Background Pustulotic arthro‐osteitis (PAO) is a major comorbidity of palmoplantar pustulosis (PPP), which is frequently seen in Japanese patients. To determine the characteristics of Japanese patients with PAO, we conducted a multicenter, retrospective epidemiologic survey at four university hospitals. Methods Clinical features including age, gender, duration of disease, extrapalmoplantar lesion, smoking habit, focal infection, site of joint pain, bone scintigraphy with Technetium99, and therapies were retrospectively evaluated. Results In total, 165 patients with PAO were identified among 576 patients with PPP (28.6%). The male to female ratio was 1 : 3.7, and the mean age was 50.2 years. The mean disease duration of PAO was 6.0 years. Smoking habit was observed in 104 patients. Focal infection was detected in 74 patients, who developed tonsillar infection (n = 41), sinusitis (8), odontogenic infection (40), and others (2). Fifteen patients had multifocal infection. Technetium bone scintigraphy was performed in 97 cases. Increased uptake was most frequently observed in the sternocostoclavicular regions, followed by wrist and ankle, sacroiliac joint, knee and elbow, finger and toe, lumbar spine, thoracic spine, scapula, and thigh. Patients were mainly treated with nonsteroidal anti‐inflammatory drugs, methotrexate, cyclosporine, antibiotics, and biologics, as well as tonsillectomy and dental treatment. Conclusion PAO frequently involves the anterior chest wall of middle‐aged women with smoking habit and is closely associated with focal infection.

This study is the first to show that L-T4 replacement may reduce serum concentrations of non-HDL-C in patients with hypothyroidism. The study also suggests that such altered serum concentrations of non-HDL-C in hypothyroidism may be related to the disturbed metabolism of low-density lipoprotein, remnant lipoprotein, and Apo B.

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Backgrounds: Color Doppler ultrasonography (CDU) has not yet been established as a method to investigate the pathogenesis of thyrotoxicosis. Objectives: Our first objective was to determine whether the measurement of peak systolic blood-flow velocity in the superior thyroid artery (STV) and thyroid tissue blood flow (TBF) using CDU could differentiate Graves' disease (GD) from painless thyroiditis (PT). The second objective was to examine the factors mediating increased blood flow to the thyroid gland in GD. Methods: Recruited patients had untreated GD or PT and visited the Department of Internal Medicine (I), Osaka Medical College, between April 1, 2006 and May 31, 2010. Age, gender, blood pressure, pulse rate, thyroid-stimulating hormone, free thyroxine, tri-iodothyronine, TSH receptor antibody and thyroid volume were evaluated in patients. In addition, bilateral measurements of STV, TBF and peak systolic velocity in the common carotid artery (CCV) were also performed. TBF was quantified by calculating the ratio of blood-flow pixels to total pixels in the region of interest using sagittal section images of the thyroid gland. Receiver-operating characteristic curve analysis was performed to determine the ability of STV and TBF measurements to differentiate GD from PT. Results: For the average of STV measured on both sides, the area under the receiver-operating characteristic curve (AUC) was 0.956. For the average of TBF measured on both sides, the AUC was 0.920. At an average STV cut-off value of 43 cm/s, the sensitivity to discriminate GD from PT was 0.87 and the specificity was 1.00. At an average TBF cut-off value of 3.8%, the sensitivity was 0.71 and the specificity was 1.00. In the GD group, neither blood pressure nor pulse rate correlated with the average STV or TBF. Moreover, there was no correlation between STV and CCV or between TBF and CCV on either side. However, STV was correlated with TBF (right side: R = 0.47; left side: R = 0.52). Conclusions: The results demonstrate that STV and TBF are useful for differentiating GD from PT. Furthermore, the increased STV and TBF found in GD are not related to hyperthyroidism-induced increases in systolic blood pressure, pulse rate or CCV.

SHORT COMMUNICATIONCryptococcosis is a fungal infection caused by Cryptococcus neoformans, and frequently presents with meningitis, pneumonia, and cutaneous eruptions in immunocompromised patients. Clinical features of cutaneous cryptococcosis vary; thus, it is necessary to suspect the disease and perform a skin biopsy in order to make an early and accurate diagnosis. We herein report 4 cases of cutaneous cryptococcosis presenting with pyoderma gangrenosum-like appearance. CASE REPORTCase 1. An 85-year-old woman was admitted to hospital, complaining of fever, as well as ulcers on the face, neck, and upper extremities. She had been suffering from erythroderma and was treated with prednisolone (20 mg/day) for the previous year. Physical examination revealed deep irregular ulcers with necrosis on the upper extremities ( Fig. 1a) and nodular lesions with crusts on the neck. In addition, erythema and hemorrhagic blisters were found on the left lower leg. Laboratory examination showed leukocytosis (10,400/μl), elevated C-reactive protein (CRP) (4.21 mg/dl) and β-D-glucan (56.1 pg/dl: normal 0-11) levels, and positive C. neoformans antigen. Histological examination revealed granulomatous inflammation infiltrated with lymphocytes and histiocytes, and degeneration of the dermis and subcutaneous fat tissues. Numerous rounded fungal bodies positively stained by PAS and Grocott were found in the subcutaneous fat tissue. Microbiological culture from ulcer exudate showed C. neoformans. Examination by computed tomography (CT) revealed pneumonia, and a cerebral abscess was detected by magnetic resonance imaging (MRI). The ulcers healed after intravenous administration of fluconazole (200 mg/ day), however the patient died of sepsis.Case 2. A 74-year-old woman presented with an ulcer on the right lower leg that had appeared 6 months previously. She had been treated at an internal medicine clinic, but the ulcer deteriorated. She was also suffering from diabetes mellitus, chronic kidney disease and bronchial asthma. Physical examination revealed irregular ulcers with necrosis on the right lower leg (Fig. 1b). Laboratory examination showed a normal white blood cell count (7,500/μl), elevated CRP (0.97 mg/dl) and β-D-glucan (12.4 pg/dl) levels, and positive C. neoformans antigen. Histological examination revealed inflammatory infiltrates of lymphocytes and histiocytes in the dermis, and a number of fungal bodies stained with PAS, Grocott, and mucicarmine were found in the dermis (Fig. 2). Culture from ulcer exudates as well as blood verified C. neoformans. Chest CT revealed pneumonia, and two weeks after administration, she died of respiratory failure. Case 3. A 93-year-old woman was hospitalized, complaining of redness and swelling of the thighs for the previous month. She had been treated without response with antimicrobial drugs. Physical examination revealed irregular deep ulcers with necrosis on the right thigh (Fig. 1c). Laboratory examination showed leukocytosis (11,680/μl), elevated CRP (4.24 mg/dl) level, normal β-D-glucan (...