Helmut Hintner

The classification of inherited epidermolysis bullosa (EB): Report of the Third International Consensus Meeting on Diagnosis and Classification of EB

BACKGROUND Since publication in 2000 of the Second International Consensus Report on Diagnosis and Classification of Epidermolysis Bullosa, many advances have been made to our understanding of this group of diseases, both clinically and molecularly. At the same time, new epidermolysis bullosa (EB) subtypes have been described and similarities with some other diseases have been identified. OBJECTIVE We sought to arrive at a new consensus of the classification of EB subtypes. RESULTS We now present a revised classification system that takes into account the new advances, as well as encompassing other inherited diseases that should also be included within the EB spectrum, based on the presence of blistering and mechanical fragility. Current recommendations are made on the use of specific diagnostic tests, with updates on the findings known to occur within each of the major EB subtypes. Electronic links are also provided to informational and laboratory resources of particular benefit to clinicians and their patients. LIMITATIONS As more becomes known about this disease, future modifications may be needed. The classification system has been designed with sufficient flexibility for these modifications. CONCLUSION This revised classification system should assist clinicians in accurately diagnosing and subclassifying patients with EB.

Ribosomal proteins Rpl10 and Rps6 are potent regulators of yeast replicative life span.

The yeast ribosome is composed of two subunits, the large 60S subunit (LSU) and the small 40S subunit (SSU) and harbors 78 ribosomal proteins (RPs), 59 of which are encoded by duplicate genes. Recently, deletions of the LSU paralogs RPL31A and RPL6B were found to increase significantly yeast replicative life span (RLS). RPs Rpl10 and Rps6 are known translational regulators. Here, we report that heterozygosity for rpl10Delta but not for rpl25Delta, both LSU single copy RP genes, increased RLS by 24%. Deletion of the SSU RPS6B paralog, but not of the RPS6A paralog increased replicative life span robustly by 45%, while deletion of both the SSU RPS18A, and RPS18B paralogs increased RLS moderately, but significantly by 15%. Altering the gene dosage of RPL10 reduced the translating ribosome population, whereas deletion of the RPS6A, RPS6B, RPS18A, and RPS18B paralogs produced a large shift in free ribosomal subunit stoichiometry. We observed a reduction in growth rate in all deletion strains and reduced cell size in the SSU RPS6B, RPS6A, and RPS18B deletion strains. Thus, reduction of gene dosage of RP genes belonging to both the 60S and the 40S subunit affect lifespan, possibly altering the aging process by modulation of translation.

Squamous cell carcinoma in junctional and dystrophic epidermolysis bullosa

We report here on three patients suffering from recessive dystrophic epidermolysis bullosa and one suffering from generalized atrophic benign epidermolysis bullosa, all of whom developed cutaneous squamous cell carcinoma. Our observations and a review of the literature suggest that squamous cell carcinoma in generalized atrophic benign epidermolysis bullosa is very infrequent and has a better outcome compared to skin cancer in recessive dystrophic epidermolysis bullosa. These differences could be explained by the distinct pathophysiology and clinical course of each of these variants of epidermolysis bullosa. In contrast to UV-induced skin cancer, the tumours in epidermolysis bullosa develop on distal extremities at sites of chronic wound healing. The cases reported here underline the exceptional importance of early histopathological assessment of suspicious skin lesions in patients with epidermolysis bullosa.

Systemic lupus erythematosus in hereditary deficiency of the fourth component of complement

Three patients from two families with complete hereditary deficiency of the fourth component of complement (C4) and systemic lupus erythematosus are described. The syndrome presented by these patients is characterized by early onset in life; exquisite sensitivity to sunlight and to cold exposure, the latter resulting Raynauds phenomenon; and skin lesions involving not only exposed areas of the body but also palms and soles and presenting as butterfly rashes, maculopapular eruptions, and lesions similar to those of chronic discoid lupus erythematosus, with marked scaling, atrophy, and scarring. Lupus erythematosus (LE) cell tests were negative and antinuclear antibody (ANA) titers low or negative. The male patient of our series died at the age of 31/2 years from septicemia, whereas the two girls, aged 18 and 11 years, respectively, were alive at the time of writing. The C4-deficient gene is associated with HLA-Aw32, Bw38, and Bf S in one family and with HLA-A30, B18, DR7, and Bf S1 in the other family; the latter is the second family in which this HLA haplotype has been found to be associated with hereditary C4 deficiency.

Revertant mosaicism: partial correction of a germ-line mutation in COL17A1 by a frame-restoring mutation

Generalized atrophic benign epidermolysis bullosa is an autosomal recessive subepidermal blistering disease typified by null mutations in COL17A1. In 1 large kindred, affected individuals were homozygous for a 2-bp deletion in COL17A1, 4003delTC, which resulted in a downstream premature termination codon, nonsense-mediated mRNA decay, and abrogation of type XVII collagen synthesis. Interestingly, 1 of these patients, although phenotypically identical to her affected siblings, showed focal expression of type XVII collagen in epidermal basement membrane in a pattern suggestive of revertant mosaicism. When studies of randomly obtained epidermal, oromucosal, and peripheral blood cells failed to identify the genetic basis of this apparent mosaicism, microscopic subpopulations of potentially revertant epidermal cells (i.e., those overlying basement membrane containing type XVII collagen) were selectively isolated using laser capture microdissection. Analysis of DNA and RNA from these cells revealed a second mutation, 4080insGG, on 1 allele of COL17A1. This 2-bp insertion corrected the reading frame just proximal to the premature termination codon, countered nonsense-mediated mRNA decay, and allowed protein production by patient keratinocytes in vivo and in vitro. These studies elucidate the molecular basis of a novel form of revertant mosaicism in humans.

Treatment‐resistant classical epidermolysis bullosa acquisita responding to rituximab

SIR, Epidermolysis bullosa acquisita (EBA) is a chronic severe subepidermal blistering disease of the skin and mucous membranes characterized by marked resistance to topical and systemic therapy. We report a patient with a 6-year history of EBA refractory to any immunosuppressive medication (Fig. 1), who responded well to a treatment with the anti-CD20 monoclonal antibody rituximab. A 71-year-old woman presented with blisters and erosions on mechanically strained areas including hands, elbows and feet, that healed with scarring and milia formation and resulted in nail dystrophy, loss of toenails and scarring alopecia. Involvement of mucous membranes was initially confined to the oral cavity (Fig. 2), and later also occurred on oesophageal and pharyngolaryngeal mucosa. Histological examination of perilesional skin showed subepidermal blister formation and a mild infiltrate composed of lymphocytes and neutrophils. Conventional direct immunofluorescence of perilesional skin detected linear deposition of IgG and C3 at the dermoepidermal junction. No IgA or IgM deposits were found. Indirect immunofluorescence (IIF) with the patient’s serum on salt-split skin revealed an exclusive dermal binding of circulating IgG antibasement membrane zone (BMZ) antibodies at a titre of 1 : 2560. These antibodies recognized a band at 290 kDa, and a 145-kDa band corresponding to the a-chain of collagen VII in immunoblotting on keratinocyte extracts. Thus, the diagnosis of a classical mechanobullous type of EBA was made. Over a 6-year period several immunosuppressive agents, including corticosteroids, azathioprine, ciclosporin, plasmapheresis, mycophenolate mofetil, colchicine, gold preparations, highand low-dose immunoglobulins and daclizumab were administered but none of them resulted in prolonged clinical benefit (Fig. 1). Then in 2004, disease activity increased, mainly due to massive erosions of the pharyngolaryngeal and oesophageal mucosa, which resulted in upper and lower oesophageal stenoses. The anti-BMZ titre (1 : 320) was at this time point lower than in the previous years of the disease. The patient required endoscopic dilatation of oesophageal stenoses, percutaneous endoscopic gastrostomy and tracheotomy because of severe obstruction of the upper airways. We therefore decided to initiate an anti-CD20 monoclonal antibody therapy attempt. Concomitantly, vaccination against influenza A and Streptococcus pneumoniae was carried out. Five rituximab infusions were given intravenously at a frequency of one infusion per week. Because of the poor health condition of our patient and to avoid potential side-effects we used a reduced dose of 144 mg m each time. Concomitant immunosuppressive therapy was azathioprine 2Æ0 mg kg daily. Our patient tolerated the rituximab therapy well with absence of any side-effects or infections. Four weeks after the first rituximab infusion the patient showed marked improvement of the skin and mucous membrane condition (Fig. 2b) and concomitant therapy of azathioprine was discontinued. Transiently, IIF became negative and a repeated immunoblotting study could no longer detect antibodies reactive with the

K14 mRNA reprogramming for dominant epidermolysis bullosa simplex

The major challenge to a successful gene therapy of autosomal dominant genetic diseases is a highly efficient and specific knock-down or repair of the disease-causing allele. In epidermolysis bullosa simplex-type Dowling-Meara (EBS-DM), a single amino acid exchange in exon 1 of the keratin 14 gene (K14) triggers a severe skin phenotype, characterized by blistering of the skin and mucous membranes after minor trauma. We chose spliceosome-mediated RNA trans-splicing to specifically replace exons 1-7 of the K14 gene. In this approach, the mutated coding region is replaced by an RNA-trans-splicing molecule (RTM) that incorporates a binding domain (BD) and the wild-type sequence of K14. Since the BD is crucial for the trans-splicing functionality, we developed a fluorescence-based RTM screen consisting of an RTM library containing random BDs. Co-transfection of the library with a target molecule enabled us to identify highly functional RTMs. The best RTMs were adapted for endogenous trans-splicing in an EBS-DM patient cell line. In this cell line, we were able to detect functional, efficient and correct trans-splicing on RNA and protein levels. Scratch assays confirmed phenotypic reversion in vitro. Owing to concomitant knock-down and repair of the mutated allele, we assume that trans-splicing is a promising tool for the treatment of autosomal dominant genetic disease.

A Compound Heterozygous One Amino-Acid Insertion/Nonsense Mutation in the Plectin Gene Causes Epidermolysis Bullosa Simplex with Plectin Deficiency

Plectin is a cytoskeleton linker protein expressed in a variety of tissues including skin, muscle, and nerves. Mutations in its gene are associated with epidermolysis bullosa simplex with late-onset muscular dystrophy. Whereas in most of these patients the pathogenic events are mediated by nonsense-mediated mRNA decay, the consequences of an in-frame mutation are less clear. We analyzed a patient with compound heterozygosity for a 3-bp insertion at position 1287 leading to the insertion of leucine as well as the missense mutation Q1518X leading to a stop codon. The presence of plectin mRNA was demonstrated by a RNase protection assay. However, a marked reduction of plectin protein was found using immunofluorescence microscopy of the patients skin and Western blot analysis of the patients cultured keratinocytes. The loss of plectin protein was associated with morphological alterations in plectin-containing structures of the dermo-epidermal junction, in skeletal muscle, and in nerves as detected by electron microscopy. In an in vitro overlay assay using recombinant plectin peptides spanning exons 2 to 15 the insertion of leucine resulted in markedly increased self-aggregation of plectin peptides. These results describe for the first time the functional consequences of an in-frame insertion mutation in humans.

Human upper epidermal cytoplasmic antibodies are directed against keratin intermediate filament proteins.

Upper cytoplasmic (U-Cyt) antibodies are directed against cytoplasmic antigens found in keratinocytes in the upper layers of the epidermis. Until now, they have been defined by indirect immunofluorescence and are known to occur in the sera of patients with cutaneous diseases such as bullous dermatoses, basal cell carcinomas, and melanomas. An increased incidence of U-Cyt antibodies has also been reported in the sera of patients with noncutaneous diseases, such as pulmonary neoplasms. They have been found in addition in the sera of some normal individuals. In this study we have identified keratin intermediate filaments (KIF) as antigens U-Cyt antibodies are directed against. KIF proteins were prepared, separated by polyacrylamide gel electrophoresis, transblotted to nitro-cellulose strips, and used as substrates for antibody binding. Sera containing U-Cyt antibodies by indirect immunofluorescence also had antibodies that were directed against high molecular weight (65,000, 63,000, 61,500) KIF proteins. When KIF proteins were separated according to their charge and their molecular weight by two-dimensional gel electrophoresis and transblotted, the anti-KIF protein antibodies bound to virtually all charge isomers of the KIF proteins at the respective molecular weight. The antibody titers measured using the transblotting technique were 10 to 160 times higher than those found by indirect immunofluorescence. To determine whether U-Cyt antibodies were directed against KIF, a series of absorption and elution experiments were performed. Absorption of test sera with purified KIF removed both U-Cyt antibodies and anti-KIF protein antibodies. Absorption with another type of intermediate filament derived from fibroblasts, vimentin, did not remove U-Cyt or anti-KIF protein antibodies. Absorbed U-Cyt and anti-KIF protein antibodies were both eluted from the same KIF preparation and shown to bind to U-Cyt antigens by indirect immunofluorescence and KIF proteins by transblotting. Absorption of a serum containing U-Cyt antibodies, anti-nuclear antibodies, and anti-basement membrane zone antibodies with purified KIF resulted in the removal of the U-Cyt antibodies but not the other types of antibody. In addition, all test sera, even those that lacked U-Cyt antibodies, were found to have low-titer antibodies against KIF proteins by the transblotting technique. These data indicate that KIF proteins bear antigens to which U-Cyt antibodies are directed and that low titer antibodies against KIF proteins may be much more common than previously appreciated.

Pathogenic mechanisms in epidermolysis bullosa naevi.

Epidermolysis bullosa naevi are large, eruptive melanocytic naevi which frequently arise in areas of former blisters in patients suffering from inherited epidermolysis bullosa. Morphologically, these naevi are similar to malignant melanoma, although so far no malignant transformation has been observed. To investigate the pathogenesis of these moles we documented their clinical evolution and their histopathological and immunocytological characteristics in three patients with epidermolysis bullosa. Clinically, we observed signs of malignant transformation, such as explosive growth and the occurrence of satellite lesions of epidermolysis bullosa naevi. However, malignant melanoma was excluded by histopathological evaluation. In addition, we evaluated the concentrations of various factors known to stimulate melanocyte growth in blister fluid. Human interleukin 8, basic fibroblast growth factor, human hepatocyte growth factor, GM-CSF, leukotriene B4 and prostaglandin E2 revealed concentrations comparable with the levels in inflammatory blisters. We were able to detect individual melanocytes/naevus cells in blister fluid from a blister over an epidermolysis bullosa naevus. The factors detected in the blister fluid might therefore promote the proliferation, migration and melanogenesis of disconnected melanocytes/naevus cells representing the basis of the highly dynamic appearance of epidermolysis bullosa naevi.