Involvement of macrophages in the pathology of toxic epidermal necrolysis

In toxic epidermal necrolysis (TEN), as in the 'epidermal type' of erythema multiforme, the necrotic epidermis is infiltrated with mononuclear cells. We studied the epidermal infiltrate in seven cases of TEN. About half the cells obtained from pieces of cleaved epidermis dissociated by trypsin were non-epithelial. On cytologic analysis, 80% of these foreign cells exhibited markers of macrophages, 15% were granulocytes and only 5% were lymphocytes (almost exclusively OKT8 T lymphocytes). Semi-thin sections of early prenecrotic lesions showed exocytosis of mononuclear cells within the epidermis with features of satellite cell necrosis and formation of colloid bodies. Almost all these mononuclear cells were macrophages as evidenced by endogenous peroxidase-positive granules. These findings suggest that some kind of macrophage-mediated cytotoxicity may play a role in the necrosis of epidermal cells during TEN.

Maintenance treatment of psoriasis by Tigason: a double-blind randomized clinical trial

Extensive lesions on 36 patients with psoriasis were treated by Tigason, I mg/kg/day plus PUVA until skin clearance. A clinical score was calculated for each body area, and erythema, scaling, thickness and pruritus of the lesions were scored from 0 to 3. Skin clearing was defined as a clinical score less than 10% of the initial score. Double-blind maintenance treatment was then started. This was Tigason at half of the maximal dose tolerated during the clearing phase of the treatment v. placebo. Relapse of the disease was defined as the occurrence of a clinical score greater than 50% of the initial score. Among the 36 patients randomized, 20 received placebo and 16 received Tigason. Relapses increased quickly in the patients on placebo, but occurred in few patients treated by Tigason with 60% remaining clear after 1 year (P less than 0.05). Surprisingly, the kinetics of disappearance of the most frequent side effect, cheilitis, was the same in the Tigason group and in the placebo group. This double-blind randomized clinical trial shows that Tigason at low doses is an efficient and well-tolerated maintenance treatment of psoriasis.

[Treatment of bullous pemphigoid by plasma exchange and prednisolone]

Between March, 1983 and March 1984, 12 previously untreated patients (7 men, 5 women) with biopsy proven active bullous pemphigoid entered this open study. Their initial therapy associated oral prednisolone 0.5 mg/kg in divided daily doses with 4 large volume plasma exchanges (one and half the theoretical plasma volume) over 2 weeks. The disease was considered under control when new blisters and pruritus were absent for 2 consecutive weeks. This initial treatment was well tolerated by these elderly patients (mean age 80 +/- 9 years), with no death and no major complication. Eight patients were controlled within 29 +/- 4 days. During progressive decrease of steroid dosage 5 of these 8 patients remained well (mean follow-up 7 months), 2 relapsed and one died of marasmus. Among the 4 patients who were not controlled, 3 needed only a slight increase in prednisolone doses (0.75 mg/kg/d) and 1 required up to 1 mg/kg/d and 4 additional plasma exchanges. This study suggests that a combined treatment with moderate doses of prednisolone and 4 large volume plasma exchanges is well tolerated and highly effective in bullous pemphigoid.

Sjögren-like syndrome after drug-induced toxic epidermal necrolysis

7 of 9 patients recovering from a drug-induced toxic epidermal necrolysis (TEN) which they had had 2 months to 4 years before had xerostomia, or keratoconjunctivitis sicca, or both. 5 patients had symptoms; 2 had severe visual impairment. In 5 cases there was lymphocytic infiltration of small salivary glands; in 2 patients this was identical to that of Sjögren syndrome. None of the patients had antinuclear antibody. TEN may occur during acute graft-versus-host disease (GVHD) and these observations are reminiscent of the sicca syndromes reported during chronic GVHD. They suggest that autoimmune mechanisms may be involved in drug-induced TEN and that Sjögren syndrome may occur as the result of a drug reaction.

Alveolar soft part sarcoma presenting as asymptomatic pulmonary nodules: report of a case with ultrastructural diagnosis

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Lymphocyte transformation test in drug-induced toxic epidermal necrolysis

Lymphocyte transformation tests (LTT) to drugs remain widely used in drug reactions, despite controversies about their real usefulness. We tested the lymphocytes of 12 patients recovering from a drug-induced Toxic epidermal necrolysis (TEN). There was no difference between the amounts of thymidine incorporated when patients' lymphocytes were cultivated with culprit or innocent drugs. In both situations the lymphocytes from patients reacted like the lymphocytes from controls cultivated with the same panel of drugs. These negative results do not exclude that a hypersensitivity reaction may play a role in the physiopathology of TEN. Anyhow, they clearly indicate that testing lymphocyte transformation to drugs has no practical value in the diagnosis of TEN.

Lymphopenia and abnormal balance of T-lymphocyte subpopulations in toxic epidermal necrolysis

A lymphopenia (peripheral-blood-lymphocyte count less than 1,000/mm3) was observed in seven out of ten patients with toxic epidermal necrolysis (TEN). The enumeration of T-lymphocyte subsets with monoclonal antibodies showed a decreased number of pan T-lymphocytes (OKT3-positive), which was related to a profound depletion of OKT4-positive cells. In contrast, OKT8-positive cell counts were not significantly changed. This abnormal balance of T-lymphocytes was linked to the acute phase of the disease and was not found after recovery. The pathogenetic mechanisms of such T-lymphocyte abnormalities in TEN remain unclear.

Bronchoalveolar lavage in radiation pneumonitis

Bronchoalveolar lavage (BAL) was carried out in six patients with radiation pneumonitis, the early radiation-induced lung damage that usually leads to radiation fibrosis. Protein analysis by immuno-electrophoresis and polyacrylamide gel electrophoresis of BAL fluid revealed leakage of circulatory proteins, including high molecular weight components. Cell count of BAL fluid showed an increased number of lymphocytes; these proved to be activated on cell cycle analysis in one patient. Collagenolytic activity, assessed by degradation of radiolabelled type I human collagen, was present in BAL fluid of all six patients. The following mechanisms are therefore considered to participate in the pathogenesis of radiation-induced lung damage: 1) permeability oedema, which led to acute respiratory distress syndrome in one case of hyperacute radiation pneumonitis, 2) lymphocyte alveolitis possibly perpetuated by activated lymphocytes, and 3) release of collagenolytic enzymes in alveolar structures contributing to fibrotic processes.

Psoriasis: a defect in the regulation of epidermal proteases, as shown by serial biopsies after cantharidin application

The possible role of epidermal serine proteases in the genesis of psoriatic lesions was investigated by sequential biopsies of the epidermal damage induced by topical cantharidin. In the skin of normal subjects, epidermal damage was followed by the transient appearance of proteolytic activity in the upper epidermis accompanied by temporary hyperacanthosis and perivascular inflammatory cells in the superficial dermis. In the uninvolved skin of five patients with psoriasis this proteolysis persisted longer, for more than 7 days. Thereafter, in three of the patients, the proteolysis abated, and this was followed by disappearance of the hyperacanthosis and the dermal infiltrate; in the other two psoriatics the proteolysis and hyperacanthosis increased, and a typical Koebner phenomenon ensued. Migration of neutrophils into the epidermis occurred as a later event. Thus the abnormal persistence of proteolytic activity in the upper epidermis after cantharidin application distinguishes the normal from the psoriatic skin injury response and might initiate the psoriatic lesion.

The contractility of fibroblasts in a collagen lattice is reduced by corticosteroids

Normal human and rat skin fibroblasts, incorporated into a three-dimensional collagen lattice, were assayed for their ability to contract collagen fibrils. This capacity is inhibited in a dose-dependent fashion by both dexamethasone and hydrocortisone. The inhibition is reversed when the corticosteroids are removed from the culture medium, but while the effect of hydrocortisone is almost entirely reversible, that of dexamethasone is not.

[Bronchogenic cysts and their atypical localizations. A case of pleuro-diaphragmatic cyst]

Bronchogenic cysts represent about 10 p. 100 of all surgical tumours of the mediastinum. They can never be diagnosed with absolute certainty prior to the operation, but when they arise in their typical sites, they can be suspected with a high probability. However, they can occur in very atypical sites, in which case the diagnosis remains very hypothetical until the operation. The authors report a case of a cyst which developed under the diaphragmatic pleura, in direct contact with the dome of the diaphragm and attached to the mediastinum by a fine vascular pedicle which inserted in the root of the triangular ligament.

A routine immuno-electron microscopic technique for localizing an auto-antibody on epidermal basement membrane

A new diagnostic technique is described, in which 0.7 mm thick slices of skin are freshly cut, thoroughly washed, slightly fixed and directly incubated in peroxidase-labelled antibodies. This easy technique allows routine immuno-electron microscopic diagnosis of subepidermal auto-immune bullous diseases, with excellent morphological results.

Endogenous peroxidases in normal human dermis: a marker of fibroblast differentiation

Incubation of unfixed and unfrozen slices of normal human skin allows visualization of a peroxidase activity associated with the perinuclear envelope and with the endoplasmic reticulum of resident dermal macrophages, dermal mastocytes, and also of some dermal fibroblasts. No peroxidase activity can be detected in fibroblasts cultivated in monolayer, while 80% of fibroblasts in an "in vitro" collagen lattice, called a dermal equivalent, express a peroxidase activity in the perinuclear envelope and the endoplasmic reticulum. Hence expression of this peroxidase activity in normal human skin fibroblasts serves as a marker of fibroblast differentiation and seems to depend on an interaction to fibroblast with the elements of a three-dimensional matrix.

[Fibrotic interstitial pneumopathies. Collagenolytic activity of the alveolar fluid]

Collagenolytic enzyme release in alveolar structures is probably one of the initial events leading to impaired balance between collagen synthesis and degradation in the connective matrix of the lung, resulting in pulmonary fibrosis. The collagenolytic activity was determined in the bronchoalveolar fluid of 40 normal subjects or patients with miscellaneous pulmonary diseases and was found to be present in seventeen, viz.: 7/7 patients with interstitial fibrosis, irrespective of its origin: 4/4 patients with radiation pneumonitis; 4/15 patients with sarcoidosis and 2/2 patients with transient eosinophilic pneumopathy. There was no evidence of fibrosis in the 23 patients who showed no collagenolytic activity. Thus, collagenolytic enzymes are present in the alveolar structures of patients with interstitial pulmonary diseases of diverse origin capable of leading to fibrosis. Monitoring the release of this enzyme by bronchoalveolar lavage could be useful to evaluate the risk of fibrosis in such patients.

Plasma exchange in pemphigus. Uncontrolled study of ten patients

Plasma exchange, together with oral immunosuppressive drugs and various doses of adrenal steroids, were used in the treatment of ten patients with pemphigus. Initially plasma exchange decreased the intercellular antibody (IC Ab) level in all patients and induced a clinical improvement in the conditions of eight of ten patients. This improvement was sustained for the six patients who received simultaneously 0.5 mg/kg/day or more of prednisone. Among the eight patients, four previously corticoresistant patients had perfect control of their disease. Conversely the other four patients, treated with low doses of prednisone, experienced a posttreatment rebound in IC Ab level and showed no or only transient clinical improvement. Plasma exchange may be useful in bringing corticoresistant pemphigus under control but it is not to be used without accompanying high doses of adrenal steroids.

A cytochemical marker for epidermal differentiation, Langerhans cells, skin resident macrophages and mitochondria

Incubation of unfixed and unfrozen slices of skin in diaminobenzidine allows visualization of peroxidatic activity in the perinuclear envelope and endoplasmic reticulum of normal human Langerhans cells. A similar peroxidatic activity is observed in supra-basal keratinocytes undergoing orthokeratotic differentiation. Basal keratinocytes and melanocytes are always negative. This enzyme is absent in mucous and parakeratotic (psoriatic) differentiation. A peroxidatic activity was also found in the endoplasmic reticulum of normal resident skin macrophages. Mitochondria are also strongly stained by this technique and it was shown that the number of epidermal mitochondria is greatly increased in psoriatic lesions.

Neutrophil studies in psoriatics: in vivo migration, phagocytosis and bacterial killing

A reproducible method for sequential study of migration out of human skin, phagocytosis and bactericidal activity of neutrophils is described. Untreated psoriatics exhibit an early increase of chemotactic activity (0-8 hr, p less than 0.02) and subsequently a strong inhibition of chemotaxis (8-24 hr, p less than 0.01), a slight decrease of phagocytosis and a decrease in bactericidal activity (20 min, p less than 0.02; 30 min, p less than 0.003); 60 min, p less than 0.001; 120 min, p less than 0.001) as compared with controls. After clearing of skin lesions, the early increased chemotactic activity returned to normal values but the subsequent chemotactic inhibition remains as strong as before treatment. Phagocytosis increased to normal values (p less than 0.02) and bactericidal activity also increased but remained significantly low. These abnormalities were more evident in migrating than in circulating neutrophils, underlining the sensitivity of the described method.

Dinitrochlorobenzene treatment of alopecia areata

Forty-two patients with alopecia areata were treated with local applications of dinitrochlorobenzene (DNCB); We used DNCB in two forms, an acetone solution applied weekly or a cream used every day, employing a wide range of DNCB concentrations. The concentration used was varied at the time of each application to produce a contact dermatitis. Seven patients experienced complete and lasting hair regrowth, 17 had poor results, and in 18 patients the treatment was a failure. Acquired tolerance to DNCB was observed in six patients; in five it was abolished by the administration of cimetidine. Certain factors such as the delay in appearance and the intensity of the sensitization reaction influence the hair regrowth. Poor prognostic criteria for treatment effect included a history of previous systemic corticosteroid therapy, atopy, and the presence of alopecia areata in close relatives.

Diaminobenzidine cytochemistry in unfixed human epidermis: a marker for epidermal differentiation and for mitochondria

Intubation of unfixed and unfrozen slices of skin in diaminobenzidine allows visualization of a peroxidatic activity in perinuclear envelope of suprabasal keratinocytes undergoing orthokeratotic differentiation. Basal keratinocytes and melanocytes are always negative. This enzyme is absent in mucous and parakeratotic (psoriatic) differentiation. Mitochondria are also strongly stained by this technique and it was shown that the number of epidermal mitochondria is greatly increased in psoriatic lesions.

[Concomitant pulmonary tuberculosis and bronchogenic carcinoma: a difficult diagnosis. Report of eighteen cases (author's transl)]

The diagnosis in the same patient of the two diseases is very often delayed. Generally, tuberculosis is diagnosed first, and then cancer when the radiologic lesions extend despite of antituberculous treatment. In half of our cases, tuberculous lesions could not be individualized from cancer on the chest X-ray films. Antineoplastic chemotherapies may favour the development of tuberculosis, or atypical mycobacteriosis, in cancer patients, and it must be considered as an opportunistic infection in such patients. Clinicians should be aware of the possible coexistence of the two diseases and, in practice, ask for fiberoptic bronchoscopy and sputum cytology in tuberculous patients presenting atypical features, and for sputum examination in cancer patients.