Oral Corticosteroid Treatment Research Articles

Predictive Factors for Autoimmune Pancreatitis Relapse After 3 Years of Maintenance Therapy.

Oral corticosteroid treatment is the standard therapy for autoimmune pancreatitis (AIP) and is highly effective. However, relapse may occur during maintenance therapy (MT). We aimed to clarify the predictive factors for relapse after 3 years of MT for use in deciding on the continuation of long-term MT. Among 56 retrospectively recruited AIP patients who received corticosteroid remission induction therapy followed by MT for a minimum of 5 years, 38 subjects were enrolled after exclusion criteria and divided into the relapse group of patients who experienced relapse after 3 years of MT and the nonrelapse group of patients who did not. According to multivariate analysis, at least 4 other organ involvement numbers at diagnosis (hazard ratio, 5.82; 95% confidence interval, 1.203-28.192) and IgG of 1400 mg/dL or greater at 3 years of MT (hazard ratio, 4.41; 95% confidence interval, 1.096-17.790) were predictive factors for relapse after MT for 3 years, with patients exhibiting both predictive factors having a higher cumulative relapse rate than those with 1 or fewer predictive factor. We uncovered 2 predictive factors for AIP relapse after 3 years of MT. These findings will assist in deciding corticosteroid therapy regimens at 3 years of MT to minimize AIP relapse risk and adverse corticosteroid effects.

The Severe Asthma Network in Italy: Findings and Perspectives

Severe Asthma Network in Italy (SANI) is a registry of patients recruited by accredited centers on severe asthma. To analyze epidemiological, clinical, inflammatory, functional, and treatment characteristics of severe asthmatics from the SANI registry. All consecutive patients with severe asthma were included into the registry, without exclusion criteria to have real-life data on demographics, asthma control, treatments (including biologics), inflammatory biomarkers, and comorbidities. A total of 437 patients (mean age: 54.1 years, 57.2% females, 70.7% atopics, 94.5% in Global Initiative for Asthma severity step V) were enrolled into the study. The mean annual exacerbation rate was 3.75. The mean blood eosinophil level was 536.7 cells/mcL, and the average serum total IgE was 470.3 kU/L. Approximately 64% of patients were on regular oral corticosteroid treatment, 57% with omalizumab and 11.2% with mepolizumab. Most common comorbidities were rhinitis, nasal polyposis, and bronchiectasis. Patients with nasal polyposis had higher age of disease onset, higher blood eosinophil count, and lower frequency of atopy and atopic eczema. Bronchiectasis was associated with more frequent severe exacerbations, higher blood eosinophils, and total IgE. Stratifying patients, those with late-onset asthma were less frequently atopic (with less frequent allergic rhinitis and food allergy), and more frequently with nasal polyposis and higher serum total IgE levels. This study revealed a high frequency of relevant comorbidities and that a substantial proportion of patients have late-onset asthma; all these features define specific different disease phenotypes. Severe asthma complexity and comorbidities require multidisciplinary approaches, led by specifically trained pulmonologists and allergists.

PSS57 - TREATMENT OF ATOPIC DERMATITIS IN PORTUGAL: INSIGHTS FROM A PHYSICIANS’ SURVEY

The study aimed at assessing physicians’ prescribing behavior regarding the treatment of adults with Atopic Dermatitis (AD) in Portugal, as well as their perception on treatments and unmet needs. A physician primary market research study was conducted through computer assisted web interviewing. A total of 59 physicians were screened to reach the target sample of 50 physicians who responded to the complete survey, including 40 dermatologists and 10 allergists. Furthermore, 9 in-depth interviews with dermatologists and allergists were conducted to validate the surveys’ outcomes. In 2017, 40% to 45% of adults with AD followed by dermatologists or allergists were classified as having moderate to severe disease. Ninety-one percent of these patients were treated in the past 12 months. Of untreated patients, 36% were due to contraindications, 36% due to previous lack of response, and 29% due to patient decision. Amongst treated patients, 37% were exclusively on topical treatment - including TCS and TCI – while the remaining received other treatments associated or not with topical treatment,: 11% phototherapy; 25% oral corticosteroids (OCS); 15% cyclosporine; 7% other immunosuppressants; 2% biologics; and 3% other combinations. 24% of moderate to severe patients were uncontrolled with current treatment, of which 74% were on topical or OCS treatment. For 50% of physicians, the efficacy in reducing the AD’s signs intensity and disease extension was the most important attribute for treatment prescription, followed by efficacy in reducing pruritus. Physicians’ classification of treatment options simultaneously positioned those regarded as most effective as being less safe (namely OCS and immunosuppressants). Based on physicians’ surveys and in-depth interviews, a comprehensive understanding of AD treatment prescribing behavior was attained. One-third of moderate to severe patients were either uncontrolled with their current treatment or not treated, demonstrating the high unmet need.

PGI23 - COST-EFFECTIVENESS ANALYSIS OF PARENTERAL METHOTREXATE FOR THE TREATMENT OF CROHN’S DISEASE IN THE CZECH REPUBLIC

Clinical evidence suggests that parenteral methotrexate (MTX) provides benefit for induction of remission and complete discontinuation of high-dose oral corticosteroid treatment (hdCS; >20mg/day) in patients with Crohn’s disease (CD). Our aim was to assess cost-effectiveness of MTX in the treatment of mild-to-moderate CD in comparison to hdCS/placebo with its gradual withdrawal in the Czech Republic. We developed a three-year Markov model with one-week cycle length in TreeAge. The model comprises four health states – initial state of mild-to-moderate CD (16-week treatment with MTX or hdCS), steroid-free remission, lack/loss of response and death. It projects quality-adjusted life-years (QALYs) and costs from healthcare payers’ perspective. Costs were based on list prices, reimbursement tariffs and previous pharmacoeconomic analyses as of 02/2018. Costs and outcomes were discounted by 3%. Transition probabilities between health states were provided by clinical trials and extrapolated using survival analysis. Mortality rate was taken from Czech mortality tables and adjusted to CD. Utilities were derived from the published mapping algorithm. One-way sensitivity analysis (OWSA) accompanied by scenario analysis (SA) was performed. Probability sensitivity analysis (PSA; 10,000 iterations) was run using an implicit willingness-to-pay threshold (WTP) of €47,000/QALY. Over a three-year time horizon, MTX yields additional 0.06 QALYs (1.92 vs. 1.86) at the additional total cost of €761 (€2263 vs. €1503) compared with hdCS, with the incremental cost-effectiveness ratio of €13,077/QALY. PSA showed that probability of MTX to be cost-effective was 99.89% at the WTP. OWSA and SA confirmed the robustness of the base-case result with all one-way changes and scenarios deeply below WTP. Parenteral MTX is a cost-effective therapy for patients with mild-to-moderate CD receiving hdCS. Therefore, it was swiftly and positively assessed by the local authority. To our knowledge, this is the first published cost-effectiveness analysis of parenteral MTX for this indication.

Shall We Focus on the Eosinophil to Guide Treatment with Systemic Corticosteroids during Acute Exacerbations of COPD?: PRO.

In an era of precision medicine, it seems regressive that we do not use stratified approaches to direct treatment of oral corticosteroids during an exacerbation of chronic obstructive pulmonary disease (COPD). This is despite evidence suggesting that 40% of COPD patients have eosinophilic inflammation and this is an indicator of corticosteroid response. Treatments with oral corticosteroids are not always effective and not without harm, with significant and increased risk of hyperglycemia, sepsis, and fractures. Eosinophils are innate immune cells with an incompletely understood role in the pathology of airway disease. They are detected at increased levels in some patients and can be measured using non-invasive methods during states of exacerbation and stable periods. Despite the eosinophil having an unknown mechanism in COPD, it has been shown to be a marker of length of stay in severe hospitalized exacerbations, a predictor of risk of future exacerbation and exacerbation type. Although limited, promising data has come from one prospective clinical trial investigating the eosinophil as a biomarker to direct systemic corticosteroid treatment. This identified that there were statistically significant and clinically worsened symptoms in patients with low eosinophil levels who were prescribed prednisolone, demonstrating the potential utility of the eosinophil. In an era of precision medicine our patients’ needs are best served by accurate diagnosis, correct identification of maximal treatment response and the abolition of harm. The peripheral blood eosinophil count could be used towards reaching these aims.

Consequences of long-term oral corticosteroid therapy and its side-effects in severe asthma in adults: a focused review of the impact data in the literature.

This review provides an overview of the role of long-term treatment of severe asthma with oral corticosteroids (OCS) and its associated side-effects in adults. It is based on a systematic literature search conducted in MEDLINE, Embase and the Cochrane Library to identify relevant studies. After a short overview of severe asthma and its treatment we present studies showing a dose-response relationship in asthmatic patients treated with OCS and then consider by organ systems the undesired effects demonstrated in clinical and epidemiological studies in patients with OCS-dependent asthma. It was found that the risk of developing various OCS-related complications, including infections, diabetes and osteoporosis as well as psychiatric disorders, was higher for patients with long-term exposure to OCS compared with control groups. In addition, studies showed a significant increase in healthcare resource utilisation due to OCS treatment. Therefore, it is incumbent on every clinician to carefully weigh the potential benefit of preventing loss of asthma control against this risk before opting to prescribe long-term OCS therapy. Effective corticosteroid-sparing strategies must be used and should aim at short-term use with the lowest effective dose and start tapering as soon as possible until OCS therapy is terminated.

Health care resource utilization and cost for asthma patients regularly treated with oral corticosteroids \u2013 a Swedish observational cohort study (PACEHR)

BackgroundPatients with severe uncontrolled asthma may receive oral corticosteroid (OCS) treatment regularly. The present study investigated the health care resource utilization and cost in regularly OCS treated Swedish asthma patients.MethodsPrimary care medical records data were linked to data from Swedish national health registries. Patients ≥18 years with a drug claim for obstructive pulmonary diseases during 2007–2009 (index date) and a prior asthma diagnosis, were classified by their OCS claims during the 12-months’ post index period: regular OCS equals ≥5 mg per day; periodic OCS less than 5 mg per day; or non-OCS users. Cost of asthma- and OCS-morbidity-related health care resource utilization were calculated.ResultsA total of 15,437 asthma patients (mean age 47.8, female 62.6%), whereof 223 (1.44%) were regular OCS users, 3054 (19.7%) were periodic, and 12,160 (78.7%) were non-OCS users. Regular OCS users were older and more often females, had lower lung function, greater eosinophil count and more co-morbidities at baseline compared with the other groups. Age-adjusted annual total health care cost was three-times greater in the regular OCS group (€5615) compared with the non-OCS users (€1980) and twice as high as in the periodic OCS group (€2948). The major cost driver in the non-OCS and periodic OCS groups were primary care consultations, whereas inpatient costs were the major cost driver in the regular OCS group. The asthma related costs represented 10–12% of the total cost in all three groups.ConclusionIn this real-life asthma study in Sweden, the total yearly cost of health care resource utilization for a regular OCS user was three times greater than for a patient with no OCS use, indicating substantial economic and health care burden for asthma patients on regular oral steroid treatment.

Efficacy and Safety of Low-to-Moderate Dose Oral Corticosteroid Treatment in Ocular Myasthenia Gravis.

To evaluate the response to corticosteroid therapy as a primary treatment for ocular myasthenia gravis. Patients diagnosed as having ocular myasthenia gravis by an acetylcholine receptor binding antibody test between January 2011 and September 2015 were included in the study and started receiving treatment with a corticosteroid. Patients with a blowout fracture, hyperthyroidism, diabetes mellitus, hypertension, cardiovascular disease, or history of strabismus surgery were excluded. Disappearance of diplopia and ptosis were considered a response to treatment. Methylprednisolone therapy was administered to 29 patients (19 men and 10 women; average age: 49 ± 16.5 years) as an initial treatment. A total of 6 patients were lost to follow-up. Twenty-three of 29 patients (82.6%) were regarded as having presented a response to treatment. The average treatment duration was 3 weeks for patients responding to primary treatment. Eight patients complained of adverse effects from steroid therapy such as heartburn, insomnia, weight gain, and myalgia. A corticosteroid could be considered as an initial treatment for patients diagnosed as having ocular myasthenia gravis by an acetylcholine receptor binding antibody test. [J Pediatr Ophthalmol Strabismus. 2018;55(5):339-342.].

Omalizumab Treatment for Severe Atopic Asthma in a Real World Montréal Cohort

Background: Individuals with severe atopic asthma are poorly controlled with standard treatments, including corticosteroids. A humanized monoclonal antibody binding immunoglobulin E (IgE), omalizumab, is approved to treat patients that are managed poorly despite optimal therapy and that have elevated serum levels of IgE. Objective: The purpose of this study was to determine omalizumab’s effectiveness in a real-world setting. The primary outcome was the number of exacerbations of asthma requiring oral corticosteroid treatment in the 2 year pre-treatment period compared to 2 years post-treatment. The secondary outcome was cumulative dose of prednisone used before and after treatment. Other outcomes that were measured included: reduction in maintenance therapy, change in spirometry (FEV1) data, the stratification of patient population based on smoking status, and average exacerbation number and prednisone use as a function of IgE level and blood eosinophilia count. Methods: Patient data were retrieved (n=41) through the hospital records of patients treated at the Montreal Chest Institute of the McGill University Health Center. Data were gathered and analyzed for the 2 years before the treatment start date and compared to data 2 years after. Results:There was a significant reduction in average exacerbation number from 6.4 pre-treatment to 3.2 post-treatment (p=0.003). There was also a reduction in cumulative prednisone use from 2504mg to 1423mg (p=0.04) following the institution of omalizumab treatment. There was no correlation between either the initial IgE levels and blood eosinophilia and the reduction in exacerbations Conclusion: Omalizumab was effective in reducing exacerbation number and prednisone use for patients with severe refractory asthma.

Efficacy and Safety of Immunosuppressive Agents for Thyroid Eye Disease

To present an update on the efficacy and safety of immunosuppressive therapy for thyroid eye disease (TED) and to offer a general recommendation for management of TED, in light of these reports. Data were retrieved from a literature search on PubMed, using the following words: thyroid eye disease, immunosuppressant, corticosteroid, methotrexate, azathioprine, cyclosporine, cyclophosphamide, rituximab, etanercept, adalimumab, tocilizumab, teprotumumab, adverse effects, side effects, and complications. Corticosteroids continue to be the primary medical therapy for TED. Recent research has offered insight into potential differences between oral corticosteroid and intravenous corticosteroid treatment regimens in terms of efficacy and side-effect profiles, which proved more favorable for the latter. The use of some traditional immunosuppressive agents, such as methotrexate and mycophenolate, seems suitable as steroid-sparing medications. In recent years, many scientific reports demonstrated the effectiveness of biologic immunosuppressive agents in the management of TED. Etanercept, adalimumab, and tocilizumab have been shown to be effective in reduction of the inflammatory signs with the possible added advantage of preventing relapse of the disease. Teprotumumab may control the disease activity, and it seems to be very effective in preventing disease progression. Infliximab might be useful in severe TED resistant to steroids and orbital decompression. Steroid therapy remains the first-line therapy for moderate/severe and severe vision-threatening TED. The biological agents may provide a deep and long-standing block of inflammatory activity in TED, with the hope to lower the risk of recurrences and to reduce the need of surgical intervention in moderate-to-severe disease. Indeed, the actual incidence of adverse effects is not yet well assessed because of the paucity of studies. Therefore, their use should be limited to those cases that really need an alternative therapy to steroids, handled by expert physician in this field.

TIM-3-Expressing Mast Cells Are Present in Chronic Rhinosinusitis with Nasal Polyps.

Objectives To identify whether TIM-3 expression is present in the mast cell population within nasal polyps and to determine its correlation with clinical severity in patients with chronic rhinosinusitis with nasal polyposis. Study Design Basic science, translational study. Setting Nasal polyp tissue collected from patients seen at a tertiary care hospital (2015-2016). Subjects and Methods Nasal polyp tissue obtained during functional endoscopic sinus surgery (n = 24) was enzymatically digested into epithelial and stromal fractions. Viable mast cells expressing TIM-3 were identified using flow cytometry for the following: CD45, Live/Dead, c-kit, FcεR1, TIM-3. Disease severity was assessed using the Sino-Nasal Outcome Test, Lund-Mackay staging system, Lund-Kennedy staging system, and complete blood counts. Results Mast cells were found in both the epithelial and stromal layers of polyps, with a greater %TIM-3+ mast cells in the epithelial layer compared with that of the stromal layer ( P = .001). As the percentage of mast cells increased, there was a comparative worsening in endoscopic severity after comparing pre- and postoperative LK scores (ρ = -0.455, P = .029). In a subgroup of patients with concomitant asthma, increased epithelial %TIM-3+ mast cells also correlated with worsening endoscopic appearance postoperatively (ρ = 0.866, P = .001, n = 11). Oral corticosteroid treatment did not change the viability of mast cells nor their influence on the increased postoperative endoscopic disease severity (ρ = -0.544, P = .020, n = 18). Conclusion Viable mast cells were found to be present in polyps with increased TIM-3 expression at the epithelial layer. This suggests that TIM-3 may play a role in chronic inflammation in CRSwNP via mast cell activation.

Prevalence of Osteoporosis in Male Patients with Chronic Obstructive Pulmonary Disease

Osteoporosis is one of the systemic features of COPD. Aims and objective is to determine the prevalence of osteoporosis in male COPD. In a cross-sectional study, we conducted dual-energy X-ray absorptiometry bone mineral density scans of the femoral neck and lumbar spine and collected data on smoking, duration of COPD, inhaled and oral corticosteroid treatment and staging by pulmonary function tests. We included 60 male patients with COPD, the mean age was 62.4 ± 8.1 years, smoking was 36.8 ± 17.2 smoking-pack year, duration of COPD was 5.4 ± 3.3 years, GOLD stage-III (56.7%) stage-IV (38.3%) and stage-II (5.0%), use of oral steroid (11.7%) inhaled steroid (63.3%) and none (25.0%). Normal bone mineral density was in 6 (10.0%), osteopenia in 24 (40.0%) and osteoporosis in 30 (50%) patients in femoral neck; whereas normal bone mineral density was in 4 (6.7%), osteopenia in 17 (28.3%) and osteoporosis in 39 (65.0%) patients in lumbar spine. Osteoporosis is highly prevalent in male COPD patients in both femoral neck and lumbar spine.Medicine Today 2018 Vol.30(1): 1-4

Nasal IL-25 predicts the response to oral corticosteroids in chronic rhinosinusitis with nasal polyps

Nasal IL-25 predicts the response to oral corticosteroids in chronic rhinosinusitis with nasal polyps

The Role of High Dose Intratympanic Dexamethasone as Salvage Therapy for Idiopathic Sudden Sensorineural Hearing Loss.

The aim of this study was to assess the efficacy of a single high dose intratympanic (IT) dexamethasone (DEX) as salvage therapy for idiopathic sudden sensorineural hearing loss (ISSNHL) after unsuccessful treatment with oral corticosteroid (CS). This was a prospective open-label study of 59 patients treated with IT DEX after systemic CS therapy has failed. All patients received high dose (24 mg/mL) IT DEX in a single injection through myringotomy. Of the 59 patients, 40.7% showed improvement in their mean pure tone average (PTA) with IT DEX (p=0.005). The difference in the mean PTA after oral CS treatment only from baseline was not statistically significant (p=0.074). The time from onset of hearing loss to the start of therapy was significantly associated with the outcome (p=0.03). We determined that high dose IT DEX as salvage therapy was beneficial when the primary treatment with oral CS had failed. An early start of the treatment significantly influenced the improvement of hearing.

Bilateral uveitis and macular edema induced by Nivolumab: a case report

BackgroundNivolumab is a fully human antibody which is routinely used at first therapy for metastatic melanoma. Usually, side effects are immune-related adverse events. We report a case of a man who developed bilateral anterior uveitis and macular serous retinal detachment during nivolumab treatment for metastatic melanoma.Case presentationA man on nivolumab treatment for a leg melanoma with duodenal and lymph nodes metastases developed a sudden bilateral visual acuity impairment and bilateral non-painfull redness eyes several days after the third infusion. The clinical examination showed a significant decreased of the visual acuity. Slit lamp examination revealed the presence of bilateral granulomatous keratic precipitates, anterior chamber cells +++, bilateral synechiae, bilateral papilledema and macular edema associated with serous retinal detachment in the left eye. The anti-Programmed cells Death-1 was stopped and a topical corticosteroid treatment was administrated. After 8 days of topical corticosteroid treatment visual acuity was worsening with similar optical coherence tomography examination. An oral corticosteroid treatment was started. Evolution was favorable with a decrease of ocular inflammation and a complete visual acuity recovery after 3 weeks. Nivolumab was re-initiated.ConclusionsThis is the second clinical report of bilateral anterior uveitis associated with macular serous retinal detachment related to anti-PD-1 treatment, and the first with nivolumab. Cases of uveitis were reported several times. Although rare, ophthalmologic manifestations that are rapidly recognized and adequately managed can be treated.

Risk Factors for Developing Choroidal Neovascular Membrane and Visual Loss in Punctate Inner Choroidopathy

To examine a large cohort of subjects with punctate inner choroidopathy (PIC) looking at risk factors for development of choroidal neovascular membrane (CNVM) and visual loss. Retrospective case series. A total of 203 participants (318 eyes) with PIC seen at Moorfields Eye Hospital between 1996 and2016. Information was gathered from the clinical notes of all subjects identified with PIC. Development of CNVM, moderate visual loss (MVL) (≤20/50), and severe visual loss (SVL) (≤20/200). Participants were predominantly young (median age at presentation, 32.9 years; interquartile range [IQR], 26.1-42.2), myopic (91.5%), female (87.2%), and white (75.9%). Disease was bilateral at presentation in 115 participants (56.7%), and CNVM was present at presentation in 152 eyes (47.8%). Median follow-up was 8.4 years. New CNVM occurred in 58 eyes (33.5% of affected eyes and 4.3% of initially unaffected eyes). An increased risk of developing CNVM was associated with the presence of a CNVM in the fellow eye (P < 0.0005; hazard ratio [HR], 2.73), and previous oral corticosteroid treatment was associated with halving of the risk of developing CNVM (P= 0.035; HR, 0.45). No difference was observed in visual outcome with oral corticosteroids, but subjects treated with anti-VEGF had better visual outcomes (12-month median visual acuity, logarithm of the minimum angle of resolution [logMAR] 0.00 with anti-VEGF and 0.20 without; P= 0.018). Median best-corrected visual acuity (BCVA) was 20/30 at presentation (IQR, 0.00-0.50) and remained at 20/30 throughout all follow-up periods. Moderate visual loss occurred in 40 eyes (12.6%), with an incidence of 0.01 per eye-year, and SVL occurred in 49 eyes (15.4%), with an incidence of 0.01 per eye-year. Female participants were half as likely as male participants to develop MVL (P= 0.030; HR, 0.448), and participants with CNVM had a higher risk of MVL (P= 0.003; HR, 21.074). Visual loss is common in subjects with PIC, predominantly secondary to late development of CNVM. Treatment with oral corticosteroids may help to reduce the risk of CNVM development, and anti-VEGF therapy for CNVM was associated with better clinical outcomes.

Oral corticosteroids for asthma exacerbations might be associated with adrenal suppression: Are physicians aware of that?

Oral corticosteroids (OCS) are a mainstay of treatment for asthma exacerbations, and short-term OCS courses were generally considered to be safe. Nevertheless, frequent short-term OCS courses could lead to hypothalamic-pituitary-adrenal (HPA) axis dysfunction. Our study aimed at investigating the integrity of the HPA axis in children with persistent asthma or recurrent wheezing at the beginning of an inhaled corticosteroids (ICS) trial. Morning basal cortisol was assessed just before the beginning of ICS, and 30, 60, and 90 days later, using Immulite® Siemens Medical Solutions Diagnostic chemiluminescent enzyme immunoassay (Los Angeles, USA; 2006). In all, 140 children (0.3-15 years old) with persistent asthma or recurrent wheezing have been evaluated and 40% of them reported short-term OCS courses for up to 30 days before evaluation. Out of these, 12.5% had biochemical adrenal suppression but showed adrenal recovery during a three-month ICS trial treatment. No significant differences were observed among children with or without adrenal suppression, neither in the number of days free of OCS treatment before cortisol evaluation (p=0.29) nor in the last OCS course duration (p=0.20). The number of short-term OCS courses reported in the year preceding the cortisol evaluation was also not different (p=0.89). Short-term systemic courses of corticosteroids at conventional doses can put children at risk of HPA axis dysfunction. ICS treatment does not impair adrenal recovery from occurring. Health practitioners should be aware of the risk of a blunted cortisol response upon exposure to stress during the follow-up of patients with persistent asthma or recurrent wheezing.

La tuberculose endobronchique

The endobronchial tuberculosis (EBTB) is an uncommon type of tuberculosis. The respiratory symptoms in EBTB are usually nonspecific and misleading. The aim of the study is to determine the clinical features and diagnostic aspects of EBTB. Twenty-eight cases of endobronchial tuberculosis collected from January 2009 to October 2015. EBTB was found in 16 females and 12 males. The mean age was 48 years. The history of tuberculosis and tuberculosis contagion were not found in any case. The respiratory symptoms were dominated by cough and dyspnea. Hemoptysis was found in 7 cases. The chest X-ray showed associated pulmonary lesions in 26 cases. Bronchoscopy finded an endobronchial granular lesion in 15 cases, a tumorous pattern in 7 cases; a thickening spurs in 4 cases and ganglio-bronchial fistula in two cases. Bronchial biopsies had found a caseo-follicular tuberculosis in 27 cases. Pleural biopsy confirmed associated pleural tuberculosis in one case. The research of Koch bacillus in the sputum was positive in 13 cases and culture in 6 cases. The antituberculosis treatment was started in all patients and an oral corticosteroids treatment was associated in 5 cases. The evolution was good in 26 cases. This study showed clinical, radiological and endoscopic bronchial tuberculosis polymorphism making its diagnosis difficult and the importance of a bacteriological and/or histological confirmation.

Paving the future of rhinosinusitis care.

Novel insights into the pathophysiology of chronic rhinosinsusitis (CRS) will lead to endo-type driven treatment and reduce oral corticosteroid treatment.

A rare case of autoimmune hypoglycaemia

We report the rare case of a female who presented with episodes of spontaneous hypoglycaemia. Although she had high baseline insulin and C-peptide levels during the time she was symptomatic, she tested negative on hypoglycaemia provocation test with ‘72 hour extended fast’. Patient was later found to have very high titres of insulin antibodies suggestive of insulin antibody syndrome (IAS). She developed this autoimmune antibody response with no known triggering factor. Her symptoms subsided completely after a short course of oral corticosteroid treatment.