Antonio Venier

Management of Recurrent Cutaneous Abscesses During Therapy With Infliximab

BACKGROUND Infliximab is a chimeric monoclonal antibody, belonging to the class of anti-tumor necrosis factor-α (TNF-α) agents, approved for the treatment of psoriasis and psoriatic arthritis. Drugs of this class are known to be associated with an infective risk, probably because they interfere with inflammatory and immune response at different levels. Although cutaneous Staphylococcus aureus infections seem to be more frequent than any other infection in the course of anti-TNF-α treatment, only a few case reports in the literature deal with this side effect, and, in particular, with its management. OBJECTIVE Our aim was to report a case of recurrent methicillin-sensitive S aureus (MSSA) cutaneous abscesses during therapy with infliximab and successful management. CASE SUMMARY In July 2009, a 53-year-old white woman (weighing 85 kg) affected by psoriasis and psoriatic arthritis was administered infliximab (5 mg/kg IV), based upon clinical appearance and previous unsuccessful treatment with cyclosporine, methotrexate, etanercept, and adalimumab. Three days after the first 3 infusions (at weeks 0, 2, and 6) she complained about the recurrent onset of painful, erythematous, indurated, and pus-draining cutaneous nodules located on her abdomen. The swab always revealed the presence of MSSA, and antibiotic oral therapy with amoxicillin + clavulanic acid (875 + 125 mg BID for 7 days) was established, with complete resolution of the abscesses. Routine laboratory findings were in normal ranges, with the exception of an elevated erythrosedimentation rate and an increased white blood cell count (range, 13,000-15,000/mm(3)) with neutrophilia (range, 75%-80%). HIV infection was ruled out. In agreement with the infectious disease consultant, 1 day before the fourth infusion, a prophylactic antibiotic therapy with amoxicillin + clavulanic acid (875 + 125 mg BID for 5 days) was added to the therapeutic regimen. This treatment schedule was successfully repeated at each following infusion (every 8 weeks), and no recurrence of skin abscesses was observed. The patient provided signed authorization for publication of this case. CONCLUSIONS This case report describes a woman with psoriasis and psoriatic arthritis who developed MSSA skin abscesses after each of the first 3 infliximab infusions, which did not recur for the next 6 infusions after amoxicillin + clavulanic acid was added to her regimen, pre- and 4 days postinfusion. Adequately designed, placebo-controlled, double-blind trials are needed to determine whether such prophylactic antibiotic treatment is well tolerated or effective for this common complication of therapy with anti-TNF-α agents, when withdrawal of the drug is not advisable, as in this case.

Non-Herlitz Junctional Epidermolysis bullosa without Hair Involvement Associated with BP180 Deficiency

Junctional epidermolysis bullosa (JEB) is a clinically and genetically heterogeneous recessively inherited blistering disease of the skin and mucous membranes due to impaired epithelial adhesion. In particular, defective expression of the 180-kD bullous pemphigoid antigen (BP180) has been correlated to a non-lethal (non-Herlitz) form of JEB, generalized atrophic benign epidermolysis bullosa (GABEB), characterized by widespread skin blistering healing with atrophy and by atrophic alopecia with onset in childhood. We report the case of a 33-year-old man suffering from a generalized blistering skin disorder since birth. He also presented nail dystrophy and tooth abnormalities. Mucosal involvement was limited to gingival erosion. Alopecia was absent and body, axillary and pubic hair were normal. Immunofluorescence analysis showed a markedly reduced expression of BP180, electron microscopy studies evidenced hypoplastic hemidesmosomes and Northern blot analysis confirmed a striking decrease in the amount of BP180 mRNA. The clinical features of our patient confirm that BP180 deficiency usually results in a non-Herlitz JEB form. However, the degree of skin, mucous membranes and hair involvement appears more variable and less typical than originally described for GABEB.

Enteric-coated mycophenolate sodium as a steroid-sparing agent in pemphigus treatment: a retrospective study

Several immunosuppressive drugs are used as steroid‐sparing agents in pemphigus vulgaris (PV) treatment, with the aim of reducing the cumulative dose of steroids and minimizing the side effects of long‐term steroid treatment. The objective of this study is to evaluate the efficacy and safety of enteric‐coated mycophenolate sodium (EC‐MPS) as a steroid‐sparing agent in PV patients. We performed a retrospective study on PV patients who had attended our dermatology department between October 2004 and December 2010 and who had been treated with a combined therapy of systemic corticosteroids and EC‐MPS. In the 16 enrolled patients, the introduction of EC‐MPS allowed the tapering of systemic corticosteroids, and in 12 of these patients, complete remission was achieved in the time of observation, on average in 4.3 months. Corticosteroid withdrawal was possible in two patients, and EC‐MPS was very well tolerated. No serious adverse events were recorded. EC‐MPS is a valid therapeutic opportunity as a steroid‐sparing agent in PV patients.

OKT4/OKT8 ratio and serum beta 2-microglobulin in mycosis fungoides and chronic benign dermatitis

Pre-treatment Serum Beta 2-microglobulin (S B2-m) and OKT4/OKT8 Ratio (T4/T8 R) were studied in 15 patients with Mycosis Fungoides (MF) and in 10 subjects with Chronic Superficial Benign Dermatitis (CSBD) in order to verify whether these parameters may lend support to an earlier differential diagnosis. S B2-m levels and T4/T8 R showed no significant difference in CSBD as compared to normal controls. MF patients displayed elevated S B2-m and T4/T8 R values in comparison to healthy controls and subjects suffering from CSBD (P less than 0.001). After photochemotherapy (PUVA), markedly decreased S B2-m and T4/T8 R values were observed in all patients but two who proved to be unresponsive to PUVA treatment. On the basis of reported data, S B2-m and T4/T8 R can be regarded as an additional tool to discriminate CSBD and MF when clinical and histological features are not significantly diagnostic. Finally, these parameters seem to provide reliable information in monitoring response to treatment.

Serum beta 2 microglobulin in psoriasis and psoriatic patients

Psoriatic patients may develop an acute destructive arthritis, with a mononuclear infiltration. Generally skin lesion precede the arthropathy [4]. Beta 2 microglobulin (B2m) is a low molecular weight protein synthesized in a relevant part by lymphocytes and reticulo-endothelial system [1]. The purpose of our study was to evaluate the behaviour of serum B2m in psoriasis and psoriatic patients. We examined the serum of 20 healthy donors (10 males and 10 females) and of 40 unconsecutive patients before any treatment: 30 patients affected by psoriasis (19 males and 11 females, aged 20 to 59) and 10 affected by psoriatic arthritis (3 males and 7 females, aged 38 to 56). Moll and Wrights criteria were applied for psoriatic arthritis diagnosis [3]. Patients with renal disease were excluded from the study. Serum concentration of B2m was determined by a solid phase radioimmunoassay (Pharmacia Diagnostic). Variance analysis and U-test were used to analyze the difference among groups. The mean values (_+ SD) of B2m obtained were: in normal controls 1.41 _+0.4, in psoriasis patients 1.58+_0.71 and psoriatic arthritis patients 2.93_+1.32 (Fig. 1). No difference was found between normal controls and psoriasis patients. On the other hand, psoriatic arthritis showed higher values of B2m in comparison to both normal controls (p<0.01) and psoriasis patients (p<0.01). In only 3 psoriasis patients the B2m level

Increased polymorphonuclear leukocyte Fc gamma-dependent chemiluminescence in active psoriasis is not related to FcRIII (CD 16) receptor expression

Abstract The role of the two main serum opsonins (IgG and C3b) in the induction of polymorphonuclear leukocyte chemiluminescence was studied in a group of psoriatic patients. Chemiluminescence was stimulated with zymosan opsonized by fresh plasma (IgG‐ and C3b‐dependent chemiluminescence) or by complement‐depleted plasma (IgG‐dependent chemiluminescence). While C3b‐dependent chemiluminescence was similar in patients with chronic or active forms of psoriasis. IgG‐dependent chemilumi‐nescence was significantly increased in patients with active disease. However, FcR‐III expression, evaluated by means of flow cytofluorimetry. was similar in the different groups of patients studied. The discrepancy between Fc‐receptor (CD 16) expression and IgG‐dependent chemilumi‐nescence is, therefore, indicative of modifications that occur in psoriatic neutrophils that do not involve FcIII‐receptor expression.