Multiple colon ulcerations, perforation and death during treatment of malignant melanoma with sorafenib

BACKGROUND

Sorafenib (Nexavar) is an oral multi-kinase inhibitor with anti-angiogenic and antiproliferative effects. It has shown in-vitro and clinical activity against several kinds of tumors, such as malignant melanoma.

HISTORY, DIAGNOSIS, TREATMENT AND COURSE

A 66-year-old man with malignant melanoma was treated with sorafenib, 2 yen 400 mg per day. Because of severe diarrhea and abdominal pain, sorafenib was eventually discontinued and the patient was hospitalized for further treatment. Diagnostic work-up by upper gastrointestinal endoscopy and colonoscopy revealed multiple deep ulcerations within the whole colon. One week after admission the patient developed symptoms of acute abdomen with signs of bowel perforation requiring an emergency operation. Colectomy of the right colon with ileostomy revealed multiple (20-30) acute and subacute colonic perforations. Despite intensive care treatment the patient died of septic complications 13 days after surgery.

CONCLUSION

Treatment with anti-angiogenic multi-kinase inhibitors may be associated with gastrointestinal perforations. This has been reported for sorafenib in up to 2.3 % of cases.

[Varicella-zoster virus infections]

The primary infection with varicella-zoster virus (VZV) is manifest clinically as varicella. It is a common very contagious disease, normally appearing in childhood. VZV is a ubiquitous virus with a high prevalence. Clinically it is characterized by pleomorphic skin lesions. Normally antiviral therapy is necessary only in severe cases, in adults or in immunosuppressed patients. Herpes zoster, also caused by (VZV), is a neurodermal disease representing the endogenous relapse of the primary varicella infection. Herpes zoster is characterized by lesions concentrated in the innervation region of a cranial or spinal nerve. One of the most feared manifestations of herpes zoster is pain. Several antiviral drugs are approved and many studies have shown that antiviral therapy, started early in the course of disease, can significantly reduce risk and duration of postherpetic neuralgia in elderly patients. Therefore, antiviral therapy in combination with an adequate pain management should be given to all elderly patients as soon as herpes zoster is diagnosed.

Early diagnosis of herpes zoster by polymerase chain reaction

BACKGROUND

Herpes zoster is a common disease caused by the varicella-zoster virus. The use of virostatic agents as early as possible is necessary in shortening zoster-associated pain.

OBJECTIVES

Rapid diagnosis is necessary for the optimal efficacy of antiviral therapy. The diagnosis in the early stage of infection is often difficult.

METHODS

In the present study skin biopsies of patients with herpes zoster and unclear skin changes were analysed by detecting viral DNA using the polymerase chain reaction (PCR) in order to amplify open reading frames (ORF) 14, 29 and 63.

RESULTS

Varicella-zoster virus DNA could be detected with PCR of all three ORF not only from blisters but also from erythematous skin.

CONCLUSIONS

PCR is the method of choice for the viral diagnosis in herpes zoster before blister eruption.

[History of the Krefeld Dermatology Clinic]

The dermatology clinic in Krefeld has treated a wide range of patients since its founding in 1845. Nowadays the spectrum consists of allergology, occupational dermatology, phototherapy, dermatosurgery, phlebology and proctology as well as special clinics for andrology, sexually transmitted diseases and patients with HIV-infection.

Assessment of pain in herpes zoster: lessons learned from antiviral trials

Pain typically accompanies acute herpes zoster and, in a proportion of patients, it persists well beyond rash healing. Pain must therefore be analyzed in trials of antiviral agents in herpes zoster, but different methods have been used to analyze pain in recent published trials. These reports are reviewed and their methodological strengths and weaknesses examined. Based on this review, recommendations for the design and analysis of future trials of antiviral agents in herpes zoster are proposed. The principal recommendation is that antiviral efficacy should be evaluated both by distinguishing post-herpetic neuralgia from acute pain and by considering pain as a continuum. The primary endpoint should address both the prevalence and duration of post-herpetic neuralgia and should be examined in those patients who have post-herpetic neuralgia. Adopting the proposed recommendations in design and analysis of future trials should facilitate comparison across trials of the efficacy of antiviral agents in the treatment of herpes zoster.

Antipsoriatic effect of fumaric acid derivatives. Results of a multicenter double-blind study in 100 patients

BACKGROUND

Psoriasis vulgaris may benefit from treatment with fumaric acid and/or its derivatives; however, because different preparations have been used, results have been contradictory and difficult to interpret.

OBJECTIVE

The purpose of this clinical trial was to evaluate the therapeutic value of fumaric acid derivatives.

METHODS

A randomized double-blind study was carried out in patients with psoriasis, comparing a well-characterized formulation of fumaric acid derivatives with placebo.

RESULTS

The results indicated statistically significant superiority of the fumaric acid derivatives over placebo. Adverse events (flush, gastrointestinal disturbances) were initially relatively frequent, but decreased thereafter.

CONCLUSION

Fumaric acid derivatives were found to be effective and safe in the treatment of psoriasis.

[Sexually transmitted diseases by herpes simplex, wart, hepatitis B, and human immunodeficiency virus]

Sexually transmissible diseases (STD), caused by viruses are by far the most important ones, even though German legislation has ignored them up to now as STD. Anogenital herpes is easily diagnosed by means of monoclonal antibodies. This makes therapy available with acyclovir without delay in atypical cases or for example in persons with immunodeficiency. The therapy regimen usually is 5 x 200-400 mg/day. Recurrent herpes in high frequency and with severe pain may be successfully suppressed by 2-5 x 200 mg/day of acyclovir orally without serious side effects. This will not eliminate herpes viruses. Anogenital warts may look very different and occasionally cannot be detected before local application of 3% acetic acid. Histology is diagnostic. There are different strains causing diseases in men. Therapy of choice is destroying infected cells by CO2-laser coagulation. The incidence of hepatitis B in developed countries is decreasing slowly within the past years, this may partly be due to vaccines, that are available since the early eighties, producing immunity in about 95%. Treatment of chronic hepatitis with interferons seems to be beneficial. Infections with the human immunodeficiency virus (HIV) and their end stage disease AIDS are a growing problem all over the world. Interventions are possible with different nucleoside analogs, e. g. zidovudine (AZT), dideoxycytidine (DDC), dideoxyinosine (DDI). Up to now there is no agreement on when to start with one of the drugs and if or when to switch to combination therapy. Hopefully this may stabilize immunologic parameters and hold disease progression to some time.

[Treatment of recurrent herpes labialis using a herpes simplex Type-I subunit vaccine. A prospective randomized double-blind multicenter study]

A herpes simplex type I subunit vaccine developed by Behring-Werke (Marburg/Lahn, FRG) was compared with placebo for therapeutic effectiveness in the treatment of recurrent orolabial herpes simplex in a multicentre study involving the major hospitals in Frankfurt/Main (n = 34), Hamburg (n = 18), Giessen (n = 17) und Kassel (n = 14). The effectiveness of the vaccine was judged on the reduction in the frequency of recurrences. Within the period of the 8-month study there was no statistically significant difference in the frequency of recurrences with vaccine or placebo. Both placebo and verum led to a significant decrease in the number of recurrences of orolabial herpes simplex, but the effect of placebo was slightly more pronounced.

[Ixodes ricinus bites]

Ticks (Ixodes ricinus) are found all over the world, with special preference of a few epidemic areas. They do not only invade their hosts one by one, but often in large groups.

[Current topics in mycology]

There is an urgent need of in vitro test methods with a good in vivo predictability both for the search of new antimycotics moderate in price and for the susceptibility testing of yeasts in antimycotic therapy. We discuss the problems of agar dilution test methods. Usually, the minimal inhibitory concentration (MIC) is measured. This parameter does not only depend on the susceptibility of the test fungus, but is greatly influenced by other factors such as inoculum size, incubation time, and culture medium. Thus the MIC of azoles can vary considerably. Moreover, the current test methods are not adjusted to the different ways of fungus growing in vitro and in vivo.

[Evaluating skin tolerance. Study of skin cleansing agents in modifications of the Duhring chamber test]

Towards Elucidation of the Problems of Skin-compatibility Testing/An investigation of hand-cleansing products using a modified Duhring chamber test The irritant potential of commercially available liquid syndets was investigated in a repetitive Duhring chamber test using a modified test procedure. Instead of regularly testing over a period of five days, the test was conducted only as long as it took for the first signs of irritation to appear. Among those products tested, substantial differences were found with respect to irritation and possible application time, and, as a result, to skin compatibility. Some of them produced skin irritation with the same intensity and just as quickly as the control substance, sodium lauryl sulfate (0.5%). These differences are not observed in a simple 24-hour epicutaneous test. For this reason, the latter, as opposed to the repetitive Duhring chamber test, appears to be unsuitable for comparative skin compatibility studies of syndets. The skin compatibility of special hand cleaners containing solvents was also investigated in a modified Duhring chamber test. In addition to the modification introduced above for the liquid syndets, here the maximum cumulative application time was reduced from 48 to 30 h. In this manner different degrees of skin compatibility to various special hand cleaners can be ascertained and taken into account when developing new products.

[Sneddon Wilkinson subcorneal pustulosis, therapy with mebhydroline]

A 60-year-old male patient suffering from subcorneal pustular dermatosis showed fast and lasting remission under treatment with mebhydrolin.

[Experimental study of the effect of raw materials of the neem tree and neem extracts on dermatophytes, yeasts and molds]

In traditional Indian medicine, various parts of the neem tree have been used for centuries, especially with skin diseases. These products are often applied in human mycoses. We tested some dried neem materials, neem oils as well as simple neem preparations and extracts with regard to their effect on 14 of the most common pathogenic fungi. Neither the dried neem materials nor the medical preparations and oils had any effect on fungal growth; most of them were even contaminated with molds. Some of the extracts, however, showed antimycotic properties, which decreased with rising solvent polarity. Petrolether leaf extract proved most effective. One of the possible explanations might be the fact that it contains quercetin, a flavonoid.

[Skin changes in syringomyelia]

Asymmetric anonychia, skin edema, and painless ulceration of the fingers may be the first symptoms of syringomyelia. Neurologic examination of the patient leads to the diagnosis, which can be proved by the demonstration of the cavity in the central spinal cord. Prophylactic dermatologic treatment may prevent the progression of the skin lesions.

[Injuries caused by stingrays]

We report on an injury caused by the bite of a South American freshwater stingray. Although wide excision is the therapy of choice, prolonged healing must be expected. We give some information on the mode of injury and biological data regarding the genus protamotrygon. This stingray may also be bred in aquariums.

Oral acyclovir for herpes zoster: a double-blind controlled trial in normal subjects

Sixty immunocompetent patients with herpes zoster of various dermatomes were treated 5 times a day for 5 days with either acyclovir at a dose of 400 mg or placebo. Acyclovir was shown to reduce significantly the time to full crusting (P = 0.02). There were also trends in favour of acyclovir for time to first dry vesicle and time to first day without macules or papules, but these were not statistically significant. There were no differences between the groups in the occurrence of adverse events or postherpetic neuralgia.

[Value of glucocorticoid treatment in herpes zoster]

48 patients suffering from severe acute zoster pain were treated with methylprednisolone 1 mg/kg body weight daily, if bed rest and analgetics had not been effective. The pain completely vanished in 33.3% of the patients; only 20.9% still suffered from unaltered pain. This therapy proved only to be effective if it was applied during the first 5 to 10 days after the appearance of the first lesions. There was no exacerbation observed in any patient. 66.6% of the patients developed postherpetic neuralgia accompanied by rather low pains, as 61.8% of the patients did not need analgetics.

[Virostatics in dermatology]

Many antiviral substances are known, but only a few are clinically effective in certain disease resulting from herpes virus infections. Early diagnosis is essential. Antiviral chemotherapy is discussed in respect to herpes infections in immunocompetent patients, and in patients with primary genital herpes, eczema herpeticum, genital and gluteal recurrent herpes and herpes zoster.

[Systemic retinoid therapy with etretinate in pachyonychia congenita]

On the basis of two case-reports it is concluded that the aromatic derivative of retinoic acid, etretinate, is a promising drug in the treatment of pachyonychia congenita.

[Possibilities and limits of chemotherapy of diseases caused by herpes simplex and varicella-zoster virus]

The available antiviral chemotherapeutic agents for the treatment of herpes simplex type 1 and 2 and varicella zoster virus infections are discussed in respect of their mechanism of action, clinical effects, and side effects. Although effective under experimental conditions most of the antiherpetic drugs need further evaluation of clinical efficacy in controlled trials. It is possible to reduce initial herpetic pain mainly in patients with zoster by topical application of 5% 5-iodo-2'-deoxyuridine solved in dimethylsulphoxide when treatment starts within the first 3 days of blister eruption. The postzosteric neuralgia is not influenced. A shortening of pain seems also possible in primary herpes simplex virus type 2 infection. For recurrent herpes simplex there is no proven effect on duration or frequency of recurrences with available antiherpetic drugs. The indication for antiviral chemotherapy is limited not only by the unpredictable, mainly self-limited, course of herpes simplex and zoster but also by the possible side effects of chemotherapeutic agents. Severe and life-threatening herpes disease, e.g., in immunosuppressed patients or newborns, can be defeated with vidarabin applied i.v. and, in the near future, with acyclovir.

[Pityriasis rosea (Gibert) ]

Pityriasis rosea (Gibert) is an acute self limited disease with clinically characteristic skin eruptions. In about 20% of cases complications with an atypic clinical picture and a prolonged course are found. Histopathology and ultrastructure of the lesions are not characteristic. The etiology is unknown.

[New aspects in infections with herpes-simplex-virus (author's transl)]

The high and increasing incidence of herpes simplex (HSV) diseases has led to increasing research activities at all levels all over the world. Particularly important for clinicians are 1. new aspects of the potential danger for certain patients, e.g. the newborns or the immunosuppressed, by exogenous herpes infections or reactivated latent virus and 2. new epidemiological or diagnostic aspects and 3. the problems with the advances, failure and evaluation of chemo- and immunotherapy.

[Clinical aspects and importance of human herpex simplex infections. Results of herpes antigen therapy]

Herpes simplex diseases are among the most frequent sociomedical problems of our age. For the patients the recurrent diseases are particularly distressing depending on the frequency of relapse, their localization and clinical course. Immunological factors, especially cellular immune mechanisms seem to affect the frequency of relapse and particularly the clinical course of the relapse. Clinical experience so far with immunotherapy of relapsing herpes diseases with heat-inactivated herpes simplex virus antigen type 1 and type 2 are optimistic. Local painful swellings or more rarely the appearance of an urticaria have been described as side-effects within 10 years in 1 to 2% of patients.

[Combined chemotherapy of herpes simplex infections of the skin]

It was possible to prolong the herpes free intervals with combined chemotherapy with 0,3% Ethyl-desoxyuridine (EDU)-Gel during the acute phase and continued application of 0,2% Jodo-desoxyuridine (IDU)-ointment with 1,8% DMSO. The combined chemotherapy did not improve the effect of the treatment with EDU alone in respect of the duration of skin lesions. In 5 out of 8 patients with recurrent cold sores and in 3 out of 10 patients with genital herpes further immunotherapeutical measures were not necessary. The results indicate that beside the chemotherapy of the recurrences with monotherapy a continuous chemoprophylaxis can be successful in patients with recurrent herpes simplex.

[Immunotherapy of recurrent Herpes simplex diseases]

Different methods of immunotherapy in patients with recurrent herpes simplex diseases are reported. The clinical improvement after immunostimulation with heterologous or homologous antigens is demonstrated. The results of different authors are summarized and compared with our own results. In ten patients the lymphocyte stimulation was studied with the lymphocyte transformation test (LTT) as a parameter for cell-mediated immunity. The LTT was performed before immunotherapy and four months later. No difference was found in the lymphocyte stimulation by phytohaemagglutinine or by an antigen, containing heat-inactivated herpes simplex virus.

Vaccination for herpes simplex genitalis

Type-specific vaccines containing heat-inactivated herpes simplex hominis virus type 1 or 2 have been developed for the treatment of herpes simplex genitalis. When patients with recurrent herpes genitalis were treated with the type 2 vaccine the clinical course of the disease improved and the eruption-free interval was extended. In severe cases, especially in permanent genital herpes, the concurrent administration of vaccine and immunoglobulin concentrates improved the clinical course of the disease. Antibody titres and the in-vitro stimulation of lymphocytes with phytohaemagglutinin or herpes simplex hominis virus antigens remained constant during administration of the vaccine.

[New possibilities of drug therapy for herpes simplex infections of the skin]

Jodo-desoxyuridine (IDU) of different concentrations in different vehicles can shorten the duration of primary infections and recurrences of herpes simplex virus (HSV) infections to about one third. Therapeutical failures can be due to the development of IDU resistence. Ethyl-desoxyuridine (EDU) in a gel base was found to reduce the mean duration of acute herpetic lesions to about 50%. 42 recurrences of 16 patients with herpes labialis and 36 recurrences of 10 patients with herpes genitalis were observed and statistically evaluated. In cold sores 0,3% EDU-gel had similar effects as the 2,0% EDU-gel, what shortened significantly (0,001 less than p less than 0,01) the duration of skin lesions. In herpes genitalis both concentrations had good effects. 0,3% EDU-gel reduced the healing time significantly (p less than or equal to 0,05). Remarkable was the quick disappearence of subjective complaints in all treated patients. Side effects were not observed.

Stimulation of lymphocytes in patients with psoriasis under photochemotherapy. A study of lymphocyte transformation

Lymphocyte-transformation by phytohaemagglutinine (PHA) was examined in 21 patients with generalized psoriasis during photochemotherapy (PUVA). Lymphocyte-transformation-tests (LTT) were performed before and after 8-methoxypsoralen (8-MOP) medication, before and after the initial irradiation and before and after the first maintenance irradiation four to six weeks later. Spontaneous and PHA-induced lymphocyte-transformation was not altered by 8-MOP alone or in combination with UVA irradiation.

[Zinc-deficiency syndrome with acrodermatitis]

The symptoms of the zinc depletion syndrome are demonstrated in two males and two females. The four patients, 23 to 39 years old, were suffering from ileocolitis Crohn. After three to eight weeks of total parenteral nutrition they showed signs of acrodermatitis. Serum zinc was found considerably below normal levels (0,21--0,68 microgram/ml). After oral nutrition was re-initiated the dermatitis healed within four weeks without zinc oxid or zinc sulphate administration. Serum zinc increased to normal levels.

[The lymphocyte transformation test in patients with recurrent herpes simplex diseases (author's transl)]

The in vivo stimulation of lymphocytes was used to assess cell mediated immunity to herpes simplex virus (hsv) in patients with recurrent skin eruptions caused by this virus. 1. Phytohaemagglutinine stimulation of lymphocytes was normal in all examined patients. There was no difference in the PHA-stimulation of a control group. 2. Specific lymphocytes stimulation by hsv-antigen may be regarded as a sensitive parameter for a previous hsv-infection. 3. In 6 patients with severe infections of hsv type I or II and more than 10 recurrences per year we found a lower stimulation than in patients with occasionally (up to 10 times a year) skin eruptions. 4. An antigen used as vaccine, Lupidon H, ten times more concentrated (100,000 EID/ml) than the commercially available antigen is able to stimulate lymphocytes in vitro.