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Hirsch W, Megna B, Adeyi O, Lim N. Macrophage activation syndrome with acute hepatitis in a patient with adult-onset immunodeficiency with anti-interferon gamma antibodies: a case report. J Med Case Rep 2024; 18:6. [PMID: 38178160 PMCID: PMC10768153 DOI: 10.1186/s13256-023-04245-w] [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: 08/02/2023] [Accepted: 11/05/2023] [Indexed: 01/06/2024] Open
Abstract
BACKGROUND Macrophage activation syndrome is a rare disorder leading to unregulated immune activity manifesting with nonspecific constitutional symptoms, laboratory abnormalities, and multiorgan involvement. We report the case of a patient who presented with acute hepatitis secondary to macrophage activation syndrome diagnosed by liver biopsy and successfully treated with intravenous immune globulin, anakinra, and rituximab. CASE PRESENTATION A 42-year-old Laotian woman with adult-onset immunodeficiency with anti-interferon gamma antibodies presented with a fever, headache, generalized myalgia, dark urine, and reduced appetite in the setting of family members at home with similar symptoms. Her laboratory workup was notable for evidence of acute hepatitis without acute liver failure. After an unrevealing comprehensive infectious and noninvasive rheumatologic workup was completed, a liver biopsy was performed ultimately revealing the diagnosis of macrophage activation syndrome. She was successfully treated with intravenous immune globulin, anakinra, and rituximab. CONCLUSION This case highlights the importance of maintaining macrophage activation syndrome on the differential of a patient with acute hepatitis of unknown etiology in the correct clinical context and the value of a liver biopsy in making a diagnosis when noninvasive testing is unrevealing.
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Affiliation(s)
- William Hirsch
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA.
| | - Bryant Megna
- Division of Gastroenterology, Hepatology, & Nutrition, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Oyedele Adeyi
- Department of Laboratory Medicine & Pathology, University of Minnesota, Minneapolis, MN, USA
| | - Nicholas Lim
- Division of Gastroenterology, Hepatology, & Nutrition, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
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Cron RQ. IL-1 Family Blockade in Cytokine Storm Syndromes. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2024; 1448:553-563. [PMID: 39117838 DOI: 10.1007/978-3-031-59815-9_36] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/10/2024]
Abstract
Interleukin-1 is a prototypic proinflammatory cytokine that is elevated in cytokine storm syndromes (CSSs), such as secondary hemophagocytic lymphohistiocytosis (sHLH) and macrophage activation syndrome (MAS). IL-1 has many pleotropic and redundant roles in both innate and adaptive immune responses. Blockade of IL-1 with recombinant human interleukin-1 receptor antagonist has shown efficacy in treating CSS. Recently, an IL-1 family member, IL-18, has been demonstrated to be contributory to CSS in autoinflammatory conditions, such as in inflammasomopathies (e.g., NLRC4 mutations). Anecdotally, recombinant IL-18 binding protein can be of benefit in treating IL-18-driven CSS. Lastly, another IL-1 family member, IL-33, has been postulated to contribute to CSS in an animal model of disease. Targeting of IL-1 and related cytokines holds promise in treating a variety of CSS.
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Wang R, Li T, Ye S, Lv L, Chen S, Wang X, Bao CD, Fu Q. Short-term, low-dose etoposide in refractory adult-onset Still's disease-associated macrophage activation syndrome. Clin Rheumatol 2022; 41:2817-2823. [PMID: 35590113 DOI: 10.1007/s10067-022-06184-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 03/29/2022] [Accepted: 04/18/2022] [Indexed: 12/12/2022]
Abstract
INTRODUCTION In this study, we modified the classical regimen of the hemophagocytic lymphohistiocytosis-04 protocol and evaluated the efficacy and safety of short-term, low-dose etoposide in patients with refractory macrophage activation syndrome (MAS) associated with adult-onset Still's disease (AOSD). METHODS A total of 17 patients with refractory AOSD-associated MAS were enrolled and received short-term, low-dose etoposide (100 mg twice a week for four times). Another 11 patients, who were not treated with etoposide, were included as historical controls. Patient information, such as clinical manifestations, laboratory results, treatments, and short-term prognosis, were recorded and analyzed. RESULTS In this case series, 88.24% of the patients with MAS who were treated with short-term, low-dose etoposide had a favorable response in 3 weeks, which was significantly higher (p = 0.017) than that in the patients with MAS who were treated without etoposide (45.45%). The 90-day survival rate after the onset of MAS was significantly higher (p = 0.0029) among the patients in the short-term etoposide group (16/17, 94.12%) than in the control group (5/11, 45.45%). CONCLUSION The regimen of short-term (2 weeks), low-dose etoposide was highly effective in the treatment for patients with refractory AOSD-associated MAS with an acceptable safety profile. Key Points • There is no high level evidence to guide the management of refractory MAS-associated AOSD patients. • This study was the first to propose and confirm the efficacy and safety of short-term, low-dose etoposide in the treatment of refractory MAS-associated AOSD patients.
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Affiliation(s)
- Ran Wang
- Department of Rheumatology, School of Medicine, Renji Hospital, Shanghai Jiaotong University, Shanghai, 200001, China
| | - Ting Li
- Department of Rheumatology, School of Medicine, Renji Hospital, Shanghai Jiaotong University, Shanghai, 200001, China
| | - Shuang Ye
- Department of Rheumatology, School of Medicine, Renji Hospital, Shanghai Jiaotong University, Shanghai, 200001, China
| | - Liangjin Lv
- Department of Rheumatology, School of Medicine, Renji Hospital, Shanghai Jiaotong University, Shanghai, 200001, China
| | - Sheng Chen
- Department of Rheumatology, School of Medicine, Renji Hospital, Shanghai Jiaotong University, Shanghai, 200001, China
| | - Xiaodong Wang
- Department of Rheumatology, School of Medicine, Renji Hospital, Shanghai Jiaotong University, Shanghai, 200001, China
| | - Chun-de Bao
- Department of Rheumatology, School of Medicine, Renji Hospital, Shanghai Jiaotong University, Shanghai, 200001, China.
| | - Qiong Fu
- Department of Rheumatology, School of Medicine, Renji Hospital, Shanghai Jiaotong University, Shanghai, 200001, China.
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Muller R, Briantais A, Faucher B, Borentain P, Nafati C, Blasco V, Gregoire E, Bernit E, Seguier J, Meunier B, Harlé JR, Ebbo M, Schleinitz N. Acute severe hepatitis in adult-onset Still's disease: case report and comprehensive review of a life-threatening manifestation. Clin Rheumatol 2020; 40:2467-2476. [PMID: 32955629 DOI: 10.1007/s10067-020-05383-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 08/27/2020] [Accepted: 08/31/2020] [Indexed: 10/23/2022]
Abstract
Acute severe hepatitis is a rare complication of adult-onset Still's disease (AOSD). This condition is poorly characterized. We performed a review of the medical literature to describe clinical, biological, pathological, and treatment characteristics from AOSD patients with acute severe hepatitis. Their characteristics were compared with AOSD patients without severe hepatitis. Twenty-one cases were collected including a new case reported here. Patients with severe hepatitis were mostly young adults with a median age of 28 years (range: 20 to 55 years). Overall, patients with severe hepatitis had less arthritis, macular rash, sore throat, lymphadenopathy, or splenomegaly than patients without severe hepatitis. Cytopenia was more frequent in case of severe hepatitis. Most patients were treated with steroids, and the use of biotherapies has increased over the last decade. Despite treatment, 49% of patients required liver transplantation and 24% died. Key Points • Acute severe hepatitis in adult-onset Still's disease (AOSD) is associated with liver transplantation and/or death in, respectively, 43% and 24% of cases. • Severe hepatitis is the inaugural manifestation of AOSD in half of cases. Diagnosis is difficult when extra-hepatic clinical manifestations are lacking. • The mechanism of hepatic necrosis in AOSD with severe hepatitis is unknown. Liver biopsy is not specific and should not delay treatment initiation.
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Affiliation(s)
- Romain Muller
- Service de médecine interne, Aix Marseille Université, APHM, Hôpital La Timone, Marseille, France
| | - Antoine Briantais
- Service de médecine interne, Aix Marseille Université, APHM, Hôpital La Timone, Marseille, France
| | - Benoit Faucher
- Service de médecine interne, Aix Marseille Université, APHM, Hôpital La Timone, Marseille, France
| | - Patrick Borentain
- Service d'hépato-gastro-entérologie, Aix Marseille Université, APHM, Hôpital La Timone, Marseille, France
| | - Cyril Nafati
- Réanimation polyvalente et des pathologies du foie, Aix Marseille Université, APHM, Hôpital La Timone, Marseille, France
| | - Valery Blasco
- Réanimation polyvalente et des pathologies du foie, Aix Marseille Université, APHM, Hôpital La Timone, Marseille, France
| | - Emilie Gregoire
- Service de chirurgie digestive, Aix Marseille Université, APHM, Hôpital La Timone, Marseille, France
| | - Emmanuelle Bernit
- Service de médecine interne, Aix Marseille Université, APHM, Hôpital La Timone, Marseille, France
| | - Julie Seguier
- Service de médecine interne, Aix Marseille Université, APHM, Hôpital La Timone, Marseille, France
| | - Benoit Meunier
- Service de médecine interne, Aix Marseille Université, APHM, Hôpital La Timone, Marseille, France
| | - Jean-Robert Harlé
- Service de médecine interne, Aix Marseille Université, APHM, Hôpital La Timone, Marseille, France
| | - Mikael Ebbo
- Service de médecine interne, Aix Marseille Université, APHM, Hôpital La Timone, Marseille, France
| | - Nicolas Schleinitz
- Service de médecine interne, Aix Marseille Université, APHM, Hôpital La Timone, Marseille, France.
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Colafrancesco S, Scrivo R, Barbati C, Conti F, Priori R. Targeting the Immune System for Pulmonary Inflammation and Cardiovascular Complications in COVID-19 Patients. Front Immunol 2020; 11:1439. [PMID: 32655577 PMCID: PMC7324709 DOI: 10.3389/fimmu.2020.01439] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Accepted: 06/03/2020] [Indexed: 12/21/2022] Open
Abstract
In December 2019, following a cluster of pneumonia cases in China caused by a novel coronavirus (CoV), named severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the infection disseminated worldwide and, on March 11th, 2020, the World Health Organization officially declared the pandemic of the relevant disease named coronavirus disease 2019 (COVID-19). In Europe, Italy was the first country facing a true health policy emergency, and, as at 6.00 p.m. on May 2nd, 2020, there have been more than 209,300 confirmed cases of COVID-19. Due to the increasing number of patients experiencing a severe outcome, global scientific efforts are ongoing to find the most appropriate treatment. The usefulness of specific anti-rheumatic drugs came out as a promising treatment option together with antiviral drugs, anticoagulants, and symptomatic and respiratory support. For this reason, we feel a duty to share our experience and our knowledge on the use of these drugs in the immune-rheumatologic field, providing in this review the rationale for their use in the COVID-19 pandemic.
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Affiliation(s)
| | | | | | - Fabrizio Conti
- Rheumatology Unit, Department of Clinical, Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
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Colafrancesco S, Manara M, Bortoluzzi A, Serban T, Bianchi G, Cantarini L, Ciccia F, Dagna L, Govoni M, Montecucco C, Priori R, Ravelli A, Sfriso P, Sinigaglia L. Management of adult-onset Still's disease with interleukin-1 inhibitors: evidence- and consensus-based statements by a panel of Italian experts. Arthritis Res Ther 2019; 21:275. [PMID: 31829244 PMCID: PMC6907145 DOI: 10.1186/s13075-019-2021-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Accepted: 10/03/2019] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Adult-onset Still's disease (AOSD) is a rare inflammatory condition characterized by fever, rash, and arthritis. Because of its rarity, clinical trials are inherently small and often uncontrolled. Our objective was to develop recommendations for the use of interleukin (IL)-1 inhibitors in the management of patients with AOSD, based on the best evidence and expert opinion. METHODS A panel of 10 experts (9 rheumatologists and 1 pediatrician) was established. The first step was dedicated to a comprehensive literature review and development of statements. Two separate literature searches were performed on the MEDLINE (Pubmed), EMBASE, and BIOSIS databases through April 2018 to identify (1) differences and similarities between AOSD and pediatric Still's disease (systemic juvenile idiopathic arthritis [SJIA]) and (2) the efficacy and safety of IL-1 inhibitors in AOSD treatment. In the second step, the statements were submitted in a Delphi process to a panel of 67 rheumatologists. Consensus threshold was set at 66%: positive, > 66% of voters selected scores 3 to 5; negative, > 66% of voters selected scores 1 or 2. In the third step, the voting results were analyzed, and the statements were finalized. RESULTS Eleven statements were developed. Forty-six of 67 rheumatologists (72%) participated in the Delphi process. A positive consensus was reached after the first round of voting and was full (> 95%) on the majority of statements. A large consensus was achieved in considering AOSD and SJIA as the same disease. The use of anti-IL-1 therapies in refractory patients was considered quite safe and effective both as the first and as a subsequent line of biologic treatment, especially in systemic patients. Because of the lack of head-to-head comparisons, a different profile of efficacy among IL-1 inhibitors could not be established. There was a large consensus that failure of the first IL-1 inhibitor does not preclude response to another one. The lack of studies comparing early versus late treatment did not allow to draw conclusions; however, data from SJIA suggest a better response in early treatment. CONCLUSIONS The Delphi method was used to develop recommendations that we hope will help clinicians in the management of patients with AOSD refractory to conventional therapies.
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Affiliation(s)
- Serena Colafrancesco
- Dipartimento di Scienze Cliniche, Internistiche, Anestesiologiche e Cardiovascolari, Rheumatology Unit, Sapienza University of Rome, Rome, Italy.
| | - Maria Manara
- Division of Rheumatology, ASST Gaetano Pini-CTO, Milan, Italy
| | - Alessandra Bortoluzzi
- Rheumatology, Department of Medical Sciences, University of Ferrara and Azienda Ospedaliera-Universitaria di Ferrara, Cona, FE, Italy
| | - Teodora Serban
- SC Reumatologia, ASL3 - Azienda Sanitaria Genovese, Genoa, Italy
| | - Gerolamo Bianchi
- SC Reumatologia, ASL3 - Azienda Sanitaria Genovese, Genoa, Italy
| | - Luca Cantarini
- Department of Medical Sciences, Surgery and Neurosciences, Rheumatology Unit, University of Siena, Policlinico "Le Scotte", Siena, Italy
| | - Francesco Ciccia
- Rheumatology, Dipartimento di Medicina di Precisione, Università della Campania "L. Vanvitelli", Naples, Italy
| | - Lorenzo Dagna
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases (UnIRAR), IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Marcello Govoni
- Rheumatology, Department of Medical Sciences, University of Ferrara and Azienda Ospedaliera-Universitaria di Ferrara, Cona, FE, Italy
| | - Carlomaurizio Montecucco
- Department of Rheumatology, IRCCS Policlinico San Matteo Foundation, University of Pavia, Pavia, Italy
| | - Roberta Priori
- Dipartimento di Scienze Cliniche, Internistiche, Anestesiologiche e Cardiovascolari, Rheumatology Unit, Sapienza University of Rome, Rome, Italy
| | - Angelo Ravelli
- Clinica Pediatrica e Reumatologia, Istituto Giannina Gaslini and Università degli Studi di Genova, Genoa, Italy
| | - Paolo Sfriso
- Rheumatology Unit, Department of Medicine, University of Padua, Padua, Italy
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Feist E, Mitrovic S, Fautrel B. Mechanisms, biomarkers and targets for adult-onset Still's disease. Nat Rev Rheumatol 2019; 14:603-618. [PMID: 30218025 PMCID: PMC7097309 DOI: 10.1038/s41584-018-0081-x] [Citation(s) in RCA: 231] [Impact Index Per Article: 46.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Adult-onset Still’s disease (AoSD) is a rare but clinically well-known, polygenic, systemic autoinflammatory disease. Owing to its sporadic appearance in all adult age groups with potentially severe inflammatory onset accompanied by a broad spectrum of disease manifestation and complications, AoSD is an unsolved challenge for clinicians with limited therapeutic options. This Review provides a comprehensive insight into the complex and heterogeneous nature of AoSD, describing biomarkers of the disease and its progression and the cytokine signalling pathways that contribute to disease. The efficacy and safety of biologic therapeutic options are also discussed, and guidance for treatment decisions is provided. Improving the approach to AoSD in the future will require much closer cooperation between paediatric and adult rheumatologists to establish common diagnostic strategies, treatment targets and goals. Adult-onset Still’s disease (AoSD) is not easily diagnosed, and treatment options are limited. This Review provides an overview of the disease and its pathogenesis, clinical trial results, therapeutic options and a plan to diagnose and clinically manage these patients. Similar to systemic-onset juvenile idiopathic arthritis, adult-onset Still’s disease (AoSD) is a rare systemic autoinflammatory disease with potentially severe inflammatory onset accompanied by a broad spectrum of disease manifestation and complications. AoSD should be considered in patients with persistent fever, and the diagnosis is based on the combination of clinical and laboratory findings as well as the exclusion of other inflammatory conditions. Central to the pathogenesis of AoSD is the intense activation of innate immune cells and overproduction of several pro-inflammatory cytokines including IL-1, IL-6 and IL-18. Two IL-1 antagonists have been approved for treatment of AoSD, and growing evidence suggests that other biologic agents are therapeutic options, such as anti-IL-6 and anti-IL-18 therapeutics. As a reliable prediction of response and outcome is not possible, therapeutic decisions have to be made on the basis of clinical, biological or imaging characteristics of disease. A close cooperation between paediatric and adult rheumatologists is required to establish common diagnostic strategies, treatment targets and goals.
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Affiliation(s)
- Eugen Feist
- Department of Rheumatology and Clinical Immunology, Charité- Universitätsmedizin, Berlin, Germany.
| | - Stéphane Mitrovic
- Department of Rheumatology, AP-HP, Pitié-Salpêtrière Hospital, AP-HP, Paris, France. .,Department of Internal Medicine, Institut Mutualiste Montsouris, Paris, France.
| | - Bruno Fautrel
- Department of Rheumatology, AP-HP, Pitié-Salpêtrière Hospital, AP-HP, Paris, France.,Sorbonne Université, GRC 08, Pierre Louis Institute of Epidemiology and Public Health, Paris, France
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Shah A, Alhusayen R, Amini-Nik S. The critical role of macrophages in the pathogenesis of hidradenitis suppurativa. Inflamm Res 2017; 66:931-945. [PMID: 28656364 DOI: 10.1007/s00011-017-1074-y] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2017] [Accepted: 06/21/2017] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION Hidradenitis suppurativa (HS) is a painful chronic inflammatory disease with a prevalence between 1 and 4% of general population. The pathogenesis of HS long eluded scientists, but growing evidence suggests that it is a consequence of inflammatory dysregulation. FINDINGS Recent studies suggest that dysregulated immune response to skin flora and overexpression of inflammatory cytokines leads to chronic skin inflammation seen in HS. Macrophages are the most numerous inflammatory cells found in HS infiltrates and release numerous pro-inflammatory cytokines such as IL-23, and IL-1β and TNF-α, exacerbating the inflammation and contributing to the pathogenesis of HS. Furthermore, in HS, there is dysregulated function of other immune players closely associated with macrophage function including: matrix metalloproteases (MMP) 2 and 9 overexpression, toll-like receptor upregulation, impaired Notch signalling, NLRP3 inflammasome upregulation, and dysregulated keratinocyte function. Lifestyle factors including obesity and smoking also contribute to macrophage dysfunction and correlate with HS incidence. CONCLUSIONS The overexpression of pro-inflammatory cytokines and subsequent efficacy of anti-cytokine biologic therapies highlights the importance of managing macrophage dysfunction. Future therapies should target key molecular drivers of macrophage dysfunction such as TLR2 and NLRP3 overexpression.
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Affiliation(s)
- Ahmed Shah
- Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Raed Alhusayen
- Faculty of Medicine, University of Toronto, Toronto, Canada.,Division of Dermatology, University of Toronto, Toronto, Canada.,Sunnybrook Health Science Center, Sunnybrook Research Institute, Toronto, Canada
| | - Saeid Amini-Nik
- Faculty of Medicine, University of Toronto, Toronto, Canada. .,Department of Surgery, University of Toronto, Toronto, Canada. .,Department of Laboratory Medicine and Pathobiology (LMP), University of Toronto, Toronto, Canada. .,Sunnybrook Health Science Center, Sunnybrook Research Institute, Toronto, Canada.
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