Description of patient with telangiectasis and palmar erythema without any structural liver changes or changes of liver laboratory parameters due to treatment of Her -2 -positive breast cancer with Ado-Trastuzumab-Emtansine

Ado- Trastuzumab-Emtansine is approved by EMA and FDA for treatment of HER-2-positive metastatic breast cancer. The drug combines the cytotoxic activity of emtansine with trastuzumab [1,2,3]. Here we are describing 50- year old woman with 3-ple positive left breast cancer with metastasis to left axillary lymph nodes treated with the drug. The patient had normal liver and spleen structure on CT of the abdomen with I.V. contrast, along with a normal liver function test. However she did have a mild elevation of her indirect bilirubin after the initiation of the drug. Despite the normal liver and spleen and absence of Cirrhosis the patient developed drug induced spider angiomas on the upper chest, upper back, shoulders along with palmar erythema. The association of the Ado-Trastuzumab-Emtansine with spider angiomas and palmar erythema in those with normal liver and spleen function, with only a mild elevation of indirect bilirubin is discussed in the article [1].

Spontaneous subconjunctival and retinal hemorrhage in acute on chronic liver failure: A case report and brief review of the literature

A 48-year-old male with a history of significant alcohol consumption (120 gm per day for six years) and a recent binge presented with jaundice for one month followed by abdominal distention for ten days. At presentation, he was normotensive (BP 110/70 mmHg), had tachycardia (HR 122/min), and maintained saturation at room air (Sp02 98%). Physical examination was remarkable for scleral icterus, palmar erythema, enlarged liver (span 14 cm), and free fluid in the abdomen. Laboratory investigations revealed anemia (Hemoglobin 10.1 gm%), leucocytosis (White blood cell count 17000/mm3), thrombocytopenia (Platelet count 90 X 103)/mm3), deranged liver function tests (Total bilirubin 9.5 gm/dl, Alanine Transaminase 52 U/L, Aspartate Transaminase (112 U/L), and coagulopathy (International normalized ratio 2.2, Prothrombin time 20 sec). A provisional diagnosis of Acute on Chronic Live Failure (ACLF) with severe alcoholic hepatitis as the precipitating event was made. The patient was started on standard therapy with nutritional supplementation, diuretics, laxatives. On day 4 of admission, the patient developed bilateral red-eye. There was no history of any diminution of vision, double diplopia, ocular discharge, orbital pain, antecedent trauma, cough, or any interventional procedure. Vision, pupillary reflexes, intraocular pressure as well as range of extraocular movements were normal.

Palmar erythema and palmar papules as predictors for dermatomyositis-related acute/subacute interstitial lung disease: a retrospective study

Objectives Dermatomyositis (DM)-related acute/subacute interstitial lung disease (A/S-ILD) remains a big therapeutic challenge due to its insidious onset and rapid development. In the present study, we aimed to investigate the association between clinical features of DM and ILD. Methods We retrospectively assessed skin manifestations, muscle damage, laboratory tests, concurrent ILD and malignancy in 207 patients with DM and analyzed the high-risk factors for ILD. Results In the 207 DM patients, 153 patients had ILD, in which 131 had chronic ILD (CILD) and 22 had A/S-ILD. The proportions of mechanic’s hands, palmar papules and muscle weakness, as well as anti-melanoma differentiation-associated gene 5 (MDA5) antibody and lactic dehydrogenase (LDH), alanine aminotransferase (ALT) and ferritin in the ILD group were significantly higher compared with the non-ILD group. The onset age over 56 years, mechanic’s hands and muscle weakness were independent predictive factors for ILD. The proportions of palmar papules, palmar erythema, anti-MDA5 antibody, ALT, aspartate aminotransferase (AST), LDH and erythrocyte sedimentation rate in the A/S-ILD group were higher compared with the CILD group. Palmar erythema and palmar papules were independent predictive factors for A/S-ILD. Palmar papules were positively correlated with anti-MDA5 antibody. Conclusion The onset age over 56 years, mechanic’s hands or muscle weakness predicted the incidence of DM-related ILD, while palmar erythema or palmar papules could predict potential DM-related A/S-ILD.

Fluctuating Palmar Erythema in a Toddler during COVID-19 Pandemic: Do You Know the Offender?

Palmar erythema in children can be due to various reasons, such as chronic liver disease, rheumatological disorders, medications, irritant contact dermatitis and atopic dermatitis. Recently, there are few reports about contact dermatitis caused by frequent, daily use of hand sanitizers during this COVID-19 pandemic. A 3-year-old toddler brought with the concern of waxing-waning bilateral palmar erythema for the past 2 weeks. The parents revealed that the child liked the bright color of a recently bought hand sanitizer bottle so much he used to wash his hands every 20–30 min throughout the day. The atypical presentation of contact dermatitis might be because the child was using the sanitizer more frequently during the daytime. The dermatitis resolved with stopping excessive use of the hand sanitizer by the toddler. Clinicians should be aware of contact dermatitis during these pandemic times. Instead of investigating them extensively, careful history taking and merely advising them to judicially utilize the sanitizer can lead to complete reversal of symptoms.

CHRONIC EFFECTS OF ALCOHOL. A CASE REPORT

OBJECTIVES: The alcohol dependence is a chronic disease and Wernicke-Korsakoff syndrome is one of the best known neurologic complication. Through a clinical case seen in the Emergency department, we will explain the importance of a good anamnesis and physical examination to obtain the diagnosis and prevent chronic defects. MATERIAL AND METHODS: A 55-year-old male patient who came to the Emergency department of our Hospital that was transferred by the ambulance of Emergency after being found at home on the ground without being able to get up. The patient presents generalized tremor, lack of strength in the lower extremities and visual hallucinations of dead relatives. The patient refers to being treated with alprazolam, lorazepam and trazodone due to anxiety, under follow-up by his family doctor.He has normally been drinking 5 glasses of brandy a day for 15 years and smoking 2 joints a day.The last time he drank alcohol was yesterday. The patient comments that for a year he has been out in a wheelchair. A blood and urine analysis is requested in addition to blood ethanol levels and an intramuscular injection of vitamin B1 is prescribed, followed by glucosaline serum and intravenous diazepam. On the general physical examination, she presented telangiectasia and bilateral palmar erythema. In the neurological examination, he presented hyporeflexia in the lower extremities, predominantly right cerebellar tremor, bilateral dysmetria in the heel-knee test, and gait ataxia with loss of strength in both legs. RESULTS AND CONCLUSIONS: This syndrome was classically described as a clinical triad consisting of altered mental status, nystagmus or ophthalmoplegia, and ataxia. However, less than a third of patients present with this complete triad. Gait abnormalities of Korsakoff syndrome are often irreversible if Wernicke encephalopathy is not treated adequately.

Joubert's syndrome as a cause of cholestasis in children

Literature review and a case report of Joubert syndrome in a preschool child are presented. This syndrome is accompanied by chronic intrahepatic cholestasis, characteristic facial dysmorphia, congenital malformations of the urinary system, eyes pathology, confirmed by a molecular genetic test of TMEM67 gene mutations. Diagnostic aspects of this pathology have been reviewed. The clinical case description. Boy K was admitted to the pediatric hepatology department with respiratory and renal failure, decompensated acidosis. On admission, complaints included shortness of breath, severe itching, pale and dry skin, poor appetite and delayed physical development. On examination, dysembryogenic stigmas: large head circumference, elongated face, protruding forehead, high rounded eyebrows, deeply set eyes, hypertelorism, antimongoloid incision of the eyes, low auricles. The skin was pale, dry with the scratch marks on the arms and legs flexor surfaces. Ankles, wrists skin lichenification, bruising and hyperpigmentation was observed. Moderate palmar erythema, spider veins on the abdomen, watch-glass nails were present. The abdomen was enlarged due to hepatosplenomegaly. A clinical and paraclinical examination was conducted, the patient was consulted by related specialists. Based on the obtained data and molecular genetic examination, the diagnosis was made. Conclusion. Joubert's syndrome may have a clinical presentation similar to that in cholestatic liver disease with typical clinical and laboratory symptoms. The molecular genetic testing is an important workup component in children with liver pathology combined with damage to other organs and systems. Successful treatment is possible providing a multidisciplinary approach used. The study was conducted by the principles of the Declaration of Helsinki. The research protocol was approved by the Local Ethics Committee of the abovementioned institution. Informed consent of the child's parents was obtained for the research. The authors declare no conflict of interest. Keywords: Joubert syndrome, cholestasis, children.