Polypharmacy May Be the Cause of Acute Lithium Intoxication at the Second Day of Treatment.

UNLABELLED: Lithium is frequently used as a mood stabilizer in patients with mood disorders. Lithium has a narrow therapeutic index and high toxicity. Predisposing factors for intoxication are advanced age, diet disturbances, comorbid medical conditions affecting heart, kidneys or central nervous system and polypharmacy. CASE REPORT: Here we present a case of a 74-year-old woman with a history of Parkinson's disease, hypertension and bipolar disorder. She was using quetiapine, valsartan with hydrochlorothiazide and levodopa with carbidopa. She presented with altered mental status and muscle rigidity. The patient was admitted with acute lithium intoxication after her second dose of treatment. Blood lithium level increased to 3.58 mEq/L. The woman was hospitalized in the Internal Medicine Intensive Care Unit. With hydration, her symptoms resolved and her lithium level returned to normal after 118 hours. CONCLUSIONS: Prescribing physicians and emergency room physicians should be aware of conditions which may cause a decreased threshold for intoxication.

The association between endothelial dysfunction and hypertensive retinopathy in essential hypertension.

BACKGROUND: Endothelial dysfunction, which is characterized by an imbalance between relaxing and contracting factors, procoagulant and anticoagulant substances, and between pro-inflammatory mediators, may play a particularly significant role in the pathogenesis of atherosclerosis. Numerous experimental and clinical reports suggest that a high von Willebrand factor (vWF) level reflects endothelial damage or dysfunction. Hypertensive retinopathy (HR) is a condition characterized by a spectrum of retinal vascular signs in people with elevated blood pressure. The pathophysiological mechanism of HR is not completely understood. Elevated blood pressure alone does not fully account for the extent of retinopathy. Endothelial dysfunction and mechanisms known to be involved in vascular lesions may be involved in the pathophysiological mechanism of HR. Therefore, this study was designed to answer the following questions: (i) Do vWf levels change in HR? and (ii) Is there any relation between degree of HR and vWf levels? MATERIAL AND METHODS: This study included 80 hypertensive patients with HR. Group 1 comprised 40 patients with grade I HR, and group 2 comprised 40 patients with grade II HR. We selected 40 healthy subjects for the control group. RESULTS: Level of vWf in group 2 was significantly higher than in group 1 (p=0.017) and the control group (p<0.001), and it was also higher in group 1 than in the control group (p<0.005). Also, vWf showed positive correlation with degree of HR in the hypertensive group (r=0.284, p=0.009). CONCLUSIONS: Our study suggests that endothelial dysfunction, which is a mechanism known to be involved in vascular lesions, may promote the development of HR.

The association of oxidative stress with hypertensive retinopathy.

This study was designed to answer the following questions: (i) Do levels of serum gamma-glutamyl transferase (GGT), a marker of oxidative stress, change in hypertensive retinopathy (HR)? (ii) Is there any relation between degree of HR and GGT levels? This study included 80 hypertensive patients with HR. Group 1 comprised 40 patients with grade I HR, and group 2 comprised 40 patients with grade II HR. We selected 40 healthy subjects for the control group. Level of GGT in group 2 was significantly higher than in group 1 (P = 0.005) and control group (P = 0.001); it was also higher in group 1 than in control group (P = 0.025). Our study suggests that oxidative stress, mechanisms known to be involved in vascular lesions, may promote the development of HR.

The relationship between levels of von Willebrand factor and mean platelet volume in subjects with isolated impaired fasting glucose.

BACKGROUND: To understand the heterogeneity of platelets, we investigated the correlation between von Willebrand factor (vWf) and mean platelet volume (MPV) in subjects with isolated impaired fasting glucose (IFG). MATERIAL/METHODS: We selected 48 subjects with isolated IFG and 48 normoglycemic control subjects matched for age, sex, and body mass index. We measured levels of vWf and MPV in all subjects. RESULTS: The levels of vWf and MPV were significantly higher in the isolated IFG group than the control group (p<0.05) Also, vWf level was positively correlated with MPV level in subjects in the isolated IFG group (r=0.452, p=0.001). CONCLUSIONS: Our results suggest that vWf seems to be profoundly related to platelet volume in subjects with isolated IFG.

Serum ferritin levels correlate with hypertensive retinopathy.

BACKGROUND: In recent years several studies showed an association between body iron stores, represented by serum ferritin, and oxidative stress. The pathophysiological mechanism of hypertensive retinopathy (HR) is not fully established. Elevated blood pressure alone does not fully account for the extent of retinopathy; other pathogenic mechanisms may be involved, such as increased oxidative stress. Therefore this study was designed to determine whether ferritin levels change in HR and whether there is any relationship between the degree of HR and ferritin level. MATERIAL/METHODS: This study included 72 essential hypertensive patients with HR. The hypertensive patients were divided into two groups according to the Keith-Wagener classification. Group 1 comprised 36 patients with grade I HR and group 2 36 patients with grade II HR Thirty-six normotensive healthy subjects matched for age, sex, and body mass index were selected for the control group. RESULTS: The level of ferritin in group 2 was significantly higher than in group 1 (92.9+/-31.8 vs. 77.8+/-23.7 ng/ml, p=0.027) and the normotensive control group (92.9+/-31.8 vs. 59.9+/-19.2 ng/ml, p=0.001). It was also higher in group 2 than in the control group (77.8+/-23.7 vs. 59.9+/-19.2 ng/ml, p=0.018). Ferritin level also showed positive correlation with the degree of HR in the hypertensive group (r=0.31, p=0.026). CONCLUSIONS: This study suggests that there is a relationship between HR and ferritin level, which may be associated with an increased level of oxidative stress.

Increased mean platelet volume in chronic hepatitis B patients with inactive disease.

BACKGROUND: Hepatitis B virus (HBV) infection is a major public health problem worldwide, responsible for considerable morbidity and mortality from chronic liver disease. Conflicting findings on the possible association between HBV surface antigen (HBsAg) positivity, indicating inactive HBsAg carrier status, and atherosclerosis have been reported. Platelet activation and aggregation are central processes in the pathophysiology of atherosclerosis. Mean platelet volume, a determinant of platelet activation, is a newly emerging risk factor for atherothrombosis. Elevated MPV levels have been identified as an independent risk factor for myocardial infarction in patients with coronary heart disease, and for death or recurrent vascular events after myocardial infarction. Moreover, increased platelet size has been reported in patients with vascular risk factors such as diabetes mellitus, in patients with acute ischemic stroke, and essential hypertension. According to our knowledge, there has been no previous study of MPV in inactive HBsAg carriers. Therefore, we have investigated the possible association between HBsAg positivity and MPV. MATERIAL/METHODS: We selected 260 inactive HBsAg carriers, and 80 healthy control subjects matched for age, sex, and body mass index. RESULTS: The MPV level was significantly higher in the inactive HBsAg carrier group than in the control group (8.8+/-1.2 fl vs 8.1+/-0.9 fl, P=.001). CONCLUSIONS: Our results suggest that inactive HBsAg carriers tend to have relatively increased platelet activation and an atherothrombotic risk.

The association of low-grade systemic inflammation with hypertensive retinopathy.

High-sensitivity C-reactive protein (hs-CRP) is a marker of systemic low-grade inflammation. The pathophysiologic mechanism of hypertensive retiopathy (HR) is not fully established. Elevated blood pressure (BP) alone does not fully account for the extent of retinopathy, other pathogenic mechanisms may be involved, such as low-grade inflammation. Therefore, this study was designed to answer the following questions. (i) Do hs-CRP levels change in HR? (ii) Is there any relation between degree of HR and hs-CRP levels? This study included 84 hypertensive patients with HR. The hypertensive patients were divided into two groups according to the Keith-Wagener classification. Group 1 comprised 42 patients with grade I HR, and Group 2 comprised 42 patients with grade II HR. We selected 42 healthy subjects matched for age, sex, and body mass index (BMI) for control group. The level of hs-CRP in group 2 was significantly higher than in group 1 group (p = 0.018) and control group (p = 0.001), it was also higher in group 1 than in control group (p = 0.002). Also, hs-CRP showed positive correlations with degree of HR (r = 0.29, p = 0.017). Our study suggests that there is a relationship between HR and hs-CRP levels, which may be associated with systemic low- grade inflammation.

Plasma levels of von Willebrand factor in subjects with isolated impaired fasting glucose.

BACKGROUND: It has been shown that an increased von Willebrand factor level reflects endothelial dysfunction and may also have prognostic value in patients with atherosclerotic disease. Impaired fasting glucose is likely a frequent glycemic disorder in the general population and is considered a prediabetic state. Impaired fasting glucose is associated with cardiovascular disease, but it is unclear whether it is an independent risk factor because it commonly coexists with other cardiovascular risk factors present in metabolic syndrome. The present study was designed to evaluate the von Willebrand factor level in subjects with isolated impaired fasting glucose compared to healthy normoglycemic subjects. MATERIAL/METHODS: We selected 48 subjects with isolated impaired fasting glucose and 48 normoglycemic control subjects matched for age, sex, and body mass index. We measured the von Willebrand factor level in all subjects. RESULTS: The von Willebrand factor level was significantly higher in the isolated impaired fasting glucose group than in the control group (111.08%+/-52.78% vs 74.08%+/-48.47%) (P=0.001). The von Willebrand factor level was also positively correlated with fasting plasma glucose in the isolated impaired fasting glucose group (P=0.004). CONCLUSIONS: Our results show that subjects with isolated impaired fasting glucose have higher von Willebrand factor levels, which suggests endothelial dysfunction.

The spectrum of diseases causing fever of unknown origin in Turkey: a multicenter study.

OBJECTIVE: The purpose of this trial was to determine the spectrum of diseases with fever of unknown origin (FUO) in Turkey. METHODS: A prospective multicenter study of 154 patients with FUO in twelve Turkish tertiary-care hospitals was conducted. RESULTS: The mean age of the patients was 42+/-17 years (range 17-75). Fifty-three (34.4%) had infectious diseases (ID), 47 (30.5%) had non-infectious inflammatory diseases (NIID), 22 (14.3%) had malignant diseases (MD), and eight (5.2%) had miscellaneous diseases (Mi). In 24 (15.6%) of the cases, the reason for high fever could not be determined despite intensive efforts. The most common ID etiologies were tuberculosis (13.6%) and cytomegalovirus (CMV) infection (3.2%). Adult Still's disease was the most common NIID (13.6%) and hematological malignancy was the most common MD (7.8%). In patients with NIID, the mean duration of reaching a definite diagnosis (37+/-23 days) was significantly longer compared to the patients with ID (25+/-12 days) (p=0.007). In patients with MD, the mean duration of fever (51+/-35 days) was longer compared to patients with ID (37+/-38 days) (p=0.052). CONCLUSIONS: Although infection remains the most common cause of FUO, with the highest percentage for tuberculosis, non-infectious etiologies seem to have increased when compared with previous studies.

The effect of rosuvastatin treatment on the mean platelet volume in patients with uncontrolled primary dyslipidemia with hypolipidemic diet treatment.

Platelet activation and aggregation are central processes in the pathophysiology of coronary heart disease. Mean platelet volume (MPV), a determinant of platelet activation, is a newly emerging risk marker for atherothrombosis. Rosuvastatin, a new hydrophilic 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitor (statin), is approved as an adjunct to diet in patients with dyslipidemia. In this study, we evaluated the effects of rosuvastatin on the MPV levels in patients with uncontrolled primary dyslipidemia with hypolipidemic treatment. We selected 30 age, sex and body mass index matched patients with uncontrolled primary dyslipidemia and hypolipidemic diet treatment and 30 normolipidemic healthy subjects. Dyslipidemic patients were treated with 10 mg/day rosuvastatin for 12 weeks. Metabolic parameters and MPV were measured at baseline and after rosuvastatin treatment in dyslipidemic group. At baseline, the dyslipidemic group had significantly higher MPV levels than in the healthy control group (8.4 +/-1.2 fl vs. 8.1 +/-0 1.0 fl, p < 0.005). The level of MPV decreased significantly after rosuvastatin treatment from a mean of 8.4 +/- 1.2 fl to 8.1 +/- 1.3 fl, (p < 0.001). The changes in MPV levels with rosuvastatin treatment were not correlated to changes in plasma lipids (p > 0.05). In addition to its well-known hypolipidemic effect, rosuvastatin also possesses significant anti-platelet activation properties. This antiplatelet effect of rosuvastatin treatment could play a role in reducing cardiovascular complications in primary hyperlipidemic patients.

Platelet activation in patients with Familial Mediterranean Fever.

Increased platelet activation and aggregation are central processes in the pathophysiology of atherosclerosis. Increased platelet activity is associated with increased platelet volume. Mean platelet volume (MPV), a determinant of platelet function, is a newly emerging risk factor for atherothrombosis. Familial Mediterranean Fever (FMF) is an autosomal recessive disease characterized by recurrent inflammatory febrile attacks of serosal and synovial membranes. Recently few studies have shown that FMF is associated with increased atherosclerosis risk. The present study was designed to evaluate levels of MPV in FMF patients compared with healthy subjects. We selected 35 FMF patients and 35 healthy control subjects matched for age, gender, and body mass index. Metabolic parameters and MPV levels were measured in all groups. Metabolic parameters were not different among the study groups (p > 0.05). The levels of MPV were significantly higher in the FMF group than in the control group (8.6 +/- 0.9 fl vs 7.8 +/- 0.5 fl, p = 0.001). The MPV levels were negatively correlated with duration of colchicine treatment (r = -0.40, p = 0.017). Also MPV levels showed positive correlation with delay of diagnosis (r = 0.58, p = 0.001). In conclusion, our results suggest that patients with FMF tend to have an increased platelet activation. Increased platelet activity could contribute to increasing the atherosclerotic risk in FMF patients.

The association of mean platelet volume levels with hypertensive retinopathy.

The pathophysiological mechanism of hypertensive retinopathy (HR) is not fully established. Elevated blood pressure alone does not fully account for the extent of retinopathy so other pathogenic mechanisms may be involved, such as increased platelet activation. Mean platelet volume (MPV) is a marker of platelet activation. Therefore, this study was designed to answer the following questions: Do MPV levels change in HR? and is there any relation between degree of HR and MPV levels? This study included newly diagnosed and 57 untreated essential hypertensive patients with HR. The hypertensive patients were divided into two groups according to the Keith, Wagener classification. Group 1 comprised 29 hypertensive patients with grade 1 HR with a mean age of 56.8 +/- 9.7 years. Group 2 comprised 28 hypertensive patients with grade 2 HR with a mean age of 58.1 +/- 10.3 years. Twenty-seven normotensive subjects who were the healthy participants and had undergone the check-up program were used as the control group. Fundoscopic examination, metabolic parameters and MPV levels were measured in all groups. The level of MPV in group 2 was significantly higher than in group 1 (8.9 +/-0 0.8 fl vs. 8.3 +/- 0.8 fl, p = 0.02) and the normotensive control group (8.9 +/- 0.8 fl vs 7.8 +/- 0.7 fl, p < 0.001). It was also higher in group 1 than in normotensive control group (8.3 +/- 0.8 fl vs.7.8 +/- 0.7 fl, p < 0.01). In addition, MPV showed a positive correlation with the degree of HR in the hypertensive group (r = 0.41, p = 0.015). Our study suggests that platelet activation, a mechanism known to be involved in vascular lesions, may promote the development of HR.

The value of low-dose intraperitoneal immunoglobulin administration in the treatment of peritoneal dialysis-related peritonitis.

BACKGROUND: Peritonitis is a major complication of continuous ambulatory peritoneal dialysis (CAPD). The value of immunomodulatory therapeutic approaches and, especially, methods aimed at augmenting opsonization in the treatment of peritoneal dialysis (PD)-related peritonitis is unclear. In this study, the effect of intraperitoneal (IP) immunoglobulin (Ig) usage, as an approach for strengthening opsonization, was evaluated in CAPD peritonitis. METHODS: The study included 24 patients with CAPD peritonitis. The patients were divided into two groups, A and B, each consisting of 12 patients. There were no significant differences between the groups in terms of age, gender, CAPD duration, and peritonitis rate. Empiric antibiotic treatment was a 2-week IP ampicillin+sulbactam/netilmycin combination. Group B was additionally given low-dose IP IgG (2 mL = 320 mg) with every exchange. The dialysate leucocyte counts were obtained in both groups until the number was <100 cells/microL to monitor the response to peritonitis treatment. RESULTS: In group A, the number of exchanges done until the dialysate leucocyte counts decreased to <100/mL was 13.9 +/- 1.4 and for group B 6.6 +/- 0.4 (p<0.001). The reduction in neutrophils was significantly faster in group B compared to group A (p<0.001). The number of exchanges until abdominal pain completely disappeared was 12.5 +/- 1.7 in group A and 5.6 +/- 0.7 in group B (p<0.001). CONCLUSIONS: The results of this study show that low-dose, continuous IP IgG administration in the treatment of PD-related peritonitis is safe and effective in shortening the treatment time.

A patient with hyper-IgD syndrome in Antalya, Turkey.

Hyper-IgD syndrome is a periodic fever syndrome that presents with recurrent episodes of high fever accompanied by lymphadenopathy, abdominal distress, arthralgias or arthritis, headache and skin lesions. The diagnosis is based on clinical grounds and elevated serum IgD levels (>100 U/ml), but requires a high index of suspicion, and a mevalonate kinase enzyme defect. Most patients are from western Europe but there are others identified in other countries. We describe a 17-year-old patient who had been followed with the diagnosis of familial Mediterranean fever for a long time before she was diagnosed with hyper-IgD syndrome.