Drug-Induced Hypersensitivity Syndrome due to Mexiletine Associated with Human Herpes Virus 6 and Cytomegalovirus Reactivation

A 66-year-old man developed a fever of 38 degrees C and generalized pruritic rash about one month after mexiletine hydrochloride administration for ventricular tachycardia. The rash appeared as edematous erythema and papules with purpura on the lower extremities. Liver dysfunction, leukocytosis, and atypical lymphocytes were also present. Elevated antibody titer against human herpes virus 6 (HHV-6) was detected during the course of the disease (1:20 -> 1:640). The patient was diagnosed as having drug-induced hypersensitivity syndrome (DIHS) due to mexiletine. Discontinuation of the mexiletine administration and systemic corticosteroid treatment led to a temporary improvement, but tapering the corticosteroid dose twice led to recrudescence. Simultaneous with the recrudescence, elevated antibody titers against HHV-6 and cytomegalovirus were detected, as well as viral DNA in the blood, suggesting that these two viruses may have been involved in the recrudescence. The patient died of myocarditis, most likely related to cytomegalovirus. Our case indicates that, in addition to HHV-6, other herpes viruses such as cytomegalovirus can be reactivated in DIHS and may modify the clinical disease activity.

Contact allergy and respiratory/mucosal complaints from heroin (diacetylmorphine)

After the start of heroin (diacetylmorphine)-assisted treatment to a selected group of chronic treatment-resistant heroin-dependent patients in the Netherlands, we reported about work-related eczema and positive patch tests to heroin in some nurses and nasal and respiratory complaints. To investigate the prevalence of heroin contact allergy, we started a questionnaire-based study with follow-up by allergological examinations. Of 120 questionnaires sent, 101 (84%) was returned: 67 from nurses and 34 from other employees. Of 101 workers, 38 (38%) had reported work-related complaints: 33 of 67 (49%) nurses and 5 of 34 (15%) other employees. Patch tests to heroin were performed in 24 nurses and were positive in 8 (33%). All the 8 had eyelid or facial eczema and, in 6, accompanied by mucosal or respiratory complaints. The prevalence of heroin contact allergy in this study was 8% (8/101) among all employees and 12% (8/67) among nurses. Respiratory and mucosal complaints could not be ascribed to a contact allergy, and in these cases, serum was analysed for specific immunoglobulin E to heroin. A type 1 allergy to heroin could not be shown. These complaints are possibly due to the histamine-liberating effect of heroin, to atopic constitution, to a combination of these factors or - less likely - to other non-allergic factors.

Effects of topical treatment with fenretinide (4-HPR) and plasma vitamin A levels in patients with actinic keratoses

Eighteen patients with facial actinic keratoses were treated with the retinoid fenretinide (4-HPR), applied topically twice-daily for 3 months. After 3 months of treatment, complete regression was observed in 56% and partial regression in 44% of cases. Eight patients relapsed within 3 months after drug discontinuation. Six months later, only two patients (11%) showed a treatment response (complete regression). Blood samples showed that 4-HPR was not absorbed and no local or distant adverse effects were observed. Baseline plasma retinol levels were lower than in healthy subjects, thus suggesting that reduced retinol levels might be involved in this pathology. These encouraging preliminary results suggest the need for further studies to evaluate the best dosage schedules and duration of 4-HPR topical application in actinic keratoses.

Fusobacterium necrophorum and Actinomyces pyogenes associated facial and mandibular abscesses in blue duiker

Anaerobic and aerobic cultures of facial and mandibular abscesses were made from 12 blue duiker (Cephalophus monticola fusicolor) housed at the Deer and Duiker Research Facility of the Pennsylvania State University (USA). Increases in concentrations of total protein and serum globulin occurred in all cases. Actinomyces pyogenes was isolated from nine animals. Fusobacterium necrophorum was present in eight and Bacteroides sp. was found in seven animals; other genera of isolated bacteria included: Streptococcus (from two animals), Lactobacillus (one), Staphylococcus (one) and Actinomyces (two). Eight (67%) of affected animals were less than or equal to 2 yr of age. Facial soft tissues and mandibles were the tissues most often affected. Tissues within the oral cavity were not affected at the time of presentation. A common finding, not reported in other host species with necrobacillosis, was the presence of nondestructive mandibular proliferation.

Unilateral nevoid telangiectasia

Unilateral nevoid telangiectasia is a cutaneous condition consisting of congenital or acquired patches of superficial telangiectases in a unilateral linear distribution. Unilateral nevoid telangiectasia has been associated with elevations of blood estrogen levels and/or an increased number of estrogen receptors in the involved skin. We present a hepatitis-B carrier case with unilateral nevoid telangiectasia on the face and the right side of the neck; she had normal blood estrogen and a normal number of estrogen receptors in the involved skin.

Recurrent mucocutaneous lymphocytic infiltration possibly associated with Epstein-Barr virus infection

A 32-year-old man had a history of recurrent but self-healing necrotizing nodules on the face and oral mucosa. Histologically the lesion was composed of necrotizing foci surrounded with dense CD8+ T lymphocytic infiltration in the dermis. Laboratory examination showed marked blood CD8+ T lymphocytosis with a reversed ratio of CD4+/CD8+ of 0.11. Except for a very high titer of antibodies against Epstein-Barr-virus-associated antigens, no signs of infection were observed.

Normal-range plasma catecholamines in patients with generalized and acrofacial vitiligo: preliminary report

BACKGROUND

There is a body of evidence that neutral factors may play a role in the pathogenesis of vitiligo.

OBJECTIVE

We look for the existence of a relationship between vitiligo and monoaminergic systems.

METHODS

We use high-pressure liquid chromatography to measure the plasma level of catecholamines, their precursor 3,4-dihydroxyphenylalanine and their metabolites 3-methoxy-4-hydroxy phenylglycol (MHPG), normetanephrine (NMN), metanephrine and homovanillic acid (HVA). Forty patients with the generalized (n = 31) and acrofacial (n = 9) types of vitiligo are studied.

RESULTS

Significant differences are not found either between males and females or between the entire group of patients and the controls. HVA and NMN levels significantly correlate with age (r = 0.332, p < 0.05, and r = 0.331, p < 0.05, respectively). Significant correlations are also seen either between noradrenergic or between dopaminergic parameters (norepinephrine vs. MHPG, r = 0.326, p < 0.05; dopamine vs. HVA, r = 0.540, p < 0.01). When the patients are grouped on the basis of vitiligo type or age of disease onset, the plasma mean levels of the neural compounds are always nonsignificantly different from those of the controls. However, both catecholamines and metabolites show higher, although not significant, concentrations in patients with a shorter duration of disease.

CONCLUSION

Monoaminergic systems seem unlikely to be related to vitiligo, at least to the generalized and acrofacial types. However, variations cannot be excluded in genetically predisposed individuals during the onset or the active phases of disease.

Normolipemic papuloeruptive Xanthomatosis in an infant

A 8-month-old boy showed several yellow to brownish yellow, papular and/or nodular eruptions predominantly on the face. Initial clinical and histologic findings indicated possible juvenile xanthogranuloma or papular xanthoma. Since his second year, the papulonodular lesions have gradually merged into large confluent plaques, particularly on the face, nape, and axillae. Consequently, it was considered that his condition had terminated in diffuse plane xanthoma. Serum lipid panels showed normolipemia. Finally, a diagnosis of papuloeruptive xanthomatosis with normal lipid metabolism and no associated systemic disorders was made. The patient's papulonodular lesions have continued to involute spontaneously since the age of three.

Serum androstanediol glucuronide in women with facial hirsutism

BACKGROUND

Measurement of serum 5 alpha-androstane-3 alpha, 17 beta-diol glucuronide (3 alpha-diolG) has been proposed as a useful biochemical marker of peripheral androgen metabolism. Is 3 alpha-diol G a useful biochemical marker of peripheral androgen metabolism and does it correlate with degree of facial hirsutism?

OBJECTIVE

Our purpose was to assess possible correlation between serum 3 alpha-diol G and degree of facial hirsutism and to compare serum 3 alpha-diol G levels with levels of other commonly measured serum androgens.

METHODS

Twenty-three consecutive women with facial hirsutism were studied, and serum concentrations of 3 alpha-diol G, testosterone (total, free, and biologically active portions), dehydroepiandrosterone sulfate, and androstenedione were measured.

RESULTS

There was no correlation between serum 3 alpha-diol G levels and degree of facial hirsutism. There was a correlation between levels of 3 alpha-diol G and dehydroepiandrosterone sulfate (p less than 0.01), biologically active testosterone (p = 0.01), free free testosterone (p less than 0.02), and androstenedione (p less than 0.05).

CONCLUSION

Serum 3 alpha-diol G concentrations have no correlation with degree of facial hirsutism and do not provide additional information over the commonly measured androgens.

[A case of mucocutaneous leishmaniasis treated with success with a low dose of pentavalent antimonial]

The authors report a case of a 89 years-old woman with mucocutaneous leishmaniasis and previous diabetes mellitus and high blood pressure, who had been treated with allopurinol for 10 months without healing of lesions. Afterwards, she has been treated with meglumine antimonate, "glucantime" for 4 days, with a total dose 2,380 mg of Sbv, but developed cardiac side effects and hypokalemia, hence the treatment was withdrawn. However, this patient developed total clinical regression of lesions, in spite of she has been received low dose of this drug.

Relevance of complement fixing antinuclear antibodies

BACKGROUND

Connective tissue diseases (CTDs) are a heterogeneous group of disorders defined by the association of a variety of clinical manifestations with immunologic and other laboratory findings. Overlap of syndromes and aberrant findings appear rather frequently.

METHODS

Sera of eight antinuclear antibody (ANA) negative, cases of subacute cutaneous lupus erythematosus (SCLE) with antibodies to Ro (SS-A) and a ninth case with clinical and laboratory signs of Sjögren's syndrome and systemic lupus erythematosus (SLE) were tested for complement (C') fixing antinuclear antibodies (C-ANAs). The ninth case was examined in depth by direct immunofluorescence (DIF) and a two-step "C + DIF" test of biopsies for C' fixation to in vivo bound ANAs, as well as serum tests for C-ANA, ANA, and SCLE markers.

RESULTS

Sera of five of the eight ANA negative, Ro(SS-A) positive SCLE cases had C-ANAs. The ninth case, a 50-year-old woman with clinical and laboratory signs of Sjögren's syndrome and SLE, gave a strong positive C + DIF reaction in the skin biopsy for in vivo bound ANAs that fix C', but negative ANAs and C-ANAs in routine serum tests; they revealed antimitochondrial antibodies. Serum tests on normal skin, however, revealed weak ANA and strong C-ANA reactions with in vitro fixed C'.

CONCLUSIONS

ANA negative cases of SCLE or Sjögren's syndrome may have C-ANAs. A case with Sjögren's syndrome and signs of SLE had both in vivo and in vitro C' fixing ANAs. C-ANA tests can aid in the identification of such cases.

Periorbital cutaneous neonatal lupus

The authors report 3 infant girls with a similar periorbital eruption. A 5-month-old infant girl presented with a 3-month history of a photosensitive facial eruption that had failed to respond to topical 1% hydrocortisone cream. The otherwise healthy infant was the product of a term pregnancy. The 25-year-old mother was in good health except for occasional arthralgias. She had 2 other healthy children. Physical examination revealed a well-developed, well-nourished infant with annular, polycyclic, erythematous scaly plaques involving the cheeks and periorbital region (Figure 1). Potassium hydroxide scraping from the face was negative for dermatophyte and yeast. Laboratory studies revealed normal complete blood cell count, normal liver function tests, strongly positive anti-SSA antibody at 118 units (>80 units, strongly positive), and a negative anti-SSB antibody. Cardiac examination and electrocardiogram (ECG) were also normal. Laboratory evaluation of the mother revealed a positive anti-SSA at 158 units and mild anemia, but anti-SSB, anti-Smith, U1RNP, and anti-Scl-70 antibodies were all negative. Within 4 months the facial eruption cleared completely with the use of desonide cream 0.05% applied twice a day and sun protection. A 6-month-old girl was referred for dermatitis that began on the trunk and face at about 2 months of age. Although the truncal component resolved after 2 months, the facial dermatitis persisted. The infant was in good health and was the first-born child. The mother was known to have Sjögren syndrome. Physical examination revealed the characteristic erythematous, annular, scaling, polycyclic plaques along the forehead, periorbital cheeks, and eyelids (Figure 2). Laboratory evaluation of the infant revealed normal complete blood cell count, liver function tests, and chemistry profile. Anti-SSA antibody was positive at >6 units (reference, <1 unit) and anti-SSB antibody was positive at 2.84 units (reference, <1 unit). U1RNP antibody was negative. Cardiac examination and ECG were normal. The skin abnormalities cleared completely in 6 weeks with the topical application of tacrolimus 0.03% ointment and sun protection. A 5-month-old girl presented with a 2-month history of a persistent facial dermatitis. The infant was in good health and was the product of a healthy first pregnancy and delivery. The mother was in good health. Physical examination of the infant revealed erythematous, annular, polycyclic periorbital patches (Figure 3). Laboratory evaluation revealed positive SSA and SSB antibodies (units unavailable) and normal complete blood cell count, liver function tests, and chemistry profile. Cardiac examination and ECG were normal. The mother's laboratory results were also positive for anti-SSA and anti-SSB antibodies (units unavailable). The infant's facial eruption resolved without specific treatment.

Elevated plasma histamine levels in systemic sclerosis (scleroderma)

Systemic sclerosis is characterized by excessive deposition of collagen and other matrix proteins in the skin and internal organs. One hypothesis supports fibroblast stimulation for production of excess amounts of collagen by factors present in the blood or released by cells composing inflammatory tissue infiltrates. Increased numbers of mast cells are present in the involved skin of patients with systemic sclerosis, and histamine has been thought to be a possible mediator of fibrosis in this and other fibrotic conditions. We therefore measured plasma histamine levels in 32 patients with systemic sclerosis and found elevated levels in 18 patients (56%). Elevated plasma histamine levels were more common in patients with diffuse disease (74%), in contrast to limited disease (31%). The degree of clinical activity and the duration of disease could not be correlated with histamine levels.

Hereditary C1q deficiency: a new family with C1qA deficiency

Hereditary deficiency of complement component C1q is a rare genetic disorder with susceptibility to recurrent infections with polysaccharide-containing encapsulated microorganisms and a high prevalence of autoimmune diseases, most often systemic lupus erythematosus (SLE). Here, we report a 29-month-old boy who presented with facial rash and history of early death of a sibling with infections, who was found to have a selective deficiency of C1q. The facial rash was composed of patchy erythematous plaques and centrally hypopigmented macules and desquamation. Two siblings had died of severe bacterial infections and his uncle had died of meningitis. Molecular study disclosed a homozygous point mutation in the C1qA chain gene. Five members of the family, including the parents and three healthy siblings, were heterozygous for this mutation.

[Preparation glycosaminosulphate efficacy in comprehensive treatment of patients with odontogenic phlegmon of maxillofacial region]

The results of 20 patients (with odontogenic phlegmon of maxillofacial region) treatment by glycosaminosulphate were compared with the results of patients received traditional treatment. Significant speeding-up of the blood indices normalization terms, humoral immunity factors and postoperative wound regeneration after odontogenic phlegmon of maxillofacial region lancing was determined.

[Skin changes in alimentary zinc deficiency caused by artificial infant food]

We report on 2 non-related newborn children who developed erythematosquamous skin eruptions on both their faces and the extensor sides of their fingers at the 4th and 10th week after birth, resp. Both children had been fed upon hypoallergenic formulas since birth. Serum investigations revealed decreased zinc levels: 0.4 and 0.17 mg/l, resp. (normal values: 0.59-0.96 mg/l). Following zinc substitution with zinc sulphate 10 mg daily for 3 days, the serum zinc levels of both children had increased to normal values and remained stationary during continued treatment with 3 mg zinc daily. The skin eruptions disappeared a few days after the start of treatment.

[Screening study methods use for substantiation of immune modulating therapy of hypergic inflammatory process in maxillofacial region]

With the help of flow cytometry it was shown that for patients with hypergic inflammatory process in maxillofacial region the reduction of lymphocytes relative number was typical as well as their absolute number reduction. Direct and very strong correlation was established between absolute lymphocytes number in peripheral blood and absolute number of CD3 and CD4 lymphocytes subpopulations by correlation analyses. The reduction of absolute lymphocytes number in peripheral blood let speak with more probability about the reduction of the number of CD3 and CD4 lymphocytes subpopulations and diagnose secondary immune deficit.

[Effect of reinfusion of UV-irradiated blood on the activity of the kallikrein-kinin system in patients with diffuse phlegmons of the face and neck]

The examination of 41 patients with phlegmons of the face and neck has revealed a considerable activation of kininogenesis. The application of the RUVIB method in 29 patients who had the most severe course of the disease allowed protease inhibitors to be rejected even in cases with sepsis and mediastinitis, effects of RUVIB exerted the regulation of processes of kininogenesis with the help of endogenous mechanisms.