Immunosuppression in Chronic Asthma

There is considerable evidence that the T lymphocyte plays a role in the pathogenesis of asthma. Cyclosporin A (CsA), an immunosuppressive agent which acts primarily by inhibition of T lymphocyte activation, improved lung function and reduced the frequency of disease exacerbations in steroid-dependent asthmatics. While oral immunosuppressive therapies are limited by toxicity, novel agents based on inhibition of the T lymphocyte and delivered by the inhaled route might provide a new approach to therapy not only for chronic severe asthma but also for the much larger number of patients with milder disease.

Acute Idiopathic Pulmonary Haemorrhage in a 2 month old Infant: Case report and review of the literature

Pulmonary haemorrhage is usually secondary to a systemic disease affecting the lung with or without other organ involvement. Idiopathic pulmonary haemorrhage is a diagnosis of exclusion; as described in the literature, it is a rare disease. We report a two months old infant who presented at the Emergency Department of Sultan Qaboos University Hospital, Oman, with respiratory failure and shock secondary to an acute severe pulmonary haemorrhage. Detailed investigations for pulmonary, cardiovascular, renal and systemic inflammatory causes were negative. His clinical presentation and radiological imaging were consistent with idiopathic pulmonary haemorrhage. Treatment with corticosteroids resulted in a remarkable and fast recovery from his critical respiratory status.

Pneumocystis jiroveci pneumonia and pneumomediastinum in an anti-TNFα naive patient with ulcerative colitis

We report the case of a 21-year-old man who was noted to have pneumomediastinum during an admission for an acute flare of ulcerative colitis. At that time, he was on maintenance treatment with azathioprine at a dose of 1.25 mg/kg per day, and had not received supplementary steroids for 9 mo. He had never received anti-tumor necrosis factor (TNF)α therapy. Shortly after apparently effective treatment with intravenous steroids and an increased dose of azathioprine, he developed worsening colitic and new respiratory symptoms, and was diagnosed with Pneumocystis jiroveci (carinii) pneumonia (PCP). Pneumomediastinum is rare in immunocompetent hosts, but is a recognized complication of PCP in human immunodeficiency virus (HIV) patients, although our patient’s HIV test was negative. Treatment of PCP with co-trimoxazole resulted in resolution of both respiratory and gastrointestinal symptoms, without the need to increase the steroid dose. There is increasing vigilance for opportunistic infections in patients with inflammatory bowel disease following the advent of anti-TNFα therapy. This case emphasizes the importance of considering the possibility of such infections in all patients with inflammatory bowel disease, irrespective of the immunosuppressants they receive, and highlights the potential of steroid-responsive opportunistic infections to mimic worsening colitic symptoms in patients with ulcerative colitis.

Allergic reactions after intravenous injection of methylprednisolone: A case report

Corticosteroid preparations have anti-inflammatory and immunosuppressive properties and are used widely for the treatment of allergic disorders and asthma. Steroids themselves, however, can induce hypersensitivity reactions. In this study, we report the case of a 66-year-old man with chronic obstructive pulmonary disease who exhibited an allergic reaction (rash, bronchospasm, bradycardia, severe hypotension and cardiac arrest) immediately after the intravenous injection of methylprednisolone sodium succinate. Despite cardiopulmonary resuscitation, sinus rhythm was not restored. The anesthesiologist should be aware that allergic reactions to corticosteroids can occur.

Concomitant gastric adenocarcinoma and stromal tumor in a woman with polymyalgia rheumatica

Gastrointestinal stromal tumors (GISTs) are rare neoplasms (1%) of the gastrointestinal tract and to our knowledge only rare cases of synchronous presentation of gastric carcinomas and GISTs are reported in the literature. A 72-year-old female with a simultaneous presentation of gastric adenocarcinoma and GIST is presented. Moreover, due to polymyalgia rheumatica the patient received corticosteroids as treatment for the last 3 years. The concomitant occurrence of these neoplasms may involve common carcinogenic factors and there could be an association with polymyalgia rheumatica either as a paraneoplastic presentation or due to its treatment with corticosteroids.

Treatment of severe steroid refractory ulcerative colitis

Although systemic steroids are highly efficacious in ulcerative colitis (UC), failure to respond to steroids still poses an important challenge to the surgeon and physician alike. Even if the life time risk of a fulminant UC flare is only 20%, this condition is potentially life threatening and should be managed in hospital. If patients fail 3 to 5 d of intravenous corticosteroids and optimal supportive care, they should be considered for any of three options: intravenous cyclosporine (2 mg/kg for 7 d, and serum level controlled), infliximab (5 mg/kg IV, 0-2-6 wk) or total colectomy. The choice between these three options is a medical-surgical decision based on clinical signs, radiological and endoscopic findings and blood analysis (CRP, serum albumin). Between 65 and 85% of patients will initially respond to cyclosporine and avoid colectomy on the short term. Over 5 years only 50% of initial responders avoid colectomy and outcomes are better in patients naive to azathioprine (bridging strategy). The data on infliximab as a medical rescue in fulminant colitis are more limited although the efficacy of this anti tumor necrosis factor (TNF) monoclonal antibody has been demonstrated in a controlled trial. Controlled data on the comparative efficacy of cyclosporine and infliximab are not available at this moment. Both drugs are immunosuppressants and are used in combination with steroids and azathioprine, which infers a risk of serious, even fatal, opportunistic infections. Therefore, patients not responding to these agents within 5-7 d should be considered for colectomy and responders should be closely monitored for infections.

Are we giving biologics too late? The case for early versus late use

Corticosteroids and immunomodulators have been the mainstay therapies for Crohn’s disease. Corticosteroids are highly effective to control symptoms in the short-term, but they are not effective in maintaining remission, they heal the mucosa in a reduced proportion of cases, and long-time exposure is associated with an increased risk of infections and mortality. Immunomodulators, azathioprine and methotrexate, heal the mucosa in a higher proportion of patients that corticosteroids but their onset of action is slow and they benefit less than half of patients with Crohn’s disease. In the last decade, medical therapy for Crohn’s disease has experienced a remarkable change due to the introduction of biologic therapy, and particularly the use of anti-tumour necrosis factor-alpha agents. Infliximab, adalimumab, and certolizumab pegol have demonstrated efficacy for induction and maintenance of remission in active Crohn’s disease. These agents have raised the bar for what is a suitable symptomatic response in Crohn’s disease and modification of the natural history of the disease has become a major goal in the treatment of Crohn’s disease. There are several data in the literature that suggest that early use of biologic therapy and achievement of mucosal healing contribute to disease course modification. However, many questions on early biological therapy for Crohn’s disease remain still unanswered.

Use of the Crohn’s disease activity index in clinical trials of biological agents

The Crohn’s disease activity index (CDAI) has been commonly used to assess the effects of treatment with different agents in Crohn’s disease (CD). However, these studies may be compromised, if the results compared to a placebo or standard therapy group (in the absence of a placebo) substantially differ from the expected response. In addition, significant concerns have been raised regarding the reliability and validity of the CDAI. Reproducibility of the CDAI may be limited as significant inter-observer error has been recorded, even if measurements are done by experienced clinicians with expertise in the diagnosis and treatment of CD. Finally, many CDAI endpoints are open to subjective interpretation and have the potential for manipulation. This is worrisome as there is the potential for significant financial gain, if the results of a clinical trial appear to provide a positive result. Physicians caring for patients should be concerned about the positive results in clinical trials that are sponsored by industry, even if the trials involve respected centers and the results appear in highly ranked medical journals.

Effective treatment with systemic corticosteroids for the relapse of the disease

We report on a case of eosinophilic esophagitis in a 33-year-old Japanese woman who visited our hospital with dysphagia and esophageal food impaction in April 2006. She had had the same symptoms in May 2005, and, by endoscopic and histologic examination, she was diagnosed with eosinophilic esophagitis. Biopsy specimens from multiple locations in the esophageal mucosa had shown remarkable infiltration of eosinophils, more than 20 eosinophils per high-power field in squamous mucosa, and she had been treated with Th2 cytokine antagonist and proton pump inhibitor at the time. Her symptoms had not improved, but she had received no further medical treatment. In 2006, upper gastrointestinal endoscopy showed edematous whitish esophageal mucosa, multiple ulcerations with whitish exudates on their surfaces, and white plaques. Biopsy specimens showed the same change as before, and corticosteroid (prednisolone 20 mg/day) was administered orally. After 2 weeks of corticosteroid therapy, her symptom had effectively improved. Endoscopy after 15 weeks of the therapy revealed remarkable improvement, and biopsy specimens from esophageal mucosa revealed the disappearance of the eosinophil infiltrates. We report on a case of eosinophilic esophagitis effectively treated with systemic corticosteroids. Eosinophilic esophagitis has, as yet, no standardized treatment. However, wider recognition of its features on endoscopy may reveal more cases, thereby increasing our understanding of this disease, and will provide new therapeutic possibilities.

RECENT TRENDS IN THE MANAGEMENT OF PEMPHIGUS VULGARIS

Pemphigus vulgaris is perhaps the most formidable disease encountered by dermatologists. In the days before steroid therapy the mortality rate was 95 per cent, death occuring usually within 14 months. The cause of death was septicaemia, starvation and toxic state. Corticosteroid, immunosuppressants and adjuvant therapy have reduced the mortality to 10-40 per cent with the cause of death being uncontrolled pemphigus, complications of corticosteroid and immunosuppressant therapy, septicaemia and thromboembolism. Elderly patients and patients with extensive lesions have higher mortality rate. Prognosis has further improved by intensive care, adequate fluid replacement, nutritional support, a co-herent antibacterial policy alongwith aggressive corticosteroid therapy and immunosuppressants. Plasmapheresis has been used in patients who fail to respond to conventional management. Extracorporeal photophoresis has been reported to be effective in patients with 'treatment resistance' pemphigus vulgaris.

Therapeutic drugs for neuropathic pain

Neuropathic pain is common and may be resistant to usual doses of analgesic medications. However, an improved understanding of the pathophysiology of neuropathic pain and a growing number of adjuvant medications that are useful for the treatment of neuropathic pain provide renewed hope for clinicians and their patients. It is useful to classify adjuvant analgesic drugs into two broad categories. Membrane stabilizing agents, which include the anticonvulsants, antiarrhythmics and probably corticosteroids, may act by blocking sodium channels on damaged neural membranes. Medications that enhance dorsal horn inhibition, which include the antidepressants and some anticonvulsants, may augment biogenic amine or GABAergic mechanisms in the dorsal horn of the spinal cord. Current evidence regarding efficacy generally does not support the use of one agent over another and selection of a particular agent may depend in part on the expected side effects or experience with a given drug. For maximum analgesic effect, more than one agent may be necessary and to improve therapy and minimize side effects, medications generally should be started at lower doses and titrated slowly to effect. Although labor-intensive, this strategy may improve compliance and optimize patient care.

Epidural steroid injections for the treatment of lumbosacral radiculopathy

OBJECTIVE

While there is an extensive body of literature concerning the use of epidural steroid injections in the treatment of sciatica, most of the literature is descriptive or anecdotal. There are few controlled studies regarding efficacy of this treatment modality. While there are few published reports of serious complications of this therapy, warnings about the hazards of epidural steroid injections occasionally appear in both medical and lay literature. It is the purpose of this review to assess the existing evidence for efficacy of epidural steroid injections for sciatica and to assess the risks of this procedure.

DATA SOURCES

Peer reviewed medical literature from 1930 to the present was reviewed in order to survey reports regarding pathophysiology of radiculopathy, mechanism of action of epidural corticosteroids, controlled efficacy studies, reports on series of epidural steroid injections for sciatica, reports of adverse effects of epidural and intrathecal steroid injections, review articles of epidural and intrathecal steroid injections, and studies of the behavioral and histological effects of epidural steroids and their vehicle in animals.

STUDY SELECTION

Studies and review articles were selected from Medline search and from the author's files of older literature.

DATA SYNTHESIS

RESULTS of this review are qualitative. It was felt that there was insufficient controlled data to analyze efficacy or safety studies in a quantitative fashion.

RESULTS

Radiculopathy following disc herniation appears to produce either mechanical or chemical nerve root inflammation. Epidurally injected corticosteroids most likely exert a beneficial effect through anti-inflammatory rather than direct analgesic mechanisms. Most descriptive studies report beneficial effects of epidural steroids in the majority of cases of radiculopathy, but not for other causes of low back pain. Most of the few controlled studies report epidural steroids to be more efficacious than placebo or epidural local anesthetic alone. Most patients who respond favorably continue to show improvement for many months. Several neurologic complications have been reported after intrathecal steroid injections, most following multiple intrathecal injections. Four cases of epidural abscess, one case of bacterial meningitis, and one case of aseptic meningitis have been reported following epidural steroid injections.

CONCLUSIONS

The majority of the published literature supports the notion that epidural steroids provide relief of pain from lumbosacral radiculopathy. There is anecdotal evidence that multiple intrathecal steroid injections may be associated with neurological dysfunction, but there is very little evidence that epidural steroids are neurotoxic.