High-dose Corticosteroid Therapy Research Articles

Corticosteroid-Associated Avascular Necrosis of the Femoral Head in Patients with Severe COVID-19: A Single-Center Study.

BACKGROUND Avascular necrosis (AVN) of the femoral head can result from high-dose corticosteroid therapy. Given that severe COVID-19 pneumonia patients respond positively to corticosteroids, this study aimed to explore the incidence of femoral head AVN associated with corticosteroid therapy in 24 patients diagnosed with severe COVID-19 at a single center. MATERIAL AND METHODS The study included 24 patients who were diagnosed with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection through real-time reverse transcription polymerase chain reaction test (rRT-PCR) and with COVID-19 pneumonia via high-resolution computed tomography (HRCT). Moderate cases received 2×4 mg Dexamethasone while severe cases were also administered with 3×40 mg Methylprednisolone. Diagnosis of femoral head AVN was confirmed with magnetic resonance imaging (MRI) and radiographs, which was subsequently treated by a total hip arthroplasty (THA) or a core decompression surgery (CDS) in line with the Ficat and Arlet classifications RESULTS Among the patients, 8 had a moderate infection course, while 16 were severe. The mean corticosteroid duration was 15±5 days for Dexamethasone and 30 days for Methylprednisolone. Severe patients presented with higher grade femoral head AVN and greater pain levels compared to moderate cases (p<0.05). Four patients developed bilateral AVN. The treatment resulted in 23 THAs and 5 CDSs CONCLUSIONS The data from this study corroborate earlier studies and case reports, suggesting an increased occurrence of AVN of the femoral head during the COVID-19 pandemic due to the high-dose corticosteroid therapy employed for patients hospitalized with severe COVID-19 pneumonia.

Optimal Dosing and Timing of High-Dose Corticosteroid Therapy in Hospitalized Patients With COVID-19: Study Protocol for a Retrospective Observational Multicenter Study (SELECT).

In hospitalized patients with COVID-19, the dosing and timing of corticosteroids vary widely. Low-dose dexamethasone therapy reduces mortality in patients requiring respiratory support, but it remains unclear how to treat patients when this therapy fails. In critically ill patients, high-dose corticosteroids are often administered as salvage late in the disease course, whereas earlier administration may be more beneficial in preventing disease progression. Previous research has revealed that increased levels of various biomarkers are associated with mortality, and whole blood transcriptome sequencing has the ability to identify host factors predisposing to critical illness in patients with COVID-19. Our goal is to determine the most optimal dosing and timing of corticosteroid therapy and to provide a basis for personalized corticosteroid treatment regimens to reduce morbidity and mortality in hospitalized patients with COVID-19. This is a retrospective, observational, multicenter study that includes adult patients who were hospitalized due to COVID-19 in the Netherlands. We will use the differences in therapeutic strategies between hospitals (per protocol high-dose corticosteroids or not) over time to determine whether high-dose corticosteroids have an effect on the following outcome measures: mechanical ventilation or high-flow nasal cannula therapy, in-hospital mortality, and 28-day survival. We will also explore biomarker profiles in serum and bronchoalveolar lavage fluid and use whole blood transcriptome analysis to determine factors that influence the relationship between high-dose corticosteroids and outcome. Existing databases that contain routinely collected electronic data during ward and intensive care admissions, as well as existing biobanks, will be used. We will apply longitudinal modeling appropriate for each data structure to answer the research questions at hand. As of April 2023, data have been collected for a total of 1500 patients, with data collection anticipated to be completed by December 2023. We expect the first results to be available in early 2024. This study protocol presents a strategy to investigate the effect of high-dose corticosteroids throughout the entire clinical course of hospitalized patients with COVID-19, from hospital admission to the ward or intensive care unit until hospital discharge. Moreover, our exploration of biomarker and gene expression profiles for targeted corticosteroid therapy represents a first step towards personalized COVID-19 corticosteroid treatment. ClinicalTrials.gov NCT05403359; https://clinicaltrials.gov/ct2/show/NCT05403359. DERR1-10.2196/48183.

P459 A SUDDEN STROKE AFTER CORTICOSTEROID THERAPY FOR HEART TRANSPLANT REJECTION

Abstract After heart transplant, the immune system of recipient could recognise the transplanted heart as foreign and reject it. To avoid it, immunosuppressive therapy is used, but sometimes it is not enough, in these cases high doses of immunosuppressors must be used. If the rejection is cellular mediated the main therapy is high corticosteroid therapy. A 63–years–old woman presented one year after heart transplant, due to acute cellular mediated graft rejection, detected at follow–up biopsies. High dose corticosteroid intravenous therapy was started. She had history of Chron’s disease treated by monoclonal therapy. Electrocardiography at admission showed a sinus rhythm. In the night of the second day of steroid therapy, she suddenly experienced facial asymmetry and left arm and leg hyposthenia. A cerebral angiographic scan was immediatly performed and it revealed a thrombotic occlusion of right internal carotid artery, from right carotid bifurcation to right internal carotid syphon (Figure 1). A few minutes later a percutaneous neuroradiological transcatheter thrombectomy was successfully performed and the patient had a full recovery without any neurological permanent disfunctions. The protocol for acute cellular mediated hear transplant rejection in our centre is corticosteroid intravenous therapy 1 gram per day for three days, followed by corticosteroids orally 1mg/kg on the fourth day, subsequently gradually reduced of 5mg per day till a dose of 5mg per day that we use to maintain as long–term prophylaxis. Three days after the stroke, the patient experienced high frequency atrial fibrillation, never detected before. She underwent a transoesophageal echocardiography to evaluate the feasibility of an electric cardioversion, but a thrombus in the left atrial appendage was firstly discovered. Therefore, the patient was treated with oral anticoagulants and beta blockers, at the follow–up echocardiography the thrombus was disappeared, and she didn’t experience any other cerebrovascular embolisms. The link between the high dose corticosteroid therapy and the stroke, in a patient with a chronic inflammatory bowel disease and maybe unknow paroxysmal atrial fibrillation, could showed that this therapy could be a trigger for rapid thrombus formation and cerebral embolisms in these patients. This highlights the importance of in hospital monitoring of this patients during high dose steroid therapy, combined to proper diagnosis and treatments of worst complications.

Steroid-Induced Activated White Adipose Tissue Detected on 18F-FDG PET/CT.

White adipose tissue (WAT) usually shows negligible 18F-FDG uptake due to negligible glucose utilization. However, corticosteroids alter the biodistribution of 18F-FDG and increase uptake in WAT. Here, we present a case of diffusely increased 18F-FDG uptake in WAT secondary to high-dose corticosteroid therapy for nephrotic syndrome.

Comparing the use of high dose to standard dose corticosteroids for the treatment of sudden sensorineural hearing loss in adults – A systematic review

ObjectiveIdiopathic sudden sensorineural hearing loss (SSNHL) is typically treated with systematic or intratympanic corticosteroids. Current ENT-UK guidelines suggest treatment with a dose of oral prednisolone 1mg/kg/day for 7 days then tapered over a further 5 days. However, there is no consensus on the effectiveness of corticosteroids for idiopathic SSNHL and no universally accepted optimal regime. The objective of this systematic review was to examine the effect of high dose versus standard dose corticosteroids in the management of idiopathic SSNHL. MethodsA systematic review was performed of all published data related to patients with idiopathic SSNHL who were treated acutely with high dose corticosteroid therapy. Articles were included that reported data on high dose, or comparing standard dose to high dose, oral or intravenous corticosteroid therapy for the treatment of patients with idiopathic sudden sensorineural hearing loss. Articles where patients received only combination treatment with intra-tympanic steroid were excluded. Risk of bias was assessed using the ROBINS-I tool and the ROB-2 tool. ResultsSix studies were included in the analysis, representing 919 patients. Two prospective single-arm studies of patients with SSNHL treated with a high dose steroid regime found mean hearing level improved (79.5dB to 42.3dB) and 45.8% of idiopathic patients had complete recovery of hearing. Three retrospective case-series comparing high dose to standard dose regimes found a significantly greater improvement in hearing level (38.3dB vs. 48.8dB, P = 0.042), a greater mean absolute hearing gain (44.4dB vs. 15.1dB) and a significantly higher rate of functionally relevant recovery (35.7% vs. 7.4%, P = 0.035) in patients treated with high dose regimes. The single included prospective randomised trial found no statistically significant difference in mean hearing level or speech discrimination score between patients treated with high dose pulse steroids or a standard dose regime. ConclusionsOur systematic review found the reported outcomes in the literature in this area to be mixed, with some studies suggesting a greater degree of hearing recovery with a high dose regime but others suggesting no difference. The overall quality of the available evidence was deemed to be low, with the studies at moderate risk of bias.

Endogenous Endophthalmitis in COVID-19 Patients: A Case Series and Literature Review

ABSTRACT Purpose To report outcomes in cases of endogenous endophthalmitis (EE) following COVID-19 infection. Material and methods In a retrospective study, patients with EE, who had a recent history of COVID-19 infection requiring hospital admission were recruited. Necessary demographic details, details of ocular examination, and microbiological details were collected. Results Six patients (10 eyes), with a mean age of 48 + 19.80 years were included. The mean duration of onset of ocular symptoms from the time of diagnosis of COVID was 28.16 + 16.15 days. 8 eyes required surgical intervention, whereas 2 eyes were managed conservatively. Three patients were positive for Candida albicans, two patients were positive for Aspergillus fumigatus, and one patient was a presumed bacterial EE. The majority of the eyes had favorable functional and anatomical outcomes during the post-operative period. Conclusion High-dose corticosteroid therapy in the management of moderate and severe COVID-19 infection may be associated with EE, predominantly fungal.

Clinical features and "early" corticosteroid treatment outcome of pediatric mycoplasma pneumoniae pneumonia.

Many children with mycoplasma pneumoniae (MP) pneumonia (MPP) developed sequelae such as bronchiolitis/bronchitis obliterans (BO). Early corticosteroid therapy might prevent disease progression. This study aimed to use "early" corticosteroid and observe the treatment outcome in patients with MPP. Patients who had pulmonary infiltrations on chest imaging within 5 days of the disease course and were suspected of having MP infection on admission were enrolled. Among them, patients whose disease course was within 10 days on admission were ultimately enrolled. We analyzed their data including the clinical features, the starting time and dose of corticosteroid therapy, and the treatment outcome. According to chest imaging, we divided patients into two groups (Group A: bronchiolitis-associated lesions or ground-glass opacities; Group B: pulmonary segmental/lobar consolidation). A total of 210 patients with confirmed MPP were ultimately enrolled. There were 59 patients in Group A and 151 patients in Group B. Patients in Group A were more prone to have allergy histories, hypoxemia, wheezing sound, and wet rales on auscultation than those in Group B. Corticosteroid treatment was initiated between 5 and 10 days of disease onset in all patients and 6-7 days in most patients. Methylprednisolone was prescribed in all patients within 10 days of disease onset, and the highest prescribed dose was at least 2 mg/kg/day. In Group A, methylprednisolone >2 mg/kg/day was prescribed in 22 patients, and among them, 8 patients with diffuse bronchiolitis-associated lesions received high-dose methylprednisolone therapy. After 3 months, lung CT revealed slightly segmental ground-glass opacity in three patients. In Group B, methylprednisolone >2 mg/kg/day was prescribed in 76 patients, and among them, 20 patients with pulmonary lobar consolidation received high-dose methylprednisolone therapy. After 3 months, chest imaging revealed incomplete absorption of pulmonary lesions in seven patients. Among them, five patients with consolidation in more than one pulmonary lobe ultimately had slight BO. In hospitalized patients with MPP, particularly severe MPP, the ideal starting time of corticosteroid treatment might be 5-10 days, preferably 6-7 days, after disease onset. The initial dosage of corticosteroid therapy should be decided according to the severity of the disease. MPP patients with diffuse bronchiolitis-associated lesions/whole lobar consolidation on imaging might require high-dose corticosteroid therapy.

Case Report] Challenging Detection of Latent Tuberculosis in a Patient Undergoing High-Dose Corticosteroid Therapy for Acute Hemolytic Anemia and Rhupus Arthropathy

Acute autoimmune hemolytic anemia requires rapid stabilization, typically through the administration of high-dose corticosteroids. However, it is important to consider reactivation of latent infection and how immune suppression can interfere with molecular screening tools. In this case report, we present a patient with Rheumatoid Arthritis/Systemic Lupus Erythematosus experiencing severe autoimmune hemolytic anemia complicated by an unknown latent tuberculosis infection.

Case Report] Challenging Detection of Latent Tuberculosis in a Patient Undergoing High-Dose Corticosteroid Therapy for Acute Hemolytic Anemia and Rhupus Arthropathy

Acute autoimmune hemolytic anemia requires rapid stabilization, typically through the administration of high-dose corticosteroids. However, it is important to consider reactivation of latent infection and how immune suppression can interfere with molecular screening tools. In this case report, we present a patient with Rheumatoid Arthritis/Systemic Lupus Erythematosus experiencing severe autoimmune hemolytic anemia complicated by an unknown latent tuberculosis infection.

Comparing the Use of High-Dose to Standard-Dose Corticosteroids for the Treatment of Bell's Palsy in Adults-A Systematic Review and Meta-analysis.

Bell's palsy is typically treated with oral corticosteroids (40-60 mg daily). Concomitant antivirals are currently not recommended. The objective of this systematic review and meta-analysis was to examine the effect of high-dose versus standard-dose corticosteroids, without antivirals, in the management of Bell's palsy. Embase, MEDLINE, PubMed, CINAHL, Cochrane Library. A systematic review and meta-analysis was performed according to PRISMA guidelines. Studies comparing high-dose (≥80 mg) or standard-dose (40-60 mg) corticosteroid therapy for Bell's palsy were included. Exclusion criteria were coexisting antiviral treatment, nonoral drug delivery, and facial palsy due to other causes. Risk of bias was assessed using ROBINS-I. A weighted estimate of treatment effects across trials as odds ratios (OR) using a Mantel-Haenzel random-effects model was calculated. Three articles were included in the analysis, representing 485 patients. There was a significant decrease in nonrecovery with high-dose, compared with standard-dose, corticosteroids at 6 months follow-up (OR = 0.17, 95% confidence interval = 0.05-0.56, p = 0.004). Overall adverse events were 5.8% (n = 28), all reported in one study in the high-dose group (transient elevated liver enzymes and fecal occult blood). Our analysis shows a favorable effect of high-dose corticosteroid in the treatment of Bell's palsy. It is the first to evaluate this effect without the use of antivirals in keeping with current treatment recommendations. As all included studies had a serious risk of bias, future research should focus on larger trials with more robust methodology. This will allow for more up-to-date and large-scale analyses where more valid conclusions can be drawn that may potentially influence treatment protocols.

Up-front single-session radiosurgery for large brain metastases-volumetric responses and outcomes.

Patients presenting with large brain metastases (LBM) pose a management challenge to the multidisciplinary neuro-oncologic team. Treatment options include surgery, whole-brain or large-field radiation therapy (WBRT), stereotactic radiosurgery (SRS), or a combination of these. To determine if corticosteroid therapy followed by SRS allows for efficient minimally invasive care in patients with LBMs not compromised by mass effect. We analyzed the change in tumor volume to determine the efficacy of single-session SRS in the treatment of LBM in comparison to other treatment modalities. Twenty-nine patients with systemic cancer and brain metastasis (≥ 2.7cm in greatest diameter) who underwent single-session SRS were included. Among 29 patients, 69% of patients had either lung, melanoma, or breast cancer. The median initial tumor size (maximal diameter) was 32mm (range 28-43), and the median initial tumor volume was 9.56 cm3 (range 1.56-25.31). The median margin dose was 16Gy (range 12-18). The average percent decrease in tumor volume compared to pre-SRS volume was 55% on imaging at 1-2months, 58% at 3-5months, 64% at 6-8months, and 57% at > 8months. There were no adverse events immediately following SRS. Median corticosteroid use after SRS was 21days. Median survival after radiosurgery was 15months. Initial high-dose corticosteroid therapy followed by prompt single-stage SRS is a safe and efficacious method to manage patients with LBMs (defined as ≥ 2.7cm).

Efficacy of initial high- versus low-dose intravenous corticosteroid therapy in patients with acute exacerbation of idiopathic interstitial pneumonia: A nationwide observational study.

Acute exacerbation of idiopathic interstitial pneumonias (AE-IIPs) has a high mortality. However, there is no established treatment for AE-IIPs. Therefore, we aimed to compare the efficacy of high- and low-dose corticosteroid therapies in AE-IIPs patients. Data were retrospectively collected from the Japanese Diagnosis Procedure Combination database from July 2010 to March 2018. Adult patients with AE-IIPs who received high-dose (methylprednisolone at a dose of 500-1000 mg/day for 3 days starting within 4 days after admission) or low-dose (methylprednisolone at a dose of 100-200 mg/day for at least 5 days starting within 4 days after admission) corticosteroid therapy were identified. Eligible patients (n = 17,317) were divided into the high-dose (n = 16,998) and low-dose (n = 319) groups. A stabilized inverse probability of treatment weighting using propensity scores was performed to compare outcomes between the groups. The primary outcome was in-hospital mortality, and the secondary outcomes were 28-day mortality, infections during hospitalization, length of hospitalization, duration of steroid use, and discharge to home. The in-hospital mortality rates of the high- and low-dose corticosteroid groups were 50.6% and 47.0%, respectively. In-hospital mortality did not significantly differ between the two groups after stabilized inverse probability of treatment weighting, and the odds ratio in the low-dose corticosteroid group was 0.86 (95% confidence interval: 0.64-1.16; p = 0.33). The secondary outcomes also did not significantly differ between the groups. There was no significant difference in outcomes between patients with AE-IIPs who received high- and low-dose corticosteroid therapies.

228 PD-1-TARGETED T-CELL CHECKPOINT INHIBITORS-RELATED MYOCARDITIS COMPLICATED BY COMPLETE ATRIOVENTRICULAR BLOCK: A CASE SERIES OF SUCCESSFUL MANAGEMENT

Abstract Background Immune checkpoint inhibitors (ICI) have revolutionized the clinical management of a broad spectrum of solid and hematopoietic malignancies over the past decade. ICI are associated with several Immune-related Adverse Events, among which myocarditis and atrioventricular blocks are uncommon but potentially fatal toxicities. Material and Methods We describe two patients undergoing treatment with PD-1 checkpoint inhibitors for metastatic cancers who developed myositis and myocarditis complicated by complete atrioventricular block (CAVB). The first patient had a history of metastatic sarcomatoid urothelial carcinoma treated with Pembrolizumab. After two cycles, he developed eyelid ptosis and was hospitalized for syncopal episodes due to CAVB associated with ICI myocarditis. The second patient had a history of metastatic melanoma and was hospitalized for myocarditis and myositis after the second infusion of Nivolumab. Results In the first case, high-dose corticosteroid therapy was promptly initiated, with subsequent rapid recovery of sinus rhythm and rapid resolution of symptoms. The second patient, despite high-dose corticosteroid therapy, developed CAVB requiring implantation of a definitive PM. After initiation of mycophenolate mofetil and intravenous immunoglobulin therapy, gradual recovery was observed. Both patients had normal left ventricular function with no wall motion abnormalities. However, speckle tracking echocardiography revealed a normal global longitudinal left ventricular strain (GLS) of -19.8% in patient 1 and a depressed GLS of -14.7% in patient 2, consistent with the different evolution of the two myocarditis. Conclusions We recommend a high degree of caution and awareness to all physicians when treating immunotherapy patients. Myocarditis is a relatively rare but potentially fatal event due to its early onset, non-specific clinical presentation and fulminant progression. GLS may be useful in detecting myocardial damage in these patients. Discontinuation of ICI, cardiac pacing, treatment with high-dose corticosteroids and immunosuppressive agents may improve the outcome.

Efficacy of High-Dose Corticosteroid Therapy in Acute Stage Severe Facial Palsy in Children.

To evaluate the efficacy of high-dose corticosteroid for severe acute facial paralysis in children. The present study enrolled 10 pediatric patients with House-Brackmann (H-B) Grade VI facial paralysis who received prednisolone (PSL) 3 to 4 mg/kg/d for 2 to 3 days followed by a 10-day taper (the child high-dose group). Eight pediatric patients who received PSL 0.5 to 1 mg/kg/d were enrolled in a child low-dose group, and nine adult patients (25-64 yr) who received a high-dose PSL 200 mg equivalent for 2 to 3 days followed by a 10-day taper were enrolled in an adult high-dose group. On the initial and follow-up visits, facial movements were evaluated using the H-B grading system. The degree of oral-ocular synkinesis was evaluated by the degree of asymmetry in eye-opening width during mouth movements. The synkinesis index was defined as a percentage of the interpalpebral space width ([normal side - affected side]/normal side). The child high-dose group achieved a significantly better H-B score than the child low-dose group ( p < 0.01). The synkinesis index was significantly lower in the child high-dose group than in the child low-dose group or the adult high-dose group ( p < 0.05). Children receiving PSL 3 to 4 mg/kg/d achieved better recovery and less synkinesis than those treated with low-dose PSL (0.5-1 mg/kg/d).

88 Tubulointerstitial nephropathy and uveitis (TINU syndrome): a paediatric case report

IntroductionTINU (Tubulo-interstitial Nephritis and Uveitis) or oculo-renal syndrome was first described by Dobrin et al. in 1975. >100 cases (mostly paediatric) have been reported since then. It should be considered as diagnosis of elimination, as some iatrogenic, infectious, or systemic diseases may cause similar oculo-renal manifestations. There is no clear therapeutic consensus. However, the rapid initiation of high-dose corticosteroid therapy was associated with favorable outcome in the majority of published cases, as well as in our patient.Case reportWe report the case of an acute tubulointerstitial nephritis associated with uveitis in 11-year-old girl who presented with abdominal pain, vomiting and asthenia of one month. Laboratory tests revealed acute renal failure with proteinuria and aseptic leucocyturia. An inflammatory syndrome was found with erythrocyte sedimentation rate of 92 mm and inflammatory anaemia. Hypoproteinemia and polyclonal hypergamma-globulinaemia was found. No aetiology was found. The renal biopsy revealed a tubulo-nephritis with an interstitial inflammatory infiltrate of lymphoid cells and normal glomeruli. The patient was treated with high-dose of steroids (Methylprednisolone pulse followed by oral Prednisone 1 mg/kg/d with gradual weaning). We noted a progressive improvement of the renal function and the appearance of ocular pain and a decrease in visual acuity. The ophthalmological examination revealed bilateral uveitis. The diagnosis of TINU syndrome was confirmed and the patient received steroids with progressive resolution of the uveitis.ConclusionIn the presence of any uveitis of unknown cause associated with disturbed renal function the diagnosis of TINU syndrome should be considered. This syndrome requires more precise diagnostic criteria and standardized management.Disclosure of InterestNone declared

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.

08 Juvenile idiopathic arthritis and corticosteroid-induced osteonecrosis of the femoral head

Abstract Background Juvenile idiopathic arthritis (JIA) is a group of inflammatory joint diseases that begin before the age of 16. Depending on the clinical form of JIA, medical treatment may involve long-term high-dose corticosteroid therapy, which may lead to aseptic femoral head osteonecrosis of patients. We report three observations of aseptic osteonecrosis of the femoral head in patients followed for JIA. 1st observation: Mr I.A, aged 19 years, presented with ankylosing spondylitis with peripheral involvement, with a juvenile onset, for which he had received a high dose of corticosteroids at an average of 1.5 mg/kg/day since the age of 15 months on an intermittent basis. Clinically, the patient had a height of 1.65, a right limp when walking and limited movement of the right hip with a Lequesne algofunctional index of 10.5 (significant disability). MRI of the pelvis showed aseptic osteonecrosis of the right femoral head (ONATF), Arlet and Ficat stage 3. Observation 2: Mr A.B, 27-year-old, had systemic JIA since the age of 12. He received corticosteroid therapy at an average dose of 1 mg/kg/day intermittently. Clinically the patient presents with signs of cortisone impregnation (a cushingoid face, purple stretch marks, thin skin) and bilateral cataract. The patient walks with the help of a crutch. The examination of the hips revealed a limitation of mobility of the left hip with a Lequesne algo-functional index of 18.5. Bone densitometry showed a decrease in bone density. Standard radiographs noted a left ONATF, Arlet and Ficat stage 4 with L4 and L5 vertebral fractures. 3rd Observation: Mr B.M, 26-year-old, followed for systemic JIA since the age of 14. He was treated with high dose corticosteroids at a rate of 1 mg/kg/day. The clinical examination revealed unevenness of the lower limbs, a left limp when walking, limited internal rotation and abduction of the right hip. The patient also had multiple inflammatory acne lesions and a bilateral cataract. Bone densitometry showed a decrease in bone density. Standard radiography showed bilateral ONATF, stage 3 on the right and 4 on the left according to Arlet and Ficat's classification, which required the placement of a double total hip replacement. Conclusion Corticosteroid therapy is one of the main risk factors for non-traumatic aseptic osteonecrosis. Our three patients presented with ONAT with major disability following long-term corticosteroid therapy. The efficacy of corticosteroids is well established but they should be used with caution to avoid side effects

NEW-ONSET SYSTEMIC LUPUS ERYTHEMATOSUS AND STEVEN JOHNSONS SYNDROME WITH SEVERE ARDS HERALDED BY POST-COVID-19 INFECTION MULTISYSTEM INFLAMMATORY SYNDROME IN AN ADULT (MIS-A)

NEW-ONSET SYSTEMIC LUPUS ERYTHEMATOSUS AND STEVEN JOHNSONS SYNDROME WITH SEVERE ARDS HERALDED BY POST-COVID-19 INFECTION MULTISYSTEM INFLAMMATORY SYNDROME IN AN ADULT (MIS-A)

SARS-CoV 2 Virus Causing Fulminant Myocarditis: A Rare but Serious Complication of COVID-19 Infection

The COVID-19 pandemic has been one that has brought widespread suffering and grief throughout the world; and the complications associated-both short and long term have been widespread and autonomous. We present a case of a 68-year-old White Hispanic male who presented to the emergency department with worsening exertional dyspnea and fatigue eight days after testing positive for SARS-CoV-2. On arrival the patient was afebrile, hypotensive, tachycardic, tachypneic and hypoxemic. Initial workup was significant for high elevated inflammatory markers, troponin and β-natriuretic peptide. EKG was unremarkable. Transthoracic echocardiogram revealed severe global hypokinesis of the left ventricle, reduced ejection fraction of 25%-30%, grade II diastolic dysfunction, mild pulmonary hypertension and mild elevated right atrial pressures, and no pericardial effusion. PCR analysis for usual cardiotropic viruses were all negative, Antinuclear antibody (ANA) was negative, therefore the patient was diagnosed with fulminant COVID-19 myocarditis. Patient was treated with heparin drip, oxygen support, pressors, and high dose corticosteroid therapy in the intensive care unit for 5 days. After showing significant signs of improvement, the patient was discharged on hospital stay day 7. Cardio-respiratory complications are the leading cause of morbidity and mortality in terms of patients suffering with COVID-19. In this case we discuss the importance of early diagnosis and prompt management to reduce the high mortality and complications associated with these complications.

Post-Covid-19 Immunological Disorder: A Possible Pathological Entity in a 43 Year Old Man

Background: Post-COVID-19 systemic inflammatory syndrome is considered to be an aquired immunological disorder, which may develop in some individuals after the remission of infection with SARS-CoV-2 and defined by inflammatory clinical manifestations (fever, arthralgias, cutaneous and mucosal pallor, physical weakness) and modified biological parametres (normochromic normocytic anaemia, increased serum levels of C reactive protein and rheumatoid factor), with no proof of an infectious process, to which corticotherapy may be a suitable therapeutic strategy. Case Report: A 43 year old male was admited in the Department of Internal Medicine for high fever (39,4°C), moderate polyarthralgias and physical weakness, with a negative test result of SARS-CoV-2 RT-PCR. The patient had been previously diagnosed with a moderate-to-severe form of COVID-19, a month prior to the current admission. The patient also experienced transitory dry cough for a month, with no other relevant clinical abnormalities. Upon physical examination, cutaneous and scleral pallor was observed and lung auscultation revealed hardened vesicular murmur bilaterally. Blood analysis revealed normochromic normocytic anaemia and increased serum levels of rheumatoid factor and of C reactive protein, which suggested a nonspecific inflammatory syndrome. Although blood cultures and other microbiological tests were negative for an infectious process, a chest X-ray was performed, which detected the presence of a nodular formation in the superior left lung lobe. Several differential diagnoses were taken into consideration, including pulmonary sarcoidosis and granulomatosis with polyangiitis, both of which were excluded, clinically and biologically. A thoracic computed tomography (CT) was later performed, which revealed the presence of a tumoral nodule in the left lung, associated with multiple mediastinal and supraclavicular lymphadenopathies, indicative of lung cancer. However, lung cancer was also excluded upon the histopathological examination of paratracheal lymphnodes, which detected multiple areas of parenchymal necrosis surrounded by dense inflammatory infiltrates, formed predominantly by histiocytes. All of these findings resulted in the diagnosis of a post-COVID-19 rheumatoid syndrome, the only therapeutic strategy being the administration of high doses of intravenous and oral methylprednisolone, which improved the patient’s health. Conclusion: Post-COVID-19 immunological disturbances should be taken into consideration in patients who experience repetitive clinical and biological inflammatory manifestations after the remission of the infection with SARS-CoV-2, which may be improved through high dose corticosteroid therapy