Principal Component Analysis to Differentiate Patients with Palmoplantar Pustulosis from Those with Palmoplantar Pustular Psoriasis

Background@#Palmoplantar pustulosis (PPP) is initiated from the acrosyringium. However, it is unclear whether PPP should be considered a distinct entity or should be classified into the spectrum of pustular psoriasis, also known as palmoplantar pustular psoriasis (PPPP). @*Objective@#We evaluated the differences in immunohistochemical staining in patients with PPP to determine whether they can be classified into two groups based on psoriatic properties or acrosyringeal properties. @*Methods@#Nineteen punch biopsy specimens diagnosed with PPP were collected. Antibodies were chosen for identifying the acrosyringeal properties of α-3-nicotine acetylcholine receptors (α-3-nAChR), psoriatic properties of interleukin (IL)-23 and IL-36R, inflammatory cell properties of human cathelicidin antimicrobial peptide 18/LL-37, IL-8, lipocalin-2 (LCN2), and CD3. The degree of staining of the epidermis was evaluated using the ordinal scale (0~3). The principal component analysis was used to derive principal components (PCs) of common variation between the stains, and the two groups were divided using PCs and cluster analysis. @*Results@#Three main PCs explained 64% of the total variance in PPP. PC1 (pustular psoriasis properties) showed a higher correlation with IL-36R. PC2 (acrosyringeal/inflammatory properties) showed a higher correlation with α-3-nAChR, IL-8, LCN2, and CD3. PC3 (psoriasis properties) showed a higher correlation with IL-23. PC1 showed a statistically significant difference (p=0.0284) between the two groups. We identified three PCs associated with the pathomechanisms of PPP. @*Conclusion@#Although PC1 showed a statistically significant difference between the two groups, we did not identify differential protein expression related to the pathogenesis between PPP and PPPP.

Hepatocellular Carcinoma Arising from Hepatocellular Adenoma in an Elderly Male Patient

Hepatocellular adenoma is a benign tumor of the liver occurring predominantly in young women taking oral contraceptives. The malignant transformation of hepatocellular adenoma into hepatocellular carcinoma has rarely been reported. Herein, we report the case of an elderly male patient with hepatocellular carcinoma that developed from hepatocellular adenoma. The patient’s high risk for surgery and conflicting biopsy and imaging results made it difficult to determine the treatment direction. Eventually, the mass was completely removed by laparoscopic left hemi-hepatectomy without complications.

Hepatocellular Carcinoma Arising from Hepatocellular Adenoma in an Elderly Male Patient

Hepatocellular adenoma is a benign tumor of the liver occurring predominantly in young women taking oral contraceptives. The malignant transformation of hepatocellular adenoma into hepatocellular carcinoma has rarely been reported. Herein, we report the case of an elderly male patient with hepatocellular carcinoma that developed from hepatocellular adenoma. The patient’s high risk for surgery and conflicting biopsy and imaging results made it difficult to determine the treatment direction. Eventually, the mass was completely removed by laparoscopic left hemi-hepatectomy without complications.

Characteristics of the Gut Microbiome of Healthy Young Male Soldiers in South Korea: The Effects of Smoking

Background/Aims@#South Korean soldiers are exposed to similar environmental factors. In this study, we sought to evaluate the gut microbiome of healthy young male soldiers (HYMS) and to identify the primary factors influencing the microbiome composition. @*Methods@#We prospectively collected stool from 100 HYMS and performed next-generation sequencing of the 16S rRNA genes of fecal bacteria. Clinical data, including data relating to the diet, smoking, drinking, and exercise, were collected. @*Results@#The relative abundances of the bacterial phyla Firmicutes, Actinobacteria, Bacteroidetes, and Proteobacteria were 72.3%, 14.5%, 8.9%, and 4.0%, respectively. Fifteen species, most of which belonged to Firmicutes (87%), were detected in all examined subjects. Using cluster analysis, we found that the subjects could be divided into the two enterotypes based on the gut microbiome bacterial composition. Compared with enterotype 2 subjects, subjects classified as enterotype 1 tended to be characterized by higher frequencies of potentially harmful lifestyle habits (current smoker: 55.6% vs 36.6%, p=0.222; heavy drinker: 16.7% vs 3.7%, p=0.120; insufficient physical activity: 27.8% vs 14.6%, p=0.318). We identified a significant difference in the microbiome compositions of current and noncurrent smokers (p=0.008); the former differed from the latter mainly in a relatively lower abundance of Bifidobacterium species and a higher abundance of Negativicutes. @*Conclusions@#A high abundance of Actinobacteria and low abundance of Bacteroidetes

Arthroscopic Treatment of Septic Arthritis of the Shoulder: Technical Pearls to Reduce the Rate of Reoperation

Background@#The aim of this study was to evaluate clinical experience with arthroscopic debridement for septic arthritis of the shoulder joint and to report on our patient outcomes. @*Methods@#The retrospective analysis included 36 shoulders (male:female, 15:21), contributed by 35 patients (mean age, 63.8 years) treated by arthroscopy for septic arthritis of the shoulder between November 2003 and February 2016. The mean follow-up period was 14.3 months (range, 12–33 months). An additional posterolateral portal and a 70º arthroscope was used to access the posteroinferior glenohumeral (GH) joint and posteroinferior subacromial (SA) space, respectively. Irrigation was performed with a large volume of fluid (25.1±8.1 L). Multiple suction drains (average, 3.3 drains) were inserted into the GH joint and SA space and removed 8.9±4.3 days after surgery. Intravenous antibiotics were administered for 3.9±1.8 weeks after surgery, followed by oral antibiotic treatment for another 3.6±1.9 weeks. @*Results@#Among the 36 shoulders, reoperation was required in two cases (5.6%). The average range of motion achieved was 150.0º for forward flexion and T9 for internal rotation. The mean simple shoulder test score was 7.9±3.6 points. Nineteen shoulders (52.8%) had acupuncture or injection history prior to the infection. Pathogens were identified in 15 shoulders, with Staphylococcus aureus being the most commonly identified pathogen (10/15). Both the GH joint and the SA space were involved in 21 shoulders, while 14 cases involved only the GH joint and one case involved only the SA space. @*Conclusions@#Complete debridement using an additional posterolateral portal and 70º arthroscope, a large volume of irrigation with >20 L of saline, and multiple suction drains may reduce the reoperation rate.

Histopathologic Study of Morbilliform Drug Eruption: Differences between Chemotherapeutic Agents and Antibiotics / 대한피부과학회지

BACKGROUND: Cutaneous drug eruption is very common, and its clinical manifestations are variable. Diagnosis of drug eruption is usually based on clinical findings and medication history. To date, few studies have compared the variable histopathologic findings of drug eruption according to medication. OBJECTIVE: We focused on morbilliform eruption among diverse manifestations of drug eruption and investigated the differences in histopathologic findings between antibiotics- and chemotherapeutic-agent-induced morbilliform drug eruption. METHODS: We reviewed medical charts established from March 1998 to August 2016 at our hospital. Inclusion criteria were histopathologically confirmed drug eruptions, clinical demonstrations of typical morbilliform eruptions obtained from medical photographs, and causative drugs identified as chemotherapeutic agents or antibiotics. Immunohistochemical staining was performed and included CD3, CD4, CD8, CD20, CD56, CD68, langerin, CD138, and c-kit. RESULTS: A total of 40 cases (20 cases, chemotherapeutic group; 20 cases, antibiotics group) were included in this study. The most frequent histologic feature of the epidermis was exocytosis (95%) in the chemotherapeutic group and necrotic keratinocytes (100%) in the antibiotics group. Inflammatory infiltration depths were significantly deeper in the antibiotics group than in the chemotherapeutic group. There was no significant difference between the two groups in terms of immunohistochemical staining. CONCLUSION: This study suggested that in patients with morbilliform drug eruption, chemotherapeutic agents cause more superficial inflammation compared to antibiotics. These findings may facilitate the differentiation of the culprit agents of morbilliform drug eruption in cancer patients. Further large, well-designed studies are needed to confirm these findings.

Metastatic Blue Nevus-Like Melanoma Detected by Liquid-Based Catheterized Urine Cytology

Primary or metastatic malignant melanoma can mimic benign blue nevus in rare cases, making the diagnosis challenging. Herein, we report an exceptionally rare case of blue nevus-like melanoma and its blue nevus-like metastasis which was detected by catheterized urine cytology. The patient presented with blue-colored papuloplaques on his temple which were diagnosed as blue nevus-like melanoma on punch biopsies. While he was admitted for administration of chemotherapy, hematuria was detected. Catheterized urine cytology revealed singly scattered oval to spindle-shaped pigmented cells with a moderate degree of variation in shape and size. Many of them had small nuclei with indiscernible to inconspicuous nucleoli while only a few cells showed nuclear enlargement and nuclear hyperchromasia, which could be diagnostic pitfalls. Most of the cells on the smear were positive for HMB45 immunostaining, which confirmed the diagnosis of metastatic blue nevus-like melanoma. To the best of our knowledge, the present case is the first report describing cytomorphologic findings of blue nevus-like metastasis of melanoma in the urine specimen.

Histopathological Differential Diagnosis of Psoriasis and Seborrheic Dermatitis of the Scalp

BACKGROUND: The differential diagnosis of psoriasis and seborrheic dermatitis can be difficult when both conditions are localized to the scalp without the involvement of other skin sites. OBJECTIVE: We aimed to evaluate the histopathological differences between psoriasis and seborrheic dermatitis on the scalp and identify favorable criteria for their differential diagnosis. METHODS: We evaluated 15 cases of psoriasis and 20 cases of seborrheic dermatitis of the scalp that had been clinicopathologically diagnosed. Skin biopsy sections stained with H&E were examined. Additional immunohistochemistry was performed, including Ki-67, keratin 10, caspase-5, and GLUT-1. RESULTS: On histopathological examination, mounds of parakeratosis with neutrophils, spongiform micropustules of Kogoj, and clubbed and evenly elongated rete ridges were significantly more frequently observed in psoriasis. Follicular plugging, shoulder parakeratosis and prominent lymphocytic exocytosis were significantly more common in seborrheic dermatitis. Moreover, significantly higher mitotic figures were observed in psoriatic lesions than in seborrheic dermatitis. Immunohistochemistry did not show any difference between psoriasis and seborrheic dermatitis. CONCLUSION: Histopathological features favoring psoriasis include mounds of parakeratosis with neutrophils, spongiform micropustules of Kogoj, clubbed and evenly elongated rete ridges, and increased mitotic figures (≥6/high-powered field). Features indicating seborrheic dermatitis are follicular plugging, shoulder parakeratosis and prominent lymphocytic exocytosis. Immunohistochemistry was not helpful in differentiating psoriasis from seborrheic dermatitis.

Comparison of Outcomes of Conservative Treatment, Early Vertebroplasty, and Delayed Vertebroplasty in Patients with Osteoporotic Vertebral Compression Fractures

STUDY DESIGN: Retrospective study. OBJECTIVES: To compare the treatment outcomes of conservative treatment, early vertebroplasty (EVP), and delayed VP (DVP) of patients with osteoporotic compression fractures. SUMMARY OF LITERATURE REVIEW: VP is regarded as an effective treatment for osteoporotic compression fractures. Few studies have compared the outcomes of each of the following treatments: conservative treatment, EVP, and DVP. MATERIALS AND METHODS: A total of 202 patients who presented with thoracolumbar osteoporotic vertebral compression fractures between January 2008 and December 2013 were divided into three groups: group 1 (conservative treatment), group 2 (VP within three weeks), and group 3 (VP after three weeks). We compared the collapse rate and the visual analog scale (VAS) score immediately after the trauma and at the 1-week, 3-week, 6-week, and 1-year follow-ups. RESULTS: The three abovementioned groups consisted of 89 patients, 60 patients, and 53 patients, respectively. The bone mass density (BMD) score of group 1 was statistically significantly higher than that of the others (p<0.05). In group 2, the average VAS score was high immediately after the trauma and low at the 1-year follow-up. Only group 2 showed a significantly high vertebral compression rate immediately after the trauma (p<0.05). Although there were no statistically significant differences in the incidence between the adjacent and the non-adjacent vertebral compression fractures, more patients underwent additional VP in groups 2 and 3 (p=0.980). CONCLUSION: The treatment method of performing EVP seems to yield the best clinical outcomes for patients with osteoporotic compression fractures who exhibit a relatively low BMD, high collapse rate, and high VAS score. Conservative management is the treatment of choice for osteoporotic compression fracture patients with a relatively high BMD, low collapse rate, and low VAS score.

Motor Weakness of Right Ankle Dorsiflexion Caused by Increasing Size of Sacroiliac Joint Cyst after Posterior Lumbar Interbody Fusion in a Patient with Spinal Stenosis: A Case Report

STUDY DESIGN: Case report OBJECTIVES: To report a case of motor weakness caused by the increasing size of a sacroiliac joint cyst after spinal fusion. SUMMARY OF LITERATURE REVIEW: There have been no reports on the increased size of a sacroiliac joint cyst and motor weakness after spinal fusion. MATERIALS AND METHODS: A 63-year-old female was admitted with low back pain and right sciatica. Magnetic resonance imaging (MRI) findings showed the spinal canal narrowing at L4-5 and a cystic lesion on the right sacroiliac joint. After surgery, the symptoms were relieved. RESULTS: One month after the operation, motor function had worsened to grade 4. Follow-up MRI revealed an increase in the size of the cystic lesion. Selective nerve root blocks were performed. There was gradual improvement, and the motor grade reached grade 5 seven months after the operation. CONCLUSIONS: We recommend that surgeons evaluate the adjacent segmental lesion by MRI before performing spinal fusion.

Usefulness of the Cytomegalovirus Antigenemia Assay in Patients With Ulcerative Colitis

BACKGROUND/AIMS: Patients with ulcerative colitis (UC) are at high risk for cytomegalovirus (CMV) reactivation. The usefulness of the CMV antigenemia assay in active UC patients has rarely been studied. We assessed whether the assay detects CMV colitis and predicts clinical outcomes in patients with UC. METHODS: We retrospectively reviewed the medical records of patients hospitalized for moderate-to-severe UC from 2003 to 2012. Positive CMV antigenemia was defined as > or =1 pp65-positive cell per 2x10(5) polymorphonuclear neutrophils. CMV colitis was defined as the presence of inclusion bodies and/or positive immunohistochemistry in the colonic mucosa. The primary outcome was steroid refractoriness, defined as the absence of clinical improvement after intravenous high-dose steroid administration. RESULTS: A total of 43 patients were enrolled. CMV antigenemia was detected in 12 (27.9%) patients. Positive CMV antigenemia was significantly associated with CMV colitis (P =0.001). The sensitivity and specificity of positive CMV antigenemia for diagnosing CMV colitis were 66.7% and 87.1%, respectively. Steroid refractoriness was found in 11 of 12 (91.7%) and 12 of 31 (38.7%) patients with positive and negative CMV antigenemia, respectively (P =0.002). The independent predictors for steroid refractoriness were positive CMV antigenemia (adjusted odds ratio [OR], 7.73; 95% confidence interval [CI], 1.22-49.19; P =0.030) and a shorter duration from the diagnosis of UC (adjusted OR, 0.99; 95% CI, 0.98-0.99; P =0.025). CONCLUSIONS: The CMV antigenemia assay shows low sensitivity but high specificity for detecting CMV colitis and may predict steroid-refractory UC. Early rescue therapy might be considered in UC patients positive for CMV antigenemia.

Prediction of Tumor Recurrence in Patients with Non-Gastric Gastrointestinal Stromal Tumors Following Resection according to the Modified National Institutes of Health Criteria

BACKGROUND/AIMS: Few studies have investigated the prognosis of non-gastric gastrointestinal stromal tumors (GISTs) under the modified National Institutes of Health (NIH) consensus criteria in Korea. This study aims to clarify the clinical usefulness of the modified NIH criteria for risk stratification. METHODS: From January 2000 through October 2012, 88 patients who underwent curative resection for primary GISTs were included in this study. The enrolled patients were stratified to predict recurrence by the original NIH criteria and modified NIH criteria. RESULTS: In all, 88 patients had non-gastric GISTs, including 82 and 6 patients with GISTs of the small intestine and colorectum, respectively. The mean age was 57.3+/-13.0 years, and the median follow-up duration was 3.40 years (range, 0.02-12.76 years). All patients who were placed in the intermediate-risk category according to the original NIH criteria were reclassified into the high-risk category according to the modified NIH criteria. Therefore, the proportion of cases in the intermediate-risk category declined to 0.0% from 25.0% (22/88), and the proportion of cases in the high-risk category increased to 43.2% (38/88) from 18.2% (16/88) under the modified NIH criteria. Among the 22 reclassified patients, 6 (27.3%) suffered a recurrence during the observational period, and the recurrence rate of high-risk category patients was 36.8% (14/38). CONCLUSIONS: Patients in the high-risk category according to the modified NIH criteria had a high GIST recurrence rate. Therefore, the modified NIH criteria are clinically useful in selecting patients who need imatinib adjuvant chemotherapy after curative surgical resection.

Acute Polymyositis/systemic Lupus Erythematosus Overlap Syndrome with Severe Subcutaneous Edema and Interstitial Lung Disease

Inflammatory myopathy is characterized by symmetrical proximal muscle weakness, elevated muscle enzyme levels and favorable response to glucocorticoids therapy. Although periorbital edema is a common manifestation of inflammatory myopathy, generalized subcutaneous edema is very rare. We report here a case of a 47-year-old female patient with acute polymyositis/systemic lupus erythematosus overlap syndrome with generalized subcutaneous edema and interstitial lung disease. We aggressively treated the disease with high-dose glucocorticoids, intravenous immunoglobulin, and immunosuppressive agents.

Expression of Glycolysis-Related Proteins in Solid Papillary Carcinoma of the Breast According to Basement Membrane Status

PURPOSE: The aim of this study was to investigate the differences of expression in glycolysis-related proteins such as Glut-1, carbonic anhydrase (CA) IX, and monocarboxylate transporter (MCT) 4 according to the myoepithelial cell (MEC) and basement membrane (BM) status in solid papillary carcinoma (SPC) of the breast. MATERIALS AND METHODS: Immunohistochemical evaluation of Glut-1, CAIX, and MCT4, as well as p63 and type IV collagen, were performed on 23 SPC cases. RESULTS: Six and nine cases of SPC showed the presence and absence of myoepithelial cells, respectively, and eight cases belonged to the borderline status (p63-positive MEC on some areas of the outer tumor surface but not in others). BM was partially or completely absent in 14 cases and present in nine cases. SPC lacking BM more frequently showed high expression of CAIX than SPC with BM (p=0.037). CONCLUSION: In SPC of the breast, a strong expression of CAIX seems to be associated with an increasing degree of loss of BM, which can be interpreted as BM degradation due to the induction of extracellular acidity with increasing expression of CAIX.

ThinPrep Cytological Findings of Desmoplastic Small Round Cell Tumor with Extensive Glandular Differentiation: A Case Study

Desmoplastic small round cell tumor (DSRCT) is a rare and highly aggressive neoplasm. The cytological diagnosis of this tumor has only been reported in a few cases. In most of these cases, the diagnosis was made using fine-needle aspiration cytology. Most DSRCTs resemble disseminated carcinomatoses in their clinical manifestation as well as cytomorphologically, even in young-adult patients. These authors report a case of using peritoneal-washing and pleural-effusion ThinPrep cytology to diagnose DSRCT, with extensive glandular differentiation and mucin vacuoles. We found that fibrillary stromal fragment, clinical setting, and adjunctive immunocytochemical staining were most helpful for avoiding misdiagnosis.

Successful Treatment of Steroid-Dependent Eosinophilic Cellulitis With Cyclosporine

Eosinophilic cellulitis (EC) is a rare idiopathic disorder, first described as a "recurrent granulomatous dermatitis with eosinophilia", that mimics cellulitis of infectious origin. We describe here a previously healthy 11-year-old girl who experienced fever and tender erythematous patch lesions after trauma to her knees. Because of the relapsing cellulitis-like skin lesions, skin biopsies were taken, resulting in a diagnosis of EC. The patient responded well to oral prednisolone but experienced side effects and relapse during dose tapering. She was switched from prednisolone to cyclosporine. Her EC remained under control, and she showed no evidence of relapse after discontinuation of cyclosporine.

Sural Artery Flap for the Treatment of Soft Tissue Defects around Knee Joint

PURPOSE: This report presents the authors' experience of twelve patients with sural artery flap for soft tissue defects around the knee joint. MATERIALS AND METHODS: The patients' age ranged from 25 to 80 years; seven of the patients were male and five were female. The cause of soft-tissue defects involved wide excision for malignant soft tissue tumor, tumor prosthesis related infection, infection after total knee arthroplasty and chronic osteomyelitis. Postoperative range of motion was checked. The sensibility of flap was evaluated by Semmes-Weinstein monofilaments and two-point discrimination. RESULTS: All flaps survived and provided satisfactory coverage of the defect. There was no complication except one delayed skin graft incorporation at donor site. Seven knee joints which had been stiff previously gained average 58 degrees of ROM postoperatively. All flaps retained sensibility and showed no significant increase in sensory thresholds comparing with contralateral side. CONCLUSION: Sural artery flap not only shows high survival rate and broad coverage ability, but also offers improvement in range of motion and preservation of sensation. We speculate that sural artery flap is valuable for the reconstruction of the soft tissue defects around knee joint.

A Case of Disseminated Skin and Soft Tissue Infection due to Mycobacterium abscessus with Metastatic Breast Cancer

Mycobacterium abscessus is a rapidly growing species of environmental mycobacteria commonly found in soil, dust, and water throughout the world. In immunocompetent patients, M. abscessus usually causes localized infection of skin and soft tissue in association with a traumatic or surgical wound. Although rare, it may cause disseminated systemic infection in patients with HIV, diabetes, or medically induced immunosuppression. Here we report a case of a 53-year-old female patient with disseminated skin and soft tissue infection due to M. abscessus who presented with multiple skin lesions on the trunk, back and four extremities. The patient had undergone salvage chemotherapy, modified radical mastectomy, and palliative chemotherapy for metastatic breast cancer. Granulomatous inflammation and acid-fast bacilli were found on skin biopsy. M. abscessus was identified via mycobacterial culture and PCR-restriction fragment length polymorphism analysis. The patient responded well to clarithromycin, cefoxitin and amikacin therapy, and was subsequently discharged on oral antimicrobial therapy. Non-tuberculous mycobacterial (NTM) infection is a rare cause of skin and soft tissue infection, and a very high index of suspicion is required to initiate an evaluation for NTM. In metastatic cancer patients with multiple skin lesions, skin infection due to NTM must be differentiated not only from cutaneous metastasis but also from bacterial or fungal infection.

Fine-Needle Aspiration Cytology of the Nodal Marginal Zone Lymphoma

BACKGROUND: Nodal marginal zone lymphoma (NMZL) is a rare B-cell neoplasm consisting of heterogeneous cellular components and residual B-cell follicles. Because of such histological features, it is difficult to diagnose NMZL by fine needle aspiration (FNA) cytology. We reviewed FNA cytology of NMZL to identify a cytological clue to avoid misdiagnosing NMZL. METHODS: Histological, cytological, and clinical findings of seven cases of NMZL were reviewed. RESULTS: Most cases showed nodular aggregates of lymphohistiocytes derived from the germinal center irrespective of histological pattern. The cellular components were heterogeneous and composed of mature small lymphocytes, intermediate and large lymphocytes, immunoblasts, tingible body macrophages, and follicular dendritic cells. Intermediate-sized neoplastic cells with a pale nucleus were observed but difficult to identify because of admixed non-neoplastic cells, which outnumbered neoplastic cells. Except for one case with a high proportion of intermediate-sized cells, the other six cases were initially diagnosed as reactive hyperplasia. A flow cytometric analysis was performed in two cases and failed to demonstrate a monoclonal B-cell population. CONCLUSIONS: The FNA showing a reactive hyperplasia-like smear pattern should be carefully observed by experienced cytopathologists to identify intermediate-sized neoplastic cells. Clinical information including the size of the lymph nodes is important to avoid a misdiagnosis.

Folliculosebaceous Cystic Hamartoma in a Patient with Neurofibromatosis Type I

Folliculosebaceous cystic hamartoma (FSCH) is a rare cutaneous hamartoma composed of dilated folliculosebaceous units and mesenchymal elements. It presents as a papule or nodule usually on the face and scalp, rarely on the genital or trunk area. Histologically, FSCH shares several similar features to sebaceous trichofolliculoma. We report one case of FSCH misdiagnosed as a neurofibroma. He was a 38-year-old man with a neurofibromatosis type I and a nodule on his left earlobe was excised under the impression of neurofibroma. Pathological examination revealed FSCH. Although FSCH is clinically not distinctive, awareness of the lesion is important to differentiate papulonodular or cyst-like cutaneous lesions.