Report

Fibrin Deposits and Fibrinolytic Activityin Schonlein-Henoch Syndrome

GASTONE BIANCHINI, M.D., TORLLLO LOTTI, M.D., AND PAOLO FABBRI, M.D.

ABSTRACT: Previous reports havt' shown that dlteralions incutaneous and plasmatic fibrinolyiic activity are found incutaneous necrotizing vasculitis (CNV). In a combined inve'sii-galion with direct immunofluorescence and autohistographicevaluation of tissue fibritiolyiic activity in the lesional skin of20 subjects affected by Schonlein-Henoch (SH) syndrome,there was a marked decrease in cutaneous fibrinolytic activityin SH syndrome accompanied by deposits of fibrin-like mate-rial at the dermo-epidert7ial junction and around the smallblood vessels of dermis in affected skin. These data suggestsome interactions between decreased fibrinolytic activity, fi-brin deposits, and the tissue damage in the development ot'skinchanges in SH syndronif.

Schonlein-Henoch (SH) syndrome is characterized bypalpable purpura, ie, erythematous macuiar, papular,and urticarial lesions with purpura, located prevalentlyon the lower limbs and sometimes accompanied by var-ious other symptoms such as polyarthritis, particularly inthe large joints, abdominal problems with colic,vomiting, diarrhea, hematemesis, melena, acute glo-merulonephritis and, rarely, cardiac involvement,' andproblems involving the central nervous system.- Thecutaneous manifestations are characterized histologi-cally by leukocytoclastic vasculitis involving mainly thepostcapiilary venules.'' Typical features of this type ofvasculitis are the presence of neutrophils, nuclear dust,fibrin-like material, endothelial swelling, degenerativeand necrotic changes in the vessel walls and, in certainmoments of development, eosinophils, lymphocytes,macrophages, and mast cells in and around the venulesand capillaries in the dermis.

The currently accepted hypothesis is that this vas-culitis is determined by the deposit of circulating im-mune complexes (mainly IgA) in perivascular siteswhich causes complement activation and liberation ofchemotactic active factors.^ There are no reports in theliterature of studies regarding cutaneous and plasmaticfibrinolytic activity in SH syndrome. There are, however,comparable investigations on the so-called "necrotizingcutaneous vasculitis"^"^ which synthetically demon-

Address for reprints: Castone Bianchini, M.D., Via Alfani, 31 -

Eirenze, Italy.

From the Dvpartment of Dermatology,School of Medicine

University of Florence,Florence, Italy

strate: (1) a pathologic increase in the euglobulin lysistime, presumably responsible for the continuation andextension of vasculitic damage related to chronic venu-lar injury; and (2) a correlation between the necroticevolution of the cutaneous lesions and the deficit incutaneous and plasmatic fibrinolytic activity.

It is precisely because of these acquisitions that westudied cutaneous fibrinolytic activity and the possiblepresence of fibrin-like deposits in the lesioned skin of agroup of SH syndrome patients.

Materials and Methods

The subjects were 20 patients, hospitalized in thewards of the Department of Dermatology of the Univer-sity of Florence, with a clinical diagnosis of SH syn-drome confirmed by histologic findings demonstrating,in all cases, the presence of leukocytoclastic vasculitis.The 20 patients (12 boys and eight girls) were childrenbetween the ages of 3 and 11 years. In all cases thepurpuric manifestations were present on the lowerlimbs, on the buttocks in five, on the upper limbs in four,and in one case, they were noticeable on the ears. Thebioptic material consisted of 1- to 3-day-old lesions re-moved under local anesthesia with mepiricaine (1%carbocaine); the specimens were washed in PBS(phosphate-buffered saline pH 7.4) solution for 5 min-utes, subjected to quick freezing, and cut in sections,6/Am thick with an Ames International CTD cryostat. Thesections thus obtained were then investigated: (1) bydirect immunofluorescence using antifibrinogen an-tiserum (Fibrinogen FITC, DAKO-Immunoglobulins,Copenhagen, Denmark) conjugated with fiuoresceinisothiocyanate to evidence deposits of fibrin-like mate-rial; and (2) by autohistographic study of cutaneous fi-brinolysis. The methods used for the direct IF study arereferred by Beutner and colleagues.'" The study ofcutaneous fibrinolytic activity was done according to

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103

104 INTERNATIONAL JOURNAL OF DERMATOLOGY March 1983 Vol. 22

TABLE t. Deposits of Fibrin-like Materialm tesioned Skin of Patients With

5H SyndromeIDirect Immunofluorescent Study)

Palient

1

234S6789

1011T21314151617181930

Age(yr)

6

745

11855954465474595

PerivascularDeposits

+-

++++++• f

+—+++• f

++++

lunctionalDeposits

+_++++——++_

——__+——

(-) = no deposits found; )+) = deposits found.

Todd's autohistographic method" as modified by Lotti,Dindelli, and Fabbri'^ in order to have uniformly thickfibrin film on the cryostat sections of the cutaneous biop-tic material.

Results

The results are summarized in Table 1 and Figure 1.Table 1 reports the results of the direct IF study of speci-mens from lesioned skin. Deposits of fibrin-like material

were evidenced in perivascular sites in 18 of the 20cases, and in the dermo-epidermal junction in nine ofthe 20.

Figure 1 presents the results regarding cutaneous fi-brinolytic activity studied by our modification of Todd'smethod. The results have been tabulated according to ascale graphically expressed with values of 0, ( + ), (-i- -I-),and (+ + -I-) which represent both the size and numberof the fibrin lysis areas at the perivascular level in thedermis. Precisely. 0 indicates the cases without cutane-ous fibrinolytic activity; ( + ) the cases with 50% less fi-brinolytic activity than that found in healthy controls;(+ +) cases with fibrinolytic activity equal to that of thecontrol group; and (+ + +) those with fibrinolytic activ-ity more than 50% higher than the control group. This ofcourse was an arbitrary method of evaluation, but can beconsidered valid since both the tissue and fibrin filmthicknesses were uniform in all the tests performed.

Figure 1 shows that cutaneous fibrinolytic activity wasabsent in 12 of the 20 cases, reduced in five, normal intwo (see Fig. 2), and increased in are (see Fig. 3). It isinteresting to note that the bioptic specimen of the onlysubject with increased fibrinolytic activity was takenfrom a very early lesion (only 3 hours after onset) whichhad a whea! aspect and only light purpura.

Comment

As was pointed out in the introduction, SH syndromeis a systemic vasculitis presumably determined by thedeposit of circulating immune complexes in perivascularsites, with the consequent activation of the complementcascade. The neutrophils, recalled to the deposit site bythe liberation of biologically active fragments of thecomplement cascade (Q,^, C3.4, Q -fi ?), supposedly de-termine vascular damage by releasing numerouslysosomal enzymes (collagenase, neutral and acid

o1 5 4 5 6 7 8 9 iZ ^2

FIC 1. Cutaneous fibrinolyiic activity in20 cases of SH syndrome. I A modified Todd'smethod.)

-f6

No. 2 FIBRIN IN SCHONLEIN-HENOCH SYNDROME • Biarichini, toll/, and Fahbri 105

FIG. 2. Normal fibrinolytic activity. FIG. 3. Increased fibrinolytic activity.

STAGE I: HYPERFIBRINOLYTIC(clinically characterized by urticarial wheals)

circulating immune complexes postcapillary venular endothelial cells

liberation of plasmifiogen proactivators

increased vascular ^permeability (wheal)

hyperfibrinolysisactivation of complement,kinin, and prostagtandinsystems

STAGE !1: HYPOFIBRINOLYTIC(clinically characterized by palpable purpura)

FIC. 4. Pathologic stages of palp-able purpura in Schonlein-Henoc hsyndrome.

exhaustion of plasminogen proactivatorsendo and perivascular depositsof "fibrin-like" material

ischemia

sparse areas of necrosis

Iactivation of coagulativesystem

further depositionof "fibrin-like"material

amplification oftissue damage

106 INTERNATIONAL JOURNAL OF DFRMATOLOGY March 1983 Vol.

proteases, hyaluronidase, and basic polycationicproteins).'•'•'"'

However, this sequence of events would not takeplace if the circulating immune complexes underwentphysiologic clearance instead of passing through the en-dothelial cells of tbe postcapillary venules to tben de-posit in perivascular sites. In the last few years it hasbeen hypothesized that the mechanisms able to condi-tion this passage are: (1) increased vessel permeabilitydue to tbe liberation of angioactive substances followingthe interaction between immune complexes andplatelets'^"'"; and (2) increased vessel permeability dueto vasopermcabilizing substances liberated followingthe interaction between basophils and antigen{s)''. Ourstudies bave demonstrated that in its later stages, tbe SHsyndrome cutaneous lesion undergoes a gross alterationin the fibrino-synthetic/fibrinolytic balance charac-terized by an inhibition of fibrinolytic activity. In fact,the autohistographic investigations with tbe modifiedTodd's method allowed us to document blockage (in 12out of 20 cases) and noteworthy reduction (five of tbe20) of fibrinolytic activity in tissue. It is interesting tonote ihal in the five cases with demonstrable reductionin fibrinolytic activity, this activity was present in thevessels witb little or no cellular cuff in the surroundingareas.

On the basis of data relative to cutaneous necrotizingvasculitis, confirming an initial increase in cutaneousfibrinolytic activity,'•-"•-'• one can bypothesize that alsoin SH syndrome (see Fig. 4) tbere is an initial hyperfi-brinolytic phase, demonstrated in the several-hour-oldweal associated with light purpura taken from one of ourpatients for investigation. This hyperfibrinolytic phase ispresumably due to the action of the circulating immunecomplexes on the venular endotbelial cells" that con-sequently liberate an increased amount of plasminogenproactivator, such that the fibrin film covering the en-dothelial cells is altered and, mostly, removed. Thisfacilitates the passage of serum and tbe immune com-plexes themselves through the cell walls and determinesthe activation of complement, kinin, and prostaglandinsynthetic systems.""-^

During this initial phase, the cutaneous lesion ischaracterized clinically by fairly stable urticarial wheals,followed sometime later by cellular infiltration andbematic overflow (palpable purpura). During the secondor hypo-fibrinolytic phase the liberation of plasminogenproactivators, work of tbe endotbelial cells, ceases andfibrin deposits increase botb in intravascular andperivascular sites with tbe formation of sparse areas ofnecrosis able to activate tbe coagulative-fibrinolytic sys-tem with increased transformation of amounts of fibrino-gen into fibrin and the consequent magnification ofthephenomenon.

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