Suspected Immune Thrombocytopenic Purpura Induced by Lenalidomide for the Treatment of Myelodysplastic Syndrome with Deletion of Chromosome 5q: A Case Report.

Lenalidomide (LEN), one of the key drugs in the treatment of myelodysplastic syndromes (MDS) with 5q deletion, as well as multiple myeloma (MM), has various immunomodulatory effects and has been associated with autoimmune diseases, including immune thrombocytopenic purpura (ITP). A 78-year-old man presented with pancytopenia and was diagnosed with MDS with 5q deletion and other chromosomal abnormalities. Two cycles of LEN therapy (one cycle: 10 mg/day for 21 days) resulted in a transient improvement in anemia, followed by MDS progression with severe thrombocytopenia (4 × 109/L) refractory to platelet transfusions. As other non-immune and alloimmune causes of transfusion-refractory thrombocytopenia were excluded, and the level of platelet-associated immunoglobulin G was extremely high compared with the level before treatment with LEN, the diagnosis of ITP was highly suspected. Despite treatment with prednisolone (PSL), eltrombopag, and repeated platelet transfusions, his platelet count did not increase, and he died of a gastrointestinal hemorrhage. Several cases of ITP induced by LEN used to treat MM had been reported, but the platelet count recovered after administration of PSL in these previous cases. However, we should be mindful of using LEN for patients with MDS because its treatment may become extremely difficult if ITP develops.

Decrease of infectious complications in outpatients with autoimmune diseases from 2019 to 2020 under the COVID-19 pandemic: A single-centre, retrospective cohort study in Japan.

OBJECTIVES: To examine how the novel coronavirus disease (COVID-19) has changed infectious complications in outpatients with autoimmune diseases. METHODS: We performed a retrospective, record-linked cohort study and questionnaire about lifestyle changes in patients who visited our department in 2019 and 2020. RESULTS: We surveyed 1316 outpatients in 2019 and 1284 in 2020. The most common underlying diseases were rheumatoid arthritis (842 vs. 814) and systemic lupus erythematosus (SLE) (126 vs. 127). No significant difference in median age (66 vs. 67 years), respiratory comorbidities (30.4% vs. 32.0%), or corticosteroid use (42.2% vs. 44.3%) was found between the years. Immunomodulating agents were used more in 2020 (33.1% vs. 39.7%, p < .001). Total number of infections (28.0/100 vs. 19.4/100 person-years), pneumonia (3.6 vs. 1.6), influenza (2.1 vs. 0.1), and nonviral dermatological infections (3.8 vs. 2.1) were significantly lower in 2020. No significant difference was found for herpes zoster (2.2 vs. 1.8), urinary tract infections (3.3 vs. 3.8), or gastrointestinal infections (2.9 vs. 3.0). According to the questionnaire, 75% of the respondents became more conscious about wearing masks and 81% began to use hand sanitizer during the pandemic. CONCLUSION: Under the COVID-19 pandemic, some infectious complications have decreased in outpatients with autoimmune diseases.

Expression of the bacterial heavy metal transporter MerC fused with a plant SNARE, SYP121, in Arabidopsis thaliana increases cadmium accumulation and tolerance.

The bacterial merC gene from the Tn21-encoded mer operon is a potential molecular tool for improving the efficiency of metal phytoremediation. Arabidopsis SNARE molecules, including SYP111, SYP121, and AtVAM3 (SYP22), were attached to the C-terminus of MerC to target the protein to various organelles. The subcellular localization of transiently expressed GFP-fused MerC-SYP111, MerC-SYP121, and MerC-AtVAM3 was examined in Arabidopsis suspension-cultured cells. We found that GFP-MerC-SYP111 and GFP-MerC-SYP121 localized to the plasma membrane, whereas GFP-AtVAM3 localized to the vacuolar membranes. These results demonstrate that SYP111/SYP121 and AtVAM3 target foreign molecules to the plasma membrane and vacuolar membrane, respectively. To enhance the efficiency and potential of plants to sequester and accumulate cadmium from contaminated sites, transgenic Arabidopsis plants expressing MerC, MerC-SYP111, MerC-SYP121, or MerC-AtVAM3 were generated. The transgenic plants that expressed MerC, MerC-SYP121, or MerC-AtVAM3 appeared to be normal, whereas the transgenic that expressed MerC-SYP111 exhibited severe growth defects. The transgenic plants expressing merC-SYP121 were more resistant to cadmium than the wild type and accumulated significantly more cadmium. Thus, the expression of MerC-SYP121 in the plant plasma membrane may provide an ecologically compatible approach for the phytoremediation of cadmium pollution.

The endoplasmic reticulum stress-inducible protein, Herp, is a potential triggering antigen for anti-DNA response.

Anti-dsDNA Abs are highly specific indicators of systemic lupus erythematosus (SLE) and play a pathogenic role in lupus nephritis. Human anti-dsDNA Abs are most likely generated by an Ag-driven mechanism. However, the Ag responsible for triggering anti-dsDNA Ab production has not been identified. To search for proteins that are cross-reactive with anti-dsDNA Abs, we screened a cDNA library from a patient with SLE with single-chain Fv of O-81 human anti-ss/dsDNA mAb by using a two-hybrid system. Homocysteine-induced ER protein (Herp), an endoplasmic reticulum (ER) stress-inducible ER membrane protein, was identified and shown to bind to original O-81 Ab and human lupus anti-dsDNA Abs. Some IgG purified from patients with active SLE by Herp-immobilized affinity chromatography bound to dsDNA. BALB/c mice immunized with Herp showed IgG anti-dsDNA Abs, IgG anti-nucleosome Abs, and glomerular IgG deposition. Herp reactivity was strongly positive in a proportion of PBLs from patients with active SLE, but undetectable in those from healthy controls. Moreover, activation of caspases was observed in the Herp-positive cells, implying that ER stress-induced apoptosis likely occurs in patients with active SLE. Herp is exposed on blebs of ER stress-induced apoptotic cells, suggesting that Herp can be recognized by immune cells. These results indicate that Herp mimics structural determinants of DNA immunologically and can be immunogenic in vivo. Thus, Herp represents a candidate autoantigen for anti-DNA Abs. This study may help explain how common environmental factors induce the production of anti-DNA Abs and contribute the development of SLE.

Clinical efficacy of belimumab in patients with systemic lupus erythematosus and headache. A report of two cases.

Intractable headache, one of the manifestations of neuropsychiatric systemic lupus erythematosus (SLE), is difficult to diagnose and decide on an appropriate treatment. In addition to conventional therapy based on the type of headache, the treatment should be conducted considering the disease activity of SLE rather than the headache. We report two patients with intractable headache who were successfully treated using belimumab therapy. The headaches in both patients were relieved after 2 weeks of belimumab administration. The neutralisation of B lymphocyte stimulator and reduced production of cytokines from B lymphocytes might contribute to the early effects. The potential benefits of using belimumab as an additional immunosuppressant for treating intractable headache complicated with SLE have been discussed.

Two cases of rheumatoid arthritis complicated by organising pneumonia successfully treated with tofacitinib therapy.

Organising pneumonia (OP) complicated by rheumatoid arthritis (RA), a rare type of interstitial lung disease, is sometimes refractory and resistant to immunosuppressive therapy. We report for the first time two cases of refractory OP with RA for which tofacitinib, an inhibitor of Janus kinase, was highly effective. Two women, aged 84 and 65 years, developed refractory OP during treatment for RA with biologics, certolizumab pegol, and etanercept. A moderate amount of prednisolone was effective in both cases; however, recurrences were observed with reduced glucocorticoid dosage. When tofacitinib was administered, OP and RA were well controlled. Thus, the glucocorticoid dosage was successfully tapered low enough until no side effects were observed. Tofacitinib therapy may be a treatment option for refractory OP.

Spontaneous Regression of Blastic Plasmacytoid Dendritic Cell Neoplasm Following Sepsis by Serratia marcescens: A Case Report and Literature Review.

Spontaneous regression is rare in patients with blastic plasmacytoid dendritic cell neoplasm (BPDCN). An 85-year-old man presented with pancytopenia and skin lesions, and the bone marrow exhibited 79.6% CD4+, CD56+, CD123+, and TCL-1+ abnormal cells, with a normal karyotype; he was thus diagnosed with BPDCN. While being followed without chemotherapy, he was admitted due to sepsis induced by Serratia marcescens, which was successfully treated with antibiotics. Notably, his blood cell counts improved, and the skin lesions disappeared. To our knowledge, this is the first reported case of spontaneous regression of BPDCN with a decrease in tumor cells in the bone marrow following sepsis.

Molecular elements of the regulatory control of keratin filament modulator AHF/trichohyalin in the hair follicle.

Hairs in mammals undergo well-programmed cyclic development, which is strictly controlled by the surrounding hair follicle cells. Among hair follicle epithelia the inner root sheath (IRS) directly envelops the hair shaft to mechanically support its cyclic growth, but the molecular mechanism underlying its sharp regulation remains obscure. Here, we identify regulatory elements for the expression of the IRS-specific protein AHF (Anagenic Hair Follicle antigen), the putative mouse orthologue of trichohyalin (THH), which plays a key role in the assembly of keratin intermediate filaments (IFs) during the hair cycle. AHF becomes abundantly present in the growing anagenic hair follicle and is suddenly diminished as the tissue enters into the subsequent resting stages under the control of ubiquitin-dependent proteolysis. Using primary human keratinocytes, we found that bone morphogenic protein-4 facilitates THH transcription, and intriguingly, a nuclear lamina component plays a key role in the posttranslational stabilization of THH protein. Silencing of the lamin A/C gene leads to rapi THH degradation, whereas exogenously introduced lamin C, but not lamin A, protects THH from proteolytic elimination. These results shed light on the strict molecular mechanisms which control stage- and compartment-specific IF assemblies in support of the cyclic development of the hair shaft.

Epimorphin acts to induce hair follicle anagen in C57BL/6 mice.

Epimorphin is a mesenchymal morphogen that has been shown to mediate epithelial-mesenchymal signaling interactions in various organs. We now show that epimorphin functions in hair follicle morphogenesis; using a novel ex vivo organ culture assay, we define a mechanism for epimorphin signaling that may provide insight into general developmental processes. We found that epimorphin was produced by follicular mesenchymal cells and bound selectively to follicular epithelial cells, and that treatment with recombinant epimorphin could stimulate procession of hair follicles from telogen (resting stage) to anagen (growing stage). Based on analyses of epimorphin proteolytic digests that suggested a smaller peptide might be able to substitute for the full-length epimorphin molecule, we determined that pep7, a 10-amino acid peptide, was capable of inducing telogen-to-anagen transition both in the culture assay and in the mouse. That pep7 showed maximal activity only when modified with specific sulfhydryl-reactive reagents suggested that a particular structural conformation of the peptide was essential for activity; molecular dynamics studies were pursued to investigate the active peptide structure. These findings define a previously unknown morphogenic process in the hair follicle that may have applications to many other organs.

Reversible bone marrow dysplasia in patients with systemic lupus erythematosus.

OBJECTIVE: Several reports of bone marrow dysplasia in patients with systemic lupus erythematosus (SLE) have been published. However, the reports are restricted primarily to descriptions of the erythroid lineage; no follow-up studies have been reported, and the clinical significance of the dysplasias is unknown. Therefore, in the present study, the dysplasias noted in bone marrow aspirates obtained from SLE patients were characterized. PATIENTS AND METHODS: The smears of bone marrow aspirates obtained from 17 SLE patients who had bone marrow aspiration due to cytopenia (WBC < 1,500/microl, or Hb < 10.5 g/dl, or platelet count < 10 x 10(4)/microl) were examined retrospectively. Of the 17 patients, 4 had a repeat bone marrow aspiration during follow-up. Clinical and laboratory data were obtained from the medical records. RESULTS: Of the 17 SLE patients, 12 had dysplasias, including: erythroid cell multinuclearity (trinuclear or more) (5 patients), megaloblastoid changes (4), pseudo-Pelger abnormalities (6), annular nuclear myeloid cells (2), separated nuclear megakaryocytes (4), and micromegakaryocytes (5). In the 4 patients who had follow-up bone marrow aspiration, these dysplasias were correlated with disease activity; some abnormalities disappeared with remission of SLE. Diffuse proliferative glomerulonephritis (3 patients) and cerebral lupus/neuropsychiatric lupus (4 patients) were seen only in patients with dysplasia. CONCLUSION: This study found that bone marrow dysplasia can be observed in all lineage cells of SLE patients, and that the dysplasia is reversible during the course of the disease. The presence of dysplasias appears to be associated with disease severity.

A monoclonal antibody against human homocysteine-induced endoplasmic reticulum protein (Herp): a useful tool for evaluating endoplasmic reticulum stress.

Hyperhomocysteinemia has been reported as one of the risk factors for vascular damage. Homocysteine induces endoplasmic reticulum (ER) stress in vascular endothelial cells, which is followed by production of homocysteine-induced ER protein (Herp). Herp has been thought to have a protective role against ER stress and inhibition of apoptosis, but the details are still obscure. To detect Herp protein precisely, we established a murine hybridoma clone producing an anti-human Herp monoclonal antibody (mAb), named HT2. The specific binding of HT2 mAb to Herp was confirmed by enzyme-linked immunosorbent assay (ELISA) and Western blot analysis. In ELISA, HT2 mAb was able to bind to Herp in a dose-dependent manner, and its binding was interrupted by recombinant Herp. In Western blot analysis, a 54-kDa band corresponding to Herp was detected with HT2 mAb in the membrane fraction of untreated HeLa cells, and its expression was remarkably increased in ER-stressed HeLa cells that had been treated with homocysteine, thapsigargin, or 2-mercaptoethanol. Importantly, the signal was eliminated by absorption of HT2 mAb with recombinant Herp prior to incubation with the blotted membrane. Immunofluorescence microscopy revealed that HT2 mAb stained the perinuclear cytoplasm of ER-stressed HeLa cells, which was similar to the staining pattern with anti-KDEL (Lys-Asp-Glu-Leu) mAb that recognizes the ER. In contrast, untreated HeLa cells were weakly stained with HT2 mAb. Thus, the HT2 mAb is useful in the quantitative and/or qualitative detection of Herp and to study the role of Herp at a variety of pathological states.

Epimorphin acts extracellularly to promote cell sorting and aggregation during the condensation of vertebral cartilage.

Formation of vertebrae occurs via endochondral ossification, a process involving condensation of precartilaginous cells. Here, we provide the first molecular evidence of mechanism that underlies initiation of this process by showing that the extracellular factor, Epimorphin, plays a role during early steps in vertebral cartilage condensation. Epimorphin mRNA is predominantly localized in the vertebral primordium. When provided exogenously in ovo, it causes precocious differentiation of chondrocytes, resulting in the formation of supernumerary vertebral cartilage in chicken embryos. To further analyze its mode of action, we used an in vitro co-culture system in which labeled 10T1/2 or sclerotomal prechondrogenic cells were co-cultured with unlabeled Epimorphin-producing cells. In the presence of Epimorphin, the labeled cells formed tightly packed aggregates, and sclerotomal cells displayed augmented accumulation of NCAM and other early markers of chondrocyte differentiation. Finally, we found that the Epimorphin expression is initiated during vertebrogenesis by Sonic hedgehog from the notochord mediated by Sox 9. We present a model in which successive action of Epimorphin in recruiting and stacking sclerotomal cells leads to a sequential elongation of a vertebral primordium.