissue, were also positive for Ber-MAC3
(data not shown). These results suggest that these cells, belonging to
the monocyte lineage, may have phagocytosed viral material. Lymph nodes
from patients 2 and 3 were not available.
The thymic tissue from patients 1 and 2 (the third patient's
thymus was not available) was clearly positive for CVB3 (Figure 2). No
positivity for CVB3 was demonstrated in the thymic cortex. With MAbs
directed against CVB1, CVB4, and CVB6, no reactivity was found either
in the medulla or in the thymic cortex (eg, Figure 2). CVB3+ staining
was seen mostly on hyalinized epithelial reticular elements surrounding
Hassall's corpuscles (Figure 2). A large population of
monocytes/macrophages was present within the epithelial
constituents. The monocytes appeared to be activated, as
demonstrated by their reactivity with Ber-MAC3 MAb (data not
shown).
Among heart specimens, we were able to amplify the CVB
genome in patient 1 only (not shown). The RT-PCR–amplified DNA segment
(present also in the thymus) was cloned and sequenced. The segment
matches 460 out of 464 base pairs from the 5'-nontranslated region of a
CVB4 strain (GeneBank S76772, base pairs 84 to
547).30 This strain was previously found to be
the active cause of myocarditis and type I diabetes in a patient who
died as a consequence of this infection.31
Compared with this published sequence, the 4 differing
nucleotides were located at positions 260 (adenine not
cytosine), 276 (guanine not adenine), and 341 to 342
(cytosine-uridine not uridine-cytosine). It is perhaps
noteworthy to point out that the distinction between different strains
of CVB (eg, CVB3 versus CVB4), defined on the basis of antibody
neutralization assays, does not consistently reflect
corresponding nucleotide variations of the 5'-nontranslated
region. Differences of 30% to 50% in nucleotide sequences
are frequently present in variants of the same immunologically
defined strain. This may explain why the specimens analyzed
were immunologically CVB3-positive, even if the isolated CVB
5'-nontranslated region was more similar to a CVB4 published
sequence.30 and Vß Repertoires in the Heart, Lymph Nodes, and
Thymus
Semiquantitative analysis of the TCR Vß repertoire of
the cells infiltrating the heart tissues of our patients revealed an
exceptionally high level of expression of the Vß3, Vß7, and
Vß13.1 gene families compared with the expression pattern observed in
both the bioptic specimens from the hearts of control subjects and the
PBMCs of age-matched children (Table 1
and Figure 3). In each case, specimens
from different areas of the same organ showed different percentages of
TCR Vß skewing (eg, 56% Vß7 in the right ventricle versus 18% in
the left ventricle of patient 2; see Table 1 and Figure 3). In patient
3, the TCR repertoire analysis was possible only in the right
ventricle. In the left ventricle, the repertoire was not interpretable,
possibly because of the paucity of T-cell infiltrates in the tissue
available from this section of the heart. When additional tissues were
available, a similar, though less prominent, skewing of the TCR Vß
repertoire was also seen in the thymus (eg, patient 1, 23.6% Vß3,
10.8% Vß7, and 10.2% Vß13.1; patient 2, 4.6% Vß3, 12.7%
Vß7, and 7.2% Vß13.1) and in lymph nodes (eg, patient 1, 17.0%
Vß3, 7.4% Vß7, and 12.4% Vß13.1).
View this table:
[in a new window]
Table 1. TCR Vß Expression in Heart Specimens From Patients
and Control Subjects
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[in a new window]
Figure 3. TCR V and Vß repertoires of T cells
infiltrating heart, lymph node, and thymus. Analysis of Vß
repertoire of T cells infiltrating right (red) and left (orange)
ventricle and thymus (yellow) of IDC patient 2. Mean values (±SD) of
TCR Vß families of peripheral blood mononuclear cells
from 16 normal control subjects are shown in green, and control hearts
in blue. Exceptionally high expression of Vß7 family is apparent in
right ventricle, where TCR V repertoire was found unskewed (inset
upper right). repertoire analysis did not reveal overexpansion
of any V gene family in any of the specimens from patients or
control subjects (eg, Figure 3). The coexpression of all the V gene
families argues against a possible "founder" effect for the Vß
skewing due to a potentially limiting number of T cells in the
successfully analyzed tissue samples.
The TCR repertoire analysis of PBMCs from 9 donors
expressing different HLA class II alleles, cultured with
CVB3-infected Vero cell lysates, showed increases of different
combinations of the Vß3, Vß7, and Vß13.1 families in the
activated (ie, CD71+) PBMCs compared with the values found in
the respective PBMCs analyzed before culture. Although
expression of these 3 Vß families increased up to 4 times in
different donors' PBMCs, the other Vß families did not significantly
change in percentage of expression. The values for each skewed Vß
family are listed in Table 2. A
time-course experiment with the PBMCs from donor 1 is shown as an
example of a progressive increase of the Vß7 family peaking at 15
days (from 9.1% of the uncultured cells to18.7%) (Figure 4). Cultures with CVB1-, CVB4-, and
CVB6-infected Vero cell lysates did not significantly increase any Vß
gene family values in the CD71+ PBMCs (eg, Figure 5). In all donors, incubation with
lysates from noninfected Vero cells did not result in a predominant
increase of any Vß family (eg, Figure 5). The polyclonality of the
CD71+ cells, belonging to the most highly expressed Vß gene families
after CVB3-infected Vero cell lysate incubation, was demonstrated by
the results of Genescan spectratype analysis (eg, Figure 5).
View this table:
[in a new window]
Table 2. Specific TCR Vß3, 7, and 13.1 Overexpression of
PBMCs Exposed to CVB3-Infected Vero Cell Lysates
View larger version (36K):
[in a new window]
Figure 4. TCR Vß repertoire of PBMCs from healthy donors
cultured with CVB3-infected Vero cell lysates. Analysis of TCR
variable region of ß-chain (Vß) repertoire of donor 1. PBMCs,
either uncultured (white) or stimulated in vitro with cell lysates,
were harvested, and TCR Vß analysis on CD71+ cells was
performed at 4 (yellow), 9 (orange), and 15 (red) days of
culture.
View larger version (33K):
[in a new window]
Figure 5. TCR Vß13.1 family expression before and after
culture with different CVB strains. CD71+ PBMCs from donor 2 were
detected before (C) and after incubation with uninfected (V),
CVB1-infected (B1), CVB4-infected (B4), CVB6-infected (B6), and
CVB3-infected (B3) Vero cell lysates. Shown are maximum values from TCR
Vß repertoire analyses reached during 15 days of culture.
Spectratype from Vß13.1 family corresponding to column B3, shown in
upper left corner, indicates polyclonality of population of CD71+ cells
after CVB3 stimulation.
Discussion
Top
Abstract
Introduction
Methods
Results
Discussion
References
In humans, IDC is generally considered to be part of the sequelae
of a viral myocarditis. Myocarditis is a disease in which a link
between viral infections and autoimmunity has long been suspected but,
so far, not confirmed.16 17 T cells and the
development of a cell-mediated immune response are considered to be the
primary factors responsible for long-term myocardial damage after the
early process of myocarditis.16 17 32 33 Evidence
of a viral link in cases of IDC has been
provided,34 35 although the mechanism(s) of
virally stimulated injury still remain elusive.
repertoire, is most consistent with an immune response
initiated by a superantigen.18 28
Selected Abbreviations and Acronyms
CDR3
=
complementary determining region 3
CVB
=
coxsackievirus B
IDC
=
idiopathic dilated cardiomyopathy
MAb
=
monoclonal antibody
MHC
=
major histocompatibility complex
PBMC
=
peripheral blood mononuclear cell
PCR
=
polymerase chain reaction
RT
=
reverse transcriptase
TCR
=
T-cell receptor
V
, Vß=
TCR
- and ß-chain variable regions
Acknowledgments
This study was supported by NIH grants to Dr Del Nido
(HL-46207), Dr McGowan (HL-52589), and Dr Trucco (DK-46864). We are
thankful to Dr Ronald Jaffe for allowing us to analyze the
clinically unused specimens from the transplanted patients, the
personnel of the Division of Immunogenetics for volunteering small but
frequent blood donations, Read Fritsch for editing the figures, and
Patrick Hnidka for preparing the manuscript. HLA class II molecular
typing was performed by Angela Alexander from the Children's Hospital
of Pittsburgh Histocompatibility Center.
References
Top
Abstract
Introduction
Methods
Results
Discussion
References
7 in tumor-infiltrating
lymphocytes of uveal melanoma. Science. 1990;249:672–674.
repertoire was
consistently unskewed. These data are strongly suggestive of a
superantigen involvement in human heart disease caused directly or
indirectly by CVB3 infection.[Medline]
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