Hollen Christopher, Suhaib Omer, Farrow Aaron, Sidorov Evgeny
Department of Neurology, University of Oklahoma, Oklahoma City, Oklahoma, USA.
Case Rep Neurol. 2018 Jan 23;10(1):25-28. doi: 10.1159/000485120. eCollection 2018 Jan-Apr.
We present a case of an 82-year-old man with new-onset neuromyelitis optica (NMO) spectrum disorder, the treatment of which was complicated by a severe pre-existing prednisone allergy. His age caused much initial doubt about his diagnosis, and his corticosteroid allergy altered our management as we attempted to minimize risk to the patient. Our patient was a healthy 82-year-old, right-handed man who presented with sensory loss of the bilateral lower extremities and progressive, painless vision loss. MRI showed bilateral pre-chiasmatic optic nerve and optic chiasm enhancement, along with enhancement within the thoracic spinal cord from T3 to T7. Serum NMO-IgG was positive with a titer >1: 100,000. Due to concern of allergic reaction, our patient initially refused high-dose Solu-Medrol and opted to try plasma exchange alone, but due to worsening of his symptoms we attempted to use dexamethasone as it had a theoretically lower risk of adverse reaction with a known prednisone allergy. There are several cases of elderly-onset NMO in the literature but this is the only case we could find of NMO accompanied by a rare severe allergy to prednisone. This case demonstrates the relative safety of dexamethasone as an alternative to methylprednisolone for acute management of NMO spectrum disorder, though efficacy has not been established in major trials. Cross-reactivity between various systemic corticosteroids is not as well established as topical corticosteroids, so it is difficult to assess the probability of a reaction between prednisone and methylprednisolone.
我们报告一例82岁男性新发视神经脊髓炎（NMO）谱系障碍病例，其治疗因先前存在严重的泼尼松过敏而变得复杂。他的年龄使最初对其诊断产生了诸多疑问，而他的皮质类固醇过敏改变了我们的治疗方案，因为我们试图将对患者的风险降至最低。我们的患者是一位82岁健康的右利手男性，表现为双下肢感觉丧失以及进行性无痛视力丧失。MRI显示双侧视交叉前视神经和视交叉强化，以及胸段脊髓T3至T7节段强化。血清NMO-IgG呈阳性，滴度>1:100,000。由于担心过敏反应，我们的患者最初拒绝使用大剂量甲泼尼龙，选择单独尝试血浆置换，但由于症状恶化，我们尝试使用地塞米松，因为理论上它与已知的泼尼松过敏相比不良反应风险更低。文献中有几例老年起病的NMO病例，但这是我们能找到的唯一一例伴有罕见的严重泼尼松过敏的NMO病例。该病例表明，地塞米松作为NMO谱系障碍急性治疗中替代甲泼尼龙的药物相对安全，尽管在主要试验中尚未证实其疗效。各种全身用皮质类固醇之间的交叉反应不像局部用皮质类固醇那样明确，因此很难评估泼尼松和甲泼尼龙之间发生反应的可能性。
