Immunothrombotic Mechanisms Induced by Ingenol Mebutate Lead to Rapid Necrosis and Clearance of Anogenital Warts

Ingenol mebutate (IM) is highly effective in the treatment of human papillomavirus (HPV)-induced anogenital warts (AGW) leading to fast ablation within hours. However, the exact mode of action is still largely unknown. We performed dermoscopy, in vivo confocal microscopy (CLM), histology, immunohistochemistry, and immunofluorescence to gain insights in mechanisms of IM treatment in AGW. In addition, we used in vitro assays (ELISA, HPV-transfection models) to further investigate in vivo findings. IM treatment leads to a strong recruitment of neutrophils with thrombosis of small skin vessels within 8 h, in a sense of immunothrombosis. In vivo and in vitro analyses showed that IM supports a prothrombotic environment by endothelial cell activation and von Willebrand factor (VWF) secretion, in addition to induction of neutrophil extracellular traps (NETosis). IM superinduces CXCL8/IL-8 expression in HPV-E6/E7 transfected HaCaT cells when compared to non-infected keratinocytes. Rapid ablation of warts after IM treatment can be well explained by the observed immunothrombosis. This new mechanism has so far only been observed in HPV-induced lesions and is completely different from the mechanisms we see in the treatment of transformed keratinocytes in actinic keratosis. Our initial findings indicate an HPV-specific effect, which could be also of interest for the treatment of other HPV-induced lesions. Larger studies are now needed to further investigate the potential of IM in different HPV tumors.

Epidemiologic Differences and Management of Eyelid Lesions in the Pediatric Population

PURPOSE

To report the relative incidence of excised pediatric eyelid lesions and describe the correlation between the clinical and pathology diagnosis.

METHODS

This was a retrospective analysis of 137 consecutive pathology-confirmed eyelid lesions excised at a U.S. quaternary children's hospital system. Chalazion was excluded from this study.

RESULTS

Benign non-cystic epithelial lesions comprised 48.2% of all excised lesions, followed by mesenchymal (14.6%) and cystic (10.2%) lesions. The most common lesions were molluscum contagiosum (21.9%) and verruca vulgaris (19.0%). Hispanic White race represented 62.0% of cases, followed by non-Hispanic White (23.3%) and Black (8.8%). There were no malignant lesions. A specific preoperative clinical diagnosis was attempted in 70.1% of cases. Of these, 60.4% had a matching histopathology.

CONCLUSIONS

The authors report a higher proportion of molluscum contagiosum and verruca vulgaris when compared to the literature; these differences may suggest geographic variance, management preference, or a general increase in incidence. Correlation with pathology showed the clinical diagnosis of eyelid lesions can be challenging even for ophthalmologists. However, malignancy in pediatric eyelid lesions is rare and submission for histopathology may be safely omitted, except in cases with atypical features or suspicion for syndromic disease. The decision for surgery should be methodically approached and take into consideration the most likely diagnosis, natural history of the disease, sociopsychological impact, anesthesia risk, and resource burden. [J Pediatr Ophthalmol Strabismus. 2022;59(6):405-409.].

Dysregulated stem cell niches and altered lymphocyte recirculation cause B and T cell lymphopenia in WHIM syndrome

Gain-of-function (GOF) mutations in CXCR4 cause WHIM (warts, hypogammaglobulinemia, infections, and myelokathexis) syndrome, characterized by infections, leukocyte retention in bone marrow (BM), and blood leukopenias. B lymphopenia is evident at early progenitor stages, yet why do CXCR4 GOF mutations that cause B (and T) lymphopenia remain obscure? Using a CXCR4 R334X GOF mouse model of WHIM syndrome, we showed that lymphopoiesis is reduced because of a dysregulated mesenchymal stem cell (MSC) transcriptome characterized by a switch from an adipogenic to an osteolineage-prone program with limited lymphopoietic activity. We identify lymphotoxin beta receptor (LTβR) as a critical pathway promoting interleukin-7 (IL-7) down-regulation in MSCs. Blocking LTβR or CXCR4 signaling restored IL-7 production and B cell development in WHIM mice. LTβR blocking also increased production of IL-7 and B cell activating factor (BAFF) in secondary lymphoid organs (SLOs), increasing B and T cell numbers in the periphery. These studies revealed that LTβR signaling in BM MSCs and SLO stromal cells limits the lymphocyte compartment size.

Intralesional Measles-Mumps-Rubella Vaccine for Genital Warts

Genital warts are caused by several strains of Human Papilloma Viruses. Although asymptomatic in most cases, they can be psychologically and physically distressing for patients. Recently, intralesional immunotherapy using different antigens—such as Bacille Calmette–Guerin vaccine, candida antigen and measles, mumps, and rubella (MMR) vaccine—have shown promising efficacy in the treatment of genital warts. We report two cases in Omani males who presented to the Dermatology Department at Barka Polyclinic with recalcitrant genital warts that resolved completely with intralesional injection of the MMR vaccine.

A Sherlock Approach to a Kindred With a Variable Immunohematologic Phenotype

Given the ubiquity of leukopenia and sinopulmonary infections in childhood, differentiating patients with inborn errors of immunity (IEI) from otherwise healthy patients can be challenging. The diagnostic complexity is further exacerbated in disorders with wide phenotypic variability such as warts, hypogammaglobulinemia, infections, and myelokathexis (WHIM) syndrome. However, using a Sherlock approach with careful attention to details in the patient's medical history and physical examination coupled with a comprehensive family history can heighten the index of suspicion for underlying IEI. Subsequent iterative and deductive reasoning incorporating results from laboratory interrogation, response (or lack thereof) to standard therapy, and emergence of new symptoms can further aid in a timely diagnosis of IEI. Herein, we detail a WHIM syndrome kindred with marked phenotype variability, identified after the presentation of a child with intermittent neutropenia and sinopulmonary infections. The complexity of this kindred highlights the utility of an interspecialty, collaborative Sherlock approach to diagnosis, and care. In addition, the genetic underpinnings, diagnostic approaches, clinical features, supportive care options, and management of WHIM syndrome are reviewed.

Synchytrium endobioticum, the potato wart disease pathogen

Potato wart disease is considered one of the most important quarantine pests for cultivated potato and is caused by the obligate biotrophic chytrid fungus Synchytrium endobioticum. This review integrates observations from early potato wart research and recent molecular, genetic, and genomic studies of the pathogen and its host potato. Taxonomy, epidemiology, pathology, and formation of new pathotypes are discussed, and a model for molecular S. endobioticum-potato interaction is proposed.

TAXONOMY

Currently classified as kingdom: Fungi, phylum: Chytridiomycota, class: Chytridiomycetes, order: Chytridiales, family: Synchytriaceae, genus: Synchytrium, species: Synchytrium endobioticum, there is strong molecular support for Synchytriaceae to be transferred to the order Synchytriales.

HOSTS AND DISEASE SYMPTOMS

Solanum tuberosum is the main host for S. endobioticum but other solanaceous species have been reported as alternative hosts. It is not known if these alternative hosts play a role in the survival of the pathogen in (borders of) infested fields. Disease symptoms on potato tubers are characterized by the warty cauliflower-like malformations that are the result of cell enlargement and cell multiplication induced by the pathogen. Meristematic tissue on tubers, stolons, eyes, sprouts, and inflorescences can be infected while the potato root system seems to be immune.

PATHOTYPES

For S. endobioticum over 40 pathotypes, which are defined as groups of isolates with a similar response to a set of differential potato varieties, are described. Pathotypes 1(D1), 2(G1), 6(O1), and 18(T1) are currently regarded to be most widespread. However, with the current differential set other pathogen diversity largely remains undetected.

PATHOGEN-HOST INTERACTION

A single effector has been described for S. endobioticum (AvrSen1), which is recognized by the potato Sen1 resistance gene product. This is also the first effector that has been described in Chytridiomycota, showing that in this fungal division resistance also fits the gene-for-gene concept. Although significant progress was made in the last decade in mapping wart disease resistance loci, not all resistances present in potato breeding germplasm could be identified. The use of resistant varieties plays an essential role in disease management.

Molluscum and Tinea and Warts, Oh My!

The skin is the largest organ in the human body, and it acts as the barrier between the world and our bodies. As such, it is constantly being exposed to infections, irritants, and allergens. Approximately one-third of primary care visits involve at least one skin complaint. This may manifest as a rash, a lesion, pruritis, pigment changes, or textural abnormalities. Whatever the presentation, it is important to know the common causes of these skin abnormalities and the appropriate management. Just as important as management is the ability to set expectations for patients, as many common skin conditions can be difficult to treat and may take significant time to resolve. This article will highlight some of the most common skin lesions we see in pediatric patients. [Pediatr Ann. 2022;51(1):e2-e5.].

Photodiagnosis of genital herpes and warts within a specialist online sexual health service: an observational (mixed methods) study of user experience and clinical outcomes

OBJECTIVES

To evaluate the feasibility and acceptability of a pilot, free, online photodiagnosis service for genital herpes and warts with postal treatment delivered by a specialist digital sexual health service.

SETTING

An online sexual health service available free of charge in South East London, UK.

PARTICIPANTS

Routinely collected data from 237 users of the pilot service during the study period and qualitative interviews with a purposive sample of 15 users.

INTERVENTION

A pilot, free, online photodiagnosis service for genital herpes and warts with postal treatment delivered by a specialist digital sexual health service.

PRIMARY AND SECONDARY OUTCOME MEASURES

Proportion of users who successfully uploaded photographs and the proportion diagnosed, treated and referred to face-to-face clinical services. User experience of this service.

RESULTS

The service was accessed by 237 users during the study period with assessment possible for 86% of users based on the photographs provided. A diagnosis of genital herpes or warts was made for 40.5% and 89.6% were subsequently treated through the service. Eighteen per cent were diagnosed as normal/not needing treatment and 42% were signposted to clinic for further clinical assessment.Qualitative data showed that users felt able and willing to provide genital images for diagnosis. Those who were treated or reassured expressed high satisfaction with the service, valuing the convenience, discreetness and support provided. However, users, particularly those who required referral to other services requested more personal and detailed communication when a clinical diagnosis is given remotely.

CONCLUSIONS

Findings suggest that online photodiagnosis was feasible and acceptable. However, effective and acceptable management of those who require referral needs careful remote communication.

Serum level of interleukin-22 in patients with cutaneous warts: A case-control study

BACKGROUND

Warts are viral cutaneous infections caused by human papilloma virus (HPV), presented by verrucous growth over the skin surface. The immune response is considered to play a crucial role in HPV clearance. It depends on intact cellular immunity including natural killer (NK) cell and cytotoxic T cells. It has been clarified that T-helper (Th) 1 cytokines (interleukin (IL)-2, interferon-γ, and tumor necrosis factor-a) and IL-17 are involved in HPV clearance. IL-22 is one of IL-10 family of cytokines produced by NK cells, Th1, Th17, and Th22 cells. In the skin, IL-22 reduces keratinocyte cornification and enhances keratinocyte production of antimicrobial peptides. IL-22 overexpression has been demonstrated in various viral infections and skin inflammatory disorders.

AIM

The aim of this study was to assess serum levels of IL-22 in patients with warts and its association with their different clinical characteristics.

METHODS

The study included 20 patients with warts and 20 control subjects. Serum concentration of IL-22 was measured by enzyme-linked immune sorbent assay.

RESULTS

Serum levels of IL-22 were significantly higher in patients with warts than in control subjects (P < .001). The levels were significantly higher in patients with recurrent warts after prior treatment than in patients with first-time warts (P = .007). Moreover, a significant positive correlation was detected between serum levels of IL-22 and the number of warts (P = .017).

CONCLUSION

Serum level of IL-22 was elevated in patients with warts. Thus, IL-22 may have a crucial role in the antiviral immune response against this infection.

Dragon Warts

NONE

Clinical and sonographic features of nipple lesions

BACKGROUND

The aim of this study was to present several cases of benign and malignant nipple lesions and contribute to diagnosis and differential diagnosis.

METHODS

A retrospective study was conducted on 13 patients. All of the patients were evaluated by ultrasonography, and 11 of them had pathological results. We analyzed the clinical and sonographic features.

RESULTS

There were 3 malignant lesions, 7 benign lesions, and 3 congenital nipple dysplasia, listed as follows:Malignant lesions (n = 3, 23%): Paget's disease (PD, n = 3, 23%). All of the patients with PD showed unilateral nipple erosion, discharge, and pain. The ultrasound showed abundant blood flow (n = 3, 23%); 2 patients (n = 2, 15%) had microcalcifications.Benign lesions (n = 7, 54%): Adenoma of the nipple (n = 2, 15%). One patient (n = 1, 8%) had nipple erosion and discharge. Two patients (n = 2, 15%) had a palpable nodule in the nipple. The ultrasound of both patients (n = 2, 15%) showed regular-shaped, clear border nodule with abundant blood flow (n = 2, 15%).Leiomyoma of the nipple (n = 1, 8%): This male patient was characterized by unilateral nipple enlargement and pain. The ultrasound showed a regular nodule with absent blood flow.Plasma cell mastitis (n = 2, 15%): Two patients showed unilateral nipple inversion and pain. One patient (n = 1, 8%) showed swollen and redness. The 2 patients showed a lesion in the gland around the nipple present as an irregular shape and unclear boundary hypoechoic mass.Nipple wart (n = 2, 15%): Two patients showed a unilateral soft exogenous neoplasm. Both of the patients showed a hypoechoic wart; the echo was similar to the nipple, the border was clear, and had no blood flow in the wart.Nipple Dysplasia (n = 3, 23%): Accessory nipple (n = 3, 23%). Two patients (n = 2, 15%) had accessory nipples in the subcoastal area, 1 patient (n = 1, 8%) in the areolar. All of the patients' sonographic features were the same as the nipple.The positive predict value (PPV) of the clinical symptoms: Erosion and discharge are both 75% (P < 0.05). The PPV of the US manifestations: irregular shape, indictinct margin, abundant blood flow, microcalcification, thicken skin in diagnosing malignant lesions are 60%,60%,60%,100%,100%, respectively (P < 0.05).

CONCLUSIONS

The characteristic sonographic features together with clinical symptoms contribute to the diagnosis of nipple lesions.

[Immunohistochemistry of p16 and p53 in vulvar cancer]

Squamous cell carcinoma of the vulva may develop in association or independently of HPV infection. The relationship between pathogenesis, classification, immunohistochemical profile and prognosis has been studied in the literature with some discrepancies. The aim of this study was to observe the classical association of keratinizing carcinomas with the absence of HPV infection and warty and basaloid carcinomas with the presence of this virus. Therefore, we reviewed the clinic, morphology, and immunophenotype of 39 cases. The tumors were histologically classified into classic keratinizing squamous carcinoma (30), warty (5) and basaloid (4). In the statistical analysis, diffuse expression with p16 was significantly associated with younger age (p = 0.0025), presence of high-grade intraepithelial lesion (p < 0.0001), koilocytosis (p = 0.02), and morphological subtype (p = 0.02), and was inversely associated with the expression of p53 (p < 0.0001) and the presence of lichen sclerosus (p = 0.0051). It is curious that 4 keratinizing carcinomas of the cases studied presented coexpression of p16 and p53. Only one warty tumor was negative for p16 and positive for p53, and 9 keratinizing tumors were positive for p16 and negative for p53. Although these findings show that the use of hematoxylin and eosin could correctly define tumors associated with HPV, we strongly suggest the performance of immunohistochemistry, especially in squamous keratinizing classic carcinomas in young patients with a history of HPV.

An Alternative Bioassay for Synchytrium endobioticum Demonstrates the Expression of Potato Wart Resistance in Aboveground Plant Parts

The obligate biotrophic chytrid species Synchytrium endobioticum is the causal agent of potato wart disease. Currently, 39 pathotypes have been described based on their interaction with a differential set of potato varieties. Wart resistance and pathotyping is performed using bioassays in which etiolated tuber sprouts are inoculated. Here, we describe an alternative method in which aboveground plant parts are inoculated. Susceptible plants produced typical wart symptoms in developing but not in fully expanded aboveground organs. Colonization of the host by S. endobioticum was verified by screening for resting spores by microscopy and by molecular techniques using TaqMan polymerase chain reaction and RNAseq analysis. When applied to resistant plants, none of these symptoms were detectable. Recognition of S. endobioticum pathotypes by differentially resistant potato varieties was identical in axillary buds and the tuber-based bioassays. This suggests that S. endobioticum resistance genes are expressed in both etiolated "belowground" sprouts and green aboveground organs. RNAseq analysis demonstrated that the symptomatic aboveground materials contain less contaminants compared with resting spores extracted from tuber-based assays. This reduced microbial contamination in the aboveground bioassay could be an important advantage to study this obligate biotrophic plant-pathogen interaction. Because wart resistance is active in both below- and aboveground organs, the aboveground bioassay can potentially speed up screening for S. endobioticum resistance in potato breeding programs because it omits the requirement for tuber formation. In addition, possibilities arise to express S. endobioticum effectors in potato leaves through agroinfiltration, thereby providing additional phenotyping tools for research and breeding. Copyright © 2019 The Author(s). This is an open access article distributed under the CC BY 4.0 International license .

Case Report: Ocular toxoplasmosis in a WHIM syndrome immunodeficiency patient

A patient with WHIM syndrome immunodeficiency presented with sudden painless right eye blindness associated with advanced retinal and optic nerve damage. Toxoplasma gondii was detected by PCR in vitreous fluid but not serum.  The patient was treated with pyrimethamine/sulfadiazine for 6 weeks due to evidence of active ocular inflammation and then received prophylaxis with trimethoprim-sulfamethoxazole due to his immunosuppression.  Vision did not return; however, the infection did not spread to involve other sites.  Toxoplasmosis is rare in primary immunodeficiency disorders and is the first protozoan infection reported in WHIM syndrome.

Enhancement of stem cell engraftment on a WHIM

WHIM (warts, hypogammaglobulinemia, infections, and myelokathexis) syndrome is a genetic autoimmune disorder that results from gain-of-function mutations in the gene encoding chemokine receptor CXCR4. A previous study characterized a patient with WHIM who underwent a chromothriptic event that resulted in spontaneous deletion of the WHIM allele in a single hematopoietic stem cell and subsequent cure of the disease. In this issue of the JCI, Gao et al. extend this work and show that Cxcl4-haplosufficient bone marrow has a selective advantage for long-term engraftment in murine WHIM models. Moreover, successful engraftment occurred without prior conditioning of recipients. Together, these results have important implications for improving hematopoietic stem/progenitor cell transplant not only for patients with WHIM but also for all patients who may require the procedure.

Fine morphology of frontal filaments in nauplii of cirriped crustaceans

Fine morphology of the frontal filaments (FFs) at all nauplius stages of two barnacle species (Verruca stroemia and Hesperibalanus hesperius) has been investigated by scanning electron microscopy. FFs have been detected at the second nauplius stage and persist during all stages. FFs contain a wide proximal and a fine distal parts, but they are not actually separated as segments of the limbs, and the area between them looks like a single cuticular crease. Apical and subapical pores have been found at the top of each FF in the larvae of both species, which may indicate the chemoreceptor function of these organs.