High-dose Intravenous Corticosteroid Therapy Research Articles

Diagnosis and Treatment of Neuro-Behçet: A Clinical Update

Behçet's disease is a relapsing multisystemic inflammatory syndrome characterized by recurrent oral and/or genital ulcers, uveitis, arthritis, skin lesions, and gastrointestinal and neurological involvement. Neuro-Behçet corresponds to nervous system involvement and is one of the most severe complications of Behçet disease. It occurs in 3% to 30% of cases and is categorized into parenchymal (most common) or non-parenchymal disease. The most common manifestation of parenchymal neuro-Behçet is meningoencephalitis with involvement of the brainstem, where patients present with cranial neuropathies, encephalopathy, sensory-motor syndromes, epilepsy, or myelitis. The main non-parenchymal manifestation is cerebral venous thrombosis. Neuro-Behçet has a predominantly subacute course, with remission within weeks, or clinical progression in one third of the cases. The diagnosis is essentially clinical and diagnostic tests help to corroborate the suspicion, distinguish from differential diagnoses, and exclude complications. Brain magnetic resonance imaging allows the identification of acute lesions (hypointense or isointense on T2-weighted and hypointense on T1-weighted sequences) contrast-enhanced, and chronic lesions characterized by non-contrast enhanced small lesions and brainstem atrophy. If non-parenchymal involvement is suspected, cerebral veno-magnetic resonance imaging /computed tomography should be performed. Cerebrospinal fluid shows elevated proteinorachia and pleocytosis in parenchymal and no changes in non-parenchymal neuro-Behçet (except increased opening pressure). Outbursts of parenchymal disease should be treated with high dose intravenous corticosteroid therapy, with subsequent switch to oral corticoids, followed by biologic therapy, usually an anti-TNF. The treatment of cerebral venous thrombosis is controversial and may consist of a combination of corticosteroids and anticoagulation.

A case of probable Vogt\u2013Koyanagi\u2013Harada disease in a 3-year-old girl

BackgroundVogt–Koyanagi–Harada (VKH) disease is a T-cell-mediated autoimmune disorder characterized by bilateral granulomatous panuveitis with various systemic manifestations. Although VKH disease rarely occurs in the pediatric population, the clinical course tends to be aggressive, and the visual prognosis is worse than that in adult patients due to severe ocular complications secondary to recurrent inflammation.Case presentationA 3-year-old girl with probable VKH was referred to Kobe University Hospital. She had severe bilateral panuveitis with posterior synechiae of the iris, marked optic disk swelling, and serous retinal detachment in both eyes, and her best corrected visual acuities (BCVAs) were 20/200 OD and 20/125 OS. A third course of therapy was administered because serous retinal detachment remained after two courses of therapy. She was treated with three courses of high-dose intravenous corticosteroid therapy, followed by slow tapering of oral corticosteroids. Her BCVAs recovered to 20/16 OU, and relapse of ocular inflammation and side effect of treatment were not observed during the 1.5-year follow-up period.ConclusionsWe experienced a pediatric patient with probable VKH disease who was treated with three courses of high-dose intravenous corticosteroid therapy. With the favorable clinical course in our patient, initial treatment with repeated high-dose intravenous corticosteroid therapy might be beneficial in pediatric VKH disease.

Nivolumab induced encephalopathy in a man with metastatic renal cell cancer: a case report

BackgroundGreat progress has recently been made in the treatment of metastatic renal cell carcinoma, including the introduction of nivolumab, an immune checkpoint inhibitor. Despite promising results, this treatment brings a completely new spectrum of adverse events, distinct from those experienced with small-molecule kinase inhibitors. Neurologic immune-related adverse events may be serious and potentially life-threatening complications requiring immediate immunosuppressive therapy. Only a few cases of immune-related encephalitis induced by checkpoint inhibitors have been described and the data regarding the management of this serious adverse event are limited.Case presentationWe report the case of a 63-year-old white man with metastatic renal cancer who developed severe chorea-like dyskinesia during nivolumab therapy. The findings on brain magnetic resonance imaging and flow cytometry of cerebrospinal fluid, and the positivity of anti-paraneoplastic antigen Ma2 immunoglobuline G class autoantibodies were consistent with a diagnosis of immune-related encephalitis. High-dose intravenous corticosteroid therapy was started immediately, with no signs of improvement, even when infliximab was added. Our patient refused further hospitalization and was discharged. Three weeks later, he presented with signs of severe urosepsis. Despite intensive treatment, he died 4 days after admission.ConclusionsThe management of less frequent immune-related adverse events has not been fully established and more information is required to provide uniform recommendations. Immune-related encephalitis is a severe and potentially fatal complication requiring immediate hospital admission and extensive immunosuppressive therapy. The examination of cerebrospinal fluid for paraneoplastic antibodies, such as anti-N-methyl-D-aspartate receptor and anti-Ma2 antibodies, in order to distinguish autoimmune etiology from other possible causes is essential and highly recommended.

Hızlı progresif görme kaybı ile giden ve puls steroid tedavisinden yararlanan bir idiyopatik intrakraniyal hipertansiyon olgusu

A case of idiopatic intracranial hypertension with rapidly progressive vision loss and that benefits from pulse steroid therapy In this report, a 28-year-old patient who had idiopathic intracranial hypertension with rapidly progressive visual loss was reported. Etiological factors were polycystic ovarian disease, short-term oral contraceptive use and iron deficiency. She was administrated oral acetozolamid and metilprednizolon IV 1g/day. In addition to drug therapy, the patient underwent repeat lumbar punctures and lumboperitoneal shunt. In idiopathic intracranial hypertension, it is very rare but loss of vision may rapidly develop. In this case, high-dose intravenous corticosteroid therapy might be a god option in terms of save time to improve vision.

Bilateral angle-closure glaucoma and multifocal choroiditis as a first presentation in hodgkin lymphoma.

To report atypical ocular manifestations in two patients with undiagnosed Hodgkin lymphoma. Observational case report. The first patient, a 27-year-old man, presented with bilateral acute angle-closure glaucoma secondary to uveal effusion. Histopathology of chest lymph nodes obtained by mediastinoscopy revealed nodular sclerosing Hodgkin lymphoma. Ocular signs resolved after systemic chemotherapy. The second patient, a 56-year-old man, presented with bilateral multifocal choroiditis. Extensive biologic and microbiologic examinations were negative. Pathologic lymph nodes were detected in the anterior mediastinum. The histopathologic examination of the nodes after mediastinoscopy revealed nodular sclerosing Hodgkin lymphoma. Systemic chemotherapy was instituted. The patient encountered a major increase in the multifocal choroiditis within 3 days after the second chemotherapy injection. High-dose intravenous corticosteroid therapy was initiated. No recurrence of choroidal lesions was observed after the treatment completion. These two patients presented with bilateral paraneoplastic uveal tract involvement as initial presentation of Hodgkin lymphoma. Systemic corticosteroid therapy may be associated with systemic chemotherapy to obtain complete remission of the ocular inflammatory activity.

Anesthesia Literature Review

Anesthesia Literature Review

High-dose intravenous methylprednisolone in recent traumatic optic neuropathy; a randomized double-masked placebo-controlled clinical trial

To compare the effect of high-dose intravenous corticosteroid therapy with placebo in the treatment of recent traumatic optic neuropathy (TON). In a double-masked placebo-controlled clinical trial, 31 eyes of 31 patients were randomly assigned to two groups. Patients with history of trauma < or =7 days were included. Unconscious patients, eyes with penetrating trauma and candidates for decompression surgery were excluded. The treatment group (16 eyes) received 250 mg methylprednisolone intravenously every 6 h for 3 days, then 1 mg/kg prednisolone orally for 14 days; the placebo group (15 eyes) received 50 ml normal saline intravenously every 6 h for 3 days, then placebo for 14 days. Visual improvement was considered as a decrease of at least 0.4 logMAR in final visual acuity. Mean final BCVA (best corrected visual acuity) in the treatment group was 1.11+/- 1.14 and the placebo group was 1.78 +/- 1.23. This difference was not significant (P = 0.13). Visual acuity was improved in 68.8% of the treatment group and 53.3% of the placebo group, but the difference was not statistically significant (P = 0.38). The difference between initial and final BCVA in both groups was determined to be statistically significant (P < 0.001 and 0.010 respectively). Our study confirms earlier findings that there is no difference in visual acuity improvement between intravenous high-dose corticosteroids and placebo in treatment of recent TNO.

Treatment of electrical status epilepticus during slow-wave sleep with high-dose corticosteroid

A 4-year-old female patient with epilepsy with continuous spike-and-waves during slow-wave sleep not classified as Landau-Klefner syndrome, refractory to antiepileptic drugs including valproate, benzodiazepines, and lamotrigine, was treated successfully with high-dose intravenous methylprednisolone therapy. Valproate, clobazam, and lamotrigine were continued at the same dose during and after high-dose intravenous corticosteroid therapy. During corticosteroid therapy, awake and sleep electroencephalogram was recorded every day. On day 7, a dramatic clinical and electroencephalographic response was observed. After high-dose intravenous methylprednisolone, prednisolone was administered orally (2 mg/kg daily) for 2 months, then gradually withdrawn. After the withdrawal of corticosteroid therapy, the patient maintained the clinical improvement in behavior, and no continuous spike-and-wave electrical status epilepticus during slow-wave sleep occurred on routine monthly sleep electroencephalogram performed for the last 6 months. In the present case, an add-on high-dose intravenous corticosteroid seems to be effective in the treatment of patients with electrical status epilepticus during slow-wave sleep syndrome, especially when antiepileptic drugs fail.

Maternal benefit of high-dose intravenous corticosteroid therapy for HELLP syndrome

Objective We compared maternal outcomes for patients with HELLP (hemolysis, elevated liver enzymes, and low platelet count) syndrome treated with or without high-dose corticosteroids to ameliorate maternal disease. Study design An analysis of data for patients with HELLP syndrome (platelets, ≤100,000/μL; lactate dehydrogenase level, ≥600 IU/L; aspartate aminotransferase and/or alanine aminotransferase level, ≥70 IU/L) who were treated during the 7-year epochs before and after the clinical trials in 1992 and 1993 demonstrated maternal benefit with high-dose dexamethasone. Results Corticosteroid use increased from 16% (39/246 patients) for fetal indication from 1985 to 1991 to 90% (205/228 patients) for maternal-fetal indications from 1994 to 2000. Significantly reduced composite maternal disease from 1994 to 2000 was evidenced by improvements in laboratory parameters, disease progression to class 1 HELLP syndrome, the degree of hypertension, the need for antihypertensive therapy, the use of transfusion, and the presence of maternal morbidity ( P<.05). Indices of postpartum recovery also were shortened significantly ( P<.001). Conclusion Routine early initiation of high-dose intravenous corticosteroids for patients with HELLP syndrome significantly lessened maternal disease, reduced maternal morbidity, and expedited recovery.

Effects of high-dose intravenous corticosteroid therapy in Landau-Kleffner syndrome

Two children with Landau-Kleffner syndrome were successfully treated with antiepileptic drugs and a high-dose intravenous corticosteroid. A combination of valproate and a benzodiazepine (clonazepam or diazepam) ameliorated epileptic seizures and electroencephalographic spikes and waves, but speech disturbances persisted. Both patients were treated with an intravenous infusion of high-dose methylprednisolone sodium succinate (20 mg/kg daily) for 3 consecutive days. This infusion was repeated three times with a 4-day interval between treatments, which resulted in a rapid improvement in speech ability. After intravenous therapy, prednisolone was given orally (2 mg/kg daily for 1 month, then gradually withdrawn), which maintained the clinical improvement in speech.

1037 The effect of high dose intravenous corticosteroid therapy on immediate skin test reactivity

1037 The effect of high dose intravenous corticosteroid therapy on immediate skin test reactivity

Tratamiento con plasma inmunoadsorción en brotes graves y prolongados de esclerosis múltiple maligna

The treatment of prolonged, severe relapses in multiple sclerosis (MS) patients who respond poorly to high-dose intravenous corticosteroids is not yet established. Plasma immunoadsortion (IA) removes immunoglobulins (IgG), immune complexes, and complement from plasma. It may bear some advantages compared to plasmapheresis, a nonselective procedure that requires substitution of patient plasma by colloids solutions or plasma, which may carry a potential risk for viral infections. Three relapsing-remitting MS patients with a malignant course received IA. All they were experiencing a prolonged relapse unresponsive to high-dose intravenous corticosteroids, causing a locked-in state in two of the patients and severe pseudobulbar impairment in the third one. Five to six IA consecutive sessions were administered along a 7-10 days course. IA was followed by a prompt and unequivocal clinical response in all three patients, which paralleled a decrease in IgG, fibrinogen, and C3 complement serum levels. IA administration was followed by immunosuppressor therapy, either with cyclophosphamide and intravenous ACTH (2 cases) or mitoxantrone (1 case). Improvement has been sustained along a mean follow-up of 7.6 years (range: 7-8.5 years), only one of the patients suffering two mild clinical relapses. We believe that IA may be useful, either as a coadyuvant or alternative treatment in severe relapses in MS patients that do not respond to high-dose intravenous corticosteroid therapy.

Focal myositis presenting as pseudothrombophlebitis of the neck in a patient with mixed connective tissue disease

This report describes a case of focal myositis in a patient with mixed connective tissue disease. The patient presented with diffuse neck swelling and pseudothrombophlebitis of the left internal jugular vein. Other clinical features included a high fever, elevated erythrocyte sedimentation rate, and prompt improvement after administration of high-dose intravenous corticosteroid therapy. Criteria for polymyositis were absent, serum levels of creatine kinase remained normal, and there was no sign of recurrence during 3 years of followup. Results of immunoprecipitation for anti-Jo-1 and other myositis-specific autoantibodies remained negative in serial serum samples obtained before, during, and after the episode.

Severe cardiovascular adverse effects in association with acute, high-dose corticosteroid administration.

Severe cardiovascular adverse reactions including death have been associated with high-dose intravenous corticosteroid therapy. Some of the patients appeared to have acute hypersensitivity reactions to the corticosteroid, with rashes and bronchospasm; other problems included arrhythmias and myocardial infarctions. Most of the patients had underlying renal disease and/or were undergoing renal transplantation. All of the patients having the cardiovascular reactions associated with the corticosteroid received individual doses of at least 250 mg of methylprednisolone or its equivalent. The doses were usually administered over a 30-minute period or less. A cause-effect relationship between high-dose corticosteroid therapy and severe cardiovascular reactions has not been scientifically proved by a controlled trial, but caution is advised when high-dose corticosteroid therapy is administered.

High-dose intravenous corticosteroids in the treatment of multiple sclerosis.

The effectiveness of high-dose intravenous corticosteroid therapy for acute bouts of multiple sclerosis (MS) was evaluated in comparison with the conventional oral prednisolone therapy. Group I comprised 11 cases of MS treated with oral prednisolone, 30-60 mg daily, and group II comprised 16 cases treated with intravenous corticosteroids; 11 cases given 1000 mg of methylprednisolone for the initial 3 days followed by 100 mg of prednisolone, while the remaining 5 were given 100 mg of prednisolone alone. The initial dosage was maintained for 1 or 2 weeks in each group, tailing off with a period of several weeks of oral prednisolone. The clinical status was evaluated using Kurtzke's expanded disability status scale (EDSS) and functional system scale before and 1, 2 and 4 weeks after the initiation of therapy. EDSS score significantly declined from week 0 (before) to weeks 1, 2 and 4 in group II, respectively, whereas no significant decline of EDSS score was observed in group I. The frequency of improvement (0.5 of an increment in EDSS score) in group II was significantly higher than that in group I at weeks 1, 2 and 4. It was thus suggested that high-dose intravenous corticosteroid therapy might be more useful in acute bouts of MS, especially for obtaining an early improvement, than conventional oral prednisolone therapy.