Pediatric pyoderma gangrenosum associated with leukocyte adhesion deficiency type 1: A case report and review of the literature

Pyoderma gangrenosum is a rare neutrophilic dermatosis characterized by painful skin ulcers with necrotic, undermined margins. In severe cases, particularly in pediatric patients, work-up for an associated autoimmune, inflammatory, malignant, or genetic disorder should be considered based on the clinical presentation. We report a unique case of pediatric pyoderma gangrenosum with a leukemoid reaction, secondary to an autosomal recessive leukocyte adhesion deficiency type 1.

Cutaneous adverse events in 155 patients with metastatic melanoma consecutively treated with anti-CTLA4 and anti-PD1 combination immunotherapy: Incidence, management, and clinical benefit

BACKGROUND

In response to the increased use of combination checkpoint inhibitors (CPIs) and the resulting increased cutaneous adverse events (CAEs), this study reviewed patients with melanoma treated with combination CPIs to characterize CAE features and their clinical impact, correlation to adverse events in other organs, and correlation to tumor response.

METHODS

Patients from the authors' institutional database who received at least 1 dose of ipilimumab in combination with either nivolumab or pembrolizumab between January 1, 2012, and December 31, 2017, for stage IV or unresectable stage III melanoma were identified. The time to next treatment (TTNT) was calculated from the start of CPI therapy to the start of the next treatment or death, and the development of CAEs was tested in a time-dependent Cox regression to identify associations with TTNT.

RESULTS

Eighty-one patients (52.3%) experienced a total of 92 CAEs, including eczematous dermatitis (25.0%), morbilliform eruption (22.8%), vitiligo (12.0%), and pruritus without rash (8.7%). The median times to the onset and resolution of CAEs were 21 days (range, 0-341 days) and 50 days (range, 1-352 days), respectively. Most CAEs resolved after patients entered the CPI maintenance phase and treatment with oral antihistamines with or without topical steroids. CPI discontinuation occurred in 4 patients (2.6%) because of CAEs, in 49 (31.6%) because of other immune-related adverse events, and in 20 (12.9%) because of melanoma progression or death. For patients definitively treated with CPIs (n = 134; 86.5%), TTNT was significantly longer with CAEs than without CAEs (hazard ratio, 0.567; 95% CI, 0.331-0.972; P = .039).

CONCLUSIONS

CAEs were mostly reversible and rarely required therapy discontinuation. The development of CAEs was associated with a longer TTNT, and this suggested a possible clinical benefit.

Potential Mechanisms for Marbling Content Differences in M. Longissimus Dorsi From Wagyu And Brahman Cattle

ObjectivesIntramuscular fat (marbling) affects consumer perceptions of meat quality. Recent studies indicated that intramuscular adipocytes are derived from fibroadipogenic progenitors (FAPs), a type of bipotent mesenchymal progenitor cells in extracellular matrix of muscle fiber. Platelet-derived growth factor receptor α (PDGFRa) is a marker in identifying FAPs. The amount of PDGFRa positive cells refers to the abundance of FAPs, a key factor determining the intramuscular adipogenic efficiency of the animal. In addition, it has been shown that both satellite cells and skeletal muscle fibers regulate the activity of FAPs. In this study, we aimed to identify some underlying mechanisms for the differences in intramuscular fat accumulation between Wagyu, a high marbling breed, and Brahman, a low marbling breed, through a comparison study.Materials and MethodsFive cattle of each breed approaching mature body composition (Wagyu born January to May 2017; Brahman two 2-yr-old and three 3-yr-old, born April 2017 and 2015) were selected for this study. Biopsy samples of M. Longissimus muscle (LM) were taken after local anesthesia between the 12th and 13th ribs. Fresh samples were frozen in isopentane chilled by liquid nitrogen immediately after trimming fat and connective tissue. Other samples were fixed for 4 h in ice-cold 4% paraformaldehyde, soaked overnight in 30% sucrose solution, and then processed in Optimal Cutting Temperature embedding medium. Frozen samples were stored at –80°C before cryosectioning (5 mm) at –25°C for immunochemical staining. Unfixed muscle tissue sections were only used for muscle fiber determinations by rinsing with 1X Tris Buffer Saline (TBS) 3 times, 5 min each, before blocking in 10% goat serum and 1% bovine serum albumin, followed by overnight incubation with primary antibodies at 4°C. Subsequent secondary antibody staining at room temperature for 1 h. TBS/T (0.3% Triton) was used for membrane permeabilization to identify satellite cells, FAPs, and basement membrane. Mounting media containing 4,6-diamidino-2-phenylindole (DAPI) was used for nucleus staining. Primary antibodies against PDGFRα, paired box 7 (PAX7), laminin, and different isoforms of skeletal muscle myosins were used to identify FAPs, satellite cells, basement membrane, and different types of muscle fiber, respectively. All the sections were visualized under a Nikon inflorescence microscope, and images were analyzed by Image J software to identify different muscle fiber types and positive signals of PDGFRα and PAX7. Minimum diameter of each muscle fiber type was the average of 30 randomly selected fibers per section. Data were analyzed with R-studio using ‘t.test ()’ function with the critical value being equal to 0.05.ResultsWagyu muscle demonstrated a greater (P = 0.01) number of FAPs compared with Brahman muscle. A trend toward a higher (P = 0.06) abundance of satellite cells in Wagyu muscle than in Brahman muscles was also identified. No differences were found in muscle fiber diameter or muscle fiber type composition between these two breeds of cattle.ConclusionThe greater number of FAP cells observed in the LM of Wagyu cattle than in Brahman cattle suggests that the higher marbling content of Wagyu meat is at least partially attributed to the more abundant adipogenic progenitor cells, which increases the capacity and efficiency of intramuscular adipogenesis in Wagyu cattle.

Antibody-Based Therapies for Cutaneous T-Cell Lymphoma

Cutaneous T-cell lymphomas (CTCLs) are a group of non-Hodgkin's lymphomas that present in the skin. In early-stage disease, the course is generally chronic and indolent; however, in advanced stages of disease, therapies rarely provide long-lasting responses, and the only potential curative therapy is allogeneic hematopoietic stem-cell transplantation. This has led to the search for novel targeted therapies to better treat more advanced stages of CTCLs that cannot be controlled by typical treatment regimens. One area of advancement has been the development of antibodies specifically targeted to cell types that are known to be involved in CTCL. At present, brentuximab vedotin, an antibody-drug conjugate composed of an anti-cluster of differentiation (CD)-30 antibody covalently linked to monomethyl auristatin E, is approved for the treatment of CD30+ lymphoproliferative disorders [lymphomatoid papulosis (LyP) and primary cutaneous-anaplastic large-cell lymphoma (pc-ALCL)] as well as transformed CD30+ mycosis fungoides (MF). Additionally, mogamulizumab, an anti-chemokine receptor 4 (CCR4) monoclonal antibody, is approved for patients with MF or Sézary syndrome (SS) for whom one prior systemic therapy has failed. Trials are underway looking into the use of immune checkpoint inhibitors in the treatment of CTCLs. As we continue to research CTCL, and as antibody-based therapies continue to advance, more antibody-specific targeted therapy could provide alternative treatment regimens for patients with advanced CTCL.

Retrospective Chart Review of Cutaneous Adverse Events Associated with Tremelimumab in 17 Patients

BACKGROUND AND OBJECTIVES

Tremelimumab is a monoclonal human antibody that inhibits cytotoxic T-lymphocyte-associated antigen 4, giving rise to increased T cell activation and interleukin-2 release. While this activation of the immune system provides a mechanism to recognize and destroy cancer cells, it also leads to off-target immune-related adverse events. Ipilimumab is a US Food and Drug Administration-approved anti-cytotoxic T-lymphocyte-associated antigen 4 antibody, which has a high incidence of cutaneous adverse events. While cutaneous adverse events for ipilimumab have been extensively studied, there is a distinct lack of cutaneous adverse event data for tremelimumab.

METHODS

We conducted a retrospective chart review of our institution's electronic medical records from January 2000 to March 2018 to characterize cutaneous adverse events induced by tremelimumab. Previous descriptions of tremelimumab cutaneous adverse events are limited to rash and pruritus.

RESULTS

We found 17 patients treated with tremelimumab who had cutaneous adverse events including pruritus (12/17), eczematous dermatitis (8/17), morbilliform rash (5/17), vitiligo (2/17), xerosis (3/17), acneiform rash (2/17), and psoriasiform dermatitis (1/17).

CONCLUSIONS

This case series demonstrates that cutaneous adverse events seen in patients taking tremelimumab overlap with those of ipilimumab. While there are some differences between rash characterizations of the two drugs, such as time to onset and clearance, the sample size of this case series is too small to draw any definite conclusions. This study addresses a gap in the descriptive knowledge on tremelimumab cutaneous adverse events and highlights the need for further large cohort prospective studies. Awareness of expected cutaneous toxicities and how best to treat these can help patients continue on immunotherapy regimens without delays or interruptions and give patients the best quality of life while receiving treatment.

The natural history of spinal deformity in patients with Coffin-Lowry syndrome

PURPOSE

Little is known about the natural history of spinal deformities in Coffin-Lowry syndrome (CLS). Our goal was to evaluate the spinal deformity progression and clinical impact.

METHODS

In this institutional review board-approved study, we performed a multinational retrospective review of six male CLS patients, aged 13 to 22 years at final follow-up, for a mean of 7.25 years (3 to 13).

RESULTS

All showed delayed skeletal maturity. Three had calcifications of their lower cervical ligamentum flavum, all experienced neural axis abnormalities, including lower extremity weakness, numbness and tingling and in one, quadriparesis. Only two were ambulatory at final follow-up.All had significant spinal abnormalities, including severe progressive thoracic lordosis, thoracolumbar kyphosis and scoliosis. All had undergone spinal fusion or were being evaluated for surgery.

CONCLUSION

CLS is a rare X-linked mutation in the RSK2 gene, affecting between 1/50 000 to 100 000 people. There are two reports in the literature of patients with calcifications of their ligamentum flavum. Both had neural axis abnormalities and one had acute onset quadriplegia. Analysis of their ligamentum flavum found abundant central calcifications. Despite our small cohort we found 50% had calcifications and 100% had neurologic consequences associated with those calcifications. There was a 100% rate of deformity progression.They all exhibited delay in skeletal maturity, which mandates longer follow-up and has implications for surgical planning.From our cohort and literature review, the natural history of CLS supports frequent patient evaluation and a lower threshold for correction of spinal deformities. Aiming to avoid spinal cord compression and improve or avoid neurological deterioration.

LEVEL OF EVIDENCE

IV - retrospective study.