RESUMEN
Eczema vaccinatum is a severe and occasionally lethal complication of smallpox vaccine, characterized by systemic viral dissemination, distant from the initial inoculation site of the vaccine. A major risk factor for eczema vaccinatum is a background of atopic dermatitis, a chronic, common allergic, relapsing disorder, manifested by dry and inflamed skin, itchy rash, Th2 biased immune response and hypersensitivity to various antigens. Unlike the severe manifestations of eczema vaccinatum in humans, current models present only mild symptoms that limits examination of potential therapeutics for eczema vaccinatum. The atopic dermatitis and eczema vaccinatum models we present here, are the first to simulate the severity of the diseases in humans. Indeed, dermatitic mice display persistent severe dermatitis, characterized by dry and inflamed skin with barrier dysfunction, epidermal hyperplasia and significant elevation of serum IgE. By exposing atopic dermatitis mice to ectromelia virus, we generated eczema vaccinatum that mimic the human disease better than known eczema vaccinatum models. Similarly to humans, eczematous mice displayed enlarged and disseminated skin lesions, which correlated with elevated viral load. Cidofovir and antiviral antibodies conferred protection even when treatment started at a late eczematous stage. Moreover, we are the first to demonstrate that despite a severe background of atopic dermatitis, modified vaccinia Ankara virus (MVA) vaccination protects against lethal ectromelia virus exposure. We finally show that protection by MVA vaccination is dependent on CD4+ T cells and is associated with significant activation of CD8+ cytotoxic T cells and induction of humoral immunity.
Asunto(s)
Dermatitis Atópica/complicaciones , Modelos Animales de Enfermedad , Virus de la Ectromelia/inmunología , Erupción Variceliforme de Kaposi/tratamiento farmacológico , Erupción Variceliforme de Kaposi/prevención & control , Vacuna contra Viruela/administración & dosificación , Vacuna contra Viruela/efectos adversos , Animales , Anticuerpos Antivirales/administración & dosificación , Antivirales/administración & dosificación , Linfocitos T CD4-Positivos , Cidofovir , Citosina/administración & dosificación , Citosina/análogos & derivados , Virus de la Ectromelia/patogenicidad , Femenino , Humanos , Erupción Variceliforme de Kaposi/patología , Ratones , Organofosfonatos/administración & dosificaciónRESUMEN
Atopic dermatitis (AD) is a common, chronic inflammatory skin disease with a highly variable clinical phenotype and heterogeneous pathophysiology. Its pathogenesis is associated with alterations to both the skin barrier and the immune system, which may in turn be influenced by genetic mutations and the patient's environment. Basic and translational research, as well as clinical trials, have helped broaden our knowledge of the molecular mechanisms underlying the development of AD and to identify potential treatment targets and approaches. These include new ways of reducing transepidermal water loss and the shedding of corneocytes, new ways of interacting with established molecular targets (such as histamine receptors and interleukins and other T-cell cytokines), and the identification of new molecular targets (such as toll-like receptors and tight junction proteins). Well-established treatment options such as emollients, corticosteroids and topical calcineurin inhibitors will clearly continue to have a role in treating AD. Among the new agents that could be joining them in the near future are sphinganin (a precursor of ceramides 1 and 3), cannabinoids, highly targeted monoclonal antibodies and subcutaneous immunotherapy.
Asunto(s)
Dermatitis Atópica/terapia , Inmunidad Adaptativa/fisiología , Antiinflamatorios/uso terapéutico , Anticuerpos Monoclonales/uso terapéutico , Péptidos Catiónicos Antimicrobianos/inmunología , Cannabinoides/uso terapéutico , Células Dendríticas/inmunología , Dermatitis Atópica/inmunología , Dermatitis Atópica/fisiopatología , Inhibidores Enzimáticos/uso terapéutico , Epidermis/fisiología , Humanos , Inmunoglobulina E/inmunología , Inmunoterapia/métodos , Erupción Variceliforme de Kaposi/prevención & control , Mastocitos/inmunología , Receptores Histamínicos/inmunología , Esfingosina/análogos & derivados , Esfingosina/uso terapéutico , Infecciones Cutáneas Estafilocócicas/prevención & control , Vitamina D/inmunología , Pérdida Insensible de Agua/inmunología , Pérdida Insensible de Agua/fisiologíaRESUMEN
Eczema vaccinatum (EV) is a complication of smallpox vaccination that can occur in persons with eczema/atopic dermatitis (AD), in which vaccinia virus disseminates to cause an extensive rash and systemic illness. Because persons with eczema are deferred from vaccination, only a single, accidentally transmitted case of EV has been described in the medical literature since military vaccination was resumed in the United States in 2002. To enhance understanding of EV, we review its history during the era of universal vaccination and discuss its relationship to complications in persons with other diseases or injuries of the skin. We then discuss current concepts of the pathophysiology of AD, noting how defective skin barrier function, epidermal hyperplasia, and abnormal immune responses favor the spread of poxviral infection, and identify a number of unanswered questions about EV. We conclude by considering how its occurrence might be minimized in the event of a return to universal vaccination.
Asunto(s)
Dermatitis Atópica/complicaciones , Eccema/complicaciones , Erupción Variceliforme de Kaposi/complicaciones , Erupción Variceliforme de Kaposi/virología , Vacuna contra Viruela/efectos adversos , Animales , Dermatitis Atópica/fisiopatología , Humanos , Erupción Variceliforme de Kaposi/prevención & control , Piel/fisiopatologíaAsunto(s)
Dermatitis Atópica/complicaciones , Inmunoglobulinas/uso terapéutico , Erupción Variceliforme de Kaposi/etiología , Erupción Variceliforme de Kaposi/prevención & control , Vaccinia/inmunología , Animales , Modelos Animales de Enfermedad , Ratones , Ratones Endogámicos BALB C , Piel/patología , Piel/virología , Resultado del Tratamiento , Virus Vaccinia/aislamiento & purificaciónAsunto(s)
Dermatitis Atópica/prevención & control , Erupción Variceliforme de Kaposi/prevención & control , Vacuna contra Viruela/inmunología , Vacuna contra Viruela/farmacología , Virus Vaccinia/inmunología , Animales , Dermatitis Atópica/inmunología , Modelos Animales de Enfermedad , Erupción Variceliforme de Kaposi/inmunología , Ratones , Ratones Endogámicos BALB CRESUMEN
BACKGROUND: Eczema vaccinatum is the most common severe pathology associated with smallpox vaccination (vaccinia virus), occurring at high rates among individuals with a previous history of atopic dermatitis (atopic eczema). METHODS: Monoclonal antibodies capable of neutralizing vaccinia virus, anti-H3 and anti-B5, were developed as a potential therapy for treatment of human eczema vaccinatum. RESULTS: Using a small animal model of eczema vaccinatum, we demonstrated that both murine and fully human monoclonal antibodies effectively limited eczema vaccinatum disease, foreshortening both the disease kinetics and the severity of the erosive viral skin lesions. CONCLUSIONS: These neutralizing antibodies would likely be effective at reducing or eliminating clinical disease in people with eczema vaccinatum or other severe side effects of the smallpox vaccine.
Asunto(s)
Anticuerpos Monoclonales de Origen Murino/administración & dosificación , Anticuerpos Neutralizantes/administración & dosificación , Erupción Variceliforme de Kaposi/inmunología , Erupción Variceliforme de Kaposi/prevención & control , Sustancias Protectoras/administración & dosificación , Vacuna contra Viruela/efectos adversos , Vacunación/efectos adversos , Animales , Anticuerpos Monoclonales de Origen Murino/inmunología , Anticuerpos Monoclonales de Origen Murino/uso terapéutico , Anticuerpos Neutralizantes/inmunología , Anticuerpos Neutralizantes/uso terapéutico , Dermatitis Atópica/complicaciones , Dermatitis Atópica/inmunología , Modelos Animales de Enfermedad , Humanos , Erupción Variceliforme de Kaposi/etiología , Erupción Variceliforme de Kaposi/virología , Ratones , Ratones Endogámicos , Sustancias Protectoras/uso terapéutico , Viruela/inmunología , Viruela/prevención & control , Vacuna contra Viruela/administración & dosificación , Virus Vaccinia/inmunología , Virus Vaccinia/patogenicidadAsunto(s)
Erupción Variceliforme de Kaposi/etiología , Erupción Variceliforme de Kaposi/prevención & control , Vacuna contra Viruela/efectos adversos , Preescolar , Necesidades y Demandas de Servicios de Salud , Humanos , Indiana , Control de Infecciones , Masculino , Rol de la Enfermera , Educación del Paciente como Asunto , Enfermedades Raras , Vacunación/efectos adversos , Vacunación/métodos , Vacunación/enfermeríaRESUMEN
Possible bioterrorism with smallpox has led to the resumption of smallpox (vaccinia virus) immunization. One complication, eczema vaccinatum, occurs primarily in patients with atopic dermatitis (AD). Skin lesions of patients with AD, but not psoriasis, is deficient in the cathelicidin antimicrobial peptide (LL-37) and human beta-defensin-2 (HBD-2). We hypothesized that this defect may explain the susceptibility of patients with AD to eczema vaccinatum. The Wyeth vaccine strain of vaccinia virus was incubated with varying concentrations of human (LL-37) and murine (CRAMP) cathelicidins, human alpha-defensin (HBD-1, HBD-2), and a control peptide. Outcomes included quantification of viral PFU, vaccinia viral gene expression by quantitative real-time RT-PCR, and changes in virion structure by transmission electron microscopy. CRAMP knockout mice and control animals were inoculated by skin pricks with 2 x 10(5) PFU of vaccinia and examined daily for pox development. Physiologic amounts of human and murine cathelicidins (10-50 micro M), but not human defensins, which had antibacterial activity, resulted in the in vitro reduction of vaccinia viral plaque formation (p < 0.0001), vaccinia mRNA expression (p < 0.001), and alteration of vaccinia virion structure. In vivo vaccinia pox formation occurred in four of six CRAMP knockout animals and in only one of 15 control mice (p < 0.01). These data support a role for cathelicidins in the inhibition of orthopox virus (vaccinia) replication both in vitro and in vivo. Susceptibility of patients with AD to eczema vaccinatum may be due to a deficiency of cathelicidin.
Asunto(s)
Péptidos Catiónicos Antimicrobianos/toxicidad , Erupción Variceliforme de Kaposi/prevención & control , Queratinas/toxicidad , Virus Vaccinia/crecimiento & desarrollo , Secuencia de Aminoácidos , Animales , Péptidos Catiónicos Antimicrobianos/administración & dosificación , Catelicidinas , Farmacorresistencia Microbiana , Humanos , Erupción Variceliforme de Kaposi/genética , Erupción Variceliforme de Kaposi/inmunología , Erupción Variceliforme de Kaposi/virología , Queratinas/administración & dosificación , Ratones , Ratones Endogámicos BALB C , Ratones Endogámicos C57BL , Ratones Noqueados , Pruebas de Sensibilidad Microbiana , Datos de Secuencia Molecular , Reacción en Cadena de la Polimerasa , Proteínas/genética , Proteínas/fisiología , Proteínas/toxicidad , ARN Viral/antagonistas & inhibidores , ARN Viral/biosíntesis , Vaccinia/genética , Vaccinia/inmunología , Vaccinia/prevención & control , Virus Vaccinia/efectos de los fármacos , Virus Vaccinia/genética , Replicación Viral/genéticaAsunto(s)
Dermatitis Atópica/complicaciones , Dermatitis Atópica/tratamiento farmacológico , Herpes Simple/complicaciones , Inmunosupresores/efectos adversos , Inmunosupresores/uso terapéutico , Erupción Variceliforme de Kaposi/etiología , Erupción Variceliforme de Kaposi/prevención & control , Tacrolimus/efectos adversos , Tacrolimus/uso terapéutico , Adulto , Contraindicaciones , HumanosAsunto(s)
Hidroterapia/efectos adversos , Erupción Variceliforme de Kaposi/transmisión , Aciclovir/uso terapéutico , Adolescente , Adulto , Anticuerpos Antivirales , Femenino , Humanos , Erupción Variceliforme de Kaposi/tratamiento farmacológico , Erupción Variceliforme de Kaposi/prevención & control , Erupción Variceliforme de Kaposi/virología , Masculino , Simplexvirus/genéticaAsunto(s)
Vacuna contra Viruela/historia , Viruela/prevención & control , Vacunación/historia , Niño , Historia del Siglo XX , Humanos , India , Lactante , Erupción Variceliforme de Kaposi/inmunología , Erupción Variceliforme de Kaposi/prevención & control , Necrosis , Viruela/complicaciones , Viruela/historia , Estados UnidosRESUMEN
Smallpox has disappeared from all countries except Ethiopia and the possibility of its eradication appears within reach. The need for vaccination of eczema patients against smallpox appears to be ending. Eczema vaccinatum is a rare but sometimes fatal complication of smallpox vaccination in atopic aczema and its incidence is discussed. Precautions in vaccinating atopic eczema patients include suitable treatment of the eczema, injection of vaccinial immunoglobulin and testing the competence of humoral and cellular immunity.