Post-acute sequelae of SARS-CoV-2 Delta variant infection: A report of three cases in a single family

Coronavirus disease 2019 (COVID-19) is caused by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) that has resulted in global pandemic and crisis in health care system. Several studies have focused only on hospitalized patients with 30 to 90 days after one cycle of illness but post-acute sequelae of COVID-19 existing even after a year remains unclear. Moreover, long-term sequelae in outpatients have not been documented and henceforth myriad clinical sequelae in long haulers continue to evolve. In this study, we report three cases represents a single family presenting several post-acute sequelae one after the other extending beyond one year of recovery. To our knowledge such a case series has not been reported in earlier studies. Herein, we present the sequelae in various organs namely neuropsychiatric (tinnitus, anxiety, depression, insomnia, and posttraumatic stress disorder, cognitive decline), cardiovascular (tachycardia, bradycardia), gastrointestinal (appendicitis) and Dermatologic (erythematous rash and acne) besides ophthalmic manifestations (conjunctivitis and dry eyes) in Long-COVID-19 and recommend management strategies.

A Therapeutic Experience of Rapid Progressive HTLV-1 Associated Myelopathy in a Convalescent Rehabilitation Ward：A Case Report / The Japanese Journal of Rehabilitation Medicine

The patient was a 76-year-old woman who developed involuntary movements in both hands and gait disorder. Weakness in both lower limbs gradually worsened, and she was referred to our hospital. Neurological findings included spastic paraplegia, deep sensory disturbance, sensory ataxia, and bladder and bowel dysfunction. Approximately 4 months after the onset, she became unable to walk independently and had to use a walker. MRI showed a long spinal cord lesion extending from the cervical to thoracic spinal cord. Blood and spinal fluid samples tested positive for anti-human T-cell leukemia virus type 1 (HTLV-1) antibodies. Given these findings and subacute course, she was diagnosed with rapidly progressive HTLV-1 associated myelopathy (HAM). High levels of neopterin and CXCL10 in the cerebrospinal fluid suggested high disease activity；thus, she underwent steroid pulse therapy followed by treatment with maintenance oral prednisolone in our convalescent rehabilitation ward. After approximately 3 months of muscle strength training, mainly for the trunk muscle and the proximal muscle of the lower limbs, and balance exercise, she was able to walk independently and her activities of daily living (ADL) and instrumental ADL (IADL) improved；however, dysuria persisted. The use of clean intermittent self-catheterization instead of indwelling urethral catheter improved her quality of life (QOL). Although rapidly progressive HAM is generally associated with poor prognosis, steroid therapy combined with comprehensive rehabilitation treatment was effective in the present case.

A Therapeutic Experience of Rapid Progressive HTLV-1 Associated Myelopathy in a Convalescent Rehabilitation Ward：A Case Report / The Japanese Journal of Rehabilitation Medicine

The patient was a 76-year-old woman who developed involuntary movements in both hands and gait disorder. Weakness in both lower limbs gradually worsened, and she was referred to our hospital. Neurological findings included spastic paraplegia, deep sensory disturbance, sensory ataxia, and bladder and bowel dysfunction. Approximately 4 months after the onset, she became unable to walk independently and had to use a walker. MRI showed a long spinal cord lesion extending from the cervical to thoracic spinal cord. Blood and spinal fluid samples tested positive for anti-human T-cell leukemia virus type 1 (HTLV-1) antibodies. Given these findings and subacute course, she was diagnosed with rapidly progressive HTLV-1 associated myelopathy (HAM). High levels of neopterin and CXCL10 in the cerebrospinal fluid suggested high disease activity；thus, she underwent steroid pulse therapy followed by treatment with maintenance oral prednisolone in our convalescent rehabilitation ward. After approximately 3 months of muscle strength training, mainly for the trunk muscle and the proximal muscle of the lower limbs, and balance exercise, she was able to walk independently and her activities of daily living (ADL) and instrumental ADL (IADL) improved；however, dysuria persisted. The use of clean intermittent self-catheterization instead of indwelling urethral catheter improved her quality of life (QOL). Although rapidly progressive HAM is generally associated with poor prognosis, steroid therapy combined with comprehensive rehabilitation treatment was effective in the present case.

Bilateral nodular episcleritis due to Varicella-Zoster virus / Episclerite nodular bilateral do vírus varicela-zoster

Abstract The patient is a 10 years-old girl, with chief complaint of recent bilateral red eye and history of chickenpox disease. Examination revealed nodular episcleritis of both eyes. After treatment with topical steroids, the disease was subsided. Varicella-Zoster virus is a rare cause of episcleritis. In this case it seems that the mechanism of involvement is immune-related, rather than direct tissue involvement by virus.

Resumo A paciente é uma menina de 10 anos de idade, com queixa principal de olho vermelho bilateral recente e história de doença da catapora. O exame revelou episclerite nodular de ambos os olhos. Após o tratamento com esteróides tópicos, a doença foi diminuída. O vírus varicela-zoster é uma causa rara de episclerite. Neste caso, parece que o mecanismo de envolvimento é imuno-relacionado, ao invés de envolvimento direto do tecido pelo vírus.

Two Cases of Lupus Miliaris Disseminatus Faciei Treated with Oral Mini-pulse Steroid Therapy / 대한피부과학회지

Lupus miliaris disseminatus faciei (LMDF) is a rare granulomatous skin disease mainly affecting the central area of the face. A variety of treatments are reportedly of some benefit; however, controlled studies to establish the best treatment are lacking. Here, we report the cases of a 33-year-old man who presented with multiple, various-sized, erythematous maculopapules on the face and a 19-year-old man who presented multiple, reddish papuloplaques distributed on the face. Histopathological examinations of the two cases revealed large clear-boundary epithelioid cell granulomas with central necrosis surrounded by lymphocytic infiltration. Based on the clinical and histological findings, diagnoses of LMDF were made. As oral tetracycline and antimalarials were not fully effective in our cases, oral mini-pulse steroid therapy (dexamethasone, 5 mg bid for 2 days per week) was initiated. After several months, the eruption significantly improved, and most lesions were resolved. Here, we report two cases of LMDF successfully treated with oral mini-pulse steroid therapy.

Limbic Encephalitis Manifesting as Selective Amnesia and Seizure-like Activity: A Case Report

Limbic encephalitis (LE) is characterized by short-term memory loss, disorientation, agitation, seizures, and histopathological evidence of medial temporal lobe inflammation. Leucine-rich, glioma inactivated 1 (LGI-1) is an auto-antigen associated with LE. We report a 37-year-old male patient with LGI-1-related LE who presented with recurrent episodes of selective amnesia, seizure-like activity, confusion, and personality change. His symptoms were significantly improved with steroid therapy. Thorough differential diagnosis with consideration for autoimmune encephalitis should be in patients with presentation of symptoms, such as memory impairment, personality change and seizure-like activity, especially when other neurological diagnoses are excluded.

A Case with Pneumatosis Cystoides Intestinalis with Intra-abdominal Free Air following Steroid Therapy for End-stage Brain Tumor

<p>Introduction: We experienced a case of pneumatosis cystoides intestinalis with intra-abdominal free air following steroid therapy for an end-stage brain tumor. Case: The patient was a 67-year-old man. He had received surgery and chemotherapy for the brain tumor, but the disease progressed and his consciousness deteriorated. Eventually, he developed aspiration pneumonia and was hospitalized. His consciousness level remained poor even after the pneumonia improved. His survival prognosis was considered to be approximately 1 month, and he was transferred to a palliative care ward. After the transfer, administration of betamethasone 8 mg/day was started for the purpose of improving his level of consciousness. Temporary improvement was observed, and administration of this drug was continued with dose adjustments, as appropriate. Six weeks after the start of betamethasone administration, when his consciousness level again deteriorated, aspiration began to recur. Chest X-rays, obtained to assess pneumonia, showed intra-abdominal free air. Pneumatosis cystoides intestinalis was confirmed by computed tomography. He had few abdominal symptoms, and was managed conservatively. He died of respiratory failure. Conclusion: Pneumatosis cystoides intestinalis is mostly secondary, and steroid therapy is considered to be one of the causes. But follow-up observation is often conservative, and judgment of discontinuation of steroid needs to be made in consideration of its effect and prognosis is there.</p>

A four-point clinical criteria distinguishes immune thrombocytopenia from acute lymphoblastic leukaemia

Immune thrombocytopenia is the most common diagnosis of isolated thrombocytopenia. The dilemma encountered by paediatricians is missing diagnosis of acute leukaemia in children with isolated thrombocytopenia. We demonstrated childhood ITP could be diagnosed using a four point clinical criteria without missing a diagnosis of acute leukaemia. Hence, bone marrow examination is not necessary in children with typical features compatible with ITP prior to steroid therapy. This can encourage paediatricians to choose steroid therapy, which is cheaper and non-blood product, as first line platelet elevating therapy in children with significant haemorrhage.

Systemic Steroid Therapy for Serous Retinal Detachment Caused by Excessive Endolaser during Diabetic Retinopathy Surgery

PURPOSE: To report cases of macular serous retinal detachment caused by excessive intraoperative endolaser in patients with diabetic vitreous hemorrhage. Macular serous retinal detachment was improved by systemic steroid therapy. CASE SUMMARY: A 64-year-old male (case 1) and a 67-year-old female (case 2) treated with vitrectomy and endolaser (case 1, 3,184 shots; case 2, 1,734 shots) because of diabetic vitreous hemorrhage visited our out-patient clinic with blurred vision. Best corrected visual acuity (BCVA) in case 1 was hand motion and 0.03 in case 2. Fundus examination and optical coherence tomography (OCT) revealed extensive subretinal fluid accumulation of the posterior pole. With the diagnosis of macular serous retinal detachment caused by excessive intraoperative endoaser, oral steroid (40 mg/qd, 5 days) was administered and then later reduced in case 1. In case 2, we administered intravenous high-dose steroid (250 mg/qid, 3 days). After systemic steroid therapy, BCVA was improved to 20/30 in case 1 and 20/40 in case 2 and OCT showed the subretinal fluid was resolved. CONCLUSIONS: During diabetic retinopathy surgery, excessive endolaser induced macular serous retinal detachment and systemic steroid therapy was necessary in diabetic patients. Thus, physicians should be well acquainted with this complication.

Intratympanic vs. Oral Steroids for Treatment of Idiopathic Sudden Sensorineural Hearing Loss: A Randomized Controlled Study.

Objective: To compare the efficacy of oral to intratympanicsteroids for treatment of idiopathic sudden sensorineural hearing loss (ISSHL). Patients and Methods: A total of 39 ISSHL patients were included in this study. They were consecutively randomized into the “control” group, who received oral prednisone (started with 60 mg/day tapering over 14 days) or the “study” group, who received intratympanic methylprednisolone sodium succinate (four 1- mL doses of 40 mg/mL of methylprednisolone over 2 weeks, with a dose given every 3-4 days by injection through the tympanic membrane into the middle ear). Pure tone audiometry (PTA) was measured for all patients before injection as baseline. Patients were asked to come to the outpatient clinic after two weeks, one month and at the end of the second month to assess hearing, vital signs, otological examination and adverse events. Results: At the last follow up visit, patients in the study group had significantly lower PTA than those in the control group (39.2±6.0 dB and 43.8±6.4 dB, respectively, p=0.027). Improvement in hearing was significantly higher among patients in the study group than those in the control group (32.1±6.9 dB and 27.5±6.5 dB respectively, p=0.041). Significantly higher proportions of patients in the control group had mood change (p=0.035), sleep change (p=0.044) and mouth dryness (p=0.020) than patients in the study group. On the other hand, a significantly higher proportion of patients in the study group had earache (p=0.030). Patients in both groups did not differ significantly as regard blood glucose problems, increased appetite, pain due to injection or weight gain. Patients’ age correlated negatively with improvement in pure tone average (r= -0.267). However, this correlation was not statistically significant. Conclusions: Treatment with intratympanic steroid injection is better than oral steroid treatment of patients with ISSHR. Adverse effects associated with intratympanic injections are less than those associated with systemic steroid therapy.

Late-onset Systemic Lupus Erythematosus with Protein-losing Enteropathy, Vitiligo, and Diffuse Alveolar Hemorrhage / 이화의대지

A 60-year-old man who had been diagnosed with protein-losing enteropathy (PLE) and vitiligo at age 51 years was admitted with dyspnea, hemoptysis, and lower-limb edema. On the basis of computed tomography findings, the cause of respiratory symptoms was thought to be diffuse alveolar hemorrhage (DAH). The final diagnosis of late-onset systemic lupus erythematosus (SLE) was established on the basis of renal biopsy examinations that revealed evidence of active SLE with lupus nephritis (World Health Organization, class V) and positive results for antinuclear antibody. DAH, as well as PLE and vitiligo were attributed to SLE. The patient was successfully treated with methylprednisolone and then prednisolone in combination with cyclosporin A. Because late-onset SLE is rare and patients tend to show atypical symptoms, close attention should be paid to the preceding symptoms.

Hypereosinophilic Syndrome Presenting as Eosinophilic Cholangiopathy and Cystitis / 대한췌담도학회지

Eosinophilic cholangiopathy is a rare disease characterized by dense transmural eosinophilic infiltration of the gallbladder and bile duct. It's clinical and laboratory manifestations are not different from those of other causes of cholangiopathy, and the diagnosis is usually made based on pathologic findings after cholecystectomy. Moreover, the occurrence of eosinophilic cystitis accompanied by cholangiopathy is extremely rare. We report a rare case of hypereosinophilic syndrome manifested as eosinophilic cholangiopathy accompanied with eosinophilic cystitis, for the first time in Korea, in a 49-year-old woman who presented with persistent right upper quadrant pain. After performing imaging study to validate the diagnosis of acute acalculous cholecystitis and cholangitis, an urgent cholecystectomy was performed. Pathologic examination of the excised gallbladder was consistent with eosinophilic cholecystitis. The patient underwent bladder biopsy because there was persistant irritative voiding symptoms combined with constant mild peripheral eosinophilia even after cholecystectomy, and the pathologic findings revealed eosinophilic cystitis. Symptoms and peripheral eosinophilia were improved after steroid therapy for an indicated period.

The Effectiveness of Intratympanic Steroid Therapy and Systemic Steroid Therapy on the treatment of Idiopathic Sudden Sensorineural Hearing Loss Patients with Damaged Glucose Tolerance / 听力学及言语疾病杂志

Objective To evaluate the efficacy of intratympanic steroid therapy compared with systemic ster‐oid therapy on the treatment of idiopathic sudden sensorineural hearing loss (ISSNHL) patients with damaged glu‐cose tolerance .Methods Fifty first -diagnosed unilateral ISSNHL patients with damaged glucose tolerance were randomized devided equally to the intervention group (intratympanic steroid therapy) or the control group (systemic steroid therapy) ,all patients received conventional drug therapy simultaneously .Pure-tone hearing threshold tests were performed in all patients every 3 days after the first time ,and repeated measures anova was used to assess effects of hearing recovery accompanied with time .Results The mean hearing threshold in the control group de‐creased from 85 .4 ± 5 .6 dB to 48 .2 ± 4 .9 dB ,while in the intervention group it decreased from 84 .8 ± 5 .6 dB to 31 .7 ± 4 .6 dB .Total effective rate in the intervention group (84 .00% ,21/95) was higher than that in the control group (68 .00% ,17/25)(P<0 .05) .Conclusion The intratympanic steroid therapy is more effective than systemic steroid therapy in the treatment of ISSNHL patients with damaged glucose tolerance .

Steroid-induced Central Serous Retinopathy—A Case Report

Long-term, high-dose corticosteroid therapy is well-known to cause systemic and ocular complications. A lesser known complication is chronic central serous chorioretinopathy (CSCR). Although idiopathic central serous chorioretinopathy (CSR) is known to be mild with spontaneous recovery and minimal effects on the final visual acuity, chronic CSCR as a complication of long-term steroid therapy behaves differently, and may cause irreversible visual impairment.

Progress in the role of steroids in Kawasaki disease therapy / 国际儿科学杂志

Kawasaki disease(KD) is the most common reason for acquired heart disease in children,which is closely related to autoimmune response and the release of cytokines in vascular endothelial cells.Steroids are strongly effective in countering inflammation as well as immune response.In the time of being,it has become a hot spot that steroids play an important role in the initial treatment for acute KD and for incomplete and refractory KD.

Clinical Characteristics of Patients with Autoimmune Pancreatitis with or without Mikulicz's Disease and Mikulicz's Disease Alone

BACKGROUND/AIMS: The objective of this study was to compare the clinical characteristics of patients with autoimmune pancreatitis (AIP) with or without Mikulicz's disease (MD) and with MD alone. METHODS: We investigated the clinical findings in 15 AIP patients with MD (group A+M), 49 AIP only patients (group A), and 14 MD only patients (group M). RESULTS: The male-female ratio was significantly higher in group A+M (73%, p<0.05) and group A (78%, p<0.01) than group M (21%). Serum immunoglobulin G (IgG) levels were significantly higher in group A+M than in group A (p<0.01) and group M (p<0.05). Serum IgG4 levels were significantly higher in group A+M than in group A (p<0.01). Other organ involvement was observed in 73% (11/15) of patients in group A+M. The number of patients with diabetes mellitus was significantly higher in group A+M (66%, p<0.01) and group A (51%, p<0.05) than in group M (7%). All of the patients responded well to steroid therapy, but the relapse rate in group A+M (33%) was significantly higher than that in group A (3%, p<0.01). Salivary gland function was impaired in all groups compared with the control group, but the degree of dysfunction was less in group A compared with group A+M and group M. CONCLUSIONS: The relapse rate of AIP in MD patients was significantly higher than that of AIP in patients without MD.

A Case of Ciliary Body Tuberculoma Causing Sclera Melting

PURPOSE: To report a case of ciliary body tuberculoma, which induced scleral melting. CASE SUMMARY: A 32-year-old man, who was diagnosed with miliary pulmonary tuberculosis 1 week earlier, presented with a conjunctival injection and mass on his right eye 3 months in duration. On excisional biopsy, melted sclera and exposed uveal tissue were found; acid-fast stain was positive. Two months after anti-tuberculosis treatment, anterior granulomatous uveitis and granuloma formation on the anterior chamber angle developed. A low-dose systemic steroid therapy was added. Six weeks after systemic steroid therapy, anterior uveitis and granuloma on anterior chamber angle disappeared. CONCLUSIONS: We experienced a case of ocular tuberculosis on the ciliary body. A low-dose systemic steroid along with multi-drug anti-tubercular therapy may be an effective treatment of ciliary body tuberculoma.

Diagnosis of adrenal failure in critically ill patients / Diagnóstico de insuficiência adrenal em pacientes críticos

In the last two decades there was important evolution on the knowledge of the function of the hypothalamic-pituitary-adrenal axis. In the last decade, the expression "relative adrenal insufficiency" (RAI) was created, and more recently "critical illness-related corticosteroid insufficiency" (CIRCI) was used to designate those patients in which cortisol production was not sufficiently increased in stress situations. Patients with CIRCI have elevated hospital morbidity and mortality. Currently, there is a wide discussion about diagnostic criteria for this dysfunction. Besides basal cortisol, some publications now study the role of other tests, such as cortrosyn test - either in low (1 μg) or high doses (250 μg); free cortisol, salivary cortisol, metyrapone test and others. With this review, we aimed at summarizing the results of the most influent papers that intended to define diagnostic criteria for CIRCI. We also suggest an approach for CIRCI diagnosis and make it clear that the decision about steroid therapy in septic shock patients is matter apart from RAI.

Nas últimas décadas, houve uma importante evolução no conhecimento sobre a função do eixo hipotálamo-pituitária-adrenal. Na última década, foi cunhada a expressão "insuficiência adrenal relativa" (IAR) e, mais recentemente, a expressão "insuficiência adrenal relacionada à doença grave" (CIRCI) foi utilizada para designar aqueles pacientes nos quais a produção de cortisol não era suficientemente elevada em situações de estresse. Pacientes com CIRCI apresentam elevada morbidade e mortalidade em hospitais. Atualmente, há uma ampla discussão sobre os critérios de diagnóstico para essa desordem. Além do cortisol basal, algumas publicações analisaram o papel de outros testes, tais como o teste de estímulo com ACTH (cortrosina), com doses baixas (1 mg) ou altas (250 mg), cortisol livre, cortisol salivar, teste da metirapona e outros. O objetivo desta revisão foi resumir os resultados dos artigos mais importantes que buscaram definir os critérios de diagnóstico para a CIRCI. Também sugerimos uma abordagem para o diagnóstico da CIRCI e deixamos claro que a decisão sobre a terapia com esteroides em pacientes em choque séptico é uma questão separada da IAR.

Duchenne muscular dystrophy: quality of life among 95 patients evaluated using the Life Satisfaction Index for Adolescents / Distrofia muscular de Duchenne: avaliação da qualidade de vida em 95 pacientes através do Life Satisfaction Index for Adolescents

The purpose of this study was to evaluate the quality of life (QoL) of patients with Duchenne muscular dystrophy (DMD) in different stages of the disease, by means of the Life Satisfaction Index for Adolescents (LSI-A). The practicality of this scale was also verified. The LSI-A was applied four times to 95 patients with DMD who were undergoing steroid therapy, at three-month intervals. The patients were divided into four groups according to age. The results from the four applications and the inter and intra-examiner concordance were treated statistically. Comparing the different age groups, patients with DMD did not lose QoL, even with disease progression. We concluded that, in spite of the progressive course of the disease, the QoL in patients with DMD does not get worse. The use of a scale that embraces a great diversity of circumstances in patients' lives, without considering clinical aspects excessively, is a good alternative for assessing the QoL of these patients.

O objetivo deste estudo foi de quantificar a qualidade de vida (QV) em crianças com distrofia muscular de Duchenne (DMD) em diferentes idades através do uso do questionário Life Satisfaction Index for Adolescents (LSI-A). Foi também avaliada a praticidade do questionário. O LSI-A foi aplicado a 95 pacientes com distrofia muscular de Duchenne em corticoterapia, em diferentes idades, e por quatro vezes com intervalos de três meses. Os resultados concernentes às quatro avaliações e a concordância inter e intra-observador foram tratados estatisticamente. Comparando diferentes faixas etárias, mesmo ao longo da progressão da doença, não notamos perda da QV. Concluímos que por não valorizar excessivamente os aspectos clínicos e abranger uma diversidade de circunstâncias cotidianas, O LSI-A é útil na avaliação da QV das crianças com DMD, sendo também de fácil aplicação.

A Case of Generalized Pyoderma Gangrenosum Involving Scalp and Face

PURPOSE: Pyoderma gangrenosum is a rare inflammatory, reactive dermatosis marked by painful cutaneous ulcer. The causes of pyoderma gangrenosum remain unclear. Gastrointestinal, hematological, rheumatological, and immmune disorders may be associated with pyoderma gangrenosum. The appearance of this disease may range from mild skin ulcers to life-threatening conditions. Generalized multiple ulcerative pyoderma gangrenosum is very rare. Here we report our experience with a case of multiple ulcerative pyoderma gangrenosum accompanied by ulcerative colitis. METHODS: A 67-year-old man had cutaneous ulcers at multiple sites including the scalp, face, chest, abdomen, hands, and buttocks. He also developed gastrointestinal symptoms such as intermittent dyspepsia and bloody excrement. Debridement and irritation aggravated the disease progress. We gave a diagnosis of pyoderma gangrenosum with ulcerative colitis based on the clinical appearance and biopsy. The patient was treated with systemic intravenous steroid therapies and careful wound cares. Ulcers of the scalp and buttocks were treated with split thickness skin grafts. RESULTS: Most of the multiple cutaneous ulcers were treated by systemic intravenous steroid therapies and wound cares. The rest of the ulcers were treated with skin grafts. Systemic intravenous steroid therapy was used to treat the ulcerative colitis. CONCLUSION: Generalized multiple ulcerative pyoderma gangrenosum is very rare. Without making an accurate diagnosis, hasty surgical treatments could aggravate the progression of the disease. Additionally, care should be taken to systemically treat underlying disease as well as administrating local treatments for the skin lesions. Intravenous systemic steroid therapy and skin grafts are useful treatments for generalized pyoderma gangrenosum.