Analysis of clinical characteristics, prognosis and antibody pathogenicity of pemphigus patients positive for anti-desmoglein IgG autoantibodies in remission: a retrospective cohort study.

BACKGROUND: The detection of serum anti-desmoglein (Dsg) IgG autoantibodies has been reported to be useful for assessment of disease activity in pemphigus. However, previous studies have reported that anti-Dsg autoantibodies remain detectable in some patients without active pemphigus lesions. OBJECTIVES: To investigate the clinical characteristics and antibody pathogenicity of pemphigus patients positive for anti-Dsg IgG autoantibodies in remission. METHODS: We retrospectively investigated pemphigus patients with a history of clinical remission who visited the Department of Dermatology of Keio University during 2019 and 2020. The antibody pathogenicity was assessed by bead aggregation assay. RESULTS: When patients were recognized as having entered remission (PDAI = 0 and PSL ≦ 10 mg/day for 2 months), serum autoantibodies against Dsg were detected in 72 of 132 patients (54.5%, positive group; PG), but were not detected in 60 patients (45.5%, negative group; NG). Anti-Dsg antibody titres in remission declined from the active phase in 33 patients in the PG for whom data were available. There were no differences in the chance of reducing PSL to 5 mg/day (P = 0.885) and rate of relapse (P = 0.279) between PG and NG, but fewer patients in PG discontinued corticosteroids (P = 0.004). The ability of patients' sera to block aggregation of Dsg/desmocollin beads was significantly reduced in remission compared to the active phase. However, our results revealed that whole sera in remission still had pathogenic activity in seven of nine patients, and the approximately equal amounts of anti-Dsg antibodies in active phase and remission showed similar pathogenicity. CONCLUSIONS: This study will provide guidance in cases where autoantibodies are found to be positive in pemphigus patients during remission or steroid reduction.

Results of the guideline-based treatment for pemphigus: a single-centre experience with 84 cases.

BACKGROUND: The Japanese guidelines for the management of pemphigus (JG) were published in 2010. However, further progress in the treatment of pemphigus requires their validation. OBJECTIVES: To examine the efficacy and safety of treatments based on the JG. METHODS: A retrospective study of 84 Japanese patients with moderate to severe pemphigus, who were initially treated in accordance with the JG and then followed up for >2 years, was performed in a single centre. Treatment typically consisted of 0.5-1 mg prednisone (PSL)/kg/day accompanied by 100 mg azathioprine/day as a steroid-sparing agent. RESULTS: In 83 of the 84 patients (98.8%), complete remission on minimal therapy (≤10 mg PSL/day and concomitant immunosuppressive agent) was achieved. The time between initiation of therapy and remission was 13.9 ± 9.4 months. In 78 patients (92.9%), remission was accomplished within the 2-year follow-up. The 32 patients with recalcitrant disease (38.1%) received additional treatment. Relapse occurred in 12 patients (14.3%) either during tapering of the PSL dose (six patients) or after achieving remission (six patients). Adverse events, mostly liver enzyme elevation, infections and diabetes, occurred in 67 patients (79.8%). One patient (1.2%) died during the observation period after gastrointestinal haemorrhage. CONCLUSIONS: Our results suggested that the elderly and patients requiring additional therapies were at higher risk of adverse events, including severe infections, and should thus be monitored carefully. This study provided clinical data that could inform revised guidelines and contribute to the evaluation of future novel therapies.

Two cases of atretic cephalocele, and histological evaluation of skin appendages in the surrounding skin.

Atretic cephalocele is a small skin-covered lesion, usually located at or near the mid-line of the scalp. Histologically, it is composed of syncytial cells expressing neurone-specific enolase and epithelial membrane antigen. The syncytial cells form capillary-like structures *(pseudovascular areas) and collagenic fibrosis with densely packed collagen bundles (fibrous areas). Such findings suggest that the atretic cephalocele is a mild form of cephalocele, with its pathogenesis lying in the spectrum of neural tube closure abnormalities. However, few descriptions of abnormalities of the skin overlying and surrounding atretic cephalocele are available. We report two cases of atretic cephalocele that showed hamartomatous change in the surrounding cutaneous appendages. These findings suggest that atretic cephalocele is associated with abnormalities not only of the neural tube, but also of the surrounding skin.

Comparison of the reliability and validity of outcome instruments for cutaneous dermatomyositis.

BACKGROUND: Reliable and validated measures of skin disease severity are needed for cutaneous dermatomyositis (DM). Cutaneous Dermatomyositis Disease Area and Severity Index (CDASI), Dermatomyositis Skin Severity Index (DSSI) and Cutaneous Assessment Tool (CAT) skin indices have been developed as outcome instruments. OBJECTIVES: We sought to demonstrate reliability and validity of the CDASI, and to compare the CDASI with other potential tools for use in measuring disease severity in cutaneous dermatomyositis. PATIENTS AND METHODS: CDASI has four activity and two damage measures, with scores from 0 to 148. DSSI assesses activity based on body surface area and severity on a scale of 0-72. CAT uses 21 activity and damage items, for a range of 0-175 for activity and 0-33 for damage. Ten dermatologists used the instruments to score the same 12-16 patients in one session. Global validation measures were administered to physicians and patients. RESULTS: Global validation measures correlated with the three outcome instruments (P < 0.0001). CAT displayed lower inter- and intrarater reliability relative to the CDASI. All scales correlate better with physician than patient global skin measures. CONCLUSIONS: It appears that the CDASI may be a useful outcome measure for studies of cutaneous DM. Further testing to compare responsiveness of all three measures is necessary.

Effects of Hydroxychloroquine in Patients With Cutaneous Lupus Erythematosus: A Multicenter, Double-Blind, Randomized, Parallel-Group Trial.

OBJECTIVE: To assess the efficacy and tolerability of hydroxychloroquine (HCQ) in patients with cutaneous lupus erythematosus (CLE), in a phase III clinical trial conducted in Japan. METHODS: We conducted a double-blind, randomized, parallel-group clinical trial. This was a baseline-controlled study, and the group differences were evaluated in an exploratory analysis. A total of 103 patients with active CLE (according to a Cutaneous Lupus Erythematosus Disease Area and Severity Index [CLASI] activity score of ≥4) were included. Patients were randomized 3:1 to receive HCQ or placebo during the 16-week double-blind period, and all patients were given HCQ during the following 36-week single-blind period. The primary efficacy end point was a reduction in the CLASI activity score at week 16. The secondary end points included the central photo evaluation (5-point scale), patient's global assessment (7-point scale), the Skindex-29 score, and investigator's global assessment (7-point scale, based on the other 3 secondary end points). In patients with systemic lupus erythematosus, fatigue and musculoskeletal pain were assessed. Safety was assessed up to week 55. RESULTS: The mean CLASI score at week 16 was significantly improved from baseline in both the HCQ group and the placebo group: mean change -4.6 (95% confidence interval [95% CI] -6.1, -3.1) (P < 0.0001), and mean change -3.2 (95% CI -5.1, -1.3) (P = 0.002), respectively, without between-group difference (P = 0.197). The investigator's global assessment demonstrated a greater proportion of "improved" and "remarkably improved" patients in the HCQ group (51.4% versus 8.7% in the placebo group [P = 0.0002 between groups]). The other secondary end points supported the efficacy of HCQ. Cellulitis, drug eruption, hepatic dysfunction, and Stevens-Johnson syndrome were shown to be serious adverse events related to HCQ use. CONCLUSION: The results of this randomized clinical trial support the efficacy and tolerability of HCQ in patients with CLE.

Molecular nature of 11 spontaneous de novo mutations in Drosophila melanogaster.

To investigate the molecular nature and rate of spontaneous mutation in Drosophila melanogaster, we screened 887,000 individuals for de novo recessive loss-of-function mutations at eight loci that affect eye color. In total, 28 mutants were found in 16 independent events (13 singletons and three clusters). The molecular nature of the 13 events was analyzed. Coding exons of the locus were affected by insertions or deletions >100 nucleotides long (6 events), short frameshift insertions or deletions (4 events), and replacement nucleotide substitutions (1 event). In the case of 2 mutant alleles, coding regions were not affected. Because approximately 70% of spontaneous de novo loss-of-function mutations in Homo sapiens are due to nucleotide substitutions within coding regions, insertions and deletions appear to play a much larger role in spontaneous mutation in D. melanogaster than in H. sapiens. If so, the per nucleotide mutation rate in D. melanogaster may be lower than in H. sapiens, even if their per locus mutation rates are similar.

Whole-genome effects of ethyl methanesulfonate-induced mutation on nine quantitative traits in outbred Drosophila melanogaster.

We induced mutations in Drosophila melanogaster males by treating them with 21.2 mm ethyl methanesulfonate (EMS). Nine quantitative traits (developmental time, viability, fecundity, longevity, metabolic rate, motility, body weight, and abdominal and sternopleural bristle numbers) were measured in outbred heterozygous F3 (viability) or F2 (all other traits) offspring from the treated males. The mean values of the first four traits, which are all directly related to the life history, were substantially affected by EMS mutagenesis: the developmental time increased while viability, fecundity, and longevity declined. In contrast, the mean values of the other five traits were not significantly affected. Rates of recessive X-linked lethals and of recessive mutations at several loci affecting eye color imply that our EMS treatment was equivalent to approximately 100 generations of spontaneous mutation. If so, our data imply that one generation of spontaneous mutation increases the developmental time by 0.09% at 20 degrees and by 0.04% at 25 degrees, and reduces viability under harsh conditions, fecundity, and longevity by 1.35, 0.21, and 0.08%, respectively. Comparison of flies with none, one, and two grandfathers (or greatgrandfathers, in the case of viability) treated with EMS did not reveal any significant epistasis among the induced mutations.

A high association with cone dystrophy in Fundus albipunctatus caused by mutations of the RDH5 gene.

PURPOSE: To analyze the RDH5 gene in patients with fundus albipunctatus with and without cone dystrophy and to determine whether the disease is stationary or progressive and whether the cone dystrophy is a part of fundus albipunctatus or a separate disease. METHODS: Fourteen patients from 12 separate Japanese families with fundus albipunctatus were examined. Six of the patients from 6 families also had a cone dystrophy. Genomic DNA was extracted from leukocytes of the peripheral blood, and exons 2, 3, 4, and 5 of the RDH5 gene were amplified by polymerase chain reaction and were directly sequenced. A complete ophthalmic examination was performed including best-corrected visual acuity, slit-lamp examination, indirect ophthalmoscopy, fundus photography, and electroretinography. RESULTS: In all the patients, either a homozygous mutation or compound heterozygous mutations in the RDH5 gene were identified. The identified mutations were nucleotide position (nt) 103 G to A (Gly35Ser), nt 319 G to C (Gly107Arg), nt 394 G to A (Val132Met), nt 719 G insertion (frame shift), nt 839 G to A (Arg280His), nt 841 T to C (Tyr281His), and nt 928 C to GAAG (Leu310 to GluVal). All these mutations except the Arg280His were new. The nt 928 C to GAAG mutation was detected in patients with and without cone dystrophy. Cone dystrophy was most frequently seen in patients over 40 years old. CONCLUSIONS: Fundus albipunctatus either with or without cone dystrophy is caused by mutations of the RDH5 gene. Cone dystrophy is frequently observed in elderly patients with fundus albipunctatus. The conclusion was reached that the mutations of the RDH5 gene caused a progressive cone dystrophy as well as night blindness.

Clinical evaluation of multifocal electroretinogram.

PURPOSE: To compare the multifocal electroretinogram (ERG) system to conventional ganzfeld and focal ERGs obtained from patients with known retinal diseases to assess its clinical applicability. METHODS: A multi-input system analysis was used to explore the field topography of ERG responses to local luminance modulation in patients with retinitis pigmentosa, pericentral pigmentary retinal dystrophy, branch retinal arterial occlusion, or idiopathic macular hole. RESULTS: The dysfunctional areas measured by multifocal ERG were compatible with those assumed by combined findings of ganzfeld and focal ERGs. However, the wave shapes of multifocal ERG in the retina with arterial occlusion differed from those of conventional focal ERG, suggesting that the negative and positive deflections shown in the first-order kernel of multifocal ERG may not correspond to conventional a- and b-waves of ERG. CONCLUSIONS: The multifocal ERG system is available for electroretinographic field mapping at the clinical level.

Multifocal electroretinogram in occult macular dystrophy.

PURPOSE: Occult macular dystrophy (OMD) is an unusual macular dystrophy presenting with an essentially normal fundus and fluorescein angiography but with progressive central visual loss. The authors studied the function of local retinal areas in the posterior pole of patients with OMD using multifocal electroretinograms (ERGs). METHODS: Multifocal ERGs were recorded using the Visual Evoked Response Imaging System with 61 hexagonal elements within a visual field of 30 degrees radius from 8 OMD patients and 20 age-matched, normal subjects. The amplitudes and implicit times of the patients and normal control subjects were compared at the various retinal eccentricities. RESULTs. The amplitudes of the multifocal ERGs in the OMD patients were markedly reduced in the central 7 degrees of the fovea. The difference of the ERG amplitudes between OMD and normal subjects became smaller toward the peripheral retina. Most OMD patients had slight but significantly delayed implicit times across the whole testing field, and the differences between the OMD and the normal subjects did not change with retinal eccentricity. CONCLUSIONS: Our results for multifocal ERG amplitudes support the idea that OMD patients have localized retinal dysfunction distal to the ganglion cells in the central retina. The delayed implicit times across the whole test field suggest that the retinal dysfunction has a broader boundary than expected by ERG amplitudes and psychophysical perimetric results.

Effect of glutamate analogues and inhibitory neurotransmitters on the electroretinograms elicited by random sequence stimuli in rabbits.

OBJECTIVE: To study the origin of the different components of the electroretinogram (ERG) elicited by a random binary m-sequence stimulus. METHODS: Electroretinograms were recorded from pigmented rabbits before and after the injection of glutamate analogues (2-amino-4-phosphono-butyric acid [APB; DL form] and cis-2,3-piperidine-dicarboxylic acid [PDA]) and inhibitory neurotransmitters (glycine and gamma-aminobutyric acid [GABA]) to abolish the contribution of different cell types to the ERG. Two types of stimuli were used: conventional full-field stimulation with short- and long-duration flashes and a random binary m-sequence of flashes designed to mimic the pseudorandom binary m-sequence stimulation used in the multifocal ERG technique. RESULTS: The effects of APB and PDA on the first-order kernel of the random ERGs were similar to those on the photopic short-flash ERG. Glycine and GABA minimized the oscillatory potentials (OPs) of the photopic ERGs, and also reduced the amplitude of the positive wave of the first-order kernel slightly but caused a large reduction in the amplitude of the second-order kernel. CONCLUSIONS: The data suggest that the ON and OFF bipolar cells contribute significantly to the photopic short-flash ERG, as previously shown, and to the first-order kernel of the responses elicited by the pseudorandom binary sequence stimuli. The second-order kernel and the OPs receive a strong contribution from the cells of the inner retinal layers.

Recording multifocal electroretinogram on and off responses in humans.

PURPOSE: To record the on and off responses of the multifocal photopic electroretinogram (ERG) from the human retina and to explore how each ERG component (a-, b-, and d-waves) changes at different retinal eccentricities. METHODS: Multifocal ERGs were recorded with the visual evoked response imaging system. Sixty-one densely packed stimulus elements were square wave-modulated between stimulus on and stimulus off, according to a binary m-sequence at a rate of 4.7 Hz under a constant background illumination. The ERGs were recorded with a bipolar Burian-Allen bipolar contact lens electrode from five normal subjects. Response densities (amplitude per retinal area) were calculated for five different eccentric rings. RESULTS: The response densities for all components (a-, b-, and d-waves) decreased with increasing retinal eccentricities. The ratio of the d-wave to b-wave amplitudes was minimal in the central retina and increased toward the periphery. The ratio of a-wave to b-wave amplitudes also increased toward the peripheral retina. CONCLUSIONS: These results demonstrate that the on and off responses of the human cone ERGs have different spatial distributions across the human retina, and they suggest a change in the photopic retinal circuitry with increasing retinal eccentricities.

Recording multifocal electroretinograms with fundus monitoring.

PURPOSE: To record multifocal electroretinograms (ERGs) with simultaneous fundus monitoring. METHODS: An infrared television fundus camera was used to monitor the fundus. A tightly packed array of 19 yellow light-emitting diodes (LEDs) was used as the stimulus source and LEDs were alternated between on and off according to a binary m-sequence at a rate of 75 Hz. The stimulus array subtended approximately 25 degrees of the visual angle. Multifocal ERGs were recorded with a Burian-Allen bipolar contact lens electrode from two normal subjects and a patient with macular dystrophy. RESULTS: When the center of the stimulus was positioned on the fovea, the amplitude of the response was largest at the fovea and decreased toward the peripheral retina; the response pattern corresponded to the spatial distribution of cone cells. When the center of the stimulus was positioned on the optic disc, the response at the optic disc was undetectable. A reliable multifocal ERG was obtained from a patient with macular dystrophy. CONCLUSIONS: This system made it possible to monitor the stimulus on the fundus and to adjust the stimulus to the correct retinal locations with exact focusing. The authors' findings indicate that this method especially can be useful in patients with poor fixation. In addition, the authors' results suggests that the stray light effect in the multifocal stimulus system is minimal if any.

Blue light-emitting diode built-in contact lens electrode can record human S-cone electroretinogram.

PURPOSE: To develop a contact lens electrode with a built-in blue light-emitting diode (LED) to record the electroretinogram from short-wave sensitive-cone (S-cone) electroretinogram (ERG) in humans. METHODS: The ERG was recorded using the blue LED (450 nm) built-in electrode under a yellow background illumination from a slide projector in five normal subjects, a patient with blue cone monochromatism, and a patient with fundus albipunctatus. For comparison, the ERG was also recorded using a yellow LED (566 nm) built-in electrode under the same background illumination in the normal subjects. RESULTS: The amplitude and the peak time of the b-wave recorded with 3-Hz blue stimuli were 5.1 to 12.4 microV and 63 to 68 msec, respectively in normal subjects, 7.3 microV and 65 msec in the patient with blue cone monochromatism, and 11.4 microV and 65 msec in the patient with fundus albipunctatus. Normal subjects responded to neither 30-Hz blue stimuli nor 3-Hz yellow stimuli. CONCLUSIONS: Results indicate that the b-wave recorded with 3-Hz blue stimuli is elicited from the S-cone system. This simple technique is useful for testing the human blue cone system.

Amplitude increase of the multifocal electroretinogram during light adaptation.

PURPOSE: To determine using the multifocal ERG technique whether there are any regional differences in the increase in the amplitude of cone electroretinograms (ERGs) during light adaptation. METHODS: Multifocal ERGs were recorded with the Visual Evoked Response Imaging System from five normal subjects. Thirty-seven hexagonal stimulus elements and a recording time of 60 seconds were used. After 20 minutes of dark adaptation, multifocal ERGs were repeatedly recorded every 2 minutes over a period of 16 minutes. The amplitudes of the multifocal ERGs at different eccentricities were compared during the 16 minutes of light adaptation. RESULTS: During the 16 minutes of light adaptation, the summed responses of the multifocal ERGs increased in amplitude an average of 36% and 47% for the negative and positive components, respectively. The magnitude of increase was minimal in the central retina at 22% and was significantly larger in the peripheral retina at 58%. The implicit time was slightly increased (<4%) with light adaptation, but there were no regional differences. CONCLUSIONS: The results demonstrated that there are topographic variations in the amplitude increase of cone ERGs during light adaptation. This topographic variation indicates that the mechanism for the increase must be based on known regional differences in the retina.

Multifocal ERG findings in complete type congenital stationary night blindness.

PURPOSE: To study the multifocal electroretinogram (mfERG) in patients with the complete type of congenital stationary night blindness (cCSNB), which is thought to be due to a defect in neurotransmission from the photoreceptors to the ON-bipolar cells. METHODS: mfERGs were recorded with the VERIS recording system from four patients with cCSNB, none of whom had nystagmus. The stimulus array consisted of 61 hexagons, and the total recording time was approximately 4 minutes. The amplitudes and implicit times of the first- and second-order kernels of the local responses were compared with those from 20 myopic controls. Waveforms of the summed response from all locations were also compared between the two groups. RESULTS: The first-order kernels of the mfERGs of cCSNB patients had normal amplitudes but delayed implicit times for nearly the whole field tested. The second-order kernel was severely attenuated in amplitude in cCSNB patients. The ratios of the second- to first-order kernel amplitudes were significantly reduced in cCSNB and clearly separated the cCSNB group from the control group without any overlap of the values. CONCLUSIONS: The second-order kernel, which is involved in adaptative mechanism of the retina to repeated flashes, is selectively reduced in cCSNB. The delay of the implicit times of the first-order kernel in patients with cCSNB may be related to the severe amplitude reduction of the second-order kernel.

Focal macular electroretinogram before and after drainage of macular subretinal hemorrhage.

PURPOSE: To record and evaluate change in preoperative and postoperative macular electroretinograms in patients undergoing surgical drainage of macular subretinal hemorrhage. METHODS: Five eyes of five patients with good visual acuity before onset of hemorrhage underwent vitrectomy between 3 and 14 days after developing hemorrhage, with drainage of submacular hemorrhage, using recombinant tissue plasminogen activator. The causes of subretinal hemorrhage were macroaneurysm in three eyes, age-related macular degeneration in one eye, and unknown in one eye. Visual acuity and macular electroretinograms were recorded preoperatively and postoperatively. RESULTS: In all eyes, preoperative electroretinographic response was remarkably reduced or not recordable. Postoperative visual acuity improved, and electroretinographic response recovered to about one half the amplitude of the fellow eye in every eye with a normal fellow eye. CONCLUSIONS: A nearly nonrecordable preoperative response on macular electroretinogram indicates severe dysfunction of the photoreceptors caused by the submacular hemorrhage. A postoperative recovered macular electroretinogram suggests that photoreceptor function is at least partially reversible with surgical intervention, including injection of recombinant tissue plasminogen activator into the subretinal space.

Occult macular dystrophy.

PURPOSE: Occult macular dystrophy is a hereditary macular dystrophy without any visible abnormality of the fundus or abnormality indicated by fluorescein angiography even when visual acuity is decreased. Normal full-field electroretinogram in both cone and rod components with abnormal focal macular cone electroretinogram is the key to diagnosing this disorder. The purpose of this study was to identify the function of the macular rods and to provide detailed clinical findings in occult macular dystrophy. METHODS: Thirteen patients from eight families were examined. The fundi of 12 patients were essentially normal (occult macular dystrophy), and the oldest patient in one family disclosed bull's eye maculopathy. In the 12 patients, including the patient with bull's eye maculopathy, the profiles of cone and rod absolute thresholds were performed across the 60-degree horizontal meridian of the posterior pole. RESULTS: All 12 patients showed cone sensitivity loss only in the macular area. Six relatively young patients revealed normal rod sensitivity, whereas six older patients showed borderline rod sensitivity or abnormal rod sensitivity in the macular area. CONCLUSIONS: The pathology of occult dystrophy involves either only the macular cone system or macular cone and rod systems without any visible abnormality. This difference of the pathology suggests a different clinical entity or a different stage of occult macular dystrophy.

Focal macular electroretinograms before and after successful macular hole surgery.

PURPOSE: To report changes in focal macular electroretinograms before and after successful macular hole surgery and to discuss whether preoperative retinal function can predict postoperative visual acuity. METHODS: In this prospective study, 28 consecutive eyes of 28 patients underwent vitrectomy for stage 2 or 3 full-thickness idiopathic macular hole. Focal macular electroretinograms using a 4-degree stimulus spot were obtained in 24 eyes of 28 patients, and those using a 5-degree stimulus spot were obtained in 24 eyes of 28 patients, to evaluate preoperative and postoperative amplitude and implicit time of the b-wave. Visual acuity was measured preoperatively and postoperatively, and results were translated into logMAR (minimum angle of resolution) values. RESULTS: After successful macular hole closure, the b-wave amplitude increased in 23 of 24 eyes measured with the 4-degree stimulus spot and in 19 of 24 eyes measured with the 5-degree stimulus spot. Postoperative b-wave amplitude recorded with either stimulus spot correlated with postoperative corrected visual acuity. The b-wave implicit time decreased in 15 of 20 eyes measured with the 4-degree spot and in 13 of 23 eyes measured with the 5-degree spot. Preoperative b-wave implicit time measured with the 5-degree stimulus spot correlated significantly (P = .001) with postoperative corrected visual acuity. CONCLUSIONS: Qualitative change (implicit time) is more important than quantitative change (amplitude) in electroretinograms for predicting postoperative corrected visual acuity. The function of the retinal tissue surrounding the hole may affect visual outcome.