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Wegscheider C, Ferincz V, Schöls K, Maieron A. Felty's syndrome. Front Med (Lausanne) 2023; 10:1238405. [PMID: 37920595 PMCID: PMC10619942 DOI: 10.3389/fmed.2023.1238405] [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] [Received: 06/11/2023] [Accepted: 10/03/2023] [Indexed: 11/04/2023] Open
Abstract
Felty's syndrome was first described in 1924 by the US-American physician Augustus Roi Felty as a triad of rheumatoid arthritis, splenomegaly and leucopenia. Even nearly 100 years later, this rare syndrome is still paralleled by diagnostic and therapeutic challenges and its pathogenesis is incompletely understood. Neutropenia with potentially life-threatening infections is the main problem and several pathomechanisms like Fas-mediated apoptosis, anti-neutrophil antibodies, anti-G-CSF antibodies, neutrophil consumption in the context of NETosis and suppression of granulopoiesis by T-LGLs have been suggested. Felty's syndrome has various differential diagnoses as splenomegaly and cytopenia are common features of different infectious diseases, malignancies and autoimmune disorders. Additionally, benign clonal T-/NK-LGL lymphocytosis is increasingly noticed in Felty's syndrome, which further complicates diagnosis. Today's treatment options are still sparse and are largely based on case reports and small case series. Methotrexate is the mainstay of therapy, followed by rituximab, but there is less evidence for alternatives in the case of adverse reactions or failure of these drugs. This article gives an updated review about Felty's syndrome including its pathogenesis and treatment options.
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Affiliation(s)
- Christoph Wegscheider
- Karl Landsteiner University of Health Sciences, Krems, Austria
- Division of Internal Medicine, University Hospital St. Pölten, St. Pölten, Austria
| | - Vera Ferincz
- Karl Landsteiner University of Health Sciences, Krems, Austria
- Division of Internal Medicine, University Hospital St. Pölten, St. Pölten, Austria
| | - Karin Schöls
- Karl Landsteiner University of Health Sciences, Krems, Austria
- Division of Internal Medicine, University Hospital St. Pölten, St. Pölten, Austria
| | - Andreas Maieron
- Karl Landsteiner University of Health Sciences, Krems, Austria
- Division of Internal Medicine, University Hospital St. Pölten, St. Pölten, Austria
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2
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Diaz MJ, Natarelli N, Wei A, Rechdan M, Botto E, Tran JT, Forouzandeh M, Plaza JA, Kaffenberger BH. Cutaneous Manifestations of Rheumatoid Arthritis: Diagnosis and Treatment. J Pers Med 2023; 13:1479. [PMID: 37888090 PMCID: PMC10608460 DOI: 10.3390/jpm13101479] [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: 08/23/2023] [Revised: 10/02/2023] [Accepted: 10/06/2023] [Indexed: 10/28/2023] Open
Abstract
Rheumatoid arthritis (RA) is a chronic, systemic autoimmune disorder characterized by inflammatory arthritis and periarticular structural damage. Available evidence suggests that RA results from complex interactions between genetic susceptibility (e.g., HLA-DRB1), environmental factors (e.g., smoking), and immune dysregulation. Alongside joint-related symptoms, individuals with RA may also experience a wide array of skin issues, including the development of nodules, neutrophilic dermatoses, vasculitis, and vasculopathy. Treatment strategies for these manifestations vary but routinely involve corticosteroids, disease-modifying anti-rheumatic drugs, and biologics, with individualized approaches guided by disease severity. In this review, we provide comprehensive insights into the skin-related issues associated with RA, outlining their clinical characteristics and histopathological findings. Our aim is to facilitate early diagnosis and personalized treatment to improve the quality of life of affected individuals.
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Affiliation(s)
- Michael J. Diaz
- College of Medicine, University of Florida, Gainesville, FL 32610, USA
| | - Nicole Natarelli
- Morsani College of Medicine, University of South Florida, Tampa, FL 33602, USA
| | - Aria Wei
- School of Medicine, University of Texas Southwestern Medical Center, Dallas, TX 75390, USA
| | - Michaela Rechdan
- College of Medicine, University of Florida, Gainesville, FL 32610, USA
| | - Elizabeth Botto
- Morsani College of Medicine, University of South Florida, Tampa, FL 33602, USA
| | - Jasmine T. Tran
- School of Medicine, Indiana University, Indianapolis, IN 46202, USA
| | - Mahtab Forouzandeh
- Department of Dermatology, University of Florida, Gainesville, FL 32606, USA
| | - Jose A. Plaza
- Department of Dermatology, Ohio State University Wexner Medical Center, Columbus, OH 43221, USA
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3
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Chin RV, Serin S, Khan A, Smith K, Kumar S. The Use of Abatacept for the Treatment of Felty Syndrome in Rheumatoid Arthritis. Cureus 2023; 15:e46086. [PMID: 37900492 PMCID: PMC10611446 DOI: 10.7759/cureus.46086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/27/2023] [Indexed: 10/31/2023] Open
Abstract
Felty syndrome is characterized by a triad of rheumatoid arthritis, neutropenia, and splenomegaly that typically occurs in patients with seropositive rheumatoid arthritis. We report a case of an 81-year-old man with a 22-year history of rheumatoid arthritis who developed pancytopenia and neutropenia for one month. An abdominal ultrasound revealed splenomegaly. A bone marrow biopsy excluded large granular lymphocytic leukemia, thus Felty Syndrome was diagnosed. He was treated with a maximum tolerated dose of methotrexate (15 mg once a week) for two months with no improvement in absolute neutrophil count. The patient was given abatacept 1000 mg intravenously every four weeks with improvement in hemoglobin, leukocyte, and platelet counts and absolute neutrophil counts from 0.2 to 2.4 K/µl.
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Affiliation(s)
- Rishika V Chin
- Internal Medicine, University of Miami John F. Kennedy (JFK) Medical Center, Atlantis, USA
| | - Sheila Serin
- Internal Medicine, University of Miami John F. Kennedy (JFK) Medical Center, Atlantis, USA
| | - Ahmed Khan
- Internal Medicine, University of Miami John F. Kennedy (JFK) Medical Center, Atlantis, USA
| | - Keneisha Smith
- Internal Medicine, University of Miami John F. Kennedy (JFK) Medical Center, Atlantis, USA
| | - Suresh Kumar
- Rheumatology, West Palm Veterans Affairs Medical Center, West Palm Beach, USA
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4
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Yao R, Vinsard DG, Sweetser S. 59-Year-Old Woman With Fever and Hematemesis. Mayo Clin Proc 2023; 98:1225-1229. [PMID: 37422737 DOI: 10.1016/j.mayocp.2022.12.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 12/27/2022] [Indexed: 07/10/2023]
Affiliation(s)
- Rebecca Yao
- Resident in Internal Medicine, Mayo Clinic School of Graduate Medical Education, Rochester, MN
| | - Daniela Guerrero Vinsard
- Fellow in Gastroenterology and Hepatology, Mayo Clinic School of Graduate Medical Education, Rochester, MN
| | - Seth Sweetser
- Advisor to residents and Consultant in Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN.
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5
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Proc K, Madej M, Wiland P, Sebastian A. Biological treatment in Felty's syndrome with profound neutropenia. Reumatologia 2023; 61:213-218. [PMID: 37522143 PMCID: PMC10373170 DOI: 10.5114/reum/167472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 06/06/2023] [Indexed: 08/01/2023] Open
Abstract
A triad of symptoms characterises Felty's syndrome: seropositive rheumatoid arthritis (RA), splenomegaly and neutropenia. The treatment of Felty's syndrome is based on using classic synthetic and biological disease-modifying anti-rheumatic drugs (DMARDs). In this article, we present a case of a patient with Felty's syndrome who was treated with biologic treatment. A systematic search of the literature on the electronic medical database was conducted. The drugs from the DMARD group, despite reducing the activity of the disease, may cause significant clinical complications. It is important to know about the diagnosis, differentiation and treatment of neutropenia and the prevention of febrile neutropenia. The article discusses the current therapeutic possibilities using both classical and biologic DMARDs.
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Affiliation(s)
- Krzysztof Proc
- Department of Rheumatology and Internal Medicine, Medical University Hospital, Wroclaw, Poland
| | - Marta Madej
- Department of Rheumatology and Internal Medicine, Wroclaw Medical University, Poland
| | - Piotr Wiland
- Department of Rheumatology and Internal Medicine, Wroclaw Medical University, Poland
| | - Agata Sebastian
- Department of Rheumatology and Internal Medicine, Wroclaw Medical University, Poland
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Hamsho S, Alannouf I, Ashour AA. Rapidly Progressive Felty Syndrome After Sudden Discontinuation of Methotrexate: A Case Report and Review of Literature. Int Med Case Rep J 2022; 15:473-477. [PMID: 36091198 PMCID: PMC9449881 DOI: 10.2147/imcrj.s365004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Accepted: 07/01/2022] [Indexed: 11/23/2022] Open
Affiliation(s)
- Suaad Hamsho
- Faculty of Medicine, Damascus University, Damascus, Syria
| | - Isam Alannouf
- Faculty of Medicine, Damascus University, Damascus, Syria
| | - Anas A Ashour
- Department of Internal Medicine, Hamad Medical Corporation, Doha, Qatar
- Correspondence: Anas A Ashour, Department of Internal Medicine, Hamad Medical Corporation, Doha, Qatar, Tel +974 55336238, Email
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7
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Saeed H, Ejikeme C, Tucktuck M, Jawed Q, Kessler W. Non-Articular Felty Syndrome Refractory to Granulocyte Colony-Stimulating Factor Therapy. Cureus 2021; 13:e17206. [PMID: 34540433 PMCID: PMC8440238 DOI: 10.7759/cureus.17206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/15/2021] [Indexed: 11/06/2022] Open
Abstract
Felty syndrome (FS), an uncommon manifestation seen in patients with rheumatoid arthritis (RA), usually presents as a triad of erosive arthritis, splenomegaly, and neutropenia. It is extremely rare for RA to present as FS or develop after initially presenting as neutropenia and splenomegaly. In this report, we describe a case of a 55-year-old woman who initially presented with fever and vaginal pain. Her sepsis workup revealed genital herpes in the setting of leukopenia, with an incidental finding of splenomegaly on imaging. The patient was managed with filgrastim and valacyclovir. Two weeks later, she presented again with pleuritic chest pain and worsening leukopenia. This led to an extensive workup by the hematology team to diagnose and confirm the diagnosis of FS. We also engage in a review of the existing literature of such cases and emphasize the importance of serological testing for RA in patients with leukopenia and splenomegaly, even in the absence of joint symptoms or prior diagnosis of RA. The management should be guided towards treating the infection, correcting the neutropenia, and treating the underlying chronic disease.
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Affiliation(s)
- Hasham Saeed
- Internal Medicine, Rutgers Health/Trinitas Regional Medical Center, Elizabeth, USA
| | - Chidinma Ejikeme
- Internal Medicine, Rutgers Health/Trinitas Regional Medical Center, Elizabeth, USA
| | - Marina Tucktuck
- Internal Medicine, St. George's University Medical School, Elizabeth, USA
| | - Qirat Jawed
- Internal Medicine, Rutgers Health/Trinitas Regional Medical Center, Elizabeth, USA
| | - William Kessler
- Hematology and Medical Oncology, Rutgers Health/Trinitas Regional Medical Center, Elizabeth, USA
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8
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Leyens J, Bender TTA, Mücke M, Stieber C, Kravchenko D, Dernbach C, Seidel MF. The combined prevalence of classified rare rheumatic diseases is almost double that of ankylosing spondylitis. Orphanet J Rare Dis 2021; 16:326. [PMID: 34294115 PMCID: PMC8296612 DOI: 10.1186/s13023-021-01945-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 07/02/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Rare diseases (RDs) affect less than 5/10,000 people in Europe and fewer than 200,000 individuals in the United States. In rheumatology, RDs are heterogeneous and lack systemic classification. Clinical courses involve a variety of diverse symptoms, and patients may be misdiagnosed and not receive appropriate treatment. The objective of this study was to identify and classify some of the most important RDs in rheumatology. We also attempted to determine their combined prevalence to more precisely define this area of rheumatology and increase awareness of RDs in healthcare systems. We conducted a comprehensive literature search and analyzed each disease for the specified criteria, such as clinical symptoms, treatment regimens, prognoses, and point prevalences. If no epidemiological data were available, we estimated the prevalence as 1/1,000,000. The total point prevalence for all RDs in rheumatology was estimated as the sum of the individually determined prevalences. RESULTS A total of 76 syndromes and diseases were identified, including vasculitis/vasculopathy (n = 15), arthritis/arthropathy (n = 11), autoinflammatory syndromes (n = 11), myositis (n = 9), bone disorders (n = 11), connective tissue diseases (n = 8), overgrowth syndromes (n = 3), and others (n = 8). Out of the 76 diseases, 61 (80%) are classified as chronic, with a remitting-relapsing course in 27 cases (35%) upon adequate treatment. Another 34 (45%) diseases were predominantly progressive and difficult to control. Corticosteroids are a therapeutic option in 49 (64%) syndromes. Mortality is variable and could not be determined precisely. Epidemiological studies and prevalence data were available for 33 syndromes and diseases. For an additional eight diseases, only incidence data were accessible. The summed prevalence of all RDs was 28.8/10,000. CONCLUSIONS RDs in rheumatology are frequently chronic, progressive, and present variable symptoms. Treatment options are often restricted to corticosteroids, presumably because of the scarcity of randomized controlled trials. The estimated combined prevalence is significant and almost double that of ankylosing spondylitis (18/10,000). Thus, healthcare systems should assign RDs similar importance as any other common disease in rheumatology.
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Affiliation(s)
- Judith Leyens
- Center for Rare Diseases Bonn (ZSEB), University Hospital, Bonn, Germany
- Department of Neonatology and Pediatric Care, Children's University Hospital, Bonn, Germany
| | - Tim Th A Bender
- Center for Rare Diseases Bonn (ZSEB), University Hospital, Bonn, Germany
- Institute of Human Genetics, University Hospital, Bonn, Germany
| | - Martin Mücke
- Center for Rare Diseases Bonn (ZSEB), University Hospital, Bonn, Germany
| | - Christiane Stieber
- Institute of General Practice and Family Medicine, University Hospital, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Dmitrij Kravchenko
- Center for Rare Diseases Bonn (ZSEB), University Hospital, Bonn, Germany
- Department of Radiology, University Hospital, Bonn, Germany
| | - Christian Dernbach
- Division of Medical Psychology and Department of Psychiatry, University Hospital, Bonn, Germany
| | - Matthias F Seidel
- Department of Rheumatology, Spitalzentrum-Centre hospitalier, Biel-Bienne, Switzerland.
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9
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Klein A, Molad Y. Hematological Manifestations among Patients with Rheumatic Diseases. Acta Haematol 2020; 144:403-412. [PMID: 33221805 DOI: 10.1159/000511759] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 09/22/2020] [Indexed: 01/02/2023]
Abstract
BACKGROUND Rheumatic diseases have many hematological manifestations. Blood dyscrasias and other hematological abnormalities are sometimes the first sign of rheumatic disease. In addition, novel antirheumatic biological agents may cause cytopenias. SUMMARY The aim of this review was to discuss cytopenias caused by systemic lupus erythematosus and antirheumatic drugs, Felty's syndrome in rheumatoid arthritis, and autoimmune hemolytic anemia, thrombosis, and thrombotic microangiopathies related to rheumatological conditions such as catastrophic antiphospholipid syndrome and scleroderma renal crisis. Key Message: The differential diagnosis of various hematological disorders should include rheumatic autoimmune diseases among other causes of blood cell and hemostasis abnormalities. It is crucial that hematologists be aware of these presentations so that they are diagnosed and treated in a timely manner.
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Affiliation(s)
- Alina Klein
- Department of Internal Medicine C, Rabin Medical Center, Beilinson Hospital, Petach Tikva, Israel,
| | - Yair Molad
- Institute of Rheumatology, Rabin Medical Center, Beilinson Hospital, Petach Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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10
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Romano C, Esposito S, Ferrara R, Cuomo G. Tailoring biologic therapy for real-world rheumatoid arthritis patients. Expert Opin Biol Ther 2020; 21:661-674. [PMID: 33147106 DOI: 10.1080/14712598.2021.1847268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Introduction: The cornerstone of rheumatoid arthritis (RA) therapy relies on the treat-to-target strategy, which aims at dampening inflammation as soon as possible in order to achieve persistent low disease activity or, ideally, remission, according to validated disease activity measures. Traditional disease-modifying antirheumatic drugs (DMARDs) may be chosen in monotherapy or in combination as first-line therapy; in case of an unsatisfactory response after a 3-6-month trial, biologic therapy may be commenced.Areas covered: Real-life RA patients may present with concomitant comorbidities/complications or be in peculiar physiological states which raise more than one question as to which biotherapy may be more well suited considering the whole clinical picture. Therefore, a thorough literature search was performed to identify the most appropriate biologic therapy in each setting considered in this review.Expert opinion: Here we provide suggestions for the use of biologic drugs having a predictable better outcome in specific real-world conditions, so as to ideally profile the patient to the best of the current knowledge.
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Affiliation(s)
- Ciro Romano
- Department of Medicine, Clinical Immunology Outpatient Clinic, "Luigi Vanvitelli" University of Campania, Naples, Italy
| | - Sergio Esposito
- Department of Medicine, Clinical Immunology Outpatient Clinic, "Luigi Vanvitelli" University of Campania, Naples, Italy
| | - Roberta Ferrara
- Department of Medicine, Clinical Immunology Outpatient Clinic, "Luigi Vanvitelli" University of Campania, Naples, Italy
| | - Giovanna Cuomo
- Department of Medicine, Clinical Immunology Outpatient Clinic, "Luigi Vanvitelli" University of Campania, Naples, Italy
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Kimura Y, Yoshida S. Successful abatacept treatment for Felty's syndrome in a patient with rheumatoid arthritis. Mod Rheumatol Case Rep 2020; 4:168-170. [PMID: 33086993 DOI: 10.1080/24725625.2020.1717740] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
We report the case of a 69-year-old man with a 38-year history of rheumatoid arthritis (RA), who developed Felty's syndrome, successful treatment with abatacept (ABT). He was treated with etanercept 50 mg/w and methotrexate 8 mg/w for the past 5 years. He was suffered from febrile neutropenia 6 months ago. Etanercept and methotrexate was discontinued 3 months ago, however, neutrophil count was not changed. Abdominal ultrasound showed splenomegaly, the diagnosis of Felty's syndrome was made. Granulocyte colony-stimulating factor therapy showed no effect on neutropenia, he was treated with ABT. After ABT therapy, absolute neutrophil count was elevated 234/μL to 1840/μL.
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Affiliation(s)
- Yuko Kimura
- Department of Immuno-Rheumatology Center, Arisawa General Hospital, Hirakata, Osaka, Japan
| | - Shuzo Yoshida
- Department of Immuno-Rheumatology Center, Arisawa General Hospital, Hirakata, Osaka, Japan
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12
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Bigot W, Viallard JF, Sellam J, Dellal A, Retbi A, Gobert D, Malard F, Mohty M, Mekinian A, Fain O. Efficacy and safety of rituximab for autoimmune neutropenia: a French case series and literature review. Rheumatology (Oxford) 2020; 59:2637-2640. [DOI: 10.1093/rheumatology/keaa045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Revised: 12/09/2019] [Accepted: 12/30/2019] [Indexed: 11/14/2022] Open
Affiliation(s)
- William Bigot
- Service de Médecine Interne et Inflammation-Immunopathology-Biotherapy Department, Sorbonne Université, AP-HP, Hôpital Saint-Antoine
- Département Hospitalo-Universitaire Inflammation-Immunopathologie-Biotherapie (DHU i2B), Paris
| | | | - Jérémie Sellam
- Service de Médecine Interne et Inflammation-Immunopathology-Biotherapy Department, Sorbonne Université, AP-HP, Hôpital Saint-Antoine
| | | | - Aurélie Retbi
- Hôpital Saint Antoine, Sorbonne Universités, AP-HP, Paris, France
| | - Delphine Gobert
- Service de Médecine Interne et Inflammation-Immunopathology-Biotherapy Department, Sorbonne Université, AP-HP, Hôpital Saint-Antoine
| | - Florent Malard
- Service de Rhumatologie, Hôpital Montfermeil, Monfermeil
| | - Mohamad Mohty
- Service de Rhumatologie, Hôpital Montfermeil, Monfermeil
| | - Arsène Mekinian
- Service de Médecine Interne et Inflammation-Immunopathology-Biotherapy Department, Sorbonne Université, AP-HP, Hôpital Saint-Antoine
| | - Olivier Fain
- Service de Médecine Interne et Inflammation-Immunopathology-Biotherapy Department, Sorbonne Université, AP-HP, Hôpital Saint-Antoine
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13
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Li R, Wan Q, Chen P, Mao S, Wang Q, Li X, Yang Y, Dong L. Tocilizumab treatment in Felty’s syndrome. Rheumatol Int 2020; 40:1143-1149. [DOI: 10.1007/s00296-020-04588-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Accepted: 04/13/2020] [Indexed: 10/24/2022]
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14
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Porto-Sinusoidal Vascular Disease as the Cause of Portal Hypertension in Felty's Syndrome: A Case Report and Literature Review. BIOMED RESEARCH INTERNATIONAL 2020; 2020:2618260. [PMID: 32714976 PMCID: PMC7352150 DOI: 10.1155/2020/2618260] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 05/24/2020] [Accepted: 06/01/2020] [Indexed: 11/17/2022]
Abstract
Felty's syndrome (FS) is a disorder wherein patients with rheumatoid arthritis develop splenomegaly, neutropenia, and in some cases, portal hypertension without underlying cirrhosis. Esophageal variceal bleeding is a complication of FS in patients with portal hypertension. In contrast to splenectomy, few reports exist on the management of variceal bleeding with endoscopic therapy. Moreover, the long-term outcome has not been reported. We present a patient with esophageal variceal bleeding due to portal hypertension secondary to Felty's syndrome. The patient was followed up for two years postendoscopy intervention. Literature review was performed and the histological features of portal hypertension in FS are discussed. The patient presented with a typical triad of rheumatoid arthritis (RA), splenomegaly, and neutropenia and was diagnosed as Felty's syndrome in 2012. She was admitted to our hospital in September 2017 for esophageal variceal bleeding. At the time of admission, her liver function test was normal. Abdominal CT showed no signs of cirrhosis and portal vein obstruction. Liver biopsy further excluded diagnosis of cirrhosis and supported the diagnosis of porto-sinusoidal vascular disease (PSVD), which was previously named as noncirrhotic idiopathic portal hypertension (NCIPH). An upper abdominal endoscopy revealed gastric and esophageal varices. A series of endoscopies was performed to ligate the esophageal varices. The patient was followed up for two years and did not show rebleeding. In conclusion, comorbid PSVD might be a cause of portal hypertension in FS patients. The present case had excellent outcome in two years, which supported the use of endoscopic therapy for the management of variceal bleeding in FS patients. Further large prospective study is needed to confirm the findings.
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15
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Guiomar VB, Tavares S, Oliveira D, Gomes C, Rodrigues P, Correia C, Pereira E. Three-years follow-up of a case of non-articular Felty Syndrome treated solely with corticosteroids. GAZZETTA MEDICA ITALIANA ARCHIVIO PER LE SCIENZE MEDICHE 2020. [DOI: 10.23736/s0393-3660.19.04183-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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16
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Hamada-Ode K, Taniguchi Y, Shimamura Y, Kagawa T, Terada Y. Efficacy of abatacept for Felty's syndrome. Rheumatology (Oxford) 2020; 59:256-259. [PMID: 31292638 DOI: 10.1093/rheumatology/kez262] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/03/2019] [Indexed: 11/14/2022] Open
Affiliation(s)
- Kazu Hamada-Ode
- Department of Endocrinology, Metabolism, Nephrology and Rheumatology, Kochi Medical School Hospital, Kochi University, Nankoku, Japan
| | - Yoshinori Taniguchi
- Department of Endocrinology, Metabolism, Nephrology and Rheumatology, Kochi Medical School Hospital, Kochi University, Nankoku, Japan
| | - Yoshiko Shimamura
- Department of Endocrinology, Metabolism, Nephrology and Rheumatology, Kochi Medical School Hospital, Kochi University, Nankoku, Japan
| | - Toru Kagawa
- Department of Internal Medicine, Kochi Memorial Hospital, Kochi, Japan
| | - Yoshio Terada
- Department of Endocrinology, Metabolism, Nephrology and Rheumatology, Kochi Medical School Hospital, Kochi University, Nankoku, Japan
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17
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Aslam F, Cheema RS, Feinstein M, Chang-Miller A. Neutropaenia and splenomegaly without arthritis: think rheumatoid arthritis. BMJ Case Rep 2018; 2018:bcr-2018-225359. [PMID: 30002215 DOI: 10.1136/bcr-2018-225359] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Felty syndrome(FS) is an uncommon, but severe, extra-articular manifestation of rheumatoid arthritis (RA). It occurs in patients with longstanding RA. It is extremely rare for RA to present as FS or develop after initially presenting as neutropaenia and splenomegaly. We describe a case of 47-year-old woman who was diagnosed simultaneously with FS and possible RA after testing positive for anticyclic citrullinated peptide antibody, but a negative rheumatoid factor. She had an excellent response to methotrexate. We review the existing literature of such cases and emphasise the importance of serological testing for RA in patients presenting with neutropaenia and splenomegaly, even in the absence of joint symptoms or prior diagnosis of RA.
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Affiliation(s)
- Fawad Aslam
- Department of Rheumatology, Mayo Clinic Arizona, Scottsdale, Arizona, USA
| | - Rabia S Cheema
- Internal Medicine, St. Mary's Hospital, Waterbury, Connecticut, USA
| | - Michael Feinstein
- Department of Hematology and Oncology, Mayo Clinic Arizona, Scottsdale, Arizona, USA
| | - April Chang-Miller
- Department of Rheumatology, Mayo Clinic Arizona, Scottsdale, Arizona, USA
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Enselmann K, Frasnelli A. [Not Available]. PRAXIS 2018; 107:463-466. [PMID: 29642792 DOI: 10.1024/1661-8157/a002947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Zusammenfassung. Das Felty-Syndrom ist eine komplizierte und seltene Form der rheumatoiden Arthritis mit Splenomegalie und Neutropenie, das von A. R. Felty im Jahr 1924 erstmals beschrieben wurde und dessen Diagnose klinisch gestellt wird. Das Felty-Syndrom geht mit hoher Entzündungs- und regelmässig hoher Krankheitsaktivität einher. Die Prognose ist aufgrund der hohen Inzidenz von Infekten schlecht. Die Ursache ist noch unklar; diskutiert werden eine chronische Entzündungsreaktion und eine entsprechende individuelle Disposition. Differenzialdiagnostisch müssen maligne Erkrankungen des Blutes ausgeschlossen werden. Die Therapie der Wahl ist Methotrexat, bei fehlendem Ansprechen können andere DMARDs (Disease-Modifying Anti-Rheumatic Drugs) in Erwägung gezogen werden; die Therapie mit Steroiden in der akuten Infektsituation ist kontrovers. Weitere Therapieoptionen wurden bisher nur in kleinen Fallstudien beschrieben. Von TNF-α-Inhibitoren wurde in einer Kleinstudie mit sechs Patienten über Unwirksamkeit berichtet. Der CD-20-Antagonist Rituximab (Mabthera®) hat in einer Studie mit acht Patienten bei der Mehrheit (n = 5) einen Anstieg der neutrophilen Granulozyten gezeigt. Als Wirkmechanismus wird eine Einflussnahme auf Anti-G-CSF-Antikörper diskutiert.
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Wang CR, Chiu YC, Chen YC. Successful treatment of refractory neutropenia in Felty’s syndrome with rituximab. Scand J Rheumatol 2017; 47:340-341. [DOI: 10.1080/03009742.2017.1334816] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- C-R Wang
- Department of Internal Medicine, Section of Rheumatology, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Y-C Chiu
- Department of Internal Medicine, Section of Gastroenterology, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Y-C Chen
- Department of Radiology, National Cheng Kung University Hospital, Tainan, Taiwan
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Silva S, Bosco D, Souza B, Ribeiro S, Pereira H, Cunha O. ARTRITE REUMATOIDE GRAVE EVOLUINDO COM SÍNDROME DE FELTY. REVISTA BRASILEIRA DE REUMATOLOGIA 2017. [DOI: 10.1016/j.rbr.2017.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Verhoeven F, Guillot X, Prati C, Wendling D. Treatment of pseudo Felty's syndrome: Is there a place for rituximab? Joint Bone Spine 2015; 82:196-9. [DOI: 10.1016/j.jbspin.2014.12.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2014] [Accepted: 12/04/2014] [Indexed: 12/29/2022]
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Brown LE, Sampath S, Ryan F, Pain CE, McCann LJ, Cleary G, Beresford MW, Baildam EM. PP6. Felty’s syndrome in rheumatoid factor positive polyarticular juvenile idiopathic arthritis: the role of rituximab. Rheumatology (Oxford) 2015. [DOI: 10.1093/rheumatology/keu499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Abstract
Felty’s syndrome is a rare variant of severe seropositive rheumatoid arthritis with neutropenia and splenomegaly. It is difficult to treat and associated with a poor prognosis due to the substantial risk of infections. This article presents the case of a patient with refractory disease who responded to rituximab with permanent normalization of neutrophil counts. Repeated infusions were necessary to induce and maintain remission.
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Owlia MB, Newman K, Akhtari M. Felty's Syndrome, Insights and Updates. Open Rheumatol J 2014; 8:129-36. [PMID: 25614773 PMCID: PMC4296472 DOI: 10.2174/1874312901408010129] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2014] [Revised: 11/20/2014] [Accepted: 11/25/2014] [Indexed: 11/28/2022] Open
Abstract
Felty’s syndrome (FS) is characterized by the triad of seropositive rheumatoid arthritis (RA) with destructive joint involvement, splenomegaly and neutropenia. Current data shows that 1-3 % of RA patients are complicated with FS with an estimated prevalence of 10 per 100,000 populations. The complete triad is not an absolute requirement, but persistent neutropenia with an absolute neutrophil count (ANC) generally less than 1500/mm3 is necessary for establishing the diagnosis. Felty’s syndrome may be asymptomatic but serious local or systemic infections may be the first clue to the diagnosis. FS is easily overlooked by parallel diagnoses of Sjӧgren syndrome or systemic lupus erythematosus or lymphohematopoietic malignancies. The role of genetic (HLA DR4) is more prominent in FS in comparison to classic rheumatoid arthritis. There is large body of evidence that in FS patients, both cellular and humoral immune systems participate in neutrophil activation, and apoptosis and its adherence to endothelial cells in the spleen.
It has been demonstrated that proinflammatory cytokines may have inhibitory effects on bone marrow granulopoiesis. Binding of IgGs to neutrophil extracellular chromatin traps (NET) leading to neutrophil death plays a crucial role in its pathophysiology. In turn, "Netting" neutrophils may activate auto-reactive B cells leading to further antibody and immune complex formation. In this review we discuss on basic pathophysiology, epidemiology, genetics, clinical, laboratory and treatment updates of Felty’s syndrome.
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Affiliation(s)
- Mohammad Bagher Owlia
- Department of Internal Medicine, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| | - Kam Newman
- Rheumatology Program, National Institute of Arthritis, Musculoskeletal, and Skin Disease (NIAMS), National Institutes of Health, 10 Center Drive, Room 6N216, Bethesda, MD 20892-1616, USA
| | - Mojtaba Akhtari
- Jane Anne Nohl Division of Hematology and Center for the Study of Blood Diseases, University of Southern California (USC)/Norris Cancer Center, USC University Hospital, 1441 Eastlake Avenue, Norris Topping Tower 3463, MC 9172, Los Angeles, CA 90033-9172, USA
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Successful Treatment of a Large Cutaneous Ulcer and Improvement in the Hematologic Manifestations of Felty Syndrome With Rituximab. J Clin Rheumatol 2014; 20:440-1. [DOI: 10.1097/01.rhu.0000450285.43361.ab] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Abstract
Isolated neutropenia is a common clinical problem seen by primary care physicians and hematologists. The evaluation of neutropenia is dictated by the acuity of the clinical presentation and the duration, age, and clinical status of the patient. In this review, we provide a practical approach to the evaluation of the adult patient with neutropenia, with the major focus on the evaluation of neutropenia in the outpatient setting.
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Autrel-Moignet A, Lamy T. Autoimmune neutropenia. Presse Med 2014; 43:e105-18. [PMID: 24680423 DOI: 10.1016/j.lpm.2014.02.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2013] [Revised: 02/13/2014] [Accepted: 02/18/2014] [Indexed: 02/08/2023] Open
Abstract
Autoimmune neutropenia (AIN) is a rare entity caused by antibodies directed against neutrophil-specific antigens. It includes primary and secondary autoimmune neutropenia. Acute autoimmune neutropenia can be related to drug-induced mechanism or viral infections. Chronic autoimmune neutropenias occur in the context of autoimmune diseases, hematological malignancies, such as large granular lymphocyte leukemia, primary immune deficiency syndromes or solid tumors. The therapeutic management depends on the etiology. Granulocyte growth factor is the main therapeutic option, raising the question of their long-term utilization safety. Corticosteroids or immunosuppressive therapy are indicated in infection-related AIN or in case of symptomatic autoimmune disease or LGL leukemia.
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Affiliation(s)
| | - Thierry Lamy
- CHU de Rennes, service d'hématologie clinique, Rennes 35043, France; Université Rennes 1, Rennes 35043, France.
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Huang T, Liu M, Xu G. Felty's syndrome with hyperthyroidism: a case report and literature review. Int J Rheum Dis 2014; 17:122-4. [PMID: 24472276 DOI: 10.1111/1756-185x.12117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Tianlun Huang
- Department of Rheumatology, Second Affiliated Hospital, Nanchang, China
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Chang SH, Yang JA, Lee SJ, Park JW, Shin K, Lee EB, Song YW, Lee EY. Treatment with Rituximab in a Patient with Refractory Felty Syndrome and Low Rheumatoid Arthritis Disease Activity: A Case Report. JOURNAL OF RHEUMATIC DISEASES 2014. [DOI: 10.4078/jrd.2014.21.1.35] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Sung Hae Chang
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Ji Ae Yang
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Sang Jin Lee
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Jun Won Park
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Kichul Shin
- Department of Internal Medicine, Seoul National University Borame Hospital, Seoul, Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Eun Bong Lee
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Yeong Wook Song
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Eun Young Lee
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
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Xiao RZ, Xiong MJ, Long ZJ, Fan RF, Lin DJ. Diagnosis of Felty's syndrome, distinguished from hematological neoplasm: A case report. Oncol Lett 2013; 7:713-716. [PMID: 24527077 PMCID: PMC3919908 DOI: 10.3892/ol.2013.1779] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2013] [Accepted: 12/13/2013] [Indexed: 01/19/2023] Open
Abstract
Felty’s syndrome (FS) is characterized by the three conditions of rheumatoid arthritis (RA), neutropenia and splenomegaly, and occurs in few cases of longstanding erosive RA. Discriminating between rare occurrences of autoimmune diseases and malignancies is crucial. The present study describes the case of a 17-year-old female with a two-year history of RA, presenting with an irregular fever, hepatosplenomegaly and enlarged lymph nodes. The antinuclear antibody titer was 1:320, while antibody results for anti-dsDNA, anti-Sm and rheumatoid factor were negative. The clinical presentation was similar to that of lymphoma. However, the fluorodeoxyglucose-positron emission tomography and biopsy examinations of the liver and cervical lymph node did not support the diagnosis of lymphoma. According to the laboratory results and clinical symptoms, the differential diagnosis indicated FS, and immunosuppressive agents were administered. Two weeks later, the patient no longer had a fever, and the transaminase levels were normal, associated with shrinkage of the liver and spleen.
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Affiliation(s)
- Ruo-Zhi Xiao
- Department of Hematology, Third Affiliated Hospital, Sun Yat-Sen University, Guangzhou, Guangdong 510630, P.R. China ; Sun Yat-Sen Institute of Hematology, Sun Yat-Sen University, Guangzhou, Guangdong 510630, P.R. China
| | - Mu-Jun Xiong
- Department of Hematology, Third Affiliated Hospital, Sun Yat-Sen University, Guangzhou, Guangdong 510630, P.R. China ; Sun Yat-Sen Institute of Hematology, Sun Yat-Sen University, Guangzhou, Guangdong 510630, P.R. China
| | - Zi-Jie Long
- Department of Hematology, Third Affiliated Hospital, Sun Yat-Sen University, Guangzhou, Guangdong 510630, P.R. China ; Sun Yat-Sen Institute of Hematology, Sun Yat-Sen University, Guangzhou, Guangdong 510630, P.R. China
| | - Rui-Fang Fan
- Department of Hematology, Third Affiliated Hospital, Sun Yat-Sen University, Guangzhou, Guangdong 510630, P.R. China ; Sun Yat-Sen Institute of Hematology, Sun Yat-Sen University, Guangzhou, Guangdong 510630, P.R. China
| | - Dong-Jun Lin
- Department of Hematology, Third Affiliated Hospital, Sun Yat-Sen University, Guangzhou, Guangdong 510630, P.R. China ; Sun Yat-Sen Institute of Hematology, Sun Yat-Sen University, Guangzhou, Guangdong 510630, P.R. China
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