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Beyler O, Demir C. Pulse Methylprednisolone-Induced Sinus Bradycardia: A Case Report. EXP CLIN TRANSPLANT 2023; 21:921-924. [PMID: 38140936 DOI: 10.6002/ect.2023.0095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2023]
Abstract
Corticosteroids have a wide range of uses. The most commonadverse side effectsofhigh-dosepulse steroids are hyperglycemia, gastrointestinal intolerance, and psychiatric symptoms. Cardiac arrhythmias have been reported in patients who receive high-dose steroid therapy. Bradycardia is a rare adverse side effect of pulse steroid therapy. We present the case of a 57-year-old male patient who developed symptomatic sinus bradycardia after he received pulse methylprednisolone therapy as treatment for graft-versushost disease. The patient's pulse steroid therapy was discontinued, and the dose of methylprednisolone was reduced to 100 mg/day. He was treated conservatively and with close observation; the patient's heart rate increased to 68 beats/min after 1 day, and then to 78 beats/min. The diagnosis of methylprednisolone-induced bradycardia was made after exclusion of other common etiologies of sinus bradycardia. This case report demonstrates the importance of careful cardiovascular monitoring in patients who receive high-dose methylprednisolone because of dose-related cardiovascular risks.
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Affiliation(s)
- Ozlem Beyler
- From the Gazi Yasargil Training and Research Hospital, Diyarbakir, Turkey
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2
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Sohn SY, Kim SY, Joo IS. Corticosteroid-induced bradycardia in multiple sclerosis and maturity-onset diabetes of the young due to hepatocyte nuclear factor 4-alpha mutation: A case report. World J Clin Cases 2022; 10:7415-7421. [PMID: 36158012 PMCID: PMC9353935 DOI: 10.12998/wjcc.v10.i21.7415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Revised: 04/08/2022] [Accepted: 06/03/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Intravenous steroid pulse therapy is the treatment of choice for acute exacerbation of multiple sclerosis (MS). Although steroid administration is generally well-tolerated, cases of cardiac arrhythmia have been reported. Herein, we describe a young woman who developed marked sinus bradycardia and T-wave abnormalities after corticosteroid administration. We also present plausible explanations for the abnormalities observed in this patient.
CASE SUMMARY An 18-year-old woman experienced vertiginous dizziness and binocular diplopia 1 wk prior to admission. Neurological examination revealed left internuclear ophthalmoplegia with left peripheral-type facial palsy. The initial laboratory results were consistent with those of type 2 diabetes. Brain magnetic resonance imaging revealed multifocal, non-enhancing, symptomatic lesions and multiple enhancing lesions. She was diagnosed with MS and maturity-onset diabetes of the young. Intravenous methylprednisolone was administered. On day 5 after methylprednisolone infusion, marked bradycardia with T-wave abnormalities were observed. Genetic evaluation to elucidate the underlying conditions revealed a hepatocyte nuclear factor 4-alpha (HNF4A) gene mutation. Steroid treatment was discontinued under suspicion of corticosteroid-induced bradycardia. Her electrocardiogram changes returned to normal without complications two days after steroid discontinuation.
CONCLUSION Corticosteroid-induced bradycardia may have a significant clinical impact, especially in patients with comorbidities, such as HNF4A mutations.
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Affiliation(s)
- Sung-Yeon Sohn
- Department of Neurology, Ajou University School of Medicine, Ajou University Medical Center, Suwon 16499, South Korea
| | - Shin Yeop Kim
- Department of Neurology, Ajou University School of Medicine, Ajou University Medical Center, Suwon 16499, South Korea
| | - In Soo Joo
- Department of Neurology, Ajou University School of Medicine, Ajou University Medical Center, Suwon 16499, South Korea
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Shahidi-Dadras M, Pishgahi M, Tabary M, Kheradmand Z, Araghi F, Dadkhahfar S, Robati RM. Cardiac function in pemphigus vulgaris patients before and after steroid pulse therapy. J DERMATOL TREAT 2019; 32:855-859. [PMID: 31868046 DOI: 10.1080/09546634.2019.1708850] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Pemphigus vulgaris which is an autoimmune dermatological disorder characterized by vesiculobullous lesions over the skin and mucosae may also give rise to cardiac disease. Global Longitudinal Strain (GLS) measurement may help to predict cardiac dysfunction in these patients. METHOD In this prospective study, the GLS was measured before and after steroid pulse therapy in pemphigus vulgaris patients using 2 D speckle-tracking echocardiography. Moreover, blood pressure, pulse rate, and corrected QT (cQT) interval were recorded before and after steroid pulse therapy. RESULTS We included 23 pemphigus patients. The mean age of patients was 34.5(±6.4). Mean GLS decreased significantly after the administration of steroid pulse therapy. The mean GLS decreased regardless of age, however, the patients with the age range of 40-50 years showed the highest change in GLS. There was no interaction between gender and GLS change. Mean cQT increased significantly after pulse therapy (p=.007). Heart rate increased significantly from 88.5 ± 10.8 to 97.0 ± 13.4 (p<.001). Mean systolic and diastolic blood pressure did not show any significant change. CONCLUSIONS The steroid pulse therapy may associate with the progression of cardiac dysfunction in pemphigus patients. GLS, as a predictor, may be a valuable marker of cardiac subclinical dysfunction in this condition.
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Affiliation(s)
| | - Mehdi Pishgahi
- Department of Cardiology, Shohada-e-Tajrish Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | | | - Zohreh Kheradmand
- Skin Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Farnaz Araghi
- Skin Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Sahar Dadkhahfar
- Skin Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Reza M Robati
- Skin Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran.,Department of Dermatology, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Steroid-induced Bradycardia During Induction Chemotherapy in Children and Young Adults Diagnosed With Acute Lymphoblastic Leukemia and Lymphoblastic Lymphoma. J Pediatr Hematol Oncol 2019; 41:537-541. [PMID: 30994505 DOI: 10.1097/mph.0000000000001483] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Systemic corticosteroids are widely used for the treatment of acute lymphoblastic leukemia (ALL) and lymphoblastic lymphoma. Anecdotal case reports demonstrate bradycardia in patients receiving corticosteroids; however, a more in-depth analysis is lacking. This study aimed to describe the incidence, timing, and outcomes of bradycardia in children with ALL receiving corticosteroids during induction chemotherapy at our center from 2010 to 2016. A total of 153 children were included, with 150 (98%) demonstrating decreased heart rate following steroid administration with a median HR decrease of 23 beats per minute. Bradycardia ≤first percentile for age developed in 90 (59%) patients, with nadir occurring, on average, 7 doses into treatment, corresponding to 79 hours after initiation of therapy. No patient experienced adverse events related to bradycardia. Resolution of bradycardia at outpatient follow-up occurred in 62 of 71 (87%). Examination of nadir heart rate during subsequent hospitalizations in which steroids were not being administered did not demonstrate a significant incidence of bradycardia. Corticosteroid-induced bradycardia is common in children with ALL receiving induction chemotherapy. It was not associated with clinical adverse events and self-resolved without intervention. Therefore, further cardiac assessment may not be warranted in the presence of asymptomatic bradycardia suspected to be secondary to steroid administration.
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Sodero A, Squitieri M, Mazzeo S, Pasca M, Matà S, Pieri F, Bessi V, Sorbi S. Acute Symptomatic Sinus Bradycardia in High-Dose Methylprednisolone Therapy in a Woman With Inflammatory Myelitis: A Case Report and Review of the Literature. CLINICAL MEDICINE INSIGHTS-CASE REPORTS 2019; 12:1179547619831026. [PMID: 30828250 PMCID: PMC6390212 DOI: 10.1177/1179547619831026] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Accepted: 01/15/2019] [Indexed: 12/02/2022]
Abstract
High dose corticosteroid therapy is widely used as attack therapy of inflammatory central nervous system disorders and can induce several adverse reactions. Bradycardia is an infrequent event after corticosteroids administration and is often asymptomatic. We report a case of a woman admitted to the neurological department of our hospital for paraesthesias of the lower limbs. She received adiagnosis of inflammatory myelitis and high dose corticosteroid therapy was prescribed. During the therapy she complained of chest tightness, dyspnoea, weakness and malaise. An electrocardiogram revealed sinus bradycardia. A significant increase in body weight, probably due to plasma volume expansion, was detected. Bradycardia and high blood pressure spontaneously resolved in few days. We provide a collection and a statistical analysis of literature data about steroid induced bradycardia. We found that higher total doses are associated with lower pulse rate and symptomatic bradycardia. Bradycardia is more frequent in older patients and those with underlying cardiac disease or with autonomic disturbance. However clinicians must be aware about the occurrence of symptomatic bradycardia in all patients who undergo high dose corticosteroid therapy, not only in those at risk, to early detect and treat this potentially dangerous condition.
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Affiliation(s)
- Alessandro Sodero
- Department of Neurological and
Psychiatric sciences (NEUROFARBA), University of Florence, Florence, Italy
- Careggi University Hospital, Neurology
unit, Florence, Italy
| | - Martina Squitieri
- Department of Neurological and
Psychiatric sciences (NEUROFARBA), University of Florence, Florence, Italy
- Careggi University Hospital, Neurology
unit, Florence, Italy
| | - Salvatore Mazzeo
- Department of Neurological and
Psychiatric sciences (NEUROFARBA), University of Florence, Florence, Italy
- Careggi University Hospital, Neurology
unit, Florence, Italy
| | - Matteo Pasca
- Department of Neurological and
Psychiatric sciences (NEUROFARBA), University of Florence, Florence, Italy
- Careggi University Hospital, Neurology
unit, Florence, Italy
| | - Sabrina Matà
- Department of Neurological and
Psychiatric sciences (NEUROFARBA), University of Florence, Florence, Italy
- Careggi University Hospital, Neurology
unit, Florence, Italy
| | - Francesco Pieri
- Department of Cardiology, Careggi
University Hospital, Florence, Italy
| | - Valentina Bessi
- Department of Neurological and
Psychiatric sciences (NEUROFARBA), University of Florence, Florence, Italy
- Careggi University Hospital, Neurology
unit, Florence, Italy
| | - Sandro Sorbi
- Department of Neurological and
Psychiatric sciences (NEUROFARBA), University of Florence, Florence, Italy
- Careggi University Hospital, Neurology
unit, Florence, Italy
- IRCCS Don Carlo Gnocchi, Florence,
Italy
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Üsküdar Cansu D, Bodakçi E, Korkmaz C. Dose-dependent bradycardia as a rare side effect of corticosteroids: a case report and review of the literature. Rheumatol Int 2018; 38:2337-2343. [PMID: 30276424 DOI: 10.1007/s00296-018-4167-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Accepted: 09/25/2018] [Indexed: 12/18/2022]
Abstract
Corticosteroids rank at the first place among the most commonly used immunosuppressive agents in the rheumatology practice. Although their conventional adverse effects including hyperglycemia, hypertension, hyperlipidemia, and osteoporosis are well-recognized and managed, steroid-induced cardiac arrhythmias are known to a lesser extent. In this regard, steroid-associated bradycardia is rarely expected and not very well known. Reported cases of steroid-associated bradycardias in the literature predominantly have emerged during the course of intravenous high-dose (pulse) methylprednisolone (MP) administrations. In this paper, we report a patient who developed sinus bradycardia following 52 mg of oral MP administration, improved once the drug was discontinued but repeated with the re-administration. Hence, the patient was shifted to prednisolone (PRED), and again suffered bradycardia which recovered upon dose reduction. Presenting this case along with other similar rare cases in the literature, our aim is to draw attention of fellow rheumatologists, who widely use steroids, to bradycardia-a rare and dose-dependent side effect of steroids.
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Affiliation(s)
- Döndü Üsküdar Cansu
- Division of Rheumatology, Department of Internal Medicine, Eskişehir Osmangazi University, Eskisehir, Turkey.
| | - Erdal Bodakçi
- Division of Rheumatology, Department of Internal Medicine, Eskişehir Osmangazi University, Eskisehir, Turkey
| | - Cengiz Korkmaz
- Division of Rheumatology, Department of Internal Medicine, Eskişehir Osmangazi University, Eskisehir, Turkey
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Pishgahi M, Dadkhahfar S, Robati RM, Kheradmand Z, Shahidi-Dadras M, Zargari O, Elpern DJ. Electrocardiographic changes after high-dose corticosteroid pulse therapy in pemphigus patients. J DERMATOL TREAT 2018; 29:802-805. [PMID: 29668335 DOI: 10.1080/09546634.2018.1466980] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE The objective of the current study was to evaluate the effect of intravenous methylprednisolone pulse therapy on myocardial repolarization alterations, especially QT dispersion in anticipation of cardiovascular risks in patients with pemphigus vulgaris. METHODS The current study is a prospective-controlled study on the electrocardiographic changes after methylprednisolone pulse therapy in 50 patients with pemphigus vulgaris. RESULTS A total of 50 patients (28 female and 22 male) were included in our study. The mean heart rate was significantly higher in male patients both before (92 ± 10.80 versus 82.75 ± 12.01 ms) and after pulse therapy (102.73 ± 14.26 versus 91.07 ± 15.02 ms) (p value < .01). The value of heart rate was significantly greater after receiving steroid pulse therapy. Corrected QT dispersion before pulse therapy was 19.92 ± 8.2 ms that increased to 40.68 ± 18.12 ms after treatment (p value < .001). CONCLUSION Our study shows that there is a relationship between pulse steroid infusion and increased predisposition to the occurrence of cardiac arrhythmias. QT dispersion could be a good marker to assess this risk in these patients.
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Affiliation(s)
- Mehdi Pishgahi
- a Department of Cardiology , Shohada-e-Tajrish Hospital, Shahid Beheshti University of Medical Sciences , Tehran , Iran
| | - Sahar Dadkhahfar
- b Skin Research Center , Shahid Beheshti University of Medical Sciences , Tehran , Iran
| | - Reza M Robati
- b Skin Research Center , Shahid Beheshti University of Medical Sciences , Tehran , Iran
| | - Zohreh Kheradmand
- b Skin Research Center , Shahid Beheshti University of Medical Sciences , Tehran , Iran
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Lazzerini PE, Capecchi PL, Galeazzi M, Laghi-Pasini F. Biologic drugs and arrhythmic risk in chronic inflammatory arthritis: the good and the bad. Immunol Res 2018; 65:262-275. [PMID: 27423435 DOI: 10.1007/s12026-016-8833-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Increasing evidence indicates that patients with chronic inflammatory arthritis (CIA), including rheumatoid arthritis and spondyloarthropathies, have an increased risk of arrhythmic events, significantly contributing to the higher cardiovascular disease (CVD) morbidity and mortality observed in these subjects compared to the general population. Although the mechanisms accounting for such an arrhythmogenic substrate are not fully understood, the main role is probably played by chronic systemic inflammation, able to accelerate the development of structural CVD, as well as to directly affect cardiac electrophysiology. In the past decade, biologic therapies have revolutionized the treatment of CIA by highly enhancing the probability to effectively control disease activity and its systemic consequences, including cardiovascular involvement. Accordingly, accumulating data demonstrated that by potently inhibiting systemic inflammation, biologic drugs can reduce CVD progression and ameliorate arrhythmic risk parameters, with a putative beneficial impact on arrhythmia incidence. Nevertheless, a significant number of reports from clinical trials and postmarketing experience suggest that some of these medications, particularly TNF inhibitor monoclonal antibodies and rituximab, may in some circumstances precipitate arrhythmia occurrence, probably by acutely amplifying myocardial electric instability intrinsically associated with these diseases. In this review, we analyze the intricate link between biologic drugs and arrhythmias in CIA in the effort to identify which factors are involved in the fine-tuning of antiarrhythmic/pro-arrhythmic balance, and understand how this knowledge should be translated in the clinical practice to obtain the most favorable benefit-to-risk profile when biologic drugs are used in these patients.
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Affiliation(s)
- Pietro Enea Lazzerini
- Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Policlinico "Le Scotte", Viale Bracci, Siena, Italy.
| | - Pier Leopoldo Capecchi
- Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Policlinico "Le Scotte", Viale Bracci, Siena, Italy
| | - Mauro Galeazzi
- Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Policlinico "Le Scotte", Viale Bracci, Siena, Italy
| | - Franco Laghi-Pasini
- Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Policlinico "Le Scotte", Viale Bracci, Siena, Italy
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9
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Bradycardia Associated with Steroid Use for Laryngeal Edema in an Adult: A Case Report and Literature Review. Case Rep Cardiol 2016; 2016:9785467. [PMID: 27999689 PMCID: PMC5143689 DOI: 10.1155/2016/9785467] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2016] [Accepted: 10/31/2016] [Indexed: 11/17/2022] Open
Abstract
Steroids are used for specific indications in the perioperative period to reduce laryngeal or spinal cord edema, or for prophylaxis and treatment of postoperative nausea and vomiting. Given the other potential causes for hemodynamic alterations in the perioperative setting, it is important for physicians to be aware of cardiovascular side effects of short term steroids. Changes in blood pressure and heart rate, cardiac dysrhythmias, and even death have been described in patients receiving short term intravenous steroids. Bradycardia has been reported following short term methylprednisolone and dexamethasone therapy in both adult and pediatric patients. There are only two case reports in the literature of bradycardia following short term intravenous dexamethasone use in adult patients. This is the first case report that describes bradycardia following the use of dexamethasone in the postoperative setting for management of laryngeal edema in an adult. Telemetry and twelve lead electrocardiograms revealed sinus bradycardia and correlated directly with administration of dexamethasone in our patient. Bradycardia resolved following discontinuation of dexamethasone. We advocate for hemodynamic monitoring in patients receiving more than one dose of intravenous steroid therapy in the perioperative period, especially those with known cardiac and hepatic comorbidities and those taking medications with negative chronotropic effects.
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Kundu A, Fitzgibbons TP. Acute symptomatic sinus bradycardia in a woman treated with pulse dose steroids for multiple sclerosis: a case report. J Med Case Rep 2015; 9:216. [PMID: 26400725 PMCID: PMC4581459 DOI: 10.1186/s13256-015-0701-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2015] [Accepted: 08/31/2015] [Indexed: 11/14/2022] Open
Abstract
Introduction Sinus bradycardia has been reported after administration of pulse dose steroids, although most cases have occurred in children and are asymptomatic. We report a case of acute symptomatic sinus bradycardia due to pulse dose steroids in a woman with multiple sclerosis. Interestingly, this patient also suffered from inappropriate sinus tachycardia due to autonomic involvement of multiple sclerosis. Case presentation A 48-year-old Caucasian woman with multiple sclerosis and chronic palpitations due to inappropriate sinus tachycardia was prescribed a 5-day course of intravenous methylprednisolone for treatment of an acute flare. Immediately following the fourth dose of intravenous methylprednisolone, she developed dyspnea, chest heaviness, and lightheadedness. She was referred to the emergency department where an electrocardiogram showed marked sinus bradycardia (40 beats per minute). Initial laboratory test results, including a complete blood count, basic metabolic profile and cardiac biomarkers, were normal. She was admitted for observation on telemetry monitoring. Her heart rate gradually increased and her symptoms resolved. Her outpatient dose of atenolol, taken for symptomatic inappropriate sinus tachycardia, was resumed. Conclusions Our patient’s acute symptoms were attributed to symptomatic sinus bradycardia due to pulse dose steroid treatment. Although several theories have been suggested to explain this phenomenon, the exact mechanism still remains unknown. It does not warrant any specific treatment, as it is a self-limiting side effect that resolves after discontinuing steroid infusion. Young patients who are free of any active cardiac conditions can safely be administered pulse dose steroids without monitoring. However, older patients with active cardiac conditions should have heart rate and blood pressure monitoring during infusion. Our patient also suffered from inappropriate sinus tachycardia, a manifestation of autonomic involvement of multiple sclerosis that has not been previously described. This case has implications for the pathogenesis and treatment of dysautonomia in patients with multiple sclerosis.
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Affiliation(s)
- Amartya Kundu
- Department of Medicine, University of Massachusetts Medical School, 55 Lake Avenue North, Worcester, MA, 01655, USA.
| | - Timothy P Fitzgibbons
- Department of Medicine, Cardiovascular Division, University of Massachusetts Medical School, 55 Lake Avenue North, Worcester, MA, 01655, USA.
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Stroeder J, Evans C, Mansell H. Corticosteroid-induced bradycardia: Case report and review of the literature. Can Pharm J (Ott) 2015; 148:235-40. [PMID: 26445579 PMCID: PMC4561462 DOI: 10.1177/1715163515597451] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Affiliation(s)
- Jasmine Stroeder
- College of Pharmacy and Nutrition, University of Saskatchewan, Saskatoon, Saskatchewan
| | - Charity Evans
- College of Pharmacy and Nutrition, University of Saskatchewan, Saskatoon, Saskatchewan
| | - Holly Mansell
- College of Pharmacy and Nutrition, University of Saskatchewan, Saskatoon, Saskatchewan
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12
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Symptomatic sinus bradycardia after a treatment course of high-dose oral prednisone. J Emerg Med 2013; 45:e55-8. [PMID: 23827163 DOI: 10.1016/j.jemermed.2013.04.020] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2012] [Revised: 07/27/2012] [Accepted: 04/30/2013] [Indexed: 12/31/2022]
Abstract
BACKGROUND High-dose corticosteroid therapy is used to treat several severe autoimmune diseases. Despite a common knowledge in the medical community of the adverse effects of chronic corticosteroid use, there is much less awareness of the affects that can occur after very high doses are administered in a relatively short period of time. OBJECTIVE Our objective was to report on the outpatient-based practice of administering high-dose corticosteroids for autoimmune disease and the possible bradycardic response that can occur as a result. CASE REPORT We present a case of a 45-year-old female with multiple sclerosis who presented to the emergency department with symptomatic sinus bradycardia secondary to a regimen of high-dose corticosteroid therapy. CONCLUSIONS More patients with autoimmune diseases may be placed on outpatient-based treatment regimens of high-dose corticosteroids in the future. It is important for emergency physicians to be aware of bradycardia as a possible adverse effect, as many of these patients may present to the emergency department for evaluation.
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Heidrich E, Greene G, Weberding J, Lin L, McGee S. Effects of methylprednisolone infusions on vital signs in children with headaches. J Pediatr Pharmacol Ther 2013; 18:39-44. [PMID: 23616734 DOI: 10.5863/1551-6776-18.1.39] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVES Intravenous methylprednisolone (IVMP) infusions have been associated with adverse cardiovascular effects. Inconsistent monitoring practices in a pediatric hospital led to questions about patient safety and allocation of nursing resources. This study describes vital sign changes in children and monitoring practices related to IVMP. METHODS This retrospective chart review received Institutional Review Board approval. Children aged 5 to 17 years receiving IVMP from January 2006 to January 2009 were included. Seventy-four patients with 94 hospital admissions were evaluated. Data collected included systolic blood pressure, diastolic blood pressure, and heart rate, as well as the time and dosage of IVMP. Frequency of vital sign monitoring as ordered and as performed was described. Interrater reliability was calculated, and descriptive statistics were used in the data analysis. RESULTS At baseline, about half of the patients had vital signs out of normal range for age. After the first dose, vital signs fluctuated, with a majority having greater than 10% changes from baseline as increases, decreases, or both. Time of initial 10% change in vital signs ranged from immediately after the dose to 135.5 hours later. Increased vital sign changes were seen in the older patients and in patients receiving higher doses. Monitoring of vital signs occurred more frequently than was ordered. Only 1 patient had a specific order for monitoring with IVMP. CONCLUSIONS The patients included in this study experienced documented fluctuations in vital signs. A prospective study to evaluate the relationship of IVMP and patient safety will assist in standardizing vital sign monitoring guidelines.
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Affiliation(s)
- Elaine Heidrich
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
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14
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Affiliation(s)
- Esin Beyan
- Department of Internal Medicine, Ankara Numune Education and Research Hospital, Ankara, Turkey
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15
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Vasheghani-Farahani A, Sahraian MA, Darabi L, Aghsaie A, Minagar A. Incidence of various cardiac arrhythmias and conduction disturbances due to high dose intravenous methylprednisolone in patients with multiple sclerosis. J Neurol Sci 2011; 309:75-8. [DOI: 10.1016/j.jns.2011.07.018] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2011] [Revised: 07/08/2011] [Accepted: 07/14/2011] [Indexed: 01/11/2023]
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16
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Rottensteiner J, Kaneppele A, Stockner I, Ladurner C, Panizza G, Wiedermann CJ. Precordial T-wave inversion of "cardiac memory" pattern after high-dose methylprednisolone pulse therapy. Intern Emerg Med 2008; 3:375-8. [PMID: 18274710 DOI: 10.1007/s11739-008-0121-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2007] [Accepted: 11/12/2007] [Indexed: 01/09/2023]
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17
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Abstract
BACKGROUND Glucocorticoids are known to cause several side-effects. This retrospective study addresses the relation of glucocorticoid therapy and heart rate. Patient charts of 61 children, treated with (the equivalent of) 1 to 5 mg/kg/d prednisone, were analyzed. OBSERVATIONS Heart rate decreased by 31 (95% CI=23-39) beats/min 72 hours after start treatment, and 63.9% of the children developed at least once a pulse rate <2.5th percentile for age during the first 88 hours after start of treatment. None of the children developed symptoms of reduced cardiac output. CONCLUSION A reduction in heart rate sometimes leading to sinus bradycardia may be a common early side-effect of glucocorticoid treatment in children.
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19
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Krous HF, Breisch E, Chadwick AE, Pinckney L, Malicki DM, Benador N. Nephrogenic systemic fibrosis with multiorgan involvement in a teenage male after lymphoma, Ewing's sarcoma, end-stage renal disease, and hemodialysis. Pediatr Dev Pathol 2007; 10:395-402. [PMID: 17929984 DOI: 10.2350/06-05-0093.1] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2006] [Accepted: 11/29/2006] [Indexed: 12/30/2022]
Abstract
Nephrogenic systemic fibrosis (NSF) is a rare condition that always occurs after acute or chronic renal failure with or without dialysis. The vast majority of cases in the literature are adults, and postmortem findings have been reported in only 5 cases. We report a 15-year-old male who developed NSF with multiorgan involvement after successful treatment of renal lymphoma and a subsequent sacral Ewing's sarcoma, and end-stage renal disease treated with hemodialysis. At autopsy, he was found to have diffuse dural osseous metaplasia, transmural bronchiolar fibrosis, diaphragmatic central tendon fibrosis, and fibrous plaques of the mitral valve. These previously unreported findings expand the spectrum of multiorgan involvement in NSF providing additional evidence that it is an emerging systemic disorder.
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Affiliation(s)
- Henry F Krous
- Pathology Department, Rady Children's Hospital--San Diego, San Diego, CA, USA.
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Akikusa JD, Feldman BM, Gross GJ, Silverman ED, Schneider R. Sinus bradycardia after intravenous pulse methylprednisolone. Pediatrics 2007; 119:e778-82. [PMID: 17308245 DOI: 10.1542/peds.2006-0029] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
High-dose intravenous pulse methylprednisolone is an important therapeutic modality for many autoimmune conditions in both children and adults. Adverse effects of this therapy include hypertension, hyperglycemia, and, in children, behavioral changes. Cardiac rhythm disturbances, both tachyarrhythmias and bradyarrhythmias, have been reported in adults but much less commonly in children. Here we report our experience over a 6-month period with 5 children with rheumatic diseases who developed sinus bradycardia during consecutive daily therapy with intravenous pulse methylprednisolone. Reductions in resting heart rate of between 35% and 50% of baseline were observed in each case. All patients were asymptomatic, and all recovered spontaneously over a variable period of time after cessation of pulse therapy. Sinus bradycardia after repeated administration of high-dose pulse methylprednisolone in children may be more common than previously appreciated.
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Affiliation(s)
- Jonathan D Akikusa
- Division of Rheumatology, Hospital for Sick Children, 555 University Ave, Toronto, Ontario, Canada M5G 1X8
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Chibane S, Feldman-Billard S, Rossignol I, Kassaei R, Mihoubi-Mantout F, Héron E. [Short-term tolerance of three days pulse methyprednisolone therapy: a prospective study in 146 patients]. Rev Med Interne 2005; 26:20-6. [PMID: 15639322 DOI: 10.1016/j.revmed.2004.09.025] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2004] [Accepted: 09/30/2004] [Indexed: 11/25/2022]
Abstract
AIM To study the immediate tolerance of high-dose intravenous pulse steroids. PATIENTS ET METHOD: Prospective study over a six months period in 146 consecutive patients treated by three pulses of 250, 500 or 1000 mg/d methylprednisolone for various eye diseases. Daily monitoring including: standardized questionnaire, electrocardiogram, automated blood pressure measurements, fasting blood glucose and kaliemia. RESULTS One hundred and twenty-nine patients (88,4%) had one ore more side effect(s), mainly transient and of mild intensity, the first one being neuropsychological disturbances (insomnia in half the patients). Myocardial ischemia was observed in three patients (2,1%) with known coronary insufficiency or high cardiovascular risk, blood pressure levels of at least 180/110 mmHg were recorded in five hypertensive patients (3,4%), bradycardia occurred in 14 patients (9,7%), symptomatic in one. After the first pulse, we observed a mean 54+/-30% increase of fasting glucose (P <0,001), followed during the next pulses by a spontaneous slow return toward baseline values in non diabetic patients, contrasting with additional hyperglycemic effects in diabetics, and a mean 5,4+/-10,3% increase of kaliemia (P <0,001) staying unchanged during the next pulses, and suggesting a rapid potassium efflux from the cell as a direct effect of methylprednisolone. CONCLUSION Severe complications of pulse methylprednisolone, mainly cardiovascular, are strongly related to underlying comorbidities. Glucose monitoring is necessary only in diabetic patients. Potassium movements suggest a risk of hypokalicystia, of potential danger in patients with cardiac disease. A close clinical, blood pressure and electrocardiographic monitoring is needed during the whole treatment.
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Affiliation(s)
- S Chibane
- Service de médecine interne, centre hospitalier national d'ophtalmologie des Quinze-Vingts, 28, rue de Charenton, 75571 Paris cedex 12, France
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Kumari R, Uppal SS. First report of supraventricular tachycardia after intravenous pulse methylprednisolone therapy, with a brief review of the literature. Rheumatol Int 2005; 26:70-3. [PMID: 15726372 DOI: 10.1007/s00296-005-0589-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2004] [Accepted: 12/06/2004] [Indexed: 01/19/2023]
Abstract
The occurrence of supraventricular tachycardia after high-dose intravenous methylprednisolone pulse therapy (HIVMPT) in a patient with active rheumatoid arthritis is described for the first time. This case report further expands the range of arrhythmias that can occur with HIVMPT. Other arrhythmias previously reported to occur after HIVMPT include atrial fibrillation, atrial flutter, junctional rhythm, and ventricular tachycardia. To the best of our knowledge, supraventricular tachycardia has not been reported previously, although severe bradycardia, hypotension, asystole, cardiovascular collapse, and sudden death have been documented. A review of the literature indicates that these case reports not withstanding, HIVMPT is generally safe, and cardiovascular toxicity is rare. However, close supervision with repeated measurements of blood pressure, electrocardiogram, and blood electrolytes is mandatory during and immediately after HIVMPT, especially for patients with pre-existing cardiovascular disease, and the lowest effective dose of methylprednisolone should be infused at a slow rate.
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Affiliation(s)
- Rakesh Kumari
- Rheumatology Division, Department of Medicine, Mubarak Al Kabeer Hospital, Kuwait
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Castro-Lizano N, Calleja C, Galindo-Rodríguez G, Aviña-Zubieta JA. Ovarian haemorrhage, rupture and haemoperitoneum secondary to thrombocytopenia in a patient with SLE. Lupus 2005; 12:648-50. [PMID: 12945728 DOI: 10.1191/0961203303lu428xx] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Fong NC, Kwan YW, Hui YW, Yuen LK, Yau EKC, Leung CW, Chiu MC. Adolescent twin sisters with severe acute respiratory syndrome (SARS). Pediatrics 2004; 113:e146-9. [PMID: 14754985 DOI: 10.1542/peds.113.2.e146] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
A novel coronavirus-associated communicable respiratory disease, severe acute respiratory syndrome (SARS), spread worldwide after an outbreak in Guangdong Province of the People's Republic of China in November 2002. Since late February 2003, there has been an epidemic in Hong Kong involving both adult and pediatric patients. The clinical course, intensive care, and outcome of adolescent twin sisters with SARS are described. Adolescents infected with SARS may develop severe illness as adults, and close monitoring for disease progression in terms of both clinical and radiologic deterioration is warranted.
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Affiliation(s)
- N C Fong
- Department of Paediatrics and Adolescent Medicine, Princess Margaret Hospital, Kowloon, Hong Kong.
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