CD28 T-cell costimulatory molecule expression in pemphigus vulgaris

Background  CD28 superfamily of immune costimulatory molecules could play an important role in autotolerance control. CD28 costimulation seems to be necessary for regulatory T cell (Treg) activation and successive suppressive activities involved in autoimmunity protection. This study investigates CD28 expression, especially inducible costimulator fraction, on T lymphocytes in pemphigus vulgaris (PV) patients.
Methods  CD28 expression on T lymphocytes was assessed in 16 PV patients during acute attack. All patients and 10 healthy control subjects were tested for lymphocyte populations, T-cell subpopulations (T-CD4⁺, T-CD8⁺), Treg and CD28 expression on T-cell subpopulations.
Results  T, B and natural killer cells average values in PV patients were close to the control group values. Compared with control group, PV values showed lower Treg (2.2% compared with 4.7%), slightly decreased CD4⁺ CD28⁺ T cells (91% compared with 95%), higher CD4⁺ CD28⁻ T cells (9% compared with 5%), decreased CD8⁺ CD28⁺ T cells (57% and 73%, respectively) and significantly enhanced CD8⁺ CD28⁻ T cells (43% compared with 27%).
Conclusions  These data suggest that Treg-mediated suppressor T-cell effects could be diminished in PV, together with an abnormal or ineffective subsequent helper T-cell suppression. CD28 high expression on helper T cells and low expression on suppressor T cells are arguments for a potential CD28 role in PV autoimmune response mechanism.

Conflicts of interest

None declared     

On the diagnosis of erythrodermic cutaneous T-cell lymphoma

Abstract:  Erythrodermic cutaneous T-cell lymphoma (E-CTCL) is the cause of less than 5% of all cases of generalized erythroderma. A methodical evaluation of skin, blood, and lymph node samples using standard histology, immunohistochemistry (IHC), flow cytometry (FC), and molecular analysis for evidence of a dominant T-cell clone has been recommended in a recently published diagnostic algorithm. In this commentary, the author discusses available information regarding the role of these diagnostic methods for the diagnosis of E-CTCL with emphasis on personal observations regarding skin IHC and polymerase chain reaction (PCR)-based molecular studies as adjunct diagnostic studies on a series of 55 patients with erythrodermic mycosis fungoides and 50 patients with Sézary syndrome compared to 50 patients with extensive benign inflammatory skin disease. The conclusions are (1) IHC of the skin does not reliably differentiate E-CTCL from benign simulants, (2) presence of phenotypically abnormal T cells in the blood or expanded subsets of CD4⁺CD7^– or CD4⁺CD26^– cells by FC is particularly helpful as a diagnostic study, (3) the presence of an identical T-cell clone in the skin and blood also is a specific diagnostic criterion for E-CTCL, but exceptions may occur, and (4) the PCRγ-denaturing gradient gel electrophoresis technique appears to be more reliable than PCRγ-single-stranded conformational polymorphism for diagnostic purposes.     

In vivo depletion of CD8+ T cells restores hair growth in the DEBR model for alopecia areata

Summary Alopecia areata (AA) is a putative autoimmune disease in which anagen hair follicles are the target of immune cell attack. While both CD4⁺ and CD8⁺ T lymphocytes are prominent in the infiltrate, their respective roles in the pathogenesis of AA remain unknown. Here we directly investigated the activity of CD8⁺ cells in the inhibition of hair growth using the Dundee experimental bald rat (DEBR) model for AA. Eight lesional DEBRs were fully depleted of their CD8⁺ cells by intraperitoneal injection of OX-8 monoclonal antibody (MoAb) specific for these cells over a 15-day therapy course. A control group of eight lesional rats was injected with the irrelevant MoAb OX-21. Sequential blood samples were analysed by flow cytometry to observe changes in the CD8⁺ cell population and macropliotography used to record changes in hair growth activity.
All eight CD8⁺ depleted rats started to regrow hair within 29 days from the start of treatment, the tinal response ranging from sparse regrowth to a near normal coal. While two rats maintained their new pelage, the remainder lost hair as the CD8⁺ population in peripheral blood increased. Two of the control rats also showed hair regrowth over the experimental period of 156 days. These results suggest that CD8⁺ cells play an active part in the pathogenesis of AA. As hair production did not fully recover in all animals, immune mechanisms other than CD8⁺ cells may be involved in effecting hair loss. However, analysis of CD8⁺ cell levels in the skin of CD8⁺ depleted rats may help resolve their full importance in AA.     

Mycosis fungoides bullosa

A case of a 52-year-old man with mycosis fungoides bullosa. plaque-stage IIA, follicular mucinosis and milia is described. The disease started about 15 years ago and evolved with periods of remission induced by photochemotherapy (PUVA) and, later, by topical nitrogen mustard and etretinate. Vesiculobullous lesions, alopecia and milia sequentially appeared in the course of its evolution. Besides characteristic features of mycosis fungoides, histopathology revealed subepidermal vesicles and follicular mucinosis associated with lymphoid cells (CD3⁺). The pathophysiology of these particular aspects of the mycosis fungoides is discussed.     

蕈样肉芽肿免疫表型分析及分子遗传学研究进展

 蕈样肉芽肿（MF）是最常见的原发皮肤T细胞淋巴瘤,临床上病程缓慢、迁延。MF肿瘤性T细胞最常见的免疫表型是 α/β T辅助细胞表型 (  βF1⁺、TCR-γ^-、CD3⁺、 CD4⁺、CD5⁺、CD8^-、CD45Ro⁺、TIA-1^-),占80%左右。但仍有一部分MF免疫表型很少见,如表达细胞毒性T细胞的标记(  CD8⁺, TIA-1⁺)、表达B细胞的标记（  CD20⁺）、表达间变大细胞的标记（  CD30⁺）、等,这些少见的免疫表型很容易与其它侵袭性较高的淋巴瘤相混淆,造成误诊、误治。本文对MF的免疫表型进行分析总结,并探讨其分子遗传学研究进展。     

Histopathological and immunohistochemical studies of infective dermatitis associated with HTLV-I

Infective dermatitis associated with HTLV-I (IDH) is a chronic, recurrent, exudative eczema occurring in childhood which is considered to be a risk factor for the development of lymphoma and HTLV-I-associated myelopathy/tropical spastic paraparesis. Skin biopsies from 19 patients with IDH were studied histologically and immunohistochemically using the following antibodies: anti-CD3, CD45RO, CD20, CD79a, CD4, CD8, CD56, CD57, TIA-1, granzyme-B, and perforin. A chronic dermatitis similar to atopic and seborrheic dermatitis was observed in 15 cases, whereas architectural aspects mimicking mycosis fungoides were observed in the remaining four. The infiltrate consisted predominantly of CD8+ lymphocytes and of CD57+ cells in the dermis and epidermis. TIA-1 and granzyme-B were expressed in 15/18 cases and 5/19 cases at the proportion of < or = 15% and < or = 3%, respectively. All cases were negative for perforin and CD56. Like other dermatites, histologically IDH may represent a benign simulator of mycosis fungoides. IDH shows a predominance of CD8+ cells and a low percentage of cells with cytotoxic granules, indicating that most CD8+ lymphocytes are not activated. These findings differ from the immunohistochemical pattern of atopic and seborrheic dermatitis, possibly representing additional means of differentiation between IDH and these dermatites. The distribution of CD57+ cells suggests that they play a role in the inflammatory process.     

The final destiny of acantholytic cells in pemphigus is Fas mediated

Background  Pemphigus is an autoimmune disease characterized by the formation of intra-epidermal blisters. Patients develop auto-antibodies against desmoglein 1 and 3 proteins and induce acantholysis.
Objective  This work addresses the issue of whether the Fas pathway mediates acantholysis. Furthermore, the possible suppliers of the Fas pathway were investigated.
Methods  Seventeen biopsies of pemphigus patients were studied by haematoxylin and eosin staining, and apoptosis was defined by TUNEL. The expression of Fas, FasL and caspase 3 was studied by in situ hybridization and immunohistochemistry. Cell infiltrates were studied by immunofluorescence with monoclonal anti-CD3, CD4, CD8, CD19 and CD69.
Results  All of the biopsies showed intra-epidermal blisters, acantholytic cells and inflammatory infiltrates. The blisters expressed Fas, FasL and caspase 3. Cell infiltrates were composed of CD8 and a few CD4⁺CD69⁺ cells. Additionally, CD19⁺ cells were detected. Interestingly, the Fas expression was increased in acantholytic cells and perilesional keratinocytes. Incidentally, these cells exhibited apoptotic features. Interestingly, the CD8 cells expressed FasL.
Conclusion  This paper presents the morphological evidence that apoptosis and acantholysis are linked. Therefore, the Fas pathway is associated with CD8 cells in pemphigus lesions.

Conflicts of interest

None declared.     

Pleomorphic CD8+ small/medium size cutaneous T-cell lymphoma

Pleomorphic small/medium-sized cutaneous T-cell lymphoma is a recently recognized rare type of cutaneous T-cell lymphoma which is clinicopathologically different from mycosis fungoides and Sezary syndrome. By definition the phenotype of the neoplastic lymphocytes in pleomorphic small/medium-sized cutaneous CD3CD4CD8 but CD8 pleomorphic small/medium sized cutaneous T-cell lymphoma cases have been occasionally described. We describe a 55-year-old female with a pruritic erythematous nodule on the lateral aspect of her right foot present for 1.5 years. Histology revealed a nonepidermotropic lichenoid infiltrate in the papillary dermis and a patchy infiltrate in the mid and lower dermis composed of small to medium-sized pleomorphic lymphocytes. The immunophenotype of these lymphocytes was CD3CD4CD8TIA-1. Staining for CD20, CD30, CD56, TdT, and LMP1 were negative, and the Ki-67 proliferation index was 5% to 10%. Gene rearrangement studies demonstrated a T-cell clone. The laboratory and imaging workup did not reveal extracutaneous involvement. The lesion was treated by local irradiation but a follow-up biopsy demonstrated only partial remission. Consequently, the lesion was treated by surgical excision.     

Protracted cutaneous disorders in association with low CD4+ lymphocyte counts

Summary We report two patients with skin disorders usually associated with severe immunosuppression, who had low CD4⁺ lymphocyte counts but normal immunoglobulin levels. The patients were HIV negative, and had CD4⁺ lymphocyte counts just above 300/mm³, but they presented with cutaneous manifestations of profound immunodeficiency. Idiopathic CD4⁺ lymphocyte deficiency is a recently described syndrome which may present with dermatological disease. We discuss the symptom complex of our patients in relationship to the diagnosis of idiopathic CD4⁺ lymphocyte deficiency.     

CD30+ lymphoproliferative disorders: histopathology, differential diagnosis, new variants, and simulators

Summary:  CD30⁺ lymphoproliferative disorders of the skin (CD30⁺ LPD) represent a well-defined spectrum of primary cutaneous T-cell lymphomas which have been recognized as distinct entities in recent lymphoma classifications. Lymphomatoid papulosis and anaplastic large-cell lymphoma share the expression of CD30 antigen as a common phenotypic hallmark but differ in regard to their clinical and histologic features as well as their biologic behavior. This article summarizes the histologic features of CD30⁺ LPD and presents recently identified new clinicopathologic variants of CD30⁺ LPD. There is an increasing number of reactive inflammatory disorders and neoplastic diseases which are composed of or contain a significant number of CD30⁺ cells and mimic LyP or anaplastic large cell lymphoma clinically or histologically. Differential diagnostic considerations focus on other lymphoproliferative processes with CD30⁺ tumor cells as well as non-lymphoid neoplasms and inflammatory simulators. The term CD30⁺ pseudolymphoma is proposed to designate inflammatory processes with CD30⁺ T cells. The final diagnosis of CD30⁺ LPD is based on a synthesis of clinical, histologic, phenotypic, and molecular genetic findings.     

Granulomatous mycosis fungoides responsive to gemcitabine

We report a 61-year-old woman with a 1-year-history of widespread erythematous scaly patches and plaques as well as red/purplish to brownish confluent plaques. Ulcerated lesions with a purulent, hemorrhagic exudate and sharp elevated borders were located on the lower extremities. Diagnosis of granulomatous mycosis fungoides was supported by histopathologic findings showing an inflammatory reaction with epithelioid and large giant cells associated with features characteristic of mycosis fungoides. Immunohistochemical studies showed a T-helper phenotype of neoplastic cells (CD3+, CD4+, CD45RO+) with expression of the cytotoxic protein TIA-1. Molecular analysis of TCRgamma gene demonstrated a monoclonal rearrangement in the lesional skin. After failure of conventional therapies, 6 cycles of gemcitabine treatment produced partial remission of cutaneous lesions and stable disease throughout a 12-month follow-up period, suggesting that gemcitabine is a promising chemotherapeutic agent for refractory mycosis fungoides.     

The prognosis of early mycosis fungoides is not influenced by phenotype and T-cell clonality

Background The influence of phenotype and detection of clonality on prognosis in early mycosis fungoides has never been addressed in large studies. Objectives To correlate immunophenotype and detection of clonality with clinical outcome. Methods We analysed 73 biopsy specimens from 68 patients with early mycosis fungoides (stage Ia or Ib) and at least 10 years of follow up (or dead of disease). Results Four phenotypic groups could be identified: group A (α/β+ CD4+ CD8? TIA1?), 51 patients; median survival time 160 months; group B (α/β+ CD4? CD8+ TIA1+), 10 patients; median survival time 195 months; group C (α/β? CD4? CD8+/? TIA1+), five patients; median survival time 165 months; and group D (α/β+ CD4? CD8? TIA1?), two patients; median survival time 130 months. Survival curves did not show statistical differences among the groups. Monoclonality was detected in 36 of 67 tested biopsies (54%), and statistical analyses did not show prognostic differences between the clonal and nonclonal cases. Conclusions We conclude that cytotoxic phenotype and detection of monoclonal T‐cell receptor‐γ gene rearrangement in early lesions of mycosis fungoides do not have any prognostic significance.     

银屑病患者骨髓CD34+细胞体外定向分化的T细胞活性研究

目的 研究有家族发病倾向的银屑病患者骨髓CD34⁺细胞体外定向发育的T细胞活性.方法 免疫磁珠法分离家族史阳性银屑病患者及正常对照骨髓CD34⁺细胞,在骨髓基质细胞条件培养液构建的微环境下,在胸腺基质细胞的支持下,使其在体外向T细胞定向分化,免疫磁珠法收集CD3⁺T细胞,流式细胞仪检测CD4⁺CD8^-细胞及CD4^-CD8⁺细胞比例.分别采用MTT法及ELISA法检测自然增殖组及链球菌超抗原刺激后T细胞增殖活性及分泌细胞因子水平.结果 ①经骨髓CD34⁺细胞定向分化并扩增的CD3⁺T细胞中可检测到CD4⁺CD8^-、CD4^-CD8⁺T细胞,且银屑病患者组与正常对照组CD4⁺CD8^-及CD4^-CD8⁺T细胞比例无显著差异.②银屑病患者骨髓CD34⁺细胞定向分化的T细胞自然增殖组及链球菌超抗原刺激组增殖活性均显著高于正常人对照组.③银屑病患者T细胞自然增殖组培养上清白介素4、白介素8及干扰素γ与正常对照组差异无统计学意义,链球菌超抗原刺激后白介素4表达水平无显著改变,而白介素8及干扰素γ水平却显著高于正常人.结论 有家族发病倾向的银屑病患者外周血T细胞活性异常可能与骨髓造血细胞相关.     

Detection of epidermodysplasia verruciformis-like human papillomavirus types in malignant and premalignant skin lesions of renal transplant recipients

Summary A 76-year-old man presented with a 3-month history of a cutaneous nodute on the right thigh. The tumour was composed of CD3⁺, large atypical cells, and CD20⁺, small normal-appearing cells. Flow cytometry showed that CD20⁺ cells outnumbered CD3⁺ cells. By Southern blot hybridization analyses, the malignant cells were shown to be of T-cell origin, because of the presence of rearranged bands for the β chain of the T-cell receptor, but not for the immunoglobulin heavy chain. This case represents a T-cell lymphoma intermingled with a large number of non-neoplastic B cells.     

Clinical effectiveness and safety experience with alefacept in the treatment of patients with moderate-to-severe chronic plaque psoriasis in Taiwan: results of an open-label, single-arm, multicentre pilot study

Background  The effectiveness and safety of alefacept for the treatment of moderate-to-severe chronic plaque psoriasis has been established in several clinical trials conducted in the United States and Europe. No clinical trial of alefacept has been conducted in Asia.
Objective  To determine the effectiveness and safety of alefacept in the treatment of psoriasis in Chinese population.
Design and methods  This was an open-label, single-arm, multicentre pilot study conducted at three centres. Patients with a body surface area ≥ 10% and psoriasis area and severity Index (PASI) ≥ 12 were given 15 mg alefacept intramuscularly once a week for 12 weeks and were then followed up for a further 12 weeks.
Results  A total of 46 patients was enrolled. Only one subject (2%) achieved a ≥ 75% improvement in PASI at week 14. The median improvement in PASI at week 14 after the 12-week treatment was 39%. At any time during the 6-month course, 3 subjects (7%) achieved a Physician Global Assessment (PGA) of 'almost clear', and a ≥ 50% and ≥ 75% improvement in PASI was seen in 46% and 9%, respectively. There is a trend for decreased counts of CD4⁺ and CD8⁺ cells after alefacept treatment, but subjects who achieved PASI50 showed a lesser degree of decrease in CD4⁺ and CD8⁺ counts compared with those in patients who did not achieve PASI50.
Conclusions  This small pilot study indicated that intramuscular alefacept was effective and safe in psoriasis in Chinese patients over 12 weeks of treatment. Further studies are needed to clarify the reason for low PASI 75 effectiveness and the paradoxical lesser decline of CD4⁺ and CD8⁺ T cells in those who responded.     

Identification of TIA-1+ and granzyme B+ cytotoxic T cells in lichen sclerosus et atrophicus

BACKGROUND: The onset and persistence of cutaneous lichen sclerosus et atrophicus (LSA) are linked to the presence of an inflammatory infiltrate of CD3+ T cells that includes CD4+ and CD8+ cells. The functional relevance of the presence of these cells is unknown. OBJECTIVE: The study intended to quantify resting and activated cytotoxic T cells in LSA lesions. METHODS: Twenty patients with active LSA were studied. Skin-infiltrating T cells were immunohistologically characterized with antibodies against CD3, CD8, T-cell-restricted intracellular antigen (TIA-1) and granzyme B (GrB). TIA-1 labels cytotoxic granules of resting and activated T cells, whereas GrB designates activated cytotoxic T lymphocytes (CTL). RESULTS: In all cases, numerous T cells were consistently found expressing cytotoxic granules. The results indicated a high number of infiltrating CD8+ TIA+ T cells. Furthermore, a notable number of GrB+ activated CTL associated with hydropic degeneration of the basal cell layer were found within the dermal infiltrate and at the dermoepidermal interface. CONCLUSION: This study shows that a high proportion of skin-infiltrating T cells in LSA has a potential cytotoxic function. The results indicate that hydropic degeneration of basal keratinocytes may at least partially be mediated by CTL-dependent mechanisms. Our data also indicate that a cell-mediated immune response may play an important role in the pathogenesis of the disease.     

A patient with plaque-stage mycosis fungoides has successfully been treated with long-term administration of IFN-γ and has been in complete remission for more than 6 years

Summary We report the successful treatment of a patient with plaque-stage mycosis fungoides with long-term and intravenous administration of recombinant human interferon-γ (IFN-γ) and discuss the possible mechanisms of this therapy.
A 55-year-old female patient had been resistant to existing treatments and had suffered repeated exacerbations over a 5-year period. Four weeks after initiation of 2 × 10⁶U/day of IFN-γ. a > 10% decrease in the affected surface area was noted. Twenty-two weeks after the administration of 228 × 10⁶U of IFN-γ, complete remission (CR) was obtained. The CR continued for 13 weeks, but this was followed by an exacerbation. The second CR was obtained after the IFN-γ dosage was increased to 16 × 10⁶U/week. The dosage was then gradually reduced by 2–4 × 10⁶U every 2 or 3 months. She was treated with a total dose of 2814 × 10⁶ of IFN-γ. She has been followed up for more than 6 years, and there has been no recurrence of mycotic skin lesions nor any visceral involvement. During therapy, no serious side-effects were noted.
Long-term administration of IFN-γ is useful for the treatment of patients with intractable mycosis fungoides. A gradual decrease in the dose of IFN-γ is important for maintaining remission.     

Prevention of psoriasis-like lesions development in fsn/fsn mice by helminth glycans

Abstract:  The helminth glycan LNFPIII is an immunomodulatory molecule, driving CD4⁺ Th2-type biasing as well as immune suppression. Psoriasis is an autoimmune disease where the immune mechanisms as well as the antigens responsible for development of immune autoreactivity are still not known. In the absence of defined immunological mechanisms, we asked whether LNFPIII would function as novel therapy for psoriasis. We tested the therapeutic efficacy of LNFPIII using the flaky skin (fsn)/fsn mutant mouse model of psoriasis-like lesion development. We found that treatment of mice with LNFPIII prevented the appearance of psoriatic skin lesions on fsn/fsn mice. Examination of the skin 2 weeks after treatment demonstrated that prevention of skin lesions was associated with maintenance of normal epidermis thickness in LNFPIII-treated mice as compared with a significantly thickened epidermis in control treated and diseased mice. In addition, cells from skin of LNFPIII-treated mice produced lower amounts of interferon-γ as compared with cells from skin of control treated diseased mice. Examination of macrophages and T cells from peripheral lymph nodes of control and LNFPIII-treated fsn/fsn mice showed that glycan treatment reduced the numbers of Gr1⁺F4/80⁺ macrophages and the numbers of CD8⁺ T cells, restoring the numbers of these two cell populations as well as the CD4 : CD8 ratio to near normal levels. Overall, the results from this study suggest that the helminth immunomodulatory glycan LNFPIII functions to prevent development of psoriatic-like skin lesions in fsn/fsn mice.     

Alopecia universalis in an HIV–positive patient: possible insight into pathogenesis

Alopecia universalis, a variant of alopecia areata, is a disease of unknown etiology, though evidence for an autoimmune etiology continues to mount. We report an HIV–positive patient with altered T-lymphocyte subsets in whom alopecia universalis developed. A skin biopsy of the patient's scalp demonstrated a classic perifollicular lymphocytic infiltrate, and immunophenotyping of the same specimen revealed that the majority of the cells were CD4⁺ lymphocytes. During the active loss of hair, the patient's CD4/CD8 ratio was decreased. This ratio normalized during the period of regrowth. Our data suggest that systemic immune dysfunction, as seen in HIV infection, may be more important in mediating alopecia areata than localized immune responses. Given the proposed mechanism of alopecia areata developing in this patient, i.e. influx of CD4⁺ lymphocytes to the perifollicular regions of skin when the CD4/CD8 ratio is low, it is surprising that alopecia areata is not seen more commonly in patients with HIV infection.     

T-cell subsets with a naive phenotype are selectively decreased in the peripheral blood of patients with mycosis fungoides

Peripheral blood lymphocytes of 33 patients with histopathologic confirmation of mycosis fungoides and 27 healthy controls matched for age and sex were analyzed with a panel of monoclonal antibodies using both single and dual color immunofluorescence. Patients with mycosis fungoides had a significant reduction in the percentage of circulating T cells with a naive phenotype (i.e., CD4+2H4+ and CD4+Leu8+), as well as a significant reduction in the absolute numbers of circulating lymphocytes with the phenotype CD8+Leu8+ compared to the control cohort. The reduction in circulating naive T cells was found to occur irrespective of stage of disease, duration of disease, or mode of treatment. The depletion of circulating naive T cells may reflect increased conversion to memory T cells in the peripheral blood or skin.