Tsutsugamushi disease in Kanagawa Prefecture, Japan: clinical report of two cases and survey of other incidences in 1998.

Tsutsugamushi disease is characterized by the early appearance of a black crust at the bitten area and the subsequent development of macular or macropapular rush on the whole body with high fever. While treatment with tetracycline derivatives and chloramphenicols is effective, delayed diagnosis or inappropriate treatment will lead to fatality. In this report, we describe two typical cases of tsutsugamushi disease and discuss other incidences in Kanagawa Prefecture, Japan, in 1998. One of the present two patients was diagnosed to be a case of the new type by Kawasaki strain of Rickettsia tsutsugamushi, while responsible strain was not identified for the other case. Since the disease is spreading widely even to suburban areas, we emphasize the need to consider the possible diagnosis of tsutsugamushi disease in patients with generalized eruption and high fever.

Molecular events involved in up-regulating human Na+-independent neutral amino acid transporter LAT1 during T-cell activation.

We investigated the regulation of system-L amino acid transporter (LAT1) during T-cell activation. In quiescent T-cells, L-leucine transport is mediated mainly by the system-L amino acid transport system and is increased significantly during T-cell activation by PMA and ionomycin. In quiescent T-cells, the LAT1 protein was heterocomplexed with 4F2 heavy chain (4F2hc) in the plasma membrane. During T-cell activation, the amounts of 4F2hc and LAT1 heterocomplex were significantly elevated compared with those in quiescent T-cells. In addition, by Northern-blot analysis, these increments were found to be due to elevated levels of LAT1 and 4F2hc mRNA. Transient expression of constructs comprising various LAT1 gene promoter fragments, which contained all three of the GC boxes, was sufficient for promoting luciferase expression in Jurkat T-cells, but the promoter of the LAT1 gene did not respond to PMA and ionomycin. Similar observations were observed in the human 4F2hc gene promoter. In nuclear run-on assay, the LAT1 and 4F2hc genes were actively transcribed even in quiescent T-cells, but the low levels of both transcripts were shown to be the result of a block to transcription elongation within the exon 1 intron 1 regions. These findings indicated that a removal of the block to mRNA elongation stimulates the induction of system-L amino acid transporter gene transcripts (LAT1 and 4F2hc) in activated T-cells.

Which is less invasive--distal pancreatectomy or segmental resection?

BACKGROUND: For a pancreatic body tumor, distal pancreatectomy (DP) has been a standard operation. Segmental resection (SR) of the pancreas has been introduced as a less invasive procedure in consideration of preservation of the pancreatic functions and postoperative quality of life. Surgical stress and exocrine and endocrine functions of the residual pancreas were compared between DP and SR. METHODS: Clinical findings including serum levels of C reactive protein (CRP), fasting blood sugar, a 120 min value of the 75 g oral glucose tolerance test, and N-benzol-L-tyrosyl-p-aminobenzoic acid excretion value (a pancreatic exocrine function test) were compared between 47 patients with DP and 10 with SR performed for benign pancreatic diseases. RESULTS: Operation time was longer in SR (356 min) than in DP (272 min; P = 0.0123). Operative blood loss and peri-operative blood transfusion were not different between the two groups. Serum levels of CRP increased after the operation, reaching the peak on postoperative day 2 or 3, and decreased thereafter The peak of serum CRP level was similar between the two groups (13.4+/-1.8 mg/dl in SR and 14.8+/-1.1 mg/dl in DP). Postoperative hospital stay in 10 patients with SR (65 days) was significantly longer than that in 47 with DP (33 days; P = 0.0001). When postoperative complications were compared between the two groups, the incidence of pancreatic fistula was significantly higher in SR (4/10 [40%]) than in DP (4/46 [9%]; P = 0.0103). Abdominal abscess was seen in 30% of SR and in 11% of DP. Postoperative intra-abdominal hemorrhage was seen only in one patient with SR After DP, glucose tolerance deteriorated at short-term in nine of 24 patients examined and at long-term in two of five patients examined. Only one patient showed improvement of glucose intolerance at short-term after the operation. On the other hand, SR showed no alteration of the pancreatic endocrine and exocrine functions in eight patients examined. CONCLUSIONS: SR is superior to DP from the view-point of preservation of the pancreatic functions, although SR has a longer operation time, a longer hospital stay and a higher incidence of postoperative complications.

Association analysis using refined microsatellite markers localizes a susceptibility locus for psoriasis vulgaris within a 111 kb segment telomeric to the HLA-C gene.

The HLA-Cw6 antigen has been associated with psoriasis vulgaris despite racial and ethnic differences. However, it remains unclear whether it is the HLA-Cw6 antigen itself or a closely linked, hitherto unidentified, locus that predisposes to the disease. Here, in order to map the susceptibility locus for psoriasis vulgaris precisely within the HLA class I region, 11 polymorphic microsatellite markers distributed throughout a 1060 kb segment surrounding the HLA-C locus were subjected to association analysis in Japanese psoriasis vulgaris patients. Statistical analyses of the distribution and deviation from Hardy-Weinberg equilibrium of the allelic frequency at each micro-satellite locus revealed that the pathogenic gene for psoriasis vulgaris is located within a reduced interval of 111 kb spanning 89-200 kb telomeric of the HLA-C gene. In addition to three known genes, POU5F1, TCF19 and S, this 111 kb fragment contains four new, expressed genes identified in the course of our genomic sequencing of the entire HLA class I region. Therefore, these seven genes are the potential candidates for susceptibility to psoriasis vulgaris.

Degenerative processes of elastic fibers in sun-protected and sun-exposed skin: immunoelectron microscopic observation of elastin, fibrillin-1, amyloid P component, lysozyme and alpha1-antitrypsin.

Degenerative processes of elastic fibers in sun-protected and sun-exposed skin were analyzed by light and electron microscopic (post-embedding) immunocytochemistry using antisera to elastin, fibrillin-1, amyloid P component, lysozyme and alpha1-antitrypsin. To assess the effect of aging and sun exposure, biopsy specimens of sun-protected skin (back) and severely and moderately sun-exposed skin (face and forearms) were obtained from a young age group (1-27 years), an adult group (31-56 years) and an old aged group (61-100 years). Elastin and fibrillin-1 were the essential components of elastic fibers; elastin being localized in the electron-lucent matrix and fibrillin-1 in the dense microfibrillar strands. Aging and sun exposure provoked degenerative condensed spots, which represented widened dense microfibrillar strands, in the matrix of altered elastic fibers in the reticular dermis. Amyloid P component was first deposited on the peripheral microfibrils, and then in the intermediate density zone of the spots. Lysozyme was observed in both the electron-dense core and in the intermediate density zone of the spots. Deposition of lysozyme correlated with basophilic degeneration of the elastic fibers. In the severely photodamaged facial skin of the aged, which showed solar elastosis in the upper reticular dermis, fibrillin-1 immunoreactivity was lost from the thickened and vacuolated elastic fibers that lacked condensed spots, and amyloid P component, lysozyme and alpha1-antitrypsin were diffusely deposited in the elastin-positive matrix. It seemed that amyloid P component deposition on the elastic fibers was closely associated with aging, while immunoreactive lysozyme was related to sun exposure. Vertically oriented, thin, elastic (oxytalan) fibers in the papillary dermis tended to decrease with age, with frequent deposition of amyloid P component but no lysozyme. In the facial skin of the aged, dermal papillae disappeared, with the formation of degenerative elastic globules beneath the dermal-epidermal junction. The present study demonstrated an intimate relationship between ultrastructural alterations and deposition of exogenous substances on the degenerative elastic fibers in sun-exposed and/or aged skin.

The quantitative and qualitative defect of CD4+ CD45RO+ memory-type T cells are involved in the abnormality of TH1 immunity in atopic dermatitis patients.

Peripheral blood mononuclear cells (PBMCs) obtained from atopic dermatitis (AD) patients produced low levels of IFN-gamma in response to Dermatophagoides farinae antigen (Der f Ag) plus IL-2 or OKT3 MoAb in contrast with PBMCs obtained from healthy donors. The reduced IFN-gamma production in AD patients' T cells appeared to be derived from the defect of CD4+ T cells but not CD8+ T cells. Indeed, from the cytoplasmic staining analysis of cytokines, it was demonstrated that the frequency of IFN-gamma producing CD4+ T cells (TH1 cells) in AD patients was markedly lower than that of healthy donors. From the phenotypic analysis using flow cytometry, it was also found that the number of CD4+ CD45RO+ memory type T cells was significantly reduced in AD patients compared with that of healthy donors. In addition to quantitative defect of memory type CD4+ T cells, functional defect of CD4+ CD45RO+ memory type T cells was also demonstrated in AD patients. Enriched CD4+ CD45RO+ T cells obtained from AD patients, who exhibited greatly reduced delayed-type hypersensitivity (DTH) response in tuberculin test, showed no significant TH1 immunity in terms of IFN-gamma production by stimulation with OKT3 MoAb or purified protein derivative (PPD). Thus, the immunological abnormality of TH1 immunity in AD patients appeared to be induced in concomitant with both the quantitative and qualitative defect of memory type CD4+ T cells.

Treatments of generalized pustular psoriasis: a multicenter study in Japan.

This study analyzed data from treatments of 385 cases of generalized pustular psoriasis (GPP) from 325 hospitals in Japan. Retinoid treatment was effective in 84.1% of patients, methotrexate in 76.2%, cyclosporine in 71.2%, oral PUVA therapy in 45.7%, and tonsillectomy in 16.7%. Short-term therapy with systemic corticosteroid for GPP during only the phase with severe systemic clinical findings may be also effective (75.4%). However, these treatments for GPP each differed in clinical effects, prognosis, and side effects. These findings may be useful in creating guidelines for treatment of generalized pustular psoriasis. Further studies based on these specific clinical effects are necessary.

HLA-A33 and -B44 and susceptibility to postherpetic neuralgia (PHN).

HLA class I and class II alleles of 32 Japanese patients with postherpetic neuralgia (PHN) and 136 healthy controls were analyzed by serological (class I) and DNA (class II) typing for any significance in the susceptibility to varicella-zoster virus (VZV). We recognized positive associations of the development of PHN with the HLA class I antigens HLA-A33 and -B44, and the HLA-A33-B44 haplotype. This haplotype is tightly linked to DRB1*1302 in a Japanese healthy population. However, no significant association between PHN and HLA class II alleles was observed with no linkage of the HLA haplotype HLA-A33-B44 to HLA-DRB1*1302 in the patients with PHN. These findings suggest that HLA class I gene may genetically control the immune response against VZV in the pathogenesis of PHN.

Cyclosporin in psoriasis: continuous monotherapy versus intermittent long-term therapy.

Using two methods (continuous monotherapy and intermittent therapy) for the treatment of psoriasis with cyclosporine, we observed the clinical efficacy and adverse reactions of each treatment method for more than 36 months to evaluate the clinical usefulness of both methods. Thirty-seven cases were analyzed and the following results were obtained: 1) The PASI score evaluated at each visit was maintained between 5 and 10 by both treatment methods and the improvement rate was more than 70%, while there was no difference in the daily dose between the two treatment methods; 2) The period required to achieve remission tended to be prolonged by intermittent therapy, while no change was observed with continuous monotherapy; 3) The period up to relapse tended to become shorter with both treatment methods but this tendency was more marked with intermittent therapy; 4) E-PAP(evaluation for prognosis with averaged PASI) was lower in the continuous monotherapy group and the patients were more satisfied; 5) The incidence of adverse reactions was similar to that reported in previous studies, with no difference between the two treatment methods in this regard; 6) A significant increase in BUN levels was observed in elderly patients; 7) There were only three cases in which the drug was discontinued due to exacerbation and adverse reactions. Based on the above findings, continuous monotherapy seems to be of greater clinical usefulness than intermittent therapy.

Follow-up of clinical efficacy of iontophoresis therapy for postherpetic neuralgia (PHN).

A great variety of therapies have been attempted for PHN, including pharmacotherapy and physical therapy. However, there has been no decisive treatment, and reports of the clinical efficacy of all available therapies have been rather controversial. Almost all studies conducted so far have looked only at short-term therapeutic efficacy, and only a few investigators have conducted long-term observations or studies on long-term outcome. We followed up the clinical efficacy of iontophoresis therapy using lidocaine and methylprednisolone in 197 PHN patients. Monitoring conducted for an average of 4 years after completion of the treatment showed that pain remained unchanged or improved compared to pain observed upon completion of the treatment in 90.4% of patients. Although 42.6% of patients were still continuing some treatment, 90.9% were found to be able to take care of themselves. Findings obtained were reviewed and discussed from various viewpoints. Our findings showed that iontophoresis therapy is not only effective at the end of the treatment, but its efficacy is maintained over a long period of time, indicating that it is clinically very useful for the treatment of PHN.

HLA class I and II alleles and susceptibility to generalized pustular psoriasis: significant associations with HLA-Cw1 and HLA-DQB1*0303.

HLA alleles in generalized pustular psoriasis (GPP) were investigated to clarify the etiology and/or pathogenesis of this disease. Not only serological typing of HLA class I and II antigens but also genotyping of HLA class II alleles were carried out in twenty-six unrelated Japanese patients with GPP. These patients were classified according to their history of psoriasis vulgaris (PV). Serological typing revealed a significantly high incidence of HLA-Cw1 (Pc = 0.04) in the patients as compared with Japanese healthy controls. The frequency of HLA-B46 was particularly high in the patients with GPP and a previous history of PV. Genotyping of HLA class II alleles showed a highly significant increase in HLA-DQB1*0303 (Pc = 0.01) in the patients vs. the healthy controls. In particular, HLA-DQB1*0303 was significantly more frequent in the patients with no prior history of PV than in those with a history of PV. Analysis on linkage disequilibrium showed remarkably different patterns for HLA class II haplotypes between the patients and the healthy controls. Based on the comparative analysis among the amino acid sequences of the beta 1-domain of the HLA-DQB1*03 alleles, proline at residue 55 was suggested to be important as a common amino acid for determination of the susceptibility to GPP. These results revealed not only an association between the etiology and/or pathogenesis of GPP and HLA, but also different mechanisms of the immune response between the patients with GPP and PV.

Interaction of cultured keratinocytes and fibroblasts from human psoriatic and normal skin in immunodeficient mice.

Clarification of the pathogenesis of psoriasis requires separate studies of the epidermis, dermis, and inflammatory cells. We previously subcutaneously transplanted a mixture of cultured human keratinocytes and fibroblasts into mice to develop cysts with human skin structures. Using this method, we separately cultured psoriatic and normal keratinocytes and fibroblasts. Four mixtures were prepared: normal keratinocytes and normal fibroblasts (NK/NF); psoriatic keratinocytes and normal fibroblasts (PK/NF); normal keratinocytes and psoriatic fibroblasts (NK/PF); and psoriatic keratinocytes and psoriatic fibroblasts (PK/PF). Each mixture was transplanted into immunodeficient mice to observe formation of cysts and histological changes. The cysts varied in structure depending on the mixture, which suggests that psoriatic keratinocytes and fibroblasts had some abnormalities. Psoriatic fibroblasts may be partially responsible for thickening of the epidermis. Cell differentiation might have been accelerated in psoriatic keratinocytes after transplantation, resulting in the loss of epidermis structures.

Histological and immunocytochemical studies of human psoriatic lesions transplanted onto SCID mice.

To investigate the pathology of psoriasis, we developed an animal model for this disease using severe combined immunodeficiency (SCID) mice. These mice possess neither B nor T Lymphocytes so that both cellular and humoral immunities are impaired. For the in vivo study of psoriasis, human psoriatic skin was grafted on SCID mice. Long-term morphological and immunohistochemical changes in the grafted skin ware examined for up to 22 weeks after transplantation. The human skin graft were generally well maintained during this period, but the histological and immunohistochemical findings characteristic of psoriasis, except for acanthosis and hyperkeratosis, gradually disappeared as lymphocytic infiltration of the psoriatic lesions declined.

[Granulomatous slack skin]. / "Granulomatous slack skin".

A 48-year-old woman developed granulomatous slack skin (GSS), one of the special forms of cutaneous T-cell lymphoma. The lesional skin slack with an atrophic, poikilodermic surface and granulomatous induration. Histopathological findings included epidermotropism, diffuse lymphoid cell infiltration and foreign body giant cells as well as granulomatous reactions from superficial to deep dermis, including part the subcutis. The diagnosis was established by positive results for rearrangement of the T-cell receptor gene. The therapeutic possibilities, especially with corticosteroids and monitoring the disease course by following serum angiotensin converting enzyme activity are discussed.

Epidermal N-acetylation of p-aminobenzoyl glutamic acid: difference in response to ultraviolet B irradiation.

Arylamine N-acetyltransferases (EC 2.3.1.5) are conjugating drug-metabolizing enzymes and consist of two major isozymes, NAT1 and NAT2. As they have different substrate specificity and expression of polymorphism, distribution of the isozymes may be detected by investigating acetylation. p-Aminobenzoyl glutamic acid (pABG), one of the specific substrates for NAT1 in human pro-monocytic cell-line, was metabolized through acetylation by 9000 x g supernatant fraction from human epidermal keratinocytes and the effect of ultraviolet B (UVB) irradiation on the acetylation was also studied. Forty-eight hours after irradiation of UVB (200 J/m2), the activity was not increased (114 +/- 8.3%, n = 3), while increase in N-acetylating capacity for 2-aminofluorene (substrate for NAT1 and NAT2) amounted to 201 +/- 16% (n = 3). These results suggest that there are at least two isozymes for N-acetylation in the human epidermic and NAT2 may be affected by UVB irradiation.

New method for determining prognosis of patients with psoriasis (E-PAP).

We developed a new method for evaluating clinical symptoms of psoriasis during the observation period, by adding a parameter of time (the number of days) to the psoriasis area and severity index (PASI). This method was named the evaluation for prognosis with averaged PASI (E-PAP). Using this method, we assessed 14 cases to determine the following items: (1) clinical symptoms during the observation period; (2) clinical effects of treatments; (3) patient's satisfaction with treatments; and (4) necessity for additional and/or alternate treatments. We evaluated the usefulness of E-PAP in determining the prognosis of patients with psoriasis by comparing the uninterrupted monotherapy and intermittent therapy with cyclosporin A (Cys A). Although there were no differences in Cys A dosages after remission as well as adverse reactions between the two groups, the E-PAP value was significantly different between them. These results suggest that this method may be useful for determining the prognosis of patients with psoriasis.

Molecular genetic analysis of HLA class II alleles in Japanese patients with melanoma.

Distribution of HLA-DQA, -DQB and -DPB alleles in ninety-six Japanese patients with melanoma was analyzed using the polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) method, and the association between clinical parameters and the presence of certain HLA class II alleles investigated. The frequency of HLA-DQB1*0302 was increased, while those of DQA1*0101(04), -DQA1*0401 and DRB1*0802 were decreased in melanoma patients compared with controls. Moreover, the frequency of HLA-DQA1*0103 in patients with acral lentiginous melanoma was increased compared with controls. However, none of these HLA class II alleles showed significant positive or negative associations after correction of the P value. In addition, there was no correlation between these antigens and clinical parameters. These results indicate that HLA class II alleles may not contribute to a strong susceptibility to melanoma in the Japanese.

PUVA treatment of human keratinocytes suppresses the surface expression of intercellular adhesion molecule 1 (ICAM-1) and inhibits adherence of PHA-blasts in vitro.

To determine the basis of the therapeutic efficacy of Psoralens and UVA (PUVA) in inflammatory skin diseases, the effect of PUVA on the expression of cell adhesion molecules of keratinocytes was investigated in vitro. The addition of IFN-gamma and TNF-alpha to human keratinocytes in culture up-regulated the expression of ICAM-1 and HLA-DR on the cell surface. The cultured human keratinocytes were exposed to UVA light in the presence of 8-methoxypsoralen (PUVA). The ICAM-1 and HLA-DR surface molecules were stained by monoclonal antibodies, and the intensity of the resultant fluorescence was analyzed by FACS-can. PUVA treatment suppressed the expression of these cell surface molecules, with increasing UVA fluence. Moreover, PHA-blasts failed to adhere to PUVA treated keratinocytes. When keratinocytes were treated with PUVA prior to the addition of IFN-gamma and TNF-alpha, ICAM-1 and HLA-DR expression was suppressed. These results suggest that one of the therapeutic mechanisms of PUVA in inflammatory skin diseases is by inhibition of the adhesion of activated lymphocytes to keratinocytes due to suppression of cell surface molecules. It also suggests that PUVA may be useful as maintenance therapy for inflammatory skin diseases.

Acetylator phenotype in patients with p-phenylenediamine allergy.

OBJECTIVE: p-Phenylenediamine (PPD) has been widely distributed as hair dye ingredient and may be responsible for contact dermatitis. Since not all the subjects exposed to PPD react to the substance, we tested a possible predisposing factor of cutaneous drug metabolism. METHODS: Eighty-five patients were selected on the basis of their patch test result for PPD. The acetylator status of patients was estimated using HPLC analysis of urinary caffeine metabolites. RESULTS: Among patients with a negative result for PPD, there were three groups, i.e. fast, intermediate and slow acetylators, just as in the healthy population. However, we could not find any rapid acetylator in the PPD-sensitive patient group, and slow acetylators were more often encountered in this group (p < 0.05). CONCLUSION: The acetylator phenotype might be a good marker for the cutaneous sensitivity to PPD.

HLA class I antigens in Japanese patients with melanoma.

In this study, we analyzed the frequencies of human leukocyte antigen (HLA) class I alleles in 110 Japanese patients with melanoma using serological methods, and compared such frequencies with clinical parameters. As expected, frequencies of HLA allele distribution in patients with melanoma reflected the frequencies observed in the normal Japanese population. Because these are different from populations belonging to other races (e.g., white), it followed that the HLA allele distribution in melanoma patients varies among different races. This differences may have significant implications for T-cell-mediated, HLA-restricted therapeutic modalities. No significant associations between HLA and clinical parameters were noted in this study. This report may help design future clinical trials involving therapeutic approaches based on HLA-restricted mechanisms.