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      Acute Symptomatic Sinus Bradycardia in High-Dose Methylprednisolone Therapy in a Woman With Inflammatory Myelitis: A Case Report and Review of the Literature

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          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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          Hyperkalemia revisited.

          Hyperkalemia is a common clinical condition that can induce deadly cardiac arrhythmias. Electrocardiographic manifestations of hyperkalemia vary from the classic sine-wave rhythm, which occurs in severe hyperkalemia, to nonspecific repolarization abnormalities seen with mild elevations of serum potassium. We present a case of hyperkalemia, initially diagnosed as ventricular tachycardia, to demonstrate how difficult hyperkalemia can be to diagnose. An in-depth review of hyperkalemia is presented, examining the electrophysiologic and electrocardiographic changes that occur as serum potassium levels increase. The treatment for hyperkalemia is then discussed, with an emphasis on the mechanisms by which each intervention lowers serum potassium levels. An extensive literature review has been performed to present a comprehensive review of the causes and treatment of hyperkalemia.
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            Transverse myelitis--a review of the presentation, diagnosis, and initial management.

            Myelitis is a rare neurological disorder of the spinal cord that is caused by inflammation and can have devastating neurologic effects with up to two-thirds of patients having a moderate to severe degree of residual disability. Symptoms typically develop over hours or days and then worsen over a matter of days to weeks. Patients can present with sensory alteration, weakness, and autonomic dysfunction including bowel and bladder problems, temperature dysregulation, or even bouts of hypertension. Evaluation for compressive etiologies must be a priority as compressive myelopathy and transverse myelitis are often clinically indistinguishable and emergent surgical intervention is indicated in such cases. However, if neuroimaging and CSF studies indicate inflammation within the central nervous system, then a work-up for myelitis must include autoimmune, inflammatory, and infectious etiologies. Acute management of these patients is dictated by which etiology is suspected and rapid initiation of that treatment portends a more favorable patient outcome. This review will discuss a practical clinical approach to the diagnosis and acute management of patients with myelitis including clinical symptoms, the role of neuroimaging, and the utility of both CSF and serological studies in the management of these patients.
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              Incidence of various cardiac arrhythmias and conduction disturbances due to high dose intravenous methylprednisolone in patients with multiple sclerosis.

              High-dose intravenous methylprednisolone is the most common therapeutic modality to treat acute exacerbations in multiple sclerosis (MS). Various cardiac arrhythmias have been reported during corticosteroid pulse therapy. This study was conducted to detect cardiac rhythm changes in patients with MS while receiving high dose methylprednisolone. We enrolled 52 consecutive MS patients with acute relapse to perform cardiac monitoring 4h before, during and 18 h after infusion of 1000 mg intravenous (IV) methylprednisolone. Sinus tachycardia was the most common change in cardiac rhythms before, during, and after corticosteroid pulse therapy. Up to 41.9% of the patients, developed sinus bradycardia after pulse infusion. Sinus arrest and sinus exit block were observed in 12 patients. Atrial fibrillation and ventricular tachycardia were observed in three patients and one patient, respectively. The most important cardiac arrhythmias including ventricular tachycardia, sinus arrest, and sinus exit block, were correlated with smoking and more commonly observed during 12h post infusion. Sinus bradycardia and atrial fibrillation were detected more commonly in patients with history of urinary dysfunction. High dose intravenous prednisolone might cause different types of arrhythmias in MS patients. Cigarette smokers and patients with autonomic disturbances like sphincter and bowel problems have more chance to develop arrhythmias while receiving high dose steroids. Copyright © 2011 Elsevier B.V. All rights reserved.
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                Author and article information

                Journal
                Clin Med Insights Case Rep
                Clin Med Insights Case Rep
                ICR
                spicr
                Clinical Medicine Insights. Case Reports
                SAGE Publications (Sage UK: London, England )
                1179-5476
                25 February 2019
                2019
                : 12
                : 1179547619831026
                Affiliations
                [1 ]Department of Neurological and Psychiatric sciences (NEUROFARBA), University of Florence, Florence, Italy
                [2 ]Careggi University Hospital, Neurology unit, Florence, Italy
                [3 ]Department of Cardiology, Careggi University Hospital, Florence, Italy
                [4 ]IRCCS Don Carlo Gnocchi, Florence, Italy
                Author notes
                [*]Alessandro Sodero, Department of Neurological and Psychiatric sciences (NEUROFARBA), University of Florence, Viale Gaetano Pieraccini, 6, 50139 Florence, Italy. Emails: alessandro.sodero@ 123456gmail.com ; alessandro.sodero@ 123456unifi.it
                Author information
                https://orcid.org/0000-0003-4356-6912
                Article
                10.1177_1179547619831026
                10.1177/1179547619831026
                6390212
                ff558cfd-1e66-4109-a202-4073099bd1cb
                © The Author(s) 2019

                This article is distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 License ( http://www.creativecommons.org/licenses/by-nc/4.0/) which permits non-commercial use, reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access pages ( https://us.sagepub.com/en-us/nam/open-access-at-sage).

                History
                : 9 January 2019
                : 15 January 2019
                Categories
                Case Report
                Custom metadata
                January-December 2019

                Medicine
                corticosteroid,bradycardia,side effects,clinical practice guideline,myelitis
                Medicine
                corticosteroid, bradycardia, side effects, clinical practice guideline, myelitis

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