Skin extensibility and consistency in patients with Ehlers-Danlos syndrome and benign joint hypermobility syndrome.

OBJECTIVES: The reproducibility of clinical tests for skin extensibility and consistency, essential for differentiating between types of Ehlers-Danlos syndrome (EDS) and benign joint hypermobility syndrome (BJHS), is unknown. Paraclinical methods may provide objective differential diagnostic methods. METHODS: Six EDS, 11 BJHS, and 19 controls completed the trial. We analysed the overall inter-examiner agreement on clinical tests for skin extensibility and consistency, in addition to analyses on suction cup (SC) and soft tissue stiffness meter (STSM) methods. RESULTS: Overall agreement on tests for skin extensibility and consistency varied between 0.44 and 0.72. Extensibility evaluated by SC showed an insignificant difference between EDS patients and controls (p = 0.056). Consistency evaluated by STSM showed significant differences (p = 0.001). CONCLUSIONS: Overall inter-examiner agreement on clinical tests for skin extensibility and consistency was below 0.80, which was required a priori to conduct a reproducibility study. Further refinement of tests and a training phase are necessary. The SC and STSM results are encouraging but must be reproduced in a larger study population.

Type V and VI collagen for cohesion of dermal fibrillar structures.

Type V and VI collagen were capable to joint each other and with type I and IV collagen, as well as mucopolysaccharides. This capability suggested that these collagens function for cohesion of fibrillar tissue components of dermis. This study demonstrated the locality of these types of collagen in dermis. Fresh specimens of normal skin were fixed in 2% paraformaldehyde in phosphate-buffered saline, overnight. Besides, in order to loosen the twist of collagen fibril, some pieces of the skin specimens were treated by citrate buffer pH 3.0, prior to fixation. The specimens were embedded in Technovit 4100 and the ultrathin sections were stained by antibody to type V collagen and followed by antibody to type I, III, IV and VI collagen. The immune reactant was visualized by gold particles for electron microscopic observation. Type V and VI collagen formed networks in dermis and jointed to collagen fibrils, elastic fibre and basal lamina. Type V collagen was found inside collagen fibrils, broad elastic fibres and junctions. Dermo-epidermal junction showed type V collagen on the dermal aspects of basal lamina and at the sites where anchoring filaments joint to basal lamina, while in junction of mesenchymal tissues, no precise structural components for type V collagen were identified. Type VI collagen wove with type V collagen in dermis and associated with mucopolysaccharides. In conclusion, type V collagen formed networks in dermal interfibrillar space and participated in assembling collagen fibrils and forming broad elastic fibres. Epithelial and mesenchymal cells cohered to the underlying dermal matrix in the junction by type V collagen. Type VI collagen interwove with type V collagen in the interfibrous space and associated with mucopolysaccharides. Types V and VI collagen preserved architecture of dermal matrix.

Secretion of type IV collagen by keratinocytes of human adult.

Secretion of type IV collagen by keratinocytes was studied by anti-type IV collagen immunoglobulin in pure keratinocyte culture of the human adult. The cultivated keratinocytes secreted type IV collagen into the space between the cell growth and the underlying fixed film of human skin collagen type I. The secreted collagen was accumulated on the cell surface to form junction structures.

A nodal gamma/delta T-cell lymphoma with an association of Epstein-Barr virus.

The postthymic gamma/delta T-cell lymphoma is rare, and most occur as extranodal tumors, e.g., in hepatosplenic or cutaneous forms. We here report an unusual nodal case that initially presented as a T-zone lymphoma. The neoplasm recurred as systemic lymphadenopathy 25 months after complete remission with terminal high-grade transformation. Phenotypic analysis showed CD1-, CD2+, CD3+, CD4-, CD5-, CD7+, CD8+, CD10-, CD16-, CD19-, CD20-, CD21-, CD25-, CD56-, CD57-, T-cell receptor (TCR) alpha/beta antigens negative, TCR gamma/delta antigens positive, and an HLA-DR+ phenotype. Cytogenetic studies showed clonal chromosomal translocations involving chromosomes 1, 5, 6, 8, 15, and X in eight of 15 cells; t(X;5;1)(q13;q13;p22) and t(6;15;8)(p22;q26;q13). Genotypic analysis showed the same clone, characterized by the TCR gamma-chain gene rearrangement pattern, to be present in both initial and recurrent tumors. The lymphoma cells were also demonstrated to express the latent membrane protein-1 by immunohistochemistry and EBV-encoded small RNAs by in situ hybridization. Southern blot analysis using the probe of the terminal repeat demonstrated incorporation of multiple copies of EBV in the recurrent tumor. However, the initial lesion, which contained a smaller number of EBV-positive cells, showed no such evidence of clonal proliferation. These data suggest that EBV may be associated with high-grade transformation, although its exact role in lymphomagenesis remains uncertain. The present study also adds to our understanding of the clinicopathologic spectrum of gamma/delta T-cell neoplasia.

Autologous blood transfusion with recombinant human erythropoietin in heart operations.

The effects of recombinant human erythropoietin (rHuEPO) on improving the anemia associated with autologous blood collection before open heart operations and on improving the postoperative anemia were studied. The study was carried out on 18 patients undergoing coronary artery bypass operations; 400 mL of autologous whole blood was taken from each patient 2 weeks before operation and was subsequently used in the operation, and rHuEPO (100 U.kg-1.day-1) was given intravenously for 2 weeks before operation and for 1 week after operation. The group in which iron preparations were also administered intravenously was designated as group I (10 patients), and the group in which rHuEPO was given alone was designated as group II (8 patients). In group III, as a control group, 11 past patients were used in whom 400 mL of autologous whole blood was collected 2 weeks before operation but neither rHuEPO nor iron preparations were given. After autologous blood collections, the hemoglobin levels improved in group I, group II, and group III, in that order, and with significant differences among them. It was shown that rHuEPO was effective in ameliorating the anemia associated with preoperative autologous blood collection, and the effect was further enhanced with intravenous supplementing iron preparations. After operation, the anemia markedly improved while rHuEPO was administered, but the hemoglobin levels decreased rapidly when the administration was terminated. Further studies are needed regarding the use of rHuEPO after operation.

Filamentous aggregates of collagen. Ultrastructural evidence for collagen-fibril degradation in situ.

Filamentous aggregates of collagen are distinct structures in the pathological dermis. These aggregates are distinguishable from fibrous long-spacing collagen (in vitro and at biopsy) and the Luse body. The aggregates are produced from dermal collagen fibrils by clostridial collagenase and culture-medium extract, which supposedly contains cellular collagenase at a neutral pH, as well as by organ cultures. In vitro experiments showed that carrageenan granuloma contains fibrous long-spacing collagen and segment long-spacing collagen. The granuloma also contains the aggregates. The aggregates were found in skin biopsies from syphilitic chancres, acrosclerotic scleroderma, morphea, mycosis fungoides, myeloid leukemia, mastocytosis and malignant melanoma. These findings indicate that the aggregates are products of the in situ degradation of collagen fibrils by some collagenolytic factor. This factor may originate in fibroblast-like cells, reticulum cells, leukemia cells, mast cells and melanoma cells.

Twisted collagen fibrils in acrocyanosis.

Essential acrocyanosis (EA) present as a dusky discoloration of the hands as the sole symptom without any other abnormal results from laboratory investigation. Previously, the authors have found twisted collagen fibrils (TCF) in the normal skin of an EA patient. This study was intended to evaluate the significance of TCF in EA. Thirteen patients showing dusky discoloration were randomly selected and studied for TCF in normal skin by routine electron microscopy. TCF were found in 10 of 13 patients; 3 patients with only the discoloration (EA), 3 with the mild symptoms which were supposed to be Ehlers-Danlos syndrome (EDS), 1 with definite symptoms of EDS, 1 with Raynaud's disease and 2 with hyperglobulinemia. TCF were the ultrastructural sign for inherited malformation of collagen fibrils. EA was probably elucidated as a vascular disorder in TCF-carrying people. EA could be included in the disease category of EDS but it seems unreasonable to force EA patients into one of the subtypes of EDS. For pathogenesis, the inherited dysfunction in the hypertrophic pericytes of the subpapillary vascular plexus was presumed.

Melanin and melanosome complexes in long standing stable vitiligo--an ultrastructural study.

To investigate the presence of melanin and melanocytes (MC) in stable vitiligo, skin biopsies from five patients with vitiligo lesions of between 1 to 17 years duration were examined under the electron microscope. Areas of the upper dermis and epidermis were explored. There was a significant amount of melanin in a few keratinocytes (KC) grouped in the stratum basale in 1-3 year-old vitiligo lesions. In these KC, the melanosomes were most often aggregated into melanosome complexes (MCo) while the remaining KC were completely devoid of melanin. Solitary MCo were also observed in a few dermal cells in all vitiligo biopsies. All non-keratinocytes were scrutinized in series of 200-300 consecutive sections and were identified according to morphological characteristics. Neither active nor inactive MC, nor MC dendrites were found. These observations show that melanin in non-negligible amounts can be found even in 3 year-old vitiligo epidermis. Since there were no MC detected in the epidermis it implies that the melanosomes can persist in certain KC for some time after the onset of vitiligo.

Elastic fibers in dermis of juvenile elastoma.

To explore the ultrastructure of elastic fibers in juvenile elastoma, three patients (two without osteopoikilosis and one under examination of bones and joints) were studied by routine electron microscopy. In addition to normal elastic fibers, all the patients also exhibited alterations in elastic fibers. The altered ultrastructures showed lucent, homogenous matrix without peripheral microfibrils. The homogenous matrix were seen in various extensions from the small protrusions of the normal elastic fibers to the complete replacement of the entire fibers. Collagen fibrils occasionally showed twisted figures. Normal shapes of dermal glycosaminoglycans were increased in number. It seems likely that the lucent, homogenous matrix without peripheral microfibrils are the characteristic changes of elastic fibers in juvenile elastoma. The alteration could be nevoid in nature.

Pityriasis rosea eruption in secondary syphilis: an isomorphic phenomenon?

A 41-year-old man was referred because of a slightly pruritic eruption, and a classic case of pityriasis rosea was diagnosed on the first examination. Results of routine tests for syphilis were strongly positive, and on repeated examination the eruption had grown further. Skin biopsy specimens showed plasma cells and Treponema pallidum. All symptoms disappeared following antisyphilitic treatment. The possibility of an isomorphic response is discussed.

[Beneficial effects of CHOP therapy in a case of intravascular large B-cell lymphoma diagnosed by skin biopsy].

We report a case of intravascular large B-cell lymphoma. A 52-year-old man gradually developed dementia and abnormal behaviors, which were later accompanied by spastic paraplegia and sensory disturbance in his lower limbs. MR imaging of his brain showed high signal intensity lesions on T2 imaging. IMP-SPECT images of the brain showed diffuse reduction of radioisotope uptake. Many skin rashes that looked like senile hemangioma were observed on his body. Several of those were biopsied, and the diagnosis of intravascular large B-cell lymphoma was made because of malignant B lymphocytes filling the vessel lumens in one of the seven biopsy specimens. CHOP therapy was performed and found to be effective for the neurological disorders such as dementia, paraplegia, and sensory disturbance. Our case suggests that skin biopsy for more than one sample of the skin rashes is very important for the diagnosis of intravascular large B-cell lymphoma. CHOP therapy might be effective in this case because of early diagnosis by skin biopsy.

[Dynamic behavior of guinea pig middle ear].

The dynamic behavior of the middle ear was studied in living guinea pigs by using a laser Doppler vibrometer coupled to a compound microscope. Placing glass microbeads 20 microns in diameter on four points of the tympanic membrane and six points of the ossicles, their velocity amplitudes were measured under a constant stimulus of 65 dB SPL. Velocity responses of the four points on the tympanic membrane differed over the frequency range from 0.1 kHz to 3 kHz. At low frequencies, the malleus and incus rotated around an axis running from the malleus head to the incus short process. At middle frequencies, the whole ossicle had a piston-like motion. At high frequencies, the malleus and incus rotated around a vertical axis running through the ossicles, while the stapes had a hinge-like movement.