Ankur Sheth

Worsening of asthma with systemic corticosteroids

AbstractDespite widespread use for treatment of asthma and allergies, glucocorticoids may cause allergic reactions, even anaphylaxis. The incidence of adverse reactions to systemic glucocorticoids is 0.3%. The most commonly reported corticosteroids causing anaphylaxis like reactions are hydrocortisone, prednisone, and methylprednisolone. Most authors agree that allergic reactions to systemic corticosteroids are possibly immunoglobulin E mediated. We report a patient with asthma, aspirin allergy, and nasal polyps who developed bronchospasm following the administration of intravenous methylprednisolone sodium succinate during an acute asthmatic attack. We discuss the differential diagnosis of worsening asthma despite adequate treatment, and suggest corticosteroid-induced bronchospasm in our patient. Corticosteroid-induced bronchospasm should be considered when asthmatics fail to improve, or frankly deteriorate with systemic corticosteroid therapy, particularly when a history of aspirin allergy is present. Teaching Point:•Know the differential diagnosis for worsening of asthma despite adequate treatment.•Consider corticosteroid-induced bronchospasm when asthmatics fail to improve, or frankly deteriorate with systemic corticosteroid therapy.•Corticosteroid-induced bronchospasm is more commonly seen in asthmatics with a history of aspirin allergy.

Is Fecal Leukocyte Test a good predictor of Clostridium difficile associated diarrhea

BackgroundFecal leukocyte test (FLT) is widely used to screen for invasive diarrheas including C. difficile associated diarrhea (CDAD), which account for more than 25 % of all antibiotic associated diarrhea.Method263 stool samples from patients with suspected CDAD were studied simultaneously for fecal leukocyte test (FLT) and Clostridium difficile toxin assay (CDTA). FLT was performed by the Giemsa technique and CDTA was performed by enzyme immuno assay (EIA).ResultsSensitivity, specificity, positive predictive value and negative predictive value of FLT as compared to CDTA were 30%, 74.9%, 13.2% and 89.3% respectively.ConclusionConsidering the poor sensitivity of FLT, and the comparable cost and time of obtaining a CDTA at our institution, we conclude that FLT is not a good screening test for CDAD. Possible reasons for FLT being a poor predictor of CDTA are discussed.

Eosinophilic gastroenteritis of the pancreas : An unusual cause of obstructive jaundice

Eosinophilic gastroenteritis (EG) is a rare gastrointestinal disorder of undetermined etiology and is manifest by eosinophilic infiltration of any area of gastrointestinal tract, most frequently stomach and small intestine. Peripheral eosinophilia is present in about 80% of patients. Definitive diagnosis requires histologic evidence of eosinophilic infiltration; which is usually patchy in distribution. Steroids are the mainstay of treatment. We present a case of 47-year-old man with abdominal pain, jaundice, and marked eosinophilia. Endoscopic retrograde cholangio-pancreatogram revealed a dilated common bile duct. There was biopsy proven eosinophilic infiltration in stomach, duodenum, gall bladder, and pancreas. Obstructive jaundice is an extremely rare manifestation of EG. This unusual case illustrates the wide variety of gastrointestinal manifestations caused by EG and emphasizes the importance of clinical suspicion and endoscopic mucosal biopsies in diagnosis of EG. This entity should be considered in the patients with chronic and relapsing gastrointestinal symptoms.

Diabetic Ketoacidosis-induced Hypertriglyceridemic Acute Pancreatitis Treated with Plasmapheresis—Recipe for Biochemical Disaster Management

Diabetic ketoacidosis (DKA)-induced hypertriglyceridemia causing pancreatitis is an interesting phenomenon that has rarely been reported in literature. Plasmapharesis is a well known treatment modality for hypertriglyceridemia-induced pancreatitis. We report a patient with DKA-induced hypertriglyceridemic acute pancreatitis treated successfully with plasmapharesis.

Substitution with Alternative Anti-TNFα Therapy (SAVANT)—Outcomes of a Crohnʼs Disease Cohort Undergoing Substitution Therapy with Certolizumab

Background:Biological therapy targeting tumor necrosis factor-alfa has revolutionized the treatment of Crohns disease (CD). Our study retrospectively reviewed clinical outcomes of 60 patients administratively substituted from Infliximab or Adalimumab to Certolizumab. Maintenance of disease and failure rates after substitution of anti–tumor necrosis factor-alfa agents in CD patients were monitored over 1 year, and this is the first outcomes study of patients maintained on Infliximab or Adalimumab substituted to Certolizumab. Methods:A hospital pharmacy directive required all patients on biological therapy to be administratively substituted to Certolizumab therapy. This single-center retrospective analysis initially included 68 CD patients presenting at Louisiana State University Health Sciences Center-Shreveport. Clinical, endoscopic, and serologic data were compared at baseline and at 4 intervals over 1 year. Results:Of 60 enrolled CD patients, 45 (75%) successfully transitioned to Certolizumab and had stable disease at 1 year. Of the 15 (25%) patients who “failed” substitution at 1 year, 5 were returned to Adalimumab and 7 to Infliximab; 3 were maintained on steroids awaiting subsequent therapy. Importantly, when patients were segregated on the basis of initial disease control, it was found that 3 (12.5%) previously well-controlled patients failed therapy, whereas 12 (33.3%) who initially had active disease failed Certolizumab substitution. Conclusions:Our study found that 25% of CD patients substituted to Cimzia failed substitution, whereas 75% still exhibited a good clinical response with stable disease at 1 year. Our findings indicate that disease status and behavior at the time of biological substitution may predict therapeutic responsiveness.