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By U. Asaru. Thomas Edison State College.

Pharmacodynamics When other treatments fail best rocaltrol 0.25 mcg, don’t Paclitaxel and docetaxel exert their chemotherapeutic effect by give up! Try paclitaxel disrupting the microtubule network essential for mitosis and oth- to treat metastatic er vital cellular functions rocaltrol 0.25mcg lowest price. Pharmacotherapeutics Paclitaxel is used when first-line or subsequent chemotherapy has failed in treating metastatic ovarian cancer as well as metastatic breast cancer. Head, neck, and below The taxanes may also be used for treating head and neck cancer, prostate cancer, and non–small-cell lung cancer. Cultural considerations with docetaxel use Adverse reactions to Clinical trials of docetaxel in Japanese and Other results showed fewer incidences of American patients with breast cancer re- fluid retention, neurosensory effects, muscle paclitaxel and vealed significant differences in the incidence pain, infection, and development of anemia in docetaxel of adverse effects between the two cultures. The study also indicat- During clinical trials, ed that Japanese patients are more likely to The results 25% or higher of patients develop fatigue and weakness than are Ameri- Japanese women were more likely to develop experienced these ad- can women. How- verse reactions to pacli- ever, the Japanese women in this study were Putting it into a plan taxel: less likely than the American patients (6% ver- These results are important to consider when • bone marrow suppres- sus 29. Docetaxel Adverse reactions to do- Quick quiz cetaxel include: • hypersensitivity reac- tions 1. What’s the major adverse reaction that’s common to all alky- • fluid retention lating drugs? Bone marrow suppression is a common adverse re- • numbness and tingling action to all alkylating drugs. The drug likely to be administered with methotrexate to mini- mize its adverse effects is: A. Leucovorin is typically administered in conjunction with methotrexate to minimize adverse effects. Before administering bleomycin to a patient, why should you administer an antihistamine and an antipyretic? An antihistamine and an antipyretic may be adminis- tered before bleomycin to prevent fever and chills. For cases of smallpox, institute airborne precautions for the duration of the illness and until all scabs fall off. For pneumonic plague cases, institute droplet precautions for 72 hours after initiation of effective therapy. In the event of chemical agent exposure, follow standard precautions and decontamination protocols, such as removing cloth- ing and sealing it in plastic bags, irrigating the eyes, washing skin and hair using copious water, treating waste water as needed, and decontaminating the health care facility according to the specific agent involved. Chemical agent Treatment Antidote Chemical agent Treatment Antidote Nerve agents • Supportive • Atropine I. Phosgene intubation and zures Sulfur dioxide mechanical ventilation with Cyanides • Supportive • Amyl nitrite via positive-end Cyanogen chloride care inhalation expiratory Hydrogen cyanide • 100% oxygen • Sodium nitrite pressure by face mask; I. Herbal medicine Common uses Special considerations Aloe Oral • The laxative actions of aloe may take up to 10 hours after ingestion to • Constipation be effective. Ginseng • Fatigue • Ginseng may cause severe adverse reactions when taken in large • Improve concentration doses (more than 3 g per day for 2 years), such as increased motor and • Treat atherosclerosis cognitive activity with significant diarrhea, nervousness, insomnia, hy- • Also believed to strengthen pertension, edema, and skin eruptions. John’s wort • Mild to moderate depression • Effects may take several weeks; however, if no improvement occurs • Anxiety after 4 to 6 weeks, consider alternative therapy. John’s wort shouldn’t be used in combination with prescription • Viral infections antidepressants or antianxiety medications. Therapies for Glaucoma,” Expert Opinion on Emerg- ing Drugs 10(1):109-18 February 2005. Philadel- cine in an Outpatient Oncology Center,” Clinical phia: Lippincott Williams & Wilkins, 2007. Introductory Clinical Pharma- out Parathyroid Glands,” Endocrinology 146(2):544- cology, 8th ed. Clinical Geriatric Psychopharmacology, 4th physiologic Basis of Drug Therapy, 2nd ed. Adrenergic blocking drugs, 40-47 Aminophylline, 183-185 Anticholinergic drugs, 27-32, 60-62, topical, 416t Amiodarone, 131-132 177-178 Adrenergic drugs, 32-39 Amitriptyline, 322-325 Anticholinesterase drugs, 24-27 classifying, 32 Amlodipine, 138-140 differentiating toxic response to, mechanism of action of, 33i Ammonium chloride, 368-369 from myasthenic crisis, 24 Adsorbent drugs, 204-205 Amobarbital, 316-317 mechanism of action of, 22i Adverse drug reactions, 17-19 Amoxapine, 322-325 Anticoagulant drugs, 161-171 dose-related, 17-18 Amoxicillin, 196-197, 241-243 Anticonvulsant drugs, 68-85 patient sensitivity–related, 18-19 Amphetamine salts, mixed, 336-337 Antidepressants, 320-329 Agonist, 12 Amphotericin B, 280-283, 418t risks of, 322 Albuterol, 37-39, 176-177 Ampicillin, 241-243 Antidiabetic drugs, 339-345 Alclometasone, 419t Amprenavir, 272-275 Antidiarrheal drugs, 208-210 Aldesleukin, 408-409 Amylase, 206 Antidiuretic hormone, 350-352 Aldosterone, 301 Amyl nitrite, 135-136 Antiemetics, 216-219 Alemtuzumab, 398-399 Anakinra, 302-306 Antiestrogens, 388-390 Alfuzosin, 40-43 Anastrozole, 387-388 Antiflatulent drugs, 205 Alkalinizing drugs, 366-368 Androgens, 390-391 Antifungal drugs, 280-289 Alkylating drugs, 371-379 Anesthetic drugs, 108-115 dermatologic, 418t mechanism of action of, 373i ophthalmic, 414t Antigout drugs, 306-309 otic, 417t Antihistamines, 216-219, 294-297 i refers to an illustration; t refers to a table. Carboplatin, 378-379 Atazanavir, 272-275 Biperiden, 60-62 Carboxamides, 80-81 Atenolol, 43-47, 137-138 Bisacodyl, 214-215 Carboxylic acid derivatives, 76-78 Atorvastatin, 149-150 Bisoprolol, 43-47 Cardiac glycosides, 120-122 Atracurium, 56-58 Bistriazole antimycotic drug, 285-287 Cardiovascular drugs, 119-152 Atropine, 27-32, 30i, 416t Bitolterol, 37-39 Carisoprodol, 50-52 Atypical antipsychotics, 331-332 Bivalirudin, 169-170 Carmustine, 375-376 Autonomic nervous system drugs, Bleomycin, 385-386 Carteolol, 43-47, 416t 21-47 Boric acid, 417t Carvedilol, 43-47, 141-142 Azaspirodecanedione derivatives, 319 Bortezomib, 400-402 Caspofungin, 287-288 Azatadine, 294-295, 297 Brimonidine, 416t Castor oil, 214-215 Azathioprine, 302-306 Brinzolamide, 416t Catecholamines, 33-37 i refers to an illustration; t refers to a table. See also inhibitors, 66-68 mechanism of action of, 22i Nonsteroidal anti-inflammatory Cefaclor, 243-246 Choline salicylate, 94-96 drugs. See Dactinomycin, 385-386 Centrally acting skeletal muscle relax- also Calcium channel blockers.

While this will restrict the number of compounds screened it should also improve the quality of hits obtained order rocaltrol 0.25 mcg visa, thereby reducing down- stream attrition generic rocaltrol 0.25mcg line. All too frequently within drug discovery programmes, and despite the greater emphasis in modern pharmaceutical and biotechnology companies on improving compound quality, problems with molecules which are either false-positives or unsuitable for further development persist. Appropriate forward-thinking synthetic strategies within medicinal chem- istry teams will widen the structural diversity of molecules tested, while oen the incorporation of relatively simple cross-checks into screening cascades can help ensure rapid elimination of unsuitable molecules that would otherwise lead to project and clinical trial failures, and potentially setting back discovery efforts in rare diseases many years. Otherwise the disturbing possibility exists that the failure of an ‘unsuitable’ compound in clinical trials may discourage further efforts on an otherwise feasible mechanism for the treatment of a particular disease. The two case studies described here, as well as being representative of the rapid and merciless progression of both diseases present in a paedi- atric population, and it is critically important to establish as soon as possible the appropriate clinical trial inclusion criteria so that the chances of seeing therapeutic benet are maximised. Cohort size, as with any clinical trial, will also play a crucial role, as will availability of the appropriate patient groups – by denition the diseases are rare and so the patient numbers will be limited. What is clear at this stage is that there are two clear emergent paradigms for curative treatment of rare neuromuscular disease, as opposed to the development of improved symptomatic treatments. The rst of these is predicated on inventing a therapy to treat the disease’s underlying cause, in these cases this being a genetic mutation. Approaches using oligonucleotides to enable exon skipping, or employing small-molecule read-through agents, have made fantastic progress, and are starting to deliver encouraging results in later stage clinical trials. However, the possibility of the disease encom- passing a more heterogeneous group of sufferers with multiple mutations limits the applicability of each specic therapy to a smaller subset of patients. The alternative is, through a detailed knowledge of the disease in question, to identify a therapeutic approach which is independent of the primary lesion. While this may be more technically challenging, and relies on the existence of an appropriate redundant/compensatory mechanism to target, the advantages are hugely signicant, in that the opportunity for treatment of all patients becomes potentially viable. View Online Drug Discovery Approaches for Rare Neuromuscular Diseases 327 There is of course a middle ground, in which a combination of drugs, each addressing a specic point in progression of the disease is used, or simply one in which an established symptomatic treatment is partnered with an emerging disease-modifying drug; examples of both of these paradigms having been summarised in the preceding text. In reality, this latter approach is likely to be the rst to be reduced to clinical practice and receive regulatory approval, with combinations of disease-modifying agents coming next, subject of course to the appropriate combination clinical trials taking place rst. This pathway parallels established development pathways, which have taken place in other therapeutic areas such as the oncology and anti-infective elds. Over the past decades pioneering work has taken place to elucidate the underlying pathological mechanisms of many rare neuromuscular diseases. This in turn has inspired the development of several truly innovative thera- peutic strategies aimed at correcting the underlying pathology. Acknowledgements The authors wish to thank Professor Dame Kay Davies, Professor Steve Davies and Dr Robert Westwood for helpful advice and comments, and for proof- reading this manuscript. Databases: Chemical Abstracts and PubMed; searched using the search terms ‘Duchenne Muscular Dystrophy’ and ‘Spinal Muscular Atrophy’ respectively. Bivona, Duchenne Muscular Dystrophy Drug could Unlock Huge Potential for this Pharmaceutical, http://beta. Tatem, View Online Drug Discovery Approaches for Rare Neuromuscular Diseases 329 K. Summit Outlines Clinical Development Plans For Utrophin Modulator Programme For Duchenne Muscular Dystrophy, http://www. Dansette, in The Practice of Medicinal Chemistry, 3rd edition Academic Press, 2008, pp. Summit Outlines Clinical Development Plans for Utrophin Modulator Programme for Duchenne Muscular Dystrophy, http://www. Janssen, Identication of Compounds Enhancing Utrophin Expression in Primary Human Skeletal Muscle Cells, http://www. Pzer Licenses Families of Spinal Muscular Atrophy Quinazoline Drug Program from Repligen, http://www. Improved precision in isolation, purication, char- acterisation and production have increased the availability of these secondary metabolites to explore their inherent chemical and biological diversity. Enriched with complex, multifunctional and distinct molecular landscapes, natural products provide creative starting points for medicinal chemists to test hypotheses via semi-synthetic manipulation.

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Evidence from disruption of the lmcpb gene array of [4] Lyons S cheap rocaltrol 0.25 mcg visa, Veeken H buy rocaltrol 0.25mcg with visa, Long J. Leishmania mexicana in patients co-infected with Leishmania infantum and human im- cysteine proteinase-deficient mutants have attenuated virulence for munodeficiency virus type 1. Lancet Infect Dis 2002; 2: 494- Leishmania donovani biopterin transporter genetic mutant and its 501. Conflict and kala-azar: Persistence without pathology in phosphoglycan-deficient determinants of adverse outcomes of kala-azar among patients in Leishmania major. Successful treatment of phosphoglycan-deficient Leishmania major protects highly suscep- refractory visceral leishmaniasis in India using antimony plus inter- tible mice from virulent challenge without inducing a strong Th1 feron-gamma. A policy for leishmaniasis with respect to the preven- Leishmania parasites by preventing programmed cell death. Bifunctional thymidylate synthase- of Old World cutaneous leishmaniasis caused by Leishmania ma- dihydrofolate reductase in protozoa. Efficacy of paromomycin ointment in the channelling in bifunctional dihydrofolate reductase-thymidylate treatment of cutaneous leishmaniasis: results of a double-blind, synthase. Selective inhibition of Leishmania dihydrofolate reduc- [16] Buates S, Matlashewski G. Treatment of experimental leishmania- tase and Leishmania growth by 5-benzyl-2, 4-diaminopyrimidines. Successful treatment of drug- sis, and evaluation of inhibitors of trypanosomal and leishmanial resistant cutaneous leishmaniasis in humans by use of imiquimod, dihydrofolate reductase. Therapy and Further Development of Anti-Leishmanial Drugs Current Drug Therapy, 2008, Vol. Folate Increased transport of pteridines compensates for mutations in the antagonists. Regulation of evaluation of 2,4-diaminoquinazolines as inhibitors of trypanoso- differentiation to the infective stage of the protozoan parasite mal and leishmanial dihydrofolate reductase. Analysis of the roles of cys- Sphingolipids are essential for differentiation but not growth in teine proteinases of Leishmania mexicana in the host-parasite inter- Leishmania. J Med Chem breakdown by the yeast silencing protein Sir2: Evidence for acetyl 2002; 45: 2695-707. Identification of novel parasitic cysteine protease inhibitors by use of virtual screening 2. This protein was discovered while trying to understand how the yeast cell type, known as mating type, is regulated. Mutational studies indicated that lysine 16 in the amino-terminal tail of histone H4, and lysines 9, 14 and 18 in histone H3 are critically important in the silencing (Braunstein et al. Moreover, lysines 9 and 14 in histone H3, and lysines 5, 8 and 16 in histones H4 are acetylated in active chromatin and hipoacetylated in silenced chromatin (Braunstein et al. Indeed, when deacetylated, the histones can fold into a more compact nucleosomal structure (Luger et al. Indeed, during the biosynthesis of cobalamin, CobT catalyzes the transfer of phosphoribose from nicotinic acid mononucleotide to dimethylbenzimidazole to form dimethylbenzimidazole-5’- ribosyl-phosphate (Trzebiatowski et al. In fact, the authors described that this enzymatic activity accounts for silencing, suppression of recombination, and life span extension (Imai et al. However, several modifications to this classification have been proposed, since there is no obvious relation between the members and their biological role. This intermediate is susceptible to catalytic attack by the acetylated substrate itself (cis) or by an acceptor protein (trans) (Figure 13, B) (Smith et al. Bacterial genomes usually encode only one sirtuin while eukaryotes usually have multiple Sirtuins (Sauve et al. Phylogenetic analysis revealed the presence of a conserved sequence of ~250aa core domain in Sirtuins (Frye, 1999; Frye, 2000). Indeed, there are some evidences suggesting the involvement of these extensions in the substrate-specific recognition and subcellular localization (Cuperus et al.

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Acute infectve conjunctvits is treated with antbacterial eye drops by day and eye ointment applied at night discount rocaltrol 0.25 mcg overnight delivery. Gentamicin is a broad-spectrum bactericidal aminoglycoside antbiotc with partcular actvity against Pseudomonas aeru- ginosa 0.25mcg rocaltrol with mastercard, Neisseria gonorrhoea and other bacteria that may be implicated in blepharits or conjunctvits. Its antbacterial actvity is atributed to precipitaton of bacterial proteins by silver ions. It is available in 1% ophthalmic solutons and is used for prophylaxis of gonococcal ophthalmia neonatorum. Tetracycline is a broad spectrum antbiotc with actvity against many Gram-positve and Gram-negatve bacteria including N. Ophthalmic tetracycline is used in blepharits, conjunctvits, and keratts produced by susceptble bacteria. Tetracycline is also used in the treatment of trachoma caused by Chlamydia trachomats and in the prophylaxis of neonatal conjunctvits (ophthalmia neonatorum) caused by N. Precautons Maintain adequate hydraton (especially with infusion or high doses); monitor neutrophil count at least twice weekly in neonates; renal impairment (Appendix 7d); lactaton (Appendix 7b); pregnancy (Appendix 7c); not to be applied on mucous membrane. Adverse Efects Nausea, vomitng, abdominal pain, diarrhoea, headache, fatgue, rash, urtcaria, pruritus, photosensitvity; very rarely, hepatts, jaundice; dyspnoea; neurological reactons (including dizziness, confusion, hallucinatons, convulsions and drowsiness); acute renal failure; anaemia, thrombocytopenia and leucopenia; on intravenous infusion; severe local infammaton (sometmes leading to ulceraton), and very rarely, agitaton, tremors; psychosis and fever; increase in blood urea and creatnine, encephalopathy; seizures; anorexia, tremors. Contraindicatons Pregnancy (Appendix 7c), lactaton (Appendix 7b), porphyria; hypersensitvity. Precautons Avoid repeated courses and prolonged treatment; reduce doses in hepatc impair- ment (Appendix 7a); renal impairment; blood counts required before and peri- odically during treatment; monitor plasma- chloramphenicol concentraton in neonates; interactons: (Appendix 6c). Adverse Efects Blood disorders including reversible and irreversible aplastc anaemia (with reports of resultng leukaemia); peripheral neurits, optc neurits; headache; depression; urtcar- ia, erythema multforme; nausea, vomitng, diarrhoea; stomatts, glossits, dry mouth; nocturnal haemoglobinuria; grey syndrome (abdominal distension, pallid cyanosis, circu- latory collapse) may follow excessive doses in neonates with immature hepatc metabolism. Dose Adult and child above 12 years- Instll 2 to 3 drops in afected eye 3 to 4 tmes daily to start with thereafer reduce slowly as infecton subsides. Exposure to excessive sunlight should be avoided (discontnue if photosensitvity occurs). Avoid excessive alkalinity of urine and ensure adequate fuid intake (risk of crystalluria); interactons (Appendix 6c); paediatric use. Adverse Efects Nausea, vomitng, dyspepsia, abdominal pain, diarrhoea (rarely, antbiotc-associated colits); headache; dizziness; sleep disorders; rash (rarely, Stevens-Johnson syndrome and toxic epidermal necrolysis) and pruritus. Less frequent side-efects include anorexia, increase in blood urea and creatnine; drowsiness,restlessness,asthenia,depression, confusion, hallucinatons, convulsions, tremor, paraesthesia, hypoaesthesia; photosensitvity, hypersensitvity reactons including fever, urtcaria, angioedema, arthralgia, myalgia, and anaphylaxis; blood disorders (including eosinophilia, leucopenia, thrombocytopenia); disturbances in vision, taste, hearing and smell. Other side-efects that have been reported include haemolytc anaemia, renal failure, intersttal nephrits, and hepatc dysfuncton (including hepatts and cholestatc jaundice). The drug should be discontnued if psychiatric, neurological or hypersensitvity reactons (including severe rash) occur. Ophthalmic soluton:local burning, discomfort, corneal ulcers, lid oedema, corneal infltraton. Ointment: discomfort, keratopathy, blurred vision, corneal staining, epitheliopathy, photophobia. Dose Instllaton into the eye Adult- Mild to moderate infectons: 1 drop every 2 h, reducing frequency as infecton is controlled, then contnue for 48 h afer healing is complete. Precautons Prolonged use may lead to skin sensitzaton and emergence of resistant organisms including fungi; discontnue if purulent discharge, infammaton or exacerbaton of pain; ophthalmic ointment may retard corneal healing, renal impairment (Appendix 7d), interactons (Appendix 6c), pregnancy (Appendix 7c). Adverse Efects Burning; stnging; itching; dermatts; conjuctval epithelial defects;conjuctval hyperemia; thrombocytopenic purpurea; hallucinaton. Dose Adult and child-Fungal infecton of eye: instll 2 to 3 drops 3 to 4 tmes a day in infected eye or as required. Precautons Contact with eyes and mucous membranes should be avoided, pregnancy (Appendix 7c). Adverse Efects Occasional local irritaton and hypersensitvity reactons include mild burning sensaton, erythema; pruritus and itching. Oxytetracycline Pregnancy Category-D Schedule H Indicatons Infectons caused by susceptble pathogens, uncomplicated gonorrhoea, external bacterial infectons of the eye, acne vulgaris. Dose Oral Infectons caused by susceptble pathogens: Adult-250-500 mg 4 tmes daily. Therapy should be contnued for at least 24–48 hours afer symptoms and fever have subsided. Ophthalmic External bacterial infectons of the eye: Adult- Apply the ointment 2-3 tmes daily. Contraindicatons Hypersensitvity to tetracyclines, children below 8 years, renal impairment, pregnancy (Appendix 7c), lactaton.

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Therefore order 0.25 mcg rocaltrol with mastercard, extreme care should be taken to avoid perivascular extravasation or intra-arterial injection purchase 0.25 mcg rocaltrol with mastercard. Extravascular injection may cause local tissue damage with subsequent necrosis; consequences of intra-arterial injection may vary from transient pain to gangrene of the limb. Corticosteroids Barbiturates appear to enhance the metabolism of exogenous corticosteroids, probably through the induction of hepatic microsomal enzymes. Patients stabilized on corticosteroid therapy may require dosage adjustments if barbiturates are added to or withdrawn from their dosage regimen. Phenytoin, Sodium Valproate The effect of barbiturates on the metabolism of phenytoin appears to be variable. Because the effect of barbiturates on the metabolism of phenytoin is not predictable, phenytoin and barbiturate blood levels should be monitored more frequently if these drugs are given concurrently. Sodium valproate appear to decrease barbiturate metabolism; therefore, barbiturate blood levels should be monitored and appropriate dosage adjustments made as indicated. The predominant actions of phenylephrine hydrochloride are on the cardiovascular system. The overall prevalence of sulfite sensitivity in the general population is unknown and probably low. Sulfite sensitivity is seen more frequently in asthmatic than in nonasthmatic people. Follow injection into a vein with 20ml of normal saline to reduce the irritation caused by the alkalinity of the solution (if administering via a peripheral vein) Intermittent infusion: Dilute phenytoin in 50-100ml of normal saline immediately before use (final concentration not to exceed 6. Note that intermittent infusion, although widely used, is not recommended by the manufacturer due to the risk of precipitation. When, in the judgment of the clinician, the need for dosage reduction, discontinuation, or substitution of alternative antiepileptic medication arises, this should be done gradually. However, in the event of an allergic or hypersensitivity reaction, rapid substitution of alternative therapy may be necessary. Effect of alcohol Acute alcoholic intake may increase phenytoin serum levels, while chronic alcohol use may decrease serum levels. Use in pregnancy A number of reports suggest an association between the use of antiepileptic drugs, including phenytoin, by women with epilepsy and a higher incidence of birth defects in children born to these women. If the rash is exfoliative, purpuric, or bullous or if lupus erythematosus, Stevens-Johnson syndrome, or toxic epidermal necrolysis is suspected, use of this drug should not be resumed and alternative therapy should be considered. The liver is the chief site of biotransformation of phenytoin; patients with impaired liver function, elderly patients, or those who are gravely ill may show early signs of toxicity. A small percentage of individuals who have been treated with phenytoin have been shown to metabolize the drug slowly. Slow metabolism may be due to limited enzyme availability and lack of induction; it appears to be genetically determined. If tonic-clonic (grand mal) and absence (petit mal) seizures are present, combined drug therapy is needed. Laboratory Tests: Phenytoin levels should only be measured if there is a specific clinical indication (i. It is possible to measure free phenytoin (green tube); however, this is a send away test and is not routinely indicated. For patients with low albumin total phenytoin levels will not represent active phenytoin levels in the blood. Drugs which may decrease phenytoin levels include: carbamazepine, chronic alcohol abuse, Drugs which may either increase or decrease phenytoin serum levels include: phenobarbital, sodium valproate, and valproic acid. Although not a true drug interaction, tricyclic antidepressants may precipitate seizures in susceptible patients and phenytoin dosage may need to be adjusted. Drugs whose efficacy is impaired by phenytoin include: corticosteroids, warfarin, frusemide, oral contraceptives, rifampin, and theophylline. Gastrointestinal System Nausea, vomiting, constipation, toxic hepatitis and liver damage. Skin Dermatological manifestations sometimes accompanied by fever have included scarlatiniform or morbilliform rashes. A morbilliform rash (measles-like) is the most common; other types of dermatitis are seen more rarely. Other more serious forms which may be fatal have included bullous, exfoliative or purpuric dermatitis, lupus erythematosus, Stevens-Johnson syndrome, and toxic epidermal necrolysis.

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