A 10-year-old Japanese boy crushed a bug on his chest. After 30 minutes, painful erythema and vesicles appeared on his chest. The following day, the patient consulted our clinic, bringing with him the crushed bug and another, uncrushed dead bug. The bugs were identified as Nezara viridula. A diagnosis of irritant contact dermatitis caused by this bug was made. Arthropods produce several defensive secretions that contain toxic compounds. Patch tests of the dead bug were performed on 8 healthy volunteers. One of the 8 volunteers had a positive reaction after 48 and 72 hours. A similar bug was applied to the forearm of the author, producing an irritant reaction at the site of application.

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Dermatomyositis is considered to be associated with an increased risk of malignant disease. We report two patients manifesting dermatomyositis with lung cancer. One was a 66-year-old woman with heliotrope rash, Gottron's signs and diffuse poikiloderma of the trunk. As she did not have myositis, we assigned the diagnosis of amyopathic dermatomyositis. She had a lung adenocarcinoma and there was a slight improvement in the skin rash after successful treatment of lung cancer. The second patient was a 67-year-old man with cutaneous manifestations and myositis as well as interstitial pneumonia. He had small cell carcinoma of the lung. Treatment with oral corticosteroid for dermatomyositis was successful, despite worsening of lung cancer.

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We report two cases of dermatomyositis associated with progressive and severe interstinal pneumonia. Case 1 was a 53-year-old man with interstinal pneumonia that continued to worsen in spite of steroid pulse therapy (succinate methylprednisolone 1 g daily for three days) and cyclophosphamide pulse therapy (750 mg daily over five days). We treated his interstinal pneumonia with intravenous immunoglobulin (25 g daily over 5 days); however, the patient died after labored respiration. Case 2 was a 56-year-old man with exacerbation of interstinal pneumonia despite administration of steroid pulse therapy and oral cyclophosphamide (100 mg daily). We started intravenous immunoglobulin therapy as in Case 1 and intravenous cyclosporin and performed plasma exchange several times. Those treatments failed to improve his interstinal pneumonia and he died of severe respiratory failure. The progression of interstinal pneumonia associated with dermatomyositis is rapid and severe. At the point of progression, it is recommended that in the early stage immunosuppressive and intravenous immunoglobulin therapy are the best therapies for this lifethreatening condition.

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A 68-year-old man with severe dysphagia caused by dermatomyositis is presented. In January 2, 2002, he was admitted to our hospital because of fever, muscle weakness and dysphagia and for evaluation of erythematous lesions with edema on the face, bilateral elbows, bilateral knees, and the hands. Dermatomyositis was diagnosed and intravenous steroid therapy was started. As that therapy was ineffective, pulse intravenous steroid therapy was given. Serum levels of muscle enzymes decreased but the patient became progressively hypoxemic. No effect was observed from the series of therapies, which included additional pulse steroid therapy and oral cyclosporin therapy. On May 19, the patient died due to severe acute interstitial pneumonia. Histological examination at autopsy revealed diffuse alveolar damage of bilateral lung and fibrosis of the throat. It is necessary to establish conservative treatment for patients with acute interstitial pneumonia associated with dermatomyositis.

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We report a case of paraneoplastic pemphigus (PNP). The 62-year-old Japanese female showed clinical, histopathological and immunohistopathological features characteristic of PNP. The results of antigen analysis by both immunoblotting and immunoprecipitation were compatible with those of PNP. The patient exhibited a bronchiolitis obliterans-like respiratory symptoms, and the course was progressive and lethal in spite of extensive therapies, including methylpredonisolone pulse therapy, high-dose cyclosporin and plasmapheresis. Extensive examination and an autopsy did not reveal an apparent tumor. This is a rare case in which no tumor was detected.

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A 52-year-old woman visited our outpatient clinic with complaints of erythema and bullae on her trunk and extremities. Physical examination at first suggested a diagnosis of erythema exudativum multiforme. However, histopathology of the skin lesion revealed sub-epidermal blister formation. Indirect immunofluorescence (IF) staining detected circulating anti-basement membrane zone (BMZ) antibodies. Confocal laser scanning with direct IF staining revealed linear depositions of IgG and C₃ at the BMZ. A final diagnosis of bullous pemphigoid was established on the basis of these findings. High doses of oral prednisolone failed to control the bullae formation. An immunosuppressive agent (cyclosporin) was effective for these eruptions. The patient was also diagnosed as having breast cancer. One month after the hospitalization, the tumor was successfully resected. Indirect IF staining showed no circulating anti-BMZ antibodies. No recurrence of bullous eruptions has been observed for four years after the operation without any medical treatment. We speculate that the onset of bullous pemphigoid in this case may be associated with the malignant tumor.

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An 81-year old man presented with spreading erythema on his extremities and trunk after he was bitten on his left shoulder by ‘Nusuto-gumo’. He was refferred to our clinic after developing numerous red papules and small nodules. Histopathological findings revealed palisading granuloma with degeneration of collagen bundles and mucin deposition. Eruptive sarcoidosis, annular elastolytic giant cell granuloma, and cutaneous mycobacterial infections including tuberculosis, Hansenian's disease or atypical mycobacteriosis were excluded by histopathological and laboratory investigations. The administration of PUVA bath therapy failed to control his eruptions, resulting in erythrodermic change with high fever, progressive anemia and hypoproteinemia. Oral minocycline (200 mg/day) therapy induced a significant improvement in the eruption and normalization of the clinical data.

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We report two cases of penile carcinoma. The first patient was an 81-year-old male who noticed an erosive lesion on his prepuce one year prior to presentation. The second patient was a 71-year-old man with a small ulcer on his glans that had been present for five years and a history of phimosis. Histopathological examination showed that both patients had Bowen's disease. Based on the clinical manifestations and histological findings, a diagnosis of squamous cell carcionoma (SCC) was made. Although penile SCC comprises nearly 6% of all urological malignancies, it is rare that dermalogists have the opportunity to inspect this kind of malignancy. Therefore, the possibility of SCC should be considered, especially when penile ulceration is present.

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We report on four cases of tinea capitis in Japanese junior high school and university judo teams and a high school wrestling team. Case 1 was a 13-year-old male judoist who first visited our clinic on October 5, 2002 ; Case 2 was a 17-year-old male wrestler who presented on May 26, 2003 ; Case 3 was a 13-year-old male judoist who presented on June 23, 2003 ; and Case 4 was a 19-year-old male judoist who visited the clinic on August 8, 2003. All four had noticed small, itchy and scaly areas of alopecia on their scalp for a few months before the first visit. When they visited our clinic, infiltrative erythema or reddish nodules with folliculitis were noted. Direct KOH examination revealed a large arthroconidia-form in the affected hair, and T. tonsurans was isolated in each patient. Medical examinations with the hairbrush technique detected four positive members out of 17 (23.5%) on the same wrestling team as case 2 and nine out of 58 (15.5%) positive members on the same judo team to which case 4 belonged. Tinea capitis caused by T. tonsurans is asymptomatic in the early stage, leading to a delay in an accurate diagnosis. Consequently, asymptomatic athletes could be transmitters within a team. It is necessary to establish a simple method of medical examination with the hairbrush technique and definitive control guidelines.

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In August 2000, an 83-year-old man got an abrasion about the size of an egg on the back of his leg when he fell into a cement gutter. He tried self-treatment, but the abrasion did not heal and became ulcerated. He consulted a local physician near his home who treated the lesion with an ointment. Four months later, healing had not occurred and the patient came to our hospital. At the initial examination, we recognized fever, skin ulcer with pain and a ring of scar and phlegmone on his right leg. Because Chromobacterium violaceum was detected at the ulcer site, we initiated treatment with intravenous administration of minocycline and local conservative therapy. The infection completely resolved. Treatment for chromobacterium violaceum infection requires careful selection of antibiotics such as tetracycline, chloramphenicol, and aminoglycosides. In this particular case, minocycline was quite effective. Because Chromobacterium violaceum usually exists in water or soil in tropical or subtropical zones, it is very rare to find a patient with this infection in Japan. This case is the first report of phlegmone with this infection. With the rising number of people traveling abroad, the increase in the number of imported animals, and the warming climate, we recommend watching for this disease, even in Japan.

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We report the case of an 87-year-old man who was referred to us with chronic and severe oral ulcerations. He had been being treated with nicorandil (Sigmart ^®) 20 mg/day since February 1994 because of angina pectoris. 55 months later, he developed chronic and severe oral ulcerations, and he lost about 13 kg in weight within 3 months. Despite receiving topical treatment from a different hospital, his oral ulcerations continued. Three days after nicorandil was stopped, the pain disappeared and the oral ulcerations healed within a month.

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We report a 40-year-old Japanese male with bullous pemphigoid associated with graft versus host disease (GVHD). He was diagnosed as having myelodysplastic syndrome at 38 years of age, followed by an allo-transplantation of peripheral blood stem cells. Three weeks post-transplantation, GVHD developed. He was successfully treated with oral predonisolone (50 mg/day) and cyclosporine (300 mg/day). On December 21, 2000, predonisolone was reduced to 15 mg/day in preparation for surgery for necrosis of hip joint. Erythema and tense blisters appeared on his trunk in January 2001. The diagnosis was bullous pemphigoid based on HE staining, immunofluorescence staining and immunoblot analyses. Predonisolone and cyclosporine did not suppress blister formation but the addition of minocycline and nicotinamide was effective for disease control. The patient died from sepsis on May 21, 2000, when predonisolone was tapered to 30 mg/day.

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Background : Photochemotherapy (PUVA), topical chemotherapy, and immunotherapy, such as with interferon (IFN), are the typical treatments for mycosis fungoides (MF) in the early stage. However, a cure is not readily achieved by these therapies alone. Therefore, several new effective modalities have been employed to treat MF and these include combination therapy using PUVA and IFN-α. Objective : The aim of our study was to evaluate the effectiveness of combination therapy using PUVA and IFN-γ. Patients/Methods : Ten patients (4 men, 6 women ; aged 40-82 years) at the MF plaque stage were treated with PUVA and IFN-γ combination therapy. The subjects were administered 3 MIU/week of IFN-γ combined with PUVA during the induction phase and 1 MIU/week of IFN-γ combined with PUVA during the maintenance phase. Results : Of the 10 patients, 6 achieved a complete response (CR) and 4 a partial response (PR). Recurrence occurred in 3 of the 6 patients who achieved a CR. During the course of treatment, fever (2 patients), general fatigue (1 patient), leukocytopenia (5 patients), anemia (2 patients), hepatic failure (2 patients) and muscle pain (1 patient) were observed as adverse effects. Conclusions : An excellent clinical result can be achieved with combination therapy using PUVA and IFN-γ in patients with early-stage MF.

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[in Japanese]

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