HIDRADENITIS SUPPURATIVA IN POSTMENOPAUSE.

BACKGROUND: Hidradenitis suppurativa (HS) is a chronic, debilitating disease with a profound impact on the quality of life of patients. OBJECTIVES: To describe a rare case of HS with postmenopausal onset, to review the literature data regarding late onset HS and to discuss the current knowledge on the role of endocrine abnormalities in the development of HS. CASE REPORT: We report the case of a 68-year-old patient in whom HS occurred 10 years after menopause. She was referred to our clinic for the presence of an open fistula on the left groin, fibrotic scars and visible alteration of the vulvar anatomy due to numerous surgical interventions. The patient shared features of the metabolic syndrome (obesity, arterial hypertension, dyslipidemia, aortic atherosclerosis), but showed no signs of virilism and no hormonal abnormality. HS was controlled using antiseptics, topical retinoids and antibiotics. CONCLUSIONS: This case is of particular interest given the late onset of HS, long time after menopause. The development of HS requires a complex interaction between genetic predisposing factors, endocrine dysregulation, metabolic alterations, bacterial overgrowth and an aberrant inflammatory response. Evidence points to an important role of sex-hormones in the emergence and progression of the disease, but the underlying mechanisms are still unclear. A better understanding of HS pathogenesis is needed to elucidate the precise way in which endocrine factors influence the disease onset and course. This would guide the way to novel therapies and a better control of this challenging disease.

Oxidative stress and alopecia areata.

Alopecia areata (AA) is an inflammatory and autoimmune disease presenting with non-scarring hair loss. The aethiopathogenesis of alopecia areata is unclear and many factors including autoimmunity, genetic predisposition, emotional and environmental stress are thought to play important roles in its development. Antioxidant/ oxidant balance perturbation is a common feature in autoimmune, emotional and environmental stress. Therefore, our paper discusses the implications of oxidative stress in alopecia areata.

Cutaneous adverse reactions specific to epidermal growth factor receptor inhibitors.

Classical antineoplastic therapy is encumbered by extensively studied adverse reactions, most often of systemic nature. The emergence of new generations of anticancer treatments, including epidermal growth factor receptor inhibitors, besides improving the response to treatment and the survival rate, is accompanied by the occurrence of new specific side effects, incompletely studied. These side effects are most often cutaneous (hand foot syndrome, acneiform reactions), and in some cases are extremely severe, requiring dose reduction or drug discontinuation. The prevention of the cutaneous adverse effects and their treatment require a close collaboration between the oncologist and the dermatologist. The occurrence of some of these skin adverse effects may be a favorable prognostic factor for the response to the cancer treatment and the overall survival.

Trigger points--ultrasound and thermal findings.

RATIONALE: Muscle pain can be elicited by any irritation of the nociceptors in the muscle or central sensitization in the central nervous system. The most frequently described muscle pain syndromes are myofascial pain syndrome and fibromyalgia syndrome. Myofascial pain syndrome has a more localized manifestation, the trigger points. OBJECTIVE: If there is a correlation between the clinical findings, the ultrasound examination and the thermal pattern of trigger points exist. MATERIAL AND METHOD: The presence of trigger points can be identified by using clinical criteria. An ultrasound examination was performed to evaluate the trigger point dimensions. The ultrasound showed an ellipsoidal hypoechogenic area in the muscle. A thermography of the low back region was performed in order to observe the thermal pattern of the area. RESULTS: Trigger points are represented by a higher temperature area surrounded by a cooler area, probably caused by a deficit in the blood flow around those points. DISCUSSION: Infrared thermography could be a great asset for the monitoring of neuromusculoskeletal disorders and their dynamics, as well as an important aid for the initial diagnosis of conditions associated with tissue temperature alterations.

Thermal patterns in zoster.

RATIONALE: Varicella zoster virus is a neurotropic virus that causes an infectious disease characterized by skin changes and neuropathic pain. After the resolution of the first infection, the virus lies dormant within the sensory ganglia. The reactivation of the virus causes zoster. An alteration in skin infrared emission might be expected in the areas of the skin affected by inflammatory changes and demyelination of the affected peripheral nerve. OBJECTIVE: To establish the importance of thermal imaging in the follow up of Zoster Zone with different localization. An infrared thermal camera was used in order to assess if the evolution of the disease determines a thermal pattern. METHODS AND RESULTS: Infrared thermography can be used for the assessment of the affected area also by using a thermography camera that is sensitive to the infrared spectrum. An intense and diffuse infrared emission is highly suggestive for the inflammation and implies that a more aggressive treatment should be initiated. After the clinical resolution of the affected area, the symmetry of the thermal pattern should be restored. If the asymmetry persists, a neuropathic complication of the virus reactivation could be involved. DISCUSSIONS: The integration of infrared thermography with the clinical findings is very useful in order to create a complete picture of the zoster lesions and this method could determine the beginning of a correct treatment and, by doing so, minimizing the risk of complications.

Non-steroidal anti-inflammatory drug - induced transient reactive papulotranslucent acrokeratoderma.

Transient reactive papulotranslucent acrokeratoderma (TRPA) is an unusual skin condition characterized by the rapid and transient development of symmetric, edematous white papules with eccrine duct prominence on the palms after exposure to water. We present the case of a 28-year-old woman diagnosed in our clinic with TRPA induced by the use of a non-steroidal anti-inflammatory drug. The possible pathophysiology and treatment options are discussed.

Psoriasis and Metabolic Syndrome--scientific evidence and therapeutic implications.

Psoriasis is a chronic inflammatory disease, predominantly affecting the skin, being included in the group of Immune Mediated Inflammatory Diseases. Growing evidence from the last 10 years suggests that several systemic conditions like metabolic syndrome, cardiovascular disease, diabetes, psychological disorders or inflammatory bowel disease are prevalent in psoriasis patients. The linker might be the chronic secretion of pro-inflammatory cytokines. In this current review, the scientific evidence that explains the relationship between psoriasis and the metabolic syndrome in particular will be addressed, as the metabolic syndrome comprises a group of risk factors for cardiovascular disease, thus offering an overall picture of the systemic involvement in psoriasis. An integrated approach, with an early detection and treatment of the components of the metabolic syndrome, are important steps in psoriasis management. Attention should be paid on influence of psoriasis treatment upon comorbidities and vice-versa.

Tattoo-induced psoriasis.

Koebner phenomenon represents the development of several inflammatory skin lesions (psoriasis, lichen planus, vitiligo, etc.) in uninvolved skin following various traumatic insults. The case of a 27-year-old male patient with scalp psoriasis who was referred to our clinic for generalized psoriatic lesions developed two weeks after tattooing his skin at the age of 18 was presented; the case illustrated the possibility of Koebner phenomenon induced by skin tattooing in patients with psoriasis.

[Our experience in the thoracoscopic surgery of the tuberculous pleural effusions]. / Experienta noastra în chirurgia toracoscopica a colectiilor pleurale tuberculoase.

Pleural tuberculosis (TB) is most often treated by a pneumologist. Some cases require operative interventions and may represent a challenge for the thoracic surgeon. There are two specific problems regarding TB pleural effusions: 15-25% of them remain undiagnosed using the conventional methods of diagnosis (imaging, thoracentesis, percutaneous pleural biopsies) and have a tendency for the rapid production of dense adherences and loculations. The authors present their experience in the diagnosis and the treatment of tuberculous pleurisy by means of mini-invasive surgical techniques. The period of study was January 2001-December 2006. In that period, the authors performed 400 video-assisted surgical operations, representing 9% of all the operations carried out in the clinic (3833). The surgical indications were for diagnosis (pleural, pericardial, lung or lymph node biopsy) and for treatment (pleurisy, pleuro-pericarditis, empyema). The contraindications for VATS were the usual ones. 56 cases were diagnosed with pleuro-pulmonary tuberculosis (14% of the VATS). For 43 patients the first approach was strictly thoracoscopic (VATS), while for the rest of 13 we started directly through a minithoracotomy with video assistance. We had 7 conversions to minithoracotomies with video assistance from those 43 aforementioned patients. Minithoracotomy with video assistance was preferred in 13 cases as a primary approach. We used two-port approach in 30 cases and the three-port triangular approach was useful for 6 patients. In 4 cases the bidigital technique was used in order to achieve greater room for exploration. We experienced only one minor intraoperative complication. Our results are comparable to those reported by other authors. The main idea of this paper is that the advantages of VATS in the pathology of the tuberculosis are undeniable.

[Bronchoscopy in thoracic trauma]. / Bronhoscopia în traumatologia toracica.

Thoracic trauma often bears difficult problems of diagnosis and treatment. This paper reports 87 procedures on 20 severe thoracic injured patients, who have also suffered multiple injuries, to whom was performed bronchoscopy. These cases were regarding gender, age, traumatic cause, associated injuries and dynamic endo-bronchial aspect. There are detailed technique used in bronchoscopy and bronchoscopic suction, additional diagnostic procedures, technical tips, incidents and are also reported close and follow up results in these cases. We discuss indications of bronchoscopy and broncho-aspiration in thoracic trauma from diagnostic and treatment point of view. Conclusions underline major role of bronchoscopy in the management of severe thoracic trauma.

Amino acid content of the brain in rats focal penicillin induced epilepsy.

The initial objective of the present study was to investigate the role of excitatory and inhibitory amino acids in generalized as compared to focal epilepsy, both forms being induced by the same convulsant agent, i.e. penicillin. Our attempts to obtain in the rat the generalized epilepsy, constantly induced in cats by systemic administration of penicillin, were unsuccessful. This is probably due to the rudimentary development of the cerebral cortex in rodents as compared to the feline cortex. The tentative conclusion was drawn that the cortex is the brain structure mainly involved in the genesis of petit mal seizures. Penicillin was applied to the cortex of 40 white Wistar rats and the electrical cortical activity was registered. The concentrations of glutamate, aspartate, glycine, GABA and serine were determined in the cerebral cortex, the brain stem and the cerebellum. The same amino acids were determined in the brain of 20 controls. No significant changes in the amino acid contents were obtained in the cerebral cortex. In the brain stem the glutamate level was significantly increased while the glycine content was markedly decreased. These findings are consistent with the involvement of the brain stem structures in seizure activity.

Neuromyotonia in alcoholic patients with gastrectomy.

Four patients with severe muscle cramps were reported. In two of them the electrical signs of neuromyotonia were demonstrated. All the patients had undergone gastrectomy and all were immoderate consumers of alcohol. The neuromuscular disorder was reversible in all the patients.

Stroke and hypertension. Antihypertensive therapy withdrawal.

The effect of antihypertensive therapy withdrawal in acute ischaemic stroke patients was assessed in order to establish possible correlations between blood pressure values and the modified Rankin Scale (mRS) outcome. One hundred and twelve consecutive patients with acute ischaemic stroke and hypertension were treated with relatively similar regimen. Seventy-two hours following the onset of stroke, systolic blood pressure decreased to < or = 180 mmHg in 110 patients. Antihypertensive therapy was randomly discontinued in 59 patients. Clinical outcome and mortality were compared in patients with and without antihypertensive therapy withdrawal, no statistically significant differences (p > 0.05) between the two groups being found. Statistically significant positive correlations (p < 0.05) between mRS outcome and the decrease of systolic and diastolic blood pressure values were in patients treated with anticoagulant and antihypertensive therapy. Statistically significant negative correlations (p < 0.05) between mRS outcome and low levels of diastolic blood pressure were noted in patients who discontinued antihypertensive therapy. Our findings emphasize the need to associate antihypertensive and anticoagulant therapy in acute ischaemic stroke patients with hypertension. Spontaneous decrease of diastolic blood pressure values showed poor outcome. The management of hypertension associated with acute ischaemic stroke should be reconsidered.

Increased susceptibility to audiogenic seizures following withdrawal of progesterone.

This investigation was performed to verify a previous hypothesis which correlates the catamenial seizures with the stoppage of progesterone secretion. White rats from a Wistar strain were tested with an electric bell. Thirty-five animals refractory to the acoustic stimulus were selected for the experiment. Each animal received 9 daily injections with progesterone, 5 mgr/day. The animals were tested with the acoustic stimulus after the 5th and the 9th injections, 24 hours after the administration of the last dose. Audiogenic seizures were obtained in 29.4% of the rats tested after 5 injections and in 40.0% of the rats tested after the 9th injection. The increased seizure susceptibility lasted 3-8 days after the hormone withdrawal. In conclusion, the withdrawal of high doses of progesterone exerts a seizure-activating effect.

Degenerative neuromuscular diseases with a late onset. Clinical, electrophysiological and morphological study.

This study carried out clinical, electrophysiological and morphological investigations (sural nerve and gastrocnemius muscle biopsies) in a group of 47 patients with neuromuscular disease of a certain or supposed degenerative origin and a late onset (over the age of 30 yrs.). It aimed the evidence of the eventual particularities of such diseases with a delayed onset. The equal involvement of sexes, the insidious onset, the clinical picture similar to that of the corresponding diseases with an onset at the usual age were observed. Regardless of the age, some interesting associations of the polyneuropathy with other diseases or its presence with in these diseases (Parkinsonism, Addison's disease, multiple symmetrical lipomatosis, etc.) were noticed, too. Electrophysiological examinations showed no particularities. Neither did the muscular morphological picture in most of the cases presenting neurogenic lesions with a moderate intensity. The sural nerve biopsy evidenced in 70% of the cases a moderately intense neuropathy of an axonal type ("dying back"), with or without secondary lesions of segmental demyelination and with the signs of a live regenerative activity.

The cerebral content of excitatory and inhibitory amino acids in rats following withdrawal of antiepileptic drugs.

The aim of the present study was to investigate the role of amino acids in the increased seizure susceptibility induced by withdrawal of antiepileptic drugs (AEDs). Fifty white Wistar rats treated with AEDs and 30 controls were used. The animals were previously exposed to the acoustic stimulus and only the non responsive were used. The administered AEDs were morphosuximide, ethosuximide, phenobarbital, valproate and gluthetimide. The treatment was discontinued after 2 weeks. The acoustic stimulation was repeated after 2-4 days of abstention. The animals were sacrificed and the amino acids glutamate, aspartate, GABA, glycine and serine were determined in the cortex and the brain stem. The withdrawal of AEDs induced seizure susceptibility in 71% of the rats treated with phenobarbital and in 76% of those receiving morphosuximide. A significant increase of glutamate levels was found in the brain stem following withdrawal of both morphosuximide and ethosuximide. The level of GABA was elevated in the brain stem after valproate and morphosuximide withdrawal. The increase of glutamate concentration can be correlated with the increased seizure susceptibility. The unexpected rise of the GABA level could be interpreted as a compensatory inhibitory mechanism.

Transient peripheral ischemia may restore quickly the motility in patients with compression neuropathy.

Transient ischemia of the extremities was applied in compression or traumatic neuropathies affecting radial nerve (17 cases), ulnar nerve (3 cases), upper brachial plexus (4 cases) or peroneal nerve (10 cases). The limb opposite to that displaying paresis was submitted repeatedly to a 15-minute-period of ischemia every other day for two weeks. The procedure induced in most patients (27 out of 34 cases) a motor improvement of variable degree. In some patients (13 cases) the motor recovery occurred two days or more after starting the procedures, while in others (14 cases) during the very day in which the initial session of ischemia was made or even during the first hour of procedure application. The most beneficial effects of peripheral ischemia were noted in compression neuropathy of peroneal nerve palsy, 9 out of 10 patients with such a disorder being improved by the procedure. We suppose that the method of therapy proposed by us restores promptly the motility of patients with compression neuropathy by inducing a long-lasting activation of some central neural mechanisms.

Ménière's attacks associated with facial paralysis.

An 85-year-old man developed in the last 5 years three attacks on Ménière's syndrome associated with facial paralysis. The syndrome could be interpreted as a transient ischemic attack in the territory of the anterior inferior cerebellar artery. An alternative hypothesis could be to admit a Ménière's disease with compression of the facial nerve during the attacks of labyrinthine hydrops.

Carotid endarterectomy.

Our study is based on 102 patients who underwent 104 carotid endarterectomies between 1980 and 1992. Sixty-three patients (61.8%) has surgery at left carotid artery bifurcation. 37 (36.2%) at right carotid artery bifurcation and in 2 cases (1.96%) the operation was performed at both carotid bifurcations. The patients' age ranged from 33 years to 73 years. The most frequently affected age group was between 41 and 50 years (47 cases). Postoperative death due to myocardial infarction occurred in one patient and other patient developed thrombosis of the internal carotid artery operated on. The remaining patients had a good surgical outcome.

Effect of hypothermia on focal experimental seizures.

The effect of general hypothermia was investigated in 15 unanesthetized cats. The animals were immobilized with Flaxedil and maintained on mechanical respiration. An epileptogenic focus was induced by stereo-tactical injection of penicillin to the right hippocampus. Cooling of the body was followed by a marked decrease of the amplitude and frequency of the penicillin spikes. The antiepileptic effect of general hypothermia was not dependent on brain stem section as suggested by previous investigations. Seizures generated by a hippocampic penicillin focus were more resistant to hypothermia than discharges produced by penicillin applied to the visual cortex.