Conversion of the CD4+ T cell profile from T(H2)-dominant type to T(H1)-dominant type after varicella-zoster virus infection in atopic dermatitis

Case report: Varicella-zoster virus infection triggering progressive encephalomyelitis with rigidity and myoclonus

Progressive encephalomyelitis with rigidity and myoclonus (PERM) is a rare neurological disease of unknown etiology, and most patients with PERM are positive for anti-glycine receptor (GlyR) antibody. In this case study, we report a clinical case of a varicella-zoster virus-infected patient who developed anti-GlyR antibody-positive PERM. He initially suffered from herpes zoster and gradually developed symptoms of impaired brainstem functions including hoarse voice and dysphagia, accompanied by paroxysmal sympathetic hyperactivity. The patient also suffered from severe spasms, which were easily triggered by external stimuli. Glycine receptor antibodies were then found to be positive in serum and cerebrospinal fluid, and the diagnosis of PERM was confirmed. Methylprednisolone and gamma globulin treatments were given, and spasms were improved after treatment. Unfortunately, the patient's family insisted on automatic discharge and the patient passed away several days later.

Th1 regulatory events by infectious pathogens, herpes zoster and herpes simplex viruses: prospects for therapeutic options for atopic eczema

Infections caused by viral and bacterial pathogens are typically perceived as harmful, such as in cases of herpes zoster and herpes simplex virus infections. However, clinical observation of an improvement in atopic skin lesions upon herpes virus infection has been noted, particularly at the site of varicella and Kaposi’s varicelliform eruption. Th1 immune cells and cytokines, mobilized and induced for protection against infectious pathogens, are expected to improve Th2 dominant atopic symptoms. This study focuses on Th1 immunoregulatory events mediated by infectious pathogens, particularly herpes viruses. Immunoregulatory events induced by herpes viruses may have a potential therapeutic value for treating atopic eczema.

Streptococcus pulmonary empyema after varicella infection in a serologically immunocompetent boy

Varicella zoster virus (VZV) is the etiologic agent of varicella, and it remains common among children in Japan due to low vaccination rates. It can cause a variety of serious and life-threatening complications. Generally, the most frequent complication of varicella in healthy children is bacterial superinfection, but empyema after VZV infection is a rare condition. This case report describes a previously healthy 21-month-old boy who attended nursery school with a recent varicella and group A β-hemolytic streptococcus (GABHS) pharyngitis outbreak and who presented with a 7 day history of vesicular rash along with progressive fever. Due to continued mild cough and prolonged fever, however, chest radiography was done, which showed a right pleural effusion. Further computed tomography showed a right pulmonary empyema, and purulent material was drained and eventually grew GABHS. This report hereby describes the development of pleural empyema caused by GABHS after VZV infection in a serologically immunocompetent patient.

Differences in the epidemiology between paediatric and adult invasiveStreptococcus pyogenesinfections

In order to investigate for possible differences between paediatric and adult invasiveStreptococcus pyogenes(iGAS) infections, a total of 142 cases were identified in 17 Greek hospitals during 2003–2007, of which 96 were children and 46 adults. Bacteraemia, soft tissue infections, streptococcal toxic shock syndrome (STSS), and necrotizing fasciitis were the main clinical presentations (67·6%, 45·1%, 13·4%, and 12·0% of cases, respectively). Bacteraemia and lymphadenitis were significantly more frequent in children (P = 0·019 and 0·021, respectively), whereas STSS was more frequent in adults (P = 0·017). The main predisposing factors in children were varicella and streptococcal pharyngotonsillitis (25% and 19·8%, respectively), as opposed to malignancy, intravenous drug abuse and diabetes mellitus in adults (19·6%, 15·2% and 10·9%, respectively). Of the two dominantemm-types, 1 and 12 (28·2% and 8·5%, respectively), the proportion ofemm-type 12 remained stable during the study period, whereasemm-type 1 rates fluctuated considerably. Strains ofemm-type 1 from children were associated with erythromycin susceptibility, STSS and intensive-care-unit admission, whereasemm-type 12 isolates from adults were associated with erythromycin and clindamycin resistance. Finally, specificemm-types were detected exclusively in adults or in children. In conclusion, several clinical and epidemiological differences were detected, that could prove useful in designing age-focused strategies for prevention and treatment of iGAS infections.

Repeated intranasal TLR7 stimulation reduces allergen responsiveness in allergic rhinitis

BACKGROUND

Interactions between Th1 and Th2 immune responses are of importance to the onset and development of allergic disorders. A Toll-like receptor 7 agonist such as AZD8848 may have potential as a treatment for allergic airway disease by skewing the immune system away from a Th2 profile.

OBJECTIVE

To evaluate the efficacy and safety of intranasal AZD8848.

METHODS

In a placebo-controlled single ascending dose study, AZD8848 (0.3-600 μg) was given intranasally to 48 healthy subjects and 12 patients with allergic rhinitis (NCT00688779). In a placebo-controlled repeat challenge/treatment study, AZD8848 (30 and 60 μg) was given once weekly for five weeks to 74 patients with allergic rhinitis out of season: starting 24 hours after the final dose, daily allergen challenges were given for seven days (NCT00770003). Safety, tolerability, pharmacokinetics, and biomarkers were monitored. During the allergen challenge series, nasal symptoms and lavage fluid levels of tryptase and α2-macroglobulin, reflecting mast cell activity and plasma exudation, were monitored.

RESULTS

AZD8848 produced reversible blood lymphocyte reductions and dose-dependent flu-like symptoms: 30-100 μg produced consistent yet tolerable effects. Plasma interleukin-1 receptor antagonist was elevated after administration of AZD8848, reflecting interferon production secondary to TLR7 stimulation. At repeat challenge/treatment, AZD8848 reduced nasal symptoms recorded ten minutes after allergen challenge up to eight days after the final dose. Tryptase and α2-macroglobulin were also reduced by AZD8848.

CONCLUSIONS

Repeated intranasal stimulation of Toll-like receptor 7 by AZD8848 was safe and produced a sustained reduction in the responsiveness to allergen in allergic rhinitis.

TRIAL REGISTRATION

NCT00688779 and NCT00770003 as indicated above.

Aberrant function of peripheral blood myeloid and plasmacytoid dendritic cells in atopic dermatitis patients

BACKGROUND

Dendritic cells (DCs) can act both as innate cells in host defense and as antigen-presenting cells for naive T cells in adaptive immunity. These functions, among others, are determined by the level of production of particular cytokines. Atopic dermatitis (AD) is a chronic inflammatory skin disorder characterized by an initial phase predominated by T(H)2 cytokines that switches into a second, more chronic T(H)1-dominated eczematous phase.

OBJECTIVE

To assess to what extent the AD phenotype is associated with an aberrant phenotype and function of DCs.

METHODS

Classic CD1c(+)/blood DC antigen (BDCA)-1(+) myeloid (m) DCs and CD304(+)/BDCA4(+) plasmacytoid (p) DCs, the natural IFN-producing cells, were isolated from peripheral blood of patients with AD and healthy controls and analyzed for their phenotype and function.

RESULTS

Purified CD1c(+)/BDCA1(+) mDCs from patients with AD showed a selective and dramatic reduction of IL-12p70 and TNF-alpha release. IL-12p70 reduction was attributed to a defective expression of both IL-12p35 and IL-12p40 subunits. Accordingly, mature CD1c(+)/BDCA1(+) mDCs from patients with AD induced considerably less IFN-gamma-producing and more IL-4-producing T(H) cells compared with mDCs from healthy controls. In addition, CD304(+)/BDCA4(+) pDCs from patients with AD produced significantly lower levels of IFN-alpha compared with healthy controls.

CONCLUSION

Myeloid DCs and pDCs from patients with AD show defective IL-12, TNF-alpha, and IFN-alpha production, which may contribute to increased susceptibility to infection and to the maintenance of the T(H)2 cell-mediated allergic state in patients with AD.

[Pneumonia with empyema during varicella]

Chicken pox is usually considered a benign viral affection; however, possible infectious complications are observed. Although cutaneous infections are well described, bacterial pneumonia with empyema is more exceptionally reported.

PURPOSE

To describe the clinical characteristics of bacterial pneumonia with empyema associated with chicken pox.

METHODS

This descriptive multicenter retrospective study was based on a questionnaire sent by Internet to 30 French pediatric and pediatric respiratory hospital wards.

RESULTS

We found 4 cases of children (mean age, 19 months) presenting during the chicken pox eruption concomitant bacterial pneumonia with empyema. The average time of diagnosis was 4.5 days after the beginning of the eruption. All the children were febrile and had an average pulsed oxygen saturation of 87%. The inflammatory syndrome was constant with a mean C reactive protein of 253 mg/l. Group A Streptococcus was identified in 3 cases out of 4. Admission to an intensive care unit was necessary for 3 children, 1 of them requiring mechanical ventilation. No clinical or radiological sequelae were observed during the complete year of follow-up.

CONCLUSION

Bacterial pneumoniae with empyema are not current complications of chicken pox but have to be sought when prolonged fever and/or alteration of the health status occurs during chicken pox eruption.

IL-5 and IL-5 receptor alpha polymorphisms are associated with atopic dermatitis in Koreans

BACKGROUND

Eosinophils are recruited into the affected tissue of asthma and atopic dermatitis (AD) patients. IL-5 and IL-5R are highly expressed in the AD skin lesions, yet the reported levels of IL-8 are controversial.

METHOD

We genotyped 17 singlenucleotide polymorphisms (SNPs) from five genes of the 1120 case-control samples (646 AD and 474 controls). We measured the serum IL-5 concentrations in 87 individuals [36 ADe (AD extrinsic), 18 ADi (AD intrinsic) and 33 controls] by ELISA, and compared the results among these groups.

RESULT

The rs2522411SNP and haplotype T-A in the IL-5 gene were significantly associated with the ADe. The serum IL-5 concentration was higher in the ADe than that in the ADi patients without any correlation with the rs2522411SNP. In the IL-5RA gene, the rs334809SNP showed a weak association with AD, and the rs6771148SNP and the haplotype T-C-T of the three adjacent tagged SNPs had an effect on the blood eosinophil counts and the serum ECP levels in the AD patients. However, we could not detect any relationship between AD and the SNPs in the IL-8 and IL-8R genes.

CONCLUSION

We found that the rs2522411SNP and the haplotype T-A in the IL-5 gene and the serum IL-5 levels were strongly associated with the allergic type of AD, but not with the nonallergic type of AD. The association of the rs6771148SNP and the haplotype T-C-T in the IL5RA gene with the blood eosinophil counts and the serum ECP levels indicates that the IL5RA gene has a role for controlling eosinophils in the peripheral blood.

Indirect regulation of CD4 T-cell responses by tumor necrosis factor receptors in an acute viral infection

Despite the well-recognized importance of CD4 T-cell help in the induction of antibody production and cytotoxic-T-lymphocyte responses, the regulation of CD4 T-cell responses is not well understood. Using mice deficient for TNF receptor I (TNFR I) and/or TNFR II, we show that TNFR I and TNFR II play redundant roles in down regulating the expansion of CD4 T cells during an acute infection of mice with lymphocytic choriomeningitis virus (LCMV). Adoptive transfer experiments using T-cell-receptor transgenic CD4 T cells and studies with mixed bone marrow chimeras indicated that indirect effects and not direct effects on T cells mediated the suppressive function of TNF on CD4 T-cell expansion during the primary response. Further studies to characterize the indirect effects of TNF suggested a role for TNFRs in LCMV-induced deletion of CD11c(hi) dendritic cells in the spleen, which might be a mechanism to limit the duration of antigenic stimulation and CD4 T-cell expansion. Consequent to enhanced primary expansion, there was a substantial increase in the number of LCMV-specific memory CD4 T cells in the spleens of mice deficient for both TNFR I and TNFR II. In summary, our findings suggest that TNFRs down regulate CD4 T-cell responses during an acute LCMV infection by a non-T-cell autonomous mechanism.

Safety, reactogenicity, and immunogenicity of live attenuated varicella vaccine in children between 1 and 9 years of age with atopic dermatitis

INTRODUCTION

Infection with varicella-zoster virus (VZV) is known to facilitate secondary bacterial infection, which is cause for particular concern in children with atopic dermatitis. This 2-year study assessed the safety, reactogenicity, and immunogenicity of a live attenuated Oka strain varicella vaccine (Varilrix, GlaxoSmithKline Biologicals) in 160 children aged 1-9 years with atopic dermatitis randomized to vaccination at the start of either the 1st or 2nd study year (VAR-1Y and VAR-2Y, respectively). Mean SCORing Atopic Dermatitis (SCORAD) scores at baseline were 19.3+/-11.1 and 26.0+/-10.4 in the two groups, respectively.

RESULTS

Varicella vaccination did not adversely affect the severity of atopic dermatitis, with analysis of variance (ANOVA) confirming equivalence for the change in SCORAD index from baseline to week 8 between vaccinated and unvaccinated subjects. Within-group comparison of post-vaccination changes in SCORAD index from baseline to week 8 and month 12 in the VAR-2Y group showed a greater reduction in mean SCORAD scores following vaccination in year 2 than in year 1 when subjects were unvaccinated. Overall, SCORAD indices fell by approximately 10 points in both study groups over the 2 years of follow-up. Varicella vaccination was well tolerated, with no children withdrawn due to adverse events. Injection site redness was the most frequent solicited adverse event, occurring in 17.1% of subjects. Seroconversion rates were 94.3% at week 8 and 88.9% at month 12. In all, 43.6% of vaccinees reported at least one varicella contact during the course of the study. However, none developed varicella infection after vaccination over the 2 years of follow-up.

CONCLUSION

In summary, vaccination with a live attenuated varicella vaccine appears safe and effective in children with atopic dermatitis.

IL-12-independent Th1 polarization in human mononuclear cells infected with varicella-zoster virus

T helper type 1 (Th1) cells perform a critical role in fighting intracellular organisms, and interleukin-12 (IL-12) is known to promote a Thl response. This study was conducted to identify whether an IL-12-independent Th1 reaction is induced by the varicella-zoster virus (VZV) in human beings. It was found that different intracellular microorganisms could induce IFNgamma but not IL-12 production. Induction of IFNgamma production by VZV was associated with IFNalpha production and phosphorylation of both the signal transducer and activator of transcription-1 (STAT-1) and STAT-4 in lymphocytes. In contrast, Bacillus Calmette-Guerin (BCG) induced IL-12 production in association with STAT-4 but not STAT-1 activation. Anti-IFNalpha but not anti-IL-12 antibodies blocked the VZV-induced Th1 polarization. A patient with an IL-12 receptor beta1 chain deficiency showed a normal VZV- but not a normal BCG-induced Th1 reaction, further supporting the concept of an IFNalpha-mediated, IL-12-independent Th1 reaction in response to certain intracellular infections. Identification of the early Th1 polarization induced by IFNalpha versus IL-12 in response to specific viruses may enable the development of better therapeutic strategies tailored to different infections.

The Toll-like receptor-2/6 agonist macrophage-activating lipopeptide-2 cooperates with IFN-gamma to reverse the Th2 skew in an in vitro allergy model

Dendritic cells (DC) are the most potent APCs with the capacity to induce, modulate, or shut down immune function. These features make them potentially useful for treating diseases associated with misled immunologic responses. Therefore, it was the aim of this study to reverse the allergen-dependent Th2 reaction responsible for allergic symptoms by modulating DC function. This issue was addressed in an in vitro test system consisting of human monocyte-derived allergen-pulsed DC from allergics cocultured with autologous lymphocytes. A Th2 reaction judged by the amplification of IL-4 and the down-regulation of IFN-gamma was induced by pulsing DC with the relevant allergen. To modulate this reaction, the Toll-like receptor 2/6 engaging mycoplasmal lipopetide macrophage-activating lipopeptide 2 kDa was combined with IFN-gamma to stimulate allergen-pulsed DC. Such treatment resulted in a 500-fold increase in IFN-gamma production in the supernatant of cocultured autologous lymphocytes, while the Th2 marker IL-4 was not affected. This phenomenon was associated with an increase in proliferation and the number of IFN-gamma-producing lymphocytes. Phenotype and function of thus treated DC remained stable. These data indicate that a former allergen-dependent Th2 reaction can be reversed toward a Th1-type response by an appropriate treatment of DC.

Therapeutic effects of streptococcal preparation OK-432 on atopic dermatitis-like lesions in NC/Nga mice: possible shift from a Th2- to Th1-predominance

BACKGROUND

The inducement of Th1 cell-mediated immune response, possibly brought about through bacterial stimulation, may serve to control atopic disorders such as atopic dermatitis (AD). The streptococcal preparation, OK-432, has been shown a potent Th1 inducer through the action of IL-12. NC/Nga mice under ordinary conditions have been found to contract dermatitis similar to human AD.

OBJECTIVE

Examination was made of the therapeutic effects of OK-432 local intra- and/or subcutaneous injections on AD-like lesions in NC/Nga mice.

METHODS

Immunohistochemical staining with IL-4/IL-12p40 and CD80/86 and phosphorylated STAT4/p-STAT6 and RT-PCR for IL-4/IL-12p40 and STAT6/STAT4 mRNA was conducted for the evaluation of OK-432 treatment of spontaneous AD-like lesions in NC/Nga mice.

RESULTS

At 5 weeks following injection of OK-432, for treating head and back lesions in NC/Nga mice, 10 of 12 OK-432 treated NC mice were found to have clinically improved quite considerably. On the head and back skin of OK-432-treated mice, IL-12p40/CD80 positive cellular infiltration was conspicuous, in contrast to non-treated mice. IL-4/CD86 positive cellular infiltrates in OK-432-treated mice had decreased significantly more than in non-treated mice and IL-4 mRNA expression was virtually absent in OK-432-treated mice. P-STAT4 positive cells could be seen abundantly present in OK-432-treated mice, and p-STAT6 positive cells were much fewer than in non-treated mice.

CONCLUSIONS

OK-432-treatment appears to induce Th1 cellular response and to down-regulate that of the Th2 pathway in AD-like lesions of NC/Nga mice. The present results demonstrate bacterial components from such Streptococcus to likely constitute an effective new therapeutic approach in the treatment of AD.

[Varicella associated necrotizing fasciitis in a child]

We present a rare case of necrotizing fasciitis in an 5-year-old infant with preexisting varicella infection. Initially, the patient showed acute pain and swelling of the left thorax with high inflammatory parameters and varicella-specific skin affections. MRT presented diffuse soft tissue swelling of the left chest consistent with necrotizing fasciitis. After aggressive surgical debridement of necrotic tissue and extirpation of axillary lymph nodes, the clinical course improved under appropriate parenteral antimicrobial therapy using penicillin and clindamycin. In conclusion, necrotizing fasciitis should be suspected in any child with a history of varicella infection and increasing complaints of pain and swelling in an extremity or other body area associated with increasing fever, erythema, lethargy, and irritability. Shock, multiorgan failure, and death will ensue if the diagnosis is not promptly recognized.

Successful treatment by double-filtration plasmapheresis of a patient with bullous pemphigoid: effects in vivo on transcripts of several genes for chemokines and cytokines in peripheral blood mononuclear cells

The involvement of various cytokines and chemokines has been reported in the pathogenesis of bullous pemphigoid (BP). Double-filtration plasmapheresis (DFPP) is an effective treatment for BP but the mechanism of action remains unclear. Using semiquantitative reverse transcription-polymerase chain reaction, we examined levels of transcripts for various cytokines and chemokines in freshly isolated peripheral blood mononuclear cells in a patient with BP before and after DFPP treatment. DFPP was performed four times. Relative levels of transcripts for interleukin (IL)-8, macrophage inflammatory protein (MIP)-1alpha and IL-5, and the ratio of relative levels of transcripts for IL-4 and interferon (IFN)-gamma, were higher, before treatment, than in healthy controls, and decreased when the extent of the lesions was reduced. Relative levels of transcripts for tumour necrosis factor (TNF)-alpha and IL-4 also decreased with regression of lesions, although they were similar to or lower than the corresponding levels in healthy individuals. When eruptions recurred, relative levels of transcripts for IL-8, MIP-1alpha, RANTES (regulated upon activation normal T cell expressed and secreted), IL-2, IFN-gamma and TNF-alpha were very much higher than those prior to the recurrence, while relative levels of mRNAs for IL-4 and IL-5 did not increase. Relative levels of transcripts for IL-8, MIP-1alpha, TNF-alpha and IL-2 were lower at the end of each individual DFPP and after the four treatments than at the beginning of treatment. Our observations suggest that cytokines and chemokines produced in mononuclear cells play important roles in the pathogenesis of BP and that regulation of their expression might be involved in the therapeutic effects of DFPP in BP.

Immunostimulatory sequence DNA linked to the Amb a 1 allergen promotes T(H)1 cytokine expression while downregulating T(H)2 cytokine expression in PBMCs from human patients with ragweed allergy

BACKGROUND

Recent studies have demonstrated that bacterially derived immunostimulatory sequences (ISSs) of DNA can activate the mammalian innate immune system and promote the development of T(H)1 cells. Promotion of T(H)1 immunity by means of immunotherapy in allergic patients has led to the alleviation of symptoms that result from allergen-specific T(H)2 responses.

OBJECTIVE

Our purpose was to investigate whether the T(H)1-enhancing properties of ISSs could be used to alter the T(H)2-dominated immune response of allergic PBMCs in vitro.

METHODS

Ragweed protein-linked ISS (PLI) was generated from a specific, highly active 22-base ISS and Amb a 1, the immunodominant allergen in ragweed pollen, to combine the T(H)1-enhancing properties of ISSs with allergen selectivity, and its activity was investigated in PBMC cultures from subjects with ragweed allergy.

RESULTS

PLI was markedly successful at reversing the dominant allergen-induced T(H)2 profile while greatly enhancing IFN-gamma production. Delivering ISSs in a linked form proved to be much more effective at modulating the resulting cytokine profile than delivering free ISSs in a mixture with unlinked Amb a 1. PLI also demonstrated cytokine-modulating properties, even when used to stimulate cells that had already been primed for 6 days with Amb a 1. The antigen specificity of the action of PLI was confirmed by the observations that PLI enhances Amb a 1--specific T-cell proliferation.

CONCLUSION

These data indicate that delivery of ISSs within an antigen-specific context exhibits potent cytokine-modulating activity and, combined with its reduced allergenicity, makes this molecule a strong candidate for use in improved immunotherapy applications.

Lack of B cell leakiness in BALB/cA-nu, scid double mutant mice

BALB/cA mice homozygous for both nu and scid mutations (BALB/cA-nu/nu, scid/scid) were developed by mating between BALB/cA-scid and BALB/cA-nu. These mice have greater longevity than C.B-17-scid because no thymic lymphoma occurs in them unlike in the latter. C.B-17-scid is known to show the leaky phenomenon in which a few clones of functional T and B cells develop in aged C.B-17-scid. Unexpectedly, the leaky B cells and T cells were absent or suppressed in BALB/cA-nu, scid mice when cytokine expressions were determined by RT-PCR, lymphocyte phenotypes by flow cytometry and serum immunoglobulin levels by ELISA. These results indicate that B cell leakiness may be induced by leaked T cells. BALB/cA-nu, scid mice may be useful as a recipient in allo- and xeno-transplantation experiments because of the absence of both thymic lymphomas and leakiness, in addition to lack of hair.

Immunoadsorption of immunoglobulins alters intracytoplasmic type 1 and type 2 T cell cytokine production in patients with refractory autoimmune diseases

Intracellular cytokine staining and flow cytometry were used to investigate whether immunoadsorption (IA) of immunoglobulins alters intracytoplasmic cytokine production in CD4+ and CD8+ T cells from the blood of patients with refractory rheumatoid arthritis (n = 7), membrane proliferative glomerulonephritis (n = 1), and Goodpasture's syndrome (n = 1). Four patients (Group 1) showed severely depressed production of TNF-alpha, IL-2, IFN-gamma, and IL-4 by CD4+ and CD8+ T cells and responded to 3 IA sessions with significant increases in CD4+TNF-alpha+, CD4+IL-2+, and CD8+IL-2+ T cells. Also, a tendency toward increased percentage levels of CD4+ T cells producing IFN-gamma or IL-4 and of CD8+ T cells producing either TNF-alpha or IFN-gamma was seen, but due to the small number of patients investigated, these differences did not attain statistic significance. Group 2 (n = 5) showed unimpaired intracellular cytokine levels and responded to IA with a heterogeneous pattern of changes in TNF-alpha, IL-2, IFN-gamma, and IL-4 production, but these alterations were smaller than those in Group 1. The present findings indicate that the extracorporeal removal of immunoglobulins by anti-IgG or protein A adsorber columns has an impact on T cell immunity and suggest that modulating effects on cellular immune system function are involved in the mode of action of IA.

Regulation of interleukin 12 and interleukin 10 expression in vaccinia virus-infected human monocytes and U-937 cell line

Regulation of IL-12 and IL-10 production in normal human monocytes infected with vaccinia virus (VV) was analysed. IL-12 and IL-10 mRNAs were measured by reverse transcriptase-polymerase chain reaction (RT-PCR) and IL-12 and IL-10 protein by ELISA. RT-PCR analysis revealed a marked-up regulation of IL-12 (p40) and IL-10 expression in virally infected cells compared with that from control (non-infected) cells at 24 h post-infection (p.i.). IL-12 transcripts occurred earlier (at 4 h p.i.) than IL-10 mRNA. A significant increase in IL-12 and IL-10 secretion into the medium was caused by the virus, and even a much more pronounced increase in both interleukins expression (mRNAs and proteins) followed LPS or Staphylococcus aureus treatment. Vaccinia virus infection did not alter IL-10 secretion and IL-10 mRNA content (or even cause a decrease) in a human monocytic cell line U937. Undetectable levels of IL-12 protein were found in the cell line although the transcripts were present in the cells at first hours p.i. It appears now that vaccinia virus transiently and sequentially induces IL-12 and IL-10 in human monocytes.

T cell-mediated Fas-induced keratinocyte apoptosis plays a key pathogenetic role in eczematous dermatitis

Clinical and histologic similarities between various eczematous disorders point to a common efferent pathway. We demonstrate here that activated T cells infiltrating the skin in atopic dermatitis (AD) and allergic contact dermatitis (ACD) induce keratinocyte (KC) apoptosis. KCs normally express low levels of Fas receptor (FasR) that can be substantially enhanced by the presence of IFN-gamma. KCs are rendered susceptible to apoptosis by IFN-gamma when FasR numbers reach a threshold of approximately 40,000 per KC. Subsequently, KCs undergo apoptosis induced by anti-FasR mAb's, soluble Fas ligand, supernatants from activated T cells, or direct contact between T cells and KCs. Apoptotic KCs show typical DNA fragmentation and membrane phosphatidylserine expression. KC apoptosis was demonstrated in situ in lesional skin affected by AD, ACD, and patch tests. Using numerous cytokines and anti-cytokine neutralizing mAb's, we found no evidence that cytokines other than IFN-gamma participate in this process. In addition, apoptosis-inducing pathways other than FasR triggering were ruled out by blocking T cell-induced KC apoptosis by caspase inhibitors and soluble Fas-Fc protein. Responses of normal human skin and cultured skin equivalents to activated T cells demonstrated that KC apoptosis caused by skin-infiltrating T cells is a key event in the pathogenesis of eczematous dermatitis.

Invasive group A streptococcal disease in children and association with varicella-zoster virus infection. Ontario Group A Streptococcal Study Group

OBJECTIVES

To describe the incidence and clinical features of invasive group A streptococcal (GAS) disease in children in Ontario and determine the risk of invasive GAS infection following chickenpox.

METHODS

During 1992-1996, we conducted prospective, active, population-based surveillance for pediatric invasive GAS disease in Ontario, Canada (population: 11 million; 2.5 million children) and reviewed clinical and laboratory records.

RESULTS

There were 1.9 cases of invasive GAS disease per 100,000 children per year. Streptococcal toxic shock syndrome (STSS) occurred in 7% of cases and necrotizing fasciitis (NF) in 4% for incidences of.08 and.13 per 100,000 per year, respectively. Case-fatality rates were 56% for STSS, 10% for NF, and 4% overall. The presence of chronic underlying illness other than asthma was associated with death (relative risk [RR]: 11; 95% confidence interval [CI]: 2.4-45). Fifteen percent of children identified had preceding chickenpox infection, which significantly increased the risk for acquisition of invasive GAS disease (RR: 58; 95% CI: 40-85). Children with invasive GAS and recent chickenpox were more likely to have NF (RR: 6.3; 95% CI: 1.8-22.3).

CONCLUSIONS

Childhood invasive GAS disease occurs at an incidence similar to the adult population but has a lower rate of STSS and case-fatality. Chickenpox dramatically increases the risk for acquiring invasive GAS disease, and universal chickenpox vaccination could potentially prevent up to 15% of all pediatric invasive GAS disease.

Different serum interleukin-12 and sCD30 levels in food- and pollen-sensitized children

It has been proposed that a down-regulation of interleukin (IL)-12 and interferon (IFN)-gamma might be related to susceptibility to allergy in early life. The aim of this study was to assess serum IL-12 levels in food-sensitized and pollen-sensitized children and to compare these with another activation marker, sCD30. Twenty children with pollen allergy and 22 food-sensitized children were included. The diagnosis of immunoglobulin (Ig)-E-mediated allergy, suggested by clinical symptoms, was based on skin-prick tests, serum IgE antibodies and total IgE levels. Samples from 24 non-allergic children were used as controls. IL-12 and sCD30 levels were measured by ELISA. It was found that pollen-sensitized patients had normal IL-12 and higher sCD30 levels than controls (114 vs. 63 U/ml, p = 0.028), but, surprisingly, food-sensitized infants showed normal sCD30 and increased serum IL-12 levels (323 vs. 118 pg/ml, p = 0.0001). No differences were found in patients suffering from asthma or allergic dermatitis. Levels of sCD30 and IL-12 determined in May showed a strong correlation with those obtained in November. Interleukin-12 and IgE levels had an inverse correlation (r = -0.494, p = 0.0001) whereas no correlation was found between sCD30 and IgE. Age had a strong negative influence on IL-12 levels in allergic (Z = 4.834, p < 0.0005) and in normal children (Z = 3.00, p < 0.002); by contrast, sCD30 levels were not significantly age-dependent. When IL-12 levels from the food-allergy group were compared with those from normal controls younger than 4 years of age, the difference remained significant (p = 0.001), ruling out an age-bias. The conclusions made in this study were that serum IL-12 and sCD30 showed different behaviors in children with food or pollen allergy. We found IL-12 and sCD30 levels in pollen-allergic patients that agree with the classical T-helper (Th) 1/Th2 paradigm of allergy. In contrast, serum IL-12 levels were increased in food-sensitized children, suggesting a different immunologic pathogenesis.

T cells and T cell-derived cytokines as pathogenic factors in the nonallergic form of atopic dermatitis

A subgroup of patients with atopic dermatitis are known to have normal serum total immunoglobulin E levels, undetectable specific immunoglobulin E, and negative skin prick tests towards allergens. This form of the disease has been termed nonallergic atopic dermatitis. In this study, we found that, among 1151 chronic atopic dermatitis patients, about 10% had normal serum immunoglobulin E levels with no evidence for immunoglobulin E sensitization. We investigated immunologic mechanisms of patients with "allergic" and "nonallergic" atopic dermatitis using peripheral blood and skin biopsy samples. Our data suggest that T cells are likely involved in the pathogenesis of both forms of atopic dermatitis. Skin T cells equally responded to superantigen, staphylococcal enterotoxin B, and produced interleukin-2, interleukin-5, interleukin-13, and interferon-gamma in both forms of the disease. Interleukin-4, however, was not detectable in the skin biopsies of both atopic dermatitis types and was secreted in very low amounts by T cells cultured from the skin biopsies. Moreover, skin T cells from nonallergic atopic dermatitis patients expressed lower interleukin-5 and interleukin-13 levels compared with allergic atopic dermatitis patients. Accordingly, T cells isolated from skin biopsies of atopic dermatitis, but not from the nonallergic atopic dermatitis, induced high immunoglobulin E production in cocultures with normal B cells that was mediated by interleukin-13. In addition, B cell activation with high CD23 expression was observed in the peripheral blood of atopic dermatitis, but not nonallergic atopic dermatitis patients. These data suggest, although high numbers of T cells are present in lesional skin of both types, a lack of interleukin-13-induced B cell activation and consequent immunoglobulin E production in nonallergic atopic dermatitis.

Preliminary study on urinary cytokine levels in interstitial cystitis: does intravesical bacille Calmette-Guérin treat interstitial cystitis by altering the immune profile in the bladder?

OBJECTIVES

To obtain preliminary urinary cytokine data on subjects with active interstitial cystitis (IC), subjects with IC in remission after bacille Calmette-Guérin (BCG), and control (non-IC) subjects. IC is a severe, debilitating bladder disease of unknown etiology and no cure. In controlled clinical trials, intravesical BCG has been shown to be an effective and durable treatment for IC. The durability of this treatment led us to speculate on the mechanism by which intravesical BCG may treat IC. Evidence exists that IC may be mediated by an abnormal immune profile within the bladder. Intravesical BCG is known to stimulate the immune system of the bladder.

METHODS

Fresh voided urine was collected from 15 subjects with active IC, 9 subjects with IC who received intravesical BCG and had been in remission for an average of 2.6 years, and 11 non-IC subjects. The urine was immediately centrifuged, aliquoted, and frozen in liquid nitrogen. At the time of urine collection, a validated IC questionnaire was completed. The enzyme-linked immunosorbent assay technique was used to determine levels of urinary cytokines interleukin (IL)-2, IL-4, IL-6, IL-8, IL-10, IL-12, tumor necrosis factor (TNF), human granulocyte-macrophage colony stimulating factor (hGM-CSF), IL-1beta, and interferon-gamma (IFN-gamma).

RESULTS

Cytokines IL-4, IL-10, IL-12, TNF, hGM-CSF, IL-1beta, and IFN-gamma were not detected. Significant elevations in symptom scores and IL-2, IL-6, and IL-8 were found in the urine of subjects with active IC compared with subjects with IC in remission and control subjects. The urinary cytokine levels and symptom scores were identical in the IC group who had received BCG and the control group.

CONCLUSIONS

Elevations in symptom scores and urinary cytokine levels were seen in subjects with active IC, suggesting an abnormal immune profile in this disease. Subjects with IC in remission after receiving BCG had identical cytokine levels and symptom scores as non-IC control subjects. Intravesical BCG may be effective in treating IC by correcting an aberrant immune imbalance in the bladder, leading to long-term symptomatic improvement. A prospective study is ongoing to further investigate the role of the immune system in IC.

Kaposi's varicelliform eruptions during the course of steroid withdrawal in a senile erythroderma patient: cure of regional erythrodermic lesions following infection

The author encountered a case of Kaposi's varicelliform eruptions on both axillar regions during the course of steroid withdrawal in a 68-year-old male with eythroderma following eczema. Immnohistochemical study gave positive indication of herpes simplex virus type I in epidermal keratinocytes in lesional vesicles. Following cure of the varicelliform eruptions, erythrodermic lesions in the axillar regions cleared up completely. For those at other sites, considerably more time was required for cure, with steroid withdrawal being a factor of this period.

The role of infection in atopic dermatitis

explain this tendency to develop infections. A decrease in the number and function of CD8+ suppressor/cytotoxic T cells from peripheral blood of AD patients has been reported.2 This could explain the increased incidence of cutaneous viral and fungal infections observed in these patients. Monocytes from AD patients secrete increased levels of interleukin (IL)-10 that can inhibit T cell mediated responses.3 Leukocytes from patients with AD have been found to produce decreased amounts of interferon gamma (IFN-g),4 which is required for the

Immune dysregulation as a cause for allergic asthma

Allergic asthma is being increasingly understood as a disease caused by Th2-mediated immune responses to inhaled allergens. Most individuals fail to respond to allergens with a Th2 response, and thus, allergic asthma can be considered the result of an abnormally regulated or dysregulated immune response. The prevalence of asthma has risen precipitously in urbanized cultures, as contrasted with third world countries. This observation underlies the heightened efforts in the past few years of basic and applied research efforts to gain a better understanding of both normal and dysregulated immunity to antigens introduced via the airways. This review focuses on recent human studies into the immune dysregulation that results in the asthma phenotype, but also cites selected relevant papers from research with experimental animals.

The role of antigen-presenting cells in the regulation of allergen-specific T cell responses

Allergic reactions in atopic patients follow from a generalized enhanced polarization of Th cells, predominantly imposed by factors derived from antigen-presenting cells from a pathogen-stressed tissue; these sample information not only on antigen structures but also on the nature of the stress. Antigen-presenting cells of atopic individuals show aberrant characteristics which, through a highly interactive communication network, play an active role in aberrant Th-cell polarization. This generalized bias may follow from intrinsic abnormalities of antigen-presenting cells and also from a low degree of cross-regulation by micro-organisms.

Local cytokine expression in steroid-modified tinea faciei

In tinea faciei, a dermatophyte infection of the face, early stage lesions show erythema with crust and/or vesicles, a condition often misdiagnosed as dermatitis. Steroid application retards the healing in some cases and may induce penetration of the dermatophyte hyphae into hair and hair follicles. In the present study, we examined local immunity mediated by cytokines derived from lesional T lymphocytes in late stage of this disease. Interferon-gamma (IFN-gamma) and macrophage migration inhibitory factor (MIF) were highly expressed, but neither interleukin-4 (IL-4) nor interleukin-5 (IL-5) could be detected by RT-PCR using cryosections. These data suggested that IFN-gamma and MIF may be important in the delayed-type hypersensitivity (DTH) response against the fungus in the hair follicle in late stages.

The efficacy of intravesical bacillus Calmette-Guerin in the treatment of interstitial cystitis: long-term followup

PURPOSE

Interstitial cystitis is a severe debilitating bladder disease characterized by unrelenting pelvic pain and urinary frequency. A prospective, double-blind, placebo controlled study of the use of intravesical bacillus Calmette-Guerin (BCG) in the treatment of interstitial cystitis was recently completed with a mean followup of 8 months. Results demonstrated a 60% BCG response rate, compared to a 27% placebo response rate. We now report the long-term followup results of those patients who received intravesical BCG.

MATERIALS AND METHODS

Subjects randomized to receive BCG were followed at routine intervals with questionnaires and voiding diaries identical to those in the blinded study. Adverse events were closely monitored in the treatment and followup phases of the study. Subject baseline values were compared to followup data.

RESULTS

Of the BCG responders mean followup was 27 months (range 24 to 33), and 8 of 9 (89%) continue to have an excellent response in all parameters measured. The global interstitial cystitis survey improved 70%, daily voids decreased 31%, nocturia improved 54%, mean voided volume increased 61%, pelvic pain decreased 81%, vaginal pain decreased 71%, urgency decreased 71% and dysuria decreased 82%. Overall well-being improved 54% and the Rand-36 quality of life survey overall improved 64%. In 86% of the patients (6 of 7) dyspareunia resolved. Of the initial BCG nonresponders there was no significant difference in interstitial cystitis symptomatology from baseline to last followup, suggesting that BCG does not worsen interstitial cystitis symptoms. No long-term adverse events from BCG were noted.

CONCLUSIONS

Intravesical Tice BCG is safe, effective and durable in the treatment of interstitial cystitis. Of those patients who received only 6 weekly treatments and responded favorably 89% continue to have an excellent response with followup ranging from 24 to 33 months.