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Kirkpatrick KV, Nocton JJ. Unusual Presentations of Systemic Lupus Erythematosus. Med Clin North Am 2024; 108:43-57. [PMID: 37951655 DOI: 10.1016/j.mcna.2023.05.015] [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] [Indexed: 11/14/2023]
Abstract
Systemic lupus erythematosus (SLE) often develops during adolescence, may affect any organ system, and may present with a wide variety of signs and symptoms. It is critical to recognize the unusual manifestations of SLE in order to make a prompt diagnosis. Earlier diagnosis allows for appropriate treatment and ultimately decreases morbidity and mortality.
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Affiliation(s)
- Kaitlin V Kirkpatrick
- Pediatric Rheumatology, Medical College of Wisconsin, Children's Corporate Center, 999 North 92nd Street Suite C465, Milwaukee, WI 53226, USA
| | - James J Nocton
- Pediatric Rheumatology, Medical College of Wisconsin, Children's Corporate Center, 999 North 92nd Street Suite C465, Milwaukee, WI 53226, USA.
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2
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Vachvanichsanong P, Dissaneewate P, Kritsaneepaiboon S, Pattarapuntakul T. Hyperlipidaemia-induced pancreatitis and infected intra-abdominal cysts in a boy with systemic lupus erythematosus: a case report. Scand J Rheumatol 2023; 52:584-586. [PMID: 37485835 DOI: 10.1080/03009742.2023.2230674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 06/26/2023] [Indexed: 07/25/2023]
Affiliation(s)
- P Vachvanichsanong
- Department of Pediatrics, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand
| | - P Dissaneewate
- Department of Pediatrics, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand
| | - S Kritsaneepaiboon
- Department of Radiology, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand
| | - T Pattarapuntakul
- NKC Institute of Gastroenterology and Hepatology, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand
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3
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Mao X, Mao S, Sun H, Huang F, Wang Y, Zhang D, Wang Q, Li Z, Zou W, Liao Z. Causal associations between modifiable risk factors and pancreatitis: A comprehensive Mendelian randomization study. Front Immunol 2023; 14:1091780. [PMID: 36999014 PMCID: PMC10043332 DOI: 10.3389/fimmu.2023.1091780] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 03/03/2023] [Indexed: 03/15/2023] Open
Abstract
BackgroundThe pathogenesis of pancreatitis involves diverse environmental risk factors, some of which have not yet been clearly elucidated. This study systematically investigated the causal effects of genetically predicted modifiable risk factors on pancreatitis using the Mendelian randomization (MR) approach.MethodsGenetic variants associated with 30 exposure factors were obtained from genome-wide association studies. Summary-level statistical data for acute pancreatitis (AP), chronic pancreatitis (CP), alcohol-induced AP (AAP) and alcohol-induced CP (ACP) were obtained from FinnGen consortia. Univariable and multivariable MR analyses were performed to identify causal risk factors for pancreatitis.ResultsGenetic predisposition to smoking (OR = 1.314, P = 0.021), cholelithiasis (OR = 1.365, P = 1.307E-19) and inflammatory bowel disease (IBD) (OR = 1.063, P = 0.008) as well as higher triglycerides (OR = 1.189, P = 0.016), body mass index (BMI) (OR = 1.335, P = 3.077E-04), whole body fat mass (OR = 1.291, P = 0.004) and waist circumference (OR = 1.466, P = 0.011) were associated with increased risk of AP. The effect of obesity traits on AP was attenuated after correcting for cholelithiasis. Genetically-driven smoking (OR = 1.595, P = 0.005), alcohol consumption (OR = 3.142, P = 0.020), cholelithiasis (OR = 1.180, P = 0.001), autoimmune diseases (OR = 1.123, P = 0.008), IBD (OR = 1.066, P = 0.042), type 2 diabetes (OR = 1.121, P = 0.029), and higher serum calcium (OR = 1.933, P = 0.018), triglycerides (OR = 1.222, P = 0.021) and waist-to-hip ratio (OR = 1.632, P = 0.023) increased the risk of CP. Cholelithiasis, triglycerides and the waist-to-hip ratio remained significant predictors in the multivariable MR. Genetically predicted alcohol drinking was associated with increased risk of AAP (OR = 15.045, P = 0.001) and ACP (OR = 6.042, P = 0.014). After adjustment of alcohol drinking, genetic liability to IBD had a similar significant causal effect on AAP (OR = 1.137, P = 0.049), while testosterone (OR = 0.270, P = 0.002) a triglyceride (OR = 1.610, P = 0.001) and hip circumference (OR = 0.648, P = 0.040) were significantly associated with ACP. Genetically predicted higher education and household income levels could lower the risk of pancreatitis.ConclusionsThis MR study provides evidence of complex causal associations between modifiable risk factors and pancreatitis. These findings provide new insights into potential therapeutic and prevention strategies.
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Affiliation(s)
- Xiaotong Mao
- Department of Gastroenterology, Changhai Hospital, Navy Medical University, Shanghai, China
- Shanghai Institute of Pancreatic Diseases, Shanghai, China
| | - Shenghan Mao
- Department of Gastroenterology, Changhai Hospital, Navy Medical University, Shanghai, China
- Shanghai Institute of Pancreatic Diseases, Shanghai, China
| | - Hongxin Sun
- Department of Gastroenterology, Changhai Hospital, Navy Medical University, Shanghai, China
| | - Fuquan Huang
- Department of Gastroenterology, Changhai Hospital, Navy Medical University, Shanghai, China
| | - Yuanchen Wang
- Department of Gastroenterology, Changhai Hospital, Navy Medical University, Shanghai, China
| | - Deyu Zhang
- Department of Gastroenterology, Changhai Hospital, Navy Medical University, Shanghai, China
| | - Qiwen Wang
- Department of Gastroenterology, Changhai Hospital, Navy Medical University, Shanghai, China
| | - Zhaoshen Li
- Department of Gastroenterology, Changhai Hospital, Navy Medical University, Shanghai, China
| | - Wenbin Zou
- Department of Gastroenterology, Changhai Hospital, Navy Medical University, Shanghai, China
- Shanghai Institute of Pancreatic Diseases, Shanghai, China
- *Correspondence: Zhuan Liao, ; Wenbin Zou,
| | - Zhuan Liao
- Department of Gastroenterology, Changhai Hospital, Navy Medical University, Shanghai, China
- Shanghai Institute of Pancreatic Diseases, Shanghai, China
- *Correspondence: Zhuan Liao, ; Wenbin Zou,
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方 优, 林 海, 楼 金, 陈 洁. Recurrent abdominal pain and vomiting with elevated triglyceride and positive antinuclear antibody in a girl aged 12 years. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2022; 24:917-922. [PMID: 36036131 PMCID: PMC9425857 DOI: 10.7499/j.issn.1008-8830.2203006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 07/05/2022] [Indexed: 06/15/2023]
Abstract
A girl aged 12 years and 2 months presented with recurrent abdominal pain and vomiting for more than 2 years and arthrodynia for 3 months. She was diagnosed with recurrent acute pancreatitis with unknown causes and had been admitted multiple times. Laboratory tests showed recurrent significant increases in fasting serum triglyceride, with elevated immunoglobulin and positive antinuclear antibody. The girl was improved after symptomatic supportive treatment. The girl developed arthrodynia with movement disorders 3 months before, and proteinuria, hematuria, and positive anti-double-stranded DNA antibody were observed. The renal biopsy was performed, and the pathological examination and immunofluorescence assay suggested diffuse lupus nephritis (type Ⅳ). She was finally diagnosed with systemic lupus erythematosus (SLE), lupus nephritis (type Ⅳ), and recurrent acute pancreatitis. Pancreatitis was suspected to be highly associated with SLE. She was treated with oral hydroxychloroquine sulfate and intravenous methylprednisolone sodium succinate and cyclophosphamide. Arthrodynia was partially relieved. She was then switched to oral prednisone acetate tablets. Intravenous cyclophosphamide and pump infusion of belimumab were regularly administered. Now she had improvement in arthrodynia and still presented with proteinuria and hematuria. It is concluded that recurrent acute pancreatitis may be the first clinical presentation of SLE. For pancreatitis with unknown causes, related immunological parameters should be tested, and symptoms of the other systems should be closely monitored to avoid delaying the diagnosis.
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Ferjani M, El Euch M, Hammi Y, Sayari T, Naija O, Ben Hamida F, Turki S, Gargah T. Systemic lupus erythematosus‐related acute pancreatitis: An exceptional form with severe exocrine and endocrine pancreatitic failure in a Tunisian child. Clin Case Rep 2022; 10:e05423. [PMID: 35169471 PMCID: PMC8832166 DOI: 10.1002/ccr3.5423] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Revised: 01/20/2022] [Accepted: 01/25/2022] [Indexed: 12/26/2022] Open
Abstract
Acute pancreatitis may be the first manifestation in systemic lupus erythematosus or occur during evolution. It is a rare complication, which is often associated with other visceral manifestations. Outcome is usually favorable but can be serious. We report a case of a 17‐year‐old girl with a past history of systemic lupus erythematosus who developed acute pancreatitis revealed by abdominal pain. Elevated serum amylase and lipase levels and pancreatic enlargement on tomography confirmed the diagnosis. Although high‐dose corticosteroid was prescribed, the patient died from a refractory diabetic ketoacidosis.
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Affiliation(s)
- Maryem Ferjani
- Pediatrics department Tunis Tunisia
- University of Tunis El Manar Tunis Tunisia
| | - Mounira El Euch
- University of Tunis El Manar Tunis Tunisia
- Internal medicine department « A » Tunis Tunisia
- Research Laboratory of Kidney Diseases (LR00SP01) Charles Nicolle hospital of Tunis Tunis Tunisia
| | - Yousra Hammi
- Pediatrics department Tunis Tunisia
- University of Tunis El Manar Tunis Tunisia
| | - Taha Sayari
- Pediatrics department Tunis Tunisia
- University of Tunis El Manar Tunis Tunisia
| | - Ouns Naija
- Pediatrics department Tunis Tunisia
- University of Tunis El Manar Tunis Tunisia
| | - Fethi Ben Hamida
- University of Tunis El Manar Tunis Tunisia
- Internal medicine department « A » Tunis Tunisia
- Research Laboratory of Kidney Diseases (LR00SP01) Charles Nicolle hospital of Tunis Tunis Tunisia
| | - Sami Turki
- University of Tunis El Manar Tunis Tunisia
- Internal medicine department « A » Tunis Tunisia
| | - Tahar Gargah
- Pediatrics department Tunis Tunisia
- University of Tunis El Manar Tunis Tunisia
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Dorraji ES, Oteiza A, Kuttner S, Martin-Armas M, Kanapathippillai P, Garbarino S, Kalda G, Scussolini M, Piana M, Fenton KA. Positron emission tomography and single photon emission computed tomography imaging of tertiary lymphoid structures during the development of lupus nephritis. Int J Immunopathol Pharmacol 2021; 35:20587384211033683. [PMID: 34344200 PMCID: PMC8351034 DOI: 10.1177/20587384211033683] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Lymphoid neogenesis occurs in tissues targeted by chronic inflammatory processes, such as infection and autoimmunity. In systemic lupus erythematosus (SLE), such structures develop within the kidneys of lupus-prone mice ((NZBXNZW)F1) and are observed in kidney biopsies taken from SLE patients with lupus nephritis (LN). The purpose of this prospective longitudinal animal study was to detect early kidney changes and tertiary lymphoid structures (TLS) using in vivo imaging. Positron emission tomography (PET) by tail vein injection of 18-F-fluoro-2-deoxy-D-glucose (18F-FDG)(PET/FDG) combined with computed tomography (CT) for anatomical localization and single photon emission computed tomography (SPECT) by intraperitoneal injection of 99mTC labeled Albumin Nanocoll (99mTC-Nanocoll) were performed on different disease stages of NZB/W mice (n = 40) and on aged matched control mice (BALB/c) (n = 20). By using one-way ANOVA analyses, we compared two different compartmental models for the quantitative measure of 18F-FDG uptake within the kidneys. Using a new five-compartment model, we observed that glomerular filtration of 18FFDG in lupus-prone mice decreased significantly by disease progression measured by anti-dsDNA Ab production and before onset of proteinuria. We could not visualize TLS within the kidneys, but we were able to visualize pancreatic TLS using 99mTC Nanocoll SPECT. Based on our findings, we conclude that the five-compartment model can be used to measure changes of FDG uptake within the kidney. However, new optimal PET/SPECT tracer administration sites together with more specific tracers in combination with magnetic resonance imaging (MRI) may make it possible to detect formation of TLS and LN before clinical manifestations.
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Affiliation(s)
- Esmaeil S Dorraji
- RNA and Molecular Pathology Research Group, Institute of Medical Biology, Faculty of Health Sciences, 8016UiT The Arctic University of Norway, Tromsø, Norway
| | - Ana Oteiza
- Nuclear Medicine and Radiation Biology Research Group, Department of Clinical Medicine, Faculty of Health Science, 8016UiT The Arctic University of Norway, Tromsø, Norway
| | - Samuel Kuttner
- Nuclear Medicine and Radiation Biology Research Group, Department of Clinical Medicine, Faculty of Health Science, 8016UiT The Arctic University of Norway, Tromsø, Norway
| | - Montserrat Martin-Armas
- Nuclear Medicine and Radiation Biology Research Group, Department of Clinical Medicine, Faculty of Health Science, 8016UiT The Arctic University of Norway, Tromsø, Norway
| | - Premasany Kanapathippillai
- RNA and Molecular Pathology Research Group, Institute of Medical Biology, Faculty of Health Sciences, 8016UiT The Arctic University of Norway, Tromsø, Norway
| | - Sara Garbarino
- Centre for Medical Image Computing, Department of Computer Science, University College London, London, UK
| | - Gustav Kalda
- Nuclear Medicine and Radiation Biology Research Group, Department of Clinical Medicine, Faculty of Health Science, 8016UiT The Arctic University of Norway, Tromsø, Norway
| | - Mara Scussolini
- Dipartimento di Matematica, 9302Universita di Genova, Genova, Italy
| | - Michele Piana
- Dipartimento di Matematica, 9302Universita di Genova, Genova, Italy.,Dipartimento di Matematica, 9302Universita di Genova, and CNR-SPIN, Genova, Italy
| | - Kristin A Fenton
- RNA and Molecular Pathology Research Group, Institute of Medical Biology, Faculty of Health Sciences, 8016UiT The Arctic University of Norway, Tromsø, Norway
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Frittoli RB, Vivaldo JF, Costallat LTL, Appenzeller S. Gastrointestinal involvement in systemic lupus erythematosus: A systematic review. J Transl Autoimmun 2021; 4:100106. [PMID: 34179742 PMCID: PMC8214088 DOI: 10.1016/j.jtauto.2021.100106] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 05/21/2021] [Indexed: 12/11/2022] Open
Abstract
Introduction Gastrointestinal involvement is a common complain observed in 40–60% of systemic lupus erythematosus (SLE) patients. We performed a systematic review of clinically severe and potential life-threatening gastrointestinal manifestations and discuss clinical presentation, pathogenesis and treatment. Methods We performed a literature search in English literature using PubMed and Embase from 2000 to December 2020. The following MeSH terms: systemic lupus erythematosus, protein-losing enteropathy, ascites, pancreatitis, vasculitis, intestinal vasculitis, enteritis and diarrhea published in the English literature. Results We identified 141 studies (case reports, case series and cohort studies). The most frequent presenting symptoms are acute abdominal pain, nausea, and vomiting. Many of the manifestations were associated with disease activity. Histological features are rarely available, but both vasculitis and thrombosis have been described. There is no treatment guideline. The majority of patients were treated with corticosteroids and the most common immunososupressant were azathioprine, cyclophosphamide and mycophenolate. Conclusion Vasculitis and thrombosis may be responsible for severe life-threatening manifestations such as pancreatitis, protein loosing gastroenteritis, acalculous cholecistyitis and enteritis. Severe Gastrointestinal manifestations are rare, however potential life threatening. Vasculitis and thrombosis are the most frequent pathological mechanism described. Cohort studies with analysis of genetic risk factors and the role of autoantibodies could improve diagnosis and prognosis.
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Affiliation(s)
- Renan Bazuco Frittoli
- Post-Graduation in Medical Pathophysiology, School of Medical Science, University of Campinas, Brazil
| | - Jéssica Fernandes Vivaldo
- Graduate Program in Child and Adolescent Health, School of Medical Science, University of Campinas, Brazil
| | - Lilian Tereza Lavras Costallat
- Department of Orthopedics, Rheumatology and Traumatology, School of Medical Science, University of Campinas, Campinas, São Paulo, 13083881, Brazil
| | - Simone Appenzeller
- Department of Medicine, School of Medical Science - State University of Campinas, Campinas, São Paulo, 13083881, Brazil.,Department of Orthopedics, Rheumatology and Traumatology, School of Medical Science, University of Campinas, Campinas, São Paulo, 13083881, Brazil.,Post-Graduation in Medical Pathophysiology, School of Medical Science, University of Campinas, Brazil.,Graduate Program in Child and Adolescent Health, School of Medical Science, University of Campinas, Brazil
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8
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Lin Q, Zhang M, Tang H, Shen Y, Zhu Y, Xu Q, Li X. Acute pancreatitis and macrophage activation syndrome in pediatric systemic lupus erythematosus: case-based review. Rheumatol Int 2019; 40:811-819. [PMID: 31377830 DOI: 10.1007/s00296-019-04388-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2019] [Accepted: 07/17/2019] [Indexed: 12/14/2022]
Abstract
Pancreatitis is uncommon in systemic lupus erythematosus (SLE) and is rarely reported in children, possibly being related to macrophage activation syndrome (MAS). The incidence of MAS in children with lupus pancreatitis is unknown, as is their prognosis. In this case-based review, we report a pediatric patient with SLE complicated with pancreatitis and MAS, and performed a literature review. We report an 11-year-old girl with SLE and MAS who developed pancreatitis on the second day of methylprednisolone pulse therapy (500 mg/day). We continued methylprednisolone pulse therapy, and performed three rounds of DNA-immunoadsorption and three rounds of hemoperfusion. A second course of methylprednisolone pulse therapy was initiated 9 days later. The patient received a monthly cyclophosphamide pulse therapy (10 mg/kg/day, 2 consecutive days every month) for 6 months, after which she was treated with mycophenolate mofetil 20 mg/kg/day. The condition of the patient gradually improved, her blood amylase and lipase decreased. She was in a stable condition during 13-month follow-up period. Review of the literature of pediatric patients with SLE and pancreatitis showed that there are 127 cases that have been reported in the past 30 years, 40 cases were excluded in our study because of inadequate information. Of the 87 patients included in our literature review, the mortality rate was 33.33%, and 52.86% of the patients with pancreatitis had MAS at the same time. Pancreatitis is uncommon in SLE, but must be suspected if a patient with SLE develops digestive symptoms. Patients with SLE with pancreatitis have a high incidence of MAS and high mortality rate; however, early recognition and effective treatment can relieve the disease symptoms.
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Affiliation(s)
- Qiang Lin
- Department of Nephrology and Immunology, Children's Hospital of Soochow University, 303, Jingde Road, Suzhou, Jiangsu, The People's Republic of China
| | - Man Zhang
- Department of Nephrology and Immunology, Children's Hospital of Soochow University, 303, Jingde Road, Suzhou, Jiangsu, The People's Republic of China
| | - Hanyun Tang
- Department of Nephrology and Immunology, Children's Hospital of Soochow University, 303, Jingde Road, Suzhou, Jiangsu, The People's Republic of China
| | - Yunyan Shen
- Department of Nephrology and Immunology, Children's Hospital of Soochow University, 303, Jingde Road, Suzhou, Jiangsu, The People's Republic of China
| | - Yun Zhu
- Department of Nephrology and Immunology, Children's Hospital of Soochow University, 303, Jingde Road, Suzhou, Jiangsu, The People's Republic of China
| | - Qinying Xu
- Department of Nephrology and Immunology, Children's Hospital of Soochow University, 303, Jingde Road, Suzhou, Jiangsu, The People's Republic of China
| | - Xiaozhong Li
- Department of Nephrology and Immunology, Children's Hospital of Soochow University, 303, Jingde Road, Suzhou, Jiangsu, The People's Republic of China.
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9
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Dwivedi P, Kumar RR, Dhooria A, Adarsh MB, Malhotra S, Kakkar N, Naidu S, Sharma SK, Sharma A, Jain S, Dhir V. Corticosteroid-associated lupus pancreatitis: a case series and systematic review of the literature. Lupus 2019; 28:731-739. [PMID: 31023131 DOI: 10.1177/0961203319844004] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Acute pancreatitis is an uncommon complication that occurs in 0.85% to 4% of patients with systemic lupus erythematosus (SLE). In some patients, it occurs within days to weeks of starting medium-to-high dose corticosteroids. The authors have used the term 'corticosteroid-associated lupus pancreatitis' for these patients, and they report a case series and perform a systematic review of previously published reports. METHODS For the purpose of this study, corticosteroid-associated lupus pancreatitis was defined as occurrence of acute pancreatitis in patients with SLE (fulfilling the 1997 ACR), within 3 weeks of starting therapy with medium-to-high dose corticosteroids - either newly initiated or escalated from a lower dose. All patients with SLE admitted in the last 2.5 years in a North Indian university hospital were reviewed, and those with pancreatitis who fulfilled the above criteria were included in the case series. For the systematic review, a PUBMED search using the keywords 'lupus' and 'pancreatitis' was performed, and reports in English were reviewed for an association with corticosteroids. RESULTS Among 420 admissions of SLE patients, six patients (1.4%) fulfilled criteria for corticosteroid-associated lupus pancreatitis. All were female, with mean age and disease duration of 19.7 ± 3.3 and 3.8 ± 2.5 years respectively. All had active disease and developed acute pancreatitis within 48-72 hours of newly initiating medium-to-high dose corticosteroids (in three patients) or escalating them to medium-high dose (in three patients). After the development of pancreatitis, corticosteroids were continued in all except one patient. In addition, two patients received pulse methylprednisolone, two received pulse cyclophosphamide and one was started on azathioprine. Three patients died during hospitalization, all with severe pancreatitis. On systematic review, among 451 cases of lupus pancreatitis reported, 23 (5%) fulfilled criteria for 'corticosteroid-associated lupus pancreatitis'. A majority of them had pancreatitis within 3 days of starting treatment with medium-to-high dose corticosteroids. The mortality in these patients was 37.5%. CONCLUSION In a small but substantial proportion of patients with lupus who develop pancreatitis, it occurs within days to weeks of starting medium-to-high dose corticosteroids. Many of these patients continue to receive corticosteroids, and some receive more aggressive immunosuppression. However, they have significant mortality, and further studies are required to identify appropriate treatment in this subgroup of patients.
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Affiliation(s)
- P Dwivedi
- 1 Department of Internal Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - R R Kumar
- 1 Department of Internal Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - A Dhooria
- 1 Department of Internal Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - M B Adarsh
- 1 Department of Internal Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - S Malhotra
- 2 Department of Pathology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - N Kakkar
- 2 Department of Pathology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - S Naidu
- 1 Department of Internal Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - S K Sharma
- 1 Department of Internal Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - A Sharma
- 1 Department of Internal Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - S Jain
- 1 Department of Internal Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - V Dhir
- 1 Department of Internal Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
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10
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Diagnosis of Systemic Lupus Erythematosus in a Polynesian Male with a History of Rheumatic Fever: A Case Report and Literature Review. Case Rep Pediatr 2019; 2018:8762482. [PMID: 30693131 PMCID: PMC6332958 DOI: 10.1155/2018/8762482] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Revised: 11/20/2018] [Accepted: 12/02/2018] [Indexed: 11/23/2022] Open
Abstract
The presence of rheumatic heart disease (RHD) and systemic lupus erythematosus (SLE) has rarely been described in one patient. This report describes an adolescent Polynesian male with RHD who developed SLE years later. Initially, he fulfilled modified Jones criteria for rheumatic fever with aortic insufficiency, transient arthritis, elevated streptococcal titers, and a high erythrocyte sedimentation rate with a negative antinuclear antibody (ANA). He responded well to nonsteroidal anti-inflammatory and penicillin prophylaxis, which supported the diagnosis of rheumatic fever. Five years after his RHD diagnosis, he developed pancreatitis with glomerulonephritis, nephrosis, and pancytopenia. In addition, laboratory results revealed that he had multiple autoantibodies: anti-Sm and extremely elevated anti-dsDNA and ANA, fulfilling diagnostic criteria for SLE. The patient was treated, and he responded to pulse steroids followed by oral steroid therapy. To our knowledge, there are no known reported cases of a patient who was diagnosed with both RHD and SLE and met the clinical criteria for both diseases. The rarity of this concurrent disease process in one patient suggests a possible overlap in humoral immunity toward self-antigens as well as ethnic variability that increases predisposition to rheumatologic diseases.
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11
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Tarvin SE, O'Neil KM. Systemic Lupus Erythematosus, Sjögren Syndrome, and Mixed Connective Tissue Disease in Children and Adolescents. Pediatr Clin North Am 2018; 65:711-737. [PMID: 30031495 DOI: 10.1016/j.pcl.2018.04.001] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Juvenile systemic lupus erythematosus (jSLE), mixed connective tissue disease (jMCTD), and Sjögren syndrome (jSS) are systemic autoimmune and inflammatory disorders with distinct patterns of organ involvement. All are characterized by autoantibody formation, with antinuclear (ANA) and anti-double-stranded DNA common in jSLE, ANA with high-titer ribonucleoprotein antibody in jMCTD, and Sjögren syndrome A and Sjögren syndrome B antibodies + ANA in jSS. Recognition, monitoring, and management for primary care providers are discussed, focusing on the role of primary physicians in recognizing and helping maintain optimal health in children with these potentially life-threatening diseases.
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Affiliation(s)
- Stacey E Tarvin
- Division of Rheumatology, Department of Pediatrics, University of Indiana School of Medicine, Riley Hospital for Children at Indiana University Health, 699 Riley Hospital Drive, Riley Research 307, Indianapolis, IN 46202, USA
| | - Kathleen M O'Neil
- Division of Rheumatology, Department of Pediatrics, University of Indiana School of Medicine, Riley Hospital for Children at Indiana University Health, 699 Riley Hospital Drive, Riley Research 307, Indianapolis, IN 46202, USA.
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12
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Acute Pancreatitis in Pediatric Patients: Demographics, Etiology, and Diagnostic Imaging. AJR Am J Roentgenol 2016; 206:632-44. [PMID: 26901022 DOI: 10.2214/ajr.14.14223] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE The objective of this article is to provide updates on acute pancreatitis in children regarding the imaging findings, causes, and complications based on a review of the current studies in the pediatrics literature. We discuss the epidemiology of acute pancreatitis, the role of imaging and imaging findings in the diagnosis of acute pancreatitis, and the causes and complications of acute pancreatitis. CONCLUSION The incidence of acute pancreatitis is increasing in children. Imaging plays an important role in the diagnosis of acute pancreatitis because imaging findings can be used to establish the cause of acute pancreatitis, evaluate for complications of acute pancreatitis, and possibly predict the course of the disease.
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Sato S, Takahashi H, Sato M, Yokoyama M, Itoi T, Kawano Y, Kawashima H. A case of walled-off necrosis with systemic lupus erythematosus: Successful treatment with endoscopic necrosectomy. Semin Arthritis Rheum 2016; 46:e13-e14. [PMID: 27318628 DOI: 10.1016/j.semarthrit.2016.05.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Accepted: 05/18/2016] [Indexed: 01/26/2023]
Affiliation(s)
- Satoshi Sato
- Department of Pediatrics, Tokyo Medical University, Tokyo, Japan; Division of Infectious Diseases and Immunology, Saitama Children's Medical Center, Saitama, Japan.
| | | | - Miki Sato
- Department of Pediatrics, Tokyo Medical University, Tokyo, Japan
| | - Maria Yokoyama
- Department of Pediatrics, Tokyo Medical University, Tokyo, Japan
| | - Takao Itoi
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Yutaka Kawano
- Division of Infectious Diseases and Immunology, Saitama Children's Medical Center, Saitama, Japan
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Abstract
OBJECTIVE Pancreatitis is a rare and a life-threatening systemic lupus erythematosus (SLE) manifestation in childhood-onset SLE (cSLE). The objective of this study was to systematically classify pancreatitis in cSLE according to the International Study Group of Pediatric Pancreatitis and determine the overall prevalence, clinical features, laboratory, and first episode outcomes. METHODS A multicenter cohort study in 10 pediatric rheumatology centers, including 852 patients with cSLE. RESULTS Pancreatitis was diagnosed in 22 of 852 (2.6%) patients with cSLE. It was classified as acute pancreatitis in 20 (91%), acute recurrent pancreatitis in 2 (9%), and none of them had chronic pancreatitis. None of them had gallstones, traumatic pancreatitis, or reported alcohol/tobacco use. The comparison of patients with pancreatitis (first episode) and without this complication revealed a shorter disease duration (1 [0-10] vs 4 [0-23] years, P < 0.0001) and higher median of Systemic Lupus Erythematosus Disease Activity Index 2000 (21 [0-41] vs 2 [0-45], P < 0.0001). The frequencies of fever (P < 0.0001), weight loss (P < 0.0001), serositis (P < 0.0001), nephritis (P < 0.0001), arterial hypertension (P < 0.0001), acute renal failure (P < 0.0001), macrophage activation syndrome (P < 0.0001), and death (P = 0.001) were also higher in patients with pancreatitis. The frequencies of intravenous methylprednisolone use (P < 0.0001) and the median of prednisone dose (55 [15-60] vs 11 [1-90] mg/day, P < 0.0001) were significantly higher in patients with pancreatitis. Of note, the 2 patients with acute recurrent pancreatitis had 2 episodes, with pain-free interval of 1 and 4 years. CONCLUSIONS This was the first study characterizing pancreatitis using the International Study Group of Pediatric Pancreatitis standardized definitions in patients with cSLE showing that the predominant form is acute pancreatitis seen in association with glucocorticoid treatment and active severe disease.
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Gormezano NWS, Otsuzi CI, Barros DL, da Silva MA, Pereira RMR, Campos LMA, Borba EF, Bonfá E, Silva CA. Macrophage activation syndrome: A severe and frequent manifestation of acute pancreatitis in 362 childhood-onset compared to 1830 adult-onset systemic lupus erythematosus patients. Semin Arthritis Rheum 2015; 45:706-10. [PMID: 26833399 DOI: 10.1016/j.semarthrit.2015.10.015] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2015] [Revised: 08/31/2015] [Accepted: 10/30/2015] [Indexed: 02/07/2023]
Abstract
OBJECTIVE We previously reported a case series of acute pancreatitis (AP) and macrophage activation syndrome (MAS) in childhood (cSLE) patients; however, there are no data regarding the comparison of AP and MAS in large populations of cSLE and adult SLE (aSLE). METHODS A study included 362 cSLE and 1830 aSLE patients. MAS was diagnosed according to preliminary diagnostic guidelines and AP according to the presence of abdominal pain or vomiting associated to an increase of pancreatic enzymes and/or pancreatic radiological abnormalities. Demographic data, clinical features, SLEDAI-2K, SLICC/ACR-DI, and treatment were assessed. RESULTS Age in MAS patients was significantly lower compared with those without this complication [15 (8.8-55) vs. 33.5 (10.2-45.7) years, p = 0.007]. The frequencies of fever (94% vs. 37%, p = 0.001), leucopenia (82% vs. 19%, p = 0.0001), thrombocytopenia (65% vs. 19%, p = 0.013), hypertriglyceridemia (87% vs. 42%, p = 0.037), and hyperferritinemia (93% vs. 37%, p = 0.011) were also more frequently observed in AP patients with MAS compared in AP patients without MAS. Fever and hyperferritinemia concomitantly were more frequent in the former group (86% vs. 12%, p = 0.0015). Higher and significant frequency of AP in cSLE compared to aSLE patients [12/362 (3.3%) vs. 20/1830 (1.1%), p = 0.003], with similar AP duration [22 (6-60) vs. 15 (4-90) days, p = 0.534]. MAS (85% vs. 30%, p = 0.003) and death by MAS complication (31% vs. 0%, p = 0.017) were significantly higher in children compared with aSLE. CONCLUSIONS This study provides novel data demonstrating that MAS occur in the majority of cSLE with AP with a higher mortality compared to aSLE. In addition, we identified in AP patients, a cluster of MAS clinical and laboratorial parameters more associated with this complication.
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Affiliation(s)
- Natali W S Gormezano
- Division of Rheumatology, Faculdade de Medicina da Universidade de São Paulo, Av. Dr. Arnaldo, no. 455, 3 andar, sala 3190-Cerqueira César, São Paulo 05403-010, Brazil; Pediatric Rheumatology Unit, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Carini I Otsuzi
- Division of Rheumatology, Faculdade de Medicina da Universidade de São Paulo, Av. Dr. Arnaldo, no. 455, 3 andar, sala 3190-Cerqueira César, São Paulo 05403-010, Brazil
| | - Diego L Barros
- Division of Rheumatology, Faculdade de Medicina da Universidade de São Paulo, Av. Dr. Arnaldo, no. 455, 3 andar, sala 3190-Cerqueira César, São Paulo 05403-010, Brazil
| | - Mariana A da Silva
- Division of Rheumatology, Faculdade de Medicina da Universidade de São Paulo, Av. Dr. Arnaldo, no. 455, 3 andar, sala 3190-Cerqueira César, São Paulo 05403-010, Brazil
| | - Rosa M R Pereira
- Division of Rheumatology, Faculdade de Medicina da Universidade de São Paulo, Av. Dr. Arnaldo, no. 455, 3 andar, sala 3190-Cerqueira César, São Paulo 05403-010, Brazil
| | - Lucia M A Campos
- Pediatric Rheumatology Unit, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Eduardo F Borba
- Division of Rheumatology, Faculdade de Medicina da Universidade de São Paulo, Av. Dr. Arnaldo, no. 455, 3 andar, sala 3190-Cerqueira César, São Paulo 05403-010, Brazil
| | - Eloisa Bonfá
- Division of Rheumatology, Faculdade de Medicina da Universidade de São Paulo, Av. Dr. Arnaldo, no. 455, 3 andar, sala 3190-Cerqueira César, São Paulo 05403-010, Brazil
| | - Clovis A Silva
- Division of Rheumatology, Faculdade de Medicina da Universidade de São Paulo, Av. Dr. Arnaldo, no. 455, 3 andar, sala 3190-Cerqueira César, São Paulo 05403-010, Brazil; Pediatric Rheumatology Unit, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil.
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