Progressive hyperpigmentation in a Taiwanese child due to an inborn error of vitamin B12 metabolism (cblJ).

The physiology of human skin pigmentation is varied and complex, with an extensive melanogenic paracrine network involving mesenchymal and epithelial cells, contributing to the regulation of melanocyte survival and proliferation and melanogenesis. Mutations in several genes, involving predominantly the KIT ligand/c-Kit and Ras/mitogen-activated protein kinase signalling pathways, have been implicated in a spectrum of diseases in which there is hyperpigmentation, hypopigmentation or both. Here, we report on a 12-year-old girl from Taiwan with a 6-year history of diffuse progressive skin hyperpigmentation resulting from a different aetiology: an inborn metabolic disorder of vitamin B12 (cobalamin), designated cblJ. Using whole-exome sequencing we identified a homozygous mutation in ABCD4 (c.423C>G; p.Asn141Lys), which encodes an ATP-binding cassette transporter with a role in the intracellular processing of cobalamin. The patient had biochemical and haematological evidence of cobalamin deficiency but no other clinical abnormalities apart from a slight lightening of her previously black hair. Of note, she had no neurological symptoms or signs. Treatment with oral cobalamin (3 mg daily) led to metabolic correction and some reduction in the skin hyperpigmentation at the 3-month follow-up. This case demonstrates that defects or deficiencies of cobalamin should be remembered in the differential diagnosis of diffuse hyperpigmentary skin disorders.

Collodion baby and loricrin keratoderma: a case report and mutation analysis.

Hereditary palmoplantar keratodermas (PPK) comprise a clinically and genetically heterogeneous group of genodermatoses, which share the characteristic of impaired epidermal differentiation, resulting in prominent palmoplantar hyperkeratosis. Molecular genetic analyses have helped characterize the underlying genetic defects in an increasing number of hereditary PPKs over the past two decades, and thus a pathophysiological classificaiton seems more reasonable. Today PPK can be classified based on defects in keratins, loricrin, desmosomes, connexins and cathepsins. In this report, we describe a 22-year-old man who had been born a collodion baby, and later developed diffuse PPK with pseudoainhum and generalized ichthyosis. His mother and grandmother had similar characteristics. Direct sequencing of genomic DNA identified a frameshift insertion mutation (730insG) in the loricrin gene. This family had the typical presentation of loricrin keratoderma. It also indicates that collodion baby may be the first presentation in patients with loricrin keratoderma.

A retrospective study of pulmonary infarction in patients with systemic lupus erythematosus from southern Taiwan.

Since large-scale reports of pulmonary infarction in systemic lupus erythematosus (SLE) are limited, a retrospective study was performed for this manifestation in 773 hospitalized patients in southern Taiwan from 1999 to 2009. Pulmonary infarction was defined as the presence of pulmonary embolism, persistent pulmonary infiltrates, and characteristic clinical symptoms. Demographic, clinical, laboratory, and radiological images data were analyzed. There were 12 patients with pulmonary embolism and 9 of them had antiphospholipid syndrome (APS). Six patients (19 to 53 years, average 38.2 ± 12.6) with 9 episodes of lung infarction were identified. All cases were APS and four episodes had coincidental venous thromboembolism. There were four episodes of bilateral infarction and seven episodes of larger central pulmonary artery embolism. Heparin therapy was routinely prescribed and thrombolytic agents were added in two episodes. Successful recovery was noted in all patients. In conclusion, there was a 0.8% incidence of pulmonary infarction in patients with SLE, all with the risk factor of APS. Differentiation between pulmonary infarction and pneumonia in lupus patients should be made; they have similar chest radiography with lung consolidation but require a different clinical approach in management. Although this report is a retrospective study with relatively small numbers of lupus patients with lung infarcts, our observation might provide beneficial information on the clinical features and radiological presentations during the disease evolution of pulmonary infarction in SLE with APS.

Novel exon nucleotide substitution at the splice junction causes a neonatal Marfan syndrome.

The fibrillin-1 gene (FBN1) mutations are associated with a broad spectrum of disorders including Marfan syndrome (MFS) and show great clinical heterogeneity. An underrepresentation for mutations leading to premature termination codon (PTC) in FBN1 exons 24-32 was found in neonatal or severe MFS but the underlying cause was unclear. This study thoroughly examined two FBN1 mutations on exons 24-32 region to illustrate the molecular mechanisms underlying these FBN1 mutations on MFS etiology. Two nucleotide substitutions, c.3208G> C, the last nucleotide of exon 26, and c.3209A>G, the first nucleotide of exon 27, affecting the same amino acid, p.D1070H and p.D1070G, respectively, gave very different phenotypes. We demonstrate that c.3208G>C generates two alternatively spliced transcripts, while c.3209A>G does not affect the splicing. We further demonstrate that the aberrantly spliced transcripts do not go through nonsense-mediated decay, but rather produce unstable, premature protein peptides that are degraded by endoplasmic reticulum associated degradation. The molecular mechanism outlined here defines a model for the pathogenesis of PTC-containing mutation within the exons 24-32 of FBN1 in MFS. Furthermore, our data suggest that PTC mutation within this region may lead to early lethality in neonatal MFS.

Mutations in TRPS1 gene in trichorhinophalangeal syndrome type I in Asian patients.

The trichorhinophalangeal syndromes (TRPSs) are rare hereditary diseases with mainly autosomal dominant inheritance. Three different forms sharing similar clinical features with heterogeneous mutations have been identified: type I (TRPS I), type II (TRPS II) and type III (TRPS III). These syndromes have characteristic facial abnormalities such as sparse and slow-growing scalp hair, laterally sparse eyebrows, bulbous pear-shaped nose, elongated and flat philtrum, thin upper lip, and protruding ears. Various skeletal abnormalities are also frequently noted: short stature, shortening of the phalanges and metacarpals, cone-shaped epiphyses and Perthes-like change of the hips.(1-4) The TRPS1 gene was first identified in 2000 and mapped to 8q24.1.(1) More than 50 mutations have been found in the gene to date. We here report mutation analysis of eight patients with the typical phenotype of TRPS I, revealing five novel mutations.

Analysis of Taiwanese ichthyosis vulgaris families further demonstrates differences in FLG mutations between European and Asian populations.

BACKGROUND: Mutations in the gene encoding filaggrin (FLG) were identified to underlie ichthyosis vulgaris (IV) and also shown to predispose to atopic eczema. Until now, no FLG mutations have been described in the Taiwanese population. OBJECTIVES: To elucidate filaggrin mutations in the Taiwanese population and further to clarify the population genetics of filaggrin gene mutations in the Asian populations. METHODS: In the present study, 12 individuals from four unrelated Taiwanese IV families were examined for FLG mutations. We carried out comprehensive sequencing of the entire FLG coding region using an overlapping polymerase chain reaction strategy. RESULTS: We identified three FLG mutations in the Taiwanese IV families. One mutation E1795X was a previously unidentified FLG mutation, which might be specific to the Taiwanese. Interestingly, another FLG mutation 3321delA is prevalent in the Japanese population and the other mutation Q2417X was found in the Singaporean Chinese population. No FLG mutation identified in the white European population was found in the Taiwanese population. CONCLUSIONS: The present findings suggest that the Taiwanese population, as an East Asian group, share FLG mutations with both the Japanese and the Singaporean Chinese population. In addition, these results exemplify differences in the population genetics of filaggrin between Europe and Asia.

A novel splicing mutation of the CYLD gene in a Taiwanese family with multiple familial trichoepithelioma.

Multiple familial trichoepithelioma (MFT) is an autosomal dominant disease characterized by numerous skin-coloured papules on the central face. Mutations in the CYLD gene, which is also the gene responsible for familial cylindromatosis, have been reported recently. Recent studies indicate that CYLD is a tumour-suppressor gene. The CYLD protein is a negative regulator of the activation of transcription factor nuclear factor-kappaB, and loss of CYLD contributes to oncogenesis. We report a novel splicing mutation (IVS12 + 1 G-->A) in the CYLD gene in a Taiwanese pedigree with MFT, and discuss new developments in treatment options.

Purification of carp growth hormone and cloning of the complementary DNA.

The growth hormone (GH) was isolated and purified from common carp (Cyprinus carpio) pituitary glands by salt precipitation and HPLC on reverse-phase C18 columns. The carp GH cDNA was synthesized and cloned in Escherichia coli using EcoRI linkers and pBR322 as vector. The positive clones were selected and sequenced. The full-length carp GH cDNA contains 1187 nucleotide basepairs with an open reading frame coding for the precursor form carp GH of 210 amino-acid residues. The partial amino-acid sequence from the protein completely agrees with that derived from the cDNA, with serine as the first residue in mature carp GH preceded by a 22-residue hydrophobic signal peptide. Comparison of the amino-acid sequence of carp GH with those of various species reveals positional identity at 32.4%, 38.8%, 42.0%, 37.2%, 66%, 55% and 49% with GHs of man, rat, duck, bullfrog, salmon, tuna and yellow tail, respectively.

Mutation report: complete paternal uniparental isodisomy of chromosome 1: a novel mechanism for Herlitz junctional epidermolysis bullosa.

Uniparental disomy denotes a situation when an individual has inherited two copies of a specific chromosome from a single parent. Uniparental disomy has been demonstrated to be involved in the pathogenesis of recessively inherited diseases in rare cases. Here we report a patient of Japanese origin with Herlitz junctional epidermolysis bullosa (OMIM no. 226700), who died at the age of 8 mo from complications of the disease. The mutation analysis revealed that the proband was homozygous for a nonsense mutation C553X in the LAMC2 gene encoding the gamma2 chain of laminin 5. The father was a heterozygous carrier of this mutation whereas the mother had two normal alleles of this gene. The patient showed homozygosity for 15 known intragenic polymorphisms in the LAMC2 gene. Furthermore, genotype analysis, performed from the parents and the proband, using 16 microsatellite markers spanning the entire chromosome 1, revealed that the patient was homozygous for all markers tested, and that these alleles originated from the father. Among the 16 markers, eight were fully informative for the absence of the maternal chromosome 1 in the proband, suggesting that the patient had complete paternal isodisomy of this chromosome. Thus, the Herlitz junctional epidermolysis bullosa phenotype in this patient is caused by homozygous LAMC2 mutation C553X that is of paternal origin and results from nondisjunction and uniparental disomy involving monosomy rescue. This is a novel mechanism resulting in Herlitz junctional epidermolysis bullosa and has implications for assessment of the risk in subsequent pregnancies.

Expression of CD40 and CD40 ligand among cell populations within rheumatoid synovial compartment.

Augmented and prolonged expression of CD40 ligand (CD40L) was recently reported in lymphoid cells from human lupus patients, suggesting that CD40/CD40L pathway was involved in the pathogenesis of systemic autoimmune diseases. This study was thus designed to study the expression of CD40 and CD40L among cell populations within inflammatory joints of patients with rheumatoid arthritis (RA). The result showed that most B cells and monocytes in synovial fluids (SF) expressed CD40. Cultured synovial fibroblasts also stained positive for CD40. Regarding CD40L, we found that T cells as well as B cells could express CD40L. Compared with normal controls, RA patients had higher levels of CD40L+ T cells (8.71 +/- 17.69% vs 1.74 +/- 2.30%, P > 0.05) and CD40L+ B cells (7.71 +/- 7.64% vs 1.12 +/- 1.59% P < 0.05). After in vitro stimulation, T cells from RA patients had higher and longer CD40L expression than T cells from normal peripheral blood. For investigating the effect of CD40 expressed on synovial fibroblasts on TNF-alpha production in joint compartment, we used anti-CD40 antibody to bind CD40 on fibroblasts for one hour and then co-cultured with synovial fluid mononuclear cells. We found that the levels of TNF-alpha decreased in the presence of anti-CD40 antibody. We concluded that there was an intrinsic hyperexpression of CD40L on lymphoid cells within rheumatoid joints, and synovial fibroblasts could contribute to articular inflammation through surface CD40 molecule.

Information technology and home glucose clamping.

Persons with diabetes are responsible for the day-to-day control of their glycemia. To assist patients in discharging this responsibility and help them achieve and sustain improvements in self-blood glucose control, we developed information technology capable of executing algorithms for "clamping glucose" at home. Algorithms for laboratory glucose clamping were translated and adapted for use by patients. The procedures were supported by a central computer and registry. Interaction with the algorithms from home required the patient to handle only a touch-tone telephone, which accessed voice response hardware in the central computer. Patients reported self-measured blood glucose levels or hypoglycemia symptoms together with dietary changes, planned exercise, stress, illness or other lifestyle events. In response, they received self-management instructions and dosing decision support. Metabolic end points were measured. System beta testing in active patients was for 1 year. Patients (n = 142) used the algorithms for their daily self-management, accumulating 1,651 patient-months of follow-up. Almost 100,000 telephone calls were received. Patients benefited. Prevalence of diabetes related crises (hyperglycemia > 400 mg/dL, hypoglycemia < 50 mg/dL or symptoms without measurement) fell approximately twofold (p < 0.05) and glycated hemoglobin levels fell 1.3% (p < 0.001), while body weight was stable. Providers benefited from the timely receipt of standardized reports to monitor the progress of their patients. Earlier intervention was possible. Information technology facilitated home glucose clamping whereby patients with diabetes received timely assistance, advice and decision support for crucial self-control of blood glucose levels. This empowered patients to achieve independence and improve diabetes self-management.

Treatment of classical type Kaposi's sarcoma with paclitaxel.

Paclitaxel has recently been shown to be effective in treating acquired immunodeficiency syndrome-associated Kaposi's sarcoma. We report good therapeutic effects of paclitaxel in two patients with classical form Kaposi's sarcoma (KS) which had poor or partial response to chemotherapy (vincristine, vinblastine, oncovin, bleomycin, epirubicin, dactinomycin, decarbazine) and interferon alpha-2b. Paclitaxel appears to be active against Kaposi's sarcoma as a single agent. The experience suggests that paclitaxel is an effective alternative in the treatment of classical form Kaposi's sarcoma.

A de novo glycine substitution mutation in the collagenous domain of COL7A1 in dominant dystrophic epidermolysis bullosa.

Dystrophic epidermolysis bullosa (DEB) is a hereditary mechanobullous disorder characterized by fragility of the skin and mucous membrane due to abnormalities of anchoring fibrils. Both dominant and recessive DEB have been shown to be caused by mutations in COL7A1, the gene encoding type VII collagen which is the major component of anchoring fibrils. De novo mutation in dominant DEB is rare. In this study, we report a novel de novo glycine substitution mutation in COL7A1 in a Chinese female patient presenting with mild DEB. In search of the mutation, we scanned the entire COL7A1 using polymerase chain reaction (PCR) amplification of all exons of COL7A1, followed by heteroduplex analysis and direct sequencing of the PCR products that exhibited heteroduplex pattern. A G-to-A transition at nucleotide position 6082 within exon 73 of COL7Al was detected. The mutation converted a glycine to an arginine (G2028R) within the triple-helical domain of type VII collagen. It was confirmed that the mutation was present only in the proband. Haplotype analyses suggested that the case arose as a de novo occurrence of autosomal dominant DEB.

Stabilization and sustained-release effect of misoprostol with methacrylate copolymer.

The use of ammonio methacrylate copolymer (Eudrgit RS, RL) to form a sustained-release solid dispersion of Misoprostol can improve and enhance two important physical and chemical properties of Misoprostol. First, the solid dispersion matrix formed by the copolymer can protect Misoprostol from being degraded by water so that its stability is improved. Second, Misoprostol can be slowly released by diffusion from the copolymer matrix. Accelerated stability studies of Misoprostol-Eudragit solid dispersion after storing at various temperatures for different time periods were carried out. According to high performance liquid chromatography (HPLC) analyses, the stability of Misoprostol in a series of Eudragit appeared significantly improved at different ratios. The Misoprostol-Eudragit dispersion can be used in a powder form, filled in capsules, or compressed into tablets. The dissolution profiles of Misoprostol-Eudragit solid dispersion and its tablets in water, pH 1. 2, 4.5 and 6.8, dissolution media show that this stable solid dispersion is a sustained-release type.

Widespread cutaneous necrosis associated with antiphospholipid syndrome.

Widespread cutaneous necrosis as the catastrophic manifestation in antiphospholipid syndrome (APLS) is rather uncommon. Even in the few documented cases, the extensive skin necrosis lesions have been stabilized and regressed with eventual healing utilizing pulse steroid therapy alone or in conjunction with further treatment with plasmapheresis. We describe one case of APLS associated with lupus-like disease. The young female suffered from widespread cutaneous necrosis of the lower legs and gangrene change in the digital end of hands and feet. This condition necessitated amputation of major lower extremities and digital amputation of both hands.

Distribution of double-negative (CD4- CD8-, DN) T subsets in blood and synovial fluid from patients with rheumatoid arthritis.

Double-negative (CD4- CD8-) T (DNT) cells have been postulated to be potentially autoreactive. However, the role of DNT cells in rheumatoid arthritis (RA) has received limited attention. We investigated the distribution of DNT subsets in peripheral blood (PB) and synovial fluid (SF) from patients with active RA to determine whether these cells have relevance to RA. Two-colour flow cytometric analysis was performed to detect DNT cells in PB from 35 RA patients, 26 healthy controls and in SF aspirated from 19 inflamed rheumatoid joints. The subsets of DNT cells, i.e those expressing T cell receptor alphabeta (alphabeta DNT) or gammadelta (gammadelta DNT) were simultaneously examined. Our results showed that DNT cells constituted a very minor subset of PB lymphocytes. When expressed as a percentage of total lymphocytes, alphabeta DNT levels in normal individuals ranged from 0.27 to 2.08% (average 0.76%), while those of gammadelta DNT ranged from 1.02 to 11.42% (average 3.23%). Compared with normal individuals, RA patients had a similar distribution of alphabeta DNT cells in both PB and SF. However, RA patients had significantly lower levels of gammadelta DNT cells in PB than control subjects (1.38 +/- 1.08% vs 3.23 +/- 2.12%, p<0.05), while the levels of gammadelta DNT cells in SF of RA patients were higher than those in PB from RA patients and normal controls. The difference between PB and SF in RA was statistically significant (3.90 +/- 1.88% vs 1.38 +/- 1.08%, p<0.05). A higher level of gammadelta DNT in SF than their paired PB was consistently noted from nine available paired samples. Our findings suggest that gammadelta NT cells, but not alphabeta DNT cells, are probably relevant to RA. The lower percentage of circulating gammadelta DNT cells might have resulted from migration from the circulation into the synovium, suggesting a role for gammadelta DNT cells in the pathogenesis of rheumatoid synovitis.

Leukemia cutis in acute lymphocytic leukemia masquerading as viral exanthem.

Leukemia cutis is a specific skin lesion caused by infiltration of leukemic cells into the skin. It is uncommon in acute lymphocytic leukemia (ALL). It typically manifests as red or violaceous papules, nodules, or plaques, mainly on the face. Leukemia cutis presenting with a generalized viral exanthem-like maculopapular eruption appears to be rare in the English literature. We report such a case. A 19 year-old man presented with a generalized purpuric maculopapular eruption of eight day's duration. Hematologic studies showed changes of acute lymphocytic leukemia, T-cell type. A skin biopsy specimen revealed a cuff-like, dense, perivascular infiltration of atypical lymphocytes in the upper and mid-dermis, consistent with leukemia cutis. The rash resolved in two weeks after chemotherapy. Our case illustrates that leukemia cutis should be considered in the differential diagnosis of a generalized morbilliform viral exanthem-like eruptions. Skin biopsy is important in establishing the diagnosis.

Trichophyton tonsurans infection in Tainan area.

We report a clinicomycologic study of eight culture-proven cases (diagnosed from May 1991 to June 1992) of Trichophyton tonsurans (T. tonsurans) infection in Tainan. T. tonsurans is the most common cause of tinea capitis in the United States and Mexico; Trichophyton violaceum (T. violaceum) is the most common cause in South Africa, India, Jordan and the Far East. To date, there has been no written report of infection caused by T. tonsurans in Taiwan. We report six cases of tinea capitis and two cases of tinea corporis which were proven to be T. tonsurans infection. In this small series, as in our previous series on T. violaceum infection, a predominance of adults of the female gender was noted. The median age of the adults was 58 years. The only child patient was an eight-year-old girl with tinea capitis whose mother was also infected. We have observed T. tonsurans infection with an increasing frequency over the last two years in Tainan. In the future, one would expect an increased incidence of T. tonsurans infections in other parts of the country, especially in adjoining cities. Dermatologists should be increasingly alerted to the possibilities of T. tonsurans as an etiologic agent in fungal infection.

Cutaneous sarcoidosis among Taiwanese.

BACKGROUND AND PURPOSE: Sarcoidosis is a multisystem disorder characterized by noncaseating, naked, epithelioid granulomas, and commonly involving the hilar lymph nodes, lungs, skin, and eyes. Once thought to be rare in Chinese, it is being encountered with increasing frequency in Taiwan. In this study, we examined the clinicopathologic findings of sarcoidosis in Chinese patients in Taiwan and investigated the role of Mycobacterium tuberculosis in the disease. METHODS: The clinicopathologic features of all patients treated for sarcoidosis at a tertiary care hospital in Taiwan during a 10-year period were retrospectively examined. Nested polymerase chain reaction (PCR), using the IS6110 sequence as the amplification target, was used to detect M. tuberculosis complex DNA in formalin-fixed, paraffin-embedded skin specimens. RESULTS: Sarcoidosis was diagnosed in a total of 12 patients (7 men, 5 women; mean age, 53 yr) during the study period. All patients presented with skin lesions varying from erythematous papules or nodules mainly located on the face (8 patients), to widespread papules, large plaques, and tumors on the extremities, trunk, or scalp (4 patients). Seven of the 12 patients had extracutaneous involvement. One developed cutaneous T cell lymphoma after 14 years of severe disease. Histopathologic examination of skin lesions revealed sarcoid or mixed sarcoid/tuberculoid granulomatous infiltration without evidence of mycobacterial, deep fungal infection, or foreign body material. Nested PCR failed to detect M. tuberculosis complex DNA in skin specimens. CONCLUSIONS: Our data suggest that sarcoidosis manifests with a wide range of cutaneous lesions in Taiwanese patients and that extracutaneous involvement is not rare. Dermatologists and general practitioners should be made aware that sarcoidosis may first manifest with skin lesions, so that the correct diagnosis can be made promptly. M. tuberculosis did not appear to be associated with sarcoidosis in this study group.