CONGRATS INTERNS ON YOUR LAST INTERN REPORT!!! And HUGE thank you to Lev for presenting a fascination case of middle aged man s/p prolonged treatment with steroids for EtoH hepatitis who presented with fevers and abdominal pain found to be in decompensated cirrhosis and later found to have semi-invasive pulmonary aspergillosis – wow!
- If the direct bilirubin makes up greater than 20% of total bilirubin this is defined as direct predominance.
- Patients likely have impaired cellular immunity when steroid dosing reaches 20 mg for at least 14 days. At this dosing level you should consider starting PCP prophylaxis. More details below…
- Classical risk factors for semi-invasive Aspergilosis pulmonary infection:
- severe or prolonged neutropenia
- receipt of high dose corticosteroids per above
- Other drugs or conditions that lead to chronically impaired cellular immune responses (e.g. AIDs, immunosuppressive regimen)
Thank you, Brad Monash, for sharing some more info on PCP prophylaxis in the setting of steroid use:
- The evidence for when to start PCP prophylaxis is weak. Some say that PCP ppx should be considered for patients on > 20 mg prednisone for > 2-3 weeks.
- Most evidence pertains to patients on steroids + underlying immunosuppressed state. Many experts will not use PCP ppx for steroids alone in the absence of other immunodeficiency.
- Here’s a fantastic review of PCP ppx from 2004, and one of the most cited papers on the topic (https://www.ncbi.nlm.nih.gov/pubmed/8274607)
- The article below cites the lowest dose of steroids on which patients developed PCP as 16 mg daily. (https://www.ncbi.nlm.nih.gov/pubmed/?term=8538233)
- Interestingly, PCP has been described in Cushing syndrome!
- Check out this outstanding review of glucocorticoids and infection from 2008. (https://www.ncbi.nlm.nih.gov/pubmed/18703175)