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Granuloma Annulare and

Tolkki, Lauri

2018

Tolkki , L , Hokynar , K , Meri , S , Panelius , J , Puolakkainen , M & Ranki , A 2018 , ' Annulare and Morphea : Correlation with Borrelia burgdorferi Infections and Chlamydia-related Bacteria ' , Acta Dermato-Venereologica , vol. 98 , no. 3 , pp. 355-360 . https://doi.org/10.2340/00015555-2831 http://hdl.handle.net/10138/233836 https://doi.org/10.2340/00015555-2831

Downloaded from Helda, University of Helsinki institutional repository. This is an electronic reprint of the original article. This reprint may differ from the original in pagination and typographic detail. Please cite the original version. Advances in and venereology ActaDV Acta Dermato-Venereologica ActaDV Central Hospital, PCR, there is no firm evidence of a causative role (6–11). ding indirect serological methods anddirect detection by G PO Box 160,FIN-00029Helsinki,Finland.E-mail:[email protected] Allergology and Venereal Diseases, UniversityHelsinki Central Hospital, Dermatology, of Department Inflammation, of Tolkki,Center Lauri Corr: Acta DermVenereol 2018;98:355–360. Accepted Oct31,2017;EpubaheadofprintNov 7,2017 feri; chlamydia-related bacteria. Key words: ; morphea; Borrelia burgdor Borrelia or Chlamydiales with morpheaisunlikely. while trigger GAinsomecorrelation cases, of either tick-mediated infectionsthy skin.Inconclusion, can ted in morphea closely resembled those found in heal ricinus ticks, while the Chlamydiales sequencesdetec mydiaceae bacteria, which are also in present geneous and contained Chlamydiales sequences detected in GA were hetero samples werealso positive for Chlamydiales DNA.The with morphea. AllBorrelia DNA-positive GA 53/73 (72.6%) biopsies with GA and 25/34 (73.4%) with morphea,whileChlamydialesDNAwasfoundin (9.6%) biopsies with GAandin1/36(2.8%)biopsies based method. Borrelia DNAwasdetectedin7/73 (members of theChlamydialesorder), usingaPCR- tick-borne novel agents, Chlamydia-related bacteria DNA usingPCR.Thesamebiopsies wereanalysedfor sies were tested for Borreliacutaneous burgdorferi tients with suspected tick bite was performed. Biop ornuloma morphea annulare(GA) histology from pa A retrospectivestudyof 109skinbiopsies with gra # 1 Lauri TOLKKI burgdorferi InfectionsandChlamydia-related Bacteria Granuloma Annulare andMorphea: Correlation withBorrelia This isan open access article under the CC BY-NC license.www.medicaljournals.se/acta explored inseveralstudiesusingvariousmethods,inclu between to humansviatickbites. Although thecausalconnections Borrelia burgdorferi sensulato,aspirochetetransmitted aetiology (1–5). One of the possible causative agents is to carryanothergroupof potential humanpathogens, causes tick-borneencephalitis (TBE)(12–15). spotted fevergroupofRickettsiae causes humangranulocytic anaplasmosis,speciesofthe causes babesiosis,Anaplasmaphagocytophilum , which and humanpathogens,suchasBabesiamicroti , which known toserveasvectorsforanumberofotheranimal Journal Compilation ©2018ActaDermato-Venereologica. Department of Dermatology, Allergology and Venereal Diseases, University of Helsinki and Center of Inflammation, Helsinki University Helsinki Inflammation, of Center and Helsinki of University Diseases, Venereal and Allergology Dermatology, of Department These authorscontributed equally to this paper. In addition to Recently, ) are skin reactions with unknown andmorphea(localized ranuloma annulare(GA) B. burgdorferi and GA and morphea have been Ixodes ricinustickshavealsobeenshown 1# , 2 Department of Virology,and Kati HOKYNAR B. burgdorferi sensu lato Waddliaceae and 2# , Seppo MERI , which , andFlavivirus, which 3 Department of Bacteriology and Immunology, University of Helsinki, Helsinki, Finland Rhabdochla 3 , ticks are , CLINICAL REPORT Jaana PANELIUS Ixodes ------but havemainlyremainedobscure. and transmissionrouteshavebeenwidelyinvestigated, pathogenic potential(20,21),andtheirreservoirs,vectors including arthropods,andhumans.Manyofthemhave from various sources), but subsequently also in animals, types ofenvironmentalsamples(e.g.soilandwater related bacteria. They wereoriginally detected in various Parilichlamydiaceae arecollectivelycalledChlamydia- ceae, Piscichlamydiaceae,Clavichlamydiaceaeand Simkaniaceae, Rhabdochlamydiaceae, Criblamydia These newfamilies:Parachlamydiaceae,Waddliaceae, are recognizedasbelongingtotheChlamydialesorder. have beendescribedand,currently, 8additionalfamilies years, anincreasingnumberofnovelchlamydialspecies Chlamydia, familyChlamydiaceae).Duringthelast20 mydia trachomatis and or morpheaandweresubmitted toB.burgdorferi DNA analysis Data forallpatientswhoseskin biopsieshadahistologyofGA Patients MATERIALS ANDMETHODS bacteria. serve asvectorsfortransmissionofChlamydia-related burgdorferii PCR. This suggeststhattickscouldindeed and 85%inskinsamplesfromsubjectspositiveforB. 49%) (19/39, skin healthy in 49% of prevalence a with Chlamydiales DNA was found in human skin samples, Finnish ticksand,furthermore,inhumanskinbiopsies. reported theoccurrenceofChlamydialesinupto40% (17). andticks dataon healthyskin published We recently examined, andtheresultscomparedwithourpreviously rence andtype(s)ofChlamydialesinthebiopsieswas role inthepathogenesisoftheseconditions,occur certain typesofChlamydia-relatedbacteriacouldplaya plasma cells in the . Inorder to determine whether ofabundant orbecause ofborreliosis a clinicalsuspicion died forthe presence ofB. burgdorferi were analysed retrospectively. The samples had been stu cally confirmedGA and localized scleroderma (morphea) of theorderareestablishedhumanpathogensChla and alarge core-setofgenes. The traditionalmembers intracellular lifestyle,biphasicdevelopmentalcycle characteristic featuresoftheorderChlamydiales:strict the share They (16–19). bacteria Chlamydia-related In this study, 109 patient skin biopsies with histologi 1 , Mirja PUOLAKKAINEN Acta DermVenereol 2018;98: 355–360 Chlamydia pneumoniae (genus 2 and Annamari RANKI doi: 10.2340/00015555-2831 , either because of 1 355 - - - - - Advances in dermatology and venereology ActaDV Acta Dermato-Venereologica ActaDV www.medicaljournals.se/acta macule (upperarm).(D)Typical presentationofawidepatchmorphea. dorsum of hand. (B) Generalized GA consisting of coalescing into plaques in certain regions. (C) InterstitialGA may present as an erythematous Fig. 1.Clinical and morpheaskinlesions. (A) pictures of granuloma annulare(GA) Localized GA typically presents with an annular on the corresponding forwardandreverseprimers,0.5µl10µMprobe, the µM 10 Scientific, µl (ThermoFisher 1 USA), MA, Waltham, ned 10µl2×MasterMixoftheDyNAmoFlashProbeqPCRKit LightCycler with PCR Real-time 22). (6, earlier described as probes, and primers 16S rRNA-andOspA-specific of routine diagnostics by PCR amplification and hybridization with B. burgdorferi sensulatoDNA detectionwasperformedasapart Detection of standard textbooks. GA and morphea were classic and identical tothe description in with patients our of samples the in findings histopathological The (3). sclerosis systemic of lesion skin the from guishable indistin is morphea of histopathology The (2). inflammation interstitial, bothofwhicharecharacterizedbymucinanddermal cases ofmorphea. examination by one of the authors (LT) in 71 cases of GA and 34 dermatopathologist. Histological slides were available forre- Hospital, HelsinkiUniversityCentralHospitalbyanexperienced tion intheLaboratoryofDermatopathology, Skinand Histopathological analysiswasperformedasroutineinvestiga Histopathology files retrospectively. morphea. Clinicalandserologicaldatawereretrievedfrompatient with 36 GAand with patients 73 from biopsies skin 109 cluded recommendation basedonhistologicalfeatures. The studyin of borreliosis,historytickbites,orthedermatopathologist’s ofB.burgdorferi forthepresence studied duetoclinicalsuspicion Hospital from 2010 to 2015 were reviewed. The sampleswere at theDepartmentofDermatology, HelsinkiUniversityCentral 356 Switzerland) was also performed. Briefly,performed. also was Switzerland) contai reactions PCR GA has2predominanthistologicalvariants,palisadingand L. Tolkkietal. B. burgdorferi inskinbiopsiesbyPCR ® (Roche, Basel, - - - - and sequencingofamplicons Detection of minescence immunoassay(Liaison chemilu confirmatory a positive, was Germany) Russelsheim, immunoassays. Ifthescreeningtest(Genzyme Virotech GmbH, determined by2 were antibodies andIgM IgG Anti-borrelia Borrelia antibodies (GA) ormorphea Table I.Characteristicsof109patientswithgranulomaannulare the 16S rRNA16S the ExoProStar Illustra by purified were region) gene run. The resulting DNA amplicons(approximately200bpof and no-template(water)controlswereincludedineachPCR Extreme precautions were taken to avoid cross-contamination, real-time TaqMan-PCR method,asdescribedearlier(17,24). Chlamydiales DNA wasdetectedwithapan-Chlamydiales were interpretedasdescribedearlier(22). procedure (Diasorin, Saluggia, Italy) by HUSLAB (23). The results a LightCyclerinstrument(Roche). cycling (60 cycles of 95°C 15 s, 60°C 1 min) was performed with and 100ngtemplateDNA inatotalreactionvolumeof20µl.PCR Patients, Male, Female, Generalized disease, Localized disease,n Follow-up time,months, mean (range) Tick-bite recalled Age, years, mean(range) n (%) n n (%) Chlamydia (%) n (%) -related bacteriainskinbiopsiesbyPCR ® ) wasperformedasaroutine GA 73 8 (11) 38 (52) 9 (0–55) 17 (23) 59 (7–85) 65 (89) 35 (48) Morphea 36 6 (17) 20 (56) 18 (0–55) 7 (19) 55 (8–84) 30 (83) 16 (44) -

Advances in dermatology and venereology ActaDV Acta Dermato-Venereologica ActaDV with confirmed migrans (22), since the very the since (22), migrans erythema confirmed with a tickbite;andthishasbeenreportedevenforpatients 8–84 years). Most of the patients did not recall having had that ofthepatientswithmorpheawas55years(range and years) 7–85 (range years 59 GAwas with patients in Clinical characteristicsofthepatientsaresummarized Clinical andhistologicalfindings RESULTS family (17,25,26). sequences wereconsideredasmembersofthesameChlamydiales ≥ was identity sequence the if and determined, was established first the from FinnishIxodesricinus ticks. For family-level classification, the Chlamydiales sequences from biopsies of healthy skin and Center forBiotechnologyInformation(NCBI)database, especially Chlamydiales sequences to the known sequences in the National sequencing unitoftheInstituteforMolecularMedicineFinland. manufacturer’s instructions.Sequencingwasthenperformedatthe 1-Step (GEHealthcare,Buckinghamshire,UK)accordingtothe bundles, atrophicsweatglandsand minimal inflammatoryinfiltrate. (Haematoxylin-eosin stain;originalmagnification:AandD×4;B×10;C×20). collagen eosinophilic and packed characterized tightly is by morphea stage fibrotic of Histology (D) present. are cells plasma case this In prominent. is histiocytes, lymphocytes and giant cells.(C)InterstitialGA:histiocytesand lymphocytes are scattered around collagen bundlesand blood vessels. Mucin morphea. and (GA) 2. Histology annulare Fig. of granuloma BLAST analysiswasperformedinordertocomparetheobtained Table I.Mostpatientswerefemale. The meanageof Chlamydiales strainoftheBLAST hitlist Granuloma annulareandmorphea:correlationwithB.burgdorferiChlamydia-relatedbacteria 90%, the 2 the 90%, (A) and (B) Palisading GA: central area of necrobiotic collagen and mucin surrounded by

DNA couldbefoundineithergroup. cells andpositivityforeitherBorrelia orChlamydiales plasma of presence the between correlation No (91%). Of the morphea cases, plasma cells were present in 31/34 GApalisading GA and70%oftheinterstitial cases c