Vitiligo as a First Sign of Vogt-Koyanagi-Harada Disease

Vogt-Koyanagi-Harada (VKH) disease is a multisystem disorder characterized by bilateral granulomatous panuveitis resulting in serous retinal detachments, disk edema, and a sunset glow fundus development. Furthermore, it is associated with various extraocular findings, such as tinnitus, hearing loss, vertigo, poliosis, and vitiligo (1). VKH is considered to be an autoimmune disease mediated by T-cells targeting melanocyte antigen tyrosinase peptide (2). Moreover, VKH more often occurs in individuals with a genetic predisposition to the disease, including those of Asian and Hispanic heritage (3). Three disease categories have been recognized, including complete, incomplete, and probable VKH. Each category has different clinical features, varying from neurological and auditory manifestations to ophthalmologic and dermatologic findings (1). Herein, we present a case of chronic complete Vogt-Koyanagi-Harada disease, which started with vitiligo. CASE REPORT A forty-year-old female patient presented to the Department of Ophthalmology with photophobia, dull eye pain, and a gradual decrease in visual acuity over two months. In addition, at clinical examination, vitiligo spots were observed on the patient's hands and the periocular area. The patient's medical history revealed she had vitiligo from a young age. Additionally, she developed generalized epilepsy and headaches in adolescence. The neurologic symptoms had been treated, whereas dermatologic workup and treatment were never performed. It was also found that our patient was of Hispanic heritage, which later helped establish a diagnosis. Ophthalmologic examination revealed eye redness, hypotony, keratic precipitates, anterior chamber cells, and posterior synechiaes. Fundoscopy showed mild vitreous haze, optic disc and macular edema, chorioretinal thickening (also seen on eye ultrasound), and disturbance of retinal pigment epithelium (Figure 1). A standard diagnostic protocol for uveitis was performed. Serology for infectious causes was performed, and IgG for CMV and HSV 1 were positive. Tuberculosis testing was negative. HLA testing showed positive HLA-DR1, HLA B13/18, and HLA DQ-1 antigens. There were no cells in the intraocular fluid, and PCR of the fluid was negative for CMV and HSV 1 and 2. Considering the noninfectious uveitis, a history of neurological and dermatological disorders, and the Hispanic heritage of our patient, the diagnosis of Vogt-Koyanagi-Harada disease was established. Systemic methylprednisone in a 1.5 mg/kg dose was introduced during the first hospitalization. After slow tapering of the corticosteroid therapy, cyclosporine A in a 175 mg/day dose and azathioprine in a 100 mg/day dose were introduced for prolonged therapy. Although signs of eye inflammation were reduced, poor prognostic signs such as hypotony and optic disc edema were persistent. Therefore, the TNF-α inhibitor adalimumab was introduced. After the introduction of adalimumab, the disease was considered stable with no worsening of visual function, but vitiligo spots continued to progress (Figure 2). DISCUSSION Our case presents a chronic stage Vogt-Koyanagi-Harada disease in a person with a Hispanic heritage. VKH is a rare autoimmune disease that involves multiple organ systems, including the eyes, skin, and auditory and neurological systems. In the pathogenesis of the disease, there is an underlying granulomatous inflammation mediated by T-lymphocytes targeting melanocyte-specific antigens (4). Besides the immune response, genetics is an integral part of the etiology of the disease. HLA-DR1 and HLA-DR4 have been associated with VKH disease, specifically in the Hispanic and Asian populations (3,5). Other studies have found that VKH is more common in people of Asian and Hispanic heritage than in Caucasian or African-American individuals (6). In our case report, the Hispanic origin of our patient was essential for the diagnosis of the disease. There are four phases of VKH disease. The prodromal phase lasts a few days to a few weeks and is characterized by extraocular findings such as headache, vertigo, meningismus, and nausea (1). After the prodromal phase, the acute uveitic phase occurs, with sudden onset of blurred vision, conjunctival injection, and photophobia (1,7). Weeks to months after, the convalescent phase occurs, with signs of depigmentation such as vitiligo, poliosis, and vitiligo in the ocular limbal area, called the Sugiura sign. Finally, six to nine months after initial symptoms, the chronic recurrent phase occurs, leading to exacerbations of anterior uveitis (1). Even though most patients develop skin changes in the convalescent phase, our patients experienced skin depigmentation years before ocular involvement. VKH can be complete, incomplete, or probable. Our patient is an example of complete VKH, since she fulfilled all criteria for complete VKH, including 1) no history of penetrating ocular trauma or surgery, 2) no clinical or laboratory evidence of other ocular diseases, 3) bilateral ocular involvement, 4) neurological findings, and 5) integumentary findings (8). Treatment for VKH consists of high-dose systemic corticosteroids, administered orally or through intravenous delivery, followed by slow tapering of oral corticosteroids. Immunosuppressive therapy with cyclosporine and/or azathioprine is considered if the symptoms are persistent or worsening. In case of no improvement, biological agents such as infliximab and adalimumab are included (4).

THE ROLE OF SALIVARY AND SERUM CA125 AND ROUTINE BLOOD TESTS IN PATIENTS WITH OVARIAN MALIGNANCIES

The use of routine blood tests has recently been shown to be promising in determining disease-free and overall survival in patients with various malignancies, and also in gynecologic malignancies. The aim of this study was to evaluate whether salivary and serum CA125 levels correlate and whether salivary and serum CA125, C-reactive protein and routine blood tests might serve as a prognostic factor in malignant ovarian tumors, and whether they might differentiate between benign and malignant ovarian tumors. A total of 98 women were included (48 with benign ovarian tumors and 50 with malignant ovarian tumors), in whom routine blood tests were made and salivary and serum CA125 levels were determined by use of ELISA. Increase in serum CA125 and amylase decreased overall survival, whereas increase in salivary CA125, potassium levels and hemoglobin increased overall survival. Significant correlation of serum CA125 and C-reactive protein was found in the group with malignant tumors. In conclusion, significant increase in the levels of serum CA125 and amylase correlated with decreased survival, whereas increased salivary CA125, hemoglobin and potassium levels significantly correlated with increased survival.

Albrecht von Graefe (1828-1870) and his contributions to the development of ophthalmology

PURPOSE

The aim of this article is to show Albrecht von Graefe's contributions to the development of ophthalmology on the occasion of the 150th anniversary of his death. He is regarded as the greatest ophthalmologist of the 19th century. Modern and scientific ophthalmology owes its beginning to him.

METHODS

Extensive literature research is made and contacts with institutions for history of medicine as well as medico-historians in the field of ophthalmology.

RESULTS

His contributions to ophthalmology were multiple. Von Graefe was the first to introduce iridectomy in acute glaucoma treatment, initiated visual field testing and developed the first tonometer. He made the first classification of glaucoma. Von Graefe was the ophthalmologist who created a special knife for cataract surgery. He was also the first to use Helmholtz' ophthalmoscope. He founded the first ophthalmological society in the world and the second ophthalmology journal which has been published continously up to now. In 1852 he founded famous private eye clinic in Berlin, where he treated many eye patients and educated many prominent ophthalmologists. At the age of 29 he became associate professor of ophthalmology, the first with such a title in Germany.

CONCLUSION

Albrecht von Graefe was founder of modern ophthalmology and separated it from surgery. Graefe's contacts, correspondency and meetings at ophthalmological congresses with his teachers, assistants, collegaues also contributed to international co-operation and internationalization in ophthalmology. Although Albrecht von Graefe died before 150 years, he still provokes great admiration and respect in the world of ophthalmology.

Quantitative analysis and detection of chaptalization and watering down of wine using isotope ratio mass spectrometry

In early 1990's European Union has established new isotopic approach for detection of wine authenticity. In this article we setup the possibility of using new approach using new EIM – Module – IRMS (Ethanol Isotope Measurement – Module – Isotope Ratio Mass Spectrometry) instrumental technique and new analytical parameter δDn(δ2Hn) wine ethanol value, which represents δ2H value of non-exchangeable hydrogen stable isotope ratio in ethanol, with other isotopic species (δ18O values in wine water) to improve detection of illegal wine production practices such as addition of sugar and/or dilution with water. Total of 42 wine samples were analyzed. 10 wine samples (out of 42) were prepared from grapes by alcoholic fermentation and analyzed for δDn values of ethanol. 19 wine samples (out of 42) were collected from wine producers in Serbia plus 1 wine samples designated from United States was taken from Serbian market and analyzed for δDn values of ethanol, δ18O values in wine water and also δ13C values in wine ethanol. Furthermore 9 wine samples (out of 42) were taken from Hungarian market and analyzed for δDn values of ethanol, and also 3 wine samples (out of 42) were taken from Austrian market and analyzed for δDn values of ethanol. All experiments were done in 4 isotope laboratories located in US, Austria, Hungary and People's Republic of China. δDn values of ethanol were measured by using EIM Module connected to FlashHT 2000 pyrolizer (one laboratory – Imprint Analytics GmbH, Austria), while in other 3 laboratories (US – COIL – Cornell University, Stable Isotope Laboratory, Hungary – Isotoptech Ltd, Debrecen, Hungary and China – C.N.R.I.F.F.I. – China National Institute of Food and Fermentation Industries Limited) EIM Module was connected to TC/EA (High Temperature Conversion Elemental Analyzer). Peripherals in all laboratories were further interfaced with isotope ratio mass spectrometer. Furthermore δ18O values in wine water were measured by using Gas Bench II interfaced also with isotope ratio mass spectrometer (one laboratory – US). Obtained results from all 4 laboratories have shown that this new approach which uses δDn in wine ethanol is more effective in improving detection of illegal wine production practices (sugar enrichment and water dilution) and origin of ethanol, and also detecting the addition of corn or beet sugar, sugar syrup to wine, or dilution of grape must with water prior to alcoholic fermentation.

Keywords: Wine authenticity; EIM – Module – IRMS; Stable Isotope; Isotope Ratio Mass Spectrometry; Wine; Watering; Chaptalization.

Abdominal Wall Endometriosis Eleven Years After Cesarean Section: Case Report

Endometriosis is a common chronic disease characterized by growth of the endometrial gland and stroma outside the uterus. Symptoms affect physical, mental and social well-being. Extrapelvic location of endometriosis is very rare. Abdominal wall endometriosis occurs in 0.03%-2% of women with a previous cesarean section or other abdominopelvic operation. The leading symptoms are abdominal nodular mass, pain and cyclic symptomatology. The number of cesarean sections is increasing and so is the incidence of abdominal wall endometriosis as a potential complication of the procedure. There are cases of malignant transformation of abdominal wall endometriosis. Therefore, it is important to recognize this condition and treat it surgically. We report a case of a 37-year-old woman with abdominal wall endometriosis 11 years after cesarean section. She had low abdominal pain related to menstrual cycle, which intensified at the end of menstrual bleeding. A nodule painful to palpation was found in the medial part of previous Pfannenstiel incision. Ultrasound guided biopsy was performed and the diagnosis of endometriosis confirmed. Surgery is the treatment of choice for abdominal wall endometriosis. Excision with histologically proven free surgical margins of 1 cm is mandatory to prevent recurrence. A wide spectrum of mimicking conditions is the main reason for late diagnosis and treatment of abdominal wall endometriosis. In our case, the symptoms lasted for eight years and had intensified in the last six months prior to surgery.

Secular Changes in Education, Urban-rural Living, Menarche and Abortion Rates in Perinatal Population

Over a 25-year period we examined the anthropological characteristics of mothers and their partners, such as the place of living: urban vs. rural, the degree of education, parity, the time of menarche, and the frequency of intentional abortions. We examined 2 414 mothers and their partners in four periods of time extending from 1985 to 2009 in order to establish changes in the said anthropological characteristics over a period of 25 years. The degree of education of mothers and their partners is on the rise. In the period from 1985 to 1994, the percentage of mothers from the country was on the rise. Women with less education have on average more children, and those with better education the least children. Women from rural areas have on average more children than women from urban areas. The time of menarche dropped by 9 months over the period of 25 years. Girls from urban areas have their first menstrual cycle earlier. Women with higher professional qualifications had their first period earlier. The number of intentional abortions over the 25-year period dropped.

Coexistence of ruptured ectopic tubal pregnancy, dermoid and endometriotic cyst with tubo-ovarian abscess in the same adnexa: case report

A 32-year-old pregnant woman presented to the hospital with abdominal pain and minimal vaginal bleeding. Transvaginal ultrasound revealed visible fluid in pelvic region with suspected tubal rupture, and subsequently laparoscopy was performed. During laparoscopy, additional gynecologic pathologies were noticed. Histopathologic finding showed dermoid and endometriotic cyst, as well as tubo-ovarian abscess in the same adnexa. This case report highlights the necessity of considering multiple diagnoses in the same organic system, which may be encountered by surgeon and histopathologist.

Efficiency of RO/NF membranes at the removal of veterinary antibiotics

The production of pharmaceuticals has increased rapidly during the last several decades as they have been used for the health of both humans and animals. Routes of environmental exposure include the release of treated wastewater, the land disposal of livestock manures and municipal biosolids (i.e. sewage sludge), as well as the use of medicated aquaculture feed. This study deals with application of reverse osmosis (RO) and nanofiltration (NF) membranes for removing of antibiotic residues (sulfamethoxazole, trimethoprim, ciprofloxacin, dexamethasone and febantel) and their mixture. According to the results obtained in this work the use of RO (LFC-1 and XLE) and the tight NF (NF90) membranes are recommended to achieve a high level of retention (>95%) of all selected veterinary antibiotics (VAs). Nanofiltration NF270, NF and HL membranes showed a lower rejection of individual components, but much higher in a mixture solution, due to the synergistic effect.

Prediction of ovarian tumor malignancy

Ovarian cancer is the leading cause of mortality among gynecological cancers. The aim of the study was to form the decision rules for distinguishing benign from malignant ovary lesions. The research was conducted on 201 women with ovary tumor. Commonly used specific markers for ovarian cancer (biochemical marker Ca 125, ultrasound and vascular markers) were used. The significant difference in the presence of an ultrasound and vascular markers between benign and malignant ovary changes along with the significantly different level of Ca 125 is confirmed. To a specific marker certain score number was appointed and the scoring system was formed. The incidence of benign/malignant ovary changes was observed in the researched group regarding anthropometric parameters (age, marital and menopausal status and number of deliveries). There is also significant difference in the incidence of benign/malignant ovary tumor regarding these parameters. Based on combination of the scoring system and anthropometric parameters the decision rules for distinguishing benign from malignant ovary tumors were formed. The logistic regression method was used. We proved that this method has higher accuracy in prediction of malignancy in women with ovary tumors than using morphological, Doppler or anthropometric parameters separately.

Platelet serotonin concentration at term pregnancy and after birth: physiologic values for Croatian population

The aim of this study was to determine physiological value of platelet serotonin (5-HT) and its variations in the group of women in term pregnancy and after birth. Obtained results were compared to the platelet 5-HT level in nonpregnant women group. Determination of normal level of 5-HT in pregnancy and after could help in its further measurement and evaluation of different psychologic and psychiatric disorders related to pregnant and postpartal period, including better understanding of mood changes after the birth. A total of 137 healthy Croatian women were enrolled in the study--82 of them were pregnant and 55 were not. Their blood was sampled and the platelet serotonin concentration was determined. In pregnant women the blood was sampled twice: at term pregnancy, and soon after birth. The mean value of 5-HT in pregnant women was 1.209 nmol/mg protein, after the delivery 1.045 nmol/mg protein, and in non pregnant 1.088 nmol/ mg protein. The concentrations were significantly different in those three groups. We did not find differences in 5-HT levels in groups divided by age.

Chloasma--the mask of pregnancy

Chloasma is a required hypermelanosis of sun-exposed areas occurred during pregnancy and it can affect 50-70% of pregnant women. It presents as symmetric hyperpigmented macules, which can confluent or punctuate. The most common locations are the cheeks, the upper lip, the chin and the forehead. The exact mechanism by which pregnancy affects the process of melanogenesis is unknown. Estrogen, progesterone, and melanocyte-stimulating hormone (MSH) levels are normally increased during the third trimester of pregnancy. However, nulliparous patients with chloasma have no increased levels of estrogen or MSH. In addition, the occurrence of melasma with estrogen- and progesterone-containing oral contraceptive pills has been reported. The observation that postmenopausal woman who are given progesterone develop melasma, while those who are given only estrogen do not, implicates progesterone as playing a critical role in the development of melasma. UV-B, UV-A, and visible light are all capable of stimulating melanogenesis. The condition is self-limited; however spontaneous resolution is time-consuming and may take months to resolve normal pigmentation. Therefore, it is worthwhile to prevent the onset of chloasma, by strict photoprotection. Prudent measures to avoid sun exposure include hats and other forms of shade combined with the application of a broad-spectrum sunscreen at least daily. Sunscreens containing physical blockers, such as titanium dioxide and zinc oxide, are preferred over chemical blockers because of their broader protection. Chloasma can be difficult to treat. Quick fixes with destructive modalities (eg, cryotherapy, medium-depth chemical peels, lasers) yield unpredictable results and are associated with a number of potential adverse effects. The mainstay of treatment remains topical depigmenting agents. Hydroquinone (HQ) is most commonly used.

[Diagnostic value of the NBT-PABA test in the functional evaluation of the exocrine pancreas]

N benzoyl-L-tyrosil PABA was orally administered to 13 controls and 35 patients with pancreatic disease: 7 with chronic exocrine pancreatic disease, 7 patients after an attack of acute pancreatitis, 3 with carcinoma of the pancreas, 8 with biliary tract disease and 10 with diabetes. The amount of PABA excreted serves as parameter exocrine pancreatic function. PABA excretion in patients with chronic pancreatitis (p < 0.01) and diabetes (p < 0.05) was significantly less then in controls. The present data justify further investigation of this procedure as a possible new oral test of exocrine pancreatic function.

[The mean values and correlation between blood pressure, body weight, height, heart rate, the PQ, QT and QTc intervals, the QRS-complex and the echocardiographic dimensions of the left atrium and ventricle in 515 14-year-old students]

In five hundred and fifteen schoolchildren, the mean values of blood pressure, body weight, height, heart rate, PQ, QT, QTc-interval, QRS-duration and echocardiographic left ventricular (LV) and left atrial (LA) diastolic internal dimension as well as their correlations were measured. There were 224 girls and 291 boys of 14 years of age. Mean systolic blood pressure was 118 +/- 15 mmHg in boys, 115 +/- 10 mmHg in girls. Mean diastolic blood pressure was 74 +/- 9 mmHg in boys, 74 +/- 7 mmHg in girls. The prevalence of systolic hypertension was 3.4% in boys, 3.1% in girls. The prevalence of diastolic hypertension was 2% in boys and 4% in girls. No significant difference was observed between body weight, height, PQ, QT, QTc-interval, QRS-duration and echocardiographic LA and LV measurement in boys and girls. Mean heart rate in girls was 98 +/- 19.7 and 88 +/- 17 in boys. The difference was statistically significant (t = 6.06; P less than 0.01). A significant positive correlation was found between body weight and height and diastolic and systolic blood pressure. The body weight and height revealed a significant positive correlation to echocardiographic left ventricular and left atrial dimension. No correlation of body weight to heart rate was observed in neither boys nor girls. A significant negative correlation was found between height and heart rate (P less than 0.05) in boys, whereas no correlation between these two variables was noticed in girls.(ABSTRACT TRUNCATED AT 250 WORDS)

Oxytocinase (CAP) activity in serum during normal pregnancy

Reference values for the activity of oxytocinase were determined in the sera of 371 women during normal pregnancy. An exponential relationship between enzyme activities and gestational age was found. The activity of oxytocinase (CAP) increased progressively from the beginning to the end of pregnancy. Statistical evaluation showed a significant difference between the 5th and 2nd months, as well as after the 20th week of pregnancy.