Haley B. Naik

Severity of Psoriasis Associates With Aortic Vascular Inflammation Detected by FDG PET/CT and Neutrophil Activation in a Prospective Observational Study

Objective—To understand whether directly measured psoriasis severity is associated with vascular inflammation assessed by 18F-fluorodeoxyglucose positron emission tomography computed tomography. Approach—In-depth cardiovascular and metabolic phenotyping was performed in adult psoriasis patients (n=60) and controls (n=20). Psoriasis severity was measured using psoriasis area severity index. Vascular inflammation was measured using average aortic target-to-background ratio using 18F-fluorodeoxyglucose positron emission tomography computed tomography. Results—Both the psoriasis patients (28 men and 32 women, mean age 47 years) and controls (13 men and 7 women, mean age 41 years) were young with low cardiovascular risk. Psoriasis area severity index scores (median 5.4; interquartile range 2.8–8.3) were consistent with mild-to-moderate skin disease severity. Increasing psoriasis area severity index score was associated with an increase in aortic target-to-background ratio (&bgr;=0.41, P=0.001), an association that changed little after adjustment for age, sex, and Framingham risk score. We observed evidence of increased neutrophil frequency (mean psoriasis, 3.7±1.2 versus 2.9±1.2; P=0.02) and activation by lower neutrophil surface CD16 and CD62L in blood. Serum levels of S100A8/A9 (745.1±53.3 versus 195.4±157.8 ng/mL; P<0.01) and neutrophil elastase-1 (43.0±2.4 versus 30.8±6.7 ng/mL; P<0.001) were elevated in psoriasis. Finally, S100A8/A9 protein was related to both psoriasis skin disease severity (&bgr;=0.53; P=0.02) and vascular inflammation (&bgr;=0.48; P=0.02). Conclusions—Psoriasis severity is associated with vascular inflammation beyond cardiovascular risk factors. Psoriasis increased neutrophil activation and neutrophil markers, and S100A8/A9 was related to both skin disease severity and vascular inflammation.

AUTOINFLAMMATORY PUSTULAR NEUTROPHILIC DISEASES

This article provides a new categorization of inflammatory pustular dermatoses in the context of recent genetic and biological insights. Monogenic diseases with pustular phenotypes are discussed, including deficiency of interleukin 1 receptor antagonist, deficiency of the interleukin 36 receptor antagonist, CARD14-associated pustular psoriasis, and pyogenic arthritis, pyoderma gangrenosum, and acne. How these new genetic advancements may inform how previously described pustular diseases are viewed, including pustular psoriasis and its clinical variants, with a focus on historical classification by clinical phenotype, is also discussed.

Psoriatic arthritis and sacroiliitis are associated with increased vascular inflammation by 18-fluorodeoxyglucose positron emission tomography computed tomography: baseline report from the Psoriasis Atherosclerosis and Cardiometabolic Disease Initiative

IntroductionPsoriasis and psoriatic arthritis (PsA) increase cardiovascular disease (CVD) risk, but surrogate markers for CVD in these disorders are inadequate. Because the presence of sacroiliitis may portend more severe PsA, we hypothesized that sacroiliitis defined by computed tomography (CT) would be associated with increased vascular inflammation defined by 18-fluorodeoxyglucose-positron emission tomography/computed tomography (FDG-PET/CT), which is an established measure of CVD.MethodsParticipants (n = 65) underwent whole-body FDG-PET/CT. Metabolic activity of the aorta was measured using the maximal standardized uptake value (SUVmax), a measure of atherosclerotic plaque activity. The primary outcome was aortic vascular inflammation. Linear regression (with β-coefficients (β) and P-values reported for PsA and sacroiliitis) was used to adjust for CVD risk factors to determine associations of PsA or sacroiliitis with vascular inflammation. Likelihood ratio testing was performed to evaluate the contribution of sacroiliitis to vascular disease estimation compared to the effects of PsA and traditional CVD risk factors.ResultsVascular inflammation (measured as SUVmax) was greater (P < 0.001) in patients with sacroiliitis (mean ± SD = 7.33 ± 2.09) defined by CT compared to those without sacroiliitis (6.39 ± 1.49, P = 0.038). There were associations between PsA and aortic inflammation (β = 0.124, P < 0.001) and between sacroiliitis and aortic inflammation (β = 0.270, P < 0.001) after adjusting for CVD risk factors. Sacroiliitis predicted vascular inflammation beyond PsA and CVD risk factors (χ2 = 124.6, P < 0.001).ConclusionsSacroiliitis is associated with increased vascular inflammation detected by FDG-PET/CT, suggesting that sacroiliac joint disease may identify patients at greater risk for CVD. Large, ongoing prospective studies are required to confirm these findings.

Risk factors and characterization of vitiligo and alopecia areata in patients with chronic graft-vs-host disease.

IMPORTANCE Cutaneous manifestations of chronic graft-vs-host disease (GvHD) are highly variable and may recapitulate well-characterized autoimmune diseases, including systemic sclerosis and Sjögren syndrome. However, vitiligo and alopecia areata (AA) have not been well characterized in the chronic GvHD setting. OBJECTIVE To determine laboratory markers, transplant-related factors, and other systemic manifestations associated with vitiligo and/or AA in patients with chronic GvHD. DESIGN, SETTING, AND PARTICIPANTS A cross-sectional, retrospective study conducted by the National Institutes of Health (NIH) of 282 adult and pediatric patients with chronic GvHD seen under the NIH natural history protocol between 2004 and 2013. MAIN OUTCOMES AND MEASURES Demographic, clinical, and laboratory data, including measures of 11 antibodies, were included in the analysis. Patients with vitiligo and/or AA were identified from dermatologist documentation and photographic evidence. Univariate and multivariable logistic regression analyses were used to determine risk factors for vitiligo and AA development. RESULTS Fifteen (5.3%) of 282 patients demonstrated vitiligo (14 of 282; 4.9%) and/or AA (2 of 282; 0.7%) (1 patient had both vitiligo and AA). Univariate analysis identified female donor to male recipient sex mismatch (P = .003), positive test results for anticardiolipin (ACA) IgG (P = .03) or antiparietal antibody (P = .049), elevated CD19 level (P = .045), and normal or elevated IgG level (P = .02) as risk factors for vitiligo or AA. Female donor to male recipient sex mismatch (P = .003) and positive findings for ACA-IgG (P = .01) retained significance in the multivariable analysis. CONCLUSIONS AND RELEVANCE Female donor and female donor to male recipient sex mismatch, in particular, are significantly associated with the development of vitiligo and/or AA. Further studies are needed to explore transplant-related risk factors that may lead to better understanding of the pathomechanisms of chronic GvHD.

Characterization of immune cells in psoriatic adipose tissue

BackgroundAdipose tissue normally contains immune cells that regulate adipocyte function and contribute to metabolic disorders including obesity and diabetes mellitus. Psoriasis is associated with increased risk for metabolic disease, which may in part be due to adipose dysfunction, which has not been investigated in psoriasis. There is currently no standardized method for immunophenotyping human adipose tissue. In prior studies, characteristic phenotypic markers of immune cell populations identified in animal models or in other human tissues have been applied in a similar manner to human adipose tissue. Rarely have these populations been verified with confirmatory methodologies or functional studies. Thus, we performed a comprehensive phenotypic and functional analysis of immune cell populations in psoriatic adipose tissue.MethodsConventional and imaging flow cytometry were used to define immune cell populations in biopsy specimens of psoriatic adipose tissue (n = 30) including T cells, B cells, NK cells, NKT cells, neutrophils, and macrophages. Relationships between adipose immune cell types and body mass index were determined using Spearman regression analysis, and multivariate linear regression analysis was performed to adjust for cardiometabolic disease risk factors.ResultsThese analyses revealed a wide range of cell surface receptors on adipose tissue macrophages, which may serve a dual purpose in immunity and metabolism. Further, both CD16+CD56Lo and CD16-CD56Hi NK cells were found to correlate inversely with body mass index. The relationship between the predominant CD16+CD56Lo NK cell population and body mass index persisted after adjusting for age, sex, diabetes, and tobacco use.ConclusionsTogether, these studies enhance our understanding of adipose immune cell phenotype and function, and demonstrate that examination of adipose tissue may provide greater insight into cardiometabolic pathophysiology in psoriasis.

Upregulation of IFN-Inducible and Damage-Response Pathways in Chronic Graft-versus-Host Disease

Although chronic graft-versus-host disease (CGVHD) is the primary nonrelapse complication of allogeneic transplantation, understanding of its pathogenesis is limited. To identify the main operant pathways across the spectrum of CGVHD, we analyzed gene expression in circulating monocytes, chosen as in situ systemic reporter cells. Microarrays identified two interrelated pathways: 1) IFN-inducible genes, and 2) innate receptors for cellular damage. Corroborating these with multiplex RNA quantitation, we found that multiple IFN-inducible genes (affecting lymphocyte trafficking, differentiation, and Ag presentation) were concurrently upregulated in CGVHD monocytes compared with normal subjects and non-CGVHD control patients. IFN-inducible chemokines were elevated in both lichenoid and sclerotic CGHVD plasma and were linked to CXCR3+ lymphocyte trafficking. Furthermore, the levels of the IFN-inducible genes CXCL10 and TNFSF13B (BAFF) were correlated at both the gene and the plasma levels, implicating IFN induction as a factor in elevated BAFF levels in CGVHD. In the second pathway, damage-/pathogen-associated molecular pattern receptor genes capable of inducing type I IFN were upregulated. Type I IFN-inducible MxA was expressed in proportion to CGVHD activity in skin, mucosa, and glands, and expression of TLR7 and DDX58 receptor genes correlated with upregulation of type I IFN-inducible genes in monocytes. Finally, in serial analyses after transplant, IFN-inducible and damage-response genes were upregulated in monocytes at CGVHD onset and declined upon therapy and resolution in both lichenoid and sclerotic CGVHD patients. This interlocking analysis of IFN-inducible genes, plasma analytes, and tissue immunohistochemistry strongly supports a unifying hypothesis of induction of IFN by innate response to cellular damage as a mechanism for initiation and persistence of CGVHD.

IL-17A Production in Human Psoriatic Blood and Lesions by CD146+ T Cells

To the Editor: CD146, also called melanoma cell adhesion molecule (MCAM), is a cell surface adhesion molecule on endothelial cells involved in homotypic and heterotypic cell interactions (Bardin et al, 2001). CD146 binding in endothelial cells (ECs) leads to a change in cellular permeability, actin distribution and redistribution of NF-kappa B p50 to the nucleus. CD146 has been shown to be present on 1–3% of circulating peripheral blood T cells in healthy humans (Elshal et al, 2005). CD146+ T cells have an effector memory phenotype, demonstrate up-regulation of a cluster of genes involved with adhesion, migration, homing, and inflammation, and have enhanced binding to endothelial monolayers in vitro (Elshal et al, 2007). These features of the CD146+ T cells in the peripheral circulation have led to speculation that these represent a small pool of cells primed for extravasation and/or homing of activated T cells (Elshal et al, 2007, Guezguez et al, 2007) in response to inflammatory stimuli. Circulating CD146+ T cells are elevated in several inflammatory autoimmune diseases such as sarcoidosis, inflammatory bowel disease, multiple sclerosis, connective tissue disease, and Behcets disease and produce IL-17 (Dagur et al, 2011, Dagur et al, 2010, LaRochelle et al, 2012). Whether these cells play a role at the site of active inflammation in these diseases remains unknown. Psoriasis, which is associated with increased vascular inflammation (Mehta et al, 2009) and access to both peripheral blood and the disease target tissue (e.g. skin), is ideal to study CD146+ T cell phenotype and function in an inflammatory condition. Here we present findings from a well-characterized patient population with psoriasis using peripheral blood samples and skin biopsies from psoriatic lesions and uninvolved skin. Forty-seven patients with psoriasis and sixty-seven healthy controls were included in this study. Diagnosis of psoriasis was confirmed by a dermatologist and severity was measured by percentage of body surface area (BSA) involved and the validated Psoriasis Area and Severity Index (PASI). Donor demographics and characteristics are presented in Supplemental Table 1. Skin biopsies were isolated from a representative psoriatic target lesion (6 mm) and are identified as lesional psoriatic skin. Non-lesional skin biopsies were obtained from a similar body area at least 10cm away from the nearest psoriasis skin lesion. Frozen sections were obtained from skin lesions for immunofluorescence studies and all patients provided written consent in as part of an IRB-approved study (NCT01778569). Venous blood was collected in sodium heparin vacutainers (Becton Dickinson (BD), San Jose, CA). Cells were stained and flow cytometric analysis was performed as previously described (6). Skin biopsies were digested in Collagenase IV (GIBCO BRL # 17104-019) at 5 mg/ml in RPMI 1640 for 45 min, stained, and then sorted in the same manner as peripheral blood. The following antibodies used for staining were obtained from BD: CD3, CD4, CD8, CD33, CD14, CD19, CD45, CD45-RO, CD146 (Clone P1H12). Anti-IL-17A (clone ebio64DEC17) was purchased from eBiosciences. Immunophenotyping results are expressed as means and standard errors of the mean. RNA was isolated from sorted CD146+ or CD146- T cell subpopulations using RNAquos Micro kits (Ambion) and real time PCR (QRTPCR) was performed using a 7900-sequence detector (PE-Applied Biosystems, Norwalk, CT). Data from a single specimen were considered one experiment (n). A p-value <0.05 was considered statistically significant. Statistical analysis was performed using STATA version 12.0 (StataCorp, College Station, TX, USA). To determine whether CD146+ T cells are prevalent in patients with a Th17 disorder, immunophenotyping was performed on fresh peripheral blood from patients with psoriasis. Psoriasis patients showed a significant elevation of circulating CD3+CD146+ T cells compared to healthy adults (3.91 ± 0.37% vs 2.96 ± 0.19% respectively, p =0.03) (Figure 1A). Increased CD146 expression reached statistical significance with the circulating CD4+ T cells (5.50 +/- 0.413% in PSO vs 3.55 +/− 0.213% respectively, p <0.0001), (Figure 1B), but not the CD3+CD8+CD146+ T cells (2.75 +/− 0.373% in PSO vs 2.30 +/− 0.216% respectively) (Figure 1C). CD146+ T cells were abundant within lesional skin biopsies, representing roughly 1/3 of the total CD4+ T and CD8+ T cell populations (Figures 1B, 1C). Immunofluorescence of frozen sections confirmed CD146+ T cells in lesional skin biopsies (Figure 1D). Lymphocytes, including CD146+ T cells, were rare in biopsies of non-lesional, unaffected skin from psoriasis patients. Figure 1 CD146+ T cells are significantly elevated in patients with psoriasis in the circulation and at the site of inflammation. Comparative frequencies (Mean +/− SEM) of: To determine IL-17A production from CD146- and CD146+ subsets of psoriatic T cells, cell suspensions from peripheral blood and lesional skin were stimulated for 3 hours with PMA and ionomycin, stained for cell surface markers, and then for intracellular IL-17A. CD146+ cells were the primary producers of IL-17A in lesional skin for both CD4+ (67.8± 9.5% p<0.005) and CD8+ (70.8± 11.4%, p<0.004) T cells (Figure 2A). In contrast, CD146+ cells accounted for ~20% of IL-17A producers in peripheral blood from both healthy adults and psoriatics. mRNA levels of IL-17A, RORc2, and CD146 were increased among unstimulated CD146+ T cells compared to CD146- cells, in both the blood and lesional skin, with a greater elevation in the lesions (Figure 2B). Figure 2 Figure 2A. Percentages of IL-17A -producing T cells which are CD146 positive. The T cells and T cell subsets secreting IL-17A were gated first and then the proportion of these cells expressing CD146 were determined. While previous studies have demonstrated increased circulating Th17 cells in psoriasis (Kagami et al, 2010), in this study we demonstrate that CD146+ T cells produce the majority of IL-17A at the active site of inflammation in psoriasis. Our study confirms previous reports of IL-17A production by CD146+ T cells in both healthy individuals and in patients with various autoimmune disorders and adds to those results by: 1) extending these findings to psoriasis; and 2) demonstrating that CD146+ T cells are important mediators of inflammation at the active site of disease. These findings suggest that CD146+ T cells in the circulation may represent a pool of cells with both the means to extravasate to the site of inflammation (via CD146 expression), and to mediate inflammation at a specific site. Limitations include analyzing patients with a variety of topical and systemic therapy and only studying patients with mild to moderate psoriasis. Previous studies examining this cell type in autoimmune diseases have been limited by not examining cells at the active site of inflammation – a hindrance overcome in the current work.

Efficacy of Intralesional Botulinum Toxin A for Treatment of Painful Cutaneous Leiomyomas: A Randomized Clinical Trial

IMPORTANCE Cutaneous leiomyomas can be associated with severe paroxysmal pain in which nerve conduction may have a key role. Medical management of painful cutaneous leiomyomas is generally unsatisfactory. OBJECTIVE To assess the efficacy of intralesional botulinum toxin A in the management of pain associated with cutaneous leiomyomas. DESIGN, SETTING, AND PARTICIPANTS Randomized, double-blind, placebo-controlled pilot study conducted from January 5, 2009, to March 27, 2014. The setting was a single-center study at the National Institutes of Health among participants 18 years or older with cutaneous leiomyomas characterized by pain at least once weekly and pain of at least 4 on a pain scale ranging from 0 to 10. INTERVENTIONS Eighteen participants were randomized to receive intralesional botulinum toxin A (5 U per 1 cm2) or equivalent volumes of intralesional saline placebo. MAIN OUTCOMES AND MEASURES The primary outcomes were the differences in average lesional pain assessed by the Brief Pain Inventory and visual analog scale before and after ice provocation over a 4-week period. RESULTS No significant difference in average lesional pain was observed between the study arms. Decreased pain was reported in the botulinum toxin vs placebo arms by visual analog scale scores before ice provocation (median, 0.00; range, -3.30 to 0.70 for botulinum toxin and median, 0.40; range, -1.30 to 1.50 for placebo; P = .06); however, this finding was nonsignificant. No significant difference was observed in change in pain after ice provocation. A significant difference was seen between the arms in skin-related quality of life by total Dermatology Life Quality Index (median, -4.00; range, -8.00 to 2.00 for botulinum toxin and median, 0.00; range, -1.00 to 4.00 for placebo; P = .007) and with the specific skin pain-related question on the Dermatology Life Quality Index (median, -1.00; range, -2.00 to 1.00 for botulinum toxin and median, 0.00; range, -1.00 to 0.00 for placebo; P = .048). No significant difference was found in pain as ascertained by Patient Global Impression of Change at week 4. No serious adverse events related to botulinum toxin use were observed. CONCLUSIONS AND RELEVANCE The use of botulinum toxin to treat painful cutaneous leiomyomas was associated with improved quality of life and with a trend toward improved pain at rest. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00971620.

Palmoplantar pustules and osteoarticular pain in a 42-year-old woman

Key teaching points • Synovitis-acne-pustulosis-hyperostosis-osteitis (SAPHO) syndrome is characterized by distinctive osteoarticular manifestations and a spectrum of neutrophilic dermatoses. • The most common dermatologic manifestations include palmoplantar pustulosis, acne conglobata, and acne fulminans. • SAPHO syndrome should be considered in patients presenting osteoarticular pain, particularly involving the anterior chest wall and/or spine, and neutrophilic skin lesions.

Prevalence of isolated joint involvement in chronic graft-versus-host disease: comment on the article by Inamoto et al.

early infancy; it frequently evolves into an afebrile chronic arthritis; and in many cases systemic JIA resolves completely over time, never to return. These differences should give us pause about classifying systemic JIA together with the monogenic autoinflammatory diseases. One peril entailed in making premature conclusions about the biology of systemic JIA is that important pathogenic mechanisms may be overlooked. Autoinflammatory diseases are commonly, albeit perhaps imprecisely, regarded as diseases of innate immunity. From this point of view, T cells and B cells might be assumed to be irrelevant. However, IL-1 is a critical modulator of lymphocytic immunity, including Th17 cell differentiation and Treg cell function. The goal of the review was to raise the possibility that IL-1 and other cytokines might engender T cell–driven pathology in systemic JIA, taking a cue from mice deficient in IL-1 receptor antagonist in which T cell–mediated arthritis develops (1). Indeed, the largest genome-wide association study in systemic JIA, which is still published only in abstract form, identifies a clear if relatively weak association of systemic JIA with the HLA class II locus, a hallmark of antigen-driven T cell autoimmunity (2). A further complication in assigning systemic JIA to the autoinflammatory family is that excessive immunity and immunodeficiency are sometimes hard to tell apart. This point is illustrated by the innate immune–sensing protein nucleotidebinding oligomerization domain–containing protein 2 (NOD2). Gain-of-function mutations affecting NOD-2 result in the autoinflammatory disease Blau syndrome. Loss-of-function mutations can result in inflammatory bowel disease, potentially through failure to properly defend the intestinal barrier (3,4). From this point of view, it is interesting that patients with systemic JIA and macrophage activation syndrome often bear mutations that result in defective cell–cell killing. Such mutations are postulated to impair control of activated macrophages, thereby leading to enhanced inflammation. Cell–cell killing is also a key mechanism for control of viruses, and it is legitimate to question whether mishandling of viral infections (i.e., immunodeficiency) might represent an important early step in the pathogenesis of systemic JIA. If this is the case, one could debate whether systemic JIA is really a primary autoinflammatory disease. Finally, it is by now well recognized that the “autoinflammatory” label is not typically all or none. Even in diseases with relatively clear antigen-driven autoimmunity, such as rheumatoid arthritis (RA) and lupus, innate immune mechanisms including neutrophils and complement represent important mediators of tissue injury. It is therefore to be expected that variation in innate immune function might affect the incidence and severity of diseases of many types. Indeed, in parts of the world where FMF is common, heterozygous carriers of MEFV mutations appear to exhibit a greater predilection for JIA, a higher incidence of Henoch-Schönlein purpura and other vasculitides, and more severe RA (5–7). In fact, most inflammatory diseases should probably be conceptualized as residing in an autoinflammatory–autoimmune continuum (8). Systemic JIA is no exception, and I share with Drs. Rigante and Cantarini the opinion that systemic JIA probably lies closer to the autoinflammatory end of the spectrum than most other subtypes of JIA, although enthesitis-related arthritis (perhaps driven by HLA–B27 misfolding) might make a competing claim (9). Only further research will tell for sure. Dr. Nigrovic’s work is supported by grants from the Rheumatology Research Foundation, the National Institute of Arthritis and Musculoskeletal and Skin Diseases, the National Institute of Allergy and Infectious Diseases, and the Cogan Family Fund. He has received consulting fees from Alkermes, Momenta Pharmaceuticals, Novartis, and Genentech, and research support from the Baxter BioScience Foundation.