Soluble CD4 and CD8 in serum from patients with localized scleroderma

Consensus statement on the diagnosis and treatment of sclerosing diseases of the skin, Part 1: Localized scleroderma, systemic sclerosis and overlap syndromes

The term 'sclerosing diseases of the skin' comprises specific dermatological entities, which have fibrotic changes of the skin in common. These diseases mostly manifest in different clinical subtypes according to cutaneous and extracutaneous involvement and can sometimes be difficult to distinguish from each other. The present consensus provides an update to the 2017 European Dermatology Forum Guidelines, focusing on characteristic clinical and histopathological features, diagnostic scores and the serum autoantibodies most useful for differential diagnosis. In addition, updated strategies for the first- and advanced-line therapy of sclerosing skin diseases are addressed in detail. Part 1 of this consensus provides clinicians with an overview of the diagnosis and treatment of localized scleroderma (morphea), and systemic sclerosis including overlap syndromes.

Sklerodermie – „die harte Haut“

Unter dem Begriff Sklerodermie ist eine heterogene Gruppe von Erkrankungen zusammengefasst, die eine kutane Sklerose gemeinsam haben. Die einzelnen Erkrankungen variieren in der Beteiligung betroffener Strukturen wie Haut, Fettgewebe, Muskulatur, Gelenkstrukturen, Knochen, innerer Organe und der damit einhergehenden Krankheitsausprägung. Es lassen sich grundsätzlich zwei verschiedene Subtypen unterscheiden: die lokalisierte Sklerodermie (LoS) und die systemische Sklerose (SSc), die sich jeweils in weitere Subgruppen unterteilen lassen. Es handelt sich um zwei verschiedene Erkrankungen, die sich in der Ausprägung der Hautsklerosierung, der Beteiligung innerer Organe, im Antikörper-Profil, im Krankheitsmanagement sowie der Prognose unterscheiden. Darüber hinaus gibt es Krankheitsbilder, die eine Sklerodermie imitieren und daher als sklerodermie-artige Erkrankungen oder auch als Pseudosklerodermien bezeichnet werden. Um die richtige Diagnose stellen zu können, ist ein standardisiertes diagnostisches Vorgehen bedeutsam. Die frühe Diagnosestellung ist wichtig, um frühzeitige eine Therapie einleiten zu können, und so funktionelle kutane und extrakutane Einschränkungen und auch kosmetische Schäden gering halten zu können.

Effects of duck circovirus on immune function and secondary infection of Avian Pathogenic Escherichia coli

Duck circovirus (DuCV) infection occurs frequently in ducks in China and is generally believed to lead to immunosuppression and secondary infection, though there has been a lack of detailed research and direct evidence. In this study, one-day-old Cherry Valley ducklings were artificially infected with DuCV alone and co-infected with DuCV and Avian Pathogenic Escherichia coli (APEC). The immune indexes at 32 d old were systematically monitored, including immune organ weight, lymphocyte transformation rate, IL-10, IL-12, soluble CD4 (sCD4), soluble CD8 (sCD8), IFN-γ, viral loads in each organ, APEC colonization, and so on. The results showed the development of immune organs in ducklings was affected, resulting in a decrease in the lymphocyte transformation rate (LTR), IL-12, sCD4, sCD8, IFN-γ and an increase in IL-10 content at 8 to 32 d postinfection (dpi). In the detection of virus loads in some organs, it was found that 8 dpi, DuCV existed stably in various organs, suggesting the importance of preventing and controlling the virus in the early stage of culture. The results of exploring the DuCV infection that shows some influence on secondary infection by APEC. The results showed that DuCV infection could significantly enhance the pathogenicity of APEC and the colonization ability of APEC in vivo. DuCV can induce more serious APEC infection in 24 dpi than in 14 dpi. Based on the above results, it can be concluded that DuCV infection will affect the immune system, cause immunosuppression, and lead to more serious secondary infection.

European Dermatology Forum S1-guideline on the diagnosis and treatment of sclerosing diseases of the skin, Part 1: localized scleroderma, systemic sclerosis and overlap syndromes

The term 'sclerosing diseases of the skin' comprises specific dermatological entities, which have fibrotic changes of the skin in common. These diseases mostly manifest in different clinical subtypes according to cutaneous and extracutaneous involvement and can sometimes be difficult to distinguish from each other. The present guideline focuses on characteristic clinical and histopathological features, diagnostic scores and the serum autoantibodies most useful for differential diagnosis. In addition, current strategies in the first- and advanced-line therapy of sclerosing skin diseases are addressed in detail. Part 1 of this guideline provides clinicians with an overview of the diagnosis and treatment of localized scleroderma (morphea), and systemic sclerosis including overlap syndromes of systemic sclerosis with diseases of the rheumatological spectrum.

Increased soluble CD4 in serum of rheumatoid arthritis patients is generated by matrix metalloproteinase (MMP)-like proteinases

Higher soluble CD4 (sCD4) levels in serum have been detected in patients of infectious and chronic inflammatory diseases. However, how and why sCD4 is produced remains poorly understood. We establish sensitive ELISA and WB assays for sCD4 detection in conditioned medium of in vitro cell culture system and serum of chronic inflammatory patients. Serum samples from patients with systemic lupus erythematosus (SLE) (n = 79), rheumatoid arthritis (RA) (n = 59), ankylosing spondylitis (AS) (n = 25), gout (n = 31), and normal controls (n = 99) were analyzed using ELISA for sCD4 detection. Results from each assay were analyzed by the Kruskal-Wallis test. Dunn's multiple comparison post-test was then applied between groups. We confirm that cells expressing exogenous CD4 produce sCD4 in a constitutive and PMA-induced manner. Importantly, sCD4 production in a heterologous expression system is inhibited by GM6001 and TAPI-0, suggesting receptor shedding by matrix metalloproteinase (MMP)-like proteinases. Moreover, similar findings are recapitulated in human primary CD4(+) T cells. Finally, we show that serum sCD4 levels are increased in patients of chronic inflammatory diseases including RA and SLE, but not in those with gout. Intriguingly, sCD4 levels in RA patients are correlated positively with the disease activities and higher sCD4 levels seem to associate with poor prognosis. Taken together, we conclude that CD4 is shed from cell surface by a MMP-like sheddase and sCD4 level is closely related with the inflammatory condition in certain chronic diseases. Hence, sCD4 might be considered an important parameter for RA disease progression with potential diagnostic importance.

Localized scleroderma

Localized scleroderma (also called morphea) is a term encompassing a spectrum of sclerotic autoimmune diseases that primarily affect the skin, but also might involve underlying structures such as the fat, fascia, muscle, and bones. Its exact pathogenesis is still unknown, but several trigger factors in genetically predisposed individuals might initially lead to an immunologically triggered release of pro-inflammatory cytokines, resulting in a profound dysregulation of the connective tissue metabolism and ultimately to induction of fibrosis. To date, there are no specific serological markers available for localized scleroderma. Within the last years, several validated clinical scores have been introduced as potential outcome measures for the disease. Given the rarity of localized scleroderma, only few evidence-based therapeutical treatment options exist. So far, the most robust data is available for ultraviolet A1 phototherapy in disease that is restricted to the skin, and methotrexate alone or in combination with systemic corticosteroids in more severe disease that additionally affects extracutaneous structures. This practical review summarizes relevant information on the epidemiology, pathogenesis, clinical subtypes and classifications, differential diagnoses, clinical scores and outcome measures, and current treatment strategies of localized scleroderma.

Dependence of conformation of D3/D4 domains of human CD4 on glycosylation and membrane attachment

Conformational dynamics of human T-helper cell receptor protein CD4 has been studied with the help of monoclonal antibody (mAb) T6. The mAb T6 discriminates between s- and m-forms of CD4 and recognizes a specific conformation of the soluble (s) form of CD4 including the first nine amino acids of CD4 transmembrane sequence. However, change of tryptophan for serine in position 2 in this sequence destabilizes the T6-type conformation. By enzymatic deglycosylation and deletions of glycosylation sites, we show that T6-type conformation depends on glycosylation in both sites (Asn271 and Asn300). We show also that the sugars are not involved in direct binding to the antibody but stabilize the D3/D4 local conformation. Deglycosylated forms of sCD4 in vivo acquire a specific conformation similar to the wild type sCD4, which however cannot be restored after denaturation/renaturation under conditions of non-reducing Western blot. This observation indicates that the correct protein folding needs chaperone assistance and cannot be achieved in vitro. Completely non-glycosylated sCD4 is synthesized and secreted into the growth medium. In the medium, this mutant appears to be unstable and aggregates during time. In a contrast to soluble CD4, mutations in glycosylation sites abrogate expression of membrane CD4, thus demonstrating a different secretion pathways for soluble and membrane proteins.

Localized scleroderma: a series of 52 patients

BACKGROUND

Localized scleroderma also called morphea is a skin disorder of undetermined cause. The widely recognized Mayo Clinic Classification identifies 5 main morphea types: plaque, generalized, bullous, linear and deep. Whether each of these distinct types has a particular clinical course or is associated with some patient-related features is still unclear.

METHODS

We report here a retrospective series of patients with localized scleroderma with an attempt to identify features related to the type of lesion involved. The medical records of all patients with a diagnosis of localized scleroderma were reviewed by skilled practitioners. Lesions were classified according to the Mayo Clinic Classification. The relationship between each lesion type and various clinical features was tested by non-parametrical methods.

RESULTS

The sample of 52 patients included 43 females and 9 males. Median age at onset was 30 y (range 1-76). Frequencies of patients according to morphea types were: plaque morphea 41 (78.8%) (including morphea en plaque 30 (57.7%) and atrophoderma of Pasini-Pierini 11 (21.1%)), linear scleroderma 14 (26.9%). Nine patients (17.3%) had both types of localized scleroderma. Median age at onset was lower in patients with linear scleroderma (8 y (range 3-44)) than in others (36 y (range 1-77)) (p=0.0003). Head involvement was more common in patients with linear scleroderma (37.5%) than in other subtypes (11.1%) (p=0.05). Atrophoderma of Pasini-Pierini was never located at the head. Systemic symptoms, antinuclear antibodies and the rheumatic factor were not associated with localized scleroderma types or subtypes.

CONCLUSION

These results suggest that morphea types, in adults are not associated with distinct patient features except for age at disease onset (lower) and the localization on the head (more frequent), in patients with lesions of the linear type.

Pathogenesis and therapeutic approaches for improved topical treatment in localized scleroderma and systemic sclerosis

SSc is a chronic progressive disorder of unknown aetiology characterized by excess synthesis and deposition of collagen and other extracellular matrix components in a variety of tissues and organs. Localized scleroderma (LS) differs from SSc in that with LS only skin and occasionally subcutaneous tissues are involved. Although rarely life threatening, LS can be disfiguring and disabling and, consequently, can adversely affect quality of life. There is no known effective treatment for LS, and various options, including, as examples, corticosteroids and other immunomodulatory agents, ultraviolet radiation and vitamin D analogues, are of unproven efficacy. Clinical trials evaluating combination therapy such as corticosteroids with MTX or UVA1 exposure with psoralens have not been established as consistently effective. New immunomodulators such as tacrolimus and thalidomide are also being evaluated. A better understanding of the molecular and cellular mechanisms of LS has led to evaluation of new treatments that modulate profibrotic cytokines such as TGF-beta and IL-4, regulate assembly and deposition of extracellular matrix components, and restore Th1/Th2 immune balance by administering IL-12 or IFN-gamma. IFN-gamma acts by directly inhibiting collagen synthesis and by restoring immune balance. In this review, we evaluate current and future treatment options for LS and cutaneous involvement in SSc. Recent advances in therapy focus mainly on anti-fibrotic agents. Delivery of these drugs into the skin as the target tissue might be a key factor in developing more effective and safer therapy.

Immunohistochemical characterization of the cellular infiltrate in localized scleroderma

BACKGROUND

Localized scleroderma is a connective tissue disorder with hardening of the skin and fibrosis of the affected tissue as the most prominent features. The etiology of localized scleroderma is still unknown, but immunologic factors may play an important role in the pathogenesis. This study was performed to determine the immunohistochemical features of the cellular infiltrate in localized scleroderma.

METHODS

Skin samples were obtained from six patients by 6-mm punch biopsy. The samples were stained with monoclonal antibodies against CD1a, CD3, CD4, CD8, CD20, CD25, CD30, and CD57. The number of cells stained with each monoclonal antibody was calculated.

RESULTS

There were more CD1a+, CD3+, CD4+, CD8+, CD20+, CD25+, and CD57+ cells in the dermal infiltrate in localized scleroderma relative to those in normal controls. The numbers of CD1a+, CD3+, CD4+, CD8+, and CD57+ cells in localized scleroderma were significantly greater than those in normal skin (P < 0.05). The number of CD30+ cells in localized scleroderma was almost the same as that in normal skin.

CONCLUSIONS

This study reveals that T lymphocytes, Langerhans cells, and natural killer cells may play important roles in the pathogenesis of localized scleroderma.

Scleroderma in children and adolescents

The scleroderma disorders remain challenging conditions in pediatric rheumatology to understand pathologically and indeed for which to provide care. It is clear that much progress is being made in the clinical approach to understanding this group of group of disorders. It seems likely that the different lesions of LS may represent unique immunopathogenic mechanisms or perhaps reflect unique genetic or other characteristics of the patients themselves. To take advantage of the revolution in therapies now occurring in rheumatology it is critical that controlled clinical trials are developed with appropriate agreed upon outcome measures for both localized and systemic disease.

Soluble CD4 concentrations predict relapse of post-partum thyroiditis

Post-partum thyroiditis (PPT) is a common autoimmune thyroid disorder which results in significant morbidity at a critical time of a woman's life. The presence of anti-thyroglobulin (anti-TG) and, more so, anti-thryroperoxidase (anti-TPO) antibodies in the first trimester of pregnancy has been reported to forecast subsequent PPT. Despite their predictive value, these tests lack in specificity. We have sought to find an alternative that is more specific and, ideally, which could be tested immediately proximate to the event. We have taken advantage of the high recurrence rate of PPT in subsequent pregnancies to perform a prospective study of serum soluble CD4 (sCD4) and CD8 (sCD8) levels in 22 pregnant women who had at least one previous episode of PPT. This group was matched with 21 pregnant women of comparable age with no evidence of thyroid disease. Both groups of women were sampled in each of the three trimesters of pregnancy, 1 month, 3 months and 6 months post-partum for sCD4, sCD8, thyroid function parameters and antibodies. Twelve of the 22 women with previous PPT had recurrent disease; they were more likely to be cigarette smokers and to have a family history of autoimmune disorders (p<0.05, for both) than those who did not. Half of these women had high anti-TG or anti-TPO each in the first trimester compared to none among those without recurrent PPT and 2/21 controls. Serum sCD8 levels showed no changes over the observation points among the two PPT patient subsets and were comparable to those of the controls. By contrast, serum sCD4 concentrations showed divergent changes in the group with recurrent PPT in the course of pregnancy and postpartum period compared to those without disease recurrence and controls: sCD4 failed to show the physiological fall in the third trimester of pregnancy [19.0+/-1.7 (+/-SD) U/ml vs 15.6+/-2.3 U/ml in controls, NS]. This trend was continued into the first month post-partum when sCD4 levels were clearly higher than in controls (22.1+/-2.6 U/ml compared to 17.9+/-1.9 U/ml in controls, p<0.001) and well before the episode of PPT. An sCD4 serum level outside the 95% reference range at 1 month post-partum (9/12 in recurrent PPT, 1/21 in controls) yields a relative risk of 6.9 (chi2=14.67, p<0.001) compared to 3.3 for first trimester thyroid antibody positivity (p=0.029). In summary, we describe a reliable test for forecasting PPT that can be obtained immediately proximate to the possible event. If our findings are verified in larger studies, the measurement of serum sCD4 concentration drawn in the first month post-partum may prove an ideal test for population screening for impending PPT.

Methotrexate and corticosteroid therapy for pediatric localized scleroderma

INTRODUCTION

Localized scleroderma (LS) can cause permanent disability, and there is no universally accepted effective treatment. Methotrexate (MTX) has been shown to be effective in the treatment of systemic sclerosis.

OBJECTIVES

To determine the efficacy and tolerability of MTX and corticosteroid therapy in patients with LS.

METHODS

MTX, 0.3 to 0.6 mg/kg per week, was given to 10 patients (6 girls, 4 boys; mean age, 6.8 years; mean disease duration before starting treatment, 4 years) with active LS. In addition, pulse intravenous methylprednisolone, 30 mg/kg for 3 days monthly for 3 months, was given to 9 patients at the initiation of therapy.

RESULTS

One patient discontinued taking MTX after a month; the remaining 9 patients responded. The median time to response was 3 months (95% CI, 1.15-4.85). One responder discontinued taking MTX after a year because of leukopenia; the LS worsened within 2 months. In another patient LS flared up after 10 months and responded to an increased dose of MTX and intravenous methylprednisolone. At the last follow-up visit, all patients who continued to receive MTX therapy had inactive skin lesions.

CONCLUSION

Treatment with MTX and corticosteroids appears to be effective in the treatment of LS and is generally well tolerated. A placebo-controlled study is necessary to confirm the efficacy of MTX therapy in LS.

Morphea and localized scleroderma in children

Localized scleroderma refers to a diverse spectrum of disorders that involve fibrosis of the skin. Children are more likely than adults to develop localized forms of scleroderma. This condition may have devastating effects on growth and development such as limb asymmetry, flexion contractures, and psychological disability. The pathogenesis of localized scleroderma is unknown but its possible relation to Borrelial infection is discussed. This article reviews associated laboratory and radiologic abnormalities, and discusses implications for monitoring disease activity. There is no universally effective therapy for this idiopathic condition and therapy is limited. A rationale for treatment based on disease subtype and severity is provided.