Low-dose Corticosteroid Therapy Research Articles

Role of Low Dose Intravenous Methylprednisolone in Pulmonary Hemorrhage Associated with Severe Leptospirosis

Leptospirosis, an emerging zoonosis endemic in Malaysia, presents with diverse clinical manifestations, ranging from mild to potentially fatal illness. Pulmonary involvement in leptospirosis, particularly pulmonary hemorrhage, poses a significant risk of mortality, prompting exploration of various treatment strategies. While high-dose corticosteroid therapy has demonstrated efficacy in some studies, data on the use of low-dose corticosteroids in pulmonary leptospirosis remain scarce. Here, we report a case of successful treatment with low-dose methylprednisolone in a patient diagnosed with Weil’s disease and pulmonary hemorrhage. The patient, initially presenting with fever, vomiting and hemoptysis, rapidly deteriorated, necessitating intubation due to respiratory distress. Prompt initiation of low-dose methylprednisolone alongside antibiotic therapy resulted in clinical improvement, resolution of pulmonary hemorrhage, and normalization of laboratory parameters. This case highlights the potential efficacy of low-dose corticosteroid therapy in managing severe pulmonary involvement in leptospirosis, offering insights into alternative treatment modalities for this challenging condition. Further studies are warranted to elucidate the optimal dosing and timing of corticosteroid therapy in leptospirosis-associated pulmonary complications.

The Effectiveness of High versus Low Dose Corticosteroid therapy in Pediatric Patients with Acute Respiratory Distress Syndrome

Abstract Background When the lungs fill with fluid as a result of an infection or injury, acute respiratory distress syndrome ensues. Inflamed and fluid-filled lungs occur. They become rigid as a result, making it difficult for them to breathe fully. Blood oxygen levels will fall, endangering the health of other organs. Patients will require a ventilator to help them breathe while their lungs mend. The aim of this study was: to evaluate safety and efficacy of high dose therapy in acute respiratory distress syndrome pediatric patients and to compare safety and efficacy of high dose versus low dose therapy in Acute respiratory distress syndrome patients. Patients and Methods A Prospective open label randomized trial included 15 patients as group1 received high dose corticosteroid therapy for 3 consequent days, high dose Methyl prednisone 30 mg/kg/day and 15 patients as group 2 received low dose corticosteroid therapy for 3 consequent days, low dose Methyl prednisone 2 mg/kg/day. Clinical and laboratory data chest ultrasound and bronchoalveolar lavage to measured pre collagen peptide were studied in each group before and after corticosteroid therapy. Results In the present study 15(50%) patients received high dose steroid and 15 (50%) patients received low dose steroid, male 23 (70%), female 7 (30%), age 7 (3.0-30.0), weight (9.55 ± 6.63), there was no significant difference in prognosis and total days in pediatric intensive care unit between high and low dose corticosteroid therapy as prognosis improving 17 patients (55%), death 13(45%) and As regards total days in pediatric intensive care unit median in high dose corticosteroid therapy 24.0 (15.50-33.0) and median in low dose corticosteroid therapy 18.50 (11.0-23.50) less days in pediatric intensive care unit in low dose steroid therapy group than high dose steroid therapy group but no significant difference between two groups as regarding decrease in chest ultrasound (BLUE Score) and increase in pre collagen peptide in bronchoalveolar lavage between study groups . Conclusion there was no significant difference in prognosis and total days in pediatric intensive care unit between high and low dose corticosteroid therapy as regarding change in chest ultrasound (BLUE Score) and change in pre collagen peptide in bronchoalveolar lavage between study groups.

Effect of Corticosteroids on Long-Term Humoral and Memory T-Cell Responses in Follow-Up Visit of Hospitalized Patients With COVID-19

Corticosteroids have beneficial effects in improving outcomes in hospitalized patients with severe COVID-19 by suppressing excessive immune responses. However, the effect of corticosteroids on the humoral and T-cell responses of survivors of COVID-19 1 year after infection remains uncertain, as it relates to the extent of immediate, antigen-specific defense provided by protective memory. What is the effect of corticosteroids on long-term humoral and T-cell immune responses? In this retrospective cohort study conducted at a single center, we analyzed data from a cohort who had survived COVID-19 to compare the 1-year seropositivity and titer changes in neutralizing antibodies (NAbs) and SARS-CoV-2-specific antibodies. Additionally, we evaluated the magnitude and rate of SARS-CoV-2-specific T-cell response in individuals who received corticosteroids during hospitalization and those who did not. Our findings indicated that corticosteroids do not statistically influence the kinetics or seropositive rate of NAbs against the Wuhan strain of SARS-CoV-2 from 6months to 1 year. However, subgroup analysis revealed a numerical increase of NAbs titers, from 20.0 to 28.2, in categories where long-term (> 15days) and high-dose (> 560mg) corticosteroids were administered. Similarly, corticosteroids showed no significant effect on nucleoprotein and receptor-binding domain IgG at 1 year, except for spike protein IgG (β, 0.08; 95%CI, 0.04-0.12), which demonstrated a delayed decline of titers. Regarding T-cell immunity, corticosteroids did not affect the rate or magnitude of T-cell responses significantly. However, functional assessment of memory Tcells revealed higher interferon-γ responses in CD4 (β, 0.61; 95%CI, 0.10-1.12) and CD8 (β, 0.63; 95%CI, 0.11-1.15) memory Tcells in the corticosteroids group at 1 year. Based on our findings, short-term and low-dose corticosteroid therapy during hospitalization does not appear to have a significant effect on long-term humoral kinetics or the magnitude and rate of memory T-cell responses to SARS-CoV-2 antigens. However, the potential harmful effects of long-term and high-dose corticosteroid use on memory immune responses require further investigation.

Outcomes of Chronic Myeloid Leukemia Patients after Therapeutic Failure to Asciminib, a Multicenter Observational Study

Introduction: Asciminib has recently entered the market as a promising option for patients with chronic myeloid leukemia (CML) and therapeutic failure to ³ 2 tyrosine kinase inhibitors (TKIs). It presents a relevant rate of therapeutic success thanks to its different mechanism of action, being the first in its class to produce an allosteric inhibition on the myristoylated pocket of ABL. However, a percentage of patients fail this drug due to intolerance or resistance. This group constitutes a highly polytreated population with few therapeutic options. The aim of this analysis is to determine the most frequent treatment strategies in this setting, as well as to ascertain the prognosis in this difficult to treat group. Material and methods: a retrospective descriptive multicenter observational study was carried out. Eligible patients were those with a diagnosis of CML, >18 years and who had presented a therapeutic failure to asciminib, due to resistance or intolerance. Patients were selected from a cohort of 85 CML patients who received asciminib through a managed-access program. Results: A total of 19 patients were recruited from 17 centers in Spain. Median age at the time of therapeutic failure to asciminib was 61.7 years. Median time from diagnosis to asciminib failure was 7.9 years (range 1.7-25.5), median number of previous lines was 5. 47% of patients had previously received ponatinib and 15.8% (3/19) had received an allogeneic hematopoietic stem cell transplantation (allo-HSCT) prior to asciminib. Median time on asciminib was 5.6 months (range 0.7- 40.9). 42% of patients (8/19) failed treatment due to intolerance and 58% (11/19) due to resistance. Four of them had progression to accelerated/blastic phase at the time of withdrawal. Of the intolerant patients, the most frequent reason for discontinuation was pancreatitis (50%, 4/8). The remaining causes were renal failure (1), pleural effusion (1), fatigue (1), and neurological symptoms (1). Regarding the intolerant group, 2 patients did not require restart of treatment due to a sustained deep molecular response (MR). The rest (6/8) required treatment, which in all cases involved restarting a classic TKI that they had already received (2 imatinib, 2 dasatinib, 2 nilotinib). In 50% (3/6) dose reductions were used to control adverse events (AEs), which in 2/3 patients compromised efficacy. In another case, low-dose corticosteroid therapy was used for the management of pleural effusion, maintaining standard dose. Only 1/8 intolerant patients required an additional change of treatment, and all of them are still alive and without progression to advanced stages at the last follow-up. Regarding the patients that required treatment change due to progression to advanced phases, one patient underwent allo-HSCT. The rest were not candidates due to age or clinical impairment (1 received dasatinib, 1 hydroxyurea (HU), 1 without treatment). Only the patient who underwent HSCT is alive more than one year after the procedure with a grade 5 MR. In the rest the median overall survival (OS) was less than 1 month. Of the remaining resistant patients, 4/7 (57%) received ponatinib (1 of 4 had received it previously), 1 imatinib, 1 allo-HSCT and the other patient received cytarabine + interferon + HU. Three of 7 patients required additional lines including change of TKI (asciminib, nilotinib, dasatinib) and other strategies (HU, busulfan, interferon, cytarabine). In terms of response, only the patient undergoing HSCT maintained a mayor MR (1/7). One patient maintained a complete cytogenetic response and the other 2 patients were unable to improve response despite treatment (maintaining worse response than CHR at the end of follow-up). Two patients died (1 acute myocardial infarction, 1 digestive neoplasia). With a median follow-up of 11.2 months, OS of the global cohort is 73%; 100% for intolerant patients, 71% for resistant patients and 25% for those in accelerated/blastic phase. Conclusions: Patients who fail asciminib are a particularly difficult to manage group. In intolerant patients, dose reductions and symptomatic management of AEs may be an appropriate strategy. Resistant patients currently represent an unmet therapeutic need, with low cytogenetic and molecular response rates and poor survival with current strategies. Patients with progression to advanced phases have a dismal prognosis, HSCT may be the only option that provides long-term survival in this group.

A Case of Sarcoidosis with Parotid Gland and Muscular Lesions Improved with Low Dose Corticosteroid Therapy

A Case of Sarcoidosis with Parotid Gland and Muscular Lesions Improved with Low Dose Corticosteroid Therapy

Efficacy of initial high- versus low-dose intravenous corticosteroid therapy in patients with acute exacerbation of idiopathic interstitial pneumonia: A nationwide observational study.

Acute exacerbation of idiopathic interstitial pneumonias (AE-IIPs) has a high mortality. However, there is no established treatment for AE-IIPs. Therefore, we aimed to compare the efficacy of high- and low-dose corticosteroid therapies in AE-IIPs patients. Data were retrospectively collected from the Japanese Diagnosis Procedure Combination database from July 2010 to March 2018. Adult patients with AE-IIPs who received high-dose (methylprednisolone at a dose of 500-1000 mg/day for 3 days starting within 4 days after admission) or low-dose (methylprednisolone at a dose of 100-200 mg/day for at least 5 days starting within 4 days after admission) corticosteroid therapy were identified. Eligible patients (n = 17,317) were divided into the high-dose (n = 16,998) and low-dose (n = 319) groups. A stabilized inverse probability of treatment weighting using propensity scores was performed to compare outcomes between the groups. The primary outcome was in-hospital mortality, and the secondary outcomes were 28-day mortality, infections during hospitalization, length of hospitalization, duration of steroid use, and discharge to home. The in-hospital mortality rates of the high- and low-dose corticosteroid groups were 50.6% and 47.0%, respectively. In-hospital mortality did not significantly differ between the two groups after stabilized inverse probability of treatment weighting, and the odds ratio in the low-dose corticosteroid group was 0.86 (95% confidence interval: 0.64-1.16; p = 0.33). The secondary outcomes also did not significantly differ between the groups. There was no significant difference in outcomes between patients with AE-IIPs who received high- and low-dose corticosteroid therapies.

Differential Diagnosis Difficulty between Biliary Cystadenoma and Cystaadenocarcinoma of the Liver: A Case Report

Biliary cystadenoma is a multilocular cystic benign tumor which arises in the intrahepatic biliary system. Diagnosis is often difficult and based on imaging, however histology remains the only argument for diagnosis certainty. We report a case of biliary cystadenoma in a 69-year-old female. Observation: it was a 69-year-old female with history of RHUPUS syndrome (Lupus + Rheumatoid arthritis) under low-dose corticosteroid therapy. She presented with pain in the right hypochondrium with permanent moderate intensity for 3 months associated to altered performance status. Physical examination showed a hepatomegaly, cervical subluxation, and pulmonary condensation syndrome. Hepatobiliary ultrasound showed presence of multiple septate cystic formations occupying segments 1, 7, 8, 5 of the left liver. Abdominal CT scan and hepatic MRI were in favor of biliary cystadenoma but could not rule out biliary cystadenocarcinoma with certainty. Conclusion: biliary cystadenoma is a benign cystic tumor of the liver. The differential diagnosis with cystadenocarcinoma is most often difficult and usually requires histological analysis for diagnostic certainty.

La cytosteatonecrose du nouveau-ne au chu de Conakry: a propos d’une nouvelle observation

Cytosteatonecrosis is an acute condition of unknown pathogenesis that occurs in the first weeks of extra-uterine life. It presents clinically in the form of a large plaque, indurated and sometimes nodular. It often sits on the trunk, buttocks and thighs (root of the limbs). The course of cytosteatonecrosis is benign but sometimes enamelled with complications such as hypercalcemia and metabolic disorders. The rarity of this affection would be justified by the ignorance of the cutaneous signs. We report here a case of neonatal cytosteatonecrosis remarkable for the delay in diagnosis and the efficacy of low-dose corticosteroid therapy.

CARDIOGENIC SHOCK AND CRITICAL ILLNESS-RELATED CORTICOSTEROID INSUFFICIENCY: DID STEROIDS MAKE MY HEART GO ON?

CARDIOGENIC SHOCK AND CRITICAL ILLNESS-RELATED CORTICOSTEROID INSUFFICIENCY: DID STEROIDS MAKE MY HEART GO ON?

Acute fibrinous and organizing pneumonia in a patient with Sjögren’s syndrome and Legionella pneumonia: a case report and literature review

BackgroundAcute fibrinous and organizing pneumonia (AFOP) is a rare clinicopathological condition. Studies in the literature have reported that AFOP may be associated with respiratory infections, such as respiratory syncytial virus, influenza virus, Pneumocystis jirovecii, Penicillium citrinum, and Chlamydia infections. However, AFOP associated with Legionella infection has not been reported previously. Here, we report a case of a patient with AFOP secondary to Sjögren’s syndrome and Legionella infection.Case presentationA 47-year-old man was admitted to the hospital because of fever, expectoration, and shortness of breath. Lung imaging showed irregular patchy consolidation. A diagnosis of Legionella pneumonia was initially considered on the basis of the patient’s history of exposure to soil before disease onset, signs of extrapulmonary involvement, and a positive Legionella urine antigen test result. However, the patient’s symptoms and lung imaging did not improve after treatment with levofloxacin, moxifloxacin, and tigecycline for Legionella infection. In addition, Sjögren’s syndrome was diagnosed on the basis of clinical manifestations and immunological indicators. Pathological changes associated with AFOP were confirmed from the results of ultrasound-guided percutaneous lung biopsy. The patient’s clinical symptoms improved rapidly after a short course of low-dose corticosteroid therapy, and lung imaging showed significant improvement.ConclusionsThe possibility of secondary AFOP should be considered when Legionella pneumonia does not improve after standard antibiotic therapy. Lung biopsy and histopathological examination are important for the adjustment of treatment strategy. Our case also highlights the importance of screening for autoimmune diseases in patients with AFOP.

Less is not necessarily more: low-dose corticosteroid therapy and long-term prognosis in generalized myasthenia gravis after thymectomy

Less is not necessarily more: low-dose corticosteroid therapy and long-term prognosis in generalized myasthenia gravis after thymectomy

Low-dose corticosteroid therapy for cardiogenic shock in adults (COCCA): study protocol for a randomized controlled trial

BackgroundCardiogenic shock (CS) is a life-threatening condition characterized by circulatory insufficiency caused by an acute dysfunction of the heart pump. The pathophysiological approach to CS has recently been enriched by the tissue consequences of low flow, including inflammation, endothelial dysfunction, and alteration of the hypothalamic-pituitary-adrenal axis. The aim of the present trial is to evaluate the impact of early low-dose corticosteroid therapy on shock reversal in adults with CS.Method/designThis is a multicentered randomized, double-blind, placebo-controlled trial with two parallel arms in adult patients with CS recruited from medical, cardiac, and polyvalent intensive care units (ICU) in France. Patients will be randomly allocated into the treatment or control group (1:1 ratio), and we will recruit 380 patients (190 per group). For the treatment group, hydrocortisone (50 mg intravenous bolus every 6 h) and fludrocortisone (50 μg once a day enterally) will be administered for 7 days or until discharge from the ICU. The primary endpoint is catecholamine-free days at day 7. Secondary endpoints include morbidity and all-cause mortality at 28 and 90 days post-randomization. Pre-defined subgroups analyses are planned, including: postcardiotomy, myocardial infarction, etomidate use, vasopressor use, and adrenal profiles according the short corticotropin stimulation test. Each patient will be followed for 90 days. All analyses will be conducted on an intention-to-treat basis.DiscussionThis trial will provide valuable evidence about the effectiveness of low dose of corticosteroid therapy for CS. If effective, this therapy might improve outcome and become a therapeutic adjunct for patients with CS.Trial registrationClinicalTrials.gov, NCT03773822. Registered on 12 December 2018

Mononeuropathy Multiplex – Case Report of An Unusual Manifestation of Primary Sjögren’s Syndrome

Sjögren’s Syndrome (SS) is a chronic autoimmune disease characterized by exocrinopathy, with xerophthalmia and xerostomia. Patients with SS may exhibit extra-glandular features such as neurologic symptoms. Peripheral neuropathy is the most common neurological complication of primary SS (pSS). We report a case of a 71-year-old female with pSS admitted to the Internal Medicine ward due to sensorimotor symptoms and petechiae. From the extensive study carried out, emphasis is given to elevation of inflammatory markers and to nerve conduction study compatible with mononeuritis of multiple nerves. The diagnosis of mononeuropathy multiplex (MM) secondary to pSS was made. She was started on corticosteroid therapy, which allowed complete regression of the petechiae as well as symptomatic and functional improvement. However, new sensorimotor deficits were noted a few days later. The decision was made to start cycles of cyclophosphamide in association with corticosteroid and physical therapies, leading to deficit improvement. Currently, the patient is in remission with low-dose corticosteroid therapy.

Prednisone combined with antiviral agents for the treatment of early idiopathic brachial plexus neuritis: report of five cases

<p><strong>Background and Objective: </strong>The aim of this study was to report the short-term outcomes of early idiopathic brachial plexus neuritis after low-dose corticosteroid combined with antiviral agent.</p>
 <p><strong>Methods:</strong> Five patients with early brachial plexus neuritis presenting from April to June 2019 were included in this study. According to individual patient conditions, electromyography (EMG), nerve B-ultrasound and/or brachial plexus magnetic resonance imaging (MRI) were performed. After the diagnosis was confirmed, modified conservative treatments were initiated, including low-dose corticosteroid therapy and antiviral therapy for 2 weeks each while neurotrophic therapy for 4 weeks.</p>
 <p><strong>Results: </strong>Of the five patients, only two patients had symptoms of pain at onset, and three patients had sensory disturbances. Two patients reported a common cold before onset. The lesion involved the upper trunk of the brachial plexus in two patients. MRI showed slightly intense signals, of which one patient also had supraclavicular lymph node augmentation. The other three patients suffered ipsilateral radial nerve (RN) palsy. At 1 month of modified treatment, four patients recovered well with almost complete shoulder and hand movements; however, their muscle strength was still weaker comparing with the contralateral side. One patient restored full range of motion after surgery in 2 months.</p>
 <p><strong>Conclusion:</strong> Early treatment is the key to good prognosis in patients with brachial plexus neuritis. Antiviral therapy combined with lowdose corticosteroid therapy may be superior to traditional treatment alone. In terms of early diagnosis, the clinical value of imaging examinations such as ultrasound and MRI is more specific as compared to that of EMG.</p>

Corticosteroid use in COVID-19 pneumonia.

Coronavirus disease 2019 (COVID-19) has a 1-2% fatality rate, where no specific treatment has yet been defined. Although corticosteroids are recommended for selected COVID-19 patients without acute respiratory distress syndrome (ARDS) and septic shock, there is no consensus regarding patient subgroups, dose, and duration. In this study, it was aimed to examine the contribution of corticosteroid treatment to the management of COVID-19 pneumonia without ARDS, septic shock both in acute and recovery setting. The study population was divided into two as those who used corticosteroids during the recovery phase (who did not develop sufficient radiological or clinical improvement) and those who did so during the activation phase (non-ARDS/septic shock condition, clinical, laboratory or radiological progression). We identified 47 patients, 26 of which were males, and mean age was 60.5 ± 16.5 years. Seventeen patients were found to receive corticosteroids during the recovery phase and the rest (n= 30) during the activation period. After corticosteroid therapy, we found reduction of increased pre-treatment levels of D-dimer, ferritin, fibrinogen, CRP, increment of decreased pre-treatment lymphocyte count and saturation. Complete symptomatic improvement was detected in 6.9% and 17.6% of the patients in the activation phase and recovery phase, respectively. Complete radiological improvement was found in 11.5% and 35.3% of the patients in the activation phase and recovery phase, respectively. While corticosteroid treatment was initiated on day 4.2 ± 2.6 and continued for a mean of 5.9 ± 2.8 days in the activation group, it was started on day 8.1 ± 11.3 and administered for 7.8 ± 3.8 days in the recovery group. In both groups, methylprednisolone was given at a median dose of 40 mg/day. Short-term low-dose corticosteroid therapy may improve clinical, radiological, laboratory outcomes in the management of COVID-19 pneumonia during the activation period without ARDS and non-septic shock and during recovery period with no satisfactory response. Further randomized controlled studies will be useful in demonstrating its efficacy.

Clinical Features and Outcome of Low and High Corticosteroids in Admitted COVID-19 Patients

IntroductionThere is no specific anti-viral therapies for 2019 Coronavirus Diseases (COVID-19) infection. Here, we compared patients receiving steroids at different dosages versus no steroids in severe and critical COVID-19 patients.MethodsWe retrospectively studied COVID-19 patients who received low-dose or high-dose corticosteroid therapy compared to no steroid.ResultsThe study period, June–August 2020, included 169 patients with COVID-19 were included and there were 39.1% female and 60.9% male with an average age of 53.1 years. The distribution of cases was as follows: high-dose 39 (23.1%), low-dose 54 (32.0%), and no steroid 76 (45.5%). Of all the patients, Intensive Care Unit (ICU) admission was for 31 (18.3%), nine (5.3%) required intubation, and 52 (30.8%) had no comorbidities. There is no difference in the mean age between the different groups. However, those being treated with steroid were more likely to have a high sequential organ failure assessment (SOFA) score (0.37 ± 0.68, 0.36 ± 0.67 and 0.04 ± 0.34, for low-dose, high-dose steroid and no steroid groups, respectively (p = 0.001). Cox regression was not possible as the mortality rate was very low (3/169; 1.78%) and none of the multivariate methods would be possible. However, there was a significant difference in the hospital Length of stay (LOS) and the ICU LOS.ConclusionCox regression was not possible as the mortality rate was very low (1.78%) and none of the multivariate methods would be possible as the model will not converge. However, in t-test only, intubation was associated risk of mortality.

Longitudinally extensive transverse myelitis combined with tuberculosis meningitis

Abstract Rationale: Central nervous system tuberculosis accounts for 1% of all the tuberculosis (TB) cases, of which tuberculous spondylitis is the most common, followed by scleritis and meningitis. Meningitis associated with transverse myelitis due to tuberculosis is rare but has been reported with severe clinical manifestations, including tuberculous sepsis, symptoms of meningitis and spinal cord injury. Patients concerns: Case 1, a 23-year-old male patient presented with fever, accompanied by quadriplegia and difficulty to urinate. Cultured Koch's Bacillus in liquid environment, Acid-Fast bacilli test, polymerase chain reaction and Xpert MTB/RIF assay for tuberculosis in the cerebrospinal fluid were positive for tuberculosis. Magnetic resonance imaging (MRI) showed heterogeneous signal on T2-weighted (T2W) hyperintensity and fluid-attenuated inversion recovery (FLAIR) images, heterogeneous signal intensity in the spinal cord, unclear medullary border and an increase in D10 - D11 diameter with clear signal in the spinal edges. Case 2, a 20-year-old male patient, presented with fever, severe headache, vomiting and paraplegia. Cultured Koch's Bacillus in liquid environment, testing for acid-fast bacilli test, polymerase chain reaction and Xpert MTB/ RIF tuberculosis in cerebrospinal fluid and sputum was positive for tuberculosis. The MRI displayed hyperintensities on T2W and FLAIR images, a slight increase in the spinal diameter and unclear, heterogeneous signal along the medullary border. Diagnoses: The first patient was diagnosed as tuberculosis meningitis combined with longitudinally extensive transverse myelitis and the second patient was diagnosed with pulmonary tuberculosis, tuberculous meningitis and longitudinally extensive transverse myelitis. Interventions: The two patients were treated with IIIA regimen, rifampicin, pyrazinamide, streptomycin, ethambutol combined with aggressive phase steroids. Outcomes: Following the anti-tuberculous therapy, the fever and mental status was alleviated in case 1, but improvement in muscle power of the limbs and sphincter function improved only after physical rehabilitation training. Case 2 was started on physical rehabilitation during the anti-tuberculous therapy. Though he tested negative for tuberculosis after the medical therapy, the muscle power of the limb showed only marginal improvement after the rehabilitation. Lessons: Meningitis combined with longitudinally extensive transverse myelitis is often difficult to diagnose early because the patients have altered mental status. If the patient has clinical manifestations of lower limb paralysis or quadriplegic paralysis, it is necessary to have an MRI of the spine to determine co-existing transverse myelitis lesions. Low-dose corticosteroid therapy in patients with meningitis combined with transverse myelitis leads to poor nerve recovery.

COVID-19 Cardiac Complication- Myocarditis

Based on the clinical experience, it has been observed that when it comes to the impact of SARS-CoV-2 virus on the cardiovascular system, it is significant. In patients with COVID-19 infection, the development of myocarditis occurs a few days after the onset of fever. The mechanism of myocardial injury alone, as well as most pathologies caused by the SARS-CoV-2 virus, is the subject of research by many experts, but two basic ways can certainly be assumed: a direct toxic effect of SARS-CoV-2 on myocardial cells and another possible way of myocardial injury is to activate the innate immune response by releasing proinflammatory cytokines, as well as to activate the adaptive mechanisms of the autoimmune type by molecular mimicry. The approach to treatment is the same as for other viral myocarditis; it is non-specific, applied supportive treatment, such as anti-inflammatory drugs, low-dose corticosteroid therapy, and immunoglobulins. The aim of this review is to present the previous experiences of physicians around the world on the clinical presentation of myocarditis caused by COVID-19 infection, diagnostic and therapeutic approach in a specific situation of high-risk infection.

Utility of Awake Prone Positioning with Low-Dose Systemic Corticosteroids in Coronavirus Disease 2019 Acute Respiratory Distress Syndrome Patients: A Case Series

Coronavirus disease 2019 (COVID-19) is caused by severe acute respiratory syndrome coronavirus 2, novel enveloped RNA beta-coronavirus. The clinical manifestations vary from no symptoms to fever, cough, respiratory distress, pneumonia, and adult respiratory distress syndrome (ARDS) or uncommonly diarrhea. Typically, the disease has viremic phase, pulmonary phase, and severe host inflammatory phase. Prompt interventions in the first two phases such as awake prone positioning and administration of low-dose corticosteroids can prevent the onset of the third phase of the deadly disease. Awake prone positioning and systemic corticosteroids are simple interventions, which can prevent the requirement of mechanical ventilation and also lead to reduction in the inflammatory response and disease severity. We report a case series of six patients who diagnosed with COVID-19 ARDS and were benefitted by awake prone positioning sessions and low-dose systemic corticosteroid therapy.

Efficacy and safety of low-dose corticosteroids for acute respiratory distress syndrome: A systematic review and meta-analysis.

There are conflicting results regarding whether corticosteroids have better efficacy than placebo in acute respiratory distress syndrome (ARDS) patients. Therefore, we aim to further evaluate the efficacy and safety of corticosteroids in adult ARDS patients. The databases, including Medline, EMBASE, and Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library, were searched from their inception to May 2, 2020. Randomized controlled trials (RCTs) and observational cohort studies were selected to assess the use of corticosteroids in adult ARDS patients. The quality of the results was judged by the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology. The inverse-variance method with random or fixed effects modeling was used to compute pooled odds ratio (OR), standardized mean difference (SMD), and their 95% confidence interval (CI). Eight eligible RCTs and six cohort studies were included. The use of corticosteroids was associated with reduced mortality (OR 0.57, 95% CI 0.43-0.76, I2=35.1%, P=0.148) in ARDS patients, and the result was confirmed in the included cohort studies (OR 0.51, 95% CI 0.27-0.95, I2=66.7%, P=0.010). The subgroup analysis stratified by the initiation time and duration of corticosteroid use showed that early ARDS and prolonged corticosteroid use had significant survival benefits in the RCTs. The low-dose corticosteroid use was also associated with significantly more ventilator-free days and a reduced rate of new infections in ARDS patients. The low-dose corticosteroid therapy may be safe and reduce mortality, especially in patients with prolonged treatment and early ARDS.