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Skin hyperreactivity. response (pathergy) in Behçet's disease
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Skin hyperreactivity response (pathergy) in Behget's disease Amos Gilhar, MD, Giora Winterstein, MD, Hana Turani, MD, Jacob Landau, M D , and Amos Etzioni, M D Haifa, Israel Beh~et's disease is very difficult to diagnose because its clinical signs overlap with those of other systemic diseases. Thus there is a clear need for nonclinical diagnostic criteria for Behget's disease. The nonspecific cutaneous hyperreactivity response, pathergy, may serve as an important diagnostic indicator. A test for pathergy may also clarify the role of an immune complex mechanism in the pathogenesis of Behget's disease. In our study of 11 patients with Beh~et's disease, deposition of immunoglobulinsor complement was not found 4 hours after histamine or saline injection. In contrast, 24 hours after histamine or saline injection, 10 of 11 patients responded positively both clinically and histologically during the active stage of their disease. Vasculitis was noted in only two patients. Thus in most patients no evidence of an immune complex mechanism was observed. We conclude that any nonspecific intracutaneous injection is a good clinical tool for the diagnosis of Behqet's disease. (J AM ACADDERMATOL 1989;21:547-52.) Behget's disease is a systemic disease that affects a number of organ systems.1 There are several sets of criteria for the clinical diagnosis of the disease; however, there is no single specific criterion sufficient to establish the diagnosis.2 Because of the overlap of symptoms with those of other systemic disorders and because months or even years m a y elapse before all major diagnostic manifestations appear, better diagnostic criteria are needed. Studies have revealed various immunologic findings and other laboratory phenomena that are characteristic of Behqet's disease.i, 2 Among these findings is skin hyperreactivity (pathergy). Tuzun et al. 3 found pathergy in 84% of patients with Beh~et's disease, compared with 3% of the control group, composed of healthy persons and persons with skin and systemic diseases, including recurrent aphthous stomatitis, iridocyclitis, erythema nodosum, rheumatoid arthritis, and Reiter's syndrome. Thus our earlier suggestion to incorporate this sign as diagnostic of the disease seems to be justified. Jorizzo 1 has emphasized the importance of uniform criteria for diagnosis. According to Jorizzo et al., 4 the use of histamine rather than saline solution in tests for pathergy yields a characteristic positive From the Laboratory of Skin Research, Faculty of Medicine, TeehnionIsrael Institute of Technology. Reprint requests: Amos Gilhar, MD, Laboratory of Skin Research, Technion Faculty of Medicine, P.O. Box 9649, Haifa 31096, Israel.
histamine test result (i.e., deposition of immunoreactants around the blood vessels in the dermis and histologic features of leukocytoclastic vasculitis 24 hours after the injection). Such an observation not only may be a diagnostic tool b u t may also lead to a better understanding of the pathogenesis of the disease. Indeed, a positive histamine test result may suggest an immune complex disease: Therefore we decided to inject simultaneously both histamine and saline solutions into our patients during active and inactive stages of their disease. W e also attempted to confirm the previously described increased number of mast cells in pathergy lesions5 and to compare the histamine and saline responses. MATERIAL AND METHODS Eleven patients with established Beh~et's disease were examined. Details of their clinical features are shown in Table I. There were seven men and four women, ranging in age from 18 to 64 years, who had their disease for 1 to 30 years. The nature of the trial was explained to the patients, and they were included in the study after written informed consent was obtained. All topical and systemic therapies were stopped at least 10 days before the first test. Patients 5, 8, and 9 were treated with eolchieine (1.5 rag/day) (patient 5 also received prednisone, 15 mg every other day). Systemic treatment was used only after the termination of the study (except for patient 5). Intracutaneous injections were repeated during an exacerbation of the disease and during spontaneous disease inactivity. The injections were given for 3 weeks while patients 547
548
Journal of the American Academy of Dermatology
Gilhar et al.
Table I. Presenting features of tested patients Presenting feature
Arterial involvement* Arthropathy Clinical pathergy Erythema nedosum Eye manifestation Genital ulceration Histopathologiefindings (24 hr after injection) Meningoencephalitis Oral ulceration Pathergy test during active disease Thrombophlebitis
+ + + PM-NI
+ MNI
+ MNI
+ MNI
+ + + + + + LCCV
+ +
+ + +
+ +
+ +
+ +
+
+ +
+
+
+ +
+ MNI
+
LCCV
+ + + + + MNI
+ +
+ +
+ +
+ +
+
+ + MNI + +
+
+ + + + + MNI
+
LCCV, Leueocytoclastiovaseulitis;MNI, mononuelear infiltration; PMNI, polymorphonuelearinfiltration. *Multiplefalse aneurysms (femoral).
showed no active signs of the disease. Thus each patient was studied during active and inactive stages of the disease. Five apparently healthy matched control subjects were simultaneously and similarly tested. The skin reactivity in each patient was examined after three intracutaneous injections of 0.1 ml normal saline solution ( p H - 7.38) into the right forearm and three simultaneous injections of 0.05 ml of a 1.0 mg/rnl solution of histamine phosphate into the contralateral aspect of the forearm. Four hours after the injection, two biopsy specimens were obtained from each forearm for direct immunofluorescencetesting and light microscopic examination. Twenty-four hours after injection, biopsy specimens were again obtained for microscopic examination. The preparation for imrnunofluorescence study was placed on a cryoform-coated cork and snap-frozen in isopentane, which had been cooled to - 70° C. Frozen sections were incubated with fluorescein-conjugated monospecific antiserum to human IgG, IgM, IgA, C3, and C4. Two patients with buUous pemphigoid served as positive control subjects for the immunofluorescence study. Biopsy specimens for routine light microscopic examination were fixed in formalin and embedded in paraffin. Sections from each specimen were stained with hematoxylin and eosin, toluidine blue, and naphthol AS-CL. The latter stain best identified mast cells.
RESULTS Four hours after injection General observations. In all subjects, both control subjects and patients, the histamine-induced wheal appeared and persisted from 45 minutes to 2 hours.
No difference was observed between active and inactive stages. In the site of saline injection, no clinical changes were noted.
Immtmofluorescenee study and histologic findings. In neither the patients nor the control group were depositions of IgG, IgM, IgA, or complement C3 or C4 observed. The main histologic finding in the patients was a variable amount of mononuclear cells around the blood vessels. Such infiltration was observed in seven patients in the site of histamine injection. Four of these seven patients had similar but much less dense infiltration in the saline injection site. Eosinophils were observed in both the histamine injection site and the saline injection site in four patients and were located mostly in the perivascular area. In the control group no infiltration was observed in the saline injection site. In the histamine injection site there were mononuclear cells and eosinophils around the blood vessels in two of five subjects. Staining for mast cells revealed prominent infiltration of the cells in two patients and slight infiltration in two other patients in the histamine injection site. In the saline injection site, mast cells were observed in two patients. In the control group, mast cells were noted in the histamine injection.site of one subject.
Twenty-four hours after injection General observations. O f 11 patients, 10 responded positively and almost equally to histamine and saline injections during the active stage of the disease. An
Volume 21 Number 3, Part 1 September 1989
erythematous area 1 × 2 cm in diameter developed with a pustule at its center (Fig. 1). No response was observed during the inactive stage of the disease. Histologic findings. No significant difference was noted between the histamine and saline injection sites. Specimens from seven patients revealed a variable amount of mononuclear plasma infiltration around the blood vessels in the papillary dermis and around the skin adnexa (Fig. 2). Small clusters of neutrophils and eosinophils were also observed. No vasculitis was noted in these patients. Specimens obtained from patient 1 revealed a dense perivascular infiltrate composed of neutrophils and eosinophils but without evidence of changes in the walls of blood vessels (Fig. 3). Specimens obtained from patients 5 and 7 revealed a leukocytoclastic vasculitis (Fig. 4). Staining with toluidine blue and NCA naphthol AS chloroacetate esterase demonstrated a marked increase in the number of mast cells. These cells were present mostly in clusters around the blood vessels at the inflamed histamine and saline injection sites of six patients (Fig. 5). The morphology of the mast cells was that of large cuboidal cells with granules in the cytoplasm. They were located mainly in the area of perivascular infiltration but were also scattered throughout the dermis. No difference in the histologic findings or mast cell population was seen between the specimens from patients at the inactive stage and those from the control group. DISCUSSION This study confirms our previous observation correlating the skin response to any nonspecific intracutaneous injection with disease activity in Behget's disease.Z 7 Of t 1 patients, nine displayed skin hyperreactivity 24 hours after the injections. Perivascular mononuclear cells predominated in specimens from seven patients, whereas in three patients the infiltrate was composed mainly of neutrophlls. Among these patients, two showed leukocytoclastic vasculitis. No correlation was found between the type of cells and severity of the disease. Nazzaro 8 described vascular changes and perivascular infiltrates after needle pricks in patients with Behget's disease. He reported thickening and homogenization of the walls of small blood vessels. These findings suggest a leukocytoclastic vasculitis similar to that of three of our patients and the group studied by Jorizzo et al. Others 9,10 have described the vascular changes as being mild or absent. Haim et al.ll did not find any difference between lesions produced by
Hyperreaetivity response in Behqet's disease 549
Fig. 1. Pathergy responseconsisting of an erythematous zone with pustule. needle prick and those produced by saline intracutaneous injections. During disease activity, both tests produced skin hyperreactivity responses with perivascular infiltrates but no signs of vasculitis. Collectively these findings and ours support the notion that nonspecific minor trauma can evoke a unique hyperreactMty response in Behqet's disease. Histologic findings observed 24 hours after the injections may suggest the onset of this hyperreactivity phenomenon. This conclusion is in conflict with the findings of Jorizzo et al. 4 They were impressed by the poor reproducibility of the clinical pathergy test. On the other hand, they found perivascular deposition of immunoglobulins in immunofluorescence studies performed 4 hours after histamine injections. Jorizzo et al. noted leukocytoclastic vasculitis or Sweet's syndrome-like changes in histologic examinations performed 24 hours after the injections. Such a positive histamine test suggests immune complex-mediated vessel damage. 5,t1,12 These studies showed deposition of immunoglobulins and complement 4 hours after the histamine injection but not during the delayed phase of the reaction. In our study we failed to demonstrate immunoglobulin deposition 4 hours after either histamine or saline injections. In a previous report Haim et a1.I1 were also unable to show immunoglobulin deposition 24 hours after the injection. Moreover, in our study, only two patients demonstrated vasculitis 24 hours after the injections. We have long used pathergy in the diagnosis of Behget's disease. Histologic preparations obtained during years of follow-up in each patient have shown a predominance of mononuclear cell infiltrates. In three patients in the current study who showed neutrophilic infiltrates, findings are in agreement with those of Nazzaro 8 and Jorizzo etal. 4 and may reflect
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Journal of the American Academyof Dermatology
Fig. 2. Photomicrograph of skin biopsy specimen from pathergy lesion. Infiltrate consists mainly of mononuclear cells and small clusters of neutrophils. There is no sign of vasculitis. (Hematoxylin-eosin stain; X300.)
Fig. 3. Patient 1. Photomicrograph of skin biopsy specimen reveals dense perivascular infiltrate composed primarily of neutrophils. There is no evidence of vaseulitis. (Hematoxylineosin stain; x250.)
different stages of the skin response. Alternatively, this apparent disparity may be related to different population origins. Indeed, human lymphocyte antigen-B5 is associated with Behget's disease in patients from the Middle and Far East, whereas no correlation has been found in Britain and in the United StatesJ 3-~5 Thus a different genetic back-
ground may explain, at least partly, these conflicting results. This possibility has also been suggested by Tuzun et al., 3 who stressed that the prevalence of some features of Beh@t's disease differs in various parts of the world; the prevalence of the results of the pathergy test may differ in each country as well. The mechanism of pathergy is still uncertain. Re-
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Hyperreactivity response in Behqet's disease
551
Fig. 4. Photomicrograph of skin biopsy specimen from patient 7 demonstrates leukocytoclastic vasculitis. (Hematoxylin-eosin stain; X250.)
Fig. 5. Photomicrograph ofstained pathergy lesion reveals large numbers ofmetachromatically stained mast cells. (Toluidine blue stain; ×400.)
cently we failed to demonstrate any skin antigen that may explain the development of reactive lesions after trivial trauma. 7,16 The increased number of mast cells described previously 17 and confirmed herein may suggest a role of these cells in the mechanism of the pathergy phenomenon. Normally the skin contains only a small number of mast cells, located mainly near the capillaries and skin appendages. Their number is increased in a variety of conditions,
including wound formation, atopic dermatitis, lymphoproliferative syndromes, arthritides, and inflammatory bowel disorders, ts This observation once again raises questions as to whether the role of mast cells in Behget's disease is a primary one or only that of an "innocent bystander." 1,6 T h e granules within the mast cells contain numerous biologically active mediators, which can be released during the degranulation process. These mediators may also enhance
552
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the migration and activation of neutrophils, eosinophils, and lymphocytes into tissue sites. We demonstrated previously degranulation of mast cells in lesions of Behget's disease. 6 We may therefore assume that these cells play a role in the pathergy response, but further studies are needed to explore this possibility. REFERENCES 1. Jorizzo JL. Beh~et's disease: an update based on the 1985 International Conference in London. Arch Dermatol 1986;22:556-8. 2. Haim S, Gilhar A~ Clinical and laboratory criteria for the diagnosis of Beh~et's disease. Br J Dermatol 1980;102: 361-3. 3. Tuzun Y, Yazici H, Pozarly H, et al. The usefulness of nonspecific skin hyperreactivlty (the pathergy test) in Beh~et's disease in Turkey. Acta Derm Venereol (Stockh) 1978;59:77-9. 4. Jorizzo JL, Solomon AR, Cevallo T. Beh~et's syndrome: immunopathologic and histopathologic assessment of pathergy lesions is useful in diagnosis and follow-up. Arch Pathol Lab Meal 1985;109:747-51. 5. Braverman IM, Yen A. Demonstration of immune complexes in spontaneous and histamine-induced lesions and in normal skin of patients with leukocytoclastic angiitis. J Invest Dermatol 1975;64:105-12. 6. Lichtig C, Haim S, Gilhar A, et al. Mast ceils in Behc;et's disease: ultrastrueture and histamine content studies. Dermatologica 1981;162:167-74. 7. Haim S, Gilhar A, Mekori T, et al. Leucocyte migration
8.
9.
10. 11.
12.
13. 14. 15. 16. 17. 18.
inhibition in Beh~et's disease. Dermatologica 1979;159: 302-6. Nazzaro P. Cutaneous manifestations of Beh~et's disease. In: Monacelli M, Nazzaro P, eds. International Symposium on Behqet's disease in Rome. Basel: S Karger AG, 1966:1541. France R, Buchanan RM, Wilson MW, et al. Relapsing iritis with recurrent ulcers of the mouth and genitalia (Beh~et's syndrome): review with report of additional case. Medicine 1951 ;30:335-42. Ship II, Merritt AD, Stanley HR. Recurrent aphthous ulcers. Am J Med 1962;32:32-7. Haim S, Sobel JD, Friedman-Birnbaum R, et at. Histological and direct immunofluorescence study of cutaneous hyperreactivity in Behcet's disease. Br J Dermatol 1976;95: 631-5. Jorizzo JL, Daniels JC, Apisarnthanarax P, et al. Histamine-triggered localized vasculitis in patients with seropositive rheumatoid arthritis. J AM ACAD DERMATOL 1983; 9:845-51. Brauther C, Chiazek T, Ben-Tuvia S, et al. A genetic study of Behget's disease in Israel. Tissue Antigens 1978;11:11320. Jung RT, Chalmers TM, Joysery VC. H L A in Beh~et's disease. Lancet 1976;2:694. O'Duffy D J, Taswell JF, Elvebeck LR. H L A in Beh~et's disease. J Rheumatol 1976;3:1-3. Gilhar A, Haim S, Wolf V, etal. Beh~et's disease leucocyte inhibitory factor (LIF) in response to skin extract. Jpn J Dermatol 1983;10:185-6. Lever WF, ed. Histopathology of the skin. 6th ed. Philadelphia: JB Lippincott, 1983:53-4. Atkins FM, Clark RAF. Mast cells and fibrosis. Arch Dermatol 1987;123:191-3.
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Skin hyperreactivity response (pathergy) in Behget's disease Amos Gilhar, MD, Giora Winterstein, MD, Hana Turani, MD, Jacob Landau, M D , and Amos Etzioni, M D Haifa, Israel Beh~et's disease is very difficult to diagnose because its clinical signs overlap with those of other systemic diseases. Thus there is a clear need for nonclinical diagnostic criteria for Behget's disease. The nonspecific cutaneous hyperreactivity response, pathergy, may serve as an important diagnostic indicator. A test for pathergy may also clarify the role of an immune complex mechanism in the pathogenesis of Behget's disease. In our study of 11 patients with Beh~et's disease, deposition of immunoglobulinsor complement was not found 4 hours after histamine or saline injection. In contrast, 24 hours after histamine or saline injection, 10 of 11 patients responded positively both clinically and histologically during the active stage of their disease. Vasculitis was noted in only two patients. Thus in most patients no evidence of an immune complex mechanism was observed. We conclude that any nonspecific intracutaneous injection is a good clinical tool for the diagnosis of Behqet's disease. (J AM ACADDERMATOL 1989;21:547-52.) Behget's disease is a systemic disease that affects a number of organ systems.1 There are several sets of criteria for the clinical diagnosis of the disease; however, there is no single specific criterion sufficient to establish the diagnosis.2 Because of the overlap of symptoms with those of other systemic disorders and because months or even years m a y elapse before all major diagnostic manifestations appear, better diagnostic criteria are needed. Studies have revealed various immunologic findings and other laboratory phenomena that are characteristic of Behqet's disease.i, 2 Among these findings is skin hyperreactivity (pathergy). Tuzun et al. 3 found pathergy in 84% of patients with Beh~et's disease, compared with 3% of the control group, composed of healthy persons and persons with skin and systemic diseases, including recurrent aphthous stomatitis, iridocyclitis, erythema nodosum, rheumatoid arthritis, and Reiter's syndrome. Thus our earlier suggestion to incorporate this sign as diagnostic of the disease seems to be justified. Jorizzo 1 has emphasized the importance of uniform criteria for diagnosis. According to Jorizzo et al., 4 the use of histamine rather than saline solution in tests for pathergy yields a characteristic positive From the Laboratory of Skin Research, Faculty of Medicine, TeehnionIsrael Institute of Technology. Reprint requests: Amos Gilhar, MD, Laboratory of Skin Research, Technion Faculty of Medicine, P.O. Box 9649, Haifa 31096, Israel.
histamine test result (i.e., deposition of immunoreactants around the blood vessels in the dermis and histologic features of leukocytoclastic vasculitis 24 hours after the injection). Such an observation not only may be a diagnostic tool b u t may also lead to a better understanding of the pathogenesis of the disease. Indeed, a positive histamine test result may suggest an immune complex disease: Therefore we decided to inject simultaneously both histamine and saline solutions into our patients during active and inactive stages of their disease. W e also attempted to confirm the previously described increased number of mast cells in pathergy lesions5 and to compare the histamine and saline responses. MATERIAL AND METHODS Eleven patients with established Beh~et's disease were examined. Details of their clinical features are shown in Table I. There were seven men and four women, ranging in age from 18 to 64 years, who had their disease for 1 to 30 years. The nature of the trial was explained to the patients, and they were included in the study after written informed consent was obtained. All topical and systemic therapies were stopped at least 10 days before the first test. Patients 5, 8, and 9 were treated with eolchieine (1.5 rag/day) (patient 5 also received prednisone, 15 mg every other day). Systemic treatment was used only after the termination of the study (except for patient 5). Intracutaneous injections were repeated during an exacerbation of the disease and during spontaneous disease inactivity. The injections were given for 3 weeks while patients 547
548
Journal of the American Academy of Dermatology
Gilhar et al.
Table I. Presenting features of tested patients Presenting feature
Arterial involvement* Arthropathy Clinical pathergy Erythema nedosum Eye manifestation Genital ulceration Histopathologiefindings (24 hr after injection) Meningoencephalitis Oral ulceration Pathergy test during active disease Thrombophlebitis
+ + + PM-NI
+ MNI
+ MNI
+ MNI
+ + + + + + LCCV
+ +
+ + +
+ +
+ +
+ +
+
+ +
+
+
+ +
+ MNI
+
LCCV
+ + + + + MNI
+ +
+ +
+ +
+ +
+
+ + MNI + +
+
+ + + + + MNI
+
LCCV, Leueocytoclastiovaseulitis;MNI, mononuelear infiltration; PMNI, polymorphonuelearinfiltration. *Multiplefalse aneurysms (femoral).
showed no active signs of the disease. Thus each patient was studied during active and inactive stages of the disease. Five apparently healthy matched control subjects were simultaneously and similarly tested. The skin reactivity in each patient was examined after three intracutaneous injections of 0.1 ml normal saline solution ( p H - 7.38) into the right forearm and three simultaneous injections of 0.05 ml of a 1.0 mg/rnl solution of histamine phosphate into the contralateral aspect of the forearm. Four hours after the injection, two biopsy specimens were obtained from each forearm for direct immunofluorescencetesting and light microscopic examination. Twenty-four hours after injection, biopsy specimens were again obtained for microscopic examination. The preparation for imrnunofluorescence study was placed on a cryoform-coated cork and snap-frozen in isopentane, which had been cooled to - 70° C. Frozen sections were incubated with fluorescein-conjugated monospecific antiserum to human IgG, IgM, IgA, C3, and C4. Two patients with buUous pemphigoid served as positive control subjects for the immunofluorescence study. Biopsy specimens for routine light microscopic examination were fixed in formalin and embedded in paraffin. Sections from each specimen were stained with hematoxylin and eosin, toluidine blue, and naphthol AS-CL. The latter stain best identified mast cells.
RESULTS Four hours after injection General observations. In all subjects, both control subjects and patients, the histamine-induced wheal appeared and persisted from 45 minutes to 2 hours.
No difference was observed between active and inactive stages. In the site of saline injection, no clinical changes were noted.
Immtmofluorescenee study and histologic findings. In neither the patients nor the control group were depositions of IgG, IgM, IgA, or complement C3 or C4 observed. The main histologic finding in the patients was a variable amount of mononuclear cells around the blood vessels. Such infiltration was observed in seven patients in the site of histamine injection. Four of these seven patients had similar but much less dense infiltration in the saline injection site. Eosinophils were observed in both the histamine injection site and the saline injection site in four patients and were located mostly in the perivascular area. In the control group no infiltration was observed in the saline injection site. In the histamine injection site there were mononuclear cells and eosinophils around the blood vessels in two of five subjects. Staining for mast cells revealed prominent infiltration of the cells in two patients and slight infiltration in two other patients in the histamine injection site. In the saline injection site, mast cells were observed in two patients. In the control group, mast cells were noted in the histamine injection.site of one subject.
Twenty-four hours after injection General observations. O f 11 patients, 10 responded positively and almost equally to histamine and saline injections during the active stage of the disease. An
Volume 21 Number 3, Part 1 September 1989
erythematous area 1 × 2 cm in diameter developed with a pustule at its center (Fig. 1). No response was observed during the inactive stage of the disease. Histologic findings. No significant difference was noted between the histamine and saline injection sites. Specimens from seven patients revealed a variable amount of mononuclear plasma infiltration around the blood vessels in the papillary dermis and around the skin adnexa (Fig. 2). Small clusters of neutrophils and eosinophils were also observed. No vasculitis was noted in these patients. Specimens obtained from patient 1 revealed a dense perivascular infiltrate composed of neutrophils and eosinophils but without evidence of changes in the walls of blood vessels (Fig. 3). Specimens obtained from patients 5 and 7 revealed a leukocytoclastic vasculitis (Fig. 4). Staining with toluidine blue and NCA naphthol AS chloroacetate esterase demonstrated a marked increase in the number of mast cells. These cells were present mostly in clusters around the blood vessels at the inflamed histamine and saline injection sites of six patients (Fig. 5). The morphology of the mast cells was that of large cuboidal cells with granules in the cytoplasm. They were located mainly in the area of perivascular infiltration but were also scattered throughout the dermis. No difference in the histologic findings or mast cell population was seen between the specimens from patients at the inactive stage and those from the control group. DISCUSSION This study confirms our previous observation correlating the skin response to any nonspecific intracutaneous injection with disease activity in Behget's disease.Z 7 Of t 1 patients, nine displayed skin hyperreactivity 24 hours after the injections. Perivascular mononuclear cells predominated in specimens from seven patients, whereas in three patients the infiltrate was composed mainly of neutrophlls. Among these patients, two showed leukocytoclastic vasculitis. No correlation was found between the type of cells and severity of the disease. Nazzaro 8 described vascular changes and perivascular infiltrates after needle pricks in patients with Behget's disease. He reported thickening and homogenization of the walls of small blood vessels. These findings suggest a leukocytoclastic vasculitis similar to that of three of our patients and the group studied by Jorizzo et al. Others 9,10 have described the vascular changes as being mild or absent. Haim et al.ll did not find any difference between lesions produced by
Hyperreaetivity response in Behqet's disease 549
Fig. 1. Pathergy responseconsisting of an erythematous zone with pustule. needle prick and those produced by saline intracutaneous injections. During disease activity, both tests produced skin hyperreactivity responses with perivascular infiltrates but no signs of vasculitis. Collectively these findings and ours support the notion that nonspecific minor trauma can evoke a unique hyperreactMty response in Behqet's disease. Histologic findings observed 24 hours after the injections may suggest the onset of this hyperreactivity phenomenon. This conclusion is in conflict with the findings of Jorizzo et al. 4 They were impressed by the poor reproducibility of the clinical pathergy test. On the other hand, they found perivascular deposition of immunoglobulins in immunofluorescence studies performed 4 hours after histamine injections. Jorizzo et al. noted leukocytoclastic vasculitis or Sweet's syndrome-like changes in histologic examinations performed 24 hours after the injections. Such a positive histamine test suggests immune complex-mediated vessel damage. 5,t1,12 These studies showed deposition of immunoglobulins and complement 4 hours after the histamine injection but not during the delayed phase of the reaction. In our study we failed to demonstrate immunoglobulin deposition 4 hours after either histamine or saline injections. In a previous report Haim et a1.I1 were also unable to show immunoglobulin deposition 24 hours after the injection. Moreover, in our study, only two patients demonstrated vasculitis 24 hours after the injections. We have long used pathergy in the diagnosis of Behget's disease. Histologic preparations obtained during years of follow-up in each patient have shown a predominance of mononuclear cell infiltrates. In three patients in the current study who showed neutrophilic infiltrates, findings are in agreement with those of Nazzaro 8 and Jorizzo etal. 4 and may reflect
550
Gilhar et al.
Journal of the American Academyof Dermatology
Fig. 2. Photomicrograph of skin biopsy specimen from pathergy lesion. Infiltrate consists mainly of mononuclear cells and small clusters of neutrophils. There is no sign of vasculitis. (Hematoxylin-eosin stain; X300.)
Fig. 3. Patient 1. Photomicrograph of skin biopsy specimen reveals dense perivascular infiltrate composed primarily of neutrophils. There is no evidence of vaseulitis. (Hematoxylineosin stain; x250.)
different stages of the skin response. Alternatively, this apparent disparity may be related to different population origins. Indeed, human lymphocyte antigen-B5 is associated with Behget's disease in patients from the Middle and Far East, whereas no correlation has been found in Britain and in the United StatesJ 3-~5 Thus a different genetic back-
ground may explain, at least partly, these conflicting results. This possibility has also been suggested by Tuzun et al., 3 who stressed that the prevalence of some features of Beh@t's disease differs in various parts of the world; the prevalence of the results of the pathergy test may differ in each country as well. The mechanism of pathergy is still uncertain. Re-
Volume 21 Number 3, Part 1 September 1989
Hyperreactivity response in Behqet's disease
551
Fig. 4. Photomicrograph of skin biopsy specimen from patient 7 demonstrates leukocytoclastic vasculitis. (Hematoxylin-eosin stain; X250.)
Fig. 5. Photomicrograph ofstained pathergy lesion reveals large numbers ofmetachromatically stained mast cells. (Toluidine blue stain; ×400.)
cently we failed to demonstrate any skin antigen that may explain the development of reactive lesions after trivial trauma. 7,16 The increased number of mast cells described previously 17 and confirmed herein may suggest a role of these cells in the mechanism of the pathergy phenomenon. Normally the skin contains only a small number of mast cells, located mainly near the capillaries and skin appendages. Their number is increased in a variety of conditions,
including wound formation, atopic dermatitis, lymphoproliferative syndromes, arthritides, and inflammatory bowel disorders, ts This observation once again raises questions as to whether the role of mast cells in Behget's disease is a primary one or only that of an "innocent bystander." 1,6 T h e granules within the mast cells contain numerous biologically active mediators, which can be released during the degranulation process. These mediators may also enhance
552
Journal of the American Academy of Dermatology
Gilhar et aL
the migration and activation of neutrophils, eosinophils, and lymphocytes into tissue sites. We demonstrated previously degranulation of mast cells in lesions of Behget's disease. 6 We may therefore assume that these cells play a role in the pathergy response, but further studies are needed to explore this possibility. REFERENCES 1. Jorizzo JL. Beh~et's disease: an update based on the 1985 International Conference in London. Arch Dermatol 1986;22:556-8. 2. Haim S, Gilhar A~ Clinical and laboratory criteria for the diagnosis of Beh~et's disease. Br J Dermatol 1980;102: 361-3. 3. Tuzun Y, Yazici H, Pozarly H, et al. The usefulness of nonspecific skin hyperreactivlty (the pathergy test) in Beh~et's disease in Turkey. Acta Derm Venereol (Stockh) 1978;59:77-9. 4. Jorizzo JL, Solomon AR, Cevallo T. Beh~et's syndrome: immunopathologic and histopathologic assessment of pathergy lesions is useful in diagnosis and follow-up. Arch Pathol Lab Meal 1985;109:747-51. 5. Braverman IM, Yen A. Demonstration of immune complexes in spontaneous and histamine-induced lesions and in normal skin of patients with leukocytoclastic angiitis. J Invest Dermatol 1975;64:105-12. 6. Lichtig C, Haim S, Gilhar A, et al. Mast ceils in Behc;et's disease: ultrastrueture and histamine content studies. Dermatologica 1981;162:167-74. 7. Haim S, Gilhar A, Mekori T, et al. Leucocyte migration
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inhibition in Beh~et's disease. Dermatologica 1979;159: 302-6. Nazzaro P. Cutaneous manifestations of Beh~et's disease. In: Monacelli M, Nazzaro P, eds. International Symposium on Behqet's disease in Rome. Basel: S Karger AG, 1966:1541. France R, Buchanan RM, Wilson MW, et al. Relapsing iritis with recurrent ulcers of the mouth and genitalia (Beh~et's syndrome): review with report of additional case. Medicine 1951 ;30:335-42. Ship II, Merritt AD, Stanley HR. Recurrent aphthous ulcers. Am J Med 1962;32:32-7. Haim S, Sobel JD, Friedman-Birnbaum R, et at. Histological and direct immunofluorescence study of cutaneous hyperreactivity in Behcet's disease. Br J Dermatol 1976;95: 631-5. Jorizzo JL, Daniels JC, Apisarnthanarax P, et al. Histamine-triggered localized vasculitis in patients with seropositive rheumatoid arthritis. J AM ACAD DERMATOL 1983; 9:845-51. Brauther C, Chiazek T, Ben-Tuvia S, et al. A genetic study of Behget's disease in Israel. Tissue Antigens 1978;11:11320. Jung RT, Chalmers TM, Joysery VC. H L A in Beh~et's disease. Lancet 1976;2:694. O'Duffy D J, Taswell JF, Elvebeck LR. H L A in Beh~et's disease. J Rheumatol 1976;3:1-3. Gilhar A, Haim S, Wolf V, etal. Beh~et's disease leucocyte inhibitory factor (LIF) in response to skin extract. Jpn J Dermatol 1983;10:185-6. Lever WF, ed. Histopathology of the skin. 6th ed. Philadelphia: JB Lippincott, 1983:53-4. Atkins FM, Clark RAF. Mast cells and fibrosis. Arch Dermatol 1987;123:191-3.
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