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Jagoda Balaban

Abstract

Methotrexate is a cytotoxic antimetabolite agent and a folic acid antagonist. Except for its use in oncology and rheumatology, it is widely used in dermatology. The most important indications include severe forms of psoriasis, but also a wide range of autoimmune diseases and dermatoses with different etiology and pathophysiology such as: bullous pemphigoid, dermatomyositis, pityriasis rubra pilaris, sarcoidosis, T-cell lymphomas, Behcet’s disease, adult atopic eczema, scleroderma, Reiter’s syndrome and many others. For dermatological indications methotrexate is usually taken in low oral doses, 5-25 mg once a week. In certain diseases it can be applied to the lesion itself, or in the form of local preparations. Considering the fact that numerous drugs affect various metabolic phases of methotrexate and may increase its toxicity, it is of utmost importance to consider other prescribed drugs, especially certain antibiotics, nonsteroidal antiinflammatory drugs, antiepileptic drugs, retinoids, proton pump inhibitors and so on. If the selection of patients is correct, if drugs are taken regularly and laboratory monitoring is included, methotrexate is a truly efficient and safe drug that can be taken for months or years if necessary.

Open access

Jagoda Balaban, Dragana Popović and Svetlana Pavlović

Abstract

Neurofibromatosis-1 (NF1) is one of the most common hereditary multisystemic disorders. The disease manifests a variety of characteristic features that include: hyperpigmentary abnormalities of the skin (café-au-lait macules, freckles in the axillae, and iris Lisch nodules) and growth of benign peripheral nerve sheath tumors (neurofibromas) in the skin. Associated extracutaneous clinical features include: skeletal abnormalities, neurological, cardiovascular, endocrine and other malformations. NF1 is caused by mutation in the neurofibromatosis-1 gene, which codes for the protein neurofibromin. The inheritance of NF1 follows an autosomal dominant trait, although about 50% of patients present with new („de novo“) mutations, and represent the first member of their family. No difference in the severity of the disease can be found in patients with familial mutations versus those with new mutations. We present a 78-year-old female patient with an extreme cutaneous form of neurofibromatosis who reported no affected family member. Apart from skin problems, she had no major health issues in childhood and adolescence, but in recent decades she had frequent headaches, occasional abdominal pain, and vision and hearing impairment. About 10 to 14 days before admission, she developed a severe cough, shortness of breath, and chest and abdominal pain. On examination, the patient of short stature (hight: 152 cm, weight: 49 kg) presented with thousands of soft nodules dispersed over the whole body, except on extensor sides of thighs and lower legs; the nodules varied in color from skin-colored, livid erythematous, to brown-grey; the nodules on the abdomen were moist, partly bleeding from the base, and accompanied by an unpleasant odor. Her feet were also densely covered by dark purple lumps, with dystrophic changes of the toe nails that were thickened, frayed, and yellowish. The skeletal abnormalities included: short stature, severe osteoporosis and osteosclerosis of the head bone structure; degenerative arthropathc-spondylotic changes of the thoracolumbar spine segment with signs of diffuse skeletal hyperostosis; pronounced degenerative changes of the lumbar spine. CT scans of the head, chest and abdomen showed the following abnormalities: flattening of the paraventricular gyri and reduction of brain parenchyma with hypodensity of the white matter in terms of cortical atrophy; periventricular bilateral small post-ischemic microvascular brain lesions of varying chronicity; in the parenchyma of the upper left lung lobe the apical presence of small areas of pleural effusion with consequent subatelectic region; distended stomach and a small inner wall herniation; hypotrophic right kidney; atherosclerotic lesions of the abdominal aorta; low grade infrarenal kinking of the abdominal aorta. Pathohistological analysis of biopsy specimen taken from the nodule corresponded with cutaneous neurofibroma. Consultative examinations of various specialists pointed to the existence of the following comorbidities: obstructive respiratory syndrome and right lobe pneumonia that were treated by antibiotics, aminophylline and dexamethasone infusions; psycho-organic syndrome without focal neurological deficit; Lisch nodules in each eye, and senile cataract. Considering the age and medical presentation of the patient, no other treatment was considered. In conclusion, this is a sporadic case of cutaneous neurofibromatosis 1 in a 78-year-old female patient who presented with extremely severe cutaneous neurofibromas, making this case at least rather peculiar.

Open access

Jagoda Balaban and Đuka Ninković-Baroš

Abstract

Drug-induced delayed multiorgan hypersensitivity syndrome, also known as drug rash (reaction) with eosinophilia and systemic symptoms (DRESS) syndrome, represents a drug-induced cluster of skin, hematologic and systemic symptoms. More than forty drugs have been associated with this syndrome. We present a case of DRESS syndrome suspecting that lamotrigine was directly responsible for the patient’s rash and other symptoms. A female patient presented with extensive skin rash, fever, hematologic abnormalities, organ involvement such as hepatitis, pancreatitis and respiratory symptoms. The symptoms developed four weeks after the initiation of the offending drug, and disappeared eight weeks after its discontinuation.

Open access

Đuka Ninković Baroš, Jagoda Balaban, Svetlana Tomašević Pavlović, Aleksandra Salapura Dugonjić, Gorana Popović and Dušanka Brđanin

Abstract

We present a 46-year-old non-atopic HIV-negative woman from Doboj, Republic of Srpska, Bosnia and Herzegovina, who was referred to the Department of Dermatovenereology, Clinical Center Banja Luka, Republic of Srpska, Bosnia and Herzegovina, with a 3-month long history of an erythematous, large indurated infl amed area on the upper arm. The condition was asymptomatic, immediately following surgical excision of a small tumor. After exlusion of pulmonary blastomycosis and other organ involvement, the diagnosis of primary inoculation cutaneous blastomycosis was made based on clinical presentation and histopathological fi ndings. Histopathology revealed thick-walled, rounded, budding yeasts with broad-based buds that stained pink with periodic acid-schiff (PAS) staining. Itraconazole therapy was initiated at a dose of 2x100 mg/day. After three months of therapy, the dose of itraconazole was increased to 2x200 mg/day during the next three months, and then the dose was reduced to 2x100 mg. Blastomycosis is an uncommon, chronic granulomatous and suppurative mycosis caused by Blastomyces dermatitidis, which belongs to the group of main endemic systemic mycoses and in the great majority of cases represents a primary pulmonary disease. Few sporadic cases have been reported in Europe. There are three forms of blastomycosis: primary cutaneous, pulmonary and disseminated. B. dermatitidis has rarely been isolated from the environment. Wood debris or land close to rivers or subject to fl ooding are considered to be the natural substrate. The fungus can grow in sterile soil in the laboratory, and it is believed that humans get infected by inhaling spores from a saprophytic source. Primary cutaneous blastomycosis is very rare and it is found in farmers and laboratory workers. Human to human transmission does not normally occur. The diagnosis of the skin lesions is made by direct microscopy of skin samples (e.g., pus, scrapings) with 10% potassium hydroxide mount and confi rmed by culture or biopsy. Histopathological analysis provides identifi cation of all the dimorphic fungi. However, this can be complicated by the fact that in some cases they can be morphologically atypical or sterile. In the tissues, B. dermatitidis produces characteristic thick-walled, rounded, refractile, and spherical budding yeasts with broad-based buds. Of the available antimycotic drugs, itraconazole 200 mg/day is probably the most effective, but at least 400 mg/day is redommended initially.