Steroid Withdrawal Research Articles

Adrenal Insufficiency in Patients with Corticosteroid-Refractory Cerebral Radiation Necrosis Treated with Bevacizumab.

Cerebral radiation necrosis is a common complication of the radiotherapy of brain tumours that can cause significant mortality. Corticosteroids are the standard of care, but their efficacy is limited and the consequences of long-term steroid therapy are problematic, including the risk of adrenal insufficiency (AI). Off-label treatment with the vascular endothelial growth factor A antibody bevacizumab is highly effective in steroid-resistant radiation necrosis. Both the preservation of neural tissue integrity and the cessation of steroid therapy are key goals of bevacizumab treatment. However, the withdrawal of steroids may be impossible in patients who develop AI. In order to elucidate the frequency of AI in patients with cerebral radiation necrosis after treatment with corticosteroids and bevacizumab, we performed a retrospective study at our institution’s brain tumour centre. We obtained data on the tumour histology, age, duration and maximum dose of dexamethasone, radiologic response to bevacizumab, serum cortisol, and the need for hydrocortisone substitution for AI. We identified 17 patients with cerebral radiation necrosis who had received treatment with bevacizumab and had at least one available cortisol analysis. Fifteen patients (88%) had a radiologic response to bevacizumab. Five of the 17 patients (29%) fulfilled criteria for AI and required hormone substitution. Age, duration of dexamethasone treatment, and time since radiation were not statistically associated with the development of AI. In summary, despite the highly effective treatment of cerebral radiation necrosis with bevacizumab, steroids could yet not be discontinued due to the development of AI in roughly one-third of patients. Vigilance to spot the clinical and laboratory signs of AI and appropriate testing and management are, therefore, mandated.

1199 Post-Operative Ileus in the Post-Kidney Transplant Setting

INTRODUCTION: Ileus is a known early complication following kidney transplant (KTx). There is limited data largely from case reports documenting the occurrence of ileus in KTx patients. Potential risk factors include post-operative setting, steroid withdrawal, or even peritoneal sclerosis in patients with a history of peritoneal dialysis (PD). The aim of this study is to assess inpatient prevalence and outcomes of ileus in the same admission as the KTx occurred. METHODS: Case-control study using the NIS 2012-2016. The ICD9-10CM procedural codes for KTx were used to identify all patients that underwent KTx during the same admission. None were excluded. Patients with associated ileus were identified using ICD9-10CM diagnostic codes. The primary outcome was determining the odds of ileus in post-KTx patients. Secondary outcomes were inpatient mortality, postoperative complications, resource utilization, length of hospital stay (LOS), total hospitalization charges and costs. Propensity score matching was used to create a matching population for gender, age and Charlson Comorbidity Index. Multivariate analysis were used to adjust for income in patients’ zip code, hospital region, location, size and teaching status. RESULTS: A total of 89,065 KTx patients were identified, of which 16,880 were propensity score matched for the selected covariates. The mean patient age was 50 years, and 40% were female. On multivariate analysis, the odds of ileus in the KTx cohort was 3.90 (P < 0.01) compared to patients who did not undergo KTx surgery. When patients that underwent KTx and developed ileus during the admission, they had greater adjusted odds of shock, TPN, AKI, multi-organ failure, post-op infection, Deep Vein Thrombosis, Pulmonary Embolism, and bleeding compared to patients with no KTx. In addition, those who developed ileus had greater hospitals costs, charges, and length of stay (LOS) (Table 1). CONCLUSION: Patients undergoing kidney transplant are more likely to develop ileus than patients who did not have kidney transplant surgery, confirming known reports documenting ileus in the early post-operative period. This cohort of patients who developed ileus following transplant have greater odds of post-operative complications, as well as increased morbidity, resource utilization and economic burden. Future studies should focus on elucidating the etiology of ileus following kidney transplant, as well as associated factors, and creating strategies to address it.

Everolimus in de novo kidney transplant recipients participating in the Eurotransplant senior program: Results of a prospective randomized multicenter study (SENATOR).

Early conversion to everolimus was assessed in kidney transplant recipients participating in the Eurotransplant Senior Program (ESP), a population in whom data are lacking. The SENATOR multicenter study enrolled 207 kidney transplant recipients undergoing steroid withdrawal at week 2 post-transplant (ClinicalTrials.gov [NCT00956293]). At week 7, patients were randomized (1:2 ratio) to continue the previous calcineurin inhibitor (CNI)-based regimen with mycophenolic acid (MPA) and cyclosporine or switch to a CNI-free regimen with MPA, everolimus (5–10 ng/mL) and basiliximab at weeks 7 and 12, then followed for 18 weeks to month 6 post-transplant. The primary endpoint was estimated GFR (eGFR). At week 7, 77/207 (37.2%) patients were randomized (53 everolimus, 24 control). At month 6, eGFR was comparable: 36.5±10.8ml/min with everolimus versus 42.0±13.0ml/min in the control group (p = 0.784). Discontinuation due to adverse events occurred in 27.8% of everolimus-treated patients and 0.0% of control patients (p = 0005). Efficacy profiles showed no difference. In conclusion, eGFR, safety and efficacy outcomes at month 6 post-transplant showed no difference between groups. The everolimus group experienced a higher rate of discontinuation due to adverse events. However, the high rate of non-randomization is highly relevant, indicating this to be a somewhat unstable patient population regardless of treatment.

Low-dose Rituximab and Thymoglobulin Induction With Steroid-free Maintenance Immunosuppression and Protocol Biopsies Improves Long-term Patient and Graft Survival After Kidney Transplantation: Survival and Safety Outcomes in More Than 1100 Patients From a Single Center.

Background.Steroid-free maintenance immunosuppression after kidney transplantation provides acceptable patient and graft survival and minimizes steroid-associated side effects among recipients with a low immunological risk. However, the long-term outcomes of such protocols, incorporating low-dose rituximab and thymoglobulin induction along with protocol biopsies, in non-European populations remains underreported.Methods.We retrospectively analyzed 1142 consecutive kidney transplantations conducted at our center from July 2005 to October 2017. Immunosuppression protocol included induction with thymoglobulin and low-dose preoperative rituximab. Maintenance immunosuppression consisted of tacrolimus and mycophenolate mofetil; prednisolone was discontinued on postoperative day 5. Protocol biopsies were carried out at 3 months and at 1, 5, and 10 years after transplantation—in addition to the indicated biopsies. The 12-year patient and graft survival and posttransplantation complications were studied.Results.The analysis of outcomes was conducted for 1111 transplant recipients. Patients (70.59%) remained steroid-free at 12 years after transplantation. The patient survival rates at 1, 5, and 12 years were 97.7%, 94.8%, and 92.4%, respectively. The corresponding graft survival rates were 97.2%, 90.9%, and 86.1%, respectively. Biopsy-proven acute rejection occurred in 12.7% of recipients, including 3.5% subclinical rejections. The cumulative incidence of graft loss was 6.56% at 12.3 years. The overall incidence of death was 5.3%.Conclusions.Steroid-free maintenance immunosuppression was associated with excellent long-term patient and graft survival rates and reduced incidence of prednisolone-related side effects, despite acceptable rejection rates. Low-dose rituximab with thymoglobulin induction with immediate steroid withdrawal and surveillance biopsies resulted in excellent long-term outcomes in our single-center experience.

Severe migraine-like headache as unique symptom of steroid withdrawal syndrome betamethasone-induced in lumbar disc herniation

Severe migraine-like headache as unique symptom of steroid withdrawal syndrome betamethasone-induced in lumbar disc herniation

Use of HCV Ab+/NAT- donors in HCV naïve renal transplant recipients to expand the kidney donor pool.

Hepatitis C (HCV) disease transmission from the use of HCV antibody-positive and HCV nucleic acid test-negative (HCV Ab+/NAT-) kidneys have been anecdotally reported to be absent. We prospectively analyzed kidney transplant (KT) outcomes from HCV Ab+/NAT- donors to HCV naïve recipients under T-cell depleting early steroid withdrawal immunosuppression. Allografts from 40 HCV Ab+/NAT- donors were transplanted to 52 HCV Ab- recipients between July 2016 and February 2018. Thirty-three (82.5%) of donors met Public Health Service (PHS) increased risk criteria. De novo HCV infection was detected at 3months post-KT in one recipient (1.9%). This was a case of transmission from a HCV Ab+ NAT+ donor with an initial false-negative NAT completed using sample collected on donor hospital admission (day 2). At the time of HCV diagnosis, a stored donor sample collected during procurement (day 4) was tested and resulted NAT-positive. Subsequently, sustained virologic response (SVR) was achieved with 12weeks of glecaprevir/pibrentasvir. One death with functioning graft at 261days post-KT was determined not related to HCV or donor factors. This experience provides evidence of a low transmission rate of HCV from HCV Ab+/ NAT- kidney donors, thereby arguing for increasing utilization.

Simultaneous Liver-Kidney Transplant: Long-Term Management (Steroid Withdrawal and Safety Net Patients).

Simultaneous Liver-Kidney Transplant: Long-Term Management (Steroid Withdrawal and Safety Net Patients).

Clinical analysis of 9 patients with transplant-related thrombotic microangiopathy

Objective: To analyze the clinical features, efficacy and outcomes in patients with transplantation associated thrombotic microangiopathy (TA-TMA). Methods: The clinical data of 9 patients who developed TA-TMA after allogeneic hematopoietic stem cell transplantation (allo-HSCT) were retrospectively analyzed from January 2011 to August 2018 in Affiliated Tumor Hospital of Zhengzhou University. Results: There were 6 male and 3 female patiens with a median age of 31 (12-38) years. The median time from transplantation to TA-TMA was 76 (24-155) days. The baseline blood and biochemical parameters at diagnosis of TA-TMA included median hemoglobin (Hb) 66 (58-77) g/L,platelet (PLT) count 22 (4-38) × 10(9)/L,serum lactic dehydrogenase (LDH) 655 (305-4 238) U/L,blood urine nitrogen (BUN) level 15.9 (4.8-26.2) mmol/L,blood creatinine (Cr) level 118 (24-380) μmol/L. The proportion of median peripheral blood schistocytes was 2.6%(1.2%-9%). All patients had positive urinary occult blood tests,and urinary protein was seen in 4 patients. Three patients had mental symptoms. Coombs tests were all negative. The main treatments of TA-TMA composed of reduction and withdrawal of calcineurin inhibitor,steroids and plasma exchange. Response was seen in 4 patients. Patients who did not response to the treatment had a higher proportion of schistocytes,more severe acute graft-versus-host disease (aGVHD),more elevated serum LDH and other transplant-related complications. Conclusions: TA-TMA after allo-HSCT is a serious complication with high mortality rate. The proportion of schistocytes in peripheral blood, serum LDH level and comorbidities are prognostic factors of clinical outcome.

Peripheral blood lymphocyte subsets change after steroid withdrawal in renal allograft recipients: a prospective study

Several studies have assessed clinical outcomes after steroid withdrawal (SW) in kidney transplant (KT) recipients, but little is known about its potential impact on lymphocyte subpopulations. We designed a prospective study to evaluate the long-term impact of SW in 19 KT recipients compared to 16 KT recipients without changes in immunosuppression (steroid maintenance, SM). We assessed renal function, presence of HLA antibodies and peripheral blood lymphocyte subsets at time of inclusion, and 3, 12 and 24 months later. The immunophenotype of 20 healthy subjects was also analyzed. Serum creatinine and proteinuria remained stable in SW and SM patients. SW did not associate with generation of de novo donor-specific antibodies. SW patients showed decreases in T-lymphocytes (p < 0.001), and in the CD4+ T cell subpopulation (p = 0.046). The proportion of B-lymphocytes (p = 0.017), and both naïve and transitional B cells increased compared to SM patients (p < 0.001). Changes in B cell subsets were detected 3 months after SW and persisted for 24 months. No changes were observed in NK cells related to steroid withdrawal. SW patients displayed significant changes in peripheral T and B cell subsets, transitioning to the phenotype detected in healthy subjects. This may be considered as a maintained positive effect of SW previously unnoticed.

Management of chronic obstructive pulmonary disease patients quitting smoking: optimization the basic therapy

The aim of this study was to investigate effects of stepping down the dose of inhaled steroid (ICS) or ICS withdrawal in patients with chronic obstructive pulmonary disease (COPD) treated with an adequate bronchodilating therapy and quitting smoking. Methods. The study was performed in real clinical settings. Patients with COPD (n = 41) involved in educational smoking cessation program were followed for 9 months in outpatient settings. Smoking cessation program included varenicline, adequate physical activity, nutritional counseling and bronchodilating therapy; one of the aims of the treatment was ICS dose reduction or complete withdrawal of ICS. Results. Long-acting beta-2-agonist (LABA) indacaterol and dual bronchodilators (indacaterol/glycopyrronium or indacaterol/tiotropium) were effective in patients with COPD quitting tobacco smoking. ICS dose was reduced more quickly in patients treated with indacaterol or dual bronchodilators compared to those treated with formoterol. Quitting smoking was associated with improvement in CAT score and reduction in COPD exacerbation rate. Conclusion. Treatment with indacaterol or indacaterol/glycopyrronium combination was associated with more rapid and safe stepping down the dose of ICS or ICS withdrawal in COPD patients quitting tobacco smoking compared to those treated with formoterol.

Steroid withdrawal or avoidance is safe in high-risk kidney transplants: A systematic review and meta-analysis.

The present study is aimed to assess the safety and efficacy of steroid withdrawal or avoidance (SWA) in high-risk kidney transplant (HRKT). We performed a systematic review of the literature and pooled analysis of the available data concerning SWA following HRKT. HRKT is associated with patients undergoing repeat kidney transplantation, in African American recipients, or in patients with panel-reactive antibody levels >20%. Seven cohort studies and one randomized controlled trial, involving a total of 22 075 patients, were included. Pooled analysis to estimate the risk ratio (RR) and 95% confidence interval (CI) demonstrated comparable graft loss (RR = 0.91, 95% CI 0.76-1.09) between the SWA and corticosteroid maintenance groups, but with reduced mortality in the SWA group (RR = 0.90, 95% CI 0.84-0.98). A subanalysis suggested that SWA was not associated with increased graft loss in patients undergoing steroid withdrawal within 1 week of transplantation, in African American recipients, or in patients with follow-up >5 years. Additionally, SWA was associated with reduced death in those undergoing withdrawal within 1 week (RR = 0.90, 95% CI 0.84-0.98), in African Americans (RR = 0.90, 95% CI 0.83-0.98), and in those with follow-up extended to >5 years (RR = 0.91, 95% CI 0.84-0.98). SWA was not associated with an increased risk of acute rejection (RR = 0.95, 95% CI 0.75-1.21) or cytomegalovirus infection (RR = 1.86, 95% CI 1-3.47); however, it was associated with a reduced risk of posttransplant diabetes mellitus (RR = 0.60, 95% CI 0.37-0.97). SWA following HRKT is safe in terms of graft survival and rejection, and patients undergoing an SWA regimen had a lower risk of death and posttransplant diabetes mellitus. Future prospective studies are required to confirm these findings.

241 Secondary adrenal insufficiency in patients with systemic lupus erythematosus: active management of steroid withdrawal reduces risk of disease flare

241 Secondary adrenal insufficiency in patients with systemic lupus erythematosus: active management of steroid withdrawal reduces risk of disease flare

A propensity score matched analysis shows no adverse effect of early steroid withdrawal in non-diabetic kidney transplant recipients with and without glomerulonephritis

Recurrent glomerulonephritis (GN) is a common cause of graft loss after kidney transplantation. Steroids are critical to GN management before transplantation, but it is unclear if early steroid withdrawal after transplantation increases the risk of graft loss in patients with GN. Here USRDS data were used to examine the association of early steroid withdrawal with death censored graft loss and all cause graft loss in GN and non-GN adult, non-diabetic, non-sensitized first kidney-only transplant recipients from 1998-2012. A 2-stage propensity score-based matching algorithm was used to match early steroid withdrawal to steroid-maintained patients in the GN and non-GN groups. Multivariate Cox models using a robust variance estimator to account for matched pairs were used to examine the association of early steroid withdrawal with death censored or all cause graft loss in patients with (6388 patients each in early steroid withdrawal and steroid groups) or without GN (6590 each in early steroid withdrawal and steroid groups). Early steroid withdrawal was not associated with an increased risk of death censored or all cause graft loss in patients with or without GN. These findings were consistent across GN types and after accounting for transplant center. Thus, our findings support consideration of early steroid withdrawal in patients with GN at high risk of the adverse consequences of prolonged steroid exposure.

Clinical characteristics of myelin oligodendrocyte glycoprotein antibody neuromyelitis optica spectrum disorder

BackgroundSerological antibodies against myelin oligodendrocyte glycoprotein (MOG) are associated with a relapsing autoimmune demyelinating disease of the central nervous system. Initially identified in the context of acute disseminated encephalomyelitis, persistent seropositivity of MOG antibodies is now recognized as a variant of neuromyelitis optica spectrum disorder (NMOSD). ObjectivesThe aim of the study is to describe the epidemiological and clinical features of MOG antibody positive cases and compare our findings with those previously published. MethodsThis is a retrospective descriptive study of 23 patients with MOG antibody disease who were cared for at Johns Hopkins Hospital over the period from 2015 to 2018. MOG testing was done at Johns Hopkins using the cell based assay (CBA). We describe their epidemiological and clinical features. ResultsTwenty-three patients were included in the study with a female to male ratio of 2.3:1. The mean age of the cohort was 42.6 years, while the mean age at onset was 37 years. The most frequent initial presentation was optic neuritis, followed by ADEM-like encephalopathic clinical picture and transverse myelitis. Five patients showed a monophasic disease course while the rest experienced a relapsing phenotype. Nine patients (39%) experienced immediate relapses on withdrawal of steroids. conclusionsOur cohort showed clinical characteristics comparable with previously published reports of MOG antibody disease worldwide. Unique features of MOG antibody disease are: high frequency of optic neuritis attacks, good long term neurological recovery and sensitivity to steroid use and withdrawal.

Differential effects of corticosteroids and anti-TNF on tumor-specific immune responses: implications for the management of irAEs.

Up to 60% of patients treated with cancer immunotherapy develop severe or life threatening immune-related adverse events (irAEs). Immunosuppression with high dose corticosteroids, or tumor necrosis factor (TNF) antagonists in refractory cases, is the mainstay of treatment for irAEs. It is currently unknown what impact corticosteroids and anti-TNF have on the activity of antitumor T cells. In our study, the influence of clinically relevant doses of dexamethasone (corresponding to an oral dose of 10-125 mg prednisolone) and infliximab (anti-TNF) on the activation and killing ability of tumor-infiltrating lymphocytes (TILs) was tested in vitro. Overall, dexamethasone at low or intermediate/high doses impaired the activation (-46 and -62%, respectively) and tumor-killing ability (-48 and -53%, respectively) of tumor-specific TILs. In contrast, a standard clinical dose of infliximab only had a minor effect on T cell activation (-20%) and tumor killing (-10%). A 72-hr resting period after withdrawal of dexamethasone was sufficient to rescue the in vitro activity of TILs, while a short withdrawal did not result in a full rescue. In conclusion, clinically relevant doses of infliximab only had a minor influence on the activity of tumor-specific TILs in vitro, whereas even low doses of corticosteroids markedly impaired the antitumor activity of TILs. However, the activity of TILs could be restored after withdrawal of steroids. These data indirectly support steroid-sparing strategies and early initiation of anti-TNF therapy for the treatment of irAEs in immuno-oncology.

Pattern of steroid misuse in vernal keratoconjunctivitis resulting in steroid induced glaucoma and visual disability in Indian rural population: An important public health problem in pediatric age group.

Purpose:To know the pattern of presentations and management outcome of steroid induced glaucoma in vernal keratoconjunctivitis (VKC).Methods:Children of VKC using steroid with two of the following criteria were enrolled: Intraocular pressure (IOP) >21 mm Hg, glaucomatous optic disc and visual field defects. Misused topical steroids were classified in 4 groups; A- Highly potent drugs (dexamethasone, betamethasone), B- Moderate (prednisolone), C- Weak (loteprednol, fluorometholone), D- Unknown drugs. Active/conservative interventions were done to control IOP. Corrected distance visual acuity (CDVA), IOP, anterior segment and fundus examinations were noted. One-way ANOVA test and post hoc Tukey HSD test were used to compare the groups.Results:Out of 1423 VKC patients, 240 were using topical steroid without prescriptions. 92 eyes of 47 patients had steroid induced glaucoma. Hence prevalence of this complication was 3.30% in this study population. Mean age was 14.1 ± 3.8 years. Mean IOP was 38 ± 12 mm of Hg and mean vertical cup disc ratio was 0.67 ± 0.25. IOP was controlled by withdrawal of steroids (9 eyes), with antiglaucoma medications (27), trabeculectomy (57) and glaucoma drainage device (1). Mean CDVA at presentation was better in group C (0.23 log MAR). Mean IOP was highest in group A (43.1 mm Hg) followed by group D (40.5 mm Hg). At presentation 17 were blind (CDVA <3/60). Post treatment marginal improvement in CDVA was found (P = 0.46). However, statistically significantly improvement was noticed in IOP (P < 0.00001).Conclusion:Injudicious use of steroids leads to vision threatening complications like ocular hypertension and glaucoma in children of VKC. Weak steroids like loteprednol or fluorometholone should be used instead of higher potency drugs. Vision and IOP should be monitored fortnightly in children using topical steroids to detect steroid responders at the earliest.

Prospective nonrandomized study with early steroid withdrawal (Day 5) postrenal transplant in low immunological risk patients: A singlecenter experience at prince sultan military medical city Riyadh

Steroids remain an essential part of immunosuppressive therapy for renal transplant patients since the start of transplant era. Different immunosuppressive regimens are prescribed so as to minimize the side effects. The purpose of our study is to compare the outcome of early steroid withdrawal with steroid maintenance protocol. It is a prospective nonrandomized study. All patients that received renal transplants from January 2011 to December 2013 were included in the study. Early steroid withdrawal at day 5 was done in low immunological risk patients, and the results were compared with the steroid maintenance group, at one-year, posttransplant. Outcome measures included acute rejection (AR), slow graft function and delayed graft function (SGF and DGF), patient and graft survival, and new-onset diabetes after transplant (NODAT), dyslipidemia, hypertension, and obesity. A total of 249 patients were divided into two groups - 105 patients had early steroid withdrawal and 144 patients were maintained on steroid therapy. Outcome measures were compared one-year posttransplant. There was no significant difference in AR, patient and graft survival, creatinine level, and weight gain. However, a significant difference in systolic and diastolic blood pressure, lipid profile, NODAT, SGF, and DGF was found in the steroid group. Our study shows that early steroid withdrawal is a safe standard of care in low immunological risk patients.

Demystifying "Steroid Withdrawal" During Remission in Cushing's Disease: Is Mineralocorticoid Replacement the Answer?

Objective:To study renin-angiotensin-aldosterone axis status (RAAS) in patients of Cushing's disease (CD) at baseline and 6 weeks after curative trans-sphenoidal surgery and evaluate the role of mineralocorticoid replacement in the resolution of “steroid withdrawal syndrome” (SWS). Postoperative RAAS status had not been evaluated in previous studies, although aldosterone levels have been shown to be suppressed during medical therapy with pasireotide and cabergoline.Materials and Methods:This was a prospective, single-center study. Patients with CD, aged between 15–75 years, undergoing curative pituitary surgery were recruited. An 8 am and 11 pm cortisol and adrenocorticotropic hormone (ACTH) were measured at baseline. An 8 am cortisol was measured 6 weeks after surgery to demonstrate remission. Plasma-renin activity and plasma-aldosterone concentration were measured at baseline and 6 weeks after curative surgery.Results:A total of 14 patients (11 female, 3 male) were recruited initially, of these 8 patients completed the study. The plasma-renin activity was not suppressed at baseline and did not rise significantly after surgery (P = 0.717). However, plasma-aldosterone concentration was in the low-normal range at baseline and had risen significantly 6 weeks after surgery (P = 0.013). No difference was noted in subgroups with or without hypertension.Conclusion:Curative pituitary surgery leads to normalization of plasma-aldosterone concentration in patients with CD just 6 weeks after surgery. Hence, mineralocorticoid replacement may not prove beneficial in alleviating the “SWS” in postsurgical CD patients who have achieved remission.

Topical Steroid Withdrawal: A Case Series of 10 Children.

Concerns about topical steroid withdrawal are causing some patients to cease long-term topical corticosteroid therapy, however, little is known about the ensuing clinical outcomes. This qualitative case series studied 10 children whose parents stopped their chronic topical corticosteroid use and subsequently developed features typically reported in adults experiencing topical steroid withdrawal. Patients were seen in an Australian general practice between April 2014 and October 2018, with follow-up periods ranging from 18 months to 4 years. Symptoms were difficult initially for the children and their families, however, all ultimately improved. At the final review, 4 of the children had clear skin and another 4 had symptoms consistent with their original, pre-treatment atopic dermatitis. More research is required into long-term topical corticosteroid use and its discontinuation, including topical steroid withdrawal, particularly in the pediatric population.

Idiopathic intracranial hypertension as a cause of severe intractable headache in a patient with Systemic Lupus Erythematosus: A case report from Eastern Nepal

Correction: Unfortunately, several authors on this paper were omitted. Therefore, on 15th April 2019 the following authors were added to the paper: Mathew Ibrahim Amprayil, Rahul Taparia and Shailesh Mani Pokhrel. The editorial board apologises for this error.&#x0D; The common risk factors for Idiopathic intracranial hypertension are obesity, female gender, hypervitaminosis A, and steroid withdrawal. Even though Idiopathic intracranial hypertension is considered as a neuropsychiatric manifestation of Systemic lupus erythematosus, it is often missed by the physician as a cause of a headache in a patient with Systemic lupus erythematosus. We report a case of 21-year-old female who presented in our outpatient department with a history of a severe intractable progressive headache for a duration of four weeks and blurring of vision for five days who was later diagnosed as a case of idiopathic intracranial hypertension with Systemic lupus erythematosus. She recovered dramatically with the institution of steroid and acetazolamide therapy.