Systemic Steroid Treatment Research Articles

A case with recurrent idiopathic anaphylaxis episodes starting soon after COVID-19 mRNA vaccination

Introduction: A patient was presented with a history of idiopathic recurrent anaphylaxis after administration of Pfizer BioNTech mRNA vaccine, and the attacks were controlled with omalizumab. To our knowledge, this is the first reported case of recurrent idiopathic anaphylaxis (IA) after administration of Pfizer BioNTech mRNA vaccine. Case Presentation: A 52-year-old man with recurrent episodes of IA after COVID-19 vaccination presented to our adult Allergy and Immunology Clinic. In the patient, urticaria and anaphylaxis episodes could not be controlled with high-dose antihistamine and systemic steroid treatment, and complete control was achieved with omalizumab treatment and anaphylaxis attacks completely regressed. Conclusion: In cases of unexplained or recurrent anaphylaxis in adult patients, COVID-19 vaccination and timing should be questioned, and its association with anaphylaxis might be considered.

Evaluating the Efficacy of a Polymerase Chain Reaction Assay for Pneumocystis carinii Detection in Respiratory Samples

Abstract Introduction: Accurately identifying patients with pneumocystis pneumonia (PCP) presents considerable challenges, primarily relying on clinical suspicion. The manifestations of PCP lack specificity, encompassing symptoms such as cough, dyspnoea, fever, hypoxaemia, malaise and weight loss. Therefore, this study assesses the efficacy of a polymerase chain reaction (PCR) assay intended for use in clinical microbiology laboratories for the identification of Pneumocystis carinii from respiratory specimens. Materials and Methods: In this retrospective study, the medical records of patients aged 18 years and above were examined, focusing on those assessed using pneumocystis PCR-based tests. The study spanned from 2019 to 2022 in our tertiary care centre at Max Hospital, Saket. In this study, sputum and bronchoalveolar lavage (BAL) samples were proceeded for both staining and PCR for multi-copy mtLSU gene and single-copy dihydropteroate synthase polymorphisms (DHPS) fas gene of P. jirovecii. Results: In the analysis of 112 BAL specimens, 17 were identified as positive for P. carinii through both Grocott-Gomori’s Methenamine Silver Staining (GMS) staining and PCR. In addition, two BAL specimens were negative through GMS staining but showed positive results with PCR. On reviewing the clinical details of the patients associated with these two specimens, it was discovered that both individuals were under systemic steroid treatment, yet neither exhibited clinical signs of pneumocystis pneumonia (PCP). Consequently, these instances were classified as false positives by PCR. In comparison to GMS, the PCR assay demonstrated a sensitivity of 100% and specificity of 98% for detecting P. carinii in BAL specimens. Conclusions: The study underscores the necessity for individualised approaches, with each laboratory assessing the positive and negative predictive values based on their specific prevalence rates. In the ongoing pursuit of improving PCP diagnosis, PCR emerges as a promising screening tool that when used judiciously in conjunction with confirmatory measures, can enhance diagnostic precision in immunosuppressed populations.

Impact of systemic steroids on the efficacy of first line imatinib treatment of patients with advanced gastrointestinal stromal tumors (GISTs).

Effective management of adverse events is required to maintain sufficient imatinib dosing when treating patients with gastrointestinal stromal tumors (GISTs). Skin rash is a common adverse event of imatinib, which can be effectively controlled by systemic steroid treatment without imatinib dose modification or interruption. However, the impact of the use of systemic steroids on the efficacy of imatinib treatment remains unclear. Between October 2014 and February 2022, 277 consecutive patients from a prospective registry of GIST patients were included as the study population. Patients who started systemic steroids due to grade ≥ 3 skin rash or grade 2 skin rash with grade 2 pruritis were classified as the steroid group, whereas patients who did not develop a skin rash or those who did not require steroids for a mild skin rash were classified as the control group. Efficacy outcomes were compared between the two groups. Among the 277 patients, 30 (10.8%) were treated with systemic steroids for skin rash. There was no significant difference in progression free survival (PFS) or overall survival (OS) between the steroid and control groups (3-year PFS, 67.7% vs. 65.1%, p = 0.53; 3-year OS, 91% vs. 89.9%, p = 0.67, respectively). The use of systemic steroids was not an independent factor associated with PFS (hazard ratio 0.73, 95% confidence interval 0.36-1.49, p = 0.39) and OS (hazard ratio 0.37, 95% confidence interval 0.12-1.18, p = 0.09). In the steroid group, patients who successfully maintained the imatinib dosage showed a trend toward more favorable survival outcomes than those who did not (3-year PFS, 73.3% vs. 44.4%, p = 0.34; 3-year OS, 95.8% vs. 75.0%, p = 0.15, respectively). The use of systemic steroids for the control of imatinib induced severe skin rash did not adversely affect the efficacy outcomes of imatinib in patients with advanced GIST.

Results of a New Treatment Protocol for Sudden Sensorineural Hearing Loss Using Betamethasone for Intratympanic Therapy.

Introduction Sudden sensorineural hearing loss (SSNHL) is defined as a rapid sensation of hearing impairment in one or both ears. Based on its personal impact on patients, the present study advances the analysis of new treatments for the prompt recognition and management of SSNHL, with higher chances of improvements in terms of hearing recovery and quality of life of the patients. Objective To describe the intratympanic (IT) corticoid infiltration technique, to demonstrate the efficacy of betamethasone injection as a sequential treatment in patients whose initial systemic steroid treatment failed, as well as to compare its use in different treatment periods. Methods The present clinical trial was conducted with 37 patients referred to our office with the diagnosis of SSNHL, from September 2019 to May 2022, who provided informed consent to participate. Results Even dividing the analysis of increasing the pure tone average (PTA) or speech recognition threshold (SRT) between the difference into initiation of the salvage therapy in up to 15 days of the sudden deafness event, and between 15 days and 3 months of the event, we did not find any difference in hearing improvement. Conclusion Intratympanic corticosteroid therapy is prescribed when conventional therapy fails or when there is a limitation to the use of corticosteroids due to the presence of systemic disorders. As such, new drugs, such as bethametasone, are studied and show promising results.

Effect of Added Inhaled Corticosteroids to Systemic Steroids on COPD Exacerbation Outcomes.

COPD exacerbations are a major cause of morbidity and mortality. Although inhaled corticosteroids (ICS) have a role as long-term treatment, their efficacy in exacerbations, particularly as an adjunct to systemic steroids, remains unclear. In this retrospective observational study, we analyzed data from 870 subjects admitted with COPD exacerbations to a tertiary medical center in Israel from January 2018-January 2023. We investigated the impact of adding ICS to standard systemic steroid treatment on hospital length of stay, intubation rates, and 30-d mortality using propensity score matching to account for confounders. The cohort, after matching, included 354 subjects treated with systemic steroids and ICS and 121 treated with systemic steroids alone. All characteristics were similar between the groups. Our analysis showed no differences in 30-d mortality (7.1% vs 5.8%, P = .63) or secondary outcomes (intubation, hospital length of stay, and readmission rates) between the groups. Subgroup analyses based on different eosinophil levels did not alter these findings. In multivariate analysis among the general cohort, eosinophil count < 150 cells/μL (adjusted odds ratio 0.45 [95% CI 0.21-0.87], P = .02) and high Charlson score (adjusted odds ratio 1.19 [95% CI 1.02-1.37], P = .02) were independent predictors for 30-d mortality. Despite the known benefits of ICS in managing chronic COPD, we did not find an added value of ICS to systemic steroids in exacerbations. These results underscore the necessity for individualized treatment strategies and further research into the role of ICS in COPD exacerbations.

Clinical course of ulcerative colitis: Frequent use of biologics and low colectomy rate first year after diagnosis-results from the IBSEN III inception cohort.

The introduction of biologic therapies and the 'treat-to-target' treatment strategy may have changed the disease course of ulcerative colitis (UC). To describe the early disease course and disease outcome at 1-year follow-up in a population-based inception cohort of adult patients with newly diagnosed UC. The Inflammatory Bowel Disease in South-Eastern Norway (IBSEN) III study is a population-based inception cohort study with prospective follow-up. Patients newly diagnosed with inflammatory bowel disease during 2017-2019 were included. Patients ≥18 years at diagnosis of UC who attended the 1-year follow-up were investigated. We registered clinical, endoscopic and demographic data at diagnosis and 1-year follow-up. We included 877 patients with UC (median age 36 years (range: 18-84), 45.8% female). At diagnosis, 39.2% presented with proctitis, 24.7% left-sided colitis and 36.0% extensive colitis. At the 1-year follow-up, 13.9% experienced disease progression, and 14.5% had received one or more biologic therapies. The colectomy rate was 0.9%. Steroid-free clinical remission was observed in 76.6%, and steroid-free endoscopic remission in 68.7%. Anaemia and initiation of systemic steroid treatment at diagnosis were associated with biologic therapy within the first year after diagnosis. In this population-based inception cohort, colectomy rate in the first year after diagnosis was low, and a high proportion of patients were in remission at 1-year follow-up. The use of biologic therapy increases, consistent with findings from previous studies.

Dermatomyositis with multiple organ involvement: a case report and literature review

Background: Dermatomyositis (DM) is a chronic autoimmune disorder characterized by muscle and skin inflammation, a part of the idiopathic inflammatory myositis (IIM). Even though the disease is idiopathic, there are multifactorial factors related to dermatomyositis. This care report aimed to describe a DM case in a male patient to increase the knowledge and management of DM patients. Case description: A 44-year-old Filipino male was referred to the emergency department (ED) of Siloam Hospital Mataram complaining of muscle pain and weakness with skin rashes 3 weeks before admission. Before the skin rash started, he had enlarged femoral lymph nodes in both thighs. The patient was afebrile with normal vital signs and was prescribed ibuprofen and amoxicillin. After that, he experienced skin rashes around his neck and the back of his ears with minimal pruritus. The symptoms worsened, making him unable to open his mouth and hard to breathe. In the ED, he also threw up dark-colored blood twice. Supporting examination showed elevated transaminase, increased LDH, and creatinine kinase. Biopsy results showed a histologic pattern of dermatomyositis. During hospitalization, he received a high-dose systemic steroid, antibiotic, and symptomatic treatment. He was discharged with a good outcome and planned to continue medical treatment in his country. Conclusion: Dermatomyositis is an idiopathic autoimmune disease involving skin and internal organs. It is a multifactorial disease yet with unclear etiopathogenesis. Specific treatment guidelines for DM are not yet established, but initial systemic corticosteroid and additional steroid-sparring agents may exhibit good outcomes.

The Management of Acute Exacerbations in COPD: A Retrospective Observational Study and Clinical Audit.

(1) Background: Acute exacerbations of chronic obstructive pulmonary disease (COPD) are not only associated with increased patient morbidity and mortality, but with extensive healthcare costs. Thus, adequate clinical management is crucial. The aim of this project was to evaluate the management of acute COPD exacerbations in a public teaching hospital in Switzerland. (2) Methods: We retrospectively analyzed clinical routine data of patients presenting with an acute exacerbation of COPD at the emergency department of a Swiss hospital between January 2019 and February 2020. Management was evaluated against recommendations from the GOLD 2019 report and previous audits. (3) Results: The data of 184 patients (mean age 73.5 years, range 41-95 years, 53% male) with 226 visits were included. While the documentation of GOLD stage (I-IV) and smoking status was consistent (81.0% and 91.6%), GOLD risk category (A-D) was only documented in 36% of the cases. Patients' respiratory rate upon presentation was measured in 73%, and blood gas analysis was performed in 70%. A total of 94% of the patients received a chest imaging; spirometry was performed in 10%. Initial symptomatic therapy with short acting bronchodilators was applied in 56%. Systemic steroid treatment was installed in 86%. Antibiotics were given in 56%, but in one fourth the indication was not clear. Non-invasive ventilation was applied in 25% of the indicated cases. Smoking cessation was recommended to 26% of the current smokers and referral to pulmonary rehabilitation was given in 16%. (4) Conclusion: GOLD recommendations were not comprehensively implemented, especially with regard to the assessment of severity, initial symptomatic therapy, and non-invasive ventilation. These results show the importance of the frequent revision of routine practice and may help to create awareness among practitioners and ultimately improve the quality of COPD management.

Efficacy of intratympanic steroid therapy for severe and profound sudden sensorineural hearing loss

BackgroundIntratympanic steroids (ITS) in treating sudden sensorineural hearing loss (SSNHL) have become more widespread. AimThis study investigates whether ITS treatment provides additional benefits when combined with systemic steroids (SS) in patients with severe and profound SSNHL. Materials and methodsPatients diagnosed with severe and profound SSNHL were divided into two groups: SS group and SS combined with ITS group. Pure-tone audiometry was performed before and three months after treatment completion. The pure-tone average (PTA), frequency-specific hearing gains, and average values were compared between the groups. ResultsThe study included 57 patients (27 SS, 30 ITS), with a mean age of 50.09 ± 15.56. Before treatment: SS PTA 84.40 ± 15 dB HL, ITS 87.50 ± 9.38 dB HL (p = 0.36). After treatment: SS 62.2 ± 23.13 dB HL, ITS 65.17 ± 12.19 dB HL (p = 0.55). Average hearing gain: SS 22.19 ± 13.81 dB HL, ITS 22.33 ± 12.24 dB HL (p = 0.96). Frequency-specific gains were similar (p > 0.05). SS group: 12 slight improvement, 10 no improvement, 3 partial, 2 complete recovery. ITS group: 23 slight improvement, 6 no improvement, 1 partial. ConclusionIn our study, combining ITS with SS treatment did not provide additional benefits in treating severe and profound SSNHL.

IgA nephropathy.

IgA nephropathy (IgAN), the most prevalent primary glomerulonephritis worldwide, carries a considerable lifetime risk of kidney failure. Clinical manifestations of IgAN vary from asymptomatic with microscopic or intermittent macroscopic haematuria and stable kidney function to rapidly progressive glomerulonephritis. IgAN has been proposed to develop through a 'four-hit' process, commencing with overproduction and increased systemic presence of poorly O-glycosylated galactose-deficient IgA1 (Gd-IgA1), followed by recognition of Gd-IgA1 by antiglycan autoantibodies, aggregation of Gd-IgA1 and formation of polymeric IgA1 immune complexes and, lastly, deposition of these immune complexes in the glomerular mesangium, leading to kidney inflammation and scarring. IgAN can only be diagnosed by kidney biopsy. Extensive, optimized supportive care is the mainstay of therapy for patients with IgAN. For those at high risk of disease progression, the 2021 KDIGO Clinical Practice Guideline suggests considering a 6-month course of systemic corticosteroid therapy; however, the efficacy of systemic steroid treatment is under debate and serious adverse effects are common. Advances in understanding the pathophysiology of IgAN have led to clinical trials of novel targeted therapies with acceptable safety profiles, including SGLT2 inhibitors, endothelin receptor blockers, targeted-release budesonide, B cell proliferation and differentiation inhibitors, as well as blockade of complement components.

Circulating pre-treatment T-cell receptor repertoire as a predictive biomarker in advanced or metastatic non-small-cell lung cancer patients treated with pembrolizumab alone or in combination with chemotherapy

The circulating T-cell receptor (TCR) repertoire is a dynamic representation of overall immune responses in an individual. We prospectively collected baseline blood from patients treated with first-line pembrolizumab monotherapy or in combination with chemotherapy. TCR repertoire metrics were correlated with clinical benefit rate (CBR), progression-free survival (PFS), overall survival (OS) and immune-related adverse events (irAEs). We built a logistic regression classifier by fitting all four TCR-β repertoire metrics to the immune checkpoint inhibitor (ICI) CBR data. In the subsequent receiver operating characteristic (ROC) analysis of the resulting logistic regression model probabilities, the best cut-off value was selected to maximise sensitivity to predict CBR to ICI. We observed an association between reduced number of unique clones and CBR among patients treated with pembrolizumab monotherapy (cohort 1) [risk ratio= 2.86, 95% confidence interval (CI) 1.04-8.73, P= 0.039]. For patients treated with pembrolizumab plus chemotherapy (cohort 2), increased number of unique clones [hazard ratio (HR)= 2.96, 95% CI 1.28-6.88, P= 0.012] and Shannon diversity (HR= 2.73, 95% CI 1.08-6.87, P= 0.033), and reduced evenness (HR= 0.43, 95% CI 0.21-0.90, P= 0.025) and convergence (HR= 0.41, 95% CI 0.19-0.90, P= 0.027) were associated with improved PFS, while only an increased number of unique clones (HR= 4.62, 95% CI 1.52-14.02, P= 0.007) were associated with improved OS. Logistic regression models combining the TCR repertoire metrics improved the prediction of CBR (cohorts 1 and 2) and were strongly associated with PFS (cohort 1, HR= 0.38, 95% CI 0.19-0.78, P= 0.009) and OS (cohort 2, HR= 0.20, 95% CI 0.05-0.76, P < 0.0001). Reduced TCR conversion was associated with increased frequency of irAEs needing systemic steroid treatment. Combined pre-treatment circulating TCR metrics might serve as a predictive biomarker for clinical outcomes among patients with advanced non-small-cell lung cancer treated with pembrolizumab alone or in combination with chemotherapy.

Managing Severe Adverse Reactions to Biologicals in Severe Asthma.

The use of biological agents in the treatment of various inflammatory and malignancy conditions has expanded rapidly. However, these agents can induce hypersensitivity reactions, posing significant clinical challenges. We conducted a retrospective study that included nine patients with severe asthma who experienced hypersensitivity reactions to biological agents (omalizumab, benralizumab and dupilumab). Hypersensitivity reactions to biologicals in severe asthma were observed in 9 of 68 patients treated. In five cases, treatment was stopped or changed to another available biological, and for four patients administered under close surveillance, titrated provocation or desensitization was applied. Successful desensitization was achieved in three of the patients, allowing them to continue therapy without adverse reactions. Improvements in asthma control were observed post-desensitization, leading to the reduced need for systemic steroid treatments and an increase in quality of life. This study highlights the importance of recognizing hypersensitivity reactions to biologicals to have an appropriate approach for patients with severe asthma. As an effective approach for patients experiencing hypersensitivity reactions to biological agents, desensitization allows treatment continuation.

Local steroid injection in severe idiopathic granulomatous mastitis as a new first-line treatment modality with promising therapeutic efficacy.

Intralesional steroid injection has recently evolved as a novel treatment modality for localized idiopathic granulomatous mastitis (= IGM). We aimed to explore the therapeutic efficacy of local steroid injections (LSI) in patients with severe IGM. Fifty-one patients diagnosed with severe IGM were included in the study and treated with either local steroid injection (LSI) alone (n = 25) or combined LSI with systemic oral steroid treatment (OST) (n = 26). The local steroid injection protocol included an intralesional triamcinolone acetonide injection into the palpable granulomas every 4-week, and topical administration of steroid-containing pomades twice a day on the affected surface of the breast. Patients with a combined LSI and OST received low-dose oral methylprednisolone (<16 mg). Patients with LSI alone required more LSI applications than those in the combined LSI with OST group (LSI: 5 ± 2.9; vs. LSI/OST: 3.5 ± 2.5; p = 0.080) to obtain an effective optimum therapeutic response. At a median of 12 months (range, 4-42), no difference was found in complete response rates between patients in the LSI group and the combined LSI group with OST (52 vs. 53.9%, p = 0.999). However, steroid-related systemic side effects were lower in the LSI alone group (p < 0.008). Local steroid injection could be considered as the first-line treatment in patients with severe IGM until a therapeutic response has been obtained either as the sole treatment modality or combined with oral steroids. Compared with systemic oral steroid therapy, local steroid administration can be considered a new treatment modality with fewer side effects.

P06.17.A OPTIC NEUROPATHY RELATED TO IMMUNE CHECKPOINT INHIBITORS: A CASE SERIES

Abstract BACKGROUND Immune checkpoint inhibitors (ICIs) are associated with a broad spectrum of neurotoxicities. ICI-related optic neuritis have been rarely reported and poorly described. However, their knowledge is essential to promptly recognise and manage them since a persisted visual decline is reported in approximately half of the patients. A systemic steroid treatment has been correlated to a better prognosis. MATERIAL AND METHODS We report a retrospective series of patients with an ICI-related optic neuritis, referred to our departments between 2018 and 2022, with the aim to describe their clinical and para-clinical features and the outcome. Other causes of optical neuropathy were excluded by blood analysis and brain MRI. RESULTS We identified three melanoma patients who developed an ICI-related optic neuropathy. They were treated with combined ipilimumab with nivolumab (n=2) or pembrolizumab monotherapy (n =1). The symptoms occurred after a delay of 43-196 days from ICI initiation and consisted of bilateral painless reduction of visual acuity, associated with colored scotomas in one case and conjunctival erythema in another case. Ophthalmological examination found a bilateral papilledema in all the patients, associated with a panuveitis in one case (patient #1). The presence of papilledema was verified by fundus fluorescein angiography and optic coherence tomography (OCT). Visual evoked potential confirmed a bilateral involvement of optical nerves in two cases, and was normal in the third case, which was thus consistent with a papillitis. ICIs were stopped in patients #1 and #2 and oral steroids started in patient #1. Both patients experienced a complete recovery within 2 weeks from steroids onset and 24 weeks from the last ICI dose, respectively. Given the quick and spontaneous improvement of both symptoms and ophthalmological exam, ICI was continued with the same regimen in patient #3, and the optic neuropathy progressively improved until complete recovery 3 months later. ICI treatment was reintroduced in patient #2 after four months, with no recurrence of the optical neuritis until the last follow up (5 years). CONCLUSION As reported in other series of immune-related optic neuropathies, a bilateral optic nerve involvement with painless decline of vision and papilledema was the most common presentation. Unlike other reports, all the patients of this series experienced a favorable outcome, with total recovery of vision and normalization of the ophthalmological exam. The recovery seems more rapid if patient receive steroids. We reintroduced or continued the ICI in two patients, with no recurrence of optic neuritis, thus suggesting that ICI treatment discontinuation is not mandatory in case of non-severe optical neuropathies. However, a careful analysis of the benefit/risk ratio should be done on a case-by-case basis.

Primary versus salvage intratympanic steroid treatment for idiopathic sudden sensorineural hearing loss.

The objective of this research is to compare primary and salvage intratympanic (IT) steroid treatments in terms of hearing outcomes in patients with idiopathic sudden sensorineural hearing loss (ISSNHL). The patients were randomized into two (primary and salvage) groups. Both groups received systemic steroid treatment for 2 weeks. The primary group also received IT dexamethasone injection three times during the treatment period, whereas the salvage group received IT dexamethasone injection only if no or slight recovery was noted at the 2-week follow-up. If needed, salvage steroid injection was administered three times during the following 2 weeks. Hearing recovery was analyzed according to the modified American Academy of Otolaryngology-Head and Neck Surgery criteria. The degrees of hearing improvement at the 3-month follow-up were similar in the two groups. Compared with baseline, the pure-tone average values and speech discrimination scores improved by 38.45 ± 21.95 dB HL and 34.32% ± 30.55%, respectively, in the primary group and 36.80 ± 22.33 dB HL and 31.87% ± 27.88%, respectively, in the salvage group (p = .762 and .659, respectively). In addition, the complete or partial hearing recovery rates were also similar in the primary and salvage groups (67.7% vs. 73.3%, respectively; p = .780). In the salvage group, 18 patients required no IT steroid injection because they recovered after systemic steroid treatment. Primary and salvage IT steroid treatments for ISSNHL led to similar outcomes. In summary, salvage IT steroid injection is recommended for patients with ISSNHL patients to prevent unnecessary IT injection. 2.

Clinical Results of Combined Systemic Steroid and Retroorbital Radiotherapy Treatment in Active Thyroid Associated Ophthalmopathy

Objective: The aim of this study is to evaluate the efficacy of a different steroid dosage protocol which consists of intravenous pulse methylprednisolone combined with retroorbital radiotherapy in the treatment of active thyroid associated ophthalmopathy.&#x0D; Methods: The medical records of 29 patients who were treated with a standard protocol and who were followed-up for at least 6 months were retrospectively analyzed. The treatment protocol consisted of intravenous pulse methylprednisolone 1gram/day for 3 consecutive days, followed by retroorbital radiotherapy. Oral prednisolone which was tapered over a 3-month course was given as a maintenance dose.&#x0D; Results: 58 eyes of 29 patients were included in the study. Twelve patients were female (41%) and 17 were male (59%) with a mean age of 47.7 ± 12.6 years. The clinical activity score was 4.8 ± 1.3 and 2.8 ± 1.2, before and after treatment, respectively (P

Biological Treatment for Uncontrolled Chronic Rhinosinusitis with Nasal Polyps: Preliminary Real-World Results from a Tertiary Medical Center.

The efficacy of biological treatment for severe uncontrolled chronic rhinosinusitis with nasal polyps (CRSwNP) has recently been demonstrated through double-blinded clinical trials. The aim of this study was to provide preliminary real-world experience regarding biological therapy for uncontrolled CRSwNP. The records of patients who received biological treatment in a tertiary medical center between the years 2019 to 2022 were retrospectively reviewed. Patients included in this study were eligible for biological treatment according to the EPOS 2020 criteria. Among patients who had their first follow-up visit <6 months from the treatment initiation, the Sino-Nasal Outcome Test 22 Questionnaire (SNOT-22) score had decreased by 22% (p = 0.01) and the nasal polyp score (NPS) had decreased by 48% (p = 0.05). Among patients who had their first follow-up visit ≥6 months from treatment initiation, the SNOT-22 score had decreased by 40% (p = 0.03) and the NPS had decreased by 39% (p = 0.1). The number of patients who needed systemic steroid treatment had decreased by 68% (p < 0.0001), and the number of patients who needed endoscopic sinus surgery had decreased by 74% (p < 0.0001). These findings correspond with the improvement of clinical symptoms observed in prior randomized clinical trials, thus showing the effectiveness of biologic medications in the treatment of severe CRSwNP in a real-life setting. Although further cohort studies are warranted, our study also suggests evaluating patients at follow-up visits mainly by quality-of-life aspects and investigating longer dosing intervals of dupilumab.

A Case of a Patient with Refractory Scleritis Treated with Rituximab

Purpose: We report a patient with refractory scleritis effectively treated with rituximab after ineffective, initial, conventional immunosuppressive therapy.Case summary: A 58-year-old woman with no specific medical history presented with recurrent scleritis of the right eye. Her uncorrected visual acuities in both eyes were 20/20, and a blood test for cytoplasmic antineutrophil cytoplasmic antibody (C-ANCA) was positive. Systemic and subconjunctival steroid treatments were not effective, and the scleritis recurred even after further treatment with oral cyclosporin A and mycophenolate mofetil. After intravenous administration of infliximab (5 mg/kg), slight improvement was noted, but the recurrence continued. Thereafter, the visual acuity of the right eye decreased markedly because of choroidal and serous retinal detachment caused by posterior scleritis. Immunohistochemically, the inflamed scleral tissue showed considerable B-cell infiltration. Accordingly, intravenous rituximab (1 g) was administered twice at a 2-week interval. The scleral vessel engorgement and inflammation dramatically improved, and the scleritis became well-controlled without recurrence for more than 8 months.Conclusions: Intravenous rituximab may be helpful when encountering scleritis refractory to conventional immunomodulation therapy.

Cutaneous arteritis: Clinicopathological study of 21 cases

AbstractObjectivesWe conducted this study to clarify the progress of cutaneous arteritis.MethodsWe examined 21 cases of cutaneous arteritis that were diagnosed at our hospital between 2005 and 2020. The male‐to‐female ratio was 1:6 with a mean age of 52.2 years.ResultsThe lower legs were involved in all cases, and the upper extremities or trunk was also involved in some cases. Cutaneous manifestations presented as indurated erythema (n = 15), subcutaneous induration (11), edema (7), livedo (6), and ulcer (3). In addition, extracutaneous conditions including numbness (10), arthritis (8), fever (2), and myalgia (1) were observed. Laboratory tests showed an increase of inflammatory markers in most cases (14). Histopathological features showed necrotizing vasculitis of small‐sized arteries at the dermo‐subcutaneous junction, and the inflammatory stages of arteritis were histopathologically divided into acute stage (5), subacute stage (5), reparative stage (7), and healed stage (1). The therapies administered were oral prednisolone (11), antiplatelet drug (14), warfarin (1), non‐steroidal anti‐inflammatory drugs (6), biological drug (1), and other drugs (14). There were no cases showing progression to systemic polyarteritis nodosa during follow‐up period. All three patients with ulceration complained of numbness, and one was revealed to have mononeuropathy multiplex. They were treated with low‐dose oral prednisolone. Three ulceration cases were histopathologically classified into the acute and subacute stages.ConclusionsIn conclusion, all 21 patients followed a chronic course with recurrent skin lesions without systemic complications. Cases with ulceration seem to reveal neurological symptoms and need systemic steroid treatment.

Local vs Systemic Use of Steroids for Sudden Deafness with Diabetes: A Systematic Review and Meta-Analysis.

Diabetes is associated with a risk of idiopathic sudden deafness. The main treatment of diabetic sudden deafness is systemic and topical application of steroids. Topical steroid therapy reduces systemic adverse reactions compared with systemic therapy. The aim of this study was to conduct a meta-analysis design on the improvement value and recovery rate of pure tone mean hearing threshold (PTA).To investigate whether there is difference between local and systemic steroid treatment as the initial treatment for sudden deafness patients with diabetes. We searched databases from publication date to October 1, 2022 including PubMed, EMBASE, Cochrane Library, web of science, CNKI, Wan fang Database, China Biomedical Literature Database (CBM), and VIP information resource system. A systematic literature review was conducted on the efficacy and safety of local and systemic steroid therapy for diabetic sudden deafness. RevMan5.4 and stata14 software were used for Meta-analysis. A total of 23 studies were included in this study, covering 1777 patients, including 885 cases in the observation group (local steroid group) and 894 cases in the control group (systemic steroid group). Meta-analysis showed that there was a significant difference in the total effective rate of local and systemic steroid treatment for diabetic sudden deafness between groups (RR = 1.17, 95% CI = 1.11-1.22, P < 0.05). The effective rate in the observation group was higher than that in the control group. For the improvement of PTA, the difference between groups was statistically significant (RR = 6.60, 95% CI = 3.07-10.14, P < 0.05). The improvement of PTA in the local steroid group was higher than that in the systemic steroid group. Subgroup analysis showed that there were significant differences between groups in hormones, drug administration, follow-up time and course of disease. Topical steroid therapy is effective in the treatment of diabetic sudden deafness. Hormone methylprednisolone has high effective rate; the shorter the course of disease and the longer the follow-up time are, the higher the total effective rate will be. Tympanic injection is more effective than post-aural injection. Topical steroid injections are safer for hormonal side effect.