Disseminated toxoplasmosis with atypical symptoms which developed with exacerbation of systemic lupus erythematosus.

Toxoplasma is a common parasite worldwide that mainly affects the brain, lungs and eyes. Although toxoplasmic encephalitis is a lethal disease without treatment, past case reports show most patients with systemic lupus erythematosus who developed toxoplasmic encephalitis were misdiagnosed and treated as neuropsychiatric systemic lupus erythematosus, which led to unfavorable outcomes. We herein describe a case of disseminated toxoplasmosis affecting all the above organs with atypical symptoms, which developed with exacerbation of systemic lupus erythematosus. She had initially manifested with retinochoroiditis without vitritis, mild cognitive impairment and an isolated lung mass. These are completely different from the classic symptoms of toxoplasmosis that have been reported in patients with HIV infection and/or those after hematopoietic transplantation. Our case, together with previously reported cases, suggests the manifestation of toxoplasmosis that develops in systemic lupus erythematosus patients can be different from that seen in conventional cases and varies between individual patients. Our case highlights both the difficulty in and the importance of diagnosing toxoplasmosis in patients with systemic lupus erythematosus and provides helpful information to identify this rare, devastating, yet treatable disease.

Successful treatment of toxoplasmic encephalitis diagnosed early by polymerase chain reaction after allogeneic hematopoietic stem cell transplantation: two case reports and review of the literature.

Toxoplasmic encephalitis represents a rare, but often fatal infection after allogeneic hematopoietic stem cell transplantation. Polymerase chain reaction (PCR)-based preemptive therapy is considered promising for this disease, but is not routinely applied, especially in low seroprevalence countries including Japan. We encountered 2 cases of toxoplasmic encephalitis after transplantation that were successfully treated. The diagnosis of toxoplasmic encephalitis in these cases was confirmed by PCR testing when neurological symptoms were observed. Both patients received pyrimethamine and sulfadiazine treatments within 2 weeks of the development of neurological symptoms, and remained free of recurrence for 32 and 12 months. These results emphasized the importance of the PCR test and immediate treatment after diagnosis for the management of toxoplasmic encephalitis.

Overexpression of IL-8 in the cornea induces ulcer formation in the SCID mouse.

AIMS: Although interleukin 8 (IL-8) is not produced in the normal cornea, it has been detected there in several pathological conditions. In this study, the direct effects of IL-8 overexpression on the cornea was examined. METHODS: The corneal surface of severe combined immunodeficiency mice was infected by the adenovirus vector encoding human IL-8 (IL-8/Ad5) and clinical and pathological changes were observed at various time points. RESULTS: Clinically, marked angiogenesis and ulcer formation in the cornea were observed by 12 hours and 24 hours, respectively. Histologically, prominent angiogenesis was observed in the corneal stroma at 12 hours. Cleft formation between the corneal epithelium and stroma, and neutrophil infiltration into the corneal stroma were seen at 16 hours. By 24 hours after the infection with IL-8/Ad5, a shallow ulcer was formed in the cornea. In contrast, infection with the control adenovirus carrying the beta galactosidase gene (LacZ) showed neither corneal ulceration nor neutrophil infiltration. Immunohistochemical analysis showed that infection with IL-8/Ad5 resulted in the production of IL-8 by corneal and conjunctival stromal cells. CONCLUSION: Our results indicate that IL-8 overexpression in corneal tissue causes ulcer formation in the cornea through chemoattraction of neutrophils, suggesting the aetiological role of IL-8 in some types of corneal ulcers.

Heat stress-induced modulation of host defense against Toxoplasma gondii infection in mice.

This study examined the effects of burn injury on murine immune response against Toxoplasma gondii infection. Male C57BL/6 mice were divided into 3 groups: T. gondii infection (group T), burn injury (group B), and burn injury followed by T. gondii infection (group BT). The survival of group BT was significantly lower than those of group B and group T. Parasite abundance in the tissues was determined by quantitative competitive-polymerase chain reaction. Group BT exhibited significantly higher numbers of T. gondii than group T. Antibody production against T.g.HSP30 in group BT was significantly lower than that in group T, whereas no significant difference was observed in SAG1-specific antibody production. Delayed-type hypersensitivity (DTH) specific for 2,4-dinitrofluorobenzene (DNFB) of both group B and group BT was significantly lower than that of group T. One week after infection, serum interferon-gamma (IFN-gamma) and interleukin (IL)-10 levels in group BT were significantly lower, whereas serum IL-6 levels were significantly higher than in group T Serum TNF-alpha levels in both group T and group BT were elevated at 1 wk after infection, although there was no significant difference between them. Serum IFN-gamma, IL-10, and TNF-alpha levels in group B were not elevated during the experimental term. In conclusion, the impaired antigen-specific antibody production and DTH response, together with the modulated patterns of cytokine responses, seemed to be strongly involved in the development of burn-induced immunosuppression and the consequent increased susceptibility to T. gondii infection in mice.

Immunologic analysis of cerebrospinal fluid lymphocytes in Vogt-Koyanagi-Harada disease.

In this study, we focused upon the immunologic aspects of Vogt-Koyanagi-Harada disease (VKH) by comparing the cytotoxic activity of peripheral blood leukocytes (PBL) to that of cerebrospinal fluid leukocytes (CSFL) against the human melanoma cell line (P-36) and the human cervical carcinoma cell line (HeLa-S3). The PBL from patients with VKH showed significant cytotoxic activity against P-36 (P less than 0.01), but did not show cytotoxic activity against HeLa-S3. The CSFL showed significantly weaker cytotoxic activity against P-36 compared to that of PBL (P less than 0.02). We also analyzed the cell membrane surface markers applying monoclonal antibodies on PBL and CSFL. The percentage of OKT8+ (CD8: T cytotoxic/suppressor lymphocytes) cells was significantly lower in CSFL than in PBL (P less than 0.05). There was a tendency toward a higher percentage of HLA-DR+ cells (B lymphocytes, monocytes, macrophages, and activated T lymphocytes) and a higher ratio of OKT4+/8+ cells (CD4/CD8: T helper/inducer lymphocytes/T cytotoxic/suppressor lymphocytes) in CSFL from patients with VKH than in their PBL (P less than 0.1).

Dominance of activated T cells and interleukin-6 in aqueous humor in Vogt-Koyanagi-Harada disease.

PURPOSE: To determine the immunopathologic role of the lymphocytes and lymphokines in aqueous humor (AH) of patients with Vogt-Koyanagi-Harada disease (VKH). METHODS: The distribution of leukocyte subsets in the peripheral blood and AH was examined using fluorescein isothiocyanate-conjugated monoclonal antibodies. The levels of lymphokines, such as interleukin-2 (IL-2) and interleukin-6 (IL-6), in the sera, AH, and cerebrospinal fluid from the patients with VKH were determined using an enzyme-linked immunosorbent assay. RESULTS: T cells constituted the majority of lymphocytes within AH. The value for CD4+ cells (helper/inducer T lymphocytes) in AH was 51.7% +/- 14.9% (mean +/- SD) and that for CD8+ cells (cytotoxic/suppressor T lymphocytes) was 31.1% +/- 13.0%. The percentage of HLA-DR+ cells (B lymphocytes, monocytes, macrophages, and activated T lymphocytes) in AH (50.8% +/- 24.9%) significantly exceeded (P < 0.001) that in blood (13.1% +/- 4.2%). The percentage of CD8+ cells in AH from three patients with the delayed type of VKH rose during their clinical course. The level of IL-6 was significantly elevated in AH from the patients with VKH. The level of IL-6 in AH correlated with the number of lymphocytes in AH, and it reflected the severity of the inflammatory response in AH of patients with VKH. The level of IL-2 in the sera, AH, and cerebrospinal fluid was in the normal range. CONCLUSIONS: Aqueous humor lymphocytes from the patients with VKH were more activated than were peripheral blood lymphocytes. IL-6 may play an important role as an inflammatory mediator in VKH. It may be useful to analyze the lymphocyte subsets and the levels of lymphokines, especially of IL-6, at the site of inflammation in uvea to improve the criteria for assessing the prognosis of VKH.

SPARC deficiency leads to early-onset cataractogenesis.

PURPOSE: To determine the role of SPARC (secreted protein, acidic, and rich in cysteine) in cataractogenesis by examining mice deficient in a matricellular protein SPARC. METHODS: Mice were rendered SPARC-deficient by a targeted disruption of the gene. Slit-lamp microscopy and histology were used to examine the eyes of SPARC-null and wild-type mice from birth to 14 months of age. RESULTS: SPARC-null mice developed opacities in the posterior cortex of the eye as early as 1.5 months after birth. The diffuse cataracts appeared to progress toward the anterior cortex and reached maturity in many animals by 3.5 months of age. Early stages of cataractogenesis in SPARC-null mice included inhibition of normal lens fiber cell differentiation, degeneration of fiber cells, vacuole formation at the equator, and liquefaction of the cortex. No cataracts were detected in wild-type mice up to the age of 8 months. CONCLUSIONS: The early onset of cataracts in SPARC-null mice establishes that the gene is essential to the maintenance of lens transparency.

Toxoplasma gondii Hsp70 as a danger signal in toxoplasma gondii-infected mice.

Toxoplasma gondii Hsp70, T gondii Hsp30/bag1, and surface antigen 1 messenger RNAs were shown to be useful in analyzing stage conversion of T gondii between bradyzoites and tachyzoites. The high-level expression of T gondii Hsp70 was correlated with mortality in interferon-gamma knockout mice infected with T gondii. Tgondii Hsp70 inhibited the induction of nitric oxide release by peritoneal macrophages of T gondii-infected mice. These findings identify T gondii Hsp70 as a danger signal during lethal, acute T gondii infection.

Quantitative polymerase chain reaction in diagnosing ocular toxoplasmosis.

PURPOSE: To determine if quantitative competitive polymerase chain reaction can be used to diagnose ocular toxoplasmosis with certainty. METHODS: We examined the vitreous humor of a patient with recurrent ocular toxoplasmosis by using quantitative competitive polymerase chain reaction. RESULTS: The number of Toxoplasma gondii in the vitreous humor was quantified by quantitative competitive polymerase chain reaction. CONCLUSION: Quantitative competitive polymerase chain reaction was useful for diagnosing ocular toxoplasmosis.

Melanoma specific Th1 cytotoxic T lymphocyte lines in Vogt-Koyanagi-Harada disease.

AIMS/BACKGROUND: To determine the functional properties and cytokine production profiles of melanoma specific cytotoxic T lymphocytes (CTLs) induced from peripheral blood leucocytes of two patients with Vogt-Koyanagi-Harada disease (VKH). METHODS: Melanoma specific CTL lines were established by long term coculture with a human melanoma cell line (P-36). Cytotoxic activity against P-36 was measured by 51Cr release. The involvement of human leucocyte antigen (HLA) class I or class II molecules in the cytotoxicity of the CTL lines against P-36 was analysed using anti-HLA class I or anti-HLA class II monoclonal antibody (MAb). Surface molecules of CTL lines were analysed by flow cytometry using MAbs specific for CD4, CD8, CD16, CD25, CD56, HLA-DR, T cell antigen receptor (TCR) alpha beta and TCR gamma delta. Cytokine production and soluble interleukin 2 receptor (sIL-2R) secretion were determined by enzyme linked immunosorbent assays. mRNAs of cytokines were analysed using reverse transcription polymerase chain reaction (RT-PCR). RESULTS: CTLs showed strong cytotoxic activity against P-36. The CTL activity of the cell lines against P-36 was inhibited by the anti-HLA-DR MAb, whereas the MAb specific for monomorphic determinants of HLA-A, B, and C failed to block lytic activity. Flow cytometry identified the following surface molecules: CD4+, CD8-, CD16-, CD25+, CD56-, HLA-DR+, TCR alpha beta +, and TCR gamma delta-. CTLs constitutively produced a high level of IL-6. IL-6 production and sIL-2R secretion of CTLs were enhanced when CTLs were stimulated with P-36. CTLs also produced high levels of interferon gamma (IFN-gamma) and IL-2, but not IL-4. mRNAs of IL-2 and IFN-gamma were detected by RT-PCR in the CTLs. CONCLUSIONS: Melanoma specific HLADR restricted T helper 1 (Th1) CTLs may play a role in the immunopathogenesis of VKH.

Bilateral tears of the retinal pigment epithelium.

This paper describes bilateral tears of the retinal pigment epithelium (RPE) which followed photocoagulation treatment of retinal pigment epithelial detachment (PED) in the right eye and which occurred spontaneously in the left eye. A 66-year-old Japanese male presented with PED approximately 4 X 6 disc diameters in size in his right eye, and one disc diameter in the left eye, both in the macular regions. The right PED was treated by placing a row of argon laser photocoagulation along the margin of the PED, with avoidance of the papillomacular bundle. Five days after treatment the PED enlarged peripherally beyond the coagulated site. Nineteen days later an RPE tear developed at the temporal edge of the detachment in the right eye. The remaining detached RPE retracted centrally, forming curled folds. About 40 days after the initial examination the patient complained of sudden reduction of vision in his left eye. At this time an enlargement of the PED was found in his left eye. One week after this examination a small RPE tear was found in the nasal border of the PED in the left eye. The tear in the left eye gradually developed centrally to the fovea.

Two-color flow cytometric analysis of activated T lymphocytes in aqueous humor of patients with endogenous vs. exogenous uveitis.

To investigate the immunopathologic role of lymphocytes in aqueous humor of patients with uveitis, we assessed activated T lymphocyte subsets stained with fluorescein isothiocyanate-labeled and phycoerythrin-labeled monoclonal antibodies in aqueous humor and in peripheral blood, using two-color flow cytometry. We divided our 25 patients into those with endogenous or exogenous uveitis. The percentages of activated T lymphocytes in uveitic aqueous humor significantly exceeded those in peripheral blood lymphocytes from patients with either disease form. CD4+HLA-DR+ lymphocytes were predominant in endogenous uveitic aqueous humor, whereas CD8+HLA-DR+ lymphocytes predominated in exogenous uveitic aqueous humor in the early stage of the disease. The percentages of CD4+HLA-DR+ lymphocytes tended to increase while those of CD8+HLA-DR+ cells tended to decrease in aqueous humor from patients in the late phase of exogenous uveitis. Our results may contribute to increasing diagnostic accuracy in patients with uveitis and to developing more rational methods of treatment.

Abnormal naive and memory T lymphocyte subsets in the peripheral blood of patients with uveitis.

PURPOSE: To better define the role of lymphocytes in the pathogenesis of uveitis, we studied the expression of memory and naive cell markers on T lymphocytes from peripheral blood. METHODS: Surface antigens on T lymphocytes obtained from peripheral blood of 27 patients with uveitis, including 12 patients with Behçet's disease (BD), 7 patients with Vogt-Koyanagi-Harada disease (VKH), and 8 patients with idiopathic uveitis (IU), were detected by three-color flow cytometric analysis. Lymphocytes from 14 age-matched healthy control subjects were similarly evaluated. RESULTS: The percentage of T lymphocytes that were CD4+CD29+ lymphocytes (memory cells) was high in all patients with uveitis, while that of CD4+CD45RA+ lymphocytes (naive cells) was lower in patients with BD and VKH, although the difference was not statistically significant. The percentage of CD29+ cells within CD3+CD4+ cell population was significantly higher in patients with BD and VKH than in the controls (p < 0.01), and the percentage of CD45RA+ cells was significantly lower in BD patients than in controls (p < 0.01). The T lymphocyte subsets in patients with IU were similar to the controls. CONCLUSIONS: These results show an abnormal distribution of T lymphocytes in patients with uveitis associated with an underlying systemic disease.

Apoptosis-related fas antigen on memory T cells in aqueous humor of uveitis patients.

To investigate the role of lymphocytes in the pathogenesis of uveitis, we analyzed the expression of memory markers, CD29 and CD45RO antigens, and apoptosis-related Fas antigen on T lymphocytes in the aqueous humor (AH) and peripheral blood (PB) from patients with uveitis. Using three-color flow cytometry, we assessed the number of T lymphocyte subsets that stained with fluorescence-conjugated anti-CD3, CD4, CD8, CD29, CD45RA, CD45RO, HLA-DR, and Fas monoclonal antibodies in the AH and PB from 19 patients with active uveitis who were diagnosed as having sarcoidosis, Vogt-Koyanagi-Harada disease, HLA-B27+ uveitis, or idiopathic uveitis. Cells from AH and PB were evaluated by light and electron microscopy before and after 6 h of incubation. The majority of lymphocytes in AH but not in PB, were CD3+HLA-DR+ (activated) T cells. The percentage of CD4+ lymphocytes was significantly higher in uveitic AH than in PBL (P < 0.01). While the percentage of CD4+ CD45RA+ (naive) cells within T cells was much lower in uveitic AH than in PB, the percentage of CD4+CD29+ or CD4+CD45RO+ (memory) cells was significantly higher in uveitic AH than in PBL (P < 0.01). Fas antigen was expressed preferentially on memory cells in uveitic AH. Apoptosis of cells in the AH was observed by microscopically following after incubation with no stimulation. Lymphocytes from the AH of patients with uveitis were more activated than those from PB. The majority of T lymphocytes from uveitic AH expressed memory markers and Fas antigen. Results suggest that an increase in the number of Fas+ memory T lymphocytes in AH is involved in the pathogenesis of uveitis.

Involvement of MyD88 in host defense and the down-regulation of anti-heat shock protein 70 autoantibody formation by MyD88 in Toxoplasma gondii-infected mice.

This study investigated the influence of TLR (toll-like receptor)4, TLR2, and MyD88 in Toxoplasma gondii-infected wild-type (WT) mice and TLR4-, TLR2-, and MyD88-deficient mice. Ninety-five percent of MyD88-deficient mice died 10-16 days after intraperitoneal infection with 100 cysts of T. gondii Fukaya strain, whereas 95-100% of TLR4- and TLR2-deficient mice and WT C57BL/6 (B6) mice survived for more than 7 wk after T. gondii infection. The distribution of T. gondii in various organs of TLR4-, TLR2-, and MyD88-deficient mice and WT B6 mice was assessed 2 wk after T. gondii intraperitoneal infection using quantitative competitive polymerase chain reaction. In MyD88-deficient mice, high levels of T. gondii load were observed in the brain, tongue, heart, lungs, spleen, liver, mesenteric lymph node, and kidneys after infection. The T. gondii load was significantly increased in the lungs in both TLR4- and TLR2-deficient mice compared with WT B6 mice. High levels of anti-mouse heat shock protein (mHSP)70 autoantibody and anti-T. gondii HSP70 antibody production were detected in the sera from MyD88-deficient mice.

Immune response to Toxoplasma gondii--analysis of suppressor T cells in a patient with symptomatic acute toxoplasmosis.

Unresponsiveness of antigen-dependent (Toxoplasma-specific and purified protein derivative of tuberculin [PPD]-specific) T-cell proliferative responses of peripheral blood leukocytes (PBL) was observed in a patient with symptomatic acute toxoplasmosis. The immunosuppression of T-cell responses was mediated by Leu 1+, Leu 2a+, and Leu 3a- suppressor T cells that were induced by Toxoplasma gondii antigen and suppressed both Toxoplasma-specific and PPD-specific PBL T-cell responses from a patient with chronic toxoplasmosis when PBL of these patients were mixed and cocultured in vitro. Participation of class II molecules of HLA in Toxoplasma-specific proliferative T-cell responses and activation of suppressor T cells was examined by using monoclonal antibodies specific for HLA-DR and HLA-DQ molecules. Anti-HLA-DQ monoclonal antibody released the suppressive activity, while anti-HLA-DR monoclonal antibody inhibited Toxoplasma-specific T-cell responses. Thus, the suppressive effect of PBL from a patient with acute toxoplasmosis on antigen-dependent PBL T-cell responses from a patient with chronic toxoplasmosis was mediated by HLA-DQ molecules. By contrast, Toxoplasma-specific T-cell responses were activated by HLA-DR molecules (presumably present on antigen-presenting cells).

Organ infectivity of Toxoplasma gondii in interferon-gamma knockout mice.

To determine the influence of interferon (IFN)-gamma on the organ infectivity and on the genetic susceptibility of susceptible (C57BL/6) and resistant (BALB/c) strains after peroral infection with cysts of Toxoplasma gondii. IFN-gamma knockout (KO) mice in C57BL/6 and BALB/c backgrounds were utilized. The kinetics of the changes in T. gondii abundance were evaluated with a quantitative competitive polymerase chain reaction assay in various organs at different times after peroral infection. In IFN-gamma KO mice, a T. gondii-specific gene, SAG1, was detected in all organs examined, and the protozoan proliferated much more actively than in wild-type mice. The abundance of T. gondii was much higher in mesenteric lymph nodes and the heart than in other organs. In contrast, in the nervous system organs and kidneys, only a weakly detectable reaction was observed. Toxoplasma gondii grew at a more rapid rate in the organs of IFN-gamma KO C57BL/6 mice than in the organs of IFN-gamma KO BALB/c mice during the course of infection. Destruction of the IFN-gamma gene showed remarkable effects on the infectivity in both susceptible and resistant mice.

Ocular findings in a patient with Prader-Willi syndrome.

A 25-year-old woman is described whose clinical features included infantile hypotonia, obesity after infancy, intellectual impairment, dysmorphic facial features, short stature, small hands and feet, and abnormal dentition, which are typical of the Prader-Willi syndrome. The patient had almond-shaped eyes, spot-like hypopigmentation under the retina, and a polychromatic luster in the anterior and posterior subcapsular regions of both lenses. Using fluorescence fundus angiography, we identified choroid-transmitted fluorescence in the areas of spot-like hypopigmentation. Recordings of both electroretinogram and visual evoked potential were normal. Ophthalmologists should be aware of the characteristic features of Prader-Willi syndrome because some of the ocular disorders associated with this syndrome can be treated.

[Analysis of infiltrating lymphocytes in choroidal melanoma].

We performed immunohistochemistry on tumor infiltrating lymphocytes (TILs) in a 78-year-old man with choroidal malignant melanoma. Cell suspensions of TILs from fresh specimens and peripheral blood lymphocytes (PBLs) were stained with anti-CD3, anti-CD4, anti-CD8, anti-CD29, anti-CD45RA, and anti-human leukocyte antigen (HLA)-DR monoclonal antibodies and analyzed using three-color flow cytometry. In light microscopy, the number of infiltrating lymphocytes around the tumor was very small. Immunohistochemically, T lymphocytes were more numerous than B lymphocytes. Flow cytometric analysis showed that CD8+ cells were more numerous than CD4+ cells in CD3+ cells in TILs, and most of these cells also expressed HLA-DR antigen. CD29+ (memory) cells were increased and CD45RA+ (naive) cells were decreased in CD4+ cells in TILs as compared with PBLs. We concluded that the increase in the percentage of activated memory T lymphocytes and the decrease of naive T lymphocytes may reflect a localized antigen-specific immunological response in choroidal malignant melanoma.