Clinical features of moyamoya disease with Graves' disease: a retrospective study of 394,422 patients with thyroid disease

Graves' disease has been reported to affect the clinical features of moyamoya disease (MMD), an occlusion of the circle of Willis. This study aimed to clarify the characteristics of MMD in patients with Graves' disease. This was a single-center, retrospective study. The prevalence and clinical features of MMD patients among all patients with thyroid disease who visited Ito Hospital from January 2005 to December 2019 were evaluated. The relationship between MMD and hyperthyroidism was analyzed in new-onset Graves' disease patients during the same period. Of all 394,422 patients with thyroid disease, 88,180 had Graves' disease, and 40 had MMD with Graves' disease, i.e., the prevalence was 45.36 per 100,000 patients with Graves' disease (0.0454%). The median age at onset of MMD was 39 years (interquartile range, 31-54 years), with a male to female ratio of 1:12. The most common time that MMD was diagnosed was within 1 year after the onset of Graves' disease, in 9 of 40 patients (22.5%), and 19 of 40 patients (47.5%) underwent bypass surgery for MMD. In MMD with Graves' disease, headache was the most frequent symptom, and ischemic types of stroke and bilateral lesions were common. Of 23,347 patients with new-onset Graves' disease, 7 were diagnosed with MMD and the incidence of MMD was 5.94 patients per 100,000 person-years. Most patients developed MMD symptoms during hyperthyroidism. Although MMD is a rare condition, it should be noted that it can occur with Graves' disease.

Propylthiouracil-induced otitis media with anti-neutrophil cytoplasmic antibody-associated vasculitis: a case report and review of the literature

Propylthiouracil (PTU)-induced otitis media with anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (OMAAV) is an extremely rare adverse event associated with anti-thyroid drugs and is not well recognized. A 42-year-old woman with Graves' disease undergoing PTU therapy for 8 years visited our hospital because of earache and congested feeling in her left ear. Blood tests, a computed tomography scan and pure tone audiometry revealed otitis media and moderate mixed hearing impairment. Antibiotics, ear drops with antibiotics and painkillers were administered. However, her earache and hearing loss gradually got worse and symptoms of facial nerve palsy appeared. At several weeks after initiation of the treatment, a high serum level of myeloperoxidase (MPO)-ANCA, 75.6 U/mL, was revealed. After excluding other causes, she was diagnosed with OMAAV. PTU was suspected as the cause of her OMAAV and was immediately discontinued, and prednisolone was started. Hearing impairment in her left ear gradually got better and showed substantial improvement. Facial nerve palsy disappeared. Although PTU-induced OMAAV is an extremely rare disease, it is important to recognize the disease, as delayed treatment can lead to irreversible hearing loss, hypertrophic pachymeningitis, and subarachnoid hemorrhage. When patients taking anti-thyroid drugs, especially PTU, are diagnosed with refractory otitis media or hearing loss, it is possible that OMAAV might be the cause and thus serum ANCA levels should be evaluated.

Therapeutic efficacy and limitations of potassium iodide for patients newly diagnosed with Graves' disease

The efficacy of potassium iodide (KI) for Graves' disease (GD) has been reported, although few clinical reports have examined the long-term efficacy of treatment. The objective of this study was to investigate the efficacy and limitations of KI treatment for GD. This study enrolled patients newly diagnosed with mild GD, defined as free thyroxine (FT4) <5.0 ng/dL, between July 2014 and June 2016. KI was started at a dose of 50 mg/day, and if FT4 values did not decrease after initiation of treatment, doses were increased to 100 mg/day. Patients for whom thyroid hormone levels could not be controlled with KI at 100 mg/day were regarded as non-responders. Of the 122 patients (13 males, 109 females) included in this study, 71 (58.2%) responded to KI therapy. The remaining 51 patients (41.8%) were non-responders. The median duration required to judge non-responsiveness was 5.9 months. Multiple logistic regression analysis performed on parameters measured at the initial visit indicated FT4 (odds ratio (OR) 2.19, 95% confidence interval (CI) 1.28-3.75; p = 0.0007) and male sex (OR 3.58, 95%CI 1.04-12.3; p = 0.04) were significantly associated with KI responsiveness. Receiver operating characteristic (ROC) curve analysis of the relationship between FT4 and KI responsiveness indicated an FT4 cut-off of 2.76 ng/dL was optimal for differentiating between responders and non-responders. KI therapy was effective and safe for about 60% of patients with mild GD.

Characteristics of Patients with Graves' Disease Whose Thyroid Hormone Levels Increase After Substituting Potassium Iodide for Methimazole in the First Trimester of Pregnancy

Background: The clinical course of Graves' disease (GD) in women who switched from methimazole (MMI) to potassium iodide (KI) during the first trimester of pregnancy has never been reported in detail. Objective: To investigate the characteristics of GD patients whose thyroid hormone levels increase after substituting KI for MMI. Patients: Two hundred forty women with GD who had been treated with MMI and switched from MMI to inorganic iodide to control hyperthyroidism during the first trimester between January 1, 2005, and March 31, 2018. Results: In 133 (55.4%) of the GD patients, medication was completely tapered during pregnancy, and the other 107 (44.6%) GD patients were taking medication at delivery: 57 were taking KI alone and 50 were taking an antithyroid drug with or without KI. It was difficult to control the maternal thyrotoxicosis of 22 of the 107 patients with KI alone, and a higher dose of MMI compared with the dose at the time of conception was required (worsened group). Multivariate analysis revealed that the TRAb value at the time of switch from MMI to KI was the only factor that predicted continuation of the thyroid suppression medication, but none of the parameters was a predictor of the worsened group. Conclusions: It must be kept in mind that a certain proportion of GD patients escape from the antithyroid effect of iodide and that careful follow-up is necessary after switching a pregnant patient's medication to KI.

Analysis of Antithyroid Drug-Induced Severe Liver Injury in 18,558 Newly Diagnosed Patients with Graves' Disease in Japan

Background: The prevalence of antithyroid drug (ATD)-related drug-induced liver injury (DILI) has been reported to vary among patients in several countries. The purpose of this study was to summarize the prevalence of liver injury induced by ATD and to determine the actual prevalence of severe liver injury. Methods: The medical records of 18,558 patients who were newly diagnosed with Graves' disease between January 2005 and December 2016 were retrospectively reviewed. Severe DILI was defined as alanine aminotransferase (ALT) 8 times higher than the upper limit of normal (ULN) or total bilirubin (T-bil) 3 times higher than the ULN. The most severe DILI was defined as ALT higher than 20 times the ULN or T-bil higher than 10 times the ULN. Results: A total of 461 subjects (470 cases) were analyzed, and they consisted of 10 males and 451 females, with a median age of 37 years (range 10-82 years). Nine of 461 patients had severe DILI with both drugs. The total prevalence of severe DILI in this study was 2.5%, and the prevalence of DILI by drug was 1.4% with metimazole (MMI) (n = 198) and 6.3% with propylthiouracil (PTU) (n = 272) (p < 0.001). The prevalence of the most severe ATD-related DILI was 0.22% (n = 40), and the prevalence for each drug was 0.08% with MMI (n = 11) and 0.68% with PTU (n = 29). The median time to DILI development was 30 days (range 7-314 days), and all patients recovered from DILI, with no fatalities. The prevalence of MMI-related DILI was significantly age dependent (p < 0.001). Conclusions: Though there were no fatalities in this study, the prevalence of PTU-related severe DILI was significantly higher than that of MMI-related severe DILI.

Incidence of Neonatal Hyperthyroidism Among Newborns of Graves' Disease Patients Treated with Radioiodine Therapy

BACKGROUND

The serum thyrotropin receptor antibody (TRAb) titers of Graves' disease (GD) patients are known to increase after radioiodine (RAI) therapy, and they can remain high for years. The incidence of neonatal hyperthyroidism (NH) among newborns of mothers with GD who conceived after RAI therapy has not been previously reported. The aims of this study were to investigate the incidence of NH among newborns of mothers who conceived within two years after RAI therapy, and to identify predictors of NH.

METHODS

GD patients (n = 145) who conceived within two years after RAI therapy were retrospectively reviewed, and information regarding their newborns was collected.

RESULTS

Of the 145 pregnant women, 54 (37%) were treated with antithyroid drugs or potassium iodide for maternal hyperthyroidism during the first trimester. There were eight newborns with NH, resulting in an incidence of 5.5%. Seven of the eight mothers whose newborns had NH were treated with antithyroid drugs or potassium iodide during their pregnancy. The incidence of NH among the newborns of mothers who conceived within 6-12 months after RAI therapy was 8.8%, within 12-18 months was 5.5%, and within 18-24 months was 3.6%. Multivariate analysis revealed that the TRAb values in the third trimester were the only risk factor for NH. The cutoff TRAb value in the third trimester for predicting NH was 9.7 IU/L (reference value <2.0 IU/L).

CONCLUSIONS

The incidence of NH among newborns of mothers who conceived within two years after RAI therapy was 5.5%. The fetuses of pregnant GD patients whose TRAb value is high in the third trimester should be carefully followed by an obstetrician during pregnancy, and the newborns should be carefully followed by a pediatrician after birth.

Molecular analysis of the cutaneous Malassezia microbiota from the skin of patients with atopic dermatitis of different severities

Cutaneous Malassezia is an exacerbating factor in patients with atopic dermatitis. We analysed the Malassezia microbiota of adult patients with head and neck atopic dermatitis of different severities (mild, moderate and severe). Of the nine human-associated Malassezia species, the number detected was similar (3.5-4.2 species per case) among the members of all severity groups. However, the ratio of the two major Malassezia species, M. globosa and M. restricta, was different in the severe group.

Combination therapy consisting of week pulses of oral terbinafine plus topical application of terbinafine cream in the treatment of onychomycosis

BACKGROUND

Terbinafine, based on its pharmacokinetic properties, is a good candidate for pulse therapy. There are, as yet, no current guidelines for a terbinafine 1-week pulse regimine.

OBJECTIVE

To determine the optimal 1-week pulse dosing regimen for combination therapy of oral terbinafine with complementary 1% terbinafine cream for the treatment of onychomycosis.

DESIGN

A total of 69 onychomycosis patients received 250 mg terbinafine, given orally once daily for 7 days as 1-week pulses, separated by intervals of 2-3 weeks, until the desired improvement was observed. A daily application of 1% terbinafine cream was advised through to the evaluation date at 12 months follow-up. The treatment regimens were compared based on the number of pulses and the duration of treatment.

RESULTS

The 45 patients (65.2%) who achieved complete cure received an average of 7.8+/-3.5 pulse treatments over 4.8+/-2.6 months. The optimal terbinafine dosing regimen consisted of alternate 1-week pulses, with most patients on this regimen (19/20 cases; 95%) achieving total cure.

CONCLUSION

Favorable treatment outcome was gained from this terbinafine 1-week pulse regimen and also better compliance compared with a standard daily regimen.

Quantitative analysis of Malassezia in the scale of patients with psoriasis using a real-time polymerase chain reaction assay

BACKGROUND

It has been suggested that Malassezia is associated with the development of skin lesions in psoriasis because of the response of the scalp lesions in psoriasis to antifungal agents. Malassezia restricta and M. globosa are the two major members of the cutaneous Malassezia flora in patients with psoriasis, although they have not been analysed quantitatively.

OBJECTIVES

This study quantified the two major cutaneous Malassezia species in psoriatic scale from different body sites using a real-time polymerase chain reaction (PCR) assay.

METHODS

Scale samples were collected from lesional and nonlesional skin of 20 Japanese patients with psoriasis and fungal DNA was extracted from the samples directly. All the Malassezia species, including the two major species M. globosa and M. restricta, were quantified with high accuracy, using a real-time PCR assay.

RESULTS

Colonization by M. restricta was approximately five times higher at all body sites than colonization by M. globosa. Malassezia colonization was significantly lower in patients with hyperlipidaemia than in patients with normolipidaemia.

CONCLUSIONS

Malassezia restricta is the predominant species in psoriatic scale.

A 13-week oral dose subchronic toxicity study of gardenia yellow containing geniposide in rats

Gardenia yellow powders A, B and C, containing geniposide at 0.284%, 0.938% and 2.783%, respectively, were administered orally to male and female SD rats as 3% feed admixtures for 13-weeks to evaluate any potential toxicity. Mean geniposide intake values were 5.72, 18.9 and 56.3mg/kg/day in groups receiving these feed admixtures, respectively. All animals survived the duration of the study. The following findings were evident in the gardenia yellow C group: chromatouria, slightly increased plasma total bilirubin, blackish brown discoloration of the kidneys and liver, brown pigments in the proximal tubular epithelium of the kidneys. Slightly increased plasma total bilirubin was considered to be due to interference of metabolite of geniposide with the system of measurement and not to be a toxic effect since there were no related changes in histopathology of the liver or in any blood chemistry parameters. Other findings were limited to pigmentations or discolorations attributable to metabolites of geniposide. No treatment-related effects were evident on body weight, food consumption, ophthalmology, hematology or organ weights in any group. Therefore, it was concluded that 3-month ingestion of the gardenia yellow powder containing geniposide at 2.783% (approximately 60 mg/kg/day as geniposide intake) does not cause any severe toxic effects.

Real-time PCR TaqMan assay for detectingTrichophyton tonsurans, a causative agent of tinea capitis, from hairbrushes

Tinea capitis caused by Trichophyton tonsurans is currently an epidemic in the United States, Europe, and Japan, and the cultivation of this microorganism is necessary for a definitive diagnosis. We recently developed a real-time PCR TaqMan assay as a culture-independent method for the rapid detection of T. tonsurans from hairbrushes.

A case of chromomycosis caused by Fonsecaea pedrosoi and a review of reported cases of dematiaceous fungal infection in Japan

We report a case of chromomycosis caused by Fonsecaea pedrosoi that developed in the left buttock of a 63-year-old female farmer. About 4 years ago, the patient developed erythema in the left buttock, which gradually spread. At the first consultation, we noted a well-defined, red-brown, infiltrated erythematous plaque (8 x 6 cm). Histopathological examination revealed a granulomatous lesion, containing sclerotic cells, associated with giant cells in the upper dermis. The causative fungus was difficult to identify due to low conidiogenesis, but was eventually identified by slide culture as F. pedrosoi. Excision and skin graft were performed, and no recurrence has been observed after 2 years. In Japan, 212 cases of dematiaceous fungal infection were reported in the period from 1982 to 2001. The causative fungus was F. pedrosoi in the majority of cases (126/212; 66%), followed by Exophiala jeanselmei (36/212; 19%). Similar incidence of dematiaceous fungal infection was reported in male and female patients. The upper limbs were affected most frequently in both male and female patients. Ten cases were associated with visceral lesions.

Abbreviated oral itraconazole therapy for tinea corporis and tinea cruris

The present study was designed to determine the lowest dose of orally administered itraconazole and the shortest duration of therapy necessary for treatment of tinea corporis and tinea cruris. For all patients, the itraconazole dose was 100 mg twice a day immediately after meals. Twenty-eight patients received itraconazole on days 1 and 8, 12 patients received itraconazole on days 1 and 2, and five patients received itraconazole only on day 1. Clinical and mycological evaluations were performed at baseline and on day 14. Based on the clinical and mycological responses, treatment efficacy was classified as excellent, good, fair, or poor. "Excellent" and "good" responses made up 86% of the first group, 100% of the second group, and 20% of the third group. A comparison of efficacy ratings of the three regimens showed that the patients who received a single 200-mg dose had a significantly inferior outcome compared with the other two groups. We conclude that an abbreviated oral regimen of itraconazole for treatment of tinea corporis and tinea cruris requires a total dose of at least 400 mg to induce a favorable outcome.

An epidemiological and clinical study of untreated patients with tinea pedis within a company in Japan

In this study, we investigated epidemiological and clinical aspects of dermatophyte foot infections among employees of one dairy product company located in Kanagawa prefecture in central Japan. Sixty-nine of 377 subjects were reported having "athlete's foot" in response to a simple questionnaire. A subsequent mycological examination revealed 41 untreated patients with tinea pedis and/or tinea unguium (89% of subjects examined) and the overall prevalence was estimated at 18%. Comparing severity scores of five clinical symptoms (itching, erythema, vesicles/pustules, erosion/maceration, and scales) between those untreated patients within the subjects and another group of patients who spontaneously attended dermatological clinics to treat tinea pedis, itching, erythema, and total score were significantly higher in the latter group.

Subcutaneous phaeohyphomycosis caused by Veronaea botryosa in the People's Republic of China

The second case of phaeohyphomycosis caused by Veronaea botryosa in China, in a 12-year-old boy from Jiangsu Province, is presented. Based on direct examination of the scrapings from crusted lesions; histologic examination of the biopsy tissue showing septate, phaeoid hyphal elements; and the culture exhibiting sympodial, conidiogenous cells producing predominantly two-celled, cylindric conidia, the etiologic agent was identified as V. botryosa.

Clinical and mycological study of occult tinea pedis and tinea unguium in dermatological patients from Tokyo

An epidemiological investigation was conducted to determine the prevalence and circumstances of untreated, unsuspected tinea pedis and tinea unguium, morbid conditions that could be termed occult athlete's foot, in patients visiting a dermatology clinic in Tokyo, Japan, for the first time, for other complaints. All subjects completed a questionnaire covering comprehensive anamnestic details, and were examined for disposition of toes, presence of signs suggestive of tinea pedis, other diseases of the foot, score of clinical signs and symptoms, potassium hydroxide (KOH) test, severity score, and mycological culture. The results showed that the prevalence of occult athlete's foot was 25%, and that 59% of those cases were complicated by tinea unguium. The characteristics of patients with occult athlete's foot included a higher proportion of men and a tendency toward a low clinical score together with a high severity score. In the patient background, a strong correlation was observed between a positive KOH test result and characteristics such as age, disposition of toes, and predisposing disease.

A case of subcutaneous phaeohyphomycotic cyst due to Exophiala jeanselmei complicated with systemic lupus erythematosus

We report a case of subcutaneous phaeohyphomycosis by Exophiala jeanselmei that appeared on the extensor surface of the left lower leg of a 34-year-old woman with systemic lupus erythematosus (SLE). The superficial symptoms were a subcutaneous nodule 2.5 x 2 cm in size discharging a serous exudate from its center. Histopathological examination revealed granulomatous changes including large numbers of neutrophils in the dermis and the subcutaneous tissues. In addition, periodic acid-Schiff-positive fungal elements consisting of many yeast-like cells and chains of cells with hyphae were seen. The statistics on E. jeanselmei infections in Japan indicated that 54 cases (24 in men and 30 in women) had been reported, of which 50 (21 in men and 29 in women) were phaeohyphomycosis, and about half had underlying diseases; and the sites of the lesions were mainly on the extremities.

Primary cutaneous nocardiosis with multiple, subcutaneous abscesses in a patient with sarcoidosis

A case of multiple subcutaneous nocardial abscesses is reported in a patient who received systemic corticosteroids over a period of about 4 years for the treatment of visceral sarcoidosis. The diagnosis of subcutaneous abscess caused by Nocardia asteroides was made based on bacteriological examination. It could not be determined before treatment whether the abscesses represented primary or secondary nocardiosis. Surgical drainage and systemic administration of minocycline hydrochloride dramatically resolved the cutaneous lesions. To the authors' knowledge, this is the first reported case in Japan of primary cutaneous nocardiosis in a patient with sarcoidosis.

Cutaneous zygomycosis: a case report and review of Japanese reports

A 69-year-old man, a carpenter with idiopathic thrombopenic purpura and interstitial pneumonia, was treated with steroid pulse therapy and antibiotics. On the seventh day of steroid therapy, a conglomeration of papules, vesicles and pustules appeared in an area of the left buttock in contact with his napkin. In a Parker KOH specimen of the crust of the lesion, many non-septate hyphae were seen, and culture of material obtained by biopsy yielded Rhizopus microsporus var. microsporus. Ketoconazole cream was applied topically for 1 week, and the exanthema healed. After the third month of inpatient treatment, the patient's overall condition had returned to normal, and he was discharged. Cutaneous zygomycosis is a rare disease, and only 19 cases have been reported in Japan. Its characteristics, as reported in these cases, have been collected and collated.

Tinea capitis infection in school children of Nepal

From among 428 Nepalese schoolchildren hair samples of 102 children with clinical features of tinea capitis, obtained by the sterile hairbrush method, were examined by mycological techniques. Age varied between 4-16 years. Itching was experienced by 96.1% sample subjects and hair loss by 32.4%. Of the 102, 11 (10.8%) were positive for Trichophyton violaceum (TV), 6 being from urban areas, the rest from rural areas. Amongst the 11 patients, 7 (63.6%) were girls and rest boys. Statistical associations were observed between the place of haircut and isolation of the organism (chi2 = 15.2, p <0.01). Statistical association was also present between frequency of bathing and isolation of organism. Sharing of combs was associated with the culture-positive subjects. The prevalence of tinea capitis in the urban and rural children was 2.3% and 3.0%, respectively. The only isolated organism was TV. An association of the isolation of TV was found with risk factors such as family members, sharing of combs, frequency of bathing with the organism. Hair loss was more common in the urban children. Discouragement of sharing combs, increased frequency of hair washing, and use of uncontaminated hair cutting instruments are recommended.

One week pulse therapy with itraconazole (200 mg day-1) for onychomycosis. Evaluation of treatment results according to patient background

We investigated background factors of patients that affect the response of onycomycosis to pulse therapy with itraconazole. The regimen used in this study involved administering 200 mg of itraconazole orally on a daily basis for 1 week as one pulse, which is half of the normally recommended dose. The number of pulses was fixed at one per month, and altered in accordance with improvements in the infected nails and/or the patients' request. Patient background (n = 63) including sex, age, occupation, duration of the disease, site of lesion (fingernail, toenail), number of affected nails, clinical types, severity of thickening, presence or absence of pathogens, the presence or absence of underlying diseases such as adult onset diseases, turbidity of the target nails before therapy and the number and duration of pulses was investigated. The efficacy of the therapy was evaluated after 12 months. A complete cure was judged to have taken place if an entirely healthy nail plate re-grew in place of the diseased nail, whereas lack of success was defined as the persistence of lesions beyond the designated time period. The average number and duration of pulses were 4.7 +/- 3.2 times over 5.6 +/- 4.3 months, respectively. The rate of complete cure was 62%. Factors in the patients' background that were judged to have an influence on treatment results were the relative duration of the disease, the number of affected nails, and severity of thickening. With regard to the efficacy of the therapy in terms of the number and duration of pulses, 78% of 23 patients who were given pulse therapy two to six times during a course of 2 to 6 months achieved total cure.

Isolation of an intron-containing partial sequence of the gene encoding dermatophyte actin (ACT) and detection of a fragment of the transcript by reverse transcription-nested PCR as a means of assessing the viability of dermatophytes in skin scales

An internal partial sequence of the gene encoding actin (ACT), 725 to 762 bp in length, was amplified by PCR from the genomic DNA extract of 12 species of dermatophytes and sequenced. An intron that is 56 to 93 bp in length was located along the ACT fragment of all of the dermatophytes at codon position 301 (-3) (a codon number followed by "-3" indicates that the intron directly follows the codon) with reference to the amino acid sequence of human alpha-smooth muscle actin. A primer pair that annealed to exon sequences flanking the ACT-associated intron produced a dermatophyte-specific 171-bp amplicon by reverse transcription-nested PCR (RT-PCR) of dermatophyte ACT mRNA. PCR primer pairs with antisense sequence based on the ACT intron sequence were species specific for dermatophytes, suggesting a potential for use in the identification of dermatophytes. The viability of dermatophytes in skin scales was subsequently assessed by the presence of ACT mRNA in total RNA extracted from a 48-h culture of scale samples in 250 microl of yeast carbon base broth. RT-nested PCR of dermatophyte-infected samples amplified an ACT fragment of the predicted size of 171 bp. The results of viability testing based on ACT mRNA detection by RT-nested PCR correlated with cultural isolation from skin scales. This method is a potential tool for rapidly assessing fungal viability in the therapeutic efficacy testing of antimycotics.

Hyperthermic treatment of Bowen's disease with disposable chemical pocket warmers: a report of 8 cases

Bowen's disease is a form of squamous cell carcinoma in situ, in which local hyperthermia may be efficacious. We studied 8 patients with Bowen's disease to ascertain whether hyperthermia can be effective against it. As a heat source, disposable chemical pocket warmers were applied daily with pressure directly to the lesion site while the patient was awake, and the clinical course was observed for 4 to 5 months. The lesion was then excised and examined to determine the histopathologic effects. The results showed efficacy in 6 cases, in which the nodular and invasive lesions and the erythematous patches abated; then the lesions disappeared, leaving deposits of pigment (complete remission). In one case, the signs improved by at least 50% (partial remission); in the other case, there was only slight palliation (no response). As for the posttreatment histopathologic effects, tumor cells were eliminated in 3 cases, isolated tumor cells were seen in 3 cases, and there was no change in 2. Although the treatment did not yield perfect results, it represents a major improvement of hyperthermic therapy and is one effective method of treating Bowen's disease.

Oral administration of bovine lactoferrin for treatment of tinea pedis. A placebo-controlled, double-blind study

A clinical study was conducted to evaluate the effectiveness of lactoferrin, which is a protein component of cow's milk, in the treatment of tinea pedis. Doses of either 600 mg or 2000 mg of lactoferrin, or a placebo was orally administered daily for 8 weeks to 37 adults who were judged to have mild or moderate tinea pedis. Dermatological improvement and antifungal efficacy were assessed. In the analysis of all subjects, dermatological symptoms scores in all groups decreased but the differences were not statistically significant comparing the three groups. However, in the analysis limited to subjects with moderate vesicular or interdigital tinea pedis, dermatological symptoms scores in the lactoferrin-treated groups decreased significantly in comparison with the placebo group (P < 0.05). The organisms isolated were Trichophyton rubrum and Trichophyton mentagrophytes. A mycological cure was not seen in any of the subjects. In the 37 subjects there were no adverse events and no subject withdrew from the study because of an adverse event. These results suggest that orally administered lactoferrin can improve the dermatological symptoms in some subjects. The potential usefulness of lactoferrin as a functional food material for treating tinea pedis was seen for the first time in this study.

Mycological examination of the hair samples of 11 school-going Nepalese children suspected of tinea capitis

Among 150 students from a semi-urban school in Kathmandu (Nepal), 30 from various age groups and both sexes with symptoms suggestive of scalp ringworm, were examined clinically. Hair samples were collected for mycological examination, using the hair brush method, from 11 of the 30 children (36.7%), aged between 5 and 14 years, who were clinically diagnosed. Four of the cultured samples were positive for isolates of Trichophyton violaceum. This minor study provides evidence that tinea capitis might constitute a substantial infectious dermatological problem in Nepal. The study also indicated T. violaceum as the causative organism of tinea capitis.

Case report. Sporotrichosis successfully treated with itraconazole in Japan

A case of lymphocutaneous sporotrichosis that had developed from the dorsum nasi to the left buccal region of a 65-year-old woman was treated with itraconazole 100 mg day-1. The lesion healed in 10 weeks after starting treatment leaving crusts, mild erythema and pigmentation, and the treatment was completed 16 weeks after the start of treatment. Neither adverse reactions nor abnormal clinical laboratory values were noted. Until the present time, 1 year and 2 months after the completion of treatment, no recurrence has been observed. In Japan, 43 cases of sporotrichosis have been treated with itraconazole, and 38 cases (88%) have been assessed as effective or better. The mean dose of itraconazole and the mean duration of administration are 100 mg day-1 and 11 weeks, respectively, in these reported Japanese cases. The use of itraconazole is expected to be one of the effective therapies for sporotrichosis.

Effectiveness of treatment of severe tinea pedis with 1% terbinafine cream in members of the Japanese self-defense forces

A clinical study was conducted to determine the efficacy of terbinafine cream in severe cases of tinea pedis. The subjects were 21 men, members of the Japanese Self-Defense Forces who were judged to have severe symptoms of tinea pedis. The description 'severe' was defined as 'considered to require the concurrent internal administration of antifungals for complete cure', or as meeting criterion 5 or 6 for the severity of tinea pedis. A simple surface application of terbinafine cream was given once daily, the subjects' clinical manifestations, mycological cure rates and safety-related changes were observed, and a final assessment was made in the 12th week. In the final assessment, the improvement rate of the cutaneous symptoms was 95.2%, and the fungal eradication and efficacy rates were 81.0%. As for side-effects, one patient complained of local irritation. These results suggested that terbinafine cream is a beneficial topical antifungal cream for severe tinea pedis.

[Fungi and atopic dermatitis]

Attention has recently been centered on fungi as aggravating factors of atopic dermatitis (AD) due to the frequent detection of IgE antibodies to fungi in patients with severe AD and to positive response of some cases of AD to antifungal therapy. Malassezia sp.: In AD patients with prominent symptoms in the head and neck, areas prone to colonization by Malassezia, the titers of specific anti-Malassezia IgE antibodies are high, which positively correlate with the total IgE value and the severity of AD. The patch test against Malassezia antigens is positive. The rate of isolation of Malassezia from the skin of AD patients is higher than that from the skin of healthy control subjects. Candida sp.: In patients with severe AD, the rate of positive skin prick tests for Candida is high, and a correlation exists between positive skin prick test results and the presence of Candida albicans in nasopharynx. However, the reactivity to Candida antigens in the patch tests is reduced, and a negative correlation is seen. There is no difference between the isolation rate of C. albicans from patients with adult-type AD and normal controls. However, AD patients give a significantly greater number of separate colonies. The range of efficacy rate of antifungal therapy of AD is reported to be 50-65 %. The efficacy rate of our own trial falls within this range. Following treatment, the rate of isolation of fungi decrease significantly, and the titers of specific antifungal IgE antibodies are not statistically significant. The clearance of fungi from the tissue following antifungal therapy probably results in the suppression of direct or indirect inflammatory reaction caused by the fungi. We therefore consider antifungal therapy as one of the second-line therapies to be administered in AD cases resistant to conventional basic therapy.

Analysis of strain variation of R1 repeated structure in varicella-zoster virus DNA by polymerase chain reaction

The tandem direct reiteration R1 in the varicella-zoster virus genome consists of two elements: units composed of 18 bp and those having 15 bp, both of whose numbers and types of combination patterns vary among strains. The variations of the R1 structure were examined in order to differentiate between the wild strains and a varicella vaccine (Oka) strain by the polymerase chain reaction using two primer sets. The results showed that the 31 wild strains were classified into nine patterns: the R1 structure consisted of a combination of 5 to 7 18-bp units and 8 to 12 15-bp units. The strain with a combination of 6 18-bp units and 10 15-bp units was found to be predominant in Japan, and the same pattern was found in the vaccine strain, so that differentiation between the vaccine strain and the wild strains in Japan merely by analysis of R1 in VZV genome is difficult.

[Pediatric onychomycosis treated with oral antifungal drugs]

Pediatric onychomycosis is a rare disease and it is difficult to decide in such cases whether or not an oral antifungal is indicated. We have observed 6 pediatric cases with onychomycosis who were treated with fluconazole or itraconazole: four male and two female patients, ranging in age from three to 14 years. One patient suffered infection in the fingernails and toenails. The etiologic organism was identified as Trichophyton rubrum. The treatment regimen consisted of systemically administering fluconazole to four of the patients and itraconazole to the other two. Treatment resulted in three of the 4 patients treated with fluconazole, and one of the 2 treated with itraconazole being healed completely. The other two patients treated with fluconazole and itraconazole showed an alleviation of symptoms. Further results of our study were that while younger patients respond quickly and positively to treatment, long-term follow-up is necessary even after treatment ceases due to the easy recurrence of this condition.

Cathepsin D expression in skin metastasis of breast cancer

Cathepsin D, an aspartic proteinase, correlates with invasion and metastasis in breast cancer and with poor prognosis. In the present study, we examined the immunohistological expression of cathepsin D in both primary (5 cases) and skin-metastatic breast cancers (13 cases) and compared it to those in gastric (2 cases) and lung (4 cases), and primary eccrine cancers (3 cases). All breast and gastric cancers were adenocarcinomas. The 2 gastric cancers were poorly differentiated, while the 4 lung cancers consisted of 2 poorly differentiated adenocarcinomas, 1 poorly differentiated large cell carcinoma, and 1 moderately to poorly differentiated squamous cell carcinoma. We also surveyed the immunohistological distribution of cathepsin B, carcinoembryonic antigen, gross cystic disease fluid protein-15, c-erbB-2, and estrogen receptor. In almost all breast cancer samples, the cancer cells demonstrated strong expression of cathepsin D in the cytoplasm, but weak staining patterns with other antibodies. Gastric and lung cancer cells did not respond with cathepsin D (except one metastatic lung cancer) or the other immunohistological markers. Since cathepsin D is strongly expressed in primary and metastatic lesions of breast cancer, cathepsin D could be useful as an adjunct to a panel of immunohistochemical stains in determining the primary site of origin of metastatic cancer in the skin.

A pediatric case of atypical Mycobacterium avium infection of the skin

We report a case of cutaneous atypical mycobacteriosis in a 12-year-old healthy girl due to Mycobacterium avium. The cutaneous symptoms were three well-defined subcutaneous nodules on both buttocks and on the posterior surface of the left thigh. One had a fistulous opening on the skin surface. Histopathological examination revealed epithelioid cell granulomas surrounded by dense lymphocytic infiltration and acid-fast bacteria were seen with modified periodic acid-carbol fuchsin staining. Using Ogawa's medium at 37 degrees C, acid-fast bacteria were isolated from the biopsied specimen and identified by the DNA-DNA hybridization method as Mycobacterium avium. In drug susceptibility test, these were resistant to all antituberculous drugs. Oral administration of minocycline 100 mg/day for two months had little effect on the two remaining lesions, which were therefore excised. Based upon reported cases of Mycobacterium avium complex, we considered that our pediatric patient with multiple intradermal or subcutaneous nodules on the buttocks and the thigh exhibited the characteristic symptoms of M. avium infection.

Expression of cathepsin D and B in invasion and metastasis of squamous cell carcinoma

To determine the involvement of proteinases with hydrolytic activity towards extracellular matrix and basement membrane, in invasion and metastasis of tumour cells, the expression of cathepsin D, an aspartic proteinase, and cathepsin B, a cysteine proteinase, was studied. Formalin-fixed paraffin-embedded specimens from 13 patients who had squamous cell carcinomas (SCC) with local recurrence, skin and/or lymph node metastasis were examined. Cathepsin D stained intensely as a granular pattern (mature enzyme) in tumour cells of 69% of primary lesions and all the secondary lesions of the patients with SCC. Cathepsin B stained more intensely in SCC cells of all of the primary and secondary lesions than in normal epidermis; staining patterns were almost diffuse (procathepsin B). Granular and diffuse patterns (mature enzyme of cathepsin D and procathepsin B, respectively) appeared in the outer and inner parts of tumour islands, respectively. The presence of the active mature form of cathepsin D and procathepsin B in metastatic skin lesions of SCC was confirmed by Western blotting analysis. The presence and localization of the active mature form of cathepsin D suggests that activated cathepsin D may be involved in the invasion and metastasis of SCC.