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Dunlea DM, Fee LT, McEnery T, McElvaney NG, Reeves EP. The impact of alpha-1 antitrypsin augmentation therapy on neutrophil-driven respiratory disease in deficient individuals. J Inflamm Res 2018; 11:123-134. [PMID: 29618937 PMCID: PMC5875399 DOI: 10.2147/jir.s156405] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Alpha-1 antitrypsin (AAT) is the most abundant serine protease inhibitor circulating in the blood. AAT deficiency (AATD) is an autosomal codominant condition affecting an estimated 3.4 million individuals worldwide. The clinical disease associated with AATD can present in a number of ways including COPD, liver disease, panniculitis and antineutrophil cytoplasmic antibody vasculitis. AATD is the only proven genetic risk factor for the development of COPD, and deficient individuals who smoke are disposed to more aggressive disease. Principally, AAT is a serine protease inhibitor; however, over the past number of years, the assessment of AAT as simply an antiprotease has evolved, and it is now recognized that AAT has significant anti-inflammatory properties affecting a wide range of cells, including the circulating neutrophil.
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Affiliation(s)
- Danielle M Dunlea
- Irish Centre for Genetic Lung Disease, Department of Medicine, Royal College of Surgeons in Ireland, Beaumont Hospital, Dublin, Ireland
| | - Laura T Fee
- Irish Centre for Genetic Lung Disease, Department of Medicine, Royal College of Surgeons in Ireland, Beaumont Hospital, Dublin, Ireland
| | - Thomas McEnery
- Irish Centre for Genetic Lung Disease, Department of Medicine, Royal College of Surgeons in Ireland, Beaumont Hospital, Dublin, Ireland
| | - Noel G McElvaney
- Irish Centre for Genetic Lung Disease, Department of Medicine, Royal College of Surgeons in Ireland, Beaumont Hospital, Dublin, Ireland
| | - Emer P Reeves
- Irish Centre for Genetic Lung Disease, Department of Medicine, Royal College of Surgeons in Ireland, Beaumont Hospital, Dublin, Ireland
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2
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Sabbagh DK, Barmayehvar B, Nguyen T, Edgar RG, Turner AM. Managing panniculitis in alpha-1 antitrypsin deficiency: Systematic review of evidence behind treatment. World J Dermatol 2018; 7:1-8. [DOI: 10.5314/wjd.v7.i1.1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Revised: 11/27/2017] [Accepted: 12/07/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To systematically review literature for management of alpha-1 antitrypsin deficiency (AATD) panniculitis.
METHODS Multiple databases were searched using combinations of pertinent terms. Articles were selected describing panniculitis treatment in patients with AAT < 11 μmol and/or PiZZ genotype, with no language limitation. All relevant articles were accessed in full text. Independent review of abstracts and full manuscripts was conducted by 2 reviewers, and quality assessment by one reviewer (checked by a second). Data extraction was conducted by one reviewer (checked by a second). Narrative synthesis only was conducted, as data were unsuitable for meta-analysis.
RESULTS Thirty-two case reports and 4 case series were found. Augmentation therapy (infusions of plasma-derived AAT) was the most successful, with complete resolution of symptoms in all patients. Dapsone is a less expensive option, and it achieved clinical resolution in 62% of patients, but it is very poorly tolerated. Among other single-agent antibiotics, doxycycline was the most successful with complete clinical resolution seen in 33% of patients. Immunosuppressants were largely unsuccessful; 80% of patients exhibited no response. Liver transplantation and therapeutic plasma exchange displayed complete resolution in 66% of patients. Other strategies, such as non-steroidal anti-inflammatory drugs or antibiotics other than dapsone did not show sufficient response rates to recommend their use. Authors note the risk of bias imposed by the type of evidence (case reports, case series) available in this field.
CONCLUSION Dapsone is the recommended first line therapy for AATD panniculitis, followed by augmentation therapy. Plasma exchange may be an alternative in the setting of rapidly progressive disease.
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Affiliation(s)
- Donah K Sabbagh
- the Medical Research Institute of New Zealand (MRINZ), CSB Building, Wellington Hospital, Newtown, Wellington 6021, New Zealand
| | - Behrad Barmayehvar
- Department of Colorectal Surgery, the Royal Wolverhampton Trust, Wolverhampton Road, West Midlands WV10 0QP, United Kingdom
| | - Thanh Nguyen
- Department of Intensive Care, United Lincolnshire Hospitals NHS Trust, Lincolnshire LN2 4AX, United Kingdom
| | - Ross G Edgar
- Therapy Services, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2WG, United Kingdom
| | - Alice M Turner
- Institute of Applied Health Research, University of Birmingham, Birmingham B15 2TT, United Kingdom
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3
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α 1-Antitrypsin infusion for treatment of steroid-resistant acute graft-versus-host disease. Blood 2018; 131:1372-1379. [PMID: 29437593 DOI: 10.1182/blood-2017-11-815746] [Citation(s) in RCA: 73] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2017] [Accepted: 01/24/2018] [Indexed: 12/17/2022] Open
Abstract
Corticosteroid resistance after acute graft-versus-host disease (SR-aGVHD) results in high morbidity and mortality after allogeneic hematopoietic cell transplantation. Current immunosuppressive therapies for SR-aGVHD provide marginal effectiveness because of poor response or excessive toxicity, primarily from infection. α1-Antitrypsin (AAT), a naturally abundant serine protease inhibitor, is capable of suppressing experimental GVHD by downmodulating inflammation and increasing ratios of regulatory (Treg) to effector T cells (Teffs). In this prospective multicenter clinical study, we sought to determine the safety and response rate of AAT administration in SR-aGVHD. Forty patients with a median age of 59 years received intravenous AAT twice weekly for 4 weeks as first-line treatment of SR-aGVHD. The primary end point was overall response rate (ORR), the proportion of patients with SR-aGVHD in complete (CR) or partial response by day 28 without addition of further immunosuppression. Treatment was well tolerated without drug-related adverse events. A significant increase in serum levels of AAT was observed after treatment. The ORR and CR rates by day 28 were 65% and 35%, respectively, and included responses in all aGVHD target organs. At day 60, responses were sustained in 73% of patients without intervening immunosuppression. Infectious mortality was 10% at 6 months and 2.5% within 30 days of last AAT infusion. Consistent with preclinical data, correlative samples showed an increase in ratio of activated Tregs to Teffs after AAT treatment. These data suggest that AAT is safe and may be potentially efficacious in treating SR-aGVHD. This trial was registered at www.clinicaltrials.gov as #NCT01700036.
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Velter C, Lipsker D. [Cutaneous panniculitis]. Rev Med Interne 2016; 37:743-750. [PMID: 27321570 DOI: 10.1016/j.revmed.2016.05.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2015] [Revised: 02/02/2016] [Accepted: 05/10/2016] [Indexed: 01/08/2023]
Abstract
Panniculitis is an inflammation of the subcutaneous fat. Skin biopsy plays a critical role in the differential diagnosis of panniculitis. The most common approach to diagnosis relies on the differentiation between predominantly septal or lobular panniculitis, followed by the distinction between lesions with and without vasculitis. It is also very important to submit a part of the skin biopsy for microbiological analysis and for T-cell clonal expansion if T-cell lymphoma is suspected. Erythema nodosum, the most frequent septal panniculitis, has many causes and in its typical clinical presentation, does not require skin biopsy. In other panniculitis, diagnosis is based on the integration of the clinical and histological data, which renders a deep cutaneous biopsy necessary. Periarteritis nodosa, a septal panniculitis with vasculitis characterized by subcutaneous nodules and livedo racemosa, can be associated with systemic involvement. Nodular thrombophlebitis needs search for associated coagulopathy, Behçet's disease, periarteritis nodosa or Buerger's disease. Lobular panniculitis are classified according to the nature of cells present in the inflammatory infiltrate. If there is a lymphocytic infiltration, lupus panniculitis is difficult to differentiate from subcutaneous panniculitis-like T-cell lymphoma. If there are histiocytes, it can be a sarcoidosis, a cytophagic histiocytic panniculitis or, in newborn, a subcutaneous fat necrosis. Neutrophilic panniculitis needs careful clinic-pathologic correlation. Treatment of panniculitis can be challenging and is based on the histopathological findings. Frequently, the precise cause of panniculitis cannot be established from the outset, so it is important to follow-up patients and not hesitate to repeat the skin biopsy.
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Affiliation(s)
- C Velter
- Clinique dermatologique, hôpitaux universitaires de Strasbourg, faculté de médecine, université de Strasbourg, 1, place de l'Hôpital, 67091 Strasbourg, France.
| | - D Lipsker
- Clinique dermatologique, hôpitaux universitaires de Strasbourg, faculté de médecine, université de Strasbourg, 1, place de l'Hôpital, 67091 Strasbourg, France
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5
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Yu Y, Rubin AG, Gee S, Banker S, Kim CN. Ulcerative panniculitis with fevers and pleural effusions: A unique case of α1-antitrypsin deficiency. JAAD Case Rep 2015; 1:1-2. [PMID: 27075122 PMCID: PMC4802580 DOI: 10.1016/j.jdcr.2014.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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6
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Hypersensitivity vasculitis with leukocytoclastic vasculitis associated with alpha-1-proteinase inhibitor. Case Rep Med 2010; 2009:941258. [PMID: 20204065 PMCID: PMC2829622 DOI: 10.1155/2009/941258] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2009] [Accepted: 11/18/2009] [Indexed: 11/17/2022] Open
Abstract
Prolastin is a commercially available form of alpha-1-antitrypsin (AAT) that is derived from pooled human plasma and used for treatment of severe alpha-1-antitrypsin deficiency (AATD). We describe a patient with AATD who developed presumed hypersensitivity vasculitis (HV) following a Prolastin infusion. Hypersensitivity vasculitis (HV), or cutaneous vasculitis, is characterized by inflammation of the small vessels of the skin with resultant ischemia to the distally supplied areas. To our knowledge, this is the first reported case of presumed hypersensitivity vasculitis following Prolastin infusion.
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8
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American Thoracic Society/European Respiratory Society statement: standards for the diagnosis and management of individuals with alpha-1 antitrypsin deficiency. Am J Respir Crit Care Med 2007; 168:818-900. [PMID: 14522813 DOI: 10.1164/rccm.168.7.818] [Citation(s) in RCA: 632] [Impact Index Per Article: 37.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
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9
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Ortiz PG, Skov BG, Benfeldt E. Alpha1-antitrypsin deficiency-associated panniculitis: case report and review of treatment options. J Eur Acad Dermatol Venereol 2005; 19:487-90. [PMID: 15987301 DOI: 10.1111/j.1468-3083.2005.01194.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Alpha(1)-antitrypsin deficiency, a relatively frequent mutation in the population, is associated with the development of panlobular emphysema and liver cirrhosis. The deficiency is in rare cases associated with the development of panniculitis, and very differentiated clinical courses have been reported in the literature. We report a case of panniculitis in a patient with alpha(1)-antitrypsin deficiency and describe briefly the pathophysiology of the disease and current treatment possibilities.
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Affiliation(s)
- P G Ortiz
- Department of Dermatology, Univeristy of Copenhagen, Gentofte Hospital, Niels Andersens Vej 65, DK 2900 Hellerup, Denmark.
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10
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Patterson CC, Ross P, Pope-Harman AL, Knight DA, Magro CM. Alpha-1 anti-trypsin deficiency and Henoch-Schonlein purpura associated with anti-neutrophil cytoplasmic and anti-endothelial cell antibodies of immunoglobulin-A isotype. J Cutan Pathol 2005; 32:300-6. [PMID: 15769280 DOI: 10.1111/j.0303-6987.2005.00304.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Alpha-1 anti-trypsin (A1AT) deficiency is an inherited enzyme deficiency that manifests with fatal lung and liver complications. In addition to pulmonary and hepatic involvement, the disease has also been linked to an increased incidence of vasculitic syndromes and autoimmune diseases, including Wegener's granulomatosis, microscopic polyarteritis nodosa and Henoch-Schonlein purpura (HSP). HSP, a systemic, small-vessel vasculitis syndrome, is characterized by a non-thrombocytopaenic purpuric rash, arthralgia, abdominal pain and nephritis. Both A1AT deficiency and HSP have been associated with anti-neutrophil cytoplasmic antibodies (ANCA) and anti-endothelial cell antibodies (AECA). We report a case of a 40-year-old man with severe A1AT deficiency, who developed HSP associated with AECA, ANCA and anti-phospholipid antibodies of the immunoglobulin-A isotype.
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11
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Abstract
BACKGROUND Alpha-1-antitrypsin is the principal serum protease inhibitor. In addition to the well-recognized association with early-onset emphysema and cirrhosis, alpha-1-antitrypsin deficiency may be associated with panniculitis. The treatment of this type of panniculitis presents a significant challenge. Previous attempts using immunosuppressive, anti-inflammatory, and cytotoxic drugs have shown variable results. AIM To report a case of alpha-1-antitrypsin deficiency-associated panniculitis treated with plasma exchange therapy. METHODS A 23-year-old patient developed painful red nodules on her thighs and buttocks with spontaneous ulceration and discharge of oily fluid. A skin biopsy specimen showed septal and lobular panniculitis. The serum alpha-1-antitrypsin level was 22 mg/dL. She was treated with plasma exchange therapy. RESULTS Treatment of this patient with plasma exchange therapy led to the control of the cutaneous lesions. CONCLUSIONS Plasma exchange therapy represents an alternative treatment which restores serum and tissue alpha-1-antitrypsin levels. This method is proposed because of its clinical benefits and greater availability.
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12
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German AJ, Foster AP, Holden D, Hotston Moore A, Day MJ, Hall EJ. Sterile nodular panniculitis and pansteatitis in three weimaraners. J Small Anim Pract 2003; 44:449-55. [PMID: 14582659 DOI: 10.1111/j.1748-5827.2003.tb00104.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The clinical and pathological findings in three unrelated weimaraners with pyrexia and multiple subcutaneous nodules are reported. Abdominal pain was an additional feature in two of the dogs and clinical investigations revealed inflammation of subcutaneous, mesenteric and falciform fat. Histopathological findings were consistent with pansteatitis. In the third dog, lesions were apparently limited to the subcutis and, hence, a diagnosis of nodular panniculitis was made. Microbiological examination of tissues was negative in all dogs, and there was no evidence of pancreatic disease. This report thus describes a presumed sterile and idiopathic panniculitis/pansteatitis complex in weimaraner dogs. Although the aetiology is unknown, this may represent an immune-mediated disorder.
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Affiliation(s)
- A J German
- Department of Clinical Veterinary Science, University of Bristol, Langford House, Bristol BS40 5DU
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13
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Parr DG, Stewart DG, Hero I, Stockley RA. Panniculitis secondary to extravasation of clarithromycin in a patient with alpha 1-antitrypsin deficiency (phenotype PiZ). Br J Dermatol 2003; 149:410-3. [PMID: 12932253 DOI: 10.1046/j.1365-2133.2003.05530.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
alpha 1-Antitrypsin deficiency (AATD) is known to be associated with panniculitis. Although reports of this association are rare, the true incidence may be unappreciated because of underdiagnosis of AATD. We report a case of panniculitis occurring in a 34-year-old woman with severe AATD following the extravasation of clarithromycin infused intravenously for treatment of community-acquired pneumonia. Resolution occurred with conservative management. The histopathology and management of this unusual condition are discussed, with a review of the literature.
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Affiliation(s)
- D G Parr
- Department of Pulmonology, University Hospital Birmingham, Birmingham, UK
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14
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Solans R, Cortés J, Selva A, Garcia-Patos V, Jimenez FJ, Pascual C, Bosch J, Vilardell M. Panniculitis: a cutaneous manifestation of dermatomyositis. J Am Acad Dermatol 2002; 46:S148-50. [PMID: 12004297 DOI: 10.1067/mjd.2002.107491] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Specific and nonspecific panniculitis sometimes occurs during the course of connective tissue diseases. However, the association of panniculitis and dermatomyositis (DM) has only rarely been described. Previous reports have suggested that panniculitis may be an inherent part of DM but, because the cases reported are few, it is difficult to know the significance of this unusual association. We describe 2 patients with DM in whom panniculitis developed during the course of the disease, and discuss its clinical and diagnostic significance.
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Affiliation(s)
- Roser Solans
- Department of Internal Medicine and Dermatology Division, Vall d'Hebrón University General Hospital, Barcelona, Spain.
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15
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Abstract
UNLABELLED The second part of our review of panniculitis summarizes the clinicopathologic features of the mostly lobular panniculitides. Erythema induratum of Bazin (nodular vasculitis) represents the most common variant of lobular panniculitis with vasculitis, although controversy persists about the nature of the involved vessels. Mostly lobular panniculitides without vasculitis comprise a series of disparate disorders. These include sclerosing panniculitis that results from chronic venous insufficiency of the lower extremities; panniculitis with calcification of the vessel walls such as calciphylaxis and oxalosis; and inflammatory diseases with crystals within the adipocytes such as sclerema neonatorum, subcutaneous fat necrosis of the newborn, and poststeroid panniculitis. Connective tissue diseases, such as systemic lupus erythematosus and dermatomyositis, pancreatic diseases, and alpha(1)-antitrypsin deficiency may also show a mostly lobular panniculitis with characteristic histopathologic features. Lobular panniculitis may also be an expression of infections, trauma, or factitial causes involving the subcutaneous fat. Lipoatrophy refers to a loss of subcutaneous fat due to a previous inflammatory process involving the subcutis, and it may be the late-stage lesion of several types of panniculitis. In contrast, lipodystrophy means an absence of subcutaneous fat with no evidence of inflammation and often the process is associated with endocrinologic, metabolic, or autoimmune diseases. Finally, cytophagic histiocytic panniculitis is the term that has been used to describe two different processes: one is inflammatory, a lobular panniculitis, and the other one is neoplastic, a subcutaneous T-cell lymphoma. The only common feature of these two different processes is the presence of cytophagocytosis in the lesions. (J Am Acad Dermatol 2001;45:325-61.) LEARNING OBJECTIVE At the completion of this learning activity, participants should be familiar with the pathogenesis, clinical manifestations, histopathologic findings, and treatment options for the most frequent variants of the lobular panniculitides.
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Affiliation(s)
- L Requena
- Department of Dermatology, Fundación Jiménez Díaz, Universidad Autónoma, Madrid, Spain
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16
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Chng WJ, Henderson CA. Suppurative panniculitis associated with alpha 1-antitrypsin deficiency (PiSZ phenotype) treated with doxycycline. Br J Dermatol 2001; 144:1282-3. [PMID: 11422069 DOI: 10.1046/j.1365-2133.2001.04260.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Coakley RJ, Taggart C, O'Neill S, McElvaney NG. Alpha1-antitrypsin deficiency: biological answers to clinical questions. Am J Med Sci 2001; 321:33-41. [PMID: 11202478 DOI: 10.1097/00000441-200101000-00006] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Alpha1-antitrypsin (alpha1AT) deficiency is a common lethal hereditary disorder of white persons of European descent. The condition is characterized by reduced serum levels of alpha1AT, a 52-kDa glycoprotein synthesized chiefly in the liver and, to a lesser extent, by macrophages and neutrophils. Alpha1AT acts as an antiprotease and is the physiological inhibitor of neutrophil serine proteases such as neutrophil elastase cathepsin G and proteinase 3. The clinical manifestations of alpha1AT deficiency occur chiefly in the lung, with a high risk of emphysema occurring by the third or fourth decade of life. Cigarette smoking accelerates the development of emphysema in persons with alpha1AT deficiency. There is also an increased risk of liver disease in alpha1AT deficiency, which occurs mostly in childhood. In this review, we will define further the diagnosis of alpha1AT deficiency and its clinical manifestations and describe the therapeutic strategies that are currently being developed to treat the hepatic and pulmonary disease associated with this condition.
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Affiliation(s)
- R J Coakley
- Pulmonary Division, Beaumont Hospital, Dublin, Ireland
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18
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Abstract
BACKGROUND Although dapsone was first synthesized in 1908, a quarter of a century was to pass before it was used in the treatment of bacterial infections. Dapsone was, however, too toxic for humans (because of the excess dosage which was administered at that time) and was thus considered to be of no value in the treatment of common bacterial infections. Since the early 1950s, dapsone has been recognized as being uniquely effective against a number of noninfectious, inflammatory diseases and, today, this is its main indication. Thus, the reason why dapsone was first introduced into medicine, namely the treatment of bacterial infections, has been set aside and its main current applications are the treatment of noninfectious, inflammatory, autoimmune, and bullous diseases. OBJECTIVE To study the anti-infective capacity of dapsone against common bacterial infections. As many patients who receive dapsone for the treatment of noninfectious, inflammatory diseases have a concomitant bacterial infection or a superinfection of their skin disease, we thought that, if dapsone proved to be effective against common bacterial infections, it may obviate the need for an additional antimicrobial drug in these patients. METHODS Three bacterial ATCC> strains (Streptococcus pyogenes, Staphylococcus aureus, and Escherichia coli) were tested by a macrodilution minimal inhibitory concentration (MIC) test for dapsone. Dapsone concentrations were between 0.06 and 1125 microg/mL. RESULTS Even the highest concentration of dapsone of 1125 microg/mL did not inhibit bacterial growth. CONCLUSIONS Our results indicate that dapsone has no antibacterial effects whatsoever. Even at very high concentrations, it does not suppress the growth of most susceptible strains of bacteria. The story of dapsone (i.e. the long time that elapsed between its synthesis to its use for the chemotherapy of infectious diseases) will not repeat itself this time.
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Affiliation(s)
- R Wolf
- Department of Dermatology, Tel-Aviv Sourasky Medical Center, Ichilov Hospital, and the Sackler Faculty of Medicine, Tel-Aviv University, Israel.
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19
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Gaillard MC, Mahadeva R, Lomas DA. Identification of DNA polymorphisms associated with the V type alpha1-antitrypsin gene. BIOCHIMICA ET BIOPHYSICA ACTA 1999; 1444:166-70. [PMID: 10023049 DOI: 10.1016/s0167-4781(98)00271-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
alpha1-Antitrypsin (alpha1-AT) is a highly polymorphic protein. The V allele of alpha1-AT has been shown to be associated with focal glomerulosclerosis (FGS) in Negroid and mixed race South African patients. To identify mutations and polymorphisms in the gene for the V allele of alpha1-AT in five South African patients with FGS nephrotic syndrome DNA sequence analysis and restriction fragment length polymorphisms of the coding exons were carried out. Four of the patients were heterozygous for the BstEII RFLP in exon III [M1(Val213)(Ala213)] and one patient was a M1(Ala213) homozygote. The mutation for the V allele was identified in exon II as Gly-148 (GGG)-->Arg (AGG) and in all patients was associated with a silent mutation at position 158 (AAC-->AAT). The patient who was homozygous for (Ala213) also had a silent mutation at position 256 in exon III (GAT-->GAC) which was not present in any of the other four patients. Although the V allele of alpha1-AT is not associated with severe plasma deficiency, it may be in linkage disequilibrium with other genes on chromosome 14 that predispose to FGS. Furthermore, the associated silent mutation at position 158 and the Ala213 polymorphism are of interest, as these could represent an evolutionary intermediate between the M1(Ala213) and M1(Val213) subtypes.
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Affiliation(s)
- M C Gaillard
- Department of Medicine, University of the Witwatersrand Medical School, 7 York Road, Parktown, Johannesburg 2193, South Africa.
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20
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Abstract
Alpha 1-Antitrypsin deficiency (PiZ) is frequent in Caucasian populations. The predominant clinical correlates of this inborn error, i.e. chronic liver disease, emphysema, and vasculitic syndromes including their pathogenetic background are discussed in the present review.
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Affiliation(s)
- S Eriksson
- Department of Medicine, Malmö University Hospital, Sweden
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Affiliation(s)
- R J Mason
- Department of Medicine, National Jewish Medical and Research Center, Denver, Colorado 80206, USA.
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22
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Abstract
The early history of alpha 1-antitrypsin deficiency, in the years between 1962 and 1965, and its impact on the understanding of emphysema abnormalities were reviewed by me in 1989. This report discusses the disease spectrum (including emphysema, liver, and vasculitic diseases) and focuses on the variable clinical expression of the deficiency state. Some new findings that may be relevant to the function of alpha 1-antitrypsin are also considered.
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Affiliation(s)
- S Eriksson
- Department of Medicine, University of Lund, University Hospital of Malmö, Sweden
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23
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Schievink WI, Puumala MR, Meyer FB, Raffel C, Katzmann JA, Parisi JE. Giant intracranial aneurysm and fibromuscular dysplasia in an adolescent with alpha 1-antitrypsin deficiency. J Neurosurg 1996; 85:503-6. [PMID: 8751640 DOI: 10.3171/jns.1996.85.3.0503] [Citation(s) in RCA: 45] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Recent studies have suggested that a deficiency of alpha 1-antitrypsin may be a genetic risk factor for the development of intracranial aneurysms and arterial fibromuscular dysplasia. The authors report a 16-year-old girl with a history of lung disease who suffered a cerebral hemorrhage due to the rupture of a giant intracranial aneurysm arising from the middle cerebral artery. This fusiform aneurysm was associated with fibromuscular dysplasia of the intimal type. She was found to have an unusual alpha 1-antitrypsin deficiency (PiMP phenotype). This case provides further evidence of an underlying arteriopathy in alpha 1-antitrypsin deficiency.
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Affiliation(s)
- W I Schievink
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
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Dowd SK, Rodgers GC, Callen JP. Effective treatment with alpha 1-protease inhibitor of chronic cutaneous vasculitis associated with alpha 1-antitrypsin deficiency. J Am Acad Dermatol 1995; 33:913-6. [PMID: 7593810 DOI: 10.1016/0190-9622(95)90436-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
The primary serum proteinase inhibitor is alpha 1-antitrypsin, and deficiency of this enzyme has been associated with a variety of systemic and cutaneous disorders. We report cutaneous vasculitis in a 49-year-old man with alpha 1-antitrypsin deficiency. His condition persisted despite treatment with colchicine, prednisone, and antibiotics but has been controlled by the administration of alpha 1-protease inhibitor.
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Affiliation(s)
- S K Dowd
- Division of Dermatology, University of Louisville School of Medicine, KY, USA
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25
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Schievink WI, Björnsson J, Parisi JE, Prakash UB. Arterial fibromuscular dysplasia associated with severe alpha 1-antitrypsin deficiency. Mayo Clin Proc 1994; 69:1040-3. [PMID: 7967755 DOI: 10.1016/s0025-6196(12)61369-x] [Citation(s) in RCA: 43] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
OBJECTIVE To elucidate the putative arteriopathy associated with alpha 1-antitrypsin (alpha 1-AT) deficiency. DESIGN We retrospectively studied the frequency of occurrence of fibromuscular dysplasia (FMD) in patients with alpha 1-AT deficiency in whom a postmortem examination had been done during a 10-year period at the Mayo Clinic. MATERIAL AND METHODS The medical records of all patients in whom an autopsy was done at the Mayo Clinic between 1983 and 1992 were reviewed to identify all those with a diagnosis of alpha 1-AT deficiency or FMD. RESULTS Arterial FMD was found in 2 of 6 patients with alpha 1-AT deficiency (33.3%; 95% confidence interval, 4.3 to 77.7%) in comparison with 23 of 6,690 patients without alpha 1-AT deficiency (0.3%; 95% confidence interval, 0.2 to 0.5%). In both patients with alpha 1-AT deficiency and FMD, the arterial media was thickened and composed of irregular arrays of muscular and connective tissue fibers in a background of mucoid ground substance. CONCLUSION These findings provide further evidence for an underlying arteriopathy in patients with alpha 1-AT deficiency and suggest that FMD may be a non-specific disorder.
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Affiliation(s)
- W I Schievink
- Department of Neurologic Surgery, Mayo Clinic Rochester, MN 55905
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26
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Geller JD, Su WP. A subtle clue to the histopathologic diagnosis of early alpha 1-antitrypsin deficiency panniculitis. J Am Acad Dermatol 1994; 31:241-5. [PMID: 8040408 DOI: 10.1016/s0190-9622(94)70155-5] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
An excisional biopsy specimen of a lesion of several days' duration in an 18-year-old woman revealed moderate splaying of neutrophils between collagen bundles throughout the reticular dermis and incipient necrosis of the dermis and subcutaneous fat. Mild infiltration of neutrophils and macrophages was seen in the septal and lobular panniculus. A biopsy performed on one of the patient's more chronic lesions demonstrated dermal necrosis, degeneration and fibrosis of septa, acute lobular panniculitis with a large number of neutrophils, and foci of subcutaneous fat necrosis with islands of sparing. Splaying of neutrophils between the collagen bundles in the reticular dermis appears to be the earliest histopathologic finding of alpha 1-antitrypsin deficiency panniculitis.
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Affiliation(s)
- J D Geller
- Department of Dermatology, Mayo Clinic, Rochester, MN 55905
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27
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Esnault VL, Testa A, Audrain M, Rogé C, Hamidou M, Barrier JH, Sesboüé R, Martin JP, Lesavre P. Alpha 1-antitrypsin genetic polymorphism in ANCA-positive systemic vasculitis. Kidney Int 1993; 43:1329-32. [PMID: 8315946 DOI: 10.1038/ki.1993.186] [Citation(s) in RCA: 152] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Alpha 1-antitrypsin (alpha 1-AT) is the major inhibitor of proteinase 3 (PR3), the main target antigen of antineutrophil cytoplasm antibodies (ANCA) in Wegener's granulomatosis. alpha 1-AT is encoded by a polymorphic gene, with over 75 alleles, defining severely, medium and non-deficient protease inhibitor (PI) phenotypes. We describe the association of severely and medium deficient PI phenotypes with anti-PR3 positive systemic vasculitis, and postulate a pathogenetic role for alpha 1-AT deficiency and the occurrence of ANCA, with specificity for PR3 in a subgroup of patients with Wegener's granulomatosis.
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Affiliation(s)
- V L Esnault
- Laboratoire d'Immunologie, Hotel Dieu, Nantes, France
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28
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Pinto AR, Maciel LS, Carneiro F, Resende C, Chaves FC, Freitas AF. Systemic nodular panniculitis in a patient with alpha-1 antitrypsin deficiency (PiSS phenotype). Clin Exp Dermatol 1993; 18:154-5. [PMID: 8481993 DOI: 10.1111/j.1365-2230.1993.tb01000.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
The association of alpha-1 antitrypsin deficiency (PiZ phenotype) with systemic nodular panniculitis has been well documented. Despite reports of cases of systemic nodular panniculitis associated with other alpha-1 antitrypsin deficiency phenotypes, it is still not known if this association is fortuitous rather than causal. We report a case of systemic nodular panniculitis associated with alpha-1 antitrypsin deficiency (PiSS phenotype), with clinico-pathological features similar to those reported in cases associated with the PiZ phenotype.
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Affiliation(s)
- A R Pinto
- Department of Medicine 2, Hospital de S. João, Porto, Portugal
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29
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McElvaney NG, Birrer P, Chang-Stroman LM, Crystal RG. Neutrophils, Neutrophil Elastase and the Fragile Lung: The Pathogenesis and Therapeutic Strategies Relating to Lung Derangement in the Common Hereditary Lung Disorders. BIOCHEMISTRY OF PULMONARY EMPHYSEMA 1992. [DOI: 10.1007/978-1-4471-3771-9_13] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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30
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Edmonds BK, Hodge JA, Rietschel RL. Alpha 1-antitrypsin deficiency-associated panniculitis: case report and review of the literature. Pediatr Dermatol 1991; 8:296-9. [PMID: 1792202 DOI: 10.1111/j.1525-1470.1991.tb00937.x] [Citation(s) in RCA: 46] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Alpha 1-antitrypsin is the primary serum proteinase inhibitor. Alpha 1-antitrypsin deficiency, especially the ZZ genotype, has been linked mainly to emphysema and cirrhosis; it is also associated with paniculitis. A case of alpha 1-AT-associated panniculitis was documented in a 13-year-old girl in whom a deficiency of the enzyme was known to be present from infancy. This is unusual, since alpha 1-AT panniculitis previously was described in older patients without prior knowledge of the duration of the deficiency. Our patient developed erythematous, subcutaneous nodules subsequent to trauma, which later developed into deep, painless ulcers. We report this case so that the condition may be suspected in patients with panniculitis. The diagnosis may be confirmed by measuring quantitative alpha 1-AT serum levels and by enzyme genotyping. The treatment of choice is dapsone.
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Affiliation(s)
- B K Edmonds
- Department of Dermatology, Ochsner Clinic, New Orleans, LA 70121
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31
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Smith KC, Su WP, Pittelkow MR, Winkelmann RK. Clinical and pathologic correlations in 96 patients with panniculitis, including 15 patients with deficient levels of alpha 1-antitrypsin. J Am Acad Dermatol 1989; 21:1192-6. [PMID: 2685058 DOI: 10.1016/s0190-9622(89)70328-5] [Citation(s) in RCA: 77] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
alpha 1-Antitrypsin levels were determined for 96 patients with various forms of biopsy-proved panniculitis. Fifteen of the 96 patients had alpha 1-antitrypsin deficiency, and 12 of these also had an abnormal alpha 1-antitrypsin phenotype. This group of patients showed substantial and characteristic clinical and histopathologic differences from the group of patients with normal levels and phenotypes of alpha 1-antitrypsin. Spontaneous ulceration and drainage of panniculitis lesions were much more common in patients with alpha 1-antitrypsin deficiency, and biopsy specimens from lesions of panniculitis in these patients were much more likely to show large areas of normal fat adjacent to necrotic lobular and septal areas, which contained many polymorphonuclear leukocytes and histiocytes. Destruction of elastic tissue was more frequent and extensive in patients with alpha 1-antitrypsin deficiency.
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Affiliation(s)
- K C Smith
- Department of Dermatology, Mayo Clinic, Rochester, MN 55905
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32
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Abstract
Two patients with benign cytophagic histiocytic panniculitis are presented and compared with the one benign and ten fatal cases previously reported. Benign-appearing histiocytes which engulf blood cells, nuclear debris, and platelets are the most characteristic feature of the disease. This cytophagia tends to be massive in the subcutaneous tissue and involves extracutaneous organs only in the fatal cases. The course is chronic in the benign form. Patients with the fatal form tend to have fever, hepatosplenomegaly, serosal effusions, ecchymoses, peripheral adenopathy, and mucosal ulcers. Anemia, leukopenia, elevated liver enzyme levels, and coagulopathy are present in almost all and hypocalcemia in many patients with a fatal course. Cytophagic histiocytic panniculitis may represent a form of regional histiocytosis primarily involving subcutaneous tissue. It is midway in the spectrum of the cytophagic histiocytoses.
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Affiliation(s)
- J W White
- Department of Dermatology, Mayo Clinic, Rochester, Minnesota
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