Identification of the cause of severe skin infection by Fournier transform infrared spectroscopy: a case of Fournier's gangrene caused by fish bone.

Fournier's gangrene (FG) is an infrequent but highly lethal infection. Here we report a 74-year-old man who presented with genital swelling and severe malaise. Based on the physical and imaging examination results, the diagnosis of FG was confirmed. Intraoperative findings showed dirty necrosis of soft tissue, and a splinter-shaped foreign body was found in the perirectal region. The foreign body was thought to be the cause of the condition, and it was analyzed using Fourier transform infrared spectroscopy. We found that the foreign body was a mixture of calcium phosphate and protein, suggesting that the splinter was a bone. Moreover, during the medical interview, the patient mentioned about intake of fish around the time of onset of symptoms. Therefore, to confirm the results of the analysis, DNA was extracted from the foreign body, and genomic PCR with subsequent sequence analysis was performed. The DNA sequence was identical to that of Oncorhynchus kisutch, a salmon that is a very popular food in Japan. On the basis of these findings, we concluded that FG in this case was caused by the penetration into the rectum of an accidentally ingested fish bone. Although some cases of intra-abdominal abscess due to accidental ingestion of fish bone have been reported, FG caused by fish bone is extremely rare.

Case of primary cutaneous peripheral T-cell lymphoma, not otherwise specified, with characteristics of follicular helper T cells.

We report a case of an 88-year-old woman with a decalvant, erythematous, ulcerated tumor extending from the right temporal to occipital region. Histopathological analysis revealed a dense infiltration of medium-to-large-sized atypical cells throughout the entire dermis. The result of immunohistochemical analysis showed that the infiltrating T cells expressed programmed death-1 (PD-1), Bcl-6 and CXCL13. Flow cytometry analysis showed that CD4(+) PD-1(hi) T cells also expressed CD10, inducible T-cell co-stimulator and CXCR5. On the basis of the clinical appearance and the histopathological findings, we diagnosed the patient with primary cutaneous peripheral T-cell lymphoma, not otherwise specified. Recently, the concept of primary cutaneous follicular helper T (TFH)-cell lymphoma was proposed, and in this case, tumor cells clearly expressed TFH-cell markers. Therefore, we considered this case to be a variant of the entity. Although this entity is still provisional, this case supports the new concept.

Two cases of autosomal recessive woolly hair with LIPH gene mutations.

BACKGROUND: Woolly hair is a hereditary disorder characterized by fine and tightly curled hair. Autosomal recessive woolly hair (ARWH) was recently determined to result from mutations in either the lipase H (LIPH) or the LPAR6 (P2RY5) gene. CASE REPORT: An 8-year-old boy (proband) and his 11-year-old brother presented with tightly coiled and sparse scalp hair. The boys did not have cardiomyopathy, palmoplantar keratoderma, or facial dysmorphism. Their parents had normal hair growth and no woolly hair. The sequence analysis of their genomic DNA revealed that the proband and his brother had a homozygous mutation of c.736T > A in the LIPH gene. On the basis of these findings, these patients were diagnosed with ARWH. CONCLUSIONS: To the best of our knowledge, only 20 cases of ARWH have been previously reported in Japan. However, several reports showed that one mutation was detected in the 4/200 normal and unrelated alleles in healthy Japanese control individuals, indicating the presence of ARWH in patients with extremely mild symptoms.

A case of endocrine mucin-producing sweat gland carcinoma.

Endocrine mucin-producing sweat gland carcinoma (EMPSGC), which is an uncommon sweat gland tumor with a predilection for the eyelids, is morphologically analogous to solid papillary carcinoma of the breast. We report the case of a 55-year-old man with a subcutaneous tumor of the upper cheek. The pathological findings for this patient were compatible with those of reported cases of EMPSGC, and p63 staining revealed partial microinvasion into the dermis. On the basis of these findings, the patient was diagnosed with EMPSGC. It is reported that EMPSGC is a precursor of invasive mucinous carcinoma of the skin. Therefore, this patient was treated and followed up as if he had mucinous carcinoma of the skin. To the best of our knowledge, this is the first report of such a case from Japan.

A Case of Metastatic Extramammary Paget's Disease Responding to Trastuzumab plus Paclitaxel Combination Therapy.

There is no effective treatment for advanced extramammary Paget's disease (EMPD). The human epidermal growth factor receptor 2 (HER2) protein is often overexpressed in EMPD. Trastuzumab is a humanized monoclonal antibody against HER2 used in the treatment of breast cancers in which HER2 is overexpressed. We report a case of advanced EMPD in which trastuzumab and paclitaxel combination therapy was effective. The patient was a 70-year-old Japanese woman who presented with EMPD on the vulva and multiple metastatic lymph nodes. Immunohistochemical staining revealed strong HER2 protein expression in the primary tumor and metastatic lymph nodes. The patient received trastuzumab and paclitaxel. After 4 courses of this regimen, the mass on the vulva and the metastatic lymph nodes regressed. Our findings may imply that trastuzumab plus paclitaxel combination therapy is useful for the treatment of advanced EMPD overexpressing HER2.

Novel immunotherapeutic approaches to skin cancer treatments using protein transduction technology.

Protein-transduction domains (PTDs) are short stretches of cationic amino acids that enable peptides, proteins, oligonucleotides, and other reagents to efficiently enter multiple cell types. Therefore, PTDs offer unique therapeutic opportunities for the treatment of many diseases. Previous studies examined the in vivo distribution of PTD-containing fusion proteins following administration via different routes, including portal vein, intravenous, intraperitoneal, and oral administration. Skin may be an appropriate target organ for this new molecular-carrier system; however, there are no studies on the in vivo kinetics and biological effects of PTD-containing proteins following intradermal application. Among the PTDs, poly-arginine peptides, especially nona-arginine (R9), is transported most efficiently with minimal cytotoxicity. Here, we review protein transduction technology from a different angle, as a novel tool in immunotherapeutic approaches to the skin cancers that depend on the biological characteristics of poly-arginine. This could be used in place of gene therapy for skin cancer patients.

A novel immunotherapeutic approach to melanoma-bearing hosts with protein-transduction domain-containing immunogenic foreign antigens.

BACKGROUND: Active immunotherapy is accomplished by two critical factors; (1) induction of strong antigen-specific immune responses, and (2) abundant expression of antigen-epitopes on target cells. Previously, we have shown that the nona-arginine protein-transduction domain (R9-PTD) induced efficient protein-antigen transduction to a variety of cell types in vitro and in vivo. We have also demonstrated that intradermal (i.d.) injections of R9-PTD-containing immunogenic foreign antigens (rR9-OVA) induced dual immunological effects: the induction of OVA-specific Tc1- and Th1-dominant immune responses, and the induction of CTL-mediated immune responses at the injection area by expressing OVA-epitopes. OBJECTIVE AND METHODS: We investigated and compared the antitumor effects by intratumoral (i.t.) injections of rR9-containing natural tumor-associated autoantigen (TAA) and other rR9-containing proteins, including rR9-OVA, into B16 melanoma. RESULTS: Our results clearly demonstrate that multiple i.t. injections of rR9-OVA, but not rR9-containing TAA, elicited strong antitumor effects in B16-bearing mice, and resulted in complete tumor regression in some (50%) animals. These antitumor effects were abrogated by depletion of CD8(+) T cells, and SIINFEKL-specific CTL lysed rR9-OVA-treated B16 cells in vitro. I.t. injections with rR9-OVA altered the proportion of CD4(+) T cell subsets in B16-bearing mice. Interestingly, B16-tumor growth at the untreated site was also reduced following multiple injections of rR9-OVA at the other B16 tumor site. Finally, we confirmed that mice that had rejected B16 tumors by i.t. injections of rR9-OVA subsequently acquired CTL activities to Trp2-epitope/B16 cells. CONCLUSION: Multiple i.t. injections of rR9-PTD-containing immunogenic foreign Ags elicit strong antitumor effects, and thereby may provide important clinical benefits to melanoma patients.

Overexpression of GRIM-19 in cancer cells suppresses STAT3-mediated signal transduction and cancer growth.

Constitutive activation of signal transducer and activator of transcription 3 (STAT3) is common in many human and murine cancer cells, and its activation leads to cellular transformation. STAT3 pathway inhibitors have been reported to suppress cancer growth. To investigate the antitumor effects of inhibiting the STAT3-mediated signaling cascade in the cancer microenvironment, using a molecular-targeting approach, we focused on the gene associated with retinoid-IFN-induced mortality 19 (GRIM-19). GRIM-19 has been reported to interact physically with STAT3 and inhibit STAT3-dependent signal transduction. We used the nona-arginine (R9)-protein transduction domain (R9-PTD) as a protein carrier to induce high levels of GRIM-19 expression in vitro and in vivo. We generated an R9-PTD-containing GRIM-19 fusion protein (rR9-GRIM19) and successfully induced overexpression in the cytoplasm of cancer cells. Analysis of the expression of downstream molecules of STAT3 confirmed that in vitro rR9-GRIM19 treatment of constitutively activated STAT3 (STAT3c) cancer cells significantly reduced STAT3-dependent transcription. Moreover, intratumoral injections of rR9-GRIM19 in STAT3c cancer-bearing mice significantly suppressed tumor growth. These results suggest that intratumoral injections of rR9-GRIM19 have potential as a novel anticancer therapy in STAT3c cancer due to their ability to inhibit STAT3-mediated signal transduction without major systemic side effects.

Vaccination with TAT-antigen fusion protein induces protective, CD8(+) T cell-mediated immunity against Leishmania major.

In murine leishmaniasis, healing is mediated by IFN-γ-producing CD4(+) and CD8(+) T cells. Thus, an efficacious vaccine should induce Th1 and Tc1 cells. Dendritic cells (DCs) pulsed with exogenous proteins primarily induce strong CD4-dependent immunity; induction of CD8 responses has proven to be difficult. We evaluated the immunogenicity of fusion proteins comprising the protein transduction domain of HIV-1 TAT and the Leishmania antigen LACK (Leishmania homolog of receptors for activated C kinase), as TAT-fusion proteins facilitate major histocompatibility complex class I-dependent antigen presentation. In vitro, TAT-LACK-pulsed DCs induced stronger proliferation of Leishmania-specific CD8(+) T cells compared with DCs incubated with LACK alone. Vaccination with TAT-LACK-pulsed DCs or fusion proteins plus adjuvant in vivo significantly improved disease outcome in Leishmania major-infected mice and was superior to vaccination with DCs treated with LACK alone. Vaccination with DC+TAT-LACK resulted in stronger proliferation of CD8(+) T cells when compared with immunization with DC+LACK. Upon depletion of CD4(+) or CD8(+) T cells, TAT-LACK-mediated protection was lost. TAT-LACK-pulsed IL-12p40-deficient DCs did not promote protection in vivo. In summary, these data show that TAT-fusion proteins are superior in activating Leishmania-specific Tc1 cells when compared with antigen alone and suggest that IL-12-dependent preferential induction of antigen-specific CD8(+) cells promotes significant protection against this important human pathogen.

A case of lymphoepithelioma-like carcinoma of the skin associated with Epstein-Barr virus infection.

Lymphoepithelioma-like carcinoma of the skin (LELCS) is a rare cutaneous neoplasm with histopathologic similarities to nasopharyngeal carcinoma. The association of nasopharyngeal carcinoma with Epstein-Barr virus (EBV) is well documented. EBV has also been reported to be associated with LELC in only four sites (the stomach, salivary glands, lung, and thymus), but not in the skin. We report herein a case of EBV-positive LELCS. An 82-year-old female presented with a red nodule on the right cheek. Histologically, the entire dermis was occupied by atypical tumor cell nests with dense lymphocytic infiltration. Neoplastic cells were strongly positive for cytokeratin 14 but were negative for cytokeratins 19 and 20. EBV genomes in neoplastic cells were detected by polymerase chain reaction analysis and in situ hybridization for EBV-encoded RNA, suggesting an association with EBV.

Rat-bite fever identified by polymerase chain reaction detection of Streptobacillus moniliformis DNA.

A 74-year-old woman presented with erythema of the extremities, a high fever and arthralgia after being bitten by a rat. The patient was diagnosed as having rat-bite fever based on the symptoms and clinical course, as well as the polymerase chain reaction detection of Streptobacillus moniliformis DNA in the crust of the bite site. This is the first case to be diagnosed using polymerase chain reaction on a crusted skin lesion specimen. Although clinical symptoms initially remitted with minocycline therapy, they relapsed. Subsequent administration of piperacillin sodium resulted in complete disappearance of the high fever and arthralgia.