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Garcia-Villanueva MJ, Garrote-Corral S, Pego-Reigosa JM, Jiménez Otero N, Uriarte Isazelaia E, Olivé Marqué A, Sangüesa Gómez C, Freire González M, Aurrecoechea Aguinaga E, Raya Álvarez E, Tomero Muriel E, Montilla Morales C, Galindo Izquierdo M, Calvo-Alén J, Menor-Almagro R, Serrano Benavente B, Martinez-Barrio J, Hernández-Beriain JA, Ibañez Barceló M, Bonilla Hernan G, Rosas J, Salgado Pérez E, Fernández-Nebro A, Rua-Figueroa I. Diffuse alveolar hemorrhage in patients with systemic lupus erythematosus: data from the Spanish society of rheumathology Lupus Register (RELESSER). Rheumatol Int 2024:10.1007/s00296-024-05684-4. [PMID: 39180523 DOI: 10.1007/s00296-024-05684-4] [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: 02/07/2024] [Accepted: 05/25/2024] [Indexed: 08/26/2024]
Abstract
INTRODUCTION Diffuse alveolar hemorrhage (DAH) is a rare complication with high mortality in patients with systemic lupus erythematosus (SLE). Early diagnosis and treatment are essential to improve patient prognosis. To determine the characteristics of patients with DAH and their mortality in a Spanish cohort of patients with SLE. METHODS Patients from the RELESSER (Spanish Society of Rheumatology Lupus Register) who had had at least one confirmed episode of DAH were included. Epidemiological, clinical, and laboratory characteristics were analyzed. RESULTS 4024 patients were included in the RELESSER register, 37 (0.9%), had at least one recorded episode of DAH. Only further data for 14 patients could be analyzed. In total, 92.9% were women, and for 4 (28.6%) DAH coincided with the debut of SLE. More than 80% of patients had renal involvement and thrombocytopenia. The most frequent manifestations were dyspnea (85.7%) and hypoxemia (100%), with the classic triad of hemoptysis, anemia and pulmonary infiltrates, appearing in 6 (46.2%) patients. The most frequently used treatments were glucocorticoids (85.7%) and cyclophosphamide (69.2%); plasmapheresis was utilized in 5 patients (35.7%) and 8, (57.1%) received intravenous immunoglobulins; 12 (85.7%) patients required admission to the ICU and 5 (35.7%) died. Tobacco use, history of lupus nephritis (LN), concomitant infection, and treatment with cyclophosphamide were more frequent in patients who died. CONCLUSIONS DAH is rare in patients with SLE; in up to one-third of patients, it may appear at the onset of the disease. Some factors, such as smoking, a history of LN, treatment with cyclophosphamide, or concomitant infection, are more prevalent in patients with an unfavorable outcome.
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Affiliation(s)
| | - Sandra Garrote-Corral
- Rheumatology Department, Hospital Universitario Ramón y Cajal, M-607, 9, 100, Madrid, 28034, Spain
| | - Jose María Pego-Reigosa
- Rheumatology Department, Complexo Hospitalario Universitario de Vigo, Vigo, Spain
- IRIDIS (Investigation in Rheumatology and Immune-Mediated Diseases)-VIGO Group, Galicia Sur Health Research Institute, Vigo, Spain
| | - Norman Jiménez Otero
- IRIDIS (Investigation in Rheumatology and Immune-Mediated Diseases)-VIGO Group, Galicia Sur Health Research Institute, Vigo, Spain
| | | | | | - Clara Sangüesa Gómez
- Rheumatology Department, Hospital Universitari Germans Trias i Pujol, Barcelona, Spain
| | - Mercedes Freire González
- Rheumatology Department, Hospital Juan Canalejo, Hospital Universitario de A Coruña, Coruña, Spain
| | | | | | - Eva Tomero Muriel
- Rheumatology Department, Hospital Universitario la Princesa, Madrid, Spain
| | | | | | - Jaime Calvo-Alén
- Rheumatology Department, Hospital Universitario Araba, Vitoria, Spain
| | - Raúl Menor-Almagro
- Rheumatology Department Hospital Jerez de la Frontera, Jerez de la Frontera, Spain
| | | | | | | | | | | | - Jose Rosas
- Rheumatology Department, Hospital Marina Baixa, Villajoyosa, Alicante, Spain
| | - Eva Salgado Pérez
- Rheumatology Department, Complejo Hospitalario Universitario de Orense, Orense, Spain
| | - Antonio Fernández-Nebro
- Rheumatology Department, Hospital Regional Universitario de Málaga, Instituto de Investigación Biomédica de Málaga (IBIMA)-Plataforma Bionand, Málaga, Spain
| | - Iñigo Rua-Figueroa
- Rheumatology Department, Hospital Universitario de Gran Canaria Dr. Negrín, Las Palmas, Spain
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Poli S, Sciorio F, Piacentini G, Pietrobelli A, Pecoraro L, Pieropan S. Acute Respiratory Failure in Autoimmune Rheumatic Diseases: A Review. J Clin Med 2024; 13:3008. [PMID: 38792549 PMCID: PMC11122618 DOI: 10.3390/jcm13103008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Revised: 05/08/2024] [Accepted: 05/17/2024] [Indexed: 05/26/2024] Open
Abstract
This review examines respiratory complications in autoimmune rheumatic diseases within intensive care units (ICUs). The respiratory system, primarily affected in diseases like rheumatoid arthritis, systemic lupus erythematosus, and scleroderma, often leads to respiratory failure. Common manifestations include alveolar hemorrhage, interstitial fibrosis, and acute respiratory distress syndrome. Early recognition and treatment of non-malignant conditions are crucial to prevent rapid disease progression, with ICU mortality rates ranging from 30% to 60%. Delayed immunosuppressive or antimicrobial therapy may result in organ system failure. Collaboration with rheumatic specialists is vital for accurate diagnosis and immediate intervention. Mortality rates for rheumatic diseases in the ICU surpass those of other conditions, underscoring the need for specialized care and proactive management. The review emphasizes comprehensive assessments, distinguishing disease-related complications from underlying issues, and the importance of vigilant monitoring to enhance patient outcomes.
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Affiliation(s)
| | | | | | | | - Luca Pecoraro
- Pediatric Clinic, Department of Surgical Sciences, Dentistry, Pediatrics and Gynecology, University of Verona, 37126 Verona, Italy
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Palafox-Flores JG, Valencia-Ledezma OE, Vargas-López G, Jamaica-Balderas L, Acevedo-Silva N, Castro-Fuentes CA. Systemic lupus erythematosus in pediatric patients: Pulmonary manifestations. Respir Med 2023; 220:107456. [PMID: 37926179 DOI: 10.1016/j.rmed.2023.107456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Revised: 11/01/2023] [Accepted: 11/02/2023] [Indexed: 11/07/2023]
Abstract
The pulmonary manifestations of Systemic Lupus Erythematosus (SLE) in pediatric patients are poorly understood and the pulmonary manifestations reported from the adult population are generally extrapolated to the pediatric population. In the present work, the review of 228 files was carried out, in which the pulmonary manifestations, symptoms and antibody levels of the patients treated at the Hospital Regional de Alta Especialidad de Ixtapaluca (HRAEI), State of Mexico, Mexico, were identified. Statistical significance between groups was estimated using the Chi-square and Mann-Whitney U test. The main pulmonary manifestations identified were pleurisy (14 %), pulmonary hemorrhage (3.9 %), pulmonary thromboembolism (0.9 %), acute lupus pneumonitis (0.4 %), pulmonary arterial hypertension (0.4 %), and small lung syndrome (0.4 %). While the initial symptomatology was dyspnea with an incidence of 9.6 %, the mean oxygen saturation in the population was 96.87 %. Pleural effusion was identified as the most frequent pulmonary manifestation in radiographic changes. No statistically significant difference was found in antibody levels when comparing the groups. The most common pulmonary manifestation associated with SLE is pleurisy, however, the range of pulmonary manifestations in this type of patient can be very varied, as well as the presentation of each of them.
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Affiliation(s)
| | | | | | | | - Nydia Acevedo-Silva
- Pediatric Rheumatology Unit, Hospital Regional de Alta Especialidad de Ixtapaluca, Mexico
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Figueroa-Parra G, Meade-Aguilar JA, Langenfeld HE, González-Treviño M, Hocaoglu M, Hanson AC, Prokop LJ, Murad MH, Cartin-Ceba R, Specks U, Majithia V, Crowson CS, Duarte-García A. Clinical features, risk factors, and outcomes of diffuse alveolar hemorrhage in antiphospholipid syndrome: A mixed-method approach combining a multicenter cohort with a systematic literature review. Clin Immunol 2023; 256:109775. [PMID: 37722463 DOI: 10.1016/j.clim.2023.109775] [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: 05/23/2023] [Revised: 08/29/2023] [Accepted: 09/13/2023] [Indexed: 09/20/2023]
Abstract
BACKGROUND Antiphospholipid syndrome (APS) is a systemic autoimmune disease clinically associated with thrombotic and obstetric events. Additional manifestations have been associated with APS, like diffuse alveolar hemorrhage (DAH). We aimed to summarize all the evidence available to describe the presenting clinical features, their prognostic factors, and short- and long-term outcomes. METHODS We performed a mixed-method approach combining a multicenter cohort with a systematic literature review (SLR) of patients with incident APS-associated DAH. We described their clinical features, treatments, prognostic factors, and outcomes (relapse, mortality, and requirement of mechanical ventilation [MV]). Kaplan-Meier methods were used to estimate relapse and mortality rates, and Cox and logistic regression models were used to assess the factors associated as appropriate. RESULTS We included 219 patients with incident APS-associated DAH (61 from Mayo Clinic and 158 from SLR). The median age was 39.5 years, 51% were female, 29% had systemic lupus erythematosus, and 34% presented with catastrophic APS (CAPS). 74% of patients had a history of thrombotic events, and 26% of women had a history of pregnancy morbidity; half of the patients had a history of thrombocytopenia, and a third had valvulopathy. Before DAH, 55% of the patients were anticoagulated. At DAH onset, 65% of patients presented hemoptysis. The relapse rate was 47% at six months and 52% at one year. Triple positivity (HR 4.22, 95% CI 1.14-15.59) was associated with relapse at six months. The estimated mortality at one and five years was 30.3% and 45.8%. Factors associated with mortality were severe thrombocytopenia (< 50 K/μL) (HR 3.10, 95% CI 1.39-6.92), valve vegetations (HR 3.22, 95% CI 1.14-9.07), CAPS (HR 3.80, 95% CI 1.84-7.87), and requirement of MV (HR 2.22, 95% CI 1.03-4.80). Forty-two percent of patients required MV on the incident DAH episode. Patients presenting with severe thrombocytopenia (OR 6.42, 95% CI 1.77-23.30) or CAPS (OR 4.30, 95% CI 1.65-11.16) were more likely to require MV. CONCLUSION APS-associated DAH is associated with high morbidity and mortality, particularly when presenting with triple positivity, thrombocytopenia, valvular involvement, and CAPS.
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Affiliation(s)
| | | | | | | | - Mehmet Hocaoglu
- Division of Rheumatology, Mayo Clinic, Rochester, MN, USA; Department of Medicine, University of Maryland Medical Center, Midtown Campus, Baltimore, MD, USA
| | - Andrew C Hanson
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, USA
| | | | - M Hassan Murad
- Evidence-based Practice Center, Mayo Clinic, Rochester, MN, USA
| | - Rodrigo Cartin-Ceba
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Scottsdale, AZ, USA
| | - Ulrich Specks
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | - Vikas Majithia
- Division of Rheumatology, Mayo Clinic, Jacksonville, FL, USA
| | - Cynthia S Crowson
- Division of Rheumatology, Mayo Clinic, Rochester, MN, USA; Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, USA
| | - Alí Duarte-García
- Division of Rheumatology, Mayo Clinic, Rochester, MN, USA; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA.
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Law AH, Chuah TY, Lee W, Teng GG, Lian TY, Saffari SE, Chew LC. Diffuse alveolar haemorrhage in systemic lupus erythematosus: A multicentre retrospective study in Singapore. Lupus 2023:9612033231180704. [PMID: 37268601 DOI: 10.1177/09612033231180704] [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: 06/04/2023]
Abstract
OBJECTIVE Diffuse alveolar haemorrhage (DAH) is a rare but life-threatening complication of systemic lupus erythematosus (SLE). We describe the clinical characteristics, treatment and survival outcomes of SLE patients with DAH in Singapore. METHODS We conducted a retrospective review of the medical records of SLE patients with DAH hospitalised in 3 tertiary hospitals between January 2007 and October 2017. Patient demographics, clinical characteristics, laboratory, radiologic and bronchoscopic findings, as well as the treatments, were compared between survivors and non-survivors. Survival rates were analysed between the various treatment groups. RESULTS A total of 35 patients with DAH were included in this study. Majority of them were female (71.4%) and of Chinese ethnicity (62.9%). Median age was 40.0 years (IQR: 25-54), with a median disease duration of 8.9 months (IQR: 0.13-102.4). Haemoptysis was the most common clinical presentation, and majority had concomitant cytopaenia and lupus nephritis. All patients received high dose glucocorticoids; 27 (77.1%), 16 (45.7%) and 23 (65.7%) received cyclophosphamide (CYP), rituximab (RTX), and plasmapheresis (PLEX), respectively. Twenty-two patients required mechanical ventilation with a median duration of 12 days. Overall mortality rate was 40%, with a median survival time of 162 days. Twenty-six patients (74.3%) achieved remission, with an overall median time to remission of 12 days (IQR: 6-46) after diagnosis of DAH. Patients on triple therapy (CYP, RTX and PLEX) had a median survival of 162 days as compared to 14 days in patients on PLEX alone (p = .0026). CONCLUSIONS The overall mortality of DAH in SLE patients remained high. There were no significant differences in patient demographics or clinical characteristics between the survivors and non-survivors. However, better survival appears to be associated with treatment with cyclophosphamide.
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Affiliation(s)
- Annie Hn Law
- Department of Rheumatology and Immunology, Singapore General Hospital, Singapore
- Duke-NUS Medical School, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Tyng Yu Chuah
- Department of General Medicine (Rheumatology), Sengkang General Hospital, Singapore
| | - Weixian Lee
- Department of Medicine (Rheumatology), Ng Teng Fong General Hospital, Singapore
| | - Gim Gee Teng
- Department of Rheumatology, National University Hospital, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Tsui Yee Lian
- Department of Rheumatology, Allergy and Immunology, Tan Tock Seng Hospital, Singapore
| | - Seyed Ehsan Saffari
- Centre for Quantitative Medicine, Duke-NUS Medical School, National University of Singapore, Singapore
| | - Li-Ching Chew
- Department of Rheumatology and Immunology, Singapore General Hospital, Singapore
- Duke-NUS Medical School, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
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Shin JI, Lee KH, Park S, Yang JW, Kim HJ, Song K, Lee S, Na H, Jang YJ, Nam JY, Kim S, Lee C, Hong C, Kim C, Kim M, Choi U, Seo J, Jin H, Yi B, Jeong SJ, Sheok YO, Kim H, Lee S, Lee S, Jeong YS, Park SJ, Kim JH, Kronbichler A. Systemic Lupus Erythematosus and Lung Involvement: A Comprehensive Review. J Clin Med 2022; 11:jcm11226714. [PMID: 36431192 PMCID: PMC9698564 DOI: 10.3390/jcm11226714] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 10/27/2022] [Accepted: 11/04/2022] [Indexed: 11/16/2022] Open
Abstract
Systemic lupus erythematosus (SLE) is a complex autoimmune disease with multiorgan manifestations, including pleuropulmonary involvement (20-90%). The precise mechanism of pleuropulmonary involvement in SLE is not well-understood; however, systemic type 1 interferons, circulating immune complexes, and neutrophils seem to play essential roles. There are eight types of pleuropulmonary involvement: lupus pleuritis, pleural effusion, acute lupus pneumonitis, shrinking lung syndrome, interstitial lung disease, diffuse alveolar hemorrhage (DAH), pulmonary arterial hypertension, and pulmonary embolism. DAH has a high mortality rate (68-75%). The diagnostic tools for pleuropulmonary involvement in SLE include chest X-ray (CXR), computed tomography (CT), pulmonary function tests (PFT), bronchoalveolar lavage, biopsy, technetium-99m hexamethylprophylene amine oxime perfusion scan, and (18)F-fluorodeoxyglucose positron emission tomography. An approach for detecting pleuropulmonary involvement in SLE includes high-resolution CT, CXR, and PFT. Little is known about specific therapies for pleuropulmonary involvement in SLE. However, immunosuppressive therapies such as corticosteroids and cyclophosphamide are generally used. Rituximab has also been successfully used in three of the eight pleuropulmonary involvement forms: lupus pleuritis, acute lupus pneumonitis, and shrinking lung syndrome. Pleuropulmonary manifestations are part of the clinical criteria for SLE diagnosis. However, no review article has focused on the involvement of pleuropulmonary disease in SLE. Therefore, this article summarizes the literature on the epidemiology, pathogenesis, diagnosis, and management of pleuropulmonary involvement in SLE.
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Affiliation(s)
- Jae Il Shin
- Department of Pediatrics, Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - Keum Hwa Lee
- Department of Pediatrics, Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - Seoyeon Park
- Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - Jae Won Yang
- Department of Nephrology, Yonsei University Wonju College of Medicine, Wonju 26426, Republic of Korea
| | - Hyung Ju Kim
- Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - Kwanhyuk Song
- Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - Seungyeon Lee
- Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - Hyeyoung Na
- Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - Yong Jun Jang
- Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - Ju Yun Nam
- Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - Soojin Kim
- Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - Chaehyun Lee
- Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - Chanhee Hong
- Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - Chohwan Kim
- Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - Minhyuk Kim
- Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - Uichang Choi
- Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - Jaeho Seo
- Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - Hyunsoo Jin
- Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - BoMi Yi
- Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - Se Jin Jeong
- Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - Yeon Ook Sheok
- Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - Haedong Kim
- Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - Sangmin Lee
- Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - Sangwon Lee
- Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - Young Soo Jeong
- Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - Se Jin Park
- Department of Pediatrics, Eulji University School of Medicine, Daejeon 34824, Republic of Korea
| | - Ji Hong Kim
- Department of Pediatrics, Yonsei University College of Medicine, Seoul 03722, Republic of Korea
- Department of Pediatrics, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul 26426, Republic of Korea
- Correspondence:
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Fukushima K, Uchida HA, Fuchimoto Y, Mifune T, Watanabe M, Tsuji K, Tanabe K, Kinomura M, Kitamura S, Miyamoto Y, Wada S, Koyanagi T, Sugiyama H, Kishimoto T, Wada J. Silica-associated systemic lupus erythematosus with lupus nephritis and lupus pneumonitis: A case report and a systematic review of the literature. Medicine (Baltimore) 2022; 101:e28872. [PMID: 35363197 PMCID: PMC9282083 DOI: 10.1097/md.0000000000028872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 02/01/2022] [Indexed: 01/04/2023] Open
Abstract
INTRODUCTION Several epidemiological studies have shown that silica exposure triggers the onset of systemic lupus erythematosus (SLE); however, the clinical characteristics of silica-associated SLE have not been well studied. PATIENT CONCERNS A 67-year-old man with silicosis visited a primary hospital because of a fever and cough. His respiratory condition worsened, regardless of antibiotic medication, and he was referred to our hospital. DIAGNOSIS The patient showed leukopenia, lymphopenia, serum creatinine elevation with proteinuria and hematuria, decreased serum C3 level, and was positive for anti-double stranded DNA antibody, anti-nuclear antibody, and direct Coombs test. He was diagnosed with SLE. Renal biopsy was performed, and the patient was diagnosed with lupus nephritis (class IV-G(A/C) + V defined by the International Society of Nephrology/Renal Pathology Society classification). Computed tomography revealed acute interstitial pneumonitis, bronchoalveolar lavage fluid showed elevation of the lymphocyte fraction, and he was diagnosed with lupus pneumonitis. INTERVENTIONS Prednisolone (50 mg/day) with intravenous cyclophosphamide (500 mg/body) were initiated. OUTCOMES The patient showed a favorable response to these therapies. He was discharged from our hospital and received outpatient care with prednisolone slowly tapered off. He had cytomegalovirus and herpes zoster virus infections during treatment, which healed with antiviral therapy. REVIEW We searched for the literature on sSLE, and selected 11 case reports and 2 population-based studies. The prevalence of SLE manifestations in sSLE patients were comparative to that of general SLE, particularly that of elderly-onset SLE. Our renal biopsy report and previous reports indicate that lupus nephritis of sSLE patients show as various histological patterns as those of general SLE patients. Among the twenty sSLE patients reported in the case articles, three patients developed lupus pneumonitis and two of them died of it. Moreover, two patients died of bacterial pneumonia, one developed aspergillus abscesses, one got pulmonary tuberculosis, and one developed lung cancer. CONCLUSION Close attention is needed, particularly for respiratory system events and infectious diseases, when treating patients with silica-associated SLE using immunosuppressive therapies.
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Affiliation(s)
- Kazuhiko Fukushima
- Department of Nephrology, Rheumatology, Endocrinology and Metabolism, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Haruhito A. Uchida
- Department of Nephrology, Rheumatology, Endocrinology and Metabolism, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
- Department of Chronic Kidney Disease and Cardiovascular Disease, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Yasuko Fuchimoto
- Department of Respiratory Medicine, Okayama Rosai Hospital, Okayama, Japan
| | - Tomoyo Mifune
- Department of Nephrology, Rheumatology, Endocrinology and Metabolism, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Mayu Watanabe
- Department of Nephrology, Rheumatology, Endocrinology and Metabolism, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Kenji Tsuji
- Department of Nephrology, Rheumatology, Endocrinology and Metabolism, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Katsuyuki Tanabe
- Department of Nephrology, Rheumatology, Endocrinology and Metabolism, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Masaru Kinomura
- Department of Nephrology, Rheumatology, Endocrinology and Metabolism, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Shinji Kitamura
- Department of Nephrology, Rheumatology, Endocrinology and Metabolism, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Yosuke Miyamoto
- Department of Respiratory Medicine, Okayama Rosai Hospital, Okayama, Japan
| | - Sae Wada
- Department of Respiratory Medicine, Okayama Rosai Hospital, Okayama, Japan
| | - Taisaku Koyanagi
- Department of Respiratory Medicine, Okayama Rosai Hospital, Okayama, Japan
| | - Hitoshi Sugiyama
- Department of Nephrology, Rheumatology, Endocrinology and Metabolism, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
- Department of Human Resource Development of Dialysis Therapy for Kidney Disease, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Takumi Kishimoto
- Department of Respiratory Medicine, Okayama Rosai Hospital, Okayama, Japan
| | - Jun Wada
- Department of Nephrology, Rheumatology, Endocrinology and Metabolism, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
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Rajasekhar L, Devarasetti P, Appani S, Prasad Irlapati R. Predictors of mortality in diffuse alveolar hemorrhage in systemic lupus erythematosus. INDIAN JOURNAL OF RHEUMATOLOGY 2022. [DOI: 10.4103/injr.injr_82_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Ono M, Matsumoto K, Boku N, Fujii N, Tsuchida Y, Furui T, Harada M, Kanda Y, Kawai A, Miyachi M, Murashima A, Nakayama R, Nishiyama H, Shimizu C, Sugiyama K, Takai Y, Fujio K, Morishige KI, Osuga Y, Suzuki N. Indications for fertility preservation not included in the 2017 Japan Society of Clinical Oncology Guideline for Fertility Preservation in Pediatric, Adolescent, and Young Adult Patients treated with gonadal toxicity, including benign diseases. Int J Clin Oncol 2021; 27:301-309. [PMID: 34791542 PMCID: PMC8850228 DOI: 10.1007/s10147-021-02082-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Accepted: 11/09/2021] [Indexed: 11/30/2022]
Abstract
In recent years, local governments in Japan have established a public financial support system for fertility preservation in pediatric, adolescent, and young adult cancer patients. Fertility preservation has become popular for patients with cancers included in the gonadal toxicity risk classification of the 2017 edition of the Guideline for Fertility Preservation in Children, Adolescents and Young Adult Cancer Patients from the Japan Society of Clinical Oncology. However, patients with cancer and non-cancer diseases that are not included in the Guideline's gonadal toxicity risk classification also often receive treatment that may affect fertility, but they are often denied the opportunity of fertility preservation because no public financial support is available for diseases not listed in the Guideline. The national research project proposes including these diseases in the indications and treatment for fertility preservation. Therefore, we cooperated with the Japan Society for Fertility Preservation and the Ministry of Health, Labour and Welfare research group to solicit opinions from experts in each therapeutic area and reviewed the literature and overseas guidelines. This paper summarizes the findings of the project. We believe that it will be an important source of information for clinicians treating patients who need fertility preservation but note that the appropriateness of fertility preservation for the disorders listed in this report needs to be continuously reviewed as medical care advances.
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Affiliation(s)
- Masanori Ono
- Department of Obstetrics and Gynecology, Tokyo Medical University, 6-7-1 Nishi-Shinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan.
| | - Kimikazu Matsumoto
- Children's Cancer Center, National Center for Child Health and Development, 2-10-1 Okura, Setagaya-ku, Tokyo, 157-8535, Japan
| | - Narikazu Boku
- Division of Gastrointestinal Medical Oncology, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, 104-0045, Japan
| | - Nobuharu Fujii
- Division of Blood Transfusion, Okayama University Hospital, 2-5-1 Shikata-cho, Kita-ku, Okayama-shi, Okayama, 700-8558, Japan
| | - Yumi Tsuchida
- Department of Allergy and Rheumatology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
| | - Tatsuro Furui
- Department of Obstetrics and Gynecology, Gifu University Graduate School of Medicine, 1-1 Yanagido, Gifu-shi, Gifu, 501-1194, Japan
| | - Miyuki Harada
- Department of Obstetrics and Gynecology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
| | - Yoshinobu Kanda
- Division of Hematology, Department of Medicine, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke-shi, Tochigi, 329-0498, Japan
| | - Akira Kawai
- Department of Musculoskeletal Oncology and Rehabilitation Medicine, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, 104-0045, Japan
| | - Mitsuru Miyachi
- Department of Pediatrics, Kyoto Prefectural University of Medicine, 465 Kajii-cho, Kawaramachi-Hirokoji, Kamigyo-ku, Kyoto-shi, Kyoto, 602-8566, Japan
| | - Atsuko Murashima
- Division of Maternal Medicine, Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, 2-10-1 Okura, Setagaya-ku, Tokyo, 157-8535, Japan
| | - Robert Nakayama
- Department of Orthopedic Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Hiroyuki Nishiyama
- Department of Urology, Faculty of Medicine and Graduate School of Comprehensive Human Science, University of Tsukuba, 1-1-1 Tennodai, Tsukuba-shi, Ibaraki, 305-8577, Japan
| | - Chikako Shimizu
- Department of Oncology, National Center for Global Health and Medicine Hospital, 1-21-1 Toyama, Shinjuku-ku, Tokyo, 162-8655, Japan
| | - Kazuhiko Sugiyama
- Department of Clinical Oncology and Neuro-Oncology Program, Hiroshima University Hospital, 1-2-3 Kasumi, Minami-ku, Hiroshima-shi, Hiroshima, 734-8551, Japan
| | - Yasushi Takai
- Department of Obstetrics and Gynecology, Saitama Medical Center, Saitama Medical University, 1981 Kamoda, Kawagoe-shi, Saitama, 350-8550, Japan
| | - Keishi Fujio
- Department of Allergy and Rheumatology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
| | - Ken-Ichirou Morishige
- Department of Obstetrics and Gynecology, Gifu University Graduate School of Medicine, 1-1 Yanagido, Gifu-shi, Gifu, 501-1194, Japan
| | - Yutaka Osuga
- Department of Obstetrics and Gynecology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
| | - Nao Suzuki
- Department of Obstetrics and Gynecology, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae-ku, Kawasaki-shi, Kanagawa, 216-8511, Japan
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Leone P, Prete M, Malerba E, Bray A, Susca N, Ingravallo G, Racanelli V. Lupus Vasculitis: An Overview. Biomedicines 2021; 9:1626. [PMID: 34829857 PMCID: PMC8615745 DOI: 10.3390/biomedicines9111626] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 10/29/2021] [Accepted: 11/03/2021] [Indexed: 12/21/2022] Open
Abstract
Lupus vasculitis (LV) is one of the secondary vasculitides occurring in the setting of systemic lupus erythematosus (SLE) in approximately 50% of patients. It is most commonly associated with small vessels, but medium-sized vessels can also be affected, whereas large vessel involvement is very rare. LV may involve different organ systems and present in a wide variety of clinical manifestations according to the size and site of the vessels involved. LV usually portends a poor prognosis, and a prompt diagnosis is fundamental for a good outcome. The spectrum of involvement ranges from a relatively mild disease affecting small vessels or a single organ to a multiorgan system disease with life-threatening manifestations, such as mesenteric vasculitis, pulmonary hemorrhage, or mononeuritis multiplex. Treatment depends upon the organs involved and the severity of the vasculitis process. In this review, we provide an overview of the different forms of LV, describing their clinical impact and focusing on the available treatment strategies.
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Affiliation(s)
- Patrizia Leone
- Department of Biomedical Sciences and Human Oncology, “Aldo Moro” University of Bari Medical School, 70124 Bari, Italy; (P.L.); (M.P.); (E.M.); (A.B.); (N.S.)
| | - Marcella Prete
- Department of Biomedical Sciences and Human Oncology, “Aldo Moro” University of Bari Medical School, 70124 Bari, Italy; (P.L.); (M.P.); (E.M.); (A.B.); (N.S.)
| | - Eleonora Malerba
- Department of Biomedical Sciences and Human Oncology, “Aldo Moro” University of Bari Medical School, 70124 Bari, Italy; (P.L.); (M.P.); (E.M.); (A.B.); (N.S.)
| | - Antonella Bray
- Department of Biomedical Sciences and Human Oncology, “Aldo Moro” University of Bari Medical School, 70124 Bari, Italy; (P.L.); (M.P.); (E.M.); (A.B.); (N.S.)
| | - Nicola Susca
- Department of Biomedical Sciences and Human Oncology, “Aldo Moro” University of Bari Medical School, 70124 Bari, Italy; (P.L.); (M.P.); (E.M.); (A.B.); (N.S.)
| | - Giuseppe Ingravallo
- Section of Pathology, Department of Emergency and Organ Transplantation, “Aldo Moro” University of Bari Medical School, 70124 Bari, Italy;
| | - Vito Racanelli
- Department of Biomedical Sciences and Human Oncology, “Aldo Moro” University of Bari Medical School, 70124 Bari, Italy; (P.L.); (M.P.); (E.M.); (A.B.); (N.S.)
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Kondoh Y, Makino S, Ogura T, Suda T, Tomioka H, Amano H, Anraku M, Enomoto N, Fujii T, Fujisawa T, Gono T, Harigai M, Ichiyasu H, Inoue Y, Johkoh T, Kameda H, Kataoka K, Katsumata Y, Kawaguchi Y, Kawakami A, Kitamura H, Kitamura N, Koga T, Kurasawa K, Nakamura Y, Nakashima R, Nishioka Y, Nishiyama O, Okamoto M, Sakai F, Sakamoto S, Sato S, Shimizu T, Takayanagi N, Takei R, Takemura T, Takeuchi T, Toyoda Y, Yamada H, Yamakawa H, Yamano Y, Yamasaki Y, Kuwana M. 2020 guide for the diagnosis and treatment of interstitial lung disease associated with connective tissue disease. Respir Investig 2021; 59:709-740. [PMID: 34602377 DOI: 10.1016/j.resinv.2021.04.011] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 04/20/2021] [Accepted: 04/21/2021] [Indexed: 01/29/2023]
Abstract
The prognosis of patients with connective tissue disease (CTD) has improved significantly in recent years, but interstitial lung disease (ILD) associated with connective tissue disease (CTD-ILD) remains a refractory condition, which is a leading cause of mortality. Because it is an important prognostic factor, many observational and interventional studies have been conducted to date. However, CTD is a heterogeneous group of conditions, which makes the clinical course, treatment responses, and prognosis of CTD-ILD extremely diverse. To summarize the current understanding and unsolved questions, the Japanese Respiratory Society and the Japan College of Rheumatology collaborated to publish the world's first guide focusing on CTD-ILD, based on the evidence and expert consensus of pulmonologists and rheumatologists, along with radiologists, pathologists, and dermatologists. The task force members proposed a total of 27 items, including 7 for general topics, 9 for disease-specific topics, 3 for complications, 4 for pharmacologic treatments, and 4 for non-pharmacologic therapies, with teams of 2-4 authors and reviewers for each item to prepare a consensus statement based on a systematic literature review. Subsequently, public opinions were collected from members of both societies, and a critical review was conducted by external reviewers. Finally, the task force finalized the guide upon discussion and consensus generation. This guide is expected to contribute to the standardization of CTD-ILD medical care and is also useful as a tool for promoting future research by clarifying unresolved issues.
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Affiliation(s)
- Yasuhiro Kondoh
- Department of Respiratory Medicine and Allergy, Tosei General Hospital, Seto, Aichi, Japan.
| | - Shigeki Makino
- Rheumatology Division, Osaka Medical College Mishima-Minami Hospital, Takatsuki, Osaka, Japan
| | - Takashi Ogura
- Division of Respiratory Medicine, Kanagawa Cardiovascular and Respiratory Center, Yokohama, Kanagawa, Japan
| | - Takafumi Suda
- Second Division, Department of Internal Medicine, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka, Japan
| | - Hiromi Tomioka
- Department of Respiratory Medicine, Kobe City Medical Center West Hospital, Kobe, Hyogo, Japan
| | - Hirofumi Amano
- Department of Internal Medicine and Rheumatology, Juntendo University Graduate School of Medicine, Bunkyo, Tokyo, Japan
| | - Masaki Anraku
- Department of Thoracic Surgery, Tokyo Metropolitan Geriatric Hospital and Institute of Gerontology, Itabashi, Tokyo, Japan
| | - Noriyuki Enomoto
- Health Administration Center, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka, Japan
| | - Takao Fujii
- Department of Rheumatology and Clinical Immunology, Wakayama Medical University, Wakayama, Wakayama, Japan
| | - Tomoyuki Fujisawa
- Second Division, Department of Internal Medicine, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka, Japan
| | - Takahisa Gono
- Department of Allergy and Rheumatology, Nippon Medical School Graduate School of Medicine, Bunkyo, Tokyo, Japan
| | - Masayoshi Harigai
- Department of Rheumatology, Tokyo Women's Medical University School of Medicine, Shinjuku, Tokyo, Japan
| | - Hidenori Ichiyasu
- Department of Respiratory Medicine, Faculty of Life Sciences, Kumamoto University, Kumamoto, Kumamoto, Japan
| | - Yoshikazu Inoue
- Clinical Research Center, National Hospital Organization Kinki-Chuo Chest Medical Center, Sakai, Osaka, Japan
| | - Takeshi Johkoh
- Department of Radiology, Kansai Rosai Hospital, Amagasaki, Hyogo, Japan
| | - Hideto Kameda
- Division of Rheumatology, Department of Internal Medicine, Faculty of Medicine, Toho University, Meguro, Tokyo, Japan
| | - Kensuke Kataoka
- Department of Respiratory Medicine and Allergy, Tosei General Hospital, Seto, Aichi, Japan
| | - Yasuhiro Katsumata
- Department of Rheumatology, Tokyo Women's Medical University School of Medicine, Shinjuku, Tokyo, Japan
| | - Yasushi Kawaguchi
- Department of Rheumatology, Tokyo Women's Medical University School of Medicine, Shinjuku, Tokyo, Japan
| | - Atsushi Kawakami
- Department of Immunology and Rheumatology, Division of Advanced Preventive Medical Sciences, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Nagasaki, Japan
| | - Hideya Kitamura
- Division of Respiratory Medicine, Kanagawa Cardiovascular and Respiratory Center, Yokohama, Kanagawa, Japan
| | - Noboru Kitamura
- Division of Hematology and Rheumatology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Tomohiro Koga
- Department of Immunology and Rheumatology, Division of Advanced Preventive Medical Sciences, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Nagasaki, Japan
| | - Kazuhiro Kurasawa
- Department of Rheumatology, Dokkyo Medical University, Mibu, Tochigi, Japan
| | - Yutaro Nakamura
- Second Division, Department of Internal Medicine, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka, Japan
| | - Ran Nakashima
- Rheumatology and Clinical Immunology, Graduate School of Medicine, Kyoto University, Sakyo, Kyoto, Japan
| | - Yasuhiko Nishioka
- Department of Respiratory Medicine and Rheumatology, Graduate School of Biomedical Sciences, Tokushima University, Tokushima, Tokushima, Japan
| | - Osamu Nishiyama
- Department of Respiratory Medicine and Allergology, Kindai University Faculty of Medicine, Osakasayama, Osaka, Japan
| | - Masaki Okamoto
- Department of Respirology, National Hospital Organization Kyushu Medical Center, Fukuoka, Fukuoka, Japan
| | - Fumikazu Sakai
- Department of Diagnostic Radiology, Saitama International Medical Center, Saitama Medical University, Hidaka, Saitama, Japan
| | - Susumu Sakamoto
- Department of Respiratory Medicine, Toho University Omori Medical Center, Tokyo, Japan
| | - Shinji Sato
- Division of Rheumatology, Department of Internal Medicine, Tokai University School of Medicine, Isehara, Kanagawa, Japan
| | - Toshimasa Shimizu
- Department of Immunology and Rheumatology, Division of Advanced Preventive Medical Sciences, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Nagasaki, Japan
| | - Noboru Takayanagi
- Department of Respiratory Medicine, Saitama Cardiovascular and Respiratory Center, Kumagaya, Saitama, Japan
| | - Reoto Takei
- Department of Respiratory Medicine and Allergy, Tosei General Hospital, Seto, Aichi, Japan
| | - Tamiko Takemura
- Department of Pathology, Kanagawa Cardiovascular and Respiratory Center, Yokohama, Kanagawa, Japan
| | - Tohru Takeuchi
- Department of Internal Medicine (IV), Osaka Medical and Pharmaceutical University, Takatsuki, Osaka, Japan
| | - Yuko Toyoda
- Department of Respiratory Medicine, Japanese Red Cross Kochi Hospital, Kochi, Kochi, Japan
| | - Hidehiro Yamada
- Center for Rheumatic Diseases, Seirei Yokohama Hospital, Yokohama, Kanagawa, Japan
| | - Hideaki Yamakawa
- Department of Respiratory Medicine, Saitama Red Cross Hospital, Saitama, Saitama, Japan
| | - Yasuhiko Yamano
- Department of Respiratory Medicine and Allergy, Tosei General Hospital, Seto, Aichi, Japan
| | - Yoshioki Yamasaki
- Department of Allergy and Rheumatology, Nippon Medical School Graduate School of Medicine, Bunkyo, Tokyo, Japan
| | - Masataka Kuwana
- Department of Allergy and Rheumatology, Nippon Medical School Graduate School of Medicine, Bunkyo, Tokyo, Japan
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Diffuse Alveolar Hemorrhage: A Cohort of Patients With Systemic Lupus Erythematosus. J Clin Rheumatol 2021; 26:S153-S157. [PMID: 31895107 DOI: 10.1097/rhu.0000000000001228] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND/OBJECTIVE Diffuse alveolar hemorrhage (DAH) is an uncommon but potentially fatal complication in patients with systemic lupus erythematosus (SLE). Its prognosis and factors associated with mortality are not completely clear, although invasive mechanical ventilation (IMV), use of cyclophosphamide, a high Acute Physiology and Chronic Health Evaluation II score, and infections are associated with high mortality rates. We investigated clinical and immunologic characteristics and factors associated with mortality in a cohort of Latin American patients with SLE who developed DAH. METHODS A medical records review study was conducted of patients with SLE who were admitted to the intensive care unit (ICU) with DAH between 2011 and 2018. Clinical, laboratory, and treatment variables were compared between survivors and nonsurvivors. RESULTS A total of 17 patients with SLE presented with DAH during the study period, of whom 11 (64.70%) were women. The median age was 28 (19-38.5) years. The Systemic Lupus Erythematosus Disease Activity Index (SLEDAI) on admission to the ICU was 15.94 ± 10.07. All patients received pulse methylprednisolone and therapeutic plasma exchange, and 13 (76. %) also received cyclophosphamide. During the hospital stay, 5 patients (29.41%) died. A high SLEDAI on admission, low albumin, and days of IMV and inotropic/vasoactive support were statistically significant in comparing nonsurvivors with survivors. Other scales of disease severity commonly used in the ICU, however, were not significantly associated with a fatal outcome. CONCLUSIONS Hypoalbuminemia, longer duration of IMV or inotropic/vasoactive treatment, and a high SLEDAI are potential prognostic factors for mortality in patients with SLE and DAH admitted to the ICU.
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Abstract
OBJECTIVE. The purpose of this article is to review the clinical and imaging features of diffuse pulmonary hemorrhage. CONCLUSION. Diffuse pulmonary hemorrhage is a life-threatening syndrome associated with a wide variety of underlying pathologic categories. Nonspecific clinical and imaging features pose challenges to promptly diagnosing this condition. Chest radiography commonly shows alveolar opacification, and CT reveals the extent of disease. Integration of clinical, radiologic, laboratory, and pathologic findings facilitates timely diagnosis and etiologic identification.
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Pulmonary manifestations in systemic lupus erythematosus: pleural involvement, acute pneumonitis, chronic interstitial lung disease and diffuse alveolar hemorrhage. ACTA ACUST UNITED AC 2019; 14:294-300. [PMID: 29773465 DOI: 10.1016/j.reuma.2018.03.012] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2017] [Revised: 02/28/2018] [Accepted: 03/22/2018] [Indexed: 12/29/2022]
Abstract
Systemic lupus erythematosus is the diffuse autoimmune connective tissue disease that most frequently involves pulmonary involvement, affecting 20% of 90% of the patients. The percentage varies depending on the defining criteria (symptoms, pulmonary tests or histopathological studies). At least once during the disease course, 50% of those affected have pleural and/or pulmonary manifestations, which are associated with higher morbidity and mortality. Pulmonary involvement has no correlation with lupus activity biomarkers, and it is necessary to rule out infectious processes in the initial approach. Bacterial infection is most frequently the cause of lung involvement in lupus and is one of the most important causes of death. Pulmonary involvement is considered to be primary when it is associated with disease activity, and secondary when other causes participate. Drugs have been reported to be associated with pulmonary damage, including interstitial disease. The incidence of malignant lung diseases is increased in systemic lupus erythematosus. Treatment depends on the type and severity of pulmonary involvement.
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Guía de práctica clínica para el manejo del lupus eritematoso sistémico propuesta por el Colegio Mexicano de Reumatología. ACTA ACUST UNITED AC 2019; 15:3-20. [DOI: 10.1016/j.reuma.2018.03.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Revised: 03/20/2018] [Accepted: 03/21/2018] [Indexed: 12/31/2022]
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Sandur S, Dweik RA, Arroliga AC. Alveolar Hemorrhage. J Intensive Care Med 2016. [DOI: 10.1177/088506669801300603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Alveolar hemorrhage (AH) is a clinical syndrome with diverse etiologies both immune and nonimmune. The defining pathological feature of AH is the presence or absence of pulmonary capillaritis. The antineutrophil cytoplasmic antibody (ANCA) related vasculitis and systemic lupus erythematosus are the commonest causes of immune AH with pulmonary capillaritis, whereas Goodpasture's syndrome and idiopathic pulmonary hemosiderosis are common causes of immune AH without pulmonary capillaritis. The major nonimmune causes of AH are primarily drug induced, or due to hematological malignancy and disorders of coagulation. Clinical features of AH include: dyspnea, fever, hemotypsis, bilateral crackles and pallor. Hypoxemia and bilateral diffuse airspace disease on the chest radiograph with relative sparing of the bases and apices which most often clears within 48 hours after its onset further characterize this syndrome. The major clinical implications of this syndrome are its potential to cause respiratory failure in severe cases and its sequelae of pulmonary fibrosis with associated morbidity and disability. In addition, AH may be the initial manifestation of a systemic immune disorder which can be managed optimally if recognized early. The diagnosis of AH is confirmed by bronchoalveolar lavage by demonstrating a progressively bloody return on successive aliquots of instilled saline or hemosiderin laden macrophages in the bronchoalveolar lavage fluid. The open lung biopsy remains the gold standard for the diagnosis of AH but is reserved for inapparent cases in whom corticosteroids and immunosuppressive therapy may be life saving. Serologic testing and examination of the urine sediment are useful adjuncts to the diagnosis. The treatment of AH is primarily supportive while an attempt is made to determine its etiology and initiate specific therapy. Glucocorticoids and cyclophosphamide are the cornerstones of therapy in immune AH with adjunctive plasmapheresis in life-threatening cases.
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Affiliation(s)
- Sunder Sandur
- Department of Pulmonary and Critical Care Medicine, Cleveland Clinic Foundation, Cleveland, OH
| | - Raed A. Dweik
- Department of Pulmonary and Critical Care Medicine, Cleveland Clinic Foundation, Cleveland, OH
| | - Alejandro C. Arroliga
- Department of Pulmonary and Critical Care Medicine, Cleveland Clinic Foundation, Cleveland, OH
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17
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Alveolar hemorrhage as the initial presentation of systemic lupus erythematosus. Reumatologia 2016; 54:264-266. [PMID: 27994272 PMCID: PMC5149575 DOI: 10.5114/reum.2016.63668] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2016] [Accepted: 10/28/2016] [Indexed: 01/08/2023] Open
Abstract
Alveolar hemorrhage (AH) is a rare syndrome that can often occur in autoimmune diseases, blood clotting disorders, infection or by acute inhalation injury, presenting rapid evolution and high mortality, especially with late diagnosis and treatment. Among the autoimmune diseases, there are reported cases in patients with primary antiphospholipid syndrome (PAPS), vasculitis and systemic lupus erythematosus (SLE). An early diagnosis is an essential tool in the successful management of this complication, requiring aggressive treatment based on vigorous immunosuppression and broad-spectrum antibiotic. We describe here a case of alveolar hemorrhage associated with glomerulonephritis as the open presentation in a patient with SLE.
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18
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Zhou S, Wang Y, Meng Y, Xiao C, Liu Z, Brohawn P, Higgs BW, Jallal B, Jia Q, Qu B, Huang X, Tang Y, Yao Y, Harley JB, Shen N. In Vivo Therapeutic Success of MicroRNA-155 Antagomir in a Mouse Model of Lupus Alveolar Hemorrhage. Arthritis Rheumatol 2016; 68:953-64. [PMID: 26556607 DOI: 10.1002/art.39485] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2015] [Accepted: 10/22/2015] [Indexed: 01/10/2023]
Abstract
OBJECTIVE Diffuse alveolar hemorrhage (DAH) is a rare but life-threatening complication of systemic lupus erythematosus (SLE). Pristane-treated B6 mice develop severe DAH within 2 weeks of treatment. MicroRNA-155 (miR-155) is a pleiotropic microRNA that plays a crucial role in the regulation of immune responses. Recent studies have revealed a pathogenic role of miR-155 in various autoimmune disorders. The purpose of this study was to examine the role of miR-155 in the development of DAH in pristane-induced lupus using miR-155-knockout (miR-155(-/-)) mice and miR-155 antagomir to silence miR-155. METHODS DAH was induced by an intraperitoneal injection of 0.5 ml of pristane. MicroRNA-155 antagomir was administered intravenously to silence miR-155 expression. Lung tissues were collected for RNA extraction and were embedded in paraffin for sectioning. Gene expression profiling data were analyzed using Ingenuity Pathway Analysis. Real-time quantitative polymerase chain reaction analysis was used for single-gene validation. Luciferase reporter assay and argonaute 2 immunoprecipitation were performed for target validation. RESULTS MicroRNA-155 expression was significantly increased during the development of DAH. Disease progression was reduced in miR-155(-/-) mice as well as by in vivo silencing of miR-155 using a miR-155 antagomir. MicroRNA-155 silencing dampened pristane-induced ectopic activation of multiple inflammatory pathways and reduced the expression of proinflammatory cytokines. Several negative regulators of NF-κB signaling were inhibited by pristane and were reactivated in miR-155(-/-) mice. In particular, the antiinflammatory factor peroxisome proliferator-activated receptor α was identified as a direct target of miR-155. CONCLUSION MicroRNA-155 promotes pristane-induced lung inflammation. It contributes to ectopic activation of NF-κB signaling pathways by targeting multiple negative regulators. MicroRNA-155 antagomir may be a promising therapeutic strategy for treating acute lung inflammation in lupus.
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Affiliation(s)
- Shiyu Zhou
- Institute of Health Sciences of Shanghai Institutes for Biological Sciences, Chinese Academy of Sciences, and Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yan Wang
- Institute of Health Sciences of Shanghai Institutes for Biological Sciences, Chinese Academy of Sciences, and Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yao Meng
- Renji Hospital and Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Chunyuan Xiao
- Renji Hospital and Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | | | | | | | | | - Qian Jia
- Renji Hospital and Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Bo Qu
- Renji Hospital and Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xinfang Huang
- Renji Hospital and Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yuanjia Tang
- Renji Hospital and Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | | | - John B Harley
- Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, and Cincinnati VA Medical Center, Cincinnati, Ohio
| | - Nan Shen
- Renji Hospital, Institute of Health Sciences of Shanghai Institutes for Biological Sciences, Chinese Academy of Sciences, and Shanghai Jiao Tong University School of Medicine, Shanghai, China, and Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
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19
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Bertoli AM, Vila LM, Apte M, Fessler BJ, Bastian HM, Reveille JD, Alarcon GS. Systemic lupus erythematosus in a multiethnic US Cohort LUMINA XLVIII: factors predictive of pulmonary damage. Lupus 2016; 16:410-7. [PMID: 17664231 DOI: 10.1177/0961203307079042] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The objective of this study was to determine the factors predictive of time to the occurrence of pulmonary damage in systemic lupus erythematosus (SLE). Six-hundred and twenty-six SLE patients from a multiethnic (Hispanics, African Americans and Caucasians) longitudinal study of outcome were studied. Pulmonary damage was defined as per the Systemic Lupus International Collaborating Clinics Damage Index. Socioeconomic-demographic, clinical, genetic, serological features, pharmacologic treatments, behavioural, psychological and disease activity [as per the Systemic Lupus Activity Measure-Revised (SLAM-R)] were examined. Factors associated with time to the occurrence of pulmonary damage were examined by Cox proportional hazards regressions. A Kaplan—Meier survival curve was also examined. Forty-six (7.3%) patients had pulmonary damage after a mean (SD) total disease duration of 5.3 (3.6) years. Among those patients, 25 had pulmonary fibrosis, 12 pulmonary hypertension, eight pleural fibrosis, four pulmonary infarction and four shrinking lung syndrome. Seven patients had more than one type of lung damage. Cumulative rates of pulmonary damage at five and 10 years were 7.6% and 11.6%, respectively. In the multivariable analyses, age (HR = 1.033, 95% CI 1.006—1.060; P = 0.0170), pneumonitis (HR = 2.307, 95% CI 1.123—4.739; P = 0.0229) and anti-RNP antibodies (HR = 2.344, 95% CI 1.190—4.618; P = 0.0138) were associated with a shorter time to the occurrence of pulmonary damage while photosensitivity (HR = 0.388, 95% CI 0.184—0.818; P = 0.0128) and oral ulcers (HR = 0.466, 95% CI 0.230—0.942; P = 0.0335) with a longer time. Pulmonary damage is relatively common in SLE. Age, pneumonitis and anti-RNP antibodies were associated with a shorter time to the development of permanent lung disease. Lupus (2007) 16, 410—417.
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Affiliation(s)
- A M Bertoli
- Department of Medicine (Division of Rheumatology), The University of Puerto Rico Medical Sciences Campus, San Juan, Puerto Rico
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Systematic Review of Diffuse Alveolar Hemorrhage in Systemic Lupus Erythematosus: Focus on Outcome and Therapy. J Clin Rheumatol 2016; 21:305-10. [PMID: 26308350 DOI: 10.1097/rhu.0000000000000291] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Diffuse alveolar hemorrhage (DAH) is an uncommon but potentially life-threatening manifestation of systemic lupus erythematosus (SLE) associated with high mortality. Although survival and its associated clinical, laboratory, and therapeutic features have been reported for case reports and series, they have not been systematically reviewed. OBJECTIVES The purpose of this systematic review was to assess survival of episodes of DAH in SLE over 3 decades and to categorize trends in therapies, commonly utilized to treat this disorder. RESULTS Overall, SLE patients survived 61% of 174 DAH episodes representing 140 patients. Episode survival was 67% in the time period from 2000 to 2013. Corticosteroids were nearly universally used therapeutically, and cyclophosphamide was used in 55%. Plasmapheresis was used in 31% and did not appear to be associated with survival. CONCLUSIONS Diffuse alveolar hemorrhage in SLE still carries a high risk of mortality; however, survival trends appear to demonstrate an increase from approximately 25% in the 1980s to 67% in the current decade. Increased use of cyclophosphamide appears to be associated with better survival, whereas plasmapheresis does not appear to influence outcome. Although these results need to be interpreted with caution because they are not derived from randomized controlled trials, we believe this represents the largest reported compilation of survival data in DAH associated with SLE.
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Nair A, Walsh SLF, Desai SR. Imaging of pulmonary involvement in rheumatic disease. Rheum Dis Clin North Am 2015; 41:167-96. [PMID: 25836636 DOI: 10.1016/j.rdc.2014.12.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Lung disease commonly occurs in connective tissue diseases (CTD) and is an important cause of morbidity and mortality. Imaging is central to the evaluation of CTD-associated pulmonary complications. In this article, a general discussion of radiologic considerations is followed by a description of the pulmonary appearances in individual CTDs, and the imaging appearances of acute and nonacute pulmonary complications. The contribution of imaging to monitoring disease, evaluating treatment response, and prognostication is reviewed. Finally, we address the role of imaging in the challenging multidisciplinary evaluation of interstitial lung disease where there is an underlying suspicion of an undiagnosed CTD.
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Affiliation(s)
- Arjun Nair
- Department of Radiology, Guy's and St Thomas' NHS Foundation Trust, Great Maze Pond, London SE1 9RT, UK
| | - Simon L F Walsh
- Department of Radiology, King's College Hospital, Denmark Hill, London SE5 9RS, UK
| | - Sujal R Desai
- Department of Radiology, King's College Hospital, Denmark Hill, London SE5 9RS, UK.
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Finucci Curi P, Pierrestegui M, Ortiz A, Ceccato F, Paira S. Hemorragia pulmonar en pacientes con lupus eritematoso sistémico. Características clínicas y pronóstico. Med Clin (Barc) 2015; 145:375-9. [DOI: 10.1016/j.medcli.2014.07.034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2014] [Revised: 07/04/2014] [Accepted: 07/07/2014] [Indexed: 10/24/2022]
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Kazzaz NM, Coit P, Lewis EE, McCune WJ, Sawalha AH, Knight JS. Systemic lupus erythematosus complicated by diffuse alveolar haemorrhage: risk factors, therapy and survival. Lupus Sci Med 2015; 2:e000117. [PMID: 26430514 PMCID: PMC4586940 DOI: 10.1136/lupus-2015-000117] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2015] [Revised: 08/14/2015] [Accepted: 08/28/2015] [Indexed: 01/09/2023]
Abstract
Objectives While diffuse alveolar haemorrhage (DAH) is recognised as a life-threatening complication of systemic lupus erythematosus (SLE), little is known about its risk factors and response to treatment. We describe 22 cases of DAH in a US lupus cohort of approximately 1000 patients, and compare them to 66 controls from the same outpatient cohort. Methods We captured variables pertaining to diagnoses of SLE and secondary antiphospholipid syndrome (APS), and analysed them by univariate testing. Those variables with p values <0.05 were then further considered in a multivariate model. Kaplan-Meier curves were constructed for each group, and survival was analysed by Log-rank test. Results Of the 22 patients with DAH, 59% were diagnosed with DAH within 5 years of lupus diagnosis. By univariate testing, several manifestations of SLE and APS were more common in patients with DAH, including history of thrombocytopenia, cardiac valve disease, low C3, leucopenia, neuropsychiatric features, haemolysis, arterial thrombosis, lupus anticoagulant, secondary APS and low C4. On multivariate analysis, history of thrombocytopenia and low C3 were maintained as independent risk factors. Importantly, only two patients had platelet counts <50 000/µL at the time of the DAH episode, arguing that DAH was not simply a haemorrhagic complication of thrombocytopenia. All patients were treated with increased immunosuppression, including various combinations of corticosteroids, plasmapheresis, cyclophosphamide, rituximab and mycophenolate mofetil. Notably, all patients in the cohort survived their initial episode of DAH. While the patients with DAH did well in the short-term, their long-term survival was significantly worse than controls. Several of the deaths were attributable to thrombotic complications after recovering from DAH. Conclusions To the best of our knowledge, this is the largest case–control study of lupus DAH to date. History of thrombocytopenia was strongly predictive of DAH (OR ∼40). A number of APS manifestations correlated with DAH by univariate analysis, and deserve further consideration in larger studies.
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Affiliation(s)
- Nayef M Kazzaz
- Division of Rheumatology, Department of Internal Medicine , University of Michigan , Ann Arbor, Michigan , USA
| | - Patrick Coit
- Division of Rheumatology, Department of Internal Medicine , University of Michigan , Ann Arbor, Michigan , USA
| | - Emily E Lewis
- Division of Rheumatology, Department of Internal Medicine , University of Michigan , Ann Arbor, Michigan , USA
| | - W Joseph McCune
- Division of Rheumatology, Department of Internal Medicine , University of Michigan , Ann Arbor, Michigan , USA
| | - Amr H Sawalha
- Division of Rheumatology, Department of Internal Medicine , University of Michigan , Ann Arbor, Michigan , USA
| | - Jason S Knight
- Division of Rheumatology, Department of Internal Medicine , University of Michigan , Ann Arbor, Michigan , USA
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Andrade C, Mendonça T, Farinha F, Correia J, Marinho A, Almeida I, Vasconcelos C. Alveolar hemorrhage in systemic lupus erythematosus: a cohort review. Lupus 2015; 25:75-80. [DOI: 10.1177/0961203315605365] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2015] [Accepted: 08/18/2015] [Indexed: 11/17/2022]
Abstract
Diffuse alveolar hemorrhage (DAH) is a rare but potentially catastrophic manifestation with a high mortality. Among rheumatologic diseases, it occurs most frequently in patients with systemic lupus erythematosus (SLE) and systemic vasculitis. Despite new diagnostic tools and therapies, it remains a diagnostic and therapeutic challenge. The aim of this work was to characterize the SLE patients with an episode of alveolar hemorrhage followed in our Clinical Immunology Unit (CIU). A retrospective chart review was carried out for all patients with SLE followed in CIU between 1984 and the end of 2013. We reviewed the following data: demographic characteristics, clinical and laboratory data, radiologic investigations, histologic studies, treatment, and outcome. We identified 10 episodes of DAH, corresponding to seven patients, all female. These represent 1.6% of SLE patients followed in our Unit. The age at DAH attack was 42.75 ± 18.9 years. The average time between diagnosis of SLE and the onset of DAH was 7.1 years. Three patients had the diagnosis of SLE and the DAH attack at the same time. Disease activity according to SLEDAI was high, ranging from 15 to 41. All patients were treated with methylprednisolone, 37.5% cyclophosphamide and 28.6% plasmapheresis. The overall mortality rate was 28.6%.
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Affiliation(s)
- C Andrade
- Internal Medicine, Hospital Pedro Hispano, Matosinhos, Portugal
| | - T Mendonça
- Clinical Immunology Unit, Centro Hospitalar do Porto and UMIB, ICBAS, Universidade do Porto, Portugal
| | - F Farinha
- Clinical Immunology Unit, Centro Hospitalar do Porto and UMIB, ICBAS, Universidade do Porto, Portugal
| | - J Correia
- Clinical Immunology Unit, Centro Hospitalar do Porto and UMIB, ICBAS, Universidade do Porto, Portugal
| | - A Marinho
- Clinical Immunology Unit, Centro Hospitalar do Porto and UMIB, ICBAS, Universidade do Porto, Portugal
| | - I Almeida
- Clinical Immunology Unit, Centro Hospitalar do Porto and UMIB, ICBAS, Universidade do Porto, Portugal
| | - C Vasconcelos
- Clinical Immunology Unit, Centro Hospitalar do Porto and UMIB, ICBAS, Universidade do Porto, Portugal
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Hadaschik EN, Wei X, Leiss H, Heckmann B, Niederreiter B, Steiner G, Ulrich W, Enk AH, Smolen JS, Stummvoll GH. Regulatory T cell-deficient scurfy mice develop systemic autoimmune features resembling lupus-like disease. Arthritis Res Ther 2015; 17:35. [PMID: 25890083 PMCID: PMC4391674 DOI: 10.1186/s13075-015-0538-0] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2014] [Accepted: 01/23/2015] [Indexed: 01/18/2023] Open
Abstract
Introduction Scurfy mice are deficient in regulatory T cells (Tregs), develop a severe, generalized autoimmune disorder that can affect almost every organ and die at an early age. Some of these manifestations resemble those found in systemic lupus erythematosus (SLE). In addition, active SLE is associated with low Treg numbers and reduced Treg function, but direct evidence for a central role of Treg malfunction in the pathophysiology of lupus-like manifestations is still missing. In the present study, we characterize the multiorgan pathology, autoantibody profile and blood count abnormalities in scurfy mice and show their close resemblances to lupus-like disease. Methods Scurfy mice have dysfunctional Tregs due to a genetic defect in the transcription factor Forkhead box protein 3 (Foxp3). We analyzed skin, joints, lung and kidneys of scurfy mice and wild-type (WT) controls by conventional histology and immunofluorescence (IF) performed hematological workups and tested for autoantibodies by IF, immunoblotting and enzyme-linked immunosorbent assay. We also analyzed the intestines, liver, spleen and heart, but did not analyze all organs known to be affected in scurfy mice (such as the testicle, the accessory reproductive structures, the pancreas or the eyes). We transferred CD4+ T cells of scurfy or WT mice into T cell-deficient B6/nude mice. Results We confirm previous reports that scurfy mice spontaneously develop severe pneumonitis and hematological abnormalities similar to those in SLE. We show that scurfy mice (but not controls) exhibited additional features of SLE: severe interface dermatitis, arthritis, mesangioproliferative glomerulonephritis and high titers of anti-nuclear antibodies, anti-double-stranded DNA antibodies, anti-histone antibodies and anti-Smith antibodies. Transfer of scurfy CD4+ T cells (but not of WT cells) induced autoantibodies and inflammation of lung, skin and kidneys in T cell-deficient B6/nude mice. Conclusion Our observations support the hypothesis that lupus-like autoimmune features develop in the absence of functional Tregs.
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Affiliation(s)
- Eva N Hadaschik
- Department of Dermatology, University of Heidelberg, Im Neuenheimer Feld 440, 69120, Heidelberg, Germany.
| | - Xiaoying Wei
- Department of Dermatology, University of Heidelberg, Im Neuenheimer Feld 440, 69120, Heidelberg, Germany. .,Department of Pathology, Affiliated Zhong-Da Hospital, Southeast University, 87 Dingjia Bridge, Gulou, 210009, Nanjing, China.
| | - Harald Leiss
- Department of Rheumatology, Medical University of Vienna, Wahringer Gurtel 18-20, 1090, Vienna, Austria.
| | - Britta Heckmann
- Department of Dermatology, University of Heidelberg, Im Neuenheimer Feld 440, 69120, Heidelberg, Germany.
| | - Birgit Niederreiter
- Department of Rheumatology, Medical University of Vienna, Wahringer Gurtel 18-20, 1090, Vienna, Austria.
| | - Günter Steiner
- Department of Rheumatology, Medical University of Vienna, Wahringer Gurtel 18-20, 1090, Vienna, Austria.
| | - Walter Ulrich
- Department of Pathology, Hietzing Hospital, Wolkersbergenstrasse 1, 1130, Vienna, Austria.
| | - Alexander H Enk
- Department of Dermatology, University of Heidelberg, Im Neuenheimer Feld 440, 69120, Heidelberg, Germany.
| | - Josef S Smolen
- Department of Rheumatology, Medical University of Vienna, Wahringer Gurtel 18-20, 1090, Vienna, Austria.
| | - Georg H Stummvoll
- Department of Rheumatology, Medical University of Vienna, Wahringer Gurtel 18-20, 1090, Vienna, Austria.
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Esper RC, Estrada IEDLM, de la Torre León T, Gutiérrez AOR, López JAN. Treatment of diffuse alveolar hemorrhage secondary to lupus erythematosus with recombinant activated factor VII administered with a jet nebulizer. J Intensive Care 2014; 2:47. [PMID: 25705408 PMCID: PMC4336265 DOI: 10.1186/s40560-014-0047-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2013] [Accepted: 07/21/2014] [Indexed: 11/10/2022] Open
Abstract
Diffuse alveolar hemorrhage (DAH) is a serious pulmonary complication in patients with autoimmune diseases who are undergoing chemotherapy or have had hematopoietic stem cell transplantation. The use of recombinant factor VIIa (rFVIIa) to treat the acute phase of DAH by endobronchial bronchoscopy has been shown to have a significant clinical impact on the survival and evolution of these patients. We report a clinical case of a patient with DAH secondary to systemic lupus erythematosus (SLE) who was treated with rFVIIa administered using a jet nebulizer, obtaining an adequate hemostatic effect with immediate control of DAH and a significant improvement in gas exchange.
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Affiliation(s)
- Raúl Carrillo Esper
- Unidad de Terapia Intensiva, Fundación Clínica Médica Sur, Puente de Piedra 150, Col. Toriello Guerra. Delegación Tlalpan, Mexico, DF 14050 Mexico
| | | | - Teresa de la Torre León
- Unidad de Terapia Intensiva, Fundación Clínica Médica Sur, Puente de Piedra 150, Col. Toriello Guerra. Delegación Tlalpan, Mexico, DF 14050 Mexico
| | - Agustín Omar Rosales Gutiérrez
- Unidad de Terapia Intensiva, Fundación Clínica Médica Sur, Puente de Piedra 150, Col. Toriello Guerra. Delegación Tlalpan, Mexico, DF 14050 Mexico
| | - Jorge Arturo Nava López
- Unidad de Terapia Intensiva, Fundación Clínica Médica Sur, Puente de Piedra 150, Col. Toriello Guerra. Delegación Tlalpan, Mexico, DF 14050 Mexico
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Chance, genetics, and the heterogeneity of disease and pathogenesis in systemic lupus erythematosus. Semin Immunopathol 2014; 36:495-517. [PMID: 25102991 DOI: 10.1007/s00281-014-0440-x] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2014] [Accepted: 06/30/2014] [Indexed: 12/30/2022]
Abstract
Systemic lupus erythematosus (SLE) is a remarkably complex and heterogeneous systemic autoimmune disease. Disease complexity within individuals and heterogeneity among individuals, even genetically identical individuals, is driven by stochastic execution of a complex inherited program. Genome-wide association studies (GWAS) have progressively improved understanding of which genes are most critical to the potential for SLE and provided illuminating insight about the immune mechanisms that are engaged in SLE. What initiates expression of the genetic program to cause SLE within an individual and how that program is initiated remains poorly understood. If we extrapolate from all of the different experimental mouse models for SLE, we can begin to appreciate why SLE is so heterogeneous and consequently why prediction of disease outcome is so difficult. In this review, we critically evaluate extrinsic versus intrinsic cellular functions in the clearance and elimination of cellular debris and how dysfunction in that system may promote autoimmunity to nuclear antigens. We also examine several mouse models genetically prone to SLE either because of natural inheritance or inheritance of induced mutations to illustrate how different immune mechanisms may initiate autoimmunity and affect disease pathogenesis. Finally, we describe the heterogeneity of disease manifestations in SLE and discuss the mechanisms of disease pathogenesis with emphasis on glomerulonephritis. Particular attention is given to discussion of how anti-DNA autoantibody initiates experimental lupus nephritis (LN) in mice.
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Hemorragia alveolar difusa en pacientes con lupus eritematoso sistémico. Manifestaciones clínicas, tratamiento y pronóstico. ACTA ACUST UNITED AC 2014; 10:248-53. [DOI: 10.1016/j.reuma.2014.02.002] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2013] [Revised: 01/03/2014] [Accepted: 02/14/2014] [Indexed: 01/08/2023]
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Pacheco Claudio C, Charbonney E, Durand M, Kolan C, Laskine M. Extracorporeal membrane oxygenation in diffuse alveolar hemorrhage secondary to systemic lupus erythematosus. J Clin Med Res 2014; 6:145-8. [PMID: 24578757 PMCID: PMC3935524 DOI: 10.14740/jocmr1685w] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/10/2013] [Indexed: 11/15/2022] Open
Abstract
Diffuse alveolar hemorrhage (DAH) is a rare and potentially deadly complication of systemic lupus erythematosus (SLE). We report two adult cases where extracorporeal membrane oxygenation (ECMO) was used as rescue therapy for severe respiratory failure in this setting. We discuss the risk related to coagulation disturbance and the need for the circuit anticoagulation in this particular setting. We also briefly discuss the clinical problem of lack of knowledge on the bioavailability of the immunosuppressive treatment with the use of ECMO. We think that ECMO should be used as rescue therapy in patients with DAH caused by SLE, but strategies for anticoagulation require further precision.
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Affiliation(s)
| | - Emmanuel Charbonney
- Hopital de Trois-Rivieres and Hopital du Sacre-Coeur de Montreal, Montreal, Canada
| | - Madeleine Durand
- Department of Medicine, Hopital Hotel-Dieu, CRCHUM, Montreal, Canada
| | - Christophe Kolan
- Department of Medicine, Hopital Hotel-Dieu, CRCHUM, Montreal, Canada
| | - Mikhael Laskine
- Department of Medicine, Hopital Hotel-Dieu, CRCHUM, Montreal, Canada
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Khor CG, Kan SL, Tan BE. Pulmonary manifestation as initial presentation for systemic lupus erythematosus. Int J Rheum Dis 2014; 21:1322-1325. [PMID: 24495523 DOI: 10.1111/1756-185x.12302] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
We report a 29-year-old Malay man who had pulmonary manifestations as an initial presentation for systemic lupus erythematosus. He had prolonged hospitalization and was treated with intensive care therapy with immunosuppressants.
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Affiliation(s)
- Chiew Gek Khor
- Rheumatology Unit, Department of Internal Medicine, Penang General Hospital, Georgetown, Malaysia
| | - Sow Lai Kan
- Rheumatology Unit, Department of Internal Medicine, Penang General Hospital, Georgetown, Malaysia
| | - Bee Eng Tan
- Rheumatology Unit, Department of Internal Medicine, Penang General Hospital, Georgetown, Malaysia
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Adams TL, Marchiori DM. Arthritides. Clin Imaging 2014. [DOI: 10.1016/b978-0-323-08495-6.00009-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Holland DV, Paul Guillerman R, Brody AS. Thoracic Manifestations of Systemic Diseases. PEDIATRIC CHEST IMAGING 2014. [DOI: 10.1007/174_2014_965] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Antin-Ozerkis D, Rubinowitz A, Evans J, Homer RJ, Matthay RA. Interstitial lung disease in the connective tissue diseases. Clin Chest Med 2013; 33:123-49. [PMID: 22365251 DOI: 10.1016/j.ccm.2012.01.004] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The connective tissue diseases (CTDs) are inflammatory, immune-mediated disorders in which interstitial lung disease (ILD) is common and clinically important. Interstitial lung disease may be the first manifestation of a CTD in a previously healthy patient. CTD-associated ILD frequently presents with the gradual onset of cough and dyspnea, although rarely may present with fulminant respiratory failure. Infection and drug reaction should always be ruled out. A diagnosis of idiopathic ILD should never be made without a careful search for subtle evidence of underlying CTD. Treatment of CTD-ILD typically includes corticosteroids and immunosuppressive agents.
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Affiliation(s)
- Danielle Antin-Ozerkis
- Yale Interstitial Lung Disease Program, Pulmonary & Critical Care Medicine Section, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT 06510, USA.
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Diffuse alveolar hemorrhage: a rare life-threatening condition in systemic lupus erythematosus. Case Rep Pulmonol 2012; 2012:836017. [PMID: 22934226 PMCID: PMC3420594 DOI: 10.1155/2012/836017] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2012] [Accepted: 03/06/2012] [Indexed: 11/17/2022] Open
Abstract
Diffuse alveolar hemorrhage (DAH) is a rare life-threatening complication in systemic lupus erythematosus (SLE) associated with high mortality rates. DAH is more common in women, and mean age of onset is around 30 years. It mostly occurs in patients with established diagnosis of SLE but can be the initial presentation of lupus in approximately 20%. DAH should be suspected in lupus patient presenting with new pulmonary infiltrates, decline in hemoglobin, hemoptysis, dyspnea, hypoxemia, and increase in carbon monoxide diffusion capacity. Radiographic evidence of bilateral pulmonary alveolar infiltrates that are usually perihilar or basilar with sparing of apices is seen. DAH can often mimic clinically and radiologically severe pneumonia or ARDS. Treatment includes high-dose corticosteroids, cyclophosphamide, and plasmapheresis. We report a case of diffuse alveolar hemorrhage complicating SLE flare-up in a male patient.
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Araujo DB, Borba EF, Silva CA, Campos LMA, Pereira RMR, Bonfa E, Shinjo SK. Alveolar hemorrhage: distinct features of juvenile and adult onset systemic lupus erythematosus. Lupus 2012; 21:872-7. [DOI: 10.1177/0961203312441047] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
We compared outcomes of alveolar hemorrhage (AH) in juvenile (JSLE) and adult onset SLE (ASLE). From 263 JSLE and 1522 ASLE, the AH occurred in 13 (4.9%) and 15 (1.0%) patients, respectively ( p < .001). Both groups had comparable disease duration (2.6 ± 3.0 vs. 5.6 ± 7.0 years, p = .151) and median SLEDAI scores [17.5 (2 to 32) vs. 17.5 (3 to 28), p = 1.000]. At AH onset, a higher frequency of JSLE were already on a high prednisone dose ( > 0.5 mg/kg/day) compared to ASLE (54% vs. 15%, p = .042). The mean drop of hemoglobin was significantly lower in JSLE (2.9 ± 0.9 vs. 5.5 ± 2.9 g/dL, p = .006). Although treatments with methylprednisolone, plasmapheresis, intravenous immunoglobulin and cyclophosphamide were similar in both groups ( p > .050), regarding outcomes, there was a trend in high frequency of mechanical ventilation use (85% vs. 47%, p = .055) and also significant mortality (69% vs. 13%, p = .006) in JSLE compared to ASLE. The sepsis frequency was comparable in both groups (50% vs. 27%, p = .433). We have identified that AH in JSLE has a worse outcome most likely related to respiratory failure. The AH onset in JSLE already treated with high-dose steroids raises the concern of inadequate response to this treatment and reinforces the recommendation of early aggressive alternative therapies in this group of patients.
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Affiliation(s)
- DB Araujo
- Rheumatology Division, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Brazil
- Rheumatology Department, Hospital do Servidor Público Estadual de São Paulo, Brazil
| | - EF Borba
- Rheumatology Division, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Brazil
| | - CA Silva
- Rheumatology Division, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Brazil
- Pediatric Rheumatology Unit, Instituto da Criança, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Brazil
| | - LMA Campos
- Pediatric Rheumatology Unit, Instituto da Criança, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Brazil
| | - RMR Pereira
- Rheumatology Division, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Brazil
| | - E Bonfa
- Rheumatology Division, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Brazil
| | - SK Shinjo
- Rheumatology Division, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Brazil
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Abstract
Diffuse alveolar hemorrhage is an uncommon, yet often fatal, complication of systemic lupus erythematosus (SLE). Advances in the treatment of alveolar hemorrhage have been hampered because of the heterogeneity of clinical findings and the lack of suitable animal models. A single intraperitoneal injection of pristane induces a lupus-like syndrome characterized by lupus-related autoantibodies and glomerulonephritis in non-autoimmune-prone strains of mice. In addition, C57BL/6 (B6) mice frequently develop alveolar hemorrhage within a few weeks of pristane injection. Immunopathogenesis of pristane-induced alveolar hemorrhage was investigated in the present study. Early (2-4 weeks after injection) mortality due to hemorrhage was unique to C57BL/6 and C57BL/10 strains of mice. Recruitment of the macrophages and neutrophils preceded the hemorrhage by several days, and hemorrhage started 3-7 days after pristane injection in some mice, peaked at 2 weeks (84% in B6) and then resolved by 4 weeks in a majority of mice. Alveolar hemorrhage was independent of MyD88 (myeloid differentiation factor 88), or TLR7 pathways, in contrast to autoantibody production and glomerulonephritis, and was also independent of FcγR or Fas. Rag1(-/-) mice had a reduced prevalence of alveolar hemorrhage compared with B6 (P=0.01) congenics. However, T-cell receptor-deficient mice developed alveolar hemorrhage at a rate comparable to wild-type controls, whereas B6 Igμ(-/-) mice surprisingly had a strikingly reduced prevalence (7% vs 84% in B6, P<0.0001). Reconstitution of B6 Igμ(-/-) mice with wild-type B cells increased the prevalence to 50% (P=0.028). Pristane-induced alveolar hemorrhage is a useful model to study the pathogenesis and develop new therapy for this underappreciated and often life-threatening complication of SLE.
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de Lauretis A, Veeraraghavan S, Renzoni E. Review series: Aspects of interstitial lung disease: connective tissue disease-associated interstitial lung disease: how does it differ from IPF? How should the clinical approach differ? Chron Respir Dis 2011; 8:53-82. [PMID: 21339375 DOI: 10.1177/1479972310393758] [Citation(s) in RCA: 87] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
The lung is frequently involved in connective tissue diseases (CTDs), although the frequency of lung manifestations varies according to the type of CTD. Interstitial lung diseases (ILD) are frequently seen in CTDs, particularly systemic sclerosis (SSc), polymyositis/dermatomyositis (PM/DM) and rheumatoid arthritis (RA), accounting for a significant proportion of deaths. A large percentage of patients with CTD-associated ILD has limited and stable disease, not requiring treatment. However, a significant minority has severe and/or progressive disease, necessitating prompt initiation of treatment. CTD-ILD histological patterns include non-specific interstitial pneumonia (NSIP), usual interstitial pneumonia (UIP), organizing pneumonia (OP), diffuse alveolar damage (DAD) and lymphocytic interstitial pneumonia (LIP). NSIP is the most common pattern in all CTDs, except for RA, characterized by a higher frequency of UIP. ILD can present acutely or chronically, with acute presentations being more common in systemic lupus erythematosus and PM/DM. Idiopathic pulmonary fibrosis (IPF) is a progressively worsening ILD characterized by inflammation and fibrosis. The characteristic histological pattern of IPF is UIP. Interestingly, a UIP pattern is associated with a significantly better survival in CTD-related disease compared to the idiopathic variety. Prognosis in IPF is dismal, with a median survival since diagnosis of 2-3 years. No treatment regimen has been shown to improve survival in IPF. By contrast, although there have been only two randomized placebo-controlled trials investigating the effect of immunosuppressive treatment in SSc-associated ILD, clinical experience suggests that immunosuppressive drugs in CTD-related ILDs are capable of benefiting a significant proportion of patients, particularly those with certain histological patterns of disease. This review will essentially focus on CTD-associated ILD and will compare aspects of clinical presentation and management to those of IPF.
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Affiliation(s)
- Angelo de Lauretis
- Department of Respiratory Medicine, Catholic University of the Sacred Heart, Rome, Italy
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Martínez-Martínez MU, Abud-Mendoza C. Predictors of mortality in diffuse alveolar haemorrhage associated with systemic lupus erythematosus. Lupus 2011; 20:568-574. [DOI: 10.1177/0961203310392430] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Abstract
The objective of this study was the evaluation of clinical, demographic and treatment-associated mortality factors in patients with diffuse alveolar haemorrhage (DAH) associated with systemic lupus erythematosus (SLE). Clinical, laboratory test, SLEDAI-2K, predictors of mortality (APACHE II) and different treatments including cyclophosphamide, methylprednisolone and rituximab were evaluated in SLE patients who were diagnosed with DAH, to determine potential association with mortality. Twenty-nine episodes of DAH in 22 SLE patients were included (one patient with four episodes, four patients with two episodes (seven recurrences)), 15 died. Mean age was 25.1 years and 1.5 years of SLE evolution with haemoglobin drop 3.4 g/dl. In 4 of 22 patients, the DAH diagnosis was confirmed by autopsy. Six episodes were in patients under 18 years of age (2 patients with recurrence). DAH was the initial manifestation of SLE in 10 patients. Of the 22 patients, 17 were women and 22/29 had DAH episodes. Dyspnoea and nephritis occurred in all patients, less common were arthritis (75.9%) and fever (65.5%); haemoptysis was present only in 44.8%. Through evaluation of all included factors, only thrombocytopenia, renal failure, requirement for mechanical ventilation and high APACHE II were associated with higher mortality. Cyclophosphamide use was associated with less mortality (not statistically significant).
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Affiliation(s)
- MU Martínez-Martínez
- Regional Unit of Rheumatology and Osteoporosis, Central Hospital ‘Dr. Ignacio Morones Prieto’ and Faculty of Medicine, Universidad Autónoma de San Luis Potosí, San Luis Potosí, México
| | - C Abud-Mendoza
- Regional Unit of Rheumatology and Osteoporosis, Central Hospital ‘Dr. Ignacio Morones Prieto’ and Faculty of Medicine, Universidad Autónoma de San Luis Potosí, San Luis Potosí, México
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40
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Isono M, Araki H, Haitani T, Morita Y, Yasuda M, Kato N, Urasaki K, Tsujimura Y. Diffuse alveolar hemorrhage in lupus nephritis complicated by microscopic polyangiitis. Clin Exp Nephrol 2011; 15:294-8. [PMID: 21225308 DOI: 10.1007/s10157-010-0394-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2010] [Accepted: 12/08/2010] [Indexed: 11/30/2022]
Abstract
Diffuse alveolar hemorrhage (DAH) is a rare but fatal complication in patients with systemic lupus erythematosus (SLE). We describe a case of a 74-year-old woman who presented with DAH as an initial presentation of SLE. She also had microscopic polyangiitis clinically manifesting as crescentic glomerulonephritis and purpura with positive myeloperoxidase (MPO)-antineutrophil cytoplasmic antibodies (ANCA). The patient transiently improved when treated with plasma exchange and methylprednisolone pulse therapy; however, she died of recurrent pulmonary hemorrhage and concurrent cryptococcal pneumonia. This case indicates that MPO-ANCA is associated with severe organ involvement such as pulmonary hemorrhage and crescentic glomerulonephritis in SLE.
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Affiliation(s)
- Motohide Isono
- Department of Medicine, Otsu Municipal Hospital, Otsu, Shiga 520-0804, Japan.
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41
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Alveolar hemorrhage in systemic lupus erythematosus: An overview. EGYPTIAN RHEUMATOLOGIST 2011. [DOI: 10.1016/j.ejr.2010.02.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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42
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Pleural and pulmonary involvement in systemic lupus erythematosus. Presse Med 2011; 40:e19-29. [DOI: 10.1016/j.lpm.2010.11.004] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2010] [Revised: 11/04/2010] [Accepted: 11/05/2010] [Indexed: 11/18/2022] Open
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43
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Carmier D, Marchand-Adam S, Diot P, Diot E. Respiratory involvement in systemic lupus erythematosus. Rev Mal Respir 2010; 27:e66-78. [DOI: 10.1016/j.rmr.2010.01.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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44
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Utility of Bronchoalveolar Lavage in Evaluation of Patients with Connective Tissue Diseases. Clin Chest Med 2010; 31:423-31. [DOI: 10.1016/j.ccm.2010.04.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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45
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46
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Shen M, Zeng X, Tian X, Zhang F, Zeng X, Zhang X, Xu W. Diffuse alveolar hemorrhage in systemic lupus erythematosus: a retrospective study in China. Lupus 2010; 19:1326-30. [PMID: 20647253 DOI: 10.1177/0961203310373106] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The objective of this study was to determine the clinical features of systemic lupus erythematosus (SLE) patients with diffuse alveolar hemorrhage (DAH). The medical records of 29 patients with DAH among 2133 SLE patients admitted to Peking Union Medical College Hospital from January 2004 to January 2009 were reviewed in this retrospective study. It was found that hypoxemia (100%), dyspnea (90%), cough (79%) and fever (72%), rather than hemoptysis (66%), were the most common symptoms. The most common extrapulmonary presentation was renal involvement (90%). In about 60% of patients nosocomial infection was also present. The mean drop in hemoglobin was 32 ± 10.9 g/l. Mean Systemic Lupus Erythematosus Disease Activity Index (SLEDAI) was 17 ± 9. All patients received high-dose corticosteroid therapy and most were also given immunosuppressive agents. Rates of concomitant nosocomial infection and mechanical ventilation in non-survivors were higher than those of survivors (p < 0.05). DAH is a rare and catastrophic event in SLE. DAH can occur at any stage of the disease course; it usually occurs in patients with active SLE, and is frequently complicated by lupus nephritis. Some patients may have no hemoptysis. Early aggressive management with high-dose steroids and cyclophosphamide is advocated.
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Affiliation(s)
- M Shen
- Department of Rheumatology and Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
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47
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Abstract
Diffuse alveolar haemorrhage (DAH) is a rare but life-threatening complication of systemic lupus erythematosus (SLE). We present the case of a 24-year-old Cambodian woman with SLE followed in the Brigham and Women’s Hospital Lupus Center in Boston, Massachusetts. She presented with dyspnoea and chest pain and was found to have DAH that required a prolonged hospitalization that was complicated by recurrent DAH episodes and multiple infections. We discuss the diagnostic approach and management of patients with SLE-associated DAH as well as treatment options for refractory disease. Emerging therapies include plasmapheresis, the anti-CD20 monoclonal antibody rituximab and recombinant activated Factor VII therapy. In addition, we review the literature to date and compile what is known about the epidemiology, presenting features, diagnostic findings, management and outcomes in this condition. We found that DAH has been reported in 1.9% of patients with SLE. These patients were mostly female (88%) and young (mean age 30.2 years). Common presenting features included dyspnoea (94%), anaemia (97%) and new radiographic chest infiltrate (99%). Bronchoscopy, when performed, identified DAH in 90% of cases. Corticosteroids were the mainstay of care, and usage of cyclophosphamide varied by report. Despite recent advances in therapy, mortality has not improved substantially (48% overall survival versus 53% survival in reports published since 1993).
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Affiliation(s)
- DJ Todd
- Division of Rheumatology, Immunology, and Allergy, Brigham and Women’s Hospital, Arthritis Center, Boston, Massachusetts, USA
| | - KH Costenbader
- Division of Rheumatology, Immunology, and Allergy, Brigham and Women’s Hospital, Arthritis Center, Boston, Massachusetts, USA
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48
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Abstract
Despite limited evidence from clinical studies, anticoagulant drugs such as vitamin K antagonists (VKA) (e.g., warfarin or phenprocoumon) are widely used in the background treatment of patients with pulmonary arterial hypertension (PAH). According to current guidelines, they are generally accepted as efficacious drugs, although their efficacy is neither supported by randomised controlled trials, nor formally approved by regulatory agencies for use in the specific PAH indication. The use of these drugs is not without problems, as a paradoxical situation has to be managed in the treatment of this condition. On one hand, thrombosis is one of the key pathophysiologic features of PAH (besides vasoconstriction, proliferation and inflammation). On the other hand, the incidence of bleeding events is increased in PAH patients. This applies particularly to PAH that is related to connective tissue diseases, congenital heart disease and chronic thromboembolic pulmonary hypertension. In patients receiving VKA, caution must be observed in particular when concomitantly using prostanoids or sildenafil. Similarly, VKA doses have to be adjusted according to the labelling when using sitaxentan concomitantly. Regular International Normalized Ratio monitoring contributes to the safety of PAH patients on VKA.
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Affiliation(s)
- C F Opitz
- DRK Kliniken Berlin Köpenick, Berlin.
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49
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Moradinejad MH. Treatment of intractable pulmonary hemorrhage in two patients with childhood systemic lupus erythematosus. Rheumatol Int 2009; 29:1113-5. [DOI: 10.1007/s00296-009-0886-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2008] [Accepted: 01/14/2009] [Indexed: 11/28/2022]
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50
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Cervera R, Espinosa G. Unusual manifestations of the antiphospholipid syndrome. ACTA ACUST UNITED AC 2009. [DOI: 10.2217/ijr.09.3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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