Intravenous Administration Of Methylprednisolone Research Articles

Cauda equina syndrome successfully treated with microdiscectomy and methylprednisolone therapy: A case report

Cauda equina syndrome (CES) caused by lumbar disc herniation is a rare neurosurgical emergency in young adults that requires immediate decompression. A surgical delay over 48 hours may result in irreversible ramifications, underscoring a crucial timeframe for managing this condition. We presented a 26-year-old man with lower limb weakness persisting for one week, accompanied with exacerbating bowel and bladder issues after massage. The patient had a history of low back pain and tingling sensations radiating to the left leg over the past year. His physical examination showed right motor strength of 5/4 and left motor strength of 5/3, with weakened bowel peristalsis, loose anal sphincter and saddle anaesthesia. A spinal MRI revealed protruded discs extending to the intervertebral levels of L4-L5 and L5-S1, implicating herniated discs as the likely cause of CES. He underwent a microdiscectomy with a posterior approach, and intravenous methylprednisolone was administered before the procedure. The next surgery demonstrated enhancements in motor strength, bowel and bladder function, and it also reduced pain. He was discharged with persistent tingling sensations in his both legs. We concluded that CES represents a critical neurosurgical emergency, which is diagnosed through clinical symptoms and neuroimaging. Rapid decompression and intravenous administration of methylprednisolone are associated with better prognosis.

Acute Cerebellar Manifestations without Limbic Involvement in GABAB Receptor Autoimmune Encephalitis: Case Report and Literature Review.

Autoimmune encephalitis is a rapidly progressive inflammatory brain disease. Gamma-aminobutyric acid type B (GABAB) receptor autoimmune encephalitis is a rare subtype characterized by distinct clinical features. Diagnosis can be especially challenging when typical limbic symptoms and neuroimaging findings are absent. This case report underscores the importance of identifying this condition and starting immunosuppressive treatment promptly. A 59-year-old man presented with gait disturbances, dysarthria, and severe ataxia without cognitive impairment. Initial examinations, including a brain MRI, were unremarkable, except for an elevated cell count and protein in the cerebrospinal fluid. Despite receiving initial empirical antiviral treatment, his symptoms worsened, prompting the administration of intravenous methylprednisolone and immunoglobulin. After these immunosuppressive therapies, the cerebellar symptoms showed gradual improvement. Subsequent testing for antibodies to the GABAB receptor was positive in both the serum and cerebrospinal fluid. Follow-up MRI revealed cerebellar atrophy, consistent with a diagnosis of GABAB receptor-associated acute cerebellitis. This case illustrates that cerebellar symptoms can occur in the absence of more common limbic manifestations in GABAB receptor autoimmune encephalitis. The progression of cerebellar atrophy following an initially normal MRI is a significant finding that offers supporting evidence for the diagnosis of cerebellitis. A review of the literature identified similar cases of acute cerebellitis without limbic symptoms, although neuroimaging abnormalities in the cerebellum were not reported. Our case underscores the importance of increased clinical awareness and consideration of autoimmune causes, even when neuroimaging appears normal. Early and appropriate immunosuppressive therapy may help change the course of the disease and enhance patient outcomes.

Features of the clinical course of Autoimmune Encephalitis Associated with various antibodies.

Despite the increasing incidence of autoimmune encephalitis and the incomplete recovery observed in patients post-affliction, the issue of timely diagnosis remains unresolved. The primary objective of this study is identification the distinctive clinical presentation features evaluation the management strategies, and assess the outcomes of the disease in patients with various forms of autoimmune encephalitis. The research aims to contribute in a better understanding of the disease progression and facilitate the selection of optimal therapeutic interventions. A retrospective observational study enrolled 68 patients aged 18 years and older with verified autoimmune encephalitis who underwent treatment in state hospitals in Sofia, Bulgaria, from the beginning of 2014 to the end of 2022. The number of patients with pathology linked to antibodies against glycine receptors (Gly-R) was half as much, with 32 and 17 patients, respectively. The primary manifestations of autoimmune encephalitis included cognitive impairments observed in 51 patients, seizures occurring in 44 patients, and mood disorders observed in 22 patients. While the findings of imaging studies were nonspecific, hospitalizations for patients with this pathology, especially those with antibodies to CASPR2 and DPPX, were prolonged (114 and 232 days, respectively). In the vast majority of cases, incomplete recovery with residual symptoms was noted. Among the diverse forms of autoimmune encephalitis, the most prevalent is NMDA-R. Cognitive impairments predominate in the autoimmune encephalitis clinical presentation. Prolonged hospitalization periods and incomplete recovery of patients are characteristic features of autoimmune encephalitis, despite combined therapy involving intravenous administration of methylprednisolone and immunoglobulins.

Isolated myelin oligodendrocyte glycoprotein antibody-associated optic neuritis in adults: The importance of age of onset and prognosis-related radiological features

BackgroundMyelin oligodendrocyte glycoprotein (MOG) antibody-associated disease (MOGAD) exhibits phenotypic diversity and it varies by age. However, less is known about whether the manifestations of isolated MOG antibody-associated optic neuritis (iMOG-ON) vary across different age groups. We aimed to investigate the clinical and prognostic features of iMOG-ON in young and middle-aged adult patients. MethodsPatients with iMOG-ON were enrolled in the Department of Neurology, Beijing Tongren Hospital, Capital Medical University between January 2018 and October 2021. Medical records were reviewed to obtain clinical data and orbital MRI images of adult patients with iMOG-ON. Multivariate linear regression analysis was performed to investigate the associations between final best-corrected visual acuity (BCVA) in logMAR and clinical characteristics. ResultsBased on the age of onset, 70 patients were divided into 2 groups: 38 young (< 46 years; female/male = 0.76:1) and 32 middle-aged (≥ 46 years; female/male = 5.56:1) adults. There were statistical differences in both the female-to-male ratio and frequencies of contrast enhancement of the optic nerve sheaths and surrounding orbital tissues between both groups (p = 0.001, p = 0.004, respectively). The average follow-up periods were 28.04 ± 11.22 months. The median final BCVA was 0 (0 - 0.50) logMAR and 0.5 (0.3 - 1.0) logMAR in the young and middle-aged patients, respectively (p = 0.000). The multivariate linear regression analysis indicated significant positive relationships between final BCVA and age of onset (p = 0.038, 95 % CI: 0.020 - 0.728), sex (p = 0.030, 95 % CI: -0.793 - -0.042), BCVA at nadir (p = 0.000, 95 % CI: 0.164 - 0.386), and numbers of segments of optic nerve lesions (p = 0.009, 95 % CI: 0.068 - 0.450) with a coefficient of determination (R2) of 0.359 after adjusting for prior attacks of ON, time intervals between sudden-onset vision loss and administration of intravenous methylprednisolone, and corticosteroid dosages. The worst final BCVA was observed in afflicted eyes with lesions extending across three segments of the optic nerve. ConclusionCompared to young adults with iMOG-ON, the middle-aged patients tended to have a female predominance, higher frequencies of perineural enhancement, and worse visual outcomes. In addition to age of onset, visual recovery may also be influenced by patient's sex, BCVA at nadir, and lengths of longitudinally expansive lesions of the optic nerve to a certain extent.

Subacute cutaneous lupus erythematosus as a rare complication of disease-modifying therapy administration in multiple sclerosis: case report

BackgroundTeriflunomide, the active metabolite of leflunomide, is a disease-modifying therapy drug used for the treatment of multiple sclerosis (MS), yet the complications associated with this drug remain not fully understood. Here we present the rare case of a 28-year-old female MS patient who developed subacute cutaneous lupus erythematosus (SCLE) following teriflunomide treatment. Though SCLE has been reported to be associated with leflunomide, the current report represents the first documented evidence demonstrating SCLE as a potential teriflunomide treatment-related complication. Additionally, a literature review on the leflunomide-induced SCLE was conducted to emphasize the association of SCLE with teriflunomide, specifically amongst the female demographic with a preexisting autoimmune diathesis.Case presentationA 28-year-old female first presented with MS symptoms in the left upper limb along with blurred vision in the left eye. Medical and family histories were unremarkable. The patient exhibited positive serum biomarkers including ANA, Ro/SSA, La/SSB, and Ro-52 antibodies. Relapsing–remitting MS was diagnosed according to the 2017 McDonald’s diagnostic criteria, and remission was achieved upon intravenous administration of methylprednisolone followed by teriflunomide sequential therapy. Three months post-teriflunomide treatment, the patient developed multiple facial cutaneous lesions. SCLE was subsequently diagnosed and was attributed to treatment-related complication. Interventions include oral administration of hydroxychloroquine and tofacitinib citrate effectively resolved cutaneous lesions. Discontinuation of hydroxychloroquine and tofacitinib citrate treatment led to recurring SCLE symptoms under continuous teriflunomide treatment. Full remission of facial annular plaques was achieved after re-treatment with hydroxychloroquine and tofacitinib citrate. The patient’s clinical condition remained stable in long-term outpatient follow-ups.ConclusionsAs teriflunomide has become a standard disease-modifying therapy for MS, the current case report highlights the importance of monitoring treatment-related complications, specifically in relation to SCLE symptoms.

Persistent meningitis followed by anti-NMDAR encephalitis: case series and literature review (P5-5.002)

<h3>Objective:</h3> To report the cases of two patients with persistent meningitis followed by anti-N-methyl-d-aspartate receptor (NMDAR) encephalitis and discuss the pathogenesis of the disease in conjunction with previous reports. <h3>Background:</h3> Although meningeal involvement has been reported in anti-NMDAR encephalitis, reports of persistent meningitis prior to the onset of encephalitis are rare. <h3>Design/Methods:</h3> Case series and literature review. <h3>Results:</h3> We experienced two patients with anti-NMDAR encephalitis preceded by persistent meningitis. Patient 1 presented with protracted fever, and a brain MRI revealed leptomeningitis. Although cerebrospinal fluid (CSF) cell counts spontaneously decreased from 87 to 16 cells/mm³ over 2 weeks without treatment, the symptoms and signs associated with meningitis lasted 60 days. Despite the administration of oral prednisolone, abnormal behavior and speech dysfunction occurred, leading to the diagnosis of encephalitis. After the detection of anti-NMDAR antibodies in CSF, the diagnosis of anti-NMDAR encephalitis was made, which improved after administration of intravenous methylprednisolone and plasmapheresis. Patient 2 had headache and fever for 22 days, and the CSF cell counts declined from 112 to 14 cells/mm³ over 2 weeks without treatment. The emergence of delusion, involuntary movement (tongue protrusion), and decreased level of consciousness prompted the diagnosis of encephalitis. Anti-NMDAR encephalitis was identified after the positive result of anti-NMDAR antibodies in CSF; it was successfully treated with intravenous methylprednisolone and plasmapheresis. In both cases, infectious meningitis was ruled out, suggesting a possible autoimmune mechanism. No tumors, including ovarian teratoma, were found during systemic evaluation. In previous cases, we found two patients with persistent meningitis followed by anti-NMDAR encephalitis. The findings in the four meningitis patients showed prolonged meningitis lasting from 5 to 60 days, and infectious or paraneoplastic meningitis was ruled out. <h3>Conclusions:</h3> Anti-NMDAR encephalitis should be considered a differential diagnosis of long-term persistent nonviral meningitis. <b>Disclosure:</b> Dr. Yamahara has nothing to disclose. Dr. Yoshikura has nothing to disclose. Dr. Kimura has nothing to disclose. Dr. Shimohata has nothing to disclose.

Acute psychosis following corticosteroid administration for COVID-19 and Respiratory Syncytial Virus infection: A case study

IntroductionSteroids are a necessary treatment for hypoxic respiratory failure; however there are many side effects that should be taken into account. A 44- year-old-woman with asthma and no past psychiatric history was admitted due to COVID-19 pneumonia and Respiratory syncytial virus (RSV) infection, presenting hypoxic respiratory failure. After two days of intravenous methylprednisolone administration, the patient presented acute psychosis and agitation.It has been previously described that steroid use can cause effects such as mania, anxiety, agitation, delirium and psychosis amongst other. However they are a necessary treatment in respiratory illnesses and are sometimes unavoidable.Objectives The aim was to examine the appropriate medical response to steroid induced psychosis in patients with acute hypoxic failure.MethodsA bibliographical review was done in PubMed database searching recent cases of steroid induced psychosis using the words (“Steroid”, “Psychosis” and “COVID-19”).Results According to literature, it has been shown that partial or complete reduction of steroid use and/or use of psychotropic has been successfully used to treat steroid induced psychosis. Following the research it was decided to reduce intravenous methylprednisolone dose from 20mg/ 8h to 20mg/12h and start oral haloperidol 5mg/8h the first 24h and reducing the dose progressively as the patient recovered. After the first 24 hours the patient presented adequate response to steroids as well as partial response to antipsychotic treatment; presenting no further agitation, absence of hallucinations and partial persistence of the persecutory delusion. A couple of days later there was complete remission of the psychotic symptoms and the patient was on the way to recovery from COVID-19 and RSV.ConclusionsThere is evidence that suggests that medications such as steroids used to treat COVID-19 and other respiratory illnesses can lead to psychotic episodes. It is very important to pay attention to possible side effects when treating with steroids and evaluate the patient history as well as suggest having a follow up visit after the hospital discharge.Disclosure of InterestNone Declared

Increased heart rhythm in response to high-dose intravenous methylprednisolone pulse therapy of moderate-to-severe Graves’ orbitopathy.

ABSTRACT&#x0D; Background: Intravenous glucocorticoids pulses administration is the main therapeutic option in the treatment of Graves’ orbitopathy. Such therapy could relate to the multiple adverse effects. The aim of the study is evaluation the influence of intravenous methylprednisolone (IVMP) pulse therapy on the heart rhythm (HR) changes in patients with active, moderate-to-severe Graves’ Orbitopathy (GO).&#x0D; Methods: We studied 20 patients with moderate-to-severe GO. All patients received 12 IVMP pulses (6x500 mg plus 6x250mg) at equal time intervals in a weekly schedule. We performed Holter ECG monitoring for 3 consecutive days (the day before, the day of IVMP and day after IVMP) to monitor HR and arrhythmias. We compared changes in HR between these 3 days and set time interval when the alteration was significant. This evaluation was performed during the 1st, 6th and 12th IVMP pulse.&#x0D; Results: Increased HR, in comparison with the day before, was registered on the day of IVMP administration. The most significant increase in HR started 5 hours (h) after a pulse administration and lasted 12 h. There were no significant differences in HR between the day before and the day after IVMP. We did not notice any major adverse cardiac events including severe arrhythmias.&#x0D; Conclusions: IVMP therapy is associated with increased HR, that occurs a few hours after infusion, lasts several hours and is transient. &#x0D; Keywords: Graves’ ophthalmopathy; Graves’ disease; glucocorticoids; heart rate

One-year recurrence rate of Graves ophthalmopathy presenting as diplopia in the primary position after varied doses of intravenous methylprednisolone followed by oral prednisolone with dosing based on the magnetic resonance imaging findings.

To reveal the recurrence rate of Graves ophthalmopathy (GO) presenting as diplopia in the primary position for 1 year after varied doses of intravenous methylprednisolone (IVMP) followed by oral prednisolone, with dosing based on the magnetic resonance imaging (MRI) findings. Retrospective study. We analyzed the medical charts of 25 patients who were diagnosed with new-onset GO and who received treatment for diplopia in the primary position at our hospital. Treatment consisted of MRI-determined varied doses of IVMP followed by oral prednisolone. If the MRI findings showed deterioration or were unchanged after 6 g of IVMP, 3 g of IVMP was added for further treatment. Simple and multiple linear regression analyses were performed to reveal the associations between the independent variables and the dependent variable, defined as recurrence. The mean patient age (± standard deviation) was 61.3 ± 11.3 years. The female to male ratio was 15:10. Twenty-one of the 25 patients received a total of 6 g of IVMP, whilst the remaining 4 patients received a total of 9 g of IVMP. In 5 patients (20%), the GO recurred within 1 year of IVMP administration. Simple and multiple linear regression analyses showed that the MRI findings after 6 g of IVMP affected recurrence (P < .05). This study showed that in 20% of patients, GO recurred within 1 year of administration of varied doses of IVMP, with the dosing based on the MRI findings. Furthermore, assessment of inflammation by use of MRI after 6 g of IVMP has a potential role in predicting recurrence.

Overlap syndrome in a 12-year-old girl with systemic lupus erythematosus and anti-oj antibody-positive polymyositis: a case report

BackgroundThe peculiar presentation of overlap syndrome in children makes precise diagnosis difficult. Children with overlap syndrome may or may not have specific antibodies. We present the case of a 12-year-old girl diagnosed with overlap syndrome of systemic lupus erythematosus (SLE) and juvenile polymyositis (JPM) who tested positive for anti-OJ antibodies.Case presentationWe describe the case of a 12-year-old girl diagnosed with SLE at the age of 7 and presented with fever with malar rash, periungual erythema, generalized weakness, and multiple joint pain at admission. The patient had persistent joint pain and weakness after intravenous methylprednisolone administration and complained of an inability to walk with a positive test for Gower's sign one week after admission, accompanied by elevated alanine aminotransferase (ALT) and creatine-phospho-kinase (CPK) levels. The results of nerve conduction velocity test were normal. Electromyography revealed abundant spontaneous activity and myopathic motor unit action potentials in the right deltoid, biceps, and iliopsoas, in addition to fibrillation and mild myopathic motor unit action potentials in the right rectus femoris muscle. Magnetic resonance imaging revealed diffusely increased signal intensities in the myofascial planes of the bilateral iliopsoas, gluteus, obturator, pectineus, and hamstring muscles. Anti-nuclear antibody, anti-RNP, and rheumatoid factor IgG tests were positive, and inflammatory myopathy autoantibodies revealed anti-OJ antibody positivity, which strongly indicated autoimmune myositis. High-resolution computed tomography of the lung revealed mild pericardial effusion without any evidence of interstitial lung disease. We initiated intravenous pulses of methylprednisolone treatment, followed by cyclosporine, mycophenolate mofetil, and oral steroids. Clinical improvement with a delayed, slowly reduced CPK level after the above treatment and she was discharged after the 18th day of hospitalization.ConclusionOverlap syndrome with inflammatory myositis can occur years later in pediatric SLE cases. We should be alert when patients with SLE develop a new presentation characterized by decreased SLE-specific autoantibody titers, positive anti-RNP antibodies, and elevated CPK. Treatment of the overlap syndrome of SLE and JPM is individualized, and the course differs between pediatric and adult patients.

Magnetic resonance imaging-negative myeloneuropathy and bilateral facial paresis unfurling systemic lupus erythematosus.

Systemic lupus erythematosus is a chronic autoimmune connective tissue disorder that can affect all the neuroaxes in the central and peripheral nervous systems. Myelopathy in systemic lupus erythematosus is one of the least common neuropsychiatric syndromes accounting for 1%–2% of cases. Myelopathy has long been diagnosed based on clinical findings, laboratory tests, and gold-standard gadolinium-enhanced magnetic resonance imaging (MRI). MRI-negative myelopathy is a recently described subset of myelopathies. Here, we report the case of a young woman from rural West Bengal, India, who presented with overlapping features of white-matter and gray-matter myelopathy associated with peripheral neuropathy and bilateral asymmetric lower motor neuron-type facial paresis. The historical analysis yielded clues toward an etiological diagnosis of systemic lupus erythematosus, further substantiated by seropositivity of lupus-specific autoantibodies. Her neurological disabilities responded poorly to oral administration of hydroxychloroquine, bolus intravenous administration of methylprednisolone, and high-dose cyclophosphamide therapy but eventually responded remarkably well to cyclical rituximab therapy. This case adds to the tally of cases of MRI-negative lupus myelopathy. MRI-negative myelopathy in systemic lupus erythematosus can be easily missed if not meticulous attention is paid during clinical history taking and examinations.

Paraneoplastic cerebellar degeneration with anti-Yo antibodies and an associated submandibular gland tumor: a case report

BackgroundAs a debilitating syndrome, paraneoplastic cerebellar degeneration (PCD) remains challenging to treat. Further, anti-Yo antibody (directed against human cerebellar degeneration-related protein 2) detection in patients with PCD is associated with unsatisfactory responses to existing therapies. Here, we present the case of a 60-year-old woman who developed PCD with anti-Yo antibodies and a submandibular gland tumor.Case presentationA 60-year-old woman presented with a 5-day history of unsteadiness of gait and inadequate coordination of her extremities, along with truncal instability. Although walking without aid was possible, dysmetria of all four limbs, trunk, and gait ataxia was observed. While routine biochemical and hematological examinations were normal, the patient’s blood was positive for anti-Yo antibodies. When the neurological symptoms deteriorated despite administration of intravenous methylprednisolone, fluorodeoxyglucose-positron emission tomography (FDG-PET) and computed tomography (CT) images with contrast enhancement were performed, which showed a tumor in the left submaxillary gland. She underwent total left submandibular gland resection, including the tumor; histological and immunohistochemical results revealed a salivary duct carcinoma. She was administered intravenous methylprednisolone, followed by 10 plasma exchange sessions, intravenous immunoglobulins, and cyclophosphamide therapy. Following treatment, her symptoms were not alleviated, even after the reduction of anti-Yo titers.ConclusionsAlthough tumor detection was delayed, early tumor detection, diagnosis, and PCD treatment are essential because any delay can result in the progression of the disorder and irreversible neurological damage. Therefore, we recommend that the possibility of a salivary gland tumor should be considered, and whole-body dual-modality CT, including the head and neck, and FDG-PET should be performed at the earliest for patients with well-characterized paraneoplastic antibodies when conventional imaging fails to identify a tumor.

Dysthyroid Optic Neuropathy: Treatment with Additional Intravenous Methylprednisolone Pulses after the Basic Schedule Is Associated with Stabilization or Further Improvement of Clinical Outcome.

Background: Dysthyroid optic neuropathy (DON) is a sight-threatening complication of Graves’ orbitopathy (GO). Treatment of DON consists of the urgent administration of intravenous methylprednisolone (ivMP) in very high doses followed by orbital decompression if the response is poor or absent. It is advised to continue the therapy with pulses of ivMP in a weekly schedule. The purpose of this study was to evaluate the impact of the additional treatment with ivMP in a 12-week protocol on visual acuity (VA), color vision, clinical activity score (CAS) and proptosis in patients with DON. Methods: This study was performed on 19 patients with DON (26 eyes) treated with ivMP in very high doses, with further orbital decompression in 11 individuals (15 eyes). VA, color vision, CAS and proptosis were evaluated prior to the DON treatment, before and after the 12-week ivMP (first and last pulse). Additionally follow up was performed (22 eyes). Results: VA and color vision improved between the first and last pulse of the additional ivMP treatment (p = 0.04 and p = 0.003, respectively). CAS and proptosis were reduced at the end of the 12-week ivMP therapy compared to observations at the beginning (p < 0.001 and p = 0.04, respectively). Follow up confirmed stabilization of this achievement. Conclusions: The results of this study suggest that additional treatment with 12 pulses of ivMP improves or stabilizes the outcome of basic therapy in patients with DON.

Flaccid quadriparesis with raised creatine kinase in Guillain-Barré syndrome: a case report with review of literature

Background: Guillain-Barré syndrome (GBS) is an immune-mediated inflammatory polyneuropathy characterized by acute flaccid paralysis. Elevated creatine kinase (CK) levels in GBS have been reported to be transient, and levels vary from mild to severe. Herein, we report a case of GBS with elevated CK mimicking acute myositis.Case Report: A 48-year-old man presented with pure motor flaccid quadriparesis. Power was 2/5 with hypotonia and areflexia in all four limbs. A nerve conduction study revealed reduced compound muscle action potential in all recorded motor nerves. Serum CK was 2,334 U/L. The patient’s symptoms progressed despite intravenous methylprednisolone administration. Cerebrospinal fluid (day 8) revealed albuminocytological dissociation, and electromyography (day 21) revealed spontaneous activity with neurogenic motor unit action potential suggestive of acute motor axonal neuropathy variant of GBS.Conclusion: In a patient with elevated CK and ascending paralysis, differential diagnosis of GBS should be considered and cerebrospinal fluid study and electromyography should aid in confirming the diagnosis.

Impact of additional intravenous methylprednisolone pulse therapy on the quality of life in patients with dysthyroid optic neuropathy

Introduction. Dysthyroid optic neuropathy (DON) is a severe complication of Graves’ orbitopathy (GO). Treatment of DON should involve immediate administration of intravenous methylprednisolone (ivMP) in very high doses. It is recommended to include additional 12 pulses of ivMP according to a weekly schedule as a further step of the treatment process. The purpose of this study was to evaluate the influence of a 12-week ivMP treatment on the quality of life (QoL) in DON patients. Material and Methods. A retrospective study was conducted on 6 patients (the tests involved 8 individual eyes) with DON and treated with ivMP in very high doses, followed by orbital decompression in one patient. All patients were qualified for additional treatment with ivMP in a 12-week protocol and completed the Polish version of the GOQoL questionnaire before and after the therapy. Visual acuity (VA) and diplopia were examined prior to the administration of ivMP pulses for DON, as well as before and after the additional ivMP treatment. Results. A minimal clinically important difference in QoL was observed in four patients at the end of the additional ivMP therapy. A significant increase in VA was observed following additional pulses of ivMP compared to the evaluation at the time of the DON diagnosis (p=0.04). Conclusions. Applying additional 12 pulses of ivMP following DON therapy may impact QoL. Performing QoL assessment throughout the entire therapy in patients with DON is particularly important in the clinical practice. Final evaluation of QoL should be performed after completing the entire therapeutic process, which involves surgical treatment to correct diplopia.

Clinical features and management of coexisting anti-N-methyl-D-aspartate receptor encephalitis and myelin oligodendrocyte glycoprotein antibody-associated encephalomyelitis: a case report and review of the literature.

Anti-N-methyl-D-aspartate (NMDA) receptor encephalitis is an autoimmune encephalitis caused by antibodies targeting the GluN1 subunit of NMDA receptors. Myelin oligodendrocyte glycoprotein (MOG) antibody disorders are now widely accepted as peculiar neuroimmunological diseases with specific clinical and pathological features. Some rare cases of overlapping anti-NMDA receptor encephalitis and MOG antibody-associated diseases have been reported, presenting complex clinical symptoms that make the disease more difficult to recognize. In accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines, the terms "NMDAR" and "MOG," "NMDAR" and "demyelination," and "MOG" and "encephalitis" were searched in PubMed. Clinical cases with dual-positive anti-NMDA cerebrospinal fluid receptors and MOG serum antibodies during the disease course were included in this study. A total of 25 patients were analyzed in this study. The age at onset ranged from 3 to 54years. The median number of relapses was 2.8. Administration of intravenous methylprednisolone and immunoglobulin was the most widely used treatment strategy (19/25 patients). Second-line treatments such as administration of mycophenolate mofetil, rituximab, interferon-β, azathioprine, cyclophosphamide, and temozolomide were also reported, followed by good outcomes. The rates of coexisting anti-NMDA receptor encephalitis and MOG antibody-associated encephalomyelitis may be underestimated. Clinical symptoms such as seizures and cognitive decline accompanied by atypical central nervous system demyelination serve as warning signs of possible coexisting anti-NMDA receptor encephalitis and MOG antibody-associated encephalomyelitis. These patients could achieve good outcomes under proper immunotherapies.

Treatment with Intravenous Methylprednisolone in Patients with Graves' Orbitopathy Significantly Affects Adrenal Function: Assessment of Serum, Salivary Cortisol and Serum Dehydroepiandrosterone Sulfate.

Treatment of active, moderate-to-severe Graves’ orbitopathy (GO) is the administration of intravenous methylprednisolone (IVMP). IVMP may be followed by additional therapy with oral prednisone. The aim of this study was to analyze the impact of IVMP on adrenal function by evaluation of serum, salivary cortisol and serum dehydroepiandrosterone sulfate (DHEA-S). Fourteen patients received IVMP treatment (cumulative dose of 4.5 g in 12 weekly infusions) followed by oral prednisone (for three months). All patients showed normal adrenal function before the 12th IVMP pulse and one patient was diagnosed with secondary adrenal insufficiency (AI) after prednisone treatment. DHEA-S was significantly lower before the 12th IVMP pulse and after oral prednisone (p = 0.015 and p = 0.00002, respectively) in comparison to evaluation before therapy. DHEA-S levels were below the reference range in one and three patients before the 12th IVMP pulse and after prednisone therapy, respectively. We observed decreased serum (p = 0.05) and salivary (p = 0.011) cortisol levels after oral prednisone therapy in comparison to evaluation before therapy. Treatment with IVMP in a cumulative dose of 4.5 g affects adrenal function, causing more severe impairment of DHEA-S secretion than that of cortisol but does not cause secondary AI. Additional therapy with oral glucocorticoids after IVMP can cause secondary AI.

Short-term effect of intravenous methylprednisolone pulse therapy on glycemic control in patients with normoglycemia and pre-diabetes.

Introduction. Systemic steroid therapy leads to disturbances in carbohydrate metabolism. The effect of immunosuppression with intravenous methylprednisolone (IVMP) pulses on glycaemia is not conclusive. Aim. This study aimed to assess the short-term effect of IVMP therapy in moderate-to-severe Graves' orbitopathy (GO) on glycaemic control in normoglycaemic patients with and without pre-diabetes. Material and Methods. Twenty-five GO patients treated with IVMP pulses (at initial dose of 6 x 0.5 g once a week, followed by0.25 g given for 6 consecutive weeksweekly) were recruited and divided into a normoglycaemic group (n = 15, patients without pre-diabetes) and a pre-diabetic group (n = 10, patients with impaired fasting glycaemia (IFG) and/or impaired glucose tolerance (IGT)). Six daily capillary blood glucose measurements were performed at fixed times the day before and on the day of the first pulse administration. Results. There was a significant increase in the glucose concentration on the day of IVMP administration in both groups of patients compared to the day before drug administration, with 50% of patients showing an increase in blood glucose above 200 mg/dl. There were no statistically significant differences between the two groups. Conclusions. Methylprednisolone in a high intravenous dose has a tremendous impact on the blood glucose level in normoglycaemic and pre-diabetic patients on the day of drug administration.

Prevention of rebound effect after natalizumab withdrawal in multiple sclerosis. Study of two high-dose methylprednisolone schedules

BackgroundNatalizumab (NTZ) is a disease-modifying treatment (DMT) in multiple sclerosis (MS) whose discontinuation can produce a “rebound effect”, consisting of severe clinical deterioration and/or evidence of disease reactivation on magnetic resonance imaging (MRI). ObjectiveTo analyze the efficacy of two treatment schedules with intravenous methylprednisolone (IVMP) administered during the washout period of natalizumab (i.e., before starting another DMT) in preventing the rebound phenomenon. MethodsFive-year retrospective study of NTZ withdrawals after at least 24 uninterrupted doses. Two IVMP schedules were tested. In schedule 1 (3-month washout), 1, 2, and 3 g of IVMP were administered on the first, second, and third month respectively. In schedule 2 (2-month washout), 1 and 2 g of IVMP were administered on the first and second month respectively. A new DMT was started 10 days after the end of each schedule. Rebound was defined as at least one clinical relapse plus rebound activity on MRI (>5 gadolinium-enhanced lesions and a number of new/T2-enhanced and/or gadolinium-enhanced lesions greater than before initiation of NTZ) during washout or at 6 months after new DMT initiation (6M-DMT). Clinical and MRI evaluations were performed at 3, 6, 12, and 24 months after initiation of the new DMT. ResultsFifty patients (68% women) were included, with a mean (SD) age of 37.76 (10.88) years and pre-NTZ annualized relapse rate (ARR) of 1.78 (1.04). During NTZ therapy, mean Expanded Disability Status Scale (EDSS) score was 3.7 (1.73) and ARR was 0.23 (0.39). The ARR (mean of both schedules) was 0.1 (0.71) during washout and 0.32 (0.84) at 6M-DMT. Rebound was observed in 10% of cases (n = 5), with no significant clinical or radiological differences (p>0.05) between the two IVMP schedules. Rebound was observed in younger patients and was associated with new MRI lesions and higher ARR at 3M-DMT and 6M-DMT respectively, with no difference in EDSS after 2 years of follow-up. Neither the ARR before NTZ initiation nor the choice of new DMT after NTZ discontinuation was associated with development of rebound effect. ConclusionsBoth IVMP schedules were well tolerated during NTZ washout and rebound was observed in only 10% of cases. In our experience, administration of IVMP during NTZ washout could reduce the possibility of a rebound effect.

Prehospital management of pediatric asthma patients in a large emergency medical services system.

Asthma is a common pediatric diagnosis for emergency medical services (EMS) transports, however there is a paucity of data on prehospital asthma management. The purpose of this study was to describe prehospital management of pediatric patients with suspected asthma exacerbation. We conducted a retrospective review of electronic medical records from 24 ground EMS agencies in Southwestern Pennsylvania between 1 January 2014 to 31 December 2017. We identified patients 2 to 17 years with documented wheezing, excluding those with suspected anaphylaxis. Patients with documented respiratory distress were classified as severe asthma. We report descriptive statistics of demographics, vital signs, and management including administration of medications and performance of procedures. Of 19 246 pediatric transports, 1078 (5.6%) patients had wheezing. Of these, 532 (49%) met criteria for severe asthma. Patients with severe asthma were more likely to be adolescents compared to those with nonsevere asthma (49.6% vs 6%; P < .001). While rates of intravenous methylprednisolone administration were higher in patients with severe asthma (68/532, 12.8%) compared to those with nonsevere asthma (13/546, 2.4%; P < .001), overall use of steroids was low (7.5%). Other therapies provided included albuterol (n = 699, 64.8%), ipratropium bromide (n = 271, 25.1%), and oxygen (n = 280, 26.0%). One hundred eighty patients (16.7%) received a peripheral IV line. Two patients (0.4%) were given continuous positive airway pressure. Approximately 6% of pediatric EMS transports are for asthma. Steroid usage was low in even those with severe asthma, representing an area of process improvement. These data provide a baseline to future research to identify interventions that may improve outcomes.