Consequences of cathepsin C inactivation for membrane exposure of proteinase 3, the target antigen in autoimmune vasculitis.

Membrane-bound proteinase 3 (PR3m) is the main target antigen of anti-neutrophil cytoplasmic autoantibodies (ANCA) in granulomatosis with polyangiitis, a systemic small-vessel vasculitis. Binding of ANCA to PR3m triggers neutrophil activation with the secretion of enzymatically active PR3 and related neutrophil serine proteases, thereby contributing to vascular damage. PR3 and related proteases are activated from pro-forms by the lysosomal cysteine protease cathepsin C (CatC) during neutrophil maturation. We hypothesized that pharmacological inhibition of CatC provides an effective measure to reduce PR3m and therefore has implications as a novel therapeutic approach in granulomatosis with polyangiitis. We first studied neutrophilic PR3 from 24 patients with Papillon-Lefèvre syndrome (PLS), a genetic form of CatC deficiency. PLS neutrophil lysates showed a largely reduced but still detectable (0.5-4%) PR3 activity when compared with healthy control cells. Despite extremely low levels of cellular PR3, the amount of constitutive PR3m expressed on the surface of quiescent neutrophils and the typical bimodal membrane distribution pattern were similar to what was observed in healthy neutrophils. However, following cell activation, there was no significant increase in the total amount of PR3m on PLS neutrophils, whereas the total amount of PR3m on healthy neutrophils was significantly increased. We then explored the effect of pharmacological CatC inhibition on PR3 stability in normal neutrophils using a potent cell-permeable CatC inhibitor and a CD34+ hematopoietic stem cell model. Human CD34+ hematopoietic stem cells were treated with the inhibitor during neutrophil differentiation over 10 days. We observed strong reductions in PR3m, cellular PR3 protein, and proteolytic PR3 activity, whereas neutrophil differentiation was not compromised.

Efficacy and Tolerance of Sirolimus (Rapamycin) for Extracranial Arteriovenous Malformations in Children and Adults.

Managing extracranial arteriovenous malformations is challenging. Sirolimus (rapamycin) is increasingly being used when surgery and embolization are not advised. Because of its anti-angiogenic properties here we report all extracranial arteriovenous malformation cases treated with sirolimus in 2 French tertiary centers for vascular anomalies. The outcomes were efficacy (complete, partial, no response) based on arteriovenous malformation volume and necrosis/hemorrhage and side effects. We retrospectively included 10 patients (7 children). The sirolimus dose ranged from 0.6 to 3.5 mg/m2. Median (interquartile range [IQR]) treatment time was 24.5 (4.5; 35) months. Five patients showed no response and 5 showed partial response at a median (IQR) of 3 (1; 5) months followed in 2 cases by therapeutic resistance (i.e., progressive disease after 9 and 24 months of treatment). The most frequent side effect was mouth ulcers. This study shows poor efficacy of sirolimus for treating extracranial arteriovenous malformations.

Search for RASA1 Variants in Capillary Malformations of the Legs in 113 Children: Results from the French National Paediatric Cohort CONAPE.

Patients with an inherited autosomal-dominant disorder, capillary malformation-arteriovenous malformation (CM-AVM), frequently have mutations in Ras P21 protein activator 1 (RASA1). The aims of this study were to determine the prevalence of germline RASA1 variants in a French multicentre national cohort of children, age range 2-12 years, with sporadic occurrence of capillary malformation (CM) of the legs, whatever the associated abnormalities, and to identify genotype-phenotype correlates. DNA was extracted from leukocytes in blood samples, purified and amplified, and all exons of the RASA1 gene were analysed. Among 113 children analysed, 7 had heterozygous variants (6.1%). Four different variants were identified; 2 were new. In children with RASA1 variants, CMs were more frequently bilateral and multifocal. In conclusion, RASA1 variants are rarely found in children with sporadic CM of lower limbs without CM-AVM syndrome. CMs in this study were heterogeneous, and no disease-causing relationship could be proven.

Efficacy and Safety of Mammalian Target of Rapamycin Inhibitors in Vascular Anomalies: A Systematic Review.

Mammalian target of rapamycin (mTOR) inhibitors are a promising new treatment in vascular anomalies, but no published randomized controlled trials are available. The aim of this systematic review of all reported cases was to assess the efficacy and safety of mTOR inhibitors in all vascular anomalies, except cancers, in children and adults. In November 2014 MEDLINE, CENTRAL, LILACS and EMBASE were searched for studies of mTOR inhibitors in any vascular condition, except for malignant lesions, in humans. Fourteen publications and 9 posters, with data on 25 and 59 patients, respectively, all < 18 years old were included. Of these patients, 35.7% (n = 30) had vascular tumours, and 64.3% (n = 54) had malformations. Sirolimus was the most frequent mTOR inhibitor used (98.8%, n = 83). It was efficient in all cases, at a median time of 2 weeks (95% confidence interval 1-10 weeks). Sirolimus was well tolerated, the main side-effect being mouth sores, which led to treatment withdrawal in one case. The dosage of sirolimus was heterogeneous, the most common being 1.6 mg/m2/day.

Somatostatin Receptors 2A and 5 Are Expressed in Merkel Cell Carcinoma with No Association with Disease Severity.

BACKGROUND/AIMS: Merkel cell carcinoma (MCC) is a rare high-grade neuroendocrine tumour of the skin. It has been speculated that MCCs express somatostatin receptors (SSTRs), but this has never been assessed in a large series of MCCs. The main aim of this study was to assess the expression of SSTR2A and SSTR5 in MCC tumours. The secondary aims were to assess whether expression of SSTR was associated with the Ki67 proliferative index, Merkel cell polyomavirus (MCPyV) status, clinical characteristics and outcome. METHODS: Clinical data and tumours were collected from an ongoing cohort of French patients with MCC. Immunohistochemistry was performed with anti-SSTR2A and anti-SSTR5 monoclonal antibodies, and tumours were classified into 3 groups: 'no expression', 'low expression' and 'moderate expression' using an SSTR staining score. RESULTS: SSTR expression was assessed for 105 MCC tissue samples from 98 patients, and clinical characteristics were available for 87 of them. SSTR expression was consistent between the primary skin tumour and the corresponding metastases for SSTR2A and SSTR5 in 3/7 and 6/7 cases, respectively. SSTR2A and SSTR5 were expressed in 58 cases (59.2%) and in 44 cases (44.9%), respectively. Overall, at least one SSTR was expressed in 75 tumours (76.5%). SSTR expression was not associated with clinical characteristics, Ki67 proliferative index, recurrence-free survival or MCC-specific survival. Expression of SSTR2A was associated with MCPyV status in MCC tumours but not SSTR5. CONCLUSION: SSTRs were expressed in a high proportion of MCCs, although expression was heterogeneous between tumours and was not associated with disease severity.

Generalized lymphedema associated with neurologic signs (GLANS) syndrome: a new entity?

BACKGROUND: Primary lymphedema in children, especially generalized disease with facial involvement, is rare. OBJECTIVE: We sought to report 3 childhood cases of lymphedema with associated neurologic findings and to provide a pathophysiologic explanation for this association. METHODS: Clinical observations, electroencephalography, and neuroimaging studies were evaluated. Microcomparative genomic hybridization was performed in 1 case. RESULTS: The 3 children had primary lymphedema of all 4 limbs and the face. This was confirmed by lymphoscintigraphy, which showed hypoplasia of vessels and hypofixation of lymph nodes. They had nonspecific neurologic disorders and electroencephalography abnormalities, without intellectual deficit. Neuroimaging revealed normal findings. Microcomparative genomic hybridization in 1 patient revealed no cytogenetic anomaly. The outcome was fatal in 1 case with development of visceral lymphedema and coma. LIMITATIONS: Genetic studies were performed in only 1 case. CONCLUSION: These observations suggest that neurologic assessment and electroencephalography are indicated for patients with lymphedema of the limbs and face to identify this syndrome.

Parameatal cyst in a 4-year-old boy.

UNLABELLED: A 4-year-old boy presented a translucent cyst on the left lateral side of the urethral meatus. The lesion was excised. Histological examination showed features of a cystic lesion within the dermis surrounded by a thin epithelium of columnar cells with a round apical pole. Immunohistochemical staining was positive for pan-cytokeratins (AE-1/AE-3) and negative for actin. These findings led to a diagnosis of urethral parameatal cyst. IN CONCLUSION: this entity is a rare congenital malformation and consists of a parameatal benign cyst occurring in prepubertal males. Treatment consists of complete resection of the cyst.

Lack of effect of propranolol in the treatment of lymphangioma in two children.

Vascular lesions such as hemangiomas and lymphangiomas can cause significant mortality and morbidity, as well as amblyopia when located in the orbit. Oral propranolol can regress infantile hemangioma during infancy and up to 23 months of age, but its effect on lymphangioma has not been demonstrated. We present two cases of lymphatic malformations treated with oral propranolol. Patient 1 is a 2-year-old boy with macrocystic bilateral cervical lymphangioma extending to the pharynx and larynx and microcystic lymphangioma of the tongue. The patient was started on propranolol 2 mg/kg/day starting at 17 months of age, and after 3 months only a very slight decrease in tongue volume was noted. Patient 2 is a 3.5-year-old boy with magnetic resonance imaging evidence of right facial complex lymphangioma with venous malformation. The patient was placed on oral propranolol 2 mg/kg/day. After 3 months of treatment, no change in the lesion was noted except for a transient decrease in the size of the conjunctival telangiectasia. Propranolol 2 mg/kg/day was not effective in treating lymphatic malformations in two children, both older than 17 months at the time of treatment.

Treatment of early-onset Gorham syndrome with 8-year follow-up.

A case of Gorham disease with several years of follow-up is reported. At birth he had a mass in the thigh which was had pathology demonstrating a lymphangioma. By age 3 years, he had lymphedema of the ipsilateral foot and discrepant leg lengths. Radiography revealed heterogenous dystrophy of the bones and osteolysis of the hallux. At age 6, a spontaneous fracture of the right tibia was treated with surgery. Histopathology of a bone sample demonstrated bone remodelling, fibrous tissue, and large vascular lacunas within bone tissue, bordered by cells expressing the lymphaticmarker D2-40. At 8 years old, lymphedema of the right inferior leg had increased, leg lengths still differed, but other clinical signs were absent.

Sturge-Weber syndrome in patients with facial port-wine stain.

Facial port-wine stain (PWS) may be associated with cerebrovascular abnormalities such as Sturge-Weber syndrome (SWS). In a large series, we aimed to assess which topography of facial PWS can predict SWS. This was a cross-sectional study of consecutive patients with facial PWS seen in pediatric dermatologic or angiodysplasia consultations from 1993 to 2005 at the University Hospital Center of Tours. A standardized form was used to collect data on clinical and imaging findings. Patients with and without SWS were compared in terms of topography of the cutaneous angioma and related ophthalmologic and neurologic features. Two hundred fifty-nine patients were included, 15 with a diagnosis of SWS. All patients with SWS showed involvement of the V1 trigeminal cutaneous area. SWS was significantly associated with bilateral topography of the PWS, its extension to another territory, and involvement of the upper eyelid. Knowledge of the topography of facial PWS with risk of associated neurological or ocular anomalies allows for early diagnosis of SWS and avoids unnecessary and costly radiography for patients with uncomplicated facial PWS.

Medial fronto-facial capillary malformations.

OBJECTIVE: To evaluate the characteristics of facial medial capillary malformations (CM), which differ from salmon patches by their wider extent, darker color, and incomplete resolution. STUDY DESIGN: Children were prospectively recruited from pediatric dermatology clinics and retrospectively from clinical and photographic databases. RESULTS: From June 2006 to June 2008, 84 children (56 girls; 66.6%) were included. The medial fronto-FCM (FFCM) involved the forehead and glabella (100%), upper eyelids (57.1%), nose (66.6%), philtrum (50.0%), and upper lip (22.6%). Extended forms were observed in 26.2%. A similar FFCM was observed within the family in 27.3% of cases. Outcome data showed complete regression in 10%, incomplete in 71.1%, and unchanging in 18%. An association with an extra facial CM was found 67.8%. Nape and/or occipital CM were associated in 63.8%. A median dorsal CM, mostly lumbosacral, was observed in 13.4%. An associated disease was seen in 33.3%. Neurological anomalies were observed in 9.5% (two cases of developmental delay, two of epilepsy, one of macrocephaly, one of cerebral arteriovenous malformation, one of cutis marmorata telangiectatica congenita, one of "macrocephaly- cutis marmorata telangiectatica congenita," and one of Rubinstein Taybi syndrome). No correlation between the site or the extent of the FFCM and extrafacial vascular or neurological anomaly was found. CONCLUSIONS: This study identifies a specific type of congenital medial FFCM that looks like salmon patch but has a wider median topography, a darker color, with slower and often incomplete resolution. Family cases are often observed. Despite their slow and incomplete regression, the aesthetic consequences are mild.

Efficacy of infliximab for hidradenitis suppurativa: assessment of clinical and biological inflammatory markers.

Treatment of hidradenitis suppurativa (HS) is often unsatisfactory. The efficacy of infliximab for treatment of the disease has been suggested. The main objective of this study was to evaluate the efficacy and side-effects of infliximab in the treatment of moderate to severe HS, resistant to local and systemic treatments. The secondary objective was to determine whether inflammation blood test results were changed. A retrospective monocentric study of all the patients seen consecutively for HS and treated with infliximab was performed. A median of six intravenous infusions (range 3-19) were performed. The end-points were self-improvement of HS (globally and in terms of pain, seeping and quality of life). The condition of six of seven patients improved (by nearly 50%) and none was aggravated. Adverse effects occurred in two patients; eczematous eruption in one case and cervical abscess in another case. We found no significant changes in inflammatory blood marker values. In conclusion, infliximab therapy was shown to be efficient and well tolerated in six of seven patients with HS resistant to previous therapy in our series. This was in agreement with pre-existing literature showing that 52 of 60 patients (87%) were improved after infliximab therapy.

Lymphatic compression by sclerotic patches of morphea: an original mechanism of lymphedema in a child.

Lymphedema in children is mostly primary, due to lymphatic hypoplasia. Secondary lymphedema is caused by lymphatic injury or obstruction. We report the case of a child that developed a lymphedema of the left upper and lower extremities, with a simultaneous onset of ipsilateral hemicorporal morphea. We concluded that lymphatic obstruction was due to sclerosis from morphea. This is a unique, rarely reported mechanism of lymphedema. Lymphoscintigraphy revealed attenuated lymphatic flow in the left upper and lower limbs. Systemic corticosteroids were associated with slow improvement in the sclerotic patches. We simultaneously noticed an improvement in the lymphedema of limbs. Repeat lymphoscintigraphy revealed dramatically improved lymphatic function. This case suggests that at least in some cases lymphedema may be caused by morphea.

Merkel cell polyomavirus strains in patients with merkel cell carcinoma.

We investigated whether Merkel cell carcinoma (MCC) patients in France carry Merkel cell polyomavirus (MCPyV) and then identified strain variations. All frozen MCC specimens and 45% of formalin-fixed and paraffin-embedded specimens, but none of the non-MCC neuroendocrine carcinomas specimens, had MCPyV. Strains from France and the United States were similar.

[Superficial angiomas: Treatment]. / Angiomes superficiels : traitements.

Beta-blockers are efficient for treating complicated infantile hemangiomas; propranolol is currently the first-line treatment. Superficial vascular malformations have to be managed by multidisciplinary teams. T2 FAT-SAT MRI is the most interesting sequence to explore superficial vascular malformations. Recent advances in molecular biology allow exploring new genetic mutations which could be involved in vascular malformations and be the target of new drugs. Mammalian target of rapamycin (mTOR) inhibitors are promising drugs for slow-flow malformations. Arteriovenous malformations are aggressive lesions with very few treatment options.

Topical sirolimus 0.1% for treating cutaneous microcystic lymphatic malformations in children and adults (TOPICAL): protocol for a multicenter phase 2, within-person, randomized, double-blind, vehicle-controlled clinical trial.

BACKGROUND: Cutaneous microcystic lymphatic malformations (CMLMs) are rare conditions in children and adults. They present as clusters of vesicles full of lymph and blood to various extents, inducing maceration, esthetic impairment, pain, and impaired quality of life. The treatment is challenging. Sirolimus is an inhibitor of mammalian target of rapamycin (mTOR) involved in angio-lymphangiogenesis. Topical sirolimus has recently been reported as effective in a few reports of patients with CMLMs. The objective is to compare the efficacy and safety of a 12-week application of 0.1% topical sirolimus versus topical vehicle in CMLMs in children and adults. METHODS: This French blinded multicenter within-person randomized controlled phase 2 trial aims to include 55 patients aged ≥ 6 years who have a primary CMLM. The CMLM will be divided into two equal areas that will be randomly allocated to 0.1% topical sirolimus or topical vehicle applied for 12 weeks. At the end of the 12-week period, the patient/parent will treat the whole area of CMLM with 0.1% topical sirolimus on remaining lesions, for eight more weeks. Patients will be seen at week 20 (treatment will be stopped) and at month 12 to evaluate long-term efficacy. The primary outcome will be improvement of the CMLM in the area treated with topical sirolimus compared to the area treated with topical vehicle by the investigator physician (blinded to the treatment) with the Physician Global Assessment score at week 12. Secondary outcomes will include: assessment of efficacy by independent experts on the basis of standardized photographs; impact on quality of life; efficacy for oozing, bleeding, erythema, and thickness evaluated by the investigators; and global efficacy as well as efficacy for functional and aesthetic impairment evaluated by the patient. Systemic passage of sirolimus will be measured at weeks 6, 12, and 20, and at week 16 for CMLMs ≥ 900 cm2. DISCUSSION: For patients with CMLMs, topical sirolimus could be a non-invasive and well-tolerated therapeutic option. If the trial demonstrates efficacy and safety of this treatment, this result will lead to a real change in the management of this condition, and 0.1% sirolimus cream would become the first-line treatment. TRIAL REGISTRATION: ClinicalTrials.gov, NCT03972592. Registered on 3 June 2019. EU Clinical Trials Register EudraCT, 2018-001359-11.

Treatment of voluminous and complicated superficial slow-flow vascular malformations with sirolimus (PERFORMUS): protocol for a multicenter phase 2 trial with a randomized observational-phase design.

BACKGROUND: Slow-flow superficial vascular malformations (VMs) are rare congenital anomalies that can be responsible for pain and functional impairment. Currently, we have no guidelines for their management, which can involve physical bandages, sclerotherapy, surgery, anti-inflammatory or anti-coagulation drugs or no treatment. The natural history is progressive and worsening. Mammalian target of rapamycin (mTOR) is a serine/threonine kinase that acts as a master switch in cell proliferation, apoptosis, metabolism and angio/lymphangiogenesis. Sirolimus directly inhibits the mTOR pathway, thereby inhibiting cell proliferation and angio/lymphangiogenesis. Case reports and series have reported successful use of sirolimus in children with different types of vascular anomalies, with heterogeneous outcomes. OBJECTIVE: The objective of this trial is to evaluate the efficacy and safety of sirolimus in children with complicated superficial slow-flow VMs. METHODS/DESIGN: This French multicenter randomized observational-phase, phase 2 trial aims to include 50 pediatric patients 6 to 18 years old who have slow-flow (lymphatic, venous or lymphatico-venous) voluminous complicated superficial VM. Patients will be followed up for 12 months. All patients will start with an observational period (no treatment). Then at a time randomly selected between month 4 and month 8, they will switch to the experimental period (switch time), when they will receive sirolimus until month 12. Each child will undergo MRI 3 times: at baseline, at the switch time, and at month 12. For both periods (observational and treatment), we will calculate the relative change in volume of the VM divided by the study period duration. This relative change weighted by the study period duration will constitute the primary endpoint. VM will be measured by MRI images, which will be centralized and interpreted by the same radiologist who will be blinded to the study period. Hence, each patient will be his/her own control. Secondary outcomes will include assessment of safety and efficacy by viewing standardized digital photographs and according to the physician, the patient or proxy; impact on quality of life; and evolution of biological makers (coagulation factors, vascular endothelial growth factor, tissue factor). DISCUSSION: The main benefit of the study will be to resolve uncertainty concerning the efficacy of sirolimus in reducing the volume of VMs and limiting related complications and the safety of the drug in children with slow-flow VMs. This trial design is interesting in these rare conditions because all included patients will have the opportunity to receive the drug and the physician can maintain it after the end of the protocol if is found efficient (which would not be the case in a classical cross-over study). TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02509468 , first received: 28 July 2015. EU Clinical Trials Register EudraCT Number: 2015-001096-43.

[Correcting the critical reading test of the national ranking examination]. / Epreuve de lecture critique d'article scientifique des épreuves classantes nationales: pertinence de la correction.

INTRODUCTION: In 2008 the national ranking examination (NRE) will include a test on critical reading of scientific articles. This decision has provoked controversy about whether reproducible correction is possible. The aim of our study was to assess the consistency of grading between this two-part test (critical analysis and summarizing, analyzed separately), and the more classic tests. METHODS: Eight graders, all instructors at the Tours Medical School, corrected papers for each of the 3 tests. Papers for the critical reading test came from medical school final examinations and for the standard test from a practice examination. The instructors worked in pairs: each pair read 30 papers for each test, and both members separately graded each paper. The final grade was the mean of the two grades. The consistency of grading between the 4 pairs was estimated by Kendall's coefficient of concordance. RESULTS: Kendall's coefficients of concordance were estimated at 0.94 (95% CI=[0.86; 0.97]) for the standard test, at 0.92 (95% CI=[0.81;0.97]) for the critical analysis test, and at 0.75 (95% CI=[0.62; 0.84]) for the summaries. Pairwise comparisons estimated the difference in concordance between the standard test and the summary at 0.18 (95% CI=[0.08; 0.32]) and that between the standard and critical reading test at 0.01 (95% CI= [-0.07; 0.12]). Finally the difference in concordance between the 2 new tests - summary and critical reading - was estimated at -0.17 (95% CI=[-0.32; -0.04]). CONCLUSION: The focus should be on the difficulty of reproducible correction of the summaries, to set up methods for appropriate correction and adequate grading. The elaboration of detailed scoring templates, including numerous items and specifying in which part of the summary each item must be placed, should help to improve the reproducibility of this test's correction.

A survey on the prevalence of orofacial herpes in France: the INSTANT Study.

Orofacial herpes is a common benign disease suspected to significantly impact the quality of life (QOL) of affected subjects. The objective of this population-based study was to evaluate the annual prevalence of orofacial herpes in France, its epidemiology, and its impact on QOL. Face-to-face home interviews were conducted among a random sample of 10,263 adults. A screening questionnaire identified subjects with a history of orofacial herpes (or cold sore) during the past 12 months; then, subjects with herpes completed another questionnaire to further describe their disorder and its management, and the SF-36 questionnaire to assess their QOL. The annual prevalence of orofacial herpes was 14.8% (95% confidence interval 14.03; 15.47); it was significantly higher in women than in men (P < .001) and decreased with age (P < .001). Among subjects with herpes, only 23% were aware of their disease. Tiredness and emotional stress were the main triggering events. There was no detectable difference between subjects with herpes and controls on SF-36 scores; however, when compared with subjects with 1 to 5 episodes per year, subjects with 6 or more episodes per year had significantly lower QOL scores.