Use of Inhaled Corticosteroids or Oral Steroids in a COVID-19 Telemedicine Cohort: Retrospective Chart Review (Preprint)

BACKGROUND We identified patients with coronavirus disease 2019 that were followed by a telemedicine clinic and eventually referred to a post COVID clinic due to persistent symptoms of COVID-19. Of those patients requiring referral to the post COVID clinic, equal percentages of patients treated acutely with inhaled corticosteroids (ICS) and/ or oral steroids required referral to a pulmonary specialist. OBJECTIVE To determine if there was a difference in long term outcomes when prescribed ICS versus oral steroids METHODS Chart review comparing new prescription ICS to new prescription oral steroid RESULTS No difference in long term outcome between the groups CONCLUSIONS It is safe to prescribe ICS or oral steroids for symptom relief, but cost may be an issue

Atypical Multiple Sclerosis Presenting as Bilateral Optic Neuritis

Purpose: We report a case of multiple sclerosis with bilateral optic neuritis that was atypical in terms of both the clinical signs and symptoms.Case summary: A 34-year-old female visited the department of neurology with a complaint of sudden-onset, left lower extremity weakness and numbness that had developed 3 weeks prior, and bilateral blurred vision that had commenced 2 weeks prior. The patient was diagnosed with multiple sclerosis and prescribed high-dose intravenous methylprednisolone for 3 days, but the blurred vision did not improve. The patient was referred to the ophthalmology department. The initial best-corrected visual acuity was 0.04 in both eyes, and the relative afferent pupillary defect test was positive for the left eye. The Ishihara color test scores were 1/17 for both eyes. No optic disc swelling was evident on fundus examination. Brain and spine magnetic resonance imaging (T2-weighted) performed during the initial visit revealed lesions of high signal intensity in the frontal, subcortical white matter; the optic chiasm; the left retrobulbar optic segment; the medulla; and the spinal C2-5 processes. Aquaproin-4 immunogloblin G antibody (AQP4-IgG Ab) was not detected in serum. One month after prescription of the oral steroid, the vision improved to 1.0 in the right and 0.8 in the left eye. The patient was lost to follow-up after prescription of interferon-beta for 4 years, without recurrence.Conclusions: Binocular optic neuritis accompanied by severe visual loss is a rare form of multiple sclerosis. A thorough diagnosis (with a focus on exclusion) is required, as is appropriate treatment.

Antituberculosis Drug-induced Linear IgA Dermatosis

Introduction: Linear IgA dermatosis is a rare autoimmune vesiculobullous disease characterized by homogeneous linear IgA deposits in basement membrane of epidermis, and it can be idiopathic or drug-induced. The pathogenesis of drug-induced linear IgA dermatosis is not fully known yet, but it is associated with specific T cells. The clinical manifestations of the disease include vesiculobullous eruption, erythematous plaques, or string of pearls. Most cases still need additional therapy to avoid the expansion of the disease. Case Presentation: In this study, we present a 17-year-old male patient with erythema plaques, vesicles, and bullae with erosion in facial, oral, neck, trunk, genital, and extremities, pruritus, and burning sensation. The patient was undergoing pulmonary tuberculosis (TB) treatment for one week. Physical examination was done, and total BSA 10% and negative Asboe-Hansen sign were seen. The treatment consisted of delaying administration of TB drugs, desoximetasone cream 0.25%, cetirizine 10 mg, and aspiration of bullae. Conclusions: Drug-induced linear IgA dermatosis can occur at any age due to the administration of rifampicin and other antibiotics, angiotensin-I converting enzyme (ACE) inhibitors, or nonsteroidal anti-inflammatory drugs (NSAIDs). The drug can stimulate specific T cells that release Th2 cytokines to produce IgA antibodies against the basement membrane of epidermis. Drugs may cause an autoimmune response by cross-reaction with the target epitope, altering the conformation of epitopes, or exposing previously sequestered antigens to the immune system. The causative drug was stopped, and methyl prednisolone 0.5 - 1 mg/kg/day was given as initial therapy. In this study, we reported a rare case of a 17-year-old male with anti-TB drug-induced linear IgA dermatosis. Diagnosis was done based on clinical manifestation, histopathology, and immunofluorescence. The causative drug was stopped, the patient was given topical and systemic steroid therapy and drug desensitization. Remission was noted after six weeks of therapy, and oral steroid was slowly tapered and stopped on day 42. After stopping oral steroids, no lesions were reported. A 6-month follow-up revealed no signs of recurrence.

Pediatric Autoimmune encephalitis: Experience from a Tertiary Care Hospital in Bangladesh

Background: Autoimmune encephalitis (AIE) are distinct group of encephalitis where production of autoimmune antibody causes neuroinflammation. The core clinical features are encephalopathy, psychiatric disorder, movement disorder and seizure. The investigation and treatment modalities are different from that of infectious encephalitis. There are limited studies in pediatric population in particularly in developing country like Bangladesh. Thus this study has been done to describe patients with AIE from a tertiary care hospital. Method: This is a retrospective study done in children of 1-16 year from January 2018 to December 2019. AIE was diagnosed on the basis of clinical, electrographic and neuroimaging features and was confirmed with detection of autoantibody in CSF. Treatment was given according to the published literature with immunotherapy mainly. Results: Total 15 children were studied, 14 patients were antiNMDAR encephalitis and 1 was antiMOG antibody syndrome. Mean age was 5.98 and 4.5 year respectively. Seizure was the most common clinical feature, mostly focal in nature. Other manifestations were movement disorder, psychiatric disorder, loss of consciousness etc. Most of the patients had abnormal EE, focal epileptic discharge being the commonest. Eight out of 15 had abnormal MRI of brain. Cortical hyperintensity was important feature located mostly in temporal region. In the case of antiMOG antibody syndrome there was demyelinating lesion in multiple areas. Cornerstone of the treatment was mostly combination immunotherapy with IV methylprednisolone and IV immunoglobulin followed by oral steroid. Majority of the patients showed improvement however 3 patients had complete recovery. Complications observed were epilepsy, speech disorder, cognitive disorder, behavioural disorder, ataxia and visual impairment. Conclusion: Timely diagnosis and prompt treatment of AIE is very important as proper treatment can cause significant improvement.

ASSESSMENT OF RISK FACTORS OF OSTEOPOROSIS IN POSTMENOPAUSAL WOMAN

Background: To determine the usefulness of risk assessment and screening for osteoporosis in a hospital based population of postmenopausal women. Methods: 100 women with post-menopausal women, age more than 40 yrs, cessation of period more than 1yr were included in the study. Result: 17 (17.0%) were more than 65 years of age. Low body weight, inadequate dietary intake of calcium and decreased physical activity were most commonly associated risk factor. 4 (4.0%) women were smokers, women had history of oral steroid intake for >3 months for various medical illnesses. Conclusion: Evaluation of postmenopausal women by screening for risk factors was found to be a powerful tool to define the risk status for osteoporosis. Low body weight and poor dietary calcium are modifiable risk factors for developing osteoporosis. Keywords: Osteoporosis, Post-Menopausal, Prevalence

253 Imaging of congenital AV block caused by maternal autoantibodies: a single-centre experience

Aims Autoimmune congenital heart block (CHB) is a severe manifestation of neonatal lupus syndrome. There is lack of consensus regarding treatment of pregnant women with anti-SSA/SSB autoantibodies. To evaluate the effectiveness of the combined protocol therapy (oral steroid, plasmapheresis, and IVIG) for the CHB treatment. Methods and results All cases of CHB from 2000 to 2020 were retrospectively enrolled. All the patients underwent foetal echocardiography for the evaluation of CHB, ventricular rate and main related foetal complications: cardiomegaly, pericardial and pleural effusion, foetal hydrops, dilated cardiomyopathy, and heart failure. Moreover, postnatal major adverse cardiovascular, such as death and pacemaker implantation, were recorded. For statistical analysis, the population was divided into two cohorts: a protocol group receiving in utero combined therapy and a control group receiving other therapies or not treated. Among 252 pregnancies with anti-SSA/SSB antibodies, 36 developed CHB. At birth, complete CHB treated with protocol therapies showed a significantly higher ventricular rate (P = 0.042), a significant reduction in intrauterine or postnatal mortality (P = 0.018), and a lower rate of pacemaker implantation (P = 0.049). Conclusions The combined treatment protocol has proven effective in improving foetal and neonatal short- and long-term survival.

Effect of oral Anabolic Steroids on BMI, Functional Capacity and Pulmonary Functions of under nourished patients of COPD

Aim: Effects of oral anabolic steroids on BMI, functional capacity and pulmonary functions of under nourished patients of COPD Methodology: All COPD patients outside pulmonary rehabilitation program, who met the inclusion criteria, were included. Subjects were given methandienone 5mg BD for six months. Weight, BMI, paO2, peak expiratory flow rate, FEV1 was measured for all subjects initially and six months after treatment. Results: There was significant improvement in weight (p <0.01), BMI (p <0.01), paO2 (p 0.04), peak expiratory flow (p <0.01), six minutes walk distance (p <0.01), CAT (p <0.01) and mMRC scores (p <0.01) after 6 months therapy with anabolic steroid. Conclusion: Treatment with Oral anabolic steroids has a significant effect on BMI and functional capacity of patients with COPD. Keywords: BMI, COPD, oral steroid

Human umbilical cord-derived mesenchymal stem cells treatment for refractory uveitis: a case series

AIM: To evaluate therapeutic outcomes of human umbilical cord-derived mesenchymal stem cells (HUC-MSCs) treatment in patients with refractory uveitis. METHODS: A retrospective and noncomparative review was performed on four patients with refractory uveitis from December 2013 to December 2017. HUC-MSCs were administered intravenously at a dose of 1×106 cells/kg. Clinical response, relapse rate, change of visual acuity, and other metrics were evaluated. RESULTS: All four patients presented with responses to HUC-MSCs treatment, with three males and one female. The numbers of uveitis attacks per year after the HUC-MSCs treatment (0, 2, 0, 0 respectively) all decreased compared with the numbers before the treatment (3, 6, 4, 4 respectively). The oral steroid and immunosuppressive agents were tapered in all patients without recrudescence of ocular inflammation, and three patients discontinued their oral medicine at the last visit. The best corrected visual acuity (BCVA) of 3 patients was improved to varying degrees, and the BCVA of 1 patient remained at 20/20 (Snellen chart) from the first to the last consultation. CONCLUSION: The study provides an effective therapy of HUC-MSCs in maintaining remission in patients affected by uveitis refractory to previous immunosuppressant treatments.

Treatment of Idiopathic Granulomatous Mastitis: Combined Intralesional Steroid Injection with Topical Steroid Administration vs. Systemic (Oral) Steroid

BackgroundIdiopathic granulomatous mastitis (IGM)is characterized by non-caseating granuloma and microabscess formation limited to mammary gland lobules. It is a form of chronic mastitis of unknown pathogenesis. In this study, we aimed to compare the effectiveness of intralesional steroid injection with topical steroids versus systemic steroid therapy in the treatment of IGM. MethodsBetween June 2017 and December 2020, the patients were collected and assessed. IGM was diagnosed histopathologically by tru-cut biopsy in patients with breast mass, pain, and erythema with suspicion of IGM. Included in the study were one hundred and eleven patients who were diagnosed with IGMand who were treated with local or oral administration of corticosteroids, with at least 6 months of follow-up. The patients were divided into 2 groups: a local corticosteroid treatment group (LC, group 1, n=57); and a peroral corticosteroid treatment group (OC, group 2, n=54). Demographic characteristics, treatment responses, recurrence rates, side effects of the steroid, and the need for surgery were compared.ResultsWhile the rate of smoking was 12.3% in the LC group, was 20.4% in the OC group. There was no history of oral contraceptive use in either group of patients. Previous steroid use was significantly lower in the LC group (10.5%) compared to the OC group (55.6%) (p = 0.001). Previous antibiotic use was significantly lower in the LC group (75.4%) compared to the OC group (100%) (p = 0.001). When complete and partial responders were grouped as “responders,” 96.5% in the LC group and 75.9% in the OC group responded after the first course of treatment (p=0.001). 98.2% in the LC group and 87.0% in the OC group were complete responders after the third course of treatment (p=0.003). While 7% of the patients in the LC group had recurrence, 37% in the OC group had recurrence (p=0.001). Steroid-related side effects were lower in the LC group (no) compared to the OC group (11.1%) (p=0.010). Surgery was performed in 3.5% of the LC group, while surgery was performed in 57.3% of the OC group (p=0.001). ConclusionSteroid injection is an IGM treatment with proven efficacy, short response time, low recurrence rate, and lower need surgery. The treatment is easy to administer and minimizes the risk of systemic side effects. Even in clinically severe cases, we believe that steroid injection might be used as monotherapy, or in combination with other therapies, to improve treatment efficacy and create a transition to less aggressive treatments.

Plasma proteins elevated in severe asthma despite oral steroid use and unrelated to Type-2 inflammation

RationaleAsthma phenotyping requires novel biomarker discovery.ObjectivesTo identify plasma biomarkers associated with asthma phenotypes by application of a new proteomic panel to samples from two well-characterised cohorts of severe (SA) and mild-to-moderate (MMA) asthmatics, chronic obstructive pulmonary disease (COPD) subjects and healthy controls (HC).MethodsAn antibody-based array targeting 177 proteins predominantly involved in pathways relevant to inflammation, lipid metabolism, signal transduction and extracellular matrix was applied to plasma from 525 asthmatics and HC in the U-BIOPRED cohort, and 142 subjects with asthma and COPD from the validation cohort BIOAIR. Effects of oral corticosteroids (OCS) were determined by a two-week, placebo-controlled OCS trial in BIOAIR, and confirmed by relation to objective OCS measures in U-BIOPRED.ResultsIn U-BIOPRED, 110 proteins were significantly different, mostly elevated, in SA compared to MMA and HC. Ten proteins were elevated in SA versus MMA in both U-BIOPRED and BIOAIR (alpha-1-antichymotrypsin, apolipoprotein-E, complement component 9, complement factor I, macrophage inflammatory protein-3, interleukin-6, sphingomyelin phosphodiesterase 3, RANK, TGF-β1, and glutathione S-transferase). OCS treatment decreased most proteins, yet differences between SA and MMA remained following correction for OCS use. Consensus clustering of U-BIOPRED protein data yielded six clusters associated with asthma control, quality of life, blood neutrophils, hsCRP, and BMI, but not Type-2 inflammatory biomarkers. The mast cell specific enzyme carboxypeptidase A3 was one major contributor to cluster differentiation.ConclusionsThe plasma proteomic panel revealed previously unexplored yet potentially useful Type-2-independent biomarkers, and validated several proteins with established involvement in the pathophysiology of severe asthma.