Dexrazoxane for rapid extended livedo reticularis-like skin reaction due to systemic epirubicin diffusion during transcatheter arterial chemoembolization procedure for hepatocellular carcinoma.

Skin reactions after transarterial chemoembolization (TACE) with anthracyclines are rare and mostly limited to small areas. We describe a 56-year-old male with hepatocellular carcinoma treated with epirubicin chemoembolization. Immediately the procedure, pain on the right side and an extended livedo reticularis-like skin reaction appeared. Since dexrazoxane, a topoisomerase-II catalytic-cycle inhibitor, has been shown to be effective in preventing or reducing skin necrosis and ulceration following anthracycline extravasation, the drug was administered 8 h after TACE and repeated in the following 2 days. Due to marked extrahepatic diffusion of epirubicin as evidenced by computed tomography imaging, the patient showed signs of systemic organ involvement. The critically ill patient required close follow-up and intensified treatment including blood supply and pulmonary drainage of a pleural effusion. The patient presented a significant clinical improvement of the skin lesions and resolution of organ involvement with normalization of laboratory parameters after dexrazoxane. In conclusion, adverse extended skin reactions and severe systemic effects related to anthracyclines diffusion could be properly treated with dexrazoxane infusion.

Medications prescriptions in COVID-19 pregnant and lactating women: the Bergamo Teratology Information Service experience during COVID-19 outbreak in Italy.

Objectives The severe acute respiratory syndrome coronavirus 2 (COVID-19) outbreak in Italy, especially in Lombardy and Bergamo city, represented probably nowadays one of the first major clusters of COVID-19 in the world. The aim of this report is to describe the activity of Bergamo Teratology Information Service (TIS) in supporting the public and health-care personnel in case of drug prescriptions in suspected/confirmed COVID-19 pregnant and lactating patients during COVID-19 outbreak in Italy. Methods All Bergamo TIS requests concerning COVID-19 pregnant and lactating women have been retrospectively evaluated from 1 March to 15 April 2020. Type of medications, drug's safety profile and compatibility with pregnancy and lactation are reported. Results Our service received information calls concerning 48 (9 pregnant, 35 lactating) patients. Among pregnant and lactating women, the requests of information were related to 16 and 60 drugs prescriptions respectively. More than half concerned drugs prescriptions during the first and second trimester (13/16) and during the first six months of lactation (37/60). Hydroxychloroquine and azithromycin were the most involved. Conclusions Hydroxychloroquine and azithromycin at dosages used for COVID-19 may be considered compatible and reasonably safe either in pregnancy and lactation. Antivirals may be considered acceptable in pregnancy. During lactation lopinavir and ritonavir probably exhibit some supportive data from literature that darunavir and cobicistat do not. Tocilizumab may be considered for COVID-19 treatment because no increased malformation rate were observed until now. However caution may be advised because human data are limited and the potential risk of embryo-fetal toxicity cannot be excluded.

Lacosamide-induced recurrent ventricular fibrillation: A case report.

Lacosamide, a new antiepileptic drug, acts at central nervous system level but may also affect the heart, increasing the risk of cardiac arrhythmias. Only few cases of lacosamide-induced cardiac dysrhythmia have been published. We report a case of several episodes of a life-threatening ventricular fibrillation requiring cardioversion following the first doses of lacosamide as adjunctive epilepsy treatment.

Glatiramer acetate-induced hepatitis in a young female patient with multiple sclerosis.

We report the first Italian case of glatiramer acetate-related acute hepatotoxicity. A 25-years-old woman suffering from multiple sclerosis presented acute hepatitis after eight months of treatment. Neither infective, nor autoimmune markers were detected. Liver biopsy histology was consistent with drug-induced acute injury. Liver function tests became normal after eight weeks of treatment discontinuation. This report points out the importance of monitoring liver function during the first year of treatment with glatiramer acetate.

Identification of taxine derivatives in biological fluids from a patient after attempted suicide by ingestion of yew (Taxus baccata) leaves.

The yew tree (Taxus baccata) is an evergreen conifer that is widespread over central and southern Europe. The toxic effects of this conifer and its leaves have been known since ancient times. The seeds are generally responsible for accidental intoxications in childhood, whereas the bark and the leaves are mainly used for homicidal or suicidal attempts. We investigated the metabolic pattern of taxines in a healthy 44-year-old male farmer who was admitted to Bergamo Emergency Department after attempting suicide. High-performance liquid chromatography was used to separate and identify taxine metabolites. Data reported in this paper confirmed that the patient attempted suicide by ingesting Taxus baccata leaves, which had been suggested by clinical examination. The most abundant free and conjugated taxine metabolites were characterized. The high concentration of conjugated metabolites found in urine underscores the critical role that conjugation in the liver plays in eliminating taxines and increasing the probability of the patient's survival.

Extracorporeal life support in a severe Taxus baccata poisoning.

INTRODUCTION: Yew (Taxus baccata) is a conifer known to be toxic since ancient times. Taxine A and taxine B, the toxic alkaloids of Taxus, block cardiac sodium and calcium channels causing nausea, vomiting, abdominal pain, cardiac arrhythmias, respiratory distress, coma, seizures, and death in yew poisoning. CASE REPORT: A 44-year-old male farmer was admitted to the hospital because of a suspected myocardial infarction. First bradycardia and then ventricular tachycardia were present and a severe right ventricular dilatation with biventricular dysfunction was observed but with normal coronary arteriography. He was resistant to conventional therapy and, 6 h after hospital admission, extracorporeal support with membrane oxygenation was applied. The patient recovered. Nine days later, a large number of yew leaves were unexpectedly observed in his feces. Botanical and laboratory analysis confirmed the poisoning. Blood (651 ng/mL) and urinary (5.6 mcg/mL) levels of 3,5-dimethoxyphenol (metabolite of taxicatine) were greater than previously reported in lethal cases. The patient was transferred to a psychiatric unit 17 days after admission. CONCLUSIONS: Intensive treatment of severe cardiovascular symptoms with antiarrhythmic drugs, temporary pacemaker, intra-aortic balloon pump, extracorporeal membrane oxygenation, and extracorporeal life support can be life-saving even after a potentially lethal ingestion of T. baccata leaves.

Update on management of caustic and foreign body ingestion in children.

The following recommendations for management of caustic and foreign body ingestion in children have been developed following a multicentre study performed by the Italian Society for Paediatric Gastroenterology, Hepatology and Nutrition (SIGENP). They are principally addressed to medical professionals involved in casualty. Because there is paucity of good quality clinical trials in children on this topic, many of the recommendations are currently extrapolated from adult experiences or based on experts opinions. The document represents a level 2 to 5 degree of evidence (according to the Oxford Centre for Evidence-based Medicine Levels of Evidence), gathered from clinical experience, recent studies, and expert reports discussed during a consensus conference of the Endoscopic Section of the Italian Society of Paediatric Gastroenterology Hepatology and Nutrition. This working group comprises paediatricians, endoscopists, paediatric surgeons, toxicologists, and ENT surgeons, who are all actively involved in the management of these children. Recommendations are intended to serve as an aid to clinical judgement, not to replace it and therefore do not provide answers to every clinical question; nor does adherence to them ensure a successful outcome in every case. The ultimate decision on the clinical management of an individual patient will always depend on the specific clinical circumstances of the patient, and on the clinical judgement of the health care team.