Short Course Of Steroids Research Articles

Different course and management of khat-induced autoimmune hepatitis: report on three cases

Khat is a plant that is commonly used for its stimulating effects and is chewed for its psychoactive properties. It creates feelings of euphoria that are similar to when taking amphetamines. There is an association between khat and liver injury, but the mechanism is not well known. We present three cases of khat-induced liver injury. All cases have elevated IgG and either positive antinuclear antibodies (ANA) or anti-smooth muscle antibody (ASMA); each case has a different course and requires different management. One case improved only by stopping khat, one required a short course of steroids and the last case required treatment such as that for autoimmune hepatitis (AIH).

#1153 Short course of steroids as a treatment for immune checkpoint inhibitors-associated acute kidney injury

Abstract Background and Aims Immune checkpoint inhibitors (ICPi) have been a revolution in oncology. Due to their mechanism of action they can produce inflammatory adverse events, called “immune related adverse events” (IrAEs). Immune-mediated renal toxicity appears to be infrequent (2.2-5%), with acute tubulointerstitial nephritis being the most common form, clinically manifested as acute kidney injury (AKI). Corticosteroids are a highly effective treatment. However, the most suitable regimen has not been established. Method Retrospective multicenter study to evaluate the efficacy and safety of a short course of steroids (Group A) versus a long course (Group B) in patients with a clinical or histologic diagnosis of ICPi-associated acute kidney injury (ICPi-AKI). Short-duration regimen was considered to be that with a duration ≤3 months. Renal response was assessed 3 months after initiation of steroid therapy. Partial and complete renal response rates were compared in both groups, as well as relapses of ICPi-AKI with the lowering or suspension of steroid treatment. The development of adverse effects attributable to corticosteroids and the evolution of the oncologic disease were also evaluated. Results Sixty-three patients were included, 30 (48%) of whom received a short course of corticosteroids. Type of malignancy and oncologic treatment were similar in both groups. Baseline serum creatinine (1.1 mg/dL Group A and 0.9 mg/dL Group B; p = 0.53) and at ICPi-AKI diagnosis (3.0 mg/dL in Group A and 2.8 mg/dL in Group B; p = 0.43) were comparable. As shown in the table below, cumulative prednisone dose was lower in Group A than in Group B (1654 mg vs 4030 mg; p = 0.001). The overall renal response was 92% (87% Group A and 97% Group B; p = 0.2). There were no differences in complete response (40% Group A and 40% Group B; p = 1) or partial response (47% Group A and 57% Group B; p = 0.4). There were no recurrences of AKI after rechallenge of ICPi treatment. Adverse events related to corticosteroids were similar. There was a trend towards greater progression of oncologic disease in group B (64% versus 40%; p = 0.08). Conclusion A short course of steroids (< 3 months) is equally effective as a treatment for ICPi-AKI as longer courses, both in terms of renal response and relapse rate of ICPi-AKI. Adverse events related to steroid treatment were comparable in both groups. There appeared to be greater oncologic progression in the prolonged steroid treatment group.

Chronic Rhinosinusitis with Extensive Recurrent Bilateral Nasal Polyposis-Third Times The Charm

The prevalence of recurrence in chronic rhinosinusitis with nasal polyposis (CRSwNP) is up to 40% after 18 months. Compliance to continuous medical therapy postoperatively is crucial to ensure disease resolution. CRSwNP endotype type 2 which is more common in Caucasian had shown higher recurrence. We report a case with third recurrence and the possible risk factors. A 37-year-old male smoker presented with rhinorrhea, bilateral facial pain, and anosmia for 3 years. He had two previous sinus surgeries and septoplasty. His nasal symptoms recurred a few months after both surgeries. Due to the recent pandemic, he defaulted on follow up. Rigid endoscopy at initial presentation revealed bilateral grade 2 nasal polyps which progressed to grade 4 despite medical polypectomy. Computed tomography of paranasal sinus showed pansinusitis with bilateral extensive polyposis, with presence of frontal intrasinus calcification possibly due to chronic sinusitis or fungal infection. He contracted Covid-19 category 2A infection two months before his planned surgery. The patient underwent bilateral endoscopic sinus surgery revealing extensive polyposis occupying all paranasal sinuses and the nasal cavity, completely obstructing the nasal. Intraoperative blood loss from the mucosa of the sinuses amounted to 2 liters without any arterial bleeding, causing an increase in operative time due to persistent need to secure hemostasis. Histopathological findings showed benign inflammatory polyps. There were reactionary polyps seen in bilateral maxillary sinuses and ethmoids at 2 weeks post operatively. A short course of steroid and chlarythromycin were given to prevent progression of polyps. At 5 weeks post operative, he reported on return of smell, and no more nasal blockage. We discuss the risk factors and endotypes of nasal polyps in recurrence cases with the operative challenges in revision endoscopic nasal surgery. In conclusion, recurrence nasal polyps after revision surgery is multifactorial with some possible prevention.International Journal of Human and Health Sciences Supplementary Issue 01: 2024 Page: S55

Conservative management of tubercular intestinal obstruction with antitubercular drugs and steroid

Objective: Tubercular intestinal obstruction is a challenging condition often necessitating surgical intervention. This case study aims to evaluate the effectiveness of conservative management, including antitubercular therapy, short-course steroids, and dietary modifications, in resolving acute and complete intestinal obstruction caused by tuberculosis. Case Description: A 17-year-old malnourished male presented with acute abdominal pain, vomiting, and constipation. Imaging revealed mid-ileal intestinal obstruction due to tuberculosis. Conservative management, involving intravenous antibiotics, nasogastric decompression, steroids, and antitubercular treatment, led to gradual resolution. The patient experienced recurrent partial obstruction episodes, each managed conservatively with antibiotics, steroids, and dietary adjustments. A slow transition from liquid to solid diet accompanied recovery. After a year of treatment, the patient achieved recovery with weight gain. Conclusion: Tubercular intestinal obstruction, challenging to treat medically, often requires surgery. However, this case demonstrates the successful outcome through a comprehensive conservative approach. The inclusion of steroids alongside antitubercular treatment played a crucial role. Additionally, a cautious transition from liquid to solid diet post-resolution proved effective in preventing recurrence. Conservative management, when tailored to the patient's nutritional needs and disease course, can lead to favorable outcomes in tubercular intestinal obstruction.

Effect of Steroids on Patients With Fibromyalgia/Chromic Widespread Pain: An Observational Study.

Fibromyalgia causes widespread chronic pain. Pain management and treating underlying conditions are of utmost importance. Recent studies found an association of thyroid autoimmunity with fibromyalgia. Pain management of patients with anti-thyroid peroxidase antibody (anti-TPO Ab) positive was studied sparsely. To determine the effect of steroid (deflazacort) on pain management using numerical rating scale (NRS) pain score at baseline and at 3-month follow-up. A retrospective observational study was undertaken, recruiting patients diagnosed with fibromyalgia as per 2010 American College of Rheumatology guidelines and treated with the steroid, deflazacort 12 mg. Patients with missing details were excluded. Patients were categorized into negative, positive, and strongly positive anti-TPO Ab groups. Baseline and follow-up (3 months) pain score was compared across the groups. Reduction in pain was considered as a primary outcome variable. The study included 128 participants with 98 (76.6%) females and 30 (23.4%) males. The age of the study population was 48±13.29 years. The proportion of hyper, hypo, and euthyroidwas 10 (7.81%), 42 (32.81%), and 76 (59.38%), respectively. The proportion of participants with negative, positive, and strongly positive anti-TPO Ab levels was 41 (32.03)%, 50 (39.06%), and 37 (28.91%), respectively.Baseline pain score was 7.3±1.32 and 3-month follow-up was 4.7±2.46. Steroid response was found in 66 (51.6%). Negative andpositive anti-TPO Ab had a 1-point reduction in pain score from baseline, p-value <0.001. The strongly positive group had 5 points reduction, p-value<0.05. Fibromyalgia patients with thyroid autoimmunity responded well to short courses of steroids. Greater pain relief was observed among those who are strongly positive anti-TPO Ab group.

Bilateral Facial Nerve Palsy Following Antibiotic Treatment for Listeria Monocytogenes Meningitis

Listeria monocytogenes (LM) is an intracellular, facultative, gram-positive bacillus transmitted mainly through contaminated food, particularly dairy products and cold deli meats. It typically affects immunocompromised patients, and a rarely neuroinvasive disease in immunocompetent healthy adults has been described in the literature. Despite the timely intervention, neurologic morbidity has been observed after extended periods of recommended antibiotic regimens. This case study highlights the challenges in diagnosing and managing LM meningitis, especially when atypical symptoms and complications arise. Herein, we describe the case of a 57-year-old healthy man admitted with symptoms of nausea, vomiting, headache, neck pain, and stiffness, who was eventually diagnosed with LM-related meningitis and treated with antibiotics. The patient’s hospital course was complicated by bilateral facial nerve palsy, while other symptoms improved with antibiotic treatment, raising suspicion for parainfectious immunological response, which improved with a short course of steroids. This case contributes to the medical literature by providing insights into the immunological response for treating LM meningitis and managing LM meningitis–associated complications. To our knowledge, this could potentially be the first case of LM meningitis causing the parainfectious immunological response of bilateral facial nerve palsy after antibiotic treatment.

Reversal of uniocular blindness with corticosteroids in a solid organ transplant recipient with cryptococcal meningitis and immune reconstitution syndrome (IRIS): A case report

Cryptococcal meningitis is a life-threatening infection commonly seen in patients with advanced HIV infection and solid organ transplant recipients. We report a case of cryptococcal meningitis with immune reconstitution syndrome (IRIS) who presented to us with a headache and complete loss of vision in the left eye. He was managed with antifungals and a short course of steroids, and he regained vision completely. In the hospital, he developed complications including tacrolimus toxicity, fluconazole-induced QT prolongation, and flucytosine-induced thrombocytopenia. Our case demonstrates the importance of a multidisciplinary approach in the management of complex cases like cryptococcal meningitis in solid organ transplant recipients.

Association between Thyroid autoimmunity and Fibromyalgia: Single center retrospective study (P9-6.004)

<h3>Objective:</h3> The objective of this study was to describe the prevalence of anti TPO ab among FM patients, their thyroid status and to evaluate clinical response to corticosteroids. <h3>Background:</h3> Fibromyalgia (FM) is a disorder characterized by widespread musculoskeletal pain and other somatic symptoms. Studies have shown that there is a high prevalence of anti TPO ab (Thyroid peroxidase antibody) positivity among FM patients. It is unknown if thyroid autoimmunity is a predisposing factor for FM. <h3>Design/Methods:</h3> We included 107 patients who were diagnosed with FM based on 2010 American College of Rheumatology Criteria who attended our neurology clinic at Appusami Hospital, India between July 2019 and 2022. We recorded data including age, gender, thyroid profile, anti TPO titer [Negative (&lt;15), positive (15 to 500), strongly positive(&gt;500)] and calculated age adjusted odds ratio for steroid responsiveness. <h3>Results:</h3> Mean age of the study group was 48.29 and 78.5% were females. In our series, 75.7% of FM patients had positive anti TPO ab (Positive- 41.12%;strongly positive-35.51%). 51.40% were euthyroid, 38.32% were hypothyroid and 10.28% were hyperthyroid. Overall 56.8% responded well to steroids. (80.85% of strongly positive;19.15% of positive patients). Age-adjusted odds of steroid response in patients with higher anti TPO ab is 5.2 times that of the one with low ab (p&lt;0.001) (95%CI 3.03;9.04) <h3>Conclusions:</h3> Thyroid autoimmunity is frequently associated with middle aged women with FM. Higher anti TPO ab titers strongly correlated with steroid responsiveness in our study and we recommend a short course of steroids for this subset of patients. These findings need to be confirmed with a larger prospective study. Further research should focus on understanding the pathophysiology of FM and it9s the causal relationship with thyroid autoimmunity. <b>Disclosure:</b> Dr. Eswaradass has nothing to disclose. C Eswaradass, 303 has nothing to disclose. Dr. Thermalingem has nothing to disclose. Dr. Thirunavukkarasu has nothing to disclose. Dr. Gurunathan has nothing to disclose.

Successful Treatment of Diffuse Pustular Inflammatory Tinea Capitis in the Elderly with Repeated Debridement, Oral Terbinafine and Short-Course Steroids.

Successful Treatment of Diffuse Pustular Inflammatory Tinea Capitis in the Elderly with Repeated Debridement, Oral Terbinafine and Short-Course Steroids.

Rheumatological symptoms after COVID-19 pneumonia presenting as long COVID: What we need to know?

COVID-19 pandemic is in verge of over and evolved over last three years in different waves across the globe with various genetic mutants or strains. As of now, many COVID-19 recovered patients are lingering with residual symptoms of illness irrespective of disease severity called as long COVID. Nonspecific or vague and organic or topographical organ specific symptoms are very well described in literature in COVID-19 survived cases. Rheumatological symptoms are most documented in published data as sequel after COVID-19 illness. Clinical presentations of rheumatological symptoms are joint or musculoskeletal pain, chronic fatigue with minimal exertion and weakness or impaired quality of life. Pathophysiology involving in rheumatological manifestations would be persistent or dysregulated inflammatory response, immune activation or thrombogenic pathway abnormality after acute COVID-19 illness. Diagnosis is little difficult and needs prompt workup to rule out underlying rheumatological illness. Inflammatory markers and autoantibody analysis has documented role in work up and confirming the diagnosis in majority of cases. Management of these cases is still evolving and showed response to lifestyle modification, physiotherapy, and short course of steroids and multivitamins in various published studies.

Transient meningism in children after non-autologous duraplasty for Chiari Malformation surgery: A case series

BackgroundIncreasing the posterior fossa volume is the mainstay of treatment for Chiari type 1 Malformation (C1M) and type 1.5 (C1.5M). Different options to restore CSF flow have been described but no consensus has been reached yet. Bony decompression of posterior cranial fossa with dural opening provides good results but at the price of complications such as pseudomeningocele and aseptic meningitis. A single center retrospective analysis was conducted to find any relationships between outcome and perioperative factors. As a second goal a specific analysis was conducted on the complications and their hypothetical causes. MethodsAll the pediatric patients who underwent to posterior fossa bony decompression and dural opening for C1M or C1.5M in the period 2008-2020 were included in the study. A minimum period of three-months follow-up was considered among the inclusion criteria. ResultsA population of fifty-three consecutive patients was collected. Pseudomeningocele and a mild meningeal irritation resulted the most frequent complications. Considering preoperative and intraoperative factors, the type of dural graft showed a relatively strong correlation (P<.01) with pseudomeningocele appearance and the development of meningism. In the latter case, a short course of steroids was the only treatment required to control symptoms. ConclusionsDifferent factors could influence the outcome in Chiari Malformation surgery and eventually the development of complications. An adequate dural graft selection is of paramount importance when a dural opening for posterior fossa augmentation is planned. In case of mild meningeal irritation, a trial with short course steroids could avoid revision surgery.

Relapses or de-novo IgA nephropathy following COVID-19 vaccination; a narrative review

Immunoglobulin A (IgA) nephropathy is the most common type of glomerulonephritis worldwide characterized by excessive serum levels of glycosylated which triggers the generation of glycan-specific IgG and IgA autoantibodies. This pathological condition results in the formation of circulatory IgA immune complexes, which are essential for the development of glomerular inflammation, especially IgA nephropathy. The serum galactosylated IgA1, IgG, and IgA autoantibodies are suggested as the biomarkers of IgA nephropathy since IgA antibodies are early markers for disease activity too. Serum IgA antibodies emerged as the early COVID-19-specific antibody response about two days after initial symptoms of COVID-19 in comparison with IgG and IgM antibody concentrations, which appeared after five days. IgA nephropathy is frequently presented as microscopic or macroscopic hematuria and proteinuria with a male predominance. COVID-19 infection can include several organs aside from the lungs, such as kidneys through different mechanisms. It is demonstrated in most cases that short-lasting symptoms such as gross hematuria resolve either spontaneously or following a short course of steroids. This review summarized the reported cases of relapses or de-novo reported cases of relapses or de-novo IgA nephropathy and IgA vasculitis following COVID-19 vaccination.

Strongyloides colitis, a rare but important mimic of Crohn’s disease, resulting in coma and multi-organ failure: a case report

BackgroundStrongyloides colitis is a severe form of strongyloidiasis that carries a high mortality rate if untreated. There is an overlapping clinical presentation between Strongyloides colitis and Crohn’s disease. Here, we present a case of a patient who was diagnosed with Crohn’s disease and was treated with immunosuppressant therapy which resulted in a poor outcome.Case presentationA middle-aged, native African male presented with diarrhea, abdominal pain, and weight loss. Colonoscopy showed some patchy inflammation in the caecum, which on biopsy was suggestive of Crohn’s disease. He had a short course of steroids before being admitted to an emergency with abdominal pain, diarrhea, malnutrition, and severe weight loss. Initial conservative treatment failed, and he became acutely unwell and septic with peritonitis. Laparotomy was carried out, which showed mild inflammation in the terminal ileum, which was not resected. Postoperatively, the patient became comatose and went into multi-organ dysfunction. He failed to progress, and a further laparotomy and subtotal colectomy were performed on the 12th postoperative day. His multi-organ failure progressed, and he succumbed to death 4 days later.DiscussionStrongyloides stercoralis is a parasite causing an enteric infection in animals and humans. Strongyloidiasis in immunocompetent individuals is usually an indolent disease. However, in immunocompromised individuals, it can cause hyperinfective syndrome. Patients with strongyloid colitis should undergo colonoscopy and biopsy where acute inflammation with eosinophilic infiltrates indicates parasitic infiltration of the colonic wall. Surgery is generally not indicated, and any surgical intervention with misdiagnosis of a flare-up of IBD can be very detrimental to the patient.ConclusionStrongyloid colitis can very harmfully mimic Crohn’s colitis, and the use of steroids and immunosuppressants can disseminate parasitic infection. Hyperinfection syndrome can lead to sepsis, organ dysfunction, and comma. Disseminated infection carries a high mortality.

Unilateral Acute Parotitis

Background: Severe acute respiratory virus coronavirus-2 infection or coronavirus disease (COVID) is categorized into acute illness and late multiinflammatory syndrome in children (MISC). This has recently been challenged with recognition of presentations with mucocutaneous-enteric symptoms that display considerable overlap between the two. We recognized a similar overlap of manifestations when encountered the three cases of fever associated with unilateral parotitis. Clinical Description: The three patients were of different age groups ranging from 2 months to 7 years of age, all of whom presented with fever, unilateral swelling of face and neck consistent with the region of the parotid gland, and absence of other localizing symptoms or abnormalities on examination. All of them were positive for COVID antibodies, had negative COVID real-time polymerase chain reaction test, did not satisfy the diagnostic criteria of MISC, but had raised inflammatory markers. Since the workup for other common causes of acute parotitis was negative, a clinical diagnosis of post-COVID immune-mediated acute parotitis was kept. Management: All the three patients were managed with systemic steroids (oral or parenteral) and showed complete resolution of symptoms and normalization of laboratory parameters within a few days, a therapeutic response in alignment with an immune-mediated phenomenon. Conclusion: Acute unilateral parotitis with pyrexia may be a hitherto unreported late post-COVID manifestation that is immune mediated and shows an excellent therapeutic response to a short course of steroids.

Treatable Ataxias: How to Find the Needle in the Haystack?

Treatable ataxias are a group of ataxic disorders with specific treatments. These disorders include genetic and metabolic disorders, immune-mediated ataxic disorders, and ataxic disorders associated with infectious and parainfectious etiology, vascular causes, toxins and chemicals, and endocrinopathies. This review provides a comprehensive overview of different treatable ataxias. The major metabolic and genetic treatable ataxic disorders include ataxia with vitamin E deficiency, abetalipoproteinemia, cerebrotendinous xanthomatosis, Niemann-Pick disease type C, autosomal recessive cerebellar ataxia due to coenzyme Q10 deficiency, glucose transporter type 1 deficiency, and episodic ataxia type 2. The treatment of these disorders includes the replacement of deficient cofactors and vitamins, dietary modifications, and other specific treatments. Treatable ataxias with immune-mediated etiologies include gluten ataxia, anti-glutamic acid decarboxylase antibody-associated ataxia, steroid-responsive encephalopathy associated with autoimmune thyroiditis, Miller-Fisher syndrome, multiple sclerosis, and paraneoplastic cerebellar degeneration. Although dietary modification with a gluten-free diet is adequate in gluten ataxia, other autoimmune ataxias are managed by short-course steroids, plasma exchange, or immunomodulation. For autoimmune ataxias secondary to malignancy, treatment of tumor can reduce ataxic symptoms. Chronic alcohol consumption, antiepileptics, anticancer drugs, exposure to insecticides, heavy metals, and recreational drugs are potentially avoidable and treatable causes of ataxia. Infective and parainfectious causes of cerebellar ataxias include acute cerebellitis, postinfectious ataxia, Whipple’s disease, meningoencephalitis, and progressive multifocal leukoencephalopathy. These disorders are treated with steroids and antibiotics. Recognizing treatable disorders is of paramount importance when dealing with ataxias given that early treatment can prevent permanent neurological sequelae.

Post covid calamity- Mucormycosis: An overview

Corona virus disease (Covid-19) it had declared an emergency global pandemic1,2,3 that cause terrible effects on respiratory system and killing more than half billion lives.4,5,6 Diabetes has been reported as a risk factor for mucormycosis in 73.5% of cases in India.7 People with diabetes and obesity tend to develop more severe Covid-19 infections. This means they're more expected to take corticosteroids, which are frequently used to treat Covid-19. But the corticosteroids along with diabetes increase the risk of mucormycosis because it has been observed that peoples are affected with mucormycosis due to weekend immunity. Even a short course of steroid (5-14 days) results in mucormycosis.8 Mucormycosis, colloquially known as black fungus, is an infection from the mucormycetes group of fungi. The virus that causes Covid-19 can damage lung tissue and blood vessels, which could also increase susceptibility to different fungal infection. brain, causing headaches or seizures. So, damage to tissue and blood vessels from Covid-19 infection, treatment with corticosteroids, high background rates of diabetes in the population most brutally affected by the coronavirus are also getting affected by life threating fungal infection called as mucormycosis. Several methods have deferred the mortality but still have a challenge in curing mucorales.

Refractory Headaches.

Medication overuse headache (MOH), new daily persistent headache (NDPH), and persistent refractory headache attributed to severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) infection represent a significant burden in terms of disability and quality of life, and a challenge in terms of definition, pathophysiology, and treatment. Regarding MOH, prevention without withdrawal is not inferior to prevention with withdrawal. Preventive medications like topiramate, onabotulinumtoxinA, and calcitonin gene-related peptide (CGRP) monoclonal antibodies improve chronic migraine with MOH regardless of withdrawal. The differential diagnosis of NDPH is broad and should be carefully examined. There are no guidelines for the treatment of NDPH, but options include a short course of steroids, nerve blocks, topiramate, nortriptyline, gabapentin, CGRP monoclonal antibodies, and onabotulinumtoxinA. The persistence of headache 3 months after SARS-CoV2 infection is a predictor of poor prognosis.

SARS-Cov-2 Associated Paracentral Acute Middle Maculopathy: A Case Report with a Challenging Diagnosis

We present an intricate case of Paracentral acute middle maculopathy (PAMM) as part of the COVID-19 complex clinic presentation. 53 years old patient, pediatric nurse developed symptoms specific to SARS-Cov-2 infection (dry cough, headaches, myalgia’s and fever) which prompted her to get tested. 11 days into the disease, she experienced right eye mild loss of vision and received a short course of steroids for her concomitant pulmonary disease with no subjective improvement on vision. After 2 weeks of self-isolation, she had an ophthalmology examination and was misdiagnosed with optic neuritis. As her visual acuity was 6/6 she was monitored closely with perimetry and OCT. Patient showed reduction of central scotoma with no further treatment. One year later, an Angio-OCT was performed and upon reviewing the initial images, PAMM diagnosis was made.

MO237: Rituximab in Treatment of Minimal Change Disease and Primary Focal Segmental Glomerulosclerosis in Adults-Single Center Experience

Abstract BACKGROUND AND AIMS Rituximab (RTX) showed some efficacy in treatment of minimal change disease (MCD) and primary focal segmental glomerulosclerosis (pFSGS) [1]. The results of its off-label use and as steroid-sparing agent were especially promising in steroid-dependent, frequently relapsing or steroid-resistant forms of MCD and pFSGS in adults [2]. METHOD All patients treated with RTX in Department of Nephrology and Dialysis, University Hospital Dubrava, Zagreb, were retrospectively reviewed. Complete remission (CR), steroid-resistant nephrotic syndrome (SRNS), steroid-dependent nephrotic syndrome (SDNS), multidrug-resistant SRNS (MDR-SRNS) and calcineurin inhibitor (CNI)-resistant SRNS were defined according to KDIGO 2021 [3]. RESULTS Of 82 patients treated with RTX, 11 patients had biopsy proven MCD and pFSGS. Table 1 summarizes relevant demographic, clinical and treatment data. RTX was applied in five patients with SDNS, four patients with MDR-SRNS, one patient with CNI-resistant SRNS and one patient with active hepatitis C and newly onset MCD as a first line therapy. Median follow-up after initial diagnosis and RTX application was 122.9 (range 30–219) and 20 (range 3–117) months, respectively. All patients were initially treated with steroids, and RTX was the drug most commonly applied after treatment with CNI and cyclophosphamide (CYC). Median proteinuria at the time of RTX application was 10 g/day (range 2.5–16.7), 10 patients had preserved kidney function and only 1 patient with collapsing FSGS (case 11) had severe acute kidney injury. Mean cumulative dose of RTX for induction was 1700 mg and short course of steroids was used concomitantly in 10 cases (except case 5). CR was achieved in seven cases (six cases of MCD and one case of MDR-FSGS). Three of seven patients with CR to RTX experienced relapse of disease. Time to relapse was 6, 15 and 40 months in case 5, 3 and 11, respectively. Repeated RTX application led to CR in all three cases. CR persisted in five patients even after the steroids cessation. There were no serious adverse effects of RTX administration in our cohort. CONCLUSION RTX showed respectable efficacy in our cohort of adults with SDNS-MCD and in case of MDR collapsing FSGS. Although statistical comparison was not performed because of small number of patients, it seems that RTX is more effective in group of SDNS than MDR-SRNS. In our cohort, patients with relapse of RTX-sensitive disease responded to repeated application. Role of RTX in treatment of MCD and pFSGS should be evaluated in randomized clinical trials.

Persistent hypoglycemia in the setting of metastatic malignant insulinoma to the liver treated with chemoembolization and bland embolization

We are describing a patient with malignant insulinoma and unusual clinical and pathological features. The patient presented late in the course of the disease with history of abdominal pain and was found to have large tumor of the pancreas and metastasis to the liver. Also, he presented with acute diarrhea which is not a feature of Insulinoma. During the hospital stay the patient had sever hypoglycemia with very inappropriately high to the low blood glucose levels of Insulin, C- peptide and Proinsulin. On biopsy of the tumor it was found to be neuroendocrine tumor, but staining’s for Insulin were negative. The patient was treated with surgical resection of the distal pancreas when the insulinoma was located, splenectomy, cholecystectomy and appendectomy. Also, chemoembolization and embolization of the metastatic tumors of the liver were done and patient’s hypoglycemia was treated with Diazoxide and short course of Steroids and Octreotide. We underscore the need of combined clinical, laboratory, radiological and pathological approach while diagnosing malignant Insulinoma.