Reticular Lesions Research Articles

Phenotypically non-suppressive cells predominate among FoxP3-positive cells in oral lichen planus.

Oral lichen planus (OLP) is a common T-cell-dominated oral chronic inflammatory disease occurring in periods of remission, quiescence, activity with pronounced inflammation, and acute ulceration. Cell infiltrates in OLP contain varying numbers of CD4+ T cells expressing the transcription factor FoxP3. FoxP3+ CD4+ T cells are, however, a heterogeneous cell population containing suppressive and non-suppressive cells, and their distribution in infiltrates from OLP is unknown. Biopsies were taken from normal oral mucosa (n = 8) and OLP lesions (n = 19), and a set of in situ methods for the determination of the functional phenotype of FoxP3+ CD4+ T cells was applied. Numbers of FoxP3+ CD4+ T cells were highest in the atrophic form of the disease, yet low in the ulcerative form. The main FoxP3+ CD4+ T-cell population observed was FoxP3+ CD45RA- CD25+ CD45RO+ and CD15s- , a phenotype delineating a non-suppressive subset. Numbers of cells with an actively suppressing phenotype (FoxP3+ CD45RA- CD25+ CD45RO+ and CD15s+ ) were, however, about twice as high in reticular lesions as compared with the atrophic form. Many FoxP3+ CD4+ T cells expressed T-bet, the hallmark transcription factor for IFN-γ-producing T cells, indicating that they may enhance immune and inflammatory responses rather than suppress them. The absence of actively suppressing FoxP3+ CD4+ T cells may in part explain why OLP is a remarkably persisting condition, in spite of the presence of substantially high numbers of FoxP3+ CD4+ T cells. The findings emphasize that it is crucial to examine not only numbers but also functional phenotype of FoxP3+ CD4+ T cells in human tissues.

Cross-sectional analysis of the dermoscopic patterns and structures of melanocytic naevi on the back and legs of adolescents.

Junctional (flat) naevi predominate on the extremities, whereas dermal (raised) naevi are found primarily on the head, neck and trunk. Few studies have investigated the anatomical site prevalence of melanocytic naevi categorized using dermoscopy. To identify the prevalence of dermoscopic patterns and structures of naevi from the back and legs of adolescents. Dermoscopic images of acquired melanocytic naevi were obtained from the back and legs of students from a population-based cohort in Framingham, Massachusetts. Naevi were classified into reticular, globular, homogeneous or complex dermoscopic patterns. Multinomial logistic regression modelling assessed the associations between dermoscopic pattern and anatomical location. In total 509 participants (mean age 14 years) contributed 2320 back naevi and 637 leg naevi. Compared with homogeneous naevi, globular and complex naevi were more commonly observed on the back than the legs [odds ratio (OR) 29·39, 95% confidence interval (CI) 9·53-90·65, P < 0·001 and OR 6·8, 95% CI 2·7-17·14, P < 0·001, respectively], whereas reticular lesions were less likely to be observed on the back than on the legs (OR 0·67, 95% CI 0·54-0·84, P = 0·001). Naevi containing any globules were more prevalent on the back than on the legs (25% vs. 3·6%, P < 0·001). Naevi containing any network were more prevalent on the legs than on the back (56% vs. 40·6%, P < 0·001). These findings add to a robust body of literature suggesting that dermoscopically defined globular and reticular naevi represent biologically distinct naevus subsets that differ in histopathological growth pattern, age- and anatomical-site-related prevalence, molecular phenotype and aetiological pathways.

Immunoexpression of Th17-related cytokines in oral lichen planus.

A recently described lineage of lymphocytes, Th17 cells, has been associated with inflammatory and autoimmune diseases. The aim of this article was to assess the immunoexpression of cytokines related to this lineage, interleukin-17 (IL-17) and IL-23 and in reticular and erosive oral lichen planus (OLP). The sample included 41 cases of OLP (23 reticular and 18 erosive) and 10 cases of inflammatory fibrous hyperplasia (IFH). Lymphocytes exhibiting cytoplasmic immunostaining were counted. Epithelial immunostaining was also evaluated. There was no statistical differences in the number of IL-17 and IL-23 lymphocytes between the OLP (55.40 and 48.40, respectively) and IFH (39.30 and 44.40, respectively). A significantly higher number of IL-23 lymphocytes was found in erosive OLP group (63.80) when compared with reticular (41.40) and IFH lesions (44.40) (P=0.019). Furthermore, epithelial immunopositivity for IL-17 and IL-23 was higher in OLP lesions than in IFH (P=0.012 and P=0.011, respectively). A significantly higher number of IL-23 lymphocytes in erosive OLP and the strong epithelial immunopositivity for IL-23 and IL-17 in OLP group could suggest an important participation of TCD4 Th17 response in this disorder.

Dermatomyositis associated with erythematous and reticular lesions on the trunk

Dermatomyositis associated with erythematous and reticular lesions on the trunk

A case report on Sarcoidosis

Sarcoidosis is a multisystem disease that may involve almost any organ system. Infiltration with non-caseating granulomas is the hallmark of the disease, and it may result in various clinical manifestations. Since the first description of the disease by British dermatologist Jonathan Hutchison in 1869, sarcoidosis has been seen in almost every part of the world and continues to engender considerable interest among clinicians because of its unknown aetiology, protean manifestations, and variable course and prognosis. Here we report a 65-year old woman who presented to us with a rather atypical presentation of sarcoidosis- subcutaneous nodules. Later, on subsequent diagnostic work-up, she was found to have bilateral hilar and mediastinal lymphadenopathy and pulmonary reticular lesions. It is a bit unusual to have only subcutaneous nodules as the presenting complaint of sarcoidosis without any prominent systemic and respiratory symptoms, which is what prompted this report. DOI: http://dx.doi.org/10.3329/jdmc.v22i2.21549 J Dhaka Medical College, Vol. 22, No.2, October, 2013, Page 225-228

Retiform purpura caused by the use of cocaine, that was probably adulterated with levamisole.

Dear Editor: Retiform purpura is a dermatological condition characterized by reticulated, stellate, or serpentine shaped purple lesions on the skin and mucous membranes. New, multiple cases of retiform purpura after the use of levamisole adulterated cocaine have been reported. Levamisole is an anthelmintic drug with immunomodulatory and immunostimulating properties. It has been used in humans to treat rheumatoid arthritis, cancer of the colon and nephritic syndrome in children. It was withdrawn from use in the United States in 2000 because of the risk of agranulocytosis1. We report the case of a 52-year-old woman receiving treatment with levothyroxine for hypothyroidism. Two days after consuming cocaine, she developed painful skin lesions with arthralgia on both wrists. Physical examination revealed plaques and papules infiltrated to touch, purpuric on the edges and necrotic in the center, with reticular and stellate lesions on both cheeks, the tip of the nose, outer left ear, and lower limbs (Fig. 1). Biopsy revealed thrombotic vasculopathy of the small and medium blood vessels in the dermis and subcutaneous cell tissue (Fig. 2). Blood tests revealed leukopenia, neutropenia, and lymphopenia. Antinuclear antibodies (ANA, titer 1 : 1.280) in anti-neutrophil cytoplasm antibodies (ANCAs) against myeloperoxidase with a p-ANCA pattern (titer, >100 [0~5]), and ANCAs against proteinase 3 with a c-ANCA pattern (titer, 6.8 [0~5]) were also found. Hypocomplementemia of C3 was detected. The tests for thrombosis and coagulation, serology, cryoglobulins and antiphospholipid antibodies were normal or negative. Cocaine was detected in the urine sample. The results of chest radiography and urine sediment test were normal. A diagnosis of retiform purpura resulting from the use of cocaine, that was probably adulterated with levamisole was made. She was prescribed with low dose oral prednisone. The hematological symptoms cleared 5 days later, after one month, the skin lesions had healed without sequelae. Fig. 1 (A) A reticular plaque with purpuric edges and necrotic center on the left cheek. (B) Reticular and stellate plaques with purpuric edges and necrotic center on low limbs. Fig. 2 Hematoxylin-eosin staining image (×10) showing thrombotic vasculopathy of the small and medium blood vessels in the dermis and subcutaneous cell tissue. Levamisole is currently only used in veterinary medicine as an anthelmintic; however, it has recently begun to be used as an adulterant in cocaine in many countries, including Spain2. Levamisole poisoning should be suspected in the case of a young patient presenting bilateral cutaneous necrosis on the earlobes, cheeks, or nose, that may be accompanied with retiform purpura lesions, primarily on the legs3. There may also be signs of arthralgia, fatigue, and general malaise. In the literature, some cases showing convulsions, kidney failure, or pulmonary haemorrhage have also been reported. The most common alterations in laboratory tests are neutropenia, a p-ANCA pattern, and the presence of antiphospholipid antibodies. More specific immune markers include antielastase antibodies. However, to confirm the diagnosis, levamisole detection in urine by using gas chromatography-mass spectrometry is required. However, most of the reported cases, including ours, are unconfirmed. This is because of the unavailability of testing techniques4 and the short half-life of levamisole (5.5~6 h)5. Two histological patterns have been documented: leukocytoclastic vasculitis and thrombotic vasculopathy. In most patients, skin lesions resolve spontaneously 2~3 weeks after stopping levamisole. However, the serological alterations may persist for up to 14 months3.

A patient with unilateral periodic leg movements associated with pontine infarction.

A patient with unilateral periodic leg movements associated with pontine infarction.

Evaluation of cellular proliferative activity in patients with oral lichen planus and hepatitis C through AgNOR method.

The objective of this study was to evaluate the cellular proliferative potential of oral lichen planus (OLP) lesions from patients without hepatitis C virus (HCV) by means of AgNOR method, as well as the cellular proliferative potential of the normal oral mucosa from patients with HCV, treated or untreated by interferon and ribavirin. A cross-sectional study was developed to investigate four groups: 10 HCV+ patients without clinical signs of OLP who had never been treated for HCV infection - Group 1; 10 HCV+ patients that were under interferon and ribavirin treatment - Group 2; 15 patients with reticular OLP lesions histopathologically confirmed, without HCV - Group 3; and 15 blood donors without HCV infection and no clinical signs of OLP GROUP 4 Control Group. The cytological material of all groups was collected by the liquid-based cytology technique. Then, the sedimented material from each patient was filled with the Nucleolar Organizer Regions impregnation by silver method (AgNOR). The count of NORs was performed on 100 epithelial cell nuclei per patient using the Image Tool(tm) software. The Tukey HSD test was used to compare the median value of NORs among the groups and showed that the oral mucosa of HCV+ patients previously treated with anti-HCV drugs (GROUP 2), presented a higher average number of NORs in relation to others (p<0.05). The anti-HCV treatment may be related to increased cell proliferation of oral mucosa, indicating a possible relationship between OLP and HCV+ patients treated with interferon and ribavirin.

Oral Lichen Planus: An Emerging Paradoxical Adverse Effect Of Anti-TNF-α Therapy

Introduction: The efficacy of anti-tumor necrosis factor alpha (TNF-α) inhibitors in the treatment of inflammatory bowel disease (IBD) is well established. The increasing use of these agents in clinical practice has led to the recognition of several adverse events, some of them being considered as paradoxical. Many skin and mucosal lesions have been described under anti-TNF-α therapy, including lichenoid reactions. Case Report: The authors present 3 cases of oral lichen planus (OLP) in 3 female patients with IBD (2 with Crohn’s disease and 1 with ulcerative colitis) treated with infliximab (2 patients) and adalimumab (1 patient). A few weeks after starting anti-TNF- α therapy, the patients complained about oral burning pain and significant limitation of food intake and speech. On examination, they had white, reticular lesions in the buccal mucosa and soft palate (Figure 1). The lichenoid origin of the lesions was confirmed histologically (Figure 2). Other etiologies were excluded. Despite the treatment, it was necessary to discontinue anti-TNF-α therapy in 2 patients due to persistent lesions and symptoms.Figure 1Figure 2Discussion: To our knowledge, there are 11 reported cases of OLP due to anti-TNF-α therapy. The development of these lesions appears to result from immunological mechanisms that disrupt the delicate balance between TNF-α and interferon-α in susceptible patients. The treatment and malignant potential of these lesions remains controversial. In light of the increasing use of TNF-α inhibitors, the occurrence of OLP is a potentially emerging side effect; thus, we recommend a thorough oral examination as a routine component of gastroenterologists’ evaluation.

Reticular macular lesions: a review of the phenotypic hallmarks and their clinical significance

Reticular macular lesions, also known as 'reticular macular disease', 'reticular drusen', 'reticular pseudodrusen', or 'subretinal drusenoid deposits', are a pattern of lesions commonly found in age-related macular degeneration and best visualized using at least two imaging techniques in combination. Reticular lesions have four stages of progression observable on spectral domain optical coherence tomography, but they do not show the usual signs of regression of soft drusen (calcification and pigment changes). Furthermore, reticular lesions correlate histologically with subretinal drusenoid deposits localized between the retinal pigment epithelium and the inner segment ellipsoid band. Reticular lesions are most commonly seen in older age groups of female patients with age-related macular degeneration and are usually bilateral. They are not clearly associated with known age-related macular degeneration genes and are highly associated with late-stage age-related macular degeneration and an increased mortality rate. They are also associated with alterations in the neural retina and choroid.

AB0330 Interstitial Lung Disease in Patients with Early Rheumatoid Arthritis

BackgroundInterstitial lung disease (ILD) in rheumatoid arthritis (RA) is frequent. Joint disease precedes the interstitial lung involvement by several years in most cases, although ILD may be the first RA...

Foxp3 gene expression in oral lichen planus: A clinicopathological study

CD4+CD25+ Forkhead‑box protein 3 (Foxp3+) regulatory T cells are important in oral lichen planus (OLP). The present study aimed to investigate Foxp3 expression in CD4+CD25+ T cells of peripheral blood mononuclear cells and oral lesions in patients diagnosed with OLP, who were grouped as OLP subtype, duration and relapse. Using quantitative polymerase chain reaction (qPCR), western blotting and immunohistochemistry, Foxp3 expression levels in explants of oral lesions and CD4+CD25+ T cells from 32 patients with OLP were measured and compared, with 10 healthy subjects as the control group. Foxp3 mRNA expression levels in the explants of oral lesions and circulating CD4+CD25+ T cells in patients with OLP were significantly higher than those in the control group (P<0.05). In patients with clinically erosive lesions, Foxp3 mRNA expression was significantly lower in circulating CD4+CD25+ T cells and tissue explants compared to patients with reticular lesions (P<0.01 and P<0.05, respectively), and lowest in patients with a history of OLP of >1 year or with a history of relapse (P<0.05 and P<0.01, respectively). Foxp3 protein levels in reticular OLP were significantly higher than those in erosive OLP and the control group. The incidence of Foxp3 protein expression in OLP tissues was 36.24±18.92 and 10.44±6.51% in normal oral mucosa (P=0.019). Atrophic/erosive OLP lesions showed a higher proportion of Foxp3‑expressing cells than that of reticular OLP lesions (P<0.05). This study indicated that Foxp3 expression in patients with OLP is associated with the severity and duration of the disorder, suggesting altered immune suppression in the development, clinical course and responsiveness to treatment.

Reduction of Retinal Sensitivity in Eyes With Reticular Pseudodrusen

To evaluate the effect of macular reticular pseudodrusen on retinal function using multiple imaging methods. Prospective cross-sectional study. Thirteen eyes with reticular pseudodrusen, but without any other macular abnormality or glaucoma, and 20 normal eyes were evaluated. All subjects underwent color fundus photography, infrared reflectance (IR), fundus autofluorescence (FAF), and microperimetry. The similarity in the number of reticular pseudodrusen was evaluated through inter-observer intraclass correlation coefficients, which ranged from 0.852-0.944. IR could detect reticular pseudodrusen within the center circle area in 12 eyes, whereas blue-channel fundus photography and FAF could only detect these lesions in 1 and 3 eyes, respectively. The number of reticular pseudodrusen correlated among the different imaging modalities (P < .001 for all) for all areas of the macula, except the center. The mean retinal sensitivity in eyes with reticular pseudodrusen was lower in all areas of the macula, compared with normal eyes (P < .001 for all). The number of reticular pseudodrusen correlated with retinal sensitivity in all areas by IR imaging (P=.003, P < .001, P= .003 for center, inner ring, outer ring, respectively), in the inner and outer rings by blue-channel fundus photography (P < .001 for both), and in the inner and outer rings by FAF (P < .001 and P= .001, respectively). Although multiple imaging modalities are capable of quantifying reticular pseudodrusen, IR appears to have the best ability to do so as compared to blue-channel photography and FAF. The distribution and number of reticular pseudodrusen lesions are closely associated with retinal sensitivity.

Prostatic paracoccidioidomycosis with a fatal outcome: a case report.

IntroductionParacoccidioidomycosis is a systemic mycosis in Latin America that can affect various organs. Few case reports of paracoccidioidomycosis affecting the prostate are found in the literature.Case presentationWe present the case of a 79-year-old Caucasian man with a six-month history of irritative symptoms of the prostate (urgency, frequency and nocturia) and difficulty initiating urination that progressed to urinary retention and the use of a urinary catheter. The anatomopathological analysis of the transurethral resection of the prostate revealed chronic granulomatous prostatitis of fungal etiology (paracoccidioidomycosis) with extensive necrosis. The patient began treatment with itraconazole at a dose of 100mg/day for six months. Radiography of the thorax revealed bilaterally diffuse nodular reticular interstitial lesions. The patient progressed to respiratory failure and was sent to the intensive care unit, but suffered a cardiopulmonary arrest and was pronounced dead.ConclusionsDue to the high incidence of paracoccidioidomycosis in countries like Brazil, urologists should suspect blastomycosis in all patients with symptoms of lower urinary obstruction with chronic abacterial prostatitis. Considering that paracoccidioidomycosis has the potential to affect various organs, following diagnosis, the treatment must be initiated as soon as possible.

Potential pathogenetic role of Th17, Th0, and Th2 cells in erosive and reticular oral lichen planus

The role of Th17 cells and associated cytokines was investigated in oral lichen planus. 14 consecutive patients with oral lichen planus were investigated. For biological studies, tissues were taken from reticular or erosive lesions and from normal oral mucosa (controls) of the same patient. mRNA expression for IL-17F, IL-17A, MCP-1, IL-13, IL-2, IL-10, IL-1β, RANTES, IL-4, IL-12B, IL-8, IFN-γ, TNF-α, IL-1α, IL-18, TGF-β1, IL-23R, IL-7, IL-15, IL-6, MIG, IP-10, LTB, VEGF, IL-5, IL-27, IL-23A, GAPDH, PPIB, Foxp3, GATA3, and RORC was measured using the QuantiGene 2.0. Results showed that Th17-type and Th0-type molecules' mRNAs, when compared with results obtained from tissue controls, were increased in biopsies of erosive lesions, whereas Th2-type molecules' mRNAs were increased in reticular lesions. When the CD4+ T-cell clones, derived from oral lichen planus tissues and tissue controls, were analyzed, a higher prevalence of Th17 (confirmed by an increased CD161 expression) and Th0 CD4+ T clones was found in erosive lesions, whereas a prevalence of Th2 clones was observed in reticular lesions. Our data suggest that Th17, Th0, and Th2 cells, respectively, may have a role in the pathogenesis of erosive and reticular oral lichen planus.

Ulcerative Lichen Planus in Childhood

Lichen planus (LP) is a chronic inflammatory mucocutaneous condition which is relatively common in adults but rarely affects children. The present study is a report on an unusual case of ulcerative oral LP involving the dorsum of tongue in a 12-year-old boy. Patient complained of painful oral lesion on the tongue which was burning in nature and obstructing talking and eating spicy foods. On intraoral examination, a white ulcerative lesion on the dorsum of tongue was observed. Diagnosis was made based on clinical examination and histopathological features. We instituted local treatment and patient responded well to the treatment. Although rarely reported in childhood, lichen planus should be considered in a differential diagnosis of hyperkeratotic, reticular, and ulcerative lesions of the oral mucosa in children.

Oral lichen planus: A retrospective study of 633 patients from Bucharest, Romania

Objective: In this retrospective study, patients’ medical records were reviewed to investigate the profiles of 633 OLP cases in a group of Romania. Material and Methods: In this retrospective study, the following clinical data were obtained from the medical charts of patients: gender, age, clinical presentation of OLP, site affected, presence of symptoms, extraoral manifestations of lichen planus, presence of systemic diseases, and history of medications. Results: Most (78.67%) OLP patients were female and the mean age at presentation was 52 years. The white type of the disease (reticular/papular/plaque lesions) was the main form encountered in this sample (48.97%). Among patients with available hepatitis C virus test results, 9.6% were serum-positive. OLP was associated with gallbladder disease (i.e. cholecystitis, cholelithiasis) in 19% of patients. Six patients (0.95%) developed squamous cell carcinoma at a site with confirmed OLP lesions. Conclusions: To the best of our knowledge, no similar study has been conducted in a Romanian population. The present investigation revealed the predominance of OLP among middle-aged white women and the prevalence of bilateral involvement of the buccal mucosa with reticular white lesions. Anti-HCV circulating antibodies were more common in patients with OLP than in the general population and, notably, OLP was associated with gallbladder disease (cholecystitis, cholelithiasis) in 19% of patients. Key words:Oral lichen planus, oral mucosal diseases, retrospective study.

Pathogenesis of Oral Lichen Planus: New Findings on the Critical Role of Th17, Th0, and Th2 Cells in the Development of Erosive and Reticular Lesions

Pathogenesis of Oral Lichen Planus: New Findings on the Critical Role of Th17, Th0, and Th2 Cells in the Development of Erosive and Reticular Lesions

FoxP3+ T regulatory cells in oral lichen planus and its correlation with the distinct clinical appearance of the lesions

The aim of this study was to evaluate the presence of FoxP3(+) cells in oral lichen planus (OLP) and to correlate the findings with clinical and histopathological features of these lesions. The sample consisted of 32 cases of OLP (17 reticular and 15 erosive cases) and 10 cases of inflammatory fibrous hyperplasia (IFH). Clinical examination, histopathological and histomorphometric analysis, and immunohistochemistry (anti-FoxP3 antibody) were performed. Cells were counted in juxtaepithelial and intraepithelial regions of the lesions, and the results are expressed as the mean and range. Most erosive lesions were keratinized and exhibited epithelial atrophy, whereas most reticular lesions were hyperkeratinized. Mean epithelial thickness and mean density of the inflammatory infiltrate were higher in reticular lesions than in erosive OLP. Juxtaepithelial FoxP3(+) cells were slightly more frequent in erosive lesions (mean: 1.7 and range: 0-9.4) than in reticular lesions (mean: 1.5 and range: 0-8.3). There was a significant difference in the frequency of these cells between OLP (mean: 1.6 and range: 0-9.4) and IFH (mean: 0.5 and range: 0-1.4) (P<0.05). The number of intraepithelial FoxP3(+) cells was higher in reticular OLP and IFH when compared with erosive lesions. The larger number of juxtaepithelial FoxP3(+) cells in OLP compared to IFH might be related to the distinct etiopathogenesis of these lesions. High disease activity or action of the oral microbiota may explain the slightly higher frequency of FoxP3(+) cells in erosive lesions.

Hereditary Sclerosing Poikiloderma

Hereditary sclerosing poikiloderma (HSP) is a very rare disease. The clinical features are principally widespread poikiloderma and linear hyperkeratotic and sclerotic bands. We report an 18-yr-old male who presented reticular hyperpigmented lesions on the trunk and extremities since 2-yr-old. Also, linear sclerosing bands appeared on both antecubital and popliteal fossae after yr. Histopathologic finding showed dense sclerotic collagen fibers with telangiectasia in the upper dermis and fragmentations of damaged elastic fibers in the elastic stain, consistent with HSP. We report the first Korean case of HSP.