Short Course Of Oral Steroids Research Articles

Antivirals vs Antivirals and Steroids for Treatment of Herpes Zoster-Related Ophthalmoplegia: A Case Series and Systematic Review.

Up to 1/3 of patients with herpes zoster ophthalmicus (HZO) may develop ophthalmoplegia. Although zoster-related ophthalmoplegia (ZO) is typically treated with antiviral agents, there is controversy regarding the therapeutic role of systemic steroids. This was a retrospective case series and case report-based systematic review. For the case series, participants were recruited from tertiary neuro-ophthalmology clinics. Eligible participants were those who developed cranial nerve palsies (CNP) within 1 month of HZO diagnosis. In the systematic review, all adults with ZO in the literature who were treated with antivirals or steroids only, or combination therapy were included. Main outcomes were initial presentation, investigations, neuroimaging, treatment regimen, and final outcomes of ophthalmoplegia. Eleven immunocompetent patients with ZO were included. The most common CNP was CN III (5/11), followed by CN VI (2/11) and CN IV (2/11). One patient had multiple CNPs. All patients were treated with antivirals, and 4 also treated with a short course of oral steroids. At 6-month follow-up, 75% of patients treated with combination therapy and 85.7% treated with antivirals alone had complete recovery of ZO. The systematic review identified 63 studies consisting of 76 cases of ZO. When comparing patients treated with antivirals with those treated with antivirals and steroids, patients on combination therapy had more severe ocular findings, including complete ophthalmoplegia (P < 0.001). Age was the only significant predictor of complete recovery of ophthalmoplegia on multivariable logistic regression (P = 0.037). The rate of complete recovery in immunocompetent patients with ZO was similar in patients treated with antivirals alone vs those treated with antivirals and oral steroids. The systematic literature review affirmed these findings. However, age may influence recovery of ophthalmoplegia.

COVID-19 and isolated oculomotor nerve palsy: Clinical features and outcomes

AimThis study aims to describe the clinical characteristics of patients with isolated oculomotor nerve palsy from COVID-19 infection, and provide guidance on their treatment and management. MethodsWe performed a systematic review and retrospective analysis on the clinical features and outcomes of patients with isolated oculomotor nerve palsy from COVID-19 reported in literature over the past three years. ResultsWe analyzed a total of 11 cases; 9 identified in literature from January 2020 to September 2022, together with our two patients. Their median age was 46 years (range 2–65), and three were children. More than half (6/11, 55 %) were without medical history. Oculomotor nerve palsies tended to occur early (longest interval of 16 days), but they can also occur concurrently (2/11, 18 %) or before the appearance of COVID-19 symptoms (1/11, 9 %). COVID-19 symptoms tended to be mild (8/11, 73 %). Oculomotor nerve palsies, however, displayed neither a clear gender predilection, nor consistent clinical features in terms of the severity of extraocular weakness and the involvement of pupillary light responses. Nearly two-thirds (7/11, 64 %) received no pharmacological treatment. Regardless, recovery was complete in nearly all (9/10, 90 %), with most occurring within a month (8/9, 89 %) ConclusionIsolated oculomotor nerve palsies are early but uncommon complications of COVID-19. They affect patients with mild infections, and can be the first symptom. Prognosis is excellent, with recovery being often complete and early. Early discharge and outpatient clinical review, with or without short courses of oral steroids, are reasonable treatment measures.

POST-COVID PULMONARY COMPLICATIONS IN THE OUTPATIENT SETTING: ARE WE PREPARED FOR THE AVALANCHE?

POST-COVID PULMONARY COMPLICATIONS IN THE OUTPATIENT SETTING: ARE WE PREPARED FOR THE AVALANCHE?

Bilateral Hindfoot Osteonecrosis Associated with Treatment for Cutaneous T-Cell Lymphoma

Category: Hindfoot; Basic Sciences/Biologics Introduction/Purpose: There are reports of bilateral atraumatic osteonecrosis of the talus associated with some chemotherapy agenst for cutaneous T-cell lymphomas (CTCL), and systemic glucocorticoid treatment is by far the most common. We report the case of a 63-year old woman with CTCL previously treated with a high-affinity folate analog, pralatrexate, and multiple short- courses of prednisone dose packs who developed bilateral ankle and hindfoot stress fractures which progressed to hindfoot necrosis involving the talus and calcaneus. Methods: Chart Review Results: MRI was used for the diagnosis of stress fractures and osteonecrosis. The right foot was most symptomatic at presentation and was treated with a 6-month period of protected weight bering in a CAM boot. Follow up imaging demonstrated complete collapse of the talar dome. The patient underwent tibiotalarcalcaneal fusion which was complicated by wound healing issues requiring a skin graft. During this time, left sided symptoms worsened, and MRI confirmed insufficiency fractures with adjacent areas of edema and necrosis about the calcaneus, talus, and lateral malleolus. Considering her recent wound healing difficulties, the left foot was definitively treated in a CAM walker boot with some improvement in symptoms. Conclusion: Insufficiency fractures of the hindfoot are known to progress to osteonecrosis and are typically associated with long- term or high dose systemic steroid administration. Cases presenting after short-courses of oral steroids are uncommon; those associated with methotrexate (a lower affinity folate analog) are rare, and cases associated with pralatrexate or CTCL outside osteonecrosis of the jaw were not found during literature review. Despite cessation of chemotherapy and CTCL remission and early institution of protected weight, this patient rapidly progressed to bilateral hindfoot collapse. Providers and patients should be aware of the associated risks and potential for less favorable outcomes.

Diffuse rash with silvery scales and anasarca

A 67-year-old African American female with a history of psoriasis presented with a rash for 9 months. The rash began on her back and limbs, did not resolve after a short course of oral steroids, and expanded. Review of systems was positive for edema of all limbs and hair loss. She denied any precipitating illness/injury, changes in medication, or substance use. She received topical triamcinolone and intravenous antibiotics with minimal improvement. Exam was significant for diffuse rash with silvery scales, with flakes covering her entire body and anasarca particularly in her limbs (Fig 1).

P065 A case of fibrodysplasia ossificans progressiva in Kenya

Abstract Background Fibrodysplasia Ossificans Progressiva (FOP) is an extremely rare and disabling disorder affecting 1 in 2 million individuals worldwide. It is caused by mutations in bone morphogenetic protein which leads to extra-skeletal ossification of soft tissues in a characteristic cranio-caudal pattern. Hallux valgus, episodic flares and progressive functional disability are characteristic features. The cause of death is often cardio-respiratory failure following thoracic insufficiency. The objective of our case study is to describe a rare but interesting case of fibrodysplasia ossificans progressiva (FOP) in an African setting. Methods This was a retrospective case review Results Two-year-old boy presented with painful firm masses of bony consistency over the axilla, neck, occiput and the forehead for seven months. He developed progressive inability to lift the arms, flex his neck and had a characteristic stiff posture while walking. The masses had a waxing and waning nature lasting about 4–5 days but with no complete resolution. He was previously treated with antibiotics for lymphadenitis which was diagnosed by biopsy of the neck mass at a different health facility. On examinationhe had bony masses on the posterior aspect of the neck tender on palpation and attached to the underlying subcutaneous tissue. Similar masses were found on his anterior and posterior chest wall measuring 1 cm by 1 cm anteriorly and larger masses- measuring 5 cm by 5 cm posteriorly. He had bilateral hallux valgus and both elbows held in fixed flexion. His fingers had varying degrees of fixed flexion. The lower limbs were unaffected. Laboratory evaluation within normal ranges. extensive dystrophic soft tissue calcification around both elbows outlining the joint capsules. dystrophic soft tissue calcification in the bilateral axillae extensive “sheet like” soft tissue dystrophic calcifications overlying the posterior elements of the vertebral column separate from the vertebrae. Histology showed muscle replacement by hyaline cartilage and bone with intervening fibromyxoid stroma. Discussion &amp; Conclusions This case is meant to raise awareness of this rare disease across Africa. The misdiagnosis of FOP approaches 90% of cases worldwide. Definitive genetic testing of FOP is now available and can now confirm a diagnosis before the appearance of heterotopic ossifications. Clinical suspicion of FOP early in life on the basis of malformed great toes can lead to early clinical diagnosis. Current management focuses on early diagnosis, avoidance of trauma and optimization of function. A short course of oral steroids is beneficial in prevention of flares.

P11 Multiple insufficiency fractures in rheumatoid arthritis

Abstract Case report - Introduction Rheumatoid arthritis (RA) is an autoimmune inflammatory arthropathy with systemic manifestations. It is 4-times more common in females. RA is recognised to induce bone loss and decrease in bone mineral density (BMD). Management may include corticosteroids (CS) for new presentations, acute flares, and more rarely longer-term management, which increases bone fragility. Patients are at 30—50% increased risk of developing osteoporosis with a 30% increase in fracture risk. This risk rises with the level of persistent disease inflammation. We present a case of a lady with longstanding RA, who sustained multiple bone fractures without significant osteoporosis on bone density scanning. Case report - Case description Our patient is a 64-year-old headteacher who took early retirement due to reduced mobility after 20 years of seropositive RA. She had received multiple disease modifying drugs (DMARDs) and biologics therapies, requiring repeated alterations primarily due to treatment failure. She was commenced on alendronic acid due to osteopaenia of the hip but 2 years later sustained a fractured neck of femur and was switched to risedronate. A year later she presented with acutely painful and swollen right foot and ankle without history of trauma. X-rays showed progressive degenerative change whilst inflammatory markers were normal. Ultrasound demonstrated sub-clinical synovitis. Her medication was optimised but the ankle swelling persisted, rendering her wheelchair-reliant. MRI revealed multiple stress fractures involving calcaneum, talus and 5th proximal phalanx. She was treated with 16 weeks of an Aircast boot. An old right upper medial tibial fracture was also identified. Repeat dual energy X-ray absorptiometry (DEXA) scan showed osteopaenia but with improvement from the previous scan (T score of -2.1 total hip and -1.6 lumbar vertebra). She smoked 1 cigarette a day, did not drink alcohol and there was no parental history of fractures. No evidence of malabsorption or endocrine disorder was identified. Unusually, she had received tamoxifen in her late 20s for cancer prevention based on breast fibroadenosis and she experienced early menopause aged 36 years. Inflammatory markers, calcium, parathyroid hormone, and immunoglobulins were normal. Vitamin D3 levels were insufficient at 40.3 nmol/l and replacement was initiated, following which she was switched to intravenous zoledronic acid. After one infusion of zolendronate, she twisted her right ankle and sustained a new malleolar fracture. She was converted to 6-monthly denosumab injections along with calcium and vitamin D, which has been continued. Her RA remains active, and she has recently commenced JAK2 inhibitors. Case report - Discussion Inflammatory arthropathies such as RA predispose to significant morbidity and disability. An earlier age of diagnosis poses a longer inflammatory response in body, with a higher incidence of bone health complications. A treat-to-target strategy in RA aids optimal disease management and reduces fracture risk. Studies have shown the risk of osteoporosis in RA is not just disease dependent but also affected by certain medications. Treatment challenges arise when a patient sustains fracture despite a BMD above osteoporosis risk criteria, leading us to consider other variables. She was further investigated for secondary causes of osteoporosis, including endocrine causes, and was found to be vitamin D insufficient, which was replaced prior to further antiresorptive treatment. Our case also highlights a diagnostic dilemma given that our patient presented with a single swollen joint assumed to be due to active RA. Multiple insufficiency fractures were only identified after MRI was performed. As per EULAR criteria, our patient had difficult to treat RA with a long disease duration. She showed intolerance to a several DMARDs and treatment failure with multiple biologic therapies. She had required local joint injections and repeated short courses of oral steroids. These factors are likely to have played a considerable role in her fracture development. RA is an independent risk factor for fracture in both men and women with disease duration and CS use being important clinical variables. Bisphosphonates are considered vital in fracture risk reduction. The compliance is an important factor for both primary and secondary prevention of fracture. They are associated with decreased bone remodelling and have been well studied for atypical femoral fractures; however, whether there is any link with stress fractures in the feet requires further studies. Long-term use (&amp;gt;5years) hasn’t shown to be beneficial in preventing hip fractures. Case report - Key learning points

O08 A case of juvenile systemic lupus erythematosus with pyrexia of unknown origin

Case report - IntroductionAn 18-year-old young man with diagnosis of Juvenile SLE with lupus nephritis maintained in remission on Mycophenolate Mofetil (MMF), presented with high-grade fever without focus close to his 18th birthday. History or examination did not point to any focus of infection, but blood tests showed systemic inflammation. Extensive investigations, including extended infection screen and bone marrow aspiration, were negative. His blood tests were suggestive of macrophage activation syndrome with no clinical or laboratory evidence of flare of lupus. MRI scan revealed extensive para-aortic lymphadenopathy and a diagnosis of classical Hodgkin's lymphoma confirmed on lymph node biopsy.Case report - Case descriptionInterestingly he first presented with fever and cervical lymphadenopathy at 13 years of age to local hospital, when a biopsy had revealed lymphoma but the diagnosis was changed to SLE following review at tertiary hospital. He was started on steroids and low-dose methotrexate. He later developed facial swelling, abdominal distension and groin swelling, following which he was referred to tertiary renal centre. His examination revealed scarring malar rash, anaemia, ankle and scrotal oedema, ascites and pleural effusion. His investigations showed anaemia, thrombocytopaenia, ESR over 100mm/hour, hypoalbuminaemia, low complement levels, positive ANA and double-stranded DNA. He had nephrotic range proteinuria and renal biopsy showed Class V lupus nephritis. He was treated with intravenous and later weaning dose of oral steroids and started on MMF. He remained in remission on a stable dose of MMF, except for brief flare of proteinuria, which settled with short course of oral steroids.A few months before his eighteenth birthday, he presented to local hospital with recurrent episodes of high-grade fever with no clear focus. He was twice managed with broad spectrum antibiotics, despite negative septic screen and an extended infection screen including viral PCRs and IGRA for tuberculosis. He had no focal symptoms or symptoms to suggest flare of underlying lupus, but had loss of appetite and loss of weight. He developed splenomegaly with increasing inflammatory markers and fall in all cell lines of full blood count with deranged coagulation. He satisfied the clinical and laboratory criteria of the preliminary Diagnostic Guidelines for Macrophage Activation Syndrome in JSLE (2009), following which he was commenced on three days of IV methylprednisolone following normal bone marrow aspirate. However, fever recurred after initial response and MRI scan revealed mediastinal and para-aortic lymphadenopathy, and a diagnosis of classical Hodgkin's lymphoma was confirmed on lymph node biopsy.Case report - DiscussionThis young man initially presented with fever and cervical lymphadenopathy, when a diagnosis of lymphoma was made. Yet, following review of the biopsy at the local tertiary centre and the abnormal immunological profile, a diagnosis of lupus was made. He then developed nephrotic syndrome, when a diagnosis of lupus nephritis was confirmed on biopsy. Other clinical and laboratory profile (raised ESR, hypocomplementeamia, serositis and haematological parameters) corroborated the diagnosis. He responded well to steroids and immunosuppression, when he presented with fever again. He had no evidence of flare of underlying lupus or any infection, but blood tests and splenomegaly pointed to macrophage activation syndrome (MAS). A negative bone marrow examination suggested that pancytopaenia was unlikely to be due to bone marrow infiltration, which is why he was treated with steroids. Yet, when fever recurred, MRI was arranged to investigate further, which eventually led to revelation of lymphadenopathy and biopsy, which eventually led to the right diagnosis. Another dilemma was if his MAS was to respond to steroids, whether we should change his baseline immunosuppression which had worked well so far for him and if we chose to, what would be the best agent.Case report - Key learning points1. Although extremely uncommon, children and young people with rheumatic diseases can develop malignancy, which may be unrelated to the primary condition or the therapeutic agents used. Unexplained symptoms in the absence of flare of underlying condition and with infections ruled out, warrant extension of investigations to rule out an underlying malignancy.2. Diagnosis of secondary MAS in a rheumatological condition without any evidence of flare of the underlying condition should be viewed as suspicious and warrants more investigations to rule out other causes.3. In patients who develop MAS, there are very few agents which work for both lupus and MAS, choosing an agent which treats both conditions is challenging.

P30 A case of recurrent orbital myositis

Case report - IntroductionAn interesting case of an 11-year recurrent isolated lateral rectus myositis. Initially responsive to short courses of oral steroids; however, this has more recently become refractory and now the patient is unable to wean off steroids. The use of biologics in these patients is uncommon and there are very few case reports of this and the outcomes. We present a case of refractory orbital myositis treated with rituximab.Case report - Case descriptionA 38-year-old female presented in 2009 with ocular pain, swelling and diplopia. After review by the ophthalmology team an MRI orbits was requested which showed swelling and enhancement of the right lateral rectus muscle, consistent with orbital myositis. She had no other symptoms of myositis elsewhere, and no other symptoms suggestive of a connective tissue disease. Her ANA, ENA and extended myositis panel were negative and therefore aetiology was uncertain. She had no past medical history, but was later diagnosed with hypothyroidism with positive TPO antibodies. Throughout the 11 years since diagnosis her thyroid disease has been well controlled, and she has had normal free T3/T4 and TSH. It was felt that thyroid eye disease was unlikely to present with a single muscle. She was initially treated with a course of 40mg oral prednisolone reducing over 6 weeks and symptoms resolved. In 2013 she had her first relapse, which was treated with prednisolone reducing over the course of 12months, and again symptoms resolved. Her third relapse in 2019 was treated with steroids, but patient was unable to wean off this, requiring 60mg of prednisolone, and at this point was referred to rheumatology for steroid sparing agents. Between 2013 and 2019 there was MRI progression with volumetric enlargement of the right lateral rectus with intra-orbital space reduction.Under the care of rheumatology, she had repeat connective tissue disorders and myositis screen. She was started on azathioprine as a steroid sparing agent. This had little effect and she was still debilitated by orbital pain and diplopia, and unable to reduce her prednisolone below 30mg daily. She trialled intra-orbital steroid injections with little benefit. She has now been started on rituximab infusions to allow us to wean steroids. Thus far she has had two doses and we await the outcome from this treatment. Case report - DiscussionOrbital myositis can be a debilitating condition causing diplopia and pain, as in the case of this 38-year-old female who has been off work for the past year due to the condition. It can affect single muscles or multiple muscles and may be unilateral or bilateral. The major differential diagnosis is thyroid eye disease which would not usually cause an isolated myopathy, is usually painless and slowly progressive and as such was felt unlikely to be the underlying pathology in this case. From a literature review into idiopathic orbital inflammation, including myositis, 75% of patients are found to have a good response to corticosteroids. Second-line treatments include radiotherapy, methotrexate/azathioprine and other biologic agents. A case report in 2014 of 10 patients with orbital myositis refractory to steroids and at least one other immunosuppressant, demonstrated that rituximab was safe and effective, with 7/10 patients noting improvement of their symptoms. Out of those seven patients, four had been on steroids at induction of rituximab and all of the patients were able to reduce their steroid dose. The patients in this trial received two initial doses of rituximab and were permitted to have a further dose at 24 weeks if there were recurrence of symptoms. Four out of the seven patients required a further infusion after 24 weeks. In a review of the literature, we have noted a further two case reports of the use of rituximab in orbital myositis from 2008 and 2012 with good response. Both patients were unable to wean from corticosteroids and had tried other DMARDs such as methotrexate. Other case reports of biologics therapy include a case report of two patients in which adalimumab was used and allowed steroid reduction with good results for at least 9 months.Case report - Key learning pointsOrbital myositis should be assessed for other features of polymyositis, as well as investigated for thyroid eye diseaseMost patients will have a good response to oral corticosteroidsAround a quarter of cases can have refractory disease. In these patients there remains a management dilemma. Options include radiotherapy, disease modifying agents such as methotrexate and azathioprine, and biologic therapy such as adalimumab or rituximabThere is limited evidence in the literature as to the best treatment option and ideal length of treatment for refractory orbital myositis cases

A case report of pleuro‐pericardial effusion in a patient on hemodialysis and a cardiac pacemaker

There are multiple causes of pleuro-pericardial effusion (PPEF) and more so in a patient with end-stage renal disease (ESRD). Postcardiac injury syndrome (PCIS) is a loosely defined term for occurrence of pericardial and/or pleural effusion (PLEF), low-grade fever, with or without systemic upset, which occurs after myocardial infarction (MI), and other cardiac interventions. PPEF is one of its salient manifestations. We report occurrence of PCIS, presenting as pericardial effusion and massive PLEF, after insertion of cardiac pacemaker in a patient with ESRD, on maintenance hemodialysis (MHD). It was successfully managed with a short course of oral steroids.

Successful Management of Treatment-Emergent Chronic Graft-Versus-Host Disease of the Liver Following Nivolumab for Relapsed Hodgkin's Lymphoma after Allogeneic Stem Cell Transplant

PD-1 inhibition has been shown to effectively treat relapsed Hodgkin's lymphoma after allogeneic stem cell transplant (AlloSCT) by augmenting the graft-versus-lymphoma immune response. While PD-1 blockade post-Allo SCT is associated with a high overall response rate, there is also a high rate of severe graft-versus-host disease (GVHD) following treatment (Blood 2017 130:221-228). Many of the reported fatalities in this patient population have been associated with new onset treatment-refractory GVHD. Interestingly, GVHD occurring in this situation commonly manifests in the liver and can have features of both acute and chronic GVHD. This unique complication raises questions about the most effective treatment strategy. We report the successful management of PD-1 inhibitor-associated liver GVHD in a 31-year-old patient with classic Hodgkin's lymphoma, mixed cellularity subtype, who received the PD-1 inhibitor nivolumab for relapsed disease following a matched sibling donor peripheral blood Allo-SCT. The original indication for Allo-SCT was chemosensitive disease relapse following autologous stem cell transplant. The conditioning regimen was reduced-intensity busulfan and fludarabine and GVHD prophylaxis was low dose methotrexate and tacrolimus. Approximately 180 days after Allo-SCT the patient developed extensive chronic GVHD (elevated liver transaminases and decreased FEV1) which was successfully treated with a short course of oral steroids. Positron emission tomography-computed tomography (PET-CT) scan 1 year after Allo-SCT showed recurrent disease above and below the diaphragm. Brentuximab was initiated, resulting in resolution of hypermetabolic lymphadenopathy, but treatment was stopped after the third dose due to a severe infusion reaction. Three months later, PET-CT revealed multiple foci of high metabolic activity suggesting relapse. Vorinostat and sirolimus were initiated, and remission was obtained for the third time after Allo-SCT while on this regimen. After five months of vorinostat and sirolimus, the patient developed a pulmonary infection and subsequent biopsy-proven disease relapse. The patient was started on single agent nivolumab 3 mg/kg. Approximately 30 days after infusion the patient developed painful sclerodermatous lesions on the shins and increasing liver transaminases (Figure 1). Further treatment with nivolumab was held and 1 mg/kg/day of prednisone-equivalent was initiated. After 1 week, no improvement in liver enzymes was observed and prednisone was increased to 2 mg/kg/day. Sirolimus and mycophenolate mofetil were added. Despite initial improvement, transaminases and bilirubin increased again and a liver biopsy on day 48 of therapy showed lymphocytic cholangitis, cholestasis, ductopenia, and portal-to-portal bridging fibrosis consistent with chronic GVHD. AST peaked at 488 U/L, ALT peaked at 1093 U/L, and total bilirubin peaked at 1.7 mg/dL. Prednisone was increased to 3 mg/kg/day and extracorporeal photopheresis and Jakafi were initiated. Liver transaminases steadily declined. Prednisone was slowly tapered and maintenance therapy with Jakafi, sirolimus, and monthly extracorporeal photopheresis has maintained remission without a subsequent GVHD flare. PET/CT six months after nivolumab showed no evidence of disease, and the patient remains in clinical remission more than eight months after treatment. This case study highlights several uncertainties in the management of GVHD following PD-1 blockade. Should patients receive higher doses of steroids upfront (> 1 mg/kg/day)? Should GVHD prophylaxis be used? How should second-line therapies be chosen and how quickly should they be added? The largest case series to date by Haverkos et al. reports a high rate of treatment resistant GVHD suggesting that rapid escalation of immunosuppression is needed. Overall, this case represents a successful management of a newly-recognized and severe form of GVHD that can occur following PD-1 blockade in Allo-SCT recipients. Given that nivolumab is one of the few effective treatment options for relapsed Hodgkin's lymphoma after Allo-SCT, effective strategies for managing GVHD after PD-1 inhibition are needed. [Display omitted] DisclosuresLin:Jazz Pharmaceuticals: Consultancy. Ganguly:Amgen: Other: Advisory Board; Seattle Genetics: Speakers Bureau.

Multiple short courses of corticosteroids in children.

Corticosteroids are adrenal steroid hormones responsible for immune homeostasis, blood pressure regulation, energy and appetite regulation, and suppression of inflammation. Oral corticosteroids ('steroids') are commonly used in children for a number of medical conditions, including asthma, croup, inflammatory bowel disease and nephrotic syndrome. There has been some concern about potential side effectsof oral, topical or inhaled steroids, including reduction in growth, weight gain, behavioural changes and immunosuppression resulting ininfection. While many recent studies have assessed individual risks, this article aims to provide an overview of steroid use in common paediatric presentations, highlighting current management and risks associated with recurrent doses of steroids in the paediatric population. Short courses of oral steroids (less than two weeks) in children are very unlikely to cause long-term side effects in children. Children requiring courses more than two weeks' duration warrant specialist referral and a weaning plan to reduce adrenal suppression and insufficiency.

Impact of type of health care provider on long term asthma control

Objective Asthma prevalence is high and adherence to asthma guidelines is still less than adequate. The main objective of this study was to determine if there were significant differences in outcome measures if asthma care was provided per guidelines either by physicians (pediatric pulmonologists) or specialty trained advance practice nurses (APNs) Methods This was a three-year, prospective cohort study of children referred by their primary care providers to a tertiary care center for better asthma control. Patients were provided asthma care per NAEPP guidelines including asthma education. Results were compared over time and between patients followed by physicians or APNs. Alpha level of significance was ≤0.05. Results The sample included 471 children, ages 2–17 years (mean = 6.4 ± 2.4 years). Physicians and APN’s provided asthma care. Of the 471 children enrolled in the study, 176 (37%) were followed for the full three-year study period. At the initial visit, physician group reported more short courses of oral steroids and more unscheduled visits to PCP for acute asthma care in the past 6 months compared to those followed by APNs (<0.05 for all). Among the total cohort and both subgroups, there were significant improvements in mean Asthma Control Test (ACT), acute care need and mean days/month with asthma symptoms over a three-year period (p < 0.05). There was significantly more improvement in use of oral steroids and urgent care visits in physician group (p < 0.05). Conclusion When asthma guidelines are followed, improvements in asthma control are achieved in children in both the MD and APN groups

Comparison of Two Therapies on Asthma Control in Children.

Background: Childhood asthma carries significant morbidity. Aim/Objectives: Aim of the study was to compare efficacy of 2 commonly used therapies for asthma control in children with asthma. Methods: This was a 1-year, prospective cohort study at a tertiary care children's hospital. Patients were referred by their primary care physicians (PCPs) for asthma control. All patients were on low-dose inhaled corticosteroids (ICSs) at baseline. They were either switched to medium-dose ICS (ICS group) or medium-dose ICS and long-acting beta agonist (ICS+LABA group). Results were compared over time and between both groups. Results: Our cohort included 163 children (ages 2-18 years) with mean age of 5.62 ± 3.61 years. Mean Asthma Control Test (ACT) score at baseline was 15.9 ± 5.4. Mean ACT and percent predicted forced expiratory volume in one second improved (P < 0.0001 for both) in both groups. Median emergency department visits, short courses of oral steroids, and unscheduled PCP visits for acute asthma significantly decreased (P < 0.001 for all) in both groups. Similarly, days/month with wheezing, nighttime cough, and missed school days significantly decreased in both groups (P < 0.001 for all). Patients in ICS group were more likely to fail to achieve asthma control compared to patients in ICS+LABA group. Conclusion: Our study suggests that in children with uncontrolled asthma on low-dose ICS, switching to either medium-dose ICS or medium-dose ICS+LABA resulted in better symptom control, ACT improvement, and less asthma exacerbations over time. ICS+LABA had the additional benefit of less risk of treatment failure when compared to medium-dose ICS.

Minocycline-induced antineutrophil cytoplasmic antibody-associated vasculitis in children

Chronic exposure to minocycline, a commonly used anti-acne medication, results in a variety of autoimmune syndromes. Minocycline-induced vasculitis often associated with the presence of antinuclear antibody (ANA) and antineutrophil cytoplasmic antibody (ANCA) has been reported in Western literature, mainly in adults. Herein, we report a rare case of a 15-year-old male child on minocycline treatment for 1 year, who presented with fever, skin rash, and polyarthralgia for 4 months. His erythrocyte sedimentation rate (ESR) level was elevated, ANA and myeloperoxidase ANCA were positive, and skin biopsy revealed leukocytoclastic vasculitis. Upon discontinuation of minocycline and prescribing a short course of oral steroids, all his symptoms resolved and ESR normalized within 2 weeks. The child remained asymptomatic with normal acute-phase reactants at 2-month follow-up. This outcome suggested that minocycline was the main cause of ANCA-associated vasculitis.

Recurrent urticaria and angioedema

<h2>Abstract</h2> Urticaria is common in childhood, affecting up to 15% of British children. It is characterised by the sudden onset of wheals, angioedema, or both. Episodes are usually acute, often triggered by viral infections ± antibiotics, with approximately a third progressing to chronic or recurrent urticaria. This review covers urticaria subtypes, diagnosis and treatment options for children. The diagnosis is usually made clinically, and a focused history is vital. Further investigations are usually unnecessary. Chronic urticaria is divided into chronic spontaneous urticaria and the inducible urticarias. Chronic spontaneous urticaria is autoimmune in origin, in approximately 40% of older children. Cold urticaria and dermographism are the most common inducible urticarias. Isolated angioedema should prompt consideration of hereditary angioedema. The mainstay of treatment is non-sedating antihistamines, often with higher doses than standard and avoidance of triggers. Tranexamic acid may provide symptomatic relief for isolated angioedema. Treatment options include leukotriene receptor antagonists, anti-IgE therapy and systemic immunosuppression in unresponsive patients. Short courses of oral steroids may be used in acute episodes or highly symptomatic patients with chronic urticaria. Urticaria usually resolves; the vast majority of patients are disease free after 7 years.

Khella induced nephropathy: a case report and review of literature

Khella (Ammi visnagais) was used in Ancient Egypt as a herbal remedy for renal colic. Khella contains group of coumarins, xanthotoxin, ammidin, furoquinoline alkaloids and, dihydroseselins with varying cytotoxic activity. The most common is Khellin and visnagin. Khellin was found to be a smooth muscle relaxant, induces diuresis, increases excretion of citrate and decreases the excretion of oxalate in urine, which improves nephrolithiasis and passage of ureteric stones. Synthetic derivatives of khellin include amiodarone, the anti-arrhythmic drug, and cromolyn, an anti-asthma drug. Khellin is not as safe as it seems to be. Its oral use is limited by its potential toxicity (eg, elevated liver enzymes, phototoxicity, dermatitis). In experimental animals, the median lethal dose (LD50) was 3.6 g/kg for intra-peritoneal administration and 10.1 g/kg for oral administration. In humans, nausea and vomiting were observed frequently in 29% and transaminitis in 7-14% of the patients. Other potential adverse reactions include dizziness, constipation, headache, itching, insomnia, photosensitivity and lack of appetite. We report for the first-time, acute kidney injury following use of khella in a CKD patient with a 5-fold increase in his serum creatinine level from 1.9 to 9.2 mg/dl. His renal biopsy revealed eosinophilic interstitial nephritis. He responded well to pulse methylprednisolone followed by short course of oral steroids. We believe this is the first case describing Khella nephropathy. Herbal nephropathy is not uncommon and herbal remedies are not as safe as it is believed. Accurate diagnosis and early management are the key in improving the renal outcome.

A 10-Year Follow-Up of a Randomized Prospective Study of 2 Treatments for Chronic Rhinosinusitis Without Nasal Polyps and Investigation of the Impact of Gastroeosophageal Reflux Disease in the Resistance to Treatment

To compare the 2 long-term medical strategies in chronic rhinosinusitis without nasal polyps (CRSnNP) and to identify the role of gastroesophageal reflux disease (GERD) and Helicobacter pylori as factors of treatment failure. Fifty-seven patients with CRSnNP were randomized into 2 therapeutic groups. The first group was treated with 4 weeks of amoxicillin/clavulanate and a short course of oral steroids. The second group received 8 weeks of clarithromycin. Sinonasal Outcome Test-20 (SNOT-20) and Lund and Mackay scores were assessed at baseline and after treatment, and GERD Health-Related Quality of Life (GERD-HRQL) questionnaire was evaluated in all patients. Patients with a GERD-HRQL score >8 received esogastroscopy and H pylori detection. Patients were followed during a 10-year period for clinical course and GERD evolution. The 10-year evolution of patients was described in terms of recurrence, medical, and surgical treatments. Thirty-seven patients completed the study; SNOT-20 and Lund and Mackay scores similarly improved in both groups. Amoxicillin/clavulanate group had significantly more adverse reactions than the clarithromycin group (P = .03). After the therapeutic course, 35% (amoxicillin/clavulanate) and 41% (clarithromycin) of patients needed functional endoscopic sinus surgery (FESS). During the long-term follow-up, 54% (amoxicillin/clavulanate) and 40% (clarithromycin) of patients had late CRSnNP recurrence; FESS was performed in less than 15% of cases of recurrence. Gastroesophageal reflux disease complaint's severity was associated with late recurrence of CRSnNP. Amoxicillin/clavulanate and clarithromycin would be competitive treatments for CRSnNP. Gastroesophageal reflux disease seems to be a negative factor for treatment response and recurrence.

Nasal polyps and rhinosinusitis.

Rhinosinusitis is defined as inflammation of one or more of the paranasal sinuses and affects approximately 12% of the population. Acute rhinosinusitis is defined as symptoms that last < 12 weeks, and chronic rhinosinusitis (CRS) is defined as symptoms that last > 12 weeks. CRS is divided into three groups: CRS with nasal polyps (CRSwNP), CRS without nasal polyps (CRSsNP), and allergic fungal rhinosinusitis. Nasal polyps are inflammatory outgrowths of paranasal sinus mucosa caused by chronic mucosal inflammation and are present in 20% of patients with CRS. Nasal polyps typically present with nasal congestion, nasal obstruction, and anosmia or hyposmia, and occur more frequently in patients with persistent asthma, aspirin-exacerbated respiratory disease (AERD), CRS, and cystic fibrosis. The sinus cavities are lined with pseudostratified ciliated columnar epithelial cells interspersed with mucous goblet cells. Cilia continuously sweep the mucous toward the ostial openings and are important in maintaining the proper environment of the sinus cavities. The frontal, maxillary, and anterior ethmoid sinuses drain into the ostiomeatal unit of the middle meatus. The posterior ethmoid sinuses and superior sphenoid sinuses drain into the sphenoethmoid recess of the superior meatus. Most acute sinus infections are caused by viruses, and, therefore, it is not surprising that the majority of patients improve within 2 weeks without antibiotic treatment. A bacterial infection should be considered if symptoms worsen or fail to improve within 7-10 days. Combining an intranasal corticosteroid with an antibiotic reduces symptoms more effectively than antibiotics alone. Topical nasal steroids are the treatment of choice for nasal polyps. They significantly decrease polyp size, nasal congestion, and rhinorrhea, and increase nasal airflow. Short courses of oral steroids may be needed to reduce polyp size, followed by maintenance therapy with topical steroids. Surgery is reserved for patients in which polyps cause severe obstruction or recurrent sinusitis and for patients for whom medical therapy has failed. Aspirin desensitization may decrease the requirement for polypectomies and sinus surgery in patients with AERD.

Adrenal insufficiency from steroid-containing complementary therapy: importance of detailed history

SummaryA 62-year-old Asian British female presented with increasing tiredness. She had multiple co-morbidities and was prescribed steroid inhalers for asthma. She had also received short courses of oral prednisolone for acute asthma exacerbations in the last 2 years. Unfortunately, the frequency and dose of steroids for asthma was unclear from history. Her type 2 diabetes mellitus (DM) control had deteriorated over a short period of time (HbA1c: 48–85 mmol/mol). Blood tests revealed undetectable cortisol and ACTH (<28 mmol/L, <5.0 ng/L). Renin, electrolytes and thyroid function were within normal limits. A diagnosis of secondary adrenal insufficiency, likely due to long-term steroid inhaler and recurrent short courses of oral steroids for asthma exacerbations was made. Patient was commenced on hydrocortisone 10 mg, 5 mg and 5 mg regimen. Steroid inhaler was discontinued following consultation with respiratory physicians. Despite discontinuation of inhaled steroids, patient continued not to mount a response to Synacthen®. Upon further detailed history, patient admitted taking a ‘herbal’ preparation for chronic osteoarthritic knee pain. Toxicology analysis showed presence of dexamethasone, ciprofloxacin, paracetamol, diclofenac, ibuprofen and cimetidine in the herbal medication. Patient was advised to discontinue her herbal preparation. We believe the cause of secondary adrenal insufficiency in our patient was the herbal remedy containing dexamethasone, explaining persistent adrenal suppression despite discontinuation of all prescribed steroids, further possibly contributing to obesity, hypertension and suboptimal control of DM. In conclusion, a comprehensive drug history including herbal and over-the-counter preparations should be elucidated. Investigation for the presence of steroids in these preparations should be considered when patients persist to have secondary adrenal insufficiency despite discontinuation of prescribed steroid medications.Learning points:The likelihood of complementary and alternative medicines (CAMs) in medication-induced secondary adrenal insufficiency should be considered in any patient presenting with potential symptoms of adrenal insufficiency.If the contents of CAM preparation cannot be ascertained, toxicology screening should be considered.Patients should be advised to stop taking CAM preparation when it contains steroids and hydrocortisone replacement therapy commenced, with periodic reassessment of adrenal function, and then if indicated weaned accordingly.Patients should be informed about the contents of CAM therapies, so they can make a truly informed choice regarding the risks and benefits.This case also highlights a need to increase regulatory processes over CAM therapies, given their propensity to contain a number of undisclosed medications and potent steroids.