Immunopathologic Demonstration of T Lymphocyte Subpopulations and Interleukin 2 in Graneloma Annulare

Immunopathologic aspects of granuloma annulare were studied in frozen sections of nine skin biopsy specimens with monoclonal antibodies directed against T lymphocytes, Langerhans' cells, interleukin 2, and interleukin 2 receptors in conjunction with immunoperoxidase techniques. The predominant lymphocyte was an activated T lymphocyte (Leu 1+, HLA-DR+) with an excess of helper/inducer phenotype (Leu 3a+) as compared with suppressor/cytotoxic phenotype (Leu 2a+). Langerhans' cells were increased in the epidermis and numerous OKT6+ cells were observed in the perivascular and granulomatous infiltrate. Both interleukin 2-positive cells and interleukin 2 receptor-positive cells were identified in the dermal lesions according to observed reactivity with the corresponding monoclonal antibodies. These findings suggest that a cell-mediated immune response producing cytokines may be important in the pathogenesis of granuloma annulare. Comparison of these results with skin specimens from patients with sarcoidosis and from a patient with granuloma annulare having some of the histologic features of sarcoidosis, suggests that the cutaneous infiltrate in granuloma annulare represents a response distinct from that of sarcoidosis.     

T-cell subsets in cutaneous sarcoidosis

Skin lesions from four patients with systemic and cutaneous sarcoidosis were studied, by the use of monoclonal antibodies, for the presence of T cells and T-cell subsets. Large numbers of lymphoid cells reacting with anti-pan T-cell (LEU-1) and anti-helper and inducer subset (LEU-3) monoclonal antibodies were observed around and within the sarcoid granulomas in three of the four patients. Only rare LEU-2-reactive suppressor cells were observed in all four patients. Activated T lymphocytes with focal acid phosphatase activity, together with epithelioid cells and multinucleated giant cells with strong diffuse activity of acid phosphatase and nonspecific esterase, were identified within the granulomas. The two patients with active disease demonstrated substantially more T cells in the sarcoid granulomas than did the two patients with chronic disease. Our study results suggest the importance of helper T cells in the formation of the sarcoid granuloma by mononuclear phagocytes and imply that the activity and duration of disease may be related to the T-cell populations.     

Caseating cutaneous granulomas in a patient with X-linked infantile hypogammaglobulinemia

A 34-year-old man with X-linked infantile hypogammaglobulinemia, bronchiectasis, and chronic liver disease had a papular eruption on the trunk and upper extremities. A biopsy specimen revealed caseating granulomas, but special stains, cultures, and electron microscopy failed to reveal an infectious organism. Immunohistochemistry showed that the lymphocytes within the granulomas were almost exclusively of the CD8+ cytotoxic/suppressor T phenotype. Phenotypic analysis of the circulating lymphocytes showed normal numbers of CD4+ (helper/inducer) and CD8+ T cells, whereas B cells were undetectable. Other examples of noninfectious granulomatous disease have been reported in patients with primary hypogammaglobulinemia, but this is the first case of caseating cutaneous granulomatous disease to be reported in a patient with X-linked infantile hypogammaglobulinemia.     

The T-lymphocyte and cutaneous Churg-Strauss granuloma

Studies of biopsy specimens from 4 patients with Churg-Strauss granulomas of the skin were performed with monoclonal antibodies to T-lymphocyte subset antigens. The finding of a predominance of a LEU3 antibody-reactive helper T-cell population in the perivascular areas and in the palisading and central granuloma areas was noteworthy. Pronounced reduction of suppressor T-cells in the lesions was observed in 2 patients; the lesions were associated with vasculitis and rheumatoid arthritis in one patient and with vasculitis and lupus erythematosus in the other. The Churg-Strauss granuloma demonstrated features of a cutaneous helper T-cell granuloma.     

Lymphocyte subsets and Langerhans' cells in toxic epidermal necrolysis. Report of a case

Toxic epidermal necrolysis is a life-threatening disease, the pathogenesis of which remains largely unknown. Histologically, in addition to the characteristic epidermal alterations, there is a sparse mononuclear cell infiltrate in the dermis. The immunologic characteristics of this infiltrate are not well known. In a case of drug-induced toxic epidermal necrolysis with fatal outcome in a 48-year-old man, we demonstrated that the majority of the inflammatory cells were of helper/inducer T-lymphocyte subsets, having only a minority of cytotoxic/suppressor T-lymphocytes and rare cells with natural killer cell phenotype. The significance of these observations is discussed, with reference to the occurrence of lesions at epithelial sites bearing local networks of antigen-presenting cells (Langerhans' cells).     

Immunohistologic identification of antigen-presenting cells in cutaneous sarcoidosis

Considerable evidence exists to show that activated T lymphocytes preferentially accumulate at sites of disease activity in sarcoidosis. Langerhans cells, which can be recognized by reactivity with an antibody to the T6 antigen are thought to play a primary role in T-lymphocyte activation by the skin, a tissue frequently involved in sarcoidosis. This immunohistologic study examined the distribution of OKT6-positive cells and surface expression of HLA-DR antigen in cutaneous sarcoid lesions. Skin specimens stained with an anti-HLA-DR antibody demonstrated diffuse staining of the granulomas. In addition, keratinocytes, which do not normally express HLA-DR antigens, were found to stain with monoclonal antibody to HLA-DR in an intercellular pattern. Examination of specimens for OKT6-reactive Langerhans cells revealed significantly greater concentrations in the epidermis overlying sarcoidal granulomas (33 +/- 7 cells/mm) than in the epidermis of age-, sex-, and race-matched controls (11 +/- 3 cells/mm, p less than 0.001). Of greater importance was the demonstration that significant numbers of OKT6-positive cells were present within the dermal sarcoid granulomas (19-208/mm2) in a distribution that paralleled that of Leu-3a-positive T lymphocytes. These data suggest that the epidermis may participate in activation of lymphocytes in cutaneous sarcoidosis, and implicate OKT6-positive cells in granuloma formation.     

In situ characterization of cellular infiltrates in lupus vulgaris indicates lesional T-cell activation.

Skin biopsy specimens from nine patients with lupus vulgaris were examined in situ by means of monoclonal antibodies directed against phenotypes of lymphocyte subsets, Langerhans cells, HLA-DR antigens, and interleukin 2 receptor. The epidermis showed prominent changes, including intense expression of HLA-DR on keratinocytes, increase in epidermal cell layers, moderate to high Langerhans cell hyperplasia, and infiltration by CD3+ pan-T cells as well as CD8+ (cytotoxic/suppressor) and CD4+ (helper/inducer) T cells. The predominant lymphocyte in the dermal granulomas was the activated CD3+ T cell, expressing major histocompatibility complex class II antigens and interleukin 2 receptor. CD4+ and CD8+ cells were randomly distributed among the epithelioid cells, which showed intense staining for major histocompatibility complex class II antigens. In all except two patients, the CD4+ population was greater than that of the CD8+ cells. CD1+ Langerhans cells were scattered in moderate numbers in the dermal granulomas. Acid-fast bacilli were conspicuously absent in the biopsy specimens. These features suggest that T-cell activation and Langerhans cell hyperplasia are prominent features of dermal tuberculosis.     

Perineural granulomas in cutaneous sarcoidosis may be associated with sarcoidosis small‐fiber neuropathy

Perineural granulomas in cutaneous sarcoidosis have been rarely reported and their clinical significance has yet to be evaluated. Recently, a 27‐year‐old male presented with multiple pink papules on the flank and lower back, accompanied by a painful, burning sensation. Biopsies revealed well‐defined granulomas, consistent with sarcoidosis, in the dermis and involving small cutaneous nerves. We hypothesized that perineural granulomas may be an under‐recognized feature of cutaneous sarcoidosis and may be responsible for sensory disturbances. We reviewed cases from 29 consecutive patients with cutaneous sarcoidosis. Perineural granulomas were identified in 18/29 (62%) patients and in 22/40 (55%) biopsies. Perineural granulomas were identified in 7/9 biopsies from the proximal upper extremity, 1/3 from the distal upper extremity, 7/12 from the head and the neck, including 4/4 from the nose, 5/9 from the back, 1/2 from the flank and 1/1 from the proximal lower extremity and 0/4 from the distal lower extremity. The anatomical distribution is similar to sarcoidosis small‐fiber neuropathy (SSFN), in which sarcoidosis patients without evident skin lesions experience sensory disturbances of unknown etiology involving the face, the proximal extremities and the trunk. Our results indicate perineural granulomas in cutaneous sarcoidosis are more common than previously appreciated, primarily involve the head, the proximal upper extremities and the back, and may be responsible for neurological manifestations.     

Foreign bodies in sarcoidosis

Sarcoidosis is a multisystem disease of unknown etiology. The demonstration of polarizable foreign bodies in cutaneous granulomas is generally thought to exclude a diagnosis of sarcoidosis. Nevertheless. some investigators have reported systemic sarcoidosis with cutaneous manifestations in which polarizable particles were associated with granuloma formation in the skin. We searched the biopsy specimens of granulomatous lesions from 50 patients with cutaneous sarcoidosis using polarization microscopy to estimate the frequency of polarizable foreign bodies in cutaneous lesions of sarcoidosis. Using electron probe microanalysis, we sought to determine what elements compose these foreign bodies. Polarizable foreign bodies were found in the granulomatous skin lesions of 12 of 50 patients with cutaneous sarcoidosis. All 12 patients also had at least one other granulomatous systemic lesion, and 4 had biopsy specimens of a systemic lesion available for review. Polarizable foreign bodies were found in two cases. The elements identified were calcium, phosphorus, silicon, and aluminum. Polarizable foreign bodies were found in cutaneous sarcoidosis far more often than expected. Foreign bodies were also found in granulomatous systemic lesions. The foreign body may serve as an inciting stimulus for granuloma formation in selected cases of sarcoidosis.     

Predominant cutaneous infiltration by OKT6- and OKT8-positive cells in a case of Sézary syndrome

Summary Using an immunoperoxidase (skin biopsy) and an immunofluorescence (peripheral blood, bone marrow punctate) technique, and monoclonal antibodies raised against peripheral mature lymphocytes, T helper subsets, T suppressor subsets, and Langerhans cells, we found a predominant dermal infiltration with lymphocytes of the suppressor phenotype and a predominant epidermal infiltration with Langerhans cells in a patient with Sézary syndrome (cutaneous T-cell lymphoma, CTCL). Repeated peripheral blood examinations showed an increased percentage of lymphocytes of the helper phenotype. A bone marrow examination revealed a ratio of suppressor/helper subsets of 1:4. The findings in the skin seem to be inconsistent with most of the results of previous studies in patients with CTCL; the significance of these findings is discussed.This study was partly supported by the Deutsche Forschungsgemeinschaft, Grant no. Lo 285/2-1This work is dedicated to Prof. Th. Nasemann on occasion of his 60th birthday     

Changes in the functional surface markers of lymphocytes in short-term culture

Cultured human lymphocytes are a suitable system for testing pharmacological, allergological, and toxicological effects of substances in vitro. For such investigations, the knowledge about the behaviour of the test system under standardized conditions is an important prerequisite. In the 72 h short-time-culture, no changes in T-lymphocytes were found. Small decreases occurred in the subpopulations of cytotoxical/suppressor cells, and inducer/helper cells, respectively. Number of cells expressing class II antigens of the main histocompatibility complex decreases, too (to 62%). Tritium thymidine incorporation rates inform about DNA-synthesis.     

Transepithelial elimination of granulomas in cutaneous tuberculosis and sarcoidosis

Transepithelial elimination of granulomas was observed in histologic specimens taken from involved skin of a patient with disseminated tuberculosis and two patients with sarcoidosis. This phenomenon, previously also observed in other granulomatous disorders, represents one of the skin's several mechanisms to rid itself of endogenous or exogenous waste material.     

Sarcoidosis appearing in a tattoo

BACKGROUND: Sarcoidosis is a systemic disease that may present as tattoo granulomas. OBJECTIVE: A patient with systemic sarcoidosis who developed a granulomatous reaction within a tattoo is presented to stimulate interest in this unusual phenomenon. METHODS AND RESULTS: A patient with a 6-year history of pulmonary sarcoidosis developed sarcoidal granulomas restricted to one pigment of a tattoo. Previous reports of sarcoidal granulomas within tattoos are reviewed, and information about the pathogenesis of this process is explored. CONCLUSION: Sarcoid granulomas may develop in tattoos as an isolated local reaction or as the presenting sign of systemic sarcoidosis. The reaction itself may provide insight into further understanding the pathogenesis of sarcoidosis.     

Demonstration of a subpopulation of Ia+ T-helper cells in mycosis fungoides and the Sézary syndrome

This is a report of the finding of a T-cell subpopulation bearing T-helper cells and Ia antigens in specimens of skin from patients with mycosis fungoides and the Sézary syndrome. Frozen sections of skin tissue from eight patients examined with monoclonal antibodies against mature T-cells, helper T-cells, suppressor T-cells, and Ia antigens exhibited similar staining patterns by a modified immunoperoxidase method. Antibodies against mature T-cells and helper T-cells stained 70-80% of the lymphocytes in the dermis. The antibody defining the phenotype of suppressor T-cells labelled 5-10% of the lymphocytes scattered throughout the lesions. Eighty to 90% of the lymphocytes took the stain for Ia antigen. Anti-thymocyte antibody (OKT6) stained cells in both the epidermis and dermis of the specimens. Of nonmalignant conditions examined, lesions from five cases of lichen planus exhibited a quantitatively different staining pattern than that of mycosis fungoides in that the number of T-helper cells was about equal to the number of T-suppressor cells. The findings reported are evidence for a homogeneous population of T-helper, Ia-positive lymphocytes in the cutaneous lesions of mycosis fungoides and the Sézary syndrome.     

Verrucous ulcerative skin lesions in sarcoidosis. An unusual clinical presentation.

A twenty-seven year old man with a two year history of sarcoidosis and systemic manifestations of this disease along with verrucous ulcerative skin lesions is presented. Biopsy specimens of the cutaneous lesions showed typical noncaseating granulomas as well as necrotizing granulomatous inflammation. After other possible etiologies were excluded, prednisone therapy was instituted with prompt resolution of the skin lesions, leaving atrophic scars.     

The immunobiology of basal cell carcinoma: an in situ monoclonal antibody study

A semi-quantitative, immunoperoxidase monoclonal antibody technique was used to study the mononuclear cells surrounding 32 basal cell carcinoma specimens from 30 patients. Tumours were analysed in subgroups based on recurrence, size and ulceration. T cell counts were high (greater than 3 out of 4) for all groups while T helper/inducer and T suppressor/cytotoxic cell counts were equal (approx. 2). Macrophage counts were low for all groups, about I X 2, while B cell and Ia positive cell counts were high (greater than 3). T/B cell and T helper/suppressor cell ratios approached one for the tumours as a whole as well as the sub-groups. The relative importance and contribution of cell mediated vs. humoral immunity in keeping basal cell carcinomas in check is discussed.     

Decreased levels of T-cells and cells with suppressor T-cell phenotype as defined by specific monoclonal antibodies in patients with atopic dermatitis

peripheral blood cells from forty patients with atopic dermatitis and elevated serum IgE levels were studied by indirect immunofluorescence using monoclonal antibodies OKT3, OKT4, OKT8 to, respectively, human T cells, helper-inducer and suppressor-cytotoxic T cell subsets. Decreased T cells with the suppressor-cytotoxic phenotype, with an abnormal balance between helper and suppressor cell subsets, and decreased peripheral blood T cells counts were found as compared to controls. Results were similar in the three age-matches group (4 months–2 years, 2–15 years, 15–50 years) studied. No correlation could be established between serum IgE levels and the elevated helper/suppressor cell ratios.     

Lesional T-cell subset in leprosy and leprosy reaction

BACKGROUND: The T-cell-mediated immune response plays an important role in leprosy. The in situ proportion and pattern of distribution of T-cell subsets in leprosy skin lesions have been studied, but no conclusion could be drawn. METHODS: We used monoclonal antibodies for T-helper and T-suppressor surface antigen to define the nature of dermal infiltration in 17 cases of nonreactional leprosy and 20 cases of reactional leprosy. RESULTS: We found T helper admixed with T suppressor in an aggregated pattern in the granulomas of most cases of nonreactional leprosy and in type I reactional leprosy, but a diffuse infiltrate throughout the dermis of type II reactional leprosy. The T-helper/suppressor ratio was 1.68 in tuberculoid and 1.5 in lepromatous cases. The T-helper/ suppressor ratios of borderline tuberculoid (3.11) and type I reactional leprosy (2.54) were not statistically different. The T-helper/suppressor ratio of type II reactional leprosy (5.83) was statistically higher than nonreactional lepromatous cases. CONCLUSIONS: The alteration of the T-helper/suppressor ratio in our study is mainly due to the reduction of T-suppressor cells in the dermal infiltrates, especially in type II reactional leprosy. Further studies of T-suppressor functions may be important in the pathogenesis of leprosy.     

Monoclonal antibody studies in the skin lesions of patients with anetoderma

In all five patients studied, monoclonal antibody studies of cryostat sections of skin biopsy specimens of anetoderma lesions revealed inflammatory cells reacting with anti-Leu-1, pan-T-cell antibody, and anti-Leu-3a, the helper/inducer T-cell antibody. Small numbers of suppressor cells were present in only three biopsy specimens. Four specimens showed OKM1, antibody-reacting cells (monocytes). The age of the lesion was not correlated with inflammation or the T-cell subsets identified.