Anorexia Nervosa Associated with Acromegaloid Features, Onset of Acrocyanosis and Raynaud's Phenomenon and Worsening of Chilblains

Patients with anorexia nervosa may develop many physical and endocrinological complications. We wish to report two patients who developed soft tissue swelling of their hands and worsening of their peripheral vascular disease, evidenced by the appearance of acrocyanosis and Raynaud's phenomenon and more severe perniosis, following the onset of their anorexia nervosa.

Zosteriform Kaposi's sarcoma

We report the case of a 92-year-old man with lesions of classic Kaposi's sarcoma occurring in a zosteriform pattern. The mechanisms of dermatomal distribution are speculated and cutaneous lesions presenting in a zosteriform pattern are reviewed.

Human anergic/suppressive CD4(+)CD25(+) T cells: a highly differentiated and apoptosis-prone population

Anergic/suppressive CD4(+)CD25(+) T cells exist in animal models but their presence has not yet been demonstrated in humans. We have identified and characterized a human CD4(+)CD25(+) T cell subset, which constitutes 7-10 % of CD4(+) T cells in peripheral blood and tonsil. These cells are a CD45RO(+)CD45RB(low) highly differentiated primed T cell population that is anergic to stimulation. Depletion of this small subset from CD4(+) T cells significantly enhances proliferation by threefold in the remaining CD4(+)CD25(-) T cells, while the addition of isolated CD4(+)CD25(+) T cells to CD4(+)CD25(-) T cells significantly inhibits proliferative activity. Blocking experiments suggest that suppression is not mediated via IL-4, IL-10 or TGF-beta and is cell-contact dependent. Isolated CD4(+)CD25(+) T cells are susceptible to apoptosis that is associated with low Bcl-2 expression, but this death can be prevented by IL-2 or fibroblast-secreted IFN-beta. However, the anergic/suppressive state of these cells is maintained after cytokine rescue. These human regulatory cells are therefore a naturally occurring, highly suppressive, apoptosis-prone population which are at a late stage of differentiation. Further studies into their role in normal and pathological situations in humans are clearly essential.

Cytomegalovirus-associated gastric ulcer in an immunosuppressed patient with pemphigus vulgaris

A 79-year-old female with pemphigus vulgaris developed a cytomegalovirus (CMV)-associated gastric ulcer whilst on standard immunosupression with azathioprine and prednisolone. Following treatment with ganciclovir and ranitidine the ulcer healed. CMV infection frequently involves the gastrointestinal tract of immunocompromised patients causing inflammation, ulceration and haemorrhage. Although it has also been described in patients treated with immunosuppressive therapy for malignancy and other autoimmune disease, we are not aware of previous reports in patients treated for autoimmune bullous disease.

The inhibition of cutaneous T cell apoptosis may prevent resolution of inflammation in atopic eczema

Atopic eczema (AE) is characterized by the persistence of infiltrating T lymphocytes in the dermis. To test the hypothesis that dysregulation of normal T cell apoptosis may contribute to the pathogenesis and chronicity of AE we compared patients with a normal resolving immune response (Mantoux reaction (MR)) induced in healthy volunteers by cutaneous PPD injection. Significantly less T cell apoptosis was observed in lesional skin of AE patients compared with either the peak or the resolution phase of the MR (P < 0.0001). The low incidence of T cell apoptosis in AE was associated with significantly increased levels of Bcl-2 relative to Bax (P < 0.0001) and significantly decreased CD95-L expression (P < 0.002) compared with the resolving MR. The cytokines IL-15 and interferon-beta (IFN-beta), which prevent activated T cell apoptosis, were expressed maximally on day 7 and day 14 of the MR, respectively. In contrast, AE patients expressed high levels of both IL-15 and IFN-beta in cutaneous lesions at the same time. This suggests that the co-expression of two anti-apoptotic cytokines, which are not found together during resolving cutaneous responses, may contribute to excessive T cell survival which leads to the persistence of inflammation in patients with AE.

Scleromyxedema: response to high-dose intravenous immunoglobulin (hdIVIg)

We report 2 patients with scleromyxedema, both associated with IgG-lambda paraproteinemia, who were treated with high-dose intravenous immunoglobulin (hdIVIg) 2g/kg per month. The response to treatment was assessed using an objective skin scoring system initially established for patients with scleroderma. This system grades the overall severity of the induration and the reduction in mobility of the skin. Both patients initially had a dramatic response to treatment which was sustained in one patient. The first patient, a 30-year-old black man, showed a reduction in skin scores from 36/60 to 11/60 over a 3-month period, during which time he had 3 infusions of hdIVIg. After an unplanned 2-month break from treatment, severe neuromuscular complications developed. These improved initially with more frequent infusions of hdIVIg but oral corticosteroids were required to treat worsening myopathy. Unfortunately, the initial response to hdIVIg has not been sustained and his skin scores at 1 year returned to baseline. The second patient, a 60-year-old white man, showed a similarly dramatic reduction in skin scores from 36/60 to 15/60 over a 3-month period after having received only 2 infusions of hdIVIg. There has been sustained improvement after 10 months of therapy and the interval between hdIVIg infusions has been increased to 10 weeks without deterioration. HdIVIg may be an effective treatment for some patients with scleromyxedema, a rare condition with few effective treatments and a poor prognosis.

Phenotypic analysis of IL-10-treated macrophages using the monoclonal antibodies RFD1 and RFD7

Suppressive or tolerogenic antigen-presenting cells (APC) might play an important role in the control of auto/hyperreactivity and the resolution of the immune response. Recent studies have provided evidence that tolerogenic APC can be induced by anergic T cells or interleukin-10 (IL-10). The aim of this study is to investigate how anergic T cells and IL-10 induce the suppressive APC phenotype and how this affects the immune response. Previously, two monoclonal antibodies (RFD1 and RFD7) were described by our lab which distinguish inductive (RFD1+RFD7-), phagocytic (RFD1-RFD7+) and suppressive (RFD1+RFD7+) macrophages. RFD1 recognizes an MHC class II-associated epitope which has restricted expression, and RFD7 recognizes a predominantly cytoplasmic antigen. Macrophages were derived from the adherent fraction of peripheral blood mononuclear cells from healthy donors. At day 5, IL-10 or IFNgamma (a cytokine which should lead to the inductive APC phenotype) was added to the cultures. At day 7, the macrophages were harvested and their phenotypes were assessed by immunohistochemical staining and FACS analysis. Upon culture of macrophages with IL-10 RFD1 staining and HLA class II expression were reduced, whereas RFD7 staining was increased. Incubation of APC with IFNgamma led to upregulation of RFD1 and HLA class II, without affecting RFD7 staining. This suggests that IL-10 induced the suppressive RFD1+RFD7+ APC population, whereas IFNgamma treatment led to the inductive RFD1+RFD7- APC subset. Thus the use of IL-10 and/or IFNgamma, and the discrimination offered by mAbs RFD7 and RFD1 represent a model whereby APC function in terms of T cell stimulation or T cell anergy can be assessed.

Lupus erythematosus vegetans

A 29-year-old woman with known systemic lupus erythematosus presented with exudative and vegetative plaques bilaterally on her groins. The clinical and histological findings indicated a diagnosis of pyodermatitis vegetans. Direct immunofluorescence studies revealed the presence of a definite basement membrane zone band for IgG, IgM and C3, favouring lupus erythematosus. We propose the term lupus erythematosus vegetans for this combination of clinicopathological and immunohistological findings.

Fine genetic mapping of diffuse non-epidermolytic palmoplantar keratoderma to chromosome 12q11-q13: exclusion of the mapped type II keratins

Diffuse non-epidermolytic palmoplantar keratoderma (NEPPK) belongs to the heterogeneous group of skin diseases characterized by thickening of the stratum corneum of the palms and soles (1). This autosomal dominant PPK is characterized by a diffuse pattern of palmar and plantar hyperkeratosis giving the affected areas a thickened yellowish appearance with a marked erythematous edge. Linkage of diffuse NEPPK to chromosome 12q11-q13 has been demonstrated in two independent reports (2, 3). In this study, we describe detailed haplotyping with microsatellite markers mapping to this chromosomal region in three diffuse NEPPK pedigrees from the south of England. Fine mapping of a previously identified recombination event and the identification of a common disease haplotype segregating in the three pedigrees places the diffuse NEPPK locus proximal to the type II keratin gene cluster.

Ichthyosis bullosa of Siemens: report of a family with evidence of a keratin 2e mutation, and a review of the literature

We report a large family with ichthyosis bullosa of Siemens (IBS) including eight affected members spanning three generations. The classical features of the disease were consistently observed with blistering, superficial peeling of the skin, and localized lichenified hyperkeratosis mainly confined to the limbs. Phenotypic variation, however, was also observed with some individuals exhibiting unusual clinical features. Specifically, the index patient was erythrodermic at birth; she subsequently developed a widespread pustular eruption. Erythroderma is classically absent in IBS and pustulation is very unusual. She also had hypertrichosis of the limbs, as did an affected female first cousin. This has not previously been reported in IBS. Electron microscopy showed complex aggregates of keratin in the spinous and granular layers associated, in places, with remarkably little cell lysis. Sequencing of genomic DNA revealed a mutation (E493K) in keratin 2e. A review of the literature on IBS indicates that E493K is the most commonly reported mutation to date and might represent a mutational hotspot for this disease.

The role of apoptosis in the resolution of T cell-mediated cutaneous inflammation

We have investigated cutaneous purified protein derivative-induced delayed-type hypersensitivity (DTH) responses in healthy volunteers to determine features associated with both the generation and resolution of the reaction. The clinical peak of the response occurred at day 3; however, T cell numbers were maximal on day 7. There was a preferential increase of CD4+ CD45RO+ T cells on day 7, which was largely due to proliferation, since a mean of 19% was in cycle. The proliferation of this subset was associated with the presence of IL-15, which was expressed as early as 12 h, and IL-2, which showed peak expression at 7 days. By day 14, there was a significant decrease in both the mean T cell number/unit area and IL-2 and IL-15 expression in perivascular infiltrates. Maximal CD95 (Fas/Apo-1) ligand and TNF-alpha expression were observed at 7 days and were associated with the presence of 1.83% (range 0.81-2.48%) apoptotic T cells. At 14 days, CD95 ligand and TNF-alpha expression were reduced significantly, and the presence of 2.5% (range 1.5-3.75%) of apoptotic T cells at this time was probably due to cytokine deprivation, associated with decreased Bcl-2 relative to Bax expression. The induction and resolution of the Mantoux reaction may depend on the expression of cytokines, such as IL-2 and IL-15, which regulate both proliferation and apoptosis in T cells. Failure to control either of these phases of the Mantoux reaction may contribute to the chronicity of inflammatory responses in certain cutaneous diseases.

Changes in CD23 expression of blood and skin in atopic eczema after Chinese herbal therapy

BACKGROUND

Aberrant expression of CD23 (low affinity IgE receptor) on cells of the monocyte/macrophage series in peripheral blood and lesional skin of patients with atopic eczema has been demonstrated. It is not known whether this abnormality results from a fundamental systemic problem of the monocytes of these patients or reflects local changes to cell populations within the skin tissues.

OBJECTIVES

This study was designed to determine whether this aberrant expression was caused by local cutaneous influences on mature cells or fundamental changes in monocyte differentiation. The possible relationship between these aberrations and clinical severity was also investigated by repeating these immunopathological studies after a course of efficacious treatment with Chinese herbal therapy (CHT).

METHODS

Peripheral blood mononuclear cells were obtained from patients with atopic eczema before, and after 8 weeks of treatment. Efficacy of CHT was quantified on clinical grounds. Monocytes were isolated by adherence to plastic and cultured for up to 7 days. Samples were harvested at 2, 5 and 7 days of culture and cytospins prepared. Immunocytochemical staining to identify phenotypic subsets was performed on the monocytes at time 0 and on maturing cells from culture. This immunocytology was quantified using computerized image analysis equipment to determine the emergence of macrophage subsets and their level of CD23 expression. Biopsies were taken from lesional skin before and after treatment and immunohistology was performed on cryostat sections to determine the number of antigen presenting cells expressing CD23 as well as the level of expression of these molecules.

RESULTS

The results showed that increased numbers of monocytes from patients with atopic eczema express CD23 at day 0 and that cultured monocytes from these patients differentiate faster during the 7 day culture period as compared to normal controls. Efficacious treatment did not affect the number of peripheral blood monocytes expressing CD23. However, treatment did lead to a significant decrease in the number of CD23+ mature macrophages in the skin as well as a reduction in the level of expression of this moiety. These results demonstrate that changes in clinical severity are more closely related to the expression of CD23 on mature antigen presenting cells in lesional skin rather than to differentiating peripheral blood monocyte CD23 expression.

CONCLUSIONS

These results suggests that local factors within lesional skin govern the accumulation and the expression of CD23 on mature macrophages and that these factors may be more relevant to the pathogenesis of the disease than aberrations in CD23 expression that may occur systemically.

Carrier status for steroid 21-hydroxylase deficiency is only one factor in the variable phenotype of acne

OBJECTIVE

Previous endocrine studies of women with acne have produced diverse results. This study was designed to seek evidence, from endocrine and genetic studies, for impaired steroid biosynthesis in patients with acne.

DESIGN

Adrenal stimulation tests with synthetic adrenocorticotrophic hormone (ACTH) were performed.

MEASUREMENTS

Steroid hormones were measured basally and 30 minutes after ACTH. The results were correlated with analysis of the steroid 21-hydroxylase gene (CYP21).

PATIENTS

Fifty-one consecutive female patients (mean age 27.1 years) referred with acne.

RESULTS

The median plasma 17-hydroxyprogesterone (17-OHP) before and 30 minutes after ACTH were 2.5 nmol/l (range 1.1-8.2) and 7.3 (2.1-17.8) nmol/l which were significantly above normal female controls (n = 11, mean age 25.6 years) at 1.5 (0.9-4.2) and 4.6 (2.6-8.4) nmol/l. Eighteen of 51 acne patients showed an abnormal 17-OHP response. The 21-hydroxylase gene (CYP21) was examined for major deletions and for three common point mutations in 31 of the patients (14 with exaggerated 17-OHP response). One patient had a deletion of CYP21 on one allele consistent with carrier status for the classical congenital adrenal hyperplasia (CAH). Five patients, one of whom had a normal 17-OHP response to Synacthen, were heterozygous for the val 281 leu mutation in exon 7 of the CYP21 and were therefore carriers for a mutation associated with late-onset CAH. One patient with a raised 17-OHP response was homozygous for the splice site mutation in intron 2 and one patient with a normal 17-OHP response was heterozygous for the mutation. None of the patients had the ile 172 asn mutation. Eight of the 31 acne patients who had CYP21 gene analysis were carriers for mutations in the 21-hydroxylase gene but only six would have been detected by an abnormal response of 17-OHP on stimulation.

CONCLUSION

Although alterations of the CYP21 gene were more common in acne than in controls there is a poor correlation between these events and raised steroids and acne. Factors other than mild impairment of CYP21 contribute to the variability of the clinical phenotype in hyperandrogenic states including acne.

Substance P binding to peripheral blood mononuclear leukocytes in atopic dermatitis

Substance P has various immunomodulatory effects, including in vitro modification of lymphocyte proliferation and cytokine release. Elevated levels of substance P and increased staining of substance P-positive nerve fibres have been reported in atopic dermatitis patients. We examined fluoresceinated substance P binding to a range of lymphocyte subsets and compared the results in atopic dermatitis, non-atopic psoriasis patients and normal controls. Fluoresceinated substance P and phycoerythrin-labelled monoclonal antibodies to CD3, CD4, CD8, CD57, CD19 and CD14 were incubated in duplicate with Ficoll-Hypaque separated peripheral blood mononuclear leukocytes. With flow cytometry the fluoresceinated substance P-positive cells were identifiable as a peak of positively fluorescent cells, and the percentages of positive cells were measured. We have demonstrated binding of fluoresceinated substance P to all subsets examined, with significantly less binding to atopic dermatitis CD3-, CD8- and CD57-positive cells. This may affect cytokine release and hence be important in the pathogenesis of atopic dermatitis.

Modulation by Chinese herbal therapy of immune mechanisms in the skin of patients with atopic eczema

Ten patients with atopic eczema (AE) received treatment with Chinese herbal therapy (CHT; Zemaphyte) for 2 months. The severity of the eczema was recorded and skin biopsies were taken from lesional (L) and non-lesional (NL) skin before and after treatment. The skin biopsies were stained to detect T-cell subsets (CD4, CD8, CD45Ro and CD25), macrophage subsets (RFD7), dendritic cells (RFD1). Langerhans cells (CD1), HLA-DR, low-affinity IgE receptors (CD23) and high-affinity IgE receptors (15A5, 22H7). A quantitative assessment of the numbers of positively stained cells was made. Monoclonal antibody binding specifically to CD23(Fc epsilon RII) was used, in combination with cell subset monoclonal antibodies to quantify the cellular distribution of CD23 antigen in the skin. Following 2 months of treatment with CHT, erythema was reduced by 53%. There was also a significant reduction in HLA-DR expression. The numbers of RFD1 + CD23 +, RFD7 + CD23 +, CD1 + CD23+ and CD25 + cells in lesional skin decreased significantly after treatment (RFD1 + CD23 + from 0.39 to 0.21, RFD7 + CD23 + from 0.29 to 0.16. CD1 + CD23 + from 0.24 to 0.09, CD25 + from 0.84 to 0.31 in epidermis and from 1.62 to 0.94 in dermis (mean cells numbers per unit area). No significant change in cell numbers in NL skin or expression of Fc epsilon RI in either L or NL samples was observed after treatment. This study confirms that CHT is clinically efficacious and that clinical improvement is associated with a significant reduction in antigen-presenting cells expressing CD23.

Clinical and pathological heterogeneity in cutaneous gamma-delta T-cell lymphoma: a report of three cases and a review of the literature

Cutaneous gamma-delta (gamma delta) T-cell lymphoma is rare. Eleven cases have been reported to date including four cases of mycosis fungoides (MF), two of pagetoid reticulosis and five of pleomorphic cutaneous T-cell lymphoma (CTCL). We report three further cases of cutaneous gamma delta T-cell lymphoma; one of MF, one of a pleomorphic CTCL and one of a subcutaneous T-cell lymphoma. Combined data suggest that although cutaneous gamma delta T-cell lymphomas do not appear to comprise a single clinicopathological entity, they may be associated with aggressive clinical behaviour and a poor prognosis.

Immunohistological analysis of 'negative' patch test sites in atopic dermatitis

BACKGROUND

Variable results have been obtained when patients with atopic dermatitis (AD),) have been patch tested with allergens known to produce a positive prick test. The significance of patch test results in our understanding of the pathogenesis of AD therefore remains questionable.

OBJECTIVE

This study was designed to determine the relevance of either positive or negative patch test results in relation to the expression of cell mediated immunity to allergens in patients with AD.

METHODS

Thirty-five patients with AD exhibiting patch test positivity to one or more aeroallergens on 'tape stripped' areas of the back were retested without prior tape stripping. Nine patients again showed positivity to one or more allergens while 26 failed to show positive reactions. In six of the positive patients both positive and negative patch tests were observed. Skin biopsies were taken from these matched positive and negative patch test sites as well as from an area of uninvolved skin. Samples were frozen and cryostat sections were analysed with immunohistological techniques using monoclonal antibodies to investigate the distribution of immunocompetent cells.

RESULTS

All positive patch tests exhibited characteristics of a cell mediated immune response. The negative patch test sites were also found to contain evidence of mononuclear cell infiltration. Both negative and positive patch test sites showed significantly greater proportions of T cells compared to uninvolved skin. No increase in numbers of RFD1 positive and RFD7 positive macrophages were observed in either positive or negative patch test sites. Expression of CD23 by CD1 positive Langerhans cells was raised in both negative and positive patch tests compared to uninvolved areas. A significant increase in the population (RFD7+, CD23+) was seen in positive patch test sites compared to uninvolved skin. An increase in the proportion of RFD1 positive cells expressing CD23 was also seen in both negative and positive patch tests compared to uninvolved skin.

CONCLUSIONS

This paper demonstrates that immunological reactions are promoted at 'non-tape stripped' patch test sites where no clinical evidence of reactivity is seen. Together the data demonstrate that the presence of systemic cell mediated immunity to specific allergens identified in patients by positive patch test, may also be present when no clinical signs are seen at the patch test site.

Skin surface lipids in HIV-positive patients with and without seborrheic dermatitis

BACKGROUND

Seborrheic dermatitis (SD) is a frequent complication of infection with the human immunodeficiency virus (HIV). Most studies examining the cause of SD have concentrated on the roles of Pityrosporum ovale and sebaceous lipids. Previous studies of skin surface lipid from patients with SD have produced conflicting results, with some authors reporting an abnormal lipid composition and others finding little or no abnormality.

METHODS

The composition of skin surface lipid was studied in 15 HIV-positive and 10 HIV-negative men with SD, in 14 HIV-positive men without SD, and in 16 unaffected controls. Total lipids were extracted from unaffected forehead skin into petroleum ether and separated into lipid classes by thin layer chromatography. The lipid classes were quantitated by densitometry after charring with sulfuric acid.

RESULTS

Patients, HIV-positive with SD, had significantly lower proportions of free fatty acid (FFA) and higher levels of triglyceride than normal controls. Patients, HIV-positive without SD, had a significantly increased proportion of FFA compared to HIV-positive patients with SD. Patients with SD, both HIV-positive and HIV-negative, had a similar pattern of skin surface lipid. Levels of FFA were lower and those of triglyceride higher than in the patients unaffected by SD, whether HIV-positive or not. There was no significant difference found between groups in free cholesterol, wax esters, and squalene.

CONCLUSIONS

Abnormalities of skin surface lipid composition may play a part in the development of SD in both HIV-positive and HIV-negative men.

Punctate palmoplantar keratoderma and malignancy in a four-generation family

We report a large kindred in which a punctate palmoplantar keratoderma (PPK) is associated with malignancy, including Hodgkin's disease, renal, breast, pancreatic and colonic adenocarcinomas. The family was traced through four generations, and over 320 individuals were identified, of whom 49 had punctate PPK. The punctate PPK appeared to be inherited as an autosomal dominant trait with variable penetrance. Ten of the 43 adults (23%) with punctate PPK developed malignancies, and five of these developed before the age of 50. Of the 271 unaffected individuals, six (2%) have developed malignancies, one prior to the age of 50. The association of keratoderma and malignancy is discussed.

Neuropeptides in the skin of patients with atopic dermatitis

There is increasing evidence that neuropeptides may be involved in the pathogenesis of atopic dermatitis (AD). This study examines whether neuropeptide distribution in the skin of patients with AD differs from normal controls. The distribution and density of several neuropeptides were examined in lesional and non-lesional skin of AD patients (n = 5) and in normal controls (n = 4) using indirect immunofluorescence and image analysis. Cholinergic innervation was studied using cholinesterase histochemistry. Staining with the general neuronal marker protein gene product 9 x 5 showed a subepidermal network of nerves with fibres penetrating the epidermis, and nerves around blood vessels, sweat glands and hair follicles. Image analysis of nerves around sweat glands showed a significantly higher nerve density in non-lesional compared with both normal controls and lesional skin (P < 0.05); lesional compared with control skin showed no significant difference. In the epidermis the density of nerves was not significantly greater in non-lesional compared with lesional skin and controls. Calcitonin gene-related peptide immunoreactivity was similar in all subjects except in three of the AD patients, where more nerves appeared to penetrate the epidermis. Substance P immunoreactivity in the papillary dermis was seen in all AD patients but no controls. Vasoactive intestinal polypeptide and neuropeptide Y staining were similar in all groups. Acetylcholinesterase-positive nerves were found around sweat glands in all subjects, the staining being greatest in non-lesional and least in lesional skin. Occasional nerves were seen in the papillary dermis in lesional skin of two out of the four patients. We have demonstrated quantitative differences in nerve growth in clinically normal skin of AD patients, and altered cutaneous neuropeptide expression in these patients which may contribute to the pathogenesis of AD. The cause of atopic dermatitis (AD) has not been fully established but it is believed that there is a complex interaction between genetic susceptibility, precipitating environmental factors and disordered immune responsiveness. There is increasing evidence that neuropeptides may be involved in the pathogenesis of AD. Exacerbations of the disease can be provoked by stress, scratching and sweating which may be the result of neurogenic inflammation. One of the first features of an exacerbation is flushing of the affected skin and pruritus. Several neuropeptides that have been identified in human skin are potent inducers of vasodilation and may induce pruritus. Substance P (SP), calcitonin gene-related peptide (CGRP) and vasoactive intestinal polypeptide (VIP) all cause vasodilation when injected intradermally, and SP and CGRP have been shown to be mediators of the weal and flare reaction. Spantide, a competitive antagonist of SP, has been shown to inhibit immediate and delayed-type hypersensitivity reactions. Part of these responses may be due to release of histamine and indeed elevated concentrations of histamine have been found in vivo in the skin and plasma of patients with AD. In this study the distribution and density of several neuropeptides were examined in lesional and nonlesional skin of AD patients and in normal controls using indirect immunofluorescence and image analysis. Cholinergic innervation was studied using cholinesterase histochemistry. Because many afferent fibres do not express CGRP or SP, the general neuronal marker protein gene product (PGP 9 x 5) was used to assess the overall nerve supply to the skin.

Differentiation and CD23 expression of peripheral blood monocytes in patients with atopic dermatitis

In this study we investigate the expression of the low affinity immunoglobulin E (IgE) receptor (Fc epsilon RII) on plastic-adherent leucocytes from patients with atopic dermatitis (AD). Peripheral blood mononuclear cells were obtained from patients with AD, normal controls (and in one study from a group of atopic asthmatic patients). Monocytes were separated by 2-h adherence to plastic. These cells were then cultured for up to 7 days. Cells were harvested at time 0 (after adherence), and after 5 and 7 days culture, and cytospins were prepared. The proportion of cells expressing the phenotype of antigen presenting cells (monoclonal antibodies (mAb) RFD1+), and mature phagocytes (mAb RFD7+) together with CD23, were evaluated using combination staining with immunoperoxidase and alkaline phosphatase anti-alkaline phosphatase methods. It was found that a significantly larger proportion of circulating adherent cells in AD patients expressed the RFD1 antigen, and that increases in the proportion of these adherent cells expressing RFD1 or RFD7 occurred faster as cells matured in culture, when compared with cells obtained from normal controls. By day 7, however, equivalent proportions of RFD1+ and RFD7+ cells were present in AD and control cultures. None the less, expression of the CD23 molecule was consistently present on a larger proportion of both RFD1+ and RFD7+ cells from AD patients compared with controls. The raised proportion of circulating RFD1+ cells found in AD was not present in samples from atopic asthmatics, while the raised expression of CD23 on these cells occurred in samples from both these groups. These data support the suggestion that abnormalities in peripheral blood adherent cell phenotype, maturation, and CD23 expression, occur in AD patients. Some of these observations may be related to atopy in general rather than being specific for this skin disease.

Efficacy of traditional Chinese herbal therapy in vitro. A model system for atopic eczema: inhibition of CD23 expression on blood monocytes

Recently, there has been growing interest in the use of traditional Chinese herbal therapy (TCHT) decoctions for the treatment of atopic eczema (AE). The mode of action of this treatment is still unknown, and in order to investigate this we have analysed the effect of an extract of these herbs (TCHTE) on interleukin 4 (IL-4)-induced CD23 expression on peripheral blood monocytes from non-atopic subjects. We found that TCHTE inhibited CD23 expression up to 60% (P < 0.001), whereas the placebo extract had no significant effect on CD23 expression. This inhibition was dose-dependent, and TCHTE was effective at a concentration of 250 micrograms/ml (P = 0.001). If TCHTE or placebo was added after IL-4, the action of TCHTE could still be seen at 12 h. This inhibition was not due to cell death, as peripheral blood mononuclear cells (PBMCs) cultured with TCHTE or placebo at a concentration used in these experiments had a similar viability to control cultures. Down-regulation of the low affinity receptors for IgE on antigen-presenting cells in patients with AE may contribute to the benefit observed following treatment with TCHT.

Follow-up of adult patients with atopic eczema treated with Chinese herbal therapy for 1 year

Adult patients with severe atopic eczema who had completed a double-blind placebo-controlled crossover trial of a specific formulation of Chinese herbal therapy were offered continued therapy for 1 year. Of 31 patients who completed the original placebo-controlled study and after a washout period and 2 months of further treatment, 17 continued treatment (group 1), 11 chose not to continue treatment (group 2), one was lost to follow-up and two patients originally in group 1 decided to stop treatment and became pregnant. At the end of the year, 12 of the patients in group 1 had greater than 90% reduction and the remaining five had greater than 60% reduction in clinical scores compared with baseline values. Clinical scores of patients in group 2 gradually deteriorated so that by the end of the year the difference between groups 1 and 2 was highly significant (P = 0.005 and P = 0.002 for erythema and surface damage, respectively). At the end of the year no patient in group 1 felt able to discontinue treatment permanently, but eight patients were on an alternate-day regimen by 6 months and remained on this regimen until the end of the year, and seven were able to control their eczema with a 1 in every 3 day treatment by the end of the year. The remaining two patients continued on daily treatments. Toxicology screening revealed no abnormalities in either full blood counts or biochemical parameters in any patient on continued treatment. Improvement in disease was not associated with any significant change in serum IgE level or peripheral blood lymphocyte subsets.(ABSTRACT TRUNCATED AT 250 WORDS)

Fibroblastic rheumatism

The first British case of fibroblastic rheumatism is reported. Treatment with apha-interferon in combination with a reducing course of steroids resulted in some regression of the cutaneous nodules, and initial improvement in the skin fibrosis and digital contractures.

Chronic rash associated with congenital rubella

Images

Stelazine-induced pigmentation

A case of a West Indian patient is reported who developed abnormal blue-grey pigmentation on exposed areas of skin following treatment with low dose stelazine. Oculocutaneous melanosis is a well-recognized side-effect of prolonged phenothiazine treatment. In this condition the areas of skin exposed to sunlight develop a violaceous, blue-grey or slate-grey colour in more severe cases. These characteristic changes are rarely seen now. We describe the case of a patient who developed pigmentation while taking a low dose of stelazine for 5 years.

Systemic lupus erythematosus in association with ulcerative colitis: related autoimmune diseases

We report a patient who developed urticaria, angio-oedema and polyarthropathy secondary to the hypocomplementaemic urticarial vasculitis syndrome, a year prior to the onset of ulcerative colitis. Ten years later, primary sclerosing cholangitis and the antiphospholipid syndrome developed concomitantly. We believe this patient represents only the second reported case of idiopathic systemic lupus erythematosus (SLE) occurring in association with ulcerative colitis.

Cyclical psoriatic arthritis responding to anti-oestrogen therapy

We report a patient with severe psoriatic arthritis in whom the severity of both the arthritis and psoriasis fluctuated with the menstrual cycle. These features failed to improve with standard therapy, but there was a prompt response to treatment which suppressed oestrogen secretion. Such treatment should be considered in patients with disabling cyclical changes in psoriatic arthritis.

Risk of cancer in relatives of patients with cutaneous melanoma

BACKGROUND

Cutaneous malignant melanoma (CMM) is a recognized feature of the Lynch type II cancer-family syndrome and the Li-Fraumeni's syndrome. A significant contribution of these syndromes to the total burden of CMM would be reflected in an increased risk of nonmelanoma cancers in first degree relatives.

METHODS

Pedigrees were taken from 85 patients with CMM using a family history questionnaire. The relative risk of death from all cancers and individual cancers in first degree relatives was calculated.

RESULTS

Of the 85 questionnaires, those of 79 patients were completed and of adequate quality for analysis. The first degree relatives of CMM patients showed no increased risk of cancer death, the relative risk of cancer death being 1.0. Six patients (7.6%) had first degree relatives with CMM. One patient had a family history compatible with the dominant transmission of a predisposition to cancer.

CONCLUSIONS

It is important to establish whether an increased cancer risk is present in relatives of patients with malignancies so that screening programs may be offered. This study provides little evidence to support seeing relatives for noncutaneous malignancies in the absence of a dominant family history of predisposition to cancers. The increased frequency of CMM in relatives suggests that relatives of CMM patients should be counseled on protection from the sun and examination of the skin for melanoma.

Generalized morphoea secondary to porphyria cutanea tarda

We report a patient with generalized morphoea secondary to porphyria cutanea tarda, who responded to treatment with cyclosporin. The differences between the sclerodermatous skin changes seen in porphyria cutanea tarda and generalized morphoea are discussed.

Bullous pemphigoid in infancy--a case report including new immunoblotting observations

A 1-year-old boy developed bullous pemphigoid. Immunoblotting, which has not been previously reported in childhood pemphigoid, showed the serum reacted to a 190 kDa band only. Bullous pemphigoid is rare in infancy and childhood with only 40 cases previously reported. A brief review of the literature is given and treatment of childhood bullous pemphigoid is discussed.

Neutrophilic eccrine hidradenitis with an unusual presentation

Neutrophilic eccrine hidradenitis (NEH) is an eruption most commonly seen in patients undergoing chemotherapy, and is characterized histologically by a neutrophilic infiltrate around the eccrine coils, with associated necrosis of the sweat coils. The rash usually affects the trunk and extremities, and the morphology of the lesions is very variable. We describe a patient with neutrophilic eccrine hidradenitis who presented with symmetrical, erythematous, swollen ears, a manifestation of NEH which has not been previously reported.

Pellagra secondary to 5-fluorouracil

The development of pellagra in a patient treated with 5-fluorouracil for malignant disease is reported. The aetiology of pellagra in this patient is discussed, and the reasons for possible under-diagnosis of pellagra in association with malignant disease considered. We report a patient who presented with the typical skin changes of pellagra. The rash, and an associated acute deterioration in cerebral function, were exacerbated by treatment with 5-fluorouracil. The importance of considering nicotinic-acid deficiency in patients with malignant disease has not been emphasized in the literature.