Tropical and exotic dermatoses and ulcers

BACKGROUND

Tropical dermatoses and ulcers, although essentially unique to tropical and subtropical areas, are occasionally seen in Australian general practice on returning travellers and migrants from endemic countries.

OBJECTIVE

This article will discuss important causes of tropical and exotic ulcers occasionally seen in Australia.

DISCUSSION

As tropical ulcers may mimic many other causes of skin ulceration and nodules, a history of recent travel should arouse clinical suspicion. The time frame since exposure to the causative organism is an important feature in the diagnostic process. For example, pyodermas and cutaneous larva migrans present a few days after contact with the causative agents, whereas leishmaniasis, cutaneous tuberculosis, atypical mycobacterial diseases (swimming pool granulomas) and tropical mycosis take weeks to months to appear.

[Therapy-resistant "psoriasis vulgaris"]

A 61-year-old patient had a 25-year history of erythematous scaling lesions, diagnosed and treated as psoriasis vulgaris. He presented with a growing nodule within the erythematous plaque. Biopsy shows epithelioid cell granulomas with prominent Langhans giant cells. There was no sign of a squamous cell carcinoma. The tuberculin test was strongly positive and M. tuberculosis complex was detected in the biopsy material by PCR. He was diagnosed with lupus vulgaris, the most frequent form of cutaneous tuberculosis. Other types include tuberculosis verrucosa cutis, tuberculosis cutis orificialis and disseminated military tuberculosis. The patient was treated with rifampicin, isoniazid, pyrazinamide and ethambutol for two months, following a four month treatment with rifampicin and isoniazid. The skin lesions rapidly resolved under antituberculotic treatment.

Maximilian Mehl und die Behandlung mit konzentriertem Sonnenlicht

In 1889, a chance observation made by Maximilian Mehl, an officer of the Berlin police force, lead him to develop a new method of treating Lupus Vulgaris with concentrated sunlight. Although first therapies proved the efficacy of this method, scientific medicine showed little interest. But Mehl found recognition among supporters of natural healing methods who saw their principles confirmed by his discovery. Mehl's tentative therapy was superseded by technological methods of sunlight treatment, as developed by the Danish doctor Niels Ryberg Finsen. In 1903 Finsen was awarded the Nobel Prize for his work while Mehl's discovery remained practically unknown. This episode in the history of medicine demonstrates how the recognition of a new method not only depends on criteria of its efficacy, but equally so on the degree of its conformity with preconceived notions and accepted standards.

Therapeutic potential of oligonucleotides expressing immunosuppressive TTAGGG motifs

Synthetic oligodeoxynucleotides (ODNs) expressing immunosuppressive TTAGGG motifs downregulate the production of proinflammatory and Th1 cytokines. The ability of these "suppressive ODNs" to slow or prevent the development of diseases characterized by over-exuberant immune stimulation was examined. Suppressive ODNs significantly reduced disease severity in murine models of arthritis, lupus, and LPS-induced toxic shock. These beneficial effects were accompanied by a significant reduction in serum autoantibody and cytokine levels. Underlying these protective effects was the ability of suppressive ODNs to bind to and prevent the phosphorylation of STAT1 and STAT4, thereby blocking the signaling cascade central to the initiation and/or perpetuation of these disease states. These findings suggest that suppressive ODNs might find use in the treatment of acute and chronic diseases characterized by excessive immune stimulation.

Lupus miliaire disséminé de la face : 6 cas

BACKGROUND

Lupus miliaris disseminatus faciei is recognized by all authors as a unique entity, despite many appellations for this disease. In fact, the real origin and the treatment of this affection are unknown. In this study we try to specify the major histological and clinical points of diagnosis, the evolution in the mid-term and the different possibilities of the treatment.

PATIENTS AND METHODS

This is a retrospective study of the patients diagnosed with lupus miliaris and followed-up by one of us (P.M.) between 1990 and 2000.

RESULTS

There were 6 patients in this study, 5 males and 1 female. The mean age was 37 years old at the time of diagnosis. The patients exhibited a facial eruption, notably in the middle of the face, eyelids and peri-oral area. All the patients had a polymorph eruption of inflammatory and smooth papules. Many of these papules progressed in several weeks to round scars with a perpendicular carved shape. Histologically and depending of the stage of evolution of the lesion, there were some epithelioid cell and giant cell granulomas organized around the necrosis. All of the trial treatments led to failure or semi-failure. Four of the patients followed-up for several years spontaneously recovered from this disease within 2 to 4 years.

DISCUSSION

Based on the anatomical and clinical similarities observed in these 6 patients, our study confirms the authenticity of the "lupus miliaris". It did not correspond to a particular form of acne, rosacea, tuberculosis or sarcoidosis. The scars are pathognomonical of this type of eruption. No treatment seems to be efficient. However our study seems to confirm the general idea of spontaneous recovery with 2 to 4 years.

Mesenchymal stem cells in autoimmune disease

Autoimmune diseases afflict more than 3% of the U.S. population. Current therapy for mild to moderate cases is symptomatic, however advanced cases suffer high morbidity and mortality. Advanced patients have benefited from stem cell therapy in the form of bone marrow transplantation in conjunction with high-dose cytotoxic therapy. Broader application of stem cell therapy requires better understanding of how adult stem cells affect development and foster treatment of autoimmune pathologies, and of better ways to manipulate the host immune responses. While extensive research documents the role of hematopoietic stem cells (HSCs) in autoimmune disease, few studies have addressed if and how mesenchymal stem cells (MSCs) contribute to their etiopathology. Recent characterization of MSCs and their role in hematopoiesis and immune modulation suggest that their potential for cell therapy extends beyond their traditional accessory function in HSC engraftment. MSCs contribute significantly to tissue restructuring and immune functioning, in addition to facilitating durable, long-lasting stem cell engraftment. MSCs are relatively easy to obtain and expand in in vitro cultures, rendering them a prime candidate for genetic manipulations for stem cell therapy. They have the potential to differentiate into multiple lineages such as osteoblasts, adipose tissue, cartilage, tendon, and stromal cells. The role of MSCs for autoimmune disease therapy could thus be based both on immune function modulation and contribution to hematopoiesis. In this review, we examine the biology of MSCs, and their potential for cell therapy of autoimmune disease.

T-helper cell intrinsic defects in lupus that break peripheral tolerance to nuclear autoantigens

Special populations of T helper cells drive B cells to produce IgG class switched, pathogenic autoantibodies in lupus. The major source of antigenic determinants (epitopes) that trigger interactions between lupus T and B cells is nucleosomes of apoptotic cells. These epitopes can be used for antigen-specific therapy of lupus. Secondly, the autoimmune T cells of lupus are sustained because they resist anergy and activation-induced programmed cell death by markedly upregulating cyclooxygenase (COX) 2 along with the antiapoptotic molecule c-FLIP. Only certain COX-2 inhibitors block pathogenic anti-DNA autoantibody production in lupus by causing death of autoimmune T helper cells. Hence COX-2 inhibitors may work independently of their ability to block the enzymatic function of COX-2, and structural peculiarities of these select inhibitors may lead to better drug discovery and design.

Activation of natural killer T cells in NZB/W mice induces Th1-type immune responses exacerbating lupus

In vivo treatment of mice with the natural killer T (NKT) cell ligand, alpha-galactosylceramide (alphaGalCer), ameliorates autoimmune diabetes and experimental autoimmune encephalomyelitis (EAE) by shifting pathogenic Th1-type immune responses to nonpathogenic Th2-type responses. In the current study, in vivo activation of NKT cells in adult NZB/W mice by multiple injections of alphaGalCer induced an abnormal Th1-type immune response as compared with the Th2-type response observed in nonautoimmune C57BL/6 mice. This resulted in decreased serum levels of IgE, increased levels of IgG2a and IgG2a anti-double-stranded DNA (anti-dsDNA) Ab's, and exacerbated lupus. Conversely, treatment of NZB/W mice with blocking anti-CD1d mAb augmented Th2-type responses, increased serum levels of IgE, decreased levels of IgG2a and IgG2a anti-dsDNA Ab's, and ameliorated lupus. While total CD4+ T cells markedly augmented in vitro IgM anti-dsDNA Ab secretion by splenic B cells, the non-CD1d-reactive (CD1d-alphaGalCer tetramer-negative) CD4+ T cells (accounting for 95% of all CD4+ T cells) failed to augment Ab secretion. The CD1d-reactive tetramer-positive CD4+ T cells augmented anti-dsDNA Ab secretion about tenfold. In conclusion, activation of NKT cells augments Th1-type immune responses and autoantibody secretion that contribute to lupus development in adult NZB/W mice, and anti-CD1d mAb might be useful for treating lupus.

Immunotherapeutic gene transfer into muscle

Immuno-gene therapy can be advantageously performed with nonviral approaches. Genes that encode regulatory cytokines or inflammatory cytokine inhibitors can be delivered intramuscularly and expressed for weeks or months. This type of gene transfer into muscle has been shown to ameliorate several autoimmune diseases and is relevant to the development of effective DNA vaccines in autoimmune diseases, infectious diseases and cancer.

Lupus vulgaris in a patient with systemic lupus erythematosus and persistent IgG deficiency

We present the case of a patient with juvenile onset systemic lupus erythematosus (SLE) who developed a persistent, acquired hypogammaglobulinaemia with IgG deficiency. The hypogammaglobulinaemia was probably a complication of high dose corticosteroid treatment. The serum IgG level remained subnormal despite intravenous immunoglobulin therapy. Lupus vulgaris, which developed on the nasal cartilage in this patient with SLE, is not an expected finding. This patient is probably the first reported case of SLE associated with lupus vulgaris.

Glomerulonephritis associated with complete deficiency of the fourth component of complement. Response to intravenous immunoglobulin

A 15-year-old girl with complete C4 deficiency and a lupus-like disorder developed evidence of nephritis after 4 years of followup. Renal biopsy demonstrated an immune complex glomerulonephritis, with deposits in the capillary loops, the paramesangium, and the mesangial matrix. Renal function was normal. The patient was treated with monthly infusions of intravenous immunoglobulin for 6 months. The treatment was well tolerated, and resulted in resolution of the rash and hematuria. Followup biopsy showed less proliferation and fewer loop deposits. In light of the serious risk of infections that is associated with complement deficiency, approaches to glomerulonephritis that do not include immunosuppression should be considered.

Treatment of murine lupus with monoclonal antibodies to lymphocyte function-associated antigen-1: dose-dependent inhibition of autoantibody production and blockade of the immune response to therapy

Monoclonal antibodies (mAb) to lymphocyte function-associated antigen-1 (LFA-1) have been used successfully in vivo to inhibit immune responses and to block inflammatory reactions. To determine whether these effects of anti-LFA-1 could retard autoimmune disease, we treated lupus-prone NZB/NZW F1 (B/W) mice with a rat mAb to LFA-1 (anti-CD11a). Mice received high-dose therapy (500 micrograms twice weekly), low-dose therapy (40 micrograms thrice weekly), or phosphate-buffered saline from age 5 months to age 10 months. Treatment with high doses of anti-CD11a suppressed both the immune response to the rat mAb and the production of autoantibodies to double-stranded DNA. In contrast, treatment with low doses of anti-CD11a elicited an immune response to the rat mAb and did not suppress autoantibody production. The immunosuppressive effects of high doses of anti-CD11a were not due to target cell depletion. In fact, treatment induced a marked lymphocytosis which involved all lymphocyte subsets equally. Despite inhibiting autoantibody production, high-dose therapy had only modest effects on longevity.

Anti-idiotype and immunosuppressant treatment of murine lupus

The effect of the administration of a xenogeneic anti-idiotype antibody (anti-Id33) to a cross-reactive idiotype (Id33) present on anti-dsDNA antibody was examined in 6-week-old (NZB/NZW) F1 (BWF1) female mice. The administration of anti-Id33 led to a transient reduction in immunoglobulins expressing Id33, followed by a rise at 30 and 34 weeks that was significantly higher than in untreated mice (P less than 0.05). Likewise, anti-dsDNA antibody levels were significantly higher at 10 and 18 weeks than in untreated mice (P less than 0.01). No differences were seen in survival to 40 weeks, proteinuria or the severity of glomerulonephritis. Concurrent administration of cyclosporin A (CyA) with anti-Id33 markedly ameliorated glomerular injury and proteinuria and improved survival. By contrast, glomerular injury, proteinuria and survival were worse in mice treated with cyclophosphamide plus anti-Id33, compared with untreated mice. Neither CyA nor cyclophosphamide treatment, when given with anti-Id33 altered serum levels of anti-dsDNA, anti-ssDNA or Id33+ immunoglobin, compared with untreated mice. The different effects of CyA and cyclophosphamide on T lymphocytes and their discrepant effects on glomerular injury when given with anti-Id33 in this model lead us to postulate a role for T lymphocytes in the glomerular injury of BWF1 lupus.

Treatment of murine lupus with monoclonal antibody to L3T4. II. Effects on immunohistopathology of thymus, spleen, and lymph node

Monoclonal antibody to L3T4 has been used successfully to suppress autoimmunity in the New Zealand black/New Zealand white F1 (B/W) mouse model for systemic lupus erythematosus. To clarify the immunopathology of murine lupus and determine the effects of anti-L3T4 treatment on the cellular composition and histopathology of lymphoid organs, we examined the distribution of lymphocyte subsets in cryostat sections of the thymus, spleen, and lymph nodes of B/W mice. Immunohistologic specimens were obtained from female B/W mice that had received weekly intraperitoneal injections of either rat monoclonal antibody to L3T4 (2 mg/mouse/week) or phosphate buffered saline (200 microliters/mouse/week) from age 5 months until euthanasia at 8 months. B and T cell domains in each organ were identified on serial sections with monoclonal antibody directed against B220 (all B cells), Thy-1.2 (all T cells), L3T4 (helper T cells), and Ly-2 (cytotoxic/suppressor T cells). In control mice, striking cytoarchitectural abnormalities were identified in the thymuses, and the spleen and lymph nodes were hypertrophied relative to anti-L3T4 treated mice. Thymic abnormalities included amplification of medulla, formation of thymomas, and cortical atrophy. Amplified medullary regions and thymomas in B/W mice contained numerous B cells and L3T4+ T cells but few Ly-2+ T cells. The enlarged spleens and lymph nodes of control mice consisted of numerous secondary follicles with germinal centers containing an unusual subpopulation of T cells that expressed L3T4 but not Thy-1.2. In contrast, mice treated with anti-L3T4 did not develop histopathologic changes characteristic of systemic lupus erythematosus in any organ. However, treatment depleted L3T4+ cells from the spleen and lymph nodes, and it modulated the expression of L3T4 by thymocytes. These observations demonstrate that treatment with anti-L3T4 not only interferes with L3T4-dependent T cell functions, but it also prevents progressive abnormalities in lymphoid tissue in lupus-prone B/W mice. This preservation of normal lymphoid structure may contribute to the beneficial effects of anti-L3T4 on autoimmunity.

An atypical case of lupus miliaris faciei simulating dermoid cyst: diagnostic and therapeutic difficulties. Case report

A case of solitary lupus miliaris disseminatus faciei simulating a dermoid cyst is reported in a 13-year-old boy. There were no abnormal biochemical parameters. The diagnostic and therapeutic difficulties involved are discussed. This type of tumour is rare in Scandinavia, and presumably carries a good prognosis.

[Lupus vulgaris (tuberculosis cutis luposa). Clinical aspects and therapy past and present]

In the developed industrial countries, the frequency of tuberculotic diseases of the skin including lupus has decreased to a very low level because of the significant decline of morbidity and mortality, the elimination of Bovine infections, the introduction of BCG vaccination, as well as effective anti-tuberculotic drugs employed for about 30 years. In spite of the very favorable therapeutic results, we have to reckon with the continuance of the present lupus incidence as long as the number of tuberculotic affections in the world is about 20 million, and even in developed industrial countries, the yearly rate of tuberculotic patients amounts to 43 in 100,000 inhabitants. We know that the disease still occurs very frequently in the developing countries of the Far East.

[The establishment and development of the dermatological clinics of the University of Münster (Alfred Stühmer, Carl Moncorps and Paul Jordan)]

The first 25 years in the history of the Dermatology Clinic of the University of Münster have been marked by continual striving for acceptable accommodations. Alfred Stühmer founded the clinic in 1925 in an old church of the Poor Clares which was under preservation order as a historical monument. In 1938 Carl Moncorps received official leave to build a new dermatology clinic but was forced to witness the complete destruction of the old clinic during World War II. He was not able to move into today's hospital complex until 1950. Stühmer introduced logical, consistent, and exemplary treatment of tuberculosis of the skin. From 1937 to 1951 Moncorps made great progress in this field which peaked when the first immunotherapeutic cure of tuberculosis appeared. Paul Jordan became head of the clinic in 1953 and began the shift to an up-to-date and efficient clinic by founding special outpatient clinics and laboratories.

Accessible plasma exchange using membrane filter - a successfully treated case of TTP with repeated plasma exchanges

Plasma exchanges with a hollow-fiber type plasma filter were attempted in a variety of diseases. The unit was easily assembled and the procedures were safely carried out by our dialysis personnel after some instruction. Approximately 2 liters of fresh frozen plasma were used during each plasma exchange and about the same amount of plasma was removed from the patient in 1.5 to 2 hours. This resulted in 66% replacement of patient's albumin on one occasion. Fifty-four plasma exchanges were done in seven patients. The procedure was well tolerated by all patients with only occasional muscle cramps or itching, which were treated with calcium gluconate infusion or antihistamines, respectively. A successfully treated case of TTP in which we used repeated membrane plasma exchanges combined with conventional treatment is also reported.