Organ-specific eosinophilic disorders of the skin, lung, and gastrointestinal tract

Eosinophils and melanoma: Implications for immunotherapy

New therapies such as immune checkpoint blockers (ICB) have offered extended survival to patients affected by advanced melanoma. However, ICBs have demonstrated debilitating side effects on the joints, liver, lungs, skin, and gut. Several biomarkers have been identified for their role in predicting which patients better tolerate ICBs. Still, these biomarkers are limited by immunologic and genetic heterogeneity and the complexity of translation into clinical practice. Recent observational studies have suggested eosinophil counts, and serum levels of eosinophil cationic protein are significantly associated with prolonged survival in advanced-stage melanoma. It is likely that eosinophils thereby modulate treatment response through mechanisms yet to be explored. Here, we review the functionality of eosinophils, their oncogenic role in melanoma and discuss how these mechanisms may influence patient response to ICBs and their implications in clinical practice.

Atopic Dermatitis Biomarkers and the Movement Toward Personalized Treatment

Atopic dermatitis (AD) is a heterogeneous disorder with varying phenotypes. Although AD has long been associated with barrier dysfunction, the pathogenesis of this disease is more complex, involving many molecular markers in different functional domains. Biomarkers can be helpful in different ways, including predicting prognosis, measuring treatment response, and gauging disease severity. With the advent of targeted immunomodulators, biomarkers have the potential to take on new significance in terms of selecting appropriate therapies for patients. In this review, we have summarized the key findings related to biomarkers and AD, including the specific subtype differences. Clinicians will use this information to better understand the potential of biomarkers in AD and have a guide because more specific treatments are developed that are tailored toward individual molecular profiles.

Ultra- and micro-structural changes of respiratory tracts in SARS-CoV-2 infected Syrian hamsters

The severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) pandemic is causing a global crisis. It is still unresolved. Although many therapies and vaccines are being studied, they are still in their infancy. As this pandemic continues, rapid and accurate research for the development of therapies and vaccines is needed. Therefore, it is necessary to understand characteristics of diseases caused by SARS-CoV-2 through animal models. Syrian hamsters are known to be susceptible to SARS-CoV-2. They were intranasally inoculated with SARS-CoV-2. At 2, 4, 8, 12, and 16 days post-infection (dpi), these hamsters were euthanized, and tissues were collected for ultrastructural and microstructural examinations. Microscopic lesions were prominent in the upper and lower respiratory tracts from 2 and 4 dpi groups, respectively. The respiratory epithelium in the trachea, bronchiole, and alveolar showed pathological changes. Inflammatory cells including neutrophils, lymphocytes, macrophages, and eosinophils were infiltrated in/around tracheal lamina propria, pulmonary vessels, alveoli, and bronchiole. In pulmonary lesions, alveolar wall was thickened with infiltrated inflammatory cells, mainly neutrophils and macrophages. In the trachea, epithelial damages started from 2 dpi and recovered from 8 dpi, consistent with microscopic results, High levels of SARS-CoV-2 nucleoprotein were detected at 2 dpi and 4 dpi. In the lung, lesions were most severe at 8 dpi. Meanwhile, high levels of SARS-CoV-2 were detected at 4 dpi. Electron microscopic examinations revealed cellular changes in the trachea epithelium and alveolar epithelium such as vacuolation, sparse micro-organelle, and poor cellular margin. In the trachea epithelium, the number of cytoplasmic organelles was diminished, and small vesicles were prominent from 2 dpi. Some of these electron-lucent vesicles were filled with virion particles. From 8 dpi, the trachea epithelium started to recover. Because of shrunken nucleus and swollen cytoplasm, the N/C ratio of type 2 pneumocyte decreased at 8 and 12 dpi. From 8 dpi, lamellar bodies on type 2 pneumocyte cytoplasm were increasingly observed. Their number then decreased from 16 dpi. However, there was no significant change in type 1 pneumocyte. Viral vesicles were only observed in the cytoplasm of type 2 pneumocyte. In conclusion, ultra- and micro-structural changes presented in this study may provide useful information for SARS-CoV-2 studies in various fields.

The role of peripheral eosinophilia in diagnosing lung disorders: experience from a single pneumonological center

Background

Eosinophilia is rare but one of the important reasons to refer patients to pneumonological centers. Determining etiology of eosinophilia has practical implications for therapeutic intervention and disease prognosis. The study aimed to determine the role of peripheral eosinophilia in the diagnosis of lung disorders.

Methods

In this retrospective study were included 46 patients diagnosed with peripheral eosinophilia with coexisting respiratory symptoms and/or radiologically detected lung lesions. All patients underwent standard diagnostic procedures, including a detailed clinical history review, physical examination, routine laboratory tests with basal cardiological examinations, and serological tests to detect parasites and allergies. Other procedures carried out depended on the symptoms of each patient. The relation between eosinophil counts in the blood and patients’ clinical manifestation was investigated to identify the degree of eosinophilia requiring immediate diagnostic procedures and treatment. Statistical analyses were performed using scientific computation libraries in the Python programming language, SciPy, v. 1.3.1. Briefly, the following tests were used: parametric Kruskal-Wallis H test, an independent t-test, ANOVA, the Shapiro- Wilk test, Fisher’s and Chi-squared tests, and the Holm-Bonferroni method.

Results

Severe eosinophilia (≥5,000 cells/μl) was associated with extrapulmonary involvement and constitutional symptoms. Skin, heart, and pleural diseases were more frequent in these patients than in patients with mild or moderate eosinophilia (p=0.010, p=0.040, and p=0.007, respectively), and only these patients showed signs of kidney disease (p=0.006). Vasculitis was significantly more frequent in the severe eosinophilia group (p=0.048) than in the other two groups. In patients with moderate eosinophilia (1,500-5,000 cells/μl), extrapulmonary symptoms were less common, although signs of cardiac involvement were confirmed in 44% of subjects. In this group, vasculitis was the most commonly observed disease (42% of cases). Mild eosinophilia (<1,500 cells/μl) was mainly associated with airway disease. In this group, vasculitis and interstitial lung diseases were identified, but most were not typically connected with eosinophilia.

Conclusions

Identification of peripheral eosinophilia may essentially determine diagnostic procedures in patients with lung disorders and may be a useful indicator of disease etiology.

Wells Syndrome - An Odyssey

BACKGROUND

Wells syndrome is a rare idiopathic dermatosis of the eosinophilic spectrum. Diagnostic criteria include cutaneous eruptions of variable morphology with eosinophilic infiltrates, peripheral blood eosinophilia, a relapsing, remitting course, and exclusion of systemic disease. Diagnosis is often delayed.

CASE PRESENTATION

We present a 28-year older man with recently developed pruritic and sometimes painful erythema. His medical history was positive for coughing in the evening that started in November 2012. Later, a pansinusitis developed. Early diagnosis improves the outcome.

CONCLUSION

Standardized treatment has yet to be developed. In our case, systemic corticosteroids were of limited value only.

Diffuse Exfoliative Rash with Sepsis and Eosinophilia: A Case of Erythroderma?

<strong>BACKGROUND</strong> Erythroderma is an exfoliative dermatitis that manifests as generalized erythema and scaling that involves 90% of the body surface. If untreated, erythroderma can be fatal because of its metabolic burden and risk of secondary infections. <strong>CASE REPORT</strong> The patient was a 56-year-old male with prior rash attributed to group A Streptococcal cellulitis and discharged on Augmentin, Clindamycin with hydrocortisone cream, and Bactrim, but he had been noncompliant. He was admitted again for rash involving the face, torso, and extremities characterized by diffuse, desquamative, dry scales in morbilliform pattern. The patient was septic with <i>Staphylococcus aureus</i> bacteremia and compromised skin barrier. He was started on vancomycin and switched to Cefazolin IV due to concern for drug reaction. Autoimmune workup included antibodies for anti-Jo-1, anti-dsDNA, anti-centromere, and ANCA. However, only antinuclear antibody and scleroderma antibody were positive. Given the unclear workup results and lack of response to antibiotics, the patient was started on prednisone 60 mg PO and topical Triamcinolone 0.1% cream. A skin biopsy revealed psoriasiform hyperplasia with atypical T cell infiltrate and eosinophils, but negative for T cell gene rearrangement. The rash resolved after day 12 of application of topical Triamcinolone. <strong>CONCLUSIONS</strong> This case is unique in terms of the rarity of erythroderma and the diagnostic challenge given confounding factors such as noncompliance and drug reaction. Serious causes, such as SLE and cutaneous T cell lymphoma, were ruled out. Fortunately, the rash responded well to steroids; however, given the adverse effects of long-term use of topical steroids, the patient will need follow up with Dermatology.

Eosinophils are surprisingly common in biopsy specimens of cutaneous herpes simplex virus and varicella zoster virus infections: Results of a comprehensive histopathologic and clinical appraisal

BACKGROUND

While usually straightforward, diagnostic features of cutaneous herpes simplex virus and varicella zoster virus infection (HSV/VZV) are not always present in biopsy specimens. Although intuitively the presence of eosinophils may lead the pathologist away from the diagnosis of cutaneous HSV/VZV infection, in our practice we have noted that eosinophils are often encountered in diagnostic specimens.

METHODS

To deduce the frequency with which the inflammatory response accompanying cutaneous HSV/VZV infection includes significant numbers of eosinophils, we performed a retrospective review. We included 159 specimens from our database, diagnosed between 2009 and 2017. We determined the number of eosinophils in 10 high-power fields and noted additional histologic factors including presence of follicular involvement, ulceration, and pseudolymphomatous change.

RESULTS

Of all included cases, 63% had 0-1 eosinophils, 24% had 2-10 eosinophils, and 13% had more than 10 eosinophils. Statistical analysis did not reveal a significant association between any demographic or histologic features examined and the presence of increased eosinophils.

CONCLUSIONS

In this study, more than one-third of biopsy specimens diagnostic of cutaneous HSV/VZV infection had a prominent number of eosinophils. The detection of eosinophils should not be unexpected and should not lessen diagnostic suspicion for cutaneous HSV/VZV infection.

Eosinophils and Respiratory Viruses

Eosinophils have been mainly associated with parasitic infection and pathologies such as asthma. Some patients with asthma present a high number of eosinophils in their airways. Since respiratory viruses are associated with asthma exacerbations, several studies have evaluated the role of eosinophils against respiratory viruses. Eosinophils contain and produce molecules with antiviral activity, including RNases and reactive nitrogen species. They can also participate in adaptive immunity, serving as antigen-presenting cells. Eosinophil antiviral response has been demonstrated against some respiratory viruses in vitro and in vivo, including respiratory syncytial virus and influenza. Given the implication of respiratory viruses in asthma, the eosinophil antiviral role might be an important factor to consider in this pathology.

Serum eosinophilic cationic protein is correlated with food impaction and endoscopic severity in eosinophilic esophagitis

BACKGROUND/AIMS

The aim of the present study was to analyze the diagnostic accuracy of serum eosinophilic cationic protein (ECP) for eosinophilic esophagitis (EoE) and the correlation of ECP with clinical, histopathological, laboratory, and endoscopic features of EoE.

MATERIALS AND METHODS

Fifteen patients with EoE and 14 healthy controls were included in the study. Demographic parameters were recorded. EoE Endoscopic Reference Score (EREFS) was calculated according to endoscopic features, and esophageal biopsies were obtained by a single experienced endoscopist in a patient group. Serum ECP levels (μg/mL), absolute eosinophil count (U/mm3), and maximum peak of eosinophils/high-power field in esophageal biopsies were analyzed.

RESULTS

The median age of all participants was 33.0 (min-max: 18-46) years. There were 27 (93.1%) male patients. Serum ECP level was significantly higher in patients with EoE than in healthy volunteers (20.4 vs. 8.8, p<0.0001). According to the receiver operating characteristic (ROC) curve analysis, ECP had 80% sensitivity and 92.8% specificity to diagnose EoE with a cut-off value of 13.9 µg/mL (area under the ROC curve 0.895; p<0.0001; 95% CI: 0.725-0.978). EREFS (p<0.0001) and the presence of food impaction (p=0.04) were significantly correlated with ECP.

CONCLUSION

Serum ECP is an accurate non-invasive biomarker for EoE with high specificity and sensitivity. In addition, ECP is strongly correlated with EREFS and the symptom of food impaction.

Critical role of CCL4 in eosinophil recruitment into the airway

BACKGROUND

Excessive eosinophil airway infiltration is a clinically critical condition in some cases. Eosinophilic pneumonia (EP) is a pulmonary condition involving eosinophil infiltration of the lungs. Although several chemokines, including eotaxin-1 (CCL11), RANTES (CCL5) and macrophage inflammatory protein 1β (MIP-1β or CCL4), have been detected in bronchoalveolar lavage fluid (BALF) from patients with EP, the pathophysiological mechanisms underlying EP, including potential relationships between eosinophils and CCL4, have not been fully elucidated.

OBJECTIVE

To examine the involvement of CCL4 in eosinophilic airway inflammation.

METHODS

We analysed supernatants of activated eosinophils and BALF from 16 patients with eosinophilic pneumonia (EP). Further, we examined the effects of CCL4 on eosinophil functions in vitro and those of anti-CCL4 neutralizing antibody in an in vivo model.

RESULTS

We found that purified human eosinophils stimulated with IL-5 predominantly secreted CCL4 and that patients with EP had elevated CCL11 and CCL4 levels in BALF compared with samples from individuals without EP. Because CCL4 levels were more strongly correlated with eosinophil count and expression of eosinophil granule proteins than CCL11, in vitro experiments using purified eosinophils concentrated on the former chemokine. Interestingly, CCL4 acted as a chemoattractant for eosinophils. In a mouse model, administration of a CCL4-neutralizing antibody attenuated eosinophilic airway infiltration and airway hyperresponsiveness.

CONCLUSIONS AND CLINICAL RELEVANCE

Overall, these findings highlight an important role of CCL4 in the mechanisms underlying eosinophil recruitment into the airway and may provide a novel insight into this potential therapeutic target.

Biological therapy of autoimmune blistering diseases

INTRODUCTION

Autoimmune blistering skin diseases are a group of disorders subdivided according to the location of blister formation: intraepidermal blistering in the pemphigus group and subepidermal in the pemphigoid group. These conditions are clinically heterogeneous and are treated with systemic corticosteroids and/or other forms of immunosuppression on the basis of clinical subtype and disease severity. These approaches may not be effective for the induction and maintenance of clinical response or need to be stopped because of intolerable side effects.

AREAS COVERED

Biological therapies can represent a valid alternative strategy in various autoimmune blistering disorders and this review article will address this issue with a special focus on pemphigus vulgaris and bullous pemphigoid. These biological approaches are designed to target B cells, autoantibodies, complement proteins, and several cytokines.

EXPERT OPINION

Innovative strategies for the treatment of autoimmune blistering conditions primarily depend on the use of drugs with a high degree of specificity targeting crucial steps in the immunopathology of these disorders. Novel biological agents offer treatment alternatives to patients with autoimmune blistering conditions by targeting B cells, pathogenic autoantibodies, complement and cytokines.

Eosinophils in the skin-a red herring masking lymphoma: a case series

Eosinophilia, both peripheral and in cutaneous tissue, is not a typical finding in mycosis fungoides; in fact, when faced with a lymphoeosinophilic infiltrate, mycosis fungoides is often not part of initial differential considerations. However, eosinophilia has been described in certain subtypes of mycosis fungoides, namely, in folliculotropic mycosis fungoides. We describe three challenging cases of folliculotropic mycosis fungoides presenting with varied clinical morphologies and a dense lymphoeosinophilic infiltrate and/or severe hypereosinophilia that obscured the final diagnosis for years. Only after treatment of the eosinophilia were the underlying atypical lymphocytes more apparent on histology and a correct diagnosis made. Thus, when characteristic features of mycosis fungoides are subtle, eosinophils can act as a red herring in terms of clinico-pathologic correlation and may prevent early and accurate diagnosis of mycosis fungoides. We suggest that further studies are needed to evaluate whether treatments to reduce eosinophilia, once other causes have been excluded, may help clear the confounding reactive inflammatory infiltrate and facilitate the diagnosis of mycosis fungoides.

CT and MRI findings in focal eosinophilic infiltration of the liver

OBJECTIVES

To investigate the findings of computed tomography (CT) and magnetic resonance imaging (MRI) of focal eosinophilic infiltration (FEI) of the liver.

METHODS

A retrospective study including 29 patients with confirmed FEI of the liver was performed. We evaluated the lesions' number, distribution, size, shape, margin, attenuation or signal intensity characteristics, the enhancement pattern, and some special features. Spearman correlation analysis was used to analyze the correlation between the number of lesions and the eosinophil counts in peripheral blood.

RESULTS

In all, 108 lesions were detected in 29 cases, including two cases with single lesion and the remaining 27 cases with multiple lesions. The mean size of all lesions was 34 mm (range, from 3 to 61 mm). 95 (88%) lesions were located in subcapsular parenchyma or surrounding the portal vein. Most (66%) subcapsular lesions were wedge shaped and all lesions surrounding portal vein were round shaped. However, the hepatic parenchymal lesions were irregular or round shaped. All lesions showed ill-defined margins. On pre-contrast CT images, the lesions showed slightly low attenuation or iso-attenuating. On T1-weighted and T2-weighted images, the lesions were slightly iso-/hypointense and hyperintense, respectively. A total of 23 (79.3%) cases were gradually enhanced. Branches of portal vein went through the lesions in all cases; 12 had 'stripe sign' and 16 had 'halo ring sign.' Spearman analysis indicated a significant correlation between the number of lesions and the increased eosinophils in peripheral blood (r = 0.627, p = 0.0003).

CONCLUSIONS

Special CT and MRI features and increased eosinophils may strongly suggest the diagnosis of FEI of the liver.

Discovery of novel 3-(hydroxyalkoxy)-2-alkylchromen-4-one analogs as interleukin-5 inhibitors

A series of novel chromen-4-one analogs 9a-d and 10a-u was designed, synthesized and evaluated for their IL-5 inhibitory activity. Most of the chromen-4-one analogs showed strong inhibitory activity in low micro molar potency. Among them, 5-(cyclohexylmethoxy)-3-(3-hydroxypropoxy)-2-isopropyl-4H-chromen-4-one (10t, 90.0% inhibition at 30 μM, IC₅₀ = 5.5 μM, CLogP = 4.76887) and 2-cyclohexyl-5-(cyclohexylmethoxy)-3-(3-hydroxypropoxy)-4H-chromen-4-one (10u, 95.5% inhibition at 30 μM, IC₅₀ = 3.0 μM, CLogP = 5.96187) showed the best inhibition. The structure activity relationship reveals that the hydrophobic cyclohexylmethoxy group at the position 5 of the chromen-4-one ring A is preferable than at position 6 and the dual hydrogen bonding acceptor property on the chromen-4-one ring should be important for the inhibitory activity. In addition, the optimum length of the side chain at position 3 of chromen-4-one ring is critical for the donation of hydrogen to the binding site and the 3-hydroxypropoxy group showed the best activity. Moreover, the conformational restrictor (isopropyl, cyclohexyl group) at position 2 is much more favorable for the formation of effective conformer of side chain with hydrogen bonding donor property of these chromen-4-one analogs.

Glycobiology of Eosinophilic Inflammation: Contributions of Siglecs, Glycans, and Other Glycan-Binding Proteins

The historical focus on protein-protein interactions in biological systems, at the expense of attention given to interactions between other classes of molecules, has overlooked important and clinically relevant processes and points of potential clinical intervention. For example, the significance of protein-carbohydrate interactions, especially in the regulation of immune responses, has recently received greater recognition and appreciation. This review discusses several ways by which cell-surface lectin-glycan interactions can modulate eosinophil function, particularly at the levels of eosinophil recruitment and survival, and how such interactions can be exploited therapeutically. A primary focus is on discoveries concerning Siglec-8, a glycan-binding protein selectively expressed on human eosinophils, and its closest functional paralog in the mouse, Siglec-F. Recent advances in the synthesis of polymeric ligands, the identification of physiological ligands for Siglec-8 and Siglec-F in the airway, and the determination of the basis of glycan ligand discrimination of Siglec-8 are discussed. Important similarities and differences between these siglecs are outlined. Eosinophil expression of additional glycan-binding proteins or their glycan ligands, including interactions involving members of the selectin, galectin, and siglec families, is summarized. The roles of these molecules in eosinophil recruitment, survival, and inflammation are described. Finally, the modulation of these interactions and potential therapeutic exploitation of glycan-binding proteins and their ligands to ameliorate eosinophil-associated diseases are considered.

Granuloma Faciale and Eosinophilic Angiocentric Fibrosis: Similar Entities in Different Anatomic Sites

BACKGROUND

Eosinophilic angiocentric fibrosis (EAF) and granuloma faciale (GF) share several histopathologic features, including eosinophil-rich inflammation, microangiitis, and progressive fibrosis. Concurrent presentation of EAF and GF suggests a pathogenetic link between them.

OBJECTIVES

To identify histologic findings that tell them apart and construe the pathogenetic mechanisms behind each morphologic variable, 14 immunohistochemical markers were used to study the cells subpopulations in 14 cases of GF and 3 cases of EAF.

MATERIALS AND METHODS

The lesions were classified according to their stage of development. The antibodies studied were: CD4, Foxp3, CD8, granzymes A and B, perforin, granulysin, CD20, CD56, CD68, ICAM-1, CD34, CD105, and 1A4.

RESULTS

The intensity of the sclerotic response and the density of 1A4-immunostained cells were significantly higher in EAF. In both diseases, CD68 cells were the most numerous, followed by CD20, CD8, and CD4 cells. About 30% of cells expressed ICAM-1. Among cells with cytotoxic granules, granulysin-positive cells were the most frequent.

CONCLUSIONS

Differences between GF and EAF were found to be mostly like due to anatomic site (usually skin of the face vs. sinonasal cavity) and stage of the disease development (usually earlier in cutaneous lesions because of their visibility). Innate and adaptive immunity, including B cells, T cells, and cytotoxic granules have a role in their pathogenesis.

Eosinophil-rich tissue infiltrates in chronic myelomonocytic leukemia patients

Chronic myelomonocytic leukemia (CMML) is a clonal hematopoietic disorder that associates dysplastic and proliferative features. Tissue inflammatory disorders occur in a fraction of CMML patients during the course of their disease. Here, we describe the occurrence of eosinophil-rich tissue inflammation, including eosinophilic pneumonia, chondritis, and cystitis, in CMML patients. Whole exome sequencing of leukemic cells did not identify a recurrent genetic abnormality among these three patients who were clinically improved by local or oral corticosteroids. Hypomethylating drugs were subsequently added in two of them, allowing decreasing corticosteroid doses and further treating their hematopoietic malignancy.

Eosinophils are required to suppress Th2 responses in Peyer's patches during intestinal infection by nematodes

Infections with enteric nematodes result in systemic type 2 helper T (Th2) responses, expansion of immunoglobulin (Ig)G1 antibodies, and eosinophilia. Eosinophils have a supportive role in mucosal Th2 induction during airway hyperreactivity. Whether eosinophils affect the local T-cell and antibody response in the gut-associated lymphoid tissue during enteric infections is unknown. We infected eosinophil-deficient ΔdblGATA-1 mice with the Th2-inducing small intestinal nematode Heligmosomoides polygyrus and found that parasite fecundity was decreased in the absence of eosinophils. A lack of eosinophils resulted in significantly augmented expression of GATA-3 and IL-4 by CD4⁺ T cells during acute infection, a finding strictly limited to Peyer's patches (PP). The increase in IL-4-producing cells in ΔdblGATA-1 mice was particularly evident within the CXCR5⁺PD-1⁺ T-follicular helper cell population and was associated with a switch of germinal centre B cells to IgG1 production and elevated serum IgG1 levels. In contrast, infected wild-type mice had a modest IgG1 response in the PP, whereas successfully maintaining a population of IgA⁺ germinal center B cells. Our results suggest a novel role for eosinophils during intestinal infection whereby they restrict IL-4 responses by follicular T helper cells and IgG1 class switching in the PP to ensure maintenance of local IgA production.

A Management Algorithm for Mitomycin C Induced Cystitis

Background/Objective: A post-bladder tumor resection dose of MMC can reduce non-invasive papillary (pTa) bladder cancer recurrences by up to 40%; this treatment is recommended in both the AUA and EUA non-muscle-invasive bladder cancer guidelines. A common complication of this treatment is eosinophilic cystitis. Symptoms range from mild urinary frequency and urgency to debilitating pain and dysuria. Currently, there is no established treatment algorithm for MMC-induced cystitis. Methods: Members of the Urologic Surgery Quality Collaborative (USQC), a group composed of over 160 private and academic urologists, met to discuss the management of patients with cystitis following MMC therapy. They devised a treatment algorithm based on experiences of urologic oncologists and neurourologists to aid in the diagnosis and management of MMC-induced cystitis. Results: The assessment begins with urinalysis and culture, followed by cystoscopy. For mild symptoms, behavioral therapy, including timed voids, fluid restriction and Kegel exercises are trialed. If symptoms have not resolved, treatment with an antihistamine, followed by a combination of anticholinergic and alpha-blocker medications. For persistent symptoms or severe symptoms at presentation, a course of prednisone plus antihistamine is prescribed. If symptoms are improving but have not resolved, this treatment is extended for a full 4 weeks prior to steroid taper. If symptoms do not improve, any visible bladder ulcerations are resected intraoperatively followed by an additional course of prednisone and antihistamine. Intravesical DMSO instillations and intra-ulcer steroid injection can be used as a final effort to treat this condition. Conclusion: We present the first formal management algorithm with escalating treatment intensity tailored to patient symptoms.

Correlation between Soil Transmitted Helminth Infection and Eosinophil Levels among Primary School Children in Medan

BACKGROUND:

Soil Transmitted Helminth infection is one of most prevalent health problems worldwide, especially in environments with poor sanitation. Based on World Health Organisation (WHO) data, more than 2 billion people, or 24% of the world’s population, are infected with intestinal parasite. The highest prevalence is located in areas of poor sanitation and unsafe water supplies. In Indonesia, the prevalence of parasite infections is 15% of the entire population.

AIM:

The purpose of this study was to determine the relationship between Soil Transmitted Helminth infection on levels of eosinophils among primary school children. In addition, this study also aimed to determine the prevalence of different types of worm infections and the levels of eosinophils in children infected with worms.

MATERIAL AND METHODS:

This study was analytic observational using a cross-sectional method. The sampling technique was consecutive and in total 132 samples was obtained. The study involved primary school children in Amplas Medan and Hamparan Perak, Deli Serdang through May to October 2016. Univariate analysis was performed to determine STH infection prevalence and bivariate analysis was used to find the correlation between STH infection and eosinophil levels through a Chi square (χ²) test.

RESULTS:

The results showed that the prevalence of Soil Transmitted Helminth was 7.6%. The most common types of STH infection were 3.8% with Trichuris trichiura and 3% with Ascaris lumbricoides. A significant correlation was found between Parasite infection and eosinophil levels (Contingency Coefficient (C) = 0.2, χ² = 5.3, p = 0.021) and the risk of STH infection that caused eosinophilia or increased eosinophil levels in the children with a Prevalence Ratio (PR) of 1.56 (Confidence Interval (CI) 95%: 1.10-2.22).

CONCLUSION:

It is recommended that schools at similar risk improve and maintain hygiene and healthy behaviour in the school environment and that parents and teachers pay greater attention to the cleanliness of their children.

The targeted eosinophil-lowering effects of dexpramipexole in clinical studies

Dexpramipexole, an orally bioavailable small molecule previously under clinical development in amyotrophic lateral sclerosis, was observed during routine safety hematology monitoring to demonstrate pronounced, dose- and time-dependent eosinophil-lowering effects, with minor reductions on other leukocyte counts. Analysis of hematology lab values across two double-blind, randomized placebo-controlled clinical trials at total daily doses ranging from 50mg to 300mg demonstrated that dexpramipexole consistently and markedly lowered peripheral blood eosinophils. This effect developed after 1month on treatment, required 3-4months to reach its maximum, remained constant throughout treatment, and partially recovered to baseline levels upon drug withdrawal. All doses tested were well tolerated. The overall adverse event rate was similar for dexpramipexole and placebo, and notably with no increase in infection-related adverse events associated with eosinophil-lowering effects. Given the reliance on and insufficiency of off-label chronic corticosteroid therapy for hypereosinophilic syndromes and other eosinophilic-associated diseases (EADs), a need exists for less toxic, more effective, targeted therapeutic alternatives. Further clinical studies are underway to assess the eosinophil-lowering effect of dexpramipexole in the peripheral blood and target tissues of EAD patients and whether such reductions, if observed, produce clinically important benefits.

Eosinophilia in Hematologic Disorders

Eosinophilia in the peripheral blood can be the manifestation various medical conditions, including benign or malignant disorders. There are 3 main types of eosinophilia-associated myeloid neoplasms (MN-eos): myeloid and lymphoid neoplasms, chronic eosinophilic leukemia not otherwise specified, and idiopathic hypereosinophilic syndrome (HES). Imatinib mesylate has revolutionized the treatment of molecularly defined MN-eos, and novel agents have been successfully used to treat HES. The discovery of new, recurrent molecular alterations in patients with MN-eos may improve their diagnosis and therapy. This review focuses on the hematologist's approach to a patient with eosinophilia and treatment options for those with eosinophilic myeloid neoplasms.

Cystatin F Ensures Eosinophil Survival by Regulating Granule Biogenesis

Eosinophils are now recognized as multifunctional leukocytes that provide critical homeostatic signals to maintain other immune cells and aid tissue repair. Paradoxically, eosinophils also express an armory of granule-localized toxins and hydrolases believed to contribute to pathology in inflammatory disease. How eosinophils deliver their supporting functions while avoiding self-inflicted injury is poorly understood. We have demonstrated that cystatin F (CF) is a critical survival factor for eosinophils. Eosinophils from CF null mice had reduced lifespan, reduced granularity, and disturbed granule morphology. In vitro, cysteine protease inhibitors restored granularity, demonstrating that control of cysteine protease activity by CF is critical for normal eosinophil development. CF null mice showed reduced pulmonary pathology in a model of allergic lung inflammation but also reduced ability to combat infection by the nematode Brugia malayi. These data identify CF as a "cytoprotectant" that promotes eosinophil survival and function by ensuring granule integrity. VIDEO ABSTRACT.

Key findings to expedite the diagnosis of hyper-IgE syndromes in infants and young children

BACKGROUND

Hyper-IgE syndromes (HIES) are primary immunodeficiency disorders characterized by elevated serum IgE, eczema, and recurrent infections. Despite the availability of confirmatory molecular diagnosis of several distinct HIES entities, the differentiation of HIES particularly from severe forms of atopic dermatitis remains a challenge. The two most common forms of HIES are caused by mutations in the genes STAT3 and DOCK8.

METHODS

Here, we assess the clinical and immunologic phenotype of DOCK8- and STAT3-HIES patients including the cell activation, proliferation, and cytokine release after stimulation.

RESULTS

Existing HIES scoring systems are helpful to identify HIES patients. However, those scores may fail in infants and young children due to the age-related lack of clinical symptoms. Furthermore, our long-term observations showed a striking variation of laboratory results over time in the individual patient. Reduced memory B-cell counts in concert with low specific antibody production are the most consistent findings likely contributing to the high susceptibility to bacterial and fungal infection. In DOCK8-HIES, T-cell lymphopenia and low IFN-gamma secretion after stimulation were common, likely promoting viral infections. In contrast to STAT3-HIES, DOCK8-HIES patients showed more severe inflammation with regard to allergic manifestations, elevated activation markers (HLA-DR, CD69, CD86, and CD154), and significantly increased inflammatory cytokines (IL1-beta, IL4, IL6, and IFN-gamma).

CONCLUSION

Differentiating HIES from other diseases such as atopic dermatitis early in life is essential for patients because treatment modalities differ. To expedite the diagnosis process, we propose here a diagnostic workflow.

Elevation of serum surfactant protein-A with exacerbation in canine eosinophilic pneumonia

A 7-year-old female spayed Labrador Retriever was admitted to our hospital, because of cough with sputum. She was diagnosed as having canine eosinophilic pneumonia (CEP) based on blood eosinophilia, bronchial pattern and infiltrative shadow observed on thoracic radiography, bronchiolar obstruction and air-space consolidation predominantly affecting the right caudal lung lobe, as revealed by computed tomography (CT), predominant eosinophils in CT-guided fine needle aspiration and the clinical course. She exhibited a good response to steroid therapy, and the cough disappeared. The serum surfactant protein (SP)-A level increased with the aggravated symptom and decreased markedly with improvement compared with the C-reactive protein level and the number of eosinophils. We propose that serum SP-A level is a good biomarker in CEP.

Spectrum of Eosinophilic End-Organ Manifestations

Eosinophil-associated disorders can affect practically all tissues and organs in the body, either individually or in combination. This article provides an overview of end-organ manifestations of eosinophilia and discusses selected organ systems, including the upper and lower respiratory, cardiovascular, gastrointestinal, nervous, dermatologic, and renal systems. Mechanisms by which eosinophilia leads to end-organ damage are also considered.

Severe eosinophilic infiltration in colonic biopsies predicts patients with ulcerative colitis not responding to medical therapy

AIM

Eosinophils are potent proinflammatory cells that are involved in the pathogenesis of ulcerative colitis (UC). We evaluated the infiltration of eosinophils into the lamina propria in patients with active and inactive ulcerative colitis (UC) and investigated its clinical significance, among other variables, in predicting the outcome of medical treatment in active disease.

METHOD

We studied colorectal biopsy specimens from 18 UC patients with disease in long-standing remission, from 22 patients with active disease who responded to therapy (12 with complete response and 10 with partial response) and from 10 patients who were nonresponders. Demographic information was obtained at baseline, and clinical, endoscopic and laboratory data were obtained at baseline and 12 weeks post-treatment. We evaluated five histological features: mucosal ulceration; mucosal erosions; crypt abscesses; cryptitis; and eosinophilic infiltration of the lamina propria. The severity of these lesions was graded as: none or minimal; mild; moderate; or severe. Statistical analyses were performed between responders and nonresponders for differences in demographic, clinical, laboratory, endoscopic and histological parameters.

RESULTS

Laboratory, endoscopic and histological parameters were significantly improved after treatment only in the complete responders group. Analyses of baseline data revealed no significant differences in parameters between complete or partial responders and nonresponders, except for a less severe eosinophilic infiltration of lamina propria in complete responders (P < 0.05). Multiple logistic regression analysis showed that severe eosinophilic infiltration in colonic biopsies was the most significant predictor of poor response to medical therapy.

CONCLUSION

Assessing the severity of eosinophilic infiltration in the lamina propria of colonic biopsies in patients with ulcerative colitis could be a valuable predictive tool of response to medical therapy.

Demographic, clinical and allergological characteristics of Eosinophilic Esophagitis in a Spanish central region

BACKGROUND

Eosinophilic esophagitis (EoE) is a chronic inflammatory emerging disease of the oesophagus with immunoallergic aetiology. The allergens involved have not been clearly defined and may depend on the exposure of the population to aeroallergens or food antigens.

MATERIALS AND METHODS

Patients diagnosed with EoE between 2006 and 2011 were referred to our Allergy Section. Patch and skin prick tests (SPT) with aeroallergens and foods were performed, and total and specific IgE levels, eosinophil cationic protein levels and eosinophil count were determined.

RESULTS

43 patients were included. 36 (83.7%) were atopic. 29 patients presented choking, 19 dysphagia, 9 food impaction with urgent endoscopy, 4 chest pain, 1 isolated vomiting and 1 epigastric pain. 22 had two or more symptoms. The mean duration of symptoms was 3.73 years. Concomitant allergic diseases included rhinoconjunctivitis and/or asthma (31 patients), IgE food allergy (21 patients) and atopic dermatitis (3 patients). 32 (74%) were sensitized to aeroallergens, of which 90% were sensitized to pollens; 23 (54%) showed positive tests to foods and 12 of them (52%) to lipid transfer proteins (LTP). Of the 29 pollen-allergic patients, 15 (52%) were sensitized to plant foods and 10 (34.4%) to LTP.

CONCLUSIONS

Our findings support those reported in the literature: the disease is more common in men aged 30-40 years with at least a three-year history of symptoms of esophageal dysfunction, sensitized to pollens, the predominant aeroallergen in our area, but also to plant foods or panallergens. These results increase the evidence for an immunoallergic aetiology and can help us in the early diagnosis of EoE.

Role of cellular effectors in the emergence of ventilation defects during allergic bronchoconstriction

It is not known whether local factors within the airway wall or parenchyma may influence the emergence and spatial distribution of ventilation defects (VDs), thereby modulating the dynamic system behavior of the lung during bronchoconstriction. We assessed the relationship between the distribution of cellular effectors and the emergence of defects in regional ventilation distribution following allergen challenge. We performed high-resolution K-edge subtraction (KES) synchrotron imaging during xenon inhalation and measured the forced oscillatory input impedance in ovalbumin (OVA)-sensitized Brown-Norway rats (n = 12) at baseline and repeatedly following OVA challenge. Histological slices with best anatomic matching to the computed tomographic images were stained with a modified May-Grunwald Giemsa and immunohistochemical staining with monoclonal anti-rat CD68, in six rats. Slides were digitized and total cells and eosinophils were counted in the walls of bronchi and vessels randomly selected within and outside of VDs on the basis of xenon-KES images. Ventilated alveolar area decreased and ventilation heterogeneity, Newtonian resistance, tissue damping, and elastance increased following OVA challenge. Eosinophil, total cell, and CD68+ counts were significantly higher in the bronchial and vascular walls within vs. outside of the VDs. The minimal central airway diameters during OVA-induced bronchoconstriction were correlated with eosinophil (R = -0.85; P = 0.031) and total cell densities (R = -0.82; P = 0.046) in the airway walls within the poorly ventilated zones. Our findings suggest that allergic airway inflammation is locally heterogeneous and is topographically associated with the local emergence of VDs following allergen challenge.

Diagnostic Complexities of Eosinophilia

Context.— The advent of molecular tools capable of subclassifying eosinophilia has changed the diagnostic and clinical approach to what was classically called hypereosinophilic syndrome.

Objectives.— To review the etiologies of eosinophilia and to describe the current diagnostic approach to this abnormality.

Data Sources.— Literature review.

Conclusions.— Eosinophilia is a common, hematologic abnormality with diverse etiologies. The underlying causes can be broadly divided into reactive, clonal, and idiopathic. Classically, many cases of eosinophilia were grouped together into the umbrella category of hypereosinophilic syndrome, a clinical diagnosis of exclusion. In recent years, an improved mechanistic understanding of many eosinophilias has revolutionized the way these disorders are understood, diagnosed, and treated. As a result, specific diagnoses can now be assigned in many cases that were previously defined as hypereosinophilic syndrome. Most notably, chromosomal rearrangements, such as FIP1L1-PDGFRA fusions caused by internal deletions in chromosome 4, are now known to be associated with many chronic eosinophilic leukemias. When present, these specific molecular abnormalities predict response to directed therapies. Although an improved molecular understanding is revolutionizing the treatment of patients with rare causes of eosinophilia, it has also complicated the approach to evaluating and treating eosinophilia. Here, we review causes of eosinophilia and present a framework by which the practicing pathologist may approach this diagnostic dilemma. Finally, we consider recent cases as clinical examples of eosinophilia from a single institution, demonstrating the diversity of etiologies that must be considered.

Workshop report from the National Institutes of Health Taskforce on the Research Needs of Eosinophil-Associated Diseases (TREAD)

BACKGROUND

Eosinophils are blood cells that are often found in high numbers in the tissues of allergic conditions and helminthic parasite infections. The pathophysiologic roles that eosinophils may serve in other human "eosinophil-associated" diseases remain obscure.

OBJECTIVE

National Institutes of Health (NIH) Institutes and the Office of Disease Prevention assembled an international taskforce of clinical and basic scientists with the charge to propose and prioritize unmet research needs in eosinophil-associated diseases.

METHODS

The taskforce used an organ system approach to identify the different and common themes of eosinophil cell involvement in these diseases. In early 2012, a draft document was circulated for review. The document was amended and the prioritizations were set at a NIH-organized workshop in June 2012.

RESULTS

The taskforce identified significant research needs. These needs cross disease entities but some are disease specific. There are substantial shortcomings to the various preclinical animal models, as well as significant gaps in our epidemiologic, pathophysiologic, diagnostic, prognostic, and therapeutic knowledge. The taskforce recognized that recent efforts by patient advocacy groups have played instrumental roles in improving the identification and characterization of these disorders. However, communications among the eosinophil-interested communities, for example, governmental funding and regulatory agencies, and industry and clinician scientists need to be more comprehensive.

CONCLUSIONS

Significant efforts are required to address our knowledge gaps to improve the outcomes of eosinophil-associated diseases. NIH Institutes, other federal agencies, lay organizations, and the pharmaceutical industry should consider the taskforce's recommendations in their future research activities.

Thymic stromal lymphopoietin stimulates the formation of eosinophil extracellular traps

BACKGROUND

Thymic stromal lymphopoietin (TSLP) that is released by epithelial cells upon certain environmental triggers activates cells of the innate and adaptive immune system resulting in a preferential T helper 2 immune response. By releasing eosinophil extracellular traps (EETs), eosinophils achieve an efficient extracellular bacterial killing. Eosinophil extracellular traps release, however, has been observed in both infectious and noninfectious eosinophilic diseases. Here, we aim to investigate whether eosinophils generate functional EETs as a direct response to TSLP, and further to study the extra- and intracellular mechanisms involved in this process as well as TSLP receptor (TSLPR) expression by eosinophils in vitro and in vivo.

METHODS

Thymic stromal lymphopoietin receptor expression on blood and tissue eosinophils was assessed by immunoblotting, flow cytometry, and immunofluorescence staining. Purified eosinophils were stimulated with recombinant human TSLP. The release of extracellular DNA in association with eosinophilic cationic protein (ECP) was detected by fluorescence staining techniques and confocal microscopy. In addition, cell survival, cell adhesion, production of reactive oxygen species (ROS), and the inhibition of bacterial growth by TSLP-stimulated eosinophils were measured.

RESULTS

Thymic stromal lymphopoietin receptor was observed on peripheral blood eosinophils as well as on tissue infiltrating eosinophils in skin diseases. TSLP did not affect eosinophil survival, but induced the formation of EETs consisting of mitochondrial DNA in association with ECP in a concentration- and time-dependent manner. Eosinophil extracellular trap release could be inhibited by blocking either cell adhesion or ROS production. While eosinophils prevented the growth of both Staphylococcus aureus and Staphylococcus epidermidis, the latter were unable to elicit EET formation and eosinophils required additional TSLP stimulation to achieve this antibacterial activity.

CONCLUSIONS

thymic stromal lymphopoietin directly stimulates eosinophils to produce EETs. Our observations link epithelial TSLP expression triggered by environmental factors with pathogen defense mechanisms involving eosinophils.

Clinical characteristics that distinguish eosinophilic organ infiltration from metastatic nodule development in cancer patients with eosinophilia

BACKGROUND

When new space-occupying lesions are observed together with peripheral blood eosinophilia in patients diagnosed with cancer, the possibility of eosinophilic organ involvement should be differentiated from metastasis of primary cancer, since a misdiagnosis could lead to unnecessary chemotherapy. The aim of this study is to identify the clinical characteristics of eosinophilic organ involvement that distinguish it from distant metastasis in patients with primary cancer.

METHODS

The medical records of 43 cancer patients who developed hepatic or pulmonary nodules with peripheral blood eosinophilia between January 2005 and February 2010 in the Asan Medical Center (Seoul) were reviewed. Eosinophilic infiltration and distant metastasis were identified on the basis of pathological findings and radiological features. Fisher's exact test, χ² test or Mann-Whitney test were used for statistical analysis.

RESULTS

In total, 33 patients (76%) were diagnosed with eosinophilic infiltration, 5 (12%) with cancer metastasis and 5 (12%) had undetermined diagnoses. Compared to the patients with metastases, the patients with eosinophilic infiltration were significantly more likely to have serology indicating a parasitic infection, a history of eating raw food, high serum levels of total IgE, normal liver function, normal C-reactive protein levels, a normal erythrocyte sedimentation rate, and fewer and smaller nodules. The most common underlying malignancy in the eosinophilic organ infiltration group was stomach cancer. Physicians tended to neglect the eosinophilia in patients with a history of cancer.

CONCLUSIONS

Several clinical characteristics of eosinophilic organ infiltration distinguish it from cancer metastasis. Physicians should make greater efforts to determine the causes of organ involvement with peripheral blood eosinophilia, especially in cancer patients.

Eosinophils and disease pathogenesis

Eosinophils are granulocytic innate immune cells whose presence is conspicuous in a variety of disease states, including eosinophilic hyperproliferative and infiltrative processes, as well as conditions associated with maladaptive Th2 inflammation. This review discusses the role of eosinophils in disease pathogenesis, including a consideration of relevant eosinophil biology. Eosinophilic disease patterns of tissue infiltration are also detailed, as are candidate mechanisms by which eosinophils cause fibrosis and hypercoagulability and the importance of eosinophils in allergic inflammation. Eosinophils are unique cells in their spectrum of associated disease, with the promise of future discoveries in delineating the manner in which they contribute to disease pathogenesis.

Lactoferrin regulates an axis involving CD11b and CD49d integrins and the chemokines MIP-1α and MCP-1 in GM-CSF-treated human primary eosinophils

Eosinophils are multifunctional immune cells that contribute to innate and adaptive immune/repair responses. Lactoferrin (LF) is an iron-binding protein indicated to alter cell adhesion and immune function by receptor-mediated interactions or by participating in redox mechanisms. The eosinophil adhesion molecules, αMβ2 and α4β1, are differentially expressed following exposure to the cytokine granulocyte-macrophage colony-stimulating factor (GM-CSF) and various redox agents. We hypothesized that LF can alter the function and production of proteins involved in adhesion/migration. Utilizing eosinophil peroxidase activity or fluorescent labeling adhesion assays, LF reduced GM-CSF-induced eosinophil adhesion in the presence of fibronectin or vascular adhesion molecule-1 compared with GM-CSF treatment alone. Flow cytometric analysis of eosinophil αM (CD11b) and α4 (CD49d) integrins revealed that cotreatments (24 h) with LF plus GM-CSF induced a significant increase in CD11b compared with control and GM-CSF treatments but a significant decrease in CD49d compared with control and GM-CSF treatments. These changes in CD11b and CD49d levels were significantly correlated with the increased production of chemokines (macrophage inflammatory Protein-1α, monocyte chemotactic protein-1) and an identified increase in S100A9 production. Thus, LF release at sites of inflammation may alter eosinophil recruitment/activation and possibly the progression of diseases such as cancer and asthma where significant eosinophil influx has been described.

Biomarkers of eosinophil involvement in allergic and eosinophilic diseases: review of phenotypic and serum markers including a novel assay to quantify levels of soluble Siglec-8

There remains considerable controversy in the management of eosinophilic disorders, mainly due to a paucity of information regarding the clinical interpretation of total blood eosinophil counts versus surface activation markers versus eosinophil-derived or eosinophil-influencing mediator levels. Regrettably, few tests have been validated that define a unique clinical or prognostic phenotype that is more useful than simply monitoring total blood eosinophil counts. In this manuscript, phenotypic (cell surface) markers, along with serum and tissue-based markers that have been examined in the context of disease activity, are reviewed. We also report the development of a novel assay for detecting soluble Siglec-8 (sSiglec-8), a protein likely derived largely from eosinophils, as a potential serum biomarker. The assay consists of a competitive ELISA using a recombinant Siglec-8-Fc fusion protein. The goal of this preliminary study was to determine if sSiglec-8 is a useful biomarker that differentiates among patients with various eosinophil-associated diseases. In the final analysis, it is fair to say that further research is sorely needed to fully understand and validate the utility of various biomarkers, including sSiglec-8, before their use in clinical practice can be recommended with confidence.

Contemporary consensus proposal on criteria and classification of eosinophilic disorders and related syndromes

Eosinophilia is an important indicator of various neoplastic and nonneoplastic conditions. Depending on the underlying disease and mechanisms, eosinophil infiltration can lead to organ dysfunction, clinical symptoms, or both. During the past 2 decades, several different classifications of eosinophilic disorders and related syndromes have been proposed in various fields of medicine. Although criteria and definitions are, in part, overlapping, no global consensus has been presented to date. The Year 2011 Working Conference on Eosinophil Disorders and Syndromes was organized to update and refine the criteria and definitions for eosinophilic disorders and to merge prior classifications in a contemporary multidisciplinary schema. A panel of experts from the fields of immunology, allergy, hematology, and pathology contributed to this project. The expert group agreed on unifying terminologies and criteria and a classification that delineates various forms of hypereosinophilia, including primary and secondary variants based on specific hematologic and immunologic conditions, and various forms of the hypereosinophilic syndrome. For patients in whom no underlying disease or hypereosinophilic syndrome is found, the term hypereosinophilia of undetermined significance is introduced. The proposed novel criteria, definitions, and terminologies should assist in daily practice, as well as in the preparation and conduct of clinical trials.

Epicutaneous immunotherapy (EPIT) blocks the allergic esophago-gastro-enteropathy induced by sustained oral exposure to peanuts in sensitized mice

Background

Food allergy may affect the gastrointestinal tract and eosinophilia is often associated with allergic gastrointestinal disorders. Allergy to peanuts is a life-threatening condition and effective and safe treatments still need to be developed. The present study aimed to evaluate the effects of sustained oral exposure to peanuts on the esophageal and jejunal mucosa in sensitized mice. We also evaluated the effects of desensitization with epicutaneous immunotherapy (EPIT) on these processes.

Methods

Mice were sensitized by gavages with whole peanut protein extract (PPE) given with cholera toxin. Sensitized mice were subsequently exposed to peanuts via a specific regimen and were then analysed for eosinophilia in the esophagus and gut. We also assessed mRNA expression in the esophagus, antibody levels, and peripheral T-cell response. The effects of EPIT were tested when intercalated with sensitization and sustained oral peanut exposure.

Results

Sustained oral exposure to peanuts in sensitized mice led to severe esophageal eosinophilia and intestinal villus sub-atrophia, i.e. significantly increased influx of eosinophils into the esophageal mucosa (136 eosinophils/mm²) and reduced villus/crypt ratios (1.6±0.15). In the sera, specific IgE levels significantly increased as did secretion of Th2 cytokines by peanut-reactivated splenocytes. EPIT of sensitized mice significantly reduced Th2 immunological response (IgE response and splenocyte secretion of Th2 cytokines) as well as esophageal eosinophilia (50 eosinophils/mm², p<0.05), mRNA expression of Th2 cytokines in tissue - eotaxin (p<0.05), IL-5 (p<0.05), and IL-13 (p<0.05) -, GATA-3 (p<0.05), and intestinal villus sub-atrophia (2.3±0.15). EPIT also increased specific IgG2a (p<0.05) and mRNA expression of Foxp3 (p<0.05) in the esophageal mucosa.

Conclusions

Gastro-intestinal lesions induced by sustained oral exposure in sensitized mice are efficaciously treated by allergen specific EPIT.

IL-4 regulates chemokine CCL26 in keratinocytes through the Jak1, 2/Stat6 signal transduction pathway: Implication for atopic dermatitis

Atopic dermatitis (AD), a chronic, pruritic, inflammatory skin disease, is histopathologically characterized by epidermal hyperplasia and infiltration of T cells, mast cells, and eosinophils. Clinical study and basic research have established that IL-4 plays an important role in the pathogenesis of AD. In this report, using HaCat cells, we show that CCL26, a chemokine for eosinophils, is up-regulated by IL-4 at both the mRNA and protein levels. IL-4 also enhances CCL26 promoter activity. Serial 5' deletion of the promoter and mutagenesis study reveal that the proximal Stat site is the key response element for IL-4 regulation of CCL26. Although IL-4 increases phosphorylation of both Stat3 and Stat6, it only activates Stat6 as shown by dominant negative studies. In addition, we found that IL-4 induces Stat6 nuclear translocation and stimulates phosphorylation of Jak1 and Jak2 but not Tyk2. IL-4 up-regulation of CCL26 can be suppressed by Jak inhibitors in a dose-dependent manner. Taken together, results of this investigation reveal that IL-4 signals through the Jak1, 2/Stat6 pathway in keratinocytes to stimulate CCL26 expression and this may provide an explanation for the pathogenesis of AD.

The functional connection between oral allergy syndrome and united airways disease assessed by oral challenge

BACKGROUND

The airways and the upper digestive tract have a common embryonic origin. In sensitized subjects they can respond to allergens with an immediate reaction (asthma, rhinitis, or oral allergy syndrome [OAS]).

OBJECTIVE

To investigate the possible functional connection between respiratory and upper digestive tract by means of specific oral allergen challenges.

METHODS

Patients sensitized to birch and apple were subdivided into group A (n = 12; asthma + rhinitis caused by birch and OAS caused by apple); group B (n = 10; OAS caused by apple without asthma/rhinitis); group C (n = 8; asthma and rhinitis caused by birch without OAS). Healthy subjects represented the control group D (n = 6). Oral provocation test with apple was performed out of the pollen season. Visual analog scale for eye, nose, and mouth symptoms, spirometry, nasal eosinophil count, and exhaled nitric oxide were assessed before and 6 hours after challenge.

RESULTS

No change occurred in nasal and ocular symptoms before versus after challenge in all groups. On the contrary, in groups A and B the oral scores significantly increased after challenge (P < .001), whereas no change was seen in groups C and D. Exhaled nitric oxide and nasal eosinophils showed no change before versus after challenge in all groups. Nitric oxide was higher before and after challenge in groups A and C vs groups B and D. No change was seen in either forced vital capacity or forced expiratory volume in 1 second.

CONCLUSION

In the case of birch-apple syndrome, eating apple does not functionally or clinically affect the respiratory tract.

Distinct eosinophil cytokine expression patterns in skin diseases - the possible existence of functionally different eosinophil subpopulations

BACKGROUND

The function of eosinophils has been attributed to host defense, immunomodulation, and fibrosis. Although eosinophils are found among infiltrating cells in a broad spectrum of skin diseases, their pathogenic role remains uncertain. This study aimed to analyze the cytokine expression by eosinophils in different skin diseases.

METHODS

Skin specimens from different skin diseases [allergic/reactive, infectious, autoimmune, and tumors/lymphomas (LY)] were stained by antibodies directed to eosinophil cationic protein, cytokines [tumor necrosis factor (TNF)-α, interleukin (IL)-5, IL-6, IL-10, IL-11, IL-13, IL-17, IL-25, IL-33, interferon-γ, transforming growth factor (TGF)-β, and thymic stromal lymphopoietin], eotaxins (CCL11, CCL24, and CCL26), metalloproteinase (MMP)-9 as well as extracellular matrix proteins (tenascin-C and procollagen-3) and then analyzed by laser scanning microscopy.

RESULTS

The number of eosinophils varied considerably in and between disease groups and did not correlate with the numbers of accompanying inflammatory cells. The expression of IL-5, IL-6, IL-11, TGF-β, CCL24, and MMP-9 by eosinophils significantly differed between disease groups. Eosinophils in tumors/LY predominantly expressed IL-6, TGF-β, and CCL24, but not IL-11. On the other hand, in autoimmune diseases, eosinophils largely contributed to MMP-9 production. IL-5-generating eosinophils were particularly obvious in allergic and infectious diseases.

CONCLUSION

In skin diseases, eosinophil expresses a broad spectrum of cytokines. The different cytokine expression patterns suggest distinct functional roles of eosinophils in these diseases that might be related to host defense, immunomodulation, fibrosis, and/or tumor development.

The role of eosinophils and mast cells in intestinal functional disease

Functional gastrointestinal disorders (FGIDs) are common and currently defined by a symptom-based classification with no discernable pathology. In functional dyspepsia (FD), the duodenum is now implicated as a key area where symptoms originate.This is attributed to immune activation with increasing evidence indicating a role for duodenal eosinophilia. In irritable bowel syndrome (IBS), mastocytosis has been documented throughout the small and large intestine. Eosinophils and mast cells are an important link between innate and adaptive immunity, and are important in allergic type TH2 inflammation. Eosinophils may give rise to symptoms due to release of preformed cytokine proteins, which trigger neural excitation, muscle spasm, and pain. The close relationship of mast cells to nerves in IBS may similarly give rise to symptoms. Genetic studies also support of the role of innate immunity in FGIDs. The data supporting a prime role for eosinophils and mast cells in subsets of FD and IBS has become credible, and these data should be used to implement advances in diagnosis and therapeutic trials.