जर्नल ऑफ़ क्लिनिकल केस रिपोर्ट्स

Patients in the intensive care unit need a strict follow-up of their levels of voriconazole because this drug has a narrow therapeutic index and a great intra, and it also presents a great rate of variability related to intra and interindividual pharmacokinetic. Monitoring the plasma levels of voriconazole has demonstrated its efficacy, but data on its safety and adequate dose in patients with liver failure are lacking and it is not recommended intravenously in renal impairment. We present a case report of invasive pulmonary fungal infection in a patient with diagnosis of liver failure who was managed with intravenous voriconazole, the dose was lowered according to the monitoring data; given that he presented hepatotoxicity by voriconazole despite having levels within range. Finally, the patient presents a renal failure and the clinical pharmacist recommends switching to an oral route, using the suspension of voriconazole.

The outcome of the teeth with coronal restoration may be unforeseeable when they need root canal therapy due to apical periodontitis, especially at the existence of a post. This case report describes a digital restoration strategy for the preservation of a serious defect tooth (left mandibular first molar). Tooth #36 with 10 years of a crown and post restoration needed root canal therapy due to apical periodontitis. After removal of the crown and cast post, the residual tooth showed fragility, and the distal root canal was seriously destroyed due to the post insertion. Selecting a suitable post was significant for the retention of the core to support the coronal restoration after the completion of the root canal therapy and apical barrier. The prefabricated fiber post and metal cast post were not good selections for the distal root canal. Therefore intraoral scanning was performed on the tooth and digitized to design a three-dimensional model of customized post-core and full crown by the Computer-Aided Design/Computer- Assisted Manufacture (CAD/CAM) technique. A 14-month follow-up showed a promising clinical and radiographic outcome. The digital CAD/CAM technique converted the concave surface of the root canal into the convex surface of the post, and fabricated an anatomical post and core using hybrid ceramic material close to the elastic modulus of natural dentin. It improved the biomechanics of this tooth #36 and reduced the occurrence of root fracture.

Oculocutaneous Albinism (OCA) is a group of inherited disorders affecting melanin pigment in the body. It is an autosomal recessive inherited disorder, characterized by hypopigmentation of skin, hair, and eyes which may cause serious problems over time. Pemphigus vegetans is an unusual localized form of pemphigus vulgaris. It is an autoimmune disease characterized by the production of IgG autoantibodies against intercellular adhesion protein desmoglein, forming acantholysis. In this case report, we’ve reported a very rare case of Pemphigus vegetans in a 24-year-old girl with Oculocutaneous albinism.

Introduction: Liver echinococcosis is an endemic disease in the Republic of North Macedonia. The liver is the most frequent site of involvement accounts for 65-75% of cases. Rupture of a hydatid cyst into the biliary tree is the most common complication, occurring in 5-25% of patients. Aim of this research work is to present the important role of radiological imaging examinations in diagnosis of this parasitic infection, and it is complications including rupture of hepatic hydatid cysts into the biliary tree.

Case presentation: We are presenting a female 68-year-old patient, with obstructive jaundice, right subcostal pain, nausea, vomiting, fatigue, and weight loss. Ultra Sound (US) and Computed Tomography (CT) examinations are perform and we found two suppurated hydatid cysts in the liver, with a diameter between 65 and 105 mm. One of them penetrated the biliary system creating a fistula. The gallbladder was chronically inflamed, filled with gallstones, and with a thickened wall. The patient underwent surgery and the hydatid cysts and gallbladder had completely removed, and the continuity of the biliary stem was established.

Conclusion: The postoperative finding completely matched the preoperative US and CT diagnosis. Cysto-biliary communication is more common in large cyst size, located in the central segments of the liver close to the biliary confluence. The postoperative finding completely matched the preoperative US and CT diagnosis.

Systemic Lupus Erythematosus (SLE) is a chronic autoimmune disease that can affect any organ in the body. Therefore, the clinical manifestations that patients present are highly variable, they can have mild conditions such as localized skin or joint manifestations, up to more serious conditions, such as kidney, hematological or central nervous system conditions. The SLE is characterized by abnormal production of autoantibodies; the most characteristic are Antinuclear Antibodies (ANA), and their specificities, and antiphospholipid antibodies. In this review, we present a clinical case of SLE with particular clinical manifestations, with the aim of providing the reader with key findings in this pathology to improve the precision of the diagnosis early and thus initiate treatment in a timely manner.

Neuroleptic Malignant Syndrome (NMS) first described nearly five decades ago, is an idiosyncratic, life-threatening complication of treatment with drugs that is characterized by fever, sever e muscle rigidity, and autonomic and mental status changes. There are many different drugs that can cause NMS. Most of the drugs are antipsychotic drugs. NMS can also develop when dopaminergic drugs are suddenly withdrawn, but there are also other drugs that don't belong to any of the above categories. An old male patient was admitted to our Emergency Department for intermittent fever with onset from three days. His medications included amlodipine, oral steroid, and donepezil, which was administered at the dose of 10 mg/day. At the time of admission the patient showed stupor without other relevant signs at the physical exam. Infectious diseases and systemic diseases were ruled out during the course. Patient experienced during the following ten hours after the admission a further worsening of the fever to a stable level of 42°. At the neurological exam appeared diffuse severe muscular stiffness and bilateral fixed miose. A lumbar puncture was also performed that was negative. He died a few hours later. An autopsy was also organized that did not show the reported results. Based on the findings in our patient and from the data from literature, we hypothesize that the patient developed a NMS due to Donepezil. This indicates that when we are faced with a patient with altered mental state, fever, muscle stiffness and/or autonomous instability, an accurate medical history is required and we must consider Donepezil as a potential cause of suspected NMS.

Objective: Older adults are at greater risk for medications-related problems due to age-related changes in drug disposition. Therefore, it is important to properly identify and mitigate the use of inappropriate medication(s) in this population. The purpose of this case is to demonstrate the importance of identifying and evaluating the medication-related problems in older adults via pharmacist-led comprehensive medication reviews.

Case: A 69-year old female patient with a past medical history of hypertension, myocardial infarction, atrial fibrillation, and hyperlipidemia has reported to her medical team with chief complaints of increased blurry vision, yellow-brown deposits within her eyes, and gradual hair loss over the last two to three months. The clinical pharmacist conducted a comprehensive medication review and noted that these symptoms were likely adverse drug reactions caused by amiodarone, and recommended discontinuation of the amiodarone in an effort to mitigate toxicities. One month later, the pharmacist followed-up with the care team, and was notified that the patient noticed improvement in her vision and continues to deny symptoms related to atrial fibrillation. The pharmacist recommended continuation of close monitoring of the patient for the next few months.

Conclusion: This case sheds light onto the importance of pharmacist-led comprehensive medication reviews to identify medication-related problems in older adults. Careful prescribing and continuous reviews of medication regimens can help to mitigate and prevent medication-related problems such as adverse drug effects and drug-drug interactions.