Histological characterization of liver involvement in systemic mastocytosis

BACKGROUND AND AIMS

Systemic mastocytosis (SM) is characterized by the accumulation of atypical mast cells (MCs) in organs. Liver histology of SM has been marginally described and accurate histological classification is critical, given the consequences of aggressive SM diagnosis. We aimed to describe the histological features associated with liver SM using updated tools.

METHODS

Using the database of the French Reference Centre for Mastocytosis, we retrospectively identified patients with a liver biopsy (LB) and a diagnosis of SM. All LB procedures were performed according to the local physician in charge and centrally reviewed by an expert pathologist.

RESULTS

A total of 28 patients were included: 6 had indolent SM, 9 had aggressive SM, and 13 had SM with an associated hematologic neoplasm. Twenty-five (89%) patients presented hepatomegaly, and 19 (68%) had portal hypertension. The LB frequently showed slight sinusoid dilatation (82%). Fibrosis was observed in 3/6 indolent SM and in almost all advanced SM cases (21/22), but none of them showed cirrhosis. A high MC burden (>50 MCs/high-power field) was correlated with elevated blood alkaline phosphatase levels (p = .030). The presence of portal hypertension was associated with a higher mean fibrosis grade (1.6 vs. 0.8 in its absence; p = .026). In advanced SM, the presence of nodular regenerative hyperplasia (NRH) was associated with decreased overall survival (9.5 vs. 46.3 months, p = .002).

CONCLUSIONS

MC infiltration induced polymorphic hepatic lesions and the degree of fibrosis is associated with portal hypertension. NRH identifies a poor prognosis subgroup of patients with advanced SM. Assessing liver histology can aid in SM prognostic evaluation.

In Situ Patch Test and Repeated Open Application Test for Fixed Drug Eruption: A Multicenter Study

BACKGROUND

Few studies have evaluated allergy workup in fixed drug eruption (FDE) in a large population.

OBJECTIVE

To evaluate the sensitivity of a standardized allergy workup for diagnosing the cause of FDE, with a focus on in situ repeated open application tests (ROATs).

METHODS

In a retrospective multicenter study, we analyzed the practice of conducting a complete allergy workup for the etiological diagnosis of FDE. It consisted of 3 steps: in situ patch tests (PTs) for all cases except pure mucosal involvement, followed by in situ ROAT if in situ PT results were negative, and finally a drug challenge (DC). The in situ ROAT involved daily application of the suspected drug on a previously affected FDE site for 7 days.

RESULTS

Of 98 suspected FDE cases, 61 patients (median age 61 y; male-to-female ratio 1.8) with a complete allergy workup were included. In 4 cases, even the DC yielded negative results. Among the remaining 57 patients with a positive workup, implicated drugs included paracetamol (12 cases), β-lactams (11 cases), imidazoles (9 cases, including 5 with metronidazole), nonsteroidal anti-inflammatory drugs (8 cases), iodinated contrast media (4 cases), cotrimoxazole (3 cases), and various other drugs in 10 patients. The diagnosis was confirmed by in situ PT in 17 of 54 cases (31.5%), in situ ROAT in 14 of 40 cases (35%) (with 4 cases showing remote reactivation of FDE sites), and DC in 26 cases.

CONCLUSIONS

The sequential allergy workup involving successively in situ PT, in situ ROAT, and DC is a reliable and safe method for diagnosing the cause of FDE. In situ tests exhibited a sensitivity of over 50%.

Efficacy and Safety of Rituximab-Based Treatments in Angioedema With Acquired C1-Inhibitor Deficiency

BACKGROUND

Angioedema (AE) due to acquired C1-inhibitor (C1-INH) deficiency (AAE-C1-INH) is related to excessive consumption of C1-INH or to anti-C1-INH antibodies, and is frequently associated with lymphoproliferative syndromes or monoclonal gammopathies. Standard of care for prophylactic treatment in this condition is not established. Rituximab may be effective to prevent attacks, especially if the lymphoid hemopathy is controlled, but data are scarce.

OBJECTIVE

To evaluate efficacy of rituximab in AAE-C1-INH.

METHODS

A retrospective multicenter study was carried out in France, including patients with AAE-C1-INH treated with rituximab between April 2005 and July 2019.

RESULTS

Fifty-five patients with AAE-C1-INH were included in the study, and 23 of them had an anti-C1-INH antibody. A lymphoid malignancy was identified in 39 patients, and a monoclonal gammopathy in 9. There was no associated condition in 7 cases. Thirty patients received rituximab alone or in association with chemotherapy (n = 25). Among 51 patients with available follow-up, 34 patients were in clinical remission and 17 patients had active AE after a median follow-up of 3.9 years (interquartile range, 1.5-7.7). Three patients died. The presence of anti-C1-INH antibodies was associated with a lower probability of AE remission (hazard ratio, 0.29 [95% CI, 0.12-0.67]; P = .004). Relapse was less frequent in patients with lymphoma (risk ratio, 0.27 [95% CI, 0.09-0.80]; P = .019) and in patients treated with rituximab and chemotherapy (risk ratio, 0.31 [95% CI, 0.12-0.79]; P = .014).

CONCLUSIONS

Rituximab is an efficient and well-tolerated therapeutic option in AE, especially in lymphoid malignancies and in the absence of detectable anti-C1-INH antibodies.

Pathophysiologic implications of elevated prevalence of hereditary alpha-tryptasemia in all mastocytosis subtypes

BACKGROUND

Mastocytosis and monoclonal mast cell (MC) activation syndrome (MMAS) are heterogeneous conditions characterized by the accumulation of atypical MCs. Despite the recurrent involvement of KIT mutations, the pathophysiologic origin of mastocytosis and MMAS is unclear. Although hereditary α-tryptasemia (HαT, related to TPSAB1 gene duplication) is abnormally frequent in these diseases, it is not known whether the association is coincidental or causal.

OBJECTIVE

We evaluated the prevalence of HαT in all mastocytosis subtypes and MMAS and assessed the pathophysiologic association with HαT.

METHODS

Clinical data, laboratory data, KIT mutations, TPSAB1 duplication (assessed by droplet digital PCR), and HαT prevalence were retrospectively recorded for all patients with mastocytosis and MMAS registered in the French national referral center database and compared to a control cohort. To increase the power of our analysis for advanced systemic mastocytosis (advSM), we pooled our cohort with literature cases.

RESULTS

We included 583 patients (27 with MMAS and 556 with mastocytosis). The prevalence of HαT in mastocytosis was 12.6%, significantly higher than in the general population (5.7%, P = .002) and lower than in MMAS (33.3%, P = .02). HαT+ patients were more likely to have anaphylactic reactions and less likely to have cutaneous lesions than HαT- patients (43.0% vs 24.4%, P = .006; 57.7% vs 75.6%, respectively, P = .006). In the pooled analysis, the prevalence of HαT was higher in advSM (11.5%) than in control cohorts (5.2%, P = .01).

CONCLUSION

Here we confirm the increase incidence of anaphylaxis in HαT+ mastocytosis patients. The increased prevalence of HαT in all subtypes of systemic mastocytosis (including advSM) is suggestive of pathophysiologic involvement.

Long-term prophylaxis in hereditary angioedema management: Current practices in France and unmet needs

Background: Hereditary angioedema (HAE) is characterized by unpredictable and potentially life-threatening attacks of cutaneous and submucosal swelling. Over the past decade, new agents, based on a better understanding of the underlying biologic mechanisms of HAE, have changed the face of long-term prophylaxis (LTP). Objective: The objective was to describe current practices and unmet needs with regard to LTP for HAE in expert centers in France. Methods: The study was conducted in France in 2020. Based on their experience with patients with HAE who had visited their center at least once in the past 3 years, physicians from 25 centers who are expert in the management of HAE were requested to fill in a questionnaire that encapsulated their active patient list, criteria for prescribing LTP, and medications used. They were asked about potential unmet needs with currently available therapies. They were asked to express their expectations with regard to the future of HAE management. Results: Analysis was restricted to 20 centers that had an active patient file and agreed to participate. There were 714 patients with C1 inhibitor (C1-INH) deficiency, of whom 423 (59.2%) were treated with LTP. Altered quality of life triggered the decision to start LTP, as did the frequency and severity of attacks. Ongoing LTP included androgens (28.4%), progestins (25.8%), lanadelumab (25.3%), tranexamic acid (14.2%), intravenous C1-INHs (5.6%), and recombinant C1-INH (0.7%). Twenty-nine percent of the patents with LTP were considered to still have unmet needs. Physicians' concerns varied among therapies: poor tolerability for androgens and progestins, a lack of efficacy for tranexamic acid and progestins, dosage form, and high costs for C1-INHs and lanadelumab. Physicians' expectations encompassed more-efficacious and better-tolerated medications, easier treatment administration for the sake of improved quality of life of patients, and less-expensive therapies. Conclusion: Despite the recent enrichment of the therapeutic armamentarium for LTP, physicians still expressed unmet needs with currently available therapies.

Le déconfinement de 2020 s’est-il accompagné d’un effet « boom » des infections sexuellement transmissibles ?

Introduction

Le confinement strict de mars 2020, visant à contenir la pandémie de SARS-CoV-2, a réduit l’accès aux soins et les interactions sociales. Nous avons souhaité en étudier les conséquences sur l’incidence des infections sexuellement transmissibles (IST).

Matériel et méthodes

Étude rétrospective, multicentrique, des tests de dépistage du Chlamydiatrachomatis (CT), du gonocoque (NG), de la syphilis, du VIH et du VHB réalisés dans les CeGIDD du Grand Est, entre le 18/03 et le 31/08/2020 avec analyse en 4 sous-périodes : confinement strict (18/03–10/05)/limitation des déplacements dans un périmètre de 100 km (11/05–01/06)/1^re partie des levées de restriction en juin (02/06–30/06)/2^e partie en juillet–août (01/07–31/07), comparativement aux mêmes périodes de 2018 et 2019.

Résultats

Durant la période de confinement strict, le nombre de tests effectués était significativement réduit (–95 %) avec une incidence de chaque IST stable, avec des observations similaires pendant la période de déplacement restreint (baisse > 50 % des dépistages totaux). Dès le mois de juin, alors que le nombre de tests effectués devenait comparable à celui des années antérieures, on commençait à noter une hausse significative des infections à CT de +8 % et +20 % comparativement à juin 2019 et 2018, alors que l’incidence des autres IST restait alors constante. En juillet–août, l’incidence globale des IST était de +25 % et de +21 %, avec majoration des infections à CT de +46 % et de +56 % par rapport à 2019 et 2018, respectivement.

Discussion

Nous rapportons ici une augmentation de l’incidence globale des IST durant l’été 2020 dans la région Grand Est, comparativement à l’été 2019 et 2018, marquée surtout par une hausse de l’incidence des cas de CT, suggérant un impact des mesures sanitaires sur le comportement sexuel de la population étudiée. Deux études rétrospectives européennes ont également montré cette tendance à la baisse des tests totaux de dépistages des IST en 2020, avec hausse des cas de CT une fois les restrictions sanitaires levées. Cette recrudescence des cas de CT et son observation précoce dès le déconfinement pourraient suggérer, du fait de l’accessibilité réduite aux CeGIDD pendant le confinement et du caractère principalement asymptomatique des infections à CT, que le comportement des jeunes sexuellement actifs n’ait pas été restreint par le confinement, voire au contraire s’est libéré, comme par opposition à la restriction des libertés.

Conclusion

Le déconfinement s’est accompagné d’une augmentation d’incidence des IST, que l’on pourrait décrire comme un « IST-boom » durant l’été 2020. Il est important que la communauté médicale en soit informée, notamment pour les IST asymptomatiques, Chlamydia trachomatis en premier lieu, ayant possiblement échappé aux dépistages et qui sont actuellement latentes.

Stress in Parents of Children With Genetically Determined Leukoencephalopathies: A Pilot Study

Genetically determined leukoencephalopathies comprise a group of rare inherited white matter disorders. The majority are progressive diseases resulting in early death. We performed a cross-sectional pilot study including 55 parents from 36 families to assess the level of stress experienced by parents of patients with genetically determined leukoencephalopathies, aged 1 month to 12 years. Thirty-four mothers and 21 fathers completed the Parenting Stress Index-4th Edition. One demographic questionnaire was completed per family. Detailed clinical data was gathered on all patients. Statistical analysis was performed with total stress percentile score as the primary outcome. Mothers and fathers had significantly higher stress levels compared with the normative sample; 20% of parents had high levels of stress whereas 11% had clinically significant levels of stress. Mothers and fathers had comparable total stress percentile scores. We identified pediatric behavioral difficulties and gross motor function to be factors influencing stress in mothers. Our study is the first to examine parental stress in this population and highlights the need for parental support early in the disease course. In this pilot study, we demonstrated that using the Parenting Stress Index-4th Edition to assess stress levels in parents of patients with genetically determined leukoencephalopathies is feasible, leads to valuable and actionable results, and should be used in larger, prospective studies.

[Resistant and progressive cutaneous lupus erythematosus treated with belimumab: A retrospective monocentric study]

BACKGROUND

Belimumab is currently approved for the treatment of active systemic lupus erythematosus (SLE). The aim of our study was to evaluate the efficacy of belimumab in the treatment of cutaneous lupus erythematosus (CLE), resistant to conventional therapy.

PATIENTS AND METHODS

Seven patients with resistant and progressive LEC and treated with belimumab were retrospectively analyzed. The efficacy and safety of belimumab were evaluated with the CLASI, RCLASI and DLQI scores, after 6 to 12 months of treatment.

RESULTS

Eighty-three percent of patients demonstrated a significant clinical improvement based on the CLASI and RCLASI activity scores, including 1 complete and 4 partial responses, without worsening of CLASI and RCLASI damage scores. Eighty percent of patients also showed an improvement of their quality of life (DLQI). Oral corticosteroids were discontinued in all patients. Tolerance was acceptable with only one serious adverse event (bacteriema).

CONCLUSION

Our study suggests the clinical efficiency of belimumab in a series of 7 patients presenting a resistant and progressive CLE.

[Anogenital granulomatosis as extradigestive Crohn disease: Efficiency of adalimumab therapy]

INTRODUCTION

Anogenital granulomatosis is a rare disease which is actually considered as a metastatic lesion of Crohn disease (CD).

OBSERVATION

A 53-year-old woman presented with intermittent vulvar and anoperineal lesions since adolescence, seeping and painful during sexual intercourse. We observed an infiltrative and asymmetric oedema of labia majora, perianal oedematous vegetative pseudo-marisca, and groin fold and perianal linear "knife-like" ulcerations. Pathological analysis revealed noncaseating giant cell granulomas. The diagnosis of CD was made. Investigations did not show any intestinal involvement. Anti-TNFα therapy with adalimumab was dramatically efficient.

CONCLUSION

Anogenital granulomatosis often precedes intestinal lesions but may also be isolated as in our case. Although treatment is difficult, anti-TNFα seem promising tools.

Hunters select for behavioral traits in a large carnivore

Human harvest can induce selection on life history and morphological traits, leading to ecological and evolutionary responses. Our understanding of harvest-induced selection on behavioral traits is, however, very limited. Here, we assessed whether hunters harvest, consciously or not, individuals with specific behavioral traits. We used long-term, detailed behavioral and survival data of a heavily harvested brown bear (Ursus arctos) population in Sweden. We found that hunters harvested male bears that were less active during legal hunting hours and had lower movement rates. Also, hunters harvested male and female bears that used habitats closer to roads. We provide an empirical example that individual behavior can modulate vulnerability to hunting and that hunters could exert a selective pressure on wildlife behaviors. This study increases our understanding of the complex interactions between harvest method, human behavior, and animal behavior that are at play in harvest-induced selection and provides better insight into the full effects of human harvest on wild populations.

A challenging diagnosis of exercise-related transient abdominal pain

A 17-year-old woman, high-performance triathlete, presented transient abdominal pain, face angioedema and sometimes syncope during exercise. Exercise-induced anaphylaxis was suspected at first. Allergic explorations with skin prick tests were negative but wheat flour specific IgE and recombinant rTri a14 (LTP) were weakly positive. However, wheat eviction did not improve the symptoms and stress test after wheat oral challenge did not show any signs of anaphylaxis. An abdominal ultrasound revealed peak expiratory velocities with a stenosis evaluated at 70 to 80 percent with turbulences in the celiac artery, confirmed by computed tomography angiogram. The diagnosis of exercise-induced median arcuate ligament syndrome (MALS) was retained and we discuss here the challenging diagnosis mimicking exercise-induced anaphylaxis.

Efficacy and survival of biologic agents in psoriasis: a practical real-life 12-year experience in a French dermatology department

Background: Drug survival in a real-life setting is critical to long-term use of biologics for psoriasis. Objective: We describe our 12-year experience with biologics in psoriasis patients. Patients and Methods: All patients treated with biologics including infliximab, adalimumab (ADA), etanercept (ETA), and ustekinumab (UST) for psoriasis vulgaris between January 2005 and December 2016 were retrospectively analyzed. Results: In total, 545 treatment series were administered to 269 patients, including 211 treatment series with ADA, 135 with ETA, 77 with infliximab, and 122 with UST. ADA and ETA were initiated most often as first-line therapy; 65.3% of treatment sequences were discontinued. UST had the highest drug survival. The major reason for treatment termination was a loss of efficacy (44.9%). Definitive discontinuation increased with the number of biologic therapy sequences. Limitations: Subjects were not randomized to the different treatments. Conclusions: In a long-term real-life setting, drug survival of UST is better than that of TNF-a inhibitors for both biologic-naive and biologic-experienced patients with psoriasis.

Influence of agricultural intensification on prey availability and nestling diet in Tree Swallows (Tachycineta bicolor)

Over the last decades, aerial insectivorous birds have been declining in both North America and Europe. Those declines have been hypothetically attributed to a decrease in prey availability caused by agricultural intensification, but empirical evidence remains scarce. Here, we quantify the effect of landscape composition on the abundance and diversity of potential prey of Tree Swallows (Tachycineta bicolor (Vieillot, 1808)) and on nestling diet in southern Quebec, Canada. We collected food boluses from nestlings and compared their composition with spatiotemporally corresponding samples from traps on farms distributed along a gradient of agricultural intensification. The diet of nestlings was mostly composed of Diptera, both in biomass and abundance, but by mid-June, these decreased with increasing proportions of intensively cultivated crops within 500 m of the nests. Trap catches for Diptera and all arthropods combined followed the same trends. Yet, the associations between Diptera subgroups (Nematocera, non-schizophoran Brachycera, Schizophora (Calyptratae), and Schizophora (Acalyptratae)) and landscape composition differed between traps and boluses, suggesting that prey selection was altered by agricultural intensification. Our results suggest that agriculture can alter the availability of preferred prey for aerial insectivores, and further studies should evaluate the impact of prey availability to explain the decline of aerial insectivores.

Human shields mediate sexual conflict in a top predator

Selecting the right habitat in a risky landscape is crucial for an individual's survival and reproduction. In predator-prey systems, prey often can anticipate the habitat use of their main predator and may use protective associates (i.e. typically an apex predator) as shields against predation. Although never tested, such mechanisms should also evolve in systems in which sexual conflict affects offspring survival. Here, we assessed the relationship between offspring survival and habitat selection, as well as the use of protective associates, in a system in which sexually selected infanticide (SSI), rather than interspecific predation, affects offspring survival. We used the Scandinavian brown bear (Ursus arctos) population with SSI in a human-dominated landscape as our model system. Bears, especially adult males, generally avoid humans in our study system. We used resource selection functions to contrast habitat selection of GPS-collared mothers that were successful (i.e. surviving litters, n = 19) and unsuccessful (i.e. complete litter loss, n = 11) in keeping their young during the mating season (2005-2012). Habitat selection was indeed a predictor of litter survival. Successful mothers were more likely to use humans as protective associates, whereas unsuccessful mothers avoided humans. Our results suggest that principles of predator-prey and fear ecology theory (e.g. non-consumptive and cascading effects) can also be applied to the context of sexual conflict.

Increased levels of circulating platelet-derived microparticles are associated with metastatic cutaneous melanoma

We investigated the plasma levels of PMPs in patients with 45 stage III and 45 stage IV melanoma. PMPs were characterised by flow cytometry and their thrombogenic activity. We also investigated the link between PMPs circulating levels and tumor burden. The circulating levels of PMPs were significantly higher in stage IV (8500 μL^-1 ) than in patients with stage III (2041 μL^-1 ) melanoma (P=.0001). We calculated a highly specific (93.3%) and predictive (91.7%) cut-off value (5311 μL^-1 ) allowing the distinction between high-risk stage III and metastatic stage IV melanoma. The thrombogenic activity of PMPs was significantly higher in patients with stage IV melanoma (clotting time: 40.7 second vs 65 second, P=.0001). There was no significant association between the radiological tumoral syndrome and the plasma level of PMPs. Our data suggest the role of PMPs in metastatic progression of melanoma.