Inhaled Steroids Research Articles

Sarcoidosis in a young adult: A rare sequelae of COVID‐19 infection

Key Clinical MessageThis case illustrates sarcoidosis as a potential complication of COVID‐19, highlighting the need for a comprehensive diagnostic approach, including histopathology and prolonged monitoring, to distinguish it from post‐COVID fibrosis. Further research is crucial to elucidate these associations and understand their underlying mechanisms.AbstractSevere Acute Respiratory Syndrome Coronavirus‐ 2 (SARS‐CoV‐2), a positive‐sense single‐stranded RNA virus, causes COVID‐19 and has been linked to autoimmune disorders. Sarcoidosis is a multi‐system disease that is frequently triggered by infections. It is characterized by non‐necrotizing granulomas in multiple organs. We present a case of sarcoidosis as rare sequelae of COVID‐19. A 26‐year‐old man presented with mild COVID‐19 symptoms, followed by prolonged fever and cough despite initial therapy, prompting a provisional diagnosis of post‐COVID fibrosis. A subsequent assessment at a tertiary hospital revealed dyspnea, weight loss, and abnormal chest imaging, all of which were consistent with pulmonary sarcoidosis with pulmonary tuberculosis as a differential diagnosis. A biopsy taken during bronchoscopy confirmed pulmonary sarcoidosis and treatment with inhalation steroids resulted in symptom relief, which was followed by remission with oral steroid therapy. Sarcoidosis is a systemic disease of unknown etiology, characterized by non‐necrotizing granulomas in multiple organs. It may be triggered by infections and involves an abnormal immune response. COVID‐19 can potentially initiate sarcoidosis, with both sharing common immune mechanisms. Diagnosis involves imaging and biopsy, and treatment typically includes glucocorticoids and regular monitoring. This case report emphasizes the potential link between COVID‐19 and autoimmune conditions like sarcoidosis, highlighting the need for a comprehensive diagnostic approach and long‐term observation to distinguish between sarcoidosis and post‐COVID fibrosis.

Local adjuncts to minimally invasive endoscopic interventions for benign laryngotracheal stenosis: a meta-analysis.

Benign laryngotracheal stenosis is widely managed with minimally invasive endoscopic interventions, such as laser incision or excision scar, and dilation. However, various endoscopic treatments are significantly associated with a high recurrence rate. Local auxiliary measures, including inhalation of steroids, injection of steroids, and local topical application of mitomycin C, have been studied in order to increase the success rate. To compare the efficacy of endoscopic treatments with and without local adjuncts in patients with benign laryngotracheal stenosis, and analyze their clinical outcomes, recurrence, and complications. In the meta-analysis, databases including PubMed, EMBASE, OVID, and Web of Science were searched for papers comparing the outcomes of adjunct therapy with non-adjunct therapy in patients with laryngotracheal stenosis. The duplicate publications, reviews, comments or letters, conference abstracts, and case reports were excluded. The random effect model was used for assessing the pooled risk estimates. Eight studies (1204 cases) referring to two prospective randomized controlled studies, two prospective cohort studies, and four retrospective cohort studies were ultimately included in the meta-analysis. Three delivery modes of adjuncts were identified, including intralesion steroid injection (n = 2), inhaled steroid (n = 2), and topical application of mitomycin C (n = 4). The decreased risk estimates of recurrence rate were detected in patients receiving endoscopic treatments with steroid injection or inhaled steroid, compared with endoscopic interventions alone (P < 0.05). Additionally, patients undergoing adjunct therapies had lower risk estimates of recurrence, compared to those receiving endoscopic procedures alone (P < 0.05), based on the subgroup of prospective cohort studies, subglottis, Mayer-Cotton scale of I-II degree, and stenosis length of < 3cm. The high heterogeneity of the pooling risk estimates perhaps was due to factors of auxiliary drug, clinical characteristics of patients, and methodology. No discernible difference in the incidence of complication was identified. Local application of steroids to minimally invasive interventions appear to reduce the recurrence rate of laryngotracheal stenosis. Various adjuncts available, including steroids and mitomycin C, appear to be safe and associated with a low risk estimate of adjuncts-specific complication rate. High quality multi-center randomized controlled studies are needed, with sufficient periods for follow-up and subjective and objective outcome indicators, to properly evaluate the efficacy, safety, and cost-effectiveness of adjuvant drugs.

A Study to Evaluate the Efficacy of Preoperative Low-dose Nebulised Dexamethasone in Decreasing the Incidence of Postoperative Sore Throat in Patients Undergoing Surgery Under General Anaesthesia

Background and Aims: Postoperative sore throat (POST) is a stereotypical postoperative complication that usually occurs in approximately 21%–65% of patients who are under general anaesthesia and is ranked around eighth among the most undesirable subjective and unpleasant complaints by the society of American anaesthesiologist after general anaesthesia. As airway management is a crucial factor in the causation of POST, various methods, especially non-pharmacological, are used to reduce the incidence of postoperative sore throat with the use of a small-sized endotracheal tube with low intracuff pressures. The tracheal tube is applied with other agents that may help in reducing the symptoms such as steroids, lozenges, lignocaine, ketamine gargles, inhalation of steroids (also included in pharmacological methods used for reducing the incidence of postoperative sore throat). Aim and Objective: The aim of this study was to evaluate the efficacy of prophylactic low-dose nebulised dexamethasone for decreasing the incidence of post-extubation sore throat and to evaluate the complications of low-dose dexamethasone nebulisation in patients undergoing surgery under general anaesthesia. Patients and Methods: The study was done in the Anaesthesiology Department of Maharishi Markandeshwar Institute of Medical Sciences and Research (MMIMSR) Mullana, Ambala, after institutional ethical committee approval and written, informed consent was obtained from the patients from March 2021 to March 2022 with a group size of Group S – 25 patients and Group D – 25 patients. Observation and Results: The results showed that patients in the dexamethasone group had a lower POST rate compared to the control group. Conclusion: We concluded that a low dose of 4 mg dexamethasone was effective in reducing the incidence and severity of POST in patients after anaesthesia, and no side effects compared to 4 mg normal saline.

Central Serous Chorioretinopathy Following Symbicort Usage in a 69-year-old Female Patient

Abstract Steroid inhaler usage is the cornerstone of asthma management. This case report describes the development of central serous chorioretinopathy (CSCR) in a 69-year-old female following the use of Symbicort for the management of asthma. The association between inhaled corticosteroids and CSCR is discussed, highlighting the need for awareness among health-care providers. Further research is necessary to establish the pathogenicity of this rare condition and alternatives for patients in whom inhaled corticosteroids are essential to the control of their long-term condition.

Impact of Procedural Variation in Endoscopic Dilation for Idiopathic Subglottic Stenosis.

A small number of Idiopathic subglottic stenosis (iSGS) patients are treated at institutions across the country. Divergence in operative techniques for endoscopic dilation (ED) of iSGS has been anecdotally recognized but not formally characterized. Additionally, the relationship between procedural variation and clinical outcome has not been studied. Secondary analysis of the NoAAC iSGS1000 cohort investigated variation in procedural techniques and treatment outcomes in patients treated with ED across high-enrolling treatment centers (enrolled >10 patients in PR-02 trial). Thirteen NoAAC centers each enrolled >10 patients treated with ED for a total of 281 subjects. There was significant variation in procedural details and rate of recurrence among institutions. Hierarchal cluster analysis revealed significant heterogeneity among institutions and clusters in all procedural variables. However, analysis demonstrated a transient delay in disease recurrence in cluster 2 which disappeared with longer longitudinal follow-up. Patient-reported outcome and peak expiratory flow data supported the potential benefit of the technical variation in Cluster 2. Distinct to cluster 2, however, was routine use of adjuvant triple medical therapy (proton pump inhibitor (PPI), antibacterial agent, and steroid inhaler). Both outcome and procedural technique vary among centers employing ED to treat iSGS. A transient delay in recurrence was observed among centers that routinely prescribed adjuvant medical therapy (antibiotic, inhaled corticosteroid, and PPI) to iSGS patients after endoscopic dilation, which was further supported by patient-reported data and peak expiratory flow data. Prospective studies are needed to understand the effects of adjuvant medical therapy on recurrence after endoscopic dilation. 4 Laryngoscope, 134:3260-3266, 2024.

Protocol for the air purification for eosinophilic COPD study (APECS): a randomised controlled trial of home air filtration by HEPA

IntroductionExposure to particulate matter (PM) pollution has been associated with lower lung function in adults with chronic obstructive pulmonary disease (COPD). Patients with eosinophilic COPD have been found to have...

Asthma and the Effects of Steroid Inhalers on the Voice

Inhaled corticosteroids are used commonly to treat asthma, and occasionally to treat other conditions. Inhaled steroids can have adverse effects on the vocal folds and voice. Some formulations are less problematic than others. Singers and singing teachers should be familiar with inhaled steroid medications, their potential adverse effects, and with treatment options.

Inhaler Steroid Use Changes Oral and Airway Bacterial and Fungal Microbiome Profile in Asthma Patients

Introduction: The full spectrum of bacterial and fungal species in adult asthma and the effect of inhaled corticosteroid use is not well described. The aim was to collect mouthwash and induced sputum samples from newly diagnosed asthma patients in the pretreatment period and in chronic asthma patients while undergoing regular maintenance inhaled corticosteroid therapy, in order to demonstrate the bacterial and fungal microbiome profile. Methods: The study included 28 asthmatic patients on inhaler steroid therapy, 25 steroid-naive asthmatics, and 24 healthy controls. Genomic DNA was isolated from induced sputum and mouthwash samples. Analyses were performed using bacterial primers selected from the 16S rRNA region for the bacterial genome and “panfungal” primers selected from the 5.8S rRNA region for the fungal genome. Results: Dominant genera in mouthwash samples of steroid-naive asthmatics were Neisseria, Haemophilus, and Rothia. The oral microbiota of asthmatic patients on inhaler steroid treatment included Neisseria, Rothia, and Veillonella species. Abundant genera in induced sputum samples of steroid-naive asthma patients were Actinomyces, Granulicatella, Fusobacterium, Peptostreptococcus, and Atopobium. Sputum microbiota of asthma patients taking inhaler steroids were dominated by Prevotella and Porphyromonas. Mucor plumbeus and Malassezia restricta species were abundant in the airways of steroid-naive asthma patients. Choanephora infundibulifera and Malassezia restricta became dominant in asthma patients taking inhaled steroids. Conclusion: The oral and airway microbiota consist of different bacterial and fungal communities in healthy and asthmatic patients. Inhaler steroid use may influence the composition of the oral and airway microbiota.

SAT340 Matters Of The HAART - Ritonavir Induced CYP3A4 Inhibition of Intranasal Fluticasone Leading To Cushing’s Syndrome

Abstract Disclosure: A. Ramachandran: None. S. Ghaith: None. A. Ramachandran: None. Background: Ritonavir, a potent inhibitor of the CYP3A4 enzyme, can lead to high systemic concentrations of even intranasal steroids causing Cushing’s syndrome. Case: A fifty-seven-year-old man with history of HIV on HAART presented with a 3-month history of fatigue, weight gain and easy bruising. History was negative for heat/cold intolerance, hair loss, constipation, erectile dysfunction. Medications included emtricitabine-tenofovir-alafenamide and ritonavir at stable doses for several years. He denied taking any oral or topical steroids, but reported using over the counter (OTC) fluticasone propionate (FP) for the past 6 months for seasonal allergies. Physical examination was significant for moon facies and abdominal striae. Labs were remarkable for low serum morning cortisol of 0.6 µg/dl (0.4-22.6 µg/dl), and low serum ACTH of &amp;lt;5 pg/ml (7-69 pg/ml). A diagnosis of exogenous steroid induced Cushing’s syndrome, as a result of ritonavir induced increase in FP levels was made. FP was gradually tapered and stopped. Serum cortisol and ACTH levels normalized at 15 µg/dl and 13 pg/ml respectively and his symptoms resolved completely after three months. Discussion: Ritonavir, a protease inhibitor (PI), is one of the strongest known inhibitors of CYP3A4 and is generally used to boost the plasma levels of other PIs. FP, a potent glucocorticoid, is generally used as monotherapy or as a combination inhaler in the treatment of asthma. It is rapidly metabolized by CYP3A4 and hence produces minimal side effects. However, its concurrent use with ritonavir results in increased serum concentration of FP leading to systemic adverse effects of glucocorticoids. Due to emerging awareness about this drug-drug interaction among physicians, prescription of inhalational steroids in patients on ritonavir is avoided. However, FP is an OTC intranasal glucocorticoid that is easily accessible, and its self-use is often times not reported by patients which makes it difficult for physicians to track on their patient’s medication list. A thorough review of OTC medications/supplements needs to be done when Cushing’s syndrome from exogenous steroids is suspected. It is also imperative that patients on ritonavir be counseled about the risks of taking any form of steroid formulations by any route. Conclusion: Educating patients on ritonavir about steroids being a component of many OTC medications/supplements, and a careful medication history and drug-drug interaction assessment is important in preventing steroid related adverse effects. Presentation: Saturday, June 17, 2023

Effect of inhaled budesonide therapy in term newborns with meconium aspiration syndrome

Background: Meconium aspiration syndrome is a common cause of respiratory distress in neonates. This study explores the possibility of altering the course of the disease by using anti-inflammatory agents to counter the chemical and inflammatory pneumonitis caused by meconium. The objective is to determine if inhaled budesonide therapy can alter the clinical course of the disease and improve outcome without causing any serious adverse effects. Methods: A comparative study was conducted in NICU of Cheluvamba hospital, Mysore over 12 months. Neonates with MAS were divided into interventional and control groups. Interventional group received budesonide nebulization 12th hourly starting after 6 hours of life, while control group received saline nebulization 12 hourly. Data was analysed by SPSS 20 software and student t test and chi square test were used to assess statistical significance. Results: The patient profile of the two groups was similar, with the interventional group showing early normalization of Downes score compared to controls. The duration of respiratory distress, oxygen dependency, and duration of hospital stay was significantly less in the steroid treated group compared to controls. There was no significant difference in the incidence of sepsis between the two groups, and three patients died during hospital stay due to pneumothorax with overwhelming sepsis with DIC. Conclusions: Nebulized budesonide improves clinical outcome in terms of morbidity and is relatively safe, however long term follow up required to recommend inhalational steroids as safe and effective.

Residual Cough and Asthma-like Symptoms Post-COVID-19 in Children.

Coronavirus disease 2019 (COVID-19) has rapidly spread worldwide and is characterized by different presentations ranging from asymptomatic to severe pneumonia. COVID-19 affects all age groups, including pediatric patients. We observed numerous children complaining of a cough post-COVID-19, even if it was trivial. The most reported persistent symptoms after recovery from COVID-19 were insomnia, coughing, fatigue, dyspnea, loss of taste and/or smell, and headache. To date, residual cough post-COVID-19 has been reported in pediatrics and adolescents. we conducted a retrospective study, with a self-administered questionnaire by the patient or caregiver, 12 months post-COVID-19-infection. A total of 94.8% of patients were Saudi citizens and were mainly from the southern region of Saudi Arabia (50.0%). Mothers (64.4%) submitted most of the results. The ages were as follows: 6-14 years (51.0%), 3-5 years (32.3%), and younger than 2 years of age (only 16.7%). Females accounted for 41.7% of those studied. Nearly half of the patients (48.5%) had had a previous COVID-19 infection in 2022, with only 2.1% infected in 2019. Only 27/194 (13.9%) patients required hospital admission, and 7 of them (4.2%) required intensive care treatment. A total of 179 (92.2%) patients still reported persistent symptoms 4 weeks post-COVID-19-infection. A cough was reported in 69.8% of patients, followed by cough and wheezing in 12.3%. The cough was described as dry in 78.0% and nocturnal in 54.1%, while 42.5% did not notice any diurnal variation. For those reporting residual cough, 39.3% found that it affected school attendance and daily activities, 31.1% reported associated chest pain, 51.9% associated it with wheezing, and 27.1% associated it with shortness of breath. For 54.4%, the residual cough lasted less than one month, while 31.4% reported a 1-2 month duration. Only 1.0% had a duration of cough of more than 3 months. For cough relief, 28.2% used bronchodilators, 19.9% used cough syrup, 16.6% used a combination of bronchodilators and steroid inhalers, and 1.7% used antibiotics. Surprisingly, 33% attempted herbal remedies for cough relief. Sesame oil was used the most (40.0%), followed by a mixture of olive oil and sesame oil (25.0%), and 21.7% used male frankincense. The majority (78.4%) sought medical advice for their post-infection cough, either from general pediatricians (39.5%) or via specialist pediatric pulmonology consultations (30.9%). A total of 11.0% with a residual cough reported having pets at home, while 27.2% reported secondhand smoke exposure in the household. Before infection with COVID-19, only 32.6% were diagnosed with asthma, while 68.2% reported a diagnosis of atopic skin. There was a high prevalence of residual cough post-COVID-19, extended for a minimum of two months, and the characteristics of the cough were very similar to those of asthmatic patients. There was still a high prevalence of using cough syrup and herbal remedies, especially olive oil, sesame oil, and male frankincense. A residual cough adversely affected school attendance in daily activities, and there was a high prevalence of other siblings in the family being affected. The study showed that a minority of patients were seen by the pulmonologist; luckily, long COVID was rare in our study, and so further studies are highly needed to confirm the association with asthma. More educational programs are highly needed regarding herbal remedies and cough syrup.

Treatment Results of Vocal Process Granuloma: Intubation versus Contact Granuloma

Introduction Contact granulomas (CGs) and intubation granulomas (IGs) are known to have different clinical manifestations despite having the same pathological features. Objective The purpose of the present study was to analyze the treatment results for CG and IG and to obtain clinical information. Methods We retrospectively reviewed the medical records of patients diagnosed with vocal process granuloma (VPG) between January 2015 and December 2018. The patient's age, sex, medical history, lesion size, lesion type, reflux finding score (RFS), response to treatment, duration of treatment, and follow-up period were compared. Results Eighteen patients with CG and 14 patients with IG were included in the study. The IG group had more female patients ( p = 0.0009), showed better response to proton pump inhibitor (PPI) and steroid inhalation (SI) ( p = 0.036), and had a shorter treatment period ( p = 0.0029) than the CG group. Five patients who received botulinum toxin injections in their vocal cords had complete remission. Conclusion Compared with CG, IG was more responsive to treatment with PPI and SI and required a shorter duration of treatment.

A Novel Trans-Tracheostomal Retrograde Inhalation Technique Increases Subglottic Drug Deposition Compared to Traditional Trans-Oral Inhalation.

Subglottic stenosis represents a challenging clinical condition in otolaryngology. Although patients often experience improvement following endoscopic surgery, recurrence rates remain high. Pursuing measures to maintain surgical results and prevent recurrence is thus necessary. Steroids therapy is considered effective in preventing restenosis. Currently, however, the ability of trans-oral steroid inhalation to reach and affect the stenotic subglottic area in a tracheotomized patient is largely negligible. In the present study, we describe a novel trans-tracheostomal retrograde inhalation technique to increase corticosteroid deposition in the subglottic area. We detail our preliminary clinical outcomes in four patients treated with trans-tracheostomal corticosteroid inhalation via a metered dose inhaler (MDI) following surgery. Concurrently, we leverage computational fluid-particle dynamics (CFPD) simulations in an extra-thoracic 3D airway model to gain insight on possible advantages of such a technique over traditional trans-oral inhalation in augmenting aerosol deposition in the stenotic subglottic region. Our numerical simulations show that for an arbitrary inhaled dose (aerosols spanning 1-12 µm), the deposition (mass) fraction in the subglottis is over 30 times higher in the retrograde trans-tracheostomal technique compared to the trans-oral inhalation technique (3.63% vs. 0.11%). Importantly, while a major portion of inhaled aerosols (66.43%) in the trans-oral inhalation maneuver are transported distally past the trachea, the vast majority of aerosols (85.10%) exit through the mouth during trans-tracheostomal inhalation, thereby avoiding undesired deposition in the broader lungs. Overall, the proposed trans-tracheostomal retrograde inhalation technique increases aerosol deposition rates in the subglottis with minor lower-airway deposition compared to the trans-oral inhalation technique. This novel technique could play an important role in preventing restenosis of the subglottis.

Associations of age, BMI, and renal function to cortisol after dexamethasone suppression in patients with adrenal incidentalomas.

The specificity of cortisol after 1 mg dexamethasone (cortisolDST) ≥50 nmol/L as a criterion for mild autonomous cortisol secretion (MACS) is approximately 85% in patients with adrenal incidentalomas (AI). The aim was to study the associations of cortisolDST to age, BMI, and renal function. We studied 1,129 patients with AI examined from 2005 to 2015 at Skåne University Hospital and Helsingborg Hospital. The covariates studied were gender, age, BMI, estimated glomerular filtration rate (eGFR), treatment with inhalation steroids, size of the AI, and size of the smallest AI in patients with bilateral AI (set to 0 in unilateral AI). We used machine learning models to uncover potential nonlinear associations. They were trained to fit the data and examined using feature importance analysis and partial dependence plots. Partial dependence plots show the marginal effect on cortisolDST of a covariate averaging over other covariates. CortisolDST was strongly associated with the size of the AI and weakly associated with age, BMI, and eGFR according to the feature importance analysis. The partial dependence plots indicated relatively linear relationships for cortisolDST to age (positively) and eGFR (negatively). The association between cortisolDST and BMI was nonlinear. At BMI below 30 kg/m2, cortisolDST was negatively associated with BMI, but it was unchanged at higher BMI levels. Using linear regression, we found that cortisolDST increased by 11% (95% CI, 7%-14%) for each 10-year increase in age. In patients with a BMI below 30 kg/m2, cortisolDST increased by 23% (95% CI, 16%-31%) for each 5 kg/m2 decrease in BMI. We found no association at BMI levels above 30 kg/m2. CortisolDST increased by 9% (95% CI, 6%-11%) for each 10 ml/min/1.73m2 decrease in eGFR. CortisolDST is positively associated with age, negatively with BMI if below 30 kg/m2, and negatively with eGFR. These associations should be considered before diagnosing MACS.

Benign Intracranial Hypertension Secondary to Intranasal Corticosteroid Administration

Steroids have been used for a wide spectrum of indications in clinical practice. The potential benefits of steroids outweigh the complications in most settings. Steroids have been used over the counter in our country for allergy and arthritis. Here we present a case of a young girl who presented with headache, tinnitus, vomiting, and papilledema, visual field defect in perimetry with elevated IOP, presumed secondary to intranasal steroid use for allergic rhinitis. There are case reports suggesting a causal relationship between steroids and benign intracranial hypertension. Here patient on follow-up had significant improvement on stopping steroid spray. This case report is to highlight the need for awareness of the possibility of benign intracranial hypertension in patients who are on inhalational steroids.

Pseudoprogression and Sarcoidosis-like Phenomena after CART-Cells and Bispecific Antibodies in Multiple Myeloma

Introduction: CAR T-cell therapy is establishing itself as a new standard of care in relapsed and refractory multiple myeloma (RRMM). Yet, there are a number of open issues including the lack of data on optimal follow-up assessments post CAR T therapy. Appreciating the high incidence of extramedullary lesions and patchy disease patterns seen in the RRMM setting, whole body 18F-Fluorodeoxyglucose (FDG) PET/CT imaging is increasingly used. Whether FDG is the best tracer in this setting has yet to be determined, as the technique is being based not only on the quantification of increased glucose uptake by tumor cells but also by others such as inflammatory cells. A phenomenon linked to this issue is pseudoprogression, which refers to an increase in the target lesion size due to influx of immune cells that may be misinterpreted as disease relapse. Pseudoprogression is a well-known event after checkpoint blockade therapy, seen in up to 10% of patients with solid cancers. Whether myeloma patients treated with CAR T or bispecific antibodies are at risk for pseudoprogression is, to the best of our knowledge, unknown. Methods: We present a case study of a RRMM patient who experienced pseudoprogression twice during his course of disease treatment that included BCMA CAR T cells Idecabtagene vicleucel and GPRC5DxCD3 bispecific antibody talquetamab. We performed a comprehensive molecular analysis including single cell RNAseq from bronchoalveolar lavage as well as PET imaging using the three PET tracers 18F-FDG, 68Ga-DOTATOC, and 68Ga-Pentixafor (binds to CXCR4) to unravel the biology underlying pseudoprogression in this case. Results: A 61-year-old Caucasian male was diagnosed with biopsy-proven pulmonary MM and treated with BCMA targeting CAR T cells in his 4th line of therapy. Ten days after CAR T infusion, the patient started violent coughing and a FDG-PET revealed full resolution of focal bone lesions but disseminated FDG uptake at the lung and mediastinal lymph nodes reminiscent to sarcoidosis. We performed a PET using 68Ga-DOTATOC that usually detects sarcoidosis with high sensitivity and specificity, which was negative. Negative results were also seen for 68Ga-Pentixafor, which is an alternative tracer to FDG in the detection of MM. Bronchoalveolar lavage (BAL) along with endobronchial ultrasound guided biopsy was done, showing noncaseating granuloma formation in the biopsy without evidence of residual MM cells. Single cell RNA-seq on the BAL sample revealed CD4-positive T cells exhibiting simultaneous expression of genes associated with Th1 T-cells (TBX21, CXCR3, IFNG, TNF) and genes associated with Th17 T-cells (RORC, IL23R, CCR6, CCL20, KLRB1), indicative for a Th1-polarized Th17 phenotype. Furthermore, these cells expressed IL4I1, ABCB1, and CSF210-12 , while IL17A, IL17B, IL17E (IL25), and or IL17F was not expressed, highlighting presence of Th17.1 cells. This cell type has been described to be pro-inflammatory and pathogenic and implicated in several auto-immune diseases, including sarcoidosis. Together, our data suggest a non-infectious, Th17.1 T-cell driven sarcoidosis-like auto-immune phenomenon located in the lungs following anti-BCMA CAR T-cell therapy. Respiratory symptoms completely resolved following high-dose inhalative steroids. The patient relapsed from complete remission (CR), and FDG PET showed the known sarcoidosis-like pulmonary changes, but also revealed a number of new soft-tissue lesions, suspicious for extramedullary relapse. In contrast to the previous scans, these lesions were CXCR4 positive, suggesting a role of using multiple PET tracers in this setting. Later, the patient was enrolled on a trial investigating talquetamab. One week after dosing, the patient experienced severe pain crisis and a diffusion-weighted MRI revealed increase in size of multiple extramedullary lesions, but no new lesions. M- protein levels were decreasing at that time suggesting either mixed response or pseudoprogression. The patient was treated with painkillers and all lesions disappeared on a follow-up scan 6 weeks later, confirming pseudoprogression, and he is in an ongoing CR for 6 months at the time of writing. Conclusion: We present two educating episodes of pseudoprogression in one patient following immune oncology drugs in MM. While one event was transient and self-limiting, the pulmonary manifestations were similar to sarcoidosis and required treatment with steroids.

Activities of Periostin and Inteleukin-13 among Asthma Patients in Comparison with Healthy people in Southern India

Background and objectives: Asthma is a chronic inflammatory airway disease which requires biomarkers that reflect refractoriness to conventional therapy with inhalational steroids. Periostin is an extracellular matrix protein that is secreted in the airway epithelium, in response to stimulation by Interleukin -13 (IL-13). IL-13 is a cytokine that mediates airway inflammation following the Type 2 immune response. Both these biomarkers can be used to signify type 2 inflammatory response, which reflects steroid hypo-responsiveness in asthmatics. The objectives of the study were to: 1. Obtain the reference value of serum Periostin and IL-13 levels in healthy south Indian adult population 2. To compare the reference range of Periostin and IL-13 with that of the asthmatics on inhalational corticosteroids. Methodology: The study was carried out among 50 asthmatics and 50 healthy volunteers aged between 25 to 65 years. After procuring the informed consent, the Pulmonary Function test assessment was done to recruit the study subjects. The blood sample was collected for assessment of Serum Periostin and IL-13. Results: The median (IQR) baseline level of Serum Periostin among control group and in asthmatics was 13.2 (8.8-28.1) ng/ml and 16.7 (10.9-20.7) respectively. Also, the median (IQR) baseline level of Serum IL-13 among healthy individuals and among asthmatics was 42.9 (37.8-52.4) pg/ml and 73.5 (60.0-91.1) pg/ml respectively, which was statistically significant. Conclusion: The obtained baseline values of Serum IL-13 and Periostin could be of clinical utility in asthmatics. The validity of the data obtained from this study can be tested out on larger study populations.

250 Tracking Asthma Medication Use in Children After an Emergency Department Visit With a Smart Inhaler and Connected Mobile Application

Asthma is the most common chronic childhood illness and the third leading cause of hospitalization among pediatric patients in the US. It is responsible for more than 1.8 million emergency department (ED) visits per year and represents significant health care burden and costs. The primary objective of this study is to determine the feasibility of employing a “smart” inhaler connected to a mobile application to track asthma inhaler use after an ED visit. Future goals are to determine if regular daily use of a steroid inhaler results in less rescue medication use, and to connect this usage with real time environmental data to build a risk profile to alert patients of conditions that increase risk of asthma exacerbation.

Adverse drug reactions, multimorbidity and polypharmacy: a prospective analysis of 1 month of medical admissions

ObjectiveTo ascertain the burden and associated cost of adverse drug reactions (ADRs), polypharmacy and multimorbidity through a prospective analysis of all medical admissions to a large university teaching hospital over...

Combination fixed-dose β agonist and steroid inhaler as required for adults or children with mild asthma: a Cochrane systematic review

BackgroundIn people with mild asthma poor adherence to regular therapy is common and increases the risk of exacerbations, morbidity and mortality. The use of fixed-dose combination inhalers containing an inhaled...