Regional differences in cell-mediated immunity in people with diabetic peripheral neuropathy.

AIM: To study cell-mediated immunity in the feet of people with type 2 diabetes with polyneuropathy. METHODS: In a cohort comprising people with type 2 diabetes with polyneuropathy (n = 17) and without polyneuropathy (n = 12) and a healthy control group (n = 12) indurations due to delayed-type hypersensitivity responses to intracutaneous Candida albicans antigen were determined in the foot and compared with those in the arm (an area relatively spared in diabetic polyneuropathy). The sizes of indurations on the foot were correlated with electromyographic measurements in the participants with diabetes. RESULTS: No differences were observed in the median size of indurations between the foot and arm in healthy controls and participants without polyneuropathy; in participants with polyneuropathy, induration sizes on the foot were smaller than on the arm: 0 (95% CI 0 to 1) vs 5 (95% CI 2 to 6) mm (P < 0.01). In participants with diabetes, larger indurations correlated with better nerve function (Spearman's rho 0.35 to 0.39). CONCLUSION: Our findings suggest that diabetic peripheral polyneuropathy negatively affects cell-mediated immunity in the foot. (Clinical Trials registry no.: NCT01370837).

Associated conditions in small fiber neuropathy - a large cohort study and review of the literature.

BACKGROUND AND PURPOSE: Small fiber neuropathy (SFN) is a common disorder leading to neuropathic pain and autonomic symptoms. The objective of this study was to investigate associated conditions in a large cohort of SFN patients and compare the prevalence to healthy individuals. METHODS: A total of 921 patients with pure SFN were screened according to a standardized comprehensive diagnostic algorithm and compared with literature findings. RESULTS: No associated condition could be found in 53% of the patients. Autoimmune diseases, sodium channel gene mutations, diabetes mellitus including glucose intolerance, and vitamin B12 deficiencies were more prevalent than reported literature findings, followed by alcohol abuse, chemotherapy, monoclonal gammopathy of undetermined significance, and haemochromatosis. In patients who were already known with a possible underlying condition at screening, additional underlying conditions were still found in another 26.7% of patients. CONCLUSIONS: Based on these results, it is recommended that patients with pure SFN are screened at least for autoimmune diseases, sodium channel gene mutations, diabetes mellitus including glucose intolerance, and vitamin B12 deficiency, even when they already have a potential underlying condition at referral.

Multidisciplinary decision-making regarding chemotherapy for lung cancer patients-An age-based comparison.

Optimising decision-making in elderly patients is becoming increasingly urgent. We analysed treatment decisions and course of therapy for patients with lung cancer in different age categories: <65, 65-75, and 75 years and older. About 349 patients with lung cancer (median age 67.8 years), discussed at the multidisciplinary team meeting in the Diakonessenhuis Utrecht, the Netherlands, were reviewed. Multidisciplinary decision-making and subsequent clinical course were extracted from medical files. We found that 39% of eligible patients older than 75 years of age started treatment with chemotherapy compared to 80% of the younger patients (<65 and 65-75). When patients did receive chemotherapy, primary and secondary treatment adaptations were effectuated in 58%: for patients aged <65 in 49%, for patients aged 65-75 and >75 years in 66%. For 44% of all patients treated with chemotherapy, unplanned hospital admissions were required: in 42% for the patients <65, in 52% for those aged 65-75 and in 27% for >75 years. The decision-making process and course of treatment for lung cancer vary per age category. In particular, patients between 65 and 75 years of age might be more frail than initially thought. Age and frailty are important characteristics that need more attention.

Characterization of bovine neutrophil gelatinase-associated lipocalin.

A protein of relative molecular mass of approximately 25,000 was purified from bovine colostrum by cation-exchange and size-exclusion chromatography. The N-terminus of the protein matched the sequence predicted by the National Center for Biotechnology Information for the bovine homolog of human neutrophil gelatinase-associated lipocalin, a glycoprotein of relative molecular mass 25,000 belonging to the family of lipocalins. The protein was further designated as bovine neutrophil gelatinase-associated lipocalin (bNGAL). Sodium dodecyl sulfate-PAGE of enzymically deglycosylated bNGAL indicated that the intact protein bears one N-linked glycan. Monosaccharide and mass spectrometric analyses of released N-linked carbohydrates revealed the presences of complex- and hybrid-type glycans, with galactose substituted with N-acetylgalactosamine. This substitution is typical for glycoproteins expressed in the bovine mammary gland. A specific ELISA revealed bNGAL concentrations in plasma and mature milk of about 0.05 and 1 microg/mL, respectively, whereas values as high as 51 microg/mL were measured in colostrum. Thus, we have isolated and characterized a novel bovine (milk) protein that is a new member of the lipocalin family.

[The value of integrated PET-CT images in 2 lymphoma patients with skeletal localisations]. / De waarde van gefuseerde PET-CT-beelden bij 2 lymfoompatiënten met skeletlokalisaties.

In two women with Hodgkin's disease, 36 and 34 years of age, the PET-scan showed increased FDG-uptake in regions where the CT-scan did not reveal any abnormalities. Integration of the PET-CT images visualised bone marrow localisations in both patients. One patient underwent a CT-guided bone biopsy that confirmed this localisation. In both cases, the results of the integrated PET-CT images altered the therapy that would have been given on the basis ofthe standard staging technique. Both patients underwent radiotherapy. After 6 months, one patient had no visible lesions. The other patient died due to progression ofthe disease. Integrated PET-CT images can play an important role, not only in the precise classification and staging of lymphoma but also at the start of therapy, as an initial scan, in the evaluation of the response to treatment, and in the early detection of recurrence.

Treatment of multifocal primary cutaneous B-cell lymphoma: a clinical follow-up study of 29 patients.

PURPOSE: Although patients with primary cutaneous B-cell lymphoma (CBCL) and localized skin lesions are generally treated with radiotherapy and have an excellent prognosis, the clinical behavior and optimal treatment of CBCL presenting with multifocal skin lesions are less well defined. In this study, we evaluated the clinical behavior of and results of treatment for multifocal CBCL in 29 patients, and we formulated therapeutic guidelines. PATIENTS AND METHODS: The study group included 16 patients with primary cutaneous follicular center-cell lymphoma (PCFCCL), eight with primary cutaneous immunocytoma (PCI), and five with primary cutaneous large B-cell lymphoma presenting on the legs (PCLBCL of the leg). RESULTS: Only one of the 24 patients with multifocal PCFCCL or PCI developed extracutaneous disease, and no patient died from lymphoma (median follow-up, 54 months). In patients with PCFCCL, treatment with either multiagent chemotherapy (nine patients) or radiotherapy directed toward all skin lesions (five patients) proved equally effective in terms of complete remission, relapse, and survival. In contrast, all five patients with PCLBCL of the leg developed extracutaneous disease, and four of the five died from systemic lymphoma, 8 to 36 months (median, 21 months) after diagnosis. CONCLUSION: The results of these preliminary studies suggest that patients with PCFCCL or PCI presenting with multifocal skin lesions have the same excellent prognosis that patients with localized PCFCCL or PCI have and that radiotherapy directed toward all skin lesions is as effective as multiagent chemotherapy. Patients with PCLBCL of the leg have a more unfavorable prognosis, particularly patients presenting with multifocal skin lesions. This last group should always be treated with multiagent chemotherapy.

Primary cutaneous marginal zone B-cell lymphoma: clinical and therapeutic features in 50 cases.

BACKGROUND: Primary cutaneous marginal zone B-cell lymphoma (PCMZL) is a low-grade B-cell lymphoma that originates in the skin, with no evidence of extracutaneous disease. Studies focusing on the optimal treatment of PCMZL have not been published thus far. We describe 50 patients with PCMZL to further characterize clinical characteristics and outcome and, in particular, to evaluate our current therapeutic approach. OBSERVATIONS: The majority of the patients (36/50 [72%]) presented with multifocal skin lesions, and 14 patients (28%) presented with solitary or localized lesions. The initial treatment of patients with solitary lesions consisted of radiotherapy or excision, whereas patients with multifocal lesions received a variety of initial treatments, most commonly radiotherapy and chlorambucil therapy. Cutaneous relapses developed in 19 (48%) of 40 patients who had complete remission and were more common in patients with multifocal disease. After a median period of follow-up of 36 months, 2 patients developed extracutaneous disease, but none of the patients died of lymphoma. CONCLUSIONS: Patients with PCMZL who have solitary lesions can be treated effectively with radiotherapy or excision. For patients with PCMZL who have multifocal lesions, chlorambucil therapy and radiotherapy are suitable therapeutic options. In case of cutaneous relapses, the beneficial effects of treatment should carefully be weighed against the potential adverse effects.

Demonstration of clonal immunoglobulin gene rearrangements in cutaneous B-cell lymphomas and pseudo-B-cell lymphomas: differential diagnostic and pathogenetic aspects.

Twenty-five patients with a benign or malignant cutaneous B-cell lymphoproliferative disease, including seven cutaneous pseudo-B-cell lymphomas, eight primary cutaneous B-cell lymphomas (CBCL), and 10 secondary cutaneous B-cell lymphomas, were investigated for the presence of clonal immunoglobulin (Ig) gene rearrangements using Southern blot hybridization analysis. The selection of pseudo-B-cell lymphomas was based on the presence of polyclonal light-chain expression with immunohistochemical analysis. All cases of CBCL demonstrated monotypic light-chain expression or absence of detectable Ig on CD20+ B cells. Clonal rearrangements of one or more Ig genes were demonstrated in four of seven cases of cutaneous pseudo-B-cell lymphomas, six of eight cases of primary CBCL, and in all cases of secondary CBCL. The observation that cutaneous pseudo-B-cell lymphomas as defined by immunohistochemical criteria often contain occult monoclonal B-cell populations implies that differentiating between pseudo-B-cell lymphomas and CBCL is not always possible by means of gene-rearrangement analysis. These findings may support the concept that cutaneous pseudo-B-cell lymphomas and primary CBCL are part of a continuous and progressive spectrum of B-cell lymphoproliferative skin disorders.

Monoclonal anti-peroxidase isotype switch variants. Applications in studies of protein A binding and characterization of rat monoclonal antibodies.

A series of heavy chain isotype switch variants was derived from a hybridoma cell line secreting monoclonal antibodies specific for horseradish peroxidase. By the combined use of sensitive isotype-specific ELISAs and sequential sublining IgG2b, IgG2a, IgE and Iga anti-peroxidase-producing variants were successively isolated out of IgG1-secreting parental cells. The anti-peroxidase isotype variant antibodies are particularly appropriate for use in studies of the influence of heavy chain isotype in the effector functions of immunoglobulins. The use of variant antibodies with specificity for an enzyme favors their application in immunoassays because an enzyme-conjugated second antibody is not needed. Here we describe two applications of the anti-peroxidase switch variants. First, the variants are compared with respect to their affinity for Staphylococcus protein A. While IgG1 anti-peroxidase showed weak binding, both IgG2 variants strongly bound to protein A, whereas IgE and IgA variants had no affinity for protein A. Next, the switch variants were used to determine the isotype specificity of rat monoclonal antibodies generated to murine IgE.

Murine monoclonal isotype switch variants. Detection with rat monoclonal antibodies in ELISA and isolation by sequential sublining.

Isotype switch variants, which arise in monoclonal antibody-producing cell lines, can be detected and selected on the basis of sensitive isotype-specific assays. In this study we used a series of enzyme-linked immunosorbent assays specific for murine IgG1, IgG2b, IgG2a, IgE or IgA, which permitted the detection of low frequency switch variants of hybridoma cell lines, irrespective of the specificity of the secreted antibody. In these assays two rat monoclonal antibodies were combined: one specific for the particular heavy-chain isotype, the other for the light-chain isotype, which was identical in all variants. The value of rat monoclonal antibodies for the detection of isotype switch variants is illustrated by the isolation of a series of variant antibodies specific for the CD3 complex present on human T lymphocytes.

Serum concentrations of erythromycin after intravenous infusion in preterm neonates treated for Ureaplasma urealyticum infection.

Erythromycin is receiving renewed attention as an alternative for treatment of neonatal infections caused by Ureaplasma urealyticum because of recently proved abilities of this organism to produce systemic disease in this population. Although erythromycin has been used clinically for almost 40 years, very little is known about its activity in the preterm neonate. Fourteen neonates, birth weights < or = 1500 g and < or = 15 days of age, from whom U. urealyticum was isolated from the lower respiratory tract were randomized to receive erythromycin lactobionate either 25 or 40 mg/kg/day in four divided doses at 6-hour intervals scheduled for a total of 10 days. Blood samples collected at multiple time points after initial and steady state doses were assayed for erythromycin by liquid chromatography. Minimal inhibitory concentrations (MICs) of erythromycin for the U. urealyticum isolates were determined. MICs ranged from 0.031 to 2 micrograms/ml; MIC90 = 2 micrograms/ml. Serum erythromycin concentrations met or exceeded most MICs, with peak values of 3.05 to 3.69 and 1.92 to 2.9 micrograms/ml for the 40- and 25-mg/kg/day dosage groups, respectively. Pharmacokinetic parameters were calculated after the initial dose and at steady state for both dosage groups and compared. No adverse effects thought to be related to administration of erythromycin were observed. These preliminary findings showed that erythromycin is well-tolerated, has favorable pharmacokinetic activity in the preterm neonate and should be further investigated for treatment of ureaplasmal infections.

A translocation (8;14) in a cutaneous large B-cell lymphoma.

A 62-year-old man with a cutaneous large-cell (cleaved, noncleaved) lymphoma had multiple facial lesions and two enlarged cervical lymph nodes. Cytogenetic analysis performed on the involved skin and lymph node revealed the following karyotype: 47,XY,inv dup(1)(q11-->q32),+3,t(8;14)(q24;q32). A t(8;14)(q24;q32) translocation is the chromosome anomaly in 75% of Burkitt's lymphomas. Other types of non-Hodgkin's lymphomas, however, may show the same translocation, especially large-cell lymphomas. Duplication of material belonging to the long arm of chromosome 1 is the most frequent additional aberration to Burkitt's translocations in Burkitt's lymphoma/leukemia. Trisomy 3 may be seen in both B- and T-cell malignancies, as well as in angioimmunoblastic lymphadenopathy. Immunogenotyping of malignant cells from a lymph node showed rearrangement of the immunoglobulin heavy and lambda light chain genes. Epstein-Barr virus (EBV) serology was positive for EBV nuclear antigen and EBV capsular antigen. No integration of EBV DNA in tumor tissue, however, could be detected by polymerase chain reaction. These results may be useful in defining the biologic characteristics of cutaneous B-cell non-Hodgkin's lymphomas.

Use of monoclonal antibody KP1 for identifying normal and neoplastic human mast cells.

The monoclonal antibody KP1 (CD68) was used to stain normal and neoplastic monocytes and macrophages in routinely processed, paraffin wax embedded tissue: mast cells also exhibited strong, consistent cytoplasmic immunoreactivity. Light microscopic findings were corroborated by electron microscopical and immunocytochemical findings. The predominant sites of immunoreactivity were the specific intracytoplasmic granules of the mast cells. All mast cell subtypes--that is, normal and reactive mast cells, such as those in lymph nodes exhibiting chronic non-specific lymphadenitis, and malignant or neoplastic mast cells in various types of mastocytosis--reacted with this antibody. This finding is of diagnostic importance, because mast cell proliferation could be mistaken for histiocyte proliferation. It also supports the hypothesis that mast cells derive from the bone marrow.

Multiple clear cell acanthomas. A clinical, histological, and ultrastructural report.

A case of multiple clear cell acanthomas in a 64-year-old woman is reported. The clinical and histological findings of this rare entity are consistent with the hypothesis that clear cell acanthomas are benign epidermal tumors. An ultrastructural study was performed with special emphasis on the melanocytic-keratinocytic interaction.

The Bazex-Dupré-Christol syndrome.

BACKGROUND: The Bazex-Dupré-Christol syndrome is characterized by follicular atrophoderma, congenital hypotrichosis, and basal cell neoformations that include basal cell carcinomas and basal cell nevi. OBSERVATIONS: We describe a large family in which 20 persons across four generations present with typical features of the Bazex-Dupré-Christol syndrome. However, the clinical picture in this family differs with regard to gender and age. Male subjects have a uniformly severe disease, whereas female subjects exhibit a range of severity of the syndrome. The most striking difference between male and female subjects is provided by hypotrichosis. In male subjects, hypotrichosis is diffuse and affects all scalp hairs. On the other hand, female subjects do not have hypotrichosis, but normal hairs are intermingled with abnormal hairs. In infancy and childhood, multiple milia are present, whereas in adults only a few milia are observed. CONCLUSIONS: The family pedigree seems to be consistent with an X-linked inheritance, since male-to-male transmission does not occur. Moreover, further evidence of an X-linked dominant mode of inheritance could be derived from the observation of gender differences that can be attributed to the lyonization phenomenon in female subjects. From a clinical and morphologic point of view, the Bazex-Dupré-Christol syndrome seems to be a disorder of the hair follicle.

Primary cutaneous large B-cell lymphomas of the legs. A distinct type of cutaneous B-cell lymphoma with an intermediate prognosis. Dutch Cutaneous Lymphoma Working Group.

BACKGROUND AND DESIGN: Primary cutaneous follicular center cell lymphomas represent a distinct type of cutaneous B-cell lymphoma, clinically characterized by localized skin lesions on the head or trunk and an excellent prognosis. Histologically similar lymphomas may occur on the legs. The clinical behavior of this group is still undefined, and controversy exists whether these lymphomas should be classified as follicular center cell lymphoma or B-immunoblastic lymphoma. We reviewed the clinical, histologic, and follow-up data of 18 patients with primary cutaneous large B-cell lymphoma of the legs. RESULTS: Primary cutaneous large B-cell lymphoma of the legs generally occurred in elderly patients (median age at diagnosis, 76 years), in particular women (male-female ratio, 7:2), and preferentially affected the lower legs (14 of 18 patients). Radiotherapy and/or systemic polychemotherapy resulted in complete remissions in 16 of 17 patients. Follow-up data demonstrated estimated 2- and 5-year survival rates of 77% and 58%, respectively. Histologic evaluation showed diffuse dermal infiltrates with variable proportions of centroblasts (large noncleaved cells), large centrocytes (large cleaved cells), and B immunoblasts. Seventeen of 18 patients were diagnosed as having primary cutaneous follicular center cell lymphoma; only 1 patient, whose histologic examination showed more than 30% immunoblasts, was diagnosed as having B-immunoblastic lymphoma. CONCLUSIONS: Primary cutaneous large B-cell lymphoma of the legs is a distinct clinicopathologic entity that mainly affects elderly patients and has an intermediate prognosis. Although most cases have a follicular center cell origin, primary cutaneous large B-cell lymphoma is proposed as the most appropriate term for this type of cutaneous lymphoma.

Mycosis fungoides: disease evolution and prognosis of 309 Dutch patients.

OBJECTIVES: To determine the disease course of Dutch patients with mycosis fungoides and to define factors related to disease progression and survival. DESIGN: A multicenter, 13-year, retrospective cohort analysis. SETTING: Eight dermatology departments collaborating in the Dutch Cutaneous Lymphoma Group. PATIENTS: Three hundred nine patients with mycosis fungoides registered between October 1985 and May 1997, including 89 patients with limited patches or plaques (stage Ia), 135 with generalized patches or plaques (stage Ib), 46 with skin tumors (stage Ic), 18 with enlarged but uninvolved lymph nodes (stage II), 18 with lymph node involvement (stage III), and 3 with visceral involvement (stage IV). MAIN OUTCOME MEASURES: Response to initial treatment, sustained complete remission, actuarial disease progression, and overall and disease-specific survival per clinical stage. RESULTS: The median follow-up was 62 months (range, 1-113 months). For the entire group, the actuarial overall and disease-specific survival was 80% and 89% at 5 years, and 57% and 75% at 10 years, respectively. The actuarial 5-year disease-specific survival of patients with stage Ia, Ib, and Ic disease was 100%, 96%, and 80%, respectively, and only 40% for patients with stage III disease. Using multivariate analysis, the presence of extracutaneous disease, the type and extent of skin involvement, the response to initial treatment, and the presence of follicular mucinosis were independently associated with higher disease progression and mortality rates. The calculated risks of disease progression at 5 and 10 years gradually increased from 4% to 10% for those with stage Ia disease, from 21% to 39% for those with stage Ib disease, and from 32% to 60% for those with stage Ic disease; for those with stage III disease, the risk remained at 70% at 5 and 10 years. The overall risk of disease progression at 5 and 10 years was 24% and 38%, respectively, for the total study group. CONCLUSION: At least within the first 10 years after diagnosis, disease progression and mycosis fungoides-related mortality occur in only a subset of patients generally presenting with advanced disease.

Morphological changes in the proximal area of the rat's hair follicle during early catagen. An electron-microscopic study.

This electron-microscopic study of the catagen phase shows that the first alteration of regression of the follicle is localized in the papilla, where the cells withdraw their offshoots and break the contact with the basal lamina. Both at the level of the papilla and of the bulb structures appear that increase the cell cohesion. Under the influence of the outer root sheath an upward migration occurs. This is followed by plication and thickening of the basal lamina. The alterations in the connective tissue sheath occur in a further stage. The first signs of autolysis occur in the center of the epithelial column. At the end of the catagen stage macrophages take care of the clearing-up.

Mantle-cell lymphomas of the skin.

The skin lesions of two elderly women lead us to the diagnosis of small cleaved lymphocytic B-cell non-Hodgkin's lymphoma, TNM stage IVb after clinical staging examinations. Relapses occurred within less than 1 year. Morphology, enzymhistochemistry (alkaline phosphatase in the first case), and immunohistochemistry (CD 5 positivity in the second case) in the skin biopsies supported the diagnosis of mantle-cell lymphoma. The histogenesis of the mantle-cell lymphoma is reviewed.

Percutaneous absorption of indomethacin from transparent oil/water gels in rabbits.

The percutaneous absorption of indomethacin from transparent oil in water gels (TOW gels) has been studied in rabbits and compared with absorption from a hydrophilic gel and from a spray formulation. The area under the curve and the Cmax values in plasma were significantly higher for the TOW gels in comparison with the other formulations after single application. The pH of the aqueous phase of the TOW gels did not significantly influence the bioavailability. After multiple application the TOW gels induced a larger increase in AUC (vs first application) in comparison with the other formulations. None of the formulations without drug damaged the skin after multiple application. For indomethacin formulations skin damage was more pronounced with the hydrophilic gel than for the TOW gels and spray formulation.