The Imbalance of MMP-2/TIMP-2 and MMP-9/TIMP-1 Contributes to Collagen Deposition Disorder in Diabetic Non-Injured Skin

The importance of the early diagnosis and treatment of diabetes and its cutaneous complications has become increasingly recognized. When diabetic non-injured skin was stained with Masson's trichrome, its dermal collagen was found to be disordered, its density was variable, and it was dispersed or arranged in vague fascicles. The collagen type I sequencing results of RNA sequencing-based transcriptome analysis of three primary human skin cell types-dermal fibroblasts, dermal microvascular endothelial cells, and epidermal keratinocytes-under high glucose were analyzed. The results showed that both COL1A1 and COL1A2 mRNA expressions were reduced in human dermal fibroblasts (HDFs). The ratio of matrix metalloproteinase (MMP)-2/tissue inhibitors of metalloproteinase (TIMP)-2 and MMP-9/TIMP-1 in HDFs increased when treated with high glucose. By inhibiting MMP-2 and MMP-9 with SB-3CT, collagen deposition disorder of the skin in streptozotocin-induced diabetes mice was alleviated. The imbalance of MMP2/TIMP2 and MMP9/TIMP1 contributes to the non-injured skin disorder of collagen deposition in diabetes, suggesting a possibility for early treatment of diabetes skin complications.

Acquired reactive perforating collagenosis: A case report and review of the literature

INTRODUCTION

Acquired reactive perforating collagenosis (ARPC) is a rare skin disorder, which is associated with various internal diseases and even malignant neoplasms. A comprehensive knowledge of the concomitant diseases in ARPC patients is helpful to decrease the misdiagnosis. Although the treatment of ARPC is challenging, systemic assessment of existing regimens is not available.

PATIENT CONCERNS

A 50-year-old woman was admitted to the hospital due to cutaneous pruritus and papules all over the body.

DIAGNOSIS

Physical examination showed various sized papules on the lower limbs, buttocks, back, chest, and upper arms with keratotic plugs in the center. Histopathology showed typical collagenous fiber perforation. The diagnosis of ARPC was made according to histopathology, onset age and typical skin lesions. Type 2 diabetes mellitus (T2DM), chronic renal failure (CRF), and hypothyroidism simultaneously presented in this patient.

INTERVENTIONS

This patient was initially treated with topical corticosteroids and oral antihistamines for the skin lesion and pruritus. Medications for glucose control and recovery of renal and thyroid functions were also applied. On the second admission, the combined therapy of topical retinoic acid, Chinese medicinal herb-Qingpeng ointment, and Zinc oxide ointment was added.

OUTCOMES

Papules and pruritus were improved significantly after the second hospitalization.

CONCLUSION

We present a case of ARPC associated with T2DM, CRF, and hypothyroidism, which has rarely been described. There is no standardized treatment for ARPC. Co-administration of two or more agents for dermatologic interventions and treatment for associated diseases may help to improve skin symptoms.

Dipeptidyl peptidase-4 inhibitor-associated bullous pemphigoid in a patient with acquired reactive perforating collagenosis

Bullous pemphigoid (BP) is a common autoimmune blistering disorder with unknown etiology. Recently, increasing numbers of BP cases which developed under the medication with dipeptidyl peptidase-4 inhibitors (DPP4i), widely used antihyperglycemic drugs, have been reported in published works. Here, we report a case of DPP4i (teneligliptin)-associated BP that developed in a 70-year-old Japanese man. Interestingly, the patient had acquired reactive perforating collagenosis (ARPC), which is also known to be associated with the onset of BP. In the present case, clinical, histopathological and immunological findings suggested that DPP4i rather than ARPC was associated with the onset of BP.

Dermatomyositis, clinically presenting with cutaneous ulcers, with histopathologic evidence of perforating collagenosis

Dermatomyositis is a systemic, autoimmune diseasewith a variety of clinical features that often includemyositis and characteristic cutaneous findings. Asubset of patients with dermatomyositis developcutaneous ulcers, often in the setting of vasculitis orvasculopathy. We present a case of dermatomyositiswith cutaneous ulcers that show perforatingcollagenosis on histopathologic examination.Acquired reactive perforating collagenosistypically occurs in the setting of diabetes mellitus,chronic renal failure, and other pruritic conditions,and this case represents a rare association withdermatomyositis, which may ultimately be helpful inelucidating the pathophysiology of this perforatingdisorder.

[Acquired perforating dermatosis in the patient with chronic kidney disease – case report and literature review]

Acquired perforating dermatosis (APD) represents a heterogenous group of skin disorders characterized histopathologically by transepithelial elimination (TEE) of dermal structures. APD is manifested clinically as multi-localized, papulo-nodular skin lesions accompanied by a refractory pruritus. APD typically coexists with long-term disorders, most often diabetic kidney disease (DKD). The paper presents a case of a 56-year-old male patient with chronic kidney disease (CKD) and concomitant acquired reactive perforating collagenosis (ARPC), which is a subtype of APD. Etiological theories of ARPC as well as current diagnostic and treatment principles in dermatosis were described. On the basis of the presented case report and the literature review attention was paid to diagnostic difficulties associated with APD. The assumption was made that APD can be an underdiagnosed disease and thus it is not treated correctly. According to the authors’ opinion, this is an important circumstance to popularize the knowledge about APD.

The spectrum of lung involvement in collagen vascular-like diseases following allogeneic hematopoietic stem cell transplantation: report of 6 cases and review of the literature

Multisystem autoimmune diseases occurring after allogeneic hematopoietic stem cell transplantation are infrequent, late-onset manifestations that resemble well-defined collagen vascular disorders. Because the lung is frequently involved in the course of connective tissue disorders, we focused on lung manifestations occurring in autoimmune diseases following allogeneic stem cell transplantation. In the present series, we report 6 patients with systemic lupus erythematous, mixed connective tissue disease, Sjögren syndrome, polymyositis, and ANCA-positive vasculitis who presented with a spectrum of pulmonary manifestations affecting the airways, lung parenchyma, and probably respiratory muscles. We identified 3 different histopathologic patterns of interstitial pneumonia consistent with the underlying autoimmune disorder: lymphocytic interstitial pneumonia and non-specific interstitial pneumonia in 2 patients with Sjögren syndrome and diffuse alveolar damage in 1 patient with ANCA-positive vasculitis. These lung manifestations had poor prognoses. Further studies are needed to determine the optimal therapy for these complications.

[Acquired reactive perforating collagenosis: report of two cases]

Acquired reactive perforating collagenosis is a perforating dermatosis characterized by transepidermal elimination of collagen. It is frequently associated to diabetes mellitus and chronic renal insufficiency, but it is also related to other systemic diseases. The lesions tend to resolve once the underlying condition is treated. We report two patients with the condition. A 65 year-old diabetic female on hemodialysis consulted for multiple itching cutaneous ulcers lasting one year. On physical examination, hyperpigmented papules and nodules were observed. A 65 year-old female with chronic renal failure in hemodialysis consulted for itching lesions in hands, forearms and arms. On physical examination, hyperpigmented lesions with ulcers, erosions and crusts were observed. In both cases, the pathological study of the lesions disclosed a reactive perforating collagenosis.

[Historical review of rheumatology and future directions]

Rheumatic diseases are suggested to be recognized 2400 years ago, but little progress had been made in distinguishing specific diseases until the 17th century. After the two decades, the concept of rheumatic diseases was established and followed by the new concept of autoimmune diseases in the 20th century. Many key drugs for rheumatic diseases, such as glucocorticoids and immunosuppressants, were developed in the 1940s and 1950s. Their effect, toxicity and limitations have been investigated for fifty years. On the other hand, new treatment strategy was developed. Advances in genetics and molecular cell biology in the 1980s brought us the discovery of many cytokines and chemokines and elucidated the role of these molecules in autoimmune diseases. These progresses have led to the development of a number of biological agents for the rheumatic diseases during past decade. Among these drugs, TNF blockade showed the remarkable effectiveness in rheumatoid arthritis and this success indicated the new treatment era. However, compared to the simplicity of target molecules in monoclonal antibody therapy, biological effects are more complex. Therefore, we must keep in mind the possibility of the appearance of unexpected adverse effects such as TGN1412. This review presents a history of rheumatology and discusses future directions of basic and clinical research for rheumatic diseases.

Myocardial infarction secondary to premature coronary artery disease as the initial major manifestation of systemic lupus erythematosus

A 32-year-old woman admitted to the emergency department was diagnosed with acute anterior myocardial infarction, treated with thrombolytics and referred for angiography on the basis of her age. The patient was then referred for angioplasty with the diagnosis of an atherosclerotic lesion in the left anterior descending (LAD) coronary artery. Successful treatment of the lesion by primary stenting ensued. Laboratory findings revealed a state of hypercoagulability as well as some collagen fibre disease. The final diagnosis, confirmed by a rheumatologist, was systemic lupus erythematosus (SLE) with premature atherosclerosis of the LAD in addition to hypercoagulability. A Medline search of the literature revealed limited previous reports of myocardial infarction due to premature coronary artery disease as the first manifestation in SLE.

[Acquired reactive perforating collagenosis after curettage of seborrheic keratoses]

Acquired reactive perforating collagenosis (ARPC) developed in an 81-year-old woman two weeks after curettage of seborrheic keratoses. Treatment with allopurinol and antipruritic ointment was given. After four months, there was complete re-epithelialization, leaving atrophic scars.

Molecular pathogenesis of oral submucous fibrosis - a collagen metabolic disorder

Oral submucous fibrosis (OSF) is a chronic debilitating disease and a premalignant condition of the oral cavity. It is characterized by a generalized submucosal fibrosis. The pathogenesis of the disease is not well established. Epidemiological evidences strongly indicate the association of the betel quid (BQ) habit and OSF. Various findings indicate the disease to be a consequence of disturbances in the homeostatic equilibrium between synthesis and degradation of extracellular matrix (ECM), wherein collagen forms a major component, thus can be considered as a collagen-metabolic disorder. Transforming growth factor-beta (TGF-beta) is a potent stimulator of production and deposition of the ECM. The objectives of this review are to highlight the molecular events involved in the overproduction of insoluble collagen and decreased degradation of collagen occurring via exposure to BQ and stimulation of the TGF-beta pathway, and elucidate the cell signaling that is involved in the etiopathogenesis of the disease process.

Ochronotic arthropathy: arthroscopic findings in the shoulder and the knee

Ochronotic arthropathy is a disorder resulting from the deposition of homogentisic acid derivatives in the articular cartilage and the menisci. Large joints of the appendicular skeleton are preferentially affected. The clinical picture resembles that of degenerative joint disease. We present the arthroscopic findings in the shoulder and the knee in a 40-year-old man with ochronotic arthropathy and discuss the role of arthroscopy in the diagnosis and management of this rare metabolic disorder.

Pathologic evidence of degeneration as a primary cause of rotator cuff tear

Histopathologic, histochemical, and morphometric studies were done on 80 medial stumps of torn rotator cuff tendons to clarify the cause of tears. A high prevalence and diffuse distribution of degenerative changes were observed in the rotator cuff tendons including thinning and disorientation of collagen fibers, myxoid degeneration, hyaline degeneration, chondroid metaplasia, calcification, vascularproliferation, and fatty infiltration. No distinct inflammatory reaction was observed. Thinning and disorientation of collagen fibers, myxoid degeneration, and hyaline degeneration were seen in all cases. All changes except vascular proliferation and fatty infiltration were more pronounced in the middle to deep layers of the tendons than in the superficial layer. The collagen fibers were disoriented in the deep layer of the tendons, shown by microscopic image analysis. The frequency and distribution of thinning and disorientation of collagen fibers, myxoid degeneration, and hyaline degeneration suggest that these are early degenerative processes. Chondroid metaplasia and calcification may be chronic pathologic changes that occur after tearing regardless of the type of tear. Preexisting degenerative change in the middle and deep layers of the tendon in association with microtrauma seems to be the main cause of rotator cuff tears.

Acquired reactive perforating collagenosis in a nondiabetic hemodialysis patient: successful treatment with allopurinol

The authors present a case of acquired reactive perforating collagenosis developed in a nondiabetic hemodialysis patient, who was treated successfully with allopurinol. Treatment of acquired reactive perforating collagenosis is difficult and often ineffective. The patient had been unresponsive to conventional treatments, but the pruritus was controlled, and skin lesions subsequently resolved after the treatment with allopurinol. Possible mechanisms of allopurinol treatment for acquired reactive perforating collagenosis are discussed.

Koebnerization of reactive perforating collagenosis induced by laser hair removal

Laser hair removal, due to demonstrated efficacy and safety, has become a commonly performed office procedure. We report an unusual occurrence after laser hair removal with the 800 nm diode laser that previously has never been described. After laser hair removal treatment to the ventral surface of the ears, a patient developed lesions of previously diagnosed reactive perforating collagenosis. Interestingly, the lesions appeared on the dorsal surface of the ears. Perhaps the koebner phenomenon was invoked as the laser energy penetrated to the untreated dorsal surface, which was not protected by epidermal contact cooling.

[Vasculitis and collagenous-vascular involvement in association with sarcoidosis]

Sarcoidosis is a systemic granulomatous disorder of unknown origin. It unusually complicates systemic vascular involvement. We concisely review clinico-pathological findings of vascular involvement, including granulomatous angitis and microangiopathy. The clinical features of sarcoidosis may mimic those of many rheumatic disorders and sarcoidosis may coexist with autoimmune diseases. We review both rheumatologic manifestations, including bone, joint, and muscle of sarcoidosis and immunological findings of autoimmune diseases complicated with sarcoidosis, including 2-case reports of Sjögren's syndrome and dermatomyositis/polymyositis.

Acquired reactive perforating collagenosis

Acquired perforating disorder has been recognized as an uncommon distinct dermatosis in which altered collagen is eliminated through the epidermis. Several disorders accompanied by itching and scratching were reported to be associated with reactive perforating collagenosis. A 67-year-old white woman diagnosed as acquired reactive perforating collagenosis with poorly controlled diabetes mellitus and congestive cardiac failure is presented.

Frameshift mutation in the collagen VI gene causes Ullrich's disease

Patients with Ullrich's disease have generalized muscle weakness, multiple contractures of the proximal joints, and hyperextensibility of the distal joints. Recently, we found a deficiency of collagen VI protein in two patients with Ullrich's disease. In this study, we detected a homozygous 26 bp deletion in exon 14 of the collagen VI alpha 2 gene (COL6A2) in one patient. This mutation causes a frameshift and a premature termination codon, and results in a truncated collagen VI alpha 2 chain. Our data suggest that at least some cases of Ullrich's disease result from recessive mutations in COL6A2.

Injection site eosinophilic granulomas and collagenolysis in 3 horses

Three horses were presented with a history of having developed raised cutaneous nodules, within 24-48 hours, in areas of previous injections using standard silicone-coated hypodermic needles. Skin biopsies were taken from a selected cutaneous nodule from all horses for histopathologic evaluation. Histologically, the nodules were consistent with a diagnosis of equine eosinophilic granuloma. A hypersensitivity reaction to the silicone, or another component of the coating formulation, was hypothesized to be responsible for these lesions. Two horses were experimentally injected using both coated and noncoated stainless steel hypodermic needles and skin biopsies were obtained 14 days after injection. The sites of the coated needle injections were characterized by severe eosinophilic granulomatous inflammation with and without collagenolysis. The eosinophilic granulomas with and without collagenolysis observed in these horses are proposed to represent a complex immunologic response to the silicone-based coating of most hypodermic needles.

[Clinical findings and genetic bases of congenital complement deficiencies]

The clinical findings and genetic bases of inherited deficiencies of plasma complement components and complement control proteins are reviewed. In Japan, since the frequencies of late complement component deficiencies (LCCD) are high, clinical features of neisserial infections associated with LCCD are described in details. C 9 deficiency is one of the most frequent genetic disorders in Japan and most of them are healthy. However, C 9 deficiency is weakly but significantly associated with the development of meningococcal meningitis but not of systemic lupus erythematosus. The common Arg 95 Stop mutation was found in most individuals with C 9 deficiency. Molecular epidemiologic study revealed that homozygous and heterozygous Arg 95 Stop mutation of C 9 gene is found in approximately one of 1000 individuals and one of 15 individuals, respectively. Complement studies including C 9 antigen and DNA analyses should be performed in patients with meningococcal meningitis or recurrent bacterial infections.

Acquired reactive perforating collagenosis associated with diabetes mellitus: eight cases that meet Faver's criteria

Reactive perforating collagenosis (RPC) is characterized by umbilicated papules with a central adherent keratotic plug. Histologically, this condition shows transepidermal elimination of altered dermal collagen bundles into a cup-shaped epidermal depression. The present paper describes eight patients with associated diabetes mellitus who meet the diagnostic criteria for the acquired form of RPC (ARPC). Although half of these patients underwent dialysis, the lesions did not tend to develop after dialysis. Pruritus and the Koebner phenomenon were common, and histologically a microvasculopathy was noted in the dermis of all patients. We speculate that this disease is triggered by a cutaneous response to superficial trauma. Furthermore, this response acts synergistically with vasculopathy in the dermis, primarily in the case of diabetes mellitus. A secondary sign of ARPC may be degenerated collagen fibres as a result of transepidermal elimination.

[Chemokines and Chemokine receptors in collagen diseases]

The chemokine is a new class of cytokine. Now, more than 30 members of chemokine superfamily and 15 members of chemokine receptors (CXCR1-4, CCR1-8, CX3CR, CCR) have been identified. They were shown to be involved in the inflammatory response. The chemokine is classified into four subgroups (CXC, CC, C and CX3C). The local production of IL-8, MCP-1 and RANTES in rheumatoid inflamed joints has been reported. The predominance of several chemokines in other collagen diseases, such as SLE, systemic sclerosis and myositis is also described. Therefore, the inhibition of chemokines or chemokine receptors might be novel targets for various human disease, including collagen diseases.

[Role of adhesion molecules in the pathogenesis of collagen diseases]

Adhesion molecules play important roles and involve in many aspects of cell-cell or cell-extracellular matrix interactions in collagen diseases. In the present article, we describe the role of adhesion molecules in the pathogenesis of collagen diseases. Adhesion molecules on endothelial cells participate in leukocyte recruitment in collagen diseases. Adhesion molecules on RA synoviocytes which interact with MNCs and destroy chondrocytes by pannus formation. In PSS, adhesion molecules on fibroblasts play important roles to form fibrosis by interacting with MNCs or collagen fibrils. We further mention on adhesion molecules in interaction between MNCs and muscle fibers in myositis, those in vasculitis in SLE and other diseases, and autoantibodies inducing adhesion molecules on endothelial cells in PSS and Wegener's granulomatosis.