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Shirai T, Ichikawa S, Saegusa J. Tacrolimus Treatment for TAFRO Syndrome. Biomedicines 2024; 12:1070. [PMID: 38791031 PMCID: PMC11118940 DOI: 10.3390/biomedicines12051070] [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: 04/11/2024] [Revised: 05/08/2024] [Accepted: 05/10/2024] [Indexed: 05/26/2024] Open
Abstract
TAFRO syndrome is an acute systemic inflammatory disorder characterized by thrombocytopenia, anasarca, fever, reticulin myelofibrosis, renal dysfunction, and organomegaly. While its lymph node pathology is similar to that of idiopathic multicentric Castleman disease (iMCD), the clinical features of TAFRO syndrome differ from those of typical iMCD, as they include a more aggressive clinical course and high mortality. However, an optimal treatment strategy for TAFRO syndrome has not yet been established, owing to a poor understanding of its pathogenesis. The limited cases we encountered suggest that tacrolimus treatment in combination with glucocorticoids may potentially be effective and well tolerated as an initial treatment, and hold promise as a glucocorticoid-sparing agent. Herein, we report an additional case and review the sparse literature available regarding TAFRO syndrome treated via tacrolimus.
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Affiliation(s)
- Taiichiro Shirai
- Department of Rheumatology and Clinical Immunology, Kobe University Graduate School of Medicine, Kobe 650-0017, Japan
- Laboratory of Immune Response Dynamics, WPI Immunology Frontier Research Center, Osaka University, Osaka 565-0871, Japan
- Department of Immune Response Dynamics, Research Institute for Microbial Diseases, Osaka University, Osaka 565-0871, Japan
| | - Shinya Ichikawa
- Department of Rheumatology and Clinical Immunology, Kobe University Graduate School of Medicine, Kobe 650-0017, Japan
| | - Jun Saegusa
- Department of Rheumatology and Clinical Immunology, Kobe University Graduate School of Medicine, Kobe 650-0017, Japan
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Yamamoto S, Wells K, Morita K, Tanigaki K, Muro K, Matsumoto M, Nakai H, Arai Y, Akizuki S, Takahashi K, Minamiguchi S, Fukuma S, Yanagita M. Severe TAFRO Syndrome Mimicking Hepatorenal Syndrome Successfully Treated with a Multidisciplinary Approach: A Case Report and Literature Review. Intern Med 2023; 62:2715-2724. [PMID: 36725034 PMCID: PMC10569924 DOI: 10.2169/internalmedicine.1178-22] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Accepted: 12/19/2022] [Indexed: 02/03/2023] Open
Abstract
Finding the ideal balance between efficacy and safety of immunosuppression is challenging, particularly in cases of severe TAFRO syndrome. We herein report a 60-year-old man diagnosed with grade 5 TAFRO syndrome mimicking hepatorenal syndrome that was successfully treated by glucocorticoid, tocilizumab, and cyclosporin despite virus infection. Furthermore, by examining 14 peer-reviewed remission cases, we revealed that the recovery periods among inflammation, renal dysfunction, and thrombocytopenia were quite different, with recovery from thrombocytopenia notably slow. All patients requiring dialysis were successfully withdrawn from dialysis, and the reversibility from kidney injury was good. This clinical information will help clinicians plan treatments and tailor the intensity of immunosuppression.
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Affiliation(s)
- Shinya Yamamoto
- Department of Nephrology, Graduate School of Medicine, Kyoto University, Japan
| | - Ken Wells
- Department of Nephrology, Graduate School of Medicine, Kyoto University, Japan
| | - Keisuke Morita
- Department of Nephrology, Graduate School of Medicine, Kyoto University, Japan
| | - Katsuya Tanigaki
- Department of Nephrology, Graduate School of Medicine, Kyoto University, Japan
- Department of Nephrology, Kansai Denryoku Hospital, Japan
| | - Koji Muro
- Department of Nephrology, Graduate School of Medicine, Kyoto University, Japan
| | - Minami Matsumoto
- Department of Nephrology, Graduate School of Medicine, Kyoto University, Japan
| | - Hirotsugu Nakai
- Department of Diagnostic Imaging and Nuclear Medicine, Graduate School of Medicine, Kyoto University, Japan
- Department of Radiology, Tenri Hospital, Japan
| | - Yasuyuki Arai
- Department of Hematology and Oncology, Graduate School of Medicine, Kyoto University, Japan
| | - Shuji Akizuki
- Department of Rheumatology and Clinical Immunology, Graduate School of Medicine, Kyoto University, Japan
| | - Ken Takahashi
- Department of Gastroenterology and Hepatology, Graduate School of Medicine, Kyoto University, Japan
| | - Sachiko Minamiguchi
- Department of Diagnostic Pathology, Graduate School of Medicine, Kyoto University, Japan
| | - Shingo Fukuma
- Human and Health Sciences, Graduate School of Medicine, Kyoto University, Japan
| | - Motoko Yanagita
- Department of Nephrology, Graduate School of Medicine, Kyoto University, Japan
- Institute for the Advanced Study of Human Biology (WPI-ASHBi), Kyoto University, Japan
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Shimada K, Sasaki T, Okabe M, Koike K, Takahashi D, Terashima R, Honda Y, Matsumoto N, Fukui A, Ishikawa M, Tsuboi N, Yokoo T. TAFRO Syndrome With Kidney Involvement: A Case Series of Patients With Kidney Biopsies. Kidney Med 2021; 3:286-293. [PMID: 33851125 PMCID: PMC8039406 DOI: 10.1016/j.xkme.2020.10.011] [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: 12/26/2022] Open
Abstract
TAFRO (thrombocytopenia, anasarca, fever, reticulin myelofibrosis/renal insufficiency, and organomegaly) syndrome is a systemic inflammatory disease sharing some features with Castleman disease and POEMS (polyneuropathy, organomegaly, endocrinopathy, monoclonal protein, and skin changes) syndrome in relation to abnormal secretions of interleukin 6 and vascular endothelial growth factor. The kidney is a main target organ of TAFRO syndrome but the kidney histopathology associated with TAFRO syndrome is yet to be completely defined. We report 3 TAFRO syndrome cases with different clinical courses in which kidney biopsies were performed. In all 3 cases, kidney biopsies showed similar glomerular lesions of diffuse global swelling of the endothelium and expansion of subendothelial spaces, consistent with severe glomerular endothelial injury. Case 3 showed an additional finding of focal tubulointerstitial injury characterized by marked plasma cell infiltration, which was absent in the other 2 cases. Clinical symptoms in cases 1 and 2, which had lower disease severity scores of TAFRO syndrome, were effectively treated with the administration of corticosteroids or a combination of corticosteroids and cyclosporine A. Case 3, with a higher disease severity score, had an aggressive clinical course that was refractory to corticosteroids and tocilizumab; the patient ultimately died of multiple organ failure. In all 3 cases, kidney biopsy provided indications for the diagnosis process and clinical management of TAFRO syndrome.
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Affiliation(s)
- Keiki Shimada
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan.,Department of Nephrology, Kawaguchi Municipal Medical Center, Kawaguchi, Japan
| | - Takaya Sasaki
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan.,Department of Nephrology, Kawaguchi Municipal Medical Center, Kawaguchi, Japan
| | - Masahiro Okabe
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | - Kentaro Koike
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | - Daisuke Takahashi
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | - Risa Terashima
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | - Yu Honda
- Department of Nephrology, Kawaguchi Municipal Medical Center, Kawaguchi, Japan
| | - Naoto Matsumoto
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | - Akira Fukui
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | - Masahiro Ishikawa
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan.,Department of Nephrology, Kawaguchi Municipal Medical Center, Kawaguchi, Japan
| | - Nobuo Tsuboi
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | - Takashi Yokoo
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
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Wada M, Nagata A, Kawashima A, Kagawa K. An Autopsy Case of TAFRO Syndrome with Type II Respiratory Failure. AMERICAN JOURNAL OF CASE REPORTS 2020; 21:e926721. [PMID: 33048915 PMCID: PMC7568526 DOI: 10.12659/ajcr.926721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Patient: Male, 66-year-old Final Diagnosis: TAFRO syndrome Symptoms: Appetite loss • dyspnea • general fatigue Medication: — Clinical Procedure: Biopsy Specialty: Hematology
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Affiliation(s)
- Mikio Wada
- Fukuchiyama City Hospital Ooe-branch, Fukuchiyama, Kyoto, Japan
| | - Akihiro Nagata
- Department of Pathology, Fukuchiyama City Hospital, Fukuchiyama, Kyoto, Japan
| | - Atsushi Kawashima
- General Internal Medicine, Fukuchiyama City Hospital, Fukuchiyama, Kyoto, Japan
| | - Keizo Kagawa
- General Internal Medicine, Fukuchiyama City Hospital, Fukuchiyama, Kyoto, Japan
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Simeni Njonnou SR, Deuson J, Royer-Chardon C, Vandergheynst FA, Wilde VD. Unexplained cause of thrombocytopenia, fever, anasarca and hypothyroidism: TAFRO syndrome with thrombotic microangiopathy renal histology. BMJ Case Rep 2020; 13:13/6/e234155. [PMID: 32606113 DOI: 10.1136/bcr-2019-234155] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
TAFRO (thrombocytopenia, anasarca, fever, reticulin myelofibrosis or renal dysfunction and organomegaly) syndrome is a systemic inflammatory disease characterised by thrombocytopenia, anasarca, fever or inflammatory syndrome, reticulin myelofibrosis or renal dysfunction and organomegaly. It was first described as a subtype of idiopathic multicentric Castleman disease. Here, we report the case of a 42-year-old woman presenting with thrombocytopenia, anasarca, inflammatory syndrome, renal insufficiency, reticulin myelofibrosis at bone marrow biopsy and cervical and axillary lymph nodes. Kidney biopsy showed double contours of the glomerular basement membrane, mesangiolysis and endothelial swelling compatible with thrombotic microangiopathy (TMA) as well as with TAFRO syndrome. She was successfully treated by corticosteroids, tocilizumab and rituximab. This new case description of TAFRO syndrome underlines three features of this disease rarely described in the literature and never simultaneously in the same patient: the association to severe hypothyroidism, the presence of TMA-like lesions on kidney biopsy and the treatment by the association of steroids, tocilizumab and rituximab.
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Affiliation(s)
- Sylvain Raoul Simeni Njonnou
- Internal Medicine, Hopital Erasme, Brussels, Belgium
- Internal Medicine and Specialties, Faculty of Medicine and Pharmaceutical Sciences, University of Dschang, Dschang, Cameroon
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Kobayashi S, Inui A, Tsunoda T, Umetsu S, Sogo T, Mori M, Shinkai M, Fujisawa T. Liver cirrhosis in a child associated with Castleman's disease: A case report. World J Clin Cases 2020; 8:1656-1665. [PMID: 32432144 PMCID: PMC7211522 DOI: 10.12998/wjcc.v8.i9.1656] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Revised: 03/27/2020] [Accepted: 04/20/2020] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Castleman's disease (CD) is a lymphoproliferative disorder. TAFRO syndrome is classified as a variant of CD based on its key clinical manifestations of thrombocytopenia, anasarca (generalized edema and pleural effusion), fever (pyrexia), reticulin fibrosis in the bone marrow and the proliferation of megakaryocytes, and organomegaly (such as hepatosplenomegaly and multiple lymphadenopathies); TAFRO syndrome is mainly reported in Japanese patients. To our knowledge, this is the first pediatric case report detailing a CD-associated disorder progressing to cirrhosis.
CASE SUMMARY A 10-year old male patient presented with fever and anemia. Six months before hospitalization, he had remarkable abdominal distention. Subsequently, he visited a clinic for a fever that lasted 5 d. The physical findings were marked hepatosplenomegaly and cervical lymphadenopathy. A blood test revealed leukocytosis, microcytic anemia, aspartate aminotransferase-dominant transaminase elevation, high levels of C-reactive protein, polyclonal hypergammaglobulinemia, and high levels of interleukin-6 and vascular endothelial growth factor. Abdominal contrast computed tomography and magnetic resonance imaging suggested cirrhosis, which was confirmed by liver histology. Histological findings in the enlarged hepatic lymph nodes revealed both hyperplasia and atrophy of lymphoid follicles with some vascular hyperplasia and moderate plasmacytosis between the lymphoid follicles, which is compatible with lymph node histology in TAFRO syndrome. Prednisolone was not effective in reducing the patient’s symptoms; therefore, the patient was prescribed tocilizumab. To date, the patient remains free of fever and continues to receive tocilizumab.
CONCLUSION We described the clinicopathological features of TAFRO syndrome to highlight the clinical presentation of this rare disease in a pediatric case.
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Affiliation(s)
- Soya Kobayashi
- Department of Pediatric Hepatology and Gastroenterology, Saiseikai Yokohama City Tobu Hospital, Yokohama 230-8765, Japan
| | - Ayano Inui
- Department of Pediatric Hepatology and Gastroenterology, Saiseikai Yokohama City Tobu Hospital, Yokohama 230-8765, Japan
| | - Tomoyuki Tsunoda
- Department of Pediatric Hepatology and Gastroenterology, Saiseikai Yokohama City Tobu Hospital, Yokohama 230-8765, Japan
| | - Syuichiro Umetsu
- Department of Pediatric Hepatology and Gastroenterology, Saiseikai Yokohama City Tobu Hospital, Yokohama 230-8765, Japan
| | - Tsuyoshi Sogo
- Department of Pediatric Hepatology and Gastroenterology, Saiseikai Yokohama City Tobu Hospital, Yokohama 230-8765, Japan
| | - Masaaki Mori
- Department of Lifetime Clinical Immunology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo 113-8519, Japan
| | - Masato Shinkai
- Department of Surgery, Kanagawa Children’s Medical Center, Yokohama 232-8555, Japan
| | - Tomoo Fujisawa
- Department of Pediatric Hepatology and Gastroenterology, Saiseikai Yokohama City Tobu Hospital, Yokohama 230-8765, Japan
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Leurs A, Gnemmi V, Lionet A, Renaud L, Gibier JB, Copin MC, Hachulla E, Hatron PY, Launay D, Fajgenbaum D, Terriou L. Renal Pathologic Findings in TAFRO Syndrome: Is There a Continuum Between Thrombotic Microangiopathy and Membranoproliferative Glomerulonephritis? A Case Report and Literature Review. Front Immunol 2019; 10:1489. [PMID: 31316523 PMCID: PMC6609882 DOI: 10.3389/fimmu.2019.01489] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Accepted: 06/14/2019] [Indexed: 12/23/2022] Open
Abstract
Background: TAFRO syndrome is a clinical subtype of idiopathic multicentric Castleman disease (iMCD) that is characterized by thrombocytopenia, anasarca, fever and/or elevated serum C-reactive protein, renal dysfunction, and organomegaly. Case Presentation: A 28-year-old woman with fever, weight gain of 13 kgs, lower extremity edema, hepatosplenomegaly, and multicentric peripheral lymphadenopathy was referred to our center. Laboratory investigations revealed anemia, thrombocytopenia, creatinine at 1.19 mg/dL and hypoalbuminemia at 33 g/L. Proteinuria was measured at 2 g/day including albuminuria at 1.5 g/day. Urinary sediment examination found leukocyturia at 44,000/mL and hematuria at 645,000/mL. Vascular endothelial growth factor (VEGF) level was elevated. A cervical lymph node biopsy found features consistent with the mixed histopathological subtype of iMCD. A renal biopsy revealed a membranoproliferative glomerulonephritis (MPGN) pattern. We initiated 3 days of methylprednisolone pulse-therapy at 1,000 mg per day, followed by prednisone 1 mg/kg/day and evolution was favorable. Review of Literature: 19 iMCD patients with TAFRO syndrome had undergone a renal biopsy: 8 cases with author's diagnosis consistent with MPGN-like and 11 cases of thrombotic microangiopathy (TMA)-like glomerulopathy without fibrin thrombi in glomerular capillaries or arterioles and without typical biological signs. Clinical, biological, and outcome characteristics were similar between the cases described as having MPGN and TMA-like presentation. After a thorough review of histopathological descriptions for each case, MPGN lesions seems to be the consequences of chronic glomerular endothelial injury in persistent TMA. We suspect that VEGF and IL-6 play a key role in the physiopathology of the spectrum of renal involvement from TMA-like to MPGN observed in TAFRO syndrome. Conclusion: We present a Caucasian iMCD patient with TAFRO syndrome with renal insufficiency secondary to MPGN, which might be secondary to a chronic TMA-like disease. We suspect that there is a continuum between TMA and MPGN lesions in TAFRO syndrome favored by VEGF and IL-6.
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Affiliation(s)
- Amélie Leurs
- Département de Médecine Interne et Immunologie Clinique, CHU Lille, Centre de Référence des Maladies Auto-Immunes Systémiques Rares du Nord et Nord-Ouest de France (CeRAINO), LIRIC INSERM U995, Université de Lille, Lille, France.,CHU Lille, Institut d'Immunologie, Université de Lille, Lille, France
| | - Viviane Gnemmi
- Département d'Anatomo-Cyto-Pathologie, CHU Lille, Centre de Biologie Pathologie, Université de Lille, Lille, France
| | - Arnaud Lionet
- Département de Néphrologie, CHU Lille, Université de Lille, Lille, France
| | - Loïc Renaud
- CHU Lille, Institut d'Immunologie, Université de Lille, Lille, France.,Département des Maladies du Sang, CHU Lille, Université de Lille, Lille, France
| | - Jean-Baptiste Gibier
- Département d'Anatomo-Cyto-Pathologie, CHU Lille, Centre de Biologie Pathologie, Université de Lille, Lille, France
| | - Marie-Christine Copin
- Département d'Anatomo-Cyto-Pathologie, CHU Lille, Centre de Biologie Pathologie, Université de Lille, Lille, France
| | - Eric Hachulla
- Département de Médecine Interne et Immunologie Clinique, CHU Lille, Centre de Référence des Maladies Auto-Immunes Systémiques Rares du Nord et Nord-Ouest de France (CeRAINO), LIRIC INSERM U995, Université de Lille, Lille, France
| | - Pierre-Yves Hatron
- Département de Médecine Interne et Immunologie Clinique, CHU Lille, Centre de Référence des Maladies Auto-Immunes Systémiques Rares du Nord et Nord-Ouest de France (CeRAINO), LIRIC INSERM U995, Université de Lille, Lille, France
| | - David Launay
- Département de Médecine Interne et Immunologie Clinique, CHU Lille, Centre de Référence des Maladies Auto-Immunes Systémiques Rares du Nord et Nord-Ouest de France (CeRAINO), LIRIC INSERM U995, Université de Lille, Lille, France.,CHU Lille, Institut d'Immunologie, Université de Lille, Lille, France
| | - David Fajgenbaum
- Department of Translational Medicine and Human Genetics, University of Pennsylvania, Philadelphia, PA, United States
| | - Louis Terriou
- Département de Médecine Interne et Immunologie Clinique, CHU Lille, Centre de Référence des Maladies Auto-Immunes Systémiques Rares du Nord et Nord-Ouest de France (CeRAINO), LIRIC INSERM U995, Université de Lille, Lille, France.,CHU Lille, Institut d'Immunologie, Université de Lille, Lille, France
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