Neurological and cardiac responses after treatment with miglustat and a ketogenic diet in a patient with Sandhoff disease.

Sandhoff disease is a progressive neurodegenerative disorder characterized by accumulation of GM2 gangliosides. We describe a 6-year-old male with coarse facial features, developmental delay, refractory seizures, hypertrophic cardiomyopathy, who was later found to have Sandhoff disease. Previous studies have revealed that caloric restriction in combination with miglustat increased survival and motor behavior in mouse model of Sandhoff disease. These findings suggest that combination therapy may result in improved outcomes for patients with Sandhoff. Initiation of treatment with miglustat and a ketogenic diet was followed by improvement of the patient's seizure control and cardiac function. Further clinical investigation is required to better determine the benefit of management in late-onset forms of Sandhoff disease.

[cartas] / [Letters]

Floridablanca, Santander, septiembre 19 de 2012 Señor Editor: Los doctores Silva, Prada, Páez y colaboradores, en la edición de la Rev Colomb Cardiol 2012; 19 (2): 100-104, presentaron el caso de un paciente con Ataxia de Friedreich (AF), en el que hicieron una interesante discusión sobre el compromiso cardíaco y neurológico, y algunas consideraciones acerca del trasplante cardíaco en estos pacientes (1). Como lo mencionan los autores, la ataxia de Friedreich es un trastorno degenerativo cerebeloso con un patrón de herencia autosómico recesivo, en el cual el compromiso cardiaco representa una de las principales causas de muerte, y en la que se ha encontrado disfunción mitocondrial y no es de carácter infiltrativo como se menciona; esto explica la fisiopatología de otras manifestaciones en estos pacientes como la misma diabetes. La cardiopatía hace parte del espectro clínico tardío y cuando se diagnostica, la discapacidad neurológica instaurada usualmente es severa y el pronóstico global muy comprometido. Recientemente, nuestro grupo publicó el caso de un paciente con historia de insuficiencia cardiaca diagnosticada desde los 18 años, que requirió trasplante cardiaco cuatro años después de iniciados los síntomas. Inicialmente se consideró que el origen de la cardiopatía era idiopático; sin embargo, seis meses después del trasplante, el paciente presentó alteraciones del equilibrio, la marcha y el lenguaje, lo que sugirió el diagnóstico de ataxia de Friedreich, el cual fue confirmado tras la determinación de la mutación homocigota con expresión de 900 y 700 tripletas GAA (2). Al re-interrogar al paciente, manifestó síntomas sutiles desde los 15 años, dados especialmente por sensación de debilidad en miembros inferiores que le generaba una ligera alteración de su patrón de marcha usual. Todos estos síntomas solo fueron evidentes pocos meses después del trasplante. De acuerdo con nuestro conocimiento, el caso reportado por nuestro grupo es el tercer caso publicado de trasplante cardiaco en un paciente con esta condición neurológica. Las dos publicaciones previas hipotetizaban un efecto del trasplante cardiaco sobre la condición neurológica de estos pacientes debido a una aparente mejoría en la ataxia y la disartria en los meses posteriores al trasplante. No obstante, los periodos de seguimiento de estos casos eran cortos (menores a dos años). A la fecha, nuestro paciente ha sido seguido durante nueve años, tiempo durante el cual ha mantenido una excelente función cardiaca, pero también una clara progresión de su compromiso neurológico a causa de la cual en el momento requiere asistencia para la marcha. A pesar del compromiso neurológico, el paciente ha llevado una calidad de vida aceptable, con posibilidades de realizar múltiples actividades cotidianas y de incorporarse activamente con su familia.

In vitro anti-inflammatory effects and immunomodulation by gemifloxacin in stimulated human THP-1 monocytes.

Cultured human THP-1 monocytes were exposed to serial concentrations of gemifloxacin over 4 h after pre-stimulation with zymogen A for 1 h or Staphylococcus aureus for 2 h. The following parameters were assessed: pH, phagocytosis, c-AMP, NO, TNFalpha, IL-1, IL-6, IL-8 and H2O2 levels, enzyme activities of protein kinase C, NADPH oxidase, SOD, gluthathion reductase, NAG and cathepsin D as well as lipid peroxidation. The reversiblity of these changes was determined in the presence of known blockers of the phagocytic process. The effects of gemifloxacin on DNA synthesis and killing of S. aureus was assessed in bacteria alone and in those bacteria phagocytosed by THP-1 monocytes over 24 h. Gemifloxacin in stimulated THP-1 monocytes over the first 30 min caused an increase in c-AMP, NO, H2O2 and TNFalpha levels and protein kinase C, NADPH oxidase, glutathione reductase, NAG and cathepsin D activities. The pH became more acidic and phagocytosis was stimulated. These parameters were reversed at 1 h and continued to decline until 4 h. Lipid peroxidation was at the highest levels at 1 h and IL-8 levels at 2 h. DNA synthesis and bacterial growth were suppressed at 2 h in both S. aureus alone and bacteria phagocytosed by THP-1 monocytes. These effects were at a higher magnitude at 24 h. Gemifloxacin initiates a phagocyticidal effect of THP-1 monocytes at an early time of 30 min which plays a role in killing bacteria but a higher magnitude of killing of bacteria occurs later by a standard static mechanism. This early action of gemifloxacin should decrease the spread of infection and the inflammatory response since the tissue destruction process was attenuated at 4 h.

In vitro susceptibilities of Bartonella and Rickettsia spp. to fluoroquinolone antibiotics as determined by immunofluorescent antibody analysis of infected Vero cell monolayers.

The in vitro susceptibilities of Bartonella and Rickettsia spp. to different concentrations of ciprofloxacin, levofloxacin, ofloxacin and sparfloxacin in Vero cell cultures, were determined by enumeration of immunofluorescent-stained bacilli. After incubation in a CO(2)-enriched atmosphere, inocula were replaced and tested with media containing 12 different concentrations of each antibiotic in replicate for each species and the monolayers were re-incubated. Growth status was determined by evaluation of immunofluorescent staining bacilli. Effective inhibitory antibiotic dilution endpoints were determined by counting Bartonella- and Rickettsia-specific fluorescent foci across a range of antibiotic dilutions with an epi-fluorescent microscope, and were compared with an antibiotic-negative control. Based upon the use of C(max):MIC and AUC:MIC data, levofloxacin exhibited activity against Bartonella elizabethae and B. quintana.

Disposition and functions of clarithromycin in human THP-1 monocytes during stimulated and unstimulated conditions.

The macrolide antibiotics are bacteriostatic agents interfering with protein synthesis but they are taken up by phagocytic cells, e.g. macrophages, neutrophils and fibroblasts which take up infectious organisms into phagosome-lysosomal vaculoes. Recent studies have suggested that these macrolide antibiotics block the spread of infections by mechanisms associated with the inflammation process. Herein is a study with clarithromycin using human THP-1 monocytes, a phagocytic cell which has not been studied to date. Clarithromycin was rapidly taken up by the monocytes (approximately 1%) utilizing both saturable carrier and passive processes at pH 7.4 but was exclusively passive at pH 6.8 and 5.0. The carrier process was energy and temperature dependent and appeared to be linked to certain ion channels. Efflux of the drug was rapid and complete in 1 hr. Intracellular disposition showed 74% in the cell sap and 11% in the nucleus. Upon stimulation with zymogen A or bacteria significant increases of uptake occurred in the isolated lysosome-phagosomes. Examination showed that initially clarithromycin treatment triggered the release of NO, H2O2, IL-1 and TNFalpha from the monocytes, known mediators of inflammation, but also mediators which cause bacterial cell death or apoptosis. The activity of the monocyte marker hydrolytic enzyme NAG was elevated at this time as well as protein kinase C activity. Treatment from 2-4 hr with clarithromycin appeared to reverse this process in that the chemical mediator release was reduced along with the activities of hydrolytic enzymes, e.g. NAG and cathepsin D with no evidence of lipid peroxidation and protective SOD enzyme activity elevation. The latter effects of the antibiotic would be useful in blocking the spread of infection or inflammation from the original site. The normal bacterial static killing effects of clarithromycin was evident at 24 but not 2 hr in both extracellular free bacteria and those bacteria phagocytosed by the THP-1 monocytes.

Mycotic infections. Effective management of conditions involving the skin, hair, and nails.

Superficial mycotic infections of the skin, hair, or nails are recurring presentations in the geriatric primary care setting. The most common infections are those caused by dermatophytes. The genus Trichophyton gives rise to most of the tinea dermatophytoses, including tinea capitis, tinea pedis, and tinea unguium (onychomycosis). Part of the diagnostic challenge lies in distinguishing the mycotic lesions from those caused by cutaneous diseases such as psoriasis, eczema, dyshidrosis, and contact dermatitis. Because environmental conditions play a major role in fungal infection onset, clinical management should include patient education about conditions conducive to fungal propagation. Oral agents are the primary mode of treatment for fungal infections of the scalp and nails, whereas topical treatments are frontline agents for other superficial skin conditions.

In vitro susceptibilities of Rickettsia and Bartonella spp. to 14-hydroxy-clarithromycin as determined by immunofluorescent antibody analysis of infected vero cell monolayers.

The in vitro susceptibilities of Rickettsia akari, Rickettsia conorii, Rickettsia prowazekii, Rickettsia rickettsii, Bartonella elizabethae, Bartonella henselae and Bartonella quintana to different concentrations of clarithromycin, 14-hydroxy-clarithromycin (the primary metabolite of clarithromycin) and tetracycline in Vero cell cultures, were determined by enumeration of immunofluorescently-stained bacilli. The extent of antibiotic-induced inhibition of foci was recorded for each dilution of antibiotic and compared with an antibiotic-negative control. Based upon MIC data, clarithromycin alone is highly active against all three Bartonella spp., R. akari and R. prowazekii, while 14-hydroxy-clarithromycin is active against R. conorii, R. prowazekii and R. rickettsii. Further testing is warranted in animal models and human clinical trials, to examine the activity of both clarithromycin and its primary metabolite and to define further the role of clarithromycin in therapy, particularly of infections caused by obligate intracellular bacteria such as Rickettsia and Bartonella spp.

In vitro susceptibilities of Bartonella henselae, B. quintana, B. elizabethae, Rickettsia rickettsii, R. conorii, R. akari, and R. prowazekii to macrolide antibiotics as determined by immunofluorescent-antibody analysis of infected Vero cell monolayers.

The in vitro susceptibilities of Bartonella (Rochalimaea) henselae, B. quintana, B. elizabethae, Rickettsia akari, R. conorii, R. prowazekii, and R. rickettsii to different concentrations of azithromycin, clarithromycin, dirithromycin, erythromycin, and roxithromycin in Vero cell cultures were evaluated. Bartonella and Rickettsia spp. were allowed to initiate infection of the antibiotic-free Vero cell monolayers, which were maintained in 16-chamber microscope slides in the absence of antibiotics at 32 degrees C in a CO2-enriched atmosphere. The monolayers were then incubated for 3 h to allow for initial host cell intracellular penetration by infecting species. After inoculation, inocula were replaced and tested with media containing 12 different concentrations of each antibiotic in replicate (10 wells of each antibiotic dilution) for each species, and the monolayers were reincubated. Tetracycline served as the control. Growth status of Bartonella spp. and Rickettsia spp. was determined by evaluation of immunofluorescent staining bacilli. Five days later, when antibiotic-free, control-infected cell monolayers demonstrated significant fluorescence, media were removed for all cell monolayers, the monolayers were fixed, and all specimens were stained with standard indirect immunofluorescent antibody reagents. Fluorescent foci were enumerated by counting such foci on random fields visualized with an epifluorescence microscope. The extent of antibiotic-induced focus inhibition was recorded for each dilution of antibiotic and compared with that of an antibiotic-negative control. Effective antibiotic dilution endpoints for inhibition of Bartonella and Rickettsia proliferation, as judged by absence of increase of significant fluorescence (as compared with no-growth controls), were enumerated by determining the number of cell culture chambers at various antibiotic dilutions that were negative or positive for significant Bartonella- or Rickettsia-specific fluorescence. All of the macrolide agents tested were readily active against all three Bartonella organisms, and azithromycin, clarithromycin, and roxithromycin may have potential in the treatment of Rickettsia infections. Animal model-based clinical trials are warranted to define the specific treatment role of the newer macrolide antibiotics.

Dermatologic adverse drug reactions in a family medicine setting.

To determine the prevalence of dermatologic adverse drug reactions in a family medicine outpatient practice setting, identify associated drug classes, and describe associated patient demographics and risk factors, we reviewed the charts of 557 patients in a university-based family medicine center who were diagnosed with a dermatologic condition. The study population included all patients diagnosed during a 1-year period. Thirty-five patients (6.3%) were identified as having dermatologic adverse drug reactions, of which the two most common types were exanthematous eruptions (n = 18 [51.4%]) and generalized erythroderma (n = 6 [17.1%]), with antibiotic use accounting for the majority (n = 21 [60.0%]) of reactions. Patient characteristics most commonly associated with a dermatologic adverse drug reaction were race (African-American), gender (female), and age (70 years and older). These data should provide insight into the types of cutaneous drug reactions commonly seen in community practice. Educational programs in all health-care disciplines, particularly medicine, pharmacy, and public health, that incorporate pharmacoepidemiologic strategies into their curricula are necessary to improve the overall process of monitoring and reporting of adverse drug reactions.