Long-term Systemic Corticosteroid Therapy Research Articles

Diagnosis and Treatment Challenges of an Atypical Case of Pemphigus vulgaris During the COVID-19 Pandemic

Pemphigus defines a group of rare autoimmune blistering diseases that affect the skin and mucous membranes, with pemphigus vulgaris being the most common form that has increased morbidity and mortality in the absence of an early diagnosis and treatment.We report the case of a 24-year-old male with an atypical form of pemphigus vulgaris with cutaneous onset and subsequent involvement of the oral cavity. The management of the patient initially consisted of long-term systemic corticosteroid therapy. Following a mild form of SARS-CoV-2 infection and a flare-up of the disease in this context, which was not controlled with high doses of systemic corticosteroids, targeted therapy with rituximab was initiated but immediately stopped due to the manifestations of urticaria and angioedema. Considering the magnitude of these reactions, dapsone systemic therapy i.e., a steroid-sparing agent with minimal risk of infections, was started and managed to control the underlying disease.The management of this case of pemphigus vulgaris was challenging for both the patient and his physician, as the patient developed COVID-19 which caused disease complications and implied additional costs. This case highlights the importance of an accurate diagnosis given the atypical onset of the disease and the financial limitations with the impossibility of performing all confirmatory diagnostic tests.

Impact of Long-term Systemic Corticosteroid Therapy on Immune Response to the Influenza Vaccine: A Review of the Literature—How about COVID-19 Vaccine

Corticosteroids have been widely applied in the treatment of various diseases, and patients exposed to corticosteroid therapy are at higher risk of infections, including the influenza, than others. Influenza vaccination are recommended for patients treated with steroids, while its efficacy and safety may be influenced by the immunosuppression induced by steroids. Therefore, we conducted an updated literature review of immune responses against influenza virus on patients treated with systemic corticosteroids to assess whether patients receiving long-term glucocorticoid therapy have developed an adequate antibody response. Findings from this review assume that influenza vaccine works safely and efficiently among patients with long-term systemic corticosteroid therapy at a low dose, 10mg/day might be a boundary value. Further studies are needed.

Osteoporosis and bone health in autoimmune blistering skin disease-an evidenced based review.

Autoimmune blistering skin diseases (AIBD) encompass a group of diseases characterised by cutaneous and/or mucocutaneous fragility. Multiple risk factors contributing to osteoporosis exist in AIBD patients, including use of long-term systemic corticosteroid therapy (SCT), decreased mobility and the presence of chronic inflammation. Despite this, there is no consensus on the prophylaxis of osteoporosis in AIBD, especially in the absence of SCT. To systemically review the current literature on the association between osteoporosis/osteopenia and AIBD, a comprehensive literature search was performed on six online databases with search terms related to bone mineral density (BMD) and AIBD. A total of 314 articles were screened by their abstract and/or full text. A total of 20 peer-reviewed full-text articles addressing BMD in patients with AIBD were identified. Eight articles examined the association between osteoporosis and pemphigus. Only two articles examined the association between osteoporosis and pemphigoid patients. Three articles examined the effectiveness of osteoporosis prophylaxis in AIBD patients. Seven papers examined the levels of vitamin D in AIBD patients. Few case-control studies examine osteoporosis in pemphigus in the context of SCT, with consistent findings. However, there is scarce literature examining the risk of osteoporosis in pemphigoid, or in AIBD without SCT. Prophylaxis and screening of osteoporosis in AIBD is suboptimal and more attention in this area is required to avoid future complications related to osteopenia and osteoporosis.

Evaluation of Practice of Prescription of the Corticotherapy in the Department of Internal Medicine of the University Hospital of Point G from 2009 to 2013

Introduction: It is estimated that about 0.2% to 0.5% of French populations received a long-term systemic corticosteroid therapy. In Mali, from March, 2007 to February, 2008, in National Center for Disease Control and Prevention, 19.2% of hospitalized patients (24/125) received long-term corticosteroid therapy. Until now, the department of internal medicine of the university hospital of Point G hasn’t done any research on the corticosteroid therapy specially. Therefore, we initiated this work to evaluate our practice of prescription of corticosteroid. The target of the study was to evaluate practical activity of prescription of corticosteroid of internal medicine. Methods: Based on all hospitalized patient materials of the department of internal medicine of Point G regional university central hospital during January 2009-December 2013, we initiated this retrospective and descriptive study. This study was based on all hospitalized patients receiving corticosteroid in the time of researching, without distinguishing their sex or age. Results: During the period of study, the department of internal medicine of point G regional central hospital had received 2155 patients; 64 were eligible: prevalence of 2.97%. Most patients were female, accounting for 87.5% with a sex-ratio of 0.14. The average age of our patients was 39.11 ± 16.92 years, ranging from 14 to 97 years. Physicians enrolled in the study Specialized Diploma (DES) and Internal represented 79.7% of prescribers. As pretreatment assessment, only 2 patients (3.12%) had carried out all of the standard balance (NFS, electrolytes, calcium, blood glucose and serum protein). The most common glucocorticoide was prednisone. Solid tumors represented 31.25% (20 cases) of the diseases treated, followed by systemic lupus erythematosus with 15.62% (10 cases). In addition, there are two cases of adrenals insufficiency (3.1%). In Point G internal medicine, pre-therapy evaluation and methods about corticosteroids therapy were insufficient and different.

An uncommon presentation of progressive disseminated histoplasmosis

Progressive disseminated histoplasmosis (PDH) caused by Histoplasma capsulatum generally develops in immunocompromised patients or those on long-term systemic corticosteroid therapy. Here, we report a case of PDH in an immunocompetent patient, which is a rare occurrence. A 56- year-old male patient, whose work often led him to caves, now reported with a low-grade fever and altered sensorium. Investigations revealed hyponatremia, bilateral adrenal enlargement, and mediastinal lymphadenopathy. A rare complication of the manifestations of histoplasmosis in an immunocompetent patient, in the form of ring lesions in the brain, came to light during the clinical investigations. The patient developed generalized tonic–clonic convulsions and needed care for the critical condition 2 weeks into treatment. This case report traces the clinical course, histological and serological findings, and response to amphotericin B therapy in the patient.

Chronic eosinophilic pneumonia

Various types of pulmonary eosinophilia have been known for several years. Chronic eosinophilic pneumonia (original word for Christoforidis and Molnar 1960) is a rare entity whose diagnosis is possible through clinical, laboratory and radiological data. Other non sophisticated data-CAT, bronchoalveolar lavage, transbronchial biopsy, transthoracic biopsy and even thoracotomy can be used. Seriousness can be very high, demanding an urgent diagnosis and treatment.

Angiœdèmes à évolution ecchymotique révélant un lupus érythémateux systémique de l’enfant avec anticorps anti-C1q

Hypocomplement urticarial vasculitis syndrome may be the presenting sign of systemic lupus erythematosus. Hypocomplement urticarial vasculitis presents as atypical urticaria associated in 50% of cases with angioedema. On laboratory investigation, hypocomplementaemia is the characteristic feature, with reduced C3, C4 and C1q. This disease is very rare in children. An eight-year-old girl was hospitalised for relapsing urticaria with ecchymotic angioedema present for one year, in a setting of impaired general health and fever. Screening for native anti-DNA and antinuclear antibodies was positive. Analysis of complement revealed activation of the classical pathway with reduced CH50, C4 and C3. These anomalies persisted outside active episodes. The C1q fraction was completely depressed and screening for anti-C1q was positive. There was no quantitative or qualitative deficit in C1-esterase inhibitor. Direct immunofluorescence of skin lesions demonstrated deposits of immunoglobulin and complement. These episodes of angioedema persisted despite long-term systemic corticosteroid therapy (1mg/kg per day). This is the first reported case of hypocomplement urticarial vasculitis syndrome arising from systemic lupus erythematosus in a child exhibiting anti-C1q antibodies. Furthermore, this case is original because of the highly ecchymotic nature of the lesions. In the presence of angioedema with ecchymotic progression associated with atypical chronic urticaria, a diagnosis of hypocomplement urticarial vasculitis syndrome should be considered.

Histoire naturelle de la lipodystrophie cervicofaciale cortico-induite: suivi prospectif d'une cohorte de 37 patients

No data is available about the natural history of the corticosteroid-induced lipodystrophy. The purpose of this study is to describe the natural history of corticosteroid-induced lipodystrophy in a selected and homogenous population. We conducted a cohort study between June 2003 and September 2005 and enrolled all consecutive patients starting long-term systemic corticosteroid therapy for giant cell arteritis (because of a standardized therapeutic schedule). After enrollment, patients were seen every month until the end of the corticosteroid therapy. After the drug withdrawal, they consulted every 3 months during 6 months. At each consultation, they were photographed in a standardized way. At the end of the study, the development of lipodystrophy was assessed by analyzing these photographs. We evaluated the incidence of corticosteroid-induced lipodystrophy during the course of giant cell arteritis therapy and the time between initiation of therapy and its apparition. Lastly, we evaluated the time between the prednisone withdrawal and the disappearance of lipodystrophy (or the mean prednisone dosage if the disappearance was observed under treatment). Thirty-seven patients were included (women: 73%; mean age: 75+/-7 years; mean initial daily prednisone dosage: 44+/-13 mg). The mean duration of follow-up was 23.6+/-7.4 months. Incidence of corticosteroid-induced lipodystrophy was 48% after 3 months and 60% after 12 months of therapy. The median time between treatment initiation and appearance of lipodystrophy was short (3 months [1-4]). During the decrease of the therapy or the 6 months following its end, we observed a regression of lipodystrophy in 71% of the patients. The median time between corticosteroids initiation and disappearance of lipodystrophy was 19 months [16-22] (concomitant median daily dosage of prednisone: 4 mg [0-7]). Lipodystrophy is frequently observed in corticosteroid-treated old patients. It appears precociously after the initiation of therapy and is usually reversible.

Incidence and risk factors for corticosteroid-induced lipodystrophy: A prospective study

Very few studies have focused on fat redistribution induced by corticosteroids. To establish the incidence and risk factors of facial ("moon face") and cervical ("buffalo hump") lipodystrophy due to long-term (> or =3 months), high dosage (>or =20 mg/d) systemic corticosteroid therapy. Between June 2003 and May 2005 we conducted a prospective study in two French tertiary centers. All consecutive patients starting long-term systemic corticosteroid therapy at an initial daily dosage of 20 mg or more were enrolled in this study. Three investigators assessed the development of facial and cervical corticosteroid-induced lipodystrophy (CIL) from standardized photographs. Demographic, clinical, and nutritional data were examined to assess risk factors of CIL. Eighty-eight patients were enrolled (women: 75%, mean age: 57.4 +/- 17.9 years, mean baseline dosage of prednisone: 56 +/- 15 mg/d). The cumulative incidence rate of CIL at months 3 and 12 was 61% +/- 8% and 69% +/- 9%, respectively. In multivariate analyses the risk of CIL at the third month was higher in women (odds ratio [OR]: 10.87 [2.43-58.82]), in subjects younger than 50 years of age (OR: 11.11 [2.19-37.89]), in subjects with a high initial body mass index (OR: 1.56 [1.21-2.03] per increment of 1 kg/m2) and in subjects with high energy intake (OR: 6.11 [1.35-27.75] when higher than 30 kcal/d/kg). Photographic analysis is not a conventional method for the diagnosis of CIL. CIL frequently occurs, especially in overweight subjects and in women, who are also at higher risk to develop other forms of lipodystrophies.

Corticothérapie systémique et alimentation : suivi des recommandations diététiques et relation entre apports alimentaires et apparition d'une lipodystrophie

Purpose No data is available about: 1) the adherence of corticosteroid-treated patients to dietary advice provided by physicians; 2) the relationship between food intake and the corticosteroid-induced lipodystrophy (CIL). Methods We conducted a cohort study in 2 French tertiary centers between June 2003 and May 2005 and enrolled all consecutive patients starting long-term systemic corticosteroid therapy. They received individual dietary advice from a qualified dietetician and were asked to record on a standardized questionnaire everything they ate during one week of the first and third months of treatment, including details of each meal. Each questionnaire was analysed by two qualified dieteticians for daily calorie, carbohydrate, fat, protein and sodium intake. Moreover, 3 investigators assessed the development of CIL from standardized patients' photographs. The relationship between food intake and CIL was investigated by a multiple logistic regression model. Results Eighty-eight patients were included and 80 were monitored until at least month 3 (women: 76%, mean age: 59.1±18.7 years). Most patients (65%) had giant-cell arteritis or connective tissue disease. The mean initial dosage of prednisone was 54±17 mg/day and the mean M3 dosage was 31±15 mg/day. Most patients were adherent to dietary advice during the first 3 months of therapy except for protidic ration which was below expected value. Sodium restriction was more strictly followed by women than by men. Multivariate analysis showed independent relationship between CIL and higher calorie intake (> 30 kcal/kg/day). No relationship was evidenced between carbohydrate, protein, fat or sodium intake and the risk of CIL. Conclusion During the first 3 months of therapy, corticosteroid-treated patients are adherent to dietary advice. A calorie-controlled alimentation could be beneficial to limit the risk of CIL.

Corticosteroids in Chronic Obstructive Pulmonary Disease: Clinical Benefits and Risks

The use of systemic and inhaled corticosteroids for COPD has increased appreciably over the past 20 years. Clearer indications for corticosteroid therapy in COPD are beginning to emerge as the results from large clinical trials become available. Systemic corticosteroids are only modestly effective for acute COPD exacerbations, increase the risk for hyperglycemia, and should be given for no more than 2 weeks. The efficacy of long-term systemic corticosteroid therapy has not been adequately evaluated in this patient population. If longer term use of systemic steroids in COPD should be found to be useful, this conclusion would have to be weighed against the risk for serious adverse effects. High doses of inhaled corticosteroids cause a small sustained increase of the FEV1 in patients with mild and moderately severe COPD, but they do not slow the rate of FEV1 decline. Based on analyses of secondary outcome, inhaled corticosteroids may improve the respiratory symptoms and decrease the number and severity of COPD exacerbations in patients with more advanced disease. Low doses of inhaled corticosteroids appear to be safe, but there is growing awareness that higher doses may not be so benign.

Is enough attention being given to the adverse effects of corticosteroid therapy?

Although the corticosteroids are valuable anti-inflammatory and immunosuppressive agents, they also possess many potential adverse effects, especially with continued use. In particular, long-term corticosteroid exposure carries a significant risk of osteoporosis. To review the use of corticosteroids in patients presenting to the major teaching hospital in Tasmania, Australia; principally to determine whether patients receiving long-term corticosteroid therapy were being monitored for loss of bone mineral density and offered preventive therapy for osteoporosis. A retrospective review of the medical records for 212 consecutive patients admitted to the medical wards of the hospital over a 5-month period and receiving treatment with either oral or inhaled corticosteroids, was performed. An extensive range of demographic and clinical variables was recorded for each patient. Patients were also questioned about diet and exercise, and whether they had undergone tests for measuring bone mineral density or blood glucose. The median age of the patients was 69 years (range: 15-90 years) and 58% were female. Over half (53%) of the patients were on oral corticosteroids only, with 26% using inhaled corticosteroids only, and 21% on both oral and inhaled corticosteroid therapy. The most common conditions for which patients were receiving corticosteroid therapy were asthma (37% of patients), chronic obstructive pulmonary disease (33%) and rheumatoid arthritis (17%). The most commonly used oral corticosteroid was prednisolone (93%), the median daily dose was 10 mg prednisolone equivalent, and the median duration of oral corticosteroid treatment was 50 weeks. Disregarding short courses, the median duration of oral corticosteroid treatment was 104 weeks. Almost one-third (31%) of the patients receiving oral corticosteroid treatment had been taking the equivalent of 7.5 mg prednisolone daily for at least 6 months. Only 11% of all patients on oral corticosteroids and 21% of those who had been taking oral corticosteroids for at least one year had documented evidence of bone mineral density testing being performed in the past in the hospital. Only 21% of all patients on oral corticosteroids and 31% of those who had been taking oral corticosteroids for at least one year were receiving medication for osteoporosis prevention, and only 15% of women over 45 years of age and on oral corticosteroid therapy were taking hormone replacement therapy. Only about half of the patients on long-term systemic corticosteroid therapy had either documented evidence in their hospital medical records, or were aware, of having undergone blood glucose testing in the preceding 12 months. More attention to the prevention and monitoring of possible adverse effects of long-term corticosteroid therapy is warranted. Guidelines covering preventive measures and treatment options for corticosteroid-induced osteoporosis need to be considered routinely when using these agents.

Posterior Subcapsular Cataract Formation Associated with Multiple Lumbar Epidural Corticosteroid Injections

Posterior Subcapsular Cataract Formation Associated with Multiple Lumbar Epidural Corticosteroid Injections

Chronische Granulomatöse Chorioretinitis bei Tuberkulose

Though the incidence of tuberculosis decreased substantially during the second half of the century, a steady increase of new cases has been observed within the last decade. Among other reasons, the growing number of immunodeficient patients (e.g. HIV, therapy with immunosuppressive agents) and migration from underdeveloped to industrial countries contribute to this finding. A 57-year-old male patient presented with a history of chronic bilateral chorioretinitis of unknown origin. During the last months a marked decrease in visual acuity of the left eye was noted. Prior diagnostic attempts had not led to a specific diagnosis. Notable was the history of long-term systemic corticosteroid therapy for chronic obstructive lung disease. Funduscopy of the right eye revealed a choroidal granuloma with adjacent serous retinal detachment. Both eyes showed multiple dot-like lesions in the retinal pigment epithelium of the posterior pole. Finally the diagnosis could be made by isolating Mycobacterium tuberculosis from sputum samples and gastric aspirate. Within a few weeks after starting tuberculostatic therapy the ocular symptoms regressed and the visual acuity improved significantly. Securing the diagnosis of tuberculous uveitis is often difficult. The differential diagnosis includes other granulomatous ocular inflammations. The detection of Mycobacterium tuberculosis and the clinical course make the diagnosis most likely. Tuberculosis should always be included in the differential diagnosis as a possible etiology for uveitis, particularly in those cases taking a chronic course. Despite the recent emergence of drug-resistant strains in most cases tuberculosis is a well curable disease.

Overview of corticosteroid therapy

Corticosteroids have been recognized as useful in the management of asthma for the past 35 years. Controversy remains as to their precise indications, dosage, and optimal methods of administration. Only recently has objective evidence been presented confirming their usefulness in acute severe attacks and status asthmaticus. In the treatment of the latter, high doses of methylprednisolone (125 mg every 6 hours) has been shown to be more effective than lower doses. The corticosteroids are also useful diagnostically to determine reversibility of airway obstruction in the bronchitis-emphysema syndrome. To prevent adrenal insufficiency, they are mandatory for patients previously receiving long-term systemic corticosteroid therapy who are undergoing stress (e.g., surgery). Indications for chronic severe asthma are the least well established. Patients with severe incapacitating asthma uncontrolled by bronchodilators or cromolyn should be considered candidates for corticosteroid therapy. When long-term therapy is necessary, aerosolized corticosteroids or alternate-day therapy are preferable to daily dosing. Regardless of the route used, it is advisable to limit the use of these agents to patients who clearly require them and to take all precautions to minimize side effects. Neither method, especially when higher doses are used, obviates possible development of serious complications.

Management of the dental patient receiving corticosteroid medications

Many dental patients are receiving long-term systemic corticosteroid therapy. Such therapy may have a profound effect upon risk of infection, wound healing, and ability to handle stress. A discussion of the adverse effects that may accompany corticosteroid therapy is followed by guidelines for mangement of the patient receiving such medication and requiring dental therapy.

The evaluation of selected parameters of immune function in asthmatics after long-term corticosteroid therapy.

The availability of inhaled beclomethasone diproprionate permitted the discontinuation of continuous, long-term systemic corticosteroid therapy (SCT) in a group of asthmatics who had previously required SCT to control their asthma. Twelve patients had been on SCT for a period of 2-22 years with an average duration of 7 years. To determine whether this previous long-term SCT and the current use of inhaled beclomethasone diproprionate had an effect on leucocyte functions, a variety of studies reflecting T lymphocyte, B lymphocyte and granulocyte function was done. The results were compared with those of twelve asthmatic patients of similar age ranges who had never received steroids. Results showed that the two patient populations could not be differentiated on the basis of phytohaemagglutinin stimulation of lymphocytes, sheep erythrocyte rosette formation, IgG, IgA, IgM and IgE concentrations or granulocyte bactericidal activity. Delayed skin reactivity was present in both groups, with more positive reactions in the non-SCT group. Polymorphonuclear adherence values were slightly lower in the SCT female population using beclomethasone diproprionate. The latter two minor differences may be due to the previous SCT, the use of beclomethasone diproprionate or the limited population of patients studied. We conclude from these studies that the long-term use of SCT at the low doses required for control of asthma resulted in little permanent effect on the variety of lymphocyte and granulocyte functions tested.

Generalized pustular psoriasis. A report on thirteen patients

Generalized pustular psoriasis shows a fluctuating pattern, its course varying with time and from patient to patient. The prognosis and results of treatment are therefore extremely difficult to assess. The patients in this series have been followed up by us with regard to the natural course of the illness including complications and precipitating factors. Oral drug therapy has suprisingly often provoked acute pustular eruptions, and these patients have also strikingly often and rapidly developed contact allergy to topical applications. The undesirable effects of long-term systemic corticosteroid therapy have been confirmed in this series, chiefly by severe rebound phenomena, notwithstanding that such treatment has proved the only means of rapidly reversing life-threatening states. The effects of methotrexate and hydroxyurea were at times good but, not uncommonly, mediocre and occasionally even useless. Large doses of antibiotics have also failed to achieve the results described by others. On the contrary, secondary infection with beta-hemolytic streptococci has caused serious problems in several cases. Apart from careful protection from infection and precipitating factors, little can be done to influence the course of generalized pustular psoriasis, but trial with cytostatics is justified during severe bouts, pending the appearance of new lines of therapy.

A New Look at the Ocular Side-Effects of Long-Term Systemic Corticosteroid and Adrenocorticotrophic Therapy [Abridged

A New Look at the Ocular Side-Effects of Long-Term Systemic Corticosteroid and Adrenocorticotrophic Therapy [<i>Abridged</i>

CATARACTS IN CHILDREN ON LONG-TERM CORTICOSTEROID THERAPY.

Introduction The relationship between long-term systemic corticosteroid therapy and the development of posterior subcapsular cataracts (PSC) has been reviewed by Straatsma. 1 From the available data, he concluded that there is increasing evidence that PSC are a direct result of systemic corticosteroid therapy. There are additional reports which support this contention, but which disagree on the significance of dosage and duration of steroid administration. 2,3 Other investigators have been unable to show a conclusive relationship between the corticosteroids and PSC, 4-6 and still others have presented evidence that such a relationship is unlikely. 7-9 It appears that the issue is not settled; however this is not surprising when one considers the many variables involved. Differences in age, sex, systemic disease, duration of disease, duration of therapy, and dosage schedules, as well as concomitant long-term therapy with other drugs, make statistical analysis difficult. Furthermore, adequate controls are difficult to obtain for