syndrome has been reported. Furthermore, we did not observe any purpura or bleeding in the skin lesions. However, the thick corneal layer on the palm may mask the clinical presentation of purpura and bleeding. Thus, the rare clinical features and rare disease location may together lead to a unique presentation mimicking pompholyx in patients with Churg-Strauss syndrome and life-threatening systemic vasculitis. Disclosure. Financial support: none. Conflict of interest: none. Department of Dermatology, Hirosaki University Graduate School of Medicine 5 Zaifu-cho, Hirosaki, Aomori 036-8562, Japan
Kayo JIN Yasushi MATSUZAKI Ayumi KOREKAWA Akiko ROKUNOHE Takayuki AIZU Chihiro KINJYO Hajime NAKANO Daisuke SAWAMURA
1. Bosco L, Peroni A, Schena D, Colato C, Girolomoni G. Cutaneous manifestations of Churg-Strauss syndrome: report of two cases and review of the literature. Clin Rheumatol 2011; 30: 573-80. 2. Marzano AV, Vezzoli P, Berti E. Skin involvement in cutaneous and systemic vasculitis. Autoimmun Rev 2013; 12: 467-76. doi:10.1684/ejd.2014.2495
Treatment of a patient with neutrophilic dermatoses with granulocyte and monocyte adsorption apheresis: effects on serum cytokine levels Neutrophilic dermatoses are a group of skin disorders characterized by intense epidermal and/or dermal inflammatory infiltrates composed of neutrophils with no evidence of infection [1]. They are often associated with ulcerative colitis and Crohn’s disease [2, 3]. Granulocyte and monocyte adsorptive apheresis (GMA) is an extracorporeal circulation therapy that effectively removes activated granulocytes and monocytes from peripheral blood to correct imbalances in immunological regulatory mechanisms. GMA was initially approved for the treatment of ulcerative colitis. The effectiveness of GMA was also reported to be useful for treating various skin diseases [4-7], attributable mainly to activated neutrophils. A 61-year-old Japanese woman had a 30-year history of ulcerative colitis. In August 2011, erythematous tender nodules and papules were observed bilaterally on her lower legs. Edematous erythema with tiny papules was observed on her trunk (figure 1A). The biopsy specimen from her right shin showed a dense deposition of neutrophils in the lower dermis and subcutis, forming clusters of neutrophils, especially in the junction of septa and lobes (figure 1C). In contrast, the biopsy specimen from her trunk showed a confluent neutrophilic infiltration forming a subcorneal pustule (figure 1D). Each skin biopsy speciEJD, vol. 25, n◦ 2, March-April 2015
men provided a definitive diagnosis of erythema nodosum and subcorneal pustular dermatosis, respectively. The dense depositions of neutrophils were observed as one of the common histopathological findings. Although erythema nodosum is not regarded as a classic neutrophilic dermatosis [8], the cutaneous manifestations in the present case fit into the disease spectrum of neutrophilic dermatoses associated with ulcerative colitis. In March 2012, erythematous tender nodules on her right ankle joint had recurred (figure 1B) and tiny pustules had developed on her palm. In our patient’s case, the skin symptoms kept fluctuating between improvement and worsening, although her bowel symptoms were well controlled without recurring exacerbation. We could not taper the dose of prednisolone successfully (figure 1E). During the clinical course, pharyngotonsillitis triggered the exacerbation of skin symptoms. The additional immunosuppressive therapy had the potential to increase the risk of systemic infections. Therefore, intensive GMA using Adacolumns (JIMRO, Takasaki, Japan), two sessions per week, was given. A total of five sessions was performed as one course of this therapy, which immediately improved her skin symptoms. During her clinical course, five sessions of GMA treatment were performed twice. Her skin symptoms were controlled without a dose increase of prednisolone over the long term. In our patient’s case, the numbers of peripheral neutrophils were persistently high during her clinical course. We hypothesized that the activation and migration of neutrophils could be associated with the disease activity. We then analyzed the correlation between the clinical disease activity and the levels of 26 serum cytokines, i.e. eotaxin, granulocyte colony-stimulating factor (G-CSF), granulocyte macrophage colony-stimulating factor (GMCSF), interferon (IFN)-␣2, IFN-␥, interleukin (IL)-1␣, IL-1, IL-2, IL-3, IL-4, IL-5, IL-6, IL-7, IL-8, IL-10, IL-12 (p40), IL-12 (p70), IL-13, IL-15, IL-17A, IFN␥ inducible protein (IP)-10, macrophage chemoattractant protein (MCP)-1, macrophage inflammatory protein (MIP)1␣, MIP-1, tumor necrosis factor (TNF)-␣, TNF- by using a Human Cytokine/Chemokine 96-Well Plate Assay (Merck Millipore, Billerica, MA). The cytokine levels associated with the activation and migration of neutrophils, i.e., G-CSF, GM-CSF, TNF-␣, IL-6, IL-8, MIP-1␣ and MIP-1, fluctuated in parallel with the disease activity. To analyze the effect of the GMA treatment on these cytokine levels, we monitored them before and after the GMA treatment. We obtained serum samples from nine sessions of GMA before and after treatment. The serum levels of GM-CSF, IL-8, MIP-1␣ and MIP-1 were significantly decreased after GMA treatment compared to pre-treatment levels (figure 1F). It was notable that the serum levels of each cytokine were spontaneously increased after the first or second session of GMA treatment (figure 1G). Accordingly, symptomatic worsening was also observed, although the skin lesions cleared rapidly after five sessions of GMA treatment. Intensive GMA in patients with active ulcerative colitis was reported to be more efficacious than weekly treatment [9, 10]. Therefore, intensive GMA seems to be necessary especially for the initial session. These observations give us a possible explanation of the mechanisms by which GMA treatment improves the clinical symptoms of neutrophilic dermatoses associated with ulcerative colitis. Further investigations are needed to prove the effects of GMA on serum cytokines.
189
A
E
cation, Culture, Sports, Science and Technology. Conflict of interest: none.
Colchicine (0.5 mg) Mesalazine (4000 mg)
GMA
Prednisolone 15 5 (mg)
20
8
8
4
5
GMA 3
5
1
Skin lesions 200
B
pg/ml G-CSF GM-CSF TNF-α IL-6
150 100 50 0 5000
pg/ml
IL-8 MIP-1α MIP-1β
2500
C
0 10
mg/dl CRP
5 0 20000
/μl WBC Neut
15000
D
10000
5000 0 2012/03/08
F pg/ml
2012/06/08
2012/09/08
G
GM-CSF
G-CSF 200
150
150
100
100
2013/03/08
pg/ml
P < 0.05
200
G-CSF GM-CSF
150
IL-6 TNF-α
100 50
50
0
0 Before
P = 0.0799
200 150 100 50 0 Before
After
TNF-α
0 Before After Before After Before After Before AfterBefore After 7 days 1st 2nd 3rd 4th 5th later
pg/ml
45 40 35 30 25 20 15 10 5 0
pg/ml
4500 4000 3500 3000 2500 2000 1500 1000 500 0
P = 0.1005
Before
IL-8 P < 0.05
GM-CSF IL-6
After
TNF-α pg/ml
250
G-CSF
50 Before
After
IL-6
pg/ml
After
MIP-1α
2500
P < 0.05
pg/ml
4500 4000 3500 3000 2500 2000 1500 1000 500 0
IL-8 MIP-1α MIP-1β IL-8 MIP-1α MIP-1β
Before After Before After Before After Before AfterBefore After 7 days 1st 2nd 3rd 4th 5th later
2000 1500 1000 500 0 Before
After
Before
After
MIP-1β pg/ml 1000
P < 0.05
750 500 250 0 Before
After
Figure 1. A) Coalescent papules on erythema were observed on the trunk of the patient, a 61-year-old Japanese woman. B) Pharyngotonsillitis triggered the recurring exacerbation of erythematous tender nodules on her right ankle joint. C) Histopathological findings from the erythematous lesion on her right shin revealed the formation of nodules with neutrophil infiltration in the lower dermis and subcutis (HE, ×200). D) Histopathological findings from the erythematous papule on her trunk revealed the subcorneal pustule formation with neutrophil infiltration (HE, ×200). E) The numbers of peripheral neutrophils and the levels of each cytokine associated with the activation and migration of neutrophils, including G-CSF, GM-CSF, TNF-␣, IL-6, IL-8, MIP-1␣ and MIP-1, were persistently high during the clinical course. The levels of CRP fluctuated in parallel with the disease activity. These laboratory values were increased when the symptomatic worsening was observed. F) The levels of GM-CSF, IL-8, MIP-1␣ and MIP-1 were significantly decreased after GMA treatment compared to pre-treatment levels (n = 9). Cytokine levels are expressed as the median (25th-75th percentiles). The interquartile range is shown by the box plots, with the median levels indicated by the line inside the box. The statistical comparison of the levels of cytokines before and after GMA treatment was done by the paired t-test. P values
Kayo JIN Yasushi MATSUZAKI Ayumi KOREKAWA Akiko ROKUNOHE Takayuki AIZU Chihiro KINJYO Hajime NAKANO Daisuke SAWAMURA
1. Bosco L, Peroni A, Schena D, Colato C, Girolomoni G. Cutaneous manifestations of Churg-Strauss syndrome: report of two cases and review of the literature. Clin Rheumatol 2011; 30: 573-80. 2. Marzano AV, Vezzoli P, Berti E. Skin involvement in cutaneous and systemic vasculitis. Autoimmun Rev 2013; 12: 467-76. doi:10.1684/ejd.2014.2495
Treatment of a patient with neutrophilic dermatoses with granulocyte and monocyte adsorption apheresis: effects on serum cytokine levels Neutrophilic dermatoses are a group of skin disorders characterized by intense epidermal and/or dermal inflammatory infiltrates composed of neutrophils with no evidence of infection [1]. They are often associated with ulcerative colitis and Crohn’s disease [2, 3]. Granulocyte and monocyte adsorptive apheresis (GMA) is an extracorporeal circulation therapy that effectively removes activated granulocytes and monocytes from peripheral blood to correct imbalances in immunological regulatory mechanisms. GMA was initially approved for the treatment of ulcerative colitis. The effectiveness of GMA was also reported to be useful for treating various skin diseases [4-7], attributable mainly to activated neutrophils. A 61-year-old Japanese woman had a 30-year history of ulcerative colitis. In August 2011, erythematous tender nodules and papules were observed bilaterally on her lower legs. Edematous erythema with tiny papules was observed on her trunk (figure 1A). The biopsy specimen from her right shin showed a dense deposition of neutrophils in the lower dermis and subcutis, forming clusters of neutrophils, especially in the junction of septa and lobes (figure 1C). In contrast, the biopsy specimen from her trunk showed a confluent neutrophilic infiltration forming a subcorneal pustule (figure 1D). Each skin biopsy speciEJD, vol. 25, n◦ 2, March-April 2015
men provided a definitive diagnosis of erythema nodosum and subcorneal pustular dermatosis, respectively. The dense depositions of neutrophils were observed as one of the common histopathological findings. Although erythema nodosum is not regarded as a classic neutrophilic dermatosis [8], the cutaneous manifestations in the present case fit into the disease spectrum of neutrophilic dermatoses associated with ulcerative colitis. In March 2012, erythematous tender nodules on her right ankle joint had recurred (figure 1B) and tiny pustules had developed on her palm. In our patient’s case, the skin symptoms kept fluctuating between improvement and worsening, although her bowel symptoms were well controlled without recurring exacerbation. We could not taper the dose of prednisolone successfully (figure 1E). During the clinical course, pharyngotonsillitis triggered the exacerbation of skin symptoms. The additional immunosuppressive therapy had the potential to increase the risk of systemic infections. Therefore, intensive GMA using Adacolumns (JIMRO, Takasaki, Japan), two sessions per week, was given. A total of five sessions was performed as one course of this therapy, which immediately improved her skin symptoms. During her clinical course, five sessions of GMA treatment were performed twice. Her skin symptoms were controlled without a dose increase of prednisolone over the long term. In our patient’s case, the numbers of peripheral neutrophils were persistently high during her clinical course. We hypothesized that the activation and migration of neutrophils could be associated with the disease activity. We then analyzed the correlation between the clinical disease activity and the levels of 26 serum cytokines, i.e. eotaxin, granulocyte colony-stimulating factor (G-CSF), granulocyte macrophage colony-stimulating factor (GMCSF), interferon (IFN)-␣2, IFN-␥, interleukin (IL)-1␣, IL-1, IL-2, IL-3, IL-4, IL-5, IL-6, IL-7, IL-8, IL-10, IL-12 (p40), IL-12 (p70), IL-13, IL-15, IL-17A, IFN␥ inducible protein (IP)-10, macrophage chemoattractant protein (MCP)-1, macrophage inflammatory protein (MIP)1␣, MIP-1, tumor necrosis factor (TNF)-␣, TNF- by using a Human Cytokine/Chemokine 96-Well Plate Assay (Merck Millipore, Billerica, MA). The cytokine levels associated with the activation and migration of neutrophils, i.e., G-CSF, GM-CSF, TNF-␣, IL-6, IL-8, MIP-1␣ and MIP-1, fluctuated in parallel with the disease activity. To analyze the effect of the GMA treatment on these cytokine levels, we monitored them before and after the GMA treatment. We obtained serum samples from nine sessions of GMA before and after treatment. The serum levels of GM-CSF, IL-8, MIP-1␣ and MIP-1 were significantly decreased after GMA treatment compared to pre-treatment levels (figure 1F). It was notable that the serum levels of each cytokine were spontaneously increased after the first or second session of GMA treatment (figure 1G). Accordingly, symptomatic worsening was also observed, although the skin lesions cleared rapidly after five sessions of GMA treatment. Intensive GMA in patients with active ulcerative colitis was reported to be more efficacious than weekly treatment [9, 10]. Therefore, intensive GMA seems to be necessary especially for the initial session. These observations give us a possible explanation of the mechanisms by which GMA treatment improves the clinical symptoms of neutrophilic dermatoses associated with ulcerative colitis. Further investigations are needed to prove the effects of GMA on serum cytokines.
189
A
E
cation, Culture, Sports, Science and Technology. Conflict of interest: none.
Colchicine (0.5 mg) Mesalazine (4000 mg)
GMA
Prednisolone 15 5 (mg)
20
8
8
4
5
GMA 3
5
1
Skin lesions 200
B
pg/ml G-CSF GM-CSF TNF-α IL-6
150 100 50 0 5000
pg/ml
IL-8 MIP-1α MIP-1β
2500
C
0 10
mg/dl CRP
5 0 20000
/μl WBC Neut
15000
D
10000
5000 0 2012/03/08
F pg/ml
2012/06/08
2012/09/08
G
GM-CSF
G-CSF 200
150
150
100
100
2013/03/08
pg/ml
P < 0.05
200
G-CSF GM-CSF
150
IL-6 TNF-α
100 50
50
0
0 Before
P = 0.0799
200 150 100 50 0 Before
After
TNF-α
0 Before After Before After Before After Before AfterBefore After 7 days 1st 2nd 3rd 4th 5th later
pg/ml
45 40 35 30 25 20 15 10 5 0
pg/ml
4500 4000 3500 3000 2500 2000 1500 1000 500 0
P = 0.1005
Before
IL-8 P < 0.05
GM-CSF IL-6
After
TNF-α pg/ml
250
G-CSF
50 Before
After
IL-6
pg/ml
After
MIP-1α
2500
P < 0.05
pg/ml
4500 4000 3500 3000 2500 2000 1500 1000 500 0
IL-8 MIP-1α MIP-1β IL-8 MIP-1α MIP-1β
Before After Before After Before After Before AfterBefore After 7 days 1st 2nd 3rd 4th 5th later
2000 1500 1000 500 0 Before
After
Before
After
MIP-1β pg/ml 1000
P < 0.05
750 500 250 0 Before
After
Figure 1. A) Coalescent papules on erythema were observed on the trunk of the patient, a 61-year-old Japanese woman. B) Pharyngotonsillitis triggered the recurring exacerbation of erythematous tender nodules on her right ankle joint. C) Histopathological findings from the erythematous lesion on her right shin revealed the formation of nodules with neutrophil infiltration in the lower dermis and subcutis (HE, ×200). D) Histopathological findings from the erythematous papule on her trunk revealed the subcorneal pustule formation with neutrophil infiltration (HE, ×200). E) The numbers of peripheral neutrophils and the levels of each cytokine associated with the activation and migration of neutrophils, including G-CSF, GM-CSF, TNF-␣, IL-6, IL-8, MIP-1␣ and MIP-1, were persistently high during the clinical course. The levels of CRP fluctuated in parallel with the disease activity. These laboratory values were increased when the symptomatic worsening was observed. F) The levels of GM-CSF, IL-8, MIP-1␣ and MIP-1 were significantly decreased after GMA treatment compared to pre-treatment levels (n = 9). Cytokine levels are expressed as the median (25th-75th percentiles). The interquartile range is shown by the box plots, with the median levels indicated by the line inside the box. The statistical comparison of the levels of cytokines before and after GMA treatment was done by the paired t-test. P values
