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Molteni M, Pelitti V, Galli M, Di Natale D, Podda G, Squizzato A. Uncommon presentation of systemic capillary leak syndrome: a case report with pulmonary embolism. Intern Emerg Med 2024; 19:1063-1066. [PMID: 38041767 DOI: 10.1007/s11739-023-03479-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Accepted: 11/02/2023] [Indexed: 12/03/2023]
Affiliation(s)
- Matteo Molteni
- Internal Medicine Residency Program, School of Medicine, University of Insubria, Varese, CO, Italy
| | - Valentina Pelitti
- Internal Medicine Residency Program, School of Medicine, University of Insubria, Varese, CO, Italy
| | - Matteo Galli
- Internal Medicine Unit, 'Sant'Anna' Hospital, ASST Lariana, Como, Italy
| | - Davide Di Natale
- Thoracic Surgery Unit, 'Circolo e Fondazione Macchi' Hospital, ASST Sette Laghi, Varese, Italy
| | - Gianmarco Podda
- Internal Medicine Unit, 'San Paolo' Hospital, University of Milan, Milan, Italy
| | - Alessandro Squizzato
- Internal Medicine Unit, 'Sant'Anna' Hospital, ASST Lariana, Como, Italy.
- Research Center on Thromboembolic Disorders and Antithrombotic Therapies, University of Insubria, Varese, CO, Italy.
- U.O.C. Medicina Generale, Ospedale Sant'Anna-ASST Lariana, Via Ravona, 20, 22042, San Fermo Della Battaglia, CO, Italy.
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Ablooglu AJ, Chen WS, Xie Z, Desai A, Paul S, Lack JB, Scott LA, Eisch AR, Dudek AZ, Parikh SM, Druey KM. Intrinsic endothelial hyperresponsiveness to inflammatory mediators drives acute episodes in models of Clarkson disease. J Clin Invest 2024; 134:e169137. [PMID: 38502192 DOI: 10.1172/jci169137] [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: 01/26/2023] [Accepted: 03/08/2024] [Indexed: 03/21/2024] Open
Abstract
Clarkson disease, or monoclonal gammopathy-associated idiopathic systemic capillary leak syndrome (ISCLS), is a rare, relapsing-remitting disorder featuring the abrupt extravasation of fluids and proteins into peripheral tissues, which in turn leads to hypotensive shock, severe hemoconcentration, and hypoalbuminemia. The specific leakage factor(s) and pathways in ISCLS are unknown, and there is no effective treatment for acute flares. Here, we characterize an autonomous vascular endothelial defect in ISCLS that was recapitulated in patient-derived endothelial cells (ECs) in culture and in a mouse model of disease. ISCLS-derived ECs were functionally hyperresponsive to permeability-inducing factors like VEGF and histamine, in part due to increased endothelial nitric oxide synthase (eNOS) activity. eNOS blockade by administration of N(γ)-nitro-l-arginine methyl ester (l-NAME) ameliorated vascular leakage in an SJL/J mouse model of ISCLS induced by histamine or VEGF challenge. eNOS mislocalization and decreased protein phosphatase 2A (PP2A) expression may contribute to eNOS hyperactivation in ISCLS-derived ECs. Our findings provide mechanistic insights into microvascular barrier dysfunction in ISCLS and highlight a potential therapeutic approach.
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Affiliation(s)
- Ararat J Ablooglu
- Lung and Vascular Inflammation Section, Laboratory of Allergic Diseases, and
| | - Wei-Sheng Chen
- Lung and Vascular Inflammation Section, Laboratory of Allergic Diseases, and
| | - Zhihui Xie
- Lung and Vascular Inflammation Section, Laboratory of Allergic Diseases, and
| | - Abhishek Desai
- Lung and Vascular Inflammation Section, Laboratory of Allergic Diseases, and
| | - Subrata Paul
- Integrative Data Sciences Section, National Institute of Allergy and Infectious Diseases (NIAID), NIH, Bethesda, Maryland, USA
| | - Justin B Lack
- Integrative Data Sciences Section, National Institute of Allergy and Infectious Diseases (NIAID), NIH, Bethesda, Maryland, USA
| | - Linda A Scott
- Lung and Vascular Inflammation Section, Laboratory of Allergic Diseases, and
| | - A Robin Eisch
- Lung and Vascular Inflammation Section, Laboratory of Allergic Diseases, and
| | - Arkadiusz Z Dudek
- Division of Medical Oncology, Mayo Clinic, Rochester, Minnesota, USA
| | - Samir M Parikh
- Division of Nephrology, Departments of Internal Medicine and Pharmacology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Kirk M Druey
- Lung and Vascular Inflammation Section, Laboratory of Allergic Diseases, and
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3
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Liu J, Gao YQ, Fu W. Ultrasound findings and specific intrinsic blood volume expansion therapy for neonatal capillary leak syndrome: report from a multicenter prospective self-control study. Eur J Med Res 2024; 29:150. [PMID: 38429824 PMCID: PMC10908005 DOI: 10.1186/s40001-024-01738-2] [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: 10/05/2023] [Accepted: 02/21/2024] [Indexed: 03/03/2024] Open
Abstract
OBJECTIVE Capillary leak syndrome (CLS) is characterized by severe systemic edema without specific treatment, resulting in a high mortality rate. This study investigated whether there is organ edema in neonatal CLS patients and specific treatment strategies to improve patient prognosis. METHODS Thirty-seven newborns diagnosed with CLS were included in this study. (1) Routine point-of-care ultrasound (POCUS) was used to identify whether the patients had visceral edema or fluid collection. (2) All patients were treated with 3% NaCl intravenously, and the clinical manifestations, laboratory indices and outcomes were compared before and after treatment. RESULTS (1) Diffuse severe edema was found in 92.0% of the patients. (2) The POCUS examination revealed that CLS patients exhibited significant visceral edema in addition to diffuse severe edema, which included pulmonary edema in 67.6%, cerebral edema in 37.8%, severe intestinal edema in 24.3%, severe myocardial edema in 8.1%, pericardial effusion in 5.4%, pleural effusion in 29.7% and peritoneal effusion in 18.9%. Two patients (5.45%) had only myocardial edema without other manifestations. (3) Before and after the intravenous injection of 3% NaCl, there were no significant differences in the serum sodium or potassium levels of CLS patients, while the hemoglobin and hematocrit levels were significantly lower after treatment (p < 0.01). Her plasma ALB concentration and arterial pressure returned to normal levels after the treatment was completed. (4) All the patients survived, and no side effects or complications were observed during or after treatment with 3% NaCl. CONCLUSIONS (1) In addition to diffuse severe edema, visceral edema and effusion are common and important clinical manifestations of neonatal CLS and need to be detected by routine POCUS. (2) The intravenous injection of 3% NaCl is a safe, effective and specific treatment strategy for neonatal CLS, with a survival rate of 100% and no adverse effects.
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Affiliation(s)
- Jing Liu
- Department of Neonatology and NICU, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing, 100026, China.
- Beijing Maternal and Child Health Care Hospital, Beijing, 100026, China.
- Department of Neonatology and NICU, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, 100043, China.
- Department of Neonatology and NICU, Beijing Chao-Yang District Maternal and Child Health Care Hospital, Beijing, 100026, China.
| | - Yue-Qiao Gao
- Department of Neonatology and NICU, Beijing Chao-Yang District Maternal and Child Health Care Hospital, Beijing, 100026, China
| | - Wei Fu
- Department of Neonatology and NICU, Beijing Chao-Yang District Maternal and Child Health Care Hospital, Beijing, 100026, China
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Ablooglu AJ, Desai A, Yoo JS, Park CH, Lee EA, Kim BY, Park H, Lee YA, Shim SR, Lee WS, Druey KM. A ligand-independent Tie2-activating antibody reduces vascular leakage in models of Clarkson disease. SCIENCE ADVANCES 2023; 9:eadi1394. [PMID: 37976351 PMCID: PMC10656064 DOI: 10.1126/sciadv.adi1394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Accepted: 10/18/2023] [Indexed: 11/19/2023]
Abstract
Vascular dysfunction resulting from endothelial hyperpermeability is a common and important feature of critical illness due to sepsis, trauma, and other conditions associated with acute systemic inflammation. Clarkson disease [monoclonal gammopathy-associated idiopathic systemic capillary leak syndrome (ISCLS)] is a rare, orphan disorder marked by spontaneous and recurrent episodes of hypotensive shock and peripheral edema due to widespread vascular leakage in peripheral tissues. Mortality from acute flares approaches 30% due to lack of effective therapies. We evaluated a monoclonal antibody (4E2) specific for the endothelial receptor tyrosine kinase Tie2 in ISCLS models. 4E2 activated Tie2 in ISCLS patient-derived endothelial cells and reduced baseline and proinflammatory mediator-induced barrier dysfunction. 4E2 also reduced mortality and/or vascular leakage associated with systemic histamine challenge or influenza infection in the SJL/J mouse model of ISCLS. These findings support a critical role for Tie2 dysregulation in ISCLS and highlight a viable therapeutic approach to this catastrophic disorder.
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Affiliation(s)
- Ararat J. Ablooglu
- Lung and Vascular Inflammation Section, Laboratory of Allergic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD 20892, USA
| | - Abhishek Desai
- Lung and Vascular Inflammation Section, Laboratory of Allergic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD 20892, USA
| | - Jin-San Yoo
- R&D Center, PharmAbcine Inc., 70, Yuseong-daero 1689 beon-gil, Yuseong-gu, Daejeon, Republic of Korea
| | - Cheon Ho Park
- R&D Center, PharmAbcine Inc., 70, Yuseong-daero 1689 beon-gil, Yuseong-gu, Daejeon, Republic of Korea
| | - Eun-Ah Lee
- R&D Center, PharmAbcine Inc., 70, Yuseong-daero 1689 beon-gil, Yuseong-gu, Daejeon, Republic of Korea
| | - Bu Yeon Kim
- R&D Center, PharmAbcine Inc., 70, Yuseong-daero 1689 beon-gil, Yuseong-gu, Daejeon, Republic of Korea
| | - Hyunsun Park
- R&D Center, PharmAbcine Inc., 70, Yuseong-daero 1689 beon-gil, Yuseong-gu, Daejeon, Republic of Korea
| | - Young Ae Lee
- R&D Center, PharmAbcine Inc., 70, Yuseong-daero 1689 beon-gil, Yuseong-gu, Daejeon, Republic of Korea
| | - Sang Ryeol Shim
- R&D Center, PharmAbcine Inc., 70, Yuseong-daero 1689 beon-gil, Yuseong-gu, Daejeon, Republic of Korea
| | - Weon Sup Lee
- R&D Center, PharmAbcine Inc., 70, Yuseong-daero 1689 beon-gil, Yuseong-gu, Daejeon, Republic of Korea
| | - Kirk M. Druey
- Lung and Vascular Inflammation Section, Laboratory of Allergic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD 20892, USA
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5
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Xie Z, Børset M, Svéen K, Bøe OW, Chan EC, Lack JB, Hornick KM, Verlicchi F, Eisch AR, Melchio R, Dudek AZ, Druey KM. Markers of endothelial glycocalyx dysfunction in Clarkson disease. Lab Invest 2022; 20:380. [PMID: 36038904 PMCID: PMC9421105 DOI: 10.1186/s12967-022-03587-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Accepted: 08/12/2022] [Indexed: 11/10/2022]
Abstract
BACKGROUND Clarkson disease (monoclonal gammopathy-associated idiopathic systemic capillary leak syndrome, ISCLS) is a rare idiopathic condition marked by transient, relapsing-remitting episodes of systemic microvascular hyper-permeability, which liberates plasma fluid and macromolecules into the peripheral tissues. This pathology manifests clinically as the abrupt onset of hypotensive shock, hemoconcentration, and hypoalbuminemia. METHODS We analysed endothelial glycocalyx (eGCX)-related markers in plasma from patients with ISCLS during acute disease flares and convalescence by ELISA and comprehensive proteomic profiling. We evaluated eGCX-related components and gene expression in cultured endothelial cells using RNA-sequencing, real-time PCR, and fluorescence staining. RESULTS Serum levels of eGCX-related core components including hyaluronic acid (HA) and the core proteoglycan soluble syndecan-1 (sCD138) were elevated at baseline and during acute ISCLS flares. Serial measurements demonstrated that sCD138 levels peaked during the recovery (post-leak) phase of the illness. Proteomic analysis of matched acute and convalescent ISCLS plasma revealed increased abundance of eGCX-related proteins, including glypicans, thrombospondin-1 (TSP-1), and eGCX-degrading enzymes in acute compared to remission plasma. Abundance of endothelial cell damage markers did not differ in acute and baseline plasma. Expression of several eGCX-related genes and surface carbohydrate content in endothelial cells from patients with ISCLS did not differ significantly from that observed in healthy control cells. CONCLUSIONS eGCX dysfunction, but not endothelial injury, may contribute to clinical symptoms of acute ISCLS. Serum levels of of eGCX components including sCD138 may be measured during acute episodes of ISCLS to monitor clinical status and therapeutic responses.
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Affiliation(s)
- Zhihui Xie
- Lung and Vascular Inflammation Section, Laboratory of Allergic Diseases, National, Institute of Allergy and Infectious Diseases/National Institutes of Health, (NIAID/NIH), 10 Center Drive, Room 11N238A, Bethesda, MD, 20892, USA
| | - Magne Børset
- Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway.,Department of Immunology and Transfusion Medicine, St. Olav's University, Hospital, Trondheim, Norway
| | - Kjell Svéen
- Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - Ole Wilhelm Bøe
- Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - Eunice C Chan
- Lung and Vascular Inflammation Section, Laboratory of Allergic Diseases, National, Institute of Allergy and Infectious Diseases/National Institutes of Health, (NIAID/NIH), 10 Center Drive, Room 11N238A, Bethesda, MD, 20892, USA
| | - Justin B Lack
- NIAID Collaborative Bioinformatics Resource, NIAID/NIH, Health, Bethesda, MD, 20892, USA
| | - Katherine M Hornick
- NIAID Collaborative Bioinformatics Resource, NIAID/NIH, Health, Bethesda, MD, 20892, USA
| | - Franco Verlicchi
- Transfusion Medicine Faenza-Lugo, Transfusion Service Ravenna, Romagna Health Unit, Ravenna, Italy
| | - A Robin Eisch
- Lung and Vascular Inflammation Section, Laboratory of Allergic Diseases, National, Institute of Allergy and Infectious Diseases/National Institutes of Health, (NIAID/NIH), 10 Center Drive, Room 11N238A, Bethesda, MD, 20892, USA
| | - Remo Melchio
- Department of Internal Medicine, Santa Croce E Carle' Hospital, Via Michele Coppino 26, Cuneo, Italy
| | | | - Kirk M Druey
- Lung and Vascular Inflammation Section, Laboratory of Allergic Diseases, National, Institute of Allergy and Infectious Diseases/National Institutes of Health, (NIAID/NIH), 10 Center Drive, Room 11N238A, Bethesda, MD, 20892, USA.
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6
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Dogan S, Kıvrak-Salim D, Ureyen I, Iltar U, Kurtoğlu E. Systemic capillary leakage syndrome. Int J Gynecol Cancer 2021; 31:1602-1605. [PMID: 34872940 DOI: 10.1136/ijgc-2021-003034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/15/2021] [Indexed: 11/04/2022] Open
Affiliation(s)
- Selen Dogan
- Department of Gynecologic Oncology, Akdeniz University Medical Faculty, Antalya, Turkey
| | - Derya Kıvrak-Salim
- Department of Medical Oncology, Antalya Training and Research Hospital, Antalya, Turkey
| | - Isin Ureyen
- Department of Gynecologic Oncology, Antalya Training and Research Hospital, Antalya, Turkey
| | - Utku Iltar
- Department of Hematology, Antalya Training and Research Hospital, Antalya, Turkey
| | - Erdal Kurtoğlu
- Department of Hematology, Antalya Training and Research Hospital, Antalya, Turkey
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7
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New-Onset Systemic Capillary Leak Syndrome in an Adult Patient with COVID-19. Case Rep Crit Care 2021; 2021:8098942. [PMID: 34631174 PMCID: PMC8497160 DOI: 10.1155/2021/8098942] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Accepted: 09/15/2021] [Indexed: 01/21/2023] Open
Abstract
Systemic capillary leak syndrome (SCLS) is a rare disorder manifesting as shock, hemoconcentration, and hypoalbuminemia, which may be either idiopathic or secondary to an underlying disease process. We report a case of an adult with COVID-19 infection associated with new onset SCLS. Our case joins only two other cases of new SCLS associated with COVID-19 infection reported in the literature. The clinical and laboratory findings in this case are distinct from findings seen in COVID-19 cytokine storm syndrome. Whether our therapeutic approach was efficacious is unknown. Further research into causes and therapies for these syndromes is urgently indicated.
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8
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Jakobsson AS, Strange DG, Møller K, Kondziella D. Clinical Reasoning: A Middle-Aged Man With a History of Muscle Pain Presenting With Progressive Leukoencephalopathy and Subsequent Coma. Neurology 2021; 97:910-915. [PMID: 34261786 DOI: 10.1212/wnl.0000000000012486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Anna Sofie Jakobsson
- Department of Neurology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Ditte Gry Strange
- Department of Anesthesiology, Bispebjerg, Copenhagen University Hospital, Copenhagen, Denmark
| | - Kirsten Møller
- Department of Neuroanesthesiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Daniel Kondziella
- Department of Neurology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark .,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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9
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Wu MA, Fossali T, Pandolfi L, Carsana L, Ottolina D, Frangipane V, Rech R, Tosoni A, Lopez G, Agarossi A, Cogliati C, Meloni F, Marchini B, Nebuloni M, Catena E, Colombo R. Hypoalbuminemia in COVID-19: assessing the hypothesis for underlying pulmonary capillary leakage. J Intern Med 2021; 289:861-872. [PMID: 33411411 DOI: 10.1111/joim.13208] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 10/03/2020] [Accepted: 10/22/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Since the first observations of patients with COVID-19, significant hypoalbuminaemia was detected. Its causes have not been investigated yet. OBJECTIVE We hypothesized that pulmonary capillary leakage affects the severity of respiratory failure, causing a shift of fluids and proteins through the epithelial-endothelial barrier. METHODS One hundred seventy-four COVID-19 patients with respiratory symptoms, 92 admitted to the intermediate medicine ward (IMW) and 82 to the intensive care unit (ICU) at Luigi Sacco Hospital in Milan, were studied. RESULTS Baseline characteristics at admission were considered. Proteins, interleukin 8 (IL-8) and interleukin 10 (IL-10) in bronchoalveolar lavage fluid (BALF) were analysed in 26 ICU patients. In addition, ten autopsy ultrastructural lung studies were performed in patients with COVID-19 and compared with postmortem findings in a control group (bacterial pneumonia-ARDS and H1N1-ARDS). ICU patients had lower serum albumin than IMW patients [20 (18-23) vs 28 (24-33) g L-1 , P < 0.001]. Serum albumin was lower in more compromised groups (lower PaO2 -to-FiO2 ratio and worst chest X-ray findings) and was associated with 30 days of probability of survival. Protein concentration was correlated with IL-8 and IL-10 levels in BALF. Electron microscopy examinations of eight out of ten COVID-19 lung tissues showed loosening of junctional complexes, quantitatively more pronounced than in controls, and direct viral infection of type 2 pneumocytes and endothelial cells. CONCLUSION Hypoalbuminaemia may serve as severity marker of epithelial-endothelial damage in patients with COVID-19. There are clues that pulmonary capillary leak syndrome plays a key role in the pathogenesis of COVID-19 and might be a potential therapeutic target.
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Affiliation(s)
- M A Wu
- From the, Division of Internal Medicine, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, University of Milan, Milan, Italy
| | - T Fossali
- Division of Anesthesiology and Intensive Care, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, University of Milan, Milan, Italy
| | - L Pandolfi
- Research Laboratory of Lung Diseases, Section of Cell Biology, IRCCS Policlinico San Matteo Foundation, Pavia, Italy
| | - L Carsana
- Pathology Unit, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, University of Milan, Milan, Italy
| | - D Ottolina
- Division of Anesthesiology and Intensive Care, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, University of Milan, Milan, Italy
| | - V Frangipane
- Research Laboratory of Lung Diseases, Section of Cell Biology, IRCCS Policlinico San Matteo Foundation, Pavia, Italy
| | - R Rech
- Division of Anesthesiology and Intensive Care, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, University of Milan, Milan, Italy
| | - A Tosoni
- Pathology Unit, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, University of Milan, Milan, Italy
| | - G Lopez
- Pathology Unit, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, University of Milan, Milan, Italy
| | - A Agarossi
- Division of Anesthesiology and Intensive Care, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, University of Milan, Milan, Italy
| | - C Cogliati
- From the, Division of Internal Medicine, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, University of Milan, Milan, Italy
| | - F Meloni
- Department of Respiratory Diseases, IRCCS Policlinico San Matteo Foundation, Pavia, Italy.,Department of Internal Medicine, Section of Pneumology, University of Pavia, Pavia, Italy
| | - B Marchini
- Department of Biomedical and Clinical Sciences, University of Milan, Milan, Italy
| | - M Nebuloni
- Pathology Unit, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, University of Milan, Milan, Italy.,Department of Biomedical and Clinical Sciences, University of Milan, Milan, Italy
| | - E Catena
- Division of Anesthesiology and Intensive Care, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, University of Milan, Milan, Italy
| | - R Colombo
- Division of Anesthesiology and Intensive Care, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, University of Milan, Milan, Italy
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10
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Vedala K, Desikan SP, McClain C, Jacob D, Desikan R. Capillary Leak Syndrome From Rituximab Therapy of Lymphoma. J Investig Med High Impact Case Rep 2021; 8:2324709620942372. [PMID: 32666835 PMCID: PMC7364833 DOI: 10.1177/2324709620942372] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Capillary leak syndrome (CLS) is characterized by plasma extravasation into the interstitium with resultant hypotension, anasarca, hemoconcentration, and hypoalbuminemia in the absence of albuminuria. Initially reported in Clarkson’s disease (systemic capillary leak syndrome), CLS has been observed in multiple disease settings, the most common being sepsis. In oncology, CLS has been reported more often as a complication from therapy, and less often from malignancy. In this case study, we documented clinical manifestation, laboratory features, and radiological findings of CLS from rituximab therapy when employed in combination with a multi-agent chemotherapy regimen (EPOCH-R). Differentiating drug-induced CLS from sepsis, which presents with the same clinical features, is important in avoiding further exposure to rituximab, which could be fatal to the patient.
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Affiliation(s)
| | | | | | - Diana Jacob
- White River Health Systems, Batesville, AR, USA
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11
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Momen SE, Diaz-Cano S, Walsh S, Creamer D. Discriminating minor and major forms of drug reaction with eosinophilia and systemic symptoms: Facial edema aligns to the severe phenotype. J Am Acad Dermatol 2021; 85:645-652. [PMID: 33872719 DOI: 10.1016/j.jaad.2021.04.020] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 03/08/2021] [Accepted: 04/02/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND Drug reaction with eosinophilia and systemic symptoms (DRESS) is a cutaneous and systemic drug allergy disorder. Patients exist on a severity spectrum, with some experiencing a mild form of the disorder that fails to meet the Registry of Severe Cutaneous Adverse Reactions (SCAR) to Drugs diagnostic criteria for DRESS. OBJECTIVE We sought to determine whether there were any cutaneous or dermatopathologic features that discriminate between the mild form of DRESS (DRESS minor) and the severe phenotype (DRESS major). METHODS Hospitalized patients from a single center with a diagnosis of DRESS were prospectively recruited over a 7-year period. Clinical and dermatopathologic features were analyzed to discriminate between DRESS minor and DRESS major. RESULTS Forty-five patients were included, of whom 19 had a Registry of Severe Cutaneous Adverse Reactions (SCAR) to Drugs score of ≤3 (DRESS minor) and 26 had a score of ≥4 (DRESS major). The mean latency period (P = .001), fever >38.5 °C (P = .001), and a reaction lasting >15 days (P = .010) discriminated DRESS major from DRESS minor. Facial edema was the sole discerning cutaneous feature (P = .025). Discriminating histopathologic features included basal squamatization (P = .005), dermal red blood cell extravasation (P = .009), and interface inflammation (P = .005). CONCLUSION We propose a new classification system-DRESS minor-to distinguish the milder illness from the severe form, DRESS major. Facial edema and certain histopathologic features can help discriminate between major and minor versions.
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Affiliation(s)
- Sophie Elizabeth Momen
- Department of Dermatology, King's College Hospital, Denmark Hill, London, United Kingdom.
| | - Salvador Diaz-Cano
- Department of Histopathology, King's College Hospital, Denmark Hill, London, United Kingdom
| | - Sarah Walsh
- Department of Dermatology, King's College Hospital, Denmark Hill, London, United Kingdom
| | - Daniel Creamer
- Department of Dermatology, King's College Hospital, Denmark Hill, London, United Kingdom
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12
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Bichon A, Carvelli J, Bourenne J, Gainnier M, Harlé JR, Schleinitz N. [Idiopathic systemic capillary leak syndrome: 2 cases with misleading presentation]. Rev Med Interne 2021; 42:660-664. [PMID: 33846036 DOI: 10.1016/j.revmed.2021.03.325] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 03/10/2021] [Accepted: 03/21/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Idiopathic systemic capillary leak syndrome (ISCLS) also known as Clarkson syndrome is a rare and sudden life-threatening entity. Three consecutive phases are described. A first non-specific prodromal phase often manifests as "flu-like" symptoms and precedes capillary leak phase with major hypovolemic and distributive shock leading to serious and frequent multiorgan dysfunction syndrome (MODS). Severe hypovolemia contrasts with edema, and hemoconcentration with hypoalbuminemia. ISCLS is characterized by these two clinical and biological paradoxes. Subsequent recovery phase exhibits organ function restoration along with interstitial/intravascular volumes normalization. The latter occurs spontaneously and systematically in patients surviving from leak phase. OBSERVATIONS We report here two ISCLS cases admitted in intensive care unit (ICU) both enhancing initial misdiagnosis possibly lowering prognosis and outcome. Our first 28-year-old female patient was admitted for « polycythemia vera » although hemoconcentration was attributable to hypovolemia. She presented circulatory arrest during the second bloodletting session and complicated with MODS. In and out ICU favorable outcome was noted on intravenous immunoglobulin therapy. A second 57-year-old male patient was admitted in ICU for severe "myositis" (myalgia and rhabdomyolysis) although rectified diagnosis retained compartment syndrome (muscular severe edema following capillary leak). Rapid and refractory hypovolemic shock appeared with subsequent MODS leading to death. CONCLUSION ISCLS pathophysiology remains unknown but certainly implies transitory endothelial dysfunction. Impossibility of randomized controlled trial for this exceptional disease led to based-on-experience therapeutic guidelines implying symptomatic care (cardiac output surveillance, nephroprotection, prudent fluid intake, prudent vasoactive amine use) and specific therapies (intravenous aminophylline during severe flares). Although enhancing controversial and even deleterious effects during the acute phase, polyvalent immunoglobulins are effective for relapse prevention. Syndromic diagnosis is difficult, but its precocious finding constitutes a key-element in better outcome before organ failure.
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Affiliation(s)
- A Bichon
- Service de médecine interne, hôpital de la Timone, AP-HM, 264, rue Saint-Pierre, 13005 Marseille, France; Université d'Aix-Marseille, Marseille, France.
| | - J Carvelli
- Service de réanimation médicale, hôpital de la Timone, AP-HM, Marseille, France; Université d'Aix-Marseille, Marseille, France
| | - J Bourenne
- Service de réanimation médicale, hôpital de la Timone, AP-HM, Marseille, France; Université d'Aix-Marseille, Marseille, France
| | - M Gainnier
- Service de réanimation médicale, hôpital de la Timone, AP-HM, Marseille, France; Université d'Aix-Marseille, Marseille, France
| | - J-R Harlé
- Service de médecine interne, hôpital de la Timone, AP-HM, 264, rue Saint-Pierre, 13005 Marseille, France; Université d'Aix-Marseille, Marseille, France
| | - N Schleinitz
- Service de médecine interne, hôpital de la Timone, AP-HM, 264, rue Saint-Pierre, 13005 Marseille, France; Université d'Aix-Marseille, Marseille, France
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13
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Caldarale F, Giacomelli M, Garrafa E, Tamassia N, Morreale A, Poli P, Timpano S, Baresi G, Zunica F, Cattalini M, Moratto D, Chiarini M, Cannizzo ES, Marchetti G, Cassatella MA, Taddio A, Tommasini A, Badolato R. Plasmacytoid Dendritic Cells Depletion and Elevation of IFN-γ Dependent Chemokines CXCL9 and CXCL10 in Children With Multisystem Inflammatory Syndrome. Front Immunol 2021; 12:654587. [PMID: 33841438 PMCID: PMC8033149 DOI: 10.3389/fimmu.2021.654587] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Accepted: 03/03/2021] [Indexed: 12/22/2022] Open
Abstract
Background SARS-CoV-2 occurs in the majority of children as COVID-19, without symptoms or with a paucisymptomatic respiratory syndrome, but a small proportion of children develop the systemic Multi Inflammatory Syndrome (MIS-C), characterized by persistent fever and systemic hyperinflammation, with some clinical features resembling Kawasaki Disease (KD). Objective With this study we aimed to shed new light on the pathogenesis of these two SARS-CoV-2-related clinical manifestations. Methods We investigated lymphocyte and dendritic cells subsets, chemokine/cytokine profiles and evaluated the neutrophil activity mediators, myeloperoxidase (MPO), and reactive oxygen species (ROS), in 10 children with COVID-19 and 9 with MIS-C at the time of hospital admission. Results Patients with MIS-C showed higher plasma levels of C reactive protein (CRP), MPO, IL-6, and of the pro-inflammatory chemokines CXCL8 and CCL2 than COVID-19 children. In addition, they displayed higher levels of the chemokines CXCL9 and CXCL10, mainly induced by IFN-γ. By contrast, we detected IFN-α in plasma of children with COVID-19, but not in patients with MIS-C. This observation was consistent with the increase of ISG15 and IFIT1 mRNAs in cells of COVID-19 patients, while ISG15 and IFIT1 mRNA were detected in MIS-C at levels comparable to healthy controls. Moreover, quantification of the number of plasmacytoid dendritic cells (pDCs), which constitute the main source of IFN-α, showed profound depletion of this subset in MIS-C, but not in COVID-19. Conclusions Our results show a pattern of immune response which is suggestive of type I interferon activation in COVID-19 children, probably related to a recent interaction with the virus, while in MIS-C the immune response is characterized by elevation of the inflammatory cytokines/chemokines IL-6, CCL2, and CXCL8 and of the chemokines CXCL9 and CXL10, which are markers of an active Th1 type immune response. We believe that these immunological events, together with neutrophil activation, might be crucial in inducing the multisystem and cardiovascular damage observed in MIS-C.
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Affiliation(s)
- Francesca Caldarale
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
- ”Angelo Nocivelli” Institute of Molecular Medicine, University of Brescia, ASST Spedali Civili, Brescia, Italy
| | - Mauro Giacomelli
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
- ”Angelo Nocivelli” Institute of Molecular Medicine, University of Brescia, ASST Spedali Civili, Brescia, Italy
| | - Emirena Garrafa
- Department of Molecular and translational Medicin and Clinical Chemistry Laboratory ASST Spedali Civili, Brescia, Italy
| | - Nicola Tamassia
- Section of General Pathology, Department of Medicine, University of Verona, Verona, Italy
| | - Alessia Morreale
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
- ”Angelo Nocivelli” Institute of Molecular Medicine, University of Brescia, ASST Spedali Civili, Brescia, Italy
| | - Piercarlo Poli
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
- ”Angelo Nocivelli” Institute of Molecular Medicine, University of Brescia, ASST Spedali Civili, Brescia, Italy
| | - Silviana Timpano
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
- ”Angelo Nocivelli” Institute of Molecular Medicine, University of Brescia, ASST Spedali Civili, Brescia, Italy
| | - Giulia Baresi
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
- ”Angelo Nocivelli” Institute of Molecular Medicine, University of Brescia, ASST Spedali Civili, Brescia, Italy
| | - Fiammetta Zunica
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
- ”Angelo Nocivelli” Institute of Molecular Medicine, University of Brescia, ASST Spedali Civili, Brescia, Italy
| | - Marco Cattalini
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
- ”Angelo Nocivelli” Institute of Molecular Medicine, University of Brescia, ASST Spedali Civili, Brescia, Italy
| | - Daniele Moratto
- Flow Cytometry & Clinical Chemistry Laboratory, ASST Spedali Civili, Brescia, Italy
| | - Marco Chiarini
- Flow Cytometry & Clinical Chemistry Laboratory, ASST Spedali Civili, Brescia, Italy
| | - Elvira Stefania Cannizzo
- Clinic of Infectious Diseases, Department of Health Sciences, ASST Santi Paolo e Carlo, University of Milan, Milan, Italy
| | - Giulia Marchetti
- Clinic of Infectious Diseases, Department of Health Sciences, ASST Santi Paolo e Carlo, University of Milan, Milan, Italy
| | | | - Andrea Taddio
- Pediatric Department, IRCCS Burlo Garofolo, Trieste, Italy
| | | | - Raffaele Badolato
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
- ”Angelo Nocivelli” Institute of Molecular Medicine, University of Brescia, ASST Spedali Civili, Brescia, Italy
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14
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Oh EH, Rhee JK, Shin JH, Cho JW, Kim DS, Park JY, Choi SY, Choi KD, Choi JH. Neutrophil-mediated immune response as a possible mechanism of acute unilateral vestibulopathy. J Vestib Res 2020; 30:363-374. [PMID: 33285659 DOI: 10.3233/ves-200044] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE This study aimed to investigate the underlying pathogenesis of acute unilateral vestibulopathy (AUV) using gene expression profiling combined with bioinformatics analysis. METHODS Total RNA was extracted from the peripheral blood mononuclear cells of ten AUV patients in the acute phase and from ten controls. The differentially expressed genes (DEGs) between these two groups were screened using microarray analysis with the cut-off criteria (|fold changes| > 1.5 and p-value < 0.05). Functional enrichment analysis of DEGs was performed using Gene Ontology and Kyoto Encyclopedia of Genes and Genomes pathway analysis, and the protein-protein interaction (PPI) network was constructed using the STRING (Search Tool for the Retrieval of Interacting Genes) database. RESULTS There were 57 DEGs (50 up-regulated and 7 down-regulated) identified in the AUV group. Functional enrichment analysis showed that most of the up-regulated DEGs were significantly enriched in terms related to the neutrophil-mediated immune pathway. From the PPI network, the top ten hub genes were extracted by calculating four topological properties, and most of them were related to the innate immune system, inflammatory processes and vascular disorders. The complete blood count tests showed that the neutrophil-to-lymphocyte ratio was significantly higher in the 72 AUV patients than in the age-matched controls (2.93±2.25 vs 1.54±0.61, p < 0.001). CONCLUSIONS This study showed that the neutrophil-mediated immune pathway may contribute to the development of AUV by mediating inflammatory and thrombotic changes in the vestibular organ.
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Affiliation(s)
- Eun Hye Oh
- Department of Neurology, Pusan National University School of Medicine, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Je-Keun Rhee
- School of Systems Biomedical Science, Soongsil University, Seoul, Korea
| | - Jin-Hong Shin
- Department of Neurology, Pusan National University School of Medicine, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Jae Wook Cho
- Department of Neurology, Pusan National University School of Medicine, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Dae-Seong Kim
- Department of Neurology, Pusan National University School of Medicine, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Ji-Yun Park
- Department of Neurology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Seo Young Choi
- Department of Neurology, Pusan National University Hospital, Pusan National University School of Medicine and Biomedical Research Institute, Busan, Korea
| | - Kwang-Dong Choi
- Department of Neurology, Pusan National University Hospital, Pusan National University School of Medicine and Biomedical Research Institute, Busan, Korea
| | - Jae-Hwan Choi
- Department of Neurology, Pusan National University School of Medicine, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea
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15
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Vadas P. Hydrochlorothiazide-induced systemic capillary leak. Am J Emerg Med 2020; 38:1299.e1-1299.e2. [PMID: 32139213 DOI: 10.1016/j.ajem.2020.02.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Accepted: 02/16/2020] [Indexed: 11/19/2022] Open
Abstract
Hypersensitivity reactions to drugs may cause very rapid physiologic derangements that can be fatal in the absence of adequate compensatory mechanisms or definitive treatment. For the most part, adverse drug reactions that progress over the course of minutes are mediated either by mast cell or complement activation. If a patient survives the acute event, appropriate long-term management requires the identification and future avoidance of the inciting drug. Here, we describe a patient who experienced two life-threatening multisystem reactions with cardiopulmonary compromise minutes after taking hydrochlorothiazide (HCTZ). The reactions were associated with systemic vascular leak resulting in hypotension and non-cardiogenic pulmonary edema.
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Affiliation(s)
- Peter Vadas
- Division of Clinical Immunology and Allergy, Department of Medicine, St. Michael's Hospital, University of Toronto, Canada.
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16
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Xie Z, Kuhns DB, Gu X, Otu HH, Libermann TA, Gallin JI, Parikh SM, Druey KM. Neutrophil activation in systemic capillary leak syndrome (Clarkson disease). J Cell Mol Med 2019; 23:5119-5127. [PMID: 31210423 PMCID: PMC6653644 DOI: 10.1111/jcmm.14381] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Revised: 04/04/2019] [Accepted: 04/29/2019] [Indexed: 11/30/2022] Open
Abstract
Systemic capillary leak syndrome (SCLS; Clarkson disease) is a rare orphan disorder characterized by transient yet recurrent episodes of hypotension and peripheral oedema due to diffuse vascular leakage of fluids and proteins into soft tissues. Humoral mediators, cellular responses and genetic features accounting for the clinical phenotype of SCLS are virtually unknown. Here, we searched for factors altered in acute SCLS plasma relative to matched convalescent samples using multiplexed aptamer‐based proteomic screening. Relative amounts of 612 proteins were changed greater than twofold and 81 proteins were changed at least threefold. Among the most enriched proteins in acute SCLS plasma were neutrophil granule components including bactericidal permeability inducing protein, myeloperoxidase and matrix metalloproteinase 8. Neutrophils isolated from blood of subjects with SCLS or healthy controls responded similarly to routine pro‐inflammatory mediators. However, acute SCLS sera activated neutrophils relative to remission sera. Activated neutrophil supernatants increased permeability of endothelial cells from both controls and SCLS subjects equivalently. Our results suggest systemic neutrophil degranulation during SCLS acute flares, which may contribute to the clinical manifestations of acute vascular leak.
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Affiliation(s)
- Zhihui Xie
- Lung and Vascular Inflammation Section, Laboratory of Allergic Diseases, NIAID/NIH, Bethesda, Maryland
| | - Douglas B Kuhns
- Neutrophil Monitoring Laboratory, NCI/NIH, Frederick, Maryland
| | - Xuesong Gu
- Genomics, Proteomics, Bioinformatics and Systems Biology Center, Division of Interdisciplinary Medicine and Biotechnology, Beth Israel Deaconess Medical Center & Harvard Medical School, Boston, Massachusetts
| | - Hasan H Otu
- Department of Electrical and Computer Engineering, University of Nebraska, Lincoln, Nebraska
| | - Towia A Libermann
- Genomics, Proteomics, Bioinformatics and Systems Biology Center, Division of Interdisciplinary Medicine and Biotechnology, Beth Israel Deaconess Medical Center & Harvard Medical School, Boston, Massachusetts
| | - John I Gallin
- Clinical Pathophysiology Section, NIAID/NIH, Bethesda, Maryland
| | - Samir M Parikh
- Department of Medicine, Division of Nephrology and Center for Vascular Biology Research, Beth Israel Deaconess Medical Center & Harvard Medical School, Boston, Massachusetts
| | - Kirk M Druey
- Lung and Vascular Inflammation Section, Laboratory of Allergic Diseases, NIAID/NIH, Bethesda, Maryland
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