First report of mesalamine (5-aminosalicylic acid) as the causative agent in a case of acute generalized exanthamous pustulosis

Acute generalized exanthamous pustulosis (AGEP)is a rare eruption of non-follicular sterile pustuleson a diffuse background of erythema and edema,commonly associated with fever and leukocytosis.Antibiotics are implicated in most cases; however,other drugs have been reported to cause AGEP. Wereport a case of a 73-year-old man with a historyof ulcerative colitis who presented with a diffusepustular rash, renal failure, elevated liver functiontests, and leukocytosis with neutrophilia. A week priorto admission, the patient was started on mesalamineto treat colitis. Upon admission, a workup includinga skin biopsy was performed and was consistentwith AGEP. Mesalamine was discontinued, and thepatient's skin eruption, renal function, liver functiontests, and leukocytosis subsequently improved.Mesalamine has an unknown mechanism of action.However, it is thought to be an anti-inflammatoryagent that blocks the production of leukotrienesand prostaglandins and is an immunosuppressantthat increases the release of adenosine, whichinterferes with leukocyte function. The decrease inprostaglandin synthesis or deregulation of leukocytefunction caused by mesalamine may be the etiologyin this case. Discontinuation of the offending agentleads to resolution of AGEP, as it did in this patient.

Following the fate of genetically modified T cells in melanoma patients

In an open clinical trial for Stage IV melanoma patients, we are testing a promising new therapy in which the patient’s own T cells are genetically engineered with a T cell receptor (TIL 1383I TCR) targeting the melanoma antigen tyrosinase. Included in the TIL 1383I TCR vector is a nonfunctional CD34 marker that can be readily tracked by flow cytometry. These transgenic T cells are infused into the patient with the goals of killing tumor cells and promoting anti-tumor inflammatory responses.

We find that the transgenic T cells persist at low levels for at least twenty months in vivo. Many of the transgenic T cells are activated in the patient, indicating that they are responding to antigen. A subset of activated cells express inhibitory receptors, including PD-1 and CTLA-4. Upon further analysis of patient samples, we found that the percent of transgene-expressing T cells can be increased up to three-fold with either cytokine stimulation and/or CD3/CD28-bead stimulation.

When cultured in vitro, transduced T cells lose transgene expression over time, and culturing in the absence of cytokines dramatically increases the rate of transgene expression loss. As seen ex vivo, restimulation of in vitro cultured T cells restores transgene expression. Cells undergoing division express substantially more transgene than resting cells. These data suggest that mitogenic factors causing cell division may promote transgene expression. We next plan to test mitogenic (high dose IL-2, IL-15) and anti-inhibition (PD-1 and CTLA-4 blockade) therapies with T cell transfer utilizing murine mouse models and potentially amend our protocol in the future to reduce the effects of exhaustion and transgene loss on transgenic anti-tumor T cells.

Blastomycosis and Pregnancy: An Unusual Postpartum Disease Course

Blastomyces dermatitidis is responsible for systemic mycoses. It is predominantly caused by inhalation of spores and often manifests as pneumonia, which can potentially disseminate; however, direct cutaneous inoculation may also occur. Blastomycosis in the perigravid period is exceedingly rare. The partial immunosuppressive state induced by pregnancy can engender more severe infections and is associated with a risk of vertical transmission. Published cases describe postpartum symptomatic improvement accompanying immune reconstitution, even in the absence of treatment. We present a 31-year-old gravid female with multifocal cutaneous blastomycosis. After delivering a healthy full-term infant with no evidence of congenital infection, the patient's cutaneous lesions continued to worsen. At 6 weeks postpartum she was treated with oral itraconazole and demonstrated clinical improvement after 5 months of therapy. This case highlights the importance of prompt disease recognition, understanding of risk factors and initiation of appropriate antifungal therapy of blastomycotic infection occurring in the unique setting of pregnancy.

Stroke and myocardial infarction as late complications of lung transplantation

A 64-year-old man who had received a lung transplant later presented with an air embolism that caused ST-segment elevation myocardial infarction, multiple strokes, and death. Transesophageal echocardiography was used to document air bubbles crossing from a bronchial fistula to a pulmonary vein and into the left atrium. Spontaneous air was seen entering a pulmonary vein during positive-pressure ventilation and exiting through the left ventricular outflow tract. Autopsy confirmed the presence of a probe-patent bronchial-to-pulmonary vein fistula within a focus of necrosis and infection with Aspergillus flavus, an angioinvasive organism. The potential for intravascular gas arising from the anastomotic site should be considered when transplant recipients who present with myocardial or peripheral arterial infarction are evaluated.