High-dose Prednisolone Research Articles

Undercarboxylated osteocalcin may be an attractive marker of teriparatide treatment in rheumatoid arthritis patients

Dear Editor, Elderly rheumatoid arthritis (RA) patients suffer from osteoporosis resulting in fragility fractures [1]. Therapy with lowdose glucocorticoids, which are often used to treat RA, suppresses bone strength. However, evidence regarding the effects of treatment for osteoporosis in RA patients remains limited. Ebina and colleagues [2] conducted an 18-month prospective trial of daily teriparatide (TPTD) in patients with RA and postmenopausal osteoporosis. Their findings showed the advantage of TPTD in the RA patients, compared to that observed in the subjects with primary osteoporosis, and identified available predictors of TPTD treatment in the setting of RA. Their findings provide several significant messages for clinicians. In the current article, I would like to discuss this topic from the point of view of a marker of bone formation, undercarboxylated osteocalcin (ucOC). It has previously been reported that the serum ucOC level is elevated by TPTD treatment in RA patients [3]. In addition, serum ucOC level and daily glucocorticoid dose are inversely correlated in RA patients treated with teriparatide [3]. The serum ucOC levels in RA patients receiving more than 10 mg per day of prednisolone are often undetectable on an electrochemiluminescence immunoassay. We recently administered TPTD treatment in a small number of RA patients and followed the BMD and serum ucOC levels for 48 weeks (n= 34, mean age 74.6 years). Based on our preliminary data, the percent change from baseline in the LS BMD at 48 weeks positively correlated with the absolute change from baseline in ucOC at 24 weeks (rs=0.389, p=0.025). These results are consistent with the observations noted by Ebina and colleagues [2]. Therefore, we agree with the suggestion that the serum ucOC level has the potential to be a useful predictor of TPTD treatment in RA patients. Nevertheless, it is unknown whether the ucOC level is a suitable biomarker for TPTD treatment in all types of glucocorticoid-induced osteoporosis (GIO). As noted above, high-dose prednisolone treatment may make the serum ucOC level undetectable. Therefore, further research is needed to clarify the relationship between ucOC and TPTD treatment in RA and GIO patients.

Effect of Intermittent Administration of hPTH(1-34) on Cortical Bone Geometry in Rats Treated with High-Dose Glucocorticoids

High-dose glucocorticoids reduce cortical bone gain in rats. The aim of the present study was to examine the effect of the intermittent administration of human parathyroid hormone (1-34) (hPTH[1-34]) on cortical bone in rats treated with high-dose prednisolone (PSL). Twenty-five female Sprague-Dawley rats (6 weeks old) were randomized into the following three groups: a vehicle administration (control) group, a PSL (10 mg/kg s.c., 5 times a week) administration group, and a PSL + hPTH(1-34) (30 μg/kg s.c., 3 times a week) administration group. After 8 weeks of treatment, the bone mineral density (BMD) of the femoral diaphysis was determined using peripheral quantitative computed tomography, and a static bone histomorphometric analysis was performed on the tibial diaphysis. PSL administration induced a decrease in the BMD of the femoral diaphysis, compared with the control group, as well as decreases in the total tissue area, cortical area, percent cortical area, and periosteal perimeter and increases in the marrow area, percent marrow area, and endocortical perimeter of the tibial diaphysis, compared with the control group. The intermittent administration of hPTH(1-34) to PSL-treated rats attenuated PSL-related changes in the BMD of the femoral diaphysis and the percent cortical area, marrow area, percent marrow area, and endocortical perimeter of the tibial diaphysis. The findings of the present study suggest that the intermittent administration of hPTH(1-34) improves cortical BMD, acts on the endocortical bone surface, and improves cortical bone geometry, in rats treated with highdose PSL.

Reduced neurotoxicity with combined treatment of high-dose methotrexate, cyclophosphamide, doxorubicin, vincristine and prednisolone (M-CHOP) and deferred radiotherapy for primary central nervous system lymphoma

ObjectiveAlthough high-dose methotrexate and whole-brain radiation therapy (WBRT) is the current standard for primary central nervous system lymphoma (PCNSL), it has a limited response rate and produces radiation-induced neurotoxicity. We report the effect of a combined treatment of high-dose methotrexate, cyclophosphamide, doxorubicin, vincristine and prednisolone (M-CHOP) for immunocompetent patients with PCNSL. MethodsWe analyzed 24 patients who had received M-CHOP administered in 28-day cycles with or without WBRT. The response rate to M-CHOP, overall survival (OS), and recurrence-free survival (RFS) were analyzed. ResultsNine patients were treated with M-CHOP plus WBRT and 15 patients were treated with M-CHOP alone. Twenty-one patients achieved a complete response and three patients achieved a partial response to M-CHOP, for a 100% response rate. With a median follow-up of 70 months, the median OS and RFS were 33 and 13 months, respectively. The median OS for patients treated with M-CHOP plus WBRT and M-CHOP alone was 33 and 32 months, respectively. Of the 13 patients whose age was above 65 years, the median OS for the M-CHOP plus WBRT group (two patients) and the M-CHOP alone group (11 patients) was 14 and 32 months, respectively. Toxicities related to M-CHOP were mostly hematologic and generally mild to moderate. Two patients whose age was above 65 years in the M-CHOP plus WBRT group developed neurotoxicity. ConclusionCombined treatment with M-CHOP was well tolerated and produced a high response rate. Deferring WBRT was associated with reduced neurotoxicity without worsening the prognosis, especially in elderly patients.

PS-088 Treatment Of Primary Immune Thrombocytopenia By Prednisolone: 4 Mg/kg/j For 4 Days Versus 2 Mg/kg/j For 6–8 Weeks

Background and aims Primary immune thrombocytopenia (ITP) is characterised by accelerated platelet destruction. Corticosteroids have been shown to increase platelet counts. The objective of our study was to compare the treatment with prednisolone at a dose of 4 mg / kg / day for 4 days (Protocol P1) to the treatment with prednisolone at the dose of 2 mg / kg / day for 6–8 weeks (Protocol P2). Methods We conducted a comparative analytical study between 2 groups: first group (G1) formed by ITP cases followed prospectively between 2010 and 2013. These patients received protocol P1. The second group (G2) collecting the same number of patients followed retrospectively between 1999 and 2008. These patients received protocol P2. Results Our study included 24 cases: 12 cases in G1 and 12 cases in G2. The response on day three was 25% for G1 and 0% for G2. The response on the fifth day was 66.7% (G1) and 54.5% (G2). The median time to response was 5 days for the 2 groups, with extremes ranging from 3 to 30 days (G1) and 5 to 30 days (G2) (p: 0.09). The complete response occurred in 15 days with a range of 5–90 days for G1 and 30 days with a range of 5–90 days for G2 (p = 0.04). Conclusion Within the limits of our study, we are able to show the interest of high dose of prednisolone during 4 days in the treatment of acute ITP.

Pericardial tamponade and pancytopenia as the first manifestation of mixed connective tissue disorder and its complete reversal with corticosteroids

We report a case of a 25-year-old lady who presented to our department with complaints of easy fatigability and shortness of breath since one week. She had a history of Raynaud’s phenomenon. Examination revealed scleroderma like skin changes and pericardial friction rub. Investigations revealed high titer of anti-U1 RNP antibodies along with co-existing pancytopenia. Chest x-ray and echocardiography confirmed pericardial tamponade. Patient was diagnosed as having mixed connective tissue disorder (MCTD) and she was started on high dose prednisolone, which led to complete reversal of pancytopenia and pericardial tamponade after 1 month of treatment. There are only 6 reported cases of pericardial tamponade in a patient with MCTD, and none of them had pancytopenia. Present case highlights the need to investigate the patient of pericardial tamponade for MCTD, especially in the presence of pancytopenia and relevant clinical history, as prompt treatment with corticosteroids can avoid invasive procedures like pericardiocentesis.

Medical Treatment of Traumatic Anosmia

Objectives: Study the effects of zinc and steroid in the treatment of traumatic anosmia. Methods: Patients with a clear history of complete loss of smell after head injury were collected from January 2010 to May 2013. All patients received phenyl ethyl alcohol threshold test, and those whose thresholds were –1 were included in this study. They were randomly divided into 4 groups. Patients in group 1 were treated with zinc sulfate (15mg tid) for a month and high dose prednisolone (1 mg/kg per day) with tapering for 2 weeks. Those in group 2 only took zinc, and those in group 3 only took prednisolone. Patients in group 4 did not take any medicine. All patients were followed up by phenyl ethyl alcohol threshold test to find whether their olfactory function improved and had magnetic resonance imaging to measure the volume of olfactory bulbs. Results: There were 145 patients completing the study. Thirty-nine belonged to group 1, 34 to group 2, 35 to group 3, and 37 to group 4. Olfactory function improved in 11 patients (28.2%) who took prednisolone and zinc, in 9 (25.7%) who took zinc, in 4 (11.8%) who took prednisolone, and in 1 (2.7%) who did not take any medicine. The olfactory improvement rates of groups 1 and 2 are significantly higher than that of group 4. The volume of olfactory bulbs is not significantly different between those with and without improved olfactory function. Conclusions: Our results show that zinc has good effect in treating traumatic anosmia.

Intratympanic Dexamethasone after High‐Dose Intravenous Methylprednisolone in Idiopathic Sudden Sensorineural Hearing Loss

Objectives: Investigate the therapeutic efficacy of intratympanic dexamethasone after high-dose systemic corticosteroids in patients with idiopathic sudden sensorineural hearing loss (ISSNHL). Methods: Prospective clinical trial at a university hospital. A total of 104 eligible patients with ISSNHL were treated consecutively. Patients in the severe group (>70 dB) were treated with intravenous high-dose prednisolone (500 mg per day, 5 days), whereas the rest were treated with oral deflazacort (1 mg per kg per day, 10 days). Failures after 5 days of systemic treatment received an additional 3 intratympanic dexamethasone injections. Results: The differences between pretreatment and posttreatment pure-tone audiometry averages (PTAs). Complete recovery was defined as PTA better than 25 dBs. Successful treatment was defined as a greater than 10 dB improvement in PTA. Results: Complete hearing recovery was achieved in 38 cases (36.53%), and significant hearing recovery in 86 cases (82.69%). After intravenous treatment of severe cases (initial PTA 83.15 dB), a median improvement of 13.61 dB was achieved; rescue intratympanic treatment obtained 18.49 dB of further improvement (final PTA 53.05 dB). Those less severe cases (initial PTA 68.38 dB) had a median improvement of 3.39 dB after oral treatment, and 9.00 dB after rescue (final PTA 56.00 dB). High-dose treatment in severe cases showed a significant improvement compared with the less severe group ( P < .01). Conclusions: High-dose intravenous corticosteroid treatment obtained significant hearing improvement in severe ISSNHL. The addition of intratympanic steroids to the conventional systemic steroid therapy may provide a safe and potentially effective therapeutic option.

Controlled release dexamethasone implants in the round window niche for salvage treatment of idiopathic sudden sensorineural hearing loss.

To evaluate the feasibility and hearing outcome of a biocompatible degradable dexamethasone releasing implant for continuous drug delivery to the round window membrane in patients with idiopathic sudden sensorineural hearing loss (ISSHL) and insufficient recovery after systemic high dose glucocorticoid therapy. Five patients with profound or moderate-to-severe hearing loss after systemic high-dose prednisolone for ISSHL received local salvage therapy with a controlled release dexamethasone implant in the middle ear. Pieces of a sterile rod shaped poly(D,L-lactide-co-glycolide) PLGA polymer matrix containing a total of 0.7 mg dexamethasone, which is approved for intravitreal use were implanted into the round window niche. Intraoperative handling and feasibility and hearing recovery as measured by change in pure tone threshold, final word recognition score, and categories of improvement were evaluated. The implants were surgically placed without major difficulties. The mean hearing threshold significantly improved at follow up by 31 ± 31 dB HL (from 94 ± 27 to 63 ± 36 dB HL; p < 0.05). Two of five patients recovered completely. One patient showed partial hearing recovery with serviceable hearing. Although no drugs are currently approved for local therapy of inner ear disorders, there is increasing evidence that intratympanic glucocorticoids are effective as salvage therapy in ISSHL. The present study has shown encouraging results with a biodegradable polymer delivery system, demonstrating the translation of preclinical studies with controlled drug delivery into clinical practice.

J W P Bradley

An 81-year-old woman presented with an enlarging, tender ulcer on her scalp over an 8-week period, attributing it to a prior graze with garden shears. C-reactive protein and erythrocyte sedimentation...

High dose (4 mg/kg/day) versus usual dose (2 mg/kg/day) oral prednisolone for treatment of infantile spasms: An open-label, randomized controlled trial

This study aimed to test the hypothesis that high-dose prednisolone (4 mg/kg/day) may be more efficacious than usual-dose (2 mg/kg/day) prednisolone for spasm resolution at 14-days in children with infantile spasms. This was a randomized, open-label-trial conducted at a tertiary-level-hospital from February-2012 to March-2013. Children aged 3-months to 2-years presenting with infantile spasms in clusters (at least 1 cluster/day) with hypsarrhythmia or its variants on EEG were enrolled. The study participants were randomized to receive either high-dose prednisolone (4 mg/kg/day) or the usual-dose (2 mg/kg/day) prednisolone. The primary outcome measure was the proportion of children who achieved spasm freedom for 48-h at day-14 after treatment initiation as per parental reports in both the groups. The adverse effects were also monitored. The study was registered with the clinicaltrials.gov (ClinicalTrials.gov Identifier: NCT01575639). Sixty-three children were randomized into the two groups with comparable baseline characteristics. The proportion of children with spasm cessation on day-14 was significantly higher in the high-dose group as compared to the usual-dose group (51.6% vs. 25%, p=0.03). The absolute risk reduction was 26.6% (95% confidence interval 11.5-41.7%) with number needed to treat being 4. The adverse effects were comparable in both the groups. High-dose prednisolone (4 mg/kg/d) was more effective than low-dose prednisolone (2mg/kg/d) in achieving spasm cessation at 14-days (as per parental reports) in children with infantile spasms.

FRI0499 Retrospective CASE Series of Refractory Antisynthetase Syndrome Successfully Treated with Rituximab (3 CASES)

BackgroundAntisynthetase syndrome (ASS) is an idiopathic inflammatory myopathy characterised by the presence of anti-Jo-1 antibodies. Patients usually present with myositis, interstitial lung diseases, and arthritis. Corticosteroid therapy is the first...

AB0522 Clinical Characteristics of Muscular Symptoms in Patients with Systemic Lupus Erythematosus

BackgroundIt is well known that myalgia occurs in 40% to 80% of patients with systemic lupus erythematosus (SLE). However, the clinical charasteristics of muscular symptoms associated SLE has not been...

Resistive home exercise in patients with recent-onset polymyositis and dermatomyositis -- a randomized controlled single-blinded study with a 2-year followup.

To evaluate the outcome of resistive home exercise and its possible longterm influence on health, disability, and disease activity in patients with active polymyositis (PM) or dermatomyositis (DM). Nineteen patients with recent-onset PM/DM were included after introduction of high-dose prednisolone. They were assessed by independent assessors as to perceived health, muscle performance, aerobic capacity, and serum creatine phosphokinase (CPK) at baseline and after 24 weeks, including repeated muscle biopsies at 24 weeks (single-blinded randomized controlled study), and in an open-label followup at 52, 78, and 104 weeks. Patients were randomized to 12 weeks, 5 days/week resistive home exercise with telephone support and encouragement for another 12 weeks of twice-a-week home or gym exercise (EG, n = 10) or to 24 weeks, 5 days/week range of motion exercise (CG, n = 9). Patients in the CG group without inflammatory infiltrates in muscle biopsies at 24 weeks were invited to the 12-week resistive home exercises. At baseline, the EG had poorer perceived health, but otherwise the groups were comparable. At 24 weeks, both groups improved in muscle performance and aerobic capacity (p < 0.001 to < 0.05) with no signs of increased inflammation assessed by CPK levels or muscle biopsies. Both groups improved in muscle performance and aerobic capacity up to 52 weeks (p < 0.05) lasting to 104 weeks in the EG (p < 0.05) and presented minor improvements in perceived health. Our study supports the safety of resistive exercise in patients with active PM/DM but did not reveal any between-group differences in exercise effects. An individually adapted physical therapist-supervised home exercise program might be recommended in early active PM/DM, with regular evaluation of muscle performance and health.

G373(P) The use of a low-dose prednisolone regimen to treat a relapse of childhood nephrotic syndrome

Background70–80% of children with nephrotic syndrome develop relapses. These are typically treated with a course of high dose prednisolone and about half go on to develop frequently relapsing disease. Not...

Parsonage-Turner Syndrome Initially Suspected of Being Orthopedic Diseases in a Primary Care Setting: A Case Report

Parsonage-Turner syndrome (PTS), also known as neuralgic amyotrophy or brachial neuritis, consists of a complex set of symptoms including sudden onset shoulder pain, usually unilaterally, followed by progressive neurologic deficits such as motor weakness, dysesthesia and numbness. We report a case of a 45-year-old Japanese man with PTS, who was initially suspected of having orthopedic diseases, such as cervical spondylosis and suprascapular nerve entrapment syndrome. The patient presented with acute-onset severe pain in his right arm and neck, followed by muscle weakness. We diagnosed PTS by taking a detailed medical history, ruling out other differential diagnoses, and by considering the characteristic clinical symptoms and the denervation pattern identified by needle electromyography. High-dose corticosteroid therapy prednisolone (PSL) relieved the initial sharp pain and oral amitriptyline successfully relieved the residual nighttime pain. Doses of PSL and amitriptyline were tapered, pain was alleviated, and the patient returned to full-time work after discharge in one-and-a-half years. For prompt diagnosis, physicians should consider the possibility of PTS in patients with acute onset of severe arm pain or subsequent muscle weakness and muscle atrophy in the arm or shoulder girdle. J Med Cases. 2014;5(4):197-201 doi: http://dx.doi.org/10.14740/jmc1696w

Re-treatment with high-dose prednisolone after rituximab infusion for childhood-onset steroid-resistant nephrotic syndrome

Sirs, We read with great interest the article titled “Rituximab treatment combined with methylprednisolone pulse therapy and immunosuppressants for childhood steroid-resistant nephrotic syndrome” by Kamei et al., which has recently appeared in Pediatric Nephrology [1]. In this retrospective observational study of ten childrenwith refractory steroid-resistant nephrotic syndrome (SRNS), seven patients (70 %) achieved complete remission after receiving multiple courses of methylprednisolone pulse therapy (MPT) and immunosuppressive agents administered after one to four doses of rituximab (RTX). Although we agree with their speculation that a RTX infusion may improve the response to various immunosuppressants, such as steroids and cyclosporine A, little information is currently available on the optimal therapeutic protocol for children with refractory SRNS after administration of the biological agent. We previously described a 2-year-old girl with refractory SRNS resistant to nine courses of MPT (total 27 treatments) and cyclosporine A (6–7 mg/kg/day) following RTX infusion. Interestingly, the patient went into complete remission after re-treatment with conventional high-dose prednisolone (PSL, 2 mg/kg/day) administered after an additional RTX infusion within 2 weeks [2]. Recently, we encountered a SRNS patient resistant to multiple courses of MPTand mycophenolate mofetil who also achieved complete remission after re-treatment with high-dose PSL administered after an RTX infusion within a short period of time. This patient, an 8-year-old boy, presented with a 2-week history of significant weight gain and generalized edema. His medical history was significant for chronic kidney disease (estimated glomerular filtration rate 60–70 ml/min/1.73 m) as he had experienced septic shock associated with pneumococcal meningitis at the age of 1 year. On admission, a physical examination showed generalized edema, abdominal distention, and a blood pressure of 111/72 mmHg. His weight was 22.2 kg, which was increased by 2 kg compared to his dry weight. Laboratory investigations were as follows: white blood cell count, 72,000/mm; hemoglobin, 13.7 g/dl; hematocrit, 39.2 %; platelets, 221,000/mm; blood urea nitrogen, 23 mg/dl; serum creatinine, 0.61 mg/dl; sodium, 137 mmol/l; potassium, 4.4 mmol/l; chloride, 107 mmol/l; calcium, 7.7 mg/dl; phosphorous, 4.8 mg/dl; total protein, 3.9 g/dl; albumin, 1.6 g/dl; total cholesterol, 404 mg/dl; serum immunoglobulin G, 202 mg/dl, C3, 105 mg/dl, and C4, 18 mg/dl. Tests with antihepatitis B surface antigen, antihepatitis C antibody, and antinuclear antibody were negative. Urinalysis showed 1+ occult blood and 3+ protein by dipstick. The 24-h urine protein excretion was 4.9 g. Based on these findings, a presumptive diagnosis of idiopathic NS in the course of chronic renal insufficiency was made, and treatment with high-dose PSL (2 mg/kg/day) was initiated without a significant reduction in the amount of proteinuria. Persistent nephrotic-range proteinuria for more than 4 weeks with conventional steroid therapy prompted us to perform a renal biopsy with histology, which showed ischemic glomerular obsolescence. Since nephrotoxic drugs such as cyclosporine A were contraindicated based on the histological findings, the patient was treated with MPT (20 mg/kg/day for 3 consecutive days per week) for 3 weeks, followed by mycophenolate mofetil (30 mg/kg/day) and alternate-day low-dose PSL. However, proteinuria did not return to baseline values. After a single infusion of RTX (375 mg/m), a second course of high-dose PSL (2 mg/kg/ S. Fujinaga (*) Division of Nephrology, Saitama Children’s Medical Center, 2100 Magome, Iwatsuki-ku, Saitama City, Saitama 339 8551, Japan e-mail: f_shuich@d2.dion.ne.jp

Acute polyarthritis immediately after kidney transplantation: A medication‐induced rheumatoid arthritis flare?

A patient with known steroid-dependent rheumatoid arthritis (RA) developed an acute symmetrical polyarthropathy of small and medium-sized joints associated with markedly elevated inflammatory markers suggestive of RA flare, on day 4 after deceased-donor renal transplantation. The patient received standard induction immunosuppression with methylprednisolone and basiliximab, and had commenced prednisolone, tacrolimus and mycophenolate mofetil. Serological investigations and joint aspirate to exclude infective causes and crystal arthropathy were unremarkable. High-dose prednisolone (50 mg daily) resulted in partial but unsustained symptomatic improvement. On suspicion of a medication-related adverse event, tacrolimus and mycophenolate mofetil were changed to cyclosporine A and azathioprine on day 16. This was followed by rapid improvement in symptoms and normalization of inflammatory markers. Unexpected sequelae in the early post-transplantation period create diagnostic and management challenges. Medication-related adverse events are not uncommon, and we speculate in this case on the potential for medication-induced immune system dysregulation stimulating disease activity in a chronic autoimmune condition after introduction of new immunosuppressants.

Unsuspected Cardiovascular Involvement in Relapsing Polychondritis

A 51-year-old man presented with a prodrome of arthralgia, intermittent oral ulceration, and raised inflammatory markers. He was extensively investigated; however, no firm diagnosis could be established, and he remained under regular surveillance by rheumatology and infectious disease services. After 12 months, he presented with painful ear swelling. Clinical examination revealed a swollen tender ear (Figure 1) and a soft diastolic heart murmur. Serum inflammatory markers were raised, with a c-reactive protein (CRP) of 28 mg/L and an erythrocyte sedimentation rate (ESR) of 25 mm/h. Figure 1. Tender, erythematous left ear. Biopsy of affected cartilage showed characteristic features of auricular chondritis (Figure 2). Echocardiogram (Movie I in the Data Supplement) revealed mild aortic incompetence, a left ventricular ejection fraction of 60%, aortic root dilatation, and an incidental patent foramen ovale (Movie II in the Data Supplement). Computed tomography (CT) of the thorax demonstrated no tracheal abnormality; however, aortic root dilatation of 4.6 cm was noted (Figure 3). A fasting positron emission tomography-CT (PET-CT) showed increased F-18 fluorodeoxyglucose accumulation in the ascending aorta (Figure 4), and a diagnosis of relapsing polychondritis with secondary aortitis with structural aortic dilatation was made. Figure 2. Left ear biopsy identified cartilage with perichondrial inflammatory granulation tissue. Figure 3. Coronal computed tomography of thorax with contrast demonstrating aortic root dilatation of 4.6 cm at the level of the sinuses with mural …

Enhanced White Adipose Tissue Metabolism in Iatrogenic Cushing's Syndrome With FDG PET/CT

A 35-year-old man commenced high-dose dexamethasone (16 mg/d) at diagnosis of cerebral metastases from non-small cell lung carcinoma. F-fluorodeoxyglucose (F-FDG) positron emission tomography (PET)/ computed tomography (CT) performed 9 days later (Figure 1) was nondiagnostic due to widespread abnormally increased FDG-uptake in sc and visceral white adipose tissue (WAT). Comparison with baseline CT demonstrated rapid interval growth of ectopic WAT in a Cushingoid distribution (Figure 2). Prominent sc and visceral WAT FDG uptake was also evident in a 14-year-old boy with Hodgkin lymphoma imaged 6 days after commencement of high-dose prednisolone (75 mg/d). Glucocorticoids induce “catabolic” lipolysis, “anabolic” lipogenesis (adipocyte hypertrophy), and adipogenesis (adipocyte hyperplasia) to remodel WAT into the characteristic Cushingoid distribution (1). Dexamethasone-induced adipocyte differentiation (2) required for ectopic WAT remodeling requires increased glycolytic mitochondrial metabolism (3), and thus ectopic WAT FDG uptake. Increased lipogenesis utilizing glucose as a nonlipid substrate could also explain the widespread WAT FDG uptake in these cases (4). Dexamethasone also induces a proinflammatory milieu within WAT (including raised serum amyloid A) (5), potentially increasing WAT FDG uptake associated with macrophage recruitment. The reduced fasting myocardial and skeletal muscle uptake presumably reflects utilization of high circulating levels of free fatty acids and reduced insulin sensitivity. This is the first description of widespread FDG uptake in WAT after commencement of high-dose glucocorticoids, and it provides unique in vivo insight into the rapid developmentof iatrogenicCushing’s syndrome.However, this uncommon finding is potentially influenced by other factors including age, sex, dosage, and duration of glucocorticoid exposure. The potential utility of FDG PET/CT for assessing WAT metabolism warrants prospective clinical evaluation.

Rheumatoid arthritis complicated with myeloperoxidase antineutrophil cytoplasmic antibody (MPO-ANCA)-associated vasculitis: a case report.

This article describes a patient with rheumatoid arthritis (RA) with crescentic glomerulonephritis (CrGN) associated with myeloperoxidase-antineutrophil cytoplasmic antibodies (MPO-ANCA), who responded well to methotrexate (MTX). A 48-year-old woman with a 4-year history of RA was admitted with fever and elevated C-reactive protein. On laboratory evaluation, her level of MPO-ANCA was 422 EU, and urinalysis revealed proteinuria and hematuria. Because she was also suffering from episcleritis, vasculitis was considered. A renal biopsy was performed, which revealed necrotizing CrGN. We diagnosed RA complicated with MPO-ANCA-associated vasculitis. We considered treatment with high-dose oral prednisolone for vasculitis, but the patient refused this treatment. We started MTX at a dose of 8 mg/week for RA from the time of admission, and the patient responded immediately. Biochemical parameters, including C-reactive protein, erythrocyte sedimentation rate, rheumatoid factor, and MPO-ANCA, improved. Seven months later, MPO-ANCA had decreased to 46 EU. In clinical studies, few patients have been reported with RA complicated with ANCA-associated CrGN. This case differs from previous cases in the treatment given. No high-dose steroid with intensive immunosuppression or plasma exchange was required.