Evaluation of the staphylococcal exotoxins and their specific IgE in childhood atopic dermatitis

Treatable Traits in Asthma: The Importance of Extrapulmonary Traits-GERD, CRSwNP, Atopic Dermatitis, and Depression/Anxiety

Treatable traits is a personalized medicine approach to the management of airway disease. Assessing traits within the 3 domains of pulmonary, extrapulmonary, and behavioral/lifestyle/risk factor traits, and applying targeted treatments to effectively manage these traits, enables a holistic and personalized approach to care. Asthma is a heterogeneous and complex airway disease that is frequently complicated by several extrapulmonary traits that impact asthma outcomes and predict future outcomes. We propose that the identification of extrapulmonary and behavioral risk factor traits and the implementation of targeted therapy will lead to improved management of people with asthma. Furthermore, many extrapulmonary traits present as "connected comorbidities"; that is, they coexist with asthma, have an impact on asthma, and effective treatment improves both asthma and the comorbidity or the comorbidities may share a similar mechanism. In this review, we explore this concept and look at atopic dermatitis, chronic rhinosinusitis with nasal polyps, gastroesophageal reflux disease, anxiety, and depression as treatable traits of asthma and how these can be managed using this approach.

Prediction of disease severity using serum biomarkers in patients with mild-moderate Atopic Dermatitis: A pilot study

Atopic dermatitis (AD) is an inflammatory skin condition that relies largely on subjective evaluation of clinical signs and symptoms for diagnosis and severity assessment. Using multivariate data, we attempted to construct prediction models that can diagnose the disease and assess its severity. We combined data from 28 mild-moderate AD patients and 20 healthy controls (HC) to create random forest models for classification (AD vs. HC) and regression analysis to predict symptom severities. The classification model outperformed the random permutation model significantly (area under the curve: 0.85 ± 0.10 vs. 0.50 ± 0.15; balanced accuracy: 0.81 ± 0.15 vs. 0.50 ± 0.15). Correlation analysis revealed a significant positive correlation between measured and predicted total SCORing Atopic Dermatitis score (SCORAD; r = 0.43), objective SCORAD (r = 0.53), eczema area and severity index scores (r = 0.58, each p < 0.001), but not between measured and predicted itch ratings (r = 0.21, p = 0.18). We developed and tested multivariate prediction models and identified important features using a variety of serum biomarkers, implying that discovering the deep-branching relationships between clinical measurements and serum measurements in mild-moderate AD patients may be possible using a multivariate machine learning method. We also suggest future methods for utilizing machine learning algorithms to enhance drug target selection, diagnosis, prognosis, and customized treatment in AD.

Consensus Update for Systemic Treatment of Atopic Dermatitis

Background

In 2015, the Korean Atopic Dermatitis Association (KADA) working group published consensus guidelines for treating atopic dermatitis (AD).

Objective

We aimed to provide updated consensus recommendations for systemic treatment of AD in South Korea based on recent evidence and experience.

Methods

We compiled a database of references from relevant systematic reviews and guidelines on the systemic management of AD. Evidence for each statement was graded and classified based on thestrength of the recommendation. Forty-two council members from the KADA participated in three rounds of voting to establish a consensus on expert recommendations.

Results

We do not recommend long-term treatment with systemic steroids forpatients with moderate-to-severe AD due to the risk of adverse effects. We recommend treatment with cyclosporine or dupilumab and selective treatment with methotrexate or azathioprine for patients with moderate-to-severe AD. We suggest treatment with antihistamines as an option for alleviating clinical symptoms of AD. We recommend selective treatment with narrowband ultraviolet B for patients with chronic moderate-to-severe AD. We do not recommend treatment with oral antibiotics for patients with moderate-to-severe AD but who have no signs of infection. We did not reach a consensus on recommendations for treatment with allergen-specific immunotherapy, probiotics, evening primrose oil, orvitamin D for patients with moderate-to-severe AD. We also recommend educational interventions and counselling for patients with AD and caregivers to improve the treatment success rate.

Conclusion

We look forward to implementing a new and updated consensus of systemic therapy in controlling patients with moderate-to-severe AD.

Colonization With Staphylococcus aureus in Atopic Dermatitis Patients: Attempts to Reveal the Unknown

Atopic dermatitis (AD) patients are massively colonized with Staphylococcus aureus (S. aureus) in lesional and non-lesional skin. A skin infection may become systemic if left untreated. Of interest, the incidence of multi-drug resistant S. aureus (MRSA) in AD patients is higher as compared to a healthy population, which makes treatment even more challenging. Information on the specific genetic background of S. aureus accompanying and/or causing AD flares would be of great importance in terms of possible treatment option development. In this review, we summarized the data on the prevalence of S. aureus in general in AD skin, and the prevalence of specific clones that might be associated with flares of eczema. We put our special interest in the presence and role of staphylococcal enterotoxins as important virulence factors in the epidemiology of AD-derived S. aureus. Also, we summarize the present and potentially useful future anti-staphylococcal treatment.

SLIT's Prevention of the Allergic March

PURPOSE OF REVIEW

The progression of atopic disorders from atopic dermatitis in infants to allergic rhinitis and asthma in children, adolescents, and adults defines the allergy march. Allergen immunotherapy is the only causal treatment altering the immunological mechanism underlying the allergic diseases. The sublingual administration route is more acceptable than the subcutaneous one in pediatric age.

RECENT FINDINGS

Several studies show the efficacy and safety profile of sublingual immunotherapy (SLIT) for the treatment of respiratory allergy diseases, but few data are available on its effect of primary and secondary prevention of allergic disease. The purpose of this manuscript is to review the latest studies addressing the effect of SLIT on the development of new sensitizations in not sensitized or already sensitized patients and progression of the allergy march.

Chronic Sinusitis with Nasal Polyps: Staphylococcal Exotoxin Immunoglobulin E and Cellular Inflammation

Background

The etiology of chronic sinusitis with nasal polyposis (CS/NP) remains enigmatic. Frequently, Staphylococcus aureus is present in the nose of CS/NP patients, although the significance is unclear. Recent reports have suggested the hypothesis that these bacteria may secrete exotoxins triggering the inflammatory mucosal changes seen in CS/NP. This mechanism of immunopathology has been established in other diseases associated with Staphylococcus colonization and exotoxin secretion such as atopic dermatitis. In atopic dermatitis, the exotoxins incite a local superantigen response in which clonal T-cell activation and massive cytokine release occur in the affected skin. Second, these exotoxins can act as traditional allergens, stimulating a typical immunoglobulin E (IgE) response in the serum, which has been correlated with disease severity. This study is designed to begin the assessment of the hypothesis that a similar mechanism takes place in CS/NP.

Methods

Serum was drawn from patients with CS/NP undergoing endoscopic sinus surgery as well as 13 atopic and nonatopic control subjects without sinusitis. IgE levels to S. aureus exotoxins A (SEA), SE exotoxins B (SEB), and toxic shock syndrome toxin 1 were measured using enzyme-linked immunosorbent assay. Tissue eosinophilia and the presence of lymphocytes on hemotoxylin and eosin-stained sections of polyps were scored by a blinded pathologist and correlated to presence of toxin IgE in the serum.

Results

Staphylococcal exotoxin (SE)-specific IgE was found in the serum of 5/10 (50%) of the patients with CS/NP. In contrast, 0/13 control patients had IgE to the exotoxins (p = 0.031). Polyp eosinophil, lymphocyte, and mononuclear cell counts were compared in IgE exotoxin-positive and -negative subjects. A trend toward increased eosinophil counts in patients with SE IgE (SE IgE+) was present, but not statistically significant.

Conclusion

These results indicate that a high percentage of CS/NP patients show a systemic IgE response to S. aureus exotoxins in comparison with controls without CS/NP. Although these results are consistent with the actions of Staphylococcus toxins in other diseases, additional work is necessary to establish a local superantigen response in the nasal mucosa of CS/NP patients. (American Journal of Rhinology 18, 273–278, 2004)

Presence and Characterization of Sensitization to Staphylococcal Enterotoxins in Patients with Allergic Rhinitis

Exotoxins derived from Staphylococcus aureus appear to be involved in the pathogenesis of allergic diseases, especially atopic dermatitis (AD). However, little is known about sensitization to enterotoxins in cases of respiratory allergies. Because the nasal cavity is a primary site of colonization by S. aureus, we sought to determine the prevalence and role of serum immunoglobulin E (IgE) antibodies against staphylococcal enterotoxin A (SEA) and SEB in patients with allergic rhinitis (AR). The presence of SEA- and SEB-specific IgE was determined in 40 patients with AR and 16 healthy control subjects. In the rhinitis group, nasal symptom score, total serum IgE, sensitization to other inhaled allergens and the presence of sinusitis were determined. Twenty-five percent of patients with AR were sensitized to SEA/SEB whereas 6.3% of controls were sensitized to the toxins. Sensitization to SEB was predominant relative to SEA. There were no significant differences in the severity of nasal symptoms and complications of other allergic diseases including AD and bronchial asthma, between patients with or without sensitization to SEA/SEB. However, patients sensitized to these toxins were likely to show increased total serum IgE and polyvalent sensitization, suggesting that exposure and subsequent sensitization to SEA/SEB may be involved in polyvalent sensitization.

Skin microbiota of first cousins affected by psoriasis and atopic dermatitis

Background

Psoriasis and atopic dermatitis (AD) are chronic inflammatory skin diseases, which negatively influence the quality of life. In the last years, several evidences highlighted the pivotal role of skin bacteria in worsening the symptomatology of AD and psoriasis. In the present study we evaluated the skin microbiota composition in accurately selected subjects affected by (AD) and psoriasis.

Methods

Three first cousins were chosen for the study according to strict selection of criteria. One subject was affected by moderate AD, one had psoriasis and the last one was included as healthy control. Two lesional skin samples and two non-lesional skin samples (for AD and psoriatic subjects) from an area of 2 cm² behind the left ear were withdrawn by mean of a curette. For the healthy control, two skin samples from an area of 2 cm² behind the left ear were withdrawn by mean of a curette. DNA was extracted and sequencing was completed on the Ion Torrent PGM platform. Culturing of Staphylococcus aureus from skin samples was also performed.

Results

The psoriatic subject showed a decrease in Firmicutes abundance and an increase in Proteobacteria abundance. Moreover, an increase in Streptococcaceae, Rhodobacteraceae, Campylobacteraceae and Moraxellaceae has been observed in psoriatic subject, if compared with AD individual and control. Finally, AD individual showed a larger abundance of S. aureus than psoriatic and healthy subjects. Moreover, the microbiota composition of non-lesional skin samples belonging to AD and psoriatic individuals was very similar to the bacterial composition of skin sample belonging to the healthy control.

Conclusion

Significant differences between the skin microbiota of psoriatic individual and healthy and AD subjects were observed.

Association between specific IgE to Staphylococcus aureus enterotoxins A and B and asthma control

BACKGROUND

Recent studies have found that serum levels of Staphylococcus aureus enterotoxin (SE)-IgE are higher in patients with severe asthma compared with patients with nonsevere asthma. However, the association between SE-IgE and asthma control is not fully understood. Furthermore, SEA and SEB were the first reported SEs and subdivided into different groups. The influences of SEA-IgE and SEB-IgE on asthma control have not been elucidated.

OBJECTIVE

To determine the relevance of SEA- and SEB-IgE in patients with adult asthma and to investigate the association of SEA-IgE, SEB-IgE, and asthma control, respectively.

METHODS

The serum concentrations of SEA- and SEB-IgE in 172 adults with asthma were measured with a fluorescent enzyme immunoassay.

RESULTS

The prevalence of SEA- and SEB-IgE was 16.2% and 22.1%, respectively. Total IgE levels and the prevalence of atopic dermatitis were higher in SEA-IgE- and SEB-IgE-positive patients than in SEA-IgE- and SEB-IgE-negative patients, respectively; more SEA-IgE- and SEB-IgE-positive patients owned pets. Sensitization to SEA was associated with a younger mean age and a younger mean age at asthma onset. Multiple regression analysis indicated an association between total IgE levels and SEB-IgE. The prevalence of poorly uncontrolled asthma was significantly higher in SEA-IgE-positive patients than in SEA-IgE-negative patients. In addition, fractional exhaled nitric oxide levels were higher in SEA-IgE-positive patients than in SEA-IgE-negative patients. Logistic regression analysis also identified an association between SEA-IgE and poor asthma control.

CONCLUSION

Our findings indicate that sensitization to SE, in particular SEA rather than SEB, is associated with poor asthma control in adults with asthma.

Correlation Between Serum 25-Hydroxyvitamin D and Virulence Genes of Staphylococcus aureus Isolates Colonizing Children with Atopic Dermatitis

The skin of children with atopic dermatitis (AD) is colonized with Staphylococcus aureus more frequently than that of their peers. We investigated the prevalence of skin and nares colonization by S. aureus in children with AD, the virulence genes of the isolates, and their association with allergy, AD severity, and serum vitamin D (25(OH)D). This was an observational, cross-sectional study in a sample of children diagnosed with AD in two settings in Spain. The samples were collected in 2012. Swabs from affected skin and nares were taken for microbiologic culture. The prevalence of S. aureus and presence of 17 staphylococcal virulence genes were studied using polymerase chain reaction. A total of 114 patients with a mean age of 5.7 ± 4.1 (range 3 mos to 14 yrs) were included in the study. Swabs were taken from the skin of 113 individuals with AD and from the nares of 85; 28.3% had S. aureus on the skin, which was significantly associated with positive allergen-specific immunoglobulin E antibodies and higher Scoring Atopic Dermatitis (SCORAD) scores in the multivariate analysis. The presence of virulence factors tsst-1, eta, cna, aur, and sec in cutaneous S. aureus isolates was associated with lower serum levels of 25(OH)D. S. aureus on nasal swabs correlated with its presence on the skin and was associated with lower 25(OH)D levels. In conclusion, S. aureus colonization is associated with allergy and severity in AD, whereas certain virulence genes are associated with lower serum 25(OH)D levels.

Is there is an association between the presence of Staphylococcus species and occurrence of vernal keratoconjunctivitis?

Purpose

The aim of this study was to identify the association of normal bacterial flora with vernal keratoconjunctivitis (VKC) occurrence in VKC and non-VKC groups.

Methods

Conjunctival specimens were collected from 18 VKC patients and 22 healthy controls, cultured and identified following standard methods. The association between the presence of bacteria and occurrence of VKC was analyzed using Chi square statistic.

Results

Comparable bacterial growth was observed in VKC (77.8%) as well as control group (77.2%) (p = 0.970). Analysis of individual bacterial revealed that Staphylococcus aureus was detected more frequently in VKC (27.78% vs. 4.55% in control, p = 0.041) and Staphylococcus epidermidis was found much more commonly in the control eyes (45.45% in control vs. 5.56% in VKC, p = 0.005).

Conclusions

An aggravating role of S. aureus colonization in the occurrence of VKC, and a possible role of S. epidermidis against the occurrence of VKC were concluded.

Clinical features of elderly chronic urticaria

BACKGROUND/AIMS

Chronic urticaria (CU) is defined as itchy wheals lasting 6 weeks or more. As the aged population increases worldwide, it is essential to identify the specific features of this disease in the elderly population.

METHODS

We investigated the prevalence and clinical features of CU in elderly patients. Medical records of 837 CU patients from the outpatient Allergy Clinic of Ajou University Hospital, Korea were analyzed retrospectively. Patients with chronic spontaneous urticaria according to the EAACI/GA2LEN/EDF/WAO guidelines were included. Patients older than 60 years were defined as elderly.

RESULTS

Of the 837 patients, 37 (4.5%) were elderly. In elderly versus nonelderly CU patients, the prevalence of atopic dermatitis (AD) was significantly higher (37.8% vs. 21.7%, respectively; p = 0.022), while that of aspirin intolerance was lower (18.9% vs. 43.6%, respectively; p = 0.003) in terms of comorbid conditions. The prevalences of serum specific immunoglobulin E antibodies to staphylococcal enterotoxin A and staphylococcal enterotoxin B were considerably higher in elderly CU patients with AD than in those without AD (37.5% vs. 0%, respectively).

CONCLUSIONS

Elderly patients with CU had a higher prevalence of AD. Therefore, there is a need to recognize the existence of AD in elderly CU patients.

The Atopic March: Progression from Atopic Dermatitis to Allergic Rhinitis and Asthma

The development of atopic dermatitis (AD) in infancy and subsequent allergic rhinitis and asthma in later childhood is known as the atopic march. This progressive atopy is dependent on various underlying factors such as the presence of filaggrin mutations as well as the time of onset and severity of AD. Clinical manifestations vary among individuals. Previously it was thought that atopic disorders may be unrelated with sequential development. Recent studies support the idea of a causal link between AD and later onset atopic disorders. These studies suggest that a dysfunctional skin barrier serves as a site for allergic sensitization to antigens and colonization of bacterial super antigens. This induces systemic Th2 immunity that predisposes patients to allergic nasal responses and promotes airway hyper reactivity. While AD often starts early in life and is a chronic condition, new research signifies that there may be an optimal window of time in which targeting the skin barrier with therapeutic interventions may prevent subsequent atopic disorders. In this review we highlight recent studies describing factors important in the development of atopic disorders and new insights in our understanding of the pathogenesis of the atopic march.

Atopic dermatitis: a practice parameter update 2012

This parameter was developed by the Joint Task Force on Practice Parameters, representing the American Academy of Allergy, Asthma & Immunology (AAAAI); the American College of Allergy, Asthma & Immunology (ACAAI); and the Joint Council of Allergy, Asthma and Immunology. The AAAAI and the ACAAI have jointly accepted responsibility for establishing "Atopic dermatitis: a practice parameter update 2012." This is a complete and comprehensive document at the current time. The medical environment is a changing environment, and not all recommendations will be appropriate for all patients. Because this document incorporated the efforts of many participants, no single individual, including those who served on the Joint Task Force, is authorized to provide an official AAAAI or ACAAI interpretation of these practice parameters. Any request for information about or an interpretation of these practice parameters by the AAAAI or ACAAI should be directed to the Executive Offices of the AAAAI, the ACAAI, and the Joint Council of Allergy, Asthma & Immunology. These parameters are not designed for use by pharmaceutical companies in drug promotion. Published practice parameters of the Joint Task Force on Practice Parameters for Allergy & Immunology are available online at http://www.jcaai.org.

Atopic dermatitis: optimizing the topical therapy

Goal. Determination of the skin microbiocenosis in patients with atopic dermatitis (AtD) and evaluation of the treatment efficacy for AtD patients using isoconazole nitrate and diflucortolone valerate. Materials and methods. The authors assessed skin microflora in 168 AtD patients. Skin scrapes were obtained for further microscopy, and inoculation tests were performed. As many as 59 secondary AtD patients were treated with a combination of isoconazole nitrate and diflucortolone valerate as well as methylprednisolone aceponate, drugs from the DARDIA line. The treatment efficacy was evaluated clinically based on the SCORAD index as well as skin microrelief assessed with the use of the Visioscan BW30 video camera. After the treatment with Travocort, the nature and degree of skin colonization with AtD microorganisms were also assessed. Results. The efficacy of topical administration of isoconazole nitrate and diflucortolone valerate as well as methylprednisolone aceponate, drugs from the DARDIA line, was confirmed for the treatment of secondary AtD patients. Conclusion. Making antibiotics and antimycotic agents a part of the complex therapy of secondary AtD patients seems to be expedient for eliminating pathogenic microorganisms.

Changing of fecal flora and clinical effect of L. salivarius LS01 in adults with atopic dermatitis

GOAL

To evaluate cytokine stimulation with 3 strains of Lactobacillus salivarius in vitro and to assess changes in intestinal microflora and clinical improvements in adults with atopic dermatitis (AD) induced by the strain showing the best immunomodulatory features.

BACKGROUND

AD is a common skin disease in children and adults. It is characterized by chronic inflammation, eczema, and increasing intestinal permeability. Various studies have shown that patients with AD presented some modifications in the intestinal microbiota composition; as a result, intestinal microflora is thought to have a pivotal role in this disease.

METHODS

Thirty-eight patients aged from 18 to 46 years with moderate/severe AD were recruited. Subjects were randomized in a double-blind placebo-controlled study to receive active treatment with L. salivarius LS01: probiotic (n=19) or placebo (n=19). Cytokine production was determined by means of specific quantitative enzyme-linked immunosorbent assays. Intestinal bacterial groups were quantified using conventional culture techniques, whereas L. salivarius LS01 was identified using polymerase chain reaction and pulse field gel electrophoresis.

RESULTS

L. salivarius LS01 showed the best immunomodulatory features and it was chosen for the second phase of the study. AD subjects showed a reduction in their SCORAD score after probiotic treatment and a significant decrease in the staphylococci load compared with the placebo group. Moreover, L. salivarius LS01 showed the ability to reduce the production of Th2 cytokines, maintaining the production of Th1 cytokines stable.

CONCLUSIONS

Treatment with the L. salivarius LS01 strain seems to positively modify clinical and immunologic status and dermatology life quality in a group of adults affected by moderate/severe AD, leading to a rebalancing of altered intestinal microbiota.

Epicutaneous exposure to staphylococcal superantigen enterotoxin B enhances allergic lung inflammation via an IL-17A dependent mechanism

Atopic dermatitis (AD) is the initial step of the atopic march: the progression from AD to allergic rhinitis and asthma. There is a close association between skin barrier abnormalities and the development of AD and the atopic march. One of cardinal features of AD is that the lesional skin of the majority of AD patients is chronically colonized with Staphylococcus aureus with half isolates producing superantigen enterotoxin B (SEB). Although diverse roles of SEB in the pathogenesis and severity of AD have been recognized, whether SEB contributes to the dermal inflammation that drives lung inflammation and airway hyperresponsiveness (AHR) has not been examined. Here we show a novel role of S. aureus superantigen SEB in augmenting allergen ovalbumin (Ova) induced atopic march through an IL-17A dependent mechanism. When mice epicutaneously (EC) sensitized with allergen Ova, addition of topical SEB led to not only augmented systemic Th2 responses but also a markedly exaggerated systemic Th17/IL-17 immune environment. The ability of SEB in enhancing Th17/IL-17 was mediated through stimulating lymphocytes in spleen and draining lymph nodes to promote IL-6 production. Epicutaneous sensitization of mice with a combination of Ova and SEB significantly enhanced Ova-induced AHR and granulocytic lung inflammation than Ova allergen alone. When IL-17A was deleted genetically, the effects of SEB on augmenting lung inflammation and AHR were markedly diminished. These findings suggest that chronic heavy colonization of enterotoxin producing S. aureus in the skin of patients with atopic dermatitis may have an important role in the development of atopic march via an IL-17A dependent mechanism.

The role of Staphylococcal enterotoxin in atopic keratoconjunctivitis and corneal ulceration

BACKGROUND

Patients with atopic eczema frequently experience colonization with Staphylococcus aureus that is directly correlated with the eczema severity. We hypothesized that S. aureus-secreted enterotoxins (SE) are involved in the pathophysiology of atopic keratoconjunctivitis (AKC).

METHODS

A total of 45 subjects (18 with AKC, nine vernal keratoconjunctivitis (VKC), eight seasonal allergic conjunctivitis (SAC), and ten healthy volunteers) were enrolled. Slit lamp examinations, including fluorescein staining, were performed. Scraped samples were collected from the upper tarsal conjunctiva, lower conjunctival sacs, and the skin around the eyelid margins. Superantigen (SAg) genes were detected using polymerase chain reaction (PCR).

RESULTS

Among 45 cases, S. aureus was detected significantly more in AKC patients than VKC patients (P = 0.026), SAC patients (P = 0.0003), and healthy volunteers (P = 0.0001). SAg genes were detected in 11 patients. SEB (2/11), SEG (8/11), and SEI (8/11) were detected, but no other SE. There was a significant difference in SE detection between AKC and SAC patients (P = 0.03). In severe types of ocular allergic disease such as AKC and VKC (N = 27), SE was detected in six of ten patients with corneal ulcers and two of 17 patients without corneal ulcers. SE was detected in significantly more patients with corneal ulcers (P = 0.025).

CONCLUSIONS

In patients with AKC, S. aureus and SE were detected more frequently compared with other patients and healthy volunteers, especially in association with corneal ulceration suggesting a role of SE. So far, it is unknown whether SE leads to tissue damage of the cornea by initiating an immune response or has direct toxic effects.

Comorbidities between nose and skin allergy

PURPOSE OF REVIEW

This review focuses on comorbidities between nose and skin allergies. For this purpose, allergic rhinitis and chronic rhinosinusitis (CRS) were selected as examples of nasal disorders and atopic dermatitis and urticaria as examples of allergic skin disorders and the individual entities of both localizations were evaluated and compared in relation to their prevalence and coincidence, underlying pathophysiological mechanisms, genetic data and shared therapy options.

RECENT FINDINGS

The inter-relationships between atopic dermatitis and allergic rhinitis are the best studied, but even for the other comorbidities it was possible to demonstrate comparable pathomechanisms in addition to a high prevalence and coincidence, particularly in the case of atopically assisted forms. In this context, the interactions of IgE, mast cells and eosinophils play a special role, but genetic issues, the significance of epithelial barrier defects and colonization with Staphylococcus aureus are also important sharing issues.

SUMMARY

Allergic skin disorders such as atopic dermatitis and urticaria are frequently associated with comorbidities of the nose as well as allergic rhinitis and CRS. By contrast, different manifestations of these diseases involve the nose and the skin. These are not separate diseases but are linked by complex and currently unclear/insufficiently defined inter-relationships.

Repeated intranasal instillation with staphylococcal enterotoxin B induces nasal allergic inflammation in guinea pigs

BACKGROUND

Staphylococcal enterotoxins (SEs) appear to play a role in the pathogenesis of allergic disease. However, no animal models have been reported to show nasal allergic inflammation by repeated inhalation with staphylococcal enterotoxin B (SEB) in the absence of adjuvant. This study was designed to determine whether intranasal instillation of guinea pigs with SEB results in nasal allergic inflammation.

METHODS

Guinea pigs were intranasally instilled with 40 μL of 4-μg SEB once every 4 days 11 times. For the control group, guinea pigs were prepared with saline instead of SEB. Sneezing and nasal scratching frequency were evaluated after each intranasal instillation. The production of antigen-specific antibodies including IgE, nasal eosinophilia, and cytokines in the nasal cavity lavage fluid (NCLF) were measured after the 11th intranasal immunization.

RESULTS

In the model group, symptoms of sneezing and nasal scratching were induced at the 8th to 11th challenges. Intranasal immunization with SEB elicited a local nasal mucosa inflammatory response characterized by apparent eosinophil infiltration. In the NCLF, the expression of IL-4 but not interferon-gamma was increased after challenges. The serum levels of total and SEB-specific IgE and IgG1 were higher in model groups in comparison with the control groups (p < 0.01).

CONCLUSION

These results indicate that repeated intranasal instillation with SEB leads to Th2 immune response, allergic nasal inflammation, and increased antigen-specific IgE production that are characteristic of allergic rhinitis (AR). The model in this study could be valuable in analyzing the pathogenesis of AR infected with Staphylococcus aureus.

Molecular and immunological characterization of Staphylococcus aureus in pediatric atopic dermatitis: implications for prophylaxis and clinical management

S. aureus represents a critical cofactor in atopic dermatitis (AD). In this paper, the prevalence of S. aureus infection/colonization was evaluated in 117 children as well as in their cohabitants, in order to assess the value of S. aureus characterization in predicting disease onset and severity and in providing indications for prophylaxis. Results showed that children with AD as well as their cohabitants had a significantly greater incidence of S. aureus infection/colonization as compared to controls. The genetic characterization showed a virtual identity of the bacteria strains collected at different sites of the patients with those found in the cohabitants, suggesting both a direct transmission between the nasal reservoir and the lesions in the same atopic subject and a risk for reinfection within family cohabitants. These data stress the need of preliminary laboratory assessment and posttherapy control in both AD patients and their close contacts for effective S. aureus eradication.

The atopic march: progression from atopic dermatitis to allergic rhinitis and asthma

Atopic dermatitis (AD) is an inflammatory disease characterized by pruritic skin lesions. The pathogenesis of AD may include disrupted epidermal barrier function, immunodysregulation, and IgE-mediated sensitization to food and environmental allergens. AD is also part of a process called the atopic march, a progression from AD to allergic rhinitis and asthma. This has been supported by multiple cross-sectional and longitudinal studies and experimental data. Research on the mechanisms of AD has been centered on the adaptive immune system with an emphasis on the T-helper 1 (Th1)-Th2 paradigm. Recently, the conceptual focus has largely shifted to include a primary defect in the epithelial barrier as an initial event in AD providing a significant insight into the disease initiation and pointing to a complex secondary interplay of environmental and immunological sequelae with barrier disruption. Further understanding of AD will help the development of more effective treatment for AD and ultimately, preventative algorithms for the atopic march. In this review we highlight recent advances in our understanding of the pathogenesis of AD and the atopic march.

The role of 9-O-acetylated ganglioside D3 (CD60) and {alpha}4{beta}1 (CD49d) expression in predicting the survival of patients with Sezary syndrome

BACKGROUND

Sézary syndrome is a rare and very aggressive leukemic variant of cutaneous T-cell lymphoma characterized by extensive skin involvement and a malignant circulating CD4(+) T-cell clone which homes to the skin, over-expresses CD60, and lacks CD7, CD26 and CD49d. So far prognostic markers in this disease are limited to treatment with systemic steroids, age, serum lactate dehydrogenase, and a white blood cell count of 20×10(9)/L or higher: no other biological marker with prognostic value, especially related to malignant cells, has been described.

DESIGN AND METHODS

We used flow activated cell sorting analysis to compare the distribution of the T-cell receptor-Vβ repertoire and several surface molecules (CD7, CD26, CD49d and CD60) within the circulating CD4(+) T-cell population in 62 patients with Sézary syndrome, 180 with mycosis fungoides, 6 with B-cell lymphomas, and 19 with chronic eczema. We calculated the 5-year overall survival of patients with Sézary syndrome after first hospital admission using Kaplan-Meier product-limit estimates and hazard ratios from the Cox proportional hazards model.

RESULTS

We found that both higher number of CD60(+) and lower number of CD49d(+) cells within circulating CD4(+) T cells at disease presentation were significantly associated with a lower probability of survival. An exceedingly high risk of death was observed for patients with a combination of a high proportion of CD4(+)CD60(+) cells (≥ 0.5×10(9)/L) and low proportion of CD4(+)CD49d(+) cells (<0.5×10(9)/L) (hazard ratio = 12.303, 95% confidence interval 1.5-95.9; P<0.02). In addition, a skewed usage of T-cell receptor-Vβ subfamilies was observed in the circulating T-cell clone for 61.9% of all patients with Sézary syndrome, T-cell receptor-Vβ 2 and 5.1 subfamilies being the most frequently represented (42.8%), followed by T-cell receptor-Vβ 12 and 13.1.

CONCLUSIONS

In this study we showed that up-regulation of CD60 and down-regulation of CD49d on circulating CD4(+) T cells are two useful markers for predicting a very poor outcome in patients with Sézary syndrome.

The infectious aspects of atopic dermatitis

Atopic dermatitis is characterized by Staphylococcus aureus colonization and recurrent skin infections. In addition to an increased risk of invasive infections by herpes simplex or vaccinia viruses, there is ample evidence that microbial pathogens, particularly S aureus and fungi, contribute to the cutaneous inflammation of atopic dermatitis. The authors describe recent developments in the pathogenesis of atopic dermatitis in relation to the role of microbial pathogens. Understanding how microbial pathogens interact or evade the cutaneous immunity of atopic dermatitis may be crucial in preventing infections or cutaneous inflammation in this disease.

Association of staphylococcal superantigen-specific immunoglobulin e with mild and moderate atopic dermatitis

OBJECTIVE

To examine the frequency of allergic sensitization to staphylococcal superantigens in young children with mild to moderate atopic dermatitis (AD).

STUDY DESIGN

AD severity was assessed with objective Scoring AD. Serum IgE to staphylococcal enterotoxin (SE) A, SEB, SEC, SED, and toxic shock syndrome toxin-1 were measured with ImmunoCAP. Comparisons between mild AD and moderate AD were performed by using logistic regressions.

RESULTS

The prevalence of allergic sensitization to staphylococcal superantigens in patients with mild and moderate AD was 38% and 63%, respectively. Allergic sensitization to staphylococcal superantigens, particularly SEA and SED, was found to be associated with moderate AD, compared with mild AD.

CONCLUSIONS

Our results suggest that allergic sensitization to staphylococcal superantigens is common even in young children with mild to moderate AD, and such sensitization may contribute to the disease severity of these patients.

Systemic therapeutic options for severe atopic dermatitis

Systemic therapy of severe atopic dermatitis (AD) is difficult in some cases, because the use of immunosuppressive agents such as cyclosporine A, mofetil mycophenolate, tacrolimus, and azathioprine is limited by adverse reactions or contraindications. Recent reports suggest a helpful role for biologics, methotrexate, anti-IgE antibodies, and immunotherapy. We review the modes of action, as well as advantages and disadvantages of current and new systemic therapeutic options for severe AD.

Role of bacterial pathogens in atopic dermatitis

The skin of atopic dermatitis (AD) patients exhibits a striking susceptibility to colonization and infection with Staphylococcus aureus. This review summarizes our understanding about the role of S. aureus in AD. Indeed, S. aureus colonization is both a cause and a consequence of allergic skin inflammation. The mechanisms that allergic skin inflammation of AD promotes the increase of S. aureus colonization include skin barrier dysfunction, increased synthesis of the extracellular matrix adhesins for S. aureus, and defective innate immune responses due to decreased production of endogenous antimicrobial peptides. On the other hand, the exotoxins secreted by S. aureus are superantigens. Staphylococcal superantigens (SsAgs) may penetrate the skin barrier and contribute to the persistence and exacerbation of allergic skin inflammation in AD through the stimulation of massive T cells, the role of allergens, direct stimulation of antigen-presenting cells and keratinocytes, the expansion of skin-homing cutaneous lymphocyte-associated antigen-positive T cells, and the augmentation of allergen-induced skin inflammation. SsAgs also induce corticosteroid resistance. In therapeutic interventions, anti-inflammatory therapy alone is very effective in reducing S. aureus colonization on the skin, but antibiotic treatment alone is unable to improve the allergic skin inflammation of AD. Therefore, we recommend the combination therapy of anti-inflammatory drugs and antibiotics in the AD patients with secondary bacterial infection, exacerbated AD, or poorly controlled AD. However, when AD is well controlled by anti-inflammatory drugs alone, we do not recommend the antibiotic therapy.

Clinical correlations of recent developments in the pathogenesis of atopic dermatitis

Atopic dermatitis is a chronic inflammatory skin disease with a steadily increasing prevalence affecting 10-20 of infants and 1-3 of adults globally. It is often the first clinical manifestation of atopic disease preceding asthma and allergic rhinitis. Probably half of the children with atopic dermatitis develop some other form of atopic disease later in life. The pathogenesis involves a complex interplay of factors including genetic predisposition due to altered immune or skin barrier function, interactions with the environment such as food and allergen exposures, and infectious triggers of inflammation. In this review, we summarize the recent advances in understanding the contribution of different factors in the pathophysiology of atopic dermatitis and how insights provide new therapeutic potential for its treatment.

Higher Bcl-2 levels decrease staphylococcal superantigen-induced apoptosis of CD4+ T cells in atopic dermatitis

BACKGROUND

Staphylococcal superantigens (SsAgs) contribute to the persistence of allergic skin inflammation in atopic dermatitis (AD). The aims of this study were to (1) determine whether there are differences between AD patients and healthy subjects in SsAg-induced caspase-3 activation and SsAg-induced changes of anti-apoptotic protein Bcl-2 and Bcl-2 mRNA levels of CD4+ T cells; (2) investigate the effect of interleukin (IL)-4 on SsAg-induced caspase-3 activation and SsAg-induced changes of Bcl-2 and Bcl-2 mRNA levels of CD4+ T cells.

METHODS

Using immunofluorescence staining followed by flow cytometric analysis and real-time PCR, we analyzed peripheral blood mononuclear cells with or without staphylococcal enterotoxin B (SEB) stimulation in the presence or absence of recombinant IL-4 or anti-IL-4 neutralizing antibodies in 16 AD patients and 14 healthy subjects.

RESULTS

SEB-reactive (TCRVbeta3+, Vbeta12+, and Vbeta17+) CD4+ T cells from AD patients were more resistant to SEB-induced caspase-3 activation and SEB-induced decrease of Bcl-2 and Bcl-2 mRNA than those from healthy subjects. Exogenously added IL-4 inhibited SEB-induced caspase-3 activation and SEB-induced decrease of Bcl-2 and Bcl-2 mRNA in SEB-reactive CD4+ T cells from healthy subjects. Inhibition of endogenous IL-4 by using anti-IL-4 neutralizing antibodies up-regulated SEB-induced caspase-3 activation and SEB-induced decrease of Bcl-2 and Bcl-2 mRNA in SEB-reactive CD4+ T cells from AD patients.

CONCLUSIONS

Following SsAg stimulation, IL-4 produced by T cells in AD patients down-regulates SsAg-induced caspase-3 activation and apoptosis of CD4+ T cells through inhibiting the decrease of Bcl-2. This may impair deletion of SsAg-activated T cells and resolution of allergic skin inflammation.

Atopic eczema: what's new?

Atopic eczema (AE) is a chronic inflammatory skin disease characterized by recurrent intense pruritus and a typical age-related distribution of skin lesions. Several new aspects with regard to the pathogenetic background as well as strategies for prevention, diagnosis and treatment of AE have emerged. There are ongoing studies on genetic susceptibility loci, as well as environmental and nutritional factors associated with an increase or a decrease of AE lesions. The atopy patch test is now available for identification of allergens in aeroallergen-triggered AE. New topical therapies, such as the calcineurin inhibitors, have broadened the therapeutic armamentarium substantially. In order to increase knowledge and coping strategies, patient education programs have been launched. Learning objective Upon completing this paper, the reader should be aware of new developments in AE, especially on nomenclature, prevention strategies, diagnostic tests, as well as therapeutic options.

The Role of Immune Response to Staphylococcus aureus Superantigens and Disease Severity in Relation to the Sensitivity to Tacrolimus in Atopic Dermatitis

BACKGROUND

Staphylococcus aureus-producing superantigens (SAgs), such as staphylococcal enterotoxin B (SEB) or toxic shock syndrome toxin-1 (TSST-1), are frequently observed in atopic dermatitis (AD). However, little has been done to establish the association of immune responses to SAgs and the therapeutic response to immunosuppressive drugs in AD. Therefore, we investigated the prevalence and role of SAgs in the pathophysiology and immunosuppressive drug sensitivity in AD patients.

METHODS

We classified 29 patients into two groups on the basis of their clinical AD scores: a low-score group (n = 14) corresponding to mild to moderate patients and a high-score group (n = 15) corresponding to severe patients. We estimated the plasma anti-SEB or TSST-1 IgE of these patients and healthy subjects by ELISA. We also estimated individual drug sensitivity by determining drug concentrations that would give 50% inhibition (IC(50)) of peripheral-blood mononuclear cell (PBMC) proliferation in vitro.

RESULTS

The levels of plasma anti-SEB or TSST-1 IgE in the severe patients were significantly higher than those in the mild to moderate patients (p < 0.05 and p < 0.01, respectively). When stimulated with concanavalin A in vitro, PBMCs in the severe patients exhibited low sensitivity to the suppressive efficacy of tacrolimus (FK506) as compared to the mild to moderate patients (p < 0.01). Furthermore, there was a significant correlation between the IC(50)s of FK506 and plasma anti-TSST-1 IgE levels (p < 0.01).

CONCLUSIONS

We showed that PBMCs in severe AD patients exhibited lower sensitivity to FK506, and had higher plasma levels of anti-TSST-1 IgE as compared to the mild AD patients. SAgs appear to be one of the causes of decreased PBMC sensitivity to FK506, and therefore an alternative treatment would be useful based on the individual drug sensitivity data and anti-TSST-1 IgE levels.

The importance of bacterial superantigens produced by Staphylococcus aureus in the treatment of atopic dermatitis using povidone-iodine

Atopic dermatitis (AD) is frequently associated with intestinal and cervical lesions. Staphylococcus aureus produces many kinds of toxins, the bacterial superantigens. The detection rate of toxins was 80.1% from 196 S. aureus strains. Neurological examinations revealed abnormalities in 59 out of 81 AD patients. Cervical magnetic resonance imaging (MRI) was performed in 46 patients randomly and showed abnormal findings in 38 of these patients. In 23 patients who underwent MRI and duodenal biopsy, 3 were found to be normal neurologically and 2 patients showed normal duodenal tissue. However, 18 patients had abnormal findings both on neurological examination and in duodenal tissue. Serial duodenal biopsy tests were performed in 10 AD patients. In 5 patients, the findings of chronic duodenitis disappeared after the therapy with povidone-iodine. These data indicate that the therapy was effective not only for the skin lesions, but improved gastrointestinal tract lesions and cervical myelopathy, by eradicating bacterial superantigens.

Efficacy and functionality of silver-coated textiles in patients with atopic eczema

BACKGROUND

Microbial skin colonization with Staphylococcus aureus is known to play an important role in atopic eczema (AE). Recently, an antibacterial effect of silver-coated textiles on S. aureus colonization has been demonstrated.

OBJECTIVES

To investigate clinical efficacy and functionality of silver-coated textiles in AE, a multicentre, double-blind, placebo-controlled trial was conducted.

PATIENTS/METHODS

From November 2001 to August 2002, 68 consecutive outpatients clinically diagnosed with generalized AE were included in the study. Inclusion criteria were the clinical diagnosis of AE with a moderate severity as measured by the scoring of atopic dermatitis (SCORAD) index with at least 20. Patients were instructed to wear either silver-coated (verum, 35 patients + 2 dropouts) or cotton garments (placebo, 22 patients + 9 dropouts) directly on the skin for 2 weeks. Only basic skin care and ongoing therapy with topical steroids or oral antihistamines was permitted. Clinical severity was assessed using the 'SCORAD' before, during and at the end of study. Quality of life (QOL), wearing comfort (WC) and functionality (FU) of study clothes were measured in parallel. Patients documented their subjective and objective symptoms daily.

RESULTS

In the verum group, eczema improved significantly after 1 week with further enhancement until the end of study (P = 0.03 and P < 0.001). Silver-coated textiles were comparable to cotton in WC and FU. Pruritus and self-assigned skin condition improved significantly more than with placebo (P < 0.001 and P = 0.003).

CONCLUSIONS

In conclusion, silver-coated textiles are able to improve objective and subjective symptoms of AE significantly within 2 weeks, showing a good wearing comfort and functionality comparable to cotton.

Topical superantigen exposure induces epidermal accumulation of CD8+ T cells, a mixed Th1/Th2-type dermatitis and vigorous production of IgE antibodies in the murine model of atopic dermatitis

Patients with atopic dermatitis (AD) have repeated cutaneous exposure to both environmental allergens and superantigen-producing strains of Staphylococcus aureus. We used a murine model of AD to investigate the role of staphylococcal enterotoxin B (SEB) in the modulation of allergen-induced skin inflammation. Mice were topically exposed to SEB, OVA, a combination of OVA and SEB (OVA/SEB), or PBS. Topical SEB and OVA/SEB exposure induced epidermal accumulation of CD8+ T cells and TCRVbeta8+ cells in contrast to OVA application, which induced a mainly dermal infiltration of CD4+ cells. SEB and OVA/SEB exposure elicited a mixed Th1/Th2-associated cytokine and chemokine expression profile within the skin. Restimulation of lymph node cells from OVA- and OVA/SEB-exposed mice with OVA elicited strong production of IL-13 protein, whereas substantial amounts of IFN-gamma protein were detected after SEB stimulation of cells derived from SEB- or OVA/SEB-exposed mice. Topical SEB treatment elicited vigorous production of SEB-specific IgE and IgG2a Abs and significantly increased the production of OVA-specific IgE and IgG2a Abs. The present study shows that topical exposure to SEB provokes epidermal accumulation of CD8+ T cells, a mixed Th2/Th1 type dermatitis and vigorous production of specific IgE and IgG2a Abs, which can be related to the chronic phase of atopic skin inflammation.

Pholcodine stimulates a dramatic increase of IgE in IgE-sensitized individuals. A pilot study

BACKGROUND

A previous study showed a relation between pholcodine (PHO) consumption, prevalence of IgE-sensitization to PHO, morphine (MOR) and suxamethonium (SUX) and anaphylaxis to neuromuscular blocking agents (NMBA). The purpose of this pilot study was to explore the effect on IgE production, in IgE-sensitized and nonsensitized individuals, of exposure to cough syrup and environmental chemicals containing PHO, MOR and SUX related allergenic structures.

METHODS

Serum concentrations of IgE and IgE antibodies to PHO, MOR and SUX allergens measured by ImmunoCAP (Pharmacia Diagnostics, Uppsala, Sweden) were followed after intake of cough syrup, or exposure to confectionary and other household chemicals containing various amounts of substances cross-reacting with PHO, MOR and SUX.

RESULTS

Cough syrup containing PHO gave, in sensitized individuals, within 1-2 weeks, an increase of IgE of 60-105 times and of IgE antibodies to PHO, MOR and SUX in the order of 30-80 times. The tested confectionary did not have any similar stimulating effect but seemed to counteract the expected decrease of IgE. No effect was seen in nonsensitized individuals. The PHO stimulated IgE showed a nonspecific binding to ImmunoCAP with common allergens and glycine background ImmunoCAP that was up to 10-fold higher than that of monomeric myeloma-IgE at twice the concentration.

CONCLUSIONS

It seems as cough syrups containing PHO have a most remarkable IgE boostering effect in persons IgE-sensitized to PHO, MOR and SUX related allergens. Household chemicals containing such allergenic epitopes seem capable of some, minor, stimulation.

Increased levels of serum-specific immunoglobulin e to staphylococcal enterotoxin a and B in patients with allergic rhinitis and bronchial asthma

BACKGROUND

The association between staphylococcal enterotoxins and atopic dermatitis (AD) is well characterized. We aim to evaluate the association between sensitization to staphylococcal enterotoxin A (SEA) and/or B (SEB) and the development of allergic airway disease.

METHODS

Two hundred and seventy-four patients were grouped into allergic rhinitis (AR) and/or bronchial asthma (BA) only, AD only and AR/BA+AD. The AR/BA only group was further divided into AR only, AR and airway hyperresponsiveness (AR+AHR) and BA. The allergen-specific and total immunoglobulin E (IgE) antibodies were determined by the CAP system. The associations of sensitization to SEA/SEB with allergic airway disease were analyzed by logistic regression analysis.

RESULTS

The overall rate of sensitization to SEA/SEB was 25.7%, whereas the rate of the AD only group (45.5%) was significantly higher than that of the AR/BA only group (24.5%, chi2=8.1). After sensitization to SEA/SEB, the geometric mean total IgE levels were significantly elevated in patients with AR+AHR and BA, but not in those with AR only. BA patients had higher geometric mean values of SEA- and SEB-specific IgE than AR only and AR+AHR patients. Logistic regression revealed that AR/BA only was more associated with sensitization to SEA/SEB (odds ratio 6.57) than AD only and AR/BA+AD (odds ratio 2.44 and 1.72).

CONCLUSIONS

Atopic status after sensitization to SEA/SEB was more closely associated with BA than with other airway allergy, implying that SEA/SEB may play a role in exacerbating airway allergy and increasing the risk of allergic airway disease. Our study suggests that staphylococcal enterotoxins play a prominent role in the pathogenesis of allergic airway disease as well as AD.

Atopic dermatitis: beyond the itch that rashes

The prevalence of atopic dermatitis is increasing, and more than 50% of children with atopic dermatitis go on to develop asthma and allergies. A better understanding of the underlying immune abnormalities of this complex chronic relapsing skin disease is needed. Although the optimal treatment approach remains to be defined, several recent studies suggest a rationale for using topical calcineurin inhibitors as early intervention and adding topical corticosteroids as rescue therapy if needed.

NR4A orphan nuclear receptor family in peripheral blood eosinophils from patients with atopic dermatitis and apoptotic eosinophils in vitro

To identify novel genes related to the clinical signs of atopic dermatitis (AD), differentially expressed genes were sought in peripheral blood eosinophils from both AD patients and healthy volunteers. RNA was prepared from eosinophils, expression of various genes was monitored using the Affymetrix GeneChip, and expression was quantified by real-time RT-PCR. Two genes, Nur77 and NOR1, members of NR4A orphan nuclear receptor family, were expressed at a significantly higher level in AD patients than in healthy volunteers. Expression of another gene in the NR4A receptor family, Nurr1, was also higher in AD patients than in healthy volunteers. When peripheral blood leukocytes from healthy volunteers were fractionated, NOR1 expression was highest in eosinophils, but expression of Nur77 and Nurr1 genes was not eosinophil-specific. Extremely intense apoptosis was induced in both eosinophils and an eosinophil cell line, AML14.3D10, by treatment with antibody (Ab) to both CD30 and Fas. Rapid expression of the genes for the NR4A receptor family was observed with anti-CD30 Ab treatment but not with anti-Fas Ab. The NR4A orphan nuclear receptor family gene expression and the subsequent eosinophil apoptosis were downregulated by the MAPK inhibitor, U0126. These results suggest that the expression of the NR4A receptor family genes through CD30 signaling may regulate eosinophil apoptosis in allergic conditions such as AD.

Nasal exposure to Staphylococcal enterotoxin enhances the development of allergic rhinitis in mice

BACKGROUND

Staphylococcal enterotoxins (SEs) appear to play a role in the pathogenesis of allergic disease. However, little is known whether the nasal exposure to SE affects the development of allergic rhinitis (AR).

OBJECTIVE

We sought to determine the in vivo effect of nasal exposure to SE on the development of AR using mouse model.

METHODS

BALB/c mice were intranasally sensitized with Schistosoma mansoni egg antigen (SmEA) in the presence or absence of staphylococcal enterotoxin B (SEB). Control mice were intranasally sensitized with either SEB or SmEA alone. The production of antigen-specific antibodies including IgE, nasal eosinoplilia and cytokines by nasal mononuclear cells was compared among mice that had or had not received SEB treatment.

RESULTS

Nasal exposure to SEB enhanced the development of AR in SmEA-sensitized mice, as manifested by SmEA-specific IgE production, nasal eosinophilia, and IL-4 and IL-5 production by nasal mononuclear cells after Ag challenge. This treatment also elicited IFN-gamma production by SmEA-primed cells. In addition, these mice produced SEB-specific IgE whereas mice treated with SEB without SmEA sensitization did not produce SEB-specific IgE or demonstrate nasal eosinophilia.

CONCLUSION

These results suggest that the nasal exposure to SEB enhances susceptibility to AR although the exposure to SE solely does not induce AR.

Persistent skin colonization with Staphylococcus aureus in atopic dermatitis: relationship to clinical and immunological parameters

BACKGROUND

Staphylococcus aureus has important implications for the pathogenesis of atopic dermatitis (AD). In some patients S. aureus can be eradicated from the skin during anti-inflammatory treatment, while in others bacterial colonization is persistent. Potential mechanisms and features of these two distinct groups of patients are not known.

OBJECTIVE

Accordingly, we studied relationships between the ability to eliminate S. aureus during an anti-inflammatory treatment and selected clinical and immunological features.

METHODS

Quantitative assessment of S. aureus on the skin, in nasal vestibule and throat, serum IgE levels, CD4/CD8 T-cell ratio, lymphocyte proliferation and phagocyte oxidative burst were determined during the exacerbation and after 4 and 12 weeks of the treatment using topical steroid and oral antihistamine in 34 patients with AD.

RESULTS

S. aureus was found on the skin of all 34 patients during exacerbation. Disease severity scoring of atopic dermatitis (SCORAD) correlated with the density of bacteria. Treatment with oral antihistamine and topical steroid resulted in a significant alleviation of symptoms, which correlated with the elimination of S. aureus from the skin in 70% of patients. In the remaining 30% of patients, dense (more than 10(10)/cm2) S. aureus skin colonization, persisted despite the treatment. Patients with persistent S. aureus presented with higher serum IgE levels, lower lymphocyte proliferation in response to staphylococcal enterotoxin B, phytohaemagluttinin and anti-CD3. Persistence of S. aureus was more common in men.

CONCLUSIONS

Patients with AD differ in the ability to clear S. aureus from the skin during anti-inflammatory treatment, which appears to be related to the abnormalities in immunological parameters. Local antibiotic therapy should be considered only in patients with persistent S. aureus colonization.

Evidence for Restricted Vβ Usage in the Leukemic Phase of Cutaneous T Cell Lymphoma

Antibodies directed against the beta chain of the T cell receptor (anti-Vbeta antibodies) are useful to identify the Vbeta repertoire of T cells in various diseases and to quantify numbers of Vbeta-bearing T cells. The goals of this study were to identify Vbeta+ cases of leukemic phase cutaneous T cell lymphoma (CTCL) and to compare the percentage of positive calls with other measures of blood tumor burden, i.e., lymphocyte subsets with a CD4+CD7- and CD4+CD26- phenotype and Sezary cell counts. Thirty-three of 49 (67%) cases of leukemic CTCL reacted with an anti-Vbeta antibody. When combined with reports from the literature, the frequency of Vbeta5 (probably Vbeta5.1) usage was relatively high when compared with Vbeta2 that is also frequently expressed by normal CD4+ T cells. The percentage of Vbeta+ cells correlated to the percentage of CD4+CD7- and CD4+CD26- cells for cases in which the neoplastic cells were deficient in expression of CD7 and CD26, respectively, but not the Sezary cell count. We hypothesize that the increased Vbeta5.1 usage in CTCL may be the result of depletion of Vbeta2 and other Vbeta-bearing T cells by staphylococcal superantigens prior to neoplastic transformation, resulting in a relative increase in the frequency of Vbeta5.1 usage in CTCL.

Immunoglobulin E to staphylococcal and streptococcal toxins in patients with chronic sinusitis/nasal polyposis

BACKGROUND

The role of infectious agents and their contribution to the inflammation in chronic sinusitis/nasal polyposis (CS/NP) is not clear. Staphylococcal and streptococcal toxins have superantigen activity and have been implicated in inflammatory conditions such as atopic dermatitis, psoriasis, and asthma.

OBJECTIVE

We investigated the presence of immunoglobulin (Ig)E antibodies to staphylococcal and streptococcal toxins in the serum of individuals with CS/NP.

METHOD

IgE antibodies to staphylococcal exotoxins, A, B, and toxic shock syndrome toxin-1 and streptococcal pyrogenic exotoxin A, B, and C were measured in 23 individuals with CS/NP before functional endoscopic sinus surgery and in controls (7 atopic and 6 nonatopic) individuals without chronic sinusitis. Presence of IgE to the toxins was also correlated with disease severity on sinus computed tomography (CT) scans.

RESULTS

Staphylococcal and streptococcal toxin specific IgE antibodies were detected in 18 of 23 (78%) and 7 of 21 (33.3%) patients, respectively. None of the controls had IgE to the staphylococcal or streptococcal toxins (P <.0001). There was no association between radiographic severity of sinus disease and the presence of IgE antibody to the toxins.

CONCLUSION

A significantly greater proportion of CS/NP patients had IgE to staphylococcal or streptococcal toxins. Evidence of IgE antibodies directed against staphylococcal and streptococcal toxins in the sera of patients with CS/NP suggests a potential role of these toxins with established superantigen effects in the pathogenesis of CS/NP.