Five-year efficacy and safety of tildrakizumab in patients with moderate-to-severe psoriasis who respond at week 28: pooled analyses of two randomized phase III clinical trials (reSURFACE 1 and reSURFACE 2).

BACKGROUND: The phase III reSURFACE 1 and reSURFACE 2 (NCT01722331/NCT01729754) trials of the anti-interleukin-23p19 monoclonal antibody tildrakizumab (TIL) for psoriasis treatment are complete. OBJECTIVES: We present 5-year pooled data from reSURFACE 1 and reSURFACE 2. METHODS: reSURFACE 1 and reSURFACE 2 were double-blind, randomized, controlled studies with optional long-term extensions. Adults with moderate-to-severe chronic plaque psoriasis were randomized 2 : 2 : 1 to TIL 100 mg (TIL 100) or 200 mg (TIL 200) or placebo at weeks 0 and 4, and every 12 weeks thereafter [reSURFACE 2 included an etanercept (ETN) arm]. Efficacy outcomes included proportions of patients achieving absolute and relative improvement from baseline Psoriasis Area and Severity Index (PASI) score through week 244 in TIL responders (≥ 75% improvement from baseline PASI; PASI 75 response) continuously receiving the same dose and ETN partial responders and nonresponders (PASI < 75 response) switched to TIL 200 at week 28. Safety was assessed from adverse events (AEs) in all patients as treated. RESULTS: Efficacy analyses included 329 and 227 week 28 responders to TIL 100 and TIL 200, respectively, and 121 ETN partial responders/nonresponders switched to TIL 200 at week 28. Of TIL 100 or TIL 200 responders and ETN partial responders/nonresponders entering the extensions, 235/302, 176/213 and 85/107, respectively, were evaluated at week 244, and 88·7%, 92·5% and 81·3%, respectively, achieved PASI 75 response. Exposure-adjusted rates of serious AEs were 6·3 and 6·0 patients with events per 100 patient-years of TIL 100 and TIL 200, respectively. CONCLUSIONS: TIL treatment provided sustained disease control over 5 years in week 28 TIL responders and ETN partial responders/nonresponders, with a reassuring safety profile.

Schnitzler's syndrome with prominent neutrophil infiltration misdiagnosed as Sweet's syndrome: a typical example of urticarial neutrophilic dermatosis.

Schnitzler's syndrome is a rare disorder of unknown aetiology characterized by a chronic urticarial eruption, intermittent fever and monoclonal gammopathy. We encountered an interesting patient with this syndrome, who had been misdiagnosed for 10 years as having Sweet's syndrome because of the histopathological picture, which was a prominent perivascular and interstitial neutrophilic infiltrate in the dermis with leucocytoclasia but without vasculitis. An urticarial eruption with this histopathological feature has recently been categorized as neutrophilic urticarial dermatosis, and it is strongly indicative of an associated systemic disease, mainly Schnitzler's syndrome and other inflammatory diseases. We therefore need to be cautious not to confuse Schnitzler's syndrome with Sweet's syndrome. Further, the serum interleukin (IL)-6 levels, but not those of other cytokines and chemokines, correlated with the disease activity in our patient, suggesting that IL-6 may be involved in some of the disease processes, including neutrophil infiltration.

[Six cases of spontaneous pneumomediastinum].

We report 6 cases of spontaneous pneumomediastinum. It is defined not to have clear etiology such as trauma, and is comparatively rare disease developing suddenly. Our patients complained of chest or neck pain, dyspnea and pain when swallowing. They were 3 men and 3 women, who were young and did not have causal disease. Chest X-ray films and computed tomography (CT) scans revealed pneumomediastinum. All of them were treated conservatively and recovered completely within 10 days hospitalization. Spontaneous pneumomediastinum is uncommon and usually benign. Most patients require only conservative treatment. However, since it possibly develops tension pneumothorax, pneumothorax, or mediastinitis, careful observation is recommended never to overlook life-threatening condition. In addition, it is important to distinguish from Boerhaave syndrome, tracheal trauma and so on.

Proteus syndrome complicated by multiple spinal meningiomas.

Proteus syndrome is a complex and highly variable disorder comprising malformations and overgrowth of multiple tissues. We present a 65-year-old Japanese man who had multiple spinal meningiomas and accompanying neural symptoms. His right leg showed hypertrophy with cerebriform connective-tissue naevus on the sole, and macrodactyly. Chest computed tomography imaging revealed mild cystic and emphysematous lung changes, which were possibly related to Proteus syndrome. Otherwise, he had no particular cutaneous, musculoskeletal or visceral involvements. Because of the rather insignificant clinical features, he had not been accurately diagnosed in the past and yet had survived to this age. In particular, the presence of spinal meningiomas as an exceptional complication was sufficiently confusing to consider that he had neurofibromatosis. Doctors should be familiar with the diverse clinical pictures of this rare syndrome for its correct diagnosis and proper management.

Regulation of cytokine expression in macrophages and the Langerhans cell-like line XS52 by calcitonin gene-related peptide.

Calcitonin gene-related peptide (CGRP) inhibits antigen presentation by Langerhans cells (LC) and macrophages, and LC are anatomically associated with CGRP-containing epidermal nerves. To determine whether CGRP may produce some of its functional effects through regulation of cytokine expression, we utilized enzyme-linked immunosorbent assay (ELISA) of conditioned supernatants to examine production of interleukin (IL)-10 and IL-1 beta protein in the LC-like cell line XS52 as well as the reverse transcriptase-polymerase chain reaction (RT-PCR) to examine levels of mRNA for IL-10, IL-1 beta, and the 40-kDa subunit (p40) of IL-12. CGRP augmented the lipopolysaccharide (LPS) and granulocyte-macrophage colony-stimulating factor (GM-CSF) -induced release of IL-10 protein and the induced expression of IL-10 mRNA in these cells. However, it suppressed the induction of release of IL-1 beta protein and the induction of mRNA for IL-12 p40 and IL-1 beta by LPS and GM-CSF. Regulation of cytokine expression in peritoneal macrophages was also examined. By ELISA, the LPS-induced expression of IL-10 was augmented by CGRP, whereas the induction of IL-1 beta was suppressed. Northern analysis demonstrated augmentation of LPS-induced IL-10 mRNA levels and inhibition of LPS-induced IL-1 beta mRNA by CGRP. CGRP inhibited the LPS-induced induction of IL-12 mRNA as assessed by RT-PCR. Up-regulation of B7-2 expression by LPS and GM-CSF was suppressed by CGRP in both XS52 cells and macrophages, as previously reported. This suppression, however, could be abrogated by co-culture with neutralizing antibodies to IL-10. Furthermore, the presence of neutralizing antibodies to IL-10 during exposure of epidermal cells (EC) to CGRP prevented the CGRP-mediated suppression of EC presentation of tumor-associated antigens (from the S1509a spindle cell carcinoma) for elicitation of delayed-type hypersensitivity in S1509a-immune mice. These data suggest that suppression of antigen-presenting function by CGRP is mediated, at least in part, by changes in cytokine expression that favor less robust antigen presentation for cell-mediated immunity.

Functional CD40 ligand is expressed on epidermal Langerhans cells.

Epidermal Langerhans cells (LC) are bone-marrow-derived major histocompatibility complex (MHC) class II antigen-expressing antigen-presenting cells (APC) that comprise 1-3% of total epidermal cells (EC). LC express high levels of MHC class II antigen and augment costimulatory molecules such as B7-1, B7-2 during culture. In a previous report, using purified murine LC, we showed that freshly prepared LC (fLC) do not express CD40, whereas cLC express CD40. Tumor necrosis factor alpha (TNF-alpha) enhanced CD40 expression on LC during culture. We examined the expression of CD40L on LC and found that both fLC and cLC expressed mRNA for CD40L. FACS analysis revealed that cLC cultured for 36 h expressed CD40L but fLC did not. When we examined the cytoplasmic CD40L, however, both fLC and cLC expressed cytoplasmic CD40L. TNF-alpha, which up-regulated CD40 expression on LC during culture, did not modulate CD40L. Co-culture of purified LC ith anti-CD40L markedly inhibited the up-regulation of B7-1 expression on LC and caused partial inhibition of B7-2 expression during culture. These results indicate that CD40L is expressed on cLC, and that CD40L on LC modulates the expression of costimulatory molecules such as B7-1 and B7-2 on LC.

Specific nucleotide sequence of HLA-C is strongly associated with psoriasis vulgaris.

The association of specific HLA-C nucleotide sequences with psoriasis vulgaris was investigated in 75 Japanese patients by the polymerase chain reaction method, followed by slot-blot hybridization using two specific oligonucleotide probes. The synthesized nucleotide primers were C180P, 5'-GACCGGGAGACACAGAAGTACAAG-3' (coding for amino acid residues 61 to 68 of the alpha 1 domain of the HLA-C molecule) and C243PR, 5'-GCTCTGGTTGTAGTAGCCGCG-3' (residues 82 to 88), respectively. The amplified sequence detected with the probe C208A (5'-AGGCACAGGCTGACCGA-3'), including the coding region for alanine at position 73, was significantly increased in frequency in the patients compared with the healthy individuals (81% versus 48%, relative risk = 4.7, chi 2 = 15.3, p less than 0.0001). This specific nucleotide sequence is common to Cw6 and Cw7, but some other HLA-C alleles including Cw4 and C blank (Cx52) also proved to have this sequence. It is suggested that alanine at position 73 of HLA-C molecules can be a good marker for psoriasis vulgaris and that this residue may play an important role in determining susceptibility to this disease.

Differential effects of cytokines and immunosuppressive drugs on CD40, B7-1, and B7-2 expression on purified epidermal Langerhans cells1.

Langerhans cells are MHC class II antigen-positive antigen-presenting cells in the epidermis. Recent studies have revealed that Langerhans cells express costimulatory molecules like B7-1 and B7-2 and the accessory molecule CD40. Although these molecules are important for the antigen-presenting function of Langerhans cells, little is known about the precise regulation of their expression on purified Langerhans cells. Using a panning technique, we purified epidermal Langerhans cells to around 95% purity. Freshly prepared Langerhans cells (fLC) expressed the mRNA for receptors for M-CSF (cfms), GM-CSF (GM-CSFR), and TNF-alpha (TNFRII). TNF-alpha markedly upregulated CD40 and B7-1 expression on Langerhans cells, but not B7-2 expression. GM-CSF moderately upregulated B7-1 and B7-2 expression, and slightly upregulated CD40 expression. M-CSF moderately upregulated B7-1 expression, but did not modulate CD40 or B7-2 expression. Dexamethasone (DEX) markedly inhibited CD40, B7-1, and B7-2 expression on Langerhans cells. Cyclosporin A (CsA) and FK506 slightly inhibited CD40 and B7-1 expression on Langerhans cells, but not B7-2. Furthermore, TNF-alpha restored the DEX-induced inhibition of CD40 expression on Langerhans cells, but not the inhibition of B7-1 or B7-2 expression. GM-CSF restored DEX-induced inhibition of CD40, B7-1, and B7-2 expression. M-CSF did not affect the DEX-induced inhibition of these molecule expressions. These data provide a better understanding of the role of selective cytokines and immunosupressive drugs in the modulation of the antigen-presenting capacity of Langerhans cells.

Analysis of HLA class II and TAP alleles in Japanese patients with psoriasis vulgaris.

We investigated HLA class II and transporter associated with antigen processing (TAP) alleles in eighty-five unrelated Japanese patients with psoriasis vulgaris and fifty-two healthy controls using the polymerase chain reaction-restriction fragment length polymorphism method. The frequencies of DRB1*1502 and DQB1*0601 were increased in the patient group (DRB1*1502; 21% vs 12%, p < 0.05, DQB1*0601; 35% vs. 21%, p < 0.05), while the frequencies of DRB1*0406 and TAP2*E were decreased in the patients (DRB1*0406; 2% vs 9%, p < 0.05, TAP2*E; 4% vs 11%, p < 0.05). However, none of these remained significant after p values were corrected for the number of comparisons made (pc > 0.05). We also analysed specific amino acids on HLA class II molecules, but no significant difference was found between the two groups. Our previous reports clarified that aspartate at residue 9 (48% vs 20%, p < 0.002) and alanine at residue 73 (81% vs 48%, p < 0.0001) on HLA-C molecules were strongly associated with Japanese patients with PsV. These specific amino acids on HLA-C molecules are supposed to play more important roles compared with HLA class II and TAP alleles in the development of psoriasis vulgaris.

Identification and DNA typing of two Cw7 alleles (Cw*0702 and Cw*0704) in Japanese, with the corrected sequence of Cw*0702.

Two alleles encoding HLA-Cw7 antigens, tentatively called C7J1 and C7J2, have been identified in Japanese using a PCR-SSCP method. The nucleotide sequence of full-length C7J1 cDNAs showed a high degree of homology to the reported Cw*0702 sequence except in exon 1. We then resequenced the allele carried by the cell line JY in which Cw*0702 was first identified, according to a request from the WHO Nomenclature Committee. The results revealed complete identity between the corrected Cw*0702 sequence and the C7J1 sequence. On the other hand, the C7J2 sequence was completely identical to the reported Cw*0704 sequence. Sequences specific for Cw*0702 and Cw*0704 were confirmed using PCR-RFLP and PCR-SSO methods. Moreover, association analysis with other HLA locus alleles showed positive associations of Cw*0702 with HLA-B7, -B39, and -B67 and of Cw*0704 with HLA-B70 in Japanese.

Colchicine and griseofulvin inhibit VCAM-1 expression on human vascular endothelial cells - evidence for the association of VCAM-1 expression with microtubules.

We have previously reported that griseofulvin inhibits VCAM-1 expression on human vascular endothelial cells. Since griseofulvin interferes with microtubule assembly, we used colchicine as another microtubule antagonist and compared it with griseofulvin to further characterize this inhibition. By flow cytometry, colchicine inhibited VCAM-1 induction on TNFalpha-stimulated human dermal microvascular endothelial cells (HDMEC) dose-dependently. Colchicine also inhibited VCAM-1 induction on both TNFalpha- and IL-1alpha-stimulated human umbilical vein endothelial cells (HUVEC). Although this inhibition was reversible, colchicine-treated cells showed slower restoration of its expression than griseofulvin-treated cells. Moreover, co-incubation with a microtubule stabilizer paclitaxel blocked this inhibition, and colchicine-treated cells were more resistant to this blocking than griseofulvin. RT-PCR of HDMEC showed inhibition of the transcript level of VCAM-1 by both antagonists. These results indicate intimate association between VCAM-1 expression and microtubules.

Study of aspartate at residue 9 of HLA-C molecules in Japanese patients with psoriasis vulgaris.

The frequency of aspartate at residue 9 (Asp-9) of HLA-C molecules was investigated among 75 Japanese patients with psoriasis vulgaris and 50 healthy controls. We developed a technique of polymerase chain reaction sequence-specific primer (PCR-SSP) amplification of genomic DNA for HLA-C alleles with a codon for Asp-9. The specificity of amplification was confirmed by direct sequencing of the amplified products and amplification from total RNA (RT-PCR). Asp-9 was positive in all individuals with Cw6 and/or Cw7, but negative in the others, indicating that Asp-9 was specific to Cw6 and Cw7 antigens in our subjects. The frequency of Asp-9 was significantly increased in the patient group (48% vs. 20%; P < 0.002). The frequency of alanine at residue 73 (Ala-73), which was positive for Cw4, Cw6, Cw7, and some C blanks, was also increased in our previous study (81% vs. 48%; P < 0.0001). Asp-9 is located on a beta sheet of alpha 1 domain of HLA-C molecule and influences the peptide binding of the C pocket of the groove together with Ala-73. Both Asp-9 and Ala-73 could contribute to the disease susceptibility to psoriasis vulgaris in the immune responses.

Increased numbers of CD68 antigen positive dendritic epidermal cells and upregulation of CLA (cutaneous lymphocyte-associated antigen) expression on these cells in various skin diseases.

CD68 is a myelomonocytic marker identified in human dermal macrophages. Although the existence of CD68 + dendritic epidermal cells has been reported, their characteristics have not been well elucidated. Cutaneous lymphocyte-associated antigen (CLA) is a homing receptor of cutaneous inflammatory T cells. Our recent report suggested that CLA was a homing molecule of CD1a+ Langerhans cells (LC) in the skin. In the present study we tested whether CD68 and CLA+ dendritic epidermal cells were present in skin specimens of normal skin and diseased skin such as lichen planus (LP), psoriasis vulgaris (PS), discoid lupus erythematosus (DLE), basal cell epithelioma (BCE), squamous cell carcinoma (SCC), irritated seborrheic keratosis (iSK), and Bowen's disease (BD). CD68+ dendritic epidermal cells were identified in normal skin and consisted of half the population of CD1a+ LC. These data indicate that CD68+ dendritic epidermal cells constitute a subpopulation of CD1a+ LC. CLA was expressed on a small percentage of CD68+ dendritic epidermal cells in normal skin. A remarkably increased number of CD68+ dendritic epidermal cells and upregulation of CLA on CD68+ dendritic epidermal cells were observed in diseased skin. The percentage of CLA+ cells among all CD68+ dendritic epidermal cells was less than that of CLA+ cells among all CD1a+ LC in diseased skin. The percentage of CLA+ cells among all CD68+ dendritic dermal cells was much less than that of CLA+ cells among all CD1a+ dendritic dermal cells. In normal skin, the epidermis showed minimal expression of monocyte chemoattractant protein (MCP)-1 and TGF-beta2, and no expression of TGF-beta1. In diseased skin, the epidermis showed elevated, but still moderate immunoreactivity for MCP-1. Slightly enhanced immunoreactivity for TGF-beta2, but not for TGF-beta1, was observed in the epidermis of diseased skin. Increased epidermal MCP-1 immunohistochemical staining was associated with the increased number of CD68 dendritic epidermal cells. These data suggest the possibility that MCP-1 secretion from the epidermis can affect the migration of CD68; Cutaneous lymphocyte-associated antigen; Monocyte chemoattractant protein-1; TAF-beta.

Immunomodulatory properties of maxadilan, the vasodilator peptide from sand fly salivary gland extracts.

Sand flies are the arthropod vector of leishmaniasis and salivary gland extracts from these flies exacerbate leishmaniasis in vivo. The mechanism of exacerbation appears to be due to immunomodulatory effects of the saliva on host immune function but the active component is unknown. The following studies reveal that maxadilan, the vasodilatory peptide present in sand fly salivary gland extracts, has immunomodulatory properties. To examine the effect of maxadilan on T cell proliferation, the peptide was added to murine spleen cells stimulated with either concanavalin A or plate-bound anti-T cell receptor antibody. Inhibition of proliferation was noted in a dose-dependent manner for both sets of experiments (P < 0.05). To examine the effect of maxadilan on alloantigen presentation, the peptide was added to mixed lymphocyte and mixed epidermal cell lymphocyte reactions. Inhibition of proliferation was found in these culture systems. Maxadilan also inhibited the delayed-type hypersensitivity reaction in mice (P < 0.05). These observations suggest a role for maxadilan in the pathogenesis of leishmaniasis since the peptide may inhibit the immune response at the site of parasite inoculation, allowing the infection to proceed.

Griseofulvin has a potential to modulate the expression of cell adhesion molecules on leukocytes and vascular endothelial cells.

Griseofulvin has been used as an antifungal drug for many years, but it has recently been shown effective for several inflammatory skin diseases. We therefore investigated its putative immunomodulatory roles by flow cytometric analysis of cell adhesion molecules on human leukocytes and human vascular endothelial cells. Griseofulvin downregulated L-selectin expression on neutrophils, but not on lymphocytes, in a dose-dependent manner. Griseofulvin did not affect CD11b/CD18 expression on neutrophils. On human dermal microvascular endothelial cells (HDMEC), griseofulvin inhibited the expression of TNF alpha-induced VCAM-1 dose-dependently, and this inhibition was fully reversible. Similarly, griseofulvin inhibited the induction of VCAM-1 expression on both TNF alpha- and IL-1 alpha-stimulated human umbilical vein endothelial cells (HUVEC). In addition, it partially inhibited the induction of E-selectin expression, whereas it had a marginal effect on ICAM-1 expression. Reverse transcription-polymerase chain reaction of TNF alpha-stimulated HDMEC showed inhibition of VCAM-1, but not ICAM-1 gene transcription. These results indicate potent immunomodulatory properties of griseofulvin, which may be associated with its feature as a microtubule antagonist.