European Guidelines (S1) on the use of high-dose intravenous immunoglobulin in dermatology.

BACKGROUND: The treatment of severe dermatological autoimmune diseases and toxic epidermal necrolysis (TEN) with high-dose intravenous immunoglobulin (IVIg) is a well-established procedure in dermatology. As treatment with IVIg is usually considered for rare clinical entities or severe clinical cases, the use of immunoglobulin is not generally based on data from randomized controlled trials that are usually required for the practice of evidence-based medicine. Owing to the rarity of the indications for the use of IVIg, it is also unlikely that such studies will be available in the foreseeable future. Because the high costs of IVIg treatment also limit its first-line use, the first clinical guidelines on its use in dermatological conditions were established in 2008 and renewed in 2011. MATERIALS AND METHODS: The European guidelines presented here were prepared by a panel of experts nominated by the EDF and the EADV. The guidelines were developed to update the indications for treatment currently considered as effective and to summarize the evidence base for the use of IVIg in dermatological autoimmune diseases and TEN. RESULTS AND CONCLUSION: The current guidelines represent consensual expert opinions and definitions on the use of IVIg reflecting current published evidence and are intended to serve as a decision-making tool for the use of IVIg in dermatological diseases.

[Sarcoidosis : Organ involvement, diagnosis, current treatment]. / Sarkoidose : Organbeteiligung, Diagnostik, aktuelle Therapie.

Sarcoidosis is characterized by the appearance of noncausating, epitheloid cell granulomas, primarily in skin and lung. Hereditary disposition is well known; additional infection-associated triggers play a role for the development of inflammation mediated by T helper (Th)1 cells. Clinically, various disease courses can be observed that are characterized by the formation of skin papules at typical sites of the body which differ in their tendency to be associated with systemic organ involvement. Systemic disease without skin affections is also possible. The diagnosis is based on the typical clinical appearance, biopsy of affected tissue (e.g. skin, lung) and laboratory investigations. Additional systemic involvement needs to be excluded. In most cases, the disease is self-limited, but can also be life threatening due to organ fibrosis. The degree of (extra-)cutaneous involvement and level of discomfort are used to select the type of treatment, which ranges from topical immune suppressive agents to systemic therapy with corticosteroids. In nonresponders, additional modern immunosuppressive/immunomodulating therapeutic options are available.

Low zone tolerance to contact allergens in mice: a functional role for CD8+ T helper type 2 cells.

Normal skin is permeable to low molecular hydrophobic substances, including allergenic chemicals. Whereas such foreign matter appears to enter the skin naturally, it rarely induces contact hypersensitivity. This suggests that immunological tolerance would be the normal state of affairs. In search of a suitable model, we painted picryl chloride or oxazolone once or repeatedly on normal skin of BALB/c or C57B1/6 mice and found subsensitizing doses to be tolerogenic. The most effective doses in inducing tolerance were doses between those at the point of inflection from no responses to threshold sensitivity. But even doses three orders of magnitude lower than these suppressed subsequent sensitization if applied repeatedly. C57B1/6 mice (low responders) were consistently easier to make tolerant than BALB/c mice (high responders). The tolerant state established by a single painting was found to be fully developed at 48 h after initiation and long-lasting (>14 d). It could be adoptively transferred by intravenous injection of total spleen cells (SC), lymph node cells (LNC), or purified T cells and shown to be hapten specific. Pretreatment with cyclophosphamide (Cy) prevented tolerization. The T cells capable of transferring suppressive activity were found to be generated irrespective of the dose applied. On day 2 after painting, tolerance could be transferred with LNC from both tolerant and sensitized animals. On day 5, however, only cells from tolerant donors transferred tolerance. But by action of Cy, suppression was shown to be part of every sensitization, although masked. Production of hapten-specific antibodies was suppressed as well. Through depletion by monoclonal antibody in vitro the T suppressor cells were shown to belong to the murine CD8+ subset (Lyt2+). Upon restimulation in vitro by haptenized and irradiated normal SC, LNC from tolerant donors produced predominantly interleukin (IL)-4, IL-5, and IL-10. In contrast, LNC from sensitized donors produced preferentially IL-2 and interferon-gamma. Thus we demonstrate that painting subsensitizing doses of contact sensitizers on normal murine skin generates CD8+ Th2-like cells that give rise to hapten-specific tolerance. The model may have broader significance and apply to other species, including humans.

The registry of the German Network for Systemic Scleroderma: frequency of disease subsets and patterns of organ involvement.

OBJECTIVE: Systemic sclerosis (SSc) is a rare, heterogeneous disease, which affects different organs and therefore requires interdisciplinary diagnostic and therapeutic management. To improve the detection and follow-up of patients presenting with different disease manifestations, an interdisciplinary registry was founded with contributions from different subspecialties involved in the care of patients with SSc. METHODS: A questionnaire was developed to collect a core set of clinical data to determine the current disease status. Patients were grouped into five descriptive disease subsets, i.e. lcSSc, dcSSc, SSc sine scleroderma, overlap-syndrome and UCTD with scleroderma features. RESULTS: Of the 1483 patients, 45.5% of patients had lcSSc and 32.7% dcSSc. Overlap syndrome was diagnosed in 10.9% of patients, while 8.8% had an undifferentiated form. SSc sine scleroderma was present in 1.5% of patients. Organ involvement was markedly different between subsets; pulmonary fibrosis for instance was significantly more frequent in dcSSc (56.1%) than in overlap syndrome (30.6%) or lcSSc (20.8%). Pulmonary hypertension was more common in dcSSc (18.5%) compared with lcSSc (14.9%), overlap syndrome (8.2%) and undifferentiated disease (4.1%). Musculoskeletal involvement was typical for overlap syndromes (67.6%). A family history of rheumatic disease was reported in 17.2% of patients and was associated with early disease onset (P < 0.005). CONCLUSION: In this nationwide register, a descriptive classification of patients with disease manifestations characteristic of SSc in five groups allows to include a broader spectrum of patients with features of SSc.

Macrophages and angiogenesis.

Macrophages are supposed to play a key role in inflammatory and tumor angiogenesis. Their importance derives from (1) their ubiquitous presence in normal and especially inflamed tissues, (2) their potential to become activated in response to appropriate stimuli, and (3) their repertoire of secretory products. By release of proteases, growth factors (bFGF, GM-CSF, TGF-alpha, IGF-I, PDGF, VEGF/VPF, TGF-beta), and other monokines (IL-1, IL-6, IL-8, TNF-alpha, substance P, prostaglandins, interferons, thrombospondin 1), activated macrophages have the capability to influence each phase of the angiogenic process, such as alterations of the local extracellular matrix, induction of endothelial cells to migrate or proliferate, and inhibition of vascular growth with formation of differentiated capillaries. This review describes macrophage physiology and the influence of macrophage secretory products on the different phases of angiogenesis in vitro and in vivo.

Induction of low zone tolerance to contact allergens in mice does not require functional Langerhans cells.

Epidermal Langerhans cells are known to be the major controlling element in the development of contact hypersensitivity. Haptenic molecules permeating the skin are taken up locally by Langerhans cells and then presented to T lymphocytes in the regional lymph nodes. Despite the presence of functional Langerhans cells, however, subsensitizing doses of hapten applied epicutaneously induce tolerance. We examined epidermal Langerhans cells at the site of contact with picryl chloride or oxazolone in BALB/c and C57B1/6 mice with regard to their responding to either subsensitizing or sensitizing doses of allergen. Subsensitizing doses did not interfere with the membranous adenosine triphosphatase system on Langerhans cells, known to relate to functional readiness of the cell. Accordingly, on electron microscopy the ultrastructure of Langerhans cells was found to be like that in untreated skin. In contrast, sensitizing doses caused a significant depletion of adenosine triphosphatase-positive Langerhans cells, and electron microscopy revealed marked cellular activation of Langerhans cells, with enlarged nuclei and increased numbers of mitochondria and Birbeck granules. Furthermore, subsensitizing doses induced tolerance regardless of whether Langerhans cells were functionally intact or had their function blocked arbitrarily. Blocking was achieved either by preceding ultraviolet B irradiation at the site of application or by painting of a sensitizer before painting another sensitizer on the same site. Moreover, not even surgical removal of the site within minutes after painting could prevent the induction of tolerance. The data suggest that subsensitizing doses of contact allergens painted on normal murine skin bypass involvement of epidermal Langerhans cells.

Fetal calf serum-free generation of functionally active murine dendritic cells suitable for in vivo therapeutic approaches.

UNLABELLED: Standard protocols to generate mouse dendritic cells (DC) generally use culture medium supplemented with fetal calf serum; however, reinjection in vivo of DC cultured in fetal calf serum results in priming to xenogeneic proteins that clearly limits the use of such DC. We therefore established a fetal calf serum-free culture system for the generation of murine DC from bone marrow precursors. DC can be generated fetal calf serum-free using RPMI supplemented with 1.5% syngeneic mouse serum. Although the yield of DC grown under fetal calf serum-free conditions was somewhat lower than that of the standard culture, large numbers of DC could be generated without the exposure to xenogeneic proteins. The yield of fetal calf serum-free cultured DC was further enhanced by addition of the proinflammatory cytokines TNF-alpha and IL-1beta with the combination resulting in up to 10% more DC. Phenotypically, CD11c + DC cultured fetal calf serum-free homogenously coexpressed the DC-specific molecule DEC-205 as well as the costimulatory molecules CD40, CD80, and CD86. In contrast, only a subpopulation of the CD11c + DC cultured in fetal calf serum-containing medium coexpressed these molecules. Functionally, fetal calf serum-free DC showed strong stimulatory capacity for naïve allogeneic CD4 + and CD8 + T cells. Importantly, fetal calf serum-free DC showed spontaneous in vivo migratory activity. Moreover, 5 x 105 subcutaneously injected TNBS-conjugated fetal calf serum-free DC were able to mediate contact sensitivity. Furthermore, the intravenous or subcutaneous injection of a single dose of 5 x 105 OVA-pulsed fetal calf serum-free DC resulted in the induction of an OVA-specific immune response in naïve TCR transgenic animals. Thus DC cultured under fetal calf serum-free conditions are suitable instruments for in vivo therapeutic approaches, especially in autoimmune models. KEYWORDS: DC vaccines/dendritic cell development/fetal calf serum-free culture conditions for DC/in vivo therapeutic DC approaches.

Ineffective elimination of Leishmania major by inflammatory (MRP14-positive) subtype of monocytic cells.

Myeloid-related protein (MRP) 14, an intracellular protein involved in calcium-dependent activation of myeloid cells, presents a differentiation marker for a subtype of macrophages. In experimental leishmaniasis, BALB/c mice succumb to visceral dissemination after infection with L. major, due to a Th2 cell response, while C57Bl/6 mice develop protective immunity associated with a Th1 cell response. We have previously shown that resistance in (C57Bl/6 mice was also associated with a significantly lower percentage of MRP14-positive cells in the infiltrate than in susceptible BALB/c mice. In C57Bl/6 mice, weekly injections of bone marrow (BM) cells enriched with MRP14-positive cells (d1 of culture) did not reverse, but prolonged the course of infection, associated with increased local parasite spread. In BALB/c mice a single dose of an antiphlogistic agent (dexamethasone or lipoxygenase inhibitor) was associated with reduction of infiltrating MRP14-positive cells and also with a decrease of parasite loads in footpads, lymph nodes as well as spleens, and with delayed progression of disease, Double labeling experiments in vitro revealed that at least 43.1% of MRP14-positive mononuclear cells in BM cultures (8h) had phagocytosed parasites after 4 h of co-incubation. Activation by IFN-gamma (20 U/ml) for 24h and 48h did not significantly reduce parasite load in these cells. In contrast, 77.0% of F4/80-positive macrophages (6d of culture) were infected with L. major parasites and these cells responded to activation with IFN-gamma (20 U/ml) with significant reduction of parasite load (25.3%). The protein MRP14 did not have an effect on parasite survival in vitro. Thus, the impaired capability of MRP14-positive cells to kill L. major upon stimulation may be one reason for the adverse course of infection observed with their increased appearance.

Induction of dendritic cell maturation and modulation of dendritic cell-induced immune responses by prostaglandins.

Dendritic cells (DC) are the most potent antigen-presenting cells of the immune system. In this study we investigated the effects of various prostaglandins (PG) on the stimulatory capacity of DC. DC were generated from peripheral progenitor cells in the presence of IL-4 and GM-CSF and stimulated with IL-1, IL-6 and TNF-alpha on day 7. Simultaneously, PG (PGD(2), PGE(1), PGE(2), PGF(2 alpha), PGI(2)) were added at various concentrations (10(-5) to 10(-9) M) on day 7. In all experiments, PGE(2) had the most potent influence on the maturation of the DC, followed by other PG in the order PGE(1) > PGD(2) > PGF(2 alpha) > PGI(2). In addition, the expression of the surface molecules CD40, CD54, CD58, CD80, CD83, CD86 and the MHC class II molecules was upregulated after stimulation with PG. Analysis of DC supernatants after treatment with PG demonstrated significantly higher amounts of the proinflammatory cytokines IL-1 beta, IL-6, TNF-alpha, and IL-12. Addition of PG to DC induced a markedly enhanced proliferation of both naive and activated CD4(+) and CD8(+) T cells in alloantigen-induced MLR assays. Assessment of coculture supernatants after restimulation revealed significantly higher amounts of the Th1-cytokines IL-2 and IFN-gamma and only minimal amounts of IL-4 compared to control cells. No production of IL-10 was observed. The effects of PG on the maturation of DC and enhanced T-cell proliferation could be mimicked by db-cAMP and forskolin, indicating that they were due to elevated cAMP levels. Collectively, our data show that members of the PG family promote the differentiation of DC and enhance their capacity to induce a Th1 immune response.

The total femoral prosthesis. A preliminary report.

The use of a total femoral prosthesis can offer a realistic alternative to amputation or disarticulation. The limited indications for such a prosthesis in the surgical management of primary bone tumours and pathological fractures still exist. In this specialised clinic there is an increased need to replace the entire femur where repeated procedures have failed, from loss of bone stock with infection or because of non-union in the presence of a prosthesis. Over the past eight years, four basic models have been developed. The most recent designs allow for the preservation of non-involved bone or for stable support where there is complete acetabular destruction.

The saddle prosthesis for salvage of the destroyed acetabulum.

We report the 12 to 74 month results of our mark I saddle prosthesis after its use as a salvage device for gross loss of pelvic bone stock in 76 patients with failed hip arthroplasties. The implant transmits load between iliac bone and bare polish chrome-cobalt. Our clinical and radiological results indicate that a useful and stable articulation can be achieved in most cases, provided that continued deep infection can be avoided. The appearance of radiological sclerosis at the bearing site in successful cases seems to indicate that significant late migration will not occur. Based on our experience with the mark I prosthesis we have designed and developed a mark II model which has freedom of axial rotation of the saddle. Our early results in 40 cases show a significant improvement over the results which could have been predicted for the mark I device.

[Value of irrigation-suction drainage in the treatment of early infection of joint implants]. / Stellenwert der Spül-Saug-Drainage bei der Behandlung des Frühinfekts von Gelenkimplantaten.

The analysis of follow-up examinations on 77 patients at the Endo-Klinik who were treated with suction irrigation drainage for acute postoperative infection after joint replacement surgery during the last 12 years showed a success rate up to a maximum of 60%. The success of this treatment increased, the earlier and more thoroughly it was performed. Only when the suction irrigation drainage is combined with radical excision of infected soft tissue this operation can save the implant and prolong its service life.

[Modular system for the total replacement of the femur--Endo-model]. / Modulares System für den Femurtotalersatz--Endo-Modell.

Total femur replacement may offer a useful solution in cases of severe trauma or neoplasia and in revision arthroplasty after failed total joint replacement when gross losses of bone have resulted in an unloadable femur and all other methods of treatment would fail to provide the patient with a stable leg. Until recently, total femur components were custom-made, but now we have a comprehensive modular total femur implant available reducing problems of preoperative preparation and simplifying the manufacture of custom-made designs. The new device can be shaped and adapted to the conditions encountered at the time of operation. The "push-through" type of prosthesis can be mounted step by step and converted into a total femur replacement with either a conventional head or a saddle at the proximal end and a total axial rotating knee prosthesis at the distal end. Elongation of the entire system is feasible.

[Injury to pelvic vessels in total hip replacement surgery]. / Verletzung von Beckengefässen bei totalem Hüftgelenksersatz.

Massive bleeding of the pelvic vessels during an alloarthroplastic operation on the hip joint should be suspected in cases of abnormal anatomic conditions. Therefore, the operative procedure should be meticulously planned including extensive X-ray investigations such as angiography and computer-tomography. Surgical preparation and procedures in case of vascular complications are described. Hints on operative techniques are given to prevent vascular complications during and after surgical intervention of the hip joint.

[Hypocomplementemic urticarial vasculitis syndrome. Successful therapy with intravenous immunoglobulins]. / Hypokomplementämisches Urtikaria-Vaskulitis-Syndrom. Erfolgreiche Therapie mit intravenösen Immunglobulinen.

Autoimmune diseases can initially present as chronic urticaria. We describe the course of a patient with hypocomplementemic urticarial vasculitis syndrome (HUVS) as well as his successful treatment with high-dose intravenous immunoglobulins (IVIG). HUVS was diagnosed clinically and confirmed by histology and laboratory studies. After only one cycle with IVIG (2 g/kg) all HUVS symptoms were significantly decreased.

[Procedure in extensive or complete loss of bone substance of the femur following shaft loosening]. / Vorgehen bei ausgedehntem oder völligem Knochensubstanzverlust des Femurs nach Schaftlockerung.

We reviewed our present method of treatment in cases of femoral bone loss. Our clinical experience with the method is based on 800 exchange operations performed at the Endo-Klinik per year. The review showed that in cases of proximal bone deficiency, custom-made protheses are increasingly required. Cemented implants are used in septic and aseptic cases but we also have had experience with a small number of cases in which reconstructive surgery was carried out using allografts and cementless shaft components. In 1.4% of revision cases total femoral replacement is required. We have had more than 12 years experience with this type of prostheses, which is available as a modular system. So far there has been no disarticulation as a result of implant failures but in some instances failure occurred due to persistent deep infections.

The case for revision arthroplasty using antibiotic-loaded acrylic cement.

For managing infected joint implants, revision arthroplasty using antibiotic-loaded acrylic cement (ALAC) has proven to be superior to other methods of treatment that are currently available. Ablation of the implant, cement, and necrotic tissue is essential. Further refinement of the ALAC method is possible. Analysis of complications shows that disarticulation and a permanent Girdlestone can become rare surgical procedures.

[Significance of immunologic tolerance in dermatology]. / Bedeutung der immunologischen Toleranz in der Dermatologie.

The immunological tolerance processes enable the organism to distinguish between self and non-self and are, therefore, critical for an efficient immune system. Exogenous or endogenous factors that disturb tolerance mechanisms induce uncontrolled activation of the immune system and the development of autoimmune diseases. In the field of dermatology, the most relevant autoimmune diseases are connective tissue diseases and autoimmune bullous skin disorders. In contrast, increased activity of tolerance shuts down parts of the normal immune response and thus facilitates the development of neoplasia and microbial infections in the skin and other organs. Immunological mechanisms for the induction of tolerance have been studied with the help of experimental models of tolerance to contact allergens. T- and B-cells, as well as antigen presenting cells, in particular dendritic cells, are involved in the immunological mechanisms of tolerance. The modification of autologous immune cells of patients with malignant tumors, allergic and autoimmune diseases might have potential for the development of new therapies.

[Treatment of periprosthetic infection of the hip using one-stage exchange surgery]. / Behandlung der periprothetischen Infektion der Hüfte durch einzeitige Austauschoperation.

This article presents the theoretical microbiological principles involved in the pathogenesis of periprosthetic infection, the role of microbiology in diagnosing this disease, and factors requiring special consideration when selecting topical antibiotics. It also describes the operative technique of one-stage exchange arthroplasty using antibiotic-loaded acrylic cement and the results achieved with this method to date.