Prednisolone Users Research Articles

Perception and usage of short-term prednisone and prednisolone in dogs.

Corticosteroids are widely used with low rates of reported side effects and a broad level of comfort in the hands of most veterinarians. With a low side effect reporting level of < 5% and high level of comfort there may be complacency and underestimation of the impact side effects of corticosteroids may have on a pet and pet owner. The objective of this clinical study was to describe the experience and perception of an owner who administered anti-inflammatory doses of oral prednisolone and prednisone to their dog for up to 14days. We hypothesized dogs receiving anti-inflammatory doses of prednisone and prednisolone would experience much greater rates of side effects by day 14 then reported in current literature. There were 45 dogs initially enrolled in the study. At each study point, 31 owners provided results. On day 5, 74% (23/31) reported at least 1 change in their dog's behavior including polyuria, polydipsia, polyphagia, polypnea and/or increased vocalization, with 11 individuals (35%) reporting these changes greatly increased. On day 14, 90% of owners (28/31) reported at least 1 change in their dog's behavior including polyuria, polydipsia, polyphagia, and/or polypnea as the most common changes noted. Overall, 61% (19/31) of owners reported an increase in filling of the water bowl over baseline and one-third (11/31) of pet owners reported cleaning up urinary accidents for pets who had been continent prior to the start of the study. Pet owner steroid satisfaction remained high through day 14 at 4.5/5 (1 = very unsatisfied, 5 = very satisfied). This study highlights the impact short term anti-inflammatory doses of prednisone or prednisolone have on dog behaviour and confirms our hypothesis that by day 14, 90% of dogs experienced one or more behaviour changes, with polyuria and polydipsia most commonly reported. Adverse events were noted regardless of starting dosage or regimen. Although most pet owners expressed satisfaction with steroid treatment due to its high efficacy, 70% would select a more costly treatment if that treatment had fewer side effects.

Long-term oral prednisolone exposure in primary care for bullous pemphigoid: population-based study.

BackgroundOral prednisolone is the mainstay treatment for bullous pemphigoid, an autoimmune blistering skin disorder affecting older people. Treatment with moderate-to-high doses is often initiated in secondary care, but then continued in primary care.AimTo describe long-term oral prednisolone prescribing in UK primary care for adults with bullous pemphigoid from 1998 to 2017.Design and settingA prospective cohort study using routinely collected data from the Clinical Practice Research Datalink, a primary care database containing the healthcare records for over 17 million people in the UK.MethodOral prednisolone exposure was characterised in terms of the proportion of individuals with incident bullous pemphigoid prescribed oral prednisolone following their diagnosis, and the duration and dose of prednisolone.ResultsIn total, 2312 (69.6%) of 3322 people with bullous pemphigoid were prescribed oral prednisolone in primary care. The median duration of exposure was 10.6 months (interquartile range [IQR] 3.4–24.0). Of prednisolone users, 71.5% were continuously exposed for >3 months, 39.7% for >1 year, 14.7% for >3 years, 5.0% for >5 years, and 1.7% for >10 years. The median cumulative dose was 2974 mg (IQR 1059–6456). Maximum daily doses were ≥10 mg/day in 74.4% of prednisolone users, ≥20 mg/day in 40.7%, ≥30 mg/day in 18.2%, ≥40 mg/day in 6.6%, ≥50 mg/day in 3.8%, and ≥60 mg/day in 1.9%.ConclusionA high proportion of people with incident bullous pemphigoid are treated with oral prednisolone in UK primary care. Action is required by primary and second care services to encourage use of steroid-sparing alternatives and, where switching is not possible, ensure prophylactic treatments and proactive monitoring of potential side effects are in place.

Mortality Risk in Patients With Adrenal Insufficiency Using Prednisolone or Hydrocortisone: A Retrospective Cohort Study.

Prednisolone has been recommended rather than hydrocortisone for glucocorticoid replacement in adrenal insufficiency due its longer duration of action and lower cost. To determine mortality rates with prednisolone versus hydrocortisone. In this observational study, we used data extracted from a UK primary care database (Clinical Practice Research Datalink) to measure the relative mortality of patients with primary and secondary adrenal insufficiency, who were treated with either prednisolone or hydrocortisone, and control individuals who were individually matched for age, sex, period, and place of follow-up. As expected, mortality in adrenal insufficiency irrespective of cause was increased, based on 5478 patients (4228 on hydrocortisone; 1250 on prednisolone) and 54 314 controls (41 934 and 12 380, respectively). Overall, the adjusted hazard ratio (HR) was similar with the 2 treatments (prednisolone, 1.76 [95% CI, 1.54-2.01] vs hydrocortisone 1.69 [1.57-1.82]; P = 0.65). This was also the case for secondary adrenal insufficiency. In primary disease (1405 on hydrocortisone vs 137 on prednisolone; 13 965 and 1347 controls, respectively), prednisolone users were older, more likely to have another autoimmune disease and malignancy, and less likely to have mineralocorticoid replacement. Nevertheless, after adjustment, the HR for prednisolone-treated patients remained higher than for those taking hydrocortisone (2.92 [2.19-3.91] vs 1.90 [1.66-2.16]; P = 0.0020). In primary but not in secondary adrenal insufficiency, mortality was higher with prednisolone. The study was large, but the number of prednisolone-treated patients was small, and they had greater risk factors. Nonetheless, the increased mortality associated with prednisolone persisted despite statistical adjustment. Further evidence is needed regarding the long-term safety of prednisolone as routine replacement.

Perspectives of Glucocorticoid Use in Patients with Rheumatoid Arthritis.

ObjectivePrednisolone is an effective oral glucocorticoid for managing symptoms of rheumatoid arthritis (RA) but has predictable and common adverse effects. We explored patient perspectives of prednisolone use in RA.MethodsPatients with RA registered with the Australian Rheumatology Association Database (ARAD) who had completed an ARAD questionnaire in the preceding 12 months were invited to participate in an online survey. Responses were linked to already collected respondent demographics, medication use, and patient‐reported outcome measures. The Beliefs about Medicine Questionnaire (BMQ) measured patient beliefs on medication necessity and concerns. Free‐text responses outlining reasons for stopping or declining prednisolone underwent thematic analysis using NVivo 12.ResultsThe survey response rate was 79.6% (804/1010), including 251 (31.2%) reporting current prednisolone use and 432 (53.7%) reporting previous use. Compared with previous users, current users were older (P = 0.0002) and had worse self‐reported pain, disease activity, health‐related quality of life, and function (all P < 0.001). Current users had higher BMQ scores for prednisolone‐specific necessity (3.6 versus 1.7; P <0.001) and concerns (2.7 versus 2.3; P <0.001). In previous prednisolone users (n = 432), the most frequent themes identified in free‐text responses for cessation were adequate disease control (30.3%), adverse effects (25.2%), and predetermined short courses (21.3%). Of respondents citing adverse effects for cessation (n = 131), weight gain (27.5%), osteoporosis (14.7%), and neuropsychiatric issues (13.8%) were most frequent.ConclusionsIn our cohort, patients with RA taking prednisolone believed it was necessary yet remained concerned about its use. Adequate disease control and adverse effects were important considerations for patients using prednisolone.

Molecular Epidemiology and Risk Factors of Clostridium difficile ST81 Infection in a Teaching Hospital in Eastern China.

BackgroundThe prevalence of Clostridium difficile causes an increased morbidity and mortality of inpatients, especially in Europe and North America, while data on C. difficile infection (CDI) are limited in China.MethodsFrom September 2014 to August 2019, 562 C. difficile isolates were collected from patients and screened for toxin genes. Multilocus sequence typing (MLST) and antimicrobial susceptibility tests by E-test and agar dilution method were performed. A case group composed of patients infected with sequence type (ST) 81 C. difficile was compared to the non-ST81 infection group and non CDI diarrhea patients for risk factor and outcome analyses.ResultsThe incidence of inpatients with CDI was 7.06 cases per 10,000 patient-days. Of the 562 C. difficile isolates, ST81(22.78%) was the predominant clone over this period, followed by ST54 (11.21%), ST3 (9.61%), and ST2 (8.72%). Toxin genotype tcdA+tcdB+cdt- accounted for 50.18% of all strains, while 29.54% were tcdA-tcdB+cdt- genotypes. Overall, no isolate was resistant to vancomycin, teicoplanin or daptomycin, and resistance rates to meropenem gradually decreased during these years. Although several metronidazole-resistant strains were isolated in this study, the MIC values decreased during this period. Resistance rates to moxifloxacin and clindamycin remained higher than those to the other antibiotics. Among CDI inpatients, longer hospitalization, usage of prednisolone, suffering from chronic kidney disease or connective tissue diseases and admission to emergency ward 2 or emergency ICU were significant risk factors for ST81 clone infection. All-cause mortality of these CDI patients was 4.92%(n=18), while the recurrent cases accounted for 5.74%(n=21). The 60-day mortality of ST81-CDI was significantly higher than non-ST81 infected group, while ST81 also accounted for most of the recurrent CDI cases.ConclusionThis study revealed the molecular epidemiology and risk factors for the dominant C. difficile ST81 genotype infection in eastern China. Continuous and stringent surveillance on the emerging ST81 genotype needs to be initiated.

Total Ankle Arthroplasty for Rheumatoid Arthritis

Category: Ankle Introduction/Purpose: Outcomes after total ankle arthroplasty (TAA) combined with additive techniques (1. augmentation of bone strength, 2. control of soft tissue balance, 3. adjustment of the loading axis) for rheumatoid arthritis (RA) cases were evaluated after mid to long-term follow-up. The influences of biologic treatment on the outcomes after TAA were also evaluated. Methods: We performed a retrospective observational study involving 50 ankles (44 patients) that underwent TAA for the treatment of rheumatoid arthritis. The mean duration of follow-up was 7.1 years. Clinical outcomes were evaluated with use of the Japanese Society for Surgery of the Foot (JSSF) scale score and a postoperative self-administered foot-evaluation questionnaire (SAFE-Q). Radiographic findings were evaluated as well. These parameters also were compared between patients managed with and without biologic treatment. Results: This procedure significantly improved the clinical scores of the JSSF rheumatoid arthritis foot and ankle scale (p &lt; 0.0001). Forty-eight of the 50 ankles had no revision TAA surgery. Subsidence of the talar component was seen in 8 ankles (6 in the biologic treatment group and 2 in the non-biologic treatment group); 2 of these ankles (both in the biologic treatment group) underwent revision TAA. The social functioning score of the SAFE-Q scale at the time of the latest follow-up was significantly higher in the biologic treatment group (p = 0.0079). The dosage of prednisolone (p = 0.0003), rate of usage of prednisolone (p = 0.0001), and disease-activity score (p &lt; 0.01) at the latest follow-up were all significantly lower in the biologic treatment group. Conclusion: TAA is recommended for RA cases, if disease control, augmentation of bone strength, control of soft tissue balance, and adjustment of loading axis are taken into account. The prevention of talar component subsidence remains a challenge in patients with the combination of subtalar fusion, rheumatoid arthritis, and higher social activity levels.

Effect of long-term low dose prednisolone administration on bone mineral density: Relating to non-compliant women with rheumatoid arthritis.

Background:Long-term treatment of rheumatoid arthritis (RA) with prednisolone (PRED) is associated with bone mineral density (BMD) loss. This study aimed to determine the status of BMD in non-compliant women who used PRED alone for RA.Methods:Non-adherent RA taking < 7.5 mg daily PRED without DMARDs for > 6 months, and RA patients taking methotrexate +PRED (RA control) were compared with age-matched non-RA controls. BMD was measured by dual energy x-ray absorptiometry (DXA) method and osteoporosis (OP) was diagnosed by WHO criteria. Influence of PRED on RA bone mass, and the risk of OP in RA was assessed by comparing PRED users RA and RA control,versus non-RA controls.Results:Sixty-four PRED user RA, 39 RA controls and 111 non RA-controls, with respective mean (±SD) age of 52±11; 8, 51±11; and 52±7.5 years (P=0.91) were studied. Median duration of treatment in PRED users and RA control was 2.5 and 4 years, respectively. BMD g/cm2 at the femoral neck (FN-BMD) and lumber spine (LS-BMD) in PRED users and RA control was significantly lower than non-RA control (P=0.001). The prevalence of OP at either FN or LS in both RA groups was significantly higher than controls (P=0.001). In PRED users, the risk of OP increased by OR=4.9, P=0.001) and in RA controls by OR=1.7 (P=0.20). The risk of OP in PRED user RA was 2.89 times (P=0.014) greater than RA controls.Conclusions:These findings indicate significantly lower BMD, and higher prevalence of osteoporosis in non-compliant women with RA taking low-dose PRED alone for a median period of 2.5 years, as compared with patients taking standard treatment comprising methotrexate +PRED.

Total Ankle Arthroplasty for Rheumatoid Arthritis in Japanese Patients: A Retrospective Study of Intermediate to Long-Term Follow-up.

Background:Outcomes after total ankle arthroplasty (TAA) combined with additive techniques (augmentation of bone strength, control of soft-tissue balance, adjustment of the loading axis) for the treatment of rheumatoid arthritis were evaluated after intermediate to long-term follow-up. The influences of biologic treatment on the outcomes after TAA were also evaluated.Methods:We performed a retrospective observational study involving 50 ankles (44 patients) that underwent TAA for the treatment of rheumatoid arthritis. The mean duration of follow-up was 7.1 years. Clinical outcomes were evaluated with use of the Japanese Society for Surgery of the Foot (JSSF) scale score and a postoperative self-administered foot-evaluation questionnaire (SAFE-Q). Radiographic findings were evaluated as well. These parameters also were compared between patients managed with and without biologic treatment.Results:This procedure significantly improved the clinical scores of the JSSF rheumatoid arthritis foot and ankle scale (p < 0.0001). Forty-eight of the 50 ankles had no revision TAA surgery. Subsidence of the talar component was seen in 8 ankles (6 in the biologic treatment group and 2 in the non-biologic treatment group); 2 of these ankles (both in the biologic treatment group) underwent revision TAA. The social functioning score of the SAFE-Q scale at the time of the latest follow-up was significantly higher in the biologic treatment group (p = 0.0079). The dosage of prednisolone (p = 0.0003), rate of usage of prednisolone (p = 0.0001), and disease-activity score (p < 0.01) at the time of the latest follow-up were all significantly lower in the biologic treatment group.Conclusions:TAA is recommended for the treatment of rheumatoid arthritis if disease control, augmentation of bone strength, control of soft-tissue balance, and adjustment of the loading axis are taken into account. The prevention of talar component subsidence remains a challenge in patients with the combination of subtalar fusion, rheumatoid arthritis, and higher social activity levels.Level of Evidence:Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Alendronate may reduce hip fracture risk in prednisolone users

Alendronate may reduce hip fracture risk in prednisolone users

Trends in steroid therapy for Duchenne muscular dystrophy in Japan.

ABSTRACT Introduction: We conducted a study to reveal trends in steroid prescription for Duchenne muscular dystrophy (DMD) patients in Japan. Methods: We asked patients (ages 5–20 years) identified in the patient registry and their clinicians about steroid therapy experiences. Regimen, dose, and starting age were compared among 3 subgroups according to prednisolone initiation year (2000–2004, 2005–2009, and 2010–2013). Results: Among 157 prednisolone users, 4 different regimens were used. Dose frequencies were: every other day (98 patients), daily (44 patients), 10 days on 20 days off (14 patients), and weekly (1 patient). Median starting age was 6 years, and median dose was 0.42 mg/kg/day. There was an increase in daily regimen use from 2005–2009 (n = 9, 16%) to 2010–2013 (n = 33, 36%). Conclusions: This study revealed a transition over time in steroid use from expert opinion to evidence‐based recommendation. Clinical research should be encouraged to optimize medication worldwide. Muscle Nerve 54: 673–680, 2016

Sequential Proximal Tibial Stress Fractures associated with Prolonged usage of Methotrexate and Corticosteroids: A Case Report

Stress fractures of the proximal tibia metaphysis are rare in the elderly. We present a case of a 65-year old male who developed sequential proximal tibia stress fractures associated with prolonged usage of methotrexate and prednisolone within a span of 18 months. Magnetic Resonance Imaging revealed an incomplete stress fracture involving the medial proximal tibial region. The patient was treated with stemmed total knee arthroplasty (TKA) bilaterally. Stress fractures should be considered in patients with atypical knee pain who have a history of methotrexate and prednisolone usage. TKA is an effective treatment in stress fractures of the proximal tibia.

Steroid-sparing effect of tacrolimus in the maintenance phase of systemic lupus erythematosus: a single-center, prospective study

Objective: The purpose of this study was to prospectively assess the steroid-sparing effect and safety of Tacrolimus (TAC) combination treatment during the maintenance phase of SLE. Methods: Thirty-eight patients were studied over a 1-year period from 2009 to 2012. If manifestations of mild active SLE, such as skin eruptions, arthritis, or asymptomatic nephritis, worsened and/or decreasing levels of serum complement (C3c) were observed, TAC combination treatment (from 1 mg to 5 mg once daily) was carried out. This was accomplished by adding TAC to the patient’s existing treatment regimen and decreasing in the usage of prednisolone (PSL). Scores on the SLE Disease Activity Index (SLEDAI), PSL dosage, and proteinuria, serum levels of C3c, anti-dsDNA levels were researched. Results: Twenty-eight patients received to TAC combination therapy. 1) The PSL dose was decreased from 11.7 ± 5.6 to 8.2 ± 4.2 mg/day (P<0.001). 2) The serum concentration of C3c increased and levels of anti-dsDNA antibodies decreased 3) Scores on the SLEDAI modified from 6.2 ± 3.7 to 2.6 ± 2.3 (P<0.001). There were no significant differences in proteinuria. In contrast, eight patients did not respond and/or had worsening SLE, and two patients discontinued treatment because of an adverse effect such as rhabdomyolysis or muscle cramps. No patients had complications of an abnormal urinalysis, and none progressed to renal failure with or without requiring dialysis. Conclusions: TAC combination treatment may have a useful steroid-sparing effect, as it does not worsen disease activity and is safe for SLE patients during the maintenance phase.

Effects of Low-Dose Prednisolone on Hepatic and Peripheral Insulin Sensitivity, Insulin Secretion, and Abdominal Adiposity in Patients With Inflammatory Rheumatologic Disease

OBJECTIVEThe metabolic effects of low-dose prednisolone and optimal management of glucocorticoid-induced diabetes are poorly characterized. The aims were to investigate the acute effects of low-dose prednisolone on carbohydrate metabolism and whether long-term low-dose prednisolone administration increases visceral adiposity, amplifying metabolic perturbations.RESEARCH DESIGN AND METHODSSubjects with inflammatory rheumatologic disease without diabetes mellitus were recruited. Nine subjects (age, 59 ± 11 years) not using oral glucocorticoids were studied before and after a 7- to 10-day course of oral prednisolone 6 mg daily. Baseline data were compared with 12 subjects (age, 61 ± 8 years) using continuous long-term prednisolone (6.3 ± 2.2 mg/day). Basal endogenous glucose production (EGP) was estimated by 6,6-2H2 glucose infusion, insulin sensitivity was estimated by two-step hyperinsulinemic-euglycemic clamp, insulin secretion was estimated by intravenous glucose tolerance test, and adipose tissue areas were estimated by computed tomography.RESULTSPrednisolone acutely increased basal EGP (2.44 ± 0.46 to 2.65 ± 0.35 mg/min/kg; P = 0.05) and reduced insulin suppression of EGP (79 ± 7 to 67 ± 14%; P = 0.03), peripheral glucose disposal (8.2 ± 2.4 to 7.0 ± 1.6 mg/kg/min; P = 0.01), and first-phase (5.9 ± 2.0 to 3.9 ± 1.6 mU/mmol; P = 0.01) and second-phase (4.6 ± 1.7 to 3.6 ± 1.4 mU/mmol; P = 0.02) insulin secretion. Long-term prednisolone users had attenuated insulin suppression of EGP (66 ± 14 vs. 79 ± 7%; P = 0.03) and nonoxidative glucose disposal (44 ± 24 vs. 62 ± 8%; P = 0.02) compared with nonglucocorticoid users, whereas basal EGP, insulin secretion, and adipose tissue areas were not significantly different.CONCLUSIONSLow-dose prednisolone acutely perturbs all aspects of carbohydrate metabolism. Long-term low-dose prednisolone induces hepatic insulin resistance and reduces peripheral nonoxidative glucose disposal. We conclude that hepatic and peripheral insulin sensitivity should be targeted by glucose-lowering therapy for glucocorticoid-induced diabetes.

Season of Birth and the Risk of Hip Fracture in Danish Men and Women Aged 65+

Vitamin D status in pregnant women has been linked to childhood bone mineral density in their offspring but it is unclear if effects extend to fracture risk in adulthood or even old age. As vitamin D levels in the population show pronounced seasonal variation in Denmark, we performed an epidemiological analysis of hip fracture rates as a function of season of birth, age, and sex. We retrieved information on all hip fractures in the 9-year period between 1997 and 2005 in all men and women aged 65–95, excluded hip fractures that occurred in current and recent prednisolone users, and subsequently calculated fracture rates and relative risks. The analysis covered 541,109 men and 691,522 women. In women, we observed a small but statistically significant difference between fracture rates by season of birth for all age intervals expect the youngest (age 65–69). A similar pattern was seen in men, but this was only statistically significant in the two oldest age groups (age 85–89 and 90–95). These findings suggest that vitamin D availability in the first and second trimester of intrauterine life could have a small but lasting impact on bone health and the risk of osteoporotic fractures. Further studies are needed.

Effects of epinephrine and cortisol on the analgesic activity of metyrosine in rats

Some endogenous hormones (epinephrine and cortisol) can change an individual's pain threshold. Propranolol is a non-selective β adrenergic receptor blocker which antagonises the anti-inflammatory effect of non-steroidal anti-inflammatory drugs via the β1 and β2 adrenergic receptors. The roles of epinephrine and cortisol were investigated in the analgesic activity of metyrosine in rats with reduced epinephrine levels induced by metyrosine. Pain threshold measurement was performed using an analgesimeter with different doses and the single or combined usage of metyrosine, prednisolone, metyrapone and propranolol in rats. Epinephrine and corticosterone levels were measured by high-performance liquid chromatography in metyrosineadministered rats. Metyrosine reduces the epinephrine levels without affecting the corticosterone levels, thereby creating an analgesic effect. It was determined that prednisolone did not have an analgesic effect in rats with normal epinephrine levels, but its analgesic activity increased with a parallel decrease in the epinephrine levels. Similarly, the combined use of prednisolone and metyrosine provided a stronger analgesic effect than that rendered by metyrosine alone. The strongest analgesic effect, however, was observed in the group of rats with the lowest epinephrine level in whom the metyrosine + prednisolone combination was administered. The findings of this study may be useful in severe pain cases in which the available analgesics are unable to relieve the individual's pain.

Membranous nephropathy (bubbling appearance and spike formation) without immunoglobulin deposition in a patient with systemic lupus erythematosus

A 53-year-old Japanese man with systemic lupus erythematosus developed proteinuria and hematuria after a urinary stone episode. A light microscopic study of a kidney biopsy specimen demonstrated a bubbling appearance and spike formation of the basement membrane. Immunofluorescent studies revealed that there were no significant depositions of immunoglobulins, such as IgG (-), IgA (-), IgM (+/-), kappa light chain (+/-), lambda light chain (+/-), or C3 (-) in the glomerular capillary wall, though C1q was present as one-plus positive staining in mesangial areas. Electron microscopic studies showed that the thickness of the basement membrane varied from thin to thick without electron dense deposits, and that the cellular components of the podocyte were irregularly present in the basement membrane. Urinary protein decreased after the usage of prednisolone and mizoribine; however, proteinuria aggravated after an episode of urinary stone during the same treatment.

Differential White Cell Count Relationships With Human Cardiac Allograft Rejection

The focus of research in allograft rejection has targeted the lymphocyte, with little attention given to the neutrophil. Recent data indicate that a perioperative neutrophil influx into the cardiac allograft influences early rejection. Factors that influence neutrophil transendothelial migration might offer predictive markers of rejection. We explored the relationship between the number of circulating neutrophils in heart transplant recipients and the development of rejection. Differential white cell counts were obtained prior to transplantation and concurrently with subsequent endomyocardial rejection surveillance biopsies for 53 heart transplant recipients undergoing 410 biopsies. Preoperative differential white cell counts had no relationship with rejection. In the first 3 months after transplantation, no relationship was found between contemporary differential white cell counts and rejection. However, more than 3 months following surgery, rejection grade positively correlated on univariate analysis with neutrophil counts and the usage of cyclosporine, prednisolone, and mycophenolate. There was no relationship with eosinophils or lymphocytes. Multivariate analysis demonstrated a persistent relationship among rejection severity, neutrophil count, and prednisolone usage. A significant positive association of higher steroid usage with higher rejection grades must reflect efforts to treat patients with rejection. The significant association of higher neutrophil counts with higher rejection severity might suggest a pathological contribution to rejection. However, given the neutrophilia response to acute steroid administration, we must conclude that the neutrophil association was related to steroid administration. The absence of a relationship between white cell counts and rejection suggests that functional rather than antiproliferative strategies may offer the greatest therapeutic potential.

TB or TB plus vasculitis: Occam versus Hickam – reply

Dear Editor, We reported an unusual case of Mycobacterium tuberculosis infection complicated initially by fever, palpable purpura and mononeuropathy multiplex (MNM), and later by chylothorax [1]. The relationship between the purpura-associated ischaemic neuropathy, i.e. vasculitis, and the pulmonary tuberculosis was identified by the disease course, exclusion of other aetiologies, and the response to antituberculosis drugs. In our patient, the palpable purpura developed on the lower extremities concurrently with foot drop, where an electromyographic study showed the ischaemic change with active axonopathy. This was the clinical findings of cutaneous small vessel vasculitis with peripheral nerve system involvement. Cutaneous vasculitis has many causes. It may be a manifestation of systemic vasculitis, rheumatic diseases, hypersensitivity reactions, or malignancy. In addition, numerous viral and bacterial infections have been associated with the cutaneous vasculitis, including tuberculosis [2]. We have searched for an underlying cause for the development of palpable purpura and MNM in the patient. Pulmonary tuberculosis was proven to be the cause of fever of unknown origin, and other infectious, malignant, or immunological aetiologies were excluded after extensive studies. There were no clinical or laboratory evidences of eyes, kidney, musculoskeletal system or gastrointestinal tract involvement, which were more or less observed in systemic vasculitis or rheumatic diseases. The low-dose prednisolone therapy was prescribed for MNM at nearly 1 month postadmission. It is of low possibility to miss major clinical manifestations of a systemic vasculitis or rheumatic disease. Although palpable purpura, peripheral neuropathy and pulmonary involvement were common features of certain forms of vasculitis, such as Wegener's granulomatosis, Churg-Strauss syndrome, microscopic polyangiitis, there was little evidence to support the diagnosis in our patient. There were also a few diagnostic clues from the disease course and history to suspect Behçet's disease or Henoch-Schönlein purpura in the reported case, although these vasculitis were occasionally reported to cause chylothorax. Moreover, the results of serological tests including antineutrophil cytoplasmic antibody (ANCA) were all normal, except a mild elevated level of rheumatoid factor. Furthermore, there were no further relapses of palpable purpura, peripheral neuropathy, chylothorax or other vasculitis features after the completeness of antituberculosis therapy, even when the usage of prednisolone was discontinued. Relapses of the disease course, which were commonly seen in most systemic vasculitis, did not occur in this patient. This as a result also implied that the underlying cause of the cutaneous vasculitis was the M. tuberculosis infection. In conclusion, concurrence of MNM and chylothorax as the manifestations of pulmonary tuberculosis is a rare condition. The relationship between vasculitis and tuberculosis was indirect; however, it was reasonable to make the illation. This illation requires a longer follow up of the patient and more reported cases to support. No conflict of interest was declared.

Knowledge, attitude and practice of prednisolone prevention of chloroquine induced pruritus among Nigerian health workers.

Severe generalized pruritus is a common drawback in chloroquine therapy of malaria in black Africans. In a cross-sectional study, we evaluated the knowledge, attitude and practice of 117 Nigerian hospital workers, who historically itch to chloroquine, to the use of prednisolone to prevent chloroquine pruritus in malaria. Ninety per cent of respondents had a positive family history of chloroquine induced pruritus. Seventy-five per cent (92) of the subjects were aware of the anti-pruritic action of prednisolone, but only 43% (n = 40) have ever used it during malaria. Among the prednisolone users (n = 40), 25 (62.5%) had total prevention, 25% (n = 10) had marked pruritus attenuation, but no effect was seen in 12.5% (n = 5). The modal prednisolone dose causing inhibition of itching was 10 mg orally given once. Concurrent prednisolone increased compliance with chloroquine in 68% of all who used the combination, and there was no evidence of malaria recurrence.