Mycosis fungoideslike T-cell cutaneous lymphoid infiltrates in patients with HIV infection

Cutaneous patch and plaque lesions, and erythroderma may suggest mycosis fungoides both clinically and histopathologically in HIV+ patients. However, in some cases, this diagnosis is questionable. Five such cases are presented. When we compared these cases with cases of mycosis fungoides unassociated with HIV infection, we found less concordance among dermatopathologists in making a histopathological diagnosis, a greater proportion of CD8 than CD4 T cells in the cutaneous infiltrates, and no instances of demonstrated clonality of the cutaneous T-cell infiltrates in the HIV+ group. We conclude that CD8 T-cell predominant dermatoses may simulate mycosis fungoides in HIV+ patients.

Primary cutaneous immunocytoma. A B-cell lymphoma that can easily be mistaken for cutaneous lymphoid hyperplasia

It has been estimated that immunocytomas comprise roughly 2% of all cutaneous lymphomas. We studied five patients with primary cutaneous immunocytomas who presented with cutaneous nodules or plaques. Many of the infiltrates were "top-heavy" and polymorphous with admixed eosinophils, macrophages, lymphoid follicles, and non-neoplastic lymphocytes. Other potentially confusing findings were one case each of spongiotic dermatitis and leukocytoclastic vasculitis. The neoplastic cells were often situated at the peripheries of nodules and ranged from those with nuclei that resembled small lymphocytes to others that resembled immunoblasts. Most had eccentrically placed nuclei and fan-shaped cytoplasm. Monotypic kappa-light chain was found in all five cases, accompanied by gamma-heavy chain in two cases, and mu-heavy chain in one. In situ hybridization detected only kappa-mRNA in the four cases that yielded technically satisfactory results. The neoplastic cells did not express the B-cell antigen CD20; T-cells formed the centers of many nodules. Inappropriate staining for CD43 was evident in the neoplastic cells of one case. Because of reports of immunocytomas complicating acrodermatitis chronica atrophicans, we stained sections with an antiserum to Borrelia burgdorferi, which did not detect that organism. In situ hybridization did not detect EBER-1 RNA of the Epstein-Barr virus, which can be present in immunocytomas in immunocompromised patients. One patient died of disease after failing chemotherapy; another is alive with disseminated disease, and three are in remission following excision of lesions alone in two patients and chemotherapy in one patient who had relapsed following both excision and radiation therapy.

Micro-assisted fertilization in patients who have failed subzonal insemination

During the past 3 years we have used direct injection of spermatozoa into the cytoplasm of the oocyte (DISCO) in an attempt to procure conception in vitro where subzonal insemination (SUZI) has failed. Acknowledging the paucity of information about this invasive procedure in humans, it was clearly the only alternative for some patients. A total of 58 patients (cycles) who had had previously failed SUZI elected for this approach. Sibling oocytes, where possible, were used as a comparison between DISCO, SUZI, partial zona dissection (PZD) and microdrop in-vitro fertilization (IVF). Fertilization and embryo transfer was achieved by 66% (n = 38) of patients. Patients with embryos derived solely from DISCO (n = 19) produced four clinical pregnancies (21%), four patients had embryo transfer from SUZI embryos only with no pregnancies, and 15 had embryo transfer from a mixture of SUZI and DISCO embryos, with one dizygotic twin pregnancy from a combined SUZI and DISCO embryo transfer (7%). Twins, one male and one female, have been delivered, there has been one miscarriage and two pregnancies are ongoing. Of the 627 oocytes, 251 were used for DISCO and 71 (28%) were fertilized, 296 were used for SUZI and 29 (10%) were fertilized; 70 were used for PZD, two (3%) were fertilized, and none of the 10 undergoing microdrop IVF were fertilized. Of the 58 patients (cycles) 31% (n = 19) had fertilization with DISCO only, 8% (n = 4) with SUZI only, 28% (n = 15) with both SUZI and DISCO, while only one (2%) had fertilization with PZD.(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of tamoxifen on the multidrug-resistant phenotype in human breast cancer cells: isobologram, drug accumulation, and M(r) 170,000 glycoprotein (gp170) binding studies

We have performed isobologram analyses of the ability of tamoxifen (TAM) to alter the response to Adriamycin (ADR) and vinblastine (VBL) in human breast cancer cells. MCF-7 cells express functional receptors for estrogen and progesterone but do not express detectable levels of M(r) 170,000 glycoprotein (gp170). CL 10.3 and MCF-7ADR cells are MCF-7 variants which express gp170. CL 10.3 but not MCF-7ADR cells express functional steroid hormone receptors. Tamoxifen (1-2.5 microM) interacts synergistically with ADR and VBL in CL 10.3 and MCF-7ADR cells. TAM increases the cytotoxicity of VBL and ADR and the intracellular levels of [3H]VBL by approximately 2-3-fold. TAM also prevents the binding of [3H]azidopine to gp170. The ability of TAM to concurrently increase the cytotoxic effects of ADR and VBL, increase VBL accumulation, and inhibit the binding of azidopine to gp170 strongly implies that the synergistic effects of TAM are mediated through its effects on gp170. TAM produces an antagonistic to additive interaction with ADR and VBL in MCF-7 cells, and at high concentrations (5 microM) the synergy apparent in CL 10.3 and MCF-7ADR cells is lost. While TAM clearly has a significant potential for use as a chemosensitizing agent, the design of clinical trials may require careful consideration.

T cells are the principal source of interleukin-5 mRNA in allergen-induced rhinitis

We have investigated the phenotype of interleukin-5 (IL-5) mRNA+ cells in the nasal mucosa of subjects with allergic rhinitis. Serial cryostat sections were cut from paraformaldehyde-fixed snap-frozen nasal biopsies from six patients, before and 24 h after local allergen provocation with grass pollen. Immunocytochemistry (APAAP) was followed by in situ hybridization on the same sections. For immunocytochemistry, antibodies against CD3, tryptase, and major basic protein (MBP) were used to identify T cells, mast cells, and eosinophils, respectively. Hybridization studies were performed using a Digoxigenin-labeled IL-5 riboprobe. Nitroblue tetrazolium (NBT) and X-phosphate-5-bromo-4-chloro-3- indoly phosphate (BCIP) served as chromogens to detect hybridized IL-5 mRNA signals. The majority of IL-5 mRNA+ cells were CD3+ (83.2%), whereas the remainder were either tryptase+ (11.3%) or MBP+ (5.4%). In contrast, only a few IL-5 mRNA+ cells were observed in nasal biopsies before challenge, all of which were co-localized to CD3+ cells. These results indicate that CD3+ cells are the principal cellular source of IL-5 transcripts in the nasal mucosa 24 h after allergen-induced late-phase nasal responses.

A multicenter study on the use of pulsed low-intensity direct current for healing chronic stage II and stage III decubitus ulcers

BACKGROUND AND DESIGN

Pulsed low-intensity direct current (300 to 600 microA) has been used in a double-blind placebo multicenter study in the treatment of stage II and stage III chronic decubitus ulcers.

RESULTS

Seventy-four ulcers were treated in four centers. Forty-three patients were selected for the experimental group, and 31 control subjects used the sham instrument (placebo group). In the treated group, 25 ulcers (58%) healed in 8 weeks, whereas in the placebo group, only one ulcer (3%) healed and most ulcers increased in size. Statistical analysis, based on surface area and ulcer depth before and after treatment, showed that low-intensity direct current had a significant influence on the healing rates for these ulcers (P < .0001). Experiments with guinea pigs (n = 10) showed that pulsed low-intensity direct current caused a rapid calcium flux in the epidermis.

CONCLUSIONS

Pulsed low-intensity direct current represents a useful approach for the treatment of stage II and stage III chronic decubitus ulcers by increasing the healing rate. The growth of fibroblasts and keratinocytes may be enhanced by pulsed low-intensity direct current due to changes in calcium homeostasis.

Influence of grass pollen immunotherapy on cellular infiltration and cytokine mRNA expression during allergen-induced late-phase cutaneous responses

We have studied the influence of grass pollen immunotherapy on cellular infiltration and cytokine mRNA expression during allergen-induced late-phase cutaneous responses. In a double-blind, placebo-controlled trial of immunotherapy in 40 adult hay fever sufferers, clinical improvement was accompanied by a decrease in the size of the late-phase skin response. When the immunotherapy-treated group was compared with the placebo group, analysis of skin biopsies obtained 24 h after intradermal allergen revealed a significant reduction in the number of infiltrating CD3+ (P = 0.04) and CD4+ (P = 0.009) cells and a trend for a decrease in EG2+ eosinophils (P = 0.08). Treatment did not influence allergen-induced recruitment of CD8+ cells, neutrophils, or macrophages. Unexpected increases in expression of CD25 (P = 0.006) and HLA-DR (P = 0.007) were observed in the actively treated group. In situ hybridization using a panel of riboprobes demonstrated "TH2-type" (IL-4, IL-5) cytokine mRNA responses in both groups of patients. In contrast, significant hybridization for IL-2 (8/16 patients, P = 0.02) and for interferon-gamma (6/16 patients, P = 0.04) was observed only in the actively treated group. These findings indicate that immunotherapy is associated with suppression of allergen-induced CD4+ T lymphocyte infiltration, but among the cells that are recruited, there is upregulation of CD25 and HLA-DR. At least in this model, immunotherapy does not appear to affect expression of TH2-pattern cytokines in response to allergen exposure, but expression of mRNA for Th1-type cytokines was enhanced in half of the patients. The results support the view that immunotherapy may possibly be working through induction of T cell tolerance.

Bipolaris-induced orbital cellulitis

We report a patient who rapidly developed unilateral proptosis and complete ophthalmoplegia following blunt trauma to the orbit. Computed tomography (CT) scan revealed a mass involving the sinuses and orbit with erosion of the cribriform plate. Biopsy of this suspected neoplasm revealed features consistent with allergic Aspergillus sinusitis, but cultures later grew a Bipolaris species. Our review of the literature suggests that when allergic fungal sinusitis involves the orbit, Bipolaris is a more commonly isolated organism than Aspergillus. Additionally, extraocular motility impairment and proptosis occur more frequently than visual loss. Treatment is controversial, but surgical drainage followed by corticosteroids is the most often recommended therapy.

No association between serum cholesterol and growth in preadolescent American children

To determine the relation between serum cholesterol level (SCL) and growth in preadolescent children (2-12 years of age) in the United States, we examined the association of SCL and three measures of growth in a national sample of American children from 1971 to 1974. We investigated three parameters: sitting height, standing height, and weight and undertook separate analyses for sex and race. We found no consistent statistically significant associations with any of these three measures of growth. This result did not change when we adjusted the data for age alone or for age, poverty index, serum protein level, and hematocrit. We conclude that growth in this population group is not dependent on SCL.

HPV-16-related DNA sequences in Kaposi's sarcoma

In the USA, Kaposi's sarcoma associated with the acquired immunodeficiency syndrome (AIDS-KS) is ten times more common in homosexual or bisexual men than in heterosexual men with AIDS. One explanation for this finding is that AIDS-KS may be caused by an infectious agent. Because there is a high incidence of human papillomavirus (HPV) infection, especially HPV-16, in homosexual men, we have sought HPV DNA sequences in Kaposi's sarcoma. We used the polymerase chain reaction with a primer pair specific for the highly conserved E6 region of HPV-16 to detect HPV-16 homologous DNA fragments in tumour tissues from 97 patients with KS and in KS-derived cell cultures. HPV DNA sequences were found in 11 of 69 KS skin tumours from homosexual men with AIDS-KS, in 3 of 11 KS biopsy specimens from homosexual men who had no clinical or laboratory evidence of HIV-infection, and in 5 of 17 KS skin lesions from HIV-1-negative elderly men and women with classic KS. The same primer pair amplified HPV-16 homologous fragments from two different continuous cell cultures derived from pleural effusion fluid of patients with pulmonary AIDS-KS and two continuous cell cultures derived from KS skin lesions. The findings suggest that HPV-16-related DNA sequences are associated with different forms of KS and may have a role in the pathogenesis of this neoplasm.

Detection of human papillomavirus DNA in squamous cell carcinoma of the nail bed and finger determined by polymerase chain reaction

Increasing evidence supports the association of squamous cell carcinoma of the finger and nail bed with human papillomavirus infection. We treated 12 patients with squamous cell carcinoma of the finger and nail bed, none of whom was originally diagnosed as having a malignant lesion. Half of the patients were referred for carbon dioxide laser ablation of what was believed to be a recalcitrant verruca vulgaris. Our objective was to evaluate these lesions for the presence of human papillomavirus by in situ hybridization techniques and the polymerase chain reaction. This is the first report of use of the polymerase chain reaction to detect human papillomavirus in formalin-fixed, paraffin-embedded specimens of periungual squamous cell carcinoma. Seven of the 12 lesions were evaluated for the presence of human papillomavirus by both in situ hybridization and the polymerase chain reaction. Five of the seven periungual lesions were found to contain human papillomavirus type 16 but not type 18 DNA with use of the polymerase chain reaction technique. In situ hybridization failed to identify human papillomavirus in any of these patients' tumors. Our data confirm the association between human papillomavirus and squamous cell carcinoma of the periungual region and suggest that biopsies should be performed on chronic, isolated lesions of the finger in adults before therapy is initiated.

Ovulation method use during breastfeeding: is there increased risk of unplanned pregnancy?

Data from two prospective studies of the ovulation method were used to assess pregnancy rates and users' fertility-related behaviors among breastfeeding women. The rate of unplanned pregnancy was less than 1% during the first 6 months of lactational amenorrhea. However, the unplanned pregnancy rate was elevated among breastfeeders during the months after menses return compared with the pregnancy rate during nonlactating cycles. Rates were also elevated at the time when infant feeding supplementation was started. This increase in unplanned pregnancies was not directly attributable to nonadherence to the ovulation method rules; there was some indication that adherence to the rules actually may be increased during those months. Therefore, special emphasis on both the need for improved breastfeeding support to delay menses return and the increased potential for method failure among new users during this period of time should be incorporated into ovulation method training and support programs.

A prospective analysis of cholestasis in infants supported with extracorporeal membrane oxygenation

Cholestasis develops in many infants supported with extracorporeal membrane oxygenation. We prospectively investigated the role of hemolysis and di-(2-ethylhexyl) phthalate exposure in the development of this cholestasis. Both di-(2-ethylhexyl) phthalate levels and hemolysis, as measured by maximum free hemoglobin, were significantly (p less than 0.025) associated with the degree of cholestasis. Other clinical and laboratory factors that may contribute to cholestasis were also investigated and not found to be related to the degree of cholestasis. We speculate that hemolysis during extracorporeal membrane oxygenation support produces a large bilirubin load whose excretion is inhibited by mechanisms similar to the inspissated bile syndrome and/or by di-(2-ethylhexyl) phthalate. This would result in a predominantly direct hyperbilirubinemia with little evidence of hepatocellular or canalicular injury.

Eosinophils, T-lymphocytes, mast cells, neutrophils, and macrophages in bronchial biopsy specimens from atopic subjects with asthma: comparison with biopsy specimens from atopic subjects without asthma and normal control subjects and relationship to bronchial hyperresponsiveness

Bronchial biopsy specimens were obtained by fiberoptic bronchoscopy from 21 atopic subjects with asthma, 10 atopic subjects without asthma, and 12 normal healthy control subjects. With immunohistochemical techniques and a panel of monoclonal antibodies, inflammatory cells were identified and counted in the bronchial mucosa. The mean number of leukocytes (CD45+) and T-lymphocytes (CD3+, CD4+, and CD8+) at two airway levels in the subjects with asthma tended to be higher than in the other groups, but this difference did not achieve statistical significance. Similarly, there were no significant differences in the numbers of mucosal-type or connective tissue-type mast cells, elastase-positive neutrophils, or Leu-M3+ cells in the airway mucosa of subjects with asthma compared with atopic subjects without asthma and healthy control subjects. In contrast, significantly more interleukin-2 receptor-positive (CD25+) cells and "activated" (EG2+) eosinophils (EOSs) were present in the airways of subjects with asthma at both proximal and subsegmental biopsy sites. When the relationships between numbers of T-lymphocytes, activated (CD25+) cells, and EOSs were analyzed, there were positive correlations between CD3 and EG2, between CD3 and CD25, and between CD25 and EG2 positive cells in the airways of subjects with asthma. Furthermore, the ratio of EG2+ to CD45+ cells correlated with the provocative concentration of methacholine that caused a 20% decrease of FEV1 in hyperresponsive subjects. Although these associations do not prove a causal relationship, the results support the hypothesis that activated (CD25) T-lymphocytes release products which regulate recruitment of EOSs into the airway wall. In addition, our findings suggest that, in the large airways at least, asthma is not associated with hyperplasia of either mucosal-type or connective tissue-type mast cell.

Suitable survival and half-life of red cells after frozen storage in excess of 10 years

To examine the appropriateness of the Food and Drug Administration's 10-year storage time for previously frozen red cells, 24-hour posttransfusion survival studies were performed, and the half-life of 3 units of autologous red cells that had been stored for 13.5, 14, and 17 years, respectively, was measured. The units had acceptable freeze-thaw-wash recovery (83.3-91.4%). When a 51Cr label was used for the previously frozen red cells and a simultaneous 52Cr label for freshly drawn autologous red cells was used as a comparison, it was seen that the previously frozen cells had normal 24-hour posttransfusion survival (75.1-88.4%) as well as normal half-life (23-33.7 days). These findings support further extension of the maximum allowable storage time for previously frozen red cells.

Immunotherapy and allergic inflammation

A double-blind placebo-controlled trial of allergen injection immunotherapy in adult patients with severe summer hayfever. We used a partially purified biologically standardised grass pollen depot preparation (Alutard SQ, ALK Denmark Ltd.). Immunotherapy was extremely effective in reducing symptoms and medication requirements. Clinical improvement was accompanied by a decrease in both a target organ (conjunctival) and skin sensitivity. The injections were well-tolerated with minimal side effects. The results suggest that 30 minutes rather than 2 hours is an acceptable post-injection observation period. Successful immunotherapy was accompanied by suppression of the late cutaneous response to allergen. Specific immunostaining of skin biopsies revealed inhibition of the characteristic CD4+ T cell and EG2+ activated eosinophil cellular infiltrate during the late response. There was a significant relationship between CD4+ T cell and eosinophil counts after immunotherapy, i.e. the lower the number of infiltrating CD4+ cells, the lower the eosinophil counts. An unexpected finding was a prominent CD25+ (interleukin-2 receptor positive) cellular infiltrate which was only observed following Alutard SQ. Further studies involving double immunostaining methods should identify the phenotype of these activated, IL-2R+ cells. Based on murine studies Mosmann and colleagues have classified T cell responses into two types according to their profile of lymphokine production [11]. TH1 cells produce predominantly the IL-4 family of cytokines (IL-3, IL-4, IL-5) whereas TH2 cells produce predominantly interleukin-2 and interferon gamma. Insofar as the Mosmann classification may possibly be relevant to human T cell responses, the above findings would support a switch from a "TH2-" to a "TH1-" lymphocyte response following immunotherapy.(ABSTRACT TRUNCATED AT 250 WORDS)