Low-dose Steroids Research Articles

Healthcare Worker Having Irritant Contact Dermatitis Due to Rubber Accelerators: A Case Report

Irritant contact dermatitis (ICD) is common among workers, especially healthcare workers, partly due to medical latex gloves. The main element found in gloves is the accelerator. Most research indicates that thiurams and dithiocarbamate groups cause allergic contact dermatitis (ACD). Rattanarak et al, 2019 reported that accelerators could cause ICD. The current research was of a 26-year-old working as a nurse in the operating room, having symptoms of erythematous rash, burning sensation, and mild itching. Opened application test of the rubber gloves was negative. The suspected glove came from the Thai rubber latex company, which declined to provide information. However, Rojruthai et al, 2022 extracted and analyzed residual accelerators from Thai rubber latex gloves and found dithiocarbamates, ZDEC, ZDBC, ZMBT, and thiuram. The worker was diagnosed with occupational ICD from rubber accelerators, thiurams and dithiocarbamate, albeit cases are rare. The worker was treated with low-dose steroids and provided access to low-dermatitis potential medical gloves. After six months of follow-up, the worker recovered. Therefore, physicians should be aware of the signs and symptoms of ICD in workers exposed to accelerators in medical gloves. Avoiding causative substances is the most effective way to avoid ICD, so providing suitable low-dermatitis potential medical gloves is essential for this group of patients. Keywords: Case reports; Irritant contact dermatitis; Medical gloves; Rubber accelerator; Occupational

Impact of Corticosteroids for IrAEs on the Clinical Outcome of Immunotherapy in Patients With NSCLC.

The impact of corticosteroids for the treatment of immune-related adverse events (irAEs) on the antitumor effect of programmed cell death-1 (PD-1) inhibitor is unclear. A total of 172 patients with non-small cell lung cancer (NSCLC) treated with PD-1 inhibitors were retrospectively reviewed. Patients were divided into four groups: those who did not develop irAEs [1] and those who developed irAE and were either not treated with corticosteroids [2] or treated with low [3] or high doses [4], and overall survival (OS) was analyzed by the time of corticosteroid treatment. Landmark analysis was performed using Cox proportional hazard model with time-dependent covariates. A high-dose steroid treatment within 60 days correlated with a significantly worse OS than that of the group with irAEs without steroids (p=0.004). Moreover, there was no significant difference in OS between the irAE without steroid and low-dose steroid groups. Early severe irAEs and high-dose corticosteroid treatment were poor prognostic factors in patients with NSCLC treated with PD-1 inhibitors.

Therapeutic plasma exchange and continuous renal replacement therapy in pediatric dengue-associated acute liver failure: A case series from Vietnam

Background and objectivesPaediatric dengue-associated acute liver failure (PALF) is a rare and fatal complication. To date, clinical data regarding the combination of therapeutic plasma exchange (TPE) and continuous renal replacement therapy (CRRT) for the treatment of dengue-associated PALF are limited. MethodsWe conducted a single-center, retrospective study of all children with dengue-associated PALF admitted to the paediatric intensive care unit of Children Hospital No.2, Vietnam, who were treated with TPE+CRRT between January 2021 and March 2022. The main study outcomes were in-hospital survival, normalisation of hepatic function, and hepatic encephalopathy improvement. ResultsTwelve patients aged from 06 to 12 years underwent TPE+CRRT procedures. Among them, three (25 %) patients died of severe sepsis and septic shock confirmed by Enterobacteriaceae spp. haemocultures (stable on maintenance treatment of COVID-19-associated MIS-C with low dose of oral steroids on hospital admission), acute respiratory distress syndrome (ARDS), and clinically apparent intracranial haemorrhage. Nine patients (75 %) survived. The paediatric mortality risk score improved significantly at discharge compared with PICU admission (P < 0.01). Markedly, all twelve patients were diagnosed with hepatoencephalopathy of grades III and IV on PICU admission. After the combined TPE+CRRT interventions, there were substantial improvements in liver transaminases levels, coagulation profiles, and metabolic biomarkers. Normal neurological functions were observed in nine alive patients at hospital discharge. Only one patient experienced an adverse event of slightly low blood pressure, which rapidly self-resolved. Interpretation and conclusionsCombined TPE+CRRT significantly improved survival outcome, neurological status, and rapid normalisation of liver functions in dengue-associated PALF.

Variability of Steroid Prescription for COVID-19 Associated Pneumonia in Real-Life, Non-Trial Settings.

The RECOVERY study documented lower 28-day mortality with the use of dexamethasone in hospitalized patients on invasive mechanical ventilation or oxygen with COVID-19 Pneumonia. We aimed to examine the practice patterns of steroids use, and their impact on mortality and length of stay in ICU. We retrospectively examined records of all patients with confirmed Covid 19 pneumonia admitted to the ICU of Dubai hospital from January 1st, 2020 - June 30th, 2020. We assigned patients to four groups (No steroids, low dose, medium dose, and high dose steroids). The primary clinical variable of interest was doses of steroids. Secondary outcomes were 28-day mortality and length of stay in ICU". We found variability in doses of steroid treatment. The most frequently used dose was the high dose. Patients who survived were on significantly higher doses of steroids and had significantly longer stays in ICU. The prescription of steroids in Covid-19 ARDS is variable. The dose of steroids impacts mortality rate and length of stay in ICU, although patients treated with high dose steroids seem to stay more days in ICU.

Non-biologic, steroid-sparing therapies for non-infectious intermediate, posterior, and panuveitis in adults.

Non-biologic, steroid-sparing therapies for non-infectious intermediate, posterior, and panuveitis in adults.

A pragmatic randomized controlled trial of standard care versus steroids plus standard care for treatment of pneumonia in adults admitted to Kenyan hospitals (SONIA)

Background: It is unclear if adjunctive steroid therapy reduces mortality in community-acquired pneumonia, as very few studies have had mortality as a primary outcome. This question has become even more relevant following demonstration of a mortality benefit of dexamethasone when used in patients with COVID-19 who had severe disease. This has led to increased prescription of steroids in adults with community acquired pneumonia in low-resource settings even when their COVID-19 diagnosis is uncertain due to low testing rates. This pragmatic parallel randomised-controlled open-label trial will determine if adjunctive low-dose steroids for treatment of adults admitted to hospital with community acquired pneumonia whose SARS-CoV-2 status is either unknown or negative reduces mortality. Methods: We will enroll and randomize 2180 patients admitted with a clinical diagnosis of community acquired pneumonia into two arms; in Stratum A-participants will receive standard care for the treatment of community acquired pneumonia. In Stratum B-participants will receive a 10-day course of low-dose oral corticosteroids in addition to standard care. All participants will be followed up to 30 days post randomization and their final status recorded (alive or dead). An immunology sub study will be conducted on a subset of the trial participants (50 per arm) to determine the correlation of pre-existing and treatment induced immune and metabolic changes with study outcomes. Discussion: Mortality among adults admitted to hospital with community acquired pneumonia in resource-limited settings is high. Steroids are readily available in these settings. If the addition of steroids to standard care for community acquired pneumonia is found to be beneficial, this easily scalable intervention would significantly reduce the currently high mortality associated with the illness.

Primary membranous nephropathy: an endless story.

Primary membranous nephropathy (PMN) is an autoimmune disease caused by the attack of autoantibodies against podocyte antigens leading to the in situ production of immune complexes. However, the etiology is unknown and the pathogenesis is still far from being completely elucidated. MN is prevalently idiopathic or primary, but in about 20-30% of cases it is secondary to chronic infections, systemic diseases, exposure to drugs, or malignancy. The differentiation between primary and secondary MN may be difficult, particularly when MN precedes signs and symptoms of the original disease, as in some cases of cancer or systemic lupus erythematosus. The natural course of PMN is variable, but in the long term 40-60% of patients with nephrotic syndrome progress to end-stage renal disease (ESRD) or die from thrombotic or cardiovascular events. PMN is a treatable disease. Patients with asymptomatic proteinuria should receive supportive care. Immunosuppressive treatments should be given to patients with nephrotic syndrome or risk of progression. The most frequently adopted treatments rely on cyclical therapy alternating steroids with a cytotoxic agent every other month, i.e., rituximab at different doses, or calcineurin inhibitors plus low-dose steroids. A good rate of response may be obtained but relapses can occur. Randomized controlled trials, with adequate size, long-term follow-up, and fair definition of endpoints are needed to identify treatment with the best therapeutic index.

TIME TO EXPAND THE USE OF CASIRIVIMAB/IMDEVIMAB MONOCLONAL ANTIBODY THERAPY? A CASE OF COMPASSIONATE USE IN SEVERE COVID-19 PNEUMONIA

TIME TO EXPAND THE USE OF CASIRIVIMAB/IMDEVIMAB MONOCLONAL ANTIBODY THERAPY? A CASE OF COMPASSIONATE USE IN SEVERE COVID-19 PNEUMONIA

S2025 Eosinophilic Enterocolitis Improved After Breast Reduction

Introduction: Hypereosinophilic Syndrome (HES) is a group of disorders characterized by an accumulation of eosinophils within peripheral tissues or blood, with manifestations dependent on organ involvement. Eosinophilic gastrointestinal disorders (EGIDs) is one manifestation. In our case, it is believed that antigenic leakage from ruptured silicone breast implants was the proximate cause, as the patient had complete resolution of symptoms and normalization of labs after implant removal. Case Description/Methods: Our patient is a 59-year-old female with a history of asthma, who presents with new-onset sharp epigastric pain worsened with oral intake and associated with diarrhea. Recent evaluation at another hospital for leg weakness revealed peripheral eosinophilia and electromyography showed chronic inflammatory demyelinating neuropathy. After a full diagnostic evaluation for HES, she was diagnosed with idiopathic HES and treated with low dose steroids, IVIG and plasmapheresis without clinical improvement. At our hospital, labs revealed a white count of 35,000/μL, eosinophil count of 21,960/mm3 and IgE of 1299 IU/mL (Table). A CT scan revealed descending colon wall thickening, and intracapsular rupture of the right breast implant. Enteroscopy demonstrated erosions and ulcerations of the duodenum and jejunum. Colonoscopy showed areas of focal ulcerations with surrounding inflammation separated by normal mucosa and histology showed eosinophilic infiltration throughout. Video capsule endoscopy demonstrated diffuse inflammation and ulceration of the entire small bowel. She was empirically treated for strongyloides before starting high dose prednisone therapy. A month later, her breast implants were removed elsewhere. After a short interval, she was successfully tapered off steroids and achieved resolution of both her GI symptoms and lower extremity weakness, as well as normalization of lab work (Figure). Discussion: EGIDs are believed to be multifactorial with an emphasis on immunologic factors. Eosinophilic infiltration seen on biopsies and exclusion of secondary causes is required. Treatment is aimed at symptomatic improvement and removal of offending agent, as seen with our patient who experienced complete clinical resolution after removal of her silicone breast implants. Our case highlights a rare case of eosinophilic enterocolitis associated with a ruptured breast implant in an otherwise healthy patient and emphasizes the importance of remaining vigilant of all external factors that may be contributing to the disease process.Figure 1.: A, B: Small intestine duodenum & Jejunum. C, D: Colonic areas of inflammation. Table 1. - Initial labs versus labs post implant removal Units Reference Labs Initial Labs Labs post implant removal White Blood Count μL 4.0 - 10.5 35 x 103 7.1 Hemoglobin g/dL 11.2 - 15.7 9.6 11.2 Platelets μL 150-400 508 x 103 369 Eosinophil # μL 0.04 - 0.36 21,960 2.5 Eosinophils % 0.7-5.8 61 35 IgE IU/mL < 100 1299

Cardiac and vascular effects of low-dose steroids during the early phase of septic shock: An echocardiographic study.

BackgroundLow-dose steroids are known to increase arterial pressure during septic shock through restoration of vasopressor response to norepinephrine. However, their effects on cardiac performance and ventriculo-arterial coupling (VAC) have never been scrutinized during human septic shock. The aim of this study was to perform a comprehensive description of the cardiovascular effects of low-dose steroids using modern echocardiographic tools (including speckle tracking imaging).MethodsThis prospective study was conducted in the intensive care unit (ICU) of a university hospital in France. Consecutive adult patients admitted for septic shock and requiring low-dose steroid therapy were prospectively enrolled within 24 h of septic shock onset. We recorded hemodynamic and echocardiographic data to explore left ventricle (LV) contractility, loading conditions and VAC just before the initiation of low-dose steroids (50 mg intravenous hydrocortisone plus 50 μg enteral fludrocortisone) and 2–4 h after.ResultsFifty patients [65 (55–73) years; 33 men] were enrolled. Arterial pressure, heart rate, almost all LV afterload parameters, and most cardiac contractility parameters significantly improved after steroids. VAC improved with steroid therapy and less patients had uncoupled VAC (> 1.36) after (24%) than before (44%) treatment.ConclusionIn this comprehensive echocardiographic study, we confirmed an improvement of LV afterload after initiation of low-dose steroids. We also observed an increase in LV contractility with improved cardiovascular efficiency (less uncoupling with decreased VAC).

OA24 Airway obstruction in an adolescent: relapsing polychondritis

OA24 Airway obstruction in an adolescent: relapsing polychondritis

It Melts Like Snow: Steroid Responsiveness of Immunoglobulin G4-Related Disease

Dear Editor, A 35-year-old male presented with insidious onset gradually progressive bilateral painless submandibular swelling, followed by periorbital swelling [Figure 1] for the past 7 years. He had no constitutional or sicca symptoms. He had no history of addiction or autoimmunity in the family. Systemic examination was unremarkable. On evaluation, he had raised inflammatory markers with a negative autoimmune panel. Magnetic resonance imaging orbit showed bilateral orbital extraconal soft-tissue masses with contrast enhancement. Incisional biopsy from the extraconal mass was suggestive of fibrocollagenous stroma with aggregation of lymphocytes, plasma cells, and histiocytes without any necrosis or granuloma. On further evaluation, submandibular gland biopsy showed chronic sialadenitis with immunoglobulin G4 (IgG4)-positive plasma cell >10/hpf and IgG4: IgG ratio >40% [Figure 2] without any major organ involvement on imaging. The diagnosis of IgG4-related disease was kept. He was started on oral steroid 0.5 mg/kg/day and observed a rapid clinical response within 15 days of steroid therapy. Later, he was started on azathioprine and continued with tapering dose of steroid. He was followed up every month for first 3 months and then every 3 monthly upto 16 months without any signs of recurrence. For a long-standing indolent disease of 7 years, drastic steroid response with resolution of clinical symptoms was quite evident in our case.Figure 1: (a) Pretreatment bilateral upper eyelid swelling, (b) pretreatment bilateral submandibular swelling, (c and d) during glucocorticoid therapy (day 15) resolution of orbital and submandibular swelling, respectivelyFigure 2: Salivary gland with seromucinous acini and ducts embedded in mildly fibrotic stroma with numerous lymphoid follicles with germinal centers (a and b: H and E). Clusters of plasma cells are highlighted with CD138 immunohistochemical stain (c). IgG4 positive cells, >10/hpf (d)IgG4-related disease (IgG4-RD) is a chronic, systemic, fibroinflammatory condition with variable organ manifestation. CD4+ T-cells and B-cells are central to the pathogenesis causing organ damage and fibrosis. Marked expansion of IgG4-secreting plasmablast in the blood is usually seen in active and untreated cases.[1] Key to diagnosis is the classical histopathological hallmarks of lymphoplasmacytic infiltrate, storiform fibrosis, and obliterative phlebitis. IgG4 RD usually has a good response to steroids but a variable relapse rate. Factors associated with lesser treatment response and relapse were well analyzed in a Japanese multicenter study. Multivariate analysis from the study revealed that intermediate steroid initial dose (0.4–0.69 mg/day), slow tapering regimen (<0.4 mg/day), and shorter disease duration were associated with a significantly lower rate of disease relapse.[2] The study of isolated IgG4 ophthalmic disease also echoed similar results regarding steroid response and relapse, with more relapse in those with elevated serum IgG4 levels and a shorter duration of initial steroid treatment (<5 months). Low-dose steroid maintenance should be considered to avoid recurrence in patients with elevated serum IgG4 levels.[3] Later on, rituximab therapy showed promising results in inducing remission[4] and steroid-free long-term maintenance.[5] Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

The role of lower dose steroid therapy with vitamin D replacement in patients with idiopathic granulomatous mastitis.

Low-dose steroid therapy has been recommended in idiopathic granulomatous mastitis (IGM) in various studies in the literature, but the therapeutic minimum dose has not been determined yet. Furthermore, vitamin D deficiency, the effect of which is accepted in autoimmune diseases, has not been previously examined in IGM. The aim of our study was to evaluate the efficacy of lower dose steroid theraphy with adjustment of vitamin D replacement doses with measuring serum 25-hydroxyvitamin D levels in patients with idiopathic granulomatous mastitis (IGM). Vitamin D levels were evaluated in 30 IGM patients who applied to our clinic between 2017-2019. Vitamin D replacement was performed in patients with serum 25-hydroxyvitamin D level below 30 ng/mL and prednisolone was given to all patients at a dose of 0.05-0.1 mg/kg/ day. Clinical recovery times of the patients were compared with the literature. Vitamin D replacement was given to 22 (73.33%) patients. Recovery time was shorter in patients receiving vitamin D replacement (7.62 ± 2.38; 9.00 ± 3.38; p= 0.680). Average recovery time was 8.00 ± 2.68 weeks. Treatment of IGM can be carried out with lower dose steroid therapy, leading to less complications and lower costs. Measuring serum 25-hydroxyvitamin D level and treating it with the appropriate dose may contribute to the healing process.

Perioperative management of patient with late rheumatoid arthritis and post-bone tuberculosis with genu contracture undergoing tenotomy

Background: Rheumatoid arthritis (RA) is an autoimmune and inflammatory disease that potentially attacks all parts of the human body. Despite the use of disease-modifying anti-rheumatic drugs (DMARDs), the rate of total knee arthroplasty (TKA) remains high. Critical complications such as infection, dislocation, and readmission following TKA are also reportedly high and therefore, appropriate management during perioperative period is critical. We reported the perioperative management of a patient with late RA and genu contracture underwent tenotomy. Case Presentation: A 22-year-old male was referred to Dr. Soetomo General Hospital with a chief complaint of pain in the right and left groin. He also complained of immobilization and stiffness in both knees. He had been diagnosed with bone tuberculosis in 2014 and underwent a total knee replacement of both knees in 2015 due to stiffness and inability to walk. Radiography examination indicated erosion and loss of joint spaces in the joints of the hip, fingers, and toes. Laboratory investigation showed positive anti-mutated citrullinated vimentin (anti-MCV), confirming RA. The patient underwent tenotomy surgery and was treated with methylprednisolone 4 mg peroral daily, chloroquine 250 mg peroral daily, and natrium diclofenac peroral to reduce pain. Tenotomy was performed. Considering the disease activity, conventional DMARDs (chloroquine 250 mg peroral and low dose steroid, methylprednisolone 1x4mg peroral) were prescribed. Conclusion: The case highlights the complexity of perioperative management of late RA and genu contracture underwent tenotomy that required multiple disciplines. Therefore, interdisciplinary collaborative team is critical to be able to achieve optimal results of the patient.

A clinical study of mycophenolate mofetil combined with low-dose steroids in the management of pediatric systemic lupus erythematosus

Purpose: To investigate the efficacy and safety of mycophenolate mofetil (MMF) combined with lowdose steroids in the treatment of pediatric systemic lupus erythematosus (pSLE).Methods: A total of 76 children were diagnosed and admitted with SLE, lupus nephritis (LN) and type IV diffuse proliferative glomerulonephritis at Hainan Women and Children’s Medical Center, Haikou, China from March 2017 to December 2018, had their clinical data analyzed retrospectively. Among them, 38 children received methylprednisolone pulse combined with MMF and intermittent oral low-dose glucocorticoids (GC), labelled MMF group, while the remaining 38 children, which served as control group, were treated with oral GC and transitional reduction. Pertinent biochemical parameters were evaluatedResults: Compared with control group, MMF group showed a notably lower level of erythrocyte sedimentation rate (ESR), a higher level of complement C3, lower level of serum creatinine (Scr) and 24-h urine protein level 6 months after treatment (p &lt; 0.05). Albumin level was higher in MMF group at 6 months and 12 months after treatment than in the control group. Compared to control group, the SLEDAI score in MMF group was significantly lower at 6 months and 12 months after treatment (p &lt; 0.05). Body mass index, triglyceride, fasting blood glucose and intraocular pressure levels in the MMF group were significantly lower than those in the control group (p &lt; 0.05). Post-treatment, peripheral blood CD3+ and CD4+ T lymphocytes, CD4+/CD8+ ratio and NK cell levels in the two groups were significantly increased, while CD8+ T lymphocyte level declined.Conclusion: MMF combined with low-dose methylprednisolone controls symptoms early and mitigates renal injury in the treatment of pSLE. It is also safe, and effectively regulates the patient's cellular immune function.

Meta-Analysis of the Effect of Glucocorticoids on Adult Acute Respiratory Distress Syndrome.

Objectives The aim of this study is to investigate the effect of glucocorticoids in adult patients with acute respiratory distress syndrome (ARDS) by meta-analysis. Methods PubMed, Cochrane Library, Embase, CNKI, Wanfang Database, and Chinese Biomedical literature database were searched. A randomized controlled trial (RCTS) on glucocorticoid therapy in adult patients with ARDS was conducted from the time of database construction to December 2021. The content is about the randomized controlled trial (RCT) of glucocorticoid treatment for adult patients with ARDS, without limiting the dose and course of glucocorticoid treatment. The quality of the included RCTS was evaluated by using the bias risk assessment tool of the Cochrane Collaboration network, and the basic information, clinical features, and target outcomes of the literature were extracted. The effects of glucocorticoids on mortality and oxygenation index (PaO2/FiO2) in adult ARDS patients were evaluated by meta-analysis. Results A total of 1,441 ARDS patients in 10 RCTs were finally included, including 734 patients in the glucocorticoid treatment group (hormone group) and 707 patients in the conventional treatment group (control group). The 10 studies included have a good overall design and high quality. Compared with controls, glucocorticoid use was significantly associated with a decrease in mortality in adult ARDS patients (relative risk (RR) = 0.73, 95% confidence interval (95% CI) = 0.59–0.90, P = 0.003). Analysis showed that glucocorticoids significantly reduced the mortality in ARDS patients treated with medium and low doses of steroids (RR = 0.73, 95% CI = 0.58–0.92, P = 0.007). In patients with early administration of steroids, intervention with glucocorticoids was significantly associated with the decreased mortality in adult ARDS patients compared with controls (RR = 0.74, 95% CI 0.56–0.99, P = 0.04). Among patients with more than 7 days of hormone therapy, treatment with glucocorticoids was significantly associated with decreased mortality in adult ARDS patients (RR = 0.66, 95% CI = 0.50–0.88, P = 0.005) compared with controls. Glucocorticoids tended to improve PaO2/FiO2 in adult ARDS patients compared with controls, but the difference was not statistically significant (weighted mean difference (WMD) = 11.60, 95% = CI = 15.02–38.22, P = 0.39). Conclusion Glucocorticoid therapy can reduce mortality in adult ARDS patients, and the benefit is more pronounced in patients with medium- and low-dose hormone therapy, early hormone administration, and hormone therapy for more than 7 days. However, no improvement in PaO2/FiO2 by glucocorticoid treatment was found, which needs to be confirmed by further studies.

Mucin receptors in chronic rhinosinusitis with nasal polyps

Background Nasal polyps (NPs) are non-neoplastic, painless inflammatory lesions of the sino-nasal mucosa. Nasal polyp physiopathology is not yet fully understood. There are many potential etiologies of NP, including chronic infections, allergies, asthma, aspirin sensitivity, anatomical disorders, and genetic causes. Objective The purpose of our study was to immunohistochemically demonstrate the presence of mucin (MUC) receptors in chronic rhinosinusitis (CRS) with nasal polyps and determine the relationships between the presence of these receptors and clinical findings. Material and Methods A total of 59 patients who underwent functional endoscopic sinus surgery due to CRS with NPs were included in the study. Groups with positive and negative MUC receptors were evaluated according to their clinical characteristics. Results According to the data we have obtained, surgery site quality and low-dose steroid response worsened with MUC5A receptor positivity and there were no significant relationships between MUC1 receptor positivity and clinical findings. Conclusion According to our results, MUC5A receptor positivity was associated with impaired surgical site quality and a reduced response to low-dose systemic steroids by NPs.

Management of Subacute Thyroiditis - A Systematic Review of Current Treatment Protocols.

PurposeThis systematic review endeavors to find an effective treatment protocol for subacute thyroiditis (SAT) to minimize side effects, recurrence and long-term hypothyroidism.Materials and MethodsWe analyzed available original studies on treatment protocols for SAT. A thorough literature search was performed on the following online databases PubMed, Cochrane library nd Google Scholar using appropriate keywords for choosing relevant articles. Two reviewers assessed the methodological quality of selected articles independently using a critical appraisal instrument. The results were analyzed and synthesized qualitatively using the level of evidence method.ResultsThe literature search retrieved a total of 460 publications after abstract screening; out of which 36 articles met the inclusion criteria. After full text screening, 23 articles were further excluded as they were focusing on aspects of SAT other than management, the remaining 15 articles were investigated for both reliability and validity. Thirteen studies provided low-quality evidence, and two randomized control trials (RCT) provided a high quality of evidence. Steroid therapy was found to be the most effective for moderate to severe SAT and provided relief from acute symptoms but was found to not be a risk factor for recurrence. Low initial doses of steroid (15 mg) were preferred over high initial dosage (30–40 mg). Furthermore, a look into the mode of steroid delivery (RCT) revealed that intrathyroidal steroid therapy can potentially become a safer and faster mode of therapy. The duration of tapering was found to be of significance as a short tapering period was linked with greater recurrence rates.ConclusionLow initial doses of steroid along with an extended tapering period may help lower recurrence rates; also, intrathyroidal steroid injections are potentially a better alternative to oral prednisone (PSN) with regard to safety and speed of action. However, the evidence is of moderate quality and further investigation is required.

Nocardia cyriacigeorgica brain abscess in a patient on low dose steroids: a case report and review of the literature

BackgroundNocardia cyriacigeorgica was first described in 2001. It is an emerging pathogen that mainly affects immunocompromised patients. A brain abscess caused by N. cyriacigeorgica has been reported only in immunocompromised hosts. We present a rare case of brain abscess caused by N. cyriacigeorgica in an adult male receiving low dose steroids.Case presentationA 75-year-old male weekend gardener without an immunocompromising condition presented with neurological complaints that were initially attributed to an ischemic stroke. Due to the unusual presentation and rapid progression, his condition was thought to be caused by a cerebral space-occupying lesion. He underwent an emergent right-sided parietal craniotomy and the histopathological report of the specimen was an abscess caused by N. cyriacigeorgica. The patient received appropriate antibiotic treatment and completely recovered without sequelae.ConclusionsNocardia species are a rare cause of brain abscess in immunocompetent patients. Their clinical presentation can mimic other more common cerebral diseases, such as brain tumors (primary and secondary) and stroke. The possibility of an abscess caused by N. cyriacigeorgica should also be considered in the differential diagnosis in an immunocompetent patient.

Co-Treatment with Steroid and Dupilumab for Eosinophilic Chronic Rhinosinusitis after Eosinophilic Pneumonitis Caused by Dupilumab.

Eosinophilic chronic rhinosinusitis (ECRS) is a Type 2 inflammatory disease that manifests as chronic inflammation of the paranasal sinus. IL-4/IL-13 receptor monoclonal antibodies (dupilumab) to suppress Type 2 inflammation have become a good treatment option for patients who are refractory to surgery. Most patients respond normally, although significant side effects such as eosinophilic pneumonia may occur, requiring discontinuation of dupilumab. Here, we present a case in which dupilumab administration caused a side-effect of eosinophilic pneumonia. A 65-year-old woman presented with nasal obstruction and olfactory dysfunction due to a nasal polyp. Her symptoms temporarily improved with dupilumab; however, dupilumab was discontinued due to eosinophilic pneumonia. Discontinuation of dupilumab resulted in the rapid resolution of eosinophilic pneumonia and reappearance of nasal polyps. We, therefore, resumed dupilumab treatment in combination with low-dose steroids; eosinophilic pneumonia did not flare up, and the nasal polyps shrank steadily. There is no established treatment strategy in cases where a side effect of eosinophilic pneumonia arises while treating ECRS with dupilumab. Based on the described case, we recommend that a combination of a low-dose steroids and dupilumab be considered as a treatment option to counter the side-effect of eosinophilic pneumonia induced by dupilumab alone.