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Nagpure K, Raju P, Dube AH, Verma I, Kumbhalkar S. Chronic Adult-Onset Still's Disease With Positive Antinuclear Antibodies: Navigating Diagnostic Dilemmas and Clinical Implications. Cureus 2024; 16:e56776. [PMID: 38650770 PMCID: PMC11034574 DOI: 10.7759/cureus.56776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/23/2024] [Indexed: 04/25/2024] Open
Abstract
Adult-onset Still's disease (AOSD) is a rare systemic autoinflammatory disorder characterized by fever, rash, and joint pain. Despite primarily affecting young adults, it can occur at any age, presenting diagnostic challenges due to its heterogeneous nature and lack of specific laboratory findings. The subset of AOSD with positive antinuclear antibody (ANA) adds complexity, potentially overlapping with other autoimmune conditions. We describe a case of a 30-year-old female with a two-year history of fever, weight loss, and joint pain, initially misdiagnosed as seronegative arthritis with hypothyroidism. Further evaluation revealed severe anemia, leucocytosis, and hepatosplenomegaly. Despite a strongly positive ANA, the absence of systemic lupus erythematosus (SLE) features led to a diagnosis of chronic AOSD. Treatment with steroids and disease-modifying antirheumatic drugs (DMARDs) resulted in clinical improvement, highlighting the importance of accurate disease classification for tailored management in ANA-positive AOSD. This case underscores the diagnostic challenges of AOSD and emphasizes the need for precise classification for optimal treatment strategies.
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Affiliation(s)
- Keshao Nagpure
- General Medicine, All India Institute of Medical Sciences Nagpur, Nagpur, IND
| | - Prasanth Raju
- General Medicine, All India Institute of Medical Sciences Nagpur, Nagpur, IND
| | - Amol H Dube
- General Medicine, All India Institute of Medical Sciences Nagpur, Nagpur, IND
| | - Ishan Verma
- General Medicine, All India Institute of Medical Sciences Nagpur, Nagpur, IND
| | - Sunita Kumbhalkar
- General Medicine, All India Institute of Medical Sciences Nagpur, Nagpur, IND
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Vordenbäumen S, Feist E, Rech J, Fleck M, Blank N, Haas JP, Kötter I, Krusche M, Chehab G, Hoyer B, Kiltz U, Fell D, Reiners J, Weseloh C, Schneider M, Braun J. Diagnosis and treatment of adult-onset Still's disease: a concise summary of the German society of rheumatology S2 guideline. Z Rheumatol 2023; 82:81-92. [PMID: 36520170 DOI: 10.1007/s00393-022-01294-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/03/2022] [Indexed: 12/23/2022]
Affiliation(s)
- Stefan Vordenbäumen
- Rheinisches Rheuma-Zentrum St. Elisabeth-Hospital Meerbusch, Meerbusch-Lank, Germany. .,Universitätsklinikum Düsseldorf, Poliklinik, Funktionsbereich und Hiller Forschungszentrum für Rheumatologie, Heinrich-Heine-Universität Düsseldorf, Düsseldorf, Germany.
| | - Eugen Feist
- Rheumazentrum Sachsen-Anhalt, Helios Fachklinik Vogelsang-Gommern, Kooperationspartner der Otto-von-Guericke Universität Magdeburg, Vogelsang-Gommern, Germany
| | - Jürgen Rech
- Medizinische Klinik 3-Rheumatologie und Immunologie, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany.,Deutsches Zentrum Immuntherapie, Friedrich-Alexander-Universität Erlangen-Nürnberg und Universitätsklinikum Erlangen, 91054, Erlangen, Germany
| | - Martin Fleck
- Klinik und Poliklinik für Innere Medizin I, Universitätsklinikum Regensburg, Regensburg, Germany.,Klinik für Rheumatologie/Klinische Immunologie, Asklepios Klinikum Bad Abbach, Bad Abbach, Germany
| | - Norbert Blank
- Medizinische Klinik 5, Sektion Rheumatologie, Universitätsklinikum Heidelberg, Heidelberg, Germany
| | - Johannes-Peter Haas
- Kinderklinik Garmisch-Partenkirchen gGmbH, Deutsches Zentrum für Kinder- und Jugendrheumatologie, Garmisch-Partenkirchen, Germany
| | - Ina Kötter
- III. Medizinische Klinik und Poliklinik, Sektion für Rheumatologie und Entzündliche Systemerkrankungen, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany.,Klinik für Rheumatologie und Immunologie, Klinikum Bad Bramstedt, Bad Bramstedt, Germany
| | - Martin Krusche
- III. Medizinische Klinik und Poliklinik, Sektion für Rheumatologie und Entzündliche Systemerkrankungen, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Gamal Chehab
- Universitätsklinikum Düsseldorf, Poliklinik, Funktionsbereich und Hiller Forschungszentrum für Rheumatologie, Heinrich-Heine-Universität Düsseldorf, Düsseldorf, Germany
| | - Bimba Hoyer
- Medizinische Fakultät, Sektion Rheumatologie und klinische Immunologie, Christian-Albrechts-Universität zu Kiel, Kiel, Germany
| | - Uta Kiltz
- Deutsche Gesellschaft für Rheumatologie e. V., Berlin, Germany.,Rheumazentrum Ruhrgebiet am Marien Hospital, Universitätsklinik der Ruhr-Universität Bochum, Herne, Germany
| | - Dorothea Fell
- Deutsche Rheuma-Liga Bundesverband e. V., Bonn, Germany
| | - Julia Reiners
- Deutsche Rheuma-Liga Bundesverband e. V., Bonn, Germany
| | | | - Matthias Schneider
- Universitätsklinikum Düsseldorf, Poliklinik, Funktionsbereich und Hiller Forschungszentrum für Rheumatologie, Heinrich-Heine-Universität Düsseldorf, Düsseldorf, Germany.,Deutsche Gesellschaft für Rheumatologie e. V., Berlin, Germany
| | - Jürgen Braun
- Deutsche Gesellschaft für Rheumatologie e. V., Berlin, Germany.,Rheumazentrum Ruhrgebiet am Marien Hospital, Universitätsklinik der Ruhr-Universität Bochum, Herne, Germany
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Hirooka Y, Okuda S, Sugiyama M, Shiga T, Nozaki Y, Kinoshita K, Funauchi M, Matsumura I. Case Report: A Rare Case of Elderly-Onset Adult-Onset Still's Disease in a Patient With Systemic Lupus Erythematosus. Front Immunol 2022; 13:822169. [PMID: 35116046 PMCID: PMC8803898 DOI: 10.3389/fimmu.2022.822169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Accepted: 01/03/2022] [Indexed: 11/13/2022] Open
Abstract
The rare systemic inflammatory disorder 'adult-onset Still's disease (AOSD)' is characterized by recurrent fever, evanescent rash, arthralgia, and leukocytosis with neutrophilia. The Yamaguchi criteria are widely used to diagnose AOSD; these criteria can be used for diagnosis after a wide range of infectious, rheumatic, and neoplastic diseases have been excluded. AOSD generally does not overlap with other rheumatic diseases. We present the rare case of an 80-year-old Japanese woman who presented with arthralgia, fever, and skin rash during treatment for systemic lupus erythematosus (SLE), which was finally diagnosed as an overlap of AOSD. Blood tests revealed leukocytosis with neutrophilia, high C-reactive protein (CRP), and liver dysfunction. Her anti-ds-DNA antibody titer and serum complement titer were at the same level as before and remained stable. We suspected AOSD based on the high serum ferritin level but hesitated to diagnose AOSD because of the patient's SLE history. We measured serum interleukin (IL)-18; it was extremely high at 161,221 pg/mL, which was strongly suggestive of AOSD. We thus diagnosed AOSD complicated during the course of treatment for SLE. The patient's arthralgia and high CRP level persisted after we increased her oral prednisolone dose and added oral methotrexate, but her symptoms eventually improved with the addition of intravenous tocilizumab. We note that the presence of autoantibodies or other rheumatic diseases cannot be absolutely ruled out in the diagnosis of AOSD. Although high serum IL-18 levels are not specific for AOSD, the measurement of serum IL-18 may aid in the diagnosis of AOSD in similar rare cases.
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Affiliation(s)
- Yasuaki Hirooka
- Department of Rheumatology, Kindai University Nara Hospital, Nara, Japan
| | - Saki Okuda
- Department of Rheumatology, Kindai University Nara Hospital, Nara, Japan
| | - Masafumi Sugiyama
- Department of Rheumatology, Kindai University Nara Hospital, Nara, Japan
| | - Toshihiko Shiga
- Department of Hematology and Rheumatology, Kindai University School of Medicine, Osaka, Japan
| | - Yuji Nozaki
- Department of Hematology and Rheumatology, Kindai University School of Medicine, Osaka, Japan
| | - Koji Kinoshita
- Department of Hematology and Rheumatology, Kindai University School of Medicine, Osaka, Japan
| | - Masanori Funauchi
- Department of Hematology and Rheumatology, Kindai University School of Medicine, Osaka, Japan
| | - Itaru Matsumura
- Department of Hematology and Rheumatology, Kindai University School of Medicine, Osaka, Japan
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Han P, Sun C, Zhang Y, Yan J. Sjögren's syndrome with adult-onset Still's disease: an overlap syndrome? Rheumatol Int 2021; 42:1281-1285. [PMID: 34014364 DOI: 10.1007/s00296-021-04900-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Accepted: 05/17/2021] [Indexed: 11/30/2022]
Abstract
Adult-onset Still's disease (AOSD) is a rare systemic auto-inflammatory disease that is an exclusive diagnosis that needs to previously exclude infections, tumors, and rheumatic diseases. There are few reports on AOSD overlapping with other rheumatic diseases. We reported a 55-year-old male who presented with a high, daily spiking fever associated with an evanescent salmon-pink rash, arthralgia, and sore throat. He had a history of dryness of the mouth and eyes for decades with no medical treatment. On admission, tests for antinuclear antibody (ANA) and anti-SSA/Ro-52 antibody were positive, and salivary gland biopsy showed focal lymphocytic sialadenitis with a focus score of ≥ 1 foci/4 mm2, which was consistent with a diagnosis of primary Sjögren's syndrome (SS). However, the disease activity of SS was low at the time of the report. Combined with significantly elevated acute phase reactants, the patient also met the classification criteria of both Yamakuchi and Futel for AOSD. His clinical symptoms were relieved quickly with glucocorticoid therapy. We also reviewed the literature on SS with AOSD and AOSD with other rheumatic diseases, and scattered case reports were retrieved. So we think that AOSD is not an absolutely exclusive diagnosis and can occur in patients with other rheumatic diseases. To our knowledge, this is the only literature review of a reported AOSD case in a SS patient.
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Affiliation(s)
- Pingyang Han
- Department of Rheumatology and Immunology, Hangzhou Normal University Affiliated Hospital, No. 126, Wenzhou Road, Hangzhou, 310015, China
| | - Chen Sun
- Department of Rheumatology and Immunology, Hangzhou Normal University Affiliated Hospital, No. 126, Wenzhou Road, Hangzhou, 310015, China
| | - Yinghong Zhang
- Department of Rheumatology and Immunology, Hangzhou Normal University Affiliated Hospital, No. 126, Wenzhou Road, Hangzhou, 310015, China
| | - Juzhen Yan
- Department of Rheumatology and Immunology, Hangzhou Normal University Affiliated Hospital, No. 126, Wenzhou Road, Hangzhou, 310015, China.
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Abstract
Adult onset Still's disease is a systemic disorder of unknown etiology. The diagnosis is difficult and based upon Yamaguchi's criteria after exclusion of infectious diseases, hematologic process or autoimmune diseases. Clinical manifestations are various. Functional prognosis depends essentially on articular involvement. Vital prognosis depends on either hepatic failure or hematological or infectious complications, or amyloidosis. Ferritinemia is an important biological parameter which is not included in current criteria. Treatment is not well codified but steroids represent the most efficient therapy to control fever and systemic manifestations. Search for new treatments and specific markers of adult onset Still's disease are needed.
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Affiliation(s)
- S Vignes
- Service de médecine interne, hôpital Saint-Louis, Paris, France
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