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Evidence demonstrates that parenteral administration of methotrexate (MTX) has a higher drug bioavailability than oral administration. This difference is even more pronounced for medium to high dosages.To compare the efficacy, safety, and tolerability of oral and subcutaneous (SC) MTX for treatment of psoriasis.A randomized, comparative, single-blind, 32-week study was conducted. The clinical response was evaluated using the Psoriasis Area Severity Index (PASI) and patient global satisfaction was assessed using a visual analogue scale (VAS).In total, 77 completed the study: 38 in the SC and 39 in the oral MTX group. No significant between-group differences were found in the number attaining PASI improvement of 75% (PASI75), 90% (PASI90) and 100% (PASI100) at Weeks 16 and 32: PASI75 (P = 0.14 and P = 0.21, respectively), PASI90 (P = 0.23 and P = 0.18) and PASI100 (P = 0.62 and P = 0.22). According to the mean VAS, no significant differences between the groups were found at any time points except at Week 32 that the mean VAS was significantly higher in the SC group (P = 0.03). Adverse events were comparable in both groups.SC and oral administration of MTX had similar efficacies in improving the PASI score even at the highest tolerable dose; however, the SC MTX group had higher overall patient satisfaction than the oral MTX group. No difference in tolerability was found.

Background: Generalized pustular psoriasis (GPP; MIM 614204) is a rare and severe pustular autoinflammatory skin disease in which acute generalized erythema and scaling develop with numerous sterile pustules. GPP shares skin manifestations, especially pustular skin reaction, with adult-onset immunodeficiency (AOID) with anti-interferon-γ autoantibodies, an autoimmune disease. Methods: Clinical examinations and whole-exome sequencing (WES) were performed on 32 patients with pustular psoriasis phenotypes and 21 patients with AOID with pustular skin reaction. Immunohistochemical and histopathological studies were performed. Results: WES identified three Thai patients presenting with similar pustular phenotypes—two with a diagnosis of AOID and the other with GPP. A heterozygous missense variant chr18:g.61325778C>A NM_006919.2: c.438G>T; NP_008850.1: p.Lys146Asn; rs193238900 in SERPINB3 was identified in two patients: one with GPP and the other with AOID. The other patient who had AOID carried a heterozygous missense variant chr18:g.61323147T>C NM_006919.2: c.917A>G; NP_008850.1: p.Asp306Gly in SERPINB3. Immunohistochemical studies showed overexpression of SERPINA1 and SERPINB3, a hallmark of psoriatic skin lesions. Conclusions: Genetic variants in SERPINB3 are associated with GPP and AOID with pustular skin reaction. The skin of patients with GPP and AOID carrying SERPINB3 mutations showed overexpression of SERPINB3 and SERPINA1. Clinically and genetically, GPP and AOID appear to share pathogenetic mechanisms.

Secukinumab demonstrated high efficacy and favorable safety profile in patients with moderate-to-severe plaque psoriasis (PsO) in clinical trials. However, understanding of patient characteristics and clinical outcomes in real world in Thailand is still limited. To describe patient characteristics, effectiveness and safety of secukinumab in Thai PsO patients. This retrospective study analyzed data from medical records of adult PsO patients who initiated secukinumab at 7 dermatology centers from September 2017 to April 2021. Study outcomes included patient characteristics and changes in Psoriasis Area and Severity Index (PASI) score from baseline at weeks 4 and 16 after secukinumab initiation. Adverse events were recorded. Subgroup analyses by adherence rate and completeness of loading dose were performed. Of 163 patients, the mean (SD) age was 44.0 (14.0) years. Most patients (84.7%) were previously treated with topical therapy while 62.0% and 21.5% of patients had received systemic and biologic therapy, respectively. The mean baseline PASI score was 15.4 (9.3). Overall, the mean PASI score improved by 58.0% at week 4 and 78.4% at week 16. Statistically significant differences in PASI approvement were revealed among subgroups of patients with different loading dose and adherence rate. Adverse effects were reported in 8.0% of patients. The characteristics of patients in this study were slightly different from clinical trials in terms of demographic and clinical characteristics, as well as PsO treatment. Secukinumab was effective and safe in Thai patients with PsO, especially among those with complete loading dose and a higher adherence rate.

Background Chronic spontaneous urticaria (CSU) is a common skin disease and has a significant impact on patients’ quality of life. The aim of treatment is complete symptom control. Aim To identify potential factors associated with antihistamine-refractory isolated CSU and to determine the factors that predict response to second-generation H1 antihistamines at dosages from one- to fourfold. Methods We conducted a retrospective cohort study, which included adult patients diagnosed with isolated CSU and had complete symptom control. Clinical and laboratory findings were compared between the patients who were responsive to second-generation H1 antihistamines (< fourfold) and those who were refractory to a fourfold dose. Clinical and laboratory data were compared by dosage in the antihistamine-responsive group. Results There were 182 isolated CSU patients who met the study criteria, of whom 150 (82.4%) were responsive to treatment with up to a fourfold dose of second-generation H1 antihistamines, while 32 (17.6%) were refractory. In univariate analysis, age at onset, body mass index, baseline Urticaria Activity Score-7 (UAS7), white blood cell count, total neutrophil count, neutrophil-lymphocyte ratio, platelet count, and new generation antihistamines were significantly higher in the antihistamine-refractory group. According to multivariate analysis, baseline UAS7 was the only independent factor associated with antihistamine-refractory isolated CSU (odds ratio 1.14, 95% CI 1.01-1.28, P = .03). In the antihistamine-responsive group, white blood cell count tended to predict response to antihistamine treatment ( P < .001, 0.04, 0.34 between onefold and twofold, twofold and threefold, and threefold and fourfold, respectively). Conclusion Baseline UAS7 was an independent factor associated with antihistamine-refractory isolated CSU.

Rapidly progressive interstitial lung disease (RP-ILD) and its distinctive cutaneous features are highly associated with the presence of anti-melanoma differentiation-associated gene 5 (anti-MDA5) antibody in patients with dermatomyositis (DM), leading to a poor prognosis. We describe the case of a 25-year-old man who developed progressive proximal muscle weakness with RP-ILD and had unusual cutaneous findings (cutaneous ulcerations and livedo reticularis) accompanied by classical cutaneous features (heliotrope rash, Gottron’s papules, Gottron’s sign, and flagellate erythema). Blood test was positive for anti-MDA5 antibody. He was treated with intravenous corticosteroids and immunoglobulin, but passed away due to respiratory failure within 1 month after admission. Our case highlights that the presence of cutaneous ulcerations and livedo reticularis, in addition to RP-ILD, are useful clinical clues that may aid in the detection of anti-MDA5 antibody, early initiation of combined immunosuppressants, and prognosis prediction in patients with classical DM.

Background: Prurigo nodularis (PN) is a chronic pruritic skin disease which can greatly impact patients’ quality of life. Moreover, the pathogenesis remains unclear, making it a difficult-to-treat condition. Aims: To investigate the expression of interleukin-31 (IL-31) in serum and skin biopsy specimens of PN patients and healthy subjects and identify its possible correlation to disease severity and itch intensity. Methods: Patients with PN and healthy volunteers were recruited for the study. Expression levels of IL-31 were measured by enzyme-linked immunosorbent assay and immunohistochemistry. Baseline characteristics, disease activity, itch intensity, and related laboratory results were collected. Results: Forty-three PN patients and 31 healthy subjects participated in our study. The PN patients had significantly higher mean serum IL-31 levels than the healthy subjects (52.9 ± 18.2 versus 36.3 ± 10.7 pg/ml, p Conclusion: Increased IL-31 expression in serum and PN lesions suggests that IL-31 has a potential role in the pathogenesis of PN.

Background Chronic spontaneous urticaria (CSU) is a common pruritic skin condition, the pathogenesis of which remains unclear. Interleukin-31 (IL-31) is a major pruritogenic cytokine that plays a role in inducing pruritus in various skin diseases. Aim. To 1) compare serum IL-31 levels among CSU patients, psoriasis patients with pruritic symptoms, and healthy subjects, 2) examine the correlations between serum IL-31 levels and disease severity, and 3) compare IL-31 levels in patients with and without CSU-associated auto-antibodies. Methods Patients with CSU, psoriasis with pruritic symptoms, and healthy volunteers were recruited in the study. Serum IL-31 levels were measured with commercial kits. Baseline characteristics, urticaria activity score, psoriasis area severity index, pruritic intensity score, and related laboratory results were collected. Results Sixty-five CSU patients, 30 psoriasis patients who had pruritus, and 31 healthy subjects participated in our study. The CSU patients had significantly higher mean serum IL-31 levels than the psoriasis patients (252.4 ± 115.5 vs 121.4 ± 16.6 pg/mL, P < 0.001). Both CSU and psoriasis patients also had significantly higher mean serum IL-31 when compared with the healthy subjects. Serum IL-31 levels of CSU and psoriasis patients did not differ significantly according to disease or itching severity. Thyroid antibodies and antinuclear antibodies were positive in 22 (33.8%) and 28 (43.1%) CSU patients, respectively. The CSU patients with ANA titers ≥1:160 had significantly higher mean serum IL-31 levels than in those who were negative for ANA and those with titers of 1:80 (P < 0.003 and P < 0.008, respectively). Conclusion Higher serum IL-31 levels were found in patients with CSU and psoriasis with pruritic symptoms. This suggests that IL-31 has a possible role in the pathogenesis of CSU and psoriasis with pruritic symptoms., Pathology; Pathophysiology; Immunology; Immune system; Internal medicine; Dermatology; Antibody, Interleukin, Pruritus, Psoriasis, Urticaria.

Sweet's syndrome (SS) is associated with various diseases including non-tuberculous mycobacterial infection (NTM). Recent reports have shown that SS associated with NTM is increasing. Clinical features of SS associated with NTM may be different from SS associated with other associated diseases. The aim of the present study was to compare clinical parameters and treatment outcomes of SS associated with NTM and other associated diseases. Patients from January 2004 to April 2014 diagnosed with SS were retrospectively enrolled. Clinical variables were compared between SS patients with and without NTM infection. There were 51 SS patients during the study period; 36 patients (70.59%) had NTM. Clinical variables between the NTM and other associated diseases were comparable: age, sex, and pattern and locations of skin lesions. Five laboratory factors were significantly different between the groups including white blood cell counts (NTM 25 800 vs 12 850 cells/mm(3) ), lymphocyte percentages (13.0% vs 18.7%), monocytes (3.0% vs 7.2%), blood urea nitrogen (BUN) (11.7 vs 8.1 mg/dL) and serum creatinine (Cr) (1.0 vs 0.7 mg/dL). The presence of markedly high white blood cell counts, a low percentage of mononuclear cells and high BUN/Cr levels in SS may be a clinical clue to recognize the association with NTM infections; particularly in dissemination.

Background Lipodermatosclerosis (LDS) is a chronic fibrosing panniculitis associated with venous insufficiency. Although LDS is often a clinical diagnosis, it can be confused with other panniculitides. Microscopic examination is therefore essential to support the diagnosis in this condition. Histopathologic changes, however, have not been extensively defined. The purpose of this study was to characterize the histopathologic spectrum of this condition correlated with clinical manifestation. Methods A total of 25 cases were collected retrospectively, and the clinical information and histopathologic findings were reviewed. Results Of 25 patients, the female to male ratio was 4 : 1. The mean age was 54 years (range, 31-74 years). Clinical features were acute in eight (32%), subacute in 12 (48%), and chronic in five (20%). The microscopic study mostly demonstrated vascular stasis changes of varying degrees depending on the age of the lesion. Adipocyte necrosis with thickened septa, extravasation of erythrocytes, and lymphocytic infiltration were major findings in the early lesions. In the chronic lesion, lipomembranous fat necrosis with microcyst formation, vascular stasis changes in subcutaneous tissue, and septal fibrosis were predominant features. Iron deposition or hemosiderin extending to the subcutaneous layer was always seen in all specimens at the subacute and chronic stages. Conclusion The diagnosis of LDS still needs clinicopathologic correlation. The constellation of findings including septal fibrosis, lipomembranous fat necrosis, prominent vascular changes of stasis, and erythrocytic extravasation can be used to define LDS histopathologically. Interestingly, iron deposition in the subcutaneous tissue is a useful finding for this chronic condition.

Systemic scleroderma-also known as systemic sclerosis (SSc)-is a chronic systemic connective tissue disease characterized by collagen deposition in cutaneous and internal organs, leading to skin sclerosis and multiple organ fibrosis. The pathogenesis is complex and remains poorly understood. Treatment is based on organ involvement and requires a multidisciplinary approach. Skin sclerosis can cause disability, leading to decreasing quality of life. Various systemic antifibrotic therapies have been used; however, most have unsatisfactory results. Recently, phototherapy and in particular ultraviolet A (UVA) has been used to treat skin sclerosis in SSc patients with satisfactory results. The main mechanisms include lymphocyte apoptosis, cytokine alteration, inhibition of collagen synthesis and increased collagenase production, and neovascularization, leading to the breakdown of collagen fibrils resulting in skin softening or even healing digital ulcers. Most studies reported that psoralen plus UVA (PUVA) and UVA1 phototherapy improved clinical outcomes vis-a-vis skin sclerosis, joint mobility, ulcers, and histopathology. PUVA and UVA1 phototherapy therefore have potential as an alternative or adjunctive therapy for patients with SSc.

The objective of this study was to demonstrate the clinical profiles of Stevens-Johnson syndrome (SJS) in Thai patients, and to compare those clinical features between younger and older patients. Medical records of all patients with SJS who were admitted to Srinagarind Hospital Medical School, Khon Kaen, Thailand, from January 2002 to December 2014 were reviewed. Epidemiological features, etiologies, treatment and clinical outcomes were collected. There were 45 patients with SJS during the 10-year period. Females were the majority (57.8%) and the median age was 49 years. Hepatitis was the most frequent complication (67.5%). Phenytoin (15.6%), sulfonamide drugs (15.6%) and allopurinol (13.3%) were implicated as leading causes of SJS. Steroids were prescribed in 37 cases (82.2%). The mortality rate was 4.4%. Comparing older patients to younger patients, allopurinol appeared to be the main instigating drug to develop SJS with an odds ratio of 5.6 (95% confidence interval, 2.8-10.6). In conclusion, clinical features of Thai patients with SJS were similar to other reports. Allopurinol had the strongest association with SJS in older patients as compared to the younger ones.

Vichai Senthong,1,* Jarin Chindaprasirt,1,* Kittisak Sawanyawisuth,1 Noppadol Aekphachaisawat,2 Suteeraporn Chaowattanapanit,1 Panita Limpawattana,1 Charoen Choonhakarn,1 Aumkhae Sookprasert1 1Department of Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand; 2Central Library, Silpakorn University, Bangkok, Thailand *These authors contributed equally to this work Background: The Angoff method is one of the preferred methods for setting a passing level in an exam. Normally, group meetings are required, which may be a problem for busy medical educators. Here, we compared a modified Angoff individual method to the conventional group method. Methods: Six clinical instructors were divided into two groups matched by teaching experience: modified Angoff individual method (three persons) and conventional group method (three persons). The passing scores were set by using the Angoff theory. The groups set the scores individually and then met to determine the passing score. In the modified Angoff individual method, passing scores were judged by each instructor and the final passing score was adjusted by the concordance method and reliability index. Results: There were 94 fourth-year medical students who took the test. The mean (standard deviation) test score was 65.35 (8.38), with a median of 64 (range 46–82). The three individual instructors took 45, 60, and 60 minutes to finish the task, while the group spent 90 minutes in discussion. The final passing score in the modified Angoff individual method was 52.18 (56.75 minus 4.57) or 52 versus 51 from the standard group method. There was not much difference in numbers of failed students by either method (four versus three). Conclusion: The modified Angoff individual method may be a feasible way to set a standard passing score with less time consumed and more independent rather than group work by instructors. Keywords: Angoff, individual, passing score, standard-setting, multiple-choice questions, internal medicine

Carbamazepine (CBZ) has been reported as the most common culprit drug for Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) in several Asian countries including Thailand. A strong association between HLA-B*1502 and CBZ-induced SJS/TEN has been reported in Han Chinese but not in Caucasian and Japanese populations. A case-control study was conducted to determine whether HLA-B*1502 is a valid pharmacogenetic test for SJS/TEN caused by CBZ in a Thai population. Among 42 CBZ-induced patients with SJS/TEN, 37 (88.10%) patients carried the HLA-B*1502 while only 5 (11.90%) of the CBZ-tolerant controls had this allele. The risk of CBZ-induced SJS/TEN was significantly higher in the patients with HLA-B*1502, with an odds ratio (OR) of 54.76 [95% confidence interval (CI) 14.62-205.13, p = 2.89 x 10(-12)]. The sensitivity and specificity of HLA-B*1502 for prediction of CBZ-induced SJS/TEN were 88.10%. By assuming a 0.27% as a prevalence rate of CBZ-induced SJS/TEN in a Thai population, the positive predictive value (PPV) and negative predictive value (NPV) of the HLA-B*1502 were 1.92% and 99.96%. Results from this study suggest that HLA-B*1502 may be a useful pharmacogenetic test for screening Thai individuals who may be at risk for CBZ-induced SJS and TEN.

Toxic epidermal necrolysis (TEN) is an uncommon severe cutaneous adverse reaction. Although controversies remain in the pathophysiology and management of this condition, improvements in survival and morbidity have been observed over the past decade. The aim of the present study was to demonstrate the clinical profiles of TEN in Thai patients and the treatment outcome with dexamethasone pulse therapy assessed by using the Severity of Illness Score for Toxic Epidermal Necrolysis (SCORTEN). Medical records of all patients with TEN were collected retrospectively from January 2002 to December 2012. Epidemiological features, etiologies, treatments and clinical outcomes were reviewed. Of 18 patients, the female to male ratio was 1:1 and the mean age was 49.7 years. Cephalosporins (27.8%), phenytoin (16.7%), carbamazepine, sulfonamide drugs and allopurinol (11.1% each) were implicated as leading causes of TEN. Hepatitis was the most frequent complication (77.8%). Pulsed high doses of dexamethasone 1-1.5 mg/kg per day for a short period were administrated in all cases. Two of the 18 patients receiving corticosteroids (SCORTEN 5 and 6) died. The mortality rate was 11% (2/18 patients), however, no patient receiving systemic corticosteroids died if the patients had less than 4 points on SCORTEN. The clinical features of Thai patients with TEN were similar to other reports. In conclusion, in addition to withdrawal of the suspected agent and intensive supportive care, the administration of short-term dexamethasone pulse therapy, particularly during the initial phase, may be beneficial in reducing the mortality rate.

Background Lupus erythematosus tumidus (LET) is a rare form of chronic cutaneous lupus erythematosus that characteristically presents as a succulent, erythematous plaques on sun-exposed areas. The histopathological change that primarily distinguishes LET from other variants of cutaneous lupus erythematosus is the lack of alterations of the dermo–epidermal junction and epidermis. Our purpose was to describe 15 cases of LET from Thailand. Methods The records of 15 patients diagnosed with LET at Srinagarind Hospital Medical School between 1995 and 2002 were reviewed on the following aspects: clinical manifestation, laboratory investigation, direct immunofluorescence study, phototesting, histopathological findings, clinical course, and treatment. Results All 15 patients consisted of 10 females and five males. The mean age at onset was 38.8 years. The lesions more commonly affect the face and trunk. One patient had concomitant discoid lupus erythematosus and two developed systemic involvement 4 and 6 months after LET. Direct immunofluorescence studies all showed negative results. Positive phototest reactions were detected in five of 10 tested patients: four with ultraviolet A and B and one with ultraviolet A only. Most patients responded well to chloroquine phosphate and the remainder successfully improved with methotrexate, topical and systemic corticosteroids. Conclusion Our data demonstrate the features of LET that are repeatable and characteristic. Lupus erythematosus tumidus in this study was more common in women, and photosensitivity reactions of the patients were seen less frequently compared with those in the earlier report of Kuhn et al2. Furthermore, two of 15 patients exhibited systemic involvement in the course of their disease.

Psoriasis is a chronic inflammatory skin disorder. Although the aetiology and pathogenesis of psoriasis are unproven, it is hypothesised that the major histocompatibility complex (MHC) gene/haplotype contributes to the susceptibility of psoriasis in many populations. MHC class I chain-related gene A (MICA), located 46-kb centromeric of HLA-B, is expressed on keratinocytes and fibroblasts. MICA is in linkage disequilibrium with HLA-B and is involved in natural killer-cell functions. To investigate the relative contribution of the MICA gene in the pathogenesis of psoriasis, extracellular polymorphisms of MICA were studied by polymerase chain reaction-sequence specific primers in 128 Thai psoriasis patients (87 and 41 were Types I and II, respectively) from Srinagarind Hospital, Faculty of Medicine, Khon Kaen University. The control group included 255 healthy, unrelated Northeast Thais. We observed 11 MICA alleles (or groups of alleles) in the patients. A comparison of the psoriasis patients and the control group revealed that MICA*010 and MICA*017 were associated with Type I psoriasis whereas only MICA*010 was associated with Type II. The haplotype analysis revealed that MICA*008-HLA-B*13-Cw*0602 and MICA*010-HLA-B*4601-Cw*01 were significantly increased in both Types I and II, whereas MICA*002-HLA-B*38-Cw*07 (01-03) and MICA*017-HLA-B*57-Cw*0602 were elevated only in Type I. MICA*010 was in strong linkage with Cw*01. Analysis of independent association of MICA*010 in individuals lacking Cw*01 failed to maintain an association. Our results suggest that a significant increase of the MICA alleles in the patient group is a part of HLA-B-Cw haplotypes. It is conceivable that an unknown susceptibility gene, on certain HLA-B-Cw haplotypes, is responsible for the development of psoriasis.

Psoriasis vulgaris, a common inflammatory skin disorder, is known to be associated with the HLA-Cw*06 allele. It has been recently suggested by microsatellite mapping that a real susceptible gene for psoriasis resides in the approximately 100-kb genomic region telomeric of the HLA-C gene. In this respect, the corneodesmosin (CDSN) gene 160-kb telomeric of HLA-C is a strong candidate because of its location and its functional role in corneocyte cohesion and desquamation. In fact, a significant association between CDSN polymorphism and psoriasis was recently recognized in Caucasian populations. However, this association has not been replicated in other studies, being still controversial. In this study, we investigated the genetic polymorphism of the CDSN gene in 139 psoriasis patients and 144 healthy controls in the North-eastern Thai population. By direct sequencing technique, a total of 28 polymorphic sites were found, consisting of 26 single nucleotide polymorphisms (SNPs) and two indels (insertion/deletion). Among them, six SNPs have not been previously reported. Through this analysis, as many as 28 different SNP/indel haplotypes within the CDSN gene were identified. Seven SNPs and one indel, namely 9C, 614 A, 722T, 971T, 1215G, 1243C, 1331G and 1606AAG (deletion), revealed significant deviation in the allelic frequencies of the patients from those of the healthy controls. However, none of them are likely to be responsible for controlling the susceptibility of psoriasis, but these associations can be explained by a linkage disequilibrium to a real pathogenic allele of a nearby gene. Further, the large variations between the CDSN SNP/indel haplotypes and the psoriatic major histocompatibility complex (MHC) haplotypes also make it unlikely that CDSN is a major psoriasis-susceptible gene.

Background As new drugs are introduced onto the market, it is important to determine those that can cause cutaneous reactions and with what frequency. In addition, drugs that have been used for a long period of time may cause new types of eruption that have not been observed previously. The purpose of this study was to evaluate the types of drug eruption and the causative agents in a hospital-based population for a period of 1 year. Methods All in- and outpatients consulting for drug eruptions at the Dermatology Clinic, Ramathibodi Hospital from June 1995 to May 1996 were included in the study. The history and physical examination were performed by one of the authors. In suspected cases, a skin biopsy was carried out to confirm the diagnosis. Rechallenge tests with suspected drugs were performed with informed consent. Results One hundred and thirty-two patients were enrolled in the study. The most common types of drug eruption were maculopapular eruption, fixed drug eruption, and urticaria. Antimicrobial agents were found to be the most common causative drugs, followed by antipyretic/anti-inflammatory agents and drugs acting on the central nervous system. Conclusions Although the most common type of drug eruption and the most common causative agents were not different from those found in previous studies, the new generation of antibiotics and antifungal agents were found to be a frequent cause of drug eruptions. New types of drug eruption, such as generalized exanthematous pustulosis and acral erythema, were observed in this study.

Carbamazepine (CBZ) has been reported as the most common culprit drug for Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) in several Asian countries including Thailand. A strong association between HLA-B*1502 and CBZ-induced SJS/TEN has been reported in Han Chinese but not in Caucasian and Japanese populations. A case-control study was conducted to determine whether HLA-B*1502 is a valid pharmacogenetic test for SJS/TEN caused by CBZ in a Thai population. Among 42 CBZ-induced patients with SJS/TEN, 37 (88.10%) patients carried the HLA-B*1502 while only 5 (11.90%) of the CBZ-tolerant controls had this allele. The risk of CBZ-induced SJS/TEN was significantly higher in the patients with HLA-B*1502, with an odds ratio (OR) of 54.76 [95% confidence interval (CI) 14.62-205.13, p = 2.89 x 10(-12)]. The sensitivity and specificity of HLA-B*1502 for prediction of CBZ-induced SJS/TEN were 88.10%. By assuming a 0.27% as a prevalence rate of CBZ-induced SJS/TEN in a Thai population, the positive predictive value (PPV) and negative predictive value (NPV) of the HLA-B*1502 were 1.92% and 99.96%. Results from this study suggest that HLA-B*1502 may be a useful pharmacogenetic test for screening Thai individuals who may be at risk for CBZ-induced SJS and TEN.

Metaplastic synovial cyst of the skin is a recently recognized entity characterized by an intradermal nodule that usually occurs at the site of previous surgical trauma. Histologically, the lesion demonstrates a cystic structure with villous-like projections and a lining resembling hyperplastic synovium. We have studied two patients with rheumatoid arthritis, aged 46 and 55 years, who presented with cystic nodules localized on the thumb and great toes, respectively, without any history of previous trauma or surgical procedures performed in the areas. The presence of vimentin and CD 68 positivity of the cells lining the cyst walls supports the similarities between normal and metaplastic synovium. We hypothesize that constant pressure on the great toe, repeated manipulation of the finger, and chronic inflammation around the affected joints may have played roles in the pathogenesis of the lesions in our patients.

Amyloidosis cutis dyschromica, a rare form of primary cutaneous amyloidosis requiring histopathological confirmation, is characterized by generalized, asymptomatic hyperpigmentation intermingled with several hypopigmented spots without papulation, atrophy, and telangiectasia. Its onset usually begins before puberty. We describe six patients from three families, four male and two female. The mean age at onset was 10.2 years. Although the skin eruptions had developed extensively since childhood, systemic involvement was not evident even after long-term follow-up. Due to its unique and characteristic features, this condition should be considered as a separate entity and differentiated from other variants of primary cutaneous amyloidosis. The familial occurrence in our report suggests a genetic causal factor in this disease.

Background To evaluate the distributions of the human leukocyte antigen (HLA) at class I and II loci that may contribute to the genetic susceptibility to psoriasis patients in the north-eastern Thai population. Materials and methods We analyzed the allelic frequencies of HLA class I and II by using the polymerase chain reaction-amplification refractory mutation system (PCR-ARMS) technique and polymerase chain reaction-single stranded conformation polymorphism (PCR-SSCP), respectively, in 140 north-eastern Thais with psoriasis that were sudivided into two groups: one with age at onset 40 years (type II psoriasis; 45 cases). Three hundred healthy unrelated north-eastern Thais were used as controls. Results HLA-A*01, -A*0207, -A*30, -B*08, -B*13, -B*4601, -B*57, -Cw*01, -Cw*0602, and -DRB1*07 were positively associated with type I psoriasis, whereas HLA-A*24, -A*33, and -Cw*04 were negatively associated with type I psoriasis with statistical significance when compared to the controls. The Cw*0602 allele showed the strongest correlation with this type. In addition, the frequencies of HLA-A*0207, -A*30, -Cw*01, and -DRB1*1401 were significantly increased in type II psoriasis. HLA-A*207, -B*4601, -Cw*01, -DRB1*09, -DQB1*0303 (AH46.1), HLA-A*01-B*57-Cw*0602-DRB1*07-DQB1*0303 (AH57.1), and HLA-A*30, -B*13, -Cw*0602, -DRB1*07, and -DQB1*02 (AH13.1) were identified as high-risk major histocompatibility complex (MHC) halotypes for psoriasis patients in the early onset group in north-eastern Thais. Conclusions This study demonstrates not only the differential association between HLA markers and types of psoriasis according to age at onset, but also a newly found high-risk and a protective haplotype in Thai psoriasis patients.

Disseminated infection due to rapidly growing mycobacteria is uncommon and occurs mostly in immunocompromised patients. We report 16 cases of such infection with an unusual presentation seen at Srinagarind Hospital, a university hospital in northeastern Thailand. The clinical features were different from those in previous reports. All of the patients presented with chronic bilateral cervical lymphadenopathy. Twelve had mycobacterial involvement of other organs (sinuses, 6 patients; lungs, 4; liver, 4; spleen, 3; skin, 3; bone and joint, 2; and tonsils, 2). An interesting occurrence in 11 patients was 14 episodes of reactive skin manifestations (Sweet's syndrome, 9; generalized pustulosis and erythema nodosum, 2 each; and pustular psoriasis, 1). No identifiable predisposing factors, including human immunodeficiency disease, were found in these patients. However, 8 patients had 11 episodes of prior infection or coinfection with other opportunistic pathogens (salmonellosis, 4; penicilliosis, 3; pulmonary tuberculosis, 2; and melioidosis and cryptococcosis, 1 each). These findings suggest that cell-mediated immunity is defective in these patients.

We report the rare association of Sweet's syndrome with non-tuberculous mycobacteria in five patients (three women, two men, aged 25-41 years). Clinical and histological evidence supported the diagnosis of Sweet's syndrome in all patients. The skin lesions responded well to systemic corticosteroid but recurred in two cases. All of our patients had chronic disseminated non-tuberculous mycobacterial infection. They initially presented with lymphadenopathy and developed involvement in other organs later. All of them were treated as having tuberculous lymphadenitis based on pathological findings before definite diagnosis was made by culture. The organisms isolated were Mycobacterium chelonae in three cases, M. scrofulaceum in one case and M. avium intracellulare complex in one case. All the patients gradually improved with treatment but one had multiple recurrences. The search for an infectious agent, especially non-tuberculous mycobacteria, should be performed in cases of Sweet's syndrome that appear in association with chronic granulomatous lymphadenitis which is recalcitrant to antituberculous drugs.