[Lack of therapeutic response: Is it really a rheumatoid Arthritis?] / Fehlendes Therapieansprechen: Ist es wirklich eine rheumatoide Arthritis?

ANAMNESIS: A 78-year-old female patient was referred to our hospital with treatment-resistant seronegative anti-citrullinated protein antibodies (ACPA)-negative rheumatoid arthritis. The course was characterized by high inflammatory activity and rapid progression of the erosive changes. Under the required high-dose prednisolone therapy, osteoporosis and a deep venous thrombosis (DVT) with pulmonary embolism developed. PHYSICAL EXAMINATION: A physical examination revealed symmetrical, painful, synovial swelling of the metacarpophalangeal, proximal-interphalangeal and distal-interphalangeal (MCP, PIP, and DIP) joints, finger joint-related violaceous erythema, contractures of the long fingers, and advanced deformities bilaterally. Pain and weakness in the muscles of her proximal extremities led to difficulties in raising her arms and climbing stairs. DIAGNOSIS: The results of laboratory tests showed negative RF (rheumatoid factor) and ACPAs, positive ANA (anti-nuclear antibodies) with titer 1:5120, a nuclear fluorescence pattern and a positive anti-Mi-2 Antibodies in the myositis blot. Conventional x-ray showed erosive and advanced mutilating joint changes in both hands. A magnetic resonance imaging (MRI) of the proximal extremities showed a pronounced muscle atrophy without sights of active myositis.This clinical constellation leads to the diagnosis of an amyopathic dermatomyositis. THERAPY AND PROGRESS: The patient was started on intravenous prednisone 100 mg daily, 4 days, followed by rapid dose tapering in the setting of accompanying risk factors such as Osteoporosis, arterial Hypertension and blurred vision. This treatment leads to improvement of symptoms. The basic therapy was switched to Rituximab. An extended tumor search was recommended on an outpatient basis. CONCLUSIONS: A seronegative, ACPA negative, therapy-resistant RA with a rapidly progressive erosive course requires a diagnostic re-evaluation. An erosive, rapidly progressing polyarthritis is commonly seen as manifestation of the subtype inflammatory myopathies associated with anti-Jo 1 antibodies, known as anti-synthetase syndrome. However, associations with the presence of other myositis specific antibodies (MSA) have been also described. The anti-Mi-2 Antibodies are highly specific for dermatomyositis (DM).Amyopathic DM is not common, but the disease course and prognosis do not differ significantly from myopathic DM.As a sudden presentation of DM may be of paraneoplastic origin a further examination in order to exclude malignancy are indicated.

Insecticide resistance in Trialeurodes vaporariorum populations and novel diagnostics for kdr mutations.

BACKGROUND: Neonicotinoids, pyrethroids and ketoenols are currently used for the control of Trialeurodes vaporariorum (Hemiptera: Aleyrodidae). In this study, insecticide resistance status and mechanisms were investigated using classical bioassays and molecular techniques. RESULTS: Dose-response bioassays were performed on 19 Greek populations, among the 35 different whitefly populations used for the whole analysis. Resistance factors scaled up to 207-, 4657- and 59-fold for imidacloprid, bifenthrin and spiromesifen, respectively. Molecular assays were used to investigate the frequency of known resistance mutations. A simple polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) assay was developed for detecting the pyrethroid-resistant alleles r1 (mutation L925I) and r2 (mutation T929I) of the para-type voltage-gated sodium channel gene (VGSC). Both alleles were present at high frequencies (on average 65% and 33%, respectively) in 14 populations from Greece. The M918 L pyrethroid resistance mutation was not detected in any of the Greek populations. Sequencing and a Taqman allelic discrimination were used to monitor the frequency of the mutation E645K of the acetyl-coenzyme A carboxylase gene (ACC) recently linked to spiromesifen resistance. This mutation was detected in 20 of the 24 populations examined in ∼38% frequency among the 433 individuals tested. However, its association with the spiromesifen resistance phenotype was not confirmed in the Greek populations. Finally, two homologues of the CYP6CM1 Bemisia tabaci P450, the known neonicotinoid metabolizer, were found upregulated in two T. vaporariorum neonicotinoid-resistant populations; they were both functionally expressed in Escherichia coli, but the recombinant proteins encoded did not metabolize those neonicotinoid insecticides tested. CONCLUSION: The development of simple diagnostics and their use alongside classical and molecular techniques for the early detection of resistant populations are of great importance for pest management strategies. The practical implications of our results are discussed in light of whitefly control. © 2017 Society of Chemical Industry.

Unique features of a global human ectoparasite identified through sequencing of the bed bug genome.

The bed bug, Cimex lectularius, has re-established itself as a ubiquitous human ectoparasite throughout much of the world during the past two decades. This global resurgence is likely linked to increased international travel and commerce in addition to widespread insecticide resistance. Analyses of the C. lectularius sequenced genome (650 Mb) and 14,220 predicted protein-coding genes provide a comprehensive representation of genes that are linked to traumatic insemination, a reduced chemosensory repertoire of genes related to obligate hematophagy, host-symbiont interactions, and several mechanisms of insecticide resistance. In addition, we document the presence of multiple putative lateral gene transfer events. Genome sequencing and annotation establish a solid foundation for future research on mechanisms of insecticide resistance, human-bed bug and symbiont-bed bug associations, and unique features of bed bug biology that contribute to the unprecedented success of C. lectularius as a human ectoparasite.

Geographic spread, genetics and functional characteristics of ryanodine receptor based target-site resistance to diamide insecticides in diamondback moth, Plutella xylostella.

Anthranilic diamides and flubendiamide belong to a new chemical class of insecticides acting as conformation sensitive activators of the insect ryanodine receptor (RyR). These compounds control a diverse range of different herbivorous insects including diamondback moth, Plutella xylostella (Lepidoptera: Plutellidae), a notorious global pest on cruciferous crops, which recently developed resistance due to target-site mutations located in the trans-membrane domain of the Plutella RyR. In the present study we further investigated the genetics and functional implications of a RyR G4946E target-site mutation we recently identified in a Philippine diamondback moth strain (Sudlon). Strain Sudlon is homozygous for the G4946E mutation and has been maintained under laboratory conditions without selection pressure for almost four years, and still exhibit stable resistance ratios of >2000-fold to all commercial diamides. Its F1 progeny resulting from reciprocal crosses with a susceptible strain (BCS-S) revealed no maternal effects and a diamide susceptible phenotype, suggesting an autosomally almost recessive mode of inheritance. Subsequent back-crosses indicate a near monogenic nature of the diamide resistance in strain Sudlon. Radioligand binding studies with Plutella thoracic microsomal membrane preparations provided direct evidence for the dramatic functional implications of the RyR G4946E mutation on both diamide specific binding and its concentration dependent modulation of [(3)H]ryanodine binding. Computational modelling based on a cryo-EM structure of rabbit RyR1 suggests that Plutella G4946E is located in trans-membrane helix S4 close to S4-S5 linker domain supposed to be involved in the modulation of the voltage sensor, and another recently described mutation, I4790M in helix S2 approx. 13 Å opposite of G4946E. Genotyping by pyrosequencing revealed the presence of the RyR G4946E mutation in larvae collected in 2013/14 in regions of ten different countries where diamide insecticides largely failed to control diamondback moth populations. Thus, our study highlights the global importance of the G4946E RyR target-site mutation, which as a mechanism on its own, confers high-level resistance to diamide insecticides in diamondback moth.

Resistance to diamide insecticides in diamondback moth, Plutella xylostella (Lepidoptera: Plutellidae) is associated with a mutation in the membrane-spanning domain of the ryanodine receptor.

Diamide insecticides such as chlorantraniliprole and flubendiamide are a new class of insecticide that selectively target insect ryanodine receptors (RyR), a distinct class of homo-tetrameric calcium release channels which play a pivotal role in calcium homeostasis in numerous cell types. Resistance to these insecticides has recently been reported in the diamondback moth, Plutella xylostella (Lepidoptera: Plutellidae), a global lepidopteran pest of cruciferous crops. In the present study a region of the gene encoding the proposed diamide binding site of the RyR from P. xylostella collected from the Philippines and Thailand and found to be over 200-fold resistant to both chlorantraniliprole and flubendiamide compared to susceptible strains, were amplified by RT-PCR and sequenced. Comparison of the sequence with those from several susceptible reference strains revealed non-synonymous mutations in each of the resistant strains that in both cases lead to a glycine to glutamic acid substitution (G4946E) in the protein. The independent evolution of the same amino acid substitution within a highly conserved region of the proposed diamide binding site in two geographically separated resistant strains of P. xylostella strongly suggests a causal association with diamide resistance. Furthermore we designed a pyrosequencing-based diagnostic assay for resistance monitoring purposes that can be used to detect the G4946E mutation in field-collected samples of diamondback moth. The implications of the reported findings for resistance management strategies are discussed.

Immunoadsorption with tryptophan columns: a therapeutic option for the treatment of rheumatoid arthritis with septic complications.

Rheumatoid arthritis (RA) is a chronic inflammatory autoimmune disease affecting multiple organs and tissues. Although there is a wide range of therapeutic applications, the coexistence of severe side effects and contraindications outlines the necessity of new therapeutic options in the treatment of severe RA. We report on the case of a 71-year-old patient with successful treatment of a complicated RA with tryptophan immunoadsorption combined with low-dose steroids. Bacterial spondylitis developed in this patient during long-term treatment with infliximab and methotrexate. Weekly immunoadsorption sessions with tryptophan columns resulted in continuous suppression of RA activity over a period of more than 5 months, as indicated by laboratory findings, the disease activity score, and the visual analog scale. This is the first report of successful treatment of a refractory and complicated RA using tryptophan immunoadsorption columns. In conclusion, immunoadsorption is a safe and effective therapeutic alternative, which should be considered to bridge infectious complications in patients with severe RA.

Identification of Botrytis cinerea genes up-regulated during infection and controlled by the Galpha subunit BCG1 using suppression subtractive hybridization (SSH).

The Galpha subunit BCG1 plays an important role during the infection of host plants by Botrytis cinerea. Delta bcg1 mutants are able to conidiate, penetrate host leaves, and produce small primary lesions. However, in contrast to the wild type, the mutants completely stop invasion of plant tissue at this stage; secondary lesions have never been observed. Suppression subtractive hybridization (SSH) was used to identify fungal genes whose expression on the host plant is specifically affected in bcg1 mutants. Among the 22 differentially expressed genes, we found those which were predicted to encode proteases, enzymes involved in secondary metabolism, and others encoding cell wall-degrading enzymes. All these genes are highly expressed during infection in the wild type but not in the mutant. However, the genes are expressed in both the wild type and the mutant under certain conditions in vitro. Most of the BCG1-controlled genes are still expressed in adenylate cyclase (bac) mutants in planta, suggesting that BCG1 is involved in at least one additional signaling cascade in addition to the cAMP-depending pathway. In a second SSH approach, 1,500 clones were screened for those that are specifically induced by the wild type during the infection of bean leaves. Of the 22 BCG1-controlled genes, 11 also were found in the in planta SSH library. Therefore, SSH technology can be successfully applied to identify target genes of signaling pathways and differentially expressed genes in planta.

Contrast-enhanced high in-plane resolution dynamic MRI of the breast. Are there advantages in comparison to standard dynamic MRI?

OBJECTIVE: To evaluate the diagnostic advantages of high in-plane resolution contrast-enhanced (CE) magnetic resonance imaging (MRI) of the breast in comparison to standard CE-MRI. METHODS: Forty-one patients with 51 hypervascularized lesions were selected prospectively after undergoing bilateral standard CE MRI (slice thickness 4 mm, in-plane resolution 1.52 x 1.25 mm2, temporal resolution 81 s). Patients underwent high in-plane resolution CE MRI, either (n=21) a two-dimensional fast-low-angle-shot sequence (slice thickness 4 mm, in-plane resolution 0.76 x 0.63 mm2, temporal resolution 96 s) or (n=20) a SE sequence being used (slice thickness 4 mm, in-plane resolution 0.8 x 0.63 mm2, temporal resolution 115 s). RESULTS: Histopathology revealed 33 malignant and 18 benign lesions (0.2-2.2 cm). Morphologic characteristics were much better visualized with high in-plane resolution. Additional diagnostic information, however, resulted only in one patient with fibroadenoma due to a better visualization of smooth contours. CONCLUSIONS: High in-plane resolution provides better visualization of morphologic patterns in comparison to standard dynamic MRI. However, a diagnostic advantage is only rare.