Antigen-driven expansion and contraction of CD8+-activated T cells in primary EBV infection

The origin of the increased numbers of CD8+ atypical lymphocytes, expressing activated markers such as HLA-DR or CD45RO, in the peripheral blood of patients with infectious mononucleosis (IM) has been debated. Using a recently developed assay to detect intracellular accumulation of IFN-gamma in EBV-reactive T cells by FACS, we have demonstrated that 34-54% of HLA-DR+/CD8+ and 34-60% of CD45RO+/CD8+ T cells in the PBMCs of febrile patients suffering from IM are EBV-specific. The EBV-specific CD8+ T cell counts in the PBMCs of four febrile patients suffering from IM ranged between 2,260 and 8,200/microl, decreasing to 5.1% and 7.9% of the counts in the first samples over 10 days in two donors. The decline of CD8+ T cell subpopulations, namely HLA-DR+, CD45RO+, and EBV-specific T cells, was in parallel with the drop in the EBV genome load. These data indicate that the Ag-driven expansion of CD8+ T cells and subsequent contraction with the Ag decline in vivo in humans is effective for clearing virus-infected cells with minimal disturbance of the homeostasis of the immune system.

Progress in diagnosing herpesvirus infections

As molecular biology has developed, several new diagnostic techniques have found application in the clinical setting. The use of the polymerase chain reaction (PCR) assay to study the molecular biology of microbial organisms has led to unparalleled advances, largely due to the rapidity with which results can be obtained. The sensitivity and specificity of PCR detection of viral DNA for diagnostic purposes are remarkable. With such excellent sensitivity, PCR is destined to become a useful diagnostic tool in herpesvirus infections. However, it is well known that herpesviruses establish latency after primary infections and that they can often be reactivated under various conditions. Because of the high sensitivity of PCR, detection of virus sequences by this method does not necessarily imply a disease state. We must be careful not to overdiagnose conditions in a clinical setting based on a PCR assay.

Rapid determination of Epstein-Barr virus-specific CD8(+) T-cell frequencies by flow cytometry

We have developed an efficient and rapid method for detection of Epstein-Barr virus (EBV)-specific CD8(+) T-cell frequencies both in freshly isolated peripheral blood mononuclear cells (PBMCs) and in vitro established cytotoxic T lymphocyte (CTL) lines. Responder cells are thereby stimulated with an autologous lymphoblastoid cell line for 5 hours and intracellular accumulation of interferon gamma (IFNgamma) is detected by multiparameter flow cytometric analysis. EBV-specific CD8(+) T-cell frequencies ranged between 0.63% and 1. 29% in PBMCs of 5 healthy long-term EBV carriers. Using EBV-specific T-cell lines, it was shown that flow cytometric analysis is more sensitive than limiting dilution analysis for CTL precursors and enzyme-linked immunospot assay detecting IFNgamma-producing T cells. The class I restriction of IFNgamma production was confirmed using an anti-class I monoclonal antibody (MoAb). Information on other cytokine production of EBV-specific CTLs could be obtained using combinations of anti-cytokine MoAbs. The sensitive and rapid nature of the flow cytometric assay for EBV-specific CD8(+) T-cell frequency has significant advantages for evaluation of EBV-specific CD8(+) T-cell responses in PBMCs of patients with EBV-related diseases.

The prevalence of TT virus (TTV) infection and its relationship to hepatitis in children

TT virus (TTV) is a newly discovered virus from a patient with post-transfusion hepatitis. We investigated the frequency and pathogenesis of TTV infection in children. A semi-nested PCR assay was used to amplify TTV-DNA in serum samples from 254 ambulatory children without liver disease, 20 with hepatitis of unknown etiology, and 18 transfusion recipients or hemophiliacs. In positive samples, TTV-DNA was quantified by real-time quantitative PCR using a fluorescent probe. We detected TTV-DNA in 20% of children with hepatitis of unknown etiology, which was not statistically different from the 23% prevalence in ambulatory children. In transfusion recipients or hemophiliacs, the frequency was higher (50%) than that in ambulatory children (P = 0.01). Among ambulatory children, TTV-DNA was frequently detected in children with acute gastroenteritis (36%). TTV-DNA was detected in 10% of the infants under 6 months old, and 20% of the children from 7 to 12 months old. The prevalence was constant after the age of 1 year; however, the copy number of TTV-DNA was significantly higher in children under 1 year of age (mean: 10(5.4) versus 10(3.8) copies/ml, P= 0.008). Finally, TTV-DNA was quantified serially in three children with chronic hepatitis who were positive for TTV-DNA. The presence or amount of TTV-DNA was unrelated to the serum alanine aminotransferase level. These results indicate that TTV infection is common in children. The larger quantity of TTV-DNA in infants and the high prevalence of TTV in children of all ages suggest that TTV may be transmitted in early childhood. Its relationship to hepatitis is doubtful in children.

Comparative study between chemiluminescence assay and two different sensitive polymerase chain reactions on the diagnosis of serial herpes simplex virus encephalitis

OBJECTIVE

A prospective study was undertaken on the diagnosis of herpes simplex encephalitis (HSVE) by comparing chemiluminescence assay (CL) and two different sensitive polymerase chain reactions (PCRs).

METHODS

The materials comprised 53 serial CSF samples from 31 patients with acute encephalitis with suspected HSVE. Each CSF was distributed to three independent laboratories to perform quantitative measurements by CL, the low sensitive (single) PCR, and high sensitive (nested) PCR. The CL provided a method of detecting HSV itself and the small fragment with HSV antigenicity which was composed of viral component proteins. The serial CSFs were found retrospectively to comprise 24 samples from 11 patients with HSVE due to HSV1 and 29 samples from 20 patients with non-HSVE.

RESULTS

the CL showed 50 to 48 000 pfu/ml in all samples of HSVE (except one) taken from the 3rd to the 25th day. The low sensitive PCR demonstrated 50 to 47 000 pfu/ml in only six samples of HSVE. The high sensitive PCR disclosed less than 100 to 120 000 copies/ml in 11 samples of HSVE. At the acute stage from the 1st to 7th day, the sensitivities of CL and the high sensitive PCR were 100%, but that of the low sensitive PCR was 75%. The sensitivity of CL was significantly higher than those of both PCRs after the acute stage on the 15th to 32nd day. The specificities and positive predictive values of the three methods were 100%. However, the negative predictive value of CL was significantly higher than that of the low sensitive PCR.

CONCLUSIONS

The sensitivity of CL is equivalent to that of the high sensitive PCR during the acute stage and significantly higher than that of the high sensitive PCR after the acute stage. A clear difference in sensitivity exists between the different PCRs. A combination of the PCR, chemiluminescence assay, and serological antibody diagnosis is currently considered the most effective approach for the clinical diagnosis of HSVE.

Prevalence of maternal cytomegalovirus (CMV) antibody and detection of CMV DNA in amniotic fluid

The prevalence of cytomegalovirus (CMV) IgG antibody was determined in 573 pregnant women in the first trimester. The overall prevalence of CMV IgG antibody was 77.5%. The rate of seropositivity was 67.7% in women < 25 yr, and increased with age to 85.7% in women 40 yr. These results imply that young women in Japan are at increased risk for primary CMV infection during pregnancy and that congenital CMV infection rates might increase in the future. We conducted a prospective study of 75 pregnant women who underwent amniocentesis for various indications to determine if CMV DNA could be detected in the amniotic fluid. None had symptoms associated with CMV infection, CMV IgM antibody, or seroconversion to CMV IgG antibody during pregnancy. CMV DNA was not detected in the amniotic fluid using a polymerase chain reaction assay. The 65 fetuses, including 3 sets of twins, were followed through birth. CMV DNA was not detected in urine samples obtained within the first 2 weeks of life. In conclusion, CMV DNA was not detected in the amniotic fluid of women who did not have CMV infection. These results, however, suggest that the negative predictive value of prenatal amniotic fluid analysis is high and that the presence of CMV DNA in the amniotic fluid has clinical significance for the diagnosis of congenital CMV infection if detected in pregnant women.

Conservation of the central proline-rich (PxxP) motifs of human immunodeficiency virus type 1 Nef protein during the disease progression in two hemophiliac patients

The nef gene is considered to play a crucial role in the development of acquired immunodeficiency syndrome (AIDS). In this study, we analyzed the sequence of nef quasispecies obtained from replication-competent HIV-1 isolates from two Japanese hemophiliac patients infected with HIV-1. At least 10 nef clones were isolated at each time point and a total of 75 individual nef quasispecies were sequenced. We observed a gradual increase in genetic diversity of the nef gene over time. Among the various functional regions of Nef protein, myristoylation site and the central PXXP (SH3 ligand) motifs were well conserved. The scattered regions responsible for downregulation of CD4 and class I MHC were also conserved. These data suggest that these functions of Nef may be involved throughout the disease process.

Isolation of a Kawasaki disease-associated bacterial sequence from peripheral blood leukocytes

BACKGROUND

The clinical and epidemiologic features of Kawasaki disease (KD) suggest an infectious etiology, but the agent(s) remains unknown. We aimed to isolate the causative bacterial gene from peripheral blood leukocytes of patients with acute KD.

METHODS

Nested polymerase chain reaction (PCR) assay was used to amplify the bacterial 16S ribosomal RNA gene (rDNA). The amplified DNA were cloned into a plasmid vector and sequenced. Phylogenetic analysis was performed with clustal W program and the neighbour-joining method.

RESULTS

First, the PCR reagents were examined by the PCR assay using conservative primers and we found more than 10 16S rDNA sequences contaminating the reagents. We then examined five KD patients using the PCR assay, excluding the contaminated sequences, and obtained five 16S rDNA sequences as possible KD-associated sequences. The primers specific to each 16S rDNA sequence were synthesized and used for specific PCR assays. Only the PCR assay specific to the 16S rDNA sequence termed 16S71-33 did not show any false positives with the control DNA from non-KD patients. The 16S71-33 sequence was positive in three of 20 patients with acute KD before gamma-globulin therapy, but it became negative after therapy. The phylogenetic analysis showed a new species of the genus Corynebacterium as the origin of the 16S71-33 sequence.

CONCLUSIONS

These data show that an infectious KD agent is traced in peripheral leukocytes and that a new Corynebacterium species may be responsible for KD in some cases. The true frequency and the role of the new Corynebacterium in KD would be clarified by measuring specific antibodies to it.

Pediatric admission for vaccine preventable diseases: a 5-year survey from 1994 to 1998 in Aichi Prefecture

Several infectious childhood diseases can be prevented by vaccination. A survey of hospital admissions for such diseases was conducted in Aichi Prefecture over 5 years beginning in 1994. A questionnaire was sent annually to hospitals with 100 or more beds to obtain information on pediatric patients requiring hospitalization for 10 vaccine preventable diseases. Information was obtained on 3,953 patients. Most admissions were for measles (49%), followed by mumps, chickenpox, pertussis, rubella, and tuberculosis. Over half of the patients were under 3 years old, with 20% aged under 12 months, 25% aged from 12 months to 2 years, and 10% aged from 2 to 3 years. The average hospital stay was longest for tuberculosis and pertussis, and was around 1 week for the other diseases. Familial transmission was the most common source of infection identified. The only death was an unvaccinated patient with measles pneumonia. Sequelae were reported at the time of discharge in 15 patients (0.4%), and were permanent in some cases. Some 96% of the patients surveyed were unvaccinated against the disease causing hospitalization. The fact that there were 14 patients with sequelae and the one patient who died were unvaccinated, emphasizes the need to promote vaccination.

Detection of influenza virus RNA by reverse transcription-PCR and proinflammatory cytokines in influenza-virus-associated encephalopathy

Eleven children with acute encephalopathy associated with an influenza virus infection were treated during the 1997-1998 influenza season. Reverse transcription-polymerase chain reaction (RT-PCR) assay was used to detect the viral genome in peripheral blood and cerebrospinal fluid (CSF) samples. The results were compared with those of control influenza patients without neurological complications. Viral RNA was detected only in the peripheral blood mononuclear cells of one patient with influenza-virus-associated encephalopathy (1 of 9; 11%) and in the CSF of another patient (1 of 11;9%). RT-PCR was negative in the blood of all the controls, but the percentage of RT-PCR-positive samples in the two groups was not significantly different. Cytokines and soluble cytokine receptors in plasma and CSF were then quantified using an enzyme-linked immunosorbent assay. The CSF concentrations of soluble tumor necrosis factor receptor-1 were elevated in two patients and interleukin-6 (IL-6) was elevated in one patient with influenza-virus-associated encephalopathy. On the other hand, the plasma concentrations of IL-6 were elevated in four of nine patients. The number of encephalopathy patients who had elevated plasma concentrations of IL-6 100 pg/ml was significantly higher than that of controls (P= .01). In conclusion, the infrequent detection of the viral genome in the CSF and blood showed that direct invasion of the virus into the central nervous system was an uncommon event. Proinflammatory cytokines and soluble cytokine receptors may mediate the disease. The high plasma concentration of IL-6 could be an indicator of the progression to encephalopathy.

Human papillomavirus types 16 and 39 in a vulval carcinoma occurring in a woman with Hailey-Hailey disease

A woman with Hailey-Hailey disease, suffering from carcinoma of the vulva, was examined by histology and for the presence of human papillomavirus (HPV) DNA by polymerase chain reaction (PCR) and in situ hybridization. Our diagnosis by histological examination revealed the vulval carcinoma to be a squamous cell carcinoma (SCC), adjacent to lesions of Hailey-Hailey disease and severe dysplasia/carcinoma in situ [vulval intraepithelial neoplasia (VIN) III]. The PCR with consensus primers for the L1 region (L1-PCR) successfully amplified HPV DNA using total DNA extracted from formalin-fixed and paraffin-embedded tissue specimens. Restriction fragment length polymorphism analysis and sequencing of L1-PCR products revealed HPV types 16 and 39. HPV 16-specific primers for the E6 region identified HPV 16 DNA. In situ hybridization analysis with biotinylated HPV 16 and 39 DNA probes revealed the presence of the HPV 39 genome in the nuclei of the tumour cells in the SCC. These results indicate that HPV 16 and 39 are associated with lesions in vulval carcinoma. Regarding the patient's susceptibility to infection in the case of Hailey-Hailey disease, there is a possibility that HPV was inoculated into the lesions of Hailey-Hailey disease and induced those of VIN III and SCC.

Characterization of Epstein-Barr virus (EBV)-infected natural killer (NK) cell proliferation in patients with severe mosquito allergy; establishment of an IL-2-dependent NK-like cell line

The clinical evidence of a relationship between severe hypersensitivity to mosquito bite (HMB) and clonal expansion of EBV-infected NK cells has been accumulated. In order to clarify the mechanism of EBV-induced NK cell proliferation and its relationship with high incidence of leukaemias or lymphomas in HMB patients, we studied clonally expanded NK cells from three HMB patients and succeeded in establishing an EBV-infected NK-like cell line designated KAI3. Immunoblotting and reverse transcriptase-polymerase chain reaction (RT-PCR) analyses revealed that KAI3 cells as well as infected NK cells exhibited an EBV latent infection type II, where EBV gene expression was limited to EBNA 1 and LMP1. As KAI3 was established by culture with IL-2, IL-2 responsiveness of peripheral blood NK cells from patients was examined. The results represented markedly augmented IL-2-induced IL-2R alpha expression in NK cells. This characteristic property may contribute to the persistent expansion of infected NK cells. However, KAI3 cells as well as the NK cells from patients were not protected from apoptosis induced by either an anti-Fas antibody or NK-sensitive K562 cells. Preserved sensitivity to apoptosis might explain the relatively regulated NK cell numbers in the peripheral blood of the patients. To our knowledge, KAI3 is the first reported NK-like cell line established from patients of severe chronic active EBV infection (SCAEBV) before the onset of leukaemias or lymphomas. KAI3 cells will contribute to the study of EBV persistency in the NK cell environment and its relationship with high incidence of leukaemias or lymphomas in HMB patients.

Quantitative analysis of Epstein-Barr virus load by using a real-time PCR assay

To measure the virus load in patients with symptomatic Epstein-Barr virus (EBV) infections, we used a real-time PCR assay to quantify the amount of EBV DNA in blood. The real-time PCR assay could detect from 2 to over 10(7) copies of EBV DNA with a wide linear range. We estimated the virus load in peripheral blood mononuclear cells (PBMNC) from patients with symptomatic EBV infections. The mean EBV-DNA copy number in the PBMNC was 10(3.7) copies/microg of DNA in patients with EBV-related lymphoproliferative disorders, 10(4.1) copies/microg of DNA in patients with chronic active EBV infections, and 10(2.2) copies/microg of DNA in patients with infectious mononucleosis. These numbers were significantly larger than those in either posttransplant patients or immunocompetent control patients without EBV-related diseases. In a patient with infectious mononucleosis, the virus load decreased as the symptoms resolved. The copy number of EBV DNA in PBMNC from symptomatic EBV infections was correlated with the EBV-positive cell number determined by the in situ hybridization assay (r = 0.842; P < 0.0001). These results indicate that the real-time PCR assay is useful for diagnosing symptomatic EBV infection and for monitoring the virus load.

Clinical survey of congenital cytomegalovirus infection in Japan

BACKGROUND

The clinical features of congenital cytomegalovirus (CMV) infection in countries with a higher percentage of maternal seropositivity for CMV has rarely been reported. We conducted a national survey for the first time in Japan to investigate the prevalence of congenital CMV infection.

METHODS

Questionnaires were sent in 1994 to pediatricians and obstetricians of 3398 hospitals with either more than 100 beds or a neonatal intensive care unit (NICU). The questionnaire asked for the number of new cases in 1992 and 1993, maternal status of CMV infection, diagnostic methods, clinical manifestations at birth, sequelae and prognosis.

RESULTS

A total of 46 cases of CMV infection were reported for the years 1992 and 1993 by 1448 hospitals; of these 39 were symptomatic. The annual incidence of symptomatic disease was 1.6 cases/100,000 live births. Major clinical manifestations such as low birthweight, hepatosplenomegaly, petechiae and intracranial calcification were noted at birth in 38-50% of symptomatic neonates. Sequelae, such as hearing loss, mental retardation and motor disability developed in 71% of survivors. Thirty-five percent of the 49 infected infants had either died or had severe disability. Several clinical manifestations at birth, including petechiae/thrombocytopenia, were significantly associated with severe sequelae or a poor prognosis.

CONCLUSION

The lower frequency of clinical findings at birth may be attributed to the higher seroprevalence of pregnant women in Japan than in Europe and the United States.

Childhood bacterial meningitis in Japan

Haemophilus influenzae type b (Hib) vaccines currently are not used in Japan, but interest in preventing H. influenzae disease by immunization has grown. We performed a retrospective survey for bacterial meningitis in 6 prefectures of Japan. Questionnaires requested the age, sex, clinical outcome and identity of the etiologic organism, if known, of all patients with meningitis younger than 16 years of age who were admitted during calendar year 1994. Of 876 hospitals within the 6 study prefectures, 363 (41.4%) returned a completed questionnaire. There were 1769 cases of meningitis reported, of which 160 (9%) were considered bacterial in origin. H. influenzae was the most common cause of bacterial meningitis, accounting for 68 cases (43%). Sixty-six cases (97%) of H. influenzae meningitis occurred in children 4 years of age or younger, and 27 (40%) occurred in children <1 year of age. Calculated incidence rates based on the population of children 4 years of age or less for each prefecture ranged from 3.4 to 9.9 cases per 100000 (mean, 4.7 cases/100000). H. influenzae is the most common cause of meningitis in Japan, and the estimated incidence rates from this study are very similar to those previously reported from Japan. More comprehensive, prospective surveillance studies will be needed to define better the incidence of Hib meningitis and to aid in making rational decisions regarding the use of Hib vaccination in Japan.

Increased hepatic glucose production and decreased hepatic glucose uptake at the prediabetic phase in the Otsuka Long-Evans Tokushima fatty rat model

To investigate the time course of the hepatic glucose metabolism in non-insulin-dependent diabetes (NIDDM), we measured hepatic glucose production (HGP) and first-pass uptake of portal glucose infusion by the liver (HGU) using dual-tracer methods in a NIDDM model, Otsuka Long-Evans Tokushima Fatty (OLETF) rats, and in normal controls, Long-Evans Tokushima Otsuka (LETO) rats, at 8, 14, and 28 weeks of age (n = 5, respectively). The fasting plasma glucose level in OLETF rats was significantly higher than in LETO rats at 28 weeks of age (8.9 +/- 1.7 v 6.3 +/- 0.4 mmol/L, P < .01), while there was no significant difference at 8 and 14 weeks. Hyperinsulinemia in OLETF rats appeared at > or = 8 weeks of age. Basal HGP was significantly higher in OLETF than in LETO rats at 8 and 28 weeks (8 weeks, 12.7 +/- 1.7 v 9.4 +/- 1.8 mg x kg(-1) x min(-1), P < .05; 28 weeks, 10.9 +/- 1.6 v 7.1 +/- 1.3 mg x kg(-1) x min(-1), P < .01). At 14 weeks, basal HGP was not significantly different between OLETF and LETO rats. However, at all study points, HGU during a portal glucose infusion was significantly lower in OLETF than in LETO rats (8 weeks, 0.9 +/- 0.2 v 2.3 +/- 0.5, P < .01; 14 weeks, 0.8 +/- 0.3 v 1.4 +/- 0.3, P < .05; 28 weeks, 0.7 +/- 0.2 v 1.4 +/- 0.3 mg x kg(-1) x min(-1), P < .01). Fasting plasma free fatty acid (FFA) levels were not significantly different between OLETF and LETO, except at 8 weeks. Suppression of plasma FFA levels by endogenous insulin during a portal glucose infusion was impaired in OLETF rats compared with LETO rats. In summary, this study demonstrates that derangement of hepatic glucose handling, such as increased basal HGP and decreased HGU, is observed in obese NIDDM model OLETF rats at the prediabetic phase when hyperglycemia is still not apparent. Furthermore, these derangements may be accompanied by impaired lipid metabolism.

Calcification in the basal ganglia with chronic active Epstein-Barr virus infection

We report three Japanese children with chronic active Epstein-Barr virus (EBV) infection and neurologic findings that included symmetric calcifications in the bilateral basal ganglia. This finding, common in pediatric acquired immunodeficiency syndrome (AIDS), suggests that EBV could be responsible for calcification in the basal ganglia seen in children with AIDS and in other idiopathic diseases.

Polymerase chain reaction-proved herpes simplex encephalitis in children

OBJECTIVE

To investigate the clinical features in PCR-proved herpes simplex encephalitis (HSE) in children, excluding neonates.

METHODS

We studied the clinical manifestations and laboratory findings of 24 children in whom the diagnosis of herpes infection was confirmed by the PCR assay and compared them with those of 38 children with central nervous system infections other than HSE.

RESULTS

There were no significant differences between groups in the percentage with fever or convulsions, the initial neurologic symptoms or the level of consciousness. Analysis of cerebrospinal fluid showed no significant differences in the cell count or concentration of protein and glucose. Computerized tomography of the brain identified localized abnormalities in 18 (75%) of the 24 HSE patients and in 10 (31%) of the 32 non-HSE patients (P = 0.001). Periodic lateralized epileptiform discharges, abnormal findings on electroencephalography, were detected in 8 (36%) of 22 HSE patients and in none of the non-HSE patients (P = 0.0001). The rates of moderate to severe morbidity and death were significantly higher in the HSE patients than in the non-HSE patients. Of the 9 HSE patients with a Glasgow Coma Scale score > or = 11, all patients recovered completely. HSE patients younger than 3 years of age were more likely to develop severe sequelae or to die of the disorder than older patients (P = 0.02).

CONCLUSIONS

There were no specific clinical characteristics of HSE patients. The results of electroencephalography and computerized tomography were helpful, but not confirmatory, in diagnosing HSE. The Glasgow Coma Scale score and age significantly influenced the mortality and morbidity in the HSE patients.

[Progress in the management of cytomegalovirus(CMV) infection]

We described the clinical feature of cytomegalovirus(CMV) infection, its epidemiology, and prognosis of congenital CMV infection. Then, the anti-viral treatment with the ganciclovir against the congenital CMV infection was discussed. We showed that the presence of CMV-DNA in the plasma was useful to determine the indication of the therapy. We also showed our case of chronic active Epstein-Barr virus infection to introduce the adoptive immune therapy as a new strategy for the treatment of severe virus infections. Lastly, application of this therapy for the CMV infection in overseas and its future prospect were described.

[A case of infiltration of scar of sarcoidosis after blepharoplasty]

A case of a 28-year-old woman with infiltration of sarcoidosis scar tissue after blepharoplasty is reported. Nodules developed two times in her right upper eyelid about 1 and 2 years after blepharoplasty of both eyes and they were resected each time, but eruption recurred. Ophthalmic examination revealed aqueous flare and cells, snowball vitreous opacities, and retinal periphlebitis. A chest X-ray disclosed bilateral hilar lymphadenopathy (BHL). Laboratory studies showed an elevation of the serum angiotensin converting enzyme (ACE). Light microscopy revealed epithelioid granuloma with no caseation necrosis in a biopsy specimen, Viewing through polarized light demonstrated crystalline-like foreign bodies with bi-refringence in the epithelioid granuloma. Electron microscopic X-ray microanalysis confirmed these foreign bodies to be composed of Si, Mg, and O. These findings indicate that this skin lesion was caused by an infiltration of sarcoidosis scar tissue.