Administration Of Intravenous Corticosteroids Research Articles

Acute rectus muscle palsy in children as a result of orbital myositis

OBJECTIVE: Acute rectus muscle palsy caused by orbital myositis is often confused with infectious orbital cellulitis. The purpose of this article is to clarify the former condition by explaining how it is manifested and treated. METHODS: The seven children less than age 11 years in this study were examined after having an acute onset of ocular pain. Physical examination indicated a loss of motility in the field of action of the involved extraocular rectus muscle. Computed tomographic examination confirmed the existence of orbital myositis. Treatment consisted of intravenous or oral administration of corticosteroids. RESULTS: In all the initial evaluations, computed tomography showed the isolated rectus muscle to be enlarged. In four of the patients in whom the lateral rectus was involved, esotropia was present in the primary position. In the fifth patient with lateral rectus involvement, esotropia was seen only in the field of gaze of the involved lateral rectus muscle. The patient with medial rectus involvement had exotropia, and the patient with superior rectus involvement had hypotropia on the involved side. Each had injection and chemosis of the conjunctiva and Tenon fascia only in the quadrant overlying the involved rectus muscle. CONCLUSIONS: Children with orbital myositis can have an acute rectus muscle palsy. The inflammation and strabismus are exquisitely sensitive to systemic corticosteroid therapy, which produces a rapid resolution of symptoms. If the steroid therapy is discontinued abruptly, the myositis can recur. (J P EDIATR 1996;128:230-3)

Visual Loss Caused by Choroidal Ischemia Preceding Anterior Ischemic Optic Neuropathy in Giant Cell Arteritis

Three patients with visual loss and normal fundi were discovered to have choroidal ischemia on fluorescein angiography. Each patient had a markedly increased Westergren erythrocyte sedimentation rate, but only one described symptoms of polymyalgia rheumatica, neck pain, and jaw claudication. Biopsy of the temporal artery confirmed giant cell arteritis in the two patients without constitutional symptoms. In one patient, typical anterior ischemic optic neuropathy developed the following day, whereas in the other two, anterior ischemic optic neuropathy later occurred despite the prompt administration of intravenous high-dose corticosteroids. Choroidal ischemia may be the first sign of giant cell arteritis in elderly patients with visual loss. Early diagnosis and treatment are mandatory in an attempt to forestall the development of anterior or posterior ischemic optic neuropathy, or central retinal artery occlusion in the affected or fellow eye.

Spinal cord resuscitation: A concept for today

Research findings and clinical experience obtained over the past 20 years have clearly established the principles of brain resuscitation in the management of closed head injuries. It is proposed that with regard to resulting morbidity, the same pathophysiological and mechanistic phenomena occur in acute spinal cord trauma. Specifically, it is secondary cord injury caused by hypoxia, edema, and aberrations in cell membrane potential that are largely responsible for resulting neurological deficits. The concept of spinal cord resuscitation is proposed as an attempt to reverse secondary changes that occur to obtain maximal neurological recovery. Such measures would include (1) prompt relief of cord deformation, (2) administration of intravenous corticosteroids, and (3) initiation of measures to facilitate spinal cord perfusion.

Autoimmune enteropathy and nephropathy with circulating anti-epithelial cell antibodies

We describe a child with circulating anti-epithelial cell antibodies, autoimmune enteropathy with intestinal villous atrophy, and membranous glomerulonephritis. The patient had persistent diarrhea at 6 months of age, and a small bowel biopsy showed active enteritis, villous atrophy, and crypt hyperplasia. When the patient was, 10 months of age, nephrotic syndrome developed because of membranous glomerulonephritis. Results of tests for circulating immune complexes were negative. Indirect immunofluorescence studies revealed a circulating antibody directed against renal epithelial cells. Circulating antibodies directed against normal small intestine epithelial cells were also detected by the immunoperoxidase technique. Western blot and immunoprecipitation identified a 55-kd antigen, in both small bowel and kidney, that reacted with an antibody in the patient's serum. High-dose prednisone therapy induced a clinical remission, resolution of the small bowel injury, and diminished serum anti-epithelial cell antibodies; after dose reduction, clinical relapse occurred with villous atrophy and reappearance of anti-epithelial cell antibodies. When the patient was 45 months of age, persistent diarrhea recurred despite intravenous administration of corticosteroids, cyclosporine, and total parenteral nutrition. Autoantibodies to a 55-kd epithelial cell protein are temporally related to the development of enteropathy and nephropathy. Study of similar patients is needed to determine the role of such antibodies in this disorder.

Early Administration of Corticosteroids in Emergency Room Treatment of Acute Asthma

To determine the effect of early administration of high-dose intravenous corticosteroids on duration of emergency room treatment and hospital admission rate in patients with acute asthma. Randomized, double-blind, placebo-controlled trial. The emergency room of a large, urban hospital with primary and referral care responsibilities. Eighty-one patients from 18 to 45 years of age with acute bronchial asthma and without pneumonitis or other serious underlying illnesses were studied on 91 occasions and were randomly assigned to control or experimental groups. The steroid group received 125 mg of intravenous methylprednisolone whereas the control group received intravenous normal saline 30 minutes after initial treatment. Additional treatment included aerosolized metaproterenol and oral theophylline therapy. Six hours after study entry, remaining patients were treated with 40 mg of intravenous methylprednisolone. Hospitalization was mandatory if total treatment time was greater than 12 hours. Age, sex, peak expiratory flow at entry, and prevalence of recent corticosteroids use were similar in both groups. Duration of emergency room treatment was 6.7 +/- 4.2 (SD) hours in the steroid group and 6.3 +/- 4.1 hours in the control group (P = 0.66). Hospitalization was necessary in 18% (95% CI, 7% to 30%) of the steroid group and in 13% (CI, 3% to 22%) of the control group. Frequency of return visits for acute asthma 2 days after emergency room discharge was 11% (CI, -1% to 22%) in the steroid group and 13% (CI, 2% to 23%) in the control group. These results fail to show any benefit for early administration of corticosteroids in patients with acute asthma. Routine administration of corticosteroids on initial presentation in such patients may not be warranted.

Rationale and Use of Corticosteroids in Chronic Obstructive Pulmonary Disease

Several studies of corticosteroid efficacy in patients with COPD performed in the last decade have had stronger study designs and larger patient populations than most of the previously reported investigations. These studies have provided evidence of the objective benefit of corticosteroid therapy on pulmonary function in clinically stable COPD patients. These positive results are due to a relatively marked beneficial effect of corticosteroids in a minority of the subjects studied rather than a modest effect in the majority of subjects. A controlled randomized trial of intravenous corticosteroid administration in patients with COPD and acute respiratory failure admitted to the hospital showed improvement in pulmonary function from 12 hours following initial administration through the remainder of the 3 days of the study in the treatment group as compared to the control group. A greater percentage of patients showed a beneficial response to corticosteroids in this study of patients with acute exacerbations as compared to most of the studies of clinically stable COPD patients with beneficial effects. This suggests the possibility that some patients may show a beneficial response to corticosteroids during an acute exacerbation although they have not shown a response when clinically stable. The response to inhaled corticosteroids in patients with COPD has not been studied as extensively as the response to oral corticosteroids. However, some studies have shown a beneficial response to inhaled corticosteroids, primarily but not exclusively, in individuals who have also shown a positive response to oral agents. Generally, the response in terms of improved pulmonary function has been less striking with the inhaled agent as compared to the oral drug, although higher relative doses of the oral drugs usually were studied. Several limitations of the currently available studies are evident. Most of the studies deal with the effects in clinically stable outpatients with COPD and no studies have dealt with maintenance therapy in patients who have responded to a 1 to 2 week course of 30 mg of prednisone or greater. Data on the efficacy of inhaled corticosteroids in COPD patients are limited. No studies have investigated the role of corticosteroids in acute exacerbations in outpatients with COPD. Recommendations are given regarding use of corticosteroids in patients with COPD. A trial of corticosteroids is recommended at some point during a patient's course, while clinically stable. If a beneficial response is obtained in terms of improvement in airflow obstruction, then clinical judgment must be used regarding whether maintenance therapy is continued and, if so, at what dose and by what route.(ABSTRACT TRUNCATED AT 400 WORDS)

Effect of intravenous administration of corticosteroids on dentin formation in the adult rat molar.

This study describes the effects of intravenously given corticosteroids on dentin formation in adult rat molars. Six rats twice a day received corticosteroids 20 mg/kg for 8 days, 10 mg/kg for 13 days, and 5 mg/kg for 19 days. Six rats given a heterotopic heart transplant received 10 mg/kg of corticosteroids twice a day for 40-64 days. Six rats were used as controls. Tetracycline was given at the start of the experiment and after 3 wk of treatment. After 40-46 days the rats were killed. Light microscopic examination of the molars showed no differences in the dentin formation or in the predentin zone between the experimental and control rats. In the ultraviolet light microscope two lines of tetracycline were visible along the root canal walls in both experimental groups. There was an obvious distance between the two lines, which indicated formation of new dentin. In the control group no formation of dentin was visible.

Single-lung transplantation: imaging features.

The imaging studies obtained after single-lung transplantation in 14 patients were reviewed. The reimplantation response occurred in 13 patients and was an early, transient process, which varied in its manifestations from a subtle perihilar haze to dense consolidation with air bronchograms. Nine episodes of acute rejection, an imprecise clinical diagnosis, occurred in eight of the patients. The associated chest radiographic changes were variable and included basal or diffuse reticular interstitial disease in three cases and basal and/or perihilar consolidation in three cases; no change was detected in three cases. On four occasions, the radiographic changes resolved within 24 hours of intravenous corticosteroid administration. The radiographic findings associated with the reimplantation response and rejection were nonspecific and could have been mistaken for those of fluid overload, atelectasis, mucous plugging, and pneumonia. Bronchial dehiscence was well demonstrated by the finding at computed tomography of extraluminal air adjacent to the bronchial anastomosis. One patient developed multiple pulmonary nodules due to cyclosporine-induced lymphoma.

Anaphylaxis after intravenous corticosteroid administration

Anaphylactic reaction to corticosteroids is an uncommon occurrence. Described is such a reaction resulting in cardiopulmonary collapse in a 66-year-old asthmatic treated with intravenous methylprednisolone. Awareness of this entity will allow for prompt and successful therapy.

Immobilization Hypercalcemic Crisis

Profound hypercalcemia associated with immobilization is rare. Hypercalcemic crisis occurring as a result of immobilization in which there was not a coexisting, contributing medical condition has not, to our knowledge, been reported previously. Failure to consider hypercalcemia as the source of progressive anorexia, nausea, vomiting, and irritability resulted in a respiratory arrest and nearly fatal outcome in the case of a 13-year-old boy one month after a simple femoral fracture. Therapy consisting of the intravenous administration of fluids and corticosteroids was successful in lowering the serum calcium level until mobilization could be accomplished. Review of previously reported cases emphasizes the difficulty in recognition and diagnosis of this unusual condition. Surgeons treating patients with fractures should be aware of this complication and familiar with its appropriate therapy.

Characterization of Metabolites in Domestic Sow Urine After Intravenous Administration of Radioactive Estrogen and Corticosteroids

We measured distribution of radioactivity among urinary metabolites excreted in nonpregnant and ovariectomized sows after intravenous injection of radionuclides (14carbon) labeled estrone, estradiol-17β, cortisol, and corticosterone. Treatment with an enzyme preparation (Glusulase) containing both β-glucuronidase and sulfatase activity, rendered extractable over 95% of the radioactivity recovered from urine with diethyl ether (estrogens) and ethyl acetate (corticoids). Only an additional 1 to 4% of the radioactivity was extracted following sol-volysis of the aqueous residue remaining after enzyme hydrolysis and extraction. Radioactivity in nonpregnant sow urine was predominantly in the estrone fraction following injection of either estrone or estradiol-17β. Moreover, the principal metabolite was estrone monoglucuronide. Only traces of estradiol-17β and an estriol-like compound were detected. Two other isolates contained radioactivity. One compound probably was 2-methoxyestrone, but structure of the other compound (XI) could not be established. The principal urinary metabolites from injection of Cortisol corresponded to chromatographic properties of tetrahydrocortisol and tetrahydrocortisone. Both metabolites were low in urine following injection of corticosterone. The major urinary metabolites from corticosterone injection corresponded to chromatographic properties of tetrahy-drocorticosterone and corticosterone. Considerable radioactivity from injection of both corticoids was isolated in the cortol, cortolone, and 11-ketoetiocholanolone −11β-hydroxyetiocholanolone areas of chromatograms. The data for corticoids agree with similar data for the human being and cow.

PLASMA-11-HYDROXYCORTICOSTEROID LEVELS IN DRUG-INDUCED COMA

Plasma-11-hydroxycorticosteroid (11-OHc.s.) levels were determined in thirty-seven cases of coma due to a self-administered overdose of barbiturates, amitriptyline, glutethimide, or 'Mandrax' (diphenhydramine and methaqualone). Values below the lower limit of the normal range were not detected, and no correlation was found between plasma-11-OHc.s. and the systolic blood-pressure, central body temperature, or degree of coma, except that " stress " levels occurred with return to consciousness. It is concluded that hypothalamicpituitary-adrenal activity is not significantly suppressed in drug-induced coma, and that there is generally no indication for the administration of intravenous corticosteroids in the management of such cases.

Accidental arterial injections

A case is presented of inadvertent intra-arterial injection of meperidine and promethazine. The initial sequence of events following injection was similar to that reported previously. Complete recovery ensued with the administration of intravenous heparin and corticosteroids. Consideration of the pathology seen with this accident suggests that the injury is a chemical endarteritis caused by a high concentration of drug delivered to the peripheral vessels. Immediate treatment should be instituted, including local sympathetic blocks, anticoagulation, and systemic corticosteroids. The basis of most inadvertent intra-arterial injections is the presence of an abnormal arterial branch adjacent to the intended vein. Prevention can best be accomplished by use of solutions containing low concentrations of the medication and by making sure that the needle is lying in the vein lumen for which it was intended.

PULMONARY ASPIRATION OF GASTRIC ACID???MENDELSON??S SYNDROME

Three cases of pulmonary aspiration of gastric acid as a complication of obstetrical anesthesia are described. The clinical picture consists of dyspnea, cyanosis, tachycardia and shock appearing several hours after the aspiration has occurred. On examination, the chest may be quite clear, but the chest radiograph shows a picture indistinguishable from that of pulmonary edema. The most important therapeutic measure is the intravenous administration of corticosteroids in large doses for several days. Bronchoscopy is contraindicated. With routine use of epidural anesthesia, this obstetrical complication can be avoided.