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Leavis HL, van Daele PLA, Mulders-Manders C, Michels R, Rutgers A, Legger E, Bijl M, Hak EA, Lam-Tse WK, Bonte-Mineur F, Fretter P, Simon A, van Paassen P, van der Goes MC, Flendrie M, Vercoutere W, van Lieshout AWT, Leek A, Vastert SJ, Tas SW. Management of adult-onset Still's disease: evidence- and consensus-based recommendations by experts. Rheumatology (Oxford) 2024; 63:1656-1663. [PMID: 37669122 PMCID: PMC11147545 DOI: 10.1093/rheumatology/kead461] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 08/04/2023] [Accepted: 08/16/2023] [Indexed: 09/07/2023] Open
Abstract
OBJECTIVES Adult-onset Still's disease (AOSD) is a rare condition characterized by fevers, rash, and arthralgia/arthritis; most doctors treating AOSD in the Netherlands treat <5 patients per year. Currently, there is no internationally accepted treatment guideline for AOSD. The objectives of this study were to conduct a Delphi panel aimed at reaching consensus about diagnostic and treatment strategies for patients with AOSD and to use the outcomes as a basis for a treatment algorithm. METHODS The Delphi panel brought together 18 AOSD experts: rheumatologists, internists and paediatricians. The Delphi process consisted of three rounds. In the first two rounds, online lists of questions and statements were completed. In the third round, final statements were discussed during a virtual meeting and a final vote took place. Consensus threshold was set at 80%. Two targeted literature searches were performed identifying the level of evidence of the consensus-based statements. RESULTS Consensus was reached on 29 statements, including statements related to diagnosis and diagnostic tests, definition of response and remission, the therapy, the use of methotrexate and tapering of treatment. The panel consented on reduction of the use of glucocorticoids to avoid side effects, and preferred the use of biologics over conventional treatment. The role of IL-1 and IL-6 blocking agents was considered important in the treatment of AOSD. CONCLUSION In this Delphi panel, a high level of consensus was achieved on recommendations for diagnosis and therapy of AOSD that can serve as a basis for a treatment guideline.
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Affiliation(s)
- Helen L Leavis
- Department of Rheumatology and Clinical Immunology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Paul L A van Daele
- Department of Immunology, Erasmus Medical Center, Rotterdam, The Netherlands
| | | | | | - Abraham Rutgers
- Department of Rheumatology and Clinical Immunology, University Medical Center Groningen, Groningen, The Netherlands
| | - Elizabeth Legger
- Department of Pediatric Rheumatology, University Medical Center Groningen, Groningen, The Netherlands
| | - Marc Bijl
- Department of Rheumatology and Clinical Immunology, Martini Hospital, Groningen, The Netherlands
| | - Elisabeth A Hak
- Department of Rheumatology and Clinical Immunology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Wai-Kwan Lam-Tse
- Department Rheumatology, Franciscus Hospital, Rotterdam, The Netherlands
| | - Femke Bonte-Mineur
- Department of Rheumatology and Clinical Immunology, Maasstad Hospital, Rotterdam, The Netherlands
| | - Peter Fretter
- Department of Rheumatology, Treant Hospitals, Emmen/Hoogeveen/Stadskanaal, The Netherlands
| | - Anna Simon
- Department of Internal medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Pieter van Paassen
- Department of Nephrology and Clinical Immunology, Maastricht University Medical Center, Maastricht, The Netherlands
| | | | - Marcel Flendrie
- Department of Rheumatology, Maartenskliniek, Nijmegen, The Netherlands
| | - Ward Vercoutere
- Department of Rheumatology, Reumazorg Zuid-West Nederland, Goes-Terneuzen-Oostburg, The Netherlands
| | | | - Arjen Leek
- Department of Pediatrics, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Sebastiaan J Vastert
- Department of Pediatrics, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Sander W Tas
- Department of Rheumatology and Clinical Immunology, Amsterdam University Medical Center, Amsterdam, The Netherlands
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Kurosawa Y, Takamura S, Wakamatsu A, Kobayashi D, Narita I. A Case of Adult-Onset Still's Disease With Hypocomplementemia. Cureus 2024; 16:e52605. [PMID: 38374851 PMCID: PMC10875399 DOI: 10.7759/cureus.52605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/19/2024] [Indexed: 02/21/2024] Open
Abstract
Adult-onset Still's disease (AOSD) causes fever, rash, pharyngalgia, and arthralgia through autoinflammation. Its complement titer has not previously received attention because this usually increases during the inflammatory process. Our female patient in her 60s was admitted to the hospital with fever, rash, arthralgia, and pharyngalgia. Her white blood cell count was 19,130/μL, hemoglobin was 11.0 g/dL, platelet count was 26.0 × 104/μL, and ferritin titer was 6,175 ng/mL. Anti-nuclear antibodies and anti-neutrophil cytoplasmic antibodies were negative. The presence of infectious diseases and malignancies was excluded. She was diagnosed with hypocomplementemia at the onset of AOSD because of her low complement component 4 (C4) titer (<5.0 mg/dL). Her complement component 3 (C3) titer was 104.5 mg/dL, which was within normal limits. There was no sign of thrombotic microangiopathy (TMA) or hemophagocytosis. She was treated with high-dose corticosteroids, including pulse methylprednisolone therapy, cyclosporine, methotrexate, and intravenous immunoglobulin, but was resistant to these, and her disease repeatedly flared up. Treatment with intravenous cyclophosphamide eventually led to remission. Post-treatment, her C4 titer increased to within the normal range. Although hypocomplementemia with TMA or hemophagocytosis has been reported in AOSD patients, our patient showed no sign of either at disease onset. Hypocomplementemia of AOSD may be a sign of high disease activity and could be a predictive marker for resistance to standard therapy.
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Affiliation(s)
- Yoichi Kurosawa
- Division of Clinical Nephrology and Rheumatology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, JPN
| | - Sayuri Takamura
- Department of Rheumatology, Niigata Rheumatic Center, Shibata, JPN
| | - Ayako Wakamatsu
- Division of Clinical Nephrology and Rheumatology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, JPN
| | - Daisuke Kobayashi
- Division of Clinical Nephrology and Rheumatology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, JPN
| | - Ichiei Narita
- Division of Clinical Nephrology and Rheumatology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, JPN
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