A case of an inflammatory variant of epidermolysis bullosa acquisita: chronic bullous dermatosis associated with nonscarring mucosal blisters and circulating IgG anti-type-VII-collagen antibody

A 42-year-old man showed prominent blistering lesions of the mouth and esophagus in addition to a few bullous lesions of the skin. Direct immunofluorescence microscopy revealed distinct linear deposition of IgG and C3 at the epidermal basement membrane zone where slight deposition of IgA and IgM was also observed. In direct immunoelectron-microscopic examination, antibody was detected in the sublamina densa of the basement membrane zone. Immunoblot analysis with dermal extracts demonstrated that the patient's serum contained circulating IgG antibodies against the 290-kD protein, which comigrated with type VII collagen. The lesions healed without any scars. The results of these studies corresponded to the laboratory findings in epidermolysis bullosa acquisita (EBA), although the clinical features were distinct from classic EBA.

Sequential chemoimmunotherapy with cisplatin, interferon-beta and interleukin-2 inhibits the growth of B16-F1 melanoma in syngeneic mice

Sequential combinations of chemotherapy with biological response modifiers has recently been evaluated as systemic treatment for patients with advanced melanoma. The response rates of the chemoimmunotherapy were reported to be higher than conventional treatment using chemotherapy or biological agents alone. To investigate the effectiveness of such chemoimmunotherapy, we evaluated the antitumour effect of sequential chemoimmunotherapy in vivo using a B16 mouse melanoma system. In this sequential regimen, administration of cisplatin (CDDP) was followed by interferon-beta (IFNbeta) and interleukin-2 (IL-2). This combination therapy synergistically inhibited the growth of B16-F1 melanoma and prolonged the survival of mice bearing B16-F1. In contrast, this therapy did not show any antitumour effect on B16-F10 melanoma. The exact mechanism of the antitumour effect is not clear, but the following results were noted: no synergistic effect of this therapy was detected in nude mice, neutralizing anti-IFNgamma antibody significantly blocked the antitumour effect of this therapy, and the number of apoptotic melanoma cells was significantly increased in melanoma tissues removed from mice treated with this therapy. These results demonstrated the potent immunological antitumour effect of this sequential chemoimmunotherapy.

Kaposi's varicelliform eruption of an elderly patient with multiple myeloma

Kaposi's varicelliform eruption (KVE) is characterized by disseminated vesiculopustules and erosions due to a herpes virus infection superimposed on a preexisting dermatosis such as atopic dermatitis. However, the occurrence of KVE in patients with multiple myeloma seems to be very rare; to our knowledge, only one such case has been reported. This report documents a second case of KVE in a patient with multiple myeloma.

Solid facial edema in a patient with rosacea

We report a 53-year old man with symmetrical nonpitting edema, conjunctivitis, and acneiform eruptions on the face. Histopathological examination showed perifollicular lymphohistiocytic infiltration and telangiectasias in the upper dermis. Loosely aggregated non-caseating granulomas were scattered through the dermis; some of them were seen in the perifollicular regions. The patient was treated with fleroxacin (100 mg/day, orally) for two weeks with a marked reduction of both solid facial edema and periorbital edema.

The sera from GM1 ganglioside antibody positive patients with Guillain-Barré syndrome or chronic inflammatory demyelinating polyneuropathy blocks Na+ currents in rat single myelinated nerve fibers

OBJECTIVE

To determine the possible role of anti-GM1 ganglioside antisera from patients with Gullain-Barr*e syndrome (GBS) or chronic inflammatory demyelinating polyneuropathy (CIDP) in the development of nerve dysfunction.

METHODS

The effect of the anti-GM1 antibody positive antisera obtained from 4 GBS patients and 1 CIDP patient on membrane potential and ionic currents in rat single myelinated nerve fibers was investigated using the voltage clamp technique and compared with that of the anti-GM1 negative antisera obtained from 3 healthy controls and 2 GBS patients.

RESULTS

In the presence of active complement, anti-GM1 positive antisera from 5 patients including 4 GBS patients and 1 CIDP patient significantly suppressed Na+ current more than anti-GM1 negative antisera.

CONCLUSION

This study supports the notion that anti-GM1 antibody is one of the causative factors of conduction abnormality in GBS patients.

Increased synthesis of hyaluronate enhances motility of human melanoma cells

Hyaluronate plays a unique role in the cancer cell microenvironment. In particular, melanoma is the tumor type in which hyaluronate and hyaluronate recognition have been most closely linked to malignancy. In this study we show that a human melanoma cell line stably transfected with hyaluronate synthase cDNA displays enhanced motility. We used a fixed erythrocyte exclusion assay to isolate subsets of the WM793 human melanoma cell line that expressed either high or low amounts of hyaluronate. A cell line with a high level of hyaluronate on its surface (WM793H) displayed significantly higher cell motility on colloidal-gold-coated coverslips than did a line with a low level (WM793L). Next, in order to directly investigate the effects of hyaluronate on melanoma cell migration, we transfected cDNA encoding mouse hyaluronate synthase HAS1 or HAS2 into the re-cloned human melanoma cell line that produced a low amount of hyaluronate (WM793L) by the lipofection method. Several clonal transfectants differentially producing hyaluronate were obtained. There was a positive correlation between total hyaluronate synthesis and formation of the pericellular hyaluronate-rich matrix. We observed an increase in the migration ability of hyaluronate cDNA (HAS1 or HAS2)-transfected cells compared with control cells on glass plates covered with colloidal gold particles. A migration-inhibition assay with anti-CD44 monoclonal antibody showed blocking of the cell motility. It is speculated that the tumor cells might migrate through a hyaluronate-rich extracellular environment when they invade nearby host tissues and that hyaluronate production by the tumor cells could increase this migration. These results suggest that hyaluronate may play a role in the aggressiveness of human melanoma cells.

Long-term open-trial of mizoribine with prednisolone in 24 patients with multiple sclerosis: safety, clinical and magnetic resonance imaging outcome

OBJECT

Mizoribine (MZR), imidazole nucleotide, inhibits purine synthesis and helper T cell functions. It is used as an immunosuppressant in chronic rheumatic arthritis in Japan. Twenty-four patients with relapsing-remitting and chronic progressive multiple sclerosis (MS) were studied for the long-term effects of MZR over 8 years.

METHODS

Average daily MZR doses of 200 mg along with prednisolone (PSL) were administered in the patients studied. Ten of 24 patients were treated for more than 5 years.

RESULTS

The mean relapse rate per year at entry (1.50 +/- 0.24, mean +/- SE, n = 22) decreased [0.46 +/- 0.24 (n = 19)] after two years. In 70% of the patients, the disability did not worsen. Eleven of 18 patients showed a mild decrease of the total lesion size in magnetic resonance imaging (MRI).

CONCLUSION

MZR was well tolerated and could be used for long-term in MS as an adjunctive immunosuppressant to PSL, and the PSL doses could be decreased. A further randomized controlled trial with PSL is necessary.

Anti-GalNAc-GD1a antibody-associated Guillain-Barré syndrome with a predominantly distal weakness without cranial nerve impairment and sensory disturbance

The serum antibodies to N-acetylgalactosaminyl GD1a (GalNAc-GD1a) and other gangliosides as well as to Campylobacter jejuni were determined in 147 patients with Guillain-Barré syndrome (GBS). We found a distinctive clinical pattern in patients with anti-GalNAc-GD1a antibodies compared with those without the antibodies, that is, lack of cranial nerve involvement (87% versus 38%), distal-dominant weakness (80% versus 25%), and no sensory disturbance (73% versus 22%). The frequency of distal-dominant weakness was significantly higher in patients with both C. jejuni infection and anti-GalNAc-GD1a positivity (100%) than in C. jejuni-negative/anti-GalNAc-GD1a-positive (25%), C. jejuni-positive/anti-GalNAc-GD1a-negative (32%) and C. jejuni-negative/anti-GalNAc-GD1a-negative patients (20%). Lack of cranial nerve involvement and sensory disturbance were found in most C. jejuni-positive/anti-GalNAc-GD1a-positive and C. jejuni-negative/anti-GalNAc-GD1a-positive patients, but not in C. jejuni-positive/anti-GalNAc-GD1a-negative and C. jejuni-negative/anti-GalNAc-GD1a-negative patients. Although the anti-GM1-positive/anti-GalNAc-GD1a-negative patients mostly (75%) lacked cranial nerve involvement, distal-dominant weakness (38%) and lack of sensory disturbance (13%) were infrequent. These results may indicate that (1) the combination of C. jejuni infection and anti-GalNAc-GD1a antibodies, but not anti-GalNAc-GD1a, anti-GM1, or C. jejuni infection alone, is associated with a predominantly distal weakness, (2) the presence of anti-GalNAc-GD1a, rather than C. jejuni infection or anti-GM1 antibody, is associated with a lack of sensory disturbance, (3) both anti-GalNAc-GD1a and anti-GM1 antibodies are independently associated with a lack of cranial nerve impairment.

Identification and characterization of human herpesvirus 8 open reading frame K9 viral interferon regulatory factor by a monoclonal antibody

OBJECTIVE

To identify and characterize an open reading frame (ORF) in association with its mRNA and a coding protein recognized by anti-human herpesvirus 8 (HHV-8) monoclonal antibody B291.

STUDY DESIGN/METHODS

The antigen detected by B291 was characterized by immunofluorescence method, Western blot analysis, laser confocal microscopy, and immunohistology cDNA of the protein was identified by immunoscreening the HHV-8 cDNA library with B291 and sequenced. Structure and kinetics of the mRNA expression was investigated by 5',3' rapid amplification of cDNA ends (RACE) and Northern blot analysis.

RESULTS

Viral interferon regulatory factor (vIRF; approximately 50 kd) was a protein recognized by B291. It was detected in 12-O-tetradecanoyl phorbol-13 acetate (TPA)-induced, but not uninduced, HHV-8-infected cell lines (BCBL-1 and BCP-1) and the tumor cells obtained from a SCID mouse injected with uninduced BCBL-1. The expression of vIRF was predominantly in the nucleus and was partially diminished by phosphonoformic acid (PFA) treatment, whereas the mRNA (approximately 2.4 kb) was accumulated.

CONCLUSIONS

vIRF is an early protein expressed in the nucleus and may be involved in Kaposi's sarcoma tumor formation.

[The clinical usefulness of high-dose intravenous immunoglobulin therapy for chronic inflammatory demyelinating polyneuropathy and multifocal motor neuropathy]

To explore the optimum dose of intravenous immunoglobulin (i.v.Ig) for treating patients with chronic inflammatory demyelinating polyrneuropathy and multifocal motor neuropathy, we compared the usefulness of i.v.Ig among 3 treatment doses. Fifty-nine patients were randomly divided into three treatment dosage groups: 20 patients for Group I using 50 mg/kg/day x 5 days, 19 patients Group II using 200 mg/kg/day x 5 days, and 20 patients Group III using 400 mg/kg/day x 5 days. We assessed clinically and electrophysiologically the effectiveness of the treatment at 5 weeks after the initial infusion. For patients in Group I and II who had not improved (or worsened) with the first treatment, we gave a one-step larger dose in the second treatment (i.e. 200 mg/kg/day x 5 days for those who had been given 50 mg/kg/day x 5 days, 400 mg/kg/day x 5 days for those who had been given 200 mg/kg/day x 5 days) after more than 9 weeks. We found that 15% of the patients in Group I, 21% in Group II and 60% in Group III improved dose-dependently with the first intravenous immunoglobulin treatment. Seven (47%) of 16 patients in Group I and 4 (40%) of 11 patients in Group II improved after the second treatment with larger doses. Adverse reactions including chill sensation, fever, skin eruption and increase in blood GOT and GPT levels were transient and mild. One patient in Group III developed left hemiparesis showing the small infarction in the right thalamus during the course of the treatment, but the symptom was mild. In conclusion, the high-dose intravenous immunoglobulin therapy (400 mg/kg/day x 5 days) is useful for treating patients with CIDP and MMN, although care must be taken of the risk of causing cerebral infarctions.

[Magnetic resonance imaging in multiple sclerosis]

Useful characteristics of MRI finding of multiple sclerosis (MS) include the distribution of lesions such as a strictly periventricular, infratentorial, or juxtacortical location, involvement of the corpus callosum and the presence of ovoid lesions with long axis directed to lateral ventricles. Our MRI-diagnostic criteria improved the sensitivity and specificity and is clinically useful. New sequences, such as fast spin echo, turbo spin echo or fluid attenuated inversion recovery have improved the detection of lesions. The presence of contrast enhancement in some but not all lesions--that is, evidence of both old and new lesions--provides additional diagnostic support. Enhanced lesions with more than 1 cm diameter often become ring-shaped. Strong correlations were found between the number and volume of enhancing lesions with changes of T 2 and magnetization transfer (MT) lesion loads in patients with secondary progressive MS. The degree of hypointensity of so called black holes on moderately T1-weighted spin echo images correlates with loss of magnetisation transfer, a marker of destruction of matrix and axon, and shows correlation with disability. One of spectroscopic indices of axonal loss is N-acetylaspartate. Atrophy is a process closely linked with the progressive phase of MS and worsening disability. Detection of the reduction in cord cross-sectional area or spinal cord atrophy over time makes an important contribution to the evaluation of therapeutic efficacy, especially in primary progressive disease.

HLA-DRB1 and tumor necrosis factor gene polymorphisms in Japanese patients with multiple sclerosis

We studied genetic polymorphisms in the tumor necrosis factor (TNF) region as well as HLA-DRB1 of 42 patients with Western-type multiple sclerosis (MS) and 38 with Asian-type MS in Japan. The sex ratio (Female:Male) was significantly higher in Asian than in Western type MS (3.8 vs. 1.3, P = 0.038). The frequency of HLA-DRB1 * 1501 allele in the Western-type MS group increased significantly compared with the control group, while Asian-type MS and control groups showed similar distribution in the frequencies of HLA-DRB1 alleles. No significant differences existed in the TNF region, however, including TNF-a microsatellite alleles. The results suggest that MS in Asians may present two different clinical and immunogenetic manifestations.

Genetic contribution of the tumor necrosis factor region in Guillain-Barré syndrome

We studied genetic polymorphisms in the tumor necrosis factor (TNF) region in 81 Japanese patients with Guillain-Barré syndrome (GBS) and 85 controls. A significantly higher frequency of the 100-base pair (bp) (TNFa2) allele of the TNFa microsatellite marker, which is associated with high TNF alpha production, existed in Campylobacter jejuni-positive (Cj+) GBS patients than in controls, suggesting the involvement of a genetic predisposition to high TNF alpha secretion in the development of C. jejuni-related GBS.

The 97 kDa linear IgA bullous dermatosis antigen is not expressed in a patient with generalized atrophic benign epidermolysis bullosa with a novel homozygous G258X mutation in COL17A1

The nature and expression pattern of the 97 kDa linear IgA bullous dermatosis antigen (LAD-1) and its role in epidermolysis bullosa have not been fully elucidated. In this study, we examined the expression of LAD-1 in the skin specimens of 70 patients with the various subtypes of epidermolysis bullosa, including simplex (n = 23), junctional (n = 15), and dystrophic variants (n = 32). For immunolabeling, we used two recently developed monoclonal antibodies to LAD-1 whose epitopes were ultrastructurally localized in the lamina lucida between NC16A and carboxyterminal domains of BPAG2, as well as autoantibodies against LAD-1 from the sera of two patients with linear IgA dermatosis. Among the 70 patients, only one patient with generalized atrophic benign epidermolysis bullosa failed to demonstrate LAD-1 expression. Although other major basement membrane components, including laminin 5, BPAG1, plectin, alpha6 and beta4 integrins, as well as type IV and type VII collagens were normally expressed, BPAG2/type XVII collagen was absent from the skin of this patient. Mutation analysis on COL17A1 using polymerase chain reaction amplification, heteroduplex scanning, and direct nucleotide sequencing revealed that this patient was homozygous for a novel nonsense mutation G258X in exon 11, and her parents were heterozygous carriers for this mutation. This is the first mutation located in the intracellular domain of BPAG2, and resides 817 bp upstream from the N-terminal amino acid sequence of LAD-1. These findings indicate that the absent expression of LAD-1 is observed in a BPAG2-deficient generalized atrophic benign epidermolysis bullosa patient with mutations in both alleles of COL17A1, and not in other epidermolysis bullosa subtypes. These findings also support the notion that LAD-1 is a degradation product of BPAG2.

HLA and T-cell receptor gene polymorphisms in Guillain-Barré syndrome

OBJECTIVE

We examined a possible involvement of genetic factors influencing the development of Guillain-Barré syndrome (GBS).

METHODS

We studied T-cell receptor (TCR), alpha-chain constant (AC), and beta-chain variable (BV) gene polymorphisms using microsatellite markers and serologic HLA class I antigens, HLA-DRB1, and HLA-DQB1 alleles in 81 Japanese patients with GBS and 87 controls.

RESULTS

There were no significant differences in these genetic markers between GBS patients and controls. Subgrouping of GBS patients according to recent Campylobacter jejuni infection, the presence of anti-GM1 antibody in the sera, or their combinations also failed to reveal significant associations with these genetic markers. There was, however, a tendency for an increased frequency of HLA-DRB1*0803 in the C. jejuni + GM1 + GBS group, when compared with controls.

CONCLUSIONS

The data suggest that the roles of TCRAC, T-cell receptor beta-chain variable (TCRBV), HLA class I or class II in the development of GBS are not critical, and further research is necessary to clarify other genes encoded within the HLA region for genetic susceptibility to GBS.

Expression of moesin and its associated molecule CD44 in epithelial skin tumors

Moesin, one of the ERM (ezrin; radixin; moesin) family members, is directly associated with the cytoplasmic domain of CD44, which is now thought to be related to the metastatic potential of tumor cells. Using immunohistochemistry we investigated the expression of moesin in normal epidermis and various kinds of epithelial skin tumors: squamous cell carcinoma, verrucous carcinoma, Bowen's disease, solar keratosis, keratoacanthoma, basal cell carcinoma, and extramammary Paget's disease. Normal skin showed positive epidermal staining for moesin with the exception of the stratum corneum. The expression of moesin varied with the type of skin tumor. In basal cell carcinoma, Bowen's disease, and extramammary Paget's disease, moesin expression was either faint or negative. In contrast to Bowen's disease, invasive squamous cell carcinoma showed more intense and heterogeneous staining of the cytoplasm and the cell membrane. Verrucous carcinoma was weakly positive, with a tendency for the moesin to be distributed in the cell membrane. The staining pattern of moesin varied among the different kinds of epithelial skin tumors, and its expression was generally similar to that of the standard form of CD44. These results suggest that moesin is closely inter-related with CD44 in epithelial skin cells as seen in other cellular systems, and that the variable pattern of moesin staining among the skin tumor cells could reflect expression disorders associated with the transformation.

Moesin and CD44 expression in cutaneous melanocytic tumours

The ERM (ezrin, radixin and moesin) family members, located just beneath the plasma membranes, are thought to be involved in the association of action filaments with the plasma membrane. One of the family members, moesin, is reported to bind to CD44. Splice variants of CD44 are thought to be associated with tumour progression or differentiation. Our aim was to investigate immunohistochemically the expression of moesin together with CD44 on paraffin tissue sections of a series of melanocytic tumours. The material included 12 ordinary melanocytic naevi, six Spitz naevi, eight dysplastic naevi, six blue naevi, seven malignant melanomas in situ, 15 primary malignant melanomas, five metastatic melanomas to the skin and five lymph node metastases. In the normal skin and the melanocytic tumours the expression of moesin was largely similar to that of CD44 standard. Strong moesin staining was observed in benign melanocytic lesions and melanomas in situ. However, the expression was decreased in advanced malignant melanomas. The moesin labelling in melanoma cells was downregulated with the depth of dermal invasion. The immunoreactivity was also diminished in the skin metastases and the lymph node metastases of melanoma. These results suggest that in melanocytic tumours, the alternation in the expression of moesin may be involved in the progression of malignancy.

Characteristic epiluminescent microscopic features of early malignant melanoma on glabrous skin. A videomicroscopic analysis

OBJECTIVE

To investigate the characteristic epiluminescent microscopic features of early lesions of malignant melanoma affecting glabrous skin, which is the most prevalent site of the neoplasm in nonwhite populations.

DESIGN

The epiluminescent microscopic features of various kinds of melanocytic lesions affecting glabrous skin were investigated using a videomicroscope. All the diagnoses were determined clinically and histopathologically using the standard criteria.

SETTING

A dermatology clinic at a university hospital.

PATIENTS

The following 130 melanocytic lesions consecutively diagnosed at our department were examined: 16 lesions of acral lentiginous melanoma, 6 lesions of malignant melanoma in situ, and 108 lesions of benign melanocytic nevus (acquired or congenital).

MAIN OUTCOME MEASURE

The incidence of each characteristic epiluminescent feature was compared among disease categories.

RESULTS

On epiluminescent microscopy, malignant melanoma in situ and the macular portions of invasive malignant melanoma showed accentuated pigmentation on the ridges of the skin markings, which are arranged in parallel patterns on glabrous skin. This "parallel ridge pattern" was found in 5 (83%) of 6 lesions of malignant melanoma in situ and in 15 (94%) of 16 lesions of malignant melanoma. The parallel ridge pattern was rarely found in the lesions of benign melanocytic nevus. Most benign melanocytic nevi showed 1 of the following 3 typical epiluminescent patterns: (1) a parallel furrow pattern exhibiting pigmentation on the parallel sulci of [he skin markings (54%), (2) a latticelike pattern (21%), and (3) a fibrillar pattern showing filamentous or meshlike pigmentation (15%). The remaining 11 benign nevi (10%) showed a nontypical pattern.

CONCLUSION

Because epiluminescent microscopic features of early malignant melanoma on glabrous skin are characteristic, we can effectively detect early lesions using this noninvasive method.

Antibodies to gangliosides and galactocerebroside in patients with Guillain-Barré syndrome with preceding Campylobacter jejuni and other identified infections

The relationship between preceding infections and antibodies to glycolipids was investigated in 205 Japanese patients with Guillain-Barré syndrome (GBS). Serological evidence of recent Campylobacter jejuni (C. jejuni) infection was found in 45% of the patients, compared with 1% in healthy controls. In contrast, recent infection of cytomegalovirus (CMV), Mycoplasma pneumoniae (M. pneumoniae) and Epstein-Barr virus (EBV) was detected in only 5%, 2% and none of the patients, respectively. C. jejuni-associated GBS was more frequent in early spring than in other seasons. All stool specimens positive for C. jejuni isolation were obtained within 10 days after the onset of GBS symptoms. Of 13 C. jejuni isolates from GBS patients, 10 (77%) belonged to Penner serotype 19 (heat-stable, HS-19). Elevated titers of anti-GM1 antibody were found in 8 (80%) of 10 GBS patients whose C. jejuni isolates belonged to HS-19 and in none of those infected with non-HS-19 C. jejuni (P = 0.04), and in 49% of 92 patients with C. jejuni infection and 25% of patients without infection of C. jejuni, CMV, EBV, or M. pneumoniae (P = 0.0007). The frequencies of elevated antibody titers to GD1a, GD1b and GQ1b were also significantly higher in GBS patients associated with C. jejuni than those not associated with C. jejuni, CMV, EBV, and M. pneumoniae. GBS in Japan seems to be associated more frequently with C. jejuni and less frequently with CMV than in Europe and North America.

Characteristic magnetic resonance imaging findings in Machado-Joseph disease

OBJECTIVE

To clarify the characteristic magnetic resonance imaging (MRI) findings in patients with Machado-Joseph disease (MJD) diagnosed by genetic analysis.

PATIENTS AND METHODS

Using MRI, we examined 31 patients genetically diagnosed as having MJD, 20 patients with sporadic olivopontocerebellar atrophy, and 26 control subjects.

RESULTS

The MRIs of patients with MJD disclosed remarkably reduced width of the superior cerebellar peduncles, atrophy in the frontal and temporal lobes, diminished transverse diameter of the globus pallidus, and decreased anteroposterior and transverse diameters of the pons, which correlated with the width of the middle cerebellar peduncle. The width of the superior cerebellar peduncles also correlated with the diameter of the dentate or red nucleus in patients with MJD, but not in controls or in patients with sporadic olivopontocerebellar atrophy. On T2- and/or proton-weighted axial MR imaging, a high signal intensity in the transverse pontine fibers was observed in 14 (45.2%) of 31 patients with MJD and in all patients with sporadic olivopontocerebellar atrophy, but not in any controls.

CONCLUSION

Affected afferent and efferent cerebellar tracts and atrophy of the frontal and temporal lobes and globus pallidus are characteristics of MRI of patients with MJD.

Characterization of Campylobacter jejuni isolates from patients with Guillain-Barré syndrome

Campylobacter jejuni is a major pathogen preceding Guillain-Barré syndrome (GBS), and most C. jejuni isolates from GBS patients belong to Penner serotype 19 (heat-stable; HS-19). We analyzed sixteen independent clinical isolates from GBS patients, twelve of which belonged to HS-19, three to HS-2, and one to HS-4, using PCR-based RFLP analysis of a flagellin-A (flaA) gene. Two isolates from patients with Miller Fisher syndrome (MFS), and 27 from patients with uncomplicated enteritis were also examined. All HS-19 isolates, regardless of GBS, showed an identical pattern (Cj-1) by RFLP typing and were distinguishable from those of the other Penner serogroups. In contrast, HS-2 and HS-4 isolates were divided into several different RFLP groups, suggesting HS-19 strains are genetically distinctive among C. jejuni isolates. A DNA fingerprinting method also failed to detect any specific band pattern for GBS-related C. jejuni isolates. We examined relationships among anti-GM1 antibody titres in the sera of GBS patients, clinical forms of GBS, serotype of C. jejuni, and the presence of GM1-like structures in lipopolysaccharide (LPS) components from C. jejuni isolates by immunoblotting. HS-19 related GBS was significantly associated with elevated anti-GM1 antibody titers in the sera of the patients, but not associated with any clinical pattern of GBS. No significant correlations were found between anti-GM1 antibody and the pattern of disease, or between GBS-related C. jejuni strains and the presence of GM1-like structures. HS-19 strains seem to be unique among C. jejuni isolates, and HS-19-related GBS may provide an excellent model for clarification of the pathogenesis of GBS.

Campylobacter jejuni isolates from Japanese patients with Guillain-Barré syndrome

Serologic evidence of recent Campylobacter jejuni infection was found in 92 (45%) of 205 Japanese patients with Guillain-Barré syndrome (GBS), and 49% of those 92 patients also had antibodies to GM1. Sixteen independent clinical isolates from GBS patients were serotyped: 12 belonged to Penner's heat-stable (HS) O serotype HS-19, 3 to HS-2, and 1 to HS-4. Of the patients whose C. jejuni isolates belonged to HS-19, 80% had elevated anti-GM1 antibodies. Although the correlation was significant between C. jejuni and GM1 antibody, anti-GM1 also was detected in 25% of patients without C. jejuni infection. Polymerase chain reaction-based restriction fragment length polymorphism analysis of an flaA gene showed that all HS-19 isolates, regardless of a GBS association, had an identical and distinguishable pattern, Cj-1, suggesting that HS-19:Cj-1 isolates are distinctive among C. jejuni isolates. Lectin typing showed that all GBS-associated HS-19 isolates contained terminal beta-N-acetylglucosamine residues on their cell surface, but HS-19 isolates from patients with enteritis did not.

The physiological effect of anti-GM1 antibodies on saltatory conduction and transmembrane currents in single motor axons

Anti-ganglioside (anti-GM1) antibodies have been implicated in the pathogenesis of Guillain-Barré syndrome, multifocal motor neuropathy and motor neuron diseases. It has been held that they may interfere with saltatory conduction by blocking sodium channels. We tested this hypothesis by analysing action potentials from 140 single nerve fibres in 22 rat ventral roots using external longitudinal current measurement. High-titre anti-GM1 sera from Guillain-Barré syndrome or multifocal motor neuropathy patients, or anti-GM1 rabbit sera were applied to the rat ventral root, where saltatory conduction in single motor fibres was serially observed for 4-12 h (mean 8.2 h). For control experiments, we also tested anti-galactocerebroside (anti-GalC) sera, which causes acute demyelinative conduction block, and tetrodotoxin (TTX), a sodium channel blocker. Conduction block was found in 82% of the fibres treated with anti-GalC sera and 100% treated with TTX, but only in 2% (one out of 44) treated with the patients' sera and 5% (two out of 38) treated with rabbit anti-GM1 sera. All the nodes blocked by anti-GM1 sera revealed intense passive outward membrane current, in the internode just beyond the last active node. This pattern of current flow was similar to that in fibres blocked by demyelination with anti-GalC sera, and quite different from that seen in fibres blocked by reducing sodium currents with TTX. Our findings suggest that anti-GM1 sera neither mediate conduction block nor block sodium channels on their own. We conclude that physiological action of the antibody alone is insufficient to explain clinically observed conduction block in human diseases.

CAG repeat length and disease duration in Machado-Joseph disease: a new clinical classification

To evaluate the clinical characteristics of Machado-Joseph disease (MJD) with reference to CAG repeat length and disease duration, we analyzed neurologic findings in 108 patients from 84 families. The majority of MJD patients presented with an ataxic gait as the initial symptom. Dysarthria and nystagmus were observed from an early stage. Bulging eyes, muscle atrophy and bradykinesia developed later. Patients with a shorter CAG repeat length or later onset had more frequent involvement of proprioceptive sensory deficit. Incidence of abnormal reflexes, tones, and proprioceptive sensation was not associated with disease duration, but with CAG repeat length. Based on these results, we propose a new clinical classification: type A (juvenile type), with hyperreflexia and dystonia, but without a proprioceptive sensory deficit; type C (adult type), with hyporeflexia and a proprioceptive sensory deficit, but without dystonia; and type B (intermediate type), the remaining patients with a mixed presentation.

Central nervous system lesions in rats infected with Friend murine leukemia virus-related PVC441: ultrastructural and immunohistochemical studies

Newborn F344 rats were injected intraperitoneally with PVC441 virus, a neuropathogenic variant of Friend murine leukemia virus, and developed paraparesis of hind limbs 35-40 days after infection. Immunohistochemical study using monoclonal anti-PVC441 antibody revealed that in the central nervous system endothelial cells but not neuronal or glial cells were infected with PVC441 virus. The major pathological changes were myelin vacuolation and oligodendrocyte degeneration in the white matter at the white-gray border zone. Anterior and lateral funiculi and intercalated myelin of anterior horns were dominantly affected in the spinal cord from the sacral to cervical level. The midbrain was also vacuolated. An ultrastructural study demonstrated that many viral particles were present outside the endothelial cells but only sparsely inside endothelial cells and pericytes. Endothelial cell membranes and tight junctions were also disrupted. Immunohistochemical studies with antibodies against major histo-compatibility complex class Ia, intercellular adhesion molecule-I, glial fibrillary acidic protein, neurofilament protein, CD3 and OX42 revealed the presence of abundant microglia but not of lymphocytes or polymorphonuclear cells in the lesions. Axonal degeneration and astrogliosis were mild in degree. These pathological changes explain the observed spastic paraparesis in the rats, and represent a good model of spongiform diseases of the human central nervous system of retroviral origin, such as human T cell leukemia virus-associated myelopathy and AIDS.

New immunodeficient (nude-scid, beige-scid) mice as excellent recipients of human skin grafts containing intraepidermal neoplasms

Engraftment of normal or lesional human skin onto nude or SCID (severe combined immunodeficiency) mice has been used as an in vivo experimental model. However, this model has some limitations, such as shrinkage and loss of the grafted skin over time. To improve the experimental model, we have produced two new SCID-lineage mouse strains, BALB/cA-nude-scid (nu/nu, scid/scid) and BALB/cA-beige-scid (bg/bg, scid/scid) mice, by the method of cross intercross. Intraepidermal neoplastic lesions such as Bowen's disease were grafted onto the back of the mice of these strains. The rate of reduction in the size of the grafts was lower on nude-scid and beige-scid mice than on SCID mice. Rates of survival of neoplastic cells in the grafts were higher in nude-scid mice than in SCID and beige-scid mice (SCID mice 38%, nude-scid mice 55%, beige-scid mice 38%). Neoplastic cells of Bowen's disease grafted onto a beige-scid mouse proliferated and invaded the dermis during 233 days of observation, confirming the progression to invasive squamous cell carcinoma from carcinoma in situ. The present study revealed that nude-scid and beige-scide mice newly produced by us provide a very useful in vivo experimental model for the investigation of carcinogenesis and tumor progression in human skin.

[Treatment of malignant melanoma: recent advances and perspectives]

Because malignant melanoma is a highly malignant neoplasm, correct diagnosis and appropriate treatment are essential to improve the prognosis. In the present paper the author summarizes the advancements in the therapy of malignant melanoma, reviewing papers recently published in this field. It is noteworthy that a narrow excision margin has been recommended even for the surgery of this neoplasm. This narrow margin has been approved by the prospective randomized trial performed by the WHO melanoma study group. The study group also confirmed that elective lymph node dissection is not significant in the improvement of the prognosis, when compared to the delayed lymph node dissection. Considering these findings, the author proposes a revised guideline for the treatment of malignant melanoma according to UICC stages. A brief comment is made on a new drug, fotemustine, that has an effect on brain metastases. In addition, high response rates obtained by the Dartmouth regimen (BCDT regimen), including tamoxifen, an estrogen antagonist, are reported. "Sequential" biochemoimmunotherapy based on a new concept of rational combination of chemotherapeutic and biologic agents seems highly effective against metastatic melanoma, showing more than 50% response rates. In the regimens, chemotherapy including CDDP is followed by administration of the cytokines, IL-2 and IFN-alpha. These regimens possibly induce specific and/or non-specific immune reactions against melanoma cells, which may contribute to the high response rates.

PCR-based restriction fragment length polymorphism (RFLP) analysis and serotyping of Campylobacter jejuni isolates from diarrheic patients in China and Japan

A molecular typing approach for Campylobacter jejuni was applied with restriction fragment length polymorphism (RFLP) analysis of a 702-bp PCR-amplified portion of the flagellin-A (flaA) gene. We analyzed a total of 179 strains, including 69 independent clinical isolates from diarrheic patients in Japan, 85 isolates in China, and 25 heat-stable (HS) serotype strains by Penner and Hennessy (1980) J. Clin. Microbiol. 12, 732-737). Six AfaI, seven MboI, and five HaeIII RFLPs were found in the 702-bp flaA segment from the 179 strains. Using a combination of these three enzymes, 25 separate RFLP groups were recognized. While 59 of 154 (38.3%) strains obtained in Japan and China were nontypeable by the HS antigenic scheme, all but two of 154 (98.7%) could be typed by RFLP typing. All 11 isolates of HS-19 strains, which are frequently isolated from Guillain-Barré syndrome (GBS) patients, showed an identical RFLP pattern (Cj-1), and Cj-1 consisted only of HS-19 strains. This suggests that the HS-19:Cj-1 strain is distinct among C. jejuni strains. This molecular typing method provides a rapid and reliable typing scheme for epidemiological studies of C. jejuni, and may also be useful for the analysis of C. jejuni subtypes from GBS patients.

Post-infectious encephalitis with anti-galactocerebroside antibody subsequent to Mycoplasma pneumoniae infection

Galactocerebroside (Gc) is a major component of myelin in both the peripheral and central nervous systems. Although it is regarded as an important glycolipid hapten of myelin in rabbit experimental allergic neuritis (EAN), its role in human demyelinating diseases is not known. We studied three post-infectious encephalitis (PIE) patients related to Mycoplasma pneumoniae infection. All three of three patients with encephalitis and M. pneumoniae infection were positive for Gc antibodies (100%), while 25% of 32 M. pneumoniae-infected patients without neurological disease were positive, and 3.8% of 52 healthy controls. This indicates anti-Gc antibody is induced by M. pneumoniae infection. One of the PIE patients, who had extraordinary high titer antibody to Gc, showed an extensive, diffuse white matter demyelination and poor recovery. Since circulating anti-Gc antibody induces central nervous system demyelination in animals with elevated antibody titers and disruption of the blood-brain barrier, anti-Gc antibody may have an important function in the increased demyelination in PIE patients after M. pneumoniae infection.

Primary malignant melanoma of the rectum

We present a case of primary malignant melanoma arising in the rectum of a 71-year-old woman who had presented with intermittent rectal bleeding following bowel movement 2 months previously. Digital and sigmoidoscopic examination of the rectum revealed a 3 x 2 x 1 cm exophytic tumor with a granular surface in the rectum 35 mm from the dentate line. No increased pigmentation was detected. Biopsy revealed degenerated mucosa accompanied by severe infiltration of inflammatory cells, but no malignant cells. The tumor and normal mucosa surrounding the tumor was excised 12 days after the biopsy. Light microscopy revealed the tumor to consist of malignant melanocytes and showed that the tumor was surrounded by normal mucosa. Immunohistochemical staining with antimelanoma antibody and HMB-45 substuntiated the diagnosis. Clinical and laboratory examination excluded the presence of melanoma at sites other than rectum. The patient refused an abdomino-perineal resection of the rectum and combination chemotherapy was performed. She died 18 months after the initial operation due to local recurrences and metastases to pelvic lymph nodes, liver, and lung.

Dual recognition of a human cytotoxic T-cell clone for melanoma antigens

It is well known that tumor-specific CTLs have a crucial role in the elimination of tumors and that different CTL populations recognize tumor antigens in MHC-restricted and MHC-unrestricted manners. We have established two alpha beta CTL clones that recognize melanoma antigens in both human lymphocyte antigen (HLA)-A2-restricted and HLA-unrestricted manners. Flow cytometry analysis showed that these CTL clones carry CD3, CD8, and alpha beta T-cell receptor (TCR) and express low levels of CD56. In contrast, these CTL clones do not express CD16, indicating that they do not contain natural killer cells. TCR analysis of these CTL clones using an anchored PCR method revealed that each clone carries a single alpha beta TCR. Both CTL clones contained the same Valpha and Vbeta gene segments although they carried different Jalpha and Jbeta gene segments. Taken together, these results confirm that CTL clones that carry a single alpha beta TCR recognize melanoma antigens in both HLA-A2-restricted and HLA-unrestricted manners. It is strongly suggested that the dual recognition of these CTL clones for the melanoma antigens is mediated by TCRs. The novel mechanism for antitumor immunity by these CTLs may be important in the effective elimination of tumors in vivo.

Cloning and expression of a rat brain basic helix-loop-helix factor

We cloned two rat cDNAs of brain basic helix-loop-helix factor 1 (BHF1). These have an identical coding region, contain 357 amino acids and exhibit 94.6% identity to MATH-2/NEX1 in the basic helix-loop-helix region. BHF1mRNAs are dominantly expressed in the brain particularly in the cerebellum, in the adult bovine, rat and mouse. Two shorter BHF1mRNAs (1.6 kb and 1.8 kb) were also detected in the mouse embryo, and these decreased in the developmental process. These results suggest that BHF1 may play important roles in cerebellum-specific functions and development of neurons.

Human T Lymphotropic Virus Type I (Htlv-I)-Specific T Helper Cell Responses from Htlv-I Seronegative Patients with Chronic Myelopathy and Ms in Japan

Human T lymphotropic virus type I (HTLV-I) is a human retrovirus etiologically linked to Adult T cell leukemia (ATL) and HTLV-I associated myelopathyltropical spastic paraparesis (HAM/TSP). Although most HAM/TSP patients have high anti-HTLV-I antibody titers in their sera, HTLV-I infected but seronegative patients with neurological diseases have been reported. To clarify whether seronegative, HTLV-I related neurological disease may exist, we have developed a method that measures the production of interleukin-2 (IL-2) from HTLV-I synthetic peptide-stimulated peripheral blood lymphocytes (PBL) of HTLV-I infected persons. This method is sensitive enough to detect exposure to HTLV-I before seroconversion or even before detection by PCR. We examined 12 patients with chronic progressive myelopathy and eight patients with multiple sclerosis (MS) in central Japan, where the prevalence rate of HTLV-I is between one and four percent among asymptomatic blood donors, using the IL-2 production assay. None of them were positive by the assay, suggesting seronegative HTLV-I myelopathy is very rare among patients with chronic progressive myelopathy and MS in Japan.

Human T lymphotropic virus type I (HTLV-I)-specific T helper cell responses from HTLV-I seronegative patients with chronic myelopathy and MS in Japan

Human T lymphotropic virus type I (HTLV-I) is a human retrovirus etiologically linked to Adult T cell leukemia (ATL) and HTLV-I associated myelopathy/tropical spastic paraparesis (HAM/TSP). Although most HAM/TSP patients have high anti-HTLV-I antibody titers in their sera, HTLV-I infected but seronegative patients with neurological diseases have been reported. To clarify whether seronegative, HTLV-I related neurological disease may exist, we have developed a method that measures the production of interleukin-2 (IL-2) from HTLV-I synthetic peptide-stimulated peripheral blood lymphocytes (PBL) of HTLV-I infected persons. This method is sensitive enough to detect exposure to HTLV-I before seroconversion or even before detection by PCR. We examined 12 patients with chronic progressive myelopathy and eight patients with multiple sclerosis (MS) in central Japan, where the prevalence rate of HTLV-I is between one and four percent among asymptomatic blood donors, using the IL-2 production assay. None of them were positive by the assay, suggesting seronegative HTLV-I myelopathy is very rare among patients with chronic progressive myelopathy and MS in Japan.

Immunohistochemical detection of CDK4 and p16INK4 proteins in cutaneous malignant melanoma

p16INK4 gene, which encodes a specific inhibitor of cyclin-dependent kinase 4 (CDK4), has been recently reported as an important tumour suppressor gene. It is mapped to chromosome 9p21, which is frequently deleted or mutated in many tumour cell lines including malignant melanoma. Since the CDK4/cyclin D complex propels a cell to go through the G1 check point of the cell cycle, a critical phase of cell division, alteration of the p16INK4 gene could lead a cell to uncontrolled proliferation and malignant transformation. To clarify any role for p16INK4 and CDK4 proteins in the development of human malignant melanoma, we have examined, immunohistochemically, the expression of these two proteins in melanocytic neoplasms including 19 primary lesions of non-familial melanoma. Intense nuclear and/or cytoplasmic expression of the CDK4 protein was observed in 11 of 19 cases (58%) of melanoma. In contrast, virtually no nuclear or cytoplasmic staining for CDK4 protein was detected in 28 benign melanocytic naevi, including six Spitz naevi. Expression of p16INK4 protein was observed in three of 19 melanomas (16%) and in 17 of 28 benign naevi (61%). Inverse expression of CDK4 and p16INK4, at individual cell level, was detected in one case of melanoma. The present study suggests that CDK4 overexpression is characteristic for malignant melanoma, and probably reflects its autonomous accelerated cell proliferation. The expression rate of p16INK4 protein in malignant melanoma was lower than that in benign naevi, although the significance of p16INK4 deletion in melanoma development has not been definitely confirmed.

Squamous cell carcinoma arising in a verrucous epidermal nevus

A 74-year-old Japanese male patient with squamous cell carcinoma arising in an epidermal nevus is described. The patient had widespread warty lesions involving large parts of the body since infancy. Recently, a nodular lesion appeared on the middle part of his back and increased in size. Histologically, the nodule was diagnosed as squamous cell carcinoma and the warty lesion showed the features of epidermal nevus. The nodular lesion was totally excised and the skin defect was covered with split-thickness skin grafting. To the best of our knowledge, this is the 16th patient with malignant change of a verrucous epidermal nevus.

[Immunotherapy of multiple sclerosis: the use of magnetic resonance imaging in the evaluation of clinical trials]

Magnetic resonance imaging (MRI) is being used increasingly as a measure of outcome in monitoring the efficacy of treatment for multiple sclerosis (MS). A major advantage of MRI is that it easily detects subclinical disease activity and thus serial MRI provides an objective and sensitive tool. In the treatment of acute attacks, corticosteroids are widely used to speed recovery from disability. Recently, methylprednisolone administered in megadose pulses was reported to reduce the conversion rate of patients with optic neuritis to MS. The beneficial effect of treatment was most apparent in patients with abnormal MRI scans. Among the immunosuppressive or immunomodulatory drugs that have been used to prevent progression or reduce relapses, interferon beta 1b is the first medication confirmed to reduce accumulations of MRI detected lesions. In a cyclosporin treatment trial, MRI studies failed to show a significant benefit. Other therapies that require further definitive study include intravenous cyclophosphamide and oral methotrexate or azathioprine. A multicenter double-blind clinical trial with mizoribine is in progress in Japan and the results will be known some time during the first half of 1997.

No association of the 11778 mitochondrial DNA mutation and multiple sclerosis in Japan

Leber's hereditary optic neuropathy (LHON), a maternally inherited disease causing severe bilateral visual loss in young men, is linked to 12 point mutations in mitochondrial DNA, the most common of which is at the nucleotide position 11778. The 11778 point mutation has also been detected in several patients with possible multiple sclerosis (MS), especially women with severe visual loss in both eyes. Because frequent and severe optic neuropathy is a feature of MS in Japan, we screened 80 Japanese MS patients for the presence of the 11778 mutation by mutation-specific polymerase chain reaction. Eighteen women with MS had bilateral optic neuropathy, but none had the mutation at 11778. There is no association between Japanese MS and the 11778 mitochondrial DNA mutation.

Expression of alpha subunit of guanine nucleotide-binding protein Go in Merkel cell carcinoma

The alpha subunit of guanine nucleotide-binding protein Go (Go alpha), which was initially isolated from bovine brain, interacts with muscarinic cholinergic receptors and regulates neuronal calcium channels. Go alpha is known to be localized in neural tissues, some endocrine cells, and neuroendocrine tumors. We have immunohistochemically investigated the expression of Go alpha in 4 cases of Merkel cell carcinoma using the method of microwave treatment. In all cases of Merkel cell carcinoma, Go alpha was consistently detected on the plasma membrane and cytoplasm of the tumor cells. Nerve fibers in the skin were also positive for Go alpha, but other epidermal or dermal components such as keratinocytes, melanocytes, fibroblasts, or lymphoid cells were negative. Tumor cells of squamous cell carcinoma, cutaneous lymphoma, sweat gland carcinoma, and malignant melanoma were negative for Go alpha. The present study indicates that Go alpha may be a useful immunohistochemical marker of Merkel cell carcinoma.

Antibodies against GM1 ganglioside affect K+ and Na+ currents in isolated rat myelinated nerve fibers

High titers of anti-GM1 ganglioside antibodies (anti-GM1 antibodies) may be implicated in lower motor neuron disease. We studied the pathogenic role of anti-GM1 antibody using the petroleum jelly-gap voltage clamp technique on isolated single myelinated rat nerve fibers. Anti-GM1 antisera were obtained from rabbits immunized with GM1 ganglioside. Extracellularly applied anti-GM1 antisera without complement activity increased both the rate of rise and the amplitude of the K+ current elicited by step depolarization, with little effect on Na+ current. In the presence of active complement, however, anti-GM1 antibodies decreased the Na+ current, and caused a progressive increase of nonspecific leakage current. Neither complement alone nor complement-supplemented antisera from which anti-GM1 antibodies were depleted by affinity chromatography had any effect on ionic current. These observations indicate that anti-GM1 antibodies themselves can uncover K+ channels in the paranodal region, while anti-GM1 antibodies bound to the nodal membrane in the presence of complement may form antibody-complement complexes that block Na+ channels and disrupt the membrane at the node of Ranvier.

In vivo observation of magnified features of pigmented lesions on volar skin using video macroscope. Usefulness of epiluminescence techniques in clinical diagnosis

BACKGROUND AND DESIGN

In vivo epiluminescence microscopy is now used as a useful noninvasive method for determining clinical diagnosis of pigmented skin lesions. Until now, however, pigmented lesions on the volar skin have been hardly studied with this method. In the present epiluminescent study, various kinds of pigmented lesions on the volar skin were extensively investigated by means of video macroscope, a newly developed electronic device with a higher magnification power, and correlation between the magnified features and histopathologic findings was evaluated.

RESULTS

Magnified features of most lesions of acquired or congenital melanocytic nevus on the volar skin were classified into the following three typical patterns: (1) a parallel pattern formed by pigmented parallel lines corresponding to the furrows of the skin markings, (2) a latticelike pattern composed of pigmented lines along and across the furrows of the skin markings, and (3) a fibrillar pattern formed by densely packed, fibrillar pigmented lines arranged in the direction crossing the furrows. In contrast, macular or plaque portions of acral lentiginous melanoma exhibited disorderly arranged, irregular pigment patterns, mainly affecting the ridges of the skin markings. In addition, brown globules of various shades and many black dots of variable sizes were often observed and, on the margin of the lesions, pseudopods and/or the "serrated" pattern were detected. Cutaneous hemorrhagic macule and so-called black heel showed highly specific features and thus could be easily diagnosed with video macroscopy.

CONCLUSION

Video macroscope proved to be a very useful instrument for the diagnosis of pigmented lesions on the volar skin.