Severe injuries among workers in heavy industry seem unusual and they are often unique because they can occur under specialized environments. Building structures on seabeds or riverbeds is performed in caisson systems that are filled with compressed air. Here we report an unusual case of traumatic ulcers that occurred in a caisson worker.A 31-year-old male was referred to our clinic in November 1998 because of deep and necrotic ulcers on his forearms. He was a caisson worker and had been injured in a caisson system 2 months previously. At the time of injury, the caisson was on a riverbed 28 m below the water level, and the pneumatic pressure in the caisson was 2.8 bar. Since water incursion into caissons often happens, a drainage pipe is always present in the system. At the time of his injury, water had infiltrated and he tried to connect the waste pipe to the exhaust port. Accidentally, his coworker opened the drain cock before he finished the connection and he was sucked into the exhaust port which was 25 cm in diameter and located 2.5 m above the ground (fig. 1). His forearms were compressed for 5 min at 2.8 bar. He lost consciousness and when the drain cock was closed, he fell down to the ground.On admission there were four severe lesions, one on the medial aspect of the dorsum of his left hand (fig. 2A), one on the medial aspect of his left forearm (fig. 2B), one on the flexor aspect of his right forearm (fig. 2C) and one on his right elbow (fig. 2D). Right ulnar nerve paresis was also found. The ulcers on the dorsum of his left hand and his right elbow were deeper than the other two and bone was observed.A tailored abdominal pedicle flap [1]was employed to cover the skin defect on his left hand and split-thickness skin grafting (STSG) was performed on the ulcer of his left forearm. Prostaglandin I2 and gentamycin ointments were applied to the ulcers on his right arm with surgical debridement of necrotic tissue for 4 weeks. After obtaining favorable granulations, STSG on his right forearm and grafting of a local skin flap on his right elbow were performed. Ulnar nerve reconstruction was done with nerve transition but not transplantation and a good prognosis of the paresis was expected.In the developed industrial countries unexpected injuries can occur under highly specialized conditions such as high temperature and high pressure, e.g. high-pressure injection injuries, degloving injury and heat press injury [2]. Caissons are used to excavate seabeds or riverbeds for foundation work. The caisson is placed directly on the seabed or riverbed like an upside-down glass and is filled with compressed air at a pressure equal to the water pressure to avoid water leakage. Caisson workers operate machines under such a high pressure that decompression diseases such as dysbarism, the so-called caisson disease, are often a problem [3]. However, there has been no previous report of traumatic ulcer caused by air pressure in a caisson.In this case it took only 5 min for the injury to be established and the damage was deep with nerve paresis and bone exposure. The major factor causing this severe injury was compression by a high air pressure of 2.8 bar, which was intensified by the small port. Initially there were only blackish macules where the damage occurred. The first physician who examined the patient did not realize the severity of the condition and did not perform any surgical treatment such as debridement. Consequently, 2 months passed before he was referred to our clinic.Although the causes of injuries vary in different industries, this case may represent a very rare occasion. Even if such injuries seem light, it is very important to know that they could be very serious and result in deep tissue damage.
Abstract In 2010, the first Japanese edition of guidelines for the management of cutaneous lymphoma was published jointly by the J apanese D ermatological A ssociation ( JDA ) and the J apanese S kin C ancer S ociety ( JSCS ) – L ymphoma S tudy G roup. Because the guidelines were revised in 2011 based on the most recent data, we summarized the revised guidelines in English for two reasons: (i) to inform overseas clinicians about our way of managing common types of cutaneous lymphomas such as mycosis fungoides/ S ézary syndrome; and (ii) to introduce J apanese guidelines for lymphomas peculiar to A sia, such as adult T ‐cell leukemia/lymphoma and extranodal natural killer/ T ‐cell lymphoma, nasal type. References that provide scientific evidence for these guidelines have been selected by the JSCS – L ymphoma S tudy G roup. These guidelines, together with the degrees of recommendation, have been made in the context of limited medical treatment resources, and standard medical practice within the framework of the J apanese N ational H ealth I nsurance system.
Abstract A case of a 39‐year‐old female with fibromuscular dysplasia (FMD) manifesting subcutaneous pulsatile nodules on the right side of her forehead and on her right wrist is reported here. These nodules proved to be FMD aneurysms of the frontal ramus of the right superficial temporal artery and the right radial artery. The patient had also suffered a stroke with subarachnoidal bleeding as a result of this disease. Angiographic examination showed aneurysms in the union and the bilateral vertebral arteries, a branch of the right renal artery, and one the right lumbar artery. A biopsy specimen taken from the frontal branch of the right superficial artery revealed segmental intimal thickening consistent with intimal fibroplasia type FMD upon histological examination. Electron‐microscopic findings were also discussed in connection with the histogenesis of the disease. This appears to be the second case of FMD involving arteries in the skin to be reported in the dermatological literature.
Growth patterns of malignant cutaneous tumors in 21 patients obtained by magneti resonance imaging (MRI) were assessed in contrast with those in histological examinations.Degree of intradermal invasion in MRI pictures of the lesions was well corresponded with that in histological examinations. In general, intensit of tumor images was higher in T2 weighted images than that of T1 weighted images. It is very likely that cellularity, inflammation, edema and degeneration of the lesions may cause the phenomena.MRI seems to be better to analyze tumor invasion arising in head and neck region than other imaging method such as CT scan, xerography and FCR, because MRI enables us to select slice freely, when the lesion occurs in unevenly surfaced region.
Adult T-cell leukemia/lymphoma (ATLL) has been divided into four subtypes up to now: (i) acute; (ii) lymphoma; (iii) chronic; and (iv) smoldering. Skin lesion(s) may be present and the cases showing less than 5% abnormal T-lymphocytes in peripheral blood without involvement of other organs, have been classified as smoldering ATLL. However, this type of ATLL with skin manifestations had a worse prognosis than that without skin lesions. This study aimed to define and distinguish cutaneous ATLL lacking nodal lymphoma and leukemic change from smoldering ATLL. We propose an entity of cutaneous ATLL, which has less than 5% abnormal T lymphocyte in peripheral blood, a normal lymphocyte count (i.e. <4 x 10(9)/L), no hypercalcemia and lactate dehydrogenase values of up to 1.5 times the normal upper limit. At least one of the histologically proven skin lesions should be present accompanying monoclonal integration of human T-cell lymphotropic virus type 1 (HTLV-1) proviral DNA in the skin lesion. Blood samples were collected from 41 HTLV-1-infected patients, 21 asymptomatic carriers, 16 patients with cutaneous ATLL and four patients with smoldering ATLL. HTLV-1 proviral loads, soluble interleukin-2 receptors and other parameters were examined in each case. HTLV-1 proviral DNA loads in smoldering ATLL group are significantly higher than those in asymptomatic carrier and cutaneous ATLL group. Cutaneous ATLL may be a distinct entity that should be separated from smoldering ATLL clinically and virologically.
