Chih-Hsun Yang

Mapping Gray Matter Reductions in Obstructive Sleep Apnea: An Activation Likelihood Estimation Meta-Analysis

STUDY OBJECTIVES The authors reviewed the literature on the use of voxel-based morphometry (VBM) in obstructive sleep apnea (OSA) magnetic resonance imaging (MRI) studies via the use of a meta-analysis of neuroimaging to identify consistent and specific structural deficits in patients with sleep apnea compared with healthy subjects. DESIGN Neuroimaging meta-analysis. DATA SOURCES We used PubMed to retrieve articles published between January 2000 and February 2012. STUDY SELECTION The authors included all VBM research on patients with OSA and healthy controls. They compared the findings of the studies by using gray matter volume (GMV) or gray matter concentration (GMC) to index differences in gray matter. DATA EXTRACTION Stereotactic data were extracted from eight VBM studies of 213 patients with OSA and 195 control subjects. RESULTS Regional gray matter reduction in the bilateral parahippocampus and less-convincing right superior frontal and left middle temporal gyri was demonstrated in patients with sleep apnea using an activation likelihood estimation (ALE) procedure to analyze significant differences. CONCLUSIONS Significant reductions in gray matter in patients with sleep apnea occurred in the bilateral parahippocampus and less-convincing frontotemporal regions, which may be related to the neurocognitive processing abnormalities that are common among populations of patients with sleep apnea.

Toxic epidermal necrolysis following combination of methotrexate and trimethoprim-sulfamethoxazole

A 15‐year‐old boy with T‐cell acute lymphoblastic leukemia (ALL) (FAB L1), diagnosed in 1995, received combination chemotherapy consisting of 6 weeks of induction (vincristine, epirubicin, L‐asparaginase, prednisolone) and 2 weeks of consolidation (cytosine arabinosides, etoposide). After achieving remission, for further maintenance of remission, he was treated with 14 cycles of intensive chemotherapy consisting of 6‐MP, 10 mg/kg orally on the first 4 days, and cyclophosphamide, 1200 mg/m2, vincristine, 1.5 mg/m2, epirubicin, 15 mg/m2, and cytosine arabinoside, 40 mg/m2, intravenously on days 4, 11, 39, and 40, respectively. On day 18 of each cycle, he received intravenous methotrexate (MTX) infusion in a total dose of 150 mg/m2 plus oral leucovorin (30 mg/m2 ) rescue 36 h after starting MTX therapy. In addition, oral trimethoprim–sulfamethoxazole was given regularly to prevent Pneumocystis carinii infection.

Patients with inhibitory and neutralizing auto-antibodies to interferon-γ resemble the sporadic adult-onset phenotype of Mendelian Susceptibility to Mycobacterial Disease (MSMD) lacking Bacille Calmette–Guerin (BCG)-induced diseases

To recognize patients with inhibitory and neutralizing auto-antibodies to interferon-γ (AutoAbs-IFN-γ) presenting with the sporadic phenotype of Mendelian Susceptibility to Mycobacterial Disease (MSMD) mainly characterized by recurrent intracellular mycobacterium or/and salmonella infections, we comprehensively investigated IL12/23-IFN-γ signaling, candidate genetic sequencings or/and protein expressions of IL12RB1, IFNRG1, IL12p40, IFNRG2, STAT1, IKKA, NEMO, CYBB and IRF8 in four patients. Their serum was further titrated to detect AutoAbs-IFN-γ, for which the biological activity was assessed in Jurkat T cells. The patients mainly presented with recurrent non-tuberculous mycobacterium osteomyelitis and lymphadenopathy (Mycobacterium abscessus, chelonae and avium intracellular complex), and salmonella sepsis (S. enterica serogroup B, C2 and D). Additionally, Penicillium marneffei, varicella-zoster virus, and herpes simplex virus infections occurred. Inhibitory and neutralizing IFN-γ downstream signaling was elucidated in Jurkat cell lines as decreased MHC class I and phosphorylated STAT1 expression. Together with 24 patients from the PubMed search, the majority of the AutoAbs-IFN-γ patients were Asian (25/28). The most common involvement was lymph nodes (in 22/28), lungs (19/28) and bones (12/28). Mycobacterium avium complex (in 14) and chelonae (7) were the most common pathogens from 40 isolations. In contrast to those with the mild form of MSMD phenotype, AutoAbs-IFN-γ patients, in the absence of BCG-induced diseases, had a more persistent course and poor response to IFN-γ treatment. In conclusion, AutoAbs-IFN-γ patients may have a sporadic adult-onset MSMD phenotype in Asian regions endemic for mycobacterial infections.

Urachal duct remnant-like umbilical clear cell acanthoma in an infant: An unusual presentation and pitfall in clinical practice

Background  Although an umbilical nodule is common in neonates and young infants, an umbilical nodule of poor therapeutic response will increase the likelihood of other uncommon etiology. Clear cell acanthoma (CCA) has never been described as an oozing umbilical nodule on infants.

Acute tuberculosis cutis miliaris disseminata in a patient with systemic lupus erythematosus

Cutaneous tuberculosis accounts for about 1.5% of all cases with extrapulmonary tuberculsosis. Acute tuberculosis cutis miliaris disseminata is an uncommon form of tuberculosis in the skin. Disseminated miliary tuberculosis was affected by the transmission of Mycobacteria tuberculosis to a variety of organs via hematogenous spreading from the primary focus of lung or meninges. Common risk factors of miliary tuberculosis include immunocompromised status, alcoholism, and acquired immunodeficiency syndrome. We herein report a rare case of acute tuberculosis cutis miliaris disseminata in a systemic lupus erythematosus (SLE) patient.

Myoepitheliomas of the Skin and Soft Tissue-A Clinicopathologic Study of Three Cases

Myoepithelioma of the skin and soft tissue is a newly recognized entity with characteristic histopathologic and immunohistochemical features, which should be differentiated from a variety of tumors. Myoepitheliomas are in the same pathologic spectrum of mixed tumors and parachordomas. Tumors comprised mostly of myoepithelial cells without obvious epithelial differentiation are designated myoepitheliomas. Since the entity has not been well documented in Taiwan, the clinicopathologic features of three cases of cutaneous and soft tissue myoepitheliomas are reported.

Chromoblastomycosis in Taiwan: A report of 30 cases and a review of the literature

Chromoblastomycosis (CBM) is an implantation mycosis characterized by the presence of pigmented muriform cells in tissue. CBM is endemic in Taiwan, but only three formal cases have been reported to date because of underreporting. To describe and update its epidemiologic features, we report a series of 30 cases between 2003 and 2016 at a single medical center. Patients were predominately male (2.75:1). The mean age of onset was 65.9 years, and disease duration ranged from 2 months to 20 years. Diabetes was the most common comorbidity, and extremities were the most frequent sites of involvement. The lesions presented as papuloplaque, verrucous, cicatricial, targetoid, or mixed types. The dermoscopic features were variable, including red dots, white vague areas, black globules, and sand-like patterns. Among 10 Fonsecaea isolates further identified by sequencing the ITS regions of ribosomal DNA, nine were F. monophora and one was F. nubica. All but one patient received either systemic antifungal agents, surgical excision, or both. Surgical excision achieved a higher complete remission rate than the other forms of treatment did.

Necrobiotic xanthogranuloma with paraproteinemia without periorbital involvement—a case report

Abstract Necrobiotic xanthogranuloma is an uncommon granulomatous disease involving the skin and extracutaneous tissues. It is characterized by indurated, yellow-red plaques and nodules, involving primarily the face and less frequently the trunk and extremities. The disease has a strong association with paraproteinemia and other hematologic or lym-phoproliferative disorders. Histologically, the dermal part shows xanthogranulomatous change with extensive necrobiosis and many Touton and foreign-body giant cells. Here, we describe a case of a 46-year-old man with a 1-year history of multiple cutaneous lesions over the trunk and thighs. Necrobiotic xanthogranuloma was diagnosed by histology and clinically associated with paraproteinemia. This case is also unusual in that there was no periorbital involvement, which is believed to be a typical feature of this disease.

Anaphylactic Shock After Injection of Foamed Sodium Tetradecyl Sulfate

A 56-year-old woman visited the hospital because of severe varicose veins in her left leg associated with a stasis ulcer for many years. She had been previously healthy and was taking no medications. She had anaphylactic shock after taking multiple drugs, including acetaminophen, ketoprofen, and sulfamethoxazole/trimethoprim. She did not smoke, drink alcohol, or use illicit drugs. Duplex ultrasound examinations revealed a pronounced reflux signal in the left saphenofemoral junction, as well as the great saphenous vein. She then underwent duplex-guided foam sclerotherapy with STS, foam of which was generated by the Tessari technique with the liquid-toair ratio of 1:4. About 10 mL of 3% STS (Fibro-Vein; STD Pharmaceuticals, Hereford, United Kingdom) foamwas injected into her great saphenous vein under duplex guidance at the mid-thigh and calf area. Soon after the injection, she reported shortness of breath and generalized itchy erythema, which was found to be urticarial wheals. She then became unconscious and hypotensive (blood pressure 60/40 mm Hg). Emergent resuscitation began immediately. Oxygen, a subcutaneous injection of 0.5 mg epinephrine, an intramuscular injection of 2.5 mg dexamethasone, and 40 mg diphenhydramine were administered. Five minutes later, the patient was awake and successfully carried out an order. Her blood pressure increased to 92/60mmHg.Her skin reaction subsided 10 hours later. L ETTERS AND COMMUN ICAT IONS

Cutaneous Adverse Events of Targeted Anticancer Therapy: A Review of Common Clinical Manifestations and Management

Targeted anticancer therapies, unlike the traditional cytotoxic chemotherapies which lead to systemic toxicities, frequently cause cutaneous adverse events that are symptomatic and manifest in cosmetically sensitive areas. The most common dermatologic toxicities related to epidermal growth factor receptor (EGFR) inhibitors are papulopustular eruption, xerosis, pruritus and paronychia. Vascular endothelial growth factor receptor (VEGFR) inhibitors usually cause hand-foot skin reaction. Reports of dermatologic side effects such as abnormalities of hair growth and mucosal changes also increased.These events may contribute to poor adherence, dose interruption and discontinuation of the regimens. In addition, psychosocial discomfort causing reduction in the quality of life does occur. However, the presence and severity of cutaneous adverse events has shown to have positive correlation with treatment response.The management of these side effects can be categorized into prophylaxis and reactive treatment. Systemic antibiotics and topical corticosteroid could possibly prevent or alleviate symptoms caused by EGFR inhibitors. The prevention of sun exposure is recommended to all patients on targeted therapy, and emollients and lubricants can be used to relieve and improve the hand-foot skin reaction.