Lesional Skin Biopsies Research Articles

Síndrome meníngeo crónico. Afectación meníngea de etiología no infecciosa

Noninfectious chronic meningitis (NICM) is defined as meningeal inflammation unrelated to an infectious process that progresses with signs and symptoms which persist for more than four weeks. The most common clinical manifestation is headache in varying combinations with altered mental status, focal neurological signs, fever, nuchal rigidity, myelopathy, cranial neuropathies, or polyradiculopathies. The approach to NICM begins with a medical history, full physical examination, and additional tests (serological tests, brain imaging tests, lumbar puncture, and biopsy of skin lesions and lymph nodes). Cerebral and meningeal biopsy can be considered in cases that progress with progressive neurological decline and an inconclusive systemic or CSF study. Systemic diseases with meningeal involvement tend to progress with a combination of chronic or relapsing chronic meningitis and uveitis (uveo-meningeal syndromes). For the initial treatment, high doses of corticosteroids and, in refractory cases, immunosuppressants are required. Neoplastic meningitis presents with both solid tumors and with malignant cerebral and hematological neoplasms; its treatment depends on the type of neoplasm. The drugs most commonly associated with NICM are intravenous non-steroidal anti-inflammatory drugs, sulfamides, penicillins, and immunoglobulins. The prognosis is good, with improvement after withdrawal of the drug implicated.

Quality parameters for RNA preparations from biopsies of ulcerated human skin.

Background: Obtaining high quality RNA from skin biopsies is complex due the physical composition and high content of nucleases of this tissue. This becomes particularly challenging when using compromised skin samples with necrotic, inflammed or damaged areas, such as those from patients suffering skin conditions, which affect more than 900 million people annually. We evaluated the impact of the biopsy size and tissue preservation method on the quality and quantity of RNA extracts. Methods: Skin lesion biopsies were obtained from patients with cutaneous leishmaniasis (CL). Biopsy specimens of 2 mm (n = 10) and 3 mm (n = 59) were preserved in Allprotect® reagent, and 4 mm biopsies in OCT (n = 54). Quality parameters were evaluated using Nanodrop and Bioanalyzer. The informativeness of the extracted samples for downstream analyses was evaluated using RT-qPCR and RNA-Seq. Results: The success rate, based on quality parameters of RNA extraction from tissue biopsies stored in OCT and 2 mm biopsies stored in Allprotect®, was 56% (30/54) and 30% (3/10), respectively. For 3 mm skin biopsies stored in Allprotect® was 93% (55/59). RNA preparations from 3 mm-Allprotect® biopsies had an average RIN of 7.2 ± 0.7, and their integrity was not impacted by sample storage time (up to 200 days at -20°C). RNA products were appropriate for qRT-PCR and RNA-seq. Based on these results, we propose a standardized method for RNA extraction from disrupted skin samples. This protocol was validated with lesion biopsies from CL patients (n = 30), having a success rate of 100%. Conclusions: Our results indicate that a biopsy size of 3 mm in diameter and preservation in Allprotect® for up to 200 days at -20°C, are best to obtain high quality RNA preparations from ulcerated skin lesion biopsy samples.

In situ expression of Th17 immunologic mediators in American cutaneous leishmaniasis caused by Leishmania (V.) braziliensis and Leishmania (L.) amazonensis in the Brazilian Amazon

American cutaneous leishmaniasis (ACL) presents a wide spectrum of clinical and immunopathological manifestations. In Brazil, Leishmania (L.) amazonensis[La] and Leishmania(V.)braziliensis[Lb] show the highest pathogenic potential for humans causing different clinical forms: localized cutaneous leishmaniasis (LCL : Lb/La), anergic diffuse cutaneous leishmaniasis (ADCL : La) and mucocutaneous leishmaniasis (MCL : Lb). ADCL and MCL are the most severe forms and infection leads to a cellular immune response at the hyposensitivity and hypersensitivity poles. Th17-cells are involved in the ACL pathogenesis, are derived from naïve TCD4+ cells regulated by RORγt, differentiate in presence of IL-6, TGF-β, IL- 1β, IL-23 and express IL-17. Aim of this study was to characterize the cellular immune response mediated by Th17-profile cells through in situ determination of the expression of RORγt, IL-17, IL-6, TGF-β, IL-1β, and IL-23 in the ACL clinical-immunopathological spectrum caused by L.(L.)amazonensis and L.(V.)braziliensis. Biopsies of skin and mucosal lesions from forty patients including ADCL(n=8), LCL[La](n=17), LCL[Lb](n=9) and MCL(n=6), were examined by immunohistochemistry. The immunostained cells density (cells/mm2) was determined in image analysis system using AxionVision 4.8 software (Zeiss). As the disease evolution time (DET) was different among ACL patients, the effect of DET on the expression of immunological markers was evaluated in different clinical forms and histopathological changes, using ANCOVA. Our results showed significantly increased expression of RORγt, IL-17, IL-6, IL-1β and IL-23 in patients with ACL polar forms (ADCL and MCL); higher TGF-β expression was found in ADCL. DET influenced the expression of RORγt and IL-6 in: clinical forms of ACL and in categories of parasitism. DET also affected the production of RORγt, IL-17, IL-6, TGF-β and IL-1β in types of inflammatory infiltrate, evidencing that DET had effect on the expression of Th17 profile cytokines in ACL. Together, the expression of immunological mediators of Th17 profile in the ACL spectrum, as well as the DET effect, demonstrate the participation of this cell lineage in the immunopathogenesis of ACL, mainly in the polar and more severe forms of ACL spectrum. The dubious role played by Th17-cells may favors immune response suppression and parasitic persistence in ADCL, while in MCL it contributes to an exacerbated immune response and parasite scarcity.

287 Targeting the inhibitory receptor Siglec-8 on mast cells represents an attractive approach to reduce MRGPRX2-mediated mast cell activation

Abstract Atopic dermatitis (AD) is a debilitating type 2 inflammatory disease of the skin characterized by pruritus. Mast cells (MCs) and eosinophils (eos) are elevated in AD tissue. Siglecs are inhibitory receptors found on immune cells, with Siglec-8 selectively expressed on MCs and eos. Engagement of Siglec-8 with antibody results in broad inhibition of MC activation (IgE-dependent and -independent pathways). MCs and eos are key drivers of itch. Crosstalk between skin MCs and sensory neurons contributes to non-histaminergic itch via activation of Mas-related G-protein receptor X2 (MRGPRX2). MRGPRX2-mediated MC activation has been implicated in chronic urticaria and allergic contact dermatitis, however, this mechanism has not been studied in the pathogenesis of AD. We hypothesize that activation of MCs through MRGPRX2 contributes to chronic inflammation and itch in patients with AD. Supernatants were collected from intact ex vivo cultured lesional and non-lesional skin biopsies from donor-matched patients with AD or healthy volunteers. Following ex vivo culture, secreted mediators were quantified using ELISA and meso-scale discovery (MSD). Biopsies were enzymatically digested and MRGPRX2 expression and function were measured using flow cytometry and MSD. Acute MRGPRX2 activation in vivo and the effects of a Siglec-8 monoclonal antibody (mAb), compared with isotype control, were studied in Siglec-8 transgenic mice. MC and eosinophil numbers were increased in lesional biopsies from patients with AD compared with patient-matched non-lesional and healthy volunteer control biopsies. MCs from AD lesional biopsies showed significant evidence of activation and degranulation compared to MCs in non-lesional biopsies. Levels of MC-specific proteases, inflammatory and pruritic mediators were significantly elevated in supernatants from ex vivo cultured lesional biopsies, including CPA3, CCL17 (TARC), IL-8, IL-13 and IL-31. Levels of MRPGRX2 ligands in supernatants from AD lesional biopsies were significantly elevated. Ex vivo challenge of healthy skin tissue with MRGPRX2 ligands partially replicated the AD lesional microenvironment. Lastly, intradermal injection of MRGPRX2 ligands in Siglec-8 transgenic mice induced inflammation and itch, which were inhibited with a Siglec-8 mAb. MRGPRX2-mediated MC activation contributes to inflammation in patients with AD through the release of chemotactic, proteolytic, pruritic and inflammatory factors. Therapeutic strategies that broadly target MCs, such as a lirentelimab (AK002) and a Siglec-8 mAb, may decrease the severity of AD.

Histopathological panoroma and clinocopathological correlation of Hansen’s disease in tertiary care hospital

Background: The present study was undertaken to study the histopathological features of leprosy in skin punch biopsies and to categories them in to various type based on microscopy and bacterial index. The aim of study was to know the role of histopathology in diagnosis of Hansen’s disease and to study the clinicohistopathological correlations of suspected cases of Hansen’s disease. Materials and methods: A retrospective hospital-based study of clinically diagnosed leprosy cases was conducted over a period of one year (April 2021 to March 2022). Lesional skin biopsies obtained were fixed, processed and stained with Haematoxylin and Eosin (H&E) followed by Fite-Faraco staining. The lesions were classified on microscopy as per Ridley-Jopling classification. Results: 63 Skin biopsies were obtained from patients with age range of 14-72 years. Highest incidence was in age group of 31 – 50 years. There was male predominance with male to female ratio of 2:1. Clinically borderline Hansen’s (BB) (25.40%) was the most frequent subtype observed followed by borderline lepromatous (BLH) (19.04%) and lepromatous Hansen’s (LL) (19.04%). On histopathology we found tuberculoid Hansen’s (TT) (28.57%) was the most frequently observed subtype followed by borderline tuberculoid Hansen’s (BT) (19.04%). Fite stain revealed lepromatous bacilli in all cases of LL, BL, histoid and indeterminate Hansen’s; whereas bacilli could be demonstrated in six cases of BB, eight cases of BT and two cases of TT. Conclusion: Early diagnosis of leprosy is clinically difficult as patient present in different clinicopathological form, depending on host immune status. Therefore combined clinical, histopathological and bacteriological features are required for accurate diagnosis and classification.

Chronic recurrent wheals - If not chronic spontaneous urticaria, what else?

Chronic urticarial rash, mostly due to chronic spontaneous urticaria (CSU), is seen in up to 1-4% of the general population. Urticarial vasculitis (UV) and autoinflammatory syndromes, i.e., cryopyrin-associated periodic syndromes (CAPS) and Schnitzler syndrome (SchS), can mimic CSU-like rash but represent rare disorders with systemic symptoms including fever, headache, conjunctivitis, and arthralgia. Clinical and laboratory features can point to the presence of any of these diseases in patients initially presenting with chronic urticarial rash. These include long-lasting wheals (> 24 hours), lesional burning, systemic symptoms, and/or increase in inflammatory markers (e.g., C-reactive protein, serum amyloid A, and/or S100A8/9). Lesional skin biopsy usually demonstrates leukocytoclastic vasculitis (UV) or neutrophil-rich infiltrate (CAPS and SchS). In contrast to CSU, where second-generation H1 antihistamines and omalizumab allow to control symptoms in most patients, systemic immunosuppression and anti-interleukin (IL)-1 therapies are needed in case of UV and autoinflammatory diseases, respectively. The rarity and low awareness of CSU differential diagnoses may be related to the longer delays in diagnosis and therapy in those affected with UV, CAPS, and SchS. Knowledge of the differential diagnoses of CSU is important because only correct diagnosis allows adequate therapy. Complications such as the development of lymphoproliferative disease in SchS and amyloidosis in CAPS, and the presence of comorbid diseases, such as systemic lupus erythematosus in UV, must be considered and monitored.

Psoriasis improvements and inflammatory biomarker normalization with secukinumab: the randomized ObePso-S study

BackgroundThe IL-17A inhibitor secukinumab has demonstrated consistent efficacy and safety in patients with moderate-to-severe plaque psoriasis, with normalization of molecular and histopathologic psoriasis markers. ObjectiveTo investigate treatment effects of secukinumab on clinical signs and psoriatic inflammation markers over 52 weeks in patients with psoriasis. MethodsIn the ObePso-S study (NCT03055494), patients with psoriasis were randomized 2:1 to receive secukinumab 300 mg (n = 54) or placebo (n = 28), stratified by body weight (<90 or ≥90 kg), for 52 weeks. At Week 12, patients receiving placebo were switched to secukinumab. Psoriasis Area and Severity Index improvement of 90% (PASI90) and Investigator’s Global Assessment modified 2011 0/1 responses were assessed at Weeks 12 and 52. Immunohistochemistry for keratin 16 (K16) and gene expression profiles were evaluated in lesional and non-lesional skin biopsies collected at baseline, Week 12, and Week 52. ResultsOf patients receiving secukinumab, 55.8% and 59.6% achieved PASI90 at Weeks 12 and 52, respectively. K16 was absent in 93.1% of Week 12 PASI90 responders and 93.6% of Week 52 PASI90 responders, which mirrored the down-regulated expression of psoriatic inflammation. Week 52 PASI90 non-responders experienced regression of clinical and inflammatory marker responses toward baseline levels. Lower control of inflammatory gene expression at Week 12 was associated with suboptimal clinical responses at Week 52. ConclusionSustained clinical responses with secukinumab were associated with rapid and sustained normalization of K16 and inflammatory gene expression in most patients. Molecular anti-inflammatory effects of secukinumab at Week 12 were associated with clinical responses at Week 52.

Hailey-Hailey disease misdiagnosed as candidal intertrigo: Case report of a rare skin disease

Hailey–Hailey disease (HHD) is a rare autosomal-dominant blistering disorder characterized by macerated velvety, fissured, hypertrophic plaques with characteristic involvement of the intertriginous areas. The diagnosis is often suspected by the clinical appearance of the lesions in intertriginous areas as well as positive family history and confirmed by histological analysis of the lesional skin biopsy. A diagnosis of HHD is rarely made in this environment due to its resemblance to other dermatoses of the intertriginous areas and the rarity of the condition itself. We present a case report of HHD, a rare hereditary disease, involving two unrelated Nigerians seen in our dermatology clinic, who were diagnosed and successfully managed at our centre.

Dysregulation of Plasma miR-146a and miR-155 Expression Profile in Mycosis Fungoides Is Associated with rs2910164 and rs767649 Polymorphisms.

Diagnosis of Mycosis Fungoides (MF) may be challenging, due to its polymorphic nature. The use of miRNAs as biomarkers to assist in diagnosis has been investigated, mainly in skin lesion biopsies. The purpose of this study is to evaluate the plasma levels of miR-146a and miR-155 in MF patients and to investigate their association with SNPs of their genes. Plasma miRNAs were quantified by RT-qPCR. Genomic DNA was used for SNPs' genotyping by Sanger sequencing. Plasma levels of miR-146a and miR-155 were significantly higher in patients vs. controls, in early MF patients vs. controls, and in advanced vs. early MF patients. Both miRNAs' levels were significantly higher in stage IIB vs. early-stage patients. miR-155 plasma levels were significantly higher in patients with skin tumors or erythroderma. CC genotype (rs2910164 C&gt;G) was significantly more frequent in healthy controls and associated with lower MF risk and lower miR-146a levels. The AA genotype (rs767649 T&gt;A) was significantly more frequent in patients and correlated with increased MF risk and increased miR-155 levels. The combination of GG+AA was only detected in patients and was correlated with higher MF susceptibility. Increased mir-146a and mir-155 plasma levels in MF is an important finding to establish putative noninvasive biomarkers. The presence of SNPs is closely associated with miRs' expression, and possibly with disease susceptibility.

A simplified technique for guarding biopsy punch

Abstract A biopsy punch is an instrument used for taking biopsies of skin and oral lesions and harvesting punch grafts for treating vitiligo. Punching out the tissue up to an optimum depth with safety is the prime concern of the procedure. A number of punch guards are proposed for the safety and depth of the punch excision to avoid unnecessary tissue excision, which causes delayed healing, cosmetic defect, and injury to the underlying vital structure. However, the procurement of the punch guard is a little time-consuming and cumbersome during fixing the depth. Moreover, these punch guards are not easily adjustable. Here, we describe a simple and fast technique for guarding a biopsy punch with use of rubber or plastic cap of a syringe piston and cyanoacrylate glue.

053 SEB-induced IL-13 production in CLA+ memory T cells defines Th2 high and Th2 low responders in atopic dermatitis

There is currently no clear in vitro model to study the Th2 status in atopic dermatitis (AD). Staphylococcus aureus, skin-homing cutaneous lymphocyte-associated antigen (CLA)+ memory T cells and IL-13 are key players in AD. Circulating CLA+ memory T cells reflect the cutaneous abnormalities in AD. We have studied the CLA+/- memory T-cell response to staphylococcal enterotoxin B (SEB) when cocultured with autologous lesional epidermal cells from adult non-treated moderate-to-severe AD patients. Also, plasma and mRNA expression from the lesional skin biopsies were analysed.

014 Tyrosine Kinase 2 Inhibition Ameliorates the Phenotype of Lesional Alopecia Areata Scalp Skin Ex Vivo, and Reverses the Induction of Human Alopecia Areata in a Humanized Mouse Model

Alopecia areata (AA) is an immune-mediated hair follicle (HF) disorder induced by elevated IFNγ levels and a Tc1-driven inflammatory response. We have previously shown that treatment with IL-12 and IL-18 induces IFNγ-dependent, immune privilege collapse of the hair bulb, which can be inhibited by blocking IL-12 receptor signaling with the TYK2 inhibitor, BMS-986202 (BMS), in human microdissected HFs. Here, we further investigate the role of TYK2 and its inhibition in AA pathogenesis. We cultured human full thickness non-lesional and lesional scalp skin biopsies from acute or chronic AA patients ex vivo with BMS.

Targeting Immunosuppressive Macrophages in the Cutaneous T-Cell Lymphoma Microenvironment

Introduction: Immunosuppressive M2-like macrophages contribute to malignancy progression in cutaneous T-cell lymphoma (CTCL). Hence targeting M2-like macrophage differentiation and function may have potential therapeutic utility in CTCL. Targetable signaling pathways in M2 macrophages include the mannose receptor CD206 and the pattern recognition receptor Toll-like Receptor 4 (TLR4). Objective: To evaluate TLR4 and CD206 function in CTCL-associated macrophages and their therapeutic potential as targets of immunomodulation. Methods: We assessed TLR4 and CD206 expression in human CTCL lesional skin biopsies and in transwell co-cultures containing macrophages and CTCL cells. Using an established murine model of CTCL, we quantified tumor burden of mouse MBL2 cells after transplantation into immunocompetent mice with and without manipulating TLR4 or CD206 function. To abrogate TLR4 function we used TLR4 deficient mice and to stimulate CD206 signaling we used a novel CD206 binding peptide, RP-832c. Results: Human CTCL lesional skin biopsies and MBL2 tumors displayed co-localized expression of CD206 and TLR4 on macrophages. CTCL-associated macrophages in co-cultures exhibited an M2-like polarized phenotype as well as increased TLR4 expression. In contrast, when these co-cultures were treated with RP-832c, macrophages displayed the M1-like phenotype. In mice lacking TLR4, CTCL tumor growth was reduced (Figure 1) and M1 to M2 macrophage ratios were significantly higher compared to that of wild type. Similarly, CTCL tumors in mice treated with RP-832c displayed a shift from M2 macrophage phenotype to M1 and exhibited attenuated tumor growth (Figure 2). Conclusion: Our data suggest that both TLR4 inhibition and CD206 activation in the CTCL tumor microenvironment inhibit tumor growth by inducing a phenotypic shift from immunosuppressive M2-like to anti-tumor M1-like macrophages. Therefore, topical or systemic formulations of CD206 binding peptide, RP-832c, and small molecule TLR4 inhibitors present promising immunomodulatory therapeutic options in CTCL. Figure 1: MBL2 cells were injected s.c. into flanks of C57BL/6 and TLR4-/- recipients (5 mice /grp.) and tumor volumes monitored overtime. Shown are the mean and standard error for each group. Figure 2: MBL2 cells were injected s.c. into flanks of C57BL/6 recipients (5 mice /grp.) and mice were treated daily with i.p. injections of RP832c or saline starting 10 days post inoculation. Tumor volumes were monitored overtime. Shown are the mean and standard error for each group. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

The Accuracy of Clinical Diagnosis in 2135 Lesions on the Face. A Retrospective Analysis of Histopathological Records.

Biopsy of facial skin lesions is an important supplement to dermatological diagnostics, especially in doubtful cases or suspected of being malignant. The aim of the retrospective study of 2135 histopathological records of lesions on the face was to: establish the most common indications for a skin biopsy in patients with facial lesions, establish the frequency of histopathological diagnoses, evaluate how often clinically suspected inflammatory lesions are identified as tumors in histopathology, evaluate the accuracy of clinical diagnoses of the most common skin tumors and dermatoses. It was a retrospective study. Histopathological records from the lesions on the face from years 2010-2017 were analyzed. The mean age of patients was 69.3 [7-98]. Fifty-eight percent of the patients were women. Among 2135 clinical diagnoses skin tumors were suspected in 1905 cases. Among 2169 obtained histopathological results (34 biopsies showed 2 diseases), we identified skin tumors in 1940 cases, with 1388 confirmed as malignant. The clinical diagnosis of a specific benign or malignant skin tumor was accurate in 1013/1634 subjects, in comparison to inflammatory lesions, which were correct in 67/148 cases, (P = 0.0001). Among all preliminary inflammatory diagnoses, 33/204 lesions were identified as skin tumors in histopathology. In conclusion in most cases of skin tumors the clinical diagnosis is confirmed by histopathological examination. In case of facial inflammatory lesions, the accuracy of clinical diagnosis is lower, with a significant number of facial lesions appearing inflammatory in clinical evaluation but being diagnosed as skin cancers in pathology.

Inflammasome and Inflammatory Programmed Cell Death in Chromoblastomycosis.

Chromoblastomycosis (CBM) is a chronic, progressive fungal disease of the skin and subcutaneous tissue caused by a group of dematiaceous fungi. Verrucous lesions present parasite-rich granulomas and predominance of a Th2 patterns of cytokines. The inflammasome constitutes a macromolecular protein complex that play a role in the activation of caspase 1 that cleaves pro-IL1β and pro-IL18, essential mediators of inflammation, and also activates pyroptosis. We intended to explore the presence and a possible role of inflammasome elements in cutaneous human lesions in CBM, considering the expression of IL1β, IL18, caspase 1, NLRP1, and also RIPK3, a key downstream component of necroptosis signaling. 35 skin biopsies of cutaneous lesions of verrucous form of CBM and 10 biopsies from normal skin were selected. The diagnosis was based on histological and clinical analysis. An immunohistochemical protocol was performed. The histopathological analysis evidenced epidermis with hyperkeratosis, irregular acanthosis, and micro abscesses. The dermis presented suppurative granulomas and inflammatory infiltrate composed by giant cells, macrophages, epithelioid cells, lymphocytes, and some eosinophils. Positive cells were distributed in the inflammatory infiltrate, with an increased number of cells expressing caspase 1, IL1β and IL18. Cells expressing RIPK3 and NLRP1 were less frequent. The intense presence of caspase 1, IL1β and IL18, allied to NLRP1 expression, suggest that inflammasome and pyroptosis could play a role in the immune response against fungal agents of CBM. Our results, allied to data from literature, could suggest that inflammasome-mediated response and pyroptosis could be a target to be explored to decrease CBM lesions.

Quality parameters for RNA preparations from biopsies of ulcerated human skin.

Background: Obtaining high quality RNA from skin biopsies is complex due the physical composition and high content of nucleases of this tissue. This becomes particularly challenging when using compromised skin samples with necrotic, inflammed or damaged areas, such as those from patients suffering skin conditions, which affect more than 900 million people annually. We evaluated the impact of the biopsy size and tissue preservation method on the quality and quantity of RNA extracts. Methods: Skin lesion biopsies were obtained from patients with cutaneous leishmaniasis (CL). Biopsy specimens of 2 mm (n = 10) and 3 mm (n = 59) were preserved in Allprotect® reagent, and 4 mm biopsies in OCT (n = 54). Quality parameters were evaluated using Nanodrop and Bioanalyzer. The informativeness of the extracted samples for downstream analyses was evaluated using RT-qPCR and RNA-Seq. Results: The success rate, based on quality parameters of RNA extraction from tissue biopsies stored in OCT and 2 mm biopsies stored in Allprotect®, was 56% (30/54) and 30% (3/10), respectively. For 3 mm skin biopsies stored in Allprotect® was 93% (55/59). RNA preparations from 3 mm-Allprotect® biopsies had an average RIN of 7.2 ± 0.7, and their integrity was not impacted by sample storage time (up to 200 days at -20°C). RNA products were appropriate for qRT-PCR and RNA-seq. Based on these results, we propose a standardized method for RNA extraction from disrupted skin samples. This protocol was validated with lesion biopsies from CL patients (n = 30), having a success rate of 100%. Conclusions: Our results indicate that a biopsy size of 3 mm in diameter and preservation in Allprotect® for up to 200 days at -20°C, are best to obtain high quality RNA preparations from ulcerated skin lesion biopsy samples.

CUTANEOUS INVOLVEMENT IN MULTIPLE MYELOMA IN THE ERA OF PROTEASOME INHIBITORS: HAS THE DISMAL PROGNOSIS CHANGED?

We present a 3-case series of MM with cutaneous involvement and a wide range of clinical manifestations and dismal prognosis after cutaneous involvement. Case 1- A 55-year-old man presenting with symptomatic MM, IgG- kappa, Durie-Salmon IIIA stage, and ISS = 3. He was treated with CyBORD, 4 cycles with complete response. Subsequently, he underwent HSCT whose conditioning was performed with MEL 200 mg/m 2 and infusion of 12 x 10 6 CD34/kg cells. After HSCT, he remained in complete response and maintenance with bortezomib. After 4 months, he developed erythematous infiltrated plaque that evolved to an exophytic tumor on the left posterior axillary line. In addition, sudden spinal cord compression on T12 level whose radiological investigation demonstrated bone plasmacytoma was also observed. Decompressive laminectomy and skin lesion biopsy were performed, which confirmed the presence of cutaneous infiltration by MM. Hence, the patient received a third-line treatment with DVd. The patient's renal function deteriorated and his skin lesions showed progressive growth. Eventually he became septic and died. Case 2- A 76-year-old man diagnosed with IgA/lambda secreting MM with Durie Salmon IIIA and ISS II. His initial treatment consisted of an association of melphalan, prednisone and bortezomib, which resulted in complete remission. A few months later, the patient relapsed leading to further treatment with lenalidomide and dexamethasone. At that moment, the patient showed no response and underwent a regimen containing KRD, which was unsuccessful. The association of dara-VMP was used after he developed renal failure, cardiovascular impairment and skin lesions over his legs were noted. A fine needle aspiration was performed and microscopic analysis showed signs of cutaneous plasmacytosis confirming cutaneous infiltration by MM. The patient developed multiple organ failure after sixty days of the onset of such cutaneous lesions. Case 3- A 50-year-old woman with a diagnosis of IgA secretory MM, Durie Salmon IIIB, ISS 3. Initial therapeutic approach was performed with thalidomide and dexamethasone. A partial response with stabilization of heavy and light chain monoclonal protein. A few months later, her condition deteriotated. Thus, a protocol with CYBORD was introduced. Despite treatment, she developed purplish plaques and nodules on the left anterior chest wall and over both arms, which evolved with rapid growth. Biopsy of the cutaneous lesions was performed, which revealed an extramedullary plasmacytoma. Afterwards, a more aggressive therapeutic regimen was applied containing melphalan, vincristine, cyclophosphamide and methylprednisolone with no clinical response.Ultimately she died of sepsis. Cutaneous plasmacytic infiltration in multiple myeloma (MM) is a rare clinical condition, usually associated with a high burden of malignant cells and a poor prognosis. The clinical management of the secondary infiltration of the MM does not have a standard optimal therapeutic regimen. There are some physiopathologic hypothesis that arise that cutanea infiltracao is owemore aggressive forms of myeloma usually with characteristics of plasmablasts and clones with high prevalence of high-risk molecular markers. In our experience, the use of these drugs has not translated into additional survival to patients, underscoring the role of skin involvement as a poor prognostic factor.

Determining biomarkers for evaluation and diagnosis of hereditary angioedema.

RationaleKallikrein‐bradykinin‐forming cascade is known to cause hereditary angioedema (HAE) acute angioedema (AE) attacks. Further research of HAE attacks is needed to explain disease heterogeneity, predict treatment response and identify biomarkers for monitoring HAE attacks. Differential expression of the microvascular endothelial cell‐surface receptors for example, g‐C1qR, cytokeratin‐1, and plasminogen‐activator‐urokinase‐receptor (PLAUR) were hypothesized as biomarkers of AE attacks.MethodTo understand HAE attacks, the differentially expressed genes (DEGs) in RNAseq and mi‐RNAseq data of total RNA extracted from skin biopsies of lesional versus non‐lesional skin collected during and between attacks in Type‐1 HAE patients (n = 11; F:M = 8:3) were compared. To understand the HAE variants, DEGs in skin biopsies from HAE with normal C1 inhibitor (n = 5, F:M = 5:0), and non‐HAE (n = 7; F:M = 3:4) patients were compared. Gene‐set enrichment analyses and regulator effects analysis of these DEGs identified biological pathways in HAE attacks and their regulators.ResultsPLAUR gene, encoding urokinase‐type plasminogen activator (u‐PAR), was constitutively over‐expressed in HAE‐Type‐1 versus non‐HAE controls suggestive of overactive u‐PAR‐mediated signaling via binding to Factor‐XII. Baseline PLAUR expression was associated with severe AE (p = 0.05). The 18 significant DEGs investigated between baseline and AE attack samples in Type1‐HAE were enriched in beta1/beta3‐integrin cell surface interactions and IL‐6‐mediated signaling. Regulator effects analysis suggests a role for IL‐1b in HAE flares. AKT2, the mRNA regulated by the differentially‐expressed miR‐184A, was also associated with HAE attacks.ConclusionAngiopoetin‐activated β1‐integrin signaling pathways causing endothelial destabilization, and avid binding of factor XII to u‐PAR are possible novel mechanisms for progression of the endothelial kinin‐bradykinin‐forming cascade in HAE attacks.

S2616 Melena: An Uncommon Presentation of Scurvy

Introduction: Scurvy is the clinical manifestation of vitamin C deficiency and presents with hemorrhage (petechiae, ecchymoses, bleeding mucosa), follicular hyperkeratosis, hemolytic anemia, hypochondriasis, hysteria, depression, and fatigue. Scurvy is a rare diagnosis in industrialized countries; however, it can be seen in alcoholic, elderly, and institutionalized patients or those following fad diets or suffering from malabsorptive disorders. The association of scurvy and GI pathology is rare, but it exists. There have been reported cases of scurvy presenting as GI bleed and even as the initial manifestation of Whipple’s disease. Case Description/Methods: A 71-year-old female with past medical history of systemic lupus erythematosus, carcinoid tumor of the small bowel and abnormal bruising presents to the hospital with worsening purpura and intermittent polyarthralgia affecting her feet, ankles, knees, hips, shoulders, and elbows. Labs were significant for anemia of 8.25 and mildly elevated CRP and ESR of 5.9 and 30 respectively. During hospitalization, the patient had multiple black bowel movements and her hemoglobin dropped to 6.8. Iron studies were significant for iron deficiency. She was transfused and underwent EGD and colonoscopy. EGD showed characteristic findings of gastric antral vascular ectasia (Figure 1) which was treated with APC and colonoscopy revealed erythematous mucosa throughout the entire colon (Figure 1). Biopsy of the colon mucosa was unremarkable. The patient was discharged with dermatology follow up for biopsy of purpuric skin lesions. After discharge, patient's labs resulted and showed an undetectable level of Vitamin C. She was seen at follow up by her PCP and treatment was started. Discussion: The water-soluble vitamin C plays a crucial component in collagen synthesis by activating hydrolases that form stabilizing components of the collagen triple-helix structure. When deficient, small vessels in the skin and mucosa become fragile resulting in submucosal hemorrhage in the stomach, duodenum and colon that presents as hematochezia or melena. Treatment consists of dietary modification and intravenous vitamin C replacement with resolution of lesions in only a few days. Vitamin C is replaced daily and generally normalizes in 3-4 weeks. This case demonstrates an unusual presentation of scurvy in the form of GI bleed. It is important for gastroenterologists to consider scurvy in the differential diagnosis of patients presenting with GI bleed, purpura and polyarthralgia.Figure 1.: (A) EGD images of mucosal hemorrhage seen in scurvy (B) Colonoscopy images of mucosal hemorrhage seen in scurvy.

S3539 ANCA-Associated Leukocytoclastic Vasculitis With Mesenteric Involvement

Introduction: Leukocytoclastic vasculitis (LCV) is a usually self-limiting, idiopathic small-vessel vasculitis with cutaneous symptoms. Extracutaneous manifestations should raise suspicion for underlying autoimmune conditions such as ANCA-associated vasculitis, of which LCV may be the initial manifestation. Mesenteric involvement is uncommon and usually represents advanced disease. Delay in recognition of mesenteric vasculitis can lead to progression and perforation. We present a case of gastrointestinal (GI) hemorrhage caused by ANCA-associated LCV. Case Description/Methods: A 69-year-old male with a history of bilateral inguinal hernia repair was admitted for post-surgical groin wound infection. He was started on antibiotics and underwent mesh removal, washout, and debridement. He developed shock, renal failure, small vessel ischemic cerebrovascular infarction, and upper extremity papular eruptions. Work-up was notable for elevated inflammatory markers, decreased C3, negative ANA, positive C-ANCA and negative P-ANCA. He met Sapporo criteria for antiphospholipid syndrome given small vessel arterial thrombosis and positive lupus anticoagulant. Shave biopsy of skin lesions confirmed LCV. He was started on IV methylprednisolone and heparin infusion. He subsequently developed melena and anemia. EGD showed grade C esophagitis, gastropathy, and diffuse erosive duodenopathy (Figure). He was diagnosed with ANCA-associated LCV with mesenteric involvement. Bleeding resolved after holding heparin and treatment with pantoprazole. He was transitioned to prednisone and started on rituximab with significant improvement. Discussion: Though uncommon, mesenteric vasculitis merits consideration in patients with abdominal pain or GI bleeding and clinical evidence of systemic autoimmune disease. Symptoms arise from intestinal ischemia which can progress to infarction and perforation if untreated. Endoscopy should be pursued with great caution due to increased perforation risk. Histopathology of superficial mucosal biopsies usually shows mucosal damage but does not yield a definitive diagnosis. Classic endoscopic findings include mucosal pallor, edema, or necrosis dispersed between normal mucosa. Ulcers and bleeding can be seen in severe cases. Timely recognition of GI manifestations of ANCA-associated LCV and initiation of therapy are pivotal in ensuring reduction of morbidity, mortality, and the need for surgery. A high index of suspicion for infarction or perforation warrants early surgical intervention.Figure 1.: Endoscopic evidence of diffuse erosive duodenopathy interspersed between normal mucosa in the setting of mesenteric vasculitis.