Methotrexate-induced acute cardiotoxicity requiring veno-arterial extracorporeal membrane oxygenation support: a case report.

BACKGROUND: Methotrexate is an antifolate antimetabolite that inhibits the activity of dihydrofolate reductase by acting as a false substrate, which leads to defects of DNA synthesis, specifically the inhibition of purine and pyrimidine synthesis. Thus, methotrexate is a powerful agent for treating autoimmune diseases and cancer. In general, methotrexate is thought to be cardioprotective and reports of methotrexate-induced cardiomyopathy are rare. We present a case of methotrexate-induced severe cardiotoxicity diagnosed by exclusion of all other potential causes. CASE PRESENTATION: The patient was a 54-year-old Caucasian man presenting to an outside hospital with a chief complaint of abdominal pain and bloating who reported taking methotrexate up to 20 mg per week for systemic sclerosis. After a transthoracic echocardiogram found a left ventricular ejection fraction of 10% and coronary catheterization demonstrated no significant disease, he was transferred to our hospital for advanced heart failure therapies. His condition deteriorated, and he was eventually placed on veno-arterial extracorporeal membrane oxygenation. Owing to a lack of an identifiable etiology of cardiac failure, toxicology consultation recommended 24 hours of intravenous leucovorin therapy to overcome any residual and potentially cardiotoxic methotrexate still in his system. Over the next 5 days, his cardiac function improved daily, such that on day 5 of extracorporeal membrane oxygenation, he had a left ventricular ejection fraction of 40% and was able to be decannulated. Two days later, his ejection fraction improved to 60% and normal right ventricular function. Initially, his renal function improved while on extracorporeal membrane oxygenation, but over the next week deteriorated such that he required intermittent hemodialysis until hospital discharge. CONCLUSIONS: After a process of elimination, the most likely cause of this patient's acute decline and rapid recovery of bi-ventricular function was methotrexate toxicity. Leucovorin may have aided the reversal of methotrexate toxicity.

Treatment of pseudofolliculitis barbae in very dark skin with a long pulse Nd:YAG laser.

BACKGROUND: Pseudofolliculitis barbae affects some individuals with coarse curly hair. Currently available treatment modalities are often ineffective. In some studies, lasers have been shown to be potentially helpful in mitigating disease severity by reducing the number and/or thickness of hair shafts. METHODS: This was a side-by-side interventional study conducted at a military tertiary medical facility. The study group included 26 patients (skin types IV, V, and VI) referred from primary care physicians with a diagnosis of pseudofolliculitis barbae refractory to medical therapy. A neodymium YAG laser was used to treat one half of the neck. One month later, shaving bumps were counted and compared to their preoperative levels on both sides. RESULTS: Mean postoperative papule counts were 11.6 +/- 6 (SD) and 30.1 +/- 19 (SD) on the treated side and untreated sides, respectively. CONCLUSION: Neodymium YAG laser treatment represents a safe and effective option for reducing papule formation in patients with pseudofolliculitis barbae.

Treatment of pseudofolliculitis barbae in skin types IV, V, and VI with a long-pulsed neodymium:yttrium aluminum garnet laser.

BACKGROUND: Pseudofolliculitis barbae affects a large number of individuals with coarse curly hair, and present treatment options are suboptimal. OBJECTIVE: We evaluated the safety and efficacy of a long-pulsed neodymium:yttrium aluminum garnet (Nd:YAG) laser in the treatment of pseudofolliculitis barbae. METHODS: This was a two-phase observational study conducted at a military tertiary medical facility. The study group included 37 patients (skin types IV, V, and VI) referred from primary care physicians with a diagnosis of pseudofolliculitis barbae refractory to conservative therapy. In phase I, one treatment with a Nd:YAG laser was performed on a tattooed area of the thigh with 3 light doses. Epidermal tolerance was evaluated, and hair counts were performed 3 months after treatment for each light dose. In phase II, the highest dose tolerated by the epidermis from phase I was applied to a small submental region of skin with an adjacent site as a control. Subsequently, papule counts were performed 90 days after treatment in the laser-irradiated and control areas. RESULTS: Phase I: When normalized for controls, there was 33%, 43%, and 40% hair reduction on the thigh for the 50, 80, and 100 J/cm(2) fluences, respectively, after 90 days. Overall, the highest doses tolerated by the epidermis were 50, 100, and 100 J/cm(2) for type VI, V, and IV skin, respectively. Phase II: Mean papule counts after 90 days were 6.95 and 1.0 for the control and treatment sites, respectively. CONCLUSION: Nd:YAG laser treatment may represent a safe and effective option for reducing hair and subsequent papule formation in patients with pseudofolliculitis barbae.