Dermal Shwartzman Reaction Research Articles

Whatever happened to the Shwartzman phenomenon?

Ninety years ago, Gregory Shwartzman first reported an unusual discovery following the intradermal injection of sterile culture filtrates from principally Gram-negative strains from bacteria into normal rabbits. If this priming dose was followed in 24 h by a second intravenous challenge (the provocative dose) from same culture filtrate, dermal necrosis at the first injection site would regularly occur. This peculiar, but highly reproducible, event fascinated the microbiologists, hematologists, and immunologists of the time, who set out to determine the mechanisms that underlie the pathogenesis of this reaction. The speed of this reaction seemed to rule out an adaptive, humoral, immune response as its cause. Histopathologic material from within the necrotic center revealed fibrinoid, thrombo-hemorrhagic necrosis within small arterioles and capillaries in the micro-circulation. These pathologic features bore a striking resemblance to a more generalized coagulopathic phenomenon following two repeated endotoxin injections described 4 yr earlier by Sanarelli. This reaction came to be known as the generalized Shwartzman phenomenon, while the dermal reaction was named the localized or dermal Shwartzman reaction. A third category was later added, called the single organ or mono-visceral form of the Shwartzman phenomenon. The occasional occurrence of typical pathological features of the generalized Shwartzman reaction limited to a single organ is notable in many well-known clinical events (e.g., hyper-acute kidney transplant rejection, fulminant hepatic necrosis, or adrenal apoplexy in Waterhouse-Fredrickson syndrome). We will briefly review the history and the significant insights gained from understanding this phenomenon regarding the circuitry and control mechanisms responsible for disseminated intravascular coagulation, the vasculopathy and the immunopathy of sepsis.

Lesions Resulting from Attempted Shwartzman Reaction in Turkey Poults Inoculated with Pasteurella multocida Lipopolysaccharide

Five-week-old turkey poults were given two consecutive intravenous injections (24 hours apart) of highly purified Pasteurella multocida lipopolysaccharide (LPS) in an effort to induce a generalized Shwartzman reaction. There were no gross lesions, and microscopic lesions were limited to focal hepatic necrosis with heterophil infiltration. Hepatic lesions did not differ qualitatively from lesions in turkeys given a single dose of lipopolysaccharide. Margination of heterophils in the pulmonary vasculature was observed in turkeys 4 hours after a single injection of LPS, but it was not present in turkeys given the consecutive injections of LPS. To induce a dermal Shwartzman reaction, turkeys were given intradermal injections of LPS followed by an intravenous injection of LPS 24 hours later. Although no grossly visible hemorrhagic dermal necrosis occurred, microscopic lesions, including heterophil infiltration, vasculitis, thrombosis, and necrosis, were present. Thrombosis and vasculitis were observed only in turkeys given the intravenous and intradermal LPS, whereas the other inflammatory changes were observed in turkeys given the intradermal injection of LPS and intravenous water. Prominent lymphocytic perivascular cuffing at the site of dermal injection was present in all turkeys given intradermal LPS.

Enzymatically deacylated Neisseria lipopolysaccharide (LPS) inhibits murine splenocyte mitogenesis induced by LPS

Acyloxyacyl hydrolase is a leukocyte enzyme that selectively removes the secondary acyl chains from the lipid A moiety of gram-negative bacterial lipopolysaccharides (LPS). As predicted by the reported contribution of secondary acyl chains to the bioactivities of lipid A analogs, enzymatic deacylation of Salmonella typhimurium Rc LPS substantially reduces its potency in the dermal Shwartzman reaction and in several in vitro assays that measure responses of human endothelial cells and neutrophils, whereas the potency of this LPS for inducing murine splenocyte mitogenesis is affected much less. In the experiments described here, we studied the impact of acyloxyacyl hydrolysis on the bioactivities of several LPS that differ from Salmonella LPS in carbohydrate and lipid A structures. Deacylated LPS from Escherichia coli, Haemophilus influenzae, Neisseria meningitidis, and S. typhimurium were similarly reduced in potency in the Limulus lysate test (30- to 60-fold reduction in potency relative to the corresponding mock-treated LPS), and the ability of all of these deacylated LPS to stimulate neutrophil adherence to human endothelial cells was reduced by a factor of 100 or more. For LPS from E. coli, H. influenzae, and Pseudomonas aeruginosa, the impact of deacylation on spleen cell mitogenesis was also similar to that observed for S. typhimurium LPS: deacylation reduced potency by less than 15-fold. Unexpectedly, the potency of Neisseria LPS in the murine splenocyte mitogenicity test was reduced over 100-fold by deacylation, and deacylated Neisseria LPS could block the mitogenic activity of Neisseria and Salmonella LPS. These studies indicate that the contribution of secondary acyl chains to the bioactivities of a given LPS cannot be predicted with confidence from the reported structure-activity relationships of lipid A or from the behavior of other deacylated LPS.

A comparison of the effects of intact and deacylated lipopolysaccharide on human polymorphonuclear leukocytes.

Enzymatic deacylation of LPS markedly reduces its activity in the dermal Shwartzman reaction. Inasmuch as polymorphonuclear leukocytes (PMN) are involved in the genesis of tissue injury in Shwartzman reactions, we have investigated the effects of deacylated LPS (dLPS) on PMN. Compared to LPS, dLPS was ineffectual as a stimulus of both PMN adherence and release of secondary granule enzymes, and dLPS inhibited specific LPS-induced adherence. Neither LPS nor dLPS caused release of the primary granule enzymes, myeloperoxidase, and elastase. Unlike LPS, dLPS failed to prime PMN for superoxide release when a second stimulus (FMLP, 10(-6) M was given. The mechanism of the LPS induced increase in PMN adherence was investigated, and we found that LPS significantly increased the amount of the adhesive glycoprotein CD11b on the surface of the PMN. dLPS had no effect on CD11b expression. Our results suggest that enzymatic deacylation of LPS profoundly alters its ability to stimulate PMN and deacylation of LPS by inflammatory cells in vivo might be an important mechanism limiting the toxic effects of LPS.

Treatment of toxic shock syndrome with endotoxin-neutralizing antibody

The enhancement of host susceptibility to endotoxin (lipopolysaccharide, LPS) by toxic shock syndrome toxin-1 (TSST-1) is an important mechanism in the pathogenesis of toxic shock syndrome. In these studies, we sought to determine whether an endotoxin-neutralizing monoclonal antibody could be useful in the treatment of toxic shock syndrome. We isolated a murine monoclonal hybridoma (3-H3) which secreted monoclonal antibody (mAb) specific for Escherichia coli 0111:B4 LPS. Spleen cells cocultured with E. coli 0111:B4 LPS demonstrated up to a 60% decrease in mitogenic activity in the presence of 3-H3 mAb, but not control mAb, demonstrating that this antibody neutralized endotoxin in vitro. Rabbits pretreated with 3-H3 mAb or control mAb were injected intradermally with E. coli 0111:B4 LPS. One day later rabbits received E. coli 0111:B4 LPS intravenously to elicit the dermal Shwartzman reaction. Rabbits pretreated with 3-H3 mAb did not develop this reaction (0/6) compared to animals pretreated with control mAb (5/6), demonstrating that this antibody neutralized endotoxin in vivo ( P < 0.05). When this antibody was evaluated in a rabbit model of lethal toxic shock syndrome, rabbits pretreated with antibody demonstrated greater survival (8/14) than saline control animals (1/10) after challenge with TSST-1 and E. coli 0111:B4 LPS ( P < 0.05). Since the suspicion exists that low levels of endogenous LPS may potentiate TSST-1 activity during clinical toxic shock syndrome, we hypothesized that endotoxin-neutralizing antibodies could be useful in the treatment of this lethal disease process.

Comparison of the biological responses induced by lipopolysaccharide and endotoxin of Treponema hyodysenteriae and Treponema innocens

The chemical composition and classical biologic activities of lipopolysaccharide (LPS; phenol-water) and endotoxin (butanol-water) preparations from virulent Treponema hyodysenteriae and avirulent Treponema innocens were examined. The LPS and endotoxin preparations from T. hyodysenteriae B204 contained approximately 80.9 and 35.2% hexose, 0.12 and 0.45% thiobarbituric acid-reactive compound, and less than 1 and 11.3% protein, respectively. The LPS and endotoxin preparations of T. innocens B1555a contained approximately 56.3 and 37.8% hexose, 0.45 and 0.4% thiobarbituric acid-reactive compound, and less than 1 and 26% protein, respectively. A silver-stained 7.5 to 15% sodium dodecyl sulfate-polyacrylamide gel showed four bands for the T. hyodysenteriae preparations, while the T. innocens preparations failed to resolve into discrete bands on electrophoresis. We determined by the Limulus amebocyte lysate assay that the treponemal preparations had comparable amounts of endotoxin activity when Escherichia coli LPS was used as a standard. The 50% lethal doses of LPS and endotoxin from T. hyodysenteriae for BALB/cByJ mice were 380 and 80 micrograms, respectively. The treponemal preparations were poor adjuvants, failed to induce a dermal Shwartzman reaction, and were not pyrogenic. The treponemal LPS preparations, unlike the endotoxin preparations, were not mitogenic for murine spleen cells. Differences in virulence between the two treponemal species could not be associated with the biologic activities of the respective LPS or endotoxin moieties, but the endotoxin preparations were consistently more active than the purified LPS preparations.

Effects of Pasteurella multocida Endotoxins on Turkey Poults

Studies of turkey poult responses to Pasteurella multocida endotoxins indicated that lipopolysaccharide (LPS) preparations from two highly pathogenic strains and free endotoxin from one of these strains were all similar in lethal toxicity. Lethal intravenous doses were generally high, 1 mg or more for 1-week-old poults (13.3 mg/kg). The toxic effects of LPS were not increased by repeated administration of small hourly doses. For both forms of endotoxin, the relationship between dose and response was considered erratic. Attempts to increase the susceptibility of poults to LPS by administering a liver-damaging substance (galactosamine) or a histamine-releasing substance (compound 48/80) or by performing surgical bursectomy were not effective. The LPS did not provoke a dermal Shwartzman reaction, even though doses used were 10 times those that produced a characteristic reaction in a rabbit.

Detoxification of bacterial lipopolysaccharides (endotoxins) by a human neutrophil enzyme.

Lipopolysaccharides in the cell walls of Gram-negative bacteria elicit toxic as well as potentially beneficial inflammatory responses in animals. It is now reported that tissue toxicity caused by lipopolysaccharides is preferentially reduced by an enzymatic activity in human neutrophils. Acyloxyacyl hydrolysis removes fatty acyl chains that are linked to the hydroxyl groups of 3-hydroxytetradecanoyl residues in the bioactive lipid A moiety of the lipopolysaccharides. Maximal acyloxyacyl hydrolysis reduced lipopolysaccharide tissue toxicity, as measured in the dermal Shwartzman reaction, by a factor of 100 or more. In contrast, the ability of the deacylated lipopolysaccharides to stimulate B lymphocytes to divide was decreased only by a factor of 12. It is suggested that during tissue invasion by Gram-negative bacteria acyloxyacyl hydrolysis may be a defense mechanism that reduces the toxicity of lipopolysaccharides while preserving some of their potentially beneficial inflammatory and immune stimuli.

Isolation, purification, and partial characterization of a lipopolysaccharide from Haemophilus pleuropneumoniae.

Lipopolysaccharide (LPS) from Haemophilus pleuropneumoniae 1536, serotype 2, was isolated and purified by a procedure designed to be equally satisfactory for both smooth- and rough-type LPS. The LPS yield was 53%. Analysis of the preparations revealed that protein, nucleic acid, and cellular phospholipid contamination was negligible (less than 0.1%). Analysis of the sugar content of the LPS by gas-liquid chromatography and colorimetric analysis revealed the presence of rhamnose, mannose, galactose, glucose, heptose, glucosamine, galactosamine, and 3-deoxy-D-manno-2-octulosonic acid. The heptose and glucose contents appeared to be unusually high. The fatty acids of the LPS consisted of a mixture of C14:0 and C16:0 in a ratio of about 4.5:1 (50% of the total) and 3-hydroxy C14:0. When used as a preparatory dose for the dermal Shwartzman reaction, as little as 10 micrograms of the LPS injected intradermally in rabbits produced reddening and swelling. After intravenous injection of a 100-micrograms LPS provoking dose, necrosis was observed at all intradermal injection sites. Limulus amebocyte lysate gelation was observed with an LPS concentration as low as 0.5 ng/ml. A typical biphasic fever response was noted in rabbits injected with as little as 0.25 ng of LPS per kg of body weight.

Influence of fine structure of lipid A on Limulus amebocyte lysate clotting and toxic activities.

We examined the relationship between the fine structure of lipid A and the toxicity of endotoxin or lipopolysaccharides as measured by the Limulus amebocyte lysate (LAL), rabbit pyrogenicity, chicken embryo lethal dose, and dermal Shwartzman reaction tests. Lipid A and lipid A-like compounds obtained from deep-rough mutants of Salmonella spp. and Escherichia coli had a wide range of structural variations. These compounds included native lipopolysaccharides, diphosphoryl and monophosphoryl lipid A's, and lipid X (a monosaccharide). The LAL test was positive for all lipids tested with lysates from Travenol Laboratories and from Associates of Cape Cod (2.9 X 10(3) to 2.6 X 10(7) endotoxin units per mg), except for O-deacylated and dephosphorylated lipid X, which were negative. The Mallinckrodt lysate gave negative tests for lipid X. In the rabbit pyrogenicity and chicken embryo lethal dose tests, only native lipopolysaccharide and diphosphoryl lipid A's were judged toxic. The Shwartzman reaction was positive for a specific purified diphosphoryl lipid A (thin-layer chromatography-3 fraction) but negative for the purified monophosphoryl lipid A (also a thin-layer chromatography-3 fraction). These results show that the LAL test is not a valid measure of all parameters of toxicity of a lipid A or lipid A-like compound and can yield false-positive results. However, these findings are not in conflict with the widespread use of the LAL assay for pyrogens in the pharmaceutical industry since a good correlation exists between LAL results and pyrogenicity when undegraded endotoxin is evaluated in parallel assays.

An immunoprotective monoclonal antibody to lipopolysaccharide.

The ability of antisera against lipopolysaccharide (LPS) raised by immunization with gram-negative bacteria to prevent LPS toxicity and death from gram-negative bacteremia is well established. To demonstrate conclusively that the protective antibody is specific for LPS, we tested an anti-LPS monoclonal antibody (mAb) in three animal models. 7G is an IgG3 mAb directed against an oligosaccharide side chain determinant of LPS from E. coli 0111:B4. This anti-LPS mAb increased the LD50 of 0111:B4 LPS in mice and protected rabbits against the dermal Shwartzman reaction elicited by 0111:B4 LPS. 7G mAb also protected mice against lethal infection with mucin-enhanced E. coli 0111:B4. Pretreatment with 250 micrograms of 7G increased the LD50 by more than 1.5 logs. These studies prove that oligosaccharide side chain-specific antibody to LPS confers protection against LPS toxicity in vivo and against experimental gram-negative infection. In addition, these studies suggest the potential of anti-LPS monoclonal antibody as therapy for gram-negative infection.

Biologic properties of bacterial lipopolysaccharides treated with chromium chloride

Addition of small amounts of chromium chloride to a saline suspension of Salmonella typhosa lipopolysaccharide (LPD; Difco) caused a marked reduction in several of the biologic activities of this substance including toxicity, B-cell mitogenicity, plasma colony-stimulating activity (CSA), radioprotective effect, and induction of the dermal Shwartzman reaction. Nevertheless, LPS treated with chromium chloride was found to be at least as effective as untreated LPS in enhancing resistance of B6CBF1 mice to the lethal effects of Klebsiella pneumoniae infection.

Role of meningococcal endotoxin in meningococcal purpura.

Enteric bacilli and meningococci (MGC) both contain potent endotoxins, but purpuric skin lesions indistinguishable from the experimental dermal Shwartzman reaction are much more common during meningococcal bacteremia than during bacteremia with enteric organisms. Highly purified lipopolysaccharides (LPS), virtually free of contamination by protein, RNA, and capsule, were extracted by a modification of the phenol-water technique from MGC (serogroups A, B, and C) and enteric bacilli (Escherichia coli 04 and 0:111, and Salmonella typhimurium). Polysaccharides in these LPS were similar by gas chromatography except for one galactose-deficient strain of MGC (135B). LPS from MGC and enterics were equally potent for the general Shwartzman reaction and mouse lethality, but LPS from MGC was 5-10 times more potent in inducing the dermal Shwartzman reaction. The greater skin potency of LPS from MGC explains the prominence of purpura in meningococcemia. Comparison of the properties of LPS may explain other differences in clinical syndromes caused by gram-negative bacteria.

Serological Studies of &lt;i&gt;Haemophilus influenzae&lt;/i&gt;

Culture fluids and washings of agar cultures (Ex antigens) and phenol-water extractions of whole bacteria or bacterial cell walls were prepared from capsulated and non-capsulated &lt;i&gt;H. influenzae &lt;/i&gt;strains. The preparations were subjected to comparative immunodiffusion analyses as well as to studies of their endotoxic effect, as demonstrated by dermal Shwartzman reaction and lethal tests. Immunodiffusion and immunoelectrophoresis analyses showed that in addition to the capsular precipitinogen a second precipitinogen, designated 2, was demonstrated in all preparations of all the strains tested. Both Ex antigens and phenol-water preparations from capsulated strains and from the non-capsulated variants could provoke a dermal Shwartzman reaction in rabbits. Ex antigens from capsulated strains and from a non-capsulated variant were lethal when given parenterally to rabbits. A relation between precipitinogen 2 and the endotoxic effect of the materials was shown. This precipitinogen was demonstrated in washings of young agar cultures as well as in phenol-water extractions of whole bacteria and of cell walls, from both M and S strains. Thus, precipitinogen 2 may be designated an·antigen. It was found to be antigenetically complex, and all the strains tested shared one of the antigen determinant of this complex.

Modification of selected host-reactive properties of endotoxin by treatment with sodium deoxycholate.

Endotoxin dissociated into subunits by sodium deoxycholate treatment exhibited diminished capacity to kill chick embryos, protect mice against the lethal effects of infection with Salmonella typhi, evoke hemorrhagic necrosis in skin inoculated with epinephrine, prepare for and provoke the dermal Shwartzman reaction, and induce pyrogenic tolerance. Surfactant-treated material which had been allowed to reaggregate displayed activity equivalent to that of untreated material. These findings were consistent with the working hypothesis that a macromolecular complex of critical size is required in order for endotoxin to elicit its characteristic effects in the host.

The biological activity of Leptotrichia buccalis endotoxin

Endotoxin obtained from Leptotrichia buccalis was found to have potent biological activity. New Zealand white female rabbits were used as the experimental animal. The parameters studied were ld 50, febrile and leukocytic responses, and the dermal Shwartzman reaction. The ld 50 of Lept. buccalis was 93.15 μg/kg with 95 per cent confidence limits of 66.44 and 131.00 μg/kg. Formal probit analysis revealed that the Lept. buccalis endotoxin, compared to Escherichia coli endotoxin, had a relative potency of 19.45 per cent with 95 per cent confidence limits of 13.50 per cent and 28.01 per cent. Lept. buccalis endotoxin was pyrogenic when administered intravenously in a quantity of 0.039 μg/kg, whereas E. coli endotoxin was pyrogenic in a quantity of 0.009 μg/kg. Parallel line bioassay methods applied to the febrile dose-response relationship of the toxins showed that, compared to E. coli, Lept. buccalis had a potency of 11.47 per cent with 95 per cent confidence limits of 9.69 per cent and 13.63 per cent. The quantity of endotoxin necessary to elicit a fever index of 40 cm 2 was estimated as 0.285 μg/kg and 2.099 μg/kg for E. coli and Lept. buccalis endotoxins, respectively. A significant correlation was found between febrile response and fever index. The quantity of endotoxin needed to produce a 50 per cent reduction in circulating leucocytes was estimated as 0.030 μg/kg and 0.213 μg/kg for E. coli and Lept. buccalis, respectively. According to this bioassay, Lept. buccalis endotoxin had a relative potency of 20–37 per cent, with 95 per cent confidence limits of 9.15 per cent and 43.60 per cent. The dermal Shwartzman reaction revealed that both E. coli and Lept. buccalis endotoxins contained preparatory and provocative factors. E. coli endotoxin was somewhat more potent, and heparin treatment prevented the Shwartzman reactions. The theoretical implications of the presence of endotoxin in Lept. buccalis are discussed in relation to the taxonomy of this micro-organism, and Vincent's necrotizing stomatitis.

Two local hemorrhagic skin responses to bacterial endotoxin in an inbred mouse strain.

SummaryThe observations previously made by Kelly et al. on production of hemorrhagic skin lesions by dermal injection of bacterial endotoxin in Rockefeller mice have been repeated with the genetically related, highly inbred, BSVS strain. BSVS mice displayed all of the reactions reported by the above authors, but with a significantly increased frequency, and at much lower doses of endotoxins. Pretreatment with Terramycin caused a marked decrease in frequency of reactors to a single injection of endotoxin. This effect gradually diminished over a period of 8 months of continued treatment. It is suggested that the single-injection reaction is a special form of the dermal Shwartzman reaction in which some microbial agent(s) plays an as yet unknown part.

Strain differences in local hemorrhagic response (Shwartzman-like reaction) of mice to a single intradermal injection of bacterial polysaccharides.

A survey of inbred strains of mice was made to determine whether the phenomenon of dermal hemorrhagic necrosis, as described in rabbits by Shwartzman, could be elicited in mice by bacterial polysaccharide preparations of demonstrated activity in rabbits. The polysaccharide preparations used were obtained from cultures of S. marcescens, S. typhosa, Ps. aeruginosa, and H. pertussis. Ten of the strains tested were unreactive. Three strains of mice and one F(1) hybrid subline developed a hemorrhagic lesion at the site of injection of a single, relatively high intradermal dose of polysaccharide. Some increase in incidence of hemorrhagic lesions was obtained when the intradermal dose was followed in 24 hours by an intravenous injection. In the gross and microscopically, the skin lesion produced in mice resembled the Shwartzman reaction in rabbits. An adrenergic blocking agent, SY-28, and an anticoagulant drug, coumadin, both of which block the dermal Shwartzman reaction in rabbits, also blocked the hemorrhagic skin reaction in mice.

Effect of dicumarol on localized Shwartzman reaction.

Summary and Conclusions1. The effect of dicumarol on the inhibition of the dermal Shwartzman reaction was studied. 2. It was found that unlike heparin, dicumarol did not inhibit the dermal Shwartzman reaction.

Acute hemorrhagic pancreatic necrosis produced by local Shwartzman reaction: experimental study on pancreatitis.

Histological observations in cases of fatal hemorrhagic pancreatic necrosis consistently show extensive vascular injury. These lesions vary from diffuse hyaline capillary thrombosis to extensive necrosis of arterioles, venules, and larger vessels.¹Frequently there is accompanying hemorrhage, thrombosis, and inflammatory cell infiltration. Whether the vascular lesion is the result of exposure to liberated trypsin or is, indeed, the primary factor producing hemorrhagic pancreatitis is not yet clear.^1b In studying the dermal Shwartzman reaction it became apparent that there was a striking similarity between this rapidly developing vascular lesion and that of acute hemorrhagic pancreatitis. Accordingly, the present study was undertaken with the object of evaluating the role of primary vascular sensitization in the pathogenesis of hemorrhagic pancreatitis. The experiments herein reported demonstrate the permeability of the pancreatic ductal system to bacterial products perfused within the physiological pressure range and the ability of such products to sensitize the pancreatic blood