Lupus erythematosus tumidus: an underestimated entity

There have been few reports of lupus erythematosus tumidus (LET) in the literature. Most of textbooks of dermatology or dermatopathology mention this entity only briefly, if at all. The authors describe an additional case of this underdiagnosed disorder that further supports its existence as a separate entity in the spectrum of the variants of chronic cutaneous lupus erythematosus. Although most cases are reported in the European countries, to our knowledge, this is the first case documented in Portugal. The clinical, photobiological and histological features as well as differential diagnosis, treatment and prognosis are also discussed.

Phase II multicentre trial of oral quisinostat, a histone deacetylase inhibitor, in patients with previously treated stage IB-IVA mycosis fungoides/Sézary syndrome

BACKGROUND

Quisinostat is a hydroxamate, second-generation, orally available pan-histone deacetylase inhibitor.

OBJECTIVES

To evaluate the efficacy and safety of oral quisinostat in patients with previously treated cutaneous T-cell lymphoma (CTCL).

METHODS

Patients received quisinostat 8 mg or 12 mg on days 1, 3 and 5 of each week in 21-day treatment cycles. Primary efficacy end point was cutaneous response rate (RR) based on the modified Severity Weighted Assessment Tool (mSWAT). Secondary end points included global RR, duration of response (DOR) in skin, progression-free survival (PFS), pruritus relief, safety and pharmacodynamic markers.

RESULTS

Eight of 26 (25 evaluable) patients achieved ≥ 50% reduction in mSWAT score at least once, with confirmed cutaneous response in six (RR 24%). There was a low global RR of 8%. DOR in skin ranged from 2·8 to 6·9 months. Median PFS was 5·1 months. Pruritus relief was more frequent in cutaneous responders (67%) than nonresponders (32%). Serial tumour biopsies revealed an increase in acetylated tubulin, indicating a target effect of histone deacetylase 6. Twenty-one of 26 (81%) patients were withdrawn from the study before or at clinical cut-off; five (19%) continued to receive treatment with quisinostat. The most common drug-related adverse events were nausea, diarrhoea, asthenia, hypertension, thrombocytopenia and vomiting. Grade 3 drug-related adverse events included hypertension, lethargy, pruritus, chills, hyperkalaemia and pyrexia.

CONCLUSIONS

Quisinostat 12 mg three times weekly is active in the treatment of patients with relapsed or refractory CTCL, with an acceptable safety profile. Combination therapy with other drugs active in CTCL may be appropriate.

Electroconvulsive therapy in elderly - a preliminary study

Introduction

Studies with electroconvulsive therapy (ECT) in elderly focus mainly on the assessment of possible side effects on the cognitive functioning; there are few studies that evaluate the effectiveness.

Objective

Evaluate the effectiveness of this treatment in the population over 65 years.

Aims

Perform a preliminary study to evaluate the response to ECT of ≥ 65 years patients with depression.

Methods

We carry out a descriptive study based on patients treated in the last 10 years in the ECT Unit of Centro Hospitalar Psiquiátrico de Lisboa.

Results

Our initial sample consisted of 457 patients. We select patients aged ≥ 65 years with depression, and with complete data, including electroconvulsive parameters, and initial and final Hamilton Rating Scale for Depression (HRSD) scores (n = 59). Of this, 81.36% (n = 48) had unipolar depression, and 18.64% (n = 11) had bipolar depression. In the first group, the mean variation between the initial and final scores in HRSD was 13.88 points, and 27.10% (n = 13) of the patients ended the treatment in the normal range of HRSD score. In the second group, the mean variation was 12.82, and 63.60% (n = 7) ended the treatment in the normal range of HRSD. Considering the initial and final HRSD scores, it appears that unipolar depression group presents higher values (severe depression) (P < 0.05). When we compare the mean variation between the initial and final HRSD scores, we didn’t observe a statistically significant difference between the two groups. There was a clinical improvement in both.

Conclusions

The acute treatment with ECT appears to improve depressive symptoms in bipolar and unipolar depression, when considering an elderly population.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Invasive Fungal Infections After Kidney Transplantation: A Single-center Experience

INTRODUCTION

Invasive fungal infections (IFI) affecting transplant recipients are associated with increased mortality and graft dysfunction.

OBJECTIVE

Describe the frequency, clinical features, and outcomes of IFI (except pneumocystis infection) in kidney transplant recipients.

METHOD

Single-center descriptive study including every kidney transplant recipient with a culture-proven or probable IFI between 2003 and 2013, according to the EORTC-MSG criteria.

RESULTS

We identified 45 IFI. There were 13 cases of invasive candidiasis (C. albicans: 6 and non-C. albicans candidial spp.: 7), 11 cases of pulmonary aspergillosis (A. fumigatus: 9 and A. flavus: 2); 11 cases of subcutaneous mycosis (Alternaria spp.: 9, Paecilomyces spp.: 1, and Pseudallescheria spp.: 1); 7 cases of cryptococcosis; 2 cases of pneumonia by non-Aspergillus molds (Mucor spp.: 1 and Cunninghamella spp.: 1); and 1 case of Geotrichum capitatum pneumonia. All patients were recipients from deceased donors. Six cases occurred in the first 3 months post-transplant, 15 cases between the third and twelfth months, and 21 cases after the twelfth month. Treatment options were fluconazole for Candida infections, voriconazole or caspofungin for aspergillosis, liposomal amphotericin for cryptococcosis, and itraconazole plus excision or cryotherapy for subcutaneous mycosis. Fifteen patients died (33%). Mortality rates were 15% for invasive candidiasis, 45% for aspergillosis, 71% for cryptococcosis, 100% for non-Aspergillus molds and G. capitatum pneumonia, and 0% for subcutaneous mycosis. Six patients who survived (14%) started regular hemodialysis.

CONCLUSION

IFI still have a high mortality and morbidity in kidney transplant recipients, as verified in this report. We reinforce the need for a high index of suspicion and prompt treatment.

Hepatitis B virus, hepatitis C virus, and kidney transplant acute rejection and survival

The effect of hepatitis Bs-antigen (AgHBs) and anti-hepatitis C virus (HCV) positivity on renal transplant outcomes is still controversial. Some studies describe higher rates of acute rejection and allograft loss, and greater mortality in transplant recipients with hepatitis. We retrospectively evaluated data from 2284 allograft recipients who underwent transplantation at our hospital between July 1980 and December 2012. Statistical analysis was made using chi-square and Student t tests, Kaplan-Meier curves, and survival analysis. We identified 62 AgHBs+ patients, 99 anti-HCV+ patients, and 14 AgHBs+/anti-HCV+ patients; 2109 patients had "no hepatitis." Mean follow-up time was 7.93 years. No statistical differences were identified on allograft acute rejection rate or patient survival between groups. AgHBs+ patients had, however, an inferior allograft survival, with statistical significance. According to our study, hepatitis B has a harmful impact on allograft survival, although it does not compromise the patient survival.

Selective cytotoxicity and cell death induced by human amniotic membrane in hepatocellular carcinoma

Hepatocellular carcinoma (HCC) has a worldwide high incidence and mortality. For this reason, it is essential to invest in new therapies for this type of cancer. Our team already proved that human amniotic membrane (hAM) is able to inhibit the metabolic activity of several human cancer cell lines, including HCC cell lines. Taking into account the previously performed work, this experimental study aimed to investigate the pathways by which hAM protein extracts (hAMPEs) act on HCC. Our results showed that hAMPE reduce the metabolic activity, protein content and DNA content in a dose- and time-dependent manner in all HCC cell lines. This therapy presents selective cytotoxicity, since it was not able to inhibit a non-tumorigenic human cell line. In addition, hAMPE induced cell morphology alterations in all HCC cell lines, but death type is cell line dependent, as proved by in vitro and in vivo studies. In conclusion, hAMPE have a promising role in HCC therapy, since it is capable of inducing HCC cytotoxicity and cell death.

New Recipes With Known Ingredients: Combined Therapy of Everolimus and Low-dose Tacrolimus in De Novo Renal Allograft Recipients

BACKGROUND

Calcineurin inhibitors (CNIs) are the cornerstones of immunosuppressive management in renal allograft recipients even though their nephrotoxicity may contribute to a reduced long-term graft survival. This has created a great interest in improving immunosuppressive strategies in the early post-transplantation period. Proliferation signal inhibitors (PSIs), such as everolimus, are promising alternatives, although their side effects may have a drawback in de novo renal transplant recipients, for instance, delaying renal function in the presence of renal ischemia/acute tubular necrosis and predisposing to lymphocele development.

STUDY AND METHODS

A retrospective study was developed to compare the combined therapy of low-dose tacrolimus and everolimus (study group) with mycophenolate mofetil/mycophenolic acid and standard-dose tacrolimus (control group) in the first 3 months post-transplantation. The study's end-points concerned renal graft function, proteinuria, incidence of biopsy-proven acute rejection, surgical complication rates, and incidence of new-onset diabetes after renal transplantation.

RESULTS

There was no more delayed graft function in the study group and graft function distribution was similar between groups. Median serum creatinine and eGFR were comparable as well as proteinuria levels. Generally, adverse events were rare in both groups and there were no significant statistical differences between them in terms of biopsy-proven acute rejection, surgical complication, and new-onset diabetes after renal transplantation rates.

CONCLUSION

Despite the slightly lower tendency for serum creatinine in the study group, renal allograft function wasn't statistically different between groups. Moreover, there weren't more metabolic or surgical complications in the study group. Everolimus may be a choice in tacrolimus-sparing strategies, but a larger study and a longer follow-up are still required.

Cyclosporine A-induced nephrotoxicity is ameliorated by dose reduction and conversion to sirolimus in the rat

Side-effect minimization strategies to avoid serious side-effects of cyclosporine A (CsA), such as nephrotoxicity, have been mainly based on dose reduction and conversion to other putatively less nephrotoxic drugs, such as sirolimus (SRL), an inhibitor of the mammalian target of rapamycin. This study intended to evaluate the impact of protocols based on CsA dose reduction and further conversion to SRL on kidney function and lesions, based on serum, urine and renal tissue markers. The following 3 groups (n=6) were tested during a 9-week protocol: control (vehicle); CsA (5 mg/kg/day) and Red + Conv (CsA 30 mg/kg/day during 3 weeks + 3 weeks with CsA 5 mg/kg/day + SRL 1 mg/kg/day during the last 3 weeks). The following parameters were analysed: blood pressure, heart rate and biochemical data; serum and urine contents and clearances of creatinine, urea and neutrophil gelatinase-associated lipocalin (NGAL), as well as, glomerular filtration rate; kidney lipid peroxidation and clearance; kidney lesions were evaluated and protein expression was performed by immunohistochemistry. After the first 3 weeks of CsA (30 mg/kg/day) treatment animals showed body weight loss, hypertension, tachycardia, as well as, increased serum levels of non-HDL cholesterol, glucose, triglycerides, creatinine and urea, accompanied by decreased GFR and insulin levels. In addition, a significant increase in the expression of connective tissue growth factor, kidney injury molecule-1 (KIM-1), mammalian target of rapamycin, nuclear factor-κβ1 and transforming growth factor-β was found in the kidney, accompanied by extensive renal damage. The following 3 weeks with CsA dose reduction revealed amelioration of vascular and glomerular lesions, but without significant tubular improvement. The last 3 weeks with the conversion to sirolimus revealed high serum and urine NGAL contents but the CsA-evoked renal damage was substantially ameliorated, by reduced of connective tissue growth factor, mammalian target of rapamycin, nuclear factor-κβ1 protein expression. In conclusion, CsA nephrotoxicity is dose dependent and moderate dysfunction could be ameliorated/prevented by SRL conversion, which could be pivotal for the preservation of kidney function and structure.

Collagen type IV-related nephropathies in Portugal: pathogenic COL4A3 and COL4A4 mutations and clinical characterization of 25 families

Pathogenic mutations in genes COL4A3/COL4A4 are responsible for autosomal Alport syndrome (AS) and thin basement membrane nephropathy (TBMN). We used Sanger sequencing to analyze all exons and splice site regions of COL4A3/COL4A4, in 40 unrelated Portuguese probands with clinical suspicion of AS/TBMN. To assess genotype-phenotype correlations, we compared clinically relevant phenotypes/outcomes between homozygous/compound heterozygous and apparently heterozygous patients. Seventeen novel and four reportedly pathogenic COL4A3/COL4A4 mutations were identified in 62.5% (25/40) of the probands. Regardless of the mutated gene, all patients with ARAS manifested chronic renal failure (CRF) and hearing loss, whereas a minority of the apparently heterozygous patients had CRF or extrarenal symptoms. CRF was diagnosed at a significantly younger age in patients with ARAS. In our families, the occurrence of COL4A3/COL4A4 mutations was higher, while the prevalence of XLAS was lower than expected. Overall, a pathogenic COL4A3/COL4A4/COL4A5 mutation was identified in >50% of patients with fewer than three of the standard diagnostic criteria of AS. With such a population background, simultaneous next-generation sequencing of all three genes may be recommended as the most expedite approach to diagnose collagen IV-related glomerular basement membrane nephropathies.

Collagen type IV-related nephropathies in Portugal: pathogenic COL4A5 mutations and clinical characterization of 22 families

Alport syndrome (AS) is caused by pathogenic mutations in the genes encoding α3, α4 or α5 chains of collagen IV (COL4A3/COL4A4/COL4A5), resulting in hematuria, chronic renal failure (CRF), sensorineural hearing loss (SNHL) and ocular abnormalities. Mutations in the X-linked COL4A5 gene have been identified in 85% of the families (XLAS). In this study, 22 of 60 probands (37%) of unrelated Portuguese families, with clinical diagnosis of AS and no evidence of autosomal inheritance, had pathogenic COL4A5 mutations detected by Sanger sequencing and/or multiplex-ligation probe amplification, of which 12 (57%) are novel. Males had more severe and earlier renal and extrarenal complications, but microscopic hematuria was a constant finding irrespective of gender. Nonsense and splice site mutations, as well as small and large deletions, were associated with younger age of onset of SNHL in males, and with higher risk of CRF and SNHL in females. Pathogenic COL4A3 or COL4A4 mutations were subsequently identified in more than half of the families without a pathogenic mutation in COL4A5. The lower than expected prevalence of XLAS in Portuguese families warrants the use of next-generation sequencing for simultaneous COL4A3/COL4A4/COL4A5 analysis, as first-tier approach to the genetic diagnosis of collagen type IV-related nephropathies.

First Report of Stigmina palmivora Causing Leaf Spots on Phoenix roebelenii in Brazil

Phoenix roebelenii (Arecaceae), known as dwarf date (tamareira-anã in Brazil), is a palm native to Southeast Asia and widely cultivated worldwide because of its ornamental value and ease of adaptation to a broad range of climates and soil types (4). In June 2012, some individuals were observed in a private garden in the municipality of Viçosa (state of Minas Gerais, Brazil) bearing numerous necrotic lesions on its leaves. Representative samples were taken, dried in a plant press, and brought to the laboratory for examination. A fungus was regularly associated with the leaf spots. Fungal structures were mounted in lactophenol and slides were examined under a microscope (Olympus BX 51). Spores were taken from sporulating colonies with a sterile fine needle and plated on PDA for isolation. A pure culture was deposited in the culture collection of the Universidade Federal de Viçosa (accession COAD1338). A dried herbarium sample was deposited in the local herbarium (VIC39741). The fungus had the following morphology: conidiophores grouped on sporodochia, cylindrical, 12 to 29 × 5 to 6 μm, dark brown; conidiogenous cells, terminal, proliferating percurrently (annellidic), 8 to 20 × 5 to 6 μm, pale to dark brown; conidia obclavate to subcylindrical, straight, 58 to 147 × 5 to 6 μm, 6 to 16 septate, hila thickened and darkened with a thin-walled projecting papilla, dark brown, and verrucose. The morphology of the Brazilian collections agrees well with the description of Stigmina palmivora (2), a species known to cause leaf spots on P. roebelenii in the United States (Florida) and Japan (3). Pathogenicity was demonstrated through inoculation of leaves of healthy plants by placing 6 mm diameter cuture disks of COAD1338 on the leaf surface followed by incubation in a moist chamber for 48 h and then transferred to a greenhouse bench at 21 ± 3°C. Typical leaf spots were observed 15 days after inoculation. DNA was extracted from the isolate growing in pure culture and ITS and LSU sequences were generated and deposited in GenBank under the accession numbers KF656785 and KF656786, respectively. These were compared by BLASTn with other entries in GenBank, and the closest match for each region were Mycosphaerella colombiensis strain X215 and M. irregulariamosa strain CPC 1362 (EU514231, GU2114441) with 93% of nucleotide homology (over 100% query coverage) for ITS and 98% of nucleotide homology (over 100% query coverage) for LSU. There are no sequences for S. palmivora deposited in public databases for comparison, but for Stigmina platani, the type species in this genus, 86% and 96% nucleotide homology for ITS and LSU with S. palmivora were found. The genus Stigmina is regarded as being polyphyletic (1) and this is probably reflected by these low homology levels found in the BLASTn search. To our knowledge, this is the first report of Stigmina palmivora in Brazil. References: (1) P. W. Crous et al. Stud. Mycol. 75:37, 2012. (2) M. B. Ellis. Dematiaceous Hyphomycetes. Commonwealth Mycological Institute, Kew, UK, 1971. (3) D. F. Farr and A. Y. Rossman. Fungal Databases. Syst. Mycol. Microbiol. Lab. ARS, USDA. Retrieved from http://nt.ars-grin.gov/fungaldatabases/ , 2013. (4) H. Lorenzi et al. Palmeira no Brasil: Exóticas e Nativas, 2nd ed. Editora Plantarum, Nova Odessa, Brazil, 2005.

Alzheimer's disease: is a vaccine possible?

The cause of Alzheimer's disease is still unknown, but the disease is distinctively characterized by the accumulation of β-amyloid plaques and neurofibrillary tangles in the brain. These features have become the primary focus of much of the research looking for new treatments for the disease, including immunotherapy and vaccines targeting β-amyloid in the brain. Adverse effects observed in a clinical trial based on the β-amyloid protein were attributed to the presence of the target antigen and emphasized the relevance of finding safer antigen candidates for active immunization. For this kind of approach, different vaccine formulations using DNA, peptide, and heterologous prime-boost immunization regimens have been proposed. Promising results are expected from different vaccine candidates encompassing B-cell epitopes of the β-amyloid protein. In addition, recent results indicate that targeting another protein involved in the etiology of the disease has opened new perspectives for the effective prevention of the illness. Collectively, the evidence indicates that the idea of finding an effective vaccine for the control of Alzheimer's disease, although not without challenges, is a possibility.

New-onset diabetes after transplantation: assessment of risk factors and clinical outcomes

BACKGROUND

New-onset diabetes after transplantation (NODAT) is a serious complicatin of kidney transplantation (KT) with adverse impacts on graft and patient survivals. This study aims assess potential risk factors for development of NODAT and compare clinical outcomes of KT recipients with versus without NODAT.

METHODS

We retrospectively evaluated 648 patients who underwent KT between 2005 and 2009. From the 83 (12.8%) subjects who developed NODAT, we selected 47 for comparison with controls free of diabetes.

RESULTS

The diagnosis of NODAT was made at 4.3 ± 8.5 months after transplantation in 47 patients, including 76.6% males, with an overall mean age of 54.5 ± 10.8 years. Patients with NODAT presented higher pretransplantation fasting plasma glucose levels (P < .001) as well as cyclosporine and tacrolimus trough levels (P = .003 and P < .001, respectively). On multivariate analysis, higher pretransplantation fasting plasma glucose and higher tacrolimus, but not cyclosporine concentrations were independent predictors of NODAT. No differences were found for other potential risk factors. Upon follow-up at 6, 12, 24, 36, 48, and 60 months, renal function (estimated Glomerular Filtration Rate using Modification of Diet in Renal Disease), 24 hour proteinuria and proportions of patients with hypertension were similar between groups. Patients with NODAT showed comparable numbers of hospitalizations and infections, as well as acute rejection episodes and acute cardiovascular events as their counterparts. Event-free survival (loss of graft function/death with functioning graft) was similar between the groups (P = .418; K-M).

DISCUSSION

In our population, higher pretransplantation fasting plasma glucose levels and higher tacrolimus concentrations were independent predictors of NODAT. During a mean follow-up of 3 years, NODAT was not associated with worse clinical outcomes.