Repeated dengue shock syndrome and 'dengue myocarditis' responding dramatically to a single dose of methyl prednisolone

The place of steroids in the management of severe forms of dengue is unclear. A retrospective observational study showed the benefits of a single dose of intravenous methyl prednisolone in a highly selected group of patients who developed severe dengue during the febrile phase of infection. We report the case of a 14-year-old boy with dengue who developed three episodes of severe hemodynamic compromise while having high fever, 'myocarditis', third space fluid accumulation, progressive reduction in urine output, and altered mentation, who made a dramatic recovery following a single dose of intravenous methyl prednisolone. Results justify a well powered randomized controlled trial to evaluate the efficacy of this treatment in severe dengue.     

Response of graft versus host disease to high doses of methyl prednisolone

Summary High dose methyl prednisolone (HDMP) was used to treat 25 episodes of graft versus host disease (GVHD) in 13 patients after bone marrow transplantation for aplastic anaemia or acute leukaemia. All patients showed rapid improvement of GVHD following HDMP with resolution of gut and skin manifestations over several days, but liver GVHD was less responsive to treatment. The major complication of treatment was infection and four patients died from infection following HDMP. The mode of action of HDMP may be a nonspecific anti-inflammatory effect but it appears to be rapidly effective in controlling GVH reactions.     

Hemodynamic response to high-dose methyl prednisolone and mannitol in severe dengue-shock patients unresponsive to fluid replacement

Nine children; 4 males and 5 females, aged ranging from 2 1/2 to 13 years presented with signs and symptoms of poor tissue perfusion associated with dengue shock syndrome. All these 9 patients were subjected to the therapeutic trial of high dose methyl prednisolone (MP; 9/9) and mannitol (M; 6/9) after their failure to the saline and plasma replacement. Following the high dose MP and M, a significant increment in the effective circulatory blood volume as reflected by the sustained increment in CVP, widening of PP and declining in PR as well as improvement in clinical tissue perfusion were established in 7 of these nine patients so treated.     

Effect of methyl prednisolone on normobaric pulmonary oxygen toxicity in rats

Male albino rats were exposed to 81, 86, 90 or 99% oxygen until death. Rats were also administered methyl prednisolone (MP) 10-60 mg/kg/day intraperitoneally. MP-treated rats survived significantly less than controls: 53.5 +/- 4.7 vs. 65.2 +/- 8.2 h, p less than 0.001 in 99% O2, 74.4 +/- 9.4 vs. 120 +/- 39.8 h, p less than 0.02 in 86% O2 and 113.7 +/- 21.4 vs. 162 +/- 17.9 h, p less than 0.03 in 81% O2. Rats were exposed to 99% O2 for 10, 30 and 50 h and the activity of superoxide dismutase (SOD) and catalase in their lungs was monitored. MP-treated rats showed less increase in pulmonary SOD after 10 h (111 vs. 171%, p less than 0.03) but no effect on SOD activity thereafter. MP had no effect on the response of catalase to O2. No effect of MP on lung morphology could be found under the light microscope.     

Acute hepatitis related to prednisolone

A 46-year-old woman, known to have multiple sclerosis (MS), presented with repeated episodes of elevated liver enzymes due to high-dose methylprednisolone therapy.     

Thrombocytopenia in a case of systemic lupus erythematosus: repeated administration of 'pulse' methyl prednisolone

The case of a young woman with systemic lupus erythematosus (SLE) is reported in whom thrombocytopenia was a major feature of her disease. She was given three courses of 'pulse' intravenous methyl prednisolone (IVMP) on separate occasions as treatment for profound thrombocytopenia. A diminishing response in platelet count was obtained following each course. She received a further course of IVMP for treatment of a nephritis, with a moderate platelet response; this may have been related in part to concomitant oral cyclophosphamide. IVMP may be an effective treatment for SLE-associated thrombocytopenia but repeated courses may result in a reduced platelet response.     

Response to intramuscular methyl prednisolone in inflammatory hand pain: evidence for a targeted clinical, ultrasonographic and therapeutic approach

BACKGROUND: Hand pain with stiffness is a common clinical presentation to early arthritis clinics, with outcome varying from resolution to the development of rheumatoid arthritis. OBJECTIVE: To assess the response and predictors of response to intramuscular methylprednisolone (MP) and hydroxychloroquine (HCQ) using a standardised treatment protocol. METHODS: Patients with inflammatory hand pain (IHP), defined as predominantly hand pain and morning stiffness of at least 30 min duration, received a standardised assessment prior to receiving intramuscular MP. Response (primary outcome) at 4 weeks was a 50% improvement in symptoms as perceived by the patient; responders who relapsed received repeat intramuscular MP and HCQ. RESULTS: 102 patients were recruited, of which 21% were rheumatoid factor (RF) positive, 23% had clinical synovitis, 25% had raised C-reactive protein level and 55% had ultrasound-detected synovitis. 73% responded, with associated significant reductions in morning stiffness, Health Assessment Questionnaire, painful and tender joint counts, and visual analogue scores (p < or = 0.006 for all). Ultrasound-detected synovitis (p<0.001) and RF (p = 0.04), but not clinical synovitis (p = 0.74), were significantly associated with response to intramuscular MP. 86% who remained on HCQ long term reported a benefit. CONCLUSIONS: Patients with IHP have significant improvement in symptoms and function following intramuscular MP. Further placebo-controlled trials are required to assess the role of intramuscular MP and ultrasonography in managing this patient group.     

Spontaneous Achilles tendon rupture in a patient with systemic lupus erythematosus due to ischemic necrosis after methyl prednisolone pulse therapy

Spontaneous tendon rupture in a patient with systemic lupus erythematosus (SLE) is a rare but potentially disabling complication. Minor trauma, local inflammation and long term corticosteroid therapy are regarded as possible causes. However, ischemic necrosis of the tendon resulting from hypercoagulability and methyl prednisolone (MTP) pulse therapy has not been reported. We present a 20-year old female, newly diagnosed with lupus, who has high titer antiphospholipid antibodies, hyperhomocysteinemia and protein S deficiency. Her severe clinical symptoms of lupus were improved after MTP pulse therapy. Several days later, cold sensation over the right lower leg developed. On day 15 after pulse therapy, acute onset of right heel pain occurred when she was ascending stairs. Rupture of the right Achilles tendon was demonstrated by sonography and MRI. A Doppler sonography revealed narrowing and abrupt cessation of blood flow in the right popliteal artery. Heparin treatment was started. The angiography performed two days after heparinization revealed narrow caliber and decreased flow of the right tibial artery below the right ankle. Surgical repair of the tendon was successful and the pathology of the resected tendon revealed focal necrosis, degeneration and capillary proliferation. MTP pulse therapy in a lupus patient with hypercoaguable state with hyperhomocysteinemia, protein S deficiency and high titer antiphospholipid antibodies may cause spontaneous tendon rupture.     

Refractory sarcoidosis responding to infliximab

Despite aggressive treatment with conventional therapy, sarcoidosis may be progressive and debilitating. Tumor necrosis factor (TNF)-alpha is critical in the genesis and maintenance of granulomatous inflammation. Agents developed to inhibit TNF-alpha have been approved to treat rheumatoid arthritis and inflammatory bowel disease with unprecedented success. As such, physicians are increasingly using these agents to treat patients with other inflammatory diseases, including sarcoidosis. We report a case of refractory sarcoidosis, involving the lung, eyes, skin, and heart, which flared despite aggressive therapy. Oculocutaneous sarcoid dramatically improved after treatment with the anti-TNF antibody infliximab.     

Refractory polymyositis responding to infliximab

SIR, We read with great interest the article by Labioche etal. [1] reporting the case of a lady with     

Hypereosinophilia responding to empirical antihelminthic treatment

We report a 20-year-old college student presents with bilateral ankle edema associated with hypereosinophilia following a history of traveling in a rural area. Physical examinations and investigations failed to diagnose any underlying cause. She was treated with antihelminth medication and the edema subsided within a week and the eosinophil counts normalized within two weeks.