Childhood neurodevelopmental disorders and maternal diabetes: A population-based cohort study

AIM

To assess the risk of a wide spectrum of neurodevelopmental disorders (NDDs) in offspring of mothers with type 1 diabetes mellitus (T1DM), type 2 diabetes mellitus (T2DM), and gestational diabetes mellitus (GDM).

METHOD

This retrospective cohort study included 877 233 singletons born between 2004 and 2008 in Taiwan. Children were followed up to 2015 for diagnoses of NDDs, including autism spectrum disorder (ASD), attention-deficit/hyperactivity disorder (ADHD), developmental delay, intellectual disability, cerebral palsy, and epilepsy/infantile spasms using health insurance claims data. We performed Cox regression models to estimate the relative risks of NDDs associated with maternal diabetes. Covariates included parental age, year of birth, child sex, family income, urbanization level, hypertensive disorder, and preterm delivery status.

RESULTS

In utero there were 338 (0.04%) children exposed to T1DM, 8749 (1.00%) to T2DM, and 90 200 (10.28%) to GDM. The effect of T1DM on NDDs was the largest, followed by T2DM, then GDM. T1DM was associated with an increased risk of developmental delay, intellectual disability, and epilepsy/intellectual spasms in offspring. T2DM was associated with an increased risk of ASD, ADHD, developmental delay, intellectual disability, cerebral palsy, and epilepsy/intellectual spasms. GDM was associated with an increased risk of ASD, ADHD, and developmental delay.

INTERPRETATION

Maternal diabetes during pregnancy, including T1DM, T2DM, and GDM, is associated with an increased risk of some NDDs in offspring.

Effects of Septin-14 Gene Deletion on Adult Cognitive/Emotional Behavior

While various septin GTPases have been reported for their physiological functions, their roles in orchestrating complex cognitive/emotional functions in adult mammals remained scarcely explored. A comprehensive behavioral test battery was administered to two sexes of 12-week-old Septin-14 (SEPT14) knockout (KO) and wild-type (WT) mice. The sexually dimorphic effects of brain SEPT14 KO on inhibitory avoidance (IA) and hippocampal mGluR5 expression were noticed with greater IA latency and elevated mGluR5 level exclusively in male KO mice. Moreover, SEPT14 KO appeared to be associated with stress-provoked anxiety increase in a stress-related navigation task regardless of animals’ sexes. While male and female WT mice demonstrated comparable cell proliferation in the dorsal and ventral hippocampal dentate gyrus (DG), both sexes of SEPT14 KO mice had increased cell proliferation in the ventral DG. Finally, male and female SEPT14 KO mice displayed dampened observational fear conditioning magnitude and learning-provoked corticosterone secretion as compared to their same-sex WT mice. These results, taken together, prompt us to conclude that male, but not female, mice lacking the Septin-14 gene may exhibit increased aversive emotion-related learning and dorsal/ventral hippocampal mGluR5 expressions. Moreover, deletion of SEPT14 may be associated with elevated ventral hippocampal DG cell proliferation and stress-provoked anxiety-like behavior, while dampening vicarious fear conditioning magnitudes.

LCMD: Lung Cancer Metabolome Database

Lung cancer, one of the most common causes of cancer-related death worldwide, has been associated with high treatment cost and imposed great burdens. The 5-year postoperative survival rate of lung cancer (13%) is lower than many other leading cancers indicating the urgent needs to dissect its pathogenic mechanisms and discover specific biomarkers. Although several proteins have been proposed to be potential candidates for the diagnosis of lung cancer, they present low accuracy in clinical settings. Metabolomics has thus emerged as a very promising tool for biomarker discovery. To date, many lung cancer-related metabolites have been highlighted in the literature but no database is available for scientists to retrieve this information. Herein, we construct and introduce the first Lung Cancer Metabolome Database (LCMD), a freely available online database depositing 2013 lung cancer-related metabolites identified from 65 mass spectrometry-based lung cancer metabolomics studies. Researchers are able to explore LCMD via two ways. Firstly, by applying various filters in the “Browse Metabolites” mode, users can access a list of lung cancer-related metabolites that satisfy the filter specifications. For each metabolite, users can acquire the value of the fold change (cancer/normal), statistical significance (p-value) of the fold change, and the comparative research designs of all the mass spectrometry-based lung cancer metabolomics studies that identify this metabolite. Secondly, by applying various filters in the “Browse Studies” mode, users can obtain a list of mass spectrometry-based lung cancer metabolomics studies that satisfy the filter specifications. For each study, users can view the type of studied specimen, mass spectrometry (MS) method, MS data processing software, and differential analysis method, as well as all the identified lung cancer-related metabolites. Furthermore, the overview of each study is clearly illustrated by a graphical summary. The LCMD (http://cosbi7.ee.ncku.edu.tw/LCMD/) is the first database that brings together the meaningful information of lung cancer-related metabolites. The development of the LCMD is envisioned to promote the biomarker discovery of lung cancer.

Influenza a virus NS1 resembles a TRAF3-interacting motif to target the RNA sensing-TRAF3-type I IFN axis and impair antiviral innate immunity

BACKGROUND

Influenza A virus (IAV) evolves strategies to counteract the host antiviral defense for establishing infection. The influenza A virus (IAV) non-structural protein 1 (NS1) is a key viral factor shown to counteract type I IFN antiviral response mainly through targeting RIG-I signaling. Growing evidence suggests that viral RNA sensors RIG-I, TLR3, and TLR7 function to detect IAV RNA in different cell types to induce type I IFN antiviral response to IAV infection. Yet, it remains unclear if IAV NS1 can exploit a common mechanism to counteract these RNA sensing pathways to type I IFN production at once, then promoting viral propagation in the host.

METHODS

Luciferase reporter assays were conducted to determine the effect of NS1 and its mutants on the RIG-I and TLR3 pathways to the activation of the IFN-β and NF-κB promoters. Coimmunoprecipitation and confocal microscopic analyses were used to the interaction and colocalization between NS1 and TRAF3. Ubiquitination assays were performed to study the effect of NS1 and its mutants on TRAF3 ubiquitination. A recombinant mutant virus carrying NS1 E152A/E153A mutations was generated by reverse genetics for biochemical, ex vivo, and in vivo analyses to explore the importance of NS1 E152/E153 residues in targeting the RNA sensing-TRAF3-type I IFN axis and IAV pathogenicity.

RESULTS

Here we report that NS1 subverts the RIG-I, TLR3, and TLR7 pathways to type I IFN production through targeting TRAF3 E3 ubiquitin ligase. NS1 harbors a conserved FTEE motif (a.a. 150-153), in which the E152/E153 residues are critical for binding TRAF3 to block TRAF3 ubiquitination and type I IFN production by these RNA sensing pathways. A recombinant mutant virus carrying NS1 E152A/E153A mutations induces higher type I IFN production ex vivo and in vivo, and exhibits the attenuated phenotype in infected mice, indicating the importance of E152/E153 residues in IAV pathogenicity.

CONCLUSIONS

Together our work uncovers a novel mechanism of IAV NS1-mediated immune evasion to promote viral infection through targeting the RNA sensing-TRAF3-type I IFN axis.

Childhood neurodevelopmental disorders and maternal hypertensive disorder of pregnancy

AIM

To examine the association of maternal chronic hypertension and pregnancy-induced hypertension (PIH)/preeclampsia with childhood neurodevelopmental disorders (NDDs) in a large-scale population-based cohort.

METHOD

We conducted a linked Taiwan National Health Insurance Research Database cohort study of children born between 2004 and 2008 (n=877 233). Diagnoses of autism spectrum disorder (ASD), attention-deficit/hyperactivity disorder (ADHD), developmental delay, intellectual disability, cerebral palsy (CP), and epilepsy/infantile spasms were identified from birth to the end of 2015. Cox proportional hazards models were fitted with adjustment for potential confounders to estimate the effect of maternal hypertensive disorder of pregnancy on childhood outcomes.

RESULTS

Compared with the offspring of unexposed mothers, offspring of mothers with chronic hypertension or PIH/preeclampsia exhibited increased risk of developing a wide spectrum of NDDs. Chronic hypertension was associated with increased risks of ADHD (hazard ratio 1.22, 95% confidence interval [CI] 1.13-1.​31), developmental delay (1.29, 1.21-1.38), intellectual disability (1.67, 1.43-1.95), CP (1.45, 1.14-1.85), and epilepsy/infantile spasms (1.31, 1.10-1.56) in the offspring, whereas PIH/preeclampsia was associated with increased risks of ASD (1.27, 1.12-1.43), ADHD (1.23, 1.17-1.29), developmental delay (1.29, 1.24-1.35), intellectual disability (1.53, 1.37-1.71), CP (1.44, 1.22-1.70), and epilepsy/infantile spasms (1.36, 1.22-1.52) in the offspring after adjustment for potential confounders. The co-occurrence of maternal diabetes, preterm deliveries, or fetal growth restriction further increased the risk.

INTERPRETATION

Chronic hypertension or PIH/preeclampsia seems to be sufficient to increase the risk of childhood NDDs. What this paper adds Children exposed to maternal hypertensive disorders have a higher cumulative incidence of neurodevelopmental disorders (NDDs) than unexposed children. Chronic hypertension or pregnancy-induced hypertension/preeclampsia seems to be sufficient to increase the risk of childhood NDDs. Co-occurrence of maternal diabetes, preterm deliveries, or fetal growth restriction further increases the risk.

Interplays between Enterovirus A71 and the innate immune system

Enterovirus A71 (EV-A71) is a growing threat to public health, particularly in the Asia-Pacific region. EV-A71 infection is most prevalent in infants and children and causes a wide spectrum of clinical complications, including hand-foot-and-mouth disease (HFMD), pulmonary and neurological disorders. The pathogenesis of EV-A71 infection is poorly understood at present. It is likely that viral factors and host immunity, and their interplay, affect the pathogenesis and outcome of EV-A71 infection. The mammalian innate immune system forms the first layer of defense against viral infections and triggers activation of adaptive immunity leading to full protection. In this review, we discuss recent advances in our understanding of the interaction between EV-A71 and the innate immune system. We discuss the role of pattern-recognition receptors (PRRs), including Toll-like receptors (TLRs), RIG-I-like receptors (RLRs), and inflammasomes, in the detection of EV-A71 infection and induction of antiviral immunity. As a counteraction, EV-A71 viral proteins target multiple innate immune pathways to facilitate viral replication in host cells. These novel insights at the virus-host interphase may support the future development of vaccines and therapeutics against EV-A71 infection.

NLRP7 Is Involved in the Differentiation of the Decidual Macrophages

Macrophage polarization, regulated appropriately, may play important roles in successful pregnancy. In the face of the vital roles of decidua macrophages in pregnancy, it is insufficient to recognize the trigger of macrophage differentiation and polarization. We aimed to explore the link between the NLRP7 gene and macrophage polarization in human deciduas. Here, we enrolled the endometrial tissues from eight pregnant women in the first trimester. We found that NLRP7 was abundant in endometrial tissues and that NLRP7 was expressed in decidual macrophages of the first-trimester pregnancy. NLRP7 was predominately expressed in the decidual M2 macrophages, as compared with the M1 macrophages. Furthermore, our results suggest that NLRP7 is associated with decidual macrophage differentiation. NLRP7 over-expression suppresses the expression of M1 markers and enhances the expression of the M2 markers. Considering that NLRP7 relates to decidualization and macrophage differentiation, we propose that NLRP7 is a primate-specific multitasking gene to maintain endometrial hemostasis and reproductive success. This finding may pave the way for therapies of pathological pregnancies.

Emerging roles of an innate immune regulator TAPE in Toll-like receptors, RIG-I-like receptors, and beyond

Pattern-recognition receptors (PRRs) trigger innate immune defenses against pathogen infection via downstream signaling pathways linking to inflammation and cell-autonomous immunity like phagocytosis and autophagy. IKK family kinases, IKKα and IKKβ, function to relay PRR signals to proinflammatory cytokine production to amplify innate immune responses. TBK1, a non-canonical IKK kinase, links nucleic acid sensors to type I interferon induction against viral infection and also regulates the autophagic clearance of intracellular bacteria. TBK1-Associated Protein in Endolysosomes designated TAPE, also known as CC2D1A, is an innate immune regulator acting upstream of Trif to regulate the TLR3 and TLR4 pathways, or upstream of MAVS to regulate the cytosolic RIG-I-like receptor (RLR) pathways. To our best knowledge, TAPE is the first regulator implicated in both the endosomal TLR and cytosolic RLR pathways at such an early step. We are thus interested in investigating in vivo roles of TAPE in innate immunity and molecular mechanisms by which TAPE regulates TLRs, RLRs, and possibly other PRRs. TAPE conditional knockout (cKO) mice, in which TAPE is selectively disrupted in immune cells, have been generated for our study. Our results showed that upon influenza A virus infection, TAPE cKO mice exhibited a more severe mortality than wild type mice. Further, TAPE cKO mice were shown to be more susceptible to Salmonella Typhimurium infection but more resistant to LPS-induced septic shock. Notably, ex vivo results showed that TAPE was critical for the autophagic clearance of Salmonella Typhimurium. Together, our data support a critical role for TAPE in regulating innate immune defenses through TLRs, RLRs, and autophagy.

Deposition of elafin in the involved vascular wall of neutrophil-mediated cutaneous vasculitis

BACKGROUND

Neutrophil elastase plays an important role in skin inflammation induced by neutrophil infiltration. Elafin is an inducible elastase inhibitor expressed by keratinocytes, and is known to be involved in pathogenesis of neutrophilic skin disorders such as psoriasis.

METHODS

Immunohistochemical studies of elafin expression in the cases of vasculitis were performed. Induction of elafin expression in cultured vascular cells and its effect on neutrophil migration were studied in vitro.

RESULTS

A positive immunoreactivity was detected in polyarteritis nodosa, giant cell arteritis and Schönlein-Henoch purpura, but no immunoreactivity was found in Churg-Strauss syndrome. Elafin expression in cultured venous endothelial cells and arterial smooth muscle cells was undetectable, but induced by interleukin-1β (IL-1β) and IL-8. Elafin inhibited the elastin peptide-induced neutrophil chemotaxis at the concentration of 10(-8) -10(-5) mol/L.

CONCLUSION

Elafin deposition induced by cytokines (IL-1β or IL-8) will be an important regulator for the progress of leucocytoclastic vasculitis by functioning as an inhibitor for neutrophil chemotaxis as well as for vascular elastin degradation.

First Report of Clubroot on Capsella bursa-pastoris Caused by Plasmodiophora brassicae in Sichuan Province of China

Shepherd's purse (Capsella bursa-pastoris (L.) Medicus) is an edible and wild medicinal plant widely distributed in China. This plant has been cultivated in Shanghai, China, since the end of the 19th century. Infection of C. bursa-pastoris by Plasmodiophora brassicae, the causal agent of clubroot disease on Brassica spp. has been reported in Korea (2), but is not known to occur in China. In February of 2011, stunted and wilted shepherd's purse (SP) plants were observed in a field planted to oilseed rapes (B. napus) in Sichuan Province of China. Symptomatic SP plants also exhibited root galls. Disease incidence was 6.2% and 100% for SP and B. napus, respectively. Root galls on diseased SP plants were collected for pathogen identification. Many resting spores were observed when the root galls were examined under a light microscope. The resting spores were circular in shape, measuring 2.0 to 3.1 μm in diameter (average 2.6 μm). PCR amplification was conducted to confirm the pathogen. DNA was extracted from root galls and healthy roots (control) of SP. Two primers, TC2F (5'-AAACAACGAGTCAGCTTGAATGCTAGTGTG-3') and TC2R (5'-CTTTAGTTGTGTTTCGGCTAGGATGGTTCG-3') were used to detect P. brassicae (1). No PCR amplifications were observed with the control DNA as template. A fragment of the expected size (approximately 520 bp) was obtained when DNA was amplified from diseased roots of SP. These results suggest that the pathogen in the galled roots of SP is P. brassicae. Pathogenicity of P. brassicae in SP was tested on plants of both SP and Chinese cabbage (CC) (B. campestris ssp. pekinensis). A resting spore suspension prepared from naturally infected SP roots was mixed with a sterilized soil in two plastic pots, resulting in a final concentration of 5 × 10⁶ spores/g soil. Soil treated with the same volume of sterile water was used as a control. Seeds of SP and CC were pre-germinated on moist filter paper for 2 days (20°C) and seeded into the infested and control pots, one seed per pot for planted for CC and four seeds per pot for SP. The pots were placed in a chamber at 15 to 25°C under 12 h light and 12 h dark. Plants in each pot were uprooted after 4 weeks and the roots of each plant were washed under tap water and rated for clubroot disease. No disease symptoms were observed in the control treatments of SP or CC. Plants of both species showed symptoms of clubroot, with the disease incidence of 62.5% and 100% on SP and CC, respectively. The pathogen was isolated from diseased roots of each plant and confirmed as P. brassicae based on morphological characteristics and PCR detection. To our knowledge, this is the first report of clubroot disease on C. bursa-pastoris in Sichuan Province of China. This finding suggests that it may be necessary to manage C. bursa-pastoris in cruciferous vegetable (cabbage, turnip) and oilseed rape production fields. References: (1) T. Cao et al. Plant Dis. 91:80, 2007. (2) W. G. Kim et al. Microbiology 39:233, 2011.

TBK1-associated protein in endolysosomes (TAPE)/CC2D1A is a key regulator linking RIG-I-like receptors to antiviral immunity

Retinoic acid-inducible gene I (RIG-I)-like receptors (RLRs) are key RNA viral sensors for triggering antiviral immunity. The underlying mechanisms for RLRs to trigger antiviral immunity have yet to be explored. Here we report the identification of TAPE (TBK1-associated protein in endolysosomes) as a novel regulator of the RLR pathways. TAPE functionally and physically interacts with RIG-I, MDA5, and IPS-1 to activate the IFN-β promoter. TAPE knockdown impairs IFN-β activation induced by RLRs but not IPS-1. TAPE-deficient cells are defective in cytokine production upon RLR ligand stimulation. During RNA virus infection, TAPE knockdown or deficiency diminishes cytokine production and antiviral responses. Our data demonstrate a critical role for TAPE in linking RLRs to antiviral immunity.

Coexistence of insulin-derived amyloidosis and an overlying acanthosis nigricans-like lesion at the site of insulin injection

A 59-year-old patient with diabetes mellitus had been treated with human recombinant insulin for 4 years. He developed a solid mass on his left abdomen at the insulin injection site, which had an overlying pigmented verrucous plaque and keratinized papules, similar to acanthosis nigricans (AN). On histological examination, the mass was found to contain a deposit of amyloid in the dermis, with hyperkeratosis, papillomatosis and acanthosis in the epidermis. Using immunohistochemistry, the amyloid deposits were found to be positive for insulin. A few cases of localized insulin-derived amyloid deposits at injection sites have been reported previously, but none had significant epidermal changes. The coexistence of dermal insulin-derived amyloidosis and an overlying AN-like change, as found in our patient, has not been reported previously, to our knowledge. The presence of a tumour-like lesion at the injection site should be carefully examined, as injection of insulin into amyloid deposits can result in insulin resistance.

Beyond-limit light focusing in the intermediate zone

We experimentally verify that a new nanolens of a designed plasmonic aperture can focus visible light to a single line with its width smaller than the limit of half the wavelength in the intermediate zone. The experimental measurement indicates that while the near field plays a role to increase the spot size in the near zone, it is negligible at the beyond-limit focused region; i.e., the focused light is dominated by the radiative fields. The image taken by the optical microscope shows that the fields focused have propagated to the far zone. Besides being of academic interest, the nanolens capable in achieving a lower diffraction limit in the intermediate zone is important for application possibilities.

TBK1-associated protein in endolysosomes (TAPE) is an innate immune regulator modulating the TLR3 and TLR4 signaling pathways

The innate immune system elicits the first wave of immune responses against pathogen infection. Its operational modes are complex and have yet to be defined. Here, we report the identification of an innate immune regulator termed TAPE (TBK1-associated protein in endolysosomes), previously known as CC2D1A/Freud-1/Aki-1, which modulates the TLR3 and TLR4 pathways. We found that TAPE activated the TBK1, NF-κB, and ERK pathways leading to IFN-β and inflammatory cytokine induction. TAPE was shown to colocalize with endosomal marker Rab5 and lysosomal marker LAMP1 in mammalian cells, suggesting that TAPE resided in endolysosomes. Knockdown of TAPE selectively impaired the TLR3 and endocytic TLR4 pathways to IFN-β induction. Furthermore, TAPE interacted and synergized with Trif to activate IFN-β. TAPE knockdown failed to block Trif-mediated IFN-β induction, whereas Trif knockdown impaired the TLR3 and TAPE cooperation on IFN-β induction, suggesting that TAPE acts upstream of Trif. Together, our data demonstrate a central role for TAPE in linking TLR3 and TLR4 to innate immune defenses at an early step.

Focusing of light beyond the diffraction limit of half the wavelength

The diffraction limit sets the smallest achievable linewidth at half the wavelength. With a subwavelength plasmonic lens allowing one to reduce the diffraction via an asymmetry and to generate and squeeze the wave functions, an incident light is focused by the aperture to a single line with its width smaller than the limited value in the intermediate zone. The focused fields are capable of propagating in free space. This light focusing process, besides being of academic interest, is expected to open up a wide range of application possibilities.

Localized cyclotron mode driven by fast alpha particles under a nonuniform magnetic field

Resonance requires precise synchronization. Surprisingly, relativistic cyclotron instability can survive under a magnetic field with its nonuniformity larger than the requirement of synchronism. Localized eigenmode observed in a hybrid simulation is found to be consistent with that predicted by an analytical theory including both profile and eigenvalue. Half of the spatial area of the wave profile is located where the frequency mismatch is negative as against to the positive requirement generally believed. The consequence on the alpha dynamics is also demonstrated.

Hypergammaglobulinaemic purpura associated with alcoholic liver cirrhosis

Hypergammaglobulinaemic purpura (HP) is commonly found in Sjögren's syndrome. We report a rare association of HP arising in a patient with alcoholic liver cirrhosis. A 65-year-old man presented with palpable purpura on the legs. Histological examination of a biopsy taken from the purpura found leucocytoclastic vasculitis in the superficial and mid-dermis. The activity of the vasculitic skin lesions correlated with liver dysfunction. Increased IgA and IgG levels, and hypocomplementaemia, may account for the pathogenesis of the hypergammaglobulinaemic immune complex-mediated vasculitis in this case.

Persistent lymphoedema in Morbihan disease: formation of perilymphatic epithelioid cell granulomas as a possible pathogenesis

Morbihan disease is a rare complication of rosacea, characterized by persistent lymphoedema on the upper half of the face, occurring during the chronic clinical course of rosacea. This refractory condition has been also designated as 'rosacea lymphoedema' and 'solid persistent facial oedema of rosacea'. We report a patient with Morbihan disease showing persistent lymphoedema on the upper half of the face accompanied by unique histological findings of striking dermal dilated lymphatics and damage of the lymphatics at the site of the adjacent epithelioid cell granulomas, with histiocytes bulging into the lymphatic lumen. The marked epithelioid cell granulomas forming around dermal lymphatic vessels with subsequent lymphatic damage and luminal obstruction by histiocytic infiltration may account for the development of lymphoedema in this patient.

Relativistic electromagnetic ion cyclotron instabilities

The relativistic instabilities of electromagnetic ion cyclotron waves driven by MeV ions are analytically and numerically studied. As caused by wave magnetic field and in sharp contrast to the electrostatic case, interesting characteristics such as Alfve nic behavior and instability transition are discovered and illuminated in detail. The instabilities are reactive and are raised from the coupling of slow ions' first-order resonance and fast ions' second-order resonance, that is an essential extra mechanism due to relativistic effect. Because of the wave magnetic field, the nonresonant plasma dielectric is usually negative and large, that affects the instability conditions and scaling laws. A negative harmonic cyclotron frequency mismatch between the fast and slow ions is required for driving a cubic (and a coupled quadratic) instability; the cubic (square) root scaling of the peak growth rate makes the relativistic effect more important than classical mechanism, especially for low fast ion density and Lorentz factor being close to unity. For the cubic instability, there is a threshold (ceiling) on the slow ion temperature and density (the external magnetic field and the fast ion energy); the Alfve n velocity is required to be low. This Alfve nic behavior is interesting in physics and important for its applications. The case of fast protons in thermal deuterons is numerically studied and compared with the analytical results. When the slow ion temperature or density (the external magnetic field or the fast ion energy) is increased (reduced) to about twice (half) the threshold (ceiling), the same growth rate peak transits from the cubic instability to the coupled quadratic instability and a different cubic instability branch appears. The instability transition is an interesting new phenomenon for instability.

Mucocutaneous manifestations in Japanese HIV-positive hemophiliacs

BACKGROUND

Although various mucocutaneous manifestations have been reported in patients infected with HIV by sexual transmission or intravenous drug use, the prevalence and characteristics of skin disorders in HIV-positive hemophiliacs coinfected with hepatitis C virus (HCV) have rarely been described.

OBJECTIVE

The purpose of this study was to clarify the characteristics of skin disorders in HIV-positive hemophiliacs and to identify differences in comparison with other HIV-positive groups.

METHODS

A prospective study of the prevalence of mucocutaneous manifestations in 110 Japanese hemophiliacs (53 HIV-positive hemophiliacs including 24 AIDS and 57 HIV-negative hemophiliacs) was performed from July 1997 to July 1998.

RESULT

None of the hemophiliacs developed Kaposi's sarcoma or sexually transmitted skin diseases. Eosinophilic folliculitis was observed in 3 AIDS patients. The incidence of folliculitis, common warts, seborrheic dermatitis, generalized eczema, oral candidiasis and herpes zoster was higher in HIV-positive than in HIV-negative hemophiliacs (p < 0.05). Although anti-HCV antibody was positive in all HIV-positive hemophiliacs, HCV-related dermatoses such as lichen planus and porphyria cutanea tarda were not observed.

CONCLUSION

Although Kaposi's sarcoma and sexually transmitted skin diseases such as molluscum contagiosum, condyloma, and scabies are frequently associated with HIV, they were not found in the HIV-positive hemophiliacs in our study. HIV infection-related mucocutaneous manifestations are influenced not only by the presence of HIV but also by other factors such as the mode of transmission and sexual habit.

Job stress and dissatisfaction in association with non-fatal injuries on the job in a cross-sectional sample of petrochemical workers

This cross-sectional study analysed the frequency and severity of work stressors and job satisfaction at workplaces in relation to work-related non-fatal injuries amongst a sample of petrochemical workers in Taiwan. The study participants consisted of 568 cases injured on the job between 1991 and 1997, and 954 injury-free controls matched to cases on frequencies of age, sex and work site. After adjusting for potential confounders, we found that cases were more likely than controls to report stressors with a higher frequency [odds ratio (OR) = 1.4, 95% confidence interval (CI) = 0.9-2.0] and a more severe reaction (OR = 1.3, 95% CI = 0.9-1.8). The dose-response analyses further indicated that the OR of injury was monotonically associated with stress reaction only (P for test for trend of ORs = 0.02). Job satisfaction, though, was unrelated to non-fatal injury. Although the cross-sectional nature of our study precludes a causal inference between stress reaction to stressors and risk of developing non-fatal injuries, our results tend to suggest that the severity of stress reaction is more associated with occupational non-fatal injury than is the frequency of stress or job dissatisfaction.

Tropical-wood-induced bullous erythema multiforme

We report a case of bullous erythema multiforme caused by an exotic wood, pao ferro (Machaerium scleroxylon). A 25-year-old female, a luthier (guitar maker) who often handles a variety of woods, developed bullous erythema multiforme. A patch test confirmed a positive reaction to one of the exotic woods, pao ferro. A subsequent accidental short contact with pao ferro 5 months following the first incidence induced a similar exudative erythema. Exotic woods such as pao ferro should be added to the list of contact allergens that can induce bullous erythema multiforme.

Granulomatous mycosis fungoides with small intestinal involvement and a fatal outcome

We report a case of granulomatous mycosis fungoides that progressed into fatal gastrointestinal involvement 4 years after the onset of skin lesions, despite improvement of the skin lesions in response to a combination of PUVA and systemic interferon-gamma therapy. Histological examination showed Pautrier's microabscesses with granuloma annulare-like features and sarcoidal granuloma formation in the plaque stage, proliferation of blast-transformed atypical lymphocytes with persistent granuloma formation in the tumour stage, and metastatic lesions. A literature review of granulomatous mycosis fungoides revealed that 11 of the 24 reported cases died of the disease, and like our case, seven died within 5 years. We suggest that mycosis fungoides with granulomatous reactions does not indicate a favourable prognosis.

Cytosine arabinoside-induced vasculitis

Dermatologic side effects of cytosine arabinoside (ara-C) are rare and most commonly occur after high-dose (more than 100 to 200 mg/m2 per day) therapy has been administered for several days. Although vascular reactions after combination chemotherapeutic regimens with ara-C have been anecdotally described, they have not been previously reported after single-agent chemotherapy with ara-C. Herein we describe two patients with acute nonlymphoblastic leukemia in whom cutaneous small vessel necrotizing vasculitis developed after high-dose single-agent chemotherapy with ara-C. Cutaneous lesions developed 3 to 5 days after initiation of therapy and resolved spontaneously within a week after the chemotherapeutic regimen was completed. No evidence of systemic vasculitis was present in either patient. Prior experimental data have demonstrated a direct toxic effect of ara-C on endothelial cells, and this outcome may represent the underlying mechanism of vascular injury.

Cutaneous vasculitis in Behçet's disease: a clinical and histopathologic study of 20 patients

BACKGROUND

Despite the frequency of small vessel vasculitis in skin lesions of Behçet's disease (BD), BD is classified as a neutrophilic dermatosis.

OBJECTIVE

Our goal was to determine whether the various cutaneous manifestations of BD are secondary to cutaneous vasculitis.

METHODS

Twenty-three specimens with histologically proven necrotizing vasculitis from 20 of 42 patients with BD were investigated.

RESULTS

The cutaneous vasculitic manifestations were characterized as erythema nodosum-like eruptions, palpable purpura, hemorrhagic blisters, infiltrated erythema, Sweet's syndrome-like eruptions, papulopustular lesions, and extragenital ulcerations. Combinations of various skin lesions were commonly seen in the same patient. Venous vessels in the entire dermis to the subcutis were affected with sparing of arterial vessels from middermis to subcutis. Histologic features included leukocytoclastic vasculitis in seven and lymphocytic vasculitis in 13 patients with extensive to focal localized fibrinoid necrosis of vessel walls.

CONCLUSION

Cutaneous vasculitis in BD is predominantly venulitis or phlebitis. Approximately half (48%; 20 of 42) of BD patients with cutaneous lesions had either lymphocytic (31%; 13 of 42) or leukocytoclastic vasculitis (17%; 7 of 42). We suggest that BD be considered as a vasculitis-associated disease separate from the neutrophilic dermatoses.

Eosinophilic vasculitis in connective tissue disease

BACKGROUND

Neutrophilic and lymphocytic vascular inflammation is common in vasculitis associated with connective tissue disease (CTD). We recently identified eight patients with CTD and eosinophilic vasculitis.

OBJECTIVE

The purpose of this study was to characterize a variant form of vasculitis in CTD with eosinophilic infiltration.

METHODS

Of 98 CTD patients with cutaneous necrotizing vasculitis, eight were found with predominantly eosinophilic vascular infiltration. Nine CTD patients with cutaneous neutrophilic vasculitis were identified for comparison. Clinical and laboratory findings were reviewed and compared. Indirect immunofluorescence for eosinophil granule major basic protein (MBP), neutrophil elastase, and mast cell tryptase was performed on lesional tissue. MBP levels and eosinophil survival enhancing activity were assayed in sera from three patients.

RESULTS

The patients with eosinophilic vasculitis had depressed serum complement levels and peripheral blood eosinophilia; MBP levels were elevated in serum and eosinophil survival was prolonged. Immunofluorescence of tissue showed marked angiocentric eosinophil MBP staining with peripheral neutrophil elastase staining; mast cell tryptase staining was notably absent. The patients with neutrophilic vasculitis were variably hypocomplementemic and did not have peripheral blood eosinophilia. Immunofluorescence showed marked angiocentric neutrophil elastase staining with scattered eosinophil MBP staining; mast cell tryptase staining showed normal mast cell numbers.

CONCLUSION

Patients with eosinophilic vasculitis, CTD, and hypocomplementemia show vessel wall destruction in association with vessel wall deposition of cytotoxic eosinophil granule MBP, which suggests that eosinophils mediate vascular damage in this disease process. In addition, perivascular mast cells appear diminished, thereby suggesting that mast cell degranulation occurs.

Coexistence of psoriasis and an unusual IgG-mediated subepidermal bullous dermatosis: identification of a novel 200-kDa lower lamina lucida target antigen

Bullous pemphigoid (BP) is characterized by autoantibodies against 230- and 180-kDa hemidesmosomal antigens located in the most superficial layers of the basement membrane zone (BMZ). Histologically, there is a predominance of eosinophils in the infiltrate. In a psoriatic patient, we identified an unusual autoimmune subepidermal bullous eruption which clinically resembled BP, but which was characterized by IgG autoantibodies against a novel 200-kDa lower lamina lucida component. Histologically there was a predominance of neutrophils in the infiltrate. Direct immunofluorescence showed linear immunoglobulin (Ig)G and C3 deposition at the BMZ. The patient's IgG autoantibodies bound exclusively to the dermal side of salt-split normal human skin. Indirect immunogold electron microscopy showed a marked deposition of IgG at the lower lamina lucida and minimal deposition at the hemidesmosomes. Immunoblot analysis identified a unique 200-kDa autoantigen in dermal extracts and a faint band of the 230-kDa BP antigen in epidermal extracts. The patient responded dramatically well to cyclosporin A. Although the patient's serum also reacted slightly with the 230-kDa BP antigen, there were significant findings different from the usual immunopathological changes of BP. These included finding a novel 200-kDa lower lamina lucida target antigen, the binding of IgG autoantibodies exclusively to the dermal side of the split skin and a predominance of neutrophils in blister infiltrate. The IgG autoantibodies against the 200-kDa lamina lucida target antigen seemed to play a major role in the pathogenesis of this unique autoimmune subepidermal dermatosis.

Cefotiam-induced contact urticaria syndrome: an occupational condition in Japanese nurses

A case of occupational contact urticaria syndrome caused by cefotiam dihydrochloride (CTM) in a Japanese nurse is reported. The patient had become sensitized to CTM through the process of preparing antibiotics 8 months before she developed symptoms. A review of the literature revealed 13 similar cases, all involving Japanese nurses, reported since CTM became available in Japan.

Eosinophilic vasculitis syndrome: recurrent cutaneous eosinophilic necrotizing vasculitis

We recently identified a syndrome of recurrent cutaneous eosinophilic vasculitis in three patients. These patients had in common widespread pruritic, erythematous, purpuric papules and angioedema of face and hands associated with peripheral blood eosinophilia. Eight skin biopsies from these three patients all showed necrotizing vasculitis of the small vessels of the skin, with exclusively eosinophilic infiltration and minimal or no leukocytoclasis. The disease followed a chronic course, with recurrent, itchy, swelling skin lesions and without evidence of systemic involvement over observation periods of 3, 17, and 23 years. The skin lesions responded promptly to systemic steroid treatment, but two patients required maintenance doses for control of the disease. Immunofluorescence studies showed marked deposition of the cytotoxic eosinophil granule major basic protein in the affected vessel walls. Eosinophil-active cytokine IL-5 was detected in the serum of one patient. Expression of the vascular cell adhesion molecule-1 for eosinophil adherence was detected on the endothelium of the affected vessels. Because this disease showed distinctive clinical manifestations and characteristic histopathological features, we believe it is a distinct entity and should be distinguished from other types of vasculitis.

Recurrent cutaneous necrotizing eosinophilic vasculitis. A novel eosinophil-mediated syndrome

BACKGROUND AND DESIGN

Review of skin biopsy specimens showing necrotizing vasculitis revealed three patients with small dermal vessel eosinophilic vasculitis and common clinical features characterized by glucocorticoid responsive pruritic erythematous, purpuric papules and angioedema associated with peripheral blood eosinophilia. Indirect immunofluorescent localization of eosinophil granule proteins, neutrophil granule proteins, and mast cell tryptase, electron-microscopic evaluation and immunoperoxidase staining for vascular cell adhesion molecule type 1, intercellular adhesion molecule type I, endothelial-leukocyte adhesion molecule type 1, and very-late activation antigen type 4 were performed. Eosinophil-active cytokines in serum were evaluated by an eosinophil survival assay.

OBSERVATIONS

Eight skin biopsy specimens from the three patients all showed small-vessel necrotizing vasculitis with exclusive eosinophil infiltration. Ultrastructural study demonstrated degenerating eosinophils and eosinophil granules in proximity to damaged endothelium. The affected small vessels showed marked deposition of the toxic eosinophil granule major basic protein in the vessel walls and expression of vascular cell adhesion molecule type 1 and intercellular adhesion molecule type 1 on the endothelium with adherence of very-late activation antigen type 4-positive eosinophils; E-selectin staining was negative. The presence of interleukin 5 in serum available from one patient was detected by an eosinophil survival assay.

CONCLUSIONS

We studied three patients whose cutaneous lesions showed small-vessel eosinophilic vasculitis and who presented with recurrent glucocorticoid-responsive pruritic purpuric papules and angioedema. The presence of eosinophil-active cytokines in serum and the expression of vascular cell adhesion molecule type 1 on the endothelium of affected vessels may contribute to the selective adherence and localization of activate eosinophils. Subsequent release of cytotoxic proteins such as major basic protein may result in destruction of the endothelium in this unique syndrome.

Churg-Strauss syndrome: report of a case without preexisting asthma

A 38-year-old male with no history of asthma, who initially presented with episcleritis and subsequently developed symptoms of systemic vasculitis with marked blood eosinophilia, was diagnosed as having Churg-Strauss syndrome (CSS). Both the patient's skin lesions and pulmonary infiltrates revealed histologically proven vasculitis with predominantly eosinophilic infiltration. All the symptoms of systemic vasculitis except the persisting peripheral neuropathy dramatically improved after corticosteroid was systemically used. Since scattered non-asthmatic cases of CSS have been reported recently, and three such patients have died of acute heart failure due to delayed diagnosis, absence of asthma should not be regarded as an absolute criterion for exclusion of the diagnosis of CSS. Earlier recognition of this disease is important, since earlier institution of steroid therapy can prevent the acute onset of fatal cardiac involvement during the course of this disease.

Cutaneous polyarteritis nodosa: a clinical and histopathological study of 20 cases

Twenty cases diagnosed as cutaneous polyarteritis nodosa (CPN) and confirmed by skin biopsy over the last 17 years were reviewed in our department. Based upon their clinical features, laboratory findings, and long-term observation of the disease course, they were divided into three groups. 1) Group 1 comprised 16 cases which were classified as the mild cutaneous form. The disease was confined to the skin with occasional involvement of peripheral nerves and skeletal muscles of the affected extremity. They generally followed a benign course. 2) Group 2 comprised 2 cases classified as the severe form. Despite severe clinical manifestations and several abnormal laboratory findings, the disease was limited to the skin, muscles, and peripheral nerves without any visceral involvement over follow-up periods of 11 years and 5 years, respectively. 3) Group 3 comprised 2 cases of the progressive form; in these the disease had begun with a cutaneous lesion and progressed to the systemic form after 19 and 18 year periods of recurrent episodes of cutaneous lesions, respectively. One died of gastrointestinal bleeding. In group 3, serum antinuclear antibodies and rheumatoid factor were positive. The autoimmune mechanism seems to play a role in this group. It is clear from the results of this study that not all patients whose vasculitic lesions are apparently limited to the skin remain in a benign course. Long-term follow-up is essential.