In a 40-year-old woman with a week of fever, cough, chest tightness, positive streptococcal infection, negative influenza test, history of Wolff-Parkinson-White syndrome, normal sinus rhythm on ECG and clear chest X-ray, are there any contraindications to giving a large dose of dexamethasone (Decadron)?

No Absolute Contraindication to Dexamethasone in This Patient

A single dose of dexamethasone 10 mg IV is not contraindicated in this 40-year-old woman with WPW syndrome, as corticosteroids do not directly interact with cardiac conduction pathways or exacerbate pre-excitation syndromes. 1

WPW-Specific Considerations

The primary concern in WPW syndrome relates to antiarrhythmic medications that affect AV nodal conduction, not corticosteroids 1:

• Contraindicated drugs in WPW include AV nodal blockers (digoxin, verapamil, diltiazem, beta-blockers) when atrial fibrillation or flutter is present, as these can paradoxically accelerate conduction through the accessory pathway and precipitate ventricular fibrillation 1
• Dexamethasone has no direct cardiac electrophysiologic effects and does not block AV nodal conduction or affect accessory pathway function 2
• Since her ECG shows normal sinus rhythm (not atrial fibrillation/flutter), even the typical WPW drug contraindications are less relevant in this acute setting 1

Clinical Context Assessment

The key question is whether dexamethasone is clinically indicated, not whether it's contraindicated 1, 3:

Evidence Supporting Use:

• Streptococcal pharyngitis with systemic symptoms: A single dose of dexamethasone 10 mg has been used for symptomatic relief in severe pharyngitis, though evidence is limited 1, 4
• Suspected viral respiratory illness: If this represents influenza (despite negative test), dexamethasone may provide symptomatic benefit 1, 5

Evidence Against Routine Use:

• Clear chest X-ray argues against pneumonia, where corticosteroids might have a role 1, 3
• Bacterial pharyngitis alone does not have strong evidence supporting corticosteroid use 3
• Corticosteroids may mask infection signs and decrease resistance to new infections 2

Safety Profile for Single-Dose Dexamethasone

A single 10 mg dose carries minimal risk 4, 3, 5:

• No tapering required after single-dose or short-course (≤5 days) therapy 4, 3
• Adrenal suppression is not a concern with single-dose administration 2
• Common short-term effects include hyperglycemia (approximately 13 mg/dL increase within 12 hours) and sleep disturbances 3, 5
• Serious adverse effects (GI bleeding, perforation) are associated with high-dose prolonged therapy (≥96 mg/day), not single doses 3

Specific Contraindications to Screen For

Before administering dexamethasone, verify the patient does NOT have 3, 2:

• Active systemic fungal infection (absolute contraindication unless on antifungal prophylaxis) 3, 2
• Known hypersensitivity to dexamethasone or sulfites (the IV formulation contains sodium bisulfite) 2
• Active tuberculosis (unless on appropriate antituberculous therapy) 2
• Recent myocardial infarction (corticosteroids associated with increased risk of left ventricular free wall rupture) 2

Practical Recommendation

If you decide to give dexamethasone 10 mg IV 4, 3, 5:

• Monitor blood glucose if diabetic or at risk 3
• Counsel about sleep disturbance (common with evening/night dosing) 5
• Document clear indication (e.g., severe pharyngitis with systemic symptoms refractory to standard therapy) 1, 3
• Consider whether symptomatic treatment (NSAIDs, acetaminophen, adequate hydration) might be equally effective with fewer risks 1

Critical Caveat

The negative influenza test does not reliably rule out influenza, especially if tested outside the optimal window (first 3-4 days of illness) or if rapid antigen testing was used (sensitivity 50-70%) 1. However, one week into illness, influenza is less likely to be the primary driver of ongoing symptoms, and bacterial superinfection or post-viral inflammation becomes more relevant 1.

The WPW diagnosis itself poses no barrier to dexamethasone administration, but the clinical indication for corticosteroids in this presentation is questionable 1, 3.