Jovan Miljković

University Medical Centre Maribor, Maribor, Maribor, Slovenia

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Publications (17)11.59 Total impact

  • Vesna Breznik, Rok Kokol, Boštjan Luzar, Jovan Miljković
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    ABSTRACT: Insulin lipoatrophy is a rare immunologic cutaneous complication in diabetes mellitus that presents with localized subcutaneous fat atrophy at the insulin injection site. We report the case of a 62-year-old woman with type 2 diabetes mellitus that developed localized lipoatrophy on the abdomen after 6 years of therapy with the insulin analogues detemir and aspart.
    Acta dermatovenerologica Alpina, Panonica, et Adriatica 12/2013; 22(4):83-85.
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    Katarina Trčko, Pij Bogomir Marko, Jovan Miljković
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    ABSTRACT: INTRODUCTION Leukocytoclastic vasculitis (LCV) is a histopathologic term used to describe a type of cutaneous small-vessel vasculitis. It may be triggered by various agents, but the definite cause can be found in only about half of cases. Mycoplasma (M.) pneumoniae may be involved, especially within a context of fever and skin eruption, even in the absence of respiratory symptoms. The classic clinical presentation of LCV is palpable purpura with symmetric distribution of lesions, most frequently involving the legs. The exact mechanism by which M. pneumoniae produces skin disease is poorly understood. In the case of LCV, it is assumed that the process is a type III reaction according to Coombs and Gell classification, in which the antigen combines with its specific antibody and complement to form circulating immune complexes that are deposited in the walls of the capillaries and venules. Here we present a case of a young patient that developed cutaneous vasculitis in the setting of M. pneumoniae pneumonia. CASE REPORT A 27-year-old man with a few days' history of a nonpruritic purpuric rash on his chin and lower extremities accompanied by swelling and arthralgia was admitted to the hospital. He had had a fever 2 weeks before that required paracetamol for fever control and he had also taken azithromycin for 3 days. His medical history included epilepsy controlled by valproic acid and carbamazepine. On physical examination, purpuric maculae, papules, hemorrhagic blisters, and ulcerations on the lower extremities and the chin were found (Figs. 1 and 2). Physical examination revealed no further anomalies. Laboratory studies revealed an elevated C-reactive protein level (82 mg/L) and elevated erythrocyte sedimentation rate (74 mm/h) with a normal leukocyte count, whereas findings of routine blood chemistry profile and urinalysis were normal. Serologic tests were negative for antinuclear antibodies, antineutrophil cytoplasmic autoantibodies, anti-streptolysin O, cryoglobulins, rheumatoid factor, human immunodeficiency virus, and antibodies to hepatitis A, B, and C viruses. Circulating immune complex levels were elevated. M. pneumoniae IgM antibodies were positive according to enzyme immunoassay. M. pneumoniae infection was confirmed by polymerase chain reaction (PCR) of the pharyngeal swab. Chest radiograph showed an infiltrate of the right upper lobe (Fig. 3). Histopathologic examination of a skin lesion specimen from the chin showed endothelial cell swelling, fibrinoid changes of vessel walls in the dermis, and a neutrophilic perivascular infiltrate with leukocytoclasis and extravasated erythrocytes (Fig. 4). The patient was treated with oral moxifloxacin, which led to almost total resolution of the infiltrate as seen on chest radiograph. Prednisone therapy led to rapid regression of the skin lesions and the patient was discharged from the hospital in good condition. DISCUSSION M. pneumoniae is usually associated with respiratory tract infections. It is an important cause of a variety of respiratory tract infections and community-acquired pneumonia in children and young adults. Extrapulmonary complications occur in 10% to 25% of cases and can develop any time after the onset of respiratory symptoms or even in their absence (1). The exact mechanism of the occurrence of extra¬pulmonary manifestations is poorly understood. Various pathogenetic mechanisms for extrapulmonary manifestations have been proposed, which can be classified into the direct type, which results from a primary skin infection, and the indirect type, in which immune-mediated mechanisms play a role (1-6). Abnormalities in various organ systems have been described. Extrapulmonary manifestations include cutaneous, gastrointestinal, renal, hematologic, neurologic, cardiac, osteoarticular, ocular, and nonspecific complications, such as ear symptoms and acute rhabdomyolysis (5). Cutaneous manifestations are common, occurring in 10% to 25% of cases, most commonly as exanthematous eruptions, erythematous maculopapular rash, or vesicular rash (6). Other dermatologic disorders associated with M. pneumoniae infection are erythema nodosum (4,7-9), urticaria (7,10), Stevens-Johnson syndrome (11-15), mucositis (15), pityriasis rosea (16), bullous erythema multiforme (17,18), toxic epidermal necrolysis (19), Kawasaki disease (20), subcorneal pustular dermatosis (21), thrombotic thrombocytopenic purpura (22), Henoch-Schönlein purpura (23), urticarial vasculitis (24), Raynaud's phenomenon (25), and LCV (26-28). The pathogenesis of LCV is not fully understood. It is suggested that the interplay between autoimmune mechanisms and M. pneumoniae antigens could induce vasculitis, but the exact mechanisms remain unexplained. In 2007, Greco et al. reviewed the literature on five cases of cutaneous vasculitis following infection with M. pneumoniae, including their case (28). This insignificant number of publications is probably due to empirical treatment without serologic confirmation, which leads to the under-diagnosis of this pathology. Our patient developed clinically and histologically confirmed cutaneous vasculitis, presumably correlated with M. pneumoniae infection. It is also possible that LCV in our patient was triggered by drug ingestion, which is the most common cause of LCV. We assume that the LCV was the result of M. pneumoniae infection because of the clinical course and prompt response of the pulmonary infiltrate to antibiotic treatment. We demonstrated the M. pneumoniae infection by radiologic findings of the chest, molecular testing (PCR) of a swab specimen, and the appearance of high anti-mycoplasma antibodies in the patient's serum. CONCLUSION M. pneumoniae is a common pathogen, especially in young adults, and it should be considered on the differential diagnosis of a febrile illness accompanied by LCV, even in the absence of respiratory symptoms. Systemic antibiotic treatment can result in rapid clinical improvement and reduce the chance of extrapulmonary complications.
    Acta dermatovenerologica Croatica : ADC. 06/2012; 20(2):119-22.
  • Rok Kokol, Jovan Miljković, Laila El Shabrawi-Caelen
    Journal der Deutschen Dermatologischen Gesellschaft 08/2011; 9(10):867-8. · 1.40 Impact Factor
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    V Breznik, M Potočnik, J Miljković
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    ABSTRACT: There has been a recent increase in the incidence of syphilis in Slovenia, similar to other countries. Secondary syphilis can manifest with various clinical and histopathological presentations. We report the case of a 52-year-old patient that presented with nonpruritic nodular lesions on the face, trunk, and insteps that clinically mimicked lymphoma or sarcoidosis. Histopathological findings showed granulomatous inflammation. The serology revealed positive non-treponemal and treponemal tests. Treatment with benzathine penicillin G was successful.
    Acta dermatovenerologica Alpina, Panonica, et Adriatica 12/2010; 19(4):27-30.
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    ABSTRACT: The term lymphedema refers to a chronic, progressive edema, usually of a limb, due to insufficient lymphatic flow. It may appear as a primary disturbance or secondary to other causes, e.g., after infections or surgery. The most common cause of lymphedema in the Western world is cancer surgery and/or radiotherapy. The authors summarize the etiology, pathophysiology and clinical staging of lymphedema. The diagnosis of lymphedema is usually based on history and clinical appearance. However, lymphoscintigraphy is the gold standard of imaging in doubtful cases. Adequate and early compression therapy and good patient compliance are the cornerstones of management of lymphedema. The authors present their experience with compression therapy for lymphedema. While no differences were found in the efficiency of compression therapy between oncologic and non-oncologic patients, compression stockings of class III seemed to be efficient in the majority of secondary lower limb lymphedemas but not as maintenance therapy for primary lower limb lymphedema.
    Acta medica Croatica: c̆asopis Hravatske akademije medicinskih znanosti 07/2010; 64(3):167-73.
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    ABSTRACT: Darier disease (DD) is an autosomal dominant genodermatosis caused by mutations in the ATP2A2 gene. It has been reported that depletion of Ca(2+) stores within the endoplasmic reticulum of keratinocytes is associated with impaired cell cycle regulation and terminal differentiation. Mechanical stress, heat, or UV irradiation might delay cell cycle exit and permit progression into the quiescent stage without repair. When there is associated DNA damage, this can lead to an accumulation of secondary somatic mutations and possible clonal proliferation of damaged keratinocyes within keratotic papules and plaques. We sought to present clinical, demographic, and genetic analysis of the cohort of Slovenian patients with DD, which represents 52% of DD patients in the country. We examined 28 Slovenians with DD and screened genomic DNA for ATP2A2 mutations and RNA for splice site mutations. The estimated prevalence of the disease in Slovenia is 2.7/100.000. We identified 7 different ATP2A2 mutations, 4 of which are novel: A516P, R559G, 463-6del6, and 1762-6del18. We also found two previously described polymorphisms in intron XVIII (2741 + 54 G>A) and in exon 15 (2172 G>A; A724A), with allele frequencies of 64.15% and 11.32%, respectively. There was a history of perceptive deafness in two DD patients from two families. Analysis of SERCA2 expression, measurements of Ca(2+) uptake and their influence on desmosomal assembly in vitro would add additional value to the study. Although single-stranded conformational analysis (SSCP) is a common and accepted method for screening for the presence of mutations, it does miss 10% to 20% of mutations. We identified 4 novel ATP2A2 mutations in Slovenian patients with DD. Deafness seems to be a new phenotypic characteristic of DD patients.
    Journal of the American Academy of Dermatology 03/2010; 62(5):819-23. · 4.91 Impact Factor
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    ABSTRACT: Cutaneous leishmaniasis is the most common form of leishmaniasis caused by flagellate protozoa of the genus Leishmania transmitted by sand fly bites. Old World leishmaniasis is endemic in the Mediterranean Sea and the neighbouring countries. We present a case of a 10-year-old boy with a cutaneous leishmaniasis in form of papules on the nose, right and left lower leg. Histopathological examination showed diffuse dermal infiltrate predominantly of macrophages with admixture of few lymphocytes, eosinophils and plasma cells. In most of macrophages amastigotes were seen. Because of higher rate of travel and work abroad increased number of sporadic cases of cutaneous leishmaniasis in non-endemic areas should be taken into account.
    Acta dermatovenerologica Alpina, Panonica, et Adriatica 01/2010; 19(2):41-3.
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    Jovan Miljković, Aleksej Kansky
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    ABSTRACT: Hereditary palmoplantar keratodermas (HPPK) are relatively frequent in Slovenia; however, the papulosa type of HPPK is rare. Epidemiological data are scarce; a population study in Croatia revealed a prevalence of 1.17/100,000 inhabitants. According to the preliminary data, it seems that HPPK papulosa is more common in Slovenia than in other countries. Efforts were made to identify all patients with HPPK papulosa in Slovenia. Existing hospital and outpatient records served as a starting point. Patients and their relatives were invited for examination. When necessary for preparing pedigrees, we visited patients. Altogether 66 patients were observed, giving a prevalence of 3.3/100,000 inhabitants. 62 patients belonged to 11 unrelated families with two or more affected members and there were also four isolated cases. Our investigation points to an autosomal dominant mode of inheritance. All of the routine biochemical and hematologic tests were within normal limits. No malignancies were observed, nor were such data revealed in patients' histories. Thickened nail-plates were observed in three patients. The prevalence of HPPK papulosa in Slovenia is higher than in other countries studied. Further loci mentioned in literature suggest a genetic heterogeneity in this condition.
    Acta dermatovenerologica Alpina, Panonica, et Adriatica 09/2009; 18(3):114-6.
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    Jovan Miljković, Vesna Breznik
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    ABSTRACT: Cutaneous larva migrans is a frequent phenomenon endemic in tropical and subtropical countries. In Europe only sporadic cases are reported. We present two cases of cutaneous larva migrans in two Slovenian tourists returning from a vacation in Brazil.
    Acta dermatovenerologica Alpina, Panonica, et Adriatica 07/2008; 17(2):83-5.
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    Mirjam Belić, Jovan Miljković, Pij B Marko
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    ABSTRACT: Mycobacterium marinum is a human opportunistic pathogen that is known to inhabit swimming pools, home aquariums, and natural bodies of salt and fresh water. Epidemic cases involving swimming pools are easily recognized, but sporadic cases are frequently misdiagnosed. A 42-year-old male presented with a 2-month history of the appearance of livid, verrucous, painless nodules on his right upper extremity. He had cleaned an aquarium with tropical fish for the past 2 years. A histopathological examination suggested a granulomatous inflammation. After incubation on Löwenstein-Jensen medium, Mycobacterium marinum was identified using biochemical methods and the PCR technique. Systemic therapy with rifampicin, ethambutol, and clarithromycin over a period of 6 months led to complete resolution of the skin lesions with some residual scars. Knowledge of this condition is very important to avoid unnecessary diagnostic procedures and improper treatment.
    Acta dermatovenerologica Alpina, Panonica, et Adriatica 10/2006; 15(3):135-9.
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    J Miljković, M Belic, A Godić, P Klemenc, J Marin
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    ABSTRACT: Lichen planus (LP) is a relatively common papulosquamous skin disease of unknown etiology, it is believed to be a T-cell mediated disorder. In addition to the cutaneous eruptions it may also affect mucous membranes, nails or cause scarring alopecia. Lichen planus appears in various clinical variants which are categorized according to the morphology and configuration of lesions. We present a 34-year-old man who developed a papular eruption localized unilaterally on the right side of the body in a linear-zosteriform pattern within the L5-S1 nerve segments. The skin lesions clinically and histologically mimicked LP. Topical treatment with betamethason ointment for one month led to remarkable improvement, but a zosteriform hiperpigmentation persisted. According to the clinical findings in our patient and a review of the literature, we believe that lichenoidzosteriform eruption is a variant of lichen planus or a herpes zoster infection.
    Acta dermatovenerologica Alpina, Panonica, et Adriatica 07/2006; 15(2):94-7.
  • Jovan Miljković, Aleksej Kansky, Gaj Vidmar
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    ABSTRACT: Previous studies carried out in Slovenia revealed a high frequency of cases of hereditary diffuse palmoplantar keratodermas (DPPK). The relatively small total population of about two million in a small territory and an efficient public health service were favorable preconditions for such a study. Existing hospital and outpatient department records served as starting points. Patients were invited to come for a follow-up examination, and visiting the patients at their homes enabled us to gather further data. Thus efforts were made to include all patients with hereditary DPPK in Slovenia. Altogether 170 DPPK patients were detected, giving a prevalence of 8.3 per 100,000 inhabitants. The patients originated from remote, mostly mountainous districts, where the local DPPK prevalence highly significantly exceeded the average Slovene prevalence. The segregation ratio showed an autosomal dominant mode of inheritance. The percentage of persons affected was 34.4% (95% confidence interval 29.8-39.4), lower than expected for autosomal dominant inheritance (the difference is highly significant, P < 0.00001; exact binomial test). One autosomal dominant gene alone does not fully explain the transmission of the disorder to siblings. Evidence is produced that additional factors are necessary for the transmission of this genetic condition. The degree of consanguinity and the physical pressure on palms and soles seem to play an important part. It is reasonable to expect that molecular-biology studies linked to the epidemiological data could contribute to the solution of the problem.
    Wiener klinische Wochenschrift 02/2006; 118 Suppl 2:35-7. · 0.81 Impact Factor
  • Katarina Trcko, Pij B Marko, Jovan Miljković
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    ABSTRACT: We present the case of a 10-year-old girl with a six months history of disseminated asymptomatic, brown pigmented macules on the trunk and proximal parts of the extremities. The clinical picture, histological findings, and the course of disease were similar to those of idiopathic eruptive macular pigmentation. The cutaneous lesions gradually disappeared over the next two years without any treatment, and no relapse occurred. The knowledge of this disease is important in order to avoid unnecessary treatment as spontaneous resolution of the lesions may be expected within months or a few years. The spontaneous regression without any treatment is an additional diagnostic criterion.
    Acta dermatovenerologica Alpina, Panonica, et Adriatica 04/2005; 14(1):30-4.
  • Jovan Miljković
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    ABSTRACT: An 82-year-old female presented with an 11-year history of multiple, symmetrically disseminated hyperkeratotic red-brown papules 3-5 mm in diameter on the dorsal aspects of the upper and lower extremities. The eruption first appeared on the dorsa of the feet and on the lower parts of the legs. During the last few years, the lesions extended gradually to the upper part of the legs and thighs, also disseminating over the trunk. There was no family case history of Flegel's disease. Histopathological examination revealed a hyperkeratosis with a focal parakeratosis overlying the thinned epidermis. In the papillary dermis there was a dense band-like infiltrate composed of lymphocytes and some histiocytes. Electron microscopy showed a normal number of membrane-coated granules (Odland bodies). The clinical and histopathological findings in the patient corresponded with the diagnosis of hyperkeratosis lenticularis perstans. The patient was treated with PUVA (psoralen plus ultraviolet A)-bath therapy, retinoid plus PUVA and calcipotriol. However, all of these treatments were unsuccessful.
    Wiener klinische Wochenschrift 02/2004; 116 Suppl 2:78-80. · 0.81 Impact Factor
  • Jovan Miljković, Pij Bogomir Marko
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    ABSTRACT: A 74-year-old man presented with a five-month history of highly pruritic keratotic papules on the trunk and extremities. Laboratory data revealed mild eosinophilia, elevated IgE (483KE/I) and no other signs of atopy. Tests to exclude parasitic infestation were negative. Two biopsies showed non-specific changes. The third biopsy revealed small acantholytic clefts in the upper part of the epidermis and confirmed the diagnosis of Grover's disease. Topical treatment with calcipotriol ointment and systemic treatment with acitretin in low doses successfully reduced the pruritus within one week, and brought about a complete remission within three weeks without any recurrence.
    Wiener klinische Wochenschrift 02/2004; 116 Suppl 2:81-3. · 0.81 Impact Factor
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    ABSTRACT: Darier disease (DD) is caused by mutations of the ATP2A2 gene, which encodes the sarco/endoplasmic reticulum Ca(2+)-ATPase isoform 2 (SERCA2). The mutations affect protein expression, degradation and activity. We report a patient with severe sporadic DD, who did not respond adequately to repeated courses of orally administered acitretin and isotretinoin. He was found to harbor the missense P160L mutation of the ATP2A2 gene in a heterozygous state in the A domain of SERCA2 and polymorphism in intron 18 (2741 + 54 G --> A). The A domain plays a key role in translocation of Ca(2+) from cytoplasm to endoplasmic reticulum lumen, thus establishing a low intracellular Ca(2+) concentration.
    Dermatology 01/2004; 209(2):142-4. · 2.02 Impact Factor
  • Jovan Miljković, Ivan Krajnc
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    ABSTRACT: A 38-year-old female presented with a history of recurrent multiple deep dermal nodules located on the dorsa of the feet, over the ankle joints and lower pretibial area. Laboratory investigation excluded rheumatoid arthritis. Histopathological examination showed changes in the deep dermis: histiocytes in palisades around foci consisting of degenerated bundles of collagen, mucin, fibrin and "nuclear dust". The diagnosis of subcutaneous granuloma annulare was made on the basis of the clinical and histological features. Treatment with dapsone was successful, and in the course of two months the nodules disappeared.
    Wiener klinische Wochenschrift 06/2003; 115(9):309-11. · 0.81 Impact Factor