Acquired latent tuberculosis infection in psoriasis patients treated with etanercept in the People's Republic of China

Background

TNF-α plays a key role in host defense against mycobacterial infection, and patients receiving TNF-α blocker treatment have increased susceptibility to tuberculosis disease. In the People’s Republic of China, an intermediate tuberculosis-burden country, the latent tuberculosis infection (LTBI) risk in patients with psoriasis who are treated with etanercept, the safest kind of TNF-α blocker, is unknown.

Objectives

This study reports the LTBI risk in patients with psoriasis after etanercept treatment and aims to answer the question of how often rescreening for LTBI should be done in order to reduce active tuberculosis infection of patients and further reduce the incidence of active tuberculosis disease.

Patients and methods:

This retrospective review evaluated patients with moderate-to-severe chronic plaque psoriasis between 2009 and 2013. All patients were excluded tuberculosis infection and received etanercept 25 mg twice weekly, then the patients were checked for LTBI 3 months after etanercept treatment to observe the incidence of LTBI and assess the need for rescreening for LTBI every 3 months.

Results

We retrospectively analyzed 192 patients with psoriasis with moderate-to-severe chronic plaque whose tuberculin skin test and chest X-rays were negative and who received etanercept 25 mg twice weekly. Eighteen of them were excluded because they received less than 3 months of etanercept therapy. After treatment with etanercept, four patients were found to have LTBI.

Conclusion

In this study, the incidence of LTBI after 3 months was four in 192 (2.1%), which is higher than the annual incidence of LTBI in the People’s Republic of China (0.72%), so LTBI could be expected to occur within 3 months in psoriasis patients on etanercept. Periodic screening for LTBI in the therapy course, as well as before initiating treatment, is necessary in those patients who use a TNF-α blocker. We recommend rescreening for LTBI every 3 months.

mRNA expression of chemokine receptors on peripheral blood mononuclear cells and correlation with clinical features in systemic lupus erythematosus patients

OBJECTIVE

To investigate the expressions of chemokine receptors and interleukin (IL) receptors on the peripheral blood mononuclear cells (PBMCs) from systemic lupus erythematosus (SLE) patients and their correlations with clinical features as well as SLE disease activity index (SLEDAI).

METHODS

The mRNA expressions of chemokine receptors and IL receptors on PBMCs of 93 SLE patients and 30 healthy controls were detected by reverse transcription-polymerase chain reaction, including CCR2, CCR3, CCR4, CCR5, CCR6, CCR8, CXCR3, CXCRS, CX3CR1, XCR1, IL-4R, and IL-10R. The clinical features of SLE patients were recorded. The correlations of chemokine receptors and IL receptors mRNA expressions with clinical features as well as SLEDAI were assayed using linear regression analysis.

RESULTS

The level of CCR5 mRNA in SLE patients (including active and inactive SLE) was significantly higher than that in healthy controls (P < 0.05), and there was no significant difference between active and inactive patients in this respect (P > 0.05). CX3CR1 mRNA expression significantly increased from healthy control to inactive SLE to active SLE in sequence. The others (except for CCR8, CXCR3, and IL-10R) in active SLE patients were significantly higher than those in both inactive SLE patients and healthy controls (all P < 0.05). There were positive correlations between SLEDAI and CCR2 (r = 0.424, t = 4.313, P < 0.001), CCR3 (r = 0.518, t = 5.410, P < 0.001), CCR4 (r = 0.376, t = 3.851, P < 0.001), CCR6 (r = 0.457, t = 4.513, P < 0.001), CXCR5 (r = 0.455, t = 4.629, P < 0.001), CX3CR1 (r = 0.445, t = 4.523, P < 0.001), as well as XCR1 (r = 0.540, t = 5.445, P < 0.001). And CCR5 mRNA expression level was positively correlated with IL-4R mRNA (r = 0.313, t = 2.353, P < 0.05). The patients with myositis and cutaneous vasculitis simultaneously showed lower levels of CCR5 and CX3CR1, and CCR5 expression was negatively correlated with the scores of SLEDAI in SLE cases accompanied by photosensitivity (r = 0.426, t = -2.155, P < 0.05).

CONCLUSION

Increased expressions of CCR5 and CX3CR1 on PBMCs may be indicators in clinical survey for SLE.

Correlation between some Th1 and Th2 cytokine receptor gene polymorphisms and systemic lupus erythematosus in Chinese patients

BACKGROUND

Genetic factors seem to play a significant role in the susceptibility to systemic lupus erythematosus (SLE). Some researchers have described amino acid polymorphisms within the interleukin-4 receptor (IL-4R) [isoleucine50valine (Ile50Val), arginine576glutamine (Arg576Gln), etc.], the IL-10R (G241A and G520A), and the interferon-gamma receptor (IFN-gammaR) [valine14methionine (Val14Met) and glutamine64arginine (Gln64Arg)].

METHODS

The Ile50Val genotypes were examined by the reverse transcription-polymerase chain reaction-single-strand conformation polymorphism (RT-PCR-SSCP) method and DNA sequencing. The RT-PCR-restriction fragment length polymorphism (RT-PCR-RFLP) method was used to detect the Arg576Gln, G241A, G520A, Val14Met, and Gln64Arg genotypes.

RESULTS

There were significant differences in the genotype frequencies of Ile50/Ile50, G520/G520, and G520/A520 between the SLE group and healthy control group. There was a positive correlation between the IL-4R Ile50/Ile50 genotype and the susceptibility to SLE (P = 0.022). This was also found for the IL-10R G520/G520 (P = 0.004) and G520/A520 (P = 0.055) genotypes. The risk of SLE susceptibility was increased in individuals with the genotype combinations Ile50/Ile50 and Gln576/Arg576 (P = 0.056) and G241/G241 and G520/G520 (P = 0.004). The IFN-gammaR2 Arg64/Arg64 genotype decreased the risk of SLE (P = 0.047). A decreased risk of development of SLE was detected in individuals with the genotype combination IFN-gammaR2 Arg64/Arg64 and IFN-gammaR1 Val14/Val14 (P = 0.004).

CONCLUSIONS

The IL-4R Ile50/Ile50 and IL-10R2 G520/G520 and G520/A520 genotypes were shown to determine the susceptibility to SLE in a Chinese population, as were the combinations Ile50/Ile50 and Gln576/Arg576, and G241/G241 and G520/G520.

The interferon-gamma receptor gene polymorphisms (Val14Met and Gln64Arg) are not associated with systemic lupus erythematosus in Chinese patients

Genetic polymorphism is a difference in DNA sequence among individuals, groups, or populations that give rise to different forms. Differences in DNA sequences that occur naturally in a population. Single nucleotide substitutions, insertions and deletions of nucleotides and repetitive sequences (microsatellites) are all examples of polymorphism. The position at which such a sequence difference is found is a polymorphic site. A single nucleotide substitution is called a single nucleotide polymorphism (SNP). SNPs can occur in coding parts of the gene. If they result in genetic code change, amino-acid polymorphism would occur. The heterodimeric IFN-gamma receptor (IFNGR) complex was made up of two receptor subunits including IFNGR-1 and IFNGR-2. There exist five dbSNP alleles in IFNGR1 exon region and six dbSNP alleles in IFNGR2. Some researchers had found that the greatest risk of the development of systemic lupus erythematosus (SLE) be detected in the individuals who had the Met14/Val14 genotype or the combination of IFNGR1 Met14/Val14 genotype and IFNGR2 Gln64/Gln64 genotype in Japanese patients. So we aimed to assess the association between two polymorphisms within the IFNGR gene (A88G and A839G) and SLE in Chinese patients. This study included 154 patients with SLE and 159 unrelated healthy controls. We examined the IFNGR genotype by the reverse transcription-polymerase chain reaction (RT-PCR)-single-strand conformation polymorphism method, RT-PCR-restriction fragment length polymorphism method and DNA sequencing. Genotype frequencies between SLE patients and controls were compared and relationship between genotype frequencies and clinical manifestations of SLE were evaluated. We found that IFNGR2 Arg64/Arg64 genotype decrease the risk of SLE (OR = 2.326, 95% CI 1.181-4.581, Fisher P = 0.015), and the same as IFNGR2 Arg64/Arg64 genotype and IFNGR1 Val14/Val14 genotype combination (OR = 2.420, 95% CI 1.206-4.854, Fisher P = 0.013). The allelic frequency of Val14/Met14 is significantly higher in the patients with oral ulcer or thrombocytopenia when compared with patient without these clinical feature (OR = 4.630, 95% CI 1.370-15.640, Fisher P = 0.021; or OR = 6.368, 95% CI 2.009-20.191, Fisher P = 0.003). On the contrary, the allelic frequency of Val14/Val14 is lower in the patients with oral ulcer or thrombocytopenia than those without these clinical feature (OR = 0.216, 95% CI 0.064-0.730, Fisher P = 0.021; or OR = 0.157, 95% CI 0.050-0.498, Fisher P = 0.003). And after data analysis, we also find that the allelic frequency of Gln64/Gln64 is lower in the patients with arthritis when compared with patient without arthritis (OR = 0.369, 95% CI 0.166-0.818, Fisher P = 0.017). We can conclude that the IFNGR polymorphisms (Val14Met and Gln64Arg) are protective in SLE in Chinese patients. We describe a novel association between Val14/Met14 carriage and patients with oral ulcer or thrombocytopenia.

Deep dermatophytosis caused by Trichophyton rubrum: report of two cases

Two patients presenting with subcutaneous nodules, plaques, papules and ulceration caused by Trichophyton rubrum are described in this report. The first case was a 46-year-old woman referred with erythema and desquamation over her trunk, hands and feet for 30 years, progressing to nodules and ulceration over her trunk, arms and scalp for the last 2 years. The second case was a 34-year-old man who presented with a 2-year-history of itchy, erythema and desquamation over the trunk, progressing to papules, nodules and cyst around his ear, on the neck and scalp for 1 year. The diagnoses were suspected after direct microscopical examinations of the discharge materials, which revealed the presence of hyaline hyphae. The histological examinations showed granulomatous inflammatory infiltrates with fungal elements in the dermis including epithelioid cells, giant cells, lymphocytes and eosinophils, and the periodic acid-Schiff stain showed hypha within the granulomas. Cultures of puncture materials, skin biopsies and nails confirmed the diagnosis identifying T. rubrum. Antifungal therapies with itraconazole were successful in both patients, the lesions were completely clear with atrophic scars after 3 months. Side effects were not noticed during the medication. We discuss the clinical types of granulomatous cutaneous lesions caused by dermatophyte infections and evaluate the therapeutic effect of itraconazole.

Skin colonization by Staphylococcus aureus in patients with eczema and atopic dermatitis and relevant combined topical therapy: a double-blind multicentre randomized controlled trial

BACKGROUND

Staphylococcus aureus has a peculiar ability to colonize the skin of patients with eczema and atopic dermatitis (AD), and is consistently found in eczematous skin lesions in these patients. A correlation between the severity of the eczema and colonization with S. aureus has been demonstrated, and it has been determined that bacterial colonization is an important factor aggravating skin lesions. Patients colonized with S. aureus have been treated with antibiotics in several open and double-blind placebo-controlled studies, with conflicting results.

OBJECTIVES

To investigate the colonizing features of S. aureus in the lesional and nonlesional skin of patients with eczema and AD in China and to compare the therapeutic effect of mupirocin plus hydrocortisone butyrate with vehicle ointment plus hydrocortisone butyrate.

METHODS

A multicentre, double-blind randomized trial was conducted. Eczema Area and Severity Index (EASI) scores were evaluated before the start of the trial and on the 7th, 14th and 28th day of treatment. Swabs for bacterial isolation were taken from lesional skin before the start of the trial and on the 7th, 14th and 28th day of treatment, and from nonlesional skin only before the start of the trial. A combination topical therapy with mupirocin plus hydrocortisone butyrate ointment was used in the experimental group, with vehicle ointment plus hydrocortisone butyrate ointment as a control.

RESULTS

Of 327 patients enrolled in the study, 208 had eczema and 119 had AD. Bacteria were isolated from 70.2% of lesional and 32.7% of nonlesional skin samples from patients with eczema, of which S. aureus accounted for 47.3% and 27.9%, respectively. Bacteria were isolated from 74.8% of lesional and 34.5% of nonlesional skin samples from patients with AD, of which S. aureus accounted for 79.8% and 80.5%, respectively. The colonization density of S. aureus was markedly higher in lesional than in nonlesional skin, both in patients with eczema and with AD (P < 0.01, P < 0.05), and was positively correlated with lesion severity. Considering the EASI scores before and after treatment and the final effective rate, good therapeutic effects were obtained in both the combination experimental groups and the control groups (P < 0.01), and there were no differences in the global therapeutic effect between the two groups in patients with eczema and with AD (P > 0.05). However, in patients with eczema with a clinical score of > 8 or in patients with AD with a clinical score of > 7, the therapeutic effect in the experimental groups was superior to that in the control groups (P < 0.05) on the 7th day of treatment. There were no differences between the two groups on the 14th and 28th days of treatment (P > 0.05). Following the improvement of symptoms and signs of eczema and AD, the positive rates of bacteria and S. aureus were reduced on the 7th day of treatment.

CONCLUSIONS

This study confirmed that lesional skin of patients with eczema and AD was more frequently colonized with S. aureus than was nonlesional skin. The more severe the eczema, the higher the colonization rate of S. aureus, and S. aureus was also more often present in lesional and nonlesional skin in patients with AD than in those with eczema. Staphylococcus aureus infection is related to the pathogenesis of eczema and AD. An antibiotic-corticosteroid combination and corticosteroid alone both gave good therapeutic effect in eczema and in AD, and both reduced colonization by S. aureus. Early combined topical therapy is beneficial to patients with moderate to severe eczema and AD, and it is unnecessary to use antibiotics at later stages of disease or in mild eczema or AD.