RU2287822C1 - Method for predicting the severity degree of chorioretinitis flow - Google Patents

Abstract

FIELD: medicine, ophthalmology.

SUBSTANCE: while inspecting a patients with chorioretinitis it is necessary to fulfill immunogenetic typing of peripheral blood lymphocytes by HLA I class (loci A and B). At detecting antigens HLA-A9 and/or A24 and/or B53 one should predict light flow of chorioretinitis, at detecting antigens HLA-B5(B51) and/or B27 - sever flow and at detecting antigens HLA-B22 and/or B56 - highly severe flow of chorioretinitis. The innovation provides improved quality of diagnostics of chorioretinitis due to predicting the severity degree of the disease flow that enables to prevent irreversible retinal alterations and vascular membrane as it is by prescribing adequate therapy in due time.

EFFECT: higher accuracy of prediction.

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Description

The invention relates to medicine, namely to ophthalmology, and can be used to predict the severity of the course of chorioretinitis.

There are various methods for assessing the severity of chorioretinitis, which mainly boil down to recording various degrees of changes in the retina and the choroid proper by subjective and objective methods: complaints, anamnesis of the disease and life, ophthalmoscopy, perimetry, electrophysiological studies, fluorescence angiography, immunodiagnosis, etc. ( O.S.Slepova et al. Information letter, M., 1994, p.24, O.S.Slepova et al. Abstracts collection dedicated to the 3rd symposium on non-invasive diagnostics, 1997, p.25).

The closest technical solution is a method for predicting the risk of second eye disease with endogenous uveitis (RU 2148260 C1, G 01 N 33/543, 2000), which consists in determining the presence of serum antibodies to the retinal S-antigen using enzyme-linked immunosorbent assay. If in the blood serum of a patient with unilateral posterior or generalized uveitis (including chorioretinitis), both classes of antibodies to the retinal S-antigen (IgG and IgM) are detected simultaneously, the risk of pair eye disease is predicted. The detection of antibodies of only IgG or IgM class is an indication for the periodic examination of patients with chronic uveitis in order to identify a possible increase in humoral autoimmune reactions. The absence of serum antibodies to the retinal S-antigen reduces the likelihood, but does not completely exclude the possibility of the pair eye involvement in the pathological process. The method contributes to the timely implementation of preventive therapeutic measures. (Bykovskaya G.N. “The Importance of Immunological Factors in the Pathogenesis of Bilateral and Unilateral Uveitis”, abstract of diss .... Candidate of Medical Sciences, M., 2000; p.5).

However, when using this method, it is possible to assess the severity of the disease only at the time of examination with already developed signs of a severe course of chorioretinitis (the addition of autoimmune processes, bilaterization of the inflammatory process). The repeated study recommended in the subsequent until the possible detection of serum antibodies to the retinal S-antigen also makes the patient donate blood each time and be under constant clinical supervision.

Thus, the analogue and prototype of the claimed method for predicting the course of chorioretinitis, revealed as a result of a patent search, do not ensure the achievement of a technical result consisting in increasing the clinical value of the diagnostic results due to the specificity of the method and the possibility of predicting the severity of the disease.

The technical result is an improvement in the quality of the diagnosis of chorioretinitis by predicting the nature of the course of the disease based on the identification of antigenic markers of HLA class I.

The technical result is achieved by a method for predicting the course of chorioretinitis, including the study of peripheral blood lymphocytes, characterized in that they carry out immunogenetic typing of peripheral blood lymphocytes by HLA class I (loci A and B) and when detecting antigens HLA-A9 and / or A24, and / or B53 mild chorioretinitis is predicted, with HLA-B5 (B51) and / or B27 - severe, and with HLA-B22 and / or B56 - extremely severe.

The proposed method allows to predict the severity of the disease from immunogenetic positions that determine the direction and strength of the immune response, including with chorioretinitis at any stages of the examination of patients, even in remission, which extends the diagnostic value of the method.

Studies of the last decade have shown that the clinical significance of genes encoding histocompatibility antigens is not limited to transplantology, but is associated with a predisposition to certain diseases. This biological role of histocompatibility antigens has formed a new clinical direction of “HLA disease”. HLA is a human tissue compatibility system (Human Leukocyte Antigens). This is an extremely intensively developed area by both foreign and domestic researchers. It has been observed that the carriage of certain HLA antigens in humans is significantly overestimated in some diseases, which indicates a genetically determined predisposition, the "programmed risk" of a person being affected by some form of the disease. As a hypothesis, it is generally accepted that HLA-A, B are not in themselves structures that determine susceptibility to a disease, but there are special “susceptibility” genes that determine the intensity of the response to a factor of the external or internal environment of the body. Moreover, the allele that induces a low immune response is a provocative gene of the disease. Allele (gene) - a provocateur increases the predisposition to the disease, provoking its manifestation. Naturally, the frequency of such an allele in the patient group is overestimated (positive association). But along with antigens positively associated with the disease, there are antigens associated negatively. This means that when sampling patients, the coding gene is extremely rare, i.e. most people who carry this gene are not predisposed to this disease. Such an allele is considered as a gene-protector of this disease (Yu.M. Zaretskaya "Clinical immunogenetics", M .: Medicine, 1983, p.133-146).

The method is as follows.

Take blood from the ulnar vein in a volume of 10 ml with heparin. Lymphocytes are isolated on a density gradient of ficoll - verographin ρ = 1,077.

Phenotyping of lymphocytes is carried out in a standard lymphocytoxic test using HLA-AB serum antibodies according to the method proposed by the Bethesda National Institute of Health (NIH method).

The phenotype (a set of HLA-A and B antigens) is established in patients with chorioretinitis who has applied for the first time, it is checked for the presence of antigens responsible for the different severity of the disease. If HLA-A9 and / or A24 and / or B53 antigens are detected, a slight degree of damage to the retina and the choroid proper is predicted; HLA-B5 (B51) and / or B27 is a severe course with the appearance of a local autoimmune component and more pronounced changes in the posterior part of the eyeball. The extremely severe course of chorioretinitis (Vogt-Koyanagi-Harad syndrome) is associated with the detection of HLA-B22 and / or B56 in the patient's phenotype.

According to the proposed method, 141 patients with chorioretinitis were examined (67 patients with central serous chorioretinitis - mild clinical course, 57 - with focal - severe course and 17 patients with posterior uveitis in Vogt-Koyanagi-Harada syndrome - extremely severe course) aged 15 to 70 years, which included, in addition to immunogenetic typing, the determination of serum tissue-specific antibodies to corneal antigens (HRV-54), the lens (α-crystallin), and the retina (S-antigen). The determination of antibodies to antigens of the cornea, lens, retina is carried out by ELISA (RU 2247385, G 01 N 33/53, 2005).

Antigens responsible for the severity of chorioretinitis have been identified. As a control, data from a survey of 573 donors of the Republican blood transfusion station were made (table 1).

Table 1
Distribution of class I HLA antigens by severity of chorioretinitis Groups Hla Frequency of occurrence Rr EF, PF R sick, n = 141 control, n = 573 abs. rel. abs. rel. mild course A9 eleven 7.8 127 22.2 0.3 0.156 <0.01 A24 10 7.1 12 2.1 3.6 0.051 <0.02 B53 28 19.9 5 0.9 28,2 0.192 <0.01 severe course B5 (B51) eighteen 12.8 3 0.5 25.7 0.125 <0.01 B27 fifteen 10.6 7 1,2 9.6 0,099 <0.01 extremely severe course B22 10 7.1 2 0.4 21.8 0,067 <0.01 B56 eleven 7.8 3 0.5 16.1 0,075 <0.01 Note: RR (RR-relative risk) - an indicator of the relative risk of chorioretinitis; EF is an indicator of the etiological fraction, with RR> 1; PF is an indicator of the preventive fraction at RR <1.

1. The frequency of occurrence of antigen Ah is expressed as a percentage of the total number of individuals examined. The antigen frequency (f) was calculated by the formula:

, где n - число носителей данного антигена;

where n is the number of carriers of this antigen;

N is the number of examined.

2. The significance of differences in the frequency of occurrence of antigens was calculated according to the Pearson criterion:

where 0.5n is the correction for continuity for small samples.

The values of a, b, c, d were found from the four-field table:

antigen + - sick but b healthy from d

N = n ₁ + n ₂ , where n ₁ is a sample of the 1st group, n ₂ is a sample of the 2nd group.

3. The value of the relative risk was calculated according to the formula Woolf, 1955:

, где а, b, с, d - количество больных и здоровых индивидов, обладающих или не обладающих данным аллелем.

, where a, b, c, d - the number of sick and healthy individuals with or without this allele.

This formula is by far the most used in calculating the value of relative risk.

If the frequency of the allele in patients is reduced compared with the frequency in healthy patients, the relative risk value is calculated with a negative sign.

4. Attributive risk or etiological fraction was calculated for RR> 1

, где EF - этиологическая фракция,

where EF is the etiological fraction,

F is the frequency of occurrence of antigen in patients.

5. Preventive fraction (calculated for RR <1)

, где PF - превентивная фракция,

where PF is the preventive fraction,

F is the frequency of occurrence of antigen in patients.

By calculating the relative risk of occurrence and the etiological fraction (EF), it was confirmed that a mild course (central serous chorioretinitis) occurs in patients with A24 and / or B53 antigens, and severe (focal chorioretinitis) is associated with HLA-B5 (B51) and / or B27, and B22 and / or B56 should be considered as markers of the extremely severe clinical course of chorioretinitis, with the development of exudative retinal detachment with Vogt-Koyanagi-Harad syndrome.

In patients with mild markers of HLA-A24 and / or B53 and / or HLA-A9 protector, the level of serum antibodies to eye antigens did not practically differ from those of healthy individuals. Whereas in patients with severe markers of HLA-B5 (B51) and / or B27, serum revealed significantly significant increased levels of antibodies to the retina and lens antigens, and in extremely severe (HLA-B22 and / or B56) - to all the whites of the eye (table 2).

Thus, the use of this method opens up the possibility of predicting the severity of the course of chorioretinitis when a set of certain HLA class I antigens is detected, which will allow us to prescribe adequate therapy in a timely manner and reduce the percentage of deep irreversible changes in the posterior part of the eye.

Example 1

Patient 3., born in 1966 (m / c 1373-2002 year), he went to the clinic complaining of a sudden deterioration in vision and the appearance of a spot in front of his left eye.

At the time of admission, visual acuity was OD - 1.0 OS - 0.4 s +1.0 ^d = 1.0. Objectively: with biomicroscopy, the anterior segment of both eyeballs without pathological changes. The ophthalmoscopic picture of the fundus is an optic nerve disc with physiological excavation, the borders are clear, the arteries are slightly narrowed, the veins are full-blooded, hyperemia and edema were observed in the macular region of the left eye, and the periphery of the retina of both eyes was unremarkable. Objectively, by means of electrooculography, a decrease in dark adaptation, restoration to light and the Arden coefficient was detected, a subnormal version of the left eye electroretinography was recorded.

The phenotype of the patient is HLA-A2A29B35B53.

The concentration of serum antibodies to antigens: cornea (HRV-54) - 0 cu, the lens (α-crystallin) - 0 cu, the retina (S-antigen) - 0 cu, that is, the physiological norm.

Was diagnosed with OD-Healthy. OS-Central serous chorioretinitis. Weak hypermetropia.

Based on the examination, a mild course of chorioretinitis was ascertained.

After the course of treatment, the spot in front of the left eye decreased in size. Visual acuity OD - 1.0, OS - 0.6 s +1.0 ^d = 1.0. On the fundus in the macular region, residual effects of edema and hyperemia were observed.

After 3 months, the visual acuity of the left eye increased to 0.8 and with a correction of 1.0.

Example 2

Patient I., born in 1960, was admitted to the Ufa Research Institute of Eye Diseases (m / c 5873-2002) with a diagnosis of OU - Panuweit. Incomplete complicated cataract. Exudative retinal detachment. Vogt-Koyanagi-Harada syndrome.

According to the patient, about one month ago, he noticed a deterioration in vision, first of the right, then the left eye. Treated on an outpatient basis. The visual acuity of both eyes was 0.2. In recent days, a “fog” appeared in front of both eyes, and vision decreased sharply. Upon receipt, the visual acuity of both eyes was determined in the form of proper light perception. A mixed injection of the eyeball, dusty precipitates on the corneal endothelium, swelling with smoothing of the iris pattern and a sluggish reaction of the pupil to the light were detected biomicroscopically. Turbidity in the middle layers of the lens, exudation in the vitreous. There was no reflex from the fundus, the fundus picture was ophthalmoscopically behind the fleur.

An ultrasonogram of both eyes was used to determine the traction subtotal retinal detachment.

The result of histotyping of HLA-A11B22B35B56.

The concentration of serum antibodies to antigens: cornea (HRV-54) - 0.354 cu, the lens (α-crystallin) - 0.429 cu, retina (S-antigen) - 0.566 cu

Of the concomitant pathology, the patient noted graying of hair from the age of 30, vitiligo, sensorineural hearing loss, arachnoiditis with frequent bouts of headache in the occipital region.

After the course of treatment, there was a slight positive dynamics in terms of subsiding of acute inflammatory phenomena, but visual acuity remained at the same level. Thus, during the examination, an extremely severe clinical course was established with the involvement of all eye structures and the systemic manifestation of the disease.

Example 3

Patient A., born in 1970, was observed at the Ufa Research Institute of Eye Diseases (m / k 4679-2001) with a diagnosis of OS-Focal chorioretinitis with hemorrhagic syndrome of unknown etiology. OU-Myopia moderate.

The examination revealed the following set of HLA-A2B44B27 antigens. The concentration of serum antibodies to eye antigens: BCP-54, α-crystallin S-antigen was 0.018, 0.085 and 0.023 cu respectively, which was slightly higher than normal. A blood test for CRP +, sialic test - 0.240 Units. The infectious nature of the disease (cytomegalovirus, toxoplasmosis) was excluded. However, the Mantoux reaction was 27 mm and further examination and treatment in the conditions of the Republican TB dispensary was recommended.

Visual acuity at the time of examination of the diseased eye was 0.01 without the possibility of correction. Vitreous destruction was detected biomicroscopically. At the fundus, the optic nerve disc was pale in color with a myopic cone, the vessels were narrowed, a grayish-white focus with fuzzy contours with a hemorrhage was defined in the macular region of the diseased eye.

Thus, during the examination, a severe clinical course was established.

Claims (1)

A method for predicting the course of chorioretinitis, including the study of peripheral blood lymphocytes, characterized in that immunogenetic typing of peripheral blood lymphocytes by HLA class I (loci A and B) is performed and, when HLA-A9 and / or A24 and / or B53 are detected, a mild course of chorioretinitis is predicted, with HLA-B5 (B51) and / or B27 - severe, and with HLA-B22 and / or B56 - extremely severe.