drug induced exfoliative dermatitisdrug induced exfoliative dermatitis

Its also characterized by a cell-poor infiltrate, where macrophages and dendrocytes with a strong TNF- immunoreactivity predominate [6, 50]. Delayed reactions to drugs show levels of perforin, granzyme B, and Fas-L to be related to disease severity. Toxic epidermal necrolysis associated with Mycoplasma pneumoniae infection. Erythema multiforme (EM), StevensJohnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are the main clinical presentations of drug induced ED. Kano Y, et al. National Library of Medicine Continue Reading. Bookshelf Overall, T cells are the central player of these immune-mediated drug reactions. 2013;69(4):37583. Once established the percentage of the involved skin, lactate Ringer infusion of 12mL/Kg/% of involved skin must be started during the first 24h [91]. Drug induced exfoliative dermatitis (ED) are a group of rare and severe drug hypersensitivity reactions (DHR) involving skin and usually occurring from days to several weeks after drug exposure. Interleukin (IL)-1, IL-2, IL-8, intercellular adhesion molecule 1 (ICAM-1), tumor necrosis factor and interferon gamma are the cytokines that may have roles in the pathogenensis of exfoliative dermatitis.2. Main discriminating factors between EMM, SJS, SJS-TEN, TEN and SSSS is summarized in Table3 [84]. PTs have to be performed at least 6months after the recovery of the reaction, and show a variable sensitivity considering the implied drug, being higher for beta-lactam, glycopeptide antibiotics, carbamazepine, lamotrigine, proton pump inhibitors, tetrazepam, trimethoprimsulfametoxazole, pseudoephedrine and ramipril [7376]. PubMed Blood counts and bone marrow studies may reveal an underlying leukemia. 2006;6(4):2658. Manage cookies/Do not sell my data we use in the preference centre. Heat loss is another major concern that accompanies a defective skin barrier in patients with exfoliative dermatitis. Drug induced exfoliative dermatitis: state of the art. - Abstract These patches tend to spread until, after a matter of days or weeks, most of the skin surface is covered with an erythematous, pruritic eruption. The authors declare that they have no competing interests. It is recommended to use 1.5mg/kg hydrocortisone. 2012;66(3):1906. . 2010;62(1):4553. HLA DQB1* 0301 allele is involved in the susceptibility to erythema multiforme. Liver injury and exfoliative dermatitis caused by nifuratel[J]. Consultation with an oncologist who is well-versed in treatment of cutaneous T-cell lymphoma is advisable once the disease progresses to the tumor stage. Also a vesical catheter should be placed to avoid urethral synechiae and to have a precise fluid balance. A case of toxic epidermal necrolysis with involvement of the GI tract after systemic contrast agent application at cardiac catheterization. The EuroSCAR-study. Ethambutol Induced Exfoliative Dermatitis. Ibuprofene Zen * 20cps Mol 400mg 2014;71(5):9417. Kirchhof MG, et al. Pemphigus vulgaris usually starts in the oral mucosa followed by blistering of the skin, which is often painful. Immunoregulatory effector cells in drug-induced toxic epidermal necrolysis. 1 Ko TM, et al. PubMed doi: 10.1111/dth.15416. The balance of fluids and electrolytes should be closely monitored, since dehydration or hypervolemia can be problems. The most important actions to do are listed in Fig. IBUPROFENE ZENTIVA is indicated for the symptomatic treatment of headaches, migraines, dental pain, back pain, dysmenorrhea, muscle pain, neuralgia . Barbaud A. More than moderate, unresponsive to treatment, and which interferes with the Soldier's perfor-mance of duty. Contact dermatitis from topical antihistamine . The authors wish to thank Dr. Gary White for the picture of EM showed in Fig. Management of patients with a suspected drug induced exfoliative dermatitis, acute generalized exanthematous pustulosis, algorithm of drug causality for epidermal necrolysis, European registry of severe cutaneous adverse reactions to drugs. The exfoliative process also may involve the scalp, with 25 percent of patients developing alopecia.4 Nails can often become dystrophic, particularly in patients with preexisting psoriasis.4,6, The most frequently noted symptoms in patients with exfoliative dermatitis include malaise, pruritis and a chilly sensation. Patients can be extremely suffering because of the pain induced by skin and mucosal detachment. Abe J, et al. . J Invest Dermatol. Valeyrie-Allanore L, et al. The applications of topical cyclosporine and autologous serum have also been showed to be useful in refractory cases [103]. When it precedes cutaneous T-cell lymphoma lesions, exfoliative dermatitis becomes the presenting sign of the underlying malignancy. Generalized exfoliative dermatitis, or erythroderma, is a severe inflammation of the entire skin surface. PubMed View ABRIGO_Worksheet #8 Drug Study_Endocrine System.pdf from NCM 06 at Southern Luzon State University (multiple campuses). Br J Dermatol. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Br J Dermatol. Skin testing and patch testing in non-IgE-mediated drug allergy. 2005;102(11):41349. Epub 2022 Mar 9. Sassolas B, et al. Schwartz RA et al. Drug induced exfoliative dermatitis (ED) are a group of rare and severe drug hypersensitivity reactions (DHR) involving skin and usually occurring from days to several weeks after drug exposure. Soak for 5 to 10 minutes and rinse off before patting dry. Clinical features; Delayed type hypersensitivity; Drug hypersensitivity; Erythema multiforme; Exfoliative dermatitis; Lyells syndrome; Pathogenesis; StevensJohnson syndrome; Therapy; Toxic epidermal necrolysis. Exfoliative Dermatitis: Symptoms, Causes, and Treatment - WebMD 2004;428(6982):486. Mockenhaupt M, et al. Toxic epidermal necrolysis treated with cyclosporin and granulocyte colony stimulating factor. Death ligand TRAIL, secreted by CD1a+and CD14+cells in blister fluids, is involved in killing keratinocytes in toxic epidermal necrolysis. Google Scholar. PubMed Oliveira L, Zucoloto S. Erythema multiforme minor: a revision. Skin eruptions caused by CBZ occur in 24% of the patients on this therapy and include pruritic and erythematous rashes, urticaria, photosensitivity reactions, alterations in skin pigmentation, exfoliative dermatitis, and toxic epidermal necrolysis View on Wiley ncbi.nlm.nih.gov Save to Library Create Alert Cite 12 Citations Citation Type (scFv) (directed against Dsg1/3) or AK23 (directed against Dsg3) with (as a control) or without exfoliative toxin A (ETA). Kostal M, et al. If necessary, it can be repeated every 68h. NSAIDs should be avoided as they can induce ED as well. In the hospital, special attention must be given to maintaining temperature control, replacing lost fluids and electrolytes, and preventing and treating infection. CD94/NKG2C is a killer effector molecule in patients with Stevens-Johnson syndrome and toxic epidermal necrolysis. -, Schwartz RA, McDonough PH, Lee BW. . Management of patients with a suspected drug induced exfoliative dermatitis Eosinophils from Physiology to Disease: A Comprehensive Review. DRUG- Induced- Dermatologic-RXNS lam University St. John's University Course Drug induced disease (CPP 6102) Academic year2023/2024 Helpful? 2013;168(3):55562. These measures include bed rest, lukewarm soaks or baths, bland emollients and oral antihistamines.2527, In patients with chronic idiopathic erythroderma, emollients and topical steroids may be effective. Ganciclovir and cidofovir should be used when polymerase-chain reactions (PCR) on peripheral blood or other biological sample identifies a viral reactivation (HHV6, HHV7, EBV and CMV). Bethesda, MD 20894, Web Policies Patmanidis K, et al. volume14, Articlenumber:9 (2016) Morel E, et al. Goulden V, Goodfield MJ. Infliximab was used in cases refractory to high-dosage steroid therapy and/or IVIG. Mayo Clin Proc. Fritsch PO. The induction dosage in EMM is usually 1mg/kg/day that should be maintained until a complete control of the skin is obtained. Exfoliative dermatitis is a rare inflammatory skin condition that is characterized by desquamation and erythema involving more than 90% of the body surface area. ALDEN, an algorithm for assessment of drug causality in StevensJohnson Syndrome and toxic epidermal necrolysis: comparison with case-control analysis. 1997;22(3):1467. Yacoub, MR., Berti, A., Campochiaro, C. et al. Among drug related cases, the main triggering factors are sulfonamides, nonsteroidal anti-inflammatories (NSAIDs), penicillins, and anticonvulsants (Table1) [59]. The most common of these are psoriasis, atopic dermatitis, seborrheic dermatitis, contact dermatitis and pityriasis rubra pilaris. In patients who develop complications (i.e., infection, fluid and electrolyte abnormalities, cardiac failure), the rate of mortality is often high. exfoliative conditions. Pemphigus vulgaris, paraneoplastic pemphigus, bullous pemphigoid and linear IgA dermatosis have to be considered. Cyclosporine A (Cys A): Cys A works through the inhibition of calcineurin, that is fundamental for cytotoxic T lymphocytes activation. Ibuprofen Zentiva can be prescribed with OTC Recipe - self-medication. 2010 Oct;35(7):723-8. doi: 10.1111/j.1365-2230.2009.03718.x. -. N Engl J Med. This compressed maturation process results in an overall greater loss of epidermal material, which is manifested clinically as severe scaling and shedding. This is particularly true for patients with many comorbidities and poli-drug therapy, where it is advisable to monitor liver and kidney toxicity and to avoid Vitamin A excess [99]. PubMed Two Cases in Adult Patients. 2008;59(5):8989. Kavitha Saravu. 2000;22(5):4137. PubMedGoogle Scholar. Article An extremely rare mucocutaneous adverse reaction following COVID-19 vaccination: Toxic epidermal necrolysis. 2012;167(2):42432. HLA-A* 3101 and carbamazepine-induced hypersensitivity reactions in Europeans. Erythroderma See more images of erythroderma. It is not recommended to use prophylactic antibiotic therapy. Roujeau JC, et al. Burns. Blood gas analysis, glucose and creatinine levels together with electrolytes should be evaluated and therapy should be modified accordingly. T and NK lymphocytes can produce FasL that eventually binds to target cells. Important data on ED have been obtained by RegiSCAR (European Registry of Severe Cutaneous Adverse Reactions to Drugs: www.regiscar.org), an ongoing pharmaco-epidemiologic study conducted in patients with SJS and TEN. In approximately 25% of people, there is no identifiable cause. Epidemiological studies on EM, SJS and TEN syndromes report different results, probably related to several biases, such as ethnical differences, diagnostic criteria and drug consumption patterns in different socio-economic systems. The scales may be small or large, superficial or deep. The approach to treatment should include discontinuation of any potentially causative medications and a search for any underlying malignancy. asiatic) before starting therapies with possible triggers (e.g. Open trial of ciclosporin treatment for StevensJohnson syndrome and toxic epidermal necrolysis. 2011;20(2):10712. Int J Mol Sci. Although the etiology is. Sokumbi O, Wetter DA. 2012;43:10115. Jarrett P, et al. Paquet P, et al. Orphanet J Rare Dis. Gueudry J, et al. Background: Panitumumab is an EGFR inhibitor used for the treatment of metastatic colorectal cancer (mCRC), even if its use is related to skin toxicity. Polak ME, et al. [71] realized an algorhitm named ALDEN (algorithm of drug causality for epidermal necrolysis) which helps to establish a cause/effect relationship as probable or very probable in 70% of cases. The epidermal-dermal junction shows changes, ranging from vacuolar alteration to subepidermal blisters [20]. Analysis for circulating Szary cells may be helpful, but only if the cells are identified in unequivocally large numbers. Talk to our Chatbot to narrow down your search. Chapter 23. Exfoliative Dermatitis | Fitzpatrick's Dermatology in Barbaud A, et al. A promising and complementary in vitro tool has been used by Polak ME et al. Exfoliative dermatitis (ED) is defined as diffuse erythema and scaling of the skin involving more than 90% of the total body skin surface area. Panitumumab Induced Forearm Panniculitis in Two Women With Metastatic Hypervolemia can also occur in patients with exfoliative dermatitis, contributing to the likelihood of cardiac failure.2124, In most patients with erythroderma, skin biopsies show nonspecific histopathologic features, such as hyperkeratosis, parakeratosis, acanthosis and a chronic perivascular inflammatory infiltrate, with or without eosinophils. Case Presentation: We report the development of forearm panniculitis in two women during the treatment with Panitumumab (6 mg/Kg intravenous every 2 weeks) + FOLFOX-6 (leucovorin, 5- fluorouracil, and oxaliplatin at higher dosage) for the . Rheumatology (Oxford). Google Scholar. Exfoliative dermatitis is a disease process in which most, and sometimes all, of the skin is involved in erythematous inflammation resulting in massive scaling.1 A variety of diseases and other exogenous factors may cause exfoliative dermatitis. Skin manifestations of drug allergy. The most notable member of this group is mycosis fungoides. Google Scholar. Qilu Pharmaceutical Co., Ltd. GEFITINIB- gefitinib tablet, coated 2009;29(3):51735. Drugs such as paracetamol, other non-oxicam NSAIDs and furosemide, bringing a relatively low risk of SJS/TEN a priori, are also highly prevalent as putative culprit agents in large SJS/TEN registries, due to their widespread use in the general population [63, 64] (Table1). MalaCards based summary: Exfoliative Dermatitis is related to holocarboxylase synthetase deficiency and dermatitis, and has symptoms including exanthema An important gene associated with Exfoliative Dermatitis is SPINK5 (Serine Peptidase Inhibitor Kazal Type 5). Eur J Clin Microbiol Infect Dis. This has been called the nose sign.18, Once the erythema is well established, scaling inevitably follows (Figure 1). Clin Exp Allergy. PDF Drug induced exfoliative dermatitis: state of the art This hypermetabolic state is also furtherly increased by the inflammation present in affected areas. Tang YH, et al. In: Eisen AZ, Wolff K, editors. An increased metabolism is typical of patients with extended disepithelizated areas. Affiliated tissues include skin, liver and bone marrow. J Burn Care Res. Systemic derangements may occur with exfoliative. Pyrazinamide-Induced Exfoliative Dermatitis in a Patient on - Hindawi Drug induced interstitial nephritis, hepatitis and exfoliative dermatitis Smith SD, et al. It is important to take into consideration the mechanism of action of the different drugs in the pathogenesis of ED [104]. Mona-Rita Yacoub. Gynecologist consultation is required for avoiding the appearance of vaginal phimosis or sinechias. Sekula P, et al. Risk factors for the development of ocular complications of StevensJohnson syndrome and toxic epidermal necrolysis. To confirm ATT induced erythroderma and narrow down the offending agents, sequential rechallenge with ATT was done and again these patients had similar lesions erupt all over the body only with isoniazid and pyrazinamide. Am J Dermatopathol. Nayak S, Acharjya B. It is also recommended to void larger vesicles with a syringe. A correlation between increased levels of perforin/granzyme B and the severity of TEN was also described [38]. A rare case of toxic epidermal necrolysis with unexpected Fever resulting from dengue virus. Drugs causing erythroderma | DermNet SCORTEN: a severity-of-illness score for toxic epidermal necrolysis. The exact source of FasL production has not been yet identified as different groups have postulated that the production might be sought in keratinocytes themselves [33] or in peripheral blood mononuclear cells [34]. Szary syndrome, the leukemic variant of mycosis fungoides, is also associated with exfoliative dermatitis. 2023 BioMed Central Ltd unless otherwise stated. Retrospective review of StevensJohnson syndrome/toxic epidermal necrolysis treatment comparing intravenous immunoglobulin with cyclosporine. doi: 10.1016/j.jaad.2013.05.003. Harr T, French LE. Int J Dermatol. 2013;27(5):65961. Article 2012;12(4):37682. Annu Rev Pharmacol Toxicol. Aminoglutethimide: Aminoglutethimide may lead to a loss of corticosteroid-induced adrenal suppression. This content is owned by the AAFP. What Is Exfoliative Dermatitis & How Does It Look? - SkinKraft J Pharm Health Care Sci. It is a reaction pattern and cutaneous manifestation of a myriad of underlying ailments, including psoriasis and eczema, or a reaction to the consumption of . The syndrome has been described previously in association with phenindione administration, leptospirosis and heavy metal poisoning. Pathogenicity and Virulence of Staphylococcus Aureus | PDF Antibiotics: amoxicillin, ampicillin, ciprofloxacin, demeclocycline , doxycycline , minocycline, nalidixic acid, nitrofurantoin, norfloxacin, penicillin , rifampicin, streptomycin, tetracycline , tobramycin, trimethoprim, trimethoprim + sulphamethoxazole, vancomycin Anticonvulsants : barbiturates, carbamazepine The enhanced activation of CD8 T cells seems also to be influenced by the impaired function of CD4+CD25+FoxP3+Treg cells found in the peripheral blood of TEN patients in the acute phase [46]. Ibuprofen Zentiva is a drug based on the active ingredient ibuprofen (DC.IT) (FU), belonging to the category of NSAID analgesics and specifically derivatives of propionic acid. 00 Comments Please sign inor registerto post comments. Epilepsia. 2010;5:39. 1995;14(6):5589. Diclofenac sodium topical solution, like other NSAIDs, can cause serious systemic skin side effects such as exfoliative dermatitis, SJS, and TEN, which may result in hospitalizations . Indian J Dermatol. However, according to a consensus definition [54], EMM syndrome has been separated from SJS/TEN spectrum. Exfoliative Dermatitis | AAFP The dermis shows an inflammatory infiltrate characterized by a high-density lichenoid infiltrate rich in T cells (CD4+ more than CD8+) with macrophages, few neutrophils and occasional eosinophils; the latter especially seen in cases of DHR [5, 50]. Patients must be cleaned in the affected areas until epithelization starts. Intravenous administration is recommended. Verma R, Vasudevan B, Pragasam V. Severe cutaneous adverse drug reactions. Privacy official website and that any information you provide is encrypted The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. J Am Acad Dermatol. Trautmann A, et al. 2018 Jan 28;2018:9095275. doi: 10.1155/2018/9095275. Paul C, et al. Erythema multiforme StevensJohnson syndrome and toxic epidermal necrolysis. Article 2012;2012:915314. EMM is characterizes by target lesions, circular lesions of 1-2cm of diameter, that are defined as typical or atypical that tends to blister. Skin reactions to carbamazepine | Semantic Scholar Arch Dermatol. Nat Med. J Invest Dermatol. Pharmacogenomics J. 2007;48(5):10158. N Engl J Med. Provided by the Springer Nature SharedIt content-sharing initiative. Clinical, etiologic, and histopathologic features of StevensJohnson syndrome during an 8-year period at Mayo Clinic. 2008;14(12):134350. 2015;64(3):2779. It could also be useful to use artificial tears and lubricating antiseptic gels. In vitro diagnostic assays are effective during the acute phase of delayed-type drug hypersensitivity reactions. Skin conditions. Immunophenotypic studies with the use of advanced antibody panels may be useful in the differential diagnosis of these two forms.10 Reticulum cell sarcoma is another form of cutaneous T-cell lymphoma that may cause exfoliative dermatitis. FDA Drug information Palynziq Read time: 10 mins Marketing start date: 04 Mar 2023 . Cutaneous graft-versus-host diseaseclinical considerations and management. PMC It might be. Takahashi R, et al. 1996;134(4):7104. TNF- has a dual role: interacts with TNF-R1 activating Fas pathway and activates NF-B leading to cell survival. 2006;34(2):768. Antitumour necrosis factor-alpha antibodies (infliximab) in the treatment of a patient with toxic epidermal necrolysis. Usually, but not always, the palms of the hands, the soles of the feet and the mucous membranes are spared. EM is a self-limited skin condition mainly associated with infections and drugs [53, 54]. Some of these patients undergo spontaneous resolution. During the acute reaction, diagnosis of ED is mainly based on clinical parameters. Anti-Allergic Agents Immunoglobulin E Allergens Cetirizine Histamine H1 Antagonists, Non-Sedating Histamine H1 Antagonists Loratadine Emollients Nasal Decongestants Dermatologic Agents Leukotriene Antagonists Antigens, Dermatophagoides Ointments Histamine Antagonists Eosinophil Cationic Protein Adrenal Cortex Hormones Terfenadine Antipruritics Antigens, Plant . J Am Acad Dermatol. Infectious agents are the major cause of EM, in around 90% of cases, especially for EM minor and in children. Other dermatoses associated with erythroderma are listed in Table 1.2,3,68. Copyright 1999 by the American Academy of Family Physicians. Su SC, Hung SI, Fan WL, Dao RL, Chung WH. The more common forms of erythroderma, such as eczema or psoriasis, may persists for months or years and tend to relapse. A review of DRESS-associated myocarditis. Plasmapheresis may have a role in the treatment of ED because it removes Fas-L [96], other cytokines known to be implied in the pathogenesis (IL-6, IL-8, TNF-) [97, 98]. Cite this article. Cancer Diagnosis & Prognosis Dupixent DUPILUMAB 200 mg/1.14mL sanofi-aventis U.S. LLC The lesions consist of pruritic, annular papules, vesicles, and bullae that are found in groups, clinically it is similar to dermatitis herpetiformis, without a gluten-sensitive enteropathy [85]. 2008;23(5):54750. Do this 2 to 3 times a week. Part of Hum Mol Genet. CAS In HIV patients, the risk of SJS and TEN have been reported to be thousand-fold higher, roughly 1 per 1000 per year [19]. Erythema multiforme (EM), Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are the main clinical presentations of drug induced ED. Gastric protection. Br J Dermatol. In particular, drug induced exfoliative dermatitis (ED) are a group of rare and more severe drug hypersensitivity reactions (DHR) involving skin and mucous membranes and usually occurring from days to several weeks after drug exposure [2]. Utility of the lymphocyte transformation test in the diagnosis of drug sensitivity: dependence on its timing and the type of drug eruption. Before Med J Armed Forces India. AQUACEL Ag in the treatment of toxic epidermal necrolysis (TEN). Each of these physiologic disruptions is potentially life-threatening. Toxic epidermal necrolysis and StevensJohnson syndrome. The https:// ensures that you are connecting to the TEN is also known as Lyell syndrome, since it was first described by Alan Lyell in 1956 [2, 60]. Usually the amount of calories is 15002000kcal/day and the velocity of infusion is gradually increased based on patients tolerability [92]. Erythroderma is the term used to describe intense and usually widespread reddening of the skin due to inflammatory skin disease. Unable to load your collection due to an error, Unable to load your delegates due to an error, Erythema multiforme (photo reproduced with permission of Gary White, MD): typical target lesions (, Mortality rate of patients with TEN has shown to be directly correlated to SCORTEN. ALDEN has shown a good accuracy to assess drug causality compared to data obtained by pharmacovigilance method and casecontrol results of the EuroSCAR casecontrol analysis for drugs associated with TEN. Erythema multiforme. Morel E, et al. Even though exfoliative dermatitis is a complex disorder involving many factors, the underlying disease is usually the key determinant of the course and prognosis. PubMed It has a wide spectrum of severity, and it is divided in minor and major (EMM). These include a cutaneous reaction to other drugs, exacerbation of a previously existing condition, infection, metastatic tumor involvement, a paraneoplastic phenomenon, graft-versus-host disease, or a nutritional disorder. Locharernkul C, et al. The erythrodermic form of mycosis fungoides and the Szary syndrome may also be difficult to distinguish from benign erythroderma. Antipyretic therapy. A central role in the pathogenesis of ED is played by CD8+ lymphocytes and NK cells. Rzany B, et al. A recent review [111] on 33 pediatric cases of TEN and 6 cases of SJS/TEN overlap showed that therapy with IVIG with a dosage of 0.251.5g/kg for 5days resulted in 0% mortality rate and faster epithelization. It is important to protect the damaged skin with sterile fat dressing especially in the genital area. 2015;49(3):33542. Anti-tubercular therapy (ATT) induced exfoliative dermatitis-A case Posadas SJ, et al. Von Hebra first described erythroderma (exfoliative dermatitis) in 1868. StevensJohnson syndrome and toxic epidermal necrolysis: the Food and Drug Administration adverse event reporting system, 2004-2013. 5% silver nitrate compresses have antiseptic properties. 2014;71(2):27883. Hematologic: anemia, including aplastic and hemolytic. Typical laboratory values include mild anemia, leukocytosis, eosinophilia, elevated erythrocyte sedimentation rate, abnormal serum protein electrophoresis with a polyclonal elevation in the gamma globulin region, and elevated IgE levels.13,68. California Privacy Statement, 2004;59(8):80920. In postmarketing reports, cases of drug-induced hepatotoxicity have been reported in the first month, and in some cases, the first 2 months of NSAID therapy. Iv bolus of steroid (dexamethasone 100300mg/day or methylprednisolone 2501000mg/day) for 3 consecutive days with a gradual taper steroid therapy is sometimes advised.

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