Ralf Hinrichs

Vascular endothelial growth factor causally contributes to the angiogenic response upon ultraviolet B irradiation in vivo

Summary Background Ultraviolet (UV)‐B irradiation has been shown to be an inducer of vascular endothelial growth factor (VEGF) in primary keratinocytes and epidermal cell lines in vitro.

Ultraviolet-B induction of interstitial collagenase and stromelyin-1 occurs in human dermal fibroblasts via an autocrine interleukin-6-dependent loop.

Ultraviolet‐B irradiation of human dermal fibroblasts has earlier been shown to induce matrix‐degrading metalloproteinases, thus driving connective tissue degradation in photoaging and photocarcinogenesis. Herein, we report that Ultraviolet‐B irradiation led to a dramatic increase in specific mRNA and protein levels of interstitial collagenase, stromelysin and interleukin‐6. By contrast, the major tissue inhibitor of matrix‐degrading metalloproteinases, TIMP‐1, was unaffected. Monospecific neutralizing antibodies directed against human interleukin‐6 significantly reduced the interstitial collagenase and stromelysin‐1 protein levels. Taken together, our data provide the first evidence that Ultraviolet‐B induction of interstitial collagenase and stromelysin‐1 occurs via the synthesis and release of interleukin‐6. Hence, this newly identified autocrine mechanism may contribute to dermal photodamage.

Successful Sulfasalazine Treatment of Severe Chronic Idiopathic Urticaria Associated with Pressure Urticaria

Sir, Chronic urticaria is a common cutaneous disease, but its pathogenesis is still poorly understood. We report on a patient with corticosteroid-dependent chronic idiopathic urticaria associated with pressure urticaria who failed to respond to treatment with antihistamines, a leukotriene receptor antagonist, and PUVA, but showed stable improvement after administration of sulfasalazine. CASE REPORT A 31-year-old male patient suffered for 5 years from recurrent episodes of hives and swellings often associated with shortness of breath. Weals occurred spontaneously and after pressure application. The patient repeatedly suffered from pronounced weals that developed after working in his profession as a moving packer, or from plantar swellings after long-distance walks. Whereas pressure testing with an 8-kg weight placed on the patient’s thigh for 20 min failed to induce wealing over an observation period of 24 h, repeated strong grasping of an object for 10 min evoked prominent palmar hives. Routine laboratory tests, including serum electrolytes, total blood cell count, erythrocyte sedimentation rate, blood sugar level, antinuclear antibodies, anti-streptolysin titer, and urine analysis, failed to reveal any abnormalities, besides a mildly elevated gammatransaminase level that was attributed to the regular alcohol consumption of the patient. Intracutaneous injection of autologous serum did not induce wealing (1) and food-associated urticaria was ruled out by food allergy testing and an elimination diet for 10 days. Based on these results, we diagnosed chronic idiopathic urticaria and pressure urticaria associated with shortness of breath. Variousantihistamines,such asloratidine,cetirizine,terfenadine,and ranitidine as well as systemic PUVA treatment failed to improve the symptoms. To control repeated episodes of shortness of breath and severeswellings,intravenouscorticosteroidswereneededatleast3times monthly. As a consequence, the patient started to develop signs of Cushing’s syndrome, with a signi® cant increase in body weight. The leukotrienereceptorantagonistmontelukastwasthenadministered, but failed to be effective. Subsequently, we started treatment with sulfasalazine at a dosage of 500 mg/day, which was slowly increased to a maximum of 3 g/day over a period of 3 months. After only a few days of treatment, the patient experienced a substantial improvement. At a dosage of 3 g/day he achieved complete resolution of the urticaria symptoms. Repeated testingdemonstrated that wealingcould nolonger beinduced even bystrong grasping.Usingavisual analoguescalewitha range of 1± 10, where 1 indicated no wealing and 10 extensive wealing, the patient ranked the wealing as being initially 9 and improving to 1 after beginning treatment with sulfasalazine. Furthermore, he denied any occurrence of wealing associated with walking. During6 months of treatment with sulfasalazine, no adverse reactions were observed and regular laboratory follow-ups were unremarkable. After 6 months of successfulsulfasalazinetreatment,wetriedtoreducethedosageto2 g/day, which resulted in an increase in pressure-related symptoms. Therefore, the patient subsequently received 3 g of sulfasalazine per day, leading again to an improvement in clinical symptoms. After 1 year of treatment, the patient is free of weals with 3 g/day of sulfasalazine.

Essential role of an activator protein-2 (AP-2)/specificity protein 1 (Sp1) cluster in the UVB-mediated induction of the human vascular endothelial growth factor in HaCaT keratinocytes.

Chronic sun exposure of the skin has long been postulated to enhance cutaneous angiogenesis, resulting in highly vascularized skin cancers. As the UVB component of sunlight is a major contributor to photocarcinogenesis, we aimed to explore the effects of UVB radiation on vascular endothelial growth factor (VEGF) gene expression, using the immortalized keratinocyte cell line HaCaT as a model for transformed premalignant epithelial cells. In the present paper, we studied the molecular mechanism of UVB-induced VEGF providing a major angiogenic activity in tumour progression and invasion. After 12-24 h of UVB irradiation, a 2.4- to 2.7-fold increase in endogenous VEGF protein level was measured, correlating with an up to 2.5-fold induction of promoter-based reporter gene constructs of VEGF. Furthermore, we identified a GC-rich UVB-responsive region between -87 and -65 bp of the VEGF promoter. In electrophoretic mobility-shift assays, this region binds Sp1-dependent protein complexes constitutively and an additional UVB-inducible protein complex distinct from Sp1 protein. The transcription factor AP-2 (activator protein-2) was detected as a component of the UVB-inducible protein complex. The critical role of the AP-2/Sp1 (specificity protein 1) cluster was supported by demonstration of a significant reduction of UVB-mediated promoter activity upon deletion of this recognition site. The specificity of this region for UVB irradiation was demonstrated using PMA, which increased VEGF activity in HaCaT cells after transient transfection of the deleted promoter construct. In conclusion, our data clarified regulatory mechanisms of UVB-dependent VEGF stimulation which may be critical for angiogenic processes in the skin.

Rofecoxib as an alternative in aspirin hypersensitivity.

. THE mechanism underlying intolerance reactions to nonsteroidal antiin ̄ammatory drugs (NSAID) is not well understood. The clinical picture resembles a type I reaction (Coombs and Gell) including conjunctivitis rhinitis, shortness of breath, angioedema, hypotension, and, in severe cases, even shock. It is assumed that the pathogenetic mechanism is IgE-independent, since intolerance reactions can be induced by NSAIDs of different chemical structures, and speci®c IgE directed against NSAIDs is only rarely detectable. Inhibition of the central enzyme in the arachidonic acid pathway, cyclooxygenase (COX), by several NSAIDs may be essential for the development of an intolerance reaction, since it leads to an increased synthesis of leukotrienes (LT) with bronchoconstrictory capacities (LTC4, LTD4, and LTE4) (1). Unfortunately, only a limited number of alternative anti-in ̄ammatory pain medications can be offered to aspirinintolerant patients. Accordingly, the selective COX-2 inhibitors celecoxib and nimesulid have been conclusively reported to prevent pulmonary symptoms in aspirin-sensitive asthmatics. We here report the ®rst case of an aspirin-intolerant patient who, upon oral challenge with aspirin, but not with the selective COX-2 inhibitor rofecoxib, developed severe cutaneous and extrapulmonary mucosal symptoms. A 39-year-old patient was referred to our department with a history of rhinitis, swelling of the nasal mucosa, conjunctivitis, and shortness of breath 30 min after ingestion of 25 mg dexketoprofen. The patient denied having asthma, drug intolerance, or other allergies in the past. Acetylsalicylic acid (aspirin)or pyrazolonespeci®c IgE antibodies in the serum could not be detected. Prick testing of a standard series with different NSAIDs in addition to dexketoprofen was negative. On the ®rst day of the study, oral challenge with increasing amounts of the selective COX-2 inhibitor rofecoxib (suspensions of 1.2, 3, and 6 mg) given every 30 min was well tolerated, and 2 days later, oral challenge with 20, 50, and 125 mg of aspirin given at 30-min intervals was tolerated without complications. However, 20 min after challenge with aspirin at a dose of 250 mg, the patient developed itching of the eyelids and nasal mucosa, conjunctivitis, and generalized urticaria. Drug intolerance to aspirin was diagnosed and intravenously treated with 250 mg methylprednisolone and 2 mg clemastine hydrochloride. Although the pathogenetic mechanism of NSAID intolerance is still incompletely understood, there are several reasons supporting the hypothesis that the enzyme COX and leukotrienes may play a crucial role. First, a mutation in the gene encoding the LTC4 synthase results in increased levels of bronchoconstrictory LTC4 in the bronchoalveolar lavage of aspirin-intolerant asthmatics (2). Secondly, bronchospasm due to NSAID intolerance in asthmatics can be successfully treated with leukotriene receptor antagonists and lipoxygenase inhibitors (3). Third, it has been recently reported that the selective COX-2 inhibitor celecoxib did not induce bronchospasm in 27 aspirin-intolerant asthmatic patients (4). We here provide evidence that the selective COX-2 inhibitor rofecoxib is well tolerated in a patient with aspirin intolerance and mainly extrapulmonary symptoms such as urticaria, rhinitis, and conjunctivitis. Thus, the new class of selective COX-2 inhibitors may be a useful alternative in the anti-in ̄ammatory treatment for patients with arthritis and NSAID intolerance.

β2 integrin-mediated adherence does not modulate superoxide anion release from neutrophils and subsequent lipid peroxidation of surrounding fibroblasts

SIR, Interferon alfa (IFN-a) therapy is highly effective in patients with chronic myelogenous leukaemia and other malignant diseases. Most side-effects, such as chills, malaise, myalgia and fatigue, are transient and tend to disappear with ongoing therapy, while others, such as anorexia, neurological and mood disorders, are dose-related and need dose adjustment or withdrawal of IFN-a. Induction of immunemediated disease, including thyroid disease, rheumatoid arthritis, systemic lupus erythematosus, vasculitis, thrombocytopenia, autoimmune haemolytic anaemia, and insulin-dependent diabetes mellitus, has also been described. Moreover, other immunological entities, such as myasthenia gravis, vitiligo, lichen planus, Henoch–Schönlein purpura and Sjögren syndrome, have been reported after IFN-a therapy for chronic viral hepatitis or multiple sclerosis (MS). Here, we report on the first case of systemic sclerosis (SSc) developing after therapy with IFN-a for chronic myelogenous leukaemia. In October 1998, a 52-year-old-woman without a personal or a familiar history of autoimmune disease, was diagnosed as having chronic myelogenous leukaemia, with a karyotype 46,XX,t(9;22), bcr ⁄ abl positive in all the metaphases. She was given hydroxyurea 20 mg kg day for 2 months and then IFN-a 2a to a maximum daily dose of 10 · 10 U. In June 1999, cytogenic evaluation showed a normalization of the karyotype in up to 33% of metaphases. Meanwhile, treatment was reduced to 6 · 10 U day for the appraisal of arthralgias, ataxia and depression. In June 2000 a further evaluation revealed the loss of efficacy of therapy (Ph chromosome positive in all the analysable metaphases). In the same period, the patient experienced fever, dyspnoea and oedema of the extremities. Laboratory findings were normal, except for an increased erythrocyte sedimentation rate (ESR, 50 mm in the first hour). Chest X-ray and computed tomography (CT) of the lung demonstrated the presence of pulmonary vascular congestion. Cardiac function, evaluated by electrocardiogram and Doppler echocardiography, was normal. The possible diagnosis of congestive heart failure was discarded and the patient’s symptoms were ascribed to a leak capillary syndrome secondary to interferon therapy; interferon therapy was interrupted. Peripheral oedema and respiratory symptoms improved on treatment with diuretics. Nevertheless, 3 months later, in November 2000 she experienced dyspnoea, oedema of both the upper and lower limbs and progressive skin thickening of the hands and wrists. A further echocardiographic evaluation revealed a normal ejection fraction (70%) and minimal tricuspid regurgitation with increased pulmonary artery pressure (34 mmHg). CT of the chest showed a picture of diffuse parenchymal and interstitial fibrosis with multiple areas of ground-glass attenuation. Pulmonary function tests demonstrated the presence of reduced volumes with an impaired diffusion capacity for carbon monoxide (DLCO, 46% predicted). Oesophagogastroduodenoscopy showed a total absence of peristalsis. Laboratory examination indicated: elevated ESR (80 mm in the first hour), impaired renal function (creatinine, 1Æ8 mg dL) with mild proteinuria (72 mg 24 h) and positive antisclero-70 antibodies. Her complete major histocompatibility phenotype was HLA-DRB1*11; 07, DQA*05;0201, DQB*03;02, A28, A24, B35, B13, Bw4, Bw6, Cw4. Capillaroscopy findings were consistent with scleroderma, showing multiple microhaemorrhages, dilation, distortion and rarefaction of capillaries. No skin biopsy was performed. A diagnosis of localized SSc was put forward, according to LeRoy et al. The patient was given loop diuretics, cyclophosphamide 100 mg day, prostanoids (iloprost, 2 ng kg min for 8 h for five consecutive days and then thrice monthly), steroids (methylprednisolone 750 mg intravenously for 3 days and then prednisone 25 mg day). In the following months the patient’s clinical condition improved, scleroedema decreased, the skin thickening partially receded and the signs of alveolitis were no longer detectable at a further CT evaluation of the lung (October 2001). Therapy has been gradually tapered and the patient is now receiving cyclophosphamide 50 mg day, prednisone 12Æ5 mg day, iloprost 2 ng kg min for 8 h every 3 weeks and hydroxyurea 10 mg kg on every alternate day. The patient’s main clinical and laboratory findings, before and after 10 months of therapy, are summarized in Table 1. Several authors showed that IFN-a therapy for malignancies, chronic viral hepatitis or MS may trigger the formation of autoantibodies directed toward various substrates, such as thyroid, platelets, erythrocytes, pancreas, parietal cells and nuclei. Their occurrence is sometimes, but not necessarily, coupled with the onset or the exacerbation of autoimmune diseases. In most cases endocrine disorders are described, but rheumatic and collagen–vascular diseases have been observed as well. Nevertheless, to date, no reports of SSc after interferon therapy have been made. However, Wandl et al. noticed that patients who develop antinuclear antibodies may experience Raynaud’s phenomenon, one of the diagnostic findings in SSc. Moreover, Black et al. pointed out that IFN-a therapy in the treatment of scleroderma may be deleterious, exacerbating life-threatening symptoms and precipitating the lung deterioration. As far as our patient is concerned, the laboratory findings, typical vascular alterations and ⁄ or clinical signs of autoimmunity are ascribable to interferon therapy. The patient had neither a personal nor a familiar history of autoimmunity, and a clear temporal relation between IFN-a administration and the occurrence of initial symptoms can be seen. Besides, she did receive IFN-a continuously for approximately 2 years. Fattovich et al. indeed noticed that de novo immuneBritish Journal of Dermatology 2002; 147: 385–410.

Zentrofaziale granulomatöse Entzündung

Bei einem 83-jährigen Patienten waren innerhalb der letzten 8 Monate Erytheme mit entzündlichen Knötchen an Wangen und Nase aufgetreten. Des Weiteren berichtete der Patient von täglicher Epistaxis und einem chronischen Hustenreiz. Seit dem 20. Lebensjahr bestünde eine unklare Entzündung im Bereich der Nase und der Nasennebenhöhlen. Es sei diesbezüglich mehrfach eine operative Sanierung erfolgt, wobei die Diagnose bisher weder klinisch noch histopathologisch zugeordnet werden konnte.

Juckende Knoten bei einer 81-jährigen Patientin

Eine 81-jährige Patientin stellte sich mit seit 8 Wochen bestehendem starkem Juckreiz und neu entstandenen Knoten an Beinen und oberem Rücken vor. Es waren zahlreiche Vorerkrankungen bekannt: Diabetes mellitus, koronare Herzkrankheit, Herzrhythmusstörungen, Hepatitis B, chronisch venöse Insuffizienz und reaktive Depression. Bei der klinischen Untersuchung sah man disseminiert an den Beinen zahlreiche, jeweils scharf begrenzte Papeln und Knoten mit zentraler braunschwarzer Kruste (⊡ Abb. 1, 2). In diskreterer Form fanden sich gleichartige Hautveränderungen auch am oberen Rücken. Weitere Diagnostik