Infliximab for hidradenitis suppurativa.

BACKGROUND: Hidradenitis suppurativa (HS) is a chronic disease characterized by significant morbidity. Current medical therapies are only minimally effective at treating the disease. Infliximab is a chimeric monoclonal antibody with high affinity for tumour necrosis factor (TNF)-alpha. TNF-alpha is known to induce proinflammatory cytokines and may play an important role in the therapy of a number of disparate inflammatory disorders. Infliximab has shown promise for the therapy of rheumatoid arthritis and psoriasis. OBJECTIVES: Retrospectively to evaluate the effectiveness of infliximab for the treatment of HS. METHODS: A retrospective chart review was performed for patients who received infliximab at the University of Miami Department of Dermatology. Patients were contacted and asked retrospectively to rate their disease activity immediately prior to and after therapy. RESULTS: Patients' self-reported disease activity scores were significantly decreased (P = 0.0001, paired t-test) following infliximab infusion. This correlated with physician-observed clinical improvement. CONCLUSIONS: Infliximab is a promising agent for the treatment of HS. These initial results suggest that infliximab is associated with objective and subjective improvement in HS. Further controlled studies of the efficacy of infliximab and its effect on the course of the disease are warranted.

T-cell release of granulysin contributes to host defense in leprosy.

A novel mechanism by which T cells contribute to host defense against microbial pathogens is release of the antimicrobial protein granulysin. We investigated the role of granulysin in human infectious disease using leprosy as a model. Granulysin-expressing T cells were detected in cutaneous leprosy lesions at a six-fold greater frequency in patients with the localized tuberculoid as compared with the disseminated lepromatous form of the disease. In contrast, perforin, a cytolytic molecule that colocalizes with granulysin in cytotoxic granules, was expressed at similar levels across the spectrum of disease. Within leprosy lesions, granulysin colocalized in CD4+ T cells and was expressed in CD4+ T-cell lines derived from skin lesions. These CD4+ T-cell lines lysed targets by the granule exocytosis pathway and reduced the viability of mycobacteria in infected targets. Given the broad antimicrobial spectrum of granulysin, these data provide evidence that T-cell release of granulysin contributes to host defense in human infectious disease.

Evidence for human CD4+ T cells in the CD1-restricted repertoire: derivation of mycobacteria-reactive T cells from leprosy lesions.

Both the CD4-CD8- (double negative) and CD4-CD8+ T cell lineages have been shown to contain T cells which recognize microbial lipid and glycolipid Ags in the context of human CD1 molecules. To determine whether T cells expressing the CD4 coreceptor could recognize Ag in the context of CD1, we derived CD4+ T cell lines from the lesions of leprosy patients. We identified three CD4+ Mycobacterium leprae-reactive, CD1-restricted T cell lines: two CD1b restricted and one CD1c restricted. These T cell lines recognize mycobacterial Ags, one of which has not been previously described for CD1-restricted T cells. The response of CD4+ CD1-restricted T cells, unlike MHC class II-restricted T cells, was not inhibited by anti-CD4 mAb, suggesting that the CD4 coreceptor does not impact positive or negative selection of CD1-restricted T cells. The CD4+ CD1-restricted T cell lines produced IFN-gamma and GM-CSF, the Th1 pattern of cytokines required for cell-mediated immunity against intracellular pathogens, but no detectable IL-4. The existence of CD4+ CD1-restricted T cells that produce a Th1 cytokine pattern suggests a contributory role in immunity to mycobacterial infection.

Hansen's disease in a patient with a history of sarcoidosis.

We report a rare case of concomitant Hansen's disease (HD) and sarcoidosis. Reticulin staining may be a helpful diagnostic tool in establishing the diagnosis of sarcoidosis in skin lesions. The diagnosis of HD can be established despite negative polymerase chain reaction results for the detection of Mycobacterium leprae DNA. Finally, a well-established diagnosis of sarcoidosis does not preclude the development of another granulomatous disorder. Hence, when new lesions developed in a patient with sarcoidosis despite appropriate therapy, other concurrent diagnoses should be pursued.

Dermatopathology via a still-image telemedicine system: diagnostic concordance with direct microscopy.

OBJECTIVE: To determine the concordance of dermatopathology diagnosis by still-image telemedicine technology and direct microscopy. MATERIALS AND METHODS: Skin specimens (N = 79) were examined by a dermatopathologist using a still-image phone system, and the diagnoses were compared with those made by the same dermatopathologist 1 year earlier by direct microscopy. The telemedical diagnoses were reached first without, and then with, patient histories. RESULTS: When the patient history was available, identical diagnoses were made in 66 of the 79 cases (84% concordance rate). Without patient history, the concordance rate was 80%. The diagnostic concordance rate for the diagnosis of benign nevocytic nevi, inflammatory diseases, and benign and malignant non-squamous cell carcinoma neoplasms was statistically significantly greater than the concordance rate for the diagnosis of squamous cell carcinoma and squamous cell carcinoma in situ (P = 0.005). CONCLUSIONS: The diagnostic concordance rate achieved by teledermatopathology using a still-image phone system fell short of the 99% intraobserver diagnostic concordance rate using direct microscopy.

Teledermatology and underserved populations.

BACKGROUND: The dermatologic needs of many communities in the United States and worldwide are underserved. Telemedicine enables physicians and non-physician primary care providers to use modern telecommunications devices to gain access to specialist consultations promptly and with much less travel. The independently developed telemedicine programs described herein support 3 traditionally underserved populations: Pacific Islanders, migrant farmworkers, and prison inmates. OBSERVATIONS: In 3 independently designed telemedicine programs, dermatology emerged as the specialty most used by remote practitioners. Patients were presented for both diagnosis and treatment and in the setting of initial evaluation and as part of follow-up care. CONCLUSION: Teledermatology is a useful way to provide dermatologic support to remote or underserved communities.

Telemedicine: caring for patients across boundaries.

Telemedicine combines computer, video and telecommunications to provide healthcare to patients at distant sites. With the improved camera and transmission technologies of the 1990s, telemedicine can be used in a variety of situations. There are two basic technological systems: live interactive video and still image ("store and forward"). Potential users include patients who live in rural or difficult to reach geographic areas, who are confined (i.e. prison inmates), Telemedicine can allow ambulatory patients to continue living at home rather than moving into costly nursing facilities. Home telemedicine also allows greater responsiveness and higher frequency of visits by home care nurses, potentially reducing future hospital visits and costs. Two home telemedicine models are the personal telemedicine unit and the enhanced personal telemedicine module with pc-based video. Telemedicine technologies developed by the military for use on the battlefield that could be adapted for civilian use include medical simulations, individual monitoring devices and biosensors, portable retinal display monitors, life support for trauma/transport, and diagnostic ultrasound imagery. Ultimately, the benefits of telemedicine will be consistency of care, easy access to specialized consultants, higher responsiveness to patient needs, and lower overall healthcare costs.

Improvement of eumycetoma with itraconazole.

Treatment of eumycetoma, both medical and surgical, is difficult and often unsuccessful. We describe a case of maduromycosis, 18 years in duration, with significant improvement after 6 months of itraconazole therapy.

Response to a telemedicine inquiry from the Florida House of Representatives and text of model act to regulate the practice of telemedicine.

This past summer, the Federation of State Medical Boards (FSMB) drafted model legislation on the practice of medicine across state lines and sent it to each state medical board for consideration. The Florida House of Representatives Committee on Business and Professional Regulation posed a series of questions about telemedicine covering issues of licensure, malpractice, insurance reimbursement, technology, physician interest and acceptance, quality of care, and cost benefit. The author's responses having been modified for this article, are presented, as is the model legislation. Appendix I is the Executive Summary of the FSMB. Appendix II is the model legislation.

The contact urticaria syndrome.

Contact urticaria may occur following contact of the skin or mucous membranes with a large number of diverse substances. When localized angioedematous reactions of the eyes or oropharynx are caused by proteinaceous substances, the distinction between contact urticaria and common inhalant or food allergies is subtle. The time course of the reaction, negative controls, or occurrence of generalized symptoms do not constitute unequivocal evidence of immunologic contact urticaria, and confirmation by RAST or passive transfer testing is required. Clinical symptoms range from mild, localized erythema to generalized anaphylaxis. When contact urticaria becomes superimposed on eczematous skin, immediate reactions that resemble eczema more than urticaria may occur. Dermatologists must increase their awareness of these clinical reactions and evaluate the external environment when searching for causes of localized urticarial reactions.