Associations of HLA-C*01:02 and HLA-B*46:01 with regorafenib-induced erythema multiforme in Japanese patients with metastatic colorectal cancer

Regorafenib improves the survival of patients with metastatic colorectal cancer (mCRC); however, it is also characterized by detrimental dermal side effects that may require treatment cessation or modified dosing. In our previous prospective pharmacokinetic, pharmacodynamic, and pharmacogenetic studies, 17.5% (7/40) of the patients with mCRC had grade 3 erythema multiforme (EM) that caused treatment discontinuation. Haplotypes in genes encoding human leukocyte antigen (HLA) are associated with EM following the administration of drugs, such as allopurinol. This study examined the association between HLA haplotypes and regorafenib-induced EM. Regorafenib was administered orally at 160 mg/body once daily for weeks 1-3 of each 4-week cycle. To determine the HLA haplotypes, we used the WAKFlow HLA Typing Kit HLA-A, -B, or -C. The carrier frequency of HLA-C*01:02 in patients with EM (6/7) was higher than that in tolerant controls (8/33; odds ratio [OR] = 18.8, 95% confidence interval [CI] = 1.95-180, p = 0.00437). HLA-B*46:01 was also associated with EM (OR = 11.6, 95% CI = 1.47-92.1, p = 0.0299). These associations were no longer significant after Bonferroni correction for multiple testing. Therefore, regorafenib-induced EM in Japanese patients appears to be associated with specific HLA haplotypes but further validation is needed.

[Effect of proteflazid on TLRs expression by mononuclear leukocytes of peripheral blood and epithelial cells of mucous membranes and skin in patients with herpes-associated erythema multiforme and erythema annulare centrifugum]

The article reports survey data on 23 patients with erythemas, including 19 patients with herpes-associated erythema multiforme (HAEM) and 4 patients with Darier's erythema annulare centrifugum (DEAC). Patients in the initial state (baseline) and after two weeks of therapy with proteflazid were characterized by measuring the levels of Toll-like receptor (TLR) expression in peripheral blood mononuclear cells (PBMC) and in epithelial cells of the throat and the skin. The TLR expression in PBMC and skin was assessed by flow cytometry with monoclonal antibodies (ICA) (Caltag Laboratories, USA; Hycult Biotech, Netherlands) against relevant antigens. In addition, patients were also characterized by the content of subpopulations of lymphocytes expressing surface markers CD3, CD4, CD8, CD16, CD21, CD23, CD72, CD25, and HLA-DR in the peripheral blood, which was measured by flow cytometry. The therapy with proteflazid in patients with both HAEM and DEAC led to normalization of the level of both T-cell and B-cell immunity, which was manifested by an increase in the total number of lymphocytes, CD3+, CD4+, CD21+, and CD72+. Measurements of the dynamics of TLR expression in the course of immunotherapy showed an increase in the number of TLR 2, 3, 4, 7, 8, and 9 in PBMC (which was especially pronounced for TLR2) and in epithelium of the pharyngeal mucosa and skin (increased expression of TLR3, 7, and 9).

Toll-like receptor 9 polymorphism in patients with erythema multiforme, Stevens Johnson syndrome and Stevens Johnson syndrome/toxic epidermal necrolysis overlap syndrome

BACKGROUND

"Toll like receptor" (TLR) 9 functions in stepping in of native immune system against different viral and bacterial pathogens and induction of adaptive immune response effectively. TLR 9 gene polymorphism makes host predisposed to microbial pathogens by affecting thefunctional capabilities of the receptor.

OBJECTIVE

We aimed to determine if TLR 9 gene polymorphism makes a predisposition to "erythema multiforme" (EM), "Stevens Johnson syndrome" (SJS) and "Stevens Johnson syndrome/toxic epidermal necrolysis overlap syndrome" (SJS/TEN).

METHODS

Forty-two patients clinically and/or histopathologically diagnosed as EM, SJS, and SJS/TEN overlap syndrome and 50 healthy control subjects were enrolled in our study. Polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) method was applied for TLR 9 gene 1237 thymine/cytosine (T/C) polymorphism. Genotypes were determined according to bands occurring on agarose gel electrophoresis.

RESULTS

In patients group, the frequencies of TT and TC genotypes were 73.8% and 26.2% while CC genotype wasn't detected. In control group, the frequencies of TT, TC and CC genotypes were 74%, 24%, and 2%. There wasn't a statistically significant difference for TT, TC and CC genotypes between patients and controls. The frequencies of T and C alleles were 84.5% and 15.5% in patients and 86% and 14% in controls, respectively.

CONCLUSION

Our results showed that there isn't any association between TLR gene polymorphism and EM, SJS, SJS/TEN overlap syndrome (Tab. 1, Fig. 1, Ref. 30).

The Herpes simplex virus gene Pol expressed in herpes-associated erythema multiforme lesions upregulates/activates SP1 and inflammatory cytokines

BACKGROUND/AIMS

Herpes-simplex-virus-associated erythema multiforme (HAEM) is characterized by lesional skin expression of the viral protein Pol and localized inflammation. The objective of this study is to examine the mechanism whereby Pol induces localized inflammation.

METHODS

A431 cells transfected with Pol or an empty vector and lesional skin from HAEM or drug-induced erythema multiforme patients were examined for expression of the transcription factor SP1 and SP1-regulated genes by immunoblotting, immunohistochemistry and immunofluorescence.

RESULTS

SP1, TGF-beta, p21(waf1) and Hsp27 were upregulated in A431 cells transfected with Pol but not the empty vector. Expression was further increased by exposure to IFN-gamma. Pol+ HAEM lesional skin expressed SP1, Hsp27, TGF-beta and p21(waf1). Normal skin and drug-induced erythema multiforme lesional skin were negative.

CONCLUSION

The data indicate that Pol activates SP1, causing upregulation of SP1 target genes (notably TGF-beta) involved in localized inflammation. Upregulation is potentiated by IFN-gamma.

CD34+ cells in the peripheral blood transport herpes simplex virus DNA fragments to the skin of patients with erythema multiforme (HAEM)

Herpes simplex virus (HSV)-associated erythema multiforme (HAEM) is a recurrent disease characterized by the presence and expression of HSV DNA fragments in lesional skin. Our studies examined the mechanism of viral DNA transport to the skin of HAEM patients. CD34+ cells were isolated from the blood of normal subjects and HSV and HAEM patients during acute lesions and at quiescence. They were cultured with cytokines that favor their differentiation into Langerhans cells (LC) precursors (CD1a+/CD14-) and examined for HSV replication, HSV-induced cellular alterations, viral DNA fragmentation, and clearance. CD34+ cells from all study groups were non-permissive for HSV replication but infection favored their differentiation into CD1a+/CD14- LC precursors and upregulated E-cadherin expression, thereby assisting LC targeting to the skin. Only HAEM patients had CD34+ cells that retained viral DNA fragments, notably polymerase DNA, for at least 7 d of in vitro culture. The percentages of circulating CD34+ (and CD34+/CLA+) cells were significantly higher in HAEM patients at the time of acute lesions. A similar increase was not seen for HSV patients. The data are the first report implicating CD34+ cells in HAEM pathogenesis, likely by transporting HSV DNA fragments to lesional skin.

CC and CXC chemokines are differentially expressed in erythema multiforme in vivo

BACKGROUND

A characteristic feature of erythema multiforme is an acute inflammatory reaction of the skin with an infiltrate largely composed of mononuclear cells around the upper dermal vessels and in the dermal-epidermal interface.

OBJECTIVE

To determine the composition and localization of leukocyte subsets and corresponding expression of chemokines with chemoattractant properties for lymphocytes and macrophages.

MATERIALS AND METHODS

Immunohistochemical analysis was performed to localize leukocyte subsets (CD1(+), CD3(+), CD4(+), CD8(+), and CD68(+)). Expression of transcripts and proteins of chemokines (macrophage chemoattractant protein [MCP] 1); macrophage inflammatory protein [MIP] 1 alpha and MIP-1 beta; regulated on activation, normal T-cell expressed and secreted [RANTES]; growth-related oncogene alpha; epithelial-derived neutrophil attractant 78; interleukin 8; macrophage interferon-gamma inducible gene [Mig]; and interferon-gamma inducible protein 10) was determined by in situ hybridization and immunohistochemical analysis.

SETTING

Department of Dermatology, University of Würzburg Medical School.

RESULTS

High levels of messenger RNA expression of MCP-1, RANTES, Mig, and interferon-gamma inducible protein 10 were detected and localized in the interface zone and subepidermal infiltrate. In contrast, other investigated chemokines (growth-related oncogene alpha, interleukin 8, epithelial-derived neutrophil attractant 78, I-309, MIP-1 alpha, and MIP-1 beta) were minimally expressed or absent. Protein expression of MCP-1, RANTES, Mig, and interferon-gamma inducible protein 10 was high in the interface zone and low in the subepidermal infiltrate. The messenger RNA expression and protein immunoreactivity patterns overlapped. According to the expression profiles, Mig, interferon-gamma inducible protein 10, MCP-1, and RANTES were expressed by basal keratinocytes above and mononuclear cells within the inflammatory foci.

CONCLUSION

These cytokines are important agents in the cytokine network and contribute to the cell-specific and spatially restricted recruitment of mononuclear cells in the acute inflammation of erythema multiforme lesions.

[Erythema multiforme. A heterogeneous pathologic phenotype]

The term Erythema Multiforme (EM) include actually a wide range of clinical expressions, from exclusive oral erosions (Oral EM) to mucocutaneous lesions (EM Minor), sometimes with severe involvement of multiple mucosal membrane (EM major, Stevens-Johnson syndrome [SJS]) or with involvement of a large area of the total body surface (toxic epidermal necrolysis [TEN]). However, this terminology is not worldwide accepted and often the various clinical categories show some overlapping features. Among the great number of suspected etiological factors, herpes simplex virus is involved in many cases of EM minor whereas SJS and TEN are caused in 80% of cases by systemic drugs, mainly by anticonvulsivants, sulfonamides, nonsteroidal anti-inflammatory drugs and antibiotics. Several oral EM seem idiopathic, but data on this topic are very few. There is no specific or consistent microscopic and immunopathologic pattern of EM and the diagnosis should be done by excluding other similar diseases. The treatment include the use of antivirals for EM minor, mainly if recurrent, and of immunosuppressants (especially systemic corticosteroids) for SJS. TEN patients require adequate supportive care and often they have to be treated in emergency departments. Finally, patients with exclusive oral lesions may be treated with both topical and systemical corticosteroids.

Recurrent herpes simplex virus-induced erythema multiforme: different HLA-DQB1 alleles associate with severe mucous membrane versus skin attacks

In some individuals a local herpetic lesion precipitates a generalized inflammation of the skin, designated as erythema multiforme (EM). We determined the frequencies of the immune response genes of the HLA system by molecular HLA class II typing in 46 patients with EM and in many of their family members. Allele frequencies were correlated with disease form and disease-inducing factors. We found that specific complications of HSV infection occur preferentially in patients with certain HLA-DQB1 alleles. In 21 of the 46 patients EM was induced by recurrent HSV infection. Thirteen of these patients showing only minor or no involvement of mucous membranes had the HLA allele DQB1*0302 (phenotype frequency 61.9% versus 18.8% in controls, p corr = 0.0008) and all three patients with major involvement of mucous membranes had the rare HLA allele DQB1*0402 (phenotype frequency in controls 6,4%, p corr = 0.017).

Increased expression of vascular permeability factor (vascular endothelial growth factor) in bullous pemphigoid, dermatitis herpetiformis, and erythema multiforme

Vascular permeability factor (VPF), also known as vascular endothelial growth factor (VEGF), plays an important role in the increased vascular permeability and angiogenesis associated with many malignant tumors. In addition, VPF/VEGF is strongly expressed by epidermal keratinocytes in wound healing and psoriasis, disorders that are also characterized by increased microvascular permeability and angiogenesis. In this study, we investigated the expression of VPF/VEGF in three bullous diseases with subepidermal blister formation that are characterized by hyperpermeable dermal microvessels and pronounced papillary dermal edema. The expression of VPF/VEGF mRNA was strongly up-regulated in the lesional epidermis of bullous pemphigoid (n = 3), erythema multiforme (n = 3), and dermatitis herpetiformis (n = 4) as detected by in situ hybridization. Epidermal labeling was particularly intense over blisters, but strong expression was also noted in areas of the epidermis adjacent to dermal inflammatory infiltrates at a distance from blisters. Moreover, the VPF/VEGF receptors, flt-1 and KDR, were up-regulated in endothelial cells in superficial dermal microvessels. High levels of VPF/VEGF (138-238 pM) were detected in blister fluids obtained from five patients with bullous pemphigoid. Addition of blister fluid to human dermal microvascular endothelial cells exerted a dose-dependent mitogenic effect that was suppressed after depletion of VPF/VEGF by immunoadsorption. These findings strongly suggest that VPF/VEGF plays an important role in the induction of increased microvascular permeability in bullous diseases, leading to papillary edema and fibrin deposition and contributing to the bulla formation characteristic of these disorders.

HLA DQB1*0301 allele is involved in the susceptibility to erythema multiforme

Erythema multiforme (EM) is an acute, episodic inflammatory disorder of the skin and mucous membranes of various etiology that could be related to immunologic hypersensitivity response. EM has been previously reported to be associated with serologically defined HLA-DRw53 and DQw3 antigens. In this report, we reevaluate the role of HLA class II alleles in EM manifestations. With use of the polymerase chain reaction, followed by sequence-specific oligonucleotide hybridization, 35 unrelated Caucasian EM patients and 80 randomly selected healthy subjects were studied, and the DRB3, DRB4, DQA1, and DQB1 alleles were analyzed. The comparison of frequencies of these alleles indicates that (i) susceptibility to EM disease is more associated with the HLA-DQ than the HLA-DR subregions and (ii) that the DQB1*0301 is the most frequent allele among EM patients. Sixty-six percent of the patients had the DQB1*0301 allele compared to 31% of the controls (RR = 4.1; p less than 0.001). An even stronger DQB1*0301 association was found in the patient group with herpes-associated EM (76%; RR = 6.5; p less than 0.001). Our data demonstrate a clear association between an HLA-DQB1 allele and susceptibility to EM.

[HLA pattern in patients with post-herpetic erythema exsudativum multiforme]

33 patients suffering from postherpetic erythema multiforme (PEM) were investigated with special reference to histocompatibility typing. In comparison with a control group (n = 54), we found strikingly high levels of HLA-DR1 and HLA-DR4 as well as a significantly elevated level of HLA-Cw3 in our patients (p less than 0.01).

Erythema multiforme is associated to HLA-Aw33 and DRw53

Erythema multiforme is an acute eruption of the skin and mucous membranes of various aetiologies. Forty-one unrelated patients were HLA typed for 53 specificities of the HLA-A, B, C, DR and DQ series. Frequencies of Aw33 and DRw53 were significantly increased: Aw33, 17.0% in patients vs 2.8% in controls (corrected p = 0.01, relative risk = 7.2); DRw53, 70.7% in patients vs 30.5% in controls (corrected p = 0.0005, relative risk = 5.5).

Erythema gyratum perstans: association with a familial neurologic disease

Two members of the same family with erythema gyratum perstans and hypertrophic neuritis are reported. The dermatosis could be an expression of localization of neuritis to nerva vasorum with abnormal neurovascular response of cutaneous small vessels to normal stimuli with active erythema followed by cyanosis.

HLA-B15 association with erythema multiforme

Erythema multiforme (EM) is a cutaneous reaction pattern which follows numerous infections, drugs, neoplastic and inflammatory disorders in some individuals. We undertook a prospective study of thirty-eight HLA specificities of the -A, -B, and -C series in 16 Caucasian patients with EM and in 140 local Caucasian controls. Seven of 16 patients (44%) with EM and 5 of 9 patients (55%) with EM following herpes simplex infections possessed the HLA-B15 antigen, compared to 7% of local controls and 11.6% of the 1980 WHO Workshop Caucasian controls. Both associations were highly significant (p = 0.0125 and p = 0.02) when corrected for 38 HLA antigens. This is the first reported HLA association for erythema multiforme, a disease which may be a host-specific immune response to various antigens, determined in part by genes linked to HLA-B15.

[Juvenile atrophying erythema multiforme]

This is a case report of an Atrophic Juvenile Erythema Multiform that has occurred in a ten year old white girl. She has been having symptoms since age three, presenting severe flares of lesions that looked like multiform erythema. When the lesions healed a loose scar was left involving the whole skin. Some of the histological and pathogenic mechanisms of the disease are discussed.