Acute generalized exanthematous pustulosis induced by the antifungal terbinafine: case report and review of the literature

Cutaneous drug reactions occur with a frequency of 1-8% and can be higher for certain classes of drugs. They can range from mild morbilliform eruptions to more severe forms such as drug-hypersensitivity syndrome, toxic epidermal necrolysis or anaphylaxis. Acute generalized exanthematous pustulosis (AGEP) is considered to be a clinical reaction pattern, which is induced in over 90% of the cases by systemic drugs. It is a rare presentation of an adverse drug reaction most frequently triggered by anti-infectious drugs. A high proportion of these cases have been attributed to aminopenicillins and macrolides. We report a terbinafine-induced AGEP in a 68-year-old male confirmed by lymphocyte stimulation in vitro, and review the published cases induced by antimycotic drugs with special emphasis on terbinafine-triggered cases.

IgM deposits on skin nerves in anti-myelin-associated glycoprotein neuropathy

Anti-myelin-associated glycoprotein (anti-MAG) neuropathy is a chronic demyelinating neuropathy with predominant involvement of large sensory fibers and deposits of IgM and complement on sural nerve myelinated fibers. We assessed the presence of IgM deposits on skin myelinated nerve fibers and the involvement of unmyelinated axons in anti-MAG neuropathy. Skin biopsies were performed in 14 patients with anti-MAG neuropathy, in 8 patients with chronic inflammatory demyelinating polyradiculoneuropathy (CIDP), and in 2 patients with IgM paraproteinemic neuropathy. Biopsies were taken at the proximal thigh in 20 patients, at the distal leg in 21 patients, at the proximal arm in 13 patients, and at the hand or fingertip in 10 patients. We found IgM deposits on dermal myelinated fibers in all anti-MAG neuropathy patients, with a greater prevalence at the distal site of the extremities. Deposits were located throughout the length of the fibers and at the paranodal loops. CIDP and IgM paraproteinemic neuropathies did not show any deposit of IgM. Anti-MAG neuropathy and CIPD patients showed a decrease in epidermal nerve fiber density reflecting an associated axonal loss. In anti-MAG neuropathy, both large- and small-diameter nerve fibers are affected, and specific deposits of IgM are found on skin myelinated nerve fibers.

IgM-enriched immunoglobulin (pentaglobin) positively influences the course of post-surgical intra-abdominal infections

BACKGROUND

Polyvalent IgM-enriched intravenous human immunoglobulin (IVIG) preparations are discussed to be beneficial regarding sepsis outcome.

MATERIALS AND METHODS

Sixty-four patients with abdominal infection were treated with Pentaglobin or Albumin. Serum levels of endotoxin and chemokines were determined.

RESULTS

Incidence of fever was 19/28 in the pentaglobin and 18/26 in the albumin group, the percentage of days with fever was 34 +/- 26 for pentaglobin and 43 +/- 25 for albumin (mean +/-SD). Procalcitonin levels of the pentaglobin treated patients fell under the upper limit of normal on day six whereas levels of albumin patients remained elevated.

CONCLUSION

Pentaglobin has a positive influence on the course of post-surgery intra-abdominal infection.

[Sudden hearing loss]

Sudden hearing loss is a reduction of sensoneurinal sound perception with a sudden onset. It is usually occurring only in one ear and without a recognizable cause. If a hearing loss is suspicioned due to otoscopic and tuning fork test findings, the patient should rapidly be sent to an ENT-specialist because of the possible consequences. After the first examinations by means of ear microscopy and audiogram further diagnostics may be necessary. If no cause is found, the idiopathic sensorineural hearing loss remains as the exclusion diagnosis. Therapy follows a polypragmatic approach based on the different theories of its origin. Therefore mainly antiinflammatory, antiviral and vasoactive drugs are applied. The high spontaneous healing rate and the still pending proof of effectiveness of all types of therapy used so far must be considered.

The effects of transdermal estradiol alone or with cyclical dydrogesterone on markers of cardiovascular disease risk in postmenopausal women with type 2 diabetes: a pilot study

The objective of this open, longitudinal, controlled study was to assess the effect of transdermal estradiol alone or combined with cyclical dydrogesterone on the markers of cardiovascular disease (CVD) risk in postmenopausal women with type 2 diabetes. The control group consisted of postmenopausal diabetic women who declined menopausal hormone replacement therapy (HRT). Twenty-eight postmenopausal women (19 on HRT and 9 controls) with type 2 diabetes were followed up for 12 months. From the active treatment group 14 women with a uterus in situ had 80 microg/24 hr transdermal estradiol (Fematrix 80; Solvay Healthcare Ltd, Southampton, UK) and oral dydrogesterone 10 mg daily for the first 12 days of the calendar month, whereas 5 women with previous hysterectomy had 80 microg/24 hr transdermal estradiol (Fematrix 80) alone. CVD risk markers were measured before and at regular intervals after starting HRT. The main outcome measures were weight, systolic and diastolic blood pressure, fasting plasma glucose, glycated hemoglobin (HbA1c), glucose/insulin ratio, total cholesterol, high-density lipoprotein (HDL) cholesterol, low-density lipoprotein (LDL) cholesterol, triglycerides, lipoprotein (a), high-sensitivity C-reactive protein (hs-CRP), fibrinogen, and endothelin-1. Transdermal estradiol with or without dydrogesterone in women with type 2 diabetes did not adversely affect any of the measured markers of cardiovascular risk. There was a significant decrease in HbA1c, total cholesterol, and LDL cholesterol at 6 months in women receiving HRT. Some of the cardiovascular disease risk markers may improve in postmenopausal women with type 2 diabetes with transdermal estradiol. This effect may have important clinical implications and it deserves further investigation in appropriately designed trials.

Time-resolved observation of the decomposition process of N,N,N-Trimethylanilinium cations on zeolite H-Y by in situ stopped-flow 13C MAS NMR spectroscopy

N,N,N-Trimethylanilinium cations were synthesized on acidic zeolite H-Y by direct reaction of N,N-dimethylaniline and methanol. Time-resolved observation of the detailed decomposition process of N,N,N-trimethylanilinium cations was achieved by in situ 13C stopped-flow (SF) MAS NMR spectroscopy at reaction temperatures of 498 K to 573 K.

Molecular basis of hyperparathyroidism and potential targets for drug development

Our appreciation of the molecular pathogenesis of primary hyperparathyroidism (HPT) has seen great advances over the past decade. This improved understanding may well lead to the development of new treatment options that are specifically targeted to defective pathways. This review summarizes recent advances in the molecular basis of HPT and associated endocrinopathies, and discusses the potential for these and future findings to provide targets for alternative approaches to therapy. The only proven contributors to common sporadic HPT, by virtue of clonal genetic abnormalities, are the cyclin D1 and MEN1 genes. Cyclin D1 is an oncogene that encodes a key regulator of the cell cycle, while MEN1 is a tumor suppressor gene that has also been implicated in familial multiple endocrine neoplasia type 1 (MEN1), in which primary HPT is common. In addition, other key parathyroid regulatory pathways may play a role in HPT pathogenesis. 1,25 (OH)2-vitamin D. Ca2+ and phosphate are regarded as principal regulators of parathyroid cell proliferation and PTH secretion. Therefore, prime candidate targets include the Ca2+ sensing receptor (CASR) gene, the vitamin D receptor (VDR) gene, a putative phosphate receptor gene, their cognate gene products, and other genes or proteins involved in their respective biochemical pathways. Attempts to identify new therapies based specifically on the defective pathways in HPT could complement or eventually supplant traditional approaches.

Pharmacologic insights into the future of trastuzumab

A combination of factors has been responsible for improvements in cancer survival and cure rates. In addition to new therapies with novel/genetic targets, these include improvements in drug delivery, new schedules/sequencing of drug administration and the identification of combination therapies with greater activity/dose density than existing regimens. The recognition that such criteria can affect treatment outcome has led to their incorporation into clinical trials of new drugs. Furthermore, pharmacokinetic and pharmacodynamic parameters have become increasingly important for the rational selection of dose, administration route and schedule. The humanized monoclonal antibody trastuzumab (Herceptin) has been rationally developed to target the human epidermal growth factor receptor-2 (HER2), which is overexpressed in 20%-30% of breast cancers and is associated with poor prognosis. Trastuzumab when administered i.v. on a weekly schedule either alone or in combination with taxanes, improves survival of women with HER2-positive metastatic breast cancer. Based upon pharmacokinetic considerations, current studies are examining whether trastuzumab can be administered i.v. every three weeks or by the s.c. route. These regimens would have advantages for patients and medical staff in terms of acceptability, ease of administration and, potentially, cost effectiveness. Furthermore, various combinations of trastuzumab and chemotherapeutic agents are being explored with the aim of identifying the optimal combination regimen for clinical use. The rationale for these various studies and the studies themselves are described.

Synthesis, spectroscopic, and structural properties of spirocyclopropanated bicyclobutylidenes and their radical cations

The spirocyclopropanated bicyclobutylidenes 3-7 have been prepared by McMurry coupling of the corresponding spirocyclopropanated cyclobutanone (3 and 5), Staudinger-Pfenniger reaction (4), oxidative coupling of a Wittig ylide (4) or Wittig olefination of perspirocyclopropanated cyclobutanone (6 and 7). The structure of the parent 2a and the perspirocyclopropanated bicyclobutylidene 5 was determined by X-ray crystallography which disclosed considerable steric congestion around the double bond. As a result 5 did undergo addition of dichlorocarbene, epoxidation with meta-chloroperbenzoic acid, and cyclopropanation with CH2I2/ZnEt2, but did not add the more bulky dibromocarbene. The reaction of 5 with tetracyanoethene proceeded smoothly, but led to a formal [3+2] cycloadduct across the proximal single bond of one of the inner cyclopropane rings. The consecutive spirocyclopropanation of bicyclobutylidene led to a bathochromic shift in the UV spectra of 12 and 17nm, respectively, for each pair of beta- and alpha-spirocyclopropane groups. In the He(I)-photoelectron spectra of these bicyclobutylidenes, the effect of spirocyclopropanation upon their pi-ionization energies (pi-IE,) was found to be almost additive, leading to a lowering of 0.05 eV per any additional beta-spirocyclopropane, and 0.28-0.22 eV per additional alpha-spirocyclopropane group; this indicates an increasing nucleophilicity of the double bonds in the order 1 < 4 < 3 < 5. Following the radical cations of the three symmetrical bicyclobutylidenes without (2a, b) and with six (5) spiroannelated cyclopropane rings, the radical cations of two symmetrical bicyclobutylidenes with two (4) and four (3) such rings were studied by ESR spectroscopy. Whereas 2b.+, 3.+, and 5.+ could be generated by electrolytic oxidation of the corresponding hydrocarbons in solution, the spectra of 2a.+ and 4.+, with unsubstituted 2,2',4,4'-positions, were observed upon radiolysis of their neutral precursors in a Freon matrix. On going from 2a.+ to 4.+, the coupling constant [aH] of the eight beta protons in the 2,2',4,4'-positions of bicyclobutylidene increases from 2.62 to 3.08 mT, and that of the four gamma protons in the 3,3'-positions changes from 0.27 to 0.049 to 0.401 mT on passing from 2a.+ via 2b.+ to 3.+. Computations by means of the density functional theory (DFT) at the B3LYP/6-311+G*//B3LYP/6-31G* level reproduce well the experimental hyperfine data.

Expression of BRCA1 gene in ewe mammary epithelial cells during pregnancy: regulation by growth hormone and steroid hormones

OBJECTIVE

Steroid hormones (estradiol and progesterone) in association with prolactin and growth hormone are involved in lobulo alveolar development of the mammary gland during pregnancy. We hypothesized that the BRCA1 gene may be induced by these different hormones.

METHODS AND RESULTS

In this study, we have demonstrated by Northern blot and in situ hybridization, that the expression of ovine (o) BRCA1 mRNA in mammary epithelial cells increased dramatically during a short period in the second half of pregnancy (days 70 to 112) and decreased at the end of pregnancy. The increase in oBRCA1 mRNA expression is concomitant with rapid lobulo alveolar growth. Using an in vivo protocol to artificially induce mammary gland development, we demonstrated by the real-time RT-PCR method that growth hormone in association with estrogen, progesterone and hydrocortisone induces an increase of BRCA1 mRNA expression in the ewe mammary gland. Moreover, we showed that estradiol and progesterone induce oBRCA1 expression in primary cultures of ewe mammary gland.

CONCLUSIONS

These results suggest that BRCA1 is a potential regulator of the effects of steroid hormones and growth hormone in the induction of mammary epithelial cell proliferation.

In vivo analysis of mammary and non-mammary tumorigenesis in MMTV-cyclin D1 transgenic mice deficient in p53

Overexpression of the cyclin D1 oncogene and inactivation of the p53 tumor suppressor have both been implicated in substantial proportions of sporadic human breast cancers. Transgenic mice with cyclin D1 overexpression targeted to mammary tissue by the MMTV enhancer-promoter have been shown to develop mammary cancers. To investigate the relationship between pathways driven by cyclin D1 overexpression and p53 loss during the development of breast cancers, we crossed MMTV-cyclin D1 mice with p53 heterozygous null (p53+/-) mice. In such crossed mice, cyclin D1-driven mammary neoplasia would need to be substantially accelerated by p53 loss in order for mammary tumors to develop prior to the expected onset of non-mammary tumors characteristic of the p53-deficient background alone. Instead, in mice heterozygous or homozygous for p53 deficiency and simultaneously carrying the MMTV-cyclin D1 transgene, only tumors typically found in p53-deficient mice developed and mammary tumors were not observed. Interestingly, MMTV-cyclin D1/p53+/- mice appeared to develop these non-mammary tumors more rapidly than p53+/- mice, and a majority of the sampled non-mammary tumors from MMTV-cyclin D1/p53+/- mice showed 'ectopic' expression of the MMTV-driven cyclin D1 transgene. Within the constraints of possible genetic background effects and limited sensitivity due to the early emergence of non-mammary tumors, these observations provide no evidence that inactivation of p53 confers a major additional selective advantage to mammary cells overexpressing cyclin D1 in this animal model of human breast cancer. Interestingly, the results do raise the possibility that p53 inactivation might complement or cooperate with cyclin D1 deregulation during the development of some types of non-mammary tumors.

Phase II study of pemetrexed disodium, a multitargeted antifolate, and cisplatin as first-line therapy in patients with advanced nonsmall cell lung carcinoma: a study of the National Cancer Institute of Canada Clinical Trials Group

BACKGROUND

Pemetrexed disodium (Alimta [Eli Lilly and Company, Indianapolis, IN], LY231514, multitargeted antifolate) is a new multitargeted antifolate agent that inhibits multiple enzymes in the folate pathway. Phase II trials showed single-agent response rates of 16% and 23% in untreated patients with nonsmall cell lung carcinoma (NSCLC). This study was undertaken to determine the response to pemetrexed disodium given in combination with cisplatin.

METHODS

Previously untreated patients were eligible if they had Stage IIIB or IV NSCLC, performance status 0, 1, or 2, adequate hematology and biochemistry and bidimensionally measurable lesions. Patients with brain metastases or neuropathy higher than Grade 2 were excluded. Pemetrexed disodium 500 mg/m(2) was given over 10 minutes, and cisplatin 75 mg/m(2) with hydration and mannitol diuresis was administered on Day 1 of each 21-day cycle. Dexamethasone 4 mg was taken orally once every 12 hours starting 24 hours before treatment and continuing for 6 doses after treatment. Four patients had detailed pemetrexed disodium pharmacokinetic analysis performed.

RESULTS

Between May 1998 and June 1999, 31 patients were treated on the study. There were 20 males and 11 females; median age was 60 years (range, 35-75 years); there were 5 Stage IIIB, 26 Stage IV, 26 performance status 0 or 1, and 5 performance status 2. In 29 patients evaluable for response, there were 13 partial responses (PRs; overall response rate [ORR], 95%; confidence interval [CI]: 26-64%) of median duration 6.1 months (1.6-7.8 months). Three of four evaluable patients with performance status 2 achieved PR, and 11 of 24 evaluable Stage IV patients responded (ORR, 45.8% in Stage IV). Eighteen patients died. The median survival rate was 8.9 months (range, 1-15+ months). A total of 160 courses were delivered (median, 6 for both cisplatin and pemetrexed disodium). Grade 3 and 4 anemia was observed in 5 and 1 patients, respectively, and Grade 3 and 4 granulocytopenia in 7 and 4 patients, respectively. Grade 3 nausea and emesis occurred in only 2 patients, Grade 3/4 diarrhea in 3 patients, and 2 patients had Grade 3 motor neuropathy. Nine patients had Grade 2 infections, and there was one case of febrile neutropenia. Pharmacokinetic results showed C(max), clearance and V(ss) values to be similar to data from single-agent pemetrexed disodium given in the same dose.

CONCLUSIONS

The combination of pemetrexed disodium and cisplatin is active against advanced NSCLC and is a well-tolerated convenient outpatient regimen. It deserves further study to compare it with other standard regimens for NSCLC.