Gokhan Sargin

Imatinib-associated bilateral gynecomastia and unilateral testicular hydrocele in male patient with metastatic gastrointestinal stromal tumor: A literature review

Imatinib mesylate is a drug that has been approved for treatment of advanced gastrointestinal stromal tumors (GISTs) and patients with leukemia such as chronic myeloid or Philadelphia chromosome-positive acute lymphoblastic. Although it has been described only in one patient with testicular hydrocele and gynecomastia in the literature, several cases of male gynecomastia have been reported with the use of imatinib mesylate in chronic myeloid leukemia (GML). Generally, male mastoplasia resolves after discontinuation of imatinib treatment. We report a 73-year-old male with metastatic GISTs who developed gynecomastia and unilateral testicular hydrocele while receiving imatinib mesylate. Nine months after commencing imatinib treatment, gynecomastia and testicular hydrocele were determined. Hormone analyses requested showed serum testosterone levels below and serum estrogen levels above normal limits. During the first month after discontinuing imatinib mesylate treatment, serum testosterone level was normal and there was a partial regression in gynecomastia and testicular hydrocele. To our knowledge, this is the second report of male gynecomastia following imatinib mesylate treatment of a patient with GIST. In conclusion, male patients who are to receive treatment with imatinib mesylate may be monitored for serum testosterone levels and for other reproductive hormone profiles before initiation of the treatment and their breasts may be examined during follow-up visits.

Hajdu-Cheney syndrome with ventricular septal defect.

Hajdu-Cheney syndrome (HCS) is a rare osteolysis syndrome characterized by generalized, progressive osteoporosis and acroosteolysis [1]. Cardiovascular abnormalities, including patent ductus arteriosus or atrial or ventricular septal defect (VSD) might be rarely accompanied by HCS as case presentations [2]. We present here a case of HCS with cardiovascular defect that has not been reported previously in the literature. A 31-year-old man presented to our clinic with a nonhealing wound on the plantar surface of his left foot. He had a history of right below-knee amputation, surgical closure of VSD, and spontaneous autoamputation of the right metatarsophalangeal joint and the first, third, and fourth distal phalanges of the left foot. His general condition was stable with blood pressure of 120/80 mmHg, pulse

Cutaneous Metastasis of Gallbladder Adenocarcinoma in a Patient with Chronic Lymphocytic Leukemia: A Case Report and Review of the Literature

Skin metastasis of primary gallbladder tumors is extremely rare with a reported incidence of 0.7~9% and it usually involves the thorax, abdomen, the extremities, neck, head region, and scalp. Cutaneous metastasis may occur synchronously or metatochronously. In the present case, the patient had chronic lymphocytic leukemia, which was being treated with an alkylating agent (chlorambucil) when the patient developed skin metastasis from gallbladder adenocarcinoma during post- cholecystectomy follow-up. Given the fact that secondary malignancies occur in chronic lymphocytic leukemia; this clinical setting warrants attention. We aimed to discuss secondary malignancy in chronic lymphocytic leukemia patients and gallbladder adenocarcinoma with skin metastasis, based on a review of the literature and the presented case.

Renal cell carcinoma and chronic lymphocytic leukemia

Dear editor Hematological malignancies with renal cell carcinoma (RCC) are rarely seen that was reported as case series. The incidence of lymphoid malignancy with RCC is higher than expected in general population [1–3]. We present here an 82-year-old female patient with coincidence of RCC and chronic lymphocytic leukemia (CLL). The patient referred to our clinic with high lymphocyte count. On physical examination, the patient was normal with a blood pressure of 100/65 mmHg, and general condition was good. Her blood parameters were as follows: hemoglobin 11.2 g/dl, MCV 87.9 fL, leukocyte count 16.610/mkrL, lymphocyte count 10.360/mkrL, platelet count 242.000/mkrL, urea 57 mg/dl, creatinine 1.31 mg/dl, and erythrocyte sedimentation rate 39 mm/h. There was ?? erythrocytes in her urine test. Immunohistochemical examination of bone marrow was stained positively with CD5, CD20, CD23, and 80 % of the lymphoid cells. Trisomy of chromosome 12 was positive, and del 13q, 17p was negative. CLL was diagnosed according to the International CLL study group after the bone marrow biopsy and flow cytometry. An abdominal ultrasound showed a 5 9 6 9 6 cm nodular hypoechogenic lesion in the left kidney. Histopathological diagnosis of left nephrectomy material was clear cell RCC without invasion of lymphatics, renal capsule, and perirenal fat tissue invasion. We have not planned treatment for Binet stage A CLL and stage I RCC. The patient is still followed up by our clinic. Coexistence of RCC and lymphoma was reported more than coincidental [4]. RCC with non-Hodgkin’s lymphoma is more frequently than Hodgkin’s lymphoma, but CLL is more rarely. Coincidence of CLL and RCC may be synchronous or asynchronous [5]. Our patient had synchronous malignancies. The coincidence of this malignancy may be associated with common genetic mutations, chemotherapy/ radiotherapy, hormonal–environmental factors, or immunmodulation. Kunthur et al. [6] reported 9 patients who had RCC and lymphoma, including 1 with CLL. CLL with RCC has been reported rarely in the literature [7–9]. We want to emphasize again this coincidence that is important for clinicians.

Acute Respiratory Distress Syndrome and Hepatotoxicity Associated with Single Dose Nitrofurantoin Use

Nitrofurantoin is a synthetic nitrofuran compound. It is generally used in urinary tract infections, either alone or in combination with other antibiotics. A number of adverse effects may develop in different body systems during nitrofurantoin treatment; however, concomitant pulmonary and hepatotoxicity are rare. In this paper, we present a case of acute respiratory distress syndrome and hepatotoxicity following administration of a single dose of nitrofurantoin.

Immunohistochemical evaluation of CD20 expression in patients with multiple myeloma

Objective CD20 expression was reported at different rates in patients with multiple myeloma. The importance of this B-cell antigen for plasma cells is still unknown. This study aimed to investigate CD20 expression of myeloma cells in bone marrow, and any relationship between the stage of disease, isotype and clinical features. Methods Sixty-one patients who were admitted to the hematology clinic of the Adnan Menderes Medical School with the diagnosis of multiple myeloma according to the criteria of the “International Myeloma Working Group” were enrolled in this study. Age, gender, Durie–Salmon stage, history of autologous hematopoietic stem cell transplantation, and the distribution pattern and positivity of CD20 expression on multiple myeloma cells in bone marrow were evaluated. The Mann–Whitney U and chi-square tests were used for statistical analysis with a p-value < 0.05 being accepted as statistically significant. Results Thirty patients (48.9%) had positive scores for CD20 with the distribution pattern being most likely interstitial in 55.6% of the cases. There was no statistically significant difference between immunohistochemical positivity for CD20 expression on multiple myeloma cells, immunoglobulin type, and the stage of disease. Conclusion The combination of immunohistochemical studies with flow cytometry may reveal the importance of CD20 positivity in patients with multiple myeloma more clearly.

Rituximab therapy in rheumatoid arthritis and primary biliary cholangitis

The prevalence of rheumatoid arthritis (RA) has been reported to be 1.8% in patients with primary biliary cholangitis (PBC), and mitochondrial antibodies (AMA) have been found in 10% of RA patients.1,2 It was reported that T and B cells play an important role in the inflammatory process of both RA and PBC.3,4 The potential therapeutic target is determined by the pathogenetic mechanism. We report a case series of patients with RA and PBC with good clinical response to rituximab. The first case was a 61-year-old female with the diagnosis of RA and PBC. The serological tests were negative, except for rheumatoid factor (RF), anti-cyclic citrullinated peptide antibodies (anti-CCP) and AMA-M2. Serum lipids, glucose, renal function tests, parathyroid-thyroid hormones, viral markers and protein electrophoresis pattern were normal. Abdominal ultrasonography showed no pathology. She had a medical history of smoking and receiving ursodeoxycholic acid (15 mg/kg/day), methotrexate (MTX, 15 mg/week), hydroxychloroquine (200 mg/day) and methylprednisolone (4–8 mg/day). Due to high disease activity (DAS-28: 6.24) rituximab (1000 mg IV every 2 weeks) was administered. The second case was a 68-year-old female with the diagnosis of RA and PBC. She had medical history of using ursodeoxycholic acid (10 mg/kg/day), leflunomide (20 mg/day), hydroxychloroquine (200 mg/day) and prednisone (10 mg/day). She had a RF of 34.2 U/mL (3–18 IU/mL) and anti-CCP of 8.7 U/mL (0–4.99 U/mL). AMA-M2 was positive and viral serology was negative. Abdominal ultrasonography showed no pathology. Due to exacerbation of

Multiple pulmonary rheumatoid nodules.

We present a case of 45-year-old female patient with the diagnosis of seropositive rheumatoid arthritis, who was admitted to our rheumatology department with exacerbation of the disease. The patients disease activity score (DAS 28) was 6.9. Physical examination revealed changes in the lung auscultation as a rough breathing sound at the middle and lower lobe of the right lung. Chest X-ray revealed multiple nodular densities in both lungs. Lung biopsy was performed for the diagnosis and revealed necrotizing granulomas with central fibrinoid necrosis surrounded by epithelioid cells. Such a histopathological picture is typical for rheumatoid nodules. Finally the patient was treated with rituximab, with significant improvement.

Zoledronic Acid Effective as Rescue Treatment for Ankylosing Spondylitis Refractory to TNF Inhibition

Ankylosing spondylitis (AS) is an inflammatory, chronic rheumatic disease that primarily affects the sacroiliac, peripheral joints, and axial skeleton. Genetic, environmental factors, HLA-B27, and cytokines play an important role in the pathogenesis. The main clinical manifestation of disease is inflammatory chronic back pain. The Bath AS Disease Activity Index (BASDAI), Bath AS Functional Index (BASFI), and Assessment of SpondyloArthritis International Society (ASAS) instrument are useful instruments for assessing disease activity in AS. Although nonsteroidal anti-inflammatory drugs are effective for axial-peripheral joints, sulfasalazine for peripheral joints, and tumor necrosis factor-α (TNF-α) blockers for active and resistant AS, clinical response cannot be obtained in many patients. At this stage, various drugs such as abatacept, anakinra, rituximab, tocilizumab, or bisphosphonates have been investigated for refractory patients. There are limited studies about the use of bisphosphonates in patients with AS. We present here the case of a 47-year-old male patient with refractory AS who had clinical and laboratory response with zoledronic acid. A 47-year-old male patient was followed in our clinic with the diagnosis of AS. His general condition was stable, with blood pressure of 110/65 mm Hg and pulse rate of 72/ min; he had a fever of 36.8°C. He had inflammatory upperand low-back pain without peripheral arthritis that negatively affected his quality of life. X-ray of the pelvis showed grade III bilateral sacroileitis. There was no medical history of malignancy, amyloidosis, and comorbid diseases except for AS. He had a medical history of taking etanercept (50 mg once a week, 12 months), adalimumab (40 mg every 2 weeks, 9 months), golimumab (50 mg once a month, 12 months), and infliximab (5 mg/kg every 6 weeks, 9 months) at various points in time for refractory disease. His laboratory test results were as follows: hemoglobin, 12,8 g/dL; mean corpuscular volume, 92 fL; neutrophil count, 7.6 × 10/μL; thrombocyte count, 514 000/μL; erythrocyte sedimentation rate, 81 mm/h, C-reactive protein, 62.3 mg/dL. The patient’s renal tests, liver function tests, electrolytes, autoantibody, and thyroid hormone levels were within normal limits, and the urine test was negative for proteinuria. The BASDAI score was 6.4, and the BASFI score was 7.3. Abdominal ultrasonography revealed hepatosteatosis, and chest X ray was normal. We planned to start zolendronic acid (4 mg, once a year, intravenously) because of active disease with the treatment of infliximab 5 mg/kg, every 6 weeks. The disease was evaluated after zolendronic acid using clinical and laboratory parameters. Significant differences were observed in both disease activity scores and laboratory parameters compared with baseline. On the third month of zoledronic acid treatment, spinal symptoms, pain, and inflammation were decreased, and erythrocyte sedimentation rate and C-reactive protein level reached 21 mm/h and 1.8 mg/dL, respectively. BASDAI score was 2.1 and BASFI score was 4.7 at the third month. The BASDAI and BASFI scores decreased significantly after the treatment. Also, significant improvement was observed in disease activity index and inflammatory markers at the sixth month of therapy. The patient’s renal and liver function tests, electrolytes, and thyroid hormone levels were also within normal limits in our follow-ups. Bisphosphonates inhibit the osteoclast activity, modulate proinflammatory cytokines, and have anti-inflammatory or immune-modifying effects. These drugs may be used in therapy because of subchondral inflammation of bone marrow in AS. There are a number of studies about bisphosphonate use (generally with pamidronate) in patients with AS and spondyloarthropathies. Substantial improvements were observed in BASDAI scores but not in BASFI scores, Bath AS Metrology Index, C-reactive protein, or erythrocyte sedimentation rate with pamidronate. According to the study by Grover et al, there was no significant improvement in BASFI, pain, and patient global assessment, except for ASAS 20. Viapiana et al reported an open-label, singlecenter study in AS patients treated with neridronate or infliximab. The results showed the effectiveness of neridronate and infliximab for disease activity. Also, zoledronic acid is more potent than pamidronate, but it is unknown whether it improves osteitis in AS. We observed good clinical and laboratory response, and pain, BASDAI and BASFI scores, C-reactive protein level, and erythrocyte sedimentation rate were improved significantly with the treatment. In conclusion, combination of TNF-α blockers with zoledronic acid may be useful in the long term and could act as rescue medication for refractory AS patients. This therapy was effective over the short term for our patient; further controlled studies are required to determine the efficacy of this treatment strategy in all stages of AS (early, late, and refractory disease). 567679 AOPXXX10.1177/1060028014567679Annals of PharmacotherapySargin and Senturk research-article2015

Tst, Quantiferon-tb Gold test and t-spot.Tb test for detecting latent tuberculosis infection in patients with rheumatic disease prior to anti-tnf therapy

Introduction Influenza subtypes vary by clinical, radiological, and prognostic courses and may go along with viral pneumonia. We aimed to identify clinical, radiological, and prognostic aspects of influenza epidemic during years 2016-2017. Materials and Methods Influenza cases reported to the Public Health Directorate in our city was assessed retrospectively. Clinical, radiological, and prognostic parameters were compared based on influenza subtypes. Result We analyzed samples from 197 cases with suspected influenza. Mean age of the subjects was 51.17 ± 26.74. We found influenza A/H1N1, influenza A/H3N2, and influenza B in 59 (30.0%), 29 (14.7%), and 3 (1.5%) cases, respectively. Comorbidity was present in 48 (24.4%) cases. Most common radiological finding was interstitial pattern. Seventy-one and 79 per cent of H1N1 and H3N2 cases were influenza pneumonia, respectively. The prevalence of overall mortality was 5.5% with a predominance in H1N1 over H3N2. Influenza vaccination had been performed in 6.8% and 3.4% of H1N1 and H3N2 cases, respectively. We detected no mortality in any vaccinated patient. We identified 6 pregnant women, 2 of which ended up with preterm birth, and another one with abortion. Conclusions Often manifested as lower respiratory tract infection, influenza may cause epidemics with increased mortality rate. Influenza should be suspected when interstitial pattern was seen on radiological images. H1N1 cases course worse. Since the prognosis is better in vaccinated patients, seasonal influenza vaccination among the community needs to be elevated. In addition, protective measures like vaccination should be taken in pregnancy to avoid preterm delivery or abortion.