A case of furuncular myiasis was reported for the first time in a 29-year-old young Taiwanese traveler returning from an ecotourism in Peru. Furuncle-like lesions were observed on the top of his head and he complained of crawling sensations within his scalp. The invasive larva of botfly, Dermatobia hominis, was extruded from the furuncular lesion of the patient. Awareness of cutaneous myiasis for clinicians should be considered for a patient who has a furuncular lesion and has recently returned from a botfly-endemic area.

OBJECTIVES: To present a case of anti NMDA receptor encephalitis in an adolescent male; to report a case of anti-NMDA receptor encephalitis who showed a rapid response to methylprednisone.
INTRODUCTION: Anti NMDA receptor encephalitis is an inflammatory encephalopathic autoimmune disease frequently affecting young women with teratomas of the ovary. It is also observed in men, children, and females without tumors.
THE CASE: A case of a 14 year adolescent right handed male adolescent presented with fever, hypertension , psychiatric symptom ,aphasia and orofacial dyskinesia. On admission he was highly febrile with dysautonomia, rigidity, catatonia and prominent orofacial dyskinesia. Upper motor signs include hyperreflexia and bilateral clonus. He latter developed Ileus, bladder and bowel incontinence, seizures, chorea, dystonia and dIe orofacial dyskinesia worsened. EEG showed continuous background slowing, Cranial MRI was normal and CSF analysis showed pleocytosis with lymphatic predominance with a normal protein and sugar. Work up for Herpes and Japanese B encephalitis was negative. Work up for tumor was negative. After 5 days of methylprednisone a rapid improvement was noted with resolution catatonia, rigidity hypereflexia and clonus. Results of the anti NMDA receptor antibodies showed positive for anti NMDA receptor encephalitis.
DISCUSSION: Anti NMDA receptor encephalitis presents with fever, headache,or malaise, followed mood and behavioral changes, psychiatric symptoms, decline of level of consciousness, hypoventilation and hyperkinesias. Immunotherapy is the current treatment. In patients with underlying tumor, immunotherapy, enhanced the effectiveness and speed of recovery. In patients without a tumour an additional treatment with second-line immunotherapy is needed but was not noted in this case. The patient showed a rapid recovery after methylprednisone and after 4 months post immunotherapy there was no recurrence of symptoms.
CONCLUSION: Anti NMDA receptor encephalitis is an inflammatory encephalopathic autoimmune disease and can be seen in children without tumors. Behavioral and hyperkinesias are prominent symptoms. Treatment with methylprednisone showed a good response.

Human ; Male ; Adolescent ; Anti-n-methyl-d-aspartate Receptor Encephalitis ; Catatonia ; Chorea ; Dyskinesias ; Dystonia ; Electroencephalography ; Encephalitis, Japanese ; Hashimoto Disease ; Hyperkinesis ; Leukocytosis ; Primary Dysautonomias ; Receptors, N-methyl-d-aspartate

OBJECTIVES: To present a case of childhood primary dystonia with good response to zolpidem.
INTRODUCTION: Dystonia is a syndrome of sustained muscle contractions causing twisting and repetitive movements or abnormal postures. It is not uncommon in children. Although there are several options to treat dystonia,its medical treatment is notoriously difficult and often unsuccessful. Zolpidem, an imidazopyridine agonist with a high affinity to benzodiazepine subtype receptor BZ1, is reported to improve basal ganglia disease including Parkinson'sdisease and various types of dystonia.
THE CASE: 11 year old female with torticollis starting the 7years old. At q10years old symptoms progressed with her back hyperexteded. Her cranial MRI was normal. She was started on Levodopa and carbidopa however no improvement of symptoms was noted. She was started on zolpidem and there was a marked improvement in speech, writing, swallowing, walking and posture observed.
DISCUSSION: Primary dystonia is defined as syndromes in which dystonia is the sole phenotypic manifestation. There is no cognitive decline and cranial MRI is normal. Management of childhood dystonia differs in certain respects from that of adult dystonia. Dopamine responsive dystonia in children is rare, but a trial of L-dopa should be performed on all patients rith childhood-onset dystonia. Dystonia is associated with hypoactivity of the globus pallidus interna, and widespread brain alterations in GABAA/benzodiazepine receptors. Zolpidem binding sites are abundant in the basal ganglia output structure the globus pallidus interna and substantia nigra pars reticulata. It is thought that by binding to these sites, zolpidem help restore Ie ganglionic output influence to the thalamus and motor cortex.
CONCLUSION: There are several options to treat dystonia,its medical treatment is notoriously difficult and often unsuccessful. Zolpidem an imidazopyridine agonist can be given in childhood dystonia unresponsive to dopamine.

Human ; Female ; Child ; Basal Ganglia ; Benzodiazepines ; Carbidopa ; Deglutition ; Dopamine ; Dystonic Disorders ; Globus Pallidus ; Levodopa ; Motor Cortex ; Parkinson Disease ; Pars Reticulata ; Dystonia

Background/Aims: Serum fibrosis scores comprised of common laboratory tests have high utility to assess severity of liver fibrosis. We aimed to derive and validate a hepatocellular carcinoma (HCC) risk score based on serum fibrosis scores to predict HCC in treatment-naïve chronic hepatitis B (CHB) patients. Methods: Fifteen thousand one hundred eighty-seven treatment-naïve adult CHB patients were identified to form the training cohort in this retrospective study. Individual fibrosis score was included to construct a new HCC prediction score. The score was externally validated in an independent treatment-naïve Korean CHB cohort. Results: 180/15,187 patients (1.2%) in training cohort and 47/4,286 patients (1.1%) in validation cohort developed HCC during a mean follow-up of 52 and 50 months, respectively. The newly developed HCC risk score, Liang score, is composed of gender, age, hepatitis B virus DNA, fibrosis-4 (FIB-4) index, and ranges from 0 to 22. Area under the time-dependent receiver operating characteristic curve of Liang score was 0.79 (95% confidence interval, 0.70–0.89). A cutoff value of nine provided an extremely high negative predictive value of 99.9% and high sensitivity of 90.0% at 5 years in the validation cohort. Patients with Liang score ≤9 had HCC incidence <0.2% per year in both training and validation cohorts, in whom HCC surveillance might be exempted. Conclusion A novel HCC risk score, Liang score, based on FIB-4 index, is applicable and accurate to identify treatment-naïve CHB patients with very low risk of HCC to be exempted from HCC surveillance.

Background/Aims: Serum fibrosis scores comprised of common laboratory tests have high utility to assess severity of liver fibrosis. We aimed to derive and validate a hepatocellular carcinoma (HCC) risk score based on serum fibrosis scores to predict HCC in treatment-naïve chronic hepatitis B (CHB) patients. Methods: Fifteen thousand one hundred eighty-seven treatment-naïve adult CHB patients were identified to form the training cohort in this retrospective study. Individual fibrosis score was included to construct a new HCC prediction score. The score was externally validated in an independent treatment-naïve Korean CHB cohort. Results: 180/15,187 patients (1.2%) in training cohort and 47/4,286 patients (1.1%) in validation cohort developed HCC during a mean follow-up of 52 and 50 months, respectively. The newly developed HCC risk score, Liang score, is composed of gender, age, hepatitis B virus DNA, fibrosis-4 (FIB-4) index, and ranges from 0 to 22. Area under the time-dependent receiver operating characteristic curve of Liang score was 0.79 (95% confidence interval, 0.70–0.89). A cutoff value of nine provided an extremely high negative predictive value of 99.9% and high sensitivity of 90.0% at 5 years in the validation cohort. Patients with Liang score ≤9 had HCC incidence <0.2% per year in both training and validation cohorts, in whom HCC surveillance might be exempted. Conclusion A novel HCC risk score, Liang score, based on FIB-4 index, is applicable and accurate to identify treatment-naïve CHB patients with very low risk of HCC to be exempted from HCC surveillance.

In 2010, the Asian Society of Cardiovascular Imaging (ASCI) provided recommendations for cardiac CT and MRI, and this document reflects an update of the 2010 ASCI appropriate use criteria (AUC). In 2016, the ASCI formed a new working group for revision of AUC for noninvasive cardiac imaging. A major change that we made in this document is the rating of various noninvasive tests (exercise electrocardiogram, echocardiography, positron emission tomography, single-photon emission computed tomography, radionuclide imaging, cardiac magnetic resonance, and cardiac computed tomography/angiography), compared side by side for their applications in various clinical scenarios. Ninety-five clinical scenarios were developed from eight selected pre-existing guidelines and classified into four sections as follows: 1) detection of coronary artery disease, symptomatic or asymptomatic; 2) cardiac evaluation in various clinical scenarios; 3) use of imaging modality according to prior testing; and 4) evaluation of cardiac structure and function. The clinical scenarios were scored by a separate rating committee on a scale of 1–9 to designate appropriate use, uncertain use, or inappropriate use according to a modified Delphi method. Overall, the AUC ratings for CT were higher than those of previous guidelines. These new AUC provide guidance for clinicians choosing among available testing modalities for various cardiac diseases and are also unique, given that most previous AUC for noninvasive imaging include only one imaging technique. As cardiac imaging is multimodal in nature, we believe that these AUC will be more useful for clinical decision making.
Area Under Curve ; Asian Continental Ancestry Group* ; Clinical Decision-Making ; Consensus* ; Coronary Artery Disease ; Echocardiography ; Electrocardiography ; Heart Diseases ; Humans ; Magnetic Resonance Imaging ; Methods ; Positron-Emission Tomography ; Radionuclide Imaging ; Tomography, Emission-Computed