Transcript The biology of eosinophils and their role in skin disease

Welcome
Willkommen
Bienvenue
Velkomen
Isten hozta
Zayt wilkum
Merhaba
Karibu
Patient 1
• 10 y.o. female with a 2-week history of
pruritic rash and mild loss of appetite
• ROS otherwise negative; no constitutional
symptoms, no recent weight loss, no
diarrhea, no abdominal pain
• Family came to US from Guatemala four
years ago
• No significant past medical history
Patient 1: Clinical photographs
Summary of initial laboratory values
Test
WBC
Neutrophils
Eosinophils
Basophils
Hemoglobin
Hematocrit
Platelet
ALT
AST
ESR
Rapid GpA Strep
Urinalysis
ANA
c-ANCA
p-ANCA
hepatitis A and B
Complement
C3
Lab value
*30,000/ml
2,400/ml
*22,500/ml
*300/ml
13.4 g/dL
39%
424,000/ml
*105 U/l
*64 U/l
*19 mm/hr
negative
negative
negative
negative
negative
past resolved infection
127 U CH50/ml
110 mg/dl
Reference range
(4,500-13,500/ml)
(1,800-7,000/ml)
(0-500/ml)
(0-200/ml)
(11.5-15.5 g/dL)
(35-45%)
(200,000-450,000/ml)
(8-49 U/l)
(10-44 U/l)
(<10 mm/hr)
negative
negative
negative
negative
negative
--(80-160 U CH50/ml)
(87-247 mg/dl)
Patient 1: Stool analysis
• Trichrome stain positive for cysts of
Giardia lamblia
Patient 1: Histopathology
Hypersensitivity tissue reaction
Differential diagnosis:
- urticaria/urticarial vasculitis
- Well’s syndrome
- hypereosinophilic syndrome
- drug reaction
- arthropod assault
- reaction to parasitic infection
Patient 1
• Initially treated with metronidazole, but
unable to tolerate after two days due to
nausea
• Finished a one week course of
furazolidone
• Urticarial plaques did not improve with
treatment
• Bone marrow biopsy revealed acute
lymphoblastic leukemia (ALL)
ALL/Eo
• Distinct entity first reported by Spitzer and
Garson in 1973
• Eosinophilia is rare with ALL
• Average age ~15 y.o., M>F
• 41 patients described in literature
• Good initial response to chemo, but high
relapse rate
• Poor prognosis; median survival time of
7.5 months
ALL/Eo
• Systemic symptoms common, including
fever, cough, LAN, arthralgias,
splenomegaly, pulmonary infiltrates
• Rash common; variably described in
literature with “purpura”, “petechial”,
“erythematous”, even “erythroderma”
Patient 2
• 51 y.o. Vietnamese female with one month
history of intensely itchy rash and blisters
• Also complains of blisters in the mouth
• Tactile fevers (no specific temp), horrible
pruritis and intermittent dysuria; remainder
of ROS unremarkable
• No significant past medical history or
medications
• Has been in US for at least five years
Patient 2: Clinical photographs
Patient 2: Laboratory values
Test
WBC
Hemoglobin
Hematocrit
Neutrophils
Eosinophils
Basophils
Reticulocyte (corr.)
Serum iron
TIBC
Transferrin satur.
Vitamin B12
Lab value
18,300 per uL
8.3 g/dL
27 %
8,970 per uL
4,940 per uL
180 per uL
1.2 %
9 ug/dL
213 ug/dL
4%
552 pg/mL
Reference range
(4,300-10,000)
(11.5-15.5)
(36-45%)
(1,800-7000)
(0-500)
(0-200)
--(55-155)
(270-400)
(15-50)
(224-1132)
- Urinalysis: 1+ WBCs, 1+ RBCs, positive leukocyte esterase
- Basic metabolic panel revealed BUN of 4, otherwise unremarkable
- LFTs showed albumin of 3.1 g/dL, otherwise unremarkable
- Blood cultures negative and viral FA and culture negative
- G6PD screen negative
Patient 2: Histopathology
Patient 2
• Started on prednisone 60 mg po qd and
dapsone 100 mg po qd
• After one week, added minocycline 100
mg po bid
• One week later, increased prednisone to
100 mg po qd, d/c’d dapsone and
minocycline, and started Cellcept 500 mg
po bid plus Keflex for superinfection
• One week later, increased Cellcept to 1
gm po bid
Malignancy and BP
• In 1990, over 600 pts described in 3 separate
reports; no association of BP with increased
cancer risk
• 1995 (Ogawa et al.) 1113 pts with BP in Japan
compared to 1987 gov’t figures (393 hosp.)
– 5.8% of pts had malignancy (M=6.6%, F=5.0%)
– BP association with malignancy was higher among
younger patients
– No difference in mucous involvement or annular
erythema; ? Lower rate of negative BMZ Ab’s
Age-group associations of BP and malignancy from Ogawa et al.
Age group
BP patients
General population*
45-54
9.2%
0.13%
55-64
5.7%
0.39%
65-69
5.9%
0.44%
70+
5.5%
0.61%
*rates for medical care for malignancy among Japanese in 1987
Malignancies seen with BP by Ogawa et al.
•
•
•
•
•
•
•
GI = 32/64
Urinary/genital = 10/64
Pulmonary = 7/64
Heme = 5/64
Breast = 6/64
Skin = 3/64
Sinus = 1/64
Patient 3
• 39 y.o. Hispanic male with one day history of
pruritic rash after release from incarceration
• Admitted to isolation for diagnosis of chickenpox
• ROS unremarkable; no current fevers but had
viral symptoms 2-3 weeks ago that resolved
• Patient purports a history of chickenpox as a
child at age 13, describing his illness in
convincing vivid detail
• PMH includes schizophrenia, stable on Seroquel
(has been on this drug for many months), and
an abdominal gunshot wound
• Unusual story about childhood hospitalization
lasting one month for workup of diarrhea;
discharged with no diagnosis
Patient 3: Clinical photographs
Patient 3: Laboratory findings
• Basic metabolic panel, LFTs, and CBC
unremarkable
• RPR and HIV negative
• No VZV DNA detected in serum by PCR
• Serologies consistent with past VZV
infection
• FA and viral culture negative for Herpes
group infection
• Anti-endomysial and anti-tissueTG
antibodies negative
Patient 3: Tzanck preparation
Patient 3: Histopathology
Patient 3
• Minimal response to topical triamcinolone
ointment
• Initiated on prednisone 40 mg po qd
• Did well on prednisone, added dapsone 100 mg
po qd
• Tapered prednisone
• Stopped dapsone secondary to difficulty with
refill
• Rash recurred during taper at prednisone 5 mg
• Restarted dapsone and slightly bumped
prednisone to 10 mg to re-taper
Eosinophilic folliculitis
• Rare inflammatory dermatosis of unclear
etiology
• Described by Ofuji in 1965
• Predominantly seen in adults; childhood
variant described as distinct entity
• Gender predominance unclear
• Most cases reported from Japan
Ofuji’s disease
HIV-associated
EPF
Infantile/neonatal
EPF
Adults with average age of 30
Adults with HIV and CD4 < 300
cells/mm3
Infants < 1 year old, M>F
Pruritis common
Pruritis common
Pruritis common
Follicular papules coalesce to form
figurate plaques
Follicular papules without figurate
lesions, looks like folliculitis
Follicular papules and pustules,
usually with erythematous base
and secondary crusting
Face, upper extremeties, trunk and
also non-follicular areas (fingers,
palms)
Face, scalp, upper trunk
Primarily scalp, but can be seen
on face and trunk, less often on
extremeties
Recurrent crops that involute over
1-2 weeks, relapse q 3-4 weeks
Chronic condition
Self-limiting condition, resolves
after cyclical 3 month to 5 year
course
- Other folliculitides
- ? Heme malignancies
- ? Parasitic infections
-Demodex folliculitis
-Drug-induced folliculitis
-Other common folliculitides
-Erythema toxicum neonatorum
-Transient neonatal pustular
melanosis
-Infantile acropustulosis
-LCH
The biology of eosinophils and
their role in skin disease
Andy J. Chien, M.D., Ph.D.
University of Washington
Division of Dermatology
(Photo from Nobel e-museum online)
Paul Ehrlich
(1854-1915)
• Born in Strehlan in 1854
• 1878 doctorate in
medicine – thesis on
staining of animal tissues,
differentiates mast cells
from plasma cells
• 1879 – defines and
names the eosinophil
• Establishes criteria based
on cell morphology,
physiology and pathology
to classify hematolgic
malignancies
(Photo from Nobel e-museum online)
Paul Ehrlich
(1854-1915)
• 1882 – washes aniline
dye with acidified alcohol
and becomes first to
visualize Koch’s bacillus
as “acid-fast bacilli”
• 1885 – uses stains to
recognize that different
tissues have different
oxygen demands
• 1886 – describes use of
methylene blue as a dye
for neural structures,
malaria parasites
(Photo from Nobel e-museum online)
Paul Ehrlich
(1854-1915)
• 1885 – “sidechain theory”
and lock-and-key
mechanism of antibody
recognition; bunnies
survive 5000-fold lethal
dose of toxin with slow,
increased exposures
• 1889 – contracts TB
• 1896 – heads institute to
standardize diptheria and
other anti-toxins
(Photo from Nobel e-museum online)
Paul Ehrlich
(1854-1915)
• 1901 – induces immunity
against transplanted
tumors in mice via
injections of tumor cells
• 1906 – prophesizes
chemical “magic bullets”
to target intracellular
parasites
• 1908 – wins Nobel prize
for theory of immunity
(Photo from Nobel e-museum online)
Paul Ehrlich
(1854-1915)
• 1910 – discovers antitreponemal effects of
arsenical compound
Salvarsan (arsphenamine
in the U.S.)
• 1915 – dies of stroke at
age 61
• 1945 – genus Ehrlichia
established to honor
Ehrlich’s work as a
microbiologist
(Photo from Nobel e-museum online)
Paul Ehrlich
(1854-1915)
• Pioneer in cell
staining
• Father of
hematology
• Pioneer in
microbiology
• Father of
immunology
• First successful
chemotherapy
Eosinophilia
•
•
•
•
•
P arasitic infection
A llergic response
N eoplasm
I diopathic hypereosinophilic syndrome
C onnective tissue disease
The eosinophil
• Life cycle consists of marrow, blood and
tissue phases
• Tissue:blood eosinophils ~100:1 (rat)
• Typically reside in tissues exposed to
external environment (lung and gut)
• Half-life of 8 to 18 hours in bloodstream
• Tissue life span estimated at 2-5 days, but
may be longer (in vitro up to 14 days with
cytokines)
The eosinophil
• In injected rats, 2 day delay before
detection of peripheral eosinophilia
• Maximum peripheral eosinophilia at 6-7
days
• Increased bone marrow eosinophils at 5
days
• Possible demargination may result in more
rapid response
Eosinophil structure
Eosinophil structure
Primary granule
• Charcot-Leyden crystal protein
• 7-10% of eosinophil protein
• Round with uniform electron
density
• A.k.a. lipophospholipase
• Found in eosinophilic
promyelocytes
• Also a major product of
basophils
• ? Protection from lytic
phospholipids
• ? Degradation of pulmonary
surfactant
Eosinophil structure
Small granule
• Aryl sulfatase B and acid
phosphatase
Eosinophil structure
Secondary granule
• Dense core surrounded by
less dense matrix
• Major basic protein (MBP)
located in the core
• Eosinophil cationic protein
(ECP), eosinophil peroxidase
(EPO), eosinophil-derived
neurotoxin (EDN) and betaglucuronidase in matrix
• Matrix:core protein ration
approximately 2:1
Major Basic Protein (MBP)
•
•
•
•
Produced as proMBP, cleaved with maturation
Cytotoxic, bactericidal and helminthotoxic
Disrupts lipid bilayers
Causes histamine release from basophils and
mast cells
• Activates neutrophils and platelets
• Neutralizes heparin effects on clotting
• Promotes bronchospasm
Eosinophil Cationic Protein
(ECP)
• Helminthotoxic, neurotoxic and
bactericidal
• Causes histamine release from mast cells
• Inhibits peripheral blood lymphs in vitro
• Neutralizes heparin effects on clotting
• Weak RNase activity
Eosinophil-Derived Neurotoxin
(EDN)
•
•
•
•
•
Severely damages myelinated neurons
Inhibits peripheral blood lymphs in vitro
Weak helminthotoxin
Potent RNase activity
60% sequence identity to ECP
Eosinophil Peroxidase (EPO)
• Distinct absorption spectra and heme
group from neutrophil myeloperoxidase
• In the presence of halide and H2O2, EPO
kills tumor cells and microorganisms
• Causes histamine release from mast cells
• Provokes bronchospasm
• Damages respiratory epithelium
Eosinophil cytokines
• IL-3
• IL-5
• GM-CSF
•
•
•
•
•
•
•
•
•
•
IL-1
IL-2
IL-4
IL-6
IL-8
IL-10
IL-16
TNFa
TGFa and b1
RANTES
IgE receptors
complement
receptors
IgA receptors
IgG receptors
LT receptors
C-C receptors
3. priming
and
activation
fibronectin,
laminin
E and P
selectin
ICAM/
VCAM
2. transmigration
1. “rolling”
and
adhesion
sialyl-diLewis X
CD11/CD18 (binds ICAM)
CD29/CD49 (binds VCAM)
Reference: Acta Anatomica, 134:341-345, 1989.
Eosinophils in skin disease
•
•
•
•
•
•
•
•
•
•
•
Atopic dermatitis
Bullous pemphigoid
Urticaria
Parasitic infection
Arthropod assaults
Wells’ syndrome/eosinophilic cellulitis
Eosinophilic fasciitis
Eosinophilic folliculitis
Angiolymphoid hyperplasia with eosinophilia
Incontinentia pigmenti
Id reactions
Atopic dermatitis
• Wassom et al. (JCI 1981):
– Atopic dermatitis subjects: >50% with elevated MBP
+/- increased eosinophils
• Leiferman et al. (NEJM 1985):
– MBP is deposited in the upper dermis with near
absence of eosinophils in atopic skin; normal skin
shows less extracellular MBP
• Ott et al. (J Allergy Clin Immunol 1994):
– Eosinophil granule proteins deposited in dermis with
few infiltrating cells seen
– 4/19 had serum eosinophilia; 10-15/19 had elevated
serum MBP, EDN, ECP
Atopic dermatitis
• Peripheral blood eosinophilia roughly correlates
with disease activity
– Pts with respiratory allergies more likely to have
eosinophilia
• Serum levels of ECP correlate with disease
activity (adults and children)
• Variable relationship between eosinophilia and
ECP levels
• TH2 activity associated with IL-5, leads to
eosinophil synthesis, activation, recruitment
Atopic dermatitis
• Wedi et al. (J Allergy Clin Immunol 1996):
– Blood eosinophils of pts with atopic derm
exhibit delayed apoptosis in vitro (ELISA, DNA
and flow cytometry)
– Increased autocrine production of IL-5, GMCSF
• Cheng et al. (J Allergy Clin Immunol
1997):
– 9/10 with increased extracellular MBP
– No normal eosinophils seen; all in various
stages of cytolysis (EM)
Atopic dermatitis
• Matsukura et al. (J Clin Lab Immunol
1996):
– Blood eosinophil apoptosis induced by
corticosteroids (dose-dependent) in AD pts
• Alam et al. (J Exp Med 1994):
– TGFb induces eosinophil apoptosis
• Wedi et al. (J Allergy Clin Immunol 1998):
– IL-4 induces apoptosis in eosinophils
(peripheral blood)
Bullous pemphigoid
• Insert histo slide here
Bullous pemphigoid
•
•
•
•
•
•
•
•
Autoantibodies to BP230 and BP180
Antibody binding
Complement activation
Mast cell degranulation
Neutrophil infiltration and activation
Increased MPO and ECP in blister fluid
Release of neutrophil proteolytic enzymes
Role of the eosinophil?
Bullous pemphigoid
• Borrego et al. (Am J Path 1996)
– In BP prior to blister formation (erythema, wheals)
extracellular granule protein deposition > eosinophil
number in dermis of involved skin
– Neutrophil protein depsition less prominent than
eosinophil protein deposition
– Protein deposition especially prominent near areas of
epidermal separation
– EM: eosinophils degranulate onto basal layer
– Blister fluid contains IL-3, IL-5 and GM-CSF (blocked
by Abs), enhances survival in vitro
– Neutrophil infiltration and degranulation variable
Bullous pemphigoid
• Stahle-Backdahl et al. (JCI 1994)
– Eosinophil-derived 92 kDa gelatinase (MMP9) is prominent in BP blister fluid
– In vitro, 92 kDa gelantinase cleaves the
extracellular domain of BP180
– Minimal gelatinase seen in suction-derived
blisters and therapy-derived blisters (cryo,
bleomycin)
Acknowledgments
• Dr. Zsolt “Hungarian
Idol” Argenyi
• Dr. Roy “Hot-legs”
Colven
• Dr. Phil “The ZenMaster” Kirby