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Motamedi M, Ferrara G, Yacyshyn E, Osman M, Abril A, Rahman S, Netchiporouk E, Gniadecki R. Skin disorders and interstitial lung disease: Part I-Screening, diagnosis, and therapeutic principles. J Am Acad Dermatol 2023; 88:751-764. [PMID: 36228941 DOI: 10.1016/j.jaad.2022.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 09/26/2022] [Accepted: 10/02/2022] [Indexed: 11/07/2022]
Abstract
Numerous inflammatory, neoplastic, and genetic skin disorders are associated with interstitial lung disease (ILD), the fibrosing inflammation of lung parenchyma that has significant morbidity and mortality. Therefore, the dermatologist plays a major role in the early detection and appropriate referral of patients at risk for ILD. Part 1 of this 2-part CME outlines the pathophysiology of ILD and focuses on clinical screening and therapeutic principles applicable to dermatological patients who are at risk for ILD. Patients with clinical symptoms of ILD should be screened with pulmonary function tests and high-resolution chest computed tomography. Screening for pulmonary hypertension should be considered in high-risk patients. Early identification and elimination of pulmonary risk factors, including smoking and gastroesophageal reflux disease, are essential in improving respiratory outcomes. First-line treatment interventions for ILD in a dermatological setting include mycophenolate mofetil, but the choice of therapeutic agents depends on the nature of the primary disease, the severity of ILD, and comorbidities and should be the result of a multidisciplinary assessment. Better awareness of ILD among medical dermatologists and close interdisciplinary collaborations are likely to prevent treatment delays improving long-term outcomes.
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Affiliation(s)
- Melika Motamedi
- Division of Dermatology, University of Alberta, Edmonton, Alberta, Canada
| | - Giovanni Ferrara
- Division of Pulmonary Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Elaine Yacyshyn
- Division of Rheumatology, University of Alberta, Edmonton, Alberta, Canada
| | - Mohammed Osman
- Division of Rheumatology, University of Alberta, Edmonton, Alberta, Canada
| | - Andy Abril
- Division of Rheumatology, Mayo Clinic, Jacksonville, Florida
| | - Samia Rahman
- Division of Dermatology, University of Alberta, Edmonton, Alberta, Canada
| | | | - Robert Gniadecki
- Division of Dermatology, University of Alberta, Edmonton, Alberta, Canada.
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An observational study of clinical recurrence in patients with interstitial lung disease related to the antisynthetase syndrome. Clin Rheumatol 2023; 42:711-720. [PMID: 36334174 DOI: 10.1007/s10067-022-06424-4] [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: 08/01/2022] [Revised: 10/10/2022] [Accepted: 10/24/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To describe the clinical characteristics and risk factors of clinical recurrence in interstitial lung disease related to antisynthetase syndrome (ARS-ILD). METHODS Patients diagnosed as ARS-ILD in Nanjing Drum Tower Hospital between January 2015 and November 2020 were retrospectively analyzed. Clinical information and treatment course were reviewed. The primary endpoint was the disease recurrence, and the secondary point was mortality. Univariate and multivariable Cox regression analyses were performed to identify risk factors for recurrence. RESULTS Totally, 132 patients with ARS-ILD received immunomodulation treatment from diagnosis. During follow-ups, sixty-nine patients showed recurrence, with a recurrency rate yielding 52.3%. The median duration from treatment initiation to recurrence was 11 (5-18) months. The median tapering course in the recurrence group was 8 (3-12.5) months, which was significantly shorter than the 16 (10-32) months in the no-recurrence group (p < 0.001). Fifty-eight patients experienced recurrence when the glucocorticoids (GC) dose dropped to 10 (9.375-15) mg/day. Twelve patients discontinued GC with a median treatment course of 11.5 (8-16.75) months, and 11 patients developed recurrence after discontinuing GC for 3 (1-4) months. Twelve patients died, with a mortality rate of 9.1%, and recurrence was not associated with increased mortality. The adjusted multivariate analysis showed that age, increased serum lactate dehydrogenase (LDH) level, relatively shorter tapering duration, and inappropriate GC discontinuation were associated with recurrence. CONCLUSION Recurrence of ARS-ILD was common during medication intensity reduction. Age, LDH, medication tapering duration, and discontinuation were risk factors for recurrence. Further efforts to reduce recurrence should take into consideration of these factors. Key Points • Recurrence is observed commonly with a recurrency rate 52.3% in patients with interstitial lung disease related to antisynthetase syndrome (ARS-ILD) when glucocorticoids (GC) tapering or discontinuation. • Age, increased serum lactate dehydrogenase (LDH) level, medication tapering duration, and GC discontinuation were identified to be significantly associated with the recurrence of ARS-ILD.
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Arya A, Anand S, Kumar S, Britto C. A rare presentation of anti-synthetase syndrome requiring intensive care in the midst of a COVID wave. Mod Rheumatol Case Rep 2022:rxac088. [PMID: 36416564 DOI: 10.1093/mrcr/rxac088] [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: 07/06/2022] [Revised: 08/16/2022] [Accepted: 11/22/2022] [Indexed: 06/16/2023]
Abstract
A 24-year-old female with pneumonia two months prior presented with fever, cough and worsening dyspnea in the midst of a COVID-19 spike. Her initial episode was treated as COVID-19 pneumonia. On presentation, her chest CT was suggestive of bilateral lower zone organizing pneumonia with mild fibrosis and was attributed to post COVID sequelae with an infective exacerbation. Oral steroids and antibiotics were administered following which she had initial improvement and then subsequent deterioration requiring ICU care. A detailed clinical examination (in-person and virtually) at this point revealed the presence of pigmented rashes over the knuckles and weakness of hip muscles. Laboratory work showed elevated creatine kinase levels, positive anti-Ro and anti-Jo1 antibodies which pointed to a diagnosis of anti-synthetase syndrome (ASS). Unique attributes of this case include younger age of presentation in an atypical ethnic group and possibly incited by COVID-19 infection in the peak of a COVID-19 wave. The work-up, diagnosis and initial management of this patient was carried out through a hybrid ICU model which functioned as a traditional ICU in the day and a tele-ICU at night with an appropriate network of sub-specialists including Rheumatologists consulting, thus highlighting a collaborative model in a low resource setting capable of managing rare cases even in the midst of increasing critical care needs during the pandemic.
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Affiliation(s)
- Akhila Arya
- Cloudphysician Healthcare Private Limited, Bengaluru, India
| | - Sanu Anand
- Cloudphysician Healthcare Private Limited, Bengaluru, India
| | - Sandesh Kumar
- Cloudphysician Healthcare Private Limited, Bengaluru, India
| | - Carl Britto
- Department of Pediatrics, Boston Children's Hospital, Boston, MA, USA
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4
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Tomassetti S, Colby TV, Wells AU, Poletti V, Costabel U, Matucci-Cerinic M. Bronchoalveolar lavage and lung biopsy in connective tissue diseases, to do or not to do? Ther Adv Musculoskelet Dis 2021; 13:1759720X211059605. [PMID: 34900002 PMCID: PMC8664307 DOI: 10.1177/1759720x211059605] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 10/26/2021] [Indexed: 12/25/2022] Open
Abstract
Bronchoalveolar lavage and lung biopsy (LBx) are helpful in patients with connective tissue diseases (CTD) and interstitial lung diseases (ILD) regardless of cause, including infectious, noninfectious, immunologic, or malignant. The decision whether to perform only bronchoalveolar lavage (BAL), and eventually a subsequent LBx in case of a nondiagnostic lavage, or one single bronchoscopy combining both sampling methods depends on the clinical suspicion, on patient’s characteristics (e.g. increased biopsy risk) and preferences, and on the resources and biopsy techniques available locally (e.g. regular forceps versus cryobiopsy). In CTD-ILD, BAL has major clinical utility in excluding infections and in the diagnosis of specific patterns of acute lung damage (e.g. alveolar hemorrhage, diffuse alveolar damage, and organizing pneumonia). LBx is indicated to exclude neoplasm or diagnose lymphoproliferative lung disorders that in CTD patients are more common than in the general population. Defining BAL cellularity and characterizing the CTD-ILD histopathologic pattern by LBx can be helpful in the differential diagnosis of cases without established CTD [e.g. ILD preceding full-blown CTD, interstitial pneumonia with autoimmune features (IPAF)], but the prognostic and theragnostic role of those findings remains unclear. Few studies in the pretranscriptomics era have investigated the diagnostic and prognostic role of BAL and LBx in CTD-ILD, and it is reasonable to hypothesize that future studies conducted applying innovative techniques on BAL and LBx might open new and unexpected avenues in pathogenesis, diagnosis, and treatment approach to CTD-ILD. This is particularly desirable now that a new drug treatment era is emerging, in which we have more than one therapeutic choice (immunosuppressive agents, antifibrotic drugs, and biological agents). We hope that future research will pave the path toward precision medicine providing data for a more accurate ILD-CTD endotyping that will guide the physicians through targeted therapeutic choices, rather than to the approximative approach ‘one drug fits them all’.
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Affiliation(s)
- Sara Tomassetti
- Department of Experimental and Clinical Medicine, Careggi University Hospital and University of Florence, 50121 Florence, Italy
| | - Thomas V Colby
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Scottsdale, AZ, USA
| | - Athol U Wells
- ILD Unit, Pulmonary Medicine, Royal Brompton Hospital, London, UK
| | - Venerino Poletti
- Department of Diseases of the Thorax, GB Morgagni Hospital, Forlì, Italy
| | - Ulrich Costabel
- Center for Interstitial and Rare Lung Diseases, Pneumology Department, Ruhrlandklinik, University Medicine Essen, Essen, Germany
| | - Marco Matucci-Cerinic
- Department of Experimental and Clinical Medicine, Careggi University Hospital, Florence, ItalyUnit of Immunology, Rheumatology, Allergy and Rare diseases (UnIRAR), IRCCS San Raffaele Hospital, Milan, Italy
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Flashner BM, VanderLaan PA, Nurhussien L, Rice MB, Hallowell RW. Pulmonary histopathology of interstitial lung disease associated with antisynthetase antibodies. Respir Med 2021; 191:106697. [PMID: 34864634 DOI: 10.1016/j.rmed.2021.106697] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Revised: 11/22/2021] [Accepted: 11/23/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND We aimed to determine if antibody type is an indicator of pulmonary histopathology, using antisynthetase antibody positive interstitial lung disease (ILD) cases with lung biopsy or autopsy findings. METHODS We conducted a comprehensive review of the English language literature in PubMed to identify ILD histopathology results for cases with antibodies against anti-aminoacyl-transfer RNA (tRNA) synthetases (anti-ARS antibodies), including Jo1, PL-12, PL-7, KS, ES, and OJ. We additionally identified patients who had ILD, anti-ARS antibodies, and a lung biopsy between 2015 and 2020 at Beth Israel Deaconess Medical Center. For each case, we documented the specific anti-ARS antibody and major histopathologic patterns identified on biopsy or autopsy, including usual interstitial pneumonia (UIP), nonspecific interstitial pneumonia (NSIP), organizing pneumonia (OP), and acute lung injury (ALI). To determine if histopathology varied by antibody type, we compared the proportion of each of four major patterns by antibody type using the Fisher's Exact test. RESULTS We identified 310 cases with pathology findings and anti-ARS antibody positivity, including 12 cases from our institution. The proportion of NSIP differed significantly across antibody type, found in 31% of Jo1 (p < 0.01), 67% of EJ (p < 0.01), and 63% of KS (p < 0.01) cases. OP was common in Jo1 (23%, p = 0.07), but rare in EJ (4%, p = 0.04) and KS (4%, p = 0.04). UIP was common in PL-12 alone (36%, p = 0.03). CONCLUSION The frequency of histopathologic findings in ILD with anti-ARS positivity varies significantly by antibody type, and NSIP occurs in less than half of all cases.
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Affiliation(s)
- Bess M Flashner
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA.
| | - Paul A VanderLaan
- Department of Pathology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Lina Nurhussien
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Mary B Rice
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Robert W Hallowell
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
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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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Popper H, Stacher-Priehse E, Brcic L, Nerlich A. Lung fibrosis in autoimmune diseases and hypersensitivity: how to separate these from idiopathic pulmonary fibrosis. Rheumatol Int 2021; 42:1321-1330. [PMID: 34605934 PMCID: PMC9287245 DOI: 10.1007/s00296-021-05002-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Accepted: 09/15/2021] [Indexed: 11/29/2022]
Abstract
Lung involvement in autoimmune diseases (AID) is uncommon, but may precede other organ manifestations. A diagnostic problem is chronicity presenting with lung fibrosis. A new category of interstitial pneumonia with autoimmune features for patients with clinical symptoms of AID and presenting with usual interstitial pneumonia (UIP) enables antifibrotic treatment for these patients. Hypersensitivity pneumonia (HP) and other forms of lung fibrosis were not included into this category. As these diseases based on adverse immune reactions often present with unspecific clinical symptoms, a specified pathological diagnosis will assist the clinical evaluation. We aimed to establish etiology-relevant differences of patterns associated with AID or HP combined with lung fibrosis. We retrospectively evaluated 51 cases of AID, and 29 cases of HP with lung fibrosis, and compared these to 24 cases of idiopathic pulmonary fibrosis (UIP/IPF). Subacute AID and HP most often presented with organizing pneumonia (OP), whereas chronicity was associated with UIP. Unspecified fibrosis was seen in a few cases, whereas NSIP pattern was rare. In 9 cases, the underlying etiology could not be defined. Statistically significant features differentiating chronic AID or HP from UIP/IPF are lymphocytic infiltrations into myofibroblastic/fibroblastic foci. Other features significantly associated with AID and HP were granulomas, isolated Langhans giant cells, and protein deposits, but seen in only a minority of cases. A combination of UIP with one of these features enabled a specific etiology-based diagnosis. Besides the antifibrotic drug regimen, additional therapies might be considered.
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Affiliation(s)
- Helmut Popper
- Medical University Graz, Diagnostic and Research Institute of Pathology, Neue Stiftingtalstr. 6, 8036, Graz, Austria.
| | | | - Luka Brcic
- Medical University Graz, Diagnostic and Research Institute of Pathology, Neue Stiftingtalstr. 6, 8036, Graz, Austria
| | - Andreas Nerlich
- Department of Pathology, Teaching Hospital Munich-Bogenhausen, Munich, Germany
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8
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Sawal N, Mukhopadhyay S, Rayancha S, Moore A, Garcha P, Kumar A, Kaul V. A narrative review of interstitial lung disease in anti-synthetase syndrome: a clinical approach. J Thorac Dis 2021; 13:5556-5571. [PMID: 34659821 PMCID: PMC8482343 DOI: 10.21037/jtd-20-3328] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Accepted: 07/23/2021] [Indexed: 12/17/2022]
Abstract
Anti-synthetase syndrome (AS) is a rare autoimmune disorder characterized by the presence of aminoacyl-transfer RNA synthetase antibodies in conjunction with clinical features such as interstitial lung disease (ILD), Raynaud's phenomenon, nonerosive arthritis, and myopathy. AS distinguishes itself from other inflammatory myopathies by its significant lung involvement and rapidly progressive interstitial lung disease (AS-ILD), therefore the management of AS-ILD requires careful clinical, serologic and radiologic assessment. Glucocorticoids are considered the mainstay of therapy; however, additional immunosuppressive agents are often required to achieve disease control. Patient prognosis is highly dependent on early diagnosis and symptom recognition as the antibody profile is thought to influence therapy response. Since progressive ILD is the leading cause of morbidity and mortality, this review will discuss the clinical approach to patient with suspected AS, with particular emphasis on diagnosis and management of AS-ILD.
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Affiliation(s)
- Naina Sawal
- Department of Internal Medicine, SUNY Upstate Medical University, Syracuse, NY, USA
| | | | - Sheetal Rayancha
- Department of Rheumatology, SUNY Upstate Medical University, Syracuse, NY, USA
| | - Alastair Moore
- Department of Radiology, Baylor Scott and White Health, Dallas, TX, USA
| | - Puneet Garcha
- Department of Pulmonary Critical-Care, Baylor College of Medicine, Houston, TX, USA
| | - Anupam Kumar
- Department of Pulmonary Critical-Care, Baylor College of Medicine, Houston, TX, USA
| | - Viren Kaul
- Department of Pulmonary Critical-Care, Crouse Health/SUNY Upstate Medical University, Syracuse, NY, USA
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9
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Egashira R. High-Resolution CT Findings of Myositis-Related Interstitial Lung Disease. MEDICINA (KAUNAS, LITHUANIA) 2021; 57:medicina57070692. [PMID: 34356972 PMCID: PMC8304263 DOI: 10.3390/medicina57070692] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 06/17/2021] [Accepted: 07/01/2021] [Indexed: 12/21/2022]
Abstract
Myositis-related interstitial lung disease presents with a wide variety of lesions, ranging from chronic to acute. It can be divided into two main forms by the types of onsets, namely, chronic to subacute type showing nonspecific interstitial pneumonia (NSIP) or NSIP with an organizing pneumonia (OP)/fibrosing OP (FOP) pattern and acute type showing acute lung injury (ALI) to diffuse alveolar damage (DAD) pattern. Anti-aminoacyl tRNA Synthetase antibody-positive cases mainly show an NSIP or FOP pattern, whereas anti-melanoma differentiation-associated gene 5 antibody-positive cases show ALI to DAD pattern. Bilateral consolidation with or without ground-glass opacification with lower lobe predominance is common as a major pattern in all types, but the distribution or extent is sometimes different. The early detection of findings that indicate a rapid progressive course is vital. Diffuse cranio-caudal distribution and multiple ground-glass opacifications with random distribution might indicate a poorer prognosis.
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Affiliation(s)
- Ryoko Egashira
- Department of Radiology, Faculty of Medicine, Saga University, 5-1-1 Nabeshima, Saga 849-8501, Japan
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10
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Zhan X, Yan W, Wang Y, Li Q, Shi X, Gao Y, Ye Q. Clinical features of anti-synthetase syndrome associated interstitial lung disease: a retrospective cohort in China. BMC Pulm Med 2021; 21:57. [PMID: 33579248 PMCID: PMC7881640 DOI: 10.1186/s12890-021-01399-5] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Accepted: 01/04/2021] [Indexed: 11/24/2022] Open
Abstract
Background Anti-synthetase syndrome (ASSD) is a chronic autoimmune condition characterized by antibodies directed against an aminoacycl transfer RNA synthetase (ARS) along with a group of clinical features including the classical clinical triad: inflammatory myopathy, arthritis, and interstitial lung disease (ILD). ASSD is highly heterogenous due to different organ involvement, and ILD is the main cause of mortality and function loss, which presents as different patterns when diagnosed. We designed this retrospective cohort to describe the clinical features and disease behaviour of ASSD associated ILD. Methods Data of 108 cases of ASSD associated ILD were retrospectively collected in Beijing Chaoyang Hospital from December 2017 to March 2019. Data were obtained from the Electronic Medical Record system. Patients were divided into 5 groups according to distinct aminoacyl tRNA synthetase (ARS) antibodies. Results Overall, 108 consecutive patients were recruited. 33 were JO-1 positive, 30 were PL-7 positive, 23 were EJ positive, 13 were PL-12 positive and 9 were OJ positive. The JO-1 (+) group had a significant higher rate of mechanic’s hand (57.6%) than other 4 groups. Polymyositis/dermatomyositis (PM/DM) was diagnosed in 25 (23.1%) patients and no difference was observed among the 5 groups. The PL-7 (+) group had a higher frequency of UIP pattern (13.3%) than the other 4 groups but the difference was not significant, and the EJ (+) group had the most frequent OP pattern (78.2%), which was significantly higher than the PL-7 (+) (P < 0.001) and PL-12 (+) groups (P = 0.025). The median follow-up time was 10.7 months, during which no patients died. All received prednisone treatment, with or without immunosuppressants. At the 6-month follow-up, 96.3% of all patients (104/108) had a positive response to therapy, the JO-1 (+) and EJ (+) groups had a significantly higher improvement of forced vital capacity than the other 3 groups (P < 0.05), and the PL-7 group had the lowest FVC improvement (P < 0.05). The JO-1 (+) group and EJ (+) group had significantly higher anti-Ro-52 positive occurrence than the other 3 groups (P < 0.05). Conclusion Anti PL-7 antibody had the same frequency as anti-JO-1 in ASSD-ILD, in which the ILD pattern was different with distinct anti-ARS antibodies. Most ASSD-ILD had a positive response to steroid therapies, with or without immunosuppressants. The PL-7 (+) group had the highest occurrence of UIP pattern, and a significantly lower response to therapy.
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Affiliation(s)
- Xi Zhan
- Beijing Institute of Respiratory Medicine, Department of Respiratory Medicine and Critical Care, Beijing Chaoyang Hospital, Capital Medical University, Beijing, 100020, China.
| | - Wei Yan
- Hunan Prevention and Treatment Institute for Occupational Diseases, Changsha, 410007, Hunan, China
| | - Ying Wang
- Beijing Institute of Respiratory Medicine, Department of Respiratory Medicine and Critical Care, Beijing Chaoyang Hospital, Capital Medical University, Beijing, 100020, China
| | - Qing Li
- Department of Pathology, Beijing Chaoyang Hospital, Capital Medical University, Beijing, 100020, China
| | - Xuhua Shi
- Department of Rheumatology and Autoimmune Diseases, Beijing Chaoyang Hospital, Capital Medical University, Beijing, 100020, China
| | - Yanli Gao
- Department of Radiology, Beijing Chaoyang Hospital, Capital Medical University, Beijing, 100020, China
| | - Qiao Ye
- Department of Occupational Medicine and Toxicology, Capital Medical University, Beijing, 100020, China
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11
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Fox SC, Trivedi AP. A 47-Year Old Woman With Rapidly Progressive Hypoxemic Respiratory Failure. Chest 2021; 159:e69-e73. [PMID: 33563457 DOI: 10.1016/j.chest.2020.08.2119] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Revised: 07/17/2020] [Accepted: 08/07/2020] [Indexed: 11/28/2022] Open
Abstract
CASE PRESENTATION A 47-year-old Hispanic woman presented to a pulmonology clinic with 2 weeks of cough productive of white sputum and worsening dyspnea on exertion, requiring increasing supplemental oxygen. In addition, she reported fatigue, night sweats, diffuse myalgias, and extremity weakness. She denied hemoptysis, fevers, chills, weight loss, or rash. Her medical history is significant for undifferentiated rapidly progressive hypoxemic respiratory failure 2 years before her current presentation. At that time, she presented to the ED with 3 weeks of progressive shortness of breath and cough. Chest CT imaging showed bilateral infiltrates concerning for infection, and she was treated empirically for community-acquired pneumonia. She developed worsening hypoxemic respiratory failure despite broadening of her antibiotics and subsequently required intubation. Her course was further complicated by pulseless electrical activity arrest with return of spontaneous circulation and development of shock requiring multiple vasopressors. Because of difficulty with oxygenation, she was referred to our center for extracorporeal membrane oxygenation evaluation and was ultimately started on venous-arterial extracorporeal membrane oxygenation. Bronchoscopy with BAL was negative for bacterial, viral, and fungal origins, and initial autoimmune evaluation (antinuclear antibody and rheumatoid factor) was negative, except an elevated creatine kinase (CK) to 3,000. Her course was complicated by heparin-induced thrombocytopenia, and as a result she suffered limb ischemia requiring amputation of her left lower extremity. Elevated CK at that time was attributed to compartment syndrome before amputation. The patient recovered clinically with supportive care and was ultimately discharged on 2 L supplemental oxygen, with a diagnosis of acute respiratory failure of unclear origin. The patient had stability in her clinical symptoms until this current presentation.
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Affiliation(s)
- Samuel C Fox
- Department of Internal Medicine, Rush University Medical Center, Chicago, IL.
| | - Abhaya P Trivedi
- Division of Pulmonary and Critical Care Medicine, Rush University Medical Center, Chicago, IL
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12
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Murota M, Johkoh T, Lee KS, Franquet T, Kondoh Y, Nishiyama Y, Tanaka T, Sumikawa H, Egashira R, Yamaguchi N, Fujimoto K, Fukuoka J. Influenza H1N1 virus-associated pneumonia often resembles rapidly progressive interstitial lung disease seen in collagen vascular diseases and COVID-19 pneumonia; CT-pathologic correlation in 24 patients. Eur J Radiol Open 2020; 7:100297. [PMID: 33318970 PMCID: PMC7724381 DOI: 10.1016/j.ejro.2020.100297] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 11/18/2020] [Accepted: 11/23/2020] [Indexed: 02/08/2023] Open
Abstract
Purpose To describe computed tomography (CT) findings of influenza H1N1 virus-associated pneumonia (IH1N1VAP), and to correlate CT findings to pathological ones. Methods The study included 24 patients with IH1N1VAP. Two observers independently evaluated the presence, distribution, and extent of CT findings. CT features were divided into either classical form (C-form) or non-classical form (NC-form). C-form included: A.) broncho-bronchiolitis and bronchopneumonia type, whereas NC-forms included: B.) diffuse peribronchovascular type, simulating subacute rheumatoid arthritis-associated (RA) interstitial lung disease (ILD) and C.) lower peripheral and/or peribronchovascular type, resembling dermatomyositis-associated ILD and COVID-19 pneumonia. In 10 cases with IH1N1VAP where lung biopsy was performed, CT and pathology findings were correlated. Results The most common CT findings were ground-glass opacities (24/24, 100 %) and airspace consolidation (23/24, 96 %). C-form was found in 11 (46 %) patients while NC-form in 13 (54 %). Types A, B, and C were seen in 11(46 %), 4 (17 %), and 9 (38 %) patients, respectively. The lung biopsy revealed organizing pneumonia in all patients and 6 patients (60 %) showed incorporated type organizing pneumonia that was common histological findings of rapidly progressive ILD. Conclusion In almost half of patients of IH1N1VAP, CT images show NC-form pneumonia pattern resembling either acute or subacute RA or dermatomyositis-associated ILD and COVID-19 pneumonia.
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Affiliation(s)
- Makiko Murota
- Department of Radiology, Faculty of Medicine, Kagawa University, Kagawa, Japan
| | - Takeshi Johkoh
- Department of Radiology, Kansai Rosai Hospital, Hyogo, Japan
| | - Kyung Soo Lee
- Department of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Tomas Franquet
- Department of Radiology, Hospital de Sant Pau, Universidad Autónoma de Barcelona, Barcelona, Spain
| | - Yasuhiro Kondoh
- Department of Respiratory and Allergic Medicine, Tosei General Hospital, Aichi, Japan
| | - Yoshihiro Nishiyama
- Department of Radiology, Faculty of Medicine, Kagawa University, Kagawa, Japan
| | - Tomonori Tanaka
- Department of Pathology, Kindai University Faculty of Medicine, Osaka, Japan
| | | | - Ryoko Egashira
- Department of Radiology, Faculty of Medicine, Saga University, Saga, Japan
| | - Norihiko Yamaguchi
- Department of Respiratory Medicine, Kinki Central Hospital of Mutual Aid Association of Public School Teachers, Hyogo, Japan
| | - Kiminori Fujimoto
- Department of Radiology, Kurume University School of Medicine, Fukuoka, Japan
| | - Junya Fukuoka
- Department of Laboratory of Pathology, Nagasaki University Hospital, Nagasaki, Japan
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13
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López-Mejías R, Remuzgo-Martínez S, Genre F, Pulito-Cueto V, Rozas SMF, Llorca J, Fernández DI, Cuesta VMM, Ortego-Centeno N, Gómez NP, Mera-Varela A, Martínez-Barrio J, López-Longo FJ, Mijares V, Lera-Gómez L, Usetti MP, Laporta R, Pérez V, Gafas ADP, González MAA, Calvo-Alén J, Romero-Bueno F, Sanchez-Pernaute O, Nuno L, Bonilla G, Balsa A, Hernández-González F, Grafia I, Prieto-González S, Narvaez J, Trallero-Araguas E, Selva-O'Callaghan A, Gualillo O, Castañeda S, Cavagna L, Cifrian JM, González-Gay MA. Influence of MUC5B gene on antisynthetase syndrome. Sci Rep 2020; 10:1415. [PMID: 31996780 PMCID: PMC6989632 DOI: 10.1038/s41598-020-58400-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Accepted: 01/15/2020] [Indexed: 01/13/2023] Open
Abstract
MUC5B rs35705950 (G/T) is strongly associated with idiopathic pulmonary fibrosis (IPF) and also contributes to the risk of interstitial lung disease (ILD) in rheumatoid arthritis (RA-ILD) and chronic hypersensitivity pneumonitis (CHP). Due to this, we evaluated the implication of MUC5B rs35705950 in antisynthetase syndrome (ASSD), a pathology characterised by a high ILD incidence. 160 patients with ASSD (142 with ILD associated with ASSD [ASSD-ILD+]), 232 with ILD unrelated to ASSD (comprising 161 IPF, 27 RA-ILD and 44 CHP) and 534 healthy controls were genotyped. MUC5B rs35705950 frequency did not significantly differ between ASSD-ILD+ patients and healthy controls nor when ASSD patients were stratified according to the presence/absence of anti Jo-1 antibodies or ILD. No significant differences in MUC5B rs35705950 were also observed in ASSD-ILD+ patients with a usual interstitial pneumonia (UIP) pattern when compared to those with a non-UIP pattern. However, a statistically significant decrease of MUC5B rs35705950 GT, TT and T frequencies in ASSD-ILD+ patients compared to patients with ILD unrelated to ASSD was observed. In summary, our study does not support a role of MUC5B rs35705950 in ASSD. It also indicates that there are genetic differences between ILD associated with and that unrelated to ASSD.
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Affiliation(s)
- Raquel López-Mejías
- Epidemiology, Genetics and Atherosclerosis Research Group on Systemic Inflammatory Diseases, Hospital Universitario Marqués de Valdecilla, IDIVAL, Santander, Spain.
| | - Sara Remuzgo-Martínez
- Epidemiology, Genetics and Atherosclerosis Research Group on Systemic Inflammatory Diseases, Hospital Universitario Marqués de Valdecilla, IDIVAL, Santander, Spain
| | - Fernanda Genre
- Epidemiology, Genetics and Atherosclerosis Research Group on Systemic Inflammatory Diseases, Hospital Universitario Marqués de Valdecilla, IDIVAL, Santander, Spain
| | - Verónica Pulito-Cueto
- Epidemiology, Genetics and Atherosclerosis Research Group on Systemic Inflammatory Diseases, Hospital Universitario Marqués de Valdecilla, IDIVAL, Santander, Spain
| | - Sonia M Fernández Rozas
- Epidemiology, Genetics and Atherosclerosis Research Group on Systemic Inflammatory Diseases, Hospital Universitario Marqués de Valdecilla, IDIVAL, Santander, Spain
| | - Javier Llorca
- Department of Epidemiology and Computational Biology, School of Medicine, University of Cantabria, and CIBER Epidemiología y Salud Pública (CIBERESP), IDIVAL, Santander, Spain
| | - David Iturbe Fernández
- Epidemiology, Genetics and Atherosclerosis Research Group on Systemic Inflammatory Diseases, Hospital Universitario Marqués de Valdecilla, IDIVAL, Santander, Spain
| | - Víctor M Mora Cuesta
- Epidemiology, Genetics and Atherosclerosis Research Group on Systemic Inflammatory Diseases, Hospital Universitario Marqués de Valdecilla, IDIVAL, Santander, Spain
| | | | - Nair Pérez Gómez
- Division of Rheumatology, Hospital Clínico Universitario de Santiago, Santiago de Compostela, Spain
| | - Antonio Mera-Varela
- Division of Rheumatology, Hospital Clínico Universitario de Santiago, Santiago de Compostela, Spain
| | - Julia Martínez-Barrio
- Department of Rheumatology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | | | - Verónica Mijares
- Epidemiology, Genetics and Atherosclerosis Research Group on Systemic Inflammatory Diseases, Hospital Universitario Marqués de Valdecilla, IDIVAL, Santander, Spain
| | - Leticia Lera-Gómez
- Epidemiology, Genetics and Atherosclerosis Research Group on Systemic Inflammatory Diseases, Hospital Universitario Marqués de Valdecilla, IDIVAL, Santander, Spain
| | - María Piedad Usetti
- Pneumology Department, Hospital Universitario Puerta de Hierro, Madrid, Spain
| | - Rosalía Laporta
- Pneumology Department, Hospital Universitario Puerta de Hierro, Madrid, Spain
| | - Virginia Pérez
- Lung Transplant Unit, Division of Pulmonology, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Alicia De Pablo Gafas
- Lung Transplant Unit, Division of Pulmonology, Hospital Universitario 12 de Octubre, Madrid, Spain
| | | | - Jaime Calvo-Alén
- Rheumatology Division, Hospital Universitario Araba, Universidad del País Vasco, Vitoria, Spain
| | - Fredeswinda Romero-Bueno
- Rheumatology Department, Bone and Joint Research Unit, Hospital Universitario Fundación Jiménez Díaz, IIS Fundación Jiménez Díaz, Universidad Autónoma de Madrid, Madrid, Spain
| | - Olga Sanchez-Pernaute
- Rheumatology Department, Bone and Joint Research Unit, Hospital Universitario Fundación Jiménez Díaz, IIS Fundación Jiménez Díaz, Universidad Autónoma de Madrid, Madrid, Spain
| | - Laura Nuno
- Rheumatology Department, Hospital Universitario La Paz, Madrid, Spain
| | - Gema Bonilla
- Rheumatology Department, Hospital Universitario La Paz, Madrid, Spain
| | - Alejandro Balsa
- Rheumatology Department, Hospital Universitario La Paz, Madrid, Spain
| | | | - Ignacio Grafia
- Department of Autoimmune Diseases, Hospital Clínico de Barcelona, Universidad de Barcelona, Barcelona, Spain
| | - Sergio Prieto-González
- Department of Autoimmune Diseases, Hospital Clínico de Barcelona, Universidad de Barcelona, Barcelona, Spain
| | - Javier Narvaez
- Rheumatology Department, Hospital Universitario de Bellvitge, Barcelona, Spain
| | - Ernesto Trallero-Araguas
- Department of Systemic Autoimmune Diseases, Hospital Universitario Valle de Hebron, Universidad Autónoma de Barcelona, Barcelona, Spain
| | - Albert Selva-O'Callaghan
- Department of Systemic Autoimmune Diseases, Hospital Universitario Valle de Hebron, Universidad Autónoma de Barcelona, Barcelona, Spain
| | - Oreste Gualillo
- Servizo Galego de Saude and Instituto de Investigación Sanitaria-Hospital Clínico Universitario de Santiago, Santiago de Compostela, Spain
| | - Santos Castañeda
- Rheumatology Department, Hospital Universitario de la Princesa, IIS-Princesa, Madrid, Spain
| | - Lorenzo Cavagna
- Division of Rheumatology, University and IRCCS Policlinico S. Matteo Foundation of Pavia and ERN ReCONNET, Pavia, Italy
| | - José M Cifrian
- Epidemiology, Genetics and Atherosclerosis Research Group on Systemic Inflammatory Diseases, Hospital Universitario Marqués de Valdecilla, IDIVAL, Santander, Spain
| | - Miguel A González-Gay
- Epidemiology, Genetics and Atherosclerosis Research Group on Systemic Inflammatory Diseases, Hospital Universitario Marqués de Valdecilla, IDIVAL, Santander, Spain.,School of Medicine, Universidad de Cantabria, Santander, Spain.,Cardiovascular Pathophysiology and Genomics Research Unit, School of Physiology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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14
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Ciancio N, Pavone M, Torrisi SE, Vancheri A, Sambataro D, Palmucci S, Vancheri C, Di Marco F, Sambataro G. Contribution of pulmonary function tests (PFTs) to the diagnosis and follow up of connective tissue diseases. Multidiscip Respir Med 2019; 14:17. [PMID: 31114679 PMCID: PMC6518652 DOI: 10.1186/s40248-019-0179-2] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Accepted: 03/15/2019] [Indexed: 12/22/2022] Open
Abstract
Introduction Connective Tissue Diseases (CTDs) are systemic autoimmune conditions characterized by frequent lung involvement. This usually takes the form of Interstitial Lung Disease (ILD), but Obstructive Lung Disease (OLD) and Pulmonary Artery Hypertension (PAH) can also occur. Lung involvement is often severe, representing the first cause of death in CTD. The aim of this study is to highlight the role of Pulmonary Function Tests (PFTs) in the diagnosis and follow up of CTD patients. Main body Rheumatoid Arthritis (RA) showed mainly an ILD with a Usual Interstitial Pneumonia (UIP) pattern in High-Resolution Chest Tomography (HRCT). PFTs are able to highlight a RA-ILD before its clinical onset and to drive follow up of patients with Forced Vital Capacity (FVC) and Carbon Monoxide Diffusing Capacity (DLCO). In the course of Scleroderma Spectrum Disorders (SSDs) and Idiopathic Inflammatory Myopathies (IIMs), DLCO appears to be more sensitive than FVC in highlighting an ILD, but it can be compromised by the presence of PAH. A restrictive respiratory pattern can be present in IIMs and Systemic Lupus Erythematosus due to the inflammatory involvement of respiratory muscles, the presence of fatigue or diaphragm distress. Conclusions The lung should be carefully studied during CTDs. PFTs can represent an important prognostic tool for diagnosis and follow up of RA-ILD, but, on their own, lack sufficient specificity or sensitivity to describe lung involvement in SSDs and IIMs. Several composite indexes potentially able to describe the evolution of lung damage and response to treatment in SSDs are under investigation. Considering the potential severity of these conditions, an HRCT jointly with PFTs should be performed in all new diagnoses of SSDs and IIMs. Moreover, follow up PFTs should be interpreted in the light of the risk factor for respiratory disease related to each disease.
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Affiliation(s)
- Nicola Ciancio
- 1Regional Referral Center for Rare Lung Diseases, A. O. U. "Policlinico-Vittorio Emanuele" Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy.,Respiratory Physiopathology Group. Società Italiana di Pneumologia. Italian Respiratory Society (SIP/IRS), Milan, Italy
| | - Mauro Pavone
- 1Regional Referral Center for Rare Lung Diseases, A. O. U. "Policlinico-Vittorio Emanuele" Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Sebastiano Emanuele Torrisi
- 1Regional Referral Center for Rare Lung Diseases, A. O. U. "Policlinico-Vittorio Emanuele" Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Ada Vancheri
- 1Regional Referral Center for Rare Lung Diseases, A. O. U. "Policlinico-Vittorio Emanuele" Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Domenico Sambataro
- Artroreuma S.R.L. Outpatient Clinic accredited with the Italian National Health System, Corso S. Vito 53, 95030 Mascalucia (CT), Italy
| | - Stefano Palmucci
- 4Department of Medical Surgical Sciences and Advanced Technologies- Radiology I Unit, University Hospital "Policlinico-Vittorio Emanuele", Catania, Italy
| | - Carlo Vancheri
- 1Regional Referral Center for Rare Lung Diseases, A. O. U. "Policlinico-Vittorio Emanuele" Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Fabiano Di Marco
- 5Department of Health Sciences, Università degli studi di Milano, Head Respiratory Unit, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Gianluca Sambataro
- 1Regional Referral Center for Rare Lung Diseases, A. O. U. "Policlinico-Vittorio Emanuele" Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy.,Artroreuma S.R.L. Outpatient Clinic accredited with the Italian National Health System, Corso S. Vito 53, 95030 Mascalucia (CT), Italy
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15
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Histological Findings of Organizing Pneumonia, Based on Transbronchial Lung Biopsy, May Predict Poor Outcome in Polymyositis and Dermatomyositis: Report of Two Autopsied Cases. Arch Rheumatol 2019; 33:376-380. [PMID: 30632536 DOI: 10.5606/archrheumatol.2018.6577] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Accepted: 11/27/2017] [Indexed: 11/21/2022] Open
Abstract
Interstitial lung disease in polymyositis and dermatomyositis is a serious complication, associated with poor prognosis. In this article, we describe two cases with histological findings of organizing pneumonia, based on transbronchial lung biopsy. One is a 66-year-old female patient with clinically amyopathic dermatomyositis with anti-melanoma differentiation-associated gene 5 antibody, and another is a 61-year-old female patient with polymyositis with anti-Jo-1 antibody. Both of our cases rapidly deteriorated to death, and autopsy findings showed diffuse alveolar damage. Our experience indicates that transbronchial biopsy findings of organizing pneumonia may be a poor prognostic factor in clinically amyopathic dermatomyositis and polymyositis, in spite of the profile of myositis-specific antibodies.
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16
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Vuillard C, Pineton de Chambrun M, de Prost N, Guérin C, Schmidt M, Dargent A, Quenot JP, Préau S, Ledoux G, Neuville M, Voiriot G, Fartoukh M, Coudroy R, Dumas G, Maury E, Terzi N, Tandjaoui-Lambiotte Y, Schneider F, Grall M, Guérot E, Larcher R, Ricome S, Le Mao R, Colin G, Guitton C, Zafrani L, Morawiec E, Dubert M, Pajot O, Mentec H, Plantefève G, Contou D. Clinical features and outcome of patients with acute respiratory failure revealing anti-synthetase or anti-MDA-5 dermato-pulmonary syndrome: a French multicenter retrospective study. Ann Intensive Care 2018; 8:87. [PMID: 30203297 PMCID: PMC6131681 DOI: 10.1186/s13613-018-0433-3] [Citation(s) in RCA: 58] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Accepted: 09/01/2018] [Indexed: 12/13/2022] Open
Abstract
Background Anti-synthetase (AS) and dermato-pulmonary associated with anti-MDA-5 antibodies (aMDA-5) syndromes are near one of the other autoimmune inflammatory myopathies potentially responsible for severe acute interstitial lung disease. We undertook a 13-year retrospective multicenter study in 35 French ICUs in order to describe the clinical presentation and the outcome of patients admitted to the ICU for acute respiratory failure (ARF) revealing AS or aMDA-5 syndromes. Results From 2005 to 2017, 47 patients (23 males; median age 60 [1st–3rd quartiles 52–69] years, no comorbidity 85%) were admitted to the ICU for ARF revealing AS (n = 28, 60%) or aMDA-5 (n = 19, 40%) syndromes. Muscular, articular and cutaneous manifestations occurred in 11 patients (23%), 14 (30%) and 20 (43%) patients, respectively. Seventeen of them (36%) had no extra-pulmonary manifestations. C-reactive protein was increased (139 [40–208] mg/L), whereas procalcitonine was not (0.30 [0.12–0.56] ng/mL). Proportion of patients with creatine kinase ≥ 2N was 20% (n = 9/47). Forty-two patients (89%) had ARDS, which was severe in 86%, with a rate of 17% (n = 8/47) of extra-corporeal membrane oxygenation requirement. Proportion of patients who received corticosteroids, cyclophosphamide, rituximab, intravenous immunoglobulins and plasma exchange were 100%, 72%, 15%, 21% and 17%, respectively. ICU and hospital mortality rates were 45% (n = 21/47) and 51% (n = 24/47), respectively. Patients with aMDA-5 dermato-pulmonary syndrome had a higher hospital mortality than those with AS syndrome (n = 16/19, 84% vs. n = 8/28, 29%; p = 0.001). Conclusions Intensivists should consider inflammatory myopathies as a cause of ARF of unknown origin. Extra-pulmonary manifestations are commonly lacking. Mortality is high, especially in aMDA-5 dermato-pulmonary syndrome.
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Affiliation(s)
- Constance Vuillard
- Service de Réanimation Polyvalente, Centre Hospitalier Victor Dupouy, 69 rue du Lieutenant Colonel Prudhon, 95100, Argenteuil, France
| | - Marc Pineton de Chambrun
- Service de Réanimation Médicale, Centre Hospitalier Universitaire Pitié-Salpétrière - Assistance Publique Hôpitaux de Paris, 47-83 boulevard de l'Hôpital, 75013, Paris, France
| | - Nicolas de Prost
- Service de Réanimation Médicale, Centre Hospitalier Universitaire Henri Mondor - Assistance Publique Hôpitaux de Paris, 51 avenue du Maréchal de Lattre de Tassigny, 94010, Créteil, France
| | - Claude Guérin
- Service de Réanimation Médicale, Hôpital de la Croix-Rousse, 103 Grande rue de la Croix-Rousse, 69004, Lyon, France.,INSERM 955, Créteil, France
| | - Matthieu Schmidt
- Service de Réanimation Médicale, Centre Hospitalier Universitaire Pitié-Salpétrière - Assistance Publique Hôpitaux de Paris, 47-83 boulevard de l'Hôpital, 75013, Paris, France
| | - Auguste Dargent
- Service de Médecine Intensive Réanimation, Centre Hospitalier Universitaire François Mitterrand de Dijon, 14 rue Paul Gaffarel, 21000, Dijon, France
| | - Jean-Pierre Quenot
- Service de Médecine Intensive Réanimation, Centre Hospitalier Universitaire François Mitterrand de Dijon, 14 rue Paul Gaffarel, 21000, Dijon, France
| | - Sébastien Préau
- Service de Réanimation, Centre Hospitalier Régional Universitaire de Lille, 2 avenue Oscar Lambret, 59000, Lille, France
| | - Geoffrey Ledoux
- Service de Réanimation, Centre Hospitalier Régional Universitaire de Lille, 2 avenue Oscar Lambret, 59000, Lille, France
| | - Mathilde Neuville
- Service de Réanimation Médicale, Centre Hospitalier Universitaire Bichat Claude-Bernard - Assistance Publique Hôpitaux de Paris, 46 rue Henri Huchard, 75877, Paris, France
| | - Guillaume Voiriot
- Service de Réanimation médico-chirurgicale, Centre Hospitalier Universitaire Tenon - Assistance Publique Hôpitaux de Paris, 5 rue de la Chine, 75020, Paris, France
| | - Muriel Fartoukh
- Service de Réanimation médico-chirurgicale, Centre Hospitalier Universitaire Tenon - Assistance Publique Hôpitaux de Paris, 5 rue de la Chine, 75020, Paris, France
| | - Rémi Coudroy
- Service de Réanimation médicale, Centre hospitalier universitaire de Poitiers, 2 rue de la Milétrie, 86021, Poitiers, France
| | - Guillaume Dumas
- Service de Réanimation médicale, Centre Hospitalier Universitaire Saint-Antoine - Assistance Publique Hôpitaux de Paris, 184 rue du Faubourg Saint-Antoine, 75012, Paris, France
| | - Eric Maury
- Service de Réanimation médicale, Centre Hospitalier Universitaire Saint-Antoine - Assistance Publique Hôpitaux de Paris, 184 rue du Faubourg Saint-Antoine, 75012, Paris, France
| | - Nicolas Terzi
- Service de Réanimation, Centre Hospitalier Universitaire de Grenoble Alpes, avenue Maquis du Grésivaudan, 38700, La Tronche, France
| | - Yacine Tandjaoui-Lambiotte
- Service de Réanimation médico-chirurgicale, Centre Hospitalier Universitaire Avicennes - Assistance Publique Hôpitaux de Paris, 125 rue de Stalingrad, 93000, Bobigny, France
| | - Francis Schneider
- Service de Réanimation, Centre Hospitalier Universitaire de Strasbourg, 1 avenue Molière, 67200, Strasbourg, France
| | - Maximilien Grall
- Service de Réanimation Médicale, Centre Hospitalier Universitaire de Rouen, 1 rue de Germont, 76000, Rouen, France
| | - Emmanuel Guérot
- Service de Réanimation Médicale, Centre Hospitalier Universitaire Hôpital Européen Georges-Pompidou - Assistance Publique Hôpitaux de Paris, 20 rue Leblanc, 75015, Paris, France
| | - Romaric Larcher
- Service de Réanimation Médicale, Centre Hospitalier Universitaire de Montpellier, 191 avenue du Doyen Gaston Giraud, 34000, Montpellier, France
| | - Sylvie Ricome
- Service de Réanimation Polyvalente, Centre Hospitalier Robert-Ballanger, Boulevard Robert Ballanger, 93600, Aulnay-sous-Bois, France
| | - Raphaël Le Mao
- Service de Réanimation médicale, Centre Hospitalier Régional Universistaire de Brest, Site La Cavale Blanche, Boulevard Tanguy Prigent, 29200, Brest, France
| | - Gwenhaël Colin
- Service de réanimation médico-chirurgicale, Centre Hospitalier Départemental de Vendée, Les Oudairies, 85925, La Roche sur Yon Cedex 9, France
| | - Christophe Guitton
- Service de Réanimation médico-chirurgicale, Centre Hospitalier du Mans, 194 avenue Rubillard, 72037, Le Mans, France
| | - Lara Zafrani
- Service de Réanimation médicale, Hôpital Saint-Louis, Assistance Publique Hôpitaux de Paris, 1 avenue Claude Vellefaux, 75010, Paris, France
| | - Elise Morawiec
- Unité de Réanimation et de Surveillance continue, Service de Pneumologie et Réanimation médicale, Groupe hospitalier Pitié-Salpêtrière, 47-83 bd de l'hôpital, 75651, Paris, France
| | - Marie Dubert
- Service d'Immunologie Clinique, Hôpital Saint-Louis, Assistance Publique Hôpitaux de Paris, 1 avenue Claude Vellefaux, 75010, Paris, France
| | - Olivier Pajot
- Service de Réanimation Polyvalente, Centre Hospitalier Victor Dupouy, 69 rue du Lieutenant Colonel Prudhon, 95100, Argenteuil, France
| | - Hervé Mentec
- Service de Réanimation Polyvalente, Centre Hospitalier Victor Dupouy, 69 rue du Lieutenant Colonel Prudhon, 95100, Argenteuil, France
| | - Gaëtan Plantefève
- Service de Réanimation Polyvalente, Centre Hospitalier Victor Dupouy, 69 rue du Lieutenant Colonel Prudhon, 95100, Argenteuil, France
| | - Damien Contou
- Service de Réanimation Polyvalente, Centre Hospitalier Victor Dupouy, 69 rue du Lieutenant Colonel Prudhon, 95100, Argenteuil, France.
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Cherin P, de Jaeger C, Crave JC, Delain JC, Tadmouri A, Amoura Z. Subcutaneous immunoglobulins for the treatment of a patient with antisynthetase syndrome and secondary chronic immunodeficiency after anti-CD20 treatment: a case report. J Med Case Rep 2017; 11:58. [PMID: 28257650 PMCID: PMC5336681 DOI: 10.1186/s13256-017-1211-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2016] [Accepted: 01/14/2017] [Indexed: 01/10/2023] Open
Abstract
Background Antisynthetase syndrome is a rare and debilitating multiorgan disease characterized by inflammatory myopathy, interstitial lung disease, cutaneous involvement, and frequent chronic inflammation of the joints. Standard treatments include corticosteroids and immunosuppressants. In some cases, treatment resistance may develop. Administration of immunoglobulins intravenously is recommended in patients with drug-resistant antisynthetase syndrome. Case presentation Here, we describe the case of a 56-year-old woman of Algerian origin. She is the first case of a patient with multidrug-resistant antisynthetase syndrome featuring pulmonary involvement and arthropathy, and chronic secondary immune deficiency with recurrent infections, after anti-CD20 treatment, in which her primary antisynthetase syndrome-related symptoms and secondary immune deficiency were treated successfully with subcutaneous administration of immunoglobulin. The administration of immunoglobulin subcutaneously was introduced at a dose of 2 g/kg per month and was well tolerated. Clinical improvement was observed within 3 months of initiation of subcutaneous administration of immunoglobulin. After 22 months of treatment, she showed a significant improvement in terms of muscle strength, pulmonary involvement, arthralgia, and immunodeficiency. Her serum creatine phosphokinase and C-reactive protein levels remained normal. Finally, she was compliant and entirely satisfied with the treatment. Conclusions Taken together, these observations suggest that administration of immunoglobulin subcutaneously may be a useful therapeutic approach to tackle steroid-refractory antisynthetase syndrome while ensuring minimal side effects and improved treatment compliance. This treatment also allowed, in our case, for the regression of the chronic immunodeficiency secondary to rituximab treatment.
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Affiliation(s)
- Patrick Cherin
- Department of Internal Medicine, Pitié-Salpetrière Hospital Group, 47-83 Boulevard de l'Hôpital, 75013, Paris, France.
| | | | | | | | | | - Zahir Amoura
- Department of Internal Medicine, Pitié-Salpetrière Hospital Group, 47-83 Boulevard de l'Hôpital, 75013, Paris, France
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Sasano H, Hagiwara E, Kitamura H, Enomoto Y, Matsuo N, Baba T, Iso S, Okudela K, Iwasawa T, Sato S, Suzuki Y, Takemura T, Ogura T. Long-term clinical course of anti-glycyl tRNA synthetase (anti-EJ) antibody-related interstitial lung disease pathologically proven by surgical lung biopsy. BMC Pulm Med 2016; 16:168. [PMID: 27903248 PMCID: PMC5131426 DOI: 10.1186/s12890-016-0325-y] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Accepted: 11/17/2016] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Anti-glycyl-tRNA synthetase (anti-EJ) antibody is occasionally positive in patients with interstitial lung disease (ILD). We aimed to define the clinical, radiological and pathological features of patients with anti-EJ antibody-positive ILD (EJ-ILD). METHODS We retrospectively analyzed the medical records of 12 consecutive patients with EJ-ILD who underwent surgical lung biopsy. RESULTS The median follow-up time was 74 months (range, 17-115 months). The median age was 62 years (range, 47-75 years). Seven of 12 patients were female. Eight patients presented with acute onset. Six patients eventually developed polymyositis/dermatomyositis. On high-resolution computed tomography, consolidation and volume loss were predominantly observed in the middle or lower lung zone. Nine patients presented pathologically nonspecific interstitial pneumonia with organizing pneumonia, alveolar epithelial injury and prominent interstitial cellular infiltrations whereas the other three patients were diagnosed with unclassifiable interstitial pneumonia. Although all patients but one improved with the initial immunosuppressive therapy, five patients relapsed. When ILD relapsed, four of the five patients were treated with corticosteroid monotherapy. Four of the six patients without relapse have been continuously treated with combination therapy of corticosteroid and immunosuppressant. CONCLUSIONS Patients with EJ-ILD often had acute onset of ILD with lower lung-predominant shadows and pathologically nonspecific interstitial pneumonia or unclassifiable interstitial pneumonia with acute inflammatory findings. Although the disease responded well to the initial treatment, relapse was frequent. Because of the diversity of the clinical courses, combination therapy of corticosteroid and immunosuppressant should be on the list of options to prevent relapse of EJ-ILD.
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Affiliation(s)
- Hajime Sasano
- Department of Respiratory Medicine, Kanagawa Cardiovascular and Respiratory Center, 6-16-1 Tomioka-higashi, Kanazawa-Ku, Yokohama, 236-0051, Japan.,Present Address: Department of Respiratory Medicine, Ise Red Cross Hospital, 1-471-2 Funae, Ise, 516-8512, Japan
| | - Eri Hagiwara
- Department of Respiratory Medicine, Kanagawa Cardiovascular and Respiratory Center, 6-16-1 Tomioka-higashi, Kanazawa-Ku, Yokohama, 236-0051, Japan
| | - Hideya Kitamura
- Department of Respiratory Medicine, Kanagawa Cardiovascular and Respiratory Center, 6-16-1 Tomioka-higashi, Kanazawa-Ku, Yokohama, 236-0051, Japan
| | - Yasunori Enomoto
- Department of Respiratory Medicine, Kanagawa Cardiovascular and Respiratory Center, 6-16-1 Tomioka-higashi, Kanazawa-Ku, Yokohama, 236-0051, Japan.,Present Address: Second Division, Department of Internal Medicine, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-Ku, Hamamatsu, 431-3192, Japan
| | - Norikazu Matsuo
- Department of Respiratory Medicine, Kanagawa Cardiovascular and Respiratory Center, 6-16-1 Tomioka-higashi, Kanazawa-Ku, Yokohama, 236-0051, Japan.,Present Address: Department of Respirology, Kurume University School of Medicine, 67 Asahi-Chō, Kurume, 830-0011, Japan
| | - Tomohisa Baba
- Department of Respiratory Medicine, Kanagawa Cardiovascular and Respiratory Center, 6-16-1 Tomioka-higashi, Kanazawa-Ku, Yokohama, 236-0051, Japan
| | - Shinichiro Iso
- Department of Radiology, Yokohama Rosai Hospital for Labor Welfare Corporation, 3211 Kozukue-Chō, Kōhoku-Ku, Yokohama, 222-0036, Japan
| | - Koji Okudela
- Department of Pathology, Yokohama City University Graduate School of Medicine, 3-9, Fukuura, Kanazawa-Ku, Yokohama, 236-0004, Japan
| | - Tae Iwasawa
- Department of Radiology, Kanagawa Cardiovascular and Respiratory Center, 6-16-1 Tomioka-higashi, Kanazawa-Ku, Yokohama, 236-0051, Japan
| | - Shinji Sato
- Department of Rheumatology, Tokai University School of Medicine, 143 Shimokasuya, Isehara, 259-1193, Japan
| | - Yasuo Suzuki
- Department of Rheumatology, Tokai University School of Medicine, 143 Shimokasuya, Isehara, 259-1193, Japan
| | - Tamiko Takemura
- Department of Pathology, Japan Red Cross Medical Center, 4-1-22 Hiroo, Shibuya-Ku, Tokyo, 150-8935, Japan
| | - Takashi Ogura
- Department of Respiratory Medicine, Kanagawa Cardiovascular and Respiratory Center, 6-16-1 Tomioka-higashi, Kanazawa-Ku, Yokohama, 236-0051, Japan.
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Abstract
Anti-synthetase syndrome is an autoimmune condition, characterized by antibodies directed against an aminoacycl transfer RNA synthetase along with clinical features that can include interstitial lung disease, myositis, Raynaud's phenomenon, and arthritis. There is a higher prevalence and increased severity of interstitial lung disease in patients with anti-synthetase syndrome, as compared to dermatomyositis and polymyositis, inflammatory myopathies with which it may overlap phenotypically. Diagnosis is made by a multidisciplinary approach, synthesizing rheumatology and pulmonary evaluations, along with serologic, radiographic, and occasionally muscle and/or lung biopsy results. Patients with anti-synthetase syndrome often require multi-modality immunosuppressive therapy in order to control the muscle and/or pulmonary manifestations of their disease. The long-term care of these patients mandates careful attention to the adverse effects and complications of chronic immunosuppressive therapy, as well as disease-related sequelae that can include progressive interstitial lung disease necessitating lung transplantation, pulmonary hypertension, malignancy and decreased survival. It is hoped that greater awareness of the clinical features of this syndrome will allow for earlier diagnosis and appropriate treatment to improve outcomes in patients with anti-synthetase syndrome.
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20
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Kim SH, Park IN. Acute Respiratory Distress Syndrome as the Initial Clinical Manifestation of an Antisynthetase Syndrome. Tuberc Respir Dis (Seoul) 2016; 79:188-92. [PMID: 27433180 PMCID: PMC4943904 DOI: 10.4046/trd.2016.79.3.188] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Revised: 06/24/2015] [Accepted: 09/19/2015] [Indexed: 11/24/2022] Open
Abstract
Antisynthetase syndrome has been recognized as an important cause of autoimmune inflammatory myopathy in a subset of patients with polymyositis and dermatomyositis. It is associated with serum antibody to aminoacyl-transfer RNA synthetases and is characterized by a constellation of manifestations, including fever, myositis, interstitial lung disease, mechanic's hand-like cutaneous involvement, Raynaud phenomenon, and polyarthritis. Lung disease is the presenting feature in 50% of the cases. We report a case of a 60-year-old female with acute respiratory distress syndrome (ARDS), which later proved to be an unexpected and initial manifestation of anti-Jo-1 antibody-positive antisynthetase syndrome. The present case showed resolution of ARDS after treatment with high-dose corticosteroids. Given that steroids are not greatly beneficial in the treatment of ARDS, it is likely that the improvement of the respiratory symptoms in this patient also resulted from the prompt suppression of the inflammatory systemic response by corticosteroids.
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Affiliation(s)
- Seo-Hyun Kim
- Department of Internal Medicine, Inje University Seoul Paik Hospital, Seoul, Korea
| | - I-Nae Park
- Department of Internal Medicine, Inje University Seoul Paik Hospital, Seoul, Korea
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21
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Piroddi IMG, Ferraioli G, Barlascini C, Castagneto C, Nicolini A. Severe respiratory failure as a presenting feature of an interstitial lung disease associated with anti-synthetase syndrome (ASS). Respir Investig 2016; 54:284-8. [PMID: 27424829 DOI: 10.1016/j.resinv.2016.01.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2015] [Revised: 01/12/2016] [Accepted: 01/25/2016] [Indexed: 12/23/2022]
Abstract
Anti-synthetase syndrome (ASS) is defined as a heterogeneous connective tissue disorder characterized by the association of an interstitial lung disease (ILD) with or without inflammatory myositis with the presence of anti-aminoacyl-tRNA-synthetase antibodies. ILD is one of the major extra-muscular manifestations of polymyositis and dermatomyositis. We report a case of a patient with dyspnea, cough, and intermittent fever as well as ILD associated ASS in the absence of muscular involvement. This patient was admitted to the emergency department with severe respiratory failure requiring non-invasive ventilation. Our patient's case demonstrates that the diagnosis of ASS may not be obvious. However, its diagnosis leads to appropriate and potentially life-saving treatment.
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Affiliation(s)
| | | | | | | | - Antonello Nicolini
- Respiratory Diseases Unit ASL4 Chiavarese, Via Terzi 43, 16039 Sestri Levante, Italy.
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22
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Devi HG, Pasha MM, Padmaja MS, Halappa S. Antisynthetase Syndrome: A Rare Cause for ILD. J Clin Diagn Res 2016; 10:OD08-9. [PMID: 27134916 DOI: 10.7860/jcdr/2016/16872.7361] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2015] [Accepted: 01/06/2016] [Indexed: 11/24/2022]
Abstract
Anti-Synthetase Syndrome (ASS) is a rare autoimmune disorder characterized by Interstitial Lung Disease (ILD), inflammatory myositis, fever, Raynaud's phenomenon, mechanic's hand, and inflammatory polyarthritis in the setting of antibodies against amino acyl-transfer RNA synthetases, with anti-Jo-1 antibody being the most common. It can sometimes present as interstitial lung disease without any other expression of the syndrome. Clinical and radiological features can be similar to atypical pneumonia and could be a challenge to diagnose at an early stage. Prognosis is generally poor, especially when there is associated ILD and delay in diagnosis can lead to increase in morbidity due to progression of pulmonary involvement. We report a patient of ASS presenting with ILD, diagnosed early and treated successfully with immunosupression.
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Affiliation(s)
- Hj Gayathri Devi
- Associate Professor, Department of Respiratory Medicine, MS Ramaiah Medical College , Bangalore, India
| | - Md Majeed Pasha
- Resident, Department of Respiratory Medicine, MS Ramaiah Medical College , Bangalore, India
| | - Mantha Sathya Padmaja
- Resident, Department of Respiratory Medicine, MS Ramaiah Medical College , Bangalore, India
| | - Sujith Halappa
- Resident, Department of Respiratory Medicine, MS Ramaiah Medical College , Bangalore, India
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Schneider F, Aggarwal R, Bi D, Gibson K, Oddis C, Yousem SA. The Pulmonary Histopathology of Anti-KS Transfer RNA Synthetase Syndrome. Arch Pathol Lab Med 2015; 139:122-5. [DOI: 10.5858/arpa.2013-0667-oa] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Context
The clinical spectrum of the antisynthetase syndromes (AS) has been poorly defined, although some frequently present with pulmonary manifestations. The anti-KS anti–asparaginyl-transfer RNA synthetase syndrome is one in which pulmonary interstitial lung disease is almost always present and yet the histopathologic spectrum is not well described.
Objective
To define the morphologic manifestations of pulmonary disease in those patients with anti-KS antiasparaginyl syndrome.
Design
We reviewed the connective tissue disorder registry of the University of Pittsburgh and identified those patients with anti-KS autoantibodies who presented with interstitial lung disease and had surgical lung biopsies.
Results
The 5 patients with anti-KS antisynthetase syndrome were usually women presenting with dyspnea and without myositis, but with mechanic's hands (60%) and Raynaud phenomenon (40%). They most often presented with a usual interstitial pneumonia pattern of fibrosis (80%), with the final patient displaying organizing pneumonia.
Conclusions
Pulmonary interstitial lung disease is a common presentation in patients with the anti-KS–antisynthetase syndrome, who are often women with rather subtle or subclinical connective tissue disease, whereas the literature emphasizes the nonspecific interstitial pneumonia pattern often diagnosed clinically. Usual interstitial pneumonia and organizing pneumonia patterns of interstitial injury need to be added to this clinical differential diagnosis.
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Affiliation(s)
- Frank Schneider
- From the Departments of Pathology (Drs Schneider and Yousem, Mr Bi), Rheumatology (Drs Aggarwal and Oddis), and Pulmonary Medicine (Dr Gibson), UPMC Presbyterian, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Rohit Aggarwal
- From the Departments of Pathology (Drs Schneider and Yousem, Mr Bi), Rheumatology (Drs Aggarwal and Oddis), and Pulmonary Medicine (Dr Gibson), UPMC Presbyterian, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - David Bi
- From the Departments of Pathology (Drs Schneider and Yousem, Mr Bi), Rheumatology (Drs Aggarwal and Oddis), and Pulmonary Medicine (Dr Gibson), UPMC Presbyterian, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Kevin Gibson
- From the Departments of Pathology (Drs Schneider and Yousem, Mr Bi), Rheumatology (Drs Aggarwal and Oddis), and Pulmonary Medicine (Dr Gibson), UPMC Presbyterian, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Chester Oddis
- From the Departments of Pathology (Drs Schneider and Yousem, Mr Bi), Rheumatology (Drs Aggarwal and Oddis), and Pulmonary Medicine (Dr Gibson), UPMC Presbyterian, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Samuel A. Yousem
- From the Departments of Pathology (Drs Schneider and Yousem, Mr Bi), Rheumatology (Drs Aggarwal and Oddis), and Pulmonary Medicine (Dr Gibson), UPMC Presbyterian, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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24
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Hara Y, Tanaka T, Tabata K, Shiraki A, Hayashi K, Kashima Y, Hayashi T, Fukuoka J. Anti-glycyl tRNA synthetase antibody associated interstitial lung disease without symptoms of polymyositis/dermatomyositis. Pathol Int 2014; 64:148-50. [PMID: 24698425 DOI: 10.1111/pin.12140] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Affiliation(s)
- Yuki Hara
- Department of Pathology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
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25
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The pulmonary histopathologic manifestations of the anti-PL7/antithreonyl transfer RNA synthetase syndrome. Hum Pathol 2014; 45:1199-204. [DOI: 10.1016/j.humpath.2014.01.018] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2013] [Revised: 01/15/2014] [Accepted: 01/24/2014] [Indexed: 11/20/2022]
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26
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Hervier B, Benveniste O. Clinical heterogeneity and outcomes of antisynthetase syndrome. Curr Rheumatol Rep 2014; 15:349. [PMID: 23794106 DOI: 10.1007/s11926-013-0349-8] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
The autoimmune connective tissue disease antisynthetase syndrome (ASS) is an inflammatory myopathy associated with myositis-specific autoantibodies, e.g. anti-tRNA-synthetase antibodies (ASA). Since 1976 eight different ASA have been rigorously identified, of which anti-hystidyl-tRNA synthetase (anti-Jo1) is the most prevalent. Other phenotype features of ASS include interstitial lung disease (ILD), Raynaud's phenomenon, polyarthritis, fever, and mechanic's hands. The clinical presentation of ASS varies greatly, as does the severity of involvement of different organs-both among patients and/or over the course of the disease. ILD has been associated with poor outcomes, but in general the heterogeneity of ASS prevents identification of robust prognosis indicators. Early identification of patients requiring aggressive immunosuppressive treatment is very challenging, and there are very few prospective trials available to help match treatment management to ASS clinical characteristics. This review will focus on the biological, clinical, functional, and morphological features of ASS associated with patient outcome. Our objective is to use compiled data on these subjects to discuss the usefulness of patient stratification in developing future prospective therapeutic trials.
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Affiliation(s)
- Baptiste Hervier
- Internal Medicine Department, French Referral Center for Lupus and Antiphospholipid Syndrome, APHP, Hôpital Pitié Salpêtrière, 47-83 Boulevard de L'Hôpital, 75651, Paris Cedex 13, Paris, France.
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27
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Hervier B, Benveniste O. [Clinical phenotypes and prognosis of antisynthetase syndrome]. Rev Med Interne 2013; 35:453-60. [PMID: 24135060 DOI: 10.1016/j.revmed.2013.09.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2013] [Accepted: 09/11/2013] [Indexed: 11/26/2022]
Abstract
Antisynthetase syndrome (ASS) was first described in 1989 as an inflammatory myopathy associated with the presence of specific auto-antibodies, namely the anti-tRNA-synthetase antibodies (ASA). To date, the ASA family comprises eight different auto-antibodies, among which anti-hystidyl-tRNA-synthetase (anti-Jo1) is the most prevalent. In addition to myositis, a constellation of clinical features has also been described in ASS, including interstitial lung disease, Raynaud's phenomenon, polyarthritis, fever and mechanic's hands. Large variations in the distribution and the severity of each of these symptoms are reported from one patient to another, and also over the course of the disease. The heterogeneity of this autoimmune connective tissue disease has led to difficulties in the early identification of patients with a poor outcome (those who will require the most intensive treatments). Additionally, very few prospective trials have so far compared the efficacy of the different immunosuppressive drugs available, and evidence is lacking to help adapting therapeutic strategies to all of the different ASS clinical situations. We will review the different characteristics of ASS (namely biological, clinical, functional, and morphological ASS parameters) that have recently been shown to correlate with patients' outcome, our aim being to discuss the usefulness of patient stratification for elaborating targeted therapeutic trials for ASS in the future.
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Affiliation(s)
- B Hervier
- Service de médecine interne 2, Centre national de référence pour le lupus et le syndrome des antiphospholipides, hôpital Pitié Salpêtrière, AP-HP, 47-83, boulevard de l'Hôpital, 75651 Paris cedex 13, France.
| | - O Benveniste
- Service de médecine interne 1, Centre national de référence des maladies musculaires, hôpital Pitié Salpêtrière, AP-HP, 47-83, boulevard de l'Hôpital, 75651 Paris cedex 13, France
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28
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Hayes D, Baker PB, Mansour HM, Peeples ME, Nicol KK. Interstitial lung disease in a child with antisynthetase syndrome. Lung 2013; 191:441-3. [PMID: 23652349 DOI: 10.1007/s00408-013-9468-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2013] [Accepted: 04/13/2013] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Antisynthetase Syndrome is associated with interstitial lung disease in adult patients, but this has not been described in children. MATERIALS AND METHODS A 13-year-old with interstitial lung disease due to Antisynthetase Syndrome and pulmonary arterial hypertension underwent emergent bilateral lung transplantation after a rapid clinical decline. CONCLUSION We present the clinical, radiographic, and histological findings of a child with interstitial lung disease due to Antisynthetase Syndrome.
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Affiliation(s)
- Don Hayes
- Department of Pediatrics, The Ohio State University College of Medicine, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA.
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29
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Salimbene I, Leli I, Valente S. Respiratory failure in a patient with dermatomyositis. Multidiscip Respir Med 2013; 8:27. [PMID: 23531196 PMCID: PMC3620045 DOI: 10.1186/2049-6958-8-27] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2013] [Accepted: 02/18/2013] [Indexed: 12/03/2022] Open
Abstract
Since its original description in 1956 the association between interstitial lung disease and polymyositis (PM) and dermatomyositis (DM) has become well established. Interstitial lung disease (ILD) can be a significant complication in rheumatic diseases (RDs). Although most patients with RD do not develop clinically evident ILD, these systemic autoimmune disorders are estimated to be responsible for approximately 25% of all ILD deaths and 2% of deaths due to all respiratory causes. Radiologic abnormalities in DM are characterized by a high incidence of airspace consolidation. Non-Specific Interstitial Pneumonia (NSIP) is the most common form of lung disease, with a frequency in biopsies 4-fold greater than that of Usual Interstitial Pneumonia (UIP) in PM and a slightly smaller predominance in DM. We report a case of a female patient, 57 years old, no former smoker, whose clinical history was onset in November 2008 with asthenia with muscle and osteoarticular pain especially located in the upper limbs and then also expanded to the lower limbs. The EMG was compatible with dermatomyositis in the acute phase. The patient received therapy with steroids and tacrolimus, also making several rounds of treatment with immunoglobulin. Given the recurrence of myositis in association with signs of poorly controlled interstitial lung disease, immunosuppressive therapy with Rituximab was administered. The Computed Tomography (CT) scans showed "bronchiectasis and traction bronchiolectasis, hypodense areas consistent with the phenomena of air trapping. The pattern of interstitial lung disease with fibrotic evolution seems consistent with NSIP. The arterial blood gas analysis showed a pattern of hypoxic-hypercapnic respiratory failure (pH: 7,34, PaO2: 67 mmHg; PaCO2: 55 mmHg). As a result of an episode of marked desaturation unresponsive to supplemental oxygen at high flows we proceeded to noninvasive mechanical ventilation with Helmet for 24 hours/24. This ventilatory support was maintained for a week, with resolution of the respiratory failure. In this brief case report we want to highlight various pulmonary complications as a result of dermatomyositis. The progression of respiratory complications may also lead to a situation of respiratory failure, as in our patient, and require a noninvasive ventilatory treatment.
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Affiliation(s)
- Ivano Salimbene
- Department of Pulmonary Medicine, A, Gemelli University Polyclinic, Sacro Cuore Catholic University, Largo A, Gemelli 8, Rome, 00168, Italy.
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30
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Schneider F, Gruden J, Tazelaar HD, Leslie KO. Pleuropulmonary pathology in patients with rheumatic disease. Arch Pathol Lab Med 2012; 136:1242-52. [PMID: 23020730 DOI: 10.5858/arpa.2012-0248-sa] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Thoracic manifestations of rheumatic disease (RD) are increasingly recognized as a significant cause of morbidity and mortality worldwide. Rheumatologic underpinnings have been identified in a significant proportion of patients with interstitial lung disease. The 5 RDs most frequently associated with pleuropulmonary disease are (1) rheumatoid arthritis, (2) systemic lupus erythematosus, (3) progressive systemic sclerosis, (4) polymyositis/dermatomyositis, and (5) Sjögren syndrome. The onset of thoracic involvement in these diseases is variable. In some patients, it precedes the systemic disease or is its only manifestation. Moreover, there is a wide spectrum of clinical presentation ranging from subclinical abnormalities to acute respiratory failure. Histopathologically, the hallmark features of thoracic involvement by RD are inflammatory, targeting one or more lung compartments. The reactions range from acute to chronic, with remodeling by fibrosis being a common result. Although the inflammatory findings are often nonspecific, certain reactions or anatomic distributions may favor one RD over another, and occasionally, a distinctive histopathology may be present (eg, rheumatoid nodules). Three diagnostic dilemmas are encountered in patients with RD who develop diffuse lung disease: 1) opportunistic infection in the immunocompromised host, 2) drug toxicity related to the medications used to treat the systemic disease, and 3) manifestations of the patient's known systemic disease in lung and pleura. To confidently address the latter, the 5 major RDs are presented here, with their most common pleuropulmonary pathologic manifestations, accompanied by brief clinical and radiologic correlations.
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Affiliation(s)
- Frank Schneider
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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Haydour Q, Wells MA, McCoy SS, Nelsen E, Escalante P, Matteson EL. Anti-synthetase syndrome presenting as cryptogenic organizing pneumonia. Respir Med Case Rep 2012; 6:13-5. [PMID: 26029595 PMCID: PMC3920447 DOI: 10.1016/j.rmcr.2012.08.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2012] [Accepted: 08/23/2012] [Indexed: 11/16/2022] Open
Abstract
Interstitial lung disease (ILD) is a unique group of lung diseases that can be associated with inflammatory conditions, such as polymyositis-dermatomyositis (PM-DM). Presentation of PM-DM with ILD is not uncommon but clinical and radiological features can be similar to other conditions (e.g. atypical pneumonia) and can be challenging to diagnose. Delayed diagnosis of PM-DM can be associated with progression of pulmonary involvement and potentially increase morbidity. We report a patient presenting with pulmonary symptoms who had positive anti-Jo-1 antibodies and cryptogenic organizing pneumonia features on biopsy, which is a rare reported finding.
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Affiliation(s)
- Qusay Haydour
- Department of Internal Medicine, Mayo Clinic College of Medicine, 200 1st St. S.W., Rochester, MN 55905, USA
| | - Melissa A Wells
- Department of Internal Medicine, Mayo Clinic College of Medicine, 200 1st St. S.W., Rochester, MN 55905, USA
| | - Sara S McCoy
- Department of Internal Medicine, Mayo Clinic College of Medicine, 200 1st St. S.W., Rochester, MN 55905, USA
| | - Eric Nelsen
- Department of Internal Medicine, Mayo Clinic College of Medicine, 200 1st St. S.W., Rochester, MN 55905, USA
| | - Patricio Escalante
- Division of Pulmonary and Critical Care, Mayo Clinic College of Medicine, 200 1st St. S.W., Rochester, MN 55905, USA
| | - Eric L Matteson
- Divisions of Rheumatology and Epidemiology, Mayo Clinic College of Medicine, 200 1st St. S.W., Rochester, MN 55905, USA
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STANCIU RALUCA, GUIGUET MARGUERITE, MUSSET LUCILE, TOUITOU DIANE, BEIGELMAN CATHERINE, RIGOLET AUDE, COSTEDOAT-CHALUMEAU NATHALIE, ALLENBACH YVES, HERVIER BAPTISTE, DUBOURG ODILE, MAISONOBE THIERRY, CHARUEL JEANLUC, BEHIN ANTHONY, HERSON SERGE, AMOURA ZAHIR, GRENIER PHILIPPE, BENVENISTE OLIVIER. Antisynthetase Syndrome with Anti-Jo1 Antibodies in 48 Patients: Pulmonary Involvement Predicts Disease-modifying Antirheumatic Drug Use. J Rheumatol 2012; 39:1835-9. [DOI: 10.3899/jrheum.111604] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Objective.To analyze the characteristics, outcomes, and predictive factors of disease-modifying antirheumatic drug (DMARD) use in 48 patients with antisynthetase syndrome [characterized by myositis, interstitial lung disease (ILD), arthritis, Raynaud’s phenomenon (RP), and/or mechanic’s hands] and the presence of anti-histidyl-transfer RNA synthetase (anti-Jo1) autoantibodies.Methods.Forty-eight patients (33 women, 15 men) who were anti-Jo1-positive referred to one center between 1998 and 2008 were analyzed retrospectively.Results.The median age of disease onset was 43 years [interquartile range (IQR) 33–53 yrs]. The median followup was 5 years (IQR 2–8 yrs). At diagnosis, 81% of patients presented with myositis, 80% ILD, 77% arthralgia, 48% RP, and 21% mechanic’s hands. During the followup, 14 patients (29%) had no need for DMARD, while 34 (71%) required DMARD. Patients with mechanic’s hands (p = 0.02) and higher creatine phosphokinase at diagnosis (median 6070 IU/l vs 1121 IU/l; p = 0.002) were more likely to need DMARD. ILD, noted on computed tomography scan by a nonspecific interstitial pneumonia score, was lower in the group of patients with no DMARD need (4 vs 7; p = 0.04). Twenty patients (44%) presented with a pulmonary aggravation (worsening of radiologic score of ILD and/or pulmonary function test results) leading to DMARD use. Nonspecific interstitial pneumonia score (7 vs 5; p = 0.05) and total lung volume (57.5% vs 70%; p = 0.02) values predicted pulmonary aggravation.Conclusion.Our study outlines the burden of chest involvement for the prognosis of antisynthetase syndrome in terms of patients’ requirement for DMARD therapy.
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Sem M, Lund MB, Molberg O. Long-term outcome of lung transplantation in a patient with the anti-synthetase syndrome. Scand J Rheumatol 2011; 40:327-8. [PMID: 21623666 DOI: 10.3109/03009742.2011.566280] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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