Case report: Cutaneous nocardiosis complicating management of Crohn's disease with infliximab and prednisone

INFLIXIMAB IS A CHIMERIC ANTI-TUMOUR NECROSIS FACTOR-α antibody that is efficacious in treating Crohn''s disease. However, its immunomodulatory properties increase susceptibility to opportunistic infections. We present a case of cutaneous Nocardia infection in a patient who was taking infliximab for Crohn''s disease. The case illustrates the challenges in the diagnosis and management of this disease and serves as a reminder of the complications associated with the use of immunomodulatory agents.A 45-year-old HIV-negative man with fistulous Crohn''s disease had a history of inadequate disease control despite ongoing prednisone therapy. He had previously taken budesonide, mesalamine, ciprofloxacin and metronidazole in attempts to induce remission of his inflammatory bowel disease. The patient was born in Canada and, other than a 1-week holiday to Mexico 10 years before presentation, had travelled only locally. He denied a family history of tuberculosis, and he had never worked in a health care facility. Infliximab was introduced, and the patient received 3 infusions of 5 mg/kg at baseline and 2 and 6 weeks later. After he received his third infusion, prednisone was tapered to 40 mg at a rate of 5 mg weekly. One month after the third infusion, in February 2000, he reported multiple erythematous papulopustular lesions on his right leg (Fig. 1). There was no associated lymphadenopathy, cough, shortness of breath, fever or constitutional symptoms. He denied a history of insect bites, but in November 1999 he had received cuts to his right leg from a metal blade when at work. He had not immersed the leg in a whirlpool or swimming pool around the time of the leg injury. The patient continued to receive further infliximab infusions (at weeks 12 and 18 after baseline), and the lesions were treated with cloxacillin for suspected Staphylococcus aureus infection. Since improvement was minimal, a skin biopsy was performed in July 2000. Granulomatous inflammation was present, and acid-fast bacilli were visualized (Fig. 2). Cultures sent for mycobacteriology and mycology were incubated at 35°C for 8 weeks, but the results from the mycobacteriology culture proved negative. A polymerase chain reaction assay for Mycobacterium tuberculosus was also negative. A clinical diagnosis of M. marinum infection was made, and the patient''s antibiotic regimen was changed to minocycline. A tuberculin skin test was not performed; since the patient was immunocompromised, a negative result would not have excluded the disease. A chest radiograph appeared normal.Open in a separate windowFig. 2: Acid-fast bacilli visualized in skin biopsy.Open in a separate windowFig. 1: Multiple erythematous papulopustular lesions on the patient''s leg 1 month after the third infusion of infliximab.The patient failed to respond to the minocycline therapy, and he was referred for infectious disease consultation in October 2000. The infliximab infusions were discontinued, and 2 more skin biopsies were performed, with acid-fast bacilli visualized in both specimens. The patient was given trimethoprim–sulfamethoxazole, and his lesions began to heal slowly but progressively.Acid-fast bacilli were recovered from the second set of biopsies, and specific instructions were given to incubate the cultures at 30°C and 35°C to ensure that M. marinum, if present, would be detected. Again, the cultures failed to recover organisms. The laboratory, using polymerase chain reaction restriction analysis of the 439-base pair segment of the gene encoding a 65-kDa heat shock protein,¹ identified the presence of Nocardia species. Nevertheless, Nocardia organisms still could not be recovered in culture, and therefore final speciation could not be performed.The patient resumed taking prednisone, and the dosage was increased in order to ameliorate the symptoms of his Crohn''s disease. The trimethoprim–sulfamethoxazole therapy was continued until late 2003, and the dosage was reduced over the subsequent months. Complete healing of the lesions was eventually achieved 4 years after therapy was initiated.     

Early induction of the Arabidopsis GSTF8 promoter by specific strains of the fungal pathogen Rhizoctonia solani

The Arabidopsis glutathione S-transferase GSTF8 promoter directs root-specific responses to stress. In this study, the response of this promoter to plant infection with Rhizoctonia solani was investigated using a luciferase reporter system. Arabidopsis seedlings harboring the GSTF8:luciferase construct were monitored in vivo for bioluminescence following infection with R. solani. Although the reporter gene was induced in infected roots, the response differed markedly between R. solani strains and was not observed with aggressive strains that caused death of the seedlings. The three strains tested in detail progressed through typical stages of infection, but ZG1-1 induced the GSTF8 promoter in most seedlings, ZG3 induced it in approximately 25% of seedlings, and ZG5 caused little response. Induction of specific root segments occurred early in the infection process in root regions with very limited mycelium visible. In root segments with substantial mycelium, GSTF8 promoter activity no longer was observed. Induction by ZG1-1 also was observed in plants harboring a tetramer of the ocs element from the GSTF8 promoter, suggesting that this element helps mediate the response. Crossing GSTF8:luciferase plants with plants harboring an Nah-G construct that degrades salicylic acid did not abolish the response, indicating that the GSTF8 promoter response to R. solani may be mediated by signals other than salicylic acid.     

Reorganization of cytoskeleton during surfactant secretion in lung type II cells: a role of annexin II

The secretion of lung surfactant requires the movement of lamellar bodies to the plasma membrane through cytoskeletal barrier at the cell cortex. We hypothesized that the cortical cytoskeleton undergoes a transient disassembly/reassembly in the stimulated type II cells, therefore allowing lamellar bodies access to the plasma membrane. Stabilization of cytoskeleton with Jasplakinolinde (JAS), a cell permeable actin microfilament stabilizer, caused a dose-dependent inhibition of lung surfactant secretion stimulated by terbutaline. This inhibition was also observed in ATP-, phorbol 12-myristate 13-acetate (PMA)- or Ca(2+) ionophore A23187-stimulated surfactant secretion. Stimulation of type II cells with terbutaline exhibited a transient disassembly of filamentous actin (F-actin) as determined by staining with Oregon Green 488 Phalloidin. The protein kinase A inhibitor, H89, abolished the terbutaline-induced F-actin disassembly. Western blot analysis using anti-actin and anti-annexin II antibodies showed a transient increase of G-actin and annexin II in the Triton X-100 soluble fraction of terbutaline-stimulated type II cells. Furthermore, introduction of exogenous annexin II tetramer (AIIt) into permeabilized type II cells caused a disruption in the cortical actin. Treatment of type II cells with N-ethylmaleimide (NEM) resulted in a disruption of the cortical actin. NEM also inhibited annexin II's abilities to bundle F-actin. The results suggest that cytoskeleton undergoes reorganization in the stimulated type II cells, and annexin II tetramer plays a role in this process.     

Phosphorylation of profilin regulates its interaction with actin and poly (L-proline)

Activation of bovine platelets with thrombin and phorbol 12,13-dibutyrate (PDBu) resulted in phosphorylation of profilin on serine. The phosphorylation was inhibited when platelets were pretreated with the PI 3-kinase inhibitor, LY294002, indicating that profilin phosphorylation is a downstream event with respect to PI 3-kinase activation. Phosphorylation of profilin resulted in significant decrease in actin polymerization (16.5%), indicating an increased affinity of phosphoprofilin towards actin. The critical actin monomer concentration (Cc) increased to 260 nM in the presence of phosphoprofilin in comparison with 200 nM in the presence of profilin. The interaction of phosphoprofilin with phosphatidylinositol 4,5-bisphosphate [PI (4,5)-P2] and poly (L-proline) (PLP) was examined by monitoring the quenching of tryptophan fluorescence. Scatchard plot and binding isotherm data obtained revealed no difference in PI (4,5)-P2 binding between profilin and phosphoprofilin (Kd=20.4 microM), while poly (L-proline)-binding studies indicated a sixfold decrease (27.34 microM for profilin and 4.73 microM for phosphoprofilin) in Kd with phosphoprofilin. In vivo studies with platelets indicated an increased association of p85alpha, the regulatory subunit of PI 3-kinase with phosphoprofilin over profilin. Overall, the data presented conclude that profilin phosphorylated under in vivo conditions and phosphorylation depends upon activation of PI 3-kinase. Phosphoprofilin exhibited increased affinity to poly (L-proline) sequences both in vitro and in vivo.     

Circulating free nitrotyrosine in obstructive sleep apnea

Obstructive sleep apnea (OSA) has been increasingly linked to cardiovascular disease, endothelial dysfunction, and oxidative stress, generated by repetitive nocturnal hypoxemia and reperfusion. Circulating free nitrotyrosine has been reported as a novel biomarker of nitric oxide (NO)-induced oxidative/nitrosative stress. Nitrosative stress has been implicated as a possible mechanism for development of cardiovascular diseases. We tested the hypothesis that repetitive severe hypoxemia resulting from OSA would increase NO-mediated oxidative stress. We studied 10 men with newly diagnosed moderate to severe OSA who were free of other diseases, had never been treated for OSA, and were taking no medications. Nitrotyrosine measurements, performed by liquid chromatography-tandem mass spectrometry, were made before and after untreated apneic sleep. We compared free nitrotyrosine levels in these patients with those obtained at similar times in 10 healthy male control subjects without OSA, with similar age and body mass index. Evening baseline nitrotyrosine levels were similar before sleep in the control and OSA groups [0.16 +/- 0.01 and 0.15 +/- 0.01 ng/ml, respectively, P = not significant (NS)]. Neither normal nor disturbed apneic sleep led to significant changes of plasma nitrotyrosine (morning levels: control group 0.14 +/- 0.01 ng/ml; OSA group 0.15 +/- 0.01 ng/ml, P = NS). OSA was not accompanied by increased circulating free nitrotyrosine either at baseline or after sleep. This observation suggests that repetitive hypoxemia during OSA does not result in increased NO-mediated oxidative/nitrosative stress in otherwise healthy subjects with OSA.     

In vitro Activation of Protein Kinase C by β-N-oxalyl-l-α, β-diaminopropionic acid,the Lathyrus sativus Neurotoxin

-N-oxalyl-l-,-diaminopropionic acid (l-ODAP) toxicity has been associated with lathyrism; a spastic paraparesis caused by excessive dietary intake of the pulse Lathyrus sativus. We investigated the effect of Lathyrus neurotoxin l-ODAP on protein kinase C (PKC) activity under in vitro conditions. l-ODAP activated phosphorylation activity of purified chick brain PKC. Both lysine-rich (histone III-S) and arginine-rich (protamine sulfate) substrate phosphorylation was enhanced in the presence of l-ODAP. The activation is concentration dependent, and maximal activation is observed at 100 M concentration. Protamine sulfate phosphorylation was enhanced by 47%, whereas histone III-S phosphorylation was enhanced by 50% over PS/PDBu/Ca²⁺ dependent activity. The nontoxic d-isomer (d-ODAP) did not affect both histone III-S and protamine sulfate phosphorylation activity. These results indicate that l-ODAP taken up by neuronal cells could also contribute to PKC activation and so be associated with toxicity.