1
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Dong Y, Wang T, Wu H. Heterogeneity of macrophage activation syndrome and treatment progression. Front Immunol 2024; 15:1389710. [PMID: 38736876 PMCID: PMC11082376 DOI: 10.3389/fimmu.2024.1389710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Accepted: 04/12/2024] [Indexed: 05/14/2024] Open
Abstract
Macrophage activation syndrome (MAS) is a rare complication of autoimmune inflammatory rheumatic diseases (AIIRD) characterized by a progressive and life-threatening condition with features including cytokine storm and hemophagocytosis. Predisposing factors are typically associated with microbial infections, genetic factors (distinct from typical genetically related hemophagocytic lymphohistiocytosis (HLH)), and inappropriate immune system overactivation. Clinical features include unremitting fever, generalized rash, hepatosplenomegaly, lymphadenopathy, anemia, worsening liver function, and neurological involvement. MAS can occur in various AIIRDs, including but not limited to systemic juvenile idiopathic arthritis (sJIA), adult-onset Still's disease (AOSD), systemic lupus erythematosus (SLE), Kawasaki disease (KD), juvenile dermatomyositis (JDM), rheumatoid arthritis (RA), and Sjögren's syndrome (SS), etc. Although progress has been made in understanding the pathogenesis and treatment of MAS, it is important to recognize the differences between different diseases and the various treatment options available. This article summarizes the cell types and cytokines involved in MAS-related diseases, the heterogeneity, and treatment options, while also comparing it to genetically related HLH.
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Affiliation(s)
- Yuanji Dong
- Department of Rheumatology, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Ting Wang
- Department of Respiratory Disease, Thoracic Disease Center, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Huaxiang Wu
- Department of Rheumatology, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
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2
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Sztajnbok F, Fonseca AR, Campos LR, Lino K, Rodrigues MCF, Silva RM, de Almeida RG, Perazzio SF, Carvalho MDFF. Hemophagocytic lymphohistiocytosis and macrophage activation syndrome: two rare sides of the same devastating coin. Adv Rheumatol 2024; 64:28. [PMID: 38627860 DOI: 10.1186/s42358-024-00370-2] [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: 01/12/2024] [Accepted: 04/02/2024] [Indexed: 04/19/2024] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a rare genetic hyperinflammatory syndrome that occurs early in life. Macrophage activation syndrome (MAS) usually refers to a secondary form of HLH associated with autoimmunity, although there are other causes of secondary HLH, such as infections and malignancy. In this article, we reviewed the concepts, epidemiology, clinical and laboratory features, diagnosis, differential diagnosis, prognosis, and treatment of HLH and MAS. We also reviewed the presence of MAS in the most common autoimmune diseases that affect children. Both are severe diseases that require prompt diagnosis and treatment to avoid morbidity and mortality.
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Affiliation(s)
- Flavio Sztajnbok
- Department of Pediatrics, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil.
- Pediatric Rheumatology Division, Hospital Universitário Pedro Ernesto, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, Brazil.
- Rare Diseases Committee, Brazilian Society of Rheumatology (SBR), Rio de Janeiro, Brazil.
| | - Adriana Rodrigues Fonseca
- Department of Pediatrics, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
- Instituto de Puericultura e Pediatria Martagão Gesteira, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Leonardo Rodrigues Campos
- Hospital Universitário Antônio Pedro, Universidade Federal Fluminense, Niterói, Brazil
- Pediatric Rheumatology Committee, Sociedade de Reumatologia do Rio de Janeiro 2022-2024, Rio de Janeiro, Brazil
| | - Kátia Lino
- Hospital Universitário Antônio Pedro, Universidade Federal Fluminense, Niterói, Brazil
| | - Marta Cristine Félix Rodrigues
- Pediatric Rheumatology Division, Instituto de Puericultura e Pediatria Martagão Gesteira, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Rodrigo Moulin Silva
- Hospital Universitário Pedro Ernesto, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Rozana Gasparello de Almeida
- Instituto de Puericultura e Pediatria Martagão Gesteira, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Sandro Félix Perazzio
- Rare Diseases Committee, Brazilian Society of Rheumatology (SBR), Rio de Janeiro, Brazil
- Division of Rheumatology, Universidade Federal de São Paulo (UNIFESP), Sao Paulo, Brazil
| | - Margarida de Fátima Fernandes Carvalho
- Rare Diseases Committee, Brazilian Society of Rheumatology (SBR), Rio de Janeiro, Brazil
- Division of Pediatric Rheumatology, Universidade Estadual de Londrina (UEL), Paraná, Brazil
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Zhu D, Ying S, Yang C, Li S, Tang S, Sun C, Fang H, Qiao J. Clinical features of macrophage activation syndrome in adult dermatomyositis: A single-center retrospective case-control study. Immun Inflamm Dis 2024; 12:e1141. [PMID: 38270325 PMCID: PMC10777878 DOI: 10.1002/iid3.1141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 12/18/2023] [Accepted: 12/24/2023] [Indexed: 01/26/2024] Open
Abstract
BACKGROUND Little is known about the features of macrophage activation syndrome (MAS) in dermatomyositis, especially the association between rapidly progressive interstitial lung disease (RP-ILD) and MAS. OBJECTIVE To determine the characteristics of MAS in patients with dermatomyositis and their association with RP-ILD. METHODS This was a retrospective cohort study of 201 dermatomyositis patients at the First Affiliated Hospital of Zhejiang University over a 10-year period. RESULTS A total of 22 (10.9%) patients were diagnosed with MAS. The rate of RP-ILD was significantly higher in patients with MAS than in those without MAS (81.8% vs. 17.4%, respectively, p < .001). Multivariate analysis indicated that RP-ILD (p = .019), ferritin level > 1685 ng/mL (p = .007) and hemoglobin < 100 g/L (p = .001) were independent risk factors for MAS. Furthermore, RP-ILD patients with MAS presented more cardiac injury (50.0% vs. 13.3%, respectively, p < .009), central nervous system dysfunction (42.8% vs. 3.4%, respectively, p < .001) and hemorrhage (38.9% vs. 3.3%, respectively, p = .003) than RP-ILD patients without MAS. The 90-day cumulative survival rate for patients with MAS was significantly lower than for those without MAS (18.2% vs. 82.1%, respectively, p < .001). CONCLUSION MAS was a common and fatal complication of dermatomyositis in our cohort. MAS is closely related to RP-ILD in patients with dermatomyositis. When RP-ILD is present in dermatomyositis patients with abnormal laboratory findings, such as cytopenia and hyperferritinemia, the presence of MAS should be considered.
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Affiliation(s)
- Dingxian Zhu
- Department of Dermatology, The First Affiliated HospitalZhejiang University School of MedicineHangzhouChina
| | - Shuni Ying
- Department of Dermatology, The First Affiliated HospitalZhejiang University School of MedicineHangzhouChina
| | - Changyi Yang
- Department of Dermatology, The First Affiliated HospitalZhejiang University School of MedicineHangzhouChina
| | - Sheng Li
- Department of Dermatology, The First Affiliated HospitalZhejiang University School of MedicineHangzhouChina
| | - Shunli Tang
- Department of Dermatology, The First Affiliated HospitalZhejiang University School of MedicineHangzhouChina
| | - Chuanyin Sun
- Department of Rheumatology, The First Affiliated HospitalZhejiang University School of MedicineHangzhouChina
| | - Hong Fang
- Department of Dermatology, The First Affiliated HospitalZhejiang University School of MedicineHangzhouChina
| | - Jianjun Qiao
- Department of Dermatology, The First Affiliated HospitalZhejiang University School of MedicineHangzhouChina
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Zhang J, Sun L, Shi X, Li S, Liu C, Li X, Lu M, Deng J, Tan X, Guan W, Li G, Wen X, Liu P, Li C. Janus kinase inhibitor, tofacitinib, in refractory juvenile dermatomyositis: a retrospective multi-central study in China. Arthritis Res Ther 2023; 25:204. [PMID: 37853451 PMCID: PMC10583374 DOI: 10.1186/s13075-023-03170-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Accepted: 09/13/2023] [Indexed: 10/20/2023] Open
Abstract
OBJECTIVES Juvenile dermatomyositis (JDM) is a chronic autoimmune disease. Some patients remain in an active state even though they were administrated with a combination of corticosteroid and methotrexate. Existing research has suggested that interferon and Janus kinase played an important role in pathogenesis. Existing research has suggested the efficacy of JAK inhibitors (JAKi). Our retrospective study aimed to investigate the efficacy of tofacitinib in refractory JDM patients. METHODS A total of eighty-eight patients in China who had been diagnosed with JDM and subjected to tofacitinib therapy for over 3 months were retrospectively analyzed. Skin and muscle manifestations were assessed using the Cutaneous Assessment Tool-binary method (CAT-BM), Childhood Myositis Assessment Scale (CMAS), and kinase. Pulmonary function was assessed using a high-resolution CT (computerized tomography) scan and pulmonary symptoms. All patients were subjected to regular follow-up, and core measures were assessed every 3 months after initiation. Furthermore, the data were analyzed using the Wilcoxon single test, Mann-Whitney U test, and chi-square test. RESULTS Compared with the baseline data, skin and muscle manifestations were found significantly improved during the respective follow-up visit. At the most recent follow-up, nearly 50% of patients achieved a clinical complete response and six patients received tofacitinib monotherapy. Sixty percent of patients suffering from interstitial lung disease well recovered on high-resolution CT. Seventy-five percent of patients showed a reduction in the size or number of calcinosis, and 25% of patients showed completely resolved calcinosis. CONCLUSION In this study, the result suggested that tofacitinib therapy exerted a certain effect on skin manifestations, muscle manifestations, interstitial lung disease (ILD), calcinosis, as well as downgrade of medication. In-depth research should be conducted to focus on the correlation between the pathogenesis of JDM and JAKi.
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Affiliation(s)
- Junmei Zhang
- Department of Rheumatology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, 100045, China
| | - Li Sun
- Department of Rheumatology, Children's Hospital of Fudan University, National Children's Medical Center, No. 399 Wanyuan Road, Shanghai, 201102, China
| | - XinWei Shi
- Department of Rheumatology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, 100045, China
| | - Shipeng Li
- Department of Rheumatology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, 100045, China
| | - Cuihua Liu
- Department of Nephrology and Rheumatology, Children's Hospital Affiliated to Zhengzhou University, Zhengzhou, 450018, China
- Department of Nephrology and Rheumatology, Henan Children's Hospital, Zhengzhou Children's Hospital, Zhengzhou, 450018, China
| | - Xiaoqing Li
- Department of Rheumatology and Immunology, Xi'an Children's Hospital, Xi'an, 710002, China
| | - Meiping Lu
- Department of Rheumatology Immunology and Allergy, Children's Hospital of Zhejiang University School of Medicine, Hangzhou, 310003, China
| | - Jianghong Deng
- Department of Rheumatology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, 100045, China
| | - Xiaohua Tan
- Department of Rheumatology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, 100045, China
| | - Wanzhen Guan
- Department of Rheumatology, Children's Hospital of Fudan University, National Children's Medical Center, No. 399 Wanyuan Road, Shanghai, 201102, China
| | - Guomin Li
- Department of Rheumatology, Children's Hospital of Fudan University, National Children's Medical Center, No. 399 Wanyuan Road, Shanghai, 201102, China
| | - Xinran Wen
- Department of Rheumatology and Immunology, Xi'an Children's Hospital, Xi'an, 710002, China
| | - Ping Liu
- Department of Nephrology and Rheumatology, Children's Hospital Affiliated to Zhengzhou University, Zhengzhou, 450018, China
- Department of Nephrology and Rheumatology, Henan Children's Hospital, Zhengzhou Children's Hospital, Zhengzhou, 450018, China
| | - Caifeng Li
- Department of Rheumatology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, 100045, China.
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Chang Y, Shan X, Ge Y. Macrophage activation syndrome in juvenile dermatomyositis: a case report and a comprehensive review of the literature. Pediatr Rheumatol Online J 2023; 21:106. [PMID: 37735702 PMCID: PMC10515226 DOI: 10.1186/s12969-023-00893-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 09/06/2023] [Indexed: 09/23/2023] Open
Abstract
BACKGROUND Macrophage activation syndrome (MAS) is a severe and life-threatening syndrome associated with autoimmune diseases. The coexistence of MAS and juvenile dermatomyositis (JDM) is not well reported. This report describes a case of JDM with MAS and summarizes the clinical characteristics and prognosis of MAS in patients with JDM. CASE PRESENTATION The patient was a 15-year-old female with JDM, presenting with heliotrope rash, muscle weakness, increased muscle enzyme, anti-nuclear matrix protein 2 (NXP2) antibody, and muscle biopsy consistent with JDM. The patient developed fever, cytopenia, and hyperferritinemia three months after the first manifestations. Hemophagocytosis was found in the bone marrow. The final diagnosis was JDM combined with MAS. Despite intensive treatment, the patient died of MAS. By reviewing the literature, we found 17 similar cases. Together with the present case, 18 patients were identified, the median age of disease onset was 13.5 years, and male to female ratio was 1.25: 1. Nine out of 16 (56.3%) patients were complicated with interstitial lung disease (ILD). The median time interval between JDM onset and MAS diagnosis was 9 weeks. At the onset of MAS, all (100%) patients had elevated levels of ferritin and serum liver enzymes. Among 18 patients, 14 (77.8%) had fever, 14/17 (82.4%) had cytopenia, 11/11 (100%) had hepatosplenomegaly, and 13/14 (92.9%) had hemophagocytosis. Five (27.8%) patients showed central nervous system (CNS) involvement. The mortality of MAS rate of in patients with JDM was 16.7%, despite various treatment methods. CONCLUSION . The coexistence of JDM and MAS is underestimated with increased mortality. Hepatosplenomegaly and increased serum levels of ferritin in patients with JDM should raise clinical suspicion for MAS.
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Affiliation(s)
- Yong Chang
- Department of Rheumatology, Tianshui Hospital of Traditional Chinese Medicine, Tianshui, China
| | - Xueyan Shan
- Department of Rheumatology, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
- Beijing University of Chinese Medicine, Beijing, China
| | - Yongpeng Ge
- Department of Rheumatology, Key Laboratory of Myositis, China-Japan Friendship Hospital, Beijing, China.
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Gibbs E, Khojah A, Morgan G, Ehwerhemuepha L, Pachman LM. The von Willebrand Factor Antigen Reflects the Juvenile Dermatomyositis Disease Activity Score. Biomedicines 2023; 11:biomedicines11020552. [PMID: 36831088 PMCID: PMC9953073 DOI: 10.3390/biomedicines11020552] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Revised: 02/03/2023] [Accepted: 02/06/2023] [Indexed: 02/16/2023] Open
Abstract
OBJECTIVE This study determined if an accessible, serologic indicator of vascular disease activity, the von Willebrand factor antigen (vWF:Ag), was useful to assess disease activity in children with juvenile dermatomyositis (JDM), a rare disease, but the most common of the pediatric inflammatory myopathies. METHODS A total of 305 children, median age 10 years, 72.5% female, 76.5% white, with definite/probable JDM at diagnosis, were enrolled in the Ann & Robert H. Lurie Cure JM Juvenile Myositis Repository, a longitudinal database. Disease Activity Score (DAS) and vWF:Ag data were obtained at each visit. These data were analyzed using generalized estimating equation (GEE) models (both linear and logistic) to determine if vWF:Ag reflects disease severity in children with JDM. A secondary analysis was performed for untreated active JDM to exclude the effect of medications on vWF:Ag. RESULT The vWF:Ag test was elevated in 25% of untreated JDM. We found that patients with elevated vWF:Ag had a 2.55-fold higher DAS total (CI95: 1.83-3.27, p < 0.001). Patients with difficulty swallowing had 2.57 higher odds of elevated vWF:Ag (CI95: 1.5-4.38, p < 0.001); those with more generalized skin involvement had 2.58-fold higher odds of elevated vWF:Ag (CI95: 1.27-5.23, p = 0.006); and those with eyelid peripheral blood vessel dilation had 1.32-fold higher odds of elevated vWF:Ag (CI95: 1.01-1.72, p = 0.036). Untreated JDM with elevated vWF:Ag had more muscle weakness and higher muscle enzymes, neopterin and erythrocyte sedimentation rate compared to JDM patients with a normal vWF:Ag. CONCLUSION vWF:Ag elevation is a widely accessible concomitant of active disease in 25% of JDM.
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Affiliation(s)
- Ellie Gibbs
- Department of Biological Sciences, Wellesley College, Wellesley, MA 02481, USA
| | - Amer Khojah
- Department of Pediatrics, College of Medicine, Umm Al-Qura University, Makkah 21421, Saudi Arabia
| | - Gabrielle Morgan
- Division of Pediatric Rheumatology, Ann & Robert H. Lurie Children’s Hospital of Chicago, Cure-JM Center of Excellence in Juvenile Myositis Research and Care, Chicago, IL 60611, USA
| | - Louis Ehwerhemuepha
- Computational Research, Children’s Hospital of Orange County Research Institute, Orange, CA 92868, USA
| | - Lauren M. Pachman
- Division of Pediatric Rheumatology, Ann & Robert H. Lurie Children’s Hospital of Chicago, Cure-JM Center of Excellence in Juvenile Myositis Research and Care, Chicago, IL 60611, USA
- Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA
- Correspondence:
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Mouri M, Kanamori T, Tanaka E, Hiratoko K, Okubo M, Inoue M, Morio T, Shimizu M, Nishino I, Okiyama N, Mori M. Hepatic veno-occlusive disease accompanied by thrombotic microangiopathy developing during treatment of juvenile dermatomyositis and macrophage activation syndrome: A case report. Mod Rheumatol Case Rep 2022:rxac086. [PMID: 36416547 DOI: 10.1093/mrcr/rxac086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Revised: 06/28/2022] [Accepted: 11/22/2022] [Indexed: 06/16/2023]
Abstract
Hepatic veno-occlusive disease (VOD) is a complication of hematopoietic stem cell transplantation (HSCT). VOD is associated with the occurrence of thrombotic microangiopathy (TMA). In HSCT, VOD and TMA are endothelial syndromes resulting from endothelial cell activation and dysfunction. In rheumatic disease, while TMA is not rare, there are few reports of VOD. In idiopathic myositis, only one case with VOD and TMA complications has been reported, there are no published cases in juvenile dermatomyositis (JDM). We report a case of JDM manifesting VOD and TMA complications during treatment for myositis and macrophage activation syndrome (MAS). A 5-year-old boy diagnosed as anti-nuclear matrix protein 2 antibody-positive JDM was complicated by MAS. He received pulsed methylprednisolone, prednisolone, and tacrolimus, but JDM and MAS progressed. He was then treated with intravenous cyclophosphamide (CY) and cyclosporine A (CsA), with improvement in myositis symptoms and MAS. After initiation of CY and CsA, he developed hemolysis, painful hepatomegaly, liver damage, and ascites. He was diagnosed with VOD and TMA. CY and CsA were discontinued, with recovery from VOD and TMA. The patient remained well on treatment with methotrexate, without any relapse of JDM and MAS to date. The presence of vasculopathy and hypercytokinemia because of JDM and MAS exacerbated endothelial cell damage. In the present case, we suggest that the main cause of VOD was medication with CY and CsA, which had been used to treat acute exacerbation of MAS and JDM.
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Affiliation(s)
- Mariko Mouri
- Department of Lifetime Clinical Immunology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
- Department of pediatrics, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Toru Kanamori
- Department of pediatrics, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Eriko Tanaka
- Department of Pediatrics, Kyorin University School of Medicine, Tokyo, Japan
| | | | - Mariko Okubo
- Department of Neuromuscular Research, National Institute of Neuroscience, National Center of Neurology and Psychiatry, Tokyo, Japan
| | - Michio Inoue
- Department of Neuromuscular Research, National Institute of Neuroscience, National Center of Neurology and Psychiatry, Tokyo, Japan
| | - Tomohiro Morio
- Department of pediatrics, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Masaki Shimizu
- Department of Pediatrics, School of Medicine, Institute of Medical, Pharmaceutical, and Health Sciences, Kanazawa University, Ishikawa, Japan
| | - Ichizo Nishino
- Department of Neuromuscular Research, National Institute of Neuroscience, National Center of Neurology and Psychiatry, Tokyo, Japan
- Department of Genome Medicine Development, Medical Genome Center, National Center of Neurology and Psychiatry, Tokyo, Japan
| | - Naoko Okiyama
- Department of Child Health and Development, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Masaaki Mori
- Department of Lifetime Clinical Immunology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
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Pakhchanian H, Khan H, Raiker R, Ahmed S, Kavadichanda C, Abbasi M, Kardeş S, Agarwal V, Aggarwal R, Gupta L. COVID-19 outcomes in patients with Dermatomyositis: A registry-based cohort analysis. Semin Arthritis Rheum 2022; 56:152034. [PMID: 35750526 PMCID: PMC9142211 DOI: 10.1016/j.semarthrit.2022.152034] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 05/09/2022] [Accepted: 05/24/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND Patients with rheumatic diseases (RDs) like DM are known to be vulnerable towards various types of infections due to aggressive disease activity mandating high dose immunosuppressive therapy. The severity of COVID-19 in RDs is limited in literature due to the heterogeneous nature of the condition. Therefore, specific details on mortality is essential to navigate any precautions required in the treatment. OBJECTIVES To determine outcomes of COVID-19 in DM as compared to controls, and identify the risk association of gender, race, interstitial lung disease, neoplasms, and use of immunosuppressant. METHODS Retrospective data of individuals with DM and COVID-19 and the general population with COVID-19 between January 2020 to August 2021 was retrieved from the TriNetX database. 1:1 Propensity Score matching was used to adjust for confounders. We assessed COVID-19 outcomes such as mortality, hospitalisation, ICU admission, severe COVID-19, mechanical ventilation (MV), acute kidney injury (AKI), venous thromboembolism (VTE), ischemic stroke, acute respiratory distress syndrome (ARDS), renal replacement therapy (RRT) and sepsis. Subgroup analyses included gender, race, ILD, cancer patients, disease-modifying rheumatic drugs (DMARDs) use, and glucocorticoids (GC) use. RESULTS We identified 5,574 DM patients with COVID-19, and 5,574 general population with COVID-19 (controls). DM with COVID-19 had a lower risk of mortality in comparison to controls [RR 0.76], hospitalisation [RR 0.8], severe COVID-19 [RR 0.76], AKI [RR 0.83], and sepsis [RR 0.73]. Males and African Americans were more likely to develop AKI [RR 1.35, 1.65], while African Americans had higher odds for severe COVID-19 [RR 1.62] and VTE [RR 1.54]. DM with ILD group also experienced higher odds for severe COVID-19 infection [RR 1.64], and VTE [RR 2.06]. DM patients receiving DMARDs and glucocorticoids had higher odds for hospitalisation [RR 1.46, 2.12], and sepsis [RR 3.25, 2.4] Subgroup analysis of 5-year neoplasm history amongst DM patients with COVID-19 was inadequate for meaningful comparison. CONCLUSION Dermatomyositis patients without comorbities have reasonable COVID-19 outcomes including mortality and hospitalisation. Black race, male gender, ILD, DMARDS and glucocorticoid users, are associated with poor outcomes.
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Affiliation(s)
- Haig Pakhchanian
- George Washington School of Medicine & Health Sciences, Washington DC, USA
| | | | - Rahul Raiker
- West Virginia University School of Medicine, Morgantown, West Virginia, USA
| | - Sakir Ahmed
- Department of Clinical Immunology and Rheumatology, Kalinga Institute of Medical Sciences (KIMS), KIIT University, Bhubaneswar, India
| | - Chengappa Kavadichanda
- Department of Clinical Immunology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | | | - Sinan Kardeş
- Department of Medical Ecology and Hydroclimatology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Vikas Agarwal
- Department of Clinical Immunology and Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGI), Lucknow, Uttar Pradesh, India
| | - Rohit Aggarwal
- Division of Clinical Immunology and Rheumatology, Department of Medicine, University of Pittsburgh, PA, USA
| | - Latika Gupta
- Department of Clinical Immunology and Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGI), Lucknow, Uttar Pradesh, India,Department of Rheumatology, Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, UK,Division of Musculoskeletal and Dermatological Sciences, Centre for Musculoskeletal Research, School of Biological Sciences, The University of Manchester, Manchester, UK.,City Hospital, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK,Corresponding author at: Department of Clinical Immunology and Rheumatology Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226014, India
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9
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Ding Y, Ge Y. Anti-melanoma differentiation-associated gene 5 antibody-positive dermatomyositis complicated with macrophage activation syndrome. Ther Adv Chronic Dis 2022; 13:20406223221098128. [PMID: 35586303 PMCID: PMC9109495 DOI: 10.1177/20406223221098128] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Accepted: 04/13/2022] [Indexed: 12/31/2022] Open
Abstract
Background: Anti-melanoma differentiation-associated gene 5 (anti-MDA5) antibody-positive
dermatomyositis (DM) has low survival rate, whereas macrophage activation
syndrome (MAS) is a severe and life-threatening syndrome associated with
autoimmune diseases. Their coexistence is very rare. This study aimed to
describe the prevalence, clinical characteristics, and outcomes of anti-MDA5
antibodies-positive DM patients complicated with MAS. Methods: In this retrospective study, we enrolled DM patients with anti-MDA5
antibodies, who were hospitalized between 2016 and 2020 and included
patients diagnosed with MAS. Results: We identified four (2%) DM patients with anti-MDA5 antibodies. They were
females with interstitial lung disease (ILD). The level of aspartate
aminotransferase (AST), lactate dehydrogenase (LDH), and ferritin were
significantly higher in the MAS group than those without MAS
(p < 0.05). Patients with MAS were significantly
more likely to develop a dysphagia (p = 0.012). Literature
review revealed eight similar cases. Together with the present study, we
identified 12 patients complicated with ILD. The median age of disease onset
was 52 years with a male to female ratio of 1:6. The median duration between
DM onset and MAS diagnosis was 3 months. The mortality of MAS in anti-MDA5
antibody-positive DM was 50%. Patients who died were older than those who
survived (56.7 years versus 35.5 years;
p = 0.015). Conclusions: MAS was rare in anti-MDA5 antibody-positive DM. The higher the level of AST,
LDH, and ferritin, the greater the risk of MAS. They were associated with
high mortality rates, particularly in older patients.
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Affiliation(s)
- Yukang Ding
- Department of Rheumatology, The Affiliated Hospital of Jiangxi University of Traditional Chinese Medicine, Nanchang, China
| | - Yongpeng Ge
- Department of Rheumatology, Key Laboratory of Myositis, China-Japan Friendship Hospital, Yinghua East Road, Chaoyang District, 100029 Beijing, China
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10
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Wang YT, Zhang Y, Tang T, Luo C, Liu MY, Xu L, Wang L, Tang XM. Anti-nuclear matrix protein 2+ juvenile dermatomyositis with severe skin ulcer and infection: A case report and literature review. World J Clin Cases 2022; 10:3579-3586. [PMID: 35611208 PMCID: PMC9048553 DOI: 10.12998/wjcc.v10.i11.3579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Revised: 02/07/2022] [Accepted: 02/27/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Juvenile dermatomyositis (JDM) is an idiopathic inflammatory myopathy that occurs in childhood. It is characterized by muscle weakness and a characteristic rash. Previous literature reports have rarely described JDM with severe skin ulcers and infections.
CASE SUMMARY Herein, we describe a case of a 2-year-old female patient who suffered from JDM, whose myositis-specific autoantibodies were positive for anti-nuclear matrix protein 2 antibody, with progressively worsening skin ulcers and severe infections. The patient was treated with glucocorticoids and various immunosuppressants. Nevertheless, further progression of the disease and the combination of primary disease and severe infection in the later period were fatal.
CONCLUSION In children, anti-nuclear matrix protein 2+ JDM combined with skin ulcers often indicates severe disease. In such cases, personalized treatment for the primary disease and infection prevention and control are essential.
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Affiliation(s)
- Ya-Ting Wang
- Department of Rheumatology and Immunology; Ministry of Education Key Laboratory of Child Development and Disorders; National Clinical Research Center for Child Health and Disorders (Chongqing); China International Science and Technology Cooperation base of Child Development and Critical Disorders; Children’s Hospital of Chongqing Medical University, Chongqing 400014, China
- Chongqing Key Laboratory of Child Infection and Immunity, Children’s Hospital of Chongqing Medical University, Chongqing 400014, China
| | - Yu Zhang
- Department of Rheumatology and Immunology; Ministry of Education Key Laboratory of Child Development and Disorders; National Clinical Research Center for Child Health and Disorders (Chongqing); China International Science and Technology Cooperation base of Child Development and Critical Disorders; Children’s Hospital of Chongqing Medical University, Chongqing 400014, China
- Chongqing Key Laboratory of Child Infection and Immunity, Children’s Hospital of Chongqing Medical University, Chongqing 400014, China
| | - Tao Tang
- Department of Rheumatology and Immunology; Ministry of Education Key Laboratory of Child Development and Disorders; National Clinical Research Center for Child Health and Disorders (Chongqing); China International Science and Technology Cooperation base of Child Development and Critical Disorders; Children’s Hospital of Chongqing Medical University, Chongqing 400014, China
- Chongqing Key Laboratory of Child Infection and Immunity, Children’s Hospital of Chongqing Medical University, Chongqing 400014, China
| | - Chong Luo
- Department of Rheumatology and Immunology; Ministry of Education Key Laboratory of Child Development and Disorders; National Clinical Research Center for Child Health and Disorders (Chongqing); China International Science and Technology Cooperation base of Child Development and Critical Disorders; Children’s Hospital of Chongqing Medical University, Chongqing 400014, China
- Chongqing Key Laboratory of Child Infection and Immunity, Children’s Hospital of Chongqing Medical University, Chongqing 400014, China
| | - Ming-Yue Liu
- Department of Rheumatology and Immunology; Ministry of Education Key Laboratory of Child Development and Disorders; National Clinical Research Center for Child Health and Disorders (Chongqing); China International Science and Technology Cooperation base of Child Development and Critical Disorders; Children’s Hospital of Chongqing Medical University, Chongqing 400014, China
- Chongqing Key Laboratory of Child Infection and Immunity, Children’s Hospital of Chongqing Medical University, Chongqing 400014, China
| | - Li Xu
- Department of Rheumatology and Immunology; Ministry of Education Key Laboratory of Child Development and Disorders; National Clinical Research Center for Child Health and Disorders (Chongqing); China International Science and Technology Cooperation base of Child Development and Critical Disorders; Children’s Hospital of Chongqing Medical University, Chongqing 400014, China
- Chongqing Key Laboratory of Child Infection and Immunity, Children’s Hospital of Chongqing Medical University, Chongqing 400014, China
| | - Li Wang
- Department of Rheumatology and Immunology; Ministry of Education Key Laboratory of Child Development and Disorders; National Clinical Research Center for Child Health and Disorders (Chongqing); China International Science and Technology Cooperation base of Child Development and Critical Disorders; Children’s Hospital of Chongqing Medical University, Chongqing 400014, China
- Chongqing Key Laboratory of Child Infection and Immunity, Children’s Hospital of Chongqing Medical University, Chongqing 400014, China
| | - Xue-Mei Tang
- Department of Rheumatology and Immunology; Ministry of Education Key Laboratory of Child Development and Disorders; National Clinical Research Center for Child Health and Disorders (Chongqing); China International Science and Technology Cooperation base of Child Development and Critical Disorders; Children’s Hospital of Chongqing Medical University, Chongqing 400014, China
- Chongqing Key Laboratory of Child Infection and Immunity, Children’s Hospital of Chongqing Medical University, Chongqing 400014, China
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11
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Rossano M, Rogani G, D’Errico MM, Cucchetti M, Baldo F, Torreggiani S, Beretta G, Lanni S, Petaccia A, Agostoni C, Filocamo G, Minoia F. Infection-Triggered Hyperinflammatory Syndromes in Children. CHILDREN 2022; 9:children9040564. [PMID: 35455608 PMCID: PMC9025340 DOI: 10.3390/children9040564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 04/08/2022] [Accepted: 04/12/2022] [Indexed: 12/02/2022]
Abstract
An association between infectious diseases and macrophage activation syndrome (MAS) has been reported, yet the exact role of infection in MAS development is still unclear. Here, a retrospective analysis of the clinical records of patients with rheumatic diseases complicated with MAS who were treated in a pediatric tertiary care center between 2011 and 2020 was performed. Any infection documented within the 30 days preceding the onset of MAS was reported. Out of 125 children in follow-up for systemic rheumatic diseases, 12 developed MAS, with a total of 14 episodes. One patient experienced three episodes of MAS. Clinical and/or laboratory evidence of infection preceded the onset of MAS in 12 events. Clinical features, therapeutic strategies, and patient outcomes were described. The aim of this study was to evaluate the possible role of infection as a relevant trigger for MAS development in children with rheumatic conditions. The pathogenetic pathways involved in the cross-talk between uncontrolled inflammatory activity and the immune response to infection deserve further investigation.
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Affiliation(s)
- Martina Rossano
- Pediatric Rheumatology, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milano IT and University of Milan, 20122 Milan, Italy; (M.R.); (G.R.); (M.C.); (F.B.); (S.T.); (G.B.); (S.L.); (A.P.); (C.A.); (F.M.)
| | - Greta Rogani
- Pediatric Rheumatology, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milano IT and University of Milan, 20122 Milan, Italy; (M.R.); (G.R.); (M.C.); (F.B.); (S.T.); (G.B.); (S.L.); (A.P.); (C.A.); (F.M.)
| | - Maria Maddalena D’Errico
- Department of Medical Sciences, IRCCS Casa Sollievo della Sofferenza, 71013 San Giovanni Rotondo, Italy;
| | - Martina Cucchetti
- Pediatric Rheumatology, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milano IT and University of Milan, 20122 Milan, Italy; (M.R.); (G.R.); (M.C.); (F.B.); (S.T.); (G.B.); (S.L.); (A.P.); (C.A.); (F.M.)
| | - Francesco Baldo
- Pediatric Rheumatology, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milano IT and University of Milan, 20122 Milan, Italy; (M.R.); (G.R.); (M.C.); (F.B.); (S.T.); (G.B.); (S.L.); (A.P.); (C.A.); (F.M.)
| | - Sofia Torreggiani
- Pediatric Rheumatology, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milano IT and University of Milan, 20122 Milan, Italy; (M.R.); (G.R.); (M.C.); (F.B.); (S.T.); (G.B.); (S.L.); (A.P.); (C.A.); (F.M.)
| | - Gisella Beretta
- Pediatric Rheumatology, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milano IT and University of Milan, 20122 Milan, Italy; (M.R.); (G.R.); (M.C.); (F.B.); (S.T.); (G.B.); (S.L.); (A.P.); (C.A.); (F.M.)
| | - Stefano Lanni
- Pediatric Rheumatology, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milano IT and University of Milan, 20122 Milan, Italy; (M.R.); (G.R.); (M.C.); (F.B.); (S.T.); (G.B.); (S.L.); (A.P.); (C.A.); (F.M.)
| | - Antonella Petaccia
- Pediatric Rheumatology, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milano IT and University of Milan, 20122 Milan, Italy; (M.R.); (G.R.); (M.C.); (F.B.); (S.T.); (G.B.); (S.L.); (A.P.); (C.A.); (F.M.)
| | - Carlo Agostoni
- Pediatric Rheumatology, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milano IT and University of Milan, 20122 Milan, Italy; (M.R.); (G.R.); (M.C.); (F.B.); (S.T.); (G.B.); (S.L.); (A.P.); (C.A.); (F.M.)
| | - Giovanni Filocamo
- Pediatric Rheumatology, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milano IT and University of Milan, 20122 Milan, Italy; (M.R.); (G.R.); (M.C.); (F.B.); (S.T.); (G.B.); (S.L.); (A.P.); (C.A.); (F.M.)
- Correspondence:
| | - Francesca Minoia
- Pediatric Rheumatology, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milano IT and University of Milan, 20122 Milan, Italy; (M.R.); (G.R.); (M.C.); (F.B.); (S.T.); (G.B.); (S.L.); (A.P.); (C.A.); (F.M.)
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12
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Stewart JA, Price T, Moser S, Mullikin D, Bryan A. Progressive, refractory macrophage activation syndrome as the initial presentation of anti-MDA5 antibody positive juvenile dermatomyositis: a case report and literature review. Pediatr Rheumatol Online J 2022; 20:16. [PMID: 35193600 PMCID: PMC8861992 DOI: 10.1186/s12969-022-00675-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Accepted: 02/06/2022] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Macrophage activation syndrome (MAS) is a severe and under-recognized complication of rheumatologic diseases. We describe a patient who presented with rapidly progressive, refractory MAS found to have anti-MDA5 antibody Juvenile Dermatomyositis (JDM) as her underlying rheumatologic diagnosis. CASE PRESENTATION We describe a 14-year-old female who at the time of admission had a history of daily fevers for 6 weeks and an unintentional sixteen-pound weight loss. Review of systems was significant for cough, shortness of breath, chest pain, headaches, sore throat, muscle aches, rash, nausea, and loss of appetite. An extensive initial workup revealed findings consistent with an autoimmune process. While awaiting results of her workup she had clinical decompensation with multi-organ system involvement including pancytopenias, interstitial lung disease, hepatitis, cardiac involvement, gastrointestinal distension and pain, feeding intolerance, extensive mucocutaneous candidiasis, and neuropsychiatric decline. Due to her decompensation, significant interstitial lung disease, and likely underlying rheumatologic condition she was started on high dose pulse steroids and mycophenolate. An MRI was performed due to her transaminitis and shoulder pain revealing significant myositis. Intravenous immunoglobulin was then initiated. The myositis antibody panel sent early in her workup was significant for anti-MDA5 and anti-SSA-52 antibodies. Despite high dose pulse steroids, mycophenolate, and IVIG, her disease progressed requiring escalating therapies. Ultimately, she responded with resolution of her MAS as well as significant and steady improvement in her feeding intolerance, interstitial lung disease, cardiac dysfunction, myositis, arthritis, and cutaneous findings. CONCLUSIONS JDM in the pediatric patient is rare, as is MAS. In patients with complex rheumatologic conditions and lack of response to treatment, it is important to continually assess the patient's clinical status with MAS in mind, as this may change the treatment approach. Without proper recognition of this complication, patients can have a significant delay in diagnosis leading to life-threatening consequences.
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Affiliation(s)
- J Alex Stewart
- Tripler Army Medical Center Department of Pediatrics, Honolulu, HI, USA.
| | - Theresa Price
- Tripler Army Medical Center Department of Pediatrics, Honolulu, HI, USA
| | - Sam Moser
- Tripler Army Medical Center Department of Pediatrics, Honolulu, HI, USA
| | - Dolores Mullikin
- Tripler Army Medical Center Department of Pediatrics, Honolulu, HI, USA
| | - Angela Bryan
- Madigan Army Medical Center Department of Pediatrics, Honolulu, HI, USA
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13
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Zhao S, Ma X, Zhang X, Jin Z, Hu W, Hua B, Wang H, Feng X, Sun L, Chen Z. Clinical significance of HScore and MS score comparison in the prognostic evaluation of anti-MDA5-positive patients with dermatomyositis and interstitial lung disease. Mod Rheumatol 2021; 32:373-379. [PMID: 34894256 DOI: 10.1093/mr/roab017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Revised: 03/13/2021] [Accepted: 05/29/2021] [Indexed: 11/12/2022]
Abstract
OBJECTIVES To evaluate the clinical significance of the HScore and MS score in the prognosis of anti-melanoma differentiation-associated gene 5 (MDA5) positive patients with dermatomyositis (DM) and interstitial lung disease (ILD). METHODS The clinical features as well as HScore and MS score were compared between the survivors (n = 61) and nonsurvivors (n = 36) among 97 anti-MDA5-positive DM-ILD patients. Potential prognostic factors were analysed. RESULTS Compared with survivors, nonsurvivors had significantly older age, tended to be male, and had a significantly higher frequency of fever at disease onset, higher levels of aspartate transaminase, lactate dehydrogenase, and serum ferritin, as well as higher values of HScore and MS score but had a significantly lower frequency of arthritis at disease onset. Multivariate analysis revealed that age ≥50 years [hazard ratio (HR) = 2.70, p = .040, 95% confidence interval (CI) 1.05-6.97)], male gender (HR = 3.20, p = .017, 95% CI 1.23-8.28), and higher HScore (HR = 3.72, p = .003, 95% CI 1.56-8.86) were independent risk factors for mortality. Patients with more risk factors had significantly poorer survival (p < .001). CONCLUSIONS Older age, high HScore, and male gender are risk factors for poor survival among anti-MDA5-positive DM-ILD patients, suggesting the potential role of macrophage activation in the pathogenesis.
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Affiliation(s)
- Shengnan Zhao
- Department of Rheumatology and Immunology, Drum Tower Clinical Medical College of Nanjing Medical University, Nanjing, China
| | - Xiaolei Ma
- Department of Rheumatology and Immunology, Drum Tower Clinical Medical College of Nanjing Medical University, Nanjing, China
| | - Xin Zhang
- Department of Rheumatology and Immunology, Drum Tower Clinical Medical College of Nanjing Medical University, Nanjing, China
| | - Ziyi Jin
- Department of Rheumatology and Immunology, Drum Tower Clinical Medical College of Nanjing Medical University, Nanjing, China
| | - Wei Hu
- Department of Clinical Laboratory, the Affiliated Drum Tower Hospital, Nanjing University Medical School, Nanjing, China
| | - Bingzhu Hua
- Department of Rheumatology and Immunology, Drum Tower Clinical Medical College of Nanjing Medical University, Nanjing, China
| | - Hong Wang
- Department of Rheumatology and Immunology, Drum Tower Clinical Medical College of Nanjing Medical University, Nanjing, China
| | - Xuebing Feng
- Department of Rheumatology and Immunology, Drum Tower Clinical Medical College of Nanjing Medical University, Nanjing, China
| | - Lingyun Sun
- Department of Rheumatology and Immunology, Drum Tower Clinical Medical College of Nanjing Medical University, Nanjing, China
| | - Zhiyong Chen
- Department of Rheumatology and Immunology, Drum Tower Clinical Medical College of Nanjing Medical University, Nanjing, China
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14
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Abdirakhmanova A, Sazonov V, Mukusheva Z, Assylbekova M, Abdukhakimova D, Poddighe D. Macrophage Activation Syndrome in Pediatric Systemic Lupus Erythematosus: A Systematic Review of the Diagnostic Aspects. Front Med (Lausanne) 2021; 8:681875. [PMID: 34150813 PMCID: PMC8211727 DOI: 10.3389/fmed.2021.681875] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 04/20/2021] [Indexed: 01/12/2023] Open
Abstract
Macrophage Activation Syndrome (MAS) is a very severe complication of different rheumatic diseases, including pediatric Systemic Lupus Erythematosus (pSLE). MAS is not considered as a frequent complication of pSLE; however, its occurrence could be under-estimated and the diagnosis can be challenging. In order to address this issue, we performed a systematic review of the available medical literature, aiming to retrieve all those papers providing diagnostic (clinical/laboratory) data on patients with pSLE-related MAS, in individual or aggregated form. The selected case reports and series provided a pool of 46 patients, accounting for 48 episodes of MAS in total. We re-analyzed these patients in light of the diagnostic criteria for MAS validated in systemic Juvenile Idiopathic Arthritis (sJIA) patients and the preliminary diagnostic criteria for MAS in pSLE, respectively. Five clinical studies were also selected and used to support this analysis. This systematic review confirms that MAS diagnosis in pSLE patients is characterized by several diagnostic challenges, which could lead to delayed diagnosis and/or under-estimation of this complication. Specific criteria should be considered to diagnose MAS in different rheumatic diseases; as regards pSLE, the aforementioned preliminary criteria for MAS in pSLE seem to perform better than the sJIA-related MAS criteria, because of a lower ferritin cut-off.
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Affiliation(s)
- Altynay Abdirakhmanova
- Department of Medicine, Nazarbayev University School of Medicine (NUSOM), Nur-Sultan, Kazakhstan
| | - Vitaliy Sazonov
- Department of Biomedical Sciences, Nazarbayev University School of Medicine (NUSOM), Nur-Sultan, Kazakhstan
| | - Zaure Mukusheva
- Program of Pediatric Rheumatology, Department of Pediatrics, National Research Center for Maternal and Child Health, University Medical Center, Nur-Sultan, Kazakhstan
| | - Maykesh Assylbekova
- Program of Pediatric Rheumatology, Department of Pediatrics, National Research Center for Maternal and Child Health, University Medical Center, Nur-Sultan, Kazakhstan
| | - Diyora Abdukhakimova
- Department of Medicine, Nazarbayev University School of Medicine (NUSOM), Nur-Sultan, Kazakhstan
| | - Dimitri Poddighe
- Department of Medicine, Nazarbayev University School of Medicine (NUSOM), Nur-Sultan, Kazakhstan.,Department of Pediatrics, National Research Center for Maternal and Child Health, University Medical Center, Nur-Sultan, Kazakhstan
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15
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Abstract
Macrophage activation syndrome is a severe yet under-recognized complication encountered in pediatric rheumatology. It manifests as secondary hemophagocytic lymphohistiocytosis leading to a hyper-inflammatory state resulting from an underlying cytokine storm. If unchecked, it may lead to multiorgan failure and mortality. Early diagnosis and timely initiation of specific therapy is pivotal for a successful outcome. This review outlines the key clinical and laboratory features and management of macrophage activation syndrome.
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Affiliation(s)
- Narendra Kumar Bagri
- Division of Pediatric Rheumatology, Department of Pediatrics, AIIMS, New Delhi; India. Correspondence to: Dr Narendra Kumar Bagri, Associate Professor, Division of Pediatric Rheumatology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi 110 027, India.
| | - Latika Gupta
- Department of Clinical Immunology and Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Ethan S Sen
- Department of Pediatric Rheumatology, Great North Children's Hospital, and Faculty of Medical Sciences, Newcastle University, Newcastle Upon Tyne, UK
| | - A V Ramanan
- Department of Pediatric Rheumatology, University Hospitals Bristol NHS Foundation Trust and Translational Health Sciences, University of Bristol, Bristol, UK
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16
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Macrophage activation syndrome in systemic lupus erythematosus and systemic-onset juvenile idiopathic arthritis: a retrospective study of similarities and dissimilarities. Rheumatol Int 2021; 41:625-631. [PMID: 33388903 DOI: 10.1007/s00296-020-04763-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Accepted: 11/25/2020] [Indexed: 01/14/2023]
Abstract
Macrophage activation syndrome (MAS) is a serious complication of rheumatic diseases. Fever and hyperferritinemia are common in active systemic-onset juvenile idiopathic arthritis (sJIA) and cytopenia in active systemic lupus erythematosus (SLE), thus recognizing MAS in them is a challenge. We compared clinical and laboratory parameters, various classification criteria, and outcomes of MAS in SLE and sJIA. Clinical and laboratory data were extracted from case records of patients with clinician diagnosed cases of SLE-MAS (adult and pediatric) and sJIA-MAS, admitted (2004-2018) at a tertiary care hospital. Ravelli, International consensus, HLH-2004, and criteria proposed by Parodi et al. were applied and compared. Among 33 patients (18 females) with MAS, 19 had SLE (7, childhood-onset SLE) and 14 had sJIA. MAS was more likely to be the presenting manifestation of disease in SLE (p < 0.05). There were no differences in the clinical features among them. Patients with SLE-MAS had lower baseline total leucocyte and platelet counts (p < 0.01), whereas patients with sJIA-MAS had significantly higher median CRP (p = 0.002), fall in TLC (p = 0.012), delta ESR/CRP ratio (p = 0.02), and lower fibrinogen level (p = 0.006). Neutrophil-to-lymphocyte ratio, ferritin/CRP ratio, and the number of patients with ferritin/ESR > 80 were similar. Only 6/33(18%) fulfilled the HLH criteria. Criteria meant for sJIA-MAS or SLE-MAS performed well for both diseases and the majority of patients could be diagnosed using them. Two patients died in each group. MAS in SLE and sJIA is more similar than dissimilar in clinical features and outcome. Criteria meant for MAS in sJIA or SLE-MAS performed equally well in both diseases.
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17
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Quintana-Ortega C, Remesal A, Ruiz de Valbuena M, de la Serna O, Laplaza-González M, Álvarez-Rojas E, Udaondo C, Alcobendas R, Murias S. Fatal outcome of anti-MDA5 juvenile dermatomyositis in a paediatric COVID-19 patient: a case report. Mod Rheumatol Case Rep 2021; 5:101-107. [PMID: 33019894 PMCID: PMC8344517 DOI: 10.1080/24725625.2020.1832755] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/17/2023]
Abstract
Anti-melanoma differentiation-associated gene 5 juvenile dermatomyositis (anti-MDA5 JDM) is associated with high risk of developing rapidly progressive interstitial lung disease (RP-ILD). Here we report an 11-year-old girl with anti-MDA5 JDM and RP-ILD which led to a fatal outcome, further aggravated by SARS-CoV-2 infection. She was referred to our hospital after being diagnosed with anti-MDA5 JDM and respiratory failure due to RP-ILD. On admission, fibrobronchoscopy with bronchoalveolar lavage (BAL) revealed Pneumocystis jirovecii infection so treatment with intravenous trimethoprim-sulfamethoxazole was initiated. Due to RP-ILD worsening, immunosuppressive therapy was intensified using methylprednisolone pulses, cyclophosphamide, tofacitinib and intravenous immunoglobulin without response. She developed severe hypoxemic respiratory failure, pneumomediastinum and pneumothorax, further complicated with severe RP-ILD and cervical subcutaneous emphysema. Three real-time RT-PCR for SARS-CoV-2 were made with a negative result. In addition, she was complicated with a secondary hemophagocytic lymphohistiocytosis and a fourth real-time PCR for SARS-CoV-2 performed in BAS sample was positive. Despite aggressive treatment of RP-ILD due to anti-MDA5 JDM, there was no improvement of respiratory failure in the following days and patient developed refractory septic shock and died. Anti-MDA5 JDM patients with RP-ILD have a poor prognosis with a high mortality rate. For this reason, intensive immunosuppressive therapy is essential including the use of promising drugs such as tofacitinib. COVID-19 in children with underlying health conditions like anti-MDA5 JDM may still be at risk for disease and severe complications.
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MESH Headings
- Adenosine Monophosphate/analogs & derivatives
- Adenosine Monophosphate/therapeutic use
- Alanine/analogs & derivatives
- Alanine/therapeutic use
- Anti-Bacterial Agents/therapeutic use
- Antibodies, Monoclonal, Humanized/therapeutic use
- Antiviral Agents/therapeutic use
- Autoantibodies/immunology
- Bronchoscopy
- COVID-19/complications
- COVID-19/therapy
- COVID-19 Nucleic Acid Testing
- Child
- Cyclophosphamide/therapeutic use
- Dermatomyositis/complications
- Dermatomyositis/drug therapy
- Dermatomyositis/immunology
- Disease Progression
- Fatal Outcome
- Female
- Humans
- Hydroxychloroquine/therapeutic use
- Immunocompromised Host
- Immunoglobulins, Intravenous/therapeutic use
- Immunologic Factors/therapeutic use
- Immunosuppressive Agents/therapeutic use
- Interferon-Induced Helicase, IFIH1/immunology
- Lung/diagnostic imaging
- Lung Diseases, Interstitial/complications
- Lung Diseases, Interstitial/diagnostic imaging
- Lung Diseases, Interstitial/immunology
- Lung Diseases, Interstitial/therapy
- Lymphohistiocytosis, Hemophagocytic/etiology
- Lymphohistiocytosis, Hemophagocytic/immunology
- Mediastinal Emphysema/etiology
- Methylprednisolone/therapeutic use
- Piperidines/therapeutic use
- Pneumonia, Pneumocystis/complications
- Pneumonia, Pneumocystis/immunology
- Pneumothorax/etiology
- Pyrimidines/therapeutic use
- Respiratory Insufficiency/etiology
- Respiratory Insufficiency/therapy
- Shock, Septic/etiology
- Subcutaneous Emphysema/etiology
- Tomography, X-Ray Computed
- Trimethoprim, Sulfamethoxazole Drug Combination/therapeutic use
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Affiliation(s)
- Cristian Quintana-Ortega
- Pediatric Rheumatology Department, La Paz Children´s Hospital, Madrid, Spain
- CONTACT Cristian Quintana-Ortega
Pediatric Rheumatology Department, La Paz Children’s Hospital, Paseo de la Castellana, Madrid 261, 28046, Spain
| | - Agustín Remesal
- Pediatric Rheumatology Department, La Paz Children´s Hospital, Madrid, Spain
| | | | - Olga de la Serna
- Pediatric Pulmonology Department, La Paz Children’s Hospital, Madrid, Spain
| | | | | | - Clara Udaondo
- Pediatric Rheumatology Department, La Paz Children´s Hospital, Madrid, Spain
| | - Rosa Alcobendas
- Pediatric Rheumatology Department, La Paz Children´s Hospital, Madrid, Spain
| | - Sara Murias
- Pediatric Rheumatology Department, La Paz Children´s Hospital, Madrid, Spain
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18
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Sag E, Keskin A, Atalay E, Demir S, Cuceoglu MK, Akca UK, Batu ED, Bilginer Y, Ozen S. Performances of the "MS-score" And "HScore" in the diagnosis of macrophage activation syndrome in systemic juvenile idiopathic arthritis patients. Rheumatol Int 2020; 41:87-93. [PMID: 33215249 DOI: 10.1007/s00296-020-04750-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Accepted: 11/03/2020] [Indexed: 10/22/2022]
Abstract
Macrophage activation syndrome (MAS) is a devastating complication of systemic JIA (sJIA), seen in approximately 10-25% of the sJIA patients. A number of criteria have been proposed to differentiate between activation of sJIA and MAS, including HScore and the recently proposed MS-score. This is the first study comparing the performances of MS-score and HScore for the diagnosis of MAS in sJIA patients. Systemic JIA patients followed at Hacettepe University Pediatric Rheumatology Unit were included in the study. Clinical features and laboratory findings at the time when the disease was most active or patients were diagnosed with MAS were recorded retrospectively. HScore and MS-score were calculated and the diagnostic performance for MAS was compared by receiver operating characteristic (ROC) curve analysis. Seventy-one sJIA patients were included (23 MAS, 48 activation). There was no difference in age of onset (median 4.7 vs. 5.0 years) and gender (73.9% vs. 54.2%) between patients who had MAS and sJIA activation. Median MS-score and HScore were higher in the MAS group. ROC curve analysis revealed that the HScore performed slightly better in diagnosing MAS, compared with the MS-score (AUC = 0.965 and 0.901 for HScore and MS-score respectively, P < 0.001). In our cohort, the optimal cut-off for the MS score was ≥ - 1.64 (sensitivity: 91.3%; specificity: 83.8%) and for the HScore it was ≥ 162.5 (sensitivity: 91.3%; specificity: 90.2%). HScore performed slightly better than MS-score for the diagnosis of MAS in our cohort.
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Affiliation(s)
- Erdal Sag
- Department of Pediatric Rheumatology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Armagan Keskin
- Department of Pediatric Rheumatology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Erdal Atalay
- Department of Pediatric Rheumatology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Selcan Demir
- Department of Pediatric Rheumatology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Muserref Kasap Cuceoglu
- Department of Pediatric Rheumatology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Ummusen Kaya Akca
- Department of Pediatric Rheumatology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Ezgi Deniz Batu
- Department of Pediatric Rheumatology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Yelda Bilginer
- Department of Pediatric Rheumatology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Seza Ozen
- Department of Pediatric Rheumatology, Hacettepe University Faculty of Medicine, Ankara, Turkey.
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Schulert GS. The Storm Beneath the Storm: MAS-HLH in Inflammatory Myopathies. J Rheumatol 2020; 47:1461-1463. [PMID: 33004480 DOI: 10.3899/jrheum.191274] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Affiliation(s)
- Grant S Schulert
- G.S. Schulert, MD, PhD, Division of Rheumatology, Cincinnati Children's Hospital Medical Center and Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.
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20
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Zhu DX, Qiao JJ, Fang H. Macrophage activation syndrome as a complication of dermatomyositis: A case report. World J Clin Cases 2020; 8:2339-2344. [PMID: 32548165 PMCID: PMC7281037 DOI: 10.12998/wjcc.v8.i11.2339] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 04/14/2020] [Accepted: 04/28/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Macrophage activation syndrome (MAS) can be a fatal complication of rheumatic disorders, which occurs most commonly in patients with systemic juvenile idiopathic arthritis or systemic lupus erythematosus. It has rarely been reported in patients with dermatomyositis. Here, we describe a fatal case of MAS that developed in an adult patient with dermatomyositis.
CASE SUMMARY A 44-year-old woman was admitted to our hospital with fever, generalized rash and muscle weakness. Fifteen days later, the fever persisted after the use of antibiotics, and repeat blood culture was negative. The patient then exhibited a typical Gottron sign and diffuse erythema on the face and neck, which were consistent with a diagnosis of dermatomyositis. The patient exhibited limb muscle strength of 2, and electromyography was suggestive of muscle-derived damage, which also supported a diagnosis of dermatomyositis. In addition, the patient exhibited high serum ferritin level, cytopenia, liver dysfunction, coagulopathy, enlarged spleen and hypertriglyceridemia, all of which are typical manifestations of MAS. The patient was diagnosed with dermatomyositis complicated by MAS. Although a high dose of methylprednisolone was administered for 15 d, the patient’s condition continued to deteriorate and central nervous system symptoms developed. Eventually, treatment was discontinued, and the patient died.
CONCLUSION MAS is an important, potentially fatal, complication of dermatomyositis. Although MAS is rare in dermatomyositis, it should be considered in the differential diagnosis of an unexplained change of hemoglobin, platelet, fibrinogen, ferritin and triglyceride, which may complicate dermatomyositis.
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Affiliation(s)
- Ding-Xian Zhu
- Department of Dermatology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou 310003, Zhejiang Province, China
| | - Jian-Jun Qiao
- Department of Dermatology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou 310003, Zhejiang Province, China
| | - Hong Fang
- Department of Dermatology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou 310003, Zhejiang Province, China
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Griffin G, Shenoi S, Hughes GC. Hemophagocytic lymphohistiocytosis: An update on pathogenesis, diagnosis, and therapy. Best Pract Res Clin Rheumatol 2020; 34:101515. [PMID: 32387063 DOI: 10.1016/j.berh.2020.101515] [Citation(s) in RCA: 136] [Impact Index Per Article: 34.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a rare, life-threatening state of immune hyperactivation that arises in the setting of genetic mutations and infectious, inflammatory, or neoplastic triggers. Sustained, aberrant activation of cytotoxic CD8+ T cells and resultant inflammatory cytokine release are core pathogenic mechanisms. Key clinical features include high persistent fever, hepatosplenomegaly, blood cytopenia, elevated aminotransferase and ferritin levels, and coagulopathy. HLH is likely under-recognized, and mortality remains high, especially in adults; thus, prompt diagnosis and treatment are essential. Familial forms of HLH are currently treated with chemotherapy as a bridge to hematopoietic stem cell transplantation. HLH occurring in rheumatic disease (macrophage activation syndrome) is treated with glucocorticoids, IL-1 blockade, or cyclosporine A. In other forms of HLH, addressing the underlying trigger is essential. There remains a pressing need for more sensitive, context-specific diagnostic tools. Safer, more effective therapies will arise with improved understanding of the cellular and molecular mechanisms of HLH.
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Affiliation(s)
- Georgia Griffin
- Division of Rheumatology, Seattle Children's Hospital, Seattle, WA, USA.
| | - Susan Shenoi
- Division of Rheumatology, Seattle Children's Hospital, Seattle, WA, USA
| | - Grant C Hughes
- Division of Rheumatology, University of Washington, Seattle, WA, USA
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Macrophage activation syndrome in adult dermatomyositis: a case-based review. Rheumatol Int 2020; 40:1151-1162. [PMID: 32356114 DOI: 10.1007/s00296-020-04590-9] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Accepted: 04/18/2020] [Indexed: 12/22/2022]
Abstract
Macrophage activation syndrome (MAS) is a severe and life-threatening syndrome associated with autoimmune diseases, characterized by fever, hepatosplenomegaly, and pancytopenia. Dermatomyositis (DM) is one of the causes of MAS; however, its clinical characteristics in DM patients remain unclear. This study aimed to present a case of anti-melanoma differentiation-associated gene 5 (MDA5) antibody-positive DM complicated by MAS in a 29-year-old woman and to review the literatures including similar cases. Even though symptoms and cytopenia of our patient were refractory to combination therapy, including glucocorticoids, immunosuppressants, and plasma exchange, the administration of rituximab (RTX) resulted in rapid clinical improvement and glucocorticoid reduction. The literature review revealed 18 adult patients with DM associated MAS. Most patients developed MAS within 3 months from DM onset. A monotherapy of glucocorticoid was insufficient to control the disease, and the mortality of MAS in DM was higher than that of MAS in other rheumatic diseases, despite being treated by various means. RTX may be an effective treatment for patients with DM complicated by MAS who are refractory to conventional therapy. Anti-MDA5 antibody could influence the development of MAS; however, further investigations are needed to elucidate the association between myositis-specific antibody and MAS.
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Identification of Potential Biomarkers and Biological Pathways in Juvenile Dermatomyositis Based on miRNA-mRNA Network. BIOMED RESEARCH INTERNATIONAL 2019; 2019:7814287. [PMID: 31886250 PMCID: PMC6925816 DOI: 10.1155/2019/7814287] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Revised: 09/14/2019] [Accepted: 11/08/2019] [Indexed: 01/09/2023]
Abstract
Objective The aim of this study is to explore the potential pathogenesis of juvenile dermatomyositis by bioinformatics analysis of gene chips, which would screen the hub genes, identify potential biomarkers, and reveal the development mechanism of juvenile dermatomyositis. Material and Methods We retrieved juvenile dermatomyositis's original expression microarray data of message RNAs (mRNAs) and microRNAs (miRNAs) from NCBI's Gene Expression Omnibus database (GEO, http://www.ncbi.nlm.nih.gov/geo/); through the R package of limma in Bioconductor, we can screen the differentially expressed miRNAs and mRNAs, and then we further analyzed the predicted target genes by the methods such as Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway enrichment analysis and miRNA-mRNA regulatory network construction and protein-protein interaction (PPI) network using Cytoscape 3.6.1. Results Compared with normal juvenile skin tissues, 6 upregulated microRNAs and 5 downregulated microRNAs were identified from 166 downregulated microRNAs and 58 upregulated microRNAs in juvenile dermatomyositis tissues. The enrichment pathways of differentially expressed microRNAs include cell adhesion molecules (CAMs), autoimmune thyroid disease, Type I diabetes mellitus, antigen and presentation, viral myocardium, graft-versus-host disease, and Kaposi sarcoma-associated herpes virus infection. By screening of microRNA-messenger RNA regulatory network and construction of PPI network map, three target miRNAs were identified, namely, miR-193b, miR-199b-5p, and miR-665. Conclusion We identified mir-193b, mir-199b-5p, and mir-6653 target miRNAs by exploring the miRNA-mRNA regulation network mechanism related to the pathogenesis of juvenile dermatomyositis, which will be of great significance for further study on the pathogenesis and targeted therapy of juvenile dermatomyositis.
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