Tocilizumab: Another medication related to osteonecrosis of the jaws? A case report and literature review

Introduction: Medication-related osteonecrosis of the jaw (MRONJ) is a serious complication in patients receiving antiresorptive medication, such as bisphosphonates and denosumab, for different oncologic and non-oncologic diseases. Here, we report a case of MRONJ in a patient treated with tocilizumab, a humanized anti-interleukin-6 receptor antibody that effectively treats moderate to severe rheumatoid arthritis in adults.

Case description: A 45-year-old female patient diagnosed with severe rheumatoid arthritis, who had been undergoing intravenous tocilizumab therapy for three years without history of bisphosphonate use, was referred to our department. Four weeks previously, several teeth in the maxilla and mandible were removed under local anesthesia by her dentist. Two weeks after the extractions, she felt pain in both jaws. We diagnosed wound dehiscence and delayed healing of the alveolar bone after the tooth extractions. Digital volume tomography showed persistent dry alveolar sockets. The patient underwent surgical debridement of necrotic bone, and intravenous antibiotics were administered in hospital. Five months later, wound dehiscence reoccurred in the same regions. Histopathological analysis of bone biopsies revealed a diagnosis of MRONJ. Four months later, wound dehiscence occurred in the left maxillary alveolar ridge, and local bone resection was performed under antibiotic treatment. Twenty-four months after the last surgery, wound dehiscence had healed completely without signs of recurrence.

Discussion: Osteomyelitis of the jaw in patients treated with tocilizumab has not been reported often. This case confirms the potential role of this interleukin-6 receptor inhibitor in the pathogenesis of MRONJ and shows that patients who receive tocilizumab with MRONJ-like symptoms should be closely monitored. The pathomechanism of MRONJ under tocilizumab therapy remains unclear, so dental practitioners, maxillofacial surgeons, and rheumatologists should look for signs of MRONJ in patients receiving tocilizumab to prevent MRONJ onset.

Eruptive Nevi Mimicking Wart-Like Lesions under Selective BRAF Inhibition in a 37-Year-Old Female Melanoma Patient

BACKGROUND

The BRAF inhibitor vemurafenib is state of the art in therapy of patients with malignant melanoma in non-resectable stage III or stage IV and evidence of oncogenetic BRAF mutation. Multiple cutaneous side effects like rash and keratoacanthoma-like lesions have been described so far.

CASE REPORT

We report a patient who presented multiple wart-like lesions under therapy with vemurafenib. Histologically we have seen multiple melanocytic nevi with a wart-like appearance. One melanoma in situ developed on the left forearm.

CONCLUSIONS

Eruptive nevi and induction of melanoma may be a further side effect in patients undergoing a therapy with BRAF inhibitors.

Mitomycin-C-treated peripheral blood mononuclear cells (PBMCs) prolong allograft survival in composite tissue allotransplantation

BACKGROUND

Composite tissue allotransplantation (CTA) was introduced as a potential treatment for complex reconstructive procedures and has become a clinical reality. Hand and face transplantation, the most widely recognized forms of CTA, have intensified immunological research in this emerging field of transplantation. Mitomycin C (MMC) is an alkylating agent that suppresses allogeneic T-cell responses. MMC-treated dendritic cells/PBMCs have been shown to induce donor-specific tolerance in solid organ allograft transplantations.

METHODS

Fully mismatched rats were used as hind limb donors [Lewis (RT1(1))] and recipients [Brown-Norway (RT1(n))]. Fifty-five allogeneic hind limb transplantations were accomplished in six groups. Group A (n = 10) received donor-derived MMC-treated PBMCs on transplantation day. Group B (n = 10) rats received no immunosuppression, group C (n = 10) received FK506 and prednisolon, group D consisted in isograft transplantation without immunosuppression, group E (n = 10) received non-treated PBMCs, and group F (n = 5) received PBS without any donor-derived cells. Rejection was assessed clinically and histologically.

RESULTS

In group A, the survival times of the allografts were prolonged to an average of 8.0 d. Rejection was significantly delayed compared with the averages of the corresponding control groups B, E, and F (5.5, 5.9, and 5.8 d). No rejection was seen in control groups C and D.

CONCLUSION

These results demonstrate that MMC-treated donor PBMCs significantly prolong allograft survival when administered systemically on the day of transplantation. However, the immunomodulatory effect is relatively modest with further research being required to clarify dose-effect relations, cell characteristics, and an optimized mechanism and timing for cell application.

Shock wave treatment in composite tissue allotransplantation

INTRODUCTION

Composite tissue allotransplantation is a newly emerged field of transplantation. Shock wave technology has already been used in the treatment of urologic and orthopedic disorders. Recent studies demonstrated a suppression of the early proinflammatory immune response.

METHODS

50 allogeneic hindlimb transplantations were performed on rats in 5 different groups. Group A (n = 10), (Lewis → Brown-Norway) received 500 impulses of extracorporeal shock wave. Groups B, C, D, and E served as control groups with group B (n = 10) receiving no immunosuppression, group C (n = 10) receiving FK506 and prednisolone, group D (n = 10) receiving no immunosuppression with isograft transplantations (Brown-Norway → Brown-Norway) and group E receiving 500 impulses of extracorporeal shock wave on the contralateral hindlimb.

RESULTS

Rejection of the allogeneic hindlimb occurred on average 7.12 days after transplantation in group A (extracorporeal shock wave). Rejection was significantly delayed compared to the control groups B (no immunosuppression) and E (contralateral hindlimb), where rejection of the allogeneic hindlimb occurred on average 5.49 and 5.6 days after transplantation (t test, P < .01). No rejection was seen in groups C and D.

CONCLUSIONS

For the first time, shock waves have been applied in a composite tissue allotransplantation model and resulted in a significant immunosuppressive effect. These promising first results have showed that shock wave treatment is clinically relevant in composite tissue allotransplantation and justify subsequent research to improve the experimental and clinical outcome.

[Solid-pseudo-papillary tumor of the pancreas (SPPT) as sonographic incidentaloma in the context of acute appendicitis]

OBJECTIVE

Review of the literature (Medline) based on a clinical case.

CASE

A twenty one year old lady presented with a one day history of acute right sided lower abdominal pain associated with leucocytosis and the clinical signs of an acute abdomen. Sonography showed fluid coincident with cocardal formation in the right lower abdomen. Incidentally a cystic formation in projection to the caudal pancreas was seen. A CT scan confirmed a cystic mass, 5 cm in diameter. An appendectomy was performed immediately after admission. After an interval of ten days an upper laparotomy leading to a left sided resection of the pancreas was performed. Histological findings showed a solid-pseudo-papillary tumor of the pancreas without any signs of metastatic spreading. Four years after the operation the patient is subjectively well and shows no signs of diabetes or of insufficiency of the exocrine pancreas nor of any recurrence. -- Characteristic findings in solid-pseudo-papillary pancreatic tumors (SPPT) are remarkable size at the time of diagnosis, low risk of malignancy, predominance in young female (10 female symbol : 1 male symbol, M = 27 a), association with oral anticonceptive drugs and mostly incidentally detection. Usually the definitive diagnosis is only found after complete radical resection which in 95 % of cases is curative.

CONCLUSION

Abdominal sonography should be performed very thoroughly in any diagnostic query even if, clinically, the diagnosis seems to be obvious.

[Scrotal abscess with inguinal lymph node swelling in an 86-year-old man]

HISTORY AND ADMISSION FINDINGS

An 86-year-old patient presented to our clinic with increasing redness and swelling of the right scrotum and inguinal lymphadenopathy. Five and a half years before admission carcinoma of the bladder (pT1,G2) had been diagnosed and was treated with several transurethral endoscopic resections as well as repeated instillations of Bacille Calmette-Guérin (BCG) into the bladder.

INVESTIGATIONS

Orchiectomy on the right side was performed. Histological analysis revealed a granulomatous inflammation consistent with a mycobacteriosis. Mycobacterium bovis BCG could be isolated from several sputum and urine specimens of the patient.

DIAGNOSIS, TREATMENT AND COURSE

Tuberculostatic therapy was started soon after surgery. After seven weeks of treatment no more mycobacteria could be detected in sputum and urine control specimens. At a follow up after twelve months there was no evidence of recurrent disease.

CONCLUSION

We describe the late manifestation of a BCG infection including the lungs and the urogenital tract. This is a rare complication with potentially serious consequences and requires rapid diagnosis and urgent treatment by a multidisciplinary team.

Comparison of Six Methods for the Assessment of Ischemia-Reperfusion Injury in Skeletal Muscle following Composite Tissue Allotransplantation

Ischemia/reperfusion (I/R) injury is one of the factors determining tissue survival in replantation and transplantation surgery. However, more than 20 methods have been used to evaluate I/R injury in muscle. The aim of this study was to examine I/R injury in muscle tissue in a model of composite tissue allotransplantation (rat hindlimb transplantation), based on the analyses of six parameters: nitroblue tetrazolium staining (NBT); histology of the anterior tibial and extensor digitorum muscle; wet-to-dry weight ratio; serum potassium; and serum creatine kinase (CK)), in order to identify the most practicable and reliable outcome parameter. Results demonstrated that NBT staining and the wet/dry weight ratio are reliable tools for outcome measurement. The wet/dry weight ratio is the easiest to perform and the authors consider it to be useful for screening purposes. Histologic assessment shows areas of necrosis, but is not a reliable method for semi-quantitative evaluation. Serum potassium and CK levels were higher following transplantation, but they cannot be recommended for assessment purposes, as no significant correlation with other parameters was seen. These findings help further researchers in their selection of reliable outcome parameters to measure I/R injury in skeletal muscle.

[Diagnosis of a high-grade B-cell lymphoma of the small bowel by means of wireless capsule endoscopy]

Wireless capsule endoscopy is a new diagnostic procedure to detect diseases of the small bowel, in particular in patients with obscure gastrointestinal bleeding. We report on a 76-year-old patient who presented at our hospital with signs of gastrointestinal bleeding and hypochromic anaemia. Bidirectional endoscopy, push enteroscopy, angiography as well as small bowel barium enema rendered no pathologic findings. Wireless capsule endoscopy demonstrated a polypous space in the cantral area of the small bowel. Subsequent intraoperative endoscopy revealed a subtotal stenosing tumour of the upper jejunum which was resected. Based on the histology a high-grade B-Cell lymphoma was diagnosed. The postoperative staging examinations did not indicate any further extranodal involvement.

The effect of knee brace on coordination and neuronal leg muscle control: an early postoperative functional study in anterior cruciate ligament reconstructed patients

Two studies were carried out after anterior cruciate ligament (ACL) reconstruction to determine the effect of a knee brace on coordination (test 1) and electromyographic muscle activity in drop jumps (test 2). Test 1 studied 25 patients with ACL reconstruction under three test conditions (one-leg static, two-legged static, two-legged dynamic) compared with a control (n=30). The results showed highly significant improvements in all braced conditions. In test 2 ten patients with ACL reconstruction and ten healthy subjects performed a two-legged drop-jump; this was repeated 15 times and again 15 times with a knee brace worn on the reconstructed limb. Changes in electromyographically determined muscle activity (vastus medialis, vastus lateralis, biceps femoris, gastrocnemius) were observed, but they were significant in only few cases because of high variability. Drop-jumps with knee brace improved jumping height, increased the maximum knee angle in the ground contact phase, and reduced the maximum knee angle in the landing phase. Patients thus develop an increased confidence in the stability of their knees. We conclude that the benefits of the knee brace are due to the mechanical action, an enhanced coordination, and a psychological effect.

[Effects of knee braces on sensorimotor capabilities of patients with ACL reconstruction]

In 25 test persons with Anterior-Cruciate-Ligament (ACL)-Operation the sensomotory capabilities of the affected and the unaffected side were examined by KAT 2000 (BREG Inc., Vista, C.A., USA) with and without knee-brace (Hypex knee-brace/Fa. Aircast-Europa GmbH). The results were compared with those of a control group. In all cases of test variations (both leg-static/both leg-dynamic/one leg-static) there were significant differences between testing with and without knee brace. In the one leg-static test there was an improvement of 30% (p < 0.01), in the both leg-static test an improvement of 24% (p < 0.01). The both leg-dynamic showed a similar result (23.8%; p < 0.01). These noticed adaptations may be mediated by improvements of proprioceptive and exteroceptive capabilities and a positive impact on the anticipative control of behavior. The results of the control group differ in only a few cases from the results in the group of patients. This may be judged as indicator for the variety of sensomotory capabilities in the general population.

Pseudotumor of the sigmoid mimicking carcinoma

On colonoscopy, the macroscopic aspect of a lesion is an important criterion for the differential diagnosis. We present a case of an apparently malignant tumor in the sigmoid. Histological investigation failed to support the diagnosis made from the gross appearance seen on colonoscopy. After surgical resection, the lesion turned out to be a reactive pseudotumor caused by fibroepithelial hyperplasia related to a severe diverticulitis with perforation of the intestinal wall.

[Coordination training after anterior cruciate ligament surgery]

Many studies have shown that ACL-surgery leads to a decrease of proprioception abilities. In spite of the resulting high importance of coordinative exercise, there is nothing like a phase specific concept for coordinative training after ACL-operations going along with rehabilitation. Following a model, including all coordinative abilities, and a current after-care concept of ACL-surgery, the presented method is based on different categories of coordinative demands.

Cumulative pregnancy rates and pregnancy outcome after in-vitro fertilization: > 5000 cycles at one centre

Cumulative pregnancy rates and pregnancy outcome analysis are useful methods for advising an infertile couple of the probability of in-vitro fertilization (IVF) success. All 5209 IVF cycles in 2391 couples at University Hospital, London, Ontario, Canada, over 10 years were studied. Cumulative pregnancy rates were estimated using life table analysis. The Cox proportional hazards model was used to estimate the influence of covariates. Oocyte retrieval and embryo transfer were achieved in 84 and 64% of cycles initiated respectively. There were 644 intra-uterine and 24 ectopic pregnancies (13%/cycle initiated, 15%/oocyte retrieval and 20%/embryo transfer). Cumulative pregnancy rates following six cycles were: tubal 55%, idiopathic 65%, endometriosis 60%, multifactorial 63% and male 40%. There were 68 spontaneous abortions (10.6%) and three induced abortions for congenital anomalies. The multiple gestation rate was 22%. Caesarean section and preterm delivery rates were 35 and 20% respectively, due in part to the high proportion of multiple gestations. Of 15 deliveries which resulted in stillbirths and/or neonatal deaths, 12 were multiple gestations; 18 pregnancies (3.3%) were complicated by congenital malformations. No increases in congenital malformations or spontaneous abortions were identified. Cumulative pregnancy rates were lower in cases of male infertility. Success rates did not decline with successive IVF cycles. IVF is an evolving infertility treatment.

Performance demand and sexual arousal in women

Up to now, no experimental studies have inquired into the possible role of performance demand in female sexuality. The objective of this study is to investigate the effects of performance demand on sexual arousal in functional women, using explicit instructions. Forty-eight female subjects were asked to respond with maximum sexual arousal within 2 min, both during sexual fantasy and while watching an erotic film excerpt. Photoplethysmographic pulse amplitude was continuously recorded and self-report ratings of sexual arousal and affective reactions were collected after each erotic condition. Subjects were also instructed to continuously indicate their subjective sexual excitement during the conditions by means of a lever. Performance demand resulted in higher genital responses and was most effective in the fantasy condition. These results corroborate the findings for functional men. Although for both measures of subjective experience of sexual arousal performance demand yielded significantly higher ratings, this was conditioned by the order in which subjects were exposed to conditions. Women who masturbate with a mean frequency of 4 times a month reported higher subjective sexual arousal during performance demand conditions as compared with women who masturbate substantially more or who do not masturbate. Genital vasocogestion did not differ between masturbation-groups. Continuous subjective monitoring yielded lower correlations with vasocongestion than discrete ratings of sexual arousal and appears to be more sensitive to order effects.