Successful treatment with hydroxychloroquine for systemic lupus erythematosus with cutaneous involvement accompanied by a xanthomatous reaction

Antimalarials are usually recommended for the first-line systemic treatment of cutaneous lupus erythematosus. Alopecia in patients with discoid lupus erythematosus (DLE) is sometimes a refractory condition in spite of topical therapies. We herein described a case of DLE on the scalp with a pathological change of a xanthomatous reaction, which was successfully treated with hydroxychloroquine (HCQ). A 34-year-old woman presented with hair loss to the parietal region. She had been diagnosed with systemic lupus erythematosus (SLE) four years previously. Treatment with 30 mg/day of prednisolone (PSL) had been initiated, and the dose was gradually reduced. At 10 mg/day of PSL, she had noticed her hair loss. Physical examination revealed some small erythematous lesions to the parietal region with accompanying hair loss. Pathological findings of the erythematous lesion on her head revealed thickening of the basement membrane zone, the interface dermatitis with vacuolar degeneration, and both superficial perivascular and perifollicular infiltration of inflammatory cells in the dermis. In addition, there was an infiltrate of xanthomatous cells detected in the papillary dermis, which were positive for CD68 and CD163. The patient started treatment with HCQ at a dose of 200 mg/day. The skin lesions completely resolved within five months after initiation of HCQ without increase in the dose of PSL. Xanthomatous reactions are rarely recognized in lupus erythematosus. The chronic epithelial injury in DLE could be implicated in triggering the secondary reactive process of a xanthomatous reaction. We believe that the reaction seen in our patient was a secondary change to pathological alteration due to SLE. However, as yet unrecognized factors may play a role in the development of a xanthomatous reaction in DLE.

Palisaded neutrophilic and granulomatous dermatitis associated with systemic lupus erythematosus: possible involvement of CD163+ M2 macrophages in two cases, and a review of published works

BACKGROUND

Palisaded neutrophilic and granulomatous dermatitis (PNGD) is a commonly occurring condition related to systemic autoimmune disease. It is characterized histopathologically by a distinct pattern of granulomatous inflammation in the presence or absence of leukocytoclastic vasculitis. The properties of granulomatous cells in PNGD are still uncertain.

OBJECTIVE

We sought further investigation on the phenotype of the infiltrated cells in PNGD from two patients with systemic lupus erythematosus (SLE) and reviewed the previous published reports in order to provide a comprehensive summary on the clinical features of PNGD in SLE.

METHODS

The immunohistochemical features of granulomatous cells in PNGD associated with SLE were analyzed. Immunohistochemical studies were performed on sections from our two cases using antibodies against CD68, CD163, CD15, Factor XIIIa, myeloperoxidase and neutrophil elastase. The clinical characteristics of the SLE patients who developed PNGD were also evaluated. We included all cases retrieved through a PubMed search with the key words PNGD and SLE.

RESULTS

Cutaneous lesions consisted of erythematous plaques distributed on the face and upper limbs in both cases. The infiltrated cells were mainly positive for CD68 and CD163, a phenotype suggestive of M2 macrophages. Some mature neutrophils and lymphocytes were also present. A review of the literature of PNGD associated with SLE revealed a predominance in females, high prevalence of lupus nephritis and a good response to systemic steroids, with frequent skin lesions relapses during tapering of the treatment.

LIMITATIONS

This study examined only two cases; the pathogenesis of the disease remains to be clarified.

CONCLUSION

PNGD lesions were abundantly infiltrated by M2 macrophages, suggesting that they may have a role in this condition. SLE accompanied by PNGD might be associated with lupus nephritis and frequent relapses of skin lesions.

A case of feline gastrointestinal eosinophilic sclerosing fibroplasia limited to the mesentery

An entire, female, mixed‐breed cat of unknown age was presented with a 6‐week history of lethargy, anorexia and vomiting. There was an increase in the number of white blood cells in the blood, including neutrophils and eosinophils; moderate anaemia; ascites; and possible mesenteric peritonitis. Exploratory laparotomy revealed firm, multifocal small nodules in the mesentery. As the nodules were surgically unresectable, they were biopsied. Histologically, the nodules were composed of thin trabeculae of dense collagen fibres mixed with plump fibroblasts and numerous eosinophils, consistent with feline gastrointestinal eosinophilic sclerosing fibroplasia. Bacteria were not detected on histological examination of the nodules and cytology of the ascites. Remission of disease occurred following treatment with prednisolone and ciclosporin A for 22 days and antibiotics for 40 days. After remission, ciclosporin A was administered for 236 days and then discontinued. Eosinophilia also resolved after treatment with ciclosporin A. The cat is still alive and in good condition on day 689. This report describes what may be an atypical case of feline gastrointestinal eosinophilic sclerosing fibroplasia, lacking involvement of the gastrointestinal tract, and was apparently cured by treatment that involved ciclosporin A.

Melanoma in association with acquired melanocytic nevus in Japan: a review of cases in the literature

BACKGROUND

Malignant melanomas clinically and/or histologically associated with melanocytic nevi have been reported worldwide. Approximately 20% of malignant melanomas in Caucasians, most of which are found on the trunk and proximal extremities, develop in association with pre-existing melanocytic nevi. In Japan, however, over half of all melanomas are acral lentiginous melanomas (ALMs) on the hands and feet; melanomas on sun-exposed areas are seen less frequently in Japanese people than in Caucasians. As ALMs are not usually accompanied by melanocytic nevi and there have been no reviews of the literature or statistical data regarding Japanese cases of melanomas with melanocytic nevi, dermatologists in Japan have few opportunities to see melanomas associated with pre-existing melanocytic nevi.

METHODS

Here we report a case of a superficial spreading melanoma that was formed on a melanocytic nevus on the trunk, and we review for the first time the case reports from the Japanese literature.

RESULTS AND CONCLUSIONS

With regard to the reported cases, melanomas associated with melanocytic nevi were mainly superficial spreading melanomas and nodular melanomas on the trunk or extremities; ALMs were rarely associated with nevi, indicating a trend similar to that observed in Caucasians. These findings suggest that the low frequency of associations between melanomas and melanocytic nevi in Japan reflects racial differences in the frequencies of each type of melanoma.

What is the physiological function of mast cells?

Under physiological conditions, skin mast cells preferentially localize around nerves, blood vessels and hair follicles. This observation, which dates back to Paul Ehrlich, intuitively suggests that these enigmatic, multifacetted protagonists of natural immunity are functionally relevant to many more aspects of tissue physiology than just to the generation of inflammatory and vasodilatory responses to IgE-dependent environmental antigens. And yet, for decades, mainstream-mast cell research has been dominated by a focus on the -undisputedly prominent and important - mast cell functions in type I immune responses and in the pathogenesis and management of allergic diseases. Certainly, it is hard to believe that the very large and rather selectively distributed number of mast cells in normal, uninflamed, non-infected, non-traumatized mammalian skin or mucosal tissue simply hanging around there lazily day and night, just wait for the odd allergen or parasite-associated antigen to come by so the mast cell can finally swing into action. Indeed, the past decade has witnessed a renaissance of mast cell research 'beyond allergy', along with a more systematic exploration of the surprisingly wide range of physiological functions that mast cells may be involved in. The current debate sketches many exciting horizons that have recently come into our vision during this intriguing, ongoing search.

IL-6 attenuates apoptosis, while neither IL-6 nor IL-10 affect the numbers or protease phenotype of fetal liver-derived human mast cells

BACKGROUND

The combination of recombinant human stem cell factor (rhSCF), rh interleukin (IL)-6 and rhIL-10 was reported to be optimal for mast cell development from cord blood progenitors and to induce chymase expression in all such mast cells earlier in their development than tryptase.

OBJECTIVE

The effects of rhIL-6 and rhIL-10 in various combinations on the rhSCF-dependent development of human mast cells from fetal liver progenitors were examined in serum-free media.

METHODS

Dispersed fetal liver cells were cultured in serum-free AIM-V medium with rhSCF alone, or with combinations of rhIL-6 and rhIL-10. Tryptase and chymase expression, surface Kit expression, metachromasia with toluidine blue and apoptosis were measured.

RESULTS

Neither rhIL-6 nor rhIL-10 nor the two interleukins together, when included from day 0 of culture, affected the number or protease phenotype of mast cells at 1 or 3 weeks. Expression of tryptase paralleled the appearance of metachromasia and surface Kit, both of which preceded chymase expression, regardless whether a rabbit polyclonal or mouse monoclonal anti-chymase antibody preparation was used. On the other hand, rhIL-6 markedly attenuated baseline levels of apoptosis in the presence of rhSCF as well as apoptosis occurring after withdrawal of rhSCF, whereas rhIL-10 had no effect.

CONCLUSION

RhIL-6 protected fetal liver-derived mast cells from apoptosis, particularly after withdrawal of rhSCF, but neither rhIL-6 nor rhIL-10 nor the combination of these interleukins affected the numbers or protease phenotype of these mast cells.

Photoinduced group transfer radical addition of carbamotelluroates to acetylenes

[reaction: see text] Te-Phenyl carbamotelluroates 1 add to acetylenes under irradiation of visible light to yield beta-telluroacrylamides 2 regioselectively. This reaction would be initiated by homolytic cleavage of the carbamoyl carbon-tellurium bond, producing carbamoyl and PhTe radicals. The addition reaction proceeds via a radical chain mechanism comprising two processes: (i) addition of carbamoyl radicals at the terminal carbon of the triple bond, giving vinylic radicals, and (ii) S(H)2 reaction on the Te atom caused by the attack of the vinyl radicals to 1.

Formation of 1,4-disilyl-2-butenes from vinyl grignard reagent and chlorosilanes catalyzed by a titanocene complex

Symmetrical 1,4-disilyl-2-butenes 1 have been prepared by the reaction of vinyl Grignard reagent with chlorosilanes. This reaction proceeds efficiently in the presence of a catalytic amount of titanocene dichloride at 0 degrees C in THF. When dichlorodiphenylsilane was used, 1,1-diphenyl-1-silacyclo-3-pentene 2 was obtained in a good yield.

Human skin-derived mast cells can proliferate while retaining their characteristic functional and protease phenotypes

Human mast cells in adult tissues have been thought to have limited, if any, proliferative potential. The current study examined mast cells obtained from adult skin and cultured in serum-free medium with recombinant human stem cell factor. During the first 4 weeks of culture, the percentages of mast cells increased from 10 to almost 100. After 8 weeks, a 150-fold increase in the number of mast cells was observed. When freshly dispersed mast cells were individually sorted onto human fibroblast monolayers and cultured for 3 weeks, one or more mast cells were detected in about two thirds of the wells, and in about two thirds of these wells the surviving mast cells showed evidence of proliferation, indicating most mast cells in skin can proliferate. Such mast cells all expressed high surface levels of Kit and Fc epsilon RI, each of which were functional, indicating IgE was not required for Fc epsilon RI expression on mast cells. Such mast cells also retained the MC(TC) protease phenotype of mast cells that normally reside in the dermis. After 4 to 8 weeks of culture these mast cells degranulated in response to substance P and compound 48/80, characteristics of skin-derived mast cells that persist outside of the cutaneous microenvironment. (Blood. 2001;97:2045-2052)

Human mouse mast cell protease 7-like tryptase genes are pseudogenes

BACKGROUND

Alpha-tryptase and beta-tryptase are important clinical markers for mast cell-dependent disorders. A third family of tryptase genes on human chromosome 16 has been identified and called human mouse mast cell protease 7 (hmMCP-7)-like tryptase.

OBJECTIVE

This study was designed to determine whether these tryptase genes are expressed by human mast cells.

METHODS

A 2842-bp hmMCP-7-like tryptase gene was cloned and sequenced from a human placental genomic library. PCR and RT-PCR procedures, respectively, were used to determine whether this tryptase gene family was present in most genomes and whether it was expressed.

RESULTS

The tryptase clone was almost identical to the hmMCP-7-like tryptase II and I genes, and therefore it was called hmMCP-7-like tryptase III. All such genes encode a Gln(-3) like alpha-tryptase. They also terminate translation after amino acid 235, whereas alpha- and beta-tryptase genes each encode a 275-amino acid protein. In this study, cell lines HMC-1, KU812, and Mono-Mac-6; mast cells derived in vitro from cord blood and fetal liver progenitors; and mast cell-enriched preparations of dispersed skin and lung cells contained hmMCP-7-like tryptases in their genomes by PCR with gene-specific primers. To identify whether such genes were transcriptionally active, RT-PCR revealed alpha- or beta-tryptase products in all mast cell preparations and cell lines and in activated skin-derived mast cells, but no hmMCP-7-like tryptase products.

CONCLUSION

These results indicate hmMCP-7-like tryptase (I, II, III) genes are pseudogenes and unlikely to affect measurements of alpha- and beta-tryptases.

Disialoganglioside GD3 is selectively expressed by developing and mature human mast cells

BACKGROUND

Disialoganglioside GD3 is expressed on the surface of selected cell types. Anti-GD3 mAb administered to human subjects with malignant melanoma produces signs and symptoms of immediate hypersensitivity reactions.

OBJECTIVE

The expression of GD3 by human mast cells was assessed during mast cell development in vitro and in samples of lung and skin.

METHODS

GD3 on tissue- and in vitro-derived mast cells was analyzed after double labeling of cells for tryptase (G3 mAb) or Kit (YB5.B8 mAb) and GD3 (R24 mAb). Glycolipids in extracts of fetal liver-derived mast cells were examined by using high-performance thin-layer chromatography.

RESULTS

Flow cytometry showed that the percentage of GD3+ cells increased in parallel to Kit+ cells during the recombinant human stem cell factor-dependent development of fetal liver-derived mast cells. Double-labeling experiments showed that GD3+ cells were also surface Kit+ and granule tryptase positive, identifying them as mast cells in preparations of lung-, skin-, fetal liver-, and cord blood-derived cells. The major acidic glycolipid detected was NeuAcalpha2-8NeuAcalpha2-3Galbeta1-4Glcbeta1-1'Cer (GD3). Among peripheral blood leukocytes, only basophils and about 10% of the T cells were labeled with anti-GD3 mAb. Anti-GD3 mAb-conjugated magnetic beads were used to purify mast cells to greater than 90% purity from dispersed skin cells enriched to approximately 12% purity by means of density-dependent sedimentation but were less proficient for dispersed human lung mast cells, most likely because of other cell types that express GD3.

CONCLUSION

GD3 is expressed on the surface of developing human mast cells in parallel to tryptase in secretory granules and, like Kit, can serve as a target for their enrichment by immunoaffinity techniques.

An improved procedure for the development of human mast cells from dispersed fetal liver cells in serum-free culture medium

The in vitro development of human mast cells from fetal liver cells with recombinant human stem cell factor in serum-containing RPMI was compared to that in AIM-V media with and without serum. Compared to serum-containing media, AIM-V medium caused mast cells to develop earlier and in greater numbers. By 2 weeks, about 60% of cells in serum-free AIM-V medium were phenotypic mast cells, approximately 2 times the percentages in serum-containing media. By 6 weeks the percentages of mast cells were > or =80% under all conditions, but the number of mast cells was 3-4-fold greater in serum-free AIM-V medium than in serum-supplemented media. Mast cells obtained in serum-free AIM-V medium exhibited rounded nuclei, like tissue-derived mast cells; mast cells obtained in serum-supplemented media had segmented nuclei. By 10-12 weeks of culture about 40% of the AIM-V-derived cells showed strong chymase immunocytochemical staining, a pattern observed for only 14% of the cells in serum-containing media. AIM-V medium is a suitable medium for the development of human mast cells in vitro, and permits an earlier, more selective and greater expansion of mast cells than serum-containing media.

Cutaneous sarcoidosis showing multiple papular eruptions with keratotic plugs

A 26-year-old woman developed 249 discrete papules on her lower extremities. Twenty-three of them had keratotic plugs. Histologic examination demonstrated granulomatous foci consisting of epithelioid cells and a epidermal invagination which was disrupted at the base and lateral sites. This invagination was considered to represent transepithelial elimination.

Combined hepatocellular-cholangiocarcinoma associated with dermatomyositis

A 56 year old female developed combined hepatocellular cholangiocarcinoma associated with dermatomyositis. Serum tumour markers except for carbohydrate antigen (CA 19-9; 6400 ng/ml) were within normal range. Despite extensive chemotherapy, no clinical response was obtained and the patient's course deteriorated after 4 months. Macroscopically, the liver was mainly occupied by hepatocellular carcinoma but cholangiocarcinoma was found in the hilum. This is the first case of a rare association of combined hepatocellular-cholangiocarcinoma and dermatomyositis.

Elastic globes: electron microscopic and immunohistochemical observations

Specimens from a patient with epidermolysis bullosa contained many elastic globes in the dermis. Ultrastructurally they were composed of (i) medium electron-dense amorphous substances, (ii) electron-dense round structures, and (iii) fine filaments. These various elements were seldom organized into typical normal elastic fiber and, therefore, it was difficult ultrastructurally to recognize them as such or components thereof. Immunohistochemically, elastic globes were strongly reactive with NKH-1, which stains elastic microfibrils, and antibody to serum amyloid P component (anti-SAP), which binds to elastic fiber microfibrils. However, elastic globes were negative with EKH-4 which recognizes 50 kd keratin of amyloid keratin and cytoid bodies. These findings suggested that elastic globes have a close immunologic profile to elastic fiber microfibrils, but not that of epidermal or epithelial keratin.

Roles of immunoglobulins in amyloidogenesis in cutaneous nodular amyloidosis

Immunoglobulin heavy and light chains and C3 were detected on amyloid deposits in cutaneous nodular amyloidosis (NA) by a direct immunofluorescence method. These immunoglobulin chains and C3 could be removed except lambda (lambda) light chain after treating sections with 0.05% Tween 20 solution, 0.1 M glycine buffer pH 7.4 or 0.5% Triton X solution. Lambda light chain was detected consistently after these treatments. Amyloid filaments were not altered with these treatments. Immunoelectron microscopy demonstrated persistent antigenicity of lambda light chain on amyloid filaments. It was suggested that lambda light chain is an inherent component of amyloid filaments in NA, whereas other chains and complement represent nonessential absorption on amyloid material.

Anti-elastofibril monoclonal antibody NKH-1: production and application

A new monoclonal antibody NKH-1 was developed using human subepidermal basement membrane zone substances as immunogen. NKH-1, IgG1 kappa light chain, labeled proteins in the subbasement membrane zone in a linear fashion. It also labeled oxytalan fibers and elaunin fibers in the papillary dermis. Mature elastic fibers were labeled only in their peripheral microfibrils (elastofibrils) and the center core of elastin was nonreactive. Basal lamina itself was not decorated with NKH-1 even at the immunoelectron microscopic level. Skin appendages such as eccrine and apocrine glands, arrector pili muscle, hair follicle, and sebaceous gland were surrounded with NKH-1-positive substances. This substance was in linear fashion closely associated with the basal lamina but deposited linearly outside of it. Species specificity tests were performed only in nonprimates: mouse and guinea pig skins were nonreactive with NKH-1. NKH-1 seems to recognize a new substance in the subbasal lamina region (subbasal lamina proteins) which crossreact with elastic fiber microfibrils.

Superficial spreading capillary hemangioma. A peculiar type of capillary hemangioma

A 57-year-old Japanese woman had a history of several years of a slowly growing, dark red plaque on the sole of her foot without any subjective symptoms. Histopathologically, the lesion was a capillary hemangioma which showed a lobular structure composed of newly formed capillaries. Each lobule was separated by thin elongated rete ridges. The lesions was definitely circumscribed in papillary and subpapillary layers and appeared to extend laterally.