Healing effect of warfarin in the course of cerulein-induced acute pancreatitis in rats

Acute pancreatitis (AP) is the most common gastrointestinal disease leading to hospitalizations and unexpected deaths. The development of AP leads to damage of the pancreatic microcirculation with a cascade of subsequent events resulting, among others, in coagulopathy. Previous research showed that anticoagulants can be important therapeutic agents. Heparin and acenocoumarol can alleviate the course of AP, as well as accelerate healing and post-inflammatory regeneration of the pancreas. The aim of this study was to determine whether warfarin, a drug with more stable effects than acenocoumarol, affects the healing and regeneration of the pancreas in the cerulein-induced AP. AP was evoked in Wistar male rats by intraperitoneal administration of cerulein. The first dose of warfarin (45, 90 or 180 μg/kg) was administered 24 hours after the first dose of cerulein and the doses of warfarin were repeated once a day in subsequent 10 days. The severity of AP was assessed immediately after the last dose of cerulein, as well as at days 1, 2, 3, 5, and 10 after AP induction. Treatment with warfarin dose-dependently increased international normalized ratio (INR) and attenuated the severity of pancreatitis in histological examination and accelerated pancreatic recovery. These effects were accompanied with a faster reduction in the AP-evoked increase in serum activity of amylase and lipase, the serum concentration of pro-inflammatory interleukin-1β, and the plasma level of D-Dimer. In addition, treatment with warfarin decreased pancreatic weight (an index of pancreatic edema) and improved pancreatic blood flow in rats with AP. The therapeutic effect was particularly pronounced after the administration of warfarin at a dose of 90 μg/kg. We conclude that treatment with warfarin accelerated regeneration of the pancreas and recovery in the course of cerulein-induced mild-edematous acute pancreatitis.

Involvement of cyclooxygenase-1 and cyclooxygenase-2 activity in the therapeutic effect of ghrelin in the course of ethanol-induced gastric ulcers in rats

Previous studies have shown that treatment with ghrelin exhibits protective and therapeutic effects in the gut. Aim of our present investigation was to examine the influence of ghrelin administration on the healing of ethanol-induced gastric ulcers and determine the role of cyclooxygenase-1 and cyclooxygenase-2 in this effect. Our studies were performed on male Wistar rats. Gastric ulcers were induced by intragastric administration of 75% ethanol. Ghrelin alone or in combination with cyclooxygenase inhibitors was administered twice, 1 and 13 hours after ethanol application. Cyclooxygenase-1 (COX-1) inhibitor (SC-560, 10 mg/kg/dose) or COX-2 inhibitor (celecoxib, 10 mg/kg/dose) were given 30 min prior to ghrelin. Twelve or 24 hours after administration of ethanol, rats were anesthetized and experiments were terminated. The study revealed that administration of ethanol induced gastric ulcers in all animals and this effect was accompanied by the reduction in gastric blood flow and mucosal DNA synthesis. Moreover induction of gastric ulcer by ethanol significantly increased mucosal expression of mRNA for COX-2, IL-1β and TNF-α. Treatment with ghrelin significantly accelerated gastric ulcer healing. Therapeutic effect of ghrelin was associated with significant reversion of the ulcer-evoked decrease in mucosal blood flow and DNA synthesis. Ghrelin administration also caused the reduction in mucosal expression of mRNA for IL-1β and TNF-α. Addition of SC-560 slightly reduced the therapeutic effect of ghrelin in the healing of ethanol-induced ulcer and the ulcer area in rats treated SC-560 plus ghrelin was significantly smaller than that observed in rats treated with saline or SC-560 alone. Pretreatment with celecoxib, a COX-2 inhibitor, abolished therapeutic effect of ghrelin. We concluded that treatment with ghrelin increases healing rate of gastric ulcers evoked by ethanol and this effect is related to improvement in mucosal blood flow, an increase in mucosal cell proliferation, and reduction in mucosal expression of proinflammatory cytokines. Ghrelin is able to reverse a deleterious effect of COX-1 inhibitor on healing of ethanol-induced gastric ulcers. Activity of COX-2 is necessary for the therapeutic effect of ghrelin in healing of ethanol-induced gastric ulcers.

Itraconazole is effective in the treatment of tinea capitis caused by Microsporum canis

Tinea capitis is a relatively common superficial fungal infection in children which requires oral antifungal therapy. In a prospective, open study over 24 weeks, itraconazole 5 mg/kg/day, given as capsules or as an oral suspension for a period of 2-12 weeks, was used to treat children 1-12 years of age who had M. canis tinea capitis. Children with mycologic evidence of M. canis tinea capitis were entered into the study and asked to return at week 2 and then every 2 weeks thereafter until cured, with a maximum of 12 weeks of active treatment. At each visit the scalp was sampled and the material processed for light microscopy and culture examination. An extra 2 weeks of itraconazole was prescribed if the mycology from the sample obtained on the previous visit indicated that there was still presence of the organism. Patients were administered either 2, 4, 6, 8, 10, or 12 weeks of treatment. The final follow-up visit was at 12 weeks from the cessation of drug therapy. Laboratory blood testing was performed only if indicated by history, examination, or the development of side effects. There were 107 patients (49 boys, 58 girls; mean +/- standard error =5.6 +/- 0.2 years). Thirteen of the 107 children were given the oral suspension. At week 12 from the cessation of treatment there was complete (clinical and mycologic) cure in all 107 children. Increasing age of the patient correlated significantly with the length of itraconazole capsule therapy (p=0.03). The duration of itraconazole treatment also correlated significantly with the severity of tinea capitis at baseline (p=0.02). Adverse effects were observed in 5 children receiving itraconazole capsules (n=94). These were regarded as being possibly or probably due to the drug in two children (mild transient stomach ache in one and moderate diarrhea in one). The child with diarrhea stopped therapy at week 4 with complete resolution of symptoms. One of 13 children receiving the oral suspension had mild, transient diarrhea. There were no drop-outs in this group. Laboratory testing was not required in any patient. Compliance was very good in the patient group. Itraconazole 5 mg/kg/day given either as a capsule or an oral suspension for 4-8 weeks is effective and safe in the treatment of tinea capitis caused by M. canis.

[Molecular biological methods and their consequences in taxonomy and diagnosis of dermatophytes]

Trichophyton rubrum, T. mentagrophytes, T. verrucosum, Microsporum canis, M. gypseum and Epidermophyton flocoosum represent the cause of human dermatomycoses isolated most often at the University Hospital of Dermatology in Graz, Austria, between 1991 and 1998. So far, identification was mainly based on the cultivation of fungal isolates on special media as well as on the analysis of their microscopic characters. Restriction enzyme length polymorphisms (RFLPs) were now used to identify these human fungal parasites. For this purpose, internal transcribed spacers (ITS) which are located between ribosomal RNA genes have been amplified by using PCR and have afterwards been used to generate species specific RFLP patterns. By this method, a fast and reliable identification of these species was made possible. Nucleotide sequence data of this region not needed for identification have been worked out to show RFLPs in more detail.

Case report. Atypical cutaneous pseudallescheriosis refractory to antifungal agents

We report on a 65-year-old male heart transplant recipient who was otherwise in good condition. The patient was immunocompromised secondarily due to cyclosporin, prednisolone and azathioprine when widespread pustular skin lesions with erythematous margins subsequently developed on his left forearm. There was no history of trauma or septic temperature. Bacterial cultures were sterile and the results of native and cultural investigation studies were negative. A biopsy specimen of the lesion demonstrated hyalohyphomycosis with numerous septate hyphae within granulomas throughout the dermis. Subcutaneous tissues were not involved. Culture plates inoculated with pus and skin from the punch biopsy showed growth of a mould yielding Pseudallescheria boydii. Sensitivity testing was performed with miconazole, ketoconazole and itraconazole showing the best in vitro activity against P. boydii. In spite of treatment with itraconazole, the erythema and pustules continued to spread and therapy was changed to intravenous miconazole. Due to ongoing progression after 3 months of antifungal therapy surgical debridement was required. After 2 years of follow up, he had no recurrence.

Randomized double-blind comparison of short-term itraconazole and terbinafine therapy for toenail onychomycosis

Previous studies evaluating short-term itraconazole and terbinafine therapy for onychomycosis have varied in protocol and size; this double-blind study enabled a large-scale, standardized, direct comparison. Patients with toenail onychomycosis were randomized to itraconazole 200 mg daily (n = 146) or terbinafine 250 mg daily (n = 146) for 12 weeks, with a 36-week follow-up. Mycological cure rates at the follow-up end-point were significantly equivalent (61% with itraconazole vs. 67% with terbinafine). A similar proportion of patients in each group experienced adverse events during treatment (itraconazole, 22%; terbinafine, 23%). More patients receiving terbinafine stopped treatment permanently because of treatment-related adverse events (8% vs. 1%).

An intermittent itraconazole 1-week dosing regimen for the treatment of toenail onychomycosis in dermatological practice

The efficacy and safety of an intermittent itraconazole dosing regimen was investigated in 354 patients with toenail onychomycosis, from 98 dermatology centres. Patients received itraconazole 400 mg daily for 1 week per month for 3 months. If the nail of the big toe was completely involved, a fourth treatment cycle was administered. Because of the short-term nature of the dosing regimen, renal and liver function tests were not compulsory. Cure rates were influenced by proximal nail involvement, particularly in the big toenails. At the end of month 10, clinical cure (complete clearance or clearance with a few small residual lesions) was achieved in 64% of patients with proximal nail involvement in the big toenails, in 77% of patients with proximal nail involvement in other toenails and in 87% of patients without proximal nail involvement; mycological cure was achieved in 77% of 197 patients examined. Fifty-nine patients (17%) reported adverse events: mainly headache, fatigue or minor gastrointestinal problems; only nine patients (3%) stopped treatment because of adverse events. Response rates were similar to those achieved with 3 months of continuous therapy with itraconazole or terbinafine but intermittent therapy is probably safer and is considerably cheaper than continuous itraconazole treatment.

Microsporum canis infections in children: results of a new oral antifungal therapy

Clinical and laboratory data from 22 children with tinea corporis and tinea capitis caused by Microsporum canis (10 tinea corporis, 12 tinea capitis), confirmed by microscopic examination and culture and partly pretreated with griseofulvin or terbinafine, are summarized. The children were treated consecutively with itraconazole in our clinic during 1994/95. The age of the children ranged between 4 and 13 years, with girls being affected much more frequently than boys. Oral, individually adapted, high-dose treatment of 5 mg itraconazole per kg body weight proved to be successful. In all 22 children, although pretreatment with griseofulvin or terbinafine was partly unsuccessful, fungal infections could be cured clinically and also were culture negative at control examinations. In 10 children with tinea corporis treatment was performed only for 4-14 (middle 11) days. In the children with tinea capitis itraconazole treatment was continued for 3-11 weeks. Among the six children without pretreatment, itraconazole solution was administered for 4-11 weeks (average 7.5 weeks). Of the patients in whom pretreatment was unsuccessful, four with griseofulvin and two with terbinafine, the duration of the subsequent oral treatment with itraconazole solution was 3-5 weeks (average 3.6 weeks). The drug seemed to be well tolerated-no significant side-effects occurred, with the exception of possible minor gastrointestinal disturbances in two patients. Laboratory values remained within normal limits.

[Increasing frequency of onychomycoses--is there a change in the spectrum of infectious agents?]

The recently developed antifungal drugs are not equally effective against the fungi causing onychomycoses: dermatophytes, yeasts and non-dermatophyte filamentous fungi (NDFF). Therapeutic failures may be due to the use of antifungal agents not primarily effective against the particular fungus. Considering the high costs of systemic antifungal therapy, it is necessary to know the frequency distribution of the different fungi causing onychomycosis. In a retrospective study, we have analysed results of fungal cultures performed between 1974 and 1994. In particular, we have compared the time periods 1982-1984 and 1992-1994. Culture results from toe nails showed in 1982-1984 the following fungal pattern (n = 833): dermatophytes 61%, yeasts 15%, NDFF 17%, mixed infections 7%. Results from 1992-1994 (n = 930) revealed an increase of dermatophytes 86% at the expense of yeasts (7%), NDFF (3%) and mixed infections (3%). In finger nails, we found a more pronounced change of infectious agents from 1982-1984 (n = 509; dermatophytes 62%, yeasts 29%, NDFF 1%, mixed infections 7%) to 1992-1994 (n = 348; dermatophytes 45%, yeasts 52%, NDFF 0.3%, mixed infections 3%). The high rate of yeast isolations (52%) from finger nails in 1992-1994 is striking. The role of yeast isolates for pathogenesis of onychomycosis remains to be elucidated. Differentiation between colonisation and infection would be necessary. The effectiveness of oral antifungal drugs against dermatophytic nail infections is well documented. The effectiveness against yeasts and NDFF, however, has not been studied thoroughly, but is not supposed to be equal with the different antifungal agents. Determination of the infectious agents in onychomycoses is recommended in order to avoid therapeutic failures.

Treatment of invasive pulmonary aspergillosis in severely neutropenic children with malignant disorders using liposomal amphotericin B (AmBisome), granulocyte colony-stimulating factor, and surgery: report of five cases

Five children with malignancies developed invasive pulmonary aspergillosis during chemotherapy-induced neutropenia. All patients were treated with liposomal amphotericin B and human recombinant granulocyte colony-stimulating factor. Two patients did not recover from bone marrow aplasia and died from organ-infiltrating fungal invasion. Two patients who recovered from bone marrow aplasia survived after surgery of the pulmonary lesions. The fifth patient had a complete resolution of invasive pulmonary aspergillosis after neutrophil recovery without surgical intervention. We conclude that not only the antifungal treatment but also the recovery of granulocytes are important in localizing invasive forms of Aspergillus infections in patients with profound immunosuppression.

Arthritis without grains caused by Pseudallescheria boydii

Severe infection of the knee joint by Pseudallescheria boydii in a 23-year-old female resulted in complete destruction of the cartilaginous surface. The possibility of entry of the fungus through mild abrasions of unperforated skin is discussed. The clinical appearance is compared with that of Scedosporium prolificans. Antimycotic miconazole-itraconazole treatment, applied during a period of 4 months, was successful; no side-effects were noted.

Liposomal amphotericin-B (AmBisome) for treatment of cutaneous widespread candidosis in an infant with methylmalonic acidaemia

In a 10-week-old infant with vitamin B12-unresponsive methylmalonic acidaemia, cutaneous candidosis (Candida albicans) progressed rapidly despite topical antifungal treatment. After 1 week of intravenous therapy with liposomal amphotericin-B (AmBisome) the dermatitis disappeared completely and blood cultures were sterile. No side-effects were observed. This is one of the first experiences in the treatment of infants with this new antifungal agent.

Granulomatous panniculitis caused by Candida albicans: a case presenting with multiple leg ulcers

A 61-year-old woman had rapidly enlarging ulcers on both legs and three draining subcutaneous nodules on the left thigh. Findings of skin biopsy specimens revealed granulomatous panniculitis with a large number of blastospores and pseudohyphae. Candida albicans was cultured from the ulcers, the nodules, the mouth, the esophagus and gastric juice, feces, and urine. The ulcers healed after 5 months of therapy with itraconazole. Predisposing factors were diabetes mellitus, dysfunction of the hypothalamic-pituitary system, hypochromic anemia, and prior treatment with a broad-spectrum antibiotic. In contrast to three other reported cases of Candida panniculitis, our patient had not undergone immunosuppressive therapy.

Vaginal yeast colonization and promiscuity. A study of 197 prostitutes

In order to study the role of promiscuity in yeast colonization of the vagina we examined vaginal smears of 197 prostitutes. Forty-two (21%) showed yeast infection on culture, and Candida albicans was isolated in 93% of these cases. This rate is comparable to the rates in reports of large series of non-promiscuous women in the literature and does not suggest that promiscuity alone is a predisposing factor for vaginal yeast carriage. The rate of Candida infections was approximately the same in prostitutes taking oral contraceptives as in those not taking the pill (22 and 21%, respectively; P > 0.05). The prevalence of vaginal yeast colonization, however, was significantly higher in prostitutes under the age of 31 (30%) as compared with those over 30 (10%; P < 0.002), thus suggesting that women in the third decade of life are more prone to vaginal Candida infections than older age groups.

[Ecology, epidemiology and clinical symptomatology of Microsporum gypseum infections]

Microsporum gypseum is a geophilic fungus with a world-wide distribution, which is considered to be involved in keratin degradation in the soil. Since 1977, mycotic skin infections due to M. gypseum have been repeatedly observed in the Department of Dermatology in Graz, Austria. A predominance of females was evident. As a rare event, M. gypseum has also been cultivated from onychomycotic lesions.

[Retrospective study of mycotic and other colpitis pathogens]

We had 170 female patients with presenting symptoms of vaginal itching, dysuria, dyspareunia, burning and vaginal discharge. We performed 200 times vaginal microbial exploration on the said 170 patients, with the repetition of the procedure on 30 out of these 200 patients for the second time. We had a positive result for vulvovaginal candidosis on 60 occasions. These positive results for yeast infection can be related to the incidence of other microbial infections such as mycoplasma-, ureaplasma-, trichomonas-, gonococcal- and chlamydia infections.

[General and advanced aspects of treatment of vulvovaginal mycosis]

In treating candida vulvovaginitis attention has to be paid to the infection itself as well as to the importance of favouring conditions. With acute or non-recurring candida vulvovaginitis topical antimycotics have proved to be successful. In case of unsuccessful therapy or recurrence or chronicity the application of an intermitting topical or oral therapy is advised for an extended period of time, during or before the general symptoms, mainly premenstrually, occur. Today, an alternative to local therapy the short term application of modern oral azoles, Ketoconazole, Itraconazole, Fluconazole is suggested since no side effects are to be expected for short-time treatment. Thus adhesion-inhibitors might become a new possibility in therapy.

[Unusual clinical manifestations caused by Trichophyton rubrum--atypical "rubrophytoses"]

Infection with trichophyton rubrum - now the most common anthropophilic dermatophyte - usually follows a chronic hypophlegmatic clinical course and is mostly confined to superficial keratin structures. In addition to the possibility of subcutaneous involvement, the following atypical clinical manifestations are emphasized: psoriasiform pustulating trichophytia, trichophytosis resembling Sweet syndrome, trichophytosis mimicking pseudolymphoma and impetiginized herpetiform trichophytosis. In three out of five cases definitive diagnosis was only possible by means of conventional histological examination. The cultivation of Trichophyton rubrum from preexisting mycotic lesions of patients with atypical dermatophytoses supports the possible role of self-inoculation.

[Atypical erythrokeratodermia with deafness, keratitis and double mycotic infection]

We report on a male patient suffering from a congenital ichthyosiform dermatosis, whose family history offered no clue to the diagnosis. The skin lesions were mainly localized on the trunk, hands, elbows, and knees. During the last few years, the cutaneous lesions had slowly changed for the worse and the following additional symptoms had developed: keratitis, deafness, diffuse alopecia, dysarthria, and ataxic abasia. According to the clinical features, we established the diagnosis of KID syndrome (keratitis, ichthyosis, deafness). Although the skin lesions of our patient clinically and histologically belong to the group of atypical erythrokeratodermias, the term "KID syndrome" recently described by Skinner represents an useful, unifying clinical term.

[Mycologic analyses of house dust in patients with mycotic infections of the paranasal sinuses and in healthy probands]

Dust samples from 30 patients suffering from an aspergillus sinusitis and from 20 healthy persons were analysed for moulds as a possible cause of mycotic sinusitis. Questionnaires were also distributed to assess the ecological environment of the patients. Mycological analyses of the dust samples showed no statistical difference in the presence of moulds, especially those of Aspergillus fumigatus and Aspergillus niger. Both moulds were found to roughly the same extent in 75%-95% of subjects. The questionnaires showed that most patients were exposed to moulds during work as well as in their spare time. The case history always showed a chronic sinusitis. Thus it appears that the development of a mycotic sinusitis is caused by many factors.