一种以IL-8和Th1通路强上调的靶样皮肤病变为特征的犬自限性急性 ...

王帆

A self-limited acute febrile sterile neutrophilic dermatosis (Sweet's-like syndrome) in a dog featuring target skin lesions with strong upregulation of interleukin-8 and T-helper 1 pathway

一种以IL-8和Th1通路强上调的靶样皮肤病变为特征的犬自限性急性发热性无菌性中性粒细胞皮肤病（Sweet样综合征）

翻译人：申瑞杰

Abstract

In this report, we provide a case of self-limiting canine acute febrile sterile neutrophilic dermatosis in which the clinical signs featured typical target skin lesions with strong upregulation of T-helper 1 markers and interleukin-8, a potent neutrophil chemoattractant. Further, large case series are needed to characterize canine sterile neutrophilic dermatosis.

KEYWORDS

canine, neutrophilic, self‐limited, Sweet's‐like syndrome

摘要 

在本报告中，我们提供了一例自限性犬急性发热性无菌性中性粒细胞皮肤病，其临床症状表现为典型的靶样皮肤病变，Th1标记物和白细胞介素-8(一种强效中性粒细胞趋化因子)明显上调。需要进一步的大规模病例来表述犬无菌性中性粒细胞性皮肤病。

关键词

犬、无菌中性粒细胞性皮肤病、自限性、Sweet样综合征

 

INTRODUCTION

简介

Acute febrile neutrophilic dermatosis or Sweet's syndrome (SS) in humans is characterized by acute onset of fever and erythematous skin lesions typically revealing an upper dermal infiltrate of neutrophils without histological evidence of infection. Skin lesions in Sweet's syndrome vary from tender erythematous papules to targetoid, vesicular and necrotic plaques. Patients are classically febrile and can have associated extracutaneous signs such as lethargy, arthralgias and myalgias. Systemic glucocorticoids constitute the mainstay of SS treatment with rare SS patients having a spontaneous resolution of symptoms.

人类急性发热性中性粒细胞皮肤病或Sweet综合征（SS）的特征是急性发热和红斑性皮肤病变，通常表现为真皮上层中性粒细胞浸润，无组织学感染证据。Sweet综合征的皮肤病变从轻度红斑性丘疹到靶样、水疱样和坏死样斑块。患者有典型的高热，可能有相关的皮肤外症状，如嗜睡、关节痛和肌肉痛。全身糖皮质激素是治疗SS的主要药物，罕见SS患者症状自行缓解。

 

Canine sterile neutrophilic dermatosis (Sweet's-like syndrome/SLS) is considered to be similar to SS in humans; however, only a few cases of SLS have been published in dogs and the syndrome remains poorly characterized. Reported skin lesions in canine SLS included erythematous macules, papules, pustules and nodules with ulcerations.The treatment of canine SLS with immunosuppressive medications (e.g. glucocorticoids, mycophenolate mofetil and azathioprine) has a variable prognosis.

犬无菌性中性粒细胞性皮肤病（Sweet样综合征/SLS）被认为与人类SS相似；然而，只有少数犬SLS病例发表，该综合征的特征仍不足。据报道，SLS犬的皮肤病变包括红斑、丘疹、脓疱和结节伴有溃疡。用免疫抑制剂（如糖皮质激素、麦考酚酯和硫唑嘌呤）治疗犬SLS的预后不同。

 

Herein, we describe a self-limited case of SLS in a dog characterized by unique typical and atypical target skin lesions, which resolved with early supportive care and pain management without immunosuppressive medications. In addition, we describe gene expression analysis of selected cytokines and chemokines in the lesional skin of this case of canine SLS.

在本文中，我们描述了一例犬SLS的自限性病例，其特征是独特的典型和非典型靶形皮肤病变，通过早期支持性护理和疼痛管理，在未使用免疫抑制剂的情况下得到改善。此外，我们描述了本例犬SLS皮肤病变中选定细胞因子和趋化因子的基因表达分析

 

CASE REPORT

病例报告

A 2-year-old, 19kg, neutered male Australian shepherd dog was referred to the Veterinary Teaching Hospital Emergency Service with 2-day duration of lethargy, inappetence and fever. The sudden change in the health of the dog was not associated with any vaccine or drug administration, and the patient was healthy up to this stage. Amoxicillin-clavulanic acid (250mg twice daily, Zoetis; Parsippany, NY, USA) was initiated a day before referral by the primary practitioner; however, there was no improvement in clinical signs.

一只2岁、19kg、已去势雄性澳大利亚牧羊犬因持续2天嗜睡、食欲不振和发热，被转诊至兽医教学医院急救服务中心。犬健康状况的突然变化与任何疫苗或药物管理无关，患犬到发病前都是健康的。主治医师转诊前一天开始给予阿莫西林克拉维酸（250mg，每日两次）；然而，临床症状没有改善。

 

On physical examination upon referral, the dog was lethargic, febrile (40.9°C) and had painful, multifocal to coalescing, raised, round, erythematous macules to-papules along the ventral abdomen, lateral thorax, dorsum/perianal and perioral areas (Figure 1a). These skin lesions resembled a target (bulls-eye) (Figure 1b, dark red centre with erosion or crust surrounded by a pale pink ring and an erythematous outermost ring) and targetoid skin lesions (Figure 1c, pale pink ring surrounded by outer erythematous ring). There was no involvement of mucous membranes or mucocutaneous junctions. Pain in the caudal spinal area with mild muscle stiffness of the rear legs was observed.

转诊后体格检查，该犬嗜睡、发热（40.9°C），腹底、胸侧、肛背侧/肛周和口周区域出现疼痛的、多灶性至融合性、凸起的、圆形、红斑至丘疹（图1a）。这些皮肤病变类似于靶样（牛眼）（图1b，深红色中心有糜烂或结痂，周围有淡粉色环和最外层的红斑环）和靶样皮肤病变（图1c，浅粉色环，外周有红斑环）。没有涉及黏膜或皮肤黏膜连接处。观察到尾椎区疼痛，后腿肌肉轻度僵硬。

 

 

FIGURE 1 (a) Painful, multifocal to coalescing, raised, round, erythematous macules-to-papules were present along the ventral abdomen, lateral thorax and dorsum. (b,c) Skin lesions featured three (b; ‘typical targets’) and two patterns of discoloration (c; ‘atypical targets’)

图1（a）腹部、胸侧和背部出现疼痛、多灶性至融合的、凸起、圆形、红斑至丘疹。（b，c）皮肤病变有三种（b；“典型靶样”）和两种变色模式（c；“非典型靶样）

 

Urinalysis, complete blood (cell) count (CBC) and biochemistry profile revealed leucocytosis  [21.0×/μl white blood count (WBC)] characterized by a mature neutrophilia (20.4×/μl  segmented neutrophils; reference range 2.9–12×/μl ), a mild increase in alkaline phosphatase (110U/L; reference range 6–80U/L) and moderate hypoalbuminaemia (21.1 g/L; reference range 29.1–30.7  g/L). Abdominal ultrasound and thoracic and thoracolumbar spinal radiographs were unremarkable. Serological testing for Dirofilaria immitis antigen and antibodies against Borrelia burgdorferi, Anaplasma spp. and Ehrlichia spp. (SNAP 4DX Plus test, IDEXX Laboratories; Westbrook, ME, USA) was negative. Cytological evaluation from skin lesions using DiffQuick revealed neutrophils without any signs of infectious organisms. Differential diagnoses for the skin lesions included SLS, the erythema multiforme-toxic epidermal necrolysis (EM-TEN) group of diseases, toxic shock-like syndrome and vasculitis.

尿液分析、全血（细胞）计数（CBC）和生化分析显示白细胞增多（白细胞计数（WBC）21.0×/μl）以成熟中性粒细胞增多为特征（分叶中性粒细胞20.4×/μl ，参考范围2.9-12×/μl），碱性磷酸酶轻度升高（110U/L；参考范围6–80U/L）和中度低蛋白血症（21.1 g/L；参考范围29.1–30.7 g/L）。腹部超声、胸部和胸腰段脊椎X线片均无异常。对心丝虫抗原和伯氏疏螺旋体、无形体和埃利希体抗体的血清学检测均为阴性。使用Diff-Quick对皮肤病变处进行的细胞学评估显示中性粒细胞，没有任何感染微生物的迹象。皮肤病变的鉴别诊断包括SLS、多形红斑-中毒性表皮坏死松解症（EM-TEN）、中毒性休克样综合征和血管炎。

 

Three 8mm punch biopsies obtained from the skin lesions and one from nonlesional skin from the lateral thorax were bisected; one half was placed in 10% neutral-buffered formalin for paraffin embedding and routine histopathological evaluation, while the second half was immediately placed in RNALater solution (Ambion; Austin, TX, USA), kept at room temperature overnight and stored at −80°C for gene expression analysis  using quantitative real-time (qRT)-PCR (Methods S1). The Institutional Animal Care and Use Committee (IACUC) approved the collection of skin biopsies for qRT-PCR analysis and the owners signed written informed consent.

从皮肤病变处获得三个8mm打孔活检样本，一个从胸侧非病变处获取的活检样本被一分为二；一半置于10%中性缓冲福尔马林中进行石蜡包埋和常规组织病理学评估，另一半立即置于RNALater溶液中，在室温下保存过夜，然后储存在−80°C使用定量实时（qRT）-PCR（方法S1）进行基因表达分析。动物护理机构和使用委员会（IACUC）批准收集皮肤活检进行qRT-PCR分析，并由宠主签署书面知情同意书。

 

Skin biopsies from the target skin lesions featured acute perivascular to interstitial dermatitis with nondegenerate neutrophils extending from the superficial to the deeper dermis (Figure 2a). Low numbers of macrophages and mast cells accompanied this neutrophilic infiltrate (Figure 2b). Mild epidermal hyperplasia with neutrophil infiltration and focal epidermal ulceration was observed in some sections. Occasionally, neutrophils were within vascular lumens in inflamed areas, but there was no evidence of primary vasculitis (Figure 2c). Dermal haemorrhages or fibrin exudation were not present in any of the sections. Neither Giemsa nor Gram stains revealed the presence of any infectious agents.

靶样皮肤病变的皮肤活检以急性血管周至间质性皮炎为特征，非退行性中性粒细胞从真皮浅层延伸至真皮深层（图2a）。有少量巨噬细胞和肥大细胞伴随中性粒细胞浸润（图2b）。在一些切片中观察到轻度表皮增生伴中性粒细胞浸润和局部表皮溃疡。偶见，炎症区域的血管腔内有中性粒细胞，但没有原发性血管炎的证据（图2c）。所有切片均未出现真皮出血或纤维蛋白渗出。Giemsa和革兰氏染色均未发现任何感染病原的存在。

 

 

FIGURE 2 Photomicrographs of skin from the Australian shepherd dog with Sweet's-like syndrome. (a) Perivascular to interstitial dermatitis with nondegenerate neutrophils extending from the superficial to the deeper dermis and focal epidermal damage at the surface. (b) Dermal neutrophil infiltration with low numbers of macrophages and mast cells was observed. (c) Occasionally, neutrophils were within vascular lumens in inflamed areas, but there was no evidence of a primary vasculitis. Haematoxylin and eosin, ×10; ×20

图2患有Sweet样综合征的澳大利亚牧羊犬的皮肤显微照片。（a） 血管周至间质性皮炎，伴随非退行性中性粒细胞从真皮浅层延伸至真皮深层，表面有局灶性表皮损伤。（b） 观察到真皮中性粒细胞浸润，巨噬细胞和肥大细胞数量较少。（c） 偶见，炎症区域的血管腔内有中性粒细胞，但没有原发性血管炎的证据。HE染色，×10；×20

 

 

The history of fever, clinical features (e.g. fever, arthralgia/myalgia and mature neutrophilia) and histopathological findings were consistent with canine SLS.

发热史、临床症状（如发热、关节痛/肌肉痛和成熟中性粒细胞增多症）和组织病理学发现与犬SLS一致。

 

The messenger RNA (mRNA) transcripts of nonlesional skin showed no upregulation, while lesional skin revealed an expression of inflammatory responses (Figure 3) with increased upregulation of cytokines interferon (IFN-γ), interleukin (IL)-1B, alarmin IL-33 and tumour necrosis factor (TNF)-α. Chemokines, IL-8 (also known as CXCL8), C–C motif chemokine ligand 2 (CCL2) and IFN-γ-induced protein 10 (CXCL10), were markedly overexpressed in SLS tissue. The markers involved in the type 2 helper T-cell (Th2) pathway, cytokines IL-4, IL-13 and chemokine CCL17, were downregulated.

非病变皮肤的信使RNA（mRNA）转录物没有上调，而病变皮肤显示炎症反应的表达（图3），伴随细胞因子干扰素（IFN-γ）、白细胞介素（IL）-1B、IL-33和肿瘤坏死因子（TNF）-α上调。趋化因子IL-8（也称为CXCL8）、C-C基序趋化因子配体2（CCL2）和IFN-γ诱导蛋白10（CXCL10）在SLS组织中显著超表达。与2型辅助性T细胞（Th2）通路相关的标志物，细胞因子IL-4、IL-13和趋化因子CCL17被下调。

 

 

FIGURE 3 Quantitative real-time PCR of selected relevant cytokine and chemokine genes in the Sweet's-like syndrome (SLS) nonlesional and lesional skin versus healthy control skin. Genes were normalized to canine reference gene ribosomal protein L8 (RPL8). CCL, C–C motif chemokine ligand; CXCL, C-X-C motif chemokine; IFN-γ, interferon gamma; IL, interleukin; TNF-α, tumour necrosis factor–alpha; MMP, matrix metallopeptidase.

图3 Sweet样综合征（SLS）的非病变皮肤和病变皮肤与健康对照皮肤中选定的相关细胞因子和趋化因子基因定量实时PCR。犬基因标准参考核糖体蛋白L8（RPL8）。CCL、C-C基序趋化因子配体；CXCL、C-X-C基序趋化因子；γ干扰素；IL、白介素；TNF-α，肿瘤坏死因子-α；MMP、基质金属肽酶。

 

 

The patient was hospitalized in the intensive care unit and supportive care was initiated with intravenous fluid resuscitation (Plasma-lyte—Baxter Healthcare Corporation, Deerfield IL, USA). To control the pain and discomfort, hydromorphone (Hospira; Lake Forest, IL, USA; 0.05mg/kg i.v. every 4–6 h for 2days,) was initiated. The supportive care and pain management resulted in significant improvement in the dog's condition over the following 24h; the fever and lethargy resolved and there was no evidence of new skin lesions. After three days of hospitalisation, follow-up bloodwork revealed no abnormalities and SLS skin lesions resolved, leaving small focal crusts at the previous macular and papular areas (Figure 4a). Skin lesions completely cleared after 10days (Figure 4b). At the time of writing, the patient had been maintained in clinical remission for more than 4years without recurrence of SLS disease.

患犬在重症监护室住院，并通过静脉液体复苏开始支持性护理。为了控制疼痛和不适，开始使用氢吗啡酮（每4-6小时静脉注射0.05mg/kg，持续2天）。在随后的24小时内，支持性护理和疼痛管理使犬的病情显著改善；发烧和嗜睡消失，没有新的皮肤病变出现。住院三天后，后续血液检查未发现异常，SLS皮肤病变已消失，在先前的斑点和丘疹区域留下小的局灶性结痂（图4a）。10天后皮肤病变完全清除（图4b）。在撰写本报告时，患犬已维持临床缓解超过4年，SLS未复发。

 

 

 

FIGURE 4 Marked reduction in the skin lesions after three days (a) and complete remission of skin lesions after 10days (b)

图4三天后皮肤病变明显减少（a），十天后皮肤病变完全缓解（b）

 

DISCUSSION

讨论

Major diagnostic criteria for human SS include abruptonset of painful erythematous cutaneous lesions (macules, papules, plaques, nodules) and histopathological findings corresponding to neutrophilic dermatitis with no infectious agents or vasculitis. In addition, fever, mature neutrophilia and rapid response to glucocorticoid therapy belong to minor human SS criteria. In our patient, the history, the presence of fever, mature neutrophilia and painful erythematous macules-to papules, along with histopathological findings of sterile neutrophilic infiltrate, supported the diagnosis of canine SLS. Human SS is classified as idiopathic, malignancy related or drug-induced;  there was no history of previous causal drug relationship or malignancies found in the patient of this report.

人类SS的主要诊断标准包括突然发作的疼痛性红斑性皮肤病变（斑点、丘疹、斑块、结节），以及与中性粒细胞性皮炎相对应的组织病理学发现，无感染因素或血管炎。此外，发烧、成熟中性粒细胞增多和对糖皮质激素治疗的快速反应属于人类轻度SS标准。在我们的患犬中，病史、发烧、成熟中性粒细胞增多症和疼痛性红斑至丘疹以及无菌性中性粒细胞浸润的组织病理学发现支持了犬SLS的诊断。人类SS分为特发性、恶性肿瘤相关或药物反应；在本报告中患犬没有药物相关或恶性肿瘤的相关病史。

 

In rare cases of human SS, erythematous skin lesions can develop true vesicles or bullae in the centre and targetoid appearance. A single case of canine SLS reported typical target skin lesions; however, three concentric zones of colour change in skin lesions were absent and vasculitis was observed on histopathological examination. Typical and atypical target skin lesions have been described in erythema multiforme and the Stevens–Johnson syndrome/toxic epidermal necrolysis spectrum of human and canine diseases, but, to the best of the authors' knowledge, this is the first description of target lesions in canine SLS. Extracutaneous manifestations commonly affecting joints and the digestive tract have been reported in dogs with SLS; this patient experienced arthralgia as observed in human and canine SS.

在罕见的人类SS病例中，红斑性皮肤病变可在中心形成真正的水疱或大疱，并出现靶样外观。一例犬SLS报告了典型的靶样皮肤病变；然而，皮肤病变未见三个同心区域的颜色变化，在组织病理学检查中观察到血管炎。人类和犬类的疾病多形红斑和SJS/中毒性表皮坏死松解症中描述了典型和非典型的靶样皮肤病变，但据作者所知，这是首次描述犬SLS的靶样皮肤病变。据报道，SLS犬的皮肤外表现通常影响关节和消化道；如在人和犬SS中观察到的，该患犬经历了关节痛。

 

The precise molecular pathogenic mechanisms leading to the development of human SS are only partially understood. The current proposed SS pathogenesis involves dysfunctional innate and adaptive immunity with cytokine dysregulation. Type 1 helper T cells with increased Th1-associated cytokines IL-1β, IL-2 and IFN-γ are proposed to be responsible for neutrophil activation and location in SS skin lesions; Th2 markers are reduced in SS. Strong cutaneous upregulation of Th1 markers IL-1β and IFN-γ, with downregulation of Th2 markers (IL-4, IL-13), was observed in the lesional skin of our SLS patient. Chemokines, CCL2, IL-8 (CXCL8) and CXCL10, which promote transendothelial migration of neutrophils and other inflammatory cells, were over expressed in the SLS lesional skin of this report. The upregulation of IL-8 and CXCL10 previously has been observed in human SS skin lesions. Although there is a homology in the behaviour of selected lesional skin molecular markers in our canine SLS patient and human SS, further large sample size molecular and protein expression studies in skin lesions of canine SLS are warranted to elucidate the pathogenesis of this disease.

仅部分了解导致人类SS发展的精确分子致病机制。目前提出的SS发病机制涉及先天性功能失调和后天性免疫细胞因子调节异常。Th1和增加的Th1相关细胞因子IL-1β、IL-2和IFN-γ被认为是SS皮肤病变中中性粒细胞活化和定位的原因；SS中Th2标记物减少。在SLS患犬病变的皮肤中观察到Th1标志物IL-1β和IFN-γ的强烈上调，而Th2标志物（IL-4、IL-13）的下调。趋化因子CCL2、IL-8（CXCL8）和CXCL10促进中性粒细胞和其他炎性细胞的皮内迁移，在本报告的SLS病变皮肤中过度表达。以前在人类SS皮肤病变中观察到IL-8和CXCL10的上调。尽管在我们的SLS患犬和人类SS中，选定的病变皮肤分子标记物存在同源性，但是犬SLS皮肤病变需要对更大样本基数的分子和蛋白质表达进行更深的研究，以阐明该疾病的发病机制。

 

Treatment of human SS involves addressing the aetiological factor (e.g. withdrawal of culprit drug and surgical excision of tumour) and providing pharmacological therapy with systemic glucocorticoids to resolve SS symptoms. However, some cases of human SS resolve without specific treatment. Systemic glucocorticoids have been the mainstay of therapy for canine SLS cases;  however, not all dogs survived the disease.  In our patient, treatment with early supportive care involving intravenous fluid resuscitation and analgesia resulted in significant improvement of clinical signs within 24h. There was no utilization of immunomodulating drugs in our patient.

人类SS的治疗包括解决病因（如停用致病药物和手术切除肿瘤），并提供全身糖皮质激素的药物治疗，以解决SS症状。然而，一些人类SS在没有特殊治疗的情况下得以解决。全身糖皮质激素是治疗犬SLS的主要药物；然而，并不是所有的犬都能幸存下来。在我们的患犬中，早期支持性护理（包括静脉液体复苏和镇痛）的治疗在24小时内显著改善了临床症状。我们的患犬没有使用免疫调节药物。

 

To the best of the author's knowledge, this is the first case of self-limiting canine SLS in which the clinical signs featured typical target skin lesions with strong upregulation of Th1 markers (IL-1B, IFN-y, CXCL10) and IL-8, a potent neutrophil chemoattractant. Further largecase series are needed to in-depth characterize the clinical signs, treatment and prognosis of canine SLS.

据作者所知，这是第一例犬自限性SLS，其临床症状表现为典型的靶样皮肤病变，Th1标志物（IL-1B、IFN-y、CXCL10）和IL-8（一种强效的中性粒细胞趋化因子）强烈上调。需要进一步的大规模病例来深入描述犬SLS的临床症状、治疗和预后。

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

bateer578

好文章，努力学习