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El Hasbani G, Ahmad Y, Cassetta M. Refractory Adult-onset Still's Disease Treated with a Combination of Methotrexate and Etanercept. Curr Rheumatol Rev 2024; 20:219-222. [PMID: 37855287 DOI: 10.2174/0115733971244440230921100912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Revised: 07/08/2023] [Accepted: 08/10/2023] [Indexed: 10/20/2023]
Abstract
BACKGROUND Adult-onset Still's disease (AOSD) is a challenging diagnosis because of the variability in clinical presentation and lack of gold-standard diagnostic investigations. Even after diagnosis, the treatment is challenging, especially when the disease is refractory to first-line therapy. Multiple pharmacotherapeutic options exist for refractory AOSD, but treatment failures still occur. Etanercept, a Tumor necrosis factor (TNF)-alpha inhibitor, is one of the options that has been rarely used for refractory AOSD, with various outcomes ranging from no response to complete remission. CASE PRESENTATION In this case, we highlight how a previously healthy lady had refractory AOSD to glucocorticoids, methotrexate, and hydroxychloroquine combination therapy. There was no response to interleukin (IL)-1 therapy, which necessitated a switch to a combination of etanercept, low-dose methotrexate, and low-dose glucocorticoids with complete remission for a total of three- -year follow-up. CONCLUSION The combination of methotrexate and Etanercept can maintain remission in patients with refractory AOSD.
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Affiliation(s)
- Georges El Hasbani
- Department of Internal Medicine, Quinnipiac University, Hartford Healthcare, St. Vincent's Medical Center, Bridgeport, 06606, USA
| | - Yaser Ahmad
- Department of Internal Medicine, Quinnipiac University, Hartford Healthcare, St. Vincent's Medical Center, Bridgeport, 06606, USA
| | - Michael Cassetta
- Department of Internal Medicine, Quinnipiac University, Hartford Healthcare, St. Vincent's Medical Center, Bridgeport, 06606, USA
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2
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Ono R, Iwahana T, Toriumi S, Aoki K, Kato H, Kato K, Yasui M, Nakagawa Y, Furuta S, Nakajima H, Kobayashi Y. Fulminant myocarditis with adult-onset Still's disease: case-based review. Clin Rheumatol 2023; 42:2507-2514. [PMID: 37261655 DOI: 10.1007/s10067-023-06648-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 05/24/2023] [Accepted: 05/25/2023] [Indexed: 06/02/2023]
Abstract
Myocarditis has been reported as a life-threatening complication of adult-onset Still's disease (AOSD), but fulminant myocarditis with AOSD is very rare. We hereby report a case of a 43-year-old female with fulminant myocarditis with AOSD. She had a refractory AOSD and cardiogenic shock with markedly elevated ferritin level up to 67,370 ng/mL. She was successfully treated with canakinumab and mechanical circulatory support (MCS) such as venoarterial extracorporeal membrane oxygenation and Impella CP. We also reviewed the previous cases of fulminant myocarditis with AOSD published from 1976 to December 2022, and only 8 cases of fulminant myocarditis with AOSD have been reported. The characteristics of these cases showed that the average age at presentation was 37.6 years (range 24-47 years). The time to myocarditis from the onset of AOSD ranged from 2 weeks to 2 years; however, most cases developed myocarditis within 1 year. Initial presenting symptoms included fever, dyspnea, chest pain, myalgia, rash, and sore throat. The median peak ferritin was 13,000 ng/mL. Left ventricular ejection fractions were not greater than 35%. Our case was the first reported case successfully treated with canakinumab and MCS. This review suggests that myocarditis may be an early phase of the complication in patients with AOSD, and the severity of AOSD may correlate with the severity of myocarditis. Canakinumab for AOSD and MCS for fulminant myocarditis may be one of the choices for overcoming the comorbidities.
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Affiliation(s)
- Ryohei Ono
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8670, Japan.
| | - Togo Iwahana
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8670, Japan
| | - Shuji Toriumi
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8670, Japan
| | - Kaoruko Aoki
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8670, Japan
| | - Hirotoshi Kato
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8670, Japan
| | - Kodai Kato
- Department of Allergy and Clinical Immunology, Chiba University Hospital, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8677, Japan
| | - Masahiro Yasui
- Department of Allergy and Clinical Immunology, Chiba University Hospital, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8677, Japan
| | - Yuzuho Nakagawa
- Department of Allergy and Clinical Immunology, Chiba University Hospital, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8677, Japan
| | - Shunsuke Furuta
- Department of Allergy and Clinical Immunology, Chiba University Hospital, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8677, Japan
| | - Hiroshi Nakajima
- Department of Allergy and Clinical Immunology, Chiba University Hospital, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8677, Japan
| | - Yoshio Kobayashi
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8670, Japan
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3
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Bodard Q, Langlois V, Guilpain P, Le Quellec A, Vittecoq O, Noel D, Eble V, Josse S, Schmidt J, Aouba A, Levesque H, Le Besnerais M, Benhamou Y. Cardiac involvement in adult-onset Still's disease: Manifestations, treatments and outcomes in a retrospective study of 28 patients. J Autoimmun 2020; 116:102541. [PMID: 32943282 DOI: 10.1016/j.jaut.2020.102541] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Revised: 08/30/2020] [Accepted: 08/30/2020] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Adult-onset Still's disease (AOSD) is a rare inflammatory disease that may be life-threatening if complicated by cardiac problems. We performed a retrospective multicenter study to describe the manifestations, treatments and outcomes of cardiac involvement in AOSD. METHODS We reviewed the medical databases of eight centers. All AOSD patients identified as fulfilling Yamagushi's or Fautrel's criteria were included in the study. Cardiac involvement, clinical manifestations, laboratory features, the course of the disease and treatments were evaluated. RESULTS We included 96 AOSD patients in this study: 28 (29%) had documented cardiac involvement (AOSD + C group) and 68 (71%) had no cardiac involvement (control group). Cardiac complications were observed at diagnosis in 89% of cases. It were pericarditis (n = 17), tamponade (n = 5), myocarditis (n = 5) and non-infectious endocarditis (n = 1). Levels of leukocytes, neutrophils and C-reactive protein were significantly higher (p = 0.02, p = 0.02 and p = 0.002, respectively in the AOSD + C group than in the control group. Admission to intensive care, and the use of biotherapy were more frequent during follow-up in the AOSD + C group than the control group (p = 0.0001 and p = 0.03 respectively). Cardiac involvement was associated with refractory form in multivariate analyzed (p = 0.01). Corticosteroids were effective with or without methotrexate in 71% of patients but not in severe involvement as myocarditis or tamponade. CONCLUSION Cardiac complications are frequent, inaugural, can be life-threatening and predictive of a refractory course in patients with AOSD. Systematic cardiac screening should be proposed at diagnosis and biotherapy early use should be considered especially in myocarditis.
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Affiliation(s)
- Quentin Bodard
- Department of Internal Medicine, Infectious Diseases, Rheumatology and Endocrinology, Angoulême Hospital, 16959, Angoulême, France
| | - Vincent Langlois
- Department of Infectious Diseases and Internal Medicine, Le Havre Hospital, 76083, Le Havre, France.
| | - Philippe Guilpain
- Department of Internal Medicine-Multiorganic Diseases, Saint-Eloi Hospital, IRMB, Univ Montpellier, INSERM, Montpellier University Hospital, 34295, Montpellier, France
| | - Alain Le Quellec
- Department of Internal Medicine-Multiorganic Diseases, Saint-Eloi Hospital, IRMB, Univ Montpellier, INSERM, Montpellier University Hospital, 34295, Montpellier, France
| | - Olivier Vittecoq
- Department of Rheumatology, Rouen University Hospital, 76000, Rouen, France
| | - David Noel
- Department of Infectious Diseases and Internal Medicine, Elbeuf-Louviers Hospital, 76410, Elbeuf, France
| | - Vincent Eble
- Department of Internal Medicine, Eure et Seine Hospital, 27015, Evreux, France
| | - Séverine Josse
- Department of Internal Medicine, Dieppe Hospital, 76200, Dieppe, France
| | - Jean Schmidt
- Department of Internal Medicine, Amiens University Hospital, 80054, Amiens, France
| | - Achille Aouba
- Department of Internal Medicine, Caen University Hospital, 14003, Caen, France
| | - Hervé Levesque
- Department of Internal Medicine, Rouen University Hospital, 76000, Rouen, France; INSERM U 905, University of Rouen IFRMP, Institute for Biochemical Research, Rouen University Hospital, 76000, Rouen, France
| | - Maelle Le Besnerais
- Department of Internal Medicine, Rouen University Hospital, 76000, Rouen, France; INSERM U 905, University of Rouen IFRMP, Institute for Biochemical Research, Rouen University Hospital, 76000, Rouen, France
| | - Ygal Benhamou
- Department of Internal Medicine, Rouen University Hospital, 76000, Rouen, France; INSERM U 905, University of Rouen IFRMP, Institute for Biochemical Research, Rouen University Hospital, 76000, Rouen, France
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4
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Gracia-Ramos AE, Contreras-Ortíz JA. Myocarditis in Adult-Onset Still's Disease: Case-Based Review. Clin Rheumatol 2019; 39:933-947. [PMID: 31745741 DOI: 10.1007/s10067-019-04814-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Revised: 09/30/2019] [Accepted: 10/03/2019] [Indexed: 12/19/2022]
Abstract
Cardiac involvement in adult-onset Still's disease (AOSD) usually manifests as a pericardial disease. Myocarditis is uncommon (prevalence of 7%). However, the cardiocirculatory failure is the second cause of life-threatening AOSD. Herein, we report the case of a 38-year-old man who was diagnosed with myocarditis caused by AOSD. He was treated medically with steroids and methotrexate, and his course was favorable. A literature search in PubMed/MEDLINE and Scopus databases from 1971 to 2019 identified 47 additional cases of myocarditis and AOSD. The main features found in these reports were reviewed and are the following: (i) myocarditis is a rare complication of AOSD manifested by fever, chest pain, dyspnea, and tachycardia; (ii) cardiac biomarkers, electrocardiogram (ECG), transthroracic echocardiography (ECHO), and cardiac magnetic resonance imaging (MRI) are useful noninvasive diagnostic tools; and (iii) myocarditis is a potentially life-threatening complication of AOSD but responds positively to steroids and other immunomodulatory drugs. This review suggests that this entity should be suspected in cases of acute febrile myocarditis after ruling out other causes since a prompt treatment results in a good prognosis.
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Affiliation(s)
- Abraham Edgar Gracia-Ramos
- Department of Internal Medicine, General Hospital, National Medical Center "La Raza", Instituto Mexicano del Seguro Social, Av. Jacarandas S/N, Col. La Raza, Azcapotzalco, 02990, Mexico City, Mexico. .,Department of Internal Medicine, Hospital Regional de Alta Especialidad de Zumpango, Carretera Zumpango-Jilotzingo 400, Barrio Santiago, Segunda Sección, 55600, Zumpango, Estado de México, Mexico.
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5
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Farooq Sheikh AS, Marks J, Hopkinson N. Adult-onset Still's disease with prominent polyserositis. Scott Med J 2018; 63:63-66. [PMID: 29506437 DOI: 10.1177/0036933018760763] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Adult-onset Still's disease is a systemic autoinflammatory disease the presentation of which can often mimic infection. As a consequence, there is often a delay in diagnosis. Serositis is a recognised but less common clinical feature that can result in complications including cardiac tamponade and constrictive pericarditis. We describe a case of adult-onset Still's disease without the hallmark rash or significant arthritis, presenting with polyserositis that showed a good response to initial steroid treatment and sustained remission with anakinra. An elevated procalcitonin level was due to active adult-onset Still's disease, not bacterial infection.
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Affiliation(s)
- Ali Sibtain Farooq Sheikh
- 1 Rheumatology Registrar, Department of Rheumatology, Queen Alexandra Hospital, Portsmouth Hospitals NHS Trust, UK
| | - Jonathan Marks
- 2 Consultant Rheumatologist, The Royal Bournemouth & Christchurch Hospitals, UK
| | - Neil Hopkinson
- 2 Consultant Rheumatologist, The Royal Bournemouth & Christchurch Hospitals, UK
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6
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Castañeda S, Blanco R, González-Gay MA. Adult-onset Still's disease: Advances in the treatment. Best Pract Res Clin Rheumatol 2016; 30:222-238. [PMID: 27886796 DOI: 10.1016/j.berh.2016.08.003] [Citation(s) in RCA: 88] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Adult-onset Still's disease (AOSD) is a rare systemic inflammatory disorder mainly characterized by persistent high spiking fevers, evanescent rash, and joint involvement. The pathogenesis of AOSD is only partially known, but pro-inflammatory cytokines such as tumor necrosis factor (TNF)-α, interleukin (IL)-1, IL-6, IL-18, and IFN-γ seem to play a major role in this disorder. AOSD is at the crossroad of auto-inflammatory syndromes and autoimmune diseases. It is diagnosed by exclusion to determine the presence of high serum ferritin levels, which is usually >1000 μg/L. AOSD is generally treated with non-steroidal anti-inflammatory drugs, corticosteroids, and disease-modifying anti-rheumatic drugs (DMARDs). Although information on biologic therapy in the management of AOSD is scarce, these drugs represent a major breakthrough in the management of patients with AOSD refractory to corticosteroids or conventional DMARDs or in patients presenting life-threatening manifestations. In this regard, TNF-α, IL-1, and IL-6 antagonists had been proved effective in patients with AOSD.
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Affiliation(s)
- Santos Castañeda
- Rheumatology Division, Hospital de La Princesa, IIS-IPrincesa, c/ Diego de León 62, 28006 Madrid, Spain; Universidad Autónoma de Madrid (UAM), Madrid, Spain.
| | - Ricardo Blanco
- Rheumatology Division, Hospital Universitario Marqués de Valdecilla, Avda. de Valdecilla, s/n, 39008 Santander, Cantabria, Spain.
| | - Miguel A González-Gay
- Rheumatology Division, Hospital Universitario Marqués de Valdecilla, Avda. de Valdecilla, s/n, 39008 Santander, Cantabria, Spain; Epidemiology, Genetics and Atherosclerosis Research Group on Systemic Inflammatory Diseases, University of Cantabria, IDIVAL, Avda. de Valdecilla, s/n, 39008 Santander, Spain.
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7
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Yamazoe M, Mizuno A, Suyama Y, Nishi Y, Suzuki K, Niwa K, Okada M. Endomyocardial Biopsy and Magnetic Resonance Imaging of Acute Myocarditis with Adult-Onset Still's Disease. Korean Circ J 2014; 44:437-40. [PMID: 25469148 PMCID: PMC4248618 DOI: 10.4070/kcj.2014.44.6.437] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2014] [Revised: 06/03/2014] [Accepted: 06/09/2014] [Indexed: 11/19/2022] Open
Abstract
A 36-year-old female with a high-grade fever and epigastric abdominal pain was prescribed antibiotics, but developed hypoxia and dyspnea. An echocardiography revealed diffuse hypokinesis and massive pericardial effusion, after which diagnostic cardiac catheterization and an endomyocardial biopsy (EMB) were peformed to reveal fibrosis and infiltration of inflammation cells composed primarily of neutrophils. Clinical manifestation of a spiking fever, leukocytosis, elevated ferritin levels, skin rash and EMB findings led to a diagnosis of adult-onset Still's disease (AOSD) with acute myocarditis. Pulse therapy of intravenous methylprednisolone was performed for three days, followed by a daily dose of prednisone (60 mg). After a course of steroid therapy for fever and pericardial effusion, and conducting a left ventricular ejection fraction, the patient showed improvement and was discharged asymptomatic within 32 days of admission. This study is the first to report on a case of myocarditis in AOSD diagnosed by neutrophil infiltration in the myocardium.
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Affiliation(s)
- Masahiro Yamazoe
- Division of Cardiology, St. Lukes International Hospital, Tokyo, Japan
| | - Atsushi Mizuno
- Division of Cardiology, St. Lukes International Hospital, Tokyo, Japan
| | - Yasuhiro Suyama
- Immuno Rheumatology Center, St. Lukes International Hospital, Tokyo, Japan
| | - Yutaro Nishi
- Division of Cardiology, St. Lukes International Hospital, Tokyo, Japan
| | - Koyu Suzuki
- Division of Pathology, St. Lukes International Hospital, Tokyo, Japan
| | - Koichiro Niwa
- Division of Cardiology, St. Lukes International Hospital, Tokyo, Japan
| | - Masato Okada
- Immuno Rheumatology Center, St. Lukes International Hospital, Tokyo, Japan
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Gerfaud-Valentin M, Sève P, Iwaz J, Gagnard A, Broussolle C, Durieu I, Ninet J, Hot A. Myocarditis in adult-onset still disease. Medicine (Baltimore) 2014; 93:280-289. [PMID: 25398063 PMCID: PMC4602418 DOI: 10.1097/md.0000000000000112] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
This study highlights the clinical features, treatments, and outcomes of the rare myocarditis in adult-onset Still disease (AOSD). Among a case series of 57 patients fulfilling either Yamaguchi or Fautrel AOSD criteria and seen between 1998 and 2010, we identified 4 cases of myocarditis. From a comprehensive literature review, we collected 20 additional cases of myocarditis-complicated AOSD. The characteristics of patients with myocarditis were compared with those of AOSD patients without myocarditis.In these 24 myocarditis-complicated AOSD cases, myocarditis occurred early and was present at AOSD onset in 54% of the cases. Myocarditis was often symptomatic (96% of patients) with nonspecific electrocardiographic abnormalities (79% of patients) and a left ventricle ejection fraction ≤50% (67% of patients). Cardiac magnetic resonance imaging and endomyocardial biopsies showed features consistent with myocarditis in 4 patients and a mononuclear interstitial inflammatory infiltrate in 4 others. Steroids alone were effective in 50% of patients with myocarditis. Intravenous immunoglobulins, methotrexate, and tumor necrosis factor-α-blockers were also prescribed and often found effective. Only 1 patient died from cardiogenic shock. Patients with myocarditis-complicated AOSD were younger and more frequently male than patients with AOSD alone. Pericarditis was more frequent in the myocarditis group; white blood cell count, polymorphonuclear cell count, and serum ferritin levels were also higher.Myocarditis is a potentially life-threatening complication of AOSD but responds positively to steroids and other immunomodulatory drugs. Its prognosis remains good (only 1 death occurred), but the condition requires close monitoring of heart function.
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Affiliation(s)
- Mathieu Gerfaud-Valentin
- Department of Internal Medicine (MGV, PS, CB), Croix-Rousse Hospital, Hospices Civils de Lyon, Lyon; Université de Lyon (MGV, PS, JI, AG, CB, ID, JN, AH), Lyon; Université Lyon 1 (MGV, PS, JI, AG, CB, ID, JN, AH), Villeurbanne; Service de Biostatistiques (JI), Hospices Civils de Lyon, Lyon; CNRS UMR 5558 (JI), Equipe Biostatistique-Santé, Laboratoire de Biométrie et Biologie Evolutive, Villeurbanne; Department of Rheumatology (AG) and Department of Internal Medicine (ID), Centre Hospitalier Lyon Sud, Hospices Civils de Lyon, Pierre-Bénite; Department of Internal Medicine (JN, AH), Edouard Herriot Hospital, Hospices Civils de Lyon, Lyon, France
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9
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Maria ATJ, Le Quellec A, Jorgensen C, Touitou I, Rivière S, Guilpain P. Adult onset Still's disease (AOSD) in the era of biologic therapies: dichotomous view for cytokine and clinical expressions. Autoimmun Rev 2014; 13:1149-59. [PMID: 25183244 DOI: 10.1016/j.autrev.2014.08.032] [Citation(s) in RCA: 117] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2014] [Accepted: 06/03/2014] [Indexed: 01/10/2023]
Abstract
Adult onset Still's disease (AOSD) is a rare inflammatory disorder characterized by hectic spiking fever, evanescent rash and joint involvement. Prognosis is highly variable upon disease course and specific involvements, ranging from benign and limited outcome to chronic destructive polyarthritis and/or life-threatening events in case of visceral complications or reactive hemophagocytic lymphohistiocytosis (RHL). AOSD remains a debatable entity at the frontiers of autoimmune diseases and autoinflammatory disorders. The pivotal role of macrophage cell activation leading to a typical Th1 cytokine storm is now well established in AOSD, and confirmed by the benefits using treatments targeting TNF-α, IL-1β or IL-6 in refractory patients. However, it remains difficult to determine predictive factors of outcome and to draw guidelines for patient management. Herein, reviewing literature and relying on our experience in a series of 8 refractory AOSD patients, we question nosology and postulate that different cytokine patterns could underlie contrasting clinical expressions, as well as responses to targeted therapies. We therefore propose to dichotomize AOSD according to its clinical presentation. On the one hand, 'systemic AOSD' patients, exhibiting the highest inflammation process driven by excessive IL-18, IL-1β and IL-6 production, would be at risk of life-threatening complications (such as multivisceral involvements and RHL), and would preferentially respond to IL-1β and IL-6 antagonists. On the other hand, 'rheumatic AOSD' patients, exhibiting pre-eminence of joint involvement driven by IL-8 and IFN-γ production, would be at risk of articular destructions, and would preferentially respond to TNF-α blockers.
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Affiliation(s)
- Alexandre Thibault Jacques Maria
- Department of Internal Medicine-Multiorganic Diseases, Saint-Eloi Hospital, 80 Avenue Augustin Fliche, F-34295 Montpellier, France; Inserm, U 844, Saint-Eloi Hospital, 80 Avenue Augustin Fliche, Montpellier F-34295, France
| | - Alain Le Quellec
- Department of Internal Medicine-Multiorganic Diseases, Saint-Eloi Hospital, 80 Avenue Augustin Fliche, F-34295 Montpellier, France
| | - Christian Jorgensen
- Inserm, U 844, Saint-Eloi Hospital, 80 Avenue Augustin Fliche, Montpellier F-34295, France; Clinical Immunology and Osteoarticular Diseases Therapeutic Unit, Lapeyronie Hospital, 191 Avenue du Doyen Gaston Giraud, F-34295 Montpellier, France
| | - Isabelle Touitou
- Inserm, U 844, Saint-Eloi Hospital, 80 Avenue Augustin Fliche, Montpellier F-34295, France; Auto-Inflammatory Diseases Unit, Genetic Laboratory, Arnaud De Villeneuve Hospital, 191 Avenue du Doyen Gaston Giraud, F-34295 Montpellier, France
| | - Sophie Rivière
- Department of Internal Medicine-Multiorganic Diseases, Saint-Eloi Hospital, 80 Avenue Augustin Fliche, F-34295 Montpellier, France
| | - Philippe Guilpain
- Department of Internal Medicine-Multiorganic Diseases, Saint-Eloi Hospital, 80 Avenue Augustin Fliche, F-34295 Montpellier, France; Inserm, U 844, Saint-Eloi Hospital, 80 Avenue Augustin Fliche, Montpellier F-34295, France.
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10
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Efthimiou P, Kadavath S, Mehta B. Life-threatening complications of adult-onset Still's disease. Clin Rheumatol 2014; 33:305-14. [PMID: 24435354 PMCID: PMC7102228 DOI: 10.1007/s10067-014-2487-4] [Citation(s) in RCA: 100] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2013] [Revised: 12/27/2013] [Accepted: 01/03/2014] [Indexed: 12/28/2022]
Abstract
Adult-onset Still's Disease (AOSD) since its description in 1971 has proven to be a very complex and challenging disease entity. This rare auto-inflammatory disease is classically described by the "Still's triad" of fever, rash, and arthritis, although the atypical cases frequently outnumber the typical ones. The exact pathogenesis and etiologic factors responsible for the clinical features remain largely obscure, despite recent suggestive cytokine biology findings. Diagnosis is made on clinical grounds, following the exclusion of mimickers of infectious, autoimmune or neoplastic etiology, with the additional consideration of non-specific laboratory abnormalities such as peripheral leukocytosis and elevation of serum ferritin and other acute phase reactants. The disease manifestations are protean and can include diverse complications, affecting multiple organ systems. Moreover, the severity of the organ involvement can vary considerably, representing a wide spectrum from the self-limited to severe. The mainstay of therapy has evolved from the traditional use of corticosteroids and oral immunosupressants to the newer targeted treatments with biologic agents. The scope of this review is to alert the clinician to the existence of life-threatening AOSD complications, namely the macrophage activation syndrome, disseminated intravascular coagulopathy, thrombotic thrombocytopenic purpura, diffuse alveolar hemorrhage, and pulmonary arterial hypertension. Such knowledge may lead in earlier recognition, prompt treatment, and, ideally, improved patient outcomes.
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Affiliation(s)
- Petros Efthimiou
- Rheumatology Division, Lincoln Medical and Mental Health Center, 234 E. 149th Street, New York, NY, 10451, USA,
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11
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Kiyonaga Y, Maeshima K, Imada C, Haranaka M, Ishii K, Shibata H. Steroid-sparing effects of etanercept in a patient with steroid-dependent adult-onset Still's disease. Intern Med 2014; 53:1209-13. [PMID: 24881751 DOI: 10.2169/internalmedicine.53.1488] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
We herein report the case of an 84-year-old man with steroid-dependent adult-onset Still's disease (AOSD) whose daily steroid dose was successfully tapered after etanercept treatment. The corticosteroids worked well initially, and the patient went into remission promptly; however, he suffered a relapse due to steroid tapering. Because treatment with cyclosporine and methotrexate was ineffective, reducing the steroid dose was difficult, and the corticosteroids induced myopathy and diabetes. However, steroid tapering was accomplished in combination with etanercept therapy, and the patient's steroid-induced side effects disappeared. Etanercept should therefore be considered as a steroid-sparing treatment option in patients with steroid-responsive, steroid-dependent AOSD.
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Affiliation(s)
- Yasuhiro Kiyonaga
- Department of Endocrinology, Metabolism, Rheumatology and Nephrology, Faculty of Medicine, Oita University, Japan
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12
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13
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Biological treatment in adult-onset Still's disease. Best Pract Res Clin Rheumatol 2013; 26:477-87. [PMID: 23040362 DOI: 10.1016/j.berh.2012.07.002] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2012] [Accepted: 07/17/2012] [Indexed: 01/29/2023]
Abstract
Adult-onset Still's disease (AOSD) is a rare systemic inflammatory disorder that is characterised by high spiking fever, arthritis or arthralgia, and evanescent rash. Many other systemic manifestations may occur. Pathogenesis of AOSD remains partially unknown but a major role has been recently attributed to pro-inflammatory Th1 cytokines, including tumour necrosis factor-α (TNF-α), interleukin (IL)-1, IL-6 and IL-18. Despite limited evidence, mainly based on observational studies and the extrapolation to AOSD of the results of a few controlled studies that have been conducted in children with systemic juvenile idiopathic arthritis, biological agents represent a major therapeutic advances for patients with AOSD refractory to conventional treatment or presenting life-threatening manifestations. Both IL-1 and IL-6 blockade may be more effective than TNF-α blockers. Although debatable, therapeutic strategies are proposed.
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Kerensky TA, Gottlieb AB, Yaniv S, Au SC. Etanercept: efficacy and safety for approved indications. Expert Opin Drug Saf 2011; 11:121-39. [DOI: 10.1517/14740338.2012.633509] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Thonhofer R, Hiller M, Just H, Trummer M, Siegel C, Dejaco C. Treatment of refractory adult-onset still’s disease with tocilizumab: report of two cases and review of the literature. Rheumatol Int 2011; 31:1653-6. [DOI: 10.1007/s00296-010-1631-y] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2010] [Accepted: 11/14/2010] [Indexed: 11/30/2022]
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ZENG TING, ZOU YUQIONG, WU MEIFANG, YANG CHENGDE. Clinical Features and Prognosis of Adult-onset Still’s Disease: 61 Cases from China. J Rheumatol 2009; 36:1026-31. [DOI: 10.3899/jrheum.080365] [Citation(s) in RCA: 70] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Objective.To describe the onset, clinical features, prognostic factors, and treatment of adult-onset Still’s disease (AOSD) in cases from China.Methods.Sixty-one Chinese patients with AOSD were analyzed retrospectively.Results.Common clinical features were fever (100.0%), rash (88.5%), and arthritis (82.0%). The laboratory findings were as follows: leukocytosis (83.6%), increased erythrocyte sedimentation rate (100.0%), elevated transaminase concentrations (23.0%), elevated ferritin levels (79.6%), negative antinuclear antibody (88.5%), and negative rheumatoid factor (88.5%). Of the 61 patients, 44.3% exhibited a monocyclic disease pattern, 29.5% experienced disease relapse at least once, 16.4% exhibited chronic articular course, and 9.8% died; most deaths were due to pulmonary infection and respiratory failure. Based on the disease course, we divided the 61 patients into 2 groups: those with favorable outcome (cyclic disease course, n = 45) and unfavorable outcome (chronic disease course or death, n = 16). We analyzed the prognostic factors for the 2 groups, and found that pleuritis, interstitial pneumonia, elevated ferritin levels, and failure of fever to subside after 3 days of prednisolone at 1 mg/kg/day were unfavorable prognostic factors for patients with AOSD.Conclusion.Patients with AOSD had complex symptoms with no specific laboratory findings. Our results indicate that AOSD is not a relatively benign disease, especially in cases that are refractory to high doses of prednisone.
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Colina M, Govoni M, Trotta F. Fatal myocarditis in adult-onset Still disease with diffuse intravascular coagulation. Rheumatol Int 2008; 29:1355-7. [PMID: 19048255 DOI: 10.1007/s00296-008-0813-3] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2008] [Accepted: 11/20/2008] [Indexed: 11/25/2022]
Abstract
Adult-onset Still disease (AOSD) is a rare condition disease of unknown etiology, characterized by quotidian or double quotidian spiking fever, with an evanescent pink-salmon rash, arthritis and multi-organ involvement. Diagnosis is usually clinical and made after other diseases in the differential diagnosis are excluded. We herein report the case of a patient with a remarkable familial autoimmune background in whom adult Still disease started off with a diffuse intravascular coagulation, probably triggered by a macrophage activation syndrome, followed by an acute interstitial myocarditis, leading to a fatal complete atrioventricular block. This case highlights that AOSD represents a troubling condition and that it may suddenly get worse with life-threatening events.
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Affiliation(s)
- Matteo Colina
- Section of Rheumatology, Department of Clinical and Experimental Medicine, University of Ferrara, Ferrara, Italy.
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