The Conradi-Hünermann-Happle syndrome (CDPX2) and emopamil binding protein: novel mutations, and somatic and gonadal mosaicism.

The Conradi-Hünermann-Happle (CHH) syndrome (X-chromosomal dominant chondrodysplasia punctata type II; MIM 302960) is an X-linked dominant disorder that is characterized by ichthyosis, chondrodysplasia punctata, cataracts and short stature. The disease occurs almost exclusively in females and shows increased disease expression in successive generations (anticipation). Recently, causative mutations in the emopamil binding protein (EBP) have been identified. To better appreciate the genetics of this syndrome we analyzed the EBP gene in seven independent families using PCR, conformation-sensitive gel electrophoresis, direct sequencing and restriction enzyme analysis. We found five novel mutations: three nonsense mutations in exon 2 and exon 3 and two frameshift mutations, one deletion in exon 4 and an insertion in exon 5. In two families, known mutations affecting exon 2 were identified. Surprisingly, we failed to detect the mutation in a grandmother exhibiting minor disease symptoms such as sectorial cataract and attribute this to gonadal and somatic mosaicism. Gonadal mosaicism appeared also to be involved in the case of healthy parents having two affected girls, one of whom died due to the disease. We conclude that gonadal mosaicism has to be considered when dealing with seemingly sporadic cases.

Detection of varicella-zoster virus and herpes simplex virus by the polymerase chain reaction with degenerate primers.

Varicella-zoster virus (VZV) and herpes simplex virus (HSV) are human pathogens of significance involved in multiple diseases with either typical or atypical clinical features. In neonates and immunocompromised patients these alphaherpesviruses may cause life-threatening diseases such as encephalitis. Detection of VZV by virus culture is difficult. Polymerase chain reaction (PCR) is quicker and more sensitive and applicable in most clinical microbiological laboratories. Using degenerate primers, glycoprotein B (gB) DNA was amplified from all alphaherpesvirus field strains present in clinical samples. The amplification of gB allowed virus typing of VZV, HSV-1 and HSV-2 using restriction enzyme digestion of the PCR products. Degenerate primers can replace conventional primers in diagnostic PCR without loss of sensitivity and specificity.

Diagnosis and treatment of pustular disorders in the neonate.

The diagnosis of a pustular dermatosis occurring during the first months of life is usually based on clinical findings. However, some cases may require simple investigations including microscopic examination of pustular content, cultures, and skin biopsies. The main benign transient neonatal types of pustulosis include erythema toxicum neonatorum, infantile acropustulosis, transient neonatal pustular melanosis, and neonatal acne. The most common causes of infectious pustular skin lesions include bacterial infections, which may be initially localized (Staphylococcus aureus) or septicemic (with Listeria monocytogenes as the leading causitive agent); viral infections (herpes simplex, varicella-zoster, and cytomegalovirus infections); fungal infections (candidiasis); or parasitic disorders (scabies). The main objective of this article is to propose a systematic approach to pustular eruptions in the neonate. The need for investigating every neonate with pustules for an infectious disease is emphasized. The Tzanck smear, the Gram's stain, and a potassium hydroxide preparation are the most important quick diagnostic tests. The Tzanck smear is a very easy, rapid, and sensitive test for detection of a herpetic infection (multinucleated giant cells) as well as noninfectious pustular eruptions (eosinophils, neutrophils). Therefore the Tzanck smear should be the first test performed. Moreover, a Gram's stain and potassium hydroxide preparation should be performed in cases of neonatal pustular disorders to detect bacterial and fungal infections. The goal of this diagnostic approach is to spare a healthy neonate with a benign transient condition an invasive evaluation for sepsis, potentially harmful antibiotic therapy, and prolonged hospitalization, with its own inherent morbidity.

Cutaneous hypersensitivity reactions to vitamin K: 2 case reports and a review of the literature.

Between 1964 and 1994, at least 52 patients with cutaneous adverse effects of vitamin K have been described in the European and North American literature. A review of the details of these patients is given and 2 new cases reported. Adverse effects are seen not only in patients with liver-function disturbances but also in patients without liver diseases, and occur mostly after intramuscular or subcutaneous administration of vitamin K1, independent of the total dose. Patch and intracutaneous tests often give positive reactions. The mechanism of action is probably in many patients a delayed-type hypersensitivity reaction.

Subcutaneous fat necrosis in a neonate, in association with aberrant plasma lipid and lipoprotein values.

A newborn infant with subcutaneous fat necrosis after perinatal hypoxia was found to have several abnormalities of plasma lipids. Further studies are needed to determine whether such abnormalities contribute to the pathophysiology of the skin lesions.

Radish, a Drosophila mutant deficient in consolidated memory.

We have characterized the behavior and genetics of the Drosophila mutant radish (rsh gene). Initial learning of radish flies in two olfactory discrimination tests is high, but subsequent memory decays rapidly at both early and late times after training. Anesthesia-resistant memory (consolidated memory) is undetectable in radish flies 3 hr after training. The mutant shows normal locomotor activity and normal sensitivity to the odor cues and electric-shock reinforcement used in the learning tests. The radish gene maps within a 180-kb interval in the 11D-E region of the X chromosome.

Immunoelectron microscopy for rapid diagnosis of varicella-zoster virus in a complicated case of human T-cell lymphotropic virus type 1 infection.

Rapid techniques for the detection of herpes simplex virus (HSV) and varicella-zoster virus (VZV) are needed for optimal therapeutic management. VZV infection poses a serious threat, especially to seriously ill patients, for instance, immunocompromised patients. We report a case of human T-cell lymphotropic virus type 1-positive leukemia complicated by atypical multidermatomal herpes zoster. Viral culture and standard serological tests failed to prove VZV infection. Herpesvirus infection was confirmed by cytodiagnosis (Tzanck test). The final diagnosis of VZV was made by immunoelectron microscopy (IEM), which can differentiate between HSV and VZV. Immunoglobulin M antibodies in serum directed against VZV were detected by IEM but not by immunofluorescence. Because IEM was able to identify virus and analyze sera in only 2 h, it is considered a valuable additional tool for the rapid diagnosis of HSV and VZV infections.

Improved detection of HSV by electron microscopy in clinical specimens using ultracentrifugation and colloidal gold immunoelectron microscopy: comparison with viral culture and cytodiagnosis.

Three tests were compared to diagnose herpes virus infection: electron microscopy (EM), viral culture (VC) and cytodiagnosis (Tzanck smear). The study comprised 67 patients with skin or mucous membrane lesions suggestive of herpes simplex virus (HSV) infection. The sensitivity of EM increased 25% after virus concentration by ultracentrifugation. Herpes virus infection was confirmed in 55 of the 67 cases by EM or VC or both. EM detected 53 herpes virus-positive lesion samples of which 14 were not detected by VC; only two lesion samples that were herpes virus-positive in VC were not detected by EM. The sensitivities of EM, VC, and Tzanck smear for the group of 55 herpes virus-positive cases were 96%, 75% and 76%, respectively. The specificity of the Tzanck smear was 83% (prevalence 82%). Colloidal gold immuno-EM was used to rapidly type HSV-1, HSV-2 and varicella zoster virus (VZV) present in skin and mucous membrane lesions in less than 4 h. Immuno-EM was able to detect antiviral antibodies on viral envelopes and viral cores in lesion samples with negative VC. Antiviral antibodies do not interfere with typing of herpes viruses by immuno-EM. It is suggested that formation of viral immune complexes and inactivation of virus particles by antibodies may have caused a negative VC. Improved EM is discussed for its applicability to special cases that cannot rely on VC and cytodiagnosis or when rapid diagnosis is required.

cAMP-dependent protein kinase and the disruption of learning in transgenic flies.

A molecular genetic approach was used to test for a role of cAMP-dependent protein kinase (PKA) in learning and memory in Drosophila. We used genes encoding a peptide inhibitor of PKA, an N-terminal regulatory subunit fragment containing a pseudosubstrate inhibitory domain, and a wild-type catalytic subunit. These dominantly acting genes were placed under control of the hsp70 promoter and transformed into wild-type flies. Induction of the transgenes by 1 hr heat shock results in overproduction of their RNA in adult flies. The same heat shock treatment disrupts the ability of the flies to learn in an odor discrimination task reinforced with electric shock. The results demonstrate the involvement of PKA in the associative learning of Drosophila.

Rapid diagnosis in varicella and herpes zoster: re-evaluation of direct smear (Tzanck test) and electron microscopy including colloidal gold immuno-electron microscopy in comparison with virus isolation.

The Tzanck test and electron microscopy with the technique of colloidal gold labelling in varicella-zoster virus (VZV) infections were compared with virus isolation in 54 patients with clinically suspected varicella or herpes zoster infection. The Tzanck test and direct electron microscopy can determine whether or not an eruption is herpetic but cannot distinguish between herpes simplex virus (HSV) and VZV infection. However, colloidal gold immuno-electron microscopy, using monoclonal antibodies against HSV and anti-VZV IgG, can distinguish between these two herpes viruses. This achieves the same specificity as virus isolation followed by virus neutralization or virus typing using immunofluorescence techniques. The Tzanck test was positive in 91%, virus isolation, under optimal conditions of sampling and transportation, in 80%, direct electron microscopy (negative staining) in 80%, and colloidal gold immuno-electron microscopy after a virus concentration procedure in 95% of the cases. The colloidal gold technique offers a rapid diagnosis in patients with suspected VZV infection.

The use of colloidal gold immunoelectron microscopy to diagnose varicella-zoster virus (VZV) infections by rapid discrimination between VZV, HSV-1 and HSV-2.

Colloidal gold immunoelectron microscopy was used to diagnose rapidly 53 cases clinically suspected of varicella-zoster virus (VZV) infection and one special case selected from another study on typical herpes simplex virus (HSV) infections. The viruses were identified and subsequently typed within 2.5 h by a direct labelling test for VZV, and within 3.5 h by an indirect labelling test with monoclonal antibodies against HSV type 1 and type 2. The protein A purified IgG fraction of human anti-VZV immunoglobulins was adsorbed to colloidal gold particles, and the specificity of the gold-labelled antibodies was tested with several human and animal herpesviruses. Viral envelopes did not crossreact in the direct labelling test. However, an indirect labelling procedure revealed that a small fraction of the anti-VZV antibodies crossreacted with the cores of herpes simplex virus and pseudorabies virus (Aujeszky disease virus). Virus-infected cellular material taken from typical herpetic lesions was used directly without virus propagation for virus typing. All cases (N = 54) were analyzed without knowing the clinical description of the results of cytopathologic examination (Tzanck smear) and viral culture. Forty-four cases were identified as VZV; however, 5 of the supposed VZV infections were proved to be HSV infections. Although the viral culture of the one HSV case was HSV- and VZV-negative, colloidal gold labelling identified the case as VZV infection. In 16 cases virus immunoglobulin complexes were detected by using gold-tagged antibodies against human immunoglobulins. Immunoglobulins on the viral envelopes did not interfere with virus typing by immunogold labelling.

Tzanck smear in diagnosing genital herpes.

In 126 patients with anogenital lesions, in which herpes simplex virus (HSV) infection was suspected or included in the differential diagnosis, the results of cytodiagnosis of herpetic infection (Tzanck smear) were compared with virus culture. Cervical lesions were excluded from this study. HSV infection was proved by culture in 78 patients and was absent or non-active in 41 patients. Excluded from this study were seven patients who did not yield the virus on culture but had positive Tzanck smear results from three investigators. The characteristic cytopathic effect of herpetic infection was found in 78 patients who yielded HSV on culture. Tzanck smear sensitivity for skin lesions was 79% and for mucous membrane lesions was 81% in men and 52% in women. Tzanck smear specificity for the 41 patients without herpetic infection proved by virus culture was 93%. Differences in sensitivity and specificity between the results found by three investigators (double blind screening) were not significant. The Tzanck smear is reliable, inexpensive, and easy and quick to perform; it is suitable for office diagnosis because it does not require a specialised laboratory.

The Tzanck smear: old, but still of inestimable value.

The Tzanck smear, introduced by the Frenchman Tzanck, has been used for many years in the diagnosis of bullous and vesicular dermatoses especially herpes simplex, herpes zoster and varicella. Also, in the vesicular dermatoses of newborns and immunocompromised patients it is an important diagnostic aid. The Tzanck smear is easy to perform, simple, reliable (if one is experienced) and inexpensive. A quick staining can be done by Hemacolor or Diff-Quik within one minute. The Tzanck smear is certainly useful and very reliable in the diagnosis of herpes simplex and varicella-zoster infections if obtained in the vesicular stage. The sensitivity of the Tzanck smear exceeds 80%, and the specificity 90% when the investigators are experienced. A positive Tzanck smear is an especially reliable and useful diagnostic aid. However, a disadvantage is that the smear cannot differentiate between herpes simplex virus or varicella-zoster virus infections. The Tzanck smear, although old and simple, remains an important aid in the diagnosis of vesicular, pustular and bullous diseases, in particular herpes. Cytology will, however, never replace culturing or histopathology.

Diagnostic value of Tzanck smear in herpetic and non-herpetic vesicular and bullous skin disorders in pediatric practice.

The diagnostic value of the Tzanck smear was investigated in 76 patients of a pediatric hospital population suffering from vesicular, erosive or bullous skin disorders. Examination took place by two investigators together (AB), besides the smears were examined by two others (C and D) double blind. Sensitivity for patients with clinical herpetic infections was greater than 80%, specificity for those without herpetic infections was greater than 90%. These figures are higher than expected from literature. Reliability was also high; between the three investigators no significant differences were found. The Tzanck smear is simple, inexpensive, easy to perform and rapid; it does not require a specialized laboratory, but experience and correct technique of sampling is required.

Subcorneal pustular dermatosis (Sneddon-Wilkinson disease)--therapeutic problems.

A patient with subcorneal pustular dermatosis with a fatal outcome is presented. Treatment with corticosteroids, vitamin E, dapsone, sulphapyridine and levamisole was ineffective. Only systemic treatment with retinoic acid and a new aromatic retinoic acid derivative (Ro 10-9359) produced a satisfactory clinical response, but a complete remission was not obtained.