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Blood, Vol. 94 No. 9 (November 1), 1999: pp. 3129-3134

Overexpression of I Kappa B Alpha Without Inhibition of NF-kappa B Activity and Mutations in the I Kappa B Alpha Gene in Reed-Sternberg Cells

By Florian Emmerich, Martina Meiser, Michael Hummel, Gudrun Demel, Hans-Dieter Foss, Franziska Jundt, Stephan Mathas, Daniel Krappmann, Claus Scheidereit, Harald Stein, and Bernd Dörken

From Humboldt University of Berlin, Universitätsklinikum Charité, Robert-Rössle-Klinik, Berlin; the Max Delbrück Center for Molecular Medicine, Berlin; and the Institut for Pathology, Universitätsklinikum Benjamin Franklin, Free University Berlin, Berlin, Germany.


    ABSTRACT
TOP
ABSTRACT
INTRODUCTION
MATERIALS AND METHODS
RESULTS
DISCUSSION
REFERENCES

The transcription factor NF kappa B (NF-kappa B) mediates the expression of numerous genes involved in diverse functions such as inflammation, immune response, apoptosis, and cell proliferation. We recently identified constitutive activation of NF-kappa B (p50/p65) as a common feature of Hodgkin/Reed-Sternberg (HRS) cells preventing these cells from undergoing apoptosis and triggering proliferation. To examine possible alterations in the NF-kappa B/Ikappa B system, which might be responsible for constitutive NF-kappa B activity, we have analyzed the inhibitor I kappa B alpha (Ikappa Balpha ) in primary and cultured HRS cells on protein, mRNA, and genomic levels. In lymph node biopsy samples from Hodgkin's disease patients, Ikappa Balpha mRNA proved to be strongly overexpressed in the HRS cells. In 2 cell lines (L428 and KM-H2), we detected mutations in the Ikappa Balpha gene, resulting in C-terminally truncated proteins, which are presumably not able to inhibit NF-kappa B-DNA binding activity. Furthermore, an analysis of the Ikappa Balpha gene in single HRS cells micromanipulated from frozen tissue sections showed a monoallelic mutation in 1 of 10 patients coding for a comparable C-terminally truncated Ikappa Balpha protein. We suggest that the observed Ikappa Balpha mutations contribute to constitutive NF-kappa B activity in cultured and primary HRS cells and are therefore involved in the pathogenesis of these Hodgkin's disease (HD) patients. The demonstrated constitutive overexpression of Ikappa Balpha in HRS cells evidences a deregulation of the NF-kappa B/Ikappa B system also in the remaining cases, probably due to defects in other members of the Ikappa B family.
© 1999 by The American Society of Hematology.


    INTRODUCTION
TOP
ABSTRACT
INTRODUCTION
MATERIALS AND METHODS
RESULTS
DISCUSSION
REFERENCES

THE TRANSCRIPTION FACTOR NF kappa B (NF-kappa B) is a mediator of inducible gene expression in response to inflammatory stimuli.1,2 The NF-kappa B family comprises 5 members (p50, p52, p65, c-rel, and RelB), which form homo- and heterodimers.3 NF-kappa B is associated with inhibitors of the I kappa B family (Ikappa Balpha , Ikappa Bbeta , Ikappa Bgamma , and Ikappa Bepsilon ), which are characterized by their ability to retain the transcription factor in an inactive complex in the cytoplasm. In response to external stimuli, Ikappa Balpha is phosphorylated at serine residues 32 and 36 by the Ikappa B kinase complex and subsequently degraded by the ubiquitin-proteasome pathway.2,4-9 As a consequence of Ikappa Balpha degradation, NF-kappa B translocates into the nucleus, where it activates transcription.10 Activated NF-kappa B induces the transcription of its own inhibitor.11 The Ikappa Balpha protein is subsequently resynthesized and accumulates in the nucleus, where it dissociates NF-kappa B from DNA binding and contributes to its export into the cytoplasm.12,13

Hodgkin's disease (HD) is a malignant lymphoma characterized by the presence of mononucleated Hodgkin (H) and multinucleated Reed-Sternberg (RS) cells in a background of reactive cells comprising lymphocytes, eosinophils, plasma cells, histiocytic cells, and fibroblasts.14 Recently, we identified constitutively activated NF-kappa B (p50/p65) as a unique and common characteristic of HRS cells.15 Blocking of constitutive NF-kappa B activity by overexpression of a dominant-negative form of Ikappa Balpha renders HRS cells susceptible towards apoptotic stimuli and suppressed proliferation and tumor growth of HRS cells after xenotransplantation into severe combined immunodeficiency (SCID) mice.16 These data show that constitutive NF-kappa B is required for apoptosis resistance and proliferation of HRS cells.

The molecular basis for constitutive nuclear NF-kappa B in HRS cells still needs to be investigated. The aim of this work was to identify possible molecular defects in the NF-kappa B regulatory system of HRS cells. In hematopoietic cells, NF-kappa B is mainly regulated by Ikappa Balpha .17 In primary HRS cells, we found high levels of Ikappa Balpha mRNA, indicating a persistently strong NF-kappa B-dependent transcriptional activity. To elucidate possible molecular defects in this system, we have analyzed Ikappa Balpha in 7 different HD-derived cell lines. In addition, the genomic sequence of Ikappa Balpha in HRS cells from 10 HD patients was analyzed using a technique involving micromanipulation of single HRS cells and analysis by polymerase chain reaction (PCR).

The analysis of 7 HD-derived cell lines showed mutations in the Ikappa Balpha gene in 2 cell lines (L428 and KM-H2), which lead to C-terminally truncated proteins. These inhibitor variants may be responsible for constitutive NF-kappa B activity in these cell lines. Moreover, we were able to identify a mutation in the Ikappa Balpha gene in HRS cells from 1 patient with HD, which encodes for a comparably defective Ikappa Balpha form. Our data provide first indications that constitutive nuclear NF-kappa B activity in HRS cells might be a consequence of mutations in the inhibitor genes.


    MATERIALS AND METHODS
TOP
ABSTRACT
INTRODUCTION
MATERIALS AND METHODS
RESULTS
DISCUSSION
REFERENCES

Tissue samples and cell lines.   All cases of classic Hodgkin's disease were selected from the files of the Institute of Pathology, Free University Berlin, and classified according to the REAL classification. The HD-derived cell lines L428, L540, L591, L1236, HDLM-2, KM-H2, and HD-MyZ were maintained in RPMI 1640 (Seromed Biochrom, Berlin, Germany), 10% heat-inactivated fetal calf serum (FCS), 2 mmol/L glutamine (GIBCO, Karlsruhe, Germany), and penicillin/streptomycin (Seromed-Biochrom, Berlin, Germany); HeLa cells were grown in Dulbecco's modified Eagle's medium (DMEM) (GIBCO, Karlsruhe, Germany) supplemented with 10% FCS, 1 mmol/L sodium pyruvate, and penicillin/streptomycin.

Preparation of protein and RNA extracts; Western blotting.   For protein extraction 5 × 106 cells were incubated in a lysis buffer containing proteinase inhibitors (complete, Mini, Boehringer-Mannheim, Germany). After 10 minutes of incubation at 4°C, the lysate was centrifuged for 5 minutes at 14,000 rpm in a microcentrifuge. Thirty micrograms protein extract were separated in 12% polyacrylamide gel containing sodium dodecyl sulfate (SDS) and blotted onto a nitrocellulose membrane (Schleicher & Schüll, Dassel, Germany) by electroblotting. Western blots were analyzed with chemiluminescence following the manufacturer's recommendations (ECL system, Amersham, Braunschweig, Germany). Antibodies directed against the N-terminus (C-15) and the C-terminus (C-21) of Ikappa Balpha were obtained from SantaCruz Biotechnology Inc (Heidelberg, Germany). The RNA was prepared using the RNeasy Kit (Quiagen, Hilden, Germany) according to the manufacturer's recommendations.

Amplification of Ikappa Balpha transcripts (reverse transcriptase [RT]-PCR).   The cDNA was synthesized under the following conditions: 1 µg total RNA was incubated with 2 µL 10 × incubation buffer, 1 mmol/L each deoxyribonucleoside-triphosphate (dNTP), 5 mmol/L MgCl2, 50 U of RNAse inhibitor, and 500 ng Oligo-(dT)15 primer. After a denaturation step (65°C for 15 minutes), 20 U of avian myeloblastosis virus (AMV) RT (Boehringer-Mannheim, Germany) were added. The reaction was incubated for 1 hour at 42°C.

To amplify full-length Ikappa Balpha cDNAs, 4 different pairs of primers were designed (Table 1). The conditions for the PCR consisted of an initial denaturation step of 90 seconds at 95°C, 30 cycles of 40 seconds at 95°C, 40 seconds at 60°C, and 60 seconds at 72°C. Buffer conditions were as follows: 1.25 µmol/L MgCl2, 200 µmol/L each dNTP, 10 pmol/L of each primer, and 1 U of Taq polymerase (InViTek, Berlin, Germany).

                              
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Table 1. Primers Used for RT-PCR of the Ikappa Balpha mRNA

Twenty microliters of each PCR was analyzed on ethidium bromide-stained agarose gels (1%) and the amplificates were isolated from the gel by the glass milk technique for DNA sequencing.

Micromanipulation of single cells.   Single HRS cells were isolated from CD30 immunostained frozen sections as previously described.18 In brief, single cells were extracted by hydraulic micromanipulators from the surrounding tissue and transferred into PCR tubes with a minimal volume of buffer (0.05 to 0.1 µL) covering the tissue sections. For control, an aliquot of at least 1 µL was drawn from the buffer covering the tissue sections during the cell isolation procedure and subjected to single-copy PCR.

Single-copy PCR.   To amplify the C-terminal portion of the Ikappa Balpha gene, we designed different sets of PCR primers capable of generating 3 overlapping amplificates in a 2-step nested primer PCR (Table 2). The first PCR contained all 6 primers in 1 assay, whereas for reamplification, the 3 primer pairs were separately applied. The conditions for the first round of PCR consisted of a denaturation step of 2 minutes at 95°C, 5 cycles of 40 seconds at 95°C, 60 seconds at 58°C, and 120 seconds at 72°C, followed by 38 cycles of 40 seconds at 95°C, 60 seconds at 58°C, and 60 seconds at 72°C. The final extension lasted 10 minutes at 72°C. For reamplification, an aliquot (1.5%) of the first PCR was subjected to each of the 3 PCRs and amplified under the following conditions: an initial step of 2 minutes at 95°C and 40 cycles of 20 seconds at 95°C, 40 seconds at 58°C, and 60 seconds at 72°C followed by the final step of 10 minutes at 72°C.

                              
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Table 2. Primers Used for Single Copy PCR of the Ikappa Balpha Gene

The same buffer conditions were used for both the first and the second amplification round: 1.5 mmol/L MgCl2, 200 µmol/L each dNTP, 8 pmol/L of each primer and 2 U of AmpliTaq (Perkin-Elmer, Weiterstadt, Germany). A total of 6 µL of each PCR was analyzed on ethidium bromide-stained agarose gels (1%), and the amplificates were isolated from the gel by the glass milk technique for DNA sequencing.

DNA sequencing.   PCR products obtained from the HD-derived cell lines or from individual HRS cells were sequenced by the chain termination technique using fluorescence-labeled ddNTPs (BigDye; PE Applied Biosystems, Weiterstadt, Germany). The sequencing reactions were analyzed on an automated DNA sequencer (377A; Applied Biosystems) and the resulting sequences were compared with the sequence of the Ikappa Balpha gene.19,20

In situ hybridization.   Radioactive in situ hybridization for the detection of Ikappa Balpha mRNA was performed on paraffin sections. For this purpose, we generated a hybridization probe by cloning a portion of the Ikappa Balpha cDNA (from base 540 to base 1379; M69043)19 into pKS. Radioactive-labeled run-off transcripts were prepared after linearization of the plasmid and applied to the pretreated tissue sections as previously described. In brief, dewaxed and rehydrated paraffin sections were exposed to 0.2 N HCl, 0.6 mg/mL pronase, followed by postfixation with 4% paraformaldehyde. After acetylation with 0.1 mol/L triethanolamine pH 8.0/0.25% (vol/vol) acetic anhydride and dehydration in graded ethanols, the slides were separately hybridized to 2 to 4 × 105 cpm of the labeled sense and antisense probes and left overnight at 50°C. Washing and autoradiography were performed as previously described.21


    RESULTS
TOP
ABSTRACT
INTRODUCTION
MATERIALS AND METHODS
RESULTS
DISCUSSION
REFERENCES

Overexpression of Ikappa Balpha transcripts in primary HRS cells.   To examine Ikappa Balpha mRNA expression in primary HRS cells, we performed an in situ hybridization with an Ikappa Balpha -specific cDNA probe spanning nucleotide from base 540 to base 137919 in 20 HD cases. Most cases harbored abundant amounts of mRNA in the HRS cells (Fig 1, Table 3). In contrast to the HRS cells, only some reactive lymphocytes expressed low to moderate amounts of Ikappa Balpha -specific transcripts (Table 3). A labeling of reactive lymphocytes with varying signal intensity was also observed in 3 cases of infectious mononucleosis. Less than 1% of the tumor cells of 5 cases of B-cell chronic lymphocytic leukemia (B-CLL) and less than 10% of the neoplastic cells of 5 cases of T-cell non-Hodgkin lymphoma (T-NHL) showed low to moderate amounts of Ikappa Balpha mRNA.


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Fig 1. mRNA expression of Ikappa Balpha in primary HRS cells of a patient with HD. (A) Hybridization with Ikappa Balpha antisense probe. Accumulation of silver grains over HRS cells (exposure time, 6 weeks). (B) Hybridization with Ikappa Balpha sense probe. No labeling of HRS cells.


                              
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Table 3. Detection of Ikappa Balpha mRNA in HRS Cells and Reactive Lymphoid Cells in 20 Cases of Classical HD by Radioactive In-Situ Hybridization

L428 and KM-H2 cells express defective Ikappa Balpha proteins due to mutations in the Ikappa Balpha gene.   We examined Ikappa Balpha proteins in 7 different HD-derived cell lines (L428, L540, L591, L1236, HDLM-2, KM-H2, and HD-MyZ). Western blot analysis was performed using antibodies directed against the N- and the C-terminal epitope of Ikappa Balpha .

The analysis of L428 cells with the antibody against the N-terminus showed the expression of a faster migrating Ikappa Balpha form of about 30 kD (Fig 2A). When using the antibody directed against the C-terminus of Ikappa Balpha , no protein was detectable in these cells (Fig 2B). Therefore, L428 cells appear to contain a C-terminally truncated form of the Ikappa Balpha protein. In KM-H2 cells, no Ikappa Balpha protein could be detected with both antibodies. The 5 remaining HD-derived cell lines (L540, L591, L1236, HD-LM2, and HD-MyZ) showed expression of full-length Ikappa Balpha proteins of 38 kD (Fig 2).


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Fig 2. Western blot analysis of Ikappa Balpha proteins in HD-derived cell lines. Whole-cell extracts were analyzed using specific antibodies against the N-terminus (A) and the C-terminus (B) of Ikappa Balpha . Specific protein bands are indicated by an arrow and the truncated form in L428 cells (Ikappa Balpha triangle C) is marked with a dot.

Next, we analyzed the Ikappa Balpha mRNA and the Ikappa Balpha gene in HD-derived cell lines. Transcripts for Ikappa Balpha were amplified by RT-PCR and sequenced. In L428 and KM-H2 cells, we detected mutated Ikappa Balpha transcripts. L428 cells showed a point mutation at nucleotide position (pos) 893 of the human cDNA19 generating a preterminal stop codon (Fig 3A). When we examined KM-H2 cells, we detected 2 deletions, 1 between pos 509 and pos 613 and another between pos 618 and pos 640 (Fig 3B). These deletions result in a frame shift and are followed by a preterminal stop at pos 715. Genomic sequencing showed that the observed alterations are due to mutations in the Ikappa Balpha gene. The genomic PCR detected only mutant and no wild-type Ikappa Balpha sequences. These data show that the occurrence of defects of Ikappa Balpha proteins in HRS cells is a consequence of mutations in the Ikappa Balpha gene. In accordance with the Western blot data in both cell lines, the mutant forms of Ikappa Balpha were expressed exclusively and no transcripts of wild-type Ikappa Balpha were detectable.



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Fig 3. Structure of mutant cDNA transcripts for Ikappa Balpha in L428 (A) cells and KM-H2 (B) cells and scheme of the predicted truncated Ikappa Balpha proteins. The ankyrin repeats required for the interaction with NF-kappa B are indicated by filled boxes. (A) A point mutation at pos 893 of the Ikappa Balpha cDNA sequence in L428 cells generates a preterminal stop as indicated. (B) Top panel: 2 deletions between pos 509 and 613 and pos 618 and 640 of the Ikappa Balpha cDNA in KM-H2 cells result in a frame shift followed by a preterminal stop codon at pos 715. Bottom panel: Alignment of the wild-type (w.t.) cDNA sequence of Ikappa Balpha and the mutant Ikappa Balpha sequence in KM-H2 cells. Deletions and the resulting frame shift are indicated.

Analysis of the Ikappa Balpha gene in single HRS cells.   To investigate whether Ikappa Balpha mutations could also be detected in primary HRS cells, we analyzed single HRS cells from lymph node biopsy samples from patients with HD. A total of 420 individual HRS cells were isolated from frozen sections of 10 patients, and the part of the Ikappa Balpha gene comprising the mutations in the cell lines (2283 nt to 4391 nt)20 was divided into 3 parts and amplified by PCR. Between 5 and 11 PCR products were obtained from each amplified region, sequenced, and compared with the Ikappa Balpha gene sequence.

In 1 case, we detected a point mutation in exon V (pos 3398; TGT right-arrow TGA) causing a stop codon, with the consequence of a preterminal breakage of the protein synthesis at amino acid 214 (Table 4; Fig 4). From 72 HRS cells of this case, 22 PCR products were obtained, 11 of which comprised the affected 3'-region of the Ikappa Balpha gene. In 4 of 11 cells, we detected the stop codon exclusively, whereas an additional 4 cells contained both the mutant and the wild-type Ikappa Balpha gene. This alteration did not occur in the remaining 3 HRS cells. This finding indicated that only 1 allele harbored the stop codon, whereas the other allele was wild-type. The Ikappa Balpha gene of reactive bystander lymphocytes isolated from the same biopsy tissue showed no alteration, indicating that this stop codon was restricted to the HRS cells.

                              
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Table 4. Detection of Mutations in the Intron and Exon Regions of the Ikappa Balpha Gene in Single HRS Cells



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Fig 4. Structure of the expected mutant Ikappa Balpha cDNA sequence in a patient with HD. Top panel: Alignment of the expected w.t. cDNA sequence of Ikappa Balpha and the predicted mutant Ikappa Balpha sequence in primary HRS cells. A point mutation at pos 739 generates a preterminal stop. Bottom panel: Presumable structure of the resulting truncated Ikappa Balpha protein in primary HRS cells. The ankyrin repeats required for the interaction with NF-kappa B are indicated by filled boxes.

Base substitutions in the introns were detectable in all cases, as well as in reactive lymphocytes (Table 4). However, because these modifications do not affect the coding sequence, they most likely represent irrelevant interindividual variations. In addition, the same silent base substitution was found in exon II of 4 cases (Table 4), indicative of an interindividual polymorphism.


    DISCUSSION
TOP
ABSTRACT
INTRODUCTION
MATERIALS AND METHODS
RESULTS
DISCUSSION
REFERENCES

The aim of this work was to identify molecular defects in the NF-kappa B regulatory system leading to constitutive NF-kappa B activation in HRS cells. In Ikappa Balpha -/- mice, constitutive NF-kappa B activation could be observed in lymphoid cells.17 Hence, this inhibitor appears to play a major role in regulating NF-kappa B activity in the lymphoid system.

In cultured HRS cells, mRNAs for Ikappa Balpha are strongly overexpressed.15 To test if this is also valid for primary HRS cells, we examined 20 cases of classic HD by a highly sensitive radioactive in situ hybridization with an Ikappa Balpha -specific cDNA probe. In all cases, we detected overexpression of Ikappa Balpha mRNA in the HRS cells, whereas in normal lymphoid tissues and in cases of B-CLL and T-cell NHL, no or very little amounts of Ikappa Balpha mRNA were found. Therefore, high levels of Ikappa Balpha are a highly characteristic feature of cultured and primary HRS cells.

Because NF-kappa B activates transcription of its own inhibitor, this finding reflects the high transcriptional activity of NF-kappa B in this lymphoid malignancy.11 It has been demonstrated that enforced expression of Ikappa Balpha leads to accumulation of the protein in the nucleus.12 Nuclear Ikappa Balpha is involved in the export of NF-kappa B into the cytoplasm, thus contributing to the termination of NF-kappa B activity.13 The paradoxical finding of high NF-kappa B activity despite the strong expression of its inhibitor indicates that the NF-kappa B/Ikappa B system is severely deregulated in HRS cells. A mechanism leading to this loss of control could be a defect of the Ikappa Balpha molecule. To investigate this possibility, we analyzed Ikappa Balpha transcripts in 7 HD-derived cell lines and found a disruption of the coding sequence by a stop codon in the cell line L428, and by 2 deletions followed by a stop codon in the cell line KM-H2. These mutations found in the RNA were confirmed by genomic sequencing, disclosing the existence of only mutated Ikappa Balpha genes in the absence of wild-type alleles. In accordance with these sequence data, we detected expression of exclusively C-terminally truncated proteins in both cell lines consistent with previous reports.22,23

To analyze whether comparable Ikappa Balpha mutations also occur in primary HRS cells, we isolated single HRS cells from CD30 immunostained tissue sections of 10 HD patients and analyzed the Ikappa Balpha gene by single cell PCR. The Ikappa Balpha gene of 1 case (case 1; Table 4) contained a mutation generating a preterminal stop of the translational machinery. The expected mRNA codes for a C-terminally truncated protein of about 214 amino acids comparable to that found in L428 cells. This stop codon was not found in nonmalignant lymphoid bystander cells of the same case, indicating that this mutation was specific for the HRS cells. No disruptive alterations were detectable in the Ikappa Balpha genes of the HRS cells in the remaining 9 HD cases.

In contrast to cell lines with only mutant genomic sequences (L428 and KM-H2), the mutated HRS cells of case 1 contained both mutant and wild-type sequences, suggesting a monoallelic mutation of Ikappa Balpha and presumably leading to coexpression of mutant and wild-type Ikappa Balpha proteins. This raises the question as to the functional significance of this monoallelic mutation. It is well conceivable that the C-terminally truncated protein can block the wild-type protein. Aside from its function of retaining NF-kappa B in the cytoplasm, Ikappa Balpha can localize in the nucleus and dissociate NF-kappa B-DNA complexes.13 A prerequisite for effective inhibition of NF-kappa B-DNA binding are the ankyrin repeats and an intact C-terminus, in which Ikappa Balpha is constitutively phosphorylated at serine and threonine residues by casein kinase II.24-27 A role of the C-terminal end for the inhibition of NF-kappa B-DNA binding has recently been suggested by an x-ray structure analysis of the NF-kappa B/Ikappa Balpha complex.28,29 Furthermore, Ikappa Balpha contains a nuclear export signal (NES) at amino acids 264-281, which confers active shuttling of the NF-kappa B/Ikappa Balpha complex to the cytosol.13,20 Therefore, the functionally defective truncated Ikappa Balpha may protect DNA-bound NF-kappa B from dissociation by wild-type Ikappa Balpha and interfere with the nuclear export pathway. As a consequence of this process NF-kappa B-DNA binding activity would be maintained in HRS cells.

Although the observed mutation is found only in 1 of 10 cases, our data provide the first indication that permanently activated NF-kappa B in primary HRS cells might be a consequence of gene mutations of one of its inhibitors. Studies on constitutive NF-kappa B activity have shown that a hypophosphorylated form Ikappa Bbeta shields NF-kappa B from Ikappa Balpha -mediated inhibition and plays an important role in permanent NF-kappa B activation. It is therefore tempting to speculate that defects of additional members of the Ikappa B family contribute to the functional blockage of Ikappa Balpha in the remaining cases. Further expression and molecular studies are required to investigate this possibility.


    NOTE ADDED IN PROOF

During the review process, a report that was submitted after ours has appeared dealing with the analysis of Ikappa Balpha mutations in enriched RS cells. The investigators described Ikappa Balpha mutations in 2 of 8 HD cases, which cause a preterminal truncation of the Ikappa Balpha protein.30


    FOOTNOTES

Submitted March 8, 1999; accepted July 2, 1999.

Supported by a grant of the Deutsche Forschungsgemeinschft (DFG; Ste 318/5-2).

The publication costs of this article were defrayed in part by page charge payment. This article must therefore be hereby marked "advertisement" in accordance with 18 U.S.C. section 1734 solely to indicate this fact.

Address reprint requests to Harald Stein, MD, Institute of Pathology, Benjamin Franklin University Hospital, Free University Berlin, Hindenburgdamm 30, 12200 Berlin, Germany; e-mail: stein{at}ukbf.fu-berlin.de.


    REFERENCES
TOP
ABSTRACT
INTRODUCTION
MATERIALS AND METHODS
RESULTS
DISCUSSION
REFERENCES

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