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Zayat N, Arora A, O'Brien J, Bal J, Sugarman R, Rivera L, Shamshirsaz A, Vani K, Mastrogiannis DS. Pregnancy-Associated Onset of Adult-Onset Still's Disease. AJP Rep 2024; 14:e145-e155. [PMID: 38799549 PMCID: PMC11126333 DOI: 10.1055/a-2318-0305] [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: 03/15/2024] [Accepted: 04/10/2024] [Indexed: 05/29/2024] Open
Abstract
Objective This study aims to elucidate the clinical manifestations, diagnostic challenges, and management strategies of adult-onset Still's disease (AOSD) during pregnancy, leveraging a case series overview and a detailed case report from our center. Study Design A comprehensive review of 21 published case reports on AOSD diagnosed during pregnancy was conducted, alongside a detailed case report of a patient diagnosed and managed at our center. This study emphasizes the importance of recognizing AOSD in pregnant patients, outlines the therapeutic challenges encountered, and discusses the potential complications arising from the disease and its treatment. Results The onset of AOSD during pregnancy predominantly occurs in the first or second trimester, with a polycyclic disease course observed in most cases. Management primarily involves corticosteroids and immunosuppressive medications, balancing the disease control with potential pregnancy complications. The case report highlights the complex interplay between AOSD, hemophagocytic lymphohistiocytosis, and pregnancy, illustrating a multidisciplinary approach to management that ensured favorable maternal and fetal outcomes despite the significant challenges. Conclusion AOSD presents unique diagnostic and therapeutic challenges during pregnancy, requiring careful consideration of maternal and fetal health. Early diagnosis, a multidisciplinary approach to care, and judicious use of immunosuppressive therapy are critical for managing AOSD flares and associated complications. Further research is necessary to optimize care for this rare condition in the context of pregnancy.
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Affiliation(s)
- Nawras Zayat
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Avish Arora
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Joselle O'Brien
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Maimonides Medical Center, Brooklyn, New York
| | - Japjot Bal
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Rebekah Sugarman
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Leeshun Rivera
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Amir Shamshirsaz
- Division of Maternal-Fetal Medicine and Surgical Critical Care, Baylor College of Medicine, Houston, Texas
| | - Kavita Vani
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Dimitrios S. Mastrogiannis
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
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Shibata M, Kaneko K, Umehara N, Matsui H, Kawai T, Nakadate H, Murashimia A, Sago H. A pregnant woman with thymoma-associated pure red cell aplasia. BMC Pregnancy Childbirth 2022; 22:795. [PMID: 36303124 PMCID: PMC9608914 DOI: 10.1186/s12884-022-05145-5] [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: 04/29/2022] [Accepted: 10/22/2022] [Indexed: 12/03/2022] Open
Abstract
Background Pure red cell aplasia (PRCA) is a hematological disorder characterized by anemia with severe reticulocytopenia caused by a marked reduction in erythroid precursors in the bone marrow. PRCA is known to be associated with pregnancy, but thymoma-associated PRCA during pregnancy is very rare, and its successful management has not been reported. Case presentation A 37-year-old primiparous woman with severe anemia was referred to our center at 27 weeks’ gestation. She was diagnosed with PRCA based on bone aspiration findings at 33 weeks’ gestation. Magnetic resonance imaging (MRI) revealed an anterior mediastinal mass 4 cm in size suspected of being thymoma. She was therefore diagnosed with thymoma-associated PRCA during pregnancy. Surgery for thymoma was planned after delivery, since the imaging findings were suggestive of early-stage thymoma (Masaoka stage I or II). With transfusion of a total 3,360 ml of red blood cells (RBCs) during pregnancy, the patient gave birth to a baby girl weighing 2,548 g at 40 weeks’ gestation. The baby showed transient congenital cutaneous candidiasis. The placental pathology revealed subamniotic inflammation with a fungal structure. Treatment with topical anti-fungal cream immediately ameliorated the baby’s skin lesion. Maternal anemia did not improve after delivery; however, the thymoma did not increase in size. At five months after delivery, the mother underwent thymectomy with oral cyclosporine A. A pathological examination revealed Masaoka stage II-a thymoma. She completely had recovered from anemia at six months after surgery. Cyclosporine A treatment was discontinued three years after surgery. Remission has been sustained for four years since surgery. Conclusions A very rare case of thymoma-associated PRCA during pregnancy was diagnosed without any subjective symptoms and was expectantly managed, resulting in a good prognosis. Although bone marrow aspiration during pregnancy is an invasive test, it is important to confirm the diagnosis. Conservative management with blood transfusion was possible for early-stage thymoma-associated PRCA during pregnancy. Active surveys, including MRI, for PRCA during pregnancy led to the detection of thymoma at an early stage and the achievement of a preferable pregnancy outcome. Supplementary Information The online version contains supplementary material available at 10.1186/s12884-022-05145-5.
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Affiliation(s)
- Megumi Shibata
- grid.63906.3a0000 0004 0377 2305Division of Obstetrics, Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, 2-10-1 Okura, Setagaya-Ku, Tokyo, Japan
| | - Kayoko Kaneko
- grid.63906.3a0000 0004 0377 2305Division of Maternal Medicine, Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, 2-10-1 Okura, Setagaya-Ku, Tokyo, Japan
| | - Nagayoshi Umehara
- grid.63906.3a0000 0004 0377 2305Division of Obstetrics, Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, 2-10-1 Okura, Setagaya-Ku, Tokyo, Japan
| | - Hitoshi Matsui
- grid.63906.3a0000 0004 0377 2305Division of Obstetrics, Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, 2-10-1 Okura, Setagaya-Ku, Tokyo, Japan
| | - Toshinao Kawai
- grid.63906.3a0000 0004 0377 2305Division of Immunology, National Center for Child Health and Development, 2-10-1 Okura, Setagaya-Ku, Tokyo, Japan
| | - Hisaya Nakadate
- grid.63906.3a0000 0004 0377 2305Division of Hematology, National Center for Child Health and Development, 2-10-1 Okura, Setagaya-Ku, Tokyo, Japan
| | - Atsuko Murashimia
- grid.63906.3a0000 0004 0377 2305Division of Maternal Medicine, Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, 2-10-1 Okura, Setagaya-Ku, Tokyo, Japan
| | - Haruhiko Sago
- grid.63906.3a0000 0004 0377 2305Division of Obstetrics, Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, 2-10-1 Okura, Setagaya-Ku, Tokyo, Japan
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Imaizumi C, Saito M, Abe F, Kaga H, Saito A, Nara M, Kameyama S, Miura H, Ogasawara H, Hirakawa T, Mizunuma M, Satoh M, Komatsuda A, Terada Y, Takahashi N. Adult-onset Still's Disease during Pregnancy Treated with Tocilizumab. Intern Med 2022; 61:3137-3140. [PMID: 35283384 PMCID: PMC9646338 DOI: 10.2169/internalmedicine.8886-21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
A 28-year-old woman exhibited a spiking fever, arthritis, and liver disfunction when she was 22 weeks pregnant. She was diagnosed with adult-onset Still's disease (AOSD). As her condition was resistant to corticosteroid therapy, tocilizumab (TCZ) was selected. The TCZ treatment was effective, and she delivered a healthy child while receiving TCZ treatment. Cases in which AOSD first arises during pregnancy are rare, and there have been no reports of TCZ treatment for AOSD being initiated during pregnancy. Although the safety of TCZ treatment during pregnancy has not been established, it may be effective against severe AOSD that develops during pregnancy.
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Affiliation(s)
- Chihiro Imaizumi
- Department of Hematology, Nephrology, and Rheumatology, Akita University Graduate School of Medicine, Japan
| | - Masaya Saito
- Department of Hematology, Nephrology, and Rheumatology, Akita University Graduate School of Medicine, Japan
| | - Fumito Abe
- Department of Hematology, Nephrology, and Rheumatology, Akita University Graduate School of Medicine, Japan
| | - Hajime Kaga
- Department of Hematology, Nephrology, and Rheumatology, Akita University Graduate School of Medicine, Japan
| | - Ayano Saito
- Department of Hematology, Nephrology, and Rheumatology, Akita University Graduate School of Medicine, Japan
| | - Mizuho Nara
- Department of Hematology, Nephrology, and Rheumatology, Akita University Graduate School of Medicine, Japan
| | - Saeko Kameyama
- Department of Obstetrics and Gynecology, Graduate School of Medicine, Akita University, Japan
| | - Hiroshi Miura
- Department of Obstetrics and Gynecology, Graduate School of Medicine, Akita University, Japan
| | - Hitoshi Ogasawara
- Department of Hematology and Oncology, Odate Municipal General Hospital, Japan
| | - Takeo Hirakawa
- Department of Obstetrics and Gynecology, Odate Municipal General Hospital, Japan
| | - Makito Mizunuma
- Department of Obstetrics and Gynecology, Odate Municipal General Hospital, Japan
| | - Makiko Satoh
- Department of Obstetrics and Gynecology, Odate Municipal General Hospital, Japan
| | - Atsushi Komatsuda
- Department of Hematology, Nephrology, and Rheumatology, Akita University Graduate School of Medicine, Japan
| | - Yukihiro Terada
- Department of Obstetrics and Gynecology, Graduate School of Medicine, Akita University, Japan
| | - Naoto Takahashi
- Department of Hematology, Nephrology, and Rheumatology, Akita University Graduate School of Medicine, Japan
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Hosoya S, Sadatsuki M, Izuka S, Yamashita H, Oishi H. A case of recurrence of adult-onset Still's disease in the third trimester: a case report and literature review. BMC Pregnancy Childbirth 2021; 21:163. [PMID: 33627085 PMCID: PMC7905546 DOI: 10.1186/s12884-021-03648-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 02/17/2021] [Indexed: 12/18/2022] Open
Abstract
Background Adult-onset Still’s disease (AOSD) is a self-inflammatory disease showing macrophage and neutrophil activation by inflammatory cytokines such as TNF-α, IL-6, and IL-18. Although some cases with the flare of AOSD during pregnancy have been reported, most had flares in the first or second trimester and few had flares in the third trimester. In this report, we present the case of a patient with recurrent flare of AOSD in the third trimester and discuss the management of AOSD in the third trimester with the review of previous literatures. Case presentation A 38-year-old woman in complete AOSD remission without medication presented with impaired liver function, low platelet count, mild fever, abdominal pain, splenomegaly, and elevated ferritin and IL-18 levels at 30 gestational weeks. Although the laboratory data and physical examination finding suggested HELLP syndrome or acute fatty liver of pregnancy and we considered the termination of her pregnancy, her fetus was in a reactive status. Considering her fetal status, some specific findings of AOSD, and her AOSD history, we and rheumatologists diagnosed her with AOSD recurrence and started systemic steroid therapy. In her clinical course, three flares of AOSD occurred, twice in the third trimester and once in postpartum; twice systemic steroid pulse therapies were then needed. Ultimately, a healthy infant was delivered transvaginally at 36 gestational weeks spontaneously. Conclusions Specific findings of the flare of AOSD such as fever, splenomegaly, elevated ferritin and IL-18 levels, and fetal status could be useful findings for differentiation from HELLP syndrome and AFLP in the third trimester. With the careful management supported by rheumatologists, patients complicated with the flare of AOSD may continue their pregnancy longer than we expected.
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Affiliation(s)
- Satoshi Hosoya
- Department of Obstetrics and Gynecology, National Center for Global Health and Medicine, 1-21-1, Toyama, Shinjuku-ku, Tokyo, 162-8655, Japan.
| | - Miyuki Sadatsuki
- Department of Obstetrics and Gynecology, National Center for Global Health and Medicine, 1-21-1, Toyama, Shinjuku-ku, Tokyo, 162-8655, Japan
| | - Shinji Izuka
- Division of Rheumatic Diseases, National Center for Global Health and Medicine, Tokyo, Japan
| | - Hiroyuki Yamashita
- Division of Rheumatic Diseases, National Center for Global Health and Medicine, Tokyo, Japan
| | - Hajime Oishi
- Department of Obstetrics and Gynecology, National Center for Global Health and Medicine, 1-21-1, Toyama, Shinjuku-ku, Tokyo, 162-8655, Japan
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Herrera-Quintana JF, Rojas-Figueroa AC, Aragón-Mendoza RL, Gallo-Roa R, Castillo-Zamora MF. Pure red-cell aplasia secondary to pregnancy: Case report and review of the literature. ACTA ACUST UNITED AC 2020; 71:365-373. [PMID: 33515443 DOI: 10.18597/rcog.3543] [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: 05/16/2020] [Accepted: 11/18/2020] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To report a case of pure red-cell aplasia secondary to pregnancy and to conduct a review of the literature regarding diagnosis and treatment, as well as maternal and perinatal prognosis. METHODS This is the case of a 24-year-old patient at 34 weeks of gestation, referred to a regional public referral hospital due to anemia. Bone marrow biopsy was performed, leading to the diagnosis of pregnancy-related pure red-cell aplasia. The patient received serial red blood cell transfusions. Delivery by Cesarean section at term resulted in a healthy newborn. Hemoglobin values remained stable during the postoperative period. A literature search was conducted in Medline via PubMed, LILACS, SciELO and ScienceDirect using the terms "pregnancy" and "pure red-cell aplasia". Case reports, case series and literature reviews in English and Spanish published between January 1999 and January 2020 that report pregnant women with pure red-cell aplasia were included. Information on diagnosis, treatment and maternal and perinatal prognosis was collected. Three of the authors selected the studies by title and abstract; A descriptive synthesis is provided. RESULTS Overall, 828 titles were identified; of these,818 were discarded after reviewing the inclusions criteria. Ten articles were included: six case reports, three case reports with literature review, and one case report in the poster modality, for a total number of 10 reported cases. Diagnosis was based on low hemoglobin levels and compromised erythroid cell line in bone marrow biopsy. Treatment consists of red blood cell transfusions, with good maternal and fetal prognosis. CONCLUSIONS Diagnosis of pure red-cell aplasia during pregnancy requires bone marrow biopsy. With transfusion support, maternal perinatal prognosis is good. Further studies are required to assess the safety and efficacy of steroid use in this pregnancy-related condition.
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Affiliation(s)
| | | | | | - Roberto Gallo-Roa
- Médico, ginecobstetra, Hospital Universitario de La Samaritana, Bogotá (Colombia)
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Adult onset Still's disease and pregnancy. Autoimmun Rev 2019; 18:102356. [PMID: 31323360 DOI: 10.1016/j.autrev.2019.102356] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Accepted: 04/19/2019] [Indexed: 11/22/2022]
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Abstract
Pure red cell aplasia (PRCA) is a syndrome defined by a normocytic normochromic anemia with severe reticulocytopenia and marked reduction or absence of erythroid precursors from the bone marrow. Diamond-Blackfan anemia is a congenital form of PRCA. Acquired PRCA may be either a primary disorder or secondary to some other disorder or agent. Primary acquired PRCA is an autoimmune disorder that is frequently antibody-mediated. Myelodysplastic syndromes may also present with the morphologic appearance of PRCA. Secondary acquired PRCA may be associated with collagen vascular/autoimmune disorders such as systemic lupus erythematosus; lymphoproliferative disorders such as chronic lymphocytic leukemia or large granular lymphocyte leukemia; infections, particularly B19 parvovirus; thymoma and other solid tumors; or a variety of other disorders, drugs, or toxic agents. The therapeutic approach to PRCA typically involves immunosuppression, but specific pathogenic subtypes are associated with specific therapeutic approaches. Cyclosporine A, with or without concurrent corticosteroids, appears to be the single most effective immunosuppressive agent.
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Plaçais L, Mekinian A, Bornes M, Poujol-Robert A, Bigé N, Maury E, Fain O. Adult onset Still's disease occurring during pregnancy: Case-report and literature review. Semin Arthritis Rheum 2017; 47:575-577. [PMID: 28781105 DOI: 10.1016/j.semarthrit.2017.07.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Accepted: 07/07/2017] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Adult onset Still's disease is a rare affection classified among non-hereditary autoinflammatory diseases. We here report a case of AOSD revealed during pregnancy with a life-threatening presentation along with a review of 19 cases from literature. CASE A 38-years old woman was treated in our department for diffuse systemic sclerosis and associated Sjögren syndrome. She was pregnant and presented with acute fever and arthralgias. Laboratory data revealed mild liver cytolysis but a large screening for infectious and auto-immune diseases was negative and hepato-biliar imaging was normal. Ferritin levels were at 41 000 ng/mL with glycosylated ferritin less than 5%. The diagnosis of AOSD was stated and because of persistent fever and polyarthralgias, after exclusion of active infection, steroids were started (prednisone 1 mg/kg) associated with colchicine, which allowed clinical remission and C-reactive protein significant decrease. CONCLUSION Pregnancy-revealed AOSD appears to be a specifical subset of the disease with a systemic course, flares on first and second trimester, obstetrical complications such as prematurity and IUGR sometimes leading to life-threatening situations requiring parenteral corticotherapy and intravenous immunoglobulins.
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Affiliation(s)
- Léo Plaçais
- Service de Médecine Interne and Inflammation-Immunopathology-Biotherapy Department (DHU i2B), AP-HP, Hôpital Saint-Antoine, Sorbonne Universités, UPMC University Paris 06, F-75012, Paris, France
| | - Arsène Mekinian
- Service de Médecine Interne and Inflammation-Immunopathology-Biotherapy Department (DHU i2B), AP-HP, Hôpital Saint-Antoine, Sorbonne Universités, UPMC University Paris 06, F-75012, Paris, France.
| | - Marie Bornes
- AP-HP, Hôpital Tenon, Service de Gynécologie et d'Obstétrique, UPMC University Paris 06, Paris, France
| | - Armelle Poujol-Robert
- AP-HP, Hôpital Saint-Antoine, Service de Hépatologie, UPMC University Paris 06, Paris, France
| | - Naiké Bigé
- AP-HP, Hôpital Saint-Antoine, Service de Réanimation Médicale, UPMC University Paris 06, Paris, France
| | - Eric Maury
- AP-HP, Hôpital Saint-Antoine, Service de Réanimation Médicale, UPMC University Paris 06, Paris, France
| | - Olivier Fain
- Service de Médecine Interne and Inflammation-Immunopathology-Biotherapy Department (DHU i2B), AP-HP, Hôpital Saint-Antoine, Sorbonne Universités, UPMC University Paris 06, F-75012, Paris, France
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Abstract
Pure red cell aplasia (PRCA) is a syndrome defined by a normocytic normochromic anemia with severe reticulocytopenia and marked reduction or absence of erythroid precursors from the bone marrow. Diamond-Blackfan anemia is a congenital form of PRCA. Acquired PRCA may be either a primary disorder or secondary to some other disorder or agent. Primary acquired PRCA is an autoimmune disorder that is frequently antibody-mediated. Myelodysplastic syndromes may also present with the morphologic appearance of PRCA. Secondary acquired PRCA may be associated with collagen vascular/autoimmune disorders such as systemic lupus erythematosus; lymphoproliferative disorders such as chronic lymphocytic leukemia or large granular lymphocyte leukemia; infections, particularly B19 parvovirus; thymoma and other solid tumors; or a variety of other disorders, drugs, or toxic agents. The therapeutic approach to PRCA typically involves immunosuppression, but specific pathogenic subtypes are associated with specific therapeutic approaches. Cyclosporine A, with or without concurrent corticosteroids, appears to be the single most effective immunosuppressive agent.
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MESH Headings
- Adrenal Cortex Hormones/therapeutic use
- Anemia, Diamond-Blackfan/drug therapy
- Anemia, Diamond-Blackfan/immunology
- Anemia, Diamond-Blackfan/pathology
- Autoimmune Diseases/drug therapy
- Autoimmune Diseases/immunology
- Autoimmune Diseases/pathology
- Cyclosporine/therapeutic use
- Humans
- Immunosuppressive Agents/therapeutic use
- Leukemia, Large Granular Lymphocytic/drug therapy
- Leukemia, Large Granular Lymphocytic/immunology
- Leukemia, Large Granular Lymphocytic/pathology
- Leukemia, Lymphocytic, Chronic, B-Cell/drug therapy
- Leukemia, Lymphocytic, Chronic, B-Cell/immunology
- Leukemia, Lymphocytic, Chronic, B-Cell/pathology
- Myelodysplastic Syndromes/drug therapy
- Myelodysplastic Syndromes/etiology
- Myelodysplastic Syndromes/immunology
- Myelodysplastic Syndromes/pathology
- Parvoviridae Infections/drug therapy
- Parvoviridae Infections/immunology
- Parvoviridae Infections/pathology
- Parvovirus B19, Human/immunology
- Thymoma/drug therapy
- Thymoma/immunology
- Thymoma/pathology
- Vasculitis/drug therapy
- Vasculitis/immunology
- Vasculitis/pathology
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Affiliation(s)
- Robert T Means
- Office of the Dean, James H. Quillen College of Medicine, East Tennessee State University, Johnson City, TN
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