High-dose Corticosteroid Pulse Therapy Research Articles

Coexistence of anti-KS and anti-TIF1-γ antibodies in clinically amyopathic dermatomyositis presenting with rapid progression of interstitial lung disease.

Polymyositis/Dermatomyositis (PM/DM) is an idiopathic inflammatory myopathy (IIM) manifesting mainly as symmetrical proximal muscle weakness and/or typical cutaneous features due to autoimmune mechanisms. Clinically amyopathic dermatomyositis (CADM) is a subset of DM that exhibits only the typical cutaneous features without any clinical muscle symptoms. Several autoantibodies have been found specifically in patients with PM/DM, including CADM patients. Anti-KS antibody is one of a group of anti-aminoacyl transfer RNA (ARS) antibodies that are mainly associated with fever, Raynaud's phenomenon, polyarthritis, and interstitial lung disease (ILD), whereas anti-TIF1-γantibody is frequently found in DM patients with malignancy. Here, we report a CADM patient having both anti-KS antibody and anti-TIF1-γantibody. This patient developed an acute exacerbation of ILD and was successfully treated with high dose corticosteroid pulse therapy together with immunosuppressive agents. Although earlier experience had indicated that the seminal characteristic of anti-KS-positive ILD was slowly developing disease onset with little or no progression over the clinical course, the present patient suffered rapidly progressive disease.

Dynamics of torque teno virus load in kidney transplant recipients with indication biopsy and therapeutic modifications of immunosuppression.

Following kidney transplantation, lifelong immunosuppressive therapy is essential to prevent graft rejection. On the downside, immunosuppression increases the risk of severe infections, a major cause of death among kidney transplant recipients (KTRs). To improve post-transplant outcomes, adequate immunosuppressive therapy is therefore a challenging but vital aspect of clinical practice. Torque teno virus load (TTVL) was shown to reflect immune competence in KTRs, with low TTVL linked to an elevated risk for rejections and high TTVL associated with infections in the first year post-transplantation. Yet, little is known about the dynamics of TTVL after the first year following transplantation and how TTVL changes with respect to short-term modifications in immunosuppressive therapy. Therefore, we quantified TTVL in 106 KTRs with 108 clinically indicated biopsies, including 65 biopsies performed >12 months post-transplantation, and correlated TTVL to histopathology. In addition, TTVL was quantified at 7, 30, and 90 days post-biopsy to evaluate how TTVL was affected by changes in immunosuppression resulting from interventions based on histopathological reporting. TTVL was highest in patients biopsied between 1 and 12 months post-transplantation (N = 23, median 2.98 × 107 c/mL) compared with those biopsied within 30 days (N = 20, median 7.35 × 103 c/mL) and > 1 year post-transplantation (N = 65, median 1.41 × 104 c/mL; p < 0.001 for both). Patients with BK virus-associated nephropathy (BKVAN) had significantly higher TTVL than patients with rejection (p < 0.01) or other pathologies (p < 0.001). When converted from mycophenolic acid to a mTOR inhibitor following the diagnosis of BKVAN, TTVL decreased significantly between biopsy and 30 and 90 days post-biopsy (p < 0.01 for both). In KTR with high-dose corticosteroid pulse therapy for rejection, TTVL increased significantly between biopsy and 30 and 90 days post-biopsy (p < 0.05 and p < 0.01, respectively). Of note, no significant changes were seen in TTVL within 7 days of changes in immunosuppressive therapy. Additionally, TTVL varied considerably with time since transplantation and among individuals, with a significant influence of age and BMI on TTVL (p < 0.05 for all). In conclusion, our findings indicate that TTVL reflects changes in immunosuppressive therapy, even in the later stages of post-transplantation. To guide immunosuppressive therapy based on TTVL, one should consider inter- and intraindividual variations, as well as potential confounding factors.

Early Stage Combination Treatment with Methylprednisolone Pulse and Remdesivir for Severe COVID-19 Pneumonia.

This study evaluated the clinical outcomes of patients with severe COVID-19 pneumonia treated with remdesivir plus standard corticosteroid treatment (SCT) or with remdesivir plus high-dose corticosteroid pulse therapy (HDCPT). One hundred and two patients with severe COVID-19 pneumonia and respiratory failure were included. The patients were divided into two cohorts. The first comprised patients who received remdesivir and SCT, consisting of 6 mg dexamethasone daily for up to 10 days or until hospital discharge. The second included patients who received remdesivir and HDCPT, composed of 250 mg iv of methylprednisolone for three days, followed by a slow reduction in the dose of steroids. The severity of hypoxemia was assessed using the SaO2/FiO2 peripheral oxygen saturation index. 55 received remdesivir plus HDCPT, and 47 received remdesivir plus SCT. Mortality at 30 days was significantly lower among patients who received remdesivir plus HDCPT (4/55) than among those who did not (15/47). In patients who received remdesivir plus HDCPT, 7.3% required invasive mechanical ventilation and admission to the ICU and 36.4% non-invasive ventilation versus 29.8% and 61.7%, respectively, among those treated with remdesivir plus SCT. Remdesivir plus HDCPT induced a significantly faster improvement in the SaO2/FiO2 index. Early combination treatment with remdesivir plus HDCPT reduced in-hospital mortality and the need for admission to the ICU. Furthermore, it improved the SaO2/FiO2 index faster in patients with severe COVID-19 pneumonia.

Combined endonasal and orbital approach for annulus of Zinn area decompression in dysthyroid optic neuropathy

BackgroundDysthyroid optic neuropathy (DON) is a serious complication of thyroid-associated ophthalmopathy (TAO) that can cause permanent vision loss from orbital apex syndrome. Urgent management of high-dose corticosteroid pulse therapy is recommended, and salvage orbital apex decompression surgery may require in refractory patients ineffective with corticosteroid pulse therapy. PurposeTo evaluate the short-term efficacy and safety of combined endoscopic endonasal and orbital approach decompression in the annulus of the Zinn (AZ) area in refractory dysthyroid optic neuropathy (DON). MethodsIn this retrospective study, patients who underwent combined endoscopic endonasal and orbital approach decompression around the AZ area for the treatment of refractory DON from May 2021 to March 2022 were enrolled. A total of 15 orbital apex were decompressed across 9 patients. The demographic, imaging, and surgical data, as well as preoperative and postoperative best corrected visual acuity (BCVA), proptosis degree and Modified-Chinese-TAO-QOL scores, were collected and assessed. The t-test was used to identify differences between preoperative and postoperative parameters: visual acuity, proptosis and QOL scores. ResultsThe mean best corrected visual acuity (BCVA) improved from 0.79 ± 0.77 LogMAR preoperatively to 0.21 ± 0.27 LogMAR (P < 0.001) postoperatively. Additionally, proptosis decreased from 22.25 ± 2.01 mm to 18.42 ± 1.85 mm (P < 0.01), with an average decrease of 3.7 mm. The preoperative scores of the visual, psychological, and comprehensive components of QoL were 14.60 ± 9.08, 37.49 ± 6.26 and 26.75 ± 3.70, respectively, which significantly improved postoperatively to 54.18 ± 7.23, 68.78 ± 12.53 and 61.88 ± 9.37, respectively. The postoperative follow-up time ranged from 2 to 11 months, and the median follow-up time was 7 months. There was 1 case of transient postoperative sinusitis and 1 new case of transient diplopia, which was relieved after 3 months. ConclusionCombined endoscopic endonasal and orbital approach adequate decompression for AZ area significantly improves visual acuity and QOL in patients with DON.

Risk Factors of COVID-19 Associated Mucormycosis (CAM) in Iranian Patients: A Single-Center Retrospective Study.

BackgroundCOVID-19 associated mucormycosis (CAM) has been known as one of the most severe post-COVID morbidities. ObjectivesTo describe CAM cases, identify possible risk factors, and report outcomes of patients.MethodsThis retrospective study was performed in Amir-Alam Hospital, Tehran, Iran between February 2020 and September 2021. Patients with mucormycosis who had an active or previous diagnosis of COVID-19 have been included.ResultsOf 94 patients with mucormycosis, 52 (33 men and 19 women; mean age: 57.0 ± 11.82 years) were identified with an active or history of COVID-19. Rhino-orbital, rhino maxillary, rhino-orbito cerebral subtypes of mucormycosis were detected in 6 (11.5%), 18(34.6%), and 28(53.8%) patients. As a control group, 130 (69 men and 61 women; mean age: 53.10 ± 14.49 years) random RT-PCR-confirmed COVID-19 patients without mucormycosis have been included. The mean interval between COVID-19 diagnosis and initial mucormycosis symptoms was 16.63 ± 8.4 days (range 0–51). Those in the CAM group had a significantly more severe course of COVID-19 (OR = 3.60, P-value < 0.01). Known history of previous diabetes mellitus (OR = 7.37, P-value < 0.01), smoking (OR = 4.55, P-value < 0.01), and history of receiving high-dose corticosteroid pulse therapy because of more severe COVID-19 (P-value = 0.022) were found as risk factors. New-onset post-COVID hyperglycemia was lower in the CAM group (46.2% vs. 63.8%; OR = 0.485, P-value = 0.028). After treatment of the CAM group, 41(78.8%) of patients recovered from mucormycosis. The mean ages of the expired patients in the CAM group were significantly higher than those who recovered from mucormycosis (66.18 ± 9.56 vs. 54.56 ± 11.22 years; P < 0.01); and COVID-19 disease was more severe (P = 0.046).ConclusionEither active or history of COVID-19 can cause an increase in the risk of mucormycosis development. Some of the most important risk factors are the medical history of diabetes mellitus, smoking, and high-dose corticosteroid therapy. CAM is important possible comorbidity related to COVID-19, which could make the post-COVID conditions more complicated. More research and studies with greater sample sizes among different ethnicities are needed to explore the association between COVID-19 and mucormycosis.

Use of High Dose Corticosteroids Reversed COVID-19 Associated ARDS in a Patient Listed for Lung Transplantation

IntroductionIn acute respiratory distress syndrome (ARDS) patients with irreversible lung damage, lung transplantation from a ventilator and/or extracorporeal membrane oxygenation support (ECMO) is feasible. Recently, selection criteria for lung transplant candidates with a COVID-19 associated ARDS have been published. Here, we report the efficacy of high dose corticosteroids as ultimate salvage therapy, despite Meduri scheme attempts, in a patient listed for transplantation.Case ReportA 50-year-old female with a medical history of Multiple Sclerosis (relapsing-remitting type under treatment with anti-alpha4 -integrin therapy), was tested positive for COVID-19. She deteriorated and was admitted to the hospital. High flow oxygen and dexamethasone (six milligram daily), were started but unfortunately, she developed a severe ARDS with need for mechanical ventilation and ECMO support. Corticosteroids according to the Meduri scheme and ciprofloxacin were started. Weaning trials were initiated but failed and CT-thorax showed consolidation and presumed fibrosis. After 37 days on ECMO, she was evaluated and listed for bilateral lung transplantation. A corticosteroid pulse therapy of 1000 mg of methylprednisolone IV for three days during antibiotic coverage with piperacillin/tazobactam was started and within three days the clinical condition of the patient improved and she could be weaned from ECMO (51 days of ECMO) and delisted from the lung transplantation waiting list. Nowadays, patient does not require oxygen, is at home and revalidating.SummaryHere, we report the efficacy of a regimen with high dose corticosteroids as ultimate salvage therapy, despite Meduri scheme attempts, in a patient listed for transplantation. Corticosteroids are beneficial for immunomodulation and may reduce hyperinflammation. Our trial with administration of high dose corticosteroids pulse therapy in COVID-19 ARDS patients refractory to corticosteroids according to “classical schemes” has been successful and is informative. Further studies, will hopefully further elucidate responders and non-responders to high dose corticosteroid pulse therapy and preferably answer the question if prophylactic use of antibiotics and antifungals (in view of possible complications such as pulmonary aspergillosis and mucormycosis) is prudent in this vulnerable group.

Use of High dose Corticosteroids Reversed COVID-19 Associated ARDS in a Patient Listed for Lung Transplantation

Patients with COVID-19 associated ARDS have a mortality rate varying from 30-60%. If there is mono-organ failure and recovery is deemed unlikely despite optimal care, these patients are eligible for lung transplantation. We present our experience with high dose corticosteroid pulse therapy in an ICU patient on ECMO and mechanical ventilation, listed for lung transplantation. The patient responded with improved oxygenation, was weaned from ECMO and delisted from lung transplant waiting list.

Outcome of patients with severe COVID-19 pneumonia treated with high-dose corticosteroid pulse therapy: A retrospective study

Outcome of patients with severe COVID-19 pneumonia treated with high-dose corticosteroid pulse therapy: A retrospective study

Date of Admission during COVID-19 Pandemic Impacted Patient Outcomes in Addition to the Higher Efficacy of Tocilizumab Plus High-Dose Corticosteroid Therapy Compared to Tocilizumab Alone.

Background: The evidence for the efficacy of glucocorticoids combined with tocilizumab (TCZ) in COVID-19 comes from observational studies or subgroup analysis. Our aim was to compare outcomes between hospitalized COVID-19 patients who received high-dose corticosteroid pulse therapy and TCZ and those who received TCZ. Methods: A retrospective single-center study was performed on consecutive hospitalized patients with severe COVID-19 between 1 March and 23 April 2020. Patients treated with either TCZ (400–600 mg, one to two doses) and methylprednisolone pulses (MPD-TCZ group) or TCZ alone were analyzed for the occurrence of a combined endpoint of death and need for invasive mechanical ventilation during admission. The independence of both treatment groups was tested using machine learning classifiers, and relevant variables that were potentially different between the groups were measured through a mean decrease accuracy algorithm. Results: An earlier date of admission was significantly associated with worse outcomes regardless of treatment type. Twenty patients died (27.0%) in the TCZ group, and 33 (44.6%) died or required intubation (n = 74), whereas in the MPD-TCZ group, 15 (11.0%) patients died and 29 (21.3%) patients reached the combined endpoint (n = 136; p = 0.006 and p < 0.001, respectively). Machine learning methodology using a random forest classifier confirmed significant differences between the treatment groups. Conclusions: MPD and TCZ improved outcomes (death and invasive mechanical ventilation) among hospitalized COVID-19 patients, but confounding variables such as the date of admission during the COVID-19 pandemic should be considered in observational studies.

Spontaneous ARIA-like Events in Cerebral Amyloid Angiopathy-Related Inflammation: A Multicenter Prospective Longitudinal Cohort Study.

Background and ObjectivesThe goal of this work was to investigate the natural history and outcomes after treatment for spontaneous amyloid-related imaging abnormalities (ARIA)-like in cerebral amyloid angiopathy–related inflammation (CAA-ri).MethodsThis was a multicenter, hospital-based, longitudinal, prospective observational study of inpatients meeting CAA-ri diagnostic criteria recruited through the Inflammatory Cerebral Amyloid Angiopathy and Alzheimer's Disease βiomarkers International Network from January 2013 to March 2017. A protocol for systematic data collection at first-ever presentation and at subsequent in-person visits, including T1-weighted, gradient recalled echo–T2*, fluid-suppressed T2-weighted (fluid-attenuated inversion recovery), and T1 postgadolinium contrast-enhanced images acquired on 1.5T MRI, was used at the 3-, 6-, 12-, and 24-month follow-up. Centralized reads of MRIs were performed by investigators blinded to clinical, therapeutic, and time-point information. Main outcomes were survival, clinical and radiologic recovery, intracerebral hemorrhage (ICH), and recurrence of CAA-ri.ResultsThe study enrolled 113 participants (10.6% definite, 71.7% probable, and 17.7% possible CAA-ri). Their mean age was 72.9 years; 43.4% were female; 37.1% were APOEε4 carriers; 36.3% had a history of Alzheimer disease; and 33.6% had a history of ICH. A history of ICH and the occurrence of new ICH at follow-up were more common in patients with cortical superficial siderosis at baseline (52.6% vs 14.3%, p < 0.0001 and 19.3% vs 3.6%, p < 0.009, respectively). After the first-ever presentation of CAA-ri, 70.3% (95% confidence interval [CI] 61.6%–78.5%) and 84.1% (95% CI 76.2%–90.6%) clinically recovered within 3 and 12 months, followed by radiologic recovery in 45.1% (95% CI 36.4%–54.8%) and 77.4% (95% CI 67.7%–85.9%), respectively. After clinicoradiologic resolution of the first-ever episode, 38.3% (95% CI 22.9%–59.2%) had at least 1 recurrence within the following 24 months. Recurrence was more likely if IV high-dose corticosteroid pulse therapy was suddenly stopped compared to slow oral tapering off (hazard ratio 4.68, 95% CI 1.57–13.93; p = 0.006).DiscussionThese results from the largest longitudinal cohort registry of patients with CAA-ri support the transient and potentially relapsing inflammatory nature of the clinical-radiologic acute manifestations of the disease and the effectiveness of slow oral tapering off after IV corticosteroid pulse therapy in preventing recurrences. Our results highlight the importance of differential diagnosis for spontaneous ARIA-like events in β-amyloid–driven diseases, including treatment-related ARIA in patients with Alzheimer disease exposed to immunotherapy drugs.

High-dose corticosteroid pulse therapy increases the survival rate in COVID-19 patients at risk of hyper-inflammatory response.

Test whether high dose corticosteroid pulse therapy (HDCPT) with either methylprednisolone or dexamethasone is associated with increased survival in COVID-19 patients at risk of hyper-inflammatory response. Provide some initial diagnostic criteria using laboratory markers to stratify these patients. This is a prospective observational study, 318 met the inclusion criteria. 64 patients (20.1%) were treated with HDCPT by using at least 1.5mg/kg/24h of methylprednisolone or dexamethasone equivalent. A multivariate Cox regression (controlling for co-morbidities and other therapies) was carried out to determine whether HDCPT (among other interventions) was associated with decreased mortality. We also carried out a 30-day time course analysis of laboratory markers between survivors and non-survivors, to identify potential markers for patient stratification. HDCPT showed a statistically significant decrease in mortality (HR = 0.087 [95% CI 0.021-0.36]; P < 0.001). 30-day time course analysis of laboratory marker tests showed marked differences in pro-inflammatory markers between survivors and non-survivors. As diagnostic criteria to define the patients at risk of developing a COVID-19 hyper-inflammatory response, we propose the following parameters (IL-6 > = 40 pg/ml, and/or two of the following: C-reactive protein > = 100 mg/L, D-dimer > = 1000 ng/ml, ferritin > = 500 ng/ml and lactate dehydrogenase > = 300 U/L). HDCPT can be an effective intervention to increase COVID-19 survival rates in patients at risk of developing a COVID-19 hyper-inflammatory response, laboratory marker tests can be used to stratify these patients who should be given HDCPT. This study is not a randomized clinical trial (RCT). Future RCTs should be carried out to confirm the efficacy of HDCPT to increase the survival rates of COVID-19.

High-Dose Corticosteroid Pulse Therapy&amp;nbsp;Increases the Survival Rate in COVID-19 Patients at Risk of Cytokine Storm

Background: COVID-19 is a disease caused by SARS-CoV-2, which can develop into a hyper-inflammatory late phase or “cytokine storm” that poses high risk of death. It has been proposed that the management of this cytokine storm is crucial to increase the survival rate of COVID-19 patients. However, to date there are no diagnostic criteria based on inflammatory markers that could be used to select the COVID-19 patients at risk of developing a cytokine storm or effective interventions that can decreased mortality in these patients. Methods: We carried out a quasi-experimental study to test whether high dose corticosteroid pulse therapy with either dexametaxona or methylprednisolone were associated with reduced mortality in patients at risk of cytokine storm and assess which laboratory markers can be used to pre-select these patients. To control the development and progression of this hyper-inflammtory phase, 64 patients (20.1%) were treated with high dose corticosteroid pulse therapy (HDCPT) by using either dexametaxona or methylprednisolone daily for 2-5 days at doses of at least 30mg or 125mg respectively. To determine diagnostic criteria that can be used to defined patients at risk of cytokine storm, we carried out a 30-day time course analysis of laboratory markers between survivors and non-survivors. A multivariate Cox regression (controlling for co-morbidities and therapies) was carried out to determine whether HDCPT (among other interventions) was associated with decreased mortality in both the full cohort, and in a subgroup containing the patients with the derived criteria. Findings: Out of 500 patients originally recruited, 381 met the inclusion criteria of SARS-COV-19 detection by PCR or serology (n=272, 71.2%) or high clinical suspicion (n= 46, 16.9 %), defined as having bilateral pulmonary infiltrate or lymphopenia with according clinical profile. HDCPT was the only intervention that showed a significant decrease in mortality (odds ratio = 0.093 [95% CI 0.023 – 0.38]; P = 40 pg/ml and/or two of the following: C-reactive protein >= 100 mg/L, D-dimer >= 1000 ng/ml, ferritin >= 500 ng/ml and lactate dehydrogenase >= 300 U/L. Multivariate Cox regression by pre-selecting the patients using this criteria evidenced also a decreased mortality rate with HDCPT with a lower odds ratio (odds ratio = 0.081 [95% CI 0.011 – 0.56]; P = 0.011). Conclusions: Preventing and/or controlling the development of the cytokine storm in patients at high-inflammatory risk with HDCPT is a widely available therapy to increase survival rate in these patients. We estimate a 14.2% [95% CI 0.792 - 0.975] increase of survival rate. We also suggest some initial clinical variables that can aid with the identification of the patients who will benefit from this intervention.Funding Statement: There were no funding sources in this study.Declaration of Interests: The authors declare no competing interests.Ethics Approval Statement: This study was approved by the Ethics Committee of the Complejo Hospitalario de Jaén (Hospital of Jaén), Spain (0946-N-20). According to the local ethics committee regulations, verbal consent was obtained from all the patients that joined the study.

Primary Central Nervous System Lymphoma Presenting with Peripheral Neuropathy; A Rare Case of Coincident PCNSL and Mononeuritis Multiplex

A 43-year-old male presented with diplopia and right sixth-nerve palsy. Brain magnetic resonance imaging (MRI) demonstrated a lesion in the right periventricular area. High-dose corticosteroid pulse therapy did not resolve the symptom. After one month, his diplopia progressed and he developed weakness of the left lower limb. Detailed examination revealed left sixth-nerve palsy, dropped foot, waddling gait, atrophy of the gluteal muscles and mild atrophy and weakness of the right upper limb. Neurological examination supported evidence of multiple cranial nerve palsies along with asymmetrical peripheral neuropathy. Electrodiagnostic studies were compatible with a mononeuritis multiplex. Rheumatologic evaluations were normal. Malignancy work-up were normal, except for some insignificant lymph nodes. Bone marrow aspiration and biopsy were normal. The second brain MRI detected multiple homogenous enhancing lesions in the right periventricular area.The result of stereotactic biopsy and immunohistochemistry staining demonstrated primary B-cell CNS lymphoma (PCNSL). Mononeuritis multiplex has not been reported as a paraneoplastic manifestation of PCNSL yet. In other words, it is not clear whether involvement of the peripheral nervous system in our patient is a paraneoplastic manifestation of PCNSL or a coincidence of PCNSL and hematologic lymphoma presenting with peripheral vasculitic neuropathy. It is recommendedthat future studies focus more on symptoms associated with PCNSL to recognize the exact relationship between PCNSL and peripheral neuropathy.

Switch from previous major depression comorbid with CLIPPERS to mania-like episode following glucocorticosteroid therapy: a case report

Bipolar disorder is associated with high rates of general medical conditions, but few cases of overlap between bipolar disorder and chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids...

Electrocardiographic changes after high-dose corticosteroid pulse therapy in pemphigus patients

Purpose: The objective of the current study was to evaluate the effect of intravenous methylprednisolone pulse therapy on myocardial repolarization alterations, especially QT dispersion in anticipation of cardiovascular risks in patients with pemphigus vulgaris.Methods: The current study is a prospective-controlled study on the electrocardiographic changes after methylprednisolone pulse therapy in 50 patients with pemphigus vulgaris.Results: A total of 50 patients (28 female and 22 male) were included in our study. The mean heart rate was significantly higher in male patients both before (92 ± 10.80 versus 82.75 ± 12.01 ms) and after pulse therapy (102.73 ± 14.26 versus 91.07 ± 15.02 ms) (p value < .01). The value of heart rate was significantly greater after receiving steroid pulse therapy. Corrected QT dispersion before pulse therapy was 19.92 ± 8.2 ms that increased to 40.68 ± 18.12 ms after treatment (p value < .001).Conclusion: Our study shows that there is a relationship between pulse steroid infusion and increased predisposition to the occurrence of cardiac arrhythmias. QT dispersion could be a good marker to assess this risk in these patients.

Comparison of High-Dose Corticosteroid Pulse Therapy and Combination Therapy Using Oral Cyclosporine with Low-Dose Corticosteroid in Severe Alopecia Areata.

BackgroundSevere alopecia areata (AA) is resistant to conventional treatment. Although systemic oral corticosteroids are an effective treatment for patients with severe AA, those drugs have many adverse effects. Corticosteroid pulse therapy has been introduced to increase therapeutic effects and reduce adverse effects. However, the treatment modality in severe AA is still controversial.ObjectiveTo evaluate the effectiveness of corticosteroid pulse therapy in patients with severe AA compared with treatment with oral cyclosporine with corticosteroid.MethodsA total of 82 patients with severe AA were treated with corticosteroid pulse therapy, and 60 patients were treated with oral cyclosporine with corticosteroid. Both groups were retrospectively evaluated for therapeutic efficacy according to AA type and disease duration.ResultsIn 82 patients treated with corticosteroid pulse therapy, 53 (64.6%) were good responders (>50% hair regrowth). Patients with the plurifocal (PF) type of AA and those with a short disease duration (≤3 months) showed better responses. In 60 patients treated with oral cyclosporine with corticosteroid, 30 (50.0%) patients showed a good response. The AA type or disease duration, however, did not significantly affect the response to treatment.ConclusionCorticosteroid pulse therapy may be a better treatment option than combination therapy in severe AA patients with the PF type.

Changes in Choroidal Thickness After Systemic Administration of High-Dose Corticosteroids: A Pilot Study

To characterize the effects of corticosteroids on choroidal thickness, we measured the choroid thickness in patients treated systemically with a high-dose corticosteroid. A prospective, pilot study was conducted on 20 patients who required high-dose corticosteroid pulse therapy (>500 mg/d). Choroidal thickness was measured at baseline, 1 day, 1 week, and 1 month after corticosteroid administration. Blood pressure was measured four times a day for the first 5 days of steroid treatment. This study ultimately included 35 eyes from 18 patients. Each patient was treated with high-dose corticosteroid therapy at a concentration of 19.5 ± 4.1 mg per kg body weight for 5.2 ± 1.1 days. Mean subfoveal choroidal thickness at baseline was 259.8 μm (range, 86.4-394.7 μm). Choroidal thickness showed no significant change at 1 day, 1 week, or 1 month after corticosteroid administration (P = 0.197). Mean systolic blood pressure increased by 13 mmHg (P = 0.008), but diastolic pressure did not change (P = 0.117). One patient (5.6%) who had presented with pigment epithelial detatchment (PED) and thick choroid (381.1 μm) developed bilateral focal subretinal fluid during the study and showed central serous chorioretinopathy (CSC) with a 13.1% increase in subfoveal choroidal thickness. No consistent changes in choroidal thickness were observed after systemic high-dose corticosteroid treatment, but one patient with PED and thick choroid showed an increase in choroidal thickening as well as features of CSC. Thus, steroid-induced CSC may be an idiosyncratic response in selected vulnerable individuals rather than a dose-dependent effect.

AIP or ARDS? Not just semantics

I read with interest the article by Kao and colleagues [1] in which the authors investigated the role of open lung biopsy in patients with early-stage acute respiratory distress syndrome (ARDS) of suspected non-infectious origin. A point that merits attention is the need to differentiate between ARDS and acute interstitial pneumonia (AIP). AIP is a rapidly progressive idiopathic interstitial pneumonia characterized by the presence of an organizing form of diffuse alveolar damage on histopathological examination of lung specimens. Although the histological pattern is indistinguishable from that found in ARDS, the term AIP is reserved for cases of unknown cause [2]. In fact, exclusion of a precipitating or etiological agent (which is usually identifiable in patients with ARDS) is one of the diagnostic criteria for AIP. The mortality from AIP is about 70% and is higher than that from ARDS [3]. Although there are no established therapies for AIP, parenteral corticosteroids, often at high doses, are used frequently. Recently Suh and colleagues [4] reported survival rates of 80% in a small series of ten patients with AIP, all of whom required mechanical ventilation (with a median positive end-expiratory pressure of 11 cmH2O) and underwent open lung biopsy (on median hospital day 4). In these patients, high-dose corticosteroid pulse therapy had been initiated (on median hospital day 3.5) after respiratory infection had been ruled out by means of an aggressive diagnostic workup (including bronchoalveolar lavage performed on median hospital day 2). The authors had postulated that the approach of aggressive diagnostics, mechanical ventilation with lung-protective strategy, and early institution of high-dose immunosuppressive therapy could have led to the improved clinical outcome [4]. In the present study, diffuse alveolar damage was seen in most of the patients who had a non-specific pathological diagnosis. Moreover, this group, in comparison with the group with a specific diagnosis, had a higher rate of treatment alteration (87% versus 56%) as well as a higher rate of hospital survival (61% versus 33%). It is possible that the trend toward improved survival that was seen in this group was a reflection of the possibility that some of these patients had AIP (rather than ARDS) and benefited from the early administration of high-dose corticosteroids.

A case of rheumatoid arthritis which developed after recovery from adult respiratory distress syndrome.

A 53-year-old previously healthy woman suddenly developed adult respiratory distress syndrome (ARDS) of unknown etiology. High-dose corticosteroid pulse therapy and artificial ventilation were started immediately and she dramatically responded to the treatment. However, soon after recovery from ARDS, she developed typical rheumatoid arthritis (RA). Although no apparent relationship between RA and ARDS was clear, this case is quite suggestive in the consideration of the etiology of ARDS.