HTLV-associated diseases: human retroviral infection and cutaneous T-cell lymphomas

An array of neurologic, oncologic, and autoimmune disorders are associated with infection with the human pathogenic retroviruses human T-cell leukemia virus types I and II (HTLV-I, II), as well as the human immunodeficiency viruses (HIV). The cutaneous T-cell lymphomas, mycosis fungoides (MF) and its hematogenous variant Sezary Syndrome (SS), share similar clinical and pathological features to HTLV-I-associated adult T-cell leukemia (ATL) and speculation of a retroviral link to MF and SS, especially in areas non-endemic for ATL, has lead to an intensified search for HTLV- and HIV-like agents in these diseases. To further explore a potential role for human retroviruses in MF and SS, skin biopsy-derived or peripheral blood mononuclear cell-derived DNA from 17 patients (MF, n = 7; erythrodermic MF (EMF), n = 5; SS, n = 5) from the North Eastern United States were screened using gene amplification by PCR and a liquid hybridization detection assay. Previously published primers and probes for HTLV-I (LTR, gag, pol, env, and pX), and our own primers and probes for HTLV-I (gag, pol, and env), HTLV-II (pol and env) and HIV-I (gag and pol) were employed. Serum antibodies to HTLV-I were negative in all but one EMF patient. The single HTLV-I seropositive patient carrying a diagnosis of EMF generated positive amplified signals for all of the eight HTLV-I regions tested. Ultimately, this individual evolved to exhibit clinical manifestations indistinguishable from ATL. The other 16 patients were negative for all 12 HTLV and HIV retroviral regions. Our findings suggest that none of the known prototypic human retroviruses are associated with seronegative MF and SS. The uniformly positive results for HTLV-I in the seropositive patient suggests that this patient initially presented with a smoldering form of ATL and illustrates the difficulty that sometimes may be encountered in the differential diagnosis of MF, SS, and ATL based solely on clinical and histopathological criteria.

Cutaneous T-cell lymphoma, tropical spastic paraparesis, cerebral vasculitis, and protein S deficiency in a patient with HTLV-I

The clinical spectrum of retroviruses is expanding rapidly. Human T-cell lymphotropic virus type I (HTLV-I) was the first retrovirus to be described, and its role had been established in adult T-cell leukemia/lymphoma and tropical spastic paraparesis. We report the case of a 35-year-old woman with HTLV-I and the unusual combination of cutaneous T-cell lymphoma, tropical spastic paraparesis, cerebral vasculitis, and protein S deficiency. We discuss the relationship of all her diseases to HTLV-I.

Cytolytic response to HIV in patients with HIV disease treated with extracorporeal photochemotherapy: preliminary study

Extracorporeal photochemotherapy (photopheresis), an immunomodulatory therapy that targets circulating T helper lymphocytes, has been applied to the management of human immunodeficiency virus (HIV) disease. Any therapy that exerts its actions on CD4+ T cells has the potential of exacerbating HIV infection. Therefore, it was necessary to observe immune function during treatment. Because cytotoxic T lymphocytes (CTL) and natural-killer cells are thought to play an important role in the response against HIV infection, we examined the effect of photopheresis on HIV cytolytic activity. The study group consisted of seven patients with late-stage HIV disease who had not received any previous treatment for HIV infection. Patients were treated exclusively with photopheresis on two consecutive days each month for 14-32 months (average, 25 months). Peripheral lymphocytes, collected at various points during treatment, were used as effectors in a 51Cr release assay. Epstein-Barr virus (EBV)-transformed autologous B cell lines transfected with recombinant vaccinia vectors that expressed the HIV env (gp120, gp41) and gag (p24) proteins were used as target cells. All seven patients demonstrated relatively constant levels of cytolysis (>10% above controls) during treatment in the context of stable CD4+ T cell counts and a stable clinical status. These results suggest that extracorporeal photochemotherapy did not impair the cytolytic response to HIV infection and may have enhanced it in some patients.

Case report: post-transfusion purpura

Post-transfusion purpura (PTP) is a rare disorder characterized by the abrupt onset of severe thrombocytopenia following a blood transfusion. We describe a case of PTP in a patient treated with plasmapheresis, noting that this is an uncommon but treatable disease entity.

Extracorporeal photochemotherapy in a patient with Ki-1-positive anaplastic large-cell lymphoma

A 57-year-old man with Ki-1 anaplastic large-cell lymphoma treated with extracorporeal photochemotherapy is described.

Silicone granuloma in acral skin in a patient with silicone-gel breast implants and systemic sclerosis

A 68-year-old white woman was referred to us by her rheumatologist for possible participation in a clinical study of photopheresis for scleroderma. In February 1993, she noticed edema of her distal phalanges, Raynaud's phenomenon in both hands, flu-like symptoms, fatigue, intermittent diarrhea, abdominal pain, tearing in both eyes, dyspnea on exertion, dysphagia, and odynophagia. Bilateral silicone-gel breast implants had been placed 12 years before; 2 months before her present evaluation, they were removed and found to be ruptured. Physical examination revealed edema, limited to the fingers and hands bilaterally, and slight induration of the skin on the dorsum of both hands and distal forearms. The remainder of the physical examination was normal. According to our study protocol, a skin biopsy specimen from the dorsum of the right hand was taken, but all other laboratory investigations were refused. Histopathologic examination revealed multiple clear spaces of varying sizes in the dermis and multinucleated macrophages containing small refractile particles, characteristic of silicone granuloma (Figs. 1 and 2); however, the specimen showed no evidence of scleroderma. X-ray energy dispersive analysis by scanning electron-microscopy confirmed the presence of elemental silicon in the small refractile particles. The patient did not receive any treatment after her diagnosis and shortly thereafter, she was lost to follow-up.

Varicella hepatitis: a fatal case in a previously healthy, immunocompetent adult. Report of a case, autopsy, and review of the literature

Varicella, usually a benign infection of childhood, is known to be associated with more serious complications, especially in adults and immunocompromised patients. Of these, varicella pneumonitis is the most common. Primary varicella hepatitis has been described, though rarely, in immunocompromised patients. We present a case of a previously healthy human immunodeficiency virus-negative 26-year-old immigrant from El Salvador in whom primary varicella developed that rapidly progressed to fulminant hepatic failure, disseminated intravascular coagulation, and death. Autopsy revealed evidence of varicella in the liver, adrenal glands, and myometrium. To our knowledge, this is the first report of a fatal case of varicella hepatitis in a previously healthy, immunocompetent patient.

Hair transplant by incisional strip harvesting

The art of hair transplantation has continued to develop, achieving surgical correction with an enhanced aesthetic outcome. We have used incisional harvesting with donor site closure and have found that incisional harvesting allows for much more latitude in choosing slit, strip, micro, mini, or the standard round or square punch technique.

Successful treatment of a patient with chronic Lyme arthritis with extracorporeal photochemotherapy

We report the use of photopheresis in a patient with chronic Lyme arthritis with apparent resolution of the signs and symptoms. Further controlled trials will be required to determine whether there is a therapeutic role for photopheresis in this disease.

Control of polycythaemia vera with photochemotherapy in a patient with cutaneous T-cell lymphoma

We report the use of photochemotherapy in a patient with polycythaemia vera (PV) and cutaneous T-cell lymphoma (CTCL). The patient was diagnosed with PV and required monthly phlebotomy. Subsequently he was diagnosed with CTCL and was started on photochemotherapy. A clinical improvement in both conditions, with haematocrit stabilizing at a level of 50%, eliminated the need for further phlebotomy. It is conceiveable that photochemotherapy induced the clinical and laboratory improvement in PV by targeting the aberrant clonal haemopoietic cell, similar to the mechanism thought to be operative in CTCL, a clonal helper T cell malignancy.

Extracorporeal photochemotherapy in progressive systemic sclerosis

BACKGROUND

Extracorporeal photochemotherapy, an immune-modulating form of therapy, has been shown to be effective in the treatment of autoimmune diseases. We evaluated the effects of extracorporeal photochemotherapy in the treatment of patients with progressive systemic sclerosis (PSS).

METHODS

Nine patients with active progressive systemic sclerosis were treated with extracorporeal photochemotherapy on 2 successive days monthly. The duration of therapy ranged from 6 to 21 months.

RESULTS

A significant improvement was noted in the skin, musculoskeletal system, functional index, and symptoms including Raynaud's phenomenon, dyspnea, fatigue, dysphagia, and arthralgias, as well as improvement of cutaneous ulcers. Stabilization of the pulmonary function studies was also noted in the majority of patients over the course of therapy. No serious side effects were noted throughout the course of therapy in the 9 patients.

CONCLUSIONS

The results suggest that photopheresis may be beneficial in selected early cases of progressive systemic sclerosis.

Extracorporeal photopheresis in the treatment of AIDS-related complex: extended trial

The objective of this study was to further evaluate the relative safety of extracorporeal photopheresis in the treatment of patients with AIDS-related complex. Twenty patients with AIDS-related complex, three from the initial report and 17 additional patients, were enrolled. The patient population had various risk factors. There were nine homosexuals, five heterosexual consorts of human immunodeficiency virus (HIV)-positive patients, four reformed i.v. drug abusers, and two hemophilia patients. The patients received monthly treatment with extracorporeal photopheresis. In 16 of the 19 patients, this study provides evidence of clinical stability over a longer period. The relative stability of beta 2-microglobulin and neopterin levels demonstrates that photopheresis therapy does not have an untoward effect on the degree of activation of the immune system with respect to induction of HIV replication. Antibody titers to the major viral antigens, envelope glycoproteins (gp) 120 and 41, reverse transcriptase enzyme gp 66/31 and 55, and the core protein p24 remained stable throughout the course of therapy. A subjective improvement was noted in the majority of patients. The evaluation of T-cell subsets revealed that the photopheresis treatment did not have a detrimental effect on CD3 and CD8 cells. Some decreases were noted in the CD4 cell counts but the decline may be less than is normally seen at corresponding stages of HIV infection. Skin test responsivity improved in 11 patients, remained unchanged in seven patients, and declined in two. The preliminary results suggest that in HIV disease, extracorporeal photopheresis is safe and warrants a prospective controlled trial.

Viral-specific immunization in AIDS-related complex by photopheresis

The potential for therapeutic intervention in 7 patients with AIDS-related complex (ARC) was evaluated through the use of photopheresis. The rationale for the study was based on: 1. the demonstration that psoralen and UVA could inactivate HIV/virus in vitro; 2. CD4 cells are the primary target population effected by HIV and photopheresis; and 3. reinfusion of inactivated virus and cell-associated virus might serve to engender an immune response. Preliminary results in 7 patients with ARC over 6 to 18 months revealed a virus-specific response with an elevation of HIV antibodies, while EBV and CMV titers remained unchanged. The immunologic results revealed an increase in the CD8 lymphocyte population, stable activation markers (B2 microglobulin neopterin), a decrease in p24 antigen titers and inability to culture HIV virus in 3 patients. All of these results were in the context of a stable or increasing CD4+ percent. Six patients did not reveal a generalized inhibition of other immune responses as demonstrated by recovery of DTH. In addition, the resolution of lymphadenopathy, night sweats, fever and weight loss, paralleled the immunologic response.

Production of hydrogen peroxide by cutaneous T-cell lymphoma following photopheresis with psoralens and ultraviolet light

Treatment of peripheral blood mononuclear cells with 8-methoxypsoralen (8-MOP) and ultraviolet light, a procedure known as PUVA, has been found to be useful in the management of systemically disseminated cutaneous T-cell lymphoma (CTCL). In the present study we used a highly sensitive flow cytometric assay in conjunction with the hydroperoxide-sensitive dye 2',7'-dichlorofluorescein diacetate to measure intracellular hydrogen peroxide in normal lymphocytes and CTCL following PUVA treatment. Based on their laser light-scattering properties, lymphocytes were separated into three major subpopulations. We found that ultraviolet light alone caused an increase in the hydrogen peroxide content of each of the subpopulations, a response that was augmented when the cells were pretreated with 8-MOP (50 ng/ml). Cells from CTCL patients were more sensitive to the effects of 8-MOP than were normal lymphocytes. In both cell types, the production of hydrogen peroxide was found to be inhibitable by catalase. We noted an increase in hydrogen peroxide production following photopheresis; however, this was observed only 24 h after treatment. In addition, a further increase in hydrogen peroxide production was observed in lymphocytes isolated from peripheral blood that had been obtained from patients at 15 min after a second photopheresis treatment. Hydrogen peroxide is known to modulate the action of cytokines as well as the immunological responses of leukocytes. Our data suggest that the production of hydrogen peroxide by lymphocytes may be important in the action of PUVA in CTCL.

Photopheresis for the treatment of cutaneous T cell lymphoma

We investigated the use of extracorporeal chemotherapy (photopheresis) in eight patients with cutaneous T cell lymphoma. Initially described by Edelson et al. for the treatment of erythrodermic cutaneous T cell lymphoma, we have expanded the treatment to include patients with extensive patch/plaque disease as well as tumor-stage disease. Four of five patients with erythrodermic stage disease had either a complete or a partial clinical remission with photopheresis alone. One patient with extensive patch/plaque disease continued to have a partial clinical remission of 7 months' duration with photopheresis alone. Of the two patients with tumor-stage disease, one remained without evidence of clinical disease at 10 months with photopheresis alone, whereas the second patient had a partial clinical remission of 5 months with a combination of local radiation therapy followed by monthly photopheresis. The skin biopsy specimen obtained from the patient with tumor-stage disease in complete clinical remission did not show cutaneous T cell lymphoma. We conclude that photopheresis is an effective modality alone or in combination with adjunctive therapy for erythroderma, extensive patch/plaque disease, and some tumor-stage disease.

Extracorporeal photopheresis in the treatment of AIDS-related complex: a pilot study

OBJECTIVE

To determine side effects of extracorporeal photopheresis in the treatment of patients with the acquired immunodeficiency syndrome (AIDS)-related complex, and to gain early evidence of efficacy of the treatment.

DESIGN

Uncontrolled trial.

SETTING

Tertiary referral center.

PATIENTS

Five patients with AIDS-related complex: three homosexual men and one man and one woman with histories of intravenous drug abuse. One patient, a homosexual man, withdrew from therapy after 5 months but returned for monthly clinical and laboratory evaluations.

INTERVENTION

Monthly treatments with extracorporeal photopheresis.

MEASUREMENTS AND MAIN RESULTS

Symptoms resolved in four patients. Lymphadenopathy disappeared in all five. Four patients had delayed-hypersensitivity reactions to skin testing (as defined by the Walter Reed staging classification). All showed increases in p24 and gp120 antibody levels. The CD4-cell percentage increased in four patients and declined in one after 6 months of therapy, but the absolute CD4 count decreased in two patients. At 15 months, the CD4 percentage remained at or increased over the baseline value in three patients still in the study but decreased in one. Levels of Beta 2-microglobulin decreased or remained stable in four patients. All patients were culture positive for the human immunodeficiency virus (HIV) before treatment. One patient had a negative viral culture after 5 months of treatment with confirmation. Two other patients became HIV culture negative, one at 14 and one at 15 months: The former patient became positive at 15 months and the latter patient remained negative at 16 months.

CONCLUSIONS

The preliminary results suggest that extracorporeal photopheresis deserves further evaluation as therapy for AIDS-related complex.

Fat transfer for aging skin: technique for rhytids

Dermatologic surgeons are familiar with many surgical and nonsurgical techniques for the reduction of facial rhytids. Injectable collagen, silicone, and fibril are commonly employed as injectable filler materials. Properly done, fat transfer is another valuable tool for use in facial restoration. Fat transfer is an excellent technique for intervention in the aging process, and is easily managed as an office procedure. We will review the near-century-old history of fat grafting and outline the structural dynamics in the process of facial aging. Our experience from the last 50 fat transfer procedures performed will be reviewed with specific attention to patient selection, extraction and injection technique, complications, and overall results.

A technique for blepharoplasty without incising or "puncturing" orbital septum

A blepharoplasty procedure is described in which the actual dissection and removal of adipose tissue has been replaced simply with unipolar electrodesiccation.

Fat transfer--a "pinch" technique for accurate placement of donor tissue

A useful and simple technique for fat transfer requiring bilateral pressure prior to injection for effective correction of cosmetic defects is described.