Outcome of patients having dermatomyositis admitted to the intensive care unit

Acute Respiratory Failure in Autoimmune Rheumatic Diseases: A Review

This review examines respiratory complications in autoimmune rheumatic diseases within intensive care units (ICUs). The respiratory system, primarily affected in diseases like rheumatoid arthritis, systemic lupus erythematosus, and scleroderma, often leads to respiratory failure. Common manifestations include alveolar hemorrhage, interstitial fibrosis, and acute respiratory distress syndrome. Early recognition and treatment of non-malignant conditions are crucial to prevent rapid disease progression, with ICU mortality rates ranging from 30% to 60%. Delayed immunosuppressive or antimicrobial therapy may result in organ system failure. Collaboration with rheumatic specialists is vital for accurate diagnosis and immediate intervention. Mortality rates for rheumatic diseases in the ICU surpass those of other conditions, underscoring the need for specialized care and proactive management. The review emphasizes comprehensive assessments, distinguishing disease-related complications from underlying issues, and the importance of vigilant monitoring to enhance patient outcomes.

Mortality and its risk factors in critically ill patients with connective tissue diseases: A meta-analysis

BACKGROUND

Systemic lupus erythematosus (SLE), primary Sjögren's syndrome (pSS), systemic sclerosis (SSc), idiopathic inflammatory myopathies (IIM) and rheumatoid arthritis (RA) are connective tissue diseases (CTD) whose complications can lead to management in the intensive care unit (ICU).

OBJECTIVES

To estimate by meta-analysis ICU mortality rates for CTD.

METHODS

A systematic literature review was performed to identify articles studying critically ill CTD patients. A random-effects model was chosen for analysis. Pooled proportion mortality was calculated using aggregated-data meta-analysis with a random-effects model and assessment of heterogeneity with the I² statistic. Risk of bias was assessed using the quality assessment tool.

RESULTS

Of the 5694 individual publications, a sample of 31 independent cohorts was used for the meta-analysis totalling 5007 patients. The main cause for admission was sepsis (43%) followed by "flare-ups" (40%). The overall pooled proportion of mortality of CTD patients across all 31 studies was 33% (95%CI: 28-38%). In the IIM subgroup and that of SSc, mortality was 70% (95%CI: 46-86%) and 40% (95%CI: 25-47%), respectively. In the SLE subgroup, mortality was similar to the overall pooled mortality of 35% (95%CI: 29-42%). Subgroup mortality for RA and pSS patients was respectively 20% (95%CI: 11-33%) and 17% (95%CI: 6-41%); lower than the overall pooled mortality. Heterogeneity in each subgroup remained high.

CONCLUSION

The overall pooled proportion of mortality of ICU patients with CTD was 33% (95%CI: 28-38%), with a high heterogeneity (I²= 89%). In the subgroup analysis, mortality was higher for patients with IIM and SSc.

Reasons for Hospitalization and In-Hospital Mortality in Adults With Dermatomyositis and Polymyositis

OBJECTIVE

Dermatomyositis (DM) and polymyositis (PM) are systemic autoimmune diseases that have been associated with high in-hospital mortality (IHM). The aim of this study was to use the National Inpatient Sample (NIS), a large US population database, to determine the reasons for hospitalization and IHM in patients with DM and PM.

METHODS

We conducted a medical records review of adult DM/PM hospitalizations in 2016 and 2017 in acute care hospitals across the United States using the NIS. The reasons for IHM and reasons for hospitalization were divided into 19 broad categories based on their principal International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10) diagnosis.

RESULTS

A total of 27,140 hospitalizations carried either a principal or secondary ICD-10 code for DM or PM. The main reasons for hospitalization were rheumatologic (22%, n = 6085), cardiovascular (15%, n = 3945), infectious (13%, n = 3515), respiratory (12%, n = 3170), and gastrointestinal, (8%, n = 2150). A total of 3.5% of all patients experienced IHM. Infectious (34%, n = 325), respiratory (23%, n = 215), and cardiovascular (15%, n = 140) diagnoses were the most common reasons for IHM. Sepsis ICD-10 A41.9 was the most frequent specific principal diagnosis for both hospitalizations and IHM.

CONCLUSIONS

Our analysis demonstrated that in the NIS the most common reasons for hospitalization in patients with DM/PM were rheumatologic diagnoses. However, IHM in these patients was most frequently from infectious diagnoses, highlighting the need for increased attention to infectious complications in these patients.

Sepsis Mortality Is high in Patients With Connective Tissue Diseases Admitted to the Intensive Care Unit (ICU)

Objectives:

Patients with connective tissue diseases (CTD) such as systemic lupus erythematosus (SLE) have an increased risk for infections. This study investigated the outcome and characteristics of CTD patients under intensive care unit (ICU) treatment for sepsis.

Methods:

A single-center retrospective analysis was conducted and reviewed all patients with a CTD diagnosis admitted to the ICU of a university hospital for sepsis between 2006 and 2019. Mortality was computed and multivariate logistic regression was used to detect independent risk factors for sepsis mortality. Furthermore, the positive predictive value of ICU scores such as Sequential Organ Failure Assessment (SOFA) score was evaluated.

Results:

This study included 44 patients with CTD (mean age 59.8 ± 16.1 years, 68.2% females), most of them with a diagnosed SLE (61.4%) followed by systemic sclerosis (15.9%). 56.8% (n = 25) were treated with immunosuppressives and 81.8% (n = 36) received glucocorticoids. Rituximab was used in 3 patients (6.8%). The hospital mortality of septic CTD patients was high with 40.9%. It was highest among systemic sclerosis (SSc) patients (85.7%). SOFA score and diagnosis of SSc were independently associated with mortality in multivariate logistic regression (P = 0.004 and 0.03, respectively). The Simplified Acute Physiology Score II (SAPS II), SOFA and Acute Physiology and Chronic Health Evaluation II (APACHE II) scores were good predictors of sepsis mortality in the investigated cohort (SAPS II AUC 0.772, P = 0.002; SOFA AUC 0.756, P = 0.004; APACHE II AUC 0.741, P = 0.007).

Conclusions:

In-hospital sepsis mortality is high in CTD patients. SSc diagnoses and SOFA were independently associated with mortality. Additionally, common ICU scores were good predictors for mortality.

Clinically amyopathic dermatomyositis presenting with isolated facial edema complicated by acute respiratory failure: a case report

BACKGROUND

In clinically amyopathic dermatomyositis, the hallmark cutaneous manifestations are the key to diagnosis. We report a case of clinically amyopathic dermatomyositis which presented with facial edema as the sole cutaneous manifestation and was later complicated by acute respiratory failure leading to death.

CASE PRESENTATION

A 58-year-old woman presented with edema of the face that had developed approximately one year ago. There was no weakness in the extremities, and the serum creatine kinase level was within normal range. On MRI, there was diffuse edematous change in the bilateral masticator and extra-ocular muscles, accompanied by subcutaneous fat infiltration in the face. A shared decision was made to defer muscle biopsy in the facial muscles. The facial swelling almost resolved with medium-dose glucocorticoid therapy but relapsed in days at glucocorticoid doses lower than 15 mg/day. Combination therapy with either azathioprine, mycophenolate, or methotrexate was not successful in maintaining clinical remission, and the swelling became more severe after relapses. A US-guided core-needle biopsy was subsequently performed in the right masseter muscle. On pathologic examination, there was a patchy CD4 + T cell-dominant lymphoplasmacytic infiltration in the stroma, necrosis of the myofibrils and prominent perifascicular atrophy. Based on those findings, a diagnosis of clinically amyopathic dermatomyositis was made. Therapy with gamma-globulin was not effective in maintaining remission. In the sixth week after starting rituximab, she presented to emergency room with altered mental state from acute respiratory failure. Despite treatment with antibiotics, glucocorticoid pulse, cyclosporin, and polymyxin B-immobilized fiber column direct hemoperfusion, she died three weeks later from persistent hypoxemic respiratory failure.

CONCLUSIONS

This case showed the full spectrum and severity of internal organ involvement of dermatomyositis, although the patient presented exclusively with subcutaneous edema limited to the head. The prognosis may be more closely associated with a specific auto-antibody profile than the benign-looking initial clinical manifestation. Close follow-up of lung involvement with prophylactic treatment for Pneumocystis pneumonia and prompt implementation of emerging therapeutic regimens may improve the outcome.

Polymyositis/dermatomyositis is a potential risk factor for acute respiratory failure: a pulmonary heart disease

Background

Studies on the association between polymyositis/dermatomyositis (PM/DM) and acute respiratory failure (ARF) are considerably limited. We investigated whether ARF is associated with PM/DM using a nationwide cohort study.

Methods

We identified 1,374 patients with newly diagnosed PM/DM and 13,740 comparison individuals without PM/DM (non-PM/DM) randomly selected from the general population; frequency matched by age, sex, and index year using the National Health Insurance Research Database; and followed up until the end of 2011 to measure the incidence of ARF. Cox proportional hazards regression analysis was used to measure the hazard ratio (HR) of ARF for the PM/DM cohort in comparison with the non-PM/DM cohort.

Results

The adjusted HR of ARF was 5.05 for the PM/DM cohort compared with the non-PM/DM cohort after adjusting for sex, age, comorbidities, Charlson comorbidity index (CCI) score and medicine. The risk of ARF significantly increased irrespective of age, sex, comorbidities and medicine. Meanwhile, the PM/DM cohort with comorbidities, such as cardiac disease (hypertension), pulmonary disease (chronic obstructive pulmonary disease and pneumonia), and pulmonary vascular diseases had additive effects on the incident ARF.

Conclusions

This study determined the cross-reaction of pulmonary heart disease in the PM/DM cohort with incident ARF even without comorbidities.

Mortality of patients with rheumatoid arthritis requiring intensive care: a single-center retrospective study

BACKGROUND

Patients with rheumatoid arthritis (RA) are at a high risk for life-threatening conditions requiring admission to the intensive care unit (ICU), but the data regarding the outcomes of these patients is limited. The present study investigated the clinical characteristics and outcomes of RA patients admitted to an ICU.

METHODS

This retrospective cohort study included RA patients admitted to the general ICU of the Sheba Medical Center during 2002-2018. The main outcome was 30-day mortality. Using Student's t test, χ², and multivariable analyses, we compared the demographic, clinical, and laboratory parameters of the survivors and the non-survivors. Figures with p value < 0.05 were considered statistically significant.

RESULTS

Forty-three RA patients were admitted to the ICU during the study period (mean age, 64.0 ± 13.1 years; 74.4% female). The leading causes of ICU admission were infection (72.1%), respiratory failure (72.1%), renal failure (60.5%), and septic shock (55.8%). The 30-day mortality rate was 34.9%, with infection (9/15, 60%) as the most frequent cause. The mean Acute Physiology and Chronic Health Evaluation (APACHE) II and Sequential Organ Failure Assessment (SOFA) scores were 19.7 ± 12.5 and 7.0 ± 4.5, respectively. Multivariable analysis showed that heart failure (p = 0.023), liver failure (p = 0.012), SOFA score (p = 0.007), and vasopressor treatment in ICU (p = 0.039) were significantly associated with overall mortality. SOFA score was linked with overall mortality (area under the curve (AUC) = 0.781 ± 0.085, p = 0.003) and mortality from respiratory failure (AUC = 0.861 ± 0.075, p = 0.002), while APACHE II score was only correlated with mortality from infection (AUC = 0.735 ± 0.082, p = 0.032).

CONCLUSIONS

Our study demonstrated a relatively high mortality rate among RA patients who were admitted to the general ICU. RA patients with risk factors such as heart failure, liver failure, elevated SOFA score, and vasopressor treatment in ICU should be promptly identified and treated accordingly. Key Points • The 30-day mortality rate of patients with RA that were admitted to the general ICU of a tertiary hospital was 34.9%. • The most common causes of ICU admission among patients with RA were infections and respiratory failure. Infections were the most common cause of death among these patients. • Patients with RA that present to the ICU with heart failure, liver failure, elevated SOFA score, and/or require vasopressor treatment in ICU should be promptly identified and treated accordingly.

Mortality of patients with systemic lupus erythematosus admitted to the intensive care unit - A retrospective single-center study

Systemic lupus erythematosus (SLE) is a heterogeneous autoimmune disease that results in increased morbidity and mortality. Under certain conditions, patients with SLE may be admitted to the intensive care unit (ICU) secondary to infectious disease flare-ups or other non-SLE disease conditions that are aggravated by SLE. The aim of our study was to investigate the causes and outcomes of ICU-admitted patients with SLE. This is a retrospective cohort study involving paitents with SLE that were admitted to the general ICU at Sheba Medical Center between 2002 and 2015. Outcome was measured by the 30-day mortality and the Acute Physiology and Chronic Health Evaluation (APACHE) II score. Demographic, diagnostic, physiological, and laboratory variables of survivors and nonsurvivors were compared using univariate and multivariate Cox regression analyses. A receiver operating characteristic curve was plotted for significant variables to illustrate their diagnostic capabilities. Twenty-seven patients were admitted to the ICU (female: 21 [77%], mean age ± SD: 51.1 ± 15.4 years). The mean ± SD APACHE II score and 30-day mortality rate were 23.4 ± 8.3 and 29.6%, respectively. Infections, especially lower respiratory tract infections, were the cause of 66.7% of admissions and accounted for 87.5% of deaths. APACHE II scores, bacteremia, and gram-negative infections were significantly associated with mortality (p = 0.033, p = 0.022, and p = 0.01, respectively). An APACHE II score of 27 and above was the strongest predictor of mortality with a sensitivity and specificity of 83.3% and 84.2%, respectively (AUC = 0.82, p = 0.022). Patients with SLE that were admitted to the ICU with gram-negative infections, sepsis, or an APACHE II score of 27 and above have a higher mortality rate and thus should be promptly identified and treated accordingly.

Patients with systemic rheumatic diseases admitted to the intensive care unit: what the rheumatologist needs to know

Patients with systemic rheumatic diseases (SRDs) may require admission to the intensive care unit (ICU) throughout the course of their disease. Therefore, the rheumatologist needs an understanding of the factors which may influence the course of patients with SRDs who are admitted to ICU. These include the causes for admission, patient characteristics including comorbidities and drug therapies, outcome (in-ICU mortality and causes of death), and prognostic factors. Infections and exacerbation/complications of SRDs are the most common (and potentially reversible) reasons for both admission and death on ICU. Mortality in patients with SRDs admitted to ICU has been reported to be either no different or higher than 'general' ICU patients. Reported prognostic factors included patient and disease characteristics, as well as ICU factors, including scoring systems. Rheumatologists need to be aware of the factors surrounding admission of patients with SRDs to ICU, including the need for strong links with critical care medicine.

Dermatomyositis and Polymyositis in the Intensive Care Unit: A Single-Center Retrospective Cohort Study of 102 Patients

Introduction

Patients with idiopathic inflammatory myopathies (IIMs) are sometimes complicated with life-threatening conditions requiring intensive care unit (ICU) admission. In the past, owing to the low incidence of IIM, little was known about such patients. Our aim was to investigate the clinical features and outcomes of these patients and identify their risk factors for mortality.

Methods

A retrospective study was performed of IIM patients admitted over an 8-year period to the medical ICU of a tertiary referral center in China. We collected data regarding demographic features, IIM-related clinical characteristics, reasons for admission, organ dysfunction, and outcomes. Independent predictors of ICU mortality were identified through multivariate logistic regression analysis.

Results

Of the 102 patients in our cohort, polymyositis (PM), dermatomyositis (DM), and clinically amyopathic dermatomyositis (CADM) accounted for 23.5%, 64.7%, and 11.7% respectively. The median duration from the onset of IIM to ICU admission was 4.3 months (interquartile range [IQR], 2.6–9.4 months). Reasons for ICU admission were infection alone (39.2%), acute exacerbation of IIM alone (27.5%), the coexistence of both (27.5%), or other reasons (5.8%). Pneumonia accounted for 97% of the infections; 63.2% of infections with documented pathogens were caused by opportunistic agents. Rapid progressive interstitial lung disease (RP-ILD) was responsible for 87.5% of acute exacerbation of IIM. The median Acute Physiology and Chronic Health Evaluation II (APACHE II) score on ICU day 1 was 17 (IQR 14–20). On ICU admission, acute respiratory failure (ARF) was the most common type (80.4%) of organ failure. The mortality rate in the ICU was 79.4%. Factors associated with increased ICU mortality included a diagnosis of DM (including CADM), a high APACHE II score, the presence of ARF, a decreased PaO₂/FiO₂ ratio, and a low lymphocyte count at the time of ICU admission.

Conclusions

The outcome of IIM patients admitted to the ICU was extremely poor. A diagnosis of DM/CADM, the presence and severity of ARF, and the lymphocyte counts at ICU admission were shown to be valuable for predicting outcome. Opportunistic infections and rapidly progressive interstitial lung disease warrant concern in treating these patients.

Outcomes and Prognostic Factors in Patients with Rheumatologic Diseases Admitted to the ICU

OBJECTIVE

To assess the outcomes in a large cohort of patients suffering from rheumatic diseases admitted to the ICU of a tertiary university medical center.

METHODS

A retrospective chart analysis was performed in 108 patients suffering from various rheumatic diseases and the outcomes, including morbidity and mortality, were assessed in relation to the underlying diseases, treatments and complications.

RESULTS

Overall, 48 patients with rheumatoid arthritis, five patients with spondyloarthritis, 14 patients with vasculitis, 30 patients with connective tissue diseases and 11 patients suffering from other rheumatologic conditions were admitted to the intensive care unit (ICU). The reasons for ICU admission included infection (30%), cardiovascular complications (22%), gastrointestinal problems (18%), endocrinological disorders (7%), neurological complications (2%) and others (3%). A total of 4% of the admitted patients required close monitoring and 14% suffered from acute exacerbation of the underlying rheumatic disease. The ICU mortality rate was 16%, whereas the overall hospital mortality rate was 20%. Fatal outcomes were related to exacerbation of the rheumatic disease in 14% of the patients, infectious complications in 46% of the patients and other reasons in 41% of the patients. An increased Apache II score, the need for mechanical ventilation, renal replacement therapy, treatment with vasopressor drugs and plasma exchange therapy were identified as risk factors for mortality.

CONCLUSION

The overall outcomes of critically ill patients with rheumatic diseases are impaired compared to that observed in other patient groups. However, there were no significant differences in outcomes between the different rheumatic disease groups or based on the use of immunosuppressive therapy in this study. An increased Apache II score, the need for mechanical ventilation, renal replacement therapy, treatment with vasopressor drugs and plasma exchange therapy were identified as risk factors for mortality.

Fulminant systemic capillary leak syndrome due to C1 inhibitor deficiency complicating acute dermatomyositis: a case report

Introduction

Dermatomyositis is a chronic inflammatory disorder characterized by muscular and dermatologic symptoms with variable internal organ involvement. This is the first report on a patient with acute dermatomyositis and fulminant systemic capillary leak syndrome.

Case presentation

A 69-year-old Caucasian woman with chronic dermatomyositis presented with clinical signs of severe hypovolemic shock and pronounced hemoconcentration (hematocrit, 69%). Her colloid osmotic pressure was 4.6mmHg. Following a bolus dose of prednisolone (500mg), fluid resuscitation was initiated. During volume loading, anasarca and acute respiratory distress rapidly developed. Echocardiography revealed an underfilled, hypokinetic, diastolic dysfunctional left ventricle with pericardial effusion but no signs of tamponade. Despite continued fluid resuscitation and high-dosed catecholamine therapy, the patient died from refractory shock 12 hours after intensive care unit admission. A laboratory analysis of her complement system suggested the presence of C1 inhibitor deficiency as the cause for systemic capillary leakage. The post-mortem examination revealed bilateral pleural, pericardial and peritoneal effusions as well as left ventricular hypertrophy with patchy myocardial fibrosis. Different patterns of endomysial/perimysial lymphocytic infiltrations adjacent to degenerated cardiomyocytes in her myocardium and necrotic muscle fibers in her right psoas major muscle were found in the histological examination.

Conclusions

This case report indicates that acute exacerbation of chronic dermatomyositis can result in a fulminant systemic capillary leak syndrome with intense hemoconcentration, hypovolemic shock and acute heart failure. In the presented patient, the cause for diffuse capillary leakage was most probably acquired angioedema, a condition that has been associated with both lymphoproliferative and autoimmunologic disorders.

Prognostic contributions of the underlying inflammatory disease and acute organ dysfunction in critically ill patients with systemic rheumatic diseases

BACKGROUND

Knowledge about the clinical features, outcomes and predictors of short-term mortality in critically ill patients with systemic rheumatic disease (SRD) requires further characterization.

METHODS

Single center retrospective observational cohort study of 149 critically ill patients with SRD followed in a French medical intensive care unit over a 20-year period. Multivariate logistic regression was used to identify predictors of day-30 mortality.

RESULTS

Most patients (63%) had systemic lupus erythematosus, rheumatoid arthritis, or systemic sclerosis. The critical illness usually developed late after the diagnosis of SRD (median time to ICU admission 82 months, IQR [9-175] in the 127 patients with a previous diagnosis of SRD). Two-thirds of patients were taking immunosuppressive drugs to treat their SRD. Reasons for ICU admission were infection (47%), SRD exacerbation (48%), and iatrogenic complications (11%); the most common organ failure was acute renal failure. Thirty-day mortality was 16%. Predictors of 30-day mortality were the LODS score on day 1 (OR 1.3 (1.06-1.48)), bacterial pneumonia (OR 3.8 (1.03-14.25)), need for vasoactive drugs (OR 7.1 (1.83-27.68)), SRD exacerbation (OR 4.3 (1.15-16.53)), and dermatomyositis (OR 9.2 (1.05-80.78)) as the underlying disease. Year of ICU admission was not significantly associated with 30-day survival.

CONCLUSION

Patients with SRD are mostly admitted in the ICU with infection or SRD exacerbation, and can be treated with immunosuppressive therapy and life-sustaining interventions with acceptable 30-day mortality. Death is associated with both the severity of the acute medical condition and the characteristics of the underlying SRD.

Morbidity and mortality in adult polymyositis and dermatomyositis

Before the use of corticosteroids, the prognosis for polymyositis/dermatomyositis (PM/DM) was extremely poor. To date, although overall prognosis appears to be better, PM and DM are still considered to be associated with increased morbidity, primarily related to severe muscle weakness and visceral involvement. Recent series underline that only 20% to 40% of treated patients will achieve PM/DM remission, whereas 60% to 80% will experience a polycyclic or chronic, continuous course of the disease. PM/DM further continues to have a great impact on life in medium- and long-term follow-up, as up to 80% of treated patients are still disabled (using Health Assessment Questionnaire scores). The overall mortality ratio in PM/DM patients also remains threefold higher compared with the general population, with cancer, lung, and cardiac complications and infections being the most common causes of deaths. Predictive factors for a poor prognosis in PM/DM patients are older age, involvement of lung and cardiac systems, dysphagia, cancer, and serum myositis-specific antibodies (including coexistent presence of anti-Ro52 and anti-Jo1 antibodies, anti-signal recognition particle antibody, anti-155/140, and anti-CADM-140 antibodies).

[Rheumatic patients in the intensive care unit]

The mortality of patients with rheumatic diseases in the intensive care unit is generally high despite their relatively young age. In these patients, it is often difficult to make the diagnosis of the underlying autoimmune disease or to differentiate between septic complications and an acute flare; likewise, the complexity of the specific antirheumatic therapy can also be accompanied by problems. The following article gives an overview of problems in the diagnosis and treatment of critically ill patients with autoimmune diseases in the intensive care unit.

Invasive ductal breast cancer associated polymyositis causing respiratory failure

Polymyositis (PM) is a very rare paraneoplastic syndrome in association with breast cancer, here we present a breast cancer patient with a sudden onset of respiratory failure caused by PM. A 47-year-old woman, with a history of a lump in her right breast for 3 months, weakness and anorexia for about 1 month, suddenly presented with respiratory failure and elevated muscle enzymes. Muscle biopsy revealed myositis and breast biopsy was consistent with invasive ductal breast cancer. Decreases of muscle enzyme levels were observed after corticosteroid therapy and the lumpectomy, but the patient died from respiratory failure. A case of respiratory failure caused by breast cancer associated polymyositis was presented. This case server to remind that breast cancer patients with muscle weakness or muscle enzyme elevation may be involved with PM.