Do Anabolic Steroids Cause Fungal Meningitis?

The recent fungal meningitis outbreak has been linked to contaminated methylprednisolone acetate (MPA) injections produced by the New England Compounding Center (NECC). The contaminated corticosteroid injections have resulted in 590 cases and 37 deaths. It has been a tragedy for the families involved. For anti-steroid crusaders, it has simply provided another tool to unfairly demonize anabolic steroids.

Various news media and anti-steroid organizations have erroneously included the risk of fungal meningitis as a possible side effect of anabolic steroids.

The Bay County Sheriff’s Office (BCSO) is the most recent agency to add to the unwarranted hysteria among users of black market anabolic steroids.
BCSO Captain Faith Bell cited the NECC case as the reason BCSO investigators were concerned about fungal contamination according to WMBB-TV in Panama City, Florida.
Potential to spread the fungus and bacteria was our main concern. In this case, that people would be injecting this stuff and within a short window of time be dead.
Whether out of willful ignorance or careless fact-checking, the irresponsible statements by the BCSO has contributed to the societal hysteria regarding anabolic steroids.
The truth is that there is essentially zero risk of non-medical anabolic steroid users contracting fungal meningitis.
MPA is a synthetic corticosteroid and NOT an anabolic steroid.
MPA are introduced directly into the central nervous system (CNS) via epidural injections.
Anabolic steroids are introduced into the muscular system via intramuscular injections.
The risk of fungal meningitis is rare.
The current outbreak was solely the result of a contaminated MPA solution being injected into the central nervous system.
Individuals injecting anabolic steroids intramuscularly are not at risk of being dead “within a short window of time” from fungal meningitis.
It is still important to note that there are significant risks associated with the potentially-contaminated injections of UGL anabolic steroids of unknown quality.
But fungal meningitis is not one of them.
The media has utterly failed to make any corrections or clarifications with regard to this matter.

Topical Steroids for Eczema Treatment

Topical steroids are used in addition to emollients for treating eczema. Topical steroids reduce skin inflammation. A short course will usually clear a flare-up of eczema. Side-effects are unlikely to occur with short courses.
What are topical steroids and how do they work?

Topical steroids are creams, ointments and lotions which contain steroid medicines. Topical steroids work by reducing inflammation in the skin. They are used for various skin conditions including eczema. (Steroid medicines that reduce inflammation are sometimes called corticosteroids. They are very different to the anabolic steroids which are used by some bodybuilders and athletes.)


What types of topical steroids are there?

There are many types and brands of topical steroid. However, they are generally grouped into four categories depending on their strength - mild, moderately potent, potent and very potent. There are various brands and types in each category. For example, hydrocortisone cream 1% is a commonly used steroid cream and is classed as a mild topical steroid. The greater the strength (potency), the more effect it has on reducing inflammation but the greater the risk of side-effects with continued use.

Creams are usually best to treat moist or weeping areas of skin. Ointments are usually best to treat areas of skin which are dry or thickened. Lotions may be useful to treat hairy areas such as the scalp.
When and how are topical steroids used?

As a rule, a course of topical steroid is used when one or more patches of eczema flare up. The aim of treatment is to clear the flare-up and then to stop the steroid treatment.

It is common practice to use the lowest strength topical steroid which clears the flare-up. So, for example, hydrocortisone 1% is often used, especially when treating children. This often works well. If there is no improvement after 3-7 days, a stronger topical steroid is usually then prescribed. For severe flare-ups a stronger topical steroid may be prescribed from the outset.

Sometimes two or more preparations of different strengths are used at the same time. For example, a mild steroid for the face and a moderately strong steroid for patches of eczema on the thicker skin of the arms or legs. A very strong topical steroid is often needed for eczema on the palms and soles of the feet of adults because these areas have thick skin.

You should use topical steroids until the flare-up has completely gone and then stop it. In many cases, a course of treatment for 7-14 days is enough to clear a flare-up of eczema. In some cases, a longer course is needed.

Many people with eczema require a course of topical steroids every now and then to clear a flare-up. The frequency of flare-ups and the number of times a course of topical steroids is needed varies greatly from person to person.

After you finish a course of topical steroid, continue to use emollients every day to help prevent a further flare-up. See separate leaflet called 'Emollients  for Eczema' for more details.
Short bursts of high-strength steroid as an alternative

For adults, a short course of a strong topical steroid may be an option to treat a mild-to-moderate flare-up of eczema. A strong topical steroid often works quicker than a mild one. Short-duration treatment to prevent flare-ups.

Some people have frequent flare-ups of eczema. For example, a flare-up may subside well with topical steroid therapy. But then, within a few weeks, a flare-up returns. In this situation, one option that might help is to apply steroid cream on the usual sites of flare-ups for two days every week. This is often called weekend therapy. This aims to prevent a flare-up from occurring. In the long run, it can mean that the total amount of topical steroid used is less than if each flare-up were treated as and when it occurred. You may wish to discuss this option with your doctor.

Drugs that can Harm the Immune System

The flu is rarely deadly. It's flu that becomes pneumonia that kills. Prescription and over-the-counter drugs should be seriously considered on the list of things that could potentially make people more susceptible to having a flu that morphs into a deadly pneumonia.

Steroids
All steroid drugs, from corticosteroids to anabolic steroids, suppress the immune system that defends against bacterial and viral infections such as pneumonia.

Chronic stress creates greater susceptibility to infection because it raises cortisol levels. Cortisol is a steroid hormone released by the adrenal glands that has many side effects when it’s chronically high. One side effect is that it reduces inflammation. At first glance that sounds good, but at the same time it suppresses the immune system. Chronically high cortisol also disrupts blood sugar balance, often leading to high insulin, obesity and sometimes, diabetes.

The most common route of steroid drug use, particularly in children, is through asthma inhalers.
Most asthma inhalers contain some form of synthetic steroid. These steroids help reduce the airway inflammation associated with asthma, but at the same time can reduce the ability of the lungs to fight bacterial and viral infections.

Steroid drug abuse among high school and college athletes is common. The National Institute on Drug Abuse estimates that 1 – 6% of high school athletes use steroid drugs to enhance their performance. This amounts to potentially hundreds of thousands of teens with suppressed immune systems who are more susceptible to viral and bacterial infection.

Steroid drugs such as prednisone are widely prescribed for people with painful inflammatory diseases such as arthritis, and for autoimmune diseases such as multiple sclerosis and lupus. They are also prescribed for those with organ transplants to suppress a rejection response by the immune system.

Even the regular use of cortisone creams for arthritis can raise cortisol levels enough to suppress the immune system.

 PPI Heartburn Drugs that Suppress Stomach Acid
Proton pump inhibitors or PPIs such as Nexium, Prevacid and Prilosec powerfully block the secretion of stomach acid. This has the effect of reducing heartburn and nausea, but it also blocks one of the body’s main defenses against bacteria and viruses. According to a 2004 study published in the Journal of the American Medical Association (JAMA), 70% of the hospitalized patients in the study received a PPI or other stomach acid-suppressing drug within hours of being admitted. The study showed that patients who were given PPIs had a 30% higher risk of developing pneumonia.

Statin Drugs to Lower Cholesterol
A medical group in Switzerland found that organ transplant patients who were taking statin drugs (e.g. Lipitor, Mevacor, Pravachol) did better than those who weren’t taking the drugs. Laboratory studies showed that statins did indeed suppress parts of the immune system, and the authors concluded, “This unexpected effect provides a scientific rationale for using statins as immunosuppressors, not only in organ transplantation but in numerous other pathologies as well.”

SSRI Antidepressants
The selective serotonin reuptake inhibitor antidepressant drugs (SSRIs) such as Prozac, Zoloft and Paxil increase serotonin levels and in so doing also give the immune system a boost. This boost can be the good news or the bad news. According to researchers at Georgetown University Medical Center, this boost can push the immune system into autoimmune disease, where the body starts attacking itself. These types of immune system over-reactions are also implicated in the “cytokine storms” that can create deadly inflammation in the lungs.

Opioid Drugs
Both short term and long term use of the pain killing opioid drugs such as hydrocodone, oxycodone, fentanyl, codeine and morphine block the immune system’s ability to attack viral and bacterial invaders. Some pain killing drugs such as Tramdol combine an opioid with acetaminophen (e.g. Tylenol), further compromising the immune system with acetaminophen’s toxic effects on liver function.

EXAMINATION OF THE NOSE

Full nose examination assesses the function, airway resistance and occasionally sense of smell. It includes looking into the mouth and pharynx.

Common nasal diseases include:

v 

Airway obstruction

v  Rhinorrhoea (runny nose)

v  Sneezing

v  Loss of smell (Anosmia)

v  Facial pain

v  Snoring

HISTORY

The following history should be covered:

v  Allergies/atopic disease

v  Smoking

v  Pets at home

v  Occupation

v  History of previous surgery

v  Previous trauma

v  General medical history

INSPECTION OF THE NOSE

First look at the external nose. Ask the patient to remove any glasses. Look at the nose from the front and side for any signs of the following.

·                     Size and shape

·                     obvious bend or deformity

·                     swelling

·                     scars or abnormal creases

·                     Redness’s (Evidence of skin disease)

·                     discharge

·                     Offensive smell.

The nose can be inspected from the front to examine the anterior narse by lifting the tip of the nose up and looking inside the without a speculum. To assess the nasal airway hold a cold metal tongue compressor under both nostrils.

METHOD

Most Otolaryngologists use either a head mirrow or illuminated Spectacle with a speculum to open up the nose. insert the speculum gentle and identify the nasal septum, check for inflammation (rhinitis), position the septum and presence of polyps (touch to check sensitivity). A foreign body, usually accompanied by an offensive unilateral discharge, may be seen inside the nose of a child.

            Finally, examine the palate; look for large polyps and tumors arising from the soft palate.

Anabolic Steroids Used for Weight Gain of HIV Patients

People with HIV suffer from a condition referred to as HIV wasting. This condition is characterized by involuntary loss of about 10% of the total body weight, often coupled with prolonged diarrhea, fever, or weakness. In HIV wasting, the weight loss is attributed to the loss of lean body mass or muscle mass.anabolic steroids

HIV wasting is caused by several factors, one of which is reduced food intake. HIV patients usually consume less food because they have low appetite. Furthermore, the medicines they take also have side effects that make them eat less.

Another factor that causes wasting in HIV patients is that their small intestine, affected by infections brought about by the disease, does not absorb nutrients effectively anymore. Finally, HIV patients experience wasting because their body?s metabolism is altered. The disease affects the way their body processes food and builds up protein.

A study conducted in 2005 showed that HIV patients have a chance to gain the weight they lost to wasting. This can be made possible by treating them with anabolic steroids.
The study involved HIV patients with ages ranging from 24 to 42. A total of 294 individuals were given anabolic steroids, which they took for 6 weeks, while 238 individuals were given the placebo. At the end of the study, those who took the anabolic steroids showed weight gain of almost three pounds.

According to medical experts, this amount of weight gained because of steroid intake is clinically relevant. This positive result has birthed the hope that more of the weight lost because of wasting can be regained by longer treatment of anabolic steroids.

Although more research is needed to establish this principle, the result of the study definitely brings good news to HIV patients. Scientists and medical experts have been trying for a long time to reverse the effect of HIV wasting, which can lead to extreme muscle loss and weakness. Wasting can even cause organs to fail and make the patient die more quickly. People with HIV or AIDS suffer from reduced testosterone levels, and their bodies are unable to build muscle mass.

So what are anabolic steroids? These are synthetic steroids that have the same characteristics as testosterone, which is the male sex hormone. They help the body to grow skeletal muscles.

Anabolic steroids have been made largely unpopular primarily because athletes misuse and abuse these products. However, they do have important medical applications and are being used to treat certain medical conditions like low testosterone level for men and anemia. Now this study involving the use of anabolic steroids for the treatment of HIV wasting proves once again that these substances have a significant role in the field of medicine.

In this study, the patients either took the anabolic steroids orally or through an injection. The side effects reported include acne, mood swings, slight increase in growth of body hair, aggressiveness, abnormal liver function tests, and irritability, which are all common manifestations of using anabolic steroids.

More study is needed to confirm if the weight gain caused by anabolic steroid intake will bring about an improvement in the patient?s quality of life. Experts also still need to determine how much gain weight translates to a successful result of treatment with anabolic steroids.

Human Diseases Caused by Viruses

When a cell is infected with a virus several effects may be seen. Many viruses cause no harm or disease whatsoever. However, some viruses may attack certain cells and multiply within them.

Once mature the daughter viruses break the cell and spread elsewhere. This is called a lytic infection. Eventually, if host immunity operates effectively, the virus-infected cell may be killed by the host, leading to interruption of the virus cycle and cure of the infection. However, this is not true for all viral infections.

The viruses may persist in the cell without damaging it and make the cell a carrier. The patient may appear to be cured but the infection persists and can spread to others. In addition, the infection may reappear later after this period of lull or latency.

Spread of viruses
Viruses cannot exist on their own and for survival they need to spread to another host. This is because the original host may either die or eliminate the infection. Some important routes of viral transfer include:
Route                                                                     Examples
Skin contact                                                         HPV (warts)
Respiratory                              Cold virusues, influenza, measles, mumps, rubella
Faecal-oral                                 Polio, echo, Coxsackie, Hepatitis A, Rotavirus
Milk                                                                 HIV, HTLV-1, CMV
Transplacental                                                Rubella, CMV, HIV
Sexually                                           Herpes 1 and 2, HIV, HPV, Hepatitis B
Insect vector                                            Yellow fever, Dengue fever
Animal bite                                                              Rabies

In addition, in order to spread the viruses also need to withstand the immune system. A special category of viruses is those that cause disease only when the immune system is deficient in some way; these are called opportunists, and  opportunistic infection is one of the main problems in patients with, for example, AIDS.

Where do viruses reside?

There are several viruses that have an animal or plant reservoir from where they affect humans. Some of the common reservoirs of viruses include;
Virus                                                            Animal reservoir
Influenza                                                     Birds, pigs, horses
Rabies                                                          Bats, dogs, foxes
Lassa and Hanta viruses                                    Rodents
Ebola and marburg viruses                               Monkeys
HIV-1 and -2                                            Chimpanzees, monkeys
Newcastle disease                                              Poultry
West Nile virus                                                     Birds


Host defence to viral infections
The body's first line of defence against viruses is the innate immune system. This is made up of cells and other mechanisms that defend the host from infection. This provides a temporary protection against the viral onslaught.

Once within the adaptive immunity faces the virus and remembers it. This is a more permanent form of immunity that may last a life time against the particular strain of virus. Specific antibodies are produced against the virus.
 This is called humoral immunity.

Two types of antibodies are important. The first called IgM is highly effective at neutralizing viruses but is only produced by the cells of the immune system for a few weeks. The one that lasts a life time is the IgG antibodies.

The second line of defence is called cell-mediated immunity and involves immune cells known as T cells. T cell recognises a suspicious viral fragment there and the killer T cells destroy the virus.

Virus spread control
Viral diseases can be prevented from spreading by vaccinations and the most successful of these is the small pox vaccine that has completely eradicated the disease in 1980. It is hoped that several other viruses, such as polio and measles, will follow.

Epidemics and pandemics of viral infections
Spread or outbreak of a viral infection in a community is termed an epidemic. A pandemic occurs when there is a worldwide epidemic.

The 1918 flu pandemic, commonly referred to as the Spanish flu was such a pandemic. It was caused by an unusually severe and deadly influenza A virus. The victims were often healthy young adults in contrast from weakened and elderly who are usual victims. It killed around 100 million people or at least 5% of the world's population in 1918.

HIV is now considered a pandemic with an estimated 38.6 million people now living with the disease worldwide.

Viruses and cancer
Some viruses may incorporate their DNA (or DNA copied from viral RNA) into host DNA, with effects on the control of cell growth. This may sometimes lead to transformation, in other words a tumour.

However, integration does not always lead to transformation and is not mandatory for transformation. The association of viruses with tumours in animals was first suspected 90 years ago but only in the 1960s was a virus (EBV) shown convincingly to be associated with a human tumour (Burkitt’s lymphoma).

Now the role of oncogenes that are activated for causing cancer is being better understood to know why all viruses and all infections do not cause cancer in all individuals.

Treatment of viral infections
Several antiviral drugs that are used to treat viral infections have been developed over the past two decades. Many of these are focussed against HIV. These do not cure HIV infection but stop the virus from multiplying and prevent the progress of the disease. Another notable antiviral drug is Ribavarin against hepatitis C.

Viruses in general are notoriously difficult drug targets as they modify and adapt themselves rapidly to build up a resistance against the drug. Case in point is Oseltamivir (trade name - Tamiflu) used in influenza.

Examination of the Ear

This includes an assessment of hearing as well as the appearance of the ear.

 History

The following issues should be included:

v Classic symptoms of ear disease: deafness, tinnitus discharge (otorrhoea) and vertiyo.

v Previous ear surgery, or head injury.

v Family history of deafness.

v Systemic disease (e.g. stroke, multiple sclerosis, cardiovascular disease).

v Ototoxic drugs (antibiotics (e.g. gentamicin), diuretics, cytotoxics)

v Exposure to noise (e.g. pneumatic drill or shooting)

v History of atopy and allergy in children.

Inspecting the External Ear

Inspect the external ear before examination with an otoscope/auriscope. Swab any discharge and remove any wax. Look for obvious signs of abnormality.

v Size and shape of the pinna.

v Extra cartilage tags/pre-auricular sinuses or pits.

v Signs of trauma to the pinna.

v Suspicious skin lesions on the pinna including neoplasia.

v Skin conditions of the pinna and external canal

v Infection/inflammation of the external ear canal, with discharge.

v Signs/scars of previous surgery.

Inspecting The Ear Canal And Eardrum

A modern electric otoscope/auriscope with its own light source is primarily used. An otoscope also has its own magnification which gives a good view of the tympanic membrane.

Examination Technique

v This involves grasping the pinna and pulling it up and backwards (posteriorly and superiorly) which helps to straighten the ear canal and for inspection of the TM.

v Hold the otoscope near to the eyepiece rather than at the end, this helps to reduce patient’s discomfort due to hand movements. Fit the correct size of speculum to achieve best view; it is tempting to use a small piece for ease of inserting, but this simply restricts the image available.

v NOTE:The condition of the canal skin, and the presence of wax, foreign tissue, or discharge.

Inspecting The Tympanic Membrane

Move the otoscope in order to see several different views of the drum. The drum is roughly circular (~1cm diameter). In a circular drum, the following structures can be identified.

v Handle/Lateral process of the malleus.

v Light reflex/cone of light.

v Pars tensa and pars flaccid (attic).

Occasionally, in a healthy, thin drum, it is possible to see the following:

v Long process of incus

v Chorda tympani

v Eustachian opening

v Promontory of the cochlea.

Common pathological conditions related to the ear include.

v Perforations

v Glue ear/middle ear effusion

v Refractions of the drum

v Blood in the middle ear (haemotympanum)

Basic Hearing Tests

A patient with normal hearing should hear equally as well in both ears.

Turning Fort Tests

This includes weber’s and Rinnes’s test.

Weber’s Test

This is performed in conjunction with Rinne’s test. The vibrating fork is placed in the middle of the forehead and the patient is asked whether any sound is heard, and if so, whether it is equally heard in the better ear. It is more likely to be a sensorineural hearing loss.

Rinne’s Test

Strike a tuning fork and hold it vertically with its nearest prong about 1cm away from the patient’s external L meatus. The patient is asked to repeat on which of the two positions was it louder. Normally, the patient should hear the air conduction better than the bone conduction (i.e. first position better than the second). This is a positive Rinne’s test. If the Rinnes’s test is positive and there is hearing impairment, it is a sensorineural and not a conductive problem. If there is a negative Rinne’s test with hearing loss, then the problem is conductive one.