Effects of ulinastatin treatment on myocardial and renal injury in patients undergoing aortic valve replacement with cardiopulmonary bypass / 대한마취과학회지

BACKGROUND: We determined the protective effects of a high dose of ulinastatin on myocardial and renal function in patients undergoing aortic valve replacement with cardiopulmonary bypass (CPB). METHODS: Sixty patients were assigned randomly to either the ulinastatin group (n = 30) or the control group (n = 30). In the ulinastatin group, ulinastatin (300,000 U) was given after the induction of anesthesia, ulinastatin (400,000 U) was added to the CPB pump prime, and then ulinastatin (300,000 U) was administered after weaning from CPB. In the control group, the same volume of saline was administered at the same time points. Creatine kinase-MB levels were assessed 1 day before surgery, and on the first and second postoperative day (POD 1 and 2). Serum creatinine and cystatin C levels were assessed 1 day before surgery, upon intensive care unit arrival, and on POD 1 and 2. The level of plasma neutrophil gelatinase-associated lipocalin was assessed before induction of anesthesia, upon ICU arrival, and on POD 1. RESULTS: No significant differences were observed in serum levels of creatine kinase-MB and biomarkers of renal injury between the two groups at any point during the study period. CONCLUSIONS: Ulinastatin showed no cardiac or renal protective effects after CPB in patients undergoing aortic valve replacement.

Analgesic Mechanism of Electroacupuncture in an Arthritic Pain Model of Rats: A Neurotransmitter Study

PURPOSE: We investigated what kinds of neurotransmitters are related with electroacupuncture (EA) analgesia in an arthritic pain model of rats. MATERIALS AND METHODS: One hundred rats were assigned to six groups: control, EA, opioid, adrenergic, serotonin and dopamine group. A standardized model of inflammatory arthritis was produced by injecting 2% carrageenan into the knee joint cavity. EA was applied to an acupoint for 30 min in all groups except fo the control group. In the opioid, adrenergic, serotonin and dopamine groups, each receptor antagonist was injected intraperitoneally to their respective group before initiating EA. RESULTS: In the opioid receptor antagonist group, adrenergic receptor antagonist group, serotonin receptor antagonist group, dopamine receptor antagonist group and the control group weight-bearing force decreased significantly from 30 min to 180 min after EA in comparison with the EA group. CONCLUSION: The analgesic effects of EA are related to opioid, adrenergic, serotonin and dopamine receptors in an arthritic pain model of rats.

CD4-/CD56+/CD123+ Hematodermic Neoplasm Showing Early Liver Metastasis

Hematodermic neoplasm (HN) is a clinically aggressive neoplasm with a high incidence of cutaneous involvement and a risk of leukemic dissemination. In the recent WHO-EORTC classification, the term blastic natural killer cell lymphoma has been replaced with CD4+/CD56+ HN because of its derivation from a plasmacytoid dendritic cell precursor. Cases of HN that completely lack CD4 or CD56 expression, therefore represents a diagnostic problem. A 68-year-old Korean male was diagnosed with CD4-/CD56+ HN and treated with hyper-CVAD (cyclophosphamide, vincristine, doxorubicin, dexamethasone) at initial treatment, and then switched to high dose methotrexate/cytarabine. His disease relapsed and resulted in death from bone and brain disease 6 months after complete clinical remission, despite diagnostic workups, including a radioisotope liver scan and ultrasound-guided fine needle aspiration biopsy. Further cytogenetic studies such as comparative genomic hybridization could elucidate the genetic mechanisms in the development and progression of lymphomas. We report an unusual case of 'CD4-/CD56+/CD123+ HN' showing early liver metastasis.

The Correlation between the Tc2 Cells and the CCR4 Expression and the PASI Score in the Peripheral Blood of Psoriasis Patients / 대한피부과학회지

BACKGROUND: Psoriasis is a chronic relapsing skin disorder that is characterized by abnormal epidermal proliferation, inflammation and angiogenesis. It causes emotional and social consequences that go far beyond the skin; therefore, many methods to measure and monitor the severity of psoriasis have been reported. OBJECTIVE: This study aims to evaluate the usability of the flow cytometric analysis of the T cell subsets and their chemokine receptors in the peripheral blood of the psoriasis patients as a severity index. METHODS: The T cell subsets and their chemokine receptor expression (CXCR3, CCR4) in the circulating blood of thirty psoriasis patients (PASI score:2.2~44.2) and twenty healthy controls were examined by flow cytometry. The relationship between the PASI score and the T cell subsets/chemokine receptors was also analyzed. RESULTS: The patients showed significantly higher number of Tc1 (CD8+CXCR3+), Tc2 (CD8+CCR4+) and CXCR3/CCR4 expressing cells than did the control group. Especially, the moderate to severe patients (a PASI score greater that 5) showed a higher number of Tc1, Tc2 and CCR4 expressing cells than did the control group. In the severe patients (a PASI score greater than 10), the frequency of circulating Tc2 cells and CCR4 expressing cells was directly correlated with the PASI score. CONCLUSION: Our findings suggest that flow cytometric analysis of the circulating T cell subsets with further classification could serve as an indicator of the disease severity in psoriasis patients.

A Korean experience with chronic actinic dermatitis during an 18-year period: meteorological and photoimmunological aspects.

BACKGROUND AND PURPOSE: The authors noted that chronic actinic dermatitis (CAD) increased in connection with increased sun exposure and believed that there may be a correlation between the two. The purpose of this study was to determine the relationship between increased sun exposure and CAD. We also applied a clinical severity scoring system to determine the correlation with various laboratory parameters. MATERIALS AND METHODS: We investigated trends in sun exposure in Pusan during an 18-year period. We conducted photopatch/patch testing in 51 CAD patients. We also determined the total IgE, percentage of eosinophils, and chemokine receptor profiles in the peripheral blood and analyzed correlations between laboratory data and the clinical severity of CAD. RESULTS: A close correlation was demonstrated between the number of CAD patients and increased sun exposure. Positive patch test reactions and positive photopatch reactions were observed in 35 and 41 of the 51 tested patients, respectively. The total IgE levels were higher in the severe group than in the others. CCR4 expression increased in parallel with clinical severity. CONCLUSION: Korean patients may have increased susceptibility to CAD with increased sun exposure. We believe that the majority of the CAD patients tested had photoallergy and contact allergy. The clinical severity seemed to correlate well with the total IgE level and CCR4 expression.

The Photosensitivity Localized in a Vitiliginous Lesion Was Associated with the Intramuscular Injections of Synthetic Progesterone during an In Vitro Fertilization-embryo Transfer

The cutaneous diseases associated with progesterone are autoimmune progesterone dermatitis, erythema multiforme- like eruption, drug-induced progesterone dermatitis and solar urticaria. Estrogen and progesterone are widely used in oral contraceptives and hormone replacement therapies, and they are rarely known to cause a photosensitive reaction. The mechanism of contraceptive-induced photosensitivity is uncertain. Estrogen, rather than progesterone, in the combined oral contraceptive pill has been most frequently implicated in the induction of photosensitivity. A 32-year-old woman presented with an erythematous patch with an itching sensation on the centrofacial area of a residual vitiligious lesion. She had a history of being previously treated with narrow band UVB for 1 year. Her skin lesions had mostly subsided, but some lesions continued. She underwent an in vitro fertilization-embryo transfer 3 months previously, and she then took synthetic progesterone for 3 weeks starting at the 4th week of pregnancy. She was in good health with neither a family history of photosensitivity nor a personal history of any other drug ingestion or topical agent such as sunscreen in association with the beginning of her lesions. Phototesting revealed her to be markedly photosensitive in the UVB and UVA ranges. The intradermal skin reactions to progesterone combined with irradiation with UVA or UVB were positive. We report here on an unusual case of photosensitivity that was localized in a vitiliginous lesion, and this was associated with the intramuscular injections of synthetic progesterone that she had received during an in vitro fertilization-embryo transfer.

The Features of Tyrosinase Expressions in Pigmentary Disorders Using TTA / 대한피부과학회지

BACKGROUND: Tyrosinase is the critical enzyme in melanin synthesis. DOPA staining has been used as a standard assay for detecting tyrosinase activity, but it exhibits several limitations. Tyramide based tyrosinase assay (TTA) is a simple and sensitive tyrosinase detecting method. OBJECTIVE: This study aimed to compare the stainability of pigmentary disorders using TTA and DOPA staining. METHODS: The subjects were composed of hyperpigmentary disorders (n=10), hypopigmentary disorders (n=7), and alopecia areata (n=7). The colocalization study of TTA and Mitf using immunofluorescence was performed on alopecia areata. DOPA staining was performed on all tissues to compare with TTA immunohistochemistry. RESULTS: TTA positive cells were correlated with Mitf positive cells in the tissue of alopecia areata. In hyperpigmentary disoders, TTA was stronger than DOPA staining. TTA and DOPA staining didn't observe the positive cells in lesion of vitiligo and piebaldism, but both showed the positive cells in normal skin. TTA staining showed positive cells in the transitional lesion of vitiligo but, DOPA staining did not. In alopecia areata, TTA positive cells were observed, but DOPA staining did not. CONCLUSION: TTA is more sensitive than DOPA staining in pigmentary disorders for detecting tyrosinase activity.

Surgical Tip: The Double-Bladed Scalpel in Mohs Micrographic Surgery

Mohs micrographic surgery is applied as the primary method of treatment for various cutaneous neoplasms. Many other methods that are modified applications of Mohs micrographic surgery have also been suggested. We introduce a technique, which is a modified vertical method of Mohs micrographic surgery using the double-bladed scalpel.

A Case of Milium-like Syringoma on Vulva / 대한피부과학회지

Milium-like syringoma is a rare variant of syringoma first described by Friedman and Butler in 1987. Clinically, it presents as milium, but histologically reveals syringoma with overlying keratin filled epidermoid cysts. It occurs predominantly on the periorbital area of middle-aged women. Syringomas on the genital area have rarely been reported. The lower portion of the cysts and keratin materials show positivity for CEA and negativity for CK7. The pathogenesis is not well defined, but there are some hypotheses, which include pruritus and increasing hormonal receptors (estrogen and progesterone receptors). We report a case of milium-like syringoma on the vulva.

Angiomatoid Spitz Nevus

Spitz nevus is a variant of melanocytic nevus which is histopathologically defined as large spindle and/or epithelioid cells. Angiomatoid Spitz nevus is a rare histologic variant of desmoplastic Spitz nevus characterized by prominent vasculature. We present a case of angiomatoid Spitz nevus, celluar type, that has not been reported before. We provide another example to show the remarkable diversity of Spitz nevus.

The Effect of Montelukast in the Treatment of Atopic Dermatitis through the SCORAD Index / 대한피부과학회지

BACKGROUND: Atopic dermatitis (AD) is a chronic, relapsing, inflammatory skin disease, with genetic and environmental background. The pathogenesis is complex, and although the dermatitis fades during childhood in most cases, the course is unpredictable. Leukotrienes are potent proinflammatory mediators derived from arachidonic acid through the 5-lipoxygenase pathway. Leukotrienes are likely to play a role in the inflammation seen in AD. It is therefore of interest to attempt to reduce the activity of AD by the use of leukotriene antagonists. Montelukast (Singulair(R)) has shown promising results in the treatment of both children and adults with AD, and the safety profile of this medicament is excellent. OBJECTIVE: The objective of our study was to evaluate the efficacy of montelukast for severe AD. METHODS: Thirteen patients with moderate to severe AD were treated with montelukast. The dose of montelukast was 10 mg/day for 8 weeks. At enrollment and on each follow-up visit, every patient was assessed by a single observer and objectively scored for disease extent and severity using SCORing Atopic Dermatitis (SCORAD). In 6 of 13 patients, we measured serum cysteinyl leukotriene levels before and after treatment using ELISA and checked serologic marker such as total Ig E at the first visit and eosinophil counts at every follow-up visit. RESULTS: Patients with a median (range) age of 18.2 (7~38) years participated in the study. Their median SCORAD scores before treatment, at first follow-up (mean 4 weeks later), and at second follow-up (mean 8 weeks later) were 52.4, 35.7, and 29.5. All components of SCORAD (extent, intensity, symptoms) of all patients and eosinophil counts (n=6) had decreased significantly except the extent. Serum cysteinyl leukotriene levels (n=6) had decreased, but not significantly. CONCLUSION: According to our study, montelukast is an effective medicament in the treatment of severe AD patients. So we can take a montelukast as an alternated agent instead of steroid and immunosuppressant agents in severe AD.

A Case of Atypical Vascular Lesion of the Skin following Radiotherapy for Breast Carcinoma / 대한피부과학회지

"Atypical vascular lesions" is the term which was first used in 1994 by Fineberg and Rosen for vascular lesions after radiation therapy except for cutaneous angiosarcoma. Vascular lesions mostly occur after radiation therapy in breast cancer patients who have undergone mastectomy. The lesions are 5 mm or less, red or red-brown papules, histologically dilated vascular channels extended as the superficial and mid-dermis are observed. Post-radiation vascular lesions tend to follow a benign course with metastasis or death not having been reported yet. The lesions look histologically similar to well differentiated cutaneous angiosarcoma occurring after radiation therapy and breast reconstruction, indeed it is possible for post-radiation vascular lesions to become cutaneous angiosarcoma. Atypical vascular lesions have recently become a new issue for concern in some countries. Within Korea however, until now, a case it had not yet been reported. The patient was 50 year-old female who had chemotherapy after Modified Radical Mastectomy and salpingoophorectomy for breast cancer and endometriosis, atypical vascular lesions in the field of radiation therapy occurred. We report an interesting case of atypical vascular lesion.

Combination Nasolabial Transposition Flap and Island Pedicle Flap Following Mohs Surgery of Simultaneous Basal Cell Carcinomas Involving Both Nasal Alae

The nasal ala is a challenging area for surgical reconstruction, with thick sebaceous skin, the lack of an ample tissue reservoir, and an adjacent free margin. Numerous flaps have been reported for the repair of alae defects. A 71-year-old woman with simultaneous basal cell carcinomas involving both nasal alae was treated by Mohs micrographic surgery. The surgical defects measured 1.5x1.5 cm on the center of the right nasal ala and 1.0x1.0 cm on the left nasal ala, including the alar crease and rim. The right nasal ala was used as a nasolabial transposition flap and the left nasal ala was reconstructed by an island pedicle flap. The final shape and texture were satisfactory. The flaps survived and nasal symmetry was preserved. Combined nasolabial transposition and island pedicle flaps thus offer a superior esthetic and functional result owing to minimized tension. This may be a valuable reconstructive option in the repair of bilateral nasal alae defects.

A Case of Trichilemmal Carcinoma Treated with Mohs Micrographic Surgery

Trichilemmal carcinoma is a cutaneous adnexal tumor originating from the outer root sheath of hair follicle, and it was first described by Headington in 1976. Clinically, it usually occurs as an asymptomatic solitary papule, nodule or mass on the face or scalp. This neoplasm is a malignant counterpart of trichilemmoma, and it has been reported in the literature as trichilemmal carcinoma, tricholemmal carcinoma, malignant trichilemmoma, and tricholemmocarcinoma. Although histologically, trichilemmal carcinoma frequently has maliganant features, it has a relatively benign clinical behavior. We think Mohs micrographic surgery is a useful treatment modality in trichilemmal carcinoma because the final skin defect is smaller than a wide excision. We report a case of primary trichilemmal carcinoma which had developed on the face, treated with Mohs micrographic surgery.

A Case of Xanthoma Disseminatum with Diabetes Insipidus / 대한피부과학회지

Xanthoma disseminatum (XD) is a rare, potentially progressive non-Langerhans cell histiocytosis, which preferentially affects males in their childhood or young adulthood. It is characterized by the insidious onset of small, yellowish-red to brown papules and nodules that are discrete and disseminated. They characteristically involve the eyelids and flexural areas of the axillary and inguinal folds, and the antecubital and popliteal fossae. Systemic disease frequently occurs, the most common manifestation being diabetes insipidus (DI), which occurs in about 40% of cases and is due to deposition of xanthoma cells in the hypothalamic-pituitary axis. We present a case of XD with DI, which was treated with the combination therapy of CO2 laser vaporization, cyclophosphamide, electrocauterization and synthetic anti-diuretic hormone.

Two Cases of Acneiform Eruption Caused by Epidermal Growth Factor Receptor Inhibitors / 대한피부과학회지

Epidermal growth factor receptor (EGFR) inhibitors are associated with unique and dramatical dermatological side effects. The most commonly encountered adverse effect is a mild skin toxicity characterized by a sterile follicular and pustular rash that may be treated empirically and usually does not require treatment modification. Secondary adverse reactions seen with anti-EGFR therapy include xerosis, pruritus, paronychia, hair abnormality, and mucositis. According to the Korean literature, there are no reports of acneiform eruption induced by erlotinib (Tarceva(R)). We report a case of acneiform eruption induced by cetuximab (Erbitux(R)) and a case of acneiform eruption induced by erlotinib (Tarceva(R)).

A Case of Churg-Strauss Syndrome Associated with Small Bowel Perforationfollowing High Dose Systemic Steroid Intravenous Injection / 대한피부과학회지

Churg-Strauss syndrome is an uncommon disorder characterized by bronchial asthma or allergic rhinitis, peripheral eosinophilia, systemic necrotizing vasculitis, and extravascular granuloma formation. It commonly affects the lungs, skin, gastrointestinal tract, peripheral nerve, kidneys and the heart. Gastrointestinal symptoms of Churg-Strauss syndrome are common, mainly shown in abdominal pain, diarrhea, or bleeding. Ulceration, perforation, stenosis can occurr with ischemia induced by vasculitis. Gastrointestinal perforation by Churg-Strauss syndrome has been reported rarely, and was recently discovered to have a close correlation to systemic steroid treatment. Nearly one third of patients infected with a gastrointestinal perforation die. This report covers the interesting case of a 54 year-old woman who was being treated for asthma, and was diagnosed as Churg-Strauss syndrome by multiple polyneuropathy and ulcerative macules. Small intestine perforation was generated 4 days after high dose systemic steroid intravenous injection.

A Case of Pigmented Neurofibroma Associated with Giant Cafe-au-lait Patches / 대한피부과학회지

Pigmented neurofibroma is a rare cutaneous tumor accounting for less than 1% of all neurofibroma. It is characterized histologically by the coexistence of scattered melanin-laden cells and benign spindle cells with neural differentiation. The origin of these tumors are unknown, and they show a storifom pattern. In our case, the patient had giant cafe au lait patches on the left trunk which had been present since birth, freckles on both axilla, and two dark-red colored plaques which had appeared 2 years ago. Histologic examination revealed pigmented neurofibromas showing the melanin-laden, pigmented cells within the upper dermis and plexiform neurofibromas in the subcutaneous tissue. We describe a case of pigmented neurofbroma in a 13-year-old male patient.

A Case of Generalized Lichen Planus Treated with Topical Pimecrolimus / 대한피부과학회지

Lichen planus is a chronic papulosquamous disease chracterized by various clinical manifestations of the skin and mucous membrane. Although its etiology is not fully understood, lichen planus has been associated with viral infection, autoimmune disease, psychologic factors, and medications. Both antigen-specific and non-specific mechanisms may be involved in the pathogenesis of lichen planus. The former includes antigen presentation by basal keratinocytes and antigen-specific keratinocyte killing by CD8+ cytotoxic T cells, the latter includes mast cell degranulation and matrix metalloproteinase activation. A large variety of topical and systemic therapies are available for the treatment of lichen planus. Also, topical pimecrolimus (Elidel(R) 0.1% cream) may be used because of its inhibitory effect on activated T cells and mast cell degranulation. Recently, it has been shown to be effective in the treatment of oral and genital lichen planus. But, its effect in cutaneous lichen planus has not been reported to date. We report on the successful use of topical pimecrolimus in the management of a generalized lichen planus patient.

Histopathologic Gradings Correlate with Clinical Prognostic Factors and Therapeutic Effects in Patient with Alopecia Areata / 대한피부과학회지

BACKGRUND & OBJECTIVE: Prognosis of alopecia areata have been attributed to various factors; age of onset, duration before treatment, extent of hair loss, clinical type of alopecia areata, sex, nail changes or accompaniment of atopy. The study on prognostic factors has only been conducted from statistical data of patients and individualized medical conditions. The histopathologic findings of alopecia areata have been investigated by the minute pathologic changes associated with the hair growth cycle in the transverse section. Moreover, these findings were used mainly for diagnostic purpose, but clinical significance of histopathologic severity in prognosis has not been established to date. METHODS: A clinical study, including histopathological and clinical evaluation was conducted on 108 alopecia areata patients between July 1997 and August 2005 at the Department of Dermatology, Dong-A University Hospital. The evaluation criteria INCLUDED: sex, age, age at onset, duration before treatment, clinical types, extent of hair loss, nail changes, accompaniment of atopy, and scalp biopsy finding. The clinical types of alopecia areata were classified as follows; patchy, subtotalis, totalis, and universalis. The extent of hair loss before treatment was classified into 5 grades (S1~S5), according to the method designed by Olsen and Canfield. Clinical improvements after treatment were classified into 5 grades according to degree of regrowth and reduction of the alopecia areata area. Biopsy findings were classified into 4 grades (type I, II, III, and IV) according to classification by Uno and Orecchia. RESULTS: The mean age was 28.6 years, without any sex predominance. The severe histopathologic gradings were significantly associated with early age of onset (p=0.008), a long disease duration before treatment (p=0.003), a greater extent of hair loss (p=0.009), and poor response to treatment (p=0.036). The histopathologic gradings were not significantly associated with sex (p=0.657), clinical types of alopecia areata (p=0.529), nail changes (p=0.746), or accompaniment of atopy (p=0.924). CONCLUSION: Histopathologic gradings in alopecia areata, using vertical sections are significantly associated with prognostic factors such as age of onset, extent of hair loss, disease duration before treatment, as well as the response to treatment. Therefore we consider that the histopathologic grading system is recommendable as an independent prognostic factor in alopecia areata, in addition to the well-known clinical prognostic factors. They may also be used to predict the response to treatment.