Systemic Glucocorticoids Research Articles

Efficacy and safety of intravenous glucocorticoid therapy for IgG4-related ophthalmic disease.

To evaluate and compare the efficacy and safety of intravenous (IV) glucocorticoid therapy with those of oral glucocorticoids as a first-line treatment for IgG4-related ophthalmic disease (IgG4-ROD). We retrospectively reviewed the medical records of patients who underwent systemic glucocorticoid therapy for biopsy-proven IgG4-ROD from June 2012 to June 2022. Glucocorticoids were given either oral prednisolone at an initial dose of 0.6 mg/kg/day for four weeks with subsequent tapering or once weekly IV methylprednisolone (500 mg for six weeks, then 250 mg for six weeks), according to the date of treatment. Clinicoserological features, initial response, relapse during follow-ups, cumulative doses of glucocorticoids, and adverse effects of glucocorticoids were compared for the IV and oral steroid groups. Sixty one eyes of 35 patients were evaluated over a median follow-up period of 32.9 months. The complete response rate was significantly higher in the IV steroid group (n = 30 eyes) than in the oral steroid group (n = 31 eyes) (66.7% vs. 38.7%, p = 0.041). Kaplan-Meier analysis showed that the 2-year relapse-free survival was 71.5% (95% confidence interval: 51.6-91.4) and 21.5% (95% confidence interval: 4.5-38.5) in the IV steroid and oral steroid group, respectively (p < 0.001). Although the cumulative dose of glucocorticoids was significantly higher in the IV steroid group than in the oral steroid group (7.8 g vs. 4.9 g, p = 0.012), systemic and ophthalmic adverse effects were not significantly different between the two groups throughout follow-ups (all p > 0.05). As a first-line treatment for IgG4-ROD, IV glucocorticoid therapy was well-tolerated, led to better clinical remission and more effectively prevented inflammatory relapse than oral steroids. Further research is needed to establish guidelines on dosage regimens.

Experience of using systemic glucocorticoids during reconvalescence of patients after a new coronavirus infection of moderate severity

Introduction. Part of the reconvalescents after new coronavirus infection (NCI), have residual respiratory structural and functional abnormalities.Aim. To evaluate the efficacy and safety of low-dose systemic glucocorticoids (SSG) in patients with respiratory symptoms and residual “fibrosis-like” changes in lung tissue after a moderately severe NCI with up to 50% lesion volume.Materials and methods. Reconvalescents with moderate NKI who had respiratory symptoms and residual fibrosis-like changes in lung tissue at the time of discharge were randomly divided into two groups: those receiving systemic glucocorticoids (n = 15) and those not (n = 27). Complaint assessment, 6-minute walk test (6-MHT), spirometry, and high-resolution computed tomography (HRT) were performed at baseline, 2, and 9 months later. The primary endpoint of the study was complete disappearance of pathological changes in the lungs according to CTVR. Secondary endpoints of the study were: disappearance of respiratory complaints, increase in the distance traveled in 6-MCG test, regression of functional ventilatory disturbances according to spirometry data.Results and discussion. In both groups by the 9th month of the study there was a significant positive dynamics: respiratory symptoms regressed, tolerance to physical activity improved, residual changes of lung tissue according to CTBPR decreased and in most cases completely disappeared. However, respiratory symptoms and residual changes in lung tissue remained in 9% of cases. Significant improvement of ventilatory lung function and exercise tolerance by the 9th month of follow-up was established in the systemic glucocorticoids group, with no adverse events detected.Conclusions. In the acute phase of moderate NKI, both spontaneous resolution of respiratory symptoms and residual lung tissue changes and their effective and safe resolution due to the use of systemic glucocorticoids can be assumed.

Chinese experts consensus statement: diagnosis and treatment of cystic fibrosis (2023)

Chinese experts consensus statement: diagnosis and treatment of cystic fibrosis (2023)

Efficacy of intratympanic or postauricular subperiosteal corticosteroid injection combined with systemic corticosteroid in the treatment of sudden sensorineural hearing loss: A prospective randomized study.

This study aimed to investigate the efficacy and safety of intratympanic or postauricular subperiosteal glucocorticoid injection combined with systemic glucocorticoid in the treatment of sudden sensorineural hearing loss (SSNHL). This study is a prospective randomized controlled study. This study included unilateral SSNHL patients who were hospitalized in our department between January 2020 and June 2021. Patients were randomly divided into three groups (groups A, B, and C). Patients in group A were treated with an intratympanic corticosteroid injection combined with systemic corticosteroid treatment, and patients in group B received a postauricular corticosteroid injection combined with systemic corticosteroid treatment. Patients in group C (control group) were treated with systemic corticosteroid alone. The case number of groups A, B, and C was 311, 375, and 369, respectively. There was no significant difference in gender distribution, the proportion of left and right affected ears, and the average interval from onset to treatment among the three groups (P > 0.05). However, there were significant differences in their average age, distribution of audiogram type, and hearing loss levels among them (P < 0.01). Our study shows that there was no significant difference in average hearing threshold improvement before and after treatment in the three groups (P > 0.05). Regarding the complications, in group A, 33 patients (10.6%) had a transient vertigo attack during tympanic injection, which lasted for ~1-3 min. In group B, 20 patients (6.43%) complained of pain at the injection site, which disappeared after 1-3 days. No other complications occurred in all the other patients. The addition of intratympanic or postauricular corticosteroid to systemic steroids did not result in a significant effect on hearing recovery in SSNHL. No obvious complications occur in SSNHL patients treated with intratympanic injection or postauricular injection of corticosteroid. [chictr.org.cn], registration number: ChiCTR2100048762.

Abstract 6308: Preclinical development of ABBV-319: a CD19-targeting glucocorticoid receptor modulator (GRM) agonist antibody-drug conjugate (ADC) for the treatment of B-cell malignancies

Abstract Introduction: Glucocorticoids are key components of standard-of-care treatment regimens (e.g., R-CHOP, Hyper-CVAD) for several B-cell malignancies. However, prolonged systemic glucocorticoid treatment results in glucocorticoid-associated adverse events and acquired resistance that limit its therapeutic potential. ABBV-319 is a novel CD19-targeting ADC engineered to reduce glucocorticoid-associated toxicity observed with systemic glucocorticoids while possessing three distinct mechanisms of action (MoA) to increase efficacy: 1) antibody-mediated delivery of GRM to activate glucocorticoid receptor (GR) induced cell death in cancer cells, 2) inhibition of CD19 signaling, and 3) enhanced Fc-mediated cancer cell killing via afucosylation of the antibody backbone. Results: We identified a GRM agonist that is 15 and 150 times more potent at driving GR transcriptional activation and cell death compared to clinical glucocorticoids dexamethasone and prednisolone, respectively. The conjugation of GRM agonist as the payload on ABBV-319 enables potent GRM-driven anti-cancer activity against malignant B-cell lines in vitro as well as in cell-line and patient derived xenograft (CDX and PDX) models in vivo. Remarkably, a single-dose of ABBV-319 induced sustained tumor regression and enhanced anti-tumor activity compared to repeat dosing of systemic glucocorticoids (e.g., prednisolone) at its maximum tolerated dose in mice. The CD19 monoclonal antibody (mAb) also reduced proliferation of a subset of B-cell malignant cell lines through inhibition of the PI3K/AKT pathway. Moreover, afucosylation of the CD19 mAb in ABBV-319 enhanced Fc-mediated antibody-dependent cellular cytotoxicity (ADCC), and this activity was maintained after conjugation with GRM payloads. ABBV-319 bound similarly to both V158 (high-affinity) and F158 (low-affinity) FcγRIIIa allotypes and mediated potent ADCC in co-culture assays with human peripheral blood mononuclear cells (PBMCs). Notably, ABBV-319 displayed superior efficacy compared to afucosylated CD19 mAb in human CD34+ hematopoietic stem cell-engrafted NSG-Tg(Hu-IL15) mice, demonstrating that the three MoA (GR-driven cell death, CD19 signaling inhibition, and ADCC) collectively contribute to anti-tumor activity in vivo. ABBV-319 also displayed on-target depletion of normal human B-cells but did not affect peripheral NK cell counts in mice. Furthermore, CITE-seq profiling revealed that ABBV-319 treatment of human PBMCs activated GRM-induced signature genes restricted to B-cells, demonstrating the specificity of CD19-mediated delivery of GRM. Conclusion: ABBV-319 has potent anti-tumor activity from three distinct MoA and exhibits safety improvements compared to systemic glucocorticoids, supporting its recent progression into Phase I clinical trial. Citation Format: Chewei Anderson Chang, Ethan Emberley, Aloma L. D'Souza, Weilong Zhao, Cormac Cosgrove, Axel Hernandez Jr, Anatol Oleksijew, Paul Ellis, Luis Rodriguez, Gail Bukofzer, David Peetz, Wissam Assaily, Raghuveer Singh Mali, Wei Liu, Danqing Xu, Gregory K. Potts, Shaun McLoughlin, Kimberley McCarthy, Zhaomei Zhang, Jos Campbell, Isabella Sturdevant, Gloria Zhang, Tyler Curran, Jon D. Williams, Erwin Boghaert, Milan Bruncko, Christopher C. Marvin, Adrian Hobson, Michael Mcpherson, Tamar Uziel, Marybeth Pysz, Xi Zhao, Alex Bankovich, Kevin J. Freise, Susan Morgan-Lappe, James W. Purcell. Preclinical development of ABBV-319: a CD19-targeting glucocorticoid receptor modulator (GRM) agonist antibody-drug conjugate (ADC) for the treatment of B-cell malignancies. [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 6308.

Rhinovirus, When Is It More Than Just a Cold? Rhinovirus as a Cause of Organizing Pneumonia in Two Patients With Hematological Cancer

Abstract Human rhinoviruses are pathogens that cause significant morbidity and economic strain from upper respiratory infections. Rhinovirus has also been associated with exacerbations of chronic lung disease. Less understood is the role of rhinovirus in organizing pneumonia (OP). Organizing pneumonia is a certain lung pattern of injury that occurs after injury to the pulmonary parenchyma, with infection being the most studied etiology. It typically presents with similar symptoms to pneumonia, and patients are often treated with antibiotics to lack of improvement. However, OP is more subacute in presentation, and the treatment, systemic glucocorticoids, differs from bacterial pneumonia. Recognition of rhinovirus as a significant pathogen in immunocompromised patients is important because it tends to cause more severe disease in this group. Here, we present a case series of 2 hematological malignancy patients with a long-standing rhinovirus infection and lung disease unresponsive to antibiotics, later found on biopsy to be OP. Both patients survived the infection, and both patients had documented rhinovirus shedding for greater than 9 months. Both patients had lymphoma and were being actively treated with a monoclonal antibody that targeted cluster of differentiation 20. Both patients reported fever and dyspnea. Both patients had multiple superimposed bacterial infections, with both patients eventually developing Pseudomonas aeruginosa pneumonia. In the immunocompromised, rhinovirus may cause morbidity through a primary infection, a secondary bacterial infection, or OP. Novel treatment strategies and increased awareness are needed not only for rhinovirus-induced OP but also for rhinovirus as an important pathogen in immunocompromised patients.

First do no harm: systemic glucocorticoids should not be used for the treatment of progressive IgA nephropathy

First do no harm: systemic glucocorticoids should not be used for the treatment of progressive IgA nephropathy

Management of contact dermatitis

AbstractAs a widespread disease, contact dermatitis affects all age groups with a high prevalence and incidence. In addition to a reduction in the quality of life, it causes considerable health and socioeconomic costs. Essentially, five subtypes can be distinguished, namely irritant contact dermatitis, phototoxic contact dermatitis, allergic contact dermatitis with its two special forms of hematogenous and aerogenous contact dermatitis, photoallergic contact dermatitis, and protein contact dermatitis. The diagnosis is based on a detailed history and clinical skin findings as well as the exposure-related performance of allergological in vivo and in vitro tests. Once the contact substance—irritant or allergen—has been identified, the key to therapeutic success lies in its strict avoidance. Symptomatic therapy of contact dermatitis should always be individualized and based on the stage of eczema. Topical glucocorticoids are considered first-line therapy for both irritant and allergic contact dermatitis. The always accompanying basic therapy with skin care products plays a central role for sustainable therapeutic success. Systemic therapy is considered when topical therapy is ineffective or not feasible. In this context, the short-term use of systemic glucocorticoids should be limited to extensive or clinically severe acute contact dermatitis and exacerbations of chronic contact dermatitis. The efficacy of the use of newer biologics and Janus kinase inhibitors in contact dermatitis is currently being evaluated in several clinical trials.

Changes in Clinical Activity, Serum Autoantibody Levels, and Chorioretinal Vessels After Systemic Glucocorticoid Therapy in Thyroid Eye Disease.

The aim of this study was to investigate changes in the Clinical Activity Score, serum thyroid-stimulating hormone receptor antibody and thyroid-stimulating immunoglobulin levels, chorioretinal blood vessels, and extraocular muscle thickness in patients with thyroid eye disease following systemic steroid treatment. This prospective observational study enrolled 57 patients with active thyroid eye disease who received systemic intravenous glucocorticoids for 12weeks. Demographics, clinical activity scores, optical coherence tomography images, and serum thyroid-stimulating immunoglobulin and thyroid-stimulating hormone receptor antibody levels were assessed at baseline, at 6 and 12weeks after intravenous (IV) GC therapy initiation, and 2months after IV GC therapy termination. The extraocular muscle thickness, choroidal thickness, and choroidal vascularity index were measured. The clinical activity scores showed a significant decrease. Serum thyroid-stimulating immunoglobulin levels dropped continuously for 2months. The thyroid-stimulating hormone receptor antibody level decreased until 12weeks after treatment but returned to within the normal range in 75% of patients after 77 and 126days, respectively. The choroidal thickness decreased at all time points. The thickness of the medial and inferior rectus muscles decreased at 2months after treatment. The clinical activity score decreased to < 3 points in 50% of patients after 78days. Intravenous glucocorticoid therapy improved the clinical activity score, chorioretinal blood flow, and extraocular muscle thickness. The serum autoantibody levels were normalized in patients with active thyroid eye disease 2 months after IV GC termination. The serum thyroid-stimulating immunoglobulin and thyroid-stimulating hormone receptor antibody levels correlated with restoration of chorioretinal capillary perfusion and improved clinical symptoms and muscle thickness. Non-invasive optical coherence tomography findings and serologic factors predict the response to intravenous glucocorticoid therapy.

A case of complete recovery in a hypereosinophilic dermatitis patient with dupilumab.

Hypereosinophilic dermatitis (HED) is a subtype of hypereosinophilic syndrome (HES). Glucocorticoids are preferred for treatment but carry substantial side effect profiles. Symptoms of HED may recur after systemic glucocorticoid tapering. As an interleukin-4 receptor (IL-4Rα) monoclonal antibody targeting interleukin-4 (IL-4) and interleukin-13 (IL-13), dupilumab might be an efficacious adjuvant therapy for HED. We report a young male diagnosed with HED who suffered from erythematous papules with pruritus for over five years. Once reducing the dosage of glucocorticoid was, his skin lesions relapsed. After using dupilumab, the patient's condition significantly improved with the glucocorticoid dosing decreased successfully. In conclusion, we report a new application of dupilumab in HED patients, especially withdifficulties in reducing the glucocorticoid dose.

Bad to the bones: prescribing of drugs for the prevention and treatment of osteoporosis in patients on chronic glucocorticoids.

This study aimed to identify a cohort of patients at risk for glucocorticoid-induced osteoporosis based on their prescribed glucocorticoid regimens and to quantify the proportion who were also prescribed osteoporosis pharmacologic treatment. The secondary objective was to recognize patient characteristics associated with receiving such treatment. A retrospective single-site cohort study used prescription order data to identify 7774 adults prescribed chronic glucocorticoids and measure the proportion also prescribed osteoporosis pharmacologic treatment. Of the total cohort, 1026/7774 (13.2%) had osteoporosis pharmacologic treatment prescribed. Of the subgroups prescribed a prednisone-equivalent of 5, 10, or 20mg per day or more for at least 180days, 584/4262 (13.7%), 153/1048 (14.6%), and 47/344 (13.7%) had treatment prescribed. Factors independently associated with osteoporosis pharmacologic treatment initiation included having osteoporosis or osteopenia on the problem list (OR = 4.45, 95% CI 3.70-5.34), history of dual-energy X-ray absorptiometry (DXA) screening (OR = 2.18, 95% CI 1.82-2.62), history of fracture (OR = 1.83, 95% CI 1.54-2.167), and longer duration of glucocorticoid use (OR = 1.33, 95% CI 1.10-1.59). The prescribing department was also a significant predictor of medication initiation, with cardiac transplant (OR = 6.04, 95% CI 3.97-9.17), oncology (OR = 4.11, OR 3.28-5.14), and lung transplant (OR = 1.51, 95% CI 1.08, 2.12) being positively correlated with this outcome, and nephrology (OR = 0.51, 95% CI 0.36-0.72) and kidney transplant (OR = 0.53, 95% CI 0.37, 0.75) being negatively correlated. Prescribing rate of osteoporosis pharmacologic treatment in patients using chronic glucocorticoids is low. Examining practices with higher prescribing rates may offer insight into improving protection against osteoporosis-induced fractures.

Effectiveness of a two-year tapered course of tocilizumab in patients with giant cell arteritis: A single-centre prospective study

ObjectiveTo evaluate the feasibility of tocilizumab tapering and withdrawal in patients with giant cell arteritis (GCA). MethodsGCA patients eligible for tocilizumab were prospectively enrolled. Tocilizumab was administered weekly for the first 12 months, every-other-week for an additional 12 months, then discontinued. Relapses on tocilizumab were managed with temporary increases in systemic glucocorticoids or addition of methotrexate. Primary outcome was relapse-free survival at month 6 after tocilizumab suspension. Relapse-free survival on tocilizumab, imaging response, and adverse events were evaluated. Results23 GCA patients were enrolled. Reasons for tocilizumab start were relapse (n = 14), persistence of activity (n = 5), or steroid-related adverse events (n = 4). At tocilizumab start, two patients were on methotrexate, which was maintained. Fourteen patients had extracranial vascular involvement on 18FDG-PET/CT. During the first 12 months, four patients (17%) had clinical relapse. At every-other-week tocilizumab start, all patients were in clinical remission, two patients had active vasculitis on 18FDG-PET/CT; two patients were on steroid therapy, and four patients were taking methotrexate. Two patients (9%) relapsed while on every-other-week tocilizumab. At tocilizumab suspension, no patient was on steroid therapy and no patient had signs of active vasculitis on 18FDG-PET/CT. In the 6 months after tocilizumab discontinuation, six patients (26%) relapsed. No new or unexpected safety findings were identified. ConclusionTocilizumab tapered over a two-year period was effective to induce and maintain remission in GCA. Relapses on tocilizumab were minor and responded to incremental changes in therapy. A significant proportion of patients relapsed in the 6 months after therapy suspension.

A rupioid rash.

A 72-year-old man presented for a thick hyperkeratotic skin rash on the shins that had erupted 7 months earlier after minimal local trauma (Fig. 1A, B). Topical treatments with glucocorticoids and antibiotics were ineffective, although a slight improvement was noted during summer. Additionally, low-grade fevers and an asymmetric oligoarthritis of the upper and lower limbs and dactylitis of the thumb and fourth toe on the left appeared over the last weeks. Mild non-specific onychodystrophy of the toes was found, whereas no inflammatory back pain or enthesitis was present. Plain radiographs did not reveal disease-specific deformities, erosions or osteo-proliferative lesions. Laboratory tests showed raised inflammatory markers (CRP: 17.7 mg/dl, ESR: 107 mm/h), leukopoenia (2.580/μL) and anaemia (haemoglobin: 10.3 g/dl). Differential diagnosis of the rash included crusted scabies, secondary syphilis, neutrophilic dermatoses, histoplasmosis and a hyperkeratotic psoriasis variant [1]. Skin biopsy revealed psoriasiform acanthosis, thick parakeratosis, dense neutrophilic infiltration and microabscess formation (Fig. 1C). Based on the type of musculoskeletal involvement and the skin histopathology, the patient was diagnosed with psoriatic arthritis with rupioid psoriasis. Treatment with medium-to-low dose systemic glucocorticoids and infliximab led to arthritis remission, skin (Fig. 1D) and laboratory improvement. Rupioid psoriasis (derived from the Greek word ρύπος = dirt) is a rare hyperkeratotic variant of psoriasis characterized by well-demarcated plaques with thick, dirty-appearing adherent crusts. It is associated with local treatment failure [2], psoriatic arthritis and male sex and it may present challenges in the diagnosis of patients with arthritis and systemic inflammation. Written informed consent has been obtained from the patient.

Cutaneous lichenoid drug eruptions: A narrative review evaluating demographics, clinical features and culprit medications.

Cutaneous lichenoid drug eruptions (LDE) are adverse drug reactions (ADR) characterized by symmetric, erythematous, violaceous papules reminiscent but rarely fully characteristic of lichen planus (LP). We aimed to analyse the literature describing cases of LDE within the last 20 years to provide additional insight into culprit drugs, typical latency to onset of the eruption, the spectrum of clinical presentations, severity and management. A literature search was conducted in MEDLINE between January 2000 and 27 January 2021. The keywords 'lichenoid drug rash' and 'lichenoid drug eruption' were used. Cases were included if LDE diagnosis was made, and culprit drugs were identified. A total of 323 cases with LDE were identified from 163 published case reports and studies. The mean patient age was 58.5 years (1month to 92 years), and 135 patients (41.8%) were female. Checkpoint inhibitors (CKI) were the most frequently reported culprit drugs (136 cases; 42.1%), followed by tyrosine kinase inhibitors (TKI) (39 cases; 12.0%) and anti-TNF-α-monoclonal antibodies (13 cases; 4.0%). The latency between initiation of the drug and manifestation was 15.7 weeks (range: 0.1-208 weeks). After discontinuing the culprit drug, the median time to resolution was 14.2 weeks (range: 0.71-416 weeks). One hundred thirty-six patients (42.1%) were treated with topical, and 54 patients (16.7%) with systemic glucocorticoids. Overall, we conclude that, albeit rare, LDE is challenging to diagnose ADR induced by mostly CKI, TKI, and biologics. Treatment modalities resemble that of lichen planus, and the culprit drugs had to be discontinued in only 26%, which is low compared with other types of adverse drug reactions. This is probably due to the low risk of aggravation (e.g. toxic epidermal necrolysis) if the drug is continued and the benefit/risk ratio favouring the drug, as is often the case in cancer therapy.

Successful treatment with rituximab and plasmapheresis of renal involvement of eosinophilic granulomatosis with polyangiitis

BackgroundEosinophilic granulomatosis with polyangiitis (EGPA) is a rare disorder characterized by asthma, eosinophilia, and systemic vasculitis. Renal involvement is not regarded as a prominent feature and the treatment is still under study.Case presentationA 68-year-old woman was admitted to our hospital because of fever, renal dysfunction, eosinophilia, and the presence of MPO-ANCA. Based on the renal pathological examination which showed extravascular eosinophilic-predominant inflammation and crescentic glomerulonephritis, EGPA was diagnosed. Considering the acute kidney injury, prominent eosinophilia, and strongly positive anti-MPO antibodies, pulse steroid therapy was administered, followed by intravenous rituximab. Plasmapheresis was also provided (9 sessions). The eosinophil count was normalized, and renal dysfunction was reversed. The patient no longer requires dialysis.ConclusionsRenal involvement of EGPA is rare, and consensus on its treatment is still lacking, because of a lack of large-scale randomized controlled trials. We treated our patient as a case with high severity. For patients with severe disease, the addition of cyclophosphamide to glucocorticoid therapy is commonly used. However, rituximab and plasmapheresis combined with systemic glucocorticoid therapy were found to be beneficial because the renal function and other clinical conditions were almost fully recovered. Thus, our treatment is highly effective against renal involvement of eosinophilic granulomatosis with polyangiitis.

Mycobacterium infection secondary to exogenous lipoid pneumonia caused by nasal drops: a case report and literature review

BackgroundExogenous lipoid pneumonia (ELP) is a rare disease and its diagnosis is often mistaken or delayed. Secondary infection with rapidly growing non-tuberculous mycobacteria is a rare complication of lipoid pneumonia.Case presentationA 38-year-old man presented with fever, cough, sputum, chest tightness, and shortness of breath. He had a 2-year history of allergic rhinitis and used liquid paraffin-containing menthol nasal drops daily. A chest CT scan showed multiple patchy ground glass opacities with blurred borders in both lungs, which were located in the inner pulmonary field and distributed along the bronchi. His ambient air PO2 was 63 mmHg. The patient was diagnosed with ELP by CT-guided lung biopsy. The nasal drops were discontinued, and systemic glucocorticoids were administered. During treatment, the pulmonary lesions deteriorated, and bronchoalveolar lavage was performed during bronchoscopy. Additionally, Mycobacterium abscessus was detected in the lavage fluid. Upon detection of a secondary M. abscessus infection, glucocorticoids were gradually discontinued, and anti-M. abscessus treatment was implemented. The patient’s symptoms rapidly ameliorated. After 11 months of anti-M. abscessus treatment, a repeat CT scan showed clear regression of the lung lesions.ConclusionRoutine microbiological examination of samples, including sputum or alveolar lavage fluid, is necessary for patients with diagnosed or suspected ELP.

Diagnostic Value of Composite and Simplified FDG-PET/CT Scores in Polymyalgia Rheumatica and the Influence of Recent Glucocorticoid Treatment-A Retrospective Diagnostic Cohort Study.

Retrospective inclusion of 198 consecutive patients ≥40 years of age referred for FDG-PET from the Department of Rheumatology. We assessed the degree of FDG uptake in predilection sites visually, as well as semiquantitatively, and through logistic regression analyses, we evaluated the performance of existing scoring systems as well as a new, simplified scoring system, against the final clinical diagnosis at 6 months after the FDG-PET scan. We found high diagnostic accuracy for the diagnosis of PMR (range 0.74-0.91) using most of the existing scoring systems in glucocorticoid-naïve patients. A simplified scoring system including only periarticular FDG uptake in the shoulders and the ischiogluteal bursae retained high sensitivity and specificity (0.92 and 0.86, respectively). We found a detrimental effect on diagnostic accuracy in all scoring systems in patients treated with glucocorticoids within 4 weeks prior to FDG-PET. Most FDG-PET scoring systems perform well for the diagnosis of PMR, and there is no loss of either sensitivity or specificity in the simplest scoring systems evaluating FDG uptake in only a few selected anatomical regions. However, systemic glucocorticoid treatment up to 4 weeks prior to FDG-PET has a markedly detrimental effect on the diagnostic accuracy of all scoring systems.

A case of Tocilizumab-induced thrombocytopenia in steroid-resistant Graves orbitopathy

Abstract Introduction Graves’ orbitopathy (GO) is the main extrathyroidal manifestation of Graves’ disease (GD). It is more common in women, but men have more severe evolution of the disease. GO appears in 25–70% of patients with GD and can have a severe evolution in 5% cases and even lead to sight loss. In mild forms local treatment is often sufficient to alleviate eye symptoms. However, in moderate-to-severe cases systemic glucocorticoids are used, combined or not with immunosuppressive drugs. In moderate-to-severe glucocorticoid-refractory cases, conventional and biological immunosuppressive drugs have been used, among which is treatment with Tocilizumab (TCZ) – a monoclonal antibody targeting the interleukin-6 receptor, involved in GO's pathogenesis. Clinical Case A 49 years old former smoking Caucasian man was admitted to the endocrinology unit with asymmetrical bilateral exophthalmos, spontaneous and movement induced retrobulbar pain, hyperlacrimation. He has been diagnosed with Graves disease 9 months prior to the admission to our clinic. At that time the patient was treated with antithyroid drugs and oral prednisolone. The clinical activity score – CAS 7/7 points confirmed an active form of GO. Laboratory findings revealed a suppressed TSH 0.01 UI/ml, increased freeT4 40,1 pmol/l, positive TR-Ab (30,04 IU/L). Treatment with high-dose regimen of i.v. methylprednisolone (Mt), cumulative dose 5.75 g in 12 weeks was applied. The patient was soon thereafter admitted repeatedly for evaluation: a non-response to Mt has been established, occurrence of diplopia, convergent strabismus, therefore a second-line treatment with tocilizumab (TCZ) was considered. His blood platelet count before TCZ was 158×10*9. The patient received the first 8 mg/kg dose of i.v. TCZ and showed an improvement in the CAS score (5/7 points), however 1 month later, the platelet count had decreased to 48×10*3 and further treatment with TCZ has been postponed until thrombocyte count increases above 100×10*9. His oral medicines were thiamazole and levothyroxine. Other causes of thrombocytopenia (HIV, Hepatitis C, Ebstein-Barr virus, Helicobacter pylori, liver disease) have been excluded. 7 weeks later thrombocyte count increased spontaneously to 102×10*3 and TCZ treatment has been resumed. Discussion. The mechanism of thrombocytopenia induced by TCZ is dependent on its effect on IL-6 receptor, which stimulates thrombopoiesis through thrombopoietin induction. Clinical studies prove the effectiveness of TCZ in the treatment of GO, but side effects limit its use. Older age and low platelet count before TCZ treatment were associated with the development of thrombocytopenia after treatment. Conclusion Thrombocytopenia induced by tocilizumab is tolerable. However, in patients with known risk factors, close monitoring of platelet counts is recommended. An individual approach is appropriate, considering the high cost of the drug, side effects and comorbidities.

Allergic bronchopulmonary aspergillosis in identical twins: Effectiveness of dupilumab

Allergic bronchopulmonary aspergillosis in identical twins: Effectiveness of dupilumab

P16 Overuse of antibiotics during the first year of the COVID-19 pandemic in Poland

Abstract Background It was a retrospective study conducted at the University Hospital in Kraków in Poland (UHC). The objectives of the study identify the trends of the antimicrobial consumption profile from February 2020 to February 2021, the first year of the COVID-19 pandemic in Poland. The hospital records data have been analysed to identify factors that were associated with antimicrobial consumption and illustrate how the situation evolved over time. The secondary objective is to identify the determinants of antimicrobial use. Methods The analysis was carried out on data based on electronically registered health care data from the UHC and hospital pharmacy. We included 250 adult patients, divided into 5 groups, and hospitalized with confirmed SARS-CoV-2 infection. The study began on 13 February 2020, when the patient with a confirmed hospital-acquired (HA)-COVID-19 in March was admitted to UHC. Next, we enrolled 49 consecutive patients and then, consecutive 50 patients admitted to the UHK on 13 May 2020, 13 August 2020, 13 November 2020 and 13 February 2021. Patients with HA-COVID-19 were eligible for inclusion in this study. Results In total, 178 patients received antimicrobials (ABX), 71.2% of all and the incidence rate of laboratory confirmed healthcare-associated infection (LC-HAI) was 20%. No patients had laboratory-confirmed bacterial co-infection at admission. The severity of COVID-19 was mild in 102 (40.8%), moderate in 92 (36.8%), and severe in 56 (22.4%) patients. Forty-three (17.2%) patients were hospitalized in an ICU, and 97.7% of them were treated with antimicrobials. The length of stay was greater among patients receiving ABX. The percentage of patients receiving antibiotic therapy changed throughout the covered time periods. The lowest proportion was recorded in May 2020 (48.0%), whereas the highest was observed in November 2021 and February 2021 (84.0% both). Systemic glucocorticoids (GCS) were used in 117 patients, 46.8% of all, significantly more frequently in patients with ABXs P&amp;lt;0.001. Patients with severe COVID-19 had the highest antimicrobial consumption values, the median DDD in this group was 20.92, P&amp;lt;0.001. Patients admitted at the beginning of the pandemic (February, May 2020) had significantly higher median DDD values, respectively 25.3 and 16.0 compared with those admitted in later months of the pandemic (August, November 2020; February 2021), 11.0, 11.0 and 11.2. Conclusions The results show that despite COVID-19 being a viral disease, the use of antimicrobials has been common in infected patients, especially at the beginning of the pandemic. The observed incidence of LC-HAI did not change during 12 months of follow-up and was very high, despite the fact that only 1/5 of the patients were hospitalized in the ICU.