Macrophage activation syndrome in juvenile systemic lupus erythematosus: a multinational multicenter study of thirty-eight patients

OBJECTIVE

To describe the clinical and laboratory features of macrophage activation syndrome as a complication of juvenile systemic lupus erythematosus (SLE).

METHODS

Cases of juvenile SLE-associated macrophage activation syndrome were provided by investigators belonging to 3 pediatric rheumatology networks or were found in the literature. Patients who had evidence of macrophage hemophagocytosis on bone marrow aspiration were considered to have definite macrophage activation syndrome, and those who did not have such evidence were considered to have probable macrophage activation syndrome. Clinical and laboratory findings in patients with macrophage activation syndrome were contrasted with those of 2 control groups composed of patients with active juvenile SLE without macrophage activation syndrome. The ability of each feature to discriminate macrophage activation syndrome from active disease was evaluated by calculating sensitivity, specificity, and area under the receiver operating characteristic curve.

RESULTS

The study included 38 patients (20 with definite macrophage activation syndrome and 18 with probable macrophage activation syndrome). Patients with definite and probable macrophage activation syndrome were comparable with regard to all clinical and laboratory features of the syndrome, except for a greater frequency of lymphadenopathy, leukopenia, and thrombocytopenia in patients with definite macrophage activation syndrome. Overall, clinical features had better specificity than sensitivity, except for fever, which was highly sensitive but had low specificity. Among laboratory features, the best sensitivity and specificity was achieved using hyperferritinemia, followed by increased levels of lactate dehydrogenase, hypertriglyceridemia, and hypofibrinogenemia. Based on the results of statistical analysis, preliminary diagnostic guidelines for macrophage activation syndrome in juvenile SLE were developed.

CONCLUSION

Our findings indicate that the occurrence of unexplained fever and cytopenia, when associated with hyperferritinemia, in a patient with juvenile SLE should raise the suspicion of macrophage activation syndrome. We propose preliminary guidelines for this syndrome in juvenile SLE to facilitate timely diagnosis and correct classification of patients.

CINCA Syndrome

CINCA syndrome is a genetic disorder characterized by early onset of recurrent fever, rash, progressive articular and neurological involvement. We report a 7-year-old girl with CINCA syndrome with an infrequent manifestation of retinal vasculitis and a relative paucity of neurological signs. She had a de novo F309S mutation in exon 3 of CIAS1 gene on chromosome 1. This is the first report of this entity from India.

Bilateral neuroretinitis associated with mumps

BACKGROUND

Involvement of the optic nerve is a rare complication of mumps infection.

OBJECTIVES

To report a case of bilateral neuroretinitis complicating a mumps infection and to review 5 previously reported cases.

DESIGN

Case report and literature review.

SETTING

Tertiary hospital.

PATIENT

A 7-year-old girl had sudden-onset blindness due to bilateral neuroretinitis. Approximately 3 weeks prior to the initial examination, she developed a self-limited febrile illness with parotid swelling and subsequent meningoencephalitis.

RESULTS

Mumps was determined to be the underlying cause of the meningoencephalitis and bilateral optic neuritis because of the exposure history in this nonvaccinated child, the typical clinical signs and symptoms, and the positive serologic test results. Recovery of visual function was gradual but nearly complete.

CONCLUSIONS

Physicians should be aware that optic nerve involvement may be a manifestation of mumps infection. The delayed onset of optic neuritis, the bilateral involvement, and the near complete recovery suggest an immune-mediated pathogenesis.