Short Course Of Steroids Research Articles

Accelerated partial breast irradiation (APBI) using intensity modulated radiation therapy (IMRT) in stage 0-II breast cancer: A preliminary report of 57 cases.

e12068 Background: Randomized trials in Stage 0-II breast cancer have proven that APBI given via HDR implant in 5 days is equivalent to whole breast External Radiation Therapy (XRT) given in 5-6 weeks in regard to breast tumor local recurrence (LR). However, complications have been significant. Recently APBI using non-invasive IMRT given in 5 fractions has been shown in another randomized trial to be equivalent to XRT in 6 weeks, with respect to LR. IMRT was superior in regard to acute effects, late effects, and cosmesis. In the randomized clinical trial of APBI IMRT, the Clinical Target Volume (CTV) was defined by the injection of individual fiducial markers bordering the surgical cavity. At our institution, we have used the Biozorb fiducial system to localize the CTV for IMRT. We sought to confirm the APBI IMRT results with this simpler less labor intensive fiducial placement system. Methods: Between 2017 and 2019, 57 patients have undergone IMRT targeted to a Biozorb defined CTV with the walls of the surgical cavity sewn to the Biozorb device. Eligible patients were older than age 40, had tumor sizes ≤ 3 cm, negative surgical margins, and negative sentinel node dissections. IMRT dose was 30 Gy given in 5 fractions. Dose Constraints were as follows : V-30 Gy < 105%, Ipsilateral Breast V-15 Gy < 50%, Ipsilateral Lung V-10 Gy < 20%, Contralateral Lung V-5 Gy < 10%, Heart V-3 Gy < 20%, Contralateral Breast Dmax < 2 Gy and Skin Dmax < 27 Gy. The Planning Target Volume (PTV) ranged from 27 to 355 cc with a median of 80 cc. PTV = CTV + 1-2 cm. Results: Follow-up ranged from 1-14 months with a median of 7 months. LR has been 0% (0/57). There were no skin reactions. One patient developed pain around the Biozorb site. This resolved within 2 days on a short course of steroids. Cosmetic results as rated by the Surgeon, Radiation Oncologist, and Nurse, were rated excellent in 100% (57/57) of cases. Conclusions: Non-invasive APBI with IMRT targeted to Biozorb has resulted in LR, complications, and cosmetic results which compare favorably to invasive APBI given with HDR implant. At last follow-up, there have been no LR, skin reactions, or complications. Cosmesis has been excellent in 100% of patients.

SUN-209 Clinical Hypogonadism Related to Incidentally Discovered Adrenal Insufficiency: Case Report

Introduction Hypogonadism can be primary or secondary. There are several causes of hypogonadism that include but are not limited to, congenital abnormalities, infections, systemic diseases, radiation therapy and glucocorticoid use. Addressing the primary cause tends to resolve the sex hormone deficiency. Case presentation Patient is a 46-year-old man with a history of HIV (on therapy), treated syphilis, and rheumatoid arthritis who presented to the office due to low testosterone levels found on laboratory tests done the prior year as well as complain of decreased libido and erectile dysfunction. He was sexually active with one male partner only and denied taking any testosterone-augmenting agents in the past. Physical exam was pertinent for truncal obesity, normal hair distribution, normal penis and testicles with no masses. Patient also endorsed taking a short course of steroids (prednisone) a few months before due to joint pain. On laboratory studies, patient had a normal prolactin, growth hormone, IGF-1 and thyroid function. Morning cortisol was low at 0.8 ug/dL (6.2 - 19.4 ug/dL) on two separate occasions, with borderline low ACTH. He also had low total and free testosterone at 203 ng/dL and 1.8 pg/ml, respectively. FSH and LH were inappropriately normal for the level of testosterone deficiency, and CD4 count was within normal limits. MRI of the brain showed a small 2.5 mm microadenoma, which was most likely a non-functional adenoma. Given low cortisol levels, the patient was started on hydrocortisone with subsequent transition to prednisone. After three months of treatment for adrenal insufficiency, his testosterone levels improved to normal range with no need for androgen replacement therapy, and his symptoms also improved significantly. Discussion Secondary hypogonadism has several causes, including but not limited to hyperprolactinemia, testosterone supplementation, opiate abuse, or glucocorticoid treatment. In this case, our patient developed adrenal insufficiency, possibly due to previous steroid administration. Glucocorticoid use is an uncommon but known cause of secondary hypogonadism, as it alters FSH and LH secretion. Low testosterone and hypogonadism have been studied and are relatively common in men with HIV (1), although how much of a role the HIV infection played in our patient’s findings is unclear, given that he was well controlled. Since the patient responded to steroid treatment with correction of his testosterone levels, his hypogonadism was most likely due to hypothalamic-pituitary axis dysfunction, also resulting in adrenal insufficiency. Reference: Mirza, F. S., Luthra, P., & Chirch, L. (2018). Endocrinological aspects of HIV infection. Journal of Endocrinological Investigation, 41(8), 881-899. doi:10.1007/s40618-017-0812-x

A female with classical paroxysmal nocturnal hemoglobinuria misdiagnosed as megaloblastic anemia

Paroxysmal nocturnal hemoglobinuria (PNH) is a rare acquired disorder of the hematopoietic stem cells, which manifests as bone marrow failure, hemolytic anemia, and thrombosis. PNH affects both sexes equally and may present at any age, although it is most often diagnosed in young adulthood. Here, we report a case of a middle-aged woman, presented with one and a half year history of anemia, significant fatigue, backache, and persistent high erythrocyte sedimentation rate. The patient has no organomegaly and did not give a history of thrombotic events previously. She was considered as a case of megaloblastic anemia at another center and treated accordingly. Her full blood count showed mild macrocytic anemia with slight polychromasia. The hemolytic anemia workup revealed slightly raised serum bilirubin (unconjugated) and undetectable haptoglobin with hemosiderin in urine. Ham's test was positive, and the diagnosis of PNH was confirmed by flow cytometry. The patient was treated with short-course steroids and folic acid, and her general condition has become stable.

The Role of Oral Steroids in the Treatment of Phonotraumatic Vocal Fold Lesions in Women.

(1) To determine the short-term effectiveness of oral steroids in women with benign vocal fold lesions and (2) to determine the effectiveness of adjuvant oral steroids in women undergoing voice therapy for benign vocal fold lesions. Randomized, double-blind, placebo-controlled clinical trial. Tertiary voice care center. Thirty-six patients undergoing voice therapy for the treatment of phonotraumatic vocal fold lesions randomly received either a 4-day course of oral steroids or a placebo prior to initiating voice therapy. Voice Handicap Index-10 (VHI-10) scores, video and audioperceptual analyses, acoustic and aerodynamic analyses at baseline, and patient perception of improvement after a short course of steroids or a placebo and at the conclusion of voice therapy were collected. Thirty patients completed the study, of whom 27 (only female) were analyzed. The primary outcome measure, VHI-10, did not improve after the 4-day course of steroids or placebo. Secondary measures similarly showed no improvement with steroids relative to placebo. Voice therapy demonstrated a positive effect on both VHI-10 and patient-perceived improvement of voice in all subjects. A short course of oral steroids did not benefit women with phonotraumatic vocal fold lesions. In addition, steroids had little beneficial effect when used adjunctively with voice therapy in this patient cohort.

359. Transient Ischemic attacks from Moya Moya disease associated with Graves disease during Pregnancy: A case report

Background Moya moya disease(MMD) is a rare idiopathic progressive vasculopathy,characterised by stenosis of the terminal portion of the internal carotid arteries and proximal portions of its major branches with the development of a thin collateral network of small vessels.It presents in young Asians with transient Ischemic attacks (TIAs), headaches,seizures,cognitive changes, ischemic or haemorrhagic strokes and is associated with many conditions including Graves disease. Case description 31 year old female with Graves disease (poorly controlled due to non-compliance) and previous 2 normal pregnancies presented during the third trimester of her 3rd pregnancy with intermittent headaches associated with right sided numbness of face and extremities lasting for few seconds without any features of Preeclampsia that were treated symptomatically.She had fluctuant thyroid function during her pregnancy and normal vaginal delivery at 40 weeks. She presented 2 months postpartum with severe headache and right sided numbness lasting for an hour without any features of Preeclampsia. She was thyrotoxic (FT4:51 pmol/L,FT3:16.6 pmol/L, TSH Although the Magnetic resonance imaging of the brain showed no infarcts and revealed features of MMD, the CT-Angiography of the Brain reported features suspicious of Takayasu’s arteritis with no evidence of it on Aortogram. She was treated with Aspirin, atorvastatin, carbimazole and a short course of Steroids. Discussion Awareness of the association between Graves’ disease and MMD in younger patients presenting with stroke like symptoms is important as early diagnosis and treatment of MMD in the setting of Graves Disease may prevent severe neurologic sequelae and eliminate the need for surgical intervention. Fluctuations in baseline thyroid function for patients with known Graves’ disease may be a potentiating factor in exacerbating Moyamoya vasculopathy. Most centres prefer caesarean delivery for patients with MMD to avoid haemodynamic instability.

Non-steroidal anti-inflammatory drugs induced acute kidney injury: incidence, clinical presentation, management and outcomes of patients at Tertiary Hospital based longitudinal study in Mymensingh, Bangladesh

Non-steroidal anti-inflammatory drugs (NSAIDs) are commonly prescribed in primary care for their analgesic and anti-inflammatory effects. Twelve percent of individuals currently report taking a NSAID daily. Renal injury caused by these agents can present in various forms, resulting from either acute or chronic use. Historically approximately five percent of patients initiated on NSAIDs experience a kidney-related adverse event. Drug-induced renal injury accounts for twenty percent of episodes of acute kidney injury (AKI). Patients requiring renal replacement therapy (RRT) have experienced an increased length of stay with associated healthcare costs per incident. The adverse effects of NSAIDs contribute to a significant economic burden, both to the patient and to the healthcare system.This study of NSAIDs induced AKI was carried out to highlight this issue. To find out the incidence, risk factors, diagnostic approach, clinical course, management and outcome of patients, this longitudinal study was carried out at Nephrology Department in Community Based Medical College Hospital Bangladesh from July 2015 to June 2016.Total 65 patients of NSAIDs induced AKI were included in this study. Any patient having pre existing renal pathology or chronic kidney disease was excluded from the study. Mean age of the patient was 36±7.12 yrs. Forty nine patients (74.38%) took NSAIDs at their own and 16 patients (24.61%) were prescribed by physician. Fifty six patients (86.15%) took NSAIDs because of musculoskeletal pain. Dehydration due to physical exertion (29.23%) gastroenteritis (16.92%) and nil per os (NPO) (6.15%)were the common predisposing factors. Common symptoms were swelling of the body (36.9%) headache (26.15%) fatigue (21.53%) and vomiting (13.84%) Oedema was the most common sign (36.9%) Blood urea and serum creatinine were raised in all patients. Treatment includes drug withdrawal (100%), fluid resuscitation (83.07%) fluid restriction (13.85%) short course of steroid (15.38%) and haemodialysis (10.76%) . Fifty one patients (78.46%) had complete recovery within two weeks of therapy whereas ten patients (15.38%) required more than two weeks to one month for complete recovery. Three patients (4.61%) developed chronic kidney disease (CKD). NSAIDs induced AKI carries a good prognosis with early diagnosis and proper management and it can be prevented by limiting the availability of over the counter drugs and creating awareness both in physicians and patients. These medications should be prescribed for the shortest duration, the lowest effective dose, and with careful surveillance to monitor nephrotoxicity precisely. NSAIDs should be used with special caution in elderly patients.
 CBMJ 2018 July: Vol. 07 No. 02 P: 09-16

Minocycline-Induced Autoimmune Hepatitis: A Rare But Important Cause of Drug-Induced Autoimmune Hepatitis

Drug-induced autoimmune hepatitis (DIAIH) is an increasingly recognized form of drug-induced liver injury that leads to a condition similar to idiopathic autoimmune hepatitis. A number of drugs have been associated with DIAIH, minocycline is one of the most well characterized. Minocycline is a semisynthetic tetracycline antibiotic used in the treatment of acne vulgaris. Minocycline-induced autoimmune hepatitis presents with serologic and histologic features similar to idiopathic autoimmune hepatitis. However, the natural history and outcomes of these two conditions differ significantly. The majority of patients with minocycline-induced autoimmune hepatitis experience complete resolution of symptoms after withdrawal of the medication. Some patients may require a short course of steroids and rarely use of an immunomodulator to achieve resolution of disease. Recurrence of symptoms is rare and typically only occurs with reintroduction of minocycline. It is important for primary care providers to consider minocycline-induced autoimmune hepatitis when liver injury develops during minocycline therapy.

Pustular psoriasis – Clinical study in a tertiary care center

Background: Pustular psoriasis is an uncommon form of psoriasis consisting of sheets of pustules on erythematous background. Treatment depends on the extent of involvement, severity, and underlying risk factors. Objectives: To study the clinical profile of pustular psoriasis, to identify triggering factors, and to study the response to treatment. Materials and Methods: A prospective clinical and therapeutic study of patients with pustular psoriasis attending DVL department over a period of 2 years. Diagnosis was made based on clinical and histopathological findings. Fourteen patients were admitted, investigated, and treated appropriately. Results: Nine were females and five were males. The mean age of the patients was 30 years. The duration of disease was 1–3 weeks. Among 14 cases of generalized pustular psoriasis, 10 were of acute type, 3 were pregnancy-related, and 1 childhood onset. In pregnancy group, all the patients were managed with systemic steroids till delivery followed by methotrexate (Mtx) and cyclosporine (CsA) during postpartum period in two patients, respectively. Eight patients were managed with short course of steroids and Mtx followed by Mtx alone. One patient with tuberculosis spine was managed with CsA and antituberculous therapy. Highly active retroviral therapy and acitretin (50 mg) were given in a retroviral-positive patient. One patient with recurrent episodes improved with antibiotics only. In our study, steroids were followed by maintenance therapy with Mtx/CsA and acitretin accordingly. CsA was given during crisis followed by maintenance with acitretin. Two patients on Mtx and one on CsA therapy with frequent flares were shifted to acitretin. Acitretin showed good response in patients who had frequent flares while on Mtx and CsA. In our study, response with acitretin, Mtx, and CsA was 100%, 57.1%, and 50%, respectively. Limitations: Only small number of patients. Conclusion: All patients were generalized type and showed good remission except one who succumbed to death due to septicemia.

Ipilimumab Lung Toxicity

SESSION TITLE: Lung Pathology 3 SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 31, 2017 at 01:30 PM - 02:30 PM INTRODUCTION: A patient being treated with Ipilimumab developed granulomatous lung disease. CASE PRESENTATION: A 54 year old man was being treated for stage IIIc Melanoma with Ipilimumab. After his second infusion he developed a rash. Biopsy of a palmar lesion showed non-caseating granulomas. He developed dry cough and chest CT (Image 1) showed mediastinal lymphadenopathy and scattered sub centimeter lung nodules. The imaging findings were concerning for metastatic disease. A bronchoscopy with EBUS and fine needle aspiration of hilar and subcarinal lymph nodes was performed. Lymph node biopsy revealed non-caseating granulomas in both left hilar and subcarinal sites. Flow cytometry on lymph node FNA showed no clonal populations and a CD4/CD8 ratio of 4. The patient was treated with Prednisone for 2 months with resolution of his symptoms and improvement in CT findings (Image 2). He continues to receive Ipilimumab infusions for Melanoma therapy without any recurrence of his granulomatous disease. DISCUSSION: Novel immunotherapy agents have revolutionized the treatment of certain cancers in recent years. Some of these work by activating the immune system to aid in fighting tumor burden. Ipilimumab blocks CTLA-4, a T-cell activation checkpoint molecule, thereby promoting immunity against the tumor (1). It has been shown to improve survival in metastatic Melanoma and has become part of the standard treatment regimen (2). There have been case reports of a granulomatous sarcoid-like reaction to these medications (3). Lung manifestations can be mistaken for progression of the underlying malignancy. Clinicians should be aware of this important reaction and pursue tissue diagnosis to differentiate the two. CONCLUSIONS: Novel immunotherapy agents are being used to treat certain kinds of cancer. An important consideration of these treatments is the effect of activation of the immune system on other organs. A pulmonary sarcoid like reaction can resemble metastatic disease on imaging. Our case illustrates the importance of pursuing tissue diagnosis. A short course of steroids resulted in resolution of the pulmonary findings. Reference #1: O’Day SJ, et al. Targeting cytotoxic T-lymphocyte antigen-4 (CTLA-4). Cancer, 110: 2614-2627. Reference #2: Hodi FS et al. Improved Survival with Ipilimumab in Patients with Metastatic Melanoma. N Engl J Med 2010; 363:711-23. Reference #3: Reule RB, North JP. Cutaneous and pulmonary sarcoidosis-like reaction associated with ipilimumab. J Am Acad Dermatol. 2013;69(5):e272-e273. DISCLOSURE: The following authors have nothing to disclose: Esha Oommen, Joanne Allam No Product/Research Disclosure Information

Infections Due to Candida, Cryptococcus, Other Yeasts, and Pneumocystis

Yeast-based fungal infections have become increasingly important over several decades, paradoxically because advances in medical practice have allowed patients with chronic medical conditions to live longer and have more productive lives. Many of these yeast infections are superficial in nature, such as thrush and candidal vaginitis among persons treated with antibiotics or with short courses of steroids. A minority of the yeast infections are associated with significant morbidity and mortality, generally among debilitated or otherwise immunosuppressed patients who have survived major surgeries or extensive chemotherapy regimens. These opportunistic yeast pathogens may originate as human commensals (e.g., Candida albicans) or have an environmental reservoir (e.g., Cryptococcus neoformans). Opportunistic Pneumocystis infections are inhaled. Knowledge of the host characteristics associated with specific infections will allow high suspicion for the type of yeast infection that may be occurring. Standard methods for making a diagnosis have included antigen testing, culture, and cytology. Newer methods for making the diagnosis include nucleic acid testing and nanotechnology. There are three general classes of antifungal agents. Treatment with antifungal agents for the most serious of these infections requires source control for cure. In addition, correction of predisposing conditions will also assist with prevention of recurrence. Immunocompromised patients require either prophylaxis or early empirical treatment during high-risk periods. This review contains 1 figure, 4 tables, and 74 references. Key words: Candida, Candidiasis, Cryptococcus, Malassezia, Trichosporon, Pneumocystis

Umeclidinium bromide versus placebo for people with chronic obstructive pulmonary disease (COPD).

People with chronic obstructive pulmonary disease (COPD) have poor quality of life, reduced survival, and accelerated decline in lung function, especially associated with acute exacerbations, leading to high healthcare costs. Long-acting bronchodilators are the mainstay of treatment for symptomatic improvement, and umeclidinium is one of the new long-acting muscarinic antagonists approved for treatment of patients with stable COPD. To assess the efficacy and safety of umeclidinium bromide versus placebo for people with stable COPD. We searched the Cochrane Airways Group Specialised Register (CAGR), ClinicalTrials.gov, the World Health Organization (WHO) trials portal, and the GlaxoSmithKline (GSK) Clinical Study Register, using prespecified terms, as well as the reference lists of all identified studies. Searches are current to April 2017. We included randomised controlled trials (RCTs) of parallel design comparing umeclidinium bromide versus placebo in people with COPD, for at least 12 weeks. We used standard Cochrane methodological procedures. If we noted significant heterogeneity in the meta-analyses, we subgrouped studies by umeclidinium dose. We included four studies of 12 to 52 weeks' duration, involving 3798 participants with COPD. Mean age of participants ranged from 60.1 to 64.6 years; most were males with baseline mean smoking pack-years of 39.2 to 52.3. They had moderate to severe COPD and baseline mean post-bronchodilator forced expiratory volume in one second (FEV1) ranging from 44.5% to 55.1% of predicted normal. As all studies were systematically conducted according to prespecified protocols, we assessed risk of selection, performance, detection, attrition, and reporting biases as low.Compared with those given placebo, participants in the umeclidinium group had a lesser likelihood of developing moderate exacerbations requiring a short course of steroids, antibiotics, or both (odds ratio (OR) 0.61, 95% confidence interval (CI) 0.46 to 0.80; four studies, N = 1922; GRADE: high), but not specifically requiring hospitalisations due to severe exacerbations (OR 0.86, 95% CI 0.25 to 2.92; four studies, N = 1922, GRADE: low). The number needed to treat for an additional beneficial outcome (NNTB) to prevent an acute exacerbation requiring steroids, antibiotics, or both was 18 (95% CI 13 to 37). Quality of life was better in the umeclidinium group (mean difference (MD) -4.79, 95% CI -8.84 to -0.75; three studies, N = 1119), and these participants had a significantly higher chance of achieving a minimal clinically important difference of at least four units in St George's Respiratory Questionnaire (SGRQ) total score compared with those in the placebo group (OR 1.45, 95% CI 1.16 to 1.82; three studies, N = 1397; GRADE: moderate). The NNTB to achieve one person with a clinically meaningful improvement was 11 (95% CI 7 to 29). The likelihood of all-cause mortality, non-fatal serious adverse events (OR 1.33; 95% CI 0.89 to 2.00; four studies, N = 1922, GRADE: moderate), and adverse events (OR 1.06, 95% CI 0.85 to 1.31; four studies, N = 1922; GRADE: moderate) did not differ between umeclidinium and placebo groups. The umeclidinium group demonstrated significantly greater improvement in change from baseline in trough FEV1 compared with the placebo group (MD 0.14, 95% CI 0.12 to 0.17; four studies, N = 1381; GRADE: high). Symptomatic improvement was more likely in the umeclidinium group than in the placebo group, as determined by Transitional Dyspnoea Index (TDI) focal score (MD 0.76, 95% CI 0.43 to 1.09; three studies, N = 1193), and the chance of achieving a minimal clinically important difference of at least one unit improvement was significantly higher with umeclidinium than with placebo (OR 1.71, 95% CI 1.37 to 2.15; three studies, N = 1141; GRADE: high). The NNTB to attain one person with clinically important symptomatic improvement was 8 (95% CI 5 to 14). The likelihood of rescue medication usage (change from baseline in the number of puffs per day) was significantly less for the umeclidinium group than for the placebo group (MD -0.45, 95% CI -0.76 to -0.14; four studies, N = 1531). Umeclidinium reduced acute exacerbations requiring steroids, antibiotics, or both, although no evidence suggests that it decreased the risk of hospital admission due to exacerbations. Moreover, umeclidinium demonstrated significant improvement in quality of life, lung function, and symptoms, along with lesser use of rescue medications. Studies reported no differences in adverse events, non-fatal serious adverse events, or mortality between umeclidinium and placebo groups; however, larger studies would yield a more precise estimate for these outcomes.

Granulomatous mastitis-a challenging surgical entity

Background: Idiopathic granulomatous mastitis is a rare benign breast disease, first described by Kessler and Wolloch in 1972. It is characterized by chronic necrotizing granulomatous lobulitis of unknown aetiology. The objective of the study is to find out the clinical and management profile of granulomatous mastitis (GM). This study was carried out at JSS hospital, Mysore, Karnataka, India during the period 2014-2016.Methods: Histopathologically diagnosed cases of GM were studied. Data included, detailed history, examination, clinical diagnosis, ultrasound, mammogram and fine needle aspiration cytology (FNAC). All patients were followed for a period of 6 months. Recurrent cases were managed by wide excision and followed for another period of 6 months.Results: 8 patients who were hisptopathologically diagnosed to have granulomatous mastitis were studied. The mean age was found to be 43.5 years. All patients presented with a painless breast lump and were unilateral. The incidence of the same was found to be higher (3.7%) compared to other large volume studies. The best treatment modality with least recurrence in 4 cases was wide local excision and 1 case of quandrantectomy.Conclusions: GM is an uncommon chronic inflammatory disease of the breast. Usually involving a single non-lactating breast in reproductive age group. It clinically mimics tuberculosis and carcinoma. Mammography remains non-conclusive. Excision and wide excision biopsy are both diagnostic and therapeutic in majority of cases. Treatment includes short course of steroids and antibiotic along with close regular surveillance.

Cancer patients with undiagnosed and poorly managed diabetes mellitus.

e18232 Background: Cancer patients are at increased risk of developing diabetes mellitus (DM) or having worsening control of their pre-existent DM. The causes of this are multifactorial but the use of steroids, either in the palliative setting or short-term whilst on chemotherapy, is a significant contributor. An audit carried out at a district general hospital demonstrated that 5% of all oncology admissions were secondary to DM complications. A study was conducted to evaluate the prevalence of impaired blood glucose (BG) control and to assess the value of routine HbA1c testing in this population. Methods: Patients having routine chemotherapy blood tests were also tested for HbA1c over a 10 day period in December 2016. HbA1c diagnostic criteria was used as per NICE guidelines. Information on previous diabetic status, primary tumour type, chemotherapy status (number of cycles and treatment intent) was recorded. Results: 134 patients were tested for HbA1c; 28 (21%) had a HbA1c diagnostic of DM and 32 (24%) were at high risk of DM. The mean HbA1c of those in the DM group was 67.3 mmol/mol (range 48-120). Of the 28 with a HbA1C diagnostic of DM, 13 (46%) were already known to have DM with 15 (54%) being newly diagnosed from this study. 11 (73%) of those with a new diagnosis of DM were receiving a short course of steroids with chemotherapy. 12 patients in the DM group were having chemotherapy with curative intent; 6 of whom were newly diagnosed. Conclusions: 11% of the study cohort met criteria for a new diagnosis of DM with 73% of this group receiving steroids. NICE advises on monitoring of BG for all diabetics receiving steroids. Monitoring of BG and using anti-diabetic medications could prevent DM related complications. This highlights the need to involve local diabetic services and primary care providers for diabetic management. 43% of patients in DM group were receiving chemotherapy with curative intent. This has large implications on cancer survivorship and it is vital that these patients receive appropriate DM treatment. This will not only improve quality of care and patient satisfaction but also lead to significant cost savings from reduced admissions and length of stay in hospital. We therefore recommend a routine HbA1c test for all cancer patients having chemotherapy.

Reversible Cerebrovascular Syndrome

Reversible cerebrovascular syndrome (RCVS) is clinico-radiological syndrome defined as severe recurrent thunderclap headache with or without seizures or neurologic deficits and constriction of cerebral arteries which resolves spontaneously within 1-3 months. RCVS affects patients in various racial and ethnic groups and in all age groups, although most commonly in the fourth decade of life. Headache is the main symptom. Headache is usually “thunderclap variety”, peaks within one minute and very intense. Many conditions and exposures have been linked to RCVS, including vasoactive drugs, metabolic disorder, vasculitis and the peripartum period. Associated strokes and cerebral hemorrhages are not uncommon. As complications we can see Localized cortical SAH (20-25%), Ischemic or hemorrhagic stroke (5-10%), posterior reversible encephalopathic syndrome ( PRES). Permanent sequelae of RCVS is usually benign entity. Prognosis is highly dependent on the occurrence of stroke (6-9%), otherwise, by definition, most resolve completely without any sequelae. Treatment is Symptomatic (pain, seizures, blood pressure control), trigger avoidance should be done (either activity or vasoactive substances), calcium channel blockers, IV magnesium and Short-course of steroids may be effective.

The other side of vitamin D therapy: a case series of acute kidney injury due to malpractice-related vitamin D intoxication .

Vitamin D deficiency is highly prevalent in Indian Kashmir. Many people get injectable vitamin D (600,000IU/injection). At times, the dose prescribed is far above the permissible limit. We report 62 patients with malpractice-related vitamin D intoxication, presenting with hypercalcemia and acute kidney injury (AKI). The diagnosis was made on basis of (1) history of multiple intramuscular vitamin D injections (2) toxic serum levels of 25-OH vitamin D and (3) exclusion of common causes of hypercalcemia (malignancy and hyperparathyroidism). Their presentation was either de novo AKI in 51 (group 1) or acute on top of chronic kidney disease in 11 (group 2). The mean age was 60±14 vs. 62±13 years, approximate number of vitamin D injections received ranged from 4 to 28 (2.4-16.8 million units) vs. 3 to 24 (1.8-14.4 million units), mean creatinine at presentation was 3.2±0.9 vs. 4.5±1.1mg/dL, which decreased to 1.2±0.2 vs. 3.3±1.0 mg/dL, mean serum calcium on admission was 13.7±1.4 vs. 13.6±2.0 mg/dL which decreased to 10.7±1.2 vs. 11.0±1.0 mg/dL on follow-up of 7.2±0.6 months, mean vitamin D level was 313.3±54.8 (range 235-375) vs. 303.7±48.4 (range 210-375) nmol/L and mean PTH was 18.1±9.6 (range 6.2-32) vs. 52.3±12.6 (range 28-88) pg/mL in group 1 vs. group 2, respectively. The clinical presentation was weakness, constipation, abdominal pain, nausea, vomiting, anorexia, altered sensorium, and oliguria. The treatment received was intravenous fluids (normal saline) in all in group 1 and in 8/11 in group 2, short course of steroids (prednisolone) in 44, and bisphosphonate in 6. This is the largest case series of AKI secondary to vitamin D toxicity ever reported. .

Neuromyelitis optica spectrum disorder in a patient with Kikuchi-Fujimoto disease.

A 26-year-old African American woman was admitted for intractable nausea and vomiting during her third trimester of pregnancy. The patient had been diagnosed with Kikuchi-Fujimoto disease (KFD) a year prior, when she presented with high fevers and cervical lymphadenopathy. Lymph node biopsy revealed necrotic foci of predominantly CD8-positive T cells and myeloperoxidase-positive histiocytes consistent with necrotizing lymphadenitis. The patient became pregnant within months of the diagnosis. At 33 weeks' gestation, the patient was given a short course of steroids for myalgias and joint pains that were thought to be due to KFD. This improved her symptoms. Three weeks later, she was admitted for headaches, hypertension, nausea, and intractable vomiting. A diagnosis of preeclampsia was made, labor was induced, and she had an uncomplicated vaginal delivery. The following day, the patient complained of “shaky” and “jumpy” vision, severe headache, weakness, and paresthesias in the lower extremities. Her blood pressure was 170/100 mm Hg. Examination revealed rapid, involuntary eye movements with both horizontal and vertical components consistent with opsoclonus, severe paraparesis, absent reflexes in the lower extremities, and a possible T10 sensory level. Brain MRI revealed hyperintensities in bilateral occipital lobes suggestive of posterior reversible encephalopathy syndrome (PRES) along with a lesion in the medulla (figure, A and B). Spine MRI revealed an extensive cord lesion spanning from C5 to T10 spinal segments consistent with transverse myelitis (figure, C). CSF and serum IgG–neuromyelitis optica antibodies, otherwise known as aquaporin-4 antibodies, were positive; rheumatologic markers, serum and CSF viral markers, cultures, and paraneoplastic autoantibodies were negative. The patient's complaints of abnormal vision and headache resolved with blood pressure control. However, the paraparesis did not improve despite treatment with high-dose IV Solu-Medrol and IVIg. She slowly regained strength over several weeks after receiving treatment with plasmapheresis and continued high-dose prednisone 60 mg/d.

Pyoderma gangrenosum (PG) associated with levamisole-adulterated cocaine: Clinical, serologic, and histopathologic findings in a cohort of patients

Recently, isolated reports of pyoderma gangrenosum (PG) secondary to levamisole-contaminated cocaine have been described, with similar serologic findings to the vasculopathic presentation. We sought to describe clinical, histopathological, and serologic findings in 8 patients with PG associated with levamisole-contaminated cocaine. Eight consecutive patients presenting with this disease spanning the period from 2011 to 2015 were included for the cohort. Observed variables included: lesion distribution, morphology, serologic titers, and histopathologic evaluation for vasculitis and vasculopathy. All patients reported cocaine exposure prior to the onset of lesions resembling PG. Lesions appeared primarily on the upper (6 of 8 patients) and lower (all 8 patients) extremities. Most patients demonstrated elevated titers for p-ANCA and antiphospholipid antibodies, and a diffuse dermal infiltrate dominated by neutrophils was seen in all biopsy specimens. Lesions improved or remained stable with conservative management or short courses of steroids, and recurrence was only noted on re-exposure to adulterated cocaine. The study is limited by sample size. PG may occur after exposure to levamisole-adulterated cocaine. Clinical and histopathological findings resemble those seen in conventional forms of PG, whereas serologic findings mirror those seen in other levamisole-associated vasculopathic or vasculitic eruptions. Cocaine avoidance represents a cornerstone of management in these patients.

Post-procedure adhesive arachnoiditis following obstetric spinal anaesthesia.

Sir, Adhesive arachnoiditis is a crippling disorder in which the pia-arachnoid undergoes extensive inflammatory reactions to injurious stimulus, resulting in subarachnoid scarring. A Swedish study reports the incidence of neurological complications as one case per 2834 subarachnoid blocks and at least one permanent damage for every 923 epidural blocks.[1] A Finnish study reports an incidence of serious complications as 0.45/10,000 for intrathecal and 0.52/10,000 for epidural blocks.[2] A 35-year-old mother with no significant medical history, in her second pregnancy, underwent spinal anaesthesia for an elective caesarean section at 40 weeks gestation at another hospital. As per the information obtained, spinal anaesthesia in sitting position was performed with due aseptic precautions in L2-L3 interspace using 10% povidone-iodine (betadine™) solution. The cerebrospinal fluid (CSF) tap could be obtained on the second attempt. After aspiration of clear, free-flowing CSF, 12 mg of 0.5% hyperbaric bupivacaine was administered. Surgery proceeded uneventfully. On the second post-operative day, on the removal of the urinary catheter, the patient complained of urinary incontinence with the loss of sensation over the perineal area and buttocks. Gradually she also complained of constipation, following which an enema was given on the fourth post-operative day. She passed stool but, subsequently, lost her bowel control too. The patient was referred 11 days post-partum to our centre with signs of S2-S4 radiculopathy, urinary retention, constipation with faecal impaction, loss of sensation over buttocks and perineal area with weak perianal reflex. All her records from the previous hospital were obtained. A thorough examination demonstrated localised unilateral right-sided sensory loss over T11-T12 dermatome. The rectum was hugely loaded with faecal matter. A lumbosacral spine magnetic resonance imaging (MRI) [Figure 1] showed thickening, clumping and nodular enhancement of cauda equina nerve roots, suggestive of arachnoiditis. CSF analysis showed mild lymphocytosis.Figure 1: Axial magnetic resonance imaging of lumbosacral spine T2 weighted, the arrow showing thickening, clumping and nodular enhancement of cauda equina nerve roots-suggestive of arachnoiditis (likely post-surgery/procedure)A neurosurgical opinion was taken and the patient was put on a short course of steroids (tablet deflazacort six mg thrice daily). She was asked to undergo physiotherapy and was also suggested transcutaneous electrical nerve stimulation therapy. The patient was discharged to a rehabilitation centre where she received oral methylprednisolone 16 mg once daily for 7 weeks with gabapentin 100 mg thrice daily for 3 weeks. A repeat MRI 2 months later showed mild enhancement of cauda, clumping of root and resolution compared to the previous MRI. The patient was advised pelvic floor exercises with dietary adjustments to control the faecal incontinence. Steroids were tapered over 2 months after reviewing her 30 days later. She was advised to remove catheter under medical guidance and watch for retention and bladder sensation. At 12 months follow-up, the patient has significantly regained her bladder control. There was still considerable impairment in bowel control. The anal tone had not completely resolved till the date of submission of this manuscript. Contamination of intrathecal local anaesthetic drugs with noxious chemicals has been widely suggested as an aetiology in cases of adhesive arachnoiditis; phenolic, acidic and detergent contaminants all being known neurotoxic agents.[34] Alcoholic chlorhexidine, in 2008, was the identified as a culprit in a case of arachnoiditis in a trial held at the United Kingdom.[5] We considered povidone-iodine contamination as a possibility in this case, by contamination of the injectate or improper cleaning of povidone iodine from the skin before proceeding with the subarachnoid block. Without more definitive data, neuraxial blocks should be done under stringent aseptic, atraumatic techniques after discarding all sources of contamination. It also seems pertinent to explain to patients the risks of late, permanent neurological deficit while obtaining informed consent. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest. Acknowledgement This case study was supported by the entire Department of Anaesthesiology and Intensive Care Medicine, B. R. Singh Hospital, Eastern Railway, Kolkata. We are also thankful to the Department of Gynaecology and Obstetrics, B. R. Singh hospital, the nursing staff and attendants for the support in patient care and to the patient and her family for giving consent to proceed with submission for publication of the report.

Nonsteroidal Anti-Inflammatory Drugs (NSAIDS) Induced Acute Kidney Injury (AKI): Patient Profile and Outcome in Bangladesh Armed Forces

Introduction: In military environment where musculoskeletal injury is more common, NSAIDs abuse and subsequent AKI carries a special risk. This study of NSAIDs induced AKI was carried out to highlight this issue.Objective: To find out the incidence, risk factors, diagnostic approach, clinical course, management and outcome of patients of Bangladesh Armed Forces.Methods: This longitudinal study was carried out in nephrology centre, combined military hospital (CMH) Dhaka from July 2010 to Jun 2013. Total 59 patients of NSAIDs induced AKI were included in this study. Any patient having pre existing renal pathology or chronic kidney disease was excluded from the study.Results: Total 59 patients were included in this study. Mean age of the patient was 36±7.12 yrs. Forty five patients (76.27%) took NSAIDs at their own and 14 patients (23.73%) were prescribed by physician. Fifty one patients (86.44%) took NSAIDs because of musculoskeletal pain. Dehydration due to physical exertion (30.50%), gastroenteritis (15.25%) and nil per os (NPO) (5.08%) were the common predisposing factors. Common symptoms were swelling of the body (40.67%), headache (32.20%), fatigue (27.11%) and vomiting (13.55%). Oedema was the most common sign (40.67%). Blood urea and serum creatinine were raised in all patients. Treatment includes drug withdrawl (100%), fluid resuscitation (86.44%), fluid restriction (61.01%), short course of steroid (13.55%) and haemodialysis (10.16%). Forty seven patients (79.66%) had complete recovery within two weeks of therapy whereas nine patients (15.25%) required more than two weeks to one month for complete recovery. Three patients (5.09%) developed chronic kidney disease (CKD).Conclusion: NSAIDs induced AKI carries a good prognosis with early diagnosis and proper management and it can be prevented by limiting the availability of over the counter drugs and creating awareness both in physicians and patients.Journal of Armed Forces Medical College Bangladesh Vol.10(2) 2014

Initial Neurologic Examination Does Not Determine Survival in Patients With Brain Metastases

was reported in 30% of patients with only three patients (43%) requiring narcotics or short-course steroids. There was no evidence of vertebral body fracture in any patient that achieved local control in the treated area. Conclusion: Spine stereotactic radiosurgery for thyroid metastases as a primary or adjuvant/salvage therapy is well-tolerated and yields high rates of local control. To our knowledge, this is the first study focusing on this modality for metastatic thyroid cancer patients only. Author Disclosure: M.B. Bernstein: None. E.L. Chang: None. B. Amini: None. M. Cabanillas: None. X. Wang: None. P.K. Allen: None. L. Rhines: None. C.E. Tatsui: None. P.D. Brown: None. A.J. Ghia: None.