Comparison of lesional skin c-KIT mutations with clinical phenotype in patients with mastocytosis.

BACKGROUND: Activating c-KIT mutations cause abnormal mast cell growth and appear to play a role in mastocytosis. However, the correlation of c-KIT mutations with disease phenotypes is poorly characterized. AIM: To evaluate the correlation of c-KIT mutations with clinical presentations and laboratory findings. METHODS: Total cellular RNA was isolated from the skin lesions of 43 adults and 7 children with mastocytosis, and PCR amplicons of cDNA were sequenced for c-KIT mutations. RESULTS: The most common activating mutation, KIT-D816V, was identified in 72% of adults and 57% of children. Additional activating mutations, namely, V560G and the internal tandem duplications (ITDs) 502-503dupAY, were detected in 12% of adults and 8% of children. V560G occurred more commonly in our patients than previously reported, and it appeared to be associated with more advanced disease. Otherwise, the presence or absence of activating mutations did not correlate with skin lesion morphology, disease extent or total serum tryptase levels. Four adults had expression only of wild-type KIT, while two others had expression of a truncated KIT lacking tyrosine kinase activity; yet these patients were clinically indistinguishable from those patients with activating c-KIT mutations. CONCLUSIONS: Activating c-KIT mutations exist in a significant portion of patients with mastocytosis, but not all patients showed expression of these mutations. Except for V560G, the presence or absence of activating c-KIT mutations did not predict the extent of disease. These observations suggest that although activating c-KIT mutations are associated with mast cell growth, other genes probably play a role in the cause of mastocytosis.

Distinct signalling pathways for mutated KIT(V560G) and KIT(D816V) in mastocytosis.

BACKGROUND: The activating mutations KIT(V560G) and KIT(D816V) are associated with mastocytosis. Thus, identifying and inhibiting the signalling pathways associated with mutated KIT gene offers a potentially important strategy for the treatment of mastocytosis. AIM: To correlate KIT mutations with specific signalling pathways in human mast-cell lines using pathway inhibitors. METHODS: Human mast-cell (HMC) lines expressing KIT(V560G) (the cell line HMC-1) and KIT(V560G and D816V) (HMC-1.2) were treated with specific signalling pathway inhibitors for 1-5 days, and the inhibitory effects on growth were determined by the 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) cell-proliferation assay, western blotting and flow cytometry. RESULTS: Growth inhibitory assays and western blot analyses showed that the Janus kinase 3/signal transducer and activator of transcription (JAK3/STAT) pathway is the preferential signalling pathway for KIT(V560G), whereas the mechanistic target of rapamycin complex 1/4E-binding protein 1 (mTORC1/4E-BP1) pathway is preferentially linked to KIT(D816V). Inhibition of these critical signalling pathways results in programmed cell death. CONCLUSIONS: KIT(V560G) and KIT(D816V) use different signalling pathways that promote mast-cell growth. Inhibitors of these specific pathways might be effective in treating mastocytosis.

Mutations in the PSTPIP1 gene and aberrant splicing variants in patients with pyoderma gangrenosum.

BACKGROUND: Pyoderma gangrenosum (PG) is a rare, noninfectious form of skin ulceration, typically accompanied by neutrophilic infiltration. Several familial cases have been reported, suggesting the involvement of genetic factors in the aetiology of PG. Two mutations (A230T and E250Q) in the PSTPIP1 gene, encoding proline-serine-threonine phosphatase-interacting protein (PSTPIP)1 have been identified in patients with PAPA (pyogenic sterile arthritis with PG and acne) syndrome, a rare autoinflammatory disorder with autosomal dominant inheritance. AIM: The aim of this study was to sequence PSTPIP1 complementary cDNA and genomic DNA for mutations, and to identify genetic polymorphisms in the promoter region of PSTPIP1 in patients with PG. METHODS: The genomic region and cDNA of the PSTPIP1 gene were sequenced from peripheral blood leucocytes of 14 patients with PG and 20 healthy controls. RESULTS: One patient (PG1) had aberrant splicing variants of the PSTPIP1 transcript with deletions of exons 9, 11 and 12 and of exons 9-12 together, and all other patients with PG carried deletions of exon 11 and of 11-12. We also identified a novel mutation (G258A) in patient PG3, and novel polymorphisms [(CCTG)(6) and (CCTG)(8) tandem repeats] in the promoter region of the PSTPIP1 gene. CONCLUSION: All combinations of aberrant splicing variants had frame shifts and premature stop codons leading to truncated proteins and loss of function of PSTPIP1. The (CCTG)(n) tandem repeats in the promoter region of PSTPIP1 had no association with PG. The mutations G258A and R52Q are predicted by the improved prediction algorithm to have a possibly damaging effect on PSTPIP1 function.

Modeling transient response of forests to climate change.

Our hypothesis is that a high diversity of dominant life forms in Tennessee forests conveys resilience to disturbance such as climate change. Because of uncertainty in climate change and their effects, three climate change scenarios for 2030 and 2080 from three General Circulation Models (GCMs) were used to simulate a range of potential climate conditions for the state. These climate changes derive from the Intergovernmental Panel on Climate Change (IPCC) "A1B" storyline that assumes rapid global economic growth. The precipitation and temperature projections from the three GCMs for 2030 and 2080 were related to changes in five ecological provinces using the monthly record of temperature and precipitation from 1980 to 1997 for each 1km cell across the state as aggregated into the provinces. Temperatures are projected to increase in all ecological provinces in all months for all three GCMs for both 2030 and 2080. Precipitation differences from the long-term average are more complex but less striking. The forest ecosystem model LINKAGES was used to simulate conditions for five ecological provinces from 1989 to 2300. Average output projects changes in tree diversity and species composition in all ecological provinces in Tennessee with the greatest changes in the Southern Mixed Forest province. Projected declines in total tree biomass are followed by biomass recovery as species replacement occurs in stands. The Southern Mixed Forest province results in less diversity in dominant trees as well as lower overall biomass than projections for the other four provinces. The biomass and composition changes projected in this study differ from forest dynamics expected without climate change. These results suggest that biomass recovery following climate change is linked to dominant tree diversity in the southeastern forest of the US. The generality of this observation warrants further investigation, for it relates to ways that forest management may influence climate change effects.

A GIS/simulation framework for assessing change in water yield over large spatial scales.

Recent legislation to initiate vegetation management in the Central Sierra hydrologic region of California includes a focus on corresponding changes in water yield. This served as the impetus for developing a combined geographic information system (GIS) and simulation assessment framework. Using the existing vegetation density condition, together with proposed rules for thinning to reduce fire risk, a set of simulation model inputs were generated for examining the impact of the thinning scenario on water yield. The approach allows results to be expressed as the mean and standard deviation of change in water yield for each 1-km2 map cell that is thinned. Values for groups of cells are aggregated for typical watershed units using area-weighted averaging. Wet, dry, and average precipitation years were simulated over a large region. Where snow plays an important role in hydrologic processes, the simulated change in water yield was less than 0.5% of expected annual runoff for a typical watershed. Such small changes would be undetectable in the field using conventional stream flow analysis. These results suggest that use of water yield increases to help justify forest-thinning activities or offset their cost will be difficult.

Mastocytosis.

Mastocytosis represents a heterogeneous group of clinical disorders resulting from the infiltration of mast cells in the skin and other organs. Although mastocytosis was first described over 130 years ago, the pathophysiologic mechanisms responsible for this disease have been identified only recently. This article discusses the salient clinical features of the disease, the mechanisms responsible for its development, and provides treatment approaches that have proven useful for managing patients with this disorder.

New insights into the second generation antihistamines.

Second generation antihistamines are recognised as being highly effective treatments for allergy-based disease and are among the most frequently prescribed and safest drugs in the world. However, consideration of the therapeutic index or the benefit/risk ratio of the H1 receptor antagonists is of paramount importance when prescribing this class of compounds as they are used to treat non-life threatening conditions. There are many second generation antihistamines available and at first examination these appear to be comparable in terms of safety and efficacy. However, the newer antihistamines in fact represent a heterogeneous group of compounds, having markedly differing chemical structures, adverse effects, half-life, tissue distribution and metabolism, spectrum of antihistaminic properties, and varying degrees of anti-inflammatory effects. With regard to the latter, there is growing awareness that some of these compounds might represent useful adjunct medications in asthma therapy. In terms of safety issues, the current second generation grouping includes compounds with proven cardiotoxic effects and others with the potential for adverse drug interactions. Moreover, some of the second generation H1 antagonists have given cause for concern regarding their potential to cause a degree of somnolence in some individuals. It can be argued, therefore, that the present second generation grouping is too large and indistinct since this was based primarily on the concept of separating the first generation sedating compounds from nonsedating H1 antagonists. Although it is too early to talk about a third generation grouping of antihistamines, future membership of such a classification could be based on a low volume of distribution coupled with a lack of sedating effects, drug interactions and cardiotoxicity.

B-cell lymphoma in a patient with WHIM syndrome.

WHIM syndrome is a rare congenital familial syndrome consisting of warts, hypogammaglobulinemia, infections, and myelokathexis. We describe a 30-year-old man with WHIM syndrome, in whom red dermal facial nodules developed. The diagnosis of B-cell lymphoma was established with biopsy and immunohistochemical studies. To our knowledge, this is the first reported case of WHIM syndrome complicated by a B-cell lymphoma.

Recalcitrant molluscum contagiosum in an HIV-afflicted male treated successfully with topical imiquimod.

Molluscum contagiosum is a common cutaneous infection complicating the course of patients afflicted with acquired immunodeficiency syndrome. We describe a human immunodeficiency virus-positive patient with a disfiguring molluscum contagiosum infection of the face. Conventional cytodestructive therapies failed in this patient, but imiquimod 5% cream, an immunomodulator, clinically cleared his cutaneous disease.

Activating and dominant inactivating c-KIT catalytic domain mutations in distinct clinical forms of human mastocytosis.

Human mastocytosis is characterized by increased mast cells. It usually occurs as a sporadic disease that is often transient and limited in children and persistent or progressive in adults. The c-KIT protooncogene encodes KIT, a tyrosine kinase that is the receptor for mast cell growth factor. Because mutated KIT can transform cells, we examined c-KIT in skin lesions of 22 patients with sporadic mastocytosis and 3 patients with familial mastocytosis. All patients with adult sporadic mastocytosis had somatic c-KIT mutations in codon 816 causing substitution of valine for aspartate and spontaneous activation of mast cell growth factor receptor (P = 0.0001). A subset of four pediatric onset cases with clinically unusual disease also had codon 816 activating mutations substituting valine, tyrosine, or phenylalanine for aspartate. Typical pediatric patients lacked 816 mutations, but limited sequencing showed three of six had a novel dominant inactivating mutation substituting lysine for glutamic acid in position 839, the site of a potential salt bridge that is highly conserved in receptor tyrosine kinases. No c-KIT mutations were found in the entire coding region of three patients with familial mastocytosis. We conclude that c-KIT somatic mutations substituting valine in position 816 of KIT are characteristic of sporadic adult mastocytosis and may cause this disease. Similar mutations causing activation of the mast cell growth factor receptor are found in children apparently at risk for extensive or persistent disease. In contrast, typical pediatric mastocytosis patients lack these mutations and may express inactivating c-KIT mutations. Familial mastocytosis, however, may occur in the absence of c-KIT coding mutations.

Once-weekly fluconazole (450 mg) for 4, 6, or 9 months of treatment for distal subungual onychomycosis of the toenail.

BACKGROUND: Fluconazole is a bis-triazole antifungal agent approved for the treatment of oropharyngeal, esophageal, and vaginal candidiasis, serious systemic candidal infections, and cryptococcal meningitis. OBJECTIVE: The purpose of this study was to evaluate three different durations of once-weekly fluconazole for the treatment of onychomycosis of the toenail caused by dermatophytes. METHODS: In a multicenter, randomized, double-blind, parallel, placebo-controlled trial, 384 patients with distal subungual onychomycosis of the toenail received fluconazole, 450 mg once weekly, or placebo for 4, 6, or 9 months. For inclusion, patients were required to have mycologically confirmed distal subungual onychomycosis of the toenail with a large toenail at least 25% clinically affected but having at least 2 mm of healthy nail between the nail fold and the proximal onychomycotic border. Efficacy was assessed by clinical and mycologic (microscopic and microbiologic) measures at screening, at every treatment visit starting at month 3, and at months 2, 4, and 6 after therapy. Observed or volunteered adverse events were recorded and classified at all visits. RESULTS: At the end of treatment, very significantly superior clinical and mycologic results were achieved in all fluconazole groups compared with placebo (p=0.0001). This superiority was largely maintained over 6 months of follow-up. The clinical and mycologic responses of the 9-month treatment duration were significantly superior to the 4- and 6-month durations. Similar percentages of patients in the fluconazole and placebo groups reported adverse experiences for all three durations of the study. CONCLUSION: Results of this study support the efficacy and safety of fluconazole in the treatment of distal subungual onychomycosis of the toenail.

Clobetasol propionate emollient 0.05% in the treatment of atopic dermatitis.

A 4-week, double-blind, randomized clinical trial, comparing the efficacy and safety of clobetasol propionate emollient cream 0.05% and its vehicle, was conducted at four private dermatology clinics in 81 non-hospitalized patients (> or = 12 years old) with moderate-to-severe atopic dermatitis covering 2% or more of their body surface. All patients had at least one lesion 2 cm or more in diameter. Three signs/symptoms of target lesions (erythema, pruritus, and induration/papulation) were scored by investigators on a scale of 0-3 (in 0.5-point increments; 0 = absent, 1 = mild, 2 = moderate, and 3 = severe); the total of the three scores had to be > or = 6 for patients to qualify for study entry. Patients were excluded if they were immunocompromised, pregnant, or nursing; had skin atrophy, telangiectasia or striae in skin areas to be treated; or had received topical treatments for atopic dermatitis within 1 week prestudy, intramuscular triamcinolone within 6 weeks prestudy, or long-term systemic corticosteroid usage within 6 months prestudy. Patients were randomized in a 1:1 ratio to receive either clobetasol propionate emollient 0.05% twice daily (n = 41), or the emollient vehicle twice daily (n = 40), for 4 weeks. A fingertip unit, equaling approximately 0.5 g in males and 0.43 g in females (enough to cover approximately 2% of the body), was used to measure and apply a thin film of study drug to the affected areas. The efficacy was evaluated by investigators and patients on days 4, 8, 15, and 29 after initiation of therapy, and 2 weeks after the end of treatment (day 43). Investigators performed a physician's gross assessment based on the percentage improvement of the target lesion. They also rated changes from baseline in mean severity scores for six individual signs/symptoms (erythema, pruritus, induration/papulation, lichenification, erosion/oozing/crusting, and scaling/dryness) and for total signs/symptoms according to the severity scoring system described above. Patients rated their response to treatment as excellent, good, fair, poor, or worse. Laboratory assessments were made on days 15, 29, and (if necessary) day 43.

Chronic urticaria: pathophysiology and treatment approaches.

Urticaria, a cutaneous reaction pattern, varies clinically and histopathologically. The origin of acute urticaria can be detected in some cases; in patients with chronic urticaria, however, the cause is rarely identified. Thus, most patients with chronic urticaria are considered to have idiopathic disease. The dermal mast cell and its mediators may play a central role in chronic idiopathic urticaria. Other inflammatory cells, including lymphocytes and polymorphonuclear cells, have also been implicated. Treatment is based on identification of the inflammatory cells within skin lesions and blockage of the effects of histamine in the skin. Urticaria in which a lymphocyte-predominant infiltrate is seen often responds to one or more H1 antihistamines. Recently, a new generation of nonsedating or mildly sedating H1 antihistamines has proved useful in the management of these cases. Antihistamine use alone may be unsuccessful in urticaria in which polymorphonuclear neutrophils predominate; frequently, the addition of agents that alter polymorphonuclear neutrophil function, such as colchicine or dapsone, is required. During the introduction of antihistamine and anti-polymorphonuclear neutrophil therapy, a simultaneous brief course of systemic corticosteroid therapy may be necessary, but the extended use of systemic corticosteroids should be avoided because of significant adverse effects. As the pathophysiologic mechanisms responsible for chronic urticaria are better defined, more effective therapeutic agents should become available.

Cetirizine: a new therapeutic alternative for chronic urticaria.

Chronic urticaria represents a cutaneous reaction pattern that may last for slightly more than six weeks to more than five years. Treatment of patients with chronic urticaria can be a problem for both physician and patient because of the significant side effects that may be caused by first-generation H1 antihistamines or long-term corticosteroid therapy. Newer antihistamines represent a major advance for the treatment of patients with chronic urticaria. Of this group, cetirizine appears to offer some distinct pharmacokinetic and pharmacodynamic advantages. An open-label multicenter trial of 217 patients with chronic idiopathic urticaria demonstrated that cetirizine was effective, rapid in onset, and well tolerated. Thus, cetirizine was shown to be an attractive alternative treatment for patients with chronic idiopathic urticaria.