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Pereira da Costa R, Bandeira M, Fontes T, Romeu JC, Dourado E. Cutaneous pathergy: Thinking beyond Behçet's disease. Int J Rheum Dis 2024; 27:e15233. [PMID: 38973397 DOI: 10.1111/1756-185x.15233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Revised: 06/01/2024] [Accepted: 06/06/2024] [Indexed: 07/09/2024]
Affiliation(s)
- Roberto Pereira da Costa
- Unidade Local de Saúde Santa Maria, Rheumatology Department, Lisbon Academic Medical Center (CAML), Lisbon, Portugal
- Rheumatology Research Unit, Faculdade de Medicina, Instituto de Medicina Molecular João Lobo Antunes, CAML, Universidade de Lisboa, Lisbon, Portugal
| | - Matilde Bandeira
- Unidade Local de Saúde Santa Maria, Rheumatology Department, Lisbon Academic Medical Center (CAML), Lisbon, Portugal
- Rheumatology Research Unit, Faculdade de Medicina, Instituto de Medicina Molecular João Lobo Antunes, CAML, Universidade de Lisboa, Lisbon, Portugal
| | - Tomás Fontes
- Unidade Local de Saúde Santa Maria, Rheumatology Department, Lisbon Academic Medical Center (CAML), Lisbon, Portugal
- Rheumatology Department, Hospital do Divino Santo, Ponta Delgada, Portugal
| | - José Carlos Romeu
- Unidade Local de Saúde Santa Maria, Rheumatology Department, Lisbon Academic Medical Center (CAML), Lisbon, Portugal
| | - Eduardo Dourado
- Rheumatology Research Unit, Faculdade de Medicina, Instituto de Medicina Molecular João Lobo Antunes, CAML, Universidade de Lisboa, Lisbon, Portugal
- Rheumatology Department, Unidade Local de Saúde da Região de Aveiro, Aveiro, Portugal
- Aveiro Rheumatology Research Center, Egas Moniz Health Alliance, Aveiro, Portugal
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Akbaba TH, Ekici M, Çolpak Aİ, Brown KL, Karadağ Ö, Balci-Peynircioglu B. Behçet's syndrome: recent advances to aid diagnosis. Clin Exp Med 2023; 23:4079-4090. [PMID: 37897656 DOI: 10.1007/s10238-023-01226-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 10/17/2023] [Indexed: 10/30/2023]
Abstract
Behçet's syndrome is a recurring inflammatory multiorgan disorder affecting the skin, mucosa, eyes, joints, stomach, and central nervous system. Behçet's syndrome epidemiology varies greatly among populations (0.64-420/100,000), and Behçet's syndrome has gained increasing international acclaim in the recent 50 years due to raising awareness of the syndrome, although it is rare in most population. In addition to the unclear etiology of the syndrome, the diagnosis of Behçet's syndrome is complicated by a vague clinical presentation, phenotypic heterogeneity and/or incomplete representation, and the lack of any specific laboratory, radiographic, or histological findings. There exists a dire need to elucidate factors that contribute to disease pathogenesis and/or are associated with clinical features of Behçet's syndrome and the classification of different forms of the syndrome. The identification of such molecular, cellular, and/or clinical factors are crucial for timely diagnosis and efficacious management of Behçet's syndrome. We discuss recent advances in the clinical diagnosis of Behçet's syndrome and related contributions of genetics, epigenetics, microbiome, inflammasomes, and autoantibodies to the improved diagnosis, management, and understanding of Behçet's syndrome.
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Affiliation(s)
- Tayfun Hilmi Akbaba
- Department of Medical Biology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
- BC Children's Hospital Research Institute, Vancouver, Canada
- Division of Rheumatology, Department of Pediatrics, Faculty of Medicine, University of British Columbia, Vancouver, Canada
| | - Mustafa Ekici
- Division of Rheumatology, Department of Internal Medicine, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Ayşe İlksen Çolpak
- Department of Neurology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Kelly L Brown
- BC Children's Hospital Research Institute, Vancouver, Canada
- Division of Rheumatology, Department of Pediatrics, Faculty of Medicine, University of British Columbia, Vancouver, Canada
| | - Ömer Karadağ
- Division of Rheumatology, Department of Internal Medicine, Faculty of Medicine, Hacettepe University, Ankara, Turkey
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Joubert M, Desbois AC, Domont F, Ghembaza A, Le Joncour A, Mirouse A, Maalouf G, Leclercq M, Touhami S, Cacoub P, Bodaghi B, Saadoun D. Behçet's Disease Uveitis. J Clin Med 2023; 12:jcm12113648. [PMID: 37297843 DOI: 10.3390/jcm12113648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Revised: 04/26/2023] [Accepted: 05/20/2023] [Indexed: 06/12/2023] Open
Abstract
Uveitis in Behçet's disease (BD) is frequent (40% of cases) and is a major cause of morbidity. The age of onset of uveitis is between 20 and 30 years. Ocular involvement includes anterior, posterior, or panuveitis. Uveitis may be the first sign of the disease in 20% of cases or it may appear 2 or 3 years after the first symptoms. Panuveitis is the most common presentation and is more commonly found in men. Bilateralization usually occurs on average 2 years after the first symptoms. The estimated risk of blindness at 5 years is 10-15%. BD uveitis has several ophthalmological features that distinguish it from other uveitis. The main goals in the management of patients are the rapid resolution of intraocular inflammation, the prevention of recurrent attacks, the achievement of complete remission, and the preservation of vision. Biologic therapies have changed the management of intraocular inflammation. The aim of this review is to provide an update to a previous article by our team on pathogenesis, diagnostic approaches, and the therapeutic strategy of BD uveitis.
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Affiliation(s)
- Morgane Joubert
- AP-HP. Centre de Référence des Maladies Auto-Immunes Systémiques Rares, Centre de Référence des Maladies Auto-Inflammatoires et de l'Amylose Inflammatoire, F-75013 Paris, France
| | - Anne-Claire Desbois
- AP-HP. Centre de Référence des Maladies Auto-Immunes Systémiques Rares, Centre de Référence des Maladies Auto-Inflammatoires et de l'Amylose Inflammatoire, F-75013 Paris, France
| | - Fanny Domont
- AP-HP. Centre de Référence des Maladies Auto-Immunes Systémiques Rares, Centre de Référence des Maladies Auto-Inflammatoires et de l'Amylose Inflammatoire, F-75013 Paris, France
| | - Amine Ghembaza
- AP-HP. Centre de Référence des Maladies Auto-Immunes Systémiques Rares, Centre de Référence des Maladies Auto-Inflammatoires et de l'Amylose Inflammatoire, F-75013 Paris, France
| | - Alexandre Le Joncour
- AP-HP. Centre de Référence des Maladies Auto-Immunes Systémiques Rares, Centre de Référence des Maladies Auto-Inflammatoires et de l'Amylose Inflammatoire, F-75013 Paris, France
| | - Adrien Mirouse
- AP-HP. Centre de Référence des Maladies Auto-Immunes Systémiques Rares, Centre de Référence des Maladies Auto-Inflammatoires et de l'Amylose Inflammatoire, F-75013 Paris, France
| | - Georgina Maalouf
- AP-HP. Centre de Référence des Maladies Auto-Immunes Systémiques Rares, Centre de Référence des Maladies Auto-Inflammatoires et de l'Amylose Inflammatoire, F-75013 Paris, France
| | | | - Sarah Touhami
- Department of Ophthalmology, Pitié-Salpêtrière University Hospital, Sorbonne Universités, F-75013 Paris, France
| | - Patrice Cacoub
- AP-HP. Centre de Référence des Maladies Auto-Immunes Systémiques Rares, Centre de Référence des Maladies Auto-Inflammatoires et de l'Amylose Inflammatoire, F-75013 Paris, France
| | - Bahram Bodaghi
- Department of Ophthalmology, Pitié-Salpêtrière University Hospital, Sorbonne Universités, F-75013 Paris, France
| | - David Saadoun
- AP-HP. Centre de Référence des Maladies Auto-Immunes Systémiques Rares, Centre de Référence des Maladies Auto-Inflammatoires et de l'Amylose Inflammatoire, F-75013 Paris, France
- Institut National de la Santé Et de la Recherche Médicale (INSERM), Unité Médical de Recherche (UMR)S 59, F-75013 Paris, France
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Vitale A, Berlengiero V, Caggiano V, Barneschi S, Mourabi M, Sota J, Gentileschi S, Maggio MC, Gaggiano C, Tarsia M, Tosi GM, Lopalco G, Fabiani C, Frediani B, Cantarini L. The diagnostic role of pathergy test in patients with Behçet's disease from the Western Europe. Intern Emerg Med 2023; 18:77-83. [PMID: 36542302 DOI: 10.1007/s11739-022-03117-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Accepted: 09/29/2022] [Indexed: 12/24/2022]
Abstract
The aim of the study is to evaluate the frequency and features of positive pathergy test (PPT) in Italy, its role in the diagnosis of Behçet's disease (BD), and any association with other BD-related manifestations. 52 BD patients, 52 patients with axial spondyloarthritis (ax-SpA), and 26 healthy controls (HCs) underwent intradermal injection of normal saline and intradermal needle soaked with fresh self-saliva. The results of pathergy tests were statistically analysed in the light of demographic, clinical, and therapeutic features of subjects enrolled. Pathergy test performed with saline resulted always negative in all groups. Skin prick test using self-saliva resulted in the occurrence of a papule in 3 (5.8%) BD patients and in 1 (1.9%) patient with ax-SpA. A ≥ 15 mm erythematous area surrounding the needle prick site was observed in 22 (42.3%) BD patients, 5 (9.6%) patients with ax-SpA, and 2 (7.7%) HCs (p = 0.00002). The frequency of skin erythema was significantly more frequent in patients with BD than those with ax-SpA (p < 0.0001) and HCs (p = 0.003). No statistically significant differences were observed between ax-SpA patients and HCs (p = 1.000). The occurrence of skin erythema at pathergy test was not associated with any BD-related clinical manifestation. Erythema at self-saliva prick test presented a sensitivity of 42.31% (CI 28.73-56.80%) and a specificity of 91.03% (CI 82.38-96.32%). The development of a ≥ 15 mm erythematous area at self-saliva prick test could be sufficient to unveil the hyper-reactivity of the innate immune system in BD patients from Western Europe, where the development of skin erythema shows good sensitivity and specificity toward the diagnosis of BD.
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Affiliation(s)
- Antonio Vitale
- Department of Medical Sciences, Surgery and Neurosciences, Research Center of Systemic Autoinflammatory Diseases and Behçet's Disease Clinic and Rheumatology-Ophthalmology Collaborative Uveitis Center, Policlinico ''Le Scotte'', University of Siena, Viale Bracci 16, 53100, Siena, Italy
| | - Virginia Berlengiero
- Department of Medical Sciences, Surgery and Neurosciences, Research Center of Systemic Autoinflammatory Diseases and Behçet's Disease Clinic and Rheumatology-Ophthalmology Collaborative Uveitis Center, Policlinico ''Le Scotte'', University of Siena, Viale Bracci 16, 53100, Siena, Italy
| | - Valeria Caggiano
- Department of Medical Sciences, Surgery and Neurosciences, Research Center of Systemic Autoinflammatory Diseases and Behçet's Disease Clinic and Rheumatology-Ophthalmology Collaborative Uveitis Center, Policlinico ''Le Scotte'', University of Siena, Viale Bracci 16, 53100, Siena, Italy
| | - Sara Barneschi
- Department of Medical Sciences, Surgery and Neurosciences, Research Center of Systemic Autoinflammatory Diseases and Behçet's Disease Clinic and Rheumatology-Ophthalmology Collaborative Uveitis Center, Policlinico ''Le Scotte'', University of Siena, Viale Bracci 16, 53100, Siena, Italy
| | - Mariam Mourabi
- Department of Medical Sciences, Surgery and Neurosciences, Research Center of Systemic Autoinflammatory Diseases and Behçet's Disease Clinic and Rheumatology-Ophthalmology Collaborative Uveitis Center, Policlinico ''Le Scotte'', University of Siena, Viale Bracci 16, 53100, Siena, Italy
| | - Jurgen Sota
- Department of Medical Sciences, Surgery and Neurosciences, Research Center of Systemic Autoinflammatory Diseases and Behçet's Disease Clinic and Rheumatology-Ophthalmology Collaborative Uveitis Center, Policlinico ''Le Scotte'', University of Siena, Viale Bracci 16, 53100, Siena, Italy
| | - Stefano Gentileschi
- Department of Medical Sciences, Surgery and Neurosciences, Research Center of Systemic Autoinflammatory Diseases and Behçet's Disease Clinic and Rheumatology-Ophthalmology Collaborative Uveitis Center, Policlinico ''Le Scotte'', University of Siena, Viale Bracci 16, 53100, Siena, Italy
| | - Maria Cristina Maggio
- University Department Pro.Sa.M.I. "G. D'Alessandro", University of Palermo, Palermo, Italy
| | - Carla Gaggiano
- Clinical Pediatrics, Department of Molecular Medicine and Development, University of Siena, Siena, Italy
| | - Maria Tarsia
- Clinical Pediatrics, Department of Molecular Medicine and Development, University of Siena, Siena, Italy
| | - Gian Marco Tosi
- Ophthalmology Unit, Department of Medicine, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Giuseppe Lopalco
- Rheumatology Unit, Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | - Claudia Fabiani
- Ophthalmology Unit, Department of Medicine, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Bruno Frediani
- Department of Medical Sciences, Surgery and Neurosciences, Research Center of Systemic Autoinflammatory Diseases and Behçet's Disease Clinic and Rheumatology-Ophthalmology Collaborative Uveitis Center, Policlinico ''Le Scotte'', University of Siena, Viale Bracci 16, 53100, Siena, Italy
| | - Luca Cantarini
- Department of Medical Sciences, Surgery and Neurosciences, Research Center of Systemic Autoinflammatory Diseases and Behçet's Disease Clinic and Rheumatology-Ophthalmology Collaborative Uveitis Center, Policlinico ''Le Scotte'', University of Siena, Viale Bracci 16, 53100, Siena, Italy.
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Durbin A, Newcomer JB, Wilson CL. Pathergy of a Medial Heel Schwannoma. Cureus 2022; 14:e29463. [PMID: 36299952 PMCID: PMC9587802 DOI: 10.7759/cureus.29463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/20/2022] [Indexed: 11/05/2022] Open
Abstract
Schwannomas are benign soft-tissue tumors derived from Schwann cells of the peripheral nervous system. They typically appear on the head, neck, or trunk, and are often asymptomatic or present with mild tenderness to palpation and numbness due to nerve compression. A 17-year-old male was referred to our dermatology clinic for evaluation and treatment of an asymptomatic, pink, flesh-colored subcutaneous nodule on the medial right heel. A biopsy was performed to rule out malignancy, with the pathology report consistent with the diagnosis of schwannoma. Following the biopsy, the patient developed a persistent, non-healing red-violaceous ulcerative plaque at the biopsy site, which persisted following additional electrodessication and silver nitrate application. Repeat biopsy showed persistent schwannoma and notably the absence of a pyogenic granuloma. The persistent ulceration following the initial biopsy is consistent with the phenomenon known as pathergy, which refers to exaggerated tissue reactivity in response to trauma. The patient eventually required surgical excision and a keystone flap for definitive treatment of the lesion. Although rare, we have demonstrated that pathergy can occur during surgical procedures on suspected schwannomas. Physicians should be aware of this possible complication so that they can provide anticipatory guidance for patients undergoing surgical procedures on undiagnosed cutaneous neoplasms for which a schwannoma is in the differential diagnosis.
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Sarcoid Uveitis: An Intriguing Challenger. Medicina (B Aires) 2022; 58:medicina58070898. [PMID: 35888617 PMCID: PMC9316395 DOI: 10.3390/medicina58070898] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 06/13/2022] [Accepted: 06/16/2022] [Indexed: 11/17/2022] Open
Abstract
The purpose of our work is to describe the actual knowledge concerning etiopathogenesis, clinical manifestations, diagnostic procedures, complications and therapy of ocular sarcoidosis (OS). The study is based on a recent literature review and on the experience of our tertiary referral center. Data were retrospectively analyzed from the electronic medical records of 235 patients (461 eyes) suffering from a biopsy-proven ocular sarcoidosis. Middle-aged females presenting bilateral ocular involvement are mainly affected; eye involvement at onset is present in one-third of subjects. Uveitis subtype presentation ranges widely among different studies: panuveitis and multiple chorioretinal granulomas, retinal segmental vasculitis, intermediate uveitis and vitreitis, anterior uveitis with granulomatous mutton-fat keratic precipitates, iris nodules, and synechiae are the main ocular features. The most important complications are cataract, glaucoma, cystoid macular edema (CME), and epiretinal membrane. Therapy is based on the disease localization and the severity of systemic or ocular involvement. Local, intravitreal, or systemic steroids are the mainstay of treatment; refractory or partially responsive disease has to be treated with conventional and biologic immunosuppressants. In conclusion, we summarize the current knowledge and assessment of ophthalmological inflammatory manifestations (mainly uveitis) of OS, which permit an early diagnostic assay and a prompt treatment.
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7
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The Yin and Yang of toll-like receptors in endothelial dysfunction. Int Immunopharmacol 2022; 108:108768. [DOI: 10.1016/j.intimp.2022.108768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Revised: 04/01/2022] [Accepted: 04/07/2022] [Indexed: 11/24/2022]
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Nazir A, Zafar A. Management of Idiopathic Pyoderma Gangrenosum With Azathioprine As the Primary Adjunct in an Asian Man: A Case Report. Cureus 2022; 14:e25177. [PMID: 35746991 PMCID: PMC9209338 DOI: 10.7759/cureus.25177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/21/2022] [Indexed: 11/19/2022] Open
Abstract
Pyoderma gangrenosum (PG) is a very rare, non-infectious, progressive inflammatory condition falling under the umbrella of neutrophilic dermatoses. It is an ulcerative condition with a wide variety of cutaneous manifestations and multiple clinical variants (classic ulcerative, pustular, bullous, and superficial granulomatous). Additionally, owing to similar patterns of mucocutaneous ulceration, it has certain overlaps with other neutrophilic diseases frequently observed in clinical practice. Pyoderma gangrenosum may occur in association with systemic conditions such as inflammatory bowel disease, hematological malignancies, or as a part of an inherited inflammatory syndrome. However, in rare cases, it may have an idiopathic origin as well. With no specific standardized diagnostic and treatment protocols in place, the management of pyoderma gangrenosum is primarily guided by pre-existing literature or is tailored according to the individual’s disease pattern, type, and associations. Currently, the pathophysiology of pyoderma gangrenosum remains elusive at best. All the aforementioned reasons contribute significantly to PG being labeled as a "diagnostic dilemma" or more commonly as a "diagnosis of exclusion" with frequent incidences of delayed diagnosis or misdiagnosis resulting in catastrophic delays in management. A 35-year-old Asian male presented with bilateral painful, violaceous ulcers with undermined edges involving the shins for the past three months. Routine investigations carried out were indicative of an underlying infection owing to a raised leucocyte count. Discharge from the lesion, however, showed no evidence of microbial growth. The ulcer progressively increased in size, despite optimal wound care and empirical treatment. Skin biopsy demonstrated central necrosis and ulceration of the epidermis and dermis with neutrophilic infiltrates. Phenomenon of pathergy was demonstrated following the formation of a new ulcer at the site of intravenous cannulation during hospital admission. Additionally, aggravation of pre-existing ulcers following their debridement was also indicative of a positive pathergy test. Ultimately, the diagnosis of pyoderma gangrenosum was made upon the successful exclusion of all the other differential diagnoses. Presence of an associated systemic disease could not be appreciated, leading to it being labeled as a case of idiopathic pyoderma gangrenosum. Supportive treatment with non-adhesive, moist dressings was initiated along with topical tacrolimus (0.1%) application. Treatment modalities utilized were steroids and azathioprine in divided doses owing to contraindications to the traditional option of cyclosporine. The patient showed a rapid response to steroids and azathioprine. The ulcers healed with characteristic cribriform scarring within three months of initiation of treatment.
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van der Houwen TB, van Hagen PM, van Laar JAM. Immunopathogenesis of Behçet's disease and treatment modalities. Semin Arthritis Rheum 2022; 52:151956. [PMID: 35038644 DOI: 10.1016/j.semarthrit.2022.151956] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 12/29/2021] [Accepted: 01/05/2022] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Behçet's disease (BD) is an auto-inflammatory disease, primarily characterized by recurrent painful mucocutaneous ulcerations. METHODS A literature search was performed to write a narrative review into the pathogenesis and current treatment options of BD. RESULTS The pathogenesis of BD remains to be elucidated, but is considered a genetically primed disease in which an external trigger causes immune activation resulting in inflammatory symptoms. GWAS data show an association between multiple genetic polymorphisms (HLA-B51, ERAP1, IL10 and IL23R-IL12RB2) and increased susceptibility to BD. Bacteria as streptococci, an unbalanced microbiome or molecular mimicry trigger the inflammation in BD. Increased production or responsiveness of pro-inflammatory components of the innate immune response (TLR, neutrophils, NK-cells or γδ T-cells) to these triggers may be a crucial step in the pathogenesis of BD. Additionally to an increased autoinflammatory response there is evidence of a dysregulated adaptive immune system, with a disturbed Th1/Th2 balance, expansion of Th17 cells and possibly a decrease in regulatory T cells, resulting in a surplus in pro-inflammatory cytokines. The inflammation causes a typical clinical phenotype including orogenital ulcerations, uveitis and skin lesions. Treatment is aimed at the aberrations found in the innate (neutrophils and γδ-T cells) and adaptive immune system (TNF-α, INF-γ, IL-1), directed at organ involvement and individualized based on patient characteristics. CONCLUSION We presented an extensive review into the pathogenesis and treatment options of BD.
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Affiliation(s)
- T B van der Houwen
- Section of Clinical Immunology, Department of Internal Medicine and Immunology, Erasmus University Medical Center Rotterdam, Room RG 535, PO Box 2040, Rotterdam, 3000CA, the Netherlands
| | - P M van Hagen
- Section of Clinical Immunology, Department of Internal Medicine and Immunology, Erasmus University Medical Center Rotterdam, Room RG 535, PO Box 2040, Rotterdam, 3000CA, the Netherlands
| | - J A M van Laar
- Section of Clinical Immunology, Department of Internal Medicine and Immunology, Erasmus University Medical Center Rotterdam, Room RG 535, PO Box 2040, Rotterdam, 3000CA, the Netherlands.
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Quddusi FI, Youssef MJ, Davis DMR. Dermatologic Manifestations of Systemic Diseases in Childhood. Pediatr Rev 2021; 42:655-671. [PMID: 34850179 DOI: 10.1542/pir.2020-000679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
| | - Molly J Youssef
- Department of Pediatric and Adolescent Medicine.,Department of Dermatology, Mayo Clinic, Rochester, MN
| | - Dawn Marie R Davis
- Department of Pediatric and Adolescent Medicine.,Department of Dermatology, Mayo Clinic, Rochester, MN
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Tono T, Kikuchi H, Sawada T, Takeno M, Nagafuchi H, Kirino Y, Tanaka Y, Yamaoka K, Hirohata S. Clinical Features of Behçet's Disease Patients with Joint Symptoms in Japan: A National Multicenter Study. Mod Rheumatol 2021; 32:1146-1152. [PMID: 34850090 DOI: 10.1093/mr/roab092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 07/12/2021] [Accepted: 10/25/2021] [Indexed: 11/13/2022]
Abstract
OBJECTIVES Approximately 30%-60% of Behçet's disease patients exhibit joint symptoms. The aim of this study was to determine the clinical characteristics of such patients in Japan. METHODS This study retrospectively analyzed 151 Behçet's disease patients with joint symptoms who had been treated at seven cooperative medical institutions from 2007 to 2017. We investigated their clinical characteristics and treatments. RESULTS The most commonly affected joints were the knee, ankle, and proximal interphalangeal joints. Of the cases with pain and swelling, 18 of 293 joints (11 cases) displayed narrowing of the cleft or deformity by Xray analysis. Improvement in their arthritis was observed in 80% of the patients who received steroids as initial treatment; however, the rate of improvement was lower in patients who had received prednisolone (PSL) at <10 mg/day. The recurrence of joint symptoms was significantly less common in the colchicine group than in the PSL group. CONCLUSIONS These results suggest that PSL is effective for remission induction for the treatment of joint symptoms of Behçet's disease, though it may not be effective at low doses. Additionally, colchicine is effective in preventing the recurrence of joint symptoms in Behçet's disease. Furthermore, joint damages like joint space narrowing or with any deformity can often be observed in Behçet's disease patients in Japan.
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Affiliation(s)
- Toshihiro Tono
- Department of Rheumatology and Infectious Diseases, Kitasato University School of Medicine, Kanagawa, Japan
| | | | - Tetsuji Sawada
- Department of Rheumatology, Tokyo Medical University Hospital, Tokyo, Japan
| | - Mitsuhiro Takeno
- Department of Allergy and Rheumatology, Nippon Medical School Graduate School of Medicine, Tokyo, Japan
| | - Hiroko Nagafuchi
- Division of Rheumatology, Department of Internal Medicine, St. Marianna University School of Medicine, Kawasaki, Kanagawa, Japan
| | - Yohei Kirino
- Department of Stem Cell and Immune Regulation, Yokohama City University, Graduate School of Medicine, Japan
| | - Yoshiya Tanaka
- The First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Kunihiro Yamaoka
- Department of Rheumatology and Infectious Diseases, Kitasato University School of Medicine, Kanagawa, Japan
| | - Shunsei Hirohata
- Department of Rheumatology and Infectious Diseases, Kitasato University School of Medicine, Kanagawa, Japan
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Pathergy test with a 23G needle with and without self-saliva in patients with Behçet's disease, recurrent aphthous stomatitis and control group compared to the 20G test. Reumatologia 2021; 59:302-308. [PMID: 34819704 PMCID: PMC8609381 DOI: 10.5114/reum.2021.110567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Accepted: 10/08/2021] [Indexed: 11/17/2022] Open
Abstract
Objectives The pathergy test (PT) is part of the diagnostic criteria of Behçet’s disease (BD). Factors like needle character and number of punctures can affect the sensitivity of PT. We tried to compare its positivity using a thinner needle with and without self-saliva in active and inactive BD, recurrent aphthous stomatitis (RAS), and healthy people. Material and methods Twenty patients with active and 13 with inactive BD, 20 with RAS, and 34 healthy controls underwent 3 types of PT: 1 – the most recommended 20G dry needle PT, 2 – 23G dry needle PT, and 3 – 23G PT with self-saliva. The positivity and diagnostic accuracy of the tests between groups were compared. Results All tests were negative in the normal healthy group. In active BD, the positivity of PT with self-saliva (70%) was higher than the 20G PT (20%) (p-value = 0.004), being more correlated to disease activity (p-value = 0.046). In the RAS group, there was no difference in the positivity of all tests (p-value = 0.068). All tests had high diagnostic accuracy in discriminating between patients with active BD and the controls (p < 0.05). The pathergy test with self-saliva showed significant diagnostic accuracy in discriminating BD from non-BD participants (p < 0.001). The results of dry 23G PT were the same as those of 20G PT. Conclusions The self-saliva PT test was more positive in patients with active BD, correlated with disease activity, was more sensitive, had equal specificity in detecting BD from the control group, and was more sensitive but less specific in detecting BD, compared to the RAS group. The positivity and accuracy of dry 23G needle PT were the same as the 20G PT. Pathergy test with self-saliva using a thin (23G) needle is more sensitive has equal specificity in detecting patients with BD compared to the control group and is more sensitive but less specific in detecting the patients with BD compared to the RAS group. The positivity and accuracy of dry 23G needle PT is the same as the most recommended 20G dry PT. Pathergy test by wet 23G needle (with self-saliva) is more positive in patients with active BD compared to PT by dry 20G needle.
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13
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Abstract
Skin pathergy reaction (SPR) is a hyperreactivity response to needle induced trauma which is characterized by a papule or pustule formation, 24-48 h after sterile-needle prick. It is affected by a wide array of factors, including the physical properties of the needles being used, number of pricks and disease related factors such as male gender, active disease. There is a great variation in reactivity among different populations with very low positivity rate in regions of low prevalence like Northern Europe, and higher prevalance mainly in communities living along the historical Silk Road, like Turkey, China and Middle Eastern countries. SPR is not constant during the disease course, has lost its sensitivity over decades and can be positive in various disorders including Sweet's syndrome, pyoderma gangrenosum, Crohn's diesease, A20 haploinsufficiency, deficiency of IL-1-receptor antagonist and few others. Nevertheless, it is a criteria included into many currently used diagnostic or classification criteria for Behçet's disease. Although, not being fully uncovered yet, available data points to the activation of both innate and adaptive immune system with an inflammatory response mediated by polymorphonuclears and T-cells. In addition to its utility in diagnosis of Behçet's Disease, SPR may serve as a model for investigating the inflammatory pathways involved in the etiopathogenesis of this complex disease.
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Affiliation(s)
- Tulin Ergun
- Department of Dermatology, Marmara University School of Medicine, Istanbul, Turkey
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14
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van der Houwen TB, Dik WA, Goeijenbier M, Hayat M, Nagtzaam NMA, van Hagen M, van Laar JAM. Leukocyte toll-like receptor expression in pathergy positive and negative Behçet's disease patients. Rheumatology (Oxford) 2021; 59:3971-3979. [PMID: 32756992 PMCID: PMC7733715 DOI: 10.1093/rheumatology/keaa251] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Revised: 04/15/2020] [Indexed: 12/14/2022] Open
Abstract
Objectives To investigate whether the auto-inflammatory nature and the pathergic reaction in Behçet’s disease (BD) are driven by a disturbed toll-like receptor (TLR) response. Methods We compared both TLR expression by flow-cytometry and TLR response by stimulation assay in 18 BD patients (both pathergy positive and pathergy negative) with 15 healthy controls. Results Expression of TLR1 and 2 was significantly elevated in B-lymphocytes of BD patients compared with healthy controls. TLR1, 2 and 4 were significantly more highly expressed in both CD4+ and CD8+ T-lymphocytes of BD patients. Granulocytes of BD patients displayed significantly higher expression of TLR1, 2, 4 and 6. TLR2, 4 and 5 expression was significantly increased on classical monocytes of BD patients. Intermediate monocytes of BD patients showed an increase in expression of TLR2. Furthermore, TLR2 and 5 were significantly more highly expressed in non-classical monocytes of BD patients. In pathergy positive patients, TLR5 was even more highly expressed compared with pathergy negative patients on B- and T-lymphocytes and granulocytes. Furthermore, TLR2 and 5 showed an elevated TNF-α response to stimulation with their cognate ligands. Conclusion Immune cells of BD patients overexpress TLR1, 2, 4, 5 and 6. Furthermore, after stimulation of TLR2 and 5, BD patients demonstrate a more potent TNF-α response. Although this is a small cohort, in the pathergy positive patients, TLR5 expression is even further augmented, suggesting that a microbial (flagellin) or damage (HMGB1) associated signal may trigger the exaggerated immune response that is characteristic for the pathergy phenomenon in BD. In conclusion, these results point to an exaggerated TLR response in the auto-inflammatory nature of BD.
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Affiliation(s)
- Tim B van der Houwen
- Department of Internal Medicine, Section Clinical Immunology.,Department of Immunology
| | | | - Marco Goeijenbier
- Department of Viroscience, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Manizhah Hayat
- Department of Internal Medicine, Section Clinical Immunology
| | | | - Martin van Hagen
- Department of Internal Medicine, Section Clinical Immunology.,Department of Immunology
| | - Jan A M van Laar
- Department of Internal Medicine, Section Clinical Immunology.,Department of Immunology
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15
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Behcet's Disease Diagnosed by Allergy Skin Testing and Positive Pathergy Test. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 9:1715-1716. [PMID: 33317952 DOI: 10.1016/j.jaip.2020.11.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Revised: 11/10/2020] [Accepted: 11/11/2020] [Indexed: 11/23/2022]
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16
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Muller DA, Henricson J, Baker SB, Togö T, Jayashi Flores CM, Lemaire PA, Forster A, Anderson CD. Innate local response and tissue recovery following application of high density microarray patches to human skin. Sci Rep 2020; 10:18468. [PMID: 33116241 PMCID: PMC7595201 DOI: 10.1038/s41598-020-75169-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Accepted: 10/09/2020] [Indexed: 12/15/2022] Open
Abstract
The development of microarray patches for vaccine application has the potential to revolutionise vaccine delivery. Microarray patches (MAP) reduce risks of needle stick injury, do not require reconstitution and have the potential to enhance immune responses using a fractional vaccine dose. To date, the majority of research has focused on vaccine delivery with little characterisation of local skin response and recovery. Here we study in detail the immediate local skin response and recovery of the skin post high density MAP application in 12 individuals receiving 3 MAPs randomly assigned to the forearm and upper arm. Responses were characterised by clinical scoring, dermatoscopy, evaporimetry and tissue viability imaging (TiVi). MAP application resulted in punctures in the epidermis, a significant transepidermal water loss (TEWL), the peak TEWL being concomitant with peak erythema responses visualised by TiVi. TEWL and TiVi responses reduced over time, with TEWL returning to baseline by 48 h and erythema fading over the course of a 7 day period. As MAPs for vaccination move into larger clinical studies more variation of individual subject phenotypic or disease propensity will be encountered which will require consideration both in regard to reliability of dose delivery and degree of inherent skin response.
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Affiliation(s)
- David A Muller
- School of Chemistry and Molecular Biosciences, The University of Queensland, Building 76 Cooper road, St. Lucia, QLD, 4072, Australia.
| | - Joakim Henricson
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden.,Department of Emergency Medicine, Local Health Care Services in Central Östergötland, Linköping, Sweden
| | - S Ben Baker
- Vaxxas Pty Ltd, Translational Research Institute, 37 Kent Street, Woolloongabba, QLD, 4102, Australia
| | - Totte Togö
- Allergy Center Linköping, Region Östergötland, Sweden
| | - Cesar M Jayashi Flores
- Vaxxas Pty Ltd, Translational Research Institute, 37 Kent Street, Woolloongabba, QLD, 4102, Australia
| | - Pierre A Lemaire
- Vaxxas Pty Ltd, Translational Research Institute, 37 Kent Street, Woolloongabba, QLD, 4102, Australia
| | - Angus Forster
- Vaxxas Pty Ltd, Translational Research Institute, 37 Kent Street, Woolloongabba, QLD, 4102, Australia
| | - Chris D Anderson
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden. .,Division of Cell Biology, Faculty of Health Sciences, Linköping University, Linköping, Sweden.
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17
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Zhao Y, Fang RY, Feng GD, Cui TT, Gao ZQ. Pyoderma gangrenosum confused with congenital preauricular fistula infection: A case report. World J Clin Cases 2020; 8:1679-1684. [PMID: 32420301 PMCID: PMC7211529 DOI: 10.12998/wjcc.v8.i9.1679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Revised: 03/22/2020] [Accepted: 04/04/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Pyoderma gangrenosum resulting from or associated with congenital preauricular fistula is rarely reported.
CASE SUMMARY We report a rare case of pyoderma gangrenosum misdiagnosed as preauricular fistula infection. To our knowledge, this is the first report to describe pyoderma gangrenosum originating from the site of preauricular fistula. The lesion continued expanding even after combined treatment of systemic antibiotics and thorough debridement. Taking into account the possibility of pyoderma gangrenosum, we applied soft care with normal saline and Vaseline gauze dressing. Systemic corticosteroids were not used until intestinal Clostridium difficile was controlled. No local recurrence was noted at the 12-mo follow-up.
CONCLUSION This case highlights the necessity of considering rare diseases, such as pyoderma gangrenosum, when the preauricular sinus deteriorates with general management. The treatment strategy is mutually conflicting between pyoderma gangrenosum and infection of the preauricular sinus.
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Affiliation(s)
- Yang Zhao
- Department of Otolaryngology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Rou-Yu Fang
- Department of Dermatology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Guo-Dong Feng
- Department of Otolaryngology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Ting-Ting Cui
- Department of Otolaryngology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Zhi-Qiang Gao
- Department of Otolaryngology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
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18
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Janowska A, Oranges T, Fissi A, Davini G, Romanelli M, Dini V. PG-TIME: A practical approach to the clinical management of pyoderma gangrenosum. Dermatol Ther 2020; 33:e13412. [PMID: 32291879 DOI: 10.1111/dth.13412] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Revised: 04/03/2020] [Accepted: 04/09/2020] [Indexed: 12/27/2022]
Abstract
Pyoderma gangrenosum (PG) is a neutrophilic dermatosis which may be rapidly progressive. Standard guidelines for local treatment are lacking. Through our experience, we suggested a local treatment algorithm based on the tissue, infection, moisture balance, and epithelization (TIME) concept. The clinical and histopathological features of 52 patients with PG, the duration, and the evolution of the lesions were retrospectively evaluated. Systemic therapies, local treatments, and standard wound treatments were reported. We observed ulcerative PG in the majority of the patients (82.6%), followed by the pustular form (9.6%), the peristomal type (3.8%), the vegetative form (1.9%), and the bullous type (1.9%). The lower leg was the most commonly area affected (90.4% of cases). Pathergy was reported in 15.3% of cases. The first-line treatment was the use of oral glucocorticosteroids (GCSs). We observed healing after 3 weeks of GCS in 17.3% of cases. In 25% of all cases, we obtained complete healing with long-term low doses (<0.5 mg/kg) of GCS in the range of 2 to 6 months. We used second-line treatments in 57.6% of patients. Local, systemic treatment, and correct wound management can be associated with better clinical results. We suggest a new local therapeutic algorithm in both the inflammatory and noninflammatory healing phases.
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Affiliation(s)
- Agata Janowska
- Department of Dermatology, University of Pisa, Pisa, Italy
| | - Teresa Oranges
- Department of Dermatology, University of Pisa, Pisa, Italy.,Department of Health Sciences, Anna Meyer Children University Hospital, University of Florence, Florence, Italy
| | - Alba Fissi
- Department of Dermatology, University of Pisa, Pisa, Italy
| | - Giulia Davini
- Department of Dermatology, University of Pisa, Pisa, Italy
| | | | - Valentina Dini
- Department of Dermatology, University of Pisa, Pisa, Italy
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19
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20
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Giannetti L, Murri Dello Diago A, Lo Muzio L. Behçet's disease: minireview with emphasis on oral aspects. ACTA ACUST UNITED AC 2018; 67:246-249. [PMID: 29915169 DOI: 10.23736/s0026-4970.18.04135-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Adamatiades-Behçet disease (BD) is a primary systemic vasculitis of unknown origin, that may involve blood vessels of all sizes. The clinical hall-mark of the disease are recurrent oral aphthous ulcers, painful, sharply margined and often associated with recurrent genital ulcers. A variety of skin lesions, such as erythema nodosum-like nodules and purpuric lesions are frequently observed. Less common manifestations of BD include thrombophlebitis, central nervous system and ocular inflammation which, however, may impact significant morbidity and mortality. The etiology is unknown, although genetic factors, infectious agents, oral and salivary microbioma, and immunologic mechanisms are implicated and studied. Topical and eventually systemic corticosteroids are the choice treatment.
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Affiliation(s)
- Luca Giannetti
- Surgical, Medical and Dental Department of Morphological Sciences Related to Transplant, Oncology and Regenerative Medicine, University of Modena and Reggio Emilia, Modena, Italy -
| | - Alberto Murri Dello Diago
- Surgical, Medical and Dental Department of Morphological Sciences Related to Transplant, Oncology and Regenerative Medicine, University of Modena and Reggio Emilia, Modena, Italy
| | - Lorenzo Lo Muzio
- Department of Clinical and Experimental Medicine, University of Foggia, Foggia, Italy
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21
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Proksell SS, Greer JB, Theisen BK, Davis PL, Rosh JR, Keljo DJ, Goyal A, Shah SA, Brand MH, Herfarth HH, Cross RK, Siegel CA, Koltun WA, Isaacs KL, Regueiro MD. IBD LIVE Case Series: Case 9: Do Race and Extraintestinal Manifestations Affect Treatment of Severe Crohn's Colitis? Inflamm Bowel Dis 2018; 24:698-713. [PMID: 29562279 DOI: 10.1093/ibd/izx114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2017] [Indexed: 12/09/2022]
Affiliation(s)
- Siobhan S Proksell
- Gastroenterology Fellow Year Iii, Department of Medicine, Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Julia B Greer
- Assistant Professor of Medicine, Department of Medicine, Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Brian K Theisen
- Assistant Professor of Pathology, Department of Pathology, George Washington University Hospital, Washington, D.C
| | - Peter L Davis
- Clinical Associate Professor of Radiology, Department of Radiology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Joel R Rosh
- Director, Division of Gastroenterology and Nutrition, Goryeb Children's Hospital, Atlantic Health, Morristown, New Jersey.,Professor of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, New York
| | - David J Keljo
- Interim Chief, Pediatric Gastroenterology, Hepatology, and Nutrition and Co-Director, Inflammatory Bowel Disease Center, Children's Hospital of Pittsburgh of Upmc, Pittsburgh, Pennsylvania.,Professor of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Alka Goyal
- Associate Professor of Pediatrics, Director of Inflammatory Disease Service, Division of Gastroenterology, Hepatology and Nutrition, Children's Mercy Hospital, Kansas City, Missouri
| | - Samir A Shah
- Chief of Gastroenterology, The Miriam Hospital, Providence, Rhode Island.,Clinical Professor of Medicine, Warren Alpert School of Medicine At Brown University, Providence, Rhode Island
| | - Myron H Brand
- Clinical Professor of Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut.,Medical Director, Shoreline Surgery Endoscopy Center, Connecticut Gastroenterology Consultants, New Haven, Connecticut
| | - Hans H Herfarth
- Professor of Medicine, Division of Gastroenterology and Hepatology, Co-Director Unc Multidisciplinary Center For Inflammatory Bowel Diseases, University of North Carolina, Chapel Hill, North Carolina
| | - Raymond K Cross
- Professor of Medicine, Director of Inflammatory Bowel Disease Program, University of Maryland School of Medicine, Department of Medicine, Division of Gastroenterology and Hepatology, Baltimore, Maryland
| | - Corey A Siegel
- Associate Professor of Medicine and of The Dartmouth Institute For Health Policy & Clinical Practice, Geisel School of Medicine At Dartmouth, Hanover, New Hampshire.,Director of The Inflammatory Bowel Disease Center At The Dartmouth-Hitchcock Medical Center In Lebanon, New Hampshire
| | - Walter A Koltun
- Chief, Division of Colon and Rectal Surgery, Milton S. Hershey Medical Center, Hershey, Pennsylvania.,Director, Hershey Penn State IBD Center, Professor of Surgery, Peter and Marshia Carlino Chair In IBD, Penn State College of Medicine, Hershey, Pennsylvania
| | - Kim L Isaacs
- Professor of Medicine, Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, North Carolina
| | - Miguel D Regueiro
- Professor of Medicine, Associate Chief For Education, Co-Director, Inflammatory Bowel Disease Center, Head, IBD Clinical Program, Department of Medicine, Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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22
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Santos MA, Manesh R, Crook T. Pyoderma gangrenosum near a cystostomy catheter. Intern Emerg Med 2018; 13:123-125. [PMID: 28756547 DOI: 10.1007/s11739-017-1717-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Accepted: 07/24/2017] [Indexed: 11/24/2022]
Affiliation(s)
- Michael Arthur Santos
- Department of Medicine, Penn State Milton S Hershey Medical Center, Hershey, USA.
- Department of Medicine, WellSpan Good Samaritan Hospital, Lebanon, PA, USA.
| | - Reza Manesh
- Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Tonya Crook
- Department of Infectious Diseases, Penn State Milton S Hershey Medical Center, Hershey, USA
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23
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Adeeb F, Ng WL, Khan MU, Devlin J, Stack AG, Fraser AD. The real-world use of different anti-tumor necrosis factor agents in a Northern European population of patients with Behçet's disease. Eur J Rheumatol 2017; 4:254-259. [PMID: 29308279 DOI: 10.5152/eurjrheum.2017.17046] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Accepted: 05/29/2017] [Indexed: 12/19/2022] Open
Abstract
Objective The aim of this study was to evaluate prescription practices, treatment responses, and serious adverse events of anti-tumor necrosis factor (anti-TNF) therapies in Behçet's disease (BD). Material and Methods Patients with BD satisfying the International Study Group for Behçet's Disease or the International Criteria for Behçet's Disease criteria were recruited from a regional rheumatology program. The choice of anti-TNF, treatment response, and adverse events were specified. Response to treatment was evaluated by the detection of new, worsening, or improving clinical features, and management was benchmarked against current The European League against Rheumatism recommendations published in 2008. Results Out of the total of 22 patients, 18 (81.9%) received anti-TNF therapies, resulting in 14 (77.8%) complete and 4 (22.2%) partial remissions. Eleven (61.1%) patients switched to a second anti-TNF, seven patients (38.9%) required three different anti-TNFs, and one required a fourth anti-TNF to achieve remission. Two patients required retrials before their disease was controlled. Anti-TNF therapy included infliximab (IFX): n=15, 83.3%; adalimumab (ADA): n=9, 50%; golimumab: n=6, 33.3%; etanercept: n=5, 27.8%; and certolizumab pegol: n=2, 11.1%. Secondary failure was observed with IFX (4/15; 26.7%) and ADA (2/9; 22.2%), and these (100%) were manifested after at least 2 years of treatment. Five patients with potentially life-threatening laryngeal involvement received anti-TNFs successfully halting disease progression. Five allergic reactions were encountered, and five serious infections were documented involving three patients aged ≥ 50 years, all with the use of IFX. Conclusion Anti-TNF therapy induced a clinical response in 100% patients and achieved complete remission in 78% patients. It provides an effective alternative option for first-line therapy in severe BD where many conventional immunosuppressive therapies fail. Patients with BD who do not respond to one or more anti-TNFs because of intolerance, ineffectiveness, or secondary failure might benefit from switching to another drug from this group or even a retrial of a previously administered anti-TNF because unsatisfactory results with one biologic is not predictive of response to another anti-TNF. For those with potentially life-threatening destructive laryngeal manifestation, anti-TNF as a first choice may be considered.
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Affiliation(s)
- Fahd Adeeb
- Department of Rheumatology, University Hospital Limerick, Limerick, Ireland.,Medical School of Graduate Entry, University of Limerick, Limerick, Ireland.,Department of Medicine, Universiti Teknologi MARA, Sungai Buloh, Selangor, Malaysia
| | - Wan Lin Ng
- Department of Rheumatology, University Hospital Limerick, Limerick, Ireland
| | - Maria Usman Khan
- Department of Rheumatology, University Hospital Limerick, Limerick, Ireland.,Medical School of Graduate Entry, University of Limerick, Limerick, Ireland
| | - Joseph Devlin
- Department of Rheumatology, University Hospital Limerick, Limerick, Ireland
| | - Austin G Stack
- Department of Nephrology, University Hospital Limerick, Limerick, Ireland.,Medical School of Graduate Entry, University of Limerick, Limerick, Ireland
| | - Alexander Duncan Fraser
- Department of Rheumatology, University Hospital Limerick, Limerick, Ireland.,Medical School of Graduate Entry, University of Limerick, Limerick, Ireland
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24
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Scherrer MAR, Rocha VB, Garcia LC. Behçet's disease: review with emphasis on dermatological aspects. An Bras Dermatol 2017; 92:452-464. [PMID: 28954091 PMCID: PMC5595589 DOI: 10.1590/abd1806-4841.20177359] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2017] [Accepted: 07/11/2017] [Indexed: 11/22/2022] Open
Abstract
Behçet's disease is a systemic vasculitis characterized by attacks of acute inflammation, which can affect almost every vascularized area of the body. There is a close correlation between the geographical distribution of HLA-B51 and its prevalence. In the etiopathogenesis there are indications of genetic susceptibility associated with environmental influence. Among the involved genes are those that encompass innate and adaptive immunities. Polymorphisms and epistatic interactions in several genes are described, as well as the presence of imbalance lineage between HLA-B51 and A (MICA). Herpes simplex and Streptococcus sanguinis may be important extrinsic factors. An increase of Th1 response and of IL-21 is observed. The production of IL-21 is positively related to Th17 cells and negatively to T-regs. The mucocutaneous manifestations are Behcet´s disease markers, and their earlier onset indicates a worse prognosis. Recurrent oral ulcers have varied sizes and arrangements, genital ulcers are recurrent, leaving scars, skin lesions are multivaried, and pathergy, although not so frequent, is important for the diagnosis. There are numerous attempts to validate indexes that can evaluate the disease activity and among them the Mucocutaneous Activity Index. This is a specific score that can help with therapeutic decisions and to reduce morbidity, but still lacks validation. The clinical manifestations of other organs are described as well as treatment options.
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Affiliation(s)
- Maria Antonieta Rios Scherrer
- Contact Dermatitis Outpatient Clinic - Dermatology Division at the Hospital das Clínicas - Universidade Federal de Minas Gerais (UFMG) - Belo Horizonte (MG), Brazil
| | - Vanessa Barreto Rocha
- Contact Dermatitis Outpatient Clinic - Dermatology Division at the Hospital das Clínicas - Universidade Federal de Minas Gerais (UFMG) - Belo Horizonte (MG), Brazil
| | - Lucas Campos Garcia
- Contact Dermatitis Outpatient Clinic - Dermatology Division at the Hospital das Clínicas - Universidade Federal de Minas Gerais (UFMG) - Belo Horizonte (MG), Brazil
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25
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Knitting the Threads of Silk through Time: Behçet's Disease-Past, Present, and Future. Int J Rheumatol 2017; 2017:2160610. [PMID: 29081805 PMCID: PMC5610876 DOI: 10.1155/2017/2160610] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Accepted: 08/07/2017] [Indexed: 12/14/2022] Open
Abstract
Behçet's disease (BD) is a chronic relapsing vasculitis that affects vessels of all types and sizes with a broad spectrum of phenotypic heterogeneity and complex immunopathogenesis. Efforts by the scientific community to resolve the unmet needs of BD and gaps in our knowledge have been hampered by considerable challenges that primarily relate to the rare nature of the disease in many parts of the world and its heterogeneity. Controversies remain in many aspects of the disease including the diagnostic criteria, immunopathogenesis and biomarker discovery, geographical variation, and therapeutic considerations. In this review, we highlight recent advances in our scientific understanding of BD, shed new insights into diagnostic and treatment strategies, and discuss residual gaps in our knowledge that will serve as the basis for current and future research.
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26
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Marzano AV, Borghi A, Wallach D, Cugno M. A Comprehensive Review of Neutrophilic Diseases. Clin Rev Allergy Immunol 2017; 54:114-130. [DOI: 10.1007/s12016-017-8621-8] [Citation(s) in RCA: 87] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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27
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Higashihara T, Okada A, Kusano T, Ishigaki K, Shimizu A, Takano H. A novel case of renal pathergy reaction in a Behçet's disease patient complicated by IgA vasculitis. BMC Nephrol 2017; 18:40. [PMID: 28129738 PMCID: PMC5273836 DOI: 10.1186/s12882-017-0451-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Accepted: 01/16/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND A pathergy reaction is defined as a hyperreactivity of the skin in response to minimal trauma, which is important in the diagnosis of Behçet's disease (BD). However, a pathergy reaction may not be restricted to the skin, and little is known about whether an invasive medical procedure can induce the reaction. Here we present a pathergy reaction induced by renal biopsy, an invasive procedure. CASE PRESENTATION A 46-year-old man who was diagnosed with IgA vasculitis (IgAV) at the age of 38 was treated with prednisolone and mizoribine. However, complications such as common carotid arteritis or recurrent oral ulcer suggested the possibility of another pathophysiology. Later, increasing urine protein developed, suggesting disease aggravation. However, renal biopsy showed arteriosclerotic changes caused mainly by hypertension, negating exacerbation. After renal biopsy, his renal dysfunction and body temperature fluctuated, and detailed examinations revealed recurrent oral and genital ulcers and a folliculitis-like rash on his scrotum. Later, he complained of myodesopsia caused by hemorrhage in the ocular fundus due to occlusive vasculitis. Complete BD was diagnosed after development of the symptoms, and he was treated with prednisolone and colchicine. CONCLUSION Co-occurrence of BD with IgAV is very rare and may be associated with immune disorders. Interestingly, a renal biopsy revealed BD, which was masked by the presence of IgAV, and elucidated the etiology of the unexplainable symptoms. To the best of our knowledge, this is the first report of renal pathergy. This case enlightens clinicians to the fact that not only a needle stimulation but also an invasive procedure can cause a pathergy reaction.
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Affiliation(s)
- Takaaki Higashihara
- Department of Nephrology, Tokyo Teishin Hospital, 2-14-23, Fujimi, Chiyoda-ku, 102-8798, Tokyo, Japan
| | - Akira Okada
- Department of Nephrology, Tokyo Teishin Hospital, 2-14-23, Fujimi, Chiyoda-ku, 102-8798, Tokyo, Japan. .,Divison of Nephrology and Endocrinology, The University of Tokyo Graduate School of Medicine, 7-3-1, Hongo, Bunkyo-ku, 113-8655, Tokyo, Japan.
| | - Taiko Kusano
- Department of Nephrology, Tokyo Teishin Hospital, 2-14-23, Fujimi, Chiyoda-ku, 102-8798, Tokyo, Japan
| | - Kazuyoshi Ishigaki
- Department of Allergy and Rheumatology, The University of Tokyo Graduate School of Medicine, 7-3-1, Hongo, Bunkyo-ku, 113-8655, Tokyo, Japan
| | - Akira Shimizu
- Department of Analytic Human Pathology, Graduate School of Medicine, Nippon Medical School, 1-1-5, Sendagi, Bunkyo-ku, 113-8603, Tokyo, Japan
| | - Hideki Takano
- Department of Nephrology, Tokyo Teishin Hospital, 2-14-23, Fujimi, Chiyoda-ku, 102-8798, Tokyo, Japan
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Bullous Pyoderma Gangrenosum With Subungual Involvement Associated With Ulcerative Colitis. Am J Dermatopathol 2016; 39:476-478. [PMID: 27893467 DOI: 10.1097/dad.0000000000000801] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Pyoderma gangrenosum (PG) is a rare inflammatory and ulcerative skin disease of unknown etiology characterized by neutrophilic infiltration of the dermis, mainly affecting the lower extremities. Bullous PG is a rare variant of this disease, usually associated with hematologic disorders. Here, we report a case of pathergy-positive bullous PG with subungual involvement associated with ulcerative colitis.
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Behcet's Disease: Is There Geographical Variation? A Review Far from the Silk Road. Int J Rheumatol 2015; 2015:945262. [PMID: 26798344 PMCID: PMC4698787 DOI: 10.1155/2015/945262] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Revised: 11/09/2015] [Accepted: 11/11/2015] [Indexed: 01/18/2023] Open
Abstract
Behcet's Disease (BD) is a systemic vasculitis characterized by the triad of recurrent mouth and genital ulcers with eye involvement. To date there are no laboratory tests specific for the disease and diagnosis continues to remain on clinical grounds. Multiple criteria have been created as guides for diagnosis; however, given the wide spectrum of organ involvement, some cases remain undiagnosed. The diagnosis of Behcet's Disease may only be made over time as the clinical manifestations emerge sometimes separated by months and even years. With an increased recognition of this disease it has become apparent that there is geographical variation in clinical manifestations. In particular cardiac manifestations are not seen commonly in Caucasians compared to Asian and Middle Eastern patients, while neurological manifestations are more common in Caucasians. Use of immunosuppressive and immunomodulatory drugs to suppress inflammation remains the cornerstone of treatment.
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Steele RB, Nugent WH, Braswell SF, Frisch S, Ferrell J, Ortega-Loayza AG. Pyoderma gangrenosum and pregnancy: an example of abnormal inflammation and challenging treatment. Br J Dermatol 2015; 174:77-87. [PMID: 26474193 DOI: 10.1111/bjd.14230] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/30/2015] [Indexed: 12/22/2022]
Abstract
Pyoderma gangrenosum (PG) is a neutrophil-predominant inflammatory disease that initially presents as a sterile pustule and may progress to ulcerations. Its root cause is unknown, but the presentation is commonly associated with systemic inflammatory conditions such as inflammatory bowel disease, arthritis and haematological abnormalities. On the other hand, pregnant women show a progressive neutrophilia during gestation, which culminates in a major inflammatory event to help drive labour. Although uncommonly, PG has been associated with pregnancy, which provides an additional link to systemic inflammation as an underlying cause of PG. We reviewed documented presentations of PG in gravid and post-partum patients, and have speculated on the possible pathogenesis based on their clinical presentations. Also, we summarize the reported treatments and their outcomes in these patients.
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Affiliation(s)
- R B Steele
- Department of Dermatology, Virginia Commonwealth University, Richmond, VA, U.S.A
| | - W H Nugent
- Department of Obstetrics and Gynecology, Virginia Commonwealth University, Richmond, VA, U.S.A
| | - S F Braswell
- Department of Dermatology, Virginia Commonwealth University, Richmond, VA, U.S.A
| | - S Frisch
- Department of Internal Medicine, University of Illinois College of Medicine at Peoria, Peoria, IL, U.S.A
| | - J Ferrell
- Department of Internal Medicine, University of Illinois College of Medicine at Peoria, Peoria, IL, U.S.A
| | - A G Ortega-Loayza
- Department of Dermatology, Virginia Commonwealth University, Richmond, VA, U.S.A
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Qiao J, Wang Y, Bai J, Wu Y, Fang H. Concurrence of Sweet's syndrome, pathergy phenomenon and erythema nodosum-like lesions. An Bras Dermatol 2015; 90:237-9. [PMID: 25830995 PMCID: PMC4371674 DOI: 10.1590/abd1806-4841.20153201] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2013] [Accepted: 11/20/2013] [Indexed: 12/17/2022] Open
Abstract
We report the case of a 54-year-old woman with concurrent Sweet's syndrome,
pathergy phenomenon and eythema nodosum-like lesions associated with suppurative
tonsillitis. Tender, violaceous and highly edematous papules and plaques were
detected on the forearms and legs, some of which were pseudovesicular. Similar
edematous papules were detected on the dorsum of the hands at the sites of
intravenous injection. Biopsies of a plaque on the forearm and a papule at the
site of intravenous injection confirmed the presence of Sweet's syndrome.
Multiple, tender, violet-red, subcutaneous erythematous nodules were revealed on
the legs. A biopsy taken from a nodule on the leg revealed septal panniculitis.
To our knowledge, no patient with concurrent Sweet's syndrome, pathergy
phenomenon, and erythema nodosum-lesions had been reported yet in previous
literature.
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Affiliation(s)
- Jianjun Qiao
- The First Affiliated Hospital, College of Medicine, Zhejiang University, Zhejiang Province, China
| | - Yan Wang
- The First Affiliated Hospital, College of Medicine, Zhejiang University, Zhejiang Province, China
| | - Juan Bai
- The First Affiliated Hospital, College of Medicine, Zhejiang University, Zhejiang Province, China
| | - Yinhua Wu
- The First Affiliated Hospital, College of Medicine, Zhejiang University, Zhejiang Province, China
| | - Hong Fang
- The First Affiliated Hospital, College of Medicine, Zhejiang University, Zhejiang Province, China
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Piccolo V, Baroni A, Russo T, Ruocco E. Pyoderma gangrenosum after aortic aneurysm repair: an umpteenth example of immunocompromised district. Int J Dermatol 2014; 54:e46. [DOI: 10.1111/ijd.12639] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Vincenzo Piccolo
- Department of Dermatology and Venereology; Second University of Naples; Naples Italy
| | - Adone Baroni
- Department of Dermatology and Venereology; Second University of Naples; Naples Italy
| | - Teresa Russo
- Department of Dermatology and Venereology; Second University of Naples; Naples Italy
| | - Eleonora Ruocco
- Department of Dermatology and Venereology; Second University of Naples; Naples Italy
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Ozluk E, Balta I, Akoguz O, Kalkan G, Astarci M, Akbay G, Eksioglu M. Histopathologic Study of Pathergy Test in Behçet's Disease. Indian J Dermatol 2014; 59:630. [PMID: 25484413 PMCID: PMC4248521 DOI: 10.4103/0019-5154.143568] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background: The pathergy test (PT) is important in the diagnosis of Behçet's disease (BD). However, misinterpretation of the test might cause false-positive or false-negative results. Therefore, immunopathologic and histopathologic tests are recommended with PT. Aims and Objectives: The aim of this study is to determine histopathologic findings of positive pathergy reaction at BD. Materials and Methods: This study was performed on 23 patients with BD. All patients were in active period of the disease. After 48 h from the injection, biopsy was performed on positive pathergy lesions. Results: Of the specimen from positive PT lesions of patients with BD, nine revealed mixed type inflammatory cell infiltration (39.1%), two revealed lobular panniculitis without vasculitis (8.7%), two revealed neutrophil rich infiltration (8.7%), and five revealed lymphocyte rich infiltration (21.7%) at the subcutaneous tissue. Mixed type inflammatory cell infiltration (43.4%), endothelial swelling and thickening (17.3%), erythrocyte extravasation (26.0%), perivascular cell infiltration (13.0%), lymphocytic vascular reaction (8.6%), lymphocytic vasculitis (13.0%), and leukocytoclastic vasculitis (21.7%) were detected in dermis by histopathologic examinations. There was no statistically significant difference between histopathologic findings and sex, family history, and systemic involvement except uveitis. Conclusion: This is an exceptional study since it is the first study that determines subcutaneous tissue findings of positive pathergy reaction in Behçet patients. In our study, uveitis was found to be statistically significant in the patients who had vasculitis in dermis. It can be a clue for prediction of disease severity and course. Further, studies that include wide number of patients will better illuminate the correlation between subcutaneous tissue findings and disease severity and clinical course.
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Affiliation(s)
- Ekin Ozluk
- Department of Dermatology, Ministry of Health, Kocaeli State Hospital, Kocaeli, Turkey
| | - Ilknur Balta
- Department of Dermatology, Kecioren Training and Research Hospital, Ankara, Turkey
| | - Ozlem Akoguz
- Department of Dermatology, Ankara Training and Research Hospital, Ankara, Turkey
| | - Goknur Kalkan
- Department of Dermatology, Gaziosmanpasa University, School of Medicine, Tokat, Turkey
| | - Muzeyyen Astarci
- Department of Dermatology, Ankara Training and Research Hospital, Ankara, Turkey ; Department of Pathology, Ministry of Health, Kocaeli State Hospital, Kocaeli, Turkey
| | - Gulfer Akbay
- Department of Dermatology, Ankara Training and Research Hospital, Ankara, Turkey
| | - Meral Eksioglu
- Department of Dermatology, Ankara Training and Research Hospital, Ankara, Turkey
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Scherrer MAR, de Castro LPF, Rocha VB, Pacheco L. [The dermatoscopy in the skin pathergy testing: case series in patients with suspected Behçet's Disease]. REVISTA BRASILEIRA DE REUMATOLOGIA 2014; 54:494-8. [PMID: 25445631 DOI: 10.1016/j.rbr.2014.06.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2013] [Revised: 04/08/2014] [Accepted: 06/12/2014] [Indexed: 02/05/2023] Open
Abstract
Behçet's disease is a multisystemic disease consisting of a varying combination of ocular, mucocutaneous, neurologic, cardiovascular, gastrointestinal and other manifestations. Its diagnosis is based on clinical criteria, in which a positive pathergy test scores 1. A case series with 26 suspected patients is presented, and the skin pathergy test was performed in 23. The results were read in 48hours, and they were considered negative when without papule, and positive with a papule or pustule. Positive results were divided by papule size, and dermatoscopy was done to measure and observe its clinical aspects. After the readings, a biopsy was performed, with annotation of histopathological aspects. The test was negative in 2 (8.7%) and positive in 21 (91.3%) patients. The results and the literature review are presented.
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Affiliation(s)
- Maria Antonieta Rios Scherrer
- Ambulatório de Dermatologia, Hospital das Clínicas, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brasil
| | - Lúcia Porto Fonseca de Castro
- Departamento de Anatomia Patológica e Medicina Legal, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brasil
| | - Vanessa Barreto Rocha
- Ambulatório de Dermatologia, Hospital das Clínicas, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brasil.
| | - Leonardo Pacheco
- Ambulatório de Dermatologia, Hospital das Clínicas, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brasil
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Atypical pyoderma gangrenosum mimicking an infectious process. Case Rep Infect Dis 2014; 2014:589632. [PMID: 25024856 PMCID: PMC4082936 DOI: 10.1155/2014/589632] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2014] [Accepted: 05/29/2014] [Indexed: 11/17/2022] Open
Abstract
We present a patient with atypical pyoderma gangrenosum (APG), which involved the patient's arm and hand. Hemorrhagic bullae and progressive ulcerations were initially thought to be secondary to an infectious process, but a biopsy revealed PG. Awareness of APG by infectious disease services may prevent unnecessary use of broad-spectrum antibiotics.
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Sifuentes Giraldo WA, Guillén Astete CA, Murillo Romero C, Amil Casas I, Rodríguez García AM, Bachiller Corral FJ. Refractory pseudoseptic arthritis in Behçet’s disease successfully treated with infliximab: a case report and literature review. Mod Rheumatol 2012. [DOI: 10.1007/s10165-012-0747-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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37
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Ndahi AA, Tahir C, Nggada HA. Photoletter to the editor: Scarring alopecia resulting from pyoderma gangrenosum of the scalp. J Dermatol Case Rep 2012; 6:34-5. [PMID: 22514589 DOI: 10.3315/jdcr.2012.1093] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2011] [Accepted: 07/25/2011] [Indexed: 11/11/2022]
Abstract
Pyoderma gangrenosum is an uncommon ulcerative cutaneous condition of uncertain aetiology. It is a disease that causes tissue to become necrotic, leading to deep ulcers. We report a case of pyoderma gangrenosum localized at the scalp, which is an unusual location. After 16 months of treatment with prednisolone 40 mg daily, methotrexate 15 mg weekly, ciprofloxacin 500 mg and honey dressing the indurated elevated ulcer margins flattened and the ulcer healed with scarring of the entire scalp.
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Affiliation(s)
- Akilahyel A Ndahi
- Department of Medicine, University of Maiduguri Teaching Hospital, P.M.B, 1414, Bema Road, Maiduguri, Borno State, Nigeria
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Kroshinsky D, Alloo A, Rothschild B, Cummins J, Tan J, Montecino R, Hoang MP, Duncan L, Mihm M, Sepehr A. Necrotizing Sweet syndrome: a new variant of neutrophilic dermatosis mimicking necrotizing fasciitis. J Am Acad Dermatol 2012; 67:945-54. [PMID: 22445215 DOI: 10.1016/j.jaad.2012.02.024] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2011] [Revised: 02/15/2012] [Accepted: 02/17/2012] [Indexed: 11/18/2022]
Abstract
BACKGROUND We report a series of patients initially given the diagnosis of necrotizing fasciitis whose course progressed despite surgical debridement, antibiotic therapy, or both, but who responded rapidly to systemic corticosteroids. OBJECTIVE We sought to evaluate the clinical data, histopathologic and microbiology information, and treatment course of this unusual entity. METHODS This was a descriptive study/case series. RESULTS Three immunocompromised patients who presented with signs and symptoms of necrotizing fasciitis were included. They appeared septic, failed multiple courses of antibiotics, demonstrated pathergy, and two of them underwent extensive surgical debridement. None of the cases yielded a microbial source. Dermatologic consultation and histopathology confirmed deep Sweet syndrome in all cases, with marked necrosis of the soft tissue--including myonecrosis--in the two patients with debridement. All patients responded rapidly to high-dose systemic corticosteroids. LIMITATIONS To our knowledge, this is the first report of this unusual presentation; there are a limited number of cases. CONCLUSION We propose that these cases represent a new variant of neutrophilic dermatosis: "necrotizing Sweet syndrome," an acute necrotizing neutrophilic dermatosis. This subtype is also characterized by the rapid onset of progressive erythematous, warm, edematous cutaneous lesions with deep-tissue neutrophilic infiltration and soft-tissue necrosis, in the absence of infectious cause. Awareness of this entity and early dermatologic consultation is critical as debridement results in expansion of the process, resulting in additional and aggressive resection--a vicious cycle with significant possible morbidity.
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Affiliation(s)
- Daniela Kroshinsky
- Department of Dermatology, Massachusetts General Hospital, Boston, Massachusetts, USA
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39
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Sjögren F, Davidsson K, Sjöström M, Anderson CD. Cutaneous microdialysis: cytokine evidence for altered innate reactivity in the skin of psoriasis patients? AAPS JOURNAL 2012; 14:187-95. [PMID: 22374383 DOI: 10.1208/s12248-012-9331-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/18/2011] [Accepted: 02/08/2012] [Indexed: 02/08/2023]
Abstract
Cutaneous microdialysis demonstrates cytokine production in living human skin. In the present study, microdialysis samples taken from uninvolved and lesional skin in three test subjects with psoriasis over 24 h have been investigated for cytokine content with a bead-based multiplex immunoassay from Luminex. Concentration curves for a set of Th1/Th2 and pro-inflammatory cytokines measured differed from a reference group of ten subjects without psoriasis. The time to return to near baseline values after innate insertion reactivity is between 9 and 16 h. Post-equilibration levels (17-24 h) for the three main cytokines elevated in the reference group were differentially elevated outside the range of the reference group for interleukin-1β (IL1β) and IL8 but not so for IL6. Two further cytokines, granulocyte-macrophage colony-stimulating factor and tumor necrosis factor-α not generally elevated in the reference group, showed elevated values in the test subjects. Multivariate time series analysis (chemometry) showed that cytokine patterns for the individual test subjects often fell outside the 99% confidence intervals of a model generated from the reference group. In a clinical research situation, cutaneous microdialysis is feasible, gives generally higher cytokine levels than in the blood and generates interpretable data on an individual's reactivity compared with a reference group. This may well prove useful in delineation of pathogenetic issues, selection of appropriate therapy and monitoring of subsequent response in inflammatory dermatoses such as psoriasis.
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Affiliation(s)
- Florence Sjögren
- Department of Clinical and Experimental Medicine, Division of Dermatology, University Hospital, Linköping University, Linköping, Sweden
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40
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Löhrer R, Eming R, Wolfrum N, Krieg T, Eming SA. [Autoinflammatory diseases as cause of wound healing defects]. Hautarzt 2012; 62:524-33. [PMID: 21647771 DOI: 10.1007/s00105-010-2115-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Ulcerations of the skin and mucosal membranes are a common feature of autoinflammatory diseases. They can give raise to chronic wound healing defects and should be considered in the differential diagnosis of chronic skin ulcers. The increased activation of the innate immune system in the absence of an apparent provocation for inflammation is a hallmark of autoinflammatory diseases. Mutations and alterations of signaling pathways regulating the innate immune response to physical trauma/tissue damage result into an unrestrained activation of the inflammasome, which leads to increased activation of Interleukin-1. Uncontrolled recruitment and activation of myeloid effector cells within the wound site lead to the release of potent proteases that cause the degradation of structural components of the skin. The majority of these diseases respond well to immunosuppressive and immunomodulatory treatment regimes. Therapeutic resistance converts the acute inflammatory response into a chronic and non-resolving inflammatory process that leads to tissue degeneration. In this article we will focus on the review of those autoinflammatory diseases that often display ulcerative cutaneous and aphthous lesions including pyoderma gangrenosum, Behçet disease, PAPA syndrome and hyperimmunoglobulinemia D with periodic fever syndrome (HIDS). Furthermore, the article will be complemented by an overview of those inflammatory diseases that are associated with non-ulcerative cutaneous manifestations.
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Affiliation(s)
- R Löhrer
- Klinik und Poliklinik für Dermatologie und Venerologie, Universität zu Köln, Kerpenerstr. 62, 50937, Köln, Deutschland
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Márquez JC, Granados AM, Castillo M. Spontaneous internal carotid artery pseudoaneurysm in a patient with behçet disease. Neuroradiol J 2011; 24:924-7. [PMID: 24059899 DOI: 10.1177/197140091102400617] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2011] [Accepted: 08/03/2011] [Indexed: 11/15/2022] Open
Abstract
We describe the uncommon case of a patient with Behçet disease who developed a giant spontaneous cervical internal carotid artery pseudoaneurysm confirmed at surgery. We also discuss the implications of this rare complication.
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Affiliation(s)
- J C Márquez
- Department of Radiology, Division of Neuroradiology, University of North Carolina; Chapel Hill, NC, USA -
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42
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Histopathological Evaluation of Behçet's Disease and Identification of New Skin Lesions. PATHOLOGY RESEARCH INTERNATIONAL 2011; 2012:209316. [PMID: 22028988 PMCID: PMC3199096 DOI: 10.1155/2012/209316] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/17/2011] [Accepted: 08/16/2011] [Indexed: 12/30/2022]
Abstract
Behçet's disease (BD) is a multisystemic, relapsing inflammatory disorder with an obscure etiology and pathogenesis. Diagnosis depends on the clinician's ability to identify a group of nonspecific mucocutaneous lesions, which also manifest in a number of other diseases. In recent years, there has been an increase in the studies focusing on the histopathological aspects of Behçet's disease diagnostic mucocutaneous lesions. Their results emphasize the value of histopathology and direct immunofluorescence (DIF) in the differential diagnosis of Behçet's disease.
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Ideguchi H, Suda A, Takeno M, Ueda A, Ohno S, Ishigatsubo Y. Behçet disease: evolution of clinical manifestations. Medicine (Baltimore) 2011; 90:125-132. [PMID: 21358436 DOI: 10.1097/md.0b013e318211bf28] [Citation(s) in RCA: 114] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Clinical phenotypes of Behçet disease (BD) vary among ethnic groups. We chronologically analyzed the clinical manifestations of BD in 412 patients meeting the Japanese criteria for BD seen at 2 Yokohama City University hospitals from July 1991 to December 2007. We examined the onset of individual symptoms in each patient. A single initial symptom appeared earlier than any other manifestation in 78% of the patients. Time from the initial symptom to diagnosis was 8.6 ± 10.1 years. Oral ulcer, the most common initial manifestation, preceded the diagnosis by 7.5 ± 10.2 years. Genital ulcer and eye and skin involvement appeared 1 or 2 years before diagnosis, whereas gastrointestinal, central nervous system, or vascular involvement developed later. The frequency of eye involvement was significantly higher in patients with neurologic lesions, but significantly lower in those with gastrointestinal or vascular involvement. However, no particular combination of major symptoms predicted the development of organ involvement. There has been a recent decrease in the rate of "complete" BD (patients having all 4 of the major symptoms of oral ulcers, genital ulcers, and eye and skin lesions), whereas the frequencies of arthritis, gastrointestinal, and vascular involvement have been increasing. Further assessment may allow the detection of early predictors of the more aggressive disease, which requires more intensive treatment.
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Affiliation(s)
- Haruko Ideguchi
- From Center for Rheumatic Diseases (HI, SO), Yokohama City University Medical Center, Yokohama; Department of Internal Medicine and Clinical Immunology (AS, MT, AU, YI), Yokohama City University Graduate School of Medicine, Yokohama; and Department of Rheumatology (AS), Yokohama Minami Kyosai Hospital, Yokohama, Japan
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Current world literature. Curr Opin Rheumatol 2010; 23:125-30. [PMID: 21124095 DOI: 10.1097/bor.0b013e3283422cce] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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45
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Sjögren F, Anderson CD. Are cutaneous microdialysis cytokine findings supported by end point biopsy immunohistochemistry findings? AAPS J 2010; 12:741-9. [PMID: 20967522 PMCID: PMC2976991 DOI: 10.1208/s12248-010-9235-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2010] [Accepted: 09/24/2010] [Indexed: 12/30/2022] Open
Abstract
Insertion of a cutaneous microdialysis catheter into normal dermis has been shown to induce the production of IL1b, IL6 and IL8 in an innate response to minimal trauma. In the present study, skin biopsy for immunohistochemistry has been performed at the site of the microdialysis catheter to compare the findings with that of the microdialysis findings 24 h after insertion. Of the three named cytokines, concordance between the two investigated technologies was highest for IL8 (100%) followed by IL6 (70%) and IL1b (50%). For seven other pro-inflammatory and T cell-relevant cytokines studied, concordance ranged between 50% and 80%. The total number of positive (microdialysis or immunofluorescence) findings was similar between the two methodologies. Technical and biological phenomenon can explain the differences. We conclude that both methodologies illustrate important features of tissue biology and that a combination of the two methods in clinical research can provide the chronology of soluble mediator participation and the more classic, but also more invasive, biopsy-based methodology at a point which constitutes the end of the observation period. We conclude further that at the 24-h time period here studied, microdialysis catheters are still functional and thus capable of producing relevant data which can be corroborated and extended by the "end point biopsy".
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Affiliation(s)
- Florence Sjögren
- />Department of Clinical and Experimental Medicine, Division of Dermatology, Linköping University, Linköping, Sweden
| | - Chris D. Anderson
- />Department of Clinical and Experimental Medicine, Division of Dermatology, Linköping University, Linköping, Sweden
- />Department of Dermatology, University Hospital, 581 85 Linköping, Sweden
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A minimally invasive human in vivo cutaneous wound model for the evaluation of innate skin reactivity and healing status. Arch Dermatol Res 2010; 302:383-93. [PMID: 20229284 DOI: 10.1007/s00403-010-1043-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2009] [Revised: 02/09/2010] [Accepted: 02/22/2010] [Indexed: 12/19/2022]
Abstract
Individual variability in skin reactivity and healing capacity after trauma are important clinical issues. The aims were to develop an in vivo, human wound model based on a standardised minimal skin injury and to demonstrate therapeutic effect of simple wound therapies in terms of morphological wound outcome with changes in skin blood perfusion as a quantified indicator of wound healing. In a series of experiments, wounds were induced on the normal forearm skin of volunteers using a blood collection lancet. This was well tolerated. Wounds were assessed by naked eye examination or laser Doppler perfusion imaging (LDPI) at baseline and at up to 6 further time points up to 96 h in control wounds and wounds treated by commonly used occlusive dressing options. Assessment by clinical observation with 10x magnification showed over 96 h a progression of erythema, surface crust, a new keratinisation layer and finally healed areas. LDPI quantifying wound erythema showed a peak at 24 h and near normal levels at 96 h. Inter-individual variability was evident but intra-individual variability was much less pronounced. Wounds treated with occlusion showed a statistically significant more rapid return to baseline blood perfusion as measured by LDPI compared to controls supported by favourable healing parameters in the clinical assessment. The paper exemplifies use of non-invasive, bioengineering technique for quantification of individual innate variability in skin reactivity, wound healing capacity and therapeutic effect in a well-tolerated in vivo, human, minimal skin trauma model.
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