Myeloid cell-specific topoisomerase 1 inhibition using DNA origami mitigates neuroinflammation.

Targeting myeloid cells, especially microglia, for the treatment of neuroinflammatory diseases such as multiple sclerosis (MS), is underappreciated. Our in silico drug screening reveals topoisomerase 1 (TOP1) inhibitors as promising drug candidates for microglial modulation. We show that TOP1 is highly expressed in neuroinflammatory conditions, and TOP1 inhibition using camptothecin (CPT) and its FDA-approved analog topotecan (TPT) reduces inflammatory responses in microglia/macrophages and ameliorates neuroinflammation in vivo. Transcriptomic analyses of sorted microglia from LPS-challenged mice reveal an altered transcriptional phenotype following TPT treatment. To target myeloid cells, we design a nanosystem using ß-glucan-coated DNA origami (MyloGami) loaded with TPT (TopoGami). MyloGami shows enhanced specificity to myeloid cells while preventing the degradation of the DNA origami scaffold. Myeloid-specific TOP1 inhibition using TopoGami significantly suppresses the inflammatory response in microglia and mitigates MS-like disease progression. Our findings suggest that TOP1 inhibition in myeloid cells represents a therapeutic strategy for neuroinflammatory diseases and that the myeloid-specific nanosystems we designed may also benefit the treatment of other diseases with dysfunctional myeloid cells.

Experimental study of endurance characteristics of Al-doped HfO2ferroelectric capacitor.

In this work, the endurance characteristics of Al-doped HfO2(HAO)-based metal-ferroelectric-metal (MFM) capacitors (which were annealed at 1000 °C) with various doping concentrations were investigated. The doping concentration was optimized for the high annealing temperature (1000 °C) process. To investigate the impact of cycling pulses on the endurance characteristics of HAO-based MFM capacitor, the rise/fall time (tr/f) and hold time (th) for the cycling pulses were varied. Moreover, by adopting the recoverable fatigue process, the endurance characteristics under repetitive wake-up/fatigue processes were studied. The HAO capacitors achieved the remnant polarization (2Pr) of 23.767µC cm-2at pristine state under the high annealing temperature. Furthermore, it was demonstrated that the endurance characteristics (∼108cycles) of the HAO capacitors were comparable to them of other HfO2-based ferroelectric capacitors. Lastly but not least, it turned out that the amount of oxygen and oxygen vacancies in the HAO thin film was dependent of doping concentrations for the film. The impact of oxygen and oxygen vacancies was quantitatively analyzed, in detail, with TEM, XPS and GIXRD analysis.

Impact of Chamber/Annealing Temperature on the Endurance Characteristic of Zr:HfO2 Ferroelectric Capacitor.

The endurance characteristic of Zr-doped HfO2 (HZO)-based metal-ferroelectric-metal (MFM) capacitors fabricated under various deposition/annealing temperatures in the atomic layer deposition (ALD) process was investigated. The chamber temperature in the ALD process was set to 120 °C, 200 °C, or 250 °C, and the annealing temperature was set to 400 °C, 500 °C, 600 °C, or 700 °C. For the given annealing temperature of 700 °C, the remnant polarization (2Pr) was 17.21 µC/cm2, 26.37 µC/cm2, and 31.8 µC/cm2 at the chamber temperatures of 120 °C, 200 °C, and 250 °C, respectively. For the given/identical annealing temperature, the largest remnant polarization (Pr) was achieved when using the chamber temperature of 250 °C. At a higher annealing temperature, the grain size in the HZO layer becomes smaller, and thereby, it enables to boost up Pr. It was observed that the endurance characteristics for the capacitors fabricated under various annealing/chamber temperatures were quite different. The different endurance characteristics are due to the oxygen and oxygen vacancies in ferroelectric films, which affects the wakeup/fatigue behaviors. However, in common, all the capacitors showed no breakdown for an externally applied pulse (up to 108 cycles of the pulse).

Comparison of the Clinical Process and Outcomes in Patients after Coronavirus Infection 2019 Outbreak.

Background and Objectives: The coronavirus infection 2019 (COVID-19) pandemic has affected emergency department (ED) management. Its viral transmission necessitates the use of isolation rooms and personal protective equipment for treating suspected patients, such as those with fever. This delays the time until the first encounter with the patients, thereby increasing the length of stay (LOS) in the ED. We aimed to compare delays in the ED LOS and clinical processes between the COVID-19 period and pre-COVID-19 period. Moreover, we intended to evaluate if the aforementioned delay affected patient outcomes. Materials and Methods: We conducted a single-center, retrospective study in Korea. Patients with fever were compared between the "COVID-19 period" from March 2020 to August 2020 and the "pre-COVID-19 period" from March 2019 to September 2019. We compared the overall ED LOS and individual time variable, including initial diagnostic tests (laboratory tests, radiography), specific diagnostic test (computed tomography), and treatment processes (antibiotics). A logistic regression analysis was conducted to identify the association between hospital admission and patient data. Results: We enrolled 931 and 749 patients during pre- and COVID-19 periods, respectively. Patients with fever remained in the ED for a longer duration during the COVID-19 period (pre-COVID-19:207.7 ± 102.7 min vs. during COVID-19: 223.5 ± 119.4 min, p = 0.004). The total time for performing laboratory tests and radiography displayed significant differences between the two periods, particularly from the time of patient arrival in the ED to the time of issuing the order. The time until antibiotic administration was delayed in the COVID-19 period (pre-COVID-19:195.8 ± 103.3 min vs. during COVID-19: 216.9 ± 108.4 min, p = 0.003). The logistic regression analysis for hospital admission identified ED LOS as an independent factor in both periods. Conclusions: The delay until encountering patients with fever resulted in longer ED LOS during the COVID-19 period; however, it possibly did not increase the hospital admission rates.

Serial measurement of glyphosate blood concentration in a glyphosate potassium herbicide-intoxicated patient: A case report.

INTRODUCTION: This report describes changes in blood and urine concentrations of glyphosate potassium over time and their correlations with clinical symptoms in a patient with acute glyphosate potassium poisoning. CASE REPORT: A 67-year-old man visited the emergency center after ingesting 250 mL of a glyphosate potassium-based herbicide 5 h before. He was alert but presented with nausea, vomiting, and bradyarrhythmia with atrial fibrillation (tall T waves). Laboratory findings revealed a serum potassium level of 6.52 mEq/L. After treatment with an injection of calcium gluconate, insulin with glucose, bicarbonate, and an enema with polystyrene sulfonate, the patient's serum potassium level normalized and the bradyarrhythmia converted to a normal sinus rhythm. During admission, the blood and urine concentration of glyphosate and urine aminomethylphosphonic acid (AMPA, a glyphosate metabolite) was measured at regular time intervals. The patient's glyphosate blood concentration on admission was 11.48 mg/L, and it had decreased rapidly by 16 h and maintained about 1mgl/L by 70 h after admission. Urine glyphosate and AMPA levels had also decreased rapidly by 6 h after admission. DISCUSSION: Glyphosate potassium poisoning causes hyperkalemia. Blood concentrations of glyphosate were decreased rapidly by 16 h after admission, and urine concentrations were also decreased by 6 h after admission.

Glycyl-l-histidyl-l-lysine prevents copper- and zinc-induced protein aggregation and central nervous system cell death in vitro.

Common features of neurodegenerative diseases are oxidative and inflammatory imbalances as well as the misfolding of proteins. An excess of free metal ions can be pathological and contribute to cell death, but only copper and zinc strongly promote protein aggregation. Herein we demonstrate that the endogenous copper-binding tripeptide glycyl-l-histidyl-l-lysine (GHK) has the ability to bind to and reduce copper redox activity and to prevent copper- and zinc-induced cell death in vitro. In addition, GHK prevents copper- and zinc-induced bovine serum albumin aggregation and reverses aggregation through resolubilizing the protein. We further demonstrate the enhanced toxicity of copper during inflammation and the ability of GHK to attenuate this toxicity. Finally, we investigated the effects of copper on enhancing paraquat toxicity and report a protective effect of GHK. We therefore conclude that GHK has potential as a cytoprotective compound with regard to copper and zinc toxicity, with positive effects on protein solubility and aggregation that warrant further investigation in the treatment of neurodegenerative diseases.

Copper toxicity and deficiency: the vicious cycle at the core of protein aggregation in ALS.

The pathophysiology of ALS involves many signs of a disruption in copper homeostasis, with both excess free levels and functional deficiency likely occurring simultaneously. This is crucial, as many important physiological functions are performed by cuproenzymes. While it is unsurprising that many ALS symptoms are related to signs of copper deficiency, resulting in vascular, antioxidant system and mitochondrial oxidative respiration deficiencies, there are also signs of copper toxicity such as ROS generation and enhanced protein aggregation. We discuss how copper also plays a key role in proteostasis and interacts either directly or indirectly with many of the key aggregate-prone proteins implicated in ALS, such as TDP-43, C9ORF72, SOD1 and FUS as well as the effect of their aggregation on copper homeostasis. We suggest that loss of cuproprotein function is at the core of ALS pathology, a condition that is driven by a combination of unbound copper and ROS that can either initiate and/or accelerate protein aggregation. This could trigger a positive feedback cycle whereby protein aggregates trigger the aggregation of other proteins in a chain reaction that eventually captures elements of the proteostatic mechanisms in place to counteract them. The end result is an abundance of aggregated non-functional cuproproteins and chaperones alongside depleted intracellular copper stores, resulting in a general lack of cuproenzyme function. We then discuss the possible aetiology of ALS and illustrate how strong risk factors including environmental toxins such as BMAA and heavy metals can functionally behave to promote protein aggregation and disturb copper metabolism that likely drives this vicious cycle in sporadic ALS. From this synthesis, we propose restoration of copper balance using copper delivery agents in combination with chaperones/chaperone mimetics, perhaps in conjunction with the neuroprotective amino acid serine, as a promising strategy in the treatment of this incurable disease.

Improved remnant polarization of Zr-doped HfO2 ferroelectric film by CF4/O2 plasma passivation.

In this work, the impact of fluorine (CF4) and oxygen (O2) plasma passivation on HfZrOx (HZO) based ferroelectric capacitor was investigated. By the fluorine passivation, the surface trap density and oxygen vacancies in the HZO-based Metal-ferroelectric-insulator-semiconductor (MFIS) capacitors were suppressed, resulting in the increased pristine remnant polarization (2Pr). The pristine value (2Pr) of baseline samples annealed at 500 °C and 600 °C were 11.4 µC/cm2 and 24.4 µC/cm2, respectively. However, with the F-passivation, the 2Pr values were increased to 30.8 µC/cm2 and 48.2 µC/cm2 for 500 °C and 600 °C, respectively. The amount of surface defects and oxygen vacancies are quantitatively confirmed by the conductance method and XPS analysis. However, due to the incorporation of fluorine atoms into the ferroelectric-insulator films, undesirable degradation on endurance characteristics were observed.

Intracranial Pressure Patterns and Neurological Outcomes in Out-of-Hospital Cardiac Arrest Survivors after Targeted Temperature Management: A Retrospective Observational Study.

We aimed to investigate intracranial pressure (ICP) changes over time and the neurologic prognosis for out-of-hospital cardiac arrest (OHCA) survivors who received targeted temperature management (TTM). ICP was measured immediately after return of spontaneous circulation (ROSC) (day 1), then at 24 h (day 2), 48 h (day 3), and 72 h (day 4), through connecting a lumbar drain catheter to a manometer or a LiquoGuard machine. Neurological outcomes were determined at 3 months after ROSC, and a poor neurological outcome was defined as Cerebral Performance Category 3-5. Of the 91 patients in this study (males, n = 67, 74%), 51 (56%) had poor neurological outcomes. ICP was significantly higher in the poor outcome group at each time point except day 4. ICP elevation was highest between days 2 and 3 in the good outcome group, and between days 1 and 2 in the poor outcome group. However, there was no difference in total ICP elevation between the poor and good outcome groups (3.0 vs. 3.1; p = 0.476). All OHCA survivors who had received TTM had elevated ICP, regardless of neurologic prognosis. However, the changing pattern of ICP levels differed depending on the neurological outcome.

Association of antigen-stimulated release of tumor necrosis factor-alpha in whole blood with response to chemotherapy in patients with pulmonary multidrug-resistant tuberculosis.

BACKGROUND: We have previously reported that TNF-α levels correlate to total mycobacterial burden in tuberculosis (TB) patients. OBJECTIVE: To characterize the dynamics of cytokine responses in TB patients during chemotherapy to identify potential surrogate markers for effective treatment. METHODS: Following induction by culture filtrate proteins in whole blood, production patterns of TNF-α, IL-10, IFN-γ and IL-12 were measured in 23 non-multidrug-resistant (MDR)-TB and 16 MDR-TB patients and in 31 healthy controls. Rates of mycobacterial clearance from the sputum were then measured and compared. RESULTS: Prior to the initiation of chemotherapy, TNF-α and IL-10 levels were significantly higher in TB patients than in healthy controls while IFN-γ and IL-12 levels were similar. During chemotherapy, the levels of all 4 cytokines increased. We evaluated these responses separately in patients that did and did not clear their sputum culture at 2 and 6 months. At 2 months, decreases in both IFN-γ and IL-12 correlated strongly with a successful early response, while after 6 months of therapy, when half (7/14) of MDR-TB patients were still sputum culture positive, downregulation of TNF-α was uniquely correlated with sputum conversion between the groups. CONCLUSION: Our findings suggest the possibility that the regulation of TNF-α production in whole blood may be a more specific indicator of sputum conversion at 6 months than IFN-γ, IL-12 or IL-10 in MDR-TB patients.

C-type lectin receptors Mcl and Mincle control development of multiple sclerosis-like neuroinflammation.

Pattern recognition receptors (PRRs) are crucial for responses to infections and tissue damage; however, their role in autoimmunity is less clear. Herein we demonstrate that 2 C-type lectin receptors (CLRs) Mcl and Mincle play an important role in the pathogenesis of experimental autoimmune encephalomyelitis (EAE), an animal model of multiple sclerosis (MS). Congenic rats expressing lower levels of Mcl and Mincle on myeloid cells exhibited a drastic reduction in EAE incidence. In vivo silencing of Mcl and Mincle or blockade of their endogenous ligand SAP130 revealed that these receptors' expression in the central nervous system is crucial for T cell recruitment and reactivation into a pathogenic Th17/GM-CSF phenotype. Consistent with this, we uncovered MCL- and MINCLE-expressing cells in brain lesions of MS patients and we further found an upregulation of the MCL/MINCLE signaling pathway and an increased response following MCL/MINCLE stimulation in peripheral blood mononuclear cells from MS patients. Together, these data support a role for CLRs in autoimmunity and implicate the MCL/MINCLE pathway as a potential therapeutic target in MS.

The usefulness of neuron-specific enolase in cerebrospinal fluid to predict neurological prognosis in cardiac arrest survivors who underwent target temperature management: A prospective observational study.

AIM: Cerebrospinal fluid (CSF) neuron-specific enolase (NSE) levels increase ahead of serum NSE levels in patients with severe brain injury. We examined the prognostic performance between CSF NSE and serum NSE levels in out-of-cardiac arrest (OHCA) survivors who had undergone target temperature management (TTM). METHODS: This single-centre prospective observational study included OHCA patients who had undergone TTM. NSE levels were assessed in blood and CSF samples obtained immediately (Day 0), and at 24 h (Day 1), 48 h (Day 2), and 72 h (Day 3) after return of spontaneous circulation (ROSC). The primary outcome was the 6-month neurological outcome. RESULTS: We enrolled 34 patients (males, 24; 70.6%), and 16 (47.1%) had a poor neurologic outcome. CSF NSE and serum NSE values were significantly higher in the poor outcome group compared to the good outcome group at each time point, except for serum Day 0. CSF NSE and serum NSE had an area under curve (AUC) of 0.819-0.972 and 0.648-0.920, respectively. CSF NSE prognostic performances were significantly higher than serum NSE levels at Day 1 and showed excellent AUC values (0.969; 95% confidence interval [CI] 0.844-0.999) and high sensitivity (93.8%; 95% CI 69.8-99.8) at 100% specificity. CONCLUSION: We found CSF NSE values were highly predictive and sensitive markers of 6-month poor neurological outcome in OHCA survivors treated with TTM at Day 1 after ROSC. Therefore, CSF NSE levels at day 1 after ROSC can be a useful early prognosticator in OHCA survivors.

Evaluation of the diagnostic utility of a whole-blood interferon-gamma assay for determining the risk of exposure to Mycobacterium tuberculosis in Bacille Calmette-Guerin (BCG)-vaccinated individuals.

We evaluated the utility of the "QuantiFERON-TB Gold In-Tube" (QuantiFERON) test that uses tuberculosis (TB)-specific antigens for the diagnosis of latent infection in such individuals. We also examined the correlation between the interferon (IFN)-gamma response to these antigens and the exposure risk to TB by evaluating antigen-specific IFN-gamma release in comparison with IFN-gamma release in response to purified protein derivative (PPD) in 3 groups: medical students, nurses in a TB hospital, and TB patients. All nurses and TB patients responded to PPD, whereas 52% (P < 0.0001) and 79.2% (P = 0.04) responded to QuantiFERON, respectively. In the medical students, only 10.4% responded to QuantiFERON, whereas 85.2% were positive to PPD (P < 0.0001). There was also a significant correlation between the levels of IFN-gamma production and the duration of employment in the group of nurses at the TB hospital, suggesting ongoing exposure in this high-risk group. Thus, these results demonstrate that Mycobacterium tuberculosis-specific IFN-gamma release assay accurately discriminates low- and high-risk healthy subjects and might therefore be a useful diagnostic tool for the diagnosis of latent infection in Bacille Calmette-Guerin (BCG)-vaccinated individuals.

Tumor necrosis factor-alpha and interleukin-10 in whole blood is associated with disease progression in pulmonary multidrug-resistant tuberculosis patients.

BACKGROUND: Cytokine production profiles may reflect the clinical pictures of patients with tuberculosis (TB). OBJECTIVE: We examined the relationship between cytokine levels and clinical parameters indicating the state of disease in active pulmonary TB patients. METHODS: We measured interferon (IFN)-gamma, tumor necrosis factor (TNF)-alpha and interleukin (IL)-10 levels in whole blood after stimulation with culture filtrate protein of Mycobacterium tuberculosis in 33 multi-drug resistant (MDR)-TB and 51 non-MDR-TB patients. RESULTS: No significant difference was found in IFN-gamma production between non-MDR-TB and MDR-TB patients, but there was a marked reduction in TNF-alpha production in MDR-TB patients accompanied by a moderate increase in IL-10 levels. In contrast, the presence of cavity was associated with a significant increase in IFN-gamma, whereas no difference in TNF-alpha between the cavity and non-cavity group was observed. Those who have TB lesions in the left lung showed lower levels of IFN-gamma and TNF-alpha and higher IL-10 levels than the patients with lesions on the right side. IFN-gamma levels were significantly increased in those with moderate or advanced lesions compared with patients with mild lesions. TNF-alpha and IL-10 levels did not change with disease severity. The number of M. tuberculosis bacilli in sputum was closely associated with TNF-alpha levels. The patient group with high value (+++) of sputum culture acid-fast bacilli produced significantly reduced levels of TNF-alpha compared with medium (++) and low (+) values. CONCLUSION: These findings suggest that IFN-gamma, TNF-alpha or IL-10 production patterns in whole blood are associated with disease progression in active pulmonary TB.

Development of sustained-release microparticles containing tamsulosin HCl for orally disintegrating tablet using melt-adsorption method.

In this study, using the melt-adsorption method, we developed sustained-release microparticles containing the potent drug, tamsulosin HCl, for use as orally disintegrating tablets. A high-speed kneading granulator was used, enabling temperature modulation and uniform material distribution. A lipid and ethylcellulose suspension (Surelease®) was applied to retard drug release, and magnesium aluminometasilicate (Neusilin®) was used as adsorbent. Among various lipid candidates for melt-adsorption, beeswax and glyceryl behenate were selected due to their high mechanical strength. Hot stage microscopy and powder X-ray diffraction analysis results showed compatibility between tamsulosin HCl and both lipids. Characteristic adsorption behavior was observed depending on the physicochemical properties of each composition. Especially, the specific surface area of Neusilin® decreased with increasing amounts of Surelease®, attributed to the pore-covering effect of Surelease®, which significantly increased the size of the microparticles after the lipid adsorption. For a Surelease®-to-beeswax ratio 1:50, both the desired particle size distribution and low burst release were achieved. Furthermore, the orally disintegrating tablet containing optimized microparticles had acceptable tablet hardness and rapid disintegration. Herein, the feasibility of melt-adsorption for the preparation of sustained-release microparticles was well demonstrated. With its convenience and efficiency, the proposed method is a promising alternative to conventional methods, which are relatively difficult and time consuming.

Relationship between time related serum albumin concentration, optic nerve sheath diameter, cerebrospinal fluid pressure, and neurological prognosis in cardiac arrest survivors.

AIM: The optimal time to measure serum albumin concentration (SAC) to predict prognosis in cardiac arrest (CA) survivors has not been elucidated. We aimed to compare the relationships between time-related SAC, optic nerve sheath diameter (ONSD), intracranial pressure (ICP), and neurological prognosis in CA survivors. METHODS: We undertook a retrospective study examining CA patients treated with target temperature management (TTM). ICP was measured using cerebrospinal fluid (CSF) pressure and ONSD was obtained before TTM. SAC was measured repeatedly at 4-6 h intervals from the hospital arrival time. We analysed CSF pressure, ONSD, and minimum SAC (MSAC) separately, or in combination, to predict poor neurological outcome. RESULTS: Of 83 patients enrolled, the good outcome group comprised 25 (34%) patients. MSAC at 24 h (MSAC24) had a higher area under the receiver operating characteristic curve (AUC) (0.687; 95% confidence interval (CI), 0.668-0.926) than other time points. CSF pressure showed a higher AUC (0.973; 95% CI, 0.911-0.996) than MSAC24 and ONSD (0.677; 95% CI, 0.565-0.776). In contrast to using MSAC24 and ONSD separately, the combination of both modalities resulted in a better AUC, thus improving the prediction of the neurological outcome (0.734; 95% CI, 0.626-0.825) and ICP (0.758; 95% CI, 0.651-0.845) after return of spontaneous circulation (ROSC) from CA. CONCLUSION: A higher ICP was strongly associated with and seemed predictive of poor outcome. Furthermore, the MSAC24/ONSD combination may be a useful predictor of high ICP and poor neurological outcome. Prospective studies should be conducted to confirm these results.

Two New Species of Cryptococcus sp. and Candida sp. from Wild Flowers in Korea.

Among 80 types of yeast isolated from wild flowers in Daejeon, Korea, two species that have not yet been identified by phylogenetic analysis of the internal transcribed spacer-2 (ITS2) genes and 26S rDNA sequences were identified as Candida sp. 44-C-1 and Cryptococcus sp. 9-D-1. Neither of the newly identified species formed ascospores, while Candida sp. 44-C-1 formed pseudomycelium and Cryptococcus sp. 9-D-1 did not.

Comparison of Microbial Diversity of Korean Commercial Makgeolli Showing High ß-Glucan Content and High Antihypertensive Activity, Respectively.

We measured physiological functionalities, including antihypertensive angiotensin I-converting enzyme inhibitory activity and immun-stimulating ß-glucan content for sixty kinds of Makgeolli that is commercially available from the market. As a result, we selected R-12 commercial raw Makgeolli, with a high content of immuno-stimulating ß-glucan, and R-14 commercial raw Makgeolli, exhibiting high antihypertensive activity. Due to the similarities in their overall physicochemical properties and raw materials used for fermentation, we compared the microbial flora in order to investigate the reason for the differences in their functionalities. Nested PCR and denaturing gradient gel electrophoresis for yeasts and bacteria were performed for analysis of microbial diversity of two different kinds of Makgeolli (i.e., R-12, R-14), which showed immuno-stimulating ß-glucan content and exhibited a very high level of antihypertensive activity, respectively. Analysis of the 18S rDNA amplicon revealed a major presence of the yeast strain Pichia burtonii in every Makgeolli sample. Analysis of the 16S rDNA amplicon revealed a predominance of lactic acid bacteria, and the most frequent lactic acid bacteria were Lactobacillus ingluviei, L. fermentum, and L. harbinensis, and Lactobacillus sp. Among these, L. harbinensis was detected only in R-12 and L. ingluviei was found only in R-14. Different functionalities from the individual commercially available Makgeolli may be attributed to actions of different microbial flora during fermentation.

Erythema multiforme major due to occupational exposure to the herbicides alachlor and butachlor.

Alachlor and butachlor are commonly used chloroacetanilide herbicides. They are cytotoxic, but there have been rare reported cases of alachlor or butachlor induced erythema multiforme major. We report the case of a 38-year-old farmer with erythema multiforme major due to the occupational exposure to alachlor/butachlor. The patient presented to the ED because of itching. Confluent erythematous to violaceous maculopatches with bullae and erosions were seen on the trunk, both upper extremities and both lower extremities. He had no relevant past or family history of a similar skin disease. He had used alachlor/butachlor for 3 days before he developed the itch. We performed a skin incisional biopsy and found diffuse hydropic degeneration with many necrotic keratinocytes in the epidermis and mild to moderate superficial perivascular lymphocytic infiltrate admixed with neutrophils and eosinophils in the upper dermis. These results confirmed the diagnosis of erythema multiforme major. The patient was admitted and received systemic and topical steroids. After 18 days, most lesions had healed, and he was discharged.