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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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2
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Tanaka K, Asano T, Watanabe E, Matsumoto K, Kashima H, Koito Y, Miura T, Takahashi Y, Tsuboi R, Ishii T, Otake H, Yoshikawa S, Uehara T, Sekine M, Matsumoto S, Asabe S, Miyatani H, Mashima H. Adult-onset Still's Disease Diagnosed during Puerperium with Liver Dysfunction in Pregnancy and Liver Failure of the Infant. Intern Med 2023; 62:2349-2354. [PMID: 37587054 PMCID: PMC10484755 DOI: 10.2169/internalmedicine.1038-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2022] [Accepted: 10/31/2022] [Indexed: 08/18/2023] Open
Abstract
Most cases of liver dysfunction in pregnancy are pregnancy-related, but the onset of systemic autoimmune diseases is also differentiated. A 24-year-old woman presented with liver dysfunction at 28 weeks' gestation with suspected autoimmune hepatitis and started taking ursodeoxycholic acid. She gave birth prematurely at 35 weeks' gestation, and the infant presented with pancytopenia and liver failure but survived because of liver transplantation. Since the patient had major symptoms during the puerperium, she was diagnosed with adult-onset Still's disease. When encountering a patient with liver dysfunction during pregnancy, we should also consider the onset of autoimmune diseases.
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Affiliation(s)
- Kenjo Tanaka
- Department of Gastroenterology, Saitama Medical Center, Jichi Medical University, Japan
| | - Takeharu Asano
- Department of Gastroenterology, Saitama Medical Center, Jichi Medical University, Japan
| | - Eri Watanabe
- Department of Rheumatology, Saitama Medical Center, Jichi Medical University, Japan
| | - Keita Matsumoto
- Department of Gastroenterology, Saitama Medical Center, Jichi Medical University, Japan
| | - Hitomi Kashima
- Department of Gastroenterology, Saitama Medical Center, Jichi Medical University, Japan
| | - Yudai Koito
- Department of Gastroenterology, Saitama Medical Center, Jichi Medical University, Japan
| | - Takaya Miura
- Department of Gastroenterology, Saitama Medical Center, Jichi Medical University, Japan
| | - Yuko Takahashi
- Department of Gastroenterology, Saitama Medical Center, Jichi Medical University, Japan
| | - Rumiko Tsuboi
- Department of Gastroenterology, Saitama Medical Center, Jichi Medical University, Japan
| | - Takehiro Ishii
- Department of Gastroenterology, Saitama Medical Center, Jichi Medical University, Japan
| | - Haruka Otake
- Department of Gastroenterology, Saitama Medical Center, Jichi Medical University, Japan
| | - Shuhei Yoshikawa
- Department of Gastroenterology, Saitama Medical Center, Jichi Medical University, Japan
| | - Takeshi Uehara
- Department of Gastroenterology, Saitama Medical Center, Jichi Medical University, Japan
| | - Masanari Sekine
- Department of Gastroenterology, Saitama Medical Center, Jichi Medical University, Japan
| | - Satohiro Matsumoto
- Department of Gastroenterology, Saitama Medical Center, Jichi Medical University, Japan
| | - Shinichi Asabe
- Department of Gastroenterology, Saitama Medical Center, Jichi Medical University, Japan
| | - Hiroyuki Miyatani
- Department of Gastroenterology, Saitama Medical Center, Jichi Medical University, Japan
| | - Hirosato Mashima
- Department of Gastroenterology, Saitama Medical Center, Jichi Medical University, Japan
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3
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Muacevic A, Adler JR. Myocarditis as the Initial Presentation of a Refractory Adult-Onset Still’s Disease. Cureus 2022; 14:e29821. [PMID: 36337832 PMCID: PMC9623201 DOI: 10.7759/cureus.29821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/01/2022] [Indexed: 11/05/2022] Open
Abstract
We present a case of adult-onset Still’s disease, a rare disease that presented with a rare complication, myocarditis. After initial therapy with prednisolone 1 mg/kg/day, the patient experienced dyspnea due to severe pleural effusion and palpitations on account of new-onset supraventricular tachycardia. Therapy with three consecutive pulses of 1000 mg of methylprednisolone and anakinra 100 mg/day proved to be effective, with a progressive resolution of all symptoms. However, at three months follow-up, oligoarthritis recurred along with high serum ferritin. Secondary failure to anakinra was assumed, and a switch to tocilizumab 162 mg was made. Nevertheless, arthralgia of the wrists and knees as well as high serum ferritin still persisted after two months of therapy. Chronic disease was assumed, and the patient switched to canakinumab 4 mg/kg/dose q4week, and a complete resolution of symptoms occurred with normalization of inflammation markers. Follow-up cardiac magnetic resonance showed a complete resolution of heart involvement.
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4
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Qiu H, Li HW, Zhang SH, Zhou XG, Li WP. Torsades de pointes episode in a woman with high-grade fever and inflammatory activation: A case report. World J Clin Cases 2021; 9:2899-2907. [PMID: 33969075 PMCID: PMC8058677 DOI: 10.12998/wjcc.v9.i12.2899] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2021] [Revised: 02/07/2021] [Accepted: 02/24/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND QT interval prolongation can induce torsades de pointes (TdP), a potentially fatal ventricular arrhythmia. Recently, an increasing number of non-cardiac drugs have been found to cause QT prolongation and/or TdP onset. Moreover, recent findings have demonstrated the key roles of systemic inflammatory activation and fever in promoting long-QT syndrome (LQTS) and TdP development.
CASE SUMMARY A 30-year-old woman was admitted with a moderate to high-grade episodic fever for two weeks. The patient was administered with multiple antibiotics after hospitalization but still had repeating fever and markedly elevated C-reactive protein. Once after a high fever, the patient suddenly lost consciousness, and electrocardiogram (ECG) showed transient TdP onset after frequent premature ventricular contraction. The patient recovered sinus rhythm and consciousness spontaneously, and post-TdP ECG revealed a prolonged QTc interval of 560 ms. The patient’s clinical manifestations and unresponsiveness to the antibiotics led to the final diagnosis of adult-onset Still’s disease (AOSD). There was no evidence of cardiac involvement. After the AOSD diagnosis, discontinuation of antibiotics and immediate initiation of intravenous dexamethasone administration resulted in the normal temperature and QTc interval. The genetic analysis identified that the patient and her father had heterozygous mutations in KCNH2 (c.1370C>T) and AKAP9 (c.7725A>C). During the 2-year follow-up period, the patient had no recurrence of any arrhythmia and maintained normal QTc interval.
CONCLUSION This case study highlights the risk of systemic inflammatory activation and antibiotic-induced TdP/LQTS onset. Genetic analysis should be considered to identify individuals at high risk of developing TdP.
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Affiliation(s)
- Hui Qiu
- Department of Cardiology, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
| | - Hong-Wei Li
- Department of Cardiology, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
| | - Shu-Hong Zhang
- Department of Pathology, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
| | - Xiao-Ge Zhou
- Department of Pathology, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
| | - Wei-Ping Li
- Department of Cardiology, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
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5
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Hori H, Yabe H, Fukuchi T, Sugawara H. A woman with adult-onset Still's disease and acute intestinal pseudo-obstruction. Clin Case Rep 2021; 9:153-157. [PMID: 33489152 PMCID: PMC7813055 DOI: 10.1002/ccr3.3488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Revised: 09/24/2020] [Accepted: 10/19/2020] [Indexed: 12/01/2022] Open
Abstract
Adult-onset Still's disease may cause intestinal pseudo-obstruction via a cytokine storm. Early diagnosis and treatment are the key for patient survival before the development of serious complications such as macrophage activation syndrome.
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Affiliation(s)
- Hiroshi Hori
- Division of General MedicineDepartment of Comprehensive Medicine 1Saitama Medical CenterJichi Medical UniversitySaitamaJapan
| | - Hiroki Yabe
- Division of RheumatologyDepartment of Comprehensive Medicine 1Saitama Medical CenterJichi Medical UniversitySaitamaJapan
| | - Takahiko Fukuchi
- Division of General MedicineDepartment of Comprehensive Medicine 1Saitama Medical CenterJichi Medical UniversitySaitamaJapan
| | - Hitoshi Sugawara
- Division of General MedicineDepartment of Comprehensive Medicine 1Saitama Medical CenterJichi Medical UniversitySaitamaJapan
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6
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Martín-Nares E, López-Iñiguez A, Castro-Gallegos PE, Ontiveros-Mercado H, Soria-Orozco M, Valerdi-Contreras L. Adult-Onset Still Disease Presenting With Insterstitial Lung Disease and Dermatomyositis-Like Atypical Persistent Eruption Successfully Treated With Mycophenolate Mofetil. J Clin Rheumatol 2019; 25:e136-e140. [PMID: 31764504 DOI: 10.1097/rhu.0000000000000787] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
- Eduardo Martín-Nares
- Department of Internal Medicine Hospital Civil de Guadalajara "Fray Antonio Alcalde," Guadalajara Jalisco, Mexico
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7
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Abstract
Adult-onset Still’s disease (AOSD) has a vast array of clinical presentations. Myopericarditis is one of the rarest cardiopulmonary manifestations of the disease and due to its rarity, the literature on the association of myocarditis with AOSD is sparse. Herein, we describe an interesting case of a 44-year-old male who presented with chest pain following exertion. He was febrile at the time of presentation and exam revealed inflammation in various joints. Electrocardiogram showed diffuse ST segment elevations in the precordial leads. Laboratory results revealed elevated troponin of 3.17 (<0.05 ng/mL) and CK-MB of 6 ng/mL along with elevated ferritin of 6225 (16-336 ng/mL). Cardiac MRI showed early and late gadolinium enhancement consistent with myocarditis. The patient was started on steroids and non-steroidal anti-inflammatory drugs (NSAID) resulting in clinical improvement. This case highlights the critical importance of diagnosis of pericarditis and myocarditis in patients with AOSD, as a missed diagnosis can lead to significant morbidity and mortality.
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Affiliation(s)
- Manish Kumar
- Internal Medicine, University of Connecticut Health Center, Farmington, USA
| | - Varun Tandon
- Internal Medicine, University of Arizona College of Medicine - Phoenix, Phoenix, USA
| | | | - Shriyanka Jain
- Rheumatology, University of Connecticut Health Center, Farmington, USA
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8
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Jung JY, Suh CH, Kim HA. The role of damage-associated molecular pattern for pathogenesis and biomarkers in adult-onset Still's disease. Expert Rev Mol Diagn 2019; 19:459-468. [PMID: 31055973 DOI: 10.1080/14737159.2019.1615449] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Introduction: Adult-onset Still's disease (AOSD) is a systemic inflammatory disease, which presents itself as an adult form of systemic juvenile idiopathic arthritis. Innate immune activation driven by a combination of genetic and environmental factors is the primary mechanism underlying disease pathogenesis in AOSD patients. Few biomarkers have been identified for AOSD diagnosis or for the assessment of disease activity or prediction of clinical outcomes. Damage-associated molecular patterns (DAMPs) can activate innate immunity, resulting in tissue damage. Changes in several DAMPs are associated with disease pathogenesis in AOSD patients. Areas covered: This review describes the role of DAMPs in AOSD pathogenesis and discusses their potential for use as disease biomarkers. Together with overall pathogenesis of AOSD, high-mobility group box-1, advanced glycation end products, S100 proteins, and neutrophil extracellular traps are introduced and discussed in detail. Expert opinion: The activation of macrophages and neutrophils is associated with several DAMPs, causing high concentrations of proinflammatory cytokines in AOSD patients. Involvement of certain DAMPs in AOSD patients is well documented due to the presence of sterile inflammation; however, direct evidence for some DAMPs is lacking. Further research into the role of DAMP molecules in AOSD patients may reveal new biomarkers and provide targets for disease intervention.
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Affiliation(s)
- Ju-Yang Jung
- a Department of Rheumatology , Ajou University of medical school , Suwon , Republic of Korea
| | - Chang-Hee Suh
- a Department of Rheumatology , Ajou University of medical school , Suwon , Republic of Korea
| | - Hyoun-Ah Kim
- a Department of Rheumatology , Ajou University of medical school , Suwon , Republic of Korea
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9
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Mehta MV, Manson DK, Horn EM, Haythe J. An atypical presentation of adult-onset Still's disease complicated by pulmonary hypertension and macrophage activation syndrome treated with immunosuppression: a case-based review of the literature. Pulm Circ 2016; 6:136-42. [PMID: 27162622 PMCID: PMC4860549 DOI: 10.1086/685112] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Pulmonary arterial hypertension (PAH) is a known complication of rheumatologic diseases, but it is only rarely associated with adult-onset Still's disease (AOSD). We describe the case of a 30-year-old woman who presented in a pulmonary hypertension crisis and was found to have underlying AOSD with PAH and nonspecific interstitial pneumonia (NSIP) with a course complicated by macrophage activation syndrome (MAS). She dramatically improved with steroids, cyclosporine A, and anakinra, with total resolution of the MAS and significant improvement of her pulmonary arterial pressures. While there are only select case reports of AOSD associated with PAH, this is the first reported case of (1) AOSD complicated by both PAH and MAS and (2) AOSD complicated by biopsy-proven NSIP. Clinically, this case highlights the efficacy of immunosuppressive agents in the treatment of PAH and MAS from underlying AOSD and supports their use in this setting.
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Affiliation(s)
- Mili V Mehta
- Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Daniel K Manson
- Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Evelyn M Horn
- Division of Cardiology, Weill Cornell Medical Center, New York, New York, USA
| | - Jennifer Haythe
- Division of Cardiology, Columbia University Medical Center, New York, New York, USA
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10
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Gerfaud-Valentin M, Sève P, Hot A, Broussolle C, Jamilloux Y. Données actualisées sur la physiopathologie, les phénotypes et les traitements de la maladie de Still de l’adulte. Rev Med Interne 2015; 36:319-27. [DOI: 10.1016/j.revmed.2014.10.365] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2014] [Accepted: 10/25/2014] [Indexed: 12/27/2022]
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11
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Kim HA, Kwon JE, Yim H, Suh CH, Jung JY, Han JH. The pathologic findings of skin, lymph node, liver, and bone marrow in patients with adult-onset still disease: a comprehensive analysis of 40 cases. Medicine (Baltimore) 2015; 94:e787. [PMID: 25929927 PMCID: PMC4603035 DOI: 10.1097/md.0000000000000787] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Adult-onset Still disease (AOSD) is characterized by fever, skin rash, and lymphadenopathy with leukocytosis and anemia as common laboratory findings. We investigated the characteristic pathologic findings of skin, lymph node, liver, and bone marrow to assist in proper diagnosis of AOSD.Forty AOSD patients were included in the study. The skin (26 patients), lymph node (8 patients), liver (8 patients), or bone marrow biopsies (22 patients) between 1998 and 2013 were retrospectively analyzed. AOSD patients were diagnosed according to the Yamaguchi criteria after excluding common infections, hematological and autoimmune diseases. Immunohistochemistry, immunofluorescence, and Epstein-Barr virus-encoded RNA (EBER) in situ hybridization were performed.Most skin biopsies revealed mild lymphocytic or histiocytic infiltration in the upper dermis. Nuclear debris was frequently found in the dermis in 14 cases (53.8%). More than half of the cases (n = 14, 53.8%) showed interstitial mucin deposition. Some cases showed interface dermatitis with keratinocyte necrosis or basal vacuolization (n = 10; 38.5%). The lymph node biopsies showed a paracortical or diffuse hyperplasia pattern with immunoblastic and vascular proliferation. The liver biopsies showed sparse portal and sinusoidal inflammatory cell infiltration. All cases showed various degrees of Kupffer cell hyperplasia. The cellularity of bone marrow varied from 20% to 80%. Myeloid cell hyperplasia was found in 14 out of the 22 cases (63.6%). On immunohistochemistry, the number of CD8-positive lymphocytes was greater than that of CD4-positive lymphocytes in the skin, liver, and bone marrow, but the number of CD4-positive lymphocytes was greater than that of CD8-positive lymphocytes in the lymph nodes.The relatively specific findings with respect to the cutaneous manifestation of AOSD were mild inflammatory cell infiltration in the upper dermis, basal vacuolization, keratinocyte necrosis, presence of karyorrhexis, and mucin in the dermis. In all cases, pathologic findings in the lymph nodes included paracortical hyperplasia with vascular and immunoblastic proliferation. Skin and lymph node pathology in addition to clinical findings can aid in the diagnosis of AOSD.
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Affiliation(s)
- Hyoun-Ah Kim
- From the Department of Rheumatology (H-AK, C-HS, J-YJ); and Department of Pathology (JEK, HY, JHH), Ajou University School of Medicine, Suwon, Korea
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12
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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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13
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Gerfaud-Valentin M, Jamilloux Y, Iwaz J, Sève P. Adult-onset Still's disease. Autoimmun Rev 2014; 13:708-22. [PMID: 24657513 DOI: 10.1016/j.autrev.2014.01.058] [Citation(s) in RCA: 364] [Impact Index Per Article: 36.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2014] [Accepted: 01/02/2014] [Indexed: 12/17/2022]
Abstract
First described in 1971, adult-onset Still's disease (AOSD) is a rare multisystemic disorder considered as a complex (multigenic) autoinflammatory syndrome. A genetic background would confer susceptibility to the development of autoinflammatory reactions to environmental triggers. Macrophage and neutrophil activation is a hallmark of AOSD which can lead to a reactive hemophagocytic lymphohistiocytosis. As in the latter disease, the cytotoxic function of natural killer cells is decreased in patients with active AOSD. IL-18 and IL-1β, two proinflammatory cytokines processed through the inflammasome machinery, are key factors in the pathogenesis of AOSD; they cause IL-6 and Th1 cytokine secretion as well as NK cell dysregulation leading to macrophage activation. The clinico-biological picture of AOSD usually includes high spiking fever with joint symptoms, evanescent skin rash, sore throat, striking neutrophilic leukocytosis, hyperferritinemia with collapsed glycosylated ferritin (<20%), and abnormal liver function tests. According to the clinical presentation of the disease at diagnosis, two AOSD phenotypes may be distinguished: i) a highly symptomatic, systemic and feverish one, which would evolve into a systemic (mono- or polycyclic) pattern; ii) a more indolent one with arthritis in the foreground and poor systemic symptomatology, which would evolve into a chronic articular pattern. Steroid- and methotrexate-refractory AOSD cases benefit now from recent insights into autoinflammatory disorders: anakinra seems to be an efficient, well tolerated, steroid-sparing treatment in systemic patterns; tocilizumab seems efficient in AOSD with active arthritis and systemic symptoms while TNFα-blockers could be interesting in chronic polyarticular refractory AOSD.
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Affiliation(s)
- Mathieu Gerfaud-Valentin
- Hospices Civils de Lyon, Hôpital Universitaire de la Croix-Rousse, Service de médecine interne, F-69004 Lyon, France; Université Lyon I, F-69100 Villeurbanne, France; Université de Lyon, F-69000 Lyon, France
| | - Yvan Jamilloux
- Hospices Civils de Lyon, Hôpital Universitaire de la Croix-Rousse, Service de médecine interne, F-69004 Lyon, France; Inserm U1111, Centre International de Recherche en Infectiologie, F-69365 Lyon, France; Département de Biochimie, Université de Lausanne, 1006 Epalinges, Switzerland
| | - Jean Iwaz
- Université Lyon I, F-69100 Villeurbanne, France; Université de Lyon, F-69000 Lyon, France; Hospices Civils de Lyon, Service de Biostatistique, F-69000 Lyon, France; CNRS UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Equipe Biostatistique Santé, F-69310 Pierre-Bénite, France
| | - Pascal Sève
- Hospices Civils de Lyon, Hôpital Universitaire de la Croix-Rousse, Service de médecine interne, F-69004 Lyon, France; Université Lyon I, F-69100 Villeurbanne, France; Université de Lyon, F-69000 Lyon, France.
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14
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An Unusual Case of Adult-Onset Still's Disease with Hemophagocytic Syndrome, Necrotic Leukoencephalopathy and Disseminated Intravascular Coagulation. Case Rep Rheumatol 2014; 2014:128623. [PMID: 24707428 PMCID: PMC3965925 DOI: 10.1155/2014/128623] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2013] [Accepted: 01/14/2014] [Indexed: 01/08/2023] Open
Abstract
Case. A 34-year-old African-American female with a history of adult-onset Still's disease presented to an outside hospital with oligoarthritis. She experienced a generalized tonic-clonic seizure en route via ambulance, was intubated upon arrival, and transferred to the intensive care unit for treatment of suspected pneumonia and sepsis. She subsequently developed generalized cutaneous desquamation that progressed despite the cessation of antibiotics and other potential offending drugs which required transfer to our hospital's burn unit. She was suspected to have reactive hemophagocytic syndrome based on her clinical presentation of fever, rash, polyarthritis, elevated liver enzymes, coagulopathy, splenomegaly, normocytic anemia, thrombocytopenia, hypertriglyceridemia, hyperferritinemia, and hemophagocytosis visualized in bone marrow biopsy specimen. Magnetic resonance imaging demonstrated necrotic demyelination of the deep white matter and corona radiata. The patient developed multiorgan dysfunction and DIC without any other attributable etiology. Despite aggressive broad spectrum therapy and high dose of steroids she progressively deteriorated and eventually expired. Conclusion. Previous publications have highlighted the prevalence of necrotic leukoencephalopathy in children with familial hemophagocytic syndrome. Our patient demonstrated some uncommon features complicating her HLH including DIC and necrotic leukoencephalopathy, which are very rare entities in AOSD.
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Lethrosne C, Pernot B, Diot P, Diot E. [Cardio-respiratory involvement in adult-onset Still's disease]. Rev Mal Respir 2013; 30:262-71. [PMID: 23664285 DOI: 10.1016/j.rmr.2012.12.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2012] [Accepted: 12/04/2012] [Indexed: 10/27/2022]
Abstract
Cardiopulmonary involvement in adult-onset Still's disease is not as common as cutaneous and articular involvement. Pleuropericarditis is the most frequent thoracic manifestation. Although difficult, diagnosis of other thoracic manifestations, which may reveal the disease, is crucial, due to the high risk to life and the efficacy of new immunosuppressive agents. The pathophysiology involves essentially immunological factors, Still's disease being increasingly seen as an autoimmune inflammatory disease. Pro-inflammatory cytokines such as interleukine (IL) 1, 6 and 18 play a crucial role in macrophage activation, which is central in the pathophysiology of adult Still's disease. The classification of cardiopulmonary manifestations is based on anatomy. Cardiac lesions may involve all the tissues of the heart and the pulmonary arteries. Respiratory lesions may involve the pleura, the lung parenchyma (organizing pneumonitis, infiltrative lung disease, alveolar damage, amyloidosis), and the respiratory muscles, including the diaphragm. Finally, some manifestations may be provoked by the treatment itself. Steroids, the first-line treatment, are very effective in pleuropericarditis. Methotrexate used to be prescribed when steroids failed, but biotherapies such as IL1 and IL6 inhibitors have transformed the prognosis of forms resistant to these drugs.
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Affiliation(s)
- C Lethrosne
- Inserm U1100/EA6305, service de pneumologie, hôpital Bretonneau, CHRU et université François-Rabelais de Tours, centre d'étude des pathologies respiratoires, 37044 Tours, France
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