[Topiramate and acute myopia with angle-closure glaucoma: case report and literature review]

Topiramate, an antiepileptic medication, has been widely used since its recent indication for migraine prophylaxis. We report a case of bilateral angle-closure glaucoma and acute myopia in a 44-year-old woman on oral topiramate therapy initiation for migraine prophylaxis. Intraocular pressure was 31 mmHg right and 32 mmHg left, myopia was 4 diopters. Topiramate was interrupted and general and local hypotensive treatment begun and rapidly stopped after improvement. Iridotomy was also performed. Fifteen days later, complete resolution was observed on ophthalmologic examination: anterior chambers were deep, myopia fully regressed, intraocular pressure returned to normal, and the visual field was complete. This new case prompts discussion on current reports in the literature and French drug monitoring database cases in this context.

Iatrogenic Cushing's syndrome in an HIV-infected patient treated with inhaled corticosteroids (fluticasone propionate) and low dose ritonavir enhanced PI containing regimen

In HIV-infected patients, ritonavir, a potent cytochrome P450 inhibitor, is increasingly used to improve the pharmacokinetic profile of the associated protease inhibitor. HIV physicians are often faced with potential drug-drug interaction while treating associated diseases. We report the case of an HIV-infected patient with clinical features of Cushing's syndrome due to the interaction of low dose ritonavir with inhaled fluticasone propionate (FP). Safety of life-long CYP450 inhibition has still to be demonstrated.

[Anti-TNF alpha monoclonal antibodies (infliximab) and tuberculosis: apropos of 3 cases]

INTRODUCTION

Monoclonal TNF alpha antibodies are a new treatment of severe rheumatoid arthritis. One of the possible side effects is the appearance of opportunistic infections. We report here on three cases of disseminated tuberculosis observed in patients undergoing treatment with infliximab.

EXEGESIS

A 45-year-old woman, treated with infliximab, was hospitalised after five infusions for fever and dyspnoea. The exams showed pulmonary and peritoneal tuberculosis. The second case is a 75-year-old woman whose symptoms were fever, cough and cervical adenopathy after three infliximab infusions. Diagnosis was disseminated tuberculosis. The third case is a 59-year-old man who was hospitalised for an infectious syndrome with dyspnoea, after two infliximab infusions. We discovered pulmonary tuberculosis.

CONCLUSION

These three cases added to the 68 cases of tuberculosis registered with the treatment of infliximab. This confirms the risk of severe opportunist infectious side effects. TNF alpha is a cytokine which has anti-infectious properties. These tuberculoses are severe and generalized. It is recommended to search for an active or latent tuberculosis before beginning treatment with infliximab, and to check these patients frequently.

Nitroso-urea-cisplatin-based chemotherapy associated with valproate: increase of haematologic toxicity

BACKGROUND

The incidence of haematologic toxicity of valproate (VPA) ranges from 1% to 32% and consists mainly of asymptomatic, dose-dependent thrombopenia. We describe a potentiation of haematologic side-effects of nitroso-urea (NU) when prescribed in association with VPA.

PATIENTS AND METHODS

We followed a cohort of 70 patients (58 men, 22 women, mean age: 56 years, range 20-75 years). Patients with high-grade gliomas were treated with up-front chemotherapy regimen consisting of fotemustine (d3: 100 mg/m2), cisplatin (d1-3: 33 mg/m2) and etoposide (d1-3: 75 mg/m2) followed by whole brain radiotherapy at progression. Sixty patients required anti-epileptic drugs (AED) for either a single, well-documented epileptic seizure, or immediatly initiated after neurosurgical procedures. AED included VPA (35 of 60), phenobarbital (PB) (17 of 60), carbamazepine (CBZ) (2 of 60) and phenytoin (PHT) (3 of 60). Two patients had both PB and CBZ and one PB and PHT.

RESULTS

Haematologic toxicity (grade 3-4 thrombopenia, neutropenia or both) was observed in 37 of 70 (52.85%) patients. Among them 24 (65%) had VPA. Group C were patients treated with fotemustine alone with or without VPA (23 patients).

CONCLUSION

When prescribed in association with a fotemustine-cisplatin regimen, VPA treatment results in a three-fold higher incidence of reversible thrombopenia, neutropenia or both. Haematologic side-effects decrease after AED modification during the continued chemotherapy. This adverse event should be managed with caution.

[Drug-induced oral ulcerations]

Different side effects of drugs have been described in the oral cavity, including oral ulcerations. Direct contact between drugs and oral mucosa may induce chemical burn or local hypersensitivity. Less frequently, these drug-induced oral ulcerations are part of a complex reaction with cutaneous or systemic manifestations. Sometimes, one or more oral ulcerations appear as the main side-effect of a drug, or exceptionally as solitary lesions. Solitary oral ulcerations usually appear after few weeks of treatment. In most of cases, these lesions resist to conventional treatments, with a rapid healing following the suppression of the responsible drug. This diagnosis is usually difficult, particularly with patients receiving multiple drug therapy. Besides, special attention must be paid to new drugs. Oral ulcerations following symptoms of burning mouth, metallic taste, dysgueusia or agueusia are strongly suggestive of a pharmacological origin. Most of the molecules able to induce solitary oral ulcerations are commonly prescribed in a) rheumatology: NSAI (diclofenac, flurbiprofen, indomethacin, naproxen), long-term rheumatoid arthritis therapy (azathioprine, methotrexate, penicillamine, gold compounds, tiopronin); b) cardiology: angiotensin-converting-enzyme inhibitors (captopril, enalapril), angiotensin 2-receptor antagonist (losartan), anti-angorous (nicorandil), c) psychiatry: antidepressants (fluoxetine, lithium), d) AIDS therapy (foscarnet, zalcitabine).

[Pharmacovigilance in practice]

Directed by the French Agency for the Safety of Health Products (AFSSAPS), the French pharmacovigilance system is in charge of the surveillance of drugs after they have been provided by AFSSAPS with official marketing authorizations that are in France either 'new drug approval certificates' (AMM) or 'temporary utilization authorizations' (ATU). About 3,700 pharmaceutical products are concerned which are used either for treatment (all drugs and remedies, inclusive plasma-derived blood products), prevention (vaccines, oral contraception), diagnosis (contrast products, ...), or to modify a physiologic function (general or local anesthetics). At the national level, the main actors of the system are AFSSAPS and its National Commission, the 31 Regional Centers of Pharmacovigilance, all the health professionnals, and the pharmaceutical laboratories. Health professionnals are held to notify any suspected serious or unexpected adverse effects as quickly as possible. The analysis of data collected by the national report bank permits alerts and inquiries about drug safety. Furthermore regional centers of pharmacovigilance are responsible for drug information. The French pharmacovigilance system works in cooperation with the European Agency for the Evaluation of Medicinal Products.

[Visceral leishmaniasis associated with Wegener disease. Use of lipid complex amphotericin B and liposomal amphotericin B]

BACKGROUND

Leishmaniasis in a patient with Wegenerís disease raises the problem of amphotericin toxicity further compromising the pre-existing renal disorder.

CASE REPORT

An anemic patient treated for Wegenerís disease developed visceral leishmaniasis. This renal failure patient was treated with lipid complex amphotericin B and liposomal amphotericin B. We report outcome at 10 months follow-up.

DISCUSSION

The new formulations of amphotericin B allow effective treatment of visceral leishmaniasis in renal failure patients. Long-lasting results are probably favored by the interruption of immuno-suppressive therapy.

Acute hepatitis, autoimmune hemolytic anemia, and erythroblastocytopenia induced by ceftriaxone

An 80-yr-old man developed acute hepatitis shortly after ingesting oral ceftriaxone. Although the transaminases gradually returned to baseline after withholding the beta lactam antibiotic, there was a gradual increase in serum bilirubin and a decrease in hemoglobin concentration caused by an autoimmune hemolytic anemia and erythroblastocytopenia. These responded to systemic steroids and immunoglobulins. Despite the widespread use of these agents this triad of side effects has not previously been reported in connection with beta lactam antibiotics.

Pancreatitis induced by codeine: a case report with positive rechallenge

A woman who developed acute pancreatitis following ingestion of low dose codeine, with positive rechallenge, is described. As this is the first case report of pancreatitis being induced solely by codeine, this side effect must be rare in view of the widespread consumption of this drug.

[Public health education integrated in hospital. An internship proposal, "Medical information and pharmacology"]

According to a recent circular reforming french medical studies, we propose a teaching of medical information and pharmacology in situ within hospital instructions. Students could acquire an investigation methodology on the medicine economy. It will cover in four sessions the succeeding stages of medical information processing and be subject to an assessment: case studies and appreciation on student's, instruction record. By combining public health teaching with clinical practice, our project promotes its development in contact with other learnings and activities such as clinical research.

[Risk related to withdrawal from non-psychotropic drugs]

A review of the available literature concerning sudden withdrawal of drugs shows that withdrawal syndrome have occurred with centrally antihypertensive drugs, beta-blockers on anginal patients, antiparkinsonian drugs and glucocorticoids. Because of a lack of controlled trials led among a large number of individuals, the correct frequency of this withdrawal syndrome is unknown. In most patients, it's hard to distinguish a return to a previous state from an overshoot phenomenon. In that way, gradual and supervised withdrawal of these agents should prevent the complication of sudden cessation of these therapy.

[Drug-induced benign intracranial hypertension. Apropos of a case with amphotericin B. Review of the literature]

Benign intracranial hypertension (BICH) is a rare adverse event. We report the case of a 31-year-old female drug addict who had been seropositive for HIV since 1987. She had stage IV C1 AIDS, and was receiving intravenous amphotericin B for generalized cryptococcosis with no neuromeningeal involvement. She developed BICH that regressed when the antifungal drug was withdrawn and treatment for cerebral edema was started. BICH is a clinical entity involving intracranial hypertension with no focal neurological signs or detectable intracranial lesion. The manifestations include headache, transitory or permanent visual disturbances (diplopia, loss of visual acuity) and the perception of intracranial noise. The cerebrospinal fluid is under increased pressure but the composition is normal. The eye fundus examination shows papillary edema, and the neuroradiological workup is normal. BICH can only be diagnosed once an expansive intracranial process, neuromeningeal infection, and non-communicative hydrocephalus have been ruled out. In the majority of cases, no etiology is found. Such cases of idiopathic BICH usually occur in overweight young women, although drugs can be implicated. Amphotericin B has not previously been held responsible for BICH. On the basis of this observation, we present a review of the literature.

[Comparative study of data banks on drug interactions]

Authors have listed 9 criteria for testing scientific quality of computerized drug-interactions data banks. Pair of drugs with or without interactions, have been selected for each of these criteria and have been used for interrogation of eight data banks. None of these are completely satisfactory but errors or omissions are more or less important.

[Economic impact of adverse drug effects. Some reflections]

The cost of adverse drug effects first began to be analyzed in the 1960s, with an evaluation of related admissions to hospital in the USA. The average cost per patient of adverse events requiring hospitalization in France was estimated at 6,250 F in neurology units in 1979/1980, and 14,920 F in geriatric units in 1984. Fifty per cent of these events were avoidable. A second approach is to measure the cost of certain iatrogenic manifestations, e.g. fever due to fipexide, stenosis and perforation of the small intestine due to potassium chloride, gastrointestinal bleeding due to NSAIDs, kidney damage due to aminosides, etc. Calculations of the economic impact of adverse drug effects must also take into account indirect costs such as loss of productivity. The lack of such studies should not make health care specialists forget the magnitude of the problem.

[Thrombopenia due to pefloxacin (Peflacine): dose-dependent toxicity?]

Pefloxacin (Peflacine) can give rise to thrombocytopenia, although the responsibility of the drug can be difficult to demonstrate in infectious patients and those receiving other drugs simultaneously. We have collated 18 cases in which the responsibility of pefloxacin was suspected. In 13 cases, the patients were also taking other drugs which may have been contributory (heparin, Bactrim, Augmentin, ranitidine,...). The remaining five cases were of particular interest as pefloxacin was the only drug administered. The mean age of the patients was 75 years, and the mean bodyweight 56 kg (range, 47-65 kg). The pefloxacin dosage was 800 to 1,600 mg/day i.v. or p.o., i.e. 13-18 mg/kg/day. Thrombocytopenia occurred from five to 19 days after beginning treatment and resolved between 7 and 12 days after drug withdrawal. A number of factors argue in favor of dose dependency: 1 patient had high plasma concentrations (peak and residual); thrombocytopenia occurred in one patient when the previous, well-tolerated dosage of 800 mg/day (for 15 days) was increased to 1,600 mg/day; thrombocytopenia resolved in one patient when the dosage was reduced to 400 mg/day (1 tablet) and continued for a further 10 days. This toxic reaction may be avoided by reducing the drug dosage to 400 mg/day in elderly patients with a low bodyweight. Differential blood counts appear to be warranted for patients at risk.

[Tolerance of famotidine. Study of network of sentinel physicians in pharmaco-vigilance]

This paper presents the results of an intensive surveillance based on a network of general practitioners and following 200 patients treated by famotidine 40 mg per day during 6 to 8 weeks. Four patients with a previous experience of adverse reaction to another H2 antagonist did not relapse with famotidine. None interaction was reported with drugs such as beta-blockers, oral anticoagulants, theophylline, benzodiazepines, calcium antagonists. Twenty four clinical side effects were reported; For 5 patients (2.5%) the treatment had to be stopped. The most common side effects were neurological. The results are compared with those of previously published studies.

[Cardiac toxicity of fluoro-uracil. Typical and atypical aspects. Apropos of 8 cases]

The cardiac toxicity of 5 fluoro-uracil, an antimitotic agent widely used in various protocols, has been known for 16 years. Several cases have been reported in the literature, leading to the suggestion, without formal evidence, that the chief mechanism responsible for this cardiac toxicity is "classical" coronary spasm. However, certain clinical aspects already described may shed doubt on this theory. On the basis of 8 cases, the authors report different clinical pictures all caused by cardiac toxicity of 5FU. It is of interest to note that chest pain with the classically described electrocardiographic changes did not apply in the majority of cases. The commonest pattern was asymptomatic electrocardiographic abnormalities and/or arrhythmias without angina. Among the reported cases, one patient had pain with electrocardiographic abnormalities, recurrent after the withdrawal of 5FU and resistant to maximal medical treatment, despite the absence of any coronary disease or signs of spasm. One patient had a first myocardial infarction, later rechallenge with the drug resulting in failure. In another patient, with known coronary disease, 5FU probably cause cardiogenic shock. In total, some of our cases, as well as other features described in the literature, raise questions as to the pathophysiology of the cardiac toxicity of 5FU.