Steroid Complications Research Articles

Gut Microbiota-Induced Regulatory T Cells in Patients with Hematological Malignancies Receiving Allogeneic Hematopoietic Stem Cell Transplantation: Towards Deciphering a Role for These Tregs in aGVHD

Prognosis for hematological malignancies treated with allogeneic stem cell transplantation (allo-HSCT) remains dismal and can often induce potentially deadly complications, such as graft versus host disease (GvHD). Steroids remain the first-line treatment for aGvHD. Nevertheless, new treatments are needed to improve allo-HSCT outcomes and reduce steroid complications. In this context, increasing evidences suggest that gut microbiota composition and the activity of regulatory T cells (Tregs) are involved in GvHD prevention (Elias and Rudensky, 2019, Br. J. Haematol. ; Shono and van den Brink, 2018, Nat. Rev. Cancer). We have identified a novel FoxP3-negative IL-10-secreting Treg subset, named DP8α, enriched in the colon mucosa and present in blood, characterized by its CD3+/CD4+/CD8αLOW/ CCR6+/CXCR6+ phenotype and its TCR-specificity for the gut ClostridiumIV bacterium Faecalibacterium prausnitzii (Sarrabayrouse et al., 2014, PLoS Biol ; Godefroy et al., 2018, Gastroenterology). Sizable fractions of these cells also expressed the membrane-bound ectonucleotidases CD39 and CD73 (gating strategy shown in Figure 1), which are directly involved in their suppressive activity in vitro (Godefroy et al., 2018, Gastroenterology). In vivo, these molecules play key regulatory roles both by degrading extracellular ATP and thus limiting its inflammasome-related proinflammatory role, and by inducing the production of immunosuppressive adenosine. Accordingly, an alteration in adenosine/purinergic signaling has been suggested in GvHD occurrence (Deaglio et al., 2007, J. Exp. Med. ; Wang et al., 2013, PLoS ONE). Thus, we postulated that F. prausnitzii-reactive DP8α Tregs, whose suppressive activity depends on purinergic signaling, could bridge microbiota dysbiosis and GvHD incidence in allo-HSCT patients. In support of this, decreased levels of Clostridium bacteria, especially Faecalibacteriumspp, in patient's stools, have been associated with aGvHD risk (Noor et al., 2019, J Innate Immun). Moreover, mice gavaged with butyrate-producing and Treg-inducing Clostridia displayed milder GvHD and improved survival (Mathewson et al., 2016, Nat. Immunol.). Therefore, we recently analyzed 63 patients with hematological malignancies, who received allo-HSCT, among which 21 developed an aGvHD (pathologies and treatments are listed Table I). We quantified circulating DP8α Tregs and analyzed their expression of CD39 and CD73 in donors, before and after mobilization, and in patients at one week before and 1, 2, and 3 months post allo-HSCT. Strikingly, results clearly showed that aGvHD development was strongly associated with a lack of expression of CD73 by DP8α Tregs (p<.0001) (Fig.2A), but not by any other T cell subsets analyzed. DP8α frequency and their CD39 expression were similar in GvHD+ versus GvHD- patients. Importantly, CD73 decrease did not result from their corticotherapy since it was equally observed before and after treatment (Fig.2B) and since in vitro treatment of PBMCs with methylprednisolone did not alter CD73 expression whatsoever. Therefore, the CD73 decrease observed in aGvHD patients, appears relevant and likely related to the aGvHD condition itself. It is noteworthy that this cohort was rather heterogeneous in terms of hematological diseases, conditioning regimens and prophylaxis treatments (Table I). Nevertheless, this drastic CD73 decrease in aGvHD patients was observed across all these conditions, strongly strengthening its relevancy. Altogether, these data strongly suggest that a CD73-dependent functional alteration of DP8α Tregs are, at least in part, involved in aGvHD occurrence. These results could therefore be used to predict GvHD risk and also give rise to the development of therapeutic strategies. Such innovative treatments could be based on the infusion of DP8α Tregs with appropriate features, since we have shown both the uniquely high proliferating potential and the stable immunosuppressive function of these cells in vitro. Moreover, administration of DP8α target antigens (F. prausnitzii-derived), in the form of peptides, proteins, or even bacterial lysates, such as probiotics, could also be foreseen to either directly in vivo expand these Tregs or indirectly through the induction of tolerogenic dendritic cells (Alameddine et al., 2019, Front Immunol) and subsequent Treg differentiation/priming to limit GvHD-related inflammation. Figure 1 Disclosures Chevallier: Incyte Corporation: Honoraria.

Effect of early integration of diabetic services in primary brain tumor patients receiving radical radiotherapy on steroid-induced diabetic complications and hospital admission.

e14522 Background: Corticosteroids are commonly used in neuro-oncology both in the perioperative setting and with chemotherapy and radiotherapy to manage cancer and treatment-associated cerebral oedema and neurological deficits. Corticosteroids are associated with significant morbidity. We sought to identify primary brain tumour patients affected by steroid complications within our centre, the repercussions on their treatment and whether these consequences are avoidable. Methods: This retrospective study curated the last 50 primary brain tumour patients treated radically and therefore at risk of long term steroid use between November 2018 and August 2019. Patient demographics, tumour and treatment type, as well as diabetic and steroid history were collected. A second cohort of primary brain patients undergoing radical radiotherapy were recruited between November 2019 and January 2020. HbA1c blood tests were performed and NICE guidelines used for HbA1c diagnostic criteria with referral to diabetic services and outcomes recorded. Results: Tumour types ranged from Glioblastoma (36%), meningioma (32%), oligodendroglioma (16%), astrocytoma (14%) and hemangioblastoma (2%). 12 (24%) had a known diabetes diagnosis. Forty-two (84%) had an operation (biopsy (30%), partial (18%) or full debulking (16%). 82% of patients were exposed to dexamethasone at some point during their neurosurgical or oncological treatment. Initial doses varied but 36% were placed on 8mg twice daily. Steroid-induced hyperglycaemia occurred in 8 (16% of the cohort) with admission to hospital as a consequence in half of these cases, of whom two were newly diagnosed diabetes patients. HbA1c testing prior to or during treatment occurred in 16 (32%) patients. In the second cohort, All 15 patients (100%) had HbA1c testing with 5 (33%) patients diagnosed with diabetes or at risk of diabetes. Diabetic team advice was sought and recommended blood glucose testing in all these patients with oral hypoglycaemic and/or insulin dose modification in 3 (60%). There were no hyperglycaemic recordings or subsequent admissions to hospital in this cohort. Conclusions: We therefore recommend HbA1c testing and early diabetic team involvement in all primary brain tumour patients receiving radical radiotherapy.

Complications of Intralesional Steroids in Management of Infantile Hemangioma

Complications of Intralesional Steroids in Management of Infantile Hemangioma

Enfermedad de Still del adulto: características clínicas y pronóstico de una cohorte de pacientes colombianos

Introducción. La enfermedad de Still del adulto (ESA) es una condición médica poco frecuente que puede presentar complicaciones graves; sin embargo, aún no se conocen con claridad sus factores de riesgo, sus factores pronósticos, ni los aspectos asociados a las recaídas y a la refractariedad a esteroides en individuos con esta condición.Objetivos. Describir el comportamiento clínico de la ESA y determinar los factores asociados a la refractariedad a esteroides, a recaídas y a complicaciones en pacientes con esta enfermedad.Materiales y métodos. Estudio retrospectivo de cohortes que incluyó 45 pacientes diagnosticados con ESA entre enero de 2007 y enero de 2017 en 2 hospitales de referencia. Se presentan medidas de resumen. Se realizaron dos análisis de regresión logística, uno crudo y otro multivariado, para identificar posibles factores que expliquen la refractariedad a esteroides, las recaídas y el desarrollo de complicaciones en la población de estudio.Resultados. La edad promedio de los participantes fue 42.13±15.8 años. De los 45 pacientes incluidos, 23 (51.1%) eran mujeres, a 42 (93.3%) se le prescribieron esteroides, y, de estos, 13 (32%) se consideraron refractarios a esteroides. Se presentaron complicaciones en 12 (26.7%) individuos y su frecuencia fue mayor en pacientes con temperatura máxima >39°C. Finalmente, 33 (73.3%) pacientes tuvieron un seguimiento mayor a 1 año, de los cuales, 17 (37.8%) presentaron recaídas, las cuales fueron más frecuentes en individuos refractarios a esteroides o con esplenomegalia. Conclusión. Los pacientes que recibieron cualquier tipo de terapia biológica fueron más refractarios a esteroides; por su parte, la refractariedad a esteroides y la esplenomegalia se asociaron a un mayor número de recaídas, y la temperatura >39°C se asoció a al desarrollo de complicaciones.

Study of Chronic Obstructive Pulmonary Disease patients in Gamal Abd El-Nasser Hospital in 2017

Abstract Background COPD is characterized by non-remitting airflow limitation and persistent respiratory symptoms which is an enhanced inflammatory response to prolonged exposure to smoking or noxious gases or particles and manifested through chronic cough, effort dyspnea, expectoration and wheezing, symptoms that appears in context of airways hyper-responsiveness and may be partially reversible. Objective Assessment of COPD patients in Gamal Abd El Nasser Hospital during period from January 2017 to June 2017. Subjects and Methods This study was a cross sectional study that included 290 COPD patients recommended for spirometric assessment. The patients were classified into 2 groups: Outpatients and inpatients in the period from January 2017 to June 2017, they were subjected to full medical history, general and local examination, Pre and post bronchodilator spirometric study according to (GOLD,2017) and each patient will be subjected to the following questionnaire [Serial number, Name, Age, Sex, Occupation, Residence, Level of education, Smoking, Smoking index, Family history of COPD, Symptoms, Number and severity of exacerbation attacks in the last year, Number of Hospitalization during the last year, Vaccination status, Spirometry, Treatment prescribed by, Treatment, Inhalation therapy, Regulation of treatment, Non pharmacological therapy, Satisfaction of treatment, co morbidities, Complications, Outcome for inpatient] Results The study included 290 patients, 259 males and 31 females with age range of 29 _ 83 years, the majority of the studied cases were Current smoking but only 22.5% was ex-smoker. Mean FEV1% pred. Post-bronchodilator was 75.9± 16.9 in outpatients and mean FEV1% pred. Post – bronchodilator was 52.9 ± 13.4 in inpatient. The most common co morbidities in COPD patients were hypertension in 25% of cases. More than half of all studied cases had complications and the most frequent complication was Cor-pulmonale and respiratory Failure. In this study, Severity of COPD according to GOLD 2017 was 27.8% in mild stage, 34.2% in moderate stage, 35.8% in severe stage and 2.5% in very severe stage. Conclusion Spirometry had a great role in diagnosis of COPD and its differential diagnosis from asthma. Smoking is the major risk factors in developing COPD and this reflects on the disease occurrence and severity. Some of COPD patients refuse to use inhalers due to fear of addiction and incorrect method in using it. Inhaler steroids were preferred due to fear of systemic complications of steroids. There is great defect in vaccination and trials of quitting smoking as a non-pharmacological treatment for COPD patients.

Effect of Local versus Systemic Steroids in Treatment of Children with Otitis Media with Effusion

Abstract Background otitis media with effusion (OME) or glue ear is the collection of fluid behind the tympanic membrane without inflammatory signs present for 6 weeks. Aim of the Work comparing the effect of intra nasal versus systemic steroids in treatment of children with Otitis media with effusion as regard: Improvement of clinical symptoms and Audiological findings. Subjects and Methods this study is a prospective, case control study on the effects of intranasal versus systemic steroids on children with otitis media with effusion. This thesis study was conducted on 30 patients diagnosed according to clinical and audiological assessment recruited from otorhinolaryngology outpatient clinic Ain Shams university hospital from October 2017 to July 2018. An informed consent was obtained from each patient or control or their legal guardians before enrolment in the study. Results however, statistically there is no significant relation between the occurrence of complete resolution of OME and the route of administration of steroid (either intranasal or systemic), whatever the cause either allergic rhinitis or adenoid hypertrophy. So we can use either intranasal or systemic steroids in management of otitis media with effusion in children with either allergic rhinitis or adenoid hypertrophy or both. Conclusion both topical intranasal and oral steroids are effective adjunctive treatment for OME in children in the short term, without significant difference between the two methods, and thus oral steroid complications could be avoided using local steroid spray.

Intraorbital Steroid Injection for Active Thyroid Ophthalmopathy.

PurposeTo evaluate the effect of orbital steroid injections in patients with active thyroid ophthalmopathy resistant to or dependent on systemic steroids, or with complications related to systemic steroid use.MethodsThis prospective non-comparative case series includes 31 eyes of 17 patients with active thyroid ophthalmopathy and clinical activity score (CAS) of 3 or more, without compressive optic neuropathy or overt exposure keratopathy. All subjects had a history of previous systemic steroid use (with steroid resistance or dependence) or had developed complications related to steroids. A combination of steroids including triamcinolone acetonide 20 mg and dexamethasone 4 mg was injected in the upper and lower retroseptal orbital spaces three or four times at one-month intervals. The patients were examined periodically after each injection and at least three months after the last injection.ResultsMean pre-injection CAS was 5.2 1.3 which was improved to 1.6 1 after the fourth injection (P 0.001). Upper and lower lid retraction improved in 100% and 68.2% of the affected eyes, respectively. Strabismus completely resolved in one of five affected patients and the most significant improvement was observed in supraduction. Mean improvement in exophthalmos was 1.2 1.1 mm. Visual acuity did not significantly change after the injections. Eyelid ecchymosis and/or subconjunctival hemorrhage was observed in 7.1% and intraocular pressure rise occurred in 8.8% of eyes.ConclusionOrbital steroid injections can be used for the treatment of active thyroid ophthalmopathy when the patient is resistant to or dependent on systemic steroids or has developed complications of systemic steroids.

Intranasal versus systemic corticosteroids in treatment of otitis media with effusion in the presence or absence of adenoid hypertrophy in children

BackgroundOtitis media with effusion (OME) is defined as the presence of fluid in the middle ear without signs or symptoms of acute infection. The condition is common and affects ~90% of children before school age, who develop an average of four episodes of OME per year, most often between the ages of 6 months and 4 years.AimThe aim of this study was to investigate the role of systemic versus local corticosteroids in treatment of OME in the presence or the absence adenoid hypertrophy in children.Patients and methodsIn our study, 60 children who fulfilled the inclusion criteria were divided into two equal groups: group A included children with OME with adenoidal hypertrophy and group B included children with OME without adenoidal hypertrophy. Then, each group was subdivided into two groups, where one received topical intranasal steroids (A1 and B1), and the other one received oral steroids (A2 and B2). Tympanograms were done for all patients every 2 weeks.ResultsThe final result is that both topical intranasal and systemic steroids are effective in the treatment of OME in children, without significant difference between the two methods, so oral steroid complications could be avoided by using local steroid spray, and the effectiveness of steroids (oral or topical) in treatment of OME is better in absence of adenoidal hypertrophy than in the presence of adenoidal hypertrophy.ConclusionBoth topical intranasal and oral steroids are effective adjunctive treatment for OME in children in the short term.

Periodically repeated rituximab administrations in children with refractory nephrotic syndrome: 2-year multicenter observational study.

Rituximab (RTX) is effective in maintaining remission in patients with nephrotic syndrome (NS), but a standard protocol of RTX administration has not been established. This study was a 2-year multicenter observational study, in which consistent treatments and evaluations were performed. We enrolled pediatric patients with refractory NS between January 2015 and December 2015. RTX infusion was performed four times at 6-month intervals, followed by mizoribine pulse therapy with early discontinuation of calcineurin inhibitor (CNI). Primary endpoints were the relapse-free survival rate and the number of relapses after RTX administration. Secondary endpoints were changes in side effects associated with long-term steroid administration. Twenty-two patients were analyzed. The relapse-free survival rate at 1year and 2years was 50 and 46%, respectively. Twenty-one patients accomplished our protocol and the frequency of relapse was reduced under the discontinuation of CNI. Although two patients were diagnosed with frequent relapse and/or steroid dependency during the observation period, the frequency of relapse decreased with each rituximab dose. Statistically significant improvements in all steroid complications were observed in the final examination, but no significant improvements were observed from 1 to 2years after RTX administration. One patient had agranulocytosis, and three patients showed electrocardiographic abnormalities. Our protocol was useful and safe for refractory NS. However, RTX administration four times might have been excessive in patients who had no relapse by 1year after the initial RTX administration. Further investigation of the most appropriate method of RTX administration is required.

Delayed Cerebral Injury in Adults With Bacterial Meningitis: A Novel Complication of Adjunctive Steroids?

To report the prevalence of delayed cerebral injury in adults with bacterial meningitis and explore its association with adjunctive steroids. Retrospective analysis of adults with bacterial meningitis between 2005 and 2016. Ten hospitals in the Greater Houston area. Consecutive subjects with culture proven community-acquired bacterial meningitis. Subjects were categorized as receiving or not adjunctive steroids within 4 hours. A total of 120 patients were identified who were admitted with community-acquired bacterial meningitis. Delayed cerebral injury was seen in five of 120 patients (4.1%); all five patients had fever and abnormal neurologic examinations. Adjunctive steroids within 4 hours were more likely given to those with delayed cerebral injury (5/5,100% vs 43/115, 37.5%; p = 0.01). Of the patients who developed delayed cerebral injury, three had Streptococcus pneumoniae, one had methicillin-resistant Staphylococcus aureus, and one had Listeria monocytogenes isolated. We observed an adverse clinical outcome as defined by the Glasgow Outcome Scale in four of the five patients (80%). Delayed cerebral injury occurred in 4.1% of adults with bacterial meningitis, and it was associated with the use of adjunctive steroids. Future studies should explore the etiology and prevention of this devastating complication.

Diffuse neonatal hemangiomatosis presenting as congestive heart failure.

Diffuse neonatal hemangiomatosis is a rare condition with a very high mortality rate if left untreated. We report a neonate having around 490 cutaneous and multiple diffuse liver hemangiomas presenting as congestive heart failure. Prompt treatment was instituted with decongestive drugs and prednisolone for anticipated life threatening complications due to hepatic hemangiomas. Propranolol was added later as it is known to precipitate congestive failure and also to avoid long-term complications of steroids. The child responded well. However, there is no consensus regarding the initial line of management, which needs to be individualized keeping in mind the efficacy, long-term side effects of the drug and the clinical presentation.

Glucocorticoids Induced End Organs Damage in Patients with Systemic Lupus Erythematosus

Background: Systemic lupus erythematosus (SLE) is a systemic autoimmune disease that affects multiple organs and requires long term treatment with GCs. GC-related end organ damage in SLE appears in the form of: osteoporosis, Avascular Necrosis (AVN), cataracts, diabetes (DM) and cardiovascular disease. Aim of the work: the present work was to assess the prevalence of the complications in SLE patients who were treated with GCs for long periods and with moderate to severe cumulative steroid doses. Patients and Methods: This study was done on 50 SLE patients who fulfilled the SLICC criteria for diagnosis of SLE. All patients subjected to full history taking, clinical examination, slit-lamp examination to assess cataract, laboratory investigations (ESR, CRP, FBS, 2-H PP, CBC, C3, C4 and anti-dsDNA), DEXA scan, MRI scan (when needed), SLEDAI score and SLICC score assessments. All data were collected, tabulated and statistically analyzed. Results: Regarding the frequency of steroid induced complications, 38% were osteopenic, while 18% were osteoporotic patients. 10% had AVN. 18% had cataract. 14% had DM. There was very strong relationship between steroid duration and the frequency of DM and cataract. But in osteopenia, osteoporosis and AVN, there were weak relationship regarding steroid duration. There was very strong relationship between cumulative steroid dose and the frequency of DM, cataract, osteoporosis and AVN. There was no relationship between age and osteoporosis and AVN but in cataract and DM, there was strong relationship. There was no relationship between sex and complications (DM, cataract, osteopenia, osteoporosis and AVN). There was no relationship between disease activity (measured by SLEDAI score) and frequency of steroid complications (DM, cataract, osteopenia, osteoporosis and AVN). There was strong relationship between end organ damage (measured by SLICC damage index) and frequency of steroid complications (DM, cataract, osteoporosis and AVN). Conclusion: Steroid intake (duration and dose) were major risk factors for developing end organ damage in SLE patients.

Ignored Complication of Steroids in an Ankylosing Spondylitis Case: Psychotic Depression

Ignored Complication of Steroids in an Ankylosing Spondylitis Case: Psychotic Depression

Polymer-induced central nervous system complications following vascular procedures: spectrum of iatrogenic injuries and review of outcomes

Polymer substances are commonly applied as surface coatings on endovascular catheters and vascular devices. Adverse effects related to their use have been reported, although the overall clinical significance and appropriate methods of detection of these complications have been unclear. In this analysis, we systematically reviewed clinical and diagnostic features in 32 patients (age, 36-87years; mean, 59years) in whom intracranial polymer reactions were documented following vascular interventions. Associated neuroradiologic and neuropathologic findings were variable and included cerebral vasculitis or vasculopathy (63%), abscess or granuloma formation (38%), ischemic infarcts (28%), parenchymal hematomas (28%), white matter change (25%), and/or chemical meningitis (22%). Location(s) of polymer reactions varied and included sites adjacent to and/or downstream from instrument insertion or implantation. Presenting clinical signs included focal neurologic deficits (41%), headache (22%), constitutional symptoms (19%), meningitis (16%), seizure and/or involuntary movements (9%), coma (6%), and syncope (3%). Adverse outcomes included stroke (31%), death (28%), delayed communicating hydrocephalus (9%), steroid dependency (9%), steroid complications (6%), and cerebral volume loss (3%). In some cases, these complications necessitated increased cost and length of medical care. In this review, we highlight the diverse features of polymer-induced reactions involving the central nervous system and summarize distinct diagnostic patterns that may enable earlier premortem detection of these lesions in the postprocedural clinical setting. Further work in this area is necessary to identify additional etiologic, preventative and therapeutic strategies. These data have potentially broad implications pertaining to the safety, efficacy, standards of use, storage, manufacturing, and regulation of new and emerging vascular devices and polymer nanotechnologies.

Collaboration in the presence of cerebral edema: The complications of steroids.

Background:Brain tumor patients often present with neurological changes in the presence of cerebral edema. High-dose dexamethasone is often required for symptom management in brain tumor patients. There are limitations in the foundational research that support the recommendations for appropriate prescribing of dexamethasone. Understanding these limitations can help prescribers and care teams collaborate to better manage this unique patient population as well as identify areas for further research.Methods:Evidence-based clinical practice guidelines for the management of adult brain tumor patients were reviewed from several certifying organizations. A complex database search and literature review was completed regarding relevant evidence used within these guidelines and for any supporting literature. The search was limited to MEDLINE, Cumulative Index to Nursing and Allied Health, Cochrane Library, and the National Guideline Clearinghouse using keywords. Each selected evidence-based guideline underwent appraisal using the Johns Hopkins Evidence-based Practice Model.Results:All clinical practice guidelines identified recommendations for appropriate dosing and tapering of dexamethasone. The management of steroid-induced side effects was addressed in two of the reviewed guidelines. Only one guideline identified specific nursing interventions for monitoring steroid-related side effects. No guideline addressed interval timing of provider or nursing-based interventions as well as the role of collaboration between provider and nurse in monitoring for steroid toxicities.Conclusions:More high-quality, well-controlled studies are needed around dexamethasone dosing for the management of cerebral edema. Clinical practice guidelines need to encompass both the prescriber and nursing-based interventions. Collaboration between disciplines is a necessity when monitoring and managing steroid-induced toxicities in brain tumor patients. Future evidence-based guidelines need recommendations for appropriate interval screening tests and quantifiable tools needed to aid in monitoring steroid-induced complications.

Sustained-release steroids for the treatment of diabetic macular edema.

Glucocorticoids have been used for decades in the treatment of ocular disorders via topical, periocular, and more recently intravitreal routes. However, their exact mechanisms of action on ocular tissues remain imperfectly understood. Fortunately, two recently approved intravitreal sustained-release drug delivery systems have opened new perspectives for these very potent drugs. To date, among other retinal conditions, their label includes diabetic macular edema, for which a long-lasting therapeutic effect has been demonstrated both morphologically and functionally in several randomized clinical trials. The rate of ocular complications of intravitreal sustained-release steroids, mainly cataract formation and intraocular pressure elevation, is higher than with anti-vascular endothelial growth factor agents. Yet, a better understanding of the mechanisms underlying these adverse effects and the search for the minimal efficient dose should help optimize their therapeutic window.

Corticosteroid therapy in regressive autism: Preliminary findings from a retrospective study.

Some children with autism spectrum disorders (ASD; 15% to 30% of patients) show a significant and persistent regression in speech and social function during early childhood. There are no established treatments for the regressive symptoms. However, there are some known causes of this type of regression, such as Rett syndrome and Landau-Kleffner syndrome (LKS). In LKS, steroids have been used as a treatment. Some evidence suggests an autoimmune contribution to the pathophysiology of autism (Chez MG, Guido-Estrada N: Immune therapy in autism: historical experience and future directions with immunomodulatory therapy. Neurotherapeutics 2010, 7:293–301, Wasilewska J, Kaczmarski M, Stasiak-Barmuta A, Tobolczyk J, Kowalewska E: Low serum IgA and increased expression of CD23 on B lymphocytes in peripheral blood in children with regressive autism aged 3-6 years old. Arch Med Sci 2012, 8:324–331, Stefanatos G: Changing perspectives on Landau-Kleffner syndrome. Clin Neuropsychol 2011, 25:963–988), raising the possibility that steroids might be a useful therapy for regression in ASD. A retrospective study published in BMC Neurology by Duffy et al. (Duffy, et al: Corticosteroid therapy in regressive autism: A retrospective study of effects on the Frequency Modulated Auditory Evoked Response (FMAER), language, and behavior. BMC Neurol 2014, 14:70) reviewed 20 steroid treated R-ASD (STAR) patients and 24 ASD control patients not treated with steroids (NSA). Improvements in clinical function and in a neurophysiological biomarker were seen in the steroid-treated children pre- to post-prednisolone treatment. This research provides a rationale for a randomized trial with steroid therapy to determine the longer term benefits and complications of steroids in this population.Please see related article http://www.biomedcentral.com/1471-2377/14/70/abstract.

Temporal arteritis.

Temporal or giant cell arteritis is an inflammation of medium and small extracranial vessels that may result in ocular ischemia, an aortitis followed by aortic dissection and peripheral limb ischemia. It should be considered a medical emergency due to the seriousness of end organ damage, in particular visual symptoms. While the presentation may be nonspecific, the presence of a tender temporal artery mandates a temporal artery biopsy. High-dose steroids should be begun the moment the diagnosis is considered and only withdrawn once it has been excluded. A gradual tapering of the steroid dose should occur over at least 1 year, with the consideration of the use of steroid-sparing agents if iatrogenic steroid complications occur. Careful monitoring of the response both clinically as well as with serial inflammatory markers is required.

Monoclonal Anti-TNF-α Antibodies for Severe Steroid-Dependent Asthma: A Case Series

Refractory asthma represents an important condition, with considerable morbidity and mortality. Tumor necrosis factor α (TNF-α) is a potential target for treatment of severe asthma. However, controlled studies have shown controversial results and the risk-benefit profile of TNF-blocking agents is still debated. To describe the effect of infliximab on asthma control in patients with severe, uncontrolled, steroid-dependent asthma. From 2007 to 2010, 7 patients received infliximab in our center. All had severe refractory asthma, with frequent severe exacerbations and hospitalizations in the intensive care unit despite maximal inhaled treatment, daily oral steroids and omalizumab treatment. Asthma control improved in the 6 patients who received infliximab for at least 3 months. Oral steroids could be stopped in 4 and the frequency of exacerbations and hospitalizations was greatly reduced, especially for the 3 patients with brittle asthma. Two patients showed severe adverse effects (bacterial pneumonia and extension of spreading melanoma). Three patients have received infliximab for more than 2 years, with good tolerance. This case series suggests that anti-TNF-α drugs may improve the condition of a subgroup of patients with severe steroid-refractory asthma, with a favourable risk-benefit profile for most, considering asthma severity, occurrence of life-threatening exacerbations and complications of long-term oral steroids. Specific controlled trials of this subgroup are warranted.

Mycobacterium fortuitum skin infection as a complication of anabolic steroids: a rare case report

Mycobacterium fortuitum is a rare cause of recurrent skin abscesses in an immunocompetent person. We report the case of a 37-year-old man presenting with multiple recurrent non-healing skin abscesses. Culture of the abscess wall yielded growth of M fortuitum. In our case, we highlight the association of anabolic steroids with non-tuberculous mycobacterial skin abscesses that fail to resolve despite repeated drainage.