Electrocardiographic changes after high-dose corticosteroid pulse therapy in pemphigus patients

Eosinophilic granulomatosis with polyangiitis associated with malignant arrhythmias: a case report

Background

Eosinophilic granulomatosis with polyangiitis (EGPA) is a rare vasculitis associated with significant cardiac morbidity and mortality. This case report presents the diagnostic and management challenges of EGPA-related arrhythmias in a remote general hospital setting.

Case summary

A 64-year-old Caucasian male presented with an indolent prodrome of fatigue, shortness of breath and anorexia, that culminated in an acute presentation with pulmonary embolism. His complicated clinical course included intracranial haemorrhage and refractory ventricular arrhythmias. Eosinophilia and sub-endocardial hypoattenuation observed on chest computed tomography were key findings that led to the diagnosis of EGPA. Multiple anti-arrhythmic therapies were required as temporary measures whilst control of the underlying eosinophilic inflammation was achieved.Once stable, the patient was transferred to a tertiary cardiac centre for further investigation and cardioverter-defibrillator implantation. With EGPA now well controlled, he has experienced no further ventricular arrhythmias and has fully recovered.

Conclusion

Cardiac complications of EGPA, including ventricular arrhythmias, are difficult to manage without concurrent immunosuppression, which may itself further destabilize cardiac electrophysiology. The role of multiple imaging modalities in the diagnosis and monitoring of EGPA is emphasized, with cardiac magnetic resonance imaging playing a crucial role in detecting sub-endocardial fibrosis.

Correlation between serum cardiac troponin I level and PDAI score in patients with pemphigus vulgaris

Pemphigus vulgaris (PV) is a rare, yet serious autoimmune disorder primarily affecting the skin and mucous membranes. While the dermatological and mucosal aspects of PV are well-documented, the potential for systemic involvement, particularly cardiac complications, remains under-explored. This study aimed to investigate the serum cardiac troponin I (cTnI) level in patients with PV versus healthy controls. The relationship between serum cardiac troponin I (cTnI) levels and various demograpgics, clinical and laboratory characteristics in patients with PV was also dealt with. This cross-sectional study was conducted on 59 patients with pemphigus vulgaris and 59 age- and sex- matched healthy controls, visited at a tertiary care hospital from August 2021 to May 2023. After thorough history taking and physical examination, troponin level was measured by the ECL (Electrochemiluminescence) method. The correlation between serum cTnI level and various variables was evaluated using Pearson's correlation coefficient. The mean serum cardiac troponin I (cTnI) level in patient group was 0.104 ± 0.05 ng/mL, with a range of 0.01 to 0.25 ng/mL. Despite mean cTnI level in patients was greater than controls, this difference was not reach to the significance level (P value: 0.058). The analysis revealed a significant positive correlation (r = 0.52, p = 0.005310), suggesting that higher PDAI scores were associated with elevated cTnI level. The correlation between serum cardiac troponin I (cTnI) level and PDAI score, even without any clinical sign or risk factor for cardiovascular disease suggests a potential link between the severity of PV and subtle cardiac involvement, highlighting the importance of cardiac monitoring in these patients.

Side effects of chronic systemic glucocorticoid therapy: what dermatologists should know

In dermatologists' clinical practice, the use of systemic glucocorticoids is recurrent for the management of different comorbidities that require chronic immunosuppression. The prescription of this medication requires caution and basic clinical knowledge due to the several adverse effects inherent to the treatment. However, different doubts may arise or inappropriate conduct may be adopted due to the lack of objective and specific guidelines for the screening, prophylaxis and management of complications from chronic corticosteroid therapy. Considering this problem, the authors carried out a narrative review of the literature to gather up-to-date data on adverse effects secondary to the chronic use of systemic glucocorticoids. The broad approach to this topic made it possible to review the pathophysiology and risk factors for these complications, as well as to develop updated orientation that can be used as a learning tool and quick reference for dermatologists during their clinical practice with glucocorticoids.

Increased heart rhythm in response to high-dose intravenous methylprednisolone pulse therapy of moderate-to-severe Graves’ orbitopathy

ABSTRACT Background: Intravenous glucocorticoids pulses administration is the main therapeutic option in the treatment of Graves’ orbitopathy. Such therapy could relate to the multiple adverse effects. The aim of the study is evaluation the influence of intravenous methylprednisolone (IVMP) pulse therapy on the heart rhythm (HR) changes in patients with active, moderate-to-severe Graves’ Orbitopathy (GO). Methods: We studied 20 patients with moderate-to-severe GO. All patients received 12 IVMP pulses (6x500 mg plus 6x250mg) at equal time intervals in a weekly schedule. We performed Holter ECG monitoring for 3 consecutive days (the day before, the day of IVMP and day after IVMP) to monitor HR and arrhythmias. We compared changes in HR between these 3 days and set time interval when the alteration was significant. This evaluation was performed during the 1st, 6th and 12th IVMP pulse. Results: Increased HR, in comparison with the day before, was registered on the day of IVMP administration. The most significant increase in HR started 5 hours (h) after a pulse administration and lasted 12 h. There were no significant differences in HR between the day before and the day after IVMP. We did not notice any major adverse cardiac events including severe arrhythmias. Conclusions: IVMP therapy is associated with increased HR, that occurs a few hours after infusion, lasts several hours and is transient.  Keywords: Graves’ ophthalmopathy; Graves’ disease; glucocorticoids; heart rate

Pemphigus-associated cardiomyopathy: report of autoimmune myocarditis and review of literature

Pemphigus is a rare disease characterized by bullous lesions of the skin and mucous membranes. The aetiology is autoimmune and related to the formation of IgG autoantibodies against desmogleins, which are structural proteins of desmosomes that ensure the stability of contacts between cells. Cardiac involvement in patients with pemphigus is poorly documented. We report the data in the literature on this topic and a case of pemphigus-associated autoimmune myocarditis with damage of intercalated disc responding to immunosuppressive therapy. The occurrence of cardiomyopathy with left ventricular dysfunction in patients affected by pemphigus should be appropriately screened with endomyocardial biopsy as it could be the myocardial extension of a potentially reversible autoimmune disorder.

Impacts of different methylprednisolone administration routes in patients with sudden hearing loss or Meniere's disease

BACKGROUND

Evidence suggests that glucocorticoids are important in the treatment of sudden hearing loss (SHL) and Meniere's disease (MD). However, different glucocorticoid administration methods may have a significant impact on treatment outcomes.

OBJECTIVE

This study aimed to investigate effects of different glucocorticoid administration methods on sudden hearing loss and Meniere's disease.

METHODS

In this study, glucocorticoids were administered orally in 18 patients, by retroauricular injection in 15 patients and by intratympanic injection in 15 patients. White blood cell (WBC) count, serum K+, fasting plasma glucose (FPG), body temperature, heart rate and blood pressure were used to evaluate effects of glucocorticoids on patients with hearing loss. Visual analog scale (VAS) of pain and sleep disorders were also surveyed, and pure tone audiometry (PTA) results were compared among groups to evaluate efficacy of different glucocorticoids administration methods.

RESULT

WBC count, heart rate and blood pressure were higher in patients taking oral glucocorticoids, while body temperature, serum K+ and FPG levels did not change in all three groups. However, patients who received intratympanic injection of glucocorticoids experienced more pain, while those taking oral glucocorticoids reported more sleep impairment. Treatment efficacy on hearing loss was not significantly different among the three groups.

CONCLUSION

These findings suggest that systemic glucocorticoid administration can result in greater whole body responses than local administration, but with similar hearing treatment efficacy.

Effects of Adrenocorticotropic Hormone Treatment on Heart Muscle in Patients with Infantile Spasm

Background and aim

Infantile spasm (IS) is a common epileptic syndrome of childhood epilepsies. The most effective treatment for IS is adrenocorticotropic hormone (ACTH). We hypothesized that ACTH treatment might change myocardial systolic and diastolic performance and cause cardiovascular side effects. This study aims to evaluate the effects of ACTH treatment on the heart muscle in IS patients.

Materials and methods

Eighteen newly diagnosed patients with IS participated in the study. ACTH (Synacthen® Depot) administered for two months in a total of 18 doses. A twelve-channel-surface electrocardiogram (ECG) and echocardiography performed in all patients before ACTH treatment, the second month after ACTH treatment (end of treatment), and two months later (after treatment). The systolic and diastolic myocardial functions were assessed by conventional and tissue Doppler imaging (TDI).

Results

The mean age of the patients was 8.1 months, and the patient group consisted of five female and 13 male subjects. None of the patients had clinically significant arrhythmia during treatment. After treatment, the mean heart rates of the patients significantly decreased (p=0.02), the systolic and diastolic blood pressures of patients did not change. We observed mild septal hypertrophy and an increase in the left ventricle mass index with ACTH treatment. Septal hypertrophy did not show progression until the fourth month after treatment. After ACTH treatment, patients had higher left ventricular myocardial performance index and lower E′ and A′ values at the mitral lateral annuli, however, these values didn't statistically significant from pretreatment values.

Conclusion

The low dose and short duration ACTH treatment in IS patients may cause subclinical myocardial hypertrophy. ACTH treatment has no significant side effects on cardiac functions.

Cardiac function in pemphigus vulgaris patients before and after steroid pulse therapy

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.

Methylprednisolone pulse therapy plus adjuvant therapy for pemphigus vulgaris: an analysis of 10 years' experience on 312 patients

Steroid pulse therapy has shown satisfactory efficacy and safety in treating pemphigus vulgaris (PV). However, there is a paucity of data about the efficacy and safety of methylprednisolone, despite its frequent administration. The aim of this study is to evaluate the efficacy and safety of steroid pulse therapy in treating PV. In this 10-year retrospective cohort study, 312 patients with PV, who had received methylprednisolone pulse therapy, were included. Data of pulse therapy sessions, adjuvant medications, dosages, remission rates, complications, and mortalities were collected from all patients. A total of 276 patients out of 312 underwent the final follow-up at least 6 months after the last session of pulse therapy. Complete remission off therapy was achieved in 83 patients (30%), and 152 patients (55%) had complete remission on therapy. About 29 (10.5%) patients had lesions of pemphigus at the time of the study follow-up, and 26.8% of remained patients were on the minimal therapy. Methylprednisolone pulse therapy could be considered as an option for proper control of PV in severe cases. It might lead to shorter periods of hospitalization and reduce the need to take long-term high-dose oral steroid therapy.