Rapid onset pembrolizumab-induced inflammatory arthritis diagnosed using musculoskeletal ultrasound.

Immune checkpoint inhibitors have revolutionised the treatment of cancer. While very effective, they commonly cause a wide spectrum of immune-related adverse events. These immune-related adverse events can be fatal and often have significant effects on quality of life. They therefore require prompt recognition and management. We report the case of a woman presenting with widespread joint pain and stiffness 6 hours after her first pembrolizumab infusion. She had no joint swelling on physical examination but an ultrasound scan revealed widespread musculoskeletal inflammation, confirming the diagnosis of inflammatory arthritis. To the best of our knowledge, this is the fastest reported inflammatory arthritis onset following immune checkpoint inhibitor treatment. It highlights the importance of timely imaging in patients on immune checkpoint inhibitors who present with new non-specific musculoskeletal pain. Her symptoms improved dramatically with intramuscular triamcinolone injection.

Comparison of the effect of topical triamcinolone 0.1% cream with sulfur 2.0% cream in the treatment of patients with hand eczema: A randomized controlled trial.

BACKGROUND: Hand eczema (HE) is a common and heterogeneous condition. It has a wide range of etiologies and clinical manifestations. In this study the efficacy of triamcinolone 0.1% cream and sulfur 2% creams was compared in treating patients with HE. METHODS: This randomized, triple-blind clinical trial was performed on 70 patients with HE (including 70 right and 70 left hands). In this study, two creams were used including triamcinolone 0.1% and sulfur 2.0%. Patients were treated with these creams twice a day (once in every 12 h) for 4 weeks. Follow-up was 4 weeks after treatment. Hand Eczema Severity Index (HECSI), itching, dryness, burning sensation, and erythema scores were collected three times during the study and compared between treatment regimens. RESULTS: Findings showed that both triamcinolone (0.1%) and sulfur (2.0%) creams could significantly reduce the scores of HECSI, itching, dryness, burning sensation, and erythema, and the therapeutic effects lasted for at least 4 weeks after cessation of topical treatment. CONCLUSION: Topical sulfur cream (2.0%) is as effective as triamcinolone (0.1%) cream in treatment of HE without any prominent adverse reactions.

Comparison of the Effect of Intracarpal Injection of Ketorolac With Triamcinolone in Carpal Tunnel Syndrome: A Randomized Controlled Trial.

BACKGROUND: The most prevalent entrapment neuropathy is carpal tunnel syndrome (CTS). Although nonsteroidal antiinflammatory drugs (NSAIDs) are frequently prescribed for musculoskeletal disorders, oral NSAIDs do not provide any additional benefits for CTS. Nevertheless, the use of NSAID phonophoresis has shown significant improvement, possibly due to increased concentration in the target tissue. The effects of intracarpal injection of NSAIDs on CTS have not been studied. OBJECTIVE: We conducted a controlled trial to compare the efficacy of ketorolac and triamcinolone in treating CTS. METHODS: Mild to moderate CTS patients were randomly assigned to receive either a local injection of 30 mg ketorolac or 40 mg triamcinolone. Patients were evaluated using visual analog scale (VAS) for pain, severity, function, electrodiagnostic findings, patient satisfaction, and any complications at the injection site, at baseline and 12 weeks after the procedures. RESULTS: Fifty patients participated, and 43 completed the study. Both groups showed significant improvement in the VAS, severity, function, and electrodiagnostic scores at 3 months compared with the baseline. A comparison of the groups showed significant differences in VAS, severity, and function, with the improvement being significantly higher in the triamcinolone group. CONCLUSION AND RELEVANCE: The present study showed that injection of triamcinolone or ketorolac into the carpal tunnel relieved pain, increased function, and improved electrodiagnostic findings in patients with mild to moderate CTS. It also showed that triamcinolone was superior to ketorolac in terms of analgesic effect and resulted in greater improvement in symptom severity and function.

Analysis of the effectiveness of PDT with 5-aminolevulinic acid in comparison to blue/red light combined with intralesional triamcinolone injection in treatment of severe inflammatory acne: A retrospective study.

OBJECTIVE: In this study, the therapeutic effect of 5-aminolevulinic acid photodynamic therapy (ALA-PDT) in comparison to blue/red light combined with intralesional triamcinolone injection for severe inflammatory acne was evaluated and analyzed. METHODS: One hundred and four cases of severe inflammatory acne were analyzed in this study. They were divided into two groups as control and observation groups, 52 cases in each group. The control group (group A) received red and blue light combined with triamcinolone injection and lidocaine injection (1:4), while the observation group (Group B) was treated with ALA-PDT. Finally, the therapeutic effect and the occurrence of adverse reactions were compared between the two groups. RESULTS: After 2, 4 and 6 weeks, the effectiveness rates of group B was 28.85%, 75.00%, and 86.54%, respectively while it was 9.62%, 51.92%, and 69.23%, respectively in group A. The difference between A and B was statistically remarkable (χ2 = 6.1905, 5.9713, 4.5217, p = 0.0128, 0.0145, 0.0335 at p < 0.05). In addition, the incidence of adverse reactions in B was 5.77%, lower than A (32.69%). This difference between A and B was statistically remarkable (χ2 = 12.1333, p = 0.0005). After 2, 4, and 6 weeks of treatment, the number of residual lesions in the group B group was remarkably lower than group A (p < 0.01). There was remarkable difference in the incidence of pain, burning sensation, pigmentation and erythema between the two groups. CONCLUSIONS: The therapeutic effect of ALA-PDT in the treatment of severe acne is better than red blue light combined with triamcinolone injection and lidocaine injection. In addition, ALA-PDT has an ideal effect in the treatment of severe acne.

Intraoperative application of triamcinolone - a risk factor for delayed CSF fistula formation?

PURPOSE: Cerebrospinal fluid (CSF) leaks are a well-known complication in spinal surgery, caused mostly by incidental durotomy (ID). However, delayed pseudomeningocele formation has been described in patients following an unremarkable surgery - without ID. Intraoperative and epidural triamcinolone application has been suspected to be a potential risk factor. This study was conducted to evaluate the management of ID and identify further risk factors for secondary CSF fistula formation. METHODS: After obtaining approval from the institutional ethics committee, a total of about 5512 patients, who underwent spine surgery between January 2014 and December 2017, were retrospectively reviewed. Of those, 139 cases with intraoperative ID and 15 with delayed pseudomeningocele formation were extracted and analyzed to identify potential risk factors for a late presenting dural injury (LPDI). RESULTS: The incidence of delayed CSF fistulas was 0.27%, with 15 patients presenting with a secondary symptomatic CSF fistula following an unremarkable surgery. Triamcinolone was identified as a risk factor (p<0.001) for pseudomeningocele formation with an OR of 11.5, as it was applied in 80.0% (n=12) of these cases. Revision surgery was performed at a mean period of 6 weeks after initial surgery. CONCLUSION: In our retrospective analysis, intraoperative application of triamcinolone was significantly associated with a high rate of delayed CSF fistulas. It should therefore be used with caution and only after weighing in potential negative side effects.

Periocular methotrexate versus periocular triamcinolone injections for active thyroid-associated orbitopathy: a randomized clinical trial.

PURPOSE: To assess the efficacy and safety of periocular injections of methotrexate versus triamcinolone in the management of active thyroid-associated orbitopathy. STUDY DESIGN: Prospective, double-masked, randomized clinical trial. METHODS: Participants with bilateral active, moderate-to-severe thyroid-associated orbitopathy were randomly assigned to receive three periocular injections of 7.5 mg methotrexate in one orbit and three periocular injections of 20 mg triamcinolone in the contralateral orbit. RESULTS: Among the enrolled 25 patients, 18 patients completed the study. A statistically significant reduction of the mean clinical activity score was detected in both arms (from 5.2 ± 0.89 at baseline to 0.9 ± 1.7 at study endpoint, p-value < 0.001 in the methotrexate arm, and from 5.1 ± 0.9 at baseline to 1 ± 1.7 at study endpoint, p-value < 0.001 in the triamcinolone arm), mean proptosis also decreased in both arms (from 25.2 ± 3.4 mm at baseline to 23.8 ± 3.7 mm at study endpoint, p-value = 0.01 in the methotrexate arm, and from 24.2 ± 3.06 mm at baseline to 23.2 ± 3.3 mm at study endpoint, p-value = 0.049 in the triamcinolone arm). Lid aperture and soft tissue signs improved significantly in both arms in comparison to baseline. A statistically significant reduction in the intraocular pressure was observed in the methotrexate arm but not in the triamcinolone arm. 88.9% of patients in both arms were overall responders at 6 months. There was no significant difference in mean CAS, proptosis, lid aperture or rate of responders between the two arms at any visit. Both drugs were found to be safe with minimal local and systemic complications. CONCLUSION: Periocular injections of methotrexate represent an effective and safe alternative option for the management of active, moderate-to-severe thyroid-associated orbitopathy. Although no serious complications occurred during the 6-month follow-up, the possibility of late complications such as orbital fat atrophy cannot be ruled out.

Novel management of granuloma formation secondary to dermal filler: A multi-modality approach.

BACKGROUND: Dermal fillers for soft tissue augmentation have become increasingly popular among patients of all ages and ethnicities. With more widespread use, there has been an increased incidence of adverse reactions, one of which is the granulomatous foreign body reaction (GFBR). MATERIALS & METHODS: We present a three patient case series in which GFBR secondary to dermal filler was successfully treated with a multi-leveled approach. The first modality involves intralesional injection of a mixture containing 1 cc of 5-fluorouracil (5-FU), 0.5 cc of dexamethasone sodium phosphate, and 0.1 cc of triamcinolone 10. The lesion is injected intradermally in small aliquots, similar to scar treatment. The patient then takes colchicine 1.2 mg loading dose on day 1, then 0.6 mg twice per day for 4 days concurrently with naproxen 500 mg orally once daily for 5-7 days. This process may be repeated in 6 weeks if the lesions have not resolved and PDL laser may be employed for residual post-inflammatory erythema. RESULTS: All three patients presented in this case series had significant aesthetic improvement in their dermal filler-derived foreign body granulomatous reactions. CONCLUSION: GFBR provides both a medical and aesthetic issue for these patients including mental distress, pain, and dysfunction, therefore having an effective treatment for GFBR will affect medical management of these patients, improving patient outcomes and satisfaction. Our proposed regimen for GFBR has been shown to be highly efficacious and safe for these patients, providing a significant improvement in both function and cosmesis of the area.

Acute systemic complications of intravitreal bevacizumab and triamcinolone injections - a comparative study.

INTRODUCTION: Macular edema is a common visual threatening complication in patients with diabetic retinopathy and retinal vein occlusion. The injection of intravitreal drugs, such as anti-vascular endothelial growth factor (anti-VEGF) and corticosteroids, revolutionized the treatment of these diseases.

Intralesional bleomycin versus intralesional triamcinolone in the treatment of keloids and hypertrophic scars.

Bleomycin is a known chemotherapeutic agent whose beneficial effects have been recently shown in the treatment of keloids and hypertrophic scars, however, it is unclear how effective it is in comparison with corticosteroids. We aimed to compare the safety and efficacy of intralesional bleomycin versus intralesional triamcinolone in the treatment of hypertrophic scars and keloids. Sixty patients were divided into two groups and treated by intralesional injection of triamcinolone (20 mg/ml) or bleomycin (1.5 mg/ml). The treatments were repeated every 3 weeks until the lesions flattened or for a maximum of six sessions. The clinical improvement was evaluated using the Japan scar workshop (JSW) scar scale (JSS) and the physician global assessment of flattening of the lesions. Side effects were also noted and recorded. 55 patients completed the study, 4 patients from the bleomycin group and 1 patient from the triamcinolone group dropped out of the study. In both groups, the total JSS scores decreased significantly after treatment compared to baseline (p < 0.001); however, the difference between groups was not statistically significant after treatment (p = 0.052). Moreover, the degree of flattening of the lesions was comparable between groups (p = 0.933). Side effects in the triamcinolone group were Hypopigmentation(55.2%), atrophy(51.7%), and telangiectasia(41.4%) and in bleomycin group included persistent pain after injection (61.5%), ulceration (69.2%), hyperpigmentation(76.9%), and secondary infection (34.6%). Intralesional bleomycin (1.5 mg/ml) is effective as triamcinolone(20 mg/ml) in the treatment of keloids and hypertrophic scars, however, bleomycin should be used carefully, due to adverse events such as pain, ulceration, and hyperpigmentation.

Hipo persistente: una rara complicación de una inyección epidural transforaminal de corticoides / Persistent hiccup: a rare complication of a transforaminal epidural corticoid injection / Soluços persistentes: uma complicação rara da injeção peridural transforaminal de corticosteroide

Se describe el caso de un paciente que instaló un hipo persistente luego de recibir una inyección epidural transforaminal lumbar de corticoides. Se destaca que es una complicación raramente reportada y por ende poco conocida por quienes practican intervencionismo en dolor. Se discuten los posibles mecanismos por los que puede presentarse, se reseña la evolución observada, y se describe el tratamiento instituido. Se señala el impacto que el hipo puede tener sobre la calidad de vida.

The case of a patient who installed a persistent hiccup after receiving a lumbar transforaminal epidural injection of corticosteroids is described. It is highlighted that it is a rarely reported complication and little known by those who practice interventional pain medicine. Possible mechanisms by which it may occur are discussed, the evolution observed and the treatment instituted are reviewed. The impact that hiccups can have on quality of life is pointed out.

Descrevemos o caso de um paciente que desenvolveu soluços persistentes após receber uma injeção peridural transforaminal lombar de corticosteróides. Ressalta-se que é uma complicação pouco relatada e, portanto, pouco conhecida por quem pratica o intervencionismo na dor. Discutem-se os possíveis mecanismos pelos quais pode ocorrer, revisa-se a evolução observada e descreve-se o tratamento instituído. O impacto que os soluços podem ter na qualidade de vida é apontado.

The Efficacy, Safety, and Side Effects of Intrapericardial Triamcinolone Treatment in Children with Post-surgical Pericardial Effusion: A Case Series.

Intrapericardial triamcinolone can be used to treat chronic pericardial effusion (PE) in adults; however, pediatric data are lacking. In this case series we aim to evaluate the efficacy, safety, and side effects of intrapericardial triamcinolone in children with PE. The incidence and treatment of post-surgical PE from 2009 to 2019 were determined using the institutional surgical database and electronic patient records. Furthermore, a retrospective analysis of efficacy, safety, and side effects of intrapericardial triamcinolone treatment for chronic post-surgical PE was performed. The incidence of postoperative PE requiring treatment was highest after atrial septal defect (ASD) closure when compared to other types of cardiac surgery (9.7% vs 4.3%). Intrapericardial treatment with triamcinolone resolved pericardial effusion in 3 out of 4 patients. All patients developed significant systemic side effects. Surgical ASD closure is associated with an increased risk of development of PE requiring treatment. Intrapericardial triamcinolone is an effective treatment for chronic postoperative PE in children, but is always associated with significant systemic side effects. Close monitoring and treatment of adrenal insufficiency are mandatory in these cases.

Case Report: Subconjunctival Triamcinolone Acetate-associated Scleral Necrosis: Is It Really Obsolete?

SIGNIFICANCE: Recent studies have established the safety of subconjunctival steroids for anterior scleritis, refuting scleral necrosis as a potential complication. However, presently, we report a rare case of scleral necrosis associated with subconjunctival triamcinolone acetate. PURPOSE: The purpose of this study was to report a case of scleral necrosis after subconjunctival triamcinolone acetate administration for nonresponsive anterior nodular scleritis. CASE REPORT: A 45-year-old man diagnosed with nodular anterior scleritis was administered subconjunctival triamcinolone acetate (4 mg) adjacent to the nodule after noting nonresponse for 4 months. Worsening of congestion was noted 3 weeks after the injection. Slit-lamp examination revealed diffuse congestion, 10 clock hours of anterior scleral necrosis, superior whitish depot of subconjunctival triamcinolone acetate, anterior segment flare, and few posterior synechiae. Ultrasound biomicroscopic imaging and contrast-enhanced computerized tomography showed a localized outpouching of sclera and buckling of anterior scleral wall superiorly. The result of the comprehensive blood profile and systemic evaluation undertaken to rule out any underlying autoimmune disorders and herpes zoster ophthalmicus was found negative. A diagnosis of subconjunctival triamcinolone acetate-associated scleral necrosis was made, and the patient was managed conservatively. Gradual improvement with dissolution of subconjunctival triamcinolone acetate and no recurrences till 2 years of follow-up were noted. CONCLUSIONS: Scleral necrosis is a potential complication of subconjunctival triamcinolone acetate. Judicious and cautious use of subconjunctival triamcinolone acetate is advocated for nonresolving anterior scleritis.

Possible effects of agent orange and posttraumatic stress disorder on hyperglycemia in Korean veterans from the US-Vietnam war.

ABSTRACT: This study was conducted to examine whether Korean veterans from the US-Vietnam War who had a diagnosis of type II diabetes mellitus (T2DM) as well as past history of exposure to agent orange (AO) are vulnerable to hyperglycemia when receiving intra-articular corticosteroid injection (IACI) for pain relief.The current study included a total of 49 patients (n = 49) who received an injection of triamcinolone 20 or 40 mg to the shoulder under sonographic guidance or did that of dexamethasone 10 mg or triamcinolone 40 mg combined with dexamethasone 20 mg to the spine under fluoroscopic guidance. Their 7-day fasting blood glucose (FBG) levels were measured and then averaged, serving as baseline levels. This is followed by measurement of FBG levels for 14 days of IACI. Respective measurements were compared with baseline levels. The patients were also evaluated for whether there are increases in FBG levels depending on insulin therapy as well as HbA1c ≥ 7% or HbA1c < 7%.Overall, there were significant increases in FBG levels by 64.7 ±â€Š42.5 mg/dL at 1 day of IACI from baseline (P < .05). HbA1c ≥ 7% and HbA1c < 7% showed increases in FBG levels by 106.1 ±â€Š49.0 mg/dL and 46.5 ±â€Š3.8 mg/dL, respectively, at 1 day of IACI from baseline (P < .05). In the presence and absence of insulin therapy, there were significant increases in them by 122.6 ±â€Š48.7 mg/dL and 48.0 ±â€Š20.4 mg/dL, respectively, at 1 day of IACI from baseline (P < .05). But there were decreases in them to baseline levels at 2 days of IACI.Clinicians should consider the possibility of hyperglycemia when using corticosteroids for relief of musculoskeletal pain in Korean veterans from the US-Vietnam War who had a history of exposure to AO.

Efficacy and safety of intralesional steroid injection in the treatment of melasma.

BACKGROUND: The etiopathogenesis of melasma is not yet completely elucidated; however, certain inflammatory cytokines are involved in its pathogenesis as interleukin (IL) 1a, IL 1b, IL6, prostaglandin (PG) D2and PGE2. Corticosteroid suppressive effect on these cytokines may explain its therapeutic effect in the treatment of melasma. AIMS: To assess the efficacy and safety of intralesional triamcinolone versus Kligman's formula in treatment of melasma. METHODS: This study included 2 groups of female patients with melasma; group1 (treatment group) included 22 patients who were treated by intralesional injection of triamcinolone acetonide at a concentration of 4 mg/mL once monthly for four sessions as a maximum and group 2 (control group), included 22 patients who were treated by Kligman's formula once daily for 3 months. All patients were evaluated by dermoscope before treatment and at each follow-up visit to record any adverse effects of treatment. RESULTS: The severity of melasma, assessed by MASI score, significantly decreased in both groups at the end of third month. There was no statistically significant difference in the therapeutic response between both groups. No side effects were reported with triamcinolone injection except for mild pain during injection, while Kligman's formula was associated with dermatitis, irritation, and burning sensation. CONCLUSIONS: Triamcinolone injection at low concentration could be an effective treatment modality of melasma.

Relationship Between Epidural Steroid Dose and Suppression of Hypothalamus-Pituitary-Adrenal Axis.

BACKGROUND: The suppression of hypothalamic-pituitary-adrenal (HPA) axis is a common complication associated with epidural steroid injections (ESIs). However, the effect of different doses is unknown. OBJECTIVES: The primary objective was to compare the differences in the duration of HPA suppression following treatment with different doses of ESI; triamcinolone acetate (TA) 40 mg and TA 20 mg. The secondary objectives were to compare the extent of salivary cortisol (SC) reduction, the incidence of adrenal insufficiency (AI), and the differences in a numeric rating scale (NRS) depending on the varying levels of TA dose used for ESI. STUDY DESIGN: A double-blind, parallel-group, randomized controlled trial. SETTING: Pain clinics in a university hospital. METHODS: The patients were treated with TA epidurally and divided into 2 groups (T20 and T40) depending on the dose of TA (20 mg and 40 mg). The SC concentration was measured before and after ESI to calculate the duration of HPA axis suppression, the extent of SC concentration reduction, and the SC recovery rate. Additionally, NRS and adrenocorticotropic hormone stimulation tests were used. RESULTS: Thirty patients were analyzed. The T40 group showed longer HPA suppression (19.7 ± 3.1 days) compared with that of the T20 group (8.0 ± 2.4 days). The recovery rate of the T40 group was lower than that of the T20 group (P < 0.015). However, there was no difference in the extent of reduction in SC concentration after ESI, the occurrence of AI, and pain reduction. LIMITATIONS: There were selection bias and no placebo control. CONCLUSIONS: Although the difference in pain relief according to the ESI dose is not significant, the HPA suppression is prolonged with a higher dose than a lower dose, and the recovery is slower. Therefore, the time interval between consecutive ESIs should be adjusted depending on the steroid dose to ameliorate the adverse effects of steroids.

Is it safe for patients to drive after intra-articular knee injection?

BACKGROUND: Intra-articular knee injection is a central component in the current management of knee pain. While this is a routinely performed outpatient procedure, institutional policies for driving post injection differ. This study examines brake response times (BRTs) before and after intra-articular knee injection. Our hypothesis is that BRTs would not significantly differ and thus patients driving ability/safety is unaffected. METHODS: Forty-five patients previously listed for right intra-articular knee injection were prospectively evaluated. Patients underwent baseline assessment of BRT prior to injection. All patients received 10 ml of fluid consisting of one milliliter of 10 mg/ml triamcinolone mixed with nine milliliters of 0.5% levobupivacaine. BRT was re-examined on the same day prior to discharge home. Pre- and post-injection BRTs were examined using the same machine and assessor. RESULTS: The mean age of the cohort was 64.0 ± 12.4 and compromised of 37.8% males. There was no significant difference in the mean pre- and post-injection braking time (0.83 ± 0.29 vs 0.78 ± 0.30 s, p = .42), or in the rate of failed braking time (11.1% vs 6.7%, p = .46). CONCLUSION: This study found that BRT did not significantly differ before and after the intra-articular injection, nor did it cause an increased number of patients failing their BRTs. These findings suggest patients should not be prevented from driving after intra-articular knee injection.