Circulating IgA immune complexes in patients with psoriasis

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.

IgA nephropathy during treatment with TNF-alpha blockers: Could it be predicted?

Immunoglobulin A (IgA) nephropathy (IgAN) may sometimes be related to exposure to pharmacological agents, among which anti-Tumor Necrosis Factor (TNF)-alpha agents. The characteristic pathological feature is a deposition of IgA-containing immune complexes in vessel walls in the kidney mesangium. The link between TNF-alpha blockers and IgAN may be hypothesized examining diseases which share pathologic features. In this respect, idiopathic IgAN and Henoch Schonlein Purpura have been the object of studies revealing a pathogenetic role of aberrant glycosylation of IgA1 molecules. The Authors suggest that anti-drug antibodies against glycan structures of TNF-alpha inhibitors may cross react against serum aberrant IgA1 leading to large antigen-antibody complexes. These large polymeric IgA complexes are then able to deposit in the mesangium and activate the complement cascade. Such hypothesis may be tested by measuring serum levels of galactose-deficient IgA1 of patients developing IgAN following introduction of TNF-alpha blockers. Such a test would be useful also before administration of anti-TNF alpha agents. The presence of aberrant IgA1 may represent a contraindication for treatment with TNF blockers.

Renal abnormalities in a population of patients with psoriatic arthritis

OBJECTIVE

To investigate the prevalence of and to identify predictive factors for renal abnormalities in patients with psoriatic arthritis (PsA).

METHODS

73 patients with PsA were consecutively examined by laboratory analyses and clinically for joint manifestations. Renal function was estimated by creatinine clearance and urinary albumin.

RESULTS

17 (23.3%) of the patients had renal abnormalities as defined by creatinine clearance below the lower cut off of normal distribution (mean - 2 SD) and/or urinary excretion of albumin more than 25 mg/24 h. These patients were significantly older at the time of the study, older at joint disease onset, had longer skin disease duration, increased serum levels of beta2-microglobulin, and higher incidence of increased ESR and/or CRP levels. Increased ESR/CRP levels had significantly predictive value in multivariate analysis.

CONCLUSIONS

In this study subclinical renal abnormalities was a prevalent finding. Predictive factor was inflammatory activity measured by laboratory variables. There were no predisposing effects of NSAID or DMARD therapy.

Insights into the pathogenesis of psoriasis and psoriatic arthritis

Psoriasis and its related arthritis are chronic inflammatory disorders affecting predominantly the skin and synovium. Although their etiology remains to be established, multiple factors seem to play important roles in their pathogenesis. These environmental (eg, infectious agents and trauma), genetic, and immunologic factors are reviewed in this article.

The immunopathology of psoriasis

Psoriasis is a common chronic skin disorder affecting 2% of the general population. Present evidence strongly suggests that it is an immunologically mediated disease; the evidence includes the results of disease association studies linking psoriasis to certain MHC antigens and immunohistochemical studies revealing early influx into lesions of activated T lymphocytes. Accumulation of these cells in skin is mediated by upregulated expression of leukocyte adhesion molecules on vascular endothelium and epidermal keratinocytes and by production of proinflammatory and chemotactic cytokines. Activation of cell-mediated immune mechanisms in lesional skin is highlighted by the increased antigen-presenting capacity of Langerhans cells isolated from psoriatic skin compared to normal skin. The nature of the antigens precipitating psoriasis, however, remains unknown although a role for streptococcal superantigens has been postulated. These studies have led to the belief that immunotherapy may hold great promise for the treatment of psoriasis. Indeed both cyclosporin A and FK506 are effective therapies and evidence suggests that anti-CD4 antibodies may be of great value.

Hidradenitis suppurativa in Crohn's disease

Three patients with Crohn's disease who developed the clinical features of hidradenitis suppurativa (HS) are reported. To our knowledge this association has not been previously described. These cases illustrate the similarity between cutaneous Crohn's and ano-genital HS once chronic and established.

Autologous mixed lymphocyte reaction is reduced in patients with psoriasis

The autologous mixed lymphocyte reaction (auto-MLR) was studied to test the interactions between immunocompetent cells in patients with psoriasis. The auto-MLR in 20 patients with psoriasis was significantly lower than in 16 normal controls. Lower values were found in untreated psoriatic patients than in those in remission following treatment. The values in the latter group were significantly lower than in controls and in six patients with atopic dermatitis in remission. The tendency for an increase in the auto-MLR with a decrease in disease activity was further confirmed in five patients studied before and after treatment. In contrast, the allogeneic lymphocyte reaction (allo-MLR) in psoriatics was similar to that in normal controls.

Psoriatic arthritis of the hands in seven adults

Psoriatic arthritis is defined as an association of psoriasis with an arthropathy characterized mainly by osteolytic changes in the X-ray. To assess its frequency among Japanese psoriatic patients and to characterize their signs and symptoms, we examined 51 patients (37 males, 14 females) for arthropathy of the fingers. Seven patients (5 males, 2 females) had abnormal X-ray findings of the hands. They were compared with psoriatic patients without arthritis epidemiologically, clinically, and hematologically. Metacarpal indices were also measured and compared with the results from rheumatic arthritis patients and controls.

Linear IgA bullous dermatosis mimicking erythema multiforme in adult

This report describes a 49-year-old woman with an erythema multiforme--like rash and direct immunofluorescence showing linear IgA deposits at the dermoepidermal junction. Light microscopy revealed features of bullous pemphigoid, dermatitis herpetiformis, and erythema multiforme; immunoelectron microscopy demonstrated IgA deposition beneath the lamina densa about anchoring fibrils. These data provide additional information about the variable clinical and histologic manifestations of the adult linear IgA bullous dermatosis and emphasize the diagnostic dilemmas of light microscopy, which are resolved by immunohistochemical methods.

Circulating immune complexes in untreated psoriasis. A comparison of Raji-cell radioimmunoassay and polymorphonuclear leukocyte phagocytosis

Three different in vitro assays for the demonstration of circulating immune complexes were compared in 49 patients with psoriasis. Granulocytes from psoriatic subjects contained immune complex-like material in 25 patients (51%). When psoriatic serum was incubated with granulocytes from healthy blood donors, phagocytosed material was found in 18 patients (37%). The Raji-cell assay was only positive in two of 27 subjects (7%). Of the patients 71% tested positively with one of the granulocyte phagocytosis tests. Both tests were positive simultaneously in 16% and negative in 29% of the patients. The pathogenetic significance of the immune complex-like material is unclear.

Stimulation of T cells by autologous mononuclear leukocytes and epidermal cells in psoriasis

Based on reports suggesting aberrant cell-mediated immunity and altered infiltration of immunocompetent cells into the skin in psoriasis, we studied the stimulation of T cells by autologous non-T mononuclear leukocytes (autologous mixed lymphocyte reaction, AMLR) and by epidermal cells isolated from lesional and clinically uninvolved skin in psoriasis (autologous mixed epidermal cell lymphocyte reaction, AMECLR). Age- and sex-matched individuals served as controls. We found that the AMLR in psoriasis (n = 11) was similar to that in healthy controls (n = 16); furthermore, cell proliferation was alike in the presence of either 5% AB-serum or autologous serum. By contrast, while the AMECLR in healthy controls (n = 9) resembled that in psoriatics employing epidermal cells from univolved skin, epidermal cells from lesional sites (n = 10) induced a significantly higher proliferation of autologous T cells in the AMECLR (P less than 0.01). We conclude that the in vitro stimulation of T cells by non-T mononuclear leukocytes is normal in psoriasis and is not regulated by autologous serum. Lesional psoriatic epidermal cells, however, are more active in stimulating autologous T cell proliferation than cells from univolved psoriatic or normal epidermis.

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.

Involvement of complement in psoriasis and atopic dermatitis--measurement of C3a and C5a, C3, C4 and C1 inactivator

Normal complement components and activation products were determined in the peripheral blood of 35 patients with atopic dermatitis (AD) and 24 patients with psoriasis at a mild to intermediate stage. None of the patients had received systemic or local steroid therapy 6 weeks prior to blood collection. Levels of C3, C4 and C1 inactivator (C1 INA) were determined in serum by radial immunodiffusion, whereas C3a and C5a levels were measured by radioimmunoassay. In comparison to healthy non-atopic controls, the levels of C3, C4 and C1 INA were found to be significantly increased in both diseases. No substantial differences were detected between patients with psoriasis vulgaris and psoriasis guttata, which suggests that the dissimilarities found were not due to preceding or concomitant infections. In AD, there was a tendency towards increased C3a levels, whereas in psoriasis, C3a levels were significantly increased. In both diseases, no measurable amounts of C5a could be detected. The results indicate that, in both AD and psoriasis, the complement participates in the inflammatory process. Elevated levels of C3a suggest that there is a continuous activation of the complement system leading to the generation of inflammatory mediators.

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.