A failure of mucocutaneous lymphangiogenesis may underlie the clinical features of lipoid proteinosis.

Lipoid proteinosis (LiP) (OMIM 247100) is a rare autosomal recessive disease caused by loss of function mutations in the extracellular matrix protein 1 gene, ECM1, on chromosome 1q21. LiP is characterized clinically by hoarseness in early infancy, followed by waxy papules and plaques on the face and body along with pox-like and acneiform scars. We studied a 20-year-old Japanese woman with LiP. She was born of consanguineous parents. Biopsy specimens obtained from a nodule on the elbow were used for histopathology, immunohistology and electron microscopy. Exons 6 and 7 of ECM1 were amplified by polymerase chain reaction (PCR) from genomic DNA from the proband, her parents, her brother and an unrelated person. PCR products were sequenced to detect the mutation. Histopathological examination revealed an irregular mass of calcium beneath deposits of a hyaline material in the dermis. Immunofluorescence double staining showed that the CD31-positive microvascular density was increased but that staining for the lymphatic-specific hyaluronan receptor LYVE-1 was drastically diminished in lesional compared with nonlesional skin of the patient and with normal skin. Electron microscopy revealed marked concentric reduplication of basal laminae not only around blood vessels but also around solitary dermal cells positive for Weibel-Palade bodies scattered in the hyaline material. Sequencing of the PCR products revealed a homozygous frameshift mutation, 507delT, in exon 6. This led to a premature stop codon 23 bp downstream. The results of immunopathological and ultrastructural characterization suggest that a failure of mucocutaneous lymphangiogenesis may underlie the clinical features of LiP. Identification of mutation 507delT in a Japanese patient with LiP further supports the thesis that this mutation represents a recurrent mutation in ECM1 in patients with LiP. To our knowledge, this case represents the first report of calcinosis cutis occurring in LiP.

Pemphigus foliaceus developing after metastasis of cutaneous squamous cell carcinoma to regional lymph nodes.

We describe a patient in whom pemphigus foliaceus developed after cutaneous squamous cell carcinoma (SCC) metastasized to regional lymph nodes. Immunologic analysis revealed that production of anti-desmoglein 1 autoantibodies started when SCC metastasized, and the SCC expressed desmoglein 1, suggesting a pathogenic role of metastasized SCC in developing pemphigus foliaceus.

Paraneoplastic pemphigus without antidesmoglein 3 or antidesmoglein 1 autoantibodies.

Paraneoplastic pemphigus (PNP) is an autoimmune mucocutaneous blistering disease characterized by IgG autoantibodies that bind to various epithelia and immunoprecipitate a complex of 250, 230, 210, 190 and 170 kDa proteins. A recent study has suggested that PNP patients have antidesmoglein (Dsg) 3 autoantibody and that the antibody plays a pathogenic role in PNP. We report a 72-year-old woman with PNP associated with thymoma and adenocarcinoma of the lung. Diagnosis of PNP was made by the characteristic clinical, histological and immunopathological findings, as well as immunoprecipitation of characteristic 230, 210 and 190 kDa proteins. Using enzyme-linked immunosorbent assay with baculovirus-expressed recombinant proteins, the patient's serum was negative against both Dsg 3 and Dsg 1. This finding is unusual, and it suggests that the target antigen, which is involved in acantholysis, may be other than Dsg 3 in this case.

CCR4 memory CD4+ T lymphocytes are increased in peripheral blood and lesional skin from patients with atopic dermatitis.

BACKGROUND: Recent studies have reported that TH1 and TH2 cells express CXCR3 and CCR4, respectively. OBJECTIVE: Our goal was to assess the association of CCR4 and CXCR3 expression with TH2 and TH1 cells and association of CCR4 and CXCR3 expression with inflammation in patients with atopic dermatitis (AD). METHODS: Intracellular cytokine production and chemokine receptor expression in blood T cells were examined by flow cytometry. Immunohistochemical expression of chemokine receptors was also investigated in chronically lesional skin. RESULTS: CCR4+ and CXCR3+ CD4+ T cells predominantly produced IL-4 and IFN-gamma, respectively. Although the frequency of CXCR3+ cells among CD4+ CD45RO+ T cells was similar for patients with AD (n = 29) and healthy control subjects (n = 19), patients with severe AD (n = 14) had a reduced frequency of CXCR3+ cells. In contrast, the frequency of CCR4+ cells and the CCR4/CXCR3 ratio were higher in patients with AD (n = 22) than healthy control subjects (n = 16) and correlated with disease severity of AD. The frequency of CCR4+ cells correlated positively with eosinophil numbers and serum IgE levels, whereas the frequency of CXCR3+ cells correlated inversely with eosinophil numbers. The frequency of CCR4+ or CXCR3+ cells was similar in patients with psoriasis (n = 6) and healthy control subjects. Immunohistochemical analysis showed that the frequency of CCR4+ cells among CD4+ T cells in chronically lesional skin of patients with AD (n = 9) was higher than that of patients with psoriasis (n = 4). CONCLUSION: Our data suggest the association of CCR4 expression with TH2 cells, the predominance of CCR4+ cells in blood from patients with AD, and an important role of CCR4 in the migration of TH2 cells from blood into AD lesional skin.

Elevated serum levels of soluble L-selectin in patients with systemic sclerosis declined after intravenous injection of lipo-prostaglandin E1.

To determine whether serum soluble L-selectin (sL-selectin) levels are elevated in patients with systemic sclerosis (SSc) and whether serum sL-selectin levels change after treatment with lipo-prostaglandin E1 (lipo-PGE1), serum sL-selectin levels were examined by ELISA in patients with SSc (n=24), psoriasis vulgaris (n=22), and contact dermatitis (n=9), as well as normal control subjects (n=26). In five patients with SSc, serum sL-selectin levels were examined before and after intravenous injections of lipo-PGE1. Serum sL-selectin levels were significantly increased in patients with SSc (P<0.01) than those in normal control subjects. The elevated serum sL-selectin levels in patients with SSc significantly decreased 1 day (P<0.05), 7 days (P<0.05) and 14 days (P<0.05) after starting the treatment with lipo-PGE1. These results suggest that L-selectin may be involved in the disease process in SSc, and lipo-PGE1 may alter some inflammatory events in SSc.

Decreased expression levels of L-selectin on subsets of leucocytes and increased serum L-selectin in severe psoriasis.

L-selectin is a leucocyte adhesion molecule involved in leucocyte interactions with vascular endothelial cells. Following leucocyte activation L-selectin is endoproteolytically released from the cell surface. To assess whether psoriasis vulgaris results in systemic leucocyte activation, we examined expression levels of L-selectin on subsets of peripheral blood leucocytes from patients with psoriasis (n = 25) and normal control subjects. Serum levels of soluble L-selectin were quantified by ELISA in patients with psoriasis (n = 75), pustulosis palmaris et plantaris, and contact dermatitis, as well as normal control subjects. Psoriasis severity was evaluated by psoriasis area and severity index (PASI). L-selectin expression levels on CD4+ T cells, B cells, monocytes, and neutrophils from patients with severe-type psoriasis (PASI > or = 15) was significantly decreased compared with leucocytes from normal control subjects. Furthermore, L-selectin expression on CD4+ T cells showed good inverse correlation with PASI scores. Monocyte L-selectin expression was restored when the skin lesions of psoriasis were remitted. The frequencies of L-selectin+ CD4+ T cells or L-selectin+ CD8+ T cells from patients with psoriasis were almost normal. Serum L-selectin levels in patients with severe-type psoriasis were significantly higher than those in normal control subjects. These results suggest that subsets of leucocytes may be activated in psoriasis, and that L-selectin expression levels on some leucocyte subsets, especially CD4+ T cells, tend to correlate with disease severity of psoriasis.

Urticarial vasculitis in systemic lupus erythematosus: fair response to prednisolone/dapsone and persistent hypocomplementemia.

Two cases of urticarial vasculitis (UV) accompanying systemic lupus erythematosus (SLE) are reported. Both patients developed characteristic wheal and purpuric lesions of UV followed by pigmentation, and histological examination revealed leucocytoclastic vasculitis. Although oral prednisolone was beneficial for the systemic symptoms and various serological abnormalities, one patient needed dapsone and the other needed dapsone and cyclophosphamide to control the UV. In both patients, hypocomplementemia with no evidence of congenital complement deficiency or complement consumption persisted even after all other laboratory data and symptoms improved.

CD19 regulates B lymphocyte responses to transmembrane signals.

CD19 is a component of a cell surface receptor complex that regulates B lymphocyte responses to transmembrane signals including those generated through the B cell antigen receptor. Studies in mice which lack or overexpress CD19 show that changes in CD19 expression levels have significant effects on B cell development and function. Recent studies suggest that CD19 establishes a Src-family kinase activation loop that amplifies tyrosine phosphorylation of numerous downstream effector molecules including potentially positive and negative regulatory elements. These observations provide an understanding of how CD19 governs the molecular ordering and intensity of signals transduced through multiple B cell receptors.

CD22 negatively and positively regulates signal transduction through the B lymphocyte antigen receptor.

The CD22 cell-surface adhesion molecule is capable of modulating B lymphocyte antigen receptor (BCR)-mediated signals, as well as the generation of BCR-independent signals. Within the cytoplasmic domain of CD22 are motifs that are structurally homologous to known activation and inhibitory motifs. These motifs demonstrate physiologic significance via associations with known effector proteins that likely mediate their corresponding inhibitory and activation roles. Furthermore, the targeted deletion of CD22 in mice results in phenotypic changes and alterations in BCR-mediated signal transduction that are consistent with both positive and negative roles for CD22 in B cell development and activation.

Increased serum levels of interleukin (IL)-5, IL-6 and IL-8 in bullous pemphigoid.

Some cytokines have been suggested to take part in the blister formation in bullous pemphigoid (BP). However, the roles of the cytokines are only partly understood. To elucidate the involvement of cytokines in the immunological mechanisms in BP, we investigated the serum levels of interleukin (IL)-2, IL-4, IL-5, IL-6, IL-8, IL-13, soluble IL-2 receptor and soluble CD23 in patients with BP, and the correlation between cytokine levels and other clinical and laboratory data. Serum levels of these cytokines and soluble receptors were determined by enzyme-linked immunosorbent assay in 19 patients with BP and in 16 normal control subjects. Serum levels of IL-5 (P < 0.0001), IL-6 (P < 0.01) and IL-8 (P < 0.05) were significantly higher in BP patients than in the control subjects. Other cytokines and soluble receptor levels were not significantly different. Serum levels of IL-6 (P < 0.05) and IL-8 (P < 0.05) were significantly decreased after treatment when skin lesions disappeared. These results suggest that serum levels of IL-6 and IL-8 could be indicators of disease activity of BP.

Nonscarring inflammatory epidermolysis bullosa acquisita with esophageal involvement and linear IgG deposits.

A 24-year-old woman with autoimmune thrombocytopenia and hypothyroidism had an inflammatory bullous eruption in the mouth, face, and trunk that left no milia or scars after healing. Histologic examination revealed a subepidermal bulla and a neutrophil infiltration. Direct immunofluorescence examination showed deposition of IgG and C3 in the basement membrane zone (BMZ). Indirect immunofluorescence examination with 1M sodium chloride-split skin showed IgG binding to the dermal side. Immunoblot analysis demonstrated IgG autoantibodies reacting with 290 kD dermal protein. We diagnosed this as epidermolysis bullosa acquisita (EBA) with a nonscarring inflammatory feature. Treatment with oral dapsone, 75 mg, and prednisolone, 20 mg, cleared the eruption. Reduction of the prednisolone dosage was associated with multiple erosions in the esophagus. Direct immunofluorescence examination revealed linear deposition of IgG in the esophageal BMZ. To our knowledge, this is the first report of EBA with esophageal involvement and deposition of IgG in the BMZ of the esophagus.

CD19-regulated signaling thresholds control peripheral tolerance and autoantibody production in B lymphocytes.

The CD19 cell surface molecule regulates signal transduction events critical for B lymphocyte development and humoral immunity. Increasing the density of CD19 expression renders B lymphocytes hyper-responsive to transmembrane signals, and transgenic mice that overexpress CD19 have increased levels of autoantibodies. The role of CD19 in tolerance regulation and autoantibody generation was therefore examined by crossing mice that overexpress a human CD19 transgene with transgenic mice expressing a model autoantigen (soluble hen egg lysozyme, sHEL) and high-affinity HEL-specific IgMa and IgDa (IgHEL) antigen receptors. In this model of peripheral tolerance, B cells in sHEL/IgHEL double-transgenic mice are functionally anergic and do not produce autoantibodies. However, it was found that overexpression of CD19 in sHEL/IgHEL double-transgenic mice resulted in a breakdown of peripheral tolerance and the production of anti-HEL antibodies at levels similar to those observed in IgHEL mice lacking the sHEL autoantigen. Therefore, altered signaling thresholds due to CD19 overexpression resulted in the breakdown of peripheral tolerance. Thus, CD19 overexpression shifts the balance between tolerance and immunity to autoimmunity by augmenting antigen receptor signaling.

CD22 is both a positive and negative regulator of B lymphocyte antigen receptor signal transduction: altered signaling in CD22-deficient mice.

B cell activation following antigen receptor cross-linking can be augmented in vitro by ligation of cell surface CD22, which associates with the SHP1 protein tyrosine phosphatase. The targeted deletion of CD22 in mice demonstrated that CD22 differentially regulates antigen receptor signaling in resting and antigen-stimulated B lymphocytes. B cells from CD22-deficient mice exhibited the cell surface phenotype and augmented intracellular calcium responses characteristic of chronically stimulated B cells, as occurs in SHP1-defective mice. Thus, CD22 negatively regulates antigen receptor signaling in the absence of antigen. However, activation of CD22-deficient B lymphocytes by prolonged IgM cross-linking resulted in modest B cell proliferation, demonstrating that CD22 positively regulates antigen receptor signaling in the presence of antigen.

Subcorneal pustular dermatosis associated with IgA myeloma and intraepidermal IgA deposits.

We report a 59-year-old woman who had subcorneal pustular dermatosis and IgA-kappa myeloma. Immunofluorescence tests showed intercellular IgA-kappa deposits in the upper portion of the lesional epidermis and circulating IgA-kappa anti-intercellular autoantibodies in a titer of 1:40. A combination chemotherapy for myeloma induced dramatic improvement of the skin lesions in accordance with a marked decrease in serum IgA levels as well as the disappearance of circulating anti-intercellular IgA autoantibodies, suggesting a pathogenetic link between skin lesions and IgA-kappa paraprotein produced by myeloma cells.

Two cases of Fabry's disease: a hemizygote with a point mutation in the alpha-galactosidase A gene and his relative.

A 34-year-old Japanese male had leg pain, edema of the legs, hypohidrosis, whorl-like opacities of the bilateral cornea, bilateral subcapsular cataracts, and chest discomfort on exercise. He had no characteristic angiokeratomas but did have telangiectases. The electrocardiogram revealed high voltage. The echocardiogram revealed mild mitral regurgitation. The alpha-galactosidase A activity in cultured lymphoblasts was deficient (0.5 nmol/h/mg protein). Electron microscopic examination of the skin revealed lamellar cytoplasmic inclusions in the endothelial cells, pericytes, and fibroblasts. He had a G--> A transition at nucleotide 982 in the coding sequence of the alpha-galactosidase A gene which resulted in a glycine to arginine amino acid substitution at residue 328. His uncle also had leg pain, edema of the legs, hypohidrosis, and chest pain on exercise. He had no characteristic angiokeratomas but did have telangiectases. Cardiovascular examination revealed hypertrophic cardiomyopathy and stenoses of coronary arteries. Electron microscopic examination of the skin revealed lamellar cytoplasmic inclusions in the endothelial cells, pericytes, and fibroblasts.

Werner's syndrome combined with quintuplicate malignant tumors: a case report and review of literature data.

The authors report a case of Werner's syndrome complicated by quintuplicate malignancy, and review the literature data. Four malignancies occurred synchronously in the case: osteosarcoma of the left distal tibia, malignant melanoma of the left plantar region, gastric cancer, pulmonary coin lesion. The osteosarcoma and malignant melanoma were treated by below-knee amputation and the gastric cancer by palliative surgery; the pulmonary coin lesion did not respond to cisplatin chemotherapy. It was difficult to treat the multiple primary cancer curatively, and patient died of respiratory failure due to a brain tumor seven months after surgery. The postmortem examination revealed a papillary carcinoma of the thyroid gland and a leiomyosarcoma of the lung. In some cases of Werner's syndrome, attention should be paid to the concurrent occurrence of multiple primary malignant neoplasms.

[Experimental studies on the mechanism of the action of staphylococcal epidermolytic toxin A utilizing recombinant toxin].

The pathogenic role of proteinases and Ca++ in the action of staphylococcal epidermolytic toxin A (ETA) was investigated using recombinant ETA (rETA). rETA was released from the periplasmic space of E. coli transformed with the plasmid carrying ETA gene and purified by high performance liquid chromatography. The epidermolytic activity of the purified rETA was 5,000 epidermolytic unit per mg of protein. Pieces of newborn mouse skin were cultured in minimum essential medium containing rETA. Various concentrations of alpha 2-macroglobulin, N-ethylmaleimide, leupeptin, L-transepoxysuccynyl-leucylamide (4-guanidino) butane, phenylmethylsulfonyl fluroide, pepstatin A, ethylenediaminetetraacetic acid (EDTA), ethyleneglycol-bis (2-aminoethylether) tetraacetic acid (EGTA) and 8-(N,N-diethylamino) octyl 3,4,5-trimethoxybenzoate (TMB-8) were added to the medium. Splitting in the upper epidermis occurred after 4 hr of incubation in the presence of 10 micrograms/ml rETA and was not inhibited by the proteinase inhibitors except EDTA and EGTA. EDTA, EGTA and TMB-8 inhibited the splitting completely at concentrations of 0.1-1 mM. The inhibitions caused by these agents were restored by the addition of Ca++ to the medium. These results strongly suggest that the action of ETA is mediated by the increase in cytoplasmic Ca++ concentration resulting from Ca++ influx and/or intracellular Ca++ mobilization.