Digital gangrene associated with idiopathic hypereosinophilia: treatment with allogeneic cultured dermal substitute (CDS)

ARTICLE

Auteur(s) : Toshio OHTANI, Katsuyuki OKAMOTO, Chikako KAMINAKA, Tomoh KISHI, Mikihisa SAKURANE, Yuki YAMAMOTO, Koji UEDE, Kentaro KUBO¹, Yoshimitsu KUROYANAGI¹, Fukumi FURUKAWA

Department of Dermatology, Wakayama Medical University, 811-1, Kimiidera, Wakayama 641-0012, Japan 
¹ R&D Center for Artificial Skin, Allied Health Science, Kitasato University, Sagamihara, Japan

Article accepted on 1/3/2004

Hypereosinophilic syndrome (HES) is characterized by peripheral blood eosinophilia and the infiltration of eosinophils into many organs, including the skin. The most common cutaneous involvements are pruritic maculopapular and nodular lesions, or urticarial and angio-edematous plaques [1]. 
Recently, Jang et al. described a HES patient presenting with multiple erythematous patches and plaques on the lower extremities complicated by digital gangrene [2]. Histopathological examination of the cutaneous lesions in that patient revealed necrotizing eosinophilic vasculitis. They speculated that necrotizing eosinophilic vasculitis may be one of the cutaneous manifestations of HES, and that digital gangrene may be less rare as one of its manifestations than has previously been thought. 
In the present case study, we investigated the efficacy of a new approach in which cultured cells are used to treat severe skin defects. A number of skin substitutes containing keratinocytes and/or fibroblasts have been developed [3-6]. These products can provide effective therapy for patients suffering from burns, diabetes ulcer or pressure sores [7-12]. Kuroyanagi et al. developed an allogeneic cultured dermal substitute (CDS) composed of a spongy matrix of collagen containing fibroblasts [13]. To improve wound management, they have developed another CDS by culturing fibroblasts on a two-layered spongy matrix of hyaluronic acid and collagen; this is the CDS that was used in the present case [14,15]. Hyaluronic acid has a high capacity for hydration, resulting in a moist environment at the wound site. This molecule plays a critical role in several cellular functions, including migration and proliferation, by promoting adhesion and disadhesion on tissue substrate [16]. Collagen and collagen-derived peptides act as chemoattractants for fibroblasts in vitro, and may have similar activity in vivo [17]. The fibroblasts contained in the present CDS can release biologically active substances such as VEGF and extracellular matrix components such as fibronectin, which are necessary for wound healing (Kubo K, Kuroyanagi Y. unpublished data). Since April 2001, the R&D Center for Artificial Skin of Kitasato University has been the main participating institution of the Regenerating Medical Millennium Project (skin department) of the Ministry of Health, Labor and Welfare of Japan. This center has established a banking system for cryopreserved allogeneic CDS, and has distributed these products to 30 hospitals across Japan in a frozen state. The results of a multi-center clinical study suggest that the present type of allogeneic CDS can provide an excellent wound bed with highly vascularized granulation tissue suitable for autologous split-thickness skin graft [18, 19]. Here, we describe use of this CDS in a case of idiopathic hypereosinophilia with digital gangrene.

Case report

A 65-year-old man noticed a cold sensation, pain, and purpuric patches on the fingers of both hands on May 10, 2002. Although vasodilators and anti-inflammatory drugs were prescribed by his doctor, the symptoms did not improve. Because the patient subsequently presented with similar lesions on both soles, he visited our hospital on June 4, 2002, and was admitted 2 days later. Although his previous and family history was unremarkable, he had smoked 1 or 2 packs of cigarettes per day for 45 years.
The patient was 162 cm in height and 56.3 kg in weight. There had been no weight loss during the previous month. On admission, his blood pressure was 110/72 mmHg, his pulse rate was 68/min, and his body temperature was 36.5 °C. There were purpuric patches on the tips of the fingers (Fig. 1) and soles. The distal area of the first toe of the left foot was necrotic. Laboratory investigations revealed the following: white blood cell count, 30700/mm³ (77.9% eosinophils); IgE, 6366U/l; anti-nuclear antibody (ANA), × 160. All other immunological screening results were negative or normal; these included anti-ds DNA, anti-SS-A, anti-SS-B, anti-Jo-1, anti-cardiolipin antibody, anti-neutrophil cytoplasmic autoantibody (ANCA), and complement components (C3, C4, CH50) Coagulation parameters, including protein C and S, were normal. Stool samples were negative for parasites. No abnormalities were found by thoracoabdominal X-ray, CT scans or echocardiographic examinations. The karyotype of peripheral blood cells was normal (46, XY). A skin biopsy specimen obtained from a lesion of the right sole showed a perivascular infiltrate composed predominantly of lymphocytes and eosinophils in the superficial dermis. In the deep dermis, thickening of the small blood vessels and obliterative changes were found (Fig. 2), but without any distinct vasculitis or panniculitis.
The patient was treated with vasodilators, anti-platelets, and oral prednisolone (60 mg/ day). Although the peripheral blood eosinophilia improved within a week, his pain and numbness persisted and digital gangrene developed day by day (Figs. 3a, 3b). Beginning on August 13, 2002, oral ciclosporin (200 mg/day) was prescribed, but was not effective. After amputation of the distal phalanges and debridement of the lateral side of the right foot on September 13, 2002 (Fig. 4), trafermin was applied to the skin defects. Due to persistent pain, we applied the allogenic CDS to the skin defects (Fig. 5), and a conventional ointment-gauze dressing was used to protect the CDS. The CDS was replaced with fresh CDS at intervals of 3 to 5 days for 6 weeks. During CDS treatment, the pain almost disappeared, and there was no other complaint about the wound area. Because healthy granulation tissue had successfully formed we covered the skin defects with split-thickness skin grafts harvested from the thigh on November 11, 2002 (Fig. 6). The treatment with prednisolone and ciclosporin was gradually discontinued, and the patient was discharged from our hospital on December 11, 2002.

Discussion

HES generally involves marked eosinophilia of unknown etiology and damage to multiple organs. The criteria for diagnosis of HES include the following: peripheral blood eosinophilia with eosinophil counts > 1 500/mm³ for at least 6 months; no evidence of parasitic, allergic or other known causes of eosinophilia; and presumptive signs and symptoms of multiple organ involvement [1]. Because we began medication as soon as the laboratory investigations revealed hypereosinophilia (eosinophil counts, 23 900/mm³), it is not clear whether the first criteria was fulfilled in the present case. However, the symptoms and laboratory results generally indicated HES.
Cutaneous manifestations occur in more than 50% of HES patients [1]. However, digital gangrene in HES has very rarely been reported [2, 20, 21]. As mentioned above, Jang et al. described a HES patient presenting with cutaneous vasculitis complicated by digital gangrene [2]. In contrast, Oppliger et al. reported a HES patient with digital gangrene associated with occlusion of medium-sized arteries, but without cutaneous vasculitis [20]; this suggests that digital gangrene in HES can develop independently of cutaneous vasculitis. In the present case, cutaneous vasculitis was not detected by histopathological analysis. Instead, some blood vessels were almost obliterated, whereas others were extremely dilated, probably due to compensation. Elastica van Gieson staining showed that these obliterated vessels were arterioles. Angiography of the extremities was not performed, because we were unable to obtain approval from the patient; thus the condition of his medium-sized arteries was unclear. However, it is possible that his long-term smoking induced thromboangiitis obliterans (TAO).
Ferguson et al. found marked eosinophilic infiltration of the thrombus and vessel wall in a patient with TAO associated with idiopathic hypereosinophilia. It is possible that, in some TAO patients, eosinophils are involved in pathogenesis of TAO [22]. In fact, other cases of hypereosinophilia with arterial occlusion have been reported [23]. Although the precise pathomechanism responsible for thrombosis in patients with hypereosinophilia is unknown, it has been suggested that eosinophilic granule protein impairs thrombomodulin function [24, 25].
In the present patient, prednisolone reduced the absolute eosinophil count. However, the severe pain in his fingers and toes was uncontrollable. Takekawa et al. have suggested that tumor necrosis factor alpha (TNF-α) may play a role in the etiology of necrosis of the fingertips in HES [21]. Further investigations are needed to determine if any other interventions, such as anti-TNF antibody, suppress the necrosis more effectively than corticosteroids. In addition, cases of HES, that respond well to imatinib, have recently been reported [26, 27].
In the present case, we used the allogeneic CDS prepared by Kuroyanagi et al. [14], at the sites where amputation and debridement were performed.
This CDS has been found to release a number of biologically active substances, including VEGF, bFGF, HGF, KGF, PDGF, TGF-β, IL-6, and IL-8 (Kubo K, Kuroyanagi Y. unpublished data), and to reduce wound size more rapidly than ordinary ointment. In the near future, CDS may be commonly used to improve skin defects. n

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