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MerhabaKaribu

Patient 1

• 10 y.o. female with a 2-week history of pruritic rash and mild loss of appetite

• ROS otherwise negative; no constitutional symptoms, no recent weight loss, no diarrhea, no abdominal pain

• Family came to US from Guatemala four years ago

• No significant past medical history

Patient 1: Clinical photographs

Summary of initial laboratory values

Test Lab value Reference rangeWBC *30,000/ml (4,500-13,500/ml)Neutrophils 2,400/ml (1,800-7,000/ml)Eosinophils *22,500/ml (0-500/ml)Basophils *300/ml (0-200/ml)Hemoglobin 13.4 g/dL (11.5-15.5 g/dL)Hematocrit 39% (35-45%)Platelet 424,000/ml (200,000-450,000/ml)ALT *105 U/l (8-49 U/l)AST *64 U/l (10-44 U/l)ESR *19 mm/hr (<10 mm/hr)Rapid GpA Strep negative negativeUrinalysis negative negativeANA negative negativec-ANCA negative negativep-ANCA negative negativehepatitis A and B past resolved infection ---Complement 127 U CH50/ml (80-160 U CH50/ml)C3 110 mg/dl (87-247 mg/dl)

Patient 1: Stool analysis

• Trichrome stain positive for cysts of Giardia lamblia

Patient 1: Histopathology

Hypersensitivity tissue reaction

Differential diagnosis:- urticaria/urticarial vasculitis- Well’s syndrome- hypereosinophilic syndrome- drug reaction- arthropod assault- reaction to parasitic infection

Patient 1

• Initially treated with metronidazole, but unable to tolerate after two days due to nausea

• Finished a one week course of furazolidone

• Urticarial plaques did not improve with treatment

• Bone marrow biopsy revealed acute lymphoblastic leukemia (ALL)

ALL/Eo

• Distinct entity first reported by Spitzer and Garson in 1973

• Eosinophilia is rare with ALL• Average age ~15 y.o., M>F• 41 patients described in literature• Good initial response to chemo, but high

relapse rate• Poor prognosis; median survival time of

7.5 months

ALL/Eo

• Systemic symptoms common, including fever, cough, LAN, arthralgias, splenomegaly, pulmonary infiltrates

• Rash common; variably described in literature with “purpura”, “petechial”, “erythematous”, even “erythroderma”

Patient 2

• 51 y.o. Vietnamese female with one month history of intensely itchy rash and blisters

• Also complains of blisters in the mouth• Tactile fevers (no specific temp), horrible

pruritis and intermittent dysuria; remainder of ROS unremarkable

• No significant past medical history or medications

• Has been in US for at least five years


Patient 2: Laboratory valuesTest Lab value Reference rangeWBC 18,300 per uL (4,300-10,000)Hemoglobin 8.3 g/dL (11.5-15.5)Hematocrit 27 % (36-45%)Neutrophils 8,970 per uL (1,800-7000)Eosinophils 4,940 per uL (0-500)Basophils 180 per uL (0-200)Reticulocyte (corr.) 1.2 % ---Serum iron 9 ug/dL (55-155)TIBC 213 ug/dL (270-400)Transferrin satur. 4 % (15-50)Vitamin B12 552 pg/mL (224-1132)

- Urinalysis: 1+ WBCs, 1+ RBCs, positive leukocyte esterase- Basic metabolic panel revealed BUN of 4, otherwise unremarkable- LFTs showed albumin of 3.1 g/dL, otherwise unremarkable- Blood cultures negative and viral FA and culture negative- G6PD screen negative


Patient 2• Started on prednisone 60 mg po qd and

dapsone 100 mg po qd

• After one week, added minocycline 100 mg po bid

• One week later, increased prednisone to 100 mg po qd, d/c’d dapsone and minocycline, and started Cellcept 500 mg po bid plus Keflex for superinfection

• One week later, increased Cellcept to 1 gm po bid

Malignancy and BP

• In 1990, over 600 pts described in 3 separate reports; no association of BP with increased cancer risk

• 1995 (Ogawa et al.) 1113 pts with BP in Japan compared to 1987 gov’t figures (393 hosp.)– 5.8% of pts had malignancy (M=6.6%, F=5.0%)– BP association with malignancy was higher among

younger patients– No difference in mucous involvement or annular

erythema; ? Lower rate of negative BMZ Ab’s

Age-group associations of BP and malignancy from Ogawa et al.

Age group BP patients General population*

45-54 9.2% 0.13%

55-64 5.7% 0.39%

65-69 5.9% 0.44%

70+ 5.5% 0.61%

*rates for medical care for malignancy among Japanese in 1987

Malignancies seen with BP by Ogawa et al.

• GI = 32/64

• Urinary/genital = 10/64

• Pulmonary = 7/64

• Heme = 5/64

• Breast = 6/64

• Skin = 3/64

• Sinus = 1/64

Patient 3• 39 y.o. Hispanic male with one day history of

pruritic rash after release from incarceration• Admitted to isolation for diagnosis of chickenpox• ROS unremarkable; no current fevers but had

viral symptoms 2-3 weeks ago that resolved• Patient purports a history of chickenpox as a

child at age 13, describing his illness in convincing vivid detail

• PMH includes schizophrenia, stable on Seroquel (has been on this drug for many months), and an abdominal gunshot wound

• Unusual story about childhood hospitalization lasting one month for workup of diarrhea; discharged with no diagnosis


Patient 3: Laboratory findings

• Basic metabolic panel, LFTs, and CBC unremarkable

• RPR and HIV negative• No VZV DNA detected in serum by PCR• Serologies consistent with past VZV

infection• FA and viral culture negative for Herpes

group infection• Anti-endomysial and anti-tissueTG

antibodies negative

Patient 3: Tzanck preparation


Patient 3• Minimal response to topical triamcinolone

ointment• Initiated on prednisone 40 mg po qd• Did well on prednisone, added dapsone 100 mg

po qd• Tapered prednisone• Stopped dapsone secondary to difficulty with

refill• Rash recurred during taper at prednisone 5 mg• Restarted dapsone and slightly bumped

prednisone to 10 mg to re-taper

Eosinophilic folliculitis

• Rare inflammatory dermatosis of unclear etiology

• Described by Ofuji in 1965

• Predominantly seen in adults; childhood variant described as distinct entity

• Gender predominance unclear

• Most cases reported from Japan

Adults with average age of 30

Pruritis common

Follicular papules coalesce to formfigurate plaques

Face, upper extremeties, trunk andalso non-follicular areas (fingers,palms)

Recurrent crops that involute over1-2 weeks, relapse q 3-4 weeks

- Other folliculitides- ? Heme malignancies- ? Parasitic infections

Adults with HIV and CD4 < 300 cells/mm3

Pruritis common

Follicular papules without figuratelesions, looks like folliculitis

Face, scalp, upper trunk

Chronic condition

-Demodex folliculitis-Drug-induced folliculitis-Other common folliculitides

Infants < 1 year old, M>F

Pruritis common

Follicular papules and pustules,usually with erythematous baseand secondary crusting

Primarily scalp, but can be seenon face and trunk, less often onextremeties

Self-limiting condition, resolves after cyclical 3 month to 5 yearcourse

-Erythema toxicum neonatorum-Transient neonatal pustular melanosis-Infantile acropustulosis-LCH

Ofuji’s disease HIV-associatedEPF

Infantile/neonatalEPF

The biology of eosinophils and their role in skin disease

Andy J. Chien, M.D., Ph.D.

University of Washington

Division of Dermatology

• Born in Strehlan in 1854• 1878 doctorate in

medicine – thesis on staining of animal tissues, differentiates mast cells from plasma cells

• 1879 – defines and names the eosinophil

• Establishes criteria based on cell morphology, physiology and pathology to classify hematolgic malignancies

Paul Ehrlich(1854-1915)

(Photo from Nobel e-museum online)

• 1882 – washes aniline dye with acidified alcohol and becomes first to visualize Koch’s bacillus as “acid-fast bacilli”

• 1885 – uses stains to recognize that different tissues have different oxygen demands

• 1886 – describes use of methylene blue as a dye for neural structures, malaria parasites



• 1885 – “sidechain theory” and lock-and-key mechanism of antibody recognition; bunnies survive 5000-fold lethal dose of toxin with slow, increased exposures

• 1889 – contracts TB• 1896 – heads institute to

standardize diptheria and other anti-toxinsPaul Ehrlich

(1854-1915)


• 1901 – induces immunity against transplanted tumors in mice via injections of tumor cells

• 1906 – prophesizes chemical “magic bullets” to target intracellular parasites

• 1908 – wins Nobel prize for theory of immunity



• 1910 – discovers anti-treponemal effects of arsenical compound Salvarsan (arsphenamine in the U.S.)

• 1915 – dies of stroke at age 61

• 1945 – genus Ehrlichia established to honor Ehrlich’s work as a microbiologistPaul Ehrlich

(1854-1915)


• Pioneer in cell staining

• Father of hematology

• Pioneer in microbiology

• Father of immunology

• First successful chemotherapy



Eosinophilia

• P arasitic infection

• A llergic response

• N eoplasm

• I diopathic hypereosinophilic syndrome

• C onnective tissue disease

The eosinophil

• Life cycle consists of marrow, blood and tissue phases

• Tissue:blood eosinophils ~100:1 (rat)• Typically reside in tissues exposed to

external environment (lung and gut)• Half-life of 8 to 18 hours in bloodstream • Tissue life span estimated at 2-5 days, but

may be longer (in vitro up to 14 days with cytokines)

The eosinophil

• In injected rats, 2 day delay before detection of peripheral eosinophilia

• Maximum peripheral eosinophilia at 6-7 days

• Increased bone marrow eosinophils at 5 days

• Possible demargination may result in more rapid response

Eosinophil structure


• Charcot-Leyden crystal protein• 7-10% of eosinophil protein• Round with uniform electron

density• A.k.a. lipophospholipase• Found in eosinophilic

promyelocytes• Also a major product of

basophils• ? Protection from lytic

phospholipids• ? Degradation of pulmonary

surfactant

Primary granule


• Aryl sulfatase B and acid phosphatase

Small granule


• Dense core surrounded by less dense matrix

• Major basic protein (MBP) located in the core

• Eosinophil cationic protein (ECP), eosinophil peroxidase (EPO), eosinophil-derived neurotoxin (EDN) and beta-glucuronidase in matrix

• Matrix:core protein ration approximately 2:1

Secondary granule

Major Basic Protein (MBP)

• Produced as proMBP, cleaved with maturation• Cytotoxic, bactericidal and helminthotoxic• Disrupts lipid bilayers• Causes histamine release from basophils and

mast cells• Activates neutrophils and platelets• Neutralizes heparin effects on clotting• Promotes bronchospasm

Eosinophil Cationic Protein (ECP)

• Helminthotoxic, neurotoxic and bactericidal

• Causes histamine release from mast cells

• Inhibits peripheral blood lymphs in vitro

• Neutralizes heparin effects on clotting

• Weak RNase activity

Eosinophil-Derived Neurotoxin (EDN)

• Severely damages myelinated neurons

• Inhibits peripheral blood lymphs in vitro

• Weak helminthotoxin

• Potent RNase activity

• 60% sequence identity to ECP

Eosinophil Peroxidase (EPO)

• Distinct absorption spectra and heme group from neutrophil myeloperoxidase

• In the presence of halide and H2O2, EPO kills tumor cells and microorganisms

• Causes histamine release from mast cells

• Provokes bronchospasm

• Damages respiratory epithelium

Eosinophil cytokines

• IL-3• IL-5• GM-CSF

• IL-1• IL-2• IL-4• IL-6• IL-8• IL-10• IL-16• TNF• TGF and 1• RANTES

IgE receptors

IgA receptors

IgG receptors

C-C receptors

complementreceptors

LT receptors

E and Pselectin

ICAM/VCAM

sialyl-di-Lewis X

CD11/CD18 (binds ICAM)CD29/CD49 (binds VCAM)

1. “rolling”and

adhesion

2. transmigration

3. primingand

activation

fibronectin,laminin

Reference: Acta Anatomica, 134:341-345, 1989.

Eosinophils in skin disease

• Atopic dermatitis• Bullous pemphigoid• Urticaria• Parasitic infection• Arthropod assaults• Wells’ syndrome/eosinophilic cellulitis• Eosinophilic fasciitis• Eosinophilic folliculitis• Angiolymphoid hyperplasia with eosinophilia• Incontinentia pigmenti• Id reactions

Atopic dermatitis

• Wassom et al. (JCI 1981):– Atopic dermatitis subjects: >50% with elevated MBP

+/- increased eosinophils

• Leiferman et al. (NEJM 1985): – MBP is deposited in the upper dermis with near

absence of eosinophils in atopic skin; normal skin shows less extracellular MBP

• Ott et al. (J Allergy Clin Immunol 1994): – Eosinophil granule proteins deposited in dermis with

few infiltrating cells seen– 4/19 had serum eosinophilia; 10-15/19 had elevated

serum MBP, EDN, ECP

Atopic dermatitis

• Peripheral blood eosinophilia roughly correlates with disease activity– Pts with respiratory allergies more likely to have

eosinophilia

• Serum levels of ECP correlate with disease activity (adults and children)

• Variable relationship between eosinophilia and ECP levels

• TH2 activity associated with IL-5, leads to eosinophil synthesis, activation, recruitment

Atopic dermatitis

• Wedi et al. (J Allergy Clin Immunol 1996):– Blood eosinophils of pts with atopic derm

exhibit delayed apoptosis in vitro (ELISA, DNA and flow cytometry)

– Increased autocrine production of IL-5, GM-CSF

• Cheng et al. (J Allergy Clin Immunol 1997):– 9/10 with increased extracellular MBP– No normal eosinophils seen; all in various

stages of cytolysis (EM)

Atopic dermatitis

• Matsukura et al. (J Clin Lab Immunol 1996):– Blood eosinophil apoptosis induced by

corticosteroids (dose-dependent) in AD pts

• Alam et al. (J Exp Med 1994):– TGF induces eosinophil apoptosis

• Wedi et al. (J Allergy Clin Immunol 1998):– IL-4 induces apoptosis in eosinophils

(peripheral blood)

Bullous pemphigoid

• Insert histo slide here

Bullous pemphigoid

• Autoantibodies to BP230 and BP180• Antibody binding• Complement activation• Mast cell degranulation• Neutrophil infiltration and activation• Increased MPO and ECP in blister fluid• Release of neutrophil proteolytic enzymes• Role of the eosinophil?

Bullous pemphigoid• Borrego et al. (Am J Path 1996)

– In BP prior to blister formation (erythema, wheals) extracellular granule protein deposition > eosinophil number in dermis of involved skin

– Neutrophil protein depsition less prominent than eosinophil protein deposition

– Protein deposition especially prominent near areas of epidermal separation

– EM: eosinophils degranulate onto basal layer – Blister fluid contains IL-3, IL-5 and GM-CSF (blocked

by Abs), enhances survival in vitro– Neutrophil infiltration and degranulation variable

Bullous pemphigoid• Stahle-Backdahl et al. (JCI 1994)

– Eosinophil-derived 92 kDa gelatinase (MMP-9) is prominent in BP blister fluid

– In vitro, 92 kDa gelantinase cleaves the extracellular domain of BP180

– Minimal gelatinase seen in suction-derived blisters and therapy-derived blisters (cryo, bleomycin)

Acknowledgments

• Dr. Zsolt “Hungarian Idol” Argenyi

• Dr. Roy “Hot-legs” Colven

• Dr. Phil “The Zen-Master” Kirby

Documents

Welcome Willkommen Bienvenue Velkomen Isten hozta Zayt wilkum Merhaba Karibu