Melanocyte destruction after antigen-specific immunotherapy of melanoma: direct evidence of t cell-mediated vitiligo

Current strategies for the immunotherapy of melanoma include augmentation of the immune response to tumor antigens represented by melanosomal proteins such as tyrosinase, gp100, and MART-1. The possibility that intentional targeting of tumor antigens representing normal proteins can result in autoimmune toxicity has been postulated but never demonstrated previously in humans. In this study, we describe a patient with metastatic melanoma who developed inflammatory lesions circumscribing pigmented areas of skin after an infusion of MART-1-specific CD8(+) T cell clones. Analysis of the infiltrating lymphocytes in skin and tumor biopsies using T cell-specific peptide-major histocompatibility complex tetramers demonstrated a localized predominance of MART-1-specific CD8(+) T cells (>28% of all CD8 T cells) that was identical to the infused clones (as confirmed by sequencing of the complementarity-determining region 3). In contrast to skin biopsies obtained from the patient before T cell infusion, postinfusion biopsies demonstrated loss of MART-1 expression, evidence of melanocyte damage, and the complete absence of melanocytes in affected regions of the skin. This study provides, for the first time, direct evidence in humans that antigen-specific immunotherapy can target not only antigen-positive tumor cells in vivo but also normal tissues expressing the shared tumor antigen.

Elimination of CD4(+) T cells enhances anti-tumor effect of locally secreted interleukin-12 on B16 mouse melanoma and induces vitiligo-like coat color alteration

CD4(+) T cells have been reported to suppress immunity against cancer in certain animal models. In this study, we investigated the role of CD4(+) T cells in the anti-tumor immune response when interleukin-12-producing melanoma cells are inoculated in mice. We found that interleukin-12-transfected B16 melanoma showed retarded tumor growth in syngeneic mice; however, all the mice developed tumors eventually. In vivo depletion of CD4(+) T cells led to complete regression of B16/interleukin-12 tumors in 12 of 20 mice (60%). Immunohistochemical analyses revealed that a number of CD8(+) T cells accumulated in close proximity to the B16/interleukin-12 tumors in the CD4(+) T cell-depleted mice, whereas CD8(+) T cells were only scarcely observed at the periphery of the tumors in control immunocompetent mice. Furthermore, 10 of 20 mice treated with both B16/interleukin-12 inoculation and CD4(+) T cell depletion exhibited vitiligo-like coat color alteration. B16/interleukin-12 tumors completely regressed in all the mice with vitiligo. Histologic examination showed that CD8(+) lymphocytes accumulated around the hair bulbs of mice with vitiligo, but not in those without vitiligo. These results suggest that CD4(+) T cells have an inhibitory effect on tumor rejection by suppressing cytotoxic CD8(+) T cells in this melanoma loading model with local interleukin-12 secretion. To investigate the mechanism of enhanced anti-tumor effects by CD4(+) T cell depletion, we examined the T helper type 1/2 cytokine profile in the tumor draining lymph nodes of B16/interleukin-12-bearing mice with or without CD4(+) T cell depletion using the reverse transcription-polymerase chain reaction method. We found that CD4(+) T cell depletion eliminated T helper type 2 cells and resulted in a T helper type 1-dominant cytokine profile in tumor draining lymph nodes. We emphasize that this T helper type 1-dominant cytokine profile may generate further activated CD8(+) T cells against B16 melanoma cells, lead B16/interleukin-12 to regress, and result in the destruction of the melanocytes in hair bulbs due to cross-antigenicity between both cell types. This mouse model not only demonstrates the depletion of CD4(+) T cells as a useful strategy for cancer gene therapy with interleukin-12 but also provides a model for human melanoma-associated vitiligo.J Invest Dermatol 115:1059-1064 2000

Growth hormone deficiency in autoimmune polyglandular disease type 1

This is a case report of 2 patients who were diagnosed to have autoimmune polyglandular disease type 1. Both developed mucocutaneous candidiasis, hypoparathyroidism, vitiligo, and adrenocortical insufficiency. Both were noticed to have subnormal linear growth velocity and delayed bone age. Both showed subnormal stimulated serum growth hormone values indicating growth hormone deficiency. The first case showed favorable response to growth hormone therapy.

In vivo delayed-type hypersensitivity in 109 patients with vitiligo

BACKGROUND

Although the etiology of the depigmentation disorder vitiligo is still not completely understood, many investigators believe that an autoimmune reaction may play a major role. In this regard, T-lymphocyte-mediated immunity has been implicated frequently in the pathogenesis of the disease. Most studies have applied in vitro testing of cell-mediated immunity, however, rather than in vivo measurements. Therefore, our study was undertaken to define the cutaneous delayed-type hypersensitivity (DTH) in vivo reaction in association with the absence/presence of serum thyroid autoantibodies, which are a good representative marker for autoimmunity in patients with vitiligo.

METHODS

DTH was evaluated in the normal pigmented skin of 109 vitiligo patients (29 men and 80 women) and in the depigmented skin of 27 of this group (5 men and 22 women) using the dermal application of seven common recall antigens together with a negative control. Individuals were considered to be hypoergic if the DTH sum score was </= 5 mm in women or </= 10 mm in men, or if they responded to only one or two antigens.

RESULTS

The mean sum score was 10.2 +/- 8.4 with an average of 2.3 +/- 1.6 positive reactions in depigmented skin vs. a sum score of 12.4 +/- 9. 0 with an average number of 2.6 +/- 1.6 positive reactions in normal pigmented skin. There was no statistically significant difference between depigmented and normal pigmented skin using the paired t-test (P > 0.05). Further evaluation of these data showed no significant correlation between the presence of thyroid autoantibodies as well as selected clinical parameters and an aberration in cutaneous DTH.

CONCLUSIONS

In contrast to earlier reports, our in vivo studies of cutaneous DTH reactions revealed no clinically significant aberrant cellular immunity in this patient group. These results indicate that the immune reaction in vitiligo may be only a secondary event in the pathogenesis of the disease.

Clonal expansion of Melan A-specific cytotoxic T lymphocytes in a melanoma patient responding to continued immunization with melanoma-associated peptides

Peptides derived from human tumor antigens have been used in a number of clinical trials to induce specific immune responses against autologous tumors in cancer patients. Although favorable clinical results were observed in single patients, immune responses correlating with tumor regression were either not detected or in case of responses, the T-cell specificity was difficult to demonstrate. In this study, we analyzed antigen-specific T-cell responses induced in the skin and in peripheral blood lymphocytes (PBL) in an HLA-A2-positive melanoma patient. The patient showed major regression of metastatic melanoma under continued immunization with peptides derived from the melanocyte differentiation antigens Melan A/MART-1, tyrosinase and gp100/Pmel17. Based on the identification of different T-cell receptor (TCR) families reactive with Melan A/MART-1, we have demonstrated that i.d. immunization with peptides alone leads to oligoclonal expansion of Melan A/MART-1-specific cytotoxic T lymphocytes (CTL), detectable in local delayed-type hypersensitivity (DTH) reactions and PBL. A monoclonal expansion of a Melan A/MART-1-specific TCR VB 16 CTL was reproducibly observed after in vitro stimulation with Melan A/MART-1 peptides. The same TCR VB 16 CTL clone was detected in skin biopsies taken from vitiligo areas. Our findings provide strong evidence for the effective induction of specific T-cell responses to Melan A/MART-1 by i.d. immunization with peptide alone, which accounts for dermal depigmentation, specific cytotoxicity against Melan A/MART-1-expressing melanoma cells and clinical tumor regression.

Genetic immunization of mice with human tyrosinase-related protein 2: implications for the immunotherapy of melanoma

The melanosomal protein TRP2 expressed by melanocytes and most melanoma cells is an attractive, clinically relevant model antigen for the experimental development of melanoma immunotherapy in mice. A peptide shared by murine and human TRP2 can be recognized by melanoma-reactive CTL in C57BL/6 mice, as well as in human melanoma patients. Previous experiments demonstrated that gene gun immunization of mice with plasmid DNA encoding autologous murine TRP2 was unable to induce protective immunity against B16 melanoma cells naturally expressing TRP2. In the present study, we investigated whether the use of cDNA encoding xenogeneic human TRP2, which is highly homologous to murine TRP2, would be more effective. Genetic immunization of mice with human TRP2 resulted in coat depigmentation as a sign of autoimmune-mediated destruction of melanocytes and provided significant protection against metastatic growth of B16 melanoma Induction of protective immunity was associated with TRP2-reactive antibodies and CD8+ T cells. Furthermore, immunization with recombinant adenovirus was more effective than immunization with plasmid DNA using the gene gun. Our results provide new insights for the development of antigen-specific immunotherapy of melanoma.

Genetic vaccination with "self" tyrosinase-related protein 2 causes melanoma eradication but not vitiligo

"Self" melanocyte differentiation antigens are potential targets for specific melanoma immunotherapy. Vaccination against murine tyrosinase-related protein (TRP)-1/gp75 was shown recently to cause melanoma rejection, which was accompanied by autoimmune skin depigmentation (vitiligo). To further explore the linkage between immunotherapy and autoimmunity, we studied the response to vaccination with a related antigen, TRP-2. i.m. inoculation of plasmid DNA encoding murine trp-2 elicited antigen-specific CTLs that recognized the B16 mouse melanoma and protected the mice from challenge with tumor cells. Furthermore, mice bearing established s.c. B16 melanomas rejected the tumor upon vaccination with a recombinant vaccinia virus encoding trp-2. Depletion experiments showed that CD8+ lymphocytes and natural killer cells were crucial for the antitumor activity of the trp-2-encoding vaccines. Mice that rejected the tumor did not develop generalized vitiligo, indicating that protective immunity can be achieved in the absence of widespread autoimmune aggression.

[How I explore ... vitiligo]

Vitiligo is likely a syndrome rather than a disease. Several pathogenic causes are indeed recognized. The exploration of such condition encompasses three distinct facets. Establishing the diagnosis and a precise typing of the skin clinical presentation represents the first step. The ophthalmologic examination is mandatory in order to detect infraclinical signs of uveitis and retinopathy. Auditory problems can also be present. Searching for associated diseases should be oriented in priority toward alopecia areata and some specific autoimmune endocrinopathies.

Association of the Köbner phenomenon with disease activity and therapeutic responsiveness in vitiligo vulgaris

OBJECTIVE

To investigate the association between the experimentally induced Kobner phenomenon (KP-e) and the Kobner phenomenon by history (KP-h), disease activity, and therapeutic responsiveness in vitiligo vulgaris.

DESIGN

Cohort study.

SETTING

An outpatient clinic.

PATIENTS

Sixty-one consecutive patients with vitiligo vulgaris.

INTERVENTION

Three months after a standardized epidermodermal injury was induced, the KP-e was evaluated. For 1 year, UV-B (311 nm) therapy or topical fluticasone propionate plus UV-A therapy was given, depending on the severity of depigmentation.

MAIN OUTCOME MEASURES

The presence or absence of the KP-e and the KP-h disease activity as scored on a 6-point scale from -1 to +4 (vitiligo disease activity [VIDA] score) and therapy-induced repigmentation grade.

RESULTS

Nineteen (31%) of the patients had a positive KP-h, whereas 37 (61%) showed a positive KP-e (P<.001). The VIDA score did not always predict a positive KP-e, although patients with a positive KP-e had a higher mean VIDA score (VIDA score of 1.6) than did patients with a negative KP-e (VIDA score of 0.5) (P<.001). The responsiveness to UV-B (311 nm) therapy among KP-e-positive or KP-e-negative patients was not significantly different (P=.66). However, KP-e-positive patients who were treated with fluticasone propionate plus UV-A showed a better response than did KP-e-negative patients (P=.01). Among patients responding to both therapies, VIDA scores were significantly decreased (P<.001) compared with VIDA scores before therapy.

CONCLUSION

The KP-e may function well as a clinical factor to assess present disease activity and may also predict the responsiveness to fluticasone propionate plus UV-A therapy but not to UV-B (311 nm) therapy.

Vogt-Koyanagi-Harada syndrome after cutaneous injury

OBJECTIVE

To describe three patients who developed Vogt-Koyanagi-Harada syndrome (VKH) after cutaneous injury.

DESIGN

Retrospective case series.

PARTICIPANTS

Three patients seen in the uveitis clinic at Aravind Eye Hospital and Postgraduate Institute of Ophthalmology, Madurai, India, participated.

MAIN OUTCOME MEASURES

The history, evaluation, and management of the three patients were summarized.

RESULTS

Three patients developed VKH syndrome shortly after cutaneous injury. In each case, the affected area of skin became vitiliginous on healing and simultaneous with the onset of ocular symptoms. One patient developed additional ectopic areas of vitiligo. All three patients developed chronic, bilateral, diffuse uveitis, one associated with an exudative retinal detachment and two with Dalen-Fuchs-like nodules. Well-recognized complications of VKH syndrome that occurred in the authors' patients included geographic atrophy of the retinal pigment epithelium (3 of 3), cataract (3 of 3), and glaucoma (1 of 3). Ocular inflammation was well controlled in each patient with local or systemic corticosteroids or both. In one patient, the area of vitiligo showed increased pigmentation in response to systemic corticosteroid treatment.

CONCLUSIONS

Vogt-Koyanagi-Harada syndrome may follow cutaneous injury, supporting the notion that this disorder may result from systemic sensitization to shared melanocytic antigens.

Vogt-Koyanagi-Harada syndrome in children

PURPOSE

To describe the clinical presentation and natural history of Vogt-Koyanagi-Harada (VKH) syndrome in children, an often unrecognized cause of pediatric uveitis.

METHODS

We performed a clinic-based cross-sectional survey and retrospective review of pediatric patients with VHK seen in the uveitis clinic at the Aravind Eye Hospital, Madurai, India, between January 1993 and December 1995.

RESULTS

A total of 98 patients with VKH syndrome were seen in the uveitis clinic at the Aravind Eye Hospital during the three years covered by the survey, of whom three (about 3%, with an approximate incidence of 1 case/year) were children 16 years of age or younger. Initial symptoms included eye pain, redness, and blurred vision in all three patients. Headache and dysacusis accompanied the onset of visual symptoms in one patient. Each patient eventually developed areas of vitiligo and poliosis, although these signs were not present at the time of presentation in any of our patients. Signs of active uveitis included anterior chamber and vitreous inflammation, optic disc edema, exudative retinal detachments, and Dalen-Fuchs'-like nodules. All three patients developed cataracts, two developed retinal pigment epithelium atrophy, and one developed glaucoma. Each patient responded well, with good visual recovery, to topical and/or systemic corticosteroids.

CONCLUSIONS

Although frequently unrecognized, VKH syndrome may affect children. As with adults, visual loss occurs most typically as the result of cataract, glaucoma, or retinal pigment epithelium atrophy.

Autoimmune polyglandular syndromes

Autoimmune polyglandular syndrome type 1 (APS1) is characterized by a variable combination of disease components: (1) mucocutaneous candidiasis; (2) autoimmune tissue destruction; (3) ectodermal dystrophy. The disease is caused by mutations in a single gene called APECED (autoimmune polyendocrinopathy-candidiasis-ectodermal-dystrophy) or AIRE (autoimmune regulator) coding for a putative transcription factor featuring two zinc-finger (PHD-finger) motifs. APS1 shows a penetrance of 100%, lack of female preponderance and lack of association with HLA-DR. Typically, onset of APS1 occurs in childhood and multiple autoimmune manifestations evolve throughout lifetime. Organ-specific autoantibodies associated with hypoparathyroidism, adrenal and gonadal failures, IDDM, hepatitis and vitiligo are discussed, and autoantibody patterns in APS1 patients are compared with autoantibodies in APS type 2 (APS2). APS2 is characterized by adult onset adrenal failure associated with IDDM and/or hyperthyroidism. APS2 is believed to be polygenic, characterized by dominant inheritance and association with HLA DR3.

Vitiligo

The destruction of melanocytes is the cause of depigmented maculae that clinically represent the disease vitiligo. Although the cause is unknown, various theories such as the autoimmune, autocytotoxic, and neural hypotheses have been proposed. Extensive research has provided numerous answers regarding the pathogenesis, histopathologic evidence, and treatment of vitiligo. This discussion of vitiligo summarizes the varied clinical presentations of the disease, theories attempting to explain the mechanism of melanocyte destruction, histopathologic findings, and different treatment modalities currently available.

Epidermal reconstructs in vitiligo: an extrinsic factor is needed to trigger the disease

The primary cellular or molecular targets accounting for melanocytes loss in vitiligo are not clearly identified. To study a putative latent epidermal defect in the epidermis of vitiligo patients, we performed in vitro studies using cultured vitiligo melanocytes and keratinocytes transplanted on to a dead de-epidermized dermis according to a variant of Pruniéras' technique. Control autologous constructs were made with keratinocytes and melanocytes of normal adult epidermis and vitiligo epidermis from perilesional skin. For heterologous reconstructs we combined vitiligo-derived melanocytes or keratinocytes with their normal phototype-matched counterpart. After 15 days of culture at the air-liquid interface, epidermal reconstructs were studied macroscopically and microscopically. Immunohistochemistry was performed using antibodies to TRP-1 and NKI-beteb. All heterologous and autologous reconstructs made with melanocytes and keratinocytes from vitiligo patients had a normal histology and ultrastructure. For vitiligo melanocytes or normal melanocytes submitted to the influence of vitiligo keratinocytes, immunophenotype and function (pigment production and transfer) were similar to normal controls. So, without additional noxious stimuli, we could not discriminate between melanocytes and keratinocytes as inducers of the disease. Our data suggest that the basic abnormality in vitiligo vulgaris needs extrinsic factors to be macroscopically revealed or requires a longer period of culture to develop. Our model will allow analysis of the various pathophysiological mechanisms of vitiligo, e.g. autoantibodies or oxidative stress, at the cellular, biochemical or molecular level.

[Anogenital condylomata acuminata, mucocutaneous candidiasis, vitiligo, keratopathy and primary hypoparathyroidism in an autoimmune polyglandular syndrome type 1]

HISTORY

6 months before admission a 21-year-old woman had developed anogenital condylomata acuminata (CA). Since early childhood she had been treated for primary hypoparathyroidism (PHPT) and recurrent mucocutaneous candidiasis. 5 years before admission corneal clouding had caused visual impairment. Recently, mainly truncal vitiligo with occipital poliosis had developed.

INVESTIGATIONS

PHPT was confirmed (parathormone level 7.7 mg/l). In addition, liver transaminases were raised (GOT 105.8 U/l, GPT 145.6 U/l, gamma-GT 56.8 U/l), pointing to noninfectious hepatitis. An ACTH stress test could not exclude manifest adrenocortical insufficiency, and thyroid function was also normal. The Merieux Multitest indicated an anergy.

DIAGNOSIS, TREATMENT AND COURSE

The constellation of test results suggested autoimmune polyglandular syndrome type I. The condylomata were treated by electrocautery and the intestinal candidiasis with amphotericin B suspension. Calcitriol capsules, 0.5 microgram, and calcium gluconate or lactate, 500 and 300 mg respectively, 3 times daily each, were given for the PHPT.

CONCLUSION

This case demonstrates a complex syndrome which can be recognized early by simple clinical tests. Early diagnosis prevents possible life-threatening complications.