Outbreak of Microsporum audouinii in Munich--the return of infectious fungi in Germany.

After experiencing an unusually high number of Microsporum (M.) audouinii infections at our hospital within only a few weeks, we began to investigate and control an outbreak in Munich, Germany. Main goals of our health management were to treat infected persons, identify extent and form of transmission and to prevent new infections. We analysed data from structured interviews with patients and mycological cultures of swabs taken of patients and investigated involved public facilities. Outbreak management included antifungal treatment of patients, decontamination of affected facilities, the introduction of a temporary kindergarten ban for M. audouinii positive children and the organisation of educational meetings. Between March and August 2011, 16 children and 4 adults were identified with M. audouinii infections. The fungus was brought to Munich by the index patients from a family vacation in Africa and then spread to fellow children in kindergarten and subsequently to their families. All patients were treated successfully and the epidemic was declared ceased after 40 weeks but causing considerable financial damage. Due to travelling and migration, M. audouinii infections will rise in Germany and Europe. Sufficient and sustainable strategies are needed for the management of future outbreaks of highly contagious fungi.

Genital ulcers associated with Epstein-Barr virus infection (ulcus vulvae acutum).

Epstein-Barr virus (EBV) infection may rarely be associated with genital ulcers (ulcus vulvae acutum), a very painful manifestation. The aetiopathogenesis of the disease is not fully understood. We describe here a case of an adolescent virgin with multiple, deep genital ulcers associated with acute infectious mononucleosis. The diagnosis was supported by the clinical symptoms, atypical lymphocytosis, elevated circulating levels of liver enzymes, positive EBV serology, and the detection of EBV in a swab sample and a biopsy specimen by PCR. The virus could not be detected by immunohistochemistry or in situ hybridization. After a short course of methylprednisolone as a supportive treatment, the ulcers healed within one month. No relapse occurred during the 2-year follow-up. Available data relating to the aetiopathogenesis of this condition are reviewed, and we speculate that it may have been caused by percutaneous autoinoculation through cervicovaginal fluid.

[Autoimmune bullous skin disorders]. / Bullöse Autoimmundermatosen.

Autoimmune bullous skin disorders are rare, potentially fatal disorders of skin and mucous membranes which are associated with IgG or IgA autoantibodies against distinct adhesion molecules of the epidermis and dermal epidermal basement membrane zone, respectively. These autoantibodies lead to a loss of skin adhesion which shows up clinically as the formation of blisters or erosions. In pemphigus, loss of adhesion occurs within the epidermis while in the pemphigoids, linear IgA dermatosis, epidermolysis bullosa acquisita and dermatitis herpetiformis, loss of adhesion takes place within or underneath the basement membrane zone. The autoantigens of these disorders are largely identified and characterized. Making the diagnosis of autoimmune bullous skin diseases is based on histology and direct immunofluorescence of perilesional skin and the serological detection of autoantibodides by indirect immunofluorescence and recombinant autoantigens. Therapeutically, systemic treatment with glucocorticoids is combined with immunosuppressive adjuvants which allow for the fast reduction of systemic steroids. A prospective trial in pemphigus showed that adjuvant treatment with azathioprine, mycophenolate mofetil and cyclophosphamide, respectively, led to a significant reduction of the cummulative dose of systemic steroids until complete clinical remission was achieved. In bullous pemphigoid, topical treatment with clobetasol led to complete clinical remissions without major side effects seen when glucocorticoids were applied systemically. Therapeutic depletion of B cells by rituximab as a second line therapy has significantly improved the overall prognosis of pemphigus. Comparable controlled therapeutic trials have not yet been performed in dermatitis herpetiformis and epidermolysis bullosa acquisita.

Targeted immunotherapy with rituximab leads to a transient alteration of the IgG autoantibody profile in pemphigus vulgaris.

In pemphigus vulgaris (PV), IgG autoantibodies against the ectodomain of desmoglein 3 (Dsg3) have been shown to be directly responsible for the loss of keratinocyteadhesion. The aim of the present study was to study the effect of the B cell depleting anti-CD20 monoclonal antibody, rituximab, on the profile of pathogenic IgG against distinct regions of the Dsg3 ectodomain in 22 PV patients who were followed up clinically and serologically by Dsg3 ELISA over 12-24 months. Prior to rituximab, all the 22 PV patients showed IgG against Dsg3 (Dsc3EC1-5). Specifically, 14/22 showed IgG reactivity against the Dsg3EC1 subdomain, 5/22 patients against Dsg3EC2, 7/22 against Dsg3EC3, 11/22 against Dsg3EC4, and 2/22 against Dsg3EC5. Within 6 months after rituximab, all the patients showed significant clinical improvement and reduced IgG against Dsg3 (5/22) and the various subdomains, that is, Dsg3EC1 (7/22), Dsg3EC2 (3/22), Dsg3EC3 (2/22), sg3EC4 (2/22), and Dsg3EC5 (0/22). During the entire observation period, 6/22 PV patients experienced a clinical relapse which was associated with the reappearance of IgG against previously recognized Dsg3 subdomains, particularly against the Dsg3EC1. Thus, in PV, rituximab only temporarily depletes pathogenic B cell responses against distinct subdomains of Dsg3 which reappear upon clinical relapse.

IgA autoantibodies in the pemphigoids and linear IgA bullous dermatosis.

BACKGROUND: Patients with bullous pemphigoid (BP), mucous membrane pemphigoid (MMP) and pemphigoid gestationis (PG) have IgG antibodies against BP180 and BP230, components of the hemidesmosomes. Patients with linear IgA bullous dermatosis (LABD) have IgA autoantibodies against a 97/120-kDa protein which is highly homologous to a shedded fragment of the BP180-ectodomain. OBJECTIVES: The aim of our study was to determine the incidence of IgA autoantibodies directed against BP180/BP230 in the pemphigoids and LABD and to determine the antigenic regions that are targeted by IgA autoantibodies. METHODS: Utilizing baculovirus-expressed recombinant BP180 and BP230 proteins, we performed immunoblot analyses for IgA reactivity of sera from patients with BP (n = 30), MMP (n = 10), PG (n = 6), LABD (n = 6) and from control patients with non-related pruritic dermatoses (n = 8). RESULTS: IgA reactivity against BP180 and/or BP230 was detected in 19/30 of the BP, in 7/10 of the MMP, in 6/6 of the LABD and in 3/6 of the PG sera, respectively, but not in the control group. In all subgroups, the major antigenic site recognized by IgA antibodies was located within the NH(2)-terminus of the BP180-ectodomain, but only a minority of the sera showed also IgA reactivity against the BP180-NC16a-domain. IgA reactivity against the central domain of BP180 was more frequently seen than against its COOH-terminus. IgA against the COOH- and NH(2)-terminus of BP230, respectively, was detected in 6/30 of the BP, 1/10 of the MMP, 1/6 of the LABD and 0/8 control sera. CONCLUSION: IgA reactivity against BP180 and/or BP230 is a common finding in the pemphigoids.

T and B cells target identical regions of the non-collagenous domain 1 of type VII collagen in epidermolysis bullosa acquisita.

Epidermolysis bullosa acquisita (EBA) is a severe immunobullous disease and is caused by IgG against type VII collagen (Col VII) of anchoring fibrils. In this study, utilizing ELISA and immunoblot, 13/15 EBA sera but 0/20 bullous pemphigoid sera and 0/30 healthy control sera showed IgG reactivity with distinct recombinant subregions of the non-collagenous domain 1 (NC1) of Col VII. In two EBA patients, IgG titers against Col VII-NC1 were grossly correlated to clinical disease activity. Moreover, Col VII-reactive T cells were identified in a representative EBA patient which recognized identical subdomains of Col VII-NC1. These findings strongly suggest that (1) the Col VII-NC1 ELISA is a powerful tool for making the diagnosis of EBA, (2) Col VII-specific IgG grossly relates to disease activity and (3) IgG reactivity is associated with T cell recognition of identical subdomains of Col VII-NC1.

Anti-basement membrane zone antibodies in elderly patients with pruritic disorders and diabetes mellitus.

Anti-basement membrane zone (anti-BMZ) antibodies are detectable in a low percentage of elderly subjects without clinical signs of bullous pemphigoid (BP). BP may initially mimic other pruritic dermatoses and may be more common in patients with diabetes mellitus (DM), since DM is frequently associated with pruritic disorders. The aim of the present study was to analyse a possible association of BP and DM and to detect subclinical BP among elderly patients with pruritic dermatoses. Ninety elderly patients (78.6 +/- 4.7 years) treated for dermatologic conditions were divided into four groups: I. DM+/pruritus+, II. DM-/pruritus+, III. DM+/pruritus-, and IV. DM-/pruritus-. Patients' sera were tested by indirect immunofluorescence (IIF) on monkey oesophagus; positive or dubious results were further evaluated by ELISA with human recombinant BP180 and BP230 proteins and purified laminin 5. Positive results were found in 1 of 21 (4.8%) patients in group I, 6/31 (19.3%) patients in group II, 1/18 (5.5%) patients in group III, 3/20 (15%) patients in group IV. In the whole cohort positive anti-BMZ antibodies of linear or basal cell cytoplasmic and membrane pattern were found in 11 cases (12.2%). ELISA was positive in 11/29 (37.9%) tested sera for at least one antigen (BP180, BP230 and laminin 5 ELISA was positive in 7, 5, and 2 sera, respectively). Positive IIF corresponded with positive ELISA in 6/11 (54.5%) cases (ELISA with BP180, BP230, laminin 5 was positive in 5, 3, and 1 serum, respectively). Thus, by IIF, a significant portion of elderly patients had anti-BMZ antibodies and these findings were confirmed by ELISA. There was no statistically significant difference in the presence of anti-BMZ antibodies among the groups I-IV. Thus, the association of anti-BMZ antibodies with age overrules the potential association with DM and/or pruritus.

The skin as a biofactory for systemic secretion of erythropoietin: potential of genetically modified keratinocytes and fibroblasts.

BACKGROUND: The skin is an interesting target tissue for gene therapy applications because of its ready accessibility. One possibility would be to utilize the genetically modified skin as a biofactory secreting a systemically needed product, such as erythropoietin (EPO). METHODS: Keratinocytes (KC) and fibroblasts (FB) were transduced with a retroviral vector encoding human EPO. Gene transfer efficiency was assessed by real-time PCR analysis and flow cytometry of transduced cells. In addition, EPO synthesis and secretion were analysed by quantifying the amount of RNA and secreted protein in both monolayer cultures and skin equivalents (SE). RESULTS: When cultured as a monolayer, EPO-KC synthesized significantly more EPO than EPO-FB, as shown by quantitatively measuring the amount of secreted protein and RNA. This correlated with an increased EPO-vector incorporation in KC compared with FB, demonstrated by determining both the percentage of transduced cells and the average transgene copy number per cell. In addition, in transduced cell cultures enriched to equally high percentages of EPO+ cells, KC showed a higher activity of EPO secretion than FB. Finally, when assembled in a SE, EPO-KC secreted significantly higher amounts of EPO than EPO-FB, although reduced secretory activity of EPO-KC monolayers grown in high calcium concentrations suggested that in stratified epidermis differentiated KC secrete less EPO than non-differentiated KC. CONCLUSION: In summary, while both transduced KC and FB are able to synthesize and secrete human EPO, KC show higher potential in serving as possible target cells for therapeutic substitution with EPO, probably because of improved transduction rates and increased secretory activity.

Recommendations for the use of rituximab (anti-CD20 antibody) in the treatment of autoimmune bullous skin diseases.

Autoimmune bullous skin disorders are induced by autoantibodies against distinct adhesion complexes of the epidermal and dermal-epidermal junction. Since most of these disorders are characterized by a severe, potentially lethal course,they require long-term immunosuppressive treatment to reduce the de novo synthesis of pathogenic autoantibodies by B lymphocytes. Rituximab, a chimeric monoclonal antibody against CD20 on B lymphocytes, has shown promise in several case reports or cohort studies in the treatment of paraneo-plastic pemphigus,refractory cases of pemphigus vulgaris and foliaceus and in other autoimmune bullous disorders. Treatment with rituximab leads to depletion of pathogenic B-cells which may last up to 12 months resulting in a reduction of plasma cells secreting pathogenic autoantibodies. Rituximab is usually administered in an adjuvant setting at a dose of 375 mg/m(2) i.v.in weekly intervals for four consecutive weeks in addition to the standard immunosuppressive treatment. The present consensus statement of German-speaking dermatologists, rheumatologists and oncologists summarizes and evaluates the current evidence for the use and mode of application of rituximab in autoimmune bullous skin disorders.

Clinical response of severe mechanobullous epidermolysis bullosa acquisita to combined treatment with immunoadsorption and rituximab (anti-CD20 monoclonal antibodies).

BACKGROUND: Epidermolysis bullosa acquisita (EBA) is an autoimmune bullous disorder with mucocutaneous involvement, skin fragility, and tendency to scarring. The mechanobullous form of EBA has a chronic relapsing course and is difficult to treat. We describe herein the therapeutic response of 2 patients with recalcitrant mechanobullous EBA to combined treatment with immunoadsorption and rituximab, an anti-CD20 monoclonal antibody that induces depletion of B cells in vivo. OBSERVATIONS: Two patients with mechanobullous EBA received combined treatment with immunoadsorption and rituximab, resulting in an almost complete clinical remission in one patient and stable disease in the other patient. In the patient with complete remission, prolonged B-cell depletion and clinical improvement with disappearance of mucocutaneous erosions paralleled the decline in titers of circulating anti-basement membrane zone autoantibodies. In the other patient, combined treatment with immunoadsorption and rituximab reduced the de novo appearance of blisters but did not lead to significant improvement of gingivitis, despite depleted B cells for 6 months that remained at 5% 12 months after the last administration of rituximab, as well as a reduction in autoantibody titers. CONCLUSION: The patients' response suggests that combined treatment with immunoadsorption and rituximab may be a valuable adjuvant treatment regimen for severe mechanobullous EBA, which is in line with recently observed beneficial effects in inflammatory EBA.

Introducing a novel Autoimmune Bullous Skin Disorder Intensity Score (ABSIS) in pemphigus.

At present, there is no consensus about the clinical criteria that define disease severity of pemphigus. During recent years several scoring systems have been introduced which mainly compare inter-individual differences in disease activity. It thus remains a challenge to reflect the disease activity of individual patients by a standardised scoring system. Due to the remarkable clinical variability of pemphigus, several parameters are needed to reflect phenotypical varieties of this severe autoimmune bullous skin disorder. In view of the evaluation of different therapeutic options a scoring system sensitive enough to reflect gradual changes in disease activity seems more appropriate than a grading system for inter-individual comparison of disease severity. Taking this challenge into account we introduce and discuss a newly developed autoimmune bullous skin disorder intensity score (ABSIS).

Histone deacetylase inhibitors induce apoptosis with minimal viral reactivation in cells infected with Kaposi's sarcoma-associated herpesvirus.

Kaposi's sarcoma-associated herpesvirus (KSHV) latently infects tumor cells in patients with Kaposi's sarcoma and primary effusion lymphoma (PEL). The purpose of this study was to determine whether histone deacetylase inhibitors (HDAI) could induce apoptosis, with minimal viral replication, in cells latently infected with KSHV. Four HDAI (depsipeptide, suberoylanilide hydroxamic acid, MS-275, and trichostatin A) were studied in two PEL B cell lines (BCBL-1, BC-3). As expected, histone hyperacetylation was readily induced in all PEL cells exposed to HDAI. HDAI also triggered KSHV reactivation in a time- and dose-dependent manner. Flow cytometric and transmission electron microscopic studies, however, revealed that reactivation occurred in only a minor percentage (3-14%) of treated cells. Importantly, and in contrast to viral reactivation, HDAI induced apoptotic cell death in a dose-dependent manner in a large percentage (up to 90%) of KSHV-infected cells. In summary, all four HDAI tested induced histone hyperacetylation in all cells, KSHV reactivation in a minority of cells, and apoptotic cell death in a majority of cells latently infected with KSHV. These findings suggest that HDAI may be a therapeutic option for patients with KSHV-mediated diseases by rendering cells infected with KSHV susceptible to apoptosis.

Delayed response of oral pemphigus vulgaris to rituximab treatment.

Rituximab is a monoclonal antibody directed against the CD20 antigen of B cells, which has been developed for the treatment of lymphomas and has been successfully used in the treatment of recalcitrant pemphigus vulgaris. Here, we report on a 26-year-old patient with an 18 month history of pemphigus vulgaris of the oral mucosa where treatment with rituximab led to a delayed but sustained therapeutic response. This case is of interest since most of the previous reports have described a more rapid clinical improvement of refractory pemphigus by rituximab treatment. The delayed clinical response to rituximab of the present case may be explained by the persistence of long-lived plasma cells that continued to produce pathogenic autoantibodies against desmoglein 3.

[Systemic contact eczema against Balsam of Peru]. / Hämatogen-allergisches Kontaktekzem auf Perubalsam.

Balsam of Peru (PB; Myroxylon pereirae) is a natural product derived from resin of a tropical tree (MyroxyIon balsamum (L.) Harms var. pereirae (Royle) Baillon). Because of its antiseptic and aromatic properties PB or PB-components can be found worldwide not only in many health care and cosmetic products, but also in food items and semiluxury food. PB contains a wide variety of potent contact allergens leading to hypersensitivity reactions not only after topical application but also oral uptake. We report a 51-year-old brewer with chronic eczema of the hands who showed delayed-type patch test reactions against PB and fragrance-mix. Oral PB-challenge led to exacerbation of the eczema 5 and in a repeated test 2 days later. We here review this probably quite often overlooked disease and the therapeutic consequences which require profound knowledge about the wide distribution of PB when advising the patient about a PB-restricted diet. In addition, this unusual case report demonstrates that one has to consider marked delayed hypersensitivity reaction when investigating a systemic contact allergy.