Bullous Pemphigoid Associated With a New Combination Checkpoint Inhibitor Immunotherapy

Novel immunotherapies including antibodies to programmed death ligand 1 (PD-1) and cytotoxic T-lymphocyte-associated antigen 4 (CTLA-4) have become common therapies for neoplasms including metastatic melanoma and non-small cell lung cancer (NSCLC). Dermatologic toxicity is the most common adverse event associated with these immunotherapies. We report a case of bullous pemphogoid (BP) in a patient receiving combination durvalumab and tremelimumab, two newer immunotherapy checkpoint inhibitors under investigation in phase III trials. J Drugs Dermatol. 2019;18(1):103-104.

Tofacitinib for the treatment of lichen planopilaris: A case series

Lichen planopilaris (LPP) is an inflammatory cicatricial alopecia for which many different therapies are attempted with varying success. The Janus kinase (JAK) inhibitor, tofacitinib, has been shown to be effective in treating the noncicatricial alopecia, alopecia areata. As in alopecia areata, upregulation of interferon and JAK signaling may play a role in LPP. We retrospectively reviewed the cases of 10 patients with recalcitrant LPP who were treated with oral tofacitinib. Patients received oral tofacitinib 5 mg twice or three times daily for 2-19 months as either monotherapy or adjunctive therapy to other ongoing treatments including intralesional triamcinolone, hydroxychloroquine, and tacrolimus ointment. Eight patients had clinical improvement in LPP with tofacitinib as either monotherapy (4/10) or adjunctive therapy (4/10). LPP Activity Index (LPPAI) before and after treatment was measured in seven patients and was significantly different (6.22 before treatment, 3.08 after treatment; p value = .0014). Reduction in LPPAI ranged from 30 to 94%. One patient complained of 10 pound (4.5 kg) weight gain after 12 months on tofacitinib. No other adverse effects were reported. Treatment with oral tofacitinib either as monotherapy or adjunctive therapy can lead to measurable improvement in recalcitrant LPP.

A review of non-invasive imaging in extramammary Paget's disease

Extramammary Paget's Disease (EMPD) is a rare intraepithelial adenocarcinoma that classically manifests with pruritic, erythematous and scaling plaques. The clinical picture frequently mimics inflammatory or infectious conditions and is thus commonly misdiagnosed. The assessment of tumour margins is equally challenging as tumours have a propensity to spread beyond clinically visible boundaries. Appropriate non-invasive diagnostic tools can assist in the early detection, diagnosis and management of EMPD. This paper will review the literature on non-invasive imaging modalities used in EMPD. Articles from the PubMed database were selected based on relevance to the topic of this review. Articles that were not specific to EMPD and non-invasive imaging were excluded. Search strategy is further described in the methods section below. Eighteen articles were selected for this review: six PET/CT, five reflectance confocal microscopy (RCM), two photodynamic diagnosis (PDD), two dermoscopy, two MRI and one optical coherence tomography (OCT) paper(s). Dermoscopy, PDD, RCM and OCT can help to distinguish malignant conditions, including EMPD, from benign conditions. RCM and OCT can identify atypical cells in real-time, and have the potential to improve the accuracy of surgical margins intraoperatively and overall management. Distinctive confocal characteristics of EMPD have been described using RCM. The sensitivity and specificity of these findings require additional validation. Radiographic techniques also play a central role in the diagnosis of EMPD and assessment of disease spread. PET/CT and MRI can detect primary disease, nodal and distant metastases, with superior delineation of disease spread on MRI. Limitations of PET/CT are mainly related to primary tumour thickness, and size and FDG-avidity of nodal and distant metastases. Limitations of MRI include the fact that few studies have examined its use in EMPD; additional research is warranted. Randomized controlled trials and large prospective studies evaluating the use of non-invasive imaging in EMPD are needed.

A review of bullous pemphigoid associated with PD-1 and PD-L1 inhibitors

BACKGROUND

Dermatologic toxicity represents a substantial portion of all immune-related adverse events (irAEs) associated with PD-1/PD-L1 inhibitors. Bullous pemphigoid (BP) is a rare cutaneous side effect of these medications, which can initially be clinically indistinguishable from other, low-grade cutaneous toxicity.

OBJECTIVE

To better characterize the clinical features of BP associated with PD-1/PD-L1 inhibitors, evaluate the efficacy of various treatment regimens, determine the frequency of prodromal pruritus, and assess whether immunological diagnostic studies for BP are warranted in patients treated with checkpoint inhibitors who develop intractable pruritus.

METHODS

A comprehensive review of the English-language medical literature was performed using key terms. Papers published on any date and from all origins were considered. Fourteen publications, containing 21 patient cases, were selected independently by two reviewers and deemed relevant to the present publication.

RESULTS

Pruritus was a prominent feature of the majority (12/21) of cases and preceded or occurred concurrently with BP development. Bullae developed within 6-8 months of initiation of PD-1/PD-L1 inhibitors; however, a smaller subset of patients did not develop bullae for 1-1.5 years following initiation of therapy. Mean time to pruritus was similar for pembrolizumab and nivolumab at 19 and 21 weeks, respectively. Development of BP required discontinuation of immunotherapy in 76% (16/21) of cases.

CONCLUSION

Prodromal or "non-bullous" variants of BP must be considered in patients treated with checkpoint inhibitors who develop protracted or worsening pruritus. Early diagnostic immunological evaluation of the skin may lead to improved patient outcomes by facilitating timely initiation of treatment and prevent disruptions in cancer therapy.

Methicillin resistant Staphylococcus aureus colonization in pigs and pig farmers

Methicillin resistant Staphylococcus aureus (MRSA) colonization has recently been identified in pigs and people that work with pigs, raising concerns about the role of pigs as reservoirs of MRSA for human infection. The objectives of this study were to evaluate the prevalence of MRSA colonization in pigs and pig farmers in Ontario, Canada and to characterize MRSA strains. Nasal and rectal swabs were collected from 285 pigs from three different age groups from 20 pig farms. Nasal swabs were collected from farm personnel and a brief questionnaire was also administered. The prevalence of MRSA colonization in farms was 45% (9/20) whereas the prevalence in pigs was 24.9% (71/285). There was no difference in MRSA colonization between age groups. The prevalence of MRSA colonization in pig farmers was 20% (5/25). There was a correlation between the presence of MRSA in pigs and humans on farms (P value=0.001). The results of spa typing revealed the predominant strain in pigs and humans was eGenomics spa type 539 (Ridom t034, clonal complex 398) which accounted for 59.2% of isolates and has been reported in pigs in Europe. A common human epidemic clone, CMRSA-2 (USA100, clonal complex 5) was also found in both pigs and pig personnel. Indistinguishable strains were found in pigs and pig personnel on all five farms with a colonized human. This study demonstrates that MRSA is common in pigs in Ontario, Canada, and provides further support to concerns about transmission of MRSA between pigs and humans.

An anomaly in the isotopomer shift of the hyperfine spectrum of LiI

A high-precision examination of the hyperfine spectrum of 6LiI in comparison with 7LiI shows a shift in the iodine nuclear electric quadrupole moment that cannot be accounted for by a model in which the electric field gradient at the iodine site is assumed to depend only upon the internuclear distance between Li and I. The other hyperfine interactions are consistent between the two isotopomers, including the previously reported electric hexadecapole interaction of the iodine nucleus.

Western blot analysis of serological response in Helicobacter pylori in acid peptic diseases

A prospective study was undertaken in 70 patients presenting with acid peptic disease with the objective of characterising the serological response to Helicobacter pylori and finding antigens specific for the serodiagnosis of H. pylori infection. H. pylori status was assessed by smear microscopy, rapid urease activity, culture and histopathology of endoscopic gastric antral biopsy specimens. Serological characterisation was carried out by using western blotting of various antigenic components of H. pylori and subsequent enzymatic detection of antibodies against them. Four reactive bands in the molecular weight range of 45-65 kDa were present in all subjects irrespective of H. pylori status. Four to six immunoreactive bands in the molecular weight range of 21-45 kDa were found only in patients with positive H. pylori status and histopathologically proven gastritis. These immunoreactive components may be valuable in specific immunodiagnosis of H. pylori infection.

Strategies for purification of four reproductive hormones from the same batch of buffalo (Bubalus bubalis) pituitaries

The occurrence of different reproductive hormones like LH, FSH, TSH and prolactin, in different side fractions obtained during the extraction of buffalo pituitary glands either by the procedure of Papkoff et al. [Arch Biochem Biophys, 111 (1965) 431] or by that of Ellis [Endocrinology, 69 (1961) 554], was examined with the aid of antisera to respective heterologous hormones as well as bio-assays. Thus in the procedure of Papkoff et al., the SP-Sephadex fractions could be taken for purification of LH and TSH, while the acid pellet yielded prolactin. Further it was shown that 50% (NH4)2SO4 could be directly size fractionated and following cation exchange chromatography yields LH and TSH. FSH could be purified from 80% ammonium sulphate pellet. In another protocol of Ellis, differential extraction and chromatographic separation yielded all the four reproductive hormones. Some of the physico-chemical and immunobiological characteristics of these hormones are described.

Enzyme linked immunosorbent assay & indirect fluorescence assay for rapid diagnosis of Bacteroides fragilis infections

Antibodies for B. fragilis (NCTC 9343) were detected in sera of 121 patients and 37 controls using four methods viz., enzyme linked immunosorbent assay (ELISA), indirect fluorescence test (JFA), countercurrent immunoelectrophoresis (CIE) and indirect haemagglutination test (IHA). Of 121 patients, 57 were culture positive for B. fragilis, 38 positive for anaerobes other than B. fragilis and 26 were negative for anaerobes. In the B. fragilis culture positive group, antibodies to B. fragilis were positive in 82.5, 84.2, 85.90 and 91.2 per cent patients by CIE, ELISA, IHA and IFA respectively. In B. fragilis positive patients IFA was more sensitive than IHA, which for other groups IHA was found to be more sensitive than IFA. When all groups were taken together IHA was found more sensitive than IFA. ELISA and IFA tests are recommended for rapid serological diagnosis of B. fragilis infections, where facilities for these tests are not available, CIE and IHA could be done. Cross reactivity with other Gram negative anaerobic and aerobic bacteria should be kept in mind since seropositivity varied for B. fragilis (82-91%). In infections with microbes other than B. fragilis seropositivity varied between 23.7 to 63.2 per cent and in patients having cultures sterile or positive for other organisms seropositivity was 30.8 to 42.3 per cent. This nonspecificity could be due to other antigens that cross react between B. fragilis and other anaerobes and aerobes or the use of an antigen lacking high purity.