A Case of Psoriasis Vulgaris Treated with Brodalumab in a Hemodialysis Patient with End-Stage Renal Disease due to Diabetic Nephropathy.

Psoriasis vulgaris is not frequently seen in patients on hemodialysis. However, these patients have limited treatment for psoriasis due to concerns about complications. We report the case of a psoriatic patient with end-stage renal disease on hemodialysis, safely treated with brodalumab. A 60-year-old man who presented with a 20-year history of recalcitrant severe psoriasis. He had diabetes from 40 years ago, and hemodialysis was initiated due to the progression of renal dysfunction two months ago. He was treated with brodalumab, and skin lesions improved markedly. He began to have a chronic cough four months after starting brodalumab. CT showed diffuse ground-glass shadow and pleural effusion in both lungs. Transbronchial lung biopsy showed no findings suggestive of interstitial pneumonia. In bronchoalveolar lavage fluid, mycobacteria and fungi were not identified. The T-SPOT.TB test was negative. It was considered to be a symptom of overflow due to excessive fluid volume based on insufficient dietary management. Brodalumab was continued, and respiratory symptoms improved with proper weight setting and adequate dietary control. No recurrence of rash has been seen 12 months after the initiation of brodalumab. There were no serious adverse events.

A Case of Cutaneous Arteritis Presenting as Infiltrated Erythema in Eosinophilic Granulomatosis With Polyangiitis: Features of the Unique Morphological Evolution of Arteritis as a Diagnostic Clue.

Eosinophilic granulomatosis with polyangiitis (EGPA, formerly Churg-Strauss syndrome) is a rare systemic vasculitis affecting small- and medium-sized vasculature, associated with asthma and eosinophilia. Different levels of vasculitis in cutaneous lesions have been observed, including dermal small vessel vasculitis and subcutaneous muscular vessel vasculitis. Although the EGPA-associated small vessel vasculitis described as leukocytoclastic vasculitis can be often found in the documented literature, the features of subcutaneous muscular vessel vasculitis in EGPA-associated cutaneous lesions have been rarely demonstrated clinically and histopathologically in English literature. Herein, we report a case of EGPA involving infiltrated erythema on the extremities, with different stages of cutaneous arteritis characterized by eosinophilic arteritis and granulomatous arteritis in the same affected artery. We present this as a unique diagnostic clue for EGPA.

Development and characterization of a new rice cultivar, 'Chikushi-kona 85', derived from a starch-branching enzyme IIb-deficient mutant line.

A new super-hard rice cultivar, 'Chikushi-kona 85', which was derived from a cross between 'Fukei 2032' and 'EM129', was developed via bulk method breeding. 'Chikushi-kona 85' showed a higher content of resistant starch than the normal non-glutinous rice cultivar, 'Nishihomare', and a higher grain yield than the first super-hard rice cultivar, 'EM10'. The amylopectin chain length of 'Chikushi-kona 85' and its progenitor line 'EM129' was longer than that of 'Nishihomare', and was similar to that of 'EM10'. This suggests that the starch property of 'Chikushi-kona 85' was inherited from 'EM129', which is a mutant line deficient in a starch branching enzyme similar to 'EM10'. Genetic analysis of 'Chikushi-kona 85' crossed with 'Nishihomare' also showed that the starch property of 'Chikushi-kona 85' was regulated by a single recessive gene. Consumption of processed cookies made from 'Chikushi-kona 85' flour showed a distinctive effect in controlling blood sugar levels in comparison to the normal non-glutinous rice cultivar 'Hinohikari'. These results show that 'Chikushi-kona 85' is a novel genetic source to develop new products made of rice, which could reduce calorie intake and contribute to additional health benefits.

Detection and validation of QTLs for milky-white grains caused by high temperature during the ripening period in Japonica rice.

The occurrence of chalky rice (Oryza sativa L.) grains caused by high temperature is a serious problem in rice production. Of the several kinds of chalky grains, milky-white grains are not well analyzed. The milky-white rice grain phenomenon is caused by genetic factors as well as environmental and nutritional conditions. To analyze the genetic control system for rice grain quality, we raised recombinant inbred lines from progeny produced from 'Tsukushiroman' (high temperature sensitive) and 'Chikushi 52' (high temperature tolerant) cultivars. Quantitative trait locus (QTL) analysis revealed that the QTL on chromosome 4, linked to the simple sequence repeat marker RM16424, contributed substantially to the occurrence of milky-white grains, as it was detected over two experimental years. To validate the effect of the QTL, we developed near isogenic lines that have the 'Chikushi 52' segment on the short arm of chromosome 4 in the 'Tsukushiroman' genetic background, and that had a lower milky-white grain ratio than that of 'Tsukushiroman' when exposed to high temperatures during the ripening period. These results suggest that the 'Chikushi 52' allele on chromosome 4 suppresses the occurrence of milky-white grains and improves rice grain quality under heat stress during the grain ripening period.

Spectrum of cutaneous vasculitis in eosinophilic granulomatosis with polyangiitis (Churg-Strauss): a case series.

BACKGROUND: The diverse histopathologic spectrum of cutaneous vasculitis in eosinophilic granulomatosis with polyangiitis (EGPA, Churg-Strauss syndrome) has not been well described. METHODS: Fifteen skin biopsy specimens from 9 EGPA patients with histopathologically proven necrotizing vasculitis were reviewed clinicopathologically. RESULTS: Among 8 patients with dermal small vessel vasculitis, neutrophilic vasculitis was observed in 2 myeloperoxidase (MPO)-antineutrophil cytoplasmic antibodies (ANCA)-positive patients, whereas the remaining 6 MPO-ANCA-negative patients showed eosinophilic vasculitis in 3 and a mixed infiltrate of neutrophils and eosinophils in another 3 patients. Five patients with muscular vessel vasculitis showed vasculitis at different inflammatory stages in separate or coexisting at the same biopsied skin lesions: acute stage (eosinophilic vasculitis), granulomatous stage (granulomatous vasculitis), and healed stage. Coexistent small vessel and muscular vessel vasculitis was found in 4 patients. CONCLUSIONS: The histopathologic spectrum of dermal small vessel vasculitis in EGPA ranges from eosinophilic vasculitis with negative MPO-ANCA at one end to neutrophilic vasculitis with positive MPO-ANCA at the other end. The affected vessels ranging from dermal small vessels to subcutaneous muscular vessels in addition to the MPO-ANCA phenotype may account for the many facets of vasculitis in EGPA.

Churg-Strauss syndrome with coexistence of eosinophilic vasculitis, granulomatous phlebitis and granulomatous dermatitis in bullous pemphigoid-like blisters.

The main histopathological features in the cutaneous lesions of Churg-Strauss syndrome (CSS) are dermal leukocytoclastic vasculitis with a variable eosinophilic infiltrate and non-vasculitic tissue eosinophilia with granuloma formation. This wide histopathological spectrum may account for the various skin manifestations of CSS. However, the unique histopathological combination of dermal eosinophilic vasculitis and subcutaneous granulomatous phlebitis accompanied by bulla formation has not been previously described. We report an unusual CSS case showing dermal necrotizing eosinophilic vasculitis and granulomatous phlebitis in purpuric lesions coupled with subepidermal blistering. The blisters showed dermal granulomatous dermatitis and eosinophilia without evidence of vasculitis. Dermal necrotizing eosinophilic vasculitis was characterized by fibrinoid alteration of the vessel wall, a prominent perivascular eosinophilic infiltrate, a few infiltrating histiocytes along the affected vessel wall, and the absence of neutrophilic infiltration. The underlying subcutaneous granulomatous phlebitis was characterized by an angiocentric histiocytic infiltrate surrounded by marked eosinophilic infiltrate. Deposition of cytotoxic proteins and radicals derived from eosinophils in the vessel walls and papillary dermis followed by a secondary granulomatous response may account for the unique clinical and histopathological features in this case.

Mantle cell lymphoma with skin invasion characterized by the common variant in the subcutis and blastoid transformation in the overlying dermis.

We report a case of common mantle cell lymphoma (MCL) with subcutis infiltration and transformation to blastoid MCL in the overlying dermis. The patient was initially diagnosed as having chronic lymphocytic leukemia and treated with chemotherapy. Eight months after the diagnosis of MCL with bone marrow involvement, subcutaneous nodules developed on the patient's left thigh and forearm. A skin biopsy showed a massive infiltration of neoplastic lymphocytes throughout the dermis and subcutaneous tissue. In the upper dermis, there was a perivascular mixed infiltrate of atypical large lymphoid cells and small-sized cells. In the mid to lower dermis, the infiltrate was dense with a nodular growth pattern and was composed of atypical large lymphoblast-like cells with large nuclei, dispersed chromatin, and numerous mitoses. In the subcutaneous tissue, there was a diffuse infiltration of neoplastic cells with common MCL cytologic features characterized by small- to medium-sized lymphoid cells. Cells in the common and blastoid variants of MCL were immunohistochemically positive for CD20 and cyclin D1 but negative for CD5. Neoplastic lymphocytes from the patient's bone marrow had the typical morphologic features and the immunophenotype of MCL (ie, CD5, CD20, cyclin D1, CD10, and CD23). Other case reports in the medical literature indicate that an MCL with skin invasion tends to have a poor prognosis. Our patient died 3 months after the appearance of skin invasion.

MPO-ANCA- and IgA-positive systemic vasculitis: a possibly overlapping syndrome of microscopic polyangiitis and Henoch-Schoenlein purpura.

Microscopic polyangiitis (MPA) can be distinguished from Henoch-Schoenlein purpura (HSP) based on the presence of renal-pulmonary complications, myeloperoxidase-antineutrophil cytoplasmic antibody (MPO-ANCA) seropositivity and pauci-immune glomerulonephritis; these characteristics of MPA are generally not found in HSP. Here, we present a unique case with MPA and HSP overlapping syndrome. A 74-year-old man presented with a skin rash accompanied by intracranial bleeding, acute renal failure and pulmonary hemorrhage resulting in a fatal outcome. An autopsy revealed the marked formation of crescentic glomerulonephritis, diffuse pulmonary alveolar hemorrhage and focal cerebral bleeding. Histological features showing both dermal small-vessel vasculitis and cutaneous polyarteritis nodosa-like arteritis suggested MPA rather than HSP, in which the dermal small vessels are exclusively affected. Meanwhile, capillary immunoglobulin (Ig)A deposits in the skin and glomeruli suggested HSP. As MPA and HSP overlapping syndrome characterized by the synergistic effect of MPO-ANCA and the IgA immune complex may result in a fatal outcome, aggressive immunosuppressive therapy should be initiated as early as possible.

Livedoid vasculopathy with underlying subcutaneous necrotizing venulitis in an asymptomatic hepatitis B virus carrier: is livedoid vasculopathy a true nonvasculitic disorder?

Livedoid vasculopathy has been accepted as a nonvasculitic disorder, but authentic vasculitis in the underlying subcutis can occur in cases of collagen disease and polyarteritis nodosa. We report a case of livedoid vasculopathy with underlying subcutaneous necrotizing venulitis in a 42-year-old carrier of hepatitis B virus. The patient also had a 15-year history of ankylosing spondylitis that was currently in remission. Skin lesions revealed superficial ulceration, purpura, atrophie blanche, and reticulate erythema on the lower extremities, and a skin biopsy showed a minimal dermal perivascular lymphocytic infiltrate with marked fibrin thrombi and fibrin deposits along luminal vessel walls, consistent with features of livedoid vasculopathy. However, necrotizing venulitis characterized by a predominant lymphocytic infiltrate in and around the vessel wall with marked fibrinoid vessel wall necrosis was found in the underlying subcutaneous tissue. A direct immunofluorescence study detected immunoglobulin M and C3 deposits in the papillary dermis. The patient responded well to oral aspirin and a prostaglandin analogue and was well controlled with a compression bandage. Vasculitic lesions in the underlying subcutis may have been overlooked in cases in which livedoid vasculopathy has been considered as a nonvasculitic disorder because our case demonstrates that livedoid vasculopathy can be accompanied by subcutaneous vasculitis.

A morphological study of evolution of cutaneous polyarteritis nodosa.

Morphologic changes including formation of vessel wall fibrinoid necrosis in evolution of cutaneous polyarteritis nodosa (C-PAN) have not been described in detail. Therefore, an investigation of 18 skin biopsy specimens from 14 cases of clinicohistologically proven C-PAN was performed. The results indicated that evolution of arteritis can be classified into 4 stages. Coexistence of different stages was common (50%) in the same or different specimens. The initial (acute) stage shows endothelial loss and fibrin thrombi with neutrophil infiltration without obvious internal elastic lamina disruption and medial fibrinoid necrosis. The second (subacute) stage has mixed cell infiltrates showing a unique intimal target-like fibrinoid necrosis with fibrinoid leakage extending through the disrupted sites of the internal elastic lamina to the media. The third (reparative) stage shows intimal fibroblastic proliferation and perivascular neovascularization with predominant infiltrates of histiocytes and lymphocytes. The final (healed) stage has minimal cellular inflammation with occlusive intimal thickening. Overall, our results show that there are 4 stages in the evolution of C-PAN. The initial change occurs in the intima, and the role of internal elastic lamina in preventing intimal fibrinoid necrosis from discharging into the media may account for the development of target-like fibrinoid necrosis in C-PAN.

Abnormal lamellar granules in a case of CHILD syndrome.

BACKGROUND: A 32-year-old female had cutaneous and musculoskeletal changes consistent with congenital hemidysplasia with ichthyosiform erythroderma and limb defects (CHILD) syndrome. She was born with the dysplastic, shortened right-sided arm and leg. Erythematous, hyperkeratotic lesion occurred on the trunk initially and extended to the right-sided arm and leg. Almost all area of her right-side body except the head and neck was covered by the erythematous lesion with yellow waxy scales, and the distal end of the rudimentary leg showed a verrucous appearance. METHODS AND RESULTS: The histology shared many features with verruciform xanthoma. Electron microscopy revealed vesicular structures in the intercellular spaces of the stratum corneum and vacuoles or vesicular structures in upper prickle cell layer. Some of them can be recognized as abnormal lamellar granules. Within the foamy cells in the papillary dermis, large vacuoles were found. CONCLUSION: These findings suggested that abnormal lipid metabolism involving lamellar granules may be responsible to the skin lesion of CHILD syndrome.