S1 Guideline onychomycosis

Onychomycosis is a fungal infection of the fingernails and toenails. In Europe, tinea unguium is mainly caused by dermatophytes. The diagnostic workup comprises microscopic examination, culture and/or molecular testing (nail scrapings). Local treatment with antifungal nail polish is recommended for mild or moderate nail infections. In case of moderate to severe onychomycosis, oral treatment is recommended (in the absence of contraindications). Treatment should consist of topical and systemic agents. The aim of this update of the German S1 guideline is to simplify the selection and implementation of appropriate diagnostics and treatment. The guideline was based on current international guidelines and the results of a literature review conducted by the experts of the guideline committee. This multidisciplinary committee consisted of representatives from the German Society of Dermatology (DDG), the German‐Speaking Mycological Society (DMykG), the Association of German Dermatologists (BVDD), the German Society for Hygiene and Microbiology (DGHM), the German Society of Pediatric and Adolescent Medicine (DGKJ), the Working Group for Pediatric Dermatology (APD) and the German Society for Pediatric Infectious Diseases (DGPI). The Division of Evidence‐based Medicine (dEBM) provided methodological assistance. The guideline was approved by the participating medical societies following a comprehensive internal and external review

Interaction of human dendritic cells with Listeria monocytogenes

Dendritische Zellen (DZ) aktivieren naive CD4+ und CD8+ T-Lymphozyten und spielen daher die entscheidende Rolle bei der Auslösung einer Immunantwort gegenüber pathogenen Mikroorganismen. In dieser Arbeit wurde die Interaktion von DZ mit Listeria monocytogenes untersucht. Es konnte gezeigt werden, dass L. monocytogenes effizient in unreife, humane DZ aufgenommen wird. Die Phagozytoserate von L. monocytogenes unter Zugabe von humanem Plasma war wesentlich höher als im Plasma-freien Medium oder Medium mit fötalem Kälberserum (FCS). Die Zugabe von Immunglobulinen führte zu einem konzentrationsabhängigen Anstieg der Phagozytose von L. monocytogenes in humane DZ, der mit der Phagozytoserate bei Zugabe von humanem Plasma vergleichbar war. Plasma von gesunden Spendern enthielt Antikörper gegen das listerielle Oberflächenprotein p60. Durch die Verwendung einer p60 Deletionsmutante konnte gezeigt werden, dass der p60 Antikörper das Haupt-Opsonin für die Aufnahme von L. monocytogenes in Mo-DZ darstellt. Die Aufnahmerate dieser Mutante zeigte nur geringe Differenzen bei An- oder Abwesenheit von humanem Plasma während der Inkubationszeit, was den Schluss zulässt, dass Immunglobuline gegen das Oberflächenprotein p60 von L. monocytogenes und anderen apathogenen Listerien, für die effiziente Phagozytose verantwortlich sind. Nach Aufnahme der Listerien befanden sich die meisten (> 95 Prozent) DZ in Membran-umgrenzten Phagosomen und sehr selten frei im Zytosol. Die Mehrzahl der Listerien wurde im Phagosom der humanen DZ effizient lysiert. L. monocytogenes-infizierte DZ entwickelten sich phänotypisch zu reifen DZ. Die durch Listerien ausgelöste Maturation der DZ ließen sich durch die Zugabe von listerieller Lipoteichonsäure (LTA) nachahmen. Obwohl bekannt ist, dass eine Listerieninfektion in anderen Zellkulturen Zelltod induziert, führte die Infektion humaner DZ lediglich in weniger als 20 Prozent der infizierten DZ zur Nekrose. Apoptotischer Zelltod konnte nicht nachgewiesen werden. Die Interaktion humaner DZ mit L. monocytogenes könnte somit eine Verbreitung der Bakterien im Organismus verhindern. Langfristig gesehen ergeben die in dieser Arbeit gewonnenen Daten zur Interaktion DZ mit L. monocytogenes Erkenntnisse zur Entwicklung neuer DNA-Vakzinierungsstrategien mit L. monocytogenes als DNA-Träger.Dendritic cells (DC) activate naive CD4+ and CD8+ lymphocytes and are therefore critical for the initiation of an immune response against microorganisms. In this work the interaction between DC and L. monocytogenes was examined. Immature DC show a very efficient uptake of L. monocytogenes. Phagocytosis was much higher in the presence of human plasma than with plasma free media or media with fetal calf serum (FCS). However, the addition of immunoglobulins showed a concentration dependent increase in phagocytosis comparable with the addition of human plasma. Human plama contains antibodies against the listerial surface protein p60. By using a iap-deletion mutant it was shown that antibodies against p60 are the main opsonin for the uptake of L. monocytogenes into DC. Because no difference in the uptake of this deletion mutant in the presence or absence of human plasma was observed; antibodies against p60 appear to be resonsible for the efficient uptake of L. monocytogenes and other apathogenic Listeria strains. A major portion of internalized bacteria is found in membrane-bound phagosomes and rarely free in the cytosol. Most of the bacteria that were taken up by DC were killed very efficiently in the phagosome. Interestingly, infection with L. monocytogenes caused maturation of the immature DC into mature DC. This effect appeared to be largely mediated by listerial lipoteichoic acid. Although L. monocytogenes infection is known to induce death in other cell types, DC were relatively resistant and only 20 per cent of infected DC underwent cell death. Uptake, maturation and resistance to apoptosis suggest that DC are essentiel antigen presenting cell (APC) for L. monocytogenes immunity. Thus these observations into the interaction of L. monocytogenes with human DC provide an important into the pathogenesis of Listeria infection as well as providing a basis for Listeria-based vaccination strategies

Cutaneous adverse events associated with interferon-β\beta treatment of multiple sclerosis

Interferons are widely used platform therapies as disease-modifying treatment of patients with multiple sclerosis. Although interferons are usually safe and well tolerated, they frequently cause dermatological side effects. Here, we present a multiple sclerosis (MS) patient treated with interferon-$\beta$ who developed new-onset psoriasis. Both her MS as well as her psoriasis finally responded to treatment with fumarates. This case illustrates that interferons not only cause local but also systemic adverse events of the skin. These systemic side effects might indicate that the Th17/IL-17 axis plays a prominent role in the immunopathogenesis of this individual case and that the autoimmune process might be deteriorated by further administration of interferons. In conclusion, we think that neurologists should be aware of systemic cutaneous side effects and have a closer look on interferon-associated skin lesions. Detection of psoriasiform lesions might indicate that interferons are probably not beneficial in the individual situation. We suggest that skin lesions may serve as biomarkers to allocate MS patients to adequate disease-modifying drugs

An update on Peginterferon beta-1a Management in Multiple Sclerosis: results from an interdisciplinary Board of German and Austrian Neurologists and dermatologists

Background: Interferon (IFN) beta drugs have been approved for the treatment of relapsing forms of multiple sclerosis (RMS) for more than 20years and are considered to offer a favourable benefit-risk profile. In July 2014, subcutaneous (SC) peginterferon beta-1a 125g dosed every 2weeks, a pegylated form of interferon beta-1a, was approved by the EMA for the treatment of adult patients with RRMS and in August 2014 by the FDA for RMS. Peginterferon beta-1a shows a prolonged half-life and increased systemic drug exposure resulting in a reduced dosing frequency compared to other available interferon-based products in MS. In the Phase 3 ADVANCE trial peginterferon beta-1a demonstrated significant positive effects on clinical and MRI outcome measures versus placebo after one year. Furthermore, in the ATTAIN extension study, sustained efficacy with long-term treatment for nearly 6years was shown. Main text In July 2016, an interdisciplinary panel of German and Austrian experts convened to discuss the management of side effects associated with peginterferon beta-1a and other interferon beta-based treatments in MS in daily practice. The panel was composed of experts from university hospitals and private clinics comprised of neurologists, dermatologists, and an MS nurse. In this paper we report recommendations regarding best practices for adverse event management, focussing on peginterferon beta-1a. Injection site reactions (ISRs) and influenza-like illness are the most common adverse effects of interferon beta therapies and can present a burden for MS patients leading to non-adherence and discontinuation of therapy. Peginterferon beta-1a shows improved pharmacological properties. In clinical trials, the adverse event (AE) profile of peginterferon beta-1a was similar to other interferon beta formulations. The most common AEs were mild to moderate ISRs, influenza-like illness, pyrexia, and headache. Current information on the underlying cause of skin reactions associated with SC interferon treatment, and the management strategies for these AEs are limited. In pivotal trials, ISRs were mainly characterized and classified by neurologists, while dermatologists were only rarely consulted. Conclusions This report addresses expert recommendations on the management of most relevant adverse effects related to peginterferon beta-1a and other interferon betas, based on literature and interdisciplinary experience

Severe and prolonged liver damage in pityriasis rubra pilaris treated with acitretin: a case report

Acitretin is a systemic retinoid that is used in dermatology for treatment of various inflammatory and especially hyperkeratotic diseases. Elevation of liver enzymes may occur occasionally but normally resolves spontaneously, at the latest after termination of acitretin. However, it can very rarely develop into a life-threatening adverse event including drug-induced liver injury (DILI). A 45-year-old man with classical pityriasis rubra pilaris, a frequently severe, inflammatory skin disease, was started on acitretin. After a seemingly harmless elevation of transaminases, a few weeks after initiation of acitretin, the patient experienced a dramatic course of liver injury with hepatic jaundice though acitretin was stopped immediately. Eventually, laboratory values recovered upon high-dose oral prednisolone therapy. Prescribing physicians should keep in mind that acitretin might induce severe liver injury. Even after termination of acitretin laboratory values should be monitored for a while in order to recognize symptomless but harmful drug-induced liver injury in time

Deletion of the Gene Encoding p60 in Listeria monocytogenes Leads to Abnormal Cell Division and Loss of Actin-Based Motility

Protein p60 encoded by the iap gene is regarded as an essential gene product of Listeria monocytogenes. Here we report, however, the successful construction of a viable iap deletion mutant of L. monocytogenes EGD. The mutant, which produces no p60, shows abnormal septum formation and tends to form short filaments and hooked forms during logarithmic growth. These abnormal bacterial cells break into almost normal sized single bacteria in the late-stationary-growth phase. The iap mutant is strongly attenuated in a mouse model after intravenous injection, demonstrating the importance of p60 during infection, and the invasiveness of the Δiap mutant for 3T6 fibroblasts and Caco-2 epithelial cells is slightly reduced. Upon uptake by epithelial cells and macrophages, the iap mutant escapes from the phagosome into the cytosol with the same efficiency as the wild-type strain, and the mutant bacteria also grow intracellularly at a rate similar to that of the wild-type strain. Intracellular movement and cell-to-cell spread are drastically reduced in various cell lines, since the iap-negative bacteria fail to induce the formation of actin tails. However, the bacteria are covered with actin filaments. Most intracellular bacteria show a nonpolar and uneven distribution of ActA around the cell, in contrast to that for the wild-type strain, where ActA is concentrated at the old pole. In an iap(+) revertant strain that produces wild-type levels of p60, intracellular movement, cell-to-cell spread, and polar distribution of ActA are fully restored. In vitro analysis of ActA distribution on the filaments of the Δiap strain shows that the loss of bacterial septum formation leads to ActA accumulation at the presumed division sites. In the light of data presented here and elswhere, we propose to rename iap (invasion-associated protein) cwhA (cell wall hydrolase A)