Endophthalmitis associated with Purpureocillium lilacinum during infliximab treatment for surgically induced necrotizing scleritis, successfully treated with 27-gauge vitrectomy.

PURPOSE: To report a case of endophthalmitis associated with Purpureocillium lilacinum (P. lilacinum) during infliximab treatment for surgically induced necrotizing scleritis, successfully treated with 27-gauge vitrectomy. METHODS: A single case report. RESULTS: A 71-year-old man who had undergone immunosuppressive therapy, including infliximab, for surgically induced necrotizing scleritis (SINS) in his left eye complained of visual disturbance and eye pain in the eye. He had a past history of surgery for recurrent pterygium: pterygium excision, amnion transplantation with mitomycin C and limbal transplantation. Visual acuity in the left eye was counting fingers at 30 cm, and intraocular pressure was 3.0 mmHg. Slit-lamp examination revealed the presence of anterior chamber cells (3+), and a B-mode ultrasound scan showed a vitreous opacity. We made a diagnosis of endophthalmitis and performed 27-gauge microincision vitrectomy surgery (27GMIVS) with antibiotic perfusion of ceftazidime, vancomycin and voriconazole. Intraoperative findings included a fungus-like ball-shaped opacity in the vitreous, and a close-to-normal retinal appearance. A vitreous body culture identified the presence of P. lilacinum. After 2 months of antibacterial and antifungal therapy, inflammation decreased and visual acuity recovered to 20/100. CONCLUSIONS: This is the first report of a case of endophthalmitis associated with P. lilacinum during infliximab treatment for SINS. Scleral thinning due to necrotizing scleritis, especially during immunosuppressive therapy, is a risk factor for endophthalmitis. We found that 27GMIVS was a useful strategy for such a challenging clinical situation.

Ulcerative keratitis in patients with rheumatoid arthritis in the modern biologic era: a series of eight cases and literature review.

AIM: To assess the prevalence, clinical characteristics, treatment, and outcomes of patients who developed ulcerative keratitis (UK) during the course of rheumatoid arthritis (RA) in the modern biologic era. METHOD: We retrospectively reviewed the medical records of 589 patients with RA who visited our department between April 2003 and October 2014, and identified patients who developed UK. We also obtained data about clinical characteristics of RA and UK, complications, treatment, and both visual and life prognoses of these patients. RESULTS: Among 589 patients with RA, eight patients (1.4%) were diagnosed with UK. The mean age at the onset of RA was 61.0 years, while the mean age at the onset of UK was 73.0 years. Most of the patients were seropositive and had established RA with a relatively low disease activity. Secondary Sjögren's syndrome was observed in two patients. Peripheral UK occurred as a complication of scleritis, while central UK was not associated with scleritis. Although the mean duration of follow-up was only 3.7 years, visual and life prognoses were both tolerable with therapy, including the use of topical and systemic corticosteroids and calcineurin inhibitors, sometimes combined with biologic disease-modifying antirheumatic drugs (DMARDs) and corneal transplantation. CONCLUSION: This retrospective study demonstrated that the prevalence of UK in patients with RA was 1.4%. Immediate combination therapy, including topical and systemic corticosteroids and calcineurin inhibitors, together with biologic DMARDs and corneal transplantation, was effective for treating RA patients who developed UK in the modern biologic era.

Mechanisms of cadmium-induced chronotoxicity in mice.

Biological defense factors show diurnal variations in their expression levels or activities. These variations can induce the different sensitivity to external toxicants of a day. We reported earlier that mice showed clear diurnal variation of cadmium (Cd)-induced toxicity, i.e., chronotoxicity. In this report, we investigated additional new evidences for the cadmium (Cd)-induced chronotoxicity, and considered the mechanisms contributed to this chronotoxicity. Male C57BL/6J mice were injected with CdCl2 (6.4 mg/kg, one shot) intraperitoneally at 6 different time points of a day (zeitgeber time (ZT); ZT2, ZT6, ZT10, ZT14, ZT18 or ZT22) followed by monitoring the mortality until 14 days after the injection. We observed extreme difference in survival numbers: surprisingly, all mice died at ZT2 injection while all mice survived at ZT18 injection. Moreover, in non-lethal dose of Cd (4.5 mg/kg), the values of alanine aminotransferase (ALT) and aspartate aminotransferase (AST) used as indexes of hepatotoxicity markedly increased at ZT6 injection while mostly unchanged at ZT18 injection. To consider the mechanisms of this extreme diurnal variation, we examined biochemical studies and concluded that the diurnal variation was not caused by the differences in hepatic Cd level, basal hepatic metallothionein (MT) level, and induction level or induction speed of hepatic MT. We suggested that one of the candidate determination factors was glutathione. We believe that the "chronotoxicology" for metal toxicity may be classic, yet new viewpoint in modern toxicology field.

Influence of injection timing on severity of cadmium-induced testicular toxicity in mice.

Cadmium (Cd) is one of the endocrine disrupter and is a well-known testicular toxicant. Recently, we reported that Cd-induced mortality was markedly different by injection timing. In this report, we investigated whether severity of testicular toxicity was affected by injection timing of Cd. C57BL/6J mice (male, 7 w) were received single intraperitoneal injection of CdCl(2) (4.5 mg/kg) at zeitgeber time 6 (ZT6) or ZT18; these injection timings showed highest (ZT6) or lowest (ZT18) mortality in our previous study (Miura, 2012). After one week of the injection, several parameters for testicular toxicity such as epididymal sperm motility and numbers of sperm head both in cauda epididymidis and testis were measured. At ZT6 injection group, all parameters examined were significantly reduced compared to the control group. However, very interestingly, no significant changes were observed at ZT18 injection group. We obtained similar results by another experiment in which mice were received single subcutaneous injection of CdCl(2) (4 or 6 mg/kg) followed by measuring the parameters ten days after the injection. This diurnal variation was not contradictory to the result of the lethal toxicity which we showed earlier. Therefore, our results indicate that the testicular toxicity of Cd is also influenced by the injection timing.

Preventive mechanism of cellular glutathione in monomethylarsonic acid-induced cytolethality.

Human pentavalent arsenic metabolic intermediate, monomethylarsonic acid (MMAs(V)), is a major arsenic type found in the blood in chronic arsenic poisoning patients, but little information is available on its toxicity potential or mechanisms of action. In this study, we investigated the molecular mechanisms of in vitro cytolethality of MMAs(V) using rat liver TRL 1215 cells. Cellular arsenic concentrations reached the nanomolar range in TRL 1215 cells when cells were exposed to millimolar levels of MMAs(V), and most of the MMAs(V) was not metabolized during the 48-h incubation. Under these conditions, MMAs(V) showed significant cytolethality when cellular reserves of reduced glutathione (GSH) were depleted. Morphological and biochemical evidence confirmed that MMAs(V) induced both necrosis and apoptosis in the cellular GSH-depleted cells. MMAs(V) significantly enhanced cellular caspase 3 activity in the cellular GSH-depleted cells, and a caspase 3 inhibitor blocked MMAs(V)-induced apoptosis. MMAs(V) also enhanced the production of cellular reactive oxygen species (ROS) in the cellular GSH-depleted cells, and addition of a membrane-permeable radical trapping reagent completely prevented both MMAs(V)-induced cellular caspase 3 activation and cytolethality in these cells. These observations suggest that MMAs(V) typically generates harmful ROS in cells, and cellular GSH prevents cytolethality by scavenging these toxic ROS. However, when cellular GSH levels are decreased, MMAs(V) induces oxidative stress in the cells, and this leads to apoptosis and/or necrosis depending on the cellular ROS/GSH ratio.

Role of glutathione in dimethylarsinic acid-induced apoptosis.

Inorganic arsenicals are clearly toxicants and carcinogens in humans. In mammals, including humans, inorganic arsenicals often undergo methylation, forming compounds such as dimethylarsinic acid (DMAs(V)). Recent evidence indicates that DMAs(V) is a complete carcinogen in rodents although evidence for inorganic arsenicals as carcinogens in rodents remains equivocal. Thus, we studied the molecular mechanisms of in vitro cytolethality of DMAs(V) using a rat liver epithelial cell line (TRL 1215). DMAs(V) selectively induced apoptosis in TRL 1215 cells; its LC(50) value after 48 h exposure was 4.5 mM. The addition of a glutathione synthase inhibitor, L-buthionine-[S,R]-sulfoximine (BSO), actually decreased DMAs(V)-induced apoptosis. DMAs(V) exposure temporarily decreased cellular reduced glutathione (GSH) levels and enhanced cellular glutathione S-transferase (GST) activity from 6 h after the exposure when the cells were still alive. Also, DMAs(V) exposure activated cellular caspase 3 activity with a peak at 18 h after the exposure when apoptosis began, and BSO treatment completely inhibited this enzyme activity. The additions of inhibitors of caspase 3, caspase 8, and caspase 9 significantly reduced DMAs(V)-induced apoptosis. Taken together, these data indicate that cellular GSH was required for DMAs(V)-induced apoptosis to occur, and activation of cellular caspases after conjugation of DMAs(V) with cellular GSH appears to be of mechanistic significance. Further research will be required to determine the role of intracellular GSH and methylation in the toxicity of arsenicals in chronic arsenic poisoning or in cases where arsenicals are used as chemotherapeutics.