Inhaled Sargramostim Induces Resolution of Pulmonary Alveolar Proteinosis in Lysinuric Protein Intolerance.

Pulmonary alveolar proteinosis (PAP) is a potentially fatal complication of lysinuric protein intolerance (LPI), an inherited disorder of cationic amino acid transport. The patients often present with mild respiratory symptoms, which may rapidly progress to acute respiratory failure responding poorly to conventional treatment with steroids and bronchoalveolar lavations (BALs). The pathogenesis of PAP in LPI is still largely unclear. In previous studies, we have shown disturbances in the function and activity of alveolar macrophages of these patients, suggesting that increasing the activity and the number of macrophages by recombinant human GM-CSF (rhuGM-CSF) might be beneficial in this patient group.Two LPI patients with complicated PAP were treated with experimental inhaled rhuGM-CSF (sargramostim) after poor response to maximal conventional therapy. BAL fluid and cell samples from one patient were studied with light microscopy and transmission electron microscopy.Excellent response to therapy was observed in patient 1 with no compliance problems or side effects. Macrophages with myelin figure-like structures were seen in her BAL sample. Slight improvement of the pulmonary function was evident also in patient 2, but the role of sargramostim could not be properly evaluated due to the complicated clinical situation.In conclusion, inhaled rhuGM-CSF might be of benefit in patients with LPI-associated PAP.

Kidney involvement in autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy in a Finnish cohort.

BACKGROUND: Autoimmune tubulo-interstitial nephritis (TIN) is a rare complication of autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy (APECED). Previous data on TIN and other renal or urologic manifestations of APECED are sparse. METHODS: We performed a retrospective study on the urinary and renal tract diseases in a cohort of 30 Finnish patients with APECED (mean age 40 years), with special emphasis on the clinical presentation and the immunologic characteristics of TIN. Clinical and laboratory findings, specific anticytokine and kidney-specific antibodies were analysed. RESULTS: Five of the 30 (17%) patients had moderate-to-severe renal failure, including 3 (10%) with TIN, leading to either transplantation, haemodialysis or immunosuppressive treatment. No other cause other than APECED was found for the TIN. All three patients with TIN had circulating antibodies against the distal part of the nephron, as did 30% of all cohort cases. Two had nephrocalcinosis, and two had renal tubular acidosis type 1. Immunosuppressive therapy with mycophenolate mofetil or rituximab in one pediatric case did not revert the TIN, however. CONCLUSIONS: Renal failure should raise concern for TIN in APECED. It discloses some specific features: no uveitis, no glycosuria and inconstant urinalysis anomalies. Regular renal monitoring for any APECED patient should be performed. Circulating antibodies against the distal part of the nephron are frequent and present in all TIN patients, but their pathologic significance is not yet known. Future studies will be needed to understand the triggers leading to overt clinical disease in these patients.

TGM5 mutations impact epidermal differentiation in acral peeling skin syndrome.

Acral peeling skin syndrome (APSS) is an autosomal recessive skin disorder characterized by acral blistering and peeling of the outermost layers of the epidermis. It is caused by mutations in the gene for transglutaminase 5, TGM5. Here, we report on clinical and molecular findings in 11 patients and extend the TGM5 mutation database by four, to our knowledge, previously unreported mutations: p.M1T, p.L41P, p.L214CfsX15, and p.S604IfsX9. The recurrent mutation p.G113C was found in 9 patients, but also in 3 of 100 control individuals in a heterozygous state, indicating that APSS might be more widespread than hitherto expected. Using quantitative real-time PCR, immunoblotting, and immunofluorescence analysis, we demonstrate that expression and distribution of several epidermal differentiation markers and corneodesmosin (CDSN) is altered in APSS keratinocytes and skin. Although the expression of transglutaminases 1 and 3 was not changed, we found an upregulation of keratin 1, keratin 10, involucrin, loricrin, and CDSN, probably as compensatory mechanisms for stabilization of the epidermal barrier. Our results give insights into the consequences of TGM5 mutations on terminal epidermal differentiation.

Validation of the Western Ontario Meniscal Evaluation Tool (WOMET) for patients with a degenerative meniscal tear: a meniscal pathology-specific quality-of-life index.

BACKGROUND: Arthroscopic partial meniscectomy is the most common orthopaedic procedure and is often carried out to treat a degenerative meniscal lesion. The purpose of the present study was to determine the psychometric properties of the Western Ontario Meniscal Evaluation Tool (WOMET) for patients with an arthroscopically verified degenerative meniscal tear. METHODS: Four hundred and eighty-five patients with an arthroscopically verified degenerative meniscal tear were included. Two groups of patients were formed: one consisted of 385 patients for the purpose of psychometric testing of the WOMET and the other consisted of 100 patients for the assessment of criterion validity. The reliability of the WOMET questionnaire was assessed by determining both internal consistency and test-retest repeatability; for the latter, a subgroup of forty patients completed the form two weeks preoperatively and again on the day of the operation. Validity assessment included determination of content validity (floor and ceiling effects), criterion validity (completion of the WOMET, the Lysholm knee score, and a generic quality-of-life questionnaire by a group of 100 patients), and construct validity (hypothesis testing). Finally, the responsiveness of the WOMET was determined with two successive assessments (on the day of surgery and six months postoperatively). RESULTS: The WOMET showed acceptable internal consistency, test-retest reliability, floor and ceiling effects, criterion validity (agreement with both Lysholm and 15-D scores), and construct validity (all hypotheses were significant). The WOMET was also found to be responsive to change. CONCLUSION: The WOMET score demonstrated acceptable psychometric performance as a patient-administered outcome measure for patients with an arthroscopically verified degenerative meniscal tear.

Oral soft tissue alterations in patients with neurofibromatosis.

Our aim was to characterize the type and frequency of oral soft tissue alterations in neurofibromatosis. A total of 103 patients with neurofibromatosis 1 (NF1) and three patients with neurofibromatosis 2 (NF2) were clinically evaluated for their oral soft tissue alterations. Disturbing growths were removed from nine patients with NF1 and from one patient with NF2. The specimens were analyzed using routine histological methods and with immunohistochemistry using antibodies to S100, type IV collagen, CD34, neurofilament, and neuron-specific tubulin (TUBB3). Alterations including oral tumors, overgrowths of gingival soft tissue, and enlarged papillae of the tongue were discovered in 74% of NF1 patients. The results showed that three tumors clinically classified as plexiform neurofibromas and five out of six discrete mucosal tumors displayed histology and immunohistology consistent with that of neurofibroma. The histology of one palatal lesion resembled that of a scar, and the lesion removed from the patient with NF2 was classified as an amyloid tumor. To conclude, oral soft tissue growths are common findings in NF1, but most lesions do not require treatment and the patients may even not be aware of these alterations. Collagen IV, S100, and CD34 are useful biomarkers in the analysis of NF1-related oral soft tissue tumors. The clinicians should recognize that oral soft tissue alterations are relatively common in NF1. Some of the growths are disturbing, and plexiform neurofibromas may bear a risk of malignant transformation.

Fetal hyperglycemia alters lung structural development in neonatal rat.

Maternal diabetes is associated with increased risk for abnormal fetal organogenesis, but its effects on the developing lungs are still insufficiently known. To determine the effect of maternal hyperglycemia on postnatal lung development, we studied lung structural and cellular changes in newborn rats exposed to intrauterine hyperglycemia. We induced hyperglycemia in Sprague-Dawley rats with i.p. streptozotocin before pregnancy and allowed the hyperglycemic and control dams deliver at term. Lungs were obtained on postnatal day (d) 0, d7, and d14 and analyzed for lung weight and morphology, as well as cellular apoptosis (TUNEL staining) and proliferation (PCNA staining). Quantitative micro-CT analysis of the lung vasculature was additionally performed at d14. At birth, maternal hyperglycemia resulted in decreased relative lung weight, thinner alveolar septa and increased cellular apoptosis and proliferation, when compared to controls. At 1 and 2 weeks of age pulmonary cell apoptosis and alveolar chord length remained unchanged, but cell proliferation and number of secondary crests were increased in the hyperglycemia-exposed neonatal lungs in comparison with the controls. Density of small arterioles on histological examination and the structure of pulmonary arterial vasculature in micro-CT analysis of the neonatal lungs were not influenced by maternal hyperglycemia. Our results suggest, that maternal hyperglycemia is related to developmental structural alterations in postnatal rat lungs. These early changes may reflect aberrant maturational adaptation in response to the hyperglycemic fetal environment.

Cutaneous lupus erythematosus after treatment with paclitaxel and bevacizumab for metastatic breast cancer: a case report.

INTRODUCTION: The monoclonal anti-vascular endothelial growth factor antibody bevacizumab is increasingly used in the treatment of several malignant tumors. The usual side effects of this drug are hypertension and proteinuria. Paclitaxel is widely used in the treatment of breast cancer and head and neck carcinomas. Neither of these two drugs typically causes skin disorders. Paclitaxel-related cutaneous lupus erythematosus has been described before, but in earlier cases patients had a history of autoimmune disease. CASE PRESENTATION: We report a case of a 65-year-old Caucasian woman who presented with cutaneous lupus erythematosus after receiving paclitaxel-bevacizumab combination treatment as first-line therapy for metastatic breast cancer. Her cutaneous symptoms and increased serum anti-SSA and anti-SSB antibodies disappeared shortly after the discontinuation of therapy. CONCLUSION: We conclude that cutaneous lupus erythematosus can also be seen in patients without earlier anamnesis of autoimmune disorders and that, furthermore, bevacizumab might cause atypical cutaneous side effects.

Compound heterozygous desmoplakin mutations result in a phenotype with a combination of myocardial, skin, hair, and enamel abnormalities.

Desmoplakin (DP) anchors the intermediate filament cytoskeleton to the desmosomal cadherins and thereby confers structural stability to tissues. In this study, we present a patient with extensive mucocutaneous blisters, epidermolytic palmoplantar keratoderma, nail dystrophy, enamel dysplasia, and sparse woolly hair. The patient died at the age of 14 years from undiagnosed cardiomyopathy. The skin showed hyperplasia and acantholysis in the mid- and lower epidermal layers, whereas the heart showed extensive fibrosis and fibrofatty replacement in both ventricles. Immunofluorescence microscopy showed a reduction in the C-terminal domain of DP in the skin and oral mucosa. Sequencing of the DP gene showed undescribed mutations in the maternal and paternal alleles. Both mutations affected exon 24 encoding the C-terminal domain. The paternal mutation, c.6310delA, leads to a premature stop codon. The maternal mutation, c.7964 C to A, results in a substitution of an aspartic acid for a conserved alanine residue at amino acid 2655 (A2655D). Structural modeling indicated that this mutation changes the electrostatic potential of the mutated region of DP, possibly altering functions that depend on intermolecular interactions. To conclude, we describe a combination of DP mutation phenotypes affecting the skin, heart, hair, and teeth. This patient case emphasizes the importance of heart examination of patients with desmosomal genodermatoses.

["Tennis leg"--calf muscle rupture of the middle-aged tennis aficionado]. / "Tennispohje"--keski-ikäisen tenniksen harrastajan pohjelihasrepeämä.

During tennis, the patient heard a bang from his left calf. The inferior edge of the calf muscle at the musculotendinous junction of the medial branch of m. gastrocnemius was tender to pressure, indicating a rupture called as "tennis leg". Foot movements are usually normal, but moving about is painful. The finding is confirmed by ultrasonography. First aid will limit the injury, and when the pain allows, active exercise therapy is initiated. Healing occurs in 2 to 6 weeks, the more difficult ones in 3 to 4 months. Return to the court may take place gradually with a bandaged calf.

Reconstruction of critical size calvarial bone defects in rabbits with glass-fiber-reinforced composite with bioactive glass granule coating.

UNLABELLED: The aim of this study was to evaluate glass-fiber-reinforced composite as a bone reconstruction material in the critical size defects in rabbit calvarial bones. The bone defect healing process and inflammatory reactions were evaluated histologically at 4 and 12 weeks postoperatively. Possible neuropathological effects on brain tissue were evaluated. The release of residual monomers from the fiber-reinforced composite (FRC) was analyzed by high performance liquid chromatograph (HPLC). RESULTS: At 4 weeks postoperatively, fibrous connective tissue ingrowth to implant structures was seen. Healing had started as new bone formation from defect margins, as well as woven bone islets in the middle of the defect. Woven bone was also seen inside the implant. Inflammation reaction was slight. At 12 weeks, part of the new bone had matured to lamellar-type, and inflammation reaction was slight to moderate. Control defects had healed by fibrous connective tissue. Histological examinations of the brain revealed no obvious damage to brain morphology. In HPLC analysis, the release of residual 1,4-butanedioldimethacrylate and methylmethacrylate from polymerized FRC was low. CONCLUSIONS: This FRC-implant was shown to promote the healing process of critical size calvarial bone defect in rabbits. After some modifications to the material properties, this type of implant has the potential to become an alternative for the reconstruction of bone defects in the head and neck area in the future.

Pancreatic phospholipase A2 contributes to lung injury in experimental meconium aspiration.

To investigate the role of pancreatic (group I) secretory PLA2 (sPLA2-I) in the pathogenesis of meconium aspiration syndrome, human particulate meconium or its supernatant either before or after extraction of PLA2-I was insufflated into rat lungs. In addition, the pulmonary effects of intra-tracheal human and bovine PLA2-I were studied. Lungs with saline instillation served as controls. Intrapulmonary particulate meconium (both before and after PLA2-I extraction), unlike meconium supernatant, resulted in markedly elevated lung tissue PLA2 catalytic activity and human PLA2-I concentrations when compared with controls. On the other hand, tissue concentrations of the group II PLA2 remained unchanged in all meconium lungs. Pulmonary PLA2-I concentrations further correlated positively with lung injury scores. Instillation of meconium-derived human PLA2-I, at a concentration of one-third of that in particulate meconium, did not raise PLA2 activity or concentrations of PLA2-I or PLA2-II in the lung tissue from the control level, but still resulted in significantly elevated lung wet/dry ratio and injury score. In contrast, insufflation of bovine pancreatic PLA2 increased the lung tissue enzyme activity and wet/dry ratio from the control level, but had no effect on the type II PLA2 concentration or lung injury score. Our data thus indicate that human pancreatic PLA2, introduced in high amounts within aspirated meconium especially in particulate form, is a potent inducer of lung tissue inflammatory injury.

Inhibition of COX-2 aggravates neutrophil migration and pneumocyte apoptosis in surfactant-depleted rat lungs.

Pulmonary inflammation and parenchymal apoptosis are implicated in the pathogenesis of the acute lung injury, but the mechanisms of these reactions are still unclear. Because inhibition of the proinflammatory cyclo-oxygenase (COX)-2 enzyme action is proposed to be useful in various inflammatory lung injuries, we decided to investigate the expression of COX-2 and the possible beneficial effects of its inhibition on pulmonary inflammation and apoptosis in surfactant-depleted lungs. The injury was induced in 2-mo-old rats by repeated lung lavage to remove alveolar surfactant. Eight of these rats were pretreated with a specific COX-2 inhibitor, NS-398. All rats, including control rats without lung lavage, were ventilated with 60% oxygen for 5 h, and the lungs were then studied histologically for tissue injury and with DNA nick-end labeling, cleaved caspase-3 immunohistochemistry, and electron microscopy for apoptotic cell death. Lung tissue myeloperoxidase activity and the expression of COX-2 protein and concentration of prostaglandin E2 were additionally analyzed. Lung lavage increased pulmonary neutrophil migration, histologic injury, and the occurrence of epithelial apoptosis. In contrast, expression of COX-2 and amount of PGE2 were significantly lower in surfactant-depleted lungs than controls. Pretreatment with the COX-2 inhibitor further increased the migration of neutrophils and occurrence of epithelial apoptosis in the surfactant-depleted lungs, compared with nontreated insulted lungs. These results suggest that specific inhibitors of COX-2 should be used cautiously in association with surfactant-deficient lung injuries.

Tight junction proteins and perineurial cells in neurofibromas.

Cutaneous neurofibromas consist of axonal processes, Schwann cells, fibroblasts, perineurial cells, mast cells, and abundant extracellular matrix. The distribution and role of perineurial cells in neurofibromas has been uncertain, partly because there has not been a specific immunohistochemical marker for perineurial cells. In this study, tight junctions (TJs) of 16 neurofibromas from 12 patients with neurofibromatosis type 1 (NF1) were analyzed using electron microscopy, immunohistochemistry, and Western transfer analysis. Cell-cell contacts with typical ultrastructural morphology of TJs were seen between adjacent perineurial cells surrounding the small nerves and between contacting perineurial cell processes embedded in tumor stroma. Immunohistochemistry showed expression of claudin-1, claudin-3, and ZO-1 in the intercellular junctions of a subpopulation of tumor cells. Occludin was present mainly in perineurium and claudin-5 localized to the blood vessels. Double immunolabelings were used to identify the cell types expressing claudin-1. The results showed that claudin-1 positive cells were also positive for type IV collagen and epithelial membrane antigen but not for S-100 protein. This labeling pattern is consistent with perineurial cell phenotype. Using claudin-1 as a marker, our results showed that clusters of perineurial cells are distributed around the rudimentary nerves within cutaneous neurofibromas and at the periphery of some neurofibromas.

Bactericidal/permeability-increasing protein in lacrimal gland and in tears of healthy subjects.

BACKGROUND: To determine the expression of bactericidal/permeability-increasing protein (BPI), a novel antimicrobial molecule, in the main lacrimal gland and its content in tears of young healthy subjects. METHODS: BPI concentration of tears was measured in 42 healthy volunteers, 13 men and 29 women, with ages ranging from 22 to 30 (mean 24.7+/-2.1) years by a time-resolved fluoroimmunoassay (TR-FIA). Immunohistochemical analysis was made to localize BPI in lacrimal gland and conjunctiva of eight autopsied subjects, two men and six women, with the age range from 44 to 87 (mean 72.3+/-14.9) years. RESULT: The mean concentration of BPI in tears was 27.8+/-29.5 microg/l, and it decreased with an increase in tear flow rate (P<0.0001). There was no statistically significant difference in BPI content of tears between the genders. BPI was immunohistochemically seen in outer basal epithelial cells of intralobular and excretory ducts, squamous and basal cells of conjunctiva as well as faintly in myoepithelial cell layer of acini. The presence of BPI in the lacrimal gland and in the tear fluid was verified by Western blotting. CONCLUSIONS: The results indicate that outer basal epithelial cells of lacrimal gland ducts contain BPI, which occurs in a relatively high concentration in tears. BPI may have a substantial antibacterial role in human tears.

Angiotensin II receptor inhibition prevents pneumocyte apoptosis in surfactant-depleted rat lungs.

Pneumocyte apoptosis is implicated in the pathophysiology of acute inflammatory lung injuries in newborns and adults. Pulmonary angiotensin (ANG) II contributes to lung epithelial apoptosis in vitro, but its role in acute lung injury in vivo is unclear. We therefore studied the effects of ANG II receptor action on the pulmonary inflammatory and apoptotic changes in surfactant-depleted lungs in rats. Lung injury was induced by repeated lung lavage with saline, and the rats were then ventilated with 60% oxygen for 1, 3, or 5 hr. Separate groups of rats were pretreated with a nonspecific ANG II receptor inhibitor saralasin, the specific ANG II type 1 receptor antagonist losartan, or ANG II type 2 receptor inhibitor PD123319, and were similarly studied. Lungs were studied histologically for tissue injury, and with terminal deoxynucleodityl transferase-mediated dUTP nick end-labeling (TUNEL) and cleaved caspase 3 antibody staining, and by electron microscopy for apoptotic cell death. Surfactant-depleted lungs showed an increased number of TUNEL-positive epithelial cells throughout the study, and intrapulmonary leukocyte migration and histological tissue injury scores were similarly elevated, compared to controls, from 1-5 hr of ventilation. Pretreatment with saralasin or losartan significantly prevented the increase of TUNEL positivity in pneumocytes, but had no effect on the amount of neutrophil influx or total injury score in lavaged lungs. In contrast, administration of PD123319 did not affect the number of TUNEL-positive epithelial cells or histological injury . The results suggest that increased epithelial apoptosis in surfactant-deficient lungs is mediated by ANG II receptor (specifically, subtype 1) action.

Reduced-intensity conditioning and blood stem cell transplantation from an HLA-identical sibling for severe aplastic anaemia: two patients with successful engraftment but a fatal post-transplant lymphoproliferative disorder in the other.

Allogeneic stem cell transplantation with reduced-intensity conditioning (RIC) can be offered to patients who are ineligible for high-dose conditioning because of their age or comorbidities. Malignant haematological diseases have so far been the most common indication of this new treatment modality; it has been less often used for nonmalignant diseases, and there are only a few reports of RIC and allotransplantation to treat acquired severe aplastic anaemia (SAA). We report two elderly patients (62 and 65 years of age) with SAA who underwent RIC (fludarabine + cyclophosphamide + ATG) and HLA-identical sibling allogeneic blood stem cell transplantation. Two important findings emerged. First, both of our patients who had failed standard immunological treatments and had a heavy transfusion history experienced successful engraftment after RIC and blood allografting, and one of them continues in full haematological remission 20+ months post-transplant. Secondly, the other patient died of Epstein-Barr virus-associated post-transplant lymphoproliferative disorder (PTLD) soon after engraftment, which implies that even if PTLD has been described in only few single cases after RIC, it may also complicate RIC allotransplants.

Angiotensin II receptor blockade inhibits pneumocyte apoptosis in experimental meconium aspiration.

Lung tissue inflammation and apoptosis are implicated in the pathogenesis of meconium aspiration-induced lung injury in the newborn, but the mechanisms of these reactions are still poorly known. We investigated the time-dependent leukocyte influx and appearance of apoptosis, as well as the contribution of angiotensin (ANG) II receptor action on these processes in the meconium-induced lung injury. Experimental meconium aspiration was induced by intratracheal instillation of human meconium in 18 rats, and eight rats were further pretreated with an unspecific ANG II receptor inhibitor saralasin. Rats were ventilated with 60% oxygen for 1, 3, or 5 h, and the lungs were then studied histologically for tissue injury and with DNA nick-end labeling and electron microscopy for apoptotic cell death. Lung tissue myeloperoxidase activity and expression of angiotensinogen mRNA and endothelial monocyte-activating polypeptide (EMAP) II protein were also analyzed. The meconium-instilled lungs showed increasing neutrophil migration and histologic injury after the first hour, whereas the number of epithelial apoptotic cells was elevated from the control level throughout the study. Myeloperoxidase activity was high, and the angiotensinogen mRNA and EMAP II protein was up-regulated at 5 h after the meconium insult. Pretreatment with saralasin significantly prevented the increase in lung tissue myeloperoxidase activity, EMAP II, and lung epithelial apoptosis. The results suggest that pulmonary meconium insult rapidly results in epithelial apoptosis, before significant neutrophil sequestration into the lungs. Apoptotic cell death is further connected with ANG II receptor action in the meconium-contaminated lung tissue.

Meconium induces only localized inflammatory lung injury in piglets.

Neonatal meconium aspiration often produces severe respiratory distress due to an inflammatory pulmonary injury, but the extension of this damaging reaction to the noncontaminated lung regions is still uncertain. To investigate the presence of generalized pulmonary inflammatory response, 31 anesthetized and ventilated neonatal piglets (1-3 d) were studied. Meconium (n = 16) or saline (n = 15) was instilled unilaterally into the right lung, and analysis of the lung tissue or bronchoalveolar lavage (BAL) fluid from both lungs was performed after 12 h. Meconium increased the wet/dry weight ratio, histologic tissue injury score and tissue myeloperoxidase activity as well as BAL fluid total cell count in the contaminated lung. Tumor necrosis factor-alfa concentrations in BAL fluid did not however differ significantly. Furthermore, in the meconium-instilled lungs the tissue and lavage fluid catalytic activity of phospholipase A2 (PLA2) and tissue PLA2 group-I and group-II concentrations were significantly elevated. Although BAL fluid catalytic activity of PLA2 was moderately increased also in the meconium noninstilled lung, significant inflammatory injury in this lung was absent. The results thus indicate that meconium aspiration induces severe local inflammation and lung injury, but significant generalized pulmonary inflammatory damage in the pathogenesis of meconium aspiration syndrome is unlikely.