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Mutoh T, Ohashi K, Nagai T, Sugiura A, Kudo M, Fujii H. Upfront rituximab therapy for thrombotic thrombocytopenic purpura in systemic lupus erythematosus: a case-based review. Rheumatol Int 2023; 43:373-381. [PMID: 35962219 DOI: 10.1007/s00296-022-05182-5] [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] [Received: 06/22/2022] [Accepted: 08/04/2022] [Indexed: 02/07/2023]
Abstract
Systemic lupus erythematosus (SLE) is an autoimmune disease characterized by the production of various autoantibodies and deposition of immune complexes on tissues. Acquired thrombotic thrombocytopenic purpura (TTP) is a life-threatening hematological disorder that rarely develops in SLE, mainly caused by inhibitory or clearing autoantibody against ADAMTS13. Although B cells play critical roles in the pathogenesis of two diseases, the role of B-cell depletion therapy using rituximab (RTX), a chimeric monoclonal antibody targeting CD20, in the management of TTP associated with SLE remains unclear. We present a 27-year-old woman who manifested TTP and nephritis simultaneously at diagnosis of SLE. This patient successfully responded to high-dose glucocorticoids combined with plasma exchange, and early administration of RTX-induced sustained remission of TTP without relapse over 16 months. This literature review in light of our case demonstrates relationship between early intervention with RTX and better treatment response despite the degree of ADAMTS13 activity. Moreover, we discuss the clinical features in TTP associated with SLE, risk factors for the development of TTP in SLE, and possible outcomes based on RTX dose. It is important to consider upfront RTX as a promising treatment strategy for SLE-associated secondary TTP to improve short-term response and long-term prognosis.
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Affiliation(s)
- Tomoyuki Mutoh
- Department of Rheumatology, Osaki Citizen Hospital, 3-8-1 Furukawa Honami, Osaki, Miyagi, 989-6183, Japan.
| | - Keiichi Ohashi
- Department of Hematology, Ishinomaki Red Cross Hospital, Ishinomaki, Miyagi, Japan
| | - Taichi Nagai
- Department of Rheumatology, Osaki Citizen Hospital, 3-8-1 Furukawa Honami, Osaki, Miyagi, 989-6183, Japan
| | - Akira Sugiura
- Department of Nephrology and Endocrinology, Osaki Citizen Hospital, Osaki, Miyagi, Japan
| | - Masataka Kudo
- Department of Rheumatology, Osaki Citizen Hospital, 3-8-1 Furukawa Honami, Osaki, Miyagi, 989-6183, Japan
- Department of Nephrology and Endocrinology, Osaki Citizen Hospital, Osaki, Miyagi, Japan
| | - Hiroshi Fujii
- Department of Rheumatology, Tohoku University Hospital, Sendai, Miyagi, Japan
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2
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Jung JY, Kim JW, Suh CH, Kim HA. Successful treatment of thrombotic thrombocytopenic purpura with plasmapheresis and anti-CD20 antibodies in a patient with immune thrombocytopenia and systemic lupus erythematosus: Case report. Medicine (Baltimore) 2022; 101:e28908. [PMID: 35363211 PMCID: PMC9282078 DOI: 10.1097/md.0000000000028908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Accepted: 12/30/2021] [Indexed: 01/04/2023] Open
Abstract
RATIONALE Systemic lupus erythematosus (SLE) is an autoimmune disease of unknown etiology with diverse clinical and laboratory manifestations, including thrombocytopenia. About 25% of patients with SLE may be affected by thrombocytopenia, many of whom are asymptomatic. Some patients, however, experience platelet counts that drop quite low and predispose them to bleeding. Thrombotic thrombocytopenic purpura (TTP) is defined with a classic pentad of clinical features, such as thrombocytopenia, microangiopathic hemolytic anemia, neurological symptoms and signs, renal symptoms and signs, and fever. The association of TTP and SLE has been sporadically reported in the literature. PATIENT CONCERNS AND DIAGNOSIS We describe a 16-year-old girl with SLE and immune thrombocytopenia, in whom TTP was diagnosed. INTERVENTIONS AND OUTCOMES She was treated with pulse methylprednisolone, whose platelet counts normalized after therapy with plasmapheresis and an anti-CD20 monoclonal antibody (rituximab). CONCLUSION A pediatric patient with SLE and immune thrombocytopenia in whom TTP developed was treated with plasmapheresis and rituximab therapy successfully, though the patient experienced a disease relapsed after 18 months, which was controlled by the same management.
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MESH Headings
- Adolescent
- Anemia, Hemolytic/complications
- Child
- Female
- Humans
- Lupus Erythematosus, Systemic/complications
- Lupus Erythematosus, Systemic/diagnosis
- Lupus Erythematosus, Systemic/therapy
- Plasmapheresis
- Purpura, Thrombocytopenic, Idiopathic/complications
- Purpura, Thrombocytopenic, Idiopathic/therapy
- Purpura, Thrombotic Thrombocytopenic/complications
- Purpura, Thrombotic Thrombocytopenic/diagnosis
- Purpura, Thrombotic Thrombocytopenic/therapy
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Affiliation(s)
- Ju-Yang Jung
- Department of Rheumatology, Ajou University of Medical School, Suwon, Korea
| | - Ji-Won Kim
- Department of Rheumatology, Ajou University of Medical School, Suwon, Korea
| | - Chang-Hee Suh
- Department of Rheumatology, Ajou University of Medical School, Suwon, Korea
| | - Hyoun-Ah Kim
- Department of Rheumatology, Ajou University of Medical School, Suwon, Korea
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Ibn Idris Rodwan AA, Ahmed Elmansour OK, Ahmed AFE, Elagib EM, Ahmed Eltahir NI, Hassan A, El-Sadig SM, Mohammed AGAA, Awadalla HH, Mohammed AA, Adam Essa ME. A Rare Association of Thrombotic Thrombocytopenic Purpura with Systemic Lupus Erythematosus in a Sudanese Woman: Case Report. J Blood Med 2021; 12:945-949. [PMID: 34785968 PMCID: PMC8579963 DOI: 10.2147/jbm.s334689] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Accepted: 10/13/2021] [Indexed: 11/23/2022] Open
Abstract
Thrombotic thrombocytopenic purpura (TTP) is an uncommon life-threatening condition characterized by hemolytic disorders. The coexistence of systemic lupus erythematosus (SLE) with TTP is extremely rare, although Africans are at increased risk due to inherited risk factors. This report describes a rare clinical manifestation of TTP associated with SLE in a Sudanese patient. A 41-year-old Sudanese woman presented to the emergency department with symptoms and features that were suggestive of malaria, for which she had been treated accordingly. However, a few days later she complained of fever, and was found to have a body temperature of 39.5°C, jaundice, anemia, and thrombocytopenia. Soon after admission, she developed confusion and unrecordable blood pressure. After the patient had stabilized, clinical assessment, immune-system investigation (antinuclear antibody profile, complements, blood panel), and imaging revealed a diagnosis of TTP associated with SLE. The patient received imipenem 500 mg, five sessions of plasmapheresis (60 mL/kg), methylprednisolone 1 g pulse for 3 days, and rituximab 375 mg/week. Three weeks later, the patient was discharged after her condition had improved, and she is now on regular follow-up.
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Affiliation(s)
| | - Osama Khder Ahmed Elmansour
- Department of Rheumatology, Sudan Medical Specialization Council, Khartoum, Sudan.,Department of Rheumatology, Faculty of Medicine, Shendi University, Shendi, Sudan
| | - Amar F Eldow Ahmed
- Department of Internal Medicine, Wayne State University, Detroit, MI, USA
| | - Elnour Mohammed Elagib
- Department of Rheumatology, Sudan Medical Specialization Council, Khartoum, Sudan.,Department of Rheumatology, Omdurman Military Hospital, Khartoum, Sudan
| | - Noha Ibrahim Ahmed Eltahir
- Department of Rheumatology, Omdurman Military Hospital, Khartoum, Sudan.,Department of Medicine, Faculty of Medicine, Karary University, Khartoum, Sudan
| | - Abubaker Hassan
- Department of Clinical Medicine, Medical and Cancer Research Institute, Nyala, Sudan
| | - Sara M El-Sadig
- Department of Medicine, Faculty of Medicine, University of Khartoum, Khartoum, Sudan
| | | | - Huyam H Awadalla
- Department of Internal Medicine, Detroit Medical Centre, Detroit, MI, USA
| | | | - Mohammed Elmujtba Adam Essa
- Department of Clinical Medicine, Medical and Cancer Research Institute, Nyala, Sudan.,Faculty of Medicine, Al Fashir University, Al Fashir, Sudan
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Carvalho JF, Shoenfeld Y. Sjögren's Syndrome Associated With Thrombotic Thrombocytopenic Purpura: A Case-Based Review. Rheumatol Ther 2021; 8:621-629. [PMID: 33315186 PMCID: PMC7991010 DOI: 10.1007/s40744-020-00265-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 11/26/2020] [Indexed: 11/01/2022] Open
Abstract
OBJECTIVE To review all published cases of the rare association between thrombotic thrombocytopenic purpura (TTP) and Sjögren's syndrome (SS). The authors report an additional case of this unique association. METHODS Systematic review of the literature and a case report. The database were articles published in PubMed/MEDLINE, Web of Science, LILACS, and SciELO, registered from 1966 to August 2020. The DESH terms were "Sjögren's syndrome" and "thrombotic thrombocytopenic purpura," without language limitation. RESULTS Most patients were female (88%), and the age varied from 30 to 75 years old. Concerning the sequence of disease appearance, SS followed by TTP was seen in seven articles, TTP and SS in three, and simultaneous appearance of both diseases in three studies. Primary SS was observed in 16 patients, and secondary SS was detected in two cases: dermatomyositis and rheumatoid arthritis. Anemia was the most common TTP manifestation, followed by thrombocytopenia, fever, consciousness alteration, renal impairment, and schistocytes' appearance on a blood smear. Treatment involved plasmapheresis, plasma exchange, rituximab, glucocorticoid, and cyclophosphamide. A good outcome was noted in most studies; few patients died. CONCLUSIONS TTP is a rare manifestation associated with SS. After the TTP diagnosis, plasmapheresis and/or plasma exchange should be immediately implemented.
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Affiliation(s)
- Jozélio F Carvalho
- Institute for Health Sciences from Federal University of Bahia, Salvador, Bahia, Brazil.
| | - Yehuda Shoenfeld
- Chaim Sheba Medical Center The Zabludowicz Center for Autoimmune Diseases, Tel Hashomer, Israel
- I.M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation (Sechenov University), Saint Petersburg, Russia
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Prasad C, Levy DM, Hebert D, Chami R, Teoh CW. An unusual etiology of thrombotic microangiopathy in an adolescent male: Answers. Pediatr Nephrol 2020; 35:1857-1864. [PMID: 32166357 DOI: 10.1007/s00467-020-04515-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Accepted: 02/20/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Charushree Prasad
- Division of Nephrology, The Hospital for Sick Children, 555 University Avenue, Toronto, Ontario, M5G 1X8, Canada
| | - Deborah M Levy
- Division of Rheumatology, The Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Paediatrics, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Diane Hebert
- Division of Nephrology, The Hospital for Sick Children, 555 University Avenue, Toronto, Ontario, M5G 1X8, Canada.,Department of Paediatrics, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Rose Chami
- Department of Paediatric Laboratory Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - Chia Wei Teoh
- Division of Nephrology, The Hospital for Sick Children, 555 University Avenue, Toronto, Ontario, M5G 1X8, Canada. .,Department of Paediatrics, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.
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Immune-mediated thrombotic thrombocytopenic purpura in patients with and without systemic lupus erythematosus: a retrospective study. Orphanet J Rare Dis 2020; 15:225. [PMID: 32859237 PMCID: PMC7456051 DOI: 10.1186/s13023-020-01510-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Accepted: 08/13/2020] [Indexed: 12/13/2022] Open
Abstract
Background Thrombotic thrombocytopenic purpura (TTP) is associated with more deleterious outcomes in patients with systemic lupus erythematosus (SLE). However, ADAMTS13 (a disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13) levels and ADAMTS13 inhibitor were not routinely assayed in most previous studies. The objective of this study is to compare the characteristics and outcomes of immune-mediated TTP (iTTP) in patients with and without SLE. Methods The medical data of 28 patients with iTTP from Peking Union Medical College Hospital were analysed. ADAMTS13 activity and ADAMTS13 inhibitor were measured in all patients. Results All 28 patients had ADAMTS13 inhibitor and severe ADAMTS13 deficiency. iTTP was considered SLE-related (SLE-TTP) in 10 patients and primary (primary iTTP) in 18 patients. Renal involvement on presentation was more severe in patients with primary iTTP as determined by higher serum creatinine (162.7 ± 110.6 vs 73.3 ± 13.4 μmol/L, p < 0.01) and more prevalent acute kidney injury (72.2% vs 10.0%, p < 0.01) than in patients with SLE-TTP. More patients with SLE-TTP were treated with steroid pulse therapy (90.0% vs 16.7%, p < 0.01) and intravenous immunoglobulin (IVIG) (50.0% vs 5.6%, p = 0.01) compared to patients with primary iTTP. After adjustments for age and treatment, including steroid pulse therapy and IVIG treatment, the likelihood of clinical remission of SLE-TTP was significantly increased compared to that of primary iTTP (HR 7.6 [1.2, 50.1], p = 0.03). Mortality was also lower among patients with SLE-TTP than among patients with primary iTTP (0 vs 38.9%, p = 0.03). Conclusions Renal involvement was less severe in patients with SLE-TTP than in patients with primary iTTP. The treatment responses and outcomes of SLE-TTP were no worse and perhaps even better than those of primary iTTP. When TTP is diagnosed in SLE patients, the ADAMTS13 level and ADAMTS13 inhibitor profile should be considered in addition to clinical features.
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Choi M, Butler E, Clarke A, Girard LP, Gibson P, Skeith L. Managing pregnancy-associated clinical emergencies in systemic lupus erythematosus: a case-based approach. Expert Rev Clin Immunol 2019; 16:5-22. [PMID: 31791152 DOI: 10.1080/1744666x.2019.1699057] [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: 10/25/2022]
Abstract
Introduction: Systemic lupus erythematosus (SLE)-related thrombocytopenia during pregnancy and the postpartum period have been associated with adverse pregnancy outcomes and perinatal complications. In this case report, we present two SLE patients with thrombocytopenia emergencies secondary to HELLP (hemolysis, elevated liver enzymes, and low platelets) syndrome and thrombotic thrombocytopenic purpura (TTP).Areas covered: The first case involved a 26-year-old woman, G1P0 at 26 weeks gestation (GA), with high-titer antiphospholipid antibodies (aPL) (positive lupus anticoagulant, anti-beta 2 glycoprotein-1 (aβ2GP1), anti-cardiolipin) and non-criteria aPL to phosphatidylserine/prothrombin complex and anti-domain 1 β2GP1. This case highlights the risks associated with aPL in pregnancy, considers management issues relating to anticoagulation during pregnancy and highlights the importance of maintaining a high index of suspicion for diagnosis of HELLP in SLE patients. The second case was a 36-year-old female, G3P2 at 32 weeks GA, with class III lupus nephritis (LN) who developed severe pre-eclampsia, which included mild thrombocytopenia. This case illustrates the challenges in identifying and differentiating between three pregnancy emergencies that can be seen in SLE patients (pre-eclampsia, LN, and TTP) and presents the management of TTP in peripartum SLE.Expert opinion: These two cases remind us of the importance of timely diagnosis and management of thrombocytopenia in this population.
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Affiliation(s)
- May Choi
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Erin Butler
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Ann Clarke
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Louis Phillipe Girard
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Paul Gibson
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Obstetrics & Gynecology, University of Calgary, Calgary, Alberta, Canada
| | - Leslie Skeith
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
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Sharma P, Gurung A, Dahal S. Connective Tissue Disorders in Patients With Thrombotic Thrombocytopenic Purpura: A Retrospective Analysis Using a National Database. J Clin Med Res 2019; 11:509-514. [PMID: 31236170 PMCID: PMC6575126 DOI: 10.14740/jocmr3850] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Accepted: 05/27/2019] [Indexed: 11/11/2022] Open
Abstract
Background Prior reports have shown acquired thrombotic thrombocytopenic purpura (TTP) co-existing with connective tissue disorders (CTD). However, these are mainly limited to case reports and case-series reports, and the patient characteristics and clinical outcomes in these patients are not well known. Methods We used National Inpatient Sample and Nationwide Inpatient Sample (NIS) database for the years 2009 to 2016 to identify all adult patients with TTP and searched for either the presence or absence of any co-existing CTD. These two cohorts of TTP patients were then compared using statistical methods for baseline patient characteristics and clinical outcomes. The primary outcome of interest was the all-cause in-hospital mortality and the secondary outcomes were in-hospital length of stay, in-hospital total charge and in-hospital complications. Results Of the 14,400 cases of TTP diagnosed between 2009 and 2016, nearly 9% (n = 1,247) had one or more underlying CTD. Patients with TTP were more likely to be young, black, female, with more than one comorbidity and with private insurance if they had an underlying CTD than when they did not have any underlying CTD. There was no difference in regards to the size, location or type of the hospital, or the time taken to initiate plasmapheresis. Patients being managed for TTP had a longer mean length of hospital stay and a greater mean total inpatient stay charge if they had underlying CTD. There was however no difference in the risks of inpatient mortality, acute coronary syndrome, cardiac arrest, acute stroke, need for mechanical ventilation or hemodialysis. Conclusion TTP and CTD frequently co-existed and contributed to a longer hospital stay and a greater hospital charge.
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Affiliation(s)
- Pratibha Sharma
- Department of Medicine, Maimonides Medical Center, Brooklyn, NY, USA
| | - Aveena Gurung
- Department of Internal Medicine, New York University School of Medicine, Woodhull Medical and Mental Health Center, Brooklyn, NY, USA
| | - Sumit Dahal
- Hospitalist Service, St. Joseph Hospital, Bangor, ME, USA
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Li C, Yap DY, Chan G, Wen YB, Li H, Tang C, Li XM, Li XW, Chan TM. Clinical Outcomes and Clinico-pathological Correlations in Lupus Nephritis with Kidney Biopsy Showing Thrombotic Microangiopathy. J Rheumatol 2019; 46:1478-1484. [DOI: 10.3899/jrheum.180773] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/13/2019] [Indexed: 10/27/2022]
Abstract
Objective.Renal thrombotic microangiopathy (TMA) is an uncommon pathological finding in lupus nephritis (LN), and its clinical significance remains to be defined.Methods.Twenty-four patients with lupus nephritis (LN) and renal TMA were selected from a retrospective review of 677 biopsy-proven LN patients, and compared with 48 LN controls without TMA (1:2 ratio) matched according to demographics and treatments.Results.Renal TMA was noted in 3.5% of kidney biopsies of LN. TMA was associated with a higher prevalence of anti-Ro (45.8% vs 18.8%; p = 0.016), higher Systemic Lupus Erythematosus Disease Activity Index scores (21.4 ± 8.5 vs 10.8 ± 2.3; p < 0.001), lower estimated glomerular filtration rate (eGFR; 16.8 ± 11.7 ml/min vs 77.8 ± 28.6 ml/min; p < 0.001), and a higher percentage of patients who required dialysis (37.5% vs 2.1%; p < 0.001) at the time of kidney biopsy. Activity and chronicity indices [median (range)] were higher in the TMA group [11 (2–19) and 3 (1–8), respectively, compared with 7 (0–15) and 1 (0–3) in controls; p = 0.004 and p < 0.001; respectively]. Patients with TMA showed inferior 5-year renal survival and higher incidence of chronic kidney disease at last followup (70% and 66.6%, respectively, compared with 95% and 29.2% in controls; p = 0.023 and 0.002, respectively). The TMA group also showed lower median eGFR compared with controls [50.1 (IQR 7–132) ml/min vs 85.0 (IQR 12–147) ml/min; p = 0.003]. Five-year patient survival rate was similar between the 2 groups (87% and 98% in TMA and control group, respectively; p = 0.127).Conclusion.TMA in kidney biopsy was associated with more severe clinical and histological activity, and significantly inferior longterm renal outcome in LN.
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10
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Merayo-Chalico J, Barrera-Vargas A, Morales-Padilla S, la Garza RRD, Vázquez-Rodríguez R, Campos-Guzmán J, Alcocer-Varela J, Sotomayor M, Abud-Mendoza C, Martínez-Martínez M, Colunga-Pedraza I, Uriarte-Hernández C, Acosta-Hernández R, Fajardo D, García-García C, Padilla-Ortíz D, Gómez-Martín D. Epidemiologic Profile of Erectile Dysfunction in Patients with Systemic Lupus Erythematosus: The Latin American Landscape. J Rheumatol 2019; 46:397-404. [DOI: 10.3899/jrheum.180292] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/11/2018] [Indexed: 01/08/2023]
Abstract
Objective.The aim of this study was to describe the prevalence of erectile dysfunction (ED), as well as associated demographic and clinical features, in men with systemic lupus erythematosus (SLE), by means of a systematic, standardized evaluation.Methods.We performed a transversal study in 8 tertiary care centers in Latin America. We included male patients ≥ 16 years who fulfilled ≥ 4 American College of Rheumatology criteria for SLE and had regular sexual activity, and evaluated them with the International Index of Erectile Function-5 questionnaire. Relevant demographic, clinical, and serological characteristics were recorded. We included 2 control groups: the first was made up of healthy men and the second of men with autoimmune diseases other than SLE (non-SLE group).Results.We included 590 subjects (174 SLE, 55 non-SLE, and 361 healthy controls). The prevalence of ED in the SLE group was 69%. Mean age in that group was 36.3 ± 1.03 years. Among SLE patients with and without ED, these factors were significantly different: the presence of persistent lymphopenia (p = 0.006), prednisone dose (9.3 ± 1.2 vs 5.3 ± 1.3 mg, p = 0.026), and the Systemic Lupus International Collaborating Clinics damage score (1.25 ± 0.14 vs 0.8 ± 0.16 points, p = 0.042). Independent risk factors for ED in patients with SLE were persistent lymphopenia (OR 2.79, 95% CI 1.37–5.70, p = 0.001) and corticosteroid use in the previous year (OR 2.15, 95% CI 1.37–3.37, p = 0.001).Conclusion.Regardless of comorbidities, treatment (excluding steroids), and type of disease activity, patients with SLE have a high prevalence of ED, especially considering that most patients are young. Recent corticosteroid use and persistent lymphopenia, which could be related to endothelial dysfunction, are risk factors for this complication in men with SLE.
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11
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Bugarin-Estrada E, Gómez-De León A, López-García YK, Díaz-Chuc EA, Priesca-Marín JM, Ruiz-Argüelles GJ, Jaime-Pérez JC, Gómez-Almaguer D. Clinical presentation in thrombotic thrombocytopenic purpura: Real-world data from two Mexican institutions. J Clin Apher 2018; 33:645-653. [DOI: 10.1002/jca.21659] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Revised: 08/09/2018] [Accepted: 08/10/2018] [Indexed: 12/16/2022]
Affiliation(s)
- Emmanuel Bugarin-Estrada
- Hematology Service, Department of Internal Medicine; Hospital Universitario “Dr. José Eleuterio González”, Universidad Autónoma de Nuevo León; Monterrey Nuevo León Mexico
| | - Andrés Gómez-De León
- Hematology Service, Department of Internal Medicine; Hospital Universitario “Dr. José Eleuterio González”, Universidad Autónoma de Nuevo León; Monterrey Nuevo León Mexico
| | - Yadith Karina López-García
- Hematology Service, Department of Internal Medicine; Hospital Universitario “Dr. José Eleuterio González”, Universidad Autónoma de Nuevo León; Monterrey Nuevo León Mexico
| | - Erik Alejandro Díaz-Chuc
- Department of Clinical Pathology; Hospital Universitario “Dr. José Eleuterio González”, Universidad Autónoma de Nuevo León; Monterrey Nuevo León Mexico
| | - José Manuel Priesca-Marín
- Department of Internal Medicine and Hematology, Centro de Medicina Interna y Hematología; Clínica Ruiz; Puebla Puebla Mexico
| | - Guillermo J. Ruiz-Argüelles
- Department of Internal Medicine and Hematology, Centro de Medicina Interna y Hematología; Clínica Ruiz; Puebla Puebla Mexico
| | - José Carlos Jaime-Pérez
- Hematology Service, Department of Internal Medicine; Hospital Universitario “Dr. José Eleuterio González”, Universidad Autónoma de Nuevo León; Monterrey Nuevo León Mexico
| | - David Gómez-Almaguer
- Hematology Service, Department of Internal Medicine; Hospital Universitario “Dr. José Eleuterio González”, Universidad Autónoma de Nuevo León; Monterrey Nuevo León Mexico
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12
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Yue C, Su J, Gao R, Wen Y, Li C, Chen G, Zhang X, Li X. Characteristics and Outcomes of Patients with Systemic Lupus Erythematosus–associated Thrombotic Microangiopathy, and Their Acquired ADAMTS13 Inhibitor Profiles. J Rheumatol 2018; 45:1549-1556. [DOI: 10.3899/jrheum.170811] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/10/2018] [Indexed: 02/01/2023]
Abstract
Objective.To investigate the characteristics and outcomes of patients with systemic lupus erythematosus (SLE)–associated thrombotic microangiopathy (TMA) based on their ADAMTS13 inhibitor profiles.Methods.The medical data of 31 SLE patients with clinically diagnosed TMA were analyzed. ADAMTS13 activity and ADAMTS13 inhibitor were measured in all patients.Results.TMA was attributable to active SLE in 19 patients. ADAMTS13 inhibitor and severe ADAMTS13 deficiency were detected in 6 of them. Patients with ADAMTS13 inhibitor (n = 6) exhibited a lower platelet count (7.3 ± 5.1 vs 25.0 ± 17.8 × 109/l, p = 0.005) and more prevalent central nervous system (CNS) involvement (100.0% vs 23.1%, p = 0.003) than patients without ADAMTS13 inhibitor (n = 13). Patients with ADAMTS13 inhibitor also had mild renal involvement characterized by a higher estimated glomerular filtration rate (112.7 ± 18.0 vs 21.6 ± 12.0, p < 0.001), lower proteinuria level [0.6 (0.2–2.5) vs 8.1 (5.2–14.0) g/d, p = 0.011], and lower mean arterial pressure (95.3 ± 13.6 vs 117.5 ± 13.1 mmHg, p = 0.008) than was observed in patients without ADAMTS13 inhibitor. All patients with ADAMTS13 inhibitor achieved complete remission within 18.6 ± 8.7 days, while 3 patients (23.1%) without ADAMTS13 inhibitor achieved complete remission during a median followup of 5.0 months, even though more patients in this group received therapeutic apheresis (100.0% vs 50.0%, p = 0.021). The chance of complete remission increased by 10.8-fold (HR 10.8, 95% CI 1.8–65.5, p < 0.001) when ADAMTS13 inhibitor was present in SLE-associated TMA.Conclusion.Acquired ADAMTS13 deficiency is associated with more severe thrombocytopenia and CNS involvement, mild renal involvement, rapid resolution, and relatively good treatment response in SLE-associated TMA.
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13
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Lupus érythémateux systémique et lymphopénie : aspects cliniques et physiopathologiques. Rev Med Interne 2017; 38:603-613. [DOI: 10.1016/j.revmed.2017.01.005] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2016] [Revised: 01/07/2017] [Accepted: 01/11/2017] [Indexed: 12/20/2022]
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Renal Thrombotic Microangiopathy in Proliferative Lupus Nephritis: Risk Factors and Clinical Outcomes: A Case-Control Study. J Clin Rheumatol 2017; 22:235-40. [PMID: 27464767 DOI: 10.1097/rhu.0000000000000425] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Renal thrombotic microangiopathy (TMA) may be associated with lupus nephritis. Its relationship to other disease factors and its specific effect on prognosis are not precisely known. Evidence regarding these aspects is controversial, and information focusing on kidney-limited TMA in systemic lupus erythematosus (SLE) patients is scarce. OBJECTIVES The aims of this study were to identify risk factors for renal TMA in patients with lupus nephritis and to determine its impact on clinical outcomes. METHODS A case-control study was performed. We studied 245 renal biopsies from SLE patients. We included patients with renal TMA, as well as control subjects adjusted for glomerulonephritis class, estimated glomerular filtration rate, activity and chronicity indices, and follow-up time. Serological and clinical features were measured at the time of the biopsy and during follow-up. RESULTS Twenty-three patients with renal TMA and 21 control subjects were included. There were no differences in Systemic Lupus Erythematosus Disease Activity Index score, end-stage renal disease, or mortality between groups during follow-up. After multivariate analysis, lymphopenia (odds ratio, 10.69; 95% CI, 1.35-84.74) and anti-Ro antibody positivity (odds ratio, 8.96; 95% CI, 1.49-53.57) remained significantly associated with renal TMA. CONCLUSIONS Lymphopenia and anti-Ro positivity are independent risk factors for renal TMA in SLE patients. This increased risk could be a consequence of the potential role of these factors in endothelial dysfunction and damage. Outcomes were similar for patients with the same estimated glomerular filtration rate and biopsy characteristics, regardless of the presence of TMA.
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15
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Farkas P, Csuka D, Mikes B, Sinkovits G, Réti M, Németh E, Rácz K, Madách K, Gergely M, Demeter J, Prohászka Z. Complement activation, inflammation and relative ADAMTS13 deficiency in secondary thrombotic microangiopathies. Immunobiology 2017; 222:119-127. [DOI: 10.1016/j.imbio.2016.10.014] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2016] [Revised: 10/17/2016] [Accepted: 10/17/2016] [Indexed: 01/17/2023]
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Merayo-Chalico J, Rajme-López S, Barrera-Vargas A, Alcocer-Varela J, Díaz-Zamudio M, Gómez-Martín D. Lymphopenia and autoimmunity: A double-edged sword. Hum Immunol 2016; 77:921-929. [DOI: 10.1016/j.humimm.2016.06.016] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2015] [Revised: 06/01/2016] [Accepted: 06/21/2016] [Indexed: 01/09/2023]
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17
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Li QY, Yu F, Zhou FD, Zhao MH. Plasmapheresis Is Associated With Better Renal Outcomes in Lupus Nephritis Patients With Thrombotic Microangiopathy: A Case Series Study. Medicine (Baltimore) 2016; 95:e3595. [PMID: 27149490 PMCID: PMC4863807 DOI: 10.1097/md.0000000000003595] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
The aim of this study was to evaluate the efficacy of plasmapheresis in patients with lupus nephritis-combined thrombotic microangiopathy (TMA) in a Chinese cohort.Clinical and therapeutic data of patients with lupus nephritis-combined TMA were collected retrospectively. A comparison between those with and without plasmapheresis was performed.Seventy patients with renal biopsy-proven TMA in lupus nephritis were treated with conventional combined corticosteroid and immunosuppressive agents as induction therapy, 9 of the 70 patients received additional plasmapheresis. The plasmapheresis group presented with more severe SLE and renal activity indices, including a significant higher ratio of neurologic disorder (P = 0.025), lower level of platelet count (P = 0.009), higher value of serum creatinine (P = 0.038), higher percentage of anti-cardiolipin antibodies positive (P = 0.001), and higher Systemic Lupus Erythematosus Disease Activity Index scores (P = 0.012), than that of the nonplasmapheresis group. However, the plasmapheresis group had a significant higher rate of remission and a lower ratio of treatment failure than that of the nonplasmapheresis group (P = 0.03). As the baseline data were significantly different between the 2 groups, the propensity score match was further designed to avoid retrospective bias. After re-analysis, the plasmapheresis group still had a significant higher rate of remission and a lower ratio of treatment failure than that of the nonplasmapheresis group (P = 0.018). More importantly, the plasmapheresis group had significant less composite endpoints than that of the nonplasmapheresis group (P = 0.005).Our study suggested that additional plasmapheresis on conventional induction therapy may benefit patients with lupus nephritis-combined TMA, which warrants further explorations.
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Affiliation(s)
- Qiu-Yu Li
- From the Department of Medicine, Renal Division, Peking University First Hospital; Institute of Nephrology, Peking University; Key laboratory of Renal Disease, Ministry of Health of China; Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China (Q-YL, FY, F-DZ, M-HZ); Department of Nephrology, Peking University International Hospital (FY); and Peking-Tsinghua Center for Life Sciences, Beijing, PR China (M-HZ)
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18
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Merayo-Chalico J, Apodaca E, Barrera-Vargas A, Alcocer-Varela J, Colunga-Pedraza I, González-Patiño A, Arauz A, Abud-Mendoza C, Martínez-Martínez M, Gómez-Martín D. Clinical outcomes and risk factors for posterior reversible encephalopathy syndrome in systemic lupus erythematosus: a multicentric case-control study. J Neurol Neurosurg Psychiatry 2016; 87:287-94. [PMID: 25804426 DOI: 10.1136/jnnp-2014-310145] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2014] [Accepted: 03/02/2015] [Indexed: 01/19/2023]
Abstract
BACKGROUND Posterior reversible encephalopathy syndrome (PRES) is a well-known but rare complication in patients (<1%) with systemic lupus erythematosus (SLE). However, current epidemiological data are quite scant. The aim of the present study was to describe potentially unrecognised risk factors. PATIENTS AND METHODS We performed a multicentre, retrospective case-control study in Mexico between 1999 and 2014. We included a total of 168 patients who accounted for 77 episodes of PRES, as follows: SLE/PRES, 43 patients with 48 episodes; SLE without PRES, 96 patients; and PRES without SLE, 29 patients. SLE diagnosis was considered when patients fulfilled ≥4 American College of Rheumatology criteria. PRES was defined by reversible neurological manifestations and MRI changes. RESULTS Patients with SLE/PRES were younger, presented with seizures as the most common manifestation (81%) and 18% had the typical occipital MRI finding. Hypertension (OR=16.3, 95% CI 4.03 to 65.8), renal dysfunction (OR=6.65, 95% CI 1.24 to 35.6), lymphopenia (OR=5.76, 95% CI 1.36 to 24.4), Systemic Lupus Erythematosus Activity Index ≥ 6 points (OR=1.11, 95% CI 1.01 to 1.22) and younger age (OR=0.86, 95% CI 0.81 to 0.91, p<0.001) were independent risk factors for development of PRES in SLE. Furthermore, dyslipidemia also characterised the association between PRES and SLE (OR=10.6, 95% CI 1.17 to 96.4). CONCLUSIONS This is the largest reported series of patients with SLE and PRES. We were able to corroborate the known risk factors for of PRES, and found two previously undescribed factors (lymphopenia and dyslipidemia), which suggests that endothelial dysfunction is a key element in PRES pathogenesis in lupus patients.
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Affiliation(s)
- Javier Merayo-Chalico
- Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Elia Apodaca
- Department of Internal Medicine, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Ana Barrera-Vargas
- Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Jorge Alcocer-Varela
- Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Iris Colunga-Pedraza
- Department of Rheumatology, Hospital Universitario Dr José E González, Monterrey, Nuevo León, Mexico
| | - Alejandra González-Patiño
- Stroke Clinic, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Mexico City, Mexico
| | - Antonio Arauz
- Stroke Clinic, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Mexico City, Mexico
| | - Carlos Abud-Mendoza
- Regional Unit of Rheumatology and Osteoporosis, Hospital Central Dr Ignacio Morones Prieto, San Luis Potosí, Mexico
| | - Marco Martínez-Martínez
- Regional Unit of Rheumatology and Osteoporosis, Hospital Central Dr Ignacio Morones Prieto, San Luis Potosí, Mexico
| | - Diana Gómez-Martín
- Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
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Habe K, Wada H, Matsumoto T, Ohishi K, Ikejiri M, Tsuda K, Kondo M, Kamimoto Y, Ikeda T, Katayama N, Mizutani H. Plasma ADAMTS13, von Willebrand Factor (VWF), and VWF Propeptide Profiles in Patients With Connective Tissue Diseases and Antiphospholipid Syndrome. Clin Appl Thromb Hemost 2016; 23:622-630. [PMID: 26759371 DOI: 10.1177/1076029615625832] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Thrombotic thrombocytopenic purpura (TTP) frequently develops in patients with connective tissue diseases (CTDs). ADAMTS13 and von Willebrand factor (VWF) are closely related to the onset of TTP. We investigated the roles of ADAMTS13 and VWF in thrombotic events of patients with CTD. ADAMTS13 activity and VWF and VWF propeptide (VWFpp) levels in CTD, primary antiphospholipid antibody syndrome (pAPS), and controls were measured to examine their relationship with thrombosis. ADAMTS13 activity levels were significantly low in the patients with CTD but not in the patients with pAPS. No significant difference in the ADAMTS13 activity levels among the various CTD subgroups was found. The levels of VWF and VWFpp were significantly elevated in the patients with pAPS and CTD compared with that of control groups. Eleven patients with CTD developed TTP, and their ADAMTS13 activity levels were significantly lower than patients having CTD without TTP. However, the ADAMTS13 activity levels showed no difference between the patients having CTD with and without thrombotic events. The VWF antigen levels were significantly high in the patients having CTD with TTP. There were no significant differences in the VWF levels of the patients having CTD with TTP and thrombosis. The VWFpp levels were significantly high in the patients having CTD with TTP and thrombosis. The VWF and VWFpp levels were significantly high in the patients with pAPS. Decreased ADAMTS13 activity and elevated VWF and VWFpp levels were observed in patients with CTD. These abnormalities in patients with CTD may represent the increased risk of thrombosis in CTD.
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Affiliation(s)
- Koji Habe
- 1 Department of Dermatology, Mie University Graduate School of Medicine, Mie, Tsu, Japan
| | - Hideo Wada
- 2 Department of Molecular and Laboratory Medicine, Mie University Graduate School of Medicine, Tsu, Japan
| | - Takeshi Matsumoto
- 3 Blood Transfusion Service, Mie University Hospital, Mie, Tsu, Japan
| | - Kohshi Ohishi
- 3 Blood Transfusion Service, Mie University Hospital, Mie, Tsu, Japan
| | - Makoto Ikejiri
- 4 Central laboratory, Mie University Hospital, Tsu, Japan
| | - Kenshiro Tsuda
- 1 Department of Dermatology, Mie University Graduate School of Medicine, Mie, Tsu, Japan
| | - Makoto Kondo
- 1 Department of Dermatology, Mie University Graduate School of Medicine, Mie, Tsu, Japan
| | - Yuki Kamimoto
- 5 Department of Obstetrics and Gynecology, Mie University Graduate School of Medicine, Mie, Tsu, Japan
| | - Tomoaki Ikeda
- 5 Department of Obstetrics and Gynecology, Mie University Graduate School of Medicine, Mie, Tsu, Japan
| | - Naoyuki Katayama
- 6 Department of Hematology and Oncology, Mie University Graduate School of Medicine, Mie, Tsu, Japan
| | - Hitoshi Mizutani
- 1 Department of Dermatology, Mie University Graduate School of Medicine, Mie, Tsu, Japan
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Delgado-García G, Cámara-Lemarroy C, Infante-Valenzuela A, Colunga-Pedraza P, Alarcón-Galván G, Armenta-González A, Villarreal-Velázquez HJ. Pure lupus podocytopathy first presenting as thrombotic thrombocytopenic purpura-like syndrome. Clin Rheumatol 2015; 35:2131-2136. [PMID: 26384822 DOI: 10.1007/s10067-015-3069-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2015] [Revised: 08/24/2015] [Accepted: 08/30/2015] [Indexed: 12/27/2022]
Abstract
Lupus podocytopathy (LP) is an uncommon proteinuric disorder in the spectrum of lupus nephropathy. Its histological features are similar to those described in minimal change disease (MCD) with or without mesangial immune deposits. Although infrequent, a close relationship between systemic lupus erythematosus (SLE) and thrombotic thrombocytopenic purpura (TTP) is well accepted. Proteinuria in the setting of SLE has previously been associated with the development of TTP-like syndrome. As far as we know, LP first presenting as a TTP-like syndrome has never been reported. Here, we describe the case of a previously healthy 45-year-old woman who developed simultaneously these two conditions and then we briefly review the literature on the topic, emphasizing the previous cases of concurrent initial diagnosis of both SLE and MCD (n = 7) and SLE and TTP (n = 72). In conclusion, renal biopsy is central to the management of SLE patients with nephrotic syndrome. Furthermore, in a SLE patient with anemia and thrombocytopenia, TTP should be part of the differential diagnosis, even when no schistocytes were detected in peripheral blood smear.
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Affiliation(s)
- Guillermo Delgado-García
- Department of Internal Medicine, University Hospital, Autonomous University of Nuevo León, Madero y Gonzalitos s/n, Col. Mitras Centro, C.P. 64460, Monterrey, Nuevo León, Mexico.
| | - Carlos Cámara-Lemarroy
- Division of Neurology, University Hospital, Autonomous University of Nuevo León, Monterrey, Nuevo León, Mexico
| | - Adrián Infante-Valenzuela
- Division of Neurology, University Hospital, Autonomous University of Nuevo León, Monterrey, Nuevo León, Mexico
| | - Perla Colunga-Pedraza
- Division of Hematology, University Hospital, Autonomous University of Nuevo León, Monterrey, Nuevo León, Mexico
| | - Gabriela Alarcón-Galván
- Service of Anatomic Pathology, University Hospital, Autonomous University of Nuevo León, Monterrey, Nuevo León, Mexico
| | - Arian Armenta-González
- Division of Rheumatology, University Hospital, Autonomous University of Nuevo León, Monterrey, Nuevo León, Mexico
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Georgiades F, Demosthenous S, Braimi M, Tsitskari T, Psarelis S. Takotsubo cardiomyopathy and thrombotic thrombocytopenic purpura preceding a lupus diagnosis: a case report. Lupus 2015; 24:1443-7. [PMID: 26130738 DOI: 10.1177/0961203315593165] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2014] [Accepted: 06/03/2015] [Indexed: 11/16/2022]
Abstract
Takotsubo cardiomyopathy, a rare stress-related cardiomyopathy, has been observed in a few cases secondary to systemic lupus erythematosus (SLE). Herein, we report an unusual case where a postmenopausal woman presented initially with Takotsubo syndrome, later developed thrombotic thrombocytopenic purpura and cerebrovascular events, initially without clinical or laboratory features of SLE. During the course of her illness, she was found to satisfy four of the Systemic Lupus International Collaborating Clinics classification criteria for a SLE diagnosis. This unique presentation of our patient, initially with Takotsubo cardiomyopathy, the development of thrombotic thrombocytopenic purpura and cerebrovascular events preceding the diagnosis of SLE illustrates the importance of clinical observation and follow-up.
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Affiliation(s)
- F Georgiades
- St George's, University of London at the University of Nicosia, Nicosia, Cyprus
| | - S Demosthenous
- St George's, University of London at the University of Nicosia, Nicosia, Cyprus
| | - M Braimi
- Haematology Department, Nicosia General Hospital, Nicosia, Cyprus
| | - T Tsitskari
- Haematology Department, Nicosia General Hospital, Nicosia, Cyprus
| | - S Psarelis
- St George's, University of London at the University of Nicosia, Nicosia, Cyprus Rheumatology Department, Nicosia General Hospital, Nicosia, Cyprus
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