Optical coherence tomographic features of feline acute corneal hydrops: A case report

OBJECTIVE

The objective of the study was to describe the optical coherence tomographic features of a cat with acute corneal hydrops.

ANIMAL STUDIED

A 4-year-old castrated male domestic shorthaired showing conjunctival redness, ocular discharge, and intermittent squinting of both eyes with asymmetrical disease onset.

METHODS

Complete ophthalmic examination and optical coherence tomography were performed.

RESULTS

On slit-lamp biomicroscopic examination, severe intrastromal fluid pockets with profound bullae were observed in the dorsomedial region in both eyes. A diagnosis of feline acute corneal hydrops was made in both eyes. Optical coherence tomography revealed profound stromal lamellar separation representing heterogeneous reflective areas, and fluid pockets and bullae of variable size were concomitant to Descemet's membrane detachment demonstrated by a well-defined homogeneous hyporeflective area. Upon reevaluation 30 days during healing process for both eyes, the thickened epithelia and the thinning pan-stromal areas were identified as homogeneously hyper-reflective epithelia and as heterogeneous hyper-reflectivity, respectively. A thickened posterior corneal surface was shown as heterogeneous with patchy hyper-reflectivity. Additionally, Descemet's membrane detachment in the initial presentation had two distinct forms suspicious of Descemet's membrane rupture in each eye: a break with rolled ends and a break with flat ends.

CONCLUSION

To the author's knowledge, this study represents the first documentation of in vivo detection of Descemet's membrane detachment and presumed rupture in a cat experiencing acute corneal hydrops. These observations strongly indicate that Descemet's membrane detachment/rupture acts as a most likely risk factor in the onset of acute corneal hydrops in cats.

Kindler syndrome with a novel mutation and gynaecological complication

Kindler syndrome is a rare genodermatosis characterized by mechanical skin fragility, acral blisters, photosensitivity, poikiloderma, skin atrophy and mucosal inflammation. Kindler syndrome occurs as a result of a mutation in the gene FERMT1 (also known as KIND1) located on chromosome 20p12.3, which codes for kindlin-1. Here, we report a case of a 40-year-old woman with Kindler syndrome associated with a giant myometrial cyst of the uterus, fused labia minora, vaginal stenosis, right eye complicated cataract and chronic periodontal disease. Clinical exome and whole mitochondrial genome sequencing showed a homozygous 4-base-pair deletion (c.1909_1912del) in exon 15 of FERMT1 (NM_017671.5).

SMARCA4 mutation causes human otosclerosis and a similar phenotype in mice

BACKGROUND

Otosclerosis is a common cause of adult-onset progressive hearing loss, affecting 0.3%-0.4% of the population. It results from dysregulation of bone homeostasis in the otic capsule, most commonly leading to fixation of the stapes bone, impairing sound conduction through the middle ear. Otosclerosis has a well-known genetic predisposition including familial cases with apparent autosomal dominant mode of inheritance. While linkage analysis and genome-wide association studies suggested an association with several genomic loci and with genes encoding structural proteins involved in bone formation or metabolism, the molecular genetic pathophysiology of human otosclerosis is yet mostly unknown.

METHODS

Whole-exome sequencing, linkage analysis, generation of CRISPR mutant mice, hearing tests and micro-CT.

RESULTS

Through genetic studies of kindred with seven individuals affected by apparent autosomal dominant otosclerosis, we identified a disease-causing variant in SMARCA4, encoding a key component of the PBAF chromatin remodelling complex. We generated CRISPR-Cas9 transgenic mice carrying the human mutation in the mouse SMARCA4 orthologue. Mutant Smarca4+/E1548K mice exhibited marked hearing impairment demonstrated through acoustic startle response and auditory brainstem response tests. Isolated ossicles of the auditory bullae of mutant mice exhibited a highly irregular structure of the incus bone, and their in situ micro-CT studies demonstrated the anomalous structure of the incus bone, causing disruption in the ossicular chain.

CONCLUSION

We demonstrate that otosclerosis can be caused by a variant in SMARCA4, with a similar phenotype of hearing impairment and abnormal bone formation in the auditory bullae in transgenic mice carrying the human mutation in the mouse SMARCA4 orthologue.

Erythema multiforme-like lip presentation in pemphigus vulgaris patients: a multicenter case series

Pemphigus vulgaris (PV) is a chronic autoimmune mucocutaneous blistering disease. Autoantibodies are directed against desmogleins, leading to the formation of intraepithelial bullae. PV, as with other autoimmune mucocutaneous disorders of the oral cavity, presents diagnostic and therapeutic challenges. Approximately 50-70% of cases present first with oral lesions. The lesions commonly start as vesicles or bullae that rapidly rupture, leading to erosions and ulcerations. The palatal, gingival, buccal, and labial mucosa are the most commonly affected sites. Oral PV can mimic several other diseases that cause mucosal erosions and/or ulcerations, including erythema multiforme (EM). EM is an acute, immune-mediated, self-limited hypersensitivity condition primarily associated with herpes simplex infection. Oral lesions can be variable, but a very characteristic presentation with labial hemorrhagic erosions, ulcerations and crusting is commonly seen. In this case series, we present six cases of PV: one male patient and five female patients whose ages ranged from 34 to 65 years old. All patients presented with hemorrhage and crusting of the lips in addition to multiple intraoral erosions and ulcerations. Three patients presented with oral and skin lesions. All patients underwent biopsies, and a diagnosis of PV was confirmed. All patients were treated with steroids (topical and systemic) and variable steroid-sparing agents. This case series emphasizes that oral PV may be misdiagnosed as EM in a subgroup of patients who present with persistent lip hemorrhage and crusting. Therefore, a comprehensive history, clinical examination and incisional biopsies should be considered in such patients.

Cytokine patterns in the blister fluid and plasma of patients with fracture blisters

BACKGROUND

Fracture blister (FB) is a complication of fracture, which damages to the skin integrity and increases the risk of infection. Inflammation plays an important role in the formation and development of FBs, but its specific mechanism is still unclear. The aim of this study was to investigate the patterns and dynamic changes of inflammatory cytokines in fracture blister fluid (FBF) and plasma.

MATERIALS AND METHODS

FBF and plasma were collected simultaneously from patients with lower extremity fractures with FBs on the first and fifth day after blisters formation. 92 inflammation-related protein biomarkers were measured in plasma and FBF using Proximity Extension Assay (PEA). We analyzed the cytokine patterns and their dynamic changes in FBF and plasma. Cytokine patterns in plasma from FB patients, fracture without blister patients, and healthy subjects were also analyzed.

RESULT

The cytokine pattern in FBF and plasma of patients with FBs was different but 11 cytokines were significantly correlated in the two sample types. 23 cytokines were different in plasma across FB patients, fracture without blister patients and healthy subjects. In the analysis of plasma from FB patients and fracture without blister patients, 15 cytokines were significantly different and they may be potential risk factors for the occurrence of FBs. The FBF and plasma showed different cytokine patterns in the early and late stages, with 50 cytokines significantly changed in FBF and 20 cytokines in plasma.

CONCLUSION

The different cytokine patterns in plasma between FB patients and fracture without blisters patients may be the potential factors for the occurrence of blisters. The cytokine patterns in FBF and plasma showed a dynamic change from the inflammatory stage to the proliferative and repair stage, which indicates that FBs may have new clinical importance in addition to being a soft tissue injury.

Short- and long-term outcomes of subtotal ear canal ablation and lateral bulla osteotomy in French bulldogs

The objective of this retrospective study was to report the overall peri-operative complications and short- to long-term outcomes of subtotal ear canal ablation and lateral bulla osteotomy in French bulldogs with otitis media. Medical records from 2018 to 2021 were reviewed for preoperative neurological signs, surgical technique, postoperative complications, and long-term outcomes. Postoperative complications, such as a head tilt, nystagmus, ataxia, facial nerve dysfunction, as well as skin or wound infection, were recorded. Eighteen client-owned dogs (20 ears) were included in the study. Postoperative complications were observed in 5/18 dogs (6/20 ears) with 2 of them being considered major complications. Referring veterinarians and owner telephone follow-up (mean: 33 mo, range: 17 to 56 mo) were obtained for all patients. Total recovery was reported in 9/18 dogs (11/20 ears) with a postoperative improvement of the vestibular signs and facial nerve paresis within 8 wk. All dogs maintained the pinnas' natural, erect morphology, and movement.

Cardiovascular Collapse after the Induction of Anesthesia Due to the MASS Effect of Unruptured Giant Bullae

Background and Objectives: Giant bullae rupture easily and cause tension pneumothorax, which can cause problems during general anesthesia. However, the hemodynamic instability that can occur due to the mass effect of an unruptured giant bulla should not be overlooked. Case report: A 43-year-old male patient visited the emergency room with an abdominal wound. There was a giant emphysematous bulla in the left lung. Emergency surgery was decided upon because there was active bleeding according to abdominal CT. After tracheal intubation, the patient's blood pressure and pulse rate dramatically decreased. His blood pressure did not recover despite the use of vasopressors and discontinuation of positive pressure ventilation applied to the lungs. Thus, a bullectomy was immediately performed. The patient's blood pressure and pulse rate were normalized after the bullectomy. Conclusions: If emergency surgery under general anesthesia is required in a patient with a giant emphysematous bulla, it is safe to minimize positive pressure ventilation and remove the giant emphysematous bulla as soon as possible before proceeding with the remainder of the surgery. Tension pneumothorax due to the rupturing of a bulla should be considered first. However, hemodynamic changes might occur due to the mass effect caused by a giant bulla.

Complications and post-operative interventions in XEN45 gel stent implantation in the treatment of open angle glaucoma-a systematic review and meta-analysis

BACKGROUND

The XEN45 Gel Stent is a subconjunctival filtering device that has demonstrated promising efficacy. This meta-analysis quantitatively evaluates reported complications and interventions after XEN45 implantation in the treatment of open angle glaucoma (OAG).

METHODS

Pilot, cohort, observational studies, and randomised controlled trials that included at least ten patients undergoing ab interno or externo XEN45 surgery, with or without phacoemulsification were deemed eligible for inclusion. A meta-analysis of proportions with random-effect models was performed using the meta routine in R version 3.2.1. Outcomes included the rate of complications and post-operative interventions.

RESULTS

One hundred and fifty-two studies were identified on initial literature search and 33 were included in final analysis. Numerical hypotony was the most common post-operative complication, involving 20% of patients (95% CI: 10-31%). Post-operative gross hyphema occurred in 14% (95% CI: 7-22%) and transient intra-ocular pressure (IOP) spikes (>30 mmHg) in 13% (95% CI: 4-27%). Stent exposure occurred in 1% (95% CI: 0-2%). Stent migration occurred in 1% (95% CI: 0-3%). XEN45 revision and/or a second XEN45 implantation was performed in 5% of patients (95% CI: 3-7%). Stent relocation was performed in 3% (95% CI: 1-7%). A second glaucoma procedure was performed in 11% (95% CI: 8-15%). 26% underwent one (95% CI: 17-36%), 13% underwent two (95% CI: 5-24%) while 4% underwent three (95% CI: 2-6%) bleb needling procedures. 35% of patients (95% CI: 29-40%) required at least one needling. The average rate of needling per patient was 0.38 (95% CI: 0.20-0.59). However, there is a lack of high-quality data, with 8 of the 33 studies assessed to have a moderate to high risk of bias.

CONCLUSIONS

While literature suggests that XEN45 Gel Stent implantation is safe in the treatment of OAG, the overall current level of evidence is low and further studies are needed. More than a third of patients require at least one post-operative bleb needling procedure.

Exploring the Profile of Cell Populations and Soluble Immunological Mediators in Bothrops atrox Envenomations

Bothrops atrox envenomations are common in the Brazilian Amazon. The venom of B. atrox is highly inflammatory, which results in severe local complications, including the formation of blisters. Moreover, there is little information on the immune mechanisms associated with this condition. Thus, a longitudinal study was carried out to characterize the profile of the cell populations and soluble immunological mediators in the peripheral blood and blisters in B. atrox patients s according to their clinical manifestations (mild and severe). A similar response in both B. atrox patient groups (MILD and SEV) was observed, with an increase in inflammatory monocytes, NKT, and T and B cells, as well as CCL2, CCL5, CXCL9, CXCL10, IL-1β and IL-10, when compared with the group of healthy blood donors. After the administration of antivenom, the participation of patrolling monocytes and IL-10 in the MILD group was observed. In the SEV group, the participation of B cells was observed, with high levels of CCL2 and IL-6. In the blister exudate, a hyperinflammatory profile was observed. In conclusion, we revealed the involvement of cell populations and soluble mediators in the immune response to B. atrox envenomation at the local and peripheral level, which is related to the onset and extent of the inflammation/clinical manifestation.

A case report of paraneoplastic bullous pemphigoid associated with mantle cell lymphoma: A rare presentation

RATIONALE

We report a rare case of paraneoplastic bullous pemphigoid associated with mantle cell lymphoma.

PATIENTS CONCERNS

The patient presented with 5 months' history of generalized skin itchiness, night sweat and loss of weight. The skin manifestations started over the foot and hand area. However, he started to developed tense blisters over the face, trunk and limbs 3 days prior to this admission.

DIAGNOSES

The skin biopsy report showed subepidermal bullae, in which the immunofluorescence findings in keeping with bullous pemphigoid. The peripheral blood immunophenotyping was suggestive of mantle cell lymphoma. Hence, a diagnosis of paraneoplastic bullous pemphigoid associated with mantle cell lymphoma was made.

INTERVENTIONS

The patient was initiated with a cytoreduction chemotherapy.

OUTCOMES

Unfortunately, patient's condition deteriorated further due to neutropenic sepsis and he succumbed after 2 weeks of intensive care.

LESSONS

Bullous pemphigoid associated with mantle cell lymphoma are very rare. The presentation of bullous pemphigoid led to the detection of mantle cell lymphoma. Early diagnosis and appropriate treatment is crucial in managing this aggressive type of the disease. Both, bullous pemphigoid and mantle cell lymphoma had a parallel clinical course which suggests a paraneoplastic phenomenon in this reported case.

Case Report: Concurrence of Dermatomyositis and Autoimmune Blistering Diseases: Two Case Reports and a Literature Review

Dermatomyositis (DM) is an idiopathic inflammatory myopathy primarily involving skin and muscles. Clinically amyopathic dermatomyositis (CADM), a subset of DM, presents with characteristic cutaneous manifestations without clinical evidence of myositis. Although rare, vesiculobullous eruptions could develop in DM patients. Such “bullous DM” is commonly considered a sign of internal malignancy. However, some cases with similar presentations were diagnosed as autoimmune blistering disease eventually. Herein, we reported two cases of CADM with autoimmune blisters formed. Case 1 presented with vesicles and was diagnosed with CADM initially. However, this patient developed blisters again years later and was diagnosed with “pemphigus foliaceous” (PF) accordingly. Case 2, with a history of nasopharyngeal carcinoma and CADM, developed bullous pemphigoid several days after using a heat patch on her abdomen. The association between disease occurrence and local skin damage might provide more evidence to support the “epitope spreading” hypothesis. Moreover, we reviewed related literature and discussed the differences between the two disease entities in clinical presentations, pathogenesis, therapy, and the risk of complications.

[Pneumothorax, pneumomediastinum and subcutaneous emphysema as complica-tions of COVID-19]

Spontaneous pneumothorax, pneumomediastinum and subcutaneous emphysema are serious complications of COVID-19 infection caused by SARS-CoV-2, occurring in approximately 1% of hospitalized patients. The risk increases with the accumulation of risk factors, namely moderate or severe illness, high-flow oxygen therapy and noninvasive ventilation. The pathophysiology may be contributed to by patient self-inflicted lung injury. Hypoxia-induced respiratory effort in patients with pneumonia puts an enormous load on certain parts of their lungs, leading to subsequent progression of lung tissue damage. These complications start with destruction of the alveolar membrane, accompanied by emergence of a pulmonary bulla. Rupture of the bulla results in air leaking to the pleural space (pneumothorax). In the case of pneumomediastinum, the air spreads within the peribronchial interstitium along the airways to the mediastinum and subcutaneous tissues (Macklin effect). While pneumomediastinum and subcutaneous emphysema resolve spontaneously in most cases, pneumothorax treatment depends on its magnitude. While small pneumothorax may be managed conservatively, large pneumothorax usually requires active treatment with an acute chest drain; the latter is also associated with worse prognosis and a higher chance of death. We report air-leak complications in nine COVID-19 patients, of whom seven had spontaneous pneumothorax and four of them died. Three patients developed spontaneous pneumomediastinum together with subcutaneous emphysema, with two of them surviving. One patient with combination of pneumothorax, pneumomediastinum and subcutaneous emphysema died. These complications may accompany moderate or severe COVID-19-associated pneumonia, mostly the late phase of the disease. They should be considered when patients complain of sudden chest or back pain or worsening respiratory insufficiency.

Osteoporosis in Skin Diseases

Osteoporosis (OP) is defined as a generalized skeletal disease characterized by low bone mass and an alteration of the microarchitecture that lead to an increase in bone fragility and, therefore, an increased risk of fractures. It must be considered today as a true public health problem and the most widespread metabolic bone disease that affects more than 200 million people worldwide. Under physiological conditions, there is a balance between bone formation and bone resorption necessary for skeletal homeostasis. In pathological situations, this balance is altered in favor of osteoclast (OC)-mediated bone resorption. During chronic inflammation, the balance between bone formation and bone resorption may be considerably affected, contributing to a net prevalence of osteoclastogenesis. Skin diseases are the fourth cause of human disease in the world, affecting approximately one third of the world's population with a prevalence in elderly men. Inflammation and the various associated cytokine patterns are the basis of both osteoporosis and most skin pathologies. Moreover, dermatological patients also undergo local or systemic treatments with glucocorticoids and immunosuppressants that could increase the risk of osteoporosis. Therefore, particular attention should be paid to bone health in these patients. The purpose of the present review is to take stock of the knowledge in this still quite unexplored field, despite the frequency of such conditions in clinical practice.

First successful combination of extracorporeal membrane oxygenation (ECMO) with video-assisted thoracic surgery (VATS) of pulmonary bullae resection in the management of refractory pneumothorax in a critically ill patient with H7N9 pneumonia and acute respiratory distress syndrome: A case report

RATIONALE

At present, data regarding refractory pneumothorax treated with video-assisted thoracic surgery (VATS) in combination with extracorporeal membrane oxygenation (ECMO) in critically ill patients with H7N9 pneumonia have never been reported.

PATIENT CONCERNS

A laboratory-confirmed case of human infection with avian influenza A (H7N9) virus was treated in our hospital. Acute respiratory distress syndrome (ARDS) developed and the patient was oxygenated via veno-venous ECMO due to the failure of mechanical ventilation. Unfortunately, a right refractory pneumothorax occurred. Despite treatment with pleural drainage and select bronchial occlusion, the patient still failed to improve.

DIAGNOSIS

Fatal H7N9 pneumonia complicated with severe ARDS, pulmonary bullae, and refractory pneumothorax.

INTERVENTIONS

Successful combination of ECMO with VATS of pulmonary bullae resection was performed and pneumothorax was cured.

OUTCOMES

One week after the operation, ECMO was removed. However, the patient finally developed multiorgan failure (MOF) complicated by refractory hypoxemia due to progressive lung fibrosis and died 36 days after admission.

LESSONS

Although the patient died of MOF triggered by severe lung fibrosis at last, the successful treatment of refractory pneumothorax by combination of ECMO with VATS is encouraging. Thus, when refractory pneumothorax in a patient with severe pulmonary dysfunction fails to improve through routine therapy, the treatment of pneumothorax by VATS based on ECMO support can be considered as a feasible selection.

Kindler syndrome in a patient with colitis and primary sclerosing cholangitis: coincidence or association?

Kindler syndrome is a rare, autosomal recessive genodermatosis, caused by mutations in the FERMT1 gene. It is thought to be primarily a skin disease, but other organs may also be involved. We report a case of a novel mutation of FERMT1 gene in a patient with a probable new phenotype of Kindler syndrome, including colitis and primary sclerosing cholangitis. A 42-year-old man, born to first cousin parents, was referred to our outpatient dermatology clinic with an unknown dermatosis since birth. He presented with neonatal blistering and developed photosensitivity and changes in skin pigmentation during childhood. Since the age of 20, he has had regular follow-up in the gastroenterology clinic, owing to esophageal stenosis, ulcerative colitis, and primary sclerosing cholangitis. Clinical examination revealed jaundice, poikiloderma, diffuse cigarette paper-like atrophy on dorsal surfaces of the hands, and palmoplantar hyperkeratosis. Skin biopsy showed epidermal atrophy covered by orthokeratotic hyperkeratosis. DNA molecular analysis revealed FERMT1 homozygous mutation c.1179G>A, p.W393X, which has not been reported before. The intestinal phenotype of Kindler syndrome has already been defined previously. However, to the best of our knowledge, no other case of primary sclerosing cholangitis in a patient with Kindler syndrome has been reported.

Breast cancer in a patient with Kindlers syndrome

Breast Cancer (BC) has associated risk factors and genetic factors like BRCA1, and BRCA2. Many benign and malignant disease processes are found concurrently with BC and believed to be additional risk factors like gall bladder stones (cholelithiasis), hypertension, diabetes mellitus, cerebrovascular lesions, arthritis, spine and spinal cord degenerative lesions, infertility, depression, sleep disturbances, obesity, autoimmune diseases (SLE), and thyroid diseases. There are some malignant disease associations like synchronous or metachronous ovarian, colonic and endometrial tumours with Breast cancer. Kindler Syndrome (KS) is a rare autosomal recessive genetic disorder manifesting as generalized dermatoses, described in 1954 by Theresa Kindler. KS is associated with acral skin blistering inducible by trauma, mucosal inflammation, photosensitivity, progressive pigmentation, telangiectasia, and skin atrophy (Poikiloderma). Repeated and progressive inflammation and subsequent fibrosis leads to ectropion, esophageal, anal, urethral, and vaginal stenosis and dryness. About 100 cases of Kindler syndrome have been reported in literature so far some from Arab World as well. Pathobiology of Kindler syndrome is not well understood. There are defects in KIND1 gene on chromosome 20. This gene expresses itself in basal keratinocytes, where it encodes a protein, called Kindlin 1. We report the second only case of Kindler's syndrome having breast cancer. These very very rare combinations have diagnostic issues, management restrictions, prognostic and follow up implications.

Concurrent pyogenic granuloma and bullous impetigo of a pregnant woman's finger

BACKGROUND

Bullous impetigo is a superficial skininfection caused by Staphylococcus aureus (S.aureus). Pyogenic granuloma is a common benigntumor frequently associated with prior trauma.Bullous impetigo and pyogenic granuloma may occurin pregnant women.

PURPOSE

The features of a pregnant womanwith pyogenic granuloma and bullous impetigoconcurrently present in a lesion on her finger aredescribed.

METHODS

PubMed was used to search the followingterms: bullous impetigo, pregnancy, and pyogenicgranuloma. All papers were reviewed; relevantarticles, along with their references, were evaluatedResults: A red ulcerated nodule with a collaretteof epithelium around the tumor and surroundingbullae appeared on the fifth digit of the left hand of a31-year-old woman who was at 36 weeks gestation. Abacterial culture grew methicillin sensitive S. aureus.An excisional biopsy was performed. Histologicfindings revealed not only a benign vascular tumorwith an infiltrate of mixed inflammatory cells, butalso an intraepidermal blister. She received oralantibiotics and there was complete resolution of thefinger lesion and infection with preservation of digitfunction.

CONCLUSION

Albeit uncommon, pyogenic granulomaand bullous impetigo may concurrently occur in thesame lesion. Therapeutic intervention should focuson treating both the benign skin tumor and theinfection.

Non-dysbaric arterial gas embolism associated with chronic necrotizing pneumonia, bullae and coughing: a case report

Arterial gas embolism (AGE) can be clinically devastating, and is most often associated with exposure to changes in ambient pressure, medical procedure or congenital malformation. Here we report a case of AGE in a 78-year-old male without these traditional risk factors. Rather, the patient's history included chronic obstructive pulmonary disease, necrotizing pneumonia, bullous disease and coughing. He was safely treated with hyperbaric oxygen (HBO₂) therapy for AGE, with initial clinical improvement, but ultimately died from his underlying condition. Pathophysiology is discussed. This case illustrates the possibility that AGE can occur due to rupture of lung tissue in the absence of traditional risk factors. HBO₂ therapy should be considered in the management of such patients.

Soft Bandage Contact Lenses in Management of Early Bleb Leak Following Trabeculectomy

PURPOSE

To investigate the efficacy of a soft bandage contact lens in the management of early bleb leak following trabeculectomy.

METHODS

Between October 2011 and April 2013, 11 patients with early bleb leak following fornix-based trabeculectomy were instructed to wear a soft bandage contact lens 14 mm in diameter continuously for 1-2 weeks. The daily visual acuity, intraocular pressure (IOP), anterior chamber situation, and healing condition were measured at 1, 3, and 7 d, after con tact lens removal, and 3 months after trabeculectomy. The conditions of blebs, sensation of wearing contact lens, and adverse events were recorded.

RESULTS

Bleb leaks were observed at 2-8 d after surgery, (4.09 ± 1.10 d on average). The daily LogMAR visual acuity did not significantly differ before and after contact lens wear (P > 0.05). The IOP was significantly raised after at 1, 3, and 7 d after lens wear (all P < 0.05).The IOP at 3 months after lens wear did not significantly differ from that measured at lens removal (t = 1.191, P = 0.089). At 1 d after lens wear, 6 cases had deeper anterior chambers. All patients presented with a significantly deepened anterior chamber at 3 d after lens wear, and were restored to the preoperative conditions. The bleb leakage was successfully treated at 7 d after lens removal in 10 patients, while 1 patient had to wear the contact lens for another 7 d for full healing of the bleb leak. No ocular infection was noted throughout the management.

CONCLUSION

A soft bandage contact lens of 14 mm diameter is a safe and efficacious therapy for an early bleb leak following fornix-based trabeculectomy.

Bullous systemic lupus erythematosus in a patient with human immunodeficiency virus infection: a paradox of autoimmunity and immunodeficiency

Bullous lupus erythematosus is a rare variant of systemic lupus erythematosus (SLE) and is characterized by autoantibodies to type VII collagen. Co-existence of SLE and human immunodeficiency virus (HIV) infection is extremely rare; the development of bullous lupus in the setting of HIV has been, to our knowledge, reported in the literature only once. We describe a 26-year-old man with an 8-year history of HIV infection who developed bullous SLE. The patient presented with widespread, tense bullae as well as oral ulcerations. Clinical, laboratory, histological, and cutaneous immunofluorescence findings confirmed the diagnosis of bullous SLE. Given the immunological consequence of HIV infection, the co-occurrence of these two diseases would, theoretically, be unusual. Theories pertaining to the interplay of immunologic mechanisms of the seemingly paradoxical occurrence of autoimmunity in the setting of HIV infection are discussed.

[Successful one-lobe ventilation in a patient combined with multiple bulla and interstitial pneumonia]

Respiratory management of interstitial pneumonia during general anesthesia is challenging, especially for one-lung ventilation. We report the successful left-side one-lung ventilation after left lower lobectomy. A 79-year-old man with interstitial pneumonia was scheduled for right side bulla resection. After epidural anesthesia at T8-9, under dexmedetomidine and propofol sedation and regional anesthesia with lidocaine, a double-lumen tube was inserted with a Macintosh laryngoscope preserving spontaneous breathing. Next, we continuously administered propofol at 1.5-2.0 microg x ml(-1) in target-controlled infusion manner, 0.8 microg x kg(-1) x hr(-1) dexmedetomidine and 50 mg x hr(-1) aminophylline for minimizing hypoxic vasocontriction. The bispectral index was maintained within 40-60 by titrating the dose of propofol. Analgesia was performed with epidural 100 microg fentalyl and 6 ml of 0.375% ropivacaine administration. The lowest Spo2 during one-lobe ventilation was 88% which recovered to 97% by oxygen administration to right lung with no pressure. We could keep about 3-4 l of minute volume and accumulation of Paco2 was acceptable. The patient was under one-lobe (left upper lobe) ventilation with spontaneous breathing during the operation. Open bulla resection was performed uneventfully. There were no complications from one-lobe ventilation and the patient was extubated in the operating room. One-lung ventilation, which preserves spontaneous breathing is considered effective for preventing barotrauma in patients with interstitial pneumonia. Dexmedetomidine as well as propofol or aminophylline may be effective avoiding hypoxic vasoconstriction. Furthermore, we could perform one-lobe ventilation with left-upper lobe with maintaining sufficient oxygenation and ventilation.

[Modern endothelial keratoplasty-based options for visual rehabilitation of patients with bullous keratopathy and concomitant glaucoma]

PURPOSE

To develop endothelial keratoplasty-based surgical treatment and management policy for patients with bullous keratopathy complicated by glaucoma. MATERIAL AND METHODS; A total of 41 patients (41 eyes) with bullous keratopathy and concomitant II-III stage glaucoma were enrolled. All patients underwent endothelial keratoplasty of different modification--DSAEK, utDSAEK, DMAEK. Two types of glaucoma drainage surgery were applied--intrascleral amniotic drainage and implantation of a domestically manufactured silicone tubular drainage wrapped in amnion.

RESULTS

Intraocular pressure (IOP) was compensated in 11 of 12 patients, on whom a glaucoma procedure was performed. In 29 post-keratoplasty patients, whose IOP was compensated both before and after the surgery, the mean IOP at the 2-year follow-up visit was 2 mm Hg higher than the preoperative values. Medication regimen was adjusted in 7 cases in order to enhance the hypotensive effect. No evident correlation between graft thickness and IOP change was found.

CONCLUSION

Based on a study of 41 patients (41 eyes) with bullous keratopathy and concomitant glaucoma who underwent endothelial keratoplasty, surgical treatment and therapeutic management policy is developed, which takes into account whether or not the IOP is compensated and whether or not its further decrease is required and implies the use of own original drainage techniques.

Injuries associated with the 580 km university student grand voluntary road march: focus on foot injuries

College student volunteers (n = 142) completed a 580 km road march for 21 consecutive days. Each volunteer carried a backpack that weighed 14.1 ± 1.4 kg on the average. We investigated the incidence and location of blisters associated with the road march using a foot map along with other injuries. Overall, 95.1% of the subjects (135 of 142) sustained one or more injuries. All injured subjects had foot blisters, and 18% had other foot injuries. The most common locations of blister development were the right 5th toe (61%) and the left 5th toe (57%). The little toes seem to have been subjected to the greatest friction and shearing forces. March-related injuries, excluding foot injuries, were ankle pain (12.7%), knee pain (12.7%) and Achilles tendon pain (7.7%). Six subjects (4.2%) needed extra medical treatment for more than 2 weeks prior to returning to their daily lives after completion of the march due to associated injuries. The present study observed a very high incidence rate of injuries (95.1%) associated with the 580 km university students grand road march. These injuries posed an obstacle against completion of the road march and against returning to daily life. Active preventive interventions such as physical therapy and customized reinforced shoes and education program are recommended for reducing incidence rate and severity of injuries.

[Secondary spontaneous pneumothorax due to a ruptured bulla at a left-sided azygoesophageal recess in a patient with right aortic arch]

Significant frequency of ruptured bullae at the azygoesophageal recess (AER) in secondary pneumothorax patients was reported recently. In normal anatomy, the AER usually exists only in the right thorax. We herein report a case of secondary spontaneous pneumothorax due to a ruptured bulla at a leftsided AER-like structure in a patient with right aortic arch. The case was a 70-year-old man who developed left spontaneous pneumothorax secondary to pulmonary emphysema. He was initially treated by thoracic drainage, but in vain, and finally referred to our department because of prolonged air leakage. Preoperative computed tomography demonstrated a bulla formation at a recess between the rightsided descending aorta and thoracic vertebrae. In thoracoscopic surgery, we confirmed air leakage from the bulla at the recess and the bulla was subsequently ligated. To the best of our knowledge bulla formation at a left-sided AER-like structure has never been reported. Local overinflation of the lung parenchyma may have been a cause of bulla formation in this case.

In vitro pathogenicity assay for anti-desmoglein autoantibodies in pemphigus

Patients with pemphigus have circulating anti-desmoglein (Dsg) 1 and/or Dsg3 autoantibodies that induce blister formation on the skin and mucous membrane. We describe here two assays that measure the pathogenic strength of autoantibodies in blister formation: an in vitro dissociation assay using primary human epidermal keratinocytes to assess pathogenicity of anti-Dsg3 autoantibodies, and an alternative method whereby anti-Dsg3 and Dsg1 autoantibodies are injected into organ-cultured human skin specimen.

Single stage minimally invasive bilateral video assisted thoracoscopic surgery for simultaneous bilateral primary spontaneous pneumothorax

Simultaneous bilateral spontaneous pneumothorax (SBSP) is a very rare life-threatening condition that requires rapid diagnosis and treatment. Most cases are secondary to various underlying lung pathology but a primary SBSP may occur due to rupture of subpleural blebs or bullae. Surgery via an open or minimally invasive approach provides definitive treatment and can be undertaken as a staged or simultaneous procedure. We report our experience with two such rare cases utilizing a single stage minimally invasive bilateral video assisted thoracoscopic (VATS) approach. The pathogenesis of this rare condition and intra-operative technical considerations for a successful outcome are discussed.

Hemopneumothorax caused by vascularized bullae and a pulmonary hemangioma in an adolescent boy

Spontaneous hemopneumothorax is a rare, potentially life-threatening condition occurring in adolescence. In general, spontaneous hemopneumothorax has not been associated with other pulmonary vascular malformations in adolescents. We present a case of a 17-year-old adolescent boy with hemopneumothorax from vascularized pleural blebs who was also noted to have a pulmonary hemangioma.

Nafcillin-induced bullous skin eruption with granulocytopenia in a patient with end-stage renal disease

Nafcillin is an antibiotic used for infections due to penicillin-resistant Staphylococcus aureus. In general, the adverse reactions to nafcillin have not been frequent and serious. We report here a new type of adverse reaction to nafcillin in a patient with end-stage renal disease in whom nafcillin caused the unexpected complication of bullous drug eruption and subseqent neutropenia. Three weeks after the start of intravenous nafcillin for the treatment of peritoneal dialysis peritonitis, the patient developed blisters on his right ankle. These became progressive and widespread, with bullae affecting most of the body surface. In addition, neutropenia developed three days after the appearance of bullous skin lesions. Spontaneous recovery of skin lesions and neutropenia was observed after the withdrawal of naficillin. When treating patients with chronic renal failure, physicians should be aware of these rare but potentially severe adverse reactions.

[Interscalene block combined with general anesthesia under spontaneous breathing in a patient with a giant bulla]

Respiratory management for patients with a giant bulla during anesthesia should avoid positive-pressure ventilation to reduce the risk of barotraumas. We report a case of anesthetic management of a 42-year-old man with a giant bulla who had an elective surgery for biopsy of a tumor on his left elbow. Balanced anesthesia consisting of general anesthesia was given under spontaneous breathing combined with interscalene brachial plexus blockade for intra- and postoperative analgesia for the elbow surgery. The patient was monitored by electrocardiography, non-invasive arterial pressure, SpO2, endtidal CO2 tension and bispectral index. Ultrasound-guided interscalene block was performed with the patient awake. After injection of 0.75% ropivacaine 20 ml and 1% lidocaine 16 ml for brachial plexus block, general anesthesia was induced with a bolus of fentanyl 100 microg to reduce cough reflex and propofol using target control infusion with a 2 microg x ml(-1) plasma concentration. The airway was maintained with a size 4 LMA-Proseal, which was inserted with care under spontaneous breathing. There were no serious complications such as pneumothorax in perioperative period. We performed successful anesthetic management, without any complications, combined with interscalene brachial plexus block and spontaneous breathing in a patient with a giant bulla.

Bullae and sweat gland necrosis in the differential diagnosis for Vibrio vulnificus infection in an alcoholic patient

Bullae and sweat gland necrosis remain rare cutaneous manifestation, and these conditions can be misdiagnosed as Vibrio vulnificus infections or other soft tissue infections because of their low index of suspicion. A 46-yr-old man with a history of continued alcohol consumption presented with erythematous and hemorrhagic bullous lesions on his left arm. The patient reported that after the ingestion of clams, he slept for 12 hr in a heavily intoxicated state. Then the skin lesions started as a reddish patch that subsequently became hemorrhagic bullae. V. vulnificus infection, cellulitis, and necrotizing fasciitis were considered in initial differential diagnosis. However, on the basis of sweat gland necrosis on histopathologic examinations and negative results on bacterial cultures, we made the diagnosis of bullae and sweat gland necrosis. Therefore, bullae and sweat gland necrosis should also be considered in chronic alcoholic patients who present with bullae and a previous history of unconsciousness.

[Adenocarcinoma developed in the pulmonary giant bulla; report of a case]

A 56-year-old man was point out chest abnormal shadow in the left lung by chest X-ray for routine follow-up of diabetes. Chest computed tomography (CT) revealed emphysematous changes in the bilateral lung, and showed an approximately 23 x 20 mm tumor in the giant bulla of the left upper lobe. Left S(1+2) segmentectomy was performed as the diagnosis of adenocarcinoma was established by intra-operative biopsy. The lesion was diagnosed as poorly differentiated adenocarcinoma (pT1N0M0P0D0PM0E0, stage IA). The frequency of lung cancer within a bulla is reported as high as 14-29% in Japan. Therefore, it is thought to be necessary that the pulmonary bullous lesion must be followed-up for a long period because of the possibility of development of malignancy.

Bullous-hemorrhagic Darier disease

A 48-year-old man presented with a 4-month history of papular hyperkeratotic diffuse lesions on his trunk, arms, and neck that were highly pruritic (Figure 1). He also had "V"-shaped nicks in the nails, mucous white papules on his palate, and diffuse desquamation on the scalp. Abnormal laboratory values included elevated levels of uric acid and triglycerides. Serum electrolytes, blood sugar, and renal and liver function test results were within normal range. X-ray film and abdominal ultrasonography findings were also normal. Histopathologic study of the biopsy from the thorax revealed acantholysis with suprabasal clefting, intraepidermal lacunae, and dyskeratosis with corps ronds. The clinical features and results of the histopathologic studies suggested a diagnosis of Darier disease (Figure 2), but the course was not typical of this entity because the patient had no family or personal history of previous cutaneous lesions and the age of onset was older than usual. In the course of the disease, he developed blisters and small black hemorrhagic macules with jagged borders on the back of his hands (Figure 3). Nikolsky's sign was negative. A biopsy of a blister was performed, which confirmed Darier disease, studied by means of immunofluorescence. Measurement of porphyrins in the urine was also ordered. Direct immunofluorescence did not show deposition of immunoglobulins or complement, and the study of porphyrins was normal. The patient was treated with an oral retinoid (acitretin 10 mg daily), but treatment was stopped because he developed an increase in triglycerides; therefore, control of the disease with oral antihistamines, 5-fluorouracil 1% cream, and topical tazarotene was used, with mild improvement.

Bullous pemphigoid in a patient with suspected non-Herlitz junctional epidermolysis bullosa

A 56-year-old man with lifelong trauma-induced blisters, nail dystrophy and dental enamel hypoplasia presented with a new spontaneous blistering eruption. Clinicopathologically, he had evidence of both an inherited and an acquired blistering disorder: non-Herlitz junctional epidermolysis bullosa (nHJEB) and bullous pemphigoid (BP). HIstological examination of a skin biopsy found reduced (but not absent) collagen XVII in nonlesional skin, in vivo bound anticollagen XVII antibodies in perilesional skin, and prominent eosinophils in perilesional and lesional skin, with subepidermal blistering. Circulating anticollagen XVII antibodies were also present. Treatment with oral corticosteroids and mycophenolate mofetil led to clinical control of the BP but had no effect on the mechanobullous blistering. Our patient is unusual in that his skin retains some labelling for collagen XVII rather than having the complete absence of immunoreactivity expected in patients with generalized nHJEB. Moreover, we were unable to identify any pathogenic mutations in the COL17A1 gene encoding collagen XVII (or in other EB-associated basement membrane genes). It is plausible that the long-term consequences of basement membrane disruption in our patient, perhaps associated with atypical inherited COL17A1 pathology, might result in a conformationally altered and more immunogenic protein with the subsequent development of anticollagen XVII antibodies and BP as a secondary pathology.

Shewanelia putrefaciens: a rare microbial agent associated with a non-healing ulcer in a leprosy patient

Female aged 55 years presented with signs and symptoms of borderline lepromatous leprosy and presence of a non-healing ulcer and multiple haemorrhagic blisters over dorsum of both feet. Discharge from the various lesions was subjected to microbiological examination and an unusual organism Shewanella purtefaciens was isolated which was sensitive to most routine antibiotics. Patient responded well to cephadroxil therapy with uneventful and complete healing of ulcer and blisters.

[Risk factors for visual outcome after bleb-related infection]

PURPOSE

To investigate risk factors for visual impairment following bleb-related infection after trabeculectomy with mitomycin C.

METHODS

We retrospectively reviewed 31 cases of bleb-related infection at Osaka Koseinenkin hospital from 2004 to 2007.

RESULTS

Twelve cases of blebitis and 19 cases of bleb-related endophthalmitis were studied. According to the stage of infection, each patient was continued to be treated following a previously decided treatment strategy. Fifteen patients underwent pars plana vitrctomy. Two patients with blebitis progressed to endopthalmitis. Visual acuity in seven eyes (22.6%) decreased by two or more lines following infection. Risk factors for visual impairments following bleb-related infections were recurrence of infection (p = 0.022), negative Seidel tests (p = 0.0056), aphakia (p = 0.045), avitreous (p = 0.00070), positive Streptococcus species (p = 0.029), and prolonged inflammation (p = 0.014).

CONCLUSIONS

Recurrence of infection, negative Seidel tests, aphakia and avitreous are risk factors for visual impairment following bleb-related infection after trabeculectomy.

Blue rubber bleb nevus syndrome causing refractory anaemia

Blue Rubber Bleb Nevus Syndrome (BRBNS) is a rare angiomatosis characterized by distinctive cutaneous and gastrointestinal venous malformations that result in gastrointestinal haemorrhage and iron-deficiency anaemia secondary to the bleeding episodes. We hope to emphasize the possibility of recurrent melaena in BRBNS and heighten physicians' awareness about the disease to contribute to its early detection.

[Respiratory management for a patient with a giant bulla and pulmonary dysfunction during off-pump coronary artery bypass grafting]

This case report describes a successful anesthetic management of a 74-year-old patient with a giant bulla and pulmonary dysfunction during off-pump coronary artery bypass grafting (OPCAB). BiPAP Vision with a laryngeal mask airway (LMA) was used for intraoperative respiratory management. General anesthesia was induced with propofol. After insertion of a LMA anesthesia was maintained with propofol and dexmedetomidine under spontaneous breathing with bilevel positive airway pressure. Epidural analgesia was used in combination with general anesthesia. The LMA was removed without coughing and bucking soon after the end of the surgery. There was no complication during and after anesthesia. This respiratory management may be beneficial for patients with a giant bulla and pulmonary dysfunction during OPCAB.

Potential role of interleukin-17 in the pathogenesis of bullous pemphigoid

Bullous pemphigoid is an autoimmune blistering disease of the skin caused by autoantibodies directed against basement membrane zone adhesion molecules. Autoantibodies cannot fully explain several important features of the disease such as the difficulty transferring with the pathogenic autoantibodies, or the presence of heavy lesional infiltration of eosinophils and neutrophils that is necessary for disease production. There is increasing evidence that Th17 cells and the cytokines they release such as interleukin-17 are important regulators of innate and adaptive immune responses in many Th1 and/or Th2 mediated autoimmune diseases such as rheumatoid arthritis, systemic lupus erythematosus, and allergic asthma. There is also evidence that Th17 cells have a role in pathogenesis of blistering skin diseases. Interleukin-17 is important in initiation and maintenance of many autoimmune reactions and it is involved in production of pro-inflammatory cytokines, matrix metalloproteinases, neutrophils, and eosinophils, all of which are important pathogenic factors in bullous pemphigoid. The hypothesis is that interleukin-17 has an important pathogenic role in BP and can describe features of the disease not explained by the autoantibody theory. This cytokine can be assessed in the blister fluid and sera of patients, and can be used as a marker of disease activity and response to therapy. The information obtained could also lead to the development of novel therapeutic strategies for this and other autoimmune blistering diseases.

Severe hemorrhagic bullous lesions in Henoch Schonlein purpura: three pediatric cases and review of the literature

Henoch Schonlein purpura (HSP) is a small-sized blood vessels vasculitis, resulting from immunoglobulin A-mediated inflammation. It is the most common acute systemic vasculitis in childhood and mainly affects skin, gastrointestinal tract, joints and kidney. Skin lesions, usually presenting as erythematous maculopapules, petechiae, and purpura, often involve lower extremities and buttocks, but may also extend to the upper extremities, face and trunk. Conversely to adults, hemorrhagic bullous evolution has been seldom described in childhood. The pressure is likely a factor into the pathogenesis of bullae. We report on three new pediatric cases of HSP with hemorrhagic bullous skin lesions, and a review of the literature. Bullous evolution represents an unusual, but well-recognized cutaneous manifestation that may be a source of diagnostic dilemma, but does not seem to have any prognostic value in the outcome of HSP.