Christoph U. Brand

Cutaneous Leukocytoclastic Vasculitis in Dermatomyositis Suggests Malignancy

Background: Dermatomyositis (DM) is a rare connective tissue disease which has been shown to be associated with an underlying malignancy. Objective: Evaluation of the prevalence of malignancy in DM at our clinic and search for characteristics of the paraneoplastic form of disease. Methods: Retrospective review of patient files and histology reports over the period from 1991 to 1998. Results: 23 patients (14 women and 9 men) with DM could be identified in this time period with a median age at diagnosis of 48 years. Malignancies were found in 5 (22%) cases. The skin biopsies of all patients showed features of DM; in 7 cases, a leukocytoclastic vasculitis was detected. Four of the 5 cases with an associated malignancy demonstrated histologically a vasculitis in lesional skin, compared to only 3 out of 18 cases without malignancy (p < 0.05, Fisher’s exact test). Conclusion: Our data suggest that vasculitis in lesional skin biopsies has a predictive value for the presence of underlying malignancy.

Human afferent lymph from normal skin contains an increased number of mainly memory / effector CD4+ T cells expressing activation, adhesion and co-stimulatory molecules

We investigated the T cell population in the afferent lymph and the peripheral blood with regard to expression of activation, adhesion and co‐stimulatory molecules and cytokine profile by immunohistochemistry and flow cytometry. The majority of the lymphoid cell population in the afferent lymph were CD4+, CD45RO+ T cells expressing the α β TCR. An increased percentage of the T cells expressed activation molecules like HLA‐DR, CD25, CD26, CD69 as well as adhesion and co‐stimulatory molecules like CD54, CD154 / 40 ligand. Furthermore, T cells in the afferent lymph predominantly expressed the type 1 cytokine IFN‐γ, whereas type 2 cytokines such as IL‐4, IL‐5, IL‐10 were not or barely detectable. Interestingly, dendritic cells expressing IL‐12 were also found in close association with some lymphocytes, indicating that these contacts may be important in promoting Th 1 cells. In conclusion, an increased number of mainly CD4+ memory / effector T cells, expressing activation, adhesion and co‐stimulatory molecules migrate through the afferent skin‐derived lymph in humans. Furthermore, our data demonstrate the dominance of a type 1 cytokine profile in these T cells and suggest that they have an important function in the immune surveillance against pathogens or other antigens in the skin and its associated lymphoid tissue.

A Comparative Study of the Expression of Cytotoxic Proteins in Allergic Contact Dermatitis and Psoriasis: Spongiotic Skin Lesions in Allergic Contact Dermatitis Are Highly Infiltrated by T Cells Expressing Perforin and Granzyme B

Recent reports indicate that cytotoxic T cells are critically involved in contact hypersensitivity reactions in animals. In this study we sought to investigate the in vivo expression of cytotoxic granule proteins in the elicitation phase of allergic contact dermatitis in humans. Skin biopsy specimens were obtained from patients with allergic contact dermatitis (n = 8) and psoriasis (n = 6) and from controls with normal skin (n = 6). Expression of perforin and granzyme B was investigated by in situ hybridization and immunohistochemistry. In contrast to normal skin and psoriasis, a significant enhancement of perforin and granzyme B gene expression and immunoreactivity was observed in the mononuclear cell infiltrate of allergic contact dermatitis. Immunoreactivity for perforin and granzyme B was mainly found in the cytoplasm of lymphocytic cells, which were located in the dense perivascular infiltrate as well as at sites of marked spongiosis in the epidermis. Double immunostaining revealed that both CD4+ and CD8+ T cells are capable of expressing perforin and granzyme B. In conclusion, our data suggest that T-cell-mediated mechanisms involving cytotoxic granule proteins may elicit epidermal cell injury in vivo and thereby strongly contribute to the development of allergic contact dermatitis in humans.

Characterization of human skin-derived CD1a-positive lymph cells

Abstract The phenotype and function of CD1a + lymph cells is of considerable interest. By means of microsurgical lymph cannulation human lymph derived from normal skin was sampled. Cells were isolated and processed for immunocytochemistry, electron microscopy, flow cytometry and functional assays. The majority of the cells, (62%), were T cells. The other cells comprised CD1a + cells (7%), monocytes/macrophages (8%), and B cells (1%); the remainder were erythrocytes or uncharacterized cells. The CD1a + cells reacted with antibodies against protein S-100, HLA-DR, the Lag antigen, CD4, CD11a, CD11b, CD18, CD25, CD40, CD54, CD80 and CD86. Interestingly, a small prolow portion the of CD1a + cells (about 5%) reacted with an antibody to CD14. The CD1a + cells did not react with an antibody against human follicular dendritic cells nor were they CD19-, CD23-, E-cadherin- or factor XIIIa-positive. Both allogenic and antigen-specific T cell proliferation stimulated by antigen-presenting lymph cells were strongly inhibited by adding anti-CD80 and anti-CD86 antibodies. By electron microscopy Birbeck granules were detected in only 22% of the CD1a + lymph cells and these cells exhibited an extensive ruffling of the surface. These findings demonstrate that CD1a + lymph cells, which do not express the dermal dendritic cell marker factor XIIIa, resemble dendritic cells formerly designated as ‘veiled’ as well as lymphoid dendritic cells, suggesting that after migration to the regional lymphoid organs, Langerhans cells form a more differentiated population of dendritic cells specialized in sensitizing T lymphocytes. Our results add further support to the view that resident Langerhans cells may be precursors of lymphoid dendritic cells acquiring the final phenotype in the microenvironment of the lymph node.

Isolation of human skin-derived lymph: flow and output of cells following sodium lauryl sulphate-induced contact dermatitis

SummaryBy means of microsugery a peripheral subcutaneous lymph vessel draining a defined skin area was isolated and cannulated on the lower leg of six healthy volunteers. Lymph was collected over a period of 8 days. During the first 2 days baseline values for lymph flow and output of cells were established. A contact dermatitis was then induced in the drained skin area by the application of 10% sodium lauryl sulphate. All six probands developed a mild to moderate irritant contact dermatitis. Lymph flow as well as output of cells increased with the intensity of the skin reaction. Subsequent local treatment with clobetasol propionate decreased the cell output, but the lymph flow increased further. Neither lymph flow nor output of cells returned to the initial baseline values at the end of the study, when the clinical signs of contact dermatitis had completely disappeared. During the experiment significant individual variations were found, with means ranging from 0.10 to 0.48 ml/h for lymph flow and from 8700 to 174000/h for cells, which probably depended mainly on the different topographies and calibres of the cannulated lymph vessels.

Successful induction of immune responses against mutant ras in melanoma patients using intradermal injection of peptides and GM-CSF as adjuvant

Abstract: The rapidly increasing incidence and mortality rate of malignant melanoma, together with the lack of efficient treatment of the late stages, makes it a serious threat to public health. Innovative new treatments are needed. The proteins of the ras‐family of proto‐oncogenes, functioning as relay switches for signalling pathways between cell surface and nucleus, are involved in cell proliferation, differentiation, apoptosis and transformation. If over‐expressed or mutated they can induce and/or maintain a transformed state of a cell. Codon 61 mutations of N‐ras seem to be involved in melanoma development on sun exposed sites. In order to induce an immune response towards mutated N‐ras proteins we performed a phase 1 feasibility study. Ten melanoma patients were immunized intradermally 6 times with N‐ras peptides (residue 49–73) with 4 codon 61 mutations using GM‐CSF as adjuvant. HLA typing was not used as an inclusion criterion. Eight patients responded with strong delayed type hypersensitivity reactions. In 2 of the patients an in vitro response to the vaccine could also be detected. The specificity of the reaction could be confirmed by cloning of peptide‐specific CD4 positive T cells from peripheral blood of the patients. Intradermal injection of ras peptides using GM‐CSF as adjuvant is simple to perform and seems to be efficient in inducing cellular immune responses. Since a majority of the patients showed positive skin reactions and 2 of the patients analysed showed a T‐helper response to this melanoma specific antigen, these promiscuous HLA class II binding mutant ras peptides may be candidates for inclusion into vaccine cocktails containing various established CTL epitopes.

Medikamentös induziertes papulopurpurisches Gloves-and-socks-Syndrom

ZusammenfassungDer Begriff papulopurpurisches Gloves-and-socks-Syndrom wurde 1990 von Harms et al. geprägt. Er beinhaltet eine akute, febrile Dermatitis mit juckenden ödematösen Erythemen sowie konfluierenden Papeln und petechialen Hautveränderungen an Händen und Füßen in einer handschuh- bzw. sockenähnlichen Anordnung, meist begleitet von einem petechialen bis erosiven Enanthem. Als Auslöser wurden bisher v.a. virale Infekte insbesondere mit Parvovirus B19 diskutiert. Wir präsentieren einen klinisch typischen Fall eines Gloves-and-socks-Syndroms, der aufgrund einer nicht beabsichtigten Reexposition eine medikamentöse Induktion durch Trimethoprim/Sulfamethoxazol sehr wahrscheinlich macht.SummaryThe papular-purpuric ”gloves and socks” syndrome (PPGSS) was first described in 1990 by Harms et al. The syndrome is characterised by fever, an itchy erythema with edema, confluent papules and purpura of the hands and feet in a ”gloves and socks” distribution. The skin lesions may be associated with purpura and superficial erosions of the oral mucosa. Viral infections, in particular parvovirus B19, are the most likely trigger. In the present case PPGSS developed after taking trimethoprim/sulfamethoxazole. Since the patient developed identical symptoms after accidental re-challenge with the same drug, this case strongly suggests medications as another factor in the pathogenesis of PPGSS.

Cutaneous Nocardiosis Caused by Nocardia brasiliensis after an Insect Bite

We report the case of a primary lymphocutaneous nocardiosis occurring on the right calf of a healthy 56-year-old man after an insect bite. Analysis of the purulent exudate obtained from the nodule revealed Nocardia brasiliensis. The initial therapy with trimethoprim-sulfamethoxazole had to be stopped due to a drug eruption. However, with minocycline treatment the patient recovered within 5 weeks. Superficial (sporotrichoid) infections and a history of outdoor injury should be considered suspicious for cutaneous nocardiosis.

IL-12 gene expression in human skin-derived CD1a+ dendritic lymph cells

Recent reports point to a role for interleukin-12 (IL-12) in regulating T-and NK-cell function, macrophage activation and initiation of Th1-type cell responses. We sought to determine whether CD1a+ dendritic cells of the skin, as major antigen-presenting cells, are a source of IL-12 and therefore important in the initiation of Th1-type cell responses. To investigate this hypothesis, we cannulated microsurgically a skindraining lymph vessel in the lower legs of five healthy volunteers. Altogether, ten different samples, each consisting of 1×106 lymph cells, were investigated. In four of the ten samples. CD1a+ dendritic lymph cells were isoalted and purified by positive selection using mouse anti-CD1a monoclonal antibodies and sheep antimouse antibody-coated Dynabeads. Messenger RNA levels were estimated using a nested reverse transcriptase polymerase chain reaction (nRT-PCR) method. Total RNA was extracted from the cells, reverse transcribed to cDNA and amplified using specific primers for the target gene. Amplified products were sized by electrophoresis and visualized by ethidium bromide. Expression of IL-12 p40 and p35 mRNA was detected in all samples, both whole lymph samples and the highly enriched CD1a+ dendrictic cell population. Our findings demonstrate that human skin-derived CD1a+ dendritic lymph cells produce IL-12 mRNA and may therefore be an important source of IL-12. Thus one might speculate that these CD1a+ dendritic cells, through their IL-12-producing capacity, might significantly influence the balance of Th1 versus Th2 reactions ultimately occurring.

Human skin lymph derived from irritant and allergic contact dermatitis: Interleukin 10 is increased selectively in elicitation reactions

BACKGROUND Recent reports suggested an immunomodulatory role for interleukin 10 (IL-10) in contact hypersensitivity. OBJECTIVE To investigate if IL-10 is important in the regulation of irritant and allergic contact dermatitis (CD), IL-10 and interferon gamma (IFN-gamma) protein levels were measured in normal skin lymph, in lymph derived from irritant and allergic (primary sensitization and elicitation) CD and in skin blister fluid from an elicitation reaction. METHODS A superficial lymph vessel was cannulated microsurgically on the lower leg of 18 healthy volunteers. Lymph was collected twice daily. Protein levels of IL-10 and IFN-gamma were determined using commercially available ELISA kits and messenger RNA was estimated by a reverse-transcriptase polymerase chain reaction (PCR) method. RESULTS Whereas the IL-10 levels in lymph derived from irritant CD and primary sensitization of allergic CD, similarly to those obtained from normal untreated skin, remained below 4.4 pg/ml, the IL-10 levels increased manifold both in the primary allergic reaction (928.5 pg/ml) and the elicitation of allergic CD (124 pg/ml). The levels of IFN-gamma also increased in all volunteers exhibiting an eczematous skin reaction and showed a tendency to be inversely correlated with IL-10. Using a reverse-transcriptase PCR, the expression of IL-10 and IFN-gamma in cells from lymph and from blister fluid was examined. While signals for IFN-gamma were not found, specific transcripts for IL-10 were detected in all samples examined, indicating that cells circulating in the lymph may also contribute to the IL-10 production measured. The IL-10 mRNA signal, however, was markedly stronger in lymph and epidermal blister cells from the elicitation reactions as compared to the signal in lymph cells derived from normal skin and from the primary sensitization of allergic CD. CONCLUSION IL-10 may limit and down-regulate elicitation reactions by inhibiting cytokine and antigen-presenting cell functions in the skin and in the skin-associated lymphoid tissue.