Eva Hadaschik

Autoantibodies in psoriasis as predictors for loss of response and anti‐infliximab antibody induction

Background  Infliximab is successfully used to treat psoriasis and psoriatic arthritis. However, some patients lose therapeutic response after several cycles. Antibodies to infliximab (infliximab‐Abs) are induced during treatment in a subgroup of patients and are thought to be associated with loss of response (LOR). Routine screening for infliximab‐Abs is expensive and not regularly performed. A reliable and affordable method for identifying patients who are at risk for LOR to infliximab is desirable.

Regulatory T cell-deficient scurfy mice develop systemic autoimmune features resembling lupus-like disease

IntroductionScurfy mice are deficient in regulatory T cells (Tregs), develop a severe, generalized autoimmune disorder that can affect almost every organ and die at an early age. Some of these manifestations resemble those found in systemic lupus erythematosus (SLE). In addition, active SLE is associated with low Treg numbers and reduced Treg function, but direct evidence for a central role of Treg malfunction in the pathophysiology of lupus-like manifestations is still missing. In the present study, we characterize the multiorgan pathology, autoantibody profile and blood count abnormalities in scurfy mice and show their close resemblances to lupus-like disease.MethodsScurfy mice have dysfunctional Tregs due to a genetic defect in the transcription factor Forkhead box protein 3 (Foxp3). We analyzed skin, joints, lung and kidneys of scurfy mice and wild-type (WT) controls by conventional histology and immunofluorescence (IF) performed hematological workups and tested for autoantibodies by IF, immunoblotting and enzyme-linked immunosorbent assay. We also analyzed the intestines, liver, spleen and heart, but did not analyze all organs known to be affected in scurfy mice (such as the testicle, the accessory reproductive structures, the pancreas or the eyes). We transferred CD4+ T cells of scurfy or WT mice into T cell-deficient B6/nude mice.ResultsWe confirm previous reports that scurfy mice spontaneously develop severe pneumonitis and hematological abnormalities similar to those in SLE. We show that scurfy mice (but not controls) exhibited additional features of SLE: severe interface dermatitis, arthritis, mesangioproliferative glomerulonephritis and high titers of anti-nuclear antibodies, anti-double-stranded DNA antibodies, anti-histone antibodies and anti-Smith antibodies. Transfer of scurfy CD4+ T cells (but not of WT cells) induced autoantibodies and inflammation of lung, skin and kidneys in T cell-deficient B6/nude mice.ConclusionOur observations support the hypothesis that lupus-like autoimmune features develop in the absence of functional Tregs.

European Guidelines (S1) on the use of high-dose intravenous immunoglobulin in dermatology.

The treatment of severe dermatological autoimmune diseases and toxic epidermal necrolysis (TEN) with high‐dose intravenous immunoglobulin (IVIg) is a well‐established procedure in dermatology. As treatment with IVIg is usually considered for rare clinical entities or severe clinical cases, the use of immunoglobulin is not generally based on data from randomized controlled trials that are usually required for the practice of evidence‐based medicine. Owing to the rarity of the indications for the use of IVIg, it is also unlikely that such studies will be available in the foreseeable future. Because the high costs of IVIg treatment also limit its first‐line use, the first clinical guidelines on its use in dermatological conditions were established in 2008 and renewed in 2011.

Analysis of high-dose intravenous immunoglobulin therapy in 16 patients with refractory autoimmune blistering skin disease: high efficacy and no serious adverse events.

High-dose intravenous immunoglobulin (IVIG) therapy is used in patients with severe autoimmune blistering diseases that are refractory to standard immunosuppressive therapy. To determine the efficacy and frequency of adverse events of IVIG therapy, we retrospectively analysed data for 16 patients with pemphigus vulgaris, pemphigus foliaceus, paraneoplastic pemphigus, bullous pemphigoid and paraneoplastic bullous pemphigoid. Frequency of adverse reactions and efficacy of IVIG were analysed over time with a scoring system for every 6 months of IVIG therapy. Headache (43.8%) and fatigue (43.8%) were the most common side-effects recorded; serious adverse reactions did not occur. There was good overall efficacy, as measured by clinical response rates using a clinical score, as well as indicated by a mean reduction of 75.8% in the starting steroid dose.

Diagnostics of autoimmune bullous diseases in German dermatology departments.

Background: No consistent data are available on the currently employed diagnostic tools for autoimmune bullous diseases in Germany. The aim of this survey was to describe currently performed diagnostic methods for bullous autoimmune diseases in German dermatology departments.

TGF-β1-induced regulatory T cells.

Besides central tolerance peripheral tolerance is an important mechanism to avoid development of autoimmunity. Naturally occurring thymic-derived regulatory T cells (nTreg) mediate peripheral tolerance by suppressing autoreactive T cells clones having escaped thymic deletional control. This implies that nTreg have therapeutic potential to dampen autoimmune disease. However, one of the main challenges for the therapeutic application of nTreg still remains the scarce amount of nTreg available. Transforming growth factor beta (TGF-β1) plays a critical role in the generation and immunosuppressive function of nTreg thereby contributing to immune homeostasis. TGF-β1 is thought to be essential for the generation and function of nTreg and regulatory T cells with suppressive properties can be induced in vitro by TGF-β1. These so-called TGF-β1-induced regulatory T cells (iTreg) can be induced in vitro from conventional CD4(+) T cells by addition of TGF-β1 and this discovery has added new options to use regulatory T cells therapeutically. Here we discuss the generation and in vitro and in vivo functions of murine and human TGF-β1-induced regulatory T cells in light of potential application as treatment for autoimmune diseases including current problems and drawbacks in their therapeutic use.

Seroprevalence of molluscum contagiosum virus in German and UK populations

Molluscum contagiosum virus (MCV) is a significant but underreported skin pathogen for children and adults. Seroprevalence studies can help establish burden of disease. Enzyme linked immunosorbent assay (ELISA) based studies have been published for Australian and Japanese populations and the results indicate seroprevalences between 6 and 22 percent in healthy individuals, respectively. To investigate seroprevalence in Europe, we have developed a recombinant ELISA using a truncated MCV virion surface protein MC084 (V123-R230) expressed in E. coli. The ELISA was found to be sensitive and specific, with low inter- and intra-assay variability. Sera from 289 German adults and children aged 0–40 years (median age 21 years) were analysed for antibodies against MC084 by direct binding ELISA. The overall seropositivity rate was found to be 14.8%. The seropositivity rate was low in children below the age of one (4.5%), peaked in children aged 2–10 years (25%), and fell again in older populations (11–40 years; 12.5%). Ten out of 33 healthy UK individuals (30.3%; median age 27 years) had detectable MC084 antibodies. MCV seroconversion was more common in dermatological and autoimmune disorders, than in immunocompromised patients or in patients with multiple sclerosis. Overall MCV seroprevalence is 2.1 fold higher in females than in males in a UK serum collection. German seroprevalences determined in the MC084 ELISA (14.8%) are at least three times higher than incidence of MC in a comparable Swiss population (4.9%). While results are not strictly comparable, this is lower than Australian seroprevalence in a virion based ELISA (n = 357; 23%; 1999), but higher than the seroprevalence reported in a Japanese study using an N-terminal truncation of MC133 (n = 108, 6%; 2000. We report the first large scale serological survey of MC in Europe (n = 393) and the first MCV ELISA based on viral antigen expressed in E. coli.

High levels of β2‐adrenoceptors are expressed in infantile capillary hemangiomas and may mediate the therapeutic effect of propranolol

To the Editor, Infantile capillary hemangiomas are tumors of endothelium with small vascular lumina and a lobated configuration. Although benign in nature, they may cause disfigurement and hemorrhage, and therefore patients with proliferative hemangiomas are referred for treatment. In 2008, propranolol was been introduced as a new systemic treatment option for infantile capillary hemangiomas and has shown convincing results to date.1 Propranolol is a well-known competitive, nonselective β-adrenergic antagonist. However, the mechanism of action in hemangiomas has not yet been elucidated. β2-Adrenoceptors are known to be the dominating adrenergic receptors on peripheral vessel endothelium.2 Infantile hemangiomas treated with propranolol regularly pass through different stages of involution: they turn brighter and softer, then they stop to grow within months and finally regress.2 It was hypothesized that these phenomena are caused by vasoconstriction, inhibition of angiogenesis and induction of apoptosis. All of these mechanisms are mediated by the inhibition of β2adrenoceptors by propranolol. The aim of this study was to analyze the expression and localization of β2adrenoceptors in infantile capillary hemangiomas in comparison to senile hemangiomas to further elucidate the mechanism of action of propranolol in the treatment of hemangiomas. Therefore we examine the expression of β2-adrenoceptors in infantile hemangiomas by immunohistochemical staining and compare the expression pattern with senile hemangiomas. The average age of the patients at the time of hemangioma surgery was 2.6 months (range: 2–12 months). None of the patients was on medication with beta blockers. Localizations of hemangiomas were head, trunk and upper extremities (data not shown). The average age of the patients with senile hemangiomas was 52.9 (range: 15–87 years). Diagnosis of infantile hemangiomas was confirmed by positive staining for glucose transporter 1 (Glut-1)3 in all cases (Fig. 1F). Both infantile and senile hemangiomas express β2-adrenoceptors (Fig. 1A–D), the isotype control was negative, indicating that staining was specific (Fig. 1E). However, infantile hemangiomas show a stronger staining for β2-adrenoceptors in comparison to senile hemangiomas (Fig. 1A–D). In both tumor entities staining was mainly detectable on endothelial cells of the vascular proliferates (Fig. 1). This finding was confirmed by CD31 and CD34 staining in several infantile hemangiomas (data not shown). To quantitatively compare the expression of β2adrenoceptors in both tumor entities, samples were stained and evaluated using the scoring system as described in the figure legend. All samples were additionally evaluated by hematoxylin and eosin staining (H&E) and several hemangiomas were exemplarily stained with CD31 and CD34 in parallel to differentiate endothelial cells from connective tissue cells. Representative examples for the different staining intensities in infantile hemangiomas are shown in Fig. 2. We found a significant difference in staining scores between infantile and senile hemangiomas (Fig. 2D). Infantile capillary hemangiomas express high levels of β2-adrenoceptors, which

Alopecia areata during treatment with adalimumab: therapy with an alternative TNF‐alpha inhibitor is possible

A 46-year-old woman developed alopecia areata (AA) for the fi rst time while being treated with adalimumab (Humira®). The patient was diagnosed at age 18 with psoriasis vulgaris, and in 2007 with psoriatic arthritis; she did not have any nail changes. After several systemic treatments (PUVA, MTX, and lefl unomide) had to be discontinued due to various side effects, we started adalimumab 40 mg subcutaneously every 2 weeks in March 2009 (PASI: 11.3). Within 3 months there was complete remission of skin lesions and joint symptoms. Six months after starting adalimumab, the patient reported the appearance of bald patches on her scalp. No scarring or redness was found (Figure 1a). Laboratory values, including thyroid parameters, hormone levels (TSH, fT3, fT4, estradiol, testosterone), and autoantibodies (ANA, dsDNA) were all unremarkable. There was no alopecia, autoimmune disease, or atopic diathesis (no allergic rhinocunjunctivitis or bronchial asthma; IgE was within normal ranges) in the family history and the patient’s medical history. Based on the clinical picture, we diagnosed AA caused by adalimumab. Given that the patient did not fi nd her condition severe, we continued adalimumab and added topical class III steroids for 7 months. Over the following months, the AA progressed signifi cantly (Figure 1b, c), which led us to discontinue adalimumab. About 6 months after stopping treatment, there was further expansion of areas affected by alopecia, but there was also re-growth of fi ne white hairs. The symptoms later improved, although some of the hair was still lacking pigmentation (Figure 1d). Complete remission Clinical Letters

Interindividual variation of NETosis in healthy donors: introduction and application of a refined method for extracellular trap quantification

Neutrophil extracellular trap (NET) formation is a mechanism of innate immune defence by which neutrophil (polymorphonuclear) granulocytes (PMN) produce net‐like structures of decondensed chromatin decorated with antimicrobial peptides for trapping and possibly killing microorganisms. If this process leads to cell death, it is termed NETosis. Alterations of this particular mechanism have been reported to be involved in the pathogenesis of chronic inflammatory diseases including psoriasis and lupus erythematosus. Still, quantification of NETosis poses a considerable challenge. We report and test a refined protocol for morphological NET quantification in healthy human donors that encompasses isolation, stimulation, DNA staining, live imaging and semi‐automated offline analysis. The results were highly reproducible and in good agreement with manual counting. The average intra‐donor coefficient of variation of NETosis rates to phorbol myristate acetate (PMA) stimulation was low compared to the respective interdonor coefficient of variation (10% vs 82%, n=4, respectively, if experiments were repeated on the same day, and 38% vs 74%, n=6, respectively, if experiments were repeated on average 42±34 days apart). Overall, the interdonor coefficient of variation was 67% (n=10). These findings altogether support the existence of a distinct predisposition of PMN from different donors for undergoing NETosis. Picogreen fluorescence correlated stronger to cell death than to morphological NETosis (r2=.89, P<.001, n=8, and r2=.68, P=.012, n=8, respectively). This indicates that cytotoxicity may confound Picogreen fluorescence. Our results and the related protocol may help investigators with the quantification of NETosis and the design of respective basic and translational research studies.