Drug eruption due to bupropion, a case report

Introduction

We present a clinical case of eruption caused by the use of bupropion. Bupropion is known to cause hypersensitivity reactions.

Case report

We report the case of a 48-year-old female who was diagnosed of depressive disorder. She went to emergency because a few days after prescribing bupropion (150 mg/24 h) scaly skin eruptions were found distributed along the skin. In the present case, after its introduction, bupropion was found to be a probable etiological agent. The patient was successfully treated with corticosteroids. Because of that, bupropion dosage was stopped and replaced with fluoxetine. No remissions and exacerbations were noticed in a month's follow up.

Discussion

In this case report, we present a patient with an eruption related to bupropion. The aetiological spectrum of eruption include drugs, infectious agents and food additives. Drugs attributing eruption include nonsteroidal anti-inflammatory drugs, antibiotics, and anti-epileptic drugs, antidepressive medication amongst others.

Conclusions

No specific diagnostic criterion exists for eruption and the diagnosis is purely based on clinical presentation. Diagnostic features, which suggest eruption, are the acute onset (or recurrent nature) and skin lesions.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Decrease in prolactine levels after treatment with aripiprazole during a maniac episode: A case report

Introduction

Hyperprolactinemia can produce clinical symptoms affecting the patient's quality of life and therefore limiting therapeutic approaches to bipolar disorder.

Case report

We report a case of a 46-year-old woman, with a 10 year history of type I bipolar disorder and a microprolactinoma, who was admitted to a psychiatry inpatient unit due to a maniac episode. Current symptoms at the moment of admission included hyperthymia, verbiage, flight of ideas and insomnia. Menstrual changes and galactorrea had been present previously. Aripiprazole was introduced, reaching a dose of 30 mg/day, in addition to her usual treatment with lithium and gabapentin. Response to treatment was good and euthymia was reached within 10 days. Moreover, gabapentin was substituted by Valproic acid, and the patient was discharged once therapeutic levels were attained. Prolactin levels were measured at the moment of admission (128.75 ng/mL) and after 11 days of treatment (92.93 ng/mL).

Discussion

Choosing an adequate antipsychotic agent can reduce the risk of iatrogenesis and thus enhance adherence to treatment and quality of life. Aripiprazole had previously shown a high potential at decreasing levels of prolactine. In this case, clinical practice supports scientific evidence.

Conclusions

Aripiprazole is an effective treatment for type I bipolar disorder. Especially, it can be a treatment of choice in patients suffering from symptoms related to high levels of prolactine, even using a high dosage.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Delirium associated with sertraline, a case report

Introduction

Delirium is a clinical entity consisting of acute loss of consciousness, with attention deficit and fluctuating evolution. Antidepressive medication can cause these symptoms or worsen them.

Case report

We report the case of a 84-year-old blind female who was diagnosed of delirium in relation to intoxication with sertraline. The patient was admitted into a short-stay psychiatric unit for three days. She presented behavioural disturbances consisting in auto and heteroaggressive behaviour, altered consciousness and visual hallucinations (rocks, turtles). When dosage of sertraline was doubled from 50 mg/day to 100 mg/day visual hallucinations started. There were not other medical causes found, so sertraline was suspended, achieving clinical improvement.

Discussion

This case report shows how a patient with antidepressive treatment can display delirium. The three main causes of delirium that are infections, side effects and methabolic syndrome.

Conclusions

In the case of treating a patient with delirium, the presence of previous illness has to be investigated. It is indispensable to describe the presence of previous illness, medication and recent changes of the dosages in the medical history in a patient with Sertraline.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Before and after nalmefene, a case report

Introduction

Clinical and social improvement after treatment with nalmefene in an alcoholic 41-year-old male, with history of dependence during 20 years.

Case report

Our patient had been abusing alcohol for almost 20 years with short breaks of abstinence (one month). Before treatment he made a consumption of 105 g of alcohol per day. Serological examination showed hepatic alterations (GGT 2115, ALT 229) and a low amount of platelets (61,000). He also had no other relevant medical history and other possible clinical diagnoses were excluded. After a week detoxification program and alcohol consumption cessation during one month, the analytical values drastically changed: ALT 35, GGT 275, platelets 222,000.

Discussion

Nalmefene is an opioid system modulator with antagonist activity at the μ and δ receptors and partial agonist activity at the κ receptor. Nalmefene as-needed has been shown to reduce the total amount of alcohol consumption and number of heavy drinking days and to improve liver function. The aim of this treatment is centered in decreasing consumption rather than achieving a total abstinence.

Conclusions

Against other pharmacologic approaches such as disulfiram an acamprosate, the options that allow acute consumption help patients in controlling drinking rampage and make them realize they will be able to afford alcohol cessation.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Prolactine borderline, a case report

Introduction

It is known that antipsychotic drugs can increase prolactinaemia, we report a case in which the use of aripiprazole after treatment with paliperidone helped regaining normality levels.

Case report

During treatment with PALiperidone12 mg/day the patient, a 27-year-old female diagnosed with borderline personality disorder, developed hyperprolactinaemia with galactorrhea and menstrual disorders. During hospitalization, aripiprazole is introduced while paliperidone is progressively decreased. Antipsychotic were prescribed because delusions of reference and auditory pseudo-hallucinations arose suddenly in a woman without history of previous psychotic breaks. Before treatment with aripiprazole, prolactinaemia was 156,96 ng/mL (pregnancy test was negative) and after stopping, paliperidone was 23,60 ng/mL.

Discussion

If hyperprolactinaemia symptoms appeared (galactorrhea…), aripiprazole is a good option if antipsychotic treatment is required. In this case, paliperidone was decreased slowly, while aripiprazole was increased, until minimum effective dose was reached.

Conclusions

Hyperprolactinaemia is a common side effect in antipsychotic treatments and if symptoms appeared aripiprazole is a good option.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Transcatheter arterial chemoembolization and percutaneous ethanol injection for Hepatocellular carcinoma: a retrospective review of the Veterans Affairs Caribbean Healthcare System

BACKGROUND

Hepatocellular carcinoma (HCC) is a common malignancy worldwide and has a poor prognosis. Although surgery and liver transplantation provide better outcomes, most patients are not candidates due to advanced disease, lack of donor availability, or presence of comorbidities. Several percutaneous approaches such as transcatheter arterial chemoembolization (TACE) and percutaneous ethanol injection therapy (PEIT) have been developed for local control and can potentially increase survival in these patients.

METHODS

We retrospectively reviewed 33 patients with HCC who were treated with TACE, PEIT, or both from 2000 to 2005 at the VA Caribbean Healthcare System in Puerto Rico to evaluate tolerability, response, and survival. Patients were evaluated with cross-sectional computed tomography imaging to determine response using response evaluation criteria in solid tumors (RECIST).

RESULTS

Thirty-three men with a mean age of 66 years were treated. Mean tumor size was 5.6 cm, ranging from 2 cm to 16 cm. All patients had cirrhosis, with alcohol abuse and hepatitis C as the most common etiologies. Objective radiographic partial response was observed in 28% of patients and 48% had disease stabilization. Most of the patients had a therapeutic response demonstrated by necrosis of the tumor and decreased contrast enhancement. Patients who underwent both TACE and PEIT had a higher response rate and disease stabilization but no difference in survival compared with those who received TACE or PEIT alone. Median survival for the whole group was 2 years. Causes of death included tumor progression, hepatic failure, gastrointestinal bleeding, and infections. The initial tumor size and Child-Pugh class did not confer a significant difference in survival rate.

CONCLUSIONS

In Puerto Rico, where liver transplantation is not performed at present, percutaneous treatments are effective local therapies for patients who are not candidates for surgery and who have disease limited to the liver.

Association of HLA-DRB1*16 with chronic discoid lupus erythematosus in Mexican mestizo patients

BACKGROUND

Chronic discoid lupus erythematosus (CDLE) is present in 15-30% of patients with systemic lupus erythematosus (SLE). Approximately 5% of CDLE cases can evolve to SLE at some stage of the disease.

AIM

The aim of this study was to determine gene frequencies of HLA-DRB1 alleles in Mexican mestizo patients with CDLE, irrespective of the presence of systemic disease.

METHODS

The study comprised 28 Mexican mestizo patients with CDLE who were attending the Passover Dermatology Centre, in Mexico City. HLA-DRB1 and DQ allele typing was performed by sequence-specific oligotyping after DNA amplification using PCR. The study also included 99 ethnically matched healthy individuals as controls.

RESULTS

In the patient group, a significantly increased gene frequency was found for the HLA-DR4 (P = 0.016, OR = 2.24, 95% CI 1.14-4.38) and HLA-DR16 alleles (P = 0.005, OR = 5.51, 95% CI 1.49-21.08).

CONCLUSION

HLA-DRB1 alleles seem to be involved in the genetic susceptibility to CDLE in the Mexican mestizo population.

Association of HLA-DR4 (DRB1*0404) with human papillomavirus infection in patients with focal epithelial hyperplasia

OBJECTIVES

To determine gene frequencies of HLA-DR alleles in 22 Mexican patients with focal epithelial hyperplasia and compare them with those present in ethnically matched healthy subjects, as well as to determine the types of human papillomavirus present in the lesions.

DESIGN

Prospective and retrospective observational study.

SETTING

Dermatology outpatient clinic in a general hospital.

PATIENTS

Twenty-two patients with clinically and histologically confirmed focal epithelial hyperplasia seen within a 10-year period.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

Results of high-resolution DNA typing for HLA-DR alleles and biopsy for viral typing.

RESULTS

HLA-DR4 (DRB1*0404) was significantly increased (P<.001; odds ratio, 3.9; 95% confidence interval, 1.86-8.03). Seventeen (85%) of 20 patients had human papillomavirus subtype 13. The data on human papillomavirus differed from reports elsewhere that described association with human papillomavirus type 32.

CONCLUSIONS

The HLA-DRB1*0404 allele suggests that Amerindian populations are at risk, and in this group, the Mexican population studied was affected only by human papillomavirus type 13.

Class II allele and haplotype frequencies in Mexican systemic lupus erythematosus patients: the relevance of considering homologous chromosomes in determining susceptibility

The aim of the present study was to determine the relevant major histocompatibility complex (MHC) class II alleles in the genetic susceptibility to systemic lupus erythematosus (SLE) in Mexican Mestizo patients. We examined the gene and haplotype frequencies of the HLA-DRB1, DQA1 and DQB1 alleles by polymerase chain reaction-sequence-specific oligonucleotide probes in 81 Mexican SLE Mestizo patients and 99 ethnically matched controls. We found a significantly increased frequency of the HLA-DRB1*0301 (p(c) = 0.031, odds ratio = 2.63) allele and significantly decreased frequencies of the DRB1*0802 (p(c) = 0.035) and DRB1*1101 (p(c) = 0.037) alleles in the SLE group. Haplotype analysis showed increased frequencies of DRB1*0301-DQA1*0501-DQB1*0201 (p(c) = 0.017, odds ratio = 2.97), and decreased frequency of DRB1*0802-DQA1*0401-DQB1*0402 (p(c) = 0.034) in SLE patients. The most frequently detected haplotypes in SLE patients showed different haplotypic combinations in the homologous chromosome from those found in controls. Thus, the combinations detected in SLE patients were either not detected in the control group or infrequently found. The results suggest that the DRB1*0301 is the principal class II allele associated with the genetic susceptibility to SLE in Mexican patients and that the presence of a specific haplotype of the homologous chromosome in patients with DRB1*0407-DQA1*03-DQB1*0302 and DRB1*1501-DQA1*0102-DQB1*0602 haplotypes could have an additive effect on the susceptibility to the disease. Finally, the low frequency of the DRB1*0301 and DRB1*1501 alleles in the control population suggests that the genetic admixture between Mexican Indians and Caucasian populations was an event that could have increased the risk of Mexicans to develop SLE.

HLA genes in Mexican Mazatecans, the peopling of the Americas and the uniqueness of Amerindians

The HLA allele frequency distribution of the Mexican Mazatecan Indians (Olmec culture) has been studied and compared with those of other First American Natives and worldwide populations (a total of 12,100 chromosomes; 6,050 individuals from 59 different populations). The main conclusions are: 1) An indirect evidence of Olmec and Mayan relatedness is suggested, further supporting the notion that Olmecs may have been the precursors of Mayans; 2) Language and genetics do not completely correlate in microenvironmental studies; and 3) Peopling of the Americas was probably more complex than postulated by Greenberg and others (three peopling waves). Significant genetic input from outside is not noticed in Meso and South American Amerindians according to the phylogenetic analyses; while all world populations (including Africans, Europeans, Asians, Australians, Polynesians, North American Na-Dene Indians and Eskimos) are genetically related. Meso and South American Amerindians tend to remain isolated in the Neighbor-Joining, correspondence and plane genetic distance analyses.

Lack of association between the polymorphism at the heat-shock protein (HSP70-2) gene and systemic lupus erythematosus (SLE) in the Mexican mestizo population

Major histocompatibility complex (MHC) alleles have been recognized as genetic factors for developing systemic lupus erythematosus (SLE). In the present study we analyzed whether a heat-shock protein gene (HSP70-2) is involved in determining susceptibility to develop SLE in a Mexican Mestizo population. A HSP70-2 Pst I polymorphism was detected by a restriction fragment length polymorphism analysis of polymerase chain reaction (PCR-RFLP) in 107 SLE patients and 158 healthy controls. No statistically significant differences were observed in the HSP70-2 allele distribution between patients and healthy controls. HLA-DR analysis showed an increased frequency of HLA-DR3 allele in the patients group (P < 0.05, OR = 2.26, EF = 6.0%). On the other hand, when we analyzed HSP70-2 polymorphism in relation to HLA-DR3 allele, we could only detect an increased frequency of AB genotype in the DR3 negative patients (pC < 0.05, RR = 2.6, EF = 11.3%). Linkage disequilibrium was observed for three haplotypes: HLA-DR3-HSP70-2A (D = 0.03, D' = 0.67, P < 0.01); HLA-DR1-HSP70-2A (D = 0.03, D' = 0.86, P < 0.01) and HLA-DR8-HSP70-2B (D = 0.02, D' = 0.46, P = 0.02). Our data indicate that HSP70-2 gene polymorphism as opposed to the other ethnic groups does not appear to be relevant in SLE susceptibility in Mexican patients and that the distribution of the different alleles depend on the frequency of HLA alleles associated with them.

[Genetic determinant factors of resistance to HIV infection and of control of progression to AIDS: implications on pathogenesis and therapeutic approaches for the eradication of HIV. A review]

In this review, we describe and discuss the genetic factors that, up to some point, determine resistance to the infection and control the progression of the disease in HIV-infected individuals. Genetic factors may account for non-progression or slow progression of the disease in some of so called long-term non progressors HIV-infected individuals. In general, this group shows no symptoms for more than 10 years, while their circulating T CD4+ cells levels remain stable and they usually have a low virus load. Even though non-progression and rapid progression phenomenon are still not fully understood, there probability exists that some class I and class II MHC alleles are associated with a greater or smaller risk to develop AIDS. Class I HLA-B*35 and Cw*04 alleles are the ones commonly associated with the rapid transition of the infection into AIDS. In contrast, heterozygosity for class I HLA alleles and, particularly, the absence of HLA-B*35 and Cw*04 may contribute to non-progression. Studies which set forward other HLA alleles as possibly taking part of the pathogenic mechanism of non-progression are also described; although, relevant methodological problems can be noticed. Furthermore, this review explains and discusses allelic variations for some of the components of the chemokine receptors family, particularly the genes which codify for CCR5 and CCR2 and other genetic factors such as the SDF1-3'. A variant of the alpha SDF1 chemokine gene that have been associated with AIDS' slow progression or non-progression in HIV-infected individuals. As a whole, the factors described in this review are those that influence the natural history of the disease due to HIV and give an example of what genetic or multigenetic influence can have over the pattern of evolution of HIV infection. Finally, we mention the possible implications that the identification of the genetic markers has in the pathogenesis of HIV disease and in the development of the new therapeutic strategies to control or eliminate HIV.

Heat-shock protein (HSP70-2) allelic frequencies in three distinct Mexican populations

The major histocompatibility complex (MHC) genes are highly polymorphic and therefore have been useful in population genetics and disease association studies. We analyzed restriction fragment length polymorphism of HSP70-2 alleles in healthy unrelated Mestizo, Mazatecan and Nahua populations. Both Indian groups, Mazatecans and Nahuas, were in Hardy-Weinberg equilibrium, while Mestizos were in disequilibrium (chi 2 = 0.399; P < 0.05). The Mazatecan Indians presented a high frequency of BB homozygosity (17.35%) compared to Mestizos (5%) (P = 0.01). Mexican ethnic groups present differences in distribution of BB genotype. The low frequency of BB genotype in Mestizos may be the result of a negative selection process.

Intron 2 and exon 3 sequences may be involved in the susceptibility to develop Takayasu arteritis

We studied Major Histocompatibility Complex (MHC) Class I and Class II genes in seven Mexican Mestizo patients with Takayasu arteritis. Takayasu arteritis is an uncommon condition in Mexican Mestizo, however, previous studies report association of the disease in this population with Human Leukocyte Antigen (HLA)-B39 and HLA-DRB1*1301. The results in the present study show that the haplotypes of the Mexican Mestizo patients with Takayasu arteritis are very heterogeneous, even when the disease is much more rare in Mexico than in Japan. The sequence analysis of HLA-B39 shows that Mexican patients exhibit the HLA-B*39061 and HLA-B*39062 subtypes. These subtypes are more common in Mexico than in Japan, where the predominant subtype is HLA-B*3901. Interestingly, HLA-B*39061 and B-39062 share the 3' end of intron 2 and the 5' end of exon 3 with HLA-B*5101 and B*52012, alleles associated to Takayasu arteritis in Japanese. This fact suggests that Takayasu arteritis patients may share a specific sequence rather than a specific allele, even when the gene involved in the susceptibility to develop Takayasu arteritis may be a neighboring gene located between the genes related at present time with the disease, i.e. a gene located between MHC Class I and Class II regions.