Hyperhidrosis treated by thoracoscopic sympathicotomy

Hyperhidrosis of the palms, axillae and face has a strong negative impact on social and professional life. The existing non-operative therapeutic options seldom give sufficient relief and have a transient effect. A definitive cure can be obtained by upper thoracic sympathectomy. The traditional open surgical techniques are major procedures and few patients and surgeons have found that the risk--benefit consideration favoured surgery. Since 1987, the authors have divided the upper thoracic sympathetic chain on 1163 patients with a simple endoscopic technique by using standard urological equipment. A bilateral procedure takes less than 20 min and requires just one night in hospital. There have been no mortality or life-threatening complications. Ten patients (< 1%) required intercostal drainage because of haemo- or pneumothorax. Horner's syndrome occurred in four cases. Primary failure occurred in 23 cases (< 2%) and 24 (< 2%) developed recurrent symptoms. The patients with failure and recurrence were successfully reoperated on and only three have required a third operation. At the end of postoperative follow-up (median 31 months) 98% of the patients were satisfied. Endoscopic transthoracic sympathicotomy is an efficient, safe and minimally invasive surgical method for the treatment of palmar, axillary and facial hyperhidrosis.     

Identification of epitopes on a mutant form of Pseudomonas exotoxin using serum from humans treated with Pseudomonas exotoxin containing immunotoxins

PE38 is a 38-kDa derivative of the 66-kDa Pseudomonas exotoxin (PE) in which the cell binding domain of PE (domain Ia, amino acids 1-252) and a portion of domain Ib (amino acids 365-380) are deleted. The immunotoxins LMB-1 and LMB-7 contain PE38 and kill cancer cells by exploiting the cytotoxic action of PE38. The major human B cell epitopes of PE38 were mapped by measuring the reactivity of 45 serum samples from patients treated with the PE38-containing immunotoxins LMB-1 or LMB-7 to two panels of overlapping synthetic peptides representing the sequence of PE38. One panel of peptides is ten amino acids long and overlap by seven amino acids, and the second panel of peptides is twenty amino acids long and overlap by ten. Five major epitopes were identified: amino acids 274-283, 470-492, 531-540, 555-564, and the C-terminal amino acids 596-609. Two minor epitopes were identified as well: amino acids 501-510 and 582-589. These epitopes are predominantly located on the surface of the protein. The amino acids believed to be critical for binding are highly solvent-accessible residues. The results of the human antibody response to peptides are compared to the pattern of reactivity previously identified with serum samples obtained from monkeys administered LMB-1 and LMB-7. The epitopes between monkey and human are almost identical, demonstrating similarity in the response of antibody repertoires between the two species and providing further support that these are the immunodominant epitopes. This information is critical for genetically engineering less immunogenic immunotoxins and provides a foundation for the development of a vaccine against pseudomonal infections which plague immunocompromised individuals and individuals with cystic fibrosis.     

Botulinum A exotoxin for the management of platysma bands

Injections of botulinum A exotoxin are successfully used to treat neuromuscular disorders and to improve hyperkinetic muscles and dynamic rhytids of the upper face. Using these principles, we extended its use to the treatment of the aging neck (hypertrophic platysma muscle bands). A classification system (I to IV) based on horizontal neck rhytids, platysma bands, and skin laxity was devised to categorize the degree of deformity and serve as a guideline for suggested dosages of botulinum. The results correlated with the degree of age-related neck degeneration. Type II (mild horizontal neck rhytids; thin, mild platysma muscle flaccidity; and mild skin laxity) and III (moderate horizontal neck rhytids; thick, moderate platysma muscle flaccidity; and moderate skin laxity) patients were the most satisfied, followed closely by types I and IV. A total of 1500 patients were treated by three independent practices. The majority of them achieved good-to-excellent results, as evaluated by both the physician and patient. The degree of muscle flaccidity and hypertrophy were the factors that most influenced success rates, not the anatomic variations in muscle configuration.     

Detection of Pseudomonas aeruginosa in bronchial and tracheal aspirates by PCR by amplification of the exotoxin A gene

For the first time, a PCR test based on the amplification of the Exotoxin A was evaluated for its ability to rapidly detect Pseudomonas aeruginosa in tracheal and bronchial aspirates from mechanically ventilated patients. The reaction is based on the amplification of a 396 bp region within the Exotoxin A gene. The results show that this PCR-method is suitable for the detection of Pseudomonas aeruginosa even in clinical samples such as aspirates. Among the 380 clinical samples tested in this way, 57 were found to be positive while only 36 were positive using routine culture. In conclusion, these results suggest that the PCR-method mentioned above can be used to provide a specific, rapid, simple, and highly sensitive detection of Pseudomonas aeruginosa in clinical samples.     

Blink reflex recovery cycle in patients with blepharospasm unilaterally treated with botulinum toxin

To study the role of arterial blood dynamics in the thrombogenesis of thrombin-induced experimental retinal vein obstruction, the retinal blood flow velocity was evaluated using scanning laser ophthalmoscopic fluorescein videoangiography in an experimental rabbit retinal vein obstruction model. Retinal vein obstruction was made by transadventitial direct instillation of thrombin to the retinal vessels from the vitreous side. The blood flow velocity in the retinal artery and vein was estimated by measuring the passing velocity of the flow head of the dye bolus and venous filling time, respectively. 23 animals were treated with thrombin and compared with 18 controls not treated. In the control group retinal artery blood flow velocity and retinal venous fluorescein filling time was 5.3 +/- 1.1 mm/sec (mean +/- standard deviation) and 6.2 +/- 1.2 sec, respectively. In the treated group the values were 5.7 +/- 1.3 mm/sec and 5.8 +/- 1.0 sec before the thrombin administration, and 3.0 +/- 0.9 mm/sec at 24 hours after its administration, and 5.7 +/- 2.0 sec and 4.0 +/- 1.5 mm/sec and 4.5 +/- 1.4 sec at 48 hours after the administration. These results indicate that a decrease in retinal artery blood flow velocity is strongly involved in the thrombogenesis in thrombin-induced experimental retinal vein obstruction.     

Hyperhidrosis as the only symptom of post-influenza diencephalitis

A prospective study to evaluate sexual dysfunction following resection of the rectum was performed in 21 male patients. Following proctocolectomy for inflammatory bowel disease (9 patients), the incidence of sexual dysfunction was 11%, and it was always partial. Following abdominoperineal excision of the rectum for carcinoma (7 patients), the incidence of sexual dysfunction was 50%, and it was total in 16%. After anterior resection with low colorectal anastomosis (5 patients), the incidence of sexual dysfunction was 40%. The risk of dysfunction following operations on the rectum increased with the age of the patient and was minimal below the age of 50 years. In patients with inflammatory bowel disease, careful dissection close to the rectum should avoid damage to the pelvic nerves, and the incidence of sexual dysfunction should be low.     

Hyperhidrosis as the presenting symptom in post-traumatic syringomyelia

Post-traumatic syringomyelia is now a well known entity and occurs months or years after a spinal cord injury. The presenting symptoms are usually pain, progressive motor weakness, sensory changes, and increased spasticity. Profuse sweating or hyperhidrosis can be a symptom of the post-traumatic syrinx or can occur in autonomic dysreflexia provoked by peripheral stimuli. We present two patients with cervical spine fractures whose presenting symptom of post-traumatic syringomyelia was hyperhidrosis affected by posture. The pathophysiology involved and the management of these patients is discussed.     

Targeting Pseudomonas exotoxin to hematologic malignancies

Malignant cells of hematopoietic origin often express a variety of different growth factor receptors and antigens on their surface, at levels much higher than normal cells. These malignant cells can be selectively targeted with Pseudomonas exotoxin (PE) derivatives directed by interleukins 2, 4 and 6, and by Fv fragments of monoclonal antibodies to interleukin 2 receptor (IL2R) subunits, CD22 and other antigens present on these cells. Anti-Tac(Fv)-PE38, a single-chain recombinant immunotoxin which targets cells bearing the IL2Ra, is furthest along in preclinical development and is being prepared for clinical testing in patients with IL2Ra-positive leukemia, lymphoma and Hodgkin's disease.     

Elevation of vacuolar pH inhibits the cytotoxic activity of furin-cleaved exotoxin A

Exotoxin A (ETA) inhibits protein synthesis in cells by a process that involves receptor-mediated endocytosis and the transport of a 37-kDa proteolytic fragment across a membrane into the cytoplasm. The fragment is apparently generated by the endoprotease furin after the toxin has been endocytosed. Cleavage of ETA by furin requires a low pH in vitro, and presumably also in vivo. Drugs that raise the pH of intracellular compartments are known to protect cells from ETA. The simplest hypothesis to explain this protection has been that the drugs interfere with furin cleavage. To test this idea, we measured the effect of pH-elevating drugs on the action of ETA that had been precleaved with recombinant furin before addition to cells. Surprisingly, we found that pH-elevating drugs protected cells from precleaved ETA as well as intact ETA. These results suggest that the process by which ETA intoxicates cells requires a low vacuolar pH for another event in addition to proteolysis by furin.     

Therapeutic use of botulinum A toxin in neurology

The highly potent neurotoxins produced by Clostridium botulinum lead to botulism when ingested in appreciable amounts. However, botulinum toxin injections delivered intramuscularly in very small quantities can produce a therapeutically intended focal paresis while producing only negligible local or systemic side effects. Over the past several years, various neurological disorders, especially those involving increased muscle tone and/or abnormal movements, have been successfully treated with local botulinum A toxin injections. The success of this method has led to a general change in the management of blepharospasm, torticollis spasmodicus, hemifacial spasm, and other disorders. Treatment is usually effective for 4 to 12 weeks; if symptoms recur, the injections can be repeated over a period of several years, usually with the same success. Side effects depend on the site of the injections, and are rare at the optimal dosage and always reversible. For optimum therapeutic results, this treatment must be restricted to specialized centers.     

Treatment of Frey's syndrome with botulinum A toxin

A 74-year-old woman suffered from severe gustatory sweating and flushing of the preauricular skin following parotidectomy (Frey's syndrome). She was treated with intracutaneous botulinum A toxin injections in the affected skin area. Minor's test was used to determine the extent of the affected area. Within one week, the symptoms disappeared. After three weeks, Minor's test was repeated and showed minimal residual hyperhidrosis. These small areas were treated again. No side effects were noted. At follow-up one year later, the patient was free of symptoms.     

Use of botulinum toxin type F injections to treat torticollis in patients with immunity to botulinum toxin type A

Fifteen patients with torticollis who had been treated with repeated injections of botulinum toxin type A (botox A) developed antibodies to the toxin. This resulted in loss of benefit in the 13 patients who had improved with botox A injections and failure to develop muscle atrophy after injection in all 15 patients. Patients were then injected with botulinum toxin type F (botox F) in the same muscles that had been injected with botox A. Ten of the 15 improved after botox F injections, including 9 of the 12 patients who had improved with type A toxin. Six of 9 patients with pain had improvement in pain after botox F injections. Patients reported similar improvement with type F and type A toxins, but duration of benefit was approximately 3 months with type A and approximately 1 month with type F. Botox F is an effective treatment for torticollis in patients who are immune to botox A. The usefulness of type F toxin, however, is limited by short duration of benefit.     

Generation of neutralizing antipeptide antibodies to the enzymatic domain of Pseudomonas aeruginosa exotoxin A

Burn patients suffer a break in the physical barrier (skin), which, when combined with their generalized state of immunodeficiency, creates an open window for opportunistic infections, mainly with Pseudomonas aeruginosa. Infection of the burn wound has always been a major factor in retardation of wound healing, and sepsis remains the leading cause of death in burn patients. Because studies have shown that topical treatment with antiexotoxin A (ETA) antibodies significantly increases survival in rats infected with toxin-producing strains of P. aeruginosa, we examined 11 synthetic peptides encompassing 12 to 45 amino acid (aa) residues, representing what were predicted by computer analysis to be the most hydrophilic and antigenic regions of ETA. These synthetic peptides were injected into rabbits for antibody production. Different groups of rabbits were immunized with a combination of peptides, with each combination representing one of the three distinct domains of ETA. Animals immunized with various peptide combinations produced peptide-specific antibodies that exhibited cross-reactivity to ETA. Two major epitopes were identified on the ETA molecule by experiments with peptide-specific antibodies in enzyme-linked immunosorbent assay and immunoprecipitation. One of these epitopes was located in the translocation domain (II) (aa 297 to 310), while the other was mapped to the last 13 aa residues at the carboxy-terminal end of the enzymatic domain (III) (aa 626 to 638). Of these two regions, the epitope in the enzymatic domain induced a much higher level of neutralizing antibodies that abrogated the cytotoxic activity of ETA in vitro. Antibodies to this epitope blocked the ADP-ribosyltransferase activity of ETA and appeared to interfere with binding of the substrate elongation factor 2 to the enzymatic active site of the ETA molecule. We conclude that polyclonal, as well as monoclonal, antibodies to short peptides, representing small regions of ETA, may have therapeutic potential in passive immunization or topical treatment of burn patients infected with toxin-producing strains of P. aeruginosa.     

Acute hepatotoxicity of Pseudomonas aeruginosa exotoxin A in mice depends on T cells and TNF

The most potent virulence factor of Pseudomonas aeruginosa, its exotoxin A (PEA), inhibits protein synthesis, especially in the liver, and is a weak T cell mitogen. This study was performed to correlate hepatotoxic and possible immunostimulatory features of PEA in vivo. Injection of PEA to mice caused hepatocyte apoptosis, an increase in plasma transaminase activities, and the release of TNF, IFN-gamma, IL-2, and IL-6 into the circulation. Most strikingly, liver damage depended on T cells. Athymic nude mice or mice depleted of T cells by anti-Thy1.2 mAb pretreatment failed to develop acute hepatic failure, and survival was significantly prolonged following T cell depletion. Neutralization of TNF or lack of TNF receptors prevented liver injury. In the liver, TNF was produced by Kupffer cells before hepatocellular death occurred. After T cell depletion, Kupffer cells failed to produce TNF. Transaminase release was significantly reduced in perforin knockout mice, and it was even elevated in lpr/lpr mice. These results demonstrate that PEA induces liver damage not only by protein synthesis inhibition but also by TNF- and perforin-dependent, Fas-independent, apoptotic signals.     

Primary HIV-1 isolates refractory to neutralization by soluble CD4 are potently inhibited by CD4-Pseudomonas exotoxin

Despite the ability of soluble forms of CD4 (sCD4) and related CD4 derivatives to neutralize human immunodeficiency type 1 (HIV-1) infectivity in vitro, these agents have shown little evidence of efficacy in clinical trials with infected individuals. These disappointing findings may be related to recent observations that much higher concentrations of sCD4 are required for in vitro neutralization of primary HIV-1 isolates compared to laboratory-adapted strains. An alternative CD4-based therapeutic strategy exploits CD4 as a targeting agent to direct cytotoxic molecules to selectively kill HIV-infected cells. In this report we demonstrate that CD4-Pseudomonas exotoxin inhibits spreading infection by primary HIV-1 isolates known to be highly refractory to neutralization by soluble CD4; the observed potency is at least as great as for a prototypic sCD4-sensitive, laboratory-adapted HIV-1 strain. Thus, the in vitro efficacy of a CD4-based agent, which acts by targeted killing of infected cells, appears not to be compromised by features which render primary HIV-1 isolates refractory to neutralization by sCD4 derivatives. These results have important conceptual and practical implications for CD4-based therapeutic strategies.