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Ataxia telangiectasia (AT) is a complex syndrome with nervous system, ocular, cutaneous, and visceral manifestations. It is an autosomal recessive disorder associated with mutations in the ataxia telangiectasia mutated (ATM) gene on chromosome 11. Its prevalence is estimated at 1 per 80,000 live births. The disease begins during infancy or early childhood with slowly progressive cerebellar ataxia. Nystagmus and gaze apraxia are characteristic ocular signs. Patients who survive beyond adolescence develop dysar-thric speech, choreoathetosis, weakness, muscle wasting, and an impaired vibratory sense. Characteristic somatic features include conjunctival and cutaneous telangiectasia, retarded growth or dwarfism, progenic changes of the hair and skin (premature aging), and delayed development of sex characteristics. Defective immune mechanism, sinopulmonary infection, and a tendency to malignancy, mostly lymphomas or leukemias, complete the syndrome. Serum levels of a-fetoprotein and...
The genetic basis of CLL is largely unknown. Probably for technical reasons, cytogenetic abnormalities appear to be less frequent in CLL than in many other hematological malignancies although the use of techniques such as in situ hybridization, comparative genomic hybridization, and others has significantly increased the proportion of cases with cytogenetic abnormalities (16). A number of chromosome breakage syndromes have been known for many years to be associated with an increased risk of leukemia (17) including the recessive disease ataxia telangiectasia (AT). AT maps to chromosome 11q23 (18). AT patients have an increased risk of lymphomas and leukemias, and AT heterozygotes may have a significantly increased risk of breast cancer (19,20). CLL has also been reported in AT families (21), suggesting that AT heterozygotes may be at an increased risk. In a retrospective study of the cancer incidence in 110 AT families, the risk of hematological and lymphoid malignancies was increased...
Ataxia-telangiectasis occurs in individuals who completely lack functional ataxia-telangiectasia mutated (ATM) protein. Originally known as Louis-Bar syndrome (2), this autosomal recessive disorder occurs worldwide, with an prevalence of 1 40,000-1 100,000 in outbred populations (reviewed in Ref. 3). The pleiotropic clinical phenotype of individuals with AT is summarized below. In addition to an increased susceptibility to malignancy and occasional insulin-resistant diabetes (21), AT homozygotes also show multiple dermatological changes associated with premature aging. Telangiectasias usually appear on the sclera, face, and antecubital popliteal fossae by 6-7 years of age (6). In the second and third decades of life, AT homozygotes develop additional cutaneous changes, including graying of the hair, senile keratoses, skin atrophy, and areas of hyper-pigmentation and hypopigmentation (4).
Sometimes the eye becomes red because of inflammation of the connective tissue underlying the conjunctiva, that is, the episclera. The condition can be localised or diffuse. There is no discharge and the eye is uncomfortable, although not usually painful. The condition responds to sodium salicylate given systemically and to the administration of local steroids or nonsteroidal anti-inflammatory agents. The underlying cause is often never discovered, although there is a well-recognised link with the collagen and dermatological diseases,especially acne rosacea. Episcleritis tends to recur and might persist for several weeks, producing a worrying cosmetic blemish in a young person (Figure 7.1). Figure 7.1. Episcleritis (with acknowledgement to Professor H.Dua).EB Figure 7.1. Episcleritis (with acknowledgement to Professor H.Dua).EB
Double-strand breaks (DSBs) result from exposure to ionizing radiation, x-rays, from enzymatic cleavage, or during replication of a single-strand break. DSBs are especially problematic because of the absence of a normal strand to serve as a template. Arrest of the cell cycle to facilitate repair of the DSB is mediated by p53. DNA damage-response proteins, including ataxia-telangiectasia mutated (ATM) and ataxia-telangiectasia related (ATR), are recruited. There are two logically alternate pathways for double-strand break repair, homologous recombination or nonhomologous end joining, which are reviewed elsewhere (16,17).
In a study using FISH, a critical region was identified around the neural cell adhesion molecule (NCAM) gene in band 11q23.1 in 15 hematological tumors (51). In another study, the extent of 11q deletions among 40 B-CLL cases was determined using a FISH probe set of overlapping yeast artificial chromosome (YAC) clones spanning bands 11q14-q24 (52,53). All aberrations affected a minimal consensus region of 2-3 Mb in size in bands 11q22.3-q23.1. In the minimal deleted region, the ataxia telangiectasia mutated (ATM) gene was localized, which, owing to its role in DNA repair and the frequent observation of lymphomas in ATM knockout mice, appeared to be a candidate tumor suppressor gene (54,55). In fact, the changes in both ATM alleles by deletion and or mutation in the sense of the two-hit hypothesis of tumor suppressor gene inactivation could
Skin cancer, lymphoma, sarcoma, and hepatic cancers also occur at higher frequency in persons with inherited conditions such as neurofibromatosis, ataxia telangiectasia, Li-Fraumeni syndrome, xeroderma pigmentosa, Fanconi pancytopenia, hereditary dys-plastic nevus syndrome, nevoid basal cell carcinoma syndrome, multiple endocrine neoplasia syndromes, and Turner syndrome. In the aggregate, however, the cancers that are known to be due to these conditions account thus far for only a small proportion of the can
In addition, IL-17 controls neutrophil chemotaxis, proliferation and maturation further fueling innate immune activation (Kolls and Linden 2004). Moreover, IL-17 producing CD8+ and CD4+ T cells have recently been reported to be widely present in human and mouse tumor microenvironments (Kryczek et al. 2007). The importance of IL-17 itself in the control of tumor growth however, is still debated and depends on the experimental setting (Kryczek et al. 2009b Wang et al. 2009). In this context, it is noteworthy that IL-23 can induce, independent of IL-17, angiogenic erythema, inflammation and keratino-cyte hyperproliferation and phenocopying aspects of human psoriatic lesions (Chan et al. 2006). Similarly, experimental encephalitis depends on IL-23 expression in the host (Cua et al. 2003) but IL17 or IL17F or both are dispensable (Haak et al. 2009).
The protein (ATM) that is mutated in ataxia-telangiectasia (AT), a rare autosomal recessive disorder, functions in cell cycle control, telomeric maintenance, chromatin structure, and matrix association. Cells from individuals with AT have shortened telomeres (59), show aberrant telomeric clustering during mitotic metaphase (60-64), contain extrachromosomal telomeric fragments of 5-25 kb (65), and arrest in meiotic prophase (66-68). ATM, a PI3 kinase family member, shows homology to Tel1, which is involved in yeast telomeric maintenance (69). In cells from patients with AT, the telomere matrix associations formed during meiosis are not properly released resulting in cell cycle arrest possibly due to an increased telomeric DNA matrix association (70,71). These associations are dispersed by the introduction of a wild-type ATM gene into the AT cells, supporting a direct role of the ATM protein in the telomere matrix structure (71).
As was noted above, there are a number of inherited cancer susceptibility gene mutations, such as xeroderma pigmentosum, Fanconi's anemia, and ataxia telangiectasia. These types of inherited defects that lead to cancer are generally caused by a deficiency in DNA repair pathways. Almost certainly we have only scratched the surface of inherited cancer susceptibility genes that make an individual more prone to developing cancer. Other susceptibility genes may include alterations in the metabolic enzymes that metabolize drugs and environmental toxins, polymorphisms in genes that regulate utilization of certain essential nutrients such as folic acid, or inherited mutations in tumor suppressor genes.
Studies in mammalian cells on the phosphorylation of the p53 tumor suppressor by Atm and Atr have indicated that these kinases respond to different types of damage. For example, the phosphorylation of p53 on serine 15 in response to ionizing radiation is significantly, but not completely, reduced in cells lacking Atm, whereas there is no defect in the phosphorylation of p53 on serine 15 in response to ultraviolet radiation (75-77). Inactivation of Atr using a dominant negative version of the protein severely reduced p53 phosphorylation in response to ultraviolet radiation, and the initial phosphorylation of p53 was normal when cells were exposed to ionizing radiation (78,79). This suggests that Atr primarily mediates the response to ultraviolet radiation and Atm mediates the response to ionizing radiation. Although p53 was phosphorylated in response to ionizing radiation in cells expressing the dominant-negative Atr, this phosphorylation was lost much faster than in parental cells...
Another argument in favor of a genetic influence on aging is the occurrence of premature aging in the so-called chromosomal instability syndromes. These represent a group of inherited diseases (e.g., xeroderma pigmentosa, ataxia-telangiectasia, and Bloom syndrome). Based on a higher rate of chromosomal instability than that found in the normal population, patients affected by these diseases exhibit signs resembling aging and an increased susceptibility to cancer (104-107).
The prenatal evaluation and diagnosis of parvovirus B19 infection in the mother is not difficult, but determination of infection in the fetus may be complicated. Universal screening for parvovirus B19 is not recommended because of the low risk of maternal infection and low risk of adverse outcome to the fetus (33). Screening is recommended for pregnant women exposed to individuals with erythema infectiosum, in an aplastic crisis, and in an outbreak (because of a high attack rate in some situations) (26- Erythema infectiosum (fifth disease) Arthropathy
Including CTCL, and is one of our preferred treatment options in early stage MF.29 It is extremely effective at clearing patch and plaque disease however, the impact of maintenance therapy remains uncertain. Several studies confirm high remission rates in early stages of MF, with reported complete remissions in up to 71.4 of patients.29-32 Long-term remissions have been reported for PUVA. We evaluated follow-up data of 66 patients with early stage disease who achieved CR after PUVA monotherapy, and showed that 50 of the patients maintained CR with a median of 84 months, and 50 of the patients relapsed with a median disease-free interval of 39 months. Median follow-up time was 94 months.32 Reported short-term side effects were most commonly nausea and erythema. About 30 of patients developed skin malignancies, such as squa-mous or basal cell carcinoma.
Recently published data of the therapeutic efficacy of total skin electron beam therapy (TSEB) from centers with extensive experience showed 40-98 complete remission rates among patients with stage IA and MF IB, with approximately 50 of patients with clinical stage IA and 25 of patients with clinical stage IB remaining in long-term remission.38 TSEB treatment in early stages remains controversial because of its potential toxicity. Side effects can be significant, and consist of erythema, edema, scaling, ulceration, and irreversible loss of skin adnexa. TSEB may be repeated for palliative effects, although at reduced doses. Adjuvant therapy including PUVA, photopheresis, and INF-a may improve the duration of response.
Inflammatory carcinoma of the breast (IBC) is a unique syndrome characterized by extensive erythema of the breast, dermal lymphatic invasion, and an aggressive clinical course. There is a high likelihood of distant metastatic deposits, even though routine staging procedures are often negative at presentation. The multimodality therapy of inflammatory breast carcinoma thus emphasizes early aggressive systemic therapy. As is the case with noninflammatory LABC, the response to primary chemotherapy provides prognostic information. For example, investigators at M.D. Anderson reported a 10-yr DFS of 48 , 28 , and 10 for those with a CR, PR, and less than PR, respectively, in patients with inflammatory breast cancer treated with anthracyline-based therapy followed by surgery and or radiation (37). Maloisel et al. reported response to primary chemotherapy to be the most significant prognostic factor determining DFS (38).
The diagnosis of AT in index cases is typically delayed until telangiectasias appear at 6 or 7 years of age (6). However, the absence of telangiectasias, immune deficits, and or elevated serum AFP do not rule out AT as a diagnosis for the toddler or young child with slowly progressive ataxia. The size of the ATM gene and the large number and even distribution of mutations along the ATM gene make molecular diagnosis difficult (see Fig. 3). As a result, sequential evaluation of children suspected of having AT is recommended, beginning with a clinical assessment of neurologic and immunologic deficits accompanied by serum AFP determination and karyotype. Further investigations include protein truncation testing and Western blot analyses of ATM protein, measurement of ATM kinase activity, colony-survival assays using lymphocytes and SSCP analysis of the ATM gene. This combined approach is thought to yield a false-negative rate of
We have developed a human allogeneic, GM-CSF-secreting breast tumor vaccine for clinical administration 67 . The vaccine itself is composed of two cell lines, SKBR3 and T47D, both of which have been genetically modified to secrete human GM-CSF by plasmid DNA transfection. The vaccine is designed to account for the majority of breast cancers that are seen clinically, with T47D representing ER-positive and HER2 neu -negative breast cancers, and SKBR3 representing ER-negative and HER2 neu-positive breast cancers. We are currently accruing to two clinical trials that are testing a fixed dose of 5 x 108 cells of this GM-CSF-secreting breast tumor vaccine in sequence with standard breast cancer therapeutics in patients with metastatic breast cancer. The first study tests this fixed dose of vaccine in sequence with a range of doses of CY (250-450 mg m2) and DOX (15-35 mg m2) given 1 day prior to and 7 days after vaccination, respectively, in patients with stable metastatic breast cancer 71 ....
Venom Myotoxic heat-labile, high-MW proteins injected through sharp spines on dorsal pectoral, and anal fins. Antidote Contact major aquariums. Diagnosis Intensifying local pain, erythema, ecchymoses, induration, hyperesthesia dyses-thesia, nausea, vomiting, dyspnea, diaphoresis, later lymphadenopathy, syncope, hypotension, dysrhythmias.
Following the induction of DSBs by IR, replicating cells are transiently arrested in cell cycle progression upon reaching cell cycle checkpoints in the G1, S, or G2 phase. It is widely believed that the transient cell cycle arrest serves to repair the DSBs prior to replication of damaged DNA templates and mitosis. Thus, cell cycle checkpoints may play crucial roles in determining the fate of damaged cells, as is exemplified in certain yeast mutants (36). In accordance with this hypothesis, cell cycle checkpoint deficiencies in G1, S, and G2 have been demonstrated conclusively in radiosensitive AT cells. The G1 arrest following IR is mainly dependent on the ataxia-telangiectasia mutated (ATM) p53 pathway (37). Upon IR, p53 is phosphorylated by the kinase activity of ATM and thus stabilized in the G1 phase. Accumulation of the p53 protein, in turn, induces p21 transcription and subsequent G1 arrest. Several studies have shown that, similar to AT cells, NBS cells exhibit delayed and...
Whittled away after each DNA replication cycle. This occurs especially in tissues lacking telomerase. Although most normal differentiated tissues consisting of quiescent cells do not express telomerase, telomerase is expressed at low levels in rapidly dividing tissues such as in the blood, skin, and epithelia of the gastrointestinal tract (59,60). Despite this, there is in vivo and in vitro evidence of progressive telomeric attrition with age (61). Telomeric shortening can therefore be used as an indicator of aging, and accelerated telomeric shortening has indeed been used as a marker of premature aging. Accelerated erosion of the telomeres is associated with a number of monogenic disorders such as the two bone marrow failure syndromes, Fanconi anemia (62) and aplastic anaemia (61), and the chromosomal instability disorder, ataxia-telangiectasia (63). Two independent studies have now shown that the presence of abnormally short tracts of telomeres is also a feature of DKC (55,64). In...
In part 2 it is mid-April, and Rabbit and Janice return to springtime Brewer. While Janice looks for a job, Rabbit reflects on his dismal past, visiting his ill lover, Thelma, whose disease, systemic lupus erythema-tosus, has depleted her family's income and spirit. Rabbit learns from her that Nelson is a cocaine addict, causing Rabbit additional worry about AIDS. He visits Springer Motors, discovering Nelson has taken down his old basketball star photos, has hired a woman, and that the homosexual AIDS-inflicted bookkeeper refuses to show him the books. Janice takes Penn State extension real estate courses, while Rabbit frets about Nelson. They talk about Nelson's drug addiction and bleeding the company then receive threatening calls from his unpaid drug dealers. They are guilt-ridden for raising Nelson to be so troubled. Rabbit asks his friend Charlie Stavros for advice, and they discuss Brewer's drug problem at large. Late one evening after the drugged-up Nelson attacks Pru, she...
An issue that has been hotly debated in the literature is whether FA cells are sensitive toward ionizing radiation (reviewed recently in Ref. 75). Within the context of the conditioning regimen for bone marrow transplantation, there has been a longstanding clinical impression of increased radiosensitivity of patients with FA who also seem to tolerate cyclophosphamide less well than patients who do not have FA. However, in vitro studies with FA cells have yielded conflicting results. An unpublished study from our laboratory shows that FA fibroblasts of all known complementation groups respond to increasing x-ray doses in the same way as control cells (Fig. 2). Moreover, when fibroblasts from patients with ataxia-telangiectasia (which are known to be highly radiosensitive) are taken as positive controls, studies from our laboratory provide no evidence for increased radiosensitivity of FA fibroblasts under in vitro conditions. A surprising result has been obtained when primary...
Safety issues involving the anti-TNF agents as a class include the risk of injection site reactions or infusion-related reactions. These are usually mild, however, and most often easily managed. For example, in the case of the self-administered subcutaneous delivery of etanercept, injection site reactions were reported in 37 of etanercept-treated patients vs. 10 of controls in placebo-controlled trials. These reactions are generally mild to moderate, occur sporadically in a minority of injections over time, and do not necessitate the discontinuation of the agent. Similarly, in the case of adalimu-mab, which is also given by self-administered subcutaneous injection, injection site reactions are the most commonly reported adverse event, occurring in 19.5 of treated patients vs. 11.6 of controls. Reactions may take the form of erythema, itching, haemorrhage, pain, or swelling at the injection site, although such events very rarely merit the discontinuation of the therapy. In the case of...
Clinical picture consists of cutaneous changes. Doses above 2-3 Gy may present with erythema, itching. Occurs within hours. Faster occurrence signifies higher doses. Other changes include epilation, desquamation, and necrosis. Appear similar to thermal burns, but unlike thermal burns erythema may reappear, delayed onset of pain, and more chronic, severe pain. Exception High dose radiation may give 3rd degree transdermal burn, pain immediate and excruciating. Surgical resection and grafting may be required.
There is an increasing clinical use and reliance on anti-TNF-a agents for the treatment of steroid refractory, or fistulating CD. The effectiveness of these agents in severe CD has revolutionized the treatment of this patient group, despite their cost and notable side effects. For the induction and maintenance of remission infliximab is given as an intravenous infusion. It is a chimeric mouse human immunoglobulin G1 (IgG1) anti-TNF-a antibody with high levels of immunogenicity, which is both a cause of erythema and reactions during infusion, and reduces the pharmacokinetic half-life, increasing the risk of systemic infections. While other anti-TNF-a approaches are in clinical development (Onercept, CDP-870, ISIS 104838, etc.), none is likely to avoid the core issue relating to increased risks of opportunistic infection and malignancy. Additionally, approximately 30 of CD patients will not respond to infliximab and currently the agent has not been approved for use in patients with UC,...
The clinical picture of the MZL is characterized by erythematous macules, papules, plaques or nodes, mainly located on the trunk and upper extremities. The histology of MZL shows a nodular to diffuse infiltrate, which is located in the dermis and subcutaneous fat and contains the small- to medium-sized marginal zone cells. Immunohistochemical stainings demonstrate expression of the B-cell marker CD20 and the anti-apoptotic protein bcl-2 on tumour cells. A clonally rearranged immunoglobulin heavy chain can be detected by PCR in most cases. The FCL is characterized by neoplastic proliferation of centrocytes and centroblasts. Patients present with bluish-reddish or reddish-brownish solitary or multiple nodes surrounded by papules and plaques or annular erythemas, primarily localized on head and back. Histologically the lesions are caused by a follicular infiltrate with germinal centres or by a diffuse infiltrate in the dermis and subcutis. In the immunohistochem-istry the cells stain...
Currently two substances, namely depsipeptide (FR901228) and suberoylanilide hydroxamic acid (SAHA), from the group of HDACIs are being investigated for the treatment of CTCL. Depsipeptide has been given to three patients with CTCL refractory to previous topical or systemic therapies (7). The drug was administered intravenously on days 1 and 5 of a 21-day cycle. Improvement of skin erythema and oedema was reported for two patients with Sezary syndrome and nearly complete remission for a patient with tumour stage CTCL. Development of multiple subcutaneous abscesses in one patient was reported as an adverse event. Because of these promising results, a phase II trial was initiated.
Other side effects, including bone marrow necrosis, hypercalcemia (63), erythema nodosum (64), marked basophilia, severe myositis (65), Sweet syndrome (66), Fournier's gangrene (necrotizing fasciitis of the penis and scrotum) (67), thrombocytosis (68), and necrotizing vasculitis, have rarely been reported with ATRA treatment.
ADA, adenosine deaminase AK2, adenylate kinase 2 ATM, ataxia-telangiectasia mutated CRAC, calcium release activated channel DNA-PKcs, DNA-dependent protein kinase catalytic subunit LIG4, DNA ligase 4 MRE11, meiotic recombination homologue 11 NBS1, Nijmegen breakpoint syndrome 1 PNP, purine nucleoside phosphorylase.
AID and UNG mutations affect class switch recombination and somatic hypermutation in distinct ways. In the absence of AID, both switching and hypermutation are defective because AID is absolutely required for both processes. In the absence of UNG, isotype switching is defective but somatic hypermutation is largely preserved, although it exhibits less A T mutations without the activity of UNG. The role of DNA repair gene mutations in class switching defects will be considered in the section on ataxia-telangiectasia later in this chapter.
Teratoid rhabdoid tumors, although both of these associations occur almost exclusively in early childhood and are therefore not applicable to the age-focus of this chapter 76-79 . Finally, there are reported medulloblastomas presenting in patients with ataxia-telangiectasia, a syndrome that is characterized by cer-ebellar degeneration and DNA repair defect and is associated with an increasing number of specific gene mutations within the AT gene complex, making the patient particularly vulnerable to the toxic consequences of radiotherapy 80-93 .
The most common injuries found are erythema, abrasions, and bruising, particularly to the radial and ulna borders of the wrist (2). The erythema is often linear and orientated circumferentially around the wrist following the line of the handcuffs, reflecting direct pressure from the edge of the cuffs. Bruising is commonly seen on the radial and ulna borders, with tender swelling often associated with abrasions or superficial linear lacerations from the edge of the cuff. Abrasions reflect relative movement between the cuff and skin surface. However, it is not possible to determine whether this movement is from the cuff moving over the wrist or the wrist moving within the cuff, because either can produce the same skin abrasions. All of these soft tissue injuries will resolve uneventfully during the course of several days, and only symptomatic treatment with simple analgesia and possibly a cold compress is required. Although rare, it is possible to have wrist fractures from restraint...
Fig. 5.1 Omega-3 fatty acids and psoriasis. 28 subjects with stable chronic psoriasis were given 1.8 g omega-3 fatty acids or placebo for 12 weeks. In the treatment group, itching, scaling, and erythema were all significantly reduced at 8 and 12 weeks compared with placebo. The percentage of surface area affected was also decreased by treatment with omega-3 fats (7 vs. 12 , treatment vs. control) (Adapted from Bittiner SB, et al. Lancet. 1988 1 378)
Not all interactions of chemicals and irradiation with DNA produce mutations. In fact, all cells have efficient repair mechanisms that repair such lesions. DNA repair mechanisms include sets of enzymes that survey DNA for specific kinds of damage, remove the altered portion ofDNA, and then restore the correct nucleotide sequence. The important role of DNA repair in human cancer has been established by the finding that a number of inherited defects in DNA repair systems predispose individuals to getting cancer. These diseases include xeroderma pigmentosum, ataxia telangiectasia, Fanconi's anemia, Bloom's syndrome, Cokayne's syndrome, and hereditary retinoblastoma.125
The vesicular rash that occurs with HSV infection may be confused with the cutaneous manifestations of other infectious diseases, such as varicella-zoster virus infection, postnatally acquired enteroviral disease, and disseminated cytomegalovirus infection. Such distinctions are especially difficult when HSV assumes an atypical cutaneous presentation. Definitive confirmation of HSV disease can be achieved by culture of the skin vesicles. Noninfectious cutaneous conditions such as incontinentia pigmenti, acrodermatitis enteropathica, erythema toxicum, and neonatal melanosis should also be considered. Lesions associated with these diseases can often be distinguished rapidly from those caused by HSV by the presence of eosinophils on staining of a tissue scraping, by peripheral eosinophilia, and by appropriate viral cultures.
Normal cells are endowed with intricate machinery that affords protection against genotoxic stress induced by cell intrinsic and extrinsic insults, including DNA replication errors, oxidative damage, microbial infection, and inflammation. The failure of the DNA damage response to resolve single-stranded or double-stranded DNA breaks poses a significant risk for malignant transformation. In this context, the innate immune system functions as an extrinsic surveillance mechanism for genotoxic injury. NKG2D ligands, which include the major histocompatibility complex (MHC) class I-related molecules (MHC class I chain-related A MICA and MHC class I chain-related B MICB ) and four UL16 binding proteins (ULBP1-4) in humans as well as the retinoic acid-early (RAE) indu-cible gene products and H60 in rodents, are induced by DNA damage through a pathway involving ataxia telangiectasia mutated (ATM), ataxia telangiectasia and Rad3 related (ATR), Chk-1, and Chk-2 (Gasser et al., 2005). The surface...
Ocular inflammation is one of the most common eye disorders in animals.45 The precise observation and interpretation of signs provides the basis for diagnosing the disease and its associated disorders, and for establishing their etiology (trauma, lid or lacrimal abnormalities, viral or bacterial infection, immune-related phenomena, corneal ulceration). Topical steroidal therapy in combination with non steroidal anti-inflammatory drugs, immunosuppressive agents such cyclosporine and azathiopr-ine, antimicrobial agents, mydriatic-cycloplegic agents (atropine) and additional specific therapies are frequently prescribed to treat conjunctivitis, keratitis and uveitis (Table l).46,47 Topically applied steroids are in most cases used in combination with an antimicrobial agent. The reason is probably that the concomitant administration of steroid can increase the efficacy of antibiotics.48 In addition, this association prevents a secondary infection that may occur after a corticosteroid...
Safety data accumulated from 3500 MS patients treated with GA in controlled and uncontrolled studies indicate withdrawal from therapy for adverse experience in 8.4 .28 The most frequent reasons recorded for treatment withdrawals were dyspnea and vasodilation (2 for each). The most commonly reported adverse experiences are local injection site reactions which generally decline over time. They consist of erythema, pain, inflammation, pruritus, and swelling, but no skin necrosis. Localized lipoathrophy occurs in some areas after X 1 year of GA treatment.
AIDS microangiopathy (noninfectious) occurs in about 50 of patients (in both developing and western countries). It consists of microa-neurysms, telangiectasia, cotton-wool spots and a few retinal haemorrhages. Retinal peripheral perivascular sheathing may sometimes occur in the absence of intraocular infections.
The p53 protein is normally unstable and its cellular levels are very low. However, following a stress, such as DNA damage, arrest of DNA or RNA synthesis, or nucleotide depletion, the p53 protein is stabilized and transactivated.36 Several proteins could relay the stress signals to p53. Among them, ATM (Ataxia telangiectasia mutated gene product)37 and DNA-PK (DNA-dependent protein kinase)38 have been shown to induce p53 activation following different types of DNA damage. In addition, ATM directly associates with p53,39 and both ATM39 and DNA-PK40 can phosphorylate p53. To investigate the possible interaction between PARP and ATM, PARP activity following DNA damage has been analyzed in ATM-deficient cells and mice.41 The unaltered response of PARP to DNA damage supports the hypothesis that PARP and ATM regulate distinct pathways.
Juliusson and Gahrton (145-147), Juliusson et al. (148), and Dohner et al. (144) summarize the status of cytogenetics in CLL. First discovered in the 1980s, the most frequent genetic aberration in CLL now appears to be a deletion in 13q14 (149-151). A 13q14 deletion may confer protection. Another frequent genetic aberration is a deletion in 11q (152-155). It is associated with disease progression and reduced survival (156,157). The area may contain the neural cell adhesion molecule, or the ataxia telangiectasia (AT) gene may be mutated (ATM). Dohner et al. (158) notes that these patients tend to have massive lymphadenopathy and do not do well clinically. Trisomy 12 appears in between 7 and 25 of the CLL cases, and is said to be associated with atypical CLL (159). Another common aberration is a 17p deletion. The short arm of chromosome 17 is the site of the TP53 tumor suppressor gene. G-banding analysis demonstrated abnormalities of chromosome 17 in 13 of these 17 patients, leading to...
More commonly, 11q deletions involve a 2-3-Mb region at band 11q22.3-q23.1 (83). The 11q14-24 region contains several important genes including ATM (ataxia telangiectasia mutated), RDX (radixin), and FDXI (ferredoxin 1), with ATM and RDX being potentially important tumor suppressor genes (83). Ataxia telangiectasia is an autosomal recessive disease in which affected individuals have an increased incidence of T-cell lymphoproliferative disorders. Deletions and mutations that lead to disruption of both ATM alleles have been reported in T-cell prolymphocytic leukemia, indicating a tumor suppressor function for the ATM gene product which is lost in this leukemia (84,85).
The incidence of Hodgkin lymphoma is greatly increased in children with certain immunodeficiency disorders, specifically ataxia-telangiectasia, Wiskott-Aldrich syndrome, and Bloom syndrome. Given the broad spectrum of underlying genetic defects associated with these disorders and their association with the mixed-cellularity subtype, severely impaired immunity may be a likely etiology with consequent enhanced susceptibility to EBV.
The other anal injuries that have been described in complainants of anal penetration are bruises (2-4 ), abrasions (4-5 ), erythema (2-8 ), and swelling edema (2-6 ) (90,134). Slaughter et al. (90) described a high number of rectal injuries, in addition to the lacerations described (ecchymosis, n 1 abrasions, n 2 redness, n 1 and swelling, n 6) that were detectable among eight sexual assaults complainants who described anal contact (90). Although bruises are indicative of blunt trauma, the other findings may have innocent explanations, for example, a superficial abrasion of the anal verge has been identified on a child who interrupted the medical to pass a motion (observation of D. Rogers). Although erythema and swelling edema are also nonspecific findings, if they have completely resolved at a follow-up examination, it may be possible to relate them to the allegation. All these minor injuries would be expected to heal within 2 weeks of the incident without any residual scarring.
Clinical Presentation (Fig. 17) Nodular vasculitis (lobular panniculitis with vasculitis) was originally defined as erythema induratum (red, indurated plaques on the lower legs) associated with tuberculosis, treatment of which leads to clearing of skin lesions (Fig. 17A)
A history of prior problems with hyper- or hypothyroidism may suggest an acquired restrictive mechanism, and if Graves' disease has been active in the past, there should be some evidence of proptosis, conjunctival erythema, che-mosis, or lid retraction. Forced duction testing (see above) will demonstrate restriction of movement, the intraocular pressure will rise with attempts to move the eye into the restricted field of gaze, and CT MRI ultrasound testing will confirm the presence of rectus muscle thickening (see Chap. 9).
Pustular psoriasis is a rare form of psoriasis that typically affects adults. Sterile, white pustules in areas of erythema and scale characterize this form of psoriasis (Fig. 9.1F, G). There are several subtypes of pustular psoriasis including von Zumbusch pustular psoriasis, palmoplantar pustular psoriasis, and acropustulosis (acrodermatitis continua of Hallopeau). Von Zum-bush pustular psoriasis is characterized by abrupt waves of widespread, erythematous patches of skin, which b ecome painful and sore. Typically within a few hours, pustules appear, which then peel off after 1-2 days. These waves of pustules may last days to weeks. Patients may also report fever, chills, muscle weakness, and weight loss. Von Zumbusch pustular psoriasis may be triggered by infections, withdrawal of topical mediations, pregnancy, and certain medications such as lithium and some hypertension medications.
Note if there are clinical signs of infection, such as erythema, edema, cellulitis, purulent discharge, or regional lymphadenopathy. Cover the wound with a sterile, nonadhesive dressing. Wound closure is not generally recommended because data suggest that it may increase the risk of infection. This is particularly relevant for nonfacial wounds, deep puncture wounds, bites to the hand, clinically infected wounds, and wounds occurring more than 6-12 hours before presentation. Head and neck wounds in cosmetically important areas may be closed if less than 12 hours old and not obviously infected.
Mucocutaneous candidiasis consists of oral thrush or diaper dermatitis or both. Oral thrush typically presents on the days 7-10 of life as whitish patches (resembling milk curds) anywhere on the oral mucosa. The lesions can extend to the posterior pharynx but most often are located on the buccal mucosa, tongue, and palate. Scraping of these lesions results in a denuded erythematous base. Microscopic examination of these scrapings placed in 10 KOH suspension on a glass slide reveals blastospores or oval-round yeast cells and pseudohyphae. The diagnosis of oral thrush is based on clinical findings. Even though this is a presumptive diagnosis, routine culturing or microscopic examination of the scrapings is not necessary unless the thrush is persistent or atypical. Candida dermatitis appears as 1- to 3-mm vesicular or pustular lesions on an erythematous base in the perineum, axillae, and neck folds. These discrete lesions can coalesce to form large patches of inflamed, denuded skin,...
Wheals and erythema are also nonpermanent evidence of trauma caused by initial vasodilatation and local release of vasoactive peptides after an injury, such as a slap, scratch, or punch, which will leave no mark after a few hours. The classic features of the triple reaction are present, but no specific damage is done to any tissues. Thus, an initial reddening associated with pain with possible subsequent development of local swelling may be present initially, but after a few hours has completely resolved, unlike bruising, which will still be present after 24 hours or more.
Thalidomide was used in the sixties as a sedative and antiemetic agent. Severe teratogenic effects, however, led to its removal from the market. It has been rein-troduced over the last decade for the treatment of ENL (erythema nodosum leprosum) and received FDA approval for this indication in 1998. It is currently used in combination with dexamethasone, in place of conventional chemotherapy, for the initial management of multiple myeloma. The drug has been found to have multiple mechanisms of action that would make it an ideal therapeutic agent in various cancers, especially melanoma, multiple myeloma, and MDS. These include accelerating degradation of TNFa RNA message potent inhibition of angiogenesis via its action on VEGF and bFGF, and inhibition of the transcriptional regulator NF-kB.40-42 In addition, thalidomide alters cellular adhesion and stimulates the Th1 immune response, possibly enhancing an antitumor response.43 Thus, thalidomide shows anti-TNFa, antiangiogenic, and...
Topical retinoid application may be an effective approach in early stage MF. They exert their effects through two basic types of nuclear receptors the retinoic acid (RAR) and rexinoid (RXR) receptor family. No comparison of different retinoids has been evaluated. In a dose-escalating phase I II trial of the RXR-specific retinoid bexarotene, 0.1-1.0 , the CR rate was 21 , with an overall response rate of 63 .28 Side effects were restricted to the application site and consisted of mild to moderate irritation, with erythema in 73 of the cases. Bexarotene 1 gel was approved by the Food and Drug Administration (FDA) as a therapy for stages IA through IIA MF.
In psoriasis clinical trial experience, etanercept has been well tolerated. The most common adverse event in patients receiving placebo or any dose of etanercept was injection site reaction, where rates in the previously mentioned two phase 3 trials ranged from 6 to 18 . These reactions typically occur 2-3 weeks into treatment and consist of erythema, pain, itching, and or swelling, and typically resolve in 3-5 days. In addition, upper respiratory tract infections (5-11 ) and headache (3-12 ) were also seen. In the study by Leo-nardi and colleagues, serious infectious adverse events were infrequent and were not more frequent in the high dose etanercept groups when compared to the placebo-crossover group of lower dose groups. In placebo-controlled trials for all uses of etanercept, the most common type of adverse event was an upper respiratory tract infection, which occurred in between 12 and 20 of patients, but not at an increased frequency when compared with placebo groups.
With proper microscopic control and using fine sutures. The lids can also be injured by chemical burns or flash burns. Exposure to ultraviolet light, as from a welder's arc or in snow blindness, can cause oedema and erythema of the eyelids. This might appear after an hour or two but resolves spontaneously after about two days.
Erythema and an erosion of the hard palate have also been described after fellatio (74,75), but the reliability of such findings is questionable. Indeed, in one such case, the mucositis was eventually diagnosed as oral candidiasis contracted from direct contact with an infected penis (75). Other nonsexual causes for similar palatal lesions include infectious mononucleosis local trauma (e.g., hard food stuffs or ill-fitting dentures) paroxysms of vomiting, coughing, or sneezing playing a wind instrument tumors and bleeding diatheses (77). Therefore, whenever palatal bruising, erythema, or erosions are identified during the examination of a complainant who may have been subjected to fellatio, alternative explanations should be excluded by taking a detailed medical, dental, and social history conducting a comprehensive general examination and, where necessary, undertaking relevant special investigations.
How To Deal With Rosacea and Eczema
Rosacea and Eczema are two skin conditions that are fairly commonly found throughout the world. Each of them is characterized by different features, and can be both discomfiting as well as result in undesirable appearance features. In a nutshell, theyre problems that many would want to deal with.