Staphylococcus aureus Serine protease-like protein A (SplA) induces IL-8 by keratinocytes and synergizes with IL-17A.

BACKGROUND: Serine protease-like (Spl) proteins produced by Staphylococcus (S.) aureus have been associated with allergic inflammation. However, effects of Spls on the epidermal immune response have not been investigated. OBJECTIVES: To assess the epidermal immune response to SplA, SplD and SplE dependent on differentiation of keratinocytes and a Th2 or Th17 cytokine milieu. METHODS: Human keratinocytes of healthy controls and a STAT3-hyper-IgE syndrome (STAT3-HIES) patient were cultured in different calcium concentrations in the presence of Spls and Th2 or Th17 cytokines. Keratinocyte-specific IL-8 production and concomitant migration of neutrophils were assessed. RESULTS: SplE and more significantly SplA, induced IL-8 in keratinocytes. Suprabasal-like keratinocytes showed a higher Spl-mediated IL-8 production and neutrophil migration compared to basal-like keratinocytes. Th17 cytokines amplified Spl-mediated IL-8 production, which correlated with neutrophil recruitment. Neutrophil recruitment by keratinocytes of the STAT3-HIES patient was similar to healthy control cells. CONCLUSION: S. aureus-specific Spl proteases synergized with IL-17A on human keratinocytes with respect to IL-8 release and neutrophil migration, highlighting the importance of keratinocytes and Th17 immunity in barrier function.

Atopic dermatitis, STAT3- and DOCK8-hyper-IgE syndromes differ in IgE-based sensitization pattern.

BACKGROUND: Increased serum IgE levels are characteristic but not specific for allergic diseases. Particularly, severe atopic dermatitis (AD) overlaps with hyper-IgE syndromes (HIES) regarding eczema, eosinophilia, and increased serum IgE levels. HIES are primary immunodeficiencies due to monogenetic defects such as in the genes DOCK8 and STAT3. As it is not known to date why allergic manifestations are not present in all HIES entities, we assessed the specificity of serum IgE of AD and HIES patients in the context of clinical and immunological findings. METHODS: Clinical data, skin prick tests, specific IgE to aero- and food allergens, and T helper (Th) subpopulations were compared in AD and molecularly defined HIES patients. RESULTS: Total serum IgE levels were similarly increased in STAT3-HIES, DOCK8-HIES, and AD patients. The ratio of aeroallergen-specific IgE to total IgE was highest in AD, whereas DOCK8-HIES patients showed the highest specific serum IgE against food allergens. Overall, clinical allergy and skin prick test results complied with the specific IgE results. Th2-cell numbers were significantly increased in DOCK8-HIES and AD patients compared to STAT3-HIES patients and controls. AD patients showed significantly higher nTreg-cell counts compared to STAT3-HIES and control individuals. High Th17-cell counts were associated with asthma. Specific IgE values, skin prick test, and T-cell subsets of STAT3-HIES patients were comparable with those of healthy individuals except decreased Th17-cell counts. CONCLUSION: Hyper-IgE syndromes and atopic dermatitis patients showed different sensitization pattern of serum IgE corresponding to the allergic disease manifestations and Th-cell subset data, suggesting a key role of DOCK8 in the development of food allergy.

Successful long-term correction of autosomal recessive hyper-IgE syndrome due to DOCK8 deficiency by hematopoietic stem cell transplantation.

Autosomal dominant hyper-IgE syndrome (AD-HIES), characterised by eczema, increased susceptibility to skin and lung infections, elevated IgE and skeletal abnormalities is associated with heterozygous STAT3 mutations. The autosomal recessive variant (AR-HIES) has similar immunological findings but mainly lacks extraimmune manifestations. Several AR-HIES patients have recently been shown to harbour mutations in the gene for dedicator of cytokinesis 8 (DOCK8). Here, we present the long-term outcome of a girl having received a hematopoietic stem cell graft for an at that time genetically undefined combined immunodeficiency associated with severe eczema, multiple food allergies, excessively elevated serum IgE levels and eosinophilia. She was recently found to carry a homozygous nonsense mutation in the DOCK8 gene. HSCT resulted in complete immunological correction, even though mixed donor chimerism occurred. Clinically, the outcome was characterised by disappearance of skin manifestations and severe infections, improvement of pulmonary function and constant decline of IgE levels. Outcome in untransplanted DOCK8 deficient patients is poor because of frequent life-threatening infections, CNS bleeding and infarction, and increased susceptibility to malignancy. This argues for early curative therapeutic approaches, supported by this report of successful long-term outcome after HSCT.

[Vaccinations with atopic dermatitis and other chronic inflammatory skin diseases]. / Impfungen bei Neurodermitis und anderen chronisch entzündlichen Hauterkrankungen.

One of the most effective preventive measures in medicine is vaccination for avoidance of vaccination preventable diseases. If higher vaccination rates could be achieved individual pathogens could be eliminated and even made extinct. Vaccination is not obligatory in Germany. In previous decades many diseases which were preventable by vaccination have become rare. Being unaware of the course of the disease, the willingness to be vaccinated decreases and doubts about vaccination increase. If atopic dermatitis or allergy is known, the doctor performing the vaccination and also the dermatologist are often asked questions on the indications, performing standard vaccination and the vaccination schedule. This review article is intended to supply dermatologists with answers to frequently asked questions on indications and performing standard vaccinations in connection with atopic dermatitis, allergies and chronic inflammatory skin diseases. Although patients often have uncertainties and doubts, undesirable severe medicinal effects are rare even for patients with atopic dermatitis.

Classification of non-bacterial osteitis: retrospective study of clinical, immunological and genetic aspects in 89 patients.

OBJECTIVE: To define non-bacterial osteitis (NBO) as a clinical entity possibly associated with autoimmune manifestations. Patients with sterile osteitis were analysed to develop diagnostic criteria. METHODS: A total of 89 patients with non-bacterial inflammatory bone lesions were observed for a median of 49 months. History, diagnostic imaging, laboratory and histological data were obtained. Mutation analysis in the genes PSTPIP1 and PSTPIP2 was performed. RESULTS: Patients had an onset of disease at a median age of 10 yrs [interquartile range (IQR) 7.5-12] and suffered a median period of 21 (IQR 9-52) months with a median of three foci per patient. Twenty percent of all the patients demonstrated associated autoimmune disorders, particularly of the skin and bowel. The majority of bone lesions were located in the vertebrae and metaphyses. Slight-to-moderate elevation of inflammation values were found in all the patients and antinuclear antibodies were elevated in 30%. Non-steroidal anti-inflammatory drugs (NSAIDs) were effective in 85% of the patients. HLA-B27 and Human Leukocyte Antigen-DR (HLA-DR)-classification did not differ from the general population. Autoimmune diseases in 40% of all the families, multiply affected family members, linkage to 18q21 and mouse models strongly indicate a genetic basis for NBO. We observed three different courses of disease regarding the duration of complaints, rate of complications and associated autoimmune manifestations leading to a new classification of NBO. CONCLUSIONS: Clinical analysis of our cohort leads us to define NBO as a distinct disease entity with three clinical presentations: acute NBO, chronic recurrent multifocal osteomyelitis or persistent chronic NBO. Diagnostic criteria were proposed to differentiate NBO from diseases with similar clinical presentation.

No indication for a defect in toll-like receptor signaling in patients with hyper-IgE syndrome.

Hyper-IgE syndrome is a rare primary immunodeficiency of unknown etiology characterized by recurrent infections of the skin and respiratory system, chronic eczema, elevated total serum IgE, and a variety of associated skeletal symptoms. Recent reports about susceptibility to pyogenic bacterial infections and high IgE levels in patients and animals with defects in toll-like receptor (TLR) signaling pathways prompted us to search for TLR signaling defects as an underlying cause of hyper-IgE syndrome. Blood samples from six patients with hyper-IgE syndrome were analyzed for serum cytokine levels, intracellular cytokine production in T cells after stimulation with PMA/ionomycin, and cytokine production from peripheral blood mononuclear cells stimulated by TLR ligands and bacterial products including LPS (TLR4), peptidoglycan (TLR2), PolyIC (TLR3), R848 (TLR7/8), CpG-A, and CpG-B (TLR9), zymosan and heat killed Listeria monocytogenes. All results were compared to data from healthy controls. A reduction in IFN-gamma, IL-2, and TNF-alpha producing T cells after PMA stimulation suggested a reduced inflammatory T cell response in patients with hyper-IgE syndrome. Increased serum levels of IL-5 indicated a concomitant Th2 shift. However, normal production of cytokines (TNF-alpha, IL-6, IL-10, IFN-alpha, IP-10) and upregulation of CD86 on B cells and monocytes after TLR stimulation made a defect in TLR signaling pathways highly unlikely. In summary, our data confirmed an imbalance in T cell responses of patients with hyper-IgE syndrome as previously described but showed no indication for an underlying defect in toll-like receptor signaling.

Genetic linkage of hyper-IgE syndrome to chromosome 4.

The hyper-IgE syndrome (HIES) is a rare primary immunodeficiency characterized by recurrent skin abscesses, pneumonia, and highly elevated levels of serum IgE. HIES is now recognized as a multisystem disorder, with nonimmunologic abnormalities of the dentition, bones, and connective tissue. HIES can be transmitted as an autosomal dominant trait with variable expressivity. Nineteen kindreds with multiple cases of HIES were scored for clinical and laboratory findings and were genotyped with polymorphic markers in a candidate region on human chromosome 4. Linkage analysis showed a maximum two-point LOD score of 3.61 at recombination fraction of 0 with marker D4S428. Multipoint analysis and simulation testing confirmed that the proximal 4q region contains a disease locus for HIES.

Development and clinical evaluation of an amplified flow cytometric fluoroimmunoassay for Clostridium difficile toxin A.

A rapid (2 h) amplified flow cytometric fluoroimmunoassay (AFCF) for Clostridium difficile toxin A was developed and compared with the cytotoxin assay (CTA) and culture of the organism from stool specimens from patients with suspected C. difficile-associated gastrointestinal disease (CAD). For this assay polyclonal antitoxin A was attached to 10-microns diameter and monoclonal antitoxin A was attached to fluorescent 0.1 micron-diameter polystyrene microspheres. The microspheres and sample were reacted together as in a conventional double-antibody sandwich assay. However, laser flow cytometric measurement allowed the omission of separation and washing steps by gating on light scattered by the larger microspheres and measuring only the fluorescence associated with these particles. The amount of fluorescence from the attached 0.1 micron microspheres was dependent on the concentration of toxin A in the sample. The AFCF detected purified toxin A at levels of 1 pg/ml and was linear from 1 to 40 pg/ml. The AFCF was compared with the CTA and culture of C. difficile for clinical use by comparing results from 198 stool specimens from patients with suspected CAD. The AFCF was 85.7% sensitive and 95.8% specific relative to the CTA, and 85.2% sensitive and 98.3% specific compared to the culture assay. If the isolation of toxigenic C. difficile or the patients clinical course was considered indicative of CAD, the sensitivities of the AFCF, CTA, and culture assay were 77.4%, 67.7% and 96.8%, respectively. The AFCF demonstrated a specificity of 98.8%, while both CTA and culture had a specificity of 100%.(ABSTRACT TRUNCATED AT 250 WORDS)

Cost of inappropriate use of ciprofloxacin in ambulatory care.

OBJECTIVE: To determine the incidence of inappropriate ciprofloxacin use and the resulting cost thereof in ambulatory care. DESIGN: Retrospective cost analysis. SETTING: Ambulatory care clinic of a Department of Veterans Affairs Medical Center. PATIENTS: One hundred thirty-seven ambulatory patients prescribed ciprofloxacin during March, April, and May 1992. Forty-six patient charts were available for review. MAIN OUTCOME MEASURE: Indications for ciprofloxacin use were determined from chart review. RESULTS: Chart review of 46 of the 137 patients prescribed ciprofloxacin during the three-month study period indicated that only 8 (17 percent) had infections that were appropriately treated with this antibiotic. If 550 patients had received ciprofloxacin that year (figure extrapolated from the three-month totals), the cost of prescribing would have been $29,260. This study indicates that $20,500 per year could be saved by prescribing equally efficacious oral antibiotics. CONCLUSIONS: Restricting ciprofloxacin use to its proven indications in the ambulatory setting may result in considerable cost savings to medical centers.

Fatal Legionnaires' disease coincident with initiation of immunosuppressive therapy.

A fatal relapse of legionnaires' disease occurred coincidental with the initiation of chemotherapy in a patient who had received previous parenteral erythromycin gluceptate therapy for 30 days. Sputum examinations utilizing the direct fluorescent antibody test for Legionella pneumophila suggested persistence of infection during the course of antibiotic therapy. This case suggests that administration of immunosuppressive agents should be delayed in patients whose sputum is positive on direct fluorescent antibody testing, regardless of previous antibiotic therapy.

Sporadic Legionnaires' disease: clinical observations on 87 nosocomial and community-acquired cases.

To add information about sporadic Legionnaires' disease, 87 cases of L. pneumophila pneumonia were reviewed. Twenty cases were nosocomial infections and 67 cases were community-acquired. Most cases (64%) occurred between July and October. The mean age of patients was 51.4 years and males outnumbered females 2.5:1.0. Thirty-one percent of patients were receiving corticosteroid, immunosuppressive, or antineoplastic chemotherapy when illness began. Immunosuppression at onset of illness was more common in nosocomial infections (90%) than in community-acquired infections (14%). Seventy percent of patients had underlying diseases. Malignancies, renal failure, and transplantation were the most common conditions underlying nosocomial infections. Chronic lung disease and malignancies were the most common diseases underlying community-acquired infections. The case-fatality rate in nosocomial infection (70%) was greater than that in community-acquired disease (22%). Clinical, laboratory, and radiologic features of the cases were examined. Illness ranged from mild to severe. Extrapulmonary findings of encephalopathy and renal failure were more common in fatal than in non-fatal cases. Indirect immunofluorescent and microagglutination antibody responses plateaued by the fourth week of illness. Twenty-nine patients died. The case-fatality rate of patients receiving erythromycin (6%) was less than that of patients receiving penicillin (36%), ampicillin (28%), cephalosporin (32%), or aminoglycosides (41%). Despite erythromycin therapy, the case fatality rate for nosocomial L. pneumophilia pneumonia was unacceptably high (25%).

A survey of domestic animals to detect serological responses against Legionella spp. by indirect fluorescent antibody.

One hundred ninety-six (196) animal sera were examined for antibodies against heat-killed antigens of Legionella pneumophila serogroups 1 to 5, L. bozemanii, L. dumoffii, L. gormanii and L. micdadei by the indirect fluorescent antibody technique. Only two animals (1%), both sheep, reacted against L. pneumophila serogroups at a titer of 256. However, 29% of the horses and 24% of the sheep tested were reactive to at least one non-L. pneumophila Legionella spp. antigen at a titer of 256. At a titer of 128, 72% of the pigs, 56% of the sheep and 50% of the horses were reactive to at least one Legionella spp. antigen. Despite the presence of high antibody titers against Legionella antigens, conclusive evidence of infection by these agents in animals is dependent upon further studies.

A new staining method for Legionella pneumophila.

Most of the methods that have been described for the staining of bacteria in tissue sections have been found unsatisfactory for Legionella pneumophila. In this report, we describe a method that consistently stains L. pneumophila in tissue and has certain advantages over recommended methods currently in use.

Coinfections of Mycoplasma pneumoniae and Legionella pneumophila with influenza A virus.

Serum samples from patients with documented influenza A virus infections were examined for antibodies to Legionella pneumophila and Mycoplasma pneumoniae to determine whether simultaneous or sequential infections with L. pneumophila and M. pneumoniae were complicating factors in influenza. When the frequency of copositivity of sera to influenza A virus and L. pneumophila was compared with the expected frequency for each infection alone, the difference was not statistically significant. However, when the frequency of copositivity of sera to influenza A virus and M. pneumoniae was compared with the expected frequency for each infection alone, there was a statistically significant (P less than 0.005) absence of coincident titers. Seasonal variations and differences in relative age frequencies for the two infections may partially explain the absence of coinfections. These data also suggest that in patients with either M. pneumoniae or influenza A virus infection, some type of protective mechanism which prevents coinfections with these organisms is present.

Seroreactivity to Mycoplasma pneumoniae and Legionella pneumophila: lack of a statistically significant relationship.

We reviewed antibody titers to Mycoplasma pneumoniae and Legionella pneumophila serogroup I in sera from 1,060 cases of acute respiratory infection to determine whether there was an association in seroreactivity to these organisms. Of the 170 serum pairs with antibodies to L. pneumophila (35 seroconversions and 135 with presumptive titers), 32 (18.8%) demonstrated seroreactivity to M. pneumoniae (17 seroconversions and 15 with presumptive titers). This frequency was not significantly greater than the seroreactivity to M. pneumoniae observed in sera without antibodies to L. pneumophila (17.5%) (0.05 less than P less than 0.10), which included 111 seroconversions and 45 sera with presumptive titers.

Sporadic Legionnaires' disease. A pathologic study of 23 fatal cases.

Twenty-three fatal sporadic cases of serogroup 1 Legionella pneumophila pneumonia have been analyzed. Bilateral consolidating fibrinopurulent pneumonia was evident in most cases. In four leukopenic immunosuppressed subjects, and acute fibrinoserous pneumonia with a remarkable lack on inflammation was present. The bacterium was found at extrathoracic sites in 27% of the cases. Involvement of the spleen (25%), bone marrow (13%), and kidneys (4.5%) suggests that hematogenous spread of the infection is not uncommon. Involvement of the hilar lymph nodes in 44% of the cases, and multiple peripheral lymph nodes in one case, suggest that lymphatic vessels may also be an important pathway of dissemination. We concluded that systemic spread of L pneumophila is not uncommon in seriously ill patients and we believe that some of the unusual extrathoracic manifestations of this disease may be related to bacteremia.

Legionnaires' disease among pneumonias in Iowa (FY 1972-1978) II. Epidemiologic and clinical features of 30 sporadic cases of L. pneumophila infection.

We reviewed retrospectively the clinical records of 30 cases of sporadic Legionella pneumophila infection that occurred in Iowa between FY 1972 and 1978. Cases occurred throughout the year, most between May and December. Twenty-one male patients and 9 female patients ranging in age from 5-80 years were infected. Half the patients smoked or had an underlying illness; five were receiving corticosteroids or immunosuppressive therapy. Occupations and exposures related to hospitals, construction and travel were common; four patients had been exposed to birds. In addition to L. pneumophila infection, six patients had evidence of infection with a viral, mycoplasmal, bacterial, mycobacterial or fungal pathogen; three had had preceding dental infections. Twenty-seven cases were pneumonias visible on radiographs. Fever, cough, chills, myalgia and rales occurred inover half the cases. Headache, gastrointestinal symptoms and encephalopathy also were seen. Upper respiratory symptoms were uncommon. Urinalysis and blood studies often suggested renal and hepatic involvement, but other routine laboratory diagnostic tests were not helpful. All but two patients were hospitalized; seven required intensive care. The median duration of hospitalization was 12 days. Two patients who did not receive erythromycin or tetracycline therapy died.

Background prevalence of microagglutination antibodies to Legionella pneumophila serogroups 1, 2, 3, and 4.

The background prevalence of microagglutination antibodies to Legionella pneumophila was determined by testing the sera of 517 individuals who lived or worked in a small Iowa town. In this population, the upper limit of normal microagglutination titer for serogroups 1, 3, and 4 was 1:16, and that for serogroup 2 was 1:8. The prevalence of microagglutination titers of greater than or equal to 1:32 against any serogroup of L. pneumophila was only 7.4% and did not vary significantly with age or sex.