Single-nucleotide polymorphism and haplotype analysis of macrophage migration inhibitory factor gene and its correlation with serum macrophage migration inhibitory factor levels in North Indian psoriatic patients with moderate disease severity: A cross-sectional study

Background: Psoriasis is associated with significant morbidity and impaired quality of life. Identification of the host genes that influence disease susceptibility and can potentially guide future, targeted therapy is the need of the hour. Aims: The aim of the study was to investigate the associations of macrophage migration inhibitory factor (MIF) gene polymorphisms, that is, a 5–8-CATT tetra nucleotide repeats at -794 (-794*CATT5–8) and a single-nucleotide polymorphism at -173 (-173*G/C) with the risk of chronic plaque psoriasis and to observe the correlation, if any, of disease determinants with genetic functional variants and circulating MIF levels. Methods: Five hundred and seventeen individuals (265 psoriasis patients and 252 controls) were genotyped for MIF gene polymorphisms. Data were analyzed with respect to disease susceptibility, serum MIF levels, disease severity, age at onset, disease duration and presence of comorbidities. Results: The presence of co-morbidities was more frequently noted in patients with late onset disease (P = 0.01). No statistically significant differences were observed either in genotype (P = 0.680) or allele frequency (P = 0.69) with respect to distribution of MIF-173*G/C polymorphism between patients and controls. The frequencies of genotypes -794*CATT 5/7 and 7/7 were significantly lower in patients (P = 0.027* and 0.038*, respectively). CATT*5/MIF-173*C haplotype occurred at a higher frequency in patients (odds ratio 3.03, 95% confidence intervals 1.09–8.47, P = 0.02). The mean serum MIF levels were significantly higher in patients as compared to controls (P < 0.001). The presence of either extended MIF -794*CATT repeats or C allele did not reveal any significant association with serum MIF levels or age at onset. Analysis of effect of various disease determinants revealed no significant association with genetic variants and serum MIF levels. Limitations: The lesional expression of MIF could not be studied. Conclusion: Our results showed that CATT*5/MIF-173*C haplotype is associated with increased susceptibility to psoriasis vulgaris.

Circulating levels of chemokines in patients with psoriasis vulgaris and their association with disease severity: A case–control study from North India

Background: Psoriasis is a chronic inflammatory skin disease characterized by hyperproliferation and incomplete differentiation of epidermis, and accumulation of neutrophils and proinflammatory T cells in epidermis and dermis. Chemokines are believed to be the main players mediating the chemotaxis of leucocytes to the lesional site. Previous studies have established the role of various chemokine ligands and receptors at the lesional site in psoriasis. Aims: In this study, we have compared the serum levels of various chemokines, namely, inducible protein-10 (IP-10) (CXCL10), MCP-1 (CCL-2), monokine induced by gamma interferon (MIG) (CXCL-9), RANTES (CCL5), interleukin (IL)-8, and eotaxin in patients with chronic plaque psoriasis with that of healthy controls. We also studied whether the chemokine levels varied within different patient groups based on various clinical and demographic parameters, and if any of these chemokines correlated with disease activity. Methods: We studied 40 patients with chronic plaque psoriasis from a single center. Their clinical and demographic details were recorded in predesigned prforma. Patients with unstable forms of psoriasis like guttate, erythrodermic, or pustular psoriasis were excluded. The serum chemokine levels were measured by flow cytometry–based bead array set system. The serum levels of the patients were compared with that of 25 healthy controls. A subgroup analysis was also done to study the correlation of chemokine levels with age, sex, duration, and severity of disease. Results: We observed a significant decrease in serum level of all these chemokines in patients, when compared with that of healthy controls. We also found that MIG levels showed a positive correlation with disease severity based on Psoriasis Area and Severity Index. Limitations: The major limitation of the study is lack of data on the lesional chemokine levels compared to serum chemokines. Conclusion: The inflammatory process in psoriasis is orchestrated through chemokines. MIG is a potential serum biomarker for assessing disease severity.

Serum macrophage migration inhibitory factor levels in leprosy patients with erythema nodosum leprosum

Background: Erythema nodosum leprosum is an immune-mediated complication of leprosy which causes significant morbidity. Biomarkers in the pathogenesis of erythema nodosum leprosum are not yet fully determined. Aim: To determine macrophage migration inhibitory factor levels in the sera of leprosy patients with erythema nodosum leprosum and to correlate the same with clinical parameters. Methods: This cross-sectional study included 37 consecutive leprosy patients with active erythema nodosum leprosum and 31 age- and sex-matched controls. Detailed clinical history and examination findings were recorded including the severity and frequency of erythema nodosum leprosum. Slit skin smears and histopathologic examination were done in all patients at baseline. Serum macrophage migration inhibitory factor levels were determined using an enzyme-linked immunosorbent assay. Results: Most of our patients were males (78.4%) and suffering from lepromatous leprosy (27, 73%) with a mean initial bacillary index of 3.38 ± 1.36. Recurrent and chronic patterns of erythema nodosum leprosum were seen in 15 (40.5%) and 6 (16.3%) patients, respectively. Most (86.5%) of our patients presented with moderate to severe erythema nodosum leprosum. The mean serum macrophage migration inhibitory factor level was 21.86 ± 18.7 ng/ml among patients while it was 11.78 ± 8.4 ng/ml in the control group (P < 0.01). There were no statistically significant correlations of macrophage migration inhibitory factor levels with erythema nodosum leprosum frequency or severity. Limitation: Serum macrophage migration inhibitory factor levels in leprosy patients with no erythema nodosum leprosum and in patients with other inflammatory and autoimmune conditions were not assessed. Hence, this study falls short of providing the predictive value and specificity of higher macrophage migration inhibitory factor concentrations in serum as a biomarker of erythema nodosum leprosum. Conclusion: Macrophage migration inhibitory factor levels are elevated in erythema nodosum leprosum patients as compared to controls. A larger sample size and macrophage migration inhibitory factor gene polymorphism analysis will be needed to elucidate the role of this pro-inflammatory cytokine in erythema nodosum leprosum.

Immunofluorescence profile of discoid lupus erythematosus.

The direct immunofluorescence (DIF) of skin in conjunction with histopathology gives the best diagnostic yield. It is invaluable in confirming the diagnosis of small vessel vasculitides and bullous lesions of the skin and can be used as an additional tool to pinpoint the diagnosis of systemic and localized autoimmune diseases involving the skin. This study was undertaken to analyze the strength of DIF vis‑à‑vis histopathology in the diagnosis of discoid lupus erythematosus (DLE) and at the same time to elaborate the specific immunofluorescence findings in the lesions of DLE. The clinical profile and cutaneous lesions of 75 patients with DLE are described. DIF was positive in 68% and histopathology in 60% of cases. The most common immunoreactant was IgG at the dermoepidermal junction, followed by IgM and IgA. A conclusive diagnosis of DLE could be achieved satisfactorily in 64 cases (85%) by a combination of the two techniques.

Immunofluorescence in dermatology.

Direct immunofluorescence (DIF) and indirect immunofluorescence (IIF) tests on skin biopsy are being done mostly in academic teaching hospitals. These tests provide a useful diagnostic aid to dermatologists. Immunohistology and serology can, in conjunction with histology, provide considerable help in delineation and diagnosis of various skin disorders as well as systemic diseases with skin involvement, e.g. systemic lupus erythematosus. Immunofluorescence (IF) studies have now become an invaluable supplement to clinical and histological examination in a variety of dermatological diseases. These skin diseases now include not only bullous and connective tissue disorders, vasculitides, and conditions such as lichen planus, but also the scaling dermatoses, notably psoriasis. In this review article, we share our experience of providing such a diagnostic facility for more than 30 years in a large tertiary care health center in North India and also help to outline the conditions, which can be diagnosed confidently, and others where IF can help in confirming a diagnosis or the immune component of the disease. The article also deals with handling of skin biopsy specimens and interpretation of biopsy findings on DIF and IIF examination.

Renal histology in pauci-immune rapidly progressive glomerulonephritis: 8-year retrospective study.

Context: The need to perform reporting of renal biopsies of antineutrophil cytoplasmic antibodies (ANCA)-associated vasculitides in a more uniform manner required relook at our eight-year data. Aims: To document detailed renal histopathology of pauci-immune rapidly progressive glomerulonephritis (RPGN) and also to seek any significant differences in renal histology of C-ANCA-positive, P-ANCA-positive, and ANCA-negative patients. Materials and Methods: A detailed analysis of the histopathologic features of renal biopsies of 48 patients in whom a diagnosis of pauci-immune glomerulonephritis was concluded on renal biopsy and who presented clinically as rapidly progressive renal failure was done. Statistical Analysis Used: One-way ANOVA and Pearson Chi square tests. Results: Compared with ANCA +ve patients, the ANCA -ve patients were much younger (46.85 ± 16.12 years vs 34.28±15.94 years). No significant differences were found between renal lesions of C-ANCA, P-ANCA, and ANCA-negative patients, except for diffuse tubular atrophy which was more severe and more frequently present with P-ANCA positivity (P value=0.013). Conclusions: Pauci-immune RPGN (irrespective of ANCA status) is a relatively rare disorder in patients who are undergoing the renal biopsy at our institute, constituting 2% of all renal biopsies submitted. It is mandatory to have ANCA serology status during reporting of a kidney biopsy showing pauci-immune crescentic or necrotizing glomerulonephritis. Also, if a uniform reporting strategy is followed throughout the country, the studies from this vast country will be comparable.

A decade long experience of anti-neutrophil cytoplasmic antibody testing in a tertiary care referral center in North India: Perspective from a developing country.

Background: In a developing, tropical country like India, discontinuous power supply, high temperatures during summer, and lack of consistent cold chain and funds provide a challenging atmosphere for anti-neutrophil cytoplasmic antibody (ANCA) testing and reporting. However, a simple in-house test and testing algorithm are described here, which have been developed and tested over time. Materials and Methods: An analysis of a decade of testing and reporting of ANCA in the Department of Immunopathology in a tertiary referral health care center was performed to highlight the importance of testing for ANCA in proposed 1999 guideline recommended indications. Results: A total of 4195 ANCA tests were conducted from 2000 to 2009. Overall, 2060 (49%) requests had indications which met the 1999 guidelines, while the remaining 2135 (51%) fell outside the guidelines. A total of 350 samples (8.3%) were positive for ANCA on indirect immunofluorescence (IIF), out of which 212 were guideline recommended and 138 (3.2%) were non-guideline recommended ANCA requests; thus, 3.2% of non-small vessel ANCA associated vasculitis (non-SVAAV) conditions showed false positive results when the population was otherwise unselected. Maximum requests (1432) were for rapidly progressive renal failure/acute renal failure. Conclusions: The audit shows that compliance with guidelines for ANCA testing would decrease the number of false positive results. In-house screening for ANCA by IIF is cost-effective and must be performed at least twice on two different samples from the same patient or on two different sets of ANCA preparations in all the cases who requested ANCA testing with a proposed 1999 guideline recommended indication.

Direct immunofluorescence of skin biopsy: Perspective of an immunopathologist.

Background: By direct immunofluorescence (DIF), presence of immune complexes in the skin biopsy at various locations such as the dermo-epidermal junction, dermal blood vessels, etc. help to arrive at a diagnosis. Aims: (1) To study the role of DIF in confirmation or exclusion of diseases involving skin vis-à-vis histopathology and clinical diagnosis, (2) to describe the annual spectrum of dermatologic conditions that present to a tertiary referral center and require DIF examination of skin biopsy for confirmation of diagnosis. Methods: A total of 267 biopsies received over a period of 16 months in the Department of Immunopathology were analyzed along with clinical and histopathological details and the correlation between them was studied. Results: DIF was positive in 204 skin biopsies. Of these, 127 biopsies showed good clinico-immuno-histopathological correlation. In 10 cases, only DIF could clinch the diagnosis. In another nine cases, immune deposits were noted, which were unexpected in light of clinical and histopathological diagnosis. The most common skin involvement was seen in vasculitides. DIF was, however, non-contributory in lesions like erythema multiformè, post Kala-azar dermal leishmaniasis, sarcoidosis, lupus vulgaris, pyoderma gangrenosum and prurigo nodularis. Conclusion: The DIF of skin in conjunction with histopathology gives the best diagnostic yield. It is invaluable in confirming the diagnosis of small vessel vasculitides and bullous lesions of skin and can be used as an additional tool to pinpoint the diagnosis of systemic and localized autoimmune diseases involving the skin.

Cutaneous metastases of internal malignancies: A clinicopathologic study.

Background: Secondary tumor deposits in the skin represent advanced malignancy and are of uncommon occurrence. The clinical presentation of these lesions is variable, and the clinical impression is rarely correct, except in cases of known primary malignancies. Aim: To summarize the clinical and histopathological findings in biopsy-proven cutaneous metastases. Methods: The present study has analyzed 14 cases of cutaneous metastases from internal malignant neoplasms, excluding hematolymphoid neoplasms. The clinical parameters analyzed include presentation of deposits and their relation to the primary tumor. The histological features of cutaneous metastases were compared with the primary tumors and the frequency of common features in them were evaluated. Results: Cutaneous metastases from internal organ malignancies showed a prevalence rate of approximately 2%. Eight cases (56%) presented as primary manifestations of the tumor; biopsy evaluation in these cases suggested the possible primary tumor site and triggered further evaluation and imaging studies. Four patients, undergoing treatment for a known malignant tumor, had recurrence of the tumor in the form of cutaneous metastatic deposits. In the remaining two patients, cutaneous metastases of the tumor appeared simultaneously with the primary neoplasm and represented a higher stage of malignancy. Conclusions: Skin biopsy findings were significant in all cases. The morphological patterns of cutaneous metastases corresponded with the primary tumors and their evaluation helped localize unknown primary malignancies. In cases with known primaries, cutaneous metastases upstaged the malignancy and affected the prognosis.

Aspiration cytology of extramammary tumours metastatic to the breast.

This study was undertaken to highlight the use of fine needle aspiration cytology (FNAC) to distinguish tumours metastatic to the breast from primary breast malignancies. A total of 1866 fine needle aspirates of the breast were performed during a period of 7 years. Three hundred and fourteen cases of breast malignancies were diagnosed and 5 (1.5%) out of these cases were metastatic in origin. The metastatic tumors included, 2 cases of malignant melanoma (chest wall and left arm), 1 case each of haematolymphoid malignancy, adenocarcinoma of the ovary, and squamous cell carcinoma (left leg). FNA diagnosis of metastasis to the breast is essential in order to avoid unnecessary mastectomy and to ensure appropriate chemotherapy and/or irradiation treatment.

Tubercular dacryoadenitis--a case report and review of literature.

A case of a 56 year old lady presenting clinically with a slow growing painless mass of the left lacrimal gland, the histopathplogical examination of which was consistent with a diagnosis of tubercular dacryoadenitis, is described. Tubercular dacryoadenitis is uncommon, with the diagnosis usually made on histological examination of the lacrimal gland. Other cases of tubercular dacryoadenitis reported in literature are also reviewed.