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Smiyan S, Dyadyk O, Kvasnitska O, Makhovska O, Antiuk Z, Bidovanets T, Komorovsky R. Management of granulomatosis with polyangiitis complicated by intestinal perforation and pancytopenia: a case report and literature review. Rheumatol Int 2024; 44:1369-1379. [PMID: 38627280 DOI: 10.1007/s00296-024-05586-5] [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: 01/20/2024] [Accepted: 03/13/2024] [Indexed: 06/15/2024]
Abstract
Granulomatosis with polyangiitis is a systemic vasculitis. While the classic triad typically comprises otorhinolaryngologic, pulmonary, and renal manifestations, it is essential to recognize that granulomatosis with polyangiitis can affect any organ. Furthermore, reports have documented less common sites of involvement, such as the gastrointestinal tract. In this case-based review, we focus on a case of granulomatosis with polyangiitis presenting with intestinal perforation and the added challenge of concurrent pancytopenia.A 25-year-old female was diagnosed with granulomatosis with polyangiitis, with her clinical course progressing from joint pain to severe multi-organ involvement, including gastrointestinal complications. Treatment challenges emerged with the development of pancytopenia. While this may not directly result from granulomatosis with polyangiitis, it introduced an additional layer of complexity and delayed the induction of remission with immunosuppressants. Despite initial stabilization, an unexpected jejunal perforation occurred, requiring surgical intervention and subsequent postoperative care. The case underscores the complex nature of granulomatosis with polyangiitis and its potential complications. A literature search yielded discrete relevant cases in the context of our patient's intricate presentation, which has been summarized.We highlight the complexities in diagnosing and managing granulomatosis with polyangiitis-related complications, especially in uncommon presentations, and emphasize the importance of a personalized approach to patient care in these circumstances.
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Affiliation(s)
- Svitlana Smiyan
- 2nd Department of Internal Medicine, Ivan Horbachevsky Ternopil National Medical University, Majdan Voli, 1, Ternopil, 46001, Ukraine
| | - Olena Dyadyk
- Department of Morphology, Clinical Pathology and Forensic Medicine, Shupyk National Healthcare University of Ukraine, Kyiv, Ukraine
| | - Oksana Kvasnitska
- 2nd Department of Internal Medicine, Ivan Horbachevsky Ternopil National Medical University, Majdan Voli, 1, Ternopil, 46001, Ukraine
| | | | - Zhanna Antiuk
- Department of Rheumatology, Ternopil Regional Hospital, Ternopil, Ukraine
| | - Taras Bidovanets
- 2nd Department of Internal Medicine, Ivan Horbachevsky Ternopil National Medical University, Majdan Voli, 1, Ternopil, 46001, Ukraine
| | - Roman Komorovsky
- 2nd Department of Internal Medicine, Ivan Horbachevsky Ternopil National Medical University, Majdan Voli, 1, Ternopil, 46001, Ukraine.
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Carlotto FM, Corrêa NB, Weber D, Zanotelli C. Diffuse large B-cell non-Hodgkin's lymphoma associated with still's disease and macrophage activation syndrome: Rare report in the literature. Hematol Transfus Cell Ther 2024; 46:80-84. [PMID: 35688789 PMCID: PMC10935472 DOI: 10.1016/j.htct.2022.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Revised: 03/28/2022] [Accepted: 04/25/2022] [Indexed: 10/18/2022] Open
Affiliation(s)
| | | | - Daiane Weber
- Hospital São Vicente de Paulo, Passo Fundo, Rio Grande do Sul, Brazil
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Magro CM, Kalomeris T, Dillard A. Panniculitic primary cutaneous gamma delta T-cell lymphoma with concomitant features of autoimmune disease emphasizing a pathophysiologic continuum of lupus profundus with the panniculitic T cell lymphomas. Clin Dermatol 2023; 41:680-691. [PMID: 37716581 DOI: 10.1016/j.clindermatol.2023.09.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/18/2023]
Abstract
Certain T-cell lymphomas exhibit unique homing properties of the neoplastic lymphocytes for the subcutaneous fat. There are two primary forms of subcutaneous panniculitic lymphomas of T-cell origin. One falls under the designation of primary cutaneous gamma-delta T-cell lymphomas (PGD-TCL) whereby there is dominant involvement of the fat defininng a panniculitic form of PGD-TCL. The neoplastic cells are of the gamma-delta subset and are either double negative for CD4 and CD8 and/or can express CD8. They often have an aggressive clinical course. The other form of panniculitic T-cell lymphoma falls under the designation of subcutaneous panniculitis-like T-cell lymphoma (SPTCL). It represents a subcutaneous lymphoma derived from CD8+ T cells of the alpha-beta subset and typically has an indolent course. These two forms of panniculitic T-cell lymphoma exhibit overlapping histologic features with lupus profundus (LP), a putative form of panniculitic T-cell dyscrasia. We present three cases of PGD-TCL of the fat in the setting of lupus erythematosus (LE) (two cases) and dermatomyositis (DM) (one case), respectively. There were concurrent features of LE and DM in their lymphoma biopsies in two cases while a prior biopsy in one was interpreted as LP. In this latter case, the LP diagnosis presaged the diagnosis of panniculitic PGD-TCL by three years. One patient diagnosed with panniculitic PGD-TCL had hemophagocytic syndrome after developing a lupus-like complex including certain supportive serologies such as antibodies to double-stranded DNA following initiation of statin therapy. The second patient presented with PGD-TCL and concomitant features of anti-nuclear matrix 2 (NXP2) DM. The third patient presented in 2003 with LP and overlying skin features of acute LE, initially responding to Plaquenil, and then four years later was diagnosed with PGD-TCL heralded by Plaquenil treatment resistance. Two of the patients died of their lymphoma. All biopsies showed a characteristic histopathology of PGD-TCL. In two cases, the PGD-TCL was associated with overlying LE-cutaneous findings; another case had skin changes of lymphocyte-rich DM. In two cases, the MXA stain was strikingly positive, the surrogate type I interferon marker that is typically upregulated in biopsies of LE and DM. There are eight prior reported cases describing SPTCL with concomitant cutaneous changes of LE. In six cases there was an established history of LE, including LP responding initially to Plaquenil, similar to one of our cases. In the context of SPTCL or panniculitic PGD-TCL, panniculitic T-cell lymphomas can be associated with concomitant clinical and histologic features of LE or DM, including an upregulated type I interferon signature. Identifying histologic features associated with either of these prototypic autoimmune conditions should not be considered exclusionary to diagnosing any panniculitic T-cell lymphoma. A clinical, histomorphologic, and pathophysiologic continuum exists with LP, SPTCL and panniculitic PGD-TCL.
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Affiliation(s)
- Cynthia M Magro
- Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, New York, USA.
| | - Taylor Kalomeris
- Department of Pathology and Laboratory Medicine, New York-Presbyterian/Weill Cornell Medicine, New York, New York, USA
| | - Alicia Dillard
- Department of Pathology and Laboratory Medicine, New York-Presbyterian/Weill Cornell Medicine, New York, New York, USA
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Martins A, Pimenta S, Oliveira D, Martins F, Samões B, Costa L. Severe and life-threatening onset of systemic lupus erythematosus. REUMATOLOGIA CLINICA 2023; 19:402-403. [PMID: 37661117 DOI: 10.1016/j.reumae.2022.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Accepted: 09/12/2022] [Indexed: 09/05/2023]
Abstract
Macrophage activation syndrome (MAS) is a potentially life-threatening complication of rheumatic diseases. We report a unique case of a previously healthy 20-year-old female presenting with MAS as first presentation of systemic lupus erythematosus. Remission was achieved with hydroxychloroquine, intravenous methylprednisolone pulse followed by oral prednisolone and cyclosporine. However, the management of MAS is still challenging, and the mortality rate remains high.
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Affiliation(s)
- Ana Martins
- Department of Rheumatology, Centro Hospitalar Universitário de São João, Porto, Portugal; Department of Medicine, Faculdade de Medicina da Universidade do Porto, Porto, Portugal.
| | - Sofia Pimenta
- Department of Rheumatology, Centro Hospitalar Universitário de São João, Porto, Portugal; Department of Medicine, Faculdade de Medicina da Universidade do Porto, Porto, Portugal
| | - Daniela Oliveira
- Department of Rheumatology, Centro Hospitalar Universitário de São João, Porto, Portugal; Department of Medicine, Faculdade de Medicina da Universidade do Porto, Porto, Portugal
| | | | - Beatriz Samões
- Department of Rheumatology, Centro Hospitalar de Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal
| | - Lúcia Costa
- Department of Rheumatology, Centro Hospitalar Universitário de São João, Porto, Portugal
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Bektaş M, Yüce S, Ay M, Uyar MH, Önder ME, Kılıç Mİ. High-dose intravenous anakinra treatment is safe and effective in severe and critical COVID-19 patients: a propensity score-matched study in a single center. Inflammopharmacology 2023; 31:787-797. [PMID: 36707494 PMCID: PMC9882740 DOI: 10.1007/s10787-023-01138-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Accepted: 01/12/2023] [Indexed: 01/29/2023]
Abstract
BACKGROUND In COVID-19, severe disease course such as need of intensive care unit (ICU) as well as development of mortality is mainly due to cytokine storm. In this study, we aimed to evaluate the high-dose intravenous anakinra treatment response and outcome in patients with severe and critically ill COVID-19 compared to standard of care. METHODS This retrospective observational study was carried out at a tertiary referral center. The study population consisted of two groups as follows: the patients receiving high-dose intravenous anakinra (anakinra group) between 01.09.2021 and 01.02.2022 and the patients treated with standard of care (SoC, control group) as historical control group who were hospitalized between 01.07.2021 and 01.09.2021. RESULTS After the propensity score 1:1 matching, 79 patients in anakinra and 79 patients in SoC matched and were included into the analysis. Mean ± SD patient age was 67.4 ± 16.7 and 67.1 ± 16.3 years in anakinra and SoC groups, respectively (p = 0.9). Male gender was 38 (48.7%) in anakinra and 36 (46.2%) in SoC (p = 0.8). Overall, ICU admission was in 14.1% (n = 11) and 30.8% (n = 24) (p = 0.013; OR 6.2), intubation in 12.8% (n = 10) and 16.7% (n = 13) patients (p = 0.5), and 14.1% (n = 11) and 32.1% (n = 25) patients died in anakinra and control groups, respectively (p = 0.008; OR 7.1). CONCLUSION In our study, mortality was lower in patients receiving anakinra compared to SoC. Intravenous high-dose anakinra is safe and effective treatment in patients with severe and critical COVID-19.
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Affiliation(s)
- Murat Bektaş
- Division of Rheumatology, Department of Internal Medicine, Aksaray Training and Research Hospital, Yeni Sanayi Mahallesi, 68200 Merkez/Aksaray, Turkey
| | - Servet Yüce
- Department of Public Health and Biostatistics, Istanbul Faculty of Medicine, Çapa, Şehremini, Istanbul, Turkey
| | - Mustafa Ay
- Department of Emergency Medicine, Aksaray Training and Research Hospital, 68200 Merkez/Aksaray, Turkey
| | - Muhammed Hamdi Uyar
- Department of Emergency Medicine, Aksaray Training and Research Hospital, 68200 Merkez/Aksaray, Turkey
| | - Mustafa Erkut Önder
- Division of Rheumatology, Department of Physical Therapy and Rehabilitation, Aksaray Training and Research Hospital, Yeni Sanayi Mahallesi, 68200 Merkez/Aksaray, Turkey
| | - Muhammed İkbal Kılıç
- Department of Internal Medicine, Aksaray Training and Research Hospital, Yeni Sanayi Mahallesi, 68200 Merkez/Aksaray, Turkey
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Nasonov EL. [Role of interleukin-1 in human diseases: pharmacotherapy prospects: A review]. TERAPEVT ARKH 2022; 94:999-1005. [PMID: 36286981 DOI: 10.26442/00403660.2022.08.201781] [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: 10/12/2022] [Accepted: 10/12/2022] [Indexed: 06/16/2023]
Abstract
According to current concepts, human immunoinflammatory diseases (IIDs), depending on the prevailing mechanisms of immunopathogenesis, are divided into two main categories: autoimmune and autoinflammatory. At the same time, both autoimmune and autoinflammatory mechanisms are involved in the pathogenesis of most IIDs, and the complex interaction of these mechanisms is reflected in the polymorphism of clinical presentation, course variants, outcomes and therapy efficacy. It is suggested that in IIDs, overproduction of cytokines of the interleukin (IL)-1 family, which is one of the key regulators of innate immunity, determines the "crossing" between autoinflammation and autoimmunity mechanisms. Currently, anakinra, a recombinant non-glycosylated analog of the IL-1 receptor antagonist that blocks both IL-1b and IL-1a signaling, and canakinumab, a monoclonal antibody to IL-1b, are used in clinical practice to inhibit the pathological effects of IL-1. Analysis of the treatment outcomes with these drugs suggests that IL-1 inhibition should be considered a promising direction of pharmacotherapy of systemic autoinflammatory diseases and critical conditions associated with hyperinflammation in children and adults.
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Affiliation(s)
- E L Nasonov
- Nasonova Research Institute of Rheumatology
- Sechenov First Moscow State Medical University (Sechenov University)
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Tran DH, Jaggon KS, Mikdashi J, Chow RD, Verceles AC, Sood A. Lamotrigine-Induced Lupus With Aseptic Meningitis and Hemophagocytic Lymphohistiocytosis. Cureus 2022; 14:e29629. [PMID: 36176480 PMCID: PMC9512686 DOI: 10.7759/cureus.29629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/26/2022] [Indexed: 11/05/2022] Open
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The spectrum of hemophagocytic lymphohistiocytosis: a retrospective study comparing adult macrophage activation syndrome to malignancy-associated hemophagocytic lymphohistiocytosis. Rheumatol Int 2022; 42:1247-1255. [PMID: 35015099 PMCID: PMC8750640 DOI: 10.1007/s00296-021-05087-9] [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: 10/11/2021] [Accepted: 12/30/2021] [Indexed: 11/05/2022]
Abstract
Secondary hemophagocytic lymphohistiocytosis (sHLH) is a life-threatening inflammatory syndrome that can be triggered by autoimmune diseases, malignancy, or infection. In rheumatologic patients, sHLH is referred to as macrophage activation syndrome (MAS). Differentiating between triggers is important for prompt treatment and prognosis. Data comparing subsets of sHLH are limited due to the rarity of this disease. We aim to explore differences in clinical features that may differentiate MAS from malignancy-associated HLH (mHLH) patients. We conducted a single-center retrospective study assessing clinical characteristics, laboratory parameters, treatment regimens and outcomes in 34 patients with sHLH over a 16 year period. We compared patients with MAS to those with mHLH. Hepatomegaly was not present in the MAS group but was present in the mHLH group (0 vs. 25%, p = 0.024). MAS patients had on average nearly double the concentration of platelets at 50.0 (IQR: 31.0–78.0 Kµ/L) vs. 29.0 Kµ/L (IQR: 14.0–37.5 Kµ/L), p = 0.003. Soluble IL-2R concentrations were four times lower in the MAS group with a median soluble IL-2R concentration of 6814.5 kU/L (IQR: 2101–2610 kU/L) vs. 27972.0 kU/L (IQR: 12,820–151,650 kU/L), p = 0.010. The MAS group fared better overall than the mHLH group but was not statistically significant (mortality 22 vs. 44%, p = 0.18). MAS and mHLH patients exhibited different laboratory parameters and clinical features, most notably differences in platelet counts, soluble IL-2R concentration and hepatomegaly, which may help differentiate these conditions early in their course.
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Su CF, Liao HT, Tsai CY. Tocilizumab and rituximab for anti-MDA-5 positive amyopathic dermatomyositis complicated with macrophage activation syndrome and progressive fibrosing interstitial lung disease. Scand J Rheumatol 2021; 51:166-168. [PMID: 34643171 DOI: 10.1080/03009742.2021.1972519] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- C-F Su
- Division of Allergy, Immunology and Rheumatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - H-T Liao
- Division of Allergy, Immunology and Rheumatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Division of Allergy, Immunology and Rheumatology, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - C-Y Tsai
- Division of Allergy, Immunology and Rheumatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
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Zhao M, Wu D, Shen M. Adult-onset Still's disease with neurological involvement: a single-centre report. Rheumatology (Oxford) 2021; 60:4152-4157. [PMID: 33369675 DOI: 10.1093/rheumatology/keaa899] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVES Adult-onset Still's disease (AOSD) is a multifactorial systemic autoinflammatory disease. Neurological damage has been rarely reported in AOSD. We aimed to characterize the clinical features of AOSD patients with neurological involvement. METHODS A total of 187 AOSD patients were admitted to Peking Union Medical College Hospital from January 2015 to August 2019. The complete medical records were reviewed in this retrospective study. Clinical features of 14 AOSD patients with neurological involvement were collected and compared with those without. RESULTS The prevalence of neurological involvement in AOSD inpatients was 7.5%. The median disease duration was 4.5 months, with a range of 1-15 months. The frequent symptoms were fever [14 (100%)], rash [13 (92.9%)], liver dysfunction [11 (78.6%)], arthralgia/arthritis [10 (71.4%)] and lymphadenopathy [10 (71.4%)]. Four (28.6%) patients had macrophage activation syndrome (MAS). Aseptic meningitis was the most common presentation (64.3%) when the nervous system was involved. Other rare manifestations included cranial nerve palsy, encephalitis and cerebral infarction. The rate of MAS, serum levels of lactate dehydrogenase and ferritin were significantly higher in AOSD patients with neurological involvement than in those without. All patients received high-dose corticosteroid therapy and immunosuppressive agents and two were given tocilizumab. Clinical remission was achieved in all 14 AOSD patients with neurological involvement. CONCLUSION Neurological involvement, particularly aseptic meningitis, is not a rare complication of AOSD. It is frequently complicated by MAS. There may be a potential relationship between the neurological damage of AOSD and MAS.
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Affiliation(s)
- Mengzhu Zhao
- Department of Rheumatology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Di Wu
- Department of Rheumatology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Min Shen
- Department of Rheumatology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
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Ke Y, Lv C, Xuan W, Wu J, Da Z, Wei H, Zhang M, Tan W. Clinical analysis of macrophage activation syndrome in adult rheumatic disease: A multicenter retrospective study. Int J Rheum Dis 2020; 23:1488-1496. [PMID: 32885598 DOI: 10.1111/1756-185x.13955] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 08/05/2020] [Accepted: 08/05/2020] [Indexed: 01/08/2023]
Abstract
AIM To evaluate the clinical and laboratory characteristics, prognostic factors, and outcome of adult rheumatic disease-associated macrophage activation syndrome (MAS). METHOD A multicenter retrospective study was performed across 4 tertiary hospitals in China between January 1, 2017 to December 31, 2019. RESULTS There were 61 rheumatic disease patients with MAS enrolled into this retrospective clinical study. Fever and hyperferritinemia are the most frequent clinical feature and laboratory abnormality in MAS patients. Serum ferritin > 6000 ng/mL (odds ratio [OR] = 9.46, 95% CI = 2.53-47.13, P = .005) and hemophagocytosis in bone marrow smear (OR = 11.12, 95%, CI = 3.29-50.65, P = .001) were the 2 most prominent predictive factors indicating MAS occurrence. The 90-day all-cause mortality rate of all rheumatic disease patients with MAS was 22.9% (hazards ratio [HR] = 2.15, 95% CI = 0.81-6.78, P = .05). Platelets < 100 × 109 /L (HR = 3.23, 95% CI = 2.51-4.81, P = .01) and ferritin > 6000ng/mL (HR = 6.12, 95% CI = 2.93-16.27, P = .005) were independent predictors of poor outcome in rheumatic disease-associated MAS. CONCLUSION Macrophage activation syndrome could be a fatal complication in rheumatic disease. Patients presenting with unexplained fever, serum ferritin > 6000 ng/mL, hepatosplenomegaly and cytopenia at baseline should raise the suspicion of MAS. The presence of serum ferritin > 6000 ng/mL, hepatosplenomegaly and low number of platelets was associated with poor outcome.
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Affiliation(s)
- Yao Ke
- Department of Rheumatology, the First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Chengyin Lv
- Department of Rheumatology, the First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Wenhua Xuan
- Department of Rheumatology, the Second People's Hospital of Wuxi, Wuxi, China
| | - Jian Wu
- Department of Rheumatology, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Zhanyun Da
- Department of Rheumatology, Affiliated Hospital of Nantong University, Nantong, China
| | - Hua Wei
- Division of Rheumatology, Clinical Medical College, Yangzhou University, China
| | - Miaojia Zhang
- Department of Rheumatology, the First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Wenfeng Tan
- Department of Rheumatology, the First Affiliated Hospital of Nanjing Medical University, Nanjing, China
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Bindoli S, Felicetti M, Sfriso P, Doria A. The amount of cytokine-release defines different shades of Sars-Cov2 infection. Exp Biol Med (Maywood) 2020; 245:970-976. [PMID: 32460624 DOI: 10.1177/1535370220928964] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
The recent outbreak of coronavirus disease (COVID 19), spreading from China all around the world in early 2020, has led scientists to investigate the immuno-mediated mechanisms underlying the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV2) infection. Depending on the amount of cytokines released as the result of the immunological activation induced by SARS-CoV2, three major clinical phenotypes can be identified: "mild",symbolized as a "drizzle" of cytokines, severe as a "storm", and critical as a "hurricane". In patients with mild symptoms, the release of pro-inflammatory cytokines is balanced to obtain a defense response against the virus which is often self-limiting and overcomes without tissue damage. In severe phenotype, resembling a "cytokine-release syndrome", SARS-CoV2 causes the lysis of the immune-mediators leading to a cytokine storm able to induce lung epithelium damage and acute respiratory distress syndrome. In critical patients, the immune response may become uncontrolled, thus the cytokine burst resembles a form of secondary hemophagocytic lymphohistiocytosis which may result in a multi organ failure. In addition to the standard of care, an immune-modulatory therapy tailored to each one of the different phenotypes should be used in order to prevent or reduce the release of cytokines responsible for organ damage and disease progression.
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Affiliation(s)
- S Bindoli
- Rheumatology Unit, Department of Medicine, University of Padova, Padova 35128, Italy
| | - M Felicetti
- Rheumatology Unit, Department of Medicine, University of Padova, Padova 35128, Italy
| | - P Sfriso
- Rheumatology Unit, Department of Medicine, University of Padova, Padova 35128, Italy
| | - A Doria
- Rheumatology Unit, Department of Medicine, University of Padova, Padova 35128, Italy
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Sun J, Wang JW, Wang R, Zhang H, Sun J. Respiratory failure and macrophage activation syndrome as an onset of systemic lupus erythematosus: A case report. World J Clin Cases 2019; 7:3859-3865. [PMID: 31799315 PMCID: PMC6887615 DOI: 10.12998/wjcc.v7.i22.3859] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2019] [Revised: 10/09/2019] [Accepted: 10/15/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Macrophage activation syndrome (MAS) is defined as a specific secondary hemophagocytic lymphohistiocytosis that refers particularly to those triggered by autoimmune diseases. MAS is a rare and highly lethal complication of systemic lupus erythematosus (SLE), which can be associated with, or mimic, disease flare. However, the data regarding the clinical course, management and outcome of SLE with MAS is limited, especially in adults. Lack of clinical recognition of the disease often leads to poor prognosis.
CASE SUMMARY We report a 36-year-old Chinese woman without relevant past medical history who was admitted to hospital with a 6-d history of jaundice and a high fever of 39.4°C lasting one day. Abdominal magnetic resonance imaging excluded obstructive jaundice, no infection was identified and empiric superior antibiotic treatment (meropenem) showed no clinical improvement. However, newly emerged pancytopenia and respiratory failure endangered the patient’s life. Autoimmune work-up finally led to the diagnosis of SLE, which initially presented as MAS and manifested respiratory failure, although neither bone marrow biopsy nor lymph node biopsy showed hemophagocytosis. To our knowledge, such a scenario has never been reported in detail before. The patient had a favorable reaction to combination treatment with corticosteroid and cyclosporine A and has been in clinical remission during the 1-year follow up period.
CONCLUSION Respiratory failure and MAS can be an onset of SLE. Early diagnosis and appropriate treatment are extremely important for a better prognosis.
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Affiliation(s)
- Juan Sun
- Department of Nephrology and Rheumatology, The Third Xiangya Hospital, Central South University, Changsha 410013, Hunan Province, China
| | - Jian-Wen Wang
- Department of Nephrology and Rheumatology, The Third Xiangya Hospital, Central South University, Changsha 410013, Hunan Province, China
| | - Rui Wang
- Department of Gastroenterology, The Third Xiangya Hospital, Central South University, Changsha 410013, Hunan Province, China
| | - Hao Zhang
- Department of Nephrology and Rheumatology, The Third Xiangya Hospital, Central South University, Changsha 410013, Hunan Province, China
| | - Jian Sun
- Department of Nephrology and Rheumatology, The Third Xiangya Hospital, Central South University, Changsha 410013, Hunan Province, China
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