Skin extensibility and consistency in patients with Ehlers-Danlos syndrome and benign joint hypermobility syndrome.

OBJECTIVES: The reproducibility of clinical tests for skin extensibility and consistency, essential for differentiating between types of Ehlers-Danlos syndrome (EDS) and benign joint hypermobility syndrome (BJHS), is unknown. Paraclinical methods may provide objective differential diagnostic methods. METHODS: Six EDS, 11 BJHS, and 19 controls completed the trial. We analysed the overall inter-examiner agreement on clinical tests for skin extensibility and consistency, in addition to analyses on suction cup (SC) and soft tissue stiffness meter (STSM) methods. RESULTS: Overall agreement on tests for skin extensibility and consistency varied between 0.44 and 0.72. Extensibility evaluated by SC showed an insignificant difference between EDS patients and controls (p = 0.056). Consistency evaluated by STSM showed significant differences (p = 0.001). CONCLUSIONS: Overall inter-examiner agreement on clinical tests for skin extensibility and consistency was below 0.80, which was required a priori to conduct a reproducibility study. Further refinement of tests and a training phase are necessary. The SC and STSM results are encouraging but must be reproduced in a larger study population.

Type V and VI collagen for cohesion of dermal fibrillar structures.

Type V and VI collagen were capable to joint each other and with type I and IV collagen, as well as mucopolysaccharides. This capability suggested that these collagens function for cohesion of fibrillar tissue components of dermis. This study demonstrated the locality of these types of collagen in dermis. Fresh specimens of normal skin were fixed in 2% paraformaldehyde in phosphate-buffered saline, overnight. Besides, in order to loosen the twist of collagen fibril, some pieces of the skin specimens were treated by citrate buffer pH 3.0, prior to fixation. The specimens were embedded in Technovit 4100 and the ultrathin sections were stained by antibody to type V collagen and followed by antibody to type I, III, IV and VI collagen. The immune reactant was visualized by gold particles for electron microscopic observation. Type V and VI collagen formed networks in dermis and jointed to collagen fibrils, elastic fibre and basal lamina. Type V collagen was found inside collagen fibrils, broad elastic fibres and junctions. Dermo-epidermal junction showed type V collagen on the dermal aspects of basal lamina and at the sites where anchoring filaments joint to basal lamina, while in junction of mesenchymal tissues, no precise structural components for type V collagen were identified. Type VI collagen wove with type V collagen in dermis and associated with mucopolysaccharides. In conclusion, type V collagen formed networks in dermal interfibrillar space and participated in assembling collagen fibrils and forming broad elastic fibres. Epithelial and mesenchymal cells cohered to the underlying dermal matrix in the junction by type V collagen. Type VI collagen interwove with type V collagen in the interfibrous space and associated with mucopolysaccharides. Types V and VI collagen preserved architecture of dermal matrix.

Viscoelastic properties and flexibility of the human muscle-tendon unit in benign joint hypermobility syndrome.

OBJECTIVE: To examine the passive energy absorption of the hamstring muscle-tendon unit in 9 women with benign joint hypermobility syndrome (BJHS) and 9 age and sex matched controls. METHODS: Resistance to stretch was measured as knee flexion moment (N.m) with an isokinetic dynamometer during passive knee extension. The angle that induced a stretch sensation without pain was the maximal stretch angle. Force, angle, angular velocity (0.09 rad/s), and electromyograph were simultaneously and continuously recorded during the stretch. Hamstring cross sectional area was obtained with magnetic resonance imaging. RESULTS: Forearm skin extensibility was greater for BJHS (3.6+/-0.5 cm) than for controls (1.3+/-0.2 cm) (p < 0.01). Similarly, the Beighton score was greater for BJHS (6.6+/-0.8) than for controls (0.4+/-0.2) (p < 0.001). Maximal stretch angle was greater for BJHS (delta1.35+/-0.07 rad) compared to controls (delta0.98+/-0.05 rad) (p < 0.001), and the corresponding peak moment was also greater for BJHS (1.3+/-0.4 Nm/cm2) than for controls (0.6+/-0.1 Nm/cm2) (p < 0.01). For a given mutual angle the passive energy absorption was the same for both groups, but at the maximal stretch angle the total area-normalized energy was greater for BJHS (0.36+/-0.04 J/cm2) than for controls (0.18+/-0.28 J/cm2) (p < 0.001). CONCLUSION: The lack of difference in passive energy absorption for a given mutual stretch angle suggests that passive properties of the muscle-tendon unit of BJHS are similar to those of controls. However, the greater maximal stretch angle and corresponding peak moment in BJHS suggests a greater subjective tolerance to passive stretch. That is, increased flexibility in BJHS is not a function of altered passive properties of the muscle-tendon complex. It remains unknown if the enhanced tolerance to passive tension plays a role in the development of musculoskeletal ailment.

[Beneficial effects of CHOP therapy in a case of intravascular large B-cell lymphoma diagnosed by skin biopsy].

We report a case of intravascular large B-cell lymphoma. A 52-year-old man gradually developed dementia and abnormal behaviors, which were later accompanied by spastic paraplegia and sensory disturbance in his lower limbs. MR imaging of his brain showed high signal intensity lesions on T2 imaging. IMP-SPECT images of the brain showed diffuse reduction of radioisotope uptake. Many skin rashes that looked like senile hemangioma were observed on his body. Several of those were biopsied, and the diagnosis of intravascular large B-cell lymphoma was made because of malignant B lymphocytes filling the vessel lumens in one of the seven biopsy specimens. CHOP therapy was performed and found to be effective for the neurological disorders such as dementia, paraplegia, and sensory disturbance. Our case suggests that skin biopsy for more than one sample of the skin rashes is very important for the diagnosis of intravascular large B-cell lymphoma. CHOP therapy might be effective in this case because of early diagnosis by skin biopsy.

Intracellular signaling mechanisms leading to synergistic effects of endothelin-1 and stem cell factor on proliferation of cultured human melanocytes. Cross-talk via trans-activation of the tyrosine kinase c-kit receptor.

We previously reported that activation of mitogen-activated protein kinase (MAPK) is involved in the mitogenic stimulation of normal human melanocytes (NHMC) by endothelin-1 (ET-1). In the present study, we determined signaling mechanisms upstream of MAPK activation that are involved in ET-1 stimulation and their synergism with stem cell factor (SCF). Pretreatment of cultured NHMC with ET(B) receptor antagonists, pertussis toxin, a specific phospholipase C inhibitor (), or a protein kinase C inhibitor (calphostine) blocked a transient tyrosine phosphorylation of MAPK induced by ET-1, whereas the addition of a calcium chelator (BAPTA) failed to inhibit that tyrosine phosphorylation of MAPK. Treatment with ET-1 and SCF together synergistically increased DNA synthesis, which was accompanied by synergism for MAPK phosphorylation. The time course of inositol 1,4,5-trisphosphate formation revealed that there is no difference in the level of inositol 1,4,5-trisphosphate stimulated by ET-1 + SCF or by ET-1 alone. Evaluations of the serine phosphorylation of MEK and Raf-1 activity showed a synergistic effect in SCF + ET-1-treated NHMC. Stimulation with SCF + ET-1 induced a more rapid and stronger tyrosyl phosphorylation of proteins corresponding to p52 and p66 Shc than did stimulation with SCF only, and this was accompanied by a stronger association of tyrosine-phosphorylated Shc with Grb2. Interestingly, a more rapid and marked tyrosine phosphorylation of c-kit was also detected in NHMC-treated with SCF + ET-1 than NHMC treated with SCF only. These data indicate that the synergistic cross-talk between SCF and ET-1 signaling is initiated through the pathway of tyrosine phosphorylation of c-kit, which results in the enhanced formation of the Shc-Grb(2) complex which leads in turn to the synergistic activation of the Ras/Raf-1/MEK/MAP kinase loop.

Twisted collagen fibrils in acrocyanosis.

Essential acrocyanosis (EA) present as a dusky discoloration of the hands as the sole symptom without any other abnormal results from laboratory investigation. Previously, the authors have found twisted collagen fibrils (TCF) in the normal skin of an EA patient. This study was intended to evaluate the significance of TCF in EA. Thirteen patients showing dusky discoloration were randomly selected and studied for TCF in normal skin by routine electron microscopy. TCF were found in 10 of 13 patients; 3 patients with only the discoloration (EA), 3 with the mild symptoms which were supposed to be Ehlers-Danlos syndrome (EDS), 1 with definite symptoms of EDS, 1 with Raynaud's disease and 2 with hyperglobulinemia. TCF were the ultrastructural sign for inherited malformation of collagen fibrils. EA was probably elucidated as a vascular disorder in TCF-carrying people. EA could be included in the disease category of EDS but it seems unreasonable to force EA patients into one of the subtypes of EDS. For pathogenesis, the inherited dysfunction in the hypertrophic pericytes of the subpapillary vascular plexus was presumed.

A radicicol-related macrocyclic nonaketide compound, antibiotic LL-Z1640-2, inhibits the JNK/p38 pathways in signal-specific manner.

Macrocyclic nonaketide compounds, radicicol and its two analogues, 87-250904-F1 and LL-Z1640-2, have various biological activities. Here we show that these compounds inhibit signal-dependent transcriptional activation with different specificity with distinct mechanism. Although all three compounds inhibited PMA-induced AP-1 transcriptional activity in cell-based reporter assay, these compounds exhibited differential effects in separate transcriptional reporter assays for NF-kappaB and glucocorticoid receptor. Next we found that one of these compounds, LL-Z1640-2, was a signal-specific inhibitor of the JNK/p38 pathways. In contrast to LL-Z1640-2, radicicol and 87-250904-F1 did not inhibit JNK/p38 activation. Recently, radicicol was reported as an inhibitor of activated-Ras-induced ERK activation. These results indicated that radicicol and LL-Z1640-2 showed distinct specificity to various MAP kinase pathways despite their structural similarity. Furthermore, LL-Z-1640-2 inhibited anisomycin-induced but not TNF-induced JNK/p38 activation, indicating that the inhibition mechanism is signal-specific.

Melanin and melanosome complexes in long standing stable vitiligo--an ultrastructural study.

To investigate the presence of melanin and melanocytes (MC) in stable vitiligo, skin biopsies from five patients with vitiligo lesions of between 1 to 17 years duration were examined under the electron microscope. Areas of the upper dermis and epidermis were explored. There was a significant amount of melanin in a few keratinocytes (KC) grouped in the stratum basale in 1-3 year-old vitiligo lesions. In these KC, the melanosomes were most often aggregated into melanosome complexes (MCo) while the remaining KC were completely devoid of melanin. Solitary MCo were also observed in a few dermal cells in all vitiligo biopsies. All non-keratinocytes were scrutinized in series of 200-300 consecutive sections and were identified according to morphological characteristics. Neither active nor inactive MC, nor MC dendrites were found. These observations show that melanin in non-negligible amounts can be found even in 3 year-old vitiligo epidermis. Since there were no MC detected in the epidermis it implies that the melanosomes can persist in certain KC for some time after the onset of vitiligo.

Elastic fibers in dermis of juvenile elastoma.

To explore the ultrastructure of elastic fibers in juvenile elastoma, three patients (two without osteopoikilosis and one under examination of bones and joints) were studied by routine electron microscopy. In addition to normal elastic fibers, all the patients also exhibited alterations in elastic fibers. The altered ultrastructures showed lucent, homogenous matrix without peripheral microfibrils. The homogenous matrix were seen in various extensions from the small protrusions of the normal elastic fibers to the complete replacement of the entire fibers. Collagen fibrils occasionally showed twisted figures. Normal shapes of dermal glycosaminoglycans were increased in number. It seems likely that the lucent, homogenous matrix without peripheral microfibrils are the characteristic changes of elastic fibers in juvenile elastoma. The alteration could be nevoid in nature.

A nodal gamma/delta T-cell lymphoma with an association of Epstein-Barr virus.

The postthymic gamma/delta T-cell lymphoma is rare, and most occur as extranodal tumors, e.g., in hepatosplenic or cutaneous forms. We here report an unusual nodal case that initially presented as a T-zone lymphoma. The neoplasm recurred as systemic lymphadenopathy 25 months after complete remission with terminal high-grade transformation. Phenotypic analysis showed CD1-, CD2+, CD3+, CD4-, CD5-, CD7+, CD8+, CD10-, CD16-, CD19-, CD20-, CD21-, CD25-, CD56-, CD57-, T-cell receptor (TCR) alpha/beta antigens negative, TCR gamma/delta antigens positive, and an HLA-DR+ phenotype. Cytogenetic studies showed clonal chromosomal translocations involving chromosomes 1, 5, 6, 8, 15, and X in eight of 15 cells; t(X;5;1)(q13;q13;p22) and t(6;15;8)(p22;q26;q13). Genotypic analysis showed the same clone, characterized by the TCR gamma-chain gene rearrangement pattern, to be present in both initial and recurrent tumors. The lymphoma cells were also demonstrated to express the latent membrane protein-1 by immunohistochemistry and EBV-encoded small RNAs by in situ hybridization. Southern blot analysis using the probe of the terminal repeat demonstrated incorporation of multiple copies of EBV in the recurrent tumor. However, the initial lesion, which contained a smaller number of EBV-positive cells, showed no such evidence of clonal proliferation. These data suggest that EBV may be associated with high-grade transformation, although its exact role in lymphomagenesis remains uncertain. The present study also adds to our understanding of the clinicopathologic spectrum of gamma/delta T-cell neoplasia.

Ultrastructure of murine dermis following topical application of the vitamin D3 analogue KH-1060.

The aim of this study, was to observe the effects of KH-1060, a new vitamin D3 analogue, on the dermis of hairless mice by electron microscopy. KH-1060 (0.2 micrograms/ml in isopropanol) or KH-1060 following betamethasone 17-valerate (2 mg/ml in isopropanol) was applied topically to the backs of hairless mice for 4 weeks. KH-1060 increased the number of dermal fibroblasts, the cytoplasm of which was dominated by secretory components. Mast cells contained normal mature granules and degranulated after disintegration. No extrusion of non-disintegrated granules was seen. Collagen fibrils were thickened and increased in number; however the content of type I collagen in the fibrils did not increase. Glycosaminoglycan figures appeared distinct. KH-1060 prevents betamethasone-induced changes in collagen fibrils and glycosaminoglycans, while no prevention was seen for mast cells.

[Dynamic behavior of guinea pig middle ear].

The dynamic behavior of the middle ear was studied in living guinea pigs by using a laser Doppler vibrometer coupled to a compound microscope. Placing glass microbeads 20 microns in diameter on four points of the tympanic membrane and six points of the ossicles, their velocity amplitudes were measured under a constant stimulus of 65 dB SPL. Velocity responses of the four points on the tympanic membrane differed over the frequency range from 0.1 kHz to 3 kHz. At low frequencies, the malleus and incus rotated around an axis running from the malleus head to the incus short process. At middle frequencies, the whole ossicle had a piston-like motion. At high frequencies, the malleus and incus rotated around a vertical axis running through the ossicles, while the stapes had a hinge-like movement.

Ultrastructure of murine epidermis treated with the vitamin D3 analogue KH-1060.

A new highly potent analogue (KH-1060) of vitamin D3 has been recently shown to stimulate the growth and differentiation of keratinocytes. This study was intended to determine the effects of this new analogue on epidermis at the ultrastructural level. KH-1060 was applied topically on the backs of hairless mice for 4 weeks; the skin was then studied by routine electron microscopy. The effects were compared with those of betamethasone-17-valerate and with concomitant treatment of KH-1060 following betamethasone. KH-1060 stimulated normal function of keratinocytes and formed a thick epidermis. The ultrastructure of the thick epidermis represents an enhanced normal process of keratinization and proliferation. Moreover, KH-1060 diminished the atrophogenic effects of betamethasone.

Protein-losing enteropathy in a child with junctional epidermolysis bullosa and pyloric atresia.

We report on a newborn boy with junctional epidermolysis bullosa and pyloric atresia. Blisters were found on his skin at birth, especially in places exposed to pressure, and appeared later on his mucous membranes. Epidermolysis bullosa was confirmed by electron microscopy. Radiography revealed pyloric atresia, and a gastroduodenostomy was carried out at 7 days of age. A connective tissue septum was found between his ventricle and duodenum. The skin changes were mild, and the clinical course was determined by his protein-losing enteropathy. He died at 66 days of age from pseudomonas sepsis.

Lipoid proteinosis.

Lipoid proteinosis (Urbach-Wiethe disease) is a rare, recessively inherited disorder that is characterized by the deposition of hyaline-like material in the skin, oral cavity, and other tissues. It usually appears in infancy with hoarseness. We report a case of lipoid proteinosis in a 10-year-old boy that demonstrates the characteristic clinical, histologic, and ultramicroscopic features of this disease.

Autologous blood transfusion with recombinant human erythropoietin in heart operations.

The effects of recombinant human erythropoietin (rHuEPO) on improving the anemia associated with autologous blood collection before open heart operations and on improving the postoperative anemia were studied. The study was carried out on 18 patients undergoing coronary artery bypass operations; 400 mL of autologous whole blood was taken from each patient 2 weeks before operation and was subsequently used in the operation, and rHuEPO (100 U.kg-1.day-1) was given intravenously for 2 weeks before operation and for 1 week after operation. The group in which iron preparations were also administered intravenously was designated as group I (10 patients), and the group in which rHuEPO was given alone was designated as group II (8 patients). In group III, as a control group, 11 past patients were used in whom 400 mL of autologous whole blood was collected 2 weeks before operation but neither rHuEPO nor iron preparations were given. After autologous blood collections, the hemoglobin levels improved in group I, group II, and group III, in that order, and with significant differences among them. It was shown that rHuEPO was effective in ameliorating the anemia associated with preoperative autologous blood collection, and the effect was further enhanced with intravenous supplementing iron preparations. After operation, the anemia markedly improved while rHuEPO was administered, but the hemoglobin levels decreased rapidly when the administration was terminated. Further studies are needed regarding the use of rHuEPO after operation.

Generalized morphea with blisters. A case report.

A patient suffering from generalized morphea developed blisters in the morpheic plaques on her buttocks. The plaques had an increased concentration of serum aminoterminal propertice of type III procollagen, an echo response and thickened skin on ultrasound scanning, and compact bundles of collagen fibrils with bimodal distribution of the diameters. The blisters appeared as an echo-free band in the subepidermal zone by ultrasound scanning. Electron microscopy revealed blisters in the upper papillary dermis, surrounded by degraded collagen fibrils.