Aluminium hydroxide granuloma

Inflammation and Autophagy: A Convergent Point between Autism Spectrum Disorder (ASD)-Related Genetic and Environmental Factors: Focus on Aluminum Adjuvants

Autism spectrum disorder (ASD), schizophrenia, and bipolar disorder are genetically complex and heterogeneous neurodevelopmental disorders (NDDs) resulting from genetic factors and gene-environment (GxE) interactions for which onset occurs in early brain development. Recent progress highlights the link between ASD and (i) immunogenetics, neurodevelopment, and inflammation, and (ii) impairments of autophagy, a crucial neurodevelopmental process involved in synaptic pruning. Among various environmental factors causing risk for ASD, aluminum (Al)-containing vaccines injected during critical periods have received special attention and triggered relevant scientific questions. The aim of this review is to discuss the current knowledge on the role of early inflammation, immune and autophagy dysfunction in ASD as well as preclinical studies which question Al adjuvant impacts on brain and immune maturation. We highlight the most recent breakthroughs and the lack of epidemiological, pharmacokinetic and pharmacodynamic data constituting a "scientific gap". We propose additional research, such as genetic studies that could contribute to identify populations at genetic risk, improving diagnosis, and potentially the development of new therapeutic tools.

Influenza vaccines: Past, present, and future

Globally, infection by seasonal influenza viruses causes 3-5 million cases of severe illness and 290,000-650,000 respiratory deaths each year. Various influenza vaccines, including inactivated split- and subunit-type, recombinant and live attenuated vaccines, have been developed since the 1930s when it was discovered that influenza viruses could be cultivated in embryonated eggs. However, the protection rate offered by these vaccines is rather low, especially in very young children and the elderly. In this review, we describe the history of influenza vaccine development, the immune responses induced by the vaccines and the adjuvants applied. Further, we suggest future directions for improving the effectiveness of influenza vaccines in all age groups. This includes the development of an influenza vaccine that induces a balanced T helper cell type 1 and type 2 immune responses based on the understanding of the immune system, and the development of a broad-spectrum influenza vaccine that can increase effectiveness despite antigen shifts and drifts, which are characteristics of the influenza virus. A brighter future can be envisaged if the development of an adjuvant that is safe and effective is realized.

EBER in situ hybridization in subcutaneous aluminum granulomas/lymphoid hyperplasia: A diagnostic clue to differentiate injection-associated lymphoid hyperplasia from other forms of pseudolymphomas and cutaneous lymphomas

BACKGROUND

Subcutaneous vaccination or desensitization may induce persistent nodules at the injection sites. Without the knowledge of prior injection, histopathological work-up may be challenging.

OBJECTIVE

Aim of this study was to contribute to the histopathological work-up of unclear subcutaneous nodules, especially their differentiation from cutaneous lymphoma.

METHODS

We retrospectively reviewed clinical data and histopathological slides of four patients with subcutaneous nodules, which were suspected to suffer from cutaneous T- or B-cell lymphoma. Sections of these cases and 12 negative controls were stained with hematoxylin and eosin and a standardized immunohistochemical panel of B- and T-cell markers including EBER in situ hybridization as well as electron microscopy.

RESULTS

In all cases, large histiocytes with granular cytoplasm compatible with intracellular aluminum hydroxide were present. EBER in situ hybridization revealed positive staining of these granular histiocytes while staining was absent in negative controls.

LIMITATIONS

Post hoc completion of medical history revealed that vaccination or specific immunotherapy had been applied before at the biopsy site in only three out of four patients; one patient was lost to follow-up.

CONCLUSION

EBER in situ hybridization is an adjunctive tool to differentiate aluminum-induced granuloma/lymphoid hyperplasia from other forms of pseudolymphoma and cutaneous B- or T-cell lymphomas.

Subcutaneous nodules following immunization in children; in Victoria, Australia from 2007 to 2016

BACKGROUND

Subcutaneous nodules are a rare adverse event following immunization (AEFI). We aimed to describe nodules at the injection site reported to SAEFVIC (Surveillance of Adverse Events Following Vaccination in the Community) using the Brighton Collaboration Case Definition (BCCD), management and recurrence following subsequent immunizations.

METHOD

We assessed 58 cases (<18 years of age) of 'nodule at injection site' reported to SAEFVIC, Melbourne, Australia, between May 2007 and June 2016. Case details were analyzed from records and phone interview follow-up. The Australian Immunization Registry was reviewed for immunization status.

RESULTS

71% (41/58 reported cases) were consistent with the BCCD for subcutaneous nodule, 14% (8 cases) were 'possible subcutaneous nodules', 10% (6 cases) were nodules associated with BCG immunization and 5% (3 cases) were attributable to an alternative diagnosis. The median age at immunization was 12 months, (range 1 month-12 years); 54% male (22/41 cases). 17% (7 cases) had multiple nodules. Nodules were associated with immunizations containing aluminum (74%, 36/49 nodules), no aluminum (8%, 4 nodules) and unknown (18%, 9 nodules). Most cases developed symptoms within 3 days post-immunization (59%, 24 cases) and in the thigh (59%, 29 nodules). Pruritus was associated in 41% (17 cases). Around 1/3 (34%) of nodules resolved 6 months post immunization, 2/3 (68%) by 12 months, however 1/4 (24%) remained persistent for >24 months. 5 cases had prior nodules and 1 case had recurrence with subsequent immunization. 83% (34 cases) were fully immunized for age at follow-up.

CONCLUSION

Subcutaneous nodules at the injection site may occur following a wide range of vaccines, including vaccines without aluminum. All cases require careful review and where possible, specialist management and to support subsequent immunizations.

Tattoo pigment agglomerates measured in commercial ink stock products by computerised light microscopy

BACKGROUND

The incidence of clinical complications such as granuloma formation and sarcoidosis is often seen in black tattoos and may be associated with agglomeration of black pigment.

AIM

To measure count and dimensions of agglomerates in black tattoo inks vs red inks and to compare old inks and new inks of identical brands.

METHOD

Examination was performed by light microscopy (Olympus BX51^™ ) with magnification 40X, immersion oil. Photographs (Jenoptik Gryphax RGB camera) were taken of each ink sample and analysed by ImageJ software; count, area, width, height, circumference and circularity index were measured. Agglomerates were defined as width and height of objects above 800 nm. Twenty-one new unopened black inks and 17 new unopened red inks were compared. Furthermore, five old black inks and five old red inks, that had been opened and stocked for over 2 years, were compared with new products of the same brands.

RESULTS

Black agglomerates were area wise and with respect to width, height and circumference significantly larger compared with red agglomerates and more circularly shaped. Count of agglomerates was lower in black inks than in red inks, in accordance with bigger dimensions of black agglomerates. Comparison of old and new inks indicated old inks have larger agglomerates but variable bottle size and storage conditions may have confounded results.

CONCLUSION

Pigment agglomerates in black tattoo ink stock products were sized larger than agglomerates in red inks. Agglomerates found directly in black inks may predispose to granuloma formation in black tattoos causing sarcoid reaction.

Critical analysis of reference studies on the toxicokinetics of aluminum-based adjuvants

We reviewed the three toxicokinetic reference studies commonly used to suggest that aluminum (Al)-based adjuvants are innocuous. A single experimental study was carried out using isotopic 26Al (Flarend et al., Vaccine, 1997). This study used aluminum salts resembling those used in vaccines but ignored adjuvant uptake by cells that was not fully documented at the time. It was conducted over a short period of time (28days) and used only two rabbits per adjuvant. At the endpoint, Al elimination in the urine accounted for 6% for Al hydroxide and 22% for Al phosphate, both results being incompatible with rapid elimination of vaccine-derived Al in urine. Two theoretical studies have evaluated the potential risk of vaccine Al in infants, by reference to an oral "minimal risk level" (MRL) extrapolated from animal studies. Keith et al. (Vaccine, 2002) used a high MRL (2mg/kg/d), an erroneous model of 100% immediate absorption of vaccine Al, and did not consider renal and blood-brain barrier immaturity. Mitkus et al. (Vaccine, 2011) only considered solubilized Al, with erroneous calculations of absorption duration. Systemic Al particle diffusion and neuro-inflammatory potential were omitted. The MRL they used was both inappropriate (oral Al vs. injected adjuvant) and still too high (1mg/kg/d) regarding recent animal studies. Both paucity and serious weaknesses of reference studies strongly suggest that novel experimental studies of Al adjuvants toxicokinetics should be performed on the long-term, including both neonatal and adult exposures, to ensure their safety and restore population confidence in Al-containing vaccines.

Old and new adjuvants

Adjuvants have been deliberately added to vaccines since the 1920's when alum was discovered to boost antibody responses, leading to better protection. The first adjuvants were discovered by accident and were used in the safer but less immunogenic subunit vaccines, supposedly by providing an antigen depot to extend antigen presentation. Since that time, much has been discovered about how these adjuvants impact cells at the tissue site to activate innate immune responses, mobilize dendritic cells and drive adaptive immunity. New approaches to vaccine construction for infectious diseases that have so far not been well addressed by conventional vaccines often attempt to induce antibodies, polyfunctional CD4+ T cells and CD8+ CTLs. The discovery of pattern recognition receptors and ligands that drive desired T cell responses has led to development of novel adjuvant strategies using immunomodulatory agents to direct appropriate immune responses.

Persistent subcutaneous nodules after immunotherapy injections for allergic asthma

Adverse effects of desensitization injections mostly consist of local transient reactions. Rarely, persistent subcutaneous nodular lesions may also develop at the site of injection. These reactions have been attributed to the vaccines containing aluminium hydroxide. Aluminium hydroxide is used as an adjuvant in vaccines and hyposensitization solutions. We describe a patient who presented persistent, itchy subcutaneous nodules as a local reaction to allergen immunotherapy for the treatment of allergic asthma.

Macrophagic myofasciitis in children is a localized reaction to vaccination

Macrophagic myofasciitis is a novel, "inflammatory myopathy" described after a variety of vaccinations, almost exclusively in adults. We examined the relevance of histological findings of this myopathy to the clinical presentation in pediatric patients. Muscle biopsies from 8 children (7 months to 6 years old) with histological features of macrophagic myofasciitis were reviewed and correlated with the clinical manifestations. Patients underwent quadriceps muscle biopsy for suspected mitochondrial disease (4 patients), spinal muscular atrophy (2 patients), myoglobinuria (1 patient), and hypotonia with motor delay (1 patient). All biopsies showed identical granulomas composed of periodic acid-Schiff-positive and CD68-positive macrophages. Characteristic aluminum hydroxide crystals were identified by electron microscopy in 2 cases. The biopsy established diagnoses other than macrophagic myofasciitis in 5 patients: spinal muscular atrophy (2), Duchenne muscular dystrophy (1), phospho-glycerate kinase deficiency (1), and cytochrome c oxidase deficiency (1). Three children with manifestations and/or a family history of mitochondrial disease had otherwise morphologically normal muscle. All children had routine vaccinations between 2 months and 1 year before the biopsy, with up to 11 intramuscular injections, including the biopsy sites. There was no correlation between histological findings of macrophagic myofasciitis in biopsies and the clinical symptoms. We believe that macrophagic myofasciitis represents a localized histological hallmark of previous immunization with the aluminum hydroxide adjuvants contained in vaccines, rather than a primary or distinct inflammatory muscle disease.

Assessment of nine candidate DTP-vaccines with reduced amount of antigen and/or without adjuvant as a fourth (booster-) dose in the second year of life

BACKGROUND

The incidence of local reactions to diphtheria-, tetanus and acellular pertussis (DTaP-) vaccines in infants and toddlers increases with each subsequent dose, and entire thigh swellings (ETS) have been reported. Lowering the amount of antigen or of adjuvant may decrease the reactogenicity of DTaP while maintaining a protective immune response.

OBJECTIVES

Following priming with three doses of a DTaP vaccine during infancy, the safety, reactogenicity and immunogenicity of nine different candidate DTaP-vaccines with reduced amounts of antigen and/or adjuvant given as fourth (booster) dose were evaluated.

METHODS

Study participants were healthy infants aged 15-27 months at the time of booster vaccination. Each participant had received three doses of a DTaP vaccine (Infanrixtrade mark, GlaxoSmithKline, Rixensart, Belgium; "reference DTaP") at age 3, 4, and 5 months as part of a previous clinical trial. More than 20,000 children were eligible for participation in the current study protocol at the time. In a first phase at a University hospital-based vaccination study center, nine sequential cohorts of 63-119 study subjects received one of nine different candidate vaccines. Patients and study personal were blinded with regard to which vaccine was currently in use. Reactogenicity was solicited from parents using diary cards. Blood was drawn prior to and 4 weeks after vaccination and immediately centrifuged. The serum was stored at -20 degrees C until serology was performed by ELISA tests. As soon as the first candidate vaccine with adequate reactogenicity and immunogenicity profile was identified in the first study phase, a second study phase was initiated in parallel, to evaluate the safety and reactogenicity of the respective candidate vaccine in private practices in large cohorts (1613-2095 study subjects per group).

RESULTS

In the first study phase, DTaP with no aluminum induced the highest frequency of ETS and fever. All other candidate vaccines caused lower rates of local and general reactions than the reference DTaP. As a general rule, vaccines with less antigen induced fewer reactions, although there was no strict dose-response effect and the difference, e.g. between a one-tenth and a one-fifth DTaP dose (DTaP 1/5; DTaP 1/10) was not clinically relevant. Separate injections of Td and aP caused fewer general reactions than the respective TdaP combination and local reactions were higher at the aP than at the Td injection site. Again, as a general rule, reduced amounts of antigen induced lower antibody concentrations, although all vaccines induced "protective" anti-tetanus and anti-diphtheria antibody responses. A total of 92-100% of children showed seroresponses to pertussis antigens even when vaccinated with reduced amounts of the respective pertussis antigen. Elimination of aluminum from DTaP vaccine induced higher anti-tetanus-antibody concentrations and so did a reduction of the amount of diphtheria antigen. Additional examples for antigen interaction were increased antibody concentrations, observed with injection of Td and aP into different limbs. In the second study phase, all three vaccines evaluated (one with a reduced amount of diphtheria antigen, TdaP; one with reduced amounts of all antigens, tdap; and one with a fifth dose of the reference vaccine (DTaP 1/5)) were safe and had an acceptable reactogenicity profile in a total of 4871 study subjects.

CONCLUSIONS

Local reactions due to DTaP booster doses in the second year of life can be reduced by reducing the amount of antigen in the respective vaccine while an adequate immunogenicity is maintained. Aluminum-free vaccines induced ETS and fever most commonly. Any changes in vaccine composition should lead to a full evaluation of the new product.

Persistent nodules at injection sites (aluminium granuloma) -- clinicopathological study of 14 cases with a diverse range of histological reaction patterns

AIMS

To assess and document the spectrum of histological appearances of persistent swellings which occur at injection sites following vaccination or allergen desensitization.

METHODS AND RESULTS

Fourteen cases were studied. Four overlapping histological reaction patterns were evident. Ten cases showed at least focal fibrosis, fat necrosis and a mixed inflammatory cell infiltrate mainly in the subcutis, giving rise to the features of a non-specific septal and lobular panniculitis. The appearance of three cases, in addition to the non-specific panniculitis pattern, also included prominent lymphoid follicles with germinal centres and a prominent perifollicular infiltrate resembling a lymphoma (pseudolymphoma pattern). A single case mimicked lupus profundus, with a perivascular and periadnexal infiltrate in the dermis and hyaline fat necrosis. Three cases showed a predominantly palisaded histiocytic infiltrate surrounding eosinophilic necrobiosis, in a pattern closely resembling deep granuloma annulare or rheumatoid nodule. The remaining case partly showed this appearance, but in combination with panniculitis, thus demonstrating an overlap of patterns. A common feature in all 14 cases was the focal presence of histiocytes with abundant violaceous granular cytoplasm. These were shown to contain aluminium on energy dispersive X-ray microanalysis.

CONCLUSION

Persistent swellings at injections sites show a variety of overlapping patterns, which mimic other conditions. Identification of characteristic histiocytes with violaceous granular cytoplasm is the key distinctive feature allowing the correct diagnosis to be reached.

Aluminium hydroxide-induced granulomas in pigs

The effect of intramuscular injection of 40 mg/2 ml aluminium hydroxide in the neck of pigs was examined in a number of ways. The investigation followed repeated slaughterhouse reports, according to which 64.8% of pigs from one particular farm were found at slaughter to have one or more nodules in the muscles of the neck (group slaughtered). The pigs had been injected with a vaccine containing 40 mg/2 ml dose of aluminium hydroxide as adjuvant. Research consisted of two phases: first, an epidemiological study was carried out, aimed at determining the risk factors for the granulomas. The results indicated that the vaccine was to be held responsible for the formation of granulomas. A clinical trial was then performed to further substantiate the initial hypothesis, by comparing pigs, which were aseptically inoculated twice with either the original vaccine or the adjuvant alone (groups vaccine and adjuvant) to pigs inoculated twice with apyrogenic bi-distilled water (group water) and to pigs inoculated once with the adjuvant and once with apyrogenic bi-distilled water (group adjuvant/water). Both studies agreed in their conclusions, which indicate that the high amount of aluminium hydroxide was the cause of the granulomas.

Vaccination-induced cutaneous pseudolymphoma

BACKGROUND

Although mild early cutaneous transient reactions to vaccinations are common, late-onset chronic lesions have been scarcely reported. We report herein a series of 9 patients presenting with cutaneous and subcutaneous pseudolymphoma.

OBSERVATIONS

Nine patients presenting with late-onset, chronic skin lesions occurring at the site of antihepatitis B (8 cases) and antihepatitis A (one case) vaccination were reported. Histopathologic and immunohistochemic studies, and molecular analysis of clonality of skin biopsy specimens, were performed. Furthermore, the presence of vaccine products was investigated in skin lesions by using histochemical, microanalytic, and electronic microscopy techniques.

RESULTS

Histopathologic studies showed dermal and hypodermal lymphocytic follicular infiltrates with germinal center formation. The center of follicles was mostly composed of B cells without atypia, whereas CD4+ T cells were predominant at the periphery. Molecular analysis of clonality revealed a polyclonal pattern of B-cell and T-cell subsets. Aluminium deposits were evidenced in all cases by using histochemical staining in all cases, and by microanalysis and ultrastructural studies in one case. Associated manifestations were vitiligo (one case) and chronic fatigue with myalgia (two cases).

CONCLUSION

Cutaneous lymphoid hyperplasia is a potential adverse effect of vaccinations including aluminium hydroxide as an adjuvant. Further prospective studies are warranted to evaluate the incidence of this complication in the immunized population.

Childhood macrophagic myofasciitis—consanguinity and clinicopathological features

Macrophagic myofasciitis has been almost exclusively detected in adults only. We describe six children of Arab Moslem origin with this disorder. Three presented with hypotonia, developmental delay and seizures and were evaluated for a mitochondrial disorder. The other three children had hypotonia and predominantly motor delay. Five of the six families were consanguineous. A massive collection of macrophages was present in the fascia and adjacent epimysium in all biopsies. The macrophages were periodic-acid-Schiff positive and immunoreactive for CD68. One biopsy which was evaluated by electron microscopy and energy-dispersive X-ray microanalysis showed crystalline structures containing aluminum in macrophages. Two children with motor delay and hypotonia were treated with oral prednisone for 3 months with no clinical improvement. Genetic predisposition probably accounts for the variability in the prevalence of macrophagic myofasciitis in different populations. At least in childhood, there seems to be no connection between macrophagic myofasciitis as a pathological entity and the clinical symptoms and signs.

Mucosal immunization against hepatitis B virus by intranasal co-administration of recombinant hepatitis B surface antigen and recombinant cholera toxin B subunit as an adjuvant

Recombinant cholera toxin B subunit (rCTB) produced by Bacillus brevis carrying pNU212-CTB has been previously found to be a potent mucosal adjuvant to aluminium-non-adsorbed tetanus toxoid (nTT) and diphtheria toxoid (nDT) co-administered intranasally, and the possibility of needle-free inoculation of these vaccines with rCTB has been suggested. In this paper we examined the potentiality of rCTB as a mucosal adjuvant to aluminium-non-adsorbed yeast-derived recombinant hepatitis B surface antigen (rHBs) being a particulate antigen when administered intranasally with rCTB. In-house ELISA showed that a mixture of rHBs (1 or 5 microg) and rCTB (10 microg) elevated not only systemic responses but also mucosal immune responses at the nasal cavity, the lung, the saliva, the small intestine and the vagina against rHBs, and these could be further increased with higher doses of antigen. With antibody isotypes of IgG, there were equally high levels of serum HBs-specific IgG1, IgG2a and IgG2b antibodies and induction of mixed Th1- and Th2-type responses was considered to occur in combination of rHBs and rCTB. Serum anti-HBs titres in almost all mice obtained from sandwich EIA using a commercial kit were higher than 1000 milli-international units ml(-1) (mIU ml(-1)). These results show that rCTB is also very effective as a mucosal adjuvant for a particulate antigen like rHBs, as well as soluble antigens like nTT and nDT reported previously, suggesting the possibility of intranasal immunization with rHBs plus rCTB in humans.

Enhancing the immunogenicity of liposomal hepatitis B surface antigen (HBsAg) by controlling its delivery from polymeric microspheres

Microencapsulated liposome systems (MELs) were investigated as a potential immunization carrier for a recombinant 22-nm hepatitis B surface antigen (HBsAg) particle. MELs were prepared by first entrapping the HBsAg particles within liposomes composed of phosphatidylcholine:cholesterol (1:1 molar ratio), which were then encapsulated within alginate-poly(L-lysine) (PLL) hydrogel microspheres. The entrapped HBsAg particles retained immunoreactivity, as judged by an enzyme-linked immunosorbent assay (ELISA). Direct imaging of HBsAg particles and HBsAg incorporated into liposomes by cryo-transmission electron microscopy (cryo-TEM) indicated that HBsAg is embedded in the liposomal membrane. The antigenic particles were released from MELs mainly within the context of liposomes. The release rates in vitro and in vivo depended on the molecular weight of PLL used for MEL coating; MELs-214, coated with 214 kDa PLL, released the liposomal HBsAg at much higher rates than MELs-25, which was coated with 25 kDa PLL. Concomitantly, the specific anti-HBsAg titers in mice receiving HBsAg in MELs-214 were higher than those induced by MELs-25. MELs-214 were more efficient than conventional liposomes or alum in eliciting higher and prolonged antibody levels in mice. The ability of MELs to provide an HBsAg depot as well as a sustained release of liposomal HBsAg suggests that these carriers may be an ideal immunoadjuvant.

Delayed-hypersensitivity granulomatous reaction induced by blepharopigmentation with aluminum-silicate

Blepharopigmentation has been introduced during the last decade as a technique for creating a permanent line along the eyelid margin, thus simulating a cosmetic eyeliner. Complications related to this procedure are mostly reported in the opthalmologic literature describing infectious, allergic, or technical problems. We report a case of a woman who underwent blepharopigmentation with aluminum-silicate and in whom a delayed hypersensitivity granulomatous reaction developed.

Intranasal or subcutaneous co-administration of recombinant cholera toxin B subunit stimulates only a slight or no level of the specific IgE response in mice to tetanus toxoid

Whether recombinant cholera toxin B subunit (rCTB) co-administered intranasally or subcutaneously with aluminium-non-adsorbed tetanus toxoid (nTT) can induce the production of tetanus toxoid (TT)-specific IgE antibodies in mice was investigated compared with aluminium-adsorbed tetanus toxoid (aTT) administered intranasally or subcutaneously. Mice immunized intranasally or subcutaneously with nTT together with rCTB showed a high level of TT-specific serum IgG antibody response and no or a slight level of TT-specific serum IgE antibody response. On the other hand, in mice vaccinated intranasally or subcutaneously with aTT alone, higher levels of TT-specific IgG and IgE antibodies were induced in comparison with intranasal or subcutaneous inoculation of nTT together with rCTB. These results suggest that intranasal or subcutaneous co-administration of rCTB with nTT is better than intranasal or subcutaneous administration of aTT to avoid IgE-mediated allergic reactions.

A tumour in the breast: vaccination granuloma as a differential diagnosis

AIMS

Breast cancer is the most frequent type of cancer in women; special attention is therefore paid to tumours in the breast region. Vaccination granuloma is a differential diagnosis of tumours in the upper part of the breast.

METHODS

All granulomatous lesions in the breast region since 1970 were retrieved from the files of the Departments of Pathology at Odense University Hospital and Svendborg Hospital.

RESULTS

Fourteen cases with a histology compatible with vaccination granuloma were found. Eight patients had a known history of tetanus vaccination. The tumours were ovoid, or even rod-shaped, and measured between 8x3 mm and 12x10 mm. Histologically, there were necrotic foci surrounded by histiocytes, lymphocytes, and plasma cells. Aluminium was detected by staining with solochrome azurine.

CONCLUSIONS

The possibility of a vaccination granuloma should be kept in mind in patients with a palpable tumour in the upper part of the breast, as well as in mammography screening conditions and in follow-up patients after previous treatment for breast cancer.

Chronic local tissue reactions, long-term immunogenicity and immunologic priming of mice and guinea pigs to tetanus toxoid encapsulated in biodegradable polymer microspheres composed of poly lactide-co-glycolide polymers

Immunogenicity of tetanus toxoid (TT) encapsulated in biodegradable polymer microspheres composed of poly lactide (PLA) or poly lactide-co-glycolide (PLGA) polymers was evaluated in mice and guinea pigs for 1 year. Microsphere formulations made from polymers differing in molecular weight and composition elicited significantly higher IgG antibody levels than soluble TT in mice. The antibody levels elicited by microsphere formulations in mice and guinea pigs were similar to those elicited by a single injection of AlPO4 adsorbed TT. Immunogenicity was not consistently better with a particular polymer composition, molecular weight or microsphere size. However, animals primed with TT-containing microspheres showed significantly higher anamnestic response to a low dose booster 1 year after priming than those primed with AlPO4 adsorbed TT. Microspheres made from low molecular weight PLGA polymer showed a minimal local tissue reaction 1 year after injection. In contrast, aluminum adjuvant formed local granulomas which persisted for 1 year after injection. Microsphere formulations used in this study released a small fraction of antigenic TT during in vitro release studies due to denaturation of TT during encapsulation and hydration of microspheres. Nevertheless, strong priming of immune responses were seen. It remains to be demonstrated whether stabilization of TT would lead to more immunogenic microsphere formulations.

Local tissue irritating effects and adjuvant activities of calcium phosphate and aluminium hydroxide with different physical properties

Effects of calcium phosphate and aluminium hydroxide adjuvants with different physical properties were examined in guinea pigs for local histopathological reactions, electron-microscopical changes of macrophages and adjuvanticity on total IgG antibody response to subcutaneously administered ovalbumin (OVA) and tetanus toxoid (TT). Calcium phosphate gel (Ca-gel) induced active inflammatory reactions consisting of neutrophils (pseudoeosinophils) and foamy macrophages associated with many multinuclear giant cells for at least 4 weeks. Aluminium hydroxide gel (Al-gel) also elicited granulomatous inflammatory reactions consisting mainly of macrophages with foamy cytoplasm, small lymphocytes and giant cells at the injection sites for up to 8 weeks or longer. Severity of local tissue irritation due to calcium phosphate gel (Ca-gel) was similar to that due to Al-gel except for the duration of the inflammatory reactions. Calcium phosphate suspension (Ca-sus)-induced local reactions completely ceased by the 4th week, while aluminium hydroxide suspension (Al-sus)-induced reactions were seen up to the 8th week. Electron-microscopical observations showed that both Al-gel and Al-sus caused damage of macrophages. The adjuvant activity of Al-gel for OVA or TT was significantly stronger than that of any other adjuvant material, whereas those of Ca-gel and Ca-sus were not seen at a dose of 3 mg calcium phosphate per millilitre. Al-sus-TT at a dose of 3 mg aluminium hydroxide per millilitre induced very low levels of antibody. These results suggest that calcium phosphate adjuvant may not be an useful alternative to Al adjuvant.

Morphologic and immunohistochemical observation of explanted Proplast-Teflon temporomandibular joint interpositional implants

PURPOSE

The objective of this study was to investigate the cellular tissue response to temporomandibular joint (TMJ) Proplast-Teflon disc material by morphologic and immunohistochemical means.

PATIENTS AND METHODS

Twelve patients who had been subjected to TMJ discectomy combined with insertion of a Proplast-Teflon interpositional implant (PTIPI) were recalled for removal of the alloplastic disc. The time elapsed between the Proplast-Teflon disc implantation and its removal varied between 13 and 71 months (mean, 54.6 +/- 5.8 [SEM]) The implants and periimplant tissues were examined by light microscopy and immunohistochemically using a panel of monoclonal antibodies reactive with different subclasses of leukocytes. The sections were immunostained using the alkaline phosphatase-antialkaline phosphatase (APAAP) technique.

RESULTS

Fibrosis and a massive foreign body giant cell reaction were seen inside the heavily disrupted alloplastic implants and in the periimplant tissues. CD68-positive monocyte-derived cells dominated the reactive infiltrate in the implants and surrounding tissue. The CD68-positive cells also were partly positive for lysozyme. The lymphocytic infiltration contained no B cells.

CONCLUSIONS

This study of the PTIPI-induced tissue reaction gave no indication of a toxic or an immunologic pathogenesis. Mechanical stress seems important in the fragmentation of the implant and induction of the foreign body reaction. It is not yet known if this fragmentation is the major contributing factor.

Iatrogenic compressive lumbar myelopathy and radiculopathy in adult cattle following injection of an adjuvanted bacterin into loin muscle: histopathology and ultrastructure

Compressive lumbar myelopathy is a recognized iatrogenic complication of injecting water-in-oil vaccines into paravertebral sites of laboratory animals and chickens. Herein, we report the histologic and ultrastructural features of a similar complication in a herd of cattle. Iatrogenic posterior paresis developed over 34 days in 56 of 610 cows (9.2%) following injection of a commercial bacterin 11-34 days earlier into M. longissimus lumborum. The bacterin was composed of inactivated Escherichia coli and Campylobacter fetus ssp. venerealis in a proprietary adjuvant. Tissues were collected for histopathology from 9 affected cattle that died or were euthanized after clinical signs lasting 6-38 days. A range of tissues, including the injection site lesion and lumbar spinal nerve roots, was obtained for ultrastructural examination from a cow with paresis of 31 days duration. There was locally extensive pyogranulomatous myositis with fibrosis and necrosis in right M. longissimus lumborum. Extension of the lesion into the vertebral canal via spinal nerve foramina resulted in focal pyogranulomatous inflammation in epidural fat and in adjacent dura mater. There was axonal degeneration in dorsal, lateral, and ventral columns and chromatolysis of spinal motor neurons in lumbar spinal cord, secondary to compression. A distinctive histologic and ultrastructural feature of pyogranulomata was the presence of osmiophilic material at the center of inflammatory foci, surrounded by macrophages and giant cells that contained intracytoplasmic lipid droplets. Ultrastructural examination of entrapped spinal nerves revealed axonal degeneration and loss of myelinated and unmyelinated fibers, segmental demyelination with remyelination, axonal spheroid formation, and early axonal regeneration.(ABSTRACT TRUNCATED AT 250 WORDS)

Adjuvant properties of aluminum and calcium compounds

It is likely that aluminum compounds will continue to be used with human vaccines for many years as a result of their excellent track record of safety and adjuvanticity with a variety of antigens. For infections that can be prevented by induction of serum antibodies, aluminum adjuvants formulated under optimal conditions are the adjuvants of choice. It is important to select carefully the type of aluminum adjuvant and optimize the conditions of adsorption for every antigen since the degree of adsorption of antigens onto aluminum adjuvants markedly affects immunogenicity. The mechanism of adjuvanticity of aluminum compounds includes formation of a depot at the site of injection from which antigen is released slowly; stimulation of immune-competent cells of the body through activation of complement, induction of eosinophilia, and activation of macrophages; and efficient uptake of aluminum-adsorbed antigen particles by antigen-presenting cells because of their particulate nature and optimal size (< 10 microns). Limitations of aluminum adjuvants include local reactions, production of IgE antibodies, ineffectiveness for some antigens, and inability to elicit cell-mediated immune responses especially cytotoxic T-cell responses. Calcium phosphate, which has adjuvant properties similar to aluminum adjuvants, has the potential advantages of being a natural component of the body and of not increasing IgE production. There is a need for alternative adjuvants, particularly for diseases in which cell-mediated immune responses are important for prevention or cure.

Humoral response in rabbits immunized with calcium phosphate adjuvanted HIV-1 gp160 antigen

Rabbits were immunized with either calcium phosphate adjuvanted purified HIV-1 gp160 or a fluid preparation. Circulating antibodies were detected by ELISA, RIPA and Western Blot tests. Sera of rabbits immunized with the adjuvanted preparation contained high levels of anti-gp160 antibodies, as well as antibodies recognizing p55, p25 and p18. On the contrary, rabbits immunized with the fluid preparation contained only anti-p18 antibodies. Neutralizing antibodies were also detected. It is concluded that the calcium phosphate adjuvant could be used for preparation of candidate anti-HIV vaccines, since it permits one to induce high levels of circulating antibodies, in the absence of untoward reactions as observed when aluminium adjuvants or water in oil emulsions are used.

Adjuvants--a balance between toxicity and adjuvanticity

Adjuvants have been used to augment the immune response in experimental immunology as well as in practical vaccination for more than 60 years. The chemical nature of adjuvants, their mode of action and the profile of their side effects are highly variable. Some of the side effects can be ascribed to an unintentional stimulation of different mechanisms of the immune system whereas others may reflect general adverse pharmacological reactions. The most common adjuvants for human use today are still aluminium hydroxide, aluminium phosphate and calcium phosphate although oil emulsions, products from bacteria and their synthetic derivatives as well as liposomes have also been tested or used in humans. In recent years monophosphoryl lipid A, ISCOMs with Quil-A and Syntex adjuvant formulation (SAF) containing the threonyl derivative of muramyl dipeptide have been under consideration for use as adjuvants in humans. At present the choice of adjuvants for human vaccination reflects a compromise between a requirement for adjuvanticity and an acceptable low level of side effects.

The development of scar sarcoidosis at the site of desensitization injections

Tender nodules may develop at the site of injection of allergen extracts. Some cases can be related to the aluminium contained in the preparation. We report a case where scar sarcoidosis developed at the site of desensitization injections. At presentation, there were no other cutaneous signs of sarcoidosis; systemic signs only developed 2 years later. We suggest that sarcoidosis be considered as a cause of granulomata developing at sites of desensitizing injections, particularly when aluminium is not involved.

Role of aluminium in skin reactions after diphtheria-tetanus-pertussis-poliomyelitis vaccination: an experimental study in rabbits

The occurrence of subcutaneous nodules at the injection site is one of the complications of diphtheria-tetanus-pertussis-poliomyelitis vaccination, but the causes and mechanisms involved are still poorly understood. An experimental study in the New Zealand rabbit enabled us to determine the frequency of occurrence of these nodules, how long they persist and the histopathologic features of the cells involved. Aluminium (Al) assays by electrothermal atomic absorption spectrometry allowed us to study concentrations both in nodules and the organism (serum, normal skin). The results show an absence of Al diffusion outside nodules, a correlation between infiltrate intensity and Al concentration in nodules and modifications in the histological constituents of nodule cells. The histological picture indicates a foreign body reaction to Al. All these data underscore the role of Al in the formation of early postvaccinal nodules at the injection site.

Aluminum-induced granulomas in a tattoo

A patient who developed localized, granulomatous reactions in a tattoo is described. With the use of scanning electron microscopy and energy dispersive x-ray microanalysis, both aluminum and titanium particles were found in the involved skin sections. Intradermal provocation testing with separate suspensions of aluminum and titanium induced a positive response only in the case of aluminum. Examination by scanning electron microscopy and energy dispersive x-ray microanalysis of the provoked response established aluminum as the only nonorganic element present in the test site tissue. This is the first report of confirmed aluminum-induced, delayed-hypersensitivity granulomas in a tattoo.

Contact sensitivity to aluminium

Contact sensitivity to aluminium is extremely rare. Sensitization occurs during continuous application of aluminium containing antiperspirants or by aluminium adjuvants in vaccines and pollen extracts. Two types of reaction pattern are known: persistent granuloma at the injection site and recurrent eczema. We report a patient with a positive patch test reaction to Al (OH)3, who had been sensitized by aluminium adsorbed triple vaccine, Previous reports are reviewed.

Aerosol antiperspirants and axillary granulomata

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Muscle granulomas following intramuscular injection

An 8-month-old child underwent a muscle biopsy because of hypotonia. The biopsy showed centronuclear myopathy and, in addition, an unusual granulomatous inflammatory infiltrate. The child died of respiratory complications and a complete autopsy failed to reveal further evidence of granulomatous disease. The lesion was reproduced in experimental animals by intramuscular injection of diphtheria and tetanus toxoids and pertussis vaccine. Granular material present in histiocytes in these lesions was shown histochemically to be an aluminum salt.

Aluminum induced pulmonary granulomatosis

The association of aluminum dusts and pulmonary fibrosis with emphysema in workers in the aluminum processing and manufacturing industries is well established. The early and minimal reactions of the lungs to the aluminum dusts are not known. This report presents the first case of pulmonary granulomatosis associated with aluminum inhalation. The occupational history of this patient was thoroughly examined, and the aluminum was identified by electron probe microanalysis of the lung biopsy specimen. The granulomatous response in this patient was similar to that observed in rabbits following aluminum dust inhalation. Hypersensitivity or individual idiosyncrasy may play a role in the development of the pulmonary granulomas following exposure to aluminum.

Proceedings: Aluminium hydroxide granuloma

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