Ante Tonkić

Use of Lamotrigine in Glossopharyngeal Neuralgia: A Case Report

We describe a case of a patient with glossopharyngeal neuralgia (refractory to treatment with carbamazepine, amytriptyline, diazepam, and indomethacin) treated with lamotrigine as monotherapy, the first described, who responded completely to the therapy and did not complain of side effects. The complete analgesic effect was reached at the lamotrigine daily dose of 200 mg per day and was maintained at that dose for additional 6 months, with the blood concentration within the reference range.

Bacteremia Caused by a Swallowed Toothpick Impacted in the Gastric Mucosa

Although most ingested foreign bodies usually pass through the gastrointestinal tract asymptomatically, toothpick injury to the gastrointestinal tract is often associated with significant morbidity and mortality. Toothpick perforation of the gastrointestinal tract is frequently reported but, to the best of our knowledge, bacteremia caused by an impacted toothpick within the gastric mucosa has not yet been described. Here, we report the case of bacteremia caused by an accidentally swallowed toothpick. The toothpick was impacted deeply in the gastric mucosa and was first seen and localized on contrast-enhanced computed tomography (CT). CT scan is a very useful imaging technique in such situations since we lack typical and relevant physical findings or laboratory studies that go with accidentally swallowed objects, in this case a toothpick. Flexible endoscopy was successful in extracting the whole toothpick. In cases without free perforation, flexible endoscopy is the treatment of choice in toothpick removal from the upper gastrointestinal tract.

Cerebral venous sinus thrombosis as a recurrent thrombotic event in a patient with heterozygous prothrombin G20210A genotype after discontinuation of oral anticoagulation therapy: How long should we treat these patients with warfarin?

BackgroundCerebral venous sinus thrombosis is an uncommon condition with many clinical manifestations, and hereditary prothrombotic conditions such as factor Leiden V, deficiency of protein S, protein C and antithrombin III, as well as prothrombin gene mutation, may account for 10–15% of cases. To date, conflicting results have been reported for recurrent venous thrombosis in the patients with factor V Leiden and prothrombin G20210A mutation, since some studies have shown a higher risk for recurrent venous thrombosis in carriers of these two mutations than in non-carriers, and the last study showed higher risk only for carriers of double defect (homozygous or double heterozygous for this mutations).MethodsCase report is presented.ResultsWe report a case of cerebral sinus thrombosis as a recurrent thrombotic event in a patient with heterozygous prothrombin G20210A genotype after discontinuation of oral anticoagulation therapy.ConclusionSince many facts are controversial, the use of secondary prophylaxis for thrombosis in these patients is still a matter of debate without clear consensus recommendation. Data on the risk of recurrent thrombotic events in thrombophilic patient is insufficient. The main unclear question concerning these patients is: how long and whom should we treat with long-term anticoagulant therapy as secondary prophylaxis of DVT? The problem for practitioner is that we do not have guidelines and precise recommendations for secondary thromboprophylaxis in this or similar cases. This case is remarkable for its favorable and quick outcome and its rarity, because CSVT is an uncommon condition and heterozygous prothrombin G20210A genotype was only found predisposing factor for CSVT. Further studies of risk of recurrent venous thrombosis in patients with heterozygous prothrombin G20210A genotype with the larger sample size are required.

Colonoscopic Polypectomies and Recommendations on the Colonoscopy Follow-up Intervals Depending on Endoscopic and Histopathological Findings.

The Aim: To show histopathological diagnoses after colonoscopic polypectomy in the University Hospital Center (KBC) Split with recommendations on further follow-up colonoscopy depending on the endoscopic and histological findings. Patients and Methods: The study included 2842 patients who underwent colonoscopy in a two-year period (2008-2009), followed by a detailed analysis of 350 patients in which one or more polyps were simultaneously removed and 163 patients who were only sampled for histological analysis. Patients from the National Program for Colorectal Cancer Prevention and patients in which colonoscopy is indicated as part of daily outpatient or inpatient treatment were included as well. Results: During 2008 and 2009 in KBC Split, out of a total of 2842 colonoscopies, 350 patients underwent colonoscopic polypectomy, whereby 618 polyps were removed (1-8 polyps in individual patients), while in 163 patients only biopsy specimens were sampled. Out of the total of 557 polyps sent for histological analysis, 236 were hyperplastic (42%), 193 were identified as tubular adenoma (35%), 84 were tubulovillous (15%), 18 villous (3%), 9 were adenocarcinoma (2%) and other 17 (3%). In 35 (15.4%) polyps high-grade dysplasia was found. The largest number of nonpolypectomized changes confirmed the presence of adenocarcinoma (76-47%), adenomas and hyperplastic polyps were 37 (22%) and regular findings 23 (14%). Mucosal high-grade dysplasia was demonstrated in 35 (23.1%) biopsied changes. Conclusion: Colonoscopies with polypectomy decreased the risk of the formation of colorectal cancer in these patients almost to the level of risk in patients who have not even had a polyp during colonoscopy. Arguably the best method of prevention and early detection of colorectal cancer are already widely established national programs. The next qualitative level is constantly improving the quality of colonoscopy with clear criteria and the establishment of a body to evaluate the performers and the equipment, and making recommendations on the colonoscopy follow-up intervals depending on endoscopic and histopathological findings of patients who for any reason underwent colonoscopy.

Successful endoscopic removal of a swallowed toothbrush: case report.

Most ingested foreign bodies will pass uneventfully through the gastrointestinal tract. Nevertheless, long and rigid foreign bodies are associated with an increased risk of gastrointestinal impaction, perforation and bleeding. Moreover, there has been no case of spontaneous passage of a toothbrush reported. Therefore, the prompt removal of such ingested foreign objects is recommended before complications develop. This case report describes a case of an 18-year-old woman who accidentally swallowed her toothbrush. The toothbrush was successfully removed via flexible endoscopy using a polypectomy snare. A swallowed toothbrush is a special clinical challenge. Early endoscopic retrieval of the toothbrush is critical for reducing morbidity and mortality. In cases when endoscopic removal fails, a laparoscopic surgical approach may be an alternative.

Successful endoscopic removal of a lighter swallowed 17 months before.

The majority of ingested foreign bodies will pass safely through the gastrointestinal tract, but long and rigid foreign bodies are associated with an increased risk of gastrointestinal impaction, perforation and bleeding. However, large foreign bodies which have been swallowed can remain trapped in the stomach over a longer period of time without any significant symptoms. This case report describes the case of a 36-year-old man addicted to heroin who purposefully swallowed a lighter (double wrapped in cellophane) and presented with hematemesis and melena 17 months after the ingestion of the foreign body. The lighter was successfully removed via flexible endoscopy using a polypectomy snare. Swallowed long and rigid foreign bodies trapped in the stomach over a long period of time always represent a special clinical and endoscopic challenge. In cases where endoscopic removal fails, a laparoscopic surgical approach may be an alternative.

Increasing Prevalence of Primary Clarithromycin Resistance in Helicobacter pylori Strains in Split, Croatia

Helicobacter pylori infection is considered the most common cause of gastritis and is etiologically involved in gastric and duodenal ulcer, non-ulcer dyspepsia, gastric adenocarcinoma, and primary low-grade B-cell gastric lymphoma. H. pylori infection may also play a role in some cases of unexplained iron deficiency anemia and idiopathic thrombocytopenic purpura1. The prevalence of H. pylori infection differs in geographic areas and H. pylori-related disease is one of the most prevalent in the world 1. A European H. pylori study group and the American College of Gastroenterology recommend triple therapy with a PPi, amoxicillin and clarithromycin as the initial treatment for H. pylori infection 1,2. Although the prevalence of H. pylori infection has been falling in developed countries, eradication rates are now lower than 10 years ago 3. Antimicrobial resistance is a major cause of treatment failure and is responsible for the declining rates of H. pylori eradication 4,5. Primary resistance to metronidazole and clarithromycin is clinically very important and often the cause of failed therapy 4,5. Primary clarithromycin resistance is increasing worldwide, and has been regarded as the main factor in reducing the efficacy of eradication therapy 3-5. in our previous studies, unlike scandinavian authors, we found a relatively high prevalence of primary antibiotic resistance to clarithromycin 6-9. The aim of this study was to search for a further possible increase in the primary antibiotic resistance of H. pylori strains to clarithromycin in our population since this is the main cause of eradication failure. H. pylori strains were cultured from gastric mucosal biopsy specimens on Pylori agar (bioMerieux, Marcy l’Etoile, France) after an incubation of 3-5 days, at 37°C in a microaerophilic atmosphere. The susceptibillity of H. pylori isolates to amoxicillin, clarithromycin, tetracycline and metronidazole was determined by E-tests (AB Biodisk, solna, sweden). Etests were performed on Columbia agar plates with 7% horse blood without supplement. Plates were inoculated with bacterial suspension (turbidity of 3-4 McFarland opacity standard) and incubated at 37°C for 72 hours under a microaerophilic atmosphere. The antibiotic breakpoints were ≥4 mg/L for amoxicillin, ≥1 mg/L for clarithromycin, >1 mg/L for tetracycline, and >8 mg/L for metronidazole. To evaluate the differences between proportions, the χ2test was used. All differences in which the probability of the null hypothesis (p) was <0.05 were considered statistically significant. Forty strains (34.8%) out of the 115 strains tested were resistant to clarithromycin. We found that the prevalence of primary clarithromycin resistance was significantly increased during the study period when compared with the period 2003-2004 when it was 20.4% (p= 0.018) (Figure 1). The resistance rate for metronidazole was 11.3% (13 out of the 115 strains tested). it was lower than in the period of 2003-2004 when it was 12.9%, the difference being not significant (p=0.434). none of the strains tested were resistant to amoxicillin or tetracycline. Primary antibiotic resistance varies greatly between countries and geographical regions. Therefore, it is important to know the local data about H. pylori resistance because antibiotic therapy in primary eradication, according to the European Helicobacter Pylori study Group, is often started on a empiric basis 1,4. Empiric treatment strategies are based on current scientific evidence and although the eradication rate of individual regimens today is unsatisfactory (<80%), the use of post-treatment testing and rescue treatment based on antimicrobial susceptibility testing can produce successful eradication rates 3,4. The frequency of primary clarithromycin resistance in H. pylori strains is increasing worldwide, with a prevalence rate of 12.9% in the UsA and a prevalence rate as high as 24% in some European countries 4,10. in our previous study we found that the high resistance rate of our H. pylori isolates to clarithromycin (20.4%) in our region was similar to resistance reported from Central italy (23.4%) and Portugal (22%) but much higher than that found in scandinavia (2.02.9 %) 4,6,8,9. The observed difference may be related to the frequency with which clarithromycin or azithromycin are prescribed in these populations 11. in the present study, we observed a further increase in primary clarithromycin resistance over the period 2003-2004, reaching alarming values of >30%. Our REpRInt

Time trends of primary antibiotic resistance of Helicobacter pylori isolates in Southern Croatia

Helicobacter pylori infection is an important factor in the pathogenesis of chronic gastritis, peptic ulcer, gastric adenocarcinoma, and primary gastric B-cell lymphoma. The efficacy of treatment depends on the susceptibility of H. pylori to the antibiotics provided in the therapy, and the resistance of H. pylori isolates to the antibiotics causes eradication treatment failure. A clarithromycin-based eradication regimen is still recommended as the first-line therapy in European regions with low clarithromycin primary resistance. Antibiotic resistance varies greatly between countries and geographical regions and is an increasing problem worldwide. Therefore, it is important to know the local data about the primary resistance of H. pylori isolates to most commonly used antibiotics in the eradication treatment, because therapy is still often started with antibiotics chosen on an empiric basis despite current guidelines. Therefore, recent consensus conference has recommended first-line treatment based primarily on local primary resistance to clarithromycin. This paper aims to establish best practice first-line eradication therapy in the region of Southern Croatia based on the prospective monitoring of local primary antibiotic resistance. H. pylori strains were isolated from gastric mucosal biopsy specimens obtained from 345 adult patients with ulcer disease and nonulcer dyspepsia in the period of 2008–2010 in the Department of Gastroenterology, University Hospital of Split. Specimens were streaked on Columbia agar (Becton Dickinson, Cockeysville, MD, USA) with 7% horse blood and an H. pylori selective supplement (Oxoid, Basingstoke, UK). Plates were incubated for 3–7 days at 37uC in a microaerophillic atmosphere (5% O2, 10% CO2 and 85% N2). Isolates were identified by Gram staining, and positive catalase, oxidase and urease tests. The susceptibility of H. pylori isolates to amoxicillin, tetracycline, clarithromycin, levofloxacin, and metronidazole was determined by Etest (AB Biodisk, Solna, Sweden). H. pylori isolates were subcultured and Etests were performed on Columbia agar plates with 7% horse blood without a supplement. Plates were inoculated with a bacterial suspension (turbidity of 3 McFarland) and incubated at 37uC for 72 hours under the same microaerophillic atmosphere. The antibiotic breakpoints employed for the Etest were >4 mg/l for amoxicillin, >1 mg/l for clarithromycin, >8 mg/l for metronidazole, >1 mg/l for levofloksacin, and >1 mg/l for tetracycline. The Chi-squared test was used to evaluate the differences between proportions. All differences in which the probability of the null hypothesis was P,0.05 were considered statistically significant. During the survey period (January 2008–December 2010) a total of 345 adult patients were included in this study. The overall resistance of H. pylori strains to clarithromycin was 21.2% (73 strains out of 345) (Table 1). We found that the prevalence of primary clarithromycin resistance significantly decreased during study period when compared with the period of 2006–2007 (P,0.05), but it is still high and it exceeds 20% (Fig. 1). The resistance rate for metronidazole was 10.2% (37 strains out of 345) (Table 1). It was lower than in the period of 2006–2007, when it was 11.4%, the difference being not significant (P.0.05) (Fig. 1). The primary antibiotic resistance to levofloxacin is relatively low (eight strains out of 175), and now stands at 4.6% (Table 1). No isolates were resistant to amoxicillin and tetracycline in this study. Despite intensive clinical research over the last 20 years, current treatment standards for H. pylori eradication still represent a clinical challenge. In Europe, based on the Maastricht III Consensus Report, in regions with a low primary resistance of H. pylori strains to macrolides, clarithromycin-based Correspondence to: A. Tonkic, Internal Clinic, Department of Gastroenterology, University Hospital Split, Spinciceva 1, 21 000 Split, Croatia. Email: ante.tonkic@hi.htnet.hr

Thrombosis of sinus sagitalis during puerperium caused by thrombophilic gene mutation.

Cerebral veno-sinus thrombosis (CVT) during puerperium may have fatal consequences. A nonspecific clinical picture must be complete with computed tomography of the brain and digital substract angiography of the brain blood vessels, and, once the clinical diagnosis is confirmed, coagulation tests and genetic analysis of the coagulation factor are to be made as well. Genetic polymorphisms associated with thrombophilia such as factor V Leiden, prothrombin G20210A, MTHFR C677T, ACE and PIA1/A2 may be the cause of the hypercoagulability that results in CVT.

Headache caused by handling the pesticide Antracol Combi WP 76 : a case report

We report on headache caused by the pesticide Antracol Combi WP 76. A headache caused by handling of pesticides should be distinguishable from migraine and headaches from other causes. This 29-year-old woman, who handled pesticides, presented with very strong headache with nausea and vomiting. Poisoning by this pesticide cannot be proven toxicologically, and there is no antidote. Following isolation from the pesticide and abundant hydration, the pain gradually decreased. History, clinical signs and neuroradiological examinations excluded other possible causes of the headache. In treatment of patients in rural areas, attention should also be paid to the pesticide Antracol Combi WP 76 as a possible cause of headaches