Successful treatment of systemic-sclerosis-related digital ulcers with a selective endothelin type A receptor antagonist (sitaxentan)

Digital ulcers represent a major vascular complication of systemic sclerosis (SSc) and can be difficult to treat with the common vasodilators. Herein, we report on a 39-year-old patient with recalcitrant SSc-related digital ulcers treated successfully with sitaxentan (100 mg q.d.), a selective endothelin type A receptor antagonist. During the 6 months of treatment, we noticed a remarkable decrease in pain, a nearly complete healing of the preexistent ulcers and no development of new ulcers. No side effects were noted.

[Acute generalized exanthematous pustulosis associated with recurrent urinary tract infections]

Acute generalized exanthematous pustulosis (AGEP) is characterized by sudden onset of non-follicular aseptic pustules with erythema often accompanied by fever and leukocytosis. While the most frequent cause of AGEP is drug reactions, especially antibiotics. Occasional cases have been described as parainfectious. An 82-year-old female presented with recurrent AGEP along with a chronic urinary infection with Escherichia coli. Her cutaneous findings resolved following antibiotic therapy and prophylaxis. To the bets of our knowledge, this is the first case of AGEP associated with an Escherichia coli urinary tract infection.

Quality-of-life (QoL) impairment in melanoma patients receiving high-dose interferon alpha 2b (IFNa2b)

e20011

Background: High-dose interferon (HDI) for patients with malignant melanoma (MM) has consistently demonstrated benefits as an adjuvant treatment. Side effects and impairment of QoL have played a major role in patients motivation to continue treatment. The adjuvant, randomized, controlled phase III DeCOG MM-ADJ-5 trial evaluates QoL and tolerability of pulsed high-dose intravenous (iv) IFNα2b compared to standard HDI regimen. In the pulsed arm, 3 courses of IFNα2b, 20 Mio IU/m2 iv 5 days a wk for 4 wks, repeated every 4 months was administered, whereas the subcutaneous (sc) treatment was 10 Mio IU/m2 3 times a wk for 11 months, after 4 wks of iv therapy. As a secondary endpoint, health related QoL was evaluated during iv and sc treatment and during treatment free intervals. Methods: 631 patients have been recruited for an expected 300 events (distant metastasis) during 4 years of follow-up. A planned interim analysis was performed after a third of the expected events occurred. The EORTC QLQ-C30 questionnaire modified for typical IFN side effects, was administered to pts before therapy, at 4, 16, 24, and 40 wks of treatment. Global QoL questions were completed by pts weekly by a visual analogue scale over the entire year of treatment. Results: Out of 377 patients having completed treatment, 300 were evaluable for QoL analysis. The iv HDI treatment led to a globally decreased QoL score in 84% of patients. During the 4 wk course of iv IFN, impairment of QoL was mainly due to physical symptoms. During the sc treatment phase, global QoL remained reduced by an average of 24%, despite dose adjustments in a majority of patients. Analysis of particular dimensions of decreased QoL revealed that fatigue was the most important determinant, especially during continuous treatment. In contrast, depression only played a minor role, being less important than physical and cognitive impairment. Conclusions: QoL impairment caused by long term sc HDI is mostly mediated by chronic fatigue, and more likely to interfere with treatment adherence than short term iv HDI treatment.

[Table: see text]

Skin cancer: follow-up, rehabilitation, palliative and supportive care

Follow-up, rehabilitation and palliative/supportive care are essential parts of the care and treatment of skin cancer patients. This review provides an overview on the state of knowledge and recent developments in these three disciplines, hereby providing standard operating procedures for the dermatologist in the care of skin cancer patients. Especially in follow-up and supportive care, the results of recent clinical trials have led to significant changes in the standard of care. These new insights and their consequences are the special focus of this article.

Herpes simplex vegetans: atypical genital herpes infection with prominent plasma cell infiltration in B-cell chronic lymphocytic leukemia

SUMMARY

Herpes simplex vegetans is a rare disorder even in immunocompromised patients. It typically affects patients with HIV or myeloproliferative diseases.The atypical cutaneous lesions show papillomatous vegetations in varying locations. Histologically the lesions show pseudoepitheliomatous hyperplasia of squamous epithelium, plasma cell infiltration and are positive for HSV 1 and/or HSV 2. Herpes simplex vegetans often responds poorly to treatment in immunocom-promised patients.

RAGE signaling sustains inflammation and promotes tumor development

A broad range of experimental and clinical evidence has highlighted the central role of chronic inflammation in promoting tumor development. However, the molecular mechanisms converting a transient inflammatory tissue reaction into a tumor-promoting microenvironment remain largely elusive. We show that mice deficient for the receptor for advanced glycation end-products (RAGE) are resistant to DMBA/TPA-induced skin carcinogenesis and exhibit a severe defect in sustaining inflammation during the promotion phase. Accordingly, RAGE is required for TPA-induced up-regulation of proinflammatory mediators, maintenance of immune cell infiltration, and epidermal hyperplasia. RAGE-dependent up-regulation of its potential ligands S100a8 and S100a9 supports the existence of an S100/RAGE-driven feed-forward loop in chronic inflammation and tumor promotion. Finally, bone marrow chimera experiments revealed that RAGE expression on immune cells, but not keratinocytes or endothelial cells, is essential for TPA-induced dermal infiltration and epidermal hyperplasia. We show that RAGE signaling drives the strength and maintenance of an inflammatory reaction during tumor promotion and provide direct genetic evidence for a novel role for RAGE in linking chronic inflammation and cancer.

[Merkel cell carcinoma--clinically often misjudged]

Merkel cell carcinoma is a rare, rapidly growing, highly malignant dermal tumor which occurs preferentially on light-exposed skin in advanced age. The course of the disease is frequently characterized by the occurrence of lymph node metastases and local recurrences, even in the first year after removal of the primary tumour. The five-year overall survival rate is only about 65 %, despite rigorous therapy. The histological pattern is characterized by trabecular strands of small, uniform cells with large basophilic nuclei and typical neuroendocrine granules. The diagnosis is confirmed immunohistochemically by neuroendocrine and epithelial markers. The excision of the primary tumor is regarded as first-line therapy. Adjuvant radiatiotherapy is almost always indicated and should also include lymph node drainage. In the stage of nodal disease, a combination of excision and radiotherapy is recommended. Adjuvant chemotherapy can be applied in this stage, as in small-cell bronchial carcinoma. The prognostic advantage has, however, not been proven. Despite good response to radiatiotherapy and chemotherapy, with at least prolonged recurrence-free intervals, Merkel cell carcinoma is rarely curable at the distant metastasizing stage. Individually defined, aggressive treatment,including radiatiotherapy, may in future considerably improve the prognosis, especially in the early stages of the disease.

Health-related quality of life measures in melanoma patients receiving pulsed high-dose intravenous interferon alpha 2b (IFNα2b)

8536

Background: Major problems of high-dose interferon (HDI) in patients with malignant melanoma (MM) result from side effects and impairment of quality of life (QoL). Up to now it is unclear whether intraveneous (iv), subcutaneous (sc), or both components of HDI treatment are necessary for the efficacy in adjuvant treatment of MM. The adjuvant phase III DeCOG MM-ADJ-5 trial evaluates efficacy, safety, and tolerability of pulsed high-dose intravenous IFNa2b. In this prospective, randomized trial, 3 courses of IFNa2b 20 Mio IU/m2 iv on 5 days a week for 4 weeks repeated every 4 months are compared to the standard HDI regimen. The higher iv dosage produces more toxicity, but for a shorter period of time, since patients in the pulsed treatment arm are 9 months off treatment as compared to the conventional sc treatment with 10 Mio IU/m2 three times a week given for 11 months after 4 weeks of iv therapy. Methods: With a planned recruitment of 600 patients, an interim analysis of QoL has been performed after half of the patients completed treatment. EORTC QLQ- C30 questionnaire modified for interferon side effects was obtained before therapy, and at 4, 16, 24, and 40 weeks of treatment. The global QoL items were obtained weekly by a visual analogue scale over the whole year of treatment. Additionally, the side effects were scored using CTC- AE toxicity levels, and dose modifications were recorded. Results: A total of 300 patients were evaluated. After 4 weeks of initial iv HDI treatment the global QoL score decreased similarly in both treatment groups (35% vs. 41%). Four weeks after the initial iv pulse, the global QoL score completely recovered in the experimental arm (104%). In the conventional HDI, QoL remained reduced by an average 22% during the whole subcutaneous treatment phase. During the second and third iv-pulse in the experimental arm, QoL again decreased and completely recovered thereafter. Overall, the cumulative QoL score measured for 12 months treatment was significantly in favour of the pulsed regimen (+16% AuC value). Conclusions: Patients under pulsed adjuvant HDI treatment experience significantly less impairment of QoL and may therefore have a higher rate of completing the scheduled dosage.

[Table: see text]

Hyalinosis cutis et mucosae

Hyalinosis cutis et mucosae is a rare autosomal recessive disorder which is characterized by deposition of hyaline material around the basement membrane of the skin and mucous membranes. Typical clinical symptoms are hoarseness, infiltration of the mucous membranes and papular verrucous skin changes. Mutations within the extracellular matrix protein gene (ECM-1) are the underlying defect. We report on a 24-year-old man, who had first been seen in our department at the age of seven and had undergone the necessary diagnostic procedures and who revisited 17 years later with hoarseness and extensive verrucous skin changes at elbows and knees which were removed by excision. A new mutation of the ECM1 gene was identified.

Low number of regulatory T cells in skin lesions of patients with cutaneous lupus erythematosus

OBJECTIVE

To define the phenotype and function of CD4+,CD25+ regulatory T cells (Treg) in patients with cutaneous lupus erythematosus (CLE), a heterogeneous autoimmune disease characterized primarily by inflammatory skin lesions.

METHODS

The number of Treg in skin specimens obtained from patients with various subtypes of CLE was investigated by immunohistochemical analysis, using anti-Foxp3 and anti-CD4 monoclonal antibodies. Furthermore, characterization of peripheral blood CD4+,CD25+ Treg from normal healthy donors and patients with CLE was carried out by flow cytometry, analyzing the expression of Foxp3 and Treg subpopulations. We also purified CD4+,CD25(high) Treg obtained from patients with CLE and tested the sensitivity of these cells to CD95L-mediated apoptosis.

RESULTS

Quantitative analysis of CD4+ T cells in skin lesions from patients with CLE revealed that the number was similar to that in lesions from patients with other chronic inflammatory diseases, but the number of Foxp3+ Treg in CLE was significantly reduced. There was no correlation between disease subtype and the frequency of Foxp3+ Treg in the skin of patients with CLE. In peripheral blood, no significant differences were observed in the number and phenotype of CD4+,CD25+ Treg or in the sensitivity to apoptosis of CD4+,CD25(high) Treg derived from patients with CLE and those derived from normal healthy donors.

CONCLUSION

These data suggest that an organ-specific abnormality of Treg in the skin underscores the importance of analyzing Treg in the affected tissue. Such a local process might give insight into the pathogenic mechanisms of CLE and differs from a global peripheral dysfunction as reported for patients with a systemic manifestation of the disease.

In vitro hymenoptera venom allergy diagnosis: improved by screening for cross-reactive carbohydrate determinants and reciprocal inhibition

BACKGROUND

Immunoglobulin (Ig) E-double positivity for honeybee (HB) and yellow jacket (YJ) venom causes diagnostic difficulties concerning therapeutical strategies. The aim of this study was to clarify the cause and relation of the cross-reactivity in patients with insect venom allergy.

METHODS

For this purpose, 147 patients with suspected stinging insect allergy and CAP-FEIA-double positivity were investigated for specific sIgE to additional cross-reactive carbohydrate determinant (CCD)-containing allergens: timothy grass pollen, rape pollen, natural rubber latex (NRL), bromelain, and horseradish peroxidase (HRP). Sera with sIgE to NRL were further investigated with the commercially available recombinant latex allergens. Reciprocal inhibition assays with both venoms and HRP were performed.

RESULTS

About 36 of 147 (24.5%) patients had sIgE to both venoms only. However, 111 of 147 (75.5%) additionally reacted to CCD-carrying allergens. 89 of 111 CCD-reactive sera had NRL-sIgE. In cases where inhibition experiments were performed, the NRL-sIgE binding was completely abolished in the presence of HRP. Only nine of 61 sera were positive for at least one recombinant latex allergen; all of them were negative in history and NRL-skin prick test. In 43 sera containing sIgE to CCD, HRP inhibition revealed unequivocal results: In 28 of 43 (65%) an HRP-inhibition >70% of sIgE to one venom occurred, pointing out the relevant venom. In three of 43 sIgE proved to be entirely CCD-specific.

CONCLUSIONS

Our data indicate that in cases of IgE positivity to both insect venoms supplementary screening tests with at least one CCD-containing allergen should be performed; HRP being a suitable tool for this test. In addition, subsequent reciprocal inhibition is an essential diagnostic method to specify cross-reacting sIgE results.