Management of asthma in adults in primary care

Asthma is a chronic inflammatory disease of the airway which is often misdiagnosed and undertreated. Early diagnosis and vigilant asthma control are crucial to preventing permanent airway damage, improving quality of life and reducing healthcare burdens. The key approaches to asthma management should include patient empowerment through health education and self-management and, an effective patient-healthcare provider partnership.

Glycated matrix up-regulates inflammatory signaling similarly to Porphyromonas gingivalis lipopolysaccharide

BACKGROUND AND OBJECTIVE

Hyperglycemia and advanced glycation end-products (AGEs) have been hypothesized as the etiologic factors of diabetic periodontitis. The aim of this study was to clarify in greater detail the patterns of AGE-mediated periodontal inflammation under various physiological conditions.

MATERIAL AND METHODS

The deposition of AGEs and expression of the receptor for AGEs (RAGE) were identified by immunohistochemistry in Sprague-Dawley rats with experimentally induced periodontitis or diabetes. Human periodontal ligament cells (PDLCs) and mesenchymal stem cells (MSCs) were cultured under simulated conditions of hyperglycemia, Porphyromonas gingivalis lipopolysaccharide (LPS) stimulation and matrix glycation. Cell viability and expression of toll-like receptors (TLRs), Rage, an inflammatory signaling initiator (nuclear factor kappa light chain enhancer of activator β cells), an oxidative stressor (heme oxygenase-1) and collagen synthesis (type I and type IV) genes were evaluated.

RESULTS

The deposition of AGEs and the expression of Rage were evident in the inflamed periodontal tissues in all rats and appeared to be enhanced in rats with diabetes. Matrix glycation augmented cytotoxicity, up-regulated RAGE and TLRs in both PDLCs and MSCs, and significantly activated downstream inflammatory signaling in MSCs. Oxidative stress was significantly increased under matrix glycation in both PDLCs and MSCs and was significantly increased at a high-glucose concentration in MSCs. A consistent decrease in expression of type I and type IV collagens was observed in MSCs, but a delayed reduction was noted in PDLCs.

CONCLUSIONS

Matrix glycation modulated cell behavior to induce inflammation equivalent to that produced by incubation with P. gingivalis LPS. Periodontal inflammation also led to matrix glycation, thus demonstrating a definite interaction between diabetes and periodontitis.

Asymptomatic urethral infection in male sexually transmitted disease clinic attendees

The purpose of this study is to determine the prevalence of asymptomatic male patients with urethral infections attending a government sexually transmitted infection clinic in Hong Kong and their microbiological profile. A total of 274 consecutive male patients without any symptoms for urethral infections were recruited. A questionnaire was used to record the symptoms, sexual history and demographics. Further assessment, including urethral smear for Gram stain, gonococcal culture and polymerase chain reaction (PCR) for Chlamydia trachomatis (CT), Mycoplasma genitalium (MG) and Ureaplasma urealyticum (UU) were performed. In 274 asymptomatic patients, 36 patients had non-gonococcal urethritis (NGU) and two patients had positive gonococcal culture. Among the asymptomatic patients with NGU, there were 6 (16.6%), 10 (22.8%) and five (13.9%) patients with positive PCR for CT, UU and MG, respectively. In addition, there were 14 asymptomatic patients with positive PCR for CT but without evidence of NGU. In conclusion, urethral infections were identified in a significant number of asymptomatic male patients and therefore, routine screening for this group is warranted.

Role of Mycoplasma genitalium and Ureaplasma urealyticum in non-gonococcal urethritis in Hong Kong

OBJECTIVE

To determine the association of Mycoplasma genitalium and Ureaplasma urealyticum in symptomatic male patients presenting with non-gonococcal urethritis in a sexually transmitted infection clinic in Hong Kong.

DESIGN

Cross-sectional study.

SETTING

A sexually transmitted infection clinic, Department of Health, Centre for Health Protection, Hong Kong.

PATIENTS

A cohort of consecutive new male patients attending the government sexually transmitted infection clinic.

MAIN OUTCOME MEASURES

Prevalence of Mycoplasma genitalium and Ureaplasma urealyticum among symptomatic male patients with non-gonococcal urethritis and asymptomatic patients without non-gonococcal urethritis.

RESULTS

Specimens of 22 and 10 patients tested positive by polymerase chain reaction for Ureaplasma urealyticum and Mycoplasma genitalium respectively, among the symptomatic non-gonococcal urethritis group (n=98). In the asymptomatic control group (n=236), corresponding patient numbers whose specimens tested positive were 47 and 5. There was no statistically significant difference between the two groups, in terms of the proportion of patients infected with Mycoplasma genitalium (P=0.799) or Ureaplasma urealyticum (P=0.535).

CONCLUSIONS

In our study, demonstration of Mycoplasma genitalium and Ureaplasma urealyticum by polymerase chain reaction was not associated with symptomatic non-gonococcal urethritis in male patients attending a Hong Kong government clinic for sexually transmitted infections.

Cutaneous melanoma: a population-based epidemiology report with 989 patients in Hong Kong

Studies in white populations have confirmed advanced age as a risk factor for cutaneous melanoma, but in nonwhite populations, its role is less clear. To clarify a possible association in our local population, comprising 94.9% Chinese, a retrospective epidemiological study of 20 years of data on cutaneous melanoma between 1983 and 2002 from a central cancer registry in Hong Kong was conducted. There were 989 new cases and 378 death cases registered, and analysis showed that both the incidence and mortality rate of cutaneous melanoma increase with increasing age. Advanced age is thus confirmed as a risk factor for cutaneous melanoma in our local population. In an ageing population, the estimated future incidence and mortality rate of cutaneous melanoma are likely to increase.

A recalcitrant case of cicatricial pemphigoid

A 57-year-old woman presented with a 1-year history of blisters and erosions on her oral mucosa with bilateral conjunctivitis and symblephara formation. A diagnosis of cicatricial pemphigoid was made based on the clinical features and immunohistological findings. A multidisciplinary team managed her with different topical and systemic immunosuppressive agents but she finally succumbed due to multi-organ failure secondary to sepsis.

Metastatic Crohn's disease in a Chinese girl

Metastatic Crohn's disease, in which non-caseating granulomatous infiltration of the skin occurs at sites separated from the gastro-intestinal tract by normal tissue, is the least common dermatologic manifestation of Crohn's disease. We report a 15-year-old girl with metastatic Crohn's disease presenting as granulomatous vulvar papules and nodules with typical histopathologic features. To the best of our knowledge, this is the first case of metastatic Crohn's disease in Chinese children reported in the English medical literature.

Glomeruloid haemangioma with cerebriform morphology in a patient with POEMS syndrome

A 40-year-old Chinese man presented with sensorimotor polyneuropathy, IgAlambda paraprotein, osteosclerotic bone lesions, hypertrichosis, and impotence with decreased testosterone and raised prolactin level. POEMS (polyneuropathy, organomegaly, endocrinopathy, monoclonal gammopathy and skin changes) syndrome was diagnosed and he was treated with melphalan and prednisolone. After chemotherapy, other manifestations of POEMS syndrome developed, such as multiple haemangiomas over the chest and neck region, splenomegaly and generalized oedema. One haemangioma had a peculiar clinical morphology, similar to the appearance of cerebral gyri. Skin biopsy confirmed the diagnosis of glomeruloid haemangioma. Chemotherapy was then switched to cyclophosphamide and prednisolone, resulting in further improvement in muscle power and hypertrichosis. To our knowledge, this is the first report on a clinically distinctive morphology of glomeruloid haemangioma, and its recognition may increase the index of suspicion for early skin biopsy.

Cutaneous tuberculosis in Hong Kong: an update

OBJECTIVE

To provide an update on cutaneous tuberculosis in Hong Kong.

DESIGN

Retrospective study.

SETTING

Social Hygiene Service (Dermatology Division), the largest dermatological referral centre in Hong Kong.

PATIENTS

Patients presented with cutaneous tuberculosis between 1993 and 2002 inclusive. Case notes, histology reports, and microbiological reports were reviewed with particular reference to the epidemiology, duration of illness, history of contact with tuberculosis, culture results, and response to treatment.

RESULTS

There were 147 patients with cutaneous tuberculosis; among these a few had true cutaneous tuberculosis (n = 16) and the remainder were tuberculids (n = 131). In all they accounted for 0.04% of new dermatology cases diagnosed. Cases of cutaneous tuberculosis were distributed as follows: lupus vulgaris (n = 6, 4%), tuberculosis verrucosa cutis (n = 6, 4%), tuberculosis of the skin unclassified (n = 2, 1%), and orificial tuberculosis (n = 2, 1%). Culture and polymerase chain reaction was positive in less than half of the latter cases. All responded well to anti-tuberculosis therapy. Erythema induratum was the most common form (n = 127, 86%), but papulonecrotic tuberculids (n = 4, 3%) were uncommon. Erythema induratum affected the lower limb in all patients, with a female predominance, and responded to isoniazid monotherapy, multidrug anti-tuberculosis therapy, or doxycycline.

CONCLUSION

Lupus vulgaris and tuberculosis verrucosa cutis remain the commonest forms of true cutaneous tuberculosis, and erythema induratum is the most common tuberculid. Culture and polymerase chain reaction are positive in a small proportion of patients.

Atypical mycobacterial cutaneous infections in Hong Kong: 10-year retrospective study

OBJECTIVE

To review the epidemiology of atypical mycobacterial cutaneous infection in Hong Kong.

DESIGN

Retrospective study.

SETTING

Social Hygiene Service (Dermatology Division), the largest dermatological referral centre in Hong Kong.

PATIENTS

Patients with a diagnosis of atypical mycobacterial cutaneous infection based on clinical features, histopathology, with or without a positive culture during the period 1993 to 2002.

MAIN OUTCOME MEASURES

Epidemiological data, clinical features, histology, microbiological investigation, and treatment response.

RESULTS

Of 345,394 dermatological cases presented over the 10-year period, 33 (0.0096%) cases (19 male, 14 female) of atypical mycobacterial cutaneous infection were diagnosed. The most common type of infection was caused by Mycobacterium marinum (n=17, 51.5%), followed by Mycobacterium avium-intracellulare (n=3, 9.1%) and Mycobacterium chelonae (n=2, 6.1%). The upper limb, especially the hands and fingers, was the most common (69.7%) site of involvement. Tissue culture was positive in 18 (54.5%) cases. All biopsies showed granulomatous histology. Thirty-two patients received treatment and 31 responded. Twenty-six were treated with oral tetracycline group of antibiotics (minocycline, doxycycline, tetracycline). The duration of treatment ranged from 8 to 54 weeks (mean, 24 weeks). Mild transient adverse effects to treatment were reported in six cases.

CONCLUSION

Atypical mycobacterial infection is rare in Hong Kong. Because of the low sensitivity of traditional culture techniques, atypical mycobacterial infection may be underdiagnosed if only culture-confirmed cases are included. Polymerase chain reaction provides a rapid and sensitive method to improve diagnostic accuracy. Tissue culture is crucial to determine antimicrobial susceptibility. In our study, tetracycline group of antibiotics, especially minocycline, was an effective treatment, particularly in cases caused by Mycobacterium marinum.

Three patients with orbital xanthogranuloma and non-progressive haematological abnormalities

Orbital xanthogranuloma is a rare dermatological condition characterized by its bilateral and rather symmetrical subcutaneous granulomatous infiltration around the eyes. It shares morphological similarities with other xanthogranulomatous diseases such as juvenile or adult type xanthogranuloma, necrobiotic xanthogranuloma and cutaneous infiltration in Erdheim-Chester disease, and should be differentiated from them. Three elderly Chinese patients with this condition were found to have underlying haematological abnormalities: normochromic normocytic anaemia, thrombocytopenia or eosinophilia. Their skin lesions remained localized and associated haematological abnormalities stable for up to 7 years. Haematological abnormalities were also reported in previous cases and this finding is unlikely to be coincidental; however, its clinical significance remains unknown.

Lipodystrophia centrifugalis abdominalis infantilis: two cases from China

We report the first two Chinese patients with lipodystrophia centrifugalis abdominalis infantilis in China. The first patient was a 3-year-old girl who developed an area of hyperpigmented skin depression on the right groin which spread centrifugally to the abdomen and right lower chest. Later, another lesion developed on the neck. The second patient was a 4-year-old girl who developed multiple areas of skin depression on her bilateral groin, periumbilical region, right axilla, and chest. The lesions also extended centrifugally. Erythematous margins and lymphadenopathy were present in both cases. Inflammatory changes were found in the subcutaneous fat. The clinical pictures and histologic features supported the diagnosis of LCAI in both cases.

Special features of non-melanoma skin cancer in Hong Kong Chinese patients: 10-year retrospective study

OBJECTIVE

To determine the incidence and clinical characteristics of non-melanoma skin cancer in Hong Kong Chinese patients.

DESIGN

Retrospective study.

SETTING

Social Hygiene Services, Hong Kong.

PATIENTS

Records of 528 Chinese patients with a histological diagnosis of non-melanoma skin cancer from 1990 to 1999 were reviewed.

MAIN OUTCOME MEASURES

Demographic data, site and clinical type of cancer, predisposing factors, history, recurrence, and the development of new skin cancers.

RESULTS

Non-melanoma skin cancer is uncommon but not rare among the Chinese population in Hong Kong. The incidence of newly diagnosed basal cell carcinoma in 1990 was 16.0 per 10,000 new skin case attendances and, in 1999, the incidence was 31.8 per 10,000 new skin case attendances. The corresponding figures for squamous cell carcinoma in 1990 and 1999 were 6.9 and 11.6 per 10,000 new skin case attendances. The incidence of basal cell carcinoma among the Hong Kong Chinese population in 1990 and 1999 was 0.32 and 0.92 per 100,000, respectively, whereas that of squamous cell carcinoma was 0.16 and 0.34 per 100,000, respectively. Demographic data and the site distribution of non-melanoma skin cancer were comparable to those reported in Caucasians living in North America and Europe, but different from those in Caucasians living in Australia and Hawaii. Pigmented basal cell carcinoma was the most common type of non-melanoma skin cancer (60.1%) in Chinese patients, in contrast with rodent ulceration in Caucasian. Multiple skin cancers, recurrence, and subsequent new skin cancers were less frequently observed than in studies of Caucasians.

CONCLUSION

When compared with reported findings in Caucasians, Chinese patients show differences in the clinical type and multiplicity of lesions, predisposing factors, recurrence, and subsequent new skin cancer rates for non-melanoma skin cancer. Pigmented basal cell carcinoma seems to be an important differential diagnosis with regard to pigmented lesions in the Chinese population.

Intermittent pulse therapy with itraconazole for onychomycosis. Experience in Hong Kong Chinese

Forty-four Hong Kong Chinese adults comprising 10 cases of fingernail and 42 cases of toenail onychomycosis were recruited for a 3-weekly itraconazole pulse therapy. Each pulse consisted of seven consecutive daily 400 mg doses with a 3-week interval between treatments. All patients in the fingernail group and 37 in the toenail group completed the study. The clinical cure, clinical response and mycological cure rates at week 36 were 70, 90 and 90% for fingernail and 35, 81 and 68% for toenail groups, respectively. Side-effects including biochemical abnormalities were minimal, and returned to normal upon cessation of treatment. We conclude that itraconazole pulse therapy is very effective, safe and well-tolerated for fingernail and toenail onychomycosis.

A controlled trial of traditional Chinese herbal medicine in Chinese patients with recalcitrant atopic dermatitis

BACKGROUND

There have been published reports from the United Kingdom of good responses to the use of traditional Chinese herbal medicine (Zemaphyte, Phytopharm Plc, Cambridge, UK) in treating recalcitrant atopic dermatitis. We conducted a double-blind, placebo-controlled, cross-over study among Chinese patients with recalcitrant atopic dermatitis using this same herbal preparation.

METHODS

Forty patients were recruited. They were given Zemaphyte and placebo in random order, each for 8 consecutive weeks with a 4-week wash-out period in between. Scores based on the severity and extent of four clinical parameters (erythema, surface damage, lichenification and scaling) were recorded at baseline and at 4-weekly intervals throughout the 20-week trial period.

RESULTS

Thirty-seven patients completed the trial. There was a general trend of clinical improvement with time throughout the trial period in both patient groups, irrespective of whether they received Zemaphyte or placebo first. Zemaphyte, however, offered no statistically significant treatment effect over placebo for all four clinical parameters, except for lichenification at week 4. There were no significant carry-over effects. Blood tests for hematologic, renal and liver functions were all normal throughout the trial.

CONCLUSIONS

Zemaphyte did not seem to benefit Chinese patients with recalcitrant atopic dermatitis in our study. Further research is required to evaluate its efficacy.

Poikiloderma-like cutaneous amyloidosis in an ethnic Chinese girl

Primary cutaneous amyloidosis is the deposition of amyloid in the skin without involvement of internal organs. It is easily diagnosed when presented in its typical manifestation. Atypical or rare clinical presentations can pose diagnostic difficulties. Poikiloderma-like cutaneous amyloidosis (PCA), a rare variant of primary cutaneous amyloidosis, was first reported in the literature in 1936 (1). It is characterised by: 1) poikilodermatous skin lesions; 2) lichenoid papules; 3) cutaneous amyloid deposit in the pigmented and lichenoid lesions; 4) light sensitivity; 5) short stature; and 6) other features such as blister formation or palmoplantar keratosis. Ogino coined the term PCA syndrome when these unusual features present early in life (2). We report a 26-year-old Chinese woman who presented with poikilodermatous skin lesions and was misdiagnosed as poikiloderma atrophica vasculare (PAV) on the basis of clinical appearance without any histological proof. The diagnosis of PCA was made after skin biopsy which showed amyloid deposits in the skin. This condition can easily be confused with other true poikiloderma skin diseases. Histology is important in confirming the diagnosis.

Clinical evaluation of ceftibuten in gonorrhea. A pilot study in Hong Kong

BACKGROUND

The escalating rates of gonococcal resistance to quinolone in Hong Kong have prompted a search for an alternative first-line antimicrobial agent for use in treating uncomplicated gonococcal urethritis. Ceftibuten is an orally active third-generation cephalosporin with potent in vitro activity against Neisseria gonorrhoeae. Its pharmacokinetic properties allow single-dose administration.

OBJECTIVE

To evaluate the efficacy, safety, and tolerability of ceftibuten in the treatment of uncomplicated gonorrhea in men.

STUDY DESIGN

Ceftibuten was evaluated in an open-label, noncomparative, multicenter study. Eligible men with uncomplicated gonococcal urethritis were treated with a single 400-mg oral dose of ceftibuten and reassessed 1 week and 3 weeks after treatment. The main outcome measures were the isolation of N. gonorrhoeae, patient-reported side effects, and other safety parameters (e.g., blood counts and renal and hepatic function tests).

RESULTS

One hundred twenty-five men were enrolled in the study. The overall cure rate was 98.2% (110 of 112 evaluable patients). Adverse events, which occurred in 4.5% of patients, were all mild, well tolerated, and of short duration. No significant changes in laboratory test results were noted. Of the 125 isolates, 4.8% were -lactamase positive. Susceptibility to ofloxacin was found to be low in 59.2% of isolates (MIC 0.1 to < 1g/mL) and 25.6% of isolates were resistant (MIC1g/mL) to ofloxacin.

CONCLUSIONS

A single 400-mg oral dose of ceftibuten is highly effective and well tolerated in the treatment of uncomplicated gonococcal urethritis in men.

HIV-associated eosinophilic folliculitis in a Chinese woman: a case report and a survey in Hong Kong

This is the first survey of eosinophilic folliculitis (EF) in patients infected with the human immunodeficiency virus (HIV) in Hong Kong. The present report provides the local data on HIV-associated eosinophilic folliculitis (HIV-EF) and includes the first Chinese, heterosexual female patient with this condition. This is a retrospective study on all HIV-positive patients (n = 451) attending the outpatient clinic of the AIDS Unit in Hong Kong. Patients diagnosed as having EF with histological support were included for analysis. The data were presented by descriptive method. Three patients were identified, all of them had skin biopsies done which confirmed the diagnosis; including the female case. Recognition of HIV-EF is important because it is indicative of significant immunosuppression with risk of opportunistic infection. We concluded that HIV-EF is no longer an exclusive male disease in homosexual patients only. We expect more female patients or heterosexual subjects who are HIV positive developing this disease in the future.

Scleredema in Chinese patients: a local retrospective study and general review

The records from 12 Chinese adult patients with scleredema, who had attended the Social Hygiene Service of the Hong Kong Department of Health between 22 January 1990 and 19 March 1996, were retrieved and analysed. The neck was the commonest site of involvement (75%), followed by the back (42%), and the shoulder (17%). The vast majority (83%) of scleredema cases were associated with diabetes mellitus; half of these were insulin-dependent. Most of the patients (92%) had hypertension for which medical treatment was needed. No cases of skin disease were preceded by acute infection, and none had any associated paraproteinaemia. The degree of skin involvement did not affect the daily activities of most of the patients. This study revealed differences between the disease in our locality and those described in the western literature.

Cutaneous tuberculosis in Hong Kong: a 10-year retrospective study

BACKGROUND

Cutaneous tuberculosis was once a relatively common skin disease in Hong Kong. Tuberculosis verrucosa cutis was the commonest type. Because the last survey was carried out 25 years ago, it was thought necessary to find out the new incidence and pattern of this important disease in this locality.

METHODS

A 10-year (1983-1992) retrospective survey on the epidemiologic and clinicobacteriologic aspects of cutaneous tuberculosis had been done in the public sector of Hong Kong. The records of the confirmed cases were retrieved for statistical analysis.

RESULTS

A total of 176 cases are included in the final analysis. This represents 0.066% of all new skin cases seen during the 10-year period. Among these, 79.5% are erythema induratum, 6.3% lupus vulgaris, and 4.5% tuberculosis verrucosa cutis. They are further divided into true cutaneous tuberculosis (14.8%, n = 26) and the tuberculide (85.2%, n = 150). Among the patients with true tuberculosis, 42.3% had lupus vulgaris, 30.8% had tuberculosis verrucosa cutis, and 26.9% had scrofuloderma. Among the tuberculides, erythema induratum accounted for 93.3%.

CONCLUSIONS

Cutaneous tuberculosis is now uncommon in Hong Kong. Tuberculosis verrucosa cutis is no longer the commonest type in Hong Kong as described in some textbooks. Erythema induratum is now the most common among the total cases and lupus vulgaris is the most common among the true cutaneous forms of tuberculosis.

Necrolytic migratory erythema in glucagonoma syndrome

A 32-year-old female Chinese presenting with typical features of necrolytic migratory erythema due to glucagonoma syndrome is reported. The clinical, biochemical, histopathological, and electron-microscopic findings are described. Various different aspects of this rare entity are discussed.