Fatal Strongyloidiasis following corticosteroid therapy

Two fatal strongyloides stercoralis infections found at autopsy in patients who had received corticosteroid therapy are presented. A successfully treated case of strongyloidiasis with pulmonary infiltration is also reported. Difficulties in diagnosis, usefulness of upper jejunal intubation, and the importance of ruling out strongyloidiasis prior to administration of corticosteroids to patients with eosinophilia, particularly Vietnam veterans, are discussed.The authors wish to thank John Li, MD, for permission to include Case 2.     

A case of Pneumocystis carinii pneumonia with bronchial asthma following long-term corticosteroid therapy

A 50-year-old man, who developed bronchial asthma at the age of 43 and was treated continuously with corticosteroids from the beginning of the first treatment, was admitted with exacerbation of exertional dyspnea. In spite of various treatments for bronchial asthma, such as theophylline, beta-stimulants, anti-allergic drugs and steroid-inhalation, asthmatic symptoms did not improve and he continued to receive intravenous administration of steroids. Five months after admission, he suddenly developed severe respiratory failure and died after five days. Autopsy revealed Pneumocystis carinii pneumonia and marked atrophy of adrenal glands. No evidence of malignancy or hematologic disease was seen. Serum HIV antibody was negative. Secondary immunodeficiency induced by long-term corticosteroid administration of over 7 years was considered to be the cause of Pneumocystis carinii pneumonia. It seems that no case of Pneumocystis carinii pneumonia with bronchial asthma alone has ever been reported in medical literature.     

Fulminant Kaposi's sarcoma complicating long-term corticosteroid therapy

Cutaneous Kaposi's sarcoma occurs rarely in patients receiving long-term corticosteroid therapy. The case of a rapidly progressive form of Kaposi's sarcoma occurring in a 29-year-old Palestinian woman with steroid-dependent Crohn's disease and familial Mediterranean fever is reported. Despite an extensive transfusion history, serologic and virologic studies failed to demonstrate exposure to the human immunodeficiency virus. Serologic and virologic evidence of concomitant cytomegalovirus infection, however, suggests possible pathogenic features similar to the acquired immunodeficiency syndrome-related form of Kaposi's sarcoma.     

Regression of invasive thymoma following corticosteroid therapy

A case of invasive thymoma is presented showing tumour regression after palliative treatment with prednisone. Moderate doses of prednisone resulted in a longtime palliation via remarkable anti-tumour effect. The literature of corticosteroid responses of thymomas is reviewed.     

The effect of long-term corticosteroid therapy on joint mobility

Long-term corticosteroid therapy has been implicated as a cause of joint hypermobility. The joint mobility of 25 patients who had been on oral corticosteroids for at least 5 years, was compared to that of 40 controls. There was no significant difference between the two groups. It was concluded that oral corticosteroids do not contribute to joint hypermobility.     

Variable response to long-term corticosteroid therapy in chronic beryllium disease

OBJECTIVES: Chronic beryllium disease (CBD) shares many of its characteristics with sarcoidosis and is often treated with corticosteroids. There is limited available literature regarding the effect of long-term corticosteroid therapy on the natural history of CBD. METHODS AND MATERIALS: We conducted an observational retrospective study of six patients with CBD who received prolonged corticosteroid treatment with a mean pulmonary function test follow-up period of 10.1 years. Five of the six patients were exposed to beryllium at the same workplace. The diagnosis in four of the six cases was confirmed by a positive beryllium lymphocyte proliferation test result on blood or BAL fluid. Periodic pulmonary function tests were analyzed in relation to removal from beryllium exposure and treatment with corticosteroids. MEASUREMENTS AND RESULTS: Two broad patterns of response were noted in these patients. The first pattern seen in two patients showed no improvement in FVC or diffusion capacity of the lung for carbon monoxide (Dlco) with corticosteroids. However, a significant improvement in these parameters was noted on cessation of beryllium exposure in one of the two patients. The second pattern showed an initial improvement in FVC and Dlco with corticosteroids, which was not sustained. An improvement was noted on stopping beryllium exposure. CONCLUSIONS: The response to long-term corticosteroids in CBD, quite like that in sarcoidosis, is variable. Significant lung function improvement may be seen following cessation of beryllium exposure.     

Guillain-Barré syndrome following danazol and corticosteroid therapy for hereditary angioedema

A case of hereditary angioedema secondary to C1 esterase inhibitor deficiency associated with lupus-like nephritis is reported. The patient was initially treated with both corticosteroids and danazol and subsequently had Guillain-Barré syndrome together with appearance of circulating immune complexes and an increase in total complement and C1q, C3, C4, B, and C1 esterase inhibitor levels. Guillain-Barré syndrome might be secondary to danazol therapy since this drug could increase both circulating immune complex production and complement synthesis, thereby providing additional substrate for the underlying immune complex disease. Normalization of complement might therefore be hazardous in lupus with underlying complement deficiency states.     

Alternate-day corticosteroid therapy

We treated five patients with persistent Staphylococcus aureus bacteremia and endocarditis. Surgical intervention or a “secondline” antistaphylococcal agent was required for bacteriologic cure in each. Special bacteriologic evaluation failed to demonstrate methicillin resistance or antibiotic “tolerance” among the strains of Staphylococcus tested. Cephalosporin agents were noted to be more susceptible to inoculum effect than either methicillin or nafcillin. All patients survived; the explanation for their atypical course is obscure. We present an approach to patients with persistent Staph. aureus bacteremia and endocarditis.     

Thrombotic microangiopathy due to malignant hypertension following corticosteroid therapy for microscopic polyangitis

A 78-year-old woman was treated with 40 mg of prednisolone for microscopic polyangitis, and favorable effects were observed. However, her blood pressure increased and she developed severe thrombocytopenia. Thrombotic microangiopathy (TMA) due to malignant hypertension was suspected and she was treated with an angiotensin-converting enzyme inhibitor; her platelet count then rose. She showed a close temporal relationship between initiation of corticosteroid therapy and the onset of TMA. Corticosteroid therapy should be used with caution in patients with underlying vascular endothelial damage.     

Fatal Aspergillus myocarditis following short-term corticosteroid therapy for chronic obstructive pulmonary disease

A 58-y-old man with chronic obstructive pulmonary disease (COPD) was admitted for treatment of an acute exacerbation of his illness. The patient's condition initially improved after therapy with oxygen, bronchodilators, antibiotic and methylprednisolone (40 mg every 8 h) was started. Soon afterwards, however, the patient's clinical status deteriorated and he died on the fifth hospital day. Post-mortem examination revealed unsuspected, isolated fungal myocarditis. The fungus was later identified as Aspergillus by indirect immunofluorescence. To our knowledge, this is the first case of fatal Aspergillus myocarditis related to short-term (< 1 week) steroid therapy in a COPD patient. We believe that this case provides further evidence to support the possibility of life-threatening infections in COPD patients who receive even a short course of corticosteroid treatment.     

Vertebral fracture risk with long-term corticosteroid therapy: prevalence and relation to age, bone density, and corticosteroid use

BACKGROUND: Few data are available regarding vertebral fracture risk in patients treated with oral corticosteroids. The aim of this study was to determine the prevalence and the role of risk factors such as age, bone mineral density (BMD), and corticosteroid use for vertebral deformity in patients receiving long-term corticosteroid therapy. METHODS: Thoracolumbar x-ray films, BMD, and details on corticosteroid use were obtained on 229 consecutive patients treated with long-term corticosteroid regimens (> or = 6 months of prednisone, > or = 5mg/d or equivalent) seen at 4 referral centers. Comparisons were made with a population control group of 286 male and female controls not taking corticosteroids (aged > or = 60 years). RESULTS: Sixty-five patients (28%) had at least 1 vertebral deformity and 25 (11%) had 2 or more vertebral deformities. Older age, independent of BMD, was a significant risk factor for deformity. Patients aged 70 to 79 years had a 5-fold increased risk of deformity compared with patients younger than 60 years (odds ratio, 5.13; 95% confidence interval, 2.03-13.0). Compared with the population controls, the prevalence of deformities increased to a greater extent with each decade of age in the corticosteroid group (P =.005). Mean lumbar spine and femoral neck BMD Z scores were lower in the steroid-treated patients with deformities compared with the nonsteroid control group with deformities. When the effects of age, sex, body mass index, and duration of corticosteroid use were adjusted for in logistic regression analysis, low BMD was a modest predictor of deformity (for a 1-SD decrease in lumbar spine BMD: odds ratio, 1.31; 95% confidence interval, 1.02-1.68) and for a 1-SD decrease in femoral neck BMD: odds ratio, 1.77; 95% confidence interval, 1.07-2.94). CONCLUSIONS: The combination of increasing age and corticosteroid use is associated with a marked increase in the risk of vertebral deformity. Elderly patients commencing long-term corticosteroid therapy should be considered for antiosteoporotic therapy independently of their BMD. Arch Intern Med. 2000;160:2917-2922