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Abdelfattah AH, Macpherson A, Javed F. Macrophage Activation Syndrome Presents as Initial Manifestation of Lupus in an Adult Female. Cureus 2024; 16:e60567. [PMID: 38894758 PMCID: PMC11184542 DOI: 10.7759/cureus.60567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/18/2024] [Indexed: 06/21/2024] Open
Abstract
Systemic lupus erythematosus (SLE) is an autoimmune disease characterized by the immune system erroneously attacking healthy tissues and organs. SLE has a wide variety of clinical presentations. The signs and symptoms of SLE are very well-known, though rare presentations could occur that require early clinical attention. Macrophage activation syndrome (MAS) is a severe and life-threatening condition in which the immune system becomes overactive, leading to the excessive stimulation and proliferation of immune cells. MAS can occur as a primary immune disorder, which is not very common. It can also happen secondary to a wide variety of pathological conditions, which include infections, malignancies, autoimmune, and rheumatologic disorders. In rare cases, SLE can present with overlapping features of MAS, further complicating the clinical picture, and may require specialized management. Early recognition and intervention of this overlap are essential for improving outcomes, as delayed diagnosis and treatment can lead to significant morbidity and mortality. Here, we present a case of a young adult female who was diagnosed with SLE with the initial presentation of MAS in the form of fever, splenomegaly, cytopenia, and hemophagocytosis.
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Affiliation(s)
- Ahmed H Abdelfattah
- Internal Medicine/Hospital Medicine, University of Kentucky College of Medicine, Lexington, USA
| | - Alexandra Macpherson
- Internal Medicine/Hospital Medicine, University of Kentucky College of Medicine, Lexington, USA
| | - Faiza Javed
- Internal Medicine/Hospital Medicine, University of Kentucky College of Medicine, Lexington, USA
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2
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Gouda W, Alsaqabi F, Moshrif A, Abbas AS, Abdel-Aziz TM, Islam MA. Macrophage activation syndrome triggered by systemic lupus erythematosus flare: successful treatment with a combination of dexamethasone sodium phosphate, intravenous immunoglobulin, and cyclosporine: a case report. J Med Case Rep 2021; 15:497. [PMID: 34620236 PMCID: PMC8495443 DOI: 10.1186/s13256-021-03072-1] [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: 07/02/2021] [Accepted: 08/23/2021] [Indexed: 11/18/2022] Open
Abstract
Background Macrophage activation syndrome is classified as a secondary form of hemophagocytic lymphohistiocytosis. It is a hyperinflammatory complication observed to be comorbid with a variety of autoimmune diseases, including adult-onset Still’s disease and systemic juvenile idiopathic arthritis. Macrophage activation syndrome is less commonly detected in adult patients with systemic lupus erythematosus, which, if untreated, can be fatal, though determining the optimum treatment strategy is still a challenge. Case presentation Herein, we report a case of macrophage activation syndrome in a 33-year-old Egyptian female as an unusual complication of a systemic lupus erythematosus flare in adult patients. Our patient was initially treated with a combination of intravenous methylprednisolone pulse therapy and intravenous immunoglobulin therapy, which was followed by a course of oral prednisolone and oral cyclosporine with little response. Switching from oral prednisone to intravenous dexamethasone sodium phosphate showed a more favorable clinical and biochemical response. Conclusion Macrophage activation syndrome is less commonly detected in adult patients with systemic lupus erythematosus. Our case demonstrates that dexamethasone sodium phosphate can be a successful alternative treatment for patients with systemic lupus erythematosus complicated by macrophage activation syndrome in whom the response to pulse methylprednisolone was inadequate to manage their illness, proving to be remarkably effective in a relatively short time frame.
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Affiliation(s)
- Wesam Gouda
- Department of Rheumatology, Faculty of Medicine, Al Azhar University, Assiut, Egypt. .,Department of Rheumatology, Al-Sabah Hospital, Kuwait, Kuwait.
| | - Faisal Alsaqabi
- Department of Rheumatology, Al-Sabah Hospital, Kuwait, Kuwait
| | - Abdelhfeez Moshrif
- Department of Rheumatology, Faculty of Medicine, Al Azhar University, Assiut, Egypt
| | - Awad S Abbas
- Department of Rheumatology, Faculty of Medicine, Al Azhar University, Assiut, Egypt
| | - Tarek M Abdel-Aziz
- Department of Rheumatology, Faculty of Medicine, Al Azhar University, Assiut, Egypt
| | - Md Asiful Islam
- Department of Haematology, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia
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3
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Bojan A, Parvu A, Zsoldos IA, Torok T, Farcas AD. Macrophage activation syndrome: A diagnostic challenge (Review). Exp Ther Med 2021; 22:904. [PMID: 34257717 PMCID: PMC8243343 DOI: 10.3892/etm.2021.10336] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Accepted: 04/26/2021] [Indexed: 12/13/2022] Open
Abstract
Macrophage activation syndrome (MAS) represents an acute and severe inflammatory syndrome, idiopathic (primary) or secondary to infections, rheumatic diseases, malignancies, or drugs. MAS is underdiagnosed, being confused with sepsis, adverse effects of anti-arthritic drugs or exacerbated symptoms of evolving rheumatologic or infectious diseases. Because of the late diagnosis, most patients do not benefit from effective therapy, leading to death. Elucidation of valid early diagnostic criteria of MAS would be a particularly important step in reducing the mortality due to this pathology. Thus, the purpose of this review based on 40 studies centered on the diagnostic criteria of MAS. We detailed the main diagnostic criteria and the few diagnostic scores or sets of criteria that have been recently published. The criteria most frequently encountered in the literature include: Fever, hepatosplenomegaly, hyperferritinemia, hepatopathy, coagulopathy, thrombocytopenia, hypertriglyceridemia, decrease in erythrocyte sedimentation rate and bone marrow hemophagocytosis. The most elaborate diagnostic score will result following an ongoing international project and consensus, the Delphi International Survey.
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Affiliation(s)
- Anca Bojan
- Hematology Department, 'Iuliu Hatieganu' University of Medicine and Pharmacy, 400124 Cluj-Napoca, Romania.,Hematology Department, 'Prof. Dr. Ioan Chiricuta' Oncological Insitute, 400124 Cluj-Napoca, Romania
| | - Andrada Parvu
- Hematology Department, 'Iuliu Hatieganu' University of Medicine and Pharmacy, 400124 Cluj-Napoca, Romania.,Hematology Department, 'Prof. Dr. Ioan Chiricuta' Oncological Insitute, 400124 Cluj-Napoca, Romania
| | - Iulia-Andrea Zsoldos
- Hematology Department, 'Prof. Dr. Ioan Chiricuta' Oncological Insitute, 400124 Cluj-Napoca, Romania
| | - Tunde Torok
- Hematology Department, 'Iuliu Hatieganu' University of Medicine and Pharmacy, 400124 Cluj-Napoca, Romania.,Hematology Department, 'Prof. Dr. Ioan Chiricuta' Oncological Insitute, 400124 Cluj-Napoca, Romania
| | - Anca Daniela Farcas
- Internal Medicine Department, 'Iuliu Hatieganu' University of Medicine and Pharmacy, 400006 Cluj-Napoca, Romania.,Cardiology Department, Emergency County Clinic Hospital, 400006 Cluj-Napoca, Romania
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Castillo JM, MÁrquez AMB, Cabada IAB. Systemic Lupus Erythematosus and Its Association with Hemophagocytic Syndrome as an Initial Manifestation. MÆDICA 2021; 15:556-560. [PMID: 33603918 DOI: 10.26574/maedica.2020.15.4.556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Introduction: Hemophagocytic syndrome (HS) is a potentially fatal hyperinflammatory condition characterized by excessive activation of macrophages and T cells. Systemic lupus erythematosus (SLE) is an autoimmune condition that predisposes to HS. The appearance of SLE and HS is rare. Clinical case: A 16-year-old male presented with fever for one month and lymphadenopathy prior to admission. During evaluation, the patient accumulated 10 points required by EULAR/ACR 2019 for classifying the condition as SLE. Hemophagocytosis was observed in the bone marrow aspirate. The diagnosis of HS secondary to SLE was concluded. Under treatment with intravenous methylprednisolone and mycophenolic acid, symptoms improved and the patient was subsequently discharged. Discussion: The most typical findings of HS include fever, hepatosplenomegaly, and cytopenias, with lymphadenopathy being the least common. The characteristics of SLE and HS are very similar, making it difficult to differentiate between these two entities. Conclusion: Although HS is not one of the frequent manifestations of SLE, a high suspicion of its possible association with SLE must be maintained for timely treatment.
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Affiliation(s)
- Jorge Medina Castillo
- Medicina Interna, Centro Médico Nacional del Noreste, Instituto Mexicano del Seguro Social, Monterrey, Nuevo León, México
| | - Ariana Maia Becerra MÁrquez
- Reumatología, Centro Médico Nacional del Noreste, Instituto Mexicano del Seguro Social, Monterrey, Nuevo León, México
| | - Isabel Anahí Borjon Cabada
- Hematología, Centro Médico Nacional del Noreste, Instituto Mexicano del Seguro Social, Monterrey, Nuevo León, México
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5
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The IL-1 family of cytokines and receptors in rheumatic diseases. Nat Rev Rheumatol 2019; 15:612-632. [DOI: 10.1038/s41584-019-0277-8] [Citation(s) in RCA: 168] [Impact Index Per Article: 33.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/18/2019] [Indexed: 02/07/2023]
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6
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Lepe-Zuniga JL, Jeronimo-Lopez FJ, Hernandez-Orantes JG, Mendez-Cigarroa AO. Non-EBV-Related Aggressive NK-Cell Leukemia: An Oncohematological Great Imitator. J Hematol 2018; 7:163-166. [PMID: 32300433 PMCID: PMC7155853 DOI: 10.14740/jh462] [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: 09/17/2018] [Accepted: 10/05/2018] [Indexed: 11/11/2022] Open
Abstract
Aggressive natural killer (NK)-cell leukemia (ANKL) is a very rare oncohematological disease among youngsters in Latin America. Its clinical picture imitates a variety of syndromes and diseases due to its pathophysiology. Its diagnosis is relatively simple due to the prominence of NK malignant cells in peripheral blood and its clinical aggressiveness. In certain circumstances though, the presence of blast NK cells and the natural course of the disease can be so modified by the treatment of one of the imitated diseases, especially when using steroids, that it becomes very difficult to diagnose early in its course. We present a case of a 16-year-old Mexican male who initiated symptoms imitating dengue to severe dengue for which he received steroids, apparently inducing a partial remission; he was then diagnosed as having community acquired pneumonia, then sepsis, septic shock w/disseminated intravascular coagulation, primary hemophagocytic syndrome, severe hepatitis, lupus and finally hyper IgE. It was not until 1 day before dying of hemorrhagic shock, a month after initiating symptoms, when the (re)emergence of blast NK cells in peripheral blood allowed the correct diagnosis to be made. Knowledge of ANKL pathophysiology may raise awareness of this multifaceted malignancy and may open up possibilities for its therapy. Gained knowledge can also be used for guiding NK cell evident aggressiveness against other malignancies.
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Affiliation(s)
- Jose L Lepe-Zuniga
- Hospital de Especialidades Pediatricas, Tuxtla Gutierrez, Chiapas, Mexico.,Research Department, Hospital de Especialidades Pediatricas, Tuxtla Gutierrez, Chiapas, Mexico
| | - Francisco Javier Jeronimo-Lopez
- Hospital de Especialidades Pediatricas, Tuxtla Gutierrez, Chiapas, Mexico.,Hematology Lab, Hospital de Especialidades Pediatricas, Tuxtla Gutierrez, Chiapas, Mexico
| | - Jorge Gregorio Hernandez-Orantes
- Hospital de Especialidades Pediatricas, Tuxtla Gutierrez, Chiapas, Mexico.,Cytometry Lab, Hospital de Especialidades Pediatricas, Tuxtla Gutierrez, Chiapas, Mexico
| | - Adriana Osiris Mendez-Cigarroa
- Hospital de Especialidades Pediatricas, Tuxtla Gutierrez, Chiapas, Mexico.,General Lab, Hospital de Especialidades Pediatricas, Tuxtla Gutierrez, Chiapas, Mexico
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Macrophage Activation Syndrome, Glomerulonephritis, Pericarditis, and Retinal Vasculitis as Initial Presentation of Systemic Lupus Erythematosus. Case Rep Med 2018; 2018:5979386. [PMID: 30356389 PMCID: PMC6178166 DOI: 10.1155/2018/5979386] [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: 06/02/2018] [Accepted: 09/17/2018] [Indexed: 11/17/2022] Open
Abstract
Macrophage activation syndrome (MAS) is a rare manifestation of systemic lupus erythematosus (SLE) with potentially life-threatening consequences. To the best of our knowledge, this is the first case reported in literature for a constellation of MAS, glomerulonephritis, pericarditis, and retinal vasculitis as initial presentation of SLE. Despite extensive multisystem involvement of his disease, the patient responded well to initial steroid treatment, with mycophenolate mofetil successfully added as a steroid-sparing agent. Our case highlights the importance of multispecialty collaboration in the diagnosis and management of SLE with multisystem involvement.
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Szulawski R, Kourlas PJ, Antonchak M. Macrophage Activation Syndrome (MAS) in a Recently Released Prisoner with Systemic Lupus Erythematosus (SLE). AMERICAN JOURNAL OF CASE REPORTS 2018; 19:734-738. [PMID: 29930239 PMCID: PMC6047585 DOI: 10.12659/ajcr.906154] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Patient: Male, 38 Final Diagnosis: Systemic lupus erythematosus • macrophage activation syndrome Symptoms: Altered mental status • diarrhea • fever • nausea • vomiting • weight loss Medication: — Clinical Procedure: — Specialty: Rheumatology
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Affiliation(s)
- Robert Szulawski
- Department of Internal Medicine, University of Pittsburgh Medical Center - Mercy Hospital, Pittsburgh, PA, USA
| | - Peter J Kourlas
- Department of Hematology Oncology, Columbus Oncology and Hematology Associates, Columbus, OH, USA
| | - Marc Antonchak
- Department of Rheumatology, Columbus Arthritis Center, Columbus, OH, USA
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Alkoht A, Hanafi I, Khalil B. Macrophage Activation Syndrome: A Report of Two Cases and a Literature Review. Case Rep Rheumatol 2017; 2017:5304180. [PMID: 29209549 PMCID: PMC5676417 DOI: 10.1155/2017/5304180] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2017] [Revised: 08/11/2017] [Accepted: 08/14/2017] [Indexed: 12/23/2022] Open
Abstract
Macrophage activation syndrome (MAS) is a severe, potentially fatal condition that may complicate autoimmune diseases, and it belongs to hemophagocytic lymphohistiocytosis (HLH) disorders. MAS occurs in adults and children. However, it is rare in juvenile systemic lupus erythematosus (jSLE), and it is extremely rare to be the initial presentation of jSLE. Here, we report two patients with juvenile SLE who initially presented with MAS. One of the two patients is 4 years old. This is the youngest reported patient to our knowledge.
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Affiliation(s)
- Asaad Alkoht
- Division of Rheumatology, Department of Internal Medicine, Faculty of Medicine, Damascus University, Damascus, Syria
| | - Ibrahem Hanafi
- Faculty of Medicine, Damascus University, Damascus, Syria
| | - Basheer Khalil
- Division of Rheumatology, Department of Internal Medicine, Faculty of Medicine, Damascus University, Damascus, Syria
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10
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Macrophage Activation Syndrome as Onset of Systemic Lupus Erythematosus: A Case Report and a Review of the Literature. Case Rep Med 2015; 2015:294041. [PMID: 26064125 PMCID: PMC4439481 DOI: 10.1155/2015/294041] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2015] [Accepted: 04/23/2015] [Indexed: 11/23/2022] Open
Abstract
Macrophage activation syndrome (MAS) is a potentially fatal condition. It belongs to the hemophagocytic lymphohistiocytosis group of diseases. In adults, MAS is rarely associated with systemic lupus erythematosus, but it also arises as complication of several systemic autoimmune disorders, like ankylosing spondylitis, rheumatoid arthritis, and adult-onset Still's disease. Several treatment options for MAS have been reported in the literature, including a therapeutic regimen of etoposide, dexamethasone, and cyclosporine. Here we report a case of 42-year-old woman in whom MAS occurred as onset of systemic lupus erythematosus.
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