A case of episodic angioedema associated with blood eosinophilia: upregulated C5a receptor expression on eosinophils

A 47-year-old woman was admitted to hospital complaining of swelling and pain of the extremities, accompanied by high fever and generalized erythema. Laboratory examination showed marked blood eosinophilia with elevation of IgM, IgE, and C-reactive protein. All autoantibodies examined were negative. The heart and lungs showed no untoward findings. Biopsies of the skin and muscle revealed cellular infiltration of eosinophils around small blood vessels. Quantitation of C5a receptor (C5aR) expression by flow cytometry using anti-C5aR antibody showed upregulated expression of C5aR on blood eosinophils but downregulated expression on neutrophils. The abnormal C5aR expression on eosinophils and neutrophils became normal after spontaneous resolution of symptoms and blood eosinophilia. The possibility that C5aR expression on granulocytes is related to the pathogenesis of this syndrome may be considered.

Sulfidoleukotriene release test (CAST) in hypersensitivity to nonsteroidal anti-inflammatory drugs

There is a great need to develop a method for making an accurate and reliable in vitro diagnosis of adverse hypersensitivity reactions to drugs. We measured the amount of sulfidoleukotriene (sLT) released from the peripheral blood leukocytes obtained from 25 patients who developed hypersensitivity reactions following the administration of nonsteroidal anti-inflammatory drugs (NSAIDs); 12 patients demonstrated reactions to Voltaren, 8 patients to Bufferin, and 5 patients to Sedes G. The stimulation index, the ratio of the amounts of sLT (pg/ml) incubated with and without drugs, was considerably higher in the patients than in the controls, which consisted of 5 nonallergic healthy subjects. The sensitivity of the CAST (cellular antigen stimulation test) was evaluated to range from 62.5 to 80%, while the specificity was 70-100%. The CAST may thus be useful as a novel in vitro test system in order to screen for possible hypersensitive reactions to NSAIDs with both reliability and safety.

Increased number of IgE positive Langerhans cells in the conjunctiva of patients with atopic dermatitis

AIM

To determine the role of Langerhans cells (LCs) found to bear IgE in patients with atopic dermatitis (AD) by evaluating the surface distribution of these cells in the conjunctival epithelium and epidermis of skin lesions in patients with AD.

METHODS

The double labelling method was used to evaluate IgE positive cells that were positive for anti-CD1a or anti-CD23 antibody in an epithelial sheet of the conjunctival limbus. Specimens of conjunctiva were obtained from 12 men, six of whom had AD and ocular complications. Five patients without atopic disease served as controls, plus one additional patient with asthma but no AD. A similar study was conducted using epidermal sheets obtained from two patients with AD and from one without AD.

RESULTS

The number of CD1a+ cells present in the conjunctival epithelium of the patients with AD significantly exceeded that of the patients without AD. Most CD1a+ cells in the conjunctival epithelium and epidermis from the patients with AD bore IgE on their surfaces. Few such cells from patients without AD bore IgE. No CD23+ cells were found in the patients with or without AD.

CONCLUSIONS

The presence of an increased number of LCs bearing IgE on their surfaces in the conjunctival epithelium of patients with AD suggests that these cells may be involved in eliciting the hypersensitivity reaction and participate in ocular inflammation.

Normal-mode ruby laser for treating congenital nevi

BACKGROUND

Q-switched laser therapy is known to be highly effective in treating dermal melanocytosis and pigmented epidermal lesions. However, to our knowledge, there are no reports on the effectiveness of laser therapy for congenital nevi. We evaluated the clinical efficacy and side effects of normal-mode ruby laser therapy for congenital pigmented lesions containing abundant melanin.

OBSERVATIONS

A normal-mode ruby laser (pulse duration, 0.3-1.0 x 10(-3) seconds; energy fluence, 10-30 J/cm2; and spot size, 10 x 10 or 15 x 15 mm) (Toshiba Corp, Tokyo, Japan) was used to treat 3 patients with congenital nevi at intervals of 1 to 4 months. In all 3 cases, the pigmented lesions were significantly reduced almost to the level of the surrounding normal skin after 4 laser treatments. The treated areas were virtually free of scarring, and the skin texture resembled that of the surrounding normal skin. Unsightly hair growth was also reduced.

CONCLUSIONS

The normal-mode ruby laser was effective in treating congenital nevi and produced good cosmetic results. The risk of recurrence is unknown, but the 3 patients in our study did not have any recurrences during the 18- to 39-month study period.

Leser-Trélat sign with anaplastic ependymoma--an autopsy case

A 36-year-old Japanese male, who 7 years previously had been diagnosed as having an ependymoma in the left parietal region, had received surgery, chemotherapy and radiotherapy. He later developed a rapid growth of multiple skin lesions on his back and extremities, which coincided with a regrowth of the tumor. Postmortem examination revealed that the ependymoma showed anaplastic transformation and necrosis; however, no malignancy was observed in the extracranial organs. The skin lesions were histologically diagnosed as seborrheic keratoses. We have, therefore, diagnosed the patient as having Leser-Trélat sign associated with anaplastic ependymoma.

Presence of elevated carcinoembryonic antigen on absorbent disks applied to nipple area of breast carcinoma patients

BACKGROUND

Carcinoembryonic antigen (CEA) is used as a serum marker to detect and monitor the status of various kinds of malignant tumors. To determine whether CEA might be detected in secretions collected topically from around the nipple area, and whether its secretion might differ in a cancerous versus a noncancerous breast, we developed a simple method for collecting and measuring CEA, using a small cellulose membrane disk and an enzyme immunoassay.

METHODS

We measured the amount of CEA excreted from the nipple area of 22 healthy control women and 32 women with unilateral breast carcinoma confirmed histologically. Secretions were collected from the nipple area by affixing a small (20 mm diameter) absorbent disk made of nitrocellulose membrane backed with filter paper to that area for 24 hours. Substances absorbed by the membrane were then subjected to an immunoassay for CEA using anti-CEA antibodies.

RESULTS

In the 22 healthy subjects, a small amount of CEA (0.6 +/- 0.9 units) was secreted from each nipple, which was equally low regardless of the phase of the menstrual cycle. In contrast, 30 of the 32 women with breast carcinoma secreted significantly greater amounts of CEA from the cancerous (16.1 +/- 8.2) than the noncancerous (2.0 +/- 2.2) breast. Such a difference (14.1 +/- 8.0) in CEA excretion was not observed in the healthy controls (0 +/- 0).

CONCLUSIONS

These findings suggest that such disks may provide a simple and noninvasive method of collecting trace molecules, including CEA, in skin secretions around the nipple to evaluate functional disorders of the mammary glands, particularly breast carcinoma. Additional studies are indicated in larger groups of women with various stages of breast carcinoma as well as with benign breast diseases.

Case report: Gianotti-Crosti syndrome associated with human herpesvirus-6 infection

We report a case of Gianotti-Crosti syndrome associated with human herpesvirus-6 (HHV-6) infection. An eight-month-old girl developed monomorphous papules on her cheeks, buttocks, and extremities after the subsidence of exanthema subitum. Viral antibody analysis confirmed primary HHV-6 infection. HHV-6 may be added to the list of causative agents of Gianotti-Crosti syndrome.

Hair cortex comedo

We report two cases of skin lesions that clinically resemble a comedo. Both lesions demonstrated a firm black papule which was histopathologically reminiscent of a dilated hair follicle associated with an abnormality of the hair cortex. These findings are thus considered to represent a unique and peculiar variant of the dilated pore of Winer, and the term "hair cortex comedo" is therefore believed to be suitable for such lesions.

Spontaneous architectural organization of mammalian epidermis from random cell packing

The cells of the stratum corneum in the epidermis of some mammalian species are precisely stacked in columns in a honeycomb fashion. The epidermis constantly loses surface cells, which are replaced by basal cells that have differentiated during migration to the surface. The path of this migration is seen as precisely defined columns of cells that are in compressed Kelvin's tetrakaidecahedral form. We present a computer simulation of this architectural organization based on the assumption that the cells that migrate upward occupy less crowded regions. The simulation not only explained the mechanism by which the architecture is maintained during the process of cell replacement, but also showed that the architecture was spontaneously organized from initial cells supplied at random. Living organisms consist of self-organizing systems at various levels; however, self-organizing systems have been investigated mostly at the molecular level. The present computer simulation clarified the self-organizing system at the cellular level.

Angiocentric immunoproliferative lesions of the skin show lobular panniculitis and are mainly disorders of large granular lymphocytes

Eleven patients with angiocentric immunoproliferative lesion (AIL) of the skin were studied. Histologically, three patients were grouped into AIL grade II (AIL-II), whereas eight showed angiocentric lymphoma (AIL-III). All the patients' specimens exhibited lobular panniculitis. Infiltrating atypical lymphocytes in nine patients possessed electron-dense membrane bound granules in electron microscopy. Phenotypically, the lymphoid cells in the AIL-II patients were positive for CD3 epsilon; two of these showed a positive reaction to CD2, CD7, and CD8, but lacked natural killer-associated (NKa) antigens CD16, CD56, and CD57. In six AIL-III patients, lymphoma cells were positive for CD2 in all patients, CD56 in five, CD3 epsilon in four, CD7 in four, interleukin-2 beta receptor in four, a pore-forming protein in four, and CD30 in three patients. The remaining two AIL-III patients had B-cell lymphoma. By the Southern blot analysis, three patients with AIL-III showed a rearranged T-cell-receptor beta-gene or a deletion of its germline. The preceding results in nine of 11 patients suggest that abnormal or neoplastic large granular lymphocytes with the characteristics of T and NK cells have an important role in producing the angiocentric/angiodestructive features and lobular panniculitis. Clinically, all three patients with AIL-II and four with AIL-III showed liver dysfunction, cytopenia, and abnormal coagulopathy during the clinical course. Five patients with AIL-III died within 8 months. The histological grading of AIL, patients' age, and limited clinical stage of the disease seem to correlate with response to the treatment and prognosis.

Effect of 5-(p-hydroxyphenyl)-5-phenylhydantoin (p-HPPH) enantiomers, major metabolites of phenytoin, on the occurrence of chronic-gingival hyperplasia: in vivo and in vitro study

The purpose of this study was to assess the possible role of the (R)- and (S)- enantiomers of the phenytoin metabolite p-HPPH in the pathogenesis of gingival hyperplasia (GH). About 98% of circulating p-HPPH is in the (S)-form. There were significant differences between patients with and without GH in (R)-p-HPPH level (0.055 vs 0.042 microgram.ml-1), both enantiomer/racemate level ratios, and R/S enantiomeric ratio (0.0313 vs 0.0232); an increase in serum (R)-p-HPPH level was observed in patients with GH. In separate experiments, the effect of p-HPPH enantiomers on the proliferation of the normal human dermal fibroblast was studied. The in vitro study showed that (R)-p-HPPH selectively stimulated fibroblast growth. The results suggest that the least abundant metabolite, (R)-p-HPPH, is the most toxic with respect to gingival hyperplasia.

Increased serum level of interleukin-6 in patients with psoriatic arthritis and thrombocytosis

The role of elevations of serum cytokines in psoriasis is a provocative issue. We report two patients with psoriasis who had episodes of fever, arthritis, and general fatigue. Their symptoms seemed to be associated with increases in serum levels of interleukin (IL)-6, which paralleled the severity of clinical symptoms as well as elevated serum titers of C-reactive protein (CRP) and platelet counts. Since IL-6 is a multipotential cytokine with B-cell activating, T-cell activating, and thrombocytopoietic functions, the symptoms and abnormal laboratory findings in these patients may have been related to their increased serum levels of IL-6. Monitoring the serum level of this cytokine may thus be useful in evaluating the clinical status of patients with psoriatic arthritis.

Degree of ultraviolet-induced tortuosity of elastic fibers in rat skin is age dependent

To elucidate differential effects of ultraviolet (UV) exposure on three-dimensional networks of elastic fibers during maturation of rat skin, Sprague-Dawley rat hind limbs were irradiated with suberythemal doses of UV light (UVB, 130 mJ/cm2, or UVA, 27 J/cm2) in three different time courses of exposure: 3-9 weeks old, 9-15 weeks old, and 3-15 weeks old. Three-dimensional arrangement with special reference to linearity of elastic fibers was quantified by image analysis using a scanning electron microscope after a combination of intravascular resin injection and selective digestion technique using formic acid. Among the three irradiation groups, the group irradiated with UVB or UVA between 3 and 15 weeks old (UVB, three times per week; UVA, five times per week) elicited the most marked decrease in the linearity of elastic fibers. Despite the same irradiation period, there was a significant difference in the decreased linearity between the two irradiation groups of 3-9 and 9-15 weeks old, with the former irradiation group exhibiting greater loss of linearity than the latter irradiation group. The magnitude of the decreased linearity was greater in the UVB-exposed groups than in the UVA-exposed group. These findings indicate that the three-dimensional linearity of elastic fibers is more susceptible to disruption by UV exposures during the growth period than that after the growth period.

A simple method for measuring the amount of immunoglobulin A secreted onto the skin surface

We developed a simple method for measuring the amount of the secretory form of immunoglobulin A (sIgA) present in sweat. A small disk (10 x 10 mm) made of cellulose membrane was attached to the skin surface for periods of 1 to 24 h. SIgA was absorbed to the membrane and accumulated during the period of application. Enzyme immunoassay using anti-sIgA and antisecretory component (SC) antibodies revealed distinct dots on the disk that corresponded to the eccrine excretory ducts. A densitograph was used to determine the number and density of the dots, thus obtaining the amount of sIgA excreted to the surface of the skin (per mm2). The amount of skin sIgA excreted differed inter-individually as well as intra-individually. That is, it varied according to the region of the skin, and its distribution roughly reflected that of the sweat ducts. SIgA excretion was maintained at a certain level, regardless of the increased sweating produced by either heat or exercise, which raised the output of sweat 3- to 15-fold. Immunohistochemical studies revealed that fewer glandular cells expressed SC in their cytoplasm as the amount of sIgA decreased. Such an independence of the excretion of sIgA from that of sweat may be necessary to the local immune defenses of the skin.

Differential cell surface distribution of adhesion molecules demonstrated by immuno-scanning electron microscopy

Scanning electron microscopy with immuno-gold labeling revealed that epidermal keratinocytes expressed ICAM-1 and HLA-DR molecules on their surfaces in patterns that differed in mycosis fungoides (MF) and lichenoid reaction (LR). ICAM-1 molecules, visualized as deposits of gold particles, were present as clusters adjacent to the junctions interconnecting the keratinocytes of MF lesions. LFA-1 molecules were seen as granules on the surfaces of all infiltrates, most of which also expressed ICAM-1. HLA-DR molecules were seen continuously along the borders of the individual keratinocytes. In LR, ICAM-1 and HLA-DR were expressed only sparsely on the undersurface of the epidermis, whereas the infiltrates expressed LFA-1 molecules on their surfaces. These findings may explain the differing histological features of MF and LR: ICAM-1 molecules present on the intercellular junctions of MF epidermis lead the LFA-1-bearing cells to migrate into the interspaces of the keratinocytes, thus producing "epidermotropism". These cells aggregate by means of co-expressed ICAM-1 to thus produce the appearance of a "microabscess". In LR, on the other hand, the minimal expression of ICAM-1 on the epidermal undersurface leaves most infiltrates within the dermis, thus producing a "band-like infiltrate" beneath the epidermis.

Clinical and immunohistochemical studies of skin eruptions: relationship to administration of interferon-alpha

We observed transient, erythematous skin eruptions in 6 patients during the intravenous administration of interferon (INF)-alpha for chronic active hepatitis C. The eruptions appeared 5 to 14 days (mean: 6.8 days) after initiating its administration. They were localized or disseminated and consisted of edematous, erythematous, and/or papular changes. Vesicles and petechiae also appeared in some cases. The eruptions disappeared in 10 to 14 days, despite the continuance of INF-alpha and without specific treatment. Histological examination obtained from skin eruptions revealed perivascular infiltration of lymphoid cells, the majority which were CD4-positive, of the upper dermis. Edematous changes were present in the papillary dermis. Vascular endothelial cells in the upper dermis expressed both intercellular adhesion molecule-1 (ICAM-1) and endothelial leukocyte adhesion molecule-1 (ELAM-1), while the epidermal keratinocytes produced neither. These findings suggested a nonallergic mechanism for such eruptions.