Chronic Steroid Therapy Research Articles

Prevalence of Metabolic Bone Disease among Chronic Rhinosinusitis Patients Treated with Oral Glucocorticoids

The treatment of chronic rhinosinusitis (CRS) often requires chronic or intermittent oral steroid therapy, which has the potential for adverse skeletal effects, including osteoporosis and increased risk of fragility fractures. The purpose of this study was to determine the prevalence of osteopenia/osteoporosis (OP) or low bone density (LBD) in patients with CRS with/without polyposis treated with oral glucocorticoids. Retrospective chart analysis was performed at a tertiary-care rhinology practice. Patients with CRS with/without polyposis evaluated between September 2003 and July 2008 were included if they had (1) previous history of oral steroid usage (> or =5 mg daily for at least 3 months) and (2) previous bone mineral density evaluation. A total of 197 patients were included with a mean age of 51.1 years (range, 15-79 years). The primary presenting diagnoses included CRS with polyposis in 176 cases (89.3%) and CRS without polyposis in 21 cases (10.7%). Concomitant asthma was present in 161 patients (81.7%). Overall, the prevalence of low bone mass was 38.6%. Among men >50 years of age and postmenopausal women, the prevalence of osteopenia/OP or LBD was 62.5 and 62.2%, respectively. Comparing men >50 years of age and postmenopausal women to their respective younger populations, both had a statistically higher presence of low bone mass (p < 0.0001), with an odds ratio of 10.6 (3.9-28.7) and 34.6 (7.4-161.5), respectively. There was no statistical difference in the presence of bone loss when comparing groups by gender. A multivariable analysis of common comorbidities revealed age to be the only factor associated with increased risk for OP/osteopenia or LBD. Patients with CRS with/without polyposis treated with oral steroids who underwent bone density testing were found to have a high prevalence of LBD. High index of suspicion is required to identify at-risk patients and to initiate careful evaluation and treatment to prevent additional bone-related complications.

Long-term Corticosteroid Use

Long-term Corticosteroid Use

Coccidioidal meningitis and brain abscesses

Coccidioides species are the most common etiologic agents of chronic meningitis in regions endemic for coccidioidomycosis. Occasionally, even short-term travel to endemic regions results in the acquisition of meningeal disease, so awareness of this complication of coccidioidomycosis is important even in nonendemic areas. The prognosis depends on the early recognition and treatment of the disease, so it is important to be familiar with the varied clinical manifestations, risk factors associated with meningeal involvement, diagnostic challenges, and therapeutic modalities. We performed a retrospective analysis of 71 cases with coccidioidomycosis involving the CNS seen from 1996 to 2007 at a referral medical center in southern Arizona. The only presenting symptom found in the majority of patients was headache. Those who were immunocompromised (most commonly HIV/AIDS and chronic steroid therapy) were at increased risk, but diabetics were not at increased risk. There was a preponderance of males (2:1) and people of Hispanic, African, and Asian (especially Pacific Isles) background. CSF anticoccidioidal antibody and culture were frequently negative on presentation, but in these cases, the serum antibody test was usually positive. Imaging studies were helpful in two thirds of cases, most commonly demonstrating basilar meningitis or hydrocephalus, which frequently required ventriculoperitoneal shunting. Most were treated with fluconazole, and prognosis was good for most of those who remained on treatment. Coccidioidal meningitis remains a diagnostic challenge, but the diagnosis can usually be made successfully when coccidioidal serum and CSF antibodies and cultures are combined with appropriate imaging studies.

Tracheal rupture after emergency endotracheal intubation

A 60-year-old woman presented to the emergency department (ED) of a suburban hospital with complaints of cough, fever, and dyspnea. She had a history of chronic obstructive pulmonary disease (COPD) and chronic steroid therapy. At presentation, she was in severe respiratory distress. Orotracheal intubation was decided due to persistence of severe hypoxia and hypercapnia with deterioration of consciousness despite a first attempt at noninvasive ventilation. The intubation was performed in rapid sequence using a 7.5-mm diameter single lumen tube without stylet. The patient had a regular and anatomically intact airway. The maneuver itself was reported to be an easy procedure and was considered successful after the first attempt. After about an hour of invasive ventilation, a subcutaneous emphysema appeared on the neck and anterior chest wall, respiratory failure worsened, and a slight hemoptysis occurred. The chest radiograph showed subcutaneous emphysema and protrusion of the cuff outside the tracheal lumen (Fig. 1). A computed tomography (CT) scan visualized the injury of the posterior tracheal wall due to the rupture of the pars membranacea (Fig. 2). The patient was then referred to our hospital to undergo a bronchoscopy, which revealed a longitudinal hole with sharp margins at the posterior part of the membranous portion, extending up to 2 cm from the carina with a total length of 5 cm. The lesion was surgically repaired via right thoracotomy. Fig. 1 a Chest radiograph in the anteroposterior view of the patient with tracheal rupture, showing subcutaneous and mediastinal emphysema. b Detailed view shows the protrusion of the cuff of the tube outside the tracheal lumen (white arrows) Fig. 2 a–c Corresponding CT axial scans corroborating the diagnosis of subcutaneous and mediastinal emphysema. d The lumen of the tracheal tube appears enlarged and deformed after the herniation of the cuff Mechanisms that may determine tracheal laceration are mechanical and anatomical [1]. An over-distended balloon cuff coupled with fragility of the tracheal wall due to chronic lung diseases and steroid therapy may be crucial [2]. The appearance of specific symptoms after intubation, like subcutaneous emphysema, hemoptysis, and persistence of hypoxia despite adequate ventilation, are consistent with a possible tracheal rupture [1–4]. Radiology may confirm the clinical suspicion.

EPAS1, a Dexamethasone-Inducible Gene in Osteoblasts, Inhibits Osteoblastic Differentiation

Glucocorticoid-induced osteoporosis is a clinical problem in patients under chronic steroid therapy. To delineate the action of glucocorticoids on osteoblasts, we performed microarray analysis using rat primary osteoblasts and identified several glucocorticoid target genes. We validated the dexamethasone-induced upregulation of CCAAT/ enhancer-binding protein delta (C/EBP ), endothelial PAS-domain protein 1 (EPAS1), matrix Gla protein (MGP), and nerve growth factor inducible-B (NGFI-B) expression by quantitative real time-polymerase chain reaction (qPCR). EPAS1 overexpression inhibited, whereas dominant-negative EPAS1 overexpression enhanced the upregulation of osteoblastic marker genes and the mineralization in ST2 mesenchymal cells under the simulated osteoblastogenesis conditions. These results suggest that glucocorticoids could inhibit osteoblastic differentiation by regulating its target genes, as exemplified by EPAS1.

Complications of Regional Anesthesia and Pain Medicine.

Complications of Regional Anesthesia and Pain Medicine. Edited by Joseph M. Neal, M.D., and James P. Rathmell, M.D. Philadelphia, Saunders Elsevier, 2007. Pages: 400. Price: $105.00.We are all aware of the increasing roles of regional anesthesia and pain medicine in today’s patient care. This book, edited by Drs. Neal and Rathmell, draws on the current literature—from large randomized trials to case reports—to identify, discuss, and quantify (when possible) complications in these two subspecialties. Its editors and their internationally known 42 coauthors discuss in-depth these complications from the common to the uncommon and from the minor to the catastrophic.This 35-chapter book, with over one-third of its references published between 2000 and 2006, is divided into three sections: Regional Anesthesia (16 chapters); Pain Medicine (16 chapters); and Medicolegal Perspective (3 chapters). The Regional Anesthesia chapters cover the often discussed complications such as bleeding, infection, and nerve injury, as well as the less-recognized complications such as myotoxicity. The chapters in the Pain Medicine section focus on complications from specific treatments and procedures such as chronic steroid therapy, epidural injections, radio-frequency treatment, and spinal cord stimulator placement. The last section covers medicolegal issues that can arise from complications, treatment, and nontreatment. Specifically, it discusses the results of closed claims analyses, the legal issues of opioid therapy, and informed consent documentation.One shortfall of this book is that it lacks an in-depth discussion of ultrasound guidance and its potential impact on complications. In fact, the index does not contain the word “ultrasound” or its synonyms. We found only two sentences in the entire book that briefly discussed the use of ultrasound guidance. Granted, before 2007, few “large” studies specifically addressed how ultrasound-guided techniques affect complications. However, given its increased use in the last decade, this area deserved greater discussion. Finally, regional anesthesia and pain medicine overlap in terms of interventions, tools, and complications, resulting in some redundancies between chapters. However, with a few exceptions, the redundancies are small and the reader is quickly referred to an appropriate chapter for greater detail.Each chapter in the first section has a similar outline, helping to ensure that the topics are presented consistently and that specific subtopics can be found quickly. This is less true in the second section, but enough so that the flow of reading from chapter to chapter is rather similar. All the chapters range between 6 and 18 pages. The authors make good use of “white space” and headings of varying font sizes to create a clean, easy-to-read layout. In addition, there is ample use of boxes, tables, illustrations, and images, all in a surprisingly esthetic monochromatic gray. They summarize key points, display anatomy, and illustrate techniques. However, there is a tendency in most chapters to exhaustively relist information in the text that is already nicely presented in boxes and tables.The editors dedicated the book to patients, trainees, and colleagues, as well as their families. Did the editors accomplish their goal to produce a text that will benefit all? Yes, the editors clearly achieved their goals. The book is the right size for its content, breadth and scope. Any greater detail would likely lose an audience of professionals.On the whole, this book is well written, well organized, nicely illustrated, and, most importantly, informative. Every anesthesiology department should have a copy; regional anesthesiology experts and pain physicians should have one as well!*University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania. herlicha@upmc.edu

Treatment of Osteoporosis/Osteopenia in Pediatric Leukemia and Lymphoma

To evaluate the efficacy and safety of various treatment options for osteopenia and osteoporosis secondary to cancer treatment in pediatric patients undergoing cancer therapy. A systematic search of PubMed (1949-November 2008) and International Pharmaceutical Abstracts (to November 2008) was conducted using the following search terms: osteoporosis, osteopenia, pediatrics, cancer, neoplasms, chemotherapy, bisphosphonates, calcium, vitamin D, calcitonin, and physical therapy. All prospective studies that evaluated various osteoporosis treatment options in pediatric patients undergoing chemotherapy were included. Results from studies evaluating bisphosphonates and other treatments in children with osteoporosis due to other causes were also included if important safety and efficacy data were provided. Most commonly reported primary efficacy endpoints included comparisons of bone density parameters measured before and after treatment. Four clinical studies and 2 case reports describing treatment with bisphosphonates, specifically alendronate and pamidronate, for osteoporosis or osteopenia in pediatric cancer patients were identified. Results from the trials showed that these medications were efficacious in reducing bone mineral density loss during cancer therapy and were well tolerated in this special population. Primary efficacy endpoints included improvements in Z-scores measured by dual-energy X-ray absorptiometry scans. The most commonly reported adverse effects included hypocalcemia, mild stomach upset, and infusion-related hyperpyrexia. Four additional clinical trials involving the treatment of osteoporosis or osteopenia in children and adolescents who developed bone degeneration after chronic steroid therapy are also included. In these trials, treatment options such as calcitonin, and calcium and vitamin D supplementation were also shown to be beneficial. The clinical trials published to date are limited to only a few conducted in small populations of patients diagnosed with lymphoblastic leukemia or non-Hodgkin's lymphoma. However, alendronate and pamidronate both appeared to be effective options in improving bone mineral density scores with minimal adverse effects.

Bisphosphonates are not associated with vertebral osteonecrosis

Intravertebral clefts are considered markers for osteonecrosis. We tested the hypothesis that bisphosphonate therapy was associated with vertebral osteonecrosis. A retrospective review of a vertebroplasty database was performed. Exposure to, duration of, and type of bisphosphonate therapy was documented. Radiographs were reviewed to identify intravertebral gas-filled or fluid-filled clefts, which are considered a marker for vertebral osteonecrosis. Proportion of patients with and without clefts was compared between the group exposed to bisphosphonates and the unexposed group using Chi-squared test. Duration of bisphosphonate exposure was compared between patients with and without clefts using Student's t-test. After exclusion of 16 patients with malignancy and 21 with chronic steroid therapy 237 patients were identified. Sixty-seven (28%) of the total cohort of patients were prescribed bisphosphonate therapy. Overall, clefts were present in 68 (29%) of the 237 patients. Among the 67 patients exposed to bisphosphonate therapy, 15 patients (22%) had clefts. Among the 170 patients not exposed to bisphosphonate therapy, 53 patients (31%) had clefts (P = 0.17 compared to bisphosphonate therapy group). Mean duration of bisphosphonate therapy among patients with clefts was 52 +/- 63 weeks and among patients without clefts was 57 +/- 79 weeks (P = 0.80). Intravertebral clefts are not associated with bisphosphonate therapy. If these clefts indicate osteonecrosis, then bisphosphonate therapy does not appear to be associated with vertebral osteonecrosis.

Delayed Colonic Perforation after ESD in a Patient with Ulcerative Colitis: A Case Report and Review of the Literature

The efficacy and safety of endoscopic mucosal resection and submucosal dissection in the setting of ulcerative colitis has not been fully established. Potential complications, such as bowel perforations, may occur as a result of multiple issues. This case demonstrates a rare complication of delayed bowel perforation after an endoscopic submucosal dissection of a polyp in a patient with ulcerative colitis on chronic steroid therapy.

Regional anaesthesia and side effects: is it safe?

The availability of new local anaesthetics and the improvement of regional techniques has caused a great increase of central and peripheral blockades for anaesthesia as well as for postoperative pain. The increase of these blockades tends to increase the rate of complications. In a Pubmed research we found more than 400 articles about this topic. In the analysis of the literature we divided two major chapters: severe complications after central blockades and after peripheral nerve blocks. Analysis of the literature showed a lower incidence of serious complications associated with neuroaxial anaesthesia. It is important to underline that authors stressed the importance of predisposing factors like pre-existing peripheral or central neurological disease, arteriosclerotic disease, osteoporosis and spinal stenosis, diabetes, cancer, chronic alcohol abuse and steroid therapy. Otherwise, the most concern about peripheral nerve blocks is nerve injury and/or neuropathy due to potential toxicity of local anaesthetics or due a nerve lesion for needle trauma or infection. Even if the incidence of severe side effects is rare, it is very important that we approach this technique knowing well the risks (even if low) so that we can prevent them improving the outcome of patients. Nevertheless, there is again the need to have a large prospective study to investigate the real incidence of severe complications of central and peripheral blocks.

The Other Campylobacter Species

Purpose: Campylobacter fetus has been documented as a cause of bacteremia, and it is typically diagnosed in immunocompromised patients with a febrile illness or extra-intestinal involvement including vascular infections, abscesses, and cellulitis. Unlike its well-known counterpart, C. jejuni, it is rarely associated with gastrointestinal manifestations. We present an unusual case of C. fetus bacteremia presenting with abdominal pain and diarrhea. An 81-year old female with a history of COPD on chronic steroid therapy and pulmonary embolism presented with complaints of abdominal pain, nausea and loose stools for the past month. Physical exam was significant for RUQ tenderness with guarding. A small bowel series and RUQ sonogram were negative. CT of the abdomen revealed a RUQ inflammatory process, better defined as a duodenal hemorrhage vs. perforation without evidence of free air. An EGD revealed chronic inactive gastritis with normal duodenal anatomy. With conservative management, the patient's symptoms improved, and she was discharged home. Three days after discharge, 2/4 blood culture bottles grew C. fetus, and the patient returned to the hospital for further evaluation. At that time, she complained of intermittent periumbilical pain without diarrhea. She was afebrile and abdominal exam was benign. WBC count was 10. During her hospitalization, the patient suffered from a single temperature spike with recurrence of diarrhea. Repeat blood cultures, stool cultures, and Clostridium difficile toxin were negative. To reassess her symptoms, a repeat CT scan was performed which demonstrated no significant change. The infectious disease specialists' impression was that the Campylobacter bacteremia was likely secondary to a GI source and recommended treatment with Meropenem for 12 days. The patient recovered without further complications, and was discharged home. Conclusion: A literature search on C. fetus yielded reports of appropriate antibiotics use, but limited information regarding clinical presentation and management. We aim to highlight an unusual presentation of Campylobacter fetus bacteremia with abdominal pain and diarrhea. This diagnosis requires a high degree of suspicion in immunocompromised hosts, and requires an adequate length of IV antibiotic therapy since it is rarely self-limited.

Chronic Steroid Therapy Versus Steroid Withdrawal Plus Pulse Steroid Therapy for Rejection in Kidney Recipients with Basiliximab Therapy

Chronic Steroid Therapy Versus Steroid Withdrawal Plus Pulse Steroid Therapy for Rejection in Kidney Recipients with Basiliximab Therapy

Epidural Angiopomatosis of the Thoracic Spine: Case report and literature review

Spinal epidural angiolipomatosis (SEA) is a rare benign neoplasm of adipose tissue with a prominent vascular component. Classified as either idiopathic or secondary to chronic steroid therapy it accounts for 0.14% of all spinal axis tumours. The clinical and radiological features and treatment of a case in a 24-year-old male are described and discussed together with a review of the literature and previous reports.

Leishmaniasis visceral y asma bronquial: influencia del tratamiento esteroideo en el desarrollo del síndrome de activación macrofágica e insuficiencia suprarrenal relativa

The risk of suffering opportunistics infections in the immunoincompetent patient is a fact perfectly established. An uncommon situation constitutes the bronchopaties, pathologies with a high prevalence among the general population that they require habitually, among other, steroid treatment. The immunosupression confers to the clinical evolution of the infections, as a consequence of the inadequate response to the physical stress, due to the inhibition of the hypothalamus-hypophysis axis being able to in particularly serious cases, to develop the denominated macrophage activation syndrome, a serious and uncommon syndrome that darkens the clinical prognosis in these patients. In presence of a feverish syndrome of uncertain origin in a patient in immunosuppressor treatment, although it is to low dose, it is necessary to carry out a exhaustive differential diagnosis, should consider, among them, the infection for Leishmania, a parasitosis whose incidence is increasing notably in the last years in the immunosuppressed population. We present the clinical case of a 63 year-old patient, immunoincompetent as a consequence of secondary chronic steroid therapy to asthmatic bronchopaty that experiences an uncommon form of visceral leishmaniasis in our area, consistent in multiorganic failure in the context of the development of a macrophage activation syndrome.

Steroid‐sparing effect of omalizumab for allergic bronchopulmonary aspergillosis and cystic fibrosis

Allergic bronchopulmonary aspergillosis (ABPA) is a complication commonly encountered in patients with CF that produces significant respiratory morbidity. Chronic airway colonization with Aspergillus induces strong inflammatory responses with high IgE levels. Current guidelines for therapy include prolonged courses of systemic corticosteroids as the main therapeutic strategy. However this has the potential to induce significant detrimental side effects in children. Omalizumab is a humanized monoclonal antibody directed against IgE that prevents its binding to high- and low-affinity receptors on effector cells. It has been shown to be effective in improving asthma control in patients with a strong allergic component. We present our long term experience with the use of Anti-IgE therapy in three children with CF and ABPA (mean age at start of therapy 14.2 years) who were steroid dependent. All three were already experiencing significant side effects from chronic steroid therapy. After the start of Omalizumab these children have experienced significant and sustained clinical improvements at the same time that they were discontinued from chronic systemic steroids. Our experience suggests that IgE blockade has tremendous potential as a strategy to control this disease in steroid dependent patients.

Acute myoclonus following spinal anaesthesia

Acute myoclonus following spinal anaesthesia

Long-Term Outcome of Early Steroid Withdrawal After Kidney Transplantation in African American Recipients Monitored by Surveillance Biopsy

Generally chronic steroid therapy is standard care for African American (AA) kidney recipients because of their higher incidence of rejections and lower long-term graft survival. This prospective study evaluated the long-term safety and efficacy of early steroid withdrawal (ESW) in AA recipients. A total of 206 recipients were studied; 103 AA and 103 non-AA recipients monitored by serial surveillance biopsies from 1 to 60 months posttransplantation to evaluate subclinical acute rejections (SCAR) and chronic allograft injury (CAI). Biopsy-proven clinical acute rejections (BPAR) and SCAR were treated. Primary end point was BPAR and secondary end points were 5-year SCAR, CAI and survival. Incidences of BPAR was 16% versus 14% (p = 1.0), prevalence of CAI due to hypertension was 48% versus 30% (p = 0.05) and interstitial fibrosis/tubular atrophy was 47% versus 32% (p = 0.05) and the mean serum creatinine levels were 2.1 versus 1.8 mg/dL (p = 0.05) at 5-years in AA versus non-AA recipients. The incidence of SCAR was 23% versus 11% at 1 month (p = 0.04), 12% versus 3% at 3 years (p = 0.04) and 10% versus 1% at 5 years (p = 0.04) in AA and non-AA recipients, respectively. Five-year patient survivals were 81% and 88% (p = 0.09) and graft survivals were 71% and 73%(p = 0.19) in AA and non-AA groups, respectively. After early steroid withdrawal AA kidney recipients have significantly lower renal function and higher SCAR and CAI but 5-year graft survival are comparable to non-AA recipients.

Salmonella Arizonae Bacteremia Associated with Septic Arthritis Following Consumption of Rattlesnake Capsules in a Patient with Idiopathic Thrombocytopenic Purpura (ITP) on Chronic Steroid Therapy.

Background: Folk medicine plays an important role in some populations in the United States. In particular, the use of rattle snake powder is becoming increasingly popular among the Mexican-American population along the US-Mexico border. Infections associated with the ingestion of this preparation have increasingly been reported in this country. We present a patient who presented with Salmonella Arizonae bacteremia and septic arthritis with underlying ITP on chronic treatment with steroids and surreptitious use of rattle snake powder.Case Report: A 53 year-old Mexican -American male with a past history of ITP on chronic oral prednisone with intact spleen was admitted with fever, chills, and an acute onset of pain, swelling and tenderness of his left knee. On admission to the hospital, his temperature was 101.5 F, blood pressure was 124/68, and pulse 102/min. The physical findings were significant for swelling and tenderness to the left knee with evidence of synovial effusion and restricted range of motion. The white blood cell count was 18,000cu/mm. Culture of the patient's left knee synovial fluid aspirate grew Salmonella Arizonae, as did his blood cultures. The pathogen was sensitive to 3rd generation cephalosporins and quinolones, and he was treated with intravenous ceftriaxone for 2 weeks with resolution of the bacteremia and improvement of the septic knee. He subsequently underwent a total knee arthroplasty, and follow up 1 year later revealed no evidence of persistent infection. After the pathogen identification, a careful alternative medicine history revealed the consumption of rattle snake powder preparation intended for treatment of his arthritis and ITP.Conclusion: Physicians should be aware of Salmonella Arizonae associated illnesses in both immunocompetent as well as immunosuppressed patients. Because the surge of interest in complementary and alternative medicine, a careful history should be elucidated, especially in immunocompromised patients who present with this syndrome.

Adrenal Trauma: Elvis Presley Memorial Trauma Center Experience

Adrenal gland injury is a potentially devastating event if unrecognized in the treatment course of a trauma patient. We reviewed our single-center experience and outcomes in patients with adrenal gland trauma. We performed a retrospective review of all patients presenting with trauma to the Regional Medical Center at Memphis who had adrenal gland injuries from January 1991 through March 2006. Each chart was reviewed with attention to the demographics, associated injuries, complications, and outcomes. Patients were stratified into two subgroups according to age (35 years or younger and older than 35 years) to allow for an age-based comparison between the two groups. Of 58,000 patients presenting with trauma, 130 (0.22%) were identified with adrenal injuries, of which 8 (6.2%) were isolated and 122 (93.8%) were not. Of these 130 patients, 125 (96.2%) had their injury diagnosed by computed tomography and 5 (3.8%) had their injury diagnosed during exploratory laparotomy. Right-sided injuries predominated (78.5%), with six (4.6%) bilateral. Four patients (3.1%) underwent adrenalectomy. Seven patients (5.4%) with adrenal injuries died. One patient (0.77%) required chronic steroid therapy. Patients older than 35 years were more likely to have complications such as deep venous thrombosis, pneumonia, and urinary tract infections. Patient age of 35 years or younger was associated with a significantly increased incidence of liver lacerations. Adrenal gland injury is uncommon, although mostly associated with greater injury severity. Although adding to morbidity, most are self-limited and do not require intervention.

Delayed Colonic Perforation after ESD in a Patient with Ulcerative Colitis

Purpose: Endoscopic submucosal dissection (ESD) removes pre-malignant lesions and intra-mucosal cancers from the GI tract, offering an alternative to surgery. As any procedure, ESD has complications. Certain conditions, such as ulcerative colitis (UC), have not been well-studied with ESD and may lead to increased complications. This case demonstrates a rare incidence of delayed colonic perforation after ESD in a patient with UC. Case: 83 yo male with UC on chronic steroid therapy was found to have a large lateral spreading tumor in the ascending colon on colonoscopy with biopsies revealing no adjacent active UC disease. After the patient refused surgery, he presented for ESD. The 4 × 8 cm mass was identified, raised, and dissected with a conventional needle knife. Two small defects were closed with 7 resolution clips. Post-procedure, IV antibiotics and steroids were initiated and he was admitted to ICU. Lesion revealed a tubulovillous adenoma with underlying cauterized submucosa and no invasive malignancy. On hospital day 3, he improved with softened abdomen and improved leukocytosis. On hospital day 4, he had flatus, decreased abdominal distention and pain, and was extubated. On hospital day 5, he had respiratory distress, increased abdominal distention, and hematochezia. He was emergently re-intubated and underwent exploratory laparotomy. A small opening was noted at the hepatic flexure with bleeding and soilage. A right hemicolectomy with diverting ileostomy was performed. Post-operatively, IV antibiotics and steroids were initiated. Surgical specimen revealed metal clips with full thickness necrosis with associated adjacent hemorrhage, cautery artifact involving the muscularis propria, and acute inflammation with dense inflammatory infiltrate extending to the subserosal fat with focal microabscesses. No cautery artifact was noted in adjacent muscularis propria. The perforation was noted 3.5 cm from the clips. On hospital day 8, the patient was extubated. After a prolonged hospital course, he succumb to sepsis and other co-morbidities. Conclusions: This case demonstrates a rare delayed colonic perforation after ESD in the setting of chronic UC and steroid therapy. Although ESD is an acceptable alternative to surgery, many conditions, such as UC, have not been fully examined. In this case, the delayed perforation may have been secondary to anatomically changes in the colonic wall from UC. More research is required to fully access the safety of ESD in UC.