Short Course Of Corticosteroids Research Articles

The Epidemiology of Newly Recognized Causes of Drug-Induced Liver Injury: An Update.

The incidence and prevalence of drug-induced liver injury appear to be increasing globally, for example, with the introduction of checkpoint inhibitors. Several reviews have been published in the last decade on the epidemiology of DILI, both among hospitalized patients and in the general population, as well as from retrospective and prospective studies on DILI. Most of these reviews have not focused on newly recognized agents that have recently changed the landscape of DILI. Apart from liver injury associated with antibiotics, oncological agents, particularly checkpoint inhibitors, are increasingly being recognized as causing liver injury. The type of liver injury associated with these agents is not idiosyncratic but rather an indirect type of injury. Furthermore, recently, COVID-19 vaccines and green tea extract have been found to lead to liver injury. Checkpoint inhibitors have revolutionized the treatment of many malignancies, such as malignant melanoma, lung cancer, and renal cancer. Via the activation of T cells, they can increase immune activity against malignant cells, but at the same time, they can decrease immune tolerance and therefore lead to immune-related adverse effects in many organs. The most common adverse effect in clinical practice is liver injury. A recent prospective study demonstrated an 8% frequency of DILI due to the use of checkpoint inhibitors among patients with malignant melanoma and renal cancer. This rate is much higher than observed with drugs, leading to idiosyncratic liver injury. Shortly after the implementation of the worldwide vaccination program against COVID-19, several case reports were published on suspected vaccination-induced autoimmune-like hepatitis occurring shortly after the vaccination. At first, these reports were met with skepticism, but currently, around 100 reports have been published, and cases of positive recurrence have been reported. The clinical, biochemical, immunological, and histological features are indistinguishable from classic autoimmune hepatitis (AIH). These reactions are very similar to drug-induced autoimmune-like hepatitis (DI-ALH) due to drugs such as nitrofurantoin, minocycline, and infliximab, which do not relapse after a short course of corticosteroids, which is the general rule in classic autoimmune hepatitis (AIH). Green tea extract has been found to be a well-documented cause of acute hepatocellular liver injury with jaundice. A strong HLA association has been reported, showing a high prevalence of HLA-B*35:01 among patients suffering from green tea-induced liver injury. Overall, 3% of patients recruited in the DILIN study were supplemented with green tea extract as one of the ingredients. In a prospective population-based study from Iceland, green tea was implicated in approximately 8% of patients with DILI.

Efficacy of different doses of corticosteroids in treating severe COVID-19 pneumonia

BackgroundTo investigate the efficacy of different doses of corticosteroids in treating severe coronavirus disease 2019 (COVID-19) pneumonia.MethodsBetween May 01, 2023, and June 20, 2023, 48 patients with severe COVID-19 pneumonia were treated at the Department of Respiratory and Critical Care Medicine of Jinan Fourth People's Hospital. The observation group (21 patients) received standard care and high-dose corticosteroids, (high-dose group). The control group (27 patients) received standard care and low-dose corticosteroids (low-dose group). We collected baseline data and recorded inflammatory marker levels after 3 days of treatment, body temperature recovery time, length of stay, and 28-day all-cause mortality. The results of outpatient follow-up were recorded after 1 month.ResultsThere were no significant differences in 28-day mortality and length of stay. The number of days it took for body temperature to return to normal in the high-dose group was less than in the low-dose group. The high-dose group had significantly more reduced inflammatory factors (C-reactive protein (CRP), interleukin-6 (IL-6). A total of 20 discharged patients were given 8–16 mg of methylprednisolone, depending on chest computed tomography (CT) and clinical symptoms after 1 month; in all discharged patients using oral corticosteroids, CT features improved.ConclusionHigh-dose corticosteroids had a significantly positive effect on the reduction of inflammatory factors and shortening body temperature recovery time. In the treatment of severe COVID-19 pneumonia, early administration of high-dose, short-course corticosteroids should be implemented.

ERAP-1 and ERAP-2 Variants in Liver Injury After COVID-19 mRNA Vaccination: A US Multicenter Study.

The aim of this study is to describe the presenting features, genetic factors, and outcomes of 23 adults who developed liver injury after coronavirus disease 2019 (COVID-19) mRNA vaccination. Patients with suspected COVID-19 vaccine hepatitis were enrolled into the Drug-Induced Liver Injury Network. Causality was assessed using the Drug-Induced Liver Injury Network expert opinion score. High-resolution HLA sequencing was undertaken using Illumina platform. Amongst the 16 high causality cases, median time to onset was 16 days, median age was 63 years, and 75% were female. The injury was hepatocellular in 75% with a median alanine aminotransferase of 497 U/L, and 37% had jaundice. An antinuclear antibody and smooth muscle antibody were detectable in 27% and 36%, but only 12% had an elevated immunoglobulin G level. During follow-up, 37% received a short course of corticosteroids, and 88% fully recovered by 6 months with no deaths observed. HLA alleles associated with autoimmune hepatitis were not overrepresented compared with controls, but an ERAP-2 variant (rs1263907) and the ERAP-1 Hap6 haplotype were significantly overrepresented in the high causality cases vs controls ( P = 0.026 and 5 × 10 -5 , respectively). Acute liver injury may arise within 8 weeks of COVID-19 mRNA vaccination that is generally mild and self-limited in most patients. The absence of an association with the AIH HLA alleles combined with the significant ERAP-2 and ERAP-1 Hap6 haplotype associations implicates a unique but very rare host immune response to vaccine-derived antigens in the pathogenesis of COVID-19 vaccine hepatotoxicity.

Obstrucción Intestinal por infección por Strongyloides Stercolaris, a propósito de un caso

Strongyloidiasis is a parasitosis caused by the nematode Strongyloides stercoralis, which commonly causes gastrointestinal problems. We present the case of a 30-year-old man who developed Strongyloides hyperinfection, with a history of a presumptive diagnosis of polymyositis for which he received a short course of corticosteroids. Upon admission, he presented with hyporexia, generalized weakness, cachectic syndrome, self-limited intermittent diarrhea, oral intolerance, and mild abdominal distension. Our patient reached the dissemination stage, which resulted in severe damage at the intestinal level. The diagnosis was difficult due to the low excretion of larvae in the feces. Treatment was started with parenteral ivermectin at a dose of 1.2ml via sc every 48 hours for 03 doses, with good response to treatment and good tolerance of the oral route. The importance of presenting the case is to present the diagnostic and therapeutic approach to this disease that has been little studied in Peru.

Effects of Early Short-Course Corticosteroids on Immune-Related Adverse Events in Non-Small Cell Lung Cancer Patients Receiving Immune Checkpoint Inhibitors

Introduction: In real-world practice, most non-small cell lung cancer (NSCLC) patients receiving combined immunochemotherapy are exposed to short-course corticosteroids following immune checkpoint inhibitor (ICI) infusion to prevent chemotherapy-related adverse events. However, whether this early short-course corticosteroid use prevents immune-related adverse events (irAEs) remains unknown. Methods: Between January 1st, 2015, and December 31st, 2020, NSCLC patients who received at least one cycle of ICI with or without chemotherapy were enrolled. Early short-course corticosteroids were defined as corticosteroids administered following ICI injection and before chemotherapy on the same day and no longer than 3 days afterward. The patients were categorized as either “corticosteroid group” or “non-corticosteroid group” depending on their exposure to early short-course corticosteroid. The frequencies of irAEs requiring systemic corticosteroid use and irAEs leading to ICI discontinuation were compared between the two groups, and exploratory survival analyses were performed. Results: Among 252 eligible patients, 137 patients were categorized as “corticosteroid group” and 115 patients as “non-corticosteroid group.” The corticosteroid group enriched patients in the first-line setting (n = 75, 54.7%), compared to the non-corticosteroid group (n = 28, 24.3%). Thirty patients (21.9%) in the corticosteroid group and 35 patients (30.4%) in the non-corticosteroid group developed irAEs requiring systemic corticosteroid use (odds ratio [OR], 0.64; 95% confidence interval [CI], 0.35–1.18; p = 0.15). Eight patients (5.8%) in the corticosteroid group, as compared with 18 patients (15.7%) in the non-corticosteroid group, permanently discontinued ICI due to irAEs (OR, 0.34; 95% CI, 0.12–0.85; p = 0.013). Conclusion: Early short-course corticosteroids following each ICI injection may reduce the rate of irAEs that lead to ICIs discontinuation, warranting further investigation of its prophylactic use to mitigate clinically significant irAEs.

Adult Atlantoaxial Subluxation in Post COVID-19 Recovery: A Case Series

Background: Non-traumatic atlantoaxial subluxation in adults is a rare condition usually common in patients with rheumatoid arthritis, and infection of the upper respiratory tract is also considered to be a trigger of inflammation and laxity of ligaments and further subluxation. to date there have been some reported cases of atlantoaxial as complication of COVID-19. Diagnosis and management of atlantoaxial subluxation is currently based on x-ray with special views. Therefore, it is important to early diagnosis and treating adult patients suffering from neck pain and stiffness as a suspected case of nontraumatic atlantoaxial subluxation. Case reports: In this case series, we reported 17 healthy elderly patients (11 male and 6 female) who had atlantoaxial subluxation after a mild (8 patients 4 male and 4 female) and 9 moderate cases (6 males with 3 females) of COVID-19. The patients had neck pain (pain score ranged 6 to9 wit mean 7,5), occipital headache (7 patient with severe and moderate occipital headache with only 3 with mild), and stiffness with different levels of limitation of cervical movements after recovering from Covid-19 in varying periods between 3 and 7 months. Conservative treatment included antibiotics; non-steroid anti-inflammatory agents, short course of corticosteroids, and immobilization with soft cervical collar followed by physiotherapy after pain subsided was done for the patients, and the clinical recovery observed within 8-10 weeks with good results in 10 patients with relieving pain and restoring the cervical motion to the normal, and 7 patients with acceptable result of treatment with slight limitation of cervical movements. Conclusion: As atlantoaxial subluxation in adult patients may be a late complication of COVID-19, more research is needed to determine the specific association between COVID-19 and atlantoaxial subluxation in adults.

The preventive effects of early short-course corticosteroids on immune-related adverse events in non-small cell lung cancer patients receiving immune checkpoint inhibitors.

144 Background: Corticosteroid is effective in treating immune checkpoint inhibitor (ICI)-induced immune-related adverse events (irAEs). However, whether its earlier use prevents irAEs remains unknown. In real-world practice, non-small cell lung cancer (NSCLC) patients receiving combined immunochemotherapy are often given corticosteroids right after ICI injection to reduce subsequent chemotherapy-related adverse events. It is thus an ideal model to examine whether this earlier use of corticosteroid also reduce irAEs following immunotherapy. Methods: NSCLC patients receiving at least one cycle of ICI with or without chemotherapy were enrolled. Patients receiving ICI with corticosteroid corticosteroid premedication exposure were categorized as “corticosteroid group (CS)”, whereas patients receiving ICI without corticosteroids premedication exposure were categorized as “non-corticosteroid group (non-CS)”. Frequency of irAEs prompting systemic corticosteroid or leading to ICI discontinuation were compared between the two groups. Exploratory survival analysis was performed. Results: Among 252 eligible patients, 137 patients were categorized as CS group, and 115 patients as non-CS group. 21.9% of patients in the CS group and 30.4% of patients in the non-CS group developed irAEs prompting systemic corticosteroid use (Odds ratio [OR], 0.64; 95% confidence interval [CI], 0.35 to 1.18; p=0.15). 5.8% of patients in the CS group and 15.7% of patients in the non-CS group developed irAEs leading to ICI discontinuation (OR, 0.34; 95% CI, 0.12 to 0.85; p=0.013). In the exploratory survival analysis, early short-course corticosteroids was not associated with a higher risk for death in first-line patients (hazard ratio [HR], 1.06; 95% CI, 0.56–2) or patients receiving immunochemotherapy (HR, 0.72; 95% CI, 0.37–1.45). Conclusions: Early short-course corticosteroids following each ICI injection may reduce the rate of irAEs that leads to ICIs discontinuation. The use of prophylactic corticosteroids on irAEs in cancer patients receiving ICIs should be evaluated in future prospective studies. [Table: see text]

Severity scale of cervicofacial cellulitis with a clinical experience

IntroductionSevere cervicofacial cellulitis are emergencies, mostly of odontogenic origin, and frequently observed in developing countries. Their management is still a challenge despite the improvement of the antibiotic therapy these last decades. We highlight our experience in the management of this life-threatening condition. Material and methodsThis was a descriptive and prospective study of all patients presenting with severe cervicofacial cellulitis between December 2020 and February 2021 in the odontostomatology department of the Garoua Regional Hospital (Cameroon). The data concerning demography (age, sex), clinical manifestations, treatment, and prognosis were analysed using SPSS version 20.0. Results45 cases of severe cervicofacial cellulitis were diagnosed, representing 13.76% of the total consultations. The female represented 55.55%. The mean age was 32.6 years. The main aetiology was odontogenic (93.33%). Clinical manifestations included swelling (100%), pain (100%), trismus (88.89%), dysphagia (53.33%), asthenia (35.56%), sepsis (4.44%). The main location involved was submandibular (75.56%). The overall severity score revealed the extremely high (24.44%), high (33.33%), and moderate (42.22%) grades. The antibiotic therapy was systematically administered. Short-course corticosteroids (46.67%), surgical debridement (88.89%), and etiological treatment (68.89%) were associated. Complications occurred in 13.33% of cases. The evolution was favourable in 95.56% of cases. ConclusionThe severity of cervicofacial cellulitis can be assess with a proper recognition and evaluation of the clinical signs. This will allow the practician to better manage these conditions and to improves their prognosis.

A CASE REPORT OF KIKUCHI DISEASE RELAPSE IN A YOUNG ADULT

Kikuchi-Fujimoto Disease (KFD) is a rare, benign and self-limited condition affecting lymph nodes predominantly, although extra lymph nodal manifestations are seen. The rst case was reported in 1972 almost simultaneously by Kikuchi and Fujimoto et al. Prevalence is more common in the Asian population, affecting females more than males. The cause of the disease is unknown but thought to be due to autoimmunity triggered by an external stimulus. Few cases are associated with infectious agents like CMV, EBV, Histoplasmosis, and toxoplasmosis. Most commonly associated with tuberculosis, SLE and lymphoma. Cases are managed conservatively, and severe cases & relapses with corticosteroids. Relapse rates are at 3 to 4 per cent in adults. Here we discuss a case of an 18-year-old male with complaints of swelling in the right arm, fever, loss of appetite and generalized weakness with a known diagnosed case of KFD four months back and TB one year back, and on further investigations of normocytic anaemia, predominant lymphocyte leucocytosis, raised ESR (50mm). CRP was normal. Chest X-ray suggests brotic changes (old TB) in the middle zone of the right lung. USG of right arm swelling suggests multiple necrotic lymph nodes with loss of hilum. USG abdomen and pelvis showed splenomegaly of 14.8 cm. sputum for AFB, and the CBNAAT result was negative. On Mantoux, no induration is seen. ANA was positive with homogenous nucleoli (1:80). Complement levels c3 were normal, and c4 was low (7), thought TB lymphadenitis, on biopsy, showedndings suggestive of KFD. The patient was further managed with a short course of corticosteroids and antibiotics and is under observation.

Association between prolonged corticosteroids use in COVID-19 and increased mortality in hospitalized patients: a retrospective study with inverse probability of treatment weighting analysis

BackgroundPrevious studies have demonstrated a beneficial effect of early use of corticosteroids in patients with COVID-19. This study aimed to compare hospitalized patients with COVID-19 who received short-course corticosteroid treatment with those who received prolonged-course corticosteroid treatment to determine whether prolonged use of corticosteroids improves clinical outcomes, including mortality.MethodsThis is a retrospective cohort study including adult patients with positive testing for Sars-CoV-2 hospitalized for more than 10 days. Data were obtained from electronic medical records. Patients were divided into two groups, according to the duration of treatment with corticosteroids: a short-course (10 days) and a prolonged-course (longer than 10 days) group. Inverse probability treatment weighting (IPTW) analysis was used to evaluate whether prolonged use of corticosteroids improved outcomes. The primary outcome was in-hospital mortality. Secondary outcomes were hospital infection and the association of different doses of corticosteroids with hospital mortality. Restricted cubic splines were used to assess the nonlinear association between mortality and dose and duration of corticosteroids use.ResultsWe enrolled 1,539 patients with COVID-19. Among them, 1127 received corticosteroids for more than 10 days (prolonged-course group). The in-hospital mortality was higher in patients that received prolonged course corticosteroids (39.5% vs. 26%, p < 0.001). The IPTW revealed that prolonged use of corticosteroids significantly increased mortality [relative risk (RR) = 1.52, 95% confidence interval (95% CI): 1.24–1.89]. In comparison to short course treatment, the cubic spline analysis showed an inverted U-shaped curve for mortality, with the highest risk associated with the prolonged use at 30 days (RR = 1.50, 95% CI 1.21–1.78).ConclusionsProlonged course of treatment with corticosteroids in hospitalized patients with COVID-19 was associated with higher mortality.

Effective Role of Teledermatology in Managing Chronic Urticaria Patients during the COVID-19 Pandemic

Sir, Chronic urticaria (CU) is a common dermatological disorder characterized by pruritus and weals with or without angioedema. More than 50 million patients are affected globally by CU.[1] Coronavirus disease 2019 (COVID-19) continues to be a threat even today, disrupting the healthcare systems and patient care. Patients with CU are also affected by the variable durations of lockdowns, social distancing measures, and travel restrictions. CU may be severe at times, requiring immediate medical care. However, usual patients of CU can be managed through teledermatology effectively. Teledermatology is a way of communication where personal information such as age, gender, medical history, and images of the skin lesions are shared by a patient to a physician. It can have real-time online consultation (synchronous) with a physician or can undertake sharing personal information through E-mails and messaging platforms (store-and forward technique, asynchronous), which is the most widely used method. Teledermatology can also be hybrid where both asynchronous and synchronous can be combined.[2] A multicenter study by Kocatürk et al.[1] which shared the experiences of Urticaria centers of Reference and Excellence (UCAREs) during this pandemic in managing CU found that there was a significant decrease in the face-to-face consultations during the pandemic due to obvious reasons and simultaneous increase in the teleconsultations by 600%. They have also mentioned that remote consultations have been a useful tool during the COVID-19 pandemic, but the long-term consequences of remote care of CU patients are yet to be characterized. There have been a few studies regarding the long-term outcomes of telehealth especially for allergy consultations. Waibel[3] found that both new and follow-up visits to the allergist were well complied by patients and demonstrated significant monetary savings. In another multicenter study by Waibel et al.,[4] tele-allergy supported most of the patients without in-person consultation with high patient satisfaction and significant time and cost savings. We have been interviewing and providing consultations to CU patients during the pandemic. Most of the old patients under follow-up are satisfied by the teledermatology. However, new-onset urticaria with fever needs attention and face-to-face consultation in lieu of early manifestation of COVID-19. CU patients do not require vigorous mucocutaneous examinations to be performed at every visit in face-to-face consultations. Patient’s disease exacerbations or control can be objectively calculated through the valid Urticaria Activity Scores over 7 days and Urticaria Control Test, which can well be filled and discussed through telephonic consultations or Internet and communication technologies (ICTs). Moreover, antihistamines dosages can also be titrated in CU patients with disease exacerbations or remissions through teledermatology and may alleviate the need to visit the centers amidst the pandemic. Patients have been treating using teledermatology with updosing of antihistamines or short course of corticosteroids to control CU. A recent study during the COVID-19 pandemic by Thomas et al.[5] which was performed in a tertiary allergy center with 23.2% of urticaria/angioedema referrals found that teleconsultation-based allergy service models may be more time and cost-effective and also improve patient accessibility to a specialized care. None of the studies during the literature search demonstrated any counter to remote consultation of urticaria/angioedema during the pandemic. It is also recommended to maintain the ongoing treatments with antihistamines and omalizumab during the present pandemic, but to be cautious with the use of immunosuppressives for CU.[1] This can well be monitored through teledermatology. However, in a resistant-CU patient, short courses of low-dose oral corticosteroids and cyclosporine may be utilized for disease control. Treating dermatologists or allergists should be cautious and should not forbid their use. Recalcitrant or refractory CU in the COVID-19 pandemic may be treated with short courses of corticosteroids and cyclosporine as there are reports of improved clinical outcomes with cyclosporine and low-dose corticosteroids treatment in patients with moderate-to-severe COVID-19.[6] The experience with teleconsultation or ICTs has been satisfactory as per various studies. Moreover, in our experience also, it provided a great relief and satisfaction to the urticaria patients especially who required tailoring of dosages and counseling regularly. Monitoring patients with CU on treatment may be well managed by teledermatology as there is no requirement of repeated clinical examination in already-established cases of CU. Validated scores and questionnaires are sufficient to assess the disease severity or disease control in CU patients and can be obtained through teleconsultation or ICTs. Non-face-to-face consultations during COVID-19 in CU patients may be more time saving and cost effective; moreover, it may also significantly decrease the chances of contracting severe acute respiratory syndrome-coronavirus-2 infection. However, face-to-face consultations may not be replaced fully by teleconsultations using ICTs, but it may be an effective alternative during the present pandemic. Further, large and long-term studies are required in future to provide much improved and validated results. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Post-COVID acute pulmonary nocardiosis: Another novel post-COVID infection.

Dear Editor, Treatment of COVID-19 remains challenging, especially in patients with severe disease. Immunosuppressive therapies such as steroids and cytokine blockers are beneficial to control the cytokine storm. However, these drugs increase the risk of opportunistic infections. Nocardiosis is caused by an actinomycete, which primarily affects immunocompromised patients. Here we report a patient with acute localized pulmonary nocardiosis, post severe COVID disease. A 70-year-old male patient with no addictions and comorbidities presented to the emergency room with complaints of high-grade fever, cough with copious brown sputum, left-sided pleuritic chest pain for 2 weeks, and breathlessness for 3 days. He had severe COVID-19 disease with respiratory failure 4 weeks ago for which he was treated with IV remdesivir and IV methylprednisolone 40 mg twice daily for 7 days and discharged. At presentation, he had a respiratory rate of 30 breaths/min and saturation of 60% on room air, which improved to 95% with 5 liters/minute of oxygen support. Arterial blood gases (ABG) showed type 1 respiratory failure. Chest X-ray showed a consolidation in the left lower zone. High-resolution computed tomography (HRCT) chest revealed consolidation in the left lower lobe with internal breakdown and minimal pleural effusion [Figure 1a]. Total leukocyte count and C-reactive protein (CRP) were elevated (21,700 cells/mm3 and 320 mg/L, respectively). Sputum showed gram-positive, acid-fast, branching filamentous structures, morphologically resembling Nocardia species [Figure 1b, c], and hence a diagnosis of acute pulmonary nocardiosis was made. The patient was treated with oral trimethoprim-sulfamethoxazole (TMP-SMX) and IV meropenem for 4 weeks. The patient improved with treatment and was off oxygen support after a week and hence discharged. On follow-up after 3 weeks, antibiotics were changed to oral linezolid and TMP-SMX for 5 months. After completion of therapy, the patient is asymptomatic and the HRCT chest showed near-complete resolution of the left lower lobe consolidation with residual fibrotic bands [Figure 1d].Figure 1: (a) Axial slice of a high-resolution computed tomography scan of the chest showing consolidation of the left lower lobe with internal breakdown. (b) Direct examination of sputum smear after modified acid-fast staining revealing branching filamentous acid-fast organisms (40 × magnification). (c) Positive culture of the same sputum specimen on the blood agar plate. (d) Axial slice of a high resolution computed tomography scan of chest post-treatment, showing near-complete resolution with residual fibroticNocardiosis, an opportunistic infection, has been reported rarely in post-COVID-19 patients. To the best of our knowledge, there are only three case reports to date.[1,2] Nocardia species are ubiquitous saprophytic gram-positive bacteria of the “aerobic actinomycetes” group.Click or tap here to enter text.[3] The primary route of transmission is inhalational, from environmental sources. The majority of patients with pulmonary nocardiosis are immunosuppressed or have chronic lung disease. Radiology usually demonstrates irregular nodular lesions that may have cavitation. “Halo sign,” diffuse consolidations, and pleural effusions have been reported. The definitive diagnosis of nocardiosis requires isolation of the organism. Nocardia appears as a filamentous bacterium with hyphae-like branching and a “beaded” acid-fast appearance on microscopy.[4] Sulfonamides are the treatment of choice for nocardiosis. TMP-SMX is the most widely used drug. Alternative treatment options include amikacin, imipenem, meropenem, ceftriaxone, cefotaxime, minocycline, moxifloxacin, levofloxacin, linezolid, tigecycline, and amoxicillin-clavulanic acid.[3] The duration of treatment is 6–12 months. Our patient, who was otherwise healthy and had received only a short course of corticosteroids developed pulmonary nocardiosis, which suggests that it is vital to investigate for uncommon etiologies in patients presenting with secondary infections post-COVID-19 disease. COVID-19 infection apart from the drugs used in its treatment as a cause of immune suppression needs further research. Abbreviations IV – Intravenous, ABG – Arterial blood gases, HRCT – High resolution computed tomography, CRP- C-reactive protein. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Evolution and prognosis of severe cervicofacial cellulitis in a Cameroonian secondary hospital

Background: Severe cervicofacial cellulitis is a fatal condition with a poor prognosis. It has a relatively high frequency in underdeveloped countries, and its treatment remains a challenge. This study aimed to document and evaluate severe cervicofacial cellulitis patterns observed in a secondary hospital in Cameroon. Methods: A descriptive and prospective study was carried out in the Odontostomatology Department of the Garoua Regional Hospital, Cameroon. All patients with severe cervicofacial cellulitis were recruited between December 2020 and February 2021. The data concerning population analysis (age, sex), clinic (risk factors, symptoms, signs, aetiologies, evolutionary stages), treatment (medical, surgical, their evolution), and prognosis were analyzed. Results: Out of the total consultations, 45 cases (13.76%) of severe cervicofacial cellulitis were diagnosed, and 55.55% were females. The mean age was 32.6 years. According to the severity criteria, 24.44% of cases had extremely high severity, and 33.33% of high severity cases. The treatment consisted of antibiotics (100%), surgical debridement (91.11%), etiological treatment (82.35%), short-course corticosteroids (46.67%), and supportive treatment (100%). Complications occurred in 13.33% of cases. The evolution was favorable in 95.56% of cases. The death rate was 4.44%. Conclusion: Severe cervicofacial cellulitis remains alarming because of its life-threatening potential. An adequate treatment is required to have an evolution with little or no complications. Their prognosis remains strongly reserved with comorbidities.

DVRd Followed By Ciltacabtagene Autoleucel Versus DVRd Followed By ASCT in Patients with Newly Diagnosed Multiple Myeloma Who Are Transplant Eligible: A Randomized Phase 3 Study (EMagine/CARTITUDE-6)

Background: For patients with newly diagnosed multiple myeloma (NDMM) who are transplant eligible, daratumumab, bortezomib, lenalidomide, and dexamethasone (DVRd) is recommended by the National Comprehensive Cancer Network guidelines as induction therapy followed by autologous stem cell transplant (ASCT), consolidation, and maintenance therapy. Ciltacabtagene autoleucel (cilta-cel) is a chimeric antigen receptor (CAR)-T cell therapy with 2 B-cell maturation antigen (BCMA)-targeting single-domain antibodies. In the phase 1b/2 CARTITUDE-1 study, a single infusion of cilta-cel resulted in deep and durable responses with a manageable safety profile in heavily pretreated patients with relapsed/refractory MM. At a median follow-up of 27.7 months, the overall response rate (ORR) was 98%, 83% of patients achieved stringent complete response (CR), and median duration of response was not reached. The randomized, open-label, global, multicenter, phase 3 EMagine/CARTITUDE-6 study (EMN28/68284528MMY3005; NCT05257083) aims to compare the efficacy of DVRd followed by cilta-cel and lenalidomide versus DVRd followed by ASCT, DVRd, and lenalidomide. Study Design and Methods: Eligible patients are aged ≥18 years with NDMM per International Myeloma Working Group diagnostic criteria, have measurable disease at screening, and have high-dose therapy and ASCT as part of their intended initial treatment plan. Exclusion criteria are patients who have received any prior therapy for MM or smoldering myeloma (except a short course of corticosteroids). After giving informed consent, patients are randomized 1:1 into 2 treatment arms (target recruitment: N=750). In the cilta-cel arm, patients will undergo apheresis before receiving 6 cycles of DVRd induction. After induction, patients will receive lymphodepletion (intravenous cyclophosphamide 300 mg/m2 and fludarabine 30 mg/m2 daily for 3 days), followed by a single cilta-cel infusion (target dose 0.75×106 CAR+ viable T cells/kg) 5-7 days later. After the cilta-cel infusion, patients will receive lenalidomide post CAR-T therapy for 2 years (or longer, at investigator discretion). In the control arm, patients will receive 4 cycles of DVRd induction, followed by ASCT and 2 cycles of DVRd consolidation. Patients will then receive lenalidomide maintenance for 2 years (or longer at investigator discretion). The dual primary endpoints are progression-free survival (PFS) and minimal residual disease (MRD)-negative CR sustained for ≥12 months, with MRD status determined by next-generation sequencing at a sensitivity of at least 10-5. Secondary endpoints include ORR, ≥CR rate, overall MRD-negative CR rate, time to subsequent therapy, PFS on next-line therapy, overall survival, adverse events, pharmacokinetic/pharmacodynamic markers, and changes in health-related quality of life. Exploratory correlative biomarker analyses will also be performed. Enrollment opens in September 2022, with anticipated primary completion in June 2026. This study will investigate the efficacy and safety of a cellular therapy approach with cilta-cel versus standard of care ASCT in patients with NDMM who are transplant eligible. Figure: EMagine/CARTITUDE-6 Study Design Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Rituximab and a Short Course of Corticosteroids for Initial Management of Adult-Onset Minimal Change Disease

Rituximab and a Short Course of Corticosteroids for Initial Management of Adult-Onset Minimal Change Disease

S2350 Mind the Steroids: Herpes Esophagitis in an Immunocompetent Patient After Steroid Therapy

Introduction: Infective esophagitis (IE) is rare, but well known to complicate the immunosuppressed state; particularly the HIV infected, transplant recipient, cancer patient and those treated with chronic corticosteroids or immunomodulators. Common infections include candida, cytomegalovirus, and herpes simplex virus (HSV). Steroids have been used for symptomatic relief of an acute sore throat. Short courses are considered benign with low risk of infectious complications. We report an immunocompetent patient found to have herpes esophagitis after a short course of corticosteroids. Case Description/Methods: A 41-year-old African American male with history of hypertension presented with worsening sore throat and odynophagia restricting oral intake. Prior to presentation, he had a 10-day history of sore throat. He was diagnosed with streptococcal pharyngitis and was on antibiotics and steroids 7 days ago. Given persistent symptoms he underwent laryngoscopy which demonstrated bilateral tonsillar exudates and normal pharyngeal mucosa, prompting admission and initiation of IV antibiotics and dexamethasone. He had modest improvement of pain, however 8 days later expressed worsening burning retrosternal chest pain and progressed oral intolerance. He underwent upper endoscopy revealing multiple circumferential erosions and Los Angeles grade D esophagitis of the lower third of the esophagus (Figure A). Biopsies demonstrated viral intranuclear inclusions that stained positive for HSV1/HSV2 (Figure B, C). His symptoms abated while on IV acyclovir allowing transition to oral valacyclovir. Discussion: Corticosteroids are well known for their anti-inflammatory effect but immunosuppression with short courses may be underestimated. Infectious sequalae such as herpetic esophagitis may complicate steroid use even when therapy duration is short. This patient was found to have progressive odynophagia while on corticosteroids administered for analgesia and had significant improvement after antiviral therapy. It is easy to overlook IE as a cause of odynophagia in the immunocompetent, however, with history of steroid use, a diagnosis of IE, especially HSV esophagitis, should be considered in the differential. Therefore, one should have a low threshold for early endoscopy when evaluating these patients.Figure 1.: A: Endoscopic photograph displaying multiple circumferential erosions and Los Angeles grade D esophagitis of the lower third of the esophagus. B: (x200): Photomicrograph of hematoxylin and eosin-stained section of the esophageal biopsy, showing multiple multinucleated epithelial cells. Cowdry type A is observed. C: (x200): IHC study using antibodies against HSV-1. Numerous intranuclear viral inclusions are positive with HSV-1 within the infected cells.

Corticosteroids for patients with vestibular neuritis: An evidence synthesis for guidelines for reasonable and appropriate care in the emergency department.

A short course of corticosteroids is among the management strategies considered by specialists for the treatment of vestibular neuritis (VN). We conducted an umbrella review (systematic review of systematic reviews) to summarize the evidence of corticosteroids use for the treatment of VN. We included systematic reviews of randomized controlled trials (RCTs) and observational studies that evaluated the effects of corticosteroids compared to placebo or usual care in adult patients with acute VN. Titles, abstracts, and full texts were screened in duplicate. The quality of reviews was assessed with the A MeaSurement Tool to Assess systematic Reviews (AMSTAR-2) tool. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) assessment was used to rate certainty of evidence. No meta-analysis was performed. From 149 titles, five systematic reviews were selected for quality assessment, and two reviews were of higher methodological quality and were included. These two reviews included 12 individual studies and 660 patients with VN. In a meta-analysis of two RCTs including a total of 50 patients, the use of corticosteroids (compared to placebo) was associated with higher complete caloric recovery (risk ratio 2.81, 95% confidence interval [CI] 1.32 to 6.00, low certainty). It is very uncertain whether this translates into clinical improvement as shown by the imprecise effect estimates for outcomes such as patient-reported vertigo or patient-reported dizziness disability. There was a wide CI for the outcome of dizziness handicap score (one study, 30 patients, 20.9 points in corticosteroids group vs. 15.8 points in placebo, mean difference +5.1, 95% CI -8.09 to +18.29, very low certainty). Higher rates of minor adverse effects for those receiving corticosteroids were reported, but the certainty in this evidence was very low. There is limited evidence to support the use of corticosteroids for the treatment of VN in the emergency department.

Acenocoumarol-Induced Anticoagulant–Related Nephropathy with Newly Diagnosed IgA Nephropathy: a Repeat Biopsy Case Report

Anticoagulant-related nephropathy (ARN) is an underestimated cause of acute kidney injury (AKI) with poor renal and overall prognosis. Pathogenesis is not fully elucidated yet, although AKI is probably resulting from glomerular hemorrhage and most commonly has been described in patients with glomerular lesions, that alter the glomerular permeability, and conditions with glomerular hyperfiltration. Herein, we describe a case with a 58-year-old man who presented with macroscopic hematuria and AKI, and recently taking acenocoumarol for aortic valve replacement. The first renal biopsy showed red cell casts in the renal tubules, one glomerular crescent formation in the glomeruli with mild immunoglobulin A deposition, and severe interstitial inflammation. Based on these findings, the patient was diagnosed with acenocoumarol-induced ARN with newly diagnosed IgA nephropathy and switched to tinzaparin with a short course of corticosteroids. Renal improvement in ARN is usually partial and is delayed, as confirmed by a second biopsy in our patient after 6 months.

RADICAL TREATMENT FOR BLASTOMYCOSIS FOLLOWING FAILED LIPOSOMAL AMPHOTERICIN

TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: Pulmonary blastomycosis is a respiratory disease that is caused by the fungus Blastomyces, most commonly through inhalation of the fungal spores. Infected individuals typically show symptoms 3 weeks to 3 months after inhalation of these spores. About 50% of patients with pulmonary blastomycosis are asymptomatic. Individuals with severe blastomycosis are initially treated with intravenous antifungal therapy with Amphotericin followed by long-term itraconazole maintenance therapy. CASE PRESENTATION: We present the case of an immunocompetent young male who was diagnosed with pulmonary Blastomyces dermatitidis and had poor clinical response to 10 days of liposomal Amphotericin B (L-AmB). Due to persistent hypoxia and hypoxemia, the patient was endotracheally intubated and extracorporeal membrane oxygenation (ECMO) was initiated. Due to the poor response to L-AmB, L-AmB was discontinued in favor of continuous infusion of amphotericin B deoxycholate (AmB-d). Additionally, the patient was started on a short course of corticosteroids. With the combination of these treatments, the patient had significant clinical improvement. The patient was taken off ECMO on day 9 and extubated on day 12 after the initiation of AmB-d. DISCUSSION: Literature review yielded limited information regarding treating blastomycosis with a continuous AmB-d infusion. To our knowledge, this is the third case reported in the literature of the use of continuous AmB-d infusion for the treatment of severe blastomycosis. ARDS due to blastomycosis has a mortality of up to 80% with the standard of treatment in such severe cases being liposomal amphotericin. Given that ECMO and AmB-d infusion were started concurrently, it is unclear if the significant improvement was due to the decrease in burden on the respiratory system by ECMO or due to AmB-d infusion demonstrating higher effectiveness compared to liposomal amphotericin B, or a combination of both. A case reported by Branick, K et al. discusses a patient on ECMO treated with L-AmB without improvement until AmB-d continuous infusion was started. Even though they attributed the treatment failure to clogging of the ECMO circuit by L-AmB, their belief was that ECMO is not an effective means to treat Blastomycosis and therefore, believed that the patient improvement was solely due to AmB-d infusion. CONCLUSIONS: While L-AmB is considered first line treatment for blastomycosis, the mortality remains high in those with ARDS associated with blastomycosis. This case demonstrates the importance of considering AmB-d in patients with severe blastomycosis who may have poor response to L-AmB. ECMO and steroids were also included in the patient's treatment plan which may have contributed to the patient's improvement. In a disease process with such high mortality rates, the need for continued evaluation of treatment options is crucial given the limited treatment options currently available. REFERENCE #1: Branick K, Taylor MJ, Trump MW, Wall GC. Apparent interference with extracorporeal membrane oxygenation by liposomal amphotericin B in a patient with disseminated blastomycosis receiving continuous renal replacement therapy. Am J Health Syst Pharm. 2019;76(11):810-813. REFERENCE #2: Meyer KC, McManus EJ, Maki DG. Overwhelming pulmonary blastomycosis associated with the adult respiratory distress syndrome. N Engl J Med. 1993;329(17):1231-1236. REFERENCE #3: Lahm T, Neese S, Thornburg AT, Ober MD, Sarosi GA, Hage CA. Corticosteroids for blastomycosis-induced ARDS: a report of two patients and review of the literature. Chest. 2008;133(6):1478-1480. DISCLOSURES: No relevant relationships by Christopher Chew, source=Web Response No relevant relationships by Henry Ogbuagu, source=Web Response No relevant relationships by Dhaval Patel, source=Web Response No relevant relationships by Nikhilesh Thapa, source=Web Response No relevant relationships by Merin Varghese, source=Web Response

Skin Adverse Reactions to Novel Messenger RNA Coronavirus Vaccination: A Case Series.

Vaccines are actually the most effective strategy to control the COVID-19 spread and reduce mortality, but adverse reactions can occur. Skin involvement with novel messenger RNA coronavirus vaccines seems frequent but is not completely characterized. A real-world experience in the recent vaccination campaign among health care workers in Sardinia (Italy) is reported. In over a total of 1577 persons vaccinated, 9 cases of skin adverse reactions were observed (0.5%). All reactions have been reported to the Italian Pharmacovigilance Authority. Eight occurred in women (mean age 46 years), and five were physicians and four nurses. All patients had a significant allergology history but not for the known vaccine excipients. After dose one, no injection site reactions were observed, but widespread pruritus (n = 3), mild facial erythema (n = 1), and maculopapular rash (n = 3) occurred in the following 24–48 h in three patients. These three patients were excluded from the second dose. Of the remaining six patients, one developed mild anaphylaxis within the observation period at the vaccination hub and five delayed facial erythematous edema and maculopapular lesions, requiring antihistamines and short-course corticosteroid treatment. Spontaneous reporting is paramount to adjourning vaccination guidance and preventive measures in order to contribute to the development of a safe vaccine strategy. Dermatologist’ expertise might provide better characterization, treatment, and screening of individuals at high risk of skin adverse reactions.