Randomized trial: inflammatory response to corticoids versus placebo in moderate and severe bronchiolitis. COTHEBstudy.

Background: The use of corticosteroids has been shown not to improve the prognosis of patients with bronchiolitis, but it could be assumed that steroids will reduce inflammation. This study aimed to assess whether corticoid therapy influenced the inflammatory and clinical response of critically ill infants. Methods: Prospective, randomized, double blind placebo-controlled trial of glucocorticoids (GCT) in infants of less than 12 monthswith severe or moderate bronchiolitis. Patients were randomized to receive systemic corticoid therapy or placebo. The main outcomes were: a) levels of lymphocyte subsets; b) levels of IL-2, IL-12, and IFNγ as pro-inflammatory factors,and c) levels of IL-4 and IL-10 as anti-inflammatory response. Secondary outcomes related with the clinical response were also analyzed. Results: 97 patients were randomized. Evolution of lymphocyte subsets was similar in both groups. Pro-inflammatory interleukins and interferon decreased, but without differences. Anti-inflammatory interleukins showed a significant decrease from baseline to the end of the study, and IL-10 values were significantly lower (p = 0.046) in the GCT group [1.82 pg/ml (1.2-3.5)] vs non-GCT [4 pg/ml (1.5-6.3)]. GCT group showed a lower time of mechanical ventilation and of hospitalization, but without statistically significant differences. No cases of severe adverse reaction to steroids were detected. Conclusions: administration of systemic GCT did not modify the inflammatory nor the clinical response of patients with severe bronchiolitis, except for IL-10 levels that were significantly lower in the GCT group. This can open a line of investigation about the relation of IL-10 and response to bronchiolitis.Trial registration: Glucocorticoid Therapy Impact on the Inflammatory Response and Clinical Evolution in Patients With Severe Bronchiolitis, Clinical Trials.gov registration number: NCT02571517.Study start date: Nov 2011.

Randomized trial: corticoids versus placebo in severe bronchiolitis. COTHEB study.

Background: Corticosteroids as modulation the inflammatory response is a controversial issue in the treatment of bronchiolitis. This study aimed to assess whether corticoid therapy influenced the inflammatory and clinical response of critically ill infants. Methods: Prospective, randomized, double blind placebo-controlled trial of glucocorticoids (GCT) in infants of less than 12 months with severe or moderate bronchiolitis. Patients were randomized to receive corticoid therapy or placebo. The main outcomes were: a) levels of lymphocyte; b) levels of IL-2, IL-12, and IFNγ as pro-inflammatory factors, and c) levels of IL-4 and IL-10 as anti-inflammatory response. Secondary outcomes related with the clinical response were also analyzed. Results: 97 patients were randomized. Evolution of lymphocyte subsets was similar in both groups. Pro-inflammatory interleukins and interferon decreased, but without differences. Antiinflammatory interleukins showed a significant decrease from baseline to the end of the study, and IL-10 values were significantly lower in the GCT group. GCT group showed a lower time of mechanical ventilation and of hospitalization, but without statistically significant differences No cases of severe adverse reaction to steroids were detected. Conclusions: administration of systemic GCT did not modify the inflammatory not the clinical response of patients with severe bronchiolitis, except for IL-10 levels that were significantly lower in the GCT group. Trial registration: Glucocorticoid Therapy Impact on the Inflammatory Response and Clinical Evolution in Patients With Severe Bronchiolitis, NCT02571517. ClinicalTrials.gov registration number: 2011-000337-36. Date of registration: 30 june 2012 (retrospectively registered).

Encephalopathy in a kidney transplant recipient

A 60-year-old man presented several times to the emergency department due to confusion and behavioral changes. He was a kidney transplant recipient dependent on hemodialysis due, presumably, to chronic nephropathy of the transplanted kidney, and was not under any immunosuppressive therapy. He was admitted to the hospital ward due to elevation of C reactive protein and severe proteinuria, leukocyturia and erythrocyturia. The alterations found in the spot urine examination were suggestive of nephritic syndrome, consistent with chronic nephropathy of the transplanted kidney. The neurologic deterioration, however, remained unexplained. CT of the brain and cerebrospinal fluid examination were unremarkable. Infection, auto-immune disease and malignancy were excluded. Corticoid therapy was started for rejection nephropathy. The patient improved dramatically and ultimately the transplanted kidney was removed. Chronic nephropathy of the transplanted kidney was confirmed histologically and the patient remained clinically asymptomatic, without corticoid therapy.

Alopecia Areata and Suicide Ideation

Alopecia areata represents an autoimmune process against an unidentified autoantigen in the follicle of the hair, which affects all ages, from young children (a few months old) to elderly patients. Alopecia areata has an important impact on the quality of life, leading to a predisposition towards anxiety and depression, especially if the patients are treated with corticoid therapy that heightens the risk for such psychiatric disorders. We present the case of a patient with alopecia areata who was diagnosed at the age of 18 months, and had been followed-up until the age of 27 years.