Beta Human Papillomavirus Infection Is Prevalent in Elephantiasis and Exhibits a Productive Phenotype: A Case-Control Study.

Elephantiasis is considered a cutaneous region of immune deficiency with cobblestone-like surface caused by a wart-like eruption. Verrucosis is a diffuse human papillomavirus (HPV) infection linked to immunodeficiency disorders. The objective of this study was to examine the prevalence of HPV infection in lymphedema and its pathogenic role in elephantiasis. A retrospective case-control study was performed examining lymphedematous skin and controls of peritumoral normal skin. HPV infection was evaluated at the DNA, protein, and histopathologic levels by polymerase chain reaction, immunohistochemistry, and light microscopy, respectively. Overall, 540 HPV DNAs were detected in 120 of 122 cutaneous samples (median 4 HPV DNAs per sample, range 0-9). Compared with controls, no differences existed in type or number of HPVs identified. Instead, a diverse spectrum of HPV-related histopathologies were evident, likely reflecting the multiplicity of HPV genotypes detected. Most notably, increasing histopathologic lymphedema stage significantly correlated with markers of productive HPV infection such as altered keratohyaline granules and HPV L1 capsid expression. Limitations of this study are the absence of normal skin controls not associated with neoplasia or subclinical lymphedema, and lack of assessment of HPV copy number per keratinocyte infected. In conclusion, productive HPV infection, not HPV type or numbers detected, distinguished lymphedematous skin from controls. These findings support the theory that lymphedema creates a region of depressed immunity that permits productive HPV infection, manifested clinically by diffuse papillomatosis, characteristic of elephantiasis.

Treatment of pretibial myxedema with dexamethazone injected subcutaneously by mesotherapy needles.

Pretibial myxedema (PTM) is a rare extrathyroidal manifestation of Graves' disease that requires treatment when the clinical picture is markedly evident. In addition to topical treatment with steroid ointments, there have been previous reports of subcutaneous injections of steroids. This procedure may cause nodular degeneration of the skin due to fat atrophy when standard needles are used. In the present study, we have tried a novel modality of treatment of PTM by injecting a solution of dexamethasone in the subcutaneous tissue using needles employed for mesotherapy. These needles are ≤4 mm long and deliver the medication within the dermis or the first layer of the subcutaneous fat. We have treated five patients, four with diffuse and one with elephanthiasic PTM. We utilized multiple injections of a solution of dexamethasone, lidocaine, and saline in the PTM plaque and in the pretibial area, both in the PTM plaque and in the area surrounding the lesions, once a week for three consecutive weeks. Two patients with a more severe form of PTM underwent another two cycles four to six weeks after initial treatment. Patients were studied before and after treatment by clinical assessment and ultrasound of the pretibial skin. The treatment was well-tolerated, with only moderate pain upon injection of the solution. One month after treatment, all patients showed improvement of PTM at clinical assessment and a reduction of the thickness of the lesions at ultrasound of ∼15%, involving mostly the dermis. Moreover, all patients reported amelioration of the leg appearance. The present study, although preliminary, shows that intralesion steroid injection with mesotherapy needles in PTM is effective and well tolerated, and does not cause undesired long-term modifications of the skin. More studies are warranted to standardize such treatment in larger groups of patients.

Protective immunity in human Bancroftian filariasis: inverse relationship between antibodies to microfilarial sheath and circulating filarial antigens.

The existence and the nature of protective immunity in human filariasis continues to be a subject of intense debate. While there is no broad consensus on functional immunity against larval and adult stage parasites, anti-microfilarial immunity has been demonstrated to be mediated by antibodies to the microfilarial sheath. In the present study, circulating filarial antigens (CFA), a marker of active filarial infection in human Bancroftian filariasis, was found to be inversely associated with antibodies to microfilarial sheath in a cohort of 411 subjects representing all categories of filariasis across the clinical spectrum of the disease. Approximately 80% of humans of all age groups (5-65 years) were found to have either CFA or anti-sheath antibodies. The inverse relationship observed between these two parameters was found to be independent of the clinical manifestation; both symptomatic and asymptomatic cases were found to display similar inverse association between CFA and anti-sheath antibodies. The prevalence of anti-sheath antibodies in the paediatric group was found to be very high as compared to adults; 78% of children below the age of 10 years tested positive for anti-sheath antibodies although the mf rate and CFA rate were only 4.5% and 22.7%, respectively, in this age group, indicating that developing larvae or juvenile adult stage parasites could have been the source of antigenic stimulus for induction of antibodies to the microfilarial sheath.

Bancroftian filariasis: profile of serum antifilarial antibody and circulating parasite antigen.

Forty-five serum specimens collected from persons living in a filaria-endemic community in Maili Nane, Coastal Kenya were analyzed by ELISA for levels of isotype specific antifilarial antibody and by Og4C3 ELISA for circulating parasite antigen. Mean levels of IgG1, IgG2, and IgG3 were lower in microfilaraemic persons than in amicrofilaraemic individuals. In contrast, mean levels of antifilarial IgG4 were significantly higher in microfilaraemic persons (p = 0.0374). Serum samples from all microfilaremic persons were positive for circulating antigen as were 15% of samples from amicrofilaremic and asymptomatic persons. The Og4C3 antigen assay may have value as a technique for identifying and targeting communities for control efforts.

Parasite-specific anergy in human filariasis. Insights after analysis of parasite antigen-driven lymphokine production.

The antigen-specific immune unresponsiveness seen in bancroftian filariasis was studied by examining lymphokine production in peripheral blood mononuclear cells (PBMC) or PBMC subpopulations from 10 patients with asymptomatic microfilaremia, 13 patients with elephantiasis and 6 normal North Americans. In each group of patients, the kinetics of the lymphokine response and the response to mitogens and nonparasite antigens did not differ significantly. In marked contrast, when antigen-induced lymphokine production was examined, most patients with microfilaremia were unable to produce either interleukin 2 (IL-2) or gamma-interferon (i.e., were nonresponders), and the few who could (hyporesponders, generally with quite low microfilaremia levels) did so at levels significantly less than those of patients with elephantiasis, all of whom showed strong responses to parasite antigen. Removal of neither adherent cells or T8+ cells affected the parasite-specific anergy seen in those with microfilaremia, suggesting a state of T cell tolerance to the parasite in patients with this most common clinical manifestation of bancroftian filariasis.

HLA and filariasis in Sri Lankans and Indians.

Similar HLA association was found in patients with elephantiasis in Sri Lankans and Southern Indians. HLA-B15 was observed in 13/44 (30%) Sri Lankan patients with elephantiasis compared to 1/27 (4%) Sri Lankan controls (p = .0058; RR = 10.9) and in 5/8 (28%) Southern Indian elephantiasis compared to 10/101 (10%) Southern Indian controls (p = 0.04; RR = 3.5). In combining the data, the significance of the difference of the frequency of B15 between patients with elephantiasis and controls was even more marked (p = 0.00045; corrected p = 0.012; RR = 4.4).

Immune reactions to Wuchereria bancrofti infections in Tanzania. I. Serum-mediated adherence of leucocytes to microfilariae in vitro, using serum from different groups of patients.

Studies on serum-mediated adherence of leucocytes to microfilariae of Wuchereria bancrofti in vitro were carried out in an area of Tanzania endemic for filarial infections. Patients were divided into age-matched groups according to parasitological and clinical conditions. No adherence was seen with serum from microfilariae-positive patients (with or without clinical disease). A slightly, but not statistically significantly, higher prevalence of adherence-positive sera was found among hydrocele patients (27%) and lymphangitis/elephantiasis patients (33%) than among endemic control patients (20%). These three positive groups exhibited a marked difference in age distribution of prevalence of positivity, with very high prevalences found among young hydrocele patients (48%) and old lymphangitis/elephantiasis patients (63%). The hydrocele fluid from hydrocele patients with adherence-positive serum also mediated adherence.

Immune reactions to Wuchereria bancrofti infections in Tanzania. II. Characterization of the serum-mediated adherence reaction of leucocytes to microfilariae in vitro.

Investigations to characterize the in vitro reaction of serum-mediated leucocyte-adherence to microfilariae of Wuchereria bancrofti were carried out in Tanzania. The adherence reaction took place within one hour and at least two serum factors were involved: a heat-labile factor, present also in normal serum (probably complement), and a more heat-stable factor, present in positive serum only (probably an antibody). Neutrophils and eosinophils were involved in the reaction proportionately to Their numbers in the cell solutions used; the reaction killed significantly more microfilariae, than did adherence-negative tests. Microfilariae could be used for at least one week after their isolation from the donor, but a significant decrease in the percentage of reactive microfilariae occurred within 16 hours of isolation. A high degree of species specificity was observed when positive sera were tested against other nematodes. The involvement of complement and the speed with which the reaction took place is in contrast to the results of similar studies from India, and may indicate a difference in the parasite in the two continents.

Immunoglobulin levels in various clinical groups of human Brugian filariasis in Malaysia.

Quantitation of serum immunoglobulin M, G, A, D and E levels was carried out in Malaysians with Brugia malayi infections. Results showed highly elevated levels of IgM and IgE as well as moderately elevated levels of IgG. These were most significant in patients with tropical pulmonary eosinophilia or elephantiasis. Serum IgE levels were extremely high in microfilaraemic patients (6,060 +/- 3,958 IU ml) probably due to a constant antigenic stimulation by dead and dying microfilariae.

Antigen-specific suppressor T lymphocytes in human lymphatic filariasis.

Immune responses to parasite antigens are much lower in patients with microfilaremia than in persons with other manifestations of brugian filariasis. To determine whether hyporeactivity is associated with changes in populations of lymphocytes that regulate immune responses, we quantitated helper and suppressor T cells in the blood of patients infected with Brugia malayi. Increased numbers of suppressor T cells were present in 15 of 17 patients with microfilaremia and in six of 11 patients with elephantiasis. This increase correlated with hyporeactivity to filarial antigens but not to nonparasite antigens. Removal of suppressor T cells activated in vivo or in vitro improved reactivity to filarial antigens. These results suggest that immunosuppression induced by filarial parasites is a possible mechanism of survival of these organisms in an immunocompetent host.

Immune responses in human Brugia malayi infections: serum dependent cell-mediated destruction of infective larvae in vitro.

Serum dependent cell-mediated cytotoxicity of subperiodic Brugia malayi infective larvae in vitro was investigated. In vitro cellular adherence of normal human buffy coat cells to infective larvae of B. malayi was promoted by sera from patients with elephantiasis, tropical pulmonary eosinophilia (TPE) and amicrofilaraemic symptomatic filariasis, as well as by sera from normal subjects from filariasis endemic areas. However, strongest adherence was observed with TPE sera. Scanning electron microscopic (SEM) studies confirmed that the cellular adherence resulted in gross surface damage to the infective larvae. Studies with the indirect fluorescent antibody test (IFAT) suggested that IgG and/or IgM might be involved in the process of adherence. Complement did not appear to be important.

[Detection of circulating immune complexes using polyethylene glycol. Its value in the therapy of phlebology patients]. / Détection des complexes immuns circulants (CIC) au moyen du polyéthylène glycol. Sa valeur pour le traitement des malades en phlébologie.

After a short exposition of the meaning and the technique for determination of immune complexes in circulating blood (after Hashkova, with polyethylene glycol) our first experience with phlebological patients is exposed. Positive reactions in a variety of cases (N = 122) includes atypical ulcus cruris, ulcerated vasculitis, Pyoderma gangrenosum, discoid lupus erythematodes, chronic rheumatoid polyarthritis (with, or without ulcus cruris), monoarthritis of the knee, pernicious anemia, chronic lymphedema (elephantiasis), some cases of sclerosis multiplex. In such positive cases the sedimentation rate of citrate blood may, or may not be elevated. Negative or uncertain reactions (below 10) were seen in 141 cases, in common's ulcus cruris cases, in vasculite nodulaire, in discopathy and most spondylarthroses and other arthrosis cases, in vasculite nodulaire, in discopathy and most spondylarthroses and other arthrosis cases, in various patients with rheumatoid complaints in coxarthrosis, osteoporosis and in a group of healthy young persons. Negative reactions were the rule in atherosclerotic and diabetic old persons with claudication or gangrene, in most dermatological cases, in necrobiosis lipoidica, in psoriasis, in postthrombotic phlebitis and in chronic rheumatism in a quiet stage. In vasculitis cases the reaction is often only slightly positive (between 10 and 20) but should be repeated as the values may vary. The determination of circulating immune complexes with polyethylenglycol is a useful screening method in the policlinic. Treatment is often directed in the right way sometimes prednisone, more often nivaquin (chloroquin) or other anti-inflammatory drugs and in pernicious anemia hepatotherapy can be of great help in the healing of complicated phlebological cases.

Antibody-dependent cell-mediated effects in bancroftian filariasis.

The nature of immunoglobulin and effector cells involved in the antibody-dependent cell-mediated adhesion and cytotoxicity to Wuchereria bancrofti larvae has been investigated. Human neutrophils and eosinophils purified from peripheral blood by metrizamide gradients readily adhered to the parasites in presence of IgG fraction of sera from majority of elephantiasis cases with amicrofilaraemia and many of the endemic normals. The cells from normal, microfilariae and elephantiasis cases were equally effective inthe adhesion reaction. While the adhered neutrophils killed the larvae, eosinophils were ineffective in this respect. DEC treatment of elephantiasis cases results in a significant reduction in the ability of their sera to promote cellular adhesion.

Immune responses in human infections with Brugia malayi: specific cellular unresponsiveness to filarial antigens.

We evaluated the cellular immune competence of 101 subjects living in an area of South Kalimantan (Borneo) where Malayan filariasis is endemic. All patients with elephantiasis but none with other clinical stages of filariasis reacted with adult worm antigens. The majority of subjects without clinical or parasitological evidence of filariasis and approximately one-half of those with amicrofilaremic filariasis reacted with microfilarial antigens. In contrast, most patients with patent microfilaremia did not respond to microfilarial antigens. The in vitro reactivity of all patient categories to nonparasite antigens was similar to that of the distant control group. These results indicate that patent microfilaremia is associated with a state of specific cellular immune unresponsiveness and are consistent with the current hypothesis that the various clinical manifestations of filariasis result from different types of immune responses to distinct antigens associated with different developmental stages of filarial worms.