The bowel bypass syndrome: a response to bacterial peptidoglycans

Palisaded Neutrophilic Granulomatous Dermatitis, Bowel-Associated Dermatosis-Arthritis Syndrome, and Rheumatoid Neutrophilic Dermatitis

Neutrophilic dermatosis is a heterogeneous group of inflammatory skin diseases characterized by the presence of a sterile neutrophilic infiltrate on histopathology. Three specific types of neutrophilic dermatoses are reviewed in this article: palisaded neutrophilic granulomatous dermatitis, bowel-associated dermatosis-arthritis syndrome, and rheumatoid neutrophilic dermatitis. The authors review the literature and highlight the clinical and histopathological features, disease pathogenesis, and the association of these conditions with various systemic diseases such as rheumatoid arthritis, inflammatory bowel disease, and others. A multidisciplinary approach is necessary for the diagnosis and management of these inflammatory skin conditions.

The Bowel-Associated Arthritis-Dermatosis Syndrome (BADAS): A Systematic Review

Bowel-associated arthritis-dermatosis syndrome (BADAS) is a rare neutrophilic dermatosis that was first described in 1971 in patients who underwent bypass surgery for obesity. Over the years, the number of reported cases associated with medical gastroenterological conditions, particularly inflammatory bowel disease (IBD), has progressively increased. To date, there are no systematic reviews in the literature on BADAS. The design of an a priori protocol was based on PRISMA guidelines, and a search of PubMed and Scopus databases was conducted for articles published between 1971 and 2023 related to the topic. Fifty-one articles including 113 patients with BADAS were analyzed in this systematic review. Bariatric surgery and IBD were the most frequently reported causes of BADAS, accounting for 63.7% and 24.7% of all cases, respectively. A total of 85% of cases displayed the typical dermatological presentation, including urticarial maculopapular lesions centered by a vesicopustule, with the majority of lesions located on the upper limbs (73.5%). Polyarthralgia or localized arthritis were always present. Atypical presentations included cellulitis-like, erythema-nodosum-like, Sweet-syndrome-like and pyoderma-gangrenosum-like manifestations. Gastrointestinal symptoms were frequently observed in IBD-related cases (67.9%). The histopathology showed a neutrophilic infiltrate (96.6%). The most commonly used treatment regimens consisted of systemic corticosteroids, metronidazole and tetracyclines, either alone or in combination. A relapsing-remitting course was observed in 52.1% of patients. In conclusion, BADAS is a neutrophilic dermatosis that presents with a wide variety of cutaneous manifestations, both typical and atypical. Gastrointestinal symptoms are frequently observed, particularly in cases related to IBD. The histopathology is clear but not specific compared with other neutrophilic dermatoses. The diagnosis can be challenging, but the relapsing-remitting course and the strong association with polyarthralgia and gastrointestinal disease can aid in the diagnosis.

Neutrophilic dermatoses: Pyoderma gangrenosum and other bowel- and arthritis-associated neutrophilic dermatoses

Neutrophilic dermatoses are a heterogeneous group of inflammatory skin disorders that present with unique clinical features but are unified by the presence of a sterile, predominantly neutrophilic infiltrate on histopathology. The morphology of cutaneous lesions associated with these disorders is heterogeneous, which renders diagnosis challenging. Moreover, a thorough evaluation is required to exclude diseases that mimic these disorders and to diagnose potential associated infectious, inflammatory, and neoplastic processes. While some neutrophilic dermatoses may resolve spontaneously, most require treatment to achieve remission. Delays in diagnosis and treatment can lead to significant patient morbidity and even mortality. Therapeutic modalities range from systemic corticosteroids to novel biologic agents, and the treatment literature is rapidly expanding. The second article in this continuing medical education series reviews the epidemiology, clinical characteristics, histopathologic features, diagnosis, and management of pyoderma gangrenosum as well as bowel-associated dermatosis-arthritis syndrome and the arthritis-associated neutrophilic dermatoses rheumatoid neutrophilic dermatitis and adult Still disease.

Is psoriasis a bowel disease? Successful treatment with bile acids and bioflavonoids suggests it is

The gut is the largest lymphoid organ in the body. The human microbiome is composed of trillions of bacteria. The DNA of these bacteria dwarfs the human genome. Diet and ethanol can cause rapid shifts in the number and types of bacteria in the gut. The psoriatic microbiome is similar to that seen in alcoholics; there is a decrease in bacterial diversity and overgrowth of bacteria in the small bowel. Psoriatics often have liver disease and deficiencies in bile acids. Psoriasis is a disease characterized by a leaky gut. All of the comorbidities of this disease are due to systemic endotoxemia. Bacterial peptidoglycans absorbed from the gut have direct toxic effects on the liver and skin. Their absorption, as well as endotoxin absorption, must be eliminated to treat psoriasis successfully. Endotoxin absorption is markedly increased by ethanol and peppers. Bioflavonoids, such as quercetin and citrus bioflavonoids, prevent this absorption. Bile acids, given orally, break up endotoxin in the intestinal lumen. Pathogens, including Helicobacter pylori and Streptococcus pyogenes, must be eliminated with antimicrobial therapy for any treatment to work. A complete protocol for curing psoriasis is provided.

Neutrophilic dermatoses: Kids are not just little people

Neutrophilic dermatoses are a group of inflammatory skin disorders characterized by an overactive innate immune system with dysregulation of neutrophils without underlying infectious etiology. The major representative conditions discussed are Sweet syndrome; pyoderma gangrenosum; neutrophilic eccrine hidradenitis; palmoplantar eccrine hidradenitis; subcorneal pustular dermatoses; bowel-associated dermatosis arthritis syndrome; and synovitis, acne, pustulosis, hyperostosis, and osteitis. We will also discuss other neutrophilic conditions present almost exclusively in the pediatric population, including congenital erosive and vesicular dermatosis with reticulated supple scarring and the recently described group of autoinflammatory diseases. The clinical characteristics, diagnostic approach, and treatment management in the pediatric and adult population are discussed.

Is it bowel-associated dermatosis-arthritis syndrome induced by small intestinal bacteria overgrowth?

Introduction

Bowel-associated dermatosis-arthritis syndrome is rare systemic diseases characterized by a prodrome of fever, chills, and influenza-like symptoms with subsequent skin eruptions, myalgias, and polyarthralgias. It is reported to be occurred in Intestinal bypass surgery and inflammatory bowel disease.

Case description

Herein, we described a 29-years-old man with Bowel-associated dermatosis-arthritis syndrome. He had no history of gastrointestinal surgery and inflammatory bowel disease. Distribution of the gut bacterial flora showed small intestinal bacterial overgrowth.

Discussion and Evaluation

It is rarely form as Non-intestinal bypass road and non-inflammatory bowel disease was induced by small intestinal bacteria overgrowth.

Conclusions

We concluded that Immuno-inflammatory response to overgrowth of intestinal bacterial antigen induce the clinical symptoms of bowel-associated dermatosis-arthritis syndrome.

Jejunoileal bypass as the main procedure in the onset of immune-related conditions: the model of BADAS

Bariatric surgery represents a common approach for the control of severe morbid obesity, reducing caloric intake by modifying the anatomy of the gastrointestinal tract. Following jejunoileal bypass, a large spectrum of complications has been described, with rheumatic manifestation present in up to 20% of cases. Although bowel bypass syndrome, also called blind loop syndrome, is a well-recognized complication of jejunoileal bypass, the same syndrome was recognized in patients who had not had intestinal bypass surgery, and the term the 'bowel-associated dermatosis-arthritis syndrome' (BADAS) was coined. The pathogenesis of BADAS is as yet poorly understood and only few data concerning this issue have been published in the literature. The aim of the present paper is to review the literature and to discuss putative pathogenic mechanisms of BADAS, focusing on the immune system.

The skin: a mirror to the gut

INTRODUCTION

This review discusses the diseases with involvement of both skin and gut. GI manifestations of vesicobullous disorders and systemic diseases and syndromes involving skin and gut, dermatologic manifestations of inflammatory bowel disease (IBD), polyposis syndromes, and GI malignancies have been discussed. Diagnostic and treatment approaches towards these disorders are summarized.

CONCLUSIONS

Interaction of the skin and gut has always been an area of inquisitiveness. Gastrointestinal (GI) tract can be involved in dermatological disorders or GI diseases can have a dermatological manifestation.

Bowel associated dermatosis - arthritis syndrome: a case report

We report a rare case of Bowel Associated Dermatosis – Arthritis Syndrome in a young patient with complex Crohn's disease who presented with fever, arthritis, rash and worsening of diarrhea with abdominal pain, who promptly responded to a short course of steroids.

Cutaneous vasculitis: a review

As the skin is commonly involved in systemic vasculitic disorders as well as those hypersensitivity states whose expression is largely skin-confined, cutaneous vasculitic lesions offer a window to diagnosis and a ready source of accessible tissue for biopsy. In this review, we discuss the pathologic manifestations of chronic vasculitic syndromes such as granuloma faciale and erythema elevatum diutinum; IgA-associated vasculitis including Henoch-Schonlein purpura; vasculitis seen in the setting of cryoglobulinemia and hypergammaglobulinemia of Waldenstrom, hereditary deficiencies of complement, and IgA deficiency; those leukocytoclastic vasculitides resulting from hypersensitivity reactions to drug, chemical and foodstuff ingestion; and those vasculitides seen in patients with systemic diseases such as polyarteritis nodosa, rheumatoid arthritis, mixed connective tissue disease, systemic lupus erythematosus, Sjogren's syndrome, relapsing polychondritis, Behcet's disease, Wegener's granulomatosis, and allergic granulomatosis of Churg and Strauss.

Cutaneous manifestations of gastrointestinal diseases

Prompt recognition of cutaneous diseases or manifestations associated with the gastrointestinal tract may be lifesaving at times, and may lead to early preventive intervention to decrease risk of malignancy.

Cutaneous small-vessel vasculitis

Cutaneous small-vessel vasculitis (CSVV) refers to a group of disorders usually characterized by palpable purpura; it is caused by leukocytoclastic vasculitis of postcapillary venules. CSVV can be idiopathic or can be associated with a drug, infection, or underlying systemic disease. Initially, the pathogenesis of CSVV is immune complex related, but in its later stages different pathogenetic mechanisms may intensify the reaction and lymphocytes may predominate in the infiltrate. Cure requires elimination of the cause (ie, drugs, chemicals, infections, food allergens) when possible, as well as therapy with nonsteroidal antiinflammatory agents, corticosteroids, dapsone, potassium iodide, fibrinolytic agents, aminocaproic acid, immunosuppressive agents (ie, cyclophosphamide, azathioprine, methotrexate, cyclosporine) or even monoclonal antibodies, depending on disease severity.

Blind loop syndrome: an unusual cause of panniculitis

We describe a 52-year-old woman with panniculitis and blind loop syndrome. She had undergone a gastrectomy for peptic ulcer 4 years before. Tender erythematous nodules on her palms and soles were associated with diarrhea and weight loss. A biopsy specimen revealed septal and lobular panniculitis. A glucose hydrogen breath test was consistent with bacterial overgrowth. These results were consistent with panniculitis associated with a blind loop syndrome. Only four cases of this association have been reported previously.

A subtle clue to the histopathologic diagnosis of early alpha 1-antitrypsin deficiency panniculitis

An excisional biopsy specimen of a lesion of several days' duration in an 18-year-old woman revealed moderate splaying of neutrophils between collagen bundles throughout the reticular dermis and incipient necrosis of the dermis and subcutaneous fat. Mild infiltration of neutrophils and macrophages was seen in the septal and lobular panniculus. A biopsy performed on one of the patient's more chronic lesions demonstrated dermal necrosis, degeneration and fibrosis of septa, acute lobular panniculitis with a large number of neutrophils, and foci of subcutaneous fat necrosis with islands of sparing. Splaying of neutrophils between the collagen bundles in the reticular dermis appears to be the earliest histopathologic finding of alpha 1-antitrypsin deficiency panniculitis.

Cutaneous manifestations of gastrointestinal disorders. Part II

The cutaneous manifestations of inflammatory bowel disorders, vascular disorders of the gastrointestinal tract, celiac disease, and bowel-associated dermatosis-arthritis syndrome are reviewed. The significance of these signs, guidelines for their management, and investigations are discussed.

Arthritis by autoreactive T cell lines obtained from rats after injection of intestinal bacterial cell wall fragments

T cell lines (B13, B19) were isolated from the lymph nodes of Lewis rats 12 days after an arthritogenic injection of cell wall fragments of Eubacterium aerofaciens (ECW), a major resident of the human intestinal flora. These cell wall fragments consist of peptidoglycan polysaccharide complexes (PPC). The cell lines that bear the helper phenotype were arthritogenic in knee or ankle joints upon intravenous injection into irradiated Lewis recipients. B13 was, however, not arthritogenic in irradiated F344 recipients that are largely RT1 identical. The arthritis induced in the knee joints of the irradiated Lewis rats was clearly shown by a 99mtechnetium-pertechnetate scanning technique and was confirmed histologically. In vitro the cell lines showed a proliferative response after stimulation with syngeneic spleen cells alone. The proliferation was significantly higher when bacterial PPC, isolated in soluble form from normal feces or ileostomy fluid were added. Recognition by B13 appeared to be MHC class II restricted. These results show that autoreactive T cell lines can be isolated from rats after injection of bacterial cell wall antigens and that these cell lines can be arthritogenic. This suggests a role for autoreactive T cells in the induction of bacterial cell wall arthritis and might give a clue for the arthritogenic properties of the normal human intestinal flora.

Rheumatoid neutrophilic dermatitis

Rheumatoid neutrophilic dermatitis is a rare entity reported to occur in association with severe rheumatoid arthritis. Three patients with seropositive rheumatoid arthritis and rheumatoid neutrophilic dermatitis are described. Clinically, the eruption is characterized by symmetric erythematous papules, plaques, and rarely vesicles on extensor skin surfaces. Light microscopy reveals a dermal neutrophilic infiltrate without vasculitis. Spongiotic intraepidermal blisters, subepidermal bullae, or papillary neutrophilic microabscesses may be seen. The histologic differential diagnosis includes the other dermatoses in which neutrophils predominate. Rheumatoid neutrophilic dermatitis is one of several neutrophilic dermatoses seen in association with rheumatoid arthritis, suggesting that it may be part of a spectrum of neutrophilic cutaneous reaction patterns in a predisposed host.

A neutrophilic reaction of Sweet's syndrome type associated with the oral contraceptive

A case is presented of a Sweet's syndrome-like eruption in association with the oral contraceptive. A 46 year old caucasian woman developed recurrent episodes of erythematous tender plaques on her trunk six weeks after commencement of the oral contraceptive (OC). Her condition clinically and histologically resembled Sweet's dermatosis. On cessation of the OC there was complete resolution of her lesions and she remains well 12 months later. This is the first report, to our knowledge, of a neutrophilic reaction to the oral contraceptive, and we believe that drugs may be implicated in the aetiology of atypical neutrophilic reactions simulating Sweet's syndrome in patients who are otherwise well.

Evidence for peptidoglycan absorption in rats with experimental small bowel bacterial overgrowth

Surgical creation of jejunal self-filling blind loops (SFBL) causes small bowel bacterial overgrowth which is associated with hepatobiliary inflammation in the susceptible Lewis and Wistar rat strains. Since hepatic injury occurs when small bowel anaerobic bacterial concentrations are increased 4 to 6 log10 units per ml and hepatic bacterial cultures are negative, we postulate that the inflammation is caused by absorption of phlogistic cell wall polymers originating from bacteria within the loop. To demonstrate absorption of bacterial cell wall polymers, we measured plasma and hepatic levels of immunoreactive peptidoglycan-polysaccharide (PG-PS) following intraluminal injection as well as anti-PG antibodies as an indirect measure of absorption and/or accumulation of endogenous PG. PG-PS purified from group A streptococci was detected in plasma by enzyme-linked immunosorbent assay after intraluminal injection; rats with SFBL showed significantly more uptake into plasma and the liver than sham-operated rats or SFBL rats which were treated with metronidazole (P less than 0.025). Total plasma immunoglobulin A (IgA), IgG, and IgM levels did not differ among sham-operated rats and those with self-emptying blind loops or SFBL, but plasma anti-PG IgA (P less than 0.05), IgG, and IgM (P less than 0.01) levels were increased in rats with SFBL. Metronidazole and tetracycline prevented the elevation of anti-PG antibody, but gentamicin and polymyxin B did not. Anti-lipid A, anti-soy protein, and anti-chow antibodies in plasma were not consistently increased in rats with SFBL indicating the lack of a generalized antibody response to luminal antigens. These data suggest that PG from normal flora bacteria is absorbed from the intestinal lumen and that mucosal injury and/or increased luminal concentrations of PG, such as those induced by small bowel bacterial overgrowth, lead to enhanced absorption of potentially inflammatory bacterial polymers.

Hepatic injury associated with small bowel bacterial overgrowth in rats is prevented by metronidazole and tetracycline

Susceptible rat strains develop hepatobiliary injury following the surgical creation of self-filling blind loops that cause small bowel bacterial overgrowth. Luminal bacteria or their cell wall polymers were implicated in the pathogenesis of the lesions because sham-operated rats and rats with self-emptying blind loops, having only slightly increased bacterial counts, did not develop hepatic injury. In this study, antibiotics with different spectra of activities were continuously administered starting 1 day or 22 days after surgery to determine which intestinal flora may be responsible for the development of hepatic injury in rats with small bowel bacterial overgrowth. Four weeks following surgery, Lewis rats with self-filling blind loops receiving no antibiotics had elevated liver histology scores (8.2 +/- 1.3 vs. 0.7 +/- 0.4) and plasma aspartate aminotransferase levels (269 +/- 171 vs. 84 +/- 24) compared with sham-operated rats, P less than 0.001. Oral gentamicin as well as oral and intraperitoneal polymyxin B, which binds endotoxin, did not prevent hepatic injury in rats with self-filling blind loops. However, oral metronidazole and tetracycline therapy continuously administered beginning 1 day after surgery diminished hepatic injury (histology score 3.0 +/- 1.8, 2.9 +/- 1.1; aspartate aminotransferase 87 +/- 25, 98 +/- 34; respectively P less than 0.001 compared with self-filling blind loops receiving no antibiotics). Metronidazole also protected Wistar rats that require 12 weeks to develop hepatic injury following experimentally induced small bowel bacterial overgrowth compared with rats with self-filling blind loops that received no antibiotic treatment (histology score 10.4 +/- 1.3 vs. 0.7 +/- 1.1, and aspartate aminotransferase 273 +/- 239 vs. 76 +/- 20, P less than 0.001). When rats started metronidazole therapy 22 days after self-filling blind loop surgery, elevated aspartate aminotransferase values decreased to normal during the next 77 days and final histology scores were normal. All rats with self-filling blind loops had negative peritoneal, liver, spleen, and blood cultures but approximately 75% of mesenteric lymph node cultures were positive irrespective of antibiotic treatment. Because Bacteroides species have been implicated in causing vitamin B12 and disaccharidase deficiencies in rats with self-filling blind loops, we documented the presence or absence of these organisms from blind loops using selective culture techniques. Metronidazole and tetracycline eliminated Bacteroides sp. from blind loops, but polymyxin B and gentamicin did not.(ABSTRACT TRUNCATED AT 400 WORDS)

Sulfapyridine and sulfones decrease glycosaminoglycans viscosity in dermatitis herpetiformis, ulcerative colitis, and pyoderma gangrenosum

Shortly after the introduction of sulfa drugs, sulfapyridine was found to have unique therapeutic properties, unrelated to antibacterial activity. Later, sulfones were found to share the same properties. The disorders initially improved were dermatitis herpetiformis, pyoderma gangrenosum, subcorneal pustular dermatosis, acrodermatitis continua, impetigo herpetiformis and ulcerative colitis. They were also sometimes helpful in many other disorders. They are effective in select disorders characterized by edema followed by granulocytic inflammation or edema followed by vesicle or bullae formation. The sulfones work in low doses in leprosy and their mode of action is not fully understood. Several pieces of experimental information are available. It is proposed that these drugs are entering or influencing the protein moiety of glycosaminoglycans and decreasing tissue viscosity. This decreased tissue viscosity prevents edema and dilution of tissue fluid and decreases acute inflammation and vesicle and bullae formation.

Bowel-associated dermatosis-arthritis syndrome

A 48-year-old woman, who had undergone reversal of a jejunal loop, presented with skin eruptions, myalgia and arthralgia. Delayed gastric emptying was associated with a gastric phytobezoar. The clinicopathological features and response to therapy were typical of the dermatosis-arthritis syndrome, and probably were related to bacterial overgrowth.

Neutrophilic vascular dermatoses

The neutrophilic vascular dermatoses are a divergent group of disorders with distinct cutaneous manifestations. Diagnosis of these diseases requires clinical acumen because of the lack of pathognomonic histopathologic features. It is important for physicians to recognize these entities because of the large number of possible associated underlying diseases.

Jejunoileal bypass arthritis

Although intestinal bypass procedures are no longer performed, important lessons have been learned concerning clinical arthritides resulting from bacterial overgrowth and immune complex deposition. This information is of considerable value in patients who present with the clinical picture of intestinal bypass arthritis on the basis of other bowel abnormalities. Furthermore, the pathogenetic mechanisms involving bacterial overgrowth, release of bacterial antigens, and immune complex deposition may be pertinent to many types of inflammatory arthritis.

Neutrophilic vascular reactions

Dermatologic diseases are classified most commonly by morphology, by pathogenesis, or by etiology. Nontraditional classifications may be useful in terms of providing a reassessment of traditional views about disease interrelationships. This review of dermatoses characterized by neutrophilic infiltrates and dermal vessel changes reveals evidence suggesting that these dermatoses result from immune complex-mediated, neutrophil-induced dermal vessel damage. Therapeutic approaches to these heretofore unlinked dermatoses are remarkably similar.

Sweet's syndrome and malignancy

Acute febrile neutrophilic dermatosis (Sweet's syndrome) is characterized by pyrexia, neutrophilia, and the abrupt appearance of erythematous, painful, cutaneous plaques, primarily on the upper extremities, head, and neck. Histologically, the salient feature is a dense dermal infiltrate of neutrophils. Approximately 10 to 15 percent of published cases of Sweet's syndrome occurred in patients with cancer. This report reviews the 39 patients with malignancy-associated Sweet's syndrome described in the world literature and compares Sweet's syndrome in cancer patients with the idiopathic form of the disease. The most common associated malignancy was acute myelogenous leukemia. However, other myeloproliferative disorders, lymphoproliferative disorders, myelodysplastic syndrome, and carcinomas have been observed. Importantly, the diagnosis of Sweet's syndrome was often the presenting sign of a new or recurrent tumor. The presence of anemia, abnormal platelet counts, immature cells in the differential, and/or severe vesiculobullous or ulcerative cutaneous lesions is infrequent in idiopathic Sweet's syndrome and should alert physicians to the possibility of a more serious underlying disease. Extracutaneous manifestations may occur and most often involve the musculoskeletal system. Response to systemic steroids is dramatic in virtually all patients, regardless of the presence of malignancy.

Autointoxication revisited

The pustular dermatitis associated with small bowel bypass surgery and the cutaneous manifestations of inflammatory bowel disease are well known and generally assumed to be due to the absorption of microbial antigens from the bowel. Monomeric serum IgA is assumed to originate in the gastrointestinal tract, and circulating IgA immune complexes, as seen in dermatitis herpetiformis, should make us suspicious of a gastrointestinal tract source. These circulating immune complexes and perhaps polyclonal increases in serum IgA may be the result of minor perturbations of mucosal permeability or the failure of locally produced dimeric serum IgA to inactivate bacterial or dietary antigens. Such disparate entities as Reiter's syndrome, psoriasis, pyoderma gangrenosum, and ankylosing spondylitis, as well as the pustular eruptions of Behçet's syndrome, pustular psoriasis, and lithium therapy, may share this common pathogenesis.

Bowel-associated dermatosis-arthritis syndrome: bowel bypass syndrome without bowel bypass

The bowel bypass syndrome is a well-recognized complication in patients who have had jejunoileal bypass for morbid obesity. It consists of an influenza-like illness with increased temperature, chills, polyarthralgia, myalgia, and inflammatory papules and pustules that are 2 to 4 mm in diameter and that usually appear on the extremities and the upper part of the trunk. A patient is reported who had an identical bowel-associated dermatosis-arthritis syndrome but who had not undergone a jejunoileal bypass operation. Seven previously reported similar cases are reviewed.

Cutaneous secondary syphilis: preliminary immunohistopathologic support for a role for immune complexes in lesion pathogenesis

A circulating immune complex-mediated pathogenesis for lesions of secondary syphilis has been postulated. Textbook descriptions of a lymphoplasmacytic histopathologic picture have contradicted a role for circulating immune complexes in lesion pathogenesis. Four patients with early cutaneous lesions of secondary syphilis were studied. All four patients had serum Raji cell and/or Clq binding assay evidence for circulating immune complexes. Three patients showed a neutrophilic vascular reaction on histologic study of early lesions. The patients studied had immunofluorescence microscopic evidence of immunoreactant deposition in dermal blood vessels (4 hours) and/or a neutrophilic vascular reaction (24 hours) after intradermal histamine injection. Dieterle staining of lesional tissue from all patients showed the presence of treponemal organisms in dermal blood vessels. This new preliminary evidence adds some support to a circulating immune complex-mediated pathogenesis of cutaneous lesions in human secondary syphilis.

Circulating immune complexes containing secretory IgA in jejunoileal bypass disease

Thirteen patients were studied after jejunoileal bypass (JIB) surgery. Seven developed arthritis and six did not. Circulating immune complexes containing IgG and IgA were detected in the sera of patients with and without arthritis. IgA complexes were shown to contain secretory component, a protein predominantly associated with intraluminal IgA, in significantly higher levels in patients with arthritis. Analytical ultracentrifugation showed complexes of approximately 10 X 8S, consistent with the size of secretory IgA. Arthritis after JIB appears to be associated with circulating immune complexes containing secretory IgA.

Circulating immune complexes: their immunochemistry, biology, and detection in selected dermatologic and systemic diseases

Circulating immune complexes (CICs) are a heterogeneous group of immunoreactants formed by the noncovalent union of antigen and antibody. Many factors influence the formation, immunochemistry, biology, and clearance of these soluble reactants. The recent development of sensitive assays for the detection of CICs and the capability to assess immune complex (IC) clearance mechanisms in humans in vivo have expanded our understanding of these mediators. CICs influence both the afferent and efferent limbs of the immune response and can mediate tissue damage in certain pathologic states. ICs probably play an important role in the pathogenesis of serum sickness, systemic lupus erythematosus, and cutaneous necrotizing vasculitis. Recent investigations have raised the possibility that CICs may be of significance in other types of vasculitis as well. In other instances, ICs may form in response to tissue injury and subsequently modify the immune response of the host. A review of this material with special emphasis on diseases of relevance to dermatologists is presented.

Behçet's syndrome: immune regulation, circulating immune complexes, neutrophil migration, and colchicine therapy

Immune regulatory dysfunction, circulating immune complexes (CIC), and polymorphonuclear (PMN) cell migration were investigated in patients with Behçet's syndrome. Six patients meeting rigorous clinical criteria were evaluated. Only one patient showed evidence of immune regulatory dysfunction (increased T4/T8 ratio). Although C1q binding and Raji cell assays for CIC yielded positive results in only one of five patients, all five patients had in vivo "histamine trap test" evidence of CIC (all controls had normal results). Sera from all Behçet's syndrome patients increased migration of neutrophils to zymosan-activated serum. Colchicine therapy abolished the enhancing effect of the patient's sera on movement of PMN cells from patients and controls. An immune complex-mediated injury that is followed by an excessive accumulation of PMN cells may lead to the cutaneous lesions and other lesions in Behçet's syndrome. Further evaluation of colchicine therapy is warranted on the basis of these studies.