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Primary intestinal T-cell lymphoma (PITL) is highly aggressive and includes celiac disease-related enteropathy-associated T-cell lymphoma (EATL), monomorphic epitheliotropic intestinal T-cell lymphoma (MEITL), and primary intestinal peripheral T-cell lymphoma, not otherwise specified (ITCL-NOS). MEITL is the most common PITL in Asia, comprising of monomorphic medium-sized cells typically expressing CD8, CD56, and cytotoxic granules. Occasional cases with intermediate features between MEITL and ITCL-NOS are difficult to be classified and warrant further investigation. We collected 54 surgically resected PITLs from Taiwan, with 80% presenting with bowel perforation. The overall outcome was poor with a median survival of 7 months. Based on histopathology (monomorphic vs. pleomorphic) and immunophenotype, we classified these cases into 4 groups: MEITL with typical immunophenotype (n=34), MEITL with atypical immunophenotype (n=5), pleomorphic PITL with MEITL-like immunophenotype (n=6), and ITCL-NOS (n=9). There was no EATL in our cohort. Targeted next-generation sequencing of the first 3 groups showed highly prevalent loss-of-function mutations for SETD2 (85%, 80%, and 83%, respectively) and frequent activating mutations for STAT5B (64%, 60%, and 50%, respectively) and JAK3 (38%, 20%, and 50%, respectively). In contrast, ITCL-NOS cases had less frequent mutations of SETD2 (56%) and STAT5B (11%) and rare JAK3 mutations (11%). Our results suggest that there is a wider morphologic and immunophenotypic spectrum of MEITL as currently defined in the 2017 WHO classification. MEITL with atypical immunophenotype and PITL with MEITL-like immunophenotype shared clinicopathologic and molecular features similar to MEITL but distinct from ITCL-NOS, indicating that such cases may be considered as immunophenotypic or histopathologic variants of MEITL.

Malignant gastrointestinal neuroectodermal tumor (MGNET) is a sarcoma typically involving the gastrointestinal tract with neuroectodermal differentiation and EWSR1-ATF1/CREB1 fusions. Recently, rare MGNET cases were reported in extragastrointestinal sites. We identified 2 cases of MGNET arising in unprecedented laryngeal and intracranial locations, respectively. Both cases showed spindle and epithelioid tumor cells with amphophilic to clear cytoplasm and occasionally prominent nucleoli, arranged in solid, fascicular, and pseudoalveolar patterns. Case 1 exhibited moderate to marked nuclear atypia and focal intraepithelial component. In contrast, case 2 comprised predominantly low-grade epithelioid cells with extensive pseudopapillary structures. Both tumors showed an S100/SOX10-positive and HMB45/melan-A-negative immunoprofile as well as EWSR1-ATF1 fusion. A chief obstacle in diagnosing case 1 was the histologic and immunophenotypic resemblance to melanoma. The striking pseudopapillary architecture and the intracranial location of case 2 rendered differential diagnoses including meningioma and ependymoma. With the peculiar locations and morphology, these cases posed great diagnostic challenge.

Microvenular hemangioma (MVH) is a rare benign vascular tumor with a controversial etiology, but hormone receptor alterations might be involved. We report a case of MVH in a 41-year-old Taiwanese woman who presented with a 1.5 × 1 cm violaceous plaque on left thigh that had appeared 1 year previously. She had taken oral contraceptives for several years and stopped 1 year prior to presentation. Histologically, the tumor was composed of small and compressed venous structures infiltrating in the dermis and subcutis. Immunohistochemically, the tumor cells displayed negative immunoreactivity for human herpesvirus-8 and positive immunoreactivity for smooth muscle actin and progesterone receptor (PR). Taken together with the patient's medical hormone therapy history and the evidence of PR immunoreactivity, our findings support that progesterone may be associated with the tumorigenesis of MVH.

Follicular lymphoma (FL) is typically presented in the form of lymphadenopathy, hepatosplenomegaly, and bone marrow infiltration. Herein, we report a case of systemic FL first presenting with a generalized asymptomatic rash with histological features of a superficial band-like lymphoid infiltrate and areas of epidermotropism. Immunohistological studies revealed a B-cell lineage of the atypical lymphocytes. FL was diagnosed through a flow cytometric analysis of the bone marrow aspirate. As per our literature review, this is the first reported case of a systemic FL with secondary cutaneous involvement mimicking the stereotypical histological pattern of mycosis fungoides.

In Taiwan, breast cancer is the leading cancer in women; every year, more than 10,000 women are newly diagnosed with breast cancer, and more than 2,000 women die of it. Some cancer research centers and academic research have previously indicated that breast cancer risk factors include tobacco exposure, alcoholic beverage consumption habits, soft drink beverage consumption habits, radiation exposure, work environment, dietary habits, aging, family genetics, obesity, the use of Diethylstilbestrol (DES), etc. This research integrates the open data of various fields to analyze and discuss breast cancer risk factors, and the results can be used as a reference for future clinical research, as well as provided to relevant government departments and medical institutions for breast cancer prevention and advocacy.

Cutaneous endocrine mucin-producing sweat gland carcinoma (EMPSGC) is a very rare low-grade malignant neoplasm analogous to the mammary solid-papillary carcinoma. It frequently expresses neuroendocrine markers and may show mucinous differentiation. Although the nodules are circumscribed, myoepithelial cells cannot be showed in most cases and about half of the cases are associated with invasive mucinous carcinoma. Hence, it has been suggested to be invasive and the precursor lesion of some primary cutaneous mucinous carcinomas. After being recognized as a distinct entity, all cases reported to date occurred either in the periocular region or on the cheek. Two thirds of the patients were female. Herein we present an unusual case of in situ EMPSGC on the chest wall skin of a middle-aged man.

Background Generalized bullous fixed drug eruption (GBFDE), a particular form of fixed drug eruption (FDE), is characterized by widespread blisters and erosions and can be confused with Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN). Objective We sought to analyze specific features of GBFDE and differentiate it from SJS/TEN. Methods We retrospectively studied patients with GBFDE and SJS/TEN during a period of 10 years. GBFDE was defined as typical FDE lesions with blisters involving at least 10% body surface area on at least 3 of 6 different anatomic sites. Clinical presentations; histopathological features; immunohistochemical patterns of cluster-of-differentiation (CD)3, CD4, CD8, CD56, Fas, Fas ligand, granzyme B, perforin, granulysin, and forkhead box P3 (Foxp3); and serum granulysin levels were compared. Results Twenty-three cases of GBFDE were collected. Patients with GBFDE had shorter latent periods, less mucosal involvement, more eosinophil infiltration, and dermal melanophages. Lesional infiltrates in GBFDE had more dermal CD4 + cells including Foxp3 + regulatory T cells, fewer intraepidermal CD56 + cells, and fewer intraepidermal granulysin + cells. The serum level of granulysin in GBFDE was also significantly lower than in SJS/TEN. Limitations The number of cases in this study is small. Conclusion GBFDE is a distinct disease distinguishable from SJS/TEN by particular features such as granulysin, CD56, and Foxp3 expressions.

Hepatosplenic abscess caused by Actinomyces is rare and often misdiagnosed as malignancy. Herein, we report a case of hepatosplenic actinomycosis in a 37-year-old immunocompetent man with a 2-month clinical history of intermittent fever and upper left abdominal pain. Physical examination revealed a mildly ill-appearing man with a low-grade fever (38°C) and upper left quadrant abdominal tenderness. Abdominal sonographic examination showed the presence of a 6.3 cm × 6.5 cm heterogeneous abscess with a hypoechoic center and honeycomb appearance in an enlarged spleen (8 cm × 5 cm). Computerized tomography of the abdomen revealed a multiloculated splenic lesion, and laparotomy showed multiple hepatic nodules and a splenic abscess. Histopathological examination of the biopsy revealed filamentous branching bacilli and sulfur granules in the hepatosplenic abscess. The patient successfully underwent splenectomy accompanied by intravenous and oral penicillin treatment. Proper and prompt diagnosis of hepatosplenic actinomycosis is important because the therapeutic plan and prognosis of this pathogen are quite different from other microorganisms and malignancies.

Introduction The aim of this study was to investigate the diagnostic value of percutaneous computed tomography (CT)-guided coaxial transthoracic needle biopsy (TNB) for small pulmonary lesions (≤3 cm) with persistent ground-glass opacity (GGO). Methods From January 2004 to February 2010, consecutive patients with persistent small GGO lesions (≤3 cm) who underwent CT-guided TNB were analyzed. The pathologic results of CT-guided TNB were compared with final diagnoses, and the GGO percentage on CT was correlated with the stromal invasion in surgical pathology. Results We performed CT-guided TNB on 1612 patients during the study period. Among them, 55 patients had persistent small GGO lesions (size range 0.5–3.0 cm; 1.72 ± 0.73 cm), 47 were diagnosed with lung adenocarcinomas, and 8 with benign nonspecific lesions. Minor procedure-related complications occurred in 26 patients (47.3%) with small pneumothorax and 11 patients (20.0%) with self-limited mild hemoptysis. The final diagnoses of the 43 patients receiving lobectomy were invasive adenocarcinoma ( n = 23), pure bronchioloalveolar carcinoma ( n = 19), and mucosa-associated lymphoid tissue lymphoma ( n = 1). The diagnostic accuracy was 93.0% (40/43) using CT-guided TNB. Pure GGO lesions had a higher incidence of pure bronchioloalveolar carcinoma than GGO-dominant lesions (70.0% versus 21.7%; p = 0.004). Compared with surgical pathology, stromal invasion was underestimated in 43.5% (10/23) of the TNB specimens, especially in pure GGO lesions (83%, 5/6). In logistic regression analysis, the GGO percentage correlated inversely with stromal tumor invasion ( p = 0.0028). Conclusions CT-guided coaxial TNB is a safe and useful method for diagnosing small (≤3 cm) persistent GGO lesions. Stromal invasion may be underestimated by TNB in GGO lesions.

Fusarium species are the second leading cause of disseminated mold infections in immunocompromised patients. The high mortality caused by such infections is attributed to the high resistance of Fusarium species to current antifungal agents. We report the first case of disseminated fusariosis after the use of alemtuzumab, an anti-CD52 monoclonal antibody, in a patient who presented with striking cutaneous and oral cavity lesions. Case reports of combination antifungal therapy for disseminated fusariosis in immunocompromised patients were reviewed. Among 19 published cases in the last 10 years plus this patient, the patients in 14 cases (70%) responded positively to combination antifungal therapy. A clinical response was achieved in seven cases before resolution of neutropenia.

A 14-year-old girl, who had been suffering from intermittent fevers for 2 months, developed painful erythematous plaques on the lower extremities. Laboratory data revealed elevated C-reactive protein, lactate dehydrogenase, and aspartate aminotransferase/alanine aminotransferase (AST/ALT). Blood and urine cultures were negative. CT showed hepatosplenomegaly. F-18 FDG PET revealed multiple patchy uptakes on the subcutaneous surfaces residing mainly at the lower trunk and extremities. The PET images and clinical manifestations appeared indistinguishable from those due to panniculitis while the pathology from skin biopsy demonstrated panniculitis-like T-cell lymphoma. She received chemotherapy and the follow-up PET showed significant resolution of previous abnormal uptakes from the subcutaneous lesions.

The clinical, histologic, and radiographic presentations of nontuberculous mycobacterial (NTM) lung disease are usually indistinguishable from those of reactivated pulmonary tuberculosis (TB), so it remains a great challenge for the clinician to make treatment decisions for patients with old TB and a positive culture result for NTM. This study investigated whether the mycobacterial specific heat shock protein 65 (hsp65) and Mycobacterium tuberculosis (MTB)-specific IS6110 gene would present in pulmonary lesions of patients with NTM pulmonary infection. Formalin-fixed and paraffin-embedded (FFPE) tissue blocks of 24 patients with NTM infections treated at the hospital from 1998 to 2008 were included. Mycobacterial hsp65 gene was amplified in 20 of the 24 patients, and the species identified by sequencing was consistent with corresponding culture results in 12 of these patients. MTB-specific IS6110 gene was detected in 3 of the 7 patients who had old TB and a subsequent diagnosis of fibrocavitary NTM lung disease. Polymerase chain reaction (PCR) analysis of hsp65 gene also confirmed the presence of MTB genes in 2 of these 3 patients. Our results indicate that PCR amplification and sequencing of the mycobacterial hsp65 gene is a sensitive assay for identification of NTM species in FFPE materials. However, consistent results of PCR analysis, microbiology study, histologic manifestations, radiology, and clinical presentation are important for correct diagnosis of NTM pulmonary infection. The presence of MTB gene in patients with fibrocavitary NTM lung lesions poses a clinical dilemma for deciding concurrent treatment TB and NTM infection.

A plexiform fibrohistiocytic tumor (PFT) is a rare mesenchymal neoplasm primarily occurring in children and young adults. PFTs have been classified as fibrohistiocytic tumors of intermediate malignancy because of the high local recurrence rate and possible lymph node and distant metastasis. Histologically, PFTs are poorly demarcated dermal-to-subcutaneous tumors composed of small nodules or cellular clusters with a characteristic plexiform arrangement. We report a 17-year-old girl presenting with a nasal root tumor and concurrent cervical lymphadenopathy. Light microscopy and immunohistochemical findings were compatible with a PFT, for both the nasal root tumor and the cervical lymph nodes. Under the diagnostic impression of a PFT with neck lymph node metastasis, the patient underwent wide excision of the primary tumor and cervical lymph node dissection, followed by concurrent chemo-radiotherapy. During a 4-year follow-up, no evidence of recurrence was noted. We also review the previously published cases of PFTs with metastasis.

EBV-induced post transplant lymphoproliferative disorder (PTLD) continues to be a major complication after transplantation. Between January 1993 and April 2006, 12 cases of B-cell lymphoproliferative disorder were identified among 577 patients after allogeneic hematopoietic SCT (HSCT) with an overall incidence of 2.51% at 1 year. Grades II-IV acute GVHD, CMV antigenemia and the use of antithymocyte globulin (ATG) were independent risk factors for PTLD. At diagnosis, all of the tumors were CD20-positive and 11 (92%) were EBV-encoded RNA (EBER)-positive. Of the 12 patients with B-cell lymphoproliferative disorder, 8 had pulmonary involvement and 10 had extranodal involvement. Eleven patients received weekly rituximab therapy at a dose of 375 mg/m(2); the median interval between the onset of symptoms and rituximab therapy was 6 days. The overall mortality rate was 92% and seven (64%) of the deaths were directly attributable to disseminated PTLD within days or weeks of presentation. In our series, pulmonary PTLD followed an extremely aggressive course and poor response to current therapy, even though rituximab was included in the therapeutic regimens.

We describe the development of nonsusceptibility to daptomycin and vancomycin during treatment for methicillin-resistant Staphylococcus aureus (MRSA) bacteremia associated with infective endocarditis and probable septic thrombophlebitis in a uremic patient. MRSA bacteremia persisted during glycopeptide and subsequent daptomycin treatment but cleared after 5 days' treatment with linezolid and fusidic acid.

To compare the differences in DNA aberrations between arsenic-exposed and non-arsenic-exposed transitional cell carcinoma (TCC), we analyzed 19 arsenic-exposed and 29 non-arsenic-exposed urinary TCCs from Chi-Mei Hospital using comparative genomic hybridization. DNA aberrations were detected in 42 TCCs including 19 arsenic-exposed and 23 non-arsenic-exposed TCCs. Arsenic-exposed TCCs had more changes than unexposed TCCs (mean ± SD, 6.6 ± 2.9 vs. 2.9 ± 2.2). Arsenic exposure was significantly associated with the number of DNA aberrations after adjustment for tumor stage, tumor grade and cigarette smoking in multiple regression analysis. The most frequent DNA gains, which were strikingly different between arsenic-exposed and non-arsenic-exposed TCCs, included those at 1p, 4p, 4q and 8q. A much higher frequency of DNA losses in arsenic-exposed TCCs compared with non-arsenic-exposed TCCs was observed in 10q, 11p and 17p. Chromosomal loss in 17p13 was associated not only with arsenic exposure, but also with tumor stage and grade. The p53 immunohistochemistry staining showed that chromosome 17p13 loss was associated with either p53 no expression (25%) or p53 overexpression (75%). The findings suggest that long-term arsenic exposure may increase the chromosome abnormality in TCC, and 17p loss plays an important role in arsenic-induced urinary carcinogenesis.

Dermatofibroma (DF) is a common, benign, dermal tumor, often occurring as a single lesion. Multiple eruptive DFs are rare and usually associated with autoimmune diseases, immunosuppressant therapy, or both. We present the case of a 28-year-old woman with dermatomyositis who developed multiple eruptive DFs after undergoing methotrexate and corticosteroid treatment. Immunosuppressants such as methotrexate and corticosteroids might cause multiple eruptive DFs.

Purpose To report a case of acute bilateral corneal opacity related to bacterial blepharoconjunctivitis. Methods Interventional case report. An 18-month-old boy had bilateral red eyes with discharge and periorbital eczema. Bilateral corneal opacity suddenly developed 1 week later. Results All clinical assessments and laboratory evaluations of viral infection and autoimmune profiles were negative except for growth of coagulase-negative staphylococcus and propionibacterium acnes from conjunctival discharge. After systemic and topical antibiotic treatment, the opacity and inflammation of both eyes decreased. The left cornea became clear, but the right eye had a sequela of corneal opacity with stromal neovascularization and conjunctival scarring. Penetrating keratoplasty was performed in the right eye 6 months later. Histology at that time showed neovascularization in the deep stroma with perivascular mononuclear cell infiltration and decreased endothelial cells. Conclusions Acute bilateral corneal opacity is rare but may occur in children with bacterial blepharokeratoconjunctivitis. Ocular surface inflammation may be induced by bacterial toxin reaction. Combined use of antibiotics and steroids may save the vision in such patients.

Primary tumor or tumor-like lesions of the spleen are rare. Among them, vascular lesions are the most common. Vascular tumor of the spleen is different from the usual hemangioma of soft tissue because the vascular structure of the spleen is unique. Sclerosing angiomatoid nodular transformation (SANT) is a recently described vascular lesion of the spleen. Grossly, it is a multinodular, well-circumscribed tumor containing a hypervascular core. Microscopically, it comprises three types of vessels, and each type recapitulates the immunohistochemical characteristics of the normal vascular elements of the splenic red pulp, i.e. capillaries, sinusoids, and small veins, respectively. Because of the rarity of this entity, its actual pathogenesis is still unknown. In this study, we report a case of SANT occurring in a 43-year-old woman, in whom there were also multiple calcifying fibrous pseudotumors (CFPTs) in the abdominal cavity. Both SANT and CFPT are thought to be variants of inflammatory pseudotumor. Coexistence of these two rare entities in a patient has never been reported, and this fact suggests that there might be a common mechanism contributing to the formation of these two types of lesions. [J Formos Med Assoc 2007;106(3):234-239]

Background/purpose Early mycosis fungoides (MF) is difficult to distinguish from other benign inflammatory dermatoses. We evaluated clonal T-cell receptor (TCR) γ Gene rearrangement by polymerase chain reaction (PCR) as a surrogate to histologic diagnosis in early MF. Methods Twenty paraffin-embedded skin biopsies from nine patients diagnosed with MF were included. Two multiplex PCR encompassing various Vγ and Jγ regions were used to detect TCRγ Gene rearrangements. Histologic diagnoses were categorized as “diagnostic”, “consistent”, “suggestive”, or “nondiagnostic”. We compared TCRγ PCR results with histologic parameters to determine the differences between PCR-positive and PCR-negative groups. Results TCRg PCR was positive in 53% (8/15) of the patch stage, in 100% (2/2) of the plaque stage, and in 100% (3/3) of the tumor stage. TCRγ PCR was positive in 50% (4/8) of the specimens in both the diagnostic and consistent of MF groups, 71% (5/7) in the suggestive of MF group. We found that inflammation was more severe in PCR-negative specimens. Papillary dermal fibrosis was common, and differed significantly between PCR-positive and PCR-negative groups ( p = 0.01). T-cell monoclonality was detected in one nondiagnostic lesion in a patient with psoriasis and MF. Conclusion TCRγ PCR allows the diagnosis of MF in patients with lymphocyte-poor lesions, suggestive of MF pathologically. TCRg PCR is more likely to be negative with moderate to severe inflammation, particularly with papillary dermal fibrosis. We suggest that the ratio of malignant clonal to reactive T-cells is critical for MF diagnosis. [ J Formos Med Assoc 2007;106(4):265-272]

Background Primary cutaneous T-cell lymphomas (CTCL) are heterogenous extranodal non-Hodgkin lymphomas including a few distinct and provisional entities. Compared with the West, Asian populations have a relatively higher frequency of nonmycosis fungoides CTCL. Primary cutaneous extranodal natural killer/T-cell lymphoma (PC-ENKTL) is distinct from other CTCL by the presence of EBV association. Method In our recent retrospective Asian study of PC-ENKTL, we identified 5 cases initially misdiagnosed as various CTCL. We fully characterized these cases with immunohistochemistry, EBV in situ hybridization, and clonality study for T-cell receptor (TCR) γ-chain gene (TRG). Results The 5 patients included 3 males and 2 females with a median age of 45. All tumors were positive for EBER. Two cases were clonal for TRG gene rearrangement but without expression of βF1 or TCR-γ (TCR-silent T-cell origin), 1 tumor expressed TCR-γ (γδ T-cell origin), and the remaining 2 were polyclonal for TRG and negative for TCR expression (NK-cell origin). On the basis of the initial diagnoses (2 as peripheral T-cell lymphoma, unspecified, 2 as primary cutaneous anaplastic large-cell lymphoma, and 1 as subcutaneous panniculitis-like T-cell lymphoma), all patients received CHOP (cyclophosphamide, doxorubicin, vincristine, and prednisolone) chemotherapy with additional radiotherapy in 3. All patients experienced persistent disease or relapse despite treatment in a mean duration of 8.8 months (range, 1 to 12 mo). Conclusions PC-ENKTL is rare and aggressive. These cases strongly demonstrate the importance of consultation/referral to experienced hematopathologists and the inclusion of EBER in the initial diagnostic work-up for patients with nonmycosis fungoides CTCL to avoid erroneous diagnosis and subsequent inadequate treatment of the patients.

We describe the case of a 13-year-old boy with stage I hypopigmented mycosis fungoides in whom minimal residual disease was detected with T-cell receptor gamma-polymerase chain reaction after the disease was in complete clinical remission. We further cloned and sequenced the T-cell receptor gamma-polymerase chain reaction product of the lesion in remission and found that the original T-cell clone still existed in decreased amounts. The patient was followed up for 3 1/2 years without any new lesions developing. The clinical significance of this residual malignant T-cell clone in mycosis fungoides remains to be elucidated.

The clinical picture of severe acute respiratory syndrome (SARS) is characterized by pulmonary inflammation and respiratory failure, resembling that of acute respiratory distress syndrome. However, the events that lead to the recruitment of leukocytes are poorly understood. To study the cellular response in the acute phase of SARS coronavirus (SARS-CoV)-host cell interaction, we investigated the induction of chemokines, adhesion molecules, and DC-SIGN (dendritic cell-specific ICAM-3-grabbing nonintegrin) by SARS-CoV. Immunohistochemistry revealed neutrophil, macrophage, and CD8 T-cell infiltration in the lung autopsy of a SARS patient who died during the acute phase of illness. Additionally, pneumocytes and macrophages in the patient's lung expressed P-selectin and DC-SIGN. In in vitro study, we showed that the A549 and THP-1 cell lines were susceptible to SARS-CoV. A549 cells produced CCL2/monocyte chemoattractant protein 1 (MCP-1) and CXCL8/interleukin-8 (IL-8) after interaction with SARS-CoV and expressed P-selectin and VCAM-1. Moreover, SARS-CoV induced THP-1 cells to express CCL2/MCP-1, CXCL8/IL-8, CCL3/MIP-1α, CXCL10/IP-10, CCL4/MIP-1β, and CCL5/RANTES, which attracted neutrophils, monocytes, and activated T cells in a chemotaxis assay. We also demonstrated that DC-SIGN was inducible in THP-1 as well as A549 cells after SARS-CoV infection. Our in vitro experiments modeling infection in humans together with the study of a lung biopsy of a patient who died during the early phase of infection demonstrated that SARS-CoV, through a dynamic interaction with lung epithelial cells and monocytic cells, creates an environment conducive for immune cell migration and accumulation that eventually leads to lung injury.

Little is known about the mechanism of necrotizing pneumonia caused by Streptococcus pneumoniae in children. Pulmonary gangrene secondary to vascular thrombosis was reported in adults with necrotizing pneumococcal pneumonia. We conducted a retrospective study of 15 children with a diagnosis of necrotizing pneumococcal pneumonia at National Taiwan University Hospital to explore its association with pulmonary gangrene, based on evidence from chest computed tomography, serial chest radiographic patterns, and pathologic results. S. pneumoniae serotype 14 was the prevalent pneumococcal serotype. Overall, 63.6% of isolates were not susceptible to penicillin. One child with pneumonia caused by S. pneumoniae serotype 3 complicated by hemolytic uremic syndrome had a rapidly fatal course. An autopsy in this patient documented lung necrosis and pulmonary gangrene. Radiographic follow-up was performed during the clinical course in 9 patients, and showed no evidence of pulmonary gangrene. Four children had no radiographic follow-up. The relationship between pulmonary gangrene and necrotizing pneumonia was unclear in the remaining one. In conclusion, necrotizing pneumococcal pneumonia may be infrequently associated with pulmonary gangrene in children.

Rhinocerebral zygomycosis was classically associated with diabetes and diabetic ketoacidosis in the past. In recent years, hematological malignancies and immunocompromised states have become increasingly more frequent underlying conditions for patients with pulmonary and disseminated zygomycosis. In this study we identified 37 patients with a histopathologic diagnosis of zygomycosis and 21 patients with a positive culture for zygomycetes seen at the National Taiwan University Hospital, Taipei, during 1986� /2003. Of these, 39 cases with probable or proven invasive zygomycosis were included in these studies. The major underlying diseases were immunocompromised states (74%), and diabetes mellitus (26%). The frequency of zygomycosis in immunocompromised hosts increased from 1.86 during 1986� /1991 to 4.13 per 100,000 discharges during 1998� /2003. Rhinocerebral involvement was the most common site (74%). An antemortem diagnosis by sinus biopsy was made in 93.1%. Immunocompromised patients were more likely to be younger than diabetics, to have an onset during hospitalization, a positive culture and a postmortem diagnosis. They were less likely than patients with diabetes to receive surgery and more likely to die in the hospital (p B /0.05). Of the 29 patients with invasive rhinocerebral zygomycosis, cerebral involvement (adjusted odds ratio [OR]: 31.7, 95% confidence interval [CI]: 2.4� /426.8, p � /0.009) and positive cultures (adjusted OR: 23.8, 95% CI: 1.7� /338.6, p� /0.019) were associated with in-hospital mortality by multivariate analysis. Hematological disease and steroid use have become the most important predisposing factors for zygomycosis. Aggressive diagnostic approaches, effective antifungal therapy and surgical debridement are essential for a successful outcome.

To prospectively evaluate lung parenchyma on paired inspiration-expiration thin-section computed tomographic (CT) scans in patients recovering from severe acute respiratory syndrome (SARS).After the institutional review board approved the study and written consent was obtained from patients, 40 patients (25 female, 15 male; mean age, 42.8 years +/- 12.3 [standard deviation]) underwent thin-section CT at 51.8 days +/- 20.2 after onset of SARS symptoms. Twenty of the 40 patients underwent follow-up thin-section CT at 140.7 days +/- 26.7 after symptom onset. Lung findings were scored according to extent and then grouped in three categories (ground-glass opacity, interstitial opacity, and air trapping) for analysis. Mean CT scores for each finding in the various patient subgroups were compared by using the Mann-Whitney test. Clinical parameters and scores were evaluated for correlation by using Spearman rank correlation analysis. Mean scores for each finding were compared between the two serial examinations by using the Wilcoxon matched-pairs signed rank test.Air trapping, ground-glass opacity, and reticulation were found in 37 (92%), 36 (90%), and 28 (70%) of 40 patients, respectively, at initial thin-section CT examination and in 16 (80%), 14 (70%), and 10 (50%) of 20 patients, respectively, at follow-up examination. Scans from patients with adult respiratory distress syndrome (ARDS) had a significantly higher score for ground-glass opacity than did those from patients without ARDS (P = .009). A comparison of scores for the serial thin-section CT examinations indicated a significant reduction in the extent of ground-glass opacity (P.001) and interstitial opacity (P.001) but not in that of air trapping (P = .38) at follow-up examination. At initial thin-section CT, scores for ground-glass opacity, interstitial opacity, and air trapping correlated with age; those for ground-glass opacity and air trapping, with peak C-reactive protein level. At the second examination, scores for ground-glass opacity and interstitial opacity correlated with peak lactate dehydrogenase level; that for air trapping, with age and peak C-reactive protein level.Thin-section CT scores correlated with clinical and laboratory parameters in patients after SARS. Although ground-glass opacity and interstitial opacity resolve over time, air trapping persists.

Summary Background Interleukin (IL)-19, a member of the IL-10 family, signals through the IL-20R1 ⁄IL-20R2 heterodimer, which is shown to be involved in abnormal keratinocyte differentiation and proliferation. Little is known about its in vitro biological functions or its role in psoriasis. Objectives To investigate the role of IL-19 in the psoriatic process. Methods The expression of keratinocyte growth factor (KGF) transcripts was measured by polymerase chain reaction in CD8+ T cells treated with IL-19. Next, we developed monoclonal and polyclonal antibodies to measure the levels of IL-19 in the sera of patients with psoriasis and healthy volunteers using an enzymelinked immunosorbent assay. In addition, we performed immunohistochemical staining on psoriatic skin and normal controls. Results We found that IL-19 upregulated KGF transcripts on CD8+ T cells. Patients with psoriasis had a lower level of IL-19 in serum than healthy volunteers. The difference between these two groups was statistically significant ( P< 0AE05). IL-19 expression was seen in basal and suprabasal keratinocytes in a continuous pattern, and was increased in psoriatic epidermis. Conclusions These results suggest that IL-19 plays a role in the complex pathological cytokine network in psoriasis.