Safe and Effective Administration of Caplacizumab in COVID-19-Associated Thrombotic Thrombocytopenic Purpura

Thrombotic thrombocytopenic purpura (TTP) is a potentially life-threatening, rare acute thrombotic microangiopathy (TMA), caused by a severe ADAMTS13 deficiency. As the COVID-19 pandemic rapidly spread around the globe, much data about the pathogenicity of this virus were published. Soon after the detection of the first cases of COVID-19, it was clear that there was a wide range of COVID coagulopathy manifestations, such as deep venous thrombosis, pulmonary thromboembolism, and thrombotic microangiopathies. In the literature, little data have been reported about the association between TTP and COVID-19, and the treatment of COVID-19-associated TTP is still under debate. Here we present the case of a 46-year-old woman who developed a COVID-associated TTP, successfully treated with plasma exchange (PEX), steroids, and caplacizumab.

Long-Term Remission Achieved by Ponatinib and Donor Lymphocytes Infusion in a Ph+ Acute Lymphoblastic Leukemia Patient in Molecular Relapse After Allogenic Stem Cell Transplant and Dasatinib: A Case Report

Currently, the prognosis of Ph+ acute lymphoblastic leukemia (Ph+ ALL) patients relapsing after an allogenic hematopoietic stem cell transplantation (allo-SCT) remains poor, with few therapeutic options available. Here we present the case of a 32 years old patient with dasatinib-resistant post-transplant molecular relapse of ALL, who received, as second-line therapy, the combination of ponatinib and donor lymphocyte infusion (DLI). The therapy was safe and the patient achieved a sustained minimal residual disease negative disease, still ongoing after 22 months, which was accompanied by several changes in the immune populations distribution within the bone marrow (i.e., the increase in the CD8/CD4 lymphocytes ratio). Our report provides evidence of the efficacy of the third generation TKI inhibitor ponatinib in combination with DLI as second line therapy for Ph+ ALL relapsing after an allo-SCT.

Stimulating TSH receptor autoantibodies immunoassay: analytical evaluation and clinical performance in Graves’ disease

Background

Thyroid-stimulating hormone (TSH) receptor (TSHR) autoantibodies (TRAbs) are a heterogeneous group of antibodies (Abs) with different functionalities. Among all TRAbs, only the stimulating ones (S-TRAbs) are considered as the pathogenetic marker of Graves’ disease (GD). To date, the methods available for TRAbs testing are based on immunoassays (IMAs) which detect total serum TRAbs or bioassays which are not suitable in clinical practice, even though they discern Abs functionality. The aim of our work was to evaluate the analytical and clinical performance of a very recent IMA (Immulite TSI method), supposed to test only the serum concentration of S-TRAbs, in comparison with a current method for total TRAbs (Roche/Elecsys IMA).

Methods

We evaluated serum samples of 145 subjects: 46 with untreated (GD), 36 with chronic autoimmune thyroiditis, 3 with atrophic thyroiditis, 10 with multinodular non-toxic goiter and 50 healthy subjects.

Results

The method showed an optimal analytical sensitivity and high precision levels (LoB: 0.04 UI/L, LoD:0.07 UI/L, LoQ:0.14 UI/L, intra-assay CV: 4.2–5.9%, inter-assay: 4.5–7.2%). By receiver operating characteristics curve analysis, we obtained a value of 0.57 (sensitivity: 98.0%, specificity: 99.9%) as the best cut-off to distinguish GD, apart from four cases. Passing Bablok regression and Bland Altman analysis pointed out a good correlation and agreement with Roche method (R2 = 0.98, slope = 1.03, bias = −2.70).

Conclusions

The new method presents very promising analytical characteristics and could be adopted in clinical practice for GD diagnosis. Moreover, the test allows to accurately detect very low values of analyte with a further clinical utility in detecting earlier possible relapses.

Ponatinib-Induced Graft-versus-Host Disease/Graft-versus-Leukemia Effect in a Patient with Philadelphia-Positive Acute Lymphoblastic Leukemia without the T315I Mutation Relapsing after Allogeneic Transplant

We describe the case of a patient with Philadelphia-positive acute lymphoblastic leukemia treated with dasatinib plus steroids as first-line therapy, who achieved a major molecular response (MMR) before undergoing matched, unrelated donor allogeneic stem cell transplant. Eleven months after the transplant, she experienced molecular relapse. Mutational screening showed negativity for the T315I mutation, The patient underwent a salvage chemotherapy regimen with clofarabine + cyclophosphamide + steroids and ponatinib (clofarabine 70 mg i.v., days 1-5, cyclophosphamide 700 mg i.v., days 1-5, and ponatinib 45 mg p.o., daily starting at day 15). We observed a rapid decrease in minimal residual disease on molecular assessment with an MMR of P190-BCR-ABL/ABL = 0.01% confirmed by bone marrow revaluations at days +23, +59, +108, and +191 after the first day of salvage chemotherapy. After starting ponatinib, the patient experienced skin graft-versus-host disease, suggesting that the efficacy of ponatinib could be related not only to the direct antileukemic effect but also to its ability to promote an indirect graft-versus-leukemia effect. Ponatinib treatment was well tolerated and considered safe with easily manageable side effects.

Disappearance of Bone Marrow Fibrosis in a Patient with Chronic Myeloid Leukemia Treated with Dasatinib

We report a case of a chronic myeloid leukemia patient showing progressive bone marrow fibrosis and anemia during imatinib therapy. Given the loss of major molecular response, we switched treatment to dasatinib 100 mg daily, observing a reduction in BCR-ABL transcript, a significant improvement of anemia, and a gradual disappearance of fibrosis. After 7 years of dasatinib therapy the patient maintains a complete cytogenetic response and a deep molecular response; the last bone biopsy confirmed the absence of fibrosis.

Prompt and sustained response of a steroid-refractory autoimmune hemolytic anemia to a rituximab-based therapy in a chronic lymphocytic leukemia patient

INTRODUCTION

Autoimmune hemolytic anemia (AIHA) is a rare and potentially life-threatening event which may complicate the course of chronic lymphocytic leukemia (CLL) at any time and steroid-refractory AIHA of CLL poses a therapeutic challenge for physicians. Here, we report the safety and efficacy of a rituximab-containing regimen in a CLL patient with steroid- and IVIg-refractory AIHA.

CASE REPORT

A 57-year- old man affected by CLL, presented with fatigue, dyspnoea, tachycardia and jaundice. His physical examination revealed overt jaundice, hepato- and splenomegaly, and enlargement of lymph nodes in all superficial sites. The blood chemistry showed severe anemia (Hb value 3.9 g/dL), high white blood cell count (89 x 10(9)/L), altered hemolysis markers and direct antiglobulin test (DAT) was positive for both complement and IgG. The patient failed to respond to both a 4-day course of high-dose dexamethasone IV (40 mg/day) and intravenous immunoglobulin (IVIg) (1 g/kg/day x 2 days). Thus, a schedule containing rituximab (375 mg/m(2) day +1), cyclophosphamide (750 mg/m(2) day +2) and prednisone (60 mg/m(2) from day +1 to day +7) (R-CP) were administered. Four cycles, repeated every 4 weeks, were administered. After 4 days from the infusion of this schedule, the patient showed a marked reduction of the lymphocytosis, and the hemoglobin level started to increase. No rituximab-related side effects were recorded. At the end of treatment DAT became negative and patient achieved a nodular Partial Remission (nPR).

CONCLUSION

Our data showed the safety and efficacy of a rituximab-containing regimen in a life-threatening CLL-related AIHA, refractory to steroid and IVIg therapy. This schedule has allowed the patient to obtain a prompt and dramatic rise in hemoglobin level and a response to both AIHA and CLL.

Comparison of cardioprotective abilities between the flesh and skin of grapes

Recent studies have documented that grapes and grape juices are equally cardioprotective as red wine. The existing reports implicate that the skin and seeds of the grapes containing polyphenolic antioxidants are instrumental for the cardioprotective properties of grapes. The present study examines if the flesh of grapes also possesses any cardioprotective abilities. Three groups of randomly selected rats were fed, water only (control), flesh of the grapes (2.5 mg/kg b. wt.) or the skins (2.5 mg/kg b. wt.) for 30 days. At the end of the 30 days, isolated perfused hearts were made ischemic for 30 min followed by 2 h of reperfusion in the working mode. The results demonstrated that both flesh and skin of the grapes could protect the hearts from ischemic reperfusion injury as evidenced by improved postischemic ventricular recovery and reduced myocardial infarct size. High performance liquid chromatography (HPLC) revealed that skin and flesh contained comparative amounts of glucose, fructose, tartaric acid, malic acid, shikimic acid, and trans-caftaric acid. In addition, the flesh contained reduced amounts (compared to skin) of cis-coutaric, trans-coutaric, caffeic, p-coumaric, cinnamics, and catechin/epicatechin. Total polyphenolic index was also lower in flesh compared to skin. The anthocyanins were present exclusively in the skin. Electron paramagnetic resonance (EPR) spectrometry of hydroxy radicals indicated that both flesh and skins possessed equal amount of ROS scavenging activities. Total malonaldehyde content in the heart was reduced comparatively with either flesh or skin. The results indicate for the first time that the flesh of grapes are equally cardioprotective as skin, and antioxidant potential of skin and flesh of grapes are comparable with each other despite of the fact that flesh does not possess any anthocyanin activities.

The introduction of the stilbene synthase gene enhances the natural antiradical activity of Lycopersicon esculentum mill

Tomato (Lycopersicon esculentum) is a vegetable rich in antioxidants, such as lycopene, lutein, and zeaxanthin. Their presence is responsible for the characteristic ability of this product to inhibit the formation of reactive oxygen species, including singlet oxygen. The grapes and wines derived from grapes also contain powerful antioxidants. The antioxidant effect is derived from the polyphenols such as resveratrol and proanthocyanidin. Resveratrol is phytoalexin that is synthesized via the activation of the gene, stilbene synthase (STS). We decided to determine if the introduction of this gene into Lycopersicon esculentum Mill could modify its antioxidant activity. Using Electronic Paramagnetic Resonance (EPR) spectroscopy, which permits the detection of antiradical activity, especially *OH (hydroxyl radical), we showed that the antioxidant activity of the products, into which the gene STS had been introduced, was almost double than that of natural products and that their activity was especially pronounced due to ripening. Moreover, resveratrol concentrations in modified tomatoes were much higher than that found in the individual fruit. In the isolated hearts subjected to ischemia/reperfusion, the rats fed with modified tomato exhibited better cardiac performance, reduced myocardial infarct size and decreased number of apoptotic cardiomyocytes, and reduced oxidative stress compared to unmodified tomato or resveratrol alone indicating superior cardioprotective abilities of modified tomatoes.

EPR evaluation of the antiradical activity of wines containing high concentrations of resveratrol

The ability of two samples of red wine with different resveratrol concentrations to inhibit hydroxyl radicals (*OH) produced by a Fenton-type reaction was assessed using the method of electronic paramagnetic resonance (EPR). One sample was an autochthonous wine, Uvalino, which has a very high resveratrol concentration; the second was another red wine with a much lower resveratrol concentration. The ability of the sample of Uvalino wine to obstruct hydroxyl radicals was evident, but it wasn't much better than the ability of the sample of wine with a lower resveratrol concentration. The resveratrol concentration of wine is an important factor for the inhibition of the formation of free radicals, especially hydroxyl radicals; however, it is not the only one responsible for this property of wine. Resveratrol concentration can act synergically with other factors, such as polyphenols, which are also contained in wine and have antioxidant properties.

Effects of uvalino, a new autochthonous wine, on the inhibition of the production of hydroxyl radicals

In view of the high concentration of resveratrol found in a new autochthonous wine (Uvalino) and the notable antioxidant activity of this substance, we decided to assess whether this wine could inhibit the production of free radicals. Nowadays, free radicals are considered to be the most noxious factors for tissues, triggering the development of many diseases. The assessments were carried out using a direct and more precise technique, electronic paramagnetic resonance (EPR), which is able to detect the ability of an antioxidant agent to inhibit the formation of hydroxyl radicals (*OH), which are among the most noxious reactive oxygen species (ROS). The results show that Uvalino wine is able to eliminate ROS production almost completely. Consequently, it has beneficial effects on health in all the diseases in which ROS plays an important pathogenetic role.

Evaluation of the antioxidant activity of new carotenoid-like compounds by electron paramagnetic resonance

The antioxidant activity of a novel series of derivatives with a carotenoid-like structure was studied. These derivatives have recently been isolated chemically as a result of studies on the pigments present in a particular species of birds, namely parrots. These novel derivatives, which are also called parrodienes, have been proved to possess interesting biological properties that differ from those that carotenoids are known to have. The objective of this study was to demonstrate the ability of these novel compounds to inhibit the formation of reactive oxygen species, especially their ability to block the formation of hydroxyl radicals, which are among the most reactive products of oxygen reactions and which produce the greatest damage to cells and tissues. The technique used to assess this antioxidant capacity of parrodienes was electron paramagnetic resonance, which allows direct assessment of inhibition of hydroxyl radical formation (.OH). The results show that these derivatives, especially octatriene, are able to exert evident antioxidant activity, thus confirming that their antioxidant properties are important for their biological activity.

Sentinel lymph node biopsy in patients with primary cutaneous melanoma: study of 455 cases

BACKGROUND

The role of elective lymph node dissection in the treatment of patients with primary melanoma is a debated topic in surgical oncology. However, recent data assure a survival improvement with this technique only for patients harbouring nodal metastases. The emergence of a new procedure of lymphatic mapping permits the identification of the sentinel lymph node (SLN), the first draining node from the site of cutaneous melanoma, which has demonstrated to be predictive of staging of the entire regional lymphatic basin and useful in selecting for lymph node dissection only those patients who have early micrometastases.

OBJECTIVES

To verify in a large series of cases whether a combination of preoperative lymphoscintigraphy and intraoperative mapping with both vital blue dye and a hand-held gamma probe would permit an increase of the rate of successful SLN localization up to 100%; to check the utility of a wider application of SLN biopsy in patients with thin melanomas owing to a favourable risk-benefit ratio; to determine the predictive value of SLN biopsy by performing regional lymphadenectomy in patients who have pathological evidence of metastases in the SLN; to observe whether the use of SLN technique and selective lymphadenectomy might improve the clinical evolution of patients and favour low rates of recurrence.

METHODS

In 425 AJCC stage I or II melanoma patients, preoperative lymphoscintigraphy by intracutaneous injection of Tc99m-labelled albumin nanocolloids around the tumour or the tumour's excision scar was combined with the intraoperative use of a hand-held gamma probe and patent blue V mapping technique, in order to identify and harvest the SLN. In five cases the blue dye was voluntarily not used because of previous allergic reactions. In other 25 preliminary cases the procedure was performed using the blue dye alone (10 cases) or combined with a preoperative lymphoscintigraphy (15 cases). A wide excision of the primary site was then undertaken in all cases. SLNs were sent to the pathologist for serial sectioning and permanent preparations with histological and immunohistochemical examination. Patients with pathological evidence of metastatic disease in SLN returned for regional lymphadenectomy.

RESULTS

The combined use of lymphoscintigraphy, blue dye and gamma probe allowed us to identify one or more SLNs in all cases except for two (99.5% rate of success). In 70 melanomas less than 0.76 mm thick, SLNs were negative for metastases, whereas in 380 patients with thicker tumours micrometastases were demonstrated in 75 cases (19.7%). In patients with SLN metastases who underwent regional lymph node dissection, no other metastases were found three times out of four. After a median follow-up period of 18 months the rate of recurrence of the disease in 335 patients with SLN free of metastasis was low (5.4%) with a very low regional nodal recurrence (1.2%). Moreover, the worsening of the disease did not exceed 18.5% of cases with metastasis in SLN.

CONCLUSIONS

Our data confirm in a large series of cases that the SLN biopsy is extremely selective and useful to find early micrometastases and to identify patients needing regional lymphadenectomy and adjuvant immunotherapy. Patients with intermediate thickness melanoma (0.76-4.0 mm) should be informed on the availability of such a revolutionary procedure, which represents a new opportunity in primary melanoma surgery.

[Anatomo-pathologic study of sentinel lymph nodes in melanoma. Analysis of 200 cases]

Pathologic evaluation of sentinel lymph node represents a new technique for managing high-risk primary melanoma. We examined the sentinel lymph node biopsies of 200 patients affected by primary melanomas of trunk, limbs, head and neck, who had been operated at "M. Bufalini" Hospital between April 1996 and July 1998. The lymphatic mapping has been performed through the preoperative intradermal injection of vital blue dye and technetium-labelled albumin. 319 sentinel lymph nodes were harvested and the 11.3% (15% of patients) were positive for melanoma metastases. No metastases were found in melanomas < or = 1 mm. The percentage of positive sentinel lymph nodes in patients with melanomas > 1 mm in thickness was 16.3% (22% of patients). In 5 cases (2.5%) nodal nevi were found, 1 of which was associated with micrometastasis. All 30 patients with positive sentinel lymph nodes underwent regional lymph node dissection and 555 lymph nodes were harvested. Melanoma metastases were found in only 7 patients, in 31 lymph nodes. The procedure of SLN detection and biopsy is a feasible surgical approach to melanoma patients. It is extremely useful in finding early metastases and in effective pathologic staging. As a consequence of the very low incidence of metastases in the sentinel lymph nodes of patients with thin melanomas, we suggest the sentinel lymph node mapping should be offered to patients with primary melanomas at least 1 mm in depth.

Isolation of a human serum protein that inhibits the growth of Cryptococcus neoformans

Human serum at 5 to 10% (v/v) in tissue culture medium RPMI-1640, inhibits the growth of Cryptococcus neoformans by 80 to 93%. Serum fractionated on molecular sieve columns (Sephadex G-200) yielded an active protein fraction. This fraction at 100 micrograms protein/ml inhibited the growth of C. neoformans by 54%. When an active G-200 fraction was applied to a dye affinity column (Affi-Gel Blue) the fraction with inhibitory activity was bound by the column and was eluted with 1.4 M NaCl in 0.1 M phosphate buffer (pH 7.4). The bound fraction at 62.5 micrograms protein/ml inhibited C. neoformans growth by 82%. On native polyacrylamide gel electrophoresis (Nu-PAGE) the bound fraction migrated as a major and a minor band. Under the reducing conditions of sodium dodecyl sulfate (SDS)-PAGE the bound fraction yielded 4 prominent bands with MW ranging from 175 kDa to 45 kDa. Purification of the active Sephadex G-200 peak was achieved using an anion exchange column (DEAE-Sephacel). Protein eluted with 0.1 M NaCl had strong anticryptococcal activity (12.5 micrograms/ml, 79% inhibition), which in SDS-PAGE migrated as a single band with an approximate MW of 85 kDA. This protein appears important in natural host resistance to C. neoformans and polymorphisms or deficiencies may have epidemiologic and diagnostic relevance.

Sentinel node biopsy and selective lymph node dissection in cutaneous melanoma patients

Sentinel node biopsy allows an accurate selection of melanoma patients to be submitted to therapeutic dissection. From February 1994 to August 1998, at the National Cancer Institute, S. Pio X Hospital in Milan and Bufalini Hospital in Cesena, 580 sentinel node biopsies were performed in 540 stage I melanoma patients (242 males; 298 females; median age 47). Primary melanoma was located in the trunk in 201 patients, in lower limbs in 242 cases, in upper limbs in 80 cases and in head and neck in 17 patients. Injection of blue dye for sentinel node identification was performed in all cases; 372 patients were submitted to preoperative lymphoscintigraphy and in 272 cases an intraoperatory probe for a radioguided biopsy was utilized. Sentinel node identification rate was 91%. Sentinel node positivity rate was 15%. Frozen sections were examined in 199 cases. Distribution of positive cases according to primary thickness is the following: <1 mm: 1%; 1-1.99 mm: 5%; 2-2.99 mm: 18% and > or =3 mm: 27%. Sentinel node appeared to be the only metastatic node in 77% of patients submitted to dissection. The adoption of preoperative lymphoscintigraphy and the intraoperative use of the gamma probe contributed substantially in S.N. identification. No complications caused by the procedure were reported. Eight patients had a regional node relapse after a negative sentinel node biopsy and were submitted to therapeutic distant dissection. Currently 513 patients are alive with no evidence of disease. Present data confirm the feasibility and safety of sentinel node technique for selection of patients to be submitted to radical node dissection and to eventual adjuvant treatments.

Capsular pseudoinvasion after fine-needle aspiration of follicular adenomas of the thyroid

Two cases of an unusual finding of capsular pseudoinvasion in follicular thyroid adenomas after fine-needle aspiration (FNA) procedures are reported. These capsular breaches were noted along the hemorrhagic needle track, which traversed the normal peripheral thyroid parenchyma into the lesions. A reparative reaction was seen at some points along one of the tracks. Histologic examination also showed extrusion of the tumor parenchyma through the capsular interruption in one case. Surgical pathologists should be aware of this rare complication of FNA of thyroid follicular adenomas as a differential diagnosis of minimally invasive (encapsulated) follicular carcinoma.

Superinfection by Listeria monocytogenes of cultured human enterocyte-like cells infected with poliovirus or rotavirus

A mixed infection with either rotavirus or poliovirus and Listeria monocytogenes was analysed in Caco-2 cells, a tumour-derived cell line, highly susceptible to these pathogens. The multiplication of these pathogens, whose usual site of entry and/or replication is the intestine, was also followed by electron microscopy. Results obtained showed an increase of L. monocytogenes internalisation in cells infected with rotavirus, whereas the preinfection with poliovirus had only a slight interfering effect on bacterial entry. Analysis of L. monocytogenes multiplication in virus-infected cells revealed that rotavirus also promoted bacterial replication, which poliovirus hampered replication. Concerning the effect of Caco-2 cell invasion by L. monocytogenes on viral replication, we observed an increase in rotavirus antigen synthesis but no significant effect on poliovirus yield under our experimental conditions.

Enteropathogens associated with childhood diarrhea in Italy. The Italian Study Group on Gastrointestinal Infections

BACKGROUND

Infectious diarrheal diseases remain an important cause of childhood morbidity in industrialized countries. The knowledge of the etiology and epidemiology of childhood diarrhea in a given area is needed to plan any measure designed to prevent or ameliorate diarrheal illness and to develop practice guidelines for the most appropriate stool examination procedures.

METHODS

We evaluated 618 children with diarrhea and 135 controls prospectively for viral, bacterial and parasitic enteric pathogens. Diarrheagenic Escherichia coli was identified by gene probes specific to different virulence factors. Stool filtrates were examined for the presence of free bacterial toxins by a cell culture cytotoxicity assay. Clinical and epidemiologic data were recorded and analyzed in relation to microbiologic findings.

RESULTS

Enteropathogens were identified in 59% of children with diarrhea and in 10.4% of asymptomatic controls. The agents mainly associated with disease were rotavirus (23.6%), Salmonella (19.2%) and Campylobacter (7.9%). Rotavirus was significantly more frequent among children observed as inpatients whereas Campylobacter was significantly more common in outpatients. Infections with diarrheagenic E. coli, Shigella flexneri, yersinia enterocolitica, Cryptosporidium and Giardia were observed in a limited number of patients. The clinical presentation of children was not sufficiently characteristic to permit presumptive diagnosis of a specific pathogen. conversely the presence of blood and/or leukocytes in stools had a high positive predictive value for Salmonella or Campylobacter infection.

CONCLUSION

The results of this study will be useful for planning strategies to prevent and control diarrheal diseases in our country.

The effects of inhibitors of vacuolar acidification on the release of Listeria monocytogenes from phagosomes of Caco-2 cells

To evaluate the role of the acidic pH of phagosomes on the invasive ability and fate of Listeria monocytogenes within host cells, entry and replication of this gram-positive bacterium in a human enterocyte-like cell line (Caco-2) were investigated by a combination of biochemical and ultrastructural approaches. The effects of inhibitors of vacuolar acidification--the lipophilic weak base ammonium chloride, the carboxylic ionophore monensin and the vacuolar proton ATPase inhibitor bafilomycin A1--on the bacterial invasion pathway were analysed. These agents, which raise the intracellular vesicle acidic pH of living cells by different mechanisms, affected L. monocytogenes replication in Caco-2 cells. Bacteria internalised by bafilomycin-treated cells were unable to escape from phagosomes, as demonstrated by electronmicroscopy. The results provide evidence that low pH is required for efficient intracellular growth of L. monocytogenes.

Characteristics of Escherichia coli strains belonging to enteropathogenic E. coli serogroups isolated in Italy from children with diarrhea

Fifty-five Escherichia coli strains belonging to enteropathogenic E. coli (EPEC) serogroups were examined for phenotypic and genetic factors associated with virulence. The strains were isolated in Italy from children with diarrhea and identified as EPEC by clinical laboratories using commercially available antisera. O:H serotyping showed that 35 strains (27 of O26, O111, and O128 serogroups) belonged to 11 serotypes considered to be classical EPEC O:H serotypes. The other 20 isolates were classified as 15 nonclassical EPEC O:H serotypes. All the potential EPEC virulence factors associated with bacterial adhesion (localized adherence, fluorescentactin staining test positivity, presence of the attaching and effacing [eaeA] gene), the production of verotoxin, and the positivity with the enterohemorrhagic E. coli probe were significantly more frequent among isolates belonging to classical than nonclassical serotypes. Strains displaying an aggregative adhesion and hybridizing with the enteroaggregative DNA probe were found in serogroups O86, O111, and O126. Verotoxin-producing isolates belonged to serogroups O26, O111, and O128. Only one of the isolates hybridized with the EPEC adherence factor (EAF) probe, but 33 strains gave positive results with the eae probe, confirming that the former is more suitable in epidemiological studies in European countries. These results indicate that up to 75% of strains identified as EPEC by commercial antisera may possess potential virulence properties and/or belong to classical EPEC O:H serotypes and suggest that O grouping is still a useful diagnostic tool for presumptive identification of diarrheagenic E. coli in clinical laboratories.

Proximal subungual onychomycosis due to Microsporum canis

A case of proximal subungual onychomycosis due to Microsporum canis in a 36-year-old woman is presented. The onychomycosis involved the left thumb and the little fingernails, with thinning of the nail plate and crumbling of the nail plate surface. A milky-white discoloration of the proximal portion of the left thumbnail was also evident. A 2-mm longitudinal nail biopsy showed a large number of fungal elements in the whole length of the nail plate. Fungal hyphae were more numerous in the ventral nail plate and produced detachment of the superficial nail plate. The nail bed was not invaded by fungal elements and was devoid of inflammatory changes. Proximal subungual onychomycosis is uncommon in immunocompetent individuals but has frequently been described in patients with AIDS. In our patient, in whom the proximal subungual onychomycosis was due to M. canis, there were no clinical or biochemical signs of immunodeficiency. Oral treatment with terbinafine, 250 mg/daily for 2 months, produced clinical and mycological cure.

Protective effect of the nitroxide tempol against the cardiotoxicity of adriamycin

Nitroxides are cell permeable, stable radicals that have been shown to exert antioxidant effects in several experimental models. In the present study, the ability of the piperidine nitroxide TEMPOL to prevent the acute cardiac toxicity of Adriamycin (ADR), which depends on oxygen-derived free radical generation, was assessed in isolated rat hearts. The results obtained show that TEMPOL (2.5 mM) significantly reduces the contractile impairment as well as the lipid peroxidation observed in rat heart preparations perfused with 100 micrograms/ml of ADR for 60 min. Both direct interaction with free radicals and decrease of Fe(II) availability (by stable oxidation and/or by chelation) seem to contribute to the cardioprotective effect to TEMPOL. HPLC and EPR studies of the subcellular distribution of TEMPOL indicate that substantial amounts of the nitroxide localize to the mitochondrial and microsomal fractions, in an ordered environment possibly corresponding to the interface between membrane and aqueous compartments.

Differential inhibition of superoxide, hydroxyl and peroxyl radicals by nimesulide and its main metabolite 4-hydroxynimesulide

The superoxide and hydroxyl radical scavenging activities of nimesulide (CAS 51803-78-2) and its main metabolite 4-hydroxynimesulide (CAS 109032-22-6) were investigated by Electron Spin Resonance (ESR) spectroscopy, with the spin trapping technique. Hydroxynimesulide is a good scavenger of both O2 degrees- (IC50 = 40 mumol/l) and HO degree (IC50 = 54.8 mumol/l) radicals, and its high reactivity towards HO degree was confirmed by the rate constant for reaction with HO degree (K = 8.9 x 10(10) mol-1 l s-1) determined by competition kinetic studies with 5,5-dimethyl-l-pyrroline-N-oxide. Nimesulide, which has been shown by ESR to be inactive as a superoxide quencher, has a rate constant of reaction with HO degree slightly greater than that of its metabolite (3.3 x 10(11) mol-1 l s-1). In the HO degree-induced peroxidation of phosphatidylcholine (PC) liposomes, both compounds act as potent preventive antioxidants, but the HO degree entrapping capacity of the parent drug was again greater than that of hydroxynimesulide (IC50 2.12 vs 3.84 mumol/l). The metabolite is also a potent scavenger of the peroxyl radical (ROO degree) in the propagation phase of PC peroxidation (marker conjugated dienes), with an IC50 = 2.67 mumol/l; at 5 mumol/l it induces a lag time in the decomposition of PC hydroperoxides (PC-OOH) into aldehydic products of 40 h longer than in the controls (markers: conjugated dienes and total carbonyl functions). In PC liposomes, in the presence of preformed PC-OOH, the metabolite prevents PC peroxidation stimulated by 5 mumol/l Fe2+, via the Fenton reaction (marker: conjugated dienes), at the micromolar level (IC50 = 17 mumol/l) through an anti-free radical activity and a free iron chelating mechanism. Hydroxynimesulide in fact interacts with Fe2+ ions, giving rise to a strong complex, with a stability constant (log K) estimated to be around 8/9. In addition, hydroxynimesulide efficiently protects ex vivo synovial fluid lipids from the oxidative stress induced by Fe2+/ascorbate, already at 10 mumol/l (marker: thiobarbituric acid reactive substances). These results provide evidence for strong antioxidant and iron-chelating properties of 4-hydroxynimesulide, which can act synergistically with the specific HO degree scavenging activity of the parent drug in preventing and limiting in vivo the free radical-mediated tissue damage in both acute and chronic inflammatory situations.

Detection of enteroadherent Escherichia coli associated with diarrhoea in Italy

One hundred and sixty-eight isolates of Escherichia coli obtained in Italy from 112 children with diarrhoea and 56 age-matched controls were examined by the HEp-2 cell adhesion assay. Sixteen strains showed localised adherence (LA), 29 showed diffuse adherence (DA) and eight strains showed aggregative adherence (AA). No adhesion pattern was significantly associated with disease. Strains that showed LA or AA were further characterised by serotyping, fluorescent actin staining (FAS) test and hybridisation with the EPEC adherence factor (EAF), E. coli attaching and effacing (eae) and enteroaggregative (EAgg) DNA probes. Strains that showed poor LA were FAS-negative, did not belong to EPEC serotypes and did not hybridise with EPEC probes. Conversely, the two strains that showed a good LA pattern belonged to serotype O128:H2, were FAS positive and hybridised with the eae probe. No isolate hybridised with the EAF probe. Only three of the eight strains with the AA pattern hybridised with the EAgg probe. Probe positivity correlated with the ability to produce clumps at the surface of the liquid culture and to agglutinate rat erythrocytes. In two of these EAgg probe-positive strains, electronmicroscopy revealed the presence of fibrillar bundles which seem to mediate bacterial aggregation.

Prevalence of nail abnormalities in children with alopecia areata

We assessed the prevalence of nail abnormalities in 272 children with alopecia areata who were seen in our department during an eight-year period. Of these, 126 (46%; 50 girls, 76 boys) had nail abnormalities that were related to alopecia areata. Nail pitting was detected in 92 patients, including 37 with alopecia totalis or alopecia universalis. Three patients experienced an onychomadesis of all 20 nails during the acute onset of alopecia areata universalis. Thirty-two (11.7%) had nail thinning and severe nail plate surface abnormalities that were consistent with a diagnosis of trachyonychia.

Free radicals scavenging action and anti-enzyme activities of procyanidines from Vitis vinifera. A mechanism for their capillary protective action

The scavenging by procyanidines (polyphenol oligomers from Vitis vinifera seeds, CAS 85594-37-2) of reactive oxygen species (ROS) involved in the onset (HO degrees) and the maintenance of microvascular injury (lipid radicals R degrees, RO degrees, ROO degrees) has been studied in phosphatidylcholine liposomes (PCL), using two different models of free radical generation: a) iron-promoted and b) ultrasound-induced lipid peroxidation. In a) lipid peroxidation was assessed by determination of thiobarbituric acid-reactive substances (TBARS); in b) by determination of conjugated dienes, formation of breakdown carbonyl products (as 2,4-dinitrophenylhydrazones) and loss of native phosphatidylcholine. In the iron-promoted (Fenton-driven) model, procyanidines had a remarkable, dose-dependent antilipoperoxidant activity (IC50 = 2.5 mumol/l), more than one order of magnitude greater than that of the monomeric unit catechin (IC50 = 50 mumol/l), activity which is due, at least in part, to their metal-chelating properties. In the more specific model b), which discriminates between the initiator (hydroxyl radical from water sonolysis) and the propagator species of lipid peroxidation (the peroxyl radical, from autooxidation of C-centered radicals), procyanidines are highly effective in preventing conjugated diene formation in both the induction (IC50 = 0.1 mumol/l) and propagation (IC50 = 0.05 mumol/l) phases (the scavenging effect of alpha-tocopherol was weaker, with IC50 of 1.5 and 1.25 mumol/l). In addition, procyanidines at 0.5 mumol/l markedly delayed the onset of the breakdown phase (48 h), totally inhibiting during this time the formation of degradation products (the lag-time induced by alpha-tocopherol was only of 24 h at 10 mumol/l concentration). The HO degrees entrapping capacity of these compounds was further confirmed by UV studies and by electron spin resonance (ESR) spectroscopy, using DMPO as spin trapper: procyanidines markedly reduced, in a dose-dependent fashion, the signal intensity of the DMPO-OH radical spin adduct (100% inhibition at 40 mumol/l). The results of the second part of this study show that procyanidines, in addition to free radical scavenging action, strongly and non-competitively, inhibit xanthine oxidase activity, the enzyme which triggers the oxy radical cascade (IC50 = 2.4 mumol/l). In addition procyanidines non-competitively inhibit the activities of the proteolytic enzymes collagenase (IC50 = 38 mumol/l) and elastase (IC50 = 4.24 mumol/l) and of the glycosidases hyaluronidase and beta-glucuronidase (IC50 = 80 mumol/l and 1.1 mumol/l), involved in the turnover of the main structural components of the extravascular matrix collagen, elastin and hyaluronic acid.(ABSTRACT TRUNCATED AT 400 WORDS)

Phalangeal osteomyelitis due to nail biting

The authors report a 39-year-old man who developed a phalangeal osteomyelitis of the right thumb in consequence of nail biting. Cultures grew Staphylococcus aureus. Treatment with intravenous teicoplamine 400 mg/day for 3 weeks resulted in complete cure of infection.

Alopecia areata. A pathological study of nonresponder patients

Fourteen patients, four male and 10 female and ranging in age from 11 to 57 years, affected by longstanding alopecia areata that had not responded to sensitizing treatments, were submitted to scalp biopsy. Five patients had alopecia totalis and nine had alopecia universalis. The biopsy was performed on a scalp area that had been bald for > or = 1 year. We distinguished four distinct pathological patterns, which we termed "established bald patch," "early regrowth," "telogen," and "scarring," in four, seven, one, and two patients, respectively. Our study shows that, from a pathological point of view, nonresponder patients constitute a heterogeneous population. The pathological study of the scalp helps predict therapeutic failure only in the small proportion of nonresponder patients that shows a scarring pathological pattern.

Hallopeau's acrodermatitis continua of the nail apparatus: a clinical and pathological study of 20 patients

The clinical diagnosis of Hallopeau's acrodermatitis (HA) restricted to nail and digital pulp may be difficult, and even dermatologists often fail to recognize this condition. The aim of this study was to review the clinical and pathological features of 20 patients, observed over a period of 5 years (1988-1993), who were affected by HA limited to the nails. Our study shows that HA of the nail unit more commonly affects middle-aged females. In all our patients HA of the nail was restricted to one digit and not associated with other manifestations of pustular psoriasis. HA of the nail unit is characterized by a chronic course. None of our patients had a complete clearing of the dermatitis during the follow-up period. In 4 patients the acute phases of HA were treated with the non-steroidal anti-inflammatory agent nimesulide 200 mg/day, with great improvement of inflammatory signs and subjective pain within a few days. In these patients, prolongation of treatment with nimesulide during remission phases prevented relapses of the dermatitis.

Cutaneous amputation of the terminal phalanges in syringomyelia

We describe a 30-year-old woman with syringomyelia, who developed recurrent painless whitlows of the left hand that led to amputation of the terminal phalanx of the 4th finger and considerable shortening of the terminal phalanges of the 1st, 2nd, 3rd and 5th fingers. A roentgenogram of the left hand showed a complete resorption of the terminal phalanges of the 3rd, 4th and 5th fingers and partial resorption of the terminal phalanx of the 2nd finger. Although the defective sensory function undoubtedly contributes to the development of bone resorption by facilitating mechanical repetitive injuries and infections, impaired vasomotor function possibly plays an equally important role.

Carpal tunnel syndrome presenting with ischemic skin lesions, acroosteolysis, and nail changes

A 58-year-old woman had a chronic necrotic ulceration of the fingertip of the third finger and nail plate abnormalities of the first, second, and third fingers of the right hand. Roentgenograms of the hands showed acroosteolysis of the distal phalanges of the second and third right fingers. Skin and nail lesions showed considerable improvement after surgical treatment of carpal tunnel syndrome. The authors review the clinical and radiologic features of similar cases that have previously been reported.

Nail changes of punctate keratoderma: a clinical and pathological study of two patients

The pathological study of the nail changes of 2 patients affected by punctate keratoderma is described. Both patients presented nail abnormalities that were clinically suggestive of a nail psoriasis. Subungual hyperkeratosis was a prominent feature but onycholysis, splinter haemorrhages and pitting were also present. The pathology of the nail bed revealed sharply limited columns of hyperkeratosis associated with hypergranulosis and depression of the underlying nail bed epidermis. Etretinate therapy produced a significant improvement in the palmoplantar keratoderma, but it was of no apparent value in treating nail keratoderma.

Carcinoma cuniculatum of the nail apparatus: report of three cases

Three patients affected by carcinoma cuniculatum involving the nail apparatus are reported. The toes were affected in 2 cases, the thumb in 1 case. In the first patient the tumour developed in the subungual area and resulted in loss of the toe-nail. In the second patient the tumour originated on the dorsum of the toe and subsequently involved the proximal nail fold. In the third patient the tumour developed in the nail bed resulting in loss of the lateral part of the nail plate. The pathology showed in all cases invaginating strands of well-differentiated keratinocytes, some of which had central crypts containing keratinous debris. Radical excision of the tumour required disarticulation of the digit in 2 cases, whereas Mohs micrographic surgery was performed in the third case.

Follicular mucinosis in alopecia areata

The pathological features of alopecia areata were described in association with those of follicular mucinosis in the scalp pathology of an 18-year-old woman. The immunohistochemical picture of the inflammatory infiltrate showed a high CD4/CD8 ratio (25:1), which was significantly different from the CD4/CD8 ratio in patients with alopecia areata. The abundance of helper/inducer cells along with the involvement of the upper part of the hair follicles might explain the development of follicular mucinosis in this case. Different possibilities were discussed, but the clinical presentation and the follow-up favored the clinical and pathological interpretation of alopecia areata with incidental findings of follicular mucinosis.

Role of foods in the pathogenesis of chronic paronychia

BACKGROUND

Chronic paronychia is a condition that is pathologically characterized by spongiotic inflammation; it can be exacerbated by various and concomitant factors.

OBJECTIVE

The aim of this study was to assess whether chronic paronychia in food handlers may have clinical, pathologic, and immunohistochemical similarities with immediate contact dermatitis caused by foods.

METHODS

Twenty food handlers affected by chronic paronychia were submitted to patch tests with the fresh foods that were suspected of being the cause of the dermatitis.

RESULTS

Nine patients had a positive reaction to a 20-minute open patch test with fresh foods applied on the proximal nailfold. In two patients the pathologic study of the positive open patch test site showed acanthosis, exocytosis, and spongiosis of the epidermis and the presence of an inflammatory lymphocytic infiltrate in the dermis.

CONCLUSION

Our results confirm the view that an immediate hypersensitivity reaction to foods can be responsible for some cases of chronic paronychia in food handlers.

[The nonspecific bronchial stimulation test with methacholine and an ultrasonic mist of distilled water: which is to be preferred in the military sphere?]

The authors compare the methacholine (Mch) and the nebulized ultrasonic distilled water (NUDW) bronchial challenge as regard sensitivity and time required to perform them. For military service fitness, were studied 24 asthmatic patients. Each subject performed random a bronchial challenge by Mch (Yan method) and by NUDW (Allegra method) in two different days; for each bronchial challenge has been measured the time required to perform it. The atopic status has been evaluated by skin-prick test. All the subjects have shown a positive response to Mch test (PD 20 FEV1 mean: 352 mcg, range 80-850) whereas 13 subjects (54%) have shown a positive response to NUDW. The time required to evaluate all the subjects by Mch test has been 199.5 minutes whereas the total time required to evaluate all the subjects by NUDW test (127 minutes) and to evaluate by Mch test the non responders to NUDW (100 minutes) has been 227 minutes. The most of subjects were skin reactors. No difference was found as regard onset of disease, basal lung function and atopic status between responders and non responders to NUDW test. We conclude that NUDW test has shown a lack of sensitivity in this sample (50% of asthmatic patients could be misdiagnosed) and that the Mch test is preferable to determine a rapid method for measurement of bronchial responsiveness.

Psoriasiform acral dermatitis. Report of three cases

The authors report 3 patients affected by psoriasiform acral dermatitis, a distinctive clinical entity characterized by a chronic dermatitis of the terminal phalanges, associated with marked shortening of the nail beds of the affected fingers. The skin biopsy showed in all cases the pathological features of a subacute spongiotic dermatitis. X-ray examination of affected fingers showed no bone or soft tissue changes. Differential diagnosis of psoriasiform acral dermatitis included psoriasis, atopic or contact dermatitis and corticosteroid-induced distal phalangeal atrophy.

Hypertrophic lichen planus occurring after surgical procedures

Two patients showed hypertrophic lichen planus at the sites of previous surgical procedures in their lower extremities after granulomatous reactions. Knots of implanted sutures too close to the epidermis may have caused the inflammatory reaction. Although granulomatous reactions occurring after surgical procedures are fairly common, no cases of lichenoid lesions have been reported previously.