Oral Steroid Use Research Articles

Risk factors for aerobic bacterial conjunctival flora in preoperative cataract patients.

PurposeTo investigate the relationship between the background of preoperative cataract patients and bacterial conjunctival flora.MethodsA total of 990 cataract patients who had completed preoperative examinations in 2007 and 2008 were included. Patients using topical antibiotics at the preoperative examination or having a history of intraocular surgery were excluded. Conjunctival cultures had been preoperatively obtained. Patient characteristics were investigated via medical records. Risk factors for conjunctival flora of seven typical bacteria were analyzed by univariate and multivariate analyses.ResultsThe detection rate of alpha-hemolytic streptococci and Enterococcus faecalis increased with age (P=0.044 and P=0.002, respectively). The detection rate of Gram-negative bacilli was higher among patients with oral steroid use or lacrimal duct obstruction (P=0.038 and P=0.002, respectively). The detection rate of Corynebacterium species was higher among older patients and men, and lower among patients with glaucoma eye drop use (P<0.001, P=0.012 and P=0.001, respectively). The detection rate of methicillin-susceptible coagulase-negative Staphylococci was higher among men and lower among patients with a surgical history in other departments (P=0.003 and P=0.046, respectively). The detection rate of methicillin-resistant coagulase-negative Staphylococci (MR-CNS) was higher among patients with oral steroid use, a visit history to ophthalmic facilities, or a surgical history in other departments (P=0.002, P=0.037 and P<0.001, respectively).ConclusionsElderly patients, men, patients with lacrimal duct obstruction or immunosuppressed patients are more likely to be colonized by pathogens that cause postoperative endophthalmitis. Moreover, MR-CNS colonization was associated with healthcare-associated infection.

PRS36 - Cost Effectiveness Of Mepolizumab In Adult Asthma Patients

Mepolizumab has been shown to reduce asthma exacerbations and the use of chronic oral steroids in patients with severe disease characterized by elevated eosinophils; however, use of this drug is an added cost to current standard of care (SoC). The objective of this analysis was to determine the cost-effectiveness of mepolizumab in addition to SoC as compared to SoC alone for adults with severe, uncontrolled asthma. From the payer perspective, we modeled a Markov cohort framework that included three states: asthma non-exacerbation state, asthma exacerbation state, and death. Model inputs were retrieved from published medical literature and drug costs from Redbook. One-way sensitivity analyses were conducted to assess the robustness of the results, as well as a scenario analysis to determine the price of mepolizumab that would produce cost-effectiveness results at common willingness-to-pay thresholds. Over a lifetime treatment horizon, 23.96 exacerbations were averted per patient receiving mepolizumab with SoC versus SoC alone. Avoidance of exacerbations and the reduction in chronic oral steroid use resulted in over $18,000 in cost offsets among those receiving mepolizumab, but treatment costs were increased by over $600,000. Treatment with mepolizumab resulted in a cost-effectiveness estimate of $385,546 per quality-adjusted life year (QALY). After accounting for model input uncertainty in a one-way sensitivity analysis, the cost-effectiveness estimates remained over $300,000 per QALY. To achieve an incremental cost-effectiveness ratio of $100,000 per QALY, the drug price would need to be discounted more than 70%. The base case cost-effectiveness estimate of mepolizumab plus SoC versus SoC alone was not cost-effective from the payer perspective. After varying the most influential parameters, the cost-effectiveness estimates remain unfavorable. Meeting willingness to pay thresholds of $50,000 per QALY, $100,000 per QALY, and $150,000 per QALY requires a significantly reduced price of mepolizumab.

Oral Steroid Usage for Otitis Media with Effusion, Eustachian Tube Dysfunction, and Tympanic Membrane Retraction.

Avoiding oral steroids for otitis media with effusion (OME) is endorsed as a performance measure by the National Quality Foundation, but data regarding current gaps and practice patterns are lacking. Our objectives were to evaluate oral steroid use for OME and the related diagnoses of eustachian tube dysfunction (ETD) and tympanic membrane retraction (TMR), to assess variations by visit setting, and to identify opportunities for measurable performance improvement. Cross-sectional analysis of a national database. Ambulatory visits in the United States. Children and adults in the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey (2005-2010). Data were coded for patient demographic information, potential confounders (eg, concurrent conditions managed by oral steroids), and diagnosis of OME, ETD, or TMR (OME/ETD/TMR). The latter 2 diagnoses were included to meet minimum numbers for reliability of weighted estimates, but OME constituted the majority of cases. Multivariate regression was used to determine the variables associated with oral steroid use. Among 590,772 observations representing 7,191,711,480 visits for OME/ETD/TMR, 3.2% resulted in a new prescription for oral steroid medication (2.3% for children, 7.0% for adults). Adults were more likely to receive steroids (odds ratio = 3.50, P < .001) than those with other diagnoses, but a similar association was not found for children. Patients seen by an otolaryngologist or in the emergency department were less likely to receive steroids than those seen in other settings. OME/ETD/TMR is infrequently treated with oral steroids, particularly in children. Opportunities for performance improvement are limited.

Patient acceptance of osteoporosis treatment: Application of the stages of change model

ObjectivesTo examine whether a commonly used model of behaviour change, stages of change, is helpful in understanding osteoporosis treatment initiation in a cohort of fragility fracture patients. Study designThis longitudinal cohort study used data from a provincial osteoporosis screening program targeting fragility fracture patients age 50 and over. Logistic regression was used to identify baseline factors associated with patients moving from the first, pre-contemplation stage at baseline to the more advanced stages of action/maintenance at follow-up, when treatment is initiated and maintained. Main outcome measurePatient’s stage-of-change readiness to accept osteoporosis treatment. ResultsAt baseline, 91% of patients were in the pre-contemplation stage. Of these, 74.1% remained at the same stage at follow-up, 2.7% moved to contemplation and preparation while 23.2% moved to action/maintenance. The adjusted analysis showed that those who moved from pre-contemplation to action/maintenance were more likely to have a previous fracture OR 1.5 (1.1–2.0), history of oral steroid use OR 2.1 (1.3–3.5), higher perceived benefits to osteoporosis drug treatment OR 1.2 (1.0–1.3), perception of bones as “thin” OR 2.8 (2.0–4.0) and were less likely to perceive that they were taking too many medications OR 0.6 (0.5–0.9). ConclusionsWith the majority of patients in the pre-contemplation and the action/maintenance stages, our results suggest an existence of a two-stage model. The baseline factors that we identified can be used to predict which patients are less likely to initiate treatment, which in turn, can be used to inform post-fracture interventions and facilitate behaviour change.

Comparison of treatment of chronic obstructive pulmonary disease (COPD) by family physician and consultants

The goal of the study is to determine whether care for COPD patients is more consistent with guidelines when a Consultant rather than a Family Physician treat the patients. We use the Global Initiative for Obstructive Lung Disease Guidelines as a standard 1. We studied seven parameters, offering Pulmonary Function Test, Smoking cassation guidance, vaccination, use of oral steroid, inhaled steroids, inhaled Impratropium bromide, and symptom documentation. We concluded that both Family Physicians and Consultants are not fully following the guidelines. In compression Consultants are better than Family Physicians.

Hemostasis in sinus surgery.

Optimization of the surgical field involves a complex interplay of many factors. Although it is agreed that hemostasis is critical to safe, efficient, and successful sinus surgery, a lack of consensus exists as to the best way to achieve it. This review examines the current body of evidence supporting many of the practices surgeons believe to influence hemostasis. Although many of the practices discussed in this article have long been considered to influence hemostasis, it is not until recently that high-level evidence supporting their use has been available. Well designed studies now exist supporting the preoperative use of oral steroids in polyp patients, the importance of adequate reverse trendelenburg positioning, the use of flexible laryngeal mask ventilation during general anesthesia, and the increased safety and comparable efficacy of topical epinephrine over other topical and injectable agents. Controversy still exists as to the ideal method of achieving controlled hypotensive anesthesia, although new evidence has emerged as to what hemodynamic parameters should be adhered to, to reduce the risk of cerebral hypoperfusion. Numerous factors influence hemostasis and so it is important that ENT surgeons have a sound understanding of the evidence supporting their everyday surgical practice. Improved standardization of scoring and reporting of bleeding may increase the power of research studies to draw more definitive conclusions about the role that certain factors have on hemostasis.

Prediction models in obstetrics: understanding the treatment paradox and potential solutions to the threat it poses.

Prediction models in obstetrics: understanding the treatment paradox and potential solutions to the threat it poses.

The prevalence and clinical characteristics of anemia in Korean patients with inflammatory bowel disease.

Background/AimsQuality of life is closely related to anemia in patients with inflammatory bowel disease (IBD). Several studies have reported on anemia in patients with IBD in Western countries. This study investigated the prevalence and clinical characteristics of anemia in Korean patients with IBD.MethodsWe reviewed the medical records of 92 patients with ulcerative colitis (UC) and 76 patients with Crohn's disease (CD) who were followed regularly at a single tertiary medical center in Korea between January 2003 and December 2012. Hemoglobin (Hb) thresholds used to define anemia were <13.0 g/dL in men and <12.0 g/dL in women according to the World Health Organization criteria. We chose the lowest Hb level in each year as a representative value because Hb levels changed at each examination and anemia was associated with disease deterioration. The relationship between clinical variables and lowest Hb level was assessed.ResultsThe prevalence of anemia was 36.3% in patients with UC and 41.6% in patients with CD. Anemia in patients with CD was associated with hospital admission, 5-aminosalicylate (5-ASA) and infliximab treatment in men. Anemia in patients with UC was associated with hospital admission, oral steroid use, thiopurine and infliximab treatment in men.ConclusionsThe prevalence of anemia in Korean patients with IBD was comparable to that of patients in Western countries. Anemia was associated with male patients with CD who were admitted to the hospital and received medications including 5-ASA and infliximab, and men with UC who were admitted to the hospital and received medications including oral steroids, thiopurine and infliximab.

Impact of the age of diagnosis on the natural history of ulcerative colitis.

Ulcerative colitis (UC) has a recognized phenotypic heterogeneity. Some studies suggest that age at diagnosis may influence features and natural history of the disease. This study aimed to compare patients', disease's and treatment's features between Portuguese patients diagnosed before and after the age of 40-years-old. Retrospective single-center study that included 310 patients with UC, divided in two groups: Those diagnosed before the age of 40-years-old (early onset UC) and those diagnosed later than that (late onset UC). In each group features of the patients (gender, family history, smoking), of the disease (duration, extension, severity, clinical course, hospitalization, extraintestinal manifestations), and of treatment (oral aminosalicylates, systemic steroids or immunomodulators) were analyzed. Statistical analysis was performed using SPSSv22.0. Univariate and multivariate analyses were performed to assess factors associated with early and late onset UC. From the analyzed patients, 207 had UC diagnosed before the age of 40 years old (43.5% men; mean age at diagnosis 29.4 ± 6.9 years) and 103 were diagnosed after that age (61.2% men; mean age at diagnosis 51.8 ± 8.1 years). In the group diagnosed before 40 years old, female gender (p = 0.003), severe disease (p = 0.002), chronic intermittent clinical course (p = 0.026), and hospitalizations (p = 0.001) were significantly more frequent. The use of oral aminosalicylates (p = 0.032), systemic steroids (p = 0.003) and immunomodulators (p = 0.012) were also more common in the early onset UC group. No differences between groups were found in family history, smoking, disease's extension, extraintestinal manifestations, and use of biological agents. Multivariate analysis pointed early onset UC to be significantly associated with female gender (odds ratio [OR], 1.77; 95% confidence interval [CI], 1.08-2.91; p = 0.024), chronic intermittent symptoms (OR, 2.34; 95% CI, 1.17-4.70; p = 0.016), and need of hospitalization (OR, 2.89; 95% CI, 1.46-5.72; p = 0.002). When diagnosed before the age of 40-years-old, UC preferably affects women and manifests as a more severe disease, with more frequent hospitalizations and chronic intermittent symptoms. These facts might have implications in planning timely and individualized future therapeutic strategies.

Oral corticosteroids in the management of chronic rhinosinusitis with and without nasal polyps: Risks and benefits.

Oral steroids are synthetic mimics of adrenal cortex hormones and are considered a staple in the management of chronic rhinosinusitis due to their anti-inflammatory effects. Despite their common use, many providers are not familiar with the potential risks of the drugs. Literature review. An overview of the existing data on the risks of oral steroids is presented as well as a review of the malpractice lawsuits with regard to oral steroid use and a discussion of the data that support the use of oral steroids in patients with chronic rhinosinusitis with and those without nasal polyps. It is essential for providers to be aware of the potential complications of a medication, the medical jurisprudence of the drugs, and the data that support their use.

Impact of Perioperative Oral Steroid Use on Low-frequency Hearing Preservation After Cochlear Implantation.

To investigate the efficacy of a perioperative oral steroid taper on low-frequency hearing preservation after cochlear implantation. Retrospective case series. Tertiary referral center. Consecutive cochlear implant recipients between January 2012 and December 2014 who were candidates for a hearing preservation approach based on preoperative pure tone thresholds were identified. A subgroup of patients received a 2-week oral corticosteroid taper beginning 3 days before surgery. All patients were implanted using standard length electrodes. The preservation of low-frequency pure tone thresholds on the first postoperative audiogram was assessed. Secondary outcome measures included the respective impacts of age, diabetes, and electrode array type on hearing preservation, the durability of hearing preservation over time, and the development of medical complications related to steroid use. Twenty-seven ears met inclusion criterion, and the mean age at implantation was 49.8 years (median 62 yr, range 2-81 yr). Twenty patients (74.1%, mean age 48.7 yr) received an oral corticosteroid taper, whereas 7 (25.9%, mean age 53.1 yr) did not. The rate (p < 0.01) and degree (p < 0.01) of hearing preservation as measured at implant activation was greater for patients who received an oral steroid taper than those who did not. There were no medical complications related to steroid use. A 2-week oral prednisone taper beginning before surgery may positively affect the incidence and degree of low-frequency hearing preservation after cochlear implantation.

Endoscopic culture-directed antibiotic therapy: Impact on patient symptoms in chronic rhinosinusitis

BackgroundEndoscopically guided cultures are frequently employed to guide antimicrobial therapy in refractory chronic rhinosinusitis (CRS) patients. The objective of this study was to determine the impact of culture-directed antibiotics on patient symptoms. MethodsRetrospective review was conducted of 105 adult CRS patients undergoing evaluation in the ambulatory clinic of tertiary care academic medical center. ResultsThe most common microbes were Staphylococcus aureus (29.5%), Pseudomonas aeruginosa (23.8%) and methicillin-resistant S. aureus (11.4%). Normal respiratory flora or no growth was found in 19% of patients. Culture results changed antibiotic choices in 77% of patients. Statistically significant change in total SNOT-20 scores and all 4 subdomains was noted, with improvement being clinically meaningful in the rhinologic subdomain (−1.10, p<0.0001). Repeat purulence was only noted in 5 cases (4.8%). Multivariate regression analysis demonstrated that concurrent use of oral steroids was independently associated with improvement in the rhinologic subdomain (p=0.0041). The mean length of follow-up was 37days. Length of follow-up (14–30, 31–60, 61–90days) did not statistically impact SNOT-20 scores. ConclusionEndoscopic-derived sinus cultures are associated with clinically meaningful change in the rhinologic subdomain of SNOT-20 scores, and repeat purulence was infrequently noted at follow-up. Further prospective studies are needed to better delineate the role of cultures in CRS management. Level of evidence4.

Relation of Anthropometric Obesity and Computed Tomography Measured Nonalcoholic Fatty Liver Disease (from the Multiethnic Study of Atherosclerosis)

We hypothesized that anthropometric measures of abdominal obesity would have a stronger positive association with nonalcoholic fatty liver disease (NAFLD) measured by noncontrast computed tomography versus general measures of obesity. The Multiethnic Study of Atherosclerosis comprised participants aged 45 to 84years free of known cardiovascular disease. We studied 4,088 participants with adequate liver and spleen computed tomography imaging and no previous use of oral steroids, class 3 antiarrhythmics, moderately heavy alcohol use, or cirrhosis. Prevalent NAFLD was defined as a liver:spleen Hounsfield attenuation ratio of <1. Multivariable log-linear regression modeled the association of 4 obesity measures-weight, body mass index (BMI), waist circumference, and waist-to-hip ratio-with prevalent NAFLD. Receiver-operator curve analysis compared NAFLD discrimination. Median age was 63years, and 55% were women. For each obesity measure, adjusted prevalence ratios for NAFLD were fourfold to fivefold greater in the highest versus the lowest quartile (p <0.001). Waist circumference and BMI had the highest prevalence ratios, and waist circumference had the best discrimination, for NAFLD in the total population, although an abnormal BMI categorized subjects with NAFLD as well if not better than waist circumference. In ethnic-specific analysis, whites and Chinese had the strongest association of obesity and NAFLD compared with other ethnicities. In conclusion, although waist circumference provided the best discrimination for NAFLD, BMI may perform similarly well in clinical settings to screen for NAFLD.

An epidemiological perspective on severe asthma

Methods From a large population based study in West Sweden, a subgroup of 744 people with active asthma was characterised with extensive clinical examinations and detailed questionnaires. In this cohort we defined different parameters of severity as follows –1) low lung function as FEV1% predicted below 70%, 2) multi-symptom asthma described day-time symptoms, 3) 2 or more night-time awakenings per month, 4) use of rescue medications 3 or more times per week, 5) any respiratory emergency visits and 6) use of oral steroids regularly or on exacerbations in the last year. We outlined particular subgroups of asthmatics who presented with different extend of overlap of these characteristics and looked into possible risk factors for the separate groups.

The Role of Neutrophils in Difficult-to-Treat Chronic Urticaria

RationaleNeutrophil predominance may be seen in the skin biopsies of difficult-to-treat chronic urticaria (dCU) patients. Data regarding the clinical course of CU patients based on the tissue infiltrate obtained from skin biopsy is limited. Our study compared serological and clinical parameters between neutrophilic-predominant urticaria (NU) and lymphocytic-predominant urticaria (LU) patients.MethodsFifty-one biopsies from dCU patients from 1999-2011 were reviewed. dCU was defined as treatment failure with at least 2 concurrent anti-histamines, use of oral steroids and/or immunomodulators. All biopsies were reviewed independently by 2 pathologists for cell count. Autoimmune markers (anti-nuclear antibody, anti-thyroid antibodies, rheumatoid factor, CU index), medications given (oral steroids, immunomodulators) and response to treatment were analyzed.ResultsSeventy-five percent (38/51) of patients were neutrophil predominant on biopsy. Forty-nine percent (25/51) had negative autoimmune markers. Sixty-seven percent (34/51) were on oral steroids and 18% (9/51) were on immunomodulators (dapsone, omalizumab, hydroxychloroquine, sulfasalazine). Twenty-seven percent (14/51) had complete resolution of symptoms, while 73% (37/51) had incomplete resolution. There was no statistically significant difference in the presence of autoimmune markers, resolution of symptoms, steroid and immunomodulator use between NU and LU patients.ConclusionsIn our study population, neutrophils were the predominant cell type on biopsy among dCU patients. However, this was not significantly associated with the presence of autoimmune markers or the use of steroids or immunomodulators. Further studies are needed to determine the influence of neutrophils and lymphocytes in dCU and its responsiveness to medical treatment. RationaleNeutrophil predominance may be seen in the skin biopsies of difficult-to-treat chronic urticaria (dCU) patients. Data regarding the clinical course of CU patients based on the tissue infiltrate obtained from skin biopsy is limited. Our study compared serological and clinical parameters between neutrophilic-predominant urticaria (NU) and lymphocytic-predominant urticaria (LU) patients. Neutrophil predominance may be seen in the skin biopsies of difficult-to-treat chronic urticaria (dCU) patients. Data regarding the clinical course of CU patients based on the tissue infiltrate obtained from skin biopsy is limited. Our study compared serological and clinical parameters between neutrophilic-predominant urticaria (NU) and lymphocytic-predominant urticaria (LU) patients. MethodsFifty-one biopsies from dCU patients from 1999-2011 were reviewed. dCU was defined as treatment failure with at least 2 concurrent anti-histamines, use of oral steroids and/or immunomodulators. All biopsies were reviewed independently by 2 pathologists for cell count. Autoimmune markers (anti-nuclear antibody, anti-thyroid antibodies, rheumatoid factor, CU index), medications given (oral steroids, immunomodulators) and response to treatment were analyzed. Fifty-one biopsies from dCU patients from 1999-2011 were reviewed. dCU was defined as treatment failure with at least 2 concurrent anti-histamines, use of oral steroids and/or immunomodulators. All biopsies were reviewed independently by 2 pathologists for cell count. Autoimmune markers (anti-nuclear antibody, anti-thyroid antibodies, rheumatoid factor, CU index), medications given (oral steroids, immunomodulators) and response to treatment were analyzed. ResultsSeventy-five percent (38/51) of patients were neutrophil predominant on biopsy. Forty-nine percent (25/51) had negative autoimmune markers. Sixty-seven percent (34/51) were on oral steroids and 18% (9/51) were on immunomodulators (dapsone, omalizumab, hydroxychloroquine, sulfasalazine). Twenty-seven percent (14/51) had complete resolution of symptoms, while 73% (37/51) had incomplete resolution. There was no statistically significant difference in the presence of autoimmune markers, resolution of symptoms, steroid and immunomodulator use between NU and LU patients. Seventy-five percent (38/51) of patients were neutrophil predominant on biopsy. Forty-nine percent (25/51) had negative autoimmune markers. Sixty-seven percent (34/51) were on oral steroids and 18% (9/51) were on immunomodulators (dapsone, omalizumab, hydroxychloroquine, sulfasalazine). Twenty-seven percent (14/51) had complete resolution of symptoms, while 73% (37/51) had incomplete resolution. There was no statistically significant difference in the presence of autoimmune markers, resolution of symptoms, steroid and immunomodulator use between NU and LU patients. ConclusionsIn our study population, neutrophils were the predominant cell type on biopsy among dCU patients. However, this was not significantly associated with the presence of autoimmune markers or the use of steroids or immunomodulators. Further studies are needed to determine the influence of neutrophils and lymphocytes in dCU and its responsiveness to medical treatment. In our study population, neutrophils were the predominant cell type on biopsy among dCU patients. However, this was not significantly associated with the presence of autoimmune markers or the use of steroids or immunomodulators. Further studies are needed to determine the influence of neutrophils and lymphocytes in dCU and its responsiveness to medical treatment.

Systemic IL-17 Signaling Relates to Gender, Disease Severity and Use of Oral Steroids in Children with Asthma

Systemic IL-17 Signaling Relates to Gender, Disease Severity and Use of Oral Steroids in Children with Asthma

Role of immunotherapy in allergic fungal rhinosinusitis.

Our understanding of the pathogenesis and treatment of allergic fungal rhinosinusitis (AFRS) continues to evolve. This article serves to update the reader on the diagnosis and management of AFRS and pays particular attention to the recent literature regarding efficacy and safety of immunotherapy in this patient population. The mainstay of treatment of AFRS remains a thorough surgery; however, adjunctive medical management is also critical to achieve optimal outcomes. Oral steroid use in AFRS remains recommended. Immunotherapy, both fungal and nonfungal, may be considered for patients exhibiting a type I hypersensitivity to specific allergens. To date, limited studies do show improvement with reduction of postoperative exacerbations and revision surgeries. There remains no evidence of unusual side-effects or formation of immune complexes from immunotherapy in AFRS patients. Double-blind placebo controlled trials on immunotherapy and AFRS are lacking, and ultimately, conclusive evidence of efficacy is not present to date. Treatment of AFRS requires multimodality therapy with immunotherapy playing a significant, yet inconclusive, role. Further studies remain warranted.

Imatinib Mesylate-Induced Erythema Multiforme: Recurrence after Rechallenge with 200 mg/day Imatinib.

Dear Editor: Imatinib mesylate (Gleevec; Novartis AG, Basel, Switzerland), a selective tyrosine receptor kinase inhibitor, is increasingly used for treating chronic myeloid leukemia, Philadelphia chromosome-positive acute lymphoblastic leukemia, and high-grade gastrointestinal stromal tumors (GISTs)1. Several cases of cutaneous reactions after imatinib use have been reported1. We report a case of EM after imatinib administration for the treatment of a GIST. A 66-year-old woman was referred for pruritus from the department of oncology. She received a diagnosis of a GIST, for which she received adjuvant imatinib therapy after gastric wedge resection. She noticed a pruritic rash on her trunk after 5 weeks of 400 mg/day imatinib therapy. Physical examination revealed generalized variable-sized erythematous wheal-like patches with some targetoid lesions on the trunk, face, and extremities (Fig. 1). Immunoglobulin (Ig) G and IgM antibodies to the herpes simplex virus were not detected. A skin biopsy from the trunk revealed vacuolar degeneration, tagging of lymphocytes along the dermal-epidermal junction, and perivascular lymphocytic and some eosinophilic infiltrations in the upper dermis (Fig. 2A). Some dyskeratotic and necrotic keratinocytes were obvious in the epidermis (Fig. 2B); therefore, EM was diagnosed. As imatinib was the only medication administered to the patient, it was considered the most probable cause. Imatinib was discontinued, and oral steroid and antihistamine were prescribed. For 2 weeks, 30 mg/day steroid, tapered to 5 mg/day, was administered. One month after the discontinuation of imatinib therapy, the rash was fully cured. Imatinib treatment was restarted at a lower dose of 100 mg/day without steroids; no skin lesion developed for 2 months. However, when the dose was increased to 200 mg/day without oral steroids, a similar rash developed. The patient could continue imatinib therapy with a gradual dose escalation from 100 to 200 mg/day with concomitant 5 mg/day oral steroids. No additional skin lesions were detected during 5 months of follow-up. Fig. 1 Clinical manifestations of the patient. (A) Generalized erythematous variable-sized wheal-like patches on the trunk. (B) Several lesions showing the typical targetoid appearance. Fig. 2 Histopathological findings of the lesion. (A) Vacuolar degeneration, tagging of lymphocytes along the dermal-epidermal junction, and perivascular lymphocytic and a few eosinophilic infiltrations in the upper dermis (H&E, ×200). (B) Spongiosis ... It is estimated that approximately 7%~21% of patients treated with imatinib experience variable degrees of skin eruptions2. There are a few reports of imatinib-induced EM. Park et al.3 reviewed patients with cutaneous eruptions after imatinib therapy, and 2 of 10 patients (20%) had EM-like drug eruptions. The cutaneous adverse effects of imatinib are dose dependent and seemingly related to a pharmacological effect of the drug1,2. The most common skin reactions are maculopapular rashes1,2, and these are spontaneously relieved with a minimal dose of antihistamine or topical steroids. Several uncommon or severe reactions such as Stevens-Johnson syndrome have also been reported; however, they seem to be an idiosyncratic adverse reaction of hypersensitivity4. These reactions require the concomitant use of oral steroids, and immediate discontinuation of imatinib therapy is imperative4,5. Here, we observed a case of imatinib-induced EM. We noted a dose-dependent relation; thus, we consider that imatinib-induced EM is related to a pharmacological effect of imatinib. The skin lesion subsided and did not recur only with the concomitant use of low-dose oral steroids. As imatinib is a very effective therapeutic agent and alternative treatment options are limited, recognition of adverse cutaneous reactions after imatinib therapy and the appropriate management required is helpful.

Necrotizing fasciitis associated with systemic lupus erythematosus in a child.

Sir, Necrotizing fasciitis (NF) is a rapidly progressive, potentially fatal necrotizing infection of skin and subcutaneous tissues.[1] It is rarely seen in children and its association with systemic lupus erythematosus (SLE) is even rarer. We report a 11-year-old female child who developed NF of the lower leg and was incidentally diagnosed to have SLE. Patients with SLE are predisposed to develop fatal infections. Early recognition of this condition and its association is important to prevent mortality. A 11-year-old female child was referred from the pediatric intensive care unit for evaluation of painful skin lesions on her left lower limb since two weeks. There was a history of local trauma following which the child developed swelling and pain of her left lower limb associated with fever. She was diagnosed to have cellulitis and treated with intravenous antibiotics ceftriaxone, amikacin, and metrogyl with not much improvement. Past history was noncontributory. Cutaneous examination revealed ill-defined ecchymotic plaque with overlying bullae on the medial aspect of left lower leg [Figure 1]. The entire limb was edematous and tender with local increase in temperature. Over one day, the lesions blackened with areas of necrosis and yellowish slough involving the entire lower limb. In few days, there was necrosis extending into deeper planes of skin. Laboratory investigations showed anemia (hemoglobin: 6.2 mg%), leukopenia (2500 cells/mm3), thrombocytopenia (32,500 cells/mm3), increased liver enzymes, and hyponatremia. Urine routine test showed hematuria and proteinuria. Erythrocyte sedimentation rate (ESR) and C-reactive protein were highly elevated. Chest radiography and ultrasonogram abdomen were normal. Serology for Human immunodeficiency virus (HIV) and blood culture was negative. Culture from the tissue and pus grew group A Streptococcus, Klebsiella, and Escherichia coli. A diagnosis of NF was considered. In view of the above clinical features and investigations, antinuclear antibody and anti-double-stranded DNA tests were done, which were strongly positive. A final diagnosis of systemic lupus erythematosus with NF was made. Surgical debridement of necrotic tissue was done [Figure 2]. As the necrosis had reached the bony tissues, amputation was done. However, the child died due to sepsis.Figure 1: Ecchymotic plaque with overlying bullae and necrotic areas on the medial aspect of left lower legFigure 2: Surgical debridement showing necrotic tissue extending into deeper planesNF is a life-threatening infection with a high mortality rate ranging from 20% to 80% despite the use of appropriate treatment modalities. The etiology of NF is polymicrobial in nature. Most patients with NF have associated comorbidities such as diabetes, HIV infection, renal failure that predispose them to infections.[2] Clinically the patient presents with ecchymosis, bullae, necrosis, and gangrene. The inflammation rapidly progress to involve deep fascial planes thus making the importance of early diagnosis and exploration. Infections are the major cause of mortality in SLE. Even though SLE patients are prone to develop infections, NF is rarely reported. There is an increased risk of infections in SLE due to impaired cell-mediated immunity, immunoglobulin deficiencies, complement factor deficiency, and various defects in other immune effector cells, including neutrophils, macrophages, and natural killer cell.[3] Genetic predisposition and presence of R131variant of FCrRIIA on Fc receptor are believed to contribute to the risk of infection.[4] NF has been associated with other rheumatic disorders that include dermatomyositis, polymyositis, systemic sclerosis, rheumatoid arthritis, and ankylosing spondylitis.[5] Clinically, NF may not be diagnosed early and only when necrosis occurs diagnosis may become evident. In our case, the child had been diagnosed as having soft tissue infection before presenting to us and treated with antibiotics, which were unresponsive. This indicated deeper infection that required aggressive approach and exploration. Even though appropriate interventions and surgical debridement was done, as the child had presented to us late, there was a delay in diagnosis; the child had to undergo amputation and eventually succumbed to sepsis. There is partly increased risk of infections due to use of oral steroids and immunosuppressants in SLE cases but our case was treatment naïve and it was SLE-associated immunosuppression that must have contributed to the infection. Impaired immune response in SLE is a primary risk factor for developing NF which is an emergency condition requiring early detection and quick debridement. Increased awareness of this condition and its association is necessary to prevent mortality.

Clinical Characteristics and Expression Pattern of IL-33 and IL-25 According to Histologic Classification in Chronic Rhinosinusitis with Nasal Polyposis

Background and Objectives:Many kinds of inflammatory cells and cytokines are suggested to be related to the patho - physiology of chronic rhinosinusitis with nasal polyposis (CRSwNP), but not yet fully understood. The objectives of this study were to classify CRSwNP patients according to histologic features and to reveal the roles of IL-33 and IL-25, on the pathophysiology of CRSwNP. Materials and Method:CRSwNP patients (n=122) were divided into 3 groups according to the type of nasal polyp; eosinophilic polyp (EP, n=38), neutrophilic polyp (NeuP, n=15) and non-eosinophilic non-neutrophil- ic polyp (NENN, n=63) groups. Clinical features and the expressions of IL-25 and IL-33 were evaluated among the groups. Results:The EP group showed many clinical features that were different from the other groups: increased prevalence of asthma and olfactory dysfunction, increased percentage of blood eosinophils, increased E/M ratio, and poor postoperative outcomes such as recurrent polyposis and the need for frequent use of oral steroids. Numbers of IL-33 and IL-25 positive cells were significantly higher in the EP group compared with the other groups in the lamina propria (p=0.001). Conclusion:These results suggest that patients with an eosinophilic polyp are clinically and pathogenetically different from patients with other types of polyps, and IL-25 and IL-33 are associated with the pathogenesis of chronic rhinosinusitis with eosinophilic polyps.