Mustafa Erman

Effect of prophylactic benzathine penicillin on mucocutaneous symptoms of Behçet's disease

BACKGROUND Recent studies point out a probable role of streptococcal antigens in the pathogenesis of Behçets disease (BD). This has led to the proposal of benzathine penicillin as a therapeutic modality in BD. OBJECTIVE A prospective study was conducted to compare the efficacy of colchicine and colchicine + benzathine penicillin treatments on mucocutaneous manifestations of BD. METHODS 60 patients (group I) were given colchicine alone and 94 (group II) were given colchicine + benzathine penicillin. Frequency, number, duration and severity of oral aphthous ulcers, genital ulcers and erythema nodosum were determined before and after treatment. RESULTS In group I, all parameters of oral ulcers and the frequency and healing time of genital ulcers and erythema nodosum decreased significantly. In group II, all parameters of oral aphthous ulcers, genital ulcers and erythema nodosum were significantly improved. When treatment results in the two groups were compared, the decrements in the frequency and duration of oral ulcers and erythema nodosum and the frequency of genital ulcers were significantly greater in group II than in group I (p < 0.05). CONCLUSION We conclude that prophylactic benzathine penicillin combined with colchicine is more effective in controlling mucocutaneous manifestations of BD than colchicine alone.

Old antihypertensives as novel antineoplastics: angiotensin-I-converting enzyme inhibitors and angiotensin II type 1 receptor antagonists

Angiogenesis, cellular growth and invasion of a cancer cell are attractive targets for new treatment strategies of malignancies in recent years. The evidences are accumulating that ACE inhibitors and angiotensin II type 1 antagonists could be novel anti-angiogenic, anti-invasive, and even anti-growth agents against neoplastic tissues: The renin-angiotensin system promotes angiogenesis directly or indirectly and growth of neoplastic cell. Some tumors carry angiotensin II type 1 receptors. Angiotensin II antagonists and angiotensin-I-converting enzyme inhibitors have shown some anti-neoplastic actions. Angiotensin II receptor blocker losartan antagonises platelets, which are thought to modulate via vascular endothelial growth factor. They may even protect the patient from the major toxicity of chemotherapy and/or radiotherapy, myelotoxicity, enabling us to give higher doses and end up with higher success rate. We believe that these agents can be useful on clinical grounds and suggest their incorporation into clinical studies.

Pneumocystis carinii pneumonia in a rheumatoid arthritis patient treated with adalimumab

Patients with rheumatoid arthritis (RA) have an increased risk of infection as a result of alterations in immune regulation, debility, and comorbid illnesses. TNF-α is of central importance in the pathophysiological responses to infection and inflammation, and plays a crucial role in host defence. Pneumocystis carinii is an opportunistic pathogen that commonly affects individuals with inadequate T-cell mediated immune response. Patients with acquired immune deficiency, as well as those receiving immunosuppressive drugs for various conditions have an increased risk of P. carinii pneumonia (PCP). We report the development of PCP in a woman with RA shortly after the initiation of anti-TNF-α treatment with adalimumab.

Platelet size has diagnostic predictive value for bone marrow metastasis in patients with solid tumors

Though not very common, solid tumor involvement of the bone marrow (BM) may have serious consequences. Recent studies have shown that mean platelet volume (MPV) is a good indicator for BM disease in the differential diagnosis of thrombocytopenia. We investigated the significance of MPV in the diagnosis of BM metastasis in patients with solid tumors. Patients with histologically‐verified solid tumors for whom BM biopsy specimens were available (n = 121) and healthy controls (n = 62) were included in this retrospective study. A total of 183 individuals were analyzed. Of the patients, 61 had a diagnosis of BM metastasis (Group A), 60 did not have BM metastasis (Group B). Group B and C (healthy controls) constituted the control group without BM metastasis (n = 122). The mean MPV was 7.0 ± 0.8 fl in patients with BM metastasis and 8.4 fl in the control group (P < 0.001). A cut‐off point of <7.4 fl was found to have significant predictive value according to receiver‐operating characteristics curve analysis. This cut‐off point had 85% positive predictive value and 90% negative predictive value in the diagnosis of BM metastasis (odds ratio: 53; 95% confidence interval: 20–135), and a sensitivity of 82.7% and specificity of 89.6%. MPV can be used as a reliable marker to guide the clinician as to the likely presence or absence of BM metastasis in patients with solid tumors.

Analysis of menstrual, reproductive, and life-style factors for breast cancer risk in Turkish women: a case-control study.

The aim of this study was to investigate the association between menstrual, reproductive, and life-style factors and breast cancer in Turkish women. In a hospital-based case-control study in Ankara, 622 patients with histologically confirmed breast cancer were compared with 622 age-matched controls, admitted to the same hospital for acute and non-neoplastic diseases. Unconditional logistic regression was used to estimate odds ratios (ORs) and 95% confidence intervals (CI) related to risk factors. Overall, menopausal status and age at menopause were found to be significantly associated with breast cancer. Having a full-term pregnancy and early age at first birth were associated with decreased breast cancer risk (OR=0.45, 95% CI=0.30–0.66; OR=0.34, 95% CI=0.22–0.53, respectively). Postmenopausal women with lactation longer than 48 mo had reduced risk of breast cancer (OR=0.36, 95% CI=0.14–0.93). In conclusion, decreased parity, late age at first birth, early menopause, and shorter duration of lactation were the most important determinants of breast cancer risk in Turkish women.

Correlation of in vitro fluconazole susceptibility with Clinical outcome for severely ill patients with oropharyngeal candidiasis

We investigated the correlation between in vitro susceptibility to fluconazole and clinical response in severely ill patients with oropharyngeal candidiasis treated with fluconazole. The study included 48 adult patients, of whom 23 were neutropenic (absolute neutrophil count, < 500/mm3). Forty-eight isolates (20 Candida albicans, 12 Candida krusei, 10 Candida kefyr, 3 Torulopsis glabrata, and 3 Candida tropicalis) were tested for susceptibility to fluconazole with use of the macrodilution method of the National Committee for Clinical Laboratory Standards. A strain was considered to be susceptible to fluconazole if the MIC was < or = 8 micrograms/mL and resistant if the value was > or = 64 micrograms/mL. All but one of the resistant strains were C. krusei isolates. Species of causative Candida, persistent neutropenia, and susceptibility to fluconazole were significant predictors of clinical response by univariate analysis. Logistic regression analysis indicated that the only significant factor was the species of Candida isolates, validating the recently recommended MIC breakpoint and the correlation between clinical outcome and in vitro antifungal susceptibility.

Metastatic granular cell tumor: A case report and review of the literature

To the EditorGranular cell tumors (GCT) are uncommon benigntumors. They may occur in various sites. The tongueand breast comprise the two most common loca-tions, while a lesion in the digestive and respiratorytracts is not unusual. Laryngeal involvement is fairlyuncommon and is present in approximately 10% ofall cases [1]. Malignant GCTs represent less than2% of all granular cell tumors [2]. As with theirbenign counterparts, malignant GCT have a wideanatomic distribution. However, they carry a poorprognosis, with recurrence and metastasis typicallywithin one year of diagnosis [3].We present a case of malignant granular celltumor arising from larynx, which has metastasizedto lungs and bones. We also conducted a search onthe MEDLINE database (National Library ofMedicine, Bethesda, MD) and identified 52 pre-viously reported cases of metastatic GCT whosesurvival data were reported. Basic characteristics ofthese cases together with ours are described in thefollowing sections. We also review the metastaticGCT in literature.Case ReportA 43-year-old woman was admitted to the hospitalfor long-standing cough and recent hemoptysis. Inher past history, she had undergone right verticallaryngectomy in another institution two years ago.The diagnosis was laryngeal GCT. Physicalexamination was unremarkable except for decreasedbreath sounds in the apex of the right lung. Chestx-ray revealed infiltration of right upper lung region.Computed tomography (CT) of the thorax showedmediastinal lymphadenopathies as well as a lesionthat partially obstructed the upper lobe bronchusand invaded the inferior vena cava. Bronchoscopyrevealed a bright, smooth and vascularized mass,obstructing the right upper lobe entrance. Punchbiopsy was performed. Histopathological examina-tion showed a GCT. The lesion appeared inoperabledue to the invasion of large vessels. Ultrasound andCT of the abdomen showed a giant hemangioma inthe right lobe of the liver. This finding was con-firmed by biopsy. Sixty Gy of external radiotherapywas administered to the pulmonary lesion.This intervention resulted in the palliation of he-moptysis, but the size of the lesion remained stable.As no other effective treatment modality wasavailable, a decision to administer chemotherapywas made. She received three cycles of cisplatinand fluorouracil. Toxicity was acceptable, however,the pulmonary lesion remained unchanged whilemultiple osteoblastic lesions appeared on directx-rays and radionuclide bone scan. Chemotherapywas discontinued, and she was given radiotherapy tothe right distal femur for pain palliation. Oraletoposide 50 mg/day was prescribed, but patientcould not tolerate and refused to use it after onlyten days of treatment.

Nonconvulsive Status Epilepticus Due to Ifosfamide

Objective: To report 2 cases of nonconvulsive status epilepticus (NCSE) following infusion of ifosfamide. Case Summaries: Two patients who received ifosfamide-containing chemotherapy developed NCSE. One woman received ifosfamide 1000 mg/m2 (1 h infusion on days 1–5); confusion, lethargy, and speech deterioration developed on day 3. The second patient developed similar symptoms on day 3 of treatment with 2500 mg/m2. Both patients responded to intravenous administration of diazepam 10 mg and were given levetiracetam as maintenance therapy. Discussion: The severity and presentation of central nervous system toxicity due to ifosfamide varies greatly and involves a spectrum ranging from subclinical electroencephalogram changes to coma. NCSE, an epileptic disorder in which typical convulsive activity is absent, has previously been reported in only 4 patients receiving ifosfamide. Levetiracetam may be used for maintenance antiepileptic therapy after diazepam administration. Conclusions: Among the many presentations of ifosfamide neurotoxicity, clinicians should consider NCSE as a possible explanation for changes in consciousness in a patient receiving this agent. An objective causality assessment by use of the Naranjo probability scale revealed that NCSE due to ifosfamide was probable.

Changes in the concentration and distribution of tissue factor pathway inhibitor in Behçet's disease and systemic lupus erythematosus: effect on the prethrombotic state

BACKGROUND Tissue factor pathway inhibitor (TFPI) is an anticoagulant which modulates the tissue factor (TF) dependent pathway, acting on the factor VIIa/TF complex, factor Xa, and thrombin. Although most TFPI is found in association with plasma lipoproteins and platelets, the functional pool is bound to vascular endothelium and is released into the circulation on stimulation with heparin or low molecular weight heparin (LMWH). OBJECTIVE To assess the vascular endothelial TFPI pool in patients with Behçets disease (BD) or systemic lupus erythematosus (SLE). METHODS Plasma TFPI concentrations were determined before, and 20 and 60 minutes after subcutaneous LMWH injection in 15 newly diagnosed patients with BD and 12 with SLE, and in 12 healthy controls. RESULTS Baseline median TFPI was 149.5 ng/ml in healthy subjects, and the percentage change in TFPI at 20 minutes (((value at 20th min − baseline value)/baseline value) × 100) was 575.2. TFPI concentrations in patients with BD were initially normal at baseline (136.0 ng/ml), but the percentage change (44.7) was significantly lower than in the patients with SLE and the controls. Baseline TFPI concentrations in patients with SLE (83.0 ng/ml) were lower than in the control group, but the TFPI response to stimulation with LMWH reached a level (626.4%) comparable to that of the controls. CONCLUSION Depletion of the functional endothelial pool in BD and low circulating concentrations of TFPI despite an intact pool in SLE may be important in the pathogenesis of thrombosis in these vasculitic syndromes.

Comparison of Cefepime and Ceftazidime in Combination with Amikacin in the Empirical Treatment of High-risk Patients with Febrile Neutropenia: A Prospective, Randomized, Multicenter Study

A total of 208 adult patients with cancer and febrile neutropenia from 5 medical institutions were randomized to receive either cefepime (2 g b.i.d.) or ceftazidime (2 g t.i.d.) in combination with amikacin (15 mg/kg/o.d.). Ninety-seven patients in the ceftazidime (CEZ) group and 98 in the cefepime group (CEF) were evaluable for efficacy. In 68 patients (35%), infection could be documented. The average duration of antibiotic therapy was 11 and 12 d and response rates to the empirical regimen were 36 and 30% for the CEZ and CEF groups, respectively (p >0.05). The average time of defervescence in responders was 3 d for both groups. Modification of the initial regimen with antivirals and/or azole antifungals raised the number of responders to 44% and 35%, respectively (p >0.05). Vancomycin was additionally given to 29 patients in the CEZ group and to 27 patients in the CEF group. Twenty-six patients in each group received empirical amphotericin B. Mild, reversible study drug-related side-effects were observed in 12 patients (12%) in the CEZ group and 13 patients (13%) in the CEF group (p >0.05). Cefepime in combination with amikacin seems to be as effective, safe and tolerable as ceftazidime + amikacin in patients with high-risk neutropenia and fever.A total of 208 adult patients with cancer and febrile neutropenia from 5 medical institutions were randomized to receive either cefepime (2 g b.i.d.) or ceftazidime (2 g t.i.d.) in combination with amikacin (15 mg/kg/o.d.). Ninety-seven patients in the ceftazidime (CEZ) group and 98 in the cefepime group (CEF) were evaluable for efficacy. In 68 patients (35%), infection could be documented. The average duration of antibiotic therapy was 11 and 12 d and response rates to the empirical regimen were 36 and 30% for the CEZ and CEF groups, respectively (p > 0.05). The average time of defervescence in responders was 3 d for both groups. Modification of the initial regimen with antivirals and/or azole antifungals raised the number of responders to 44% and 35%, respectively (p > 0.05). Vancomycin was additionally given to 29 patients in the CEZ group and to 27 patients in the CEF group. Twenty-six patients in each group received empirical amphotericin B. Mild, reversible study drug-related side-effects were observed in 12 patients (12%) in the CEZ group and 13 patients (13%) in the CEF group (p > 0.05). Cefepime in combination with amikacin seems to be as effective, safe and tolerable as ceftazidime + amikacin in patients with high-risk neutropenia and fever.