A. Burhan Aksakal

Skin problems of musicians.

Objective We investigated the skin problems of high level musicians in a professional orchestra. This study was prompted by our observation of violinists with skin changes.

Severe Acne With Lithium

TO THE EDITOR: The Diagnostic and Statistical Manual of Mental Disorders, 4th edition, (DSM-IV)1 describes stuttering as a disturbance in normal fluency and time patterning of speech. It is characterized by one or more frequent sound and syllable repetitions, prolongations, interjections, broken words, audible or silent blocking, circumlocutions, or words produced with excess of physical tension or monosyllabic wholeword repetitions. Approximately 1% of the adult population has persistent developmental stuttering that has not undergone spontaneous or therapy-induced remission.2 Speech pattern changes should be considered a potential drug-induced event in patients being prescribed psychotropic agents. Lithium use is frequently accompanied by adverse drug reactions like lethargy, fatigue, weakness, cognitive blunting, and tremor.3 There are reported cases4 of selective serotonin-reuptake inhibitors (SSRIs), tricyclic antidepressants, and phenothiazine/lithium combinations causing exacerbation of stutter. However, after a MEDLINE search (1985–August 2000), there were no reported cases implicating lithium as the cause of this phenomenon. We describe exacerbation of stutter after initiation of lithium treatment for bipolar affective disorder. Case Report. A 48-year-old white man with persistent developmental stutter since childhood began experiencing symptoms of irritable mood, behavioral disturbances such as excessive spending, and decreased need for sleep. He had a history of depression for the past four to five years and was receiving fluoxetine 20 mg/d. During this recent manic episode, the patient was hospitalized, and lithium was added to fluoxetine for treatment of bipolar affective disorder. The patient’s mood was stabilized on lithium at a dose of 1200 mg at bedtime. One month following treatment initiation, the patient experienced lightheadedness, hand tremor, and worsening of stutter. Psychiatric evaluation determined the patient’s mental status as stable; he was not taking any new prescription or over-the-counter medication. Since childhood, his stutter was characterized by prolongations and tense pauses. These characteristics became more pronounced during lithium therapy, and he developed a repetitive word stutter that severely limited his verbal communication ability. At this time, his lithium concentration was therapeutic (0.7 mmol/L). The patient denied any added stressors, anxiety, or medical conditions that could have contributed to this exacerbation. He did not have speech pattern changes during manic episodes or following fluoxetine therapy. Lithium was tapered off in this patient due to these changes, treatment with valproic acid was started, which was successful in continued stabilization of his mood at a dose of 2750 mg/d and a blood concentration of 87 μg/mL. His stutter returned to baseline within a few weeks of discontinuing lithium therapy. Discussion. Lithium is still used widely as treatment for bipolar affective disorder, although the therapeutic window is narrow and the incidence of adverse drug reactions can be high. Based on the Naranjo probability scale5 this case scored a possible for the likelihood that the exacerbation of stutter was caused by lithium. Other psychoactive medications such as SSRIs can alter stuttering, but in this case the fluoxetine dosage was not changed during the exacerbation. It is also possible that the exacerbation was caused by the interaction of lithium and fluoxetine since the patient was not exclusively taking lithium when the exacerbation occurred. Mechanisms involving cholinergic, dopaminergic, noradrenergic, and serotonergic pathways have been implicated in stutter exacerbation and provocation.4 However, the role of lithium on these pathways is still not fully understood. The clinician needs to be aware of the potential of lithium to cause adverse drug reactions such as exacerbation of stutter when used alone or in combination. Alison L Netski BS Medical Student School of Medicine University of Nevada Reno, Nevada

Method For Facilitating the Application of Digital Tourniquets

The authors have indicated no significant interests with commercial supporters.

Human Herpes Virüsleri 6, 7 ve 8 ile İlişkili Olan Deri Hastalıkları

Herpes virus family is a great DNA containing virus family that constitute more than 100 members. Eight types of herpes virus have been reported to cause disease in humans. Human herpes virus HHV-6, HHV-7 and HHV-8 have been lately defined members of this family, and have similar features of other herpes viruses: they may cause primary infection, may cause latent infection in the host, and have ability to reactivate in conditions of immune alteration. HHV-6 infection is common all over the world. Its transmission is not known exactly. There are evidents that suggest it is transmitted by saliva. In 90% of healthy adults HHV-6 DNA is shown by polymerase chain reaction in saliva. Roseola infantum which is also called as sixth disease, is primary infection caused by HHV-6. HHV-7 is closely related to HHV-6 due to its biological properties. HHV-7 infects only T-cells and cord blood mononuclear cells. Virus replicates in the salivary glands. It is thought that the virus probably transmitted by saliva. HHV-7 does not have primary role on a disease, it is suggested that HHV7 is associated with pityriasis rosea. HHV-8 is first detected in HIV positive patients with Kaposi syndrome. Because of that it is also called ‘Herpes virus associated with Kaposi sarcoma’. This virus is not common worldwide, and its seroprevalence varies according to the geographical region. Although viral load in the saliva of healthy people is higher than vaginal and seminal secretions, sexual transmission is the most common transmission way. It is known that HHV-8 is primarily related with occurrence of Kaposi sarcoma. In this article, we aimed to focus on clinical manifestation of HHV-6, HHV-7 and HHV-8.