Low-dose Corticosteroid Therapy Research Articles

Can Steroids plus Surgery Become a First-Line Treatment of Idiopathic Granulomatous Mastitis?

Background: The aim of this study is to compare the clinical course of idiopathic granulomatous mastitis (IGM) treated with low-dose oral corticosteroid therapy alone as opposed to treatment with low-dose corticosteroid therapy followed by surgery. Patients and Methods: 37 patients were treated with an approach that consisted of methylprednisolone at a dose of 0.5 mg/kg/day followed by wide excision, and 23 patients were treated with an approach that consisted only of methylprednisolone. The treatment efficacy was compared between the two groups. Results: Clinical and radiological regression was reported in all patients with steroid therapy, and the regression rate had a median of 75% (25-100%). No recurrence was observed in patients who were treated with wide surgical excision after steroid therapy during the median follow-up period of 38 (22-78) months. The control group of 23 patients was treated only with steroid therapy, and 7 (30%) of these patients experienced recurrence in the follow-up period (p < 0.001). Conclusions: Steroid therapy was effective in the treatment of IGM by reducing the lesion size and extent. With regard to the current treatment options available for IGM, surgical excision after steroid therapy seems the better treatment option compared to steroid therapy without surgical excision. This treatment sequence reduces the rate of recurrence.

Intraocular pressure in chronic users of low-dose oral corticosteroids for connective tissue disease

ObjectiveTo investigate the mean intraocular pressure (IOP) of patients with connective tissue disease (CTD) on low-dose chronic systemic corticosteroid therapy and compare with control subjects. DesignCross-sectional comparative study. ParticipantsA total of 86 patients with CTD were grouped according to corticosteroid therapy. Group 1 (n = 27) was composed of patients with CTD receiving low-dose systemic corticosteroid therapy (<10 mg prednisone or its equivalent oral corticosteroid) for at least 6 months, and group 2 (n = 59) included patients with CTD without use of corticosteroid therapy. Group 3 (n = 20) was composed of healthy control subjects. MethodsAll patients underwent a complete ophthalmic evaluation by an experienced investigator and had their clinical records reviewed by another independent investigator. IOP was measured by Goldmann applanation tonometry. ResultsIn all 3 groups, the IOPs were within the normal range. The mean IOP was 13.1 ± 2.7 mm Hg (range 8–19 mm Hg) in the CTD corticosteroid group (group 1), 13.7 ± 2.7 mm Hg (range 9–22 mm Hg) in CTD group without corticosteroid therapy (group 2), and 13.1 ± 1.6 mm Hg (range 10–16 mm Hg) in the control group (group 3). No significant differences in IOP were observed among the 3 groups (p = 0.50). ConclusionsPatients under chronic treatment with low-dose systemic corticosteroid therapy for CTD presented with IOP within the normal range, not clinically significant different from the IOP of patients with CTD without any steroid therapy or from healthy control subjects.

Efectos de la Corticoterapia Sistémica Sobre la Densidad Mineral Ósea en Pacientes con Artritis Reumatoide

Se realizó un estudio transversal de tipo casos y controles en 180 pacientes con artritis reumatoide (AR) a quienes se les determinó la densidad mineral ósea (DMO). Los pacientes fueron separados en dos grupos, según recibían o no terapia esteroidea. Fueron excluidos los pacientes con patología concomitante o tratamiento que afecte la DMO. Se controló la edad, raza, sexo, tiempo de enfermedad, uso de metotrexato o calcio, fecha de última regla, capacidad funcional y hábitos nocivos. El grupo de casos incluyó pacientes de 31 - 85 años (promedio 54,6 ± 11,8) que habían recibido prednisona 2,5 - 10 mg/día (5,8 ± 2,0 mg/día) durante 3 - 300 meses (54 ± 71,1 meses). La terapia esteroidea no se asoció con diferencias estadísticamente significativas al comparar la DMO (g/cm2) a nivel de columna lumbar (L2: 0,917 ± 0,173 vs. 0,930 ± 0,162; L3: 0,957 ± 0,187 vs. 0,969 ± 0,170; L4: 0,957 ± 0,187 vs. 0,969 ± 0,170; L2 - L4: 0,937 ± 0,170 vs. 0,956 ± 0,166), cuello de fémur (0,731 ± 0,143 vs. 0,761 ± 0,159) y triángulo de Ward (0,630 ± 0,176 vs. 0,679 ± 0,188). A pesar que se hallaron diferencias a nivel de trocánter (0,617 ± 0,139 vs. 0,672 ± 0,145; p &amp;lt; 0,05), en el análisis de regresión lineal múltiple éstas desaparecieron. Se concluye que en los pacientes con AR estudiados, la DMO no varió significativamente entre quienes recibían terapia esteroidea a dosis bajas y los que no recibieron corticoides.

Mooren's ulcer of the cornea after immune reconstitution

Mooren's ulcer is an uncommon idiopathic form of peripheral ulcerative keratitis (PUK), which, to our knowledge, has never been described in a patient with HIV infection. Although the pathogenesis is poorly understood, Mooren's ulcer is currently considered a T-cell-mediated auto-immune phenomenon [1]. Sustained T-cell-dependent immune activation of inflammatory cells in the peripheral cornea occurs in Mooren's ulceration [1]. Immune reconstitution inflammatory syndrome (IRIS) encompasses a group of disorders that follow after immune recovery on highly active antiretroviral therapy (HAART). Auto-immune diseases occurring as part of IRIS have been described previously [2–5]. We describe the first case of an HIV-positive patient who developed bilateral Mooren's ulcers soon after commencement of HAART. A 40-year-old man presented to our eye clinic with a 3-month history of bilateral red, painful eyes. The onset was insidious and he had no history of previous ocular injuries or surgery. He was known with HIV infection and had commenced treatment with efavirenz, lamivudine and tenofovir 4 months prior to presentation when his CD4+ cell count nadir was 187 cells/μl. Systemic examination revealed no abnormalities. On ocular examination, he had normal visual acuity and mild conjunctival injection in both eyes. His right eye revealed a grey white, crescent-shaped peripheral corneal ulcer concentric to the corneoscleral junction extending from 6 o’clock to 9 o’clock. The edge closest to the pupil was undermined and de-epithelialized (Fig. 1a). A lesion with similar morphology was noted in his left eye, extending from 7 o’clock to 10 o’clock, with the base of the ulcer showing early vascularization (Fig. 1b). Because Mooren's ulcer is a diagnosis of exclusion, we performed a number of special investigations to search for a possible systemic cause of this PUK. These included a complete blood count with differential erythrocyte sedimentation rate, rheumatoid factor, antinuclear antibody, antineutrophil cytoplasmic antibodies, syphilis serology, hepatitis C serology, chest radiograph examination, as well as sputum cultures for tuberculosis and stool microscopy for hookworms. None of these investigations produced a positive result. In addition, his CD4+ cell count was 503 cells/μl and his CD8+ cell count was 1668 cells/μl, with a CD4+/CD8+ ratio of 0.30. The serum HIV viral load was undetectable.Fig. 1: Ocular examination.(a) The right eye demonstrates a gutter-like ulceration of the peripheral cornea with undermining of the central edge of the lesion. (b) The left eye demonstrates a similar peripheral ulcerating process with significant thinning of the cornea and undermining of the central wound edge.Treatment was commenced with hourly 0.1% dexamethasone drops and 6-hourly hydroxypropyl methylcellulose drops to both eyes. The patient experienced rapid resolution of symptoms and signs in both eyes and has remained asymptomatic on low-dose topical corticosteroid therapy for 6 months. An extensive literature search was performed and we were unable to find any description of Mooren's ulcer in an HIV-infected patient. A possible explanation for this is the fact that CD4+ cells play an important role in the pathogenesis of Mooren's ulcer and patients with low CD4+ cell counts are therefore unable to develop this condition unless HAART-induced immune reconstitution takes place. Other auto-immune diseases such as Graves’ disease, sarcoidosis, Guillain–Barré syndrome and Alopecia Universalis have all previously been described to occur as an IRIS [2–5]. It is therefore likely that our patient, who had experienced immune recovery with an increase in CD4+ cell count from 187 to 503 cells/μl falls into this category of IRIS-related auto-immune disorders. Another interesting facet of this case is the finding of a high CD8+ cell count and a low serum CD4+/CD8+ ratio in our patient. This is contrary to previous findings which showed both serological and histopathological evidence of high CD4+/CD8+ ratios in cases of Mooren's ulcer [1,6,7]. Further investigation is required to determine whether this is a consistent and significant finding in similar cases. The study not only describes the first case of Mooren's ulcer in an HIV-positive patient, but also adds Mooren's ulcer to the ever-increasing list of autoimmune phenomena occurring as part of HAART-induced IRIS. Acknowledgements Conflicts of interest There are no conflicts of interest. Source of funding: No grant or funding process was involved in the present study.

Short-term Low-dose Oral Corticosteroid Therapy of Impingement Syndrome of the Shoulder: A Comparison of the Clinical Outcomes to Intra-articular Corticosteroid Injection

BACKGROUND: To assess the clinical outcomes of short-term oral corticosteroid therapy for impingement syndrome of the shoulder and determine whether it can be substituted as an alternative to the intra-articular injection.METHODS: The clinical outcomes of the 173 patients, the oral steroid group (n=88) and the injection group (n=85), were measured at 3 weeks, 2, 4, and 6 months postoperatively. The clinical outcomes were assessed by measuring the the University of California at Los Angeles (UCLA) score, visual analog scale (VAS) and range of motion (ROM) at every follow-up. Any complications and recurrence rate were noted. A relationship between the treatment outcomes and factors such as demographic factors, clinical symptoms and radiographic findings were determined.RESULTS: No difference was observed in VAS and UCLA scores between the two groups, but forward flexion and internal rotation of ROM were significantly improved in the injection group at the 2nd and 4th postoperative month (p &lt; 0.05). At 6th postoperative month, recurrence rate of symptoms was 26% in the oral steroid group and 22% in the injection group. No major adverse effects were observed. When the clinical outcomes of the oral steroid group were compared to either demographic, clinical symptoms, or radiographic findings, UCLA score was found to be significantly low (p &lt; 0.05) in patients with joint stiffness and UCLA score, whereas VAS score was significantly improved in patients with night pain (p &lt; 0.05).CONCLUSIONS: Short-term low-dose oral corticosteroid therapy of impingement syndrome showed comparable clinical outcomes to intra-articular injection without any remarkable adverse effects. Low-dose oral steroids can be regarded as a partial alternative to intra-articular injection for the initial therapy of impingement syndrome of the shoulder.

A Case of Idiopathic Bilateral Sensorineural Hearing Loss in which Low Dose Immunosuppressive Therapy and Corticosteroid Therapy were Applied

A Case of Idiopathic Bilateral Sensorineural Hearing Loss in which Low Dose Immunosuppressive Therapy and Corticosteroid Therapy were Applied

ステロイド併用少用量免疫抑制剤治療を施行した特発性両側性感音難聴例

ステロイド併用少用量免疫抑制剤治療を施行した特発性両側性感音難聴例

A Rare Case of Episodic Angioedema and Hypereosinophilia – Gleich Syndrome

Gleich syndrome is a distinct clinical entity characterized by episodic angioedema, hypereosinophilia and increased body weight. Being a rare cause of hypereosinophilia, extensive diagnostic evaluation has to be carried out to rule out the other common causes like allergic diseases, Idiopathic hypereosinophliic syndrome (HES), connective tissue disorders, parasitic infestations, lympho-proliferative disorders and neoplastic conditions. We report a rare case of Gleich syndrome in a young Indian female. It usually runs a benign course and shows a good response to low dose corticosteroid therapy.

Immunoglobulin G4–related multiple systemic aneurysms and splenic aneurysm rupture during steroid therapy

Immunoglobulin G4 (IgG4)-related disorders in various organs have recently been described, but multiple systemic aneurysms have not yet been reported. Here, we present a 68-year-old Japanese man with multiple systemic aneurysms and tumor-forming pericoronary arteritis who was undergoing low-dose corticosteroid therapy. Elevated serum IgG4 (2390 mg/dL) and IgG4-positive plasmacyte infiltration in the salivary glands led to a diagnosis of IgG4-related disease. High-dose corticosteroid therapy was initiated, whereupon the inflammatory lesions shrank. However, the large, well-developed common hepatic aneurysm and splenic aneurysm did not change. Our patient died of splenic aneurysm rupture in the sixth month of treatment. The autopsy revealed IgG4-positive plasmacyte infiltration in the coronary wall and a thinned splenic aneurysm wall. This case suggests that early high-dose corticosteroid therapy may be necessary for the treatment of IgG4-related cardiovascular disorders. A minor salivary gland biopsy might facilitate the early diagnosis of IgG4-related disease even if (18)F-fluorodeoxyglucose positron emission tomography provides no inflammatory findings.

Development of lupus erythematosus during infliximab treatment

Infliximab is a TNFα inhibiting recombinant monoclonal antibody, which provides an efficient therapeutic opportunity in the treatment of psoriasis and other immune-mediated inflammatory diseases. It is well tolerated and improves quality of life significantly. The authors present a case of drug-induced lupus erythematosus as a possible side effect of this medication. The patient developed psoriasis 9 years ago when she was on beta-receptor blocker therapy. The symptoms deteriorated despite topical and systemic treatments and, therefore, biological therapy was introduced. In the third year of treatment drug-induced lupus erythematosus was diagnosed on the background of general symptoms. After cessation of the biologic treatment a low dose corticosteroid therapy was introduced which proved to be effective. Symptoms as well as pathological laboratory parameters showed an improvement. The authors conclude that biologicals are effective and safe in the treatment of psoriasis, nevertheless, they have risks too. To reduce side effects a meticulous follow-up of patients is essential. Any general symptom requires careful examination since they might be linked to serious side effects of the biological therapy. Orv. Hetil., 2013, 154, 590–598.

Lung miliary micro‐nodules in human T‐cell leukemia virus type I carriers

Human T-cell leukemia virus type 1 (HTLV-1) carriers are rarely subject to inflammatory disorders in multiple organs, other than the well-known complication, adult T-cell leukemia/lymphoma (ATLL). HTLV-1 associated bronchiolo-alveolar disorder (HABA) has been proposed as an immune mediated pulmonary reaction seen rarely in HTLV-1 carriers. The reported clinico-pathological patterns of HABA are diffuse panbronchiolitis (DPB) and lymphoid interstitial pneumonia (LIP). We here report three cases of HTLV-1 carriers showing miliary micro-nodules throughout both lungs. Microscopic examination in the video assisted thoracic surgery biopsies demonstrated that all cases had multiple discrete micro-nodules which consisted of marked lymphoid infiltration, granulomas, eosinophils and a few foci of necrosis inside the granuloma. No findings indicating ATLL, other neoplastic conditions, infection or interstitial pneumonia, including DPB and LIP, were present following panels of special staining and immunohistochemical examinations. Two patients improved without treatment within one month, with no evidence of recurrence after 7 years. One patient showed slow deterioration of lung reticular shadows in spite of a low dose corticosteroid therapy (prednisolone 10 mg/day). We believe these cases may be a newly recognized variant of HABA.

気管支血管束病変，空洞を伴い，ステロイド少量治療で改善した肺サルコイドーシスの１例

気管支血管束病変，空洞を伴い，ステロイド少量治療で改善した肺サルコイドーシスの１例

De novo acute hepatitis B in myeloperoxidase-specific anti-neutrophil cytoplasmic autoantibody-related microscopic polyangiitis treated with corticosteroids.

An 82-year-old female was referred to our hospital because of low-grade fever, anemia, and rapidly progressive nephritic syndrome. Her laboratory data showed mild proteinuria, mild renal failure, and the presence of myeloperoxidase-specific anti-neutrophil cytoplasmic autoantibody. A skin biopsy specimen taken from the erythematous purpura revealed neutrophilic infiltration around the blood vessels with fibrinoid changes in the vessel walls. A renal biopsy specimen revealed segmental necrotizing glomerulonephritis with fibro-cellular crescent formation without deposits of immunoglobulin or complement components, indicating microscopic polyangiitis. The use of corticosteroid treatment, including intravenous methylprednisolone, improved renal failure. After 4years with low-dose maintenance corticosteroid therapy, she developed de novo acute hepatitis B, and entecavir was remarkably effective, showing a rapid recovery from liver dysfunction with jaundice. To prevent hepatitis B virus (HBV) reactivation and de novo acute hepatitis B induced by immunosuppressive or cytotoxic therapy, including corticosteroids alone, the measurement of HBV-related serological markers needs to be performed prior to the initiation of such therapy, even in renal diseases.

Pulmonary position cryopreserved homograft in non-Ross patients: how to improve the results?

The outcomes of homografts (HGs) in the reconstruction of the right ventricular outflow tract (RVOT) in non-Ross patients are often considered disappointing, compared with Ross patients; and the risk factors for HG degeneration are still controversial. The objective of this study was to determine the durability and prognostic factors related to the HGs implanted in non-Ross patients and to propose potential ways to improve the results. A retrospective study (1993-2010) included 115 consecutive non-Ross patients who received a HG for RVOT reconstruction. The median age at implantation was 2.8 years (4 days-58 years). The main heart defects were pulmonary atresia with ventricular septal defect (n = 40; 34%), truncus arteriosus (n = 28; 24%) and tetralogy of Fallot (n = 23; 20%). Thirty-eight percent had preoperative pulmonary hypertension. A low-dose corticosteroid therapy was used during the postoperative period in patients displaying a HG-related inflammatory response (no septic context) (n = 11). The median diameter of the implanted HG was 22 mm (range 9-30 mm). The median age of the HG donor was 14 years (range 0.5-65 years). ABO compatibility rules were not systematically respected for the HG implantation: 43% of the implanted HGs were ABO compatible with the recipient. The endpoints were HG stenosis (peak gradient ≥20 mmHg), regurgitation (moderate or severe), dysfunction (peak gradient ≥ 50 mmHg or regurgitation moderate or severe) and failure (explantation or balloon dilation). Freedom from HG explantation and failure were 89 and 80% at 5 years, and 76 and 69% at 10 years, respectively. HG donor age <30 years [hazard ratio (HR): 2; P = 0.012], preoperative pulmonary hypertension (HR: 3; P = 0.02) and HG mismatch (HR: 5; P = 0.04) were multivariate risk factors for HG stenosis, regurgitation and failure, respectively. HG diameter <22 mm was a multivariate risk factor for HG regurgitation (HR: 8; P < 0.001), dysfunction (HR: 9; P = 0.02) and failure (HR: 5; P = 0.03). ABO incompatibility increased the risk of HG stenosis (HR: 4; P = 0.009) and dysfunction (HR: 2; P = 0.04). The use of corticosteroids significantly protected against the risk of HG regurgitation (HR: 0.08; P = 0.04) in the multivariate analysis. The cryopreserved HG implanted to reconstruct the RVOT in non-Ross patients remains one of the most acceptable options in this specific non-Ross population. The outcomes of HGs in non-Ross patients might be improved by implanting an ABO-compatible HG with an adapted diameter, coming from a donor >30 years and by optimizing the perioperative afterload of the HG.

Early initiation of low-dose corticosteroid therapy in the management of septic shock: a retrospective observational study

IntroductionThe use of low-dose steroid therapy in the management of septic shock has been extensively studied. However, the association between the timing of low-dose steroid therapy and the outcome has not been evaluated. Therefore, we evaluated whether early initiation of low-dose steroid therapy is associated with mortality in patients with septic shock.MethodsWe retrospectively analyzed the clinical data of 178 patients who received low-dose corticosteroid therapy for septic shock between January 2008 and December 2009. Time-dependent Cox regression models were used to adjust for potential confounding factors in the association between the time to initiation of low-dose corticosteroid therapy and in-hospital mortality.ResultsThe study population consisted of 107 men and 71 women with a median age of 66 (interquartile range, 54 to 71) years. The 28-day mortality was 44% and low-dose corticosteroid therapy was initiated within a median of 8.5 (3.8 to 19.1) hours after onset of septic shock-related hypotension. Median time to initiation of low-dose corticosteroid therapy was significantly shorter in survivors than in non-survivors (6.5 hours versus 10.4 hours; P = 0.0135). The mortality rates increased significantly with increasing quintiles of time to initiation of low-dose corticosteroid therapy (P = 0.0107 for trend). Other factors associated with 28-day mortality were higher Simplified Acute Physiology Score (SAPS) 3 (P < 0.0001) and Sequential Organ Failure Assessment (SOFA) scores (P = 0.0007), dose of vasopressor at the time of initiation of low-dose corticosteroid therapy (P < 0.0001), need for mechanical ventilation (P = 0.0001) and renal replacement therapy (P < 0.0001), while the impaired adrenal reserve did not affect 28-day mortality (81% versus 82%; P = 0.8679). After adjusting for potential confounding factors, the time to initiation of low-dose corticosteroid therapy was still significantly associated with 28-day mortality (adjusted odds ratio (OR) 1.025, 95% confidence interval (CI) 1.007 to 1.044, P = 0.0075). The early therapy group (administered within 6 hours after the onset of septic shock, n = 66) had a 37% lower mortality rate than the late therapy group (administered more than 6 hours after the onset of septic shock, n = 112) (32% versus 51%, P = 0.0132).ConclusionsEarly initiation of low-dose corticosteroid therapy was significantly associated with decreased mortality.

Comparison of Dose of Corticosteroid Therapy in Patients With Severe COPD Exacerbation in Intensive Care Unit

PURPOSE: Systemic corticosteroids are the mainstay of therapy for COPD exacerbation along with oxygen therapy, bronchodilators and antibiotics. They are shown to reduce treatment failure rates, hospital length of stay (LOS) as well as to improve lung function tests and dyspnea scores. The optimal dose and duration of steroid therapy is not defined specially in patients requiring mechanical ventilator (MV) support in the intensive care unit (ICU) setting. The purpose of our study was to compare outcomes with low dose (≤ 80mg methylprednisolone) vs high dose (> 80mg methylprednisolone) intravenous corticosteroid therapy in critically ill patients with severe COPD exacerbation requiring MV support.

Low‐dose hydrocortisone treatment for patients with septic shock: A pilot study comparing 3 days with 7 days

Although there is controversy regarding the benefit of low-dose corticosteroid therapy in patients with septic shock, the Surviving Sepsis Campaign has advocated that low-dose intravenous hydrocortisone be used to treat adult septic shock patients. This study investigated the effect of the duration of a stress dose of hydrocortisone on survival of septic shock patients with relative adrenal insufficiency. One hundred and thirty consecutive patients who met the American College of Chest Physicians/Society of Critical Care Medicine criteria for septic shock were included in the study. An additional inclusion criterion was vasopressor support after fluid resuscitation. The primary end-point was 28-day mortality, and the secondary end-points were shock reversal and mortality in the intensive care unit and hospital. All eligible patients were prospectively randomized to receive hydrocortisone treatment for 3 or 7days. Hydrocortisone treatment was started at a dose of 50mg every 6h. Baseline data at recruitment did not differ between the two groups. After 28days, mortality did not differ between the 3- and 7-day treatment groups (33.8% vs 36.9%, P=0.629). Mortality rates in the intensive care unit and hospital did not differ significantly between the two groups. The median time to withdrawal of vasopressor therapy was 5.0days in the 3-day treatment group and 6.4days in the 7-day treatment group (P=0.102). This pilot study showed that in patients with septic shock and relative adrenal insufficiency, 28-day mortality did not differ between those treated with low-dose hydrocortisone for 3 or 7days.

Cytomegalovirus Colitis and Hypo-IgG After Rituximab Therapy for Rheumatoid Arthritis

To the Editor: Rituximab (RTX) is an anti-CD20 antibody used in patients with rheumatoid arthritis (RA) after failure of anti-tumor necrosis factor (anti-TNF) therapy. Side effects are mainly infectious, probably related to B cell lymphopenia. However, opportunistic infections are not frequent with use of RTX. We describe a case of cytomegalovirus (CMV) colitis in a patient with RA with hypo-IgG after 2 cycles of RTX. A 66-year-old woman was followed for 18 years for RA with positive anticitrullinated protein antibodies and structural erosions. She was successively treated with methotrexate (MTX) alone for 17 years and then in combination with anti-TNF-α for 9 months (adalimumab, then etanercept), without success. She improved after a first course of RTX (1 gram twice) in 2007 associated with low-dose corticosteroid therapy (prednisone 10 mg daily) and MTX 10 mg. In July 2008, the serum IgG level was found to be low: 5.25 g/l; IgG level was not monitored … Address correspondence to Prof. Mariette; E-mail: xavier.mariette{at}bct.aphp.fr

Remitting seronegative symmetrical synovitis with pitting edema (RS 3PE) syndrome in a tertiary care hospital: A retrospective analysis

Remitting seronegative symmetrical synovitis with pitting edema (RS 3 PE) affects mainly elderly males, characterized by acute onset pitting edema of hands, negative rheumatoid factor and excellent result with short course of low dose corticosteroid therapy. To re-evaluate the clinical, laboratory features, management, and ultimate disease progression of RS 3 PE cases in rheumatology clinic in tertiary care hospital and compare results with previous literature. We selected the patients of RS 3 PE in the Rheumatology clinic, Medical College, Kolkata, between 1 January 2002 and 1 January 2010 and followed them up. Among the cases reviewed 23 were female patients and 12 were male patients with mean (SD) age of 54.74 (3.03) and 58.33 (5.33) years, respectively. Oral Hydroxychloroquine was started in all, giving a satisfactory result in 21 patients; rest of the 14 patients needed additional corticosteroid, to alleviate musculoskeletal symptoms. Baseline mean (SD) C-reactive protein and erythrocyte sedimentation rate were 21.63 (2.08) mg/L and 81.34 (9.29) mm/hr, respectively, and reduced to 3.23 (0.95) mg/L and 17.43 (5.55) mm/hr, respectively, following therapy. During follow-up, musculoskeletal symptoms relapsed in 17 patients, seven (20%) of them were found to be associated with malignancy. At the time of last visit during the follow-up period, only four patients developed definite arthropathy (one seronegative rheumatoid arthritis, three undifferentiated spondyloarthropathy), rest of the 31 cases were remitted. Regarding RS 3 PE, results of our study showed similarity with previous reports excepting the gender. Hydroxychloroquine has been proved as a good steroid-sparing agent in RS 3 PE. This study supported the association of RS 3 PE with malignancy in the previous literatures.

Complications in Immunosuppressive Therapy of Liver Transplant Recipients

In liver transplantation (LT), modern immunosuppressive protocol is focused on early corticosteroid (CS) weaning. The aim of the study was to investigate all early transplant-related complications using Clavien grading system, in order to identify a significant relation in two homogenous groups of consecutive liver transplanted patients, only different for steroid avoidance in immunosuppressive regimen. One group was treated with a tacrolimus-based CS-free immunosuppressive protocol, the other one underwent tacrolimus plus low dose CS therapy. The preoperative continuous variables analyzed were age, gender, model for end-stage liver disease (MELD) score, and the pre-allocation score for predicting survival following liver transplantation (P-SOFT). There were 39 patients in Group A (CS free) (37.9%), and 64 patients in Group B (CS on board) (62.1%). No statistically significant differences between the two groups were detected regarding the incidence and Clavien grade of complications (P = 0.116). No significant relation was revealed between Clavien rate of complications and tacrolimus-based CS-free immunosuppressive protocol, comparing the two subgroup of patient with P-SOFT score < 6 and ≥ 6 (P = 0.193). This association was noted comparing the two subgroups on tacrolimus plus low dose CS regimen (P = 0.013). In this series, the use of CS in sick patient is associated with higher morbidity identified by the Clavien classification.