Extracorporeal photochemotherapy does not suppress T- or B-cell responses to novel or recall antigens.

BACKGROUND: Extracorporeal photopheresis (ExP) is an effective therapy for several conditions including cutaneous T-cell lymphoma, scleroderma, and allograft rejection. Experimental animal models suggest that ExP may induce antigen-specific immunosuppression. OBJECTIVE: Our purpose was to determine the effect of photopheresis on humoral and cell-mediated immunity in human subjects. METHODS: Recall and primary immune responses of patients with scleroderma receiving monthly ExP treatments were assessed by delayed type hypersensitivity skin tests, T-cell proliferative responses after immunizations with tetanus toxoid and keyhole limpet hemocyanin, and serum antibody titers against common viral pathogens. RESULTS: After 6 months of ExP, viral antibody titers and delayed type hypersensitivity responses were not significantly different from baseline values in all 7 patients tested. T-cell responses to tetanus toxoid remained normal in 3 of 3 patients tested for a minimum of 6 months after booster immunization. Immunization with the protein antigen keyhole limpet hemocyanin after initiation of ExP therapy resulted in sustained T-cell proliferative responses up to 6 months in 3 of 3 patients. CONCLUSION: These results, along with the observation of no increased incidence of opportunistic infections or neoplasms, suggest that ExP is not broadly immunosuppressive and does not prevent primary responses to vaccination or other antigenic challenges.

S. aureus isolation from the lesions, the hands, and the anterior nares of patients with atopic dermatitis.

Staphylococcus aureus colonization is common in atopic dermatitis (AD) and can exacerbate the disease. Additionally, some evidence shows that patients with AD may act as reservoirs for S. aureus transmission to others. This study compared S. aureus colonization in AD patients and their caregivers with control patients and their caregivers. Quantitative cultures were obtained from the lesions, clinically normal skin, hands, and anterior nares of 100 patients with AD, 100 controls with other cutaneous disorders, and 200 caregivers. AD patients had a significantly greater carriage of S. aureus from lesional and clinically normal skin as well as the hand. Significant increases in carriage of S. aureus were found in the anterior nares and hands of caregivers of AD patients compared with control caregivers. Topical corticosteroid use did not affect recovery of S. aureus. There was a significant correlation between recovery of S. aureus from lesional skin and recovery from the anterior nares (p = .002) and hands (p < .0001). These findings suggest that the anterior nares and the hands may be important reservoirs and vectors for transmission of S. aureus to lesional skin and to close contacts of these patients.

Identification and immunohistochemical localization of protein precursors to human axillary odors in apocrine glands and secretions.

OBJECTIVES: To determine the cellular localization in male and female axillary tissue for apocrine secretion odor-binding proteins 1 (ASOB1) and 2 (ASOB2) and the electrophoretic pattern of female apocrine proteins and to begin characterization of the ASOB1 protein. DESIGN: Immunohistochemical techniques were used with biopsy samples from axillary tissue of male and female subjects. Immunological techniques and microsequencing were used to characterize several of the proteins in male and female apocrine secretions. SETTING: A university medical center. PARTICIPANTS: Healthy male and female volunteers who donated apocrine secretions and/or axillary tissue. RESULTS: Specific immunoreactivity was localized only to the apocrine glands in both sexes. Furthermore, only preabsorption with a mixed apocrine secretion sample eliminated all immunoreactivity. The electrophoretic pattern of proteins in female apocrine secretions is similar to that in male secretions. Western blotting of the separated proteins from female samples using serum samples containing antibodies to ASOB1 and ASOB2 yielded identical results to those found with separated proteins from male samples. Partial sequence data obtained from the N-terminus of ASOB1 suggested that it shares homology with the alpha-chain of apolipoprotein J (Apo J). Apocrine secretion odor-binding protein 1 is not immunologically similar to ApoJ, but 2 other apocrine secretion proteins are. CONCLUSIONS: Male and female subjects appear to have the same glycoprotein carriers for (E)-3-methyl-2-hexenoic acid localized to the apocrine glands. The N-terminal sequence for ASOB1 may be homologous to Apo J, but it is not immunologically similar to it. However, 2 other proteins in the apocrine secretion appear to be the monomer and dimer forms of Apo J.

Pathogenesis of cutaneous T-cell lymphoma: implications for the use of recombinant cytokines and photopheresis.

Cutaneous T-cell lymphoma (CTCL) is a clonally derived, skin invasive malignancy of CD4+ cells with the phenotype of mature helper T cells. We previously demonstrated that the leukaemic form of CTCL (Sézary), is characterized by prominent immunological defects including depressed cell-mediated immunity. We also demonstrated increased production of T-helper type 2 (Th2) cytokines (IL-4, IL-5) and deficient Th1 cytokines (IL-2 and IFN-gamma) by their peripheral blood mononuclear cells (PBMC) and detected IL-4 and IL-5 mRNA within lesional skin of patients with all stages of CTCL. A marked defect in IL-12 production has also been noted, which may also play a role in depressed cell-mediated immunity. These results suggested that the malignant CD4+ cells were Th2 cells. Thus, the immune aberrations have been attributed to the cytokine abnormalities triggered by the malignant T-cell population. Because CTCL responds to biological response modification, we focused on strategies for reversing the cytokine and immune defects by in vitro testing of novel biological response modifiers. Our results indicate that IFN-alpha potently suppresses the abnormal IL-4 and IL-5 production, that IL-12 can correct the deficient IFN-gamma production and cell-mediated cytotoxicity, and that retinoids can enhance IFN-gamma and IL-12 production. We also studied the in vitro growth characteristics of the malignant CD4+ cells and determined that IL-12 and IFN-alpha significantly suppress growth of these cells. These studies led to a phase I trial of IL-12 to treat CTCL. Also, we have determined that photopheresis produces a high clinical response rate among Sézary syndrome patients. This therapy not only augments functions of monocytes but also induces the malignant T cells to undergo a high rate of apoptosis. We discuss how these therapies might be employed in concert to produce the optimum desired anti-tumour effect.

Effects of topical erythromycin on ecology of aerobic cutaneous bacterial flora.

We have demonstrated previously that application of topical erythromycin, an antibiotic commonly used for the treatment of acne, results in an increased density of cutaneous erythromycin-resistant (Emr) coagulase-negative staphylococci; however, it is unknown if this increase results in an overall higher density of total cutaneous staphylococci or if upon cessation of erythromycin use, Emr coagulase-negative staphylococci remain at an increased density compared with the pretreatment density. To investigate this, 2% erythromycin or vehicle was applied to each subject's forehead (n = 225) twice a day by laboratory personnel for a period of 6 weeks. Samples were obtained for culture from the forehead, anterior nares, and back of the subjects at baseline and at weeks 6, 9, and 12 of the study. Cultures were performed on differential media. Plates into which erythromycin was incorporated (8 micrograms/ml) were used to identify Emr coagulase-negative staphylococci. The species of all Emr coagulase-negative staphylococci were determined, and an antibiogram for 16 antibiotics was obtained. The baseline prevalence of Emr coagulase-negative staphylococci on the forehead and nose was about 80% at the two study sites, whereas that on the back was 50%. The baseline density of Emr coagulase-negative staphylococci on the forehead, nose, and back was approximately 20% of the total flora. Following 6 weeks of erythromycin treatment, the prevalence of Emr coagulase-negative staphylococci on the forehead and nose was nearly 100% and the densities were 73 and 62%, respectively; the prevalence and density for the back were 78 and 42%, respectively. The most prevalent erythromycin resistance gene expressed by the Emr coagulase-negative staphylococci was ermC. There was no increase in the numbers of Staphylococcus aureus, gram-negative rods, or yeasts, nor was there increased resistance to any other antibiotic except clindamycin. The density of total aerobic organisms also remained static. There were no changes in the prevalence or density of Emr coagulase-negative staphylococci in the vehicle group. A statistically significant decrease in the prevalence and density of Emr coagulase-negative staphylococci in the erythromycin group was observed within 3 weeks posttreatment and by 6 weeks posttreatment, the prevalence and density returned to baseline values. These data demonstrate that the increased prevalence and density of Emr coagulase-negative staphylococci as a result of topical 2% erythromycin use are transient on both population and individual levels.

The potential therapeutic role of interleukin-12 in cutaneous T-cell lymphoma.

Cutaneous T-cell lymphoma (CTCL) is a lymphoproliferative disorder characterized by skin invasion of clonally derived malignant CD4+ lymphocytes that phenotypically resemble mature T-helper (Th) cells. Sezary syndrome (SzS) represents an advanced form of CTCL associated with generalized erythroderma and involvement of the peripheral blood by the malignant cell population. We have previously demonstrated aberrant cytokine production by peripheral blood mononuclear cells (PBMCs) in SzS characterized by increased IL-4 and deficient IL-2 and IFN-gamma production, as well as increased expression of mRNA for IL-4 and IL-5 within active skin lesions, indicating that the clonal T-cell population is likely derived from the T-helper type 2 (Th2) subset of helper T lymphocytes. Furthermore, a variety of immune abnormalities have been observed in association with SzS that have been attributed to the cytokine abnormalities. Because IL-12 is a potent inducer of IFN-gamma production and causes the activation of cytotoxic lymphocytes, we assessed the production of IL-12 by PBMCs from SzS patients, and whether IL-12 could alter the unfavorable cytokine balance typical of SzS and, thus, possibly lead to correction of immune defects. In this review, we present our data, which indicate that patients with SzS exhibit marked defects in monocyte production of IL-12 p70. Moreover, in vitro culture of PBMC from SzS patients with recombinant IL-12 leads to reconstitution of normal IFN-gamma production and markedly enhances cell-mediated cytotoxicity.

Failure to detect human T-lymphotropic virus type-I proviral DNA in cell lines and tissues from patients with cutaneous T-cell lymphoma.

Previous molecular studies investigating the presence of HTLV-I proviral DNA in cell lines and tissue samples of patients with cutaneous T-cell lymphoma (CTCL) have reported a detection rate ranging from 0-92%. Despite the lack of epidemiologic data linking HTLV-I infection with CTCL, the molecular data still invite speculation regarding the precise role of HTLV-I in the pathogenesis of CTCL. To determine the detection rate of HTLV-I proviral DNA among CTCL patients referred to our medical center, we analyzed Epstein-Barr virus-transformed cell lines established from peripheral blood of seven CTCL patients and 43 tissue samples from 22 patients with different stages of disease. Genomic DNA was polymerase chain reaction-amplified with primers within the HTLV-I tax gene region. Amplification products were probed with nested oligonucleotide probes by Southern blot analysis. No HTLV-I proviral sequences were detected in the samples (0/50). Using HTLV-I/II pol primers, no HTLV-I pol gene sequences were detected. In tissues from one patient, HTLV-II pol and tax gene sequences were detected; however, HTLV-II proviral integration was not detected by Southern blot analysis of the genomic DNA. Our data suggest: (i) HTLV-I does not appear to be a primary etiologic agent in CTCL; and (ii) HTLV-II pol and tax gene sequences can be detected in a minority of CTCL patients, but this does not necessarily imply an etiologic role.

Replicate plating: does it increase reliability?

As a part of a clinical study to evaluate the antibacterial effect of a topically applied erythromycin gel, microbiological specimens were taken from two groups of patients: one group using 2% erythromycin gel and the other group using a placebo gel. These specimens were plated in triplicate using a common source on bacteriological media using standard procedures. After the appropriate incubation times, the numbers of aerobic and anaerobic organisms were counted separately from each of three plates. A comparison of the bacterial colony counts from the replicate plates showed a high degree of similarity for each type of organism. Tests for treatment differences in organism counts were performed based on single, double and triplicate plating. The results obtained were almost identical, suggesting that replicate plating from a common source is no more accurate than single plating. The only apparent advantage of this type of replicate plating is heightened confidence in the reliability of bacterial counts from single plates.

Apoptosis induction of ultraviolet light A and photochemotherapy in cutaneous T-cell Lymphoma: relevance to mechanism of therapeutic action.

The anti-tumor action of many chemotherapeutic agents has recently been attributed to the induction of apoptosis in the malignant cell population. In this study, we investigated the ability of extracorporeal photopheresis (ExP) and in vitro PUVA (8-methoxy-psoralen + ultraviolet A) therapy to induce apoptosis in peripheral blood mononuclear cells from Sezary syndrome patients and normal controls. Flow cytometric analysis of ExP- or PUVA-treated peripheral blood lymphocytes demonstrated two distinct cell populations within 24 h of treatment. One population was similar to untreated controls with the other exhibiting characteristics of apoptotic cell death, i.e., a loss of cell volume and an accompanying increase in cell density. This latter population was comprised of cells with DNA strand breaks as determined by the Tdt-mediated deoxyuridine triphosphate-biotin nick end labeling assay. Apoptosis was also confirmed morphologically by fluorescent and electron microscopy as well as by demonstration of characteristic DNA strand breaks (laddering) using gel electrophoresis. Apoptosis was not observed with 8-methoxypsoralen (< or = 300 ng per ml) alone; however, ultraviolet A alone at doses > or = 2 J per cm2 induced apoptosis in lymphocytes. Peripheral blood T-cell subpopulations of Sezary syndrome patients, including the malignant clone, were equally susceptible to apoptosis subsequent to either photopheresis or PUVA treatment. In contrast, monocytes (CD14+/CD45+) appear to be resistant to apoptosis induction by ExP or PUVA treatment. Moreover, ExP-treated and untreated monocytes phagocytized apoptotic, but not untreated, peripheral blood mononuclear cells. ExP and PUVA have been shown to be efficacious and well-tolerated therapies in the treatment of dermatologic diseases and transplant rejection. These data suggest that induction of apoptosis may be an important event for therapeutic efficacy.

A human axillary odorant is carried by apolipoprotein D.

The characterization of the source of the odor in the human axillary region is not only of commercial interest but is also important biologically because axillary extracts can alter the length and timing of the female menstrual cycle. In males, the most abundant odor component is known to be E-3-methyl-2-hexenoic acid (E-3M2H), which is liberated from nonodorous apocrine secretions by axillary microorganisms. Recently, it was found that in the apocrine gland secretions, 3M2H is carried to the skin surface bound to two proteins, apocrine secretion odor-binding proteins 1 and 2 (ASOB1 and ASOB2) with apparent molecular masses of 45 kDa and 26 kDa, respectively. To better understand the formation of axillary odors and the structural relationship between 3M2H and its carrier protein, the amino acid sequence and glycosylation pattern of ASOB2 were determined by mass spectrometry. The ASOB2 protein was identified as apolipoprotein D (apoD), a known member of the alpha2mu-microglobulin superfamily of carrier proteins also known as lipocalins. The pattern of glycosylation for axillary apoD differs from that reported for plasma apoD, suggesting different sites of expression for the two glycoproteins. In situ hybridization of an oligonucleotide probe against apoD mRNA with axillary tissue demonstrates that the message for synthesis of this protein is specific to the apocrine glands. These results suggest a remarkable similarity between human axillary secretions and nonhuman mammalian odor sources, where lipocalins have been shown to carry the odoriferous signals used in pheromonal communication.

Kinetic analysis of apoptosis induction in human cell lines by UVA and 8-MOP.

Whereas previous studies have indicated that DNA damage as a result of 8-methoxypsoralen (8-MOP) and UVA treatment leads to cell death, this study establishes the minimum concentrations of 8-MOP and UVA necessary to induce apoptosis in human T-lymphocytic and monocytic cell lines. In order to asses apoptosis, we used fluorescent microscopy to examine changes in light scattering as well as internucleosomal DNA fragmentation. Generation of a dose response curve showed that the minimum combination of UVA and 8-MOP that was necessary to induce greater than background levels of apoptosis within 24 h of treatment was 0.5 J/cm2 UVA and 12.5 ng/mL of 8-MOP. A striking observation was that UVA alone at doses > or = 1.0 J/cm2, but not 8-MOP alone (0-300 ng/mL), induced significant apoptosis in the Sup-T1 cells induced by UVA alone was not as great as that of 8-MOP and UVA in combination, a highly significant correlation between the product of the concentration of 8-MOP (ng/mL) times the dose of UVA (J/cm2) and the percentage of apoptotic cells was observed. This correlation provides an important tool for studying the relationship of UVA-induced DNA damage to apoptosis induction. moreover, it will provide a means by which early events in the apoptotic pathway can be dissected.

A new method for in vivo evaluation of antimicrobial agents by translocation of complex dense populations of cutaneous bacteria.

Previously, we described methods for measuring in vivo antimicrobial activity in which the resident bacterial flora of the forearm is expanded by occlusion with an impermeable plastic film, test agents are applied and quantitative cultures are obtained at varying time points. This methodology allows for an in vivo quantitative assessment of antimicrobial effects directed against a dense flora comprised primarily of staphylococci. This method may not be applicable to situations in which there is a high density of multiple species of bacteria. We describe herein new methods which permit in vivo determination of antimicrobial activity against a dense, mixed flora. Swabs moistened with a dilute nonionic detergent are used to remove bacteria from the subject's axilla or groin which are then translocated to the subject's forearm. Occlusion of the forearm with a large, sterile plastic chamber provides the necessary humid environment to yield a dense flora (10(5)-10(6) CFU) consisting of gram-positive cocci, gram-positive coryneforms and gram-negative rods. In this manner, multiple test sites are created on each forearm allowing for the simultaneous evaluation of multiple antimicrobial agents in a single subject. This method allows for the evaluation of the immediate, as well as sustained, in vivo bactericidal effect of an antimicrobial agent against a dense mixed flora with quantitative cultures obtained at varying time points after application of the test agent. Furthermore, ecological pressures which select for resistant organisms or allow for an overgrowth of nonsensitive bacteria can be evaluated by determining the composition of the flora after single or repeated applications of a test agent. The testing methodologies described herein can provide relevant information regarding the antimicrobial effectiveness of an agent in a variety of situations such as use against the axillary flora (including its utility as a deodorant), use as a perineal cleanser for critically ill, hospitalized patients and use in situations where a dense mixed flora exists, e.g. stasis ulcers and infected intertriginous dermatoses.

Induction of proinflammatory cytokines by a soluble factor of Propionibacterium acnes: implications for chronic inflammatory acne.

Although many cytokines have been implicated in the development and persistence of inflammatory immune responses, it is unknown if any of these are important in inflammatory acne. This study investigated the production of the proinflammatory cytokines interleukin-8 (IL-8), IL-1 beta, and tumor necrosis factor alpha (TNF-alpha) by human monocytic cell lines, ThP-1 and U937, and by freshly isolated peripheral blood mononuclear cells from acne patients. Both Propionibacterium acnes and supernatants obtained from 72-h P. acnes cultures could induce significant concentrations of IL-1 beta, TNF-alpha, and IL-8 by both cell lines and by peripheral blood mononuclear cells as determined by enzyme-linked immunosorbent assay. There was no significant difference between acne and non-acne subjects. Endotoxin quantification and addition of polymyxin B to assays indicated no lipopolysaccharide (LPS) contamination. P. acnes supernatant was fractionated into components with molecular weights of < 3,000, < 10,000, and < 30,000 and assayed for the ability to induce IL-8 and TNF production in ThP-1 cells. Nearly 90% of the original activity was found in the < 30,000-molecular-weight fraction, 50% was in the < 10,000-molecular-weight fraction, and only 15% remained in the < 3,000-molecular-weight fraction. The effluent from the < 3,000-molecular-weight fraction contained about 70% activity, indicating that the inducing factor was not retained in the membrane. Incubation of P. acnes supernatant with various concentrations of mutanolysin or lysozyme resulted in a loss of 60% of the original activity. The addition of jimson lectin, which binds peptidoglycan, resulted in a loss of 70% of the activity in a dose-response manner, whereas peanut lectin had little or no effect on the activity. Heating of the P. acnes supernatant to 65 degrees C also had no effect on the activity. Blocking of CD14, a receptor for both LPS and peptidoglycan, reduced cytokine production by > 50%, suggesting that the soluble stimulating factor may be a secreted form of peptidoglycan-polysaccharide.

Expression of interleukin-4 and interleukin-5 mRNA in developing cutaneous late-phase reactions.

The stimuli for the accumulation and activation of eosinophils, which are prominent components of IgE-mediated allergic late-phase reactions (LPRs), are not defined. Messenger RNA for interleukin-5 has been found in lymphocytes present in biopsy specimens of skin obtained during LPR 24 hours after antigen challenge. However, it is not known whether interleukin-5 is present to attract or activate the eosinophils that accumulate during the first 6 hours after antigen challenge when cutaneous LPRs are developing. Using reverse transcription-polymerase chain reaction, we have found mRNA for interleukin-5 in biopsy specimens obtained from control challenge sites nor in specimens from sites of antigen challenge of nonreactive subjects. We also found mRNA for interleukin-4 in these sites developing LPR. This pattern suggests that these cytokines may be important in eosinophil accumulation and activation during developing LPR. These findings are of considerable clinical relevance because the eosinophils in LPR are postulated to play major pathogenic roles in chronic allergic diseases.

IL-12 reverses cytokine and immune abnormalities in Sezary syndrome.

Cutaneous T cell lymphoma is a lymphoproliferative disorder typically characterized by skin invasion of clonally derived malignant CD4+ lymphocytes that phenotypically resemble mature Th cells. Sezary syndrome (SzS) represents an advanced form of cutaneous T cell lymphoma associated with generalized erythroderma and involvement of the peripheral blood by the malignant cell population. We have previously demonstrated aberrant cytokine production by PBMC in SzS characterized by increased IL-4 and deficient IL-2 and IFN-gamma production, as well as increased expression of mRNA for IL-4 and IL-5 within active skin lesions, suggesting that the clonal T cell population is derived from the Th 2 subset of helper T lymphocytes. These findings have been associated with a constellation of immune abnormalities that have been attributed to the cytokine abnormalities. Because IL-12 is a potent inducer of IFN-gamma production, and causes the activation of cytotoxic lymphocytes, we examined the production of IL-12 by PBMC from SzS patients and whether IL-12 could alter the unfavorable cytokine balance typical of SzS and thus lead to correction of immune defects. Despite normal numbers of peripheral blood monocytes and normal TNF-alpha production, mean Staphyloccus aureus and LPS-induced IL-12 p40 and p70 production by SzS PBMC was significantly decreased compared with PBMC from normal controls. Mean IFN-gamma production by patient PBMC in response to PHA alone was depressed, but increased to levels comparable with normal after addition of 1 ng/ml IL-12. Pretreatment of PBMC for 24 h with IL-12, IFN-alpha, or both together resulted in a decrease in PHA-stimulated IL-4 production from a base line of 1818 pg/ml to 1520, 1350, and 1058 pg/ml, respectively. Lastly, culture of patient PBMC with IL-12 for 24 h also resulted in significant increases in NK activity against K562 cells. These results indicate that PBMC from patients with SzS manifest a defect in IL-12 production and that the cytokine abnormalities associated with SzS can be favorably altered by IL-12.

Th2 cytokine mRNA expression in skin in cutaneous T-cell lymphoma.

We have previously demonstrated that peripheral blood mononuclear cells from patients with Sézary syndrome, the leukemic form of cutaneous T-cell lymphoma which is accompanied by erythroderma and lymphadenopathy, have a Th2 cell cytokine [interleukin 4 (IL-4) and interleukin 5] production pattern. In this study, we extend these observations to demonstrate a correlation of the presence of a Th2 cytokine pattern with a malignant T-cell clone in different stages of cutaneous involvement among patients with cutaneous T-cell lymphoma (CTCL). Skin biopsies were obtained from 12 CTCL patients with various disease stages (three patch, three plaque, six tumor), three patients with parapsoriasis, four patients with inflammatory dermatoses, including two psoriasis and two lichen planus, and 12 normal controls. Total RNA was extracted, reverse transcribed, and PCR amplified with IL-2, IL-4, IL-5, interferon gamma (IFN-gamma), and beta-actin oligonucleotide primers. Although all skin specimens tested had detectable IL-2 and IFN-gamma mRNA, only specimens from patients with CTCL or parapsoriasis had demonstrable IL-4 and/or IL-5 mRNA. Specifically, IL-5 mRNA was detected in skin biopsies from five of six tumor-stage CTCL, two of three plaque-stage CTCL, one of three patch-stage CTCL, and 1 of 3 parapsoriasis patients, whereas IL-4 mRNA was demonstrated to be present in five of six tumor-stage, one of three plaque stage, none of three patch-stage CTCL, and none of three parapsoriasis patients. These results indicate that in all stages of cutaneous involvement of CTCL, encompassing patch stage through tumor stage, IL-4 and IL-5 mRNA is variably detectable. In tumor-stage skin lesions, typically characterized by a dense dermal infiltrate of malignant T cells, Th2 cytokine mRNA is virtually always detectable. The ability to detect Th2 cytokine mRNA in the skin of patients with CTCL supports our previous findings that the malignant T cells in CTCL possess a Th2-helper cell phenotype.

Retroviruses and cutaneous T-cell lymphoma.

Since the discovery of the first human retrovirus, HTLV-I, and its etiologic role in ATL, the search for a retrovirus and its role in the development and progression of CTCL has been vigorously pursued and debated. Current studies in CTCL have evaluated serum antibodies to retroviral proteins, electron microscopy to identify viruslike particles, and Southern blot analysis and PCR amplification to detect proviral DNA sequences. There have been inconsistent findings within and between a variety of studies, emphasizing the need for critical evaluation of experimental methods and their potential shortcomings. Several interesting observations have included (1) serologic evidence of HTLV-I infection in a small subset of CTCL patients, (2) cloning of a deleted HTLV-I proviral genome from a B-cell line established from the peripheral blood of a CTCL patient, (3) detection of retrovirus in Langerhans cells and B cells, and (4) molecular evidence for the presence of an HTLV-I-like retrovirus. By viewing CTCL as a model of tumor progression, mechanisms by which retroviruses play a role in the development and progression of CTCL are facilitated. Future studies will need to correlate the detection of proviral sequences and the nature of a retroviral infection with specific cell types and stage of disease and determine if these findings demonstrate a causal role in CTCL or a secondary phenomenon due to CTCL-associated immunosuppression. It is likely that new data will be reported between the writing of this article and the time of publication; however, the currently available data reviewed in this article do not provide conclusive evidence that retroviruses play a primary etiologic role in CTCL.

Therapeutic applications of photopheresis.

Photopheresis is a useful therapy for advanced cutaneous T-cell lymphoma, particularly for Sezary syndrome. Additional conditions in which clinical studies have suggested a therapeutic role for photopheresis include certain autoimmune diseases and reversal of rejection of solid organ allografts. Because photopheresis is extremely well tolerated and evidence is lacking for a direct immunosuppressive effect produced by this therapy, randomized trials should be pursued to determine the full spectrum of clinical benefit of this novel therapeutic modality.