This case study studies the adverse effects of methotrexate toxicity as well as the importance of early recognition of the symptoms and signs of methotrexate toxicity. This study involves a 54-year-old female who accidentally took methotrexate in high doses for a period of five consecutively days. The patient had been diagnosed with mixed connective tissue disease and was being treated with methotrexate once weekly. However, she took 7.5 mg (three tablets) three times a day for five days instead of 15 mg once weekly in two divided doses. The patient immediately went to the ER but was asymptomatic and discharged after a CBC showed values within the normal range. The patient was then seen by her primary care physician and advised to return to the ER. At this time, the patient had mucocutaneous lesions and was complaining of oral and throat pain, and a repeat CBC demonstrated pancytopenia. The patient was admitted to the hospital for further management and treatment of methotrexate toxicity.

Methotrexate is an anti-inflammatory and immunomodulatory drug, widely used for moderate to severe psoriasis and other rheumatological conditions such as rheumatoid arthritis, besides some types of malignancies. Side effects are more prevalent in high acute doses but can also be seen in low-dose chronic use, especially in cases of drug-dosing errors. Possible symptoms of toxicity include gastrointestinal, hepatic, hematologic and renal dysfunctions, but may also include mucositis and worsening of the psoriatic lesions. Here, we describe a case involving methotrexate toxicity in an elderly patient with psoriasis, detailing the management.

UNASSIGNED: Methotrexate is a widely used immunosuppressant with good efficacy and cost-effectiveness. However, one of the drawbacks of methotrexate has been toxicity due to accidental overdose. During the COVID pandemic, there was an alarming increase in the number of patients with methotrexate toxicity which prompted us to do this study.
UNASSIGNED: To evaluate the clinical features and contributing factors in patients presenting with methotrexate toxicity.
UNASSIGNED: A detailed evaluation of the clinical features, laboratory indices, contributing factors, and outcomes of the patients presenting with methotrexate toxicity was analyzed.
UNASSIGNED: A total of 19 cases were seen during the study period. All of the patients had oral mucositis and several developed cutaneous ulcerations. Laboratory abnormalities included cytopenia, transaminitis, and renal impairment. While sixteen patients recovered successfully, three people died as a result of delays in medical assistance. In addition to comorbidities, pandemic-induced restrictions played a major role in patients accidentally overdosing with methotrexate.
UNASSIGNED: This study highlights the fact that even low-dose methotrexate taken incorrectly can result in a lethal outcome, which is preventable.

Peri-implant diseases including peri-implant mucositis and peri-implantitis are among the major causes of failure of implant-supported dental restorations. They are characterized by progressive inflammation of the peri-implant mucosa, extending to the surrounding connective tissues and leading to bone loss and implant failure. Although strict oral hygiene practices help in preventing peri-implant diseases, plaque buildup around the implant restoration leads to chronic inflammation, due to the adherent bacterial biofilm. While mechanical debridement and non-surgical therapy to remove inflamed connective tissue (ICT) form the mainstay of treatment, additional local adjunctive therapies enhance clinical outcomes. Topical oxygen therapy is known to reduce inflammation, increase vascularity, and act as a bacteriostatic measure. The use of oxygen-based therapy (blue®m) products as a local adjunctive therapy for peri-implant mucositis and peri-implantitis can result in clinical outcomes similar to that of conventional local adjuncts such as chlorhexidine, antibiotics, and antibacterial agents. This report aims to present the clinical findings of patients with peri-implant mucositis and peri-implantitis, who were managed using local oxygen-based therapy as an adjunct to non-surgical therapy. In addition, a review of the literature about commonly used local adjuncts for peri-implant diseases has been included in the report to provide a means of comparison between conventional local adjunct therapy and topical oxygen-based therapy. Based on the reported findings and reviewed literature, local oxygen-based adjunct therapy was equally effective as conventionally used local adjuncts such as antibiotics, antibacterials, and probiotics, in treating patients with peri-implant diseases.

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UNASSIGNED: Plasma cell orificial mucositis (PCOM) associated with cocaine use is an emerging, rare condition that has become a concern in Spain in recent years. Limited knowledge exists regarding this novel condition.
UNASSIGNED: To delineate the clinicopathologic characteristics of this emerging entity and establish a novel approach in the differential diagnosis of cocaine-associated lesions.
UNASSIGNED: A descriptive, retrospective, multicenter case series of 10 patients diagnosed with cocaine-associated PCOM was conducted in Spain from April 2020 to March 2023.
UNASSIGNED: Patient demographic, clinical, histopathologic, and treatment data were collected.
UNASSIGNED: A total of 10 patients (6 [60%] male; median [range] age, 45.5 [36-66] years) presenting with exudative ulcerated plaques were identified for this study. The lesions had raised and erythematous edges over the nostril and a median (range) evolution time of 9 (2-24) months. Septal or palate perforations were observed in 4 (40%) of the patients. Biopsies revealed a dense inflammatory infiltrate of plasma cells in the dermis without atypia and with eosinophils. All patients reported recent cocaine use. Three urine tests detected cocaine but found no presence of amphetamines or opiates. Six patients improved with corticosteroid therapy. Up to 60% of patients were lost to follow-up.
UNASSIGNED: This case series describes the clinicopathologic characteristics of PCOM, an emerging entity associated with cocaine use in Spain, and demonstrates a novel approach in the differential diagnosis of cocaine-associated lesions. To date, cocaine-associated skin lesions have been reported as neutrophilic dermatoses and vasculitis. The appearance of a plasma cell infiltrate changes what has been described in the medical literature so far. PCOM is a benign condition of unknown cause characterized by a proliferative polyclonal plasma cell infiltrate. A comprehensive differential diagnosis workup is required to reach this exclusionary diagnosis. Several irritants have been documented in cases of PCOM, and a hypersensitivity mechanism has been proposed. Since the initial report of cocaine-associated PCOM in Spain, its incidence has experienced a surge in the country. The cause of this phenomenon may be attributed to newly unidentified adulterants. The administration of corticosteroids and discontinuation of cocaine use are the sole treatments that have demonstrated efficacy. Clinicians should be vigilant regarding this emerging condition and conduct inquiries into cocaine use. Additional research is required to clarify the pathophysiology of this emerging condition.

BACKGROUND: Mercaptopurine (6MP) and methotrexate (MTX) are commonly used for maintenance chemotherapy for acute lymphoblastic leukemia (ALL). These medications have been associated with various side effects such as myelosuppression, colitis, and thyroiditis in addition to numerous cutaneous adverse events. Cutaneous side-effects most reported include mucositis, alopecia, xerosis, and pruritus. We report an interesting case of hand-foot syndrome to 6MP in a child on maintenance therapy for B-cell ALL from an alteration in medication metabolism.
METHODS: We report a 10-year-old male on maintenance chemotherapy for pre-Bcell ALL who presented to the hospital with worsening oral lesions and erythematous, fissured plaques on the palms and soles. Maintenance therapy consisted of IV vincristine and 5-day pulse of steroids every 12 weeks, daily 6MP, and weekly MTX, which were increased to  ≥ 150% of standard dosing due to persistent absolute neutrophil counts  > 1500. Metabolites obtained on admission demonstrated elevated 6MMP metabolites at 35,761 (normal < 5700). TPMT and NUDT15 enzyme activity were normal and no alterations in genotyping were discovered.
RESULTS: Patient\'s oral chemotherapy, including both 6MP and MTX, were stopped and allopurinol 100 mg daily was initiated, which lead to overall improvement.
CONCLUSIONS: Clinical findings of acute mucositis and worsening of hand-foot syndrome, in the setting of inadequate myelosuppression in a child on maintenance therapy for ALL should raise concerns to consider altered metabolism pathway leading to toxic metabolite buildup. Allopurinol can play in improving cutaneous manifestation and chemotherapeutic dosing in patients with altered metabolism.

Reactive Infectious Mucocutaneous Eruption is an acute mucocutaneous inflammation secondary to an infection with minimal to absent cutaneous features that has recently been linked to the Severe Acute Respiratory Syndrome Coronavirus-19 (SARS-CoV-19 virus). Unfortunately, the relative rarity of case reports of Reactive Infectious Mucocutaneous Eruption in paediatric populations has led to fewer known successful treatment options with the current mainstay being systemic immunosuppression (e.g. corticosteroids, cyclosporine and etanercept). In this case report, we discuss a case of an adolescent patient with (polymerase chain reaction) PCR+ coronavirus disease 2019 infection and an oral eruption without cutaneous symptoms. He was treated successfully using a single dose of dexamethasone and supportive care through amorphous hydrogel (Intrasite gel), thus providing a safe, cheap and effective treatment option in mild coronavirus disease 2019-associated Reactive Infectious Mucocutaneous Eruption in paediatric patients. We also discuss the current findings, diagnostic terms and treatment options of mucosal manifestations of coronavirus disease 2019 in children.

BACKGROUND: The purpose of this study was to evaluate the reliability and accuracy in the assignment of the case definitions of peri-implant health and diseases according to the 2018 Classification of Periodontal and Peri-implant Diseases and Conditions.
METHODS: Ten undergraduate students, 10 general dentists, and 10 experts in implant dentistry participated in this study. All examiners were provided with clinical and radiographic documentation of 25 dental implants. Eleven out the 25 cases were also accompanied by baseline readings. Examiners were asked to define all cases using the 2018 classification case definitions. Reliability among examiners was evaluated using the Fleiss kappa statistic. Accuracy was estimated using percentage of complete agreement and quadratic weighted kappa for pairwise comparisons between each rater and a gold standard diagnosis.
RESULTS: The Fleiss kappa was 0.50 (95% CI: 0.48 to 0.51) and the mean quadratic weighted kappa value was 0.544. Complete agreement with the gold standard diagnosis was achieved in 59.8% of the cases. Expertise in implantology affected accuracy positively (p < 0.001) while the absence of baseline readings affected it negatively (p < 0.001).
CONCLUSIONS: Both reliability and accuracy in assigning case definitions to dental implants according to the 2018 classification were mostly moderate. Some difficulties arose in the presence of specific challenging scenarios.

Toxicity associated with low doses of methotrexate (MTX) is low, but it may be fatal. Bone marrow suppression and mucositis are among the common side effects of low dose MTX toxicity. Different risk factors have been reported for toxicities associated with low doses of MTX, including accidental use of higher doses, renal dysfunction, hypoalbuminemia, and polypharmacy. In this paper, we present a female patient who had mistakenly used 7.5 mg of MTX daily instead of the same dose of MTX on Thursday and Friday. She was presented with mucositis and diarrhea to the emergency department. Moreover, we searched the databases Scopus and PubMed for available studies and case reports on toxicities associated with MTX dosing errors. The most frequently observed toxicities included gastrointestinal lesions, nausea, vomiting, skin lesions, and bone marrow suppression. Leucovorin, hydration, and urine alkalinization were among the most frequently used treatments. Finally, we summarize the data on the toxicities of low doses of MTX in different diseases.