Case for diagnosis

Majocchi's granuloma is a persistent supurative folliculitis, associated with a deep granulomatous reaction induced by dermatophytes. There are two clinical forms of Majocchi's granuloma: the superficial form that appears in healthy individuals after localized trauma; and the nodular form, which occurs in inmunocompromised patients. We present a case of nodular Majocchi's granuloma on the forearm of an immunocompetent patient. Microbiological culture and examination of a deep aspiration sample identified Trichophyton rubrum. Collecting a deep sample of tissue is essential in achieving a good diagnostic performance.

Revisiting the Rich's formula: an update about granulomas in human tuberculosis

The formula proposed by Rich in 1951 explained the formation in a tuberculous lesion in a period that was unknown cellular functions, cytokines and other immunological aspects involved in granuloma formation by tuberculosis; its components are assembled conceptually to explain the pathogenic mechanisms involved in the granulomatous lesion in tuberculosis. In this manuscript, we report an update of Rich's formula based on the new and old concepts about pathogenic mechanisms involved in the granulomatous lesion in tuberculosis. Current knowledge allows us to conclude that the balance between the characteristics of the bacillus and host protective response is necessary to indicate the outcome of pathogenesis, infection or active disease and the necrosis degree of the tuberculosis lesion.

T Regulatory Cell Responses to Immunization with a Soluble Egg Antigen in Schistosoma mansoni-Infected Mice

The aim of the study is to characterize the phenotypes of CD4+ CD25+ T regulatory cells within the liver granulomas and association with both Foxp-3 gene expression and splenic cytokines. Naive C57BL/6 mice were intravenously injected with multiple doses of the soluble egg antigen (SEA) 7 days before cercarial infection. The immunized and infected control groups were sacrificed 8 and 16 weeks post-infection (PI). Histopathology, parasitological parameters, splenic phenotypes for T regulatory cells, the FOXP-3 expression in hepatic granuloma using real-time PCR, and the associated splenic cytokines were studied. Histopathological examination of the liver revealed remarkable increase in degenerated ova within hepatic granuloma which decreased in diameter at weeks 8 and 16 PI (P<0.01). The percentage of T regulatory cells (CD4+ CD25+) increased significantly (P<0.01) in the immunized group compared to the infected control at weeks 8 and 16 PI. The FOXP-3 expression in hepatic granulomas increased from 10 at week 8 to 30 fold at week 16 PI in the infected control group. However, its expression in the immunized group showed an increase from 30 at week 8 to 70 fold at week 16 PI. The splenic cytokine levels of pro-inflammatory cytokines, IFN-gamma, IL-4, and TNF-alpha, showed significant decreases (P<0.05) compared to the infected control group. In conclusion, the magnitude and phenotype of the egg-induced effects on T helper responses were found to be controlled by a parallel response within the T regulatory population which provides protection in worm parasite-induced immunopathology.

Control of Mycobacterium fortuitum and Mycobacterium intracellulare infections with respect to distinct granuloma formations in livers of BALB/c mice

Mycobacterium fortuitum is a rapidly growing nontuberculous Mycobacterium that can cause a range of diseases in humans. Complications from M. fortuitum infection have been associated with numerous surgical procedures. A protective immune response against pathogenic mycobacterial infections is dependent on the granuloma formation. Within the granuloma, the macrophage effector response can inhibit bacterial replication and mediate the intracellular killing of bacteria. The granulomatous responses of BALB/c mice to rapidly and slowly growing mycobacteria were assessed in vivo and the bacterial loads in spleens and livers from M. fortuitum and Mycobacterium intracellulare-infected mice, as well as the number and size of granulomas in liver sections, were quantified. Bacterial loads were found to be approximately two times lower in M. fortuitum-infected mice than in M. intracellulare-infected mice and M. fortuitum-infected mice presented fewer granulomas compared to M. intracellulare-infected mice. These granulomas were characterized by the presence of Mac-1+ and CD4+ cells. Additionally, IFN-γmRNA expression was higher in the livers of M. fortuitum-infected mice than in those of M. intracellulare-infected mice. These data clearly show that mice are more capable of controlling an infection with M. fortuitum than M. intracellulare. This capacity is likely related to distinct granuloma formations in mice infected with M. fortuitum but not with M. intracellulare.

Inmunopatogenia de las arteritis de grandes vasos / Immunopathogenesis of arteritis of large vessels

La vasculitis es un proceso anatomo-clínico caracterizado por la inflamación y lesión de los vasos sanguíneos. La arteritis de células gigantes y la arteritis de Takayasu se clasifican dentro de las vasculitis de grandes vasos. Ambas se caracterizan por la formación de granulomas. Los linfocitos T CD4 dirigen el daño a los tejidos como un sine qua non en el proceso vasculítico; la activación de los linfocitos T en el ambiente no linfoide de las paredes arteriales requiere la activación de las células dendríticas. Como consecuencia, la activación de monocitos y macrófagos es responsable de un síndrome sistémico inflamatorio. El resultado final es una vasculopatía oclusiva causada por una rápida proliferación de la íntima (arteritis de células gigantes) o la formación de un aneurisma causado por la destrucción de la pared arterial (arteritis de Takayasu).

Vasculitis is a clinical anatomic process characterized by inflammation, and blood vessel damage. Giant cell arteritis and Takayasu arteritis are classified into large-vessel vasculitis. Both are characterized by the formation of granulomas. CD4 T cells direct the tissue damage as a sine qua non in the vasculitic process; activation of T cells in the nonlymphoid environment of the arterial walls requires activation of dendritic cells. As a result, the activation of monocytes and macrophages is responsible for a systemic inflammatory syndrome. The end result is an occlusive vasculopathy caused by a rapid proliferation of the intima (giant cell arteritis), or the formation of an aneurysm caused by the destruction of the arterial wall (Takayasu arteritis).

B-1 cell: the precursor of a novel mononuclear phagocyte with immuno-regulatory properties

Characterization of the origin, properties, functions and fate of cells is a fundamental task for the understanding of physiological and pathological phenomena. Despite the bulk of knowledge concerning the diverse characteristics of mammalian cells, some of them, such as B-1 cells, are still poorly understood. Here we report the results obtained in our laboratory on these cells in the last 10 years. After showing that B-1 cells could be cultured and amplified in vitro, a series of experiments were performed with these cells. They showed that B1 cells reside mostly in the peritoneal and pleural cavities, migrate to distant inflammatory foci, coalesce to form giant cells and participate in granuloma formation, both in vitro and in vivo. They are also able to present antigens to immunologically responsive cells and are endowed with regulatory properties. Further, we have also shown that these cells facilitate different types of infection as well as tumor growth and spreading. These data are presently reviewed pointing to a pivotal role that these cells may play in innate and acquired immunity.

A caracterização da origem, propriedades, funções e destino das células representam objetivo fundamental para a compreensão dos fenômenos fisiológicos e patológicos. Apesar da grande quantidade de conhecimentos relativos às diversas características das células de mamíferos, muitas delas, inclusive células B-1, são pouco entendidas. Depois de mostrar que as células B-1 podem ser cultivadas e amplificadas in vitro, uma série de experimentos visando esclarecer as propriedades dessas células puderam ser feitos em nosso laboratório nos últimos 10 anos. Assim, pudemos demonstrar que células B-1 residem principalmente nas cavidades peritoneal e pleural do camundongo, migram para focos inflamatórios distantes, coalescem para formar células gigantes e participam na formação de granulomas, tanto in vitro como in vivo. São também capazes de apresentar antígenos a células responsivas e são dotadas de propriedades imuno-regulatórias. Mostramos ainda que estas células favorecem diferentes tipos de infecções bem como o crescimento e metastatização tumoral. Esses resultados sugerem que células B-1 devem exercer papel central na imunidade como um todo.

An approach to the diagnosis of neutrophilic dermatoses: A histopathological perspective.

Neutrophilic dermatoses comprises of non-infective dermatoses which are histopathologically characterized by neutrophil predominant infiltrate and clinically, respond promptly to corticsteroids. Conditions primarily with vasculitis though neutrophilic are excluded from this group. In this article we intend to briefly outline the approach to diagnose these conditions with histological perspective. The ambiguity regarding few recent dermatosis viz, rheumatoid neutrophilic dermatosis, bowel associated-dermatosis-arthritis syndrome etc. with regard to their inclusion in this group has also been highlighted.

The identification and characterization of new immunogenic egg components: implications for evaluation and control of the immunopathogenic T cell response in schistosomiasis

In schistosomiasis, granuloma formation to parasite eggs signals the beginning of a chronic and potentially life-threatening disease. Granulomas are strictly mediated by CD4+ T helper (Th) cells specific for egg antigens; however, the number and identity of these T cell-sensitizing molecules are largely unknown. We have used monoclonal T cell reagents derived from egg-sensitized individuals as probes to track down, isolate and positively identify several egg antigens; this approach implicitly assures that the molecules of interest are T cell immunogens and, hence, potentially pathogenic. The best studied and most abundant egg component is the Sm-p40 antigen. Sm-p40 and its peptide 234-246 elicit a strikingly immunodominant Th-1-polarized response in C3H and CBA mice, which are H-2k strains characterized by severe egg-induced immunopathology. Two additional recently described T cell-sensitizing egg antigens are Schistosoma mansoni phosphoenolpyruvate carboxykinase (Sm-PEPCK) and thioredoxin peroxidase-1 (Sm-TPx-1). In contrast to Sm-p40, both of these molecules induce a more balanced Th-1/Th-2 response, and are relatively stronger antigens in C57BL/6 mice, which develop smaller egg granulomas. Importantly, Sm-p40 and Sm-PEPCK have demonstrated immunogenicity in humans. The findings in the murine model introduce the important notion that egg antigens can vary significantly in immunogenicity according to the host's genetic background. A better knowledge of the principal immunogenic egg components is necessary to determine whether the immune responses to certain antigens can serve as indicators or predictors of the form and severity of clinical disease, and to ascertain whether such responses can be manipulated for the purpose of reducing pathology

Inoculation of Lacazia loboi into the subcutaneous tissue of the hamster cheek pouch

The subcutaneous tissue of the hamster cheek pouch, a site of immunologic privilege, has been used to investigate the potential infectivity of different types of parasites. It has been demonstrated that the implantation of fragments of lesions induced by the fungus Lacazia loboi, the etiologic agent of Jorge Lobo's disease, into the subcutaneous tissue of the hamster cheek pouch resulted in parasite multiplication and dissemination to satellite lymph nodes16. Here we describe the evolution of lesions induced by the inoculation of the isolated fungus into this immunologically privileged site. The morphology of the inflammatory response and fungal viability and proliferation were evaluated. Inoculation of the fungus into the cheek pouch induced histiocytic granulomas with rare lymphocytes. Although fungal cells were detected for a period of up to 180 days in these lesions, the fungi lost viability after the first day of inoculation. In contrast, when the parasite was inoculated into the footpad, non-organized histiocytic lesions were observed. Langhan's giant cells, lymphocytes and fungal particles were observed in these lesions. Fungal viability was observed up to 60 days after inoculation and non-viable parasites were present in the persistent lesions up to 180 days post-inoculation. These data indicate that the subcutaneous tissue of the hamster cheek pouch is not a suitable site for the proliferation of Lacazia loboi when the fungus isolated from human tissues is tested.

Significance of schistosomal granuloma modulation

Hepatic Schistosoma mansoni periovular granulomas undergo changes in size, cellular composition and appearance with time. This phenomenom, known as "immunological modulation", has been thought to reflect host immunological status. However, as modulation has not been observed outside the liver, participation of local factors, hitherto little considered, seems crucial. Components of the extracellular matrix of periovular granulomas of the mouse were particularly studied in three different organs (liver, lung and intestine) and during three periods of infection time (acute, intermediate and chronic) by means of histological, biochemical and imunofluorescence techniques, while quantitative data were evaluated by computerized morphometry, in order to investigate participation of local factors in granuloma modulation. Results confirmed modulation as a exclusively hepatic phenomenom, since pulmonary and intestinal granulomas, formed around mature eggs, did not change size and appearance with time. The matricial components which were investigated (Type I, III and IV collagens, fibronectin, laminin, proteoglycans and elastin) were found in all granulomas and in all organs examined. However, their presence was much more prominent in the liver. Elastin was only found in hepatic granulomas of chronic infection. The large amount of extracellular matrix components found in hepatic granulomas was the main change responsible for the morphological aspects of modulation. Therefore, the peculiar environment of the liver ultimately determines the changes identified in schistosomal granuloma as "modulation".

Antigenic stimulation is more efficient than LPS in inducing nitric oxide production by human mononuclear cells on the in vitro granuloma reaction in schistosomiasis

Nitric oxide (NO) is an extremely important and versatile messenger in biological systems. It has been identified as a cytotoxic factor in the immune system, presenting anti- or pro-inflammatory properties under different circumstances. In murine monocytes and macrophages, stimuli by cytokines or lipopolysaccharide (LPS) are necessary for inducing the immunologic isoform of the enzyme responsible for the high-output production of NO, nitric oxide synthase (iNOS). With respect to human cells, however, LPS seems not to stimulate NO production in the same way. Addressing this issue, we demonstrate here that peripheral blood mononuclear cells (PBMC) obtained from schistosomiasis-infected patients and cultivated with parasite antigens in the in vitro granuloma (IVG) reaction produced more nitrite in the absence of LPS. Thus, LPS-induced nitrite levels are easily detectable, although lower than those detected only with antigenic stimulation. Concomitant addition of LPS and L-N-arginine methyl ester (L-NAME) restored the ability to produce detectable levels of nitrite, which had been lost with L-NAME treatment. In addition, LPS caused a mild decrease of the IVG reaction and its association with L-NAME was responsible for reversal of the L-NAME-exacerbating effect on the IVG reaction. These results show that LPS alone is not as good an NO inducer in human cells as it is in rodent cells or cell lines. Moreover, they provide evidence for interactions between LPS and NO inhibitors that require further investigation.

The clearance of tubercle bacilli & mycobacterial antigen vis a vis the granuloma in different organs of guinea pigs.

In the present study, an attempt was made to define the relationship of intact tubercle bacilli and/or their antigenic fragments to a granuloma in the guinea pig in order to distinguish an active from a resolving granuloma. In one set of animals, granuloma was induced in the skin by injecting heat-killed Mycobacterium tuberculosis intradermally and in another set, granuloma was produced in the lung and spleen by injecting live M. tuberculosis intramuscularly. The animals were sacrificed at various time points and skin, lung and spleen from the two groups were subjected to histological examination for the presence of granuloma, bacilli and antigenic fragments. In the dermal lesion, intact acid fast bacilli were cleared first by day 42 followed by the removal of their antigenic fragments by day 63 and finally by day 84, the granuloma had resolved completely. In the guinea pigs infected with live M. tuberculosis, removal of the bacilli followed by the clearance of antigen was observed. Though the granuloma itself did not subside completely in these animals, it was found that there was a reduction in congestion and oedema of the granulomatous area. It is concluded from the results that the demonstration of antigen at the site of lesion may be potentially useful to discriminate between a persisting and a resolving tuberculous granuloma.

Immunization with PIII, a fraction of Schistosoma mansoni soluble adult worm antigenic preparation, affects nitric oxide production by murine spleen cells

Nitric oxide (NO) is an important effector molecule involved in immune regulation and defense. NO produced by cytokine-activated macrophages was reported to be cytotoxic against the helminth Schistosoma mansoni. Identification and characterization of S. mansoni antigens that can provide protective immunity is crucial for understanding the complex immunoregulatory events that modulate the immune response in schistosomiasis. It is, then, essential to have available defined, purified parasite antigens. Previous work by our laboratory identified a fraction of S. mansoni soluble adult worm antigenic preparation (SWAP), named PIII, able to elicit significant in vitro cell proliferation and at the same time lower in vitro and in vivo granuloma formation when compared either to SEA (soluble egg antigen) or to SWAP. In the present work we report the effect to different in vivo trials with mice on their spleen cells ability to produce NO. We demostrate that PIII-immunization is able to significantly increase NO production by spleen cells in vitro stimulation with LPS. These data suggest a possible role for NO on the protective immunity induced by PIII.

Induction of protective immunity against Schistosoma mansoni infection by antigens purified from PIII, a fraction of adult worm, associated to the downregulation of granuloma formation

This study was performed in order to define Schistosoma mansoni antigens able to function as modulator agents in BALB/c mice granulomatous hypersensitivity to parasite egg. The antigens P-24, P-35 and P-97 were purified by affinity chromatography from a fraction of S. mansoni adult worm antigenic preparation, denominated PIII, involved in the inhibition of granulomatous response to eggs. Immunization of mice with these antigens, in the presence of Corynebacterium parvum and Al(OH)3 as adjuvant, induced a significant protection degree against challenge infection, as observed by the decrease on worm burden recovered from portal system. In vitro blastogenesis assays revealed that purified antigens were able to induce significant proliferation of spleen cells from S. mansoni-infected mice. This protection was correlated to significant decrease in granuloma size induced by PIII. From these results, we concluded that PIII preparation contains antigens capable of mediating protective anti-parasite immunity and down-regulating granulomatous hypersensitivity to S. mansoni eggs.

Adhesion and co-stimulatory molecules in the pathogenesis of hepatic and intestinal schistosomiasis mansoni

Infection of a susceptible host with the blood fluke Schistosoma mansoni results in the formation of periovular granulomas and subsequent fibrosis in the target organs. Granulomogenesis and fibrogenesis are mediated by immunological events which require cell-cell and cell-matrix interactions. In this review, the role of adhesion and co-stimulatory molecules in the genesis of the schistosomal pathology (granulomogenesis and fibrogenesis) is outlined. These molecules provide essential immunological interactions not only for the initiation of granuloma formation but also for the maintenance and modulation of the schistosomal granuloma during chronic infection. Furthermore, the role of secreted soluble adhesion molecules in the different clinical forms and in the modulation of the schistosomal granuloma is discussed. Recent new insights into the role of adhesion molecules for the induction of pathology by other development stages of the parasite (other than eggs) will be presented.

Modulação do granuloma periovular esquistossomótico: morfometria e comportamento da matriz extracelular / Periovular schistosomal granuloma modulation: morphology and behavior of the extracellular matrix

O granuloma formado em torno de ovo maduro do Schistosoma mansoni no fígado se modifica no seu tamanho, forma e composição com o passar do tempo. Este fenômeno,denominado "modulação imunológica", tem sido atribuído fundamentalmente a fatores imunes. Como a "modulação" ocorre apenas no fígado, e não em outros órgãos, a participação de fatores locais parece ser decisiva para que o fenômeno ocorra. Estes últimos têm sido pouco estudados e agora, numa tentativa de contribuir para o seu entendimento, foram particularmente considerados. A presente investigação foi feita em camundongos infectados com 50 e 100 cercárias do S. mansoni. Os granulomas formados em torno de ovos madurosforam estudados e comparados em três órgãos (pulmão, fígado e intestino) e em três fases distintas da infecção: aguda (8 semanas), intermediária (16 semanas) e crônica (22 semanas), com técnicas histológicas, morfométricas, bioquímicas e de imuno-fluorescência. Os resultados confirmaram que o fenômeno da modulação é exclusivamente hepático, não sendo observadas modificações semelhantes no pulmão e intestino. Os elementos da matriz extracelular pesquisados (colágenos de tipo I, lU e IV, fibronectina, laminina, proteoglicanos e elastina) estiveram presentes em todos os locais, mas eram muito mais proeminentes no fígado. Exceto a elas tina, que apareceu apenas no fígado, exclusivamente em casos crônicos. A avaliação morfométrica indicou redução no volume, área e densidade de volume apenas nos granulomas hepáticos ao longo das três fases estudadas. A abundância de elementos da matriz extracelular presente nos granulomas hepáticos foi a principal alteração responsável pelos aspectos morfológicos da modulação. Esse aspecto foi correlacionado com particularidades da estrutura celular não parenquimatosa do fígado, onde as células perinusoidais e as células de Kupffer participam de um eixo "sui generis" relacionado com a formação e degradação da matriz. No estudo do fenômeno da "modulação" do granuloma esquistossomótico fica evidente que é o comportamento destes elementos celulares que determina as modificações da matriz extra-celular em torno dos granulomas hepáticos, representando, na sua essência, o fenômeno da "modulação".

Subpopulação de células T e citocinas na reação inflamatória granulomatosa induzida pelo Sporothrix Schenchii / Subpopulation of T cells and cytokines in granulomatous inflammation induced by Sporothrix Schenchii

No presente trabalho observamos que camundongos isogênicos BALBlc inoculados por via endovenosa com leveduras viáveis da cepa 18 do Sporothrix schenckíi, apresentam reação inflamatória que evolui para padrão granulomatoso. O granuloma observado resulta da interação das células do sistema mononuclear fagocitário com o fungo e constituintes polissacarídicos de sua parede. Dessa interação decorre a diferenciação morfológica dos fagócitos mononucleares identificando-se, principalmente, macrófagos e células epitelióides, dispostas de forma a conter a disseminação do fungo. Observamos ainda ativação dessas células com produção e secreção de interleucina (lL)-1 e fator de necrose tumoral (TNF-a), intenso afluxo de leucócitos para o sítio inflamatório e a diferencias;ão morfológica dessas células, formando granulomas competentes capazes de controlar a infecção. Quanto ao mecanismo microbicida dos fagócitos, demonstramos que é dependente da ativação da via de produção de intermediários reativos do nitrogênio com produção de óxido nítrico {NO) a partir da ativação da enzima óxido nítrico sintase induzível (iNOS). Considerando-se que o granuloma observado neste modelo apresenta características de uma resposta tecidual de hipersensibilidade e que correlaciona-se com a presença de citocinas como interferon-gama (IFN-y), IL-1 e TNF-a, avaliamos a participas;ão de eventos da resposta imune como possíveis moduladores desta lesão. Observamos que depleção de células T CD4+ e de CD8+ modificou o padrão do granuloma. Na ausência de células CD4+ houve um maior comprometimentotecidual com granuJomas pouco delimitados, frouxos, com menor número de células mononucleares que se apresentavam com mOrfolo.Qia de menor diferenciação e com maior quantidade de leveduras nas lesões...

Cellularity of macrophage granuloma and morphological index.

In the present study, morphological index (MI) and average macrophage count per microscopic field in skin sections of 94 lepromatous (LL) patients is correlated. The subjects included 14 cases with some histoid features. The MI in the lepromatous cases varied from less than one to 40 and the corresponding macrophage counts ranged from 40 to 156. In cases with histoid changes the MI varied from 30 to 60 and the cell count ranged from 215 to 360. The histoid cases showed a higher MI and cell count compared to the other lepromatous cases. There was a positive correlation between MI and macrophage count and the hypercellular state appears to depend on living and multiplying bacteria.

Host parasite response in nerve in leprosy.

Nerve granulomas occur at all points across the leprosy spectrum. Studies have been made using experimental models in which mycobacteria were injected directly in the sciatic or posterior tibial nerve of the guinea pig. Clinical and electrophysiological studies demonstrated axonal damage which was confirmed by morphometric studies showing disrupted myelin sheaths and in places complete demyelination. Further immunohistological studies showed a complete disappearance of staining for certain neuropeptides. The role of Schwann cells has also been investigated. Schwann cells in nerves affected by mycobacterial granulomas, both experimental and in leprosy patients were not demonstrated to be MHC class II positive suggesting that they did not play a role in antigen presentation. Macrophages in leprosy granulomas were shown to contain TNF alpha, suggesting that this cytokine played a role in axonal damage. The role of mycobacterial heat-shock protein in nerve granulomas has not as yet been determined. The localized nature of granulomas in leprosy nerves and nerves with experimental mycobacterial granulomas has been studied by a process of excision and repair with muscle grafts. Marked recovery has been demonstrated by clinical, electrophysiological, morphometric and immuno-histochemical techniques, the latter demonstrating a return of neuropeptide production.