Elias E. Mazokopakis

Recommendations for diagnosis and management of metformin-induced vitamin B12 (Cbl) deficiency

Metformin treatment is a known pharmacological cause of vitamin B12 (Cbl) deficiency with controversial responsible mechanisms. A possible diagnosis of this deficiency is based mainly on the combination of patients medical history (usually long-term metformin use), clinical examination (possible neuropsychiatric symptoms and signs), laboratory studies which confirm a Cbl deficiency (haematological abnormalities, low serum Cbl levels, elevated serum total homocysteine and methylmalonic acid levels), and exclusion other causes of Cbl deficiency (as pernicious anaemia, food-cobalamin malabsorption syndrome, other drugs, etc.). In our review, recommendations for diagnosis and management of metformin-induced Cbl deficiency (MICD) in diabetic patients based on medical bibliography are presented and discussed.

Epstein Barr Virus hepatitis

OBJECTIVES Epstein-Barr Virus (EBV) infection has the potential to establish life-long, benign infections in their hosts. Although biochemical evidence of hepatocellular damage is common, jaundice is uncommon and complete recovery is the rule. The present study describes clinical characteristics and changes of liver function tests during the course of infectious mononucleosis. PATIENTS AND METHODS All immunocompetent patients with hepatic dysfunction associated with acute EBV infection, cared for at the University Hospital of Heraklion, over a 6-year period, were identified and retrospectively studied. RESULTS The study included 41 patients with a median age of 18.5 (15-51) years. Aspartate-aminotransferase (AST) and alanine-aminotransferase (ALT) were increased in an average maximum of 5-fold. Both transaminase levels started to rise 2 days after the clinical onset of the disease, and returned to normal after a period of 20 days. Alkaline-phosphatase (ALP), γ-glutamyltransferase (γ-GT) and bilirubin levels also increased above the normal values during the course of the disease and returned to normal after a period of 20, 30 and 22 days respectively. The changes of mean AST and ALT levels over time were statistically significant, while those of mean ALP, γ-GT and bilirubin levels over time were not. Anicteric cholestatic liver disease was observed in 24 patients (59%), while icteric only in 2 (6%). CONCLUSION Liver involvement in acute EBV infection represents mild and self-limited hepatitis with predominantly cholestatic features.

Hepatitis caused by the herbal remedy Teucrium polium L.

Herbal remedies have become increasingly popular throughout the globe as a result of disappointment with conventional medicines and also of the alleged belief that herbal preparations are basically harmless. On the other hand, their effects can be exceedingly potent or even lethal if used improperly. Drugs and other chemicals account for less than 5% of cases of jaundice or acute hepatitis and smaller number of cases of chronic liver disease. Drug reactions can mimic any hepatobiliary disease, posing a diagnostic challenge for physicians and pathologists. Hepatotoxicity generally occurs after approximately 2 months of ingestion and consists of a non-specific hepatitis, which usually runs a benign course. Typical features include anorexia, nausea, abdominal pain, and jaundice associated with a marked elevation in serum aminotransferases. We present a case of acute hepatitis in a 70-year-old farmer, using Teucrium polium (golden germander) as hypoglycaemic aid. The patient presented only with jaundice, after 1 months consumption of large quantities of this herb in a tea form.

Acute rhabdomyolysis caused by Spirulina (Arthrospira platensis).

Rhabdomyolysis is a potentially life-threatening disorder that occurs as a primary disease or as a complication of a broad spectrum of other diseases. We report the first case of acute rhabdomyolysis after ingestion of Spirulina (Arthrospira platensis), a plantonic blue-green alga, as a dietary supplement.

Changes of bone mineral density in pre-menopausal women with differentiated thyroid cancer receiving L-thyroxine suppressive therapy

ABSTRACT Objective: We studied the effect of levothyroxine (L-T4) suppressive therapy on bone mineral density (BMD) in pre-menopausal women with total thyroidectomy and radioactive iodine (131I) ablation therapy post-operatively for differentiated thyroid cancer (DTC). Patients and methods: We prospectively studied 26 athyroid pre-menopausal women (median age 39 years, range 28–48 years) receiving suppressive L‐T4 therapy postoperatively for 48 months. BMD was measured by dual energy X‐ray absorptiometry (DEXA) at the femoral neck, femoral trochanter and Wards triangle, before (basal) and during (12th and 48th month) the follow-up period. None of the women gave a medical history that could possibly affect bone metabolism. Patients were free of thyroid cancer in clinical and laboratory examinations at the time of the study. Paired t‐test was used for comparisons among BMD measurements during the suppressive therapy. Results: There were statistically significant decreases of BMD at all measured regions during (12th and 48th month) L‐T4 suppressive therapy. The overall decreases in BMD at the femoral neck, femoral trochanter and Wards triangle were 7.5%, 10.9% and 3.4%, respectively, at the end of the follow-up period. The coefficient of variation (CV) of all BMD measurements was around 10%, showing a rather homogenous group of patients. Our patients had a statistically significant decrease in their body mass index (BMI) and weight at the end of the follow-up period. However, there was no significant correlation between the decrease in BMI and BMD. Patients did not experience significant adverse effects from L‐T4 suppressive therapy during the study. Conclusion: L‐T4 suppressive therapy for at least 1 year in pre-menopausal women with DTC causes a reduction in BMD of the femoral neck, femoral trochanter and Wards triangle.

The hypolipidaemic effects of Spirulina (Arthrospira platensis) supplementation in a Cretan population: a prospective study

BACKGROUND Spirulina (Arthrospira platensis) is a filamentous cyanobacterium used as a food supplement. The objective of the study was to determine the lipid-lowering effects of Spirulina in Cretan Greek dyslipidaemic patients, and to document its effectiveness as a possible alternative treatment for dyslipidaemia. Fifty-two adultCretan outpatients (32 men, 20 women), median age 47 (range, 37-61) years, with recently diagnosed dyslipidaemia, consumed orally 1 g Spirulina (Greek production) per day for 12 weeks. The full lipid profile was measured in fasting blood samples at the beginning and end of the study period. Anthropometric measurements including systolic and diastolic blood pressure, height, weight and body mass index were also recorded. RESULTS At the end of the 3-month intervention period the mean levels of triglycerides, low density lipoprotein-cholesterol, total cholesterol, non-high density lipoprotein-cholesterol levels, and the ratio of total cholesterol to high-density lipoproteincholesterol were significantly decreased: 16.3% (P < 0.0001), 10.1% (P < 0.0001), 8.9% (P < 0.0001), 10.8% (P < 0.0001) and 11.5% (P = 0.0006) respectively, whereas the mean high-density lipoprotein-cholesterol levels were not significantly increased (3.5%). Blood pressure, weight and body mass index remained almost unchanged. CONCLUSIONS Spirulina supplementation at a dose of 1 g daily has powerful hypolipidaemic effects, especially on the triglyceride concentration in dyslipidaemic Cretan outpatients.

Q fever endocarditis.

Coxiella burnetii, the agent of Q fever, produces a variety of clinical syndromes. The most frequent and serious chronic presentation is endocarditis, which presents unspecifically as a blood-culture negative endocarditis. It occurs almost exclusively in patients who have pre-existing valvular disease or who are immunocompromised. Without prompt recognition and appropriate antimicrobial therapy, the course of Q fever endocarditis is severe and potentially fatal. The epidemiology, signs and symptoms, laboratory findings, diagnosis and treatment of Q fever endocarditis are presented in our review.

Nonbacterial Thrombotic Endocarditis (Marantic Endocarditis) in Cancer Patients

The term nonbacterial thrombotic endocarditis (NBTE), or marantic endocarditis, refers to a spectrum of lesions ranging from microscopic aggregates of platelets to large vegetations on previously undamaged heart valves (most often aortic and mitral) in the absence of a bloodstream bacterial infection. NBTE is a rare condition often associated with hypercoagulable states or advanced malignancy such as adenocarcinomas. In this article, the pathogenesis, incidence, clinical manifestations, diagnosis, and management of NBTE in cancer patients are reviewed.

Acute febrile neutrophilic dermatosis (Sweet's syndrome) with erythema nodosum and anterior scleritis. A case report.

A 53‐year‐old Greek housewife was admitted to hospital because of painful erythematous lesions on the lower ( Fig. 1 ) and upper ( Fig. 2 ) extremities in association with painful ocular hyperemia. These symptoms were preceded by an upper respiratory infection with persistent high‐grade fever for about 1 week. Erythematous lesions had appeared 3 days previous to admission. Her medical history included two previous episodes of erythema nodosum (unknown etiology), essential hypertension treated with perindopril 4 mg/day, diabetes mellitus type II under diet only, and multinodular goiter under treatment with thyroxine 0.1 mg/day.

Seroprevalence of hepatitis A, B and C markers in Greek warship personnel

A seroepidemiological study was conducted to assess the seroprevalence of hepatitis A, B and C markers in 285 males (mean age: 24.4 ± 4.4 years) aboard a Greek warship. Two hundred and sixty three serum samples were tested. None was found to be positive for HAV antibodies, three persons (1.1%) were positive for HBsAg, four persons (1.5%) were positive for anti-HBc and one person (0.4%) was positive for anti-HCV. Forty-five persons (17.1%) had developed titles anti-HBs >10 IU/L. The establishment of a vaccination policy against hepatitis A among warship personnel is strongly recommended.