Conflicts of interest:None declared.To the Editor, Methotrexate (Mtx) is an immunosuppressive and antimitotic agent that terminates deoxyribonucleic acid (DNA) synthesis by inhibiting the enzyme dihydrofolate reductase. The spectrum of clinical usage and the side effects are quite common. Reactivation of radiation dermatitis, generalized maculopapular rash, stomatitis, and exacerbation of acne lesions can be associated with the use of Mtx (1). Phototoxicity is a direct tissue damage that is caused by phototoxic agents and UV light via inflammatory mediators (2).Sunburn reactivation is a rare and specific UV recall dermatitis that is seen in patients previously suffering from sunburn (3). This phenomenon is quite different from other cytotoxic drug-induced radiation recall dermatitis. Low dose Mtx given to psoriasis patients does not appear to cause this recall reaction. This may be a time-and doserelated reaction (1). Some points will be emphasized in this paper to avoid this side effect.A 45-year-old male who was receiving Mtx treatment for psoriasis developed an erythematous, painful, and edematous rash on the chest, abdomen, and extremities. He went to the shore for swimming and sunbathing on Sunday and had a moderate erythema on sun-exposed areas. Three days after sunbathing, he took 16 tablets of Mtx (2.5 mg tablets, a total of 40 mg) by mistake, even though he was prescribed to take 10 mg a week. Twentyfour hours after receiving high-dose Mtx, the patient noticed burning and increased redness on his skin at sites where he had sun-induced erythema previously. The dermatologic examination revealed erythema on the sunexposed areas of his upper back, chest, arms, and legs. There was erythematous to violaceous and edematous plaques with hyperemia and pain in involved skin areas (Fig. 1a, b). Patient was hospitalized, and Mtx therapy is ceased. It was revealed from the patient's history that he has been taking Mtx 40 mg/week since 6 weeks, and his psoriasis was in remission. Complete blood count and biochemical values were in normal range. Histopathological examination revealed epidermal spongiosis, intraepidermal apopitotic keratinocytes, and vesiculation, which was consistent with phototoxic reaction. Symptomatic treatment with wet dressings and antihistaminics resulted in a rapid resolution of the lesions. He was free of psoriasis lesions when he was discharged from the hospital but had recurrence after 6 weeks.Mtx is an antimitotic and immunosuppressive agent used for the treatment of cancer, psoriasis, and rheumatologic disorders. The well-known side effects include mucosal ulceration, hepatotoxicity, pulmonary fibrosis, myelosuppression, alopecia, and renal toxicity (1).
ÖZET Obezitenin insülin direnci, tip 2 diyabetes mellitusObezite endokrin ve metabolik bozukluklara neden olur. Obezitenin insülin direnci, tip 2 diyabetes mellitus (DM), hiperlipidemi, metabolik sendrom, nonalkolik steatohepatit, reprodüktif anormallikler gibi endokrin ve metabolik komplikasyonlarla ilişkisi gös-terilmiştir. Adipoz doku artık bir endokrin organ olarak kabul edilmektedir. Adipokinler veya adipositokinler olarak isimlendirilen sitokinler ile adipoz doku kronik düşük dereceli inflamasyona neden olmakta, sonuçta obezite ile ilişkili metabolik komplikasyonlar gelişmektedir. Adipositokinler lipid ve glukoz homeostazını bozarak metabolik komplikasyonları yaparken, artmış adipoz dokudan kana salınan serbest yağ asitleri insülin sensitivitesini bozarak metabolik komplikasyonların oluşmasını artırır (1)(2)(3)(4) . Hipokrat tarafından bile obezlerde ani ölümün daha sık olduğu bildirilmiştir. Obezite ne kadar ileri derecede ve uzun süreli olursa diyabetin ortaya çıkış oranı o derece artar. Obezitede ürik asit düzeyi de artarak gut hastalı-ğına zemin hazırlar. Obez kişilerde hipertansiyon sık görülür. Ayrıca angina pektoris, miyokard infaktüsü ve kalp yetmezliği obezlerde daha sıktır. Hastanın zayıflaması ile bu hastalıklarda olumlu iyileşmeler görülür. Kolelityazis ve komplikasyonlarına da obezlerde daha sık rastlanır. Obezitede yağın abdominal bölgede ve iç organlarda toplanması tip 2 DM, hipertansiyon, dislipidemi, koroner arter hastalığı ile de yakın ilişkili olan insülin direncine yol açmaktadır. Obezite ve Tip 2 Diyabetes MellitusObezite tip 2 diyabet için önemli bir risk faktörüdür. Özellikle abdominal obezite bu riski artışı ile ilişkili-dir. Obezite ve tip 2 diyabet arasındaki ilişki aslında obezite ve insülin direnci arasındaki ilişkiye dayanır. Hiperinsülinemi yani insülin hormonunun yükselme-si veya insülin direnci yağlanmanın oluşmasında ve obezitenin gelişmesinde etkilidir. Glisemik indeksi düşük bir beslenme programına uymak ve fiziksel aktivite kandaki insülin seviyesinin düşmesine ve insü-lin direncinin azalmasına neden olur. Sağlıklı ve dengeli bir beslenme programında kaybedilecek % 5-10'luk bir kilo kaybı tip 2 diyabet riskinin azalmasında önemlidir.
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