NEVUS FLAMMEUS ASSOCIATED WITH DYSPLASTIC NEVI AND LICHEN SCLEROSUS: THE FIRST REPORT IN THE MEDICAL LITERATURE.

We describe a rare case of a 28 year-old male patient presenting with pruritus and increased sensitivity of the prepuce accompanied by erythematous confluent papules, unilateral nevus flammeus (NF) along almost the whole length of the right lower limb and two dysplastic nevi (DN), one located on the mid back and the other on the medial border of the right fifth toe, the latter coinciding with the NF. A biopsy of the prepuce revealed lichen sclerosus et atrophicus (LSA). Mental health assessment revealed anxiety disorder and predisposition to panic attacks. Several clinical, paraclinical and histopathological examinations were undertaken to evaluate potential underlying factors for such unusual combination of findings. Both dysplastic nevi were surgically removed. A topical calcineurin inhibitor treatment of the LSA was prescribed. For the first time in medical literature, we report an extremely rare association of NF, DN (including DN over NF) and LSA, and we are focusing our discussion on a potentially common genetic background which could explain this unusual combination of different diseases, which could in turn be caused by different mutations in common genes and/or different genes with close location in the genome.

The "mystery" of cutaneous sarcoidosis: facts and controversies.

The reason why the cutaneous form of sarcoidosis is well known in the literature is because of its spectrum of manifestations granting it the fame of a Great Imitator. The mystery shrouding the pathogenesis of this rare cutaneous disease is still there (in spite of the fundamental progress of the various diagnostic methods in current day medicine). The production of the morphological substrate - the epithelioid cell granuloma - which is considered to be characteristic of skin sarcoidosis, could, however, also be the end result of a reaction to i) various specific infectious agents such as Leishmaniasis cutis, coccidioidomycosis, etc., ii) certain residual bacterial or other mycobacterial antigens which, at the moment of setting the diagnosis are - by definition - non-infectious but still immunogenic, as well as iii) different tumor antigens in lesional tissue or other location. Often, differentiating between sarcodiosis and a sarcoid-like reaction, based on the updated criteria for cutaneous sarcoidosis, is problematic to downright impossible. A future characterization of the genetic signature of the two conditions, as well as the implementation of additional mandatory panels for i) the identification of certain infectious or ii) non-infectious but immunogenic and iii) tumor antigens in the epithelioid cell granuloma (or in another location in the organism), could be a considerable contribution to the process of differentiating between the two above-mentioned conditions. This will create conditions for greater accuracy when setting the subsequent therapeutic approaches.

Macrophages and dendritic cells in the development of liver injury leading to liver failure.

Liver failure (LF) continues to be a serious problem due to different underlying disorders. Not only hepatocytes but Kupffer cells (KCs) and dendritic cells (DCs) are of importance in this instance. We wanted to investigate the possible role of KCs and liver DCs in the development of liver injury in patients with liver failure. Liver specimens from 23 patients who died after liver failure were examined for the presence and distribution of CD68-positive KCs and CD83-positive DCs by immunohistochemistry. The distribution of the CD83-positive DC in the sinusoidal and the periportal spaces was not even. While 39.1% of patients had a high sinusoidal density of CD83-positive cells, 60.9% demonstrated a high density of CD83-positive cells in the periportal tract. The number of CD83-positive DCs in periportal tracts in patients with advanced liver fibrosis (n=5) were high, while those with mild liver fibrosis (n=18) had low numbers of mature dendritic cells (χ2=4.107; p=0.043). In addition, all patients with intensive fibrosis had low counts of CD68-positive KC’s in portal tracts vs patients with mild fibrosis of which 67% had high counts (χ2=6.97; p=0.008). In seven of the patients with moderate steatosis (87.5%) low numbers of CD68-positive KCs were found in sinusoids, in contrast to those with severe steatosis, where 12 patients (80%) had high KC counts (χ2=13.4; p less than 0.001). The distribution and number of CD68-positive KC and CD83-positive DC reflect the progression of liver fibrosis leading to liver failure.

[Dermatofibromyxoma of the inguinal fold mimicking accessory mammilla: surgical approach].

Dermatofibromyxoma is a rare benign tumor which most often surgically removed and requires consideration of a number of differential diagnoses, in order to confirm its histogenesis. We present a rare case of a female patient with tumour formation in the inguinal region, with clinical manifestation and characteristics similar to those of accessory mammilla, which was surgically excised and histologically established as dermatofibromyxoma.

Angiomyolipoma of the helix without signs of systemic involvement: successful surgical approach.

Cutaneous angiomyolipoma (AMP) of the ear is an extremely rare benign mesenchymal tumour. Angiomyolipomas are the most common benign tumour of the kidney and could be associated in 20% of the cases with the tuberous sclerosis complex (TBC), in which condition, most of the patients have several angiomyolipomas affecting both of the kidneys. We report the rare case of a 66-year-old female who had an asymptomatic, solitary, nodule on the helix of the right ear for several years, which was histologically assessed as angiomyolipoma. There were no clinical signs of the tuberous sclerosis complex (TBC) or renal AML. A surgical excision was performed with an excellent therapeutic result. In contrast to renal AMLs or PEComas, which are often invasive and may involve regional nodes, cutaneous AMLs are solitary, non-invasive, and not associated with tuberous sclerosis, and are curable by simple elliptical excision.

Wrong melanoma thickness measurement: check it or leave it?

Cutaneous malignant melanoma (CMM) is one of the most aggressive forms of skin cancer, accounting for about 90% of deaths from cutaneous neoplasms, and its incidence has increased significantly in recent years. According to the 2012 European criteria for diagnosis and treatment of malignant melanoma, diagnosis should be based on the combination of clinical features, dermoscopic data and histological examination, preferably after excisional biopsy. Tumour thickness and other parameters for local staging according to the AJCC classification should be included in the pathology report. Although many factors influence the prognosis and course of the disease, it has been established in a number of studies that tumour thickness is the most important parameter. Therapy of malignant melanoma in its initial stages mostly consists of wide local excision with 1 to 2 cm margins, and sentinel lymph node biopsy that is usually performed in cases of tumours with a thickness greater than 1 mm. We present the case of a 58-year-old Bulgarian male with cutaneous superficial spreading malignant melanoma, in which, after complete excision, histological examination established an inaccurate tumour thickness (0.7 mm), with consequent inadequate staging and further management. After reassessment of the results in another institution (as well as their confirmation by two additional independent histopathology laboratories in our country – 1.92 mm), in the National Oncological Hospital where the patient was initially evaluated, sentinel lymph node biopsy was not performed, contrary to the generally accepted European and World standards. With the present case we raise some current issues regarding diagnosis and therapy of Bulgarian patients (not only in the case presented) with malignant melanoma in the 21st century, and discuss the urgent need for external quality control procedures and standardization of the histopathologic reporting, which is of paramount importance in the staging and subsequent management of these patients.

Cellular localization of NGF and NGF receptors in aged human thymus.

Recent evidence indicates that some thymic cells of developing and adult laboratory animals express the neurotrophin NGF and its low-affinity p75NTR and high-affinity TrkA receptor. Less is known as to whether the thymus of adult and aged humans express these markers. We hypothesize that the presence and distribution of immunopositive cells for NGF and NGF receptors undergo some alterations during the involution of human thymus. Specimens from normal thymuses of old individuals were obtained from autopsy and surgery cases, and examined immunocytochemically at the light and transmission electron microscopic level. The immunoreactivity of NGF, p75NTR, TrkA and cytokeratin was found in the epithelial thymocyte microenvironment. Our results provide the first ultrastructural evidence for NGF/receptor immunocytochemical localization in human thymus. They suggest a possible immunotrophic/immunoregulatory role of the NGF-p75NTR-TrkA system for T-cell development in human thymus during senile involution.

Alkaloids from Isopyrum thalictroides L.

Three new bisbenzylisoquinoline alkaloids, isopyruthaldine, isopythaldine and isothalmidine, containing new type of bridges were isolated from roots and rhizomes of Isopyrum thalictroides. The known isoquinoline alkaloids, reticuline, isocorydine. columbamine and palmatine, obtained from the aerial parts, are new for the genus Isopyrum. All structures were elucidated by spectroscopic analysis.

Phytochemical study and cytotoxic activity of alkaloids from Uvaria chamae P. Beauv.

Phytochemical study of leaves of Uvaria chamae resulted in the isolation for the first time for the genus Uvaria of benzylisoquinoline alkaloids (+)-armepavine (1) and racem. O,O-dimethylcoclaurine (2). The aporphines nornantenine (3), nantenine (4) and corydine (7) are new for the species. The alkaloids were found to express cytotoxic activity against L 929 transformed cells. The highest activity was shown by 1, 3, and 5. At a concentration corresponding to their IC50 against L929 cells, they were nontoxic against mouse thymocytes.

IMMUNOSUPPRESSION AND RECOVERY OF DRUG-IMPAIRED HOST RESISTANCE AGAINST CANDIDA ALBICANS INFECTION BY OXOGLAUCINE.

The immunosuppressive action of aporphinoid alkaloid oxoglaucine was studied in experimental Candida albicans (C. albicans) infection in mice. The alkaloid augmented host resistance to pathogen applied to mice (6-8 weeks of age) at a low dose of 2 mg kg(-1)in 3 days and impaired it at a high dose of 10 mg kg(-1). The suppressive activity observed under the latter schedule correlated with the inhibited proliferative response of splenic cells to mitogens and with decreased popliteal lymph node (PLN) reaction to C. albicans. Treatment of mice with oxoglaucine (at the age of 5 days) at a dose of 5 mg kg(-1)in 3 consecutive days increased the susceptibility to Candida inoculation at the age of 6 weeks. Delayed type hypersensitivity (DTH) response to C. albicans was enhanced after pretreatment of adult mice and was suppressed after administration to newborn mice. Long-time treatment (10 days) with oxoglaucine, cyclophoshamide or prednisolone at a dose of 10 mg kg(-1)increased the rate of mortality of Candida -infected mice. Combined pretreatment of mice with cyclophosphamide or prednisolone (5 days at a dose of 5 mg kg(-1)) followed by oxoglaucine (5 days at a dose of 5 mg kg(-1)), prolonged the survival of infected mice. 2000 Academic Press@p$hr Copyright 2000 Academic Press.

Immunosuppression and recovery of drug-impaired host resistance against Candida albicans infection by oxoglaucine.

The immunosuppressive action of aporphinoid alkaloid oxoglaucine was studied in experimental Candida albicans (C. albicans) infection in mice. The alkaloid augmented host resistance to pathogen applied to mice (6-8 weeks of age) at a low dose of 2 mg kg(-1) in 3 days and impaired it at a high dose of 10 mg kg(-1). The suppressive activity observed under the latter schedule correlated with the inhibited proliferative response of splenic cells to mitogens and with decreased popliteal lymph node (PLN) reaction to C. albicans. Treatment of mice with oxoglaucine (at the age of 5 days) at a dose of 5 mg kg(-1) in 3 consecutive days increased the susceptibility to Candida inoculation at the age of 6 weeks. Delayed type hypersensitivity (DTH) response to C. albicans was enhanced after pretreatment of adult mice and was suppressed after administration to newborn mice. Long-time treatment (10 days) with oxoglaucine, cyclophoshamide or prednisolone at a dose of 10 mg kg(-1) increased the rate of mortality of Candida-infected mice. Combined pretreatment of mice with cyclophosphamide or prednisolone (5 days at a dose of 5 mg kg(-1)) followed by oxoglaucine (5 days at a dose of 5 mg kg(-1)), prolonged the survival of infected mice.

Influence of berberine on T-cell mediated immunity.

The protoberberine alkaloid berberine is isolated as a main alkaloid from the roots and bark of Berberis vulgaris. Berberine strongly inhibited in vitro the proliferative response of mouse spleen cells to T-dependent mitogens concanavalin A (Con A) and phytochemagglutinin (PHA). Spleen cells obtained from berberine-treated mice (10 mg/kg/3 days) expressed enhanced proliferative response to both mitogens. Berberine was applied to mice at different intervals before or after the induction of adjuvant arthritis (AIA) and Candida albicans (C. albicans) infection. The application of the alkaloid to new born mice (5 days after birth at a dose of 5 mg/kg/3 days) did not change the course of AIA and C. albicans infection. Its application at three 10 day intervals (5 mg/kg), starting from the 5 day after birth increased the joint inflammation in AIA. The host resistance to C. albicans infection was not affected, while the delayed type hypersensitivity (DTH)-reaction against the pathogen was enhanced. The alkaloid inhibited the development of AIA when applied after its onset (10 mg/kg from day +3 to +12 day). Berberine treatment during the ongoing infection did not influence its outcome (from +2 to +10 day).

Complement modulatory activity of bisbenzylisoquinoline alkaloids isolated from Isopyrum thalictroides--I. Influence on classical pathway in human serum.

Eleven bisbenzylisoquinoline alkaloids (BBI) were isolated from the plant Isopyrum thalictroides (L.). Treatment of normal human serum (NHS) with BBI resulted in a diminution of the haemolytic activity of the classical pathway (CP). The mode of action of the main alkaloids isopyruthaline (It1), fangchinoline (It2) and isotalictrine (It3) on CP activation was investigated in vitro. The inhibition was time- and temperature-related and for Itl and It3 depended on the concentration of Ca2+ and Mg2+ ions. It was established that the substances reduced C1 haemolytic activity. It2 and It3 enhanced the complement consumption caused by heat aggregated human IgG (HAGG). The BBI prevented the formation of C3 convertase of the classical pathway. The loss of haemolytic activity was partially restored by the addition of C142 reagent (zymosan-treated guinea pig serum) to alkaloids-treated NHS. The addition of the late components C3-9 (EDTA-treated rat sera) recovered to some extent the haemolytic activity of It1-treated NHS, but not of It2- and It3-treated NHS.

Complement modulatory activity of bisbenzylisoquinoline alkaloids isolated from Isopyrum thalictroides--II. Influence on C3-9 reactions in vitro and antiinflammatory effect in vivo.

The main alkaloids isopyruthaline (It1), fangchinoline (It2) and isothalictrine (It3), isolated from Isopyrum thalictroides (L.) were investigated in complement-mediated reactions. The alkaloids influenced the alternative pathway (AP) activity in normal human serum (NHS). They enhanced the inhibitory action of complement activators--carrageenan (Car), zymosan (Zy), hydrogen peroxide (HP) and high temperature via classical pathway (CP) in NHS. Substances strongly potentiated the action of zymosan and cobra venom (CV) in guinea pig serum (GPS). It was established that they could provoke C3 conversion in NHS and mouse sera (MS). The antiinflammatory properties of the alkaloids were evaluated in mouse paw oedema induced by CV, Zy and histamine (His). Isopyruthaline and isothalictrine suppressed paw swelling in CV- and Zy-oedema. They were applied in Zy-induced multiple organ dysfunction syndrome (MODS) in mice. The alkaloids inhibited the increase of the serum complement activity provoked by the injection of zymosan. Itl lowered the mortality rate of mice with MODS if its application proceeded Zy. An increase of the number of mice without tissue injury was established after treatment with It1 and It3.

Glaucine analogues as inhibitors of mouse splenocyte activity.

The inhibitory effect of 15 semi-synthetic analogues of glaucine (1) on the lipopolysaccharide (LPS)-induced and the concanavalin A (Con A)-induced proliferation of mouse splenocytes was compared in vitro. Isoboldine (3), bracteoline (4) and dehydroglaucine (9) showed a significantly higher potency to suppress LPS-induced proliferation than 1, while 7-hydroxy-4-methylglaucine (8), 7-formyldehydroglaucine (11), 7-acetyldehydroglaucine (13), 7-benzoyldehydroglaucine (14), oxoglaucine (15) and glaucine-quinol (16) were less inhibitory. Compounds 3, 4, boldine (5), 15 and 16 surpassed significantly the inhibition expressed by 1 on Con A-induced proliferative response. The effect was equal to the inhibition determined for mitomycin C (Mit C) with both mitogens. In contrast to all others analogues, thaliporphine (2) stimulated splenocyte proliferation in both assays. Antibody response against sheep red blood cells (SRBC) was lowered most strongly by cataline (6), 7-methyldehydroglaucine (10) and 16.

Phytochemical study and antiinflammatory properties of Lobelia laxiflora L.

Three new piperidine alkaloids were isolated from stems, leaves and flowers of Lobelia laxiflora L. (Campanulaceae). The structures of racem. cis-8,10-diethyl-3,4-dehydrolobelidiol (1), racem. trans-8-ethyl-10-phenyl-3,4-dehydrolobelidiol (2) and racem. cis-8-ethyl-10-phenyl-3, 4-dehydrolobelidiol (3) were established by spectral analyses. The residues obtained from the ethanol extracts from stems (S), leaves (L), and flowers (F) were applied in carrageenan (Car)- and cobra venom (CV)-induced acute inflammation in mice. A suppression of paw edema formation at a dose of 100 mg kg-1 was established. In this study the antiinflammatory potential of Lobelia l. was regarded in connection with the complement system. The sequential activation and assembly into functional units of complement components can proceed via two different pathways, named classical (CP) and alternative (AP). The ability of the residues, nonalkaloid fractions, alkaloid fractions and the three alkaloids at a concentration from 0.125 to 1.0 mg ml-1 to inhibit complement activation and thus to prevent inflammatory process was estimated in vitro in human serum via both pathways. All of them inhibited complement activity with a predominant action on CP.

Immunopharmacological activity of aporphinoid alkaloid oxoglaucine.

The ability of aporphinoid alkaloid oxoglaucine to influence T- and B-cell immune response was studied in mice models. The substance inhibited in vitro mitogen-induced lymphocyte proliferation and suppressed antibody response to sheep red blood cells (SRBC) and lipopolysaccharide (LPS) in vivo effectively. The action depended on the relative timing of antigen and oxoglaucine administration. The substance manifested stimulatory effect in popliteal lymph node (PLN) reaction and LPS-induced B-cell activation. In the chronic inflammatory model of adjuvant arthritis oxoglaucine exhibited stimulatory or suppressive action related to the kinetics of the process. At low doses (1 or 2 mg kg-1) oxoglaucine improved the outcome of Klebsiella pneumoniae infection, while at higher doses (10 or 20 mg kg-1) the substance caused an impairment of host resistance to infectious agent. The comparison with cyclophosphamide in some tests showed that oxoglaucine was effective in manifold lower doses. In conclusion, oxoglaucine exerted immunomodulatory effects in vivo in a dose-dependent and protocol-dependent manner. Yet, its overall action might be attributed to the different sensitivity of the cells involved in the developing immune response.

A low dose immunorestorative effect of aporphinoid alkaloid oxoglaucine on experimentally immunosuppressed and infected mice.

The immunoregulatory activity of aporphinoid alkaloid oxoglaucine was studied in delayed-type hypersensitivity (DTH) reaction and Klebsiella pneumoniae infection in normal and immunosuppressed mice. The alkaloid enhanced DTH reaction when applied during the developing phase and abolished the inhibitory action of cyclophosphamide. Oxoglaucine possessed a restorative effect in K. pneumoniae infection in immunosuppressed mice in combination with indomethacin, prednisolone or artemisinin, as evaluated by the number of survivors and mean survival time. These data suggest that oxoglaucine affects selected lymphocyte clones responsible for antiinfectious host resistance. Its use as a second agent in combination with another immunosuppressant might enable reduction in the dosage or time of application.