POS1464 TOXOPLASMOTIC CHORIORETINITIS IN A PATIENT WITH RHEUMATOID ARTHRITIS

Background

Biological disease-modifying antirheumatic drugs (bDMARD) are one of the most effective in the treatment of rheumatoid arthritis. Infectious complications are one of the most common complications of this type of therapy. Before the therapy is started, patients are examined for tuberculosis, human immunodeficiency virus and hepatitis B and C, but the spectrum of chronic infections is much wider, for example toxoplasmosis infection is widespread. Toxoplasma gondii mainly affects the brain, lungs, liver and organ of vision.

Objectives

To present a clinical case of toxoplasma chorioretinitis in a patient with rheumatoid arthritis.

Methods

Case report. The patient was treated and examined based on real clinical practice.

Results

A 59-year-old woman was admitted to the rheumatology department with symmetric arthritis of the hand joints, long morning stiffness duration (up to 4 hours). The diagnosis of rheumatoid arthritis was previously verified according to the ACR / EULAR 2010 criteria (three years ago). She received treatment in accordance with the clinical guidelines of the Ministry of Health of the Russian Federation: methotrexate 12.5 mg per week with a subsequent increase in dosage to 20 mg per week. Due to the increase in transaminases, the dosage of methotrexate was reduced to 17.5 mg per week, the daily intake of glucocorticosteroids (prednisone 7.5 mg per day). Nevertheless she had high disease activity (Disease Activity Score (DAS28) 5.54, Clinical Disease Activity Index (CDAI) 26.6, Simplied Disease Activity Index (SDAI) 30.12). Considering the continued high activity of the disease against the background of ongoing therapy lasting more than 6 months, infliximab was added to the treatment at a dose of 3 mg per kg of body weight. A good clinical response was achieved (DAS28 2.67, CDAI 4.0, SDAI 9.4, prednisone canceled). After 4 months, there were complaints of acute decrease in vision in the right eye. Referred to an ophthalmologist. Visual Acuity: best corrected visual acuity (BCVA) on right eye is 0.4 (Snellen Chart), BCVA on left eye is 0.9 (Snellen Chart), intraocular pressure: right eye - 18 mmHg (non-contact), left eye - 19 mmHg (non-contact). Right eye: palpation is painful; cornea and anterior chamber humor are transparent; mild cataract in lens; inflammation cells in vitreous body (3+). Fundus (right eye): disc of optic nerve is normal; edema along upper-temporal vessels in macular region, exudates with pigmentation; periphery is normal. Left eye: findings are not clinical significant. Optical coherence tomography of retina (OCT): macular depression is normal; in paramacular region is epiretinal membrane, no traction; along upper-temporal vessels in macular region is chorioretinal focus with retina layer disorganization and tractions. Laboratory: Diaskintest is negative; Toxoplasma IgG = 170 ME / ml (positive is> 8 ME / ml). Diagnosis: Toxoplasma chorioretinitis, infiltration phase of right eye. Topical therapy: dexamethasone 0.1% - 1 x 6 times / day - 20 days, nepafenac 0.1% - 1 x 3 TID - 20 days. Oral: rovamycine 3 mil. ME - 2 TID - 20 days. Infliximab and methotrexate were canceled for the entire period of toxoplasma chorioretinitis treatment. Ophthalmologist’s follow-up after 20 days: no complaints on visual acuity, BCVA on right eye is 1.0 (Snellen Chart). No cells in vitreous body. Fundus: decrease evidence of edema. OCT: decrease evidence of edema. Taking into account the presence of chronic toxoplasmosis infection, the patient was prescribed sulfasalazine 3 g per day as a basic therapy.

Conclusion

In this clinical case we demonstrated the possibility of activating chronic infections such as toxoplasmosis during therapy with bDMARD infliximab. To avoid risk of activating toxoplasmosis patients with rheumatoid arthritis should be screened for this infection before start bDMARD therapy.

Figure 1.

References

[1]B. Bobić, I. Klun, A. Nikolić and O. Djurković-Djaković (2012). Toxoplasma gondii Infection in South-East Europe: Epidemiology and Epizootiology, Toxoplasmosis - Recent Advances, Olgica Djurković Djaković, IntechOpen, DOI: 10.5772/50831.

Disclosure of Interests

None declared

Pharmacodynamic measurements of methyl nicotinate percutaneous absorption

The local kinetics of percutaneous absorption provide information of relevance to the treatment of skin diseases and to the potential efficacy of transdermally delivered chemotherapy for systemic effect. This paper describes two non-invasive procedures (laser Doppler velocimetry and photopulse plethysmography) which permit pharmacodynamic measurements of methyl nicotinate skin penetration to be made in vivo in man. The methods are sensitive to the local vasodilative action elicited by the nicotinic acid ester. Dose-response behavior as a function of time has been monitored (1) over the concentration range 5-100 mM, and (2) by variation of drug application time and administration area. At the higher concentrations used, the magnitude of the erythemal response is saturable, and the effect is then progressively prolonged by further increasing the applied dose. Analysis of the data permits assessment of (a) the kinetics of drug delivery to and depletion from the site of action, and (b) the hypothetical level of steady state drug input necessary to sustain 50 % of the maximum detected response. Measurements of the type described here may prove useful, therefore, for elucidating otherwise inaccessible aspects of transcutaneous kinetics in vivo.

Minocycline-induced cutaneous hyperpigmentation: confocal laser scanning microscope analysis

BACKGROUND

Minocycline has a characteristic yellow-green fluorescent emission. This fluorescence has been previously demonstrated only in type 1 minocycline-induced skin hyperpigmentation.

OBJECTIVE

To investigate whether the fluorescence can be detected in other types of minocycline-induced cutaneous hyperpigmentation, and to study the possible mechanisms.

METHODS

Biopsies of pigmented and nonpigmented skin from 3 patients with different types of skin hyperpigmentation induced by minocycline were analysed by light microscopy and Confocal Laser Scanning Microscope (CLSM).

RESULTS

A yellow-green fluorescence was observed in the hyperpigmented skin of two patients with type 2, and one patient with type 4 minocycline-induced cutaneous hyperpigmentation. No fluorescence was detected in the non-pigmented skin.

CONCLUSION

Minocycline can possibly serve as a fluorescent probe in the diagnosis of all types of minocycline-induced cutaneous hyperpigmentation.

Pemphigus vulgaris: environmental factors. Occupational, behavioral, medical, and qualitative food frequency questionnaire

BACKGROUND

There have been reports suggesting the involvement of environmental factors in the disease process of pemphigus. Factors suggested include exposure to pesticides or certain drugs.

OBJECTIVE

To analyze the association of pemphigus with environmental exposure to various agents, including smoking, recreational and occupational insults, drugs, and food.

DESIGN AND SETTING

In-person interviews of pemphigus patients and control subjects were conducted by trained medical investigators using a structured questionnaire. Questions included occupational, behavioral, medical, and qualitative food frequency details. The multicenter study was conducted at outpatient services of teaching hospitals in Bulgaria, Brazil, India, Israel, Italy, Spain, and the USA.

PARTICIPANTS

A total of 126 pemphigus patients (55 men, 71 women; age, 54 +/- 17 years) and 173 healthy controls (87 men, 86 women; age 50 +/- 19 years) were interviewed in the period between October 1, 1999 and March 31, 2000. The diagnosis of pemphigus was based on clinical, histologic, immunohistologic, and immunohistochemical criteria. The disease duration was 2-27 years (8.4 +/- 7.2 years). Individuals with skin diseases other than pemphigus were selected as control subjects.

MAIN OUTCOME MEASURE

Information on drugs, foods, and occupational, environmental, constitutional, and other possible risk factors was analyzed by t-tests and chi-squared tests as applicable. A multivariate logistic regression model was applied to the data to study simultaneously the independent relationship between each risk factor and pemphigus vulgaris.

RESULTS

The risk for pemphigus vulgaris was lower for ex-smokers and current smokers than for patients who had never smoked. Exposure to pesticides and occupational exposure to metal vapor were associated with an increased risk of pemphigus. Pemphigus patients had more pregnancies than controls. There were differences in environmental factors between countries, with exposure to gardening materials and pesticides being highest among patients from Bulgaria, followed by Israel. Disease characteristics also exhibited differences between countries. Bulgarian patients less frequently had oral mucous membrane lesions: 66% compared to 92% for Israeli patients and 83% for Italians. The distribution of the disease in skin and mucous membranes was similar among patients from all countries. Exclusive skin involvement was seen in 50% of patients, mucous membranes alone in 23% of patients, and both skin and mucous membranes in 27% of patients.

CONCLUSIONS

The beneficial effect of smoking on pemphigus might be explained by its effect on the immune system. In addition, smoking has an antiestrogenic effect, while pesticides have an estrogenic effect. The lower numbers of smokers among patients, the higher exposure rates to pesticides, and the higher number of female patients who had been pregnant may point to the contribution of estrogens to the disease process. It remains to be determined whether measures, such as avoiding exposure to pesticides or metal vapor, may be beneficial in the clinical context. As the present study was a survey, more definitive studies should be conducted to validate the results.

In vitro tannin acantholysis

BACKGROUND

Exogenous factors, such as certain drugs, may be involved in the induction of pemphigus. Other offenders sharing a similar chemical composition to these drugs may also play a role. Tannins with their considerable biologic activity were suggested as possible factors. To substantiate the role of tannins in the pathomechanism of pemphigus, the present study examined the acantholytic potential of tannins in vitro.

METHODS

Normal human breast skin from patients without any bullous disease was cultured for 3 days in the presence of tannic acid at concentrations of 0.02, 0.05, 0.1, 0.25, 0.5, 1.0, and 2.0 mM. The effect of the tannic acid was microscopically examined in a blind fashion by three independent investigators.

RESULTS

In addition to the cytotoxic effect, tannic acid caused marked acantholytic changes, with a clear suprabasal cleavage and intraepidermal acantholytic cells. The acantholytic changes were the most constant and specific effects. They were constantly observed at 1.0 and 2.0 mM, whereas lower concentrations showed changes only in some of the explants. The concentrations needed to exert this effect were notably low. There was a remarkable variability among the subjects who had provided the explants.

CONCLUSIONS

The results suggest a possible role of tannin in the disease process of pemphigus. The tannin acantholytic potential was much greater than the potential of known acantholytic drugs, such as penicillamine and captopril. The interindividual variability in susceptibility to acantholysis may explain the variability in the individual potential for developing pemphigus.

Classic Kaposi's sarcoma: low-dose interferon alfa treatment

BACKGROUND

Classic Kaposi's sarcoma, a rare form of cancer, has no definitive cure. A beneficial effect of low-dose interferon (IFN) alfa was indicated by some case reports. In the present report, we summarize the results of our experience with subcutaneous low-dose IFN alfa treatment of 11 patients with extensive classic Kaposi's sarcoma and review the literature.

DESIGN

Eleven patients, 56-96 years old, were treated: 10 men, 1 woman, 3 of whom had an associated malignancy. Subcutaneous injections of IFN alfa were given, starting with 3 million units 5 times a week, and modified according to side effects and response after 2 weeks (2-6 million units, 3-6 times a week). This treatment was continued for 6 months, except for 1 patient who died after 4 months and another who stopped treatment at 4 months due to surgery but was treated again after recurrence. Treatment was continued after 6 months when a partial response was noted, but further improvement was desired (1 patient).

RESULTS

In 9 out of the 11 patients, initial response was noted after 3-13 weeks of treatment. This was manifested by a reduction of lesion size and fading of color, leading to a partial resolution. Maximum response was achieved after 4-6 months. Remission lasted 4-72 months. Recurrences were retreated, with additional remissions after only 5-8 weeks of treatment. Side effects included fever and fatigue, which were overcome by dose reduction.

CONCLUSION

Whereas in AIDS-related Kaposi's sarcoma patients become refractory to IFN, this was not observed in our patients with classic Kaposi's sarcoma. Moreover, unlike AIDS-related Kaposi's sarcoma, continuous treatment was not needed in classic Kaposi's sarcoma, and recurrences were responsive to retreatment.

Computerized system to enhance the clinical diagnosis of pigmented cutaneous malignancies

BACKGROUND

An increase in the incidence of cutaneous malignant melanoma in recent years has not been accompanied by satisfactory progress in diagnostic methods. This study was carried out to evaluate a specially designed computerized image analysis system, called Derma Vision, to aid in the differentiation between malignant and benign cutaneous pigmented lesions.

METHODS

Seventy-one lesions were photographed with a digital camera and the data were analyzed by the Derma Vision system. The system assessed the variation of hues in each image, calculated the mean standard deviation of the hues, and produced a value that expressed the range of hues in the lesion. The lesions were then excised and examined histologically. The computer-assisted clinical diagnosis was correlated with the histologic diagnosis to determine the accuracy of the former.

RESULTS

Derma Vision predicted the malignant character of a lesion with 92% precision, compared with 87% accuracy based only on the clinical features.

CONCLUSIONS

This simple, inexpensive device can boost the accuracy of clinical diagnosis and provide a useful tool to the physician faced increasingly with having to determine whether pigmented lesions are malignant or benign.

Pemphigus and pemphigoid-like effects of nifedipine on in vitro cultured normal human skin explants

BACKGROUND

A variety of drugs have been implicated in the onset and exacerbation of pemphigus and bullous pemphigoid. The demonstration of biochemical acantholysis in skin explants to various drugs in the absence of autoantibodies, in which the tested drugs evoke a biochemical reaction that leads to desmosomal function loss, may be a valuable adjunct to patient management by confirming the suspicion of drug-related pemphigus or bullous pemphigoid.

OBJECTIVE

To determine whether a skin explant model might serve as a possible in vitro correlate of drug-induced pemphigus and pemphigoid-like effects related to the calcium channel blocker nifedipine.

METHODS

Normal human breast skin obtained from nonpemphigus and nonpemphigoid patients undergoing mastectomy was cultured with nifedipine at final concentrations of 2, 4, and 8 mM. The drug effect on skin explants evidenced by morphologic changes was evaluated by microscopy by three observers.

RESULTS

Five out of seven explants cultured with nifedipine at concentrations ranging from 2 to 8 mM exhibited obvious morphologic changes of two types: intraepithelial (or pemphigus-type) splittings and subepithelial (or pemphigoid-type) splittings. Two explants showed no acantholysis and no subepithelial splittings. Control cultures without polyethylene glycol 200 (PEG) showed no changes. Skin control samples cultured in medium supplemented with 10% PEG displayed vacuolar degeneration throughout the entire epidermis, but no sign of cell-cell dyshesion or dermo-epidermal detachment.

CONCLUSIONS

A type of skin susceptibility to nifedipine may be genetically determined, with some nifedipine-treated patients developing an acantholytic reaction and others a subepidermal bullous eruption.

Diet and pemphigus. In pursuit of exogenous factors in pemphigus and fogo selvagem

Individuals with a genetic predisposition to pemphigus will develop the disease only when one or more additional factors are present. The nature of these factors is as yet unknown, but our starting point was that certain drugs (penicillamine, captopril, and rifampicin) are recognized as such factors. Since some nutrients have chemical compositions similar to these known causative drugs, these nutrients may act similarly and, therefore, nutritional factors should also be suspected. As when drugs are involved, elimination of the inciting ingredients may be crucial for management of the disease. This article discusses the possible role of nutritional ingredients in the disease process of pemphigus, including fruit, leaves, roots, seeds, and even water. Possible causative candidates are thiol, thiocyanate, phenols, and tannins.

Duodenal ulcer patients exhibit a greater skin response to histamine

BACKGROUND

Histamine is considered a major mediator in the process of gastric acid secretion. When acid peptic activity overpowers the mucosal defense mechanism, peptic ulceration may develop. Is the hyperreactivity of patients with duodenal ulcer to histamine also expressed in the skin?

OBJECTIVE

The aim of the present study was to assess the reactivity of patients with duodenal ulcer to histamine as reflected in the skin, by comparing the erythema and the cutaneous blood flow response to histamine in duodenal ulcer patients and healthy controls.

METHODS

Twenty volunteers participated in the study: 10 duodenal ulcer patients and 10 age and gender matched healthy controls. Histamine was topically administered to the back and to the volar side of the forearm, and the induced response was quantified by spectrophotometry and laser Doppler flowmetry (LDF). The extent of the response and time parameters were compared.

RESULTS

The maximum response, as measured by LDF, was greater in the peptic ulcer patients (P < 0.05) compared to healthy controls. Aging was accompanied by decreased responsiveness in both groups.

CONCLUSION

The results suggest that some peptic ulcer patients exhibit a greater cutaneous response to topical application of histamine than healthy controls. As the methods used are non-invasive, simple and rapid, they might be useful in preclinical ulcer diagnosis and detection of patients at risk.

Treatment of Kaposi's sarcoma

The classic form of Kaposi's sarcoma (KS) is a rare multifocal neoplasm, as described by Kaposi in 1872. One hundred nine years after Kaposi's first description of the disease, the interest in all aspects of this disease escalated because of the emergence of human immunodeficiency virus (HIV), which is frequently accompanied by KS. This prompted zealous research, as reflected by numerous reports. Despite recent important discoveries, we are still far from understanding the pathogenesis of the disease and the mechanism of action of its various treatment modalities. As of today, treatment consists of most of the old modalities, some old ones in an updated improved version, and some new and experimental therapies. Our purpose is to focus on recent or novel data and to mention available treatments and their advantages, disadvantages, and side effects. We will also speculate on future directions.

Scrofuloderma (tuberculosis colliquativa cutis)

A 16-year-old girl presented with long-standing purulent sinuses to the skin overlying the lacrimal ducts, which had evolved into ulcers and resulted in hypertrophic scarring. The ulcers were serpiginous, with an uneven soft floor, and undermined edges. Histological examination revealed non-caseating tuberculoid granulomas in the dermis. Cultures for Mycobacterium tuberculosis were positive. Chest X-ray did not show pulmonary involvement. Antituberculous therapy with isoniazid 300 mg/day and rifampicin 600 mg/day achieved a great improvement within 5 weeks of being started. A further improvement was seen at 4 months and complete resolution had occurred by 9 months. To the best of our knowledge, there are no other documented cases of scrofuloderma over the lacrimal system. The delay in the diagnosis emphasizes the importance of maintaining a high level of awareness.

Age-related regional variations of human skin blood flow response to histamine

The process of ageing involves many changes in the skin. These changes are not necessarily uniform, so the pattern of regional variations may vary with ageing. The aim of the present study was to assess age-related regional variations in skin function, by measuring the cutaneous microvascular response to histamine. Histamine was topically applied to the back and forearm of a young and an aged group of volunteers (n = 28, 14 in each group), and the response was quantified utilizing laser Doppler flowmetry. The following parameters were calculated from the data and compared between the two groups: (i) peak response; (ii) the time required to reach the peak; (iii) the time required to decay to half the peak flow; and (iv) the area under the response time curve. For the young group, the magnitude of the maximum response, as well as the extent of the response as measured by the area under the response curve, were significantly greater on the back than on the forearm (p < 0.01 and p < 0.05, respectively). In contrast, for the aged group, the two sites did not significantly differ from each other. The time required to reach the peak was longer in the aged group over both sites, and so was the time required to decay to half the peak flow. These observations indicate regional anatomical or functional differences between old and young skin, which may provide insight into inherent differences influencing cutaneous manifestations of endogenous and exogenous diseases in various age groups.

Sweat secretion, stratum corneum hydration, small nerve function and pruritus in patients with advanced chronic renal failure

Sweat secretion, stratum corneum hydration and small nerve fibre function were measured in 40 patients with advanced chronic renal failure (CRF), using pilocarpine iontophoresis, electrical capacitance and a thermal sensory analyser which measures the thresholds of warm and heat pain sensation. Correlations were sought between these parameters, and the presence and severity of pruritus and skin xerosis were compared with 45 healthy control subjects. The mean sweat secretion and stratum corneum hydration of CRF patients were significantly lower than in controls. Thirteen patients had pathological thresholds to warm sensation on the foot, and eight on the hand. None had pathological thresholds to heat-pain. The presence of pruritus did not correlate with any of the following: xerosis, stratum corneum hydration, sweat secretion or the results of thermal testing.

Topical hydrogen peroxide treatment of ischemic ulcers in the guinea pig: blood recruitment in multiple skin sites

BACKGROUND

Oxygen deficit is a key factor associated with delayed healing of ischemic wounds in human beings. Topical oxygen-releasing compounds such as hydrogen peroxide or tetrachlorodecaoxide have been suggested as therapy for ischemic tissue.

OBJECTIVE

Our purpose was to monitor the effect of hydrogen peroxide cream on the process of ischemic ulcer healing with a model for ischemic ulcers in the guinea pig.

METHODS

Measurement of vascular perfusion with a laser Doppler velocimeter and gross observations of percentage of nonnecrotic wound surface were made on ischemic wounds in guinea pigs after treatment with either a hydrogen peroxide cream or a placebo cream.

RESULTS

Visual evaluations of the percentage of nonnecrotic wound surface showed no statistically significant differences among the treatments. In contrast, vascular perfusion measurements resulted in statistically significant differences. Blood flow was significantly higher up to day 15 in ulcers treated with 2% hydrogen peroxide cream than in those treated with placebo cream. Vascular perfusion was significantly higher in ulcers treated with 3.5% hydrogen peroxide cream than in ulcers treated with either 1.5% hydrogen peroxide cream or placebo. Adjacent control sites in guinea pigs whose ulcers were treated with hydrogen peroxide cream showed increased vascular perfusion compared with corresponding sites in animals whose ulcers were treated with placebo. Even distant flank control sites of ulcers treated with 3.5% hydrogen peroxide cream showed increased vascular perfusion.

CONCLUSION

Treatment of ischemia-induced ulcers with hydrogen peroxide cream enhanced cutaneous blood recruitment not only to ulcers and adjacent sites, but also to distant sites.

Modification of late epidermal differentiation in photoaged skin treated with topical retinoic acid cream

BACKGROUND

Retinoic acid (RA) cream treatment alters epidermal proliferation and differentiation in photoaged skin.

OBJECTIVE

To study the changes in the expression of markers of epidermal differentiation in photoaged skin following RA cream treatment.

METHODS

Ten subjects with photoaged skin were examined before treatment and at regular intervals during 12 months of once daily application of 0.05% tretinoin cream over the left forearm. Paraffin-embedded biopsy sections from the forearm were stained with loricrin, filaggrin, involucrin and cornifin antisera in addition to hematoxylin and eosin. The various layers were measured using a calibrated optical micrometer.

RESULTS

The thickness of the epidermis increased rapidly, reaching a substantial increase after 1 month of retinoid cream application and retaining it during the following 12 months. The stratum granulosum achieved a transient but substantial increase after 1 and 3 months. Except involucrin, the ratio between the layers expressing the various markers of epidermal differentiation and the epidermis significantly increased following tretinoin cream treatment.

CONCLUSION

RA cream treatment not only increases the thickness of the epidermis but also the programming of late terminal epidermal differentiation, as expressed by the markers studied. Thus, RA appears to affect both proliferation and differentiation of keratinocytes in vivo.

Sweat electrolytes in patients with advanced renal failure

The sweat gland has some similarity with the convoluted tubules of the kidney. Little is known about sweat secretion and electrolyte content of sweat in the uremic gland. A pilocarpine ionotophoresis sweat test was performed in 40 patients with advanced renal failure (RF). Sweat secretion was measured and analyzed for Na, K, and Cl and correlated to blood parameters, type, and duration of dialysis. The sweat weight was significantly lower in all RF patients when compared with this parameter in healthy controls (p < 0.0001). No difference was noted between patients undergoing hemodialysis, those undergoing continuous ambulatory peritoneal dialysis, and those not undergoing dialysis. Men sweated more than women among RF patients and among controls (p < 0.0001). An inverse correlation was found between sweat weight and blood calcium levels (p < 0.001). Sweat K concentration was significantly higher (p < 0.0001) in patients with RF than in healthy controls, while the concentrations of Na and Cl were similar. Several mechanisms are suggested as possible explanations for these changes.

Cutaneous blood flow abnormalities in hypertriglyceridemia

An accelerated atherosclerosis, in particular of the coronary arteries, was documented in hypertriglyceridemia. The objective of the present study was to assess the cutaneous dynamic blood flow in hypertriglyceridemia, utilizing the optical noninvasive method of laser Doppler flowmetry. The cutaneous blood flow on the forearms was measured during the postischemic reactive hyperemia test in treated and non-treated patients with hypertriglyceridemia and healthy control subjects. The subjects were 32 patients with hypertriglyceridemia--15 untreated and 17 following 6-9 months of bezafibrate treatment--and 27 healthy control subjects. In untreated patients with hypertriglyceridemia, the peak flow was significantly lower than in both the treated group (p < 0.005) and control group (p < 0.02). Similarly, the area under the response-time curve of the untreated patients with hypertriglyceridemia was smaller (p < 0.01 and p < 0.05, respectively). These parameters were similar in the treated group and the control group. The reaction was faster in the treated group, as compared to the other two groups (p < 0.001). The control group exhibited a longer time to decay than the treated group (p < 0.01). Postischemic reactive hyperemia tests in patients with hypertriglyceridemia reveal cutaneous microcirculatory changes in the forearm. These changes may arise from several mechanisms, including functional abnormalities of the endothelium or vascular smooth muscle, or structural changes in the blood vessels that limit vasodilatation. These changes are reversible, and corrected when reducing the triglyceride levels, but other abnormalities are then present, suggesting a permanent damage. These dynamic measurements of cutaneous blood flow are sensitive indicators of atherogenesis, and can be employed for the evaluation of microvascular involvement and follow-up of patients with hypertriglyceridemia.

Histamine effect on human cutaneous blood flow: regional variations

Different reactivities of small blood vessels to the histamine released by exogenous and endogenous substances may play a role in the regional variations of the elicited cutaneous response. To study the regional dependence of cutaneous blood flow in response to histamine, the compound was administered intradermally (prick introduction), thereby bypassing the spatially dependent penetration process. The induced response was quantified with cutaneous blood flow measurements utilizing laser Doppler flowmetry. Extent of response and time parameters were compared. Three anatomical sites, the back, volar side of the forearm, and ankle, were studied on 20 volunteers (10 men and 10 women, age 24-34). For comparison, topical administration was also performed. Significant differences in the measured responses at the three sites were observed: the increase of the cutaneous blood flow on the back was greater than the forearm (p < 0.01 prick test, p < 0.05 topical application), and that of both sites was greater than the ankle (p < 0.01 prick test, p < 0.05 topical application). There were no significant differences among the different sites in time parameters and no gender variations. As expected, the time required to reach maximum response was shorter for the intradermal method as compared to the topical application on the back (p < 0.001) and forearm (p < 0.05). On the other hand, the time required to decrease to 50% of maximum response was not different for the intradermal and topical methods of histamine application. These blood vessel response observations may provide initial insight into inherent functional differences influencing cutaneous manifestations of endogenous and exogenous diseases.

Low dose recombinant interferon alfa treatment for classic Kaposi's sarcoma

BACKGROUND

High doses of interferon alfa are used to treat Kaposi's sarcoma in patients with immunodeficiency, whereas low doses are generally ineffective. Following low-dose recombinant interferon alfa treatment for lymphoma, two patients showed a regression of their hematologic malignancy-associated Kaposi's sarcoma. This observation prompted us also to try low-dose interferon alfa treatment in uncomplicated classic Kaposi's sarcoma, and two additional patients were thus treated on an outpatient basis.

OBSERVATIONS

Initial response was noted after 3 to 13 weeks of treatment. Remission was achieved after 4 to 6 months of low-dose interferon alfa treatment and its duration was 8 to 14 months. Recurrences were treated again and additional remissions were obtained after only 5 to 8 weeks of treatment.

CONCLUSION

Low-dose interferon alfa treatment may represent an effective therapeutic modality for the treatment of patients with both lymphoma-associated and uncomplicated classic Kaposi's sarcoma.

Skin surface pH in intertriginous areas in NIDDM patients. Possible correlation to candidal intertrigo

OBJECTIVE

To compare skin surface pH and moisture in intertriginous areas in diabetic patients and healthy control subjects and to study the relationship between these parameters and candidal infection.

RESEARCH DESIGN AND METHODS

We measured the skin surface pH and moisture in the axillary, inframammary, inguinal, and forearm skin with a pH meter with a flat-glass electrode and skin corneometer. The subjects were 50 NIDDM patients from the diabetic outpatient clinic at Beilinson Medical Center, Petah Tiqva, Israel, and 40 healthy control subjects from hospital personnel. The main outcome measures were skin surface pH, skin moisture, and skin culture for Candida.

RESULTS

Skin pH in the inguinal and axillary regions was significantly higher in diabetic patients compared with healthy control subjects (P < 0.0001), whereas no difference was noted in the forearm. In the inframammary region, diabetic women had significantly higher pH than nondiabetic women (P < 0.01). No difference was noted in men in this region. Six patients (12%) had candidal infection in intertriginous areas.

CONCLUSIONS

Our study indicates that in intertriginous regions, skin surface pH of diabetic patients is significantly higher than in normal control subjects and implies the significance of skin pH as a possible factor promoting host susceptibility to skin candidal infection.

Cutaneous blood flow in gestational hypertension and normal pregnancy

A laser Doppler flowmeter was used to assess skin blood flow changes in three groups of young subjects: women with gestational hypertension, healthy pregnant women, and healthy non-pregnant women. Responses to four vasoactive stimuli were studied: isometric and cognitive activities, cutaneous post ischemic reactive hyperemia, and local heating. The first two stimuli are vasoconstrictive and were performed on the fingertip, whereas the latter two are vasodilative and were performed on the forearm. The most prominent differences were observed in the isometric test, where the expected decrease, which was indeed registered in non-pregnant women, was almost absent in the healthy pregnant group. The gestational hypertension group had a greater decrease in blood flow than normal pregnancy, but lesser than non-pregnant control subjects. We conclude that although normal pregnancy modifies the response of the skin microvasculature to some vasoactive stimuli, gestational hypertension pushes that response back toward the non-pregnancy state.

Chronic and acute effects of cigarette smoking on skin blood flow

A laser Doppler flowmeter was used to assess blood flow changes in habitual smokers, as compared with nonsmokers, where members of both groups were young and healthy. Acute and chronic effects of cigarette smoking were measured by using the cutaneous postischemic reactive hyperemia test. Basic flow was recorded in four sites: forehead, postauricular, forearm, and finger. Recovery time from reactive hyperemia was longer in habitual smokers than in nonsmokers. Peak flow during reactive hyperemia was significantly lower after smoking. Basic blood flow during smoking did not show significant variation in the sites tested. The authors conclude that skin microvasculature is influenced by acute and chronic effects of cigarette smoking in young subjects; they discuss some of the possible mechanisms and their implications.

Cutaneous blood flow measurements for the detection of malignancy in pigmented skin lesions

This work assesses cutaneous blood flow measurements as an adjunct in the differentiation between malignant and benign pigmented skin lesions. Blood flow in pigmented lesions and in their vicinity was measured by laser Doppler flowmetry (LDF), which measures the superficial skin blood flow. The lesions were then excised and histologically examined. While LDF readings for most of the benign lesions did not differ from those of control measurements, basal cell carcinomas showed a significant elevation and so did the melanomas (p less than 0.0001). Moreover, comparing the two groups of malignant lesions, namely the melanomas and basal cell carcinomas, the melanomas showed a significantly higher elevation (p less than 0.02). These results suggest that LDF may serve as an additional tool in the diagnosis of pigmented skin lesions: the probability of malignancy is low when LDF readings show no difference from adjacent normal skin; on the contrary, elevated readings suggest an increased likelihood of malignancy.

Skin reactive hyperemia in diabetic patients. A study by laser Doppler flowmetry

OBJECTIVE

To assess whether laser Doppler flowmetry could detect differences in the cutaneous response to postischemic reactive hyperemia between patients with non-insulin-dependent diabetes mellitus (NIDDM) and nondiabetic controls and among subgroups of NIDDM patients.

RESEARCH DESIGN AND METHODS

We measured the cutaneous blood flow on the forearms during the postischemic reactive hyperemia test in diabetic patients and nondiabetic controls. Subjects were 25 patients with NIDDM from the outpatient clinics of dermatology, ophthalmology, and endocrinology and 25 nondiabetic volunteers matched for sex and age. Of the patients with NIDDM, 14 had proliferative retinopathy, and 13 were obese. Cutaneous postischemic reactive hyperemia test monitored by measuring the cutaneous blood flow with laser Doppler flowmetry was used. Peak blood flow (P) after arterial occlusion, the time required to reach this peak (Tp) and the ratio (K) between these two quantities (K = P/Tp) were measured.

RESULTS

In diabetic patients, P was significantly lower (P less than 0.02) than in nondiabetic control subjects. In diabetic patients with proliferative retinopathy, K was lower (P less than 0.05) than in diabetic patients without retinopathy. Diabetic patients with a body mass index (BMI; wt/ht2) less than 25 kg/m2 had a longer Tp (P less than 0.002), whereas the control group BMI did not affect this parameter. The combination of retinopathy and BMI less than 25 gave the longest Tp values (P less than 0.0001).

CONCLUSIONS

Postischemic hyperemia tests in diabetic patients reveal cutaneous microcirculatory changes in the forearm (lower P). Advanced retinopathy is associated with functional disturbances (lower K), especially when combined with a low BMI (less than 25; longer Tp).

Percutaneous penetration of methyl nicotinate at three anatomic sites: evidence for an appendageal contribution to transport?

Percutaneous absorption of the vasodilator methyl nicotinate (MN) was evaluated in human volunteers at three anatomic sites (forehead, forearm and palm) using the technique of laser Doppler flowmetry (LDF). The experiments were designed to test the hypothesis that the kinetics and extent of skin penetration are dependent upon the appendageal density at the site of application. The LDF technique measured the increase in skin blood flow elicited by topically applied MN once the chemical had penetrated to the microvasculature. Significant differences in the measured LDF responses at the three sites were found, and further analysis of the data suggested that MN penetration was greatest through forehead skin, least through the palm and intermediate across the skin of the forearm. A correlation therefore existed between apparent MN absorption and appendageal density.

Cutaneous manifestations and impaired chemotaxis of polymorphonuclear leukocytes associated with Kartagener's syndrome

Persistent deep-seated folliculitis and impaired chemotaxis are described in a 24-year-old woman with situs inversus, bronchitis and sinusitis, i.e. the three characteristics of Kartagener's syndrome. While patients with chemotactic defects not associated with the syndrome often suffer from skin infections, to the best of our knowledge this is the first report of a Kartagener patient with cutaneous manifestations.

Idiopathic recalcitrant facial flushing syndrome

This report neologizes a new syndrome name, idiopathic recalcitrant facial flushing syndrome, to describe all cases of persistent facial flushing with unknown etiology. Three cases of recalcitrant flushing are described. Therapy with a variety of modalities, monitored objectively with laser Doppler velocimetry, proved unsuccessful. Some investigational and management aspects of difficult cases of idiopathic flushing are reviewed.

Cutaneous responses to topical methyl nicotinate in black, oriental, and caucasian subjects

The response of human skin to topical methyl nicotinate (MN) has been monitored in black, oriental, and caucasian subjects. The study aimed to address the question: "Do racial differences in percutaneous absorption and microcirculatory sensitivity exist?" MN-induced vasodilatation was assessed visually and by laser Doppler velocimetry (LDV). At three dose levels, in the three subject populations, four parameters were compared: (a) the diameter of the maximum visually perceptible erythematous area (Emx); (b) the area under the erythematous diameter versus time curve (AUE); (c) the maximum LDV response (Lmax); and (d) the area under the LDV response versus time curve (AUL). At p less than 0.05, AUL (black) greater than AUL (caucasian) for all MN concentrations; AUL (oriental) greater than AUL (caucasian) for the higher dose levels. Emx, AUE and Lmx showed no significant differences between races within concentrations. For all subjects, Emx, AUE, and AUL were significantly dependent on MN dose whereas Lmx was not. The results suggest that some racial differences in response to topical MN exist and that perception of these distinctions may depend upon the method of measurement.

Dorfman-Chanarin syndrome. A case report and a review

Dorfman-Chanarin syndrome in two sisters of Jewish Iraqi origin is reported. This heritable disorder of the metabolism of neutral lipids was manifested by congenital ichthyosis, vacuoles in the leukocytes, and variable involvement of liver, muscle, central nervous system, and the auditory system. In two asymptomatic members of the family leukocyte vacuoles were found as the only sign of the syndrome. Clinical, pathologic, ultrastructural, and biochemical findings are described. Previous reported cases are reviewed.

Blood flow in psoriatic skin lesions: the effect of treatment

Laser Doppler velocimetry (LDV) was used to assess the effect of treatment upon cutaneous blood flow in psoriatic skin lesions. The resolution of two separate plaques in each of seven subjects was followed. Six of the subjects received the Goeckerman regimen, the seventh was treated with psoralen-ultraviolet A (PUVA) therapy. Control LDV readings were taken from uninvolved skin sites during the treatment period. Cutaneous blood flow in the psoriatic lesions of the Goeckerman-treated patients decreased to levels comparable to those in uninvolved skin early in the course of treatment and significantly preceeded the observed clinical resolution from 4 to 8 days after initiation of therapy (P less than 0.05). Visible flare-ups sometimes appeared when patients were untreated (over a weekend, for example) and these eruptions were accompanied by a transient elevation of LDV readings. Perfusion of the lesions of the PUVA-treated patient remained consistently higher than perfusion of uninvolved skin despite clinical healing. In a separate series of experiments, blood flow at the extensor surface of the forearm was measured in the skin of normal subjects, the uninvolved skin of psoriatic patients and the untreated lesional skin of psoriatic patients. While the lesional skin had significantly higher perfusion levels than uninvolved psoriatic or normal control skin (P less than 0.01), there was no significant difference between blood flow to the uninvolved psoriatic skin of psoriatics and that to the skin of healthy controls.

Spatial variability of vasodilatation in human forearm skin

Vasodilatation elicited by topical application of methyl nicotinate was measured by photoplethysmography at various positions on human ventral forearm skin. The time-to-peak response, the magnitude of the peak response, the area under the response-time curve and the time for the response to decay to 75% of the maximum value, were recorded at six positions on the left and right forearms of eight subjects. There was no significant difference between response on the right and left forearm sites and no difference in response between the lateral and medial sites on the forearms. In a second experiment, the vasodilatation was measured at proximal and distal positions on the forearm. The magnitude of the peak response at the proximal position was significantly higher than that found distally (P less than 0.01) as was the area under the response-time curve (P less than 0.05). These results suggest a possible cause for the variation observed in vasoconstrictor assays of corticosteroids.

Are there age and racial differences to methyl nicotinate-induced vasodilatation in human skin?

Preliminary experiments have been performed to determine whether there are age and racial differences in the response of human skin to the topically applied vasodilator methyl nicotinate. With the use of a constant stimulus (a 15-second exposure to a 100 mM aqueous solution of drug), the subsequent time-course of the vasodilatation response was followed noninvasively and objectively with the optical technics of laser Doppler velocimetry (LDV) and photoplethysmography (PPG). Three groups of subjects were considered: young white subjects (20 to 30 years of age), elderly white subjects (63 to 80 years old), and young black subjects (20 to 30 years old). Analysis of the results shows that the time to peak response, the area under the response-time curve, and the time for the response to decay to 75% of its maximum value are statistically indistinguishable for all three groups at the p = 0.05 level of significance. Only the magnitude of the peak response revealed some significant differences between the cohorts (young greater than black, determined by PPG; young greater than old, determined by LDV). The data suggest, therefore, a remarkable similarity in response across a wide range of skin types. The origin of this consistency may, however, be complex and is not revealed by these experiments.

Basal perfusion of the cutaneous microcirculation: measurements as a function of anatomic position

Noninvasive optical techniques of photopulse plethysmography (PPG) and laser Doppler velocimetry (LDV) have been used to identify regional variations in the basal skin blood flow of humans. The procedures assess either the volume (PPG) or the volume-velocity product (LDV) of cutaneous blood vessel perfusion. Fifty-two anatomic positions have been studied in 10 normal subjects resting horizontally. The mean perfusion levels were ranked to reveal the variations in cutaneous blood flow as a function of body site. Groups of data were collected into cohorts and average perfusion values for the subjects within each cohort were compared by the Newman-Keuls multiple comparison test. Most transparently, the results reveal a collection of regions (fingers, palms, face, ears) for which cutaneous perfusion is much higher than all other positions. More subtle differences and some unexpected similarities, however, are also apparent and, in some cases, agree or, in others, conflict, with previously published information. With some exceptions, good general agreement between the two techniques was observed.

Noninvasive assessments of the percutaneous absorption of methyl nicotinate in humans

Percutaneous penetration of the vasodilator methyl nicotinate (methyl 3-pyridinecarboxylate) has been monitored in vivo in humans with the noninvasive techniques of laser Doppler velocimetry and photopulse plethysmography. These optical methods use different technologies to generate a voltage output which is related to perfusion of the cutaneous microcirculation. The procedures are therefore sensitive to the pharmacologic stimulus and duration of local vasodilation. Following topical application of methyl nicotinate, excellent correlation was found between the response of both methods and the visual observation of erythema. Lower drug concentrations delayed the onset and magnitude of the response and shortened the time period for which elevated microperfusion was observed. These techniques appear to provide a useful noninvasive assessment of the time course of drug behavior in the region of skin to which topical application is made.

Noninvasive assessment of local nicotinate pharmacodynamics by photoplethysmography

The local pharmacodynamics of a topical vasodilator (methyl nicotinate) has been followed noninvasively using photopulse plethysmography. This technique is sensitive to changes in blood flow through the cutaneous microcirculation and responds to the pharmacologic stimulus of the vasoactive agent employed. Five different application sites for the drug were studied and the time course of the local effect (i.e., onset, duration, and decay) was recorded. The applied amount of drug elicited, within a short period, a response which was saturable such that the observed increase in blood flow reached a plateau level. The decay of the elevated perfusion required approximately 1 h, suggesting a half-life for elimination of the drug from the skin of about 10 min. This result agrees closely with other reported values and suggests that the pharmacodynamic measurements of this study may prove useful in elucidating aspects of dermal pharmacokinetics.

Alkaline phosphatase immuno-enzymatic technique in the diagnosis of pemphigus vulgaris

Alkaline phosphatase was used in an immuno-enzymatic procedure to detect tissue-bound and circulating antibodies in pemphigus vulgaris. Pemphigus antibodies were revealed by a direct method using alkaline phosphatase conjugated goat anti-human IgG. Cryostat sections were incubated with the specific antiserum, and alkaline phosphatase activity was then revealed histochemically either by Gomori's technique or by the azo dye method. The sections were examined by light microscopy and intercellular staining was demonstrated in the epidermis. The indirect method, in which the patient's serum was incubated with sections of normal skin, gave similar results. Using parallel sections, an immunofluorescent technique was used to demonstrate tissue-bound and circulating antibodies. The alkaline phosphatase method appeared to be slightly less sensitive than the immunofluorescent method.