Oral Prednisone Therapy Research Articles

Intravenous methylprednisolone for nephrotic syndrome with minimal change lesions in adults: a randomized controlled trial.

Patients with minimal change nephrotic syndrome (MCNS) usually experienced severe edema which can affect the absorption of oral corticosteroid during the first 2 weeks. We conducted a randomized controlled trial to compare the efficacy of intravenous isovalent methylprednisolone induction followed by oral prednisone therapy with conventional oral prednisone therapy in highly edematous MCNS patients, aiming to provide a better therapy for MCNS patients. A single-center, open-label, parallel-arm randomized controlled trial was performed in the Nephrology Department of the Affiliated Hospital of Guangdong Medical University. Patients who met the inclusion were enrolled in our study from May 2015 to October 2020, and were randomized to receive conventional oral steroid or 2 weeks intravenous methylprednisolone followed by oral prednisone. 117 patients were enrolled and randomly assigned to either the sequential group (N=57) or the oral group (N=60). Total remission rate in the sequential group was higher than the oral group after treatment for 2 weeks and 4 weeks (P=0.032, P=0.027). Complete remission rate was higher in the sequential group than in the oral group (63.3% vs. 41.5%, P=0.031) after treatment for 2 weeks. The time to achieve CR is shorter in the sequential group than the oral group, with a statistically significant difference (14.0 days, 95% CI [13.5 to 14.5] vs. 16.0 days, 95% CI [12.7 to 19.3], P=0.024). There were no significant difference in relapse rate (24.5% vs 28.3%, P=0.823) and time to relapse (155±103 days vs 150.7±103.7 days, P=0.916) between two groups. This study suggested that highly edematous MCNS patients received intravenously isovalent methylprednisolone induction therapy follow by oral prednisone achieved earlier remission than the conventional oral prednisone regimen without differences in relapse rates or adverse effects. Short-term intravenous methylprednisolone followed by oral prednisone may be a better choice for MCNS patients with highly edema.

Cryptococcal Necrotizing Fasciitis in a Patient With Sarcoidosis

Abstract Necrotizing fasciitis, a severe soft tissue infection that rapidly destroys the fascial layer through necrosis and inflammation, is often caused by Streptococcus pyogenes, gram-negative bacteria, Clostridium, and, rarely, fungal organisms. We present a case of necrotizing fasciitis caused by Cryptococcus neoformans in a patient with sarcoidosis on oral prednisone therapy.

A Randomized Controlled Trial Comparing Remission Induction with Modified Multitarget Therapy with Intravenous Cyclophosphamide in Proliferative Lupus Nephritis.

Therapy of proliferative lupus nephritis (PLN) is yet to be optimized. Standard of care for induction consists of intravenous (IV) cyclophosphamide (CYC) and steroids, which shows an improved outcome, but end-stage renal disease (ESRD) progression, increased mortality, and therapy-related adverse effects remain a major concern. The other treatment reported to induce early remission was the multitarget therapy comprising tacrolimus, mycophenolate, and steroid, but infections were high in the multitarget therapy. Considering azathioprine as a potentially safer and effective alternative anti-B-cell therapy, modified multitarget therapy (MMTT) was planned replacing mycophenolate with azathioprine. A single-center, 24-week, open-label, randomized controlled trial comprising adults of age 18-65 years with biopsy-proven PLN was carried out. The intervention groups were 1) MMTT: tacrolimus 0.075 mg/kg/day and azathioprine 2 mg/kg/day and 2) IV CYC group with a starting dose of 0.75 (adjusted to 0.5-1.0) g/m2 every 4 weeks for 6 months. Both groups received 3 days of pulse methylprednisolone followed by a tapering course of oral prednisone therapy. Among 100 randomized patients, 48 were in MMTT arm and 52 were in IV CYC arm. At the end of 24 weeks, overall remission (complete and partial) was comparable in both the arms: MMTT (86.36%) and IV CYC (87.75%). There was comparable proteinuria reduction and systemic lupus erythematosus disease activity index (SLEDAI) score improvement with recovery of complement level C3 in both groups. Major adverse events were numerically more in the IV CYC group, including one death from pneumonia. The MMTT arm is as effective as IV CYC in improving short-term outcome in PLN, with a comparable safety profile.

Drug-induced liver injury after high-dose methylprednisolone: Clinical case

We present a clinical case of acute hepatitis confirmed by liver biopsy. A 24-year-old patient underwent pulse therapy with methylprednisolone due to the onset of multiple sclerosis. The liver enzyme values were within the normal range 15 days later. Blood tests revealed the development of cytolysis syndrome during an unrelated medical examination two months later. Obvious causes of hepatitis were excluded, and liver biopsy was performed to verify the diagnosis. The biopsy showed a picture of acute hepatitis with high histological activity and development of submassive necrosis. The situation was interpreted as drug-induced liver injury after pulse therapy with methylprednisolone. Oral prednisone therapy was prescribed, and the inflammation and liver injury were reverted. The presented clinical case highlights the importance of follow-up of patients receiving high doses of methylprednisolone.

Myasthenia Gravis Presenting after Administration of the mRNA-1273 Vaccine.

The mRNA-1273 SARS-CoV-2 vaccine received emergency use authorization in December 2021. We present a case of myasthenia gravis (MG) which became clinically apparent following vaccination against SARS-CoV-2. A 30-year-old man developed acute onset diplopia, 2 days after receiving his first mRNA-1273 vaccination against SARS-CoV-2. He reported blurred vision with horizontally displaced images, which worsened with increased eye strain. Diplopia resolved when one eye was covered. He also had fatigable arm weakness, but denied dysphagia, dysarthria, dysphonia or dyspnoea. On examination, he had left-sided ptosis and esotropia at rest which worsened with sustained upward gaze and prolonged focus. He also had fatigable weakness of neck flexion and extension (4+/5), and generalized, fatigable weakness (4/5). His single-breath count was 38. Cranial nerves, sensory examination and deep tendon reflexes were normal. A 2-min ice-pack test and neostigmine test temporarily improved his diplopia and ptosis. The acetylcholine receptor (AChR) antibody was borderline high and muscle-specific tyrosine kinase (MuSK) antibody was negative. Chest CT and brain MRI with contrast were unremarkable. The patient was diagnosed with MG and oral pyridostigmine and prednisone therapy were initiated.We present a case of newly diagnosed MG after administration of mRNA-1273 vaccination against SARS-CoV-2. Although there has been long-standing discussion regarding the potential for vaccines to exacerbate autoimmune conditions, data remain sparse and consensus has not been reached. Consequently, this case is important to make providers aware of potential side effects of a novel vaccine, and may also help guide the selection of vaccination candidates and monitoring parameters.LEARNING POINTSWe present a case of newly diagnosed myasthenia gravis after administration of the mRNA-1273 SARS-CoV-2 vaccine.mRNA-1273 vaccination against SARS-CoV-2 may exacerbate subclinical cases of myasthenia gravis.Recognition of new vaccine side effects may guide the selection of vulnerable patients.

Treatment outcomes of Pediatric Lupus Nephritis Class III and IV in National Children’s Hospital

Treatment of lupus nephritis (LN) remains challenging. A prospective observational study on the children with newly diagnosed LN class III and IV from 9/2019 to 9/2021 intended to examine the efficacy of MMF with corticosteroids as induction therapy for pediatric lupus nephritis class III and IV. All patients received 3 days of pulse methylprednisolone followed by a tapering course of oral prednisone therapy in combination with Mycophenolate mofetil (MMF) 1200mg/m2/day (max 2g/day). Those with urine protein-creatinine ratio (uPCR) > 200mg/mmol and normal renal function after 1-month treatment received MMF and low dose Calcineurin Inhibitors (CNI). There were 57 children who were 75.4% females, 42.1% of children in class III, and 57.9% in class IV. The mean age was 10.88. 82.5% of patients r eceived Corticosteroid and MMF, and 10 children were treated with Corticosteroid, MMF, and CNI. Early responses at week 12 were achieved by 71.9%. The overall response was seen in 93.3% of patients after 6 months of therapy ( 42.2% complete response and 51.1% partial response). 2 patients (3.5%) had infections. MMF is effective in the treatment of children with proliferative lupus nephritis in induction therapy.

Mean time to platelet recovery in children 1-12 years of age with newly diagnosed idiopathic thrombocytopenic purpura receiving 1 week of oral prednisone therapy

Mean time to platelet recovery in children 1-12 years of age with newly diagnosed idiopathic thrombocytopenic purpura receiving 1 week of oral prednisone therapy

ACTINOMYCES BACTEREMIA FROM PULMONARY ACTINOMYCOSIS

TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: Actinomycosis is an infection caused by actinomyces species, an anaerobe colonized within the mouth and gastrointestinal tract. Actinomyces bacteremia is rare clinical finding of which the etiology, identification, and treatment are debated. We present a case report of a 59-year-old male with stage IV breast cancer who required intensive care for actinomyces bacteremia and acute hypoxic respiratory failure secondary to pulmonary actinomycosis. CASE PRESENTATION: A 59-year-old male presented to the hospital with respiratory distress. On initial evaluation, the patient was found to be obtunded and hypoxic, prompting endotracheal intubation. Pertinent history was significant for breast cancer managed with trastuzumab. Three months prior, the patient was diagnosed with trastuzumab induced lung disease of which he was treated with oral prednisone therapy. A CT scan of the chest was significant for bilateral ground glass opacities and a left upper lobe consolidation, the latter being new relative to a CT scan three months prior. Broad spectrum antibiotics and mechanical ventilation were initiated for a diagnosis of acute hypoxic respiratory failure secondary to a superimposed pneumonia. Blood cultures from admission revealed Actinomyces species, and the patient was diagnosed with Pulmonary Actinomycosis. Unfortunately, further identification of the species of Actinomyces isolated in the blood was unable to be obtained. The patient's oxygen requirements improved following antibiotic therapy and the patient was extubated after one week on mechanical ventilation. He was successfully discharged on amoxicillin with plans for a three to six month course. DISCUSSION: Actinomyces bacteremia is a rare finding that has debated clinical significance. Historically, treatment has always been warranted in the event that the patient exhibited signs of Actinomyces infection, with or without evidence of bacteremia. A 2016 retrospective analysis of patients found to have Actinomyces positive blood cultures reported 43 patients who did not receive treatment for Actinomyces bacteremia, all of which had no reported complications after discharge. Though, none of these patients exhibited evidence of an active Actinomycocis infection. Our patient developed an acute respiratory failure in the setting of known trastuzumab induced lung injury that previously did not require supplemental oxygen therapy. Blood isolates of Actinomyces species in conjunction with new pulmonary infiltrates suggested a superimposed pulmonary Actinomyces infection was the source. Because an active source of Actinomycosis infection was present, the decision to treat the patient with antibiotics was not called into question. CONCLUSIONS: Further studies on treatment indications and duration of Actinomyces bacteremia are need. REFERENCE #1: Jeffery-Smith A, Nic-Fhogartaigh C, Millar M. Is the Presence of Actinomyces spp. in Blood Culture Always Significant?. J Clin Microbiol. 2016;54(4):1137-1139. doi:10.1128/JCM.03074-15 REFERENCE #2: G.F. Mabeza, J. Macfarlane. Pulmonary actinomycosis. European Respiratory Journal Mar 2003, 21 (3) 545-551; DOI: 10.1183/09031936.03.00089103 REFERENCE #3: Mani RK, Mishra V, Singh PK, Pradhan D. Pulmonary actinomycosis: a clinical surprise! BMJ Case Rep. 2017;2017:bcr2016218959. Published 2017 Jan 27. doi:10.1136/bcr-2016-218959 DISCLOSURES: No relevant relationships by John Madara, source=Web Response No relevant relationships by Nathaniel Rosal, source=Web Response

S2171 Esophageal Dysphagia: A Rare Manifestation of Sarcoidosis

Introduction: Sarcoidosis is a multi-systemic inflammatory disease with noncaseating granulomas as the main pathological finding in the affected organs. Extrapulmonary involvement of sarcoidosis has been reported in a variety of organs. However, Extrahepatic GI involvement is uncommon. We present an unusual case of sarcoidosis presenting with dysphagia. Case Description/Methods: A 32 years old male with recent history of COVID-19 infection presented with esophageal dysphagia for 1 week, initially to liquids then progressed to solids. On review of systems, patient admitted to subacute dry cough associated with shortness of breath (for?) but denied constitutional symptoms. Physical examination was unremarkable with no palpable lymphadenopathy. Basic laboratory studies were unremarkable. HIV screening test and COVID-19 PCR were negative. CT-chest with contrast showed prominent mediastinal and bilateral hilar adenopathy and multiple pulmonary nodules. Angiotensin converting enzyme level was elevated. Esophagram findings were compatible with extrinsic mass effect involving the middle esophagus. On third day of admission, Patient underwent Endobronchial Ultrasound Bronchoscopy with transbronchial needle aspiration. Flow cytometry was negative. Pathology report showed abundant non-necrotizing granulomas. GMS and AFB stains, Fungus and AFB cultures were negative. Patient was started on oral prednisone therapy resulting in improvement of respiratory symptoms but dysphagia persisted. He underwent EGD with dilation showing normal esophageal mucosa and normal pathology. Manometry studies were unremarkable. Patient reported partial improvement after dilation. Discussion: Digestive tract sarcoidosis is rare. It mainly affects esophagus either by infiltration or extrinsic compression, resulting in dysphagia which is the main presenting symptom in most reported cases. Inflammatory Infiltration can involve mucosa, muscular layer or myenteric plexus. Extrinsic compression is mainly related to mediastinal lymphadenopathy which can lead to direct compression, as in our case, or it can lead to traction esophageal diverticulum or even perforation. Diagnostic approach for dysphagia includes performing EGD or Esophagram depending on whether oropharyngeal involvement is present or not. In our case, patient’s description for dysphagia was esophageal. However, CT chest findings sparked the clinical suspicion for compressive adenopathy affecting mid esophagus level, making esophagogram our initial test of choice.Figure 1.: Esophagram showing narrowing at middle esophagus due to extrinsic mass effect. Figure 2: CT chest ( Sagittal plane ) showing esophageal narrowing. Figure 3: CT chest ( Axial plane ) showing multiple arch mediastinal and bilateral hilar lymph nodes conglomerate measuring 7.9 x 3.6 cm.

Comparable Outcomes Using Oral Methylprednisolone vs. Prednisone in IgA Nephropathy: A Retrospective Cohort Study

Background: To compare effectiveness and adverse reactions after oral methylprednisolone versus prednisone in patients with IgA nephropathy. Methods: A retrospective cohort study was conducted in 85 patients with IgA nephropathy. Patients were divided into three groups: 34 patients received oral methylprednisolone of 0.4 mg/kg/d (MP-QD group), 31 patients received prednisone of 0.5 mg/kg/d (PND-QD group), and 20 patients received prednisone of 0.5 mg/kg on alternate days (PND-QOD group). The levels of creatinine and proteinuria, and adverse reactions were monitored for 6 months of follow-up. Results: The excretion of urine protein at 24h was significantly decreased while serum creatinine was not significantly changed after corticosteroids treatment. 20 adverse events were observed in 16 participants (47.1%) in the MP-QD group, 8 adverse events were observed in 7 participants (22.5%) in the PDN-QD group, and 2 adverse events were observed in 2 participants (10%) in the PDN-QOD group. The risk of adverse events in PDN-QD and PDN-QOD groups was lower than that in MP-QD group with a risk difference of 40.4% (95% CI, 16.6 to 98.2%, P = 0.045) for the comparison of PDN-QD vs MP-QD, and a risk difference of 17.2% (95% CI, 4.1 to 75.1%, P = 0.019) for the comparison of PDN-QOD vs MP-QD. Conclusions: Oral methylprednisolone or prednisone therapy in patients with IgA nephropathy significantly decreased the excretion of proteinuria and no obvious change was found in the level of serum creatinine in 6-month follow-up period. However, more adverse effects were observed in the patients who received oral methylprednisolone. Funding Information: None. Declaration of Interests: The authors declare that they have no competing interests. Ethics Approval Statement: This study was conducted in accordance with the ethical principles of the Declaration of Helsinki and with the Methods for the Ethical Review of Biomedical Research Involving Humans issued by the National Health and Family Planning Commission of China. The study was approved by the Ethics Review Committee of Sixth Affiliated Hospital of Sun Yat-sen University (ID: 2020ZSLYEC-224). As the data were obtained retrospectively from patient charts, it is impossible to recall each patient one by one and sign the inform consents form in person and the research project does not involve personal privacy or commercial interests, informed consent was deemed unnecessary following the above guidelines.

Immediate Treatment of Sudden Sensorineural Hearing Loss: A Case Study

Immediate Treatment of Sudden Sensorineural Hearing Loss: A Case Study

Treatment with Intravenous Methylprednisolone in Patients with Graves' Orbitopathy Significantly Affects Adrenal Function: Assessment of Serum, Salivary Cortisol and Serum Dehydroepiandrosterone Sulfate.

Treatment of active, moderate-to-severe Graves’ orbitopathy (GO) is the administration of intravenous methylprednisolone (IVMP). IVMP may be followed by additional therapy with oral prednisone. The aim of this study was to analyze the impact of IVMP on adrenal function by evaluation of serum, salivary cortisol and serum dehydroepiandrosterone sulfate (DHEA-S). Fourteen patients received IVMP treatment (cumulative dose of 4.5 g in 12 weekly infusions) followed by oral prednisone (for three months). All patients showed normal adrenal function before the 12th IVMP pulse and one patient was diagnosed with secondary adrenal insufficiency (AI) after prednisone treatment. DHEA-S was significantly lower before the 12th IVMP pulse and after oral prednisone (p = 0.015 and p = 0.00002, respectively) in comparison to evaluation before therapy. DHEA-S levels were below the reference range in one and three patients before the 12th IVMP pulse and after prednisone therapy, respectively. We observed decreased serum (p = 0.05) and salivary (p = 0.011) cortisol levels after oral prednisone therapy in comparison to evaluation before therapy. Treatment with IVMP in a cumulative dose of 4.5 g affects adrenal function, causing more severe impairment of DHEA-S secretion than that of cortisol but does not cause secondary AI. Additional therapy with oral glucocorticoids after IVMP can cause secondary AI.

Tofacitinib for Rescue Therapy in Acute Severe Ulcerative Colitis: A Real-world Experience.

Acute severe ulcerative colitis is a high stakes event with significant numbers still requiring emergent colectomy, representing a need to establish alternative medical management options. We report a case series of tofacitinib as rescue therapy in biologic-experienced patients with acute severe ulcerative colitis. Four patients were identified over a 1-year period at our institution who initiated tofacitinib for acute severe ulcerative colitis. All four had previously failed at least two biologics, including infliximab, and were failing high-dose oral prednisone therapy before admission. All patients had Mayo disease activity index of at least 10 at admission. After no significant improvement despite receiving a minimum of 3 days of intravenous methylprednisolone and based on elevated Ho and Travis indices at Day 3, patients were offered rescue tofacitinib for induction of remission, or colectomy. Standard induction of tofacitinib was used [10 mg twice daily], and one patient was escalated to 15 mg twice daily after inadequate response. All patients experienced improvement in objective symptoms and laboratory markers, and were discharged without colectomy on tofacitinib as maintenance therapy and prednisone taper; 30-day and 90-day colectomy rates on tofacitinib maintenance therapy were zero and 90-day readmission rate was also zero. Two of four patients achieved steroid-free remission on maintenance tofacitinib monotherapy based on clinical symptoms and follow-up endoscopy. No major adverse reaction was reported during induction or maintenance therapy. Tofacitinib may be an acceptable rescue agent in biologic-experienced patients with acute severe ulcerative colitis. Tofacitinib may also be safely continued as maintenance therapy once remission has been achieved.

An unusual complication of hepatitis A: secondary hemophagocytic lymphohistiocytosis

Background: Secondary hemophagocytic lymphohistiocytosis (HLH) is characterized by severe cytopenias due to uncontrolled hemophagocytosis. Other laboratory signs and clinical symptoms result from disordered immune regulation, and cytokine storm is well recognized. It is often a fatal complication of infections. It is not as uncommon as thought of previously. Case Presentation: We discuss a 7-year-old boy, born out of non-consanguineous marriage with acute hepatitis A infection, who developed HLH during treatment and was successfully managed with methyl prednisolone pulse therapy followed by oral prednisone therapy. Conclusion: Secondary HLH is a rare complication in a case of hepatitis A. A high index of suspicion at the early stage of HLH may produce a favorable outcome.

Effect of short-term oral prednisone therapy on blood gene expression: a randomised controlled clinical trial

BackgroundEffects of systemic corticosteroids on blood gene expression are largely unknown. This study determined gene expression signature associated with short-term oral prednisone therapy in patients with chronic obstructive pulmonary disease (COPD) and its relationship to 1-year mortality following an acute exacerbation of COPD (AECOPD).MethodsGene expression in whole blood was profiled using the Affymetrix Human Gene 1.1 ST microarray chips from two cohorts: 1) a prednisone cohort with 37 stable COPD patients randomly assigned to prednisone 30 mg/d + standard therapy for 4 days or standard therapy alone and 2) the Rapid Transition Program (RTP) cohort with 218 COPD patients who experienced AECOPD and were treated with systemic corticosteroids. All gene expression data were adjusted for the total number of white blood cells and their differential cell counts.ResultsIn the prednisone cohort, 51 genes were differentially expressed between prednisone and standard therapy group at a false discovery rate of < 0.05. The top 3 genes with the largest fold-changes were KLRF1, GZMH and ADGRG1; and 21 genes were significantly enriched in immune system pathways including the natural killer cell mediated cytotoxicity. In the RTP cohort, 27 patients (12.4%) died within 1 year after hospitalisation of AECOPD; 32 of 51 genes differentially expressed in the prednisone cohort significantly changed from AECOPD to the convalescent state and were enriched in similar cellular immune pathways to that in the prednisone cohort. Of these, 10 genes including CX3CR1, KLRD1, S1PR5 and PRF1 were significantly associated with 1-year mortality.ConclusionsShort-term daily prednisone therapy produces a distinct blood gene signature that may be used to determine and monitor treatment responses to prednisone in COPD patients during AECOPD.Trial registrationThe prednisone cohort was registered at clinicalTrials.gov (NCT02534402) and the RTP cohort was registered at ClinicalTrials.gov (NCT02050022).

A Comparison of the Effectiveness of Oral Prednisone Therapy Given at Different Frequencies among Pediatric Asthma Patients

A Comparison of the Effectiveness of Oral Prednisone Therapy Given at Different Frequencies among Pediatric Asthma Patients

A Comparison of the Effectiveness of Oral Prednisone Therapy Given at Different Frequencies among Pediatric Asthma Patients

Purpose Asthma is a common chronic disease that affects 334 millions of people of all ages in all parts of the world, with 14% of the world’s children experiencing asthma symptoms. It is one of the most common causes of childhood emergency room visits, hospitalizations and missed school days. Despite a better understanding of the pathophysiology of the disease and the advancement in management, asthma prevalence and burden disability continue to rise, especially in developing countries. According to …

Asymptomatic Transaminitis: A Case of Hepatic Sarcoidosis

Background: Sarcoidosis is a chronic inflammatory multisystem disease characterized by the presence of non-caseating granulomas. Pulmonary involvement is most common, however hepatic manifestations occur in up to 70% of cases.1 We present a patient with asymptomatic transaminitis who was found to have isolated hepatic sarcoidosis, a rare diagnosis. Case: A 47 year old female with a PMH of cholecystitis status post cholecystectomy, iron deficiency anemia and history of migraines presented for evaluation of abnormal liver enzymes. Labs were notable for AST 50-70s, ALT 60-80s, and ALP 122. She reported intermittent fevers, once a week, ranging from 99 - 101F, but denied chills or night sweats. Abdominal ultrasound and CT scan revealed peripancreatic and porta hepatis lymphadenopathy. PET scan showed increased uptake in corresponding regions. Inflammatory markers were elevated (CRP 21 and ESR 112). Hematologic work-up was unremarkable for malignancy or lymphoma. She underwent extensive serologic evaluation, which was unremarkable for autoimmune or infectious etiologies. Left lobe liver biopsy was performed after which patient started oral prednisone therapy. Biopsy results showed multiple non-caseating granulomas in portal and lobular distribution with mixed portal and periportal inflammation, as well as bile duct injury and lesions without evidence of fibrosis, steatosis, copper deposition, or stainable microorganisms. On follow-up, there was no significant improvement in transaminitis. ACE level elevated to 73. Steroids were discontinued and she is now being managed conservatively for hepatic sarcoidosis with close follow-up and discussion of long-term immunosuppressive therapy. Discussion: The etiology of sarcoidosis is still not well understood and presentations with only hepatic involvement are uncommon. This case demonstrates that isolated hepatic sarcoidosis, while a rare diagnosis, should be considered in asymptomatic patients with abnormalities in liver function tests whose preliminary laboratory and imaging work-up has been unrevealing. Serum ACE levels along with liver biopsy for histopathology provides a diagnostic clue. Management options include close medical observation, prednisone and/or ursodeoxycholic acid, as well as initiation of immunosuppressive agents.

Optimal timing of thymectomy in nonthymomatous myasthenia gravis patients in China

Introduction:While thymectomy is a recommended therapy for patients with Myasthenia Gravis (MG), there is insufficient evidence of its benefits over other therapies in patients in China, specifically, or of the most optimal timing for the procedure. Thus, there remains a clinical need for the investigation of these questions. Therefore, it is important to compare the clinical efficacy of thymectomy plus oral prednisone, an immunosuppressant protocol with prednisone, or immunosuppressants alone.Conclusion:We propose here to prospectively assess 822 cases of MG and 1886 medical records from individuals hospitalized at the First Affiliated Hospital of Guangzhou University of Chinese Medicine and follow them for 3 years. Inclusion criteria will include the following: a Myasthenia Gravis Foundation of America (MGFA) clinical classification between I and IV while on optimal anticholinesterase therapy with or without oral prednisone or immunosuppressive therapy, an MG history of longer than 3 years, being 18 to 60 years of age, and positive testing for serum acetylcholine receptor antibodies (AchR-Ab). Both thymomatous-naïve and non-naïve participants will be included. The primary outcomes will be: mortality, frequency of myasthenic crises, MGFA classification, and changes to the required dose of prednisone and immunosuppressants. Based on these outcomes, we will evaluate the efficacy of thymectomy as well as oral drugs in managing patients with nonthymomatous MG. As of September 2017, this study has been approved by the ethics committee of the First Affiliated Hospital of Guangzhou University of Chinese Medicine and the Registration number is ChiCTR1800017564(Version1.0, September 8,2017).

Papanicolaou Cytology as a Suitable Technique for a Diagnostic Approach to an Adverse Reaction to Polyalkylamide Gel Filler

To the Editor: Mr. Editor: the use of fillers in cosmetic dermatology has increased in recent decades.1 However, there is not yet a perfect material because all of them can induce adverse reactions, although some fillers are known to be riskier than others. Sometimes these reactions can be serious and require early treatment.2 We present a clinical case of a severe inflammatory reaction by polyalkylamide gel (Bio Alcamid), where Papanicolaou cytology allowed us to perform an early diagnosis. We present a 59-year-old woman referred to our service by her primary care physician because of a left facial cellulitis that did not improve with antibiotic treatment. The examination revealed a warm erythematous plaque with ill-defined borders located in the left periorbital area and cheek (Fig. 1, up). There were palpable but not fluctuating subcutaneous nodules, not attached to deep tissues of the face. An ultrasound was performed showing multiple round hypoechogenic lesions with posterior reinforcement and without visible vascularization in Doppler mode. A punch biopsy was performed, and yellowish gelatinous material drained from the incision (Fig. 1, down). A sample was taken to perform a Papanicolaou stain, where we observed a basophilic amorphous material surrounded by an intense inflammatory infiltrate constituted mainly by neutrophils and erythrocytes (Fig. 2). The patient was treated with 30 mg of oral prednisone and systemic antibiotic therapy. In addition, a new suborbital incision was made to drain the material that still persisted after the biopsy. The lesions resolved completely within 10 days of treatment. The skin biopsy finally confirmed the diagnosis of late adverse reaction to polyalkylamide gel (Fig. 3). The filling material was visible as an intensely basophilic, nonvacuolated amorphous material that occupied the whole deep dermis and was surrounded by red blood cells and an intense inflammatory reaction.FIGURE 1.: Erythematous plaque with ill-defined borders located in the left periorbital area and cheek. A yellowish gelatinous material drained from the incision after of punch-biopsy.FIGURE 2.: Papanicolaou stain shows a basophilic amorphous material surrounded by an intense inflammatory infiltrate constituted by neutrophils and erythrocytes.FIGURE 3.: Skin biopsy shows a basophilic, nonvacuolated amorphous material that occupied the whole deep dermis and was surrounded by red blood cells and an intense inflammatory reaction.Each filler presents specific histopathological features, so it is important to know these features and be able to recognize them.3 Cytology can be a useful technique to guide the diagnosis faster than conventional skin biopsy and offer an optimal early treatment. To the best of our knowledge, there is only 1 article analyzing the cytological characteristics of the polyalkylamide gel by Papanicolaou staining.4 The view of an amorphous basophilic material surrounded by inflammatory cells and erythrocytes in the cytology is similar to the findings in the histopathological analysis. As a conclusion, we propose Papanicolaou cytology as a technique able to offer an adequate diagnostic approach to adverse reactions to polyalkylamide gel. Further studies are needed to confirm our findings and to analyze the cytopathological correlation of this technique on other filler materials.