V. D. Vuzevski

The localisation of treponemes and characterisation of the inflammatory infiltrate in skin biopsies from patients with primary or secondary syphilis, or early infectious yaws

OBJECTIVE--To study the localisation of treponemes and to analyse the inflammatory infiltrate in biopsy specimens from patients with primary or secondary syphilis, or early infectious yaws. MATERIALS AND METHODS--Skin biopsies originating from human lesions of primary (29x) or secondary (15x) syphilis (Rotterdam), or early yaws (18x) (West Sumatra) were studied. Different histochemical and immunohistochemical detection methods were used in this study. RESULTS AND CONCLUSION--The histochemical silver staining method according to Steiner revealed the presence of T. pallidum in all cases of primary syphilis studied. In 10 out of 14 cases of secondary syphilis, treponemes were demonstrated. With an immunofluorescence staining technique (IF) using anti-T. pallidum antiserum raised in rabbits (a-Tp), T. pallidum was demonstrated in 28 out of 29 cases of primary syphilis, and in 14 out of 14 studied cases of secondary syphilis. The silver staining method and IF showed identical localisations of T. pallidum (mainly in the dermal-epidermal junction zone or throughout the dermis). Using a-Tp antiserum in the indirect immunofluorescence technique, T. pertenue could be demonstrated in the dermis more often than with Steiner silver staining. However, epidermotropism of T. pertenue in yaws specimens was remarkable, compared with more mesodermotropism of T. pallidum; numbers of T. pertenue in the dermis were limited in all specimens. The dermal inflammatory infiltrate in primary and secondary syphilis was composed mainly of lymphocytes and plasma cells. In most cases more T (CD3 positive) cells than B (CD22 positive) cells were present. Regarding T cell subpopulations, in primary syphilis, T helper/inducer (CD4 positive) cells predominated in 86% of cases. In secondary syphilitic lesions, numbers of T helper/inducer cells were less frequent than or equal to T-suppressor/cytotoxic (CD8 positive) cells in 60% of cases. Remarkably, in yaws specimens the inflammatory infiltrate consisted mainly of IgG, but also IgA and IgM producing plasma cells. T or B lymphocytes were scarce, which is in sharp contrast with findings in syphilitic lesions.

Endemic treponematoses. Part I. Yaws.

The causal organism of yaws (framboesia tropica, pian, parangi, paru, buba, bouba), a chronic relapsing tropical disease, is Treponema pallidum subspecies pertemie {T. pertemie), belonging to the order Spirochaetales, family of the Treponemataceae, genus Treponema. Other pathogenic treponemes are Treponema pallidum subspecies pallidum (T. pallidum), causative organism of venereal syphilis, Treponema pallidum subspecies endemicum, causative organism of endemic syphilis (bejel), and Treponema carateum, causative organism of pinta. For Treponema carateum propagation an animal model has not yet been developed and it is still considered to be a separate species, T. pertenue has been passaged successfully in rabbits and hamsters, thus providing both a source of microorganisms for study and an experimental model, Currently, T. pertenue cannot be distinguished from the other pathogenic treponemes morphologically^** or by laboratory tests,^ Recently, an alarming resurgence of yaws has been observed in several countries in the tropics, Millions of children are at risk of contracting this disease, which ean destroy bone and tissue. In most endemic areas the current extent of yaws is not fully known; presumably there is considerable underreporting. The current resurgence of yaws in the world is due partly to a false sense of security caused by the decline in number of patients after the mass campaigns,^ Yaws is still a serious health problem in different countries of the endemic areas in the world, from which people might emigrate to the United States and Europe.

Primary and secondary syphilis: a histopathological study.

We present a study of biopsies taken from skin lesions of 44 patients presenting with primary or secondary syphilis. In most primary lesions erosion or, more often, ulceration was present, with a dense inflammatory infiltrate. In secondary syphilis a wide variety of histological changes was present. Blood vessels were frequently involved, with marked endothelial swelling and often proliferation. Treponemes were demonstrated with the Steiner staining method in all investigated cases of primary syphilis and in 71% of secondary syphilis cases. Treponemes were present throughout the dermis, particularly perivascularly, and in the dermal–epidermal junction zone. In two specimens of secondary syphilis treponemes were located predominantly in the epidermis, but there were always some microorganisms demonstrable in the dermis. The inflammatory infiltrate was often located in a perivascular coat-sleeve-like arrangement. In this study plasma cells and lymphocytes were present in all specimens of primary and secondary syphilis. Syphilitic lesions differed from yaws lesions mostly in the location of treponemes and the affection of blood vessels. In this histopathological study of early syphilis, treponemes did not show the epidermiotropic character of yaws, and blood vessel changes were more pronounced than in yaws. Unfortunately, due to the protean histopathological manifestations described in venereal syphilis and in yaws, these two treponemal diseases cannot always be differentiated on histological grounds alone.

Early yaws : a light microscopic study

This paper presents the light microscopic findings in biopsies of skin lesions from 45 patients, in whom a diagnosis of early yaws was suspected. In 27 cases typical light-microscopic features of yaws were observed, consisting of parakeratosis or crust containing exudate, marked acanthosis with widening and elongation of the rete ridges or pseudo-carcinomatous hyperplasia and spongiosis. Intraepidermal microabscesses consisting of polymorphonuclear leucocytes were frequently encountered. In a large majority a moderate to dense infiltrate was present, composed mainly of lymphocytes and plasma cells. Vascular changes consisted of only slight endothelial cell proliferation and thickening of vessel walls. Steiner staining revealed the presence of treponemes in the epidermis in 23 of 27 cases. Remarkably, clusters of treponemes were also seen in the papillary dermis in three out of 23 cases. Seven other cases were strongly suggestive of yaws. Other histopathological diagnoses were made in 6 patients, due to the simultaneous occurrence of other skin diseases. The remaining five specimens did not contain enough tissue to allow conclusions to be made.

Subepidermal bullous autoimmune disease associated with immune nephritis: Immunomorphologic studies

There are only a few reports of the association of immune-complex glomerulonephritis with bullous pemphigoid. The occurrence of immune-complex nephritis with linear IgA bullous disease has not been previously reported. We report two cases, one a case of bullous pemphigoid and the other a case of linear IgA bullous disease, both of which were associated with immune-complex glomerulonephritis. The clinical and immunomorphologic data are briefly discussed.

Clinical and laboratory studySubepidermal bullous autoimmune disease associated with immune nephritis: Immunomorphologic studies

There are only a few reports of the association of immune-complex glomerulonephritis with bullous pemphigoid. The occurrence of immune-complex nephritis with linear IgA bullous disease has not been previously reported. We report two cases, one a case of bullous pemphigoid and the other a case of linear IgA bullous disease, both of which were associated with immune-complex glomerulonephritis. The clinical and immunomorphologic data are briefly discussed.

Secondary erythermalgia associated with an autoimmune disorder of undetermined significance.

A 50-year-old female patient is described with an acquired, persisting and yet incurable erythermalgia featured by symmetric burning pain and red congestion of the extremities secondary to cutaneous vasculitis. A weakly positive antinuclear antibody titer and high titers of antibodies against gastric parietal mucosa cells pointed to an underlying but unclassifiable autoimmune disorder. It is concluded that histopathology of lesional skin contributes to the differential diagnosis of primary and secondary erythermalgia.

Ultrastructural aspects of infection with Treponema pallidum subspecies pertenue (Pariaman strain).

OBJECTIVE--To study ultrastructural aspects of infection with Treponema pertenue (Pariaman strain), originating from West Sumatra, Indonesia. MATERIALS AND METHODS--Biopsy material originating from skin lesions in ten young children suffering from early infectious yaws in Indonesia, and rabbit testicular tissue inoculated with T pertenue. Human skin as well as rabbit testicular tissue was examined by means of conventional electron microscopy. RESULTS--In human skin, treponemes were found in interepidermal spaces in 5 out of 10 specimens. In two of five positive specimens, treponemes were also seen in the dermis. In one out of five specimens from rabbit testicular tissue a profusion of treponemes was found lying in the interstitial myxomatous tissue. Microorganisms showed no adhesion to fibroblasts. CONCLUSION--This ultrastructural study of T pertenue demonstrated the scarcity and focal distribution of treponemes in tissue and did not reveal any morphological differences from the Gauthier strain of T pertenue. No differences from the ultrastructure of T pallidum were observed either.

Infantile seborrheic dermatitis: morphological and immunopathological study

The pathomechanisms of infantile seborrheic dermatitis (ISD) are unknown. An allergic reaction to candidal antigens is one of the hypotheses. The skin of 6 patients suffering from ISD was studied by immunostaining techniques. The lymphocytic infiltrate was composed of Leu4-reactive T cells in which Leu3a-reactive (helper/inducer) cells predominated. Direct immunofluorescence studies revealed no significant deposits of immunoglobulins or complement factors. No candidal antigens could be demonstrated, either in epidermis or in dermis, although candida species were cultured from different sites in 4 of the 6 patients.

Malakoplakia of the endometrium: a rare cause of postmenopausal bleeding

A rare cause of postmenopausal bleeding in a 72-yr-old woman due to malakoplakia of endometrium is described. The light and electron microscopic features are described and it is postulated that malakoplakia is due to an abnormal macrophage response to Escherichia coli infection.