Dose Oral Steroids Research Articles

466 The Combination of Left Ventricular Torsion and Global Strain Based on Two-Dimensional Speckle Tracking Echocardiography Could Detect Treatment-Requiring Rejection in Heart Transplant Recipients

detecting risk of rejection in cardiac transplant recipients. Clinical factors, other than cellular rejection, may be reflected in the results of this testing. A better understanding of these clinical factors is important in interpreting test results. We hypothesized that pre-transplant panel reactive antibody testing and racial mismatch between donor and recipient could affect GEP results. Methods and Materials: We studied 140 GEP test results performed in 52 post-cardiac transplant recipients at our center. Peripheral blood mononuclear cells were isolated and processed. Samples were subjected to Allomap® GEP testing. Some patients had a single test, and others had up to 9 tests performed at various time points. Results: The GEP test scores were evaluated using univariate and multivariate modeling. Since transplant rejection grade is known to increase GEP score, the data were stratified based on rejection grade. Current prednisone dose emerged as an independent predictor of the GEP score, consistent with previously published data. Intravenous or oral pulse steroid dosing within the previous 30 days also emerged as an independent predictor. Quantitative panel reactive antibody testing (p 0.05) and racial mismatch between the donor and recipient (p 0.05) were independent predictors of the GEP score. The age of the donor, the age of recipient, gender-mismatch between donor and recipient, and the use of cyclosporine-based immunosuppression versus tacrolimus-based immunosuppression were not independent predictors of GEP score. Conclusions: These data suggest that clinical factors affect immune activation, particularly pre-transplant panel reactive antibodies and donorrecipient differences. Furthermore, the data suggest that these effects persist on current immunosuppressant regimens and influence GEP test results. These clinical parameters should be taken into account when interpreting results of GEP testing.

Extensive Coronary Aneurysms With Thrombosis in Resistant Kawasaki Disease

Giant coronary artery aneurysms that occur in 0.5 to 1% of patients with Kawasaki disease can be fatal if associated with thrombosis. Some patients may show persistent inflammation and fever despite treatment with repeated doses of intravenous immunoglobulin (IVIG), steroids, and aspirin. This report describes an infant boy with resistant Kawasaki disease who presented with extensive coronary artery involvement and coronary thrombosis. His inflammation was not controlled with multiple doses of IVIG, parenteral and oral steroids, or high-dose aspirin, and he finally needed infliximab, a monoclonal antibody against tumor necrosis factor alpha. The progression of coronary thrombosis was arrested by the platelet glycoprotein 2b/3a receptor blocker, abciximab, during the acute phase of the disease.

Juvenile dermatomyositis is a different disease in children up to 3 years of age at onset than in children above 3 years at onset

ObjectiveJuvenile dermatomyositis (JDM) is a different disease than dermatomyositis in adults in many ways including more vascular inflammation and vasculopathic thrombosis as previously described. The authors tested the hypothesis that...

A fatal case of hepatitis B virus (HBV) reactivation during long-term, very-low-dose steroid treatment in an inactive HBV carrier

Hepatitis B virus (HBV) may be reactivated after chemotherapy or immunosuppressive therapy, and therefore administration of antiviral agents before such treatment is recommended. Most reported cases of reactivation are associated with high doses of immunosuppressive agents or combination therapy. We present a case of a previously inactive HBV carrier with an acute severe flare-up during a long-term, very-low-dose (2.5 mg/day) steroid treatment for rheumatoid arthritis. We suggest that even a minimal dose of single-regimen oral steroid can cause reactivation of indolent, inactive HBV.

The course and prognosis of pemphigus in 47 Tunisian patients

Pemphigus is a severe and life-threatening autoimmune bullous dermatosis. We have analysed parameters that may influence prognosis of pemphigus (P). It was a retrospective study (2002-2010), with pemphigus considered as severe if body surface involvement ≥ 30%. Disease control and relapse-free survival (Kaplan-Meier) were analysed and compared according to several parameters (P < 0.05). 47 cases of pemphigus were collected, mean age 51 years ± 16.8 (F/H = 3.27). There were 30 pemphigus profundus and 17 superficial pemphigus. The median remission period was of 9 months (1.2 months-5 years). The mean healing time was of 40 days (6 days-4 months), which did not depend on type of P, its severity or infectious complications, whereas it was shorter in aged patient (≥ 65 years) compared to non aged ones (P = 0.018). 36.2% of patients had relapsed. Relapses were significantly more frequently observed only in the presence of mucosal involvement at presentation (P = 0.015). The median overall 1st relapse-free survival was of 2.33 years. Only mucosal involvement at presentation was associated with a shorter median 1st relapse-free survival time (1.28 years vs. 3 years) (P = 0.0017). Mortality rate was of 10.6% (n = 5); in four patients the death was directly related to pemphigus and occurred rapidly after the onset of lesions. Our study illustrates the poor prognosis of pemphigus by a long duration to disease control, a high initial dose of oral steroid, a high rate of relapse and a short remission period. Only mucosal involvement at presentation was identified as a poor prognostic factor.

P107 Effectiveness of omalizumab on asthma control and lung function in severe allergic asthma patients in the Czech Republic

IntroductionAnti-IgE therapy (omalizumab) is indicated for severe persistent allergic asthma, which is uncontrolled despite appropriate therapy according to current GINA guidelines.Aim of this studyAim of this study was to describe...

Successful treatment of a pregnant woman with active systemic lupus erythematosus (SLE) and secondary idiopathic thrombocytopenic purpura (ITP) after three sessions of plasma exchange: a case report

We report a case with active systemic lupus erythematosus (SLE) who was treated successfully with plasma exchange (PE). A 26-year-old female, pregnant at 24 weeks, presented to the emergency room with vaginal bleeding, bleeding gums, facial rash, blurry vision, pallor, and lymphadenopathy. A diagnosis of SLE with secondary ITP was made based on her laboratory findings which revealed leucopenia, thrombocytopenia, evidence of hemolysis, positive antinuclear antibody, positive anti-double-stranded DNA antibody, positive lupus anticoagulant, false-positive VDRL, and decreased complement levels. High doses of corticosteroids were given when her illness was worsening with persistent hemolysis and thrombocytopenia. Plasma exchange was conducted after 2 weeks when she was not responding to the conventional therapy. Rapid and excellent responses were achieved when three PE sessions were carried out in combination with the previous therapy. The patient continued PE sessions for another week. A maintenance dose of steroids was prescribed after the sessions. She remained in good condition, on low dose of oral steroids (10 mg), and gave birth to a healthy baby. Based on our case report, plasma exchange initiated early in combination with steroids might be beneficial and could prevent further deterioration in some patients with therapy-resistant active SLE.

Orbital Wegener's granulomatosis as the initial presentation in a 9-year-old child

A 9-year-old child was referred by her general practioner (GP) to eye casualty clinic with a six-week history of unexplained painless swelling of her right upper lid. Her GP, having treated first as an allergy with oral antihistamine, was now concerned that this was a case of preseptal cellulits progressing to orbital cellulitis and commenced a course of Erythromycin and Fucithalmic ointment and referred for review. A detailed history had revealed four months previously she had developed right upper lid swelling in the context of a mild upper respiratory tract infection. However this was short-lived and resolved without any therapeutic intervention. She also frequently suffered from recurrent ear infections, which required eventual grommet insertion, and nose bleeds. On examination she was found to have right painless upper lid swelling with no associated proptosis (Figure 1). Her ocular movements were full with no diplopia. Best corrected vision was 6/9 both eyes, her conjunctiva was injected in the right eye, anterior segment examination was normal with pressures of 14 both eyes. Pupils were reactive and equal with, no evidence of a relative afferent pupillary defect. Colour vision was also full. Posterior segment examination was normal no evidence of disc swelling or pallor. The antibiotics were continued with a provisional diagnosis of dacroadenitis. In view of the chronicity of the symptoms an orbital computed tomography scan and bloods were ordered. Her CT scan displayed diffuse homogenous soft tissue swelling within the right lacrimal gland suggesting an inflammatory process, extraocular eye muscles were normal (Figure 2). Her chest X-ray was normal and urine analysis was also normal. Her blood tests was positive for cANCAwith a titre of 1:20 and pANCAwith a titre of 1:40, ESR was normal at 11 the rest of her blood tests including full blood count, U&Es, LFTs, autoantibody screen and sACE were also normal. She was referred on to a paediatric rheumatologist to confirm the diagnosis of Wegener’s granulomatosis and assist on further management. A biopsy of the lacrimal failed to show the classical triad of granulomatous inflammation with giant cell, necrosis and vasculitis although there was evidence of chronic inflammation with perivascular infiltrates. Further examination of the child revealed saddling of the nose and a congenital sinus in the tragus of the left ear. Systemic examination failed to reveal any renal or pulmonary involvement. In view of the positive ANCA and clinical examination, a diagnosis of Wegener’s granulomatosis was made. She was commenced initially with intravenous methylprednisolone for three days then on a tapering dose of oral steroids. The lid swelling has reduced and she is currently in remission.

Steroids for Idiopathic Sudden Sensorineural Hearing Loss

IDIOPATHIC SUDDEN SENSORINEURAL HEARING LOSS, OR sudden deafness, is the acute onset of hearing loss of at least 30 dB in 3 connected frequencies occurring instantaneously or over a period of up to 3 days. Sudden hearing loss is thought to be relatively rare, occurs mainly in patients between the ages of 30 and 60 years, and can be devastating for the patient. Therefore, sudden hearing loss should be treated as a medical emergency. The natural course is characterized by spontaneous recovery among approximately 50% of patients. Accurate estimates of incidence are difficult to obtain because a significant number of patients who spontaneously recover do not seek medical attention. As the term idiopathic implies, the etiology and pathophysiology of hearing loss are unknown. Possible causes include infections (especially viruses), autoimmune disease, circulatory problems, and neurological disease, including multiple sclerosis. Treatment options include oral steroids, intratympanic steroid injections, oral antivirals, vasodilators, diuretics, hyperbaric oxygen therapy, and vitamins. As a result of the high rate of spontaneous resolution, multiple potential causes, and absence of validated tests for etiological identification, the evaluation of treatment effectiveness is difficult. In this issue of JAMA, Rauch and colleagues describe the findings from the first multi-institutional study of oral vs intratympanic corticosteroid therapy for hearing loss. In this study, 2443 adult patients were assessed for eligibility at 16 different academic and community-based otology practices. Of these patients, 250 (10%) agreed to participation and were randomized to receive either 60 mg/d oral prednisone for 14 days with a 5-day taper (n=121) or four 1-mL doses of 40 mg/mL of methylprednisolone injected into the middle ear over a 2-week period (n=129). Audiometry and safety monitoring were performed at screening, and after 1 week, 2 weeks, 2 months, and 6 months of treatment. The primary study hypothesis was that intratympanic methylprednisolone is inferior to oral prednisone for the treatment of hearing loss. The investigators established an average of more than 10 dB as the clinically significant amount of audiometric difference between the 2 study groups. Subgroup analyses of patients based on the amount of hearing loss ( 90-dB or 90-dB pure-tone average [PTA]) were specified a priori. The primary finding of the study was a 2.0-dB difference in PTA between the 2 treatment groups at 2 months with a maximum difference (upper limit of the confidence interval) of 6.6 dB. This value of 6.6 dB was below the required value of 10 dB to demonstrate clinical significance and reject the null hypothesis of noninferiority (ie, intratympanic treatment is worse than oral prednisone). Among the patients who presented with hearing loss of 90 dB or greater and dizziness, came for treatment in fewer than 7 days from onset, or had no prior steroid use, the possibility of a clinically meaningful difference in hearing recovery between the 2 groups could not be ruled out. Overall, the 2 treatments were well tolerated, and the number and severity of serious adverse events and adverse events were similar between groups, as had been anticipated from prior studies. However, of the patients randomized to receive intratympanic steroids, 3.1% had persistent tympanic membrane perforation and 4.7% had persistent otitis media vs 0% and 0.8% in the oral group, respectively. At present, the emergency administration of a tapering dose of systemic steroids after hearing loss onset is widely considered standard treatment. Several uncontrolled studies suggested that intratympanic steroids have equivalent efficacy as oral steroids, while minimizing the potential adverse systemic effects of oral steroids. The practice of prescribing a tapering dose of oral steroids is largely based on the results of 1 randomized clinical study and a retrospective study. In the study by Wilson et al, patients in the steroid group had a recovery rate (61%) that was similar (65%) to untreated patients reported by Mattox and Sim-

Response to immunotherapy in CLIPPERS syndrome

Dear Sirs,Chronic lymphocytic inflammation with pontine perivas-cular enhancement responsive to steroids (CLIPPERS) is arecently described treatable, brainstem-predominant, clin-ical and radiological entity [1]. Patients with this conditionpresent with an episodic brainstem syndrome and showcharacteristic scattered and punctate gadolinium (Gd)enhancement in the pons and adjacent CNS structures.They prototypically respond to high dose glucocorticos-teroids and may require chronic steroid or immunosup-pressive treatment, although the effect of intravenousimmunoglobulins (IVIG) in this disease is unknown. Herewe report a patient with CLIPPERS that experienced aclinical rebound of the disease after a short pulse of IVIG.A 28-year-old woman with subacute gait ataxia anddiplopia was admitted to the hospital. Neurologicalexamination revealed internuclear ophthalmoplegia, hori-zontal bidirectional nystagmus and gait and four-limbataxia. Brain and spinal MRI showed multiple punctate Gdenhancing lesions in the mesencephalon, cerebellum andcervical spinal cord. The patient was tested for the presenceof systemic auto-antibodies, anti-neuronal antibodies,infectious pathogens (HIV, T. Pallidum, Brucella spp., B.burgdorferi) and tumoral serum biomarkers. CSF analysisincluded standard biochemistry, cytology and bacteriolog-ical cultures, oligoclonal bands and tests for Tropherymawhippelii and Herpesviridae, with no significant findingsexcept for mildly raised CSF protein. Body-CT and bodyand brain PET-CT were also normal. The patient wastreated with intravenous methylprednisolone for 3 days(1 g/day) followed by oral prednisone tapering startingfrom a dose of 60 mg/day. One week after starting meth-ylprednisolone, she had completely recovered and wascontinued on a slow reduction of oral steroid dose. How-ever, any attempt to taper the oral steroid dose below12.5 mg/day led to neurological relapse of the symptomsand, therefore this dose was maintained for the next6 months. After this period (1 year after disease onset), shewas asymptomatic and physical examination was normal,and therefore treatment discontinuation was reassessed.After she stopped steroids for a few days she suffered arebound of her symptoms: she had new onset mild gaitataxia and brisk symmetric ankle- and knee-jerks. Newbrain and spinal cord MRI disclosed multiple scatteredpunctuate and non-confluent enhancing lesions of a maxi-mum diameter of 0.7 cm visible mainly in the white matterof both cerebellar hemispheres, cerebellar peduncles and inthe cervical spinal cord. (Fig. 1a). At that moment, pontineGd enhancement was relatively scarce compared with thecerebellar hemispheres. Additionally, mild but appreciableamount of diffuse Gd peppering was visible in the whitematter of the whole brain adjacent to the cortico-subcor-tical border. Prednisone dose was increased to 30 mg/dayand the patient recovered to normal in 3 days. Thereafter, a12.5 mg/day dose was maintained for the following9 months and the patient remained asymptomatic. A newMRI 3 months after restoration of steroid therapy showedclear improvement of Gd lesions (Fig. 1b). Notwithstand-ing, steroid side-effects became evident with amenorrhea,hirsutism, mild weight gain and acne. Any attempt to tapersteroid dose below 10 mg/day resulted in a blooming ofneurological symptoms. After assuring 2 weeks of clinicalstability, a short attack pulse of intravenous immunoglob-ulins (IVIG) was administered (0.4 g/kg/day for 5 days)

A study of a multi-level intervention to improve non-adherence in difficult to control asthma

Difficult to control asthma accounts for significant morbidity and healthcare cost, and non-adherence to medication is a common cause. It remains unclear if targeting non-adherence in this population improves healthcare outcomes. All subjects were referred to a Specialist Difficult Asthma Service (60% from Respiratory physicians); poor adherence was identified using prescription refill records for inhaled combination therapy. A sequential 2 phase study examined the effect of identifying and targeting non-adherence to inhaled long-acting β-agonist/inhaled steroid combination therapy; phase 1 - an observational study utilising objective measures of non-adherence to facilitate a medical concordance discussion followed by phase 2, a 12 month prospective single blind randomised controlled trial where subjects with persistent poor adherence were randomised to a nurse-led menu driven intervention. A total of 239 patients were assessed; 31 of 83 subjects (37%) who were initially non-adherent, significantly improved adherence after concordance interview, with reduced prescribed daily dose of ICS (data p<0.001), rescue prednisolone courses (data, p<0.001) and hospital admissions (data, p=0.006). With the menu driven intervention, adherence also improved (intervention 37.6% to 61.9%, control group 31.7% to 28.8%) with reduced maintenance oral steroid dose in subjects on maintenance steroids. Poor adherence in difficult-to control asthma is common, but when identified and targeted can be improved and this is associated with large improvements in important healthcare outcomes. Previous nihilism towards non-adherence in this population is not supported by this study.

Omalizumab in the management of oral corticosteroid-dependent IGE-mediated asthma patients

Background:Several studies have demonstrated the beneficial effects of omalizumab in asthma patients. Here we describe the drug’s tolerance and oral corticosteroid sparing capacity in a long-term observational study.Methods:Thirty-two patients aged ≥18 years with obstructive airway disease and FEV1 reversibility ≥12% and 200 mL, with an oral steroid requirement ≥7.5 mg per day of prednisolone during a period of ≥1 year, a positive prick test or in vitro reactivity (RAST) to at least one perennial aeroallergen and a baseline immunoglobulin E level ranking between 30–700 IU/mL were prospectively followed for 17.2 ± 8.5 months. Patients were visited once or twice a month, depending on their schedule for omalizumab administration. Intervention: blood analysis every six months; spirometry and nitric oxide measurement at every visit.Results:One patient who dropped out early was excluded. Follow-up period: the treatment benefited 83.9% (26/31) of the cohort; oral corticosteroids were reduced from 7.19 ± 11.1 to 3.29 ± 11.03 mg (p < 0.002) and withdrawn in 74.2% of patients. FEV1 (percent predicted) was 64.4 ± 22.7 at the beginning and 62.9 ± 24.3 at the end. IgE at entry was 322.2 ± 334.2 IU/mL and increased 2.34-fold. Respiratory function and NO did not present statistically significant changes. We identified three groups of patients: the first (n = 17) receiving oral steroid at entry in whom the accumulated dose of oral steroids progressively decreased; another (n = 10) including patients who had quit oral steroids before starting omalizumab although they had not been instructed to do so and whose oral steroid dose at the end of follow-up was zero; and a third group (n = 4) that did not benefit from omalizumab treatment. The only relevant side effect was a flu-like syndrome which required discontinuation of treatment in one patient.Conclusion:In our series, a substantial, safe decrease in oral corticosteroid requirements was observed due, at least to some extent, to omalizumab therapy. Oral corticosteroids were withdrawn in three-quarters of the patients. We were unable to identify a factor able to predict which patients would benefit most from omalizumab treatment.

P173 Management of sputum eosinophil-negative patients in a severe asthma clinic

Asthma is a heterogeneous disease that requires physicians to further phenotype their patients in order to offer carefully customised treatment. Among recent and rapidly evolving tools at clinicians' disposal are...

Interstitial nephritis and autoimmune pancreatitis: a case report

Autoimmune pancreatitis is a rare form of pancreatitis characterized by responsiveness to steroid therapy and an often relapsing disease course. The mainstay of therapy is oral corticotherapy. Associations of interstitial nephritis with various autoimmune disorders have been described. We hereby report the case of a 69-year-old Caucasian man with a 2-year history of autoimmune pancreatitis, who presented with impairment of kidney function, proteinuria, and hypertension. Renal histopathology showed severe diffuse interstitial nephritis. With oral prednisone and ACE inhibitor therapy, complete recovery of kidney function was not achieved and proteinuria persisted. Therefore, mycophenolate mofetil was initiated. After 8 weeks, serum creatinine decreased, and a nearly complete and sustained resolution of proteinuria was seen, while tapering oral steroid doses. With autoreactive T cells playing a major role in the pathogenesis of both diseases, a common etiology of pancreatitis and interstitial nephritis can be assumed, and the beneficial effects of an inhibitor of lymphocyte proliferation, such as mycophenolate mofetil, can be explained. We infer from our case that mycophenolate mofetil can be effective in the control of simultaneous autoimmune pancreatitis and interstitial nephritis.

Update on the diagnosis and treatment of Pneumocystis pneumonia

Pneumocystis is an opportunistic fungal pathogen that causes an often-lethal pneumonia in immunocompromised hosts. Although the organism was discovered in the early 1900s, the first cases of Pneumocystis pneumonia in humans were initially recognized in Central Europe after the Second World War in premature and malnourished infants. This unusual lung infection was known as plasma cellular interstitial pneumonitis of the newborn, and was characterized by severe respiratory distress and cyanosis with little or no fever and no pathognomic physical signs. At that time, only anecdotal cases were reported in adults and usually these patients had a baseline malignancy that led to a malnourished state. In the 1960-1970s additional cases were described in adults and children with hematological malignancies, but Pneumocystis pneumonia was still considered a rare disease. However, in the 1980s, with the onset of the HIV epidemic, Pneumocystis prevalence increased dramatically and became widely recognized as an opportunistic infection that caused potentially life-treating pneumonia in patients with impaired immunity. During this time period, prophylaxis against this organism was more generally instituted in high-risk patients. In the 1990s, with widespread use of prophylaxis and the initiation of highly active antiretroviral therapy (HAART) in the treatment of HIV-infected patients, the number of cases in this specific population decreased. However, Pneumocystis pneumonia still remains an important cause of severe pneumonia in patients with HIV infection and is still considered a principal AIDS-defining illness. Despite the decreased number of cases among HIV-infected patients over the past decade, Pneumocystis pneumonia continues to be a serious problem in immunodeficient patients with other immunosuppressive conditions. This is mostly due to increased use of immunosuppressive medications to treat patients with autoimmune diseases, following bone marrow and solid organ transplantation, and in patients with hematological and solid malignancies. Patients with hematologic disorders and solid organ and hematopoietic stem cell transplantation are currently the most vulnerable groups at risk for developing this infection. However, any patient with an impaired immunity, such as those receiving moderate doses of oral steroids for greater than 4 weeks or those receiving other immunosuppressive medications are at also at significant risk.

A Retrospective Chart Review of the Use of Colchicine for the Treatment of Refractory Chronic Idiopathic Urticaria

RATIONALE: Colchicine, a microtubule polymerization inhibitor, may be effective in the treatment of chronic idiopathic urticaria (CIU) because it suppresses mast cell degranulation and leukotriene generation. METHODS: Charts of 55 patients with CIU treated with greater than 7 days of colchicine were reviewed for the following: type of urticaria, type of response, and oral steroid therapy before and after colchicine initiation. The number of steroid courses or the number of exacerbations requiring an increase in baseline steroid dose was tabulated for a minimum of 6 months before and after starting colchicine. Response was defined as subjective improvement and a decrease of at least 50% in oral steroid dose within 3 months of starting colchicine. A partial response was defined as subjective improvement without a decrease in oral steroids by 50% within 3 months of starting colchicine. RESULTS: 24 (44%) patients were responders, 29 (53%) were non-responders, and 2 (4%) were partial-responders. The number of steroid courses before and after colchicine initiation was significantly decreased in the responders (2.44 vs 0.33, P<0.05). Skin biopsies were performed in 27 patients (14 responders, 12 non-responders, 1 partial responder). Skin biopsies showed neutrophilic urticaria in 86% of responders and 25% of non-responders. CONCLUSION: Colchicine is an effective steroid-sparing agent which may be used for the treatment of refractory CIU.

Low-dose cyclosporine treatment for sight-threatening uveitis: Efficacy, toxicity, and tolerance

Aim:To ascertain the effectiveness, tolerability, and safety of low-dose cyclosporine in the management of sight-threatening uveitis.Materials and Methods:This was a retrospective clinical case series of patients using oral low-dose cyclosporine for the management of sight-threatening uveitis in the uvea clinic (UC). Patients receiving cyclosporine were identified from the clinic database. Main outcome measures were degree of intraocular inflammation, visual acuity and dose reduction of oral steroid for effectiveness and adverse symptoms, systemic hypertension, and raised serum creatinine for tolerability and safety.Results:Intraocular inflammation was improved or stable in 97% of patients, visual acuity was improved or stable in 91%, and oral steroid dosage was reduced in 73% (by half or more in 51%). Adverse symptoms were almost universal, the commonest being peripheral paresthesia/burning in 70% and fatigue in 67%. Significant systemic hypertension developed in 27% and raised creatinine in 30%, necessitating dose reduction. Cyclosporine was discontinued in 35%, being intolerable in 20% and ineffective in 15%.Conclusions:Cyclosporine was found to be effective in reducing inflammation and protecting vision in sight-threatening uveitis. It was safe with proper monitoring, including in children. It had a significant toxicity profile and a high incidence of adverse symptoms which required close supervision, and a prompt dose reduction or drug exchange.

The effect of oral steroids with and without vitamin D3 on early efficacy of immunotherapy in asthmatic children

The possibility of additional strategies to enhance the effectiveness of specific immunotherapy (SIT) is highly attractive. The aim of our study was to assess the influence of oral corticosteroids and oral corticosteroids combined with vitamin D(3) on the early clinical and immunological effects of SIT. It was a randomized, double-blind, placebo-controlled trial conducted in 54 asthmatic children allergic to house dust mites. Intervention was based on receiving a single dose of oral steroid, with or without vitamin D(3), or placebo only on the day of the build-up phase of SIT. After 12 months of SIT, the median daily inhaled corticosteroid (ICS) dose, which controls the symptoms of asthma, was reduced by 25% in the steroid group. However, a 50% reduction of the median daily ICS dose was observed in the control group. The clinical effects of SIT were not affected in the steroid+D(3) group. Concomitantly, we found that intervention with prednisone significantly impaired the induction of T regulatory lymphocytes. Importantly, the clinical and immunological effects of SIT were not affected by intervention with steroids administered with vitamin D(3). Our study failed to show a beneficial effect of oral corticosteroids on allergen-specific immunotherapy. We observed that the combined administration of a corticosteroid drug and allergen extract suppressed the early clinical and immunological effects of SIT and that vitamin D(3) prevented this 'adverse' influence of steroids.

The effects of antifungal therapy on severe asthma with fungal sensitization and allergic bronchopulmonary aspergillosis

Very little is known about the response rates to or appropriateness of treatment for patients with allergic fungal diseases of the lung. This study assessed the effect of antifungal therapy in patients with severe asthma with fungal sensitization (SAFS) and allergic bronchopulmonary aspergillosis (ABPA). A retrospective cohort study of 33 adult patients who fulfilled the criteria for either SAFS (n = 22) or ABPA (n = 11) was conducted. All patients had received antifungal therapy for at least 6 months. The primary study end point was the effect of antifungal therapy on patients' lung function. Overall, total IgE values and radioallergosorbent test (RAST) for A. fumigatus markedly decreased after 6 months of therapy in both SAFS and ABPA patients (P = 0.004 and P = 0.005, respectively). Reduction was seen in the eosinophil count (P = 0.037), dose of oral steroids (P = 0.043) and courses of systemic steroids required (P = 0.041). Lung function also improved (P = 0.016). Four of 10 patients discontinued oral steroids after 6 months of therapy. Reduction in IgE levels (P = 0.015) and RAST for A. fumigatus was also observed (P = 0.006) for those patients treated for at least 1 year with antifungal drugs. Both ABPA and SAFS patients benefited from oral antifungal therapy. The antifungal therapy may act by reducing the antigenic load, interacting with corticosteroids or by a direct immunological effect.

CMV Colitis in a Patient with HIV and Ulcerative Colitis After Use of Infliximab

Purpose: A 53y man with h/o HIV for 7 years, on treatment with antiretrovirals presented complaining of diarrhea with up to 12 bowel movements per day and intermittent blood in the stools for 2 months. He had presented with similar complaints 1 yr ago to another facility and was diagnosed with ulcerative colitis by colonoscopy with biopsies. At that time, he was treated with oral steroids and mesalamine, and symptoms improved. However, diarrhea worsened a month later; the dose of oral steroids was increased and mesalamine switched to balsalazide with remission of symptoms for the next 6 months. Steroids were tapered off and he was given 3 infusions of infliximab biweekly, following which he did well for another few months. The patient lost his medical insurance and was off medications for about a month before his current symptoms started. Oral mesalamine 4.8 g/d had been restarted at another facility with minimal improvement in symptoms. His clinical examination was unremarkable and despite significant symptoms he was clinically stable. Labs revealed CD4 count of 660 and undetectable HIV RNA levels. Colonoscopy showed pancolitis, more severe in rectum and sigmoid colon. Biopsies revealed exuberant granulation tissue with numerous viral inclusions in endothelial cells in multiple specimens throughout the colon consistent with cytomegalovirus colitis. The patient was treated with oral valgancyclovir 900 mg/d for 3 weeks and oral mesalamine was continued. Diarrhea improved to 3-4 bowel movements per day, however intermittent bleeding continued. Repeat colonoscopy in 2 months revealed severe colitis in rectum and sigmoid with moderate colitis till hepatic flexure. Rebiopsies showed no evidence of CMV and were suggestive of UC. Oral mesalamine was continued and rectal mesalamine started. In a few weeks, diarrhea and intermittent bleeding both resolved completely. Although CMV colitis is seen with HIV, the level of immunosuppression in this patient was not consistent with this explanation. CMV colitis can rarely occur in the immunocompetent individuals. We believe that infliximab may have predisposed this patient to opportunistic CMV infection. CMV colitis should be kept as an important differential diagnosis in patients with history of UC especially after the use of TNF antagonists.Figure: CMV colitis.