Specificity and effector mechanisms of autoantibodies in congenital heart block

Complete congenital atrio-ventricular (AV) heart block develops in 2-5% of fetuses of Ro/SSA and La/SSB autoantibody-positive pregnant women. During pregnancy, the Ro/SSA and La/SSB antibodies are transported across the placenta and affect the fetus. Emerging data suggest that this happens by a two-stage process. In the first step, maternal autoantibodies bind fetal cardiomyocytes, dysregulate calcium homestasis and induce apoptosis in affected cells. This step might clinically correspond to a first-degree heart block, and be reversible. La/SSB antibodies can bind apoptotic cardiomyocytes and thus increase Ig deposition in the heart. The tissue damage could, as a second step, lead to spread of inflammation in genetically pre-disposed fetuses, progressing to fibrosis and calcification of the AV-node and subsequent complete congenital heart block. Early intrauterine treatment of an incomplete AV-block with fluorinated steroids has been shown to prevent progression of the heart block, making it clinically important to find specific markers to identify the high-risk pregnancies.

Questions about dexamethasone use for the prevention of anti-SSA related congenital heart block

BACKGROUND

Mothers with anti-SSA/Ro antibodies who have had a previous fetus with congenital heart block (CHB) have a risk of recurrence estimated to be up to 16%.

OBJECTIVE

To improve the management of these "high risk patients" by determining (a) whether or not prophylactic treatment is efficient; (b) whether or not fluorinated steroids (betametasone and dexamethasone) that do cross the placenta in an active form are safe for the fetus; and (c) which prophylactic treatment should be used.

METHODS

Retrospective study performed on seven mothers sent to a university hospital owing to a past history of one (six mothers) or two children (one mother) with CHB.

RESULTS

13 subsequent pregnancies occurred. No CHB was observed. All four pregnancies in women treated with 10 mg/day prednisone were uneventful. Three pregnancies in women receiving no steroids resulted in two early spontaneous abortions and one live birth. The six pregnancies in women treated with dexamethasone (4-5 mg/day) ended in one early and one late spontaneous abortion, two stillbirths, and two live births with intrauterine growth restriction and mild adrenal insufficiency. A histological study of one stillbirth disclosed intrauterine growth restriction and marked adrenal hypoplasia.

CONCLUSION

Adverse obstetric outcomes were often seen here and major concerns have been raised by paediatricians about the safety of fluorinated steroids, owing to the results of animals studies, retrospective data, and randomised trials. Because fluorinated steroids have not been shown to improve prophylactic treatment of CHB in pregnant women at high risk, their use is questionable.

Increased leukotrienes in exhaled breath condensate in childhood asthma

Cysteinyl leukotrienes (cys-LTs; LTC4, LTD4, and LTE4) are generated predominantly by mast cells and eosinophils and induce airway smooth muscle contraction, microvascular leakage, and mucous hypersecretion whereas leukotriene B4 (LTB4) is a potent chemoattractant of neutrophils. We measured cys-LTs and LTB4 in exhaled breath condensate from children aged 7-14 years including healthy nonatopic children (n = 11) and children with mild intermittent asthma (steroid naive, n = 11), mild persistent asthma (low-dose inhaled steroid treatment, n = 13), or moderate to severe persistent asthma (high-dose inhaled steroid treatment, n = 13). Exhaled LTB4 levels were increased in patients with mild and moderate to severe persistent asthma compared with patients with mild intermittent asthma (126.0 +/- 8.8 and 131.9 +/- 7.1 versus 52.7 +/- 3.8 pg/ml, p < 0.001 and p < 0.0001) and normal subjects (126.0 +/- 8.8 and 131.9 +/- 7.1 versus 47.9 +/- 4.1 pg/ml, p < 0.0001). Elevated exhaled cys-LT levels were found in patients with mild and moderate to severe persistent asthma compared with normal subjects (27.9 +/- 2.8 and 31.5 +/- 4.5 versus 18.5 +/- 0.5 pg/ml, p < 0.01 and p < 0.05). There was an inverse correlation between exhaled cys-LTs and LTB4 in patients with mild persistent asthma. We conclude that exhaled cys-LTs and LTB4 may be noninvasive markers of airway inflammation in pediatric asthma.

Response of mononuclear leukocyte cyclic adenosine monophosphate-phosphodiesterase activity to treatment with topical fluorinated steroid ointment in atopic dermatitis

Our studies of mononuclear leukocyte peripheral blood homogenates demonstrate significantly increased cyclic adenosine monophosphate-specific phosphodiesterase activity in patients with atopic dermatitis who were untreated for 1 week, compared with normal adult nonatopic control subjects. Phosphodiesterase activity is not related to the extent or activity of the patient's disease or the presence or absence of allergic respiratory disease. Enzyme kinetic studies showed a triphasic plot in normal mononuclear leukocytes but a biphasic plot in atopic dermatitis. This may be interpreted as an absence of an enzyme with a low (0.080) Michaelis Menton constant (Km) in atopic dermatitis samples. One week of therapy with a topical fluorinated steroid ointment caused a significant reduction in disease activity. Although a slight reduction in mean total phosphodiesterase activity occurred, it did not reach statistical significance. One week's treatment, however, caused the abnormal biphasic kinetic plot to revert to a triphasic plot with return of the low Km enzyme form in those patients who showed a fall in phosphodiesterase activity. This finding suggests that the elevated phosphodiesterase activity in atopic dermatitis may be responsive in a limited degree to topical steroid therapy.

[Gluteal granuloma in an infant]

This report deals with a 5-month-old infant who at the age of 2 months was treated with topical fluorinated steroids for dermatitis in the diaper area. The treatment was continued for about 2 months. Some weeks later, multiple oval and round dark brown nodules developed in the inguinogenital areas. Histologic examination of these lesions revealed intense granulomatous infiltration in the upper dermis that consisted of lymphocytes, neutrophilic and eosinophilic granulocytes, and histiocytes. After steroid therapy was discontinued, the nodules slowly disappeared.

Topical steroids and UV radiation in psoriasis

This study evaluates the benefits of a potent and midstrength topical steroid compared with simple lubricating agents when used in combination with erythemagenic doses of sunlamp fluorescent UV irradiation in psoriasis. Twenty-six patients were studied in a bilateral symmetrical comparison. No significant differences were observed between topical corticosteroids and lubricants in the number of patients achieving a 75% or greater resolution of psoriasis. Topical corticosteroids did not reduce the number of treatments required for clearing. We did not observe faster recurrences in sites treated with topical corticosteroids. More severe burns and slightly less effectiveness were noted in patients irradiated five times weekly compared with three.

Hydrocortisone valerate. Double-blind comparison with two other topical steroids

Hydrocortisone valerate cream (0.2 percent) was evaluated in three controlled clinical trials involving a total of sixty-eight patients with atopic dermatitis. This new nonfluorinated steroid was found to be as effective as the fluorinated beta-methasone valerate cream (0.1 percent) and significantly more effective than hydrocortisone cream (0.1 percent) and the placebo cream base. All studies were double-blind, paired comparisons, utilizing application of the medications three times a day for up to four weeks or until clearing occurred.

Relapse of chromate dermatitis from sheet metal

Galvanised sheet metal has previously been described as a source of chromate dermatitis (Fregert et al. 1970). We report a patient who appears to have been sensitised many years previously by an entirely different source of chromate, but whose resulting hand eczema has relapsed while handling galvanised sheet metal at work.

Topical steroid depression of the hypothalamic-pituitary-adrenal axis in psoriasis vulgaris

Significant suppression of the hypothalamic-pituitary-adrenal axis has been found in patients hospitalized with psoriasis vulgaris and receiving topical fluorinated steroid therapy. Depression of thyroid function and involvement of autoimmune processes is also suggested by the data.

Treatment of ragweed hay fever with an intranasal spray containing fluinsolide, a new synthetic corticosteroid

Flunisolide, a new synthetic fluorinated corticosteroid, was administered as a nasal spray via a squeeze bottle to patients with ragweed hay fever for 4 wk during the hay fever season. Fifty-one patients, paired on the basis of similar skin sensitivity to intradermal ragweed (greater than or equal to 10-1 PNU/ml), were randomly assigned in a double-blind manner either an aerosol-containing flunisolide dissolved in vehicle (a mixture of polyethylene glycol and propylene glycol) or vehicle alone. Flunisolide was sprayed as a 0.025% solution two times in each nostril twice a day. Forty-eight patients completed the study. Three patients dropped out for reasons unrelated to flunisolide usage. On the basis of physician interviews and daily symptom dairy scores, patients receiving flunisolide showed significant improvement of hay fever symptoms when compared to their counterparts receiving vehicle. No systemic steroid side effects were observed. Morning plasma cortisol levels measured prio to and after 3 wk of flunisolide therapy showed no significant difference between the treatment groups. Adverse local effects were minor and were noted less frequently with flunisolide than with vehicle. Flunisolide's topical efficacy and lack of adrenal suppression provide distinct advantages over other steroid preparations available in the United States for treatment of seasonal allergic rhinitis.

[Diagnosis and therapy of bromoderma tuberosum]

After taking bromine-containing drugs two patients developed bromoderma on the leg. This diagnosis was confirmed by high bromine-levels in the blood. Topical occlusive treatment with glucocorticosteroids was successfull.

Effect of topical administration of antiinflammatory drugs to rats with adjuvant arthritis

Oral or intramuscular administration of antiinflammatory agents produces numerous undesirable side effects. This work explores the hypothesis that topical administration of such agents directly to the site of inflammation would have beneficial antiinflammatory effects. Topical administration of steroidal and nonsteroidal antiinflammatory drugs to rats with adjuvant arthritis was as effective as oral or intramuscular administration. Peak blood levels of radioactivity following administration of equal doses of hydrocortisone-3H were considerably lower after topical administration than after oral administration.

Norwegian scabies following topical steroid therapy

Following an outbreak of scabies in a hospital ward, a correct diagnosis of Norwegian scabies was made in an eczematous patient whose skin had unexpectedly deteriorated with topical potent fluorinated cortico-steroid therapy.

Do excoriations in psoriasis delay or prevent the effect of topical treatment?

Topical treatment of a number of out-patients with psoriasis vulgaris resulted in reduced induration and diminished thickness of the layer of scales but complete involution was not obtained. A sequential photographic study of the macroscopic appearance of the lesions over a 3-month period of treatment revealed that artificially produced excoriations and a horny layer without scales were prominent features. The view is put forward that the cutaneous reaction to the injury probably elicited by the excoriations, together with an unsatisfactory treatment, may give rise to tissue changes which counteract the effect of topical treatment.

Double-blind comparison of halcinonide and betamethasone valerate. Use with occlusive dressings in psoriasis treatment

In a double-blind, paired-comparison study of the effectiveness of corticosteroid creams used under occlusion for the treatment of moderate to severe psoriasis, a new drug, halcinonide cream, was superior to betamethasone valerate cream, a steroid widely and effectively used for the treatment of psoriasis. This superiority was demonstrated in patients after both one and two weeks of treatment.